1
Q
What does a sputum sample film show in acute bronchitis?
A
Neutrophil granulocytes (inflammatory WBCs)
2
Q
When is Abx indicated in acute bronchitis?
A
- When bacterial infection is suspected.
- CRP 20 - 100mg/l (delayed prescription
- CRP > 100mg/l (Abx therapy)
3
Q
If Abx is indicated in acute bronchitis, what is the 1st line?
A
Doxycycline (5-day course)
- X pregnancy, uses amoxicillin (500mg TD for 5 days)
- young people (amoxicillin)
4
Q
What pathogen causes influenza?
A
RNA virus - orthomyxoviridae
5
Q
How is influenza diagnosed?
A
Clinical diagnosis
- viral culture - PCR
6
Q
What are the symptoms of influenza?
A
- Coryzal symptoms
- Fever
- Headache
- Non-productive cough
- Sore throat
7
Q
Management of influenza and indication for medication
A
Antivirals:
Selective use of antivirals : oral oseltamivir and inhaled zanamivir
Indication:
1) if able to start treatment within 48 hours of symptoms onset
2) Known circulation of virus in community
3) High-risk : pregnant, obese, > 65 + < 6 y.o, immunocompromised, comorbidities
Conservative:
- analgesia
- increase fluid intake
- rest
8
Q
What is croup?
A
- Inflammation of the upper respiratory tract
- acute laryngotracheitis
- due to viral infection
9
Q
What organism is most responsible for croup?
A
- Parainfluenza
- RSV
10
Q
What are the symptoms of croup?
A
Seal-like barking cough
- runny nose
- fever
- stridor
- voice hoarseness
11
Q
How do you diagnosis croup?
A
Clinical diagnosis
- Significant resp impairment ( O2 <95%)
12
Q
What is the management of croup?
A
Conservative:
- ensure patient remains calm ; agitation can lead to increased o2 demand
- paracetamol (for fever)
Medical:
- Whilst awaiting hospital admission: give O2, oral dexamethasone
- Mild illness (no hospital admission): single dose corticosteroid (oral dexamethasone)
- -> symptoms usually resolve within 48 hours
13
Q
Is RSV contagious?
A
Yes
14
Q
What is the most common complication RSV?
A
Bronchiolitis
15
Q
What age group is most affected by RSV?
A
- Babies in 1st year of life
- Usually 3-6 months
16
Q
How is RSV spread?
A
air droplet
17
Q
What are the RSV symptoms?
A
Cold-like symptoms:
- low grade fever
- wheezing
- chest congestion / rhinorrhea
- SOB
- Cough
18
Q
What is the management of RSV?
A
- Conservative : observation + hydration
- Medical: Bronchodilators, alpha agonists
19
Q
What is bacterial pneumonia?
A
- bacterial mediated inflammation
- infection of the lung tissue in which the alveoli become filled with MO, fluid & inflamm cells
20
Q
What are the most common microorganism causing bacterial pneumonia?
A
- streptococcus pneumonia
- H.influenza
- staphylococus aureus
21
Q
What are the key symptoms for bacterial pneumonia?
A
- Green Productive Cough*
- SOB
- Fever
- Chest pain
22
Q
What are the key signs for bacterial pneumonia?
A
- Increased tactile & vocal fremitus
- Dullness to percuss
- Bronchial breath sounds
- Late inspiratory crackles
23
Q
Investigations for pneumonia?
A
- CXR : to identify location and extent
- CRP : inflammation
24
Q
What score is used to admit pt to hospital with pneumonia?
A
CRB-65
> 3 = urgent admission
> 2 = hospital management
0 = conservative management at home
25
Management of bacterial pneumonia?
Medical
Abx:
- co-amoxiclav (hospital)
- amoxicillin = 500mg TD for 5/7 (home) (1st line)
- oral doxycycline = (penicillin allergy)
Oxygen for hypoxia
Long-term: pneumococcal vaccine
26
What are the key symptoms for viral pneumonia?
*Non-productive cough*
Systemic symptoms:
- fever
- runny nose
- myalgia
- fatigue
27
What are the investigation findings for viral pneumonia?
- Viral PCR
| - CXR : more likely bilateral consolidation
28
Management of viral pneumonia
Conservative:
- fluids & oxygen therapy
- flu vaccine for high risk groups
Medical:
- self-resolving
Antiviral depending on the causative organism:
- Tamiflu = oseltamavir, influenza = zanamavir
- Herpes & VZV = acyclovir
- RSV = Ribavarin
29
What is acute bronchiolitis?
- Acute viral infection of the LRT
| - Characterised by epithelial destruction, cellular oedema & airwary obstruction by inflamm debris & mucus
30
Most common cause of bronchiolitis
RSV
31
what are the symptoms of acute bronchiolitis?
- Fever
- Cough
- Poor feeding
- Apnoea
32
What are the signs of acute bronchiolitis?
