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Flashcards in Resp Deck (253):
1

What is pleura made from?

a serous membrane of a single layered mesothelial cells & thin CT underneath

2

What is parietal pleura?

the inside part lining each hemithorax and continues with the visceral pleura at hilum of lung

3

What is visceral pleura?

lines the outside of lunges extending between lobes into the fissures

4

What is the BS of pleura?

Intercostal & internal thoracic arteries and veins

5

Innervation of pleura?

Parental pleura = somatic (intercostal & phrenic nerves) & autonomic
Visceral = no somatic, only autonomic

6

What is the pleural cavity/space?

potential peace between layers of pleura which is filled with fluid produced from the parietal space & absorbed by parietal lymphatic vessels

7

What is the function of pleural fluid?

allow the 2 layers to slide - allowing chest & lung moment in breathing

8

What is an important characteristic of the pleural fluid?

Surface tension - provides cohesion keeping lung surface in contact with thoracic wall so when thorax expands in inspiration, the lunch expands and fills with air along with it

9

Where is the apex of the lungs?

Above 1st rib, into the neck

10

Where is the base of lungs?

concave shape resting on diaphragm

11

How many lung lobes are there?

Left = 2 --> 1 fissure
Right = 3 --> 2 fissure

12

What are the 3 surfaces of the lung?

costal, mediastinal, diaphragmatic

13

What are the names of the Right lobes and lung fissures?

Superior, middle & inferior lobes created b the right oblique & horizontal fissure

14

Left lung lobes and fissure?

superior and inferior lobes created by left oblique fissure

15

what is in the lung hilum?

bronchi, pulmonary arteries, superior & inf. pulmonary veins, pulmonary plexus of nerves and lymphatics

16

What is the pathway of the trachea?

Lower border of cricoid cartilage terminating into the Right and Left main bronchi at sternal angle

17

What shape cartilage are found in trachea?

c-shaped

18

What epithelium is the trachea?

pseudostratified ciliated columnar

19

what is the carina?

the angle between the the right & left main bronchi

20

what is the pathway of the airways?

Trachea> R main bronchus> lobar bronchi> segmental? bronchioles> terminal bronchioles>alveolar ducts> alveoli

21

What bronchus is shorter wider and more vertical?

the right main bronchus

22

What is the blood supply of the lungs from the heart?

1 Pulmonary A from pulmonary trunk
2 Pulmonary veins

23

What is the BS to the supporting lung structures?

Bronchial arteries coming from the Thoracic aorta

24

What is the mediastinum?

central compartment of the thoracic cavity

25

What is the mediastinum covered by?

the mediastinal pleura

26

what is contained in the mediastinum?

all thoracic viscera except lungs

27

Where is the heart and great vessels located?

the middle inferior mediastinum

28

What is important about the pulmonary circ. compared to systemic?

pulm. circ. must accept entire CO and work with low resistance as many capillaries in parallel and articles with little smooth muscles - so the circulation operates under a low pressure

29

What is the Boyle's law?

Given amount of air is compressed into smaller volume, molecules hit more often so increase pressure.

30

Kinetic theory of gases?

gases move around a space and collide with walls to generate pressure. the more freq. and harder collisions, the more pressure

31

Charle's law?

kinetic energy increases with temp

32

Universal gas laws?

calculation of volume when pressure and temp change
PxV = gas constant x Temp (kelvin)

33

What is the partial pressure?

in a gas mixture, it's the proportion of pressure a particular gas gives

34

vapour pressure?

partial pressure of gas dissolved into evaporated water

35

saturated vapour pressure?

rate of molecules entering and leaving water

36

tension?

how readily gas leaves a liquid

37

Content of gas in liquid?

Solubility x tension
dissolving x readily leaving

38

Total gas content?

TC = reacted gas + dissolved gas

39

Total content of O2 in blood?

O2 bound to Hb + O2 dissolved in plasma

40

Tidal volume?

the volume of air breathed in and out in normal inspiration & expiration

41

Respiratory rate?

#breaths per minute

42

What are the pulmonary circulations?

Pulmonary - to the alveoli for gas exchange, and bronchial - part of systemic to meet lungs demand

43

Key features of the pulmonary circulation?

