Respiratory Flashcards
(202 cards)
1
Q
Asthma definition and presentation
A
Chronic inflammatory airway disease. Intermittent obstruction due to hypersensitivity
Recurrent episodes: wheeze, Breathlessness, Chest tightness, Coughing
2
Q
Types of Asthma
A
Allergic (linked to atopy - Inc IgE production)
Non-allergic
3
Q
Triggers
A
Allergic (IgE -> Mast cell): dust mites, pet fur, grass pollen
Non-allergic: Exercise, cold air, stress, strong emotion, viral infection, smoking
Drug causes: NAIDs/Aspirin block COX1 = dec prostaglandins and inc pro-inflam leukotrienes, Beta blockers (B2)
4
Q
Acute and chronic changes to airway in asthma
A
Acute: airway bronchoconstriction, oedema, mucus hyper secretion
Chronic: airway remodelling, hyper responsiveness
- Gives more persistent obstruction
5
Q
Hygiene hypothesis
A
Growing up in clean env suppresses the natural development of immune system
6
Q
Asthma Pathopys: Early phase (constriction phase)
A
Exposure to allergen in presensitised individual
cross link IgE on mast cells
Release histamine, leukotrienes, TNFa
Migration of inflammatory cells
Inc vascular permeability (airway oedema) + mucus hyper secretion, inc airway tone through smooth muscle
7
Q
Asthma Pathopys: Late phase (inflammation phase)
A
Eosinophil mediated (IL4/5 recruits) at 6 hours
Inc goblet cells Epithelial denudation (leads to hyper responsiveness)
Deposition of matrix proteins and swelling (remodelling and SMC hyperplasia)
8
Q
Asthma Presentation (when taking a Hx)
A
Worse at night and early morning
Wheeze Episodic SOB Chest tightness Cough FH atopy
9
Q
How to assess general asthma severity/control
A
In the past 4 weeks
- How often SOB
- How often woken from sleep
- How often used reliever
- How often interfered with ADL (e.g. school/work)
- How do they rate asthma control
10
Q
What is important to assess in asthmatic control
A
Inhaler technique
11
Q
Asthma Investigations
A
Peak Expiratory Flow Rate (PEFR)
- Diurnal variation over 20%
- Reversibility testing: FEV1 improves 15% with SABA/ PEFR 20% improv
Spirometry: FEV1/FVC less than 70% + FEV1 less than 80% predicted.
FBC: Eosinophilia
Skin prick testing for allergen triggers
12
Q
What is the aim of asthma management (2)
A
Good control on minimal meds
FEV1 and PEFR over 80% predicted
13
Q
Asthma management
1 ->5
A
1) SABA
2) Add low ICS (400mcg budesonide)
3) Add LTRA (Montelukast)
4) Add LABA (LRTA can be kept or removed depending on response)
5) SABA + MART (Steroid+laba = can be used as maintenance AND releiver)
14
Q
What are Theophylines and where do they come in on Asthma ladder?
A
Methylxanthine - phosphodiesterase inhibitor. inhibits leukotriene synthesis and TNFa
One of the final steps in management.
15
Q
Acute asthma exacerbation management
A
OSHITMS
Oxygen (aim 94-98%) Salbutamol (neb) Hydrocortisone IV/Pred oral within one hour Ipratropium (neb) Theophylline (IV) Mag Sulf (IV) Salbutamol (IV)
16
Q
Acute asthma exacerbation Investigations
A
Peak expiratory flow
SpO2
ABG
17
Q
Moderate asthma exacerbation
A
PEF 50-75%
18
Q
Severe asthma exacerbation
A
One of the following:
- PEF 33-50%
- RR over 25
- HR over 110
- Cant complete sentences
19
Q
Life threatening asthma exacerbation
A
One of the following: - PEF less than 33% - SpO2 less than 92% - PaO2 less than 8kPa - Silent chest Exhaustion
May need these patients to be intubated
20
Q
COPD
- Definition
- Types
A
Chronic & irreversible airflow obstruction giving air trapping and hyperinflation
Chronic bronchitis
Emphysema
21
Q
What is Chronic Bronchitis
A
Narrowing of airways due to oedema of mucosa, mucous hyper secretion,
Cough due to excessive mucous and poor ciliary clearance
- Over 3M of the year for 2 yr
22
Q
What is emphysema
A
Due to elastin breakdown causing permanent destruction and reduced SA in alveoli
Less elastin recoil/inc compliance = hyperinflation
23
Q
COPD Aetiology & Pathophysiology
A
Cigarette smoking, A1AT
Emphysema: inc inflammation = inc neutrophils = inc oxidative stress + elastase to break down elastin in emphysema
Chronic bronchitis: Poor ciliary clearance and goblet cell hyperplasia (inc mucous)
24
Q
COPD Pulmonary Pathology description
A
Chronic inflammation of central and peripheral airways/lung parenchyma/alveoli/vasculature
Increased goblet cells
Narrowing of airways
Vascular change = Pulm HTN
25
COPD Presentation
SOB - initially with exercise but this progresses
| Cough
26
COPD examinatory findings
Barrel chest, CO2 flap, hyperresonant percussion, distant breath sounds (over bullae, hyperinflation and trapping), coarse crackles (exacerbation), wheeze (exacerbation)
27
COPD complications
Cor pulmonale: RHF secondary to long standing COPD (raised JVP, distended neck veins, hepatomegaly - Rx: long-term O2 therapy + loop diuretic)
Pneumonia - pneumococcal vaccine and yearly influenza vaccine
Depression
Polycythaemia
Respiratory failure (T1, T2)
28
Resp failure
