Resp Flashcards
1
Q
What is pleura made from?
A
a serous membrane of a single layered mesothelial cells & thin CT underneath
2
Q
What is parietal pleura?
A
the inside part lining each hemithorax and continues with the visceral pleura at hilum of lung
3
Q
What is visceral pleura?
A
lines the outside of lunges extending between lobes into the fissures
4
Q
What is the BS of pleura?
A
Intercostal & internal thoracic arteries and veins
5
Q
Innervation of pleura?
A
Parental pleura = somatic (intercostal & phrenic nerves) & autonomic
Visceral = no somatic, only autonomic
6
Q
What is the pleural cavity/space?
A
potential peace between layers of pleura which is filled with fluid produced from the parietal space & absorbed by parietal lymphatic vessels
7
Q
What is the function of pleural fluid?
A
allow the 2 layers to slide - allowing chest & lung moment in breathing
8
Q
What is an important characteristic of the pleural fluid?
A
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
Q
Where is the apex of the lungs?
A
Above 1st rib, into the neck
10
Q
Where is the base of lungs?
A
concave shape resting on diaphragm
11
Q
How many lung lobes are there?
A
Left = 2 --> 1 fissure Right = 3 --> 2 fissure
12
Q
What are the 3 surfaces of the lung?
A
costal, mediastinal, diaphragmatic
13
Q
What are the names of the Right lobes and lung fissures?
A
Superior, middle & inferior lobes created b the right oblique & horizontal fissure
14
Q
Left lung lobes and fissure?
A
superior and inferior lobes created by left oblique fissure
15
Q
what is in the lung hilum?
A
bronchi, pulmonary arteries, superior & inf. pulmonary veins, pulmonary plexus of nerves and lymphatics
16
Q
What is the pathway of the trachea?
A
Lower border of cricoid cartilage terminating into the Right and Left main bronchi at sternal angle
17
Q
What shape cartilage are found in trachea?
A
c-shaped
18
Q
What epithelium is the trachea?
A
pseudostratified ciliated columnar
19
Q
what is the carina?
A
the angle between the the right & left main bronchi
20
Q
what is the pathway of the airways?
A
Trachea> R main bronchus> lobar bronchi> segmental? bronchioles> terminal bronchioles>alveolar ducts> alveoli
21
Q
What bronchus is shorter wider and more vertical?
A
the right main bronchus
22
Q
What is the blood supply of the lungs from the heart?
A
1 Pulmonary A from pulmonary trunk
2 Pulmonary veins
23
Q
What is the BS to the supporting lung structures?
A
Bronchial arteries coming from the Thoracic aorta
24
Q
What is the mediastinum?
A
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
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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
```
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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
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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
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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
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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
