BLOCK 13 WEEK 1 Flashcards

1
Q

TB Microorganisms

A
  • Acid fast bacilli -
  • Special staining is required, using the Zeihl-Neelsen stain, which turns them bright red against a blue background
  • TB can be stained with Ziehl Nielsen (stains red), or auramine (fluorescent).
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2
Q

TB Pathophysiology

A

The macrophages often migrate to regional lymph nodes, the lung lesion plus affected lymph nodes is referred to as a Ghon complex.

This leads to the formation of a granuloma which is a collection of epithelioid histiocytes.

There is the presence of caseous necrosis in the centre.

The inflammatory response is mediated by a TYPE 4 HYPERSENSITIVITY REACTION.

In healthy individuals the disease may be contained, in the immunocompromised disseminated (miliary TB) may occur.

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3
Q
A

Multiple small calcifications in the lung can be due to miliary TB, which is associated with extrapulmonary TB.

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4
Q
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5
Q

Can TB be transmitted via breastmilk and harm the baby?

A

Yes TB can be transmitted via breastmilk and harm the baby

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6
Q

Disease Progressision

A

Tuberculosis is mostly spread by inhaling saliva droplets from infected people. Once in the body, there are several possible outcomes:

-Immediate clearance of the bacteria (in most cases)

-Primary active tuberculosis (active infection after exposure)

-Latent tuberculosis (presence of the bacteria without being symptomatic or contagious)

-Secondary tuberculosis (reactivation of latent tuberculosis to active infection)

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7
Q

LATENT TUBERCULOSIS

A

Latent tuberculosis is present when the immune system encapsulates the bacteria and stops the progression of the disease.

Patients with latent tuberculosis have no symptoms and cannot spread the bacteria.

Most otherwise healthy patients with latent tuberculosis never develop an active infection.

When latent tuberculosis reactivates, and an infection develops, usually due to immunosuppression, this is called secondary tuberculosis.

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8
Q

Where do you get TB

A

The most common site for TB infection is in the lungs, where it gets plenty of oxygen. Extrapulmonary tuberculosis refers to disease in other areas:

-Lymph nodes
-Pleura
-Central nervous system
-Pericardium
-Gastrointestinal system
-Genitourinary system
-Bones and joints
-Skin (cutaneous tuberculosis)

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9
Q

BCG VACCINE

A

The Bacillus Calmette–Guérin (BCG) vaccine involves an intradermal injection of live attenuated (weakened) Mycobacterium bovis bacteria (a close relative of M. tuberculosis that does not cause disease in humans).

This creates an immune response, providing lasting immunity against M. tuberculosis without causing infection.

The vaccine protects against severe and complicated TB but less against pulmonary TB.

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10
Q

Before being given TB vaccine

A

MANTOUX TEST: Before vaccination, patients are tested with the Mantoux test and only given the vaccine if this test is negative. They are also assessed for the possibility of immunosuppression and HIV due to the risks related to a live vaccine.

The BCG vaccine is not part of the routine vaccination schedule. It is offered to patients at increased risk of TB, such as those from areas of high TB prevalence, with close contact with TB (e.g., family members) and healthcare workers

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11
Q

SYMPTOMS

A

Cough
Haemoptysis (coughing up blood)
Lethargy
Fever or night sweats
Weight loss
Lymphadenopathy
Erythema nodosum (tender, red nodules on the shins caused by inflammation of the subcutaneous fat)
Spinal pain in spinal tuberculosis (also known as Pott’s disease of the spine)

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12
Q

INVESTIGATONS

A

Investigations
Tuberculosis can be challenging to diagnose. The bacteria grow very slowly in a culture, cannot be stained with traditional gram stains and require specialist stains (e.g., Ziehl-Neelsen stain).

There are two tests for an immune response to tuberculosis caused by previous infection, latent TB or active TB:

  1. Mantoux test
  2. Interferon‑gamma release assay (IGRA)

In patients where active disease is suspected, investigations to support the diagnosis include:

-Chest x-ray
-Cultures

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13
Q

MANTOUX TEST

A

The Mantoux test involves injecting tuberculin into the intradermal space on the forearm. Tuberculin is a collection of tuberculosis proteins isolated from the bacteria. It does not contain any live bacteria.

The infection creates a bleb under the skin. After 72 hours, the test is “read”. This involves measuring the induration of the skin at the injection site. An induration of 5mm or more is considered a positive result.

