Respiratory Flashcards
1
Q
2 common lower respiratory tract infections
A
Pneumonia
Tuberculosis
2
Q
Define pneumonia
A
Acute inflammation of lung parenchyma (terminal bronchioles and area surrounding the alveoli)
Usually caused by an infection
3
Q
Describe the 2 categories of acquired pneumonia
A
- Hospital acquired pneumonia - community or <48h in hospitals
- Community acquired pneumonia - >48h after hospital admission
4
Q
RFs of pneumonia (5)
A
- Infants and elderly
- COPD, asthma
- Nursing home residents
- Immunocompromised - long term steroids
- Alcoholics or IVDU
5
Q
Name 3 bacteria that commonly cause CAP
A
- Strep. pneumoniae
- Staph. aureus
- Haem. influenzae (mc in COPD)
6
Q
Name 4 atypical bacteria that cause CAP
A
- Mycoplasma pneumoniae
- Chlamydophila pneumoniae
- Coxiella burnetti
- Legionella pneumophilia - typical returning from holiday
7
Q
Why are atypical bacteria difficult to detect
A
- Intracellular
- Don’t grow on agar easily
- Need serology
8
Q
What class of Ab are atypical bacteria resistant to and how are they treated
A
- Not susceptible to Beta lactams/ penicillin’s
- Treat with macrolides (clarithromycin), tetracyclines (doxycycline) or fluoroquinolones (ciprofloxacin)
9
Q
Bacterial causes of HAP
A
- Strep pneumoniae
- MRSA
- Pseudomonas aeruginosa
10
Q
Viral causes of pneumonia
A
- Influenza virus A/B
- respiratory syncytial virus
11
Q
Fungal cause of pneumonia and how it is treated
A
Pneumocystis jirovecii
Co-trimoxazole
12
Q
Who is mc affected by P.jirovicii
A
Most people who get Pneumocystis pneumonia have a medical condition that weakens their immune system, like HIV/AIDS
13
Q
Pathophysiology of pneumonia
A
Invasion of mainly bacteria in lung parenchyma which overwhelms host defences and produces intra-alveolar exudates
* Atypical pneumonia infection outside the alveoli in the interstitium
14
Q
Give 3 ways pathogens can reach the LRT
A
- Inhalation
- Aspiration
- Haematogenous spread
15
Q
Symptoms of pneumonia
A
- Productive cough: mucopurulent sputum = bacterial, scant/watery = atypical
- Fever, night sweats, rigor
- Pleuritic chest pain and dyspnoea
- Confusion
- Lethargy, malaise
16
Q
Signs of pneumonia
A
- Tachycardia and tachypnoea
- Fever
- Dullness to percussion
- Crackles and wheeze
- Decreased breath sounds
- Low blood pressure
17
Q
Describe the findings of the GS Investigation for pneumonia
A
CXR
* Consolidation: air bronchogram i.e. air filled bronchi made visible by adjacent fluid filled alveoli
* Multiple abscesses = S.aureus
* Multi-lobar suggest S.pneumoniae, S.aureus or Legionella
* Upper lobe lesions suggest klebsiella (but must exclude TB)
18
Q
Other investigations for pneumonia (exc CXR)
A
- Sputum and blood culture - causative organism
- U+E - deranged = severe
- CRP elevated
- FBC - leukocytosis
- Pulse oximetry - assess severity and (if done with ABG) defines RF
19
Q
Describe the assessment of CAP severity
A
CURB65 score - 1pt for each
* Confusion - abbreviated mental score <8
* Urea >(=)7 mmol/L
* Respiratory rate >(=) 30/min
* BP; low systolic < 90mm/Hg or diastolic <(=) 60mm/Hg
* Age >(=) 65
20
Q
Describe the implication of CURB65 score
A
- 0-1 = mild, at home Tx
- 2 = moderate = admit
- 3-5 = severe, admit and monitor closely (consider ICU)
21
Q
How is CURB65 adjusted in a community setting
A
- Urea is not available = CRB65
- 0= mild, 1-2 = moderate and 3-4 = severe
22
Q
General treatment for pneumonia
A
- 02 if needed
- Analgesia
- Ab depending on trust and causative pathogen
23
Q
Management for low risk pneumonia (CRB65 0) in a primary care setting
A
- Oral amoxicillin
- Clarithromycin or doxycycline
- 5 day course
- treatment at home
24
Q
Management of intermediate risk (CRB65 1-2) pneumonia in a primary care setting
A
- Oral amoxicillin + clarithromycin
- 7-10 day course
- hospital assessment should be considered
25
Management of high risk pneumonia (CRB65 3-4) in a primary care setting
* IV co-amoxiclav + clarithromycin
* Alternative: cefuroxime + clarithromycin
* 7-10 day course
* urgent admission to hospital
26
When should all cases of pneumonia have a repeat chest X-ray and why?
