Respiratory System Flashcards
What is the relation of Pulm. artery to bronchus at each lung hilum ??
“RALS”
Right bronchus = Anterior
Left bronchus = Superior
CARINA - is Posterior to ascending aorta & Anteromedial to descending aorta
What are the lung
- Volumes
- Capacities
TV ( 6 to 8 ml/kg = 500ml)
IRV (
ERV (
Residual Volume (TLC minus VC)
Insp. Capacity (IRV + TV)
Func. Residual C (RV + ERV)
Vital C (IRV + TV + ERV)
TLC (IRV + TV + ERV + RV = VC + RV)
How much is the normal Peak Expiratory Flow ??
520 to 700 L/min
Define Lung capacity ?
Sum of >= 2 physiological volumes
- there are 4 volumes & 4 capacities
What is Physiological dead space (VD) ??
VD = TV * (PaCO2 - PeCO2)/PaCO2
(PeCO2 = expired air CO2)
- It is approx. = to Anatomical dead space in normal lungs
What is Transfer factor ??
Rate at which gas will diffuse from alveoli ==> blood
- Carbon monoxide is used to test rate of diffusion
What are the causes of raised TLCO (Total gas transfer) ??
Raised - “MAPLE- H”
- Male gender
- Asthma
- Pulm. Haemorrhage (Wegener’s, Goodpastures)
- Polycythaemia
- Left- Right Cardiac shunt
- Exercise
- Hyperkinetic states
What are the causes of lower TLCO ??
Lower “LAPE”
- Lower Cardiac Output
- Anaemia
- Pulm. FIBROSIS
- Pulm. OEDEMA
- Pulm. EMOBOLI
- Pneumonia
- Emphysema
- Cryptogenic Organizing Pneumonia
What conditions cause Increased KCO (transfer coefficient) with a normal/ reduced TLCO ??
Pneumonectomy/ Lobectomy
Kyphosis/ Scoliosis
Neuromuscular weakness
Ankylosis of costo-vertebral joints (Ank. Spon.)
What are the ABCs of obstructive lung disease ??
Asthma
Bronchiectasis
Bronchiolitis obliterans
COPD
Eg. of Restrictive Lung disease ??
ARDS
Asbestosis
Infant RDS
Kypho-scoliosis (eg. Ank. Spon.)
Pulm. Fibrosis
Neuromuscular disorders
Sarcoidosis
Severe Obesity
Salicylate poisoning hallmark ??
Early- Resp. Alkalosis (Resp. centre stimulation
Late - Met. Acidosis (direct acid effect + Acute renal failure)
What is O2 dissociation curve ??
Relationship b/w Percentage of saturated Hb & partial pressure of O2 in blood
- NOT affected by Hb conc.
Cause of
- Left Shift
- Rt. Shift
Left –Lower O2 delivery ==> Low CADET
Rt. – RaiseD O2 delivery ==> Raised CADET
CADET - Co2, Acid, (2,3-DPG), Exercise, Temp.,
How does Salbutamol work ??
Beta receptor AGONIST (relaxes bronchial SM by effects on Beta 2 receptors)
How does Ipratropium work ??
Muscarinic ACh receptor BLOCKERS
- Relaxes Bronchial SM
TIOTROPIUM is long acting
Methylxanthines or Aminophyllines action ??
Non-specific PD inhibitor (increases cAMP)
Non-specific Adenosine receptor blockers
Drug for Aspirin induced asthma
Leukotriene ANTAGONISTS
- Montelukast, Zafirlukast
- Anti-inflammatory + bronchodilator action
Contraindication for Leukotriene antagonists ??
Churg-Strauss synd.
CRP levels and starting antibiotics in Pneumonia ??
< 20 mg/L = no antibiotics
20 to 100 mg/L = consider DELAYED antibiotics prescription
> 100 mg/L = OFFER antibiotics
in admitted pts., CRP monitoring determines response to Rx.
