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1
Q

PNEUMONIA
Name 3 pathogens that can cause community acquired pneumonia (CAP)

A
  1. Streptococcus pneumoniae (most common)
  2. Haemophilus influenzae
  3. s.aureus
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2
Q

PNEUMONIA
Name 3 pathogens that can cause hospital acquired pneumonia (HAP)

A

mainly gram negative

  1. Pseudomonas aeruginosa
  2. E.coli
  3. Staphylococcus aureus
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3
Q

PNEUMONIA
What is the treatment for someone with mild CAP (CRUB65 score 0-1)?

A

oral amoxicillin at home

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4
Q

PNEUMONIA
What is the treatment for someone with moderate CAP (CRUB65 score 2)?

A

consider hospitalising, amoxicillin (IV or oral) + macrolide (clarithromycin)

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5
Q

PNEUMONIA
What is the treatment for someone with severe CAP (CRUB65 score 3-5)?

A

consider ITU,

IV Co-Amoxiclav + macrolide (clarithromycin)

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6
Q

PNEUMONIA
What is the treatment for someone with Legionella pneumoniae?

A

Fluoroquinolone + clarithromycin

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7
Q

PNEUMONIA
What is the treatment for someone with Pseudomonas aeruginosa pneumonia?

A

IV ceftazidime + gentamicin

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8
Q

BRONCHIECTASIS
What can cause bronchiectasis?

A
  1. Congenital = Cystic fibrosis
  2. Idiopathic (50%)
  3. Post infection - (most common)
    • pneumonia,
    • TB,
    • whopping cough
  4. Bronchial obstruction
  5. RA
  6. Hypogammaglobulinaemia
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9
Q

BRONCHIECTASIS
Which bacteria might cause bronchiectasis?

A
  1. Haemophilus influenza (children)
  2. Pseudomonas aeruginosa (adults)
  3. Staphylococcus aureus (neonates often)
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10
Q

BRONCHIECTASIS
what are the symptoms of bronchiectasis?

A
  1. Chronic productive cough
  2. Purulent sputum
  3. Intermittent haemoptysis
  4. Dyspnoea
  5. Fever, weight loss
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11
Q

BRONCHIECTASIS
what are the signs of bronchiectasis?

A
  1. Finger clubbing
  2. Coarse inspiratory crepitate (crackles)
  3. Wheeze
  4. rhonchi (low-pitched snore-like sound)
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12
Q

BRONCHIECTASIS
what are the investigations?

A

CXR - dilated airways with thickened walls (tram-tracks)

High resolution CT (gold standard) - bronchial dilation + wall thickening

sputum cultures

FBC

spirometry - obstructive pattern (FEV1/FVC <70%)

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13
Q

Describe the treatment for bronchiectasis

A

1st line
- treat underlying cause
- chest physio
- annual flu vaccine
- antibiotics ofr exacerbations

2nd line
- mucoactive agent (carbocisteine)
- bronchodilator
- nebulised isotonic/hypertonic saline
- long term antbiotics (azithromycin)

long term oxygen

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14
Q

CYSTIC FIBROSIS
Describe the pathogenesis of Cystic fibrosis

A

Autosomal recessive defect in chromosome 7 coding CFTR protein (F508 deletion = most common mutation)

  • Cl- transport affected
  • Decreased Cl secretion and increase Na reabsorption this causes an increase H2O reabsorption –> thickened mucus secretion
  • in the lungs, this leads to dehydrated airway surface liquid, mucus stasis, airway inflammation and recurrent infection
  • this leads to progressive airway obstruction and bronchiectasis
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15
Q

CYSTIC FIBROSIS
Give 3 signs of CF

A
  1. Clubbing
  2. Cyanosis
  3. Bilateral coarse crepitations
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16
Q

CYSTIC FIBROSIS
What is the management of the respiratory component of CF?

A

AIRWAY CLEARANCE

BRONCHODILATOR
- salbutamol

MUCOACTIVE AGENTS
- 1st line = rhDNase
- 2nd line = hypertonic saline +/- mannitol powder +/- rhDNase
- 3rd line = orkambi (lumacaftor + ivacaftor)

IMMUNOMODULATION
- 1st line = azathioprine
- 2nd line = oral corticosteroids

ANTIBIOTICS

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17
Q

LUNG CANCER
From what cells are small cell carcinomas derived from and what is the significance of this?

A

Neuroendocrine cells

Can secrete peptide hormones - ACTH, PTHrP, ADH, HCG

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18
Q

LUNG CANCER
where does lung cancer commonly metastasise to?

A
  1. Bone
  2. Brain
  3. Lymph nodes
  4. Liver
  5. Adrenal
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19
Q

LUNG CANCER
which cancers most commonly metastasise to the lungs?

