Respiratory Flashcards
(239 cards)
1
Q
define COPD
A
Chronic Obstructive Pulmonary Disease
2
Q
What two conditions come over the umbrella term COPD?
A
Emphysema and chronic bronchitis
3
Q
What is the pathology of COPD
A
loss of alveolar attachments leading to a decrease of elastic recoil resulting in collapse of the airways. There is fibrosis and lung destruction.
4
Q
name 2 features that are characteristic of COPD
A
airflow obstruction
usually progressive
not fully reversible
associated with enhanced chronic inflammatory response in the airways
5
Q
name three types of cells that are associated in the chronic inflammatory response seen in COPD
A
Neutrophils, many macrophages and CD8+ T lymphocytes
6
Q
what is emphysema?
A
enlarged air spaces distal to terminal bronchioles with destruction of alveolar walls. Often visualised on CT.
7
Q
What is chronic bronchitis defined as clinically?
A
defined clinically as cough, sputum production on most days for 3 months of 2 successive years.
8
Q
Name two vascular changes you can get in COPD?
A
Poor V/Q mismatch
Low PaO2
Poor ventilation may give a high pCO2
Hypertrophy of smooth muscle cells and elastic lamina cause vasoconstriction leading to secondary pulmonary hypertension.
9
Q
What is the aetiology of COPD?
A
smoking
need a genetic susceptibility
10
Q
name 3 risk factors besides smoking that increase a person’s risk of having COPD?
A
Occupational dust and chemicals
Environmental tobacco smoke (passive smoking)
Indoor and outdoor air pollution
Infections and childhood infections
Socioeconomic status (+ parents = in utero development )
Ageing population
11
Q
What can cause an acute exacerbation in COPD?
A
Can be triggered by a viral or bacterial infections
12
Q
what are three symptoms of COPD?
A
Shortage of breath
Cough, phlegm
Wheeze
13
Q
Name 5 signs of COPD?`
A
Raised Respiratory Rate Hyperexpanded chest / barrel shaped chest Cyanosis Weight loss (caused by patients finding difficulty to coordinate breathing and chewing) Cor pulmonale - Secondary heart failure - Swollen ankles - Raised JVP - Cardiac output is maintained
14
Q
What are the two phenotypes that illustrate the two extremes of COPD?
A
Pink puffer
Blue bloater
15
Q
Describe a classic pink puffer
A
very breathless but not cyanosed. Have increased alveolar ventilation, breath hard. Normal PaO2 and a normal or low PaCO2. Weight loss.
16
Q
describe a classic blue bloater?
A
Decreased alveolar ventilation. Low PaO2 and a high PaCO2. Cyanosed but not breathless. Cor pulmonale.
17
Q
What are the symptoms of an acute exacerbation of COPD?
A
Increasing cough
Breathlessness
Wheeze
Decreased exercise capacity
18
Q
What 6 investigations would you do in someone with COPD?
A
Spirometry Full Blood Count Chest X-ray CT ECG COPD assessment test to assess the quality of life
19
Q
what would a FBC show in a COPD patient?
A
increased packed cell volume
20
Q
what would a chest x-ray show in a COPD patient?
A
Hyperinflation; flat hemidiaphragms, large central pulmonary arteries.
Also looking to see if there is any possibility of a different diagnosis e.g pneumonia or lung cancer
21
Q
What may you be able to see on a CT scan of someone with COPD?
A
Bronchial wall thickening, scarring, air space enlargement
22
Q
What FEV1 score is predictive of COPD?
A
less than 80%
23
Q
What FEV1:FVC ratio is predictive of COPD?
A
less than 70%
24
Q
What investigations would you do in someone having an acute exacerbation of COPD?
A
ABG CXR to exclude pneumothorax and infection FBC, U&E, CRP ECG Send sputum for culture if purulent
25
what are the lifestyle interventions for COPD mamagement?
Smoking cessation
| Regular activity
26
Name three types of medication you can use in the treatment of COPD?
```
B2 agonist (long or short acting)
Anticholinergic (long or short acting)
Inhaled corticosteroid
```
27
what are the surgical options for treatment of COPD in certain selected patients?
Lung volume reduction surgery
| Lung transplant
28
What is the treatment of an acute exacerbation of COPD?
1) Nebulized bronchodilators
2) Controlled oxygen therapy
3) Steroids
4) Antibiotics if there is evidence of infection
5) If no response consider non-invasive positive pressure ventilation or consider a respiratory stimulant drug e.g doxapram
6) If still no response may have to consider intubation and ventilation
29
What is asthma?
Bronchial hyperresponsiveness causing a reversible airways obstruction
30
What is the pathology of asthma?
Increased number of smooth muscle cells (which become hypertrophied).
Smooth muscle cells constrict, narrowing the lumen. This is triggered by many stimuli.
Mucosal swelling and inflammation caused by eosinophils in the lungs.
Increased mucus production
All three factors lead to obstruction and unventilated parts of the lung
31
how is asthma classified?
1) Eosinophilic or non-eosinophilic?
2) If eosinophilic is it atopic asthma or non-atopic asthma
3) if non-eosinophilic is it:
a) smoking associated
b) non-smoking, non-eosinophilic
c) obesity related
32
What is eosinophilic asthma?
Allergic inflammation is characterised by the recruitment of eosinophils.
33
What is atopic asthma? And name two causes?
Atopy is the tendency to develop IgE mediated reactions to common aeroallergens e.g cats, dust.
34
Name 4 symptoms of asthma?