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14
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A
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15
Q
A
  • To manage and diagnose active TB where we show symptoms we use the NAAT test
  • To manage diagnose or manage potential latent TB we do the Mantoux test
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16
Q
A
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17
Q
A
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18
Q

Erythema Nodosum

A
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19
Q
A
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20
Q

Interferon Gamma Release Assays

A

IGRA involves mixing a blood sample with antigens from the M. tuberculosis bacteria. After previous contact with M. tuberculosis, white blood cells become sensitised to the bacteria antigens and will release interferon-gamma on further contact. A positive result is when interferon-gamma is released during the test.

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21
Q

CHEST X RAY TB

A

Primary tuberculosis may show patchy consolidation, pleural effusions and hilar lymphadenopathy.

Reactivated tuberculosis may show patchy or nodular consolidation with cavitation (gas-filled spaces), typically in the upper zones.

Disseminated miliary tuberculosis gives an appearance of millet seeds uniformly distributed across the lung fields.

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22
Q

TB culture

A

Culture samples are ideally collected before starting treatment. This allows testing for drug resistance. However, cultures can take several months. Treatment is usually started while waiting for the culture results.

There are several ways to collect cultures:

-Sputum cultures (3 separate sputum samples are collected)

-Mycobacterium blood cultures (require special blood culture bottle)

  • Lymph node aspiration or biopsy
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23
Q

NAAT

A

Nucleic acid amplification tests (NAAT) assess for the genetic material of a pathogen. To detect tuberculosis DNA, NAAT is performed on a sample containing the bacteria (e.g., a sputum sample). It provides information about the bacteria faster than traditional culture, including drug resistance. NAAT is used for:

-Diagnosing tuberculosis in patients with HIV or aged under 16

-Risk factors for multidrug resistance (where the results would alter management)

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24
Q

TREATMENT

A

Latent tuberculosis is treated with either:

Isoniazid and rifampicin for 3 months
Isoniazid for 6 months

The treatment for active tuberculosis can be remembered with the RIPE mnemonic:

R – Rifampicin for 6 months
I – Isoniazid for 6 months
P – Pyrazinamide for 2 months
E – Ethambutol for 2 months

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25
Q
A
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26
Q

TOM TIP

A

Remember that isoniazid causes peripheral neuropathy, and pyridoxine (vitamin B6) is co-prescribed to help prevent this.

An exam question might say, “…are started on R, I, P and E. What else should be prescribed?”

The answer would be pyridoxine or vitamin B6.

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27
Q

HOW TO WE STOP SPREAD IN HOSPITALS

A

In hospitals, negative pressure rooms are used to prevent airborne spread. Negative pressure rooms have ventilation systems that actively remove air to prevent it from spreading onto the ward.

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28
Q

SIDE EFFECTS OF TREATMENT

A

Side Effects of Treatment
Rifampicin can cause red/orange discolouration of secretions, such as urine and tears. It is a potent inducer of the cytochrome P450 enzymes and reduces the effects of drugs metabolised by this system, such as the combined contraceptive pill.

Isoniazid can cause peripheral neuropathy. Pyridoxine (vitamin B6) is co-prescribed to reduce the risk.

Pyrazinamide can cause hyperuricaemia (high uric acid levels), resulting in gout and kidney stones.

Ethambutol can cause colour blindness and reduced visual acuity.

Rifampicin, isoniazid and pyrazinamide are all associated with hepatotoxicity.

TOM TIP: A common exam question asks “…has recently started treatment for tuberculosis. They notice _____. Which medication is most likely to be implicated?” Numbness or unusual sensations in their feet implicates isoniazide (“I’m-so-numb-azid”). Difficulty recognising colours implicates ethambutol (“eye-thambutol”). Urine or tears that are orange or red implicates rifampicin (“red-I’m-pissin’”).

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29
Q

LUNG CANCER

A
  • Lung cancer is the third most common cancer in the UK behind breast and prostate cancer.
  • Lung cancer has the highest mortality rate.
  • Smoking is the biggest cause.
  • Around 80% of lung cancers are thought to be preventable.
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30
Q

CARCINOGENS IN CIGARETTES

A
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31
Q

CARCINOMA OF THE LUNGS - OTHER CAUSES

A
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32
Q

Anatomy of the lungs

A

-The right lung has three lobes.

