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MAY MEDICINE 1 REVISION > Respiratory pathology 2 > Flashcards

Respiratory pathology 2 Flashcards

1
Q

What does COPD stand for ?

A

Chronic Obstructive pulmonary disease

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2
Q

What two conditions make up COPD ?

A

Chronic bronchitis and emphysema

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3
Q

How does the disease present ?

A

Chronic condition with exacerbations

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4
Q

What is Chronic bronchitis ?

A

A cough that produced sputum most days for three consecutive months for two ore more consecutive years.

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5
Q

What is the effect of chronic bronchitis in the large airways ?

A
  • Hyperplasia of the goblet and mucous cells
  • Short term inflammation
  • Fibrosis
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6
Q

What is the effect of chronic bronchitis in the small airways ?

A
  • Appearance of goblet cells
  • Long term inflammation
  • Fibrosis
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7
Q

What can happen to complicate chronic bronchitis ?

A

Infections

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8
Q

What elements of chronic bronchitis are most readily treated ?

A

Inflammation and infections

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9
Q

What is emphysema ?

A

Emphysema is an increase beyond the normal in the size of the airspaces distal to the terminal bronchioles (Acini) arising as a result of dilation or destruction of alveolar walls. The alveoli enlarge and loss elasticity making it hard to exhale.

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10
Q

How does emphysema develop?

A

It is caused by a lack of anti-elastase enzymes which normally remove elastase enzymes. Elastase enzymes are produced by immune cell such as macrophages and neutrophils and destroy alveolar walls if they are left to build up.

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11
Q

What happens after emphysema develops?

A

Emphysema causes vasoconstriction of capillaries in that area of lung (because they are not getting well oxygenated), this can cause pressure in the heart because there is less functioning capillaries in the lungs and therefore a greater resistance. . Greater pressure can cause Cor pulmonary (RH failure), decreases blood flow in the lung capillaries can cause fibrosis which further restricts flow through those capillaries and causes thickening of the blood which makes it even harder to pump.

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12
Q

What are the names of the four types of emphysema ?

A

Centriacinar
Scar
Panacinar
Periacinar

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13
Q

Describe centriacinar emphysema

A

Centriacinar emphysema starts with bronchial dilation and then alveolar tissue is lost, this type occurs at the top of the lobes. Often caused by smoking

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14
Q

Describe Panacinar emphysema

A

Panacinar emphysema affects whole acini in a larger area of lung. It most commonly is found at the bottom lobes and caused by genetics.

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15
Q

Describe Periacinar emphysema

A

Periacinar empyema damaged just the distal part of the acini which is often found near the periphery of the lung. These dilated alveoli can burst and leak air into the pleural cavity then it causes a pneumothorax to develop.

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16
Q

Describe Scar emphysema

A

Scar emphysema is no clinical effects and is just the formation of emphysema next to scars.

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17
Q

Does everyone develop emphysema ?

A

Yes especially as they age

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18
Q

What is the expected FVE1/FVC ration in a COPD patient ?

A

lower then 80%

For diagnosis <0.7

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19
Q

Is the total lung capacity of COPD patients higher of lower than normal people?

A

Often higher due to hyperinflation (i.e. air is stuck in the lungs because of difficulties with expiration)

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20
Q

Draw a diagram to represent the 4 types of emphysema

A

-

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21
Q

What are the risk factors for emphysema ?

A

No.1 Smoking.
Other modifiable risk factors: pollution, dust, low socioeconomics,
Non-modifiable risk factors: older age, genetics, maternal (or grandmaternal) smoking [ Causes reduced lung size which increases risk of COPD], Alpha 1 Anti-trypsin deficiency (causes early onset of COPD), Alpha 1-antiprotease deficiency (only results in emphysema)

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22
Q

What % of smokers will develop COPD ?

A

less than 50%

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23
Q

Why can maternal smoking cause COPD ?

A

Smaller lungs

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24
Q

What is Alpha 1 Anti-trypsin deficiency ?

A

Causes early onset of COPD

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25
Q

What is Alpha 1-antiprotease deficiency ?

A

Causes emphysema without chronic bronchitis

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26
Q

Signs of COPD

A 
Fine tremor (Bronchodilator treatment)
Flapping tremor (CO2 retention)
Hyper-resonance (From hyperinflation due to trapped air)
Peripheral oedema 
Raised JVP
Cachexia 
Cyanosis 
Pursed lip breahting
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27
Q

Symptoms of COPD

A 
Productive cough 
Dyspnoea 
Expiratory wheeze
Chest infections 
Acute exacerbations 
Continued decline
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28
Q

What are the signs of symptoms or a COPD exacerbation ?

A

Worsening symptoms, fatigue, temperature, chest tightness

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29
Q

What investigations are carried out to help determine if someone has COPD?

A 
CXR 
Spirometry (FVE1/FVC and reversibility test)
mMRC breathlessness scale 
ABG 
GOLD 
History of or present heart conditions
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30
Q

What are you looking for on a CXR ?

