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
2
Q
Epidemiology of bronchiectasis?
A
- Incidence increasing – 1 in 200
- Women > Men
- Increases with age
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
4
Q
Symptoms of bronchiectasis?
A
o Chronic productive cough – copious purulent sputum (foul-smelling, green)
o Recurrent infections
o SOB, wheeze, haemoptysis
5
Q
Signs of bronchiectasis?
A
o Clubbing
o Coarse inspiratory crepitations
o Wheeze
6
Q
Infective exacerbation of bronchiectasis?
A
o Worsening cough
o Increased sputum volume, viscosity, purulence
o Increased breathlessness
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
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
9
Q
Management of bronchiectasis - general advice?
A
- Refer to respiratory consultant
- Annual pneumococcal and influenza vaccine
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
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
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
13
Q
Management of bronchiectasis - step 2?
A
o Reassess physio
o Add carbocysteine
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
15
Q
Management of bronchiectasis - Step 4?
A
o Long term macrolide and long term inhaled antibiotics
16
Q
Management of bronchiectasis - Step 5?
A
o Regular IV antibiotics every 2-3 months
- Consider transplant
17
Q
When to move up in management of bronchiectasis?
A
- Move up steps if 3 or more exacerbations per year
18
Q
Prognosis of bronchiectasis?
A
o Normal life expectancy
o Most have few symptoms
o Worse prognosis associated with extensive disease, smokes
19
Q
Complications of bronchiectasis?
A
o Pneumonia
o Pneumothorax/Rib fractures
o Respiratory Failure
o RHF
20
Q
Definition of carbon monoxide poisoning?
A
• Colourless, odourless, tasteless gas produced by incomplete combustion of fuels
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
22
Q
Sources of carbon monoxide poisoning?
A
- Poorly installed/maintained/faulty chimneys, gas ovens, boilers, engines
- Smoke in burning buildings
- Paint removers
- Aerosol
23
Q
Risk groups of carbon monoxide poisoning?
A
- Old people
- Children
- Pregnant women
- Resipratory or cardiovascular disease
- Anaemia
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
25
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
26
Prevention of carbon monoxide poisoning?
* Fit Carbon Monoxide alarm
* Chimney swept at least once a year
* Keep rooms well ventilated while using gas appliances
27
Complications of carbon monoxide poisoning?
• Apathy, apraxia, dementia, disorientation, unable to concentrate, irritability, personality changes, psychosis
28
Definition of idiopathic pulmonary fibrosis?
- Commonest cause of interstitial lung disease
| - Inflammatory cell infiltrate and acute fibroblastic proliferation leading to collagen deposition
29
Epidemiology of idiopathic pulmonary fibrosis?
- Men
- Age of onset 60 years
- 40% of all interstitial lung disease
30
Risk factors of idiopathic pulmonary fibrosis?
o Smoking
o Familial
o Chronic viral infections – Hep C, EBV
31
Symptoms of idiopathic pulmonary fibrosis?
```
o Dry Cough
o Exertional dyspnoea
o Malaise
o Low weight
o Arthralgia
```
32
Signs of idiopathic pulmonary fibrosis?
o Cyanosis
o Finger Clubbing
o Fine end-inspiratory crepitations
33
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
34
Investigations if diagnosis cannot be made for idiopathic pulmonary fibrosis?
- Bronchoalveolar lavage or transbronchial biopsy
- Surgical biopsy
o Usual interstitial pneumonia
35
Management of idiopathic pulmonary fibrosis - initial information?
o Lung Transplant 3-6 months after diagnosis
| o Ventilation has poor outcomes with IPF
36
Management of idiopathic pulmonary fibrosis - assess prognosis?
o Using LFTs at diagnosis and 6 and 12 months after diagnosis
37
Management of idiopathic pulmonary fibrosis -pulmonary rehabilitation?
o Assess eligibility using 6-minute walk test and QoL assessment at diagnosis, 6 and 12 months
38
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
39
Management of idiopathic pulmonary fibrosis - further management?
- Lung transplant
| - Palliative Care
40
Management of idiopathic pulmonary fibrosis - follow up?
- Follow-up every 3-6 months
| o Assess lung function, oxygen therapy, smoking status, exacerbations
41
Management of idiopathic pulmonary fibrosis -prognosis?
o 50% 5-year survival rates
42
Management of idiopathic pulmonary fibrosis - complications?
o Respiratory failure
| o Increased risk of lung cancer
43
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
44
Definition of progressive massive fibrosis?
o Progression of CWP, causes progressive SOB, fibrosis and eventually cor pulmonale
45
Definition of Caplan's syndrome?
o Associated between RA, pneumoconiosis and pulmonary rheumatoid nodules
46
Epidemiology of coalworkers' pneumoconiosis?
- High in countries with or had coal mines
| - Males
47
Risk factore of coalworkers' pneumoconiosis?
o Coal workers
| o Smoking
48
Symptoms of coalworkers' pneumoconiosis?
o Asymptomatic
o SOB exertional
o Cough – black sputum
49
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
50
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
51
Management of coalworkers' pneumoconiosis - general measures?
o Notifiable industrial disease
o Compensation via UK Industrial Act
o Avoid exposures
o Stop Smoking
52
Management of coalworkers' pneumoconiosis - if SOB or hypoxic?
o Pulmonary rehabilitation
| o Oxygen therapy
53
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
```
54
Definition of malignant mesothelioma?
