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1

COPD epidemiology

Common in smokers, rarely symptomatic before middle age.

2

COPD signs and symptoms

Cough with production of sputum, wheeze and breathlessness.
Often lean forward, barrel chested, prolongued expiration.
May have secondary pulmonary hypertension, raised JVP and oedema.
Cachexia can occur.

3

COPD investigations

Spirometry
FEV1 reduced more than FVC

4

Diagnosis for COPD

FEV1 less than 80% predicted (unless mild)
FEV1:FVC less than 0.7 (all COPD sufferers)
Little or no reversibility.

5

COPD pathology

Chronic bronchitis is inflammation
Emphysema is enlargement of air spaces accompanied by destruction of their walls.
Single greatest factor is cigarette smoking.

6

How does cigarette smoking cause COPD

Irritant causing hypertrophy of submucosal glands and hypersecretion of mucus in large airways, and respiratory bronchiolitis in small airways.
Alters oxidant/anti-oxidant balance and protease/antiprotease balance (due to increased inflammation) leading to emphysema.
Low α1-antitrypsin leads to emphysema with/w’out smoking.

7

Complications of COPD

Cor pulmonale
Respiratory failure.

8

Treatment of COPD

Smoking cessation
Bronchodilators (B2-agonists and antimuscarinic ipratropium bromide)
Corticosteroids sometimes
Vaccination to prevent IECOPD.
Oxygen.

9

Treatment of IECOPD

Oxygen
Bronchodilators
Antibiotics
BiPAP (Bilevel positive airway pressure)

10

Bronchiectasis epidemiology

In developed countries most common cause is cystic fibrosis, but can be caused by infections.

11

Bronchiectasis clinical picture

Cough and sputum production; if severe, latter is green and foul-smelling.
Possible massive haemoptysis, breathlessness and wheeze

12

Bronchiectasis OE

clubbing and coarse inspiratory crackles.

13

Bronchiectasis investigations.

Chest X-ray can be normal or dilated bronchi with thickened walls, and multiple fluid containing cysts.
CT may show airway dilatation, bronchial wall thickening and cysts.
In infective exacerbration do sputum culture.
Spirometry often shows obstructive pattern.

14

Bronchiectasis treatment

Physiotherapy for postural drainage
Antibiotics
Bronchodilators if airway limitation
Steroids to decrease progression

15

Cystic fibrosis definition

An autosomal recessive condition caused by mutations in CFTR gene resulting in a defective chloride channel in epithelial cell membranes and hence an increase in viscosity and tenacity of mucus on epithelial surfaces in the pancreas, respiratory, GI and reproductive tracts.

16

Cystic fibrosis epidemiology

1:2000 live births.

17

Cystic fibrosis clinical picture.

Normal at birth, respiratory symptoms normally present.
Bronchiectasis and obstructive disease are primary causes of morbidity and mortality.
Meconium ileus in 1/5 of CF newborns: pathognomic.

18

Causes of infections in cystic fibrosis

Gram -ives, Staph aureus and H. influenzae in infants.
Pseudomonas in adult.

19

Cystic fibrosis treatment

Management of bronchiectasis and exocrine pancreatic insufficiency

20

Cystic fibrosis investigation

Family history
High sweat sodium and chloride (more than 60 mmol/l)
Blood DNA analysis of gene defect
Absent vas deferens and epididymis.

21

Asthma definition

A common chronic inflammatory condition characterised by reversible airflow limitation, airway hypersensitivity and inflammation of the bronchi.

22

Asthma epi

Common, especially in teenage

23

Asthma pathogenesis

Narrowing of airway is due to smooth muscle contraction, thickening of for airway wall and increased secretion within the lumen.

24

Asthma clinical features

Wheezing, cough, chest tightness and shortness of breath; intermittent, worse at night.

25

Asthma treatment

B-agonists
Antimuscarinic bronchodilators
Corticosteroids
Anti-inflammatory agents such as sodium cromoglicate (in mild)
leukotriene receptor antagonists.

26

Emergency treatment of acute severe asthma

O2
Salbutamol or terbutaline by oxygen driven nebs
Hydrocortisone 100 mg IV or 60mg oral
NO SEDATIVES
Abx
CXR to exclude pneumothorax or pneumonia.

27

Definition of pneumonia

An inflammation of lung tissue usually caused by infection. It is defined both anatomically and by aetiology.

28

Clinical features of pneumonia
How to assess severity.

Very variable: pyrexia, cough, sputum, pleurisy and dyspnoea.
Consolidation, pleural rub, pleural effusion.
Assess severity using CURB 65

29

Pneumonia investigations

CXR for outpatients
For inpatients: bloods (WBC, liver biochem, U&Es, serology), ABGs, CXR,

30

Pneumonia treatment

Mild CAP: oral amoxicillin or clarithromycin.
Severe CAP: both above
CURB-65 > 3: IV cefuroxime and clarithromycin

Fluids.

31

Pneumonia complications

Pleural effusion,
Respiratory failure
Lung abscess
Empyema.