```
Episodic wheeze
Breathlessness
Cough
Diurnal variation (asthma is worse at 3-5am in the morning probably due to a natural dip in adrenaline)
Some may have reflux
```
35
Name 4 provoking factors that can make asthma worse?
Something you’re allergic to e.g cats, dogs etc.
Cold air
Exercise
Laugher
Can be worse just before women get period
NSAIDs
Beta blockers
36
What other atopic diseases are commonly associated and found alongside asthma?
Eczema
Hay fever
Allergies
37
What are three signs of asthma?
Physical examination may be normal as the wheeze is episodic.
Hear a wheeze that is polyphonic, can occur on expiration and inspiration and is widespread across the chest.
Hyperinflated chest
Tachypnoea
38
What are signs of an uncontolled/moderate acute asthma attack?
PEFR > 50%
Resp Rate < 25
Pulse < 110bpm
Normal speech
39
What are the signs of a severe asthma attack?
PEFR 33-50% predicted
RR > 25
Pulse > 110bpm
Inability to complete sentences
40
What are the signs of a life threatening asthma attack?
PEFR < 33%
SaO2 < 92%
Normal PaCO2
Altered consciousness level, exhaustion, arrhythmia, hypotension, silent chest, cyanosis
41
What aspects are important when taking a history in an asthma patient?
Presenting complaint
- Work out the severity of the disease (A&E attendances, admissions, ITU care, attendance at GP for courses of antibiotics and steroids)
- RCP3 questions for assessing severity of chronic disease
* Recent nocturnal waking?
* Usual asthma symptoms in day?
* Interference with activities of daily living?
- Age of onset
- Associated symptoms (e.g eczema)
- PMH
- Drugs (make sure not on beta blockers)
- Family and social history e.g smoking, pets in the home
- Occupational history - work may provide the trigger if symptoms are better at weekends/holidays
42
What tests can you do to investigate chronic asthma
FBC
Fraction of expired Nitrous Oxide (FeNO).
Tests for atopy and allergy : skin prick test, radioallergosorbent test (RAST)
CXR
Lung Function Tests
Reversibility testing
43
What may a FBC show when investigating an asthma patient?
Eosinophilia
44
What does a high FeNO suggest?
Eosinophilic disease
45
Why may you perform a chest X-ray when investigation asthama?
Make sure not missing a potential cancer
| Make sure not COPD
46
What may the lung function tests show in an asthma patient?
Airway obstruction may be present (reduced FEV1 and reduced FEV1/FVC ratio)
Peak flow - PEFR reductions from percent predicted (varied)
Increased response to challenge agents
47
What is reversibility testing and why would you use it when investigating asthma?
Increase in lung capacity with bronchodilators or anti-inflammatory treatment (increase of 12% in FEV1 together with increase in 200ml in volume strongly suggests asthma)
48
What tests would you do in a patient presenting with acute asthma?
Peak Flow
Measure oxygen level
ABGs analysis may be needed.
CXR
49
Why is a normal PaCO2 very bad in acute asthma? What needs to happen to patient?
Suggests that there is an increased work in breathing and lungs are not reciprocating the work needed i.e not hyperventilating
Need to get to ITU NOW!
50
What lifestyle advice can you give to asthma patients to manage their condition?
Stop smoking
Weight loss if overweight
Avoid precipitants
Educate to enable self management
51
Name three medications available in the treatment of asthma?
Bronchodilators - mainly beta2-adrenoreceptor agonists
Corticosteroids
New biologic agents
52
What is the mechanism of action of beta2-adrenoreceptors?
| Give an example of a short and a long acting one?
Relax the bronchial smooth muscle
short acting : salbutamol
long acting: salmeterol
53
What is the benefit of having a long acting beta2-adrenorecptor agonist?
can help nocturnal symptoms and reduce morning dips.
54
name two side effects of salbutamol?
Tachyarrhythmias
| Anxiety
55
What is the best way to give corticosteroids to an asthma patient? Why?
inhaled to prevent systemic side effects such as diabetes.
56
Name an inhaled corticosteroid?
Beclometasone
57
when would you use new biologics in the treatment of asthma patients?
These are heavily regulated.
Patient has to have severe eosinophilic uncontrolled asthma and tried several other drugs before being offered.
Very expensive!
58
Name two examples of new biologic drugs used in asthma?
Omalizumab (anti-IgE)
| Mepolizumab (anti-IL-5)
59
what is the treatment plan in acute asthma?
Oxygen (40-60%) to maintain sats 94-98%.
Salbutamol nebulizer with oxygen and give prednisolone
Repeat the salbutamol if PEF remains < 75%
Monitor PEFR, oxygen, heart rate and resp rate
60
How are primary lung cancers classified?
Into :
Small cell lung carcinomas (20%)
Non-small cell lung carcinomas
61
Describe small cell lung carcinomas
High grade epithelial neoplasm with STRONG cigarette smoking association
62
What features so small cell lung carcinomas usually have?
often secreting polypeptide hormones resulting in paraneoplastic syndromes:
- Secretion of PTH
- SIADH
- Secretion of ACTH and other hormones
The majority of SCLC are disseminated (spread beyond the chest to rest of the body) at the time of presentation
63
Describe non-small cell carcinomas?
Variable grade/type epithelial neoplasm with cigarette smoking association. May have metastasis by presentation/diagnosis.
64
Name three types of non-small cell carcinoma?
Squamous cell carcinoma
Adenocarcinoma
Large cell undifferentiated carcinoma
65
Briefly outline the pathology of primary lung carcinomas?
