Lung Pathology Flashcards
(264 cards)
1
Q
WHAT ARE THE CAUSES OF OBSTRUCTIVE LUNG DISEASE?
A
- Asthma
- COPD
- Bronchiectasis
- Bronchiolitis obliterans
2
Q
What are the causes of restrictive lung diseases?
A
- Pulmonary fibrosis
- Asbestosis
- Sarcoidosis
- Acute respiratory distress syndrome
- Infant respiratory distress syndrome
- Kyphoscoliosis e.g. ankylosing spondylitis
- Neuromuscular disorders
- Severe obesity
3
Q
WHAT IS COPD?
A
Collection of lung diseases that cause IRREVERSIBLE obstruction to airflow out of the lungs.
Umbrella term for two diseases chronic bronchitis and emphysema
4
Q
What are the causes of COPD?
A
- Cigarette smoking. (MAINLY)
- Alpha-1-antitrypsin deficiency
- Coal dust exposure
- Cadmium toxicity
5
Q
What are the non-pharmocological management options of COPD?
A
- Stop smoking
- Physical activity
-
Vaccinations
- Annaul Flu
- ONE- OFF Pneumococcal
- Pertussis
6
Q
What is the pharmocological management options of COPD?
A
- SABA + SAMA is first line
- Asthmatic features?
- Any previous, secure diagnosis of asthma or of atopy
- A higher blood eosinophil count - note that NICE recommend a full blood count for all patients as part of the work-up
- Substantial variation in FEV1 over time (at least 400 ml)
- Substantial diurnal variation in peak expiratory flow (at least 20%)
- No - SABA as required, LABA + LAMA regularly
- Yes - SABA or SAMA as required, LABA + ICS regularly
- SABA as required, LABA + LAMA + ICS
7
Q
What are the complications of COPD?
A
- Pneumothorax
- Cor pulmoale
- Acute exaccerbations
- Infection
8
Q
Under what circumstances is long term oxygen therapy considered in COPD?
A
COPD - LTOT if pO2 of 7.3 - 8 kPa AND one of the following:
- Secondary polycythaemia
- Peripheral oedema
- Pulmonary hypertension
9
Q
What are the different stages of COPD?
A
- Stage 1 (Mild) as his FEV1 is >80% of what is expected.
- Stage 2 (Moderate) is an FEV1 which is 50-79% of the predicted value.
- Stage 3 (Severe) is an FEV1 which is 30-49% of the predicted value.
- Stage 4 (Very severe) is an FEV1 <30% of the predicted value
Post-bronchodilator FEV1/FVC is <0.7
10
Q
What should be given to COPD patients who have recurrent exaccerbations?
A
- Home supply of prednisolone and an antibitoic
11
Q
What are the investigations for COPD?
A
- Post-bronchodilator spirometry to demonstrate airflow obstruction: FEV1/FVC ratio less than 70%
- Chest x-ray
- Hyperinflation
- Bullae: if large, may sometimes mimic a pneumothorax
- Flat hemidiaphragm
- Also important to exclude lung cancer
- Full blood count: exclude secondary polycythaemia
- Body mass index (BMI) calculation
12
Q
WHAT IS CHRONIC BRONCHITIS?
https://www.youtube.com/watch?v=Y29bTzKK_P8
A
Bronchial tubes inflammation
IRREVERSIBLE
13
Q
What is chronic bronchitis defined as?
A
Cough, sputum production on most days for 3 months of 2 successive yrs
14
Q
How can pulmonary hypertension happen in chronic bronchitis?
A
Decreased gas exchange causign vasocontriction
Large proportion
Increases pulminary vascular resistance
Develops pulmonary hypertension
Right side of heart enlarges
Cor pulmonale
15
Q
How can a person become cyanosed in chronic bronchitis?
A
CO2 trapped in alveoli takes up more space
O2 unable to fill alveoli
Less goes into the blood
More CO2 in alveoli means less CO2 can come out the blood
More CO2 in blood less O2
16
Q
What is the reid index?
A
Size of the mucinus glands relative to the rest of the layers
17
Q
Who does chronic bronchitis affect?
A
Affects middle aged heavy smokers
Some following pollution chronically
Recurrent low grade bronchial infections
18
Q
What are the symptoms of chronic bronchitis?
A
- Dyspnea
- Wheeze
- Crackles
- Cough
- Production of mucus (sputum)
19
Q
What are the signs of chronic bronchitis?
A
- Hypoxemia
-
Hypercapnia
- These cause cyanosis
- Pulmonary hypertension
-
Result of low O2
- Causing cor pulmonale
- Tachypnoea
- Use of accessory muscles
- Hyperinflation
20
Q
What are the investigations for chronic bronchitis?
A
- Spirometry
-
Chest X-ray
- Rule out other lung conditions, such as pneumonia.
-
ECG
- Right venticle and atria enlargment (cor pulmonale)
- Sputum (bacteria).
- ABG: PaO2 decrease ± hypercapnia
21
Q
WHAT IS ACUTE BRONCHITIS?
A
Acute bronchitis is a type of chest infection which is usually self-limiting in nature.
It is a result of inflammation of the trachea and major bronchi and is therefore associated with oedematous large airways and the production of sputum
22
Q
What are the features of acute bronchitis?
A
- cough: may or may not be productive
- sore throat
- rhinorrhoea
- wheeze
23
Q
How do you differentitate acute bronchitis from pneumonia?
A
- History: Sputum, wheeze, breathlessness may be absent in acute bronchitis whereas at least one tends to be present in pneumonia.
- Examination: No other focal chest signs (dullness to percussion, crepitations, bronchial breathing) in acute bronchitis other than wheeze. Moreover, systemic features (malaise, myalgia, and fever) may be absent in acute bronchitis, whereas they tend to be present in pneumonia.
24
Q
What are the investigations for acute bronchitis?
A
- acute bronchitis is typically a clinical diagnosis
- however, if CRP testing is available this may be used to guide whether antibiotic therapy is indicated
25
What is the management for acute bronchitis?
1. analgesia
2. good fluid intake
3. consider antibiotic therapy if patients:
* are systemically very unwell
* have pre-existing co-morbidities
* have a CRP of 20-100mg/L (offer delayed prescription) or a CRP \>100mg/L (offer antibiotics immediately)
4. NICE Clinical Knowledge Summaries/BNF currently recommend doxycycline first-line
* doxycycline cannot be used in children or pregnant women
* alternatives include amoxicillin
26
WHAT IS EMPHYSEMA?
https://www.youtube.com/watch?v=TEuSV\_7gWA8
Enlargement of alveolar airspaces with destruction of elastin in walls.
27
What happens when the alveoli becomes irritated by smoke?
What does this do?
What happens when exhaling?
1. Triggers an inflammatory response, immune cells come in
2. Releasing inflammatory mediators (Proteases, Collangenases)
3. Breaks down the collagen and elastin in the alveoli wall
**_Bernoulli principle_**
1. Exhalation of air has a lower pressure and pulls the airway inwards, ormal airways can withstand this
2. Emphysema airways have less elastin and collagen therefore collapse
**_Leads to air trapping_**
28
What happens when air comes into emphysema lungs?
Lungs are more compliant
Lungs overinflate
29
What happens in alpha-1 antitrypsin deficiency?
