Respiratory Flashcards
(121 cards)
1
Q
Define pleural effusion
A
Accumulation of an abnormal volume of fluid in the pleural space
2
Q
Describe the fluid that is normally found in the pleural space
A
<15ml in volume
Clear, serous fluid with few cells
3
Q
What sign is suggestive of a pleural effusion on a CXR?
A
Blunting of the costaphrenic angles
4
Q
What symptoms can be associated with a pleural effusion?
A
Asymptomatic
SOB
Cough
Pleuritic chest pain
5
Q
What clinical signs are associated with a pleural effusion? I.e 1. chest expansion 2. tacile vocal fremitis 3. percussion 4. breath sounds 5. any other...
A
- Chest expansion is reduced
- Reduced tactile vocal fremitis
- Stony dull percussion
- Quiet breath sounds
+ Bronchial breathing above fluid level
+ Rub with pleural inflammation
6
Q
Describe the mechanism of a pleural effusion
A
Disturbed balance between pleural fluid production and absorption
7
Q
If there is a bilateral pleural effusion, what type of effusion is it generally?
A
Transudate (protein <30g/l)
8
Q
What type of pleural effusion can be caused by cardiac failure?
A
Unilateral effusion on the right
9
Q
How should pleural effusion be sampled?
A
USS guidance
Need >100ml to cytology + paired serum samples
Biochemistry - Light’s criteria
Microbiology
10
Q
How much pleural effusion can be drained at a time?
A
1 litres
11
Q
What are causes of transudative pleural effusion?
A
Cardiac failure
Hepatic cirrhosis
Nephrotic syndrome
Hypoalbuminaemia
12
Q
What are causes of exudative pleural effusion?
A
Bacterial pneumonia
Malignancy
Mesothelioma
TB
13
Q
At what site should a thoracentesis be performed?
A
Above the rib (below rib is the neurovascular bundle)
14
Q
Describe Light’s criteria for establishing whether a pleural effusion is a transudate or exudate
A
- Pleural/serum protein ratio >0.5
- Pleural LDH/serum LDH >0.6
- LDH >2/3 the upper limit of normal value for serum LDH
15
Q
When is a medical thoracoscopy indicated?
A
Undiagnosed cytology negative pleural effusions
16
Q
What are the four management options for malignant pleural effusion?
A
- Drain to dryness and discharge
- , Medical pleurodesis
- Thoracoscopic pleurodesis
- Indwelling pleural catheter (IPC) - high output pleural effusion
17
Q
What percentage of pneumonias will have an associated effusion?
A
50% (parapneumonic)
18
Q
Describe a complex parapneumonic effusion
A
pH <7.2
LDH >1000
Glucose <2.2
Loculated on ultrasound
19
Q
What mortality is associated with an empyema?
A
15%
20
Q
On CXR, what shaped effusion is suggestive of empyema?
A
D-shaped
21
Q
When should an empyema be considered?
A
Effusion + sepsis
Pneumonia and not improving
22
Q
How should an empyema be managed?
A
Small bore chest drain
Frequent sterile saline flushes
IV antibiotics and DVT prophylaxis
Fibrinolytics - streptokinase or DNAase and tPA (alteplase)
23
Q
Describe sarcoidosis
A
Multisystem inflammatory disease of unknown aetiology that predominantly affects the lungs and the intrathroacic lymph nodes
24
Q
What skin lesion is associated with sarcoidosis?
A
Erythema nodosum
25
What eye condition is associated with sarcoidosis?
Uveitis
26
In what population is sarcoidosis most commonly seen?
African American women
27
What type of granulomas are associated with sarcoidosis?
Non-caseating granulomas (T cell surrounding macrophages)
28
What histology is commonly present in sarcoidosis?
Langhans Giant Cells
| Contain Schaumann bodies and astroid bodies
29
What are the general symptoms of sarcoidosis?
| In what percentage of patients are these present?
```
Weight loss
Anorexia
Fever
Malaise
Night sweats
```
45%
30
What electrolyte disturbance is associated with sarcoidosis?
Hypercalcaemia (increased Vitamin D produced by macrophages)
31
What happens to ACE levels in sarcoidosis?
Increased (from T cells)
32
What is stage 1 CXR classification for sarcoidosis?
Bilateral hilar lymphadenopathy without infiltration
33
What is stage 2 CXR classification for sarcoidosis?