A

Hyperinflation - Chronic

Consolidation - Acute

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31
Q

What investigations would you carry out in hospital if someone is having an acute exacerbation of COPD?

A 
CXR
ABG
RBC and Hb 
U&Es
Sputum culture 
Underlying heart conditions
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32
Q

How is a COPD diagnosis made ?

A

Combination of history, investigations and symptoms/sins

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33
Q

What are the differential diagnoses ?

A

Chronic bronchial asthma - Younger, non - smokers, wheeze, atopy family history etc
Bronchiectasis - Clubbing and course crackles

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34
Q

Treatment for COPD

A

Non-pharmlogical (Smocking cessation, vaccinations and pulmonary rehabilitation). SABA, LAMA, LABA and ICS.

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35
Q

Treatment for COPD exacerbations

A

May be treated at home or in hospital, treated with steroids, antibiotics and SABA.

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36
Q

What is often the end result of COPD ?

A

Respiratory failure

Continued worsening and pronounced decline after even exacerbation

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37
Q

What are the two types of respiratory failure ?

A

Type 1 - Low O2

Type 2 - Low O2 and High CO2

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38
Q

What does the mMRC breathlessness scale say ?

A

0 - Only gets breathless on strenuous exercise
1 - Gets breathless when hurrying on level ground or walking up a slight hill
2 - Walks slower than people of the same ability and age because of breathlessness and may have to stop to catch breath
3 - Stops for breath after walking 100 yds or after a few minuets on level ground
4 - Too breathless to leave the house or breathless while dressing

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39
Q

Treatment pathway for a COPD patient who has breathlessness

A 
SABA 
(Taking every day)
SABA + LAMA 
(Still breathless)
SABA + LAMA / LABA 
(Still breathless)
No use of further treatment
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40
Q

Treatment pathway for a COPD patient who are having exacerbations

A 
SABA + LAMA
(Continued exacerbations)
SABA + LAMA/LABA 
(Continued exacerbations and FEV1/FVC < 50%)
SABA + LAMA / LABA / ICS
No further treatment
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41
Q

What does SABA stand for ?

A

Short Acting Beta2 Agonist

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42
Q

What does LAMA stand for ?

A

Long Acting Muscarinic antagonist

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43
Q

What does LABA stand for ?

A

Long acting beta2 agonist

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44
Q

What are the differences between asthma and COPD ?

A 
Smokers
Age 
Productive cough 
Breathless 
Woken during night 
Variability of symptoms
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45
Q

When would you bring a COPD patient into hospital ?

A 
If they are not coping 
If they are very breathless 
If there are in a poor or deteriorating condition s
If there level of activity is poor or they are confined to bed 
If they have cyanosis 
If they have worsening peripheral oedema 
If they have impaired consciousness 
if they have LTOT 
If they are confused 
If they have a rapid onset 
If they have significant comorbidity 
If there SaO2 < 90% 
If there have changes of CXR
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46
Q

What is the GOLD classification of severity

A 
GOLD 1 FEV1 > 80% 
GOLD 2 FEV1 50-79% 
(No hospital admission)
GOLD 3 FEV1 30-49% 
GOLD 4 FEV1 < 30 %
(Hospital admission)
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47
Q

What is Asthma ?

A

An obstructive pulmonary disease that results from type 1 hypersensitivity.

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48
Q

What are the risk factors for Asthma?

A

Genetics (Atopic gene which predisposes to Hay fever, eczema and asthma important to ask about in family history), Occupations (Exposure to chemicals or particles i.e. Painter, baker), Smoking (Maternal smoking leads to small lungs and an increased chance of Asthma)

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49
Q

What are the signs and symptoms of asthma ?

A

Variability of symptoms, Wheeze (in children ‘No Wheeze no asthma’), cough, shortness of breath, chest tightness, sleep disturbances, exacerbations.

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50
Q

What are investigations done to help diagnose asthma ?

A

Spirometry (FEV1/FVC, Bronchodilator Reversibility test),
Skin allergy panel,
CXR (To check for other causes),
PEFR (Used on one off or given to patient to record results at regular intervals, variability in results suggests asthma).
Exposure to certain triggers which brings on attacks (i.e. pets, smoke, exercise, perfume etc).
You can also measure exhaled FeNO (Nitric oxide) levels as FeNO is produced in inflammation and therefore high FeNO would suggest asthma.

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51
Q

How is a diagnosis of asthma made ?

A

Combination of history, investigations (Importantly reversibility – Often treatment is started before the diagnosis) and signs/symptoms. In children as a rule of thumb to diagnosis treat with ICS if quality of life is affected, then take an inhaler break over easter (When infections are least prevalent) and see if the symptoms return. If they don’t stop medication it is not asthma. If they do then diagnose Asthma and continue treatment.

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52
Q

How is a asthma attack diagnosed?

A

Patients presents with an acute worsening of symptoms. Can be classified based on severity.