A

breast
bowel
kidney
bladder

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20
Q

LUNG CANCER
Give examples of paraneoplastic syndromes due to lung cancer

A
  • ↑PTH -> Hyperparathyroidism
  • ↑ADH -> SIADH
  • ↑ACTH -> Cushing’s disease
  • lambert-eaton myasthenic syndrome
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21
Q

LUNG CANCER
Name 3 differential diagnosis’s of lung cancer

A
  1. Oesophageal varices
  2. COPD
  3. Asthma
  4. Pneumonia
  5. Bronchiectasis
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22
Q

LUNG CANCER
What investigations might you done on someone to determine whether they have lung cancer?

A

First line:
- CXR - central mass, hilar lymphadenopathy, pleural effusion
(a negative CXR does not rule out cancer)

  • CT chest, liver & adrenal glands (gold standard) - for staging
  • Sputum cytology - malignant cells in sputum
    (high specificity but mixed sensitivity)

diagnostic = biopsy + histology

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23
Q

LUNG CANCER
What is the treatment for SCLC?

A

Limited disease = chemo (cisplatin) + radio
Extensive = palliative chemo + care

  • Superior vena cava stent + radiotherapy + dexamethasone for superior
    vena cava obstruction
  • Endobronchial therapy - used to treat symptoms of airway narrowing:
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24
Q

ASTHMA
What are the signs of an acute asthma attack?

A
  1. Can’t complete sentences
  2. HR > 110 bpm
  3. RR > 35/min
  4. PEF < 50% predicted
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25
Q

ASTHMA
What are the signs of a life threatening asthma attack?

A
  1. Hypoxia = PaO2 <8 kPa, SaO2 <92%
  2. Silent chest
  3. Bradycardia
  4. Confusion
  5. PEFR < 33% predicted
  6. Cyanosis
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26
Q

ASTHMA
What investigations might you do someone to determine whether they have asthma?

A
  • Spirometry with reversibility testing (>5 years) = Obstructive pattern:
    • FEV1 <80% of predicted normal (reduced)
    • FVC = normal
    • FEV1/FVC ratio <0.7
  • Peak flow rate - diurnal variation
  • FeNO = >40 is positive
  • CXR
  • Atopy = skin prick, RAST
  • Bloods = high IgE, Eosinophils
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27
Q

ASTHMA
What is the long-term guideline mediation regime for asthma?

A
  1. low dose ICS/formoterol combination inhaler (AIR therapy) or if very symptomatic start low dose MART
  2. low dose MART
  3. moderate dose MART
  4. check FeNO + eosinophil level (if either is raised, refer to specialist).
    - If neither are raised = LTRA or LAMA in addition to moderate dose MART
    - if still not controlled, stop LTRA or LAMA and try other drug option (LTRA/LAMA)
  5. refer to specialist
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28
Q

COPD
What is the clinical diagnosis of chronic bronchitis?

A

Cough/sputum for >3 months in 2 consecutive years

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29
Q

COPD
Describe the pathophysiology of chronic bronchitis

A

Airway inflammation –> fibrosis and luminal plugs –> decreased alveolar ventilation

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30
Q

COPD
Describe the pathophysiology of emphysema

A

Dilation and destruction of the lung tissue distal to the terminal bronchioles
Enlarged alveoli + loss of elastic recoil = increased alveolar ventilation

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31
Q

COPD
What can cause COPD?

A
  1. Genetic = alpha 1 antitrypsin deficiency
  2. Smoking = major cause
  3. Air pollution
  4. Occupational factors = dust, chemicals
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32
Q

COPD
Give 4 signs of COPD

A
  1. Tachypnoea
  2. Barrel shaped chest
  3. Hyperinflantion
  4. Cyanosis
  5. Pulmonary hypertension
  6. Cor pulmonale
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33
Q

COPD
What investigations might you do to diagnose someone with COPD?

A

Spirometry = FEV1:FVC < 0.7
CXR = hyperinflation, bullae, flat hemi-diaphragms, large pulmonary arteries
CT = Bronchial wall thickening, enlarged air spaces
ECG = RA and RV hypertrophy
ABG = decreased PaO2 +/- hypercapnia

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34
Q

COPD
Give 3 factors that can be used to establish a diagnosis of COPD

A
  1. Progressive airflow obstruction
  2. FEV1/FVC ratio < 0.7
  3. Lack of reversibility
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35
Q

COPD
What are the treatments for COPD?

A

general:

  • stop smoking (refer to cessation services)
  • pneumococcal vaccine
  • annual flu vaccine

step 1:
- SABA (salbutamol or terbutaline) or SAMA (ipratropium bromide)

step 2:

  • If no asthmatic / steroid response:
    • LABA (salmeterol)
    • LAMA (tiotropium)
  • If asthmatic / steroid response:
    • LABA (i.e. salmeterol)
    • ICS (i.e. budesonide)

step 3:
- long term oxygen therapy

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36
Q

COPD
what is the criteria for LTOT?

A

pO2 <7.3

pO2 7.3-8kPa and one of the following:
- secondary polycythaemia
- peripheral oedema
- pulmonary hypertension

do not offer LTOT to people who continue to smoke despite being offered smoking cessation

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37
Q

COPD
What is the treatment for an exacerbation of COPD?

