Week 3 - COPD, ILD, sarcoidosis, bronchiectasis Flashcards
1
Q
Which neurotransmitter mediates the sympathetic innervation of bronchiolar smooth muscle?
A
Noradrenaline
2
Q
Which neurotransmitter mediates the parasympathetic innervation of bronchiolar smooth muscle?
A
Acetylcholine
3
Q
Which receptor does noradrenaline act on during the sympathetic innervation of bronchiolar smooth muscle?
A
Beta receptors
4
Q
Which receptor does acetylcholine act on during the parasympathetic innervation of bronchiolar smooth muscle?
A
Muscarinic receptors
5
Q
What effect does noradrenaline have on bronchiolar smooth muscle during sympathetic innervation?
A
Bronchodilation
6
Q
What effect does acetylcholine have on bronchiolar smooth muscle during parasympathetic innervation?
A
Bronchoconstriction
7
Q
What is the function of Type 1 alveolar cells ?
A
Gas exchange between alveoli and capillaries
8
Q
What is the function of Type 2 alveolar cells ?
A
Secrete surfactant to lower surface tension
9
Q
What is the appearance of Type 1 alveolar cells ?
A
Large squamous cells
10
Q
What is the appearance of Type 2 alveolar cells ?
A
Smaller cuboid-shaped cells
11
Q
Are there more or less Type 1 Vs Type 2 alveolar cells ?
A
More type 2 than type 1
12
Q
Are there secretory organelles present in Type 1 alveolar cells?
A
No
13
Q
Are there secretory organelles present in Type 2 alveolar cells?
A
Yes
14
Q
The pulmonary arteries supply deoxygenated blood from where, to where?
A
From the right ventricle to the alveolar capillary network
15
Q
The pulmonary veins supply oxygenated to where?
A
To the left atrium
16
Q
Do the bronchial arteries supply oxygenated or deoxygenated blood to the lungs ?
A
Oxygenate d
17
Q
The bronchial arteries supply blood from where, to where?
A
From the thoracic aorta to the lung tissues
18
Q
The bronchial veins supply blood to where?
A
The pulmonary and systemic venous systems
19
Q
What are the main conditions that fall under the respiratory system that cause the symptom of breathlessness?
A
- asthma
- COPD
- PE
- lung fibrosis
- sarcoidosis
- lung cancer
- pneumothorax
- pneumonia
20
Q
What are the main conditions that fall under the cardiac system that cause the symptom of breathlessness?
A
- heart valve disorders
- congestive heart failure (CHF)
21
Q
What is the main condition that falls under the haematological system that can cause the symptom of breathlessness?
A
Anaemia
22
Q
What does the MRC dyspnoea scale depict ?
A
The degree of breathlessness related to activities
23
Q
How many levels are there on the MRC dyspnoea scale ?
A
5
24
Q
What does a level 1 mean on the MRC dyspnoea scale ?
A
1 = not troubled by breathlessness unless on strenuous exercise
25
What does a level 2 mean on the MRC dyspnoea scale ?
2 = SOB when hurrying or walking up a slight hill
26
What does a level 3 mean on the MRC dyspnoea scale ?
3 = **walks slower** than counterparts on level ground due to SOB, or has to **stop for breath** when walking at own pace
27
What does a level 4 mean on the MRC dyspnoea scale ?
4 = stops for breath after walking 100 metres/after a few mins on level ground
28
What does a level 5 mean on the MRC dyspnoea scale ?
5 = **too breathless to leave the house**, or SOB when dressing/undressing
29
What system pathology might be indicated of SOB is worse when lying flat?
Cardiac pathologies
*e.g CHF*
30
What condition(s) is indicated if the patient describes night-time symptoms of SOB?
- Asthma
- COPD/Asthma overlap syndrome
31
What condition(s) is indicated if the patient describes ankle swelling paired with SOB?
- **CHF** (bilateral swelling)
- **PE/DVT** (unilateral swelling)
32
What condition(s) is indicated if the patient describes lightheadedness paired with SOB?
