Respiratory - Level 3 Flashcards
Definition of bronchiectasis?
- Chronic, progressive infection of bronchi/bronchioles leads to permanent dilatation of airways
- Can be focal or diffuse
Epidemiology of bronchiectasis?
- Incidence increasing – 1 in 200
- Women > Men
- Increases with age
Causes of bronchiectasis?
Post-infection – Most common
Measles, pertussis, bronchiolitis, pneumonia, TB
Congenital
CF, Young’s syndrome, Kartagener’s syndrome
Other Bronchial obstruction (tumour, foreign body) Allergic Aspergillosis Hypogammaglobulinemia Rheumatoid Arthritis Ulcerative Colitis
Symptoms of bronchiectasis?
o Chronic productive cough – copious purulent sputum (foul-smelling, green)
o Recurrent infections
o SOB, wheeze, haemoptysis
Signs of bronchiectasis?
o Clubbing
o Coarse inspiratory crepitations
o Wheeze
Infective exacerbation of bronchiectasis?
o Worsening cough
o Increased sputum volume, viscosity, purulence
o Increased breathlessness
Investigations in people with suspected bronchiectasis?
o Sputum culture
Infective exacerbation
Mainly H.influenziae, Strep pneumoniae, S.aureus, Pseudomonas aeruginosa
o CXR
Cystic shadows
Thickened bronchial walls
Dilated bronchi
o Post-bronchodilator spirometry
o Document BMI, smoking status
Secondary care investigations of bronchiectasis?
o All patients High-resolution CT • Shows extent and distribution • Diagnostic in Secondary care Sweat Test (<40 or >40 and features of CF) Gross antibody deficiency Total immunoglobulin IgE and specific IgE Antibody levels against S.pneumoniae
o Test ciliary function – no other cause identified
o Bronchoscopy – suspected foreign body or lesion
o 24-hour pH monitoring – if secondary to GORD and aspiration
Management of bronchiectasis - general advice?
- Refer to respiratory consultant
- Annual pneumococcal and influenza vaccine
Management of bronchiectasis - annual review?
o Smoking advice o Number of exacerbations o Activity of daily living o Sputum volume and character o Bronchiectasis Severity Index o BMI o O2 sats
Management of bronchiectasis - specialist follow up?
o Deteriorating with declining lung function
o Long-term prophylactic antibiotics
o Associated with RA, immune deficiency, PCD, aspergillosis
Management of bronchiectasis - Step 1?
o Treat cause
o Physiotherapy
Postural drainage BDS
Aids sputum expectoration and mucous drainage
o Pneumococcal and annual influenza vaccine
o Antibiotic treatment of exacerbations
PO Amoxicillin for 7-14 days (alternatives – clarithromycin, doxycycline)
If >3 then long-term Abx
Management of bronchiectasis - step 2?
o Reassess physio
o Add carbocysteine
Management of bronchiectasis - Step 3?
o If Pseudomonas aeruginosa – long-term inhaled anti-pseudomonal antibiotics (or oral macrolide)
o If other microorganism – oral macrolide
Management of bronchiectasis - Step 4?
o Long term macrolide and long term inhaled antibiotics
Management of bronchiectasis - Step 5?
o Regular IV antibiotics every 2-3 months
- Consider transplant
When to move up in management of bronchiectasis?
- Move up steps if 3 or more exacerbations per year
Prognosis of bronchiectasis?
o Normal life expectancy
o Most have few symptoms
o Worse prognosis associated with extensive disease, smokes
Complications of bronchiectasis?
o Pneumonia
o Pneumothorax/Rib fractures
o Respiratory Failure
o RHF
Definition of carbon monoxide poisoning?
• Colourless, odourless, tasteless gas produced by incomplete combustion of fuels
Mechanism of carbon monoxide poisoning?
- CoHb binds to haemoglobin and displaces O2 (240x affinity) and forms carboxyhaemoglobin
- Carboxyhaemoglobin takes several hours to dissociate from haemoglobin, results in prolonged hypoxia
- Hypoxia impairs cell function and cause tissue damage
Sources of carbon monoxide poisoning?
- Poorly installed/maintained/faulty chimneys, gas ovens, boilers, engines
- Smoke in burning buildings
- Paint removers
- Aerosol
Risk groups of carbon monoxide poisoning?
- Old people
- Children
- Pregnant women
- Resipratory or cardiovascular disease
- Anaemia
Symptoms of carbon monoxide poisoning?
• Low levels
o Dizziness, flushing, headache, muscle pain, nausea and vomiting
• High Levels
o Confusion, loss of consciousness, movement problems, respiratory failure, weakness
Management of carbon monoxide poisoning?