1. Macrophages produce proteases
* Helps clear debris
* Can damage tissue
2. Alpha-1 antitrypsin is a protease inhibitor
3. Protects against damage
4. Deficiency means proteases can damage lungs
30
What are the oxygen and carbon dioxide levels in emphysema?
‘pure’ emphysema appears with reduced PaCO2 and normal PaO2 at rest due to overventillation (‘pink puffers’)
31
What are the symptoms of emphysema?
Dyspnea - shortness of breath
Exhaling through pursed lips to keep lungs inflated
Cough - sputum
Weight loss due to metabolic demands
1/3 of lung capacity is destroyed before symptoms
32
What are the signs of emphysema?
1. Barrel chest - overinflated chest on x-ray
2. Flattened diaphragm
3. Pulmonary hypertension
4. Right heart failure
33
What are the investigations for emphysema?
1. **Pulmonary/Lung Function tests**
* Spirometry is the best test to detect airflow limitation and obstruction.
2. **Blood tests**
* Hb level increase secondary polycythaemia.
3. **Chest x-ray**
* This helps to show hyperexpansion of the lungs.
4. **ECG or Echocardiogram**
* Right heart failure (a complication of emphysema and COPD).
5. **Blood gases**
* Normal, later stages of disease, low oxygen and high carbon dioxide levels.
6. **High resolution CT**
* Best test for detecting emphysema and bullae (big dilated air spaces).
34
WHAT IS AN EXACERBATION OF COPD DEFINED AS?
An exacerbation can be defined as a sustained worsening of the patient's symptoms from his or her usual stable state that is beyond normal day-to-day variations, is acute in onset and requires additional therapy
35
What are the most likely causative organism in an exacerbation of COPD?
1. H. influenzae - MOST COMMON
2. S. pneumoniae
3. Moraxella cartarrhalis
36
What are the clinical features of an exacerbation of COPD?
1. worsening of previous stable condition
2. increased wheeze
3. increased dyspnoea
4. increased sputum volume
5. increased sputum purulence
6. chest tightness
7. fluid retention
8. reduced exercise tolerance
9. increased fatigue
37
What are the investigations for an exacerbation of COPD?
1. **Many clinical diagnosis**
2. **Sputum samples**
3. **Pulse oximetry** is of value if there are clinical features of a severe exacerbation
4. **X-ray**
5. **ABG**
6. **ECG**
7. **FBC**
38
What is the treatment for an exacerbation of COPD?
1. Increase B**ronchodilator** use and consider giving via a N**ebuliser**
2. Give **Prednisolone** 30 mg daily for 5 days
3. Oral antibiotics **IF PURULENT SPUTUM**
* First-line: **Amoxicillin** or **clarithromycin** or **doxycycline**
39
When should NIV be considered for acute exaccerbation of COPD?
1. Respiratory acidosis
* **PaCO2 \> 6kPa**
* **pH \<7.35 ≥7.26**
2. Persists despite immediate maximum standard medical treatment
40
What is given for prophylaxis against exaccerbations in COPD?
Azithromycin 250mg 3 times a week
41
WHAT IS BRONCHIECTASIS?
https://www.youtube.com/watch?v=rTcVPHszU5E
Irreversible dilation of the bronchioles
42
What are the causes of bronchiectasis?
1. **Congenital**
* Cystic fibrosis (CF);
2. **Post-infection**
* TB
* HIV
3. **Immune deficiency**
* Selevtive IgA, hypogammaglobulinaemia
4. **Other**
* Bronchial obstruction (tumour, foreign body)
43
What is the pathology of bronchiectasis?
Infection and imparied drainage
Activates neutrophilic proteases and cytokines causing inflammation
Increaed mucus and increased stagnent bacteria
Cycle starts again
44
What are the signs and symptoms of bronchiectasis?
1. Chronic cough - foul smelling sputum
2. Flecked with blood sometimes.
3. Finger clubbing
4. Coarse inspiratory crepitations.
5. Wheeze
45
What are the tests for bronchiectasis?
1. **Sputum culture**
2. **Chest X-Ray**
* Cystic shadows, thickened bronchial walls
3. **HRCT chest**
* To assess extent and distribution of disease.
4. **Spirometry**
* Obstructive
46
What is the management for bronchiectasis?
1. Stop smoking
2. Airway clearance exercises
3. Bronchodilators
4. Corticosteroids
5. **Antibiotics - if infective cause**
* Amoxicillin
6. **Surgery in selected cases**
* Disease confined to one lobe
47
What are the complications with bronchiectasis?
Pneumonia
Emphysema
Septicaemia
Amyloid formation.
48
WHAT IS ALPHA-1 ANTITRYPSIN DEFICIENCY?
A deficiency in alpha-1 antitrypsin
49
What does alpha-1 antitryspin do?
What is the gene that codes for it?
What chromosome is it on?
Inactivates elastase (a protease)
SERPINA1
Long arm of chromosome 14
50
When would you favour alpha 1-antitryspin deficiency as a dignosis?
1. Never smoked
2. Young
3. **Lower lobes affected**
51
What are the symptoms of alpha-1 antitrypsin deficiency?
1. Shortness of breath
2. Wheezing
3. Mucus production
4. Chronic cough
**_Cirrhosis_**
1. Inability to make coagulation factors
2. Build up of toxins
52
What investigations are done for alpha-1 antitrypsin deficiency?
How do you diagnose a child in utero with this?
1. **Bloods**
* A1AT low
2. **Biopsy**
* Liver - Periodic-acid shiff stain
3. **Spirometry**
* Obstructive picture
4. **Diagnose a child**
* Amniocentesis
53
What is the treatment of alpha-1 antitrypsin deficiency?
1. No smoking
2. **Supportive**
* Bronchodilators, physiotherapy
3. Intravenous alpha1-antitrypsin protein concentrates
4. **Surgery**
* **Lung volume reduction surgery**
* Lung transplantation
54
WHAT ARE INTERSTITIAL LUNG DISEASES?
Disease of the alveoli primarily
Scarring
Fibrosis
55
What are some causes of interstitial lung disease?
**Congenital**
Neurofibromatosis
Tuberous sclerosis
**Chemical or dust inhalation**
Organic dusts e.g. moulds, avian proteins
Mineral dusts e.g. silica, coal dust, asbestos
**Unknown causes:**
Idiopathic haemosiderosis
Sarcoidosis
56
What are the symptoms of interstitial lung diseases?
1. Dry cough
2. Digital clubing
3. Diffuse inspiratory crackles
4. Dysponea
57
What can acute interstitial lung diseases cause?
Acute respiratory distress syndrome
58
WHAT ARE SOME CAUSES OF ACUTE RESPIRATORY DISTRESS?
1. Pancreatitis
2. Shock
3. Trauma
4. Infections
5. Gas inhalation
6. Narcotic abuse
59
What are the symptoms of acute respiratory distress syndrome?
1. Tachypnoea
2. Dyspnoea
3. Pulmonary oedema
60
WHAT IS PNEUMOCONIOSIS?
Lung disease caused by inhaled dust Organic or inorganic dust (mineral)
61
What happens in coal workers' pneumoconiosis?
Coal is ingested by alveolar macrophages (dust cells)
They aggregate around bronchioles
The consequences vary from trivial to lethal.
62
WHAT IS RHEUMATOID ARTHRITIS INTERSTITIAL LUNG DISEASE?
