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Year 4 CCC conditions > AF & COPD > Flashcards

AF & COPD Flashcards

1
Q

what is atrial fibrillation

A

A type of supraventricular tachyarrhythmia. Characterized by uncoordinated atrial activity on the surface ECG with fibrillatory waves of varying shape, amplitude, and timing associated with irregularly irregular ventricular response when atrioventricular conduction is intact

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2
Q

pathophysiology of atrial fibrillation

A
  • Rapidly firing ectopic foci located inside 1 or more pulmonary veins
  • Abnormal atrial tissue substrate - ↑ atrial pressure, ↑ atrial muscle mass, atrial fibrosis, inflammation and infiltration of the atrium
  • Only a proportion of electrical impulses in the atria reach the ventricles  electrical re-entry which then results in atrial fibrillation
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3
Q

what are the different types of atrial fibrillation

A

initial episode - AF > 30 second diagnosed by ECG

paroxysmal - recurrent 2 or more episodes that terminate within 7 days

peristent - continuous > 7 days or AF > 48 in which a decision is made to perfrom CV

long standing - continuous AF for > 12 months

permanent - joint decision by patient and clinician to cease further attempts to restore or maintain sinus rhythm

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4
Q

aetiology of AF?

A
  • in developed country most common  HTN, coronary artery disease and MI
  • in developing country most common  congestive heart failure, HTN and rheumatic valvular disease
  • Cardiac conditions  Sinus sick syndrome (electrophysiological abnormalities), Wolff-Parkinson-White syndrome, Cardiac surgery, congenital heart disease, tumour near heart
  • Infections  pericarditis, amyloidosis, myocarditis
  • Alcohol intoxication/Caffeine/Drugs
  • Hyperthyroidism/thyrotoxicosis
  • Lung cancer/PE
  • Diabetes
  • Obesity
  • Idiopathic – 11%
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5
Q

clinical features of AF

A 
palpitations 
tachycardia 
irregularly irregular pulse 
SOB 
chest pain 
dec exercise capacity/fatigue 
stroke as 1st presentation 
elevated JVP 
hypotension - AF induced haemodynamic instability
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6
Q

investigation for AF

A

feels for irregularly irregular pulse

ECG - if AF, will show fibrillation, irregular ventricular rate (RR intervals), no clear P waves, QRS rhythm is rapid and irregular

if paroxysmal AF is suspected and no AF recorded in initial ECG –> 24 hour ambulatory ECG

FBC, U&E, TFTs

CXR to exclude HF or resp. causes

Transthoracic echocardiography in those confirmed with AF - find any structural heart causes and baseline for long-term management

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7
Q

when will you admit a person with AF to hospital

A

if severe symptoms/serious complication

  • pulse > 150
  • BP < 90
  • LOC / severe dizziness/ongoing chest pain/inc SOB
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8
Q

mx of acute AF

A 
cardiovesion - electrical DC shock/IV drugs if 
- new-onset AF (<48 hours) 
- AF with a reversible cause 
- heart failure a cause 
\+ atrial flutter
  • If unstable  electrical DC shock + IV amiodarone after
  • If stable  either DC shock of IV amiodarone at a later stage
  • A transesophageal echo is done to look for clots in heart before cardioversion otherwise it can dislodge and case a stroke or anti-coag for 4 weeks before cardioversion

Rate control - B-blocker, CCB or digoxin

Rhythm control - amiodarone

Anti-coag - after CHA2DS2-VASc and HAS-BLED

  • DOAC as 1st line
  • warfarin if mechanical valve, aortic stenosis or rheumatic fever
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9
Q

mx of chronic AF

A
  • Rate controlling drugs – beta blockers, Ca channel blockers
  • Antiarrhythmic drug – Quinidine, Beta blockers, amiodarone
  • CHA2DS2-VASc for stroke assessment + HAS-BLED for bleeding risks
  • Oral anticoagulant e.g. warfarin, NOACs – need to be calculated by the CHA2DS2-VASc scoring system
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10
Q

what is discussed in AF annual review

A
  • Follow up 1 week after starting rate control treatment
  • Check symptoms at rest and during exercise/assess HR
  • If not controlled consider increasing dose/combining any 2 of beta blockers/digoxin/diltiazem (check this + beta blocker with specialist)
  • If still not controlled refer within 4 weeks to cardiologist
  • Side effects
  • HR/BP
  • Calculate TTR to ensure an INR of between 2 and 3 with warfarin
  • Exclude measurements taken within the 1st 6 weeks of treatment
  • Calculate over a maintenance period of at least 6 months
  • If poor control then attempt to correct contributing factors/switch to NOACs
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11
Q

