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1
Q

What are the two types of asthma?

A 
Eosinophillic = associated with allergy, T cells recruit eosinophills which damge the epitherlium leading to inflammation and mucus production
Non-eosinophillic = influenced by smoking an dobesity, involves neutrophils instead of eosinophills
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2
Q

What is the atopic triad?

A

Eczema, Hayfever and Asthma

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3
Q

S&S of asthma?

A

Episodic polyphonic expiratory wheeze with cough and dysponea. There will be diurnal variation (worst between 3-5am) and may be hyperinflation of the chest.
Symptoms worsened by Bera-blockers and aspirin

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4
Q

Tests for asthma?

A

FEV1:FVC < 70% as FEV1 <80% but FVC is normal
Eosinophillic = increased eosinophils, do FENO test.
Atopy tests, no crackles or sputum in the lungs

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5
Q

Treatment for asthma?

A

Avoid allergens and quit smoking/lose weight
Bronchodilators (Beta-2 agoinsts e.g. SA - Salbutamol and LA - salmeterol) or anticholinergics (tiotropium).
Severe cases = inhaled steroids.
Omalizumab/mepolizumab in severe eosinophilic disease.
Bronchial thermoplasty

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6
Q

What is the diagnostic criteria for severe asthma?

A

1 of = continuous steroid treatment needed or high dose inhaled steroids neededd
2 of = additional reliever medication needed, FEV1 < 20%, > 1 A&E visit per year, >3 steroid courses per year, rapid deterioration with 25% steroid reduction or any near fatal event

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7
Q

What is brittle asthma?

A

A rare form of severe asthma which is unpredictable and difficult to control. It can be life threatening

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8
Q

When should you admit an asthma attack to hospital, what are the criteria?

A

Severe (1 of) = PEFR 33-50%, RR >25, HR >110, inability to complete scentences
Life-theatening (1 of) = PEFR <33%, PaO2 <8kPa, PaCO2 >4.6kPa, exhaustion/confusion/coma, arrythmia/hypotension, silent chest/cyanosis

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9
Q

Treatment of asthma attack?

A

Salbutamol nebulised with oxygen, prednisolone (IV/PO), add ipratropium if no improvement.
Concider ICU admission.
Measure PEFR 20 mins after nebulising and take ABG (repete every 2 hours)

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10
Q

What criteria must be met to discharge a patient after an acute astma attack?

A

Achieve PEFR >75% with <25% diurnal variation
Been stable on discharge medication for >24 hours
Had inhaler technique checked
Have their own PEF meter and management plant
Steroids and bronchodilator therapy to take home
GP appointment <48hrs booked
Resp clinic appointment <4 weeks booked

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11
Q

What is COPD?

A

Progressive disease of irreversible airway obstruction.
Is a combination of chronic bronchitits (airway inflammation and mucus = increased airway resistance) and emphysema (loss of alveolar attachments and decreased elastic recoil)

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12
Q

What are the 2 main causes of COPD?

A

Smoking, Alpha-1 antitrypsin deficiency

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13
Q

S&S of COPD?

A

Dysponea, wheeze and productive cough with minimal diurnal variation. There will be tachyponea, hyperressonant percussion and hyperinflation/barrel chest due to use of accessory muscles to breath

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14
Q

What is the scoring system used to grade COPD dysponea?

A 
MRC dysponea score (mMRC = US, same but 0-4)
1 = SOB on marked exertion
2 = SOB on hills
3 = has to slow or stop on flat
4 = tolerates 100-200 yards on flat
5 = housebound/ SOB at minor tasks
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15
Q

Treatment for COPD?

A

Bronchodilators = Beta-agonists (SA - salbutamol, LA - salmeterol) or anti-cholinergics (e.g. tiotropium), inhaled corticosteroids, oxygen therapy with/without NIV, mucolytics, lung transplant/volume reduction surgery

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16
Q

How is COPD classified?

