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ESA 3 Callum's Cards > Respiratory S7 (Done) > Flashcards

Respiratory S7 (Done) Flashcards

1
Q

List some of the common microbial flora in the Upper respiratory tract (URT)

A

Common permanent colonies:

Viridans streptococci

Neseria spp.

Anaerobes

Candida sp

Common transient colonies:

Streptococcus pneumoniae

Strep pyogenes

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2
Q

List the specific defenses of the respiratory system against infection

A

Muco-ciliary clearance:

Nasal hairs, ciliated columnar epithelium

**Cough and sneezing reflex **

Respiratory mucosal immune system:

Lymphoid follicles in the pharynx and tonsils, alveolar macrophages, secretory IgG and IgA

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3
Q

Give examples of URT infections

A

Rhinitis (Common cold)

Pharyngitis

Epiglotitis

Laryngitis

Tracheitis

Sinusitis

Otitis media

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4
Q

What are the common features of URTIs?

A

Most commonly causes by viruses:

Rhinovirus

Coronavirus

Respiratory syncytial virus (RSV)

Can lead to bacterial superinfection:

Esp. Sinusitis and otitis media

Can lead to mastoiditis, meningitis, brain abscess

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5
Q

What are the two common forms of Lower respiratory tract (LRT) infections?

A

Bronchitis

Pneumonia

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6
Q

Differentiate aetiology of acute and chronic bronchitis

A

Acute:

Viruses and bacteria

May lead to pneumonia

Chronic:

Not primarily infective

Exacerbations can be infective

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7
Q

Give a brief description of pneumonia

A

Infection of pulonary parenchyma:

Involves distal airspaces and results in inflammatory exudate

Fluid filled air spaces and consolidation lead to heavy, stiff lungs

Gas exchange impaired resulting in local and systemic effects

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8
Q

By what methods might we classify pneumonia?

A

Clinical setting (Hospital, community)

Presentation (acute, sub-acute, chronic)

Organism (bacteria, fungi, viral)

By lung pathology (lobar, broncho- or interstitial pneumonia)

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9
Q

What is pneumonitis?

A

Non-infective inflammatory disease of lung parenchyma

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10
Q

Give examples of common and atypical bacteria implicated in pneumonia

A

Common:

S. pneumoniae

H influenzae

Kleb pneumoniae

Atypical:

Chlamydia spp.

Mycoplasma

Legionella

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11
Q

Give examples of common viruses implicated in pneumonia

A

Influenza

Parainfluenza

RSV

Adenovirus

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12
Q

Give examples of common microbiota implicated in:

    • Hospital acquired pneumonia*
    • Aspirational pneumonia*
    • Pneumonia in immunocompromised host*
A

Hospital:

G-neg enteric bacteria

Pseudomonas

S aureus and MRSA

Aspirational:

Anaerobes and oral flora

Immunocompromised host:

Candida sp

Aspergillus

Viruses (HSV, VZV)

Pneumocystis jirovecii

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13
Q

What are some patient features associated with S pneumoniae infection?

A

Elderly

Co-morbidities

Acute onset

High fever

Pleuritic pain

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14
Q

What are some patient features associated with H influenza infection

A

COPD

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15
Q

What are some patient features associated with Legionella infection

A

Recent travel

Infected aerosol exposure

Smokers

Young

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16
Q

What are some patient features associated with Mycoplasma infection

A

Young

Prior antibiotics

Extra-pulmonary involvement (haemolysis, skin and joints)

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17
Q

What are some patient features associated with S aureus infection

A

Post viral

People who inject drugs (PWID)

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18
Q

What is lobar pneumonia?

A

Confluent consolidation involving a complete lung lobe

Most often due to Strep pneumoniae

Usually community acquired

Acute onset

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19
Q

Describe the pathology of lobar pneumoniae

A

Disease:

Acute inflammatory response

Exudation is fibrin rich fluid

Neutrophil and macrophage infiltration

Response:

Resolution due to immune system

Antibodies opsonise and lead to phagocytosis of bacteria

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20
Q

What is broncho-pneumonia?

A

Infection starting in the airways and spreading to adjacent alveoli and lung tissue

Most commonly seen in context of pre-existing disease

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21
Q

What might be the causes of broncho-pneumonia?

A

Complication of viral infection (influenza)

Aspiration of gastric contents

Cardiac failure

COPD

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22
Q

Describe the appearance of broncho-pneumonia when viewed radiologically

A

Pathy infiltrates that are not confined to lobar architecture

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23
Q

List the typical organisms causing broncho-pneumonia

A

Srep pneumoniae

H. influenza

S. aureus

Anaerobes

Coliforms

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24
Q

What is the treatment for typical acute bacterial pneumonia?