- Types
- Reasons
- Description
Type 1 & 2
- T1 = VQ mismatch. PaO2 less than 8kPa (can get rid of CO2 but O2 not going to right place for oxygenation)
- T2 = Alveolar hypoventilation. PaO2 less than 8kPa, PaCO2 over 6kPa (large collapse, secretions blocking etc)
Pink puffer - emphysema
Blue bloater - Bronchitis
29
Pink puffer (emphysema)
```
CO2 responsive
Pink skin
Purse lip breathing and accessory muscle use
Inc Res rate
Old and cachectic
```
30
Blue bloater (Bronchitis)
```
CO2 retention (T2) means insensitive to it
Obese
Peripheral oedema (RHF)
```
31
COPD Investigations
Spirometry
- Obstructive pattern (FEV1/FVC less than 0.7)
- Non-reversible
Decreased pulse oximetry
ABG: hypoxia + hypercapnia may be seen
CXR: flattened diaphragm, increased intercostal spaces, hyper lucent lungs
FBC: may have polycythemia (HCT over 0.55 - venesection, too viscus)
Sputum culture - infectious exacerbation
32
COPD severity score
Mild FEV1 less than 80%
Moderate FEV1 50-80%
Severe FEV1 30-50%
V Sev less than 30%
33
COPD management
Patient education + Lifestyle (smoking, exercise, obesity management)
Vaccination (Pneumococcal, Flu)
Depression screen
Inhaled therapy
Long term O2 therapy (if PaO2 less than 7.3, sats less than 88% or congestive HF
34
COPD inhaled therapy
1) SABA or SAMA
2) If still uncontrolled
- FEV1 over 50% add LABA/LAMA
- FEV1 under 50% add LABA+ICS
3) LABA + LAMA + ICS
35
COPD exacerbation Tx
Similar to OSHITMS
SABA + SAMA neb (salbutamol+ipratropium)
O2 (24% venturi - aim 88-92%)
Oral Prednisolone
Airway clearance - mucolytic + physio
If respiratory insufficiency - BIPAP
36
Why can BIPAP be used in T2 RF
Because it doesnt have to be 100% O2.
It works more by keeping airways open rather than high O2 which can take away rest drive in T2RF patients
37
COPD exacerbation organisms + Investigation
H. influenza
Strep Pneumonie
Moraxella catarrhalis
Blood + Sputum culture and gram stain
38
Abx for COPD exacerbation
Extra therapies.
Community acquired (less severe) - amoxicillin or Doxycycline + PREDNISALONE
Hospital acquired - Vancomycin or Tazocin (piperacillin/tazobactam)
Oral Theophyline
Mucolytics (acetylcysteine)
O2 therapy
Furosemide in HF
39
Difference Between Asthma Vs COPD
Reversible/Irreversible
Airway hyperactivity only in asthma
Mast cells/ Eosinophils (A) Vs Neutrophils and macrophages (C)
Peak flow diurnal variation (A), minimal variation (C)
Spirometry may be ok (A) but always bad (C)
40
Total Lung Capacity
Tidal Volume
Expiratory reserve volume
Residual volume
6L
0. 5L
1. 25L
1. 25L
41
Obstructive and restrictive effects on spirometry
Obstructive gives decrease in inspiratory reserve as tidal volume occurs at higher total volume (more air conserved)
Restrictive gives less total lung volume but also less expiratory volume moving the tidal volume at lower lung volume
42
Types of pneumonia
Community acquired
Hospital acquired
43
Pneumonia score
CRB65 (add U if in secondary care setting - can get urea)
44
CURB65 and how to use
Confusion
Urea (over 7)
Resp (over 30)
BP (less than 90 systolic, 60 dias)
65yrs+
0-1 low risk - outpatient
2 mod risk - hospital
3-5 high risk - ITU (15-40% 30 day mortality)
45
Community acquired pneumonia
- RF
- Causes
- Atypical caused
over 65, Care home, COPD (h.influena), smoking, alcohol (Klebsiella),
S.pneumonia (rusty sputum in 30%) most commonly
```
Mycoplasma pneumonia (different symptoms)
chlamydia psitacci (Bird fanciers)
Legionella pneumophilia (aircon, asco with hyponatraemia)
```
46
Hosp acquired pneumonia
Gram negative bacilli
E.coli, Klebsiealla (upper lobes), Pseudomonas aeruginosa, MRSA
47
Mycoplasma pneumonia (atypical - diff pres, diff, Tx)
Dry cough
Haemolytic anaemia
Erythema multiforme
Interstitial opacities (nodular) on CXR
48
Pneumonia
- Presentation
- Examinatory findings
Cough + Sputum
Fever (high in pneumococcal)
Bacteraemia
Arthralgia, myalgia, confusion
Inc HR, RR, temp
Dullness to percuss, crackles/reduced air entry/vocal fremitus on auscultation
If septic - low BP
49
Pneumonia investigations
FBC (Raised WCC)
CRP - raised
ABG - low O2x
Sputum culture and sensitivity for ABx
CXR - For lobar pneumonia to looks for consolidation. Atelectasis - small airway obstruction
Blood cultures for causative organism
Urinary antigen - legionalla, pneumococcus
50
Pneumonia Management
O2 if needed IV fluids if needed
Low risk: (0-1)
- Amoxicillin or macrolide (ACE: azithro, clarithro, erythro)
Mod risk: (2)
- Amoxicillin + Clarithromycin (Doxy if allergic)
High risk:
- Co-amox/3rd gen ceph + macrolide
- Co-amoxlclav + Clarithromycin
Hosp acquired:
- IV cefotaxime + Gentamicin
Legionalla:
- Clarithromycin + fluoroquinolone
51
Pneumonia complications
Sepsis
| ARDS: non-cariogenic pulmonary oedema
52
TB
- Types
- RF
- Cause
- Type of infection
Pulmonary (latent, active - primary or reactivation of latent), Extra-pulmonary (military)
