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Flashcards in Respiratory Deck (576):
1

What is pneumonia?

inflammation of the lung parenchyma caused by a lower RTI after a upper RTI as epithelial cells have been damaged

2

What are the signs and symptoms of pneumonia?

fever, confusion, chills, rigor, tachycardia, tachyponea, productive cough, vomiting, diarrhoea, dyspnea, pleuritic chest pain, punilent sputum, dull percussion, cyanosis, resp failure, speticaemia

3

Risk factors for pneumonia?

>65, smokers, malnourished, underlying lung disease, medications, recent RTI, infants, COPD, immunocompromised, nursing home residents, impaired swallowing, alcoholics, drug users

4

How do the lungs prevent against infection?

mucus lining the bronchiole, sterile lower resp tract, alveolar macrophages, mucociliary escalator, cough, IgA antibody, microflora, node hairs (mouth acidity)

5

What is the epithelium of the bronchi?

ciliated columnar epithelium

6

What does the epithelium of the bronchi secrete for immunoprotection?

mucus and IgA to eliminate microorganisms

7

What are the causative pneumonia agents?

bacteria: streptococcus pneumonia, haemopholus influenza, legionella pneumonia, staph aureus, mycoplasma
virus: influenze, RSV
fungi: (not common - most likely in immunocompromised)

8

What kind of impaired pulmonary defenses can cause pneumonia?

loss of cough reflex, injured mucocillary apparatus, decreased alveolar macro-phages, pulmonary congestion, odemea, accumulation of secretions

9

How does bacteria cause pneumonia?

bacteria enter alveoli causing immune response, leading to vasodilation and increasing vascular permeability so fluid shifts from vascular space into alveoli causing congestion

10

How do viruses cause pneumonia?

infect the respiratory cell, and release its genetic material and uses the respiratory cell proteins to replicate and make new viral particle, so the respiratory cells lysis causing immune response in the alveoli

11

How does fungi cause pneumonia?

the spores are inhaled and it grows into a fungal ball (seen in imaging), this can then spread to vasculature, causing systemic effects

12

What makes up a fungal ball?

fungus, mucus, cellular debris

13

What is seen in an alevoli in pneumonia?

fluid filled alveoli (congestion/consolidation), constriction, increase in mucus secretion

14

What is consolidation?

When the alveoli are fluid filled, causing a backflow of fluid into other alveolis, until the whole lobe is full of fluid, pus, blood and cells, resulting in lobar diffuse opacity

15

What is lobar pneumonia?

When there is consolidation in a lobe, starts distally and spreads throughout

16

What is broncho pneumonia?

when there are patches of consolidation throughout both lungs, starts proximally and moves distally towards the alveoli

17

What are the signs of pneumonia?

fever, raised HR, raised RR, low BP, signs of consolidation, decrease in chest expansion on affected side, bronchal breath sounds, vocal resonance, caitation, pleural effusion

18

What are the four stages of lobar pneumonia?

congestion, red hepatization, grey hepatization, resolution

19

When to hospitalise a pneumonia patient?

use CURB-65 severity criteria, if >2, needs to be hospitalised

20

What does CURB-65 stand for in pneumonia severity?

confusion, urea >7mmol/L, RR >30/min, BP 65years (1 point for each)

21

how many points match each stage in CURB-65 pneumonia?

mild = 0-1
moderate = 2
severe = 3 or more

22

What is the transmission of pneumonia?

inhalation, aspiration of organisms that colonise the oropharnyx, aspiration of stomach contents, hematological spread, direct innoculation

23

What mainly causes a community acquired pneumonia?

bacterial or viral normally from an upper RTI infection of a viral origin, main organisms are strep pneumonia, H.influenza, Morexaella cateralis, influenza, RSV

24

What is hospital acquired pneumonia?

pneumonia that is not incubating at time of admission and develops in a patient who is hospitalized for more than 48 hours

25

What organisms mainly cause hospital acquired pneumonia?

enterobacterzae, pseudomonas species and staphylococcus aureus and MRSA, aerobic gram negative bacilli

26

What is aspiration pneumonia?

occurs in hospitals, in markedly debilitated patients during unconsciousness or vomiting as it can aspirate the stomach with bacteria and can lead to abscess formation in the lungs (normally right lung)

27

What are lung abscess complications?

extension into plural cavity, meningitis, hemorrhage, brain abscess, secondary amyloidosis.

28

What microorganisms usually cause aspiration pneumonia?

streptococcus and staph aureus, gram negative

29

What is chronic pneumonia caused by?

usually by fungus, in immunocompromised eg. histoplasmosis, tuberculosis, aspergillus, nocardia

30

What are the complications of pneumonia?

abscess formation that can cause tissue destruction, emphyema, bacteriaic dissemination which causes bacterimia and sepsis

31

What investigations should be done for pneumonia?

CXR - consolidation
sputum testing
urine antigen testing
blood testing - WCC up if severe, neurtrophilia if bacteria, haemolytic anaemia, high urea if severe, LFTs are abnormal if its inflamed the liver
blood culture
gram stain

32

What would haemolytic anaemia suggest as a causative agent for pneumonia?

mycoplasma

33

What bacteria dose a urine antigen test identify in pneumonia?

strepto penumonia, legionella

34

What does bacteramia lead to in pneumonia?

sepsis

35

What is the treatment of pneumonia?

oxygen
IV fluids - if severe
NSAIDs and opioids
antibiotics - NARROW SPECTRUM
pneumoncoccal vaccines
smoking cessation
influenza vaccine
protein conjugate vaccine

36

What are the cardinal signs of pneumonia? (CDEF)

chest pain, dyspnoea, exudate, fever

37

What is a risk of using opioids?

respiratory depression

38

What is needed to be done to find the causative agent in pneumonia?

empirical therapy using b lactams or macrolides, once this is done, a more specific causative agent can be found

39

What is empirical therapy for pneumonia?

most likely pathogen
risk factors for antimicrobial resistance
medical co morbidities and allergies

40

What antibiotics are used in mild, moderate and severe pneumonia?

mild - amoxicillin
moderate - amoxicillin and clarithromycin
severe - coamoxiclav and clarithromycin

41

What is the empirical therapy for gram positive and gram negative bacteria?

positive = penicillins (b lactams)
negative = -mycins (macrolides)

42

How do B-lactams (amoxicillin and flucoxacillin) treat bacteria (staph)?

attack the peptidoglycan cell wall of the bacteria

43

How do macrolides (clarithromyscin and erythromycin) treat bacteria?

inhibit protein synthesis

44

When would you use IV antibiotics for pneumonia?

if it was complicated

45

What will strep pneumoniae show on CXR?

air bronchograms, effusions and collapses due to retenetion of secretions (raised WBC)

46

What will mycoplasma show on CXR?

bilateral or extensive infection of one lobe (normal WBC)

47

What will legionella show on CXR?

multilobar shadowing, pleural effusion and lymphopena

48

What are the clinical features of a hospital acquired pneumonia?

new fever, purulent secretions, radiological infiltrates, leukocytosis, increase in o2 requirements

49

What is a lung abscess?

a localised area of pus in the parenchyma (alveolar tissue)

50

What causes a lung abscess?

aspiration, bacterial pneumoniia, mechanical obstruction of the bronchi, alcoholics, poor dental hygiene, TB, aomebic liver disease

51

Sign and symptoms of a lung abscess?

fever, chills, weight loss, chest pain, productive cough, dull of absent lung sounds

52

What investigations should be done for a lung abscess?

CXR, CT, blood and sputum cultures, thoracentesis

53

What is the treatment of a lung abscess?

postural drainage, antibiotics, lobectomy,

54

What is empyema?

pus in the pleural cavity

55

What causes empyema?

chest trauma, pneumonia, TB

56

Signs and symptoms of empyema?

fever, chest pain, dyspnea, anorexia, malaise, diminished or absent lung sounds

57

What is the treatment of empyema?

thoracentesis to id the pathogen, use antibiotics
thoracotomy and surgical drainage

58

When does a lung effusion need drainage?

pH 1000iu or pH

59

What is bronchitis?

inflammation of the bronchial tubes

60

symptoms of bronchitis?

cough, SOB, wheeze, chest tightness, fever

61

What causes acute bronchitis?

viruses that cause colds, tobacco smoke, air pollution, dusts, vapors, fumes

62

What is the treatment of acute bronchitis?

rest, fluids, analgesic, no antibiotics if viral, amoxicillin if suspected bacterial infection

63

What is pneumothorax?

air in the pleural space

64

Which lung is more affected in pneumothorax?

both are equally affected

65

In who is primary pneumothorax most common?

tall, slim, men (men more common than women)

66

What are the causes of pneumothorax?

ruptured pleural bleb from congenital defects in connective tissue of alveiolar wall, COPD, TB, sarcoidosis, RA, ankylosing spondylitis, lung trauma, idiopathic pulmonary fibrosis, emphysema, asthma, air that cannot be removed on expiration due to a one way valve leading to mediastinal shift and lung collapse

67

What causes primary pneumothorax?

tall young men in 20s, smoking, diving, high altitude flying

68

What is tension pneumothorax?

when air is sucked into pleural space during inspiration but not expelled so interpleural pressure remains positive so lung deflates further

69

What is the difference of treatment of tension and non tension pneumothorax?

tension - medical emergency, immediate needle thoractemy, chest drainage
non tension - observe, aspirate, chest tube drainage

70

How does a tension pneumothorax present?

falling o2 sats, hypotension, tracheal deviation, diagnose clinically with immediate treatment

71

What are the complications of tension pneumothorax?

respiratory and cardiac arrest and death

72

symptoms of pneumothorax?

dyspnea, unilateral pleuritic chest pain, decreased lung sounds on affected side, percussion hyper-resonance,

73

What is pleuritic chest pain?

pain when breathing

74

How do you diagnose non tension pneumothorax?

