RESPIRATORY MEDICINE Flashcards
high-risk characteristics are defined as follows:
For pneumothorax
haemodynamic compromise (suggesting a tension pneumothorax)
significant hypoxia
bilateral pneumothorax
underlying lung disease
≥ 50 years of age with significant smoking history
haemothorax
the lifetime risk of developing a pneumothorax in healthy smoking men is around 10% compared with around 0.1% in non-smoking men
Fitness to fly
absolute contraindication, the CAA suggest patients may travel 2 weeks after successful drainage if there is no residual air. The British Thoracic Society used to recommend not travelling by air for a period of 6 weeks but this has now been changed to 1 week post check x-ray
Scuba diving post pneumothorax
Diving should be permanently avoided unless the patient has undergone bilateral surgical pleurectomy and has normal lung function and chest CT scan postoperatively.’
Lower lung zone fibrosis
Drug induced - amiodarone
Coal workers pneumoconiosis affect *** lung zones
Ankylosing spondylitis
Connective tissue disorders
Silicosis
Upper lung zones
Acronym for causes of upper zone fibrosis:
CHARTS
C - Coal worker’s pneumoconiosis
H - Histiocytosis/ hypersensitivity pneumonitis
A - Ankylosing spondylitis
R - Radiation
T - Tuberculosis
S - Silicosis/sarcoidosis
Fibrosis predominately affecting the lower zones
idiopathic pulmonary fibrosis
most connective tissue disorders (except ankylosing spondylitis) e.g. SLE
drug-induced: amiodarone, bleomycin, methotrexate
asbestosis
Dyspnoea, obstructive pattern on spirometry in patient with rheumatoid → ?
bronchiolitis obliterans
Restrictive pattern
Methotrexate pneumonitis
Pulmonary Fibrosis
PEF Variability
with a >20% variation in PEF between morning and evening values, supports the diagnosis of asthma and highlights its dynamic, reversible nature.
Diseases that restrict lung expansion like *** may reduce FVC
fibrosis or pneumonia
neurological manifestations of sarcoidosis (neurosarcoidosis) require immediate management with steroids.
Both unilateral and bilateral facial nerve palsy are common manifestations of neurosarcoidosis.
As per the Scadding criteria, perihilar lymphadenopathy on chest X-ray is stage 1 pulmonary sarcoidosis
Sarcoidosis
malt workers’ lung:
Aspergillus clavatus
farmers lung:
spores of Saccharopolyspora rectivirgula from wet hay , (formerly Micropolyspora faeni)
Causes of upper zone pulmonary fibrosis:
Coal workers pneumoconiosis
Hypersensitivity pneumonitis, histiocytosis
Ankylosing spondylitis
Radiation
Tuberculosis
Silicosis, sarcoidosis
Causes of lower zone pulmonary fibrosis:
Most connective tissue diseases (e.g. rheumatoid arthritis)
Asbestosis
Idiopathic pulmonary fibrosis
Drugs (e.g. methotrexate)
The most common organism causing infective exacerbations of COPD is
Haemophilus influenzae
patients with a secondary spontaneous pneumothorax that is managed conservatively should be
monitored as an inpatient
is a subset of sarcoidosis: a combination of parotid enlargement, fever, and anterior uveitis.
Heerfordt syndrome
CF diet
High calorie and high fat with pancreatic enzyme supplementation for every meal. Patients with cystic fibrosis (CF) have an increased energy requirement due to the chronic inflammation and infection associated with their disease. The UK Cystic Fibrosis Trust’s nutritional guidelines recommend a high-energy, high-fat diet to meet these needs. Additionally, CF patients often suffer from pancreatic insufficiency which leads to malabsorption of nutrients, especially fat. Therefore, they require pancreatic enzyme replacement therapy (PERT) with every meal and snack to aid digestion and absorption of nutrients.
chronic infection with *** is an important CF-specific contraindication to lung transplantation
Burkholderia cepacia
Chest x-ray: cavitating lung lesion
Differential
abscess (Staph aureus, Klebsiella and Pseudomonas)
squamous cell lung cancer
tuberculosis
Wegener’s granulomatosis
pulmonary embolism
rheumatoid arthritis
aspergillosis, histoplasmosis, coccidioidomycosis
, characterised by clustered cystic air spaces with thickened walls, is indeed a classic sign of advanced IPF. However, this finding develops later in the disease process and thus would not be expected to present first.