32

Lung abscess definition

Localised suppuration of the lung associated with cavity formation.

33

Lung abscess clinical features

Worsening pneumonia
Copious amounts of foul smell sputum.

34

Lung abscess investigations

Bacteriological investigation on aspiration or bronchoscopy samples.

35

TB clinical features

Malaise, anorexia, weightloss, fever and cough
Mucoid, purulent or blood stained sputum

36

TB investigations

CXR (patchy shadows in upper zones)
Ziehl-Neelsen stain for acid fast bacilli (sputum)
PCR testing (not entirely reliable)

In miliary TB: lumbar puncture and CSF examination.
HIV testing.

37

TB management

6 months: rifampicin and isoniazid.
2 months at start: pyrazinamide and ethambutol

38

Sarcoidosis def

A multisystem granulomatous disorder of unknown aetiology.

39

Sarcoidosis epi

All ethnicities, but rare in Japanese and severe in African blacks. Peak incidence in 30s. More women than men.

40

Sarcoidosis clinical features

Bilateral hilar lymphadenopathy
Erythema nodosum
Uveitis
Polyarthralgia

41

Sarcoidosis complications

Progressive fibrosis of lungs leading to increased effort, cor pulmonale and death.
Blindness.

42

Sarcoidosis investigations

CXR
Transbronchial biopsy
Lung function tests show restrictive lung defect
ACE is raised in 75% of patients (not diagnostic)

43

Sarcoidosis differential diagnoses

Lymphoma, TB, Bronchial carcinoma w secondary spread.

44

Sarcoidosis management

Steroid use contested.
Topical steroids used for eye involvement.

45

Wegener's granulomatosis def

This is a vasculitis of unknown aetiology characterised by lesions involving the upper resp tract, the lungs and the kidneys.

46

Wegener's granulomatosis clinical picture

Often starts with rhinorrhea, progresses to nasal mucosal ulceratoin, cough, haemoptysis and pleuritic pain.

47

Wegener's granulomatosis investigations

ANCA in 90% of active cases.
CXR (nodular masses, pneumonic infiltrates with cavitation)

48

Wegener's granulomatosis treatment

Cyclophosphamide

49

Idiopathic pulmonary fibrosis epi

rare

50

Idiopathic pulmonary fibrosis def

Rare disorder of unknown aetiology characterised by sequential acute lung injury resulting in scarring, which generally presents in middle age.

51

Idiopathic pulmonary fibrosis presenting clinical features

Exertional dyspnoea and non-productive cough.

52

Idiopathic pulmonary fibrosis end-stage clinical features

Respiratory failure, pulmonary hypertension and cor pulmonale.

53

Idiopathic pulmonary fibrosis investigations

Blood gases (hypoxaemia w normal PaCO2)
CXR (ground glass, honeycombing)
CT (irreg linear opacities and honeycombing)
Resp fuction tests (restrictive defect)
Histology biopsy
(Autoantibodies in 1/3)

54

Idiopathic pulmonary fibrosis treatment

Oxygen, pulmonary rehab, opiates and palliative. No high dose steroids unless diagnosis in doubt.
Lung transplantation.

55

Extrinsic allergic alveolitis def

A disease of widespread diffuse inflammation in the alveoli and small airways of the lung in response to an inhaled antigen.

56

Type 1 resp failure definition

PaO2 less than 8, PaCO2 less than 6

57

Type 2 resp failure definition

PaO2 less than 8, PaCO2 more than 6.

58

Type 1 resp failure definition

PaO2 less than 8, PaCO2 less than 6

59

Type 2 resp failure definition

PaO2 less than 8, PaCO2 more than 6.

60

Normal PaO2

10.5-13.5 kPa

61

Spirometry results showing restrictive defect

FVC decreased and FEV1/FVC ratio is normal or raised

62

Causes of restrictive defect

Sarcoidosis, Pneumoconiosis, interstitial pneumonias, connective tissue diseases, pleural effusion, obesity, kyphoscoliosis, neuromuscular problems.

63

Common organisms causing CAP

Strep pneumoniae
Haemophilus influenzae
Mycoplasma pneumoniae.

64

Common organisms causing HAP

Staph aureus, pseudomonas, klebsiella, bacterioides and etc.

65

Describe CURB-65 score

Confusion. Abbreviated mental test score less than 8.
Urea of more than 7 mmol/L
Resp rate of more than 30 breaths per minute
BP of less than 90 systolic.
Age above 65.
One point for each of the above:

66

Pneumococcal pneumonia (basic and treatment)

Commonest bacterial pneumonia. Treat with amoxicillin, benzylpenicillin or cephalosporin.

67

Staphylococcal pneumonia

Bilateral cavitating bronchopneumonia

68

Who gets Pseudomonas pneumonia?

People with bronchiectasis or CF. Also those in ITU or after surgery.

69

Symptoms for mycoplasma pneumonia?

Headaches, myalgia, arthralgia.
Dry cough.

