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Respiratory Flashcards

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1
Q

What is the leading cause of acute bronchitis

A

Viruses

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2
Q

Describe the symptoms of acute bronchitis

A

Acute onset of:
-Cough: may be productive
Sore throat
Rhinorrhoea
Wheeze

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3
Q

What signs might you expect on examination of someone with acute bronchitis

A

Low grade fever
Wheeze
Typically normal chest

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4
Q

How can history help differentiate between acute bronchitis and penumonia

A

Sputum, wheeze, breathlessness may be absent in acute bronchitis but usually one is present in pneumonia

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5
Q

How can examination findings help differentiate between acute bronchitis and pneumonia

A

No focal chest signs other than wheeze (dullness to percussion, crepitations, bronchial breathing)
No systemic features like malaise, myalgia, fever

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6
Q

How is acute bronchitis diagnosed?

A

Clinical
CRP can be used to guide management

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7
Q

How is acute bronchitis treated?

A

Analgesia
Fluids
COnsider abx theraoy:
1. doxycycline 1st line (not in children.preggos)
2. amoxicillin

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8
Q

What features might prompt abx in a patient with acute bronchitis

A

Systemically unwell
Pre-existing co-morbidities
CRP 20-100 (delayed script), >100-immediate script

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9
Q

What causes allergic bronchopulmonary aspergillosis?

A

Allergy to aspergillus spores

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10
Q

how do patients with allergic bronchopulmonary aspergillosis typically present

A

Hx of bronchioectasia+eosinophilia

Bronchoconstriction: wheeze, cough, dypnoea, may have precious asthma dx
Bronchiectasis

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11
Q

What investigations are useful for diagnosing allergic bronchopulmonary aspergillosis

A

Eosinophilia
Fitting CXR changes
Positive RAST test to aspergillus
Positive IgG precipitins
Raised IgE

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12
Q

How is allergic bronchopulmonary aspergillosis managed?

A

Oral glucocorticoids
Itraconazole 2nd line

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13
Q

What lung problems can aruse from asbestos

A

Pleural plaques
Pleural thickening
Abestosis
Mesothelioma
Lung cancer

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14
Q

How long after exposure to asbestos do pleural plaques form?

A

20-40 years

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15
Q

Do pleural plaques require follow up?

A

No-benign and don;t undergo malignant change

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16
Q

What does asbestosis cause?

A

Lower lobe firbosis

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17
Q

What is the latent period of asbestosis?

A

15-30 years

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18
Q

How is the severity of asbesotiss and mesothelioma correlate with severity

A

Asbestosis: severity correlates to length of exposure
Mesothelioma: even limited exposure can cause disease

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19
Q

Describe the clinical features of asbestosis

A

Dyspnoea and reduced exercise intolerance
Clubbing
Bilateral end-inspiratory crackles

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20
Q

What is seen on lung function tests in aptietns with asbestosis

A

Restrictive pattern with reduced gas transfer

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21
Q

How is asbestosis treated?

A

Conservatively

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22
Q

What is the most common form of cancer associated with asbestos?

A

Lung cancer

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23
Q

What is bronchiectasis?

A

Permanent dilatation of the airway secondary to chronic infection or inflammation