CXR - pleural line shows tracheal deviation away from lesion, absent vascular markings, air, shrunken lobe of lung, diaphragm hyperexpansion, mediastinal shift
Ct scan
ABG - hypoxia

75

When should you do drainage in pneumothorax?

if ventilated, tension after needle, persistant or recurrent, >2cm secondary spontaenous pneumothorax >50yrs after aspirate

76

When do you put the needle in needle decompression?

the 2nd intercostal space in the midclavicular line?

77

How can you prevent pneumothorax?

advice on flying/diving and pleurectomy and chemical pleurodesis with talc if they cant have surgery, bleb resection

78

When is pain generalised in pneumothorax?

if no pleural adhesions

79

When is pain localised in pneumothorax?

if visceral pleura has previously become adherant to parietal pleura as the negative pressure would be lost once there is communication with the atmospheric pressure so elastic recoil pressure causing lung to partially deflate

80

What is a chylothorax?

accumalation of lymph in pleural space

81

What cause a chylothorax?

due to leakage from thoracic duct post trauma of infiltration by carcinoma

82

What is a pleural effusion?

excessive fluid in pleural space (transudate or exudate)

83

Which is the outer pleura?

the parietal

84

What are the symptoms of pleural effusion?

pleuritic chest pain, dyspnoea, dry cough,

85

What is the cause of an EXUDATE pleural effusion?

parapenumonic, TB, breats cancer, PE, RA, SLE, haemothorax, parasites, fungi, lymphoma, ARDS, hypothyroidism

86

What is a exudate fluid?

protein = >35g/L
lactic dehydrogenase = >200iu/L

87

What is a transudate fluid?

protein is

88

What is the cause of a TRANSUDATE pleural effusion?

ovarian tumours, CCF, cirrhosis, HF, hypoalbuminaemia, nephrotic syndrome, constrictive pericarditis, peritoneal dialysis, unithorax, malignancy, PE

89

What does pleural effusion fluid contain?

proteins and cells

90

How do you diagnose pleural effusion?

pleural aspiration with US guidance

91

How is a pleural effusion detected and how much fluid is needed to detect it?

CXR >300ml

92

For a pleural effusion to be detected clinically, how much fluid is needed?

>500ml

93

What is the treatment of pleural effusion?

transthorantesis, needle drainage, aspiration to dryness, inhalation of sclerosing agent, treat underlying cause

94

What is used to prevent a recurrence of a pleural effusion?

pleurodesis

95

How much fluid is produced and reabsorbed by the parietal pleura?

15ml/day

96

How happens when airway and pleural communication is maintained?

a bronchopleural fistula results, then air will be rebasorbed once it closes and it will collapse in 40 days

97

What kind of pleural effusion causes raised hemidiaphram?

subpulmonary effusion

98

how does fluid in the fissures present?

intrapulmonary mass

99

How is drainage of a pleural effusion achieved?

lymphatic pump from contractions of lymphatic wall smooth muscle and tissue pressure oscillations related to resp movement

100

What is the max drainage that can be done from a lymphatic pump?

300ml/day

101

When is a Abrams needle good in pleural effusion?

for TB, but there is low malignancy pick up

102

How does pleurodosis work?

insert an irritant into the pleural space to cause tissue damage, then as the tissue heels, it cause scar tissue to develop, so the two pleuras adhere together to remove potential space for pleural effusion

103

Why is drainage of a pleural effusion done slowly?

to prevent pain and shock but it is only a temporary relief

104

What is the first line of treatment for pleural effusion'?

transthorantesis

105

What is a complication of pleural effusion?

empyema which can then harden (organising) making it harder to treat and drain - and can spill over into blood vessels

106

What is a parapneumonic effusion?

a pleural effusion caused by pneumonia, lung abscess of bronciectasis

107

What are the 3 classifications of parapneumonic effusion?

uncomplicated, complicated, empyema thoracis

108

What is an uncomplicated parapneumonic effusion?

exudative, from increasing passage of interstitial fluid from pneumonia inflammation

109

What is complicated parapneumonic effusion?

bacterial invasion into the pleural space, visibly infective, pH

110

What kind of parapneumonic effusion is cloudy or clear?

uncomplicated

111

What is the treatment of complicated parapneumonic effusion?

drainage for resolution and antibiotics, decortication (surgical drainage), intrapleural fibrinolytics

112

What is empyema thoracis?

frank pus accumulating in the pleural space

113

What are the 3 stages of parapneumonic effusion?

exudative, fibrinopurulent, organisation

114

What are the signs of a pleural effusion?

decreased expansion, stony dull percussion, diminished breath sounds on affected side, bronchial breathing above the effusion

115

How are small effusions seen compared to large effusions on CXR?

small - blunt costophrenic angles
large - water dense shadows with concave upper borders

116

What is a bullae?

air space in lung parenchyma

117

How is bronchitis clinically defined?

cough and sputum production on most days for 3 months of two successive years

118

What is pulmonary hypertension?

increased resistance in the lungs so pulmonary artery pressure is 25mmHg at rest

119

What is the normal pulmonary artery pressure?

10-14mmHG

120

What can pulmonary hypertension lead to?

arteriosclerosis, medial hypertrophy, intimal fibrosis of pulmonary arteries, cor pulmonale

121

What are the symptoms of pulmonary hypertension?

SOB, dyspnoea, fatigue, syncope, exercise intolerance, structural lung damage (scarring), cough, right ventricular hypertrophy, left parasternal heave, loud P2 sound, portal hypertension, abdominal distension

122

What are the causes of pulmonary hypertension?

idiopathic, left heart disease, lung diseases, hypoxia, chronic thromboembolic, haematologic, systemic, metabolic, familial hereditary, drugs, toxins, connective tissue disorder, congential heart disease, portal hypertension, HIV

123

What are the types of pulmonary hypertension?

pulmonary arterial hypertension (PAH)
pulmonary venoocclusive disease
pulmonary hypertension from LHD
pulmonary hypertension due to hypoxia and lung disease
chronic thromboembolic pulmonary hypertension

124

What will a CXR show in pulmonary hypertension?

enlarged RA and RV, prominent pulmonary arteries

125

What does an ECG show in pulmonary hypertension?

p pulmonale, right axis deviation due to RVH

126

What do blood tests show in pulmonary hypertension?

raised Hb, haematocrit, e.g. polycythamia

127

What is the treatment of pulmonary hypertension?

treat the underlying cause, O2, ABG monitor, treat cardiac failure, stop smoking, endothlin antagonists to restrict pulmonary vasculature

128

What is the diagnostic test for pulmonary hypertension?

right heart catheterization to show pressure >30
ECHO estimates pressure and shows ventricular function

129

What is cor pulmonale?

right sided heart failure due to chronic pulmonary hypertension due to RV strain, causing compensatory hypertrophy and eventual failure

130

What is the most common cause of cor pulmonale?

COPD

131

What are the side effects of cor pulmonale?

centrally cyanosed, breathless, ankle oedema, venous overload, progressive hepatic congestion, parasternal heave from RVH, loud P2 sound, fatigue, dyspnea, tachypnea, orthopnea, distended jugular veins

132

What effect does cor pulmonale have on the valves?

The pulmonary valve will become incompetent so will develop a tricuspid incompetence with increase jugular venous pressure, ascites and upper abdominal discomfort from liver swelling

133

Treatment of cor pulmonale?

bed rest, treat underlying cause, stop smoking, treat heart condition, small frequent meals, limit fluid

134

What is a pulmonary embolism?

occlusion of the pulmonary vasculature by a clot

135

What is the cause of a pulmonary embolism?

DVT, air embolus, fat embolus, amniotic fluid embolus, foreign material introduced by an IV drug user, RV thrombus post MI, septic emboli, neoplastic cells, parasites

136

How is a pulmonary embolism classified?

small/medium, multiple or massive

137

Pathophysiology behind pulmonary embolism?

platelet factor is released causing vasoconstriction, meaning decreased alveolar perfusion of the lung so reduced gas exchange leading to decreased surfactant, a ventilation/perfusion mismatch, hypoxaemia and dyspnoea

138

Risk factors for pulmonary embolism?

recent surgery, thrombophilia, pregnancy, leg fracture, prolonged best rest, reduced motility, malignancy, previous PE

139

What investigations should be done for a pulmonary embolism?

D dimer, thrombophilia screening, CXR, ECG, ABG, CT with pulmonary angiography, V/Q scan, Wells score

140

What will an ECG show in pulmonary embolism?

sinus tachycardia, S1Q3T3 pattern, excludes MI

141

What will an ABG show in pulmonary embolism?

hypoxaemia

142

When should a Thrombophilia screening take place?