Rheumatoid arthritis interstitial lung disease (RA-ILD) is increasingly recognised and is clinically significant in up to 5% of patients with RA
63
What are the investigations for rheumaotid arthritis interstitial lung disease?
1. Pulmonary function testing
2. High resolution CT
64
What is the treatment for rheumatoid arthritis interstitial lung disease?
**High-dose corticosteroids**
Prednisolone
**Immunosuppresants**
Azathioprine
65
What is Caplan's syndrome?
The association between rheumatoid arthritis, pneumoconiosis, and pulmonary rheumatoid nodules.
66
How do you treat coal workers pneumoconiosis?
Avoid exposure to coal dust
Treat co-existing chronic bronchitis
67
WHAT IS ASBESTOSIS?
Pneumoconiosis caused by inhalation of asbestos fibres, classically causing a chronic, diffuse, interstitial fibrosis of the lun
68
What is asbestosis caused by?
Inhaltion of asbestos.
69
What are the features of asbestosis?
Similar to other fibrotic lung diseases with progressive dyspnoea, clubbing, and fine end-inspiratory crackles.
Also causes pleural plaques, increased risk of bronchial adenocarcinoma and mesothelioma.
70
What are the investigations for asbestosis?
**Chest X-ray**
Diffuse bilateral shadowing, honeycomb lung. There may be pleural plaques which are an indicator of previous exposure to asbestos
**Lung function tests**
Restrictive
71
What is the management of asbestosis?
Symptomatic.
Patients are often eligible for compensation through the UK Industrial Injuries Act.
72
WHAT IS EXTRINSIC ALLERGIC ALVEOLITIS?
https://www.youtube.com/watch?v=PIuj6XiMlps
Inflammation of the alveoli due to an extrinsic allergen of known type
73
What are the differnt types of extrinsic allergic alveolitis?
1. **Bird fanciers' lung**
* Avian proteins from bird droppings
2. **Farmers lung**
* Spores of Saccharopolyspora rectivirgula from wet hay (formerly Micropolyspora faeni)
3. **Malt workers' lung**
* Aspergillus clavatus
4. **Mushroom workers' lung**
* Thermophilic actinomycetes\*
74
What is the pathology of EAA?
What type of sensitivity is it?
Allergens comes in
Irritates alveoli and activates neutrophils
Releases inflammatory cytokines
Cascade leads to B cell antibody prodction
Complexes form
TYPE 3
75
What are the two durations of EEA?
Acute (few hours after only inflammation)
Chronic (fibrosis)
76
What is seen in chronic that is not seen in acute EAA?
Granulomas
Non-caseating
Macrophages fuse with eachother making granulomas
77
What are the symptoms of extrinsic allergic alveolitis?
1. **Acute (occurs 4-8 hrs after exposure)**
* Dyspnoea
* Dry cough
* Fever
2. **Chronic (occurs weeks-months after exposure)**
* Lethargy
* Dyspnoea
* Productive cough
* Anorexia and weight loss
78
What are the tests for extrinsic allergic alveolitis?
1. **CXR**
* Upper-zone mottling/consolidation
* Honeycombing sometimes
2. **Blood**
* FBC (neutrophilia) but NO esosinophilia
* ESR increase; ABGS; positive serum precipitins (indicate exposure only).
3. **Lung function tests**
* Restrictive defect; reduced gas transfer during acute attacks.
79
What are the management options for extrinsic alergic alveolitis?
1. Remove allergen
2. O2
3. Oral prednisolone
80
What is the difference between asthma and EAA?
**_Asthma_**
Obstructive
Larger airways
Type 1 allergic
**_EAA_**
Restrictive
Smaller airways
Type 3 and 4 allergic
81
WHAT IS SARCOIDOSIS?
https://www.youtube.com/watch?v=D-ahTqbqnqE
Granulomatous disease affecting mainly the lungs, but also lymph nodes in a greater frequency.
82
What type of granuloma is sarcoidosis?
Non-ceasiating granulomatous disease
83
What is the epidemology of sarcoidosis?
1. African-americans
2. Women more than men
3. Under 40 years of age
4. Non smokers
84
What is the cause of sarcoidsis?
What cells are disregulated?
Unknown
Disregulation of CD4 cells
85
What are the pulmonary symptoms of sarcoidosis?
4 D's!
Dry cough
Digital clubbing
Dyspnoea
Diffuse inspiatory crackles
86
What are the non-pulmonary symptoms of sarcoidosis?
1. Skin – erythema nodosum
2. Arthritis - esp. of feet, hands
3. Cardiac– heart block, VT, heart failure
4. Ocular– anterior uveitis, can lead to blindness
5. Intracranial (brain) – chronic meningitis, seizures, neuropathy
6. Derangement of liver and renal function – hepatic granuloma (70% patients), hypercalcaemia(
87
What are the tests for sarcoidosis?
1. **Tissue biopsy**
* Diagnostic non-caseating granulomatas
2. **X-ray**
* Enlarged lymph nodes
3. **24h urine**
* Ca2+ increase.
4. **Blood**
* Increased ESR, lymphopenia, LFT incerease,
* Serum ACE increase
* Increased Ca2+
88
What is the management of sarcoidosis?
1. **Nothing usually**
2. **Indications for steroids**
* Patients with chest x-ray stage 2 or 3 disease who are symptomatic. Patients with asymptomatic and stable stage 2 or 3 disease who have only mildly abnormal lung function do not require treatment
* Hypercalcaemia
* Eye, heart or neuro involvement
89
What does facial rash (lupus pernio) plus lymphadenopathy indicate?
Sarcoidosis
90
What is an acute version of sarcoidosis called?
Lofgren sydrome
91
WHAT IS IDIOPATHIC PULMONARY FIBROSIS?
Uknown excess amount of collagen in the lungs connective tissue and interstitial tissue after damage
92
What is the cause of IPF?
Uknown
93
What are the risk factors for IPF?
1. Old age
2. Smoking
3. Male
94
What happens with fluid in IPF?
Loss of alveoli and start pooling fluid
Seen as honeycombing
95
What are the symptoms of IPF?
4 D's!
Dry cough
Digital clubbing
Dyspnoea
Diffuse inspiatory crackles
96
What are the tests for IPF?
1. **CXR**
* Thickening of alveoli walls
* Honeycomb lung
2. **CT**
* Needed for diagnosis
3. **Spirometry**
* **Restrictive FEV1 LOW, FVC LOW**
* **TLCO REDUCED**
* Decrease transfer factor
4. **Blood**
* ABG decrease in oxygen, increase in CO2
* CRP increase; immunoglobulins increase;
* ANA (30% +ve), rheumatoid factor (10% +ve).
5. **BAL (Bronchoalveolar lavage)**
97
What are the management options for idiopathic pulmonary fibrosis?
1. Pulmonary rehabilitation
2. **Pirfenidone** (an antifibrotic agent) **may be useful** in selected patients (see NICE guidelines)
3. Many patients will require **supplementary oxygen** and eventually a **lung transplant**
98
WHAT ARE THE TWO TYPES OF LUNG TUMOUR?
1. Bronchial
2. Pleural
99
What are the different types of bronchial cancers?
**_Malignant (95%) = lung cancer_**
1. Non small cell cancer
2. Small cell cancer
**_Benign_**
1. Hamartoma
2. Carcinoid
3. Lipoma
100
What are the causes of lung cancer?
