Respiratory - Lung Infections Flashcards
Specifics for resp hx
Age Gender Occupation Smoking hx Asbestos exposure Pets/ birds at home Hx of childhood resp illness
Classification of resp diseases
Airways diseases Lung parenchymal diseases Pleural diseases Pulmonary vascular diseases Lung infections Lung cancer Thoracic oncology
Examples of airway diseases
Asthma
Allergic rhinitis
Examples of lung parenchymal diseases
Emphysema
ILD
What’s included in the conducting airways
Trachea
Bronchi
Bronchioles
Terminal bronchioles
What included in the acinar airways
Transitional bronchioles
Alveolar ducts
Alveolar sacs
What does the control of respiration involve
Higher brain centres, chemoreceptors and other reflexes
Common symptoms to look out for
Breathlessness
Cough
Chest pain
General inspection for resp
Pallor Jaundice Clubbing Cyanosis Oedema Lymphadenopathy Pulse and RR
Common resp ix
Pulse oximetry Lung physiology - LFTs/ PFTs Gas exchange analysis - ABG Radiological modalities - CXR, CT Bronchoscopy Pleural procedures Blood test, sputum test Urine antigens
Lung defence mechanisms
Muco-cillairy apparatus
Alveolar macrophages
Cytotoxic T cells and NK cells: intracellular pathogens
Epidemiology of CF
Most common inherited lethal disease
1 in 2500 babies born have CF
Inheritance of CF
Autosomal recessive inheritance on long arm of chromosome 7
What genes is affected in CF
CFTR gene contains code to create CFTR chloride channel
LOF mutation causes increased Na and Cl in sweat and increased reabsorption of water from resp system –> viscous mucus and dehydration of epithelium
Clinical features of CF
C/c sinusitis Abnormal sweat [Na] and [Cl] Bronchiectasis Liver disease Constipation Male infertility - loss of vas deferens Finger clubbing Pancreatic insufficiency, pancreatitis, DM
The Sweat test
Pads soaked in pilocarpine are placed on skin to stimulate sweat
Sweat is collected then amount of chloride is measure - should be high to get a +ve result
Dx and ix for CF
Clinical assessment and examination Oxygen saturations Resp secretions samples LFT - FEV1, FVC, FEF Infant screening test - trypsinogen
Aims of CF treatment
Prevent or delay serious lung problems
Maintain lung function and clinical stability for long periods
Symptoms associasted w. exacerbation of pulmonary infection
Increased frequency and duration of cough
Increased sputum production
Increased SOB
Decreased exercise tolerance
Decreased appetite
Feeling of increased congestion in the chest
Signs associated w/ exacerbation of pulmonary infection
Increased RR Use of accessory muscles for breathing Fever and leukocytosis Wt loss New infiltrate on CXR
Prophylactic abx given for Staph A
Fluclox
Treatment of Staph A infections
Fluclox
Co-amoxiclav
Mx of Psuedomonas A
Needs combo of nebuliser and systemic abx
Nebulised - 3/12 of nebuliser Colistin OR 1/12 of individual abx
PLUS
Systemic: 3/52 of po Ciprofloxacin (or 3/52 of iV ceftazidime/ Tobramycin)
Treating a/c infections of Aspergillus
Antifungals
Treatment of ABPA
Steroids and antifungals
ABPA
Allergic Bronchopulmonary Aspergillosis
When would we give mucolytics and hydrators
Impaired muco-cilairy clearance
Decreased airway surface liquid volume
Secretions that are difficult to expectorate
Mucus degrading agent used in CF
Dornase alfa
Long-term maintenance therapy is required
Practical issues of dornase alfa
Given via nebuliser
Expensive - hosp prescription
Given at least 30 mins - 1hr before PT
What does hypertonic saline do
Expectorant
Increases thickness of ASL
Promotes coughing
ASL
Airway Surface Layer
Order of inhaled medicines
Bronchodilator
Mucolytics
Airways clearance
Inhaled abx
How is pancreatic insufficiency assessed in CF pts
Clinically
By stool elastase
Dietary mx of CF pts
Start on lifelong PERT
Regular growth monitoring
Fat soluble Vit supplementation - A, D, E, K
Higher caloric needs
Ionising ix of lung
CXR
CT
Nuclear med
Conventional angiography
Non-ionising ix of lung
MRI
Ultrasound
VQ scan
Ventilation/ perfusion scan
Inhaling radioactive material to examine airflow and blood flow in lungs
Usually looking for PE
When are pts most likely to have a PET scan
When they are candidates for surgery - to complete staging
Use of MRI in resp med
Charcterising mediastinal masses
Paravertebral masses (neurogenic tumours)
Monitoring of thoracic aneurysms
Use of ultrasound in resp med
Detects pleural abnormalities
Probe can be placed in IC space
What types of imaging are used in image-guided biopsy or drainage
Ultrasound
CT
Collapse (atelectasis)
Reduction of volume in various parts of lung
Obstruction or compression
AP vs PA CXRs
Cannot see scapula in PA view