6 weeks after clinical resolution to ensure consolidation has resolved and to check for any underlying secondary abnormalities (e.g., lung tumour)
27
What are the discharge criteria for pneumonia
Patients should not be routinely discharged if, in the past 24 hours, they have had 2 or more of the following findings:
* Temperature > 37.5°C
* Respiratory rate ≥ 24 breaths per minute
* Heart rate > 100 beats per minute
* Systolic blood pressure ≤ 90 mmHg
* Oxygen saturation < 90% on room air
* Abnormal mental status
* Inability to eat without assistance
28
Tx of pseudomonas aeruginosa
IV Ceftazidime or Piperacillin-tazobactam
29
Tx of suspected or confirmed MRSA
* Vancomycin
* Linezolid
30
What are 4 non-infectious causes of pneumonia
* Malignancy
* Vasculitis
* Drugs
* Chronic interstitial pneumonia
31
What is tuberculosis
Infectious granulomatous disease caused by Mycobacterium tuberculosis
* mc involves lungs but can affect almost any organ system
32
Features of M. TB
* Slow growing
* Waxy mycolic acid capsule - hard to culture and treat
* Non-motile and non-spore forming
33
RFs of TB
* Exposure to infection
* HIV infection - progresses HIV more rapidly and Tx drugs interact
* Silicosis
* Immunosuppressants
* Endemic country - Asia, Latin America, Africa
* Homeless/ crowded housing
* IVDU
34
Describe the initial exposure to TB
* TB phagocytosed by macrophages but resist killing and form granulomata
* macrophages and lymphocytes contain and kill majority of infecting bacilli
35
Describe the pathophysiology of primary TB
* Cell mediated immune response from T cells
* Central region of granuloma undergoes caseating necrosis = Ghon focus
* This is a type 4 hypersensitivity reaction
* Ghon complex is a Ghon focus that spreads to hilar lymph node
* Often ASx
36
Describe latent TB
* Occurs after primary infection
* Patient remains asymptomatic and bacteria is dormant ( = -ve sputum)
* Infection is contained within granulomas but TB doesn't die
* Disease can progress/reactivate in immunocompromised Px
37
Describe miliary TB
This occurs when TB spreads systemically via the lympho-haematogenous spread
Bacteria spread via pulm venous system
38
Describe secondary infection of TB
* Latent TB reactivates resulting in features of haemoptysis and fever
* Typically occurs in lung apex where pO2 is highest and mycobacteria are aerobic
* Bacteria can spread locally (caseating granulomata) or systemically (miliary TB)
39
Presentation of TB
* Systemic: weight loss, anorexia, malaise, night sweats, low grade fever
* Dyspnoea, pleuritic chest pain
* Cough
40
Presentation of extrapulmonary TB
* CNS TB - meningitis
* Enlarged lymph nodes
* Genito-urinary TB - haematuria & dysuria
* Bone - joint pain and swelling
* Abdo TB - ascites, ileal malabsorption
41
Investigation of TB
* Sputum microbiology - Ziehl-Neelsen stain will turn red, +ve acid-fast bacilli
* Lymph node biopsy
* CXR - ghon complex (latent), patch/ nodular consolidations, millet seeds uniformly distributed (miliary), hilar lymphadenopathy
42
Describe investigation of latent TB
