Resp Lecture 2

Question 1

Definition of asthma

Answer 1

Condition characterized by reversible airway obstruction caused dueto airway inflammation, bronchial hyper-responsiveness, which mayor may not be triggered by allergens

Question 2

What are the different types of asthma?

Answer 2

allergic asthma

non allergic asthma

late onset asthma

occupational asthma

asthma with obesity

Question 3

Pathophysiology of allergic asthm

Answer 3

Th2 mediated asthma

• Step 1: Allergen enters the body
• Step 2: dendritic cells identify the allergen (throughDAMPS and PAMPS)
• Step 3: allergen uptake by dendritic cells
• Step 4: activation of the helper T cells-Th2activation
• Step 5: B cell activation + mast cell + eosinophil cellrecruitment
• Step 6: B cellIgEantibodiesThe patient is now said to be sensitized to the allergen
• Step 7: on subsequent exposure,IgEantibodiesbind onto mast cells
• Step 8: degranulation of the mast cells (containprestored inflammatory mediators like histamine+leukotriene)
• Step 9: allergic reaction:
• Histamine causes arteriolar dilatation and venularendothelial contraction
• Leukotrienes: primarily cause vasoconstriction andincreased vascular permeability

Question 4

Pathophysiology of non-allergic asthma

Answer 4

Th17 mediated

• Step 1: Neutrophil activation
• Step 2: extended neutrophil lifespan
• Step 3: release of granular enzymes +ROS
• Step 4: ROS + enzymes causebronchoconstriction

Thus, non allergic asthma tends to bepresent with non-resolving mucosalinflammation-Tends to be triggered by viruses-Do not respond to antihistamines

Question 5

Classic signs and symptoms of asthma

Answer 5

Wheeze

Cough

Breathlessness/SOB

Variation insymptoms-worsein the morningand at night

Question 6

Diagnosis of asthma in adults

Answer 6

• Spirometry→(FEV1/FVC<0.7)=obstructive disease
• BDR-increase in FEV1-12% + 200ml inresponse to ICS/ B2 agonists
• FeNO→40ppm
• Fractional exhaled Nitric oxide
• During inflammation higher amount of NOproduced by the epithelial cells and hencehigh levels of NO is indicative of airway inflammation
• PEF (peak expiratory flow)variation by12% (best of 3)
• BHR→Drop in FEV1-20%•Patients with asthma will respond to muchlower doses of pharmacological agents likehistamine or methacholineas compared toa normal perso

Question 7

Diagnosis ofasthma in children

Answer 7

• Spirometry→(FEV1/FVC<0.7)= obstructivedisease
• BDR-increase in FEV1-12% inresponse to ICS/ B2 agonists
• FeNO→35ppm
• Greater than 20% variability inPEF monitored over 2-4 weeksis diagnostic of asthma

Question 8

How do you differentiate between COPD and Asthma?

Answer 8

Asthma

• Variation in symptom presentation (worse in the morning and at night)
• Chronic productive cough is uncommon- Sputum production only in acute exacerbations
• May not having a smoking history
• A trigger or allergen may be associated with the symptoms
• Reversible lung function
• Variable SOB

COPD

Symptoms are always present

Chronic productive cough with production of sputum (chronic bronchitis)

Almost always have a smoking history!

Less likely to find an allergen

Progressively worsening lung function

Progressively worsening SOB

Question 9

Differentiating asthma from cardiacconditions

Answer 9

•Asthma

• Chest pain/tightness
• SOB-not on exertio

•Other cardiac conditions

• Chest pain/tightnessradiating to thejaws/shoulder/left arm
• EXERTIONAL SOB withother cardiac symptoms such as peripheral oedem

Question 10

Treatment for asthma

Answer 10

• Bronchodilators
• First choice: SABA-salbutamol inhalers–reliever inhalers
• LABA-third line
• Second line: Steroids (ICS)
• Beclomethasone
• Prednisolone
• Third line: LRTA-leukotriene receptor antagonists)
• LAMA
• Theophylline
• Oxygen-as needed

Question 11

Give examples of Upper respiratory tract ifections?

Answer 11

Epiglottitis

Tonsilitis

Croup

Viral illness

Question 12

Give examples of Lower respiratory tract infections?

Answer 12

Bronchiolitis

Influenza

Viral induced wheeze

Question 13

Tonsilitis

Symptoms:

Signs

Bugs

Ix:

Tx:

Answer 13

• Symptoms: sore throat, earache, pyrexia > 38C
• -Signs: enlarged, inflamed tonsils +/- lymphadenopathy
• -Bugs: Group A Strep
• • Investigations: Throat swab
• -Tx: Ab if bacterial, analgesia ( difflam spray, ibuprofen)

Question 14

What is croup?

Answer 14

inflammation of the larynx and trachea in children, associated with infection and causing breathing difficulties

Question 15

Croup

symtons

signs

bugs

Tx

Answer 15

• -Symptoms : viral illlness-> barking cough and stridor middle of night
• -Sign: inspiratory stridor, intercostal/subcostal recession
• -Bugs: Parainfluenza> RSV
• -Tx: dexamethasone
• -Mnemonic: CrouP: C: corticosteroids->dexamethasone

P: parainfluenza

Question 16

What is epiglottitis?

