1
Q
Define Asthma
A
Chronic inflammatory disease of airways characterised by
1) Bronchial hyperresponsiveness to stimuli (t1)
2) Reversible and variable airflow obstruction
3) Inflammation of bronchi
2
Q
Pathophysiology of asthma
A
- type 1 igE mediated hypersensitivity reaction to stimuli
- igE on mast cells activated -> cytokine ->
- Early phase: smooth muscle contraction, mucus production, bv permeability
- Late phase: Inflammation
- Long term: airway remodelling, BM thicken, collagen deposit = irreversible airflow restriction
3
Q
Epidemiology of asthma
A
More common in boys as children and girls as adults
Likely larger genetic role as children and env as adults
4
Q
Presentation of asthma and features of history
A
Wheeze
SOB
Chest tight
Cough
Diurnal variation (worse at night and early morning)
Triggered by or made worse by something
Variable, recurrent and frequent symptoms
History of allergies
Smoker or around them
Family history of atopy or asthma
5
Q
Asthma :aetiology precipitating factors
A
genetic and environmental component (atopic triad)
hygiene hypothesis
2 types of triggers: inducer + provoke
INDUCER enhance inflammatory response (physical antigen). Intrinsic asthma, children more
- allergens, viral, occupation exposure
PROVOKER enhance bronchospasm. Extrinsic asthma
- excercise, cold air, emotions, drugs (NSAID/aspirin, beta blocker)
6
Q
Clinical signs of asthma on examination
A
Expiratory wheeze (polyphonic)
Hyperinflated chest
May see pec/SCM hypertrophy in poor managed
NB Severe asthma = no wheeze, silent chest
7
Q
Investigations for asthma
A
Peak flow- show variable airflow limitation
Spirometry - show obstructive, decreased FEV1 to predicted
CXR + FBC to rule out other pathology
8
Q
Stepwise management of asthma and SE of BA, ICS
A
- Remove triggers, stop smoking, lose weight
- Step 1 - PRN ICS + SABA or PRN ICS(budesonide) + LABA(formoterol)
- Step 2 - latter of step 1 or daily ICS + PRN SABA
- Step 3 - daily ICS + daily LABA(salmeterol, formoterol) + PRN SABA or higher dose ICS+PRN SABA
- Step 4 - add oral corticosteroids like prednisolone
- Beclametasone = Clenil, Qvar
- Budesonide = Pulmicort
- SE: sore throat/oral thrush, osteoporsis high dose
Beta agonists - tachy, hypOK
- Target infalmm- Leukotriene receptor antagonist
- Oral monteleukast
- CI in pregnancy and liver disease
- Add on, can be combined w 3 if 4 fails
- SE: hypersensitivity, Gi SE
9
Q
Define acute severe asthma
A
Any one of:
- Cannot complete sentences
- HR >= 110
- RR >=25
- PEF <50% of predicted
Life threatening:
- silent chest, exhaustion, confused
- Sp02 <92% Pa02< 8
- hypotensive
- PEF <33%
10
Q
Management of asthma attack
A
- 15L non rebreathe (A-> E assess)
- Nebulised salbutamol or terbutiline
- IV prednisolone
- nebulised iprotroprium bromide (short antimuscarinic)
?. MgS04 aminophylline mechanical vent
aim: sats > 94%
11
Q
Define COPD
A
Chronic, partly irreversible, progressive, airway obstruction due to airway and parenchyma damage
may be accompanied by hypersensitivity
encompasses:
- Chronic bronchitis
- Emphysema
12
Q
Risk factors for COPD
A
- Smoking (majority)
- Occupational exposure- coal, silica, dust, textile
- Biomass/coal/fuels internationally
- Alpha-1 antitrypsin deficiency
13
Q
Define chronic bronchitis + pathophysiology
A
Chronic bronchitis:
- chronic productive cough for 3 months each in 2 consecutive years with no other explanation for cough
Path:
inflammation, mucus hypersecretion + airway narrowing
14
Q
Define emphysema
A
Abnormal permanent dilation of airways distal to terminal bronchioles + destruction of their walls without obvious fibrosis
15
Q
How does smoking -> COPD (pathophysiology)
A
toxin -> macrophage/cd8 lymphocyte recruitment -> neutrophil response -> protease activation
