TO DO RESPIRATORY Flashcards
(164 cards)
1
Q
PNEUMONIA
Name 3 pathogens that can cause community acquired pneumonia (CAP)
A
- Streptococcus pneumoniae (most common)
- Haemophilus influenzae
- s.aureus
2
Q
PNEUMONIA
Name 3 pathogens that can cause hospital acquired pneumonia (HAP)
A
mainly gram negative
- Pseudomonas aeruginosa
- E.coli
- Staphylococcus aureus
3
Q
PNEUMONIA
What is the treatment for someone with mild CAP (CRUB65 score 0-1)?
A
oral amoxicillin at home
4
Q
PNEUMONIA
What is the treatment for someone with moderate CAP (CRUB65 score 2)?
A
consider hospitalising, amoxicillin (IV or oral) + macrolide (clarithromycin)
5
Q
PNEUMONIA
What is the treatment for someone with severe CAP (CRUB65 score 3-5)?
A
consider ITU,
IV Co-Amoxiclav + macrolide (clarithromycin)
6
Q
PNEUMONIA
What is the treatment for someone with Legionella pneumoniae?
A
Fluoroquinolone + clarithromycin
7
Q
PNEUMONIA
What is the treatment for someone with Pseudomonas aeruginosa pneumonia?
A
IV ceftazidime + gentamicin
8
Q
BRONCHIECTASIS
What can cause bronchiectasis?
A
- Congenital = Cystic fibrosis
- Idiopathic (50%)
- Post infection - (most common)
- pneumonia,
- TB,
- whopping cough
- Bronchial obstruction
- RA
- Hypogammaglobulinaemia
9
Q
BRONCHIECTASIS
Which bacteria might cause bronchiectasis?
A
- Haemophilus influenza (children)
- Pseudomonas aeruginosa (adults)
- Staphylococcus aureus (neonates often)
10
Q
BRONCHIECTASIS
what are the symptoms of bronchiectasis?
A
- Chronic productive cough
- Purulent sputum
- Intermittent haemoptysis
- Dyspnoea
- Fever, weight loss
11
Q
BRONCHIECTASIS
what are the signs of bronchiectasis?
A
- Finger clubbing
- Coarse inspiratory crepitate (crackles)
- Wheeze
- rhonchi (low-pitched snore-like sound)
12
Q
BRONCHIECTASIS
what are the investigations?
A
CXR - dilated airways with thickened walls (tram-tracks)
High resolution CT (gold standard) - bronchial dilation + wall thickening
sputum cultures
FBC
spirometry - obstructive pattern (FEV1/FVC <70%)
13
Q
Describe the treatment for bronchiectasis
A
1st line
- treat underlying cause
- chest physio
- annual flu vaccine
- antibiotics ofr exacerbations
2nd line
- mucoactive agent (carbocisteine)
- bronchodilator
- nebulised isotonic/hypertonic saline
- long term antbiotics (azithromycin)
long term oxygen
14
Q
CYSTIC FIBROSIS
Describe the pathogenesis of Cystic fibrosis
A
Autosomal recessive defect in chromosome 7 coding CFTR protein (F508 deletion = most common mutation)
- Cl- transport affected
- Decreased Cl secretion and increase Na reabsorption this causes an increase H2O reabsorption –> thickened mucus secretion
- in the lungs, this leads to dehydrated airway surface liquid, mucus stasis, airway inflammation and recurrent infection
- this leads to progressive airway obstruction and bronchiectasis
15
Q
CYSTIC FIBROSIS
Give 3 signs of CF
A
- Clubbing
- Cyanosis
- Bilateral coarse crepitations
16
Q
CYSTIC FIBROSIS
What is the management of the respiratory component of CF?
A
AIRWAY CLEARANCE
BRONCHODILATOR
- salbutamol
MUCOACTIVE AGENTS
- 1st line = rhDNase
- 2nd line = hypertonic saline +/- mannitol powder +/- rhDNase
- 3rd line = orkambi (lumacaftor + ivacaftor)
IMMUNOMODULATION
- 1st line = azathioprine
- 2nd line = oral corticosteroids
ANTIBIOTICS
17
Q
LUNG CANCER
From what cells are small cell carcinomas derived from and what is the significance of this?
A
Neuroendocrine cells
Can secrete peptide hormones - ACTH, PTHrP, ADH, HCG
18
Q
LUNG CANCER
where does lung cancer commonly metastasise to?
A
- Bone
- Brain
- Lymph nodes
- Liver
- Adrenal
19
Q
LUNG CANCER
which cancers most commonly metastasise to the lungs?