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24
Q

What are the symptoms of bronchiectasis

A

Persistent productive cough-large volumes of sputum
Dyspnoea
Haemoptysis

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25
What are the signs of bronchiectasis
Coarse crackles Wheeze Clubbing
26
How is bronchiectasis diagnosed?
High resolution CT thorax-diagnostic Bronchail dilatation (signet ring sign), bronchial wall thickening, lack of bronchial tapering
27
What are some causes of bronchiectasis
-Idiopathic -Previous sever LRTI like pneumonia, TB, flu -Immunodeficiency Defective mucociliary clearance(CF) -Airway obstriction -Chronic aspiration -AI disease
28
What are the most common organisms isolated from bronchiectasis
H influenzae-mc Pseudomonas aeruginosa Klebsiella S pneumoniae
29
How is bronchiectasis managed?
Assess for reversible causes Physical training: inspiratory muscle training Postural drainage Abx for exacerbations Bronchodilators for select cases Immunisations Surgery if localised disease
30
What is the most common cause of bronchiolitis?
RSV
31
Describe the epidemiology of bronchiolitis
LRTI in <1yr olds Peak incidence 3-6 months (maternal IgG provides protection to newborn) Higher incidence in winter
32
What are the causes of bronchiolitis
RSV-mc Mycoplasma Adenoviruses May be secondary bacterial infection
33
What factors can make bronchiolitis more severe
Bronchopulmonary dysplasia-premature Congenital heart disease Cystic fibrosis
34
Describe the general clinical features of bronchiolitis
Coryzal sx-including mild fever preceding: -Dry cough -Increasing breathlessness 0Wheezing, fine inspiratory crackles -Feeding difficulties associated with dyspnoea
35
What are indications for immediate hospital referral in patients with bronchiolitis
Apnoea Child looks unwell to healthcare professional Severe reso distress: grunting, chest recessiong, RR >70bpm Central cyanoiss Persistent O2 sat <92% room ari
36
What factors are indications for consideration of a hospital referral in bronchiolitis
RR>60 Difficulty with breatfeeding or inadequate oral fluid intake (50-70% normal volume) Clincal dehydration
37
What investigation is used in bronchiolitis
Immunofluorescence of nasopharyngeal secretions may show RSV
38
How is bronchiolitis managed?
Supportive Humidified O2 NG feeding Suction for upper airway secretions# Palivizumab to prevent spread of RSV in children at risk of severe disease
39
When should a diagnosis of pneumonia be considered in 1 year olds?
High fever (>39 degrees) and/or persistently focal crackles
40
Who is the RSV vaccine offered to?
Pregnant women from 28 weeks gestation onwards to protect infants from RSV bronchiolitis during first 6 months of life Adults aged 75-79yrs
41
What abx should be used for bronchiectasis exacerbations
Non psuedomonal infections: amoxicillin or doxycycline Pseudomonas: cirpofloxacin or ceftazidime
42
What is the inheritance pattern of CF
Autosomal recessive
43
Describe the pathophysiology of CF
Defect in CFTR gene (CF transmembrane conductance regulator ) which codes a cAMP regulated chloride channel Mc due to delta F508 on the long arm of chromosome 7
44
What is the carrier vs affected rate of CF in the UK?
Affect: 1/2500 births Carrier rate: 1/25
45
What organisms can commonly colonise CF patients?
S aureus-kids Pseudomonas aeruginosa-adults Aspergillus Burkolderia cepaci
46
Describe the pathophysiology of CF
Mutation in CFTR gene disrupts water and chloride transport-> thick, dehydrated mucus in airways-> impairs mucociliary clearance and traps pathogens, promiting chronic infection
47
Describe the features of CF in neonates
Meconium ileus Prolonged jaundice
48
How do patients with CF present?
Recurrent chest infections Malabsorption: steatorrhoea, failure to thrive Liver disease Short stature DM Delayed puberty Rectal prolapse (bulky stools) Nasal polyps Male infertility, female subfertility
49
How is cystic fibrosis most commonly diagnosed?
heel prick test at birth
50
How is CF investigated?
Sweat test -Abnormally high sweat chloride (>60)
51
What are some causes of falsely positive sweat test for CF
Malnutrition Adrenal insufficiencyc Glycogen storage diseases Nephrogenic DI Hypothyroidism, hypoparathyroidism G6PD Ectodermal syplasia
52
What are some causes of false negative tests in CF sweat test?
Skin oedema-> from hypoalbuminaemia/hypoparaprotinaemia caused by pancreatic exocrine insufficiency
53
Describe the management of CF
Twice daily chest physio and postural drainage High calorie diet with high fat intake Minimise contact with other CF patients Vitamin supplementation Pancreatic enzyme supplements taken with meals Lung transplantation Lumacaftor/ivacaftor (orkambi)
54
What is a contraindication for lung transplant in CF patients?
Chronic infection with burkholderia cepacia
55
What is lumacaftor/ivacaftor used for and how does it work?
CF patients who are homozygous for the delta F508 mutation Lumacaftor: increases number of CFTR proteins that are transported to the cell surface Ivacaftor: Potentiato of CFTR-> increases probability that the defective channel will be open and allow chloride ions to pass through the channel pore
56
Name some complications of CF
Bronchiectasis Cor pulmonale, RHF GI: meconium ileus, malnutrition, bowel obstruction Infertility Osteoporosis Nasal polyps and sinus infection
57
What causes infertility in male patients with CF
Obstructive azoospermia
58
What is the pathophysiology behind Type 1 resp failure
V/Q mismatch-> impaired oxygenation
59
How does Type 1 reps failure appear on an ABG
Low PaO2 Low/normal PaCO2
60
What conditions can cause Type 1 respiratory failure
Pneumonia PE ARDS
61
What is the pathophysiology behind Type 2 respiratory failure
Alevolar hyperinflation-> impaired CO2 expelling
62
How does Type 2 resp failure appear on an ABG?
Low PaO2 High PaCO2
63
What conditions cause a type 2 resp failure
COPD Asthma Neuro-MND, GBS
64
What is the ICU treatment for Type 1 resp failure and why?
CPAP -Single constant pressure that keeps alveoli open and improves oxygen diffusion (no ventilation help) -Think back to causes: alveoli collapse/fill with fluid so need help staying open
65
What is the ICU treatment for Type 2 respiratory failure and why?
BiPAP -Bilevel positive airway pressure, 2 pressures: -IPAP: Assisite inspiration, pushes air in and removes CO2 -EPAP: Keep alveoli open to improve O2 Overall ventilation and oxygenation support
66
What 3 domains are measured in pulmonary function tests?
Airflow-> obstruction Lung volume-> restriction Gas transfer-> diffusion ability
67
What can spirometry not measure?
Residual volume Total lung capacity Diffusion capacity
68
What is FEV1
Air exhaled in 1st second
69
What is FVC
Total forced breath
70
What spirometry pattern implies obstructive disease and what are some causes?
Obstructive= airflow problem (air can't get out) Low FEV1 Low FEV1/FVC ratio (<70%) Causes: COPD, asthma etc
71
What spirometry pattern implies restrictive disease and what are some causes?
Restrictive=volume problem (lungs can't expand) Low FVC Normal/high FEV1/FVC Causes: interstitial lung disease-Pulmonary fibrosis, obesity, NMD,
72
What is the bronchodilator reversibility test?
positive: asthma FEV1 improves >=12% and >200ml after bronchodilator
73
What key LFTs measure lung volume and capacity?
TLC-usually around 5L RV VC TV
74
What is used to check for CO poisoning and why?
Carboxyhaemoglobin level CO binds haemoglobin-> carboxyhaemoglobin which prevents oxygen transport
75
What cells line the respiratory tract?
Pseudostratitifed ciliated columnar epithelium with interspersed goblet cells
76
What is surfactant?
Overcomes elastic recoil and reduces surface tension of alveoli
77
When is surfactant produced?
Around 34 weeks gestation by type 2 pneumocytes
78
What is laplace law
P=2T/r T: surface tension r: radius of alvoli
79
What is fraction expired nitric oxide and what is it used to diagnose?
Marker of eosinophilic airway inflammation-active asthma Used for diagnosing asthma (high) and predicting steroid response
80
Describe vesiculare breath sounds
Soft, low-pitched Inspiration >expiration No pause
81
Describe bronchial breath sounds
Loud, harsh Expiration >=inspiration Gap between phases Suggests consolidation like pneumonia
82
Describe fine crackles
Popping/bubbling-high pitches End inspiration Causes: fibrosis, early pulmonary oedema
83
Describe coarse crackles
Popping/bubbling-low pitched Throughout inspiration Causes: oneumonia, bronchiectasis, pulmonary oedema
84
What are the causes of a wheeze
Narrowed airways Asthma COPD Anaphylaxia
85
Describe stridor
Loud, harsh, high-pitched Caused by upper airway obstruction Causes: epiglottitis, foreign body, laryngeal oedema
86
Describe the features and causes of a pleural rub
Creaking leater/walking in snow Inflamed pleura rubbing Causes: pleurisy, PE, oneumonia
87
Describe the features and causes of rhonchi
Low-pitched snoring, often clears after coughing Mucus in large airways Pneumonia, COPD, bronchiectasis
88
How would you interpret pH in an ABG
Normal: 7.35-7.45 (or compensated) <7.35: acidosis >7.45: alkalosis
89
What would you expect pH, PaCO2 and HCO3 to look like in a patient with respiratory acidosis?
pH: low-acidosis PaCO2: high-retaining CO2 HCO3: normal if no compensation high with compensation=chronic retainer (normal pH) High with abnormal pH-acute flare-acidosis and kidneys can't keep up
90
What would you expect pH, PaCO2 and HCO3 to look like in a patient with respiratory alkalosis?
pH: high PaCO2: low HCO3: normal (low if compensating)
91
What causes respiratory acidosis?
CO2 retention -COPD Respiratory depression (head trauma, drugs etc)
92
What causes respiratory alkalosis
Hyperventilation E.g. anxiety, pain PE
93
How can you distinguish between PE and hyperventilation syndrome on an ABG?
PE: Low PaO2 Anxiety: high/normal PaO2
94
What would you expect pH, PaCO2 and HCO3 to look like in a patient with metabolic acidosis?
pH: low HCO3: low PaCO2: normal (low fi compensation)
95
