Respiratory Flashcards
(46 cards)
What is a white milky fluid from aspiration?
- A chylous effusion is suggested by the white milky fluid aspirated on thoracocentesis. Cardiothoracic and head or neck surgery, including excision of cervical lymph nodes, can result in damage to the thoracic duct resulting in a chylothorax. To confirm the diagnosis, test for pleural fluid triglycerides and cholesterol levels.
- A tryglyceride level greater than 1.2mmol/L indicates a 99% chance the fluid is chylous.
What gives the difference between giving steroids and not giving steroids in sarcoidosis ?
- Multiple organ involvement or cardiac/neuro involvement
- Hypercalcaemia
- Pulmonary only symptoms but where there is parynchimal lung involvement, stage 4 radiological changes, or significant impact on quality of life
- Uveitis
Poor prognosticating facors for sarcodosis according to a french cohor study?
- Age over 60 years at diagnosis
- diffuse cutanous disease
- scleroderma renal crisis - 50% survival at 5 years
- < 6 minutes walking capacity due to dyspnoea
- forced vital capacity less than 70%
- pulmonary arterial hypertension
- valvular disease
- Malignancy
- Anaemia
How is the diangosis of cystic fibrosis made ?
Sweat test and genetic analysis . Sweat test chloride concentration over 60 mmol/L is indicative of cystic fibrosis.
What is the pathophysiology of hypercalcaemia in sarcoidosis ?
1-alpha hydroxylasae is activated by macrophages in sarcoid granuloma. 1-alpha hydroxylase than converts 25-hydroxyvitamin D3 to 1,25 - dihydroxivtiamin D3 which is the active form. This than results in larger amount of calcium reabsorbtion both from the gut and the distal renal tubule.
Interstitial lung disease causing lower pattern fibrosis ?
ACID
- Asbestosis
- Connective tissue disorders excluding ankilosing spondylitis
- Idiopathic
- Drug induced - e.g amiodarone, bleomycin and methotrexate
CMV infection in HIV patients - diagnosis and management ?
- High risk if CD4 count < 50 .
- Can cause hepatitis, colitis, retinitis, pneumonitis, rediculopathy and encephalitis and therefore the clinical scenerio may include elemetns of this.
- Diangosis is made by PCR and if histological sample from transbronchial biopsy is present than that may demonstrate pathognomic owl’s eye cells. Other things are rapid culture methods such as DEAFF.
- Treatment is with IV ganciclovir.
Diagnostic criteria for allergic bronchopulmonary aspirgilosis?
The diagnostic criteria include:
- Asthma (in most cases)
- Peripheral blood and sputum eosinophilia
- Abnormal chest X-ray (infiltrates, segmental or lobar collapse)
- Positive skin tests/RAST to an extract of A. fumigatus
- A. fumigatus IgG serum-precipitating antibodies
- Raised total IgE >1000 ng/ml
- Fungal hyphae of A. fumigatus on microscopy of sputum.
Causes of pulmonary–renal syndromes:
Systemic diseases:
- Granulomatosis with polyangiitis
- Microscopic polyangiitis
- Goodpasture syndrome
- Systemic lupus erythematosus
- Polyarteritis nodosa
- Henoch–Schönlein purpura
- Churg–Strauss syndrome (renal involvement less common)
Primary pulmonary disease:
- Legionella pneumonia and interstitial nephritis
- Bacterial pneumonia with renal compromise secondary to sepsis
Others:
- Pulmonary oedema with acute kidney disease
- Uraemic pneumonitis
- Right-sided bacterial endocarditis – may cause pulmonary embolic lesions and glomerulonephritis
- Iatrogenic glomerulonephritis with ciprofloxacin, e.g. in patients given ciprofloxacin for cystic fibrosis.
What are the criteria to be considered suitable for surgery for a aspergilloma?
- FEV1 over 1.5 L for lobectomy and > 2L for pneumonectomy.
Pathognomonic feature of chronic eosinophilic pneumoniae?
- CXR - dense bilateral peripheral infiltrates. (pleural based infiltrates)
- raised serum IgG in 2/3 of patients
- raised ESR
- sometimes peripheral oesinophilia
Pulmonary disease with oesinophilia - summary?