A

MILD
- managed in community
- increased salbutamol
- oral antibiotics
- 5 day course prednisolone

MODERATE
- hospital admission
- nebulised bronchodilators (salbutamol/ipratropium bromide)
- IV antibiotics
- steroids
- oxygen

SEVERE
- hospital admission
- non-invasive ventilation (BiPAP)
- nebulised bronchodilators (salbutamol/ipratropium bromide)
- IV antibiotics
- steroids
- oxygen

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38
Q

PLEURAL EFFUSION
what are the causes of a transudate pleural effusion?

A

fluid movement (systemic causes)

  1. Heart failure
  2. fluid overload
  3. Peritoneal dialysis
  4. Constrictive pericarditis
  5. hypoproteinaemia
    • cirrhosis
    • hypoaluminaemia
    • nephrotic syndrome
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39
Q

PLEURAL EFFUSION
Name 3 causes of a exudate pleural effusion

A

inflammatory (local causes)

  1. Pneumonia
  2. Malignancy
  3. TB
  4. pulmonary infarction
  5. lymphoma
  6. mesothelioma
  7. asbestos exposure
  8. MI
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40
Q

PLEURAL EFFUSION
How does a pleural effusion present?

A
  • SOB especially on exertion
  • Dyspnoea
  • Pleuritic chest pain
  • dry cough
  • Loss of weight (malignancy)

SIGNS
- Chest expansion reduced on side of effusion
- In large effusion the trachea may be deviated away from effusion
- Stony dull percussion note on affected side
- Diminished breath sounds on affected side
- Decreased tactile vocal fremitus (vibration of chest wall when speaking)
- Loss of vocal resonance

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41
Q

PNEUMOTHORAX
What investigation might you do in someone you suspect to have a pneumothorax?

A

1st line - CXR = translucency and collapse

ABG = in dyspnoeic patients check for hypoxia

Gold standard = CT chest (rarely done in clinical practice)

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42
Q

PNEUMOTHORAX
What is the treatment for a primary pneumothorax?

A

PRIMARY
- small (<2cm) + asymptomatic = consider discharge
- if >2cm or breathless = aspirate with 16-18G needle
- if successful consider discharge + follow-up
- If unsuccessful insert chest drain + admit

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43
Q

TENSION PNEUMOTHORAX
What is the treatment for a tension pneumothorax?

A

Put out cardiac arrest call
Start high flow O2
Insert 14G needle at 4/5th intercostal space mid-axillary line
insert chest drain

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44
Q

INTERSTITIAL LUNG DISEASE
Would pulmonary function tests taken from someone with interstitial lung disease show a restrictive or obstructive pattern?

A

Restrictive

Decreased gas transfer and a reduction in PaO2

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45
Q

SARCOIDOSIS
What kind of disease is sarcoidosis?

A

Granulomatous disease - type of interstitial lung disease

It is defined by presence of non-caseating granulomas

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46
Q

SARCOIDOSIS
Describe the pathophysiology of sarcoidosis

A

Chronic inflammation –> non-caseating granuloma in various body sites

thought to be due to type VI hypersensitivity reaction

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47
Q

SARCOIDOSIS
what are the symptoms?

A
  • non-productive cough
  • gradual onset dyspnoea
  • polyarthralgia
  • uveitis (red eye, photophobia)
  • fever
  • fatigue
  • weight loss
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48
Q

SARCOIDOSIS
What is the effect of sarcoidosis on the skin?

A

erythema nodosum (dusky coloured nodules on shins)

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49
Q

SARCOIDOSIS
What is the effect of sarcoidosis on the eyes?

A

Uveitis (red eyes + photophobia)

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50
Q

SARCOIDOSIS
What is the effect of sarcoidosis on the bone?

A

polyarthralgia

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51
Q

SARCOIDOSIS
What is the effect of sarcoidosis on the liver?

A

Hepatosplenmeagly

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52
Q

SARCOIDOSIS
What investigations might you do in someone who you suspect to have sarcoidosis?

A

BLOODS
- Raised inflammatory markers
- raised serum calcium

CXR
- hilar lymphadenopathy
- bilateral infiltrates

Chest CT
- ground glass appearance

SPIROMETRY
- restrictive (FEV1/FVC >0.8)

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53
Q

SARCOIDOSIS
How can you stage sarcoidosis?

A

Using CXR
Stage 1 = bilateral hilar lymphadenopathy (BHL)
Stage 2 = pulmonary infiltrates with BHL
Stage 3 = pulmonary infiltrates without BHL
Stage 4 = progressive pulmonary fibrosis, bulla formation and bronchiectasis

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54
Q

SARCOIDOSIS
How do you treat sarcoidosis?

A

asymptomatic non-progressive = observation

symptomatic or progressive = 1st line - corticosteroids, 2nd line - immunosuppressants

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55
Q

SARCOIDOSIS
Give 2 possible differential diagnosis’s for sarcoidosis

A
  1. Lymphoma

2. Pulmonary TB

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56
Q

IDIOPATHIC PULMONARY FIBROSIS
what are the risk factors of idiopathic pulmonary fibrosis?