What would you expect pH, PaCO2 and HCO3 to look like in a patient with respiratory alkalosis?
pH: high HCO3-: high PaCO2: normal (high in compensation)
96
What causes metabolic acidosis?
High lactate-> anaerobic respiration from tissue hypoxia High ketones-> DKA High H+: renal failure, type 1 tubular acidosis, rhabdomyolysis Low HCO3-: diarrhoea, renal failure, type 2 renal tubular acidsois
97
What causes metabolic alkalossi?
Loss of H+ ions 1) Vomiting 2) Kidneys/increased aldosterone causes: -Conn's -liver cirrhosis -Heart failure -Loop diuretics -Thiazide diuretics
98
What can help determine the cause of metabolic acidosis?
Anion gap
99
What does a high anion gap indicate?
Cause of metabolic acidosis: lactate, toxins, ketones, renal MUDPIES Methanol, metformin Uremia DKA Propylene glycol, paracetamol Iron, isoniazid Etylene glycol, ethanol Salicylate
100
What does a normal anion gap in metabolic acidosis indicate?
GI loss, renal loss as cause HARDUP H+ excretion failure: Addison's, renal tubular acidosis, hyperaldosteronism Acetazolomide, addison's Renal tubular acidosis Diarrhoea Uterosigmoid fistula Pancreatic fistula
101
What is a quick way to interpret ABG's
pH to determine acidosis/alkalosis Respiratory: look at CO2 as primary Metabolic: look at HCO3 as primary If HCO3 and CO2 match: compensation If HCO3 and CO2 don't match: mixed picture
102
Out of CO2 and HCO3 which makes it acidotic and which makes it alkaline?
CO2-> acid HCO3-? alkaline
103
What is interstitial lung disease?
Group fo disorders characterised by inflammation and fibrosis of the lung parenchyma
104
What conditions come under the umbrela of interstitial lung disease
Idiopathic pulmonary fibrosis Secondary pulmonary fibrosis Hypersensitivity pneumonitis Cryptogenic organising pneumonia Asbestosis
105
What are the symptoms of insterstitial lung disease
SOB Cough-dry Fatigue
106
What are the signs of interstitial lung disease?
Bibasal fine end inspiratory crackles Finger clubbing
107
What is idiopathic pulmonary fibrosis
Chronic lung condition characterised by progressive fibrosis of the interstitium of the lungs -Term used when no underlying cause exists
108
Describe the epidemiology of idiopathic pulmonary fibrosis
50-70yrs Twice as common in men
109
Describe the clinical features of idiopathic pulmonary fibrosis
Progressive exertional dyspnoea Bibasal fine end inspiratory crepitations on auscultation Dry cough Clubbing
110
How is idiopathic pulmonary fibrosis investigated?
Spirometry: restrictive picture Reduced transfer factor (TLCO) High resolution CT thorax, CXR
111
What is seen on spirometry in patients with idiopathic pulmonary fibrosis
Restrictuve picture FEV1 normal/decreased FVC decreased FEV1/FVC increased
112
What is seen on imaging in idiopathic pulmonary fibrosis
Bilateral insterstitial shadowing (small irregular, peripheral opacities-'ground glass', later progressing to 'honeycombing')
113
Describe the management of idiopathic pulmonary fibrosis
Pulmonary rehabilitation Pirfenidone (antifibrotic) Nintedanib (tyrosine kinase inhibitor) Supplementarly O2, lung transplant
114
What is the prognosis of idiopathic pulmonary fibrosis
Average life expectancy 3-4 years
115
What conditions cause upper zone fibrosis
CHARTS Coal worker's pneumoconiosis Histiocytosis/hypersensitivity pneumonitis Ankylosing sponydlitis Radiation TB Sarcoidosis/silicosis
116
What conditions cause lower zone fibrosis
Idiopathic pulmonary fibrosis Connective tissue disorders (except ankylosing spondylitis) Drug induced Asbestosis
117
What drugs can cause pulmonary fibrosis
Amiodarone Bleomycin Methotrexate
118
What causes hypersensitivity pneumonitis?
Inhalation of specific environmental agents trigger hypersensitivity reaction in the lungs
119
What are some triggers of hypersensitivity pneumonitis
Chemicals Agricultural dust Plant and animal and fungal proteins
120
What is Farmer's lung
Type of hypersensitivity pneumonitis caused by mould spores on hay or straw
121
How do patients with hypersensitivity pneumonitis clinically present?
One off exposure to trigger-> acute onset flu-like sx like fever, cough, SOB Repeated exposure-> interstitial fibrosis and ILD
122
How is hypersensitivity pneumonitis managed?
Reversal if causitve agent ID'd and removed Trial of steroids Other immunosuppressants like cyclophosphamide, azathioprine
123
What does a CXR show in asbestosis
Pleural plaques or thickening
124
What is sarcoidosis?
Multisystem disorder characterised by noncaseating granulomas-> inflammation and scarring in organs, especially lungs and skin Others: nerves, brain, heart, liver, eyes
125
What is the peak age of onset of sarcoidosis
30-55 yrs
126
Describe the pulmonary manifestations of sarcoidosis
Dry cough Dyspnoea Reduced exercise tolerance Chest pain Clubbing-only if severe -Fine crackled on asucultation
127
Describe the systemic features of sarcoidosis
Fatigue Weight loss Arthralgia Low grade fevers lymphadenopathy Enlarged parotid glands
128
Describe the dermatological manifestations of sarcoidosis
Erythema nodosum-> tender nodules, especially on shin Lupus pernio Hyper/hypo-pigmentation of skin
129
Describe the neurological manifestations of sarcoidosis
Meningitis Peripheral neuropathy Facial nerve palsy-may be bilateral Headache Seizures/encephalopathy
130
Describe the ocular manifestations of sarcoidosis
Uveitis Keratoconjunctivitis sicca Glaucoma
131
Describe the cardiac manifestations of sarcoidosis
Arrhythmias Restrictive cardiomyopathy Syncope
132
Describe the abdominal manifestations of sarcoidosis
Hepatomegaly Splenomegaly Renal stones
133
What is Lofgren's syndrome
Acute onset of: -Fever -Polyarthralgia -Erythema nodosum -Bilateral hilar lymphadenopathy on CXR
134
What is Heerfordt's syndrome
Fever Uveitis parotid swelling facial nerve palsy
135
Name some differentials for sarcoidosis
TB Lymphoma Other ILD
136
How is sarcoidosis diagnosed?
ACE levels-not reliable Bloods: may show raised ESR, hypercalcaemia Spirometry: restrictive Tissue biopsy-non caseating granulomas CXR-ILD
137
What findings would you expect on a CXR in sarcoidosis
Satge 0-normal Stage 1-bilateral hilar lymphadenopathy Stage 2: BHL and interstitial infiltrates Stage 3: diffuse interstitial infiltrates only Stage 4: diffuse fibrosis
138
Describe the management of sarcoidosis
Conservative: pt education and support, smoking cessation, no active treatment in many cases Medical: steroids, immunosuppressants like methotrexate, biologics (infliximab) Surgical: Lung transplant
139
When should medical treatment be started in sarcoidosis
Only if sx affecting QOL or there is a significant risk of morbidity or mortality
140
Name some complications of sarcoidosis
Pulmonary fibrosis Cor pulmonale Pulmonary hypertension Arrhythmias and sudden death low mood and anxiety Complications for long-term steroid use-> osteoporosis, hyperglycaemia
141
What is tuberculosis?
Infection caused by mycobacterium tuberculosis that most commonly affects the lungs
142
Describe the pathophysiology of primary TB
Non-immune host exposed to M.TB may develop a primary infection of lungs-> development of small lung lesion (Ghon complex) composed of tubercle-laden macrophages Ghon focus + hilar lymph nodes-> Ghon complex Immunocompetent: lesion heals by fibrosis Immunocompromised: disseminated disease (miliary TB)
143
Describe the pathophysiology of secondary TB
If host becomes immunocompromised: initial infection becomes reactivated, usually in apex of lungs and may spread locally or to more distant sites, mc lungs
144
Where can extra pulmonary infection occur in secondary TB
CNS-TB meningitis-most serious Vertebral bodies-Pott's disease Cervical lymph nodes Renal GI tract
145
Describe how macrophages migrating to regional lymph nodes may lead to miliary TB
Macrophages migrate to regional lymph nodes + lung lesion =Ghon complex-> formation of a granuloma
146
What is a granuloma?
Collection of epithelioid histocytes with caseous necrosis in the centre (TB)
147
What hypersensitivity reaction occurs in TB
Type 4
148
Name some risk factors for catching TB
Lived in Asia, Latin America, Eastern Europe, Africa Exposure to infectious TB HIV infection, other immunocompromised people Silicosis Apical fibrosis
149
What are the symptoms of latent TB
Asx and non-infectious
150
How are patients with latent TB diagnosed?
Positive tuberculin skin test or interferon gamma release assay with a normal cxr
151
What is used to treat latent TB
3 months of isoniazid (with pyridoxine) and rifampicin OR 6 months of isoniazid (with pyridoxine)
152
When is 3 months of isoniazid (with pyridoxine) and rifampicin given for latent TB
<35 yrs if hepatotoxicity a concern
153
3 months of isoniazid (with pyridoxine)
Interactions with rifamycins are a concern, e.g. patietns with HIV or who have had transplants
154
What restrictions for employment are there for patients with latent TB
None-not infectious if latent
155
Name some risk factors for developing active TB
Silicosis Chronic renal failure HIV positive Immunosuppression with solid organ transplant IVDU Haem malignancy Anti-TNF tx Previsou gastrectomy
156
What is silicosis
Lung disease caused by inhaling crystalline silica dust (common in mining/construction)-> lung inflammation and fibrosis, mostly upper lobes
157
What screening is used for latent TB
Mantoux test
158
Describe how the Mantoux test is carried out
Used to screen for latent TB 0.1ml of 1:1000 purified protein derivative injected intradermally, result read 2-3 days later
159
Describe the interpretation of a Mantoux test
Measure diameter of induration: <5mm: negative-no significant hypersensitivity >=5mm: TB infection
160
What would you do after a negative Mantoux result
If clinical suspicion or patient is immunocompromised, consider IGRA or referral to TB specialist
161
What would you do with a positive Mantoux test?
If active TB excluded: consider interferon-gamma blood test and/or tx ofr latent TB
162
What factors can cause a falsely negative Mantoux test
Miliary TB Sarcoidosis HIV Lymohoma Very young age (< 6 months)
