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MSRA Content > Respiratory - Level 3 > Flashcards

Respiratory - Level 3 Flashcards

1
Q

Definition of bronchiectasis?

A
  • Chronic, progressive infection of bronchi/bronchioles leads to permanent dilatation of airways
  • Can be focal or diffuse
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2
Q

Epidemiology of bronchiectasis?

A
  • Incidence increasing – 1 in 200
  • Women > Men
  • Increases with age
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3
Q

Causes of bronchiectasis?

A

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
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4
Q

Symptoms of bronchiectasis?

A

o Chronic productive cough – copious purulent sputum (foul-smelling, green)
o Recurrent infections
o SOB, wheeze, haemoptysis

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5
Q

Signs of bronchiectasis?

A

o Clubbing
o Coarse inspiratory crepitations
o Wheeze

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6
Q

Infective exacerbation of bronchiectasis?

A

o Worsening cough
o Increased sputum volume, viscosity, purulence
o Increased breathlessness

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7
Q

Investigations in people with suspected bronchiectasis?

A

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

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8
Q

Secondary care investigations of bronchiectasis?

A 
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

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9
Q

Management of bronchiectasis - general advice?

A
  • Refer to respiratory consultant

- Annual pneumococcal and influenza vaccine

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10
Q

Management of bronchiectasis - annual review?

A 
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
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11
Q

Management of bronchiectasis - specialist follow up?

A

o Deteriorating with declining lung function
o Long-term prophylactic antibiotics
o Associated with RA, immune deficiency, PCD, aspergillosis

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12
Q

Management of bronchiectasis - Step 1?

A

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

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13
Q

Management of bronchiectasis - step 2?

A

o Reassess physio

o Add carbocysteine

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14
Q

Management of bronchiectasis - Step 3?

A

o If Pseudomonas aeruginosa – long-term inhaled anti-pseudomonal antibiotics (or oral macrolide)
o If other microorganism – oral macrolide

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15
Q

Management of bronchiectasis - Step 4?

A

o Long term macrolide and long term inhaled antibiotics

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16
Q

Management of bronchiectasis - Step 5?

A

o Regular IV antibiotics every 2-3 months

- Consider transplant

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17
Q

When to move up in management of bronchiectasis?

A
  • Move up steps if 3 or more exacerbations per year
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18
Q

Prognosis of bronchiectasis?

A

o Normal life expectancy
o Most have few symptoms
o Worse prognosis associated with extensive disease, smokes

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19
Q

Complications of bronchiectasis?

A

o Pneumonia
o Pneumothorax/Rib fractures
o Respiratory Failure
o RHF

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20
Q

Definition of carbon monoxide poisoning?

A

• Colourless, odourless, tasteless gas produced by incomplete combustion of fuels

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21
Q

Mechanism of carbon monoxide poisoning?

A
  • 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
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22
Q

Sources of carbon monoxide poisoning?

A
  • Poorly installed/maintained/faulty chimneys, gas ovens, boilers, engines
  • Smoke in burning buildings
  • Paint removers
  • Aerosol
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23
Q

Risk groups of carbon monoxide poisoning?

A
  • Old people
  • Children
  • Pregnant women
  • Resipratory or cardiovascular disease
  • Anaemia
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24
Q

Symptoms of carbon monoxide poisoning?

A

• Low levels
o Dizziness, flushing, headache, muscle pain, nausea and vomiting

• High Levels
o Confusion, loss of consciousness, movement problems, respiratory failure, weakness

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25
Q

Management of carbon monoxide poisoning?

A

• 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

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26
Q

Prevention of carbon monoxide poisoning?

A
  • Fit Carbon Monoxide alarm
  • Chimney swept at least once a year
  • Keep rooms well ventilated while using gas appliances
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27
Q

Complications of carbon monoxide poisoning?

A

• Apathy, apraxia, dementia, disorientation, unable to concentrate, irritability, personality changes, psychosis

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28
Q

Definition of idiopathic pulmonary fibrosis?

