Revision Flashcards by Miranda King

Localised Oedema

Pneumonia (fluid filled airspaces leading to consolidation)

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What is lobar pneumonia most often due to?

Who does this typically present in?

Strep pneumoniae (pneumococcus) = most common

Klebsiella and Legionella as well

Healthy young adults in the community

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Describe the pathology of lobar pneumonia

ACUTE inflammatory response involving:

exudation if fibrin rich fluid in alveoli
neutrophil > macrophage infiltration
resolution

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What is Bronchopneumonia?

Infection that starts in the airways and spreads to adjacent alveolar lung

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Who gets Bronchopneumonia?

Usually in the context of pre-existing disease:

COPD
Cardiac failure in the elderly
Complication of viral infection (influenza)
Aspiration

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Organisms involved in Bronchopneumonia

Strep. pneumoniae, H. influenza, Staph, anaerobes, coliforms

ASPIRATION = staph, anaerobes, coliforms

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Lung abscess context

Aspiration

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Pathology of TB

A delayed Type IV Hypersensitivity reaction: granulomas with necrosis, accumulation of neutrophils and gram cells

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Lesion in secondary TB

Fibrosing and cavitating apical lesion (cancer is important lesion)

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Galloping consumption

Rapidly progressing TB pneumonia

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Opportunistic pathogens in immunocompromised hosts

Virus - CMV

Bacteria - Mycobacterium avium intracellulare

Fungi - aspergillus, candida, pneumocystis

Protozoa - cryptosporidia, toxoplasma

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Appearance of CMV (cytomegalovirus) pneumonia on transbronchial biopsy

‘Pulmonary Oedema’

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Fungal pneumocystis on biopsy

‘Bubbly fluid’

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Pulmonary Interstitium

Alveolar lining + thin elastin-rich connective component which contains capillary blood vessels

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Alveolitis

Early interstitial disease due to injury with inflammatory cell infiltration

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Fibrosing alveolitis

Idiopathic Pulmonary Fibrosis

Cryptogenic Fibrosing Alveolitis

Usual Interstitial Pneumonia

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Pathology of Fibrosing Alveolitis

In subpleural and basal areas
Variable immune component

END STAGE: lung structure replaced by dilated spaces, surrounded by fibrous walls (honeycombing)

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Other names for EAA

Hypersensitivity pneumonitis

Chronic Inflammatory disease (affecting small airways, interstitium, occasional granulomas)

Allergic origin in Type III + IV hypersensitivity

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Farmer’s Lung

Bird Fancier’s Lung

Malt Worker’s Lung

Thermophilic bacteria
Avian proteins
Fungi

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Lung scarring in Sarcoidosis

Apical

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Severity of Pneumoconiosis

Particle size
Particle reactivity
Clearance of particle
Host response

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Describe the pathology and pathogenesis of ARDS

Injury (ie. bacterial endotoxin) > infiltration of inflammatory cells > cytokines > oxygen free radicals > injury to cell membranes

May lead to death/resolution/fibrosis (chronic restrictive lung disease)
Fibrous exudate lining alveolar walls (hyaline membranes) > cellular regeneration > inflammation

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Primary Pulmonary Hypertension

Rare, usually young women

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What inflammatory cell characterises the late phasa of asthma?

What does this do?

Eosinophil

Releases major basic and cationic proteins
These cause epithelial damage which results in airway hyper-responsiveness and inflammation
This leads to bronchospasm, wheezing and mucous over secretion

Infiltration of cytokine releasing Th2 cells and monocytes also occurs here > delayed response

Eosinophils + Lymphocytes

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Inflammatory cells which show the immediate phase of asthma

**Mast Cells** - Which release spasmogens, cysLTs and histamine to cause bronchospasm and early inflammation

SABA

Salbutamol Terbutaline

LABA

Salmeterol Formoterol

Ultra-LABA

Indacaterol

cysLT receptor antagonists

Montelukast Zafirlukast

Methylxanthines (PDE inhibitors)

Theophylline Aminophylline

Glucocorticoids

Beclometasone Budenoside Fluticasone

Cromones (mast cell stabilisers)

Sodium cromogylcate

Mono-clonal Antibodies

Omalizumab (anti IgE) Mepolizumab (anti IL-5)

SAMA

Ipratropium Oxtitropium

LAMA

Tiotropium Aclindinium

PDE4 Inhibitor

Rofumilast Used in COPD

H1 receptor antagonists

Loratidine Fexofenadine Cetirizine

A1 adrenoceptor agonist

Oxymetazoline

Mucolytics

Carbocistein

Location of peripheral chemoreceptors

Aortic arch and carotid arteries

Where are the central chemorecptors located? What is their role?