• Use TOXBASE
• Remove source
• VBG sample
• 100% O2 using tight-fitting mask until asymptomatic and CoHb <3% (non-smokers) or <10% (smokers)
• If neurological problems:
o Mannitol IVI (if cerebral oedema suspected)
o Hyperbaric O2
Severe impairment, no response or pregnant
• Discuss with poisons service & local health protection team
Prevention of carbon monoxide poisoning?
- Fit Carbon Monoxide alarm
- Chimney swept at least once a year
- Keep rooms well ventilated while using gas appliances
Complications of carbon monoxide poisoning?
• Apathy, apraxia, dementia, disorientation, unable to concentrate, irritability, personality changes, psychosis
Definition of idiopathic pulmonary fibrosis?
- Commonest cause of interstitial lung disease
- Inflammatory cell infiltrate and acute fibroblastic proliferation leading to collagen deposition
Epidemiology of idiopathic pulmonary fibrosis?
- Men
- Age of onset 60 years
- 40% of all interstitial lung disease
Risk factors of idiopathic pulmonary fibrosis?
o Smoking
o Familial
o Chronic viral infections – Hep C, EBV
Symptoms of idiopathic pulmonary fibrosis?
o Dry Cough o Exertional dyspnoea o Malaise o Low weight o Arthralgia
Signs of idiopathic pulmonary fibrosis?
o Cyanosis
o Finger Clubbing
o Fine end-inspiratory crepitations
Clinical investigations of idiopathic pulmonary fibrosis?
- Spirometry o Restrictive (>0.7 FEV1/FVC, decreased FVC)
- CXR
o Decreased lung volume, bilateral lower zone reticulonodular shadows
o Honeycomb lung - CT
o Diagnostic
Investigations if diagnosis cannot be made for idiopathic pulmonary fibrosis?
- Bronchoalveolar lavage or transbronchial biopsy
- Surgical biopsy
o Usual interstitial pneumonia
Management of idiopathic pulmonary fibrosis - initial information?
o Lung Transplant 3-6 months after diagnosis
o Ventilation has poor outcomes with IPF
Management of idiopathic pulmonary fibrosis - assess prognosis?
o Using LFTs at diagnosis and 6 and 12 months after diagnosis
Management of idiopathic pulmonary fibrosis -pulmonary rehabilitation?
o Assess eligibility using 6-minute walk test and QoL assessment at diagnosis, 6 and 12 months
Management of idiopathic pulmonary fibrosis - drugs?
o To treat IPF
o Nintedanib or Pirfenidone
If FVC 50-80% of predicted
Treatment stopped if disease progresses by 10% or more of FVC In 12 months
o Symptom Control
Oxygen (ambulatory or LTOT)
Opioids for chronic cough
Management of idiopathic pulmonary fibrosis - further management?
- Lung transplant
- Palliative Care
Management of idiopathic pulmonary fibrosis - follow up?
- Follow-up every 3-6 months
o Assess lung function, oxygen therapy, smoking status, exacerbations
Management of idiopathic pulmonary fibrosis -prognosis?
o 50% 5-year survival rates
Management of idiopathic pulmonary fibrosis - complications?
o Respiratory failure
o Increased risk of lung cancer
Definition of coalworkers’ pneumoconiosis?
o Inhalation of coal dust particles (2-5um) into alveoli are ingested by macrophages, which die and release enzymes which fibrose lung tissue
o Long lag time – 10 years
o Morbidity and mortality related to type of coal dust and duration of exposure
Definition of progressive massive fibrosis?
o Progression of CWP, causes progressive SOB, fibrosis and eventually cor pulmonale
Definition of Caplan’s syndrome?
o Associated between RA, pneumoconiosis and pulmonary rheumatoid nodules
Epidemiology of coalworkers’ pneumoconiosis?
- High in countries with or had coal mines
- Males
Risk factore of coalworkers’ pneumoconiosis?
o Coal workers
o Smoking
Symptoms of coalworkers’ pneumoconiosis?
o Asymptomatic
o SOB exertional
o Cough – black sputum
CXR findings of coalworkers’ pneumoconiosis?
o Small pulmonary nodules – fibrotic masses in upper lobes (1-10cm) – PMF
o Grading
A – diameter of opacities 1-5cm
B – opacities diameter >5cm but <1/3 of right lung field
C – Opacities diameter >5cm and >1/3 of righ tlung field area
Other investigations in coalworkers’ pneumoconiosis?
- CT scan used
- Lung function test
o Restrictive pattern (both FVC and FEV1 decreased) so FEV1/FVC is normal or higher
Management of coalworkers’ pneumoconiosis - general measures?
o Notifiable industrial disease
o Compensation via UK Industrial Act
o Avoid exposures
o Stop Smoking
Management of coalworkers’ pneumoconiosis - if SOB or hypoxic?
o Pulmonary rehabilitation
o Oxygen therapy
Complications of coalworkers’ pneumoconiosis - ?
o COPD o Respiratory Failure o Progressive Massive Fibrosis (PMF) Progression of CWP, causes progressive SOB, fibrosis and eventually cor pulmonale o Lung Cancer o TB
Definition of malignant mesothelioma?
