Revision - Asthma, COPD, Lung Cancer & Pleural Effusion Flashcards
What bronchodilator reversibility test result indicates asthma?
Improvement in FEV1 >12% after bronchodilator therapy
Stepwise mx of asthma in adults?
1) SABA
2) SABA + low dose ICS
3) SABA + ICS + LTRA
4) SABA + ICS + LABA +/- LTRA
5) SABA +/- LTRA, switch ICS/LABA for a MART (that includes a low dose ICS)
- or SABA +/- LTRA + LABA + med dose ICS
6) SABA +/- LTRA and one of the following:
- increase ICS to high-dose (only as part of a fixed-dose regime, not as a MART)
- trial of an additional drug e.g. theophylline
What is a MART?
A form of combined ICS and fast acting LABA.
Can dose of ICS be increased in a MART to medium?
No - switch to fixed-dose regime
Medium dose ICS + LABA
What type of hypersensitivity reaction is an asthma attack?
IgE type 1
What medications can exacerbate asthma? (3)
- beta blockers
- acetylcholinesterase inhibitors e.g. donepezil, neostigmine
- NSAIDs
Why can AChEIs exacerbate asthma?
Due to increased bronchial secretions
(think OPPOSITE of anticholinergics)
Give some features of a severe asthma attack
- PEFR 33-50%
- RR >25
- inability to speak in full sentences
Give features of a life-threatening asthma attack
- PEFR <33%
- silent chest
- bradycardia
- hypotension
- O2 sats <92%
- cyanosis
- exhaustion
- ‘normal’ PaCO2
Stepwise pharmacological mx of acute asthma?
1) ABCDE
2) O2 15L NRBM
3) Back to back nebulised salbutamol
4) Corticosteroids: 40-50mg oral pred or IV hydrocortisone
5) Nebulised ipratropium bromide
6) IV mag sulphate or IV aminophylline (specialist input)
Dose of pred giben in acute asthma?
40-50mg daily for 5 days
IV steroid option in acute asthma?
IV hydrocortisone
What is ipratropium bromide?
SAMA
Which inherited disorder can predispose to COPD?
A1AT deficiency
How is alpha 1 antitrypsin deficiency inherited?
Autosomal dominant
COPD is usually a combination of what 2 disease?
Bronchitis & emphysema
Why are those with COPD prone to headaches?
CO2 retention
How can COPD affect the heart?
Low O2 levels –> additional strain on heart.
This can lead to right ventricle hypertrophy and potentially cor pulmonale.
What 2 cardiac conditions can COPD lead to?
1) RV hypertrophy
2) Cor pulmonale
What is cor pulonale?
Cor pulmonale is a condition that causes the RIGHT side of the heart to fail.
Long-term high blood pressure in the arteries of the lung and right ventricle of the heart can lead to cor pulmonale
Cause of polycythaemia in COPD?
compensatory physiologic response to hypoxia.
Pharmacological mx of acute exacerbation of COPD?
1) O2
2) nebulised salbutamol
3) nebulised ipratropium bromide
4) steroids
Stepwise mx of chronic COPD?
1) SAMA or SABA as required
2) Are there asthmatic featues:
2a) yes –> SABA/SAMA as required, ICS + LABA regularly
2b) no –> SABA as required, LABA + LAMA regularly
3) SABA as required, ICS + LABA + LAMA regularly
What are some asthmatic features or features suggestive of steroid responsiveness in COPD?
1) previous diagnosis of asthma or atopy
2) raised eosinophil count
3) substantial variation in FEV1 over time
4) substantail diurnal variation in peak PEFR (at least 20%)
What are the 2 types of NSCLC?
1) Adenocarcinoma
2) Squamous cell carcinoma
Which lymph nodes tend to be found first on examination in lung cancer?
Supraclavicular
What antibodies is limbic encephalitis associated with?
Anti-Hu abs
Target of antibodies in Lambert-Eaton myasthenic syndrome?
Its caused by antibodies against small-cell lung cancer cells.
These antibodies also target and damage voltage-gated calcium channels sited on the PREsynaptic terminals in motor neurones.