Honeycombing
Erythromycin, and the macrolide class of antibiotics, are second-line options for treating ****. Doxycycline remains first-line.
psittacosis
*** is an uncommon and rather complex clinical condition which occurs due to endometrial tissues and is generally encountered in reproductive women. The mean ages are between 32-35 years old. In most of the cases, it involves the right side presenting with shortness of breath or difficulty breathing, fatigue, and dry cough. It can produce monthly episodes of chest pain which may radiate to the shoulder.
Catamenial pneumothorax
*** is stress-induced cardiomyopathy (either physical or emotional) which results in the weakening of the left ventricular muscle and characteristically produces an apical ballooning of the heart. It can give symptoms of chest pain and shortness of breath
Takotsubo cardiomyopathy
Anti GBM
Good Pasteur’s disease
Leukotriene receptor antagonists may trigger eosinophilic granulomatosis with polyangiitis (
Churg-Strauss syndrome)
IV Aminophyllin has narrow therapeutic index
Can Cause arrhythmia and seizures
Alpha 1 antitrypsin deficiency inherited in an
autosomal recessive / co-dominant fashion*
Investigations
A1AT concentrations
spirometry: obstructive picture
Management
no smoking
supportive: bronchodilators, physiotherapy
intravenous alpha1-antitrypsin protein concentrates
surgery: lung volume reduction surgery, lung transplantation
bluish-red nodules and plaques over the nose and cheeks which is lupus pernio+ Hypercalcaemia + bilateral hilar lymphadenopathy
Sarcoidosis
While***** can cause bilateral hilar lymphadenopathy on chest X-ray, it typically presents with a more characteristic pattern of upper lobe fibrosis with nodules
silicosis
A longer smoking history (typically 20+ pack-years) is a stronger risk factor for developing SCLC
Squamous cell lung cancer
***** is a common pathogen in bronchiectasis and cystic fibrosis. It is a common cause of hospital-acquired pneumonia, especially in those patients in the ITU on a ventilator., ‘ground-glass’ attenuation can often be noticed on a CT scan.
Pseudomonas aeruginosa
***** causes flu-like symptoms such as a headache, arthralgia and myalgia followed by a dry cough which are not seen in this case. Chest X-ray often shows patchy consolidation of one lower lobe.
Mycoplasma pneumoniae
****. also causes flu-like symptoms such as fever, myalgia. It can also cause extra-pulmonary symptoms such as hepatitis, diarrhea and vomiting. Bi-basal consolidation can be seen on chest X-ray.
Legionella pneumophilia
Staphylococcus aureus is often seen in intravenous drug users (IVDU), young, elderly or people with an underlying disease such as leukemia or cystic fibrosis.
A pH less than*** likely represents carbon dioxide retention in a tiring patient and is an ominous sign in acute asthma.
7.35
patients who manifest disease usually have PiZZ genotype
Alpha 1 antitrypsin deficiency
Aspergillus clavatus causes malt workers’ lung, a type of EAA
mushroom workers’ lung: thermophilic actinomycetes*
Sarcoidosis steroid Rx ?
Indications for corticosteroid treatment for sarcoidosis are: parenchymal lung disease, uveitis, hypercalcaemia and neurological or cardiac involvement
patients with chest x-ray stage 2 or 3 disease who are symptomatic.
2ndary pneumothorax
COPD patients, particularly those with advanced disease, may not present with overt signs of distress even when their secondary pneumothorax is worsening. Therefore, inpatient monitoring is warranted to detect any changes in clinical status that could require escalation of care, such as the need for a chest drain or even more invasive interventions.
Primary spontaneous pneumothorax
Discharge with follow-up in 1-2 days would be appropriate for primary spontaneous pneumothorax in a young, otherwise healthy individual
is a common cause of secondary bacterial pneumonia following influenza A infection.