1. Smoking
2. Asbestos
3. Chromium
4. Arsenic
101
What are the cell types of lung cancer?
1. **Small Cell Lung cancer - 15%**
2. **Non Small Cell lung cancer - 85%**
* **Adenocarcinoma (adenocarcinoma-in situe)** - MOST COMMON
* Squamous
* Large cell 5%
* Alveolor Cell Carcinoma
* Bronchial adenoma - mostly carcinoid
102
What are the symptoms of local lung cancer?
Cough (40%)
Chest pain (20%)
Haemoptysis (7%)
103
What are the signs of lung cancer?
Weight loss
Anaemia
Clubbing
Supraclavicular or axillary nodes
104
What are the features of lung adenocarcinomas?
1. Most common in non smokers
2. Gynaecomastia
3. Hypertrophic pulmonary osteoarthropathy (HPOA)
105
What are the features of small cell lung cancer?
1. **MOST COMMON IN SMOKERS**
2. Usually central
3. Arise from APUD\* cells
4. Associated with ectopic ADH, ACTH secretion
5. ADH → hyponatraemia
6. ACTH → Cushing's syndrome
7. ACTH secretion can cause bilateral adrenal hyperplasia, the high levels of cortisol can lead to hypokalaemic alkalosis
8. **Lambert-Eaton syndrome:** antibodies to voltage gated calcium channels causing myasthenic like syndrome
106
What are the investigations for lung cancer?
1. CXR
* First line
2. **Constrast** chest CT
* Further investigation
3. Bronchoscopy
4. Needle or surgical biopsy
5. **Bloods**
* Raised platelets
107
What are the sites of metastatic disease from lung cancer?
BBALL
Bone
Brain
Adrenal glands
Lymph glands
Liver
108
What is the treatment of lung cancers?
**_Stage I/II_**
surgical excision and radical deep x-ray therapy
**_Stage III/IV_**
Palliative chemotherapy, chemotherapy and radiotherapy, palliative care
109
What are the complications of lung cancer?
1. Superior vena cava syndrome
2. Hoarseness of voice
110
What is the criteria for a lung cancer referral for a 2 week wait?
1. Have chest x-ray findings that suggest lung cancer
2. Are aged 40 and over with unexplained haemoptysis
111
WHAT IS MESOTHELIOMA?
https://www.youtube.com/watch?v=MMmjTbywMSI
Tumour of mesothelial cells in the pleura
112
What is the pathology of mesothelioma?
Epithelioid (Activated macrophages resembling epithelial cells)
Sarcomatoid (Sarcomatous, spindled or diffuse malignant fibrous mesothelioma)
Inflammation
DNA damage
113
What are the symptoms of mesothelioma?
1. FEVER
2. WEIGHT LOSS
3. FATIGUE
4. SOB
5. Persistent cough
6. Clubbed fingers
114
What are the tests for mesotheiomas?
1. **CXR**
* Pleural thickening/effusion. Bloody pleural fluid
2. **Pleural CT scan**
3. **Pleural aspiration**
* ****This should be sent for MC&S, biochemistry and cytology
4. **Thoracoscopic Biopsy AND HISTOLOGY - GOLD STANDARD**
115
What is the treatment for mesotheliomas?
1. Symptomatic
2. Industrial compensation
3. Chemotherapy, Surgery if operable
4. Prognosis poor, median survival 12 months
116
What is type 1 respiratory failure? What is the cause?
1. **Type 1**
* Low PaO2,
* Normal (or low) paCO2,
* Normal or high A-a gradient.
* **Limited of ventilation, perfusion or diffusion**
117
What is type 2 respiratory failure? What is the cause?
1. Type 2:
* Low paO2,
* High CO2
* Usually normal A-a gradient (acute or chronic).
* **Alveolar hypoventilation**
* CO2 enters alveoli, but not removed
118
WHAT IS PNEUMONIA?
An infection in the lungs by microbes
Brings water into lung making it harder to breath
119
Who are the people at risk of pneumonia?
1. Infants and the elderly.
2. COPD and certain other chronic lung diseases.
3. Immunocompromised.
4. Nursing home residents.
5. Diabetes.
6. Alcoholics and intravenous drug users.
120
How can pneumonia be classified?
1. **Bronchopneumonia**
* Throughout lung
2. **Lobar**
* Single lobe
3. **Atypical**
* Interstatium
121
What are the common microbes that cause pneumonia?
**_Viruses_**
1. Influenza
**_Bacteria_**
1. Strep pneumoniae
2. Staph aureus
3. Legionella's (hot country, air conditioning)
4. Jirovecci (HIV patients)
122
What are the symptoms of pneumonia?
1. Fever
2. Rigors
3. Fatigue
4. Pleuritic chest pain
5. SOB
6. Headache
7. Cough with sputum (rusty green)
123
What are the symptoms of klebsiella pneumonia?
1. More common in alcoholic and diabetics
2. May occur following aspiration
3. 'Red-currant jelly' sputum
4. Often affects upper lobes
124
What are the signs of pneumonia?
1. Pyrexia
2. Cyanosis
3. Tachypnoea
4. Drop in BP
5. SPUTUM
6. Confusion(esp. elderly)
125
How can you investigate if somebody has suspected pneumonia?
1. Gold standard - **CXR**
* Consolidation
2. **Urea and electrolytes**
* Check for dehydration
3. **CRP**
* Raised in response to infection
* Can be a lag
4. **Sputum sample**
* Determine the causative organism
5. **Urinary antigen test**
* Legionellas
126
How do you manage pneumonia?
**Antibiotics for CAP:**
1. Mild: oral amoxicillin
2. Moderate: oral amxoicillin and clarithromycin
3. Severe: IV co-amoxiclav and clarithromycin
**Antibiotics for Legionellas:**
1. Fluoroquinolone (ciprofloxacin) + clarithromycin
127
WHAT IS ASTHMA?
REVERSIBLE chronic obstructive airway disease
128
What are the two main types of asthma?
Eosinophilic.
Associated with allergy.
Also non-allergic variant.
Non-eosinophilic.
129
What is asthma if not eosinophilic?
Overlaps with smoking and obesity.
130
What are the two different triggers of asthma and what are some examples?
**_Allergic_**
Genetics, environmental stimuli, hygiene hypothesis
**_Non-allergic_**
Intrinsic e.g. stress, cold air, infection
131
What is atopy?
Asthma
Hayever
Eczema
132
What type of hypersensitivity is asthma?
Type 1 as it involves IgE
133
What are the symptoms of asthma?
1. Chest tightness
2. Coughing
3. Wheezing
4. Dyspnea
5. Sputum
134
What are the tests for occupational asthma?
1. Peak flow measurements at work and away from work
135
What are the tests for asthma?
1. **FeNO**
* In adults level of \>= 40 parts per billion (ppb) is considered positive
* In children a level of \>= 35 parts per billion (ppb) is considered positive
2. **Spirometry**
* FEV1 - significantly reduced
* FVC - normal
* FEV1/FVC\<70% + Reversibility testing
3. **Peak flow**
* (keep a diary –diurnal variation)
4. **Bronchodilator reversability**
136
What are the steps of treatment for chronic asthma?
