Respiratory medicine Flashcards
1
Q
Definition of COPD
A
A disease state characterised by airflow limitation that is not full reversible, is progressive and associated with an abnormal inflammatory response of the lungs to noxious particles or gases
2
Q
Definition of emphysema
A
Abnormal permanent enlargement of the air spaces distal to the terminal bronchioles with destruction of alveolar walls without fibrosis
3
Q
Definition of chronic bronchitis
A
Persistent cough with sputum production for at least 3 months in at least 2 consecutive years
4
Q
Pathophysiology of COPD
A
Smoking - inc. neutrophils - elastases and proteases released - emphysema (breakdown of alveolar wall etc.)
a1-antitrypsin inactivated by cigarette smoke - imbalance between protease and antiprotease activity
5
Q
Emphysema classifications
A
According to site of damage:
CENTRI-ACINAR emphysema:
- destruction concentrated around respiratory bronchioles
- distal alveolar ducts and alveoli tend to be preserved
- extremely common form, not always associated with disability
PAN-ACINAR emphysema:
- less common
- distension and destruction of WHOLE acinus (area supplied by terminal bronchiole)
- associated with a1-antitrypsin deficiency
IRREGULAR emphsema:
- patchy scarring and damage of lung parenchyma
6
Q
Cause of airflow limitation in COPD
A
Reduced elasticity due to emphysema - red. recoil - collapse of airway during expiration
Inflammation and scarring - narrow airway
Mucus plugging of smaller airways
ALL CAUSE V/Q MISMATCH
7
Q
Clinical features of COPD
A
Productive cough Wheeze SOB Frequent infective exacerbations If severe: - cyanosis - pursed lip breathing, accessory muscles - tachypnoea with prolonged expiration - intercostal recession - hyperinflated chest - reduced chest expansion - loss of normal cardiac and liver dullness to percussion
8
Q
Investigations in COPD
A
FEV1:FVC less than 0.8 Reduced PEF May be partly reversible (less than 12%) CXR: - often normal - overinflation of lungs, low flattened diaphragms - sometimes large bullae - large proximal blood vessels, relatively little blood visible in peripheries
9
Q
Management of COPD
A
COPD-X guidelines: C: confirm diagnosis and severity O: optimise function P: prevent deterioration D: Develop support (therapeutic relationship, MultiD care, action plans, support group) X: manage exacerbations
10
Q
Assessing severity in COPD
A
FEV1/FVC less than 70% in all, class according to % predicted Mild: over 80% predicted Moderate: less than 80% predicted Severe: less than 50% predicted Very severe: less than 30% predicted
(Mod: breathlessness on walking, cough and sputum, Severe: SOB on minimal exertion, daily activities severely curtailed, chronic cough)
11
Q
Optimising function in COPD
A
Goals: active therapy v palliative v terminal
Relievers: SABA, SAMA (ipratropium bromide)
Preventers: LAMA (tiotropium) LABA (indacterol - OD, salmeterol - BD)
ICS: consider if mod-sev and frequent exacerbations
Non-pharm: physical activity, pulmonary rehab, chest physio, smoking cessation, nutrition
Management of co-morbidities
12
Q
Preventing deterioration in COPD
A
Smoking cessation
Immunisations: annual influenza, pneumococcal
+/- Mucolytic agents (N-acetylsysteine)
Oxygen therapy if hyopxaemia
13
Q
Management of COPD exacerbations
A
Early diagnosis
Inhaled bronchodilators
Systemic corticosteroids
Antibiotic therapy (if clinical signs of infection)
Controlled O2 delivery
NIPPV for acute hypercapnie venitlator failure
14
Q
Complications of COPD
A
Respiratory failure
Cor pulmonale (Pulmonary HTN)
Fluid retention and peripheral oedema secondary to renal hypoxia
15
Q
Definition of asthma
A
A chronic inflammatory condition of the airways characterised by reversible airflow limitation, airway hyper-responsiveness to a wide range of stimuli and bronchial inflammation
16
Q
