Case 6- illness

Question 1

Pneumothorax

Answer 1

Air in pleural cavity, can result in a collapsed lung

Question 2

Pleural effusion

Answer 2

Fluid in pleural cavity

Question 3

Haemothorax

Answer 3

Blood in pleural cavity

Question 4

Chylothorax

Answer 4

Lymph in pleural cavity

Question 5

What causes a collapsed lung

Answer 5

Pneumothorax, pleural effusion, Haemothorax and Chylothorax. These all cause a collapsed lung which is unable to expand

Question 6

How many cases of lung cancer are caused by smoking

Answer 6

90%

Question 7

Lung cancer- when to refer for chest x-ray?

Answer 7

Findings are suggestive of cancer or they are over 40 with unexplained haemoptysis

Question 8

Lung cancer- when to offer an urgent chest x-ray

Answer 8

In people over 40 with 2 or more of the following symptoms. The same is true if they have ever smoked and have one or more of the following unexplained symptoms: cough, fatigue, chest pain, weight loss, shortness of breath and appetite loss.

Question 9

Lung cancer- what can happen to the tumours

Answer 9

Tumours may obstruct airways causing: persistent cough, shortness of breath and chest pain.
Tumours may also invade arteries causing bleeding: Haemoptysis (coughing up blood)
Tumours may compress mediastinal structures: Phrenic nerve compression (difficulty breathing), recurrent laryngeal nerve compression (hoarseness) and compression of the oesophagus (dysphagia).

Question 10

Other side effects of lung cancer

Answer 10

Anaemia, bone pain, finger clubbing, fatigue, loss of appetite and weight loss

Question 11

Paraneoplastic

Answer 11

Where seemingly false signs and symptoms are seen. The tumour may secrete hormones, antibodies and enzymes that affect sites far away from the tumour.

Question 12

Symptoms of lung cancer associated Paraneoplastic syndrome

Answer 12

Neurologic, endocrine, dermatologic, rheumatologic, hematologic, and ophthalmological, nephrotic/glomerular symptoms.

Question 13

Pancoast tumours

Answer 13

Tumour growths in the apical region of the lungs, typically squamous carcinoma. It presents with shoulder pain and Horner’s syndrome causing unilateral: ptosis (dropping of one eyelid), Miosis (pupil constricted in one eye) and Anhidrosis (loss of ability to sweat)

Question 14

Small lung carcinomas

Answer 14

20% of lung cancers. An aggressive tumour with poor prognosis as it grows rapidly and metastases early. It develops centrally near the main bronchus. Neuroendocrine cells of the lung appear to have scant cytoplasm, the nuclei looks bigger by comparison. The cells appear indistinct. Associated with paraneoplastic syndrome.

Question 15

Types of non-small cell lung carcinomas (80%)

Answer 15

1) Squamous cell carcinoma
2) Adenocarcinoma
3) Large-cell carcinoma

Question 16

Squamous cell carcinoma

Answer 16

25% of lung cancers. Develops centrally near the main bronchus. Histological features include a change from columnar epithelium to squamous epithelial cells, deposition of keratin ‘pearls’. And it is surrounded by concentric circles of squamous epithelial cells.

Question 17

Adenocarcinomas

Answer 17

35% of lung cancers. It develops peripherally. Histological features include mucoid glands. It is more common in woman and is the most common lung cancer in non-smokers.

Question 18

Large cell carcinoma’s

Answer 18

10-15% of lung cancers. Epithelial tumours that lack the cytological features of small cell carcinoma and have no glandular or squamous differentiation

Question 19

Symptoms of pleural effusion

Answer 19

Symptoms include chest pain, dyspnoea, cough, finger clubbing and symptoms of the underlying disease like weight loss. There must be a large effusion before it causes symptoms- 200ml for diagnosis (x-ray) and 500ml for it to be clinically evident.

Question 20

How does pleural effusion present in examination

Answer 20

Inspect their hands for clubbing, you should also examine their breathing. During palpations you will see that chest expansion is reduced on the side of the effusion. During auscultation, the breath sound will be lower or absent and the vocal resonance will be lower or absent.

Question 21

What can you see in an x-ray of pleural effusion

Answer 21

It will apear white, as it progresses the costophrenic angle disappears. As the fluid fills the lungs a meniscus will appear (curved upper surface of a liquid in a tube).