In pulmonary embolism patients younger than 50

143

What is the treatment of a pulmonary embolism?

oxygen, IV fluids, thrombolysis therapy if indicated, LMW heparin, anticoagulation, IVC filter

144

When would thrombolysis therapy be indicated?

massive pulmonary embolism or haemodynamically unstable

145

What are the symptoms of a small pulmonary embolism?

pleuritic chest pain
breathless
haemoptysis
tachypoenic
fever

146

What are the symptoms of a massive pulmonary embolism?

severe chest pain
shocked, pale, sweaty
syncope
tachypoenic
tachycardia
hypotension and peripheral shut down
raised JVP

147

What are the symptoms of multiple pulmonary embolism?

increased breathlessness, weakness, syncope, occasional angina

148

What causes a pulmonary infarct?

a pulmonary embolism with chronic left heart failure, which causes decreased surfactant levels

149

In how many patients with pulmonary embolism does a pulmonary infarct occur?

10-15%

150

What does a CXR show in a pulmonary infarct?

Hamptom hump (wedge shape on pleura without air bronchograms) in lower lobes usually - leaves linear scar on healing

151

What does a CT show on a pulmonary infarct?

Hamptom hump and bubbly consolidation, convex borders

152

What is extrinsic allergic alveolitis?

inhalation of allergens which provoke a hypersensitivity reaction
diffuse granulomatous inflammation of lung tissue and airways in people who are sensitised by repeated inhalation of organic antigens in dusts

153

What happens in the acute and chronic phase of extrinsic allergic alveolitis?

acute - alevoli infiltrated with acute inflammatory cells
chronic exposure - small granuloma formation and obliterative bronchiolitis

154

What are the acute clinical features of extrinsic allergic alveolitis?

fevers, rigors, dry cough, dyspnoea, crackles, SOB

155

What are the chronic clinical features of extrinsic allergic alveolitis?

weight loss, exertional dyspnoea, type 1 respiratory failure, cor pulmonale, inspiratory cackles in lower lung

156

What is the most common cause of extrinsic allergic alveolitis?

farmers lung from mouldy hay

157

What is causes pigeons fanciers lung?

avian protein in bird droppings

158

What is Malt workers lung?

aspergillus clavatus from mouldy malt

159

What causes Bagassois/sugar workers lung?

sugar cane fibres

160

What is another name for extrinsic allergic alveolitis?

occupational lung disease

161

What is seen in the CXR of extrinsic allergic alveolitis?

upper zone mottling/consolidation
ground glass appearance
honeycomb lung in advance, micronodular shadowing

162

What is the treatment of extrinsic allergic alveolitis?

remove allergen, O2, oral prednisolone, compensation if occupational

163

What organism causes farmers lung?

saccharopolyspora rectivigula

164

What organism causes Hot tub lung?

poorly maintained hot tubs - aspergillus clavatus

165

What organism causes mushroom workers lung?

mushroom compost - thermophillic actinomycetes

166

What causes chemical workers lung?

plastics, rubber, foam industry - anhydride, diisocyanate

167

In chronic extrinsic allergic alveolitis, what happens to symptoms when the antigen is removed?

there is only partial improvement - and it eventually leads to chronic hypoxaemia and pulmonary hypertension leading to RH failure

168

What will bloods show in extrinsic allergic alveolitis?

increased CRP and ESR, serum antibodies

169

What will spirometry show in extrinsic allergic alveolitis?

restrictive spirometry

170

What causes type 1 hypersensitivity?

IgE mediated (mast cells and basophils) e.g. anaphylaxis, hayfever, asthma

171

What is the hypersensitivity classification called?

Gell-Coomb

172

What causes type 2 hypersensitivity?

antibody mediated e.g. goodpastures syndrome, haemolytic anaemia, Grave's disease

173

What causes type 3 hypersensitivity?

immune complex formation which are then deposited around the body, acute and chronic e.g. extrinsic allergic alveolitis, SLE, RA

174

What causes type 4 hypersensitivity?

T lymphocyte mediated, delayed, forms granulomas e.g. TB, sarcoidosis

175

What is hypersensitivity pneumonitis?

inflammation of lung tissue from an inhaled antigen

176

When type of hypersensitivity is hypersensitivity pneumonitis?

mix of type 3 and 4

177

example of hypersensitivity pneumonitis?

farmers lung, cigarette smokers

178

What can hypersensitivity pneumonitis lead to?

recurrent infections, COPD, cor pulmonale, pneumothorax

179

How does hypersensitivity pneumonitis cause complications?

chronic exposure leads to inflammation and fibrosis, decreasing gas exchange, leading to stiff lung from reduced surfactant production, causing respiratory failure and death

180

symptoms of hypersensitivity pneumonitis?

SOB on exertion, dry cough, fever, burning sensationin chest, fatigue, weight loss, improved symptoms on no exposure (e.g. during the week)

181

DD for hypersensitivity pneumonitis?

idiopathic pulmonary fibrosis, infection, sarcoidosis,

182

What causes berylliosis?

inhalation of beryllium from aerospace, nuclear, electrical and manufacturing industries

183

What does beryylliosis show on histology?

granulomatous

184

What makes up a granuloma?

giant cells, macrophages, epithelioid cells

185

What is the treatment of berylliosis?

steroids

186

How does berylliosis present?

progressive dyspnoea and pulmonary fibrosis

187

What causes silicosis?

silica particle inhalation from foundries, sandblasting, mines, quarries and pottery

188

Why can't silica be removed by the respiratory defences?

macrophages engulf the silica, causing the macrophages to release fibrogenic factors, leading to fibrosis, collagen deposit and COPD

189

What does silicosis increase the risk of?

TB and bronchogenic carcinoma

190

What does a CXR show in silicosis?

eggshell calcification of hilar lymph nodes and nodular lesions in upper lobes

191

How does silicosis present?

progressive dyspnoea and restrictive ventilatory defect

192

What causes asbestosis?

inhalation of asbestos fibres seen in old roofing and plumbing, ship building

193

What are the three types of asbestosis and which is most fibrogenic?

crocidolite (blue) = most
amosite (brown)
chrysotile (white) = least

194

What are asbestos fibres?

they are inconsumable silicate

195

What can asbestosis lead to?

malignant mesothelioma, lung cancer, chest neoplasia, persistant pleural effusion, diffuse pleural fibrosis and diffuse interstitial lung fibrosis

196

What is malignant mesothelioma?

pleural mesothelial cell tumours - mainly from asbestos exposure

197

What does the CXR show in asbestosis?

ivory white, calcified supradiaphramatic and pleural plaques

198

What are the symptoms of asbestosis?

dyspnoea, clubbing, fine and inspiratory cackles, SOB, weight loss, bloody pleural effusions, metastases

199

What is the treatment of asbestosis?

treat the symptoms and stop smoking

200

What does fibrotic shadowing on CXR in the upper zone suggest?

TB, EEA, Berylliosis, coal workers, silicosis, sarcoidosis

201

What does fibrotic shadowing on CXR in the middle zone suggest?

progressive massive fibrosis

202

What does fibrotic shadowing on CXR in the lower zone suggest?

asbestosis, idiopathic pulmonary fibrosis

203

What causes coal workers lung?

coal dust inhalation

204

How does coal dust inhalation cause pneumoconiosis?

it accumulates in the lung parenchyma and engulfed by macrophages, the macrophages then die and release fibrogenic factors causing tissue fibrosis

205

What are the symptoms of simple pneumoconiosis?

asymptomatic or chronic bronchitis

206

What does the CXR show in acute and chronic pneumoconiosis?

acute - round opacities in upper zone
chronic - upper zone fibrotic masses

207

What is the treatment of pneumoconiosis?

avoid exposure, treat chronic bronchitis, stop smoking, claim compensation

208

What is progressive massive fibrosis?

progression of coal workers lung

209

What are the symptoms of progressive massive fibrosis?

progressive dyspnoea on exertion cough with black sputum, fibrosis and cor pulmonale and respiratory failure, shows upper zone fibrotic masses

210

What is byssinosis?

cotton workers lung caused by cotton mills that limits the airway

211

What are the symptoms of byssinosis?

tight chest, cough, breathlessness

212

What is Caplans syndrome?

the association between RA, pneumoconiosis and pulmonary rheumatoid nodules

213

Which occupational diseases have RhF present?

Caplans, Progressive massive fibrosis, asbestosis, silicosis

214

What is Bauxite fibrosis?

shavers disease cuased by bauxite fibres

215

What is siderosis?

inhalation of iron particles - but no resp symptoms of altered lung function

216

Which cancer is closely related to asbestos exposure?

malignant mesothelioma

217

Where does malignant mesothelioma usually occur?

in pleura (rarely peritoneum or other organs)

218

What can the latent period between asbestos exposure and malignant mesothelioma be?