Accepts all of CO
Low resistance as short, wide capillaries with many in parallel and the arterioles have little smooth muscles
Low pressure

44

What is ventilation: perfusion matching?

Efficient oxygenation requires the ventilation to the alveoli to be matched by the blood perfusion via pulm. circ.
The V/P ratio = 0.8

45

How to maintain the V/P ratio?

Hypoxic pulmonary vasoconstriction - to increases resistance so less flow which is instead diverted to well ventilated areas.

46

What is a complication of chronic hypoxic vasoconstriction?

Right ventricular failure as chronic increase in vascular resistance = after load on right ventricle causing failure

47

What is the upper resp. tract?

Above the thorax - nasal cavity, pharynx, larynx

48

What is the lower resp. tract?

Inside the thorax:
Trachea, Main bronchi, Lobar bronchi, segmental bronchi, bronchioles, terminal bronchioles, resp. bronchioles, alveolar ducts and alveoli

49

How many lobar bronchi are there?

3 on right
2 on left
Have cartilage in walls

50

Characteristic of bronchioles

No cartilage in walls and more smooth muscle than bronchi

51

Function of cartilaginous rings in trachea and bronchi?

To hold the airways open when moving neck

52

Characteristics of alveoli?

single cell thick
Short diffusion distance with Type 1 Simple Squamous cells
Type 2 cells release surfactant to reduce surface tension of alveoli

53

How do bronchioles draw air in?

Increasing volume by using smooth muscle in walls

54

What lines the conducting portion of the tract?

Mucous membranes containing goblet cells

55

What lines the pleural sacs enveloping the lungs?

Serous membrane

56

What is the epithelium for the upper tract, trachea and bronchi?

Pseudostratified, ciliated with goblet cells

57

What is the epithelium for the bronchioles and terminal bronchioles?

simple columnar with cilia and clara cells, no goblet cells

58

What is the epithelium for respiratory bronchioles and alveolar ducts?

simple cuboidal, clara cells and cilia

59

What is the epithelium of the alveoli?

Simple squamous

60

What are clara cells?

Cells that release surfactant to prevent the walls sticking together during expiration from surface tension.

61

Patient's blood results indicates abnormal levels of protein CC16, what does this means?

High = leakage across air-blood barrier
Low = lung damage

62

What is it important that there are no goblet cells in the terminal bronchiole?

Prevent person drowning in own mucus as very narrow airways

63

Describe terminal bronchioles?

no alveolar openings

64

Respiratory bronchioles?

some wall openings onto alveoli

65

Describe the alveolar duct?

duct wall with openings everywhere for alveoli

66

What is an alveolus?

a single alveoli

67

What is the alveolar sac?

air space onto which many alveoli open onto

68

Describe the structure of alveoli:

abundant capillaries
electric and reticular fibre network
covered in Type 1 pneumocytes - simple squamous
scattered Type 2 pneumocytes - simple cuboidal surfactant-releasing
macrophages lune the alveoli

69

Describe how lungs inhale air?

Lungs: bronchioles dilate to increase radius - lowering resistance, decreasing pressure within the lungs drawing air in.

Muscles: external intercostals elevate the ribs in bucket-handle movement (30%), and the diaphragm contracts to descend to increase the chest volume

Chest wall: expansion, and due to surface tension by pleural fluid, the lung parietal pleura follows taking the visceral pleura with it

70

What muscles are involved with quiet breathing?

I: Diaphragm and external intercostal
E: none (elastic recoil)

71

What muscles are involved in forced breathing?

I: diaphragm, Ext. I, scalee, pec minor, SCM, serrates ant

E: Internal & Innermost I, abo. muscles

72

What determines the rate of gas exchange?

Surface area - lots of alveoli
Resistance to diffusion
- short dd
- CO2 is more soluble, so diffuses faster so diffusion only changes O2 as it is limiting
Gradient of partial pressures
- air pushed in and out of alveoli by pressure differences through inspiration & expiration

73

What is Inspiratory reserve volume?

