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Flashcards in CSIM lungs Deck (110):
1

three reasons you see a diffusely abnormal CXR?

1. impaired gas transfer
2. reduced lung volume
3. restrictive ventilatory function (stiffened or shrunken lungs)

2

ratio of FEV1 : FVC in an obstructive picture?

FEV1 < FVC
< 70% is diagnostic

3

in obstructive disease why is there gas trapping and what symptom does this cause?

bronchiole collapse on expiration
difficult to exhale completely

4

when is bronchiolitis seen in adults?

transplants
rheumatoid disease
idiopathic
chemical exposure

5

Lung biopsy - focal bronchiolar fibrosis and fibroblast proliferation
most likely diagnosis?

bronchiolitis

6

define bronchioles

branches of a bronchus that are smaller than 2mm and have NO cartilage

7

what is hypersensitivity pneumonitis?

AKA extrinsic allergic alveolitis - inflammation of the alveolar due to inhaled dust particles

8

define pneumoconiosis and give examples

lung disease from mineral dust
it can be fibrogenic or non-fibrogenic

silicosis
coal works pneumoconiosis
asbestosis

those are all FIBROGENIC

9

who is at risk of silicosis

working with:
concrete
sand blasting
artificial stone

10

why is sand not dangerous?

silica only dangerous when an unnatural force is applied to it to make it smaller

11

characteristic finding on biopsy in silicosis?

dense fibrosis with bi-refringent particles

12

characteristic finding on biopsy in coal miners pneumoconiosis

Dust accumulation around terminal bronchioles with fibrosis

13

light exposure to asbestos is associated with what?

pleural disease (mesothelioma, pleural plaques /fibrosis )

need heavy exposure to affect lungs

14

what is the radiological marker of asbestos exposure?

pleural plaques - these will be asymptomatic

15

whos at risk of siderosis and what is it?

welders - this is a non-fibrogenic pneumoconiosis

16

what do pleural plaques look like on CXR?

holly leaves (they dont really)

17

most common complication of pleural plaques?

benign diffuse pleural thickening -> fluid accumulation -> breathlessness

18

two things that can help differentiate ILD from asbestosis?

IDL :
dont get plaques
can get clubbing ( never clubbing in asbestosis)

19

when does malignant mesothelioma present?

~30 yrs post exposure

20

why is there a reduced lung volume in malignant mesothelioma ?

diffuse pleural thickening

21

what are TLCO and KCO?

they are both measurements of the transfer factor of CO
they are used to assess the integrity of the gas–exchanging part of the lung

TLCO = transfer factor for the lung for carbon monoxide i.e. Total diffusing capacity for the lung
KCO = transfer coefficent i.e. Diffusing capacity of the lung per unit volume, standardised for alveolar volume (VA)

22

what systemic symptom is there in extrinsic allergic alveolitis?

shivers after exposure due to immunological response

23

4 causes of L tracheal deviation?

1. right tension PT
2. L lobar collapse
3. goitre
4. right pleural effusion

24

5 causes of unilaeral pleural effusion

lung cancer
mesothelioma
TB
pneumonia
asbestosis

25

how does asbestosis cause pleural effusion?

diffuse pleural irritation causes the blood vessels to be leaking

26

how is a pleural tap made safer?

US guidence

27

what tests are done on pleural fluid?

bio chem: protein, glucose, pH, LDH (lactate dehydrogenase)

culture and sensitivity

TB test

28

sensitivity and specificity in cytological exam of pleural fluid?

looking for cancer cells:
if present then definitely cancer
not always present in cancer
i.e. specific not sensitive

29

differences on CT between benign and malignant pleural disease

malignant mesothelioma: lumpy and affects the whole way round the lung including mediastinum

benign: just thicker but still smooth

30

what screening would you do for mesothelioma in people who are a high risk?

none because there is no treatment :(

31

commonest cause of new onset breathlessness before 32?

asthma

32

some occupations that increase risk of astma

farming
painting
plastics
cleaning

33

what type of allergen react with specific IgE antibodies?

high molecular weight allergens e.g. flour

34

when does occupational asthma occur?

normally within a year of new work after a latent interval of symptomatic exposure

35

when in the day is occupational asthma worst?

at work and evening / nighttime

36

how much asthma is occupational

1/6 cases

37

on going exposure to occupational allergens can lead to what?

progressive and permanent asthma

38

what immunological investigations can be done to help diagnose asthma?

