Respiratory (Quesmed) Flashcards
1
Q
What is Acute Respiratory Distress Syndrome?
What are 2 examples of diseases that typically cause it?
A
It is defined as a Non-Cardiogenic Pulmonary Oedema and Diffuse Lung Inflammation- usually secondary to an underlying illness (like Pancreatitis/ Pneumonia)
The pathophysiology includes Diffuse Alveolar Damage
Alveoli are being accumulated with Fluid
2
Q
What is the pathophysiology of Acute Respiratory Distress Syndrome?
How is it different from NEONATAL RESPIRATORY DISTRESS SYNDROME?
A
1) ARDS is a respiratory failure that occurs within a week of onset of Lung Injury
2) It involves BILATERAL ALVEOLAR INJURY due to inflammation mediated by Inflammatory Mediators like TNF-Alpha, IL1 and IL8
3) The resulting Endothelial Injury ACTIVATES NEUTROPHILS in Pulmonary Capillaries- this releases Reactive OXYGEN SPECIES and PROTEASES that damage the Alveolar Endothelium and Type 2 Alveolar Cells
4) So the Vascular Permeability increases and the Lung Surfactant is lost. This Fluid Accumulation in the Alveoli causes Pulmonary Oedema and Hypoxaemia as a result
5) This is NOT DUE TO Cardiogenic Pulmonary Oedema, Pleural Effusion or Atelectasis
6) ARDS is not the same as Neonatal Respiratory Distress Syndrome btw (which is due to Inadequate Surfactant Production due to Prematurity)
3
Q
What are the causes of ARDS?
What is the most common cause? What are the 3 other important causes of ARDS?
A
Pneumonia (most common cause)
Sepsis
!!!!!!!!!!!SMOKE INHALATION
Aspiration
Pancreatitis
Trauma and Fractures
Transfusion Reactions
Fat Embolism
4
Q
What are the signs of ARDS? What are the Four Defining Features of ARDS?
What can you measure if there is a doubt on whether the ARDS is cardiogenic or not?
What is the ONLY Heart Failure symptom seen in ARDS?
A
It presents as Acute Respiratory Failure which does NOT improve with Supplemental Oxygen
There are FOUR Defining features of ARDS
1) Acute Onset (<1 week of a known risk factor)
2) Pulmonary Oedema (Bilateral Infiltrates on CXR)
3) Non-Cardiogenic (Pulmonary Artery Wedge Pressure needed if there is a doubt)
4) PaO2/FiO2<40
Dyspnoea
Tachypnoea
Confusion
Presyncope
There will be Bibasal Crackles (but no other signs of Heart Failure)
5
Q
What imaging investigations should be ordered in ARDS?
What is the defining feature of ARDS?
A
Chest Xray- Bilateral Alveolar Infiltrates- NO OTHER SIGNS OF HEART FAILURE like the Kerley B Lines or Cardiomegaly
CXR will ONLY show the Pulmonary Oedema- nothing else that suggest Heart Failure
CT Scan may help to characterise changes found on X ray
PaO2/FiO2<40 is a Defining Feature of ARDS
6
Q
What is the management of ARDS?
Where should ARDS be managed?
A
!!!!!!!!!!!!!!!!!!Transfer them to ITU!!!!!!!!!!!!!!!!!!!!!!
1) Mechanical Ventilatory Support- A Low Tidal Volume is associated with better outcomes- Give them OXYGEN!
2) Haemodynamic Support to maintain Mean Arterial Pressure>60mmHg- VASOPRESSORS can be given
3) DVT Prophylaxis
4) Nutritional support through Enteral/ Parenteral if NEEDED
5) Regular Repositioning of Patients for Pressure Ulcer Prophylaxis
6) Antibiotics only needed if an infective cause is suspected (Pneumonia or Sepsis)
7
Q
What is Asbestosis?
A
It is a LOWER ZONE interstitial lung fibrosis that manifests in patients with Pleural Plaque diseases 10 or more years after they have exposure to Asbestos
8
Q
What are the signs and symptoms of Asbestosis?
A
History of Asbestos Exposure- usually 20 or more years prior
Symptoms- Dyspnoea and Cough
Signs- Crepitations on Auscultation (cos it is fibrosis) , Finger Clubbing, Cyanosis and Reduced Chest Expansion
9
Q
What is seen on the Chest Xray for Asbestosis?
What must you remember about the Pleural Plaques?
How do you manage Atelectasis?
A
Linear Interstitial Fibrosis
Pleural Plaques (Pleural Plaques are BENIGN and do NOT undergo a malignant change)
Pleural Thickening
Atelectasis (partial collapse or incomplete inflation of a lung)
- Management- Position them upright and Chest Physiotherapy
10
Q
What do pulmonary function tests show for Asbestosis?
A
Restrictive pattern (Small Lung)
- Low FVC
- Low TLC
- Normal FEV1/FVC ratio
Can also be Obstructive (Blocked Lung)
- Reduced FEV1
11
Q
What is needed for the definitive diagnosis of Cancer in Asbestosis?
A
Open Lung Biopsy
12
Q
What is the management of Asbestosis?
A
CONSERVATIVE, then O2 then Surgery
Smoking Cessation
Pulmonary Rehabilitation
Oxygen if SpO2 <90%
Lung Transplant
If death occurs due to Asbestosis, this must be reported to the coroner
13
Q
Which conditions cause Aspiration Pneumonia?
A
Anything that may cause an Unsafe Swallow
Neurological Conditions plus Upper GI Conditions plus ALCOHOL and SEIZURE
- Stroke
- Myasthenia Gravis
- Bulbar Palsy
- Achalasia
- G.O.R.D.
- Alcoholics
- Post Ictal State
14
Q
What microorganisms cause Aspiration Pneumonia?
A
Streptococcus Pneumoniae
Staphylococcus Aureus
Haemophilus Influenza
Pseudonomas
Enterbacteriaceae
Can Also be Gram Negative Bacteria
15
Q
What is the treatment of Aspiration Pneumonia?
A
Cover for both Gram Positive and Negative
IV Ceftriaxone and IV Metronidazole
Aspiration= CEF-MET
16
Q
When must food and water be stopped before a Hernia Surgery?