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53
Q

What is a mild asthma attack ?

A

Use of inhalers and oral steroids. Follow up is arranged.

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54
Q

What is a moderate asthma attack ?

A 
Able to speak and complete sentences
HR < 110 
RR < 25 
PEF 50-75% (Of what is predicted for this person)
Sa02 > 92% 
PaO2 > 8kPa (80mmHg)
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55
Q

What is a severe asthma attack ?

A

Inability to complete sentences in one breath
HR > 110
RR > 25
PEF 33-50% (Of what is predicted for this person)
SaO2 > 92%
PaO2 > 8kPa

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56
Q

What is a life threatening asthma attack ?

A 
Grunting 
Impaired consciousness, confusion and exhaustion 
Bradycardia (Slow HR Less than 60 bpm)
Arrhythmia 
Hypotension (low BP > 90/60)
PEF < 33% (Of what is predicted for this person)
Cyanosis (Blue lips)
Silent chest (Air is not moving)
Poor respiratory effort 
SaO2 < 92%
PaO2 < 8kPa
PaCo2 (Normal - this is worrying because they should be low if someone is trying to breath as hard as you are in an asthma attack)
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57
Q

What is near fatal asthma attack ?

A

Raised PaCo2

Need for mechanical ventilation

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58
Q

What are the differential diagnosis for Asthma ?

A

COPD (in older smoking patients whose symptoms decline – See table for differences),
Bronchiectasis (Clubbing, course crackles),
Lung cancer (Clubbing, mass of CXR, cervical lymphadenopathy [metastasis to lymph nodes in the neck]),
Foreign body (Stridor).
Upper respiratory tract infection especially in <18 months old (See flow chart),
Cystic fibrosis,
Cardiac cause,
A collapsed lung (asymmetrical expansion, dull percussion).

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59
Q

What is the aim of Asthma treatment ?

A

Aim of treatment is that patients wont need to take the ‘rescue’ inhalers (Will be using there inhaler less than 2 times a week), wont wake up in the night and wont be limited in there actions in any way. Medication aims to reverse inflammation and relax smooth muscles.

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60
Q

What is used to treat asthma ?

A

Actions plans are used to help control asthma (Individualised sheet to show what steps to take if asthma gets worse).
Main stay of treatment in inhalers.
Also oral therapies
And specialist treatments.

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61
Q

What are the two types of inhaler ?

A

They can be metered dose inhalers (pMDI Used with spacers) or dry powder inhalers (DPI Relies on sucking).

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62
Q

What is the step up, step down approach to treating asthma in kids ?

A 
SABA and very low dose ICS 
(Relieves symptoms)
BREAK
(Symptoms return)
SABA + very low dose ICS (Or LATA in < 5)
(Use of SABA > 2 times a week)
Add in a LABA (or LATA in < 5)
(Use of SABA > 2 times a week)
Stop LABA + start low dose ICS 
or 
Continue LABA + start low dose ICS 
or 
LABA + very low dose ICS and oral therapy i.e. LTRA
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63
Q

What is the step up, step down approach to treatment asthma in adults ?

A 
SABA + Low dose ICS 
(Relieves symptoms)
BREAK 
(Symptoms come back)
SABA + low does ICS 
(Use of SABA > 2 times a week)
SABA + low dose ICS + LABA 
(Use of SABA > 2 times a week)
SABA + Medium dose ICS + LABA 
or 
Oral therapy i.e. LTRA
64
Q

Examples of oral therapies?

A

LTRA and Prednisolone

65
Q

What is “troublesome” asthma

A

Before stepping up treatment make sure that patients have the correct technique and are actually taking there medication, this is more likely to be the cause than a lack of response to treatment.

66
Q

Prognosis of asthma

A

Good it can be well controlled however it cannot be cured.

67
Q

What would you expect to find on auscultation of an asthmatic ?

A

Normal people or controlled asthma = Normal breath sounds and no wheeze
Mild asthma attack = Normal breath sounds and start of a wheeze on expiration
Moderate = Normal breath sound but clear wheeze on expiration
Severe asthma attack = High pitched, faint and distant wheeze
Life threatening = silent chest, no breath sounds and no wheeze

68
Q

When would a COPD patient be suitable for LTOT

A

if they have PaO2 < 7.3 kPa. Or if they have a PaO2 < 8 and complications of chronic hypoxia such as pulmonary hypertension, peripheral oedema etc.

69
Q

When is hyperinflation present on a CXR ?

A

hyperinflation is present if there are more than 6 rubs visible anteriorly or 10 rubs posteriorly

70
Q

What is bronchiectasis ?

A

A long term obstructive lung condition where an insult to the airways cause the dilation of the bronchi. The insult causes damage to the elastic fibres of the bronchi leading to loss of structure and dilation. The insult also causes loss of cilia which along with the dilatation leads to the build up of mucous and failure to clear bacteria in those areas. This causes infections which cause further damage which cause more infections.
The infections can be called exacerbations.

