Respiratory diagnosis+management Flashcards

Question

PEFR procedure overview

Answer 1

Wash hands Introduce self Check ID Explain and gain consent Insert mouthpiece and set dial to 0 Sit straight and take deep breath in Seal mouth around mouthpiece Full breath out as hard and fast as possible Look at reading on dial and note reading Teach this to patients to do at home; make them repeat this back to you and show you how they would do it. Repeat 3 times and take best of three readings

Answer 2

``` Shortness of breath Lung sounds Cough Haemoptysis Chest pain ```

Answer 3

Chronic respiratory condition associated with airway inflammation and hypersensitivity responsiveness Can present in many forms (heterogeneous) Hygiene hypothesis - immune response is not as developed due to increased hygiene with standard of living Migration to urban areas from rural tends to be associated with this too Symptoms: can resolve spontaneously or in response to medication, may sometimes be absent for weeks or months at a time Cough Wheeze Tight chest SoB Signs: Variable expiratory airflow limitation can vary over time and in intensity

Answer 4

``` Exercise Allergen or irritant exposure e.g. hayfever or animal fur Changes in weather Night time or early morning Viral infection exposure Strong emotion (children) ```

Answer 5

Personal or family history of atopic disease (asthma, eczema, allergic rhinitis or allergic conjunctivitis) More common in boys before puberty and girls post puberty Respiratory infections in infancy - early antibiotics exposure Passive or prenatal smoke Premature birth and associated low birth weight Obesity Social deprivation Exposure to inhaled particles - occupation is important!

Answer 6

``` varying evidence not conclusive Vaginal birth (not C section) Increasing sibship - exposure to allergens etc Farming environment - animal exposure Breastfeeding ```

Answer 7

Episodic symptoms Diurnal (worse at night or early morning) Triggered or exacerbated by exercise, viral infection and exposure to cold air or allergens) In children; may be triggered by emotion or laughter In adults; triggered by non-steroidal anti-inflammatory drugs and beta blockers Onset is typically under 35 years old

Answer 8

Spirometry on anyone above age 5; FEV1/FVC less than 70% shows airflow limitation. Can be normal for asymptomatic pts. Results can be impaired by inhaled corticosteroids Bronchodilator reversibility (BDR): anyone over age 17 (but can be considered in 5-16) due to need to follow instructions well. Improvement of FEV1 of 12% or more together with an increase in volume of at least 200mL in response to beta-2 agonists or corticosteroids is regarded as +ve result Variable peak expiratory flow: compare predictive with actual fo height, age and gender. 20% variability after monitoring at least twice daily for 2-4weeks FeNO test (fractional exhaled nitric oxide); used to confirm eosinophilic airway inflammation in ages 17 and above (consider in ages 5-16). Result of above 40 parts per billion is considered positive

Answer 9

``` -Bronchiectasis •Chronic obstructive pulmonary disease (COPD) •Ciliary dyskinesia •Cystic fibrosis •Dysfunctional breathing •Foreign body aspiration •Gastro-oesophageal reflux •Heart failure •Interstitial lung disease (asbestosis, pneumoconiosis, fibrosing alveolitis, sarcoidosis) •Lung cancer •Pertussis •Pulmonary embolism (PE) •Tuberculosis •Upper airway cough syndrome •Vocal cord dysfunction ```

Answer 10

Step 1: •Beta2-agonist inhaler – short term relief for those with very mild, intermittent asthma. Salbutamol. Step 2: •ICS (fluticasone propionate; 16+ 100-500mcg 2xdaily max per dose 1mg, beclometasone diproprionate; 12+ 200-400mcg 2xdaily ). Prompts for starting inhaled corticosteroids: An exacerbation in the previous two years. Use of a beta2-agonist inhaler >3x/week. Symptomatic of asthma >3x/week. Waking due to asthma >1x/week. Step 3: •a leukotriene receptor antagonist (LTRA) before treatment + a long-acting beta2 agonist (LABA). ** LABA must be used with ICS <800ug/day. +/- sustained release (SR) theophylline. Or MART regimen. Step 4: •ICS - < 2g/day + LTRA + SR theophylline or beta2-agonist tablet. Step 5: •Regular use of oral steroids + ICS

Answer 11

``` Step 1 Low paediatric dose ICS: fluticasone propionate; 5-15year 50-100mcg 2xdaily max per dose 200mcg; beclometasone diproprionate; 5-11 years 100-200mcg 2xdaily; 12+ 200-400mcg 2xdaily OR LTRA such as montelukast for 6months-5years 4mg once in evening; review in 4-8 weeks Step 2 paediatric dose ICS + inhaled LABA (salmeterol 5+ years; 50mcg 2xdaily; in 12+ can increase up to 100mcg 2xdaliy) or LTRA for children (montelukast; 5-14 years; 5mg once in evening) In under 5 years add LTRA Step 3 Consider increasing ICS dose 5+ years adding LTRA/LABA If no response consider stopping LABA Step 5 Specialist therapies referral ```

Answer 12

review 2 weeks after starting treatments and 2 weeks post every change after safety net always to come back if breathing gets worse or changes at all ensure you teach the correct inhaler method to all patients

Answer 13

Blue inhaler - short acting beta 2 agonists (salbutamol) for relief of symptoms taken as and when Brown inhaler - inhaled corticosteroids ( fluticasone, budesonide and beclometasone) taken morning and night as preventatives Pink/purple - MART; maintenance and relieving therapy regiment (symbicort, fostair, duoresp spiromax, fobumix easyhaler) is combination of ICS and fast acting LABA used for both daily prevention and symptomatic relief (usually used in moderate to severe cases based on patient preference or if other drugs not working etc.)

Answer 14

Bronchodilators: Via beta2- agonist receptors •Short-acting beta2-agonists (SABA): salbutamol and terbutaline. •Long-acting beta2-agonists (LABA): formoterol, salmeterol (twice daily) and (once daily) indacaterol, olodaterol and vilanterol. Leukotriene receptor antagonists (LTRAs): Montelukast Steroids: •Inhaled corticosteroids (ICS): fluticasone, budesonide, and beclometasone. •Oral corticosteroids: Prednisolone – risk of DM, osteoporosis, hyperlipidaemia.

Answer 15

Add short-acting beta 2 agonist inhaler (e.g. salbutamol) as required for infrequent wheezy episodes. Add a regular low dose inhaled corticosteroid. Add an oral leukotriene receptor antagonist (i.e. montelukast). Add LABA inhaler (e.g. salmeterol). Continue the LABA only if the patient has a good response. Consider changing to a maintenance and reliever therapy (MART) regime. Increase the inhaled corticosteroid to a “moderate dose”. Consider increasing the inhaled corticosteroid dose to “high dose” or oral theophylline or an inhaled LAMA (e.g. tiotropium). Refer to a specialist. Additional management: Individual asthma self management plan Yearly flu jab Yearly asthma review Advice exercise and avoid smoking

Answer 16

Individual asthma self management plan Yearly flu jab Yearly asthma review Advice exercise and avoid smoking

Answer 17

Death Respiratory complications: irreversible airway changes, pneumonia, pulmonary collapse (atelectasis caused by mucus plugging of airways), respiratory failure, pneumothorax and status asthmaticus (repeated asthma attacks without respite, or non-response to appropriate treatment). Imparied quality of life from suboptimal control of asthma including fatigue and underperformance at work/school etc.

Answer 18

Onset of severe symptoms can be life threatening Refer the same day to the hospital for review by the respiratory team. Or send via A+E Symptoms: Exhaustion (inability to complete sentences) Cyanosis Use of accessory muscles at rest Reduced PEFR: moderate (PEFR more than 50-75% predicted, at least 50% in children and normal speech with no features of acute asthma); acute severe (PEFR 33-50% predicted, less than 50% in children, or RR of at least 25/min in people over age 12, over 30/min in ages 5-12 and 40/min between 2-5 years. Pulse rate at least 110/min over 12 years, 125 between 5-12 years and 140/min between 2-5 years. Inability to complete sentences in one breath or accessory muscle use or inability to feed (infants) with O2 sats of at least 92% Life threatening (PEFR less than 33% predicted or O2 sats less than 92%, altered consciousness, exhaustion, cardiac arrhythmia, hypotension, cyanosis or poor respiratory effort or silent chestor confusion In children: monitor for signs of agitation and behavioural changes as may indicate hypoxia

Answer 19

O SHIT! - Oxygen, Salbutamol, Hydrocortisone, Ipratropium, Theophylline! Oxygen SABA via nebuliser 5mg to all over age 5 years and 2.5mg to children ages 2-5 years. Ideally oxygen driven usually 6L/min SABA via metered dose inhaled with large volume spacer - 4 puffs initially followed by 2 puffs every 2 mins for up to 10 puffs. Repeat every 10-20 minutes. For children give every 30-60 seconds up to 10 puffs Excessive salbutamol can cause tachycardia and fine tremors Review all pts 48 hours after admission or conservative management Also consider: Oral prednisolone 40-50 mg for adults (once a day for 5days ) – also available as soluble tablet ( 5 mg) Intramuscular (IM) methylprednisolone 160 mg Hydrocortisone (IV) 100 mg in people aged over 5 years

Answer 20

Persistent respiratory symptoms (SoB, cough and sputum) and airflow obstruction Aetiology: Chronic bronchitis - cough and sputum production for 2-3 years Emphysema - loss of parenchymal lung texture Chronic obstructive airway disease Presentation: Tend to be over 35 years Breathlessness; typically persistent and progressively worse over time Chronic cough Sputum production regularly Wheeze Frequent LRTI

Answer 21

Smoking - including marijuana and passive smoke Occupational exposure to dusts, fumes, chemicals Air pollution Genetics - alpha1 antitrypsin deficiency (typically present in younger pts under 45 years) Lung development - in utero factors affecting lung development such as maternal smoking and preterm birth. In childhood severe RTI and passive smoking can affect lung development and increase risk of COPD developing

Answer 22

``` CXR: cancers, bronchiectasis, TB, heart failure FBC: anaemia, polycythaemia (increase in RBC) Spirometry Reversibility test: not routine Sputum culture Serial home PFM ECG Echo Serum natriuretic peptides CT thorax: fibrosis or bronchiectasis Serum alpha1 antitrypsin ```

Answer 23

* Asthma — may co-exist and can be difficult to distinguish clinically. * Consider asthma if the person has a family history, other atopic disease, or nocturnal or variable symptoms, is a non-smoker, or experienced onset of symptoms at younger than 35 years of age. * Bronchiectasis * Heart failure * Lung cancer * Interstitial lung disease (asbestosis, pneumoconiosis, fibrosing alveolitis, or sarcoidosis) * Anaemia * Tuberculosis (TB) * Cystic fibrosis * Upper airway obstruction (tumour)

Answer 24

Spirometry - post bronchodilator FEV1/FVC less than 0.75 confirms persistent obstruction Calculate FEV1/predicted FEV1 score for severity (more than 80% is mild, 50-80% moderate, 30-50% severe, less than 30% is very severe); if at the higher end of scale then can classify mild-moderate etc. Consider other causes in older people without typical COPD symptoms Consider COPD in younger people with symptoms of COPD even with ratio above 0.7

Answer 25

grade 0-Not troubled by breathlessness except during strenuous exercise grade 1-SoB when hurrying or walking up slight hill grade 2-Walks slower than contemporaries on level due to SoB or has to stop for breath when walking at own pace grade 3-Stops for breath after walking roughly 100m or after few mins on same level grade 4-Too breathless to leave house or breathless when dressing/undressing

Answer 26

Inhalers Oral medicines Oxygen therapy Lifestyle modifications

Answer 27

SABA or SAMA to reduce breathlessness and improve exercise capacity With asthmatic features: LABA plus ICS; Without asthmatic features: combined LABA and LAMA Triple inhaled therapy (LAMA + LABA + ICS) to people with COPD with asthmatic features suggesting steroid responsiveness who remain breathless or have exacerbations despite taking LABA+ICS = trimbow In both groups only consider combination inhalers if non-pharmacological options, vaccinations and smoking cessation have been addressed

Answer 28

Theophylline - relaxes smooth muscle and relieves bronchial spasm Mucolytic therapy - chronic productive cough; an adjuntive therapy for excessive viscous mucus - carbocisteine (mucolytic that helps you cough up phlegm. It works by making your phlegm less thick and sticky) Prophylactic antibiotics - discussion with respiratory specialist

Answer 29

For the management of hypoxic patients – not breathlessness Usually with severe COPD •MRC score: 4-5 •FEV1: Stage 3 (severe) 30–49% of predicted value – 4 (very severe) less than 30% of predicted value or FEV1 less than 50% with respiratory failure. Under the direction of a respiratory specialist. Flammable - need to be made aware Can't smoke near!!

Answer 30

Smoking cessation - offer multiple times Pulmonary rehabilitation - individually tailored, MD care program for people with COPD which aims to optimize physical and psychological condition through exercise training, education and nutritional, psychological and behavioural interventions Vaccinations - influenza and pneumococcal as are high risk for LRTI TRAVEL advice: MCR score of 1-2 and stable oxygen levels do not need to inform DVLA Unstable oxygen sats air exceeding 4L/min at sea level cannot travel on planes.

Answer 31

•Exacerbations are acute episodes of worsening COPD symptoms (such as increased breathlessness, cough and sputum) which are beyond normal day-to-day variations.

Answer 32

Symptoms: •Worsening breathlessness. •Increased sputum volume and purulence. •Cough. •Wheeze. •Fever without an obvious source. •Upper respiratory tract infection in the past 5 days. •Increased respiratory rate or heart rate >20% above baseline. In severe cases •Pursed-lip breathing and/or use of accessory muscles at rest. •New-onset cyanosis or peripheral oedema. •Acute confusion or drowsiness. •Marked reduction in activities of daily living.

Answer 33

Be prepared to refer the same day ! •If managing in clinic: •Maximise dose of short-acting bronchodilator inhalers. •Prednisolone 30 mg PO once daily for 5/7. SE – osteoporosis. •Antibiotics: Amoxicillin 500 mg TDS 5/7; Doxycycline 200 mg on first day, then 100mg OD for 5/7; Clarithromycin 500 mg BD for 5/7. •Send a sputum sample for MCS if no resolution. •Follow up within a week or sooner if needed, then in 6/52. •Consider CXR, pulmonary rehab/respiratory referral, as well as a rescue pack (antibiotics + steroid at home).