Extra volume that can be breathed in

74

What is Expiratory reserve volume?

extra air that can be breathed out

75

What is residual volume?

the volume left after max. expiration - only measured using helium diffusion, not a spirometer

76

What is vital capacity?

the max inspiration and max expiration
~5L

77

What is functional residual capacity?

volume of air in lungs are resting expiratory level ~2L

78

What is inspiratory capacity?

the biggest breath from resting expiratory level ~3L

79

Draw a spirometer trace

See picture

80

What is Serial/ Anatomical Dead Space?

same air entering and leaving airway. Last air in = last air out so not used in gas exchange

81

What is Nitrogen Washout test used for?

Measuring serial dead space

82

Describe the Nitrogen washout test

1. Inhale 100% O2 - oxygen will mix with alveoli and will contain N2, but conducting airways will be just O2
2. Exhale and measure % N2 in air expired

83

What is physiological dead space?

volume of air not taking part in gas exchange = anatomical dead space + alveolar dead space

84

How to measure alveolar ventilation rate?

about of air reaching the alveoli = Pulmonary vent rate - Dead space vent rate = RR(Tidal volume - dead space volume)

85

What is a pneumothorax?

integrity of the pleural seal is broken leading to the lung collapsing as air has entered between the 2 pleura layers so loss of fluid surface tension

86

What is lung compliance?

the stretchiness of the lungs (volume change per unit of pressure)

87

High lung compliance means...?

the lungs are easy to stretch

88

What type of compliance do stiff lungs have?

low compliance

89

What type of compliance do elastic lungs have?

high compliance

90

What factors affect compliance?

elasticity of the lungs
surface tension - resist stretching

91

What is the surface tension when lungs are deflated?

lower

92

What is the surface tension when fully inflated lungs?

high surface tension

93

What type of breathing is easier?

little breaths as it takes less force to expand small alveoli than larger alveoli

94

Explain laplace's law:

Pressure related to radius of bubbles, so larger alveoli would eat smaller alveoli, but bigger alveoli have greater surface tension so surfactant is less effective. This pressure stops big alveoli eating small alveoli, so creates interconnecting set of bubbles with equal size.

95

Explain Poiseulle's law:

resistance of tube increases with decreasing radius

96

Describe the level of resistance of small airways:

Whilst having a small radius, because they are parallel they have a low resistance so easy flow

97

What 'work' is done to inspire?

Work against the elastic recoil of the lungs and thorax to overcome the elasticity of lungs and surface tension forces of alveoli

Overcome the resistance to flow in the airways

98

What is Forced Vital Capacity?

maximum volume expired from full lungs

99

What is FEV1?

Forced expiratory volume in 1st second, speed of air flow - low if narrowed airways (COPD)

100

What is Restrictive disease?

Lungs are unusually stiff or inspiratory efforts are compromised by muscle weakness, injury or deformity.

101

What is the FVC and FEV1 in restrictive disease?

FVC reduced
FEV1 > 70% of FVC
(difficult to fill lungs, but air comes out normally)

102

What is Obstructive defect?

small airways are compressed so high flow resistance during expiration leading to no more air being driven out of alveoli. Expiratory flow compromised

103

What is the FVC and FEV1 in Obstructive defect?

FVC = normal
FEV1 = reduced
Lungs are easy to fill but hard to empty

104

What is measure in vitalograph?

Volume expired against time

105

What is measured in flow volume curves?

Volume expired against time, and Flow against Volume expired, taken from a vitalograph

106

What is PEFR?

Peak Expiratory Flow Rate - seen on flow volume curves, the exp. flow is max when lungs are full, airway are stretched and resistance is minimum

107

What happens to flow after PEFR?

Lungs compress are air leaving narrows the airways leading to increased resistance and decreased flow

108

What does COPD look like on flow volume loops?

Same PEFR, but rapidly dropping flow after & same total volume expired.
More severe COPD leads to reduced PEFR

109

What does Restrictive defect look like?

Normal PEFR, but smaller total volume expired (as less inspired)

110

What does fixed airway obstruction look like?

No peak, but level PEFR limited in height

111

What is helium dilution test used for?

Measuring Functional residual capacity which is used to calculate residual volume.