Staphylococcus aureus
COPD exacerbation admission guidelines
Admission is recommended if any of the following criteria are met
severe breathlessness
acute confusion or impaired consciousness
cyanosis
oxygen saturation less than 90% on pulse oximetry.
social reasons e.g. inability to cope at home (or living alone)
significant comorbidity (such as cardiac disease or insulin-dependent diabetes)
Levels > 30g/L suggest an exudate. Protein
Pleural fluid protein
A transudative pleural effusion is defined by a pleural fluid protein level < 30g/L.
Heart failure, hypoalbuminemia, nephrotic syndrome
Unmasking of Churg-Strauss syndrome:
Montelukast
asthma, eosinophilia, presence of mono-/polyneuropathy, flitting pulmonary infiltrates, paranasal sinus abnormalities and histological evidence of extravascular eosinophils
EGPA
** is a small vessel vasculitis that also affects the lungs and kidneys. Its presentation can often be with constitutional symptoms such as weight loss, lethargy and low-grade fever, though in advanced disease it can progress to haemoptysis and renal failure. Perinuclear anti-cytoplasmic antibodies (p-ANCA) is often positive and renal biopsy will reveal focal segmental glomerulonephritis.
Microscopic polyangiitis
The triad of asthma, nasal polyposis and salicylate sensitivity is eponymously known as
Samter’s triad
LTRA s/e
Hepatic impairment
Church Strauss syndrome unmasking
Depression, suicidal ideation
Organisms which may colonise CF patients
Staphylococcus aureus
Pseudomonas aeruginosa
Burkholderia cepacia*
Aspergillus
results from an allergy to Aspergillus spores. In the exam questions often give a history of BRONCHIECTASIS and EOSINOPHILIA .
Allergic bronchopulmonary aspergillosis
Loeffler syndrome is associated with evidence of tropical infections
history of foreign travel here
syndrome is associated with eosinophilia but tends to cause a rash and systemic upset such as a fever.
DRESS
Common indications for lung transplantation referral for patients with CF include
life-threatening exacerbation requiring ICU admission,
pulmonary hypertension,
FEV1 less than 30% of predicted,
recurrent exacerbations requiring antibiotic therapy,
recurrent and/or refractory pneumothorax, and recurrent haemoptysis not controlled by embolisation.
Idiopathic Pulmonary Fibrosis
honeycombing, reticular opacities, traction bronchiectasis, and architectural distortion on the base of lung
GGO not usually found,
Respiratory alkalosis causes
Common causes
anxiety leading to hyperventilation
pulmonary embolism
salicylate poisoning*
CNS disorders: stroke, subarachnoid haemorrhage, encephalitis
altitude
pregnancy
Salicylate overdose
Early respiratory alkalosis, and then metabolic acidosis
Asbestosis CT FINDINGS
Intralobular, small, rounded and branching opacities; thickened interlobular septa; pleural plaques
High urate levels in pneumonia
This is because elevated blood urea nitrogen levels indicate dehydration or reduced renal perfusion, both of which can lead to increased mortality
severe hyponatraemia can be associated with poor outcomes in CAP due to its link with ****infection
Legionella pneumophila
Confusion AMT score ?
</= 8/10
Rectal prolapse in CF
Rectal prolapse, where part or all of the wall of the rectum slides out of place, sometimes sticking out of the anus, can occur in children with cystic fibrosis due to frequent coughing and high stool burden secondary to pancreatic insufficiency causing increased intra-abdominal pressure.
Drug induced lupus
Drug-induced lupus erythematosus (DILE) is a rare adverse reaction seen more commonly with certain classes of medications such as hydralazine, procainamide, and isoniazid
varenicline or bupropion
Smoking cessation
Smoking and pregnancy
All women who smoke, or have stopped smoking within the last 2 weeks, or those with a CO reading of 7 ppm or above should be referred to NHS Stop Smoking Services.
Despite a normal chest x-ray an ex-smoker with shortness of breath, weight loss and hyponatraemia should be investigated on an urgent basis for lung cancer.
is a cause of lung disease and lung fibrosis but pathology is found throughout the lung fields.