* Mantoux screening (tuberculin skin test) - Won't distinguish active from passive and -ve doesn't exclude active
* Interferon-gamma release assay: Measure the response of T cells to TB antigens in order to diagnose prior exposure. More sensitive than Mantoux
* Less sensitive in immunocompromised or miliary TB (false -ve)
43
Treatment of active TB
ROPE
* Rifampicin - 6m
* Isoniazid - 6m
* Pyrazinamide - first 2m only
* Ethambutol - first 2m
44
Describe the MOA of rifampicin and SEs
* Inhibition of bacterial RNA polymerase = prevents protein synthesis
* Red/orange urine, hepatitis, Impaired combined oral contraceptive pill function
45
Why should Pyridoxine be administered with isoniazid
Prevent isoniazid associated peripheral neuropathy
46
Which vaccine should be taken to prevent TB and when
Neonatal BCG
47
Causes of pharyngitis
* Viral (80%): rhinovirus, adenovirus and EBV
* Bacterial: Group A beta-haemolytic streptococci
48
Give 3 other diseases associated with GABHS
* Scarlet fever
* Post-streptococcal glomerulonephritis
* Rheumatic fever
49
Presentation of pharyngitis
* Pyrexia - >38 degrees
* Red, inflamed and enlarged tonsils
* pharyngeal exudate = GABHS
* Fever, headache
* Viral can be distinguished from GABHS by presence of cough and nasal congestion
50
Tx of pharyngitis
Most are self limiting and Sx last a week
* Phenoxynethylpenicillin 10 days
* Amoxicillin or clarithromycin
51
Define sinusitis
inflammation of the mucosal lining of the nasal cavity and paranasal sinuses
52
Describe causes of sinusitis
* Mostly viral infection -
* Bacterial - Strep. pneumo, H.influenzae
* Duration of Sx for >10 days often indicates bacterial cause
53
Sx of sinusitis
* Purulent nasal discharge
* Facial pain/ pressure
* Fever and cough
54
Tx of sinusitis
Usually self limiting
* Amoxicillin if bacterial and not resolving
* Nasal corticosteroids
55
What is mesothelioma
Aggressive lung malignancy affecting mesothelial cells of the pleura
56
3 RFs of mesothelioma
* Asbestos exposure (80%)
* Age 60-80
* Male
57
Describe the relationship between asbestos exposure and mesothelioma
There is a latency period where the development of mesothelioma occurs 20-40 years after asbestos exposure
58
Give 5 ways mesothelioma presents
* Dry and non-productive cough
* Cancer Sx - fatigue, fever, sweats and weight loss
* Dyspnea and diminished breath sounds
* Dullness to percussion - pleural effusion
* Signs of metastases - bone and abdo pain
59
3 investigations done for mesothelioma
* CXR
* Contrast CT chest
* Video-assisted thoracoscopic surgery (VATS) - evaluate pleural lining and obtain optimal biopsy
60
Give 3 findings that may be seen on a CXR of suspected mesothelioma
* Unilateral pleural effusion
* decreased lung volumes
* Parenchymal changes
61
Give 2 findings that may be seen on a contrast CT of suspected mesothelioma
* Pleural thickening
* Pleural plaques
62
Why is mesothelioma often inoperable
Often metastasised by diagnosis
63
How is inoperable mesothelioma treated
* Chemo with cisplatin and pemetrexed
* Radiotherapy and palliative care
64
What is a pancoast tumour
Tumour in the pulmonary apex