Rx. of Low-severity Pneumonia ??
1st line = AMOXICILLIN
Macrolides/ Tetracycline if Penicillin allergics
5 days course
Rx. for Moderate severity Pneumonia ??
Dual Abx. Therapy
- Amoxicillin + Macrolides
- 7 to 10 days course
Rx. for High severity Pneumonia ??
Dual Abx. Therapy
- Beta-lactamase stable penicillin (Co-amoxiclav, Ceftriaxone, Piptaz)+ Macrolides
Klebsiella Pneumonia features
- Gram -ve rods, part of normal gut flora
- MC in Alcoholics, DM, Aspiration cases
- RED-CURRANT Jelly sputum
- often affects UPPER Lobes
- Lung abscess, Empyema common
What is Cryptogenic Organizing Pneumonia (COP) ??
Diffuse interstitial lung disease which affects
- Distal bronchioles
- Resp. bronchioles
- Alveolar ducts & walls
Features of COP ??
M = F, MC in 5th to 6th decade of life
- Cough + SoB + Fever & malaise
- H/o NON-response to antibiotics
- NOT a/w Smoking
X-ray of COP??
B/L patchy or Diffuse Consolidative or Ground glass opacities
- TLCO is reduced
MC cause of Lung abscess ??
secondary to Aspiration pneumonia
Features of Lung abscess ??
Night sweats, fever, wt. loss
- Foul smelling sputum, haemoptysis
- Chest pain, dyspoenia
Signs- Dull on percussion + Bronchial breathing + Clubbing
X-ray = Fluid filled space within area of consolidation + AIR-FLUID level is typical
Rx. for Lung Abscess ??
IV Abx.
- If NOT resolving = Percutaneous drainage
- Surgical resection (in rare cases)
What is MERS ??
Middle East Resp. Synd.
- Betacorona virus MERS-CoV
- limited to ARABIAN Peninsula
- Incubation period = 2 to 14 days
RF - Contact with CAMELS & its products (MILK)
Pulm. Fibrosis features ??
Dry cough + Bibasal end-inspiratory crackles
- NO wheeze
When should we suspect Psittacosis ??
- Fever + H/o Bird contact (or)
- Pneumonia + Severe headache/ Organomegaly + Failure to respond to Penicillin based Abx.
- Young adults
Features of Chlamydia psittaci??
- Obligate intracellular bacterium
- Birds/ bird secretions (urine/ faeces) after cleaning bird cage
Psittacosis presentation ??
- Flu like symp. (90%) = Fever, Headache, Myalgia
- Resp. symp. (82%) = Dyspnoea, DRY cough, chest pain
Signs : - U/L crepts & Vesicular breathing
- Hepato-Spleno megaly (rare)
X-ray : CONSOLIDATION
IOC for Psittacosis ??
Serology
Consolidation on CXR
Raised Inflammatory markers
Rx. for Psittacosis ??
1st line= TETRACYCLINES (Doxy.)
2nd line= MACROLIDE (Erythromycin)
What is Bronchiectasis ??
Permanent dilation of airways due to destruction of muscular & elastic components of bronchial walls ==> Mucus plugging ==> OBSTRUCTION
Strong predictor of mortality in Bronchiectasis ??
BREATHLESSNESS
Pseudomonal colonization (3x)
Rx. for Bronchiectasis + suspect Pseudomonas infection ??
Nebulized TOBRAMYCIN for Pseudomonas
Acute infection - 14 days Abx. & prolonged if colonized
CT features of Bronchiectasis ??
Tram track
Signet ring
Enlarged airways & thickened walls filled with mucus
Kartagener’s synd.??
Dextrocardia
Situs inversus
Chr. sinusitis
Ix.OC- Nasal brushing for electron microscopy
Yellow Nail Synd. ??
a/w
- Pleural effusions
- Lymphoedema
- Yellow nails
Young’s synd. ??
