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Phase 2 Mine > Revision List Respiratory > Flashcards

Revision List Respiratory Flashcards

1
Q

What is hypersensitivity pneumonitis?

A

Distinct granulomatous inflammation with cellular infiltrates in lung distal to the terminal bronchiole.
Usually people in already been sensitised by repeated exposure to antigen and inhalation.

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2
Q

What are the two ways you can get hypersensitivity pneumonitis?

A
  1. Inhaled antigen

2. Occasional following ingestion of drug

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3
Q

Pathophysiology of hypersensitivity pneumonitis?

A
  1. Allergic response to inhaled antigen –> cellular immunity and deposition of immune complex and activation of complement via classical pathway
  2. Mechanism attract and activate alveolar macrophages –> continued ag exposure –> pulmonary fibrosis
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4
Q

Causes of hypersensitivity pneumonitis?

A
  1. Farmer’s lung
  2. Bird/pigeon fancier’s lung
  3. Cheese worker’s lung
  4. Malt-worker’s lung
  5. Humidifier fever
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5
Q

What is farmer’s lung?

A
  1. Inhale fungi e..g. aspergillus umbrosus in mouldy hay - bronchiolitis –> later chronic inflammatory cells -> seen with non-caseating granuloma
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6
Q

What is bird fancier’s lung?

A

Inhaling avian proteins in bird droppings.

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7
Q

Risk factors for HP?

A
  1. Pre-existing lung disease
  2. Occupations - farmer’s, cattle workers, ventilation
  3. Bird keeping
  4. Regular use of hot tubs
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8
Q

Clinical presentation of HS phases?

A
  1. Acute
  2. Subacute
  3. Chronic
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9
Q

What is acute phase HS and clinical presentation?

A
  1. 4-6hrs post-exposure
  2. fever, rigors, myalgia
  3. dry cough, dyspnoea, crackles
  4. Chest tightness
    May be mistaken for chest infection and usually resolves after 1-2 days following removal of Ag.
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10
Q

Clinical presentation of subacute HS?

A
  1. Intermittent/lower exposure
  2. History of repeated acute attacks
  3. Signs same as acute, symptoms less severe and gradual onset
  4. Recurrent pneumonia
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11
Q

Clinical presentation of chronic HS?

A
  1. Cyanosis
  2. Clubbing
  3. Increasing dyspnoea
  4. Weight loss
  5. TIRP
  6. Cor pulmonale
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12
Q

Differential diagnosis of HS?

A
  1. Infection
  2. CTD causing ILD
  3. Pulmonary fibrosis
  4. Asthma
  5. Drug induced ILD
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13
Q

Diagnosis of HS?

A
  1. CXR: fibrotic shadows, nodules
  2. FBC: raised WCC and ESR
  3. Lung function test: reversible restrictive
  4. Broncheoalveolar lavage: lymphocyte count, CD4/CD8 ratio
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14
Q

Treatment of acute HS?

A
  1. Removal of causative Ag
  2. Give O2 35-60%
  3. Oral prednisolone then decrease dose
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15
Q

Treatment of chronic HS?

A
  1. Avoid exposure to Ag
  2. Long term steroids
  3. Cortiosteroids e.g. prednisolone
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16
Q

Pneumonia what is it?

A

Inflammation of lung parenchyma usually due to bacterial infection - -> inflammatory exudate.

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17
Q

Risk groups for pneumonia?

A
  1. Elderly
  2. Immunocompromised
  3. Nursing home residents
  4. Alcoholics and IVDU
  5. COPD + other chronic lung disease
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18
Q

Pathogenesis of pneumonia?

A

Spread by resp droplets.
Bacteria translocate to normally sterile airway –> overwhelm alveolar macrophage –> release inflammatory cytokines to attract neutrophil to alveolar space. Hole in epithelium - fluid and Ab entry
Dead neutrophils and bacteria and fluids = pus
Resolution phase when bacteria cleared - inflammatory cells are removed by apoptosis, leads to complete recovery

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19
Q

Conditions for severe pneumonia?

A
  1. Lung failure
  2. Excessive inflammation
  3. And/or failure to resolve without lung damage
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20
Q

Symptoms of pneumonia?

A
  1. Cough with sputum - rusty in S.pneumoniae
  2. Dyspnoea
  3. Sweat, fever, rigor - classic infection
  4. Pleuritic chest pain
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21
Q

Signs of pneumonia

A
  1. Raised HR, RR
  2. Decreased BP
  3. Fever
  4. Dehydration
  5. Dull to percuss, crackles with or without wheeze
  6. Signs of lung consolidation
  7. Increased vocal resonance
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22
Q

Investigations for pneumonia?

A
  1. CXR - consolidation
  2. FBC - raised wcc in S. pneumoniae, CRP
  3. Biochemistry - U&E,LFT,
  4. Pulse oximetry - assess severity + if required ABG
  5. Microbiological tests:
    - sputum culture + antibiotics sensitivity
    - culture
    - serology - virus and atypical organisms
  6. Test for HIV
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23
Q

What are the signs of sepsis?

