respiratory to work on Flashcards
Briefly describe the pathophysiology of pneumonia
- invasion and overgrowth of a pathogen in lung parenchyma
- overwhelming of host immune defences
- production of intra-alveolar exudates
Name 3 pathogens that can cause community acquired pneumonia (CAP)
- Streptococcus pneumoniae (most common)
- Haemophilus influenzae
- Mycoplasma pneumoniae
Name 3 pathogens that can cause hospital acquired pneumonia (HAP)
mainly gram negative
- Pseudomonas aeruginosa
- E.coli
- Klebsiella penumoniae
- Staphylococcus aureus
What symptoms might you see in someone with pneumonia?
SOB cough sputum fever pleuritic chest pain delirium
What signs might you see in someone with pneumonia?
- increased resp rate and HR
- hypotension
- decreased O2 saturation
- dull to percuss
- increased tactile fremitus
What investigations might you do on someone you suspect has pneumonia?
- FBC, U&E, CRP– increased WCC, urea and CRP
- Sputum culture - MC+S
Chest X ray: localised/widespread consolidation, effusion, abscesses, empyema
Multi-lobar – strep pneumoniae, s. aureus
Multiple abscesses – s. aureus
What is the treatment for someone with mild CAP (CRUB65 score 0-1)?
oral amoxicillin at home
What is the treatment for someone with moderate CAP (CRUB65 score 2)?
consider hospitalising, amoxicillin (IV or oral) + macrolide (clarithromycin)
What is the treatment for someone with severe CAP (CRUB65 score 3-5)?
consider ITU,
IV Co-Amoxiclav + macrolide (clarithromycin)
What is the treatment for someone with Legionella pneumoniae?
Fluoroquinolone + clarithromycin
What is the treatment for someone with Pseudomonas aeruginosa pneumonia?
IV ceftazidime + gentamicin
Give 3 potential complications of pneumonia
- Respiratory failure
- Hypotension
- Empyema
- Lung abscess
Describe the pathophysiology of bronchiectasis
Failed mucociliary clearance and impaired immune function means microbes easily invade and cause infection
This causes inflammation and progressive lung damage
Bronchitis –> bronchiectasis –> fibrosis
What can cause bronchiectasis?
- Congenital = Cystic fibrosis
- Idiopathic (50%)
- Post infection - (most common)
- pneumonia,
- TB,
- whopping cough
- Bronchial obstruction
- RA
- Hypogammaglobulinaemia
Which bacteria might cause bronchiectasis?
- Haemophilus influenza (children)
- Pseudomonas aeruginosa (adults)
- Staphylococcus aureus (neonates often)
Give 3 symptoms of bronchiectasis
- Chronic productive cough
- Purulent sputum
- Intermittent haemoptysis
- Dyspnoea
- Fever, weight loss
Give 3 signs of bronchiectasis
- Finger clubbing
- Coarse inspiratory crepitate (crackles)
- Wheeze
What investigations might you do on someone to determine whether they have bronchiectasis?
CXR = kerley B lines, dilated bronchi with thickened walls, multiple cysts containing fluid
High resolution CT = bronchial wall dilation
Spirometry = obstructive lung disease
Sputum culture - h.influenzae is most common
Describe the treatment for bronchiectasis
- Antibiotics
- Anti-inflammatories (azithromycin)
- Bronchodilators (nebulised salbutamol)
- Chest physio - physical training
- Surgery = lung resection or transplant
Give 3 possible complications of Bronchiectasis
- Pneumonia
- Pleural effusion
- Pneumothorax
What are the main systemic consequences of CF?
Pancreatic insufficiency = dehydrated secretion –> enzymes stagnation
GI = intraluminal water deficiency –> concentrated bile
Resp = thick mucus can’t be cleared –> infection risk and inflammatory damage
How do children/young adults present with CF?
- Cough and wheeze
- Recurrent infections
- Haemoptysis
- Pancreatic insufficiency
- Malabsorption
- Male infertility
What are 3 possible respiratory complications of CF?
