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Flashcards in Resp Session 6 Deck (66):
1

What two conditions is COPD a combination of?

Emphysema and chronic bronchitis

2

What is the pathogenesis of chronic bronchitis?

Inflammation in large always causes:
Remodelling and narrowing of airways
Hyper secretion of mucus and proliferation of goblet cells
Chronic productive cough and frequent infections

3

What is the pathogenesis of emphysema?

Terminal bronchioles and distal airspaces destroyed causing:
Loss of elastic tissue --> hyperinflation
Small airways collapsing on expiration
Bullae due to large redundant air spaces

4

What causes COPD?

Smoking
Alpha-1 antitrypsin deficiency (esp

5

What are the S/S if COPD?

Cough with sputum
Purse lip breathing
SoB
Use of accessory muscles in breathing
Tachypnoea
Wheeze --> quiet breath sounds --> silent chest

6

What are the S/S of more advanced cases of COPD?

Silent chest
Peripheral +/- central cyanosis
CO2 retention flap
Cor pulmonale
Oedema

7

What are the 5 stages of the MRC dyspnoea score used to assess COPD?

1. SoB on strenuous exercise only
2. SoB on hurrying/walking up slight hill
3. Walks slower due to SoB
4. Stops for breath after walking ~100m on level ground
5. Too SoB to leave house/SoB on dressing

8

What investigations can be used in COPD?

Spirometry
CXR
HRCT
ABG
Alpha-1-antitrypsin blood test

9

Why is HRCT used in investigation of COPD?

Gives detailed assessment of macroscopic alveolar destruction in emphysema, useful if considering surgery

10

Why is CXR mandatory in COPD investigation?

To exclude other diagnoses

11

What do NICE guidelines state are mild, moderate and severe levels of airflow obstruction detectable by spirometry?

Mild: FEV1 = 50-80%
Moderate: FEV1 = 30-49%
Severe: FEV1

12

How is COPD diagnosed?

Hx: smoker, >40 y.o. with onset of symptoms later in life, chronic productive cough, persistent and progressive SoB
AND
obstructive pattern on spirometry

13

How is stable COPD managed?

Smoking cessation
Pulmonary rehabilitation
Bronchodilators
Antimuscarinics
Steroids
Mucolytics
Dietary review
Supportive Tx
Long term O2 and surgery if appropriate

14

What is the cycle of reconditioning seen in stable COPD pts?

Feel SoB --> avoid activities that worsen SoB --> do less --> muscles weaken --> worsened SoB --> feel depressed --> avoid activities etc.

15

What are some of the S/E associated with treatment of stable COPD?

Beta-2 agonist: tachycardia, anxiety, hypokalaemia, tremor
Antimuscarinics: urinary difficulty, dry mouth, URT, glaucoma
Steroidal S/E

16

How is an acute COPD exacerbation managed?

Aim for sats of 88-92% with titrated O2 therapy
Nebulised bronchodilators
Oral steroids
Abx if blood tests indicate infection
Consider IV bronchodilator
Repeat ABG to assess need for ventilation

17

How can COPD generally be distinguished from asthma by using clinical features?

Pts tend to be smokers
S/S >65 y.o.
Chronic productive cough
Persistent and progressive SoB
Night time waking with cough/wheeze uncommon
Diurnal pattern/day-to-day variability uncommon

18

What characterises COPD?

Airflow obstruction which is usually progressive, not fully reversible and does not change markedly over several months

19

What are common microbial flora of the URT?

Viridans streptococci
Neisseria sp.
Candida sp.

20

What are URTIs most commonly caused by?

Self limiting viruses

21

Why can viral URTI lead to secondary bacterial infection?

Due to viral action on cilia

22

Give some examples of common URTIs.

Rhinitis
Tracheitis
Pharyngitis
Sinusitis
Laryngitis
Otitis media

23

What deferences does the respiratory tract have against infection?

Nasal hairs
Ciliated columnar epithelium
Cough+sneeze reflexes
Respiratory mucosa
Lymphoid follicles of pharynx and tonsils
Alveolar macrophages
Secretory IgA and IgG

24

Give some examples of LRTIs.

Bronchitis
Pneumonia
Bronchiolitis
Empyema
Bronchiectasis
Lung abscess

25

How does a poor swallow lead to aspiratory pneumonia?

Allows secretory pool in pharynx which can enter LRT

26

What is acute bronchitis?

Inflammation of medium sized airways often seen in smokers

27

What are the S/Sof acute bronchitis?

Cough
Fever
Increased sputum production
Sob due to exudation
Pulmonary oedema and cellular infiltration

28

How does a CXR appear in acute bronchitis?

Normal as terminal bronchioles and air sacs are not affected

29

What can cause acute bronchitis?

Viruses
S.pneumoniae
H.influenzae
M.catarrhalis

30

What is the treatment for acute bronchitis?

Bronchodilation
Physiotherapy
Abx if absolutely necessary

31

What is penumonitis?

