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MBChB > Respiratory > Flashcards

Respiratory Flashcards

1
Q

Define pleural effusion

A

Accumulation of an abnormal volume of fluid in the pleural space

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2
Q

Describe the fluid that is normally found in the pleural space

A

<15ml in volume

Clear, serous fluid with few cells

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3
Q

What sign is suggestive of a pleural effusion on a CXR?

A

Blunting of the costaphrenic angles

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4
Q

What symptoms can be associated with a pleural effusion?

A

Asymptomatic
SOB
Cough
Pleuritic chest pain

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5
Q 
What clinical signs are associated with a pleural effusion?
I.e 
1. chest expansion
2. tacile vocal fremitis
3. percussion
4. breath sounds
5. any other...
A
  1. Chest expansion is reduced
  2. Reduced tactile vocal fremitis
  3. Stony dull percussion
  4. Quiet breath sounds
    + Bronchial breathing above fluid level
    + Rub with pleural inflammation
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6
Q

Describe the mechanism of a pleural effusion

A

Disturbed balance between pleural fluid production and absorption

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7
Q

If there is a bilateral pleural effusion, what type of effusion is it generally?

A

Transudate (protein <30g/l)

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8
Q

What type of pleural effusion can be caused by cardiac failure?

A

Unilateral effusion on the right

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9
Q

How should pleural effusion be sampled?

A

USS guidance
Need >100ml to cytology + paired serum samples
Biochemistry - Light’s criteria
Microbiology

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10
Q

How much pleural effusion can be drained at a time?

A

1 litres

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11
Q

What are causes of transudative pleural effusion?

A

Cardiac failure
Hepatic cirrhosis
Nephrotic syndrome
Hypoalbuminaemia

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12
Q

What are causes of exudative pleural effusion?

A

Bacterial pneumonia
Malignancy
Mesothelioma
TB

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13
Q

At what site should a thoracentesis be performed?

A

Above the rib (below rib is the neurovascular bundle)

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14
Q

Describe Light’s criteria for establishing whether a pleural effusion is a transudate or exudate

A
  1. Pleural/serum protein ratio >0.5
  2. Pleural LDH/serum LDH >0.6
  3. LDH >2/3 the upper limit of normal value for serum LDH
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15
Q

When is a medical thoracoscopy indicated?

A

Undiagnosed cytology negative pleural effusions

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16
Q

What are the four management options for malignant pleural effusion?

A
  1. Drain to dryness and discharge
  2. , Medical pleurodesis
  3. Thoracoscopic pleurodesis
  4. Indwelling pleural catheter (IPC) - high output pleural effusion
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17
Q

What percentage of pneumonias will have an associated effusion?

A

50% (parapneumonic)

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18
Q

Describe a complex parapneumonic effusion

A

pH <7.2
LDH >1000
Glucose <2.2
Loculated on ultrasound

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19
Q

What mortality is associated with an empyema?

A

15%

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20
Q

On CXR, what shaped effusion is suggestive of empyema?

A

D-shaped

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21
Q

When should an empyema be considered?

A

Effusion + sepsis

Pneumonia and not improving

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22
Q

How should an empyema be managed?

A

Small bore chest drain
Frequent sterile saline flushes
IV antibiotics and DVT prophylaxis
Fibrinolytics - streptokinase or DNAase and tPA (alteplase)

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23
Q

Describe sarcoidosis

A

Multisystem inflammatory disease of unknown aetiology that predominantly affects the lungs and the intrathroacic lymph nodes

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24
Q

What skin lesion is associated with sarcoidosis?

A

Erythema nodosum

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25
Q

What eye condition is associated with sarcoidosis?

A

Uveitis

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26
Q

In what population is sarcoidosis most commonly seen?

A

African American women

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27
Q

What type of granulomas are associated with sarcoidosis?

A

Non-caseating granulomas (T cell surrounding macrophages)

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28
Q

What histology is commonly present in sarcoidosis?

A

Langhans Giant Cells

Contain Schaumann bodies and astroid bodies

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29
Q

What are the general symptoms of sarcoidosis?

In what percentage of patients are these present?

A 
Weight loss
Anorexia
Fever
Malaise
Night sweats

45%

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30
Q

What electrolyte disturbance is associated with sarcoidosis?

A

Hypercalcaemia (increased Vitamin D produced by macrophages)

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31
Q

What happens to ACE levels in sarcoidosis?

A

Increased (from T cells)

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32
Q

What is stage 1 CXR classification for sarcoidosis?

A

Bilateral hilar lymphadenopathy without infiltration

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33
Q

What is stage 2 CXR classification for sarcoidosis?