Helium = inert and can not diffuse across, known conc at start and new conc at end of normal exp. to calculate volume of lungs.

112

What is Carbon Monoxide transfer factor used for?

the rate of CO transfer from alveoli to blood measures how well gas diffusion is.

Tiny fraction of CO as is toxic

113

Solubility of water?

Not very soluble in water

114

Draw an oxygen-Hb dissociation curve:

ppO2 of lungs = 13.3kPa

ppO2 of tissues = 5kPa

115

Properties of Hb?

Reversible binding to O2
Tetrameric with 4 team groups so 4 O2 bind
Low affinity T-state when in tissues, high affinity R-state in lungs
sigmoidal binding curve = co-operative binding

116

O2 dissociation and temperature?

decreased affinity

117

O2 dissociation and low pH

decreased affinity

118

O2 dissociation and high CO2

decreased affinity --> Bohr Effect shift curve to the RIGHT

119

How does CO2 react in the blood?

Dissolved in water
reacting with water --> H+ & HCO3-

Binding to proteins --> carbamino compounds

CO2 mostly travels in the blood as HCO3-

120

What is Henderson-Hasselbach equation?

pH= 6.1 + Log ({HCO3-] / (pCo2 x 0.23))

121

What is the buffering effect of Hb?

Co2 reacts with water to produce H+ by carbonic anhydrase, which binds to Hb and pushes for more HCO3- production

122

What is hypoxia?

Low alveolar O2 leading to low arterial O2

123

Hypercapnia?

rise in alveolar, therefore arterial CO2

124

Hyperventilation?

Vent. increase without change in metabolism

125

What effect on pH does hyperventilation have?

Less CO2
Higher pH

126

What effect on pH does hypoventilation have?

More CO2
Lower pH

127

What are the effects of hypoventilation?

Respiratory acidosis and hypercapnia. Enzymes denature

128

What are the effects of hyperventilation?

Respiratory alkalosis and hypocapnia, free calcium conc falls as Ca only soluble in acid--> fatal tetany as nerves = hyper-excitable

129

What detects low pO2?

Peripheral chemoreceptors in carotid & aortic bodies. Fall in O2 supply to cells and only respond to large O2 drop.

130

How do the peripheral chemoreceptors respond to a fall in O2?

Increasing the tidal volume to increase rate of respiration - hyperventilate
Directing blood to kidneys & brain
Increasing HR and CO

131

How do peripheral chemoreceptors detect pCO2?

they don't! dun dun duuuuuun!

132

What detects blood pCO2?

Central chemoreceptors in the medulla of the brain
Small rise in pCO2 > hyperventilation

133

How do central chemoreceptors work?

Art pCO2 = CSF pCO2 as CO2 transfers across the blood-brain barrier but HCO3- and H+ don't.
CSF [HCO3-] are fixed by Choroid Plexus Cells, so pH rises with increased CO2 --> detected by Chemoreceptors so hyperventilate.

Persistently high CO2 --> CPC release more HCO3- to compensate therefore pH rises to normal but pCO2 remains high.

134

Respiratory failure is when..?

Art pO2 falls below 8kPa

135

What O2 saturation do clinicians aim for in T1RF?

94-98%

136

What are the signs of T1RF?

Central and peripheral cyanosis, SOB, confusion, cor pulmonale, excess RBCs

137

What are the signs of T2RF?

confusion, bounding pulse, headaches, flushing, CO2 retention flap

138

Why does T1 become T2 RF?

The muscles and cells fatigue so produce CO2 which is not adequately removed from the blood

139

What O2 saturation do clinicians aim for in T2RF?

88-92%

140

Treatments for T2RF?

Controlled O2, Non-invasive ventilation - mask

141

Causes of V/Q mismatch?

Ventilation problems = asthma
Perfusion problems = PE, pulmonary hypertension, R-->L shunt like patent foramen ovale

142

Causes of diffusion failure?

Liquid: pulmonary oedema and pneumonia

Structural: Emphysema (LESS SA) and fibrosis (THICKER)

Affects O2 not CO2

143

Causes of alveolar hypoventilation?