Epidemiology of asthma
A
Peak age of 1st presentation = 3y
M:F 2:1 in childhood, 1:1 by adulthood
affects up to 15% children, 10% adults
More common in developed countries
17
Q
Assessing severity of asthma
A
Intermittent:
- less than weekly daytime sx
- less than 2 night-time sx per month
- infrequent, brief exacerbations
- FEV1 80% predicted, variability less than 20%
Mild persistent:
- more than weekly, not daily daytime sx
- less than weekly night-tin sx
- occasional exacerbations, may affect activity or sleep
- FEV1 80% predicted, 20-30% variability
Moderate persistent:
- daily symptoms
- night-time sx weekly or more
- occassional exacerbations may affect sleep or activity
- FEV1 60-80% predicted, variability over 30%
Severe persistent:
- daily symptoms, restricting physical activity
- frequent night-time symptoms
- frequent exacerbations
- FEV1 60% predicted or less, variability over 30%
18
Q
Conditions suggestive of CF in adults
A
BRANIAC Bronchiectasis Recurrent pancreatitis Allergic bronchopulmonary mycosis Infertility (Male) Nasal polyposis Infection with non-tuberculous mycobacterium Adult (there isn't' actually another A) - could be osteoporosis Chronic sinusitis
19
Q
Definition of bronchiectasis
A
The congenital or acquired irreversible abnormal dilation and destruction of bronchial walls
20
Q
Types of bronchiectasis
A
Cylindrical:
- dilated bronchi with straight, regular outlines
- tram-track lines (parallel to each other)
- Signet ring
Saccular/cystic:
- most severe form
- ballooned appearance of bronchi +/- air-fluid levels
- large, cystic areas with honeycomb appearance
- thicker bullae of emphysema
Varicose:
- bronchi with dilated segments and other areas of constriction - “string of pearls”
Follicular:
- extensive lymphoid nodules in bronchial walls
21
Q
Clinical features of bronchiectasis
A
Chronic cough w purulent sputum Haemoptysis dyspnoea and wheezing Chest pain Postnasal drip Chronic fatigue Bilateral basal crackles Wheeze Ronchi Clubbing (in long-standing, severe bronchiectasis)
22
Q
Investigations in bronchiectasis
A
High resolution CT:
- signet ring (end-on dilated bronchi are larger than accompanying pulmonary artery)
- Tramlines (non-tapering bronchi)
- cysts with air-fluid levels
- mucus plugging of dilated bronchi (flame and blob sign/tree-in-bud pattern)
Sweat chloride test Electron microscopic evaluation of ciliary structure (primary ciliary dyskinesia) Genetic tests (CFTR, a1 antitrypisin genotypes)
23
Q
Management of bronchiectasis
A
Prolonged Abx for infective exacerbations (10-14d Augmentin)
Bronchodilators - if airflow obstruction
Inhaled corticosteroids
Pulmonary rehab
Bronchial hygiene therapy (inc. removal of secretions)
Surgery (if obstructing tumour, removal of severely damaged segments etc.)
24
Q
CXR findings in PE
A
Often normal in small/medium PE
May show small effusion (blunting of costophrenic angle)
Massive PE:
- oligaemic lung fields
- dilation of pulmonary arthery in hilum
- is often normal
25
ECG findings in PE
Sinus tachycardia
Sometimes AF
In massive:
Peaked P waves lead II (RA dilatation)
R axis deviation (RV dilatation)
RBBB, T wave inversion on R precordial leads
Classic S1Q3T3 is rare
26
Wells criteria for PE
```
Clinical sx of DVT = 3
PE more likely than other diagnoses = 3
Prior DVT/PR = 1.5
Tachycardia = 1.5
Immobilised 3d or surgery in last 4w = 1.5
Haemoptysis = 1
Malignancy = 1
```
5 or more, likely - perform CTPA
If less than 5, low risk, perform D-dimer to exclude
27
Management of PE
```
Parenteral anticoagulant
- LMWH is agent of choice for initial treatment (unfractionated if significant renal disease)
Oral warfarin or rivaroxaban
Target INR 2-3
Minimum 3 months anticoagulation
```
Thrombolytics are indicated in patients with haemodynamic instability (systolic BP under 90)