163
What investigations are used to diagnose active TB
Sputum smear Sputum culture-gold standard NAAT CXR
164
What would you see on CXR in active TB
Upper lobe cavitation Unilateral hilar lymphadenopathy (also bilateral)
165
Describe the use of a sputum smear for diagnosing active TB
3 specimens Stained for presence of acid-fast bacilli with Ziehl Neelsen stain-all mycobacteria will stain positive Sensitivity between 50-80%
166
What factor can decrease the sensitivity of sputum smear test for active TB
HIV Sensitivity decreased to 20-30%
167
Describe the use of the sputum culture for diagnosing active TB
GS Can assess drug sensitivities Takes 1-3 weeks
168
What are NAAT useful for when diagnosing active TB
Rapid dx: 48 hours more sensitive than smear but less sensitive than culture
169
How does the interferon gamma release assay detect latent TB
Mixes patients blood with specific TB antigens to stimulate an immune response If infected: WBC's will release interferon gamma indicating a positive result
170
When is the IGRA test particularly useful?
latent TB dx: Patients who have had the BCG vaccine or may not respond well to TB tests v(clinical suspicion remains despite negative mantoux)
171
Describe the management for active TB
Initial phase (first 2 months): RIPE Rifampicin Isoniazid Pyrazinamide Ethambutol Continuation phase (next 4 months) Rifampicin Isoniazid
172
How does management change for patients with meningeal TB?
Treated for a prolonged period (>=12 months) with addition of steroids
173
When might directly observed therapy with TDS dosing regimen be indicated?
Homeless people with active TB Patients likely to have poor concordance All prisoners with active/latent TB
174
What are the side effects of rifampicin
Potent liver enzyme inducer Hepatitis Orange secretions Flu-like sx
175
What are the side effects of isoniazid?
Peripheral neuropathy Hepatitis Agranulocytosis Liver enzyme inhibitor
176
What can be used to prevent periphheral neuropathy in patients being treated with isoniazid
Pyridoxine(vitamin B6)
177
What are the side effects of pyrazinamide?
Hyperuricaemia-> gout Arthralgia Myalgia Hepatitis
178
What are the side effects of ethambutol
Optic neuritis-> check visual acuity before and during tx
179
What are some ways to rememebr TB drug side effects?
RIPE Oranges Never Go Off Rifampicin: orange urine Isoniazid: neuropathy Pyrazinamide: gout Ethambutol: optic neuritis
180
What is the mechanism of action of rifampicin?
Inhibits bacterial DNA-dependent RNA polymerase, preventing transcription of DNA into mRNA
181
What is the MOA of isoniazid
Inhibits mycolic acid synthesis
182
What is the MOA of pyrazinamide?
Converted into pyrazinoic acid-> inhibits fatty acid synsthase whcih disrupts fatty acid production needed for bacterial growth
183
What is the MOA of ethambutol
INhibits arabinosyl transferase whcih polymerises arabinose into arabinan
184
Which active TB drugs should be stopped if the patient develops hepatitis?
RIP Rifampicin Isoniazid Pyrazinamide
185
What is Goodpasture's syndrome?
Rare type of small vessel vasculitis associated with pulmonary haemorrhage and rapidly progressive glomerulonephritis
186
What causes Goodpasture's
Anti-glomerula basement membrane antibodies against type 4 collagen
187
What gene is associated with Goodpasture's
HLA DR2
188
Describe the epidemiology of Goodpasture's
Men Bimodal: Peaks: 20-30yrs, 60-70yrs
189
Describe the clinical features of Goodpasture's
Pulmonary haemorrhage Rapidly progressive glomerulonephritis-> rapid onset AKI with proteinuria and haematuria
190
How is Goodpasture's diagnosed?
Renal biopsy-> linear IgG deposits along basement membrane Raised transfer factor secondary to pulmonary haemorrhages
191
Describe the management of Goodpasture's
Plasmapharesis Steroids Cyclophosphamide
192
What factors increase the likelihood of pulmonary haemorrhage in Goodpasture's
Smoking LRTI Pulmonary oedema Inhalation of hydrocarbons Young males
193
What is granulomatosis with polyangitis
(previously Wegener's granulomatosis) AI condition associated with a necrotizing granulomatous vasculitis affecting the upper and lower resp tract and the kidneys
194
Describe the clinical features of granulomatosis with polyangitis
URT: epistaxis, sinusitis, nasal crusting LRT: dyspnoea, haemoptysis Rapidly progressing glomerulonephritis Saddle shaped nose deformity Vasculitis rtash Eye involvement (proptosis) Cranial nerve lesions
195
How is granulomatosis with polyangitis diagnoes?
cANCA->90% pANCA-25% CXR-cavitating lesions Renal biopsy
196
What is seen on renal biopsy in granulomatosis with polyangitis
Pacui-immune necrotising crescentic glomerulonephritis Epithelial crescents in Bowman's capsule
197
Describe induction of remission treatment for granulomatosis with polyangitis
High dose steroids for induction of remission Cyclophosphamide Rituximab Plasma exchange (severe cases)
198
What is used for maintenance therapy after remission in granulomatosis with polyangitis
Azathioprine or methotrexate
199
Describe the prognosis of granulomatosis with polyangitis
Untreated-> fatal
200
What is eosinophilic granulomatosis with polyangiitis?
Previously Churg-Strass syndrome ANCA associated small-medium vessel vasculitis
201
Describe the clinical features of eosinophilic granulomatosis with polyangiitis
Asthma Blood eosinophilia Paranasal sinusitis Mononeuritis multiplex Renal involvement in 20%
202
What may precipitate eosinophilic granulomatosis with polyangiitis
Leukotriene receptor antagonists
203
What antibodies are associated with eosinophilic granulomatosis with polyangiitis
pANCA
204
What is penumothorax?
Accumulation of air in the pleural space-> partial or complete collapse of the affected lung
205
How can pneumothoraces be classified?
Primary Spontaneous Secondary spontaneous Traumatic Iatrogenic
206
Describe the general features of a primary spontaneous pneumothorax
No underlying lung disease Tall, thin, young people Rupture of subpleural blebs or bullae
207
Describe the general features of secondary spontaneous pneumothorax
Pre-existing lung disease like COPD, asthma, CF, lung cancer, pneumocystis pneumonia Connective tissue diseases like Marfan's as risk factor
208
What causes traumatic pneumothorax?
Penetrating or blunt chest trauma-> lung injury and pleural air accumulation
209
What causes iatrogenic pneumothorax
Complication of medical procedures: -Thoracentesis -Central venous catheter placement -Ventilation including NIV -Lung biopsy
210
What is a tension pneumothorax
Severe pneumothorax-> displacement of mediastinal structures that may result in severe resp distress and haemodynamic collapse
211
What is catamenial pneumothorax?
Cause of 3-6% of spontaenous oneumothoraces occuring in menstruating women-> caused by endometriosis within the thorax
212
Describe the symptoms of pneumothorax
Dyspnoea-sudden onset Chest pain-often pleuritic Dry cough
213
Describe the signs of pneumothorax
On affected side of chest: -Hyper-resonant lung percussion -Reduced breath sounds -Reduced lung expansion Tahcypnoea Tachycardia
214
What are the additional clinical features of a tension pneumothorax
Respiratory distress Tracheal deviation away from the side of the pneumothorax Hypotension Distended neck veins
215
How is a pneumothorax diagnosed?
Tension-clinical, treat immediately Other: erect PA chest x-ray CT chest if unclear if its safe to place a chest drain
216
What is the stepwise assessment for determining treatment for pneumothorax
1) symptomatic? -No: conservative care -Yes: step 2 2) High-risk features? -No: choose intervention -Yes: chest drain
217
What are high risk characteristics of pneumothorax
Haemodynamic compromise-tension? Significant hypoxia Bilateral Underlying lung disease >=50yrs with smoking hx Haemothorax
218
What are the choices of intervention in patients who are symptomatic but no high risk characteristics with pneumothorax
Conservative care Ambulatory device Needle aspiration
219
What should be considered before needle aspiration/chest drain insertion in pneumothorax
2cm laterally or apically on CXR or Any size on CT scan that can be safely accessed with radiological support
220
Describe the follow up required if conservative treatment used to treat pneumothorax
Primary spontaneous pneumothorax: review every 2-4 days as outpatient Secondary: monitor as inpatient If stable: follow up in OPD in 2-4 weeks
221
Give an example of an abulatory device used for pneumothorax
Rocketmu pleural vent One way valve and vent to prevent air and fluid return to the pleural space whilst allowing for controlled escape fo air and drainage of fluid
222
What should be used if needle aspiration of pneumothorax is unsuccessful?
Chest drain
223
When should follow up be arranged if pneumothorax resolved after needle aspiration
2-4 WEEKS LATER
224
What follow up is needed post chest dain insertion for a pneumothorax
Daily review as inpatient Remove drain when resolved Discharge and FU in OPD in 204 weeks
225
What should be considered in cases of recurrent pneumothoraces
video-assisted thorascopic surgery (VATS)-> allow for mechanical/chemical pleurodesis +/- bullectomy
226
What discharge advice should be given in patients with pneumothorax
Smoking cessation May fly 2 weeks after successful drainage if no residual air/1 week post x ray check Never scuba dive
227
Describe the management of a tension pneumothorax
Decompression of the pleural space Needle thoracostomy then chest drain
228
Where is needle thoracostomy done in tension pneumothorax
5th IC space at mid axillary line on the affected side using a large bore cannula
229
Describe the pathophysiology of a tension pneumothorax.
Air enters pleural space and is unable to escape-> one way valve Continuous accumulatin of air-> increased intrapleural pressure which exceeds atmosepheric pressure thorughout resp cycle: -Lung collapse -mediastinal shift -Impaired venous return: compress great veins reducing venous return to heart -Reduced cardiac filling:
230
Where should chest drains be inserted?