A

Bilateral hilar lymphadenopathy with infiltration

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34
Q

What is stage 3 CXR classification for sarcoidosis?

A

Peripheral infiltration alone

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35
Q

What is stage 4 CXR classification for sarcoidosis?

A 
Bullae
Fibrotic bands
Bronchiectasis
Diaphragmatic tenting 
Hilar retraction
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36
Q

How can severe symptoms of sarcoidosis be managed?

A

Steroids

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37
Q

Describe the epidemiology of Usual Interstitial Pneumonia (UIP)

A

Age >50y

M:F = 2:1

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38
Q

What signs and symptoms are associated with UIP?

A

Progressive breathlessness (worse with exercise), hacking cough
Bibasilar crackles
Clubbing
Appetite and weight loss

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39
Q

What pathological findings are associated with UIP?

A 
Peripheral interstitial pattern 
Subpleural honeycombing (radiological sign)
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40
Q

What are some of the non-idiopathic causes of UIP?

A

Occupational and environmental
Drug induced - amiodarone, cocaine, nitrofurantoin, methotrexate
Connective tissue disease - SLE, RA, scleroderma
Primary disease - sarcoidosis, LAM

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41
Q

What percentage of cases of UIP are idiopathic?

A

25%

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42
Q

How can UIP be diagnosed?

A

High resolution CT

VATS (3 samples)

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43
Q

What are the four features of UIP that need to be detected following VATS?

A
  1. Spatial heterogeneity
  2. Temporal heterogeneity
  3. Smooth muscle hyperplasia
  4. Fibroblastic focus
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44
Q

What is extrinsic allergic alveolitis also called?

A

Hypersensitivity pneumonitis

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45
Q

Define EAA/HSP:

A

Immunologically mediated (T-cells) inflammatory reaction in the alveoli and respiratory bronchioles following exposure to organic dust, moulds, foreign proteins (animal dander), and some chemicals

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46
Q

How long after the exposure to the allergen do symptoms develop?

A

4-8 hours

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47
Q

What symptoms are associated with EAA/HSP?

A

Flu-like symptoms: high fever, chills, malaise and myalgia

Chest symptoms: cough, dyspnoea, chest tightness

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48
Q

Describe some of the radiological findings associated with acute HSP:

A 
Numerous poorly defined small opacities throughout both lungs
May have sparing of the apices/bases
Ground glass opacities
Fine reticulation may occur
Zonal distribution
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49
Q

What are the symptoms of chronic HSP?

A 
Dyspnoea on strain 
Sputum production 
Fatigue
Anorexia 
Weight loss
50
Q

Describe the pathology of chronic HSP:

A

Non-necrotising granulomatous inflammation (Giant cells)

Overproduction of surfactant –> lipid is phagocytksed by macrophages –> foamy macrophages in alveolar space

51
Q

What is the difference, in terms of pathology, of sarcoidosis and EAA/HSP?

A

Sarcoidosis = non-necrotising granulomatous inflammation in the interstitium

EAA/HSP = non-necrotising granulomatous inflammation in the alveolar air space

52
Q

Define COPD

A

Progressive, irreversible airway obstruction which does not change markedly over several months

53
Q

Define Emphysema

A

Permanently dilated airways distal to the terminal bronchioles with alveolar destruction and bullae formation

54
Q

Define chronic bronchitis

A

Cough with sputum production for at least three months in two consecutive years

55
Q

What percentage of lung cancers are due to lifestyle factors, the most important being smoking?

A

90%

56
Q

What types of lung cancer does smoking predispose the most to?

A

Squamous carcinoma

Small cell carcinoma

57
Q

Give 4 risk factors (other than smoking) for developing lung cancer

A 
Environmental tobacco smoke 
Irradiation - radon, uranium
Air pollution
Asbestos 
Other - HPV, fibrosing conditions of the lung, hereditary
58
Q

What are some of the common signs and symptoms of a lung cancer?

A 
Cough 
Haemoptysis
SOB
Chest pain
Weight loss/anaemia
General malaise
59
Q

What symptoms are more commonly seen in central lung cancers?

A

Haemoptysis
Bronchial obstruction - SOB, retention pneumonia
Cough

60
Q

What symptoms are more commonly seen in peripheral lung cancers?

A

Largely asymptomatic

Pain if pleura/chest wall involvement

61
Q

Give some signs and symptoms that may occur if there is local spread of a lung cancer?

A

Pancoast tumour - brachial plexus involvement, Horner’s syndrome

Mediastinum involvement:
Paralysis of diaphragm - involvement of phrenic nerve
Hoarseness - involvement of recurrent pharyngeal nerve
Super vena caval obstruction

62
Q

Describe haematogenous spread of lung cancer

A

Spread through pulmonary veins

Mets in liver, bone, brain, adrenals

63
Q

Which lymph nodes are involved in lung mets?