immunocompromised (e.g. HIV), exposure, poor nutrition, overcrowding, IVDU, homeless, prisons
M.tuberculosis, M.bovis
Granulomatous
53
What is a granuloma
A collection of epithelioid histiocytes (macrophages). These might also fuse to form multinucleate langerhans giant cells
54
TB prevention
BCG vaccine
55
TB screen
Tuberculin skin test (cant distinguish between active and latent disease
56
Latent TB
Infections with M.tuberculosis but no clinical, bacteriological or radiographic evidence of active TB
57
Gohn Complex
Gohn focus (Calcified focus from TB, often in mid to lower lung zones)
PLUS an affected lymph node
58
TB pathophysiology
Macrophage in mid zone of lung engulfs bacteria
Results in Granuloma formation, MP presentation to T-cell --> Caseation
Caseation heals and calcifies
Mediastinal LN involvement
Secondary lesions in lung apices (after 1-2 year)
59
TB Presentation
Cough (haemoptysis) + fever + weight loss + night sweats + RF
Pleuritic chest pain, erythema nodosum
Examination: crackles, bronchial breathing
60
TB investigations
CXR:
- Primary: consolidation, hilar enlargement
- healed primary: Gohn focus
Sputum acid fast (Ziehl-Neelsen) bacilli smear X3
Sputum culture shows no growths
FBC - leukocytosis and anemia
Nucleic acid amplification test +ve for TB
HIV concurrent infection possible
CT, urinalysis, Ascitic fluid analysis for extra-pulmonary TB
61
TB Tx
RIPE DOTS
Rifampicin - 6m (hepatotoxic, p450 inducer)
Isoniazid - 6m (hepatotoxic, peripheral neuropathy)
Pyrazinamide - 2m (liver toxic, hepatitis)
Ethambutol - 2m (optic neuritis: loss of acuity)
Directly Observed Therapy for 3 weeks
Isolate patient, contact tracing + Tx. infectivity decreased after 2w tx
62
Extra pulmonary TB
```
Pleura: effusion
GU: hameaturia/dysuria
Bone: osteomyelitis, Pott's - vertebral fracture assoc with TB
Brain: meningitis
Abdo: ascites
```
Miliary = haematogenous seeding. liver spleen, lung. Can be seen on CT
63
DVT RF
```
Cancer
Trauma
Major surgery
Hopitalisation
Immobilisation (including limb immobilisation and long haul travel)
OCP
Obesity
Pregnancy (high oestrogen)
```
Genetics: Factor V leiden, Protein C deficiency
Protein S deficiency, antithrombin deficiency, antiphospholipid syndrome
64
Virchows triad
Three broad categories contributing to thrombosis:
1) Venous stasis
2) Vessel injury
3) Activation of clotting system/hypercoagulable state
65
Where do DVT form
Deep venous system of leg, often behind a valve
66
DVT marker
Active thrombus breakdown by fibrinolytic system releases cross linked fibrin breakdown products esp. D-dimer (also acute phase protein - poor specificity, more helpful if -ve)
67
DVT pres
Unilateral calf swelling and pain along venous system
68
DVT score
Wells
- Active Ca in last 6 months
- Paralysis, paresis or recent plaster immobilisation
- Recently bed ridden for 3+ days
- Localised tenderness alone deep venous system
- Entire leg swollen
- Calf swelling more than 3cm more than other
- pitting oedema
- Previous DVT
- contralateral superficial non-varicose veins
69
Using Wells score
0-1: D-dimer and if positive then proximal venous USS (if negative then repeat at 6 days
2+ Proximal venous USS, +ve = tx, -ve = repeat in 6-8 days
If USS not available within 4 hours then anticoagulant and do within 24 hours
70
PE
- Definition
- Complications
- Causes
Life threatening condition resulting from dislodged thrombi occluding pulmonary vasculature
If not Tx --> RHF and cardiac arrest
Distal vein thrombosis (50% will embolise), Amniotic fluid embolus, Fat/Air embolus, tumour embolus
71
PE RF (try to get 5)
```
Cancer
Trauma
Major surgery
Hopitalisation
Immobilisation (including limb immobilisation and long haul travel)
OCP
Obesity
Pregnancy (high oestrogen)
```
Genetics: Factor V leiden, Protein C deficiency
Protein S deficiency, antithrombin deficiency, antiphospholipid syndrome
72
PE presentation
Chest pain (pleuritic), dyspnoea, tachypnoea, cough, fever
Large PE: shock, collapse, acute RHF, sudden death
73
PE signs
```
Tachycardia
Tachypnoea
Elevated JVP
Hypoxia
Shock (low BP)
```
74
Classical CXR PE
Wedge-shaped lesion against the pleura
75
PE Ddx
ACS
Aortic dissection (tearing pain - anticoagulant here fatal)
Pneumothorax
76
PE investigation
```
2 level wells
DVT
PE most likely cause
Tachy Card
Immobilisation (Surg, bed for 3 day+)
Hx DVT/PE
Haemoptysis
Malig last 6 month
```
4 points = PE likely
Other: FBC, US, clotting, Trops (MI rule out), ECG, CXR (late sign = wedge), ABG (reduced PaO2, high lactate)
77
PE management algorithm
Well under 4 D-dimer, if +ve CTPA
If Wells over 4 CTPA immediately (if renal impair V/Q scan - contrast) if positive Tx, if negative but suspect Proximal vein USS
If CTPA not available immediately then anticoagulant until available
78
VTE Tx
PE: O2, IV access for fluids, Morphine
Haemodynamically stable - LMWH (dalteparin) or Fondaparinux (10a inhibitor)
Active Ca - LMWH 6m