Cell dysplasia leads to carcinoma. Occurs due to a mutation, then increased cell proliferation and decreased apoptosis. These mechanisms are controlled by genes. More p53 gene expression → severe dysplasia → car
66
Name 4 cancers that commonly metastasise to the lung?
Breast
Colorectal
Kidney
Testicular
67
Name three causes of lung cancer?
Cigarette smoking
Passive smoking
Occupational risk factors: asbestos, radon, nickel, chromate, arsenic
Lung fibrosis
68
Name 5 symptoms of lung cancer?
```
Cough
Recurrent chest infections
Haemoptysis
Increasing shortness of breath
Extra-pulmonary changes (directly/indirectly due to cancer)
Chest pain
General malaise
Weight loss
```
69
Name two signs of lung cancer?
Cachexia
| May be lung collapse or pleural effusion
70
Name 3 extrapulmonary changes that may be a sign of lung cancer?
Clubbing, Hypertrophic pulmonary osteoarthropathy (causing wrist pain)
Cushing’s, hypercalcaemia, gynaecomastia, dilutional hyponatremia caused by ectopic secretions
Cerebellar degeneration, myopathy, polyneuropathy
DIC
71
Name symptoms / signs of lung metastasis?
```
Bone tenderness
Hepatomegaly
Confusion
Fits
Focal CNS signs
Cerebellar syndrome
Proximal myopathy
```
72
What investigations would you do in someone with suspected lung cancer?
```
Chest X-ray
Cytology
Fine needle aspiration/biopsy of peripheral lesions/lymph nodes
CT chest to stage the tumour
PET/CT scan to help in staging
```
73
What may a chest X-ray show in someone with lung cancer?
- look for peripheral nodules (a mass) : increased density/whiteness in lungs
- hilar enlargement
- Consolidation (region of normally compressible lung tissue that has been filled with liquid instead of air)
- Pleural effusion
74
What patients should be offered PET/CT scan?
all patients who may be suitable for surgery with curative intent should be offered this before treatment
75
Name two preventative things you can do to to try and prevent lung cancer?
Stop smoking
| Prevent occupational exposure to carcinogens
76
What is the treatment for small cell lung carcinoma?
Chemotherapy +/- radiotherapy
77
What is the treatment of non-small cell lung carcinoma?
- Lobectomy is the treatment of choice if medically fit/able. Usually smaller tumours
- Radical radiotherapy (stage I, II, III)
- Chemotherapy +/- radiotherapy for more advanced disease
- May be offered new gene-based chemotherapy
78
what is mesothelioma?
A tumour of mesothelial cells that usually occurs in the pleura
79
What is mesothelioma associated with?
Associated with occupational exposure to asbestos. Latent period can be up to 45 years.
80
Name 5 signs/symptoms of mesothelioma?
Chest pain, dyspnoea, weight loss, finger clubbing, recurrent pleural effusions
81
What investigation would you do in mesothelioma?
CXR/CT
82
What would a CT/CXR show in a patient with mesothelioma
Pleural thickening / effusion
83
What treatment would you give to a patient with mesothelioma?
Chemotherapy can help improve survival
84
describe the usual pathology of PE?
Usually arises from venous thrombosis in the pelvis or legs.
Clot that starts in the leg and has detached, gone through the right side of the heart and become lodged in the pulmonary arteries
85
what is the main cause of pulmonary embolism?
Deep Vein Thrombosis
86
Name three risk factors for developing a pulmonary embolism?
```
Recent surgery (esp hip/knee replacement)
Thrombophilia
Leg fracture
Prolonged bed rest
Malignancy
```
87
Name 5 symptoms of a pleural embolism?
```
Acute breathlessness
Pleuritic chest pain
May have signs/symptoms of DVT
Haemoptysis
Dizziness
Syncope
```
88
Name 5 signs of a pulmonary embolism?
```
Tachycardia
Tachypnoea
Pleural rub
Cyanosis
Severe dyspnoea
Hypotension
Pyrexia (fever)
```
89
What tests would you do to investigate a pulmonary embolism?
```
Chest X-ray
ECG
ABG
D-dimer
CT pulmonary angiogram
```
90
Why do we do a chest x-ray when investigating a pulmonary embolism?
May be normal.
CXR is normally done to look for signs of pneumonia
May show a dilated pulmonary artery or small pleural effusion
91
What would an ABG show of someone who has a pulmonary embolism?
Type 1 respiratory failure
| Decreased PaO2 and decreased PaCO2
92
What test is diagnostic in PE?
CT pulmonary angiogram
93
What is the treatment for a pulmonary embolism?
Clot lysis
Haemodynamically unstable: IV altepase
Haemodynamially stable: LMWH, then start DOAC/warfarin
94
What preventative actions can you take to reduce the risk of PE?
Early mobilisation if in surgery
Compression stockings
Heparin to all immobile patients
95
What is the difference between active and latent TB?
| What is the differing natural history?
- Active disease
Local immune response is not enough to control the disease. Bacilli and macrophages continue to come together to form granulomas (primary Ghon focus). The granuloma slowly enlarges and the middle becomes necrotic, it continues to grow until it becomes a cavity. Can spread to the lymph nodes. Active TB disease can arise from primary infection or reactivation of previously latent disease.
- Latent TB Disease
An infection without disease due to the persistent immune system containment (granuloma formation prevents bacteria growth and spread). Patient is asymptomatic and non-infectious. 1 in 10 people who have latent disease, the TB will reactivate and cause active disease (post primary disease)
96
What is the cause of TB?
Mycobacterium tuberculosis
97
How is TB spread?
Catch as the bacteria is spread in aerosol from infected individuals lungs to another lung via spitting, sneezing.