65
What syndrome can a pancoast tumour cause and how
Horners syndrome
Pancoast tumour presses on the sympathetic ganglion
66
Triad of symptoms of horners syndrome
* ptosis
* anhidrosis ( lack of sweat)
* miosis (constricted pupil)
67
Which category of lung cancer is most common
Non small cell lung cancer
68
Give 4 types of non small cell lung cancers
Adenocarcinoma - 40%
Squamous cell carcinoma - 25-30%
Large cell - 10%
Carcinoid
69
Describe adenocarcinoma of the lung
Peripheral lesion that originates from mucus-secreting glandular cells
70
Which paraneoplastic syndrome is associated with squamous cell lung carcinoma
Tumour secreting Parathyroid hormone-related protein (PTHrP) which results in hypercalcaemia
71
Describe typical location of small cell lung cancers
Fast growing, Central lesion near main bronchus
Originate from neuroendocrine cells
72
Give 3 paraneoplastic syndromes associated with small cell lung cancer
* SIADH - hypOnatraemia
* Ectopic ACTH - Cushing’s syndrome
* lambert Eaton myasthenia syndrome
73
5 symptoms of lung cancer
* persistent cough
* dyspnoea
* weight loss
* hayemotypsis
* chest/ shoulder pain
74
Describe 3 ways in which lung cancers are investigated
* GS: bronchoscopy + biopsy
* CCT neck, thorax and upper abdo - TNM stagings, lymphadenopathy, enlarged hilar
* CXR - pleural effusion, pulm nodules, lung collapse
75
5 RFs of lung cancer
* smoking
* env tobacco exposure (2nd hand smoking)
* FHx
* COPD
* radon gas
76
5 complications of lung cancer
* super vena cava syndrome - facial swelling, distended neck veins, SOB
* recurrent laryngeal nerve palsy - hoarse voice
* metastasis
* Pancoast tumour
* paraneoplastic syndromes
77
What sign is likely to be positive in superior vena cava syndrome
Describe the sign
Pemberton’s sign
Bilateral arm elevation above head results in facial swelling and cyanosis
78
State the mc type of non-small cell lung cancer
Adenocarcinoma
79
What is hypersensitivity pneumonitis
The result of non-IgE (mainly T3) mediated immunological inflammation of the lungs
80
Give 4 RFs of hypersensitivity pneumonitis
* Bird keeping
* Smoking
* Pre-existing lung condition
* Occupation, e.g. farming
81
Give 4 different causes of hypersensitivity pneumonitis
* Farmer's lung - reaction to mouldy spores in hay
* Bird fanciers lung - reaction to bird droppings
* Mushroom picker's lung
* Malt workers lung - mould on barley
82
Explain the pathophysiology of hypersensitivity pneumonitis
* Mainly T3 hypersensitivity but can be type 4
* Previous exposure produces IgG Ab that retain immune memory of Antigen
* 2nd exposure result in Ab-Ag complexes forming and these deposit in the lungs where they are not properly cleared
* Repeated exposure to Ag = repeated Sx
83
Describe how hypersensitivity pneumonitis may present (6)
* Dyspnea
* Cough
* Fever/ chills
* Malaise, weight loss
* Clubbing
84
Give 4 ways hypersensitivity pneumonitis is investigated
* CT chest
* CXR - nodular
* +ve serum IgG
* Abnormal pulmonary function tests
85
Would hypersensitivity pneumonitis show a restrictive or obstructive pattern on PFTs?