71
Q

What causes an insult to the airways in bronchiectasis?

A

Anything!

Causes may include pneumonia, TB and cystic fibrosis

72
Q

What are the risk factors for bronchiectasis?

A

Previous infections and anything which causes insult to the lungs

73
Q

What are the signs and symptoms of bronchiectasis ?

A

Productive cough (Cough up pus and mucous, it is very smelly and disgusting),
Recurrent lower respiratory tract infections (Due to problems clearing bacteria and build ups of mucus),
Breathlessness and wheeze (trapped air). These are the main symptoms.
There are other however such as hemoptysis (rare but serous with lots of blood, occurs when a blood vessel bursts in the lungs),
course crackles / Crepitations (caused by build up of fluid and or pus in the alveoli),
Clubbing (indicate a heart or lung condition and hypoxia),
Parenchymal destruction (the parenchymal is the part of the lung involved in gas exchange).
Look out for yellow nail syndrome which sometimes co-exists with bronchiectasis.

74
Q

What investigations can be done to help determining if someone has bronchiectasis ?

A

High resolution CT is the best method of diagnosing bronchiectasis. On CT you will see cysts (see image). If on CT the airway diameter is greater than the accompanied blood vessel diameter then you can diagnose bronchiectasis. i.e. the bronchoarterial ration > 1. On CT you may also see neutrophilia which can be an important sign of bronchiectasis. From CT you can classify the bronchiectasis into cylindrical (Dilated long sections), varicose (multiple small sections of dilatation in a row) or cystic (repeating large areas of dilatation).
CXR can also be used and will show cystic shadow and tramlines (See image).
Obstructive spirometry.
Bronchoscopy (locate site of obstructions and take samples for culture). If cystic fibrosis is suspected as the caused, then the sweat test may be performed.

75
Q

What are the different types of bronchiectasis ?

A

From CT you can classify the bronchiectasis into cylindrical (Dilated long sections), varicose (multiple small sections of dilatation in a row) or cystic (repeating large areas of dilatation)

76
Q

How is a bronchiectasis diagnosis made ?

A

History of recurrent chest infections
Productive cough
Radiological findings

77
Q

How is bronchiectasis treated ?

A

It is treated with non-pharmacological methods i.e. Smoking cessation, vaccinations, home oxygen, postural drainage and chest physiotherapy (Performed twice a day to help move and clear the mucous). Phrenological treatment includes antibiotics (normally a 10-14 day course) which is used in the management of chronic bronchiectasis. Long term antibiotics can be considered if a patient has more than 3 exacerbations a year. In long term therapy macrolides are usually used. Surgical resection can be used for very severe cases.

78
Q

How is an bronchiectasis exacerbation treated ?

A

Based on results of sputum culture (i.e. treat the cause)

79
Q

What is the prognosis of bronchiectasis ?

A

It varies a lot. Some people will have mild symptoms for many years while others will have rapid deterioration.

80
Q

What is pneumonia ?

A

Pneumonia is a build up of fluid (blood, pus, microbes, water) in the alveoli as a result of an infection. The alveoli are normally sterile however if bacteria (most common), fungi or viruses get into it they can cause an immune response. This results in the production of debris / fluid.

81
Q

How can pathogens get into the alveoli ?

A

Pathogens can be inhaled, aspirated or transmitted from the blood.

82
Q

What does the build up of fluid cause ?

A

The build up of fluid results in reduced gas exchange, hypoxia and CO2 retention.

83
Q

What can the build up of fluid be called ?

A

Consolidation

84
Q

What are the names of the different types of pneumonia ?

A

Bronchopneumonia
Segmental
Lobar

85
Q

Describe Bronchopneumonia

A

scattered in small patches

86
Q

Describe Segmental pneumonia

A

Segmental pneumonia affects a whole bronchopulmonary segment

87
Q

Describe Lobar pneumonia

A

Affects a whole lobe of the lung. Lobar pneumonia can spread to the pleura and cause pleural effusion (fluid in the pleura) or emphysema (pus in the pleura).

88
Q

What are the risk factors for pneumonia ?

A

Smoking, alcohol excess, preceding viral illness, Pre-existing lung disease, chronic illness, Immunocompromises, Hospitalization, IVDU, recent antibiotic use, travel, age >65.

89
Q

What are the cardinal signs of pneumonia ?

A

CDEF (Chest pain, dyspnoea, exudate [sputum] and fever)

90
Q

What are the signs and symptoms of pneumonia ?

A

Cough (As our body tries to get rid of the fluid. If sputum is rusty brown, then that suggests a Streptococcus pneumoniae infection), fever, malaise, confusion, Dyspnoea, haemoptysis, tachypnoea, tachycardic, have reduced expansion, and dull percussion sounds (increases vocal resonance), bronchial breathing and crepitations. Decreased lung expansion on the affected side. Crackles on auscultation (occurs when there is fluid in the lungs).