What muscles does Lambert-Eaton myasthenic syndrome affect?
Weakness in proximal muscles
Weakness in Lambert-Eaton vs myasthenia gravis?
Lambert-Eaton –> improves with repetitive movement
Myasthenia Gravis –> worsens with repetitive movement
What is referral criteria for suspected cancer (2 week referral for CXR)?
Patients over 40 with:
- Clubbing
- Lymphadenopathy (supraclavicular or persistent abnormal cervical nodes)
- Recurrent or persistent chest infections
- Raised platelet count (thrombocytosis)
- Chest signs of lung cancer
What investigation is then used to assess the stage, lymph node involvement and presence of metastases in lung cancer?
Staging CT w/ contrast of chest, abdomen & pelvis
Which type of lung cancer is most likely to cause a pleural effusion?
Adenocarcinomas (& mesotheliomas)
Which type of lung cancer is most commonly related to hypercalcaemia?
Squamous cell carcinoma
What cells do small cell lung cancers arise from?
From endocrine cells (Kulchitsky cells) – these are APUD cells
1st line management in NSCLC in patients with disease isolated to a single area?
Surgery –> intention is to remove the entire tumour and cure the cancer
Management options in SCLC?
Usually with chemotherapy or radiotherapy
The prognosis is generally worse than NSCLC.
What PEFR is needed for discharge following an asthma attack?
> 75%
Prior to discharge, following an acute asthma attack, how long must patients be stable for on their discharge medication (i.e. no nebulisers or oxygen)?
12-24h
Stepwise diagnostic testing in asthma (age 5-16 y/o)?
1) all children should have spirometry with a bronchodilator reversibility (BDR) test
2) a FeNO test should be requested if there is NORMAL spirometry or obstructive spirometry with a negative bronchodilator reversibility (BDR) test
Stepwise diagnostic testing in asthma (age ≥17 y/o)?
1) patients should be asked if their symptoms are better on days away from work/during holidays. If so, patients should be referred to a specialist as possible occupational asthma
2) ALL patients should have spirometry with a bronchodilator reversibility (BDR) test
3) ALL patients should have a FeNO test
Does a negative result on spirometry exclude asthma as a diagnosis?
no - refer for FeNO testing
Vaccinations in COPD?
- annual influenza
- one off pneumonoccal
In acute asthma, when is an ABG indicated?
If patient has O2 sats <92%
What anaesthetic agents are patients with myasthenia gravis very sensitive to?
Non-depolarising agents, such as rocuronium
Next step in asthma mx in children aged 5-16 years with asthma not controlled by a SABA + paediatric low-dose ICS?
Add trial of LTRA
Can A1AT deficiency be diagnosed prenatally?
Yes - via CVS or amniocentesis
Why should you be cautious of using EllaOne (Ulipristal acetate) in severe asthma?
Due to the anti-glucocorticoid effect of ulipristal acetate
What is coal worker’s pneumoconiosis?
An occupational lung disease caused by long term exposure to coal dust particles.
It is most commonly experienced by those who have been involved in the coal mining industry and severity is linked to the extent of exposure.
What is seen on CXR in coal worker’s pneumoconiosis?
Upper zone fibrosis
Spirometry results in coal worker’s pneumoconiosis?
Restrictive lung function tests - a normal or slightly reduced FEV1 and a reduced FVC
Mx of asthma in children aged 5-16 y/o not controlled by a SABA + paediatric low-dose ICS + LTRA?
Add LABA and stop LTRA
Asthma mx during pregnancy?
Inhaled drugs, theophylline and prednisolone can be taken as normal during pregnancy and breast-feeding
Describe Light’s criteria for establishing an exudative effusion
1) Fluid protein/serum protein >0.5
2) Fluid LDH/serum LDH >0.6
3) Pleural fluid LDH >2/3 of normal upper limit of serum LDH
What are the most common causes of transudative pleural effusions?
(6)
1) Congestive cardiac failure
2) Liver failure
3) Hypoalbuminaemia
4) Hypothyroidism
5) Meig’s syndrome
6) Nephrotic syndrome
How does hypoalbuminemia cause transudative pleural effusion?