70

Complications of mycoplasma pneumonia.

Skin rash (erythema multiforme), SJS, meningococcal encephalitis, Guillan-Barre syndrome.

71

Legionella pneumonia symptoms

Fever, malaise, myalgia,
Dry cough, dyspnoea

72

Extrapulmonary features of legionella infection

Anorexia, D&V, hepatitis, renal failure, confusion and coma.

73

Blood tests in legionella infection

Lymphopenia, hyponatraemia, and deranged LFTs.

74

What are Light's criteria to diagnose exudative pleural fluid?

Pleural fluid is an exudate if one or more of the following
criteria are met:
 Pleural fluid protein divided by serum protein is >0.5
 Pleural fluid lactate dehydrogenase (LDH) divided by
serum LDH is >0.6
 Pleural fluid LDH >2/3 the upper limits of laboratory
normal value for serum LDH.

75

Congenital diseases causing bronchiectasis

CF, Young's syndrome, primary ciliary dyskinesia, Kartagener's syndrome.

76

Infections causing bronchiectasis

Measles, pertusis, bronchiolitis, pneumonia, TB, HIV

77

Non-congenital, non-infective causes of bronchiectasis

Obstruction, allergic bronchopulmonary aspergillosis, hypogammaglobulinaemia, rheumatoid arthritis, ulcerative colitis, idiopathic.

78

5 ways aspergillus can affect the lung

Asthma in response to spores
Allergic bronchopulmonary aspergillosis
Aspergilloma
Invasive aspergillosis
Extrinsic allergic alveolitis

79

Allergic bronchopulmonary aspergillosis

Type I and III hypersensitivity reactions to aspergillus fumigatus. Occurs in 1-5% of asthmatics, 2-25% of CF.
Initially constriction, then bronchiectasis.

80

Risk factors for invasive aspergillosis

Immunocompromise (HIV, leukaemia, burns, Wegener's and SLE)
Broad-spectrum antibiotic use.

81

COPD pink puffers tend to progress to...

Type 1 respiratory failure

82

COPD blue bloaters tend to progress to...

Cor pulmonale.

83

Causes of type 1 resp failure

Pneumonia, pulmonary oedema, PE, asthma, emphysema, pulmonary fibrosis, ARDS.

84

Causes of type 2 resp failure

Pulmonary disease such as asthma, COPD, pneumonia, fibrosis,
Reduced respiratory drive due to sedative drugs, CNS tumour or trauma.
Neuromuscular disease
Thoracic wall disease (flail chest, kyphoscoliosis)

85

Neuromuscular diseases causing type 2 resp failure

Cervical cord lesion, diaphragmatic paralysis, poliomyelitis,, myasthenia gravis, Guillain-Barre syndrome

86

When to consider an ABG

Any sudden deterioration in an ill patient
Any acute exacerbation of resp condition
Any impaired consciousness or impaired resp effort.
Any signs of CO2 retention
Cyanosis, confusion, visual hallucinations.

87

Causes of transudative pleural effusions

Increased venous pressure or hypoproteinaemia.
Also hypothyroidism and Meigs' syndrome.

88

Increased venous pressure: causes of transudative pleural effusion

cardiac failure, constrictive pericarditis, fluid overload.

89

Hypoproteinaemia: causes of transudative pleural effusion

cirrhosis, nephrotic syndrome, malabsorption

90

Causes of exudative pleural effusion

infection, inflammation or malignancy.

91

Extrinsic allergic alveolitis - causes

Proteins in bird droppings,
Farmer's and mushroom worker's lung
Malt worker's lung
Sugar worker's lung

92

Extrinsic allergic alveolitis - clinical features

4-6 h after exposure: fever, rigors, myalgia, dry cough, dyspnoea and crackles (no wheeze)
Chronically: dyspnoea, weight loss, type 1 resp failure.

93

Obstructive sleep apnoea

Intermittent closure of pharyngeal airway causing apnoeic episodes during sleep.

94

Obstructive sleep apnoea classical presentation

Obese middle-aged man presenting due to snoring and/or daytime somnolence, with partner describing apnoeic episodes during sleep.

95

Probable pathogen in 6-month-old who is 'chesty', has rhinitis and is off her feeds. Auscultation of her chest reveals bibasal crackles and an expiratory wheeze.

Respiratory syncytial virus

96

Disease caused by Mycoplasma pneumoniae

Atypical pneumonia

Flu-like symptoms classically precede a dry cough. Complications include haemolytic anaemia and erythema multiforme

97

Disease caused by Legionella pneumophilia

Atypical pneumonia

Classically spread by air-conditioning systems, causes dry cough. Lymphopenia, deranged liver function tests and hyponatraemia may be seen

98

Disease caused by Pneumocystis jiroveci

Common cause of pneumonia in HIV patients. Typically patients have few chest signs and develop exertional dyspnoea

99

Disease caused by Haemophilus influenzae

Community-acquired pneumonia
Most common cause of bronchiectasis exacerbations
Acute epiglottitis