A
  • cigarette smoking
  • infectious agents - CMV, Hep C, EBV
  • occupational dust exposure
  • drugs - methotrexate, imipramine
  • GORD
  • genetic predisposition
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57
Q

IDIOPATHIC PULMONARY FIBROSIS
what are the clinical features of idiopathic pulmonary fibrosis

A
  1. non-productive cough
  2. SOB on exertion
  3. Systemic = malaise, weight loss, arthralgia
  4. Cyanosis
  5. Finger clubbing
  6. bibasal crackles (Inspiratory crackles/crepitus)
  7. dyspnoea
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58
Q

IDIOPATHIC PULMONARY FIBROSIS
What investigations might you do in someone you suspect to have idiopathic pulmonary fibrosis?

A

Bloods = raised CRP, immunoglobulins and check autoantibodies

CXR/CT = degreased lung volume + honeycomb lung

High resolution CT = ground glass appearance

Spirometry = restrictive

Lung biopsy = confirmation

ABG = type 1 respiratory failure

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59
Q

IDIOPATHIC PULMONARY FIBROSIS
What is the treatment for idiopathic pulmonary fibrosis?

A

SUPPORTIVE CARE
- pulmonary rehab
- long term oxygen
- pneumonia + flu vaccines

ANTI-FIBROTIC AGENTS
- pirifenidone
- nintedanib

LUNG TRANSPLANTATION

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60
Q

PULMONARY FIBROSIS
what are the causes of upper lobe pulmonary fibrosis?

A

SCART
- sarcoidosis
- coal miners pneumoconiosis
- ankylosing spondylitis
- radiation
- TB

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61
Q

PULMONARY FIBROSIS
what are the causes of lower lobe pulmonary fibrosis?

A

RASIO
- Rheumatoid
- Asbestosis
- Scleroderma
- Idiopathic pulmonary fibrosis (most common)
- other

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62
Q

PULMONARY HYPERTENSION
what are the causes of pulmonary hypertension

A
  • pre-capillary
    • multiple small PE’s
    • left-to-right shunts
    • primary
  • capillary
    • emphysema
    • COPD
  • Post-capillary
    • backlog of blood causes secondary hypertension
    • LV failure
  • chronic hypoxaemia
    • living at high altitude
    • COPD
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63
Q

PULMONARY HYPERTENSION
what is the clinical presentation of pulmonary hypertension

A
  • progressive breathlessness
  • exertional dizziness/syncope
  • fatigue
  • haemoptysis
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64
Q

PULMONARY HYPERTENSION
What are the investigations?

A

Initial tests:
- CXR - Enlarged main pulmonary artery, enlarged hilar vessels and pruning.

  • ECG - right ventricular hypertrophy,right axis deviation, right atrial enlargement. (A normal ECG does not rule out the presence of significant pulmonary hypertension)
  • TTE - (trans-thoracic echocardiogram)

Diagnostic test: Right heart catheterisation

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65
Q

PULMONARY HYPERTENSION
Describe the treatment of pulmonary hypertension

A

1st line
- CCBs
- pulmonary vasodilators e.g. prostacyclin, sildenafil
- diuretics
- oxygen therapy
- anticoagulation (warfarin or NOAC)

2nd line
- lung transplant
- balloon atrial septostomy

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66
Q

TB
Describe the pathogenesis of pulmonary TB disease

A

TB spread via respiratory droplets as it is an airborne infection
1. Alveolar macrophages ingest bacteria and the rods proliferate inside.

  1. Drain into hilar lymph nodes 🡪 present antigen to T lymphocytes 🡪 cellular immune response.
  2. Delayed hypersensitivity reaction 🡪 tissue necrosis and granuloma formation: caseating.
    • Primary Ghon Focus
    • Ghon Complex – Ghon focus + lymph nodes
67
Q

TB
Give 3 risk factors for TB

A
  1. Living in a high prevalence area
  2. IVDU
  3. Homeless
  4. Alcohol
  5. HIV +ve
68
Q

TB
A special culture medium is needed to grow TB, what is it called?

A

Lowenstein Jenson Slope

69
Q

TB
What is the drug treatment commonly used for TB?

A

RIPE
RI = 6 months
PE = for first 2 months

R = rifampicin
I = isoniazid
P = pyrazinamide
E = ethambutol

70
Q

TB
Give 2 potential side effects of Rifampicin

A
  1. Red urine
  2. Hepatitis
  3. Drug interaction - it’s an enzyme inducer
71
Q

TB
Give 2 potential side effects of Isoniazid

A
  1. Hepatitis

2. Neuropathy

72
Q

TB
Give 2 potential side effects of Pyrazinamide

A
  1. Hepatitis
  2. Gout
  3. Neuropathy
73
Q

TB
Give a potential side effect of Ethambutol

A

Optic neuritis

74
Q

WHOOPING COUGH
What is the treatment of whooping cough?