- cardiac pathologies e.g **aortic stenosis**
- **anxiety**
33
What condition(s) is indicated if the patient describes exposure/secondhand exposure to asbestos paired with SOB?
- asbestosis
- mesothelioma
- lung cancer (adenocarcinoma)
34
What condition(s) is indicated if the patient has pet birds paired with SOB?
Hypersensitivity pneumonitis
*repeated inhalation of avian antigens*
35
How do you calculate a persons ‘pack year’ smoking history ?
no. cigs per day X no. years smoked for
*e.g 20 cpd = 1 pack year, for 40 years…
So, 1 X 40 = 40 pack years*
36
What is the likelihood of someone being a smoker/ex smoker if they are diagnosed with
A) asthma ?
B) COPD?
Asthma = potentially a smoker but not necessarily
COPD = nearly every patient is a smoker/ex smoker
37
*Asthma Vs COPD…*
Is it often or rare for symptoms to present under the age of 35?
Asthma = often
COPD = rare
38
*Asthma Vs COPD…*
How common is a chronic productive cough?
Asthma= uncommon
COPD = common
39
*Asthma Vs COPD…*
What is the characteristics of the breathlessness?
Asthma = variable
COPD = persistent and progressive
40
*Asthma Vs COPD…*
How common is night time waking with SOB/wheeze ?
Asthma = common
COPD = uncommon
41
*Asthma Vs COPD…*
How common is day-to-day symptom variability ?
Asthma = common
COPD = uncommon
42
What are the hall mark symptoms of COPD?
- SOB
- chronic cough
- sputum production
*Others include…
- wheeze
- winter exacerbations*
43
What are some physical signs of COPD to look for on examination?
- **pursed lip breathing**
- **accessory muscle use** (for breathing)
- **wheeze** on auscultation
- **barrel chest** (chest hyper expansion)
- **palpable liver** (due to hyperinflation or CHF)
- **tar staining** on hands/fingers
- **ankle oedema** (indicated right sided heart failure due to cor pulmonary)
44
What is the most common lung disease in the UK ?
Asthma
45
What is the second most common lung disease in the UK ?
COPD
46
Which gender (between male and female) are most likely to
A) be diagnosed with COPD?
B) die from COPD?
**Men** for both :(
47
Is age a risk factor for COPD?
Yes
*it is uncommon under the age of 40 and gets more prevalent with age*
48
What are the main risk factors for COPD?
- cigarette smoking
- cannabis smoking
- indoor air pollution *(e.g firewood, animal dung, cooking coal…)*
- alpha-1 antitrypsin deficiency *(a rare genetic condition)*
- being male
- age (>40)
49
True or false…
Quitting smoking is a requirement for home oxygen therapy ?
True
*oxygen is flammable, so smoking near oxygen tanks pose a risk of explosion and faire hazards*
50
True or false…
Quitting smoking is true only intervention that will slow the disease progression into COPD?
True
*smoking cessation reverts the rate of lung function decline back to the background rate*
51
Does smoking cessation reverse some of the damage already done to the lungs by smoking?
**no** it only reduces the rate of further decline
52
What in the pathogens is of COPD causes the cough and sputum?
Goblet cell hyperplasia
53
What in the pathogens is of COPD causes the SOB and wheeze ?
Airway narrowing
54
What in the pathogens is of COPD causes the SOB ?
Alveolar destruction
55
What is the gold standard investigation for diagnosis and grading the severity of COPD ?
Spirometry
56
What reading on a post-bronchodilator FEV1/FVC ratio confirms COPD/a persistent airflow obstruction ?
FEV1/FVC **<0.7**
57
What FEV1 reading indicates **mild COPD** ?
>/=80%
58
What FEV1 reading indicates **moderate COPD** ?
50-79%
59
What FEV1 reading indicates **severe COPD** ?
30-49%
60
What FEV1 reading indicates **very severe COPD** ?
<30%
61
What is the progression of cor pulmonale, starting with hypoxia?