45 years

219

How does malignant mesothelioma present?

chest pain, weight loss, SOB, finger clubbing, recurrent pleural effusions

220

What are the signs of malignant mesothelioma metastases?

lymphadenopathy, hepatomegaly, bone pain, abdo pain

221

What will investigations show in malignant mesothelioma?

pleural thickening and blood in pleural fluid (these pleural plaques can also increase bronchial adenocarcinoma)

222

What is the treatment of malignant mesothelioma?

chemo - but poor prognosis

223

What is sarcoidosis?

a multisystem chronic inflammatory condition with NON-CASEATING granulomas at various sites in the body

224

What is a granuloma?

a collection of epithelioid histiocytes

225

Who who is sarcoidosis commonly seen?

adults over 50, normally sporadic, more common in females

226

Where is sarcoidosis usually seen?

thorax > skin > eyes > liver > heart > nervous system

227

What are the symptoms of sarcoidosis?

fever, fatigue, cachexia, decreased exercise tolerance, chest pain
lung - interstitial lung disease, dry cough, fever, SOB, chest tight
skin - erythema nodosum on legs, lupus pernio on nose and cheeks
eyes - granulomatous uveitis (worse on posterior)
hepatomegaly, hypercalcaemia

228

What does a CXR show in sarcoidosis?

bilateral hilar/para tracheal lymphadenopayhy, pulmonary infiltration

229

What will investigations show in sarcoidosis?

increase in eosinophils, calcium and ESR
INCREASED SERUM ACE
interstitial lung disease
increase CD4:CD8 ratio
transbronchial biopsy and histology
staging
increased Igs
restrictive ventilatory defect
non caseating granuloma biopsy

230

What is the management of sarcoidosis?

symptomatic relief, oral corticosteroids, surgery, stop smokiing, osteoporosis prophylaxis, influenza vaccination, bed rest, NSAIDs

231

What are the complications of sarcoidosis?

lung infections, PE, increased fibrotic disease,, pulmonary hypertension, respiratory failure

232

What is idiopathic pulmonary fibrosis?

idiopathic interstitial pneumonia, inflammatory cell infiltrate, unknown cause of fibrosis

233

What is the main cause of interstitial lung disease?

idiopathic pulmonary fibrosis

234

What are the complications of idiopathic pulmonary fibrosis?

respiratory failure and increased risk of lung cancer

235

What are the signs and symptoms of idiopathic pulmonary fibrosis?

dry cough, dyspnoea on exertion, weight loss, malaise, cyanosis, finger clubbing, fine late inspiratory crackles

236

What does the CXR show in idiopathic pulmonary fibrosis?

bilateral lower lung reticulonodular shadows and honeycombing, decreased lung volume

237

What is the treatment of idiopathic pulmonary fibrosis?

supportive care with oxygen and pulmonary rehabilitation, lung transplant, opiates

238

What does idiopathic pulmonary fibrosis show on biopsy?

usual interstitial pneumonia

239

What is the prognosis like for idiopathic pulmonary fibrosis?

poor due to the resp fialure and lung cancer risk
50% 5 year survival
3000 deaths per year

240

What is a secondary cause of pulmonary fibrosis?

infarction, TB and pneumonia

241

Risk factors for idiopathic pulmonary fibrosis?

cigarettes, infectious agents, dust exposure, antidepressant, chronic aspiration, genetics

242

What is an interstitial lung disease?

distinct cellular infiltrates and extracellular matirx deposition in the lung distal to the terminal bronchiole

243

What will histology show in most interstitial lung disease?

hyperplasia of type 2 pneumocytes

244

What are the common symptoms in interstitial lung disease?

dyspnoea on exertion, dry cough, restrictive spirometry, decreased gas transfer

245

What are the causes of interstitial lung disease?

hypersensitivity pneumonitis, industrial dusts, drugs, infections, GORD, sarcoidosis, RA, connective tissue disorders e.g. SLE, idiopathic pulmonary fibrosis

246

What is Langerhans cell histiocytosis?

rare, multisystem disease of histocyte proliferation

247

What are the clinical features of Langerhans cell histiocytosis?

unifocal bone lesions in older children, multifocal in young children , pulmonary Langerhand cell hisiocyte in smokers, honeycomb lung, fibrosis, nodular shadows

248

What is Lymphangiolyomyomatosis?

benign proliferation of lymphatic smooth muscle cells

249

How does lymphangiolyomyoatosis present?

dyspnoea, chylous pleural effusions, haemoptysis, pneumothorax

250

What is pulmonary alveolar proteinosis?

accumulation of lipoproteinaceous material in alveoli caused by a defect in the GM-CSF stimulation of alveolar macrophages

251

How does pulmonary alevolar proteinosis present?

bronchial lavage with milky appearance, large, foamy macrophages from lack of maturation, causing proteinaceous fluid accumulation

252

what does neutrophils with a linear and reticular morphological appearance with lower and peripheral distirbution suggest?

idiopathic pulmonary fibrosis

253

What does a nodular morphological appearance with central distribution and lymphocytes suggest?

sarcoid

254

What do eosinophils in a BAL suggest?

eosinophilic pneumonia

255

How does cryptogenic organising pneumonia present?

malaise, cough, breathlessness, fever, pleuritic chest pain, bilateral parenchymal shadowing, normal/restrictive lung function, normal WBC, increased ESR, buds of connective tissue in bronchioles, ground glass appearance

256

Treatment of interstitial lung disease?

corticosteroids, immunosuppresants, lung transplant

257

Risk factors for interstitial lung disease?

RA, RhF, male, age, anti CCP, smoking, DMARDS

258

What is bronchiectasis?

chronic infection of bronchi and bronchioles leading to permanent dilation of these airways, leading to increased infection risk

259

What organisms cause bronchiectasis?

H.influenzae, Strep.pneumoniae, Staph.aureus, Pseudomonas aeruginosa

260

What are the causes of bronchiectasis?

CF, post infection of measles/pertussis/bronchiolitis/penumonia/TB/HIV, bronchial obstruction, allergic bronchopulmonary aspergillosis, hypogammaglobulinaemia, IBD, tumours, a1trypsin deficiency

261

signs and symptoms of bronchiectasis?

persistent cough, copious purulent foul smelling (yellow/green) sputum, intermittent haemoptysis, clubbing, coarse inspiratory creps, wheeze, increased fungal infection risk, febrile episodes, weight loss, recurrent exacerbations

262

What is clubbing?

distorted angle of nail bed

263

What will a CXR show in bronchiectasis?

thickened bronchial walls, dilated bronchi, tram track opacities of bronchi and bronchioles

264

What is the sputum like in bronchiectasis?

foul smelling, green/yellow, purulent, lots of

265

What will investigations show in bronchiectasis?

thickened dilated bronchioles and cysts, serum Igs, IgA deficiency, sweat electrolytes, mucociliary clearance, obstructive spirometry, aspergillus screen

266

What is the treatment of bronchiectasis? (ABCDS)

postural drainage, chest physio to aid mucus clearance, antibiotics, bronchodilators e.g. salbutamol, corticosteroids for ABPA, surgery,

267

pathophysiology behing bronchiectasis?

chronic infection causes chronic inflammation, destroys elastic and muscular tissue, airways dilate permanently, poor mucus clearance, impaired airflow and drainage, accumulation of mucus in lungs, mucus colonises bacteria so frequent and severe lower RTIs, worsening of bronchiectasis

268

complications of bronchiectasis?

empyea, lung abscess, pneumothorax, resp failure, reduced QoL, pleural effusion, metastatic abscess formation, septicaemia,

269

What organism is common in bronchiectasis and CF?

pseudomonas aeruginosa

270

What is the macroscopic appearance of bronchiectasis?

cylindrical, varicose, cystic

271

What is the pathophysiology of cystic fibrosis?

a mutation in the CF transmembrane conductance regulator gene (CFTR) Ch7 which codes for Cl- channel, this leads to defective cl- secretion and increased Na+ absorption across the airway epithelium so there is thick mucus leading to the inability to clear pathogens so increased infections and bronchiectasis

272

In who is cystic fibrosis most common?

1/2000 caucasian births, increasing prevalence,

273

What genetic pattern in cystic fibrosis?

autosomal recessive

274

What is the mean survival of cystic fibrosis?

around 40 years

275

What are the symptoms of a neonate with cystic fibrosis?

failure to thrive, meconium ileus (SI blockage due to thicker secretions), rectal prolapse

276

What are the general symptoms of a child/adult with cystic fibrosis?

cough, wheeze, recurrent, brochiectasis, pneumothorax, haemoptysis, respiratory failure, cor pulmonale

277

What are the signs of cystic fibrosis?

clubbing, cyanosis, bilateral coarse crackles

278

How does cystic fibrosis affect fertility?

men - 98% infertile due to blocked ducts, but no reduced libido
women - normal fertility

279

What GI symptoms are seen in cystic fibrosis?

pancreatic insufficiency (DM, steatorrhoea), distal intestinal obstruction syndrome, gallstones, cirrhosis

280

What other symptoms are associated with cystic fibrosis?

osteoporosis, arthritis, vasculitis, nasal polyps, sinusitis, neuropathy, right blindness, salty sweat, bone loss

281

What are the diagnostic tests of cystic fibrosis?

sweat test - shows high chloride and sodium content (salty) >60mml/L sodium
faecal elastatse - shows pancreatic dysfunction
screening of CF mutation
Guthnes test in neonatal showing increased serum immunoreactive trypsinogen
may show bronchiestasis

282

What is the used for prevention of cystic fibrosis?

hygiene, vaccination, flu vaccine, penumovax, pseudomonal vaccine, segregation in and out of hospital, prophylactic antibiotics (flucoxacillin for s.aureus and amoxyl for h.influenzae)

283

What is the treatment of cystic fibrosis?

postural drainage, chest physio, antibiotics for acute severe exacerbations, mucolytics, bronchodialators, oxygen, diuretics, ventilation, transplant, pancreatic enzyme replacement, fat soluble vitamin replacement, ursodeoxycholic acid, treat complications, screening and counselling, gene therapy transfer,

284

What are the 3 main organisms that cause cystic fibrosis?

psuedomonas aeruginosa, burkholderia cepecia complex, mycobacteria abscessus

285

What is the treatment of pseudomonas aeruginosa cystic fibrosis?

nebulised recombinant human DNAase
nebulised tobramycin
oral azithromycin
decrease exacerbations once chronic colonisation

286

Why is pseudomonas aeruginosa so resistant?

has unique strains with a flagella, and improving antibiotics sensitivity
the loss of the flagella and biofilm formation is associated with chronicity, antibiotic resistance and epidermic strains

287

How will symptoms differ in those with a multiresistant strain of pseudomonas aeruginosa cystic fibrosis?

lower fev1, consume more rescources, poor outcomes

288

What are the 3 types of Burkholderia cepecia complex?

