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Respiratory 1 Flashcards

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1
Q

what is cor pulmonale?

A

enlargement and failure of right side of the heart due to disease of lungs/pulmonary blood vessels - leads to oedema and raised JVP

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2
Q

describe what is happening in the lungs of a patient with extrinsic allergic alveolitis (hypersensitivity pneumonitis)

A

inhalation of allergens provokes a hypersensitivity reaction, with complement activation, granuloma formation and obliterative bronchiolitis.

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3
Q

give 2 causes of EAA (hypersensitivity pneumonitis)

A 
Farmer's lung.
Bird-fancier's lung - proteins in bird droppings.
Malt-worker's lung.
Bagassosis/Sugar worker's lung.
humidifier fever.
Mushroom workers.
Cheese washer's lung.
Wine maker's lung.
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4
Q

give 3 clinical features of EAA seen after exposure to the allergen

A

fevers, rigors, myalgia, dry cough, dyspnoea, crackles (no wheeze)

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5
Q

give 3 chronic features of EAA

A

increasing dyspnoea, weight loss, exertional dyspnoea, type I respiratory failure, cor pulmonale

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6
Q

what would been seen on CXR of a patient with EAA?

A

fibrosis/mottling of upper lobes and honeycomb lung

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7
Q

list some investigations that might be performed on a patient with EAA

A

bloods - neutrophilia, raised ESR
CXR.
lung function tests (reversible restrictive).
broncheoalveolar lavage.

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8
Q

how would you treat EAA in an acute and a chronic situation?

A

acute - remove allergen, give O2 + oral prednisolone.

chronic - avoid exposure (facemask), long-term steroids.

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9
Q

list 3 occupational lung diseases

A 
EAA (e.g. Farmer's lung).
Coal worker's pneumonconiosis.
Silicosis. 
Asbestosis.
Byssinosis.
Berylliosis.
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10
Q

what causes the fibrosis seen in coal worker’s pneumoconiosis?

A

inhalation of coal dust particles - ingested by macrophages - these die and release their enzymes - fibrosis

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11
Q

what would a CXR show in coal worker’s pneumoconiosis?

A

round opacities in upper zone.

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12
Q

what causes progressive massive fibrosis? what are the features of this?

A

progression of coal worker’s pneumoconiosis.

progressive dyspnoea, fibrosis + eventual cor pulmonale.

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13
Q

give some examples of jobs at risk of silicosis

A

metal mining, stone quarrying, sand blasting, pottery/ceramic manufacture

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14
Q

what do investigations show in silicosis?

A

CXR - diffuse miliary/nodular pattern in upper and mid-zones + egg shell calcification of hilar nodes.
Spirometry - restrictive.

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15
Q

what disease are patients with silicosis at greater risk of?

A

TB

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16
Q

what are the clinical features of asbestosis?

A

progressive dyspnoea.

O/E - clubbing, fine end-inspiratory crackles, pleural plaques.

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17
Q

what two diseases are asbestosis patients at greater risk of?

A

bronchial adenocarcinoma and mesothelioma

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18
Q

in what industries might workers get byssinosis? and for berylliosis?

A

byssinosis - cotton mill workers.

berylliosis - beryllium-copper alloy used in aerospace industry, electronics, atomic reactors.

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19
Q

describe the pathogenesis of bronchiectasis

A

chronic infection of bronchi/bronchioles leads to inflamed, thickened and irreversibly damaged walls with permanent dilation.
mucociliary transport mechanism is impaired.

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20
Q

give 2 of the main organisms involved in bronchiectasis

A

H influenza, Strep pneumonia, Staph aureus, Pseudomonas aeruginosa

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21
Q

give 3 possible causes of bronchiectasis

A

congenital - CF.
post-infection - measles, pertussis, pneumonia, TB, HIV.
Other - bronchial obstruction (tumour, foreign body), allergic bronchopulmonary aspergillosis (ABPA), hypogammaglobulinaemia, rheumatoid arthritis, UC.