A
Food- 6 hours before
Only Water until 2 hours before
17
Q
Which Lung Regions usually mean Aspiration Pneumonia?
A
If the RIGHT MIDDLE and LOWER Lung Lobes are consolidated
18
Q
When is the Pneumococcal vaccination routinely offered?
A
2 Months
4 Months
12-13 Months
And Over 65 years
2-4-12-65
19
Q
What groups are at risk of Pneumonia and need the vaccination every 5 years?
What suggests immunocompromisation?
A
Chronic Heart, Lung, Liver or Kidney Disease
Liver Cirrhosis
!!!!!!!!!!!!!Post-Transplant
Renal Failure
Nephrotic Syndrome
Immunosuppression)- AIDS, Chemotherapy, Splenectomy, SICKLE CELL DISEASE
Chronic Lung Conditions- CPD/ Bronchiectasis
20
Q
What are the causes of Bilateral Hilar Lymphadenopathy?
A
Inflammatory- Sarcoidosis
Infective- Tuberculosis and Mycoplasma
Neoplastic- Bronchial Carcinoma and Lymphoma
Interstitial Lung Disease can also cause this. It can be Inorganic (Silicosis) or Organic (Extrinsic Allergic Alveolitis)
21
Q
What is Bronchiectasis?
What is the most likely organism that causes it?
A
It is the PERMANENT Dilatation of the Bronchi and Bronchioles due to Chronic Infection/ Inflammation
This is usually caused by (These 4 are the ones associated with ASPIRATION PNEUMONIA AS WELL)
1) Haemophilus Influenzae
2) Pseudonomas Aeruginosa
3) Streptococcus Pneumoniae
4) Staphylococcus Aureus
22
Q
What are the causes of Bronchiectasis?
What are the 5 main ones to remember?
Also remember YOUNG-KART
A
Post Infection- Tuberculosis, HIV, Measles, Pertussis, Pneumonia
Bronchial Pathology- Obstruction caused by Foreign Body or Tumour
Allergic Bronchopulmonary Aspergillosis (ABPA)
Congenital- Cystic Fibrosis, KARTAGENER’s SYNDROME, Primary Ciliary Dyskinesia, Young Syndrome
Hypogammaglobuminaemia (Low Antibodies)- IMMUNE DEFICIENCY causes Bronchiectasis
Rheumatoid ARTHRITIS
23
Q
What is the presentation of Bronchiectasis?
A
Persistent (DAILY) Productive Cough (+/-Haemoptysis) in a YOUNG person with Resp Issues (that may be the cause of it)
PLUS the 2C’s-
1) Clubbing
2) Coarse Inspiratory Crackles
Dyspnoea
Wheeze
24
Q
What investigations should be ordered in Bronchiectasis?
What is the best investigation to order?
What are the 2 signs that are seen?
Is Bronchiectasis OBSTRUCTIVE or RESTRICTIVE on Spirometry?
A
Spirometry- Bronchiectasis is OBSTRUCTIVE
Sputum Culture- To identify pathogens and guide management with Antibiotics
High Resolution CT- BEST DIAGNOSTIC INVESTIGATION for Bronchiectasis
Chest Xray- thickened Bronchial Walls and Cystic Appearance- TRAMLINE and SIGNET RING SHADOWS
Bronchoscopy- can locate areas of obstruction and haemoptysis or sample tissue for Culture
25
What Additional Investigations can be ordered to identify the cause of Bronchiectasis?
_Serum Immunoglobulins_- Hypogammaglobuminaemia
Cystic Fibrosis Sweat Test- Cystic Fibrosis
_Aspergillus Precipitins_ or _Skin Prick_ Test- ABPA
Rheumatoid Factor or _ANA_- Rheumatoid Arthritis
26
What is the management of Bronchiectasis?
Remember the 2 conservative managements and the ABC
Conservative
- Patient Education
- Support Group
- MOST IMPORTANT- _Chest Physiotherapy _ (_Postural Drainage_ *at least Twice Daily* to help with Mucous Drainage)
- _Smoking Cessation_
Medical Management _ABC_
1) _Antibiotics_ (long term if recurrent- PROPHYLACTIC if 3 or more exacerbations)
2) Bronchodilators (given if _Dyspnoea and Wheeze_ (COPD, ABPA, Asthma))
3) Corticosteroid- _Prednisolone if ABPA_
- Carbocysteine- a Mucolytic Agent
Surgical Management
- Surgical Excision of Localised Area of Disease or Cessation of the Haemoptysis
- Lung transplant may be indicated
27
What is Primary Ciliary Dyskinesia (Kartagener's)?
What is the inheritance?
What is weird about these Kartagener's patients?
PCD is an _Autosomal Recessive_ disorder of dysfunctional cilia.
Cilia are important as they determine the orientation/laterality of internal organs and line the inner walls of bronchi. Consequently, their dysfunction results in bronchiectasis and recurrent infections.
Percussion usually changes at the RIGHT lung base due to movement of the liver during inspiration and expiration. Patients may display this phenomena at their LEFT lung base, suggesting _SITUS INVERTUS_ – a key features of PCD
_CHEST XRAY shows DEXTROCARDIA_
28
What are the Musculoskeletal signs of Cystic Fibrosis?
What is HPOA? What 3 conditions is it associated with?
Clubbing
_Hypertrophic Pulmonary Osteoarthropathy_
- Lung disease (CF, Lung cancer or Bronchiectasis) which causes Clubbing and Arthritis
Osteoporosis
Arthritis
29
What can be ordered for the diagnosis of Cystic Fibrosis?
When can the HEEL PRICK test be ordered?
1) Neonatal heel prick day between _day 5 and day 9_
2) Sweat test: sweat sodium and chloride _>60mmol/L_
3) _Faecal elastase_: this can provide evidence for abnormal pancreatic exocrine function.
4) Genetic screening: This can identify CF mutations
30
What kind of tests should be ordered in patients with KNOWN Cystic Fibrosis?
What is the Spirometry picture in Cystic Fibrosis?