Bcc genomovars
Non Bcc CF pathogens
Cepacia syndrome

289

What is Wegners granulomatosis?

a granulomatosis with polyangitis (GPA) with unknown cause - necrotising granulomatous inflammation and vasculitis of small and medium vessels, endobronchial involvement and caviating nodules

290

What are the clinical features of Wegners granulomatosis?

nasal obstruction, ulcers, nasal septum destruction, progressibe glomerulonephritis, cough, haemoptysis, purpura, nodules, peripheral neuropathy

291

What will investigations show in Wegners granulomatosis?

raised cANCA, antibodies against pr3
proteinuria, haematuria
cxr - nodules and fluffy infiltrates of pulmonary haemorrhage
Ct show diffuse alveolar haemorrhage

292

What is the treatment of Wegners granulomatosis?

corticosteroids and cyclophosphamide to cause remission
azathioprine and methotrexate for maintenance
plasma exchange in severe renal disease

293

What is the prognosis like for Wegners granulomatosis?

poor

294

What causes Goodpastures syndrome?

a type 2 cytotoxic reaction driven by antibodies, directed against the basement membrane of kidney and lung (antiglomerular basement membrane antibodies)

295

What are the symptoms of Goodpastures syndrome?

acute glomerulonephritis, lung symptoms, haemoptysis, diffuse pulmonary haemorrhage, upper RTI, cough, tiredness, anaemia, massive bleeding

296

What does the CXR show in Goodpastures syndrome?

infiltrates due to pulmonary haemorrhage in the lower zones

297

What does a kidney biopsy show in Goodpastures syndrome?

crescentric glomerulonephritis

298

What is the treatment of Goodpastures syndrome?

treat shock, vigorous immunosuppressive treatment and plasmapheresis to remove autoantiboeds against the basement membrance
can improve spontaneously or lead to renal failure

299

What is Churg Strauss syndrome?

a triad of asthma, eosinophilia and vasculitis that affects lungs, nerves, heart and skin

300

What can Churg Strauss syndrome lead to?

septic shock, systemic inflammatory response syndrome, glomerulonephritis, renal failure

301

What do investigations show in Churg Strauss syndrome?

eosinophilic infiltration and increased eosinophils in blood count, vasculitis of small arteries and veins, extravascular granulomas, ANCA positive, ground glass consolidation and bronchial wall thickening, anti MPO positive

302

What is vasculitis?

inflammatory disorder of blood vessels causing destruction or stenosis, primary or secondary

303

What is vasculitis of large vessels called?

Giant cell arteritis or Takayasus arteritis

304

What is vasculitis of medium vessels called?

polyarteritus nodoas, kawasaki disease

305

What is vasculitis of small vessels called?

ANCA positive vasculities e.g. Churg Straus, Wegeners granulomatosis, microscopic polyangiitis, glomerunephritis
ANCA negative vasculities e.g. Henoch Schoelein purpura, good pastures syndrome and cryoglobuliemia

306

What are the symptoms of vasculitis?

depends on which organ is affected, fatigue and raised inflammatory markers , proteinuria, haematuria

307

What is the treatment of vasculitis?

steroids and immunosuppressants

308

What are the 4 x-ray stages of sacoidosis?

1-BHL only
2-BHL and infiltrates
3-infiltrates only
4-advanced parenchymal disease (fibrosis, bullae, bronchiectasis)

309

What is the main lung malignancy?

carcinoma of the bronchus

310

Risk factors for carcinoma of the bronchus?

smoking, asbestos, chromium, arsenic, iron oxides, radon gas

311

Symptoms of carcinoma of the bronchus?

cough, haemoptysis, weight loss, anorexia, lethargy, sypnoea, chest pain

312

Signs of carcinoma of the bronchus?

cachexia, clubbing, anaemia, lymph nodes, metastases sign e.g. bone tenderness (particularly vertebral and hepatomegaly)

313

What is the most common histology in carcinoma of the bronchus in smokers?

squamous

314

What is the most common histology in carcinoma of the bronchus in non smokers?

adenocarcinoma

315

What are the 5 histologys seen in carcinoma of the bronchus?

squamous, adenocarcinoma, small cell, large cell, alveolar cell carcinoma

316

Management of NSCLC?

mainly pallitative - surgical resection and radiotherapy w/wo adjuvant chemo

317

Management of SCLC

chemotherapy and radiotherapy

318

How can lung cancer be prevented?

quit smoking, reduce exposure to carcinogens

319

Management of lung cancer?

palliative, radiotherapy, SVC stent, endobronchial therapy, pleural drainage for symptomatic pleural effusions, analgesics, steroids, anti emetics, bronchodilators

320

Types of lung malignancy?

carcinoma of the bronchus, slow growing bronchial adenoma, benign hamartoma, malignant mesothelioma

321

Where in the UK smoke the most?

Yorkshire and Humber and North West

322

What does a PET scan do?

a functional non anatomical image that characterizes extent of mediastinal nodal involvement and highlights distant metastases - good for detecting asymptomatic metastases

323

Positive and negative of PET scans?

high negative predicted value but low positive predicated value

324

What causes false negatives in a PET scan?

BAC, carcinoid small lesions

325

What causes false positives in a PET scan?

inflammation and infection

326

What chemical is used in a PET scan?

fluro 2 deoxyglucose (FDG) is taken up by rapidly dividing cells, with a half life of 110mins

327

Is NSCLC or SCLC more common?

80% NSCLC

328

What is the 10yr survival for NSCLC?

329

Symptoms of lung cancer metastatic disease?

bone pain, headache, siezures, neurological deficit, hepatic pain, abdominal pain

330

At what stage is NSCLC mainly diagnosed?

stage 4

331

What investigations help identify lung cancer type?

CXR, Ct scan, bronchoscopy, percutaenous needle biopsy, US guided aspirate, surgical biopsy

332

What investigations help stage a lung cancer?

bloods, CT thorax and abdo, PET scan, CT head, medistinoscopy, pleural aspiration

333

What investigations are used to determine how fit a lung cancer patient is?

ECG, lung function, exercise test with ECHO, exercise capacity, perfromance status, risk of pre op morbidity

334

What are the stages of a performance status for lung cancer?

0-normal activity without restriction
1-restricted in strenuous work but can do light work
2-self caring but no work
3-limited self care, in bed/chair >50% of day
4-no self care, bed/chair bound

335

What is the function of surgery and chemo in cancer?

surgery controls primary tumour
chemo eradicated micro metastases

336

How to 60-70% of SCLC present?

as a perihilar mass (5% as a peripheral coin lesion)

337

What is a pleural fibroma?

soft tissue neoplasm of pleura, mainly benign, can grow and compress lung tissue

338

What does a pleural fibroma occasionally secrete and what does this cause?

insulin related factors that can produce hypoglycaemic symptoms

339

What makes up a pleural neoplasma?

a pleural fibroma and malignant mesothelioma

340

What is a BALTOMA?

a bronchus associated tissue lymphoma

341

What are hamartomas?

irregular proliferations of benign or normal tissue, most commonly condroid hamartoma which incorporates cartilage, glandular tissue, fat, fibrous tissue and blood vessels

342

What is the difference between radical and palliative radiotherapy?

radical is treatment 5x/week, it is curative
palliative is minimum number of visits needed for symptom control - normally not curative

343

What is conformal radiotherapy?

conformation of target volume more accurately to shape of tumour and then the reduced tumour is irradiated, there is an escalation of radiation dose and then toxicity is reduced

344

What is sterotactic ablative radiotherapy?

conformal radiotherapy with allowance for breathing motion and dose escalation, for those with peripheral tumours who are inoperable from co morbidity etc, it allows high rates of local control with low morbidity

345

Side effects of palliative radiotherapy?

fatigue, anorexia, oesophagitis, systemic symptoms, skin reactions, nausea, alopecia if it is cranial

346

Side effects of chemotherapy?

alopecia, nausea, vomiting, peripheral neuropathy, constipation, diarrhea, mucositis, rash, bone marrow suppression, fatigue, anaphylaxis

347

Symptoms of a paraneoplastic lung cancer?

secretion of PTH, SIADH, ACTH secretion, hypertrophic pulmonary osteo arthropathy, myasthenic syndrome, finger clubbing, migratory thrombophebitis, non infective endocarditis, DIC

348

What is TB?

a granulomatous disease that can affect any organ, mainly the lungs, caused by Mycobacterium tuberculosis or M.bovis (acid fast bacillus)

349

How is TB transmitted?

aerosal droplets

350

Is TB organisms aerobic or anaerobic?

aerobic, slow growing and immpermeable due to high lipid in cells wall, non spore forming, non mobile

351

How does TB cause infection?