Clinical diagnosis: < 2 presenting with 1-3 days hx of coryzal symptoms
- persistent cough
- tachypnoea or chest recession (both)
- wheeze or crackles OA (both)
33
Investigation for acute bronchiolitis
CLINICAL DIAGNOSIS
- check 02 sats
- CXR not recommended unless evidence of deterioration
34
Management of acute bronchiolitis
Conservative:
- self-limiting , can be managed at home
Medical:
- O2 if sats < 92%
- CPAP if resp failure
- Ribavarin (RSV)
- oral corticosteroids (hx of wheeze)
Referral:
- RR > 60 breaths/min
- inadequate fluid intake/ signs of dehydration
- if child is < 3 months or born prematurely.
35
What is acute epiglottitis?
Cellulitis of the supra-glottis - may cause airway compromise.
- Airway emergency in children
36
What is the most common cause for acute epiglottitis?
H.Influenza
37
What are the symptoms of acute epiglottitis?
- Sore throat
- Stridor
- Tripod position : lean forward + extending neck.
- Dysphagia
- Fever
- Drooling
38
What are the signs for acute epiglottitis?
High - pitched inspiratory wheeze
| * DO NOT EXAMINE THROAT*
39
What are the investigation finding for acute epiglottitis?
Lateral neck radiograph - THUMB SIGN
40
What is the acute management for acute epiglottitis?
1st line = contact paediatrics + arrange same day review & admission (anaesthetists)
- Secure airway + oxygen
- IV Abx
- Corticosteroids (dexamethasone)
once stable and extubated --> 1st line : oral abx (amoxicillin)
41
What is the surgical management of acute epiglottitis and when is it indicated?
Tracheostomy (compromise of airway)
42
What are the complications of acute epiglottitis?
- Abscess formation
- Sepsis
- Pneumothorax
- Meningitis
43
What is pertussis?
- Whooping cough
44
What organism causes pertussis?
- Bordetella Pertussis
45
How is pertussis transmitted?
- Sneeze or cough (airborne)
46
What is the pathophysiology of pertusis?
- BP toxins anchor to the epithelium.
- Toxin paralyse the cilia --> excess mucus build up
- Mucus build up triggers violent cough reflex (coughing spells, "paroxysms")
- Swollen airways cause whooping noise
47
What are the 3 phases of symptoms called in Pertussis?
1st phase = catarrhal
- runny nose
- malaise
- sore throat
- low-grade fever
- dry cough
2nd phase = paroxysmal (1-6 weeks)
- short expiratory burst followed by inspiratory gasp (whoop)
- thick mucus secretions
3rd phase = convalescent (3 months)
- gradual improvements in cough frequency + severity
48
What are the key symptoms should you suspect for pertussis?
Acute cough > 14 days w/ no apparent cause w/:
- paroxysmal cough
- inspiratory whoop
- Post-tussive vomiting
- undiagnosed apnoeic attack
49
How to diagnose pertussis?
Nasopharyngeal swab
50
What is the medical management of pertussis?
1st line:
- macrolide abx : clarithromycin, erythromycin for pregnant women
- co-trimoxazole if contra-indicated
House hold prophylaxis
< 6 month - admission to hospital
51
How long to isolate with pertussis?
- 21 days after symptoms onset
| - 48 hours after abx
52
What is empyema?
Defined as the presence of frank pus in the pleural space.
53
What are the common infection causing empyema?
- Due to post pneumonia
- Anaerobic, staph & gram-negative infections
- Klebsiella: alcoholism, currant jelly-like sputum.
54
What is the aetiology of empyema?
free flowing fluid which becomes infected
55
What are the symptoms of empyema?
- SOB
- Fever
- Pleuritic chest pain
56
What are the signs of empyema?
- Tachypnoea
- Reduced breath sounds
- Dullness to percuss
57
What are the investigation findings of empyema?
CXR: blunting of the costophrenic angle or effusion on affected side
CRP & WCC- raised in infection
58
What investigation is diagnostic for empyema?
Thoracentesis: aspiration of the frank pus
59
What is the management of empyema?
+ 1st line
- IV empirical abx:
- Community = Ceftriaxone + metronidazole
- Hospital = vancomycin + cefepime + metronidazole
+ Chest tube drainage
+ Fluid resuscitation
60
What is chronic bronchitis?
Long-term inflammation of the lining of the bronchial tubes
61
What are the symptoms of chronic bronchitis?
- Cough
- Sputum
- Fatigue
- SOB
- Chest discomfort
62
What is the 1st line for infective
| exacerbation of chronic bronchitis?
Amoxicillin or clarithomycin
63
What is emphysema?
Condition causes SOB due to damaged alveoli in the lungs
64
What are the signs and symptoms of emphysema?
- SOB (progressive & at rest)
- Fatigue
- Central & peripheral cyanosis
- Persistent wheeze
- Productive cough
65
What are the signs of emphysema?
- " Pink puffers"
- Accessory muscle use
- Barrel chest
- Hyper-resonance on percussion
- Absent or quiet breath sounds on auscultation
66
What are the investigation for emphysema?