Other people get Warfarin for 3 months then reassess (6m if unprovoked DVT)
Mechanical prevention = graduated compression stocking
79
Investigating cause of DVT
```
Cancer screen:
- Physical examination, CXR, Bloods (FBC, Ca2+),
Ca markers BhCG - Testis
CA125 - Ovary
CA19-9 - Pancreas
PSA - Prostate
```
Thrombophila testing:
Antiphospholipid Ab
Protein C/S (deficiency)
80
VTE prevention
Early mobilisation and hydration post surgery
Avoid OCP
Graduated pressure stockings (TED)
81
Pulmonary fibrosis
- Pathophys
- Spirometry
- Presentation
Interstitial lung damage and fibrosis leading to decreased compliance
Restrictive - FVC low, FEV1/FVC high
4Ds: Dry cough, Dyspnoea, Digital clubbing, Diffuse inspiratory crackles
82
Where is pulmonary interstitium
Areas in-between alveoli and capillary basement membrane
83
Types of pulmonary fibrosis
Replacement fibrosis:
- Secondary to lung damage e.g. infarction, TB, pneumonia
Focal fibrosis:
- due to irritants
- coal, dust, silica
Diffuse parenchymal lung disease:
- Idiopathic pulmonary fibrosis
- EAA
84
Causes of PF
CTDs: RA, SLEm SSc, Sjogren's
Occupational: asbestos, coal dust, silica
Medications: amiodarone, bleomycin, MTX
Inhaled irritants: hypersensitivity pneumonitis, birds, mould
Radiation
85
Upper lobe fibrosis causes
Granulomatous diseases - SCHART
silicosis, sarcoidosis
coal workers pneumoconiosis
histiocytosis
ank spond
radiotherapy
TB
86
Lower lobe fibrosis
Systemic diseases RASCO
```
RA
Asbestosis
Scleroderma/SLE
Cryptogenic fibrosing alveoli's (IPF)
Other (e.g. drugs)
```
87
Idiopathic PF Cause, RF and Pathophys
No known aetiology
Smoking, infection, dust exposure, aspiration (GORD)
Insult giving pro-inflammatory, for-fibrotic response
Influx of macrophages, increased fibroblast and myofibroblast activity = fibroblastic foci + collagen/EC matriculates deposition
88
IPF presentation
dry cough, dyspnoea, diffuse inspiratory crackles, digital clubbing, weight loss (increased work)
89
IPF complications
Pulmonary HTN (Cor Pulmonale)
90
Important thing to ask about in IPF
OCCUPATION!
91
Investigations and findings in Pulmonary fibrosis
CXR
- net-like shadowing of lung peripheries/bases
- shaggy heart border
High resolution CT
- honeycombing, reticular pattern
- Ground glass opacification marital air space filling by exudate OR interstitial thickening
Lung function tests
- restrictive pattern
- impaired gas exchange: decreased DLCO, increased PaCO2, decreased PaO2
ANA: SLE
RF: RA
Lung biopsy: fibroblastic foci, interstitial fibrosis
92
IPF management and prognosis
6 monthly assessment for pulmonary rehab
O2 therapy
Physiotherapy
Weight loss
Vaccination (pneumococcal)
Smoking cessation
PPI for GORD + opiated for cough
acute exacerbation: admit + high dose oral prednisolone, sputum culture and ABx
Extreme cases - lung transplant
Median survival 2-5 years
93
Scleroderma PF
Chest wall fibrosis
Leading cause of death
Pneumonia from aspiration from stiff oesophagus
ANA in 95%
94
RA PF
Interstitial lung disease
Rheumatoid nodules
MTX also give pneumonitis - stipend use Steroids instead
Caplan's: PF in coal workers with RA
CXR well defined nodules, may capitate at lung peripheries
95
Tx of systemic causes of PF (scleroderma, RA etc)
Immunosuppression with steroids
96
SLE pneumonitis
Interstitial inflammation leading to interstitial fibrosis
97
What is a lagerhans giant cell
This is formed by the fusion several histiocyte (Macrophages)
98
Granulomatous lung diseases
TB
Sarcoidosis (non-caveating)
EAA
Tx: Oral Prednisalone
99
Extrinsic allergic alveolitis (Hypersensitivity pneumonitis)
- RF
- Pathophys
- Types of granuloma
RF: hx of exposure to organic dust (birds, agricultural, mould)
Non-IgE inflammation of alveoli and distal bronchioles
Sensitised individuals inhale allergens giving hypersensitivity reaction (Type 3 or 4)
Widespread inflammation of small airways, cellular infiltrate (neutrophils, macrophage), non-caveating granulomas (reticulo-nodular)
100
Types of EAA
Farmer's lung (hay mould)
pigeon fanciers lung (dropping proteins)
Maltworkers lung
Cheese makers lung
Always ask about pets, Occupation etc
101
EAA presentation
Acute (4-8hrs): flu like illness- fever, chest tightness, dry cough, dyspnoea, aches and pains
Sub-acute" less severe more gradual onset.. dyspnoea, fatigue, anorexia
Chronic: weight loss, cyanosis, RH
102
Investigations EAA
Blood: Raised WCC and CRP
CXR: diffuse micro nodular interstitial shadowing
CT: reticula-nodular shadowing, ground glass, micro nodules
Lung function: restrictive spirometry, decreased diffusing lung capacity of carbon monoxide (DLCO), decreased SpO2
Bronchoalveolar lavage: CD8
103
EAA Tx
Allergen avoidance/removal is best
Acute/subacute presentation: O2 +oral Prednisolone
Chronic: low dose ICS
104
Pneumoconiosis
- Definition
- E.G
- Latency according to cause
Group of chronic lung diseases due to exposure to mineral dust or metal.