A

Stage 1 = FEV1 >80%, chronic cough and no-mild SOB
Stage 2 = FEV1 50-79%, SOB on exertion
Stage 3 = FEV1 30-49%, SOB on low exertion
Stage 4 = FEV1 <30%, SOB at rest

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17
Q

Pink Puffers vs Blue Bloaters?

A 
PP = increased alveolar ventilation normal O2/CO2, emphysematous and weight loss - breathless but NOT cyanosed
BB = decreased alveolar ventilation, low PaO2/high PaCO2, cyanosed but not breathless - may relt on hypoxic drive to breath
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18
Q

What is bronchiectasis?

A

Chronic inflammation of the bronchi/bronchioles leading to permanent dilation and thickening of the airway. Patients struggle to clear the airways and suffer frequent infections

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19
Q

Causes of bronchiectasis?

A

Pneumonia, granulamotous disease e.g. TB, measlesm whooping cough, CF, HIV, foreign body, allergy or tumour

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20
Q

S&S of bronchiectasis?

A

Nail clubbing, wheeze, foul-smelling purluent sputum, chest pain, dysponea and intermitent haemoptyisis

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21
Q

Treatment of bronchiectasis?

A

Chest physio, postural drainage, mucolytics, anti-imflammatories e.g. long-term azithromycin, surgery if local disease and bronchodilators

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22
Q

What is idiopathic pulmonary fibrosis?

A

A type of ILD characterised by progressive chronic pulmonary fibrosis with minimal/abscent inflammation and collagen deposition leading to loss of elasticity and loss of gas exchange ability. Restrictive lung disease.

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23
Q

S&S of idiopathic pulmonary fibrosis?

A

dry cough with or without sputum, exertional dysponea, cyanosis, weight loss, finger clubbing and fine bi-basal crackling

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24
Q

Treatment for idiopathic pulmonary fibrosis?

A

Ambulatory oxygen, pulmonary rehab, pirfenidone to reduce FVC decline, lung transplant and opioids in palliative care.
DO NOT give high dose steroids