Obstructive: COPD, asthma

Restrictive: Obesity, fluid, fibrosis, chest wall problems, kyphosis, pneumothorax, Neuromuscular problems - resp. depression in opiate OD, head injury, muscle weakness

144

Causes for reduced O2 carriage by Hb?

Anaemia

145

What does a pulse oximeter measure?

the % saturation of O2 in Hb

146

What does ABG measure?

amount of dissolved O2 in blood

147

Consequence of chronic hypoxia?

Increased Erythropoietin production & increased vent.

148

Chronic hypercapnia?

The Choroid Plexus cells release HCO3- to compensate for high CO2, hence hypoxia drives ventilation

149

Key features about asthma?

Chronic, reversible airflow obstruction, characterised by inflammation and re-modelling of airway walls.

Triggers: cold, exercise, pollen, dust

It is treated with bronchodilators - salbutamol

150

What is the pathophysiology of Asthma?

Acute - T1H, IgE mediated, mast cell release of histamine and prostaglandins

Chronic - T4H, TH2 cells release cytokines and leukotrienes to stimulate mast cells and eosinophils.

Asthma gives thicker smooth muscle and basement membranes (deposit collagen) > reduce radius > increase resistance > reduce flow

Goblet cell hypertrophy > dry cough

151

Causes of asthma?

Genetic risk

Atopy: smoke, pollens, pollution, dust mites, fungus (aspergillus)

Stress: cold, exercise, viral URTI

Toxins: beta blockers, NSAIDs

152

Clinical presentation of Asthma?

Wheeze - expiratory sound that varies intensity & tone (polyphonic)

Dry cough - worse at night, excrete induced

SOB - esp. with exercise

Chest tightness

Airflow obstruction (entry)

Hyper-resonant percussion of chest as lungs = hyper inflated

Patient using accessory muscle to breathe

Hyper inflated chest / barrel chest

Increased RR

153

What investigations do you do fro asthma?

Bedside:
Sputum MC&S
Peak flow
Bloods:
eosinophilia, CRP
Imaging: CXR - hyperinflation
Atrophy: skin prick test

Spirometry - obstructive pattern:
FEV1 improves by 20% using salbutamol - bronchodilator reversibility

154

Causes of asthmatic attacks?

X Tx adherence
Viral URTI
Allergens & triggering drugs (NSAIDs)

155

Treatment for Asthma?

Education, prevention. drugs - B2-adrenoagonist - Salbutamol, anti-inflammatory - corticosteroids

156

Obstructive airway conditions?

COPD, Asthma, lung cancer, bronchiectasis

157

Constrictive airway conditions?

Pulmonary fibrosis
Kyphosis, scoliosis, NMD - brain, MS; obesity, pneumothorax

158

What is COPD?

Chronic and slow-progressing airway obstruction, not fully reversible. Mostly caused by smoking.

159

Pathophysiology of COPD?

Chronic Bronchitis: - chronic inflammation of bronchioles leading to fibrosis of airways and mucous gland hyperplasia

Emphysema: - destruction of alveolar walls leading to reduced SA for gas exchange and reduced expiratory volume. Often caused by smoking

160

Clinical features of COPD?

Wheeze, SOB, cough with white sputum, weight loss

161

Signs of COPD?

High RR, hyper-resonant and hyper inflated chest, cor pulmonate (raised JVP and Pulmonary oedema), barrel chest, obstructive breathing

162

Causes of COPD?

Smoking
A1AT deficiency - young and genetic
Industrial pollutants

163

Test for COPD?

Bedside: MC&S of white sputum

Bloods: FBC - raised RBCs, a1AT deficiency, ABG

Spirometry: Obstructive defect and FEV1 used to gage severity

CXR: hyperinflation, flattened diaphragm, bulla (air pocket), pulmonary vessel enlargement

164

Treatment for COPD?

Conservative: stop smoking, pulmonary rehab - exercise training to increase capacity to

Meds: bronchodilators - salbutamol
steroids as prevention
mucolytics - reduce mucus production
Abi for infections

O2 therapy - but non-smoking and not pO2 dependant for ventilation

Surgical- lung volume reduction

165

How do you assess the impairment from COPD?