1. Hypoxia
2. Pulmonary artery vasoconstriction
3. Increased pulmonary artery pressure
4. Right ventricular hypertrophy
5. Right ventricular failure
62
What inhaled medications can be offered to COPD a patients for relief or during exercise …
SABA or SAMA
*to cause bronchodilation*
63
What systems do steroids interact with/effect?
- Protein, fat and carb metabolism
- blood pressure *(hypertension)*
64
How do steroids interact with protein metabolism and what symptoms does this cause?
**increases** protein metabolism
- thin skin
- leaky vessels = bruising
- osteoporosis
- kyphosis (hunched back)
- muscle wasting
65
How do steroids interact with lipid metabolism and what symptoms does this cause?
**decreases** lipid metabolism
causing weight gain on the face, back and tummy
66
How do steroids interact with carb metabolism and what symptoms does this cause?
**increases** carb metabolism
causing diabetes
67
What are the most common causes of COPD exacerbations?
50% Respiratory viruses
50% bacterial infections
68
What do ‘coryzal symptoms’ mean?
Symptoms of a cold
69
What are the symptoms of a COPD exacerbation ?
- preceding coryzal symptoms
- increased breathlessness
- increased cough
- increased sputum
- purulent sputum
- ankle swelling
*- potential chest pain*
70
What investigations would you do during a suspected COPD exacerbation ?
- **CXR** *(rule out pneumothorax etc)*
- **ABGs** *(to see which reps failure it is)*
- **ECG**
- **bloods** *(FBC, CRP, U+E, LFTs)*
- **sputum culture** *if purulent*
71
What’s the initial treatment for a COPD exacerbation ?
- **O2** *(to give SaO2 no more than 92%)*
- **nebulised SABAs** *(high dose)*
- **corticosteroids** *(high dose, usually prednisone)*
- **antibiotics** *(if purulent sputum)*
*reassess after an hour*
72
If, after an hour, the initial treatment hasn’t resolved the COPD exacerbation, what do you do next?
- IV bronchodilator *(salbutamol, theophylline)*
- urgent ICU opinion
- non-invasive ventilation
- intubation and assisted ventilation
73
What is the difference between Type 1 and Type 2 respiratory failure ?
Type 1 = **low PaO2** *normal pH and HCO3*
Type 2 = **low PaO2, high PaCO2** *can have low pH and high HCO3*
*high HCO3 in type 2 suggests long standing resp failure causing compensation*
74
What are the clinical features on hypercapnia ?
- altered mental state
- dilated pupils
- flushes skin
- bounding pulse
- asterixis (flapping tremor)
75
What CXR findings might indicate COPD ?
- flattened diaphragm
- hyper inflated lungs *(can be spotted by horizontal ribs and smaller heart size)*
- nipple shadows
76
What respiratory conditions are associated with nail clubbing?
- lung cancer
- bronchiectasis
- cystic fibrosis
- interstitial lung disease
77
What would a CXR look like for interstitial lung disease?
Often normal
*sometimes some mild basal interstitial changes (white markings between the ribs*
78
What are the major investigations/tests to do for a diagnosis of Interstitial lung disease (ILD)?
- blood tests
- CXR
- HRCT *(high resolution CT)*
- Spirometry / lung function tests
79
Does interstitial lung disease show a
A) restrictive pattern of lung function ?
B) obstructive pattern of lung function ?
ILD = Restrictive
80
What changes are seen in ILD, to the
A) FVC
B) FEV1
C) FVC/FEV1 ratio
FVC = **low**
FEV1 = **low**
*these are proportional, so the **FVC/FEV1 ratio = normal** *
81
How is lung volume affected in interstitial lung disease (ILD) ?
Lung volume is **decreased**
82
What is meant by the lungs ‘transfer factor’ (DLCO) ?
The lungs ability to soak up oxygen into the blood stream
83
What happens to the transfer factor in ILD ?
Decreased
*= less ability to soak up oxygen*
84
What might you see on a CT for interstitial lung disease ?