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22
Q

give 3 clinical features of bronchiectasis

A

persistent cough, copious purulent sputum, intermittent haemoptysis, finger clubbing, coarse inspiratory crepitations, wheeze

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23
Q

give 2 possible complications of bronchiectasis

A

pneumonia, pleural effusion, pneumothorax, haemoptysis, cerebral abscess, amyloidosis

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24
Q

name 3 investigations you would carry out in bronchiectasis and their results

A

*sputum culture.
*CT scan - shows the dilated airways.
CXR - cystic shadows, thickened bronchial walls.
spirometry - obstructive pattern.
broncoscopy - locate site of haemoptysis, exclude obstruction, obtain samples.

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25
how would you manage a patient with bronchiectasis?
physiotherapy - postural drainage. Abx - flucloxacillin for staph, amoxicillin for strep, tazocin for pseudomonas. bronchodilators - salbutamol nebulisers. Oral/inhaled corticosteroids.
26
what causes cystic fibrosis?
autosomal recessive mutation in the CF transmembrane conductase regulator gene on chromsome 7. defective chloride secretion and increased sodium absorption over airway epithelium - produces very viscous and sticky mucous.
27
give 3 respiratory symptoms of CF
cough, wheeze, recurrent infections, bronchiectasis, pneumothorax, haemoptysis, respiratory failure, cor pulmonale
28
give 3 extrapulmonary features of CF
pancreatic insufficiency - DM, steatorrhoea. | intestinal obstruction, gallstones, cirrhosis, male infertility, osteoporosis, arthritis, vasculitis, sinusitis.
29
name 3 investigations you would carry out in CF and their results
sweat test - increased sodium and chloride secretion in sweat. faecal elastase - screens for pancreatic dysfunction. genetic screening for CF mutations. CXR - hyperinflation, bronchiectasis.
30
how would CF be managed?
``` physiotherapy. Abx for exacerbations. mucolytics - DNase (dornase alfa). bronchodilators. fat soluble vit supplements. pancreatic enzyme replacement. ```
31
what is sarcoidosis? what genes is it associated with?
multisystem granulomatous disorder of unknown cause. | associated with HLA-DRB1 and DQB1 alleles.
32
what is seen on transbronchial biopsy in sarcoidosis?
infiltration of alveolar walls and interstitial spaces with mononuclear cells - later, granulomas
33
how does acute sarcoidosis present?
erythema nodosum ± polyarthralgia
34
give 3 pulmonary features of sarcoidosis?
dry cough, progressive dyspnoea, decreased exercise tolerance, chest pain.
35
give 3 extra-pulmonary features of sarcoidosis
lymphadenopathy, hepatomegaly, splenomegaly, uveitis, conjunctivitis, glaucoma, Bell's palsy, neuropathy, meningitis, brainstem and spinal syndromes, space occupying lesions, erythema nodosum, cardiomyopathy, arrhythmias, hypercalcaemia, renal stones, pituitary dysfunction
36
what are the features of sarcoidosis on CXR?
bilateral hilar lymphadenopathy ± pulmonary infiltrates/fibrosis
37
list some differential diagnoses for bilateral hilar lymphadenopathy
sarcoidosis, infection (TB, mycoplasma), malignancies, silicosis, EAA
38
what investigations would you carry out, apart from CXR, in sarcoidosis, and what might they show?
SERUM ACE is raised. lung function - restrictive pattern, reduced TLC, reduced FEV1/FVC ratio. tissue biopsy - non-caseating granuloma.
39
how would you treat sarcoidosis?
if symptomatic - corticosteroids (prednisolone). | if severe - IV methylprednisolone or methotrexate.
40
what is the underlying pathology of idiopathic pulmonary fibrosis?
disruption of alveolar epithelium and basement membrane activates inflammation. fibroblasts convert to myofibroblasts - synthesise collagen and aggregate to form fibrotic foci.
41
give 3 symptoms and 3 signs of idiopathic pulmonary fibrosis
symptoms - dry cough, exertional dyspnoea, malaise, weight loss, arthralgia. signs - cyanosis, finger clubbing, fine end-inspiratory crepitations.
42
what investigations would you carry out in idiopathic pulmonary fibrosis? what do they show? which one is needed for diagnosis?
CXR - ground glass appearance, decreased lung volume, bilateral lower zone reticulo-nodular shadows - honeycombing if severe. lung function tests - restrictive pattern, increased FEV1/FVC ratio. need a lung biopsy.