Non-infective inflammatory disease

32

What is chronic bronchitis?

Recurrent bouts of SoB associated with but not caused by infection (not primarily infective)

33

What is pneumonia?

Inflammation of the lung alveoli, terminal bronchioles and lung parenchyma

34

What are the S/S if pneumonia?

Fever
Cough
Pleuritic chest pain
SoB
Opacities on CXR

35

How is pneumonia classified?

Clinical setting
Presentation (acute->bacterial/viral, chronic->TB)
Causative organism
Lung pathology - lobar, broncho (patchy), interstitial

36

What is the pathogenesis of pneumonia?

Acute inflammatory response --> exudation of fibrin rich fluid, neutrophil and macrophage infiltration --> fluid filled air sacs --> heavy, stiff lung --> red hepatisation --> grey hepatisation

37

What factors may help identify the causative agent in pneumonia?

Pre-existing lung disease
Immunocompromise
Geography
Seasons
Epidemics
Travel
Animal exposure
Recent ventilation

38

How long does grey hepatisation take to develop following red hepatisation in pneumonia?

2-3 days

39

What are the typical causative agents of CAP?

S.pneumoniae
H.influenzae

40

What are atypical causes of CAP?

Legionella
Mycoplasma
Coxiella bunetti (livestock)
Chlamydia psittaci (birds)

41

What are the S/S of CAP?

SoB
Cough +/- sputum (yellow, rusty, recurrent jelly)
Fever
Rigors
Pleuritic chest pain
Malaise
Nausea

42

What causative agent does recurrent jelly sputum suggest?

Klebsiella

43

What is detected O/E in CAP?

Pyrexia
Tachycardia
Bronchial breathing
Tachypnoea
Cyanosis
Crackles
Dullness to percussion
Tactile vocal fremitus

44

What investigations are used to support diagnosis and assess severity of CAP?

FBC
U&Es
CRP
ABG
CXR

45

What methods can be used to collect samples for sputum and blood culture to identify the causative agent in CAP?

Broncho alveolar lovage fluid
Nose and throat swabs
Urine antigen tests
Serum antibody test

46

When are urine antigen tests or serum antibody tests used to investigate CAP?

Atypical causes due to difficulty in culture

47

What are the criteria included in the CURB-65 score used to assess severity of CAP?

Confusion
Urea > 7 mmol per litre
RR > 30
Blood pressure

48

What does a CURB-65 indicate?

Severe pneumonia, consider admittance to hospital

49

What is the empiric Tx for CAP?

Mild-moderate: amoxicillin (doxycycline or erythromycin for penicillin allergic pts)
Moderate-severe: co-amoxiclav (clarithromycin/doxycycline for penicillin allergic pts and to cover atypical penicillin resistant causes)

50

How can CAP lead to chronic lung disease?

Resolution of infection with fibrous scarring

51

What complications can arise following CAP?

Lung abscess --> empyema
Bronchiectasis --> recurrent infections

52

What is atypical pneumonia?

Pneumonia caused by organisms without a cell wall

53

What additional features are seen in atypical pneumonia?

Extra-pulmonary features e.g. hepatitis, hyponatraemia

54

What is the Tx for atypical pneumonia?

Agents that work on protein synthesis: macrolides and tetracyclines

55

What is the pathogenesis of viral pneumonia?

Immune cells and virus cause damage to epithelial cells --> necrosis/haemorrhage into lung parenchyma --> acute hypoxia --> ARDS

56

How is viral pneumonia identified on CXR?

Patchy/diffuse ground glass opacity on CXR

57

What causes viral pneumonia?

Influenza
Parainfluenza
Respiratory syncytial virus
Adenovirus

58

What is the definition of hospital acquired pneumonia?

Onset within 48hrs of being in hospital

59

What causative agents are associated with hospital acquired pneumonia?

G-ve:
Staph aureus
Enterobacteriaciae
Pseudomonas sp.
H.influenza
Acinetobacter baumannii
Candida sp.

60

What is the Tx for HAP?

1st line: co-amoxiclav
2nd line: pipperacillin/Tazobactam/meropenem

61

What method is used to distinguish causative agent of HAP form UR flora?

Bronchial lava he

62

What is aspiration pneumonia?

Exogenous material/endogenous secretions --> resp tract seen in dysphagia, epilepsy, alcoholics, drowning

63

What is the causative agent for aspiration pneumonia?

Mixed infection as you can't selectively aspirate certain organisms, commonly viridans streptococci and anaerobes

64

What is the treatment for aspiration pneumonia?

Co-amoxiclab

65

What causative agents are seen in immunosuppression associated LRTI?

HIV: PCP, TB, atypical mycobacteria
Neutropenia: fungi
BM transplant: CMV
Splenectomy: encapsulated organisms e.g. S.pneumoniae, H.influenzae, malaria

66

How is LRTI associated with immunosuppression prevented?

Flu vaccine every year
Pneumococcal vaccine every 5 years
Lifelong amoxicillin in asplenic
Smoking advice