Normal Sweat test/ pancreas BUT
Bronchiectasis, Azoospermia, Sinusitis similar to CF
What is Bronchiolitis ??
Acute bronchiolar inflammation
- RSV (75 to 80%)
- MCC of serious LRTI in < 1yr old (peak incidence 3-6 months)
- MC in Winter
What is the Protective factor against Bronchiolitis in newborns ??
Maternal IgG
Rx. for Bronchiolitis ??
largely Supportive
-Humidified O2 via Headbox (typically when sats. persistently < 92%)
- NG feeding (if unable to feed PO)
- Suction (if excessive upper airway secretion)
Dx. tool for Asthma ??
Obj. testing preferred over Subj. clinical judgement
- FeNO (measures airway inflammation)
- Spirometry
- Peak Flow variability
Applicable in >= 5yrs pts.
What is FeNO ??
Fractional exhaled Nitric oxide
- measures airway inflammation
- linked to “inducible Nitric Oxide Synthase” (iNOS) which increases in eosinophillic inflammation.
How to Dx. asthma in >= 17 yrs old pts. ??
- 1st rule out occupational asthma
- Spirometry + BDR
- FeNO
How to Dx. asthma in 6 to 17 yrs old pts. ??
- 1st = FeNO (+ve if >= 35 ppb)
- if not positive or unavailable do Spirometry + BDR
When is FeNO called +ve in asthma ??
Adults : >= 50 ppb
Children : >= 35 ppb
When is {Spirometry + BDR} termed +ve in asthma ??
FEV1/FVC < 70%
Post BD
- Adults :- FEV1 improves by >= 12% & increase in volume of >= 200ml
- Children :- FEV1 improves by >= 12%
MCC of occupational asthma ??
ISOCYNATES (spray painting, foam moulding using adhesives)
Other causes: Soldering flux resin, Glutaraldehyde, Flour, Epoxy resin, Proteolytic enzyme
Rx. of newly dx. MILD asthma ??
AIR therapy (Anti-Inflam. Reliever)
- Low dose ICS + Formaterol
- used as needed
used in >= 12yrs old pts.
How to escalate Rx. in Asthma ??
(5 steps ??)
- AIR therapy (sos)
- Low dose MART (sos + maintenance)
- Moderate dose MART
- Moderate dose MART + Add on therapy (LTRA or LAMA)
- Specialist Referral ( biologics like Omalizumab + Mepolizumab + Dupilumab)
NOTE - Always check for TECHNIQUE & ADHERENCE in every step
Criteria to start regular therapy in asthma ??
symp. ocurring for >= 3 days/week (or) Night time awakenings
How is asthma classified for BIOLOGICS Rx. ??
- Allergic
- Eosinophillic
- Type 2 inflammation driven asthma
What are the specific cytokines involved in Type 2 inflam. driven asthma ??
IL-4, IL-5 & IL-13
Biological drug used for Allergic asthma ??
Anti-IgE therapy
OMALIZUMAB
Biologic drug used for Eosinophilic asthma ??
Anti- IL-5 therapies
- MEPOLIZUMAB
- BENRALIZUMAB
- RESLIZUMAB
Biologics used in Type 2 inflam. driven asthma ??
Anti- IL-4/ IL-13 therapy
- DUPILUMAB
Biologics used for Severe asthma regardless of Eosinophil count ??
TEZEPELUMAB (Tezspire)
COPD causes ??
SMOKING
A1AT deficiency
Cadmium (Smelting)
Cement, Grain, Coal, Cotton
When should we consider a dx. of COPD ??
(>= 35yrs) + (current Smoker/ Ex-Smoker) + C/F (SoB on exertion, Chr. cough, regular Sputum)
When is LTOT offered ??
pO2 < 7.3 kPa + NOT Smoking (or)
pO2 7.3 to 8.0 kPa + NOT Smoking with any one of the following :
- Secondary Polycythaemia
- Pulm. HTN
- Peripheral Odema
Signs of Cor-Pulmonale in COPD pts. ??