protease -> mucus hypersecretion in chronic bronchitis or alveolar destruction in emphysema
alpha 1 antitrypsin usually inhibits neutrophil protease activity
16
Q
Presentation of COPD px
A
- SOB, worse on exertion
- Chronic productive cough (quantify)
- Expiratory wheeze
- Weight loss
- May have astham overlap - diurnal variation
- Chronic hypoxoemic, shut down pul circ -> RHF signs raised JVP, peripheral oedema
- Peripheral cyanosis, barrel chest
17
Q
Investigation for COPD
A
- spirometry FEV1/ FVC <0.7
- Severity = how reduced their FEV is
Also need to do:
Bedside sats
FBC (elevated hb and rbc)
CXR
ABG
ECG (RH strain)
CT - distribution of emphysema may indicated a1antitrypsin if > at bases
18
Q
Management of COPD
A
conservative = smoking cessation, vaccines (flu, pneumococcal), pulmonary rehab,reduce occupation exposure
FIRST: SABA(salbutamol) or SAMA (iprotroprium)
then ? asthma
if no asthma then LABA (salmeterol, formoterol) + LAMA (tiotropium) + SABA - SAMA if on before
if asthma + ICS
can also try:
- oral PDE inhibitor, bronchodilator theophyline
- ? prophylactic abx and mucolytics
- ? LTOT
-? surgery
19
Q
Management of COPD exacerbation
A
- oxygen (84-92)
- increase bronchodilator frequency
- Add oral prednisolone
- abx - amoxicillin, clarithromycin, doxycycline
- phsyio (sputum)
MAY need NIV for pxs in T2RF
20
Q
Smoking cessation devices
A
lots of forms of NRT - lozynges, patches, vape
or prescribed drugs:
- Bupropion (zyban)- antidepressant which can help smoking cessation, CI: seizures
- Varenicline (champix) NRagonist, not for px with psychiatric problems
21
Q
Define bronchiectasis
A
Abnormal and permanent dilation of airways leading to accumulation of secretions and secondary infection/inflammation
22
Q
Causes of bronchiectasis
A
- Cystic fibrosis
- post infection
- idiopathic
23
Q
Presentation of px with bronchiectasis
A
Chronic productive cough copious amounts
recurrent chest infections
may have haemoptysis, sob, wheeze
24
Q
Investigating for bronchiectasis
A
HRCT is gold standard, will show dilation and wall thickening- signet ring
Sputum culture on exacerbation
CXR may be helpful
25
Management of bronchiectasis
* Physiotherapy
* smoking cessation
* vaccines
medical:
* abx
* bronchodilators/corticosteroids
* neb saline
* NIV
* may have surgical
26
Lung cancer risk factors
1. SMOKING
2. occupation exposure
3. air pollution
4. radiation
5. idiopathic + post infectious pulmonary fibrosis
6. rarely genetic
7. can sporadically occur in young females
27
Types of lung cancer
4 types of primary bronchial carcinomas = 95% of all lung cancer. first 3 are NSCC
1. Adenocarcinoma
2. Squamous cell carcinoma
3. Large cell carinoma (rarest)
4. Small cell (oat) carcinoma
5. Carcinoid tumour
28
Types of lung cancer other than bronchial
1. Malignant mesothelioma of pleura
2. Secondary to mets
29
Adenocarcinoma (most common NSCC)
* cancer of larger airway
* peripheral solid mass, may appear ground glass so appear as infection
* Arise from neuroendocrine cells so can -\> paraneoplastic syndromes
* **Most strongly assd with smoking**
* Highly aggressive, poor prognosis, present with mets
* untreated median survival 6 weeks
30
Squamous cell carcinoma (NSCC)
* Central cavitating mass can be confused w abscess
* Used to be most common
* **most strongly assd with smoking**
*
31
Presentation of px with lung cancer
* Persistent cough (\>6w)
* Haemoptysis
* SOB
* Chest
* Unintentional weight loss
* Fatigue
* Lymphadenopathy
May present with signs of paraneoplastic syndrome
Cushing XS ACTH (esp oat)
SiADH (oat)
Hypercalcaemia (SCC)
Clubbing
32
Diagnosis for lung cancer
Tissue sampling (many methods depending on frailty and location) and then immunohistochemistry
33
Small cell carcinoma
Only 10% of lung cancers
**strong smoking asscn**
* massive mediastinal lymphadenopathy
* may cause SVCO