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25
Risk factors for idiopathic pulmonary fibrosis?
Being male, smoking, infection e.g. CMV/EBV, drugs e.g. methotrexate, GORD and occupational dust exposure
26
What causes cystic fibrosis?
An autosomal recessive mutation on chromosome 7 meaning a defective CFTR protein is made so less chloride ions are secreted and more sodium ions are absorbed = thicker mucus
27
S&S of CF
``` Neonate = failure to thrive, meconium ileus and rectal prolapse Resp. = cough, wheeze, dysponea, thick mucous production, reccurent infections and bronchiestasis GI = thick secretions, pancreatic insufficiency, increased cholesterol gall stones, intestinal obstruction and poor nutrition Other = male infertility, salty sweat, clubbing and osteoporosis ```
28
What is a diagnostic test for CF?
``` One or more of: Sweat test (salty) Absent vas deferens and epididymis GI and nutritional disorders Genetic screening in known genotypes ```
29
Treatment for CF?
Stop smoking, chest physio, prophylactic antibiotics/vaccines, Beta-2 agonists and inhaled corticosteroids, mucolytics, pancreatic enzyme replacement, bisphosphonates and lung transplant
30
What is sarcoidosis?
ILD. It is a granulomatous disorder of unknown cause affecting any organ system but mainly the lymp nodes and the lungs
31
S&S of sarcoidosis?
Fever, weight loss, fatigue, dry cough, progressive dysponea, decreased exercise tolerance, chest pain, lymphadenopathy, hepatosplenomegaly, conjunctivitis, Bell's palsy, cardiomyopathy, arrhythmias, erythma nodosum and renal stones
32
Treatment of sarcoidosis?
Acute = bed rest and NSAIDs Prednisolone or if severe IV methyprednisolone/immunosuppresants e.g. methotrexate. Lung transplant If BHL alone there is no need for treatment.
33
What is a definitive test for sarcoidosis?
Tissue biopsy showing non-caseating granulomatas
34
What is Wegener's granulomatous?
Granulomatous disease characterised by necrotising granulomatous inflammation and vasculitis of the small/medium vessels - ANCA positive
35
S&S of Wegener's granulomatous?
Severe rhinorrhoea and nasal mucosal ulceration, glomerulonephritis, proteinuria/haematuria, skin purpura, cough, peripheral neuropathy and arthritis
36
Treatment of Wegener's granulomatous?
Predisolone and cyclophosphamide/rituximab
37
What is Hypersensitivity pneumonitits?
ILD. Caused by allergic response (type 3 hypersensitivity) to an inhaled antigen or ingested drug which leads to granulomatous inflammation of the lung parnchyma. Acute/subacute = reccurrent pneumonitits Chronic = fibrosos/emphysema/permanent lung damage
38
S&S of hypersenitivity pneumonitis?
``` Acute = fever, rigours, myalgia, dry cough, dysponea, crackles (no wheeze) and chest-tightness Subacute = history of acute attacks. Same as above but more severe and more gradual onset Chronic = cyanosis, weight loss, clubbing, increased dyspone and type 1 respiratory failure ```
39
When do the different types of hypersensitivity pneumonitis onset/begin to heal?
``` Acute = onset 4-6 hours post exposure, resolves 24-48 hours post removal of causative antigen Sub-acute = onset due to intermittent low level exposure, resolves in weeks-months after causative antigen is removed Chronic = no history of preceeding acute symptoms and only partial recovery on removal of causative antigen ```
40
Treatment of hypersensitivity pneumonitis?
Remove/avoid allergen, give oxygen and prednisolone (long term in chronic)
41
What is is Goodpasture's syndrome?
A type II hypersensitivity reaction and autoimmune disease against the basement membrane of the kindeys and lungs leading to alveolar haemorrhage and acute glomerulonephritis
42
S&S of Goodpasture's syndrome?
anaemia, acute glomerulonephritis, cough, intermittent haemoptysis and tiredness. Starts with symptoms of URT infection e.g. sneezing/fever
43
What is the diagnostic test for goodpasture's syndrome?
anti-GBM antibodies in the blood
44
Treatment for goodpasture's syndrome?
Treat shock, prednisolone and plasmapheresis. | Some patients improve spontaneously others progress to renal failure
45
Risk factors for PE?
DVT, recent surgery, throbophillia, imobilisation, malignancy, pregnancy, combined oestrogen pill/HRT and previous PE
46
S&S of PE?
Tachycardia, tachyponea, cyanosis, hypotension, pleural rub, pleural effusion, dysponea, heamoptysis, dizziness, syncope and tender hard calf
47
Tests for PE?
V/Q mismatch, D-dimer is positive - then do CT pulmonary angiography (will also be positive), increased troponin (due to RH failure)