Coal workers pneumoconiosis, silicosis, asbestosis
Coal - 10 years
Asbestos - 15-60 years
Notifiable industrial disease: may be eligible for compensation
105
Coal workers pneumoconiosis
- Pathology
- what is caplans
- Presentation
1) Coal particles retained in alveoli
2) Engulfed by macrophages
3) Immune response
4) Fibrosis (interstitial)
When assoc with RA (Rheumatoid nodules + fibrosis)
Dry cough, dyspnoea, Black sputum, SOBOE
106
Coal workers pneumoconiosis
- Investigations
- Management
- Prevention
Occupational Hx,
Lung function testing (restrictive),
CXR (upper lobes large nodular fibrotic mass)
Sputum microscopy (black)
Avoid exposure
incurable, CT/CXR/LuFT oto monitor
smoking cessation
In those working with coal: adequate ventilation, low dust, facemasks
107
Abestosis
- Latency
- Presentation
- Hx
5-10 years
Dry cough, dyspnoea, digital clubbing. Diffuse inspiratory crackles can be heard
Occupational hx:
Building trade. Asbestos used for fireproofing
108
Asbestosis
- Investigations
- Management
Lung function (Spirometry = restrictive and reduced DLCO)
CXR: Ground glass opacification, small nodular opacities (asbestos bodies at lung bases) shaggy cardiac sillouette
Sputum microscopy: asbestos bodies
Prevent: adequate ventilation, low dust, facemasks
109
Asbestosis complication
Mesothelioma
110
Pleural Mesothelioma
- Latent period
- Definition
- RF
50 years
Aggressive epithelial neoplasm from lining of the lungs
Asbestos (80% of cases) or asbestiform minerals
111
Mesothelioma pathophys
Asbestos fibres recruit and activate alveolar macrophages and neutrophils
Generate ROS (oxidative stress), chronic inflammation, DNA damage and altered gene expression
112
Mesothelioma presentation
Dry cough, dyspnoea, digital clubbing and pleuritic chest pain (recurrent pleural effusion)
113
Mesothelioma staging
1a: ipsilateral parietal pleura
1b: ipsilateral visceral pleura
2: diaphragm or lung involvement
3: ipsilateral bronchopulmonary or hilar LN
4: contralateral or distant mets
114
Mesothelioma investigations
CXR: irregular pleural thickening, reduced lung volume, unilateral pleural effusion
CT: pleural thickening, pleural plaques, hilare LN enlargement
Thoracocentesis: exudate contains malignant cells
Pleural biopsy: Epithelioid mesothelioma
115
Mesothelioma treatment and prognosis
Surgery: only curable for stage 1 disease
Platinum based pre+post op chemo ± radio
Pleurectomy/Pleurodesis for recurrent pain/effusions
if inoperable: chen-radio
Survival = 1 year
116
Pleural effusion
- Definition
- Types
Excessive fluid in potential space between visceral and parietal pleura
Transudate: low protein (less than 30g/L
- Disrupted hydrostatic and oncotic forces across pleura membranes (inc venous pressure or hypoproteinaemia)
Exudate (high protein (over 30g/L
- Increased permeability of pleura from inflammation/malig
Pulmonary, pleural or extra pulmonary
117
Malignant causes of pleural effusion
40% lung mets
25% breast mets
10% malignant mesothelioma
118
Pleural effusion: Mechanism & Causes of transudate
Increased hydrostatic, low oncotic
HF (LVF), cirrhosis, hypoalbuminaemia, nephrotic syndrome
119
Pleural effusion: Mechanism & Causes of exudate
Increased vascular permeability due to inflammation
Pneumonia, malignancy, TB, AI disease (RA), Dressler's (complication of MI causing pericardial + pleural inflammation
120
Pleural effusion Presentation + examination findings
Pleuritic chest pain, SOBOE, cough
unilateral reduced chest expansion, stony dullness on percussion, decreased breath sounds
If large - tracheal deviation (away)
121
Pleural effusion investigations
CXR: blunted costophrenic angle Effusion is visible on AP if over 200ml
USS guided pleural aspiration (if clinical picture suggests exudate rather than transudate)
- clear = trans or ex
- turbid/yellow = empyema, parapneumonic
- Haemorrhagic = haemothorax, malignancy, PE, trauma
Low pH/Glucose = RA, SLE, TB, Malig
Bilateral strongly suggests transudate
122
Pleural effusion management
Underlying cause
DO NOT TAP
(will result in fluid shift and pulmonary oedema)
Chest drain - controlled removal
If malignant then recurrence likely - may attempt pleurodesis (with talc)
123
Causes of Bilateral lymphadenopathy
TIMES
TB
Inorganic dust - silicosis
Malignant - lymphoma, Lung Ca
EAA e.g. bird fanciers
Sarcoidosis
124
Pneumothorax
- Definition
- Important when...