droplets inhaled, bacteria colonise alveoli, bacteria engulfed by macropahegs, multiplication of bacteria within macrophages, granulomas form about M.tuberculosis (caseous necrosis)

352

What are the two types of granulomas that form in TB?

immunocopetent and non immunocompetent

353

What happens in immunocompetent TB?

caseous necrosis produces conditions that decrease growth of bacteria e.g. decrease o2 and ph levels

354

What does immunocompetent TB lead to?

latency

355

What happens in non immunocompetent TB?

granuloma formation does not contain bacteria, leading to liquification of necrotic tissue, drained into the bronchus which is then coughed up

356

What are the primary symptoms of TB?

cough, chest pain, haemoptysis, weight loss, anorexia, night sweats, fever, malaise, dyspnoea

357

What is progressive TB?

when TB progresses or causes miliary disease

358

What is post progressive TB?

asymptomatic with nodules, fibrosis or cavity, systemic haemoptysis, pneumonic, pleurisy

359

What are the different forms of TB?

primary, latent reactivation, secondary, lymph node, bone, abdominal, genitourinary, miliary, meningitis

360

How does lymph node TB present?

node swelling and is centrally necrotic

361

How does bone TB present?

joint pain and swelling, Potts disease of the spine

362

How does abdominal TB present?

ascites, abdominal lymph nodes

363

How does GU TB present?

epidymitis, dysuria

364

How does miliary TB present?

systemic upset from spread of bacili

365

How does meningitis TB present?

bacilli in CSF, meningitis and raised ICP

366

What is the treatment of TB?

rifampicin, isoniazid, pyrazinamide, ethambutol, educate for compliance, surgery depends on location

367

Side effects of rifampcin?

fever, hepatitis, rash, blood dyscrasia

368

Side effects of isoniazid?

hepatisis, peripheral neuropathy, psychosis, haemolytic anaemia

369

Side effects of pyrazinamide?

hepatisism hyperuricaemia

370

Sife effects of ethambutol?

optic neuritis

371

What tests should be done for TB?

sputum culture, sputum stain, transbronchial biopsy, pleural fluid analysis, xray for infiltrates and cavitations, tuberculin skin test

372

What does a transbronchial biopsy show in TB?

granulomas

373

What are the two stains you do in a TB invetsigation?

Ziehl Neelsen stain for acid fast bacilli
Auramine rhodamine staining is more sensitive

374

What does an x-ray show in TB?

Millet seed lesions in miliary TB

375

What medium is used in a TB sputum culture?

Ogawa/Lowenstein Jensen medium

376

How long does a liquid and solid sputum culture take in TB?

liquid is 1-3 weeks growth
solid = 3-8 weeks growth

377

What is used to detect TB in a culture?

automated systems BACTEC M.gorwth indicator tube (MGIT) fleurometric detection in liquid media

378

What happens in a TB skin test?

protein derived from the TB organism is injected intradermally and stimulates type 4 delayed hypersensitivity reaction, causing a positive result 48-72 hours post injection
causes increased indurated lesion of >6mm in non BCG vaccinated and >15mm in vaccinated
wont distinguish injection and disease

379

Risk factors for TB?

previous treatment, contact with drug resistant patient, originates of travelled to place of high incidence, HIV, non adherance history, substance abuse, homeless,

380

Prevention of TB?

skin test and IGRA if susceptible
BCG jab
contact tracing
remove risk factors

381

What does IGRA do in TB?

detects the IFN-y production from T cells in TB exposure but does not differentiate between active and latent disease, but it is more sensitive than TST

382

Pathogenesis behind TB?

pathogen is ingeted by macrophage and survives in phagosome, preventing acidification, inhibiting ROS and limits antigen presentation

3-9 weeks after, CD4+ T cells via IFN-y prime macrophages to kill bacilli and release tissue dmaging enzymes and CD8+ T cells lyse infected cells so infection is quescent but can cause reactivation

controlled by activated macrophaes to form a granulomata and Langerhan giant cells in an organised reaction

383

When do caseous necrosis and cavitation necrosis occur in TB?

caseous - 10^2-10^4 bacilli
cavitation - 10^7-10^9bacilli

384

Where is the most common site of infection?

respiratory tract

385

are children or adults most likely to get an RTI?

children

386

What kind of viruses can cause RTI?

rhinovirus, coronavirus, adenoovirus, respiratory syncytial virus, parainfluenza, influenza A

387

What virus is responsible for the common cold, bronchitis and sinusitis?

Rhinovirus

388

What virus is responsible for upper RTI, pharyngitis, bronchitis, and occasionally pneumonia?

Adenoviruses

389

What virus is responsible for colds and severe respiratory illness?

coronavirus

390

What virus causes pharyngitis?

adenovirus (B hemolytic streptococci in 10-30% of cases)

391

How does pharyngitis present?

sore throat, tender neck glands, larger tonsils, raised temp and tender anterior cervical LN

392

What virus causes glandular fever?

Epstein Barr virus

393

What is persistent and severe tonsilities treated with?

phenoxymethylpenecillin (amoxicillin in serious cases)

394

How does sinusitis present?

dull constant pain over frontal and maxiallary sinuses with tenderness and posy nasal drip, fever, punilent nasal discharge, ear and tooth pain but no dental problems, recent cold, pain worse on bending over

395

What organisms mainly cause sinusitis?

streptococcus pneumoniae and H.influenzae, fungal

396

What complications can sinusitus lead to?

brain abscess, sinus vein thrombosis, orbital cellulitis

397

What is the treatment of sinusitis?

nasal decongestants, broad spectrum antibiotics, anti inflammatory therapy, topical corticosteroids

398

How does acute epiglottis present?

sore throat, pain on wallowing, febrile, wheezing noise on breathing in, fatigue, weight loss, diarrhoea, oral thrush, fever, severe air flow obstruction

399

What organism mainly causes acute epiglottis?

haemophilus influenzae type B

400

How do children present with acute epiglottis ?

dysphagia, drooling, stridor

401

Treatment of acute epiglottis?

life threatening, need endotracheal intubation and Iv antibiotics

402

How does bordetella pertussis present?

whooping cough, chronic cough, occasional vomiting, afebrile, vitals stable

403

What is the trasmission of bordetella pertussis?

droplet

404

How long is the incubation of bordetella pertussis?

7-10days

405

What are the 3 phases of bordetella pertussis?

catarrhal stage, paroxysm stage, convalescent phase

406

At what stage of bordetella pertussis are you highly infectious?

cararrhal stage (1-2 weeks)

407

How is bordetella pertussis diagnosed?

nasopharyngel swab early in infection, PCR asaay, serology ELISA for IgG against PT

408

What is the treatment of bordetella pertussis?

antimicrobials (clarithromycin) and vaccination with acellular pertussis at 2,3, 4 months and 3 years

409

How does croup present?

barking cough in children and inspiratory stridor
acute laryngo-tracheobrnchitis due to parainfluenza virus

410

complications of bordetella pertussis?

pneumonia, encephalopathy, subconjucntival haemorrhage

411

What medium is used for nasopharyngeal aspriate and swab medium?

Bordet Gengou medium (15-80% sensitivity)

412

What is asthma?

a common chronic relapsing episodic inflammatory condition of the lung airways

413

What are the main 3 characteristics of asthma?

airflow limitation, airway hyperresponsiveness, inflammation on bronchi

414

What is atopy?

increased responsiveness of the airways of the lung to stimuli, type 1 hypersensitivity reaction, increased IgE antibodies, runs in the family and linked to other atopic diseases

415

What enviromental factors can affect atopy?

hygiene hypothesis, childhood exposure to allergens, maternal smoking, RSV infection

416

pathogensis of asthma?

narrowing of the airway due to smooth muscle contraction and thickening of the airway wall by cellular infiltration and inflammation, increased secretions within airway lumen

417

What are the 4 stages of asthma?

inflammation, bronchoconstriction, mucus and oedema, and remodelling

418

What is the process of inflammation in asthma?

allergen exposure, T helper cells release IL-4, produces IgE, mast cell activation, release histamine causes mucus production, validations and bronchoconstriction

419

What is involved in sustained inflammation in asthma?

eosinophils

420

What causes bronchoconstriction in asthma?

IgE and histmaine blocks B adrenorectors in the smooth muscles surrounding the airways, causing bronchoconstriction

421

What causes oedema in asthma?

increased vascular permeability

422

What causes mucus plugs in asthma?

increased bronchial secretions of mucus

423

What 3 things are remodelled in asthma and how?

smooth muscle - hypertrophy and hyperplasia
basement membrane - collagen and matrix proteins deposited causing thickening
epithelieum - loss of ciliated columnar cells causes mucus secreting goblet cells

424

Symptoms of asthma?

intermittent dyspnoea, wheeze, nocurnal cough, sputum, chest tightness

425

Signs of asthma?

tachypnoea, audible wheeze, hyprinflated chest, hyperresonant percussion note, decreased air entry, widespread polyphonic wheeze

426

What will respiratory function tests show in asthma?

spirometry - decreased FEV1/FVC (20% on 3 days/week for 2 weeks
exercise test
skin prick tests - identify allergens

427

What are the Royal College of Physicians 3 questions for asthma?

have you had difficulty sleeping because of your asthma symptoms?
have you had your usual asthma symptoms during the day?
has your asthma interfered with your usual activities?

428

What are the 5 steps of asthma treatment?