Peripheral edema
Raised JVP
Systolic Parasternal Heave
Loud P2
What is the MCC of infective acute exacerbation of COPD ??
H influenzae (MC)
Strep. pneumonia
M catarrhalis
MC resp. virus : Human Rhino-virus (30% cases)
Rx. of acute exacerbation of COPD ??
- increase BD frequency or use Nebulizers
- PREDNISOLONE 30mg for 5 days
- Oral Antibiotics (ONLY if purulent sputum or signs of Pneumonia present)
1st line Abx. for acute exacerbation of COPD ??
Amoxicillin or Clarithromycin or Doxycycline
OSA features ??
Obesity, Macroglosia, Large tonsils, Marfan’s
Snoring + daytime somnolence + Compensated Resp. Acidosis + HTN
How to assess sleepiness in OSA ??
Epworth Sleppiness Scale
Multiple Sleep Latency Test (MSLT)
Dx. test for OSA ??
Sleep studies (Polysomnography)
Rx for OSA ??
- Wt. loss
- 1st line for moderate to severe OSA- CPAP
- Mild OSA + CPAP not tolerated - Intraoral devices (Mandibular advancement devices)
- DVLA informed only if excessive daytime sleepiness
What are the Indications for NIV ??
- COPD + Resp. Acidosis pH 7.25 to 7.35 (- if pH < 7.25 ==> HDU + greater degree of monitoring with a lower threshhold for intubation and ventilation)
- Type 2 Resp. Failure secondary to chest wall deformity, neuromuscular disease or OSA
- Cardiogenic Pulm. Edema UNRESPONSIVE to CPAP
- Weaning from Tracheal intubation
What is the recommended initial setting for Bi-level pressure support in COPD ??
EPAP : 4-5 cm H2O
IPAP : 10 cm H2O (RCP guideline)
12-15 cm H2O (BTS guidelines)
Back up rate : 15 breaths/ min
Back up Insp. : Exp. ratio = 1 : 3
What is the O2 sats. target ??
- Acute ill - 94 to 98%
- Pt. at risk of Hypercapnia (eg. COPD) = 88 to 92% { 28% Venturi mask at 4 l/min}
Situations where O2 therapy NOT used if sats. are normal ??
MI & ACS
Stroke
Obstetretic Emergencies
Anxiety related Hyperventilation
Which smoking cessation therapy is Indicated & CI during Pregnancy ??
Indicated - CBT, Nicotine Replacement Therapy (NRT)
CI : Varenicline, Bupropione
(Vare. is more effective than Bup.)
MOA of
- Varenicline
- Bupropione
V - Nicotinic receptor Partial AGONIST
B - NE & DA reuptake inhibitor & Nicotinic antagonist
Ix.oC to detect smoking in Pregnant ladies ??
Carbon Monoxide detectors
- All women who smoke/ have stopped smoking in the past 2 wks. (OR) CO reading >= 7 ppm should be referred to NHS Stop Smoking Services
Causes of Transudate ??
< 30 g/L protein
- Heart failure (MCC)
- Hypoalbuminaemia (Liver disease, Nephrotic synd., Malabsorption)
- Hypothyroidism
- Meig’s synd.
Causes of Exudate ??
> 30 g/L protein
- Infection : Pneumonia (MCC)
- TB, Sub-phrenic abscess
- Neoplasia (lung Ca, Mesothelioma, Metastates)
- Connective Tissue Disorder: RA, SLE
- Pulm. Embolism
- Pancreatitis
- Dressler’s synd.
- Yellow Nail synd.
Features of Pleural Effusion ??
- Dyspnoea, Non-productive cough, Chest pain
- O/E : Dullness on percussion, Reduced breath sounds & chest expansion
When do we use Light’s criteria ??
Border line protein levels 25 to 35 g/L
- (Exudate > 30 g/l & Transudate < 30 g/L)
What is Light’s criteria ??