- Aggressive epithelial tumour of mesothelial cells occurring in pleural (90% of times), rarely in peritoneum or other organs
Epidemiology of malignant mesothelioma?
- Incidence increasing
- Men 3x
- ½ over 75
Causes of malignant mesothelioma?
o Exposure to asbestos (90%)
But 20% have pulmonary asbestosis
o FHx
Symptoms of malignant mesothelioma?
- Long latent period between exposure to asbestos and disease (up to 50 years)
o Chest pain Dull, diffuse and progressive Sometimes pleuritis o SOB o Weight loss o Fever, fatigue and sweating
Signs of malignant mesothelioma?
o Diminished breath sounds o Dullness to percuss o Finger clubbing o Recurrent pleural effusions o Signs of mets: lymphadenopathy, hepatomegaly, bone pain, abdominal obstruction/pain
When to refer in 2 week pathway of malignant mesothelioma?
- Urgent 2-week CXR
o Pleural thickening/effusion
Investigations to confirm diagnosis of malignant mesothelioma?
CT with IV contrast
o Pleural thickening/plaques, enlarged lymph nodes
PET Scans
Diagnosis – Thoracoscopy under LA
o Pleural fluid – bloody
o Pleural biopsy
Staging IASLC
When to offer urgent 2 week CXR for lung cancer?
o Offer urgent 2-week CXR if people >40 if:
2 or more of following symptoms OR
1 or more of following symptoms and have ever smoked OR
1 or more of following unexplained symptoms and been exposed to asbestos:
• Cough
• Fatigue
• SOB
• Chest pain
• Weight Loss
• Appetite Loss
o Consider urgent CXR if >40 with finger clubbing or chest signs
Management of malignant mesothelioma - general measures?
o Refer to regional mesothelioma MDT
o Compensation
o Pleural Effusions
Talc pleurodesis OR indwelling pleural catheters if symptomatic
Management of malignant mesothelioma - surgery?
Localised (stage 1) mesothelioma
Extra-pleural pneumonectomy OR pleurectomy with decortication
Management of malignant mesothelioma - chemotherapy?
Unressectable mesothelioma, neoadjuvant or adjuvant chemotherapy
Pemetrexed + Cisplatin +/- Bevacizumab every 21 days improves survival
Management of malignant mesothelioma - radiotherapy?
Adjuvant after surgery or palliative
Palliative management in mesothelioma?
o Palliative pleurodesis
Prognosis of malignant mesothelioma?
- Survival around 1 year
Definition of asbestosis?
o Interstitial lung disease caused by inhaled asbestos, with latent period of 20-30 years
o Pleural abnormalities include – plaques, pleural thickening, effusions
o Risk of asbestosis-related lung injury increase with duration and degree of exposure
Causes of asbestosis?
o Caused by inhalation of asbestos fibres
o Used in building trade for fire-proofing, pipe-lagging, electrical wire insulation and roof felting
Types of disease in asbestosis?
o Benign – pleural plaques, pleural thickening, benign pleural effusions
o Interstitial – asbestosis
o Malignant – mesothelioma, lung cancer
Types of asbestosis?
o Crocidolite (blue) o Amosite (brown) o Chrysotile (white)
Risk factors of asbestosis?
o Construction workers, joiners, plumbers, electricians, painters, shipyard workers, railroad workers, asbestos miners
o Smoking
Symptoms of asbestosis?
o Progressive SOB
o Reduced exercise tolerance
o Productive/Non-productive cough
o Wheeze
Signs of asbestosis?
o Clubbing
o Fine-end inspiratory crackles
o Cor pulmonale
Lung nction test findings of asbestosis?
o Restrictive pattern – Normal FEV1/FVC ratio but reduced FVC and FEV1
Imaging of asbestosis?
- CXR
o May be normal or bilateral pleural plaques and thickening - CT Scan more sensitive than CXR
- Lung biopsy if suspicious of malignancy
Management of asbestosis - general measures?
o Stop smoking
o Vaccination (influenza and pneumococcal)
o Eligible for compensation through UK Industrial Injuries Act
Management of asbestosis - if signs of COPD?
o Bronchodilators
o Pulmonary Rehabilitation
o Oxygen therapy
o Lung Transplant
Prognosis of asbestosis?
Complications of asbestosis?
- Depends on extent of lung disease, usually doesn’t progress if just asbestosis
- Complications – malignant mesothelioma, cor pulmonale and lung cancer
Definition of lung abscess?