-The left lung has two lobes.

-The heart is on the left, leaving less room for an extra lobe.

-Both lungs have an oblique fissure separating the lobes. The right lung also has a horizontal fissure.

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33
Q

Pleura

A

There is a membrane that surrounds the lungs called the pleura. There are two layers of this membrane, with a small amount of fluid between them (less than 20mls). These layers separate the lungs from the chest wall.

Lubrication between the two layers allows the lungs to expand and move without creating friction with the chest wall.

Between the two layers, there is a potential space, called the pleural cavity.

The two layers are usually touching each other, which is why it is only a potential space.

There is negative pressure within the pleural cavity, pulling the two layers of the pleura together.

As the chest wall expands, the negative pressure within the pleural cavity pulls the lungs outwards with the chest wall, causing them to expand.

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34
Q

Pleural Effusion

A
  • A pleural effusion is when the potential space of the pleural cavity fills with excess fluid.
  • This creates an inward pressure on the lungs, reducing the lung volume

Symptoms
- Dyspnoea (SOB) ( usually not suddenly could have a one month history of SOB for example)
- Reduced exercise tolerance
- Pleuritic chest pain (sharp chest pain when you breathe in)

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35
Q

Causes of Pleural effusion

A

Causes of pleural effusions are mainly divided into:

Exudative (protein content >35 g/l)
Transudative (protein content <35 g/l)
The history and clinical examination of the patient will usually be able to identify the most likely cause.

It is important to differentiate whether there is a unilateral effusion or bilateral effusions.

Note: transudative pleural effusions are more likely to be bilateral; exudative pleural effusions are more likely to be unilateral

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36
Q
A
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37
Q

Investigations Pleural Effusion

A

Blood Tests:
FBC – may show a raised WCC suggestive of infection

U&E – may show a raised creatinine suggestive of renal impairment

LFTs – may show a low albumin and raised alanine aminotransferase (ALT)/aspartate aminotransferase (AST) suggestive of cirrhosis

Imaging:

Chest X-ray is the first-line imaging investigation in all patients with a suspected pleural effusion

will reveal blunting of the costophrenic angle or white-out of lung (if large)

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38
Q

Pleural Effusion Question

A
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39
Q

Pleural Effusion question

A
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40
Q

Rhesus disease go over

A
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41
Q

MEIGS SYNDROME

A
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42
Q

Pleural Effusion question

A
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43
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A
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44
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45
Q

Pleural Effusion Management

A
  1. Oxygen therapy for breathlessness
  2. Deal with underlying cause (eg. diuretics for heart failure or antibiotics for chest infections)
  3. Ultrasound guided Pleural Aspiration
  4. Pleuritic chest drain insertion - An intercostal drain – for large pleural effusions or empyemas (pus in pleuritic cavity)
  5. Chemical pleurodesis - for recurrent or persistent pleural effusions
    This is injection of an irritant through a chest drain (usually sterile Talcum powder), which will cause a fibrotic reaction in the pleura aiming to seal the potential pleural space
  6. Tunnelled indwelling pleural catheter – can be inserted to allow regular drainage of recurrent fluid

This is especially helpful in palliative patients and reduces hospital stays

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46
Q

Pleural Aspiration

A

Pleural Aspiration (Needle Thoracocentesis)

is an invasive medical procedure to remove fluid or air from the pleural space for diagnostic or therapeutic purposes. A cannula, or hollow needle, is carefully introduced into the thorax, generally after administration of local anesthesia.

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47
Q

Pneumothorax

A
  • A pneumothorax is when air gets into the pleural cavity.
  • which can be spontaneous or traumatic in origin.

SYMPTOMs:
- sudden onset of shortness of breath

  • pleuritic chest pain (sharp pain when your breathe in)

Signs:

  • reduced chest expansion,
  • reduced or absent breath sounds on the affected side
  • hyper resonant on affected side
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48
Q

Causes of pneumothorax

A

Causes can be classified into spontaneous and traumatic.

Spontaneous causes can be further classified:

  • primary causes (no underlying lung pathology - typically tall thin young men)
  • secondary causes (underlying lung pathology).

Secondary causes include connective tissue disease (such as Marfan’s syndrome and Ehlers-Danlos syndrome),

obstructive lung disease (such as asthma and COPD), infective lung disease (such as TB and pneumonia),

fibrotic lung disease (such as cystic fibrosis and idiopathic pulmonary fibrosis), and neoplastic disease (such as bronchial carcinoma).