RAST: specific IgE
skin prick test

39

what is the airway responsiveness test and when is it used?

inhale bronchoconstrictor (histamine) and see how much the airway narrows
asthmatics narrow more

40

4 types of investigation in diagnosing occupational asthma

immunological
serial PEF
serial airway responsiveness test
inhalation challenge (inhale allergen)

diagnosis on Hx alone is unreliable

41

who's duty to report occupational hazards?

the employer

42

what is a RAST test and how is that different to a skin prick test?

Radioallergosorbent test - blood test for specific IgE antibodies to determine the substance to which a person is allergic to

skin prick test looks at how the skin reacts to different substances

43

define chronic bronchitis

Chronic or recurrent excessive mucus secretion in the bronchial tree due to irritation

productive cough lasting longer than 3 months on two consecutive years

44

define emphysema

An increase beyond the normal in the size of the air spaces distal to the terminal bronchiole accompanied by destruction of their walls and without obvious fibrosis

basically destruction of the alveolar walls increases the size of the air spaces

45

which drug given in COPD can be considered a disease modifying drug and why?

regular tiotropium leads to reduced hospitalizations due to exacerbations

46

treatment pathway for COPD

smoking cessation
flu jab

SABA
LAMA
ICS / LABA

pulmonary rehab

47

how can anxiety in COPD be addressed?

CBT

48

define cor pulmonale

right side HF caused by lung disease

49

cor pulmonale pathophys. ?

in emphysema all parts of the lung are hypoxic so there is vasoconstriction over the whole lung (an attempt to get blood to parts that ARE well ventilated)
this means the heart is effectively pumping against a 'closed door'

50

how is V/Q matching suppose to work?

vasoconstriction in areas of the lung that have poor ventilation means that more blood gets to the better ventilated parts

51

who is LTOT indicated in?

PaO2 < 7.3 when stable
OR
PaO2 <8 AND ONE OF
- secondary polycaethemia
- peripheral oedema
- pulmonary hypertension
- nocturnal hypoxaemia

52

define hypoventilation?

abnormal breathing leads to insufficient ventilation causing hypercapnia

53

how does COPD cause hypoventilation?

increased dead space in the lungs: breaking down the alveolar walls

reduced perfusion:
- due to compression (due to overinflated lungs) of capillaries
- destruction of pulmonary vasculature

54

define type 2 resp failure

low O2
high CO2
ACIDOTIC

55

Mx for type 2 resp failure?

O2 aiming for 88-92% (chemoreceptor for CO2 does not stimulate patient to breath so keep them a little bit hypoxic)

steroids, NEBs and maybe abx

consider non invasive ventilation (reduced mortality by 50%)

56

what is obstructive sleep apnoea?

upper airway narrowing provoked by sleep -> sleep fragmentation -> significant daytime symptoms

57

pathophys of OSA?

dilator muscles (mainly pharyngeal dilator) fail to maintain airway patency so repeated arousal is needed to reactivate dilator.
some narrowing is normal, it can be excessive when:
- sedatives e.g. alcohol
- NM disorder effecting the pharyngeal muscle
- mass overloading

58

prevalence of OSA in the UK?

0.5 -1 %

59

why is OSA more common in men?

fat distribution

60

clinical features of OSA?

from most common to least:

snoring with periods of apnoea
excessive sleepiness / poor concentration
loss of libido
nocturia
unrefreshing sleep
nocturnal sweating

61

exam findings in OSA?

pink (polycythaemia)
obese
associated with acromegaly
large neck circumference

62

what score can be used to assess tiredness and whats an abnormal score?

Epworth
<9 is abnormal

63

how does OSA lead to HF?

cor pulmonale due to hypoxia

64

how does cpap work?

delivers constant pressure to splint airway open

65

pro and cons of cpap?

highly effective
poorly tolerated (dedicated cpap nurse for education)

66

who must patients inform about OSA?

DVLA ( only allowed to drive after 3 months of compliance with treatment)

67

best investigation for assessing OSA?

polysomnogram

68

3 investigations in OSA?

ABG
pulmonary function test
CXR

also always do a neuro-exam

69

in ILD, what is the interstitium?

the cells between the basement membrane of the alveolar and other alveolar and between the alveolar and capillaries

70

if ILD is suspected, what questions do you need to ask yourself before tx?

is there an underlying cause?
?sarcoidosis
?acute/ chronic hypersensitivity pneumonitis

71

what are the possible underlying causes of ILD?

connective tissue disease
drugs
organic dust
inorganic dust

72

define pneumonia

inflammation of the alveolar

73

two most common connective tissue diseases associated with ILD?