- Cavitating area of localised, suppurative infection within lung
- May be single or multiple
- Associated with necrotic cavity formation
Causative organisms of lung abscess?
o Anaerobes – Pepstreptoccocal, Bacteroides, Fusobacterium
o Aerobes – S.aureus, S.pyogenes, H.influenzae, P.aeruginosa, K.pneumoniae
o Atypicals – Burkholderia cepacia, S.pneumoniae, Legionella, Actinomyces, Nocardia, Proteus, Pasteurella multocida
o Others – TB, Aspergillus, Cryptococcus, Histoplasma, Entamoeba
Risk factors of lung abscess?
o Alcoholism/Drug abuse o DM o General anaesthesia o Stroke/Cerebral palsy o Immunosuppressed o Congenital heart disease o CLD - CF
Causes of lung abscess?
o Pneumonia severe or incompletely treated
o Aspiration (alcoholism, oesophageal dysfunction, bulbar palsy)
o Bronchial obstruction (tumour, foreign body)
o Pulmonary infarction
o Septic emboli (sepsis, right-heart endocarditis, IVDU)
o Subphrenic/Hepatic abscess
Types of lung abscess?
o Primary – occurs in previously normal lungs
o Secondary – patient with underlying lung abnormality
Symptoms of lung abscess?
o Swinging fever (night sweats, rigors) o Cough o Purulent, foul-swelling sputum o Pleuritic chest pain o SOB o Haemoptysis o Malaise, weight loss
Signs of lung abscess?
o Clubbing o Tachypnoea o Tachycardia o Pyrexia o Anaemia o Crepitations
Bloods to do in lung abscess?
- Bloods o FBC (anaemia, neutrophils) o ESR, CRP raised o U&Es o LFTs - Blood cultures (including AAFB) - Sputum microscopy, culture and cytology (including AAFB)
Imaging to do in lung abscess?
- CXR
o Walled cavity, often with fluid level
o If aspiration – right more common
o If pneumonia/bronchiectasis/septic – multiple, basal, diffuse - CT
Diagnostic investigations of lung abscess?
Tapping fluid or empyema
Bronchoscopy for diagnostic specimens
Management of lung abscess - general measures?
o Analgesia
o Oxygen
o Rehydration
o Postural Drainage
Management of lung abscess - antibiotics?
- Antibiotics (4-6 weeks) o IV and then oral switch o 1st line – Ampicillin/Cefotaxime/Cefuroxime + Clindamycin OR benzylpenicillin + Metronidazole o Alter according to sensitivies
Management of lung abscess - surgery?
- Surgical excision
o Via bronchoscope, CT-guided percutaneous drainage
Complications of lung abscess?
o Empyema
o Bronchiectasis
o Bronchopleural fistula
o Brain abscess, sepsis
Definition of empyema?
- Presence of frank pus in pleural space
Epidemiology of empyema?
- Mortality is 15-20%
- Men 2x
Risk factors of empyema?
o Pneumonia o Iatrogenic intervention (thoracic surgery, thoracentesis, chest drain) o Aspiration (stroke, NG tube) o Immunocompromised o DM o Alcohol abuse o CLD
Causative organisms of empyema?
o CAP – Steptococcus pneumoniae, milleri and staphylococci
Anaerobes
o HAP – staphylococci (MRSA)
Symptoms of empyema?
o Recent pneumonia infection o Fever, rigors o Cough – green sputum o Chest pain – pleuritic o Malaise, anorexia, weight loss
Signs of empyema?
o Dullness to percuss
o Reduced breath sounds and vocal resonance
o Sepsis – pyrexia, tachypnoea, tachycardia, hypotension
Bloods to do in empyema?
- Bloods
o FBC (raised WBC)
o CRP (raised) - Blood cultures
Imaging to do in empyema?
- CXR
o Blunt costophrenic angles, consolidation, pleurally-based ‘D’ shape - Thoracic US
o Echogenic, loculated lesions - CT if uncertain
Diagnostic testing to perform in empyema?
- Thoracentesis
o Pleural fluid assessment
Frank pus, pH<7.2, protein >30g/dL, LDH raised, glucose <3.3, polymorphonuclear leucocytes, culture positive
Management of empyema - initial treatment?
Urgent Thoracentesis (pleural aspiration) under US
Empirical IV Antibiotics
If community-acquired – cefuroxime + metronidazole
If hospital-acquired - vancomycin
Analgesia
Fluids
Management of empyema -other management?
o Fibrinolytics
If haemodynamically unstable, older or not for surgery
Urokinase/streptokinase
o Thoracoscopic Surgery
Management of empyema - monitoring?
o CXR after 4-6 weeks after discharge
Complications of empyema?
o Sepsis
o Respiratory failure
Prognosis of empyema?
o Some respond to antibiotics and chest drain insertion within a couple of weeks
o 30% require surgery
o Mortality 15-20%