- Bloods: Serum Alpha 1-antitrypsin
- CXR
- Sputum culture
- Lung function test
67
What is the management for emphysema?
Conservative:
- Smoking cessation
- Pulmonary rehabilitation
- Nutrition therapy
Medical:
- Oxygen therapy
- Bronchodilators (SABA/SAMA, LABA/LAMA)
- Inhaled corticosteroids
- Antibiotics – of bacterial infection
Surgery:
- Lung volume reduction surgery
- Lung transplant
68
What does COPD stand for?
Chronic Obstructive Pulmonary Disease
69
What is COPD?
- Airflow limitation
| Group of progressive lung disease including chronic bronchitis & emphysema (treatable but not curable)
70
What is the pathophysiology of COPD?
CB: damage to endothelium impairing the mucociliary response to clear mucus & bacteria – airway deformation & narrowed lumen
EMP: enlargement of alveoli, leading to decline in gas exchange
71
What deficiency causes COPD?
Alpha 1-trypsin
72
What are the symptoms for COPD?
- SOBOE (progressive)
- Chronic cough
- Regular sputum production
- Wheeze
- Weight loss
- Fatigue
- PND
- Ankle swelling (cor pulmonale)
- Chest pain
- Haemoptysis
73
What are the signs for COPD?
- Frequent LRTI
- Cyanosis
- Raised JVP
- Cachexia
- Barrel chest
- Accessory muscle use
- Purse lip breathing
- Crackles OA
74
How is COPD diagnosed?
Clinical features + spirometry
75
What investigations are carried when suspecting COPD?
- Spirometry
- CXR
- ABG
- Sputum culture
- Serum alpha 1-trypsin
76
What spirometry findings confirms persistent airflow obstruction?
A post-bronchodilator FEV1/FVC < 0.7
77
How is the severity of COPD classified?
Post-bronchodilator FEV1/FVC < 0.7
FEV1 (of predicted)
> 80% : Stage 1 - Mild - symptoms should be present to diagnose COPD in these patients
50-79% : Stage 2 - Moderate
30-49% : Stage 3 - Severe
< 30% : Stage 4 - Very severe
78
What are CXR findings in COPD?
- Hyperinflation
- Bullae
- Flat haemodiaphragm
(exclude cancer)
79
What is the medical management algorithm for COPD?
See algorithm on PASSMED
1) SOB + exercise limitation : SABA/SAMA
- > SAMA : Ipratropium
- > SAMA: 1st line in new diagnosis
2) No asthmatic features: LABA + LAMA (for day-day symptoms)
3) Asthmatic features: LABA + ICS
- -> LABA + LAMA + ICS – if pt’s day-day symptoms is affecting QOL or 1 serious hospitalisation or 2 moderate exacerbations
4) ICS – increased risk (including pneumonia)
5) Other add on treatments : oral corticosteroids, oral theophylline, oral mucolytic therapy, oral anti-tussive therapy, prophylactic antibiotic therapy -> azithromycin, macrolides, phosphodiesterase-4 inhibitors
80
What are the asthmatic features when treating COPD?
1) any previous, secure diagnosis of asthma or of atopy
2) a higher blood eosinophil count
3) substantial variation in FEV1 over time (at least 400 ml)
4) substantial diurnal variation in peak expiratory flow (at least 20%)
81
What are the complications of COPD?
- Secondary polycythaemia : Increased haematocrit due to long-term hypoxia
- Respiratory acidosis: indicates BiPAP
- Recurrent chest infections
- Cor pulmonale
82
What can a large bullae in CXR in COPD mimic?
Pneumothorax
83
What type of bacteria is Haemophilus influenza?
- Gram negative rod
84
How do you manage acute exacerbation of COPD?
1) Nebulised salbutamol
2) Ipratropium (SAMA) + oxygen
3) Steroids (prednisolone)
4) Abx (amoxicillin)
85
What is asthma?
Chronic respiratory condition associated with airway inflammation and hyper-responsiveness.
86
What is asthma associated with?
Eczema + Hay fever
87
What features is required for the classification of moderate asthma?
1) PEFR 50-75% best or predicted
2) Speech normal
3) RR < 25 / min
4) Pulse < 110 bpm
88
What features is required for the classification of severe asthma?
1) PEFR 33 - 50% best or predicted
2) Can't complete sentences
3) RR > 25/min
4) Pulse > 110 bpm
89
What features is required for the classification of life-threatening asthma?
1) PEFR < 33% best or predicted
2) Oxygen sats < 92%
3) 'Normal' pC02 (4.6-6.0 kPa)
4) Silent chest, cyanosis or feeble respiratory effort
5) Bradycardia, dysrhythmia or hypotension
6) Exhaustion, confusion or coma
90
What are the features of klebsiella pneumonia?
- RF: alcohol and diabetes
- 'red-currant jelly' sputum
- Upper lobe
91
What are the types of influenza and how does affect treatment ?