Restrictive
Can be mixed in fibrotic HP
86
Describe the possible CT chest findings of someone with hypersensitivity pneumonitis
* Ground-glass shadowing
* Poorly defined micronodules
* Fibrotic HP - mosaic attenuation
87
How is hypersensitivity pneumonitis treated
* Identify and avoid trigger/ allergen
* Smoking cessation
* Prednisolone if Sx persist despite avoidance
88
Define cystic fibrosis
Inherited autosomal recessive, multi-system disease affecting mucous glands
89
Explain the pathophysiology of cystic fibrosis
* Mutation in the CF transmembrane conductance regulator (CFTR)
* CFTR is a channel protein that mumps chloride into secretion which makes then thin and watery
* Defective CFTR gene = thick secretions
90
Explain how cystic fibrosis causes lung issues
* Impaired mucociliary clearance due to thick mucus
* This increases infection and inflammation which can lead to bronchiectasis
91
Which chromosome is the gene coding for CFTR found on
chromosome 7
92
2 RFs of cystic fibrosis
FHx
Caucasian
93
Describe how cystic fibrosis may present in neonates
* failure to pass meconium (1st stool)
* meconium ileus - too thick to pass through bowel and causes obstruction
94
Describe the presentation of cystic fibrosis in the following systems:
GIT, Resp, GU
* Resp: thick and sticky sputum, recurrent airway infection, wet-sounding cough
* Genital: bilateral absence of vas deferens = infertility
* GI: steatorrhea, GORD, Failure to thrive despite voracious appetite (untreated pancreatic insufficiency)
95
Describe 3 investigations conducted for cystic fibrosis
* GS: Sweat test - induce sweating and analyse chloride concentration. +ve if Cl- >60mmol/L
* Genetic testing - 2 disease causing mutations
* Newborn screening - +ve immunoreactive trypsinogen
96
Give 3 infection commonly affecting cystic fibrosis patients
* Staph. aureus
* H. influenzae
* P. aeruginosa
97
How is cystic fibrosis treated
* Resp: chest physio, salbutamol, mucolytics
* Infection: Ab, e.g. oral amoxicillin/ ciprofloxacin
* Pancreatic insufficiency: Pancreatin + omeprazole, Fat-soluble Vit supplements
* Lung transplant in severe cases
98
Define bronchiectasis
Permanent dilation of bronchi due to destruction of elastic and muscular parts aof bronchial wall
99
Give 4 RFs of bronchiectasis
* Cystic fibrosis
* HIV
* Primary ciliary dyskinesia
* Infection
100
Explain the pathophysiology of bronchiectasis
* Dilation and thickening of bronchi due to chronic inflammation
* This leads to increased mucus production and damage to cilia by immune cell cytokines
* This ultimately increases risk of persistent infection leading to progressive airway damage
101
Describe the presentation of bronchiectasis (6)
* Productive cough with lots of sputum ( +/- flecks of blood)
* Dyspnoea with exertion
* Crackles on pulmonary auscultation
* Recurrent fever
* Wheezing
* Pleuritic chest pain during exacerbation
102
Give 4 investigations conducted for bronchiectasis
* GS - High resolution chest CT
* CXR
* Sputum culture
* Spirometry
103
Describe the possible findings on a chest CT of bronchiectasis
* Thickened, dilated airways
* Cysts
* Signet ring sign
104
Describe the possible findings on a CXR of bronchiectasis
* Thin-walled ring shadows
* Volume loss
105
Would bronchiectasis show a restrictive or obstructive pattern on spirometry
Obstructive
106
Describe how bronchiectasis is treated (4)
* Chest physio
* Bronchodilators
* Ab for infection
* Anti-inflammatory agents, e.g. long term azithromycin to decrease exacerbation frequency
107
What is a pleural effusion
Excess fluid accumulation within the pleural space
108
Describe a transudative pleural effusion
* protein <30g/L
* transparent effusion
109
Describe the protein level and appearance of an exudative pleural effusion
* Protein >30g/L
* Cloudy effusion
110
What causes an exudative effusion
Give 3 specific examples
* Caused by inflammation/ infection of the lung leading to capillary leakage of fluid into the pleural space
* E.g. Malignancy, pneumoniae/ TB, pancreatitis
111