98
Name an alternative method for catching TB?
Can also get TB caused by Mycobacterium bovis which is bovine TB by drinking milk with it in.
99
Name three risk factors that increase a person's likelihood for developing TB?
```
Born in high prevalence areas
IVDU
Homeless
Alcoholic
Prisons
HIV positive
```
100
What are the systemic features of TB?
```
Weight loss
Low grade fever
Anorexia
Night sweats
Malaise
```
101
What are the Pulmonary features of TB?
Persistent cough (more than 3 weeks)
Chest pain
Breathlessness
Haemoptysis
Lung consolidation
Collapse (caused by obstruction in bronchus)
Pleural effusion (cavity erodes into the pleura, causing fluid to enter the lungs and build up)
102
What is tuberculosis lymphadenitis?
Painless enlargement of cervical or supraclavicular lymph nodes
103
What organs/parts of the body can TB commonly affect (other than lungs)
```
Abdomen
Spine
CNS
GU
Cardiac
```
104
Outline features of abdominal TB?
Ascites,
abdominal lymph nodes,
ileal malabsorption,
colicky abdominal pain
105
2 features of spinal TB?
Pain or swelling of joint, Pott’s disease with spinal cord lesion
106
What is miliary TB?
Bacteria spreads throughout the lung forming tiny granulomas that can be seen as tiny spots on a chest x-ray.
107
What problems can TB cause if it gets into the CNS?
TB meningitis
| Formation of tuberculomas
108
Name 4 features of GU TB?
Epididymitis, frequency, dysuria and haematuria
109
What can cause cardiac TB?
Can get erosion from the lymph nodes into the pericardium, when infection spreads can cause a pericardial effusion.
110
What are the tests for active TB?
```
Chest X-ray
Blood tests
Sputum smear!!
Sputum culture
Nucleic acid amplification test
Biopsy specimen
```
111
what may a CXR show in active TB disease?
Fibronodular/linear opacities in the upper lobe
112
What blood tests would you do in TB and what could they show?
FBC : normochromic normocytic anaemia
Raised ESR/CRP
Hypergammaglobulinemia
Hypercalcaemia
113
What stain do you use for TB microscopy?
What does look for?
What is an alternative? What are the benefits of this stain?
ZIEHL NEELSEN
- Stains acid fast bacilli pink
Auramine phenol
- fluorescent stain
- faster and more sensitive
114
What tests would you do for detecting latent TB?
Tuberculin skin testing (Mantoux test)
- this is an intradermal injection of purified protein from TB
- skin reaction used to determine if patient has had past exposure to TB
- Positive inflammatory response = positive test
Interferon-gamma release assay
- diagnose exposure to TB by measuring the release of interferon-gamma from T cells reacting TB antigen
115
What is a disadvantage of Mantoux test?
Cannot differentiate between BCG vaccine or if latent TB
116
What is an advantage of interferon-gamma release assay
Increase specificity compared to mantoux test if there is a history of BCG vaccination
117
what is the treatment for active TB?
Pyrazinamide + ethambutol (only first 2 months)
Rifampicin + isoniazid (all 6 months)
Notify public health england
118
What is the treatment for latent TB?
Balance risk of developing active disease with possible side effects.
Increased risk: HIV, transplantation, chemotherapy, diabetes, CKD,
3 months isoniazid + rifampicin OR 6 months isoniazid
119
Name three preventative methods used to reduce the risk of infection of TB?
Active case finding - make non infectious to reduce incidence
Detection and treatment of latent TB
Vaccination : given to neonates from high risk groups and those more at risk for coming into contact e.g healthcare workers.
120
What is drug resistant TB defined as?
Multi Drug resistance = rifampicin and isoniazid
| Most common single drug resistance is isoniazid
121
What is the pathology of pneumonia?
Bacteria from the upper respiratory tract get micro aspirated into the lung.
Macrophage engulfs but can become overwhelmed if there is an increase in bacteria.
Inflammatory cytokines recruit neutrophils to the area.
This means that the endothelial lining of the blood vessel has to open to allow cells in so fluid also may enter the alveolus. Neutrophils will die and this will form pus which is what is coughed up and prevents gas exchange.
122
What is the classification of pneumonia?
Community acquired pneumonia.
Hospital acquired
Aspiration
Immunocompromised patients
123
What are the typical organisms that cause pneumonia?
| What are the features of the bacteria which the most common cause of pneumonia?
Streptococcus pneumoniae : most common. Gram positive cocci. Alpha haemolysis. Optochin sensitive
Haemophilus influenzae: Gram negative coccobacilli
Staph. Aureus : ventilator-associated pneumonia
124
Name the 4 atypical organisms that can cause pneumonia?
Mycoplasma pneumoniae
Legionella pneumophila
Chlamydia pneumonia
Coxiella burnetii
125
Name three groups of people who are at a higher risk of catching pneumonia?
```
Infants and elderly
COPD and other chronic lung disease
Immunocompromised
Nursing home resident
Impaired swallowing (e.g from a neurological condition)
Diabetes
Congestive heart disease
Alcoholics and IV drug users
```
126
Name 5 symptoms of pneumonia
Fever, sweats, rigors (generic infection response)
Cough
Sputum (classically rusty sputum suggests S.pneumonia)
Short of breath
Pleuritic chest pain particularly S.pneumonia
Systemic feature
Weakness, malaise, tiredness
127
Name 5 signs of pneumonia?