- Pneumothorax
- Respiratory failure
- Cor pulmonale
- Bronchiectasis
Give 3 signs of CF
- Clubbing
- Cyanosis
- Bilateral coarse crepitations
Name 3 associated conditions with CF
- Osteoporosis
- Arthritis
- Vasculitis
What investigations might you do to diagnose cystic fibrosis?
heel prick test - newborns
Sweat test = Na and Cl < 60 mmol/L
Genetic screening for common mutations
Faecal elastase - tests pancreatic enzyme function
Absent vas deferent and epididymis (males)
Microbiology - for infections
Spirometry
What is the management of CF?
- Physical therapies (airway clearance) and surveillance
- Antibiotics for infections and prophylaxis
- Bronchodilators
- B2 agonist (SALBUTAMOL) and inhaled corticosteroids (BECLOMETASONE) - Pancreatic enzymes replacement (creon)
- ADEK vitamin supplements
- Screening for consequent conditions - osteoporosis
- Bilateral lung transplant
- must not have m. abscessus
- Vaccinations - flu and pneumococcal
- high calorie, high fat diet
what are the risk factors of lung cancer
- Smoking = main cause
- Asbestos
- Radon exposure
- Coal products
- pulmonary fibrosis
- HIV
- genetic factors
Which type of NSCC is most common in smokers?
Squamous cell carcinoma - it is most stronlgy associated with cigarette smoking
where does lung cancer commonly metastasise to?
- Bone
- Brain
- Lymph nodes
- Liver
- Adrenal
Give 4 symptoms of local disease lung cancer
Persistent cough Shortness of breath Haemoptysis Weight loss Chest pain, wheeze, recurrent infections
Give 4 symptoms of lung cancer that has metastasised
- Bone pain
- Headaches
- Abdominal pain
- Seizures
- Neuro deficit - Confusion
- Weight loss
Give 3 examples of paraneoplastic syndromes due to lung cancer
- ↑PTH -> Hyperparathyroidism
- ↑ADH -> SIADH
- ↑ACTH -> Cushing’s disease
Name 3 differential diagnosis’s of lung cancer
- Oesophageal varices
- COPD
- Asthma
- Pneumonia
- Bronchiectasis
What investigations might you done on someone to determine whether they have lung cancer?
First line:
- CXR - central mass, hilar lymphadenopathy, pleural effusion
(a negative CXR does not rule out cancer)
- CT chest, liver & adrenal glands – for staging
- Sputum cytology - malignant cells in sputum
(high specificity but mixed sensitivity)
diagnostic = biopsy + histology
What is the treatment for NSCLC?
- Surgical excision for peripheral tumours with no metastatic spread
- Curative radiotherapy is an alternative if respiratory reserve is poor - complications include radiation pneumonitis + fibrosis
- Chemotherapy +/- radiotherapy for more advanced disease e.g. with monoclonal antibodies e.g. CETUXIMAB
What is the treatment for SCLC?
Limited disease = chemo + 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:
Give 4 possible complications of lung cancer
- SVC obstruction
- ADH secretion –> SIADH
- ACTH secretion –> Cushing’s
- Serotonin secretion –> carcinoid
- Peripheral neuropathy
- Pathological fractures
- Hepatic failure
Describe asthma
Chronic, inflammatory condition, causing episodes of reversible airway obstruction, due to:
Bronchoconstriction
Excessive secretion production
What are the 3 characteristic features of asthma?
- Airflow limitation - usually reversible spontaneously or with treatment
- Airway hyper-responsiveness
- Bronchial inflammation with T lymphocytes, mast cells, eosinophils with associated plasma exudation
What is the mechanism behind hyper-reactivity?