Complicated :
1) CNS involvement or exacerbation of underlying condition
2) Antivirals : oseltamivir or zanamivir
Uncomplicated :
1) generalised symptoms
2) ONLY oseltamivir
92
What are the common symptoms associated with asthma?
- Wheeze
- Chest tightness
- SOB
- Cough
93
What are the clinical signs associated with asthma?
- OBS : HR > 110, RR > 25
- Tracheal deviation
- Widespread wheeze OA
- Chest deformity/ hyperinflated chest ( chronic asthma)
94
When do symptoms of asthma commonly present (timing)?
- Worse at night
- Early in the morning
- In response to exercise
- Allergen exposure
- Cold air
- After taking aspirin or BB
95
What is the management algorithm for asthma in adults?
1) SABA
2) SABA + ICS (low dose)
3) SABA + ICS + LABA or MART
4) SABA + ICS (increase dose) + LTRA +/- LABA
5) Refer
96
What are the examples of drug used in asthma for each class of drugs?
```
SABA = salbutamol
ICS = belclamethasone
LTRA = montelukast
LABA = salmeterol
```
97
When is ICS indicated in asthma?
- Pt uses SABA > 3 x week
- asthma symptoms > 3 x week
- woken at night due to symptoms
98
When is SABA indicated in asthma?
- Symptomatic asthma
99
Immediate management of acute asthma
1) Admission to hospital
2) Oxygen
3) Nebulised SABA
4) Corticosteroid
5) Ipratropium bromide
6) IV magnesium sulphate
7) IV aminophylline
100
What does normal PaCO2 in acute asthma indicate?
- Exhaustion
This is classified as life-threatening
101
When is chest X-RAY indicated in acute asthma?
Not routinely done"
- life-threatening asthma
- suspected pneumothorax
- failure to respond to treatment
102
What investigations are considered in asthma?
1) Spirometry : < 70 % in FEV1/FVC suggests airflow limitation
- -> normal spirometry does not r/o asthma
- -> BDR: confirms diagnosis, > 12% improvement, with an increase in volume of > 200ml is positive result
2) Peak flow : > 20% variability is positive result
- ->support diagnosis
3) FENO testing : esonophilic airway limitation support diagnosis (> 40 ppb)
4) Allergy testing
103
What is sleep apnoea?
the interruption of sleep as a result of a narrowing of the throat
104
What is the pathophysiology of OSA?
- When we sleep out throat muscles generally relax and become floppy
In OSA - muscles become excessively relaxed and floppy
- -> results in partial or complete obstruction of the airway
- -> partial = snoring
105
What symptoms can indicate sleep apnoea?
- Loud snoring
- Day time sleepiness
- impaired concentration
- Unrefreshed on waking
- Witnessed apnoea: choking noises while sleeping
106
What should you examine for in sleep apnoea?
- Enlarged tonsils
- small jaw
- nasal blockage
107
What questionnaire is helpful in diagnosing OSAS?
Epsworth sleepiness questionnaire
108
What investigations can be carried out in sleep apnoea?
- Polysomnography : sleep study to measure apnoea /hypoapnoea episodes
- Lung function
- Endoscopy
109
What is the medical management of sleep apnoea?
1st line = CPAP (severe)
| 2nd line = Intra-oral if CPAP is not tolerated
110
What conservative management can you advice for sleep apnoea?
- weight loss
- exercise
- smoking cessation
- nasal decongestants
- sleep on side
111
What is Pulmonary Embolism?
One or more emboli from a thrombus in the vein, lodged in and obstructing the pulmary arterial system causing resp dysfunction
112
What are the types of PE?
Provoked PE: associated with transient RF
| Unprovoked PE: absence of transient or persistent RF
113
What are the risk factors for PE?
1) Immobilisation
2) Surgery in the last 4 weeks
3) Previous DVT/PE
4) Malignancy
5) Increased coagulability
114
What is the triad of symptoms for PE?
1) SOB
2) Chest pain
3) Haemoptysis
- cyanosis
- unilateral leg swelling
- syncope
115
Signs of PE
- Tachycardia
- RR > 20
- Raised JVP
- Pleural rub
- Hypotension
116
What score is used for PE?
Wells score :
1) DVT
2) PE is #1 diagnosis OR equally likely
3) Heart rate > 100
4) Immobilization at least 3 days OR surgery in the previous 4 weeks
5) Previous, objectively diagnosed PE or DVT
6) Haemoptysis
7) Malignancy w/ treatment within 6 months or palliative
117
What is the 1st line investigation for PE?
CTPA
| > 4 points on Well's
118
When is CTPA contraindicated?
| What is 1st line in this case?
Renal impairment - due to contrast
Pregnancy
1st line in above = V/Q scan
119
When do you offer D-dimer test?
< 4 points on Well's
120
If CTPA is negative, what is the next step if DVT is suspected?
Proximal Leg USS
121
What ECG changes is associated with PE?
1) Large S wave in lead I
2) Q wave in lead III
3) Inverted T-wave in lead III
* S1Q3T3*
4) RBBB
5) RAD
122
What might you see on an ABG in PE?