- basal lung fibrosis
- honeycombing
85
Is interstitial lung disease one thing or a term to cover multiple conditions ?
**umbrella term** for hundreds of lung diseases affecting the parenchyma
86
What are the 2 main classes of interstitial lung diseases ?
- primarily inflammatory
- primarily fibrotic
87
What can be heard on auscultation to indicate fibrotic lung disease ?
**velcro-like crackles**
*bi-basal, fine, end-inspiratory crepitations*
88
What are some types of ILDs that have no known causes ?
- idiopathic pulmonary fibrosis (IPF)
- sarcoidosis
- cryptogenic organising pneumonia (COP)
89
What are some known occupational causes of IDLs?
- Asbestos exposure
- Silicosis
90
What are some known environmental/social causes of ILDs?
- smoking
- birds
- hypersensitivity pnuemonities
- drugs
91
What are some known medications to cause interstitial lung diseases ?
- Methotrxate
- Amiodarone
- Nitrofurantoin
- Bleomycin
92
How do you treat idiopathic pulmonary fibrotic (IPF) disease ?
- antifibrotics *(pirfenidone, nintedanib)*
- oxygen if needed
- *meds to help with side effects of antifibrotics*
93
Do antifibrotics cure IPF?
No they **slow it down** by about 50% to give the patient a longer life
94
What are the main side effects of antifibrotics ?
- GI upset *(nausea, vomiting, diarrhoea)*
- Acid reflux
- skin rashes/UV sensitivities
95
What are the clinical features of systemic sclerosis ?
- reynauds
- telangiectasia *(spider veins)*
- puckering round the mouth
- sclerodactyly *(tightness of skin on hands, pulling fingers in)*
96
What would lung function test results look like in systemic sclerosis ?
- FVC = normal
- FEV1 = normal
- FVC/FEV1 ratio = showing restrictive
- DLCO = very low
97
What would be seen on a CT scan of systemic sclerosis ?
bilateral basal changes
**ground glass** abnormalities *(looks like cotton wool)* in early stages
**severe basal fibrosis, traction bronchiectasis** in later stages
98
What would you here on auscultation of systemic sclerosis ?
Fine, bi-basal, end-inspiratory crepitations
99
What is the mean survival time after a diagnosis of interstitial lung disease?
2.5 - 5 years without treatment
2-3 years extra with treatment
100
What is sarcoidosis ?
An **inflammatory disease** in which the immune system overreacts, **causing granulomas** *(inflamed tissue clusters)* in the lungs/organs
101
What can be seen on a CXR for sarcoidosis ?
- bi-hilar lymphadenopathy
- diffuse inflammatory infiltrates
102
What systems are often involved in sarcoidosis ?
- visual
- nervous
- salivary glands
103
What are the features of uveoparotid fever/Heerfordt’s syndrome ?
- acute uveitis *(eye inflammation)*
- fever
- parotid gland swelling
*this is a form of neurosarcoidosis*
104
What is the most typical presentation of acute sarcoidosis?
- Afro Caribbean *(not necessarily, but more common)*
- young female
- no red flag symptoms
- cough, SOB, chest pain *(pulmonary specifically)*
- mild ankle swelling/pain
- feeling generally run down/tired
- no resp symptoms
- feels hot but no fever
- erythema nodosum *(tender redness on shins symmetrically)*
105
Who is most at risk from sarcoidosis ?
- Afro Caribbean heritage
- young adult (30-40)
- women
106
What are the top diagnoses for a complaint of weight loss and night sweats ?
Cancer
TB
107
What does erythema nodosum indicate ?
**systemic disease**
- sarcoidosis
- TB
- bacterial/deep fungal infection
- cancer
- inflammatory bowel disease
108
What tests are done for suspected sarcoidosis ?
- bloods (inflammatory markers)
- urine tests
- lung function
- CXR
- CT
- ECG
- biopsy
109
How do the stages of pulmonary sarcoidosis show on a CXR ?