A
  1. Pro-inflammatory cytokines
  2. Vasodilation
  3. Impaired cardiac contractility
  4. Decreased BP
  5. Impaired organ perfusion
  6. Tissue hypoxaemia
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24
Q

How do you assess CAP severity?

A
  1. C - Confusion
  2. U - Urea >7mmol
  3. R - RR > 30/min
  4. B - BP 90/60
  5. 65 - >65
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25
Q

What to do if CURB score 0-1?

A

Mild - watch and wait?

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26
Q

CURB score 2?

A

Admit to hospital - moderate

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27
Q

CURB score 3?

A

Severe, admit, monitory closely

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28
Q

CURB score 4-5?

A

Consider admitting to CCU

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29
Q

Organisms indicated in CAP?

A
  1. S. pneumoniae
  2. H. influenzae
  3. Klebsiella pneumoniae
  4. Chlamydophilia pneumoniae
  5. Legionella pneumoniae
  6. Mycoplasma pneumoniae
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30
Q

Treatment with S. pneumoniae?

A
  1. Beta lactams: amoxicillin, cefuroxime, cefotaxime
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31
Q

Treatment with H. influenzae?

A

Co-amoxiclav/doxycycline

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32
Q

Treatment with S.aureus?

A

Flucloxacillin, cefuroxime

33
Q

Treatment with K.pneumoniae

A

Co-amoxiclav, cephalosporins

34
Q

Treatment for atypical pathogens?

A
  1. Macrolides - erythromycin, clarithromycin
  2. Fluoroquinolones - ciprofloxacin
  3. Tetracycline - doxycycline
35
Q

Presentation of mycoplasma pneumoniae?

A
  1. Usually YA, milder illness

2. Extrapulmonary features: haemolytic anaemia, raynaud’s, erythema multiforme, encephalitis

36
Q

Presentation of legionella pneumoniae?

A
  1. Severe illness and resp failure
  2. May be elderly immunocompromised
  3. Extrapulmonary: diarrhoea, abnormal LFT, hyponatraemia, encephalitis
37
Q

What microbiological tests are involved in diagnosis?

A
  1. MCS
  2. Blood culture
  3. Serology virus and atypical organisms
  4. Urinary Ag - Legionella spp, S.pneumoniae
  5. PCR - virus
    IF TB SUSPECT THEN ZN
38
Q

What to treat for CURB65 score 0-1?

A

Mild severity pneumoniae 5 days
Amoxicillin 5mg TDS
Penicillin allergy clarithromycin 500mg BD

39
Q

What to treat for CURB65 score 2?

A

Moderate severity pneumonia

Amoxicillin + clarithromycin PO

40
Q

What to treat for CURB65 score 3-5?

A

Severity pneumonia >5 days –> 14-21 days
IV co-amoxiclav 1.2g TDS and clarithromycin
Alternative cefuroxime and clarithromycin

41
Q

How to prevent pneumonia?

A
  1. Polysaccharide pneumococcal vaccine >65
  2. Influenza vaccination
  3. Smoking cessation
42
Q

What are the complications of pneumonia?

A
  1. Resp failure
  2. Hypotension
  3. Parapneumonic effusion and empyema
  4. Lung abscess
43
Q

What indicates an empyema?

A
  1. Ongoing fever, failure of fever/marker of inflammation to settle after Abx
    - signs of pleural collection - stony dull percussion.
44
Q

How to assess severity of empyema?

A

Thoracentesis - remove fluid from pleural space
Drain by chest tube/cardiothoracic surgery and decortication
Abx: co-amoxiclav, piperacillin tazobactam, meropenam

45
Q

What is HAP?

A

Hospital acquired pneumonia = pneumonia >48 hours after hospital admission

46
Q

What is late onset HAP?

A

> 5 days after hospital admission

47
Q

Organisms that causes late onset HAP?

A

S.aureus, pseudomonas aeruginosa, acetinobacter baumanni, klebsiella pneumoniae

48
Q

Antibiotics for late onset HAP?

A
  1. Piperacillin tazobactam , meropenam, ceftazadime
    Linezolid/vancomycin –> MRSA
    IV colistin for multidrug resistant gram negatives
49
Q

Tests for asthma attack?

A
  1. PEF
  2. Spirometry
  3. Reversibility test
50
Q

Classifying acute asthma attacks: uncontrolled/moderate

A

PEFR> 50%
RR<25
Pulse<110
normal speech/no other severe markers

51
Q

Classifying acute asthma attacks: severe

A 
One of:
PEFR 33% -50%
RR>25
HR>110
Inability to complete sentences
52
Q

Classifying acute asthma attacks: life threatening

A

PEFR: <33%
SaO2 <92% or PaO2 <8kPa
Normal PaCO2 4.6-6 kPa
Altered consciousness level, exhaustion, arrhythmia, hypotension, silent chest, poor effort, cyanosis

53
Q

Classifying acute asthma attacks: near death

A

Increased PaCO2 and/or requiring ventilation with increased airway pressure

54
Q

Immediate management of acute asthma attack?