91
Q

How is pneumonia diagnosed ?

A

Diagnosed based on radiological findings, symptoms and examination.

92
Q

What are the differential diagnosis of pneumonia ?

A 
COPD (Chronic, productive cough over a long period of time, slowly getting worse), 
Asthma (not caused by infection), 
Pulmonary oedema (caused by congenital heart failure), 
Pulmonary embolism (has more sudden onset and the shortness of breath is more prominent than the cough and sputum)
93
Q

What are the investigations for pneumonia ?

A 
CXR is used to show consolidation. 
Sputum or blood culture testing (To identify the type of infection and will also identify is there is any bacteria in the blood [Bacteraemia] which is severe as it can cause sepsis), 
Urine testing (Again to help determine the cause of infection), 
Fully bloods (which blood cells are elevated will help to identify the cause and severity, remember neutrophils suggest bacteria and lymphocytes suggest viral), 
Urea will be high in severe pneumonia, liver function test.
94
Q

How is the severity of pneumonia established ?

A

CURB 65

95
Q

What does CURB 65 stand for ?

A 
C = confusion 
U = Urea > 7 mmol/L
R = RR > 30
B = Systolic BP < 90 Diastolic BP < 60 
65 = Age > 65
96
Q

What doe CURB 65 scores mean ?

A

0-1 Low risk manage at home
2 Probability admit to hospital
3-5 Admit and manage as severe

97
Q

What is the treatment for pneumonia ?

A

If it is mild there is often no need to treat however sometimes it needs treatment. Oxygen (tachypnoea, hypoxia), Fluids. IV fluids for the elderly and those who are vomiting. NSAIDS (for pain medication) and opioids (if NSAIDS don’t work) Antibiotics (This is tricky because you will hardly ever know the bacteria – this is called empirical therapy) [See table for treatments].

98
Q

Why might pneumonia not be getting better ?

A

Pneumonia will often resolve however it its not then it might be due to pleural involvement, organization (formation of fibrous tissue), lung abscess, bronchiectasis.

99
Q

What is the prognosis for pneumonia ?

A

Worst in the elderly or very young

100
Q

Table of antibiotics used to treat pneumonia

A

CURB 0-1 = 5 days of Amoxicillin. Clarithromycin or doxycycline can be used if penicillin allergic.
CURB 2 = 5-7 days of Amoxicillin + clarithromycin. Use Levofloxacin instead of Amoxicillin is penicillin allergic.
CURB 3 -5 7-10 days of Co-amoxiclav + clarithromycin. Use levofloxacin or co-trimoxazole if penicillin allergic.

101
Q

What is a pneumothorax ?

A

A pneumothorax is a collection of air in the pleura. It can be small or can cause collapse of a whole lung.

102
Q

How is a pneumothorax formed ?

A

It causes the detachment of the chest wall from the lung.

103
Q

What are all the different things which can cause a pneumothorax ?

A

Pneumothorax can be spontaneous. A primary spontaneous pneumothorax occurs mainly in tall, thin, healthy, young men. A small puncture in an alveoli creates a small collection of air in the surrounding tissue. This can busrt releasing air into the pleura creating a pneumothorax. A secondary spontaneous pneumothorax occurs as a result of an underlying health condition such as COPD, asthma, interstitial lung disease, cystic fibrosis etc.
Pneumothorax can also be caused by treatment. For example, it can happen during a biopsy. This is called a iatrogenic pneumothorax.
Trauma can also result in a pneumothorax i.e. A stab wound. A tension pneumothorax occurs when a flat of tissue allow air to move into the pleura but not out again. It can be caused by a broken rib which perises the lung allowing air to move into the pleura. Imagine a burst balloon if you blow into it air will move through and out of it but not be able to get back in. It can also be caused by a stab wound where air is able to move into the pleura from outside but is not able to move into the lung our back out. The build up of air causes the movement of the heart and other structures, low BP and low SaO2. A needle or chest drain needs to be inserted quickly to get the air out.

104
Q

What are the signs and symptoms of a pneumothorax ?

A

Sudden onset of chest pain and or breathlessness. Tachypnoeic, hypoxic, asymmetrical chest wall expansion, Reduced breath sounds on auscultation, hyper resonant on percussion.. Sometimes patients may however feel and appear normal.

105
Q

What are the investigations /Diagnosis of a pneumothorax made ?

A

CXR will usually clearly show a pneumothorax. An ultrasound (For patient who are too sick to be moved) or a CT thorax can also be used. It can be hard to see a small pneumothorax so be careful.

106
Q

What is the treatment of a pneumothorax ?