MRC Dysponea scale: 1-5
1 being no trouble except breathlessness from strenuous exercise to 5- total breathlessness when dressing/unable to leave house

166

What are the natural defences of the resp. tract against infection?

Mucus - traps bacteria
Cilia wafts them to the back of the throat to be swallowed
Sneezing & coughing reflex
Lymphoid tissue of pharynx, alveolar macrophages and secretory IgA and IgG

167

What do URTI affect?

Nose, pharynx, epiglottis, larynx, sinuses and middle ear

168

Viral causes of URTI?

Rhinovirus
influenza

169

Bacterial causes of URTI?

Streptococcus pneumonia,
Haemophillis Influenza
Morexella

170

Common URTI?

Rhino sinusitis and otitis media --> mastoiditis, meningitis and brain abscesses

171

What is pneumonia?

a LRTI, inflaming the alveolar surfaces responsible for gas exchange and producing exudate

172

Lobar pneumonia is..?

Pneumonia affecting a particular lobe caused by strep. pneumonia

173

Bronchopneumonia is?

Diffuse and patchy - starting in airways and spreads to alveoli

174

Aspiration pneumonia?

Aspiration of food, drink or vomit leads to pneumonia

175

Interstitial pneumonia?

Inflammation of intersticium of lungs - epithelium, capillary end, BM

176

Chronic pneumonia?

Persisting inflammation of the LRT over a long period of time

177

How does pneumonia appear on a CXR?

consolidation - pus, cellular fluid

178

Most common cause of community acquired pneumonia?

Strep. pneumoniae
Haemophilus influenza
Atypical: chlamydia pneumophilia

179

Most common causes of hospital acquired pneumonia?

Pseudomonas aeruingosa, staphylococcus aureus, e.coli

Aspiration - stroke/elderly

Immunocompromised: TB, HSV, CMV, PCP

180

Symptoms of pneumonia?

Productive cough - purulent, heamoptysis
Pleuritic chest pain
SOB
Fevers, rigors

181

Signs of pneumonia?

Increased RR and HR
Fever
Cyanosis
Confusion
Consolidation - reduced expansion, reduced air entry, dull precision, bronchial breathing, crackles, reduced vocal resonance

182

What is CURB-65?

C = confusion
U- urea >7mmol/L
R- RR>30
B = blood pressure 65

CURB 1 = mild, 2=moderate & hospital, 3+ = severe

183

Investigations for Pneumonia?

Bedside:
MC&S of sputum
Urine for Ig - legionella
Blood:
FBC, U&Es CRP, LFTs, ABG & cultures - PCR viruses, serology

Imagining - CXR for consolidation & abscesses

184

Tx for pneumonia?

Depends on CURb-65

Community: Amoxicillin & Doxycycline

Hospital: Co-amoxiclav

IV fluids, anti-paretics, analgesia, O2

185

Outcomes of pneumonia?

Resolution

Pleural effusion & empyema
Abscesses
Septic shock

186

Prevention of pneumonia?

Immunisation for flu
Prophylaxis - oral penicillin for asplenia, IC

187

What atypical bacteria is responsible for TB?

Mycobacterium tuberculosis

188

How is TB spread?

aerosol spread through droplets and coughs

189

What does TB form on the pleural space?

Ghon focus

190

TB involvement with the lymph nodes is called a..?

Ghon complex

191

Primary TB symptoms?

Asymptomatic

192

Primary Progressive TB?

TB spread extrapulmonry and military spread (throughout body) via lymphohaematogenous system

193

Outcomes of TB?

Spontaneous resolution or localised infection - e.g. meningitis

194

Military Tb?

widespread dissemination throughout body by bloodstream - primary or in reactivation. can causes retina involvement or ascites

195

Dormant TB?

Infected, but TB is not expressing clinical or CXR signs. Will reactivate when weakened immune resistance

196

Pathology of TB?

MB injected by macrophages which escape the phagolysosomes and multiply in the cytoplasm. The intense immune response causes destruction of local tissue --> cavitation of lungs & granuloma formation, and systemic cytokine-mediated effects - weight loss & fever

197

Clinical presentation of primary TB?