- Aetiology
Air in pleural space
Tension pneumothrax (like a one way valve which keeps filling)
Primary spontaneous: tall, thin males, SMOKING, Marfan's, FH
Secondary: pre-exhisting lunge disease, COPD (bullae), CF, TB,
125
Pneumothorax Pathophys
Normally pressure in alveoli high than in pleural space.
If communication between alveolus and pleural space then gases follow pressure to equalise gradient
Thoracic cavity enlarges and lungs shrink
126
What is tension pneumothorax
MEDICAL EMERGENCY
intrapleural pressure is able reach exceed atmospheric due to ball valve mechanism letting air in but not out
Lung deflates, mediastinum shifts contra laterally, compression of great veins and decreased venous return to heart
127
Pneumothorax presentation
```
chest pain (on same side, pleuritic - on inhale)
Dyspnoea (size determines sev)
```
128
Pneumothorax examinatory findings
Hyper-resonant
Reduced expansion
Dec breath sounds
129
Tension Pneumothorax près
Resp distress with rapid shallow breathing
Distended neck veins (block great arteries)
Tracheal deviation
Tachycardia Tachypnoea
130
Pneumothorax investigations
CXR: Visceral pleural line can be seen (dark area with no leg markings)
TP CXR: contralateral mediastinal shift, depression of hemidiaphragm
131
Pneumothorax Tx
Primary:
- if less than 2cm discharge
- if more than 2cm, aspirate (2nd intercostal space mid clavic). If this not success chest drain and admit
Secondary:
- if SOB or over 2cm then admit for chest drain
- if less than 1cm admit for high flow O2, observe 24 hours
- 1-2cm aspirate then chest drain if not success
Supplemental O2 for all
132
Safe triangle for chest drain
Lateral border pec major
Anterior border lat dorsi
Horizontal line through nipples
Mid axillary line, IC space 4-6, pain relief
133
Tension Pneumothorax Tx
Immediate needle thoracostomy 2nd IC mid clavicular line
134
Recurrent pneumothorax
Hospitalisation and high flow O2
Pleurodesis may be considered
135
Chest drains in relation to ribs
Aim just above rib to avoid Neuromuscular bundles
136
Causes of pleuritic chest pain
```
ACS
Aortic dissection
Pneumothorax
PE
Pneumonia
Malignancy
```
137
Bronchiectasis
- Def
- Characteristics
- Types
Permanent dilatation and thickening of airways from recurrent infection/inflammation
Recurrent (chronic daily) cough, excessive sputum, bacterial colonisation gives recurrent infection
Diffuse or Local
138
Bronchiectasis
- Pathophysiology
- Aetiology
Failed mucociliary clearance, impaired immune function gives chronic inflammation = continued bronchial wall insult
Post infection: Measels, peruses, aspergillus, pneumonia
Immunodeficiency: HIV, Ig deficiency
Genetic: CF, ciliary dyskinesia, A1ATD
CTDs: RA, sjogren's
IBD: UC, CD
139
Cyst forming bacteria (RF bronchiectasis)
```
Staph aureus
Bordatella pertussis (paeds)
Pseudomonas aeruginosa
H influenza
Strep pneumoniae
```
140
Bronchiectasis Presentation
Cough and daily sputum (bloody in 50%)
- mild = yellow/green
- more severe = khaki
Intermittent haemoptysis
Obstructive symptoms: dyspnoea and wheeze
Weight loss
141
Bronchiectasis examinatory findings
Inspiratory coarse crackles
and squeaks and pops
Low pitched rhonci (snoring sounds)
Clubbing
142
Early inspiratory Vs Late inspiratory crackles
Early = airway disease e.g. bronchiectasis
Late = interstitial disease e.g. IPF
143
Bronchiectasis Investigations
CT ( imaging modality of choice): thickened dilated airways ± air fluid levels, cysts
CXR: normal/dilted bronchi with thickened walls + cysts. Ovoid opacities
FBC: high eosinophils if aspergillosis, Neutrophilia = bacterial infection
Serum A1AT
Sputum culture:
G+ = s.aureus, s.pneumoniae
G- = pseudomonas
144
Bronchiectasis Tx
Lifestyle: exercise and nutrition
Physio + mucolytics
Inhaled: Bronchodilator + hypertonic saline (thins mucous through drawing water)
Acute exacerbation:
- Mild = oral amoxicillin
- Severe = IV ABX with pseudomonas cover (ciprofloxacin)
145
Cystic fibrosis
- Detected
- Def
Mostly at birth (newborn heel prick-Guthrie test)
Genetic disease with mutation in CFTR gene (Cl channel)
146
Locations of CFTR
Lunges, bowel, pancreas, sweat glands, reproductive organs
147
Epidemiology and Pathophysiology
1/2500 white people in UK
1 in 25 carriers
Failure of Cl channel in response to cAMP in epithelial cell. Decreased excretion of Cl to lumen, increased Na reabsorption decreased H2O excretion.