An EXUDATE is likely if atleast one of the following criteria are met :
- PP / SP > 0.5
- P-LDH / S-LDH > 0.6
- P-LDH > 2/3rd the upper limit of normal S-LDH
When should we insert a chest drain in cases of pleural effusion if we suspect pleural infection ??
- If Purulent or Turbid/Cloudy pleural fluid
- CLEAR but pH < 7.2
Charecteristic Pleural Fluid findings-
- Low Glucose ??
- Raised Amylase ??
- Heavy Blood staining ??
- Rheumatoid A, TB
- Pancreatitis, OESOPHAGEAL Perforation
- Mesothelioma, Pulm. Embolism, TB
What needle is used for Pleural aspiration ??
21 G needle & a 50cc syringe
- sent for pH, Protein, LDH, Cytology & microbiology
What is Pneumothorax ??
Air within pleural space
- it disrupts the (-ve) pressure required for lung expansion, leading to partial or complete lung collapse
What are types of Pneumothorax ??
- Primary Spontaneous P
- Secondary Spontaneous P
- Traumatic P
- Iatrogenic P
- Tension P
Significant features of Tension Pneumothorax ??
Tracheal deviation
Cyanosis, Hypotension & Shock
Gold std. Ix. for Pneumothorax ??
CT Chest
(CXR is used 1st line if pt. is unstable)
Tension P Rx. ??
Immediate Needle decompression followed by Chest drain insertion
Site of Needle decompression in Pneumothorax ??
4th/ 5th ICS at MAL (preferred)
2nd ICS at MCL -depending on pt. anatomy (eg. High BMI)
What is permanently CI until B/L Pleurectomy is done ??
SCUBA Diving
Indication for Early Pleurodesis ??
High risk Secondary Spontaneous P pts. (recurrent episodes & significant lung disease)
Relative CI for Chest drain insertion ??
INR > 1.3
Platelets < 75
Pulm. bullae
Pleural adhesions
What is Lung Fibrosis ??
Progressive scarring of lung tissue
UPPER Lobes Fibrosis causes ???
CHARTS
- Coal worker Pneumoconiosis
- Histiocytosis
- Hypersensitive Pneumonitis (EAA)
- Ankylosing Spondylitis
- Radiation induced
- TB
- Sarcoidosis
- Silicosis
Causes of LOWER Lobe Fibrosis ??
AIDC
- Asbestosis
- Idiopathic Pulm. Fibrosis
- Drug induced : Amiodarone, MTX, Bleomycin
- Connective Tissue Diseases (EXCEPT Ank. Spon., eg. SLE)
What is Idiopathic Pulm. Fibrosis ??
specific type of Chr. fibrosing interstitial pneumonia, with no identifiable cause & characterized by Usual Interstitial Pneumonia (UIP) pattern on imaging &/or biopsy
Pathophysiology of IPF ??
Repeated alveolar injury + aberrant repair mechanisms==> FIBROBLAST activation & excessive Extracellular Matrix deposition
TERT & MUC5B gene mutations
C/F of IPF ??
Men aged 50 to 60 yrs
- Progressive dysponea on exertion
- persistent Dry cough
- Bibasal VELCRO crackles
- Digital clubbing
Imaging in IPF ??
HRCT (gold std.)
- HONEYCOMBING at basilar & periphery
- Traction Bronchiectasis
- Ground glass opacities
CXR : B/L basal Reticular opacities
UIP histopathology features of IPF ??
- Patchy fibrosis
- Fibroblast foci
- Temporal heterogeneity
Anti-fibrotic agents used in IPF ??
PIRFENIDONE : Slows disease Progression & improves Survival
NINTEDANIB : TK inhibitor (reduces FVC decline)
Anti-CTGF, Telomerase activator
C/F of Hypersensitive Pneumonitis or EAA
Acute : Dyspnoea, DRY cough, Fever
Chronic : Recurrent fever, Dyspnoea, Wt. loss, Productive Cough
Dx. of EAA ??