Question 22

Pleural effusion- thoracentesis

Answer 22

Aspiration of fluid (removing) can be done to identify cause. This is done under the guidance of ultrasound and you insert the needle between the 7th and 8th rib. You then measure the protein to identify the type of effusion

Question 23

Pleural effusion- Transudate

Answer 23

Pleural effusion caused by an increase in hydrostatic pressure due to venous outflow obstruction. This is caused by congestive heart failure. There will also be a drop in colloid osmotic (oncotic) pressure as not enough protein is made or too much is being lost. This causes the fluid to leak across but the proteins don’t. Most common causes include Heart failure, Hypoalbuminemia, Cirrhosis and Nephrotic syndrome. Less oncotic

Question 24

How to identify pleural effusion caused by Transudate

Answer 24

Light criteria: pleural effusion to serum protein ratio should be <0.5

Question 25

Pleural effusion- Exudate

Answer 25

Inflammation leads to increased permeability and protein and fluid leakage. Most common cause is Pneumonia and malignancy (breast and lung cancer). Large unilateral pleural effusions are probably due to malignancy. More oncotic then transudate

Question 26

How to identify pleural effusion caused by Exudate

Answer 26

Pleural fluid protein vs. serum protein ratio >0.5

Question 27

Types of Pneumothorax

Answer 27

* Primary spontaneous- occurs in health people (typically tall thin men). * Secondary spontaneous- underlying condition (e.g. rupture of bulla in COPD). * Traumatic- penetrating chest trauma (e.g. stab wound). * Latrogneic- follows a procedure (e.g. mechanical ventilation.

Question 28

How does Pneumothorax present

Answer 28

Unilateral pleuritic chest pain with breathlessness and possible cyanosis

Question 29

Examination findings in Pneumothorax

Answer 29

In examination of the affected side there will be reduced chest expansion, decreased or absent breath sounds and hyper-resonance on percussion.

Question 30

Chest x-ray of pneumorothorax

Answer 30

In a chest x-ray the collapse of lung tissue will be visible as the lung recoils and peels away from the chest wall.

Question 31

Treatment of pneumorothorax

Answer 31

It is treated using a chest drain which when inserted into the pleural space can drain the air and fluid.

Question 32

Features of tension pneumothorax

Answer 32

1) Tracheal deviation away from the site. 2) Tachycardia is >135bpm. 3) You get a pulsus paradoxus when there is an abnormally large decrease in stroke volume, systolic blood pressure and pulse wave amplitude during inspiration. The drop in blood pressure is more than 10mmHg. 4) Hypotension and a raised JVP. 5) It is a life threatening condition that requires instant action such as urgent decompression in the 2nd intercostal space. There is a mediastinal shift and signs of respiratory disease.

Question 33

Haemothorax

Answer 33

Presence of frank blood in the pleural space. It can be caused by chest trauma, cancer or a pulmonary embolism.

Question 34

Chylothorax

Answer 34

Presence of lymphatic fluid in the pleural space

Question 35

Empyema

Answer 35

Presence of pus in the pleural space. Secondary to infection, usually pneumonia. Causes prominent systemic features and severe chest pain

Question 36

Pleural Mesothelioma

Answer 36

Malignant mesothelioma affects the mesothelial lining but can also affect the pleura. This tumour rarely metastasises to distant sites and most patients present with locally advanced disease. It has a poor prognosis of approx. 1 year.

Question 37

Signs and symptoms of pleural Mesothelioma

Answer 37

* Breathlessness. * Pleural effusion or pleural thickening * Chest pain is typically dull, diffuse, progressive. * Palpable chest wall * Weight loss, fatigue and fever. * Finger clubbing (related to asbestosis).

Question 38

What causes pleural Mesothelioma

Answer 38

Associated with asbestos in 70-80% of patients, may be many years after exposure of from another family members exposure

Question 39

Pulmonary embolism

Answer 39

When one or more emboli (normally a blood clot) are lodged in and obstruct the pulmonary artery system

Question 40

Risk factors for PE

Answer 40

Significant immobility and surgery

Question 41

Causes of PE

Answer 41

* Emboli originating in the abdominal or axillary veins, or from the right ventricle. * The most common type of emboli is DVT in the lower limbs (80%). * Tumours. * Fat emboli from long bone fractures. * Amniotic fluid-pregnant woman * Sepsis- i.e. infected catheters * Foreign bodies, during IV drug use. * Air- admitted during surgery.

Question 42

Small and medium PE

Answer 42

Small and medium PE may not have any specific signs and symptoms. They may have dyspnoea, tachypnoea (abnormally rapid breathing), pleuritic chest pain or features of DVT. These features are present in most people with a PE even if they don’t have a DVT.

Question 43

Signs and symptoms of PE

Answer 43

Dyspnoea, tachypnoea (rapid breathing), pleuritic chest pain, tachycardia, haemoptysis, syncope, hypotension (systolic BP less than 90 mmHg), crepitations (crackling sound), cough or fever.