Bilateral hilar lymphadenopathy with infiltration
34
What is stage 3 CXR classification for sarcoidosis?
Peripheral infiltration alone
35
What is stage 4 CXR classification for sarcoidosis?
```
Bullae
Fibrotic bands
Bronchiectasis
Diaphragmatic tenting
Hilar retraction
```
36
How can severe symptoms of sarcoidosis be managed?
Steroids
37
Describe the epidemiology of Usual Interstitial Pneumonia (UIP)
Age >50y
| M:F = 2:1
38
What signs and symptoms are associated with UIP?
Progressive breathlessness (worse with exercise), hacking cough
Bibasilar crackles
Clubbing
Appetite and weight loss
39
What pathological findings are associated with UIP?
```
Peripheral interstitial pattern
Subpleural honeycombing (radiological sign)
```
40
What are some of the non-idiopathic causes of UIP?
Occupational and environmental
Drug induced - amiodarone, cocaine, nitrofurantoin, methotrexate
Connective tissue disease - SLE, RA, scleroderma
Primary disease - sarcoidosis, LAM
41
What percentage of cases of UIP are idiopathic?
25%
42
How can UIP be diagnosed?
High resolution CT
| VATS (3 samples)
43
What are the four features of UIP that need to be detected following VATS?
1. Spatial heterogeneity
2. Temporal heterogeneity
3. Smooth muscle hyperplasia
4. Fibroblastic focus
44
What is extrinsic allergic alveolitis also called?
Hypersensitivity pneumonitis
45
Define EAA/HSP:
Immunologically mediated (T-cells) inflammatory reaction in the alveoli and respiratory bronchioles following exposure to organic dust, moulds, foreign proteins (animal dander), and some chemicals
46
How long after the exposure to the allergen do symptoms develop?
4-8 hours
47
What symptoms are associated with EAA/HSP?
Flu-like symptoms: high fever, chills, malaise and myalgia
| Chest symptoms: cough, dyspnoea, chest tightness
48
Describe some of the radiological findings associated with acute HSP:
```
Numerous poorly defined small opacities throughout both lungs
May have sparing of the apices/bases
Ground glass opacities
Fine reticulation may occur
Zonal distribution
```
49
What are the symptoms of chronic HSP?
```
Dyspnoea on strain
Sputum production
Fatigue
Anorexia
Weight loss
```
50
Describe the pathology of chronic HSP:
Non-necrotising granulomatous inflammation (Giant cells)
| Overproduction of surfactant --> lipid is phagocytksed by macrophages --> foamy macrophages in alveolar space
51
What is the difference, in terms of pathology, of sarcoidosis and EAA/HSP?
Sarcoidosis = non-necrotising granulomatous inflammation in the interstitium
EAA/HSP = non-necrotising granulomatous inflammation in the alveolar air space
52
Define COPD
Progressive, irreversible airway obstruction which does not change markedly over several months
53
Define Emphysema
Permanently dilated airways distal to the terminal bronchioles with alveolar destruction and bullae formation
54
Define chronic bronchitis
Cough with sputum production for at least three months in two consecutive years
55
What percentage of lung cancers are due to lifestyle factors, the most important being smoking?
90%
56
What types of lung cancer does smoking predispose the most to?
Squamous carcinoma
| Small cell carcinoma
57
Give 4 risk factors (other than smoking) for developing lung cancer
```
Environmental tobacco smoke
Irradiation - radon, uranium
Air pollution
Asbestos
Other - HPV, fibrosing conditions of the lung, hereditary
```
58
What are some of the common signs and symptoms of a lung cancer?
```
Cough
Haemoptysis
SOB
Chest pain
Weight loss/anaemia
General malaise
```
59
What symptoms are more commonly seen in central lung cancers?
Haemoptysis
Bronchial obstruction - SOB, retention pneumonia
Cough
60
What symptoms are more commonly seen in peripheral lung cancers?
Largely asymptomatic
| Pain if pleura/chest wall involvement
61
Give some signs and symptoms that may occur if there is local spread of a lung cancer?
Pancoast tumour - brachial plexus involvement, Horner's syndrome
Mediastinum involvement:
Paralysis of diaphragm - involvement of phrenic nerve
Hoarseness - involvement of recurrent pharyngeal nerve
Super vena caval obstruction
62
Describe haematogenous spread of lung cancer
Spread through pulmonary veins
| Mets in liver, bone, brain, adrenals
63
Which lymph nodes are involved in lung mets?