Answer 34

``` Progressive pulmonary HTN; development of RV hypertrophy leading to cor pulmonale (RHF secondary to lung disease) Pneumothorax Respiratory failure Arrhythmias including AF Infection Secondary polycythaemia (too many RBCs) Depression ```

Answer 35

OSAHS: The coexistence of excessive daytime sleepiness with irregular breathing at night Irregular breathing from upper airway collapse during sleep Collapse can be partial (hypopnoea) or full (aponea) Leads to transient arousal from deep sleep to wakefulness; allowing restoration of normal airway muscle tone Cycle repeats once in deep sleep again Broken sleep pattern results in reduced sleep quality, excessive daytime sleepiness and reduced concentration and alertness

Answer 36

Excessive daytime sleepiness and snoring and/or impaired concentration Witnessed apneas or choking noises while sleeping Feel unrefreshed when waking Mood swings, personality changes or depression Nocturia - weeing lots at night time Rarely, nocturnal sweating, reduced libido and gastro-oesophageal reflux disease (GORD)

Answer 37

Snoring and pauses in breathing often followed by a gasp or a snort Restlessness and sudden arousals from sleep, laboured breathing, unusual sleep posture (head bent back) and bedwetting Daytime symptoms: changes in behaviour, irritability, poor concentration, decreased performance at school, tiredness and sleepiness, failure to gain weight or grow and mouth breathing

Answer 38

Unilateral nasal bleeding and/or severe nasal obstruction Change in voice character and/or unexplained hoarseness Dysphagia Rapid onset symptoms without significant weight gain Any red flag symptoms need 2 week referral

Answer 39

``` •Male (2–3:1). •Middle aged/increasing age •Obesity. •Neck circumference greater than 43 cm. •Family history. •Smoking. •Alcohol intake before bed. •Sleeping supine. •Hypothyroidism. •Craniofacial abnormalities. •Acromegaly (abnormal growth due to excess growth hormone). OSAS in children is around 1–2%, and this may be increasing due to increasing obesity. The incidence in children with congenital conditions (for example Down's syndrome, neuromuscular disease, and craniofacial abnormalities) is higher. Adenotonsillar hypertrophy is also a risk factor. ```

Answer 40

``` Epworth sleepiness questionnaire. •Eight questions •Assessing likelihood of dozing off. •A score greater than 10 represents abnormal sleepiness •Range: •Mild (11–14) •Moderate (15–18) •Severe (more than 18) ```

Answer 41

•Referral to a sleep center for sleep studies to confirm diagnosis. •Polysomnography (PSG) measures sleep and breathing patterns simultaneously. Five or more episodes of apnoea/hypopnoea episodes per hour needed to confirm the diagnosis. •Scale of mild, moderate & severe. •Continuous Positive Airway Pressure (CPAP) – highly effective. •Intra oral mandibular advancement devices and weight loss may also be appropriate. Urgent refer: Severe OSAS, respiratory failure/CHF, people sleepy whilst driving or operating machinery at work. Advise the person not to drive until they have been assessed by a specialist. Routine refer: Symptomatic patients with an Epworth sleepiness questionnaire score >10. Refer children to paediatric ENT specialist if they have features of OSAS/persistent snoring as well as adenotonsillar hypertrophy. Children management - mouth breathing, nasal obstructions, large tonsils, can resolve apnea, advise weight loss if necessary

Answer 42

tachypnoea of 20 breaths per minute or greater (in 70% of people with PE), crackles (51%), tachycardia (30%), signs of DVT (11%). Hypoxia, pyrexia, elevated JVP, widely split second heart sound, tricuspid regurgitation murmur, pleural rub, hypotension and cardiogenic shock may also occur. symptoms: acute-onset breathlessness (in 73% of people with PE), pleuritic pain (66%), cough (37%), haemoptysis (13%). Severe cases may lead to dizziness or syncope.

Answer 43

immobilization, surgery, cancer, acute medical illness, obesity, prolonged travel, symptoms or signs of deep vein thrombosis (DVT), previous DVT, thrombophilia, or age over 60 years.

Answer 44

signs: reduced chest wall movements on the affected side, stony dull percussion note, diminished or absent breath sounds, decreased tactile vocal fremitus/vocal resonance and bronchial breathing just above the effusion. There may be signs of the underlying condition. symptoms: progressive breathlessness, pleuritic pain and symptoms of the underlying condition

Answer 45

signs chest examination is often normal but there may be unilateral wheeze, decreased breath sounds, or signs of pleural effusion. Other signs include finger clubbing, and supraclavicular or cervical lymphadenopathy. symptoms cough, shortness of breath, haemoptysis, chest pain, weight loss, appetite loss, fatigue, hoarseness, persistent chest infections, symptoms relating to bone or brain metastases.

Answer 46

smoking | asbestos exposure

Answer 47

heart, liver, or renal failure, pneumonia, pulmonary embolism, cancer (including mesothelioma), tuberculosis, pleural infection (empyema), and autoimmune disease.

Answer 48

Acute: accumulation of fluid in lung parenchyma leading to decreased gaseous exchange Pathophysiology: as heart begins to fail; compensatory mechanisms maintain BP and CO increased sympathetic tone increases SVR and stimulates renin release RAAS increases salt and fluid retention, initially increasing preload and EDV, but overtime leads to cardiac dilation and reduced contractility (and CO) leading to congestion of pulmonary and systemic veins with associated tissue oedema (pitting/ankle and sacral oedema) alveolar oedema increases causing dyspnoea venous return increases when patient lies flat causing orthopnoea and paroxysmal dyspnoea (PND)

Answer 49

``` cardiac: ACS arrhythmia valvular heart disease HTN cardiomyopathy cardiac tamponade Non-cardiac: non-compliance with medication negatively inotropic medication fluid overload high output cardiac failure: anaemia, thyrotoxicosis, sepsis ARDS acute respiratory distress syndrome renal artery stenosis RAS Chest trauma Infections e.g. sepsis ```

Answer 50

fatigue worsening dyspnea progressing from exercise tolerance of dyspnoea on exertion to at rest Orthopnoea; shortness of breath worsens when lying down PND cough producing pink, frothy sputum ankle swelling (pitting oedema)

Answer 51

``` ABG FBC U+Es Mg Ca TFTs 12 lead ECG: shows ischaemia, infarction, LVH, arrhythmia CXR: ABCDE signs (alveolar oedema, bats wings and kerley B lines, cardiomegaly, diversion to upper lobes, effusions; blunting of costophrenic angles) echocardiogram if needed ```

Answer 52

Initial management: assess patient ABCDE sit upright and attach monitoring: BP, oximeter, 3 lead cardiac monitor maintain airway; suctions oxygen if needed; 15L non-rebreathing mask IV access and blood tests consider troponin if concerned about cardiac event Furosemide 40mg IV (diuretic) Morphine 2.5-10mg IV (dilate venous system; decrease preload and improve breathing) GTN 1mg/ml at 2ml/hour or give sublingually if fails IV start CPAP if severe oedema (continuous positive airway pressure) Further management: continuing CPAP or inotropic support needs referral to HDU for continuous BP, ABG, CVP, oxygen, cardiac monitoring and urine output monitoring

Answer 53

``` URTI LRTI Sinusitis - nasal passages Cold Pharyngitis (sore throat) Laryngitis (voice change) Influenza Bronchitis (acute/chronic) Pneumoniae ```

Answer 54

Cough lasting 10 days to 3 weeks (acute infection) Chronic is inflammation and cough lasting longer than this; usually due to irritants such as smoking Cause: Viruses cause 85-95% of acute bronchitis in adults Can be same virus as common cold etc. Rare cases can develop bacterial bronchitis after viral infection of bronchitis Risk factors: Smoking Immunocompromised Reflux Exposure to irritants Age 50 and over

Answer 55

Acute respiratory illness Often self-limiting although acutely debilitating In vulnerable individuals can be fatal Symptoms usually last 3-5 days but cough and tiredness may last 1-2 weeks Cause: Caused by influenza A or B viruses (also C)

Answer 56

Upper and/or lower respiratory tract involvement Indications of systemic illness e.g. fever Headache Myalgia - muscle pain involving tendons, ligaments and fasica Weakness

Answer 57

Young children under 5, especially under 6 months Adults above age 65 Residents of nursing homes and other long-term care facilities Pregnant women and women up to two weeks after giving birth People with weakened immune systems People who are very obese, with a body mass index (BMI) of 40 or higher Native Americans People who have chronic illnesses, such as asthma, heart disease, kidney disease, liver disease and diabetes, neurological disease, immunosuppression,pregnancy etc.

Answer 58

Droplet coughing and sneezing Direct nasal or eye contact with hands carrying virus Infectiveness continues for 5 days from onset, although children can remain infectious for 2 weeks and severely immunocompromised can shed virus for weeks

Answer 59

``` usually not needed only for formal stats etc. Clinical Nasopharyngeal swabs/aspirates PCR Antigen testing ```

Answer 60

Advice: Do not prescribe antiviral drugs for otherwise healthy people Reassure person worst symptoms of uncomplicated influenza resolve after 1 weeks, although cough, headache, insomnia, loss of appetite etc. may persist for longer than 2 weeks Treatments: Oseltamivir (tammiflu) and zanamivir reduce replication of influenza A and B They are most effective if started within a few hours of the onset of symptoms. In otherwise healthy individuals they reduce the duration of symptoms by about 1-1.5 days. When influenza is circulating in the community, either oseltamivir or zanamivir is recommended for the treatment of influenza in at-risk patients who can start treatment within 48 hours (within 36 hours for zanamivir in children) of the onset of symptoms

Answer 61

Acute bronchitis (20% cases with increased risk in elderly and chronic disease sufferers) Secondary bacterial pneumonia (especially staph. aureus) Primary viral pneumonia Exacerbations of asthma and COPD Empyema Pulmonary aspergillosis Sinusitis

Answer 62

Age: especially infants, young children and the elderly. Lifestyle: smoking, alcohol. Preceding viral infections - eg, influenza predisposing to Streptococcus pneumoniae infection. Respiratory: asthma, chronic obstructive pulmonary disease (COPD), malignancy, bronchiectasis, cystic fibrosis. Immunosuppression, AIDS, cytotoxic therapy - increased risk of infection with Staphylococcus spp., tuberculosis, Gram- negative bacilli and P. jirovecii. Intravenous drug abuse, often associated with Staphylococcus aureus infection. Hospitalisation - often involving Gram-negative organisms. Aspiration pneumonia: patients with impaired consciousness, neurological disease such as cerebrovascular or Parkinson's disease, or patients with oesophageal obstruction are at risk of aspiration pneumonia which usually affects the right lung and is caused by anaerobes from the oropharynx. Underlying predisposing disease: diabetes mellitus, cardiovascular disease.

Answer 63

Defined as the presence of symptoms and signs consistent with acute lower respiratory tract infection in association with new radiographic shadowing for which there is no alternative explanation. The most likely (TYPICAL) organisms are: S. pneumoniae, S. aureus, Mycoplasma pneumoniae, Haemophilus influenzae, Chlamydophila pneumoniae and respiratory viruses[3]. Mixed pathogens occur up to 25% of the time. 0.5-1% of people develop community-acquired pneumonia (CAP) in the UK every year. The mortality rate is between 5% and 14%.

Answer 64

defined as onset of infection in a patient admitted more than 48 hours Occurs mostly in pts severely debilitated, immunocompromised or mechanically ventilated Infection occurring less than five days after admission is usually strep. Pneumonia Infection occuring after this time usually caused by H. influenzae, MRSA, pseudomonas aeruginosa and other non-pseudomonal gram -ve bacteria Often caused by multiple organisms

Answer 65

Pleural effusion Emphysema Pneomothorax Lung abscess (due to S. pneumoniae classically seen in pts with klebsiella or staphycoccal pneumonia Pyopneumothorax e.g. following rupture of Staphylococcal lung abscess in pleural cavity AKI - acute kidney injury; stage 1; creatinine baseline 1.5x higher; check pts previous creatinine values if possible but if not; assume normal kidney function range DVT - less mobile while ill Septicaemia Pericarditis Endocarditis Osteomyelitis Septic arthritis Cerebral abscess Meningitis (particularly pneumococcal pneumonia)

Answer 66

Mortality from CAP is less than 1% in those well enough to be managed within community Mortality in those admitted to hospital is 5-10% in those not requiring ICU admission As high as 25% in intubated pts Nearly 50% in ICU pts Legionella has most severe course and may cause significant morbidity if not treated early

Answer 67

Symptoms: cough, purulent sputum which may be blood- stained or rust-coloured, breathlessness, fever, malaise. Signs: tachypnoea, bronchial breathing, crepitations, pleural rub, dullness with percussion. Diagnosis is unlikely if there are no focal chest signs and heart rate, respiratory rate and temperature are normal. Would instead call this a LRTI as pneumonia usually has these features The elderly may present with mainly systemic complaints of malaise, fatigue, anorexia and myalgia. Young children may present with nonspecific symptoms or abdominal pain.

Answer 68

scoring system to determine severity of pneumonia and if it can be managed within the community or needs hospital admission. One point for each factors Should also be admitted with delirium (acute confusion) or hypoxia Confusion (AMTS above 8 or disorientated to person, place, time) Raised serum Urea over 7mmol/L (U+Es tests) Raised Respiratory rate over 30bpm Low Blood pressure Over 65 years of age Risk of death: 0-1: low risk (less than 3% mortality risk) 2: intermediate risk (3-15%) 3-5: High risk (more than 15%)

Answer 69

CURB65 score 0-1: COVID UPDATE: Doxycycline 1st line 200mg day one then 100mg once daily for four days Offer 5 day course of amoxicillin 500mg 3xdaily; 125mg 1-11months old; 250mg 1-4years; 500mg 4+years all 3xdaily Reserve clarithromycin (500mg 2xdaily for 5 days; weight based in under 12 years; 250-500mg 2xdaily for 12-18 years), erythromycin (pregnancy; 500mg 4x daily for 5 days; 8-17 years 150-500mg 4xdaily) or doxycycline (for pts allergic to penicillin or if atypical pathogen suspected) Stop ABs after 5 days unless microbiology results suggest longer course or pt is not clinically stable If atypical add clarithromycin to amoxicillin MOD severity CAP as above pending microbiology results

Answer 70

Co-amoxiclav (broad spectrum; 500/125mg 3xdaily orally or 1.2g 3xdaily IV for 5 days; 1-11months 0.5ml/kg of 125/31 3x daily; 1-5 years 10ml of 125/31 3xdaily; 6-11 years 10ml of 250/62 3xdaily; 12-17 500/125mg 3xdaily orally) with clarithromycin (atypical forms; 500mg 2xdaily orally or IV for 5 days; 1month-11 years weight based; 12-17 years 250-500mg 2xdaily 5 days orally) or erythromycin (pregnancy; 500mg 4xdaily orally for 5 days; 8-17 years 250-500mg 4xdaily orally 5 days) should be offered Levofloxacin orally or IV (500mg 2xdaily) for pts allergic to penicillin Follow local guidelines

Answer 71

Oxygen: for hypoxia IV fluids: for pts with hypotension, tachycardic, signs of sepsis etc. 0.9% saline/Hartmann's 250mL, 500mL , 1L bolus then 1L over 4/6 hrs. Use with caution in heart failure pts Nebulised saline might help expectoration Failure to improve within 72hrs should seek medical attention Community pts should be advised to return is symptoms persist for more than 3 weeks

Answer 72

Atypical organisms might be implicated in approx. 20% of CAP: Mycoplasma pneumoniae - spread by person-person contact most commonly in closed populations e.g. schools and offices Chlamydia pneumoniae - spread by person-person contact most commonly in closed populations e.g. schools and offices Legionella pneumophila - found most commonly in freshwater and man made systems Wont respond to broad spectrum ABs like amoxicillin, but often give both ABs before lab results arrive to cover for both possibilities

Answer 73

Vague and slow onset history over few days or weeks of fever, upset, headache, dry cough with tracheitic +/- pleuritic pain, myalgia, malaise and sore throat Persistence and progression helps determine this diagnosis In otherwise healthy individuals, it usually resolves spontaneously over a few weeks.

Answer 74

SYMPTOMS: The hacking, dry cough can be very persistent. COMPLICATIONS: Extra-respiratory features include rashes such as erythema multiforme, erythema nodosum and urticaria; neurological complications like Guillain- Barré syndrome, transverse myelitis, cerebellar ataxia and aseptic meningitis; haematological complications such as cold agglutinin disease and haemolytic anaemia; joint symptoms like arthralgia and arthritis; cardiac complications such as pericarditis and myocarditis; rarely, may cause pancreatitis.

Answer 75

Gradual onset, which may show improvement before worsening again; incubation period is 3-4 weeks. Where it causes significant problems, this may be due to secondary infection or co-existing illness - eg, diabetes.

Answer 76

Initial nonspecific upper respiratory tract infection symptoms lead on to bronchitic or pneumonic features. Most of those infected remain quite well or are asymptomatic. Cough with scanty sputum is a prominent feature. Hoarseness is a common feature. Headache affects the majority of symptomatic sufferers. Fever is relatively unusual. Symptoms may drag on for weeks or months, despite a course of appropriate antibiotics.

Answer 77

This tends to be the most severe of the pneumonias due to atypical pathogens Focal outbreaks centred around poorly maintained air- conditioning or humidification systems (although this is often noted retrospectively by public health physicians). 2-10 days' incubation period.

Answer 78

Initial mild headache and myalgia leading to high fever, chills and repeated rigors; non-chest symptoms often predominate early on. Cough is nearly always present, initially unproductive but may lead to expectoration later. Dyspnoea, pleuritic pain and haemoptysis (coughing up blood) are not uncommon. Gastrointestinal upset, such as diarrhoea, nausea and vomiting or loss of appetite/anorexia, may occur.

Answer 79

There may be neurological complications such as confusion, disorientation and focal neurological deficit. Arthralgia and myalgia are often reported. Severe complications include pancreatitis, peritonitis, pericarditis, myocarditis, endocarditis and glomerulonephritis.

Answer 80

Legionella pneumoniae - water cooled air condition Strep pneumonia - most likely in adults with rusty sputum Staphylococcus areus - most likely following influenza and IV drug users Mycoplasma pneumonia - atypical flu like sympts, dry cough, people living close together, rash (erythema multiforme)

Answer 81

Routine bloods; FBC, U+Es, LFT, CRP Blood cultures - determine strain Pneumococcal and legionella urinary antigen tests CXR with 6 week post recovery repeat as follow up Sputum culture Pulse oximetry or ABC Aspiration of pleural fluid

Answer 82