A

Clarithromycin - in catarrhal or early paroxysmal stages

  • have little effect on disease course in paroxysmal stage
75
Q

WHOOPING COUGH
Give 2 possible complications of whooping cough

A
  1. Pneumonia
  2. Encephalopathy
  3. Sub-conjunctival haemorrhage
76
Q

CYSTIC FIBROSIS
what is CFTR and what is it’s function?

A
  • Transport protein on membrane of epithelial cells that acts as a chloride
    channel
  • Transports chloride ions
  • Normally; it actively exports NEGATIVE IONS especially Cl- and Na+ passively follows causing an osmotic gradient and movement of water out of the cell and into the mucus
77
Q

PLEURAL EFFUSION
what is transudate pleural effusion?

A
  • transparent (less protein)
  • Pleural fluid protein is less than 30g/L since vessels are normal so only
    fluid is able to leak out and not protein
  • Occurs when the balance of hydrostatic forces in the chest favour the accumulation of pleural fluid i.e. increased pressure due to the backing up of blood in left sided congestive heart failure
78
Q

PLEURAL EFFUSION
what is exudate pleural effusion?

A
  • exudes proteins
  • Pleural fluid protein is more than 30g/L since endothelial cells of vessels are more apart meaning fluid and protein is able to leak out
  • Occurs due to the increased permeability and thus leakiness of pleural
    space and or capillaries usually as a result of inflammation, infection or
    malignancy
79
Q

PLEURAL EFFUSION
what are the risk factors for pleural effusion?

A
  • Previous lung damage

- Asbestos exposure

80
Q

PNEUMOTHORAX
what are the risk factors for pneumothorax?

A

Smoking
Family history
Male
Tall and slender build
Young age
Presence of underlying lung disease

81
Q

PNEUMOTHORAX
what are the causes of pneumothorax?

A
  • In patients over 40 years of age the usual cause is underlying COPD
  • Other/rarer causes include:
    • Bronchial asthma
    • Carcinoma
    • Breakdown of a lung abscess leading to bronchopleural fistula
    • Severe pulmonary fibrosis with cyst formation
    • TB
    • Pneumonia
    • Cystic fibrosis
    • Trauma (penetrating or rib fracture)
    • Iatrogenic e.g. pacemakers or central lines
82
Q

TB
what are the signs of TB?

A 
Signs of bronchial breathing
Dullness to percuss
Decreased breathing
fever
crackles
83
Q

PNEUMONIA
which bacteria causes rusty sputum in pneumonia?

A

strep pneumoniae

84
Q

PNEUMONIA
what is atypical pneumonia?

A

Bacterial pneumonia caused by atypical organisms that are not detectable on Gram stain and cannot be cultured using standard methods.

85
Q

PNEUMONIA
what are the common organisms that cause atypical pneumonia?

A

Mycoplasma pneumoniae,
Chlamydophila pneumoniae,
Legionella pneumophila
coxiella burnetii

86
Q

BRONCHIECTASIS
what antibiotics are used for bronchiectasis?

A
  • pseudomonas aeruginosa = oral ciprofloxacin
  • h.influenzae = oral amoxycillin, co-amoxyclav or doxycycline
  • staph aureus = flucloxacillin
87
Q

GOODPASTURES SYNDROME
what is the pathophysiology of goodpasture’s syndrome?

A

Specific autoimmune disease caused by a type II antigen-antibody reaction leading to diffuse pulmonary haemorrhage, glomerulonephritis (and often acute kidney injury and chronic kidney disease)

  • There are circulating anti-glomerular basement membrane (anti-GBM) antibodies
88
Q

LUNG CANCER
where does squamous cell carcinoma of the lung arise from?

A
  • epithelial cells typically in the central bronchus
89
Q

LUNG CANCER
what is squamous cell carcinoma associated with the production of?

A

associated with the production of keratin

90
Q

LUNG CANCER
where does small cell lung cancer arise from?

A

Arises from endocrine cells typically in the central bronchus

91
Q

LUNG CANCER
where does adenocarcinoma arise from?

A

mucus-secreting glandular cells

92
Q

PULMONARY HYPERTENSION
what is the pathophysiology of pulmonary hypertension?

A

The main vascular changes are:
Vasoconstriction
Smooth-muscle cell and endothelial cell proliferation
Thrombosis

93
Q

what are the investigations for IE COPD?

A

ABG

  • CO2 retention → acidosis
  • Raised pCO2 + low pO2 = T2RF

Chest X-Ray, sputum culture + sensitivities for antibiotic therapy, FBC + U&E

94
Q

ASTHMA
which drugs can trigger asthma attacks?

A

NSAIDs and aspirin

beta blockers - results in bronchoconstriction which results in airflow limitation and potential attack

95
Q

PHARMACOLOGY
give 2 examples of LABAs

A
  • salmeterol

- formoterol (full agonist)

96
Q

PHARMACOLOGY
give an example of a SAMA

A

ipratropium

97
Q

PHARMACOLOGY
give an example of a LAMA

A

tiotropium

98
Q

PHARMACOLOGY
what is the mechanism of action for ICS?