HRCT (gold std.)
- Centrilobular Ground glass nodules & opacities, UPPER lobe predominance
BAL - Lymphocytosis
Eg. of EAA ??
Bird Fancier’s lung: AVIAN Proteins
Farmer’s Lung: Saccharopolyspora rectivirgula (from wet hay)
Malt worker’s lung: Aspergillus clavatus
Mushroom worker’s lung: Thermophillic actinomycetes (umbrella term covering strains such as Micropolyspora faeni
Rx. of EAA ??
Avoid causitive agents
Oral GLUCOCORTICOIDS
What is Pulm. HTN ??
Sustained elevation of Mean Pulm. Arterial Pressure of >= 25 mmHg at rest
Features of Lung Carcinoids ??
- Most of BRONCHIAL Adenomas are lung carcinoids
- arises from APUD system like small cell tumours
- 40 to 50 yrs
- Smoking NOT a risk factor
C/F of Lung Carcinoids ??
Long H/o Cough (slow growing), recurrent Haemoptysis
Ix. & Rx. in Lung Carcinoids ??
Centrally located mass NOT seen on CXR
Bronchoscopy : Cherry Red Ball
Sx. resection
Granulomatosis with Polyangitis features ??
Midline sinusitis + Nasal bridge collapse
Pulm. Haemorrhage
Renal vasculitis
CXR- Patchy interstitial shadowing of both lung fields
cANCA (+ve)
Churg Strauss or Eopsinophillic Granulomatosis with Polyangitis ??
Asthma
RAISED Eosinophils
Mononeuritis multiplex
Renal involvement- Proteinuria, Haematuria, raised Cr., HTN
pANCA (+ve)
Rx. Corticosteroids +/- Cyclophosphamide
Aspirin cause of Asthma symp. ??
Bronchospasm
Nasal polyps
Rhinitis
Most likely finding on CXR of a pt. with Pulm. Embolism ??
NORMAL cxr
Liver capsule pain due to edema from metastates; pain relief DoC ??
Oral Dexamethasone
What are the CI for pneumonectomy in Sq. cell CA of bronchus ??
- Spread to involve the C8, T1, T2 nerve roots seen in Pancoast tumour
- Gas transfer reduced by >= 50%
- FEV1 of < 2l
ABPA features ??
Results from an allergy to Aspergillus spores
H/o Proximal BRONCHIECTASIS & Eosinophilia + previously labeled as Asthma
Ix. for ABPA ??
Eosinophilia (raised IgE)
Flitting CXR changes
(+ve) RAST to Aspergillus
(+ve) IgG precipitins (NOT as +ve as in Aspergilloma)
Rx. for ABPA ??
1st line = CORTICOSTEROIDS
Iatraconazole can be added
Which factor relates most closely with mortality in COPD pts. ??
FEV1
Rt. Heart strain Features ??
- Retrograde flow of contrast into IVC
- ST depression with T wave inversion in V1 to V4, Inferior leads (II, III, aVF) more pronounced in (III)
Which organism causes pneumonia after the following infections:
- Post Influenza virus
- recurrent or current Cold sores (Herpes Simplex Virus)
- Staph. aureus (cavitation seen)
- Strepto. pneumonia
Which organism causes recurrent pulm. exacerbtations in CF patients ??
Adults - P aeruginosa
Children - Staph. aureus
ARDS is a/w ??
INCREASED Elastic recoil
LOW Pulm. artery wedge pressure
Reduced Gas exchange
Name the cancers caused by the following
- Vinyl chloride
- Isocyanates
- Aromatic amines
- Angiosarcoma of liver
- Non-Small cell CA of lungs
- Bladder Ca
Best test to confirm Intra-thoracic & Extra-thoracic airway/ tracheal compression ??
Flow volume loop
Retro-sternal goitre = reduced inspiratory flow rate than expiratory flow rate
Q fever organism ??