- Loeffler syndrome (eosinophils about 10% of blood WCC), also known as acute eosinophilic pneumonia/simple eosinophilic pneumonia. Mild self-limiting illness with transient migratory pulmonary shadows. Associated with parasitic infections, drug allergies and exposure to inorganic chemicals
- Tropical pulmonary eosinophilia (eosinophils >20%) – in tropical countries usually due to migrating larvae of the filarial worms Wucheria bancrofti and Brugia malayi
- Chronic/prolonged pulmonary eosinophilia (eosinophils >20%) – eosinophilic pneumonia persisting for more than one month. Chronic debilitating illness characterised by malaise, weight loss, fever and dyspnoea
- Allergic bronchopulmonary aspergillosis (eosinophils 5–20%) as in this case
- Churg–Strauss syndrome (eosinophils 5–20%) associated with asthma
- Hyper-eosinophilic syndrome (eosinophils >20%: eosinophilic infiltrations of various organs – e.g. lungs, heart, bone marrow. Can be associated with an eosinophilic arteritis
- External agents – drugs, toxins, parasitic infection
Eligibility for lung transplant for COPD patients?
To be eligible for a lung transplant, patients must be on maximal medical therapy and be predicted to have a survival of at least 5 years, at an acceptable quality of life for the patient, post-transplant. In addition, patients with chronic obstructive pulmonary disease (COPD) must meet one of the following criteria:
- FEV1 < 20% of predicted and a diffusion capacity of the lungs for carbon monoxide of less than 20% predicted, or uniform distribution of emphysema throughout the lungs.
- Increasing frequency of hospitalisation with hypercapnia and hypoxia.
- Pulmonary hypertension or cor pulmonale.
- BODE score ≥ 7
A BODE classification (B – Body mass index; O – airflow Obstruction; D – Dyspnoea; E – Exercise capacity) score is an indicator of functional capacity. The score ranges from 0–10; a higher score indicates a poorer prognosis
Clinical manifistation of invasive aspergillosis?
- Fever cough, dyspnea and pleuritic chest pain
- Immunosupressed patient cohort
- Haematoxylin and eosin staining doesn’t stain most fungal species except aspergillus and Zygomycete
Acute severe asthma ?
Any 1 of:
- PEF 33-50% best or
predicted
- RR >25/ min
- HR >110
- Inability to complete
sentences in 1 breath
Moderate Asthma exacerbation ?
- Increasing symptoms
- PEF 50-75% best/
predicted - No features of acute
severe asthma
Life threatening asthma?
- PEF <33% best/
predicted - SpO2 <92%
- PaO2 <8kPa
- Normal PaCO2
- Silent Chest/ Cyanosis
- Confusion / Neurological deterioration
At what point in the FVC is increased respiratory support required ?
20ml per kg FVC -> around 1l for 50kg patient.
Treatment for small cell lung cancer ?
- Platinum-based combination chemotherapy represents the mainstay of treatment for small cell lung cancer (SCLC), as per current NICE guidelines, ± radiotherapy dependent on the stage of the disease at the time of diagnosis or response to chemotherapy.
- Those with limited-stage disease, or with extensive disease that shows a complete response to chemotherapy at distant sites, should be considered for adjunctive radiotherapy.
Criteria for diagnosis of obesity hypoventilation syndrome ?
- Body mass index > 30
- pCO2 > 6
- Absence of other causes of hypoventilation e.g opioid use
What is yellow nail syndrome ?
Rare condition consisting of the triad of :
- primary lymphoedema
- recurrent pleural effusions
- dystrophic yellow nails
Associated with bronchiectasis and sinusitis. Pleural fluid is typically a clear exudate in which lymphocytes predominate. The underlying abnormality is hypoplasia of the lymphatics with impaired drainage. This results in subungual oedema, lymphoedema and pleural effusions.
What is Meig’s syndrome ?
Another rare condition…. Characterised by :
- Pleural effusion
- Ascitis
- Ovarian tumours - benign
The two medications approved for trial in the management of idiopathic pulmonary fibrosis ?
- Nintedanib and pirfenidone - > for patients with FVC between 50% and 80% of perdicted.
Indications for oxygen therapy in patients with ILD ?
As per BTS guidelines two scenerios in which LTOT should be offered:
1. Resting pO2 less or equal to 7.3
2. Patients with ILD with resting pO2 less or qual to 8 where there is peripheral oedema, polycythemia (e.g hematocrit equal or less than 55%) or evidence of pulmonary hypertension.