~~~~~~~
_Aspergillus Skin Prick_
Spirometry- Obstructive
Abdominal Ultrasound- Distal Intestinal Obstruction, Liver Cirrhosis, _Chronic Pancreatitis_
Chest X Ray- Bronchiectasis, Hyperinflation
31
What is the management of Cystic Fibrosis?
(Read over but memorise the one in PAEDS)
~~~~~~
If INFECTIVE EXACERBATION
- Antibiotics
- Nebulised Mucolytics (Dornase Alfa)
- Bronchodilators (Inhaled Corticosteroids or B2 Agonists)
Pancreatic Insufficiency
- Insulin Replacement
- Creon
- Vitamin ADEK
If ABNORMAL LFTs
- URSODEOXYCHOLIC ACID
If Worsening Progressive Lung Disease
- Oxygen
- Non Invasive Ventilation
- Diuretics if Signs of Cor Pulmonale
Surgical Management
- If Cirrhosis- LIVER TRANSPLANT
- Lung Transplant may be needed
32
What suggests Cystic Fibrosis? (non-standard symptoms)
Recurrent Chest Infections
_Short_
Signs of _Diabetes_
DELAYED PUBERTY
33
What are the 4 types of differentials for Haemoptysis?
What is an Aspergilloma and when does it usually present?
What is GOODPASTUREs?
1) Vascular Causes
- _Pulmonary Embolism_
2) Infective Causes
- Pneumonia (dyspnoea)
- Tuberculosis (systemic symptoms- _weight loss_, night sweats)
- _Aspergilloma_- Ball of fungus in a cavity- usually *_secondary to TB or Sarcoidosis_*- _No other symptoms_
- Bronchiectasis
3) Immunological Causes
- _Goodpasture's Disease_- Pulmonary-renal disease with features of _GLOMERULONEPHRITIS- (Haematuria, Proteinuria and Hypertension)_- This is due to Autoantibodies against Type 4 Collagen
-Granulomatosis with Polyangiitis- Vasculitis causing Necrotising Granulomatous Inflammation of Small and Medium Blood Vessels- NASAL Obstruction, _Saddle Nose_, Haemoptysis, Glomerulonephritis (if _NOSE_ is affected)
4) Malignant Causes
- Lung Cancer- _Squamous Cell Carcinoma is the most common type of Lung Cancer_. Look for Signs of ANAEMIA and Lymphadenopathy
- _Malignant Pleural Effusion_
- Also *_LUNG ABSCESS if there are Air-Fluid Levels_*
34
What are the Xray findings and the main sign of a Lung Abscess?
They are causes of MASSIVE HAEMOPTYSIS (Large amounts of Blood)
_Central Cavitation with an Air-Fluid Level_
_FOUL SMELLING Sputum_
35
What are the risk factors for Lung Cancer?
What are the 3 UNUSUAL RISK factors?
Smoking
Occupational Exposure (Silica, Asbestosis, Welding Fumes, Coal)
*H._O._B.*
_HIV_
_Organ Transplantation_
Radiation Exposure (Xray, Gamma Rays)
_Beta Carotene supplements_ in Smokers
36
What are the signs of Lung Cancer?
What are the Paraneoplastic Syndromes?
What type of cancer is associated with Lambert-Eaton and with Hyperparathyroidism?
1) Haemoptysis
2) Dyspnoea and Chest Pain
3) _NAUSEA and VOMITING_
4) Weight Loss and Anorexia
5) Clubbing
6) _Hypertrophic Pulmonary Osteoarthropathy_
7) Anaemia
8) _Horner's Syndrome_ (if the tumour is located Apically)
9) PARANEOPLASTIC SYNDROMES (4)- Cushing's Syndrome, SIADH, _Lambert-Eaton_ (which suggests a Small Cell Carcinoma), _Hyperparathyroidism_ (which suggests Squamous Cell Carcinoma)
37
What is seen on Examination in Lung Cancer?
4 signs
Which lymph nodes are enlarged in Lung Cancer?
1) Consolidation (_Pneumonia_)
2) Collapse (Absent Breath Sounds, _Ipsilateral Tracheal Deviation_)
3) Pleural Effusion (Stony dull percussion, _Decreased vocal resonance and breath sounds_)
4) _Supraclavicular_ and _Axillary_ Lymph Nodes are enlarged
38
What is Superior Vena Cava Obstruction?
Cancer may invade into Surrounding Tissues which compresses the Superior Vena Cava
This leads to _Dyspnoea_ and _FACIAL PLETHORA_
39
What are the features of Squamous Cell Carcinoma?
It s typically CENTRAL
How is Squamous on Xray?
How is Squamous with cavitation?
What are the 2 HYPERS of Squamous?
1) Usually presents as Obstructive Lesions of the Bronchus *_leading to Infection_*
2) It is the lung cancer that _MOST COMMONLY CAVITATES_
3) _On Xray it is not possible to tell_ whether it is an Abscess or Cancer (as the border's definition can not be seen). However, the _JAGGED BORDER of cancer can be seen on CT_
4) Metastasis is late
5) It often causes _HYPERCALCAEMIA_- bone destruction or production of PTH-LIKE PEPTIDES
6) Also associated with Clubbing and _Hypertrophic Pulmonary Osteoarthropathy_
40
What are the features of Adenocarcinoma?
Peripheral
What does it most commonly cause compared to the other lung cancers?
Which lymph nodes are usually affected? Where does it spread to?
What are the Paraneoplastic Syndromes?
1) This is the _most common_ type of Lung Cancer in the UK
2) It arises from Mucous Cells in the Bronchial Epithelium
3) It commonly invades _Mediastinal Lymph Nodes and the Pleura_- it spreads to BRAINS and BONEs
4) It usually does _NOT Cavitate_ (unlike Squamous)
5) It is the LEAST Likely to be linked to Smoking and is the _MOST COMMON in NON-Smokers_
6) It is also the MOST LIKELY to cause _Pleural Effusions_
7) Paraneoplastic Syndromes- Gynaecomastia and HPOA
41
What are the features of Small Cell Carcinoma?
It is a CENTRAL Cancer
What cells does it arise from?
What are the paraneoplastic conditions associated with it?
How quick or late doe they metastasise?