Hypoalbuminemia can cause a decrease in oncotic pressure causing extravasation of fluid into the interstitial space
Why would a urine dip be indicated in pleural effusion?
Assess for proteinuria - may indicate nephrotic syndrome
What imaging is indicated in idiopathic pulmonary fibrosis?
High resolution CT –> ‘ground glass’ appearance
Spirometry result in pulmonary fibrosis?
Restrictive picture:
1) FEV1 and FVC are equally reduced
2) FEV1/FVC ratio greater than 70%
What 2 medications are licensed that can slow the progression of pulmonary fibrosis
1) Pirfenidone
2) Nintedanib
Give 3 causes of drug induced pulmonary fibrosis
1) Amiodarone
2) Nitrofurantoin
3) Methotrexate
What conditions can pulmonary fibrosis occur 2ary to? (4)
1) A1AT deficiency
2) RA
3) Sarcoidosis
4) SLE
What triad is seen in yellow nail syndrome?
1) yellow fingernails
2) bronchiectasis
3) lymphoedema
What is an important area of the history to cover in bronchiectasis?
Childhood LRTIs
What are the 2 most common infective organisms in bronchiectasis?
1) H. influenzae
2) Pseudomonas aeruginosa
What is the test of choice for establishing a bronchiectasis diagnosis?
High resolution CT
What do lung function tests typically show in bronchiectasis?
Typically obstructive pattern
What should be done before prescribing Abx in bronchiectasis?
Sputum culture
What is the he Abx of choice for bronchiectasis exacerbations caused by Pseudomonas aeruginos?
Ciprofloxacin
Abx length in bronchiectasis exacerbations?
Extended: 7-14 days
RR in moderate vs severe acute asthma?
Moderate: <25
Severe: >25
PEFR in moderate, severe and life-threatening acute asthma?
Moderate: 50-75%
Severe: 33-50%
Life-threatening:<33%
Murmur in mitral stenosis?
Mid diastolic murmur
features of mitral stenosis?
- haemoptysis
- AF
- SOB
- malar flush
- mid diastolic murmur
What is there often a history of in aspergilloma?
TB
What may CXR show in aspergilloma?
Rounded opacity
What are pleural plaques?
Fibrous thickenings on the pleura
What are pleural plaques often associated with?
Asbestos exposure (e.g. boiler engineer)
Are pleural plaques malignant?
No - don’t undergo malignant chance so NO follow up needed
What is the most common form of asbestos-related lung disease?
Pleural plaques
When is Abx prophylaxis required in COPD patients?
COPD patients who have had more than 3 exacerbations requiring steroid therapy and at least 1 exacerbation requiring hospital admission in the previous year.
What class of Abx is used for prophylaxis in COPD patients?
Macrolides e.g. azithromycin
What pO2 level is indicator for long term oxugen therapy (LTOT)?
pO2 <7.3 kPa
or pO2 7.3-8 kPa and one of the following:
1) 2ary polycythaemia
2) peripheral oedema
3) pulmonary HTN
Pleural fluid findings of low glucose may indicate what?
1) Rheumatoid arthritis (exudate)
2) TB (exudate)
Pleural fluid findings of raised amylase may indicate what?
1) pancreatitis
2) oesophageal perforation
What is the most common cause of occupational asthma?
Isocyanates e.g. factories producing spray painting, foam moulding using adhesives
What pCO2 indicates near-fatal asthma?
Raised >6.0 kPa
What electrolyte abnormality is seen in sarcoidosis?
Hypercalcaemia
What skin manifestation is seen in sarcoidosis?
Erythema nodosum
Mainstay of treatment in small cell lung cancer?
Chemotherapy
Where in the lungs does asbestosis cause fibrosis?
Lower zone fibrosis
What does lung abscess most commonly form 2ary to?
Aspiration pneumonia
Common causes of respiratory alkalosis?
Anxiety leading to hyperventilation
Altitude
PE
Salicylate poisoning
CNS disorders e.g. stroke, subarachnoid haemorrhage, encephalitis
Pregnancy
What type of metabolic disurbance does salicylate poisoning cause?
Salicylate overdose leads to a MIXED respiratory alkalosis and metabolic acidosis.