43
what is the ultimate end treatment of idiopathic pulmonary fibrosis?
lung transplant
44
name 3 causes of pulmonary hypertension
hereditary, SLE, systemic sclerosis, rheumatoid arthritis, drugs, HIV, portal hypertension, schistosomiasis, chronic haemolytic anaemia, COPD, pulmonary fibrosis, mitral valve disease, sarcoidosis
45
define pulmonary hypertension
elevated pulmonary artery pressure (>25mmHg at rest) and secondary right ventricular failure
46
give 3 clinical features of pulmonary hypertension
exertional dyspnoea, lethary, peripheral oedema, loud pulmonary second sound, right parasternal heave
47
give 3 signs that pulmonary hypertension has progressed to right heart failure (cor pulmonale)
elevated JVP, hepatomegaly, pulsatile liver, peripheral oedema, ascites, pleural effusion
48
what is the eventual end treatment of primary pulmonary hypertension?
heart and lung transplant
49
what 3 investigations would you carry out in pulmonary hypertension and what would they show?
CXR - enlarged proximal pulmonary arteries which taper distally. ECG - RVH, P pulmonale (peaked P waves) Echo - RV dilation/hypertrophy
50
how would you treat pulmonary hypertension?
warfarin - reduce thrombosis risk. diuretics - oedema. oral CCBs - pulmonary vasodilators sidenafil (PDE5 inhibitor) for primary pulmonary hypertension
51
what is a haemothorax?
blood in the pleural space
52
what is a chylothorax?
chyle (lymph + fat) in the pleural space
53
what is an empyema?
pus in the plerual space
54
what is a pleural effusion? define transudates and exudates
fluid in the pleural space transudates = low protein content exudates = high protein content
55
give 3 causes of a transudate pleural effusion
cardiac failure, constrictive pericarditis, fluid overload, cirrhosis, nephrotic syndrome, malabsorption, hypothyroidism. increased venous pressure and fluid overload.
56
give 3 causes of an exudate pleural effusion
pneumonia, TB, rheumatoid arthritis, SLE, bronchogenic carcinoma, malignant metastases, lymphoma, mesothelioma, lymphangitis carcinomatosis. increased leakiness of pleural capillaries secondary to infection, inflammation or malignancy.
57
what would you hear on auscultation of a patient with a pleural effusion?
on side of the effusion: | decreased expansion, stony dull percussion note, diminished breath sounds.
58
what investigations would you perform to diagnose a pleural effusion? what would they show?
CXR - small effusions blunt the costophrenic angles. larger = water-dense shadows with concave upper borders. diagnostic pleural aspiration (US guided) - send for clinical chemistry, bacteriology and cytology.
59
how would you treat a symptomatic pleural effusion?
drain it, repeat if necessary
60
how would you treat recurrent pleural effusion?
pleurodesis with tetracycline, bleomycine or talc. | smoking cessation.
61
what group of people are most likely to have a spontaneous pneumothorax?
young, thin men - rupture of sub-pleural bulla
62
what is a pneumothorax?
air in pleural space, leading to partial or complete collapse of the lung
63
what is a tension pneumothorax? how does it present?
pleural tear acts as a one way valve - air passes through during inspiration but is unable to exit during expiration. presents in patient on mechanical ventilation - unilateral increase in pleural pressure with increasing respiratory distress - then shock - then cardiorespiratory arrest
64
give 3 causes of a pneumothorax
spontaneous, chest trauma, asthma, COPD, TB, pneumonia, lung abscess, carcinoma, cystic fibrosis, lung fibrosis, sarcoidosis, connective tissue disorders (Marfan's, Ehler-Danos)
65
give 3 signs of a pneumothorax
reduced expansion, hyper-resonance to percussion, diminished breath sounds on affected side. (in tension pneumothorax, trachea deviates away from the affected side)
66
how would you manage a pneumothorax?
chest drain - urgent.
67
give 3 risk factors for bronchus carcinoma
smoking, asbestos, chromium, arsenic, iron oxides, radiation (radon gas)
68
which bronchial carcinoma is more common in non-smokers?
adenocarcinoma
69
what cells do small cell lung cancers arise from? what can be the side effects of this?