Traumatic causes can be further classified into iatrogenic causes (such as insertion of a central line or positive pressure ventilation) and non-iatrogenic causes (either a penetrating trauma or blunt trauma with rib fracture).

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49
Q

A large right sided pneumothorax.

A

On left hand side you can see grey haziness which is the lung

  • On the right hand side you can see black (all air) with a collapse lung on the side
50
Q

Another example

A
51
Q

TENSION PNEUMOTHORAX

A

A tension pneumothorax is a life-threatening emergency that:

  • occurs when there is an ongoing, one-way air leak into the pleural space
    as the pressure in this space increases, it will begin to displace the mediastinum, impeding venous return and cardiac output
  • this will eventually cause cardiovascular collapse and cardiac arrest
  • in a simple pneumothorax, air does not continue entering the pleural cavity in this way, so it does not cause tension
52
Q

Tension Pneumothorax pathophysiology

A

When there’s damage to the pleura, either due to lung disease or trauma to the chest wall, air from the outside or from the lungs can flow freely into the pleural space, but cannot leave.

The accumulated air in the pleural space puts positive pressure on the lung and prevents it from expanding properly, which causes respiratory distress.

As the air continues to accumulate, the trachea and other structures of the chest can be pushed away from the pneumothorax, leading to increased difficulty breathing.

Additionally, the increased pressure inside the chest can compress the heart and lead to a collapse of the blood vessels that drain to the heart, in turn decreasing venous return and cardiac output.

If left untreated, tension pneumothorax can rapidly progress to cardiovascular collapse, which ultimately leads to cardiac arrest.

53
Q

Left sided tension pneumothorax

A
  • The heart is being pushed to the right hand side
54
Q

Management of tension pneumothorax

A

A patient will therefore be in respiratory distress and in cardiogenic shock – tachycardic and hypotensive

urgent treatment is required
Initially the patient should be approached using the ABCDE algorithm

give high-flow oxygen (15 litres/min) via a non-rebreather mask
Emergency management is with chest decompression

Use open thoracostomy followed by a chest drain if expertise is available.
Otherwise a needle decompression can be used with a 16-gauge cannula, which is inserted at the second intercostal space, mid-clavicular line, on the affected side. The needle should be inserted just above the third rib, to avoid damaging the neurovascular bundle.

55
Q

Pneumothorax question

A
56
Q

Pneumothorax question

A
57
Q
A

Iatrogenic pneumothorax is a patient safety indicator (PSI) condition. It is a traumatic pneumothorax secondary to an invasive procedure or surgery.

58
Q

Histology of lung cancers

A

The histological types of lung cancer can be broadly divided into:

  • Small cell lung cancer (SCLC) (around 20%)
  • Non-small cell lung cancer (around 80%)
59
Q

Non - small lung cancer

A

Non-small cell lung cancer can be further divided into:

-Adenocarcinoma (around 40% of total lung cancers)

-Squamous cell carcinoma (around 20% of total lung cancers)

-Large-cell carcinoma (around 10% of total lung cancers)

-Other types (around 10% of total lung cancers)

Small cell lung cancer:
- Small cell lung cancer cells contain neurosecretory granules that can release neuroendocrine hormones. This makes SCLC responsible for multiple paraneoplastic syndromes.

60
Q
A
61
Q

Lung cancer presentation

A

-Shortness of breath
-Cough
-Haemoptysis (coughing up blood)
-Finger clubbing
-Recurrent pneumonia
-Weight loss
-Lymphadenopathy – often supraclavicular nodes are the first to be found on examination

62
Q

PANEOPLASTIC SYNDROME

A
  • Paraneoplastic syndromes are a group of rare disorders that occur when the immune system has a reaction to a cancerous tumor known as a “neoplasm.”
  • The immune system is very important in keeping you healthy.
63
Q

REFERRAL CRITERIIA

A

The NICE guidelines on suspected cancer (updated January 2021) recommend offering a chest x-ray, carried out within 2 weeks, to patients over 40 with:

-Clubbing

-Lymphadenopathy (supraclavicular or persistent abnormal cervical nodes)

-Recurrent or persistent chest infections

-Raised platelet count (thrombocytosis)

-Chest signs of lung cancer

64
Q

EXTRAPULOMARY MANIFESTATIONS

A

Lung cancer is associated with a lot of extrapulmonary manifestations and paraneoplastic syndromes. These are linked to different types and distributions of lung cancer. Exam questions commonly ask you to suggest the underlying cause of the paraneoplastic syndrome. Sometimes they can be the first evidence of lung cancer in an otherwise asymptomatic patient.