+/- patients with poor prognostic markers (inc. troponin, RV dilatation)
28
Assessing severity of pneumonia
```
SMART-COP
Systolic BP less than 90 = 2
Multilobar involvement on CXR = 1
Albumin less than 35 = 1
Respiratory rate over 25 (30 if 50 or older) = 1
Tachycardia over 125 = 1
Confusion = 1
Oxygen low (93%, 90% if 50) = 2
pH - acidaemic = 2
```
Severe if over 5 points - high risk of needing intensive respiratory or vasopressor support
29
Management of community acquired pneumonia
Mild CAP:
- oral amoxicillin
- augmentin if suspect haemophilus
- doxy or clariithromycin if atypical
- oral clarithromycin if penicillin allergic
Moderate: inpatient treatment
- IV benzylpenicillin + oral doxy or clarithromycin
- + gentamicin if gram -ve organism identified in sputum or blood
- IV ceftriaxone if allergic to penicillin
Severe:
IV antibiotics + IV azithromycin
30
Definition of tuberculosis
A multi-systemic infection that most commonly affects the pulmonary system and is caused by mycobacterium tuberculosis
31
Areas highly endemic for TB
Sub-Saharan Africa
| Russia
32
Diagnosis of TB:
CXR:
- Primary: Ghon foci in midzones
- Secondary: cavitation in upper zone
Tissue or fluid MC&S -don't swab
- Acid fast bacilli test (Ziehl-Neelsen or auramine)
- NAAT e.g. PCR
+/- tracheal aspirates
+/- bronchoscopy specimens (e.g. alveolar lavage)
33
Management of TB
NOTIFIABLE DISEASE
6 months antibiotic therapy (12m minimum if CNS TB)
For fully susceptible TB:
- 2 months RIPE: rifampicin, isoniazid, pyrazinamide, ethambutamol
- following 4: isoniazid + rifampicin
+ supplemental pyridoxine (VitB6)
+ adjunct corticosteroids in CNS and pericardial disease (reduce long-term complications)
34
Symptoms of TB
Pulmonary:
- productive cough +/- haemoptysis
- weight loss
- fevers - low-grade, late afternoon
- night sweats
- larynx involvement (hoarse voice, severe cough)
- pleura involvement (pleuritic chest pain)
LN:
- enlarged cervical or supraclavicular
- +/- indurated overlying skin
- +/- sinus tract formation with purulent d/c
GI:
- abdominal pain
- diarrhoea +/- blood
Spinal (Pott's) articular TB:
- monoarticular arthritis
- weight bearing joints
Miliary TB:
- Includes CNS in 20%
- respiratory symptoms
- cholestasis
- GI symptoms
CNS:
- HIV +ve patients mainly
- tuberculous meningitis
35
Latent TB infection
Initial containment of infection within granuloman (Ghon focus)
- Negative sputum therefore not infectious to others
- Tuberculin skin test usually +ve
- May visualise small calcified Ghon focus on CXR
36
What is a Ghon focus
The initial focus of disease in TB
On CXR: small calcified nodules
Ghon complex = Ghon focus + regional LN caseation
Primary complex of Ranke = Ghon focus within regional draining LN
37
Tuberculin (Mantoux) skin test
+ve 2-4 weeks after infection
+ve test = visible AND palpable induration peaking 48-72h following intracutaenous injection of purified protein derivative of M tuberculosis
(+ve reflects T-cell mediated immunity to mycobacterial antigens, does not differentiate between infection, active disease or vaccination)
38
Epidemiology of primary lung cancer
- Most common cause of malignancy-related death in developed countries
- 5th most frequently diagnosed cancer in australia
- Avg age of diagnosis 40-70y
- 1y survival 40%
- 5y survival 15%
Cigarette smoking accounts for over 90%
39
Most common forms of primary lung cancer
Squamous cell carcinoma (25-40%)
- closely related to smoking
- usually central and close to carina
- relatively slow-growing
- 60% resectable at time of diagnosis
- firm, grey-white, may be ulcerated
- highly variable microscopic appearance
Adenocarcinoma (25-40%)
- bronchial derived or bronchioalveolar types
- not as closely linked to smoking as SCC
- most common type in women
- peripherally located (small bronchi and bronchioles) THEREFORE DON'T PRESENT WITH FEATURES OF OBSTRUCTION