A
  • They reduce the number of inflammatory cells in the airways
  • Suppress production of chemotactic mediators
  • Reduce adhesion molecular expression
  • Inhibit inflammatory cell survival in the airway
  • Suppress inflammatory gene expression in airway epithelial cells
99
Q

PHARMACOLOGY
what are the side effects of ICS?

A

Loss of bone density
Adrenal suppression
Cataracts
Glaucoma

100
Q

LUNG CANCER
what are the extra-pulmonary manifestations of lung cancer?

A

Recurrent laryngeal nerve palsy - hoarse voice

Superior vena cava obstruction - facial swelling, distended veins in neck and upper chest, Pemberton’s sign

Horner’s syndrome - ptosis, miosis, anhidrosis

101
Q

PNEUMONIA
which bacteria is associated with causing pneumonia in COPD patients?

A

h.influenzae

102
Q

PNEUMONIA
which bacteria is associated with aspiration pneumonia?

A

klebsiella pneumoniae

103
Q

PNEUMONIA
what is the management of HAP?

A

low severity = oral co-amoxiclav
high severity = broad spectrum abx (IV tazocin or ceftriaxone)

104
Q

BRONCHIECTASIS
what spirometry pattern is found in bronchiectasis?

A

obstructive
FEV1/FVC <70%

105
Q

CYSTIC FIBROSIS
how does orkambi work?

A
  • LUMACAFTOR - increases number of CFTR proteins transported to cell membranes
  • IVACAFTOR - potentiates CFTR proteins on cell surface, increases chance channel will open
106
Q

LUNG CANCER
What are the contraindications to surgery in NSCLC?

A
  • frail
  • metastatic disease
  • malignant pleural effusion
  • SVC obstruction
  • tumour near hilum
  • vocal cord paralysis
107
Q

ASTHMA
what is the management of a severe/life-threatening asthma exacerbation?

A
  • oxygen
  • nebulised bronchodilator (salbutamol)
  • corticosteroid (40-50mg prednisolone)
  • ipratropium bromide
  • IV magnesium sulfate
  • IV aminophylline
108
Q

ASTHMA
what is the management of a moderate exacerbation of asthma?

A
  • salbutamol
  • 5 days oral prednisolone
109
Q

PLEURAL EFFUSION
what are the signs of pleural effusion?

A
  • reduced chest expansion
  • tracheal deviation
  • Stony dull percussion note on affected side
  • Diminished breath sounds on affected side
  • Decreased tactile vocal fremitus
  • Loss of vocal resonance
110
Q

PLEURAL EFFUSION
what criteria can be used to distinguish between transudate and exudate effusions?

A

lights criteria
it is used in borderline cases between 25-35g/L

111
Q

PLEURAL EFFUSION
what is the light’s criteria?

A

exudate is likely if:
- pleural fluid to serum protein ratio >0.5
- pleural fluid LDH to serum LDH ratio >0.6
- pleural fluid LDH >2/3 upper limits of normal serum LDH

112
Q

PLEURAL EFFUSION
what does low glucose in pleural fluid indicate?

A
  • rheumatoid arthritis
  • tuberculosis
113
Q

PLEURAL EFFUSION
what does a raised amylase in pleural fluid indicate?

A
  • pancreatitis
  • oesophageal perforation
114
Q

PLEURAL EFFUSION
what does heavy blood staining in pleural fluid indicate?

A
  • mesothelioma
  • PE
  • tuberculosis
115
Q

PLEURAL EFFUSION
what are the indications of a pleural infection?

A
  • purulent or turbid/cloudy fluid
  • clear fluid but pH <7.2 (chest drain must be inserted)
116
Q

PNEUMOTHORAX
what are the risk factors for a primary spontaneous pneumothorax?

A
  • tall, slender, young
  • smoking
  • marfan syndrome
  • rheumatoid arthritis
  • family history
  • rheumatoid arthritis
  • driving or flying
117
Q

PNEUMOTHORAX
what are the risk factors for secondary spontaneous pneumothorax?

A
  • underlying lung disease e.g. COPD, asthma, lung cancer
  • TB
  • pneumocystis jirovecii
118
Q

PNEUMOTHORAX
what are the signs of a pneumothorax?

A
  • tachycardia
  • tachypnoea
  • cyanosis
  • hyperresonance ipsilateral
  • reduced breath sounds ipsilateral
  • hyperexpansion ipsilateral
  • contralateral tracheal deviation
119
Q

PNEUMOTHORAX
what is the management for a secondary spontaneous pneumothorax?

A

SMALL (1-2cm)
- aspirate with 16-18G needle
- admit with high flow oxygen

LARGE (>2cm) or breathless
- insert chest drain
- admit with high flow oxygen

120
Q

PNEUMOTHORAX
where is the needle for aspiration of a spontaneous pneumothorax placed?

A
  • 2nd intercostal space midclavicular line
121
Q

PNEUMOTHORAX
where are chest drains placed?