A
breast
bowel
kidney
bladder
20
Q
LUNG CANCER
Give examples of paraneoplastic syndromes due to lung cancer
A
- ↑PTH -> Hyperparathyroidism
- ↑ADH -> SIADH
- ↑ACTH -> Cushing’s disease
- lambert-eaton myasthenic syndrome
21
Q
LUNG CANCER
Name 3 differential diagnosis’s of lung cancer
A
- Oesophageal varices
- COPD
- Asthma
- Pneumonia
- Bronchiectasis
22
Q
LUNG CANCER
What investigations might you done on someone to determine whether they have lung cancer?
A
First line:
- CXR - central mass, hilar lymphadenopathy, pleural effusion
(a negative CXR does not rule out cancer)
- CT chest, liver & adrenal glands (gold standard) - for staging
- Sputum cytology - malignant cells in sputum
(high specificity but mixed sensitivity)
diagnostic = biopsy + histology
23
Q
LUNG CANCER
What is the treatment for SCLC?
A
Limited disease = chemo (cisplatin) + radio
Extensive = palliative chemo + care
- Superior vena cava stent + radiotherapy + dexamethasone for superior
vena cava obstruction - Endobronchial therapy - used to treat symptoms of airway narrowing:
24
Q
ASTHMA
What are the signs of an acute asthma attack?
A
- Can’t complete sentences
- HR > 110 bpm
- RR > 35/min
- PEF < 50% predicted
25
ASTHMA
What are the signs of a life threatening asthma attack?
1. Hypoxia = PaO2 <8 kPa, SaO2 <92%
2. Silent chest
3. Bradycardia
4. Confusion
5. PEFR < 33% predicted
6. Cyanosis
26
ASTHMA
What investigations might you do someone to determine whether they have asthma?
- Spirometry with reversibility testing (>5 years) = Obstructive pattern:
- FEV1 <80% of predicted normal (reduced)
- FVC = normal
- FEV1/FVC ratio <0.7
- Peak flow rate - diurnal variation
- FeNO = >40 is positive
- CXR
- Atopy = skin prick, RAST
- Bloods = high IgE, Eosinophils
27
ASTHMA
What is the long-term guideline mediation regime for asthma?
1. low dose ICS/formoterol combination inhaler (AIR therapy) or if very symptomatic start low dose MART
2. low dose MART
3. moderate dose MART
4. check FeNO + eosinophil level (if either is raised, refer to specialist).
- If neither are raised = LTRA or LAMA in addition to moderate dose MART
- if still not controlled, stop LTRA or LAMA and try other drug option (LTRA/LAMA)
5. refer to specialist
28
COPD
What is the clinical diagnosis of chronic bronchitis?
Cough/sputum for >3 months in 2 consecutive years
29
COPD
Describe the pathophysiology of chronic bronchitis
Airway inflammation --> fibrosis and luminal plugs --> decreased alveolar ventilation
30
COPD
Describe the pathophysiology of emphysema
Dilation and destruction of the lung tissue distal to the terminal bronchioles
Enlarged alveoli + loss of elastic recoil = increased alveolar ventilation
31
COPD
What can cause COPD?
1. Genetic = alpha 1 antitrypsin deficiency
2. Smoking = major cause
3. Air pollution
4. Occupational factors = dust, chemicals
32
COPD
Give 4 signs of COPD
1. Tachypnoea
2. Barrel shaped chest
3. Hyperinflantion
4. Cyanosis
5. Pulmonary hypertension
6. Cor pulmonale
33
COPD
What investigations might you do to diagnose someone with COPD?
Spirometry = FEV1:FVC < 0.7
CXR = hyperinflation, bullae, flat hemi-diaphragms, large pulmonary arteries
CT = Bronchial wall thickening, enlarged air spaces
ECG = RA and RV hypertrophy
ABG = decreased PaO2 +/- hypercapnia
34
COPD
Give 3 factors that can be used to establish a diagnosis of COPD
1. Progressive airflow obstruction
2. FEV1/FVC ratio < 0.7
3. Lack of reversibility
35
COPD
What are the treatments for COPD?
general:
- stop smoking (refer to cessation services)
- pneumococcal vaccine
- annual flu vaccine
step 1:
- SABA (salbutamol or terbutaline) or SAMA (ipratropium bromide)
step 2:
- If no asthmatic / steroid response:
- LABA (salmeterol)
- LAMA (tiotropium)
- If asthmatic / steroid response:
- LABA (i.e. salmeterol)
- ICS (i.e. budesonide)
step 3:
- long term oxygen therapy
36
COPD
what is the criteria for LTOT?
pO2 <7.3
pO2 7.3-8kPa and one of the following:
- secondary polycythaemia
- peripheral oedema
- pulmonary hypertension
do not offer LTOT to people who continue to smoke despite being offered smoking cessation
37
COPD
What is the treatment for an exacerbation of COPD?