48
Treatment of PE?
Oxygen, morphine plus anti-emetic, LMW heparin, IV fluids, thrombolysis, long term = LMW heparin and warfarin/DOAC
49
What is pulmonary hypertension?
Mean pulmonary arterial pressure >25mmHg and secondary right heart failure. Occurs due to increase in pulmonary vascular resisitance or increase in pilmonary blood flow.
50
What are the different types of pulmonary hypertension?
Group 1 = pulmonary arterial hypertension - connective tissue diseases, HIV or cirrhosis Group 2 = L heart disease - mitral/aortic valve disease and LVHF Group 3 = lung disease - COPD, pulmonary fibrosis and obstructive sleep apnoea Group 4 = chronic blood clots - PE or clotting disorders Group 5 = other causes e.g. inflamatory/metabolic disorders, tumours and kidney disease
51
S&S of pulmonary hypertension?
Exertional dysponea, lethargy, fever, ankle oedema, chest pain, syncope and cor pulmonale
52
Treatment of pulmonary hypertension?
Treat underlying cause, oxygen, warfarin, diuretics, CCBs, phosphodiesterase-5-inhibitors and heart-lung transplant
53
What are the two types of pleural effusion?
Transudate = <25g/l of protein with transparent fluid. The blood vessels remain intact Exudate = >35g/l of protein with cloudy fluid. The pleural cappilaries are leaky to protein
54
Causes of pleural effusion?
``` Transudate = increased venous pressure (e.g. due to HF or fluid overload), hypoproteinemia (e.g. due to cirrhosis, malabsorption or nephrotic syndrome) and peritoneal dialysis Exudate = pneumonia, malignancy, TB and pulmonary/myocardial infarction ```
55
S&S of pleural effusion?
Pleuritic chest pain, decreased chest expansion on the effected side, tracheal deviation away from effected side, stony dull percussion, decreased vocal resonance, breathlessness and cough
56
How do you diagnose pleural effusion?
Aspiration with pleural tap. Purulent = pus effusion, turbid = infection effusion and milky = lymph fluid effusion 300-600ml seen on CXR
57
Treatment of pleural effusion?
Treat the underlying cause, drain if symptomatic, pleurodesis with talc (with doxycycline injections) to prevent ruccurence and surgery
58
What are the types of pmeumothorax?
``` Simple = 2 way valve in the lung, can be open (caused by penetrating thoracic injury which allows air to enter teh chest - pleural cavity pressure = thoracic pressure) or closed (caused by air originating from the respiratory sytem - pleural cavity pressure < atmospheric pressure) Tension = one way valve, pleural cavity pressure > atmospheric pressure ```
59
S&S of pneumothorax?
Reduced chest expansion on the affected side, hyper-resonant percussion on teh affected side, absent breath sounds on the affected side, tachycardia, tachyponea, dysponea and pleuritic chest pain. IF TENSION = tracheal deviation away from affected side
60
Treatment for pneumothorax?
Stop smoking, oxygen mask, needle thoacostomy aspiration (2nd intercostal space in mid-clavicular line), intercostal chest drain in triangle of saftey if traumatic/haemothorax/mechanically ventilated
61
What is the main complication of tension pneumothorax?
Cardiorespiratory arrest
62
Common causes of pharygitis/tonsillitis?
Adenovirus, rhinovirus, EBV, HIV and lancefield group A beta-haemolytic streptococcus e.g. strep pyogenes
63
S&S of pharygitis/tonsillitis?
Sore throat, fever, tender and enlarged neck lympnodes/glands, large tonsils with exudate in tonsillitis
64
Common causes of sinusitis?
streptococcus pneumoniae | haemophillus influenzae
65
S&S of sinusitis?
fever, purulent nasal discharge, facial/ear/teeth pain
66
Common causes of acute epiglottitis?
Haemophilus influenzae, steptoccocus pneumoniae, fungal infections (if immunocompromised), herpes simplex virus and VZV
67
S&S of acute epiglottits?
Fever, sore throat, odonophagia, weight loss, inspiratory stridor, oral thrush, severe airflow obstuction and diarrhoea
68
Treatment for acute epiglottits?
Urgent endotracheal intubation and IV ceftazidime
69
Causes of whooping cough?
Bordetella pertussis - most common, B.parapertussis and B. bronchiseptica
70
S&S of whooping cough?
chronic cough, fever, subconjunctival haemorrhage, rhinorrhoea, malaise, anorexia and coughing spasms ending in vomiting
71
Treatment for whooping cough?
Clarithromycin early on and vaccination
72
What is coup/acute laryngotracheobronchitis?
A complication of URT infections leading to inflammatory oedema extending to the vocal cords and epiglottis. Causes narrowing of teh neck and abdomen during inspiration