A

Depends on the type and symptoms. If the pneumothorax is small, then regulator observation may be the only thing which is required. Pleural aspiration can be used to remove fluid from the pleura. Often however a needle or chest drain is put in. These should be inserted in the safe triangle, the 2nd intercostal space at the midclavicular line.
An pleurodesis is a surgical procedure which sticks the pleura and the lung back together again and it is offered to patients with recurrent pneumothorax. It is also offered to patients whose chest drains are still releasing air 5-7 days after being put in, or the lung has not expanded after 5 – 7 days. It is done to patients with fluid in the lungs, these are often cancer patients. It is normally a keyhole surgery where they an abrasive such as sandpaper, or an inflammation causing agent such as talc ( sterile talcum powder) is sprayed or scratched against the chest wall to allow the lung to better stick to it.

107
Q

What is TB ?

A

TB is a mycobacterium infection (most commonly caused by M.Tuberculosis, M.Africanum or M.Bovis [found in unpasteurized milk]) which most commonly affects the lungs but can affect most of the body.

108
Q

How is TB transmitted ?

A

TB can be spread through aerosol droplets. An person with active TB in there lungs or larynx coughs and releases these droplets into the air. They can then be breathed in by an uninfected person however they are killed by UV and so transmission is unlikely to happen outside.

109
Q

What is the immediate response to the TB inhalation ?

A

If the bacteria gets into the lungs it causes a immune cells to from a granuloma around the bacteria the centre of which contains debris called caseous necrosis. This granuloma can also be called a Ghon focus. This is often asymptomatic

110
Q

What are the different courses of TB through the lifetime of a person ?

A

In some people this process results in the total destruction of the bacteria. In others this causes the bacteria to become latent and in a very small number it progresses to an active infection called a primary infection. Latent TB can re-activate at any point over the next 40 years. This activation may be due to old age, immunosuppressants etc, AIDS etc. When latent TB re-activation it is called a post primary or secondary infection. A post primary or secondary infection can spread to other parts of the body. It can spread through the lymphatic system (Ghon focus develops into a cavity, immune cells move the infection to the lymph nodes, lymph nodes discharge infection to other parts of the lungs, build up of fluid/debris sin the alveoli, bronchopneumonia develops) to other parts of the lungs causing bronchopneumonia or it can spread further to other organs in the blood. TB with is spread in the blood is called Miliary TB.

111
Q

What are the risk factors for TB ?

A

Non-UK born, between the age of 15 and 44, HIV positive, diabetes and being Immunosuppressed.

112
Q

What are the signs and symptoms of TB ?

A 
productive Cough, Haemoptysis,  fever, sweats and weight loss 
Bronchial breathing (loud breath sounds), a wheeze or crackles may be heard on auscultation.
113
Q

What investigations are carried out for TB ?

A

CXR (cavitation, lymphadenopathy (infected and abnormal lymph nodes) and parenchymal infiltrate (stuff like pus and blood which appears darker)). Sputum samples. You could also do a bronchoscopy (camera into lungs) Urine and AAFB test (to detect the presence of a mycobacterium).

114
Q

How is TB diagnosed ?

A

Combination of radiological, lab results and history.

115
Q

What are the differential diagnosis of TB ?

A

Lung cancer (No fever in lung cancer), Asthma (No fever and not caused by infection), COPD (no fever), chest infection (lab results, CXR results, severity usually greater in TB, TB last longer

116
Q

How is TB treated ?

A

In an active TB infection the patient is given a combination of drugs for 6-9 months. A HIV and hepatitis B and C test should also be carried out. There are a number of different drugs that can be used to treat TB [See table]. All four are used for 2 months and then two are continues for a further 4 months.

117
Q

Describe the TB medications

A

-

118
Q

What causes CF ?

A

Cystic fibrosis is a single gene autosomal recessive disorder (if both parents are carried there is a 1 in 4 chance you will have CF).

119
Q

If both parents are carriers of CF what is the chance the child will have it ?

A

1/4

120
Q

What does the CF gene cause ?

A

CF occurs due to a mutation in the transmembrane conductance regulator protein (CFTR) which is coded for on chromosome 7 causing it to dysfunction. There are a number of mutations which cause CF the most common of which is called the ΔF508 gene. Mutations can be classified into 6 groups. Class 1 -3 mutations cause all the proteins to dysfunction and so cause sever CF. Class 4-6 cause only some of the proteins to dysfunction and so it causes a less sever disease. The CFTR protein is found in several places in the body.

121
Q

Name two places where the affects of CF are seen ?

A

Airways

Pancreas

122
Q

Describe the affect CF has on the airways

A

Airways: The CFTR protein starts to traps Cl- inside the cell which causes sodium and water to follow chloride and flow into the cell. This causes dehydrated airways and thick sticky mucous. The mucous rubs against the walls and sheers them. The mucous is difficult to cough up and collects bacteria. Dehydration causes a reduction in mucociliary clearance. This leaves patient very vulnerable to infection. Which can leads to conditions such as pneumonia, bronchiectasis, scarring and abscesses. This is a vicious cycle as chest infections cause further damage to the airways which leave patients more vulnerable to infection.

123
Q

Describe the affect CF has on the pancreas

A

Pancreas: CFTR mutation prevents production of enzymes (trypsin and colistin) which are used to digest food. This causes malabsorption, abnormal stool (pale, smelly and they float), and failure to thrive (See growth chart).