- Aggressive epithelial tumour of mesothelial cells occurring in pleural (90% of times), rarely in peritoneum or other organs
55
Epidemiology of malignant mesothelioma?
- Incidence increasing
- Men 3x
- ½ over 75
56
Causes of malignant mesothelioma?
o Exposure to asbestos (90%)
But 20% have pulmonary asbestosis
o FHx
57
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
```
58
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
```
59
When to refer in 2 week pathway of malignant mesothelioma?
- Urgent 2-week CXR
| o Pleural thickening/effusion
60
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
61
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
62
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
63
Management of malignant mesothelioma - surgery?
Localised (stage 1) mesothelioma
| Extra-pleural pneumonectomy OR pleurectomy with decortication
64
Management of malignant mesothelioma - chemotherapy?
Unressectable mesothelioma, neoadjuvant or adjuvant chemotherapy
Pemetrexed + Cisplatin +/- Bevacizumab every 21 days improves survival
65
Management of malignant mesothelioma - radiotherapy?
Adjuvant after surgery or palliative
66
Palliative management in mesothelioma?
o Palliative pleurodesis
67
Prognosis of malignant mesothelioma?
- Survival around 1 year
68
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
69
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
70
Types of disease in asbestosis?
o Benign – pleural plaques, pleural thickening, benign pleural effusions
o Interstitial – asbestosis
o Malignant – mesothelioma, lung cancer
71
Types of asbestosis?
```
o Crocidolite (blue)
o Amosite (brown)
o Chrysotile (white)
```
72
Risk factors of asbestosis?
o Construction workers, joiners, plumbers, electricians, painters, shipyard workers, railroad workers, asbestos miners
o Smoking
73
Symptoms of asbestosis?
o Progressive SOB
o Reduced exercise tolerance
o Productive/Non-productive cough
o Wheeze
74
Signs of asbestosis?
o Clubbing
o Fine-end inspiratory crackles
o Cor pulmonale
75
Lung nction test findings of asbestosis?
o Restrictive pattern – Normal FEV1/FVC ratio but reduced FVC and FEV1
76
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
77
Management of asbestosis - general measures?
o Stop smoking
o Vaccination (influenza and pneumococcal)
o Eligible for compensation through UK Industrial Injuries Act
78
Management of asbestosis - if signs of COPD?
o Bronchodilators
o Pulmonary Rehabilitation
o Oxygen therapy
o Lung Transplant
79
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
80
Definition of lung abscess?
- Cavitating area of localised, suppurative infection within lung
- May be single or multiple
- Associated with necrotic cavity formation
81
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
82
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
```
83
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
84
Types of lung abscess?
o Primary – occurs in previously normal lungs
| o Secondary – patient with underlying lung abnormality
85
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
```
86
Signs of lung abscess?
```
o Clubbing
o Tachypnoea
o Tachycardia
o Pyrexia
o Anaemia
o Crepitations
```
87
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)
```
88
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
89
Diagnostic investigations of lung abscess?
Tapping fluid or empyema
Bronchoscopy for diagnostic specimens
90
Management of lung abscess - general measures?
o Analgesia
o Oxygen
o Rehydration
o Postural Drainage
91
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
```
92
Management of lung abscess - surgery?
- Surgical excision
| o Via bronchoscope, CT-guided percutaneous drainage
93
Complications of lung abscess?
o Empyema
o Bronchiectasis
o Bronchopleural fistula
o Brain abscess, sepsis
94
Definition of empyema?
- Presence of frank pus in pleural space
95
Epidemiology of empyema?
- Mortality is 15-20%
| - Men 2x
96
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
```
97
Causative organisms of empyema?
o CAP – Steptococcus pneumoniae, milleri and staphylococci
Anaerobes
o HAP – staphylococci (MRSA)
98
Symptoms of empyema?
```
o Recent pneumonia infection
o Fever, rigors
o Cough – green sputum
o Chest pain – pleuritic
o Malaise, anorexia, weight loss
```
99
Signs of empyema?
o Dullness to percuss
o Reduced breath sounds and vocal resonance
o Sepsis – pyrexia, tachypnoea, tachycardia, hypotension
100
Bloods to do in empyema?
- Bloods
o FBC (raised WBC)
o CRP (raised)
- Blood cultures
101
Imaging to do in empyema?
- CXR
o Blunt costophrenic angles, consolidation, pleurally-based ‘D’ shape
- Thoracic US
o Echogenic, loculated lesions
- CT if uncertain
102
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
103
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
104
Management of empyema -other management?
o Fibrinolytics
If haemodynamically unstable, older or not for surgery
Urokinase/streptokinase
o Thoracoscopic Surgery
105
Management of empyema - monitoring?
o CXR after 4-6 weeks after discharge
106
Complications of empyema?
o Sepsis
| o Respiratory failure
107
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%