Respiratory alkalosis
123
If a pt has PE + hypotension, what would you do?
Thrombolyse (alteplase)
124
What is 1st line medication in PE without hypotension?
DOAC - apixaban or rivaroxaban
125
What is another criteria used in PE?
pulmonary embolism rule-out criteria (the PERC rule)
- -> all the criteria must be absent to have negative PERC result, i.e. rule-out PE
- -> this should be done when you think there is a low pre-test probability of PE, but want more reassurance that it isn't the diagnosis
- -> a negative PERC reduces the probability of PE to < 2%
- -> if your suspicion of PE is greater than this then you should move straight to the 2-level PE Wells score, without doing a PERC
126
What is the PERC?
Criteria:
1) Age > 50
2) HR > 100
3) O2 < 94%
4) Previous DVT or PE
5) Recent surgery or trauma in the past 4 weeks
6) Haemoptysis
7) Unilateral leg swelling
8) Oestrogen use
127
If Well's score is > 4 points, what does it mean and what is the algorithm?
PE likely:
1) CTPA
2) Delay in CTPA, interim anticoag until scan
128
If Well's score is < 4 points, what does it mean and what are the next steps?
PE unlikely:
1) D-dimer test
- -> If + , CTPA
- -> if - , stop anticoag and consider alternative diagnosis
129
What is the possible CXR finding in PE?
- Typically normal
| - Possible wedge-shaped opacification
130
What is the interim anticoag in PE?
DOACs - Rivoraxaban or Apixaban
131
What is 1st line management for confirmed PE?
- DOAC
132
What medication is used if DOAC is not suitable in PE?
LMWH followed by Vitamin K antagonist (Warfarin)
133
Medication for PE if renal impairment ?
LMWH
134
How long should patient have anticoagulation in PE?
at least 3 months
- Provoked: stopped after 3 months
- unprovoked: continue for 3 more months (6 months in total)
135
Which score is used when starting and continuing anticoagulation in PE?
HAS-BLED
136
What is Cor Pulmonale?
Right ventricle failure through pulmonary artery htn due to lung disorder
137
What is the pathophysiology of Cor Pulmonale?
- Result of high BP in pulmonary arteries
- increased afterload
- right ventricle is good volume pump and not pressure pump
- so hypertrophy of the right ventricle
- decreased right ventricle output results in decreased left ventricle filling
- therefore, reduced CO
138
What can cause Cor Pulmonale?
- PE
- Acute respiratory distress syndrome
- Chronic : COPD
139
What are the symptoms of COR Pulmonale?
- SOB
- Chest pain
- Fatigue
- DIzziness
- SOBOE
- Ankle swelling
140
What are signs associated with Cor Pulmonale?
* Left parasternal heave* (sign of right ventricular hypertrophy)
- S3, S4 + pansystolic murmur
- Intercostal recession
- Systolic bruits
- Raised JVP
- Increased HR
- Crackles
141
What are the ECG findings associated with Cor Pulmonale?
- Increased P wave amplitude
- PR depression
- RAD
142
What investigation can be carried out for Cor Pulmonale?
CXR = rught artial size + pulmonary artery enlargement
CTPA/MRI of the chest
V/Q scan = PE or RHF
143
What is the management for Cor Pulmonale?
*Treat the underlying cause*
Medical:
- Diuretics: furosemide
- long-term O2 therapy
- Vasodilators: nifedipine & diltiazem
Surgical:
- Heart or lung transplant = last resort
144
Painful rash + cough = diagnosis?
sarcoidosis
145
What pathogen is the most common cause for fungal pneumonia?
Pneumocystis Jiroveci
| Typically seen in patients with HIV
146
What are the symptoms and signs associated with Pneumocystis Jiroveci?
- dry cough
- SOB
- Fever
- exercise induced desaturations
- absence of chest signs
147
What medication can be used in fungal pneumonia?
- Azole based antifungals
e. g. voriconazole
- Always discuss with micro when suspecting fungal pneumonia
148
What is pneumocystis pneumonia?
- fungal infection in one or both lungs
| - common in people with weakened immune system (AIDs)
149
What is the treatment for pneumocystis jiroveci?
1. Co-trimoxazole
2. for severe disease: IV or high dose orally
- IV pentamidine
3. steroids if hypoxic
150
What is pneumocystis jiroveci also known as?
Pnuemocystis carinii pneumonia (PCP)
| - most common opportunistic infection in AIDs
151
What is a common complication of PCP?
pneumothorax
152
What investigations are carried our for PCP?
1. CXR: bilateral interstitial pulmonary infiltrates but can present with other x-ray findings e.g. lobar consolidation.
2. Sputum often fails to show PCP
3. Special test: bronchoalveolar lavage (BAL) - often needed to demonstrate PCP (silver stain shows characteristic cysts)
153
When is PCP prophylaxis indicated?
all patients with a CD4 count < 200/mm³
154
What is Tuberculosis?