``` High flow oxygen Take blood cultures Give IV antibiotics Give fluid challenge Measure lactate Measure urine output ```

Answer 83

Results from inhalation of stomach contents or secretions of oropharynx, leading to LRTI. In many healthy adults very small quantities of aspiration occur frequency but normal defences (cough) remove material with no ill effects Usual site for aspiration pneumonia is apical and posterior segments of lower lobe of right lung If pt is supine then may aso enter posterior segment of upper lobes

Answer 84

``` non-specific symptoms e.g. fever, heachache, nausea, vomiting, anorexia, myalgia, weight loss Cough SoB Pleuritic chest pain Purulent sputum Signs may include: Tachycardia Tachyponea Decreased breath sounds Dullness to percussion over areas of consolidation Pleural friction rub ```

Answer 85

Impaired consciousness; drug, alcohol misuse, general anaesthesia, seizures, sedation, acute stroke, CNS lesions, head injury Poor mobility Increasing age Nil-by-mouth COPD Male gender Increasing number of medications Swallowing disorders: oesophageal stricture, dysphagia, stroke, bulbar pasly Other: tracheo-oesophageal fistula, ventilator associated pneumonia, periodontal disease, GORD Complications: Severe infection may lead to hypoxia and septic shock

Answer 86

Pathogens of community-acquired aspiration pneumonia are often the normal flora of the oropharynx, including: Streptococcus pneumoniae. Staphylococcus aureus. Haemophilus influenzae. Anaerobes - eg, Peptostreptococcus, Fusobacterium and Prevotella spp. 'Streptococcus milleri' group. Klebsiella pneumoniae - increasingly seen in those with a history of alcohol misuse.

Answer 87

Pathogens of nosocomial (occurring within hospital) aspiration pneumonia include: Oral anaerobes - as above. Gram-positive cocci - eg, Peptostreptococcus spp., Peptococcus spp. Gram-negative bacilli - eg, enterobacteria (K.pneumoniae, Escherichia coli, Enterobacter spp.), Pseudomonas aeruginosa. Methicillin-resistant S. aureus (MRSA). Treated the same as pneumonia; but ensure there is no airway compromise first (suction, ABCDE etc.)

Answer 88

silent chest, oxygen saturation below 92%, bradycardia poor respiratory effort

Answer 89

ABG FBC - raised WCC and CRP indicate infection causing exacerbation U+Es - dehydration Blood Cultures for suspected infections CXR ECG if indicated - other comorbidities present Sputum sampling for culture if productive cough

Answer 90

Assess and reassuring PEFR is >75% of predicted upon discharge Patient education and training to use PEF meter and other medications at home for more information on asthma Advice to keeping diary recorded PEFR measurements To see their GP within 2 days To complete the oral steroid course , and /or oral antibiotics if prescribed .

Answer 91

``` Increased breathing rate Colour changes - cyanosis Grunting (mainly in children) Retractions (children) Use of accessory muscles Sweating Wheezing Body position - leaning forward etc. ```

Answer 92

Acute breathlessness: onset develops over minutes Subacute breathlessness: onset over hours or days Chronic breathlessness: onset develops over weeks or months

Answer 93

Heart rate more than 130 beats per minute Respiratory rate of more than 30 breaths per minute Altered level of consciousness Systolic blood pressure less than 90 mmHg or diastolic blood pressure less than 60 mmHg Oxygen saturation less than 92%, or central cyanosis PEFR less than 33% of predicted ( refer to asthma severity criteria )

Answer 94

Pulmonary embolism blockage in one of the pulmonary arteries in your lungs. In most cases, pulmonary embolism is caused by blood clots that travel to the lungs from deep veins in the legs or, rarely, from veins in other parts of the body (deep vein thrombosis). Venous thromboembolism VTE: term used to describe both PE and DVT

Answer 95

Family history of DVT, clotting conditions or PE Heart disease Cancer: especially brain, ovary, pancreas, colon, stomach, lung and kidney cancers, and cancer metastases — can increase the risk of blood clots, and chemotherapy further increases the risk. Women with a personal or family history of breast cancer who are taking tamoxifen or raloxifene also are at higher risk of blood clots. Surgery Clotting disorders: APS COVID-19 Prolonged immobility Smoking obesity/overweight Supplemental oestrogen: birth control pills Pregnancy

Answer 96

Provoked PE: associated with acquired risk factors, either transient or persistent. These risk factors can be removed therefore reducing risk of recurrence. Unprovoked PE: aka idiopathic PE; associated with no apparent clinical risk factors, or risk factors that are persistent and not easily correctable (such as active cancer or thrombophilia). Because these factors cannot be removed, they are at increased risk of recurrence.

Answer 97

ECG: most commonly see sinus tachycardia. “S1Q3T3” pattern of acute cor pulmonale is classic (McGinn-White Sign). A large S wave in lead I, a Q wave in lead III and an inverted T wave in lead III together indicate acute right heart strain. Two level PE wells score: 0-4 order DDIMER; if positive arrange immediate CTPA or offer interim therapeutic anticoagulation (apixaban or LMWH) try to choose drug that can be continued if PE confirmed If DDIMER is negative; stop anticoagulation and consider alternative diagnosis Above 4: PE is highly likely; arrange hospital admission for an immediate computed tomography pulmonary angiogram (CTPA) and, where necessary, carry out other tests ABG CXR Lower limb ultrasound - useful in pregnancy to avoid harmful irradiation Echocardiography - for hypotension (clinically massive PE) to assess RV function and thrombus

Answer 98

``` Anticoagulants Compression stockings Leg elevation Physical activity Pneumatic compression: thigh/calf-high cuffs that inflate to squeeze veins and improve blood flow in lower limbs ```

Answer 99

Arrange immediate admission for people with suspected PE if: They have signs of haemodynamic instability (including pallor, tachycardia, hypotension, shock, and collapse). They are pregnant or have given birth within the past 6 weeks. Pharmacological treatment options for confirmed pulmonary embolism (PE) include: Low molecular weight heparin (LMWH). Fondaparinux. Unfractionated heparin. Oral anticoagulant treatment (warfarin, apixaban, or rivaroxaban). LMWH followed by an oral anticoagulant (dabigatran or edoxaban). Thrombolytic therapy may be used to remove the embolic material from the pulmonary arteries by promoting lysis of blood clots. *Treatment choice and duration made by consultant decision, based on overall assessment of the patient and associated comorbidities. In some cases, mechanical or physical interventions may be considered; IVC filters - designed to trap fragmented thromboemboli from deep leg veins en route to pulmonary circulation (whilst preserving blood flow) can be put in on temporary or permanent basis

Answer 100

Adequate monitoring of specific anticoagulant treatments Ensure they’re provided with all relevant info on anticoagulants, PE, specific requirements of treatment they're on etc. For people with unprovoked PE; review medical history and baseline blood test results including FBC, renal and hepatic function, prothrombin time etc. Offer physical exam for people not known to have cancer If planned to stop anticoagulation; consider testing for APS and hereditary thrombophilia in people with first degree relative with DVT or PE

Answer 101

Increased effort to breathe Increased respiratory rate Dullness to percussion Tactile vocal fremitus - more vibrations from persons back on vocal tactile test due to sound travelling better in fluid Late inspiratory crackles Bronchial breath sounds Bronchophony Egophony CXR: bronchopneumonia showing patchy areas spread throughout of fluid. Lobar pneumonia showing fluid localised to single lobe/lobes Atypical pneumonia; concentrated in the perihilar region in reticular pattern (stripes of fluid around the hilum)

Answer 102

Bronchipneumonal throughout the lungs, bronchial and alveoli CXR: showing patchy areas spread throughout of fluid. Atypical interstitial in lung interstitium CXR showing fluid concentrated in the perihilar region in reticular pattern (stripes of fluid around the hilum) Lobar is consolidation of a whole lung lobe CXR showing fluid localised to single lobe/lobes

Answer 103

Viral pneumonia: mostly caused by influenza Fungal pneumonia: candida, aspergillus and mucor species tend to cause Mycobacteria: Mycoplasma pneumoniae Bacterial pneumonia: pneumococcal, staphylococcal, pseudomonas, legionella pneumophila, chlamydophila pneumoniae

Answer 104

Fluoroquinolones effective against 3 common infective organisms (ciprofloxacin, levofloxacin) Amoxicillin - COVID-19 guidelines suggest doxycycline first line treatment! clarithromycin/erythromycin for ATYPICAL STRAINS *With ABs - after 72 hrs there should be some kind of improvement in pts suggesting its working such as no tachycardia, BP restoring; if they are the same or worse; then may need other kind of ABs/treatment etc.*

Answer 105

serious fungal infection caused by pneumocystis jirovecii Most suffers have weakened immune systems from immunosuppressive conditions such as HIV/AIDS or medicines such as corticosteroids Less likely to contract due to availability of antiretroviral therapy (ART) Transmission is airborne from healthy carriers

Answer 106

``` fever, cough, difficulty breathing, chest pain, chills, fatigue ```

Answer 107

fungus can live in the lungs asymptomatically in 20% adults and is removed naturally after several months in healthy individuals 30-40% of people with this infection have HIV/AIDS People on corticosteroids chronic conditions such as; chronic lung diseases, cancer, inflammatory or autoimmune diseases (rheumatoid arthritis) or solid organ/stem cell transplant PREVENTERS: Given to individuals more likely to suffer from PCP infection trimethoprim/ sulfamethoxazole (TMP/SMX)

Answer 108

``` sputum/mucus sample Lung biopsy Blood test to detect beta-D-glucan TREATMENT: TMP/SMX given orally or via IV for 3 weeks Side effects: rash and fever ```

Answer 109

Caused by Mycobacterium tuberculosis in humans, (MTB, M.Tb) Chronic granulomatous disease. Can be inactive for decades similar to HIV etc. Can affect every organ of the body but only transmitted via the lungs (airborne): meaning that only lung and occasionally laryngitis TB is transmissible, aside from in 3rd world countries where can also be spread via polluted cows milks

Answer 110

Globally 9.6 million new cases/yr. Roughly 37% are unreported/undiagnosed 12% of new cases show co-infection with HIV UK 8000/yr; 73% born outside UK (immigration) It is most commonly spread by inhalation of infected droplets (accounts for almost all cases in the UK). Infectious patients cough up huge numbers of mycobacteria, which can survive in the environment for long periods of time.

Answer 111

Mycobacterium tuberculosis, MTB has slow metabolism in the body and is resistant against the immune system Aerobic metabolism >> prefers the more oxygenated areas of the organs i.e. areas with richer blood vessels e.g. apex of the lung, anterior part of vertebral column, … BK is swallowed by PMNs (polymorphonuclear cells; phagocytosis), but it is not digested/killed (like other bacteria) >> it survives and proliferates inside the cell + it is transferred to the Lymph Nodes by the PMN >> Lymphadenopathy (disease of the lymph nodes, in which they are abnormal in size or consistency) Usually, specially-trained CMI (Cell-mediated immunity, trained T-cells/Macrophages) are able to kill the MTb. Cell mediated immunity (trained T-cells/Macrophages) can kill MTb. Tubercle in the lung/Granuloma in the body, is an organized collection of macrophages and is a special defensive cell arrangement. Body/TB interaction results in a special type of necrosis ‘Caseous necrosis

Answer 112

Cavitation [evacuation of necrotic materials] and/or Calcification [Ca deposition on necrotic materials]. TB may cause Cold Abscess. [Classic 4 signs of inflammation: swelling, warmth, redness, ~pain.]

Answer 113

Liquefactive necrosis, the dead tissue appears as a liquid viscous mass. Coagulative necrosis, the dead tissue appears as a soft and white proteinaceous mass [something like a boiled egg] Fat necrosis Caseous necrosis, the dead tissue appears as a cheese-like appearance. Caseous [‘keɪsiəs’, Latin]: Cheese Caseous necrosis can be considered a combination of coagulative and liquefactive Necrosis.

Answer 114

When containment by the immune system (T-cells/macrophages) is inadequate. It can arise from primary infection, or re-activation of previously latent disease. Transmission is through inhalation of aerosol droplets containing bacterium. Only active pulmonary TB is contagious.

Answer 115

Persistent immune system containment, i.e. granuloma formation prevents bacteria growth and spread. Positive skin/blood testing shows evidence of infection. But the patient is asymptomatic and not contagious (normal sputum/CXR). Lifetime risk of reactivation is 5–10%.

Answer 116

new infection (<2y), HIV, organ transplantation, immunosuppression (incl. corticosteroids), elderly, young children, silicosis, illicit drug abuse, malnutrition, high-risk settings (homeless shelter, prison), low socio-economic status, haemodialysis, etc.

Answer 117

M. tuberculosis is first encountered (Primary infection) Host macrophages in the lung engulf the organisms and carry them to hilar lymph nodes in an attempt to control the infection. Some organisms may disseminate via the lymphatics or bloodstream to distant sites (Extra-pulmonary TB). Small granulomas (tubercles) are formed around the body to contain the mycobacteria. These may heal spontaneously and the bacteria are eliminated (in 80% of cases) Or bacteria are encapsulated in a defensive barrier but persist in an otherwise healthy individual where the disease is considered dormant (Latent TB). Only a small proportion of patients progress to overt disease (Active TB).

Answer 118

Pulmonary TB, Tuberculous Pneumonia Cardiac TB >> Constrictive Pericarditis Tuberculous cervical lymphadenitis >> Scrofula Gastrointestinal TB Spinal TB, Tuberculous Spondylitis, Pott’s disease Miliary TB, Disseminated Tuberculosis Urogenital TB: Tuberculous Nephritis, Tuberculous Cystitis, etc. Genital TB >> “Beading” of Vas/F. tube Cutaneous TB, Lupus vulgaris Tuberculous Osteomyelitis Tuberculous Meningitis (CNS TB)

Answer 119

``` Systemic features/General presentations Low-grade Fever, POU pyrexia of unknown origin Night Sweats Anorexia, Weight Loss Fatigue, Malaise Clubbing, Erythema Nodosum Symptoms of involved organ ```

Answer 120

Pulmonary TB accounts for 60% of TB cases in the UK. Presentation varies and may be silent or atypical, especially with immunosuppression, e.g. HIV, post-transplantation. Symptoms: Chronic, productive Cough >2–3 weeks, dry then productive: purulent ± bloodstained sputum. May result in lobar collapse, bronchiectasis, pleural effusion, pleurisy, or pneumonia, ± cavities Haemoptysis - Uncommon, seen with bronchiectasis, not always shows an active disease

Answer 121

Enlargement of cervical or supraclavicular lymph nodes (LAP). Axillary and inguinal node involvement is less common. Systemic symptoms in only 40–50%. Can occur with or without pulmonary disease. Node is typically firm and painless and not acutely-inflamed (Cold abscess). Skin can adhere to the underlying mass with risk of rupture and Sinus formation. Diagnosis is fine-needle aspiration (FNA), AFB staining, and culture.

Answer 122

Haematogenous dissemination leads to the formation of discrete foci (~2mm) of granulomatous tissue throughout the lung (‘millet’ seed appearance). Dissemination is throughout the body, TB meningitis ~25%. Diagnosis - Sputum may be negative for AFB, as spread is haematogenous. Have a low threshold for LP. >> NAAT IGRAS Treatment - Untreated mortality is assumed to be close to 100%. Do not delay treatment while test results are pending.

Answer 123

Most disease is in the ileocaecal area. Bowel obstruction (colicky abdominal pain and vomiting) due to bowel wall thickening, stricture formation, or inflammatory adhesions. Biopsy is required for diagnosis and to differentiate from Crohn.