A
  • Commonest cause of interstitial lung disease

- Inflammatory cell infiltrate and acute fibroblastic proliferation leading to collagen deposition

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29
Q

Epidemiology of idiopathic pulmonary fibrosis?

A
  • Men
  • Age of onset 60 years
  • 40% of all interstitial lung disease
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30
Q

Risk factors of idiopathic pulmonary fibrosis?

A

o Smoking
o Familial
o Chronic viral infections – Hep C, EBV

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31
Q

Symptoms of idiopathic pulmonary fibrosis?

A 
o	Dry Cough
o	Exertional dyspnoea
o	Malaise
o	Low weight
o	Arthralgia
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32
Q

Signs of idiopathic pulmonary fibrosis?

A

o Cyanosis
o Finger Clubbing
o Fine end-inspiratory crepitations

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33
Q

Clinical investigations of idiopathic pulmonary fibrosis?

A 
-	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
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34
Q

Investigations if diagnosis cannot be made for idiopathic pulmonary fibrosis?

A
  • Bronchoalveolar lavage or transbronchial biopsy
  • Surgical biopsy
    o Usual interstitial pneumonia
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35
Q

Management of idiopathic pulmonary fibrosis - initial information?

A

o Lung Transplant 3-6 months after diagnosis

o Ventilation has poor outcomes with IPF

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36
Q

Management of idiopathic pulmonary fibrosis - assess prognosis?

A

o Using LFTs at diagnosis and 6 and 12 months after diagnosis

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37
Q

Management of idiopathic pulmonary fibrosis -pulmonary rehabilitation?

A

o Assess eligibility using 6-minute walk test and QoL assessment at diagnosis, 6 and 12 months

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38
Q

Management of idiopathic pulmonary fibrosis - drugs?

A

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

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39
Q

Management of idiopathic pulmonary fibrosis - further management?

A
  • Lung transplant

- Palliative Care

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40
Q

Management of idiopathic pulmonary fibrosis - follow up?

A
  • Follow-up every 3-6 months

o Assess lung function, oxygen therapy, smoking status, exacerbations

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41
Q

Management of idiopathic pulmonary fibrosis -prognosis?

A

o 50% 5-year survival rates

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42
Q

Management of idiopathic pulmonary fibrosis - complications?

A

o Respiratory failure

o Increased risk of lung cancer

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43
Q

Definition of coalworkers’ pneumoconiosis?

A

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

44
Q

Definition of progressive massive fibrosis?

A

o Progression of CWP, causes progressive SOB, fibrosis and eventually cor pulmonale

45
Q

Definition of Caplan’s syndrome?

A

o Associated between RA, pneumoconiosis and pulmonary rheumatoid nodules

46
Q

Epidemiology of coalworkers’ pneumoconiosis?

A
  • High in countries with or had coal mines

- Males

47
Q

Risk factore of coalworkers’ pneumoconiosis?

A

o Coal workers

o Smoking

48
Q

Symptoms of coalworkers’ pneumoconiosis?

A

o Asymptomatic
o SOB exertional
o Cough – black sputum

49
Q

CXR findings of coalworkers’ pneumoconiosis?

A

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

50
Q

Other investigations in coalworkers’ pneumoconiosis?

A
  • CT scan used
  • Lung function test
    o Restrictive pattern (both FVC and FEV1 decreased) so FEV1/FVC is normal or higher
51
Q

Management of coalworkers’ pneumoconiosis - general measures?

A

o Notifiable industrial disease
o Compensation via UK Industrial Act
o Avoid exposures
o Stop Smoking

52
Q

Management of coalworkers’ pneumoconiosis - if SOB or hypoxic?

A

o Pulmonary rehabilitation

o Oxygen therapy

53
Q

Complications of coalworkers’ pneumoconiosis - ?

A 
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
54
Q

Definition of malignant mesothelioma?

A
  • Aggressive epithelial tumour of mesothelial cells occurring in pleural (90% of times), rarely in peritoneum or other organs
55
Q

Epidemiology of malignant mesothelioma?