- Infection caused by Mycobacterium tuberculosis that most commonly affects the lungs
155
What are the types of TB?
Primary TB - 1st infection (evidence of symptoms)
Secondary TB - If the host becomes immunocompromised the initial infection may become reactivated
Latent disease - not clinically active, not contagious, can become active
Extra- pulmonary TB - manifest in other organs (brain, CNS)
--> CNS - TB meningitis
156
What are the symptoms of TB?
1. Coughing > 3 weeks
2. Haemoptysis
3. Night sweats
4. Unintended weight loss
157
What are the investigations carried out for TB?
1) Chest x-ray
- upper lobe cavitation is the classical finding of reactivated TB
- bilateral hilar lymphadenopathy
2) Sputum smear
- 3 specimens are needed
- rapid and inexpensive test
- stained for the presence of acid-fast bacilli (Ziehl-Neelsen stain)
- -> all mycobacteria will stain positive
3) Sputum culture
- the gold standard investigation
- more sensitive than a sputum smear and nucleic acid amplification tests
- can assess drug sensitivities
- can take 1-3 weeks
4) Nucleic acid amplification tests (NAAT)
- allows rapid diagnosis (within 24-48 hours)
- more sensitive than smear but less sensitive than culture
158
What is the gold standard investigation for TB?
Sputum culture
159
What is the management for active TB?
Initial phase - first 2 months (RIPE)
- Rifampicin
- Isoniazid
- Pyrazinamide
- Ethambutol
Continuation phase - next 4 months
- Rifampicin
- Isoniazid
160
What are the side effects of the drugs used in TB?
Rifampicin = hepatoxicity , orange tears & urine
Isoniazid = hepatoxicity, peripheral neuropathy
Pyrazinamide = gout
Ethambutol = optic neuritis
161
What should all patients with TB be tested for?
HIV
162
What is Bronchiectasis?
Permanent dilatation of the airways secondary to chronic infection or inflammation.
163
What are the causes of Bronchiectasis?
- post-infective: tuberculosis, measles, pertussis, pneumonia
- cystic fibrosis
- bronchial obstruction e.g. lung cancer/foreign body
- immune deficiency: selective IgA, hypogammaglobulinaemia
allergic bronchopulmonary aspergillosis (ABPA)
164
What are the symptoms of Bronchiectasis?
1. Persistent production of mucous
2. Cough >8 weeks
3. SOB
165
What are the signs for Bronchiectasis?
1. Coarse crackles
2. Wheeze
3. Stridor
4. large airway rhonchi (snore-like)
166
What are the investigations for Bronchiectasis?
1. CXR (1st line)
- Tramlines
- honey-combing
2. High-resolution computered tomography (gold-standard)
- bronchial wall dilation
3. Spirometry
4. Assess for cystic fibrosis
167
What are the most common organisms causing Bronchiectasis?
- Haemophilus influenzae (most common)
- Pseudomonas aeruginosa
- Klebsiella spp.
- Streptococcus pneumoniae
168
What is the management for Bronchiectasis?
1. physical training (e.g. inspiratory muscle training)
2. postural drainage
3. antibiotics for exacerbations + long-term rotating antibiotics in severe cases
4. bronchodilators
5. immunisations
6. surgery in selected cases (e.g. Localised disease)
169
What abx are used in bronchiectasis?
- amoxicillin
- doxycycline
- clarithomycin
170
What is Cystic Fibrosis?
- An autosomal recessive disorder causing increased viscosity of secretions (e.g. lungs and pancreas)
171
What are the presenting features of Cystic Fibrosis?
- neonatal period : meconium ileus, less commonly prolonged jaundice
- recurrent chest infections
- malabsorption: steatorrhoea, failure to thrive
- other features (10%): liver disease
172
What are some other features associated with Cystic Fibrosis?
- short stature
- diabetes mellitus
- delayed puberty
- rectal prolapse (due to bulky stools)
- nasal polyps
- male infertility, female subfertility
173
What test is used for diagnosis of Cystic Fibrosis?
* *Sweat test**
- patient's with CF have abnormally high sweat chloride
- normal value < 40 mEq/l, CF indicated by > 60 mEq/l
174
What is the management of Cystic Fibrosis?
- Involves MDT approach
1. regular (at least twice daily) chest physiotherapy and postural drainage.
- Parents are usually taught to do this.
- Deep breathing exercises are also useful
2. high calorie diet, including high fat intake*
3. patients with CF should try to minimise contact with each other to prevent cross infection with Burkholderia cepacia complex and Pseudomonas aeruginosa
4. vitamin supplementation
5. pancreatic enzyme supplements taken with meals
6. lung transplantion
175
What is Pulmonary Hypertension?
- Mean pulmonary arterial pressure > 25 mmHg at rest
176
What are the symptoms of Pulmonary Hypertension?
- Chest pain
- Exertional SOB
- Fatigue
- Syncope
177
What are the signs of Pulmonary Hypertension?