MILD
- managed in community
- increased salbutamol
- oral antibiotics
- 5 day course prednisolone
MODERATE
- hospital admission
- nebulised bronchodilators (salbutamol/ipratropium bromide)
- IV antibiotics
- steroids
- oxygen
SEVERE
- hospital admission
- non-invasive ventilation (BiPAP)
- nebulised bronchodilators (salbutamol/ipratropium bromide)
- IV antibiotics
- steroids
- oxygen
38
PLEURAL EFFUSION
what are the causes of a transudate pleural effusion?
fluid movement (systemic causes)
1. Heart failure
2. fluid overload
3. Peritoneal dialysis
4. Constrictive pericarditis
5. hypoproteinaemia
- cirrhosis
- hypoaluminaemia
- nephrotic syndrome
39
PLEURAL EFFUSION
Name 3 causes of a exudate pleural effusion
inflammatory (local causes)
1. Pneumonia
2. Malignancy
3. TB
4. pulmonary infarction
5. lymphoma
6. mesothelioma
7. asbestos exposure
8. MI
40
PLEURAL EFFUSION
How does a pleural effusion present?
- SOB especially on exertion
- Dyspnoea
- Pleuritic chest pain
- dry cough
- Loss of weight (malignancy)
SIGNS
- Chest expansion reduced on side of effusion
- In large effusion the trachea may be deviated away from effusion
- Stony dull percussion note on affected side
- Diminished breath sounds on affected side
- Decreased tactile vocal fremitus (vibration of chest wall when speaking)
- Loss of vocal resonance
41
PNEUMOTHORAX
What investigation might you do in someone you suspect to have a pneumothorax?
1st line - CXR = translucency and collapse
ABG = in dyspnoeic patients check for hypoxia
Gold standard = CT chest (rarely done in clinical practice)
42
PNEUMOTHORAX
What is the treatment for a primary pneumothorax?
PRIMARY
- small (<2cm) + asymptomatic = consider discharge
- if >2cm or breathless = aspirate with 16-18G needle
- if successful consider discharge + follow-up
- If unsuccessful insert chest drain + admit
43
TENSION PNEUMOTHORAX
What is the treatment for a tension pneumothorax?
Put out cardiac arrest call
Start high flow O2
Insert 14G needle at 4/5th intercostal space mid-axillary line
insert chest drain
44
INTERSTITIAL LUNG DISEASE
Would pulmonary function tests taken from someone with interstitial lung disease show a restrictive or obstructive pattern?
Restrictive
| Decreased gas transfer and a reduction in PaO2
45
SARCOIDOSIS
What kind of disease is sarcoidosis?
Granulomatous disease - type of interstitial lung disease
It is defined by presence of non-caseating granulomas
46
SARCOIDOSIS
Describe the pathophysiology of sarcoidosis
Chronic inflammation --> non-caseating granuloma in various body sites
thought to be due to type VI hypersensitivity reaction
47
SARCOIDOSIS
what are the symptoms?
- non-productive cough
- gradual onset dyspnoea
- polyarthralgia
- uveitis (red eye, photophobia)
- fever
- fatigue
- weight loss
48
SARCOIDOSIS
What is the effect of sarcoidosis on the skin?
erythema nodosum (dusky coloured nodules on shins)
49
SARCOIDOSIS
What is the effect of sarcoidosis on the eyes?
Uveitis (red eyes + photophobia)
50
SARCOIDOSIS
What is the effect of sarcoidosis on the bone?
polyarthralgia
51
SARCOIDOSIS
What is the effect of sarcoidosis on the liver?
Hepatosplenmeagly
52
SARCOIDOSIS
What investigations might you do in someone who you suspect to have sarcoidosis?
BLOODS
- Raised inflammatory markers
- raised serum calcium
CXR
- hilar lymphadenopathy
- bilateral infiltrates
Chest CT
- ground glass appearance
SPIROMETRY
- restrictive (FEV1/FVC >0.8)
53
SARCOIDOSIS
How can you stage sarcoidosis?
Using CXR
Stage 1 = bilateral hilar lymphadenopathy (BHL)
Stage 2 = pulmonary infiltrates with BHL
Stage 3 = pulmonary infiltrates without BHL
Stage 4 = progressive pulmonary fibrosis, bulla formation and bronchiectasis
54
SARCOIDOSIS
How do you treat sarcoidosis?
asymptomatic non-progressive = observation
symptomatic or progressive = 1st line - corticosteroids, 2nd line - immunosuppressants
55
SARCOIDOSIS
Give 2 possible differential diagnosis's for sarcoidosis
1. Lymphoma
| 2. Pulmonary TB
56
IDIOPATHIC PULMONARY FIBROSIS
what are the risk factors of idiopathic pulmonary fibrosis?