Question 44

Treatment for PE

Answer 44

Heparin and anticoagulants

Question 45

PE

Answer 45

If untreated the risk of death is 23-87%, for clinically massive PE the risk of death is 50%. PE is the leading cause of maternal death in the UK

Question 46

In PE when should the patient be admitted to hospital

Answer 46

* The patient is pregnant or given birth within the past 6 weeks. * They have an altered level of consciousness. * Systolic BP of less than 90 mmHg. * Heart rate of more than 130 beats per minute. * Respiratory rate of more than 25 breaths per minute. * Oxygen saturation of less than 91% * Temperature of less than 35 degrees

Question 47

How does lung compliance change in emphysema

Answer 47

Compliance is higher because a lower pressure can cause a higher volume. There is less recoil due to the loss of elastic tissue

Question 48

How does lung compliance change in alveolar fibrosis

Answer 48

The lungs are stiffer and have less compliance as the lung tissue gets replaced by fibrous tissue. A higher pressure causes a lower volume (right shift)

Question 49

Pathway of care- lung cancer

Answer 49

GP -detection Radiologist- diagnosing through investigations (CT scans, biopsy) Multi-disciplinary team (including lung cancer specialist)- discussion of treatment plan Surgeon- surgery to remove cancer Oncologist- chemotherapy May have to refer to palliative care

Question 50

Airway resistance in COPD and asthma

Answer 50

It increases in asthma and COPD, the higher the resistance the harder it is to breathe. In asthma the resistance is reversible, in COPD the resistance is irreversible. In COPD small bronchioles offer the most resistance even though normally they offer the least.

Question 51

Volume/Pressure graph in COPD

Answer 51

In inspiration a higher pressure is needed to increase the volume of the lungs. In expiration there is little reduction in volume as the airways collapse. At low pressure the airways do empty

Question 52

COPD

Answer 52

Persistent respiratory symptoms due to airway obstruction which is not fully reversible. Includes bronchitis and emphysema

Question 53

Emphysema

Answer 53

You get inflammation. There is an increase in elastase and metalloproteinase. Protein and elastin gets broken down and there is damage to tissues and capillaries. Less blood will move into the diffusion barrier. Less gases are able to diffuse across the alveolar membrane. As more tissue gets broken down elastic recoil decreases. You get enlarged alveolar which causes air trapping. There is lung hyperinflation. Air becomes trapped in the lungs as the alveolar membrane breaks down.

Question 54

Risk factors for emphysema

Answer 54

Smoking, toxins, pollutants, Genetics ( a mutation in Alpha1- antitrypsin, which causes its deficiency)

Question 55

Morphology of bronchiectasis

Answer 55

Permanent dilation of bronchi and bronchioles due to inflammation and scarring, usually the lower lobe

Question 56

Symptoms of bronchiectasis

Answer 56

Persistent or recurrent cough and foul-smelling purulent sputum production. Recurrent respiratory infection and Haemoptysis

Question 57

What is bronchiectasis associated with

Answer 57

It is associated with respiratory infection. This causes sustained epithelial injury and hypersecretion of mucus. If you have epithelial injury you are more likely to get chronic Bronchial infection. The lungs then become inflamed. There is a decrease in mucocilliary clearance. There is now permanent airway damage. Often associated with COPD.

Question 58

Respiratory infections which can cause bronchiectasis

Answer 58

Congenital (diffuse)- Cystic fibrosis and Ciliary dysfunction. Acquired (localised)- Pneumonia, TB and Bronchial tumours.

Question 59

How is bronchitis diagnosed

Answer 59

A persistent productive cough for at least three consecutive months in at least two consecutive years

Question 60

Morphology of chronic bronchitis

Answer 60

1) Cilia gets damaged so less mucus is removed. 2) Lumen blockage due to mucus hypersecretion. 3) There is an increase in goblet cells and an increase in mucus gland size and activity. 4) Increase in smooth muscle and bronchospasm

Question 61

Where do you tend to get emphysema

Answer 61

In the upper two thirds of the lungs

Question 62

Hyperinflation of lungs

Answer 62

Associated with air trapping as there is a bigger lung volume

Question 63

Signs of emphysema

Answer 63

Barrel chest and progressive dyspnoea

Question 64

Why do we see the signs and symptoms of chronic bronchitis

Answer 64

1) Mucus hypersecretion- productive cough 2) Bronchoconstriction- wheezing 3) Decrease in pO2- cyanosis 4) Alveolar hypoxia- pulmonary hypertension 5) Right sided heart failure- Cr pulmonale Unlikely to have a fever or dullness to percusion.

Question 65

Chronic bronchitis- bronchial spasm

Answer 65

There will be a degree of Bronchiolitis as there is inflammation of the Bronchioles. This causes bronchiole spasm which reduced the area of the lumen.