A
  • Incidence increasing
  • Men 3x
  • ½ over 75
56
Q

Causes of malignant mesothelioma?

A

o Exposure to asbestos (90%)
 But 20% have pulmonary asbestosis
o FHx

57
Q

Symptoms of malignant mesothelioma?

A
  • 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
58
Q

Signs of malignant mesothelioma?

A 
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
59
Q

When to refer in 2 week pathway of malignant mesothelioma?

A
  • Urgent 2-week CXR

o Pleural thickening/effusion

60
Q

Investigations to confirm diagnosis of malignant mesothelioma?

A

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

61
Q

When to offer urgent 2 week CXR for lung cancer?

A

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

62
Q

Management of malignant mesothelioma - general measures?

A

o Refer to regional mesothelioma MDT
o Compensation
o Pleural Effusions
 Talc pleurodesis OR indwelling pleural catheters if symptomatic

63
Q

Management of malignant mesothelioma - surgery?

A

 Localised (stage 1) mesothelioma

 Extra-pleural pneumonectomy OR pleurectomy with decortication

64
Q

Management of malignant mesothelioma - chemotherapy?

A

 Unressectable mesothelioma, neoadjuvant or adjuvant chemotherapy
 Pemetrexed + Cisplatin +/- Bevacizumab every 21 days improves survival

65
Q

Management of malignant mesothelioma - radiotherapy?

A

 Adjuvant after surgery or palliative

66
Q

Palliative management in mesothelioma?

A

o Palliative pleurodesis

67
Q

Prognosis of malignant mesothelioma?

A
  • Survival around 1 year
68
Q

Definition of asbestosis?

A

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

69
Q

Causes of asbestosis?

A

o Caused by inhalation of asbestos fibres

o Used in building trade for fire-proofing, pipe-lagging, electrical wire insulation and roof felting

70
Q

Types of disease in asbestosis?

A

o Benign – pleural plaques, pleural thickening, benign pleural effusions
o Interstitial – asbestosis
o Malignant – mesothelioma, lung cancer

71
Q

Types of asbestosis?

A 
o	Crocidolite (blue)
o	Amosite (brown)
o	Chrysotile (white)
72
Q

Risk factors of asbestosis?

A

o Construction workers, joiners, plumbers, electricians, painters, shipyard workers, railroad workers, asbestos miners
o Smoking

73
Q

Symptoms of asbestosis?

A

o Progressive SOB
o Reduced exercise tolerance
o Productive/Non-productive cough
o Wheeze

74
Q

Signs of asbestosis?

A

o Clubbing
o Fine-end inspiratory crackles
o Cor pulmonale

75
Q

Lung nction test findings of asbestosis?

A

o Restrictive pattern – Normal FEV1/FVC ratio but reduced FVC and FEV1

76
Q

Imaging of asbestosis?

A
  • CXR
    o May be normal or bilateral pleural plaques and thickening
  • CT Scan more sensitive than CXR
  • Lung biopsy if suspicious of malignancy
77
Q

Management of asbestosis - general measures?

A

o Stop smoking
o Vaccination (influenza and pneumococcal)
o Eligible for compensation through UK Industrial Injuries Act

78
Q

Management of asbestosis - if signs of COPD?

A

o Bronchodilators
o Pulmonary Rehabilitation
o Oxygen therapy
o Lung Transplant

79
Q

Prognosis of asbestosis?

Complications of asbestosis?

A
  • Depends on extent of lung disease, usually doesn’t progress if just asbestosis
  • Complications – malignant mesothelioma, cor pulmonale and lung cancer
80
Q

Definition of lung abscess?

A
  • Cavitating area of localised, suppurative infection within lung
  • May be single or multiple
  • Associated with necrotic cavity formation
81
Q

Causative organisms of lung abscess?

A

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

82
Q

Risk factors of lung abscess?

A 
o	Alcoholism/Drug abuse
o	DM
o	General anaesthesia
o	Stroke/Cerebral palsy
o	Immunosuppressed
o	Congenital heart disease
o	CLD - CF
83
Q

Causes of lung abscess?