- Large A wave in JVP
- Peripheral cyanosis
- Parasternal - right ventricular heave
- Peripheral oedema
178
What are the special tests carried out in Pulmonary Hypertension?
- Echo : dilated R ventricle with impaired function
- Cardiac catheterisation : essential for diagnosis
- CT or MRI : enlargement of pulmonary arteries
179
What is the management of Pulmonary Hypertension?
- Diuretics: control oedema from HF
- O2: correct hypoxia
- Anticoagulation : for PAH
180
What are the ECG findings in Pulmonary Hypertension?
- RAD
- R wave in V1
- Inverted T wave in right pericardial leads
- RBB
- Tall peaked p waves in lead II
181
What does SSRI in 3rd trimester cause?
- Pulmonary HTN in newborn
182
What is Pleural Effusion?
Fluid collect between the parietal and visceral pleural surfaces of the thorax
183
What is the aetiology of Pleural Effusion?
- if the normal flow of fluid is disrupted with either too much fluid production or not enough being removed.
184
What are the symptoms of Pleural Effusion?
- SOB
- Non productive cough
- Pleuritic chest pain
185
What are the signs of Pleural Effusion?
- Quieter breath sounds
- Decreased or absent tactile fremitus
- Dull to percuss
- Reduced chest expansion
186
How can Pleural Effusion be classified?
According to the protein conc:
1. Transudate (< 30 g/L)
2. Exudate (> 30g/L)
187
What investigation are carried out for Pleural Effusion?
Imaging:
- Posterioranterior (PA) chest x-ray
- USS: for pleural aspiration
- Contrast CT : investigate underlying cause
Pleural aspiration :
- fluid sent for pH, protein, LDH, cytology and microbiology
188
What is light's criteria?
Used to distinguish between transudate and exudate
189
What are the pleural findings indication in pleural effusion
1. low glucose: rheumatoid arthritis, tuberculosis
2. raised amylase: pancreatitis, oesophageal perforation
3. heavy blood staining: mesothelioma, pulmonary embolism, tuberculosis
190
When is pleural fluid sampling diagnostic?
- Pleural infection : all pt with pleural effusion associated with sepsis or pneumonia
1. Fluid = purulent or cloudy --> chest tube for drainage
2. Fluid = clear but pH < 7.2 --> chest tube placed
191
What are the pleural findings in empyema?
Turbid effusion with :
1. pH < 7.2
2. low glucose
3. high LDH
192
How do you manage Pleural Effusion?
1. CHF
- Diuretic : furosemide
2. Symptomatic large effusion
- Therapeutic thoracentesis
- O2
3. Infective
- IV abx : amoxicillin + metronidazole
- Therapeutic thoracentesis
193
What is Pneumothorax?
- when air gain access to & accumulates in the pleural space
194
What are the types of pneumothorax?
1. Primary - occurs without a cause
2. Traumatic - results of trauma. commonly - stab wound
3. Tension - large amount of air present within the lung causing the lung to deflate
195
What are the symptoms of pneumothorax?
Symptoms onset sudden:
- SOB
- Pleuritic chest pain
- sweating
- tachypnoea
- tachycardia
196
What are the signs for pneumothorax?
- Absent breath sounds
- Trachial deviation
- Hyperressonance on percussion
197
What are the investigations for pneumothorax
- CXR
- CT : differentitate between emphysema + pneumothorax
- Bronchoscopy
198
What is the management of secondary pneumothorax if < 1 cm?
- Admit + give oxygen for 24 hours + review
199
What is the management of Primary Pneumothorax?
1. < 2 cm + no SOB = discharge
2. Otherwise, aspirate
3. > 2 cm or SOB = chest drain inserted
200
What is the management of Secondary Pneumothorax?
1. > 50 years old + rim of air is > 2cm +/- SOB = chest drain
2. 1-2cm = aspiration
- -> If aspiration fails = chest drain
3. All patients should be admitted for at least 24 hours
if the pneumothorax < 1 cm
--> oxygen + admitting for 24 hours
201
What conservative advice should be given to someone with Pneumothorax on discharge?
- Smoking cessation
- Cannot travel until 1 week post x-ray/drainage
- Avoid scuba diving
202
What scoring system is used for suspected obstructive sleep apnoea?
Epworth scale
203
What would the finding of TB be on a chest radiograph?
Upper zone fibrosis
204
What is pleurisy?
Inflammation of the pleura which compromises lubrication and results in pain
205
What are the signs of pleurisy?
- Reduced breath sounds
- Pleuritic rub
- Rapid/shallow breathing
206
What are the symptoms of pleurisy?
- Chest pain
- sharp stabbing pain
- worse on inspiration
Dependent on cause:
- cough (productive)
- systemic symp: fever, rigors
- SOB /altered breathing
207
When is a diagnosis of pleurisy made?
- When other differentials have been confidently excluded
208
How to investigate pleurisy?
Tests done to r/o other causes:
- bloods : trop, ABG, D-dimer
- X-Ray: pneumothorax, pleural effusion
- CT: show the condition of the pleura
209
What is the management of pleurisy?