'Safe triangle' Mid axillary line of the 5th IC space Bordered by: -Anterior edge latissimus dorsi -lateral border of pectoralis major, a line superior to horizontal level of the nipple and apex below the axilla
231
What is pleural effusion?
Accumulation of fluid within the pleural cavity, often from an imbalance between secretion and absorption
232
How can pleural effusions be classified?
Transudate (<30g/L protein) Exudative (>30g/L protein) To remember: exudative-eggsudative i have eggs in the mornign as they are full of protein
233
What are the causes of transudate pleural effusion
Heart failure-mc Hypoalbuminaemia (liver disease, nephrotic syndrome, malabsorption) Hypothyroidism Meig's syndrome
234
What are the causes of exudative pleural effusions
Infection (pneumonia-mc, TB) Connective tissue disease (RA, SLE) Neoplasia (lung cancer, mesothelioma, mets) Pancreatitis PE Dressler's Yellow nail syndrome
235
Describe the clinical features of pleural effusions
Dyspnoea Non-productive cough Chest pain On exam: -Dullness to percussion -Reduced breath sounds -Reduced chest expansion
236
How are pleural effusions diagnosed?
PA CXR USS-> increases likelihood of successful pleural aspiration and sensitive for detecting pleural fluid septations Contrast CT to dx underlying cause Pleural aspiration
237
How is a pleural aspiration carried out
USS used to reduce complication rate 21G needle and 50ml syringe
238
What tests should pleural aspiration fluid be sent for
pH Protein LDH Cytology Microbiology
239
What criteria is used to differentiate between exudate and transudate pleural effusion
Light's criteria
240
Describe Light's criteria
Applied if protein level is between 25-35 (borderline exudative/transudative) Exufate likely if: -Pleural fluid protein/serum protein >0.5 -Pleural fluid LDH/serum LDH >0/6 -Pleural fluid LDH>2/3 upper limits of normal serum LDH
241
What conditions might you see low glucose in pleural aspirate
RA TB
242
What conditions might you see raised amylase in pleural aspirate
Pancreatitis Oesophageal perforation
243
What conditions might you see low complements in pleural aspirate
SLE
244
What conditions might you see heavy blood staining in pleural aspirate
Mesothelioma PE TB
245
What is required in patients with pleural effusion in association with sepsis or pneumonic illness?
Diagnostic pleural fluid sampling
246
When should a chest tube be placed in patients withj pleural effusions with sepsis or pneumonic illness
Diagnostic pleural fluid sampling Chest tube if: -Fluid is purulent or turbid/cloudy-> to allow drainage OR -Fluid clear but pH <7.2 in patients with suspected pleural effusion
247
What are the options for managing recurrent pleural effusions
Recurrent aspiration Pleurodesis Indwelling pleural catheter Drug management for sx e.g. opioids to relieve dyspnoea
248
What is seen on CXR in pleural effusions
Blunting of costophrenic angle and fluid in lung fissures +/- meniscus
249
What is empyema?
Accumulation of pus in the pleural space
250
How is empyema treated?
Abx and chest drain
251
What does pleural aspiration show in empyema?
Pus pH <7.2 Low glucose High LDH
252
When is chest drain insertion indicated?
Pleural effusion Pneumothorax not suitable for conservative management/aspiration Empyema Haemothorax Haemopneumothorax Penetrating chest wall injury in ventilated patients
253
Name some relative contraindications for chest drain insertion
INR >1.3 Platelet count <75 Pulmonary bullae Pleural adhesions
254
Describe the process of chest drian insertion
Position pt supine at 45 degree angle with forearm behind head ID 5th IC space in midaxillary line-consider use of USS Anaesthetic: lidocaine Drainage tube using Seldinger technique and secure tube with straight stitch or adhesive dressing
255
How can positioning of the chest drain be confirmed?
Aspiration of fluid from drainage tubing 'Swinging' of the fluid within the drain tubing when pt inspires CXR
256
What complications can arise from chest drain insertion
Failure of insertion-remove/re-site Bleeding-around site or into pleural space -Infection -Penetration of the lung -Re-exapnsion pulmonary oedema
257
What is re-expansion pulmonary oedema
Occurs when a collapsed lung is rapidly re-expanded-> fluid accumulation in the lungs
258
What are the symptoms of re-expansion pulmonary oedema
Cough and/or SOB
259
How should re-expansion pulmonary oedema be treated?
Clamp chest drain and get urgent x-ray
260
How is re-expansion pulmonary oedema prevented?
Drain tubing should be clamped regularly in the event of rapid fluid output
261
When should chest drains be removed if used for fluid drainage from pleural cavity
When there has been no output for >24 hours and imaging showed resolution of fluid collection
262
When should chest drains be removed if inserted to treat pneumothorax
Drain should be removed when no longer bubbling spontaneously/when pt coughs and when imaging shows resolution of pneumothorax
263
What is a haemothorax?
Blood enters pleural cavity
264
What is pulmonary hypoplasia
Underdeveloped lungs in newborn infants
265
What causes pulmonary hypoplasia
Oligohydramnios Congenital diaphragmatic hernia
266
What is a pulmonary embolism?
>=1 blood clots lodge in and obstruct the pulmonary arterial vasculature, often from a DVT
267
Describe the clinical features of a PE
Chest pain: pleuritic Dyspnoea Haemoptysis Tachycardia Tachypnoea Resp exam: may be clear or may finr crackles
268
What clinical features make a PE more likely?
Tachypnoea Crackles Tachycardia Fever >37.8
269
What test is used to rule out PE
PE rule out criteria-all criteria absent to rule out a PE
270
When should the PE rule out criteria be used?
If you think there is a low pre-test probability of PE but want more reassurance that it isn't the diagnosis
271
What are the criteria in the PE rule out test?
Age >=50 Heart rate >=100 O2 sats <=94% Previous DVT/PE Recent surgery/trauma in past 4 weeks Haemoptysis Unilateral leg swelling Oestrogen use(HRT/contraceptives) All need to be negative
272
What test should be used if a PE is suspected?
2 level PE Well's score
273
What features are included in a 2 level PE Well's score?
Clinical signs and sx of DVT(min leg swelling and pain with palpation of deep veins)-3 points Alternative dx less likely than PE-3 points HR >100 bpm-1.5 points Immonilisation for >3 days or surgery in last 4 weeks-1.5 points Previous DVT/PE-1.5 points Haemoptysis-1 point Malignancy (on tx, tx in alst 6 months or palliative)-1 point
274
Describe the interpretation of the 2 level Well's score
> 4 points: PE likely <=4 points: PE unlikely
275
What test should be arranges if Well's score is >4?
Arrange immediate CTPA
276
What test should be arranged if Well's score is <4?
D-dimer
277
What should be used if there is a delay in getting CTPA in a likely PE?
Give interim therapeutic anticoagulation-DOAC like apixaban/rivaroxaban
278
What should you do after: a)positive CTPA b) negative CTPA
a) PE diagnosed-treat b) consider proximal leg vein USS if DVT suspected
279
What should be done if a Well's score is <4?
D-dimer
280
What should be done if a D-dimer test is : a) positivie b)negative Following a Well's score <4?
a) arrange immediate CTPA and if delay give interim anticoagultion with DOAC b) PE unlikely-stop anticoagulation and consider alternative dx
281
When would a V/Q scan be used in diagnosing PE?
Renal impairment: doesn't need contrast unlike CTPA
282
What is seen on ECG in PE
S1Q3T3: Lrge S wave in lead 1, large Q wave in lead 3, inverted T wave in lead 3 RBBB and right axis deviation Sinus tachycardia
283
What imaging modality is recommended for all patients with a suspected PE?
CXR-recommended to exclude all other pathology Typically normal in PE May find a wedge-shaped opacification
284
What might be missed on CTPA for a PE?
Peripheral emboli affecting subsegmental arteries
285
Describe the management of patients with PE with haemodynamic instability
Thrombolysis 1st line
286
How are patients with recurrent PE's despite adequate anticoagulation treated?
May be considered for inferior vena cava filters (IVC)-> work by stopping clots formed in the deep veins of the leg from moving to the pulmonary arteries
287
When is outpatient treatment recommended for a PE
Anyone deemed low risk-use pulmonary embolism severity index (PESI) score
288
What are the key requirements for PE treatment at home?
Haemodynamic stability Lack of comorbidities Support at home
289
Describe the choice of anticoagulant for PE
DOAC 1st line-apixaban/rivaroxaban -Use once suspected 2nd line: LMWH then edoxaban OR warfarin
290
What anticoagulation should be used in patients with a PE with active cancer?
DOAC unless CI
291
What anticoagulation should be used in patients with a PE with renal impariment?
If severe : <15/min then: LMWH or unfractionated heparin or LMWH then vit K antagonist
292
What anticoagulation should be used in patients with a PE with triple-positive antiphospholipid syndrome
LMWH then Vit K antagonist (warfarin)
293
How long should anticoagulation be continued for after a PE?
Minimum 3 months Provoked: 3 months is enough (3-6 months in active cancer) Unprovoked-6 months total
294
What score is used to assess the risk of bleeding?
ORBIT score
295
What is pulmonary hypertension?
Increase in mean pulmonary arterial pressure to >25mmHg at rest
296
What is normal mean pulmonary arterial pressure?
11-20mmHg
297
Describe the aetiology of pulmonary hypertension
Pulmonary arterial hypertension COPD, ILD, bronchiectasis, OSA Chronic thromboembolic disease-PE Chronic hypoventilation: scoliosis, neuromuscular disorders Left heart disease Multifactorial e.g. sarcoidosis
298
What is the difference between pulmonary hypertension and pulmonary arterial hypertension?
Pulmonary hypertension-umbrella term for lots of causes Pulmonary arterial hypertension-specific subtype
299
What are the causes of pulmonary arterial hypertension?
Idiopathic Familial Associated with other diseases-HIV, connective tissue diseases, portal hypertension Drugs/toxins: amphetamines, fenfluramine