Answer 124

Usually involves pericardium: pericarditis, pericardial effusion, and/or constrictive pericarditis. Diagnosis is CXR (pulmonary TB, mediastinal lymph nodes), Echo., IGRAS, ± biopsy Treatment is Anti-TB medications Pericardiectomy, if persistent constriction despite anti-TB med.

Answer 125

Based on the presentation/s Cancer, like lymphoma Pneumonia PUO pyrexia of unknown origin (FUO) Fibrotic lung disease (e.g., Sarcoidosis, Hypersensitivity Pneumonitis, Pneumoconiosis, Silicosis) Chronic diseases such as Anorexia nervosa (AN) and Diabetes (DM).

Answer 126

Been in close contacts of [active] pulmonary or laryngeal TB patients, those with immune dysfunction, healthcare workers, and high-risk populations, e.g. elderly, children, prison, homeless, vulnerable migrants, etc.

Answer 127

• Tuberculin skin testing, TST, Mantoux test, PPD Intradermal injection of purified protein derivative (PPD) tuberculin. Assess skin reaction to the injection. Positive result: Skin induration >5mm if risk factors; >15mm if no risk factors It is dependent on BCG (bacillus Calmette-Guérin) vaccination history, and the immune status. Reaction will be false positive in pts with BCG vaccine. Not a very sensitive test. • Interferon-gamma release assays, IGRAS (newer test): exposure to TB >> release of interferon-gamma (IFN-γ), from T-cells, reacting to TB antigen. More Specific test >> If history of BCG vaccination (unlike TST) won't give a positive result. *These tests are mainly for screening. Neither test can diagnose or exclude active disease (false negative in 20–25%) and clinical evaluation is required. Immune-suppressed states reduce the sensitivity of both tests*

Answer 128

Active Pulmonary TB Offer HIV, HBV, HCV test for all. CXR - can be normal so does not rule out TB. Typically shows Non-specific Fibronodular/Linear Opacity (tubercle) in Upper lobe, Ipsilateral Hilar Lymphadenopathy, Cavitation, Calcification, Effusion, Miliary disease Ghon lesion/focus - Upper lobe opacity, usually sub-pleural. Ipsilateral hilar LAP. It is sometimes seen in TB. It is noy pathognomonic of TB. Sputum smear - Sputum can be spontaneously produced or induced (with nebulized saline and precautions to prevent transmission). 3 specimens are needed, including an early-morning sample. It is stained for the presence of acid-fast bacilli (AFB). If AFB are seen, Tx should be commenced, and Pt. isolated (hospital/home). Sputum culture - More sensitive than smear testing. Provides Drug sensitivity. Takes 1–3 weeks (liquid media) or 4–8 weeks (solid media). [other bacteria 2 days!] NAAT - Nucleic acid amplification test. Direct detection of M. tuberculosis in sputum [or other fluid samples] by DNA or RNA amplification. Quick (<8hrs). Can detect drug resistance. AFB - acid fast bacilli; staining technique for gram staining resistant bacteria; will colour red with acid staining

Answer 129

Offer HIV tests for all. [PCR, ‘Fourth-generation test (detection of HIV antibody and p24 antigen), 'IgG sensitive’ tests, etc.] Investigate for coexisting pulmonary disease. [CXR, Sputum, …] Obtain material from aspiration or biopsy (lymph node, pleura, bone, synovium, GI, GU tract. >> AFB staining, histological examination (caseating granuloma) and/or culture. NAAT >> on any sterile body fluid [interact with other bacteria]: CSF, pericardial fluid, Investigate for co-existing pulmonary disease >> CXR, Sputum smear and culture Involved Organ-related test e.g. CSF Lumbar Puncture >> CSF >> AFB staining (Acid-Fast staining, Ziehl-Neelsen staining) NAAT in CSF: - Nucleic acid amplification test (NAAT) - Direct detection of M. tuberculosis, in sputum/CSF/…, by DNA/RNA amplification - Rapid diagnosis (< 8 hrs) *Tests are time-consuming >> Start treatment on suspicion*

Answer 130

Balance the risk of development of active disease, with the possible side-effects of Tx, like hepatotoxicity. Consider Tx in all at high risk of active disease: HIV, transplantation, chemotherapy, etc. Offer HIV, hepatitis B and C testing prior to treatment.

Answer 131

All forms of active TB are statutorily notifiable in the UK. Notification >> www.gov.uk/health-protection-team Treatment is given under the care of a specialist TB clinician/service Offering HIV, hepatitis B and C testing, prior to treatment. Patient’s compliance and Patient tracking is of extreme importance.

Answer 132

``` 2 antibiotics (isoniazid and rifampicin) for 6 months 2 additional antibiotics (pyrazinamide and ethambutol) for the first 2 months of the 6-month treatment period). If you have TB in areas like your brain or the sac surrounding your heart (pericardium), you may initially be prescribed a corticosteroid (Links to an external site.) such as prednisolone (Links to an external site.) for several weeks to take at the same time as your antibiotics. This will help reduce any swelling in the affected areas ```

Answer 133

Abnormal permanent dilation of the airways Leads to impaired clearance of bronchial secretions with secondary bacterial infections and bronchial inflammation May be localised to a lobe or generalised throughout the bronchial tree Bronchiectasis is usually a complication of other conditions like pneumonia. Bronchiectasis itself has important and dangerous complications, like recurrent Infections.

Answer 134

common causes: Cystic fibrosis (CF) Post-infectious - After Pneumonia, Whooping cough (Pertussis), TB, HIV, Measles, Bronchiolitis etc. Idiopathic Rarer causes Immunodeficiency (Hypogammaglobulinaemia,…) Congenital ciliary defect e.g. Kartagener’s syndrome: immotile cilia, situs invertus, chronic sinusitis Airway obstruction (tumor, inhaled FB) RA (rheumatoid arthritis, UC (ulcerative colitis)

Answer 135

Chronic productive Cough Recurrent chest infections Severe cases - copious amounts of thick, foul-smelling green sputum. Haemoptysis (which may be massive and life-threatening) SOB (breathlessness) Wheeze [as a symptom] Clubbing Coarse Crackles/crepitations, over the affected area (usually the lung bases) Wheeze

Answer 136

CXR - Normal, Dilated bronchi with thickened bronchial walls, multiple cysts, containing fluid. High resolution CT scan (GOLD STANDARD) - airway dilatation, bronchial wall thickening, bronchial wall cysts Sputum culture >> essential during an infective exacerbation. The common organisms: Staphylococcus aureus, Pseudomonas aeruginosa and Haemophilus influenzae. Where an underlying cause is suspected: Serum immunoglobulins Sweat test (CF) Spirometry >> shows an obstructive pattern Bronchoscopy >> to locate site of haemoptysis, exclude obstruction, and obtain samples for culture.

Answer 137

Smoking cessation Respiratory physiotherapy and mucolytics, to promote mucociliary clearance and sputum production. Annual influenza vaccination, pneumococcal vaccination Prompt Antibiotic therapy for exacerbations. Bronchodilators (β2 agonists [nebulized Salbutamol] and/or anticholinergics) Inhaled or oral Steroids >> can decrease the rate of disease progression. [vicious cycle] Surgery/Resection is reserved for the very small minority with localized disease or severe haemoptysis. Severe disease sometimes requires lung or heart–lung transplantation.

Answer 138

Patients with increased cough, sputum production, or purulence of sputum. Mild: Cefaclor, 500 mg three times daily. If Staph. is isolated on sputum culture >> Flucloxacillin If the sputum remains yellow or green despite regular physiotherapy and antibiotics >> it is probable that there is infection with P. aeruginosa Ceftazidime, by aerosol or parenterally. Ciprofloxacin, oral ≥3 exacerbations a year consider >> Long-term antibiotics

Answer 139

``` Haemoptysis Pneumonia Empyema (Pyothorax) Pleural effusion Pneumothorax Respiratory failure Cerebral abscess Amyloidosis ```

Answer 140

One of the commonest life-threatening autosomal recessive conditions (1:2000 live births) affecting Caucasians. 1:25 people carry a copy of the faulty gene. [Carrier] All UK babies are screened at birth.

Answer 141

``` Mutated CFTR (chromosome 7) → absent or dysfunctional chloride channel → dysfunctional transport of chloride → abnormal secondary transport of sodium and water In sweat glands: inability to reabsorb chloride from the lumen → reduced reabsorption of sodium and water → sweat with elevated levels of sodium chloride + excessive loss of salt In rest of exocrine glands: inability to secrete chloride into the lumen → accumulation of intracellular chloride → increased sodium and water reabsorption → formation of hyperviscous mucus → accumulation of secretions → blockage of small passages → chronic inflammation → multiple organ damage ``` The lungs of babies born with CF are structurally normal at birth, frequent respiratory infections soon develop and are the presenting feature. The resultant inflammatory response damages the airway, leading to progressive bronchiectasis, airflow limitation and eventually respiratory failure. 20% develop ABPA (allergic bronchopulmonary aspergillosis). Mycobacterial colonization affects up to 20% of children, making a rapid deterioration of condition. In the newborn, thick tenacious intestinal secretions cause small bowel obstruction (meconium ileus), an early manifestation of CF.

Answer 142

``` Meconium ileus [obstruction due to impaction of thick meconium] FTT (Failure to thrive) Rectal prolapse Fatty stool Cyanosis Finger clubbing Bilateral lung crackles ```

Answer 143

``` Respiratory: cough, wheeze, recurrent infections, bronchiectasis, pneumothorax, haemoptysis, respiratory failure, cor pulmonale - nasal polyps, sinusitis Bilateral lung crackles Fatty stool Cyanosis Finger clubbing ```

Answer 144

Pancreatic insufficiency (DM, Steatorrhoea), Malabsorption Intestinal obstruction (content impaction), Gallstones, Cirrhosis, GORD, … Other Male Infertility Osteoporosis, Arthritis, Hypertrophic pulmonary osteoarthropathy (HPOA) Vasculitis

Answer 145

Usually based on Sweat test and Genetic assessment. Sweat test - Sweat Na and Cl >60mmol/L. Initial investigation. Genetics - Blood DNA analysis. Genetic screening and counselling [family] Faecal elastase - It is a simple and useful screening test for exocrine pancreatic dysfunction.

Answer 146

``` Sweat test genetic assessment Bloods: FBC, U&E, LFT, Clotting screen - vitamin A, D, E levels Annual glucose tolerance test, OGTT from 12yrs Bacteriology: Cough swab, sputum culture Imaging CXR: hyperinflation, bronchiectasis Abdominal ultrasound: Fatty liver, cirrhosis, chronic pancreatitis DEXA bone scanning (osteoporosis) Spirometry: Obstructive lung disease Aspergillus serology/skin test (20% develop ABPA, allergic bronchopulmonary aspergillosis) Biochemistry: Faecal fat analysis ```

Answer 147

Holistic management (psychosocial + physical wellbeing): MDT: physician, GP, physiotherapist, specialist nurse, and dietician Chest: Respiratory Physiotherapy (postural drainage, airway clearance techniques). Abx (Antibiotics) for acute infective exacerbations and prophylactically. Mucolytics, Bronchodilators Chronic Pseudomonas infection is an important predictor of survival. Annual CXR surveillance GI Pancreatic enzyme replacement, vitamin supplements (A, D, E, K) … Other: Mx of CF-related DM Screening (DEXA scan) >> treatment of osteoporosis Advanced lung disease: Oxygen Diuretics (cor pulmonale) Non-invasive ventilation Lung or heart/lung transplantation

Answer 148

Pseudomona Lung damage associated with persistent infection with P. aeruginosa is a major cause of morbidity and mortality in patients with CF. Nebulized anti-pseudomonal antibiotic therapy, e.g. Tobramycin, improves lung function, slows the rate of respiratory decline and decreases the risk of infective exacerbations and hospitalization in these patients. Regular sputum culture for Pseudomonas allows early detection and treatment.

Answer 149

Today: Median survival is now ~ 41yrs in the UK. In future: A baby born today would expect to live longer. Post-lung-transplant survival = 5 years.

Answer 150

Exposure to dusts, gases, vapours and fumes at work can lead to the following types of lung disease: 1. Acute bronchitis and pulmonary oedema by irritants - sulphur dioxide, chlorine, ammonia or oxides of nitrogen 2. Pulmonary fibrosis, Pneumoconiosis - inhalation of inorganic dust: coal, silica, asbestos, iron, tin 3. Occupational asthma –the commonest industrial lung disease in the more-developed world 4. Hypersensitivity pneumonitis 5. Bronchial carcinoma (Lung cancer) due to Asbestos, polycyclic hydrocarbons and radon in mines. 6. Mesothelioma (neoplasm of pleura), due to Asbestosis

Answer 151

Underground coal-mines, inhalation of coal dust particles over 15–20yrs. Particles are ingested by macrophages >> cell death >> releasing enzymes >> Fibrosis Normally, particles are destroyed by clearance mechanisms. (trapped in the nose, removed by the mucociliary clearance system, destroyed by alveolar macrophages). But these particles are small and scape from this mechanism. CWP includes a wide range in pathology and presentation (asymptomatic – col pulmonale)

Answer 152

Asymptomatic SOB Cough, with black sputum Chronic bronchitis (co-existing CB) PMF (Progressive massive fibrosis) progression of CWP >> progressive dyspnoea, fibrosis >> cor pulmonale. Unlike simple CWP, even after stopping exposure to coal dust, PMF may progress.

Answer 153

CXR: round opacities (1–10mm), especially in upper zone PMF: fibrotic masses (1–10cm), bilateral, upper-mid zone

Answer 154

There is no specific treatment: Smoking cessation (if smoker) Avoid exposure to coal dust Treatment of co-existing chronic bronchitis Claiming compensation (Industrial Injuries Act).

Answer 155

Cause: inhalation of asbestos fibres. Asbestos was used in the building trade (fire-proofing, pipe-lagging, electrical wire insulation, roofing felt, …), shipyard workers and ship engineering, etc. Degree of asbestos exposure is related to the degree of pulmonary fibrosis.

Answer 156

``` A long latency period (20–40 years) Progressive dyspnoea, productive cough and wheezing Clubbing Bilateral Lung Crackles Presentations of cor pulmonale. ```

Answer 157

Based on History of exposure + typical CXR Fx Sometimes >> CT, lung function tests (restrictive pattern), pleural biopsy CXR: Normal Pleural plaques, pleural thickening, benign pleural effusions Presentations of lung cancer, or mesothelioma

Answer 158

Pulmonary fibrosis | Risk of bronchial adenocarcinoma and mesothelioma

Answer 159

``` Symptomatic Tx, smoking cessation, … Avoid (further) asbestos exposure Claiming compensation (UK Industrial Injuries Act) ```

Answer 160

A multi-system granulomatous disorder of unknown cause Women, 20–40yrs, African–Caribbean Two main forms: Pulmonary Sarcoidosis, Non-Pulmonary Sarcoidosis

Answer 161

Asymptomatic 20–40% >> is discovered incidentally by a routine CXR shows bilateral (B/L) hilar lymphadenopathy (BHL) ± pulmonary infiltrates or fibrosis Symptomatic: Constitutional: fever, night sweats, malaise, fatigue, weight loss. Respiratory: dry cough, progressive dyspnoea, ↓exercise tolerance, chest pain Progressive disease in 20% of cases results in Pulmonary Fibrosis

Answer 162

Any organ can be affected: skin, lymph nodes, eye, heart, brain, kidney, joint etc. signs: enlarged lymph nodes, scarring and granulomas Eyes: dry and blurry vision Heart: complications Liver and spleen: enlargement Joints: pain, arthritis, knee swelling Skin: rashes, lupus pernio, erythema nodosum, skin lesions on back, subcutaneous nodules

Answer 163

TB Lymphoma Pneumoconiosis Metastatic disease

Answer 164

Diagnosis: a matter of exclusion, as there is no specific test for the condition. As an example, to exclude sarcoidosis in a case presenting with pulmonary symptoms, might involve: CXR CT scan of chest PET scan CT-guided biopsy Mediastinoscopy open lung biopsy bronchoscopy with biopsy endobronchial ultrasound, and endoscopic ultrasound with fine-needle aspiration of mediastinal lymph nodes (EBUS FNA).