Postero-anterior is preferred over antero-posterior
Silhouettes of CXR
Image margins or areas of contrast where structures that are bordering have a clear delineation
Is loss of silhouette shadowing on CXR normal
No
Normal silhouette on CXR
Lung, heart and hemipericardium border
Silhouette sign on CXR
Increased shadowing of interface of lung and heart border
What does the silhouette sign on a CXR indicate
Abnormalily - loss of normal silhouette
Clinical definitions of consolidation
Dull to percussion
Reduced breath sounds
Bronchial breathing
Histopathological definition of consolidation
Filling of the alveolar spaces w/ pus, water, blood, tumour or protein
Air space opacity on CXR
Abnormal density in areas that should normally be aerated in X-ray contrast
Air bronchogram
Part of lung is consolidated - alveoli filled w/ fluid but larger airways are patent
Radiological definition of consolidation
Presence of air bronchogram
Types of loss of lung volume
Lung
Lobar
Segmental
Subsegmental
Diagnosing loss of volume of X-ray
Mediastinal shift - main factor Tracheal deviation Elevation of diaphragm Displaced hilum Rib crowding
Hilar point on CXR
Angle between lower lobe & pulmonary artery and upper lobe & pulmonary vein
Other patterns of consolidation
Diffuse Multifocal Perihilar - Bat's wing Bibasal Peripheral
Contusion
An injury to the lung parenchyma (bruised) leading to haemorrhage and oedema
What is pneumonia caused by
Invasion and overgrowth of pathogens in lung parenchyma
Symptoms of pneumonia
Dyspnoea - harsh breathing sounds Fever Rigours Shaking chills Dry/ productive cough Chest pain Malaise
Pathophysiology of pneumonia
Infection to the lung initiates an infl response
Causing alveolar oedema + exudate formation
Alveoli & resp bronchioles fill w/ serous exudate, blood cells, fibrin bacteria
Consolidation of lung tissues
Pathogen factors affecting infection
Virulence factors
Host factors affecting infection
Innate immunity - physical-mechanical, complement
Phagocytes - macrophages, neutrophils
Cellular immunity - B cells, T cells
Cytokine, chemokine
Environmental factors affecting infection
Travel, occupation Medical devices (ventilators)
Pneumonia classification
Community (CAP)
Hosp (HAP)
Immune compromised
Age group affected in CAP
All ages
Classic infection seen in CAP
Bacterial or viral
When does HAP occur
2-3 days after admission
Who gets immuno-compromised pneumonia
HIV pts
Transplant pts
Cancer pts
1’ immunodeficiency pts
CAP epidemiology
6th leading cause of death in world
Leading cause of death due to infectious diseases
Highest incidence <5yrs and >65yrs - incidence increases w/ age and in winter
Resp tract bacterial pathogens
Strep pyogenes
Strep pneumonia
H. influenza
Bacterial/ viral pathogens causing CAP
Strep pneumonia and H. influenza cause 85% of cases
Moraxella catarrhalis
Influenza - Staph A
Resp viruses
Atypical bacteria causing CAP
Chlamydia psittaci Coxiella birmetoo - Q fever Mycoplasma pneumonia Legionnaire's disease Mycobacterium TB
DDx signs of pneumonia
Sputum
Halitosis
General appearance
Haemoptysis
Most common symptoms of bacterial pneumonia
Productive cough
How can colour of sputum help suggest pathogen
Rust (S. Pneumoniae)
Green (Pseudomonas)
Redcurrant (Klebsiella)
Bad-smelling (anaerobes)
What is a sudden onset on pneumonia symptoms associated with
Bacterial infection
What is slow onset of URTI and wheezing associated w/ in pneumonia
Viral infection
Who gets pneumococcal pneumonia
V young and v elderly
People w/ asplenia or functional asplenia
People w/ other cases of impaired immunity and certain c/c condns
What is lobular pneumonia likely to progress to in pneumococcal pneumonia
Empyema or pleural effusion if treated insufficiently
Empyema
Collection of pus in pleura
How many serotypes are there of pneumococcal pneumonia
90
Vaccines against pneumococcal pneumonia
13-valent pneumococcal conjugate vaccine - intro childhood immunisation in 2010
23-valent pneumococcal polysaccharide vaccine
What months do pneumococcal pneumonia peaks in
Dec and Jan
CURB-65
Tool used to determine whether pts w/ pneumonia should be admitted or not
Confusion Urea >7mmol/l RR > 30 BP < 90/60 mmHg Age > 65
CURB-65 score of 0-1
Low severity
<3% mortality
Treatment at home if 0 or hosp If 1
Ix for CAP
CXR
Sputum culture - viral throat swabs
Hospitilisation
Resp virus PCR and further bloods - CRP/ESR, serology
When do abx need to be started for CAP
Within 4 hrs of admission
Treatment for moderate/severe CAP
Empirical therapy (dual) - penicillin (amoxicillin, tazobactam) and macrolide (clarithromycin) Antivirals --> oseltamovir for 7/7 (but within 3/7 - 5/7 of start of symptoms)