A

Cervical lymph nodes

64
Q

Describe the hormonal effects of lung cancer

A

ACTH released by tumour –> adrenal hyperplasia –> raised blood cortisol –> Cushing’s syndrome

ADH secretion –> water retention –> dilute hypernatraemia

Parathyroid Hormone Related Peptide released –> increased osteoclast activity –> increased bone resorption —> hypercalcaemia

65
Q

What are non-hormonal non-metastatic effects of lung cancers?

A

Encephalopathy
Cerebellar degeneration
Neuropathy
Myopathy

66
Q

Describe small cell lung carcinoma

A

Most aggressive form of lung cancer
Metastasises early and widely
Treat with chemo - usually good response but most patients relapse

67
Q

Describe the histology associated with small cell lung carcinoma

A 
Oval to spindle shaped cells 
Scant cytoplasm
Inconspicious nucleoli 
Nuclear moulding 
Lots of apoptosis and mitosis
68
Q

What are the types of non-small cell lung carcinoma?

A

Squamous cell carcinoma
Adenocarcinoma
Large cell carcinoma

69
Q

Describe squamous cell carcinoma

A

Tends to arise centrally from the major bronchi - may block the bronchi –> retention pneumonia/collapse

Slow growing and metastases late –> ? surgery

70
Q

Describe the histological appearance of squamous cell carcinoma

A

Malignant epithelial tumour with keritanisation and/or intracellular bridges (desmosomes)

In situ squamous cell carcinoma may be seen in adjacent airway

71
Q

Describe adenocarcinoma lung cancer

A

Common in females
Can be seen in non-smokers
2/3 in periphery
Can spread from lobe to lobe

72
Q

Describe the histological appearance of adenocarcinoma lung cancer

A

Glandular
Solid
Papillary
(Grows along alveolar walls –> produce mucin)

73
Q

Define large cell carcinoma

A

An undifferentiated malignant epithelial tumour that lacks the cytological features of SCLC and glandular/squamous differentiation

74
Q

What are carcinoid tumours?

A

Neuroendocrine cells

Can metastases but much better prognosis

75
Q

What lung cancers are arise centrally?

A

Squamous
Small cell carcinoma

(arise in and around the Hilar)

76
Q

What lung tumour generally arises in the periphery?

A

Adenocarcinoma

77
Q

Describe the role of EGFR in NSCLC

A

Ligand binds –> activation of tyrosine kinase –> pathway activation –> production of GF, proliferation etc

If tyrosine kinase is continually activated –> continuous cell division

78
Q

What two drugs target EGFR in NSCLC?

A

Cetruximab

Erlotinib

79
Q

Describe the MoA of Cetruximab

A

Targets the ligand binding site with a blocker

80
Q

Describe the MoA of Erlotinib

A

Tyrosine kinase inhibitor

81
Q

What can be used to assess for mutation in EGFR gene?

A

PCR

82
Q

What is associated with a good response to EGFR inhibitors?

A

Deletion in exon 19

83
Q

What fusion gene is implicated in some NSCLC?

A

ALK-EML4

84
Q

What occurs following the chromosomal translocation that results in ALK-EML4 fusion gene being produced?

A

Activation of tyrosine kinase –> cell proliferation

85
Q

What drug can inhibit ALK-EML4?

A

Crizotinib

86
Q

How can ALK-EML4 gene be assessed?

A

FISH

87
Q

Describe how PD-L1 inhibitors can be used to treat NSCLC

A

PD-L1 (tumour cell) binds to PD-1 on T lymphocytes to prevent the T cells from killing the tumour cell

inhibiting PD-L1 will prevent the tumour cell from evading the immune system

88
Q

Describe mesothelioma

A

Primary pleural tumour
Almost always due to asbestos exposure
Very long lag period before disease develops

89
Q

What is the most common cause of Community Acquired Pneumonia?

A

S.pneumoniae

90
Q

Give bacteria which cause typical CAP

A

S.pneumoniae
H.influenzae
Moraxella catharralis

91
Q

Give bacteria which cause atypical CAP

A

Mycoplasma pneumoniae
Legionella pneumoniae
Chlamydophilia pneumoniae

92
Q

What is the appearance of S.pneumoniae?

A

Chains of gram positive cocci

93
Q

What are risk factors of developing CAP caused by S.pneumoniae?

A 
Alcohol
Smoking
Influenza
Airway disease
Immunosuppression
94
Q

What signs and symptoms are associated with CAP caused by S.pneumoniae?