A

Amoxicillin (Mild to moderate)

Co-amoxiclav (severe)

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25
What are the possible outcomes of acute bacterial pneumonia?
**Resolution** Organisation of tissue (Fibrous scarring) **Complications:** Lung abscess Bronchiectasis Empyema
26
Describe the investigations and appearance of atypical pneumonia
**Investigations:** Sputum stain and G culture CXR Urine antigen test (legionella) Bllod testing for antibodies **Appearance:** Unilateral/bilateral path segmental infiltrates (usually lower lobes)
27
Describe the typical causative organisms and treatment for atypical pneumonia
**Organisms:** Chlamydia pneumoniae Mycoplasma pneumoniae Legionella pneumoniae (Notifiable) **Treatment:** Levofloxacillin, Erythromycin, Clarithromycin, Doxycycline
28
Describe the pathology and appearance of viral pneumonia
**Pathology:** Damage to cells lining the airways/alveoli by the virus and immune cells Fluid fills air spaces and interferes with gas exchange Severe forms can lead to necrosis/haemorrhage into lung parenchyma **Appearance:** Patchy or diffuse Ground glass opacity on CXR
29
What is the definition of hospital acquired pneumonia? In who is it most common?
Pneumonia occuring 48hrs post-admission Most common in ITU, post surgical and ventilated patients
30
What organisms are the likely causes of HAP and how is it treated?
**Organisms:** Enteric Gram-neg bacteria (E. coli) Pseudomonas Anaerobes S aureus/MRSA **Treatment:** Broad spectrum antibotics
31
What conditions predispose aspirational pneumonia? What are the at risk groups for aspirational pneumonia?
**Predisposing conditions:** Alcoholism Dsyphagia Epileptics Drowning **Risk groups:** Eldery in care homes Drug takers
32
What are the symptoms of pneumonia?
Fever, Chills, Sweats, Rigor Cough Purulent/Rust-coloured sputum Dyspnoea Pleuritic chest pain Maliase, Anorexia, Vomiting Headache Myalgia Diarrhoea
33
What are the specific chest signs of pneumonia?
Bronchial breath sounds Crackles Wheeze Dullness to percussion Reduced vocal resonance
34
List the non-microbiological investigations for pneumonia
CXR O2 sats and ABG FBC, WBCC, Platelets Urea, LFT and CRP
35
What are the useful markers in assessment of pneumonia disease progression?
**WBCC:** \>20 or \<4 indicate severe disease **CRP:** Assessment of response to treatment **Radiology:** Reliable Radiological signs can very rarely lag behind clinical characteristics (24-48hrs)
36
What are the microbiological samples that might be taken during diagnosis/treatment of pneumonia?
Sputum Nose or throat swabs Endotracheal aspirates Broncho-alveolar lavage fluid Open lung biopsy Blood culture Urine (Detect legionella antigens) Serum
37
What are the microbiological investigations into pneumonia?
Macroscopy (Mucoid, purulent, blood stained) Microscopy (Gram stain, acid fast, special stains) Culture (Bacteria and virus) PCR (respiratory virus ID) Antigen detection (Legionella in urine) Antibody detection (serology)
38
What is the CURB-65 prognostic index?
Used to assess severity of pneumonia **Criteria:** Confusion (AMT \<8) Urea - \>7 RR - \>30 BP - \<90s or \<60d Age - \>65 Add 1 point if yes to any of these If score is \>2 then admission +/- ITU referal advised
39
What are the principles of pneumonia treatment?
Assess severity and co-morbidities Give supportive and specific treatment Broad spectrum antibiotics to cover most organisms Review patient if change in microbiology resuts or poor response Follow local guidelines
40
Describe the antibiotic treatment of pneumonia
**1st line:** Penicillin class antibiotics (Amoxycillin) **Severe infection:** Penicillin class + Clavulanic acid (Co-amoxiclav) **Legionella pneumonia:** Levofloxacin **Other atypical organisms:** Tetracyclines or macrolides **Poor response:** Discuss with microbiology
41
Describe pneumonia prophylaxis
**Immunisation:** Flu vaccine - annual to high risk patients Pneumococcal vaccine (2 vaccines) **Chemoprophylaxis:** Oral penicillin/erythromycin to high risk patients (i.e asplenia, immunodeficient)
42
In what circumstances should you refer to ITU in a patient with pneumonia?
CURB-65 of \>2 Respiratory failure occurs Rising pCO2 Worsening metabolic acidosis Hypotension despite fluid resus *Query patient suitability for ITU (E.g. If ITU treats successfully will there be any quality of life?)*
43
What special measures must be taken in the dignosis of pneumonia in the immunocompromised host?
High index of suspicion Multidisciplinary involvement Broncho-alveolar lavage and lung biopsies as a more standard method of histological diagnoses (lots of special stains!)