pathophysiology of COPD

A

poorly reversible airflow limitation that is usually progressive

associated with persistent inflammatory response of the lungs

chronic bronchitis
- airway narrowing
- hypertrophy and hyperplasia of mucus secreting glands
- bronchial wall inflammation
- mucosal oedema
- epithelial cell later may ulcerate
squmaous epithelium may replace columnar epithelium when ulcers heal –> squamour metaplasia

emphysema

  • dilatation and destruction of the lung tissue distil to the terminal bronchioles
  • loss of the elastic coil
  • expiratory airflow limitation and air trapping
  • smoking > 20 years
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12
Q

what scale is used to classify COPD

A

Medical Research Council Dyspnoea Scale

Grade 1 - breathless on strenuous exercise
Grade 2 - breathless on walking up hil
Grade 3 - breathless that slows walking on the flat
Grade 4 - stop to catch their breath after walking 100 meters on the flat
Grade 5 - unable to leave the house due to SOB

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13
Q

investigation of COPD?

A

MRC Dyspnoea Scale
spirometry - PEV1/FVC ratio < 0.7
CXR - hyperinflation and to exclude other diagnosis

FBC - anaemia, inc haematrocrit, polycythaemia, eosinophil count, 
sputum culture
BMI 
ECG 
ECHO 
BNP 
Alpha 1 antitrypsin
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14
Q

what is used to assess the severity of COPD?

A

GOLD framework

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15
Q

what is the single most important diagnostic test for COPD

A

spirometry with bronchodilator reversibility test

  • FEV1/FVC < 0.7
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16
Q

what are the different stages of COPD?

A

Stage 1, mild — FEV1 80% of predicted value or higher. With these values, a diagnosis of COPD can only be made on the basis of respiratory symptoms.

Stage 2, moderate — FEV1 50–79% of predicted value.

Stage 3, severe — FEV1 30–49% of predicted value.

Stage 4, very severe — FEV1 less than 30% of predicted value.

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17
Q

what is considered to be asthma features

A

previous diagnosis of asthma or of atopy, a higher blood eosinophil count, substantial variation in FEV1 over time (at least 400ml) or substantial diurnal variation in peak flow (at least 20%)

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18
Q

management of COPD without asthma features

A

1) SABA or SAMA PRN

2) LABA + LAMA

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19
Q

management of COPD with asthma features

A

1) SABA or SAMA PRN
2) ICS + LABA
3) if still exacerbations –> ICS + LAMA + LABA

20
Q

what is pleura effusion

A

collection of fluid in the pleural cavity

21
Q

what are the 2 types of pleural effusion

A

exudative - high protein count (>3g/L), protein leaking out of the tissues into the pleural space

transudative - relatively low protein count (< 3g/L protein), fluid moving across into the pleural space

22
Q

aetiology of o exudative pleural effusion

A

local inflammation

  • lung cancer
  • penumonia
  • TB
  • PE
  • post CABG
  • systemic disease eg RA
23
Q

aetiology of transudative pleural effusion

A

systemic shift in fluid

  • congestive heart fialure
  • cirrhosis, nephromatic syndrome
  • Meig’s syndrome - R sided pleural effusion with ovarian malignancy
24
Q

clinical features

A

SOB
cough - can be productive or not
dullness to percussion over the effusion
tracheal deviation away from the effusion - if massive
reduced breath sounds
improving pneumonia with a/onging fever - suspect empyema