A 
Abrupt onset
Cough
Fever
Pleuritic chest pain
Dull percussion
Coarse crepitations
Increased vocal resonance
95
Q

What Abx should be prescribed for a patient who has CAP due to S.pneumoniae?

A

Amoxicillin

Clarithromycin or doxycycline if allergy to penicillin

96
Q

What is the appearance of Haemophilius influnzae?

A

Gram negative

97
Q

Who is at risk of developing CAP due to Haemophilius influenzas infection?

A

Older people

People with underlying lung disease

98
Q

What other infections can be caused by H.influenzae?

A

Otitis media
Conjunctivitis
Headache/sinusitis
Meningitis (type B)

99
Q

What are the signs and symptoms of H.influenzae CAP?

A 
Abrupt onset
Fever
Pleuritic chest pain
Dull percussion
Coarse creps
Increased vocal resonance
100
Q

Describe the management of H.influenzae CAP

A

Co-amoxiclav

if allergy to penicillin: clarithromycin, doxycycline

101
Q

Describe the presentation of Mycoplasma pneumoniae

A

Non-specific (headache, lethargy, cough, myalgia)
Signs of consolidation on auscultation

Higher rates in autumn and winter
Spreads from person to person
Affects younger people

102
Q

What are the other effects of Mycoplasma pneumoniae?

A 
Haemolysis (cold agglutinins)
Guillain-Barre syndrome
Erythema multiform
Arrhythmias
Arthritis
103
Q

How is Mycoplasma pneumoniae CAP diagnosed?

A

Serology - rising Ab against M.pneumoniae

PCR from sputum, gargle, throat swab

104
Q

Describe the treatment of Mycoplasma pneumoniae CAP

A

Macrolides - clarithromycin
Tetracyclines - doxycycline
Quinolones - ciprofloxacin

105
Q

Describe legionella pneumophilia

A

Exists within the soil and water
Hx is key
Causes atypical presentation

106
Q

How is Legionella pneumophilia diagnosed?

A

Ab raised against legionella

Urinary antigen test

107
Q

How is legionella pneumophilia CAP treated?

A

Macrolides - clarithromycin
Tetracycline - doxycycline
Quinolones - ciprofloxacin

108
Q

What is the CURB65 score?

A

Assess severity of pneumonia

C = confusion
U = urea >7
R = RR >/= 30
B = DBP <60 or SBP <90
65 = >65y

> 2 = severe pneumonia

109
Q

What is Sepsis qSOFA score?

A

SBP <100mmHg
Altered mental state
Respiratory rate >22 breaths/min

110
Q

Other than the CURB65 score, what is the other definition of a severe pneumonia?

A

Multilobular consolidation on CXR and/or hypoxic on RA

111
Q

Define obstructive sleep apnoea

A

Recurrent episodes of partial or complete upper (pharyngeal) airway obstruction during sleep resulting in intermittent hypoxia and sleep fragmentation

(If manifests with excessive daytime sleepiness –> obstructive sleep apnoea syndrome)

112
Q

Describe of mechanism of OSAS

A

Airway collapses and closes during sleep
Hypoxia –> arousal
Sleep disruption –> sleepiness, reduced QoL, increase risk of RTA
Blood BP surge –> increased free radical production –> CVA (MI, stroke)

113
Q

What are the symptoms of OSAS?

A 
Snorer
Witnessed apnoea
Disrupted sleep - nocturia, choking, dry mouth, sweating
Unrefreshed sleep
Daytime somnolence
Fatigue, low mood, poor concentration
114
Q

What scoring system quantifies daytime sleepiness?

A

Epworth Sleepiness Sore

115
Q

What are the components of a physical examination in OSAS?

A 
Weight/BMI
BP
Neck circumference (>40%)
Craniofacial appearance: retrognathia (abnormal posterior position of maxilla/mandible) or micrognathia (small jaw)
Tonsils
Nasal patency
116
Q

What are the two methods in which OSAS can be investigated?

A

Limited Sleep Study - at home

Full polysomnography

117
Q

Define apnoea

A

The cessation, or near cessation, of airflow

4% oxygen desaturations, lasting >/= 10 seconds

118
Q

Define hypopnoea

A

Reduction in airflow to a degree insufficient to meet the criteria for an apnoea

119
Q

What is the Apnoea-Hypoapnoea Index?

A

Calculated by adding the total number of apnoeas and hypopnoeas and dividing by the total sleep time (in hours)

120
Q

How is the Apnoea-Hypoapnoea Index used to diagnose OSAS?

A

AHI >/= 15 = diagnostic

AHI 5-14 + symptoms = diagnostic

121
Q

Define Oxygen Desaturation Index

A

The number of times per hour of sleep that the SpO2 falls >/= 4% from baseline

MBChB (14 decks)

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