Answer 16

Epiglottitis is inflammation and swelling of the epiglottis. It’s often caused by an infection, but can also sometimes happen as a result of a throat injury. The epiglottis is a flap of tissue that sits beneath the tongue at the back of the throat.

Question 17

Epiglottitis

Symtoms

signs

bugs

Answer 17

• • Young children, HIB unimmunized
• -Symptoms: very unwell, pyrexia, soft stridor, little cough ,drooling (can’t swallow secretions)
• -Signs: drooling, tripod position, dysphagia
• -Bugs: Haemophilus influenza type B >> Strep Pyogenes, pneumoniae

4 D’s: Dysphagia, Dysphonia, Drooling, Distress

Question 18

Viral Illness

Symptoms

Signs

Bugs

Ix

Answer 18

• Common cold
• Symptoms: nasal discharge, sneezing, painful, throat/ears, pyrexia, headache, malaise
• Signs: red pharynx, pus, bilateral red tympanic membranes, yellow/green discharge
• Bugs: Rhinovirus> Enterovirus> Coronavirus> RSV> Parvovirus > Adenovirus
• Investigations: NONE

Question 19

Bronchiolitis

symotoms

signs

bugs

RF

Ix

Tx

Answer 19

• Symptoms: coryzal symptoms, cough, progressive increased WOB, poor feeding
• Signs: tug, nasal flare, head bobbing, recession, crackles, wheeze, cyanosed
• Bugs: RSV, adenovirus, metapneumovirus, influenza
• RF: premature, immunocompromised, congenital heart/lung disease
• Investigations: Cough swab
• Tx: supportive, Palivizumab- prophylactic injection for RSV

Question 20

Influenza

Defintion

Subtypes

symptoms

signs

Ix

Tx

Answer 20

• Highly contagious disease occurring in winter months.
• Influenza virus A,B,C ( rarely C).
• Subtypes: based on surface antigens H ( haemagglutinin), N ( neuraminidase)
• Symptoms: pyrexia, myalgia, headache, cough, chills
• Signs: red throat, hypotension, bradycardia
• Investigations: blood test, rapid antigen test
• Tx: supportive: antipyretics, analgesia, oseltamivir

Question 21

What is pneumonia?

Answer 21

•Inflammation of lungs due to a causative organism, produces consolidation/ interstitial lung infiltrates

Question 22

Pneumonia

symptoms

Signs

Ix

Answer 22

• Symptoms: productive cough, SOB, chest pain, haemoptysis, fever
• Signs: SoB, tachypnea, cyanosis, hypotensive, reduced chest expansion. Dull percussion, coarse crackles on auscultation
• Investigations: CURB- 65/CRB-65, CXR, sputum culture, bloods

Question 23

What are the bacterial viral and fungal pathogens associated with pneumonia?

Answer 23

•Bacterial:

• Typical: Strep Pneumoniae (CAP), Haemophilus influenzae , Pseudomonas Aeruginosa (HAP/VAP)
• Atypical: Legionella, Chlamydia spp.

•Viral:

• Influenza
• RSV
• SARS-COV2

•Fungal:

• TB aspergillosis
• Pneumocystis jirovecci

Question 24

What is pleural empyema

Answer 24

•Collection of pus in the pleural cavity

Question 25

Pleural empyema Symptoms signs RF bugs Ix

Answer 25

* Symptoms: fever, cough, breathlessness, lethargy, reduced exercise tolerance * Signs: reduced chest expansion, reduced breath sounds, stony dull percussion * RF: pneumonia, iatrogenic intervention, DM, underlying carcinoma/TB * Bugs: Strep pneumoniae, Staph A * Investigations: blood culture, CXR, thoracentesis

Question 26

What is a lung abscess? stages rf symptoms

Answer 26

* Cavity filled with pus in lung parenchyma, suppurative inflammation of lung tissue * - As a result of aspiration, malignancy, pathogens * -Right\>\> Left lung : wider, straighter mainstem bronchus * -Stages: pneumonitis-\> necrosis-\> cavitation-\> abscess formation * -RF: Chronic aspiration, chronic lung infection, immunocompromised * -Symptoms: fever, cough, weight loss, night sweats

Question 27

What is Interstitial Lung Disease?

Answer 27

- Restrictive Lung Disease - Umbrella term that describes a collection of lung disorders that affect the interstitium

Question 28

ILDs can be classed into two groups what are they?

Answer 28

Known cause Idiopathic

Question 29

Examples of idiopathic ILD

Answer 29

Idiopathic pulmonary fibrosis NSIP- Nonspecific interstitial pneumonia

Question 30

Known cause ILDs can be further split into what?

Answer 30

Connective tissue disease Occupational Exposure Granulomatous disease Treatment induced

Question 31

Examples for connective tissue disease ILD s

Answer 31

Systemic Lupus Erythematosus Rheumatoid Arthritis Systemic Sclerosis

Question 32

Examples of occupation exposure ILDs

Answer 32

Asbestosis Silicosis

Question 33

Examples of Granulomatous diseases ILDs?