Results in thick sticky secretion
148
Organ specific explain CF
Pancreas: block of exocrine ducts, early pancreases duct activation = autodigestion
Intestine: bulky stools, intestinal block, prolapse in paeds
Lung: mucous retention, chronic infection, inflammation
Skin: NaCl channels reabsorbing from gut doesn't work leaving increase in sweat
149
Screening CF
Guthrie test (5d) shows serum immunoreactive trypsinogen
150
CF presentation
Neonates/infants: failure to pass meconium, fail to thrive, large appetite (pancreases insufficiency- foul smelling stools), chronic wet cough
VAS absent - infertility
Digital clubbing
Very salty sweat (rusts glasses)
151
CF Investigations
Sweat test: +ve Na and Cl over 60mmol/L (CL more than Na)
Genetic testing
Pancreatic assessment: faecal elastase (low)
Chest infect: Sputum culture and sensitivity
- Pseudomonas (70%): highly transmissible esp the contact other CF
- Burkholderia cepacia
- S.aureus and mycobacterium abscessus
152
CF:
- Tx referral
- Prog
- Burden & complications
Very complex, lots of drugs, physio and high cal diet.
Refer to specialist CF centre
Median survival 40
Huge burden of drugs (lots) and high cal.
Bone disease from malnutrition, depression, short, cor pulmonate (RHF), infertility/subfertility
153
Tx CF
Abx
- Prophylactic Oral Co-amoxiclav/Fluclox
- If IV needed: Gentamycin + cover pseudomonas.staph - Tazocin)
Chest physio
Inhaled bronchodilator
Inhaled mucolytic (hypertonic saline, dornase alfa)
Segregate in hosp. (prev pseudomonas)
Vaccine: influenza, pneumococcal
Pancreatic enzyme replace, Fat soluble vitamins
PPI for GORD
Bilateral lung transplant
154
Pulmonary HTN
- Prognosis
- Definition
Poor as most patients develop RHF - cor. Pulmonale
Disease with HTN in small pulmonary arteries characterised by vascular proliferation and remodelling
155
Diagnostic criteria Pulm HTN
Mean pulmonary artery pressure >25mmHg at rest with pulmonary capillary wedge pressure <15mmHg
(pressure in LA)
156
Causes of pulmonary HTN
CTDs: CREST syndrome
COPD, Interstitial Lung disease
Heart disease: structural, valvular failure
157
Pulmonary HTN Pres + Examinatory findings
```
Dyspnoea
Accentuated P2 (pulmonary component of second heart sound)
```
Tricuspid regurgitation murmur/other causative murmurs
RHF: oedema, exertional syncope, pulsatile JVP, hepatomegaly (pulsatile)
158
Pulmonary HTN Investigation
CXR: enlarged pulmonary artery shadow
ECG: Tall R in V1 = RVH, Large in II, III, aVF = RA enlarge
Right heart catheter shows pressure over 25mmHg in pulmonary artery and less than 15mmHg cap wedge
159
Pulmonary HTN Tx
CCB (nifedipine or amlodipine) or sildenafil (PDE5 inhibitor - augments pulmonary vascular response to nitric oxide)
Anticoagulant: warfarin target 1.5 to 2.5
Lifestyle: low level graded exercise
Oedema: furosemide and low salt diet
Supplemental O2 if needed
160
Types of Lung Ca
| & Epidemiology
Small cell (least common) 15%
Non-small cell (most common) 85%
Adenocarcinoma
Squamous cell carcinoma
Large cell carcinoma
Most common non-cutaneous cancer: M>F (x3)
161
Lung Ca RF
Occupational, Smoking asbestos, radiation, COPD
162
Two week referral in Lung Ca
>40 + 2 of following:
Smoking. Cough, fatigue, SOB, chest pain, weight loss, appetite loss
Refer if:
Supraclavicular lymphadenopathy, finger clubbing
163
Paraneoplastic features of:
SC
Squam
Adeno
SC
SIADH (hyponatraemia)
Sq
PTH (hyperCa, bone pain), hyperthyroid
Ad
Gynaecomastia
164
NSCLC
- Location
- Mets
- Other
Adeno (40%)
- peripheral
- brain, adrenal, bone
- most common in smokers and non-smokers
Sq (20%)
- central
- mets late, local spread common
Large cell (10%)
- central
- mets early and large
165
Lung Ca Pres
Cough + dyspnoea + haemoptysis (new or persistent)
Requires imaging
Fixed monophonic wheeze
Chest pain (lung has no pain fibres therefore this suggests invasion of pleura or chest wall)
Constitutional symptoms: Weight loss, fatigue
Other: SVC obstruct, bone pain, clubbing (Sq)
166
Pancoast tumour Pres
invasion of brachial plexus -> weakness, parasthesia, pain in C8-T1, shoulder pain
Invasion of sympathetic chain -> Horner’s syndrome
Ptosis, miosis/constrict, ipsilateral anhydrosis
167
Lung Ca prognosis
10 year survival = 5%
| SCLC worse prognosis than NSCLC (70% have extensive)
168
Lung Ca Mets
Liver, bones, brain, adrenals
LN
Hilar, mediastinal, supraclavicular
169
Lung Ca Investigations
CXR: opacity (Periph = adeno), Hilar enlarge, boney secondaries
Contrast CT: chest, liver, adrenals
Bronchoscopy may allow for biopsy
Cytology from sputum/pleural effusion (if pres)