```
Abdominal vital signs (related to infection, the more present and greater they are suggests a larger severity)
Raised heart rate
Raised respiratory rate
Low blood pressure
Fever
Dehydration
```
128
What are 5 signs of lung consolidation on percussion and auscultation in pneumonia?
Dull to percussion
Decreased air entry
Bronchial breath sounds
Crackles +/- wheezes - due to pus in alveolar when breathing in
Increased vocal resonance
+/- hypoxia and signs of respiratory failure especially if chronic lung disease or severe pneumonia
129
What investigations would you do in suspected pneumonia?
```
Chest X-Ray
FBC
Biochemistry
C-reactive protein
Pulse oximetry
Sputum
Blood cultures
Urine
Always check for HIV
```
130
What a CXR show on a patient with pneumonia?
Lobar or multilobar infiltrates, cavitation or pleural effusion
131
Why would you test urine in a pneumonia patient?
Check for Legionella/pneumococcal urinary antigens
132
How do you assess the severity of pneumonia in a patient?
```
CURB65
- Confusion
- Urea > 7mmol/L
- Resp rate > 30/min
-Blood pressure ; low
- Age > 65
Each scores one.
0-1 : PO antibiotic, home treatment
2 : hospital therapy
3+ : severe pneumonia indicates increased mortality risk - ITU consider
```
133
What antibiotics would you use to treat a patient with S.pneumoniae pneumonia?
Amoxicillin, cefuroxime or cefotaxime
134
What antibiotics would you use to treat a patient with H. influenzae pneumonia?
Co-amoxiclav
135
What antibiotics would you use to treat patients with Staph aureus pneumonia?
Flucloxacillin or Vancomycin if MRSA
136
What antibiotics would you use to treat patients with atypical organisms causing pneumonia?
- Macrolides (erythromycin, clarithromycin)
- Fluoroquinolones (ciprofloxacin)
- Tetracyclines (doxycycline)
137
What 4 complications can you develop from pneumonia?
- Type I respiratory failure
- Hypotension (may be due to a combination of dehydration and vasodilation due to sepsis)
- Atrial fibrillation. Usually resolves with treatment of the pneumonia
- Pleural effusion, inflammation of the pleura by adjacent pneumonia may cause fluid exudation into the pleural space
- Empyema : pus in the plural space.
- Lung abscess : cavitating area of localized, suppurative infection within the lung
- Sepsis
138
What are upper respiratory tract infections?
Self limited irritation and swelling of the upper airways with associated cough with no proof of pneumonia.
These infections can involve the nose, sinuses, pharynx, larynx and large airways.
Direct invasion of the upper airway mucosa by the organism.
139
Name four types of virus that cause upper respiratory tract infections?
```
Rhinoviruses (45-50%)
Influenza A virus (25-30%)
Coronaviruses (10-15%)
Adenoviruses (5-10%)
Parainfluenza viruses (5%)
```
140
Name three risk factors that increase the likelihood of developing a viral upper respiratory tract infection?
- Close contact with children
- Medical disorder e.g people with asthma and allergic rhinitis
- Smoking
- Immunocompromised
- Anatomical anomalies including facial dysmorphic changes or nasal polyposis increases the risk
141
Name 5 symptoms of a upper respiratory tract infection?
```
Cough
Sore throat
Runny nose
Nasal congestion
Headache
Low-grade fever
Facial pressure
Sneezing
Malaise
Myalgias
```
142
How do you diagnose an upper respiratory tract infection?
The presence of classical features of a rhinovirus infection coupled with the absence of signs of bacterial infection or serious respiratory illness is sufficient to make the diagnosis of the common cold. No testing necessary.
143
What is the treatment for upper respiratory tract infections?
Symptom relief
Decongestants
Early antiviral treatment for influenza infection shortens the duration of the influenza symptoms
144
What is interstitial lung disease?
group of lung diseases affecting the interstitium (the tissue and space around the alveoli)
145
What is the pathophysiology of idiopathic pulmonary fibrosis?
1. Fibroblasts try to repair damaged lung tissue
2. Fibroblasts migrate to the lungs and become myofibroblasts
3. These myofibroblasts deposit collagen within the extracellular matrix of the lung
4. Fibroblasts are resistant to apoptosis
5. Myofibroblasts proliferate and form fibroblastic foci
6. Leads to thickened tissue causing a lower gas exchange efficiency in the lungs (decreased DLCO)
146
Name 5 symptoms of idiopathic pulmonary fibrosis?
```
Dry cough
Exertional dyspnoea
Malaise
Weight loss
Arthralgia
```
147
Name 3 signs of idiopathic pulmonary fibrosis?
Cyanosis
Finger clubbing
Fine end-inspiratory crepitations
148
What investigations would you do for idiopathic pulmonary fibrosis?
```
High resolution CT scanning !!
Lung biopsy
Spirometry
Diffusing capacity of lung for CO
Exercise testing
```
149
What does a HR CT scan show if the patient has idiopathic pulmonary fibrosis?
Shows honeycombing and thickening of the alveoli. Predominantly affects the outside and the bases of the lung. Can see a thickened dilated bronchus (traction bronchi)
150
What will spirometry of a patient with idiopathic pulmonary fibrosis patient show?
restrictive lung disease
| FVC shows restriction of lung volume
151
What does the diffusing capacity of the lungs for CO show in a patient with idiopathic pulmonary fibrosis?
Reduction in gas transfer exchange
152
What does exercise testing show in a patient with idiopathic pulmonary fibrosis?
Shows hypoxia on exertion and a reduction in exercise capacity
- incremental shuttle walk test or 6 minute walk test
153
what is the treatment for idiopathic pulmonary fibrosis? Name 2 side effects for each medication?