- cigarette smoking
- infectious agents - CMV, Hep C, EBV
- occupational dust exposure
- drugs - methotrexate, imipramine
- GORD
- genetic predisposition
57
IDIOPATHIC PULMONARY FIBROSIS
what are the clinical features of idiopathic pulmonary fibrosis
1. non-productive cough
2. SOB on exertion
3. Systemic = malaise, weight loss, arthralgia
4. Cyanosis
5. Finger clubbing
6. bibasal crackles (Inspiratory crackles/crepitus)
7. dyspnoea
58
IDIOPATHIC PULMONARY FIBROSIS
What investigations might you do in someone you suspect to have idiopathic pulmonary fibrosis?
Bloods = raised CRP, immunoglobulins and check autoantibodies
CXR/CT = degreased lung volume + honeycomb lung
High resolution CT = ground glass appearance
Spirometry = restrictive
Lung biopsy = confirmation
ABG = type 1 respiratory failure
59
IDIOPATHIC PULMONARY FIBROSIS
What is the treatment for idiopathic pulmonary fibrosis?
SUPPORTIVE CARE
- pulmonary rehab
- long term oxygen
- pneumonia + flu vaccines
ANTI-FIBROTIC AGENTS
- pirifenidone
- nintedanib
LUNG TRANSPLANTATION
60
PULMONARY FIBROSIS
what are the causes of upper lobe pulmonary fibrosis?
SCART
- sarcoidosis
- coal miners pneumoconiosis
- ankylosing spondylitis
- radiation
- TB
61
PULMONARY FIBROSIS
what are the causes of lower lobe pulmonary fibrosis?
RASIO
- Rheumatoid
- Asbestosis
- Scleroderma
- Idiopathic pulmonary fibrosis (most common)
- other
62
PULMONARY HYPERTENSION
what are the causes of pulmonary hypertension
- pre-capillary
- multiple small PE's
- left-to-right shunts
- primary
- capillary
- emphysema
- COPD
- Post-capillary
- backlog of blood causes secondary hypertension
- LV failure
- chronic hypoxaemia
- living at high altitude
- COPD
63
PULMONARY HYPERTENSION
what is the clinical presentation of pulmonary hypertension
- progressive breathlessness
- exertional dizziness/syncope
- fatigue
- haemoptysis
64
PULMONARY HYPERTENSION
What are the investigations?
Initial tests:
- CXR - Enlarged main pulmonary artery, enlarged hilar vessels and pruning.
- ECG - right ventricular hypertrophy, right axis deviation, right atrial enlargement. (A normal ECG does not rule out the presence of significant pulmonary hypertension)
- TTE - (trans-thoracic echocardiogram)
Diagnostic test: Right heart catheterisation
65
PULMONARY HYPERTENSION
Describe the treatment of pulmonary hypertension
1st line
- CCBs
- pulmonary vasodilators e.g. prostacyclin, sildenafil
- diuretics
- oxygen therapy
- anticoagulation (warfarin or NOAC)
2nd line
- lung transplant
- balloon atrial septostomy
66
TB
Describe the pathogenesis of pulmonary TB disease
TB spread via respiratory droplets as it is an airborne infection
1. Alveolar macrophages ingest bacteria and the rods proliferate inside.
2. Drain into hilar lymph nodes 🡪 present antigen to T lymphocytes 🡪 cellular immune response.
3. Delayed hypersensitivity reaction 🡪 tissue necrosis and granuloma formation: caseating.
- Primary Ghon Focus
- Ghon Complex – Ghon focus + lymph nodes
67
TB
Give 3 risk factors for TB
1. Living in a high prevalence area
2. IVDU
3. Homeless
4. Alcohol
5. HIV +ve
68
TB
A special culture medium is needed to grow TB, what is it called?
Lowenstein Jenson Slope
69
TB
What is the drug treatment commonly used for TB?
RIPE
RI = 6 months
PE = for first 2 months
R = rifampicin
I = isoniazid
P = pyrazinamide
E = ethambutol
70
TB
Give 2 potential side effects of Rifampicin
1. Red urine
2. Hepatitis
3. Drug interaction - it's an enzyme inducer
71
TB
Give 2 potential side effects of Isoniazid
1. Hepatitis
| 2. Neuropathy
72
TB
Give 2 potential side effects of Pyrazinamide
1. Hepatitis
2. Gout
3. Neuropathy
73
TB
Give a potential side effect of Ethambutol
Optic neuritis
74
WHOOPING COUGH
What is the treatment of whooping cough?