A

5th intercostal space mid-axillary line

122
Q

PNEUMOTHORAX
what are the indications for surgical management?

A
  • 2nd ipsilateral pneumothorax
  • 1st contralateral pneumothorax
  • bilateral spontaneous pnemothorax
  • persistent air leak after 5-7 days chest drain
  • pregnancy
  • at risk profession e.g. pilots + divers
123
Q

TENSION PNEUMOTHORAX
what are the risk factors?

A
  • mechanical ventilation
  • traumatic chest injury
  • chest line insertion
  • lung biopsy
124
Q

SARCOIDOSIS
what are the signs?

A
  • cervical + submandibular lymphadenopathy
  • lupus pernio (lupus-type rash)
  • erythema nodosum (dusky coloured nodules on shins)
125
Q

PULMONARY HYPERTENSION
what are the signs?

A
  • right parasternal heave
  • loud 2nd heart sound
  • pulmonary or tricuspid regurgitation
  • raised JVP
  • signs of underlying condition
126
Q

ASBESTOS-RELATED LUNG DISEASE
what is the spectrum of conditions?

A
  • pleural plaques
  • pleural thickening
  • asbestosis
  • mesothelioma
  • lung cancer
127
Q

ASBESTOS-RELATED LUNG DISEASE
what is asbestosis?

A
  • restrictive lung disease
  • lower lung zones affected predominantly
  • severity is related to length of exposure
  • presents with dyspnoea + reduced exercise tolerance
128
Q

ASBESTOS-RELATED LUNG DISEASE
what is mesothelioma?

A
  • malignant disease of pleura
  • can occur with only short term exposure to asbestos
129
Q

PNEUMOCONIOSIS
what is it?

A

interstitial lung disease secondary to occupational exposure causing an inflammatory reaction

130
Q

PNEUMOCONIOSIS
what is the pathophysiology?

A
  • when dust particles are inhaled, they reach terminal bronchioles + are ingested by interstitial + alveolar macrophages
  • dust particles are carried by macrophages + expelled as mucus
  • if exposed for a long time these systems no longer function
  • macrophages accumulate in alveoli resulting in immune system activation + lung tissue damage
131
Q

PNEUMOCONIOSIS
what are the different types?

A
  • coal workers pneumoconiosis (coal miners)
  • silicosis (quarry workers, silica miners)
  • berylliosis (aerospace industry, beryllium miners)
  • asbestosis (construction workers, plumbers)
132
Q

PNEUMOCONIOSIS
what are the risk factors?

A
  • male
  • increasing age
  • substance exposure
133
Q

PNEUMOCONIOSIS
what are the symptoms?

A

SIMPLE PNEUMOCONIOSIS
- asymptomatic

PROGRESSIVE MASSIVE FIBROSIS
- exertional dyspnoea
- dry cough
- wheezing
- haemoptysis
- weight loss

134
Q

PNEUMOCONIOSIS
what are the clinical signs?

A
  • fine crackles
  • wheezing
  • clubbing
135
Q

PNEUMOCONIOSIS
what are the investigations?

A
  • CXR - opacities in upper lobes, eggshell calcification of hilar lymph nodes
  • SPIROMETRY - restrictive pattern (FEV1/FVC>0.7)
  • HIGH RESOLUTION CT CHEST - interstitial fibrosis
136
Q

PNEUMOCONIOSIS
how is it staged?

A

using CXR
- 0 = small rounded opacities absent
- 1 = small rounded opacities but few in number
- 2 = numerous small rounded opacities but normal lung markings
-3 = numerous small rounded opacities + obscured lung markings

137
Q

PNEUMOCONIOSIS
what is the management?

A
  • smoking cessation
  • avoidance of exposure
  • pulmonary rehab
  • supplementary oxygen
  • corticosteroids
  • lung transplant
138
Q

HYPERSENTIVITY PNEUMONITIS
what is it?

A

type III + IV hypersensitivity reaction to an environmental allergen

139
Q

HYPERSENTIVITY PNEUMONITIS
give some examples of causes

A
  • bird fanciers lung (bird droppings)
  • farmers lung (mould spores in hay)
  • mushroom workers lung (mushroom antigens)
  • malt workers lung (mould on barley)
140
Q

HYPERSENTIVITY PNEUMONITIS
what is the pathophyisology?

A

type III + IV hypersensitivity reaction to environmental allergen
inhalation of allergens in patients sensitised to allergen causes an immune response
leads to inflammation + damage to lung tissue

141
Q

HYPERSENTIVITY PNEUMONITIS
what are the symptoms?

A
  • SOB
  • cough
  • chest tightness
  • fatigue
142
Q

HYPERSENTIVITY PNEUMONITIS
what are the investigations?

A
  • bronchoalveolar lavage = raised lymphocytes
143
Q

HYPERSENTIVITY PNEUMONITIS
what is the management?

A
  • removal of allergen
  • oxygen
  • corticosteroids
144
Q

RESPIRATORY FAILURE
what is the pathophysiology of type 1 respiratory failure?