Pirfenidone (inhibitor of growth factor-beta and slows down the ability of fibroblasts to damage the lungs. SE = photosensitivity and GI upset
Nintedanib SE = diarrhoea and GI upset
154
What is the palliative treatment for idiopathic pulmonary fibrosis?
Commonly patients will experience symptoms from ILD which do not resolve with treatment of disease
Opioids for breathlessness and pain
Anxiolytics for anxiety (benzodiazepines)
Oxygen therapy
155
What is sarcoidosis?
Multisystem granulomatous disorder
90% of cases affect the lungs
156
What is the aetiology of sarcoidosis?
Unknown
| Associated with HLA-DQB1 and DBQ1 alleles
157
What are the symptoms of acute sarcoidosis?
Fever
Erythema nodosum (swollen fat under the skin causing red bumps)
Polyarthralgia
Bilateral hilar lymphadenopathy
(in 20-40% of cases the disease is discovered incidentally after a routine CXR and so is asymptomatic)
158
What are the features of pulmonary disease sarcoidosis?
| What are the symptoms?
Bilateral hilar lymphadenopathy
May be pulmonary infiltrate or fibrosis
Symptoms: dry cough, progressive dyspnoea, decreased exercise tolerance and chest pain
159
Name 4 non-pulmonary signs of sarcoidosis?
```
Lymphadenopathy
Hepatomegaly
Splenomegaly
Conjunctivitis
Glaucoma
Neuropathy
Many others p. 196
```
160
What investigations should you do for sarcoidosis?
```
Bloods
Chest X-ray
ECG
Lung Function Tests
Tissue biopsy
Bronchoalveolar lavage
```
161
What may the bloods of a patient with sarcoidosis show ?
Increased ESR
| Lymphocytopenia
162
What are the stages of sarcoidosis as seen on a chest x-ray
Stage 0: normal
Stage 1: BHL
Stage 2: BHL + peripheral pulmonary infiltrates
Stage 3: peripheral pulmonary infiltrates alone
Stage 4: progressive pulmonary fibrosis, bulla formation (honeycombing)
163
What test is diagnostic for sarcoidosis and what does it show?
Tissue biopsy
| Shows non-caseating granulomata
164
What may lung function tests show for a patient with sarcoidosis?
May be normal or show reduced lung volumes, impaired gas transfer and a restrictive ventilatory defect
165
What is the treatment for sarcoidosis?
Patients with BLH ususally don’t need treatment and will resolve on their own
Acute sarcoidosis : rest and NSAIDs
Corticosteroids in some cases
166
What is bronchiectasis ?
Chronic inflammation of the bronchi and bronchioles leading to permanent dilation and thinning of these airways
167
What are causes of bronchiectasis?
```
Main organisms
H. influenzae
Strep. Pneumoniae
Staph. Aureus
Pseudomonas aeruginosa
```
Congenital causes
CF
Young’s syndrome
```
Post-infection
Measles
Pertussis
Bronchiolitis
Pneumonia
TB
HIV
```
Other
Bronchial obstruction e.g tumour, foreign body
Allergic bronchopulmonary aspergillosis
168
Name three symptoms of bronchiectasis?
Persistent cough
Copious purulent sputum (contains pus)
Intermittent haemoptysis
169
Name three signs of bronchiectasis?
Finger clubbing
Coarse inspiratory crepitations
Wheeze
170
What tests would you do in a patient for bronchiectasis?
```
Sputum culture
Chest X-rays
CT chest
Spirometry
Bronchoscopy
```
171
What would the CXR show of a patient with bronchiectasis?
Cystic shadows
Marked abdominal dilatation of the airways
Thickened bronchial walls
172
What is the treatment of bronchiectasis?
Airway clearance techniques and mucolytics
- chest physiotherapy
- flutter valve may aid sputum expectoration and mucus drainage
Antibiotics that are sensitive to the organism found in sputum culture
173
What antibiotics do you use to treat Streptococcus pneumoniae?
Amoxicillin
Cefuroxime
Cefotaxime
174
What antibiotics do you use to treat H. influenzae?
Co-amoxiclav
175
What antibiotics to you use to treat Staph. aureus?
Flucloxacillin
176
What antibiotic do you use to treat MRSA?
Vancomycin
177
What antibiotic do you use to treat Pseudomonas aeruginosa
oral ciprofloxacin
178
What is the pathology of cystic fibrosis?
Mutation in Cl- channel. Defect leads to a combination of defective chloride secretion and increased sodium absorption across airway epithelium. The changes in the composition of airway surface liquid predispose the lung to chronic pulmonary infections and bronchiectasis.
Increased thickness in mucosal secretions.
179
Aetiology of cystic fibrosis?
Mutations in the CF transmembrane conductance regulator (CFTR) gene on chromosome 7.
Autosomal recessive inheritance
180
What are the symptoms of cystic fibrosis in a neonate?
Failure to thrive
Meconium ileus (bowel obstruction caused by meconium in child’s intestine to be thicker and stickier than normal)
Rectal prolapse
181
Name 5 symptoms relating to the respiratory system of cystic fibrosis in children/young adults?
```
Cough
Wheeze
Recurrent infections
Bronchiectasis
Pneumothorax
Haemoptysis
Respiratory failure
Cor pulmonale
```
182
Name 3 GI symptoms of cystic fibrosis in children/young adults?
Pancreatic insufficiency
Distal intestinal obstruction syndrome
Gallstones
Cirrhosis
183
Name three signs of cystic fibrosis?