1) Arise from Endocrine Cells (Kulchitsky Cells). These are _APUD cells_- so they will secrete many Polypeptides such as ACTH
- APUD= (Amine - high amine content. Precursor Uptake - high uptake of amine precursors. Decarboxylase - high content of the enzyme decarboxylase)
2) These can cause various presentations- Addison's and Cushing's and Lambert Eaton Myasthenic Syndrome_(Limb weakness- due to VGCC antibodies)
3) Small cell carcinomas spread EARLY- _metastatise early_
4) These tumours respond to CHEMOTHERAPY
5) In addition to ACTH, these release ADH- which causes HYPONATRAEMIA
6) It causes _Central Hilar Lymphadenopathy_
7) Paraneoplastic SCLC _(Sodium, Cushings, LEMS)_
- ACTH- Cushings
- ADH- Hyponatraemia
- Lambert Eaton Myasthenic Syndrome
42
What are the Paraneoplastic Syndromes in Lung Cancer?
- Small cell *(The A_H's and LAMBERT EATON)*
1) ADH- Hyponatraemia
2) ACTH - not typical, hypertension, hyperglycaemia, hypokalaemia, alkalosis and muscle weakness are more common than buffalo hump etc- look for the _METABOLIC SIGNS of CUSHINGs- not the physical ones_
3) Lambert-Eaton syndrome
- Squamous cell *(The 2 HYPERS and Clubbing)*
1) parathyroid hormone-related protein (PTH-rp) secretion causing Hypercalcaemia
2) Clubbing
3) Hypertrophic pulmonary osteoarthropathy (HPOA)
hyperthyroidism due to ectopic TSH
- Adenocarcinoma
1) _Gynaecomastia_
2) Hypertrophic pulmonary osteoarthropathy (HPOA)
43
What investigations should be ordered in Lung Cancer?
Which is the investigation of choice and which is first line?
Which blood test is an indicator for lung cancer?
How are biopsies obtained?
1) _Sputum cytology_
2) FIRST LINE- _Chest X-ray_: abnormalities that may be seen include nodules, lung collapse, pleural effusion, consolidation, and bony metastases.
3) INVESTIGATION of CHOICE= _Contrast-enhanced CT scan_: this is used to further confirm the diagnosis and stage (TNM classification) the disease. The CT scan should also include both the adrenals and liver to look for sites of metastases.
4) Bronchoscopy: used to _obtain a BIOPSY for histology_
5) Endobronchial ultrasound transbronchial needle aspiration (EBUS-TBNA): allows biopsy of lymph nodes, paratracheal and bronchial lung lesions for histology
6) Cardiovascular review and lung function tests should also be performed to assess patient's suitability for treatment options.
7) _RAISED PLATELETS is an indicator for LUNG CANCER_
44
What is the management of Non-small Cell Lung Cancer?
At what stages are radiotherapy and chemotherapy offered?
First Line- _LOBECTOMY_
Curative Radiotherapy can be offered to Stage 1, 2 and 3 Non-Small Cell Carcinomas
Chemotherapy should be offered if Stage 3 or 4
45
What is the management of Small Cell Lung Cancer?
Chemotherapy and Palliative Care
46
What is the management of Hypercalcaemia?
_IV Fluid Replacement first_
with *_NORMAL SALINE_*
47
What is the management of Superior Vena Cava Obstruction?
Immediate _Oral Dexamethasone_
48
What 3 conditions increase the likelihood of a Lung Abscess?
1) Lung Malignancy
2) Pneumonia
3) Aspiration of Oropharyngeal Secretions- breathing in stuff that is secreted from mouth/nose
49
What are the signs of a Lung Abscess?
What most commonly causes a lung abscess and what pathogens?
1) Typically following ASPIRATION PNEUMONIA or a STROKE
2) They are typically _POLYMICROBIAL_
_Fever_
*DENTAL EROSIONS*- cos poor dental hygiene increases the risk
_SMELLY Productive Cough_
Dyspnoea
Lethargy
_SYSTEMIC SYMPTOMS_-
1) Night Sweats
2) Weight Loss/ Cachexia
CLUBBING
Bronchial Breathing
50
What investigations should be ordered in Lung Abscesses?
What must be obtained in a lung abscess?
What is seen in a CHEST XRAY?
Blood- High ESR/CRP and Leukocytosis- cos it is an INFECTION after all
_Sputum Culture and Blood Culture MUST BE OBTAINED_
_Chest Xray_- an Abscess affects ONE SIDE- commonly the POSTERIOR SEGMENT of the UPPER LOBE and the APEX of the LOWER LOBE
- It will show a _FLUID-FILLED SPACE with an AIR-FLUID LEVEL_
CT Scan
Bronchoscopy- Aspirates can be obtained for Culture and for Drainage
51
What is the management of a Lung Abscess?
Conservative- *Do _NOT_ forget the Conservative management*
- Chest Physiotherapy for Postural Drainage
- _Smoking Cessation_ if Necessary
Medical
- Supportive Treatment- Oxygen, Fluid Regime, Analgesia
- _Antibiotic Treatment- IV Therapy for 3 weeks then Oral Antibiotics for 1-2 Months_
Surgical
- CT-guided _Percutaneous Drainage_ or Pulmonary Resection
52
What are the signs of Obstructive Sleep Apnoea?
*_if they sleep but it doesn't help and they snore_*
Excessive Daytime Sleepiness (so like fatigue)
Lack of Concentration
Snoring
Sleep is not Refreshing
_Irritability and Personality Change_
53
What are the risk factors for Obstructive Sleep Apnoea?
Obesity
_Male_
Smoking
Alcohol
_Neuromuscular Disease_
_Micrognathia_
54
What investigations should be ordered in Obstructive Sleep Apnoea?
What is the gold standard for obstructive sleep apnoea?
_Polysomnography_ is the GOLD STANDARD (measuring physiological parameters while the patient is asleep at night)
ALSO *Blood Pressure*
55
What is the management of Obstructive Sleep Apnoea?
*BASICALLY manage the risk factors and CPAP*
1) Weight Loss
2) Smoking Cessation
3) Avoid Alcohol in the evening
4) CPAP- maintains upper airway patency and it is the GOLD STANDARD
56
What are the signs of Pleural Effusion?