A

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

84
Q

Types of lung abscess?

A

o Primary – occurs in previously normal lungs

o Secondary – patient with underlying lung abnormality

85
Q

Symptoms of lung abscess?

A 
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
86
Q

Signs of lung abscess?

A 
o	Clubbing
o	Tachypnoea
o	Tachycardia
o	Pyrexia
o	Anaemia
o	Crepitations
87
Q

Bloods to do in lung abscess?

A 
-	Bloods
o	FBC (anaemia, neutrophils)
o	ESR, CRP raised
o	U&amp;Es
o	LFTs
-	Blood cultures (including AAFB)
-	Sputum microscopy, culture and cytology (including AAFB)
88
Q

Imaging to do in lung abscess?

A
  • CXR
    o Walled cavity, often with fluid level
    o If aspiration – right more common
    o If pneumonia/bronchiectasis/septic – multiple, basal, diffuse
  • CT
89
Q

Diagnostic investigations of lung abscess?

A

Tapping fluid or empyema

Bronchoscopy for diagnostic specimens

90
Q

Management of lung abscess - general measures?

A

o Analgesia
o Oxygen
o Rehydration
o Postural Drainage

91
Q

Management of lung abscess - antibiotics?

A 
-	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
92
Q

Management of lung abscess - surgery?

A
  • Surgical excision

o Via bronchoscope, CT-guided percutaneous drainage

93
Q

Complications of lung abscess?

A

o Empyema
o Bronchiectasis
o Bronchopleural fistula
o Brain abscess, sepsis

94
Q

Definition of empyema?

A
  • Presence of frank pus in pleural space
95
Q

Epidemiology of empyema?

A
  • Mortality is 15-20%

- Men 2x

96
Q

Risk factors of empyema?

A 
o	Pneumonia
o	Iatrogenic intervention (thoracic surgery, thoracentesis, chest drain)
o	Aspiration (stroke, NG tube)
o	Immunocompromised
o	DM
o	Alcohol abuse
o	CLD
97
Q

Causative organisms of empyema?

A

o CAP – Steptococcus pneumoniae, milleri and staphylococci
 Anaerobes
o HAP – staphylococci (MRSA)

98
Q

Symptoms of empyema?

A 
o	Recent pneumonia infection
o	Fever, rigors
o	Cough – green sputum
o	Chest pain – pleuritic
o	Malaise, anorexia, weight loss
99
Q

Signs of empyema?

A

o Dullness to percuss
o Reduced breath sounds and vocal resonance
o Sepsis – pyrexia, tachypnoea, tachycardia, hypotension

100
Q

Bloods to do in empyema?

A
  • Bloods
    o FBC (raised WBC)
    o CRP (raised)
  • Blood cultures
101
Q

Imaging to do in empyema?

A
  • CXR
    o Blunt costophrenic angles, consolidation, pleurally-based ‘D’ shape
  • Thoracic US
    o Echogenic, loculated lesions
  • CT if uncertain
102
Q

Diagnostic testing to perform in empyema?

A
  • Thoracentesis
    o Pleural fluid assessment
     Frank pus, pH<7.2, protein >30g/dL, LDH raised, glucose <3.3, polymorphonuclear leucocytes, culture positive
103
Q

Management of empyema - initial treatment?

A

Urgent Thoracentesis (pleural aspiration) under US

Empirical IV Antibiotics
 If community-acquired – cefuroxime + metronidazole
 If hospital-acquired - vancomycin

Analgesia

Fluids

104
Q

Management of empyema -other management?

A

o Fibrinolytics
 If haemodynamically unstable, older or not for surgery
 Urokinase/streptokinase

o Thoracoscopic Surgery

105
Q

Management of empyema - monitoring?

A

o CXR after 4-6 weeks after discharge

106
Q

Complications of empyema?

A

o Sepsis

o Respiratory failure

107
Q

Prognosis of empyema?

A

o Some respond to antibiotics and chest drain insertion within a couple of weeks
o 30% require surgery
o Mortality 15-20%

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