- Near the surface if the medulla of the brainstem - To respond to the H⁺ ion concentration of the cerebrospinal fluid

Blood Brain Barrier

- Impermeable to H⁺and HCO₃^- - Permeable to CO₂ and O₂

Chronic Adaptations to high altitude hypoxia

- Increased RBCs and 2,3 BPG - Increased capillaries, acid conservation in the kindeys, mitochondria

Peripheral Chemoreceptors

Adjust for acidosis caused by non-carbonic acid H⁺

Normal Tidal Volume

500ml

Airflow

Change in Pressure / Resistance

Peak Flow Rate

Speed at which you can bring air out of the lungs/airways

How is pulmonary compliance measured?

Volume change/ unit pressure change **across the lungs**

TLCO (Transfer factor for the lung of CO) is increased in...

Alveolar haemorrhage

To increase pulmonary ventilation, why is it more advantageous to increase the depth of breathing?

Due to dead space

Type I alveolar cells

- Simple squamous epithelium that lines the alveolar surface, providing a thin barrier that is permeable to gases -

Respiratory Epithelium

Psuedostratified ciliated epithelium with goblet cells

Which antbiotic is streptococcus sensitive to?

Amoxicillin

Primary Influenza Pneumonia

A disease of young adults in pandemic years

Complication of coxiella

Endocarditis

Flu vaccines

Killed - adults at risk, HC workers, babies age 2 (influenza A + 1B virus) Live attenuated - intranasal, all children aged 2-5 years

Pneumonia in... OLD YOUNG

Old = strep pneumoniae Young = mycoplasma

Formoterol/Salmeterol - which has the advantage?

Formoterol has the faster onset of action

2 Neutrophil chemotactic factors

Il-8 LTB4

Isoprenaline

Non-selective B adrenoceptor agonist

Thrombophlebitis

Increased coaguability of blood in cancer patients

IPF on Chest X ray

Rounded areas of honeycombing

Causes of macrocytic cells

B12/Folate deficiency Anaemia Alcohol excess Liver Disease Hypothyroidism

Types of hypoxia

Circulatory = due to blockage e.g. abcess Anaemic Hypoxaemic Toxic

Exhaled breath NO

- Measure of eosinophilic airway inflammation in asthma Used with bronchial challenge to assess asthmatic inflammation especially if bronchial challenge is normal

Diagnosis and management of pleural effusion

Diagnosis: CXR, Aspirate, Pleural biopsy Treatment: Drain, Pleurodesis

Diagnostic features of ARDS

1. Acute onset 2. CXR showing bilateral infiltrates 3. Pulmonary capillary wedge pressure \<19mm Hg (not congestive heart failure) 4. Refractory hypoxaemia 5. Cyanosis, Tachypnoea, Tachycardia, fine inspiratory crackles

Croup

Steeple sign Treat with steroids

Squeaks and crackles...

Bronchiolitis

Pleural click

Pneumothorax

Coarse crackles Fine crackles

Oedema, consolidation, bronchiectasis Fibrosis

Signs of Cor Pulmonale

Cyanosis, raised JVP, pitting oedema, parasternal heave and loud P2

Diagnosis of sarcoidosis

Do a transbronchial biopsy of hilar lymph nodes

Monoclonal antibody against RSV

Palivizumab

Intrinsic Asthma

Not IgE mediated

Treatment of anaphylaxis

IM adrenaline IV anti-histamine IV corticosteroids High flow O₂ Nebulised bronchodilators Intubation (if needed)

Why do B-Lactams not act on mycoplasma pneumoniae?

They don't have a peptidogylcan cell wall

Methaemoglobin

A form of Hb made from Fe³⁺ which has a decreased ability to bind O₂

Expression of adhesion molecules on leukocytes is increased by

C5a LTB4 TNF

Expression of adhesion molecules on endothelial cells is increased by

IL-1 TNF Endotoxins

Bronchial arteries

2 left 1 right

Cells which are effectors in allergic reactions

Basophils

Endothelium

Epithelium of the blood vessels - simple squamous

Management of Sarcoidosis

NSAIDs Systemic corticosteroids

Mycoplasma pneumoniae

Treat: Claryithromycin/Doxycycline/Fluroquinalone Resistant to B Lactams

Klebsiella pneumoniae

Treat: Carbopenem (Cefotaxine or Imipenem)

Pseudomonas

Treat: Ciprofloxacin, Gentamicin

Stapylococcus aureus

Treat: Flucloxacillin +/- Rifampicin MRSA \> Vancomycin

Streptococcus pneumoniae

0-2 CURB 65 score: Amoxicillin 3-5: Co-amoxiclav, Doxycycline ICU/HDU: Co-amoxiclav, Clarithromycin

Legionella

Treat: Clarithromycin/Erythromycin OR Levofloxacin

Chlamydophila pneumoniae

Treat: Doxcycline OR Clarithromycin

Chlamydophila psittaci

Treat: Doxycycline OR Clarithromycin

Pneumocystis pneumonia (PCP)

Treat: Co-trimoxazole or Pentanamide

Phrenic Nerve

Passes into the chest and runs anterior to the lung hilum on the lateral aspect of the firbrous pericardium

Sensitisation of airway smooth muscle by asthmatic inflammatory mediators

Results in airway hyperactivity (excessively twitchy)

Revision Flashcards

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