**_Step 1_**
SABA (salbutamol)
**_Step 2_**
SABA + low-dose ICS
**_Step 3_**
SABA + low-dose ICS + LTRA (montoleukast)
**_Step 4_**
SABA + low-dose ICS + long-acting beta agonist (LABA) + LRTA
**_Step 5_**
SABA + LTRA + Low dose MART
**_Step 6_**
SABA + LTRA + medium dose MART
**_Step 7_**
SABA + LTRA + High dose ICS + Muscarnic receptor agonist
137
What are the features of a severe asthma attack?
1. PEFR 33 - 50% best or predicted
2. Can't complete sentences
3. RR \> 25/min
4. Pulse \> 110 bpm
138
What are the features of a life-threatening asthma attack?
1. PEFR \< 33% best or predicted
2. Oxygen sats \< 92%
3. 'Normal' pC02 (4.6-6.0 kPa)
4. Silent chest, cyanosis or feeble respiratory effort
5. Bradycardia, dysrhythmia or hypotension
6. Exhaustion, confusion or coma
7. pH \<7.35
139
What is the treatment for an acute asthmatic?
**O**xygen 15L O2 sats 94-98%
**S**albutamol 5mg nebs
**H**hydrocortisone 100mg IV (safe to continue whilst breastfeeding)
**I**patropium bromide 0.5mg nebs
**T**heophyilline IV
**M**agnesium sulphate 2mg IV
**E**scalate care
140
How often should step down asthma therapy be considered?
How much of a reduction should be considered?
1. The British Thoracic Society (BTS) guidelines recommend that we should consider stepping down treatment every 3 months or so
2. When reducing the dose of inhaled steroids the BTS advise us to do this by 25-50% at a time
141
What are the target oxygen sats for an asthma attack?
94-98%
142
What is the treatment for a life-threatening asthma attack?
ITU
143
What should all children recieve in an asthma attack?
Steroids for 3-5 days with any other treatment e.g. new inhaler
144
WHAT IS TUBERCULOSIS CAUSED BY?
What is this bacteria?
Mycobacterium Tuberculosis
Which is an AEROBIC, NON-MOTILE SLIGHTLY CURVED ROD
145
What are the risk factors for TB?
1. Born in high prevalence area
2. IVDU Homeless
3. Alcoholic
4. Prisons
5. HIV+
146
How is TB spread?
AIRBORNE DROPLETS
147
What are the different types of TB?
**_Healthy_**
Person has never been infected with TB
**_Active TB_**
This is when the bacterium are multiplying in the lungs and people have symptoms
**_Latent_**
The TB bacteria are NOT dividing in the lungs. Individual asymptomatic.
148
What are the symptoms of TB?
1. Fever
2. Night sweats
3. Chills
4. Chest pain
5. Cough
6. Sputum
7. Haemoptysis
8. Breathlessness
149
What are the signs of TB?
Coughing up BLOOD
Individual will look unwell
150
How can you diagnose TB?
1. **Sputum test (3x) - Ziehl–Neelsen stain**
* Used to detect acid fast organisms
2. **Mantoux skin test**
* Latent TB
3. **CXR**
* Bilateral hilar lymphadenopathy
* UPPER ZONE FIBROSIS
* GOHN COMPLEX
4. **CT scan**
151
What is the treatment for active TB?
**_R_**ifampicin. 6 months
**_I_**soniazid. 6 months
**_P_**yrazinamide 2 months
**_E_**thambutol. 2 months
152
What are some side effects of RIPE?
**_Rifampicin_**
Red urine, hepatitis, drug interactions.
**_Isoniazid_**
Hepatitis, neuropathy
**_Pyranzidimide_**
Hepatitis, arthralgia / gout, rash.
**_Ethanbutol_**
Optic neuritis
153
What test should be offered to all patients with TB?
HIV test
154
WHAT IS PNEUMOTHORAX?
Build up of AIR in the pleural space
155
What are the causes of a pneumothorax?
**_Primary_**
No underlying lung disease, but risk factors include
1. Male
2. Smoking
3. Connective tissue disease (Marfans, Ehlers Danlos).
**_Secondary_**
Underlying lung pathology that has caused it.
1. Trauma
2. Fractured ribs
3. Stab wound
4. Gunshot
5. Catheter
6. Biopsy
156
What are the clinical features of a pneumothorax?
**_Symptoms_**
1. SOB
2. Sharp
3. ONE SIDED chest pain
4. Altered consciousness
**_Signs_**
1. Tachycardia
2. Tachypneoa
157
What are the tests for a pneumothorax?
**_CXR_**
BLACK
158
What are the management options for a pneumothorax?
**_Primary pneumothorax_**
1. If the rim of air is \< 2cm and the patient is not short of breath then discharge should be considered
2. Otherwise, aspiration should be attempted
3. If this fails (defined as \> 2 cm or still short of breath) then a chest drain should be inserted
**_Secondary pneumothorax_**
1. If the patient is \> 50 years old and the rim of air is \> 2cm and/or the patient is short of breath then a chest drain should be inserted.
2. Otherwise aspiration should be attempted if the rim of air is between 1-2cm. If fails then chest drain. All patients should be admitted for at least 24 hours
3. If the pneumothorax is less the 1cm then the BTS guidelines suggest giving oxygen and admitting for 24 hours
159
What is the emergency pneumothroax?
Tension pneumothorax
Thrachea deviation
160
How do you treat a tension pneumothorax?
Needle decompresion and chest drain 2nd intercostal space
161
What discharge advice is given after a penumothorax?
1. **Smoking**
* Patients should be advised to avoid smoking to reduce the risk of further episodes - the lifetime risk of developing a pneumothorax in healthy smoking men is around 10% compared with around 0.1% in non-smoking men
2. **Fitness to fly**
* Absolute contraindication, the CAA suggest patients may travel 2 weeks after successful drainage if there is no residual air. The British Thoracic Society used to recommend not travelling by air for a period of 6 weeks but this has now been changed to 1 week post check x-ray
3. **Scuba diving**
* the BTS guidelines state: 'Diving should be permanently avoided unless the patient has undergone bilateral surgical pleurectomy and has normal lung function and chest CT scan postoperatively.'
162
What is the difference between a tension pneumothorax and pneumothorax?
Tension you get hypotension
163
WHAT IS A PLEURAL EFFUSION?
What type of fluid can be there?
Fluid in the pleural space
Chyle, blood, serous, pus.
164
How can pleural effusions be divided?
**_Transudates_**
Excessive production of pleural fluid or resorption is reduced. E.g. heart failure, cirrhosis, nephrotic syndrome
**_Exudates_**
Result from damaged pleura. E.g. PE, bacterial pneumonia, cancer, viral infection, pancreatitis
165
What are the different names for blood in pleural splace etc?
Blood in the pleural space is a haemothorax, pus in the pleural space is an empyema, and chyle (lymph with fat) is a chylothorax.
Both blood and air in the pleural space is called a haemopneumothorax.
166
What are the symptoms of a pleural effusion?
SOB
Cough
Chest pain
167
What are the signs of a pleural effusion?
Decreased chest movement
Reduced breath sounds
Dull to percussion
168
What are the tests for a pleural effusion?
1. **PA CXR**
* White (fluid)
2. **Ultrasound + Pleural aspiration**
3. **Contrast CT**
4. **Listen to the chest**
* Dull to percussion
* Reduced breath sounds
5. **Thoracocentesis**
* Pleural protein divided by serum protein
* \>0.5 exudate
* \<0.5 transudate
169
What are the management options for a pleural effusion?