Answer 165

Acute sarcoidosis often presents with erythema nodosum ± polyarthralgia. Usually self-limited >> Tx: bed rest, NSAIDS BHL (only) is usually self-limited >> No Tx needed, just follow up

Answer 166

Corticosteroids: Prednisolone Antimetabolites: Methotrexate, Azathioprine, Leflunomide, Mycophenolate Anti-tumour necrosis factor (TNF) monoclonal antibodies: Infliximab, Adalimumab Prognosis: response over 2 yr Tx: 60% resolve of disease 20% get better 20% no response – progressive disease

Answer 167

Three types 1. Replacement fibrosis- secondary to lung damage in a medical condition - infarction [PE],TB, pneumonia. 2. Focal fibrosis - in response to irritants - e.g., coal dust and silica. (Pneumoconiosis) 3. Diffuse parenchymal lung disease (DPLD) - in Idiopathic pulmonary fibrosis (IPF), and Hypersensitivity pneumonitis.

Answer 168

accounts for ~40% of diffuse parenchymal lung disease. The most common interstitial lung disease (7.4/100,000) Men, median age of presentation: 70 Most, smoker or ex-smoker Often co-existing COPD - No underlying causes can be identified. - IPF (previously, cryptogenic fibrosing alveolitis) is the commonest type. IPF, Pathology patchy fibrosis of the interstitium minimal or absent inflammation, acute fibroblastic proliferation collagen deposition.

Answer 169

Smoking Industrial exposure (Pneumoconiosis): asbestos, heavy metals, silica, … Environmental factors: pigeon breeding, contaminated ventilation systems. Chronic viral infections: HCV, EBV (Epstein-Barr virus)- COVID-19 (?) GORD, with micro-aspiration.

Answer 170

``` Any patient, with breathlessness, + pre-existing medical condition or environmental exposure >> pulmonary fibrosis But: If Persistent/Progressive breathlessness + Age >45 Persistent non-productive/dry cough B/L inspiratory basal crackles Finger clubbing Normal spirometry or restrictive spirometry No Hx of med. Condition/environmental exposur >> IPF End sage IFP: respiratory failure, pulmonary hypertension cor pulmonale. ```

Answer 171

CXR Initially, ground-glass appearance, Later, fibrosis and honeycomb lung. most prominent in the lower zones. HRCT (High-resolution CT scan) >> the most sensitive imaging technique bilateral irregular linear opacities and honeycombing Respiratory function tests [spirometry]: Restrictive defect, lung volumes↓, gas transfer↓ ABG: O2↓, CO2 normal - [decreases O2 absorption but no issue losing CO2] Histological confirmation is necessary in some patients. >> video-assisted thoracoscopic [VATS] lung biopsy

Answer 172

``` detailed Hx, including Past medical History Drug history Occupational exposure (past and present) Treatment: Multidisciplinary team Pulmonary rehabilitation Pirfenidone (NICE, in some), Nintedanib, etc. Lung transplantation Prognosis - There is no cure - Poor prognosis (2.5 years survival from the time of diagnosis) ```

Answer 173

caused from fluid in interlobular fissures (heart failure causes leakages etc.) found on the PERIPHERY of lung fields so can differ from pulmonary vessels which will remain more visible closer to the lung hilum.

Answer 174

Cardiac shadow -Normal heart takes up less than 50% cardiothoracic volume on PA projection! Lung fields - can see pulmonary vessels (spidery), no lung edges, no shadowing or opacity, nice clear costophrenic angles (diaphragm meeting lung angle) Mediastinum (middle mediastinum - great vessel roots etc.)- no more than 6cm width on PA, no more than 8cm width on AP

Answer 175

``` Date and name Side labelling and projection markers - no projection make judgment (usually PA) Lung fields - ABCDE? Any consolidation? Hilum - any consolidation? Mediastinum Diaphragm and costophrenic angles - lifted? Gas underneath? Fluid in angles? Sharp angles? Trachea - side deviation? Bones - broken? Alignment? dislocations? Soft tissues ```

Answer 176

Pneumothorax - can see lung edge due to air pushing it into chest space; can be so subtle but if in doubt get a CT scan! Tension pneumothorax - can see trachea being pushed to one side by this air Put needle into 2nd ICS to drain air Pleural effusion upside down meniscus shape suggests fluid in the lungs not consolidation as this will be more solid looking! Sounds like Stony dullness on percussion. Can be unilateral or bilateral (heart failure characteristic) Takes a lot of fluid to be able to be seen on CXR! To get better view can take a lateral view Consolidation: lower lobe consolidation - less meniscus shape more defined edging to mass. upper lobe consolidation middle lobe consolidation Consolidation doesn’t always occur at the base of the lung and can follow bronchial tubes while pleural effusion only fills the lungs from the bottom up. Also less likely to see other chest structures with consolidation as more XR absorbing Mediastinal widening if extends over the apexes of the lung is very bad sign. What disease?? google Tumors: cannonball metastases. Secondary tumors - tend to be round and discrete calcium deposits seen in the mass in the lung, left upper lobe mass, often at the root of consolidation seen in CXRs so often see consolidation after. Can see bronchial vessels within consolidation but only Ca deposits in tumor mass. Masses have more defined edges usually. This is primary tumor is usually larger and less defined edges. Pectus excavatum - on CXR heart is missing right side border, ribs are ‘7’ shaped and heart is displaced more to the left

Answer 177

Systemic symptoms: fever, night sweats, weight loss (TB, lymphoma, bronchial carcinoma) Haemoptysis (TB, bronchial carcinoma) Significant dyspnea (HF, COPD, fibrotic lung disease)

Answer 178

Sound: barking, hacking, whooping etc. Duration: acute less than 3 weeks, subacute (3-8 weeks), chronic more than 8 weeks Timing: nocturnal, diurnal (asthma), trigger response to allergens or weather etc. Secretion: dry, productive, moist cough (smokers) Associated symptoms: SoB, fever, vomiting, blood, chest pain, weight loss

Answer 179

acute - less than 3 weeks: allergic rhinitis, asthma, COPD exacerbations, irritant exposure, pneumonia, PE, viral URTI subacute - 3-8 weeks: postinfectious cough and bacterial sinusitis chronic - longer than 8 weeks: asthma, beta blockers, chronic LVF, CHF, COPD, cystic fibrosis, GORD, lung cancer, postnasal drip, sarcoidosis, tobacco use, ACEi use

Answer 180

Haemoptysis: Coughing up blood. Streaks or clots in sputum (lung Cancer) if mixed with green sputum (infection) Other causes: TB, lung abscess, bronchiectasis Duration and frequency: intermittent over years (bronchiectasis), more than one week (lung cancer), single episode with pleuritic chest pain (PE).

Answer 181

OTC medicines: Cough expectorant Cough suppressant - decrease cough reflex to normal levels, most common OTC suppressant is dextromethorphan Clinical use: dry cough with little phlegm needs cough suppressant (antitussive drugs) Productive cough needs cough expectorant or mucolytic to help bring up phlegm. Designed to force cough reflex and propel phlegm out of airway. No evidence they have any effect! Sedating antihistamines used as suppressant component of many compound cough preps on sale in public.

Answer 182

Acute bronchitis: Cough lasting 10 days to 3 weeks (acute infection) Chronic is inflammation and cough lasting longer than this; usually due to irritants such as smoking Chronic bronchitis: Daily productive cough that lasts for 3 months of the year and for at least 2 years in a row. Mostly affects those under age 40 Main causative factor is smoking

Answer 183

Viruses cause 85-95% of acute bronchitis in adults Breathing irritant substances such as dust, smoke or occupational exposure to them Rare cases can develop bacterial bronchitis after viral infection of bronchitis Most common complication is pneumonia, especially in high risk groups(1 in 20 cases get pneumonia) Most common in children under 5 More common in winter with common colds and flu

Answer 184

``` Sore throat Headache Runny nose/blocked nose Aches and pains in muscles Fatigue Cough - may persist several weeks post infection/after other symptoms have gone; may bring up clear/yellow or greenish mucus Fever Wheezes or Rhonchi may be heard on auscultation SoB ```

Answer 185

``` Smoking Immunocompromised Reflux Exposure to irritants Age 50 and over ```

Answer 186

Mostly self-limiting will go away by itself within a few weeks without need for treatment Home-care: hydration, bed rest, warm drinks, paracetamol or ibuprofen for headaches and pain relief, OTC cough suppressant medications (little evidence that these actually work however) There's no cure for chronic bronchitis, but some lifestyle changes can help ease your symptoms, such as: eating a healthy diet regular moderate exercise avoiding smoking Can also give bronchodilators and oral steroids to open up airway (inhalers or tablets) Mucolytic medicines to help expectoration

Answer 187

Fungi from soil/bird droppings can cause pneumonia Usually caused in those with compromised immune systems Cannot spread from person to person; comes from contaminated environment Pathogens: Cryptococcus species Histoplasmosis species Pneumocystis jirovecii (HIV related)

Answer 188

Presentation: Dry cough (no sputum) SoB on exertion Night sweats Treatment: Co-trimoxazole Low CD4 pts are given prophylactic oral co-trimoxazole to protect against fungal pneumonia infection Anti-fungal treatments may need longer periods of treatment *mortality can be as high as 90% in immunocompromised pts*

Answer 189

HIV related pneumonia serious fungal infection caused by pneumocystis jirovecii Most suffers have weakened immune systems from immunosuppressive conditions such as HIV/AIDS or medicines such as corticosteroids Less likely to contract due to availability of antiretroviral therapy (ART) Transmission is airborne from healthy carriers

Answer 190

``` fever, Dry cough SoB chest pain, chills, Fatigue Night sweats ```

Answer 191

fungus can live in the lungs asymptomatically in 20% adults and is removed naturally after several months in healthy individuals 30-40% of people with this infection have HIV/AIDS People on corticosteroids chronic conditions such as; chronic lung diseases, cancer, inflammatory or autoimmune diseases (rheumatoid arthritis) or solid organ/stem cell transplant

Answer 192

PREVENTERS: Given to individuals more likely to suffer from PCP infection trimethoprim/ sulfamethoxazole (TMP/SMX or co-trimoxazole) TREATMENT: TMP/SMX aka co-trimoxazole given orally or via IV for 3 weeks Side effects: rash and fever

Answer 193

sputum/mucus sample Lung biopsy Blood test to detect beta-D-glucan

Answer 194

Is a complication of viruses causing colds or the flu Accounts for roughly one third of pneumonia cases Virus invades the lungs causing swelling and blocking oxygen flow Many cases of viral pneumonia are self-limiting and resolve on their own within a few weeks Severe cases can be life-threatening Transmitted via coughing or sneezing or touching contaminated surfaces Symptoms usually persist for 1-2 weeks but cough and headaches may last longer

Answer 195

Adenoviruses (common cold or bronchitis causing) Chickenpox (varicella zoster virus) Influenza virus Respiratory syncytial virus (cold-like symptoms)

Answer 196

``` Cough with yellow or green mucus Fever Shaking or chills Fatigue Sweating Blue lips Weakness Headaches SoB Muscle pain Worsening cough Children may show symptoms more gradually and less severe, may also lose appetite or eat poorly ```

Answer 197

``` Working in hospital or care setting Age 65 + Age 2 or under Pregnancy Autoimmune diseases Immunosuppression such as cancer pts Recent viral infection Smoking ```

Answer 198

``` CXR Sputum culture Nasal swab FBC ABC CT scan Blood culture Bronchoscopy - look into airways; rarely needed Diagnosis: Decreased airflow Crackling sounds Wheezing Rapid HR ```

Answer 199

Usually self-limiting and goes away by itself. Home-care: bed rest, good hydration, OTC cough suppressant medications, warm drinks and herbal teas etc. Antiviral medications are given to pts with severe illness or not otherwise healthy individuals (eg also immunocompromised) to help reduce symptoms and speed recovery In some cases can develop secondary bacterial pneumonia from primary viral pneumonia and so will need to follow treatment for bacterial pneumonia (AB courses) Advise flu vaccine yearly in vulnerable pts

Answer 200

``` New onset confusion Rapid breathing BP drop SoB Constant fever Chest pain ```

Answer 201

Also called collapsed lung Air gets between the pleura of one lung The pressure can cause the lung to give way Causes decreased chest expansion Can be caused by blockage or lack of pressure inside the lung instead of outside (atelectasis)

Answer 202

``` Symptoms: SoB Chest pain - pleuritic one sided, sudden and stabbing Signs: Reduced air entry in auscultation Reduced vocal resonance and fremitus Hyperresonance on affected side ```

Answer 203

CXR | CT scan

Answer 204

Primary - no clear cause Secondary - underlying lung conditions Tension pneumothorax Traumatic pneumothorax

Answer 205

Male gender Ruptured air blisters more likely to occur between ages 20-40 years Tall and thin body structure Smoking Family history/genetics Lung diseases such as COPD, mechanical ventilation, previous pneumothorax

Answer 206

Haemothorax - pleural space fills with blood | Haemopneumothorax - blood fills pleura and lung filling from the bottom up

Answer 207

Occur when intrapleural air accumulates progressively exerting positive pressure on mediastinal and intrathoracic structures PUSHING the trachea Develops when a lung or chest wall injury is such that it allows air into the pleural space but not out of it (a one-way valve) The pressure decreases venous return to the heart causing shock. Life threatening as can cause cardiorespiratory arrest Usually caused my trauma

Answer 208

Hypotension & Hypoxia Deviated trachea Hyperresonant, Jugular venous distention Tachycardia, tachypnoea investigations: CXR

Answer 209

Immediate needle decompression insert large bore (14-16 gauge) needling into 2nd ICS in mid clavicular line Air released and this will result in simple pneumothorax so chest drain should be inserted immediately after

Answer 210

Patients should be advised to return to hospital if increasing breathlessness develops. All patients should be followed up by respiratory physicians until full resolution. Flying with a pneumothorax can be dangerous. This is because air in the pleural space in your chest will expand at the lower cabin pressure during the flight. This can compress the lung and can be dangerous. Until full resolution. Diving should be permanently avoided unless the patient has undergone bilateral surgical pleurectomy and has normal lung function and chest CT scan postoperatively.

Answer 211

Also called water on the lung, is an excessive buildup of fluid in the space between your lungs and chest cavity. ➤ The pleura creates too much fluid when it’s irritated, inflamed, or infected. This fluid accumulates in the chest cavity outside the lung, causing what’s known as a pleural effusion. ➤ A pleural effusion is a collection of fluid next to the lung. There are various causes. The effusion may cause you to become breathless. The fluid can be drained if necessary. Treatment is mainly aimed at the underlying cause.

Answer 212

``` Lung infections (pneumonia) TB Cancers Heart failure Liver cirrhosis/ kidney disease Arthritic conditions may cause inflammation of the pleura e.g Systemic Lupus Erythematosis (SLE), Rheumatoid Arthritis (RA) ```

Answer 213

Usually painless, but may have some chest pain Fluid amount varies - but with a larger effusion, it presses on the lung which cannot expand fully when you breath and therefore may cause breathlessness Symptoms relating to the underlying cause Pleural effusion may be the first sign of an underlying cause Signs: Reduced or absent breath sounds on the side or area of pleural effusion Stony Dull percussion Reduced vocal resonance or fremitus - vibrations transmitted through the body