Clarithromycin - in catarrhal or early paroxysmal stages
- have little effect on disease course in paroxysmal stage
75
WHOOPING COUGH
Give 2 possible complications of whooping cough
1. Pneumonia
2. Encephalopathy
3. Sub-conjunctival haemorrhage
76
CYSTIC FIBROSIS
what is CFTR and what is it's function?
* Transport protein on membrane of epithelial cells that acts as a chloride
channel
* Transports chloride ions
* Normally; it actively exports NEGATIVE IONS especially Cl- and Na+ passively follows causing an osmotic gradient and movement of water out of the cell and into the mucus
77
PLEURAL EFFUSION
what is transudate pleural effusion?
- transparent (less protein)
* Pleural fluid protein is less than 30g/L since vessels are normal so only
fluid is able to leak out and not protein
* Occurs when the balance of hydrostatic forces in the chest favour the accumulation of pleural fluid i.e. increased pressure due to the backing up of blood in left sided congestive heart failure
78
PLEURAL EFFUSION
what is exudate pleural effusion?
- exudes proteins
- Pleural fluid protein is more than 30g/L since endothelial cells of vessels are more apart meaning fluid and protein is able to leak out
- Occurs due to the increased permeability and thus leakiness of pleural
space and or capillaries usually as a result of inflammation, infection or
malignancy
79
PLEURAL EFFUSION
what are the risk factors for pleural effusion?
- Previous lung damage
| - Asbestos exposure
80
PNEUMOTHORAX
what are the risk factors for pneumothorax?
Smoking
Family history
Male
Tall and slender build
Young age
Presence of underlying lung disease
81
PNEUMOTHORAX
what are the causes of pneumothorax?
- In patients over 40 years of age the usual cause is underlying COPD
- Other/rarer causes include:
* Bronchial asthma
* Carcinoma
* Breakdown of a lung abscess leading to bronchopleural fistula
* Severe pulmonary fibrosis with cyst formation
* TB
* Pneumonia
* Cystic fibrosis
* Trauma (penetrating or rib fracture)
* Iatrogenic e.g. pacemakers or central lines
82
TB
what are the signs of TB?
```
Signs of bronchial breathing
Dullness to percuss
Decreased breathing
fever
crackles
```
83
PNEUMONIA
which bacteria causes rusty sputum in pneumonia?
strep pneumoniae
84
PNEUMONIA
what is atypical pneumonia?
Bacterial pneumonia caused by atypical organisms that are not detectable on Gram stain and cannot be cultured using standard methods.
85
PNEUMONIA
what are the common organisms that cause atypical pneumonia?
Mycoplasma pneumoniae,
Chlamydophila pneumoniae,
Legionella pneumophila
coxiella burnetii
86
BRONCHIECTASIS
what antibiotics are used for bronchiectasis?
- pseudomonas aeruginosa = oral ciprofloxacin
- h.influenzae = oral amoxycillin, co-amoxyclav or doxycycline
- staph aureus = flucloxacillin
87
GOODPASTURES SYNDROME
what is the pathophysiology of goodpasture's syndrome?
Specific autoimmune disease caused by a type II antigen-antibody reaction leading to diffuse pulmonary haemorrhage, glomerulonephritis (and often acute kidney injury and chronic kidney disease)
- There are circulating anti-glomerular basement membrane (anti-GBM) antibodies
88
LUNG CANCER
where does squamous cell carcinoma of the lung arise from?
- epithelial cells typically in the central bronchus
89
LUNG CANCER
what is squamous cell carcinoma associated with the production of?
associated with the production of keratin
90
LUNG CANCER
where does small cell lung cancer arise from?
Arises from endocrine cells typically in the central bronchus
91
LUNG CANCER
where does adenocarcinoma arise from?
mucus-secreting glandular cells
92
PULMONARY HYPERTENSION
what is the pathophysiology of pulmonary hypertension?
The main vascular changes are:
Vasoconstriction
Smooth-muscle cell and endothelial cell proliferation
Thrombosis
93
what are the investigations for IE COPD?
ABG
- CO2 retention → acidosis
- Raised pCO2 + low pO2 = T2RF
Chest X-Ray, sputum culture + sensitivities for antibiotic therapy, FBC + U&E
94
ASTHMA
which drugs can trigger asthma attacks?