300
How is pulmonary hypertension classified?
Group 1: pulmonary arterial hypertension Group 2: secondary to left heart disease Group 3: Secondary to chronic pulmonary disorders and/or hypoxia Group 4: due to chronic thrombotic or embolic disease Group 5: Others: metabolic disorders, ssytemic disorders, haematological disease
301
Describe the clinical presentation of pulmonary hypertension
Progressive SOB Fatigue Syncope Fluid overload-> ascites, peripehral oedema
302
What are the signs of pulmonary hypertension
Fluid overload-ascites, peripheral oedema Raised JVP Parasternal heave Loud P2 S3 sound Pansystolic murmur-> tricuspid regurgitation End-diastolic murmur indicative or pulmonary regurgitatio
303
What causes a pansystolic murmur in pulmonary hypertension
Tricuspid regurgitation due to the right ventricle becoming pressure and volume overloaded
304
What causes an end-diastolic murmur in patients with pulmonary hypertension
Pulmonary regurgitation due ot high pulmonary pressure
305
What are some differentials for pulmonary hypertension
COPD CHF ILD Mitral stenosis
306
How is pulmonary hypertension diagnosed?
Right heart catheterisation-Gold standard-> direct measurement of pulmonary arterial pressure Imaging to assess for cause: -CR-enlarged RA, V and PA -High res CT chest: ILD -CT.MRI pulmonary angiogrpahy: chronic thomboelbolic disease Transthoracic echo: can estimate pulmonary arterial pressure
307
How is pulmonary hypertension managed?
Conservative Medical: O2, diuretics for fluid overload, treat underlying cause Medications to reduce pulmonary vascular resistance Surgical
308
What are the medications used to treat pulmonary hypertension
Reduce pulmonary vascular resistance: -CCB: nifedipine -PDE5 inhibitors: sildenafil -Prostacyclin analogues: iloprost -Endothelin receptor antagonists: bosentan -Soluble guanylate cyclase stimulators: riociguat
309
What are the surgical treatments for pulmonary hypertension
Thrombo-arterectomy/balloon angioplasy for chronic thromboembolic disease Atrial septostomy: palliative Heart lung transplant if severe
310
What is an atrial septostomy?
Palliative treatment where a hole is made between atria to reduce right-sided pressures
311
What are the complications of pulmonary hypertension
RHF Exertional syncope Alveolar haemorrhage Pulmonary artery dissection Pericardial effusions High risk of death during pregnancy
312
Why do pregnant patients have a hgih risk of death in pulmonary hypertension
Increased right ventricular stress
313
What is seen on a chest x-ray in pulmonary oedema?
ABCDE Alvolar bat wing oedema Kerlye B lines Cardiomegaly Diversion of pulmonary vessels Effusions
314
What is pulmonary oedema?
Accumulation of fluid in the lungs, especially within alveoli and interstitial space
315
Describe the pathophysiology of pulmonary oedema
Anything increases pressure in left side of heart-> a backlog of pressure into lungs via pulmonary veins-> increases hydrostatic pressure within the pulmonary capillaries and forces fluid out of blood vessels into lung parenchyma-> impaired gas exchange
316
What are some causes of pulmonary oedema
Left ventricular heart failure-mc Postero-inferior MI-> can lead to acute mtiral regurg Hypertensive crisis Iatrogenic fluid overload
317
What are the symptoms of pulmonary oedema
Severe dyspnoea Orthopnoea and paroxysmal nocturnal dyspnoea Distressed if acute
318
What are the signs of acute pulmonary oedema
Severe respiratory distress Sitting upright, tripoding Pink frothy sputum Widespread crackles and wheeze Raised JVP Pale and sweaty Tachycardic Pulsus alternans and S3 gallop
319
Name some differentials for acute pulmonary oedema
Acute asthma attack Non-infective COPD exacerbation Anaphylaxis ARDS
320
Describe the emergency management of acute pulmonary oedema
Sit upright O2 therapy Loop diuretics: IV furosemide 40mg stat with close fluid balance Escalation Stop beta blockers In ITU: CPAP, vasopressors, intubation etc
321
What vasopressors are given in ITU in acute peripheral oedema and why?
IV dopamine can be used to drive myocardial contractiliy
322
Why should beta blockers be stopped during acute pulmonary oedema
Negatively inotropic
323
What is type 1 respiratory failure?
Hypoxaemia with low/normal levels of CO2 in arterial blood
324
What is Type 2 respiratory failure?
Hypoxaemia with hypercapnia
325
What causes type 1 respiratory failure?
Problem with oxygenation: 1)V/Q mismatch-mc 2) Diffusion limitation 3)Shunting
326
What is V/Q mismatch
Imbalance in ventilation vs perfusion of the lungs-> inefficient oxygenation
327
What causes a low V/Q?
Alveoli not sufficiently ventilated e.g airways disease
328
What causes a high V/Q?
Limited blood flow in the lungs e.g. PE
329
What is diffusion limitation and what are some causes?
Impaired gas exchange across the alveolar membrane Inflammation/fibrosis of membrane e.g. idopathic pulmonary fibrosis or decrease in available surface area for diffusion e.g. emphysema
330
Why is hypoxemia commonly seen without hypercapnia?
CO2 more soluble than oxygen
331
What is shunting and what are some causes?
Blood that passes through the lungs without undergoing gas exchange Anatomical shunting: AVM;s Physiological response May be physiological rsponse to V/Q mismatch (if alvoli with poor ventilation the blood going to them won;t be ventilated)
332
What causes type 2 respiratory failure?
Problem with ventilation: 1)Increase in dead space 2) Reduced minute ventilation
333
What is increase in dead space and what are some causes?
Dead space ventilated but not perfused so no gas exchange -Natural alveolar dead space increases if capillaries are destroyed e.g. in emphysema or ILD
334
What is reduced minute ventilation
Total amount of air entering the lungs per minute If it decreases-> decrease in alveolar ventilation resp rate x tidal volume
335
What conditions can cause a decrease in minute ventilation?
=resp rate x tidal volume Things that reduce resp rate: -Resp depressants like alcohol/opiate Things that reduce tidal volume: -Neurological disorders like MND -Chest wall deformities
336
What are the symptoms of respiratory failure?
Dyspnoea Headache Light-headedness Confusion Drowsiness Agitation Sx related to underlying cause: productive cough, fever in pneumonia
337
What are the signs of respiratory failure
Tachypnoea(or bradypnoea) Cyanosis Accessory muscle use Nasal flaring Aigns of CNS dysfunction-> reduced GCS, irritability Signs related to hypercapnia (in Type 2 resp failure)
338
What are the signs of hypercapnia
Flushed skin Bounding peripheral pulses Asterixis Tachycardia or arrhythmia Drowsiness
339
What is the diagnostic investigation for respiratory failure?
ABG
340
Describe the management of respiratory failure
O2 for hypoxaemia -caution in patietns in T2RF Severe T1RF: CPAP T2RF: BiPAP Intubation and ventilation if severely unwell
341
What is important to remember when giving supplementary oxygen?
Use caution in patients with T2RF-> can worsen hypercapnia -O2 induced vasoconstriction increases V/Q mismatch and dead space-> decreasing CO2 clearance
342
What are the target O2 saturations for patients at risk for CO2 retention?
88-92%
343
Give some examples of conditions where CPAP might be used?
Pneumonia Pulmonary oedema
344
What are contraindications to NIV?
Confusion Vomiting-aspiration risk Untreated pneumothorax (would blow more air in)
345
What are some examples of conditions where BiPAP would be used?
COPD with resp acidosis T2RF in the context of neuromuscular disease
346
What are the complications of respiratory failure?
Decline in lung function after recovery Hypoxaemic ischaemic injury Cor pulmonale Polycythaemia Death
347
What are the complications of CPAP/NIV
Mask leak Pressure sores Hypotension Aspiration due to gastric inflation Pneumothorax Epistaxis
348
What are the complications of invasive ventilation?
Dental injury Barotrauma Ventilator associated pneumonia Tracheomalacia Complications of immobility e.g. VTE, pressure ulcers
349
What is the difference between acute bronchitis, pneumonia, and bronchiolitis
Acute bronchitis: acute inflammation of bronchial airways without evidence of penumonia Pnuemonia: infection of lung tissue and alveoli compromising respiratory function Bronchiolitis: inflammation of smaller airways typicaly in younger children
350
What are the main causes of lower respiratory tract infections?
Acute bronchitis: virusus Penumonia: bacterial-s.pnuemoniae mc
351
What viruses cause acute bronchitis?
Rhinovirus Influenza Parainfluenza Coronavirus
352
Describe the symptoms of lower respiratory tract infections
SOB Wheeze Pleuritic chest pain Fever Elderly: atypical presentations Pneumonia: more unwell than bronchitis alone
353
What are the signs of lower respiratory tract infections
Bronchitis: wheeze, rhonchi, mild systemic features Pneumonia: more unwell, focal chest signs, consolidation, abnormal obs
354
What investigations might be done in someone presenting with a lower respiratory tract infections
Basic bloods including ABG if needed If septic: lactate, urine output, cultures Sputum culture CURB65 score
355
What score is used to assess the severity of lower respiratory tract infections?
CURB 65 Confusion Urea >7 RR >30 BP(systolic <90) 65 years and older Primary care: CRB 65 as urea not available
356
What are the main complications of acute bronchitis
Cough-can persist for up to 6 months Development of pneumonia
357
What are the main causes of upper respiratory tract infections?
Virusus >1/2 caused by rhinoviruses others: -corona -adeno -entero -RSV -influenza
358
Describe the presentation of upper respiratory tract infections
Coryza (rhinorrhoea, nasal congestion, loss of smell) Sneezing Cough Sore throat-erytheema -Low grade fever -malasie -Headache -Hoarse voice -Conjunctival infection
359
What are some differentials for upper respiratory tract infections
Allergic rhinitis Influenza Whooping cough Mono Nasal foreign body in small children
360
How are upper respiratory tract infections diagnosed/investigated?