Small cell carcinoma (20-25%)
- highly malignant, mets early
- strong link to smoking
- most common type linked with ectopic hormone production
- derived from neuroendocrine cells of broncial epithelium
- most often in hilar/central regions
- virtually incurable by surgery
Large cell carcinoma (10-15%)
- central or peripheral
- poor prognosis
- microscopically: large polygonal cells with pleomorphic nuclei
40
Metastasis sites of primary lung cancer
```
LABB
Liver
Adrenals
Brain
Bone
```
41
Paraneoplastic syndromes associated with lung canceer
```
Mostly seen in small cell carcinomas
ADH - SIADH
ACTH - Cushing's syndrome
PTHrP - hypercalcaemia
Calcitonin - hypocalcaemia
```
42
Stages of non-small cell lung cancer
I: only in lung, no nodal spread
II: Lung + local nodal involvement
III: lung and LN in middle of chest, IIIa = only ipsilateral LN involved, IIIb = contralateral or cervical LN involvement
IV: both lungs, pleural space or distant metastasis
43
Stages of small cell cancer
Limited: cancer only in one area of lung +/- local ipsilateral LN
Extensive: spread to contralateral lung, other areas of chest or distant organs
44
Management of non-small cell lung cancer
Stage I-II: Surgical resection (RTx, CTx, or observation if not suitable for surgery)
Stage IIIa: Induction chemotherapy - surgical resection + mediastinal RTx
OR Radical combination chemoradiotherapy
Stage IIIb: radical combination chemoradiotherapy
Stage IV: Chemotherapy + palliative radiotherapy for specific sites (brain, bone pain)
45
Management of small cell lung cancer
Limited disease:
Platinum based CTx + thoracic radiotherapy
Extensive disease:
- Combination CTx
46
Genetic mutation associated with squamous cell cancer of the lung
DDR2 in 4%
| sensitive to treatment by dasatinib (kinase inhibitor)
47
Definition of pulmonary hypertension
A haemodynamic state in which the pressure in the pulmonary artery is elevated above a mean of 25mmHg
pulmonary ARTERIAL hypertension = pulmonary artery pressure over 25 with left heart filling pressure less than 15
48
Classifications of pulmonary hypertension
Group 1: pulmonary arterial HTN
- idiopathic, heritable, CTD, HIV, congenital heart disease etc.
Group 2: HTN secondary to LH failure
Group 3: Pulmonary HTN secondary to lung disease and/or hypoxia (COPD, ILD)
Group 4: Chronic thromboembolic pulmonary hypertension
Group 5: Pulmonary HTN with unclear multifactorial mechanisms (myeloproliferative neoplasms, splenectomy, sarcoid, vasculitis, thyroid disorders etc.)
49
signs of pulmonary HTN
```
Loud P2
Parasternal lift (hypertrophied RV)
Pansystolic murmur (TR)
RV S4
Other signs of RHF (hepatomegaly, oedema, ascited, raised JVP etc.)
```
50
Management of pulmonary HTN
General (for all groups of pulmonary HTN):
- diuretics
- O2 therapy
- Anticoagulation (warfarin)
- Digoxin (inc. RVEF)
- Exercise
- Vaccinations
51
Definition of interstitial lung disease
Chronic, non-malignant, non-infectious disease of the lower respiratory tract characterised by inflammation and derangement of the alveolar walls and damage to the lung parenchyma by inflammation and fibrosis
52
Causes of ILD
Acute ILD:
- idiopathic
- allergy (penicillin, fungi, helminths)
- toxins (amiodarone, sulfasalazine, MTX, immunosuppresants, chlorine)
- Vasculitis (Goodpastur syndrome)
Chronic ILD:
- idiopathic
- inorganic dusts (asbestosis, siderosis[iron], silicosis, granulomatous)
- organic dusts (bacteria or animal protein [bird fancier's lung])
Systemic diseases:
- collagen vascular disease (RA, AS, SLE, Sjogren syndrome)
- Neoplastic (lymphoma)
- sarcoidosis
- IBD
- amyloidosis
- HIV-associated
53
Clinical features of interstitial lung disease
Progressive SOBOE
Persistent non-productive cough
Fever
Haemoptysis (alveolar haemorrhage syndromes e.g. Goodpastures)
Symptoms of collage vascular disease etc.