Question 66

Interstitial lung disease (parenchymal lung disease)

Answer 66

A heterogeneous group of restrictive lung disease. An initial injury to the epithelium or endothelium leads to diffuse chronic inflammation and fibrosis with end stage honeycomb appearance. Lung volume and compliance decreases. In pulmonary fibrosis a trigger causes repeated inflammation. This causes the release of cytokines which promote fibrogenesis. Eventually this cycle leads to the dilation of airways.

Question 67

Interstitial lung disease- fibroblasts

Answer 67

Pulmonary fibrosis is a pathological feature of interstitial lung disease. The fibroblasts lay down fibrous tissue, this makes the tissue stiffer reducing compliance.

Question 68

Pulmonary fibrosis- Pathogenesis

Answer 68

1) Inflammation causes leukocyte induced cytokine release i.e. from inhalation of dust, drugs or idiopathic conditions. 2) Stimulation of fibrosis via increased fibroblasts 3) Alveolar epithelial cell damage. 4) Decreased surface area for gas transfusion. 5) Increased stiffness and decreased compliance

Question 69

Types of interstitial lung disease

Answer 69

Huge range of conditions linked by pulmonary fibrosis

Question 70

What can cause interstitial lung disease

Answer 70

1) Occupation/Environment- asbestosis, Coal miners pneumconiosis. 2) Hobbies- wine making, glass blowing. 3) Pets- pigeon fancier's lung 4) Past medical history- connective tissue diseases, lupus, sarcoidosis, rheumatoid arthiritis. 5) Drugs- Amiodarone (heart medication), Nitrofurantoin (antibiotic), Methotrexate.

Question 71

Idiopathic pulmonary fibrosis

Answer 71

Accounts for 15-25% of chronic interstitial lung disease where the cause of inflammation is unknown

Question 72

Types of restrictive lung disease

Answer 72

Interstitial lung disease

Question 73

Types of obstructive lung disease

Answer 73

COPD, asthma and bronchiectasis

Question 74

Obstructive lung disease

Answer 74

``` Limitation of airflow due to obstruction Total lung capacity- Normal Forced vital capacity (FVC)- Normal Expiratory flow (FEV1)- decreased FEV1:FVC ratio- decreased ```

Question 75

Restrictive lung disease

Answer 75

``` Fibrosis reduces ability of parenchyma to expand Total lung capacity- decreased Forced vital capacity (FVC)- decreased Expiratory flow (FEV1)- decreased FEV1:FVC ratio- normal ```

Question 76

Vital capacity (VC)

Answer 76

The greatest volume you can expire starting from a position of maximal inspiration = IRV + VT + ERV = 4600 ml. The vital capacity is affected by posture, is proportional to height, decreases with age and is generally higher in males than females.

Question 77

Tidal volume (VT)

Answer 77

The volume breathed in or out at rest (500ml)

Question 78

Inspiratory Reserve Volume (IRV)

Answer 78

The volume of air that can be inspired in addition to normal resting (tidal) inspiration = 3000 ml.

Question 79

Expiratory Reserve Volume (ERV)

Answer 79

The volume of air that can be expired following a normal (tidal) expiration = 1100 ml.

Question 80

Residual volume (RV)

Answer 80

The volume of air remaining in the lungs at the end of a maximal expiration (i.e. it is the air that cannot be expired) = 1200 ml.

Question 81

Functional residual capacity (FRC)

Answer 81

The volume of air remaining in the lungs at the end of a normal resting expiration = ERV + RV = 2300 ml.

Question 82

Forced Expiratory Volume in one second (FEV1)

Answer 82

The greatest volume of air which the subject can expire in the first second starting from the position of maximal inspiration and expiring as hard and fast as possible.

Question 83

Forced vital capacity (FVC)

Answer 83

The greatest volume of air the subject can expire starting from a position of maximal inspiration and expiring as hard and fast as possible

Question 84

Peak expiratory flow (PEF)

Answer 84

The maximum flow rate during forced expiration

Question 85

FVC and FEV1 in restrictive

Answer 85

FEV1 - <80% predicted FVC- <80% predicted FEV1/FVC ratio- >0.7

Question 86

FVC and FEV1 in obstructive disease

Answer 86

FEV1- <80% predicted FVC- unchanged, drops in severe disease FEV1/FVC ratio- <0.7

Question 87

Classification gained from FEV1 % predicted value:

Answer 87

* FEV1 80% or above of predicted: Mild disease * FEV1 50-79 % of predicted: Moderate disease * FEV1 30-49% of predicted: Severe disease * FEV1< 30% of predicted: V. severe disease