Answer 33

sarcoidosis Hypersensitivity Pneumonitis

Question 34

What is idiopathic pulmonary fibrosis? trigger? RF?

Answer 34

-Ongoing repair process → excess collagen and scar tissue in the interstitial tissue of the lung **-The trigger is unknown** -It is a chronic progressive fibrotic lung disease and ultimately fatal **-Risk factors** - Male - 50-70 years - Tobacco smoking

Question 35

Pathophysiology of IPF

Answer 35

Loss of structural integrity, loss of elasticity and restricted gas exchange leading to progressive respiratory failure

Question 36

Characterisitics of IPF

Answer 36

Characteristics of IPF - Irreversibly enlarged damaged bronchioles and alveoli - Fibroblastic foci - Honeycombing (cystic airspaces with fibrous walls)

Question 37

What is the management for IPF

Answer 37

- Median survival time for patients with IPF is 2-5 years - Anti-fibrotic therapy (Pirifenidone, nintedanib) - Lung transplant Best supportive care (palliative care, pulmonary rehabilitation, oxygen therapy

Question 38

How do you know if it is non specific interstitial pneumonitis?

Answer 38

CT: Ground-glass opacities

Question 39

What is Hypersensitivity Pneumonitis

Answer 39

Hypersensitivity pneumonitis (HP) or extrinsic allergic alveolitis (EAA) is a rare immune system disorder that affects the lungs. It is an inflammation of the airspaces (alveoli) and small airways (bronchioles) within the lung, caused by hypersensitivity to inhaled organic dusts and molds.

Question 40

What causes Hypersensitivity Pneumonitis?

Answer 40

- Caused by an immunologic reaction to an inhaled known organic agent causing an inflammatory response in the alveoli and small airways - There are \>3000 known causes of hypersensitivity pneumonitis - Aspergillus species - Mycobacterium species - Animals, plants, chemicals

Question 41

Types of hypersensitivity pneumonitis related to occupation ?

Answer 41

Question 42

Patho of hypersensitivity pneumonitis

Answer 42

Question 43

Clinical features of hypersensitivity pneumonitis

Answer 43

Question 44

Diagnosis of Hypersensitivity Pneumonitis?

Answer 44

- History of antigen exposure (IgG-specific antibodies) - Clinical symptoms - radiological : HRCT * Ground glass airway opacities * Honeycombing * Dilated airways - PFT: restrictive or obstructive pattern - Bronchoscopy: lymphocytosis (\>20%) - Lung biopsy: poorly defined, non-caseating granulomas

Question 45

Management of hyoersensitivity pneumonitis

Answer 45

- Antigen avoidance - Corticosteroids - Immunosuppressive therapy

Question 46

What is sarcoidosis? Epidemiology?

Answer 46

- Chronic, immune-related, multi-system granulomatous disease characterised by the presence of non-infectious, noncaseating granulomas and chronic interstitial pulmonary fibrosis - More common in female - African descent - Peak presentation is 20-50 years

Question 47

Patho of sarcoidosis?

Answer 47

Question 48

CF of sarcoidosis?

Answer 48

**Lung (90%)** * interstitial lung disease * Bilateral hilar lymphadenopathy **Brain** * Cranial nerve palsies * Meningitis **Eye** * Uveitis * Glaucoma **Heart** * Myocarditis, pericarditis * Restrictive cardiomyopathy * Arrhythmia, AV blocks **MSK** * Phalangeal bone cysts * Arthritis **Splenomegaly, Granulomatous hepatitis** **Skin (10-30%)** * Erythema nodosum * Subcutaneous nodules * Lupus pernio

Question 49

Diganosis for sarcoidosis?

Answer 49

- CXR - Blood tests * -Elevated Serum ACE * -Hypercalcaemia, hypercalciuria - Bronchoscopy+biopsy * -Noncaseating granuloma - Bronchioalveolar lavage * -Raised CD4:CD8 ratio

Question 50

What is abestosis?

Answer 50

-Diffuse pulmonary fibrosis caused by inhalation of asbestos fibres, mostly affecting the lower lobes of the lung

Question 51

What are related diseases to abestos?

Answer 51

Latency period is 20-30 years after initial exposure - Pleural plaques (most common) → increases risk of pleural effusion - Diffuse interstitial pulmonary fibrosis (asbestosis) * -Small linear opacities in lower lung fields - Primary Bronchogenic Carcinoma (cigarette smoking) - Malignant Mesothelioma * -Haemorrhagic pleural effusion and pleural thickening

Question 52

CF and History for abestosis?

Answer 52

Clinical features - Dyspnoea - Finger clubbing - O/E shows bi-basal end-inspiratory crackles - Systemic features History - Connective tissue disease? - History of occupational exposure? - Idiopathic?

Question 53

Ix for abestosis

Answer 53

- Lung function tests - Bloods (systemic diseases, connective tissue diseases) - Radiology: Chest X-ray, HRCT - Bronchoscopy + biopsy

Question 54

Answer 54

Question 55

Answer 55

Question 56

Answer 56