Cervical lymph nodes
64
Describe the hormonal effects of lung cancer
ACTH released by tumour --> adrenal hyperplasia --> raised blood cortisol --> Cushing's syndrome
ADH secretion --> water retention --> dilute hypernatraemia
Parathyroid Hormone Related Peptide released --> increased osteoclast activity --> increased bone resorption ---> hypercalcaemia
65
What are non-hormonal non-metastatic effects of lung cancers?
Encephalopathy
Cerebellar degeneration
Neuropathy
Myopathy
66
Describe small cell lung carcinoma
Most aggressive form of lung cancer
Metastasises early and widely
Treat with chemo - usually good response but most patients relapse
67
Describe the histology associated with small cell lung carcinoma
```
Oval to spindle shaped cells
Scant cytoplasm
Inconspicious nucleoli
Nuclear moulding
Lots of apoptosis and mitosis
```
68
What are the types of non-small cell lung carcinoma?
Squamous cell carcinoma
Adenocarcinoma
Large cell carcinoma
69
Describe squamous cell carcinoma
Tends to arise centrally from the major bronchi - may block the bronchi --> retention pneumonia/collapse
Slow growing and metastases late --> ? surgery
70
Describe the histological appearance of squamous cell carcinoma
Malignant epithelial tumour with keritanisation and/or intracellular bridges (desmosomes)
In situ squamous cell carcinoma may be seen in adjacent airway
71
Describe adenocarcinoma lung cancer
Common in females
Can be seen in non-smokers
2/3 in periphery
Can spread from lobe to lobe
72
Describe the histological appearance of adenocarcinoma lung cancer
Glandular
Solid
Papillary
(Grows along alveolar walls --> produce mucin)
73
Define large cell carcinoma
An undifferentiated malignant epithelial tumour that lacks the cytological features of SCLC and glandular/squamous differentiation
74
What are carcinoid tumours?
Neuroendocrine cells
| Can metastases but much better prognosis
75
What lung cancers are arise centrally?
Squamous
Small cell carcinoma
(arise in and around the Hilar)
76
What lung tumour generally arises in the periphery?
Adenocarcinoma
77
Describe the role of EGFR in NSCLC
Ligand binds --> activation of tyrosine kinase --> pathway activation --> production of GF, proliferation etc
If tyrosine kinase is continually activated --> continuous cell division
78
What two drugs target EGFR in NSCLC?
Cetruximab
| Erlotinib
79
Describe the MoA of Cetruximab
Targets the ligand binding site with a blocker
80
Describe the MoA of Erlotinib
Tyrosine kinase inhibitor
81
What can be used to assess for mutation in EGFR gene?
PCR
82
What is associated with a good response to EGFR inhibitors?
Deletion in exon 19
83
What fusion gene is implicated in some NSCLC?
ALK-EML4
84
What occurs following the chromosomal translocation that results in ALK-EML4 fusion gene being produced?
Activation of tyrosine kinase --> cell proliferation
85
What drug can inhibit ALK-EML4?
Crizotinib
86
How can ALK-EML4 gene be assessed?
FISH
87
Describe how PD-L1 inhibitors can be used to treat NSCLC
PD-L1 (tumour cell) binds to PD-1 on T lymphocytes to prevent the T cells from killing the tumour cell
inhibiting PD-L1 will prevent the tumour cell from evading the immune system
88
Describe mesothelioma
Primary pleural tumour
Almost always due to asbestos exposure
Very long lag period before disease develops
89
What is the most common cause of Community Acquired Pneumonia?
S.pneumoniae
90
Give bacteria which cause typical CAP
S.pneumoniae
H.influenzae
Moraxella catharralis
91
Give bacteria which cause atypical CAP
Mycoplasma pneumoniae
Legionella pneumoniae
Chlamydophilia pneumoniae
92
What is the appearance of S.pneumoniae?
Chains of gram positive cocci
93
What are risk factors of developing CAP caused by S.pneumoniae?
```
Alcohol
Smoking
Influenza
Airway disease
Immunosuppression
```
94
What signs and symptoms are associated with CAP caused by S.pneumoniae?
```
Abrupt onset
Cough
Fever
Pleuritic chest pain
Dull percussion
Coarse crepitations
Increased vocal resonance
```
95
What Abx should be prescribed for a patient who has CAP due to S.pneumoniae?