Coxiella burnetii (zoonotic infection)
Features of Q fever ??
Shepards (cattle, sheep, goat)
Fever, Pharyngitis, headache, myalgia
Resp.: Non productive Cough, haemoptysis
Hepatitis features
GI symp. (N & V, diarrhoea, Abd. pain)
CVS- Endocarditis (new murmur)
Ix. & Rx. for Q fever ??
Dx.- Serology
Abnormal LFT
Rx. - DOXYCYCLINE
What is Sarcoidosis ??
Multisystem disorder of unknown etiology charecterized by NON-CASEATING Granulomas
-MC in Young + African descent
What is Lofgren’s Synd. ??
Acute form of Sarcoidosis
- B/L Hilar Lymphadenopathy + Erythema nodosum + Fever + Polyarthralgia
- Typically seen in YOUNG Females
- Excellent prognosis
What is Loffler’s syndrome ??
Transient CXR shadowing & Blood eosinophilia
Cause- Parasites (Nematodes- Ascariasis & Strongyloidiasis)
C/F- Fever, cough, Night sweats for < 2 wks
Tropical Pulm. Eosinophilia is a/w ??
Wuchereria bancrofti
CI of Lung transplantation in Cystic Fibrosis ??
Chr. infection with Burkholderia cepacia
MOA of
- Lumacaftor
- Ivacaftor
- Increases the no. of CFTR proteins that are transported to the cell surface
- POTENTIATES the already present CFTR proteins
What are the Resp. manifestation of Rheumatoid Arthritis ??
- Pulm. Fibrosis
- Pulm. Nodules
- Pleural Effusion
- Pleurisy
- Bronchiolitis obliterans
- Caplan’s synd.
- MTX Pneumonitis
- Infection (ATYPICAL secondary to immunosuppression)
What is Caplan synd. ??
aka RHEUMATOID PNEUMOCONIOSIS
Massive Fibrotic nodules with Occupational Coal dust exposure or Silica
Causes of B/L Hilar Lymphadenopathy ??
MCC- Sarcoidosis & TB
- Lymphoma/ other malignancy
- Pneumoconiosis eg.- Berylliosis
- Fungi- Histoplasmosis, Coccidioidomycosis
Which type of Hypersensitivity reaction is seen with EAA/ Hypersensitivity Pneumonitis ??
Type 3 HS (Immune complex mediated)
Chronic phase- Type 4 (Delayed HS)
Most dangerous form of Asbestos ??
CROCIDOLITE (Blue) Asbestos
Rx. of C - Palliative Chemo.
What is severity of Asbestosis related to ??
Length of exposure
(Mesothelioma- even very limited exposure can cause the disease)
Egg shell calcification of hilar LN are seen in ??
Silicosis
What Ix. are done in Lung Cancer ??
- 1st Ix. in suspected pts.: CXR
- Ix.oC in suspected pts.- CT Thorax
- Bronchoscopy +/- Endobronchial USS for Biopsy & Histological dx.
- PET scan: Typically done in Non- SCL cancer to establish eligibility for Curative Rx.
- Bloods: Raised Platelets can be seen
Rx. of Non- Small cell lung Ca ??
- Only 20% are suitable for Sx.
- Mediastinoscopy performed before Sx. as CT does’t always show mediastinal LN involvement
- Curative or Palliative RT
- POOR response to Chemo
CI of Sx. in NSC Lung Cancer ??
Assess general health
Stage IIIb or IV (ie.Metastates present)
FEV1 < 1.5 litres is general cut-off
- Lobectomy: FEV1 < 1.5 lt. or Pneumonectomy < 2.0 lt, some authority advocate further Lung F T as operations may still go ahead based on results
Malignant Pleural effusion
Tumour near hilum
Vocal cord paralysis
SVC obstruction
Name the Paraneoplastic features a/w
- Small Cell L C ??
- Squamous Cell L C ??