RA (low percecntage but high burden due to amount of RA)
systemic sclerosis (high percentage but low burden as it's rare)

74

common drugs that cause ILD?

methotrexate (DMARD for RA)
amiodarone (for arrhythmias)
nitrofurantoin (for UTIs)
bleomycin (for cancer)
radiotherapy

75

inorganic dust that cause ILD?

asbestos, coal ( technically organic), silica

76

organic dust that causes ILD?

farmer's lung
pigeon fancier's lung
mould in the house

77

Raynaud's phenomenon is typical of what?

connective tissue disease

78

what questions to ask to rule out CT disease in ILD?

cold/ pale hands
dry eyes / mouth
muscle pain
joint pain

79

reflux is common in what cause of ILD?

systemic sclerosis

80

sound of lungs in ILD?

velcro crackles at base of lungs

81

what do squeaks on inspiration suggest?

hypersensitivity pneumonitis

82

Ix in suspected ILD?

CXR
CT

83

appearance of ILD on CXR?

shaggy boarders to the lungs where there has been thickening of the interlobular membranes

84

what imaging is best in ILD and why?

CT: 1 mm helical scan prone and supine, on insiration and expiration
CXR is very non-specific

85

in ILD how can you tell fluid from interstitial disease on CT?

do the scan PRONE and SUPINE, if the suspicious area disappears when the patient is turned over then it's just fluid

86

why do an expiratory CT scan in ILD?

in ILD: on expiration the bronchioles will snap shut too early and this will lead to a mosaic pattern (air trapping)

87

define usual interstitial pneumonia

this is the histological hallmark of IPF:
normal healthy alveolar next to destroyed lung

this is also seen on CT

88

what is it that restricts the lung function on ILD?

band of fibrosis inhibits elastic quality of lung

89

when is ILD usually diagnosed?

72 yrs

90

classical presentation of ILD?

progressive breathlessness and dry cough

91

what is the typical prognosis of ILD?

poor but very varable

92

blood tests in ILD?

Autoantibodies
- RhF/anti-CCP,
- extractable nuclear antigens (anti-Ro/La/Jo-1)
- Anti-dsDNA,
- ANCA

Angiotensin converting enzyme (ACE)/calcium (sarcoid)

Precipitating antibodies (hypersensitivity pneumonitis)

93

what is sarcoidosis?

Chronic, multi-system granulomatous disease
of unknown aetiology

94

diagnosis of sarcoidosis?

diagnosed by characteristic features:
- bilateral lymphadenopathy on the neck

rarely biopsied

95

what are the three component to pulmonary function tests?

spirometry: FEV1 , FVC
lung volumes: TLC, RV
transfer factor: TLCO, KCO

96

what is the disadvantage of the transfer factor test?

have to be able to hold breath for 10s , lots of patients cant do that

97

draw out flow-vol. loops for normal lungs, large airway obstuctioin and small airway obstruction

normal - upside down V
large airway disease- looks like a BURGER
small diffuse airway disease - looks like a church and steeple

98

on a flow-vol graph:
what is the point where the line crosses the x axis?
what is the top of the curve?

FVC
Peak expiratary flow

99

how can spirometry be normal in asthma patients?

asthma is a variable and reversible disease

100

what will TLC and RV look like in an obstructive picture?

TLC -raised due to chronic hyper inflation
RV - raised due to gas trapping

101

RV in restrictive picture

falls / same

102

what things decrease the TLCO

Ventilation Perfusion Mismatch - common in many lung diseases
Reduction in the area of alveolar-capillary membrane - e.g. emphysema
Increased thickness of alveolar-capillary membrane - e.g. pulmonary fibrosis
Pulmonary Blood flow - e.g. pulmonary hypertension
Haemoglobin concentration - e.g. anaemia leads to a decrease in TLCO

103

in a healthy person with one lung what will the KLO and TLCO be?

KLO - 100%
TLCO - 50%

104

TCLO and KCO in asthma?

both normal

105

TLCO and KCO in COPD?

both decreased

106

TLCO and KCO in ILD?

both decreased

107

in extra-thoracic restrictive conditions e.g. obesity what will the KCO and TLCO be?

TLCO - decreased
KCO - can be increased due to lung working even harder to keep up

108

what imaging is most useful in ILD?

high resolution CT - more detail in each picture but less frequently taken (every 10mm ish)

109

what 5 conditions can asbestos cause?

1. pleural plaques - asymptomatic
2. pleural fibrosis - benign breathlessness
3. mesothelioma

4. lung cancer
5. asbestosis (pulmonary fibrosis caused by asbestos)

110

which conditions require heavy exposure to asbestos?

lung cancer and asbestosis