What are the 3 core signs of a pleural effusion?
What are the Chest Expansion, Breath Sounds, Vocal Resonance and Percussion like?
What about Tracheal DEVIATION?
What 3 signs of the cause should you bear in mind?
_Dyspnoea, NON-PRODUCTIVE cough, !!!!!chest pain_
- *Chest Expansion, Breath sounds, Vocal Resonance and Percussion is LOWER on the affected side*
- *Trachea MAY be deviated AWAY from the affected side*
1) Trachea is NORMAL or DEVIATED away from the affected lung
2) Chest Expansion is REDUCED on the Affected Side
3) Percussion is DULL on the Affected Side
4) Reduced BREATH SOUNDs and VOCAL RESONANCE on Affected Side
///////////////////////////////////////////
Signs of the CAUSE
1) Pyrexia- Infection
2) Cachexia and Clubbing- Malignancy
3) Raised JVP and Ankle Oedema- Heart Failure
57
What are the 4 causes of Exudative Pleural Effusion?
What is the PROTEIN RANGE?
(usually UNILATERAL)
What is the MOST COMMON CAUSE
Diseases which _increase Permeability_
- REMEMBER *IMIP=EXUDATIVE*
_(Protein>30)_
1) Infections (Pneumonia or TB)- PNEUMONIA is the most common EXUDATIVE cause
2) Malignancy
3) Inflammatory Conditions (Rheumatoid Arthritis, Lupus, _Pancreatitis_)
4) Pulmonary Infarct (secondary to _Pulmonary Embolism_) and _Trauma_
58
What are the causes of Transudative Pleural Effusion?
What is the PROTEIN LEVEL?
(usually BILATERAL)
Conditions that cause _Imbalance in the Starling Forces_
(Protein<25)
1) High Capillary Hydrostatic Pressure- _Congestive Cardiac Failure_
2) Low Capillary Oncotic Pressure- Cirrhosis, Nephrotic Syndrome/ CKD, GI Malabsorption or Malnutrition (Coeliac Disease)-
- _Cirrhosis leads to LOW ALBUMIN, Kidney injuries cause LOW PROTEIN in blood, Malabsorption also causes LOW PROTEIN_
3) _Hypothyroidism and Meig's Syndrome_ (Ascites, Pleural Effusion and Benign Ovarian tumour)
- Suspect Meig's if patient has an OVARIAN TUMOUR/ ASCITES as well as the Effusion
59
What Investigations should be ordered in Pleural Effusion?
What is seen on Chest Xray
When is Thoracentesis contraindicated for pleural fluid analysis?
What 4 things must you investigate in Thoracocentesis?
Blood Tests
- To help identify the cause
- E.g. _Low Albumin_ + High AST/ALT= Cirrhosis- *remember low albumin= low oncotic pressure= exudative*
- High WCC= Infection
Imaging
- FIRST LINE IMAGING= PA CHEST XRAY
- _Blunting of COSTOPHRENIC ANGLE_
1) Ultrasound guided THORACENTESIS for Pleural Fluid Analysis needed in ALL Patients unless they have _CLEAR HEART FAILURE_
2) Pleural Fluid should be sent for Biochemistry- _protein level, LDH, Glucose, pH_, Amylase, Cytology, Microbiology)
60
If the Protein Content is 25-35, Light's Criteria is Applied in Pleural Effusion to decide whether it is Transudate or Exudate
What is Light's Criteria?
- Only 1 needed
Exudate if (*0.5 for Protein, 0.6 for LDH*) plus *LDH PF> 2/3 of upper reference for SerumLDH*
1) Pleural Fluid Protein: Serum Protein >0.5
2) Pleural Fluid LDH: Serum LDH >0.6
3) _Pleural Fluid LDH >2/3 Upper Reference Limit for Serum LDH_
61
What are the 4 measured Pleural Fluid Parameters to aid diagnosis?
What 3 things cause LOW GLUCOSE in PF analysis?
What suggests EMPYEMA?
What do the Complement levels suggest?
When should an oesophageal perforation be suspected?
1) Glucose- Low in Rheumatoid Arthritis, Tuberculosis or Malignancy (_RTM_)-
*Raytrace my Glucose*
2) pH <7.2 if Empyema
3) Amylase is Raised if Pancreatitis/ _Oesophageal RUPTURE_
4) Immunology- Rheumatoid Factor for Rheumatoid Arthritis. ANA for SLE. _LOW COMPLEMENT if Rheumatoid Arthritis or SLE_
5) Suspect Oesophageal perforation- HIGH Amylase, LOW Glucose, LOW pH
62
What is the management of Pleural Effusion?
What are the 2 things done on ACUTE PRESENTATION
What should be done if it is LARGE or if there is EMPYEMA?
_What is done if it is RECURRENT?_
1) ABCDE (Oxygen and everything Diuretics for Heart Failure, Antibiotics for Chest Infections)
2) FLUIDS- _even if NOT IN SHOCK_
//////////////////////////////
1) _Intercostal chest drainage_ if LARGE Pleural Effusion or Empyema
2) If Recurrent or Persistent Effusions- _Pleurodesis_ (Obliteration of Pleural Space) can be chemical (_tetracycline or bleomycin_) or surgical
63
What is Pneumocystis Pneumonia? Which FUNGUS causes it?
What kind of patients may it present in?
It is an infection with Pneumonia _Jiroveci_
It is a common presentation in _HIV patients who are non compliant_ with cART or Antibiotic Prophylaxis
- _C_YSTIS
- _c_ART
- JIROVECI
64
What are the signs of Pneumocystis Pneumonia?
What is the cough like?
What measurement means the patient are at a high risk of Jiroveci?
What is typically seen JUST in Pneumocystis Pneumonia?
Fever
A _NON-PRODUCTIVE COUGH_ (but can be productive if there is superimposed bacteria)
High risk if _CD4<200_
_Exertional Breathlessness_ is associated with the _onset of the infection_ (this is a specific sign for PCP vs other infections so remember this)
MAY be End-inspiratory Crackles
65
What investigations should be ordered in Pneumocystis Pneumonia? What should be done if it is severe?