44
List the likely causes of pneumonia or LRTIs in a cystic fibrosis patient
**Early infections:** H influenza S aureus **Later:** Pseudomonas aeuruginosa Burkholderia cepecia
45
What is the common causative organism of pneumocystic pnumonia? Who are at risk for this infection?
**Organism:** Penumocystis jirovecii **Risk groups:** HIV infected Transplant recievers Immunocompromised
46
How is diagnosis of Pseudomonas jirovecci infection made? What is the reccomended treatment?
**Diagnosis:** Induced sputum, broncho-alveolar lavage and lung biopsy used to determine diagnosis histogogically PCR can be used to confirm P jirovecii **Treatment:** High dose Cotrimoxazole
47
What is Whooping cough? What are the symptoms?
**What:** Disease of respiratory tract caused by Bordetella pertussis **Symptoms:** Starts off cold-like Progresses to characteristic 'whoop' or vomiting Can last 2-3 months
48
Who is at greatest risk of Whooping cough? How is it spread?
**High risk:** \<1 year **Transmission:** Droplets
49
Outline the clinical management of whooping cough and prevention of whooping cough
**Diagnosis:** Specimens (Nasal or nasopharyngeal swbs or aspirates) Culture/PCR **Treatment:** Erythromycin **Prevention:** Childhood vaccination Vaccination of pregnant mothers
50
What is the incidence rate of lung cancer and related mortality in the UK?
37,500 new cases per year 33,000 deaths per year
51
Smoking causes what proportion of lung cancer in: * - Male smokers* * - Female smokers* * - Non smokers*
90% 80% 20%
52
What proportion of cancer deaths are attributable to smoking?
1/3
53
What are some risk factors for lung cancer other than smoking?
**COPD** (3-6x relative risk) Asbestos Radon gas exposure (mining or indoor exposure) Occupational carcinogens (Chromium, nickel, arsenic) Genetic/familial factors
54
How is Lung cancer distributed over socio-economic groups?
**Higher prevalence in the poorer:** 40 per 100,000 in affluent 100 per 100,000 in poorest *Age standardised*
55
What are the symptoms of a primary lung tumour?
Cough Dyspnoea Wheezing Haemoptysis Chest/Shoulder pain Weight loss Lethary/Malaise
56
What are the possible symptoms of a region lung cancer metastases?
Superior vena caval obstruction Hoarseness (Left reccurent laryngeal nerve palsy) Dyspnoea (Phrenic nerve palsy) Dysphagia
57
What are some of the possible symptoms of distant lung cancer metastases?
Bone pain/fracture CNS symptoms (Headache, double vision, confusion)
58
List the range of paraneoplastic syndromes possible in lung cancer
**Endocrine:** Hypercalcaemia Cushings SIADH **Neurological:** Encephalopathy Peripheral neuropathy **Haematological:** Anaemia Thrombocytosis **Skeletal:** Clubbing
59
Where are the common sites of metastases for lung cancer?
**Local:** Draining nodes Pleura Pericardium **Distant:** Brain Liver Adrenals Bone
60
How is lung cancer first investigated then diangosed and staged?
**On first clinical suspicion:** Plain CXR **Diagnosis and staging:** Serum biochemistry (Na+, LFT, Ca2+) Imaging (CT and PET CT, Isotope bone scan) Tissue: * - Endobronchial ultrasound* * - CT guided biopsy of lung* * - Biopsy of lymph nodes, pleura and metastatic sites*
61
What are the major cell types in lung cancer?
**Carcinoma:** Non-small cell carcinoma: ~**80%** * - Squamous cell carcinoma ***~40%** * - Adenocarcinoma* * - Large cell carcinoma* Small cell carcinoma ~**12%** Rare tumours (E.g. Carcinoid) ~**5%**
62
Describe squamous cell carcinoma
Often central tumours Angulate cells Eosinophilic cytoplasm Keratinisation Intercellular bridges Keratin pearls
63
Describe adenocarcinoma
Often peripheral tumour Columnar/cuboidal cells Form acini (glands) Papillary structures May line alveoli Some produce mucin
64
Describe small cell carcinoma
Very cellular tumour Small nuclei Little cytoplasm Nuclear moulding Often necrosis and lots of mitoses
65
Describe the local effects of cancer within the lung
Necrosis +/- cavitation Ulceration (haemoptysis) Infection (abscess formation Bronchial obstruction, lung collapse, consolidation
66
Describe the effects of spread of lung cancer within the thorax
Direct spread or metastasis to pleura/pericardium Pleural/pericardial effusions Compression of structures (Superior vena caval obstruction, dysphagia) Reccurent laryngeal nerve might be effected (Hoarseness) Phrenic nerve might be affected (Diaphragm palsy/dyspnoea)
67
68
What is the role of imaging in lung cancer?