124
Q

Describe a growth chart of a CF patient

A

Height of CF patients will be less than the average population

125
Q

Name three conditions which CF puts you at a higher risk of

A

Diabetes
Osteopetrosis
Pneumothorax

126
Q

What are risk factors for CF ?

A

Genetics (If you have family members with the condition)

127
Q

What are the signs and symptoms of CF ?

A

Pulmonary disease ( this is the main cause of morbidity and mortality in CF patient and 90% of CF patient will die from respiratory failure). Clubbing. Haemoptysis (result of bronchial wall destruction. Can be massive. These massive once can be preceded by gurgling in the chest and it is important to admit and resuscitate these patients and they may need a bronchial angiogram and embolization) Recurrent chest infections.

128
Q

What investigations are carried out to help diagnose CF ?

A

CXR will show issues with the lungs however a CT scan is used to diagnose. CT will show tramlines, mucous plugs, consolidation, signet rings.

129
Q

How is a CF diagnosis made ?

A

CF can be diagnosed at different points in life. Antenatal testing is carried out when a parent or sibling is known to have or carry CF. This can be done using pre-implantation genetic diagnosis, chorionic villous sampling, or amniocentesis. Screening can also be neonatal using a Guthrie test (done on day 5 and does miss some diagnoses). A sweat test can be done any time postnatally and it measures the concentration of chloride excreted in sweat. In children if sweat chloride is > 60 then it is likely they have CF. 30-59 is inconclusive or = 30 is probably not CF. Tests are usually repeated to confirm. Faecal elastase can also be measured and used to diagnose CF. After tests patient will either be diagnosed as positive, negative or SPID patients (where they have screened positive but there is an inconclusive diagnosis)

130
Q

What is the treatment of CF ?

A

Average 30 drugs. Management of pancreatic insufficiency is done through replacing missing enzymes (CREON), eating high energy high calorie diet, Increasing nutrient, vitamins and minerals. Management of pulmonary disease (See picture). Single or double lung transplants for patients with FEV1<30%, a life threatening condition or an estimated survival < 2 years. Contraindications of transplant are other organ failure, malignancy within the last 5 years, significant peripheral vascular disease, dependency of drugs, nicotine or alcohol. Having osteopetrosis (Drugs given after treatment can damage bone). Exercise and planning for palliative care can also be helpful in treatment. New drug modulators are being developed.

131
Q

What is the prognosis of CF ?

A

Progressive respiratory decline occurs because recurrent chest infections causes progressive airflow obstruction making patients increasingly breathless. Survival is related to the FEV1. They will then enter respiratory failure (Type 1 or 2) and oxygen or nocturnal NIV (type of non-invasive ventilation) may be required.
CF children can often miss school and be quite different which makes it hard for them to fit in and make friends, and this can cause cases of depression and anxiety. There can also be a huge impact on the family, meaning time off work for parents etc. CF in Adults brings with it an restriction of career and hobbies, transport costs, anxiety around prognosis, possibility of lung transplants, slightly more complicated path to parenthood, large number of drugs etc.

132
Q

Why is lung cancer often detected late ?

A

symptoms often don’t develop until the cancer is quite advanced

133
Q

What causes lung cancer?

A

Lung cancer is caused by a unique combination of mutation which vary between individuals.

134
Q

Describe the causes of lung cancer in someone who has never smoked

A

If someone has never smoked then the cancer is likely to be a result of one molecular change. This can often be targeted using KRAS or EGFR and a number of other drugs.

135
Q

What kind of cells does lung cancer develop from ?

A

Lung cancer develops mainly from stem cells which are found in the central lung airways or in the periphery’s of the lung .

136
Q

Describe the stem cells in the periphery of the lung

A

Stem cells in the lung periphery, undergo atypical adenomatous hyperplasia, which develops adenocarcinomas in situ and then goes on to develop invasive adenocarcinomas (if patients have never smoked then it will be this type and molecularly be more simple).

137
Q

Describe the stem cells in the central airways of the lung

A

Stem cells can also be found in the central lung airway where bronchial basal cells undergo hyperplasia, developing into squamous dysplasia and carcinoma in situ, these then go on to becomes invasive squamous cells of the carcinoma. This is almost always caused by tobacco.

138
Q

What are the risk factors for developing cancer?

A

Smoking (makes up about 85% of lung cancer patients and 10% of smokers will develop lung cancer). The more you smoke the more at risk you are but If a patient stops smoking there risk of lung cancer will start to decreases slowly. Tobacco smoke mutates epithelial stem cells continuing towards the risk of lung cancer. Asbestos, environmental radon, air pollution, deiseal exhaust etc. Genetics (mutations and genetic can increase nicotine addiction)

139
Q

What are the signs and symptoms of lung cancer ?