Neurogenic inflammation
Describe neurogenic infalmmation
Sensory nerve activation initiates impulses which stimulates CGRP (pro-inflammatory)
this activates mast cells and innervates goblet cells
Describe the process of airway remodelling in asthma
- Hypertrophy and hyperplasia of smooth muscle cells narrow the airway lumen
- Deposition of collagen below the BM thickens the airway wall
- metaplasia occurs with an increase in number of mucus-secreting goblet cells
What type of T cell is involved in asthma?
CD4+
Extrinsic asthma: what happens when IgE binds to mast cells?
Vasodilative substances are released causing bronchoconstriction, oedema, bronchial inflammation and mucus hyper-secretion
Name 4 factors that can exacerbate asthma
- Allergens
- Viral infection
- Cold air
- Exercise
- Stress
- Cigarette smoke
- Drugs - NSAIDs/BB
What are the symptoms of asthma?
- Episodic cough
- Expiratory wheeze
- SOB
- often worse at night (and in the morning)
- Chest tightness
- dyspnoea
What are the signs of asthma?
- Tachypnoea - rapid breathing
- Audible wheeze
- Widespread polyphonic wheeze
- Cough
What are the signs of an acute asthma attack?
- Can’t complete sentences
- HR > 110 bpm
- RR > 35/min
- PEF < 50% predicted
What are the signs of a life threatening asthma attack?
- Hypoxia = PaO2 <8 kPa, SaO2 <92%
- Silent chest
- Bradycardia
- Confusion
- PEFR < 33% predicted
- Cyanosis
Give 3 differential diagnosis’s of asthma
- COPD
- Bronchial obstruction
- Pulmonary oedema
- Pulmonary embolism
- Bronchiectasis
What investigations might you do someone to determine whether they have asthma?
- PEFR
- Spirometry with reversibility testing (>5 years)
- Obstructive pattern:- FEV1 <80% of predicted normal (reduced)
- FVC = normal
- FEV1/FVC ratio <0.7
Peak flow measurement (reduced)
- CXR
- Atopy = skin prick, RAST
- Bloods = high IgE, Eosinophils
What is the long-term guideline mediation regime for asthma?
- SABA
- SABA + ICS
- SABA + ICS + LTRA
- SABA + ICS + LTRA/LABA + MART
Give 3 possible complications of asthma
- Exacerbation
- Pneumothorax
- Pneumonia
Describe the pathophysiology of chronic bronchitis
Airway inflammation –> fibrosis and luminal plugs –> decreased alveolar ventilation
Would a patient with chronic bronchitis be a ‘pink puffer’ or a ‘blue bloater’?
Blue bloater
Patient have low PaO2 and high PaCo2 –> cyanosis –> cor pulmonale
Cyanosis = blue
Describe the pathophysiology of emphysema
Dilation and destruction of the lung tissue distal to the terminal bronchioles
Enlarged alveoli + loss of elastic recoil = increased alveolar ventilation
Would a patient with emphysema be a ‘pink puffer’ or a ‘blue bloater’?
Pink puffer
Breathless but not cyanosed
Type 1 respiratory failure
Normal or near normal PaO2 and normal or low PaCO2
What are the main cells responsible for inflammation in COPD?
Neutrophils and macrophages
What type of T cell is involved in COPD?
CD8+
What can cause COPD?
- Genetic = alpha 1 antitrypsin deficiency
- Smoking = major cause
- Air pollution
- Occupational factors = dust, chemicals
Name 4 symptoms of COPD
- Dyspnoea
- Cough +/- sputum
- Expiratory wheeze
- Weight loss
- SOB
Give 4 signs of COPD
- Tachypnoea
- Barrel shaped chest
- Hyperinflantion
- Cyanosis
- Pulmonary hypertension
- Cor pulmonale
Give 3 differential diagnosis’s for COPD
- Asthma
- HF
- Pulmonary embolism
- Bronchiectasis
- Lung cancer
What investigations might you do to diagnose someone with COPD?