* Most present at stage 4, poor prognosis bc nearly always mets
34
Carcinoid tumour
* Very rare type of lung cancer
* no/little asscn with smoking
* well defined golf balls on x ray
* majority are localised therefore curable
35
Management of lung cancer
Local: radio, surgery + adjuvant chemo if adv on surg
Stage 4: palliative chemo, immuno, targeted molecular, maybe radio
Molecular targeted therapy target mutations in normal molecular processes that have enabled tumour growth
Immunotherapy targets tumours ability to evade T cell destruction
36
Mesothelioma
Tumour of pleura
NB rare cause, tumours of pleura are usually emtastatic adenocarcinoma
Presnets with SOB and **chest pain!**
**asbestos exposure**
poor prognosis
palliative chemo/radio
37
Define Pneumonia
Infection of lung parenchyma
Usually caused by bacterial organism:
streptococcocus pneumoniae (pneumococcus)
Can be lobar or broncho
38
Presentation of px with pneumonia
* Fever
* Productive cough
* SOB
* Pleuritic chest pain
* Confusion, weakness ,malaise esp elderly
May present with septic shock, organ dysfunction
39
Precipitating factors for pneumonia
1. Underlying lung disease
2. smoking
3. alcohol abuse
4. immunosuppresion
5. any chronic illness
40
Organisms causing pneumonia and relevant history q
Bacterial:
1. **Pneumococcus** (most common)
2. Haemophilus influenza
3. Chlamydia psittacosis (BIRDS) may assd rash, hep
4. Coxiella burnetti (farm animals)
5. **Legionella** (hotels etc) assd w GI problem, multilobar
6. mTB (alcohol abuse)
7. mTB, staph aures (IVDA)
8. **Mycoplasma** (young, headache, malaise, cough, rashes) reticular opacity, fine
Many other viral and fungal causes too
41
Diagnosing/investigating for pneumonia
Bedside: blood culture, sputum culture
urinary antigen test for pneumococcal/legionella cause
serology and throat swab for mycoplasmic cause
Imaging: CXR (changes lag)
42
Assessing severity of pneumonia
CURB-65 helps assess mortality risk
C: confusion
U: urea
R: resp rate
B: BP hypotensive
65 age
43
Management of pneumonia
If septic -\> sepsis 6, wil prob need ox and fluid
Pneumococcal or haemophilus : Benzylpenicillin/amoxicillin or clarithromycin for pen allergy
Legionella: Levofloxacin/macrolide
Mycoplasma: clarithromycin
ie if really unwell: levofloxacin/clarithromycin may be +
44
Why does HAP happen and how is it managed
Px severely ill stay \> 1w -\> change normal flora and aspirate
Early: co-amoxiclav
Late: Piperacillin-tazobactam
45
Aspiration pneumonia cause consequence and management
Impaired swallow/gag reflex due to stroke, dementia, MND
Aspirate saliva, gastric contents (GNA), food
tends to go down R bronchus: shorter and steep
Leads to infection and lobar bronchiectasis
Manage: co-amoxiclav and SALT
46
Definition and types of pneumothorax
Air in pleural space leading to lung deflation.
1) Primary (normal lung)
2) Secondary (underlying lung disease)
3) Tension
47
Causes of pneumothoraces by type
**Primary Spontaneous Pneumothorax**
* RF: men, marfans, 30-40, cigs, cannabis
* Path: ? maybe rupture of apical bleb/bullae
**Secondary Spontaneous Pneumothorax**
* RF: lung disease eg COPD, Asthma, ILD
**Tension Pneumothorax**
* **B**lunt trauma nb can -\> compress mediastinum, hypotension -\> cardiac arrest
48
Presentation of pneumothorax
ACUTE onset of SOB, pleuritic chest pain (PE same)
Tension: assd raised JVP, hypotension
49
Inv pneumothoraces
CXR
dont wait for CXR if high suspicion of tension
50
Management of pneumothoraces
**PSP**: Depends on px symptoms, size of pneumo, age (old treat same as SSP)
Asymptomatic + small = discharge
Symptomatic + large = cannula 2nd ICS MCL, may need to chest drain
**SSP:** depends on size
Either discharge, attempt aspiration or drain, drain and 15L oxygen
may have underwater seal drainage system
**Tension: 15L ox, large cannula