Initially few symptoms - enlarged LNs

Post-primary:
Chronic cough, heamoptysis, fever, night sweats, weight loss and recurrent bacteria pneumonia

198

Tuberculosis meningitis presentation?

Fever, headaches and deteriorating level of consciousness

199

Common sites of TB infection?

Meninges,
kidneys,
lumbosacral spine - vertebral collapse and nerve compression
Large joints - destructive arthritis

200

Signs of TB?

Pleural effusion - deviated trachea, stony dull percussion, reduced vocal resonance
CXR: shadowing, cavities, consolidation, cardiomegaly, military seeds

201

Tuberculosis spondylitis?

Osteoarticular TB - affecting vertebral bones

202

TB risk factors?

history of TB
TB contact
born in country with high TB prevalence
foreign travel
immunosupression

203

Investigations?

3 Sputum cultures - acid fast, MC&S, PCR
Bloods: FBC, CRP, LFTs, HIV test
Imaging:
CXR, MRI if suspect military TB spread

204

Diagnostic tests for TB?

Quantiferon test
Measures IFN-Y production after patient lymphocytes incubated with TB antigens

205

TB Tx?

2 months RIPE
R = rifampicin
I = isoniazid
P= pyrazinamide
E = ethambutol

4 months of RI
Rifampicin & isoniazid

206

Why so many TB medications?

Reduce resistance, Directly Observed Therapy

207

Preventing TB?

BCG vaccine = attenuated liver Bovine TB

208

Public health regulations about TB?

Notifiable disease
Contact tracing - 3 months prior
Isolation in hospital
DOT if uncomplient/homeless

209

TB is associated with..?

HIV
Overcrowding
Asians
Malnutrition

210

What is Bronchiectasis?

chronic infection of bronchioles and bronchi - causing permanent airway dilatation and retention of inflammatory secretions leading to recurrent infections

211

Causes of bronchiectasis?

Congenital - CF
Post-infection - TB, pneumonia, Whooping cough
Inflammatory - RA, UC

212

Symptoms of Bronchiectasis?

Purulent cough
haemoptysis
fever
weight loss

213

Sign of Bronchiectasis?

clubbing
wheeze
fine inspiratory crepitus

214

investigations of bronchiectasis?

Sputum MC&S
Bloods - FBC, immunology, blood cultures
Imaging - CXR - thickened bronchiole walls, hyper inflated lungs
Spirometry & CT sweat test (measuring level of chloride in sweat)

215

Bronchiectasis Tx?

Chest physio
ABx - 14 days co-amoxiclav and flucloxacillin
Bronchodilators

216

What is pleural effusion?

build up of fluid in pleural space between lungs and chest wall

217

Risk factors for lung cancer?

Smoking
Age
FHx
Exposure to radiation or asbestos

218

Types of lung cancers?

Small Cell Carcinoma - presents late and mets early
Non-small cell:
Squamous cell
Adenocarcinoma
Large cell

219

Clinical features of lung cancer?

SOB
Chronic cough with heamptysis
Hoarseness
Weight loss
Fatigue
chest pain

220

Signs of lung cancer?

clubbing
supraclavicular/axillary LNs
anaemia,
Horners
Pleural effusions

221

Investigations for Lung cancer?

Bloods - FBC, U&Es, Lung function test, bone profile
Imaging:
CXR, staging CT (TNM), PET-CT as detects mets

Biopsy - bronchoscopy, thoracoscopy

Pleural fluid aspiration
Lung function test

222

Complications of LC?

Local: recurrent laryngeal nerve palsy, phrenic nerve palsy, SVC obstruction, AF, Horners syndrome

Distant:
mets to bone
compression of VC - weak legs, back pain, loss off sensation, NM problems

Liver - hepatomegaly
Brain - confusion
Adrenal gland - addison's

Paraneoplastic:
MSK - clubbing
Peripheral neuropathy
Anaemia
Endo:
Raised Ca - PTHrp
SIADH
Cushings - ATCH

223

LC Tx?

Curative vs Palliative

Surgery
Chemo
Radio

224

Stages of LC?