73
S&S of coup?
Fever, cyanosis, prominent barking cough, increased resp. rate, prominent intercostal recessions and inspiratory stridor
74
Common causes of TB?
Mycobacterium tuberculosis - most common, mycobacterium bovis, mycobacterium africanum and mycobacterium microti
75
S&S of TB infection?
weight loss, fever, anorexia, night sweats, malaise Pulmonary = productive cough >3weeks, occasional haemoptysis, chest pain, hoarse voice and dysponea Extrapulmonary = lymphadenopathy, bone pain, frequency, dysuria, haematuria, meningeal inflammation with thick exudatem raised ICP
76
Treatment of TB?
Antibiotic treatment: rifampficin and isoniazib for 6 months, pyrazinamide and ethambutol for 2 months. THE FIRST 2 MONTHS OF ALL 4 IS INTENSIVE. Offer patient DOTS to enusre compliance, contact tracing and notify PHE
77
How do you diagnose TB?
Ziehl-neelsen stain of sputum collected on 3 seperate occassions and tuberculin stain test for latent disease checks
78
What are the types of pneumonia?
``` CAP = no underlying malignancy or immunosuppresion can be localised or diffuse HAP = new onset in patients who have been hospitalized >48hours or who have been in the health care setting for >3months, often seen in ventilated patients Immunocompromised = as it sounds Aspiration = acute aspiration of gastric contents into the lungs ```
79
Causes of pneumonia?
CAP: Strep. pneumonia = most common, H. influenzae, staph.aureau, Klebsiella pneumoia, Mycoplasma pneumonia and E.coli HAP: MRSA, E.coli, Klebsiella pneumonia, pseudomonas aeruginosa
80
S&S of pneumonia?
Fever, night sweats, anorexia, pleuritic chest pain, tachyponea, tachycardia, dysponea, chest is dull to percuss, dry/productive cough, cyanosis, purulent sputum, decreased blood pressure and condusion
81
What is CURB 65?
An assesment criteria for CAP severity. 1 point for each: Confusion, Urea >7mmol/l, RR>30, BP <90mmHg systolic and/or <60mmHg diastolic, older than 65. 0-1 = mild, no admission necessary, 2 = moderate, admit 3-5 = severe, admit and closely monitor
82
Treatment for pneumonia?
Oxygen and analgesics, Stage 0-2 = amoxicillin for 5-7 days Stage 3+ = co-amoxiclav/clarithromycin for 7-10days Long term = stop smoking and vaccinate
83
What is empyema?
A collection of pus in the plural cavity often associated with pneumonia
84
S&S of empyema?
Ongoing fever, pain on deep inspiration, dull stony percussion, decreased air entry to the lungs and failure of symptoms to improve on antibiotics
85
Treatment of empyema?
Immediate chest drain, co-amoxiclav, piperacillin-tazobatam AND meropenem
86
What is a lung abscess?
Severe localised cavity and pus fromation within the lungs. Caused by strep. milleri and klebsiella pneumoniae
87
Treatment of a lung abscess?
6 weeks of antibiotics and surgical drainage
88
What is small cell lung cancer?
A very aggressive lung cancer which metasisises early. It arises from epithelial cells in the central bronchus and has a strong association with smoking. They secrete polypetptide hormoes and have a poor prognosis
89
What is non-small cell lung cancer?
Can be divided into squamous cell carcinoma (arises from central epithelial cells - strong association with smoking and causes necorsis), adenocarcinoma (arises from mucous-secreting cells - associtaed with asbestos) and carcinoid tumours (are neuroendocrine secreting cells). It has some association with smoking and metastises less aggressivley
90
Where do secondary lung tumours commonly come from?
Breast, bowel, kidney and bladder cancers
91
S&S of lung cancer?
Cough, dysponea, haemoptysis, chest pain, anorexia, weight loss, anaemia, clubbing, pleural effusions and reccurent infection
92
What staging is udsed for lung cancer?
TNM staging system
93
Treatment of lung cancer?
NSCLC (more common) - surgical excision, chemotherapy and/or radiotherapy SCLC - combined chemotherapy and radiotherapy. Palliative care with dexamethosone, tracheal stenting, pleural drainage, steroids, analgesics and antiemetics
94
What is a mesothelioma?
A high grade malignancy of the pleura which is strongly associated with asbestos. Also affects the mesthelial cells of the peritoneum, pericardium and testes
95
S&S of mesothelioma?
Chest pain, dysponea, reccurent pleural effusions, finger clubbing, weight loss, anorexia and anemia
96
Treatment of mesothelioma?
Prognosis is very poor, death <8months. | Refer all cases to HM coroner

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