Answer 214

``` Protein less than 30g/L Caused by factors that alter hydrostatic pressure, pleural permeability and oncotic pressure such as: CCF Liver cirrhosis Severe hypoalbuminemia Nephrotic syndrome ```

Answer 215

Protein greater than 30g/L Caused by changes to local factors influencing formation and absorption of pleural fluid such as: Malignancy Infection (empyema due to bacterial pneumonia) Trauma PE

Answer 216

Directly mostly to correcting underlying cause If underlying causes persists or there is recurrent pleural effusions, draining the fluid can help to manage Small pleural effusion that cause no or mild symptoms are usually left and ‘observed’ Treatment is usually only needed if the effusion causes breathlessness Large effusions can be drained using a pleural fluid aspiration or pleural tap. Repeated draining of the fluid when symptoms become a problem for a patient is one option. Depending on the underlying cause, other treatment options that are sometimes considered include: Pleurodesis - chemical injection into pleural space Leaving permenant drain in Surgery to insert shunt for fluid pleurectomy - remove pleura only last resort once all else fails

Answer 217

Inflammation of the pleura usually causing pleuritic chest pain for a patient - sharp/ stabbing pain worse when breathing in or cough May feel pleuritic chest pain anywhere in the chest depending on the site of the inflammation or problem with the pleura. Two parts of the inflamed pleura rub over each other.

Answer 218

Viral infection is the most common cause - pain typically lasts a few days and goes as the virus clears away and the inflammation settles Bacterial Pneumonia PE Chest injuries Pneumothorax Lung Cancer Inflammation with some forms of arthritis

Answer 219

Clinical diagnosis Rule out other serious causes of pleuritic chest pain Most common viral pleurisy - no signs on a chest x ray; viral Management: Painkillers for viral pleurisy Otherwise treat for underlying cause pneumonia, PE, other causes

Answer 220

Aka pyothorax Pus gathers in pleural space Can’t be coughed out, needs to be drained

Answer 221

Develops after pneumonia - most common causative organisms are strep. Pneumoniae and staph. Aureus. Occasionally caused by post surgical compilation

Answer 222

The pleural space naturally has some fluid, but infection can cause fluid to build up faster than it can be absorbed. The fluid then becomes infected with the bacteria that caused the pneumonia or infection. The infected fluid thickens. It can cause the lining of your lungs and chest cavity to stick together and form pockets. This is called an empyema. Your lungs may not be able to inflate completely, which can lead to breathing difficulties.

Answer 223

CXR shows curved line across lung Simple empyema: Early stages of illness - pus is free flowing SoB Dry cough Fever Pleuritic chest pain Systemic symptoms of headache, loss of appetite and confusion Complex empyema: SOB, Decreased breath sounds, weight loss chest pain

Answer 224

Complex empyema occurs in the later stage of the illness. In complex empyema, the inflammation is more severe. Scar tissue may form and divide the chest cavity into smaller cavities. This is called loculation, and it’s more difficult to treat. If the infection continues to get worse, it can lead to the formation of a thick peel over the pleura, called a pleural peel. This peel prevents the lung from expanding. Surgery is required to fix it. Symptoms: SOB, Decreased breath sounds, weight loss chest pain

Answer 225

Treatment is aimed at removing the pus and fluid from the pleura and treating the infection. Antibiotics are used to treat the underlying infection. The method used to drain the pus depends on the stage of the empyema. In simple cases, a needle can be inserted into the pleural space to drain the fluid. This is called percutaneous thoracentesis. In the later stages, or complex empyema, a drainage tube must be used to drain the pus - thoracostomy/ chest drain; video assisted thoracic surgery; open decortication.

Answer 226

Drowning is the process of experiencing respiratory impairment from submersion/immersion in liquid. Drowning outcomes should be classified as: death, morbidity, and no morbidity. Epidemiology: 4th most common injury. 2/3rd most common cause of accidental death in children in UK, Australia and USA Incidence peaks for toddlers and teenage boys

Answer 227

Initial gasp with possible aspiration or period of breath hold Apnoea eventually exceeds breaking point stimulating hyperventilation, causing aspiration and variable degree of laryngospasm Leads to hypoxia and acidosis 85% cases asphyxia leads to relaxation of airway before inspiratory efforts have ceased and lungs filled with water In young children immersion in cold water (less than 10 degrees) can stimulate protective diving reflex and produce apnoea, bradycardia and preferential shunting of blood to coronary and cerebral circulation which increases survival chance

Answer 228

Pulmonary oedema Foreign body aspiration, laryngospasm or bronchospasm may worsen the hypoxia. Hypothermia, if it occurs, leads to a slowing of the metabolic rate but respiration is slowed even more so and hypoxia and hypercapnia develop. Prolonged hypoxia can lead to CNS and renal damage. Cold water immersion may also cause life-threatening cardiac arrhythmias. Haemolysis occasionally occurs after freshwater drowning. Freshwater drowning can be much faster than saltwater drowning. This can also induce hyperkalemia that can stop the heart.

Answer 229

Unattended children under 5 years People who can’t swim Alcohol use Water sports Unsupervised swimming particularly in open water Underlying risk factors such as epilepsy, cardiac dysrhythmias, hyperventilation, hypoglycemia, hypothermia and illicit drug use

Answer 230

Mechanism and duration of submersion Type and temperature of water Time until CPR started Time of first spontaneous breath Time of return of spontaneous cardiac output Vomiting Likelihood of associated trauma and other conditions like arrhythmias, MI, seizure etc.

Answer 231

``` ABCDE Vitals - oxygen Treat hypothermia or other associated conditions Immediate action Basic life support at scene - remember cervical spine may be injured Hospital action: Treat underlying or associated conditions Oxygen if needed CPAP if needed ECMO for severe pulmonary oedema Nasogastric tube +/- urinary catheter Dialysis for acute kidney injury? ```

Answer 232

``` Prognosis: Ultimately related to duration and magnitude of hypoxia Poor survival related with need for continued CPR Prevention: Education and water safety Safety barriers PPE such as buoyancy aids Pool coverings and safety signs etc. ```

Answer 233

If no SOB and there is a < 2cm rim of air on the chest CXR then no treatment required as it will spontaneously resolve. Follow up in 2-4 weeks is recommended. Give safety netting advice !! If SOB and/or there is a > 2cm rim of air on the chest xray then it will require aspiration and reassessment. If aspiration fails twice it will require a chest drain. Unstable patients or bilateral or secondary pneumothoraces generally require a chest drain

Answer 234

inserted into the “triangle of safety”. This triangle is formed by: The 5th intercostal space (or the inferior nipple line) The mid axillary line (or the lateral edge of the latissimus dorsi) The anterior axillary line (or the lateral edge of the pectoris major) The needle is inserted just above the rib to avoid the neurovascular bundle that runs just below the rib. Once the chest drain is inserted obtain a chest xray to check the positioning.

Answer 235

MABP normal systemic: 70-100mmHg MABP (PAP) normal pulmonary: 10-14mmHg To calculate: double diastolic BP, + systolic BP then divide by 3

Answer 236

PAP above 25mmHg at rest. Progressive complication of many heart, lung or systemic diseases Rarely idiopathic Is a haemodynamic and pathophysiological condition with wide range of aetiologies Finding the cause is important for the management! More common in severe respiratory and cardiac diseases such as in acute PE; 0.5-4% show chronic thromboembolic PH In US most common PH cause is left heart disease

Answer 237

Pulmonary vascular resistance increases Pulmonary blood flow increases causing further increased pulmonary resistance Injury to pulmonary endothelium causes tendency for in-situ thrombosis (thrombotic pulmonary arteriopathy). Disease process continues through vascular scarring, endothelial dysfunction and proliferation of smooth muscle cells within intima and media of pulmonary arterial tree Causing progressive pulmonary arterial HTN Obliteration of small pulmonary arterial vessels leads to right ventricular hypertrophy, progressive right heart strain and eventually right heart failure (COR PULMONALE)

Answer 238

Idiopathic Hereditary Drug-induced, toxin induced Secondary causes: HIV, congenital heart disease, portal HTN, chronic haemolytic anaemia Connective tissue disorders: rheumatoid arthritis, systemic lupus erythematosus, CREST syndrome etc. WHO PH classifications: Secondary to chronic lung disease or environmental hypoxaemia Secondary to left heart disease, valvular disease (eisenmenger syndrome), restrictive cardiomyopathy Secondary to chronic thrombotic disease, embolic disease or both Secondary to metabolic disorders, systemic disorders, haematological diseases and other causes such as sarcoidosis Idiopathic

Answer 239

Rare Severe Often rapidly progressive Diagnosis based on exclusion of other possible causes of PAH

Answer 240

``` Early: Progressive exertional dyspnea Weakness Fatigue Loud pulmonary S2 Right parasternal have (due to RVH) Late: Abdominal pain (hepatic congestion - RVH) Angina Tachyarrhythmia (AF) Increased JVP Hepatojugular reflux Hepatomegaly (enlarged liver) Pulsatile liver Ascites Peripheral oedema Pleural effusion Will also show presentations of underlying disease ```

Answer 241

``` Cor pulmonale (secondary to PH) Cardiomyopathies Primary RV failure eg after MI CHF Recurrent PE Valvular disease Portal HTN Obstructive sleep apnea Hypothyroidism Sickle cell disease ```

Answer 242

CXR:enlarged proximal pulmonary arteries +/- cause in heart or lung such as emphysema, calcified mitral valve etc. ECG: shows RVH pattern (may be normal) also may show P pulmonale signs; right axis deviation, peaked P waves higher than 2.5mm and right bundle branch block. Echo: RV hypertrophy/dilation (may be normal) +/- causes such as CHD can also estimate pulmonary artery pressure Raised NT-proBNF blood test indicated RVF MRI Lung biopsy Right heart catheterisation to confirm diagnosis by directly measuring pulmonary pressure

Answer 243

Provided by specialist units: Manage underlying cause Medications can significantly help symptoms and exercise tolerance in short term Specific treatments exist for PAH and chronic thromboembolic PH Cardiosupportive therapy: Oxygen increases exercise tolerance Diuretics, digoxin lessens RHF and peripheral oedema CCB (pulmonary vasodilators) for idiopathic PAH Warfarin - reduce risk of intrapulmonary thrombosis; needs bleed risk assessment Intravenous prostacyclin (potent vasodilator and inhibitor of platelet aggregation) Bosentan, Ambrisentan (endothelin-A receptor antagonists; vasoconstrictor) Heart and lung transplantations Primary pulmonary hypertension can be treated with: IV prostanoids (e.g. epoprostenol) Endothelin receptor antagonists (e.g. macitentan) Phosphodiesterase-5 inhibitors (e.g. sildenafil) Secondary pulmonary hypertension is managed by treating the underlying cause such as pulmonary embolism or SLE. Supportive treatment for complications such as respiratory failure, arrhythmias and heart failure. The prognosis is quite poor with a 30-40% 5 year survival from diagnosis. This can increase to 60-70% where specific treatment is possible.

Answer 244

Right heart failure caused by chronic PAH Difficult to assess how common it is In the UK, COPD is most common causative Four main aetiologies: Chronic lung disease; COPD, bronchiectasis, pulmonary fibrosis, severe chronic asthma, lung restriction Pulmonary vascular disorders; pulmonary emboli, pulmonary vasculitis, primary PH, ARDS, sickle-cell disease, parasite infection Neuromuscular disease; Myasthenia gravis, poliomyelitis, motor neuron disease Skeletal diseases; scoliosis, kyphosis

Answer 245

``` COPD Pulmonary embolism Interstitial lung disease CF Primary pulmonary HTN ```

Answer 246

Non-specific (especially in early disease) Peripheral oedema Raised CVP/JVP Systolic parasternal heave Loud pulmonary S2 Worsening tachypnea, exertional dyspnea, fatigue Angina type chest discomfort (often non-responsive to GTN) Haemoptysis Exertional syncope Cyanosis (worsening) Tachycardia SoB and increased difficulty breathing Hepatomegaly Usually chronic and progressive However massive PE usually from acute PH and acute cor pulmonale *NICE guidelines for diagnosis - cor pulmonale diagnosis only made clinically after excluding other causes for peripheral oedema*

Answer 247

FBC, Hb, haematocrit (secondary polycythaemia) ABG; hypoxia with or without hypercapnia CXR: enlarged right heart, prominent pulmonary arteries ECG: P pulmonale (peaked P waves and right axis deviation), right ventricular hypertrophy Spirometry/lung function tests CT/MRI Bronchoscopy Lung biopsy

Answer 248

Treat underlying cause Treat respiratory failure; acute situation (massive PE) give 24% oxygen, if PaO2 is less than 8kPa In COPD; long term oxygen therapy 16hrs/day/nocturnal oxygen therapy (NOT) Diuretics for HF Venesection if Haematocrit is above 55% heart/lung transplant in younger pts may be possible

Answer 249

``` Exertional syncope Hypoxia Significant reduction in exercise capacity Peripheral oedema Peripheral venous insufficiency Tricuspid regurgitation Hepatic congestion and cardiac cirrhosis Death ```

Answer 250

Irreversible lung disease Primarily caused by smoking Alveoli and lung tissue are destroyed. Alveoli cannot support the bronchial tubes. The tubes collapse and cause an obstruction, which traps air inside the lungs. Too much air trapped in the lungs can give some patients a barrel-chested appearance. Less oxygen will be able to move into the bloodstream.

Answer 251

``` Male Ages 50-70 Smoking Genetics (alpha-1 antitrypsin deficiency) Frequent respiratory infections ```

Answer 252

``` can be almost asymptomatic until up to 50% of lung tissue has been destroyed! Cough (long term ‘smokers cough’) Wheezing SoB Long term mucus problems Fatigue ‘Hollow’ sound on resonance ```

Answer 253

Clinical examination CXR; moderate to severe cases can be detected Pulse oximetry - low O2 sats Spirometry and PFTs ABGs ECGs; rule out heart problems as cause of SoB

Answer 254

No known cure so treatment focussed on reducing rate of decline: Smoking cessation Bronchodilator medications Anti-inflammatory meds; long term side effects include osteoporosis, HTN, high blood sugar and fat redistribution Oxygen therapy for hypoxic pts Lung volume reduction surgery: remove portions of diseases lung and join remaining tissues may help relieve pressure on breathing muscles and improve elasticity

Answer 255

Good hand hygiene to prevent other infections Brush and floss teeth daily and use antibacterial mouthwash Keep breathing equipment clean Keep house clean and tidy Yearly flu shots Following Dr prescribed exercise program Avoid irritants such as smoking, exhaust fumes, perfumes, dust etc.

Answer 256

``` PINK PUFFERS cause: - pneumonia - PE - pulmonary oedema - Fibrosing alveolitis symptoms: ABCD - agitation - breathlessness - confusion - drowsiness and fatigue ``` Signs: central cyanosis PaO2 less than 8kPa (or less than 10 of whatever O2 conc. if pt on Oxygen) PaCO2 normal or low (4.7-6kPa) Treatment: - oxygen replacement therapy - treatment of underlying cause Complications: - nosocomial infections like pneumonia - HF - Arrhythmia - pericarditis

Answer 257

``` BLUE BLOATERS cause: - COPD and asthma - cerebrovascular disease - opiate overdose - myasthenia gravis - motor neuron disease Symptoms: ABCD: - agitation - breathlessness - confusion - Drowsiness and fatigue ``` ``` Signs: ABC - A flapping tremor -bounding pulse - cyanosis PaO2 below 8 kPa (or 10 less than whatever O2 conc. pt is on if on oxygen) PaCO2 above 6kPa (hypercapnia) ``` treatment: - noninvasive ventilation - treatment of underlying cause complications: - nosocomial infections like pneumonia - HF - arrhythmias - pericarditis

Answer 258

aka Potters rot caused by inhaling silica particles unable to be removed by respiratory defenses Macrophages engulf silica particles releasing TNF and cytokines inducing fibroblasts resulting in fibrosis and collagen deposition Associated with increased TB infection Acute: Symptoms happen a few weeks up to 2 years after exposure to a large amount of silica. Chronic: Problems may not show up until decades after you’re exposed to low or moderate amounts of silica. It’s the most common type of silicosis. Symptoms may be mild at first and slowly worsen. Accelerated : You’ll notice signs about 5 to 10 years after heavy exposure to silica. They’ll worsen quickly.

Answer 259

Most people get silicosis because they’re exposed to silica dust at work. Jobs in these fields may put you at higher risk: ``` Mining Steel industry Construction Plaster or drywall installation Glass manufacturing Road repair Sandblasting Masonry Roofing Farming ```

Answer 260

A nagging cough Phlegm Trouble breathing as an early symptom of silicosis. Later symptoms include: ``` Trouble breathing Fatigue Weight loss Chest pain Fever that comes on suddenly Shortness of breath Swollen legs Blue lips ```

Answer 261

CXR shows eggshell calcification of hilar lymph nodes with nodular lesions in upper lobes bronchoscopy Lung biopsy Sputum test

Answer 262

Medications: inhaled steroids to reduce mucus and bronchodilators Oxygen therapy Lung transplant

Answer 263

caused by inhalation of Beryllium causes granuloma formation made of giant cells, macrophages and epitheliod cells Acute beryllium disease is very rare today. Current workplace safety regulations prevent the massive quantities of beryllium that cause acute beryllium disease from being released into the air. Chronic beryllium disease (CBD, berylliosis) is associated with inhaling beryllium powder or fumes An exposed person usually gets sensitized (allergic) to beryllium prior to progressing to CBD. Beryllium sensitivity (BeS) and CBD can develop soon after exposure or many (30-40) years later. Of those working around beryllium, about 10% get sensitized to it and about half of those progress to develop CBD. There is no health threat associated with contact with solid beryllium; however, both the solid and powder forms can cause irritation if they come in contact with broken skin

Answer 264

``` Difficulty breathing/shortness of breath Weakness Fatigue Loss of appetite Weight loss Joint pain Cough Fever ```

Answer 265

While there is no cure, commonly adopted management options involve cessation of beryllium exposure and use of systemic corticosteroids 4. Early treatment with corticosteroids may lead to disease regression and prevent further progression. If fibrosis has developed, the lung damage is irreversible.