A
  • due to problem with gas exchange between alveoli + blood
  • typically due to V/Q mismatch
  • oxygen predominantly affected due to ow blood solubility
145
Q

RESPIRATORY FAILURE
what are the causes of type 1 respiratory failure?

A
  • pneumonia
  • heart failure
  • asthma
  • PE
  • high altitude pulmonary oedema
146
Q

RESPIRATORY FAILURE
what is the pathophysiology of type 2 respiratory failure?

A
  • failure of adequate alveolar ventilation
  • due to reduced respiratory drive, reduced compliance of lungs, increased airway resistance or muscle weakness
  • impairs delivery of O2 + removal of CO2 from lungs
147
Q

RESPIRATORY FAILURE
what are the causes of type 2 respiratory failure?

A
  • opiate toxicity
  • iatrogenic
  • neuromuscular disease (MND, GBS)
  • reduced chest wall compliance (Obesity)
  • increased airway resistance (COPD)
148
Q

RESPIRATORY FAILURE
what is the management for type 1 respiratory failure?

A
  • treat underlying cause
  • oxygen therapy
  • PEEP through CPAP
149
Q

RESPIRATORY FAILURE
what is the management for type 2 respiratory failure?

A
  • treat underlying cause
  • oxygen therapy
  • lower oxygen sats threshold (88-92%)
  • NIV
  • invasive mechanical ventilation
150
Q

INFLUENZA
what are the clinical signs?

A
  • raised respiratory rate
  • rhinorrhoea
  • reduced air entry or crackles on auscultation
  • pyrexia
151
Q

INFLUENZA
what is the management?

A
  • not treatment required for majority
  • if at risk or have severe flu, offer anti-virals (zanamivir, oseltamivir)
152
Q

ACUTE BRONCHITIS
what are the causes?

A
  • viral infections (coronavirus, rhinovirus, RSV, adenovirus)
153
Q

ACUTE BRONCHITIS
what are the symptoms?

A
  • cough (may or may not be productive)
  • sore throat
  • rhinorrhoea
  • wheeze
  • low grade fever

SIGNS
- no focal chest signs

154
Q

ACUTE BRONCHITIS
what are the investigations?

A

clinical diagnosis

can consider following tests to rule out other causes
- pulmonary funciton test
- CXR
- bloods - CRP

155
Q

ACUTE BRONCHITIS
what is the management?

A
  • analgesia
  • good fluid intake
  • antibiotics (DOXYCYCLINE (or AMOXICILLIN if contraindicated))

consider antibiotics if:
- systemically unwell
- have pre-existing co-morbidities
- delayed abx prescription if CRP 20-100
- immediate abx if CRP >100

156
Q

HYPERSENSITIVITY
what is a type 1 hypersensitivity reaction?

A

Classical allergy, mediated by the inappropriate production of specific IgE antibodies to harmless antigens

mast cells are activated + release histamine

157
Q

HYPERSENSITIVITY
what is type II hypersensitivity?

A

Caused by IgG and IgM antibodies that bind to antigens cells or tissues leading to cell or tissue damage

158
Q

HYPERSENSITIVITY
give some examples of type II hypersensitivity reactions

A
  • blood transfusion reactions
  • haemolytic disease of the newborn
  • goodpastures disease
159
Q

HYPERSENSITIVITY
what is a type III hypersensitivity reaction?

A

Caused by antibody-antigen complexes being deposited in tissues, where they activate the complement system and cause inflammation

160
Q

HYPERSENSITIVITY
give some examples of type III hypersensitivity reactions

A
  • rheumatoid arthritis
  • farmers lung (hypersensitivity pneumonitis)
161
Q

HYPERSENSITIVITY
what is a type IV hypersensitivity reaction?

A

A delayed type hypersensitivity reaction caused by T helper cells traveling to the site of antigens, recruiting macrophages and causing inflammation

162
Q

HYPERSENSITIVITY
give some examples of type IV hypersensitivity reactions

A
  • poison ivy
  • nickel and gold
  • mantoux test
  • TB
  • graft vs host disease
  • pneumoconiosis
  • MS
  • GBS
163
Q

ANAPHYLAXIS
what is the management?

A
  • IM adrenaline 500 micrograms
  • give high flow O2
  • antihistamine (chlorphenamine or cetirizine)

if no response after 5 mins repeat IM adrenaline + IV fluid bolus

no improvement after 2 doses of IM adrenaline = refractory anaphylaxis

164
Q

ANAPHYLAXIS
when can patients be discharged?

A

AFTER 2 HOURS
- good response (within 5-10 mins) to single IM adrenaline
- complete resolution of symptoms
- has autoinjector + trained

AFTER 6 HOURS
- 2 doses of IM adrenaline
- previous biphasic reaction

AFTER 12 HOURS
- severe reaction (>2 doses IM adrenaline)
- severe asthma
- possibility of continued exposure to allergen
- presents at night or in area difficult to access in emergency

MY REVISION - ALL TO DO (21 decks)

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