Cyanosis
Finger clubbing
Bilateral coarse crackles
184
What tests do you do to diagnose cystic fibrosis?
```
Neonatal heel prick test (blood spot immunoreactive trypsin test)
Sweat test!
Genetic testing
Bloods
Chest X-ray
Spirometry : obstructive
```
185
What is the sweat test? What result shows cystic fibrosis is a very likely diagnosis?
Sweat sodium and chloride. Measure the concentration.
| Conc. > 60mmol/L = CF is likely to be diagnosed
186
What is the management for respiratory symptoms in cystic fibrosis?
Physiotherapy (postural drainage, airway clearance techniques)
Antibiotics given for acute infection exacerbations and prophylactically
Mucolytics e.g rhDNase
Bronchodilators
187
What treatment may be needed in advanced lung disease?
Oxygen
Diuretics
Non-invasive ventilation
Lung or heart/lung transplantation
188
What immunomodulatory agent may be used to treat people with cystic fibrosis?
used for people with deteriorating lung function
| Azithromycin
189
What is pleural effusion?
Fluid in the pleural space
190
How are pleural effusions classified?
Divided by their protein concentration into transudates (<25g/L) and exudates (>35g/L)
191
What is a cause of transduate pleural effusion?
- Increased venous pressure (cardiac failure, constrictive pericarditis, fluid overload)
- Hypoproteinemia (cirrhosis, nephrotic syndrome, malabsorption)
192
What is a cause of exudate pleural effusion?
increased leakiness of pleural capillaries secondary to infection, inflammation or malignancy
Pneumonia, TB, pulmonary infection, rheumatoid arthritis
193
Name 2 symptoms of pleural effusion?
Asymptomatic
| Or dyspnoea, pleuritic chest pain
194
Name 5 signs of pleural effusion?
Decreased expansion on the affected side
Stony dull percussion note on the affected side
Diminished breath sounds on the affected side
May be bronchial breathing above the effusion where the lung is compressed
With large effusions there may be tracheal deviation away from the effusion
195
What three investigations would you do for a pleural effusion? Which is diagnostic?
Chest X-ray
Ultrasound
Diagnostic aspiration
196
What would a CXR show of a patient with pleural effusion?
large effusions are seen as water-dense shadows with concave upper borders.
Smaller ones blunt the costophrenic angles
197
what do you test the pleural fluid for in a pleural effusion?
Draw off 10-30mL of pleural fluid and send to the lab for clinical chemistry, bacteriology, cytology and immunology if indicated
198
What is the management of a pleural effusion? (4)
Management is of the underlying cause
Drainage (if effusion is symptomatic drain it repeatedly if needed)
Pleurodesis with talc may be helpful for recurrent effusions. It adheres your lung to your chest wall. It seals up the space between the outer lining of your lung and chest wall (pleural cavity) to prevent fluid or air from continually building up around your lungs
Surgery if persistent
199
What is the difference between a pneumothorax and a tension pneumothorax?
A pneumothorax is a collection of air within the pleural space in between the lung (visceral pleura) and the chest wall (parietal pleura) that can lead to partial or complete pulmonary collapse
Tension pneumothorax: life-threatening variant of pneumothorax characterized by progressively increasing pressures within the chest and cardiorespiratory compromise
200
What is the pathology of a pneumothorax?
Increased intrapleural pressure → alveolar collapse → decreased V/Q ratio and increased right-to-left shunting
201
What is the pathology of a tension pneumothorax?
In tension pneumothorax there is disrupted visceral pleura, parietal pleura or tracheobronchial tree → air enters the pleural space on inspiration but cannot exit → progressive accumulation of air in the pleural space and increasing pressure within the chest → collapse of ipsilateral lung and compression of contralateral lung, trachea, heart and SVC → imparied resp function and reduced venous return to the heart and reduced CO
202
What are the causes of pneumothorax?
Primary
- pontaneous due to rupture of a subpleural bullae (focal regions of emphysema with no discernible wall). Especially the case in young, thin, men
Secondary
- complication of an underlying disease
COPD, asthma, carcinoma, connective tissue disorder
203
name three symptoms of pneumothorax?
Can be asymptomatic (esp in fit young people with small pneumothoraces)
Sudden onset of dyspnoea and/or pleuritic chest pain
Ipsilateral chest pain
204
Name 3 signs of a pneumothorax?
Reduced expansion
Hyper resonance to percussion
Diminished breath sounds on the affected side
Patient will be very unwell
205
Name 5 signs of a tension pneumothorax?
- Respiratory distress
- Tachycardia
- Hypotension
- Distended neck veins
- Trachea deviated away from side of pneumothorax
- Hemodynamically unstable
- Cyanosis
- Restlessness
Reduced chest expansion on the ipsilateral side
206
What 2 investigations would you do for a pneumothorax?
Chest X-ray
| ABGs
207
what would you NOT do in a suspected tension pneumothorax
Chest X-ray
208
What type of chest x-ray would you order for a pneumothorax and what may it show?
Expiratory film
| Look for an area devoid of lung markings, peripheral to the edge of the collapsed lung
209
What treatment would you do for a primary pneumothorax?
If SOB + rim of air > 2cm on CXR
Aspiration
If unsuccessful then chest drain
210
What treatment would you do for a secondary pneumothorax?
SOB OR rim of air > 2cm on CXR
Chest drain
If smaller size then aspiration, if unsuccessful then chest drain
211
What immediate treatment would you do for a tension pneumothorax?
Insert large bore needle into the 2nd intercostal space in the midclavicular line on the side of the suspected pneumothorax
Then insert a chest drain
212
Define pulmonary hypertension
Increase in the mean pulmonary arterial pressure > 25 mmHg at rest
213
Name 5 causes of pulmonary hypertension?