Answer 266

``` pain, swelling and tenderness around your cheeks, eyes or forehead a blocked nose a reduced sense of smell green or yellow mucus from your nose a sinus headache a high temperature toothache bad breath ``` Signs of sinusitis in young children may also include irritability, difficulty feeding, and breathing through their mouth.

Answer 267

mild sinusitis - home care: rest, fluids, taking painkillers, such as paracetamol or ibuprofen (do not give aspirin to children under 16), avoiding allergic triggers and not smoking, cleaning your nose with a salt water solution to ease congestion OTC drugs: should not be used for more than 1 week: decongestant nasal sprays or drops to unblock your nose (decongestants should not be taken by children under 6) salt water nasal sprays or solutions to rinse out the inside of your nose GP treatment: steroid nasal sprays or drops – to reduce the swelling in your sinuses antihistamines – if an allergy is causing your symptoms antibiotics – if a bacterial infection is causing your symptoms and you're very unwell or at risk of complications (but antibiotics are often not needed, as sinusitis is usually caused by a virus) You might need to take steroid nasal sprays or drops for a few months. They sometimes cause irritation, sore throats or nosebleeds. A GP may refer you to an ear, nose and throat (ENT) specialist if, for example, you: still have sinusitis after 3 months of treatment keep getting sinusitis only have symptoms on 1 side of your face They may also recommend surgery in some cases ( functional endoscopic sinus surgery (FESS).) widen your sinuses by either: removing some of the blocked tissue inflating a tiny balloon in the blocked sinuses, then removing it

Answer 268

Sinusitis is swelling of the sinuses, usually caused by an infection. It's common and usually clears up on its own within 2 to 3 weeks. But medicines can help if it's taking a long time to go away.

Answer 269

pneumoconiosis Disorders such as sarcoidosis, asbestos, pulmonary fibrosis, silicosis etc. FEV1/FVC will be above 75% but individual FEV1 and FVC measurements will be less than predicted Calculate FEV1/predicted FEV1 score for severity (more than 80% is mild, 50-80% moderate, 30-50% severe, less than 30% is very severe); if at the higher end of scale then can classify mild-moderate etc.

Answer 270

arise from malignant epithelial cells in lungs. globally is most common cancer (11.6% new diagnoses) and leading cause of cancer deaths Poor prognosis with 5 year survival rate of 17% Neoplastic pulmonary disease divisions: Bronchogenic carcinoma - primary lung cancer SCLC (oat cell) NSCLC (adenocarcinoma, large cell) Metastatic tumours - secondary lung tumours Carcinoid tumours (wannabes) Pulmonary nodules (coin lesions/SPN)

Answer 271

aka coin lesions solitary nodules with no other clinical presentation; presents as a round/oval shadow usually less than 3cm on CXR Can also have calcification present Wide range of causes benign (80%) and malignant (20%)

Answer 272

Benign: infectious granuloma eg TB other infections eg localised pneumonia, abscess, hydatid cyst, benign neoplasms, arteriovenous malformations, bronchogenic cyst, pulmonary infarct, inflammatory conditions like rheumatoid nodule or Wegeners granuloma ``` Malignant: bronchial carcinoma single metastasis lymphoma pulmonary carcinoid ```

Answer 273

``` Primary lung tumour (95% malignant; 5% benign) Secondary malignancy Carcinoid tumour Arteriovenous malformation (AVM) -Hamartoma^ -Chondroma -Abscess -Granuloma: TB, Non-tuberculous mycobacteria (NTM), Fungi, Sarcoidosis, RA,) -Encysted effusion (fluid, blood, pus) (e.g. Vanishing tumor/Phantom tumor) -Cyst -Foreign body (FB) -Hydatid cyst Not all spots are SPN/Coin lesions: Nipple Skin lesion/tumour ECG monitoring leads Encysted pleural fluid Healing rib fracture (callous) ```

Answer 274

main risk factor is tobacco smoking, which is associated with 80% of lung cancer cases. Passive smoke inhalation Air pollution Family history of cancer, especially lung cancer Male sex (3:1 ratio) Radon gas (typically affects miners) and ionising radiation

Answer 275

``` Pulse oximetry ECG preoperatively FBC: anaemia LFTs: raised ALP and GGT indicate hepatic or bone metastases U+Es: baseline before treatment Serum Calcium: elevation of PTH-related protein common in SCC CXR PET/CT-scan for staged imaging bronchoscopy+/- biopsy if indicated CYTOLOGY of sputum, pleural fluid etc. ``` *all Pts with NSCLC considered for radical treatment should have a staging PET.CT scan to detect occult distant metastasis in brain, bone and liver*

Answer 276

Begins with TNM staging classification then to I-IV staging below: I - one small tumour (less than 4cm) localised to lung II - larger tumour (more than 4cm) may have spread to nearby lymph nodes III - tumour spread to contralateral lymph nodes or grown into nearby structure eg trachea IV - tumour spread to lymph nodes outside of chest or other organs eg liver

Answer 277

Stage I-III: surgery: lobectomy/pneumonectomy in pts with intact lung functions wedge resection in pts with reduced lung function Preoperative chemotherapy Postoperative chemo and radiotherapy (Neoadjuvant preoperative chemo: may downstage tumours to render them operable . Adjuvant postoperative chemo and radio: improves survival chance reducing risk of tumour recurrence after resection) Stereotactic ablative radiotherapy in pts unsuitable for surgery Stage IV: Targeted therapy: target specific mutated cells Immunotherapy: drugs target immune checkpoints preventing pts immune cells from killing tumour cells (emerging therapy) Chemotherapy: especially important for those who do not have mutations for targeting via other methods Palliative care: palliative radiotherapy for metastases and symptoms control

Answer 278

Chemotherapy and radiotherapy Surgery: rare in small cell lung cancer, as most patients present with advanced disease. Prophylactic cranial irradiation: since small cell lung cancer is associated with a high risk of brain metastases, radiotherapy is directed at the brain to prevent brain metastases.

Answer 279

CXR approach: based on risk factors for malignancy: Age above 40 years Smoker Occupational exposure to carcinogens etc. Suspicious CXR features: Lesion size greater than 3cm Irregular border (spiculated margin) Eccentric calcification (eg popcorn calcification) Increasing size in follow up CXR PET-CT scan/CT-guided biopsy Excision if suspicious Based on clinical judgement in MDT In Pts with high risk excision could precede all steps after CXR In cases of benign looking lesions and very low risk pt. Follow ups could also feature in approach to see if there are any changes etc.

Answer 280

Type of coin lesion Is not a neoplasm, just a mass of disarranged normal lung tissue benign and rare condition Diagnosed by CT scan shows lobulated mass with flecks of calcification Treatment is often excision to exclude malignancy

Answer 281

Localised fluid in interlobular fissue, secondary to chronic heart failure treatment is to treat the CHF and tumour appearance on CXR should also 'vanish' aka phantom tumour

Answer 282

Most common lung cancer: due to lungs receiving venous blood from whole body, therefore likely to pick up metastases spread from other sites in body is 2nd most common site for distant metastases (1st is liver for same reason) Typical sites for primary tumour: kidneys, prostate, breast, GIT, cervix, ovary Metastases usually develop in parenchyma

Answer 283

Presentations: Relatively asymptomatic even if extensive Carcinoma of the stomach, pancreas and breast may involve mediastinal lymph nodes, causing progressive and severe breathlessness Investigations: CXR: multiple and bilateral ‘cannonball lesions’ appearance CT scan Biopsy if indicated

Answer 284

Management of primary tumour Lung metastases is usually sign of stage 4 cancer; indicating start of palliative chemo-radiotherapy Metastasectomy can be performed in exceptions like colon cancer, Wilms tumour, oligometastatic breast cancer. These have slow growth characteristics meaning that it may be useful to remove primary and secondary metastases if there is only one/few metastases. May help to improve survival chances or alleviate symptoms.

Answer 285

most common Primary lung carcinoma (95% cases) less common cancer than secondary arises from bronchus Leading cause of cancer death - very very aggressive Peak incidence between 55-65 years

Answer 286

Small cell lung cancers: (15% cases) Approach from beginning is palliative Cancer is incredibly aggressive with very poor prognosis Non-small cell lung cancers (85% cases) Squamous cell carcinoma SCC (37%) thought to arise from proximal airway Adenocarcinoma (35%) more distal airway origins Large cell carcinoma (7%) Carcinoid tumours (6%)

Answer 287

arise from endocrine cells (kulchitsky cells) secretes polypeptide hormones causing paraneoplastic syndromes More common in elderly smokers located centrally cells are poorly differentiated (multiply too fast to specialize) early development of widespread metastases responds to chemotherapy but has poor prognosis

Answer 288

adenocarcinoma: located peripherally in smaller airways. Glandular differentiation. Associated with asbestos exposure. more common in NON SMOKERS and ASIAN WOMEN Metastases early but responds well to immunotherapy SCC: located centrally (bronchi), squamous cell differentiated (KERATINISATION). more common in smokers. Secrete PTHrP causing hypercalcaemia metastases late via lymph nodes. Large cell: Poorly differentiated cells, metastases early. located peripherally. more common in smokers

Answer 289

Often no physical signs on clinical examination Tumours located in the periphery tend to give earlier signs (like adenocarcinoma): pleural and chest wall invasion: Signs of pleuritic chest pain - parietal pleural irritation or invasion Constant chest wall pain - rib/muscle involvement, intercostal nerve involvement etc. Pleuritic friction rub Pleural effusion Tumours localised in central areas tend to give later signs (like SCC, carcinoid): bronchus invasion: Cough - bronchial irritation or compression Hemoptysis - tumor erosion or irritation Chest pain Breathlessness - obstruction or compression of airway Recurrent infections (pneumonia, lung abscess)

Answer 290

Needs FULL RESP. EXAM if cancer suspected Cachexia: increased resting energy expenditure and lipolysis Finger clubbing Dullness to percussion: tumour Cervical lymphadenopathy: metastases in lymphatics Wheeze on auscultation: tumour obstructing airway

Answer 291

``` Patient above age 40 with two of following symptoms (or is smoker with one of following symptoms): cough weight loss appetite loss dyspnoea chest pain fatigue ``` Consider urgent referral for anyone above 40 with one of follwing: persistent or recurrent chest infections finger clubbing supraventricular lymphadenopathy or persistent cervical lymphadenopathy chest signs consistent with lung cancer thrombocytosis Unexplained haemoptysis or CXR suggestive of carcinoma Urgernt referral for 2 week wait CXR and follow ups

Answer 292

General approach: Confirm diagnosis via tissue sample Assess spreading to other areas of body (image staging CT/PET scan) Refer to MDT Management then based on TNM staging and MDT decision

Answer 293

pancoast tumour: unique due to apical location causing many VESSEL COMPLICATIONS! Apical lung cancer non-SCLC (mostly, but can be SCLC rarely) Invasion to adjacent structures: subclavian vessels, lymphatic system, brachial plexus, spine, 2-3rd ribs, stellate ganglion, SNS Mass effect: local inflammation due to tumour site causes compression of surrounding vessels Difficult to treat Typical symptoms of lung cancer usually absent Pt is usually a smoker with rapid deterioration symptoms and signs in the eye, face, neck, shoulder, arm and vocals (whatever vessels are invaded) Mass seen in apex of lung in CXR

Answer 294

Severe shoulder pain or paraesthesia towards axilla and scapula (brachial plexus) Atrophy of hand or arm muscles (nerve invasion) Horner syndrome(occurs on same side of face as the nerve affected!!)- caused from T1 sympathetic nerves compression! These supply the head, neck and eyes so will cause; ptosis (drropy eyelids), miosis (constricted pupils), anhydrosis (failure to sweat), hemianhidrosis, enophthalmos (SNS invasion) Compression of blood vessels with oedema in face and arms, flushed face, shortness of breath (SVC invasion) Hoarse voice (recurrent laryngeal nerve invasion) Bovine (non-exposive) cough (recurrent laryngeal nerve invasion) General symptoms: malaise, fever, weight loss, fatigue etc.

Answer 295

``` Diagnosis: CT scan/CXR Biopsy to confirm cell type Treatment: Preoperative chemo/raidotherpy to shrink tumours make them operable Surgery ```

Answer 296

Usually starts on bronchus (central area) on lung and doesn’t present clinically until later Produces airway obstruction symptoms: cough, hemoptysis, chest pain, SoB, recurrent infections Strongly associated with smoking May show cavitation (diagnosis similar to TB) Most common in elderly men Doesn’t tend to metastasis early Better prognosis

Answer 297

More common in women Most common cancer in non-smokers Most common cancer with asbestos exposure Starts near lung periphery: gives earlier signals in development Invasion of pleura, mediastinal lymph nodes are common with later chest wall invasion In later stages can often spread to brain and bone Asbestosis: In lung causes adenocarcinoma In pleura causes mesothelioma (range of benign to malignant tumours)

Answer 298

Start in any part of lung | Poor prognosis; undifferentiated (high grade) tumours that spread early in the body

Answer 299

Aka oat cell carcinoma Usually starts in central lung in proximal/central bronchi: signals occur in later disease; cough, chest pain, haemoptysis, SoB, recurrent pneumonia, lung abscess Grows rapidly and spreads to lymph nodes and other organs quickly Usually only palliative treatment of chemo-radiotherapy Response to chemotherapy better than others Arises from endocrine cells: causing hormone secretion producing Paraneoplasic syndromes Highly proliferative Accounts of 10-20% all lung cancer Strongest associated with smoking (only 1% occur in non-smokers) Mostly males Diagnosis common at age 60 Onset of symptoms is rapid Endobronchial biopsy to confirm

Answer 300

``` Endocrine: PTHrP causing hypercalcemia ACHT Cushings syndrome ADH (inappropriate secretion) Carcinoid syndrome Gynecomastia etc. ``` Neurology: encephalopathy subacute cerebellar degeneration progressive multifocal leukoencephalopathy peripheral neuropathy Eaton-lambert syndrome (esp. associated with SCLC) Skeletal: finger clubbing Haem: anaemia Thrombocytosis many more

Answer 301

Carcinoid tumour of lung.GIT, phyllodes tumour of breast, mesothelioma of pleura, desmoid tumour of abdominal wall, mucinous/serous adenoma of pancreas Tumour between adenoma and adenocarcinoma in terms of grading All are malignant but with very low grade Slow growing with good prognosis Carcinoid: means Tumour-like: 1-2% lung malignancies uncommon Low grade malignant very slow spreading Often in central airways of lung One of the neuroendocrine tumours of lung originating from Kulchitsky cells Pathology shows ‘rosette’ formation

Answer 302

``` Cough Wheeze Haemotpysis Chest pain SoB Recurrent infections Carcinoid syndrome (flushing, sweating, abdominal cramps, oedema, diarrhoea etc.) is rare (unlike in GI carcinoids) as not enough hormones made to produce these symptoms ```

Answer 303

``` Diagnosis: 2wk referral CXR PET-CT scan Treatment: Referral to MDT Surgery if advised ```

Answer 304

Lambert-Eaton myasthenic syndrome is a result of antibodies produced by the immune system against small cell lung cancer cells. These antibodies also target and damage voltage-gated calcium channels sited on the presynaptic terminals in motor neurones. This leads to weakness, particularly in the proximal muscles but can also affect intraocular muscles causing diplopia (double vision), levator muscles in the eyelid causing ptosis and pharyngeal muscles causing slurred speech and dysphagia (difficulty swallowing). This weakness gets worse with prolonged used of the muscles. This syndrome has similar symptoms to myasthenia gravis although the symptoms tend to be more insidious and less pronounced in Lambert-Eaton syndrome. In older smokers with symptoms of Lambert-Eaton syndrome consider small cell lung cancer.