1 - occasional SA inhaled B2 agonists (salbutamol) as required for symptoms (move to step 2 if >1/day)
2 - add inhaled corticosteroid (beclomethasone)
3 - add LA B2 agonist (salmeterol)
4 - high dose corticosteroid and leukotriene receptor anatagonist (monteleukast)
5 - add daily oral corticosteroid and continue with inhaled steroids, refer to asthma clinic (prednisolone)

429

When would you move back a step of treatment in asthma?

when control is good for >3months

430

What is the long term management of asthma?

stop smoking, avoid precipitants, educate on good inhaler technique, PEFR monitoring and self management

431

What is the classification of acute severe asthma?

33,92,CHEST

432

What does 33,92 CHEST stand for in asthma management?

PEFR

433

What is each severity in asthma based on PEFR%?

mild = >75%
moderate = 25, PR>110)

434

Management for acute severe asthma?

O SHIT ME
oxygen, salbutamol nebulised, hydrocortisone IV or oral prednisolone, ipratropium 4-6 hourly

theophylline in ICU, magnesium sulphate one off, escalate care to intubation and ventilation

435

Triggers of asthma?

cold air, exercise, allergens, infection, smoking, pollution, NSAIDS, BBs, car fumes, smokes, strong perfume, dusts, stress, emotions, occupational, dust mites

436

examples of obstructive lung disease?

COPD, asthma, bronchietasis, cystic fibrosis

437

Examples of restrictive lung diseases?

pulmonary fibrosis, pleural effusion, interstitial pneumonias

438

What do respiratory function tests show in restrictive lung diseases?

FVC reduced more than FEV1 (though it is still reduced)
FEV1/FVC is normal or >80%

439

How many people in the UK have asthma?

5.5 million

440

How many children in the UK have asthma?

1/11

441

At what age does asthma commonly present in children?

3-5 years

442

After a bronchodilator in asthma, how much improvement is seen in an FEV1 or PEFR?

>15%

443

What is PEFR?

peak expiratory flow rate

444

DD of asthma?

lower RTI, LVHF, PE, bronchial cancer

445

What questions should be asked in a asthma diagnosis?

duration, relieving factors, triggers, blood in sputum, colour of sputum,

446

At what time in the day are asthma symptoms worst?

morning and night

447

Risk factors for asthma?

FH, atopic conditon, previous bronchiolitis, exposure to smoke, mother smokes in pregnancy, premature birth, low birth weight due to underdeveloped lungs

448

Is a PEFR diagnosis of asthma better for children or adults?

adults, children use mainly symptoms for diagnosis

449

What is classed as complete control in asthma?

no daytime symptoms, no night time awakening due to asthma, no need for resuce medication, no asthma attack, no exacerbations, no limitations on activities, normal lung function, minimal medication side effects

450

How often should asthma treatment be reviewed?

every 6 months

451

Prevention of asthma?

smoking cessation, weight loss, breathing exercises, reduce dust levels, breast feeding

452

What is the difference between extrinsic and intrinsic asthma?

extrinsic in atopic individuals (type 1 hypersensitivity)
intrinsic starts in middle age from sensitization to occupational agents (type 3 hypersensitivity)

453

What genes are involved in developing asthma?

genes that produce IL-3/4/5 as they increase mast cell and eosinophil development and IgE production
polymorphic varitation in IL4-13 proteins
ADAM 33 links to hyperresponsivness and tissue remodelling
CD14, TLRZ, TLR4

454

Where are eosinophils found?

bronchial walls and in secretions of asthmatics

455

Is asthma reversible or irreversible?

reversible

456

Describe the eicosanoid pathway

phospholipid -> arachidonic acid -> prostagladins or leukotrienes

457

what enzyme converts phospholipids to arachidonic acid?

phospholipase A2

458

What enzyme converts arachidonic acid to prostagladins?

cyclo oxygenase

459

What enzyme converts arachidonic acid to leukotrienes?

5-lipoxygenase

460

How long does it take histamine, eicosanoids and cytokines to take effect?

histamine = seconds
eicosanoids (lipid derived) = minute
cytokines (protein derived) = hours

461

What happens to the bronchioles in 30mins, 3 hours and 6 hours of asthma?

30 mins - bronchoconstriction and inflammation
3 hours - vasodilation, increased vascular permeability, WBC recruitment, less bronchoconstriction
6 hours - worsening inflammation, second wave of bronchoconstriction, eosinophil recruitment, basophils and neutrophils

462

How to B agonists treat asthma?

cause bronchodilation, increase cAMP, relax smooth muscle, mast cell stabilization, inhibit histamine release,

463

What kind of protein is a B2 adrenoreceptor?

G coupled protein

464

Example of non selective muscuranic antagonist?

short acting - ipratropium bromide
long acting - tiotropium

465

How do muscuranic antagonists treat asthma?

block ACh binding sites so it can't activate smooth muscle, preventing bronchoconstriction

466

Where are muscurinic receptors found?

resp tract
large airways = M3
peripheral lung tissue = M3 and M1

467

What is COPD?

an irreversible airway disease that is progressive and has airway obstruction

468

What do respiratory tests show in COPD?

decreased FEV1

469

What is COPD made up of?

chronic bronchitis and emphysema

470

What is chronic bronchitis clinically defined as?

cough and sputum production on most days for 3 months of 2 successive years

471

What is emphysema histologically defined as?

enlarged air spaces distal to terminal bronchioles with destruction of alveolar walls

472

Causes of COPD?

genetics - a1 antitrypsin deficiency causing loss of protection against proteases causing alveolar desturction

air pollution

smoking (90%)

exposure through occupation

second hand gas exposure

473

What is the pathophysiology behind COPD?

infiltration of the bronchi/bronchiole walls with inflammatory cells, neutrophils and CD8+ lymphocytes or inactivation of a1 antitrypsin by cigarette smoke cuases granulocyte release, elastases and proteases causes ulceration, scarring and columnar cells are replaced by squamous cells. squamous cell metaplasia, fibrosis of bronchial wall and mucus gland hypertrophy, leads to air flow limitation

474

What is chronic bronchitis?

hypersecretion of mucus due to marked hypertrophy of mucus secreting glands and hyperplasia of goblet cells.

if small airways are affected its reversible but becomes irreversible as the larger ones become affected

epithelial layer become ulcerated and squamous epithelium may be replaced by coloumnar cells, resulting in increased gas diffusion distance

475

What is emphysema?

abnormal dilation of air spaces with destruction of alveolar walls, inflammation and scarring, reducing size of lumen of airways and reducing lung elasticity, hypersecretion of mucus reduces lumen size and increases gas exchange distance

476

symptoms of COPD?

cough, sputum, dyspnoea, wheeze

477

signs of COPD?

tachypnoea, use of accessory muscles of respiration, hyperinflation, decreased cricosternal disatnce

478

What will imaging show in COPD?

normal, or hyperinflated lungs, reduced peripheral lung markings and emphysematous bullae

479

What will Hb be in COPD?

may be high due to persistent hypoxaemia and secondary polycythaemia

hypoxia, and hypercapnia if advanced

480

Management of COPD?

stop smoking, exercise, weight loss, vaccinations, cardiopulmonary rehlabilitation, broncho pulmonary exercise, caution of flying, steroid trial

481

What are the 5 steps of COPD treatment?

1 - pulmonary rehab programme (physio and bronchopulmonary exercises, SABA or antimuscarinics
2 - add LABA and cardiopulmonary rehab
3 - inhale glucocorticoid
4 - anticholinergics and LABA and inhaled steroid
5 - add LTOT and lung surgery

482

Is corticosteroid repsonse better in COPD or asthma?

asthma

483

Are night time symptoms more common in asthma or COPD?

asthma

484

Does asthma or COPD have a better bronchodilator response?

asthma

485

Is asthma or COPD caused by smoking mostly?

COPD

486

complications of COPD?

cor pulmonale, lung cancer, infection, pneumothorax, polycythaemia, respiratory failure

487

How does smoking cause COPD?

it increases neutrophil granulocytes that realease elasteses and proteases causing emphysema, then inactivates a1 antitrypsin and causes mucous gland hypertrophy

488

How does the predicted FEV1 value change from mild to very severe COPD?

mild - >80%
moderate -

489

What are the 3 types of emphysema and the difference between them?

centri-acinar - damage of lung tissue around the respiratory bronchioles
pan acinar - affects whole acinus, so just becomes a collection bullae - associated with a1-antitrypsin deficiency
irregular - affects lung parenchyma patchily, independent of acinar

490

What does a bullous emphysema cause?

gas trapping

491

What questionnaire is used to assess impact of COPD on a patients life?

CAT

492

What is the difference between blue bloaters and pink puffers in COPD patients?

blue - become insensitive to co2, odematous and cyanosed, not particularly breathless, rely on hypoxic drive

pink - remain responsive to co2 and are breathless but rarely cyanosed

493

Is steroid response better in eosinophil or non eosinophil asthma and why?

better in eosinophil as they induce eosinophil death with anti IL-5 which reduces exacerbation and anti Il-3 and anti IgE

494

Where are eosinophils produced?

in bone marrow (IL-5)

495

What does an airway biopsy show in non eosinophil asthma?

eosinophil abscence and neutrophil prescence

496

What is the best treatment for non eosinophil asthma?

bronchodialators and bronchial thermoplasty

497

What are the two types of eosinophil asthma?

atopic and non atopic

498

What are the 3 types of non eosiophil asthma?

smoking associated, obesity related, non smoking

499

What is reversibility testing in asthma?

when there is an increase in lung capacity with bronchodialators or anti inflammatory treatment (20%% improvement in PEFR or 15% in FEV1)

500

What is exhaled NO a marker of?

eosinophillic inflammation

501

What are results in moderate asthma?