0. Normal CXR
1. Just hilar lymphadenopathy
2. Lymphadenopathy and parenchyma involvement
3. Just parenchymal involvemnt
4. Pulmonary fibrosis
110
Which stages of sarcoidosis could spontaneously resolve without treatment ? Which need treatment ?
0. Resolve
1. Resolve
2. Resolve
3. Treatment
4. Treatment
111
Roughly, what % of patients with pulmonary sarcoidosis present as symptomatic on CXR ?
30-60%
112
What results would you find from lab tests in the incidence of sarcoidosis ?
- raised inflam markers (ESR)
- leukopenia
- hypercalcaemia
- hypercaliuria
- elevated ACE levels *(not diagnostic)*
113
Why is it important to wean steroid treatment rather than abrupt stop ?
**Giving exogenous steroids suppresses endogenous cortisol synthesis** by the adrenal glands, so an abrupt stop could **cause an adrenal crisis**
114
What is the treatment for sarcoidosis ?
- monitor if mild
- exclude all other potential diagnoses
- steroids if must
115
What types of sarcoidosis must you treat with steroids immediately ?
**Neuro**sarcoidosis
**Cardio**sarcoidosis
**Renal**sarcoidosis
*because these are life threatening*
116
What features are consistent with bronchiectasis on CXR ?
- mucus plugging
- consolidation
- tram-track opacity
- ring shadow
117
What are tram-track opacities seen on a CXR?
dilated airway seen in the longitudinal plane
118
What are ‘ring opacities’ seen on CXR?
Dilated airways seen end-on
119
What investigations would you do to diagnose bronchiectasis?
- bloods
- ABGs
- CXR *(not diagnostic by itself)*
- CT (diagnostic)
120
What is bronchiectasis?
- Chronic condition
- bronchial tree irreversibly dilated
- bronchial walls thickened and inflamed
- bronchial tree builds up excess mucus
*makes lungs vulnerable to infection*
121
Is bronchiectasis an acute or chronic condition ?
Chronic
122
How are CF and bronchiectasis related ?
CF is **an inherited form** of bronchiectasis
123
What are the most common causes of non-CF bronchiectasis?
- **Idiopathic** *(most common)*
- **post infective** *(e.g bacterial pneumonia)*
- **allergic** *(to mould/fungus…)*
- **autoimmune** *(associated with connective tissue diseases)*
- **immunodeficiency** *(e.g HIV)*
- **obstruction** *(secondary to severe asthma/COPD)*
124
Are males or females more often effected by bronchiectasis?
Females
125
At what age are the majority (60%) of bronchiectasis diagnoses made?
Over 70s
*prevalence increases with age*
126
Does bronchiectasis tend to affect the more deprived or least deprived areas ?
Least deprived areas
*different to other resp disorders*
127
Which investigation is usually the diagnostic tool for bronchiectasis?
HRCT scan
128
What is the favoured screening test for suspected CF ?
Sweat test
129
What is the treatment for bronchiectasis?
- short course of **antibiotics** for exacerbations/chest infections
- **physiotherapy** for airway cleaning
- **cough assist devices**
- **smoking cessation**
- **flu/pneumococcal vaccines**
- **lobectomy** if localised and debilitating **rare**
130
What is a ‘sail sign’ on CXR ?
Triangular opacity overlying the cardiac shadow
131
What is a ‘sail sign’ indicative of on CXR?
left lower lobe collapse
132
What aspect of bronchiectasis could cause a left lower lobe collapse ?
Mucus plugging
133
What classes as a bronchiectasis exacerbation ?
Deterioration in 3 or more of the following for >48hrs…
- cough
- sputum volume and/or consistency
- sputum purulence
- breathlessness and/or exercise tolerance
- fatigue and/or malaise
- haemoptysis
134
What is the most common prognosis of bronchiectasis?
Most patients have **few day-to-day symptoms** and **normal life expectancy**. Some chest infections are common
135
What are some uncommon complications of bronchiectasis ?
- cor pulmonale
- pulmonary hypertension
- massive haemoptysis