Answer 305

``` PH 7.35-7.45 PaCO2 4.7-6.0kPa Bicarbonate 22-26 mEq/L Base excess +2 - -2mmol/L PaO2 11-13kPa ```

Answer 306

How is the patient? assess history eg vomiting likely loss of acidity etc. Assess oxygenation (can rely on ABG for this, not VBG): less than 8kPa on air is resp failure but if pt on oxygen; anything less than 10kPa of inspired air is resp. failure (type 1 just hypoxia; type 2 hypoxia and hypercapnia) Determine pH or H+ (between 7.35-7.45) acidosis is low; alkalosis is high Determine respiratory component (CO2 between 4.6-6kPa) Determine metabolic component (bicarb between 22-26; BE between -2 to 2) ROME = respiratory opposite (to pH) Metabolic equal (to pH) eg if CO2 is high then is low pH (acidosis) and if bicarb/base excess is high then pH also high (alkalosis)

Answer 307

``` Caused by increased CO2 CAUSES: Hypoventilation sedatives/sedation/opiates due to respiratory depression Depression of respiratory centre in brain stem via trauma Pneumonia Asthma COPD ```

Answer 308

``` Caused by hyperventilation blowing off too much CO2 CAUSES: Anxiety Hypoxaemia (HF) PE Pneumothorax Pain ```

Answer 309

``` Increase in circulating acids or loss of HCO3- CAUSES: Renal failure (unable to excrete H+) Lactic acidosis (increased acids) Keto acidosis (increased acid) Diarrhoea (HCO3- loss) ```

Answer 310

``` Increase in HCO3- Or loss of metabolic acids CAUSES: Prolonged vomiting (acid loss) GI suctioning (acid loss) Hypokalaemia (H+ excretion) ```

Answer 311

primary insult will reflect the pH, while compensatory system will reflect the OPPOSITE (high pH with high bicarb is primary insult, but CO2 also raised in order to compensate for alkalosis by developing resp. acidosis!!) Always go by pH to determine primary cause and match to bicarb or CO2 Compensatory mechanism always state ‘partial’ or ‘full’ to describe if it is correcting the problem or not For cases of FULL COMPENSATION: look at patient and assess which is primary insult based on history OR based on results alone; use judgement on if pH looks more on the acidic or alkali side (low or high) the one it's closer to is probably primary insult

Answer 312

Less than 2 normally High lactate = disease with lactate accumulation In general, the higher the lactate the more severe the condition When associated with hypoxia, lactate increase can indicate organs aren’t functioning properly Separated into two groups: Type A: most common type may be due to hypoxia from hypoventilation or reduced blood flow Conditions include: shock from trauma or hypovolaemia, sepsis, MI, CHF, severe lung disease or resp. Failure, pulmonary oedema, severe anaemia Type B: reflects excess demand for O2 or metabolic problems including: liver disease, kidney disease, uncontrolled diabetes, drugs like salicylates and metformin, exposure to toxins like cyanide and methanol, variety of rare inherited metabolic and mitochondrial diseases that are forms of MD and affect ATP productions or strenuous exercise like marathon runners

Answer 313

Derived variable used for evaluation of metabolic acidosis to determine presence of unmeasured anions To work out if acidosis is from increased acid production vs decreased acid excretion can calculate anion gap Na+ - (CL- + HCO3-) Increased gap indicated increased acid production or ingestion such as diabetic ketoacidosis, lactic acidosis or aspirin overdose Decreased gap indicates decreased excretion or loss of HCO3- such as diarrhoea, ileostomy, proximal colostomy, renal tubular acidosis (retaining H), addison's disease etc.

Answer 314

Causes respiratory tract and lung infections So common that most children have been infected by age 2 Can also infect adults In adults and healthy children RSV is usually mild and typically mimics the common cold Self care measures are usually all that's needed Spread via droplet infection Contagious for a few days post infection but can be up to few weeks

Answer 315

``` SYMPTOMS: most commonly appear 4-6 days after viral exposure Congested or runny nose Dry cough Low grade fever Sore throat Mild headache Severe cases: Fever Severe cough Wheezing Tachypnea Cyanosis In severe cases in infants: Short, shallow and rapid breathing Cough Poor feeding Fatigue Irritability ```

Answer 316

Premature infants Young children with congenital heart or lung defects Children with immunosuppression Older adults Adults with asthma, CHF or COPD Immunodeficient pts (HIV, transplants/chemotherapy)

Answer 317

Pneumonia Middle ear infection Asthma Repeated infections

Answer 318

Usually diagnosed via auscultation and exam Wheeze in chest Blood tests for infection (WCC, RBC, FBC, CRP) CXR for lung inflammation Swab of mouth or nose for culture Pulse oximetry to detect hypoxia

Answer 319

TREATMENT: Generally self care is all that’s needed; stay hydrated OTC meds like acetaminophen (tylenol) to reduce fever, nasal saline drops Antibiotics if there is a bacterial complication (pneumonia) Hospital care includes IV fluids, humidified O2 and mechanical ventilation PRN Preventative medications: Palivizumab (Synagis) can help protect children at high risk of RSV complications Medication recommended for children born prematurely with or without chronic lung disease, infants under 12 months with congenital heart disease, under age 2 who needed supplemental O2 at birth for at least 1 month and continue to have lung treatments or children under 2 who are immunocompromised during RSV season (winter) Medication usually given monthly for five months during peak RSV season Does not help symptoms once virus has been caught, only helps prevent

Answer 320

Common LRTI affecting infants under 2 years Most cases (90%) are mild and clear up within 2-3 weeks without need for treatment Caused by virus called respiratory syncytial virus (RSV) Spread via droplet infection (coughs n sneezes) Causes bronchioles to become inflamed reduced air intake in lungs and causing dyspnea Around 1 in 3 children in UK develop during 1st year of life (most common between 3-6 months old) By age 2 almost all infants have been infected with RSV and up to half have had bronchiolitis Possible to get more than once - more common from Nov to March

Answer 321

usually worst between days 3-5. Cough usually resolves around 3 weeks. Runny nose Cough (dry and persistent) Fever Difficulty feeding typically after 3-5 days of illness Rapid or noisy breathing (wheezing or crackles on auscultation) WHEN TO SEEK HELP: Child taken less than half their usual amount during last 2-3 week feeds Have had dry nappy for 12 hours or more Persistent fever above 38 degrees Seems irritable or tired RED FLAGS: Severe respiratory distress e.g.: grunting, marked chest recession Nasal flaring RR over 70bpm Persistent O2 sats under 92% on air Clinical dehydration (fluid intake is 50-75% or normal or no wet nappy for 12 hours Central cyanosis (blue lips or tongue) Aponea Exhaustion (not responding to social cues normally, wakes only with prolonged stimulation)

Answer 322

for developing severe bronchiolitis: Chronic lung diseases Hemodynamically significant congenital heart disease Infants under 3 months old Premature birth particularly under 32 weeks Neuromuscular disorders Immunodeficiency *take into account social risk factors (housing, ability and availability of carer to monitor child while unwell; as other factors for referral to secondary care while unwell*

Answer 323

INVESTIGATIONS: Clinical assessments: RR, auscultations etc. Oxygen saturation DIFFERENTIALS: Asthma (consider in infants with recurrent or persistent episodic wheeze or crackles and family history of atopy)

Answer 324

Based on clinical assessment of child's symptoms and respiratory rate: Persistent cough AND Either tachypnea or chest recession (or both) AND Either wheeze or crackles on chest auscultation (or both) Young infants (especially under 6 weeks) may present with apnea without other clinical signs

Answer 325

Mostly mild will clear up within 2-3 weeks without treatment Self care; good hydration, paracetamol or ibuprofen PRN 2-3% admitted to hospital for serious symptoms of breathing difficulties (more common in premature babies and those with congenital heart or lung conditions) Give supplemental O2 for hypoxia Fluids by nasogastric or orogastric tube (if cant take fluids by mouth) Fluids IV isotonic for children not tolerating above or have impending resp. failure Chest physiotherapy assessment for children with relevant comorbidities (spinal muscular atrophy etc) Consider CPAP with respiratory failure Capillary blood gas testing if worsening respiratory distress (when supplemental O2 is greater than 50%)

Answer 326

PREVENTION: Good hygiene Clean toys and surfaces Keep infected children at home until better Avoid smoking near children High risk children for severe bronchiolitis can have monthly antibody injections to help limit severity of infection DISCHARGE: Clinically stable Taking adequate oral fluids Maintained O2 above 92% for 4 hours including period of sleep

Answer 327

Common childhood disease usually caused by virus Most common in children aged 6 months - 6 years; peak incidence at age 2 Usually self limiting resolves in around 48 hours

Answer 328

``` Sudden onset barking cough Usually with stridor (inspiratory) on auscultation Symptoms usually worse at night Mild: Seal like barking cough Moderate: Cough With stridor And sternal recession at rest Severe: Cough With stridor And sternal recession at rest Associated with agitation and lethargy Symptoms of impending respiratory failure: Increasing upper airway obstruction sternal/intercostal recession Asynchronous chest wall Abdominal movement Fatigue Pallor or cyanosis Altered conscious levels Respiratory rate over 70bpm ```

Answer 329

Bacterial tracheitis: fever, sudden onset stridor and resp. Distress, following viral like illness Epiglottitis: high fever, dysphagia, drooling, anxiety, cough, sit upright head extended preferred Foreign body in upper airway: stridor, dyspnoea, history in inhalation Allergic reaction: rapid onset dysphagia, stridor, rash, family history of allergies

Answer 330

All children with mod-severe presentation should be admitted immediately to hospital All children should be given single dose of oral dexamethasone (0.15mg per kg body weight) If child too unwell for this; give inhaled budesonide (2mg nebulised single dose) or intramuscular dexamethasone (0.6mg/kg single dose) Mild croups can be managed at home however admission considerations include: chronic lung disease, congenital heart disease, neuromuscular disorders, immunodeficiency, under 3 months old, dehydration, social factors meaning care would not benefit etc. Mild home management includes paracetamol or ibuprofen for fever distress, good hydration, regularly check child's wellbeing and monitor signs, advise parents symptoms usually resolve within 48 hours and safety net to come back/phone ambulance if signs of respiratory distress or persists longer than this

Answer 331

Highly contagious bacterial infection Caused by bacteria bordetella pertussis Incubation time roughly 5-10 days but symptoms may not appear for up to 3 weeks Infectious from 6 days - 3 weeks post infection Antibiotics can help reduce this infective window Infants are at highest risk of death even after starting treatment Children and adults generally recover quickly with early medical intervention

Answer 332

Early symptoms mimic the common cold; runny nose, cough and fever Coughing bouts lasting a few minutes Worse at night Makes ‘Whoop’ sound with gasps for breath in between coughing (may not if infants) Thick mucus Can cause vomiting Red flushed face (more common in adults)

Answer 333

``` Complications in infants under 6 months: Dehydration Breathing difficulties Pneumonia Seizures Complications in children and adults: Nosebleeds Sore ribs Hernia ``` ``` COMPLICATIONS: Brain damage Pneumonia Seizure Bleed on brain Apnea Convulsions Death Urinary incontinence Rib fractures Sleeping difficulty ```

Answer 334

URGENT 111 CALL IF: Baby under 6 months Cough is worsening Been in contact with someone with whooping cough and are pregnant Been in contact with someone with whooping cough and are immunocompromised *best to call GP before coming in as is very very contagious* CALL 999 for: Apnoea Cyanosis Shallow breathing (resp. Rate over 70) Pain worsening with breathing or coughing (pneumonia) Seizures

Answer 335

Sputum cultures/samples Pulse oximetry Blood tests and cultures

Answer 336

Severe cases or under 6 months old: Hospitalisation: IV fluids, respiratory support, antibiotics for infection but do not treat the cough (may persist for long time post infection) If diagnosed within 3 weeks of infection will be given antibiotics to help reduce spread to others If diagnosed after 3 weeks of infection antibiotics are not needed For mild cases: self care; rest, hydration, paracetamol or ibuprofen for discomfort/fever PREVENTION: Vaccination in infants and young children Usually given as part of the 6 in 1 vaccination for infants aged 8, 12 and 16 weeks and the 4 in 1 pre school booster for pre school children Should also be vaccinated if pregnant ideally between 16-32 weeks

Answer 337

Inflammation and swelling of the epiglottis Often caused by infection Can occur from throat trauma/injury Can be fatal if throat becomes completely blocked With prompt treatment most recover from condition within a week and can be discharged within 5-7 days

Answer 338

Haemophilus influenzae type b bacteria Pneumonia Meningitis Spread by droplet infection and contaminated surfaces Less common causes include strep. Pneumonia, fungal infections (in immunosuppressed) and viral infections like chickenpox.

Answer 339

Severe sore throat Dysphagia and pain while swallowing Difficulty breathing (may improve when leaning forward) Stridor on auscultation Fever Irritability and restlessness Muffled or hoarse voice Drooling *main symptoms in children are breathing difficulties, stridor, dysphagia and drooling* *main symptoms in adults and older children are dysphagia and drooling*

Answer 340

Hospitalisation Intubation and oxygenation In severe and urgent cases tracheostomy needed for oxygen access Nasal oxygenation tube inserted once patient is more stable Once the patient is stable; tests can be carried out: Fiberoptic laryngoscopy (flexitube with camera to examine throat) Throat swab to test for infection CXR or CT scan to check level of swelling PREVENTION: Vaccination for HiB, particularly in children who are most vulnerable to this infection Babies vaccinated in 6 in 1 vaccination Should receive 3 doses at 8, 12 and 16 weeks of age followed by booster vaccine at age 1 Due to this vaccination, most child cases are rare and now only really occur in adults

Answer 341

High probability asthma: typical clinical assessment, recurrent symptoms, wheeze heard, historical record of variable airflow obstruction and +ve history of atrophy without features to suggest alternative diagnosis Record pt as likely having asthma and commence carefully monitored inhalation treatment (typically 6wks ICS) Assess lung function and daily life (questionnaires) With good symptomatic relief and objective response can confirm asthma diagnosis If response is poor or equivocal check inhaler technique and adherence, arrange further tests and consider alternatives Intermediate probability: spirometry with bronchodilator reversibility tests if appropriate, FeNO for eosinophilic inflammation if spirometry is normal, ‘watch and wait’ technique if children are asymptomatic or careful monitoring with symptomatic child Low probability asthma: undertake further tests into alternative diagnoses or further lung function tests to widen clinical picture

Answer 342

Clubbing Til Pulmonary Bronchi Burst ``` Cystic fibrosis Tuberculosis Pulmonary fibrosis Bronchiectasis Bronchial carcinoma ```

Answer 343

Lung Ineffective mucociliary clearance; obstruction of the alveoli/bronchioles with an increased risk of infection Destruction of the lung and reformation into a honeycomb parenchymal pattern due to chronic inflammation Pancreas Blockage of the exocrine gland’s secretion outlets Fibrotic and cystic mutation Loss of exocrine function Gallbladder Obstruction of bile drainage Development of biliary cirrhosis Intestines Obstipation

Answer 344

Chronic inflammatory disease of the middle to small sized airways Hypersensitivity reaction causing increased goblet cell secretion increases mucus build up lining the airways This blocks the mid to small sized airways due to the mucus taking up too much of the lumen (as the lumen is smaller) and so creates obstruction of air This can cause high pitched wheeze noises classic presentation of asthmatics

Respiratory diagnosis+management Flashcards

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