- Idiopathic
- Heritable (autosomal dominant inheritance)
- Drug and toxin induced
- Associated with HIV infection, portal hypertension, congenital heart disease, certain connective tissue disorders
- PH due to lung diseases and/or hypoxia e.g COPD, interstitial lung disease
- After a PE
- PH due to left heart disease
214
Name 4 symptoms of pulmonary hypertension?
Progressive breathlessness
Weakness
Tiredness
Exertional dizziness and syncope may also develop
Oedema and ascites tend to occur late in the disease
215
Name three clinical signs of pulmonary hypertension
Right ventricular heave
Loud pulmonary second heart sound
Raised JVP
216
What investigations would you do for pulmonary hypertension?
```
Right heart catheterisation
Liver Function Tests
TFTs
CXR
Pulmonary function tests
Lung biopsy may be needed to exclude interstitial lung disease
Echocardiography
High resolution CT
MRI
```
217
What confirms a diagnosis of pulmonary hypertension
Right heart catheterisation is needed to confirm the diagnosis by directly measuring pulmonary pressure
218
What would be the treatment for pulmonary hypertension?
```
Treat underlying condition
Cardio Supportive therapy
Prostacyclin analogues
Endothelian-A receptor antagonists
Phosphodiesterase-5 inhibitors
```
219
What is the pathology of hypersensitivity pneumonitis / extrinsic allergic alveolitis?
1. Encounter the antigen (allergen) : there is no reaction. Prior sensitisation.
2. IgG antibodies develop against this antigen, produced by lymphocytes.
3. On secondary exposure, IgG antibodies will recognise the antigen and react forming antigen-antibody complexes.
4. These deposit in lungs and are not adequately cleared causing lung damage.
5. Repeated exposure leads to repeated symptoms which leads to repeated damage.
220
What type of hypersensitivity reaction is hypersensitivity pneumonitis?
Type III
221
Name some common causes of hypersensitivity pneumonitis?
Inhalation of allergens in sensitized individuals. Common causes:
Proteins in bird droppings (bird-fancier’s lung)
Farmer’s and mushroom worker’s lung
Malt worker’s lung
Bagassosis or sugar worker’s lung
222
Name 4 symptoms of acute hypersensitivity pneumonitis?
```
Fever
Rigors
Myalgia
Dry cough
Dyspnoea
```
223
What would you hear on ausculation of someone with acute hypersensitivity pneumonitis
Fine bibasal crackles (abnormal sounds from the base of the lungs)
224
What are 5 features of chronic hypersensitivity pneumonitis?
```
Finger clubbing
Increasing dyspnoea
Weight loss
Exertional dyspnoea
Type I respiratory failure
Cor pulmonale
```
225
What 2 investigations would you do in acute hypersensitivity pneumonitis?
What may they show?
Bloods
- neutrophilia
- raised ESR
- specific blood IgG levels may be useful to show that there has been previous exposure
Lung function tests
- reversible restrictive defect
226
What investigations would you do for chronic hypersensitivity pneumonitis?
```
Blood tests
Serum antibodies
CXR
CT chest
Bronchoalveolar lavage
```
227
What is useful in using bronchoalveolar lavage as an investigation for hypersensitivity pneumonitis?
detects increased lymphocytes (useful from distinguishing from other ILDs)
228
what is the treatment for hypersensitivity pneumonitis?
Identification and removal of antigen
Steroids for acute/subacute disease
229
What are occupational lung disorders?
They represent a wide-range of respiratory conditions caused by inhaling a harmful substance in the workplace
Inhalable particles, gases and vapours are generated from a wide range of industrial processes
230
Name 4 conditions which come under occupational lung disorders
Occupational asthma
Asbestosis
Coal worker's pneumoconiosis
Silicosis
231
What types of inhalable particles can cause occupational lung disorders?
And name an example for each when you could inhale them?
Dust - cutting wood
Fumes - colophony fume from soldering electronics or welding fume generated by heating metal components to join
Mists - metalworking fluid mist
Inhaled vapours and gases-paint spraying (isocyanate vapours)
232
What can cause occupational asthma? (3)
```
wood
flour
metal
working fluids
isocyanate paint
```
233
what are the symptoms of ocupational asthma?
```
These diseases develop after an asymptomatic or latent period
Shorter latency (months or a few years) commonly present whilst an individual worker is still exposed to a harmful material in the workplace
Longer latency (often decades) commonly present close to or after retirement
```
Deteriorating symptoms of work related asthma
Improves when away from work
234
What are the symptoms/signs of asbestosis?
progressive dyspnoea
clubbing
fine end inspiratory crackles
Pleural plaques
235
what are the symptoms of coal worker's pneumoconiosis?
asymptomatic
| co-existing chronic bronchitis is common
236
what are the clinical features of silicosis?
progressive dyspnoea
| CXR shows diffuse miliary or nodular pattern in upper and mid zones and egg shell calcification of hilar nodes
237
what tests would you do in suspected industrial dust diseases?
CXR
| Lung function tests
238
what is the treatment for occupational lung diseases?
Avoid exposure
Symptomatic treatment for asbestosis
Can usually claim for compensation
239
How can you prevent occupational lung diseases?
- Legal requirement under COSHH
- Risk assessment
- Prevent or minimise exposures to harmful substances
- Elimination (asbestos)
- Substitution (latex to nitrile gloves)
- Engineering controls (exhaust ventilation)
RPE (masks and respirators)