What causes a transudative effusion
Give 3 specific examples
* Caused by increased hydrostatic pressure/ reduced oncotic pressure
* E.g. Congestive HF, Liver cirrhosis, hypothyroidism
112
Describe how pleural effusions present
* Dyspnoea due to decreased lung volume
* Dullness to percussion over effusion (stony)
* Pleuritic chest pain - worse with inspiration and exacerbated by cough and movement
* Cough (+/- sputum)
* Quieter breathing sounds over effusion
* Decreased/ absent tactile fremitus - decreased vibration of chest wall when speaking
113
Describe the 2 main investigations conducted for a pleural effusion
* CXR
* Aspiration and pleural fluid analysis
114
Give 3 findings that may be seen on CXR of a pleural effusion
* Blunting of costophrenic angle (area where diaphragm meets rib)
* Excess fluid appears white
* Tracheal and mediastinal deviation
115
Describe the expected results of a pleural fluid analysis
* Glucose - low
* Protein - Trans/ Exu
* pH - low, acidic
* Microscopy - possible bacterial culture
* WBC - raised
116
How is a pleural effusion treated
* Congestive HF - furosemide
* Infection - IV Ab, e,g, amoxicillin
* Malignant: thoracentesis (severe) - drain excess fluid
pleurodesis - adhesion of pleural layers together
117
What is empyema
Infected pleural effusion
118
What will pleural aspiration show if there is empyema
* Pus
* Low pH
* Low glucose
* Raised LDH
119
How is an empyema treated
* Ab - Co-amoxiclav, clindamycin
* Thoracostomy - drainage
120
How is an empyema treated
* Ab - Co-amoxiclav, clindamycin
* Thoracostomy - drainage
121
What criteria is used to differentiate between transudative and exudative effusions
Light's criteria
122
Describe Light's criteria
States that an exudate is defined as the presence of any of the following:
* Pleural protein to serum protein ration >0.5
* Pleural lactate dehydrogenase to serum LDH ratio >0.6
* Pleural LDH greater than 2/3 of upper limit of normal for serum
123
What are the 3 components of virchow’s triad
* Endothelial damage
* Venous stasis
* Hypercoagulability
124
State 3 things that can cause venous stasis
* Immobility
* Varicose veins
* Recent surgery
125
State 4 things that can cause endothelial damage
* trauma
* prior deep vein thrombosis
* venous catheters
* smoking
126
State 4 things that can cause hypercoagulability
* Pregnancy
* Contraception
* Cancer
* IBD
127
Describe the presentation of pulmonary embolism (6)
* Dyspnoea
* Unilateral pleuritic chest pain
* Pain and swelling in one/ both legs
* HypOtension
* cough
* Rapid breathing
128
What is the gold standard investigation of a pulmonary embolism
CT pulmonary angiogram
129
When is the GS investigation for a pulmonary embolism avoided
* Renal impairment
* contrast allergy
* Avoid in young people
130
What test are conducted alongside the GS to investigate a pulmonary embolism
* D-dimer
* ECG
* Ventilation-perfusion scan - area won’t be perfused
* CXR - usually normal
131
Describe the ECG findings of a pulmonary embolism
* S1Q3T3: Large S wave lead I, large Q wave Lead III, inverted T wave lead III
* Sinus tachycardia
* RBBB
132
What scoring system is used to determine the probability of a pulmonary embolism in non-pregnancy people
Wells score
133
Give 5 criterion used in the wells score
* Sx of DVT (leg swelling, pain on palpitation) - 3pts
* PE most likely diagnosis - 3pts
* Tachycardia - 1.5pts
* Active cancer - 1pt
* Haemoptysis - 1pt
134
Describe how wells score is categorised
* Score >(=)4 = PE likely
* Score <4 = PE unlikely
135
What test should be ordered if a patients wells score is below 4
D-dimer
136
Describe the treatment of a confirmed case of PE in a haemodynamically unstable patient
* Start IV unfractionated heparin prior to thrombolysis
* Thrombolysis (clot dissolver) - alteplase
* surgical embolectomy if thrombolysis is CI/ ineffective
137
Describe the treatment of a confirmed case of PE in a haemodynamically stable patient
Anticoagulants
* Apixaban or rivaroxaban
* Low molecular weight heparin if above is unsuitable