What is seen in CXR?
What is DEFINITIVE?
1) First LINE- Chest Xray- _Bilateral Bihilar Interstitial Infiltrates_- Reticular Appearance
2) If the chest Xray is normal however and you still suspect PCP- then High Resolution CT- look for _CYSTS and NODULES_
3) DEFINITIVE DIAGNOSIS- Bronchoscopy with Bronchoalveolar Lavage
- Samples are stained using _Grocott's Silver Stain_ which shows a _"Mexican Hat"_ Appearance- *Grocott Jiroveci sounds Mexican*
4) Blood gas used to define Severity of Disease. If _pO2<9.3kPa_ and _arterial alveolar O2 Gradient >4.7kPa_- then give CORTICOSTEROIDS
66
What is the management of Pneumocystis Pneumonia? Remember the First Line
1) _Co-trimoxazole_
2) Clindamycin-Primaquine, Dapsone, IV Pentamidine
67
What is the management of Hypoxia?
*What type of mask do you start them off on?*
_Non-rebreathe_ Mask First
(then adjust to Venturi etc.)
68
What are the signs of Pneumonia?
What is the Vocal Resonance like?
What kind of breathing pattern is seen?
remember the 2 highs
Fever
Purulent Sputum
PLEURITIC CHEST PAIN
Haemoptysis
Rigors
Tachycardia, Hypotension and Tachypnoea
_HIGH VOCAL RESONANCE_
- _Bronchial Breathing_= Higher Pitch- Expiration and Inspiration are equal. There will be an AUDIBLE PAUSE between Inspiration and Expiration
Pleural Rub may also be heard
69
What are the signs of Hospital-Acquired Pneumonia?
What 3 pathogens cause Hospital-Acquired Pneumonia?
Develops >2 days after Hospital Admission
Usually due to Pseudonomas Aeruginosa, Staphylococcus Aureus and Enterobacteria
*Pseudonomas, Enterobacter and Aureus*- PEA
The PEA causes Hospital Acquired Pneumonia
70
What are the signs of Aspiration Pneumonia?
Unsafe Swallow- Stroke, Myasthenia Gravis, Bulbar Palsy, Alcoholism and Achalasia
Right Lung is commonly affected as the right bronchus is wider
71
What are the signs of STAPHYLOCOCCAL PNEUMONIA?
What 3 groups of patients are at risk?
*BILATERAL Cavitating Bronchopneumonia*
Seen in
1) Intravenous Drug Users
2) Elderly Patients
3) Patients who already have an Influenza Infection
72
What are the signs of KLEBSIELLA Pneumonia?
Which Lobes are affected?
What is the hallmark feature of Klebsiella?
Which 2 groups of patients are typically affected by Klebsiella (underlined)? What typically occurs before Klebsiella?
Usually affects the _UPPER LOBES_- resulting in Cavitating Pneumonia
This presents with _Red-currant Sputum_
There is a higher risk of complications such as Empyema, Lung Abscesses and Pleural Adhesions
Risk Factor- _Alcoholics and Diabetics_, Elderly (weakened Immune System)
Risk Factor- Malignancy, Steroid Use, Renal Failure, COPD
_ASPIRATION typically occurs before Klebsiella_
73
What are the signs of MYCOPLASMA Pneumonia?
What can it lead to?
*WORSENING Flu, Dry cough and _Erythema multiforme_*
Presents like a FLU
- Arthralgia
- Myalgia
- Dry Cough
- Headache
It usually affects _YOUNGER PATIENTS_
It can cause _AUTOIMMUNE HAEMOLYTIC ANAEMIA_
Complications- Erythema Multiforme, Meningoencephalitis, _Steven-Johnsons, Guillain-Barre_
*Leads to Erythema Multiforme, Meningoencephalitis, Steven-Johnsons, Guillain Barre, Autoimmune Haemolytic Anaemia*
74
What are the signs of LEGIONELLA Pneumonia?
Which 2 things should you look for?
What 3 things are low? (one of these things is one of the things you should look out for as well)
What is the HALLMARK Risk Factor for this?
Fever, Myalgia, Malaise
with BRADYCARDIA and CONFUSION and _LYMPHOPAENIA_
Followed by Dyspnoea and a DRY COUGH
Look for 1) _HYPONATRAEMIA_ and 2) _DERANGED LFTs_
Usually occurs AFTER Hospital Air Conditioning/ Water exposure
*THREE THINGS low- _Lymphocytes, Heart Rate and Sodium_*
75
What are the signs of Chlamydophilia Psittaci Pneumonia?
It is acquired from contact with INFECTED BIRDS like Parrots, Cattle, Horses and Sheep
- Lethargy
- Arthralgia
- Headache
- Anorexia
- Dry Cough
- Fever
Additional features seen with Chlamydophilia Psittaci
- Hepatitis
- Splenomegaly
- Nephritis
- Infective Endocarditis
- Meningoencephalitis
- Rash
76
What investigations should be ordered in Acute Pneumonia?
ABG
Bloods- FBC, U&E, LFT, ESR, CRP
Blood Culture
Sputum for Microscopy & Culture
1) PCR for Mycoplasma Pneumonia
2) Urine Antigen- for Legionella and Pneumococcal Pneumonia
Chest Xrays- Lobar, Multilobar, Cavitation and signs of Pleural Effusion
77
What is the CURB65 Scoring System for Pneumonia?
Confusion (8 or less on AMTS)
Urea >7
Resp Rate>30
Blood Pressure <90/60
Age >65
1- Home Treatment
2- Hospital Treatment
3- Hospital Admission with consideration for ITU Referral
78
What is the management of Pneumonia?
Oxygen- keep sats above 94%
Fluid Management
Analgesia if there is Pleuritic Chest Pain- Paracetamol
Antibiotics Orally if not NBM (AMOXICILLIN and CLARITHROMYCIN)
Antibiotics Intravenously if Severe Pneumonia
79
What kind of Pneumonia is prevented by the Pneumococcal Vaccine?
Streptococcus Pneumoniae
80
What is Streptococcus Pneumonia associated with?
Herpes Labialis
81
What bacteria is commonly associated with patients with COPD?