- if patient is otherwise stable (PMH)
1st line: NSAIDs
2nd line: indomethacin
Treat underlying cause (Abx)
210
What are the 2 types of lungs cancer based on histology?
1. Small Cell Lung cancer (SCLC)
| 2. Non- Small Cell Lung Cancer (NSCLC)
211
What are the different types of NSCLC?
1. Adenocarcinoma
2. Squamous
3. Large cell
4. alveolar cell carcinoma
5. bronchial adenoma
212
What are the features of lung cancer?
1. Persistent cough
2. haemoptysis
3. dyspnoea
4. chest pain
5. Weight loss
6. hoarseness
213
What the examination findings of lung cancer?
1. Fixed monophonic wheeze
2. supraclavicular lympadenopathy or persistent cervical lympadenopathy
3. Clubbing
214
What is the investigation used for definitive diagnosis for lung cancer?
Biopsy guided by CT or bronchoscopy
215
What is the first line investigation when suspecting lung cancer?
CXR
| - can give false negative
216
What is the referral criteria for 2WW pathway for lung cancer?
1. CXR suggest lung cancer
| 2. > 40 y/o + unexplained haemoptysis
217
What is the criteria to offer urgent CXR to assess lung cancer?
> 40 y/o + 2 or more of:
- cough
- fatigue
- SOB
- Chest pain
- weight loss
- appetite loss
- smoker
218
What are the electrolyte disturbances caused by small cell lung cancer?
1. ADH --> Hyponatraemia
| 2. Secretes ACTH --> Cushing's
219
What is the management of SCLC?
```
Early stage (T1-2a,N0,M0):
--> Surgery
```
Limited disease:
--> Chemo + radiotherapy
Extensive disease:
--> palliative chemotherapy
220
What are the features of squamous?
- PTH --> hypercalcaemia
| - clubbing
221
Which type of lung cancer may secrete beta-hCG?
Large cell carcinoma
222
What is the management of NSCLC?
- Surgery
| - Curative or palliative radiotherapy
223
What are the common site for metastases from lung cancer?
- Brain
- Bone
- Abdo (Liver)
- Prostate
- Adrenal
- Kidneys
224
What investigation is carried out metastatic tumours?
PET Scan
225
What is carcinoid tumour?
Slow-growing tumour that originate in cells of the diffuse neuroendocrine system
226
What is carcinoid syndrome?
- Usually occurs when metastases are present in the liver + release serotonin into circulation
227
What symptoms does carcinoid tumour cause?
Entire body involvement:
- Flushin
- diarhhoea
- bronchospasm
- hypotension
- valvular stenosis (right)
228
What are lung nodules?
Circular/round structures on CXR/CT <3cm
229
What can cause lung nodules?
- Benign tumours
- lung infection
- scars from previous infection
- cancer
- Autoimmune disorder
230
Management of lung nodules
Refer to specialist
231
What is
| Idiopathic pulmonary fibrosis?
Chronic lung condition characterised by progressive fibrosis of the interstitium of the lungs.
232
What are the features of Idiopathic pulmonary fibrosis?
1. progressive exertional dyspnoea
2. bibasal fine end-inspiratory crepitations on auscultation
3. dry cough
4. clubbing
233
What investigation is used for diagnosis of Idiopathic pulmonary fibrosis?
High - resolution CT scan
234
What is the CXR finding for Idiopathic pulmonary fibrosis?
bilateral interstitial shadowing - typically small, irregular, peripheral opacities -
- 'ground-glass'
- later progressing to 'honeycombing'
235
What is the management of Idiopathic pulmonary fibrosis?
- Pulmonary rehabilitation
- Supplementary oxygen
- Eventually lung transplant
236
What is the prognosis of Idiopathic pulmonary fibrosis?
- Poor (3-4 year)
237
What is Pneumoconiosis?
Accumulation of dust in the lungs
- and response of the bodily tissue to its presence
AKA - Black lung disease
238
What is the CXR finding for pneumoconiosis?
- Upper zone fibrosis
239
Management of pneumoconiosis
- Manage symptoms of chronic bronchitis
- Pulmonary rehab
- corticosteroid therapy
240
What are the symptoms of pneumoconiosis?
- SOBOE
| - Cough (black sputum)
241
What are the examination findings for pneumoconiosis?
- Normal chest exam
| - crackles OA
242
What is Sarcoidosis?
Multisystem disorder of unknown aetiology characterised by non-caseating granulomas
--> Small patches of red and swollen tissues
243
What are the features of Sarcoidosis?
- SOB
- Dry cough
Acute:
- eythema nodosum
- bilateral hilar lymphadenopathy
- swinging fever
- polyarthralgia
- Hypercalcaemia
244
How is Sarcoidosis diagnosed?
- No diagnostic test, largely clinical
245
What is the 1st line management of Sarcoidosis ?
Oral glucocorticoid
| steroids
FCM Matrix
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