Spirometry = FEV1:FVC < 0.7 CXR = hyperinflation, bullae, flat hemi-diaphragms, large pulmonary arteries FBC = exclude secondary polycythaemia
CT = Bronchial wall thickening, enlarged air spaces ECG = RA and RV hypertrophy ABG = decreased PaO2 +/- hypercapnia
Give 3 factors that can be used to establish a diagnosis of COPD
- Progressive airflow obstruction
- FEV1/FVC ratio < 0.7
- Lack of reversibility
What are the treatments for COPD?
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
Give 3 advantages and 1 disadvantage of using ICS in the treatment of COPD?
Advantages
- Improve QOL
- Improve lung function
- Reduce the likelihood of exacerbations
Disadvantages:
1. There is an increased risk of pneumonia
Give 3 possible complications of COPD
- Exacerbations
- Infection
- Respiratory failure
- Cor pulmonale
- Pneumothorax
Give 2 potential consequences of exacerbations of COPD/asthma
- Worsened symptoms
- Decreased lung function
- Negative impact of QOL
- Increased mortality
- Huge economic cost
What is the likely cause for an exacerbation of COPD?
Viral URTI
Bacterial infections
What is the treatment for an exacerbation of COPD?
Steroids (hydrocortisone / prednisolone)
+
nebulised bronchodilators (salbutamol / ipratropium bromide)
+
antibiotics
Physiotherapy → sputum clearance
If severe:
IV aminophylline (bronchodilator),
NIV (CPAP / BIPAP)
Give 3 ways in which subsequent exacerbations of COPD can be prevented
- Smoking cessation
- Vaccination
- LABA/LAMA/ICS
Give 3 functions of pleura
- Allows movement of the lung against the chest wall
- Coupling system between the lungs and chest wall
- Clearing fluid from the pulmonary interstitium
What does the pleural fluid contain?
Protein - albumin, globulin, fibrinogen
Mesothelial cells, monocytes and lymphocytes
what are the causes of a transudate pleural effusion?
fluid movement (systemic causes)
- Heart failure
- fluid overload
- Peritoneal dialysis
- Constrictive pericarditis
- hypoproteinaemia
- cirrhosis
- hypoaluminaemia
- nephrotic syndrome
Name 3 causes of a exudate pleural effusion
inflammatory (local causes)
- Pneumonia
- Malignancy
- TB
- pulmonary infarction
- lymphoma
- mesothelioma
- asbestos exposure
- MI
How does a pleural effusion present?
- SOB especially on exertion
- Dyspnoea
- Pleuritic chest pain
- cough
- Loss of weight (malignancy)
- 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
How might you diagnose a pleural effusion?
1st line: CXR =
blunt costophrenic angles, fluid in lung fissures, meniscus, tracheal and mediastinal deviation
USS - identify pleural fluid
aspiration (thoracentesis/pleural tap)
- purulent = empyema (pus)
- turbid (cloudy) = infected
- milky = chylothorax
How would you treat a pleural effusion?
Dependent on cause
Fluid overload or congestive HF - diuretic
Infective - antibiotics
Large effusions often need aspiration or drainage
How can pneumothorax be classified?
Spontaneous pneumothorax Traumatic pneumothorax Iatrogenic pneumothorax Lung Pathology Tension pneumothorax
How does a pneumothorax present?
- Sudden onset dyspnoea and pleuritic chest pain
- as the pneumothorax enlarges the patient becomes more breathless and may develop pallor and tachycardia
- Reduced expansion
- Hyper-resonant percussion
- Diminished breath sounds
What investigation might you do in someone you suspect to have a pneumothorax?
CXR = translucency and collapse
ABG = in dyspnoeic patients check for hypoxia
What is the treatment for a pneumothorax?
Small primary spontaneous PTX (visible rim ≤ 2cm) and not SOB
- Consider discharge and follow up CXR in review
Large primary spontaneous PTX (visible rim >2cm) and/or SOB
- Needle aspiration
If not <2cm on repeat CXR insert chest drain and supplemental O2 if needed, admit.
- Secondary Pneumothorax – requires chest drain if large/ needle aspiration if small, admission and high flow O2