1. Pleural aspiration
* Ultrasound is recommended to reduce the complication rate
* **A 21G needle** and **50ml syringe** should be used
* Fluid should be sent for pH, protein, lactate dehydrogenase (LDH), cytology and microbiology
* **pH most important factor to consider chest tube insertion**
2. Pleurodesis if recurrent pleural effusion
* Plug the hole with talc
170
WHAT IS A PULMONARY EMBOLISM?
Where is it most commonly from?
Clot inside a pulmonary vessel
a DVT
171
What are the risk factors for a pulmonary embolism?
1. Immobility - \>3 days, surgery within last 4 weeks
2. Previous DVT/ PE
3. Pregnancy
4. Thrombophilic syndromes
5. Malignancy
6. Hormone Therapy
172
What are the symptoms of a pulmonary embolism?
1. Sudden onset dyspnoea
2. Chest pain
3. Red, swollen leg
4. Haemoptysis
5. Pre-syncope, syncope
6. Tachycardia
173
What are the signs of a pulmonary embolism?
Pyrecia
Cyanosis
Tachycardia
Tachypnoea
Hypertension
Raised jvp
174
What are the tests for a PE?
1. Essential to do a chest x-ray first - rule out other pathology
2. D-dimer – negative excludes PE but positive doe not prove it
3. If positive, need to do CTPA
175
What is the management of a PE?
1. Oxygen
2. Analgesia
3. **Anticoagulation**
* DOAC (apixaban or rivaroxaban)
* 3 months for provoked
* 6 months for unprovoked
4. **DOAC use unless**
* Renal impairment \<15/min
* Antiphospholipid syndrome
176
What should be done if a well's score is \>4?
1. arrange an immediate computed tomography pulmonary angiogram (CTPA)
2. If there is a delay in getting the CTPA then interim therapeutic anticoagulation should be given until the scan is performed.
* interim therapeutic anticoagulation used to mean giving low-molecular-weight heparin
* NICE updated their guidance in 2020. They now recommend using an anticoagulant that can be continued if the result is positive.
* this means normally a direct oral anticoagulant (DOAC) such as apixaban or rivaroxaban
177
What should be done if a well's score is \<4?
1. Arranged a D-dimer test
* If positive arrange an immediate computed tomography pulmonary angiogram (CTPA). If there is a delay in getting the CTPA then give interim therapeutic anticoagulation until the scan is performed
* If negative then PE is unlikely - stop anticoagulation and consider an alternative diagnosis
178
WHAT IS GOODPASTURE'S SYNDROME?
Vasculitis
**Triad of:**
1. Glomerulonephritis
2. Pulmonary haemorrhage
3. Autoantibodies to GBM and alvelor basement membrane
179
What is goodpasture's syndrome caused by?
Antibodies form against type IV collagen
180
What type of sensitivty reaction is goodpastures syndrome?
Type 2
181
What are the environmental risk factors for a pulmonary haemorrhage in goodpatures syndrome?
1. Smoking
2. Lower respiratory tract infection
3. Pulmonary oedema
4. Inhalation of hydrocarbons
5. Young males
182
What are the symptoms for goodpasture's syndrome?
1. Pulmonary haemorrhage
2. Rapidly progressive glomerulonephritis
* This typically results in a rapid onset acute kidney injury
* Nephritis → proteinuria + haematuria
183
What are the tests for goodpasture's syndrome?
1. **CXR**
* Infiltrates due to pulmonary haemorrhage, often in lower zones.
2. **Kidney biopsy**
* Crescentic glomerulonephritis
* Linear IgG deposits along the basement membrane
184
What are the treatment options for goodpasture's syndrome?
1. **Plasmapheresis**
2. **Steroids**
* Prednisolone
3. **Immunosuppressive**
* Cyclophosphamide, rituximab
185
WHAT IS GRANULOMATOSIS WITH POLYANGITIS (formerly termed Wegener's granulomatosis)?
https://www.youtube.com/watch?v=Ax98k35h\_jk
Small vessel vasculitis with caseating granulomas
186
What type of sensitivity is Granulomatosis with polyangiitis (Wegener's granulomatosis)?
Type 4
187
What parts of the body are affected in Granulomatosis with polyangiitis (Wegener's granulomatosis)?
1. Nasal passage
2. Respiratory tract
3. Kidneys
188
What are the features of Granulomatosis with polyangiitis (Wegener's granulomatosis)?
1. **Lung**
* Migrating cavitatingcoin nodules, haemoptysis, pulmonary infiltrates
2. **URT**
* Saddle nose deformity, epistaxis
3. **Kidneys**
* RPGN with crescent cells, haematuria
4. **Eyes**
* Iritis, scleritis, episcleritis
5. **Arthritis**
6. **Elbow nodules**
189
What antibodies are involved in Granulomatosis with polyangiitis (Wegener's granulomatosis)?
cANCAs
190
What are the tests for Granulomatosis with polyangiitis (Wegener's granulomatosis)?
1. **cANCA/pANCA sometimes**
* Positive
2. **Urinalysis**
* Proteinuria or haematuria
3. **Biopsy of kidneys**
* Granulomas, crescentic glomerulonephritis
4. **CXR**
* Nodules ± fluffy infiltrates of pulmonary haemorrhage
5. **Increased ESR/CRP**
191
What is the treatment for Granulomatosis with polyangiitis (Wegener's granulomatosis)?
1. Steroids
2. Cyclophosphamide (90% response)
3. Plasma exchange
Median survival = 8-9 years
192
What is Eosinophilic granulomatosis with polyangiitis (EGPA)?
Eosinophilic granulomatosis with polyangiitis (EGPA) is now the preferred term for Churg-Strauss syndrome.
It is an ANCA associated small-medium vessel vasculitis.
193
What are the features of Eosinophilic granulomatosis with polyangiitis (EGPA)?
1. asthma
2. blood eosinophilia (e.g. \> 10%)
3. paranasal sinusitis
4. mononeuritis multiplex
5. pANCA positive in 60%
194
What are the differences between granulomatosis with polyangiitis and eosinophilic granulomatosis with polyangiitis?
195
WHAT IS PULMONARY HYPERTENSION?
https://www.youtube.com/watch?v=Dx4QgdN\_hI4
Mean arterial blood pressure greater than 25 mmhg
196
What are the causes of pulmonary hypertension?
1. **Pre-capillary**
* Multiple small PEs cause obliteration of vascular bed
* Left-to-right shunts cause increased pulmonary blood flow and pressure
2. **Capillary**
* Disease of pulmonary vascular bed
* Eg emphysema, COPD
3. **Post-capillary**
* Backlog of blood causes secondary pulmonary hypertension
* LV failure
4. **Chronic hypoxaemia**
* Living at high altitude
* COPD
197
What are the symptoms of pulmonary hypertension?
1. Fatigue, pre-syncope
2. Tachycardia
3. Raised JVP
4. Altered heart sounds (louder S2)
5. Peripheral oedema – sacral, ankle
198
What is the diagnosis of pulmonary hypertension?
1. **Chest radiology**
* May show right atrial dilatation and right ventricular enlargement
2. **ECG**
* Increase pressure in pulmonary articles and right venticle, right axis deviation, R wave in V1, inverted T waves in right precordial lead
3. **Echocardiography**
* Demonstrates a dilated right ventricle with impaired function and often provides the first evidence of pulmonary hypertension
4. **Spirometry**
* Chronic lung disease sometimes
199
What is the treatment for pulmonary hypertension?