Marijuana
**** is incorrect as this condition is characterised by transient pulmonary infiltrates associated with peripheral eosinophilia, typically occurring in response to parasitic infections. While it can cause respiratory symptoms,
Loffler’s syndrome
Exercised induced asthma
Exercise-Induced Bronchoconstriction: LTRAs are also used in patients with exercise-induced bronchoconstriction (EIB), reducing symptoms by preventing the leukotriene-mediated bronchoconstriction.
Serum ACE is used in diagnosis of
Sarcoidosis
Mucosal oedema and mucus plugging
Chronic bronchitis and asthma
Emphysema pathogenesis
destruction of alveolar walls secondary to proteinases. This is the fundamental pathophysiological mechanism underlying emphysema. The condition primarily results from an imbalance between proteases (particularly neutrophil elastase) and antiproteases (mainly alpha-1 antitrypsin) in the lung tissue. This imbalance leads to the breakdown of elastin and other structural proteins in the alveolar walls, causing permanent destruction of the air spaces distal to the terminal bronchioles. The result is decreased elastic recoil, air trapping, and reduced gas exchange surface area.
**** are commonly used in various industries, including automotive, paint manufacturing, and furniture production. They are known to be potent respiratory sensitizers and have been identified as one of the most common causes of occupational asthma.
Isocyanates
Most common organisms isolated from patients with bronchiectasis:
Haemophilus influenzae (most common)
Pseudomonas aeruginosa
Klebsiella spp.
Streptococcus pneumoniae
Calcification is seen with******* as well as metastases from papillary thyroid carcinoma.
osteosarcomas and chondrosarcomas
Adenocarcinoma is seen as
Consolidation in chest x ray
Cavitation in chest x ray is associated with ***** cancer
Squamous cell ca
occur with choriocarcinoma and angiosarcoma.
Haemorrhagic pulmonary metastases
A miliary pattern of metastases is visualised with
renal cell carcinoma and malignant melanoma.
Contra indications to CF Lung transplant
absolute contraindications include systemic sepsis and failure to identify an appropriate antibiotic regimen for treatment.
Chronic infection with Burkholderia cepacia is an important CF-specific contraindication to lung transplantation
Kartagners syndrome is not associated with
Malabsorption, as ciliary dyskinesia is restricted to respiratory endothelium rather than gut
Bilateral hilar lymphadenopathy
Bilateral hilar lymphadenopathy
The most common causes of bilateral hilar lymphadenopathy are sarcoidosis and tuberculosis.
Other causes include:
lymphoma/other malignancy
pneumoconiosis e.g. berylliosis
fungi e.g. histoplasmosis, coccidioidomycosis
Silica exposure has been found to be causing increased risk of
TB
Crocidolite (blue) asbestos is the most dangerous form
A normal FEV1/FVC ratio and total lung capacity with low diffusing capacity are indicative of conditions that compromise effective gas exchange while ventilation remains preserved. These include disorders affecting pulmonary perfusion like chronic pulmonary embolism and alveolar gas exchange issues such as thickening alveolar walls seen in pulmonary fibrosis.
LTOT should be offered to patients with
a pO2 of < 7.3 kPa or to those with a pO2 of 7.3 - 8 kPa and one of the following:
secondary polycythaemia
nocturnal hypoxaemia
peripheral oedema
pulmonary hypertension
Patients typically present with a cough, shortness of breath, fever and malaise. Symptoms can be present for weeks or months. There is often a history of non-response to antibiotics. Haemoptysis is rare. Clinical examination is often normal but inspiratory crackles can be heard. Wheeze and clubbing are rare.
Bloods show a leukocytosis and an elevated ESR and CRP. Imaging typically shows bilateral patchy or diffuse consolidative or ground glass opacities. Lung function tests are most commonly restrictive but can be obstructive or normal. The transfer factor is reduced.
Treatment is watch and wait if mild or high dose oral steroids if severe.
COP
Cryptogenic organizing pneumonia (COP) is a diffuse interstitial lung disease that affects the distal bronchioles, respiratory bronchioles, alveolar ducts and alveolar walls
Adenocarcinoma lung
Non smoker
Either mets from other adenocarcinoma
Alveolar cell carcinomas are rare and usually present with a productive cough with copious sputum and fluffy infiltrates on chest x-ray.
Vital capacity normal range
Vital capacity - 4,500ml in males, 3,500 mls in females