endocrine cells (enterochromaffin cells) - carcinoid syndrome - flushing, diarrhoea, hyponatraemia
70
which type of bronchial carcinoma is most likely to cause an obstruction?
squamous cell carcinoma
71
describe the features of a squamous cell bronchial carcinoma
35%. mostly present as obstructive lesion leading to infection. occasionally cavitates. local spread common. widespread metastases occur late.
72
describe the features of an adenocarcinoma of the bronchus
``` 27%. most common lung cancer associated with asbestos exposure. more common in non-smokers. usually occurs peripherally. local and distant metastases. ```
73
what are the features of a large cell bronchial carcinoma?
10%. | poorly differentiated tumour, metastasizes early.
74
which type of bronchial carcinoma generally has a worse prognosis, NSLC or SCLC?
small cell
75
give 3 symptoms of bronchial carcinoma
cough, haemoptysis, dyspnoea, chest pain
76
give 3 signs of bronchial carcinoma
cachexia, anaemia, clubbing, HPOA (hypertrophic pulmonary osteoarthropathy), supraclavicular or axillary nodes. chest signs - none, or consolidation/collapse/pleural effusion
77
give 3 examples of signs that there are distant mets in bronchial carcinoma
bone tenderness, hepatomegaly, confusion, fits, focal CNS signs, cerebellar syndrome, proximal myopathy, peripheral neuropathy
78
give 3 local complications of bronchial carcinoma
recurrent laryngeal nerve palsy, phrenic nerve palsy, SVC obstruction, Horner's syndrome, rib erosion, pericarditis, AF
79
give 3 neurological complications of bronchial carcinoma
confusion, fits, cerebellar syndrome, proximal myopathy, neuropathy, polymyositis
80
list the differential diagnoses of a nodule on the lung seen on CXR
malignancy, primary or secondary; abscesses, granuloma, carcinoid tumour, pulmonary hamartoma, arterio-venous malformation, encysted effusion (fluid, blood, pus), cyst, foreign body, skin tumour
81
where do bronchial adenocarcinomas most commonly metastasise to?
mediastinal lymph nodes, brain, bone, adrenals
82
how would you investigate a possible bronchial carcinoma?
sputum and pleural fluid samples for cytology. CXR. fine needle aspiration or biopsy. bronchoscopy, CT, PET.
83
list some possible features of a CXR of a patient with bronchial carcinoma
peripheral nodule, hilar enlargement, consolidation, lung collapse, pleural effusions, bony secondaries (e.g. ribs).
84
what staging system is used for bronchial carcinomas?
TNM. T = tumour, N = nodes, M = distant metastases. converted into stage I-IV.
85
how would you treat NSCLC?
peripheral tumours, stageI/II - surgical excision. or, curative radiotherapy. more advanced disease = chemo ± radiotherapy
86
how would you treat small cell lung cancer?
may respond to chemo, but will relapse. cyclophosphamide + doxorubicin + vincristine + etoposide. OR cisplatin ± radiotherapy.
87
describe some features of palliative care given to patients with bronchial carcinoma
radiotherapy - bronchial obstruction, haemoptysis, bone pain, cerebral mets. SVC stent + radio - SVC obstruction. pleural drainage. analgesia, steroids, antiemetics, codeine for cough etc.
88
name two benign lung cancers
bronchial adenoma, hamartoma | benign mesothelioma
89
what is the biggest cause of mesothelioma?
occupational ASBESTOS exposure
90
what is mesothelioma?
tumour of mesothelial cells that usually occurs in the pleura
91
how would you diagnose mesothelioma?
CXR/CT - pleural thickening/effusion. bloody pleural fluid. histology following thoracoscopy - often only diagnosed postmortem.
92
how would you treat mesothelioma?
chemo - cisplatin + premetrexed
93
what are the two main features of Goodpasture's disease?
acute glomerulonephritis + lung symptoms
94
what are the pulmonary features of Goodpasture's disease?
cough, intermittent haemoptysis, anaemia, upper respiratory tract infecions
95
what investigation would you need to confirm a diagnosis of Goodpasture's disease?
kidney biopsy - crescenteric glomerulonephritis
96
how would you treat Goodpasture's disease?
immunosuppression (corticosteroids) + plasmapheresis to remove antibodies
97
what causes the features of Goodpasture's disease?
anti-glomerular basement membrane antibodies - bind to kidney basement membrane and alveolar membrane

Respiratory (9 decks)

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