NSAIDs and aspirin
| beta blockers - results in bronchoconstriction which results in airflow limitation and potential attack
95
PHARMACOLOGY
give 2 examples of LABAs
- salmeterol
| - formoterol (full agonist)
96
PHARMACOLOGY
give an example of a SAMA
ipratropium
97
PHARMACOLOGY
give an example of a LAMA
tiotropium
98
PHARMACOLOGY
what is the mechanism of action for ICS?
- They reduce the number of inflammatory cells in the airways
- Suppress production of chemotactic mediators
- Reduce adhesion molecular expression
- Inhibit inflammatory cell survival in the airway
- Suppress inflammatory gene expression in airway epithelial cells
99
PHARMACOLOGY
what are the side effects of ICS?
Loss of bone density
Adrenal suppression
Cataracts
Glaucoma
100
LUNG CANCER
what are the extra-pulmonary manifestations of lung cancer?
Recurrent laryngeal nerve palsy - hoarse voice
Superior vena cava obstruction - facial swelling, distended veins in neck and upper chest, Pemberton’s sign
Horner’s syndrome - ptosis, miosis, anhidrosis
101
PNEUMONIA
which bacteria is associated with causing pneumonia in COPD patients?
h.influenzae
102
PNEUMONIA
which bacteria is associated with aspiration pneumonia?
klebsiella pneumoniae
103
PNEUMONIA
what is the management of HAP?
low severity = oral co-amoxiclav
high severity = broad spectrum abx (IV tazocin or ceftriaxone)
104
BRONCHIECTASIS
what spirometry pattern is found in bronchiectasis?
obstructive
FEV1/FVC <70%
105
CYSTIC FIBROSIS
how does orkambi work?
- LUMACAFTOR - increases number of CFTR proteins transported to cell membranes
- IVACAFTOR - potentiates CFTR proteins on cell surface, increases chance channel will open
106
LUNG CANCER
What are the contraindications to surgery in NSCLC?
- frail
- metastatic disease
- malignant pleural effusion
- SVC obstruction
- tumour near hilum
- vocal cord paralysis
107
ASTHMA
what is the management of a severe/life-threatening asthma exacerbation?
- oxygen
- nebulised bronchodilator (salbutamol)
- corticosteroid (40-50mg prednisolone)
- ipratropium bromide
- IV magnesium sulfate
- IV aminophylline
108
ASTHMA
what is the management of a moderate exacerbation of asthma?
- salbutamol
- 5 days oral prednisolone
109
PLEURAL EFFUSION
what are the signs of pleural effusion?
- reduced chest expansion
- tracheal deviation
- Stony dull percussion note on affected side
- Diminished breath sounds on affected side
- Decreased tactile vocal fremitus
- Loss of vocal resonance
110
PLEURAL EFFUSION
what criteria can be used to distinguish between transudate and exudate effusions?
lights criteria
it is used in borderline cases between 25-35g/L
111
PLEURAL EFFUSION
what is the light's criteria?
exudate is likely if:
- pleural fluid to serum protein ratio >0.5
- pleural fluid LDH to serum LDH ratio >0.6
- pleural fluid LDH >2/3 upper limits of normal serum LDH
112
PLEURAL EFFUSION
what does low glucose in pleural fluid indicate?
- rheumatoid arthritis
- tuberculosis
113
PLEURAL EFFUSION
what does a raised amylase in pleural fluid indicate?
- pancreatitis
- oesophageal perforation
114
PLEURAL EFFUSION
what does heavy blood staining in pleural fluid indicate?
- mesothelioma
- PE
- tuberculosis
115
PLEURAL EFFUSION
what are the indications of a pleural infection?
- purulent or turbid/cloudy fluid
- clear fluid but pH <7.2 (chest drain must be inserted)
116
PNEUMOTHORAX
what are the risk factors for a primary spontaneous pneumothorax?
- tall, slender, young
- smoking
- marfan syndrome
- rheumatoid arthritis
- family history
- rheumatoid arthritis
- driving or flying
117
PNEUMOTHORAX
what are the risk factors for secondary spontaneous pneumothorax?
- underlying lung disease e.g. COPD, asthma, lung cancer
- TB
- pneumocystis jirovecii
118
PNEUMOTHORAX
what are the signs of a pneumothorax?
- tachycardia
- tachypnoea
- cyanosis
- hyperresonance ipsilateral
- reduced breath sounds ipsilateral
- hyperexpansion ipsilateral
- contralateral tracheal deviation
119
PNEUMOTHORAX
what is the management for a secondary spontaneous pneumothorax?
SMALL (1-2cm)
- aspirate with 16-18G needle
- admit with high flow oxygen
LARGE (>2cm) or breathless
- insert chest drain
- admit with high flow oxygen
120
PNEUMOTHORAX
where is the needle for aspiration of a spontaneous pneumothorax placed?