Surgical biopsy: Transthoracic needle aspiration
CT/MRI brain, FBC (anaemia), LFT (mets), Bone scan (mets), U+E (hyperCa - mets or Sq, hypoNa+ SC)
170
Staging Lung Ca
T1: < 3cm
T2: 3-7cm, assoc atelectas
N1: ipsilateral bronchopulmonary or hilar
N2: ipsilateral mediastinal or subcarinal
Extensive =
Metastatic lesions in contralateral lung
Distant mets: brain, bone, liver, adrenal
171
NSCLC Lung Ca Tx
Stage 1 or 2: surgical resection lobar resection (lobectomy) or pneumonectomy + hilar/mediastinal LN sampling + pre-op cisplatin chemotherapy
If not operable:
Radical radiotherapy +
chemotherapy - cisplatin based + bevacizumab (anti-angiogenic)
If EGFR mutation use EGFR-tyrosine kinase inhibitors
E.g. Afatinib
172
SCLC management
chemo (cisplatin + etoposide) 4-6 cycles + radio + prophylactic cranial irradiation
173
Lung Ca palliative Tx:
Breathless
Lung Obstruction
Effusions
Cough
SVCO
Bone pain
Spinal cord compression
Breathlessness
Opiate
Obstruction
External beam radiotherapy
Pleural effusion
Aspiration/drainage
Cough
Opiate
SVCO
Chemo + radio
Bone pain
Radio
Spinal cord compression
Dexamethasone
174
Types of Respiratory fail
Type 1: hypoxia (<8kPa) without hypercapnia Type 2 hypoxia + hypercapnia (>6kPa)
175
Causes of Resp failure and names given
T1: COPD (pink puffer), pneumonia, pulmonary oedema, fibrosis, asthma, PE, ARDS
T2: COPD (blue bloater), asthma, myasthenia gravis, polyneuropathy
176
Resp failure pres
Confusion and reduced consciousness
177
Resp failure investigations
ABG, CXR, Functional residual volume, ECG
178
Resp failure management
Admit and resuscitate
Treat hypoxia aim for sats 90%
Always start on high flow
Beware of prolonged high conc O2 if lost hypercapnia drive (may reduce RR) - BIPAP may be better
179
When to intubate Resp failure
If unstable
If unconscious
180
What is ARDS and what can cause
Non-cariogenic pulmonary oedema + diffuse lung inflammation
Dyspnoea and hypoxaemia which may progress to resp failure
SEPSIS and Pancreatitis most common
181
ARDS Presentation
Low SATS, RFs (sepsis, aspiration, pneumonia, blood trans, panc), respiratory failure
182
ARDS investigations
CXR (bilateral infiltrates), ABG, blood culture, sputum culture, urine culture
(due to common in SEPSIS)
183
ARDS Tx
Low tidal volume ventilation (6cc/kg)
Supportive care - resus and then slightly negative fluid balance
ABX + treat cause
184
ABCD for Hypersensitivity types
I = Allergic Anaphylaxis and Atopy
II = antBody
III = immune Complex
IV = Delayed
185
T1RF causes and Tx
Inadequate oxygenation (alveolar collapse: pneumonia, Fluid in alveoli: LHF)
VQ mismatch
CPAP: alveoli forced open, fluid removed
186
T2RF causes and Tx
Limited Alveolar expansion: COPD, Muscular dystrophy
BiPAP: expands and holds open collapsing airways allow oxygenation and CO2 release
187
Cough + Wheeze + Nasal polyps
| - Suspected disease + test
Churg strauss
pANCA
188
Productive cough plus glomerulonephritis and Saddle shaped nose
GPA
| Wegners, Granulomatosis with Polyangitis.
189
Relevance of Kartagener syndrome in resp
Dysfunction of cilia reversal of organs + recurrent chest infections.
190
COPD exacerbation, no consolidation. Cause and Tx?
H.Influenzae (S.pneumoniae usually more common, Hi more in COPD)
Amoxicillin + Prednisalone
191
COPD features on CXR
Hyperinflation
Hyperlucent (v black) lung fields
Flattened diaphragm
192
Preferd Tx to stop smoking in preg
Nicotine patches are the only pharmacological intervention for smoking cessation in preg
193
Lambert Eaton syndrome
Myasthenic like disease seen with small cell LC
Lower limbs more than upper
May have oesophageal motility (dysphagia)
Weakness improves with use
194
What is diagnostic of COPD
FEV1/FVC ratio less than 70% PLUS symptoms suggestive of COPD
195
Sarcoidosis Tx
None initially for early stage (some take ibuprofen)
parenchymal lung disease, uveitis, hypercalcaemia and neurological or cardiac involvement
196
Oxygen targets
- Acutely ill
- COPD
94-98%
88-92%
197
Hx of TB, Round lesion with air around rim, haemoptysis and fever
Aspergilloma
198
A1AT Vs COPD
- Imaging
- Age
A1AT more basal changes Vs Apical in COPD
A1AT in younger patients
199
Testing adult for suspected Asthma
FeNO (nitrous oxide exhaled) and bronchodilator reversibility testing
200
Raised ACE level, lung and joint involvement diagnosis
Sarcoidosis
201
Who offered Long term O2 Therapy
PaO2 under 7.3kPa on two occasion
| OR pO2 of 7.3 - 8 kPa PLUS: Polycythemia, peripheral oedema, pulmonary HTN
202
Resp complication of Pancreatitis
| What else can cause this
ARDS
COPD, Trauma, Shock