25
investigation of pleural effusion?
``` CXR - 1st line • Blunting of the costophrenic angle • Fluid in the lung fissures • Larger effusions will have a meniscus • Tracheal and mediastinal deviation – massive effusion ``` USS - more sensitive than CXR * Thoracentesis * High protein count, pH<7.2, ↓ glucose, ↑ LDH = empyema * Blood = malignancy, PE with infarction, trauma * Light’s criteria is used when the pleural fluid is between 25-30g/L to differentiate between exudate and transudate
26
what is the light's criteria for pleural effusions
it looks into protein and LDH to differentiate between exudate and transudate pleural effusion Transudate - protein (pleura/serum) < 0.5 - LDH (pleural/serum) <0.6 - pleura LDH < 2/3 of upper limit of normal serum LDH Exudate - protein (pleura/serum) > 0.5 - LDH (pleural/serum) >0.6 - pleura LDH > 2/3 of upper limit of normal serum LDH
27
management of pleural effusion?
small - conservative management larger - pleural aspiration and chest drain empyema (pH<7.2) - chest drina + ABx
28
what cancer most commonly mets to the lungs
``` breast colorectal renal bladder prostate ```
29
where does lung cancer most commonly mets to?
bone liver adrenals brain BLAB
30
clinical features of lung mets
enlarged axillary lymph nodes bone pain ascites
31
investigations of lung mets
CT chest abdo pelvis PET-CT - for distant mets (not useful for brain, kidney or bladder) MRI
32
what is mesothelioma
neoplasma arising from the lining of the lung commonly caused by asbestos exposure, aged 60-85, male
33
what are the management of lung mets
bone - single fraction radiotherapy for bone mets, denosumab - prevent skeletal-related events from bone mets Liver - peritoneal catheter drainage system for treatment resistant, recurrent malignant ascties adrenal - surgical and replacemetn of cortisol and alderstone and androgen brain - 1x met --> chemo/immuno otherwise stereotactic radiosurgery/radiotherapy - if > 1x mets --> stereotactic radiosurgery/radiotherapy
34
what are the different types of lung cancer?
non small cell lung cancer small cell lung cancer
35
what is sarcoidosis
granulomatous (nodules of macrophages) inflammatory condition commonly affecting the lungs, skin and eyes
36
aetiology of sarcoidosis
unknown most commonly affect - women, black, young adulthood, > 60 yrs old
37
clinical faetures of sarcoidosis
CNS - diabetes inspidius, encepahlopathy PNS - facial nerve palsy, mononeuritis multiplex eye - uveitis, conjunctivitis, optic neuritis lung - dry cough, SOB, wheeze, mediastinal lymphadenopathy, pulmonary fibrosis heart - bundle branch block, heart block liver - cirrhosis, cholestasis skin - erythema nodosum, lupus pernio, granuloma development in scar tissues systemic - fever, fatigue, weight loss kidney - kidney stones, hypercalcaemia, nephrocalcinosis, interstitial nephritis MSK - arthralgia, arthritis, myopathy
38
aetiology of sarcoidosis
unknown most commonly affect - women, black, young adulthood, > 60 yrs old
39
management of sacroidosis
no/mild symptoms - no treatment moderate symptoms 1) orla steriod - indicated for parenchymal lung disease/uveitis/hypercalacemia/neurological/cardiac involvment 2) bisophophonates for boen protection 3) methotrexate/azathioprien severe lung transplant
40
what genetic mode of transfer is cystic fibrosis
autosomal recessive - gene mutation in the cystic fibrosis transmembrane conductance regulatory gene on chromosome 7 most common variant = delta F508
41
clinical features of cystic fibrosis
meconium ileus recurrent LRTI chronic cough nasal polyps esp if bilateral thick sputum production crackles/wheeze on auscultation salty sweat finger clubbing ``` FFT abdo pain abdo distension pancreatitis steatorrhoea ```
42
what genetic mode of transfer is cystic fibrosis
autosomal recessive - gene mutation in the cystic fibrosis transmembrane conductance regulatory gene on chromosome 7
43
management of cystic fibrosis
MDT approach chest physio with nebulised saline - twice daily salbutamol Nebulised DNase ABx - prophylactic flucloxacillin CFTR modulators eg ivacaftor (G551D mutation only) vaccine - pneumococcal, influenza, varicella transplants - lung, liver high calorie diet, CREON tablets
44
investigation for cystic fibrosis
1) newborn screening via guthrie test (majority diagnosed here) + typical clinical symptosm/FHX of sibling 2) sweat test - gold standard - diagnostic if > 60 on 2 separate occasions or genetic testing for CFTR gene during pregnancy by aminocentesis, CVS
45
clinical features of TB
``` persistent productive cough SOB Haemoptysis - late features weight loss fever night sweats malaise ``` extra-pulmonary involvement - headache, vomiting, irritability, confusion, cranial nerve abnor - TB meningitis - lymphadenopathy - cervical and supraclavicular lymph nodes - SOB, chest pain, ankle swelling - TB pericarditis - abdo/pelvic pain, constipation, bowel obstruction sterile pyuria - renal TB - skin lesions - erythema nodosum, lupas vulgaris - cutaneous TB - bone/joint/back pains, joint swelling
46
investigation of TB
Active TB • CXR • 3x early morning sputum samples – acid fast bacilli +ve • If active extrapulmonary, arrange scanning of the relevant areas Latent TB • Mantoux test – tuberculin injected and skin reaction after 2-3 days = +ve test • Interferon gamma release assay (IGRA) test • HIV/Hep B/Hep C testing • CXR – calcified Ghon complex
47
management of TB
• Notifiable disease + immediate contact tracing 6 months (or 3 months if latent) of isoniazid with pyridoxine and rifampicin, supplemented in the first 2 months with pyrazinamide and ethambutol

Year 4 CCC conditions (7 decks)

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