Which type of pneumonia is associated with herpes labialis?
Strep. pneumoniae
Does a PE cause respiratory acidosis or alkalosis?
Respiratory alkalosis
3 most common causes of meningitis in >60 y/o?
1) Strep pneumoniae
2) Neisseria meningitidis
3) Listeria monocytogenes
An elderly patient presents with watery diarrhoea after being treated for pneumonia. Blood tests show a new, marked neutrophilia.
What is most likely organism?
C. diff
What is silicosis a risk factor for?
Developing TB
Features of silicosis?
Persistent cough
Exertional SOB
upper zone fibrosing lung disease
‘egg-shell’ calcification of the hilar lymph nodes
How does Cushing’s affect muscles?
Proximal muscle weakness
What respiratory condition can lead to Cushing’s?
Small cell lung cancer
What triad is seen in Kartagener syndrome?
1) situs inversus totalis (including dextrocardia)
2) chronic sinusitis
3) bronchiectasis
Gold standard investigation to diagnose mesothelioma?
Thoracoscopic biopsy & histology
FEV1 (of predicted) indicates the severity of COPD.
Describe FEV1 for COPD stage 1, 2, 3 and 4
Stage 1: >80%
Stage 2: 50-79%
Stage 3: 30-49%
Stage 4: <30%
Does COPD cause clubbing?
No
Where is emphysema in A1AT most prominent?
What about in COPD?
COPD - upper lobes
A1AT - lower lobes
What is the commonest cause of stridor in children?
Laryngomalacia
1st line Abx in infective exacerbation of COPD?
Amoxicillin or doxycycline or clarithromycin
Presentation of Klebsiella pneumonia on CXR?
Cavitating pneumonia in upper lobes
How often should you consider ‘stepping down’ asthma treatment?
Every 3 months or so
What should you aim for in the step down treatment of asthma?
Aim for a reduction of 25-50% in the dose of inhaled corticosteroids
What is the most common organism found on ascitic fluid culture in SBP?
E. coli
Is post-exposure prophylaxis for HIV recommended following human bites?
No (even if the individual has known HIV/AIDS) due to low risk of transmission
Mx of PCP pneumonia?
Co-trimoxazole
What is the most common cause of infective endocarditis?
Staph. aureus
What are two most notable types of Streptococcus viridans?
1) Strep. mitis
2) Strep. sanguinis
Who is prone to developing endocarditis secondary to Viridans streptococci e.g. Streptococcus sanguinis?
Patients with poor dental hygiene
Post-exposure prophylaxis for HIV routine?
4 weeks of antiretroviral therapy, arrange HIV testing at 12 weeks
What is the timeframe for post-exposure prophylaxis for HIV being started?
4 weeks
What are the causes of UPPER zone lung fibrosis?
Mneumonic: CHARTS
C - Coal worker’s pneumoconiosis
H - Histiocytosis/ hypersensitivity pneumonitis
A - Ankylosing spondylitis
R - Radiation
T - TB
S - Silicosis/sarcoidosis
How may lower lobe pneumonia present?
With upper quadrant abdo pain
What is the reason that Mycoplasma pneumoniae causes haemolytic anaemia?
IgM antibodies against Mycoplasma pneumoniae react against human red blood cells at cold temperatures causing them to agglutinate.
This can be seen in a peripheral blood smear.
What test should be offered to all patients with TB?
HIV
What is the most common cause of neutropenic sepsis?
Staph epidermis - associated with central line infections.
Is smoking a risk factor for Grave’s?
Yes
Mx of all patients with a CD4 count lower than 200/mm3?
All patients with a CD4 count lower than 200/mm3 should receive prophylaxis against PCP pneumonia w/ oral co-trimoxazole
What is the most common cause of death in measles?
Pneumonia
How can the risk of oral candidiasis be reduced in inhaled steroid use?
Take ICS using large volume spacer (less local drug deposition in mouth)
Why are dry powder asthma inhalers better for the environment than metered dose inhalers?
Metered dose inhalers use hydrofluorocarbon propellant (a greenhouse gas).
Dry powder inhalers do not
use propellants.