Clinical If admitted: nasal/throat swabs may be used for viral assays/PCR
361
Describe the management of upper respiratory tract infections
Fluids and rest Vapour rubs Inhalaing steam for nasal congestion Lonzengers Simple analgesia Good hand hygriene Safety net if not improving after 10 days/worsening
362
What are the complications of upper respiratory tract infections
Acute otitis media Sinusitis Exacerbations of COPD/asthma Pneumonia or superadded bacterial infections
363
What are some maternal complications of obesity in pregnancy?
Gestational diabetes Pre-eclampsia Increased likelihood for C section
364
What are some fetal complications of obesity in pregnancy
Macrosomia COngenital abnormalities Stillbirth Neonatal death Long term: childhood obesity and metabolic syndrome
365
What is pneumonia?
Any inflammatory condition affecting the alveoli of hte lungs, usually secondary to a bacterial infection
366
What is the most common cause of pneumonia?
Strep pneumoniae Vaccine available Associated with high fever, rapid onset and herpes labilais
367
What causative organism is associated with pneumonia in patients with COPD?
Haemophilius influenzae
368
What causative organism is associated with pneumonia in patients following an influenza infection?
Staph aureus
369
What causative organism is associated with atpical pneumonias?
Mycoplasma oneumoniae-dry cough and atypical CXR. Legionella-air conditioning units
370
What causative organism is associated with pneumonia in patients with alcoholism?
Klebsiella pneumoniae
371
What causative organism is associated with pneumonia in patients with HIV?
Pneumocystis jiroveci (fungal)
372
What are some additional features of pneumonia caused by mycoplasma pneumoniae?
Presents with dry cough and atypical CXR findings Autoimmune haemolytic anaemia and erythema multiforme
373
What are some additional features of pneumonia caused by legionella pneumophilia?
Atypical presentation Hyponatraemia nd lymphopenia common Often secondary to infected air conditioning units
374
How do patients with pneumocystic jiroveic present?
HIV patients Dry cough, exercise induced desaturations and absence of chest signs
375
What is idiopathic interstitial pneumonia?
Group of non-infective causes of pneumonia
376
What is cryptogenic organising pneumonia?
Example of idiopathic interstitial pneumonia Form of bronchiolitis that may develop as a complication of RA or amiodarone therapy
377
How can pneumonia be classified?
Community-mc- Hospital acquired- develops within hospitals >=48 hours post admisssion
378
What are the symptoms of pneumonia
Cough Sputum-rust coloured/blood stained Dyspnoea Chest pain-may be pleuritic Fever Malaise
379
What are the signs of pneumonia
Systemic inflammatory response: fever, tachycardia, hypotension, confusion Reduced O2 sats Auscultation: reduced breath sounds, bronchial breathing, creps/crackles Dullness on percussion (fluid)
380
What investigations are used to diagnose pneumonia
CXR FBC-neutrophilia U&Es CRP-raised ABG-if O2 sats low or pre-existing resp disease like COPD
381
What is classicaly seen on CXR with pneumonia
Consolidation
382
What score is used to assess risk in patients with pneumonia
CURB65
383
What features are included on the CRB65
Confusion (abbreviated mental test score <=8/10) RR>30 BP<90/60 Age>=65
384
Describe the interpretation of the CRB65 score?
Score =0: home based abx-oral amoxicillin 1-2: consider hospital assessment >2: definite hopsital assessment
385
What does a CURB65 score of 4 imply?
30% mortality rate at 30 days
386
Name some risk factors for pneumonia
Age <5yrs or >65 yrs Smoking Recent viral RTI Chronic resp disease like CF or COPD Immunosuppression At risk of aspiration IVDU Non-resp co-morbidities like diabetes and CVR
387
What is the point of care CRP test
Can help determine abx therapy in pneumonia patients CRP <20: don't routinely offer abx 20-100: delayed >100? offer abx
388
Describe the management of low severity CAP
5 day course Amoxicillin 1st line If allergic use a macrolide or tetracycline
389
Describe the management of moderate and high severity CAP
Dual abx therapy with amoxicillin and macrolide 7-10 day course If high severity: consider co-amoxicillin, ceftriazone, pip-taz and a macrolide
390
Describe the discharge criteria for CAP
Do not routinely discharfe if >=2 of the following in past 24 hours: -Temp >37.5 -RR>24 -HR>100 -SBP<90 -O2<90 -Abnormal mental status -Inability to eat eithout assistance
391
What information should be given to patients with pneumonia in terms of how quickly their sx should subside
1 week: fever resolves 4 weeks: chest pain and sputum reduced 6 weeks: cough and SOB reduced 3 months: most resolved apart from fatigue 6 months: normal
392
What should be done for all patients after clinical resolution of pneumonia?
Repeat CXR at 6 weeks to ensure consolidation resolved and no underlying secondary anbormalities like a lung tumour
393
What are the specific features of pneumonia caused by strep pneumoniae?
Lobar consolidation-unilateral, dense, homogenous Typically sudden onset with rust coloured sputum, pleuritic pain and high fever Associated with herpes labialis (cold sores)
394
What kind of organism is Pneumocystis jiroveci pneumonia?
Unicellular eukaryote-generally classified as a fungus
395
What is the most common opportunistic infection in AIDS
Pneumocystis jiroveci pneumonia
396
What CD4 count warrants Pneumocystis jiroveci pneumonia prophylaxis in HIV patients
CD4 count <200
397
Describe the clinical features of Pneumocystis jiroveci pneumonia
Dyspnoea Dry cough Fever Very few chest signs Exercise induced desaturation
398
What is a common complication of Pneumocystis jiroveci pneumonia
Pneumothorax
399
What might extrapulmoanry manifestations of Pneumocystis jiroveci pneumonia cause?
Hepatosplenomegaly Lymphadenopathy Choroid lesions
400
What is seen on CXR in Pneumocystis jiroveci pneumonia
Bilateral interstitial pulmonary infiltrates May have lobar consolidation May be normal
401
Aside from CXR, what other investigation can help diagnose Pneumocystis jiroveci pneumonia
Bronchoalveolar lavage-silver stain shows characteristic cysts Sputum often fails to show PCP
402
Describe the management of Pneumocystis jiroveci pneumonia
Co-trimoxazole IV pentamidine in severe cases Steroids if hypoxic (reduce risk of resp failure and death)
403
What is the most common cause of bacterial pneumonia in children?
S penumoniae
404
Describe the management of pneumonia in chidlren
1st line: amoxicillin Add macrolides if: -No response Use macrolides isntead if mycoplasma or chalmydia suspected If associated with influenze, use co-amoxiclav
405
Describe the clinical features of Mycoplasma pneumoniae
Typically prolonged and gradual onset Flu like sx preceded by a dry cough Bilateral consolidation on x-ray Complications
406
What complications can arise from mycoplasma oneumoniae infection?
Cold agglutins: IgM-haemolytic anaemia, thrombocytopaenia Erythema multiforme, erythema nodosum Meningoencephalitis: GBS and other immune neurological disorders Pericarditis/myocarditis GI: hepatitis, pancreatitis Acute glomerulonephritis
407
How is mycoplasma pneumoniae diagnosed?
Mycoplasma serology Positive cold agglutination test-> peripheral blood smear may show RBC agglutination
408
How is mycoplasma pneumoniae treated?
Doxycycline/macrolide e.g. erythromycin/clarithromycin
409
What is the difference between HAP and VAP
HAP: occurs >=48 hours after admission VAP: >=48 hours after endotracheal intubation
410
What is the most common cause of ventilator-associated pneumonia in patients ventilated for >5 days
Pseudomonas aeruginosa
411
What are the common causative organisms of HAP
S aureus (MSSA and MRSA) Gram negative bacilli: (especially in late onset HAP ) -E.Coli -Klebsiella -Enterobacter Polymicrobial infections Multidrug resistant pathogens
412
Describe the clinical features of HAP
Same as CAP: cough, dyspnoea, fever, sputum, consolidation on xr, raised wcc and CRP Increased resp rate and low O2 More complicated as many will already have features like raised CRP from cause for admission
413
What features of pneumonia might you see in ventilated patients
Decreased tidal volume Increased inspiratory pressures Decreased O2
414
What investigations are used to diagnose HAP/VAP?
CXR Bloods: CRP, WCC Microbiology: peripehral blood cultures, sputum/bronchoalveolar lavage Should be done prior to initiation of abx
415
Describe the management of HAP/VAP
Non-severe/not at high risk of resistance: -Oral co-amoxiclav Severe or higher risk of resistance: -IV pip/taz OR IV 3rd gen cephalosporin ceftazidime OR IV meropenem -If mRSA: add IV vancomycin
416
What is aspiration pneumonia
Pneumonia that develops as a result of foreign materials gaining entry to the bronchial tree, usually oral/gastric contents like food/saliva
417
Name some risk factors for aspiration pneumonia
Poor dental hygiene Swallowing difficulties Prolonged hospitalisation or surgical procedures Imapired consciousness Impaired mucociliary clearance
418
What conditions can increase your risk of aspiration pneumonia
Neurological diseases like stroke, MS, parkinson's, intoxication Intubation
419
What parts fo the lungs are most commonly affected by aspiration pneumonia and why?
Right midle and lower lung lobes due to larger calibre and more vertical orientaton of the right main bronchus
420
Give some examples of aerobic bacteria implicated in aspiration pneumonia
S penumoniea S AUREUS H influenzae Pseudomonas Klebsiella: alcoholics
421
Give some examples of anaerobic bacteria that can cause aspiration pneumonia
Bacteroides Prevotella Fusobacterium Peptostreptococcus
422
What is atelectasis?
Common post op complication where basal alveolar collapse can lead to respiratory difficulty from airways being obstructed by bronchial secretions
423
What should a diagnosed of atelectasis be considered?
Dyspnoea and hypoxaemia around 72 hours post-op
424
How is atelectasis managed?
Positioning pt upright Chest physio: breathing exercises