- 2nd intercostal space midclavicular line
121
PNEUMOTHORAX
where are chest drains placed?
5th intercostal space mid-axillary line
122
PNEUMOTHORAX
what are the indications for surgical management?
- 2nd ipsilateral pneumothorax
- 1st contralateral pneumothorax
- bilateral spontaneous pnemothorax
- persistent air leak after 5-7 days chest drain
- pregnancy
- at risk profession e.g. pilots + divers
123
TENSION PNEUMOTHORAX
what are the risk factors?
- mechanical ventilation
- traumatic chest injury
- chest line insertion
- lung biopsy
124
SARCOIDOSIS
what are the signs?
- cervical + submandibular lymphadenopathy
- lupus pernio (lupus-type rash)
- erythema nodosum (dusky coloured nodules on shins)
125
PULMONARY HYPERTENSION
what are the signs?
- right parasternal heave
- loud 2nd heart sound
- pulmonary or tricuspid regurgitation
- raised JVP
- signs of underlying condition
126
ASBESTOS-RELATED LUNG DISEASE
what is the spectrum of conditions?
- pleural plaques
- pleural thickening
- asbestosis
- mesothelioma
- lung cancer
127
ASBESTOS-RELATED LUNG DISEASE
what is asbestosis?
- restrictive lung disease
- lower lung zones affected predominantly
- severity is related to length of exposure
- presents with dyspnoea + reduced exercise tolerance
128
ASBESTOS-RELATED LUNG DISEASE
what is mesothelioma?
- malignant disease of pleura
- can occur with only short term exposure to asbestos
129
PNEUMOCONIOSIS
what is it?
interstitial lung disease secondary to occupational exposure causing an inflammatory reaction
130
PNEUMOCONIOSIS
what is the pathophysiology?
- when dust particles are inhaled, they reach terminal bronchioles + are ingested by interstitial + alveolar macrophages
- dust particles are carried by macrophages + expelled as mucus
- if exposed for a long time these systems no longer function
- macrophages accumulate in alveoli resulting in immune system activation + lung tissue damage
131
PNEUMOCONIOSIS
what are the different types?
- coal workers pneumoconiosis (coal miners)
- silicosis (quarry workers, silica miners)
- berylliosis (aerospace industry, beryllium miners)
- asbestosis (construction workers, plumbers)
132
PNEUMOCONIOSIS
what are the risk factors?
- male
- increasing age
- substance exposure
133
PNEUMOCONIOSIS
what are the symptoms?
SIMPLE PNEUMOCONIOSIS
- asymptomatic
PROGRESSIVE MASSIVE FIBROSIS
- exertional dyspnoea
- dry cough
- wheezing
- haemoptysis
- weight loss
134
PNEUMOCONIOSIS
what are the clinical signs?
- fine crackles
- wheezing
- clubbing
135
PNEUMOCONIOSIS
what are the investigations?
- CXR - opacities in upper lobes, eggshell calcification of hilar lymph nodes
- SPIROMETRY - restrictive pattern (FEV1/FVC>0.7)
- HIGH RESOLUTION CT CHEST - interstitial fibrosis
136
PNEUMOCONIOSIS
how is it staged?
using CXR
- 0 = small rounded opacities absent
- 1 = small rounded opacities but few in number
- 2 = numerous small rounded opacities but normal lung markings
-3 = numerous small rounded opacities + obscured lung markings
137
PNEUMOCONIOSIS
what is the management?
- smoking cessation
- avoidance of exposure
- pulmonary rehab
- supplementary oxygen
- corticosteroids
- lung transplant
138
HYPERSENTIVITY PNEUMONITIS
what is it?
type III + IV hypersensitivity reaction to an environmental allergen
139
HYPERSENTIVITY PNEUMONITIS
give some examples of causes
- bird fanciers lung (bird droppings)
- farmers lung (mould spores in hay)
- mushroom workers lung (mushroom antigens)
- malt workers lung (mould on barley)
140
HYPERSENTIVITY PNEUMONITIS
what is the pathophyisology?
type III + IV hypersensitivity reaction to environmental allergen
inhalation of allergens in patients sensitised to allergen causes an immune response
leads to inflammation + damage to lung tissue
141
HYPERSENTIVITY PNEUMONITIS
what are the symptoms?
- SOB
- cough
- chest tightness
- fatigue
142
HYPERSENTIVITY PNEUMONITIS
what are the investigations?
- bronchoalveolar lavage = raised lymphocytes
143
HYPERSENTIVITY PNEUMONITIS
what is the management?