1 - small, localised to 1 area
2&3 - larger and growth to LNs
4 - distant metastasis

225

TMN of LC?

T1 - within lung 1 cancer in same lobe

N0 - no LNs
N1 - nearest node
N2 - same side of mediastinum
N3- opposite side/supraclavicular

M0/1

226

How to obtain a biopsy of lung?

Bronchoscopy with needle or surgical biopsy

227

What type of LC is worse?

Small cell

228

What causes pleural effusions?

Exudate from increased capil. permeability - cancers, pneumonia, TB, inflam. (RA, SLE)

Transudate: increase hydro. or reduced oncotic pressure
PE, HF, CKD, liver failure

229

Investigations for pleural effusions?

Bloods: FBC, U&Es, LFT, CRP
CXR: blunt costophrenic angle, meniscus sign, mediastinal shift

US-guided pleural aspirationL colour, biochem (pH LDH, proteins, glucose), cytology, microbiology,

230

What are different types of pleural effusions?

Haemothorax - blood
Empyema - pus
Chylothorax - lymphatic fluid
Simple effusion - serous fluid

231

What are interstitial lung diseases?

disorders affecting lung parenchyma (between capillaries and alveoli) - contains fibrous tissue, cells of fluid

232

Causes of ILD?

Occupation - asbestos, silica
Iatrogenic - methotrexate, chemo
Inflammatory - RA, SLE
Idiopathic
Infection - TB

233

Symptoms of ILD?

SOB
Progressive dry cough
Coarse inspiratory crackles
Abnormal CXR - shadowing
Restrictive spirometry

234

Investigations for ILD?

Bloods - FBC (eosinophilia), immunology, CXR, spirometry

235

ILD Tx?

Underlying cause
High dose steroids
O2 therapy
analgesics
X smoking

236

Talk about asbestos exposure?

Causes asbestosis, mesothelioma, pleural plaques, pleural thickenings, pleural effusions

237

Mesothelioma signs?

Chest pain, weight loss, SOB, recurrent pleural effusions

CXR - pleural effusions, thickenings
Pleural biopsy

238

What is extrinsic allergic alveolitis?

exposure to inhaled allergen causing reaction.

Inspiratory crackles
wheeze
No finger clubbing
Micro nodules

Acute - sudden onset within hours, reversible spont. / with tx

Chronic - less reversible

239

Causes of allergic alveolitis?

bird fanciers - droppings
mouldy hay with farmers - aspergillus

240

What is a pneumothorax?

air trapped in pleural space - associated with trauma

241

What is a tension pneumothorax?

tracheal shifts AWAY from pneumothorax

242

CXR - calcified plaques?

Asbestos exposure

243

Hyperinflation?

COPD - blunting of costophrenic angles and hemidiaphragms

244

Pneumoperitoneum?

Bowel perforation with air seen under the diaphragm

245

CXR - cardiomegaly?

Over 50% the width of the thorax (measuring from widest past of heart and ribcage laterally)

246

Why is it harder to breath with ILD?

Fibrosis is restrictive deficit, resistance not increased, lengthened diffusion pathway

247

What is fibrosis alveolitis?

Progressively inflammatory condition - activated alveolar macrophages attracting neutrophils and eosinophils, damaging lung with proteases and ROS leading to fibrosis.

Finger clubbing, SOB, non-productive cough, micro-nodules on CXR.

Tx - high dose steroids

248

What is sarcoidosis?

non-caseasting granuloma
idiopathic
fluid in always and lots of cells in the alveoli
diffuse fibrosis
genetic predisposition
Features - asymptomatic, cough & SOB
Tx - steroids

249

What is pleurisy/ pleuritis?

Inflammation of pleura

250

Signs of pleurisy?

Sharp pain on inspiration and pleural rub - creaking noise in steph. with resp. movements

251

Causes of pleurisy?

Infection - TB, pneumonia

Autoimmune - SLE, RA

Lung cancer
Pneumothorax
PE

252

Chest wall abnormalities?

scoliosis
kyphosis
broken ribs --> pneumothorax

253

Muscle and neuro disease?

Muscular dystrophy
Motor neurone disease
polio

At risk of resp. failure, and infections