425
What cancer is SVC obstruction most commonly associated with?
Lung
426
Describe the clinical features of SVC obstruction
Dyspnoea-mc Swelling of face, neck and arms-conjunctival and periorbital oedema Headache worsens in mornings Visual disturbance Pulseless jugular venous distention Pemberton'ssign!
427
What are the causes of SVC obstruction
Malignancies: SCLC, lymphoma-mc Others: metastatic seminoma, Kaposi's sarcoma, breast cancer Aortic aneurysm Mediastinal firbosis Goitre SVC thrombosis
428
Describe the management of SVC obstruction
Endovascular stenting-sx relief Chemo/raiotherapy for certain cancers Glucocorticoids often given
429
How can lung cancer be initially classified?
Either small cell lung cancer (worse prognosis) or non small cell lung cancer
430
How can non small cell lung cancer be broken down into?
Adenocarcinoma Squamous cell carcinoma Large cell Alveolar cell carcinoma Bronchial adenoma
431
What si the most common type of lung cancer?
Adenocarcinoma
432
What cancers are often seen in non smokers?
NSCLC
433
What type of lung cancers are cavitating lesions most commonly found in?
Squamous cell
434
What are the features of alvolar cell caricinoma
Not related to smoking ++sputum
435
Describe the clinical features of lung cancer
Persistent cough Haemoptysis Dyspnoea Chest pain Weight loss and anorexia Hoarseness SVC syndrome
436
Why is hoarseness seen in lung cancer
Pancoast tumours pressing on the recurrent laryngela nerve
437
What might be found on exam in lung cancer
Fixed monomorphic wheeze Supraclavicular lymphadenopathy or persistent cervical lymphadenopathy Clubbing
438
Describe the paraneoplstic features of small cell lunc cancer
ADH Lambert Eaton syndrome ACTH-htn, hyperglycaemia, hypokalemia, muscle weakness
439
What are the paraneoplastic features of squamous cell carcinoma
PTH-related -> hypercalcaemia Clubbing Hypertrophic pulmonary osteoarthropathy Hyperthyroidism due to ectopic TSH
440
What are the paraneoplastic features of adenocarcinoma
Gynaecomastia Hypertrophic pulmonary osteoarthropathy
441
What causes Lambert Eaton syndrome?
Antibody directed against presynapctic voltage gated calcium channel in peripheral nervous system
442
What conditions are associated with Lambert-Eaton syndrome
SCLC-mc Also breast and ovarian cancer Can occur by itself as an AI disorder
443
Describe the clinical features of Lambert-Eaton syndrome
Repeated muscle contraction-> increased muscle strength Limb girdle weakness (lower limbs first) Hyporeflexia Autonomic sx-dry mouth, impotence, difficulty micturating Differentiate from myasthenia gravis: eye sx not usually a problem
444
What is seen on EMG in Lambert Eaton syndrome
Incremental response to repetitive electrical stimulation
445
Describe the management of Lambert Eaton syndrome
Tx underlying cancer Sx: amifampridine Immunomodulatory: especially if non-paraneoplastic: -Oral corticosteroids -Azathioprine -IVIG
446
How does amifampridine help to treat Lambert Eaton syndrome
Blocks presynaptic potassium channels-> prolongs depolarisation-< increases ACh release Improves weakness, autonomic sx and fatiguability
447
What is the 1st line investigation for lung cancer in primary care?
CXR
448
What abnormality might be seen on FBC in lung cancer?
Raised platelets
449
Describe the investigations used for lung cancer
CXR-1st line CT-Ix of choice Bronchoscopy with biopsy PET scan: Non small cell to establish eligibility for curative tx
450
Describe the features of small cell lung cancer
Usually central Associated with ectopic ADH, ACTH secretion ADH-> hyponatraemia ACTH-> Cushing's ACTH secretion-> bilateral adrenal hyperplasia-> hypokalaemic alkalosis Lambert Eaton syndrome
451
What cells does small cell lung cancer arise from?
APUD cells Amine precursor uptake decarboxylase
452
Describe the management of small cell lung cancer
Usually metastatic at dx Very early stage (T1-2a, N0,M0)-> surgery Combination of chemo and radiotherapy
453
Where does lung cancer typically spread to?
Liver brain bone adrenals
454
Which type of lung cancer is most associated with finger clubbing?
Squamous cell (non small cell )
455
Which type of lung cancer is most commonly associated with hypercalcaemia?
Squamous
456
Which type of lung cancer is most commonly associated with cavitating lesions
Squamous cell lung cancer
457
Which type of lung cancer is most common in non-smokers?
Adenocarcinoma (although most are smokers)
458
When is the urgent 2 week for appointment referral appropriate for lung cancer?
CXR findings suggesting lung cancer >40yrs with unexplained haemoptysis
459
When should an urgent CXR be offered for potential lung cancer?
>40yrs and >=2 of: OR smoker and >=1 of: -Cough -Fatigue -SOB -Chest pain -Weight loss -Appetite loss
460
When should an urgent cxr be considered for lung cancer
>40yrs with any of: -Persistent or recurrent chest infection -Finger clubbing -Supraclavicular/persistent cervical lymphadenopathy -Chest signs consistent with lung cancer -Thrombocytosis
461
Describe the management of non-small cell lung cancer
Surgery (only about 20%) Curative/palliative radiotherapy poor response to chemo
462
What should be performed prio to surgery for non small cell lung cancer and why?
Mediastinoscopy-CT doesn't always show mediastinal lymph node involvement
463
What are some contraindications for surgery in non small cell lung cancer
Assess general health Stage 3b/4 (mets) FEV1<1.5 L Malignant pleural effusion Tumour near hilum Vocal cord paralysis SVC obstruction
464
What cancers often metastasise to lung
Breast Colorectal Renal cell Bladder Prostate
465
How do lung metastases appear on CXR?
'cannonball metastases'-multple round well-defined lung secondaries Mc seen with renal cell cancer but also secondary to choriocarcinoma and prostate cancer
466
What are some indications for lung transplant
End stage COPD-mc Idiopathic pulmonary fibrosis CF Pulmonary arterial hypertension Bronchiectasis, sarcoidosis
467
What are some absolute contraindications to lung transplant
Active cancer Untreatable infection Significant dysfunction of another major organ Recent MI Poor adherence or psychosocial support Active smoking or substance misuse
468
What are some relative contraindications for a lung transplant
Age >65yrs BMI : 30-35 Osteoporosis Chronic infection: hep, HIV Previous thoracic surgery
469
What are the types of transplant used in lung transplants?
Single lung-COPD, pul fibrosis Double lung-CF, bronchiectasis (avoid infecting new lung) Hear lung-severe pulmonary hypertension with right heart failure
470
What requirements are needed for donor-recipient matching in lung transplants
ABO blood group compatible Size match HLA matching less important than in renal transplant
471
What peri-operative measures might be needed before and immediately after a lung transplant?
Mechanical ventilation and ECMO Ichaemia reperfusion injury-> primary graft dysfunction within 72 hours post transplant Immunosuppression started immediately
472
What immunosuppression is used post lung transplant?
Triple therapy: -Corticosteroid -Calcineurin inhibitor: tacrolimus -Antiproliferative agent-mycophenolate
473
What are the early complications of a lung transplant?
<1 month Infection Anastomotic dehiscence Primary graft dysfunction
474
What are the intermediate complications of lung transplant
1-6 months -Acute rejection (T cell mediated-> dyspnoea, decreased FEV1, infiltrated on CXR) Infection (CMV, bacterial, fungal)
475
What are the late complications of a lung transplant
>6 months: Chronic lung allograft dysfunction-> main long term problem Bronchiolitis obliterans syndrome Malignancy due to immunosuppression
476
What is bronchiolitis obliterans syndrome?
Progressive airflow obstruction from small airway fibrosis
477
What monitoring and follow up is used post-lung transplant
Regular spirometry to detect early rejection (decreased FEV1 early sign) Surveillance bronchoscopy and biopsy Infection prophylaxis
478
What conditions does COPD encompass?
Chronic bronchitis Emphysema
479
Describe the presentation of COPD
Cough-often productive Dyspnoea Wheeze Severe: right heart failure-> peripheral oedema NO clubbing
480
What investigations are recommended for suspected COPD?
Post-bronchodilator spirometry CXR FBC-exclude secondary polycythaemia BMI
481
What would you see in post bronchodilator spirometry in COPS?
Airflow obstruction FEV1/FVC <70%
482
What might be seen on CXR in COPD
Hyperinflation Bullae-if large, may mimic pneumothorax Flat hemidiaphragm Exclude lung cancer
483
How is COPD categorised?
Using FEV1
484
Describe the use of FEV1 to categorise the severity of COPD
Post bronchodilator FEV1/FVC<0.7 in ALL severities Stage 1: mild: FEV1 (of predicted)>80% Stage 2: moderate: 50-79% Stage 3: severe: 30-49% Stage 4: very severe: <30%
485
What are the causes of COPD?
Smoking! A1AT deficiency Others: -Cadmium -Coal -Cotton -Cement -Grain
486
Describe the non-medical management of chronic COPD
-Smoking cessation advice: nicotine replacement therapy, bupropion -Annual flu vaccine -One off pneumococcal vaccine -Pulmonary rehabilitation-everyone MRC grade 3 or above
487
What is 1st line medical management for COPD patients?
SABA/LAMA Then determine asthmatic/steroid-responsive features for next step
488
What features might suggest someone with COPD has asthmatic/steroid responsive features?
-Previous dx of asthma/atopy -Higher blood eosinophil count -Substantial variation in FEV1 over time (>=400ml) -Substantial diurnal variation in peak expiratory flow (>=20%
489
What would the 2nd line treatment be for COPD patients who have asthmatic/steroid responsive features?
LABA + ICS LAMA+LABA+ICS (If already on a SAMA, switch to SABA)
490
What would the 2nd line treatment be for COPD patients who don't have asthmatic/steroid responsive features?
Add LAMA + LABA to existing SABA/SAMA If on a SAMA, switch to LABA
491
What should you be aware of when prescribing ICS to COPD patients?
Risk of pneumonia
492
Final finals!
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