Haemophilus Influenzae
82
What can be given as management for Aspiration Pneumonia?
Co-Amoxiclav
83
What is the most likely causative organism of Pneumonia AFTER Mechanical Ventilation?
Pseudonomas
- Treat with CIPROFLOXACIN
84
How do you differentiate between Staphylococcus Aureus and Streptococcus Pneumoniae (both Gram Positive and Cocci)?
Staph- Clusters
Strep- Chains
85
What is the management of Hospital Acquired Pneumonia?
IV Tazocin
86
What are the signs of Empyema in Pneumonia?
Recurrent Fever Despite Antibiotic Treatment for Pneumonia
pH<7.3
Manage with CHEST DRAIN under radiological guidance
87
Which 2 Pneumonias are associated with HIV and how can they be differentiated?
Streptococcus Pneumoniae and Pneumocystis Jiroveci
Streptococcus- Rust Coloured Sputum and Focal Consolidations
Pneumocystis Jiroveci- Bilateral Bihilar Interstitial Infiltrates
88
What is Pulmonary Hypertension?
An Increase in Mean Pulmonary Arterial Pressure (around 15mmHg)
89
What are the signs of Pulmonary Hypertension?
Shortness of Breath and ANKLE SWELLING (if COR PULMONALE)
Fatigue
Syncope
RAISED JVP
Parasternal Heave
Loud P2
Presence of an S3 Sound
Pansystolic Murmur (Tricuspid Regurgitation)
End Diastolic Murmur (Pulmonary Regurgitation)
90
What are the causes of Pulmonary Hypertension?
1) Parenchymal Lung Disease
- COPD
- Asthma
- etc.
2) Pulmonary Vascular Disease (Pulmonary Embolism, Portal Hypertension)
3) Hypoventilation
- Kyphosis/ Scoliosis
- Neuromuscular Conditions (Myasthenia Gravis)
4) Left Heart Disease
- Mitral Stenosis/ Regurgitation
- Left Ventricular Failure
91
What investigations should be ordered in Pulmonary Hypertension?
ECG- P Pulmonale, Right Ventricular Hypertrophy, Right Axis Deviation
Echocardiogram
Right Heart Catheterisation (GOLD STANDARD)- which will show a MEAN PULMONARY ARTERY PRESSURE >25mmHg
92
What is the management of Pulmonary Hypertension?
Treat the underlying condition
Reduction of Pulmonary Vascular Resistance
- Long Oxygen Therapy
- NIFEDIPINE
- Sildenafil
- Prostacycline analogues
- BOSENTAN (Endothelin Antagonist)
Manage the Heart Failure
Heart-lung transplant for selected cases
93
What are the possible causes of Pulmonary Fibrosis?
Lung Damage- Pneumonia, Infraction, Tuberculosis
Irritants- Coal or Silica
Diffuse Parenchymal Lung Disease- Idiopathic Fibrosis and Extrinsic Allergic Alveolitis
Connective Tissue Disease- Rheumatoid Arthritis, Systemic Lupus Erythematosus, Systemic Sclerosis, Sjogren's Disease
Medications- AMIODARONE, NITROFURANTOIN, BLEOMYCIN
Hypersensitivity Pneumonitis- Exposure to BIRDS or MOULDS
94
When does Idiopathic Pulmonary Fibrosis present?
In 70 year olds
95
What are the signs of Idiopathic Pulmonary Fibrosis?
Suspect if RESTRICTIVE LUNG DISEASE with Shortness of Breath and Non-Productive Cough- especially if Elderly
Dry cough and Shortness of Breath
Fatigue
ARTHRALGIA is seen in Idiopathic Pulmonary Fibrosis
Cyanosis and Clubbing
FINE End-Inspiratory Crackles
96
What are the complications of Idiopathic Pulmonary Fibrosis?
Type 2 Respiratory Failure
Increased chance of Lung Cancer
COR PULMONALE
97
What investigations should be ordered in Idiopathic Pulmonary Fibrosis?
Blood Tests- CRP, ANA and Rheumatoid Factors to find a cause
ABGs- Hypoxia and Hypercapnia are likely
Chest Xray- Bilateral LOWER ZONE Reticulo-nodular Shadowing
High Resolution CT- Reticulonodular Shadowing and Honeycomb Lung
Spirometry- RESTRICTIVE Deficit with Reduced Transfer Factor
98
What is the management of Idiopathic Pulmonary Fibrosis?
Stop Smoking, Pulmonary Rehabilitation
Lung term Oxygen Therapy
Antifibrotics (Pirfenidine)
Symptom control in Right Heart Failure
Cure- Lung Transplant is the only cure
99
What are the ABGs in Respiratory Alkalosis?
High pH
Low pCO2
Low HCO3
100
What are the causes of Respiratory Alkalosis?
CNS Infection
Subarachnoid Haemorrhage
Panic Attack
Pulmonary Emboli (through Reflex Hyperventilation)
Aspirin Overdose (then it becomes Metabolic Acidosis)
Hypoxia (like Hyperventilation)
Anaemia
101
What is Type 1 Respiratory Failure?
It it is when there is a NORMAL PaCO2 with LOW O2
This is due to V/Q Mismatch- The volume of air entering the lung is TOO LOW to keep up with the amount of blood perfusing the lungs
102
What are the causes of Type 1 Respiratory Failure?
Congestive Cardiac Failure
Asthma
Pulmonary Embolism
Pneumonia
Pneumothorax
103
What are the V/Q levels for the different causes of Type 1 Respiratory Failure?
Low V/Q- Poor Ventilation but Well Perfused
1) Bronchoconstriction (Asthma)
2) Airway Collapse (Emphysema)
3) Mucus Plug
4) Congestive Cardiac Failure
High V/Q- Ventilation is fine but Perfusion is bad
1) Pulmonary Embolism
104
What is Type 2 Respiratory Failure?
Low PaO2 (<8)
but PaCO2 is HIGH (>6)
This occurs due to Alveolar Hypoventilation- The lungs are NOT ABLE to Oxygenate the blood and Decarbondioxify the blood
(so Low O2 and High CO2)
105
What are the causes of Type 2 Respiratory Failure?