Recurrent laryngeal nerve palsy presents with a hoarse voice. It is caused by a tumour pressing on or affecting the recurrent laryngeal nerve as it passes through the mediastinum.

Phrenic nerve palsy, due to nerve compression, causes diaphragm weakness and presents with shortness of breath.

Superior vena cava obstruction is a complication of lung cancer. It is caused by direct compression of the tumour on the superior vena cava. It presents with facial swelling, difficulty breathing and distended veins in the neck and upper chest. “Pemberton’s sign” is where raising the hands over the head causes facial congestion and cyanosis. This is a medical emergency.

Horner’s syndrome is a triad of partial ptosis, anhidrosis and miosis. It can be caused by a Pancoast tumour (tumour in the pulmonary apex) pressing on the sympathetic ganglion.

Syndrome of inappropriate ADH (SIADH) can be caused by ectopic ADH secreted by a small cell lung cancer. It presents with hyponatraemia.

Cushing’s syndrome can be caused by ectopic ACTH secretion by a small cell lung cancer.

Hypercalcaemia can be caused by ectopic parathyroid hormone secreted by a squamous cell carcinoma.

Limbic encephalitis is a paraneoplastic syndrome where small cell lung cancer causes the immune system to make antibodies to tissues in the brain, specifically the limbic system, causing inflammation in these areas. This causes symptoms such as short term memory impairment, hallucinations, confusion and seizures. It is associated with anti-Hu antibodies.

Lambert-Eaton myasthenic syndrome can be caused by antibodies produced by the immune system against small cell lung cancer cells. These antibodies also target and damage voltage-gated calcium channels sited on the presynaptic terminals in motor neurones. This leads to weakness, particularly in the proximal muscles but can also affect intraocular muscles causing diplopia (double vision), levator muscles in the eyelid causing ptosis and pharyngeal muscles causing slurred speech and dysphagia (difficulty swallowing). Patients may also experience dry mouth, blurred vision, impotence and dizziness due to autonomic dysfunction.

65
Q

INVESTIGATIONS IN LUNG CANCER

A

Chest x-ray is the first-line investigation in suspected lung cancer. Findings suggesting cancer include:

-Hilar enlargement

-Peripheral opacity – a visible lesion in the lung field

-Pleural effusion – usually unilateral in cancer

-Collapse

66
Q

INVESTIGATIONS

A

STAGING CT SCAN OF CHEST: abdomen and pelvis is used to assess the stage, lymph node involvement and presence of metastases. This should be contrast-enhanced, using an injected contrast to give more detailed information about different tissues.

PET-CT (positron emission tomography) scans involve injecting a radioactive tracer (usually attached to glucose molecules) and taking images using a combination of a CT scanner and a gamma-ray detector to visualise how metabolically active various tissues are. They are useful in identifying areas that cancer has spread to by showing areas of increased metabolic activity.

BRONCHOSCOPY WITH ENDOBRONCHIAL ULTRASOUND (EBUS) involves endoscopy with ultrasound equipment on the end of the scope. This allows detailed assessment of the tumour and ultrasound-guided biopsy.

HISTOLOGICAL DIAGNOSIS requires a biopsy to check the type of cells in the tumour. This can be either by bronchoscopy or percutaneous biopsy (through the skin).

67
Q

TREATMENT for Non-small cell lung cancer

A

Surgery is offered first-line in non-small cell lung cancer to patients that have disease isolated to a single area. The intention is to remove the entire tumour and cure the cancer. See below for more detail on surgery.

Radiotherapy can also be curative in non-small cell lung cancer when diagnosed early enough.

Chemotherapy can be offered in addition to surgery or radiotherapy in certain patients to improve outcomes (“adjuvant chemotherapy”) or as palliative treatment to improve survival and quality of life in later stages of non-small cell lung cancer (“palliative chemotherapy“).

68
Q

TREATMENT for Small cell lung cancer

A

Treatment for small cell lung cancer is usually chemotherapy and radiotherapy.