A
  1. O2 40-60%
  2. Salbutamol neb 5mg
  3. Prednisolone 30-60mg
  4. ?magnesium / aminopylline IV
  5. ABG
  6. Key complications: tension pneumothorax, arrhythmia, hypokalaemia
  7. CXR
55
Q

3 primary features of pulmonary fibrosis?

A

Cyanosis
Clubbing
Cough - Dry

56
Q

Respiratory causes of clubbing?

A 
A - Lung Abscess
B - Bronchiectasis
C - Cystic fibrosis/Cancer
D - Decreased oxygen (hypoxia)
E - Empyema
F - Pulmonary Fibrosis
57
Q

What is asbestosis?

A
  1. Distinct cellular infiltrates and ECM deposition in lung distal to terminal bronchiole
58
Q

5 potential consequences of asbestosis?

A
  1. Plaques/fibrosis
  2. Effusion.
  3. Asbestosis.
  4. Mesothelioma.
  5. Bronchial adenocarcinoma.
59
Q

Clinical presentation of asbestosis?

A

Breathlessness and progressive dyspnoea, finger clubbing and bilateral end inspiratory crackles

60
Q

Definition of COPD?

A

Usually progressive and associated with an enhanced chronic inflammatory response in airways, lungs to noxious particles.

61
Q

Aetiology of COPD?

A
  1. Cigarette smoking
  2. Occupational pollution
  3. Alpha 1 antitrypsin deficiency
62
Q

Pathophysiology of chronic bronchitis?

A

Airway narrowing and airflow limitation as a result of hypertrophy and hyperplasia of mucus secreting glands of bronchial wall inflammation and mucosal oedema.

63
Q

Pathophysiology of emphysema?

A
  1. Dilation and destruction of lung parenchyma distal to bronchioles
  2. Loss of elastic recoil, normally airway kept open during expiration
  3. Expiratory airflow limitation and air trapping due to alverolar enlargement.
64
Q

How does COPD affect V/Q mismatch?

A
  1. Damage due to inflammation and mucus plugs of smaller airways from chronic inflammation - loss of elastic support + rapid closure of airways in expiration.
65
Q

Symptoms of COPD?

A
  1. Chronic productive cough
  2. Wheeze
  3. Progressive breathless
66
Q

Signs of COPD?

A
  1. Wheeze
  2. Barrel chest
  3. Hyperresonance on percussion
67
Q

Differential diagnosis for COPD?

A
  1. Asthma
  2. CHF
  3. Bronchiectasis
  4. PE
  5. Pneumonia
68
Q

Diagnosing COPD?

A
  1. History and clinical exam
  2. Spirometry - obstructive pattern and no reversibility
  3. CXR - flat diaphragm, hyperinflated lungs, maybe decreased peripheral lung markings
  4. CT/Hb+PCV/ABG
69
Q

Treating COPD?

A
  1. Smoking cessation , exercise, lose weight, pulmonary rehab
  2. Pneumococcal and influenza vaccinations
  3. Pharmacological treatment
  4. Abx for acute exacerbations
  5. O2 therapy.
70
Q

Pharmacological Management of COPD?

A
  1. SABA/SAMA - PRN relieve breathlessness and exercise limitation
  2. Continued breathlessness/exacerbation:
    - LABA + LAMA - discontinue SAMA
  3. If asthmatic features, steroid responsiveness
  4. Combine all 3 if exacerbations:
    LABA + LAMA + ICS
71
Q

Cells in asthma vs COPD?

A 
Asthma = mast cells, eosinophils, CD4+ T cells
COPD = neutrophils, macrophages, CD8+
72
Q

Lung changes in asthma vs COPD?

A

Asthma:

  • all airways
  • little alveolar disruption
  • BM and ASM thickening
  • little fibrosis
  • epithelial shedding

COPD:

  • peripheral airways
  • lung destruction
  • little ASM thickening
  • lots of fibrosis
  • alveolar/BM disruption
  • squamous cell metastasia
73
Q

COPD co-morbidities

A
  1. Cardiac disease
  2. Cancer
  3. Renal failure
  4. Weight loss
  5. Depression
74
Q

Surgery in COPD?

A
  1. Lung volume reduction surgery

2. Lung transplantion - severe COPD

75
Q

What can cause COPD exacerbations

A

Viral infection e.g. RSV, infleunza, parainfluenza, rhino and coronaviruses

76
Q

Management of COPD exacerbation?

A
  1. O2
  2. Bronchodilator
  3. Systemic steroids
  4. Abx for breathlessness/sputum
77
Q

Prevent COPD exacerbation?

A
  1. Smoking cessation
  2. Vaccine
  3. LABA/LAMA/ICS
78
Q

Function of lungs?

A
  1. Gas exchange
  2. Acid-base balance
  3. Defence
  4. Hormones
  5. Heat exchange

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