1) COPD
2) Idiopathic Pulmonary Fibrosis
3) Opiates (as they cause Depression of the Respiratory Centers)
4) Neuromuscular Diseases- Guillain-Barre Syndrome and Motor Neuron Disease
5) Thoracic Wall Disease- Rib Fracture
106
What is Sarcoidosis?
1) Suspect if Afro-Caribbean
2) High ESR/ Calcium
3) Red Lesions
4) Joint Pain
It is a multisystem disease characterised by Granuloma formation
This results in Widespread Inflammatory Changes and Complications
107
What are the Acute signs of Sarcoidosis?
Fever
Polyarthralgia
Erythema Nodosum
Bilateral Hilar Lymphadenopathy
This is also known as LOFREN SYNDROME
108
What are the Chronic Signs of Sarcoidosis?
Pulmonary (most common manifestation)
1) Dry Cough
2) Dyspnoea
3) EXERTIONAL DYSPNOEA
4) Examination may reveal CREPITATIONS
Constitutional
1) Fatigue
2) Weight Loss
3) Arthralgia
4) Low-grade Fever
5) There will also be Lymphadenopathy and ENLARGED PAROTID GLANDS
Neurological
1) MENINGITIS
2) Peripheral Neuropathy
3) Bilateral BELL's PALSY
Ocular
1) Uveitis
2) Keratoconjunctivitis Sicca
Cardiac
1) Arrhythmias
2) RESTRICTIVE CARDIOMYOPATHY
Abdominal
1) HEPATOSPLENOMEGALY
2) Renal Stones
Dermatological
1) Erythema Nodosum
2) Lupus Pernio
109
What Investigations should be ordered in Sarcoidosis?
(Any) Tissue Biopsy is DIAGNOSTIC- you would see NON-CASEATING GRANULOMAs on Biopsy
Bloods
1) HIGH ESR
2) Raised ACE
3) Raised Calcium
4) LOW Lymphocytes
CXR or CT
1) Stage 1- Bilateral Hilar Lymphadenopathy (BHL)
2) Stage 2- BHL with PERIPHERAL INFILTRATES
3) Stage 3- ONLY Peripheral Infiltrates
4) Stage 4- Pulmonary Fibrosis
110
What is the management of Sarcoidosis?
Stage 1- usually self-resolving
Acute Sarcoidosis- Bed Rest/ NSAIDs
Steroid Treatment- Either Oral or IV depending on the severity
If SEVERE- give IMMUNOSUPPRESSANTS
111
What are the Spirometry results for Restrictive Lung Diseases?
Decrease in both FEV1 and FVC
So FEV1/FVC will be normal and GREATER than 0.7
This is seen where the Lung Volume is reduced
112
What are the causes of Restrictive Lung Disease?
Respiratory
1) Pulmonary Fibrosis
2) Acute Respiratory Distress Syndrome
3) Pneumoconiosis
Neuromuscular
1) Myasthenia Gravis
2) Motor Neurone Disease
Thoracic
1) Obesity
2) Kyphosis
113
What are the Spirometry results for Obstructive Lung Diseases?
FEV1 is lower than the FVC
So FEV1<0.7
114
What are the causes of Obstructive Lung Diseases?
Asthma and COPD
Bronchiectasis
Cystic Fibrosis
115
How is TB Spread and what are the risk factors for TB?
Spread through Droplets
Risk Factors
1) Sub-saharan Africa/ South Asia
2) Homeless
3) Drug and Alcohol Abuse
4) Contact with Infected Patient
5) IMMUNOSUPPRESSION
6) Young or Old Age
116
What are the signs of Tuberculosis?
General
- Night Sweats
- Fever
- Weight Loss
Pulmonary (Most Common)
- Chronic Cough and Purulent Sputum (with or without Haemoptysis)
- Bronchiectasis, Pneumonia, Pleural Effusion
- INSPIRATORY CHEST PAIN
Genitourinary (Second Most Common)
- "Sterile" Pyuria
- Kidney Pathology
- Abscesses
- Salpingitis and Infertility
- Epididymo-Orchitis
CNS Presentation
1) TB Meningitis or Tuberculoma
2) Headache
3) Meningism
4) Focal Neurological Signs
5) Decreased Consciousness
Musculoskeletal
1) Arthritis/ Osteomyelitis
2) PSOAS Abscess
3) Pott's Disease of the Spine
Gastrointestinal
1) Abdominal Pain
2) Appendicitis due to Ileocaecal Lesions- Can get to Peritoneum which causes ASCITES
Pericardial
1) Pericardial Effusions
2) Constrictive Pericarditis
Lymph Nodes
1) Tender and Firm
Cutaneous
1) Erythema Nodosum and Bazin's Disease
117
What investigations should be ordered in Tuberculosis?
1) Chest X ray
2) Early Morning Sputum samples for culture and sensitivity- ACID FAST BACILLI
3) Samples from Non-pulmonary sites- May need Biopsy and Needle Aspiration
4) Ziehl-Neelsen or Auramine Staining
5) PCR with drug sensitivity
6) Interferon-Gamma Release Assays- Use this if the patient has had a PRIOR BCG INFECTION
7) Mantoux Test- it is AFFECTED by a PRIOR BCG INFECTION
118
What is the management of Tuberculosis?
RIPE for 2 months then just RI for 4 months
If Multidrug Resistance- Macrolides, Quinolones, Capreomycin
119
What are the side effects of Isoniazid (TB)?
Peripheral Neuropathy (Pyridoxine is given to prevent this)
Gout
LIVER TOXICITY
120
What are the side effects of Rifampicin (TB)?
Body Fluids become ORANGE
It induced Liver Enzyme P450
LIVER TOXICITY
121
What are the side effects of Ethambutol (TB)?
Visual Disturbances (Colour blindness, Loss of Acuity)
Avoid in CKD
122
What are the side effects of Pyrazinamide (TB)?
LIVER TOXICITY
123
What is the only TB Drug that does NOT have the LIVER TOXICITY Side Effect?
Ethambutol
124
What are the Chest Xray Findings in Tuberculosis?
Fibro-Nodular Opacities (Usually Upper Lobe)