Prognosis is generally worse for small cell lung cancer compared with non-small cell lung cancer.

69
Q

Lung cancer surgery

A

There are several options for removing a lung tumour:

Segmentectomy or wedge resection involves taking a segment or wedge of lung (a portion of one lobe)
Lobectomy involves removing the entire lung lobe containing the tumour (the most common method)
Pneumonectomy involves removing an entire lung

The types of surgery that can be used are:

Thoracotomy – open surgery with an incision and separation of the rib to access the thoracic cavity
Video-assisted thoracoscopic surgery (VATS) – minimally invasive “keyhole” surgery
Robotic surgery

Minimally invasive surgery (i.e., VATS or robotic surgery) is generally preferred as it has a faster recovery and fewer complications.

70
Q

3 main thoracotomy incisions

A
  • Anterolateral thoracotomy with an incision around the front and side
  • Axillary thoracotomy with an incision in the axilla (armpit)
  • Posterolateral thoracotomy with an incision around the back and side (the most common approach to the thorax)
71
Q

Mesothelioma

A
  • Mesothelioma is a lung malignancy affecting the mesothelial cells of the pleura.
  • It is strongly linked to asbestos inhalation.
  • There is a huge latent period between exposure to asbestos and the development of mesothelioma of up to 45 years.
  • The prognosis is very poor.
  • Chemotherapy can improve survival, but it is essentially palliative.
72
Q

Mesothelioma

A
73
Q

Mesothelioma

A
74
Q

BREATHLESSNESS

A
75
Q

BREATHLESSNESS

A
76
Q

BREATHLESSNESS

A
77
Q

COUGH

A
78
Q

SPUTUM

A
79
Q

HAEMOPTYSIS

A
80
Q
A
81
Q

WHEEZE

A
82
Q

ASTHMA

A

Asthma is a chronic inflammatory airway disease leading to variable airway obstruction. T

The smooth muscle in the airways is hypersensitive and responds to stimuli by constricting and causing airflow obstruction.

This bronchoconstriction is reversible with bronchodilators, such as inhaled salbutamol.

83
Q

ASTHMA SYMPTOMS

A

Typical symptoms are:

Shortness of breath
Chest tightness
Dry cough
Wheeze

  • Typically symptoms are worse at night
  • Symptoms should improve with bronchodilators. No response to bronchodilators reduces the likelihood of asthma.
  • Patients may have a history of other atopic conditions, such as eczema, hayfever and food allergies
84
Q

SPIROMETRY

A

Spirometry is the test used to establish objective measures of lung function.

It involves different breathing exercises into a machine that measures volumes of air and flow rates and produces a report.

A FEV1:FVC ratio of less than 70% suggests obstructive pathology (e.g., asthma or COPD).

85
Q

ACUTE ASTHMA EXACBERATIONS

A

Presenting features of an acute exacerbation are:

Progressively shortness of breath
Use of accessory muscles
Raised respiratory rate (tachypnoea)
Symmetrical expiratory wheeze on auscultation
The chest can sound “tight” on auscultation, with reduced air entry throughout

86
Q

CHEST PAIN

A
87
Q

SIGNS

A
88
Q
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89
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90
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91
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92
Q
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93
Q

PNEUMONIA

A

Pneumonia is an infection of the lung tissue, causing inflammation in the alveolar space.

Pneumonia can be seen as a consolidation on a chest x-ray.

94
Q

UPPER VS LOWER RESP TRACT INFECTIONS

A

Acute bronchitis refers to infection and inflammation in the bronchi and bronchioles. Both pneumonia and acute bronchitis are classed as lower respiratory tract infections.

Upper respiratory tract infections (e.g., a common cold) are usually viral.

As a general rule, the lower down the respiratory tract, the higher the probability of bacterial infection, as opposed to viral.

95
Q

CLASSIFFCATION OF PNEUMONIA

A

Community-acquired pneumonia (CAP) develops in the community

Hospital-acquired pneumonia (HAP) develops after more than 48 hours in a hospital

Ventilator-acquired pneumonia (VAP) develops in intubated patients in the intensive care unit

Aspiration pneumonia is when the infection develops due to the aspiration of food or fluids, usually in patients with impaired swallowing

96
Q

4 Stages of Lobar Pneumonia

A
97
Q
A
98
Q

COMMUNITY ACQUIRED PNEUMONIA CAUSES

A
99
Q

BRONCHOPNEUMONIA

A
100
Q

Legionella pneumophila

A

Legionella pneumophila (Legionnaires’ disease) is typically caused by inhaling infected water from infected water systems, such as air conditioning units.