- removal of allergen
- oxygen
- corticosteroids
144
RESPIRATORY FAILURE
what is the pathophysiology of type 1 respiratory failure?
- due to problem with gas exchange between alveoli + blood
- typically due to V/Q mismatch
- oxygen predominantly affected due to ow blood solubility
145
RESPIRATORY FAILURE
what are the causes of type 1 respiratory failure?
- pneumonia
- heart failure
- asthma
- PE
- high altitude pulmonary oedema
146
RESPIRATORY FAILURE
what is the pathophysiology of type 2 respiratory failure?
- failure of adequate alveolar ventilation
- due to reduced respiratory drive, reduced compliance of lungs, increased airway resistance or muscle weakness
- impairs delivery of O2 + removal of CO2 from lungs
147
RESPIRATORY FAILURE
what are the causes of type 2 respiratory failure?
- opiate toxicity
- iatrogenic
- neuromuscular disease (MND, GBS)
- reduced chest wall compliance (Obesity)
- increased airway resistance (COPD)
148
RESPIRATORY FAILURE
what is the management for type 1 respiratory failure?
- treat underlying cause
- oxygen therapy
- PEEP through CPAP
149
RESPIRATORY FAILURE
what is the management for type 2 respiratory failure?
- treat underlying cause
- oxygen therapy
- lower oxygen sats threshold (88-92%)
- NIV
- invasive mechanical ventilation
150
INFLUENZA
what are the clinical signs?
- raised respiratory rate
- rhinorrhoea
- reduced air entry or crackles on auscultation
- pyrexia
151
INFLUENZA
what is the management?
- not treatment required for majority
- if at risk or have severe flu, offer anti-virals (zanamivir, oseltamivir)
152
ACUTE BRONCHITIS
what are the causes?
- viral infections (coronavirus, rhinovirus, RSV, adenovirus)
153
ACUTE BRONCHITIS
what are the symptoms?
- cough (may or may not be productive)
- sore throat
- rhinorrhoea
- wheeze
- low grade fever
SIGNS
- no focal chest signs
154
ACUTE BRONCHITIS
what are the investigations?
clinical diagnosis
can consider following tests to rule out other causes
- pulmonary funciton test
- CXR
- bloods - CRP
155
ACUTE BRONCHITIS
what is the management?
- analgesia
- good fluid intake
- antibiotics (DOXYCYCLINE (or AMOXICILLIN if contraindicated))
consider antibiotics if:
- systemically unwell
- have pre-existing co-morbidities
- delayed abx prescription if CRP 20-100
- immediate abx if CRP >100
156
HYPERSENSITIVITY
what is a type 1 hypersensitivity reaction?
Classical allergy, mediated by the inappropriate production of specific IgE antibodies to harmless antigens
mast cells are activated + release histamine
157
HYPERSENSITIVITY
what is type II hypersensitivity?
Caused by IgG and IgM antibodies that bind to antigens cells or tissues leading to cell or tissue damage
158
HYPERSENSITIVITY
give some examples of type II hypersensitivity reactions
- blood transfusion reactions
- haemolytic disease of the newborn
- goodpastures disease
159
HYPERSENSITIVITY
what is a type III hypersensitivity reaction?
Caused by antibody-antigen complexes being deposited in tissues, where they activate the complement system and cause inflammation
160
HYPERSENSITIVITY
give some examples of type III hypersensitivity reactions
- rheumatoid arthritis
- farmers lung (hypersensitivity pneumonitis)
161
HYPERSENSITIVITY
what is a type IV hypersensitivity reaction?
A delayed type hypersensitivity reaction caused by T helper cells traveling to the site of antigens, recruiting macrophages and causing inflammation
162
HYPERSENSITIVITY
give some examples of type IV hypersensitivity reactions
- poison ivy
- nickel and gold
- mantoux test
- TB
- graft vs host disease
- pneumoconiosis
- MS
- GBS
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ANAPHYLAXIS
what is the management?
- IM adrenaline 500 micrograms
- give high flow O2
- antihistamine (chlorphenamine or cetirizine)
if no response after 5 mins repeat IM adrenaline + IV fluid bolus
no improvement after 2 doses of IM adrenaline = refractory anaphylaxis
164
ANAPHYLAXIS
when can patients be discharged?
AFTER 2 HOURS
- good response (within 5-10 mins) to single IM adrenaline
- complete resolution of symptoms
- has autoinjector + trained
AFTER 6 HOURS
- 2 doses of IM adrenaline
- previous biphasic reaction
AFTER 12 HOURS
- severe reaction (>2 doses IM adrenaline)
- severe asthma
- possibility of continued exposure to allergen
- presents at night or in area difficult to access in emergency