SMALL CELL L C
- ADH
- ACTH: not typical, HTN, Hyperglycaemia, Hypo K+, Alkalosis & muscle weakness more common than Buffalo hump
- Lambert-Eaton Synd.
SQUAMOUS Cell L C
- PTH-related Protein secretion causing Hyper Ca2+
- Clubbing
- HPOA
- Ectopic TSH => Hyperthyroidism
Paraneoplastic features a/w Adenocarcinoma of lungs ??
- Gynaecomastia
- Hypertrophic Pulm. Osteoarthropathy (HPOA) : is a proliferative periostitis that involves the long bones, often Painful
In the past it was thought that HPOA is MC in Sq. Cell LC but some studies show that AdenoCA is the MCC.
How is Referral made in Lung Cancer cases ??
(1) Suspected Ca pathway (appointment within 2 weeks)
- CXR suggesting lung Ca
- > 40 yrs + unexplained Haemoptysis
(2) Urgent CXR (done in < 2 wks.) + > 40 yrs + (>=2) of the following unexplained C/F (OR) have ever Smoked + (>= 1) of the following unexplained C/F
- Cough. - Fatigue. - SoB. - Wt. loss
- Chest pain. - Appetite loss
(3) Urgent CXR + (>= 40 yrs) + Any of the following-
- Persistent/ Recurrent Chest infec.
- Clubbing. - Thrombocytosis
- Supraclavicular LN-pathy/ Persistent Cervical LN-pathy
- Chest signs consistent with Lung Ca
RFs for Lung cancer ??
Smoking (10x)
Asbestosis (5x)
Smoker + Asbestosis = 10*5= [50x]
Arsenic, Radon, Nickel, Chromate
Aromatic Hydrocarbons
Cryptogenic Fibrosing Alveolitis
Factors NOT related to Lung Cancer development ??
Coal dust
What is Small Cell Lung Cancer ??
CENTRAL tumour
Arises from APUD cells- Amine Precursor Uptake Decarboxylase
- a/w ADH & ACTH secretion
- ADH: Hypo Na+
- ACTH: Cushing’s disease (B/L Adrenal hyperplasia) => HypoK+ Alkalosis
- Lambert-Eaton synd.- antibodies to Voltage gated Ca2+ channels
Rx. of Small Cell L C ??
usually Metastatic at the time of dx.
- Sx.- Only for Early stage Ca (T1-2a, N0, M0)
- Chemo + RT: Limited disease
- Palliative Chemo: Extensive disease
Hallmarks of Aspergilloma ??
Is a Mycetoma (Mass-like Fungal Ball)
- Can colonise the Existing lung cavity
- eg.- 2ndary to TB, Lung Ca, CF)
Cough & Haemoptysis (may be severe)
Dx.-
- CXR: Rounded opacities, Crescent sign (MONOD’S Sign) may be present
- HIGH Titres of Aspergillus Precipitins
What is Mucormycosis ??
Fungal Infection
- MC seen poorly controlled DM
- Infects Sinuses, Lungs & Brain
Klebsiella Pneumonia ??
Gram (-)ve rods
Red currant jelly sputum
Predominantly affects Upper lobes
MC in Alcoholics & DM
Commonly causes Lung abscess & Empyema
Rx- Ciprofloxacin, Genta., Tetracyclin, Cephalosporins, Meropenam, Tazocin
- Resistant to Amox., & Co-Amox.
Yellow Nail Syndrome ??
Exudative Pleural Effusion
Yellow, thick nails
Lymphedema
Young’s Syndrome ??
Bronchiectasis, Azoospermia, Sinusitis (Very similar to CF) but Normal Sweat Cl- test & Normal Pancreas
Poor prognostic factors of Pulm. HTN ??
Elevated Hepatoma derived GF
Elevated NT-pro-BNP (RV dysfunction)
Reduced RVEf,
SVT
AF
Infectious Pulm. TB IoC ??
Multiple Sputum smear & Cultures
- >= 3 samples may be needed