It can cause a syndrome of inappropriate ADH (SIADH), resulting in hyponatraemia (low sodium).

The typical exam patient has recently had a cheap hotel holiday and presents with pneumonia symptoms and hyponatraemia. A urine antigen test can be used as an initial screening test.

101
Q

MYCOPLASMA PNEUMONIA

A

Mycoplasma pneumoniae causes milder pneumonia and a rash called erythema multiforme, characterised by varying-sized “target lesions” formed by pink rings with pale centres.

It can cause neurological symptoms in young patients.

102
Q

Presenting symptoms of pneumonia

A

Cough

Sputum production

Shortness of breath

Fever

Feeling generally unwell

Haemoptysis (coughing up blood)

Pleuritic chest pain (sharp chest pain, worse on inspiration)

Delirium (acute confusion)

103
Q

SIGNS OF PNEUMONIA

A

Characteristic chest signs of pneumonia include:

-Bronchial breath sounds (harsh inspiratory and expiratory breath sounds) due to consolidation around the airways

-Focal coarse crackles caused by air passing through sputum in the airways

-Dullness to percussion due to lung tissue filled with sputum or collapsed

104
Q

CURB-65 score

A
105
Q

CURB-65 score

A
106
Q

MAIN CAUSES OF PNEUMONIA

A

The top causes of typical bacterial pneumonia are:

-Streptococcus pneumoniae (most common)

  • Haemophilus influenzae
107
Q

Other bacterial causes of pneumonia

A

Moraxella catarrhalis in immunocompromised patients or those with chronic pulmonary disease

Pseudomonas aeruginosa in patients with cystic fibrosis or bronchiectasis

Staphylococcus aureus in patients with cystic fibrosis

Methicillin-resistant Staphylococcus aureus (MRSA) in hospital-acquired infections

108
Q

INVESTIGATIONS

A

Investigations
Patients in the community with CRB 0 or 1 pneumonia do not necessarily need investigations.

A point-of-care test for the CRP level can be used in primary care to help guide diagnosis and the use of antibiotics.

Investigations for patients admitted to hospital include:

-Chest x-ray
-Full blood count (raised white cell count)
-Renal profile (urea level for the CURB-65 score and acute kidney injury)
-C-reactive protein (raised in inflammation and infection)

Patients with moderate or severe infection will also have:

-Sputum cultures
-Blood cultures
-Pneumococcal and Legionella urinary antigen tests

White blood cells and CRP are raised roughly in proportion to the severity of the infection.

The trend can help monitor the progress of the patient towards recovery. CRP starts rising 6 hours behind the onset of inflammation and peaks after 24-48 hours.

It may initially be low before becoming very high a day or two later.

109
Q

PREVENTING PNEUMONIA

A
110
Q

COMMENSUALISM AND OPPORTUNISTIC INFECTION

A
111
Q

ACUTE BRONCHITIS

A
  • Inflammation of the bronchi
  • Acute bronchitis may also be called a chest cold.
  • Most symptoms of acute bronchitis last for up to 2 weeks. The cough can last for up to 8 weeks in some people.
  • Chronic bronchitis lasts a long time. It is more common among smokers.
  • Usually caused by virus, but can be caused by bacteria or allergens
112
Q

Acute Bronchitis Symptoms

A
  • Cough, first dry (non-productive), later, a lot of mucus is produced
  • Headache
    -Runny nose
    -Slight fever
    -Shortness of breath
  • Wheezing
113
Q

How is Acute Bronchitis diagnosed ?

A
  • History and Physical Examination
  • Chest X-ray
  • Arterial blood gas
  • Pulse Oximetry
  • Cultures of nasal discharge and sputum
114
Q

How is acute bronchitis treated?

A

Acute bronchitis is usually mild and does not cause complications. The symptoms often resolve on their own and lung function goes back to normal.

In most cases, antibiotics are not needed to treat acute bronchitis. That’s because most of the infections are caused by viruses. Antibiotics are not effective against viruses. If it has progressed to pneumonia, then antibiotics may be necessary.

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120
Q
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