1. **Oxygen**
2. **Diuretics**
* Furosemide
3. **Anticoagulation**
* DOAC
4. **Prostacyclin analogue**
* Apoprostenol
200
WHAT IS CYSTIC FIBROSIS?
https://www.youtube.com/watch?v=BhFpFiZumS0
Excessive mucus build up in lungs and pancreas
201
What causes cystic fibrosis?
1. Autosomal recessive
2. CF transmembrane conductance regulator (CFTR) gene
3. Chromosome 7
4. DeltaF508
202
What is the pathophysiology of cystic fibrosis?
1. Defect in chlorine channel
2. Chlorine can therefore not be transported into the lumen.
3. Water does not move out by osmosis, making the mucus thick and sticky, clogging up the lumen.
4. Na+ also moves into the cells via an electrochemical gradient (Cl- is negative, Na+ is positive), which also draws water in with it and makes the mucus even more thick and sticky.
203
What can happen in newborns for cystic fibrosis?
Meconium - first stool
Can get stuck in intestine
Meconium ileus
204
How is pancreatic insufficiency caused in cystic fibrosis?
1. Thick secretions block the duct
2. No enzymes into intestine
3. Protein and fat not absorbed
4. Failure to thrive
5. Steatorrhoea
6. Pancreas damaged due to backup of enzymes
7. Localised inflammation - pancreastitis
205
What are the symptoms for cystic fibrosis?
1. Neonatal period (around 20%): meconium ileus, less commonly prolonged jaundice
2. Recurrent chest infections (40%)
3. Malabsorption (30%): steatorrhoea, failure to thrive
4. Other features (10%): liver disease
206
What are the signs for cystic fibrosis?
1. Steatorrhea
2. Children with a failure to thrive
3. Finger clubbing
4. Rectal prolapse
207
What tests are done for cystic fibrosis?
90% diagnosed before the age of 8.
FAECAL ELASTASE
**_Sweat (NaCl) test_**
Parents taste salt when kissing baby
**_Genetics testing_**
DeltaF508
208
What are the management options for cystic fibrosis?
NO CURE, therefore symptom management
**_Non-pharmalogical_**
Physio for airway clearance
**_Pharmalogical_**
Antibiotics, anti-mucinolytics, bronchodilators, enzymes, insulin, bisphosphonates
**_Surgery_**
Lung transplant
209
What are the complications of CF?
INFERTILITY
Pancreatitis
RESP TRACT INFECTIONS
Bronchiectasis
210
WHAT CONDITIONS CAUSE UPPER ZONE FIBROSIS?
C - Coal worker's pneumoconiosis
H - Histiocytosis/ hypersensitivity pneumonitis
A - Ankylosing spondylitis
R - Radiation
T - Tuberculosis
S - Silicosis/sarcoidosis
211
What conditions cuase fibrosis of the lower zones?
1. Idiopathic pulmonary fibrosis
2. Most connective tissue disorders (except ankylosing spondylitis) e.g. SLE
3. Drug-induced: amiodarone, bleomycin, methotrexate
4. Asbestosis
212
What is the correct inhaler technique?
1. Remove cap and shake
2. Breathe out gently
3. Put mouthpiece in mouth and as you begin to breathe in, which should be slow and deep, press canister down and continue to inhale steadily and deeply
4. Hold breath for **10 seconds**, or as long as is comfortable
5. For a second dose wait for approximately **30 seconds** before repeating steps 1-4.
Only use the device for the number of doses on the label, then start a new inhaler.
213
WHAT ARE THE CAUSES OF A LOBAR COLLARPSE?
1. Lung cancer (the most common cause in older adults)
2. Asthma (due to mucous plugging)
3. Foreign body
214
What are the signs of lobar collapse on a chest x-ray?
1. Tracheal deviation towards the side of the collapse
2. Mediastinal shift towards the side of the collapse
3. Elevation of the hemidiaphragm
215
WHAT ARE THE BIOCHEMICAL FEATURES OF AN EMPYEMA?
1. pH\<7.2
2. Low glucose
3. High LDH
216
WHAT IS KARTAGENER'S SYNDROME?
Kartagener's syndrome (also known as primary ciliary dyskinesia) was first described in 1933 and most frequently occurs in examinations due to its association with dextrocardia (e.g. 'quiet heart sounds', 'small volume complexes in lateral leads')
217
What are the features of kartagener's syndrome?
1. Dextrocardia or complete situs inversus
2. Bronchiectasis
3. Recurrent sinusitis
4. Subfertility (secondary to diminished sperm motility and defective ciliary action in the fallopian tubes)
5. Right testicle hanging lower than left due to situs inversus
218
WHAT DRUG CAN HELP WITH ALTITUDE SICKNESS?
Acetazolamide
219
WHAT CONDITIONS PULL THE TRACHEA TOWARDS THE LUNG?
1. Pneumonectomy
2. Complete lung collapse
3. Pulmonary hypoplasia
220
What pushes the trachea away from the white-out?
1. Pleural effusion
2. Diaphragmatic hernia
3. Large thoracic mass
221
What keep the trachea central in a white out?
1. Consolidation
2. Pulmonary oedema
3. Mesothelioma
222
WHAT IS THE MOST COMMON PART OF THE LUNG AFFECT IN ASPIRATION PNEUMONIA?
Right lower lobe
223
What is ALLERGIC BRONCHOPULMONARY ASPERGILLOSIS?
Allergic bronchopulmonary aspergillosis results from an allergy to Aspergillus spores. In the exam questions often give a history of bronchiectasis and eosinophilia.
224
What are the features of Allergic bronchopulmonary aspergillosis?
1. Bronchoconstriction: wheeze, cough, dyspnoea. Patients may have a previous label of asthma
2. Bronchiectasis (proximal)
225
What are the investigations for Allergic bronchopulmonary aspergillosis?
1. Eosinophilia
2. Flitting CXR changes
3. Positive radioallergosorbent (RAST) test to Aspergillus
4. Positive IgG precipitins (not as positive as in aspergilloma)
5. Raised IgE
226
What is the management of Allergic bronchopulmonary aspergillosis?
1. Oral glucocorticoids
2. Itraconazole is sometimes introduced as a second-line agent
227
WHAT IS USED IN OBSTRUCTIVE SLEEP APNOEA?
1. Epworth Sleepiness Scale - questionnaire completed by patient +/- partner
2. Multiple Sleep Latency Test (MSLT) - measures the time to fall asleep in a dark room (using EEG criteria)
228
What are the tests for sleep apnoea?
**Assessment of sleepiness**
1. Epworth Sleepiness Scale - questionnaire completed by patient +/- partner
2. Multiple Sleep Latency Test (MSLT) - measures the time to fall asleep in a dark room (using EEG criteria)
**Diagnostic tests**
1. **Sleep studies (polysomnography)** - ranging from monitoring of pulse oximetry at night to full polysomnography where a wide variety of physiological factors are measured including EEG, respiratory airflow, thoraco-abdominal movement, snoring and pulse oximetry
229
What are the consequnces of sleep apnoea?
1. Daytime somnolence
2. Compensated respiratory acidosis
3. Hypertension
230
What is the treatment for sleep apnoea?