PEFR >50%, RR

502

What are the results in severe asthma?

PEFR 33-50%, RR>25, HR >110, cant complete sentences

503

What are the results of life threatening asthma?

PEFR

504

In life threatening asthma, what does a raised CO2 mean?

fatal

505

When can you discharge a life threatening asthma?

PEFR is >75% and

506

How do glucocortisoids treat asthma?

intefere with gene transcription, reduce MC activity and improve anti-inflammatory effect

507

What is the effect of GRE?

suppression of cytokines and increase lipocortin

508

Side effects of GRE?

susceptibility to infection, osteoporosis, muscle wasting

509

How does anti IgE therpy (monoclonal antibodies) treat asthma?

binds to free IgE on the Fc region so it cant bind to receptors , can be free or bound e.g. omalizumab - neutralises free IgE and reduces mast cell sensitisation

510

What are anti histamines treatment for?

hayfever not asthma

511

What is the best way to give anti histamines?

inhaled as straight to the needed place and has reduced side effects

512

At what step in asthma treatment are oral corticosteroids given?

step 5

513

When are inhaled corticosteroids given in asthma treatment?

step 2

514

How does an oral cysteinyl leukotriene receptor antagonist treat asthma?

inhibits cysteinyl LT which is an asthma mediator, used if not controlled by inhaled steroids in step 2

515

When is oral cysteinyl leukotriene receptor antagonist beneficial in asthma treatment?

if aspirin intolerant asthma, asthmatic smokers or those who need a higher dose of corticosteroids or have asthma combine rhinitis

516

Management of catastrophic sudden severe asthma?

optimise standard therapy, emergency supplies everywhere, 02 resusciatation at home and work, nebulised B2 adrenorecptors agoists, self injectable adrenaline, prednisolone tablets, medic alert bracelet

517

Example of off target immune responses?

goodpastures syndrome, myaesthania gravis

518

Example of excessive immune response?

ARDS, EAA, asthma

519

Example of failure to control immune activation?

a1-antitrypsin deficiency

520

Example of ontarget immune response?

bronchiolitis obliterans

521

Example of bystander damage?

COPD

522

Example of immunity gone wrong?

unclear mechanisms e.g. connective tissue associated ILDs e.g. organizing pneumonia and complications of RA

523

What clues suggest primary immunodeficiency (PID)?

>4 new ear infections/year
>2 serious sinus infections/year
>2 bouts of pneumonia/year
>2 month on antimicrobials/year
growth retardation in children
recurrent deep skin or organ abscesses
persistent mu oral thrush or fungal infection of skin
>2 deep seated infections or septicaemia
family history

524

examples of recurrent respiratory infections?

smoking, copd, asthma, bronchietasis, cf, foriegn body, ciliary dysfunction, HIV, immunocompromised, hypogammaglobulinemia

525

What influences the risk of infection in immunodeficient?

defect in neutrophil numbers e.g.chemo, duration of neutropenia e.g. in haematological malignancy not solid tumours, duration is long in AML, malignancy e.g. hodgkins lymphoma, steroids or HSCT

526

treatment for fungal infection?

targeted and general, fever based, HRCT, galctomannan, salvage therapy

527

What does a focal infiltrate on CXR suggest?

bacterial agents of CAP and s.pneumoniae or PCP, Mycobacterial disease, fungal and cancer

528

What does a diffuse infiltrate on CXR suggest?

pneumocystis, TB, fungal, viral, CMV

529

What does a cavity on CXR suggest?

MTB, bacteria, pseudomonas, s.aureus, dimorphic fungi, malignancy and IVDA

530

What does a nodule and mass on CXR suggest?

mainly infectious, mycobacterial, dimorphic fungi, cryptococcomas, KS, granulomata associated with PCP, lymphoma, cancer and septic emboli, s.aureus, aspergillus

531

What microorgansism are in the lower respiratory tract but don't cause inflammatory damage so are thought to be protective?

prevotella, fusobacteria, velonella

532

What is used in the innate immune system of the resp tract?

mucosal defences, macrophages, neutrophils

533

What is in the adaptive immune system of the resp tract?

B cell antibodies and T cell cytotoxicity

534

What can cause a granulocyte defect and what does this lead to a risk of?

chemo and HSCT - risk of invasive infection of gram bacteria, fungal infection and mycobacteria

535

What can cause a B cell defect and what does this increase the risk of?

rituximab, haemotological malignancy and CVID - increased risk of encapsulated bacteria and oto-sino-pulmonary infection

536

What can cause a T cell defect and what does this increase the risk of?

immunosuppressin, HIV and SCID - increased risk of viral infection, fungal, mucobacteria, pneumocytosis jinovecu pneumonia

537

What can cause a neutrophil defect?

chemo, drugs, granulomatous disease

538

What can cause secondary immunodeficiency?

immunosuppressant treatment, haemotological malignancies, HIV infection, malnutriton, alcohol, sepsis

539

What organism cause pneumocystic pneumonia?

pneumocytis jirovecii

540

How does pneumocystic pneumonia present?

6 week progrssive breathlessness and dry cough
lymphopenia (CD4

541

What investigations would you do for pneumocystic pneumonia?

induced sputum or BAL for PCR

542

What is the treatment of pneumocystic pneumonia?

high dose co-trimoxazole and pentamidine 2nd line, prednisolone if severe, secondary prophylaxis

543

In who is CMV commonly seen?

transplant recipients and HIV

544

Treatment of invasive aspergillosis?

vonconzole, caspofungin, amphotencin, liposomal amphotencin

545

What causes invasive aspergillosis?

fever in neutropaenic patient caused by borad spectrum antibiotics

546

What is Cheyer stokes respiration?

alternatin hyper/hypoventilation every 60seconds, severe cariac disease, secondary to slow perfusion of peripheral chemoreceptors

547

What is agonal breathing?

pre terminal patients or from opiate poisoning, 4-8 breaths alternate with complete apnoea

548

Causes of hypoventilation?

OHS, hypothyroidism, respiratory muscle weakness, post sedation, REM sleep, loop diuretics

549

Causes of hyperventilation?

hyperthyroidism, post cortical CVA, liver cirrhosis, metabolic acidosis, anxiety, stress

550

Type 1 respiratory failure symptoms?

cyanosis, increased RR (tachypnoea), accesory muscle use, tachycardia, hypotension, signs of underlying disease and confusion

551

Type 2 respiratory failure symptoms?

confusion, drowsiness, warm peripheris, flapping tremor, bounding pulses, myoclonic jerks, papilloedema, frequent chest infection due to impaired cough reflex

552

Treatment of respiratory control disturbance?

ABC, treat cause, o2 therapy, CPAP, NIVm IPPV

553

When is continuous positive airways pressure used?

positive pressure applied throughout respiratory cycle to a spontaneously breathing patient, used in type 1 hypoxic resp failure, to imporve oxygenation, ventilation and V/Q ratios

554

What is used for type 2 resp failure treatment?

non invasive ventilation

555

What is transfer factor?

the extent to which 02 passes from air sacs to lungs in blood

556

What resp diseases cause a reduction in transfer factor?

IPF, PH, anaemia, COPD

557

What is seen radiologically in lobar collapse?

triangular opacity with apex at hilum
sickle sign of air around aortic knuckle
loss of right hemidiaphragm
sail sign

558

What is seen in sarcoidosis?

heart block, lymph node enlargement, skin nodules, nephrocalcinosis

559

Criteria for home o2 in COPD?

pao2

560

What percentage of asthma is thought to be caused by occupation?

10%

561

How long is treatment for idiopathic PE?

6 months

562

What does antigentic drift cause?

epidemic flu

563

Is it strong or weak ions and acids that completely dissociate in water?

strong

564

Do strong or weak ions and acids make good buffers and why?

weak as they incompletely dissociate in water, but can dissolve so are good buffers

565

What is a buffer?

a weak acid or base that can donate or accept H+ ions to allow changes in H+ ion content with little change in free ionised H+ concentration

566

Examples of extracellular buffers?

bicarbonate system, phosphates, proteins

567

Example of intracellular buffer?

Hb

568

What is base excess?

the amount of acid or base required to return 1 litre of blood to normal mean standard bicarbonate of 22.9ntq/L

569

What should the base excess value be?

should be in the range of -2 to +2, any more or less is metbolic acidosis or metabolic alkaliosis, averga eis 1.2

570

Where are chemoreceptors found in the body?

aortic arch and carotid sinus and ventral surface of medulla

571

how does the respiratory compensatory mechanism work?

detect change in CSF pH, a lower pH stimulates respiration

572

How does the metabolic compensatory mechanism work?

control of SID by removal of Cl- from extracellular fluid from transcellular pumps and urinary loss in response to acidosis

573

How does an increase in CO2 affect pH?

reduces pH

574

How does an increase in HCO3 affect pH?

increase pH

575

What is the lass of mass action?

the velocity of a reaction is proportional to the product on the concentrations of the reactants

576

Are cations positive or negative?

positive (cat purr positive)