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What is bronchiectaisis?

Abnormal permanently dilated airways with inflamed thickened bronchial walls.

On CT see signet ring sign and on CXR see tramline and ring shadows


What are the causes of bronchiectasis?

Congenital - impaired microcilary transport
Cystic fibrosis, Young's syndrome, primary ciliary dyskinesia, Kartagener's syndrome

Acquired -
Post infection: measles, pertusis, bronchiolitis, pneumonia, TB, HIV
Bronchial obstruction: foreign body, tumour
Allergic broncopulmonary aspergillosis,


What are the clinical features of bronchiectasis?

Persistent cough, copious purulent sputum, intermittent haemoptysis,
Clubbing, coarse inspiratory crackles, wheeze,

Complications - pneumonia, pleural effusion, pneumothorax, cerebral abscess, amyloidosis


Describe the illness cystic fibrosis:

Autosomal recessive condition
Mutation in 7q31.2 results in defect in cystic fibrosis transmembrane conduction regulator (Chlorine channel)
Failure of opening of the channel when cAMP increases in the cells, leads to a decrease in chlorine excretion into the airway lumen. This leads to an increase in the reabsorption of Na into the epithelial cells, which is followed by water, so there is less water excreted which increases the viscosity of the secretions.

The result of the increased viscosity of the secretions is an increase in respiratory infections leading to chronic lung disease, infections and bronchiectasis.

Patients also have pancreatic insufficiency leading to malnutrition and diabetes


What are the clinical features of cystic fibrosis at the different ages?

Neonate - Meconium ileus

Children and young adults -
Respiratory: cough, wheeze, chronic infections, etc Pts start with staph aureus and strep pneumonia infections and then develop chronic pseudomonas and burkholderia cepacia later on.

GI: energy needs increase by 130%, pancreatic insuffieceny requires enzymes, diabetes, GI obstruction more common

Other: infertility, osteoporosis, arthritis, vasculitis,


What result on the sweat test would diagnosis CF?

> 60mmol/l with chloride > Sodium


What are the three characteristics of asthma?

Airflow limitation - reversible
Airway hyperesponsiveness
Bronchial inflammation : T and Mast cells, plasma exudation, oedema, muscle hypertrophy, matrix deposition, mucus plugging

There are three factors that contribute to the airway narrowing:
1. bronchial muscle contraction
2. mucosal swelling
3. increased mucus production


What are the steps in asthma management?

Step 1: inhaled short acting B2 agonist

Step 2: Add inhaled corticosteriod 200-800 ug/ day

Step 3: Add inhaled long acting B2 agonist
if good response from LABA cont
if response to LABA but inadequte control increase steroid to 800ug if not yet on
if no response to LABA stop it and increase steroid. if still inadequate consider adding leukotriene receptor agonist or SR theophylline

Step 4: increased steroid to 2000ug/day
think of adding a fourth drug (leukotriene receptor agonist, SR theophylline or B agonist tablet

Step 5: use daily steroid tablet - refer for specialist care


What are the different levels of acute asthma?

Moderate asthma:
increasing symptoms
PEF >50 - 70% best or predicted

Severe asthma:
PEF 33-50% best or predicted
RR >25
HR >110
inability to complete full sentences

Life threatening asthma:
PEF <8
normal pCO2
Silent chest
Poor respiratory effort
Exhaustion, altered LOC

Near Fatal:
Increased PaCO2


How do you treat acute asthma?

Maintain stats between 94-98%
Use oxygen to drive nebuliser

2.5 - 5mg nebuliser - back to back if not helping
Can use IV but only in patients not responsive to nebs

Ipratropium Bromide:
0.5 mg neb 4-6hrly

100mg IV hydrocortisone or 30mg pred PO STAT
continue 40-50mg pred for 5 days post attack

Magnesium sulphate
IV 1.2-2g over 20mins (need to be on cardiac monitor)


When do you need to refer an asthmatic patient to ITU?

need to refer early!!


What is a significant diurnial variation when diagnosing asthma?

>20% difference in peak flow on >3days a week for 2 weeks.


What are the three commonest causes of a chronic cough with a normal chest xray?

Sinusitis and post nasal drip
Reflux oesophagitis


What are the differences between community acquired, hospital acquired and aspiration pneumonia?

CAP - pneumonia developed in the community
Strep pneumoniae is the most common, followed by haemeophilus influenzae

HAP - pneumonia developed >48hrs after hospital admission.
Gram -ve enterobacteria or staph aureus most common

Aspiration - results from aspiration of oropharyngeal organisms.
More common in patients with stroke, myasthenia, low consciousness, oesophageal disease


What is the CURB 65 score?

A scoring system to help guide if hospital management of pneumonia is needed.