Amoxicillin
| Clarithromycin or doxycycline if allergy to penicillin
96
What is the appearance of Haemophilius influnzae?
Gram negative
97
Who is at risk of developing CAP due to Haemophilius influenzas infection?
Older people
| People with underlying lung disease
98
What other infections can be caused by H.influenzae?
Otitis media
Conjunctivitis
Headache/sinusitis
Meningitis (type B)
99
What are the signs and symptoms of H.influenzae CAP?
```
Abrupt onset
Fever
Pleuritic chest pain
Dull percussion
Coarse creps
Increased vocal resonance
```
100
Describe the management of H.influenzae CAP
Co-amoxiclav
| if allergy to penicillin: clarithromycin, doxycycline
101
Describe the presentation of Mycoplasma pneumoniae
Non-specific (headache, lethargy, cough, myalgia)
Signs of consolidation on auscultation
Higher rates in autumn and winter
Spreads from person to person
Affects younger people
102
What are the other effects of Mycoplasma pneumoniae?
```
Haemolysis (cold agglutinins)
Guillain-Barre syndrome
Erythema multiform
Arrhythmias
Arthritis
```
103
How is Mycoplasma pneumoniae CAP diagnosed?
Serology - rising Ab against M.pneumoniae
| PCR from sputum, gargle, throat swab
104
Describe the treatment of Mycoplasma pneumoniae CAP
Macrolides - clarithromycin
Tetracyclines - doxycycline
Quinolones - ciprofloxacin
105
Describe legionella pneumophilia
Exists within the soil and water
Hx is key
Causes atypical presentation
106
How is Legionella pneumophilia diagnosed?
Ab raised against legionella
| Urinary antigen test
107
How is legionella pneumophilia CAP treated?
Macrolides - clarithromycin
Tetracycline - doxycycline
Quinolones - ciprofloxacin
108
What is the CURB65 score?
Assess severity of pneumonia
```
C = confusion
U = urea >7
R = RR >/= 30
B = DBP <60 or SBP <90
65 = >65y
```
>2 = severe pneumonia
109
What is Sepsis qSOFA score?
SBP <100mmHg
Altered mental state
Respiratory rate >22 breaths/min
110
Other than the CURB65 score, what is the other definition of a severe pneumonia?
Multilobular consolidation on CXR and/or hypoxic on RA
111
Define obstructive sleep apnoea
Recurrent episodes of partial or complete upper (pharyngeal) airway obstruction during sleep resulting in intermittent hypoxia and sleep fragmentation
(If manifests with excessive daytime sleepiness --> obstructive sleep apnoea syndrome)
112
Describe of mechanism of OSAS
Airway collapses and closes during sleep
Hypoxia --> arousal
Sleep disruption --> sleepiness, reduced QoL, increase risk of RTA
Blood BP surge --> increased free radical production --> CVA (MI, stroke)
113
What are the symptoms of OSAS?
```
Snorer
Witnessed apnoea
Disrupted sleep - nocturia, choking, dry mouth, sweating
Unrefreshed sleep
Daytime somnolence
Fatigue, low mood, poor concentration
```
114
What scoring system quantifies daytime sleepiness?
Epworth Sleepiness Sore
115
What are the components of a physical examination in OSAS?
```
Weight/BMI
BP
Neck circumference (>40%)
Craniofacial appearance: retrognathia (abnormal posterior position of maxilla/mandible) or micrognathia (small jaw)
Tonsils
Nasal patency
```
116
What are the two methods in which OSAS can be investigated?
Limited Sleep Study - at home
| Full polysomnography
117
Define apnoea
The cessation, or near cessation, of airflow
| 4% oxygen desaturations, lasting >/= 10 seconds
118
Define hypopnoea
Reduction in airflow to a degree insufficient to meet the criteria for an apnoea
119
What is the Apnoea-Hypoapnoea Index?
Calculated by adding the total number of apnoeas and hypopnoeas and dividing by the total sleep time (in hours)
120
How is the Apnoea-Hypoapnoea Index used to diagnose OSAS?
AHI >/= 15 = diagnostic
| AHI 5-14 + symptoms = diagnostic
121
Define Oxygen Desaturation Index
The number of times per hour of sleep that the SpO2 falls >/= 4% from baseline