A

haemoptysis (often central tumour bleed), cough, SOB, chest pain, finger clubbing (of hands and feet, patient may find it hard to cut there toe nails). Lung cancers release macromolecules and sometimes symptoms are a result of them.

140
Q

What investigations are carried out when diagnosing lung cancer?

A

Chest X-ray (Tumours – Benign carcinoid tumours [Low grade malignancy], bronchial glandular, lymphomas, sarcomas and metastases). A CT scan is then done to clarify findings and stage cancer. A biopsy is then taken and cancer will be classified (through bronchoscopy for tumorous in the large airways, EBUS or mediastinoscopy for lymph node tumours, Ultrasound or CT guidance biopsies for peripheral or deep lung cancers). There also a number of other tests that’s can be carried out if needed. FBC, renal and liver function test, calcium test, clotting screen, spirometry.

141
Q

How is cancer staged ?

A

T = Size of tumour (measured using a contract CT or a PET-CT or a bronchoscopy. N = Involvement of the lymph nodes (measured using a PET-CT, CT, mediastinoscopy and EBUS/EUS) M = Metastases (measured using a PET-CT, CT or bone scan). It is also good to consider elements from the history as well like symptoms when staging.

142
Q

Describe the table for staging

A

-

143
Q

How is lung cancer classified ?

A

Squamous cell (40%), adenocarcinoma (41%), large cell carcinoma (5%). These three can be grouped into ‘non-small cell lung cancer’ and have a doubling time = 129days. Small cell carcinoma (15%) which has a doubling time = 29 days.

144
Q

How is lung cancer diagnosed ?

A

Based on findings of investigations.

145
Q

What are some differential diagnosis for lung cancer ?

A

Benign tumour (Different biopsy results), TB, Pneumonia and bronchiectasis (tumour present in cancer).

146
Q

How are treatment decisions for lung cancer made ?

A

Decision made by MDT and considers staging, tumour type, patient history, wishes and fitness and decide on a treatment plan

147
Q

How is non-small cell lung cancer treated ?

A

Non-small cell lung cancer. Treated with a combination of drug therapies (Chemo, targeted and immuno), surgery and radiotherapy (1 in 5 patients who receive radiotherapy are curved from NSCLC).

148
Q

How is small cell lung cancer treated ?

A

Small cell lung cancer. Treated with a combination of radiotherapy and chemotherapy. Surgery is usually not possible but can be used if cancer is found very early on. Prophylactic cranial radiation (PCI) is also used in early stage small cell lung cancer to help prevent metastasis to the brain. There is often a combination of drugs used i.e. cisplatin and etoposide.

149
Q

What are the names of the two drugs used in PCI for lung cancer ?

A

cisplatin and etoposide.

150
Q

Describe surgery as a treatment for lung cancer

A

Surgery (50% of surgeries cure cancer). Most patients are not suitable for surgery. There are a number of assessments which are performed to determine suitability. ECOG (performance assessment - see table), spirometry (FEV1>1 for a lobectomy and a FEV1>2 for a pneumonectomy), assessment of heart (using ECG, ECHO, angiogram etc), assessment of respiratory system, mental health, underlying health conditions. If the cancer is T4 of there is any nodal involvement then there are no surgical options.
Surgical procedure include a pneumonectomy, lobectomy, wedge resection (just the tumour is cut out), open and close thoracotomy (Lobectomy was intended but when the chest was opened it became apparent that a pneumonectomy would be needed however he patient isn’t suitable for than and so they surgeon doesn’t remove anything but just closes the chest).

151
Q

Describe immunotherapy as a treatment for lung cancer

A

Immunotherapy is a new method of treatment where the immune system is helped to fight cancer. For example in the PD1/PD-L1 pathway the tumour inactivate the immune cells. The immunotherapy drugs then re-activate the immune system allowing the body to destroy the cancer. Currently this is only available for stage III NSCLC after chemotherapy.

152
Q

Describe radiotherapy as a treatment for lung cancer

A

Radiotherapy – commonly a 55Gy in 20 fractions where treatment is given money to Friday for four weeks. Side effects my include lethargy, oesophagitis, SOB and long term cardiac, pulmonary fibrosis.

153
Q

Describe SABR as a treatment for lung cancer

A

SABR – Stereotactic ablative radiotherapy is very high does for a very short period of time. Standard dose is 54Gy in 3 fractions. This can have similar outcomes to surgery.

154
Q

Describe chemotherapy as a treatment for lung cancer

A

Chemotherapy – survival is better than RT. There are no standard chemo regimes, most centres use a doublet regime. You can give a patient sequential chemotherapy and then radiotherapy. Side effects include marrow suppression, nausea, neuropathy, and hair loss. Neutropaenic sepsis is the most common complication of chemotherapy.

155
Q

What is the prognosis of lung cancer ?

A

80% of patients with lung cancer cannot be cured. Here palliate care has to be given.

156
Q

Describe the ECOG performance scale

A

-

MAY MEDICINE 1 REVISION (23 decks)

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