**Extensive use through clinical experience** Screening Diagnosis, staging, trreatment planning Assessing response to treatment Assessing complications Aiding interventions Checking for recurrence
69
How is lung cancer staged?
TNM staging I - IV
70
Describe the difference between a stage I and Stage IV primary lung tumour
**TI:** \<3cm diameter, operable **TIV:** Large, usually inoperable lung mass Invades into surrounding structures (Trachea, pleura, bronchi, mediastinum, great vessels)
71
Describe nodal staging in lung cancer
Nodes with short axis diameter of \>10mm considered abnormal Where abnormal nodes appear determines stage **NI:** Peribronchial Ipsilateral hilar **N2:** Ipsilateral mediastinal Subcarinal **N3:** Contralateral mediastinal Contralateral hilar Scalene Supraclavicular
72
Describe metastases staging in lung cancer
**M0:** No metastases **M1a:** Lung nodules, pleural effusion **M1b:** Distant metastases
73
What radiological investigations would you perform to find/assess bone metastases
X ray Scintigraphy
74
Describe scintigraphy of bone and how it's useful to visualising bone metastases
**Scintigrpahy:** Radioiostopes administered and prefferentially taken up by bone Greatest concentrations will be in areas of greatest cellular activity Radiation detected by external cameras **Use:** Metastases will appear as areas of bone with higher than normal activity and hence darker
75
What is the role of ultrasonography in lung cancer?
Guided biopsy (Lung, liver, ribs, peripheral lesions) Identification of pleural effusion Identification of chest wall invasion of tumour
76
What is the role of stenting in lung cancer?
Primary tumours or local metastases can compress and obstruct flow through structures, stenting alleviates this E.g. Superior vena cava obstruction stenting or airway stenting
77
What is the role of MRI in lung cancer?
Identification of metastases
78
What is FDG PET?
FGD is a glucose analogue with a Flourine-18 atom attached FDG taken up into cells as a marker for glucose uptake Increased FGD uptake therefore indicates metabolic rate Flourine 18 emits positrons to allow this to be visualised in a PET scanner
79
What are overall 5 year and median survival rates for lung cancer? What factors influnece prognosis?
**5 yr survival:** 10-15% **Median:** 6 months **Prognosis:** Cell type Stge Performance ststus (General fitness) Biochemical markers Co-morbities
80
What is the most coomon routes to diagnosis for pateints?
Emergency presentation (~40%) Screening (~20%)
81
How does route to diagnosis affect survival rates?
Emergency presentation has a 12% survival rate at 1 year Screened, two week waiters, GP referral or other outpatients have 40% survival at 1 yr
82
What are the treatment options for lung cancer?
**Surgery:** Normally non-small cell (20-25% operable) **Radiotherapy:** Either radical (potentially curative) or palliative (Symptom control **Combination chemotherapy:** Small cell is potentially curative Non-small cell gives modest survival increase and symptom control **Combination therapy:** Chemo-radiotherapy (potentially curative) **Biological therapies** **Palliative care**
83
Describe non-small cell lung cancer management
**Multimodality therapy** **Palliative radiotherapy:** For local symptom relief and bony metastases symptom relief **Chemotherapy:** 50-60% response rates, modest survival improvement, can be cell type targeted **Combination Chemo-radiotherapy:** Important in locally advanced disease **Targeted agents:** Epidermal growth factor inhibitors ALK inhibitors Immunotherapy
84
Describe small cell lung cancer management
Systemic and rarely operable disease with ~3 month survival untreated Treatment focus is therefore palliative 85-90% respond to combination chemo, gives approx 1 year added survival if combined with radiotherapy in early stage disease Death from cerebral metastases common
85
What and who is involved in supportive treatment for lung cancer?
Focuses on prompt treatment of symptoms Palliative care involvement from early stage Nurse specialists have a central role Specific palliation best done by appropriate clinician for symptoms
86
What are the problems with lung cancer management and attempts to treat?
Late diagnosis common Poor prognosis Very symptomatic Professional nihlism Variable standards of care Lack of public pressure for improvement
87
What are the effects of public health campaigns and screening regarding lung cancer?
E.g. 3 week cough campaign Reduced incidence of death from lung cancer in those screened Shift towards earlier stage diagnosis

ESA 3 Callum's Cards (55 decks)

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