1. Weight loss
2. **Continuous positive airway pressure (CPAP) is first line for moderate or severe OSAHS**
3. Intra-oral devices (e.g. mandibular advancement) may be used if CPAP is not tolerated or for patients with mild OSAHS where there is no daytime sleepiness
4. the DVLA should be informed if OSAHS is causing excessive daytime sleepiness
231
What is the most common pneumonia for alcohlics to get?
Klebsiella pneumonia
232
What type of oxygen therpay should be given to critically ill patients?
Oxygen via a reservoir mask at 15 l/min
233
What are the target oxygen saturations for:
acute ill patients?
Patinets at risk of hypercapnia (e.g. COPD)?
COPD patients if pCO2 if normal?
What oxygen mask should be used for COPD patients?
94-98%
88-92%
94-98%
28% venturi mask at 4 l/min
234
Disorders of acid - base balance
235
WHEN ARE CHEST DRAINS INDICATED?
1. Pleural effusion
2. Pneumothorax not suitable for conservative management or aspiration
3. Empyema
4. Haemothorax
5. Haemopneumothorax
6. Chylothorax
7. In some cases of penetrating chest wall injury in ventilated patients
236
When are chest drains contraindicated?
1. INR \> 1.3
2. Platelet count \< 75
3. Pulmonary bullae
4. Pleural adhesions
237
How is a chest drain inserted?
1. Once patient consent has been obtained and patient imaging assessed, the patient should be positioned in a supine position or at a 45º angle.
2. The patient's forearm may be positioned behind the patient's head to allow easy access to the axilla.
3. **Identify the 5th intercostal space in the midaxillary line**
4. **Base of the axilla, lateral edge pectoralis major, 5th intercostal space and the anterior border of latissimus dorsi**
238
What are the complications of inserting a chest drain?
1. Failure of insertion - the drain may be abutting the apical pleura, in which case it should be pulled back, or may be subcutaneous or in rare cases could enter the abdominal cavity. In both latter cases, the drain should be removed and re-sited.
2. Bleeding - around the site of the drain or into the pleural space
3. Infection
4. Penetration of the lung
5. Re-expansion pulmonary oedema
239
WHAT ARE THE CAUSES OF A RAISED TLCO?
1. asthma
2. pulmonary haemorrhage (Wegener's, Goodpasture's)
3. left-to-right cardiac shunts
4. polycythaemia
5. hyperkinetic states
6. male gender, exercise
240
What are the causes of a lower TLCO?
1. pulmonary fibrosis
2. pneumonia
3. pulmonary emboli
4. pulmonary oedema
5. emphysema
6. anaemia
7. low cardiac output
241
What are the causes of a increased KCO with a normal or reduced TLCO?
1. Pneumonectomy/lobectomy
2. Scoliosis/kyphosis
3. neuromuscular weakness
4. ankylosis of costovertebral joints e.g. ankylosing spondylitis
242
WHAT ARE THE OPTIONS FOR STOPPING SMOKING?
1. **Patients should be offered:**
* Nicotine replacement therapy (NRT)
* Varenicline
* Bupropion
243
What are the side effects of nicotine replacement therapy?
1. Nausea & vomiting
2. Headaches
3. Flu-like symptoms
244
What is varenicline and when should it be started?
1. A nicotinic receptor partial agonist
2. Should be started 1 week before the patients target date to stop
245
What are the side effects of varenicline?
1. Nausea is the most common adverse effect.
2. Other common problems include
* Headache
* Insomnia
* Abnormal dreams
246
Who should varenicline not be used in?
1. History of depression or self-harm
2. Contraindicated in pregnancy and breast feeding
247
What is bupropion and when should it be started?
1. A norepinephrine and dopamine reuptake inhibitor, and nicotinic antagonist
2. Should be started 1 to 2 weeks before the patients target date to stop
248
Who should bupropion not be used in?
1. Epileptic patients - small risk of seizures (1 in 1,000)
2. Contraindicated in epilepsy, pregnancy and breast feeding. Having an eating disorder is a relative contraindication
249
What are the interventions for pregnant women who wish to stop smoking?
1. The first-line interventions in pregnancy should be **cognitive behaviour therapy,** **motivational interviewing** or s**tructured self-help and support from NHS Stop Smoking Services**
2. The evidence for the use of NRT in pregnancy is mixed but it is often used if the above measures failure. There is no evidence that it affects the child's birthweight. Pregnant women should remove the patches before going to bed
3. **As mentioned above, varenicline and bupropion are contraindicated**
250
WHAT ARE THE RISK FACTORS FOR ASPIRATION PNEUMONIA?
1. Poor dental hygiene
2. Swallowing difficulties
3. Prolonged hospitalization or surgical procedures
4. Impaired consciousness
5. Impaired mucociliary clearance
251
Which lobes are more affected by aspiration pneumonia?
The right middle and lower lung lobes are the most common sites affected, due to the larger calibre and more vertical orientation of the right main bronchus.
252
What are the organisms most likely to cause aspiration pneumonia?
1. Streptococcus pneumoniae
2. Staphylococcus aureus
3. Haemophilus influenzae
4. Pseudomonas aeruginosa
5. Klebsiella: often seen in aspiration lobar pneumonia in alcoholics
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WHAT IS ATELECTASIS?
Atelectasis is a common postoperative complication in which basal alveolar collapse can lead to respiratory difficulty. It is caused when airways become obstructed by bronchial secretions.
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What are the features of atelectasis?
It should be suspected in the presentation of dyspnoea and hypoxaemia around 72 hours postoperatively
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What is the management of atelectasis?
1. positioning the patient upright
2. chest physiotherapy: breathing exercises
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WHAT IS A FLAIL CHEST?
Chest wall disconnects from thoracic cage
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What are the features of a flail chest?
1. Multiple rib fractures (at least two fractures per rib in at least two ribs)
2. Associated with pulmonary contusion
3. Associated with tension pneumothorax
4. Abnormal chest motion
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What is the management of a flail chest?
1. Avoid over hydration and fluid overload
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HOW CAN YOU TELL IF A CHEST DRAIN IS LOCATED IN THE CORRECT POSITION?
Chest drain swinging: Rises in inspiration, falls in expiration
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What is cor pulmonale?
Heart failure secondary to chronic pulmonary hypertension
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WHAT ARE THE CAUSES OF A LUNG ABSCESS?
1. most commonly forms secondary to aspiration pneumonia
* poor dental hygiene, previous stroke and reduced consciousness are some of the risk factors for this
2. other potential causes include:
* haematogenous spread e.g. secondary to infective endocarditis
* direct extension e.g. from an empyema
* bronchial obstruction e.g. secondary from a lung tumour
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What are the features of a lung abscess?
1. similar features to pneumonia but generally runs a more subacute presentation
* symptoms may develop over weeks
* systemic features such as night sweats and weight loss may be seen
2. fever
3. productive cough
* often foul-smelling sputum
* haemoptysis in a minority of patients
4. chest pain
5. dyspnoea
6. signs
* dull percussion and bronchial breathing
* clubbing may be seen
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What are the investigations for a lung abscess?
1. chest x-ray
* fluid-filled space within an area of consolidation
* an air-fluid level is typically seen
2. sputum and blood cultures should be obtained
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What is the management of a lung abscess?
1. intravenous antibiotics
2. if not resolving percutaneous drainage may be required and in very rare cases surgical resection