Confusion (AMTS 7 = 1 point)
Respiratory rate (>30 = 1 point)
BP (systolic 3 indicates severe disease inform ITU


Which pneumonia is most commonly complicated by influenza?

Causes bilateral cavitating bronchopneumonia


Where does Klebsiella pneumonia usually affect?

The upper lobes


Which pathogens cause atypical pneumonia, and what is atypical about them?

Mycoplasma pneumonia
occurs in epidemics every 4 years
has insidious onset with flu like symptoms followed by dry cough
CXR usually looks worse than the symptoms suggest Autoimmune haemolytic anaemia may occur as a result of cold agglutinins
Associated with skin rashes

Legionella pneumophilia
Colonizes water tanks and air conditioning units
Flu like symptoms preceed a dry cough and SOB.
Extra pulmonary features - anorexia, D+V, hepatitis, renal failure, confusion
CXR - bibasal consolidation
Lymphopenia, hyponatraemia
Urine - haematuria,

Chlamydophila pneumoniae
Biphasic illness: pharyngitis followed by pneumonia

Chlamydophila psittaci
Acquired from parrot
Headache, fever, ,dry cough, lethargy, arthralgia,
Extra pulmonary - menigoencephalitis, infective endocarditis, hepatitis, nephritis, rash, splenomegaly


Who gets PCP?

Patients are are immunocompromised
Now called pneumocystis jiroveci

Dry cough, exertional dyspnoea, fever. bilateral creps


What are the causes of PE?

Clot breaking off from a pre-existing venous thrombosis

Right ventricular thrombus (post MI)
Septic emboli (right sided endocarditis)
Fat, air or amniotic fluid embolism
Neoplastic cell


What risk factors increase the chance of developing a PE?

Recent surgery - espc abdominal/ pelvic or ortho
Leg #
Prolonged bed rest
Pregnancy, the pill, HRT
Previous PE


What are the symptoms, signs and results seen in PE?

Acute breathlessness and chest pain
Dizziness and syncope

Pyrexia, cyanosis, tachypnoea, tachycardia, hypotension, raised JVP, pleural rub
Signs of a DVT

Low PaO2 and PaCO2
Normal CXR
ECG - sinus tachy with signs of right heart strain or SI, QIII TIII
-ve d-dimer rules out, a +ve one does NOT rule it in


How do you treat a PE

LMWH + warfarin until INR is stable for 3months if provoked
If unprovoked then longer than 3 months depending on risks

If cardiovascularly unstable may need to thrombolyse


What is the scoring system used to classify patients risk of developing a VTE?

Wells Score

for PE:
Clinical signs of DVT
Is PE the most likely diagnosis
HR >100
Immbolisation for >3days or surgery in previous 4 weeks

for DVT:
Paralysis or casting of leg
Bed ridden for 3 days or surgery in previous 4 weeks
Swelling of entire leg
Calf swelling >3cm compared to other leg
Greater pitting odeama in symptomatic leg
Collateral non varicose veins
Other diagnosis more likely (-2 points)


What is sarcoidosis and what are the features of it?

Multisystem granulomatous disorder of unknown cause.
Associated with HLA DRB1 and DQB1 alleles

Bilateral hilar lymphadenopathy, cough, dyspnoea, chest pain
Lymphadenopathy, hepatomegaly, splenomegaly
Uveitis, conjunctivits, keratoconjuctivitis sicca, gluacoma
Terminal phalangeal bone cysts
Enlargment of lacrimal and parotid glands
Bell's palsy
Erythema nodsum
Lupus pernio - chronic plaques on the nose, ears, lips and cheeks
Hypercalcaemia, hypercalcuria


What are the stages of sarcodosis?

Stage 0 = normal
Stage 1 = bilateral hilar lymphadenopathy
Stage 2 = BHL + peripheral pulmonary infiltrates
Stage 3 = pulmonary infiltrates alond
Stage 4 = progressive pulmonary fibrosis, bulla formation, pleural involvement


What are the indications for giving steriods in sarcoidosis?

Parenchymal lung disease
Neurological or cardiac involvement


What are the common causes for pneumothorax?

Primary = Spontaneous - due to rupture of a sub pleural bulla.
Secondary = Asthma, COPD, TB, pneumonia, lung abscess, carcinoma, C, lung fibrosis, sarcoidosis, connective tissue disorders, trauma, iatrogenic - CVP insertion, pacemaker,)


What is the safe triangle to insert a chest drain?

4th-6th intercostal space (above the nipple)
Anterior to mid axillary line, posterior to pec major.


What is the pathogenesis of Obstructive Sleep Apnoea?

Intermittent closure of the pharyngeal airway causing apnoeic episodes in sleep.
The respiratory muscles decrease activity during REM, so the diaphragm is the only muscle working.
The airway at the back of the throat is sucked closed.
Apnoea causes hypoxia, which results in increased effort and then the patient wakes up.