```
Clubbing (esp in idiopathic)
End-expiratory fine crackles (like velcro) THAT DO NOT SHIFT WITH COUGHING
Signs of Pulm HTN
- loud P2
- Pansystolic murmur (TR)
- raised JVP
- R sided heave and S3
Extrapulmonary signs of collagen vascular disease
```
54
CXR in interstitial lung disease
May help to narrow differentials for cause
- Patterns (upper v lower lobe)
- Ground-glass attenuation
- Kerly B lines
- Hilar/mediastinal lymphadenopathy
55
Management of interstitial lung disease
General measures:
- oxygen therapy
- pulmonary rehabilitation
- smoking cessation
- vaccinations
Idiopathic:
- N-acetylcysteine (mucolytic)
- Lung transplantation
- trial prednisolone 6-12w
Collage vascular disease related:
- Treat underlying cause
- mycophenolate mofetil
Wegener Granulomatosis:
- Cyclophosphamide + prednisolone
Goodpasture syndrome:
- Plasmapheresis (eliminate anti-GBM antibodies)
- Cyclophosphamide OR prednisolone
56
Definition of sarcoidosis
A chronic multisystem granulomatous disease of unknown cause, characterised by the presence of non-specific, non-caseating granulomas
Over 90% have respiratory tract involvement
57
Common symptoms in symptomatic individuals with sarcoidosis
```
Fatigue
Night sweats
Weight loss
Dry cough
Dyspnoea
Skin disease (e.g. erythema nodosum)
Eye disease
Cardiac disease (arrhythmias)
Neurosarcoidosis (CNeuropathies, myelopathy, seizures)
MSK (arthritis in 35%)
```
LOCALISED WHEEZING +/- crackles
58
CXR in sarcoidosis
Bilateral hilar adenopathy
R paratracheal adenopathy
Parenchymal infiltration
Fibrosis: honeycombing, cysts, bullae, traction bronchiectasis
59
CT chest in sarcoidosis
```
Nodules
Ground-glass opacities
Bronchiectasis
Cysts
Thickening of pleural surface
```
60
Management for respiratory sarcoidosis
Prednisolone 20-40mg/day if SOB or reduced FVC
| Inhaled corticosteroid for wheezing
61
Definition of respiratory failure
Syndrome in which the respiratory system fails in one or both of its gas exchange functions: oxygenation and carbon dioxide elimination
62
Classifications of respiratory failure
Type I/Hypoxaemic:
Arterial oxygen pressure less than 60 with normal or low arterial CO2 pressure
i.e hypoxaemia WITHOUT hypercapnia
Type II/Hypercapnic:
PaCO2 over 50 (patients are often hypoxaemic as well)
63
Causes of type I respiratory failure
Pretty much any acute lung disease, generally involving fluid filling or alveolar collapse
- COPD
- Pneumonia
- Pulmonary oedema
- Pulmonary fibrosis
- Asthma
- Pneumothorax
- Pulmonary embolism
- Pulmonary arterial hypertension
- Acute respiratory distress syndrome
64
Causes of type II respiratory failure
```
COPD
Severe asthma
Drug overdose/poisoning
Neuromuscular disease
Chest wall abnormalities
```
65
Management of respiratory failure
```
Reverse/prevent tissue hypoxia
- ICU admission if acute
- secure airway
- Supplemental O2 (intubation and ventilation may be required in severe hypoxaemia)
Treatment of underlying cause
```
66
Management of pneumothorax
Small (less than 20%)
- observe at 2-weekly intervals until air reabsorbed
Medium pneumothorax (20-50%)
- aspirate air, if no recurrence treat as above
Large pneumothorax (over 50%):
- aspirate air, if no recurrence treat as above
- if recurrence - intercostal drainage tube with underwater seal for 2-3 days
If recurrent (more than twice) consider surgery or if contraindicated, peurodesis (adhesion of visceral and parietal pleura with talc, bleomycin or tetracycline)
67
Causes of pleural effusion
Transudates (often larger on R side)
- Heart failure
- Hypoproteinaemia (e.g. nephrotic syndrome)
- constrictive pericarditis
- Hypothyroidism
- Ovarian tumours (Meigs' syndrome)
Exudates:
- Bacterial pneumonia (common)
- Carcinoma of the bronchus and pulmonary infarction (common)
- Tuberculosis
- Autoimmune rheumatic disease
- RARE: post-MI syndrome, acute pancreatitis
68
At what point can a pleural effusion be detected
Radiologically at 300mL
| Clinically at 500mL
69
Biochemistry of transudate v exudate
Transudate:
Protein under 30
Lactic dehydrogenase under 200
Fluid:serum LDH ratio less than 0.6
Exudate:
protein over 30
LDH over 200
70
Clinical features of pleural effusion
```
Reduced chest expansion on affected side
Mediastinal shift away from lesion
Stony dull percussion
Reduced or absent vesicular breath sounds
Reduced vocal resonance
Nil adventitious sounds
```
71
Spirometry in obstructive v restrictive pictures
Obstructive:
- FEV1 reduced
- FVC reduced or normal
- FEV1/FVC reduced
Restrictive:
- FEV1 reduced OR normal
- FVC reduced
- FEV1/FVC Normal or increased
Mixed: reduced FEV1, FVC and FEV1/FVC
Asthma - over 12% (or 200mL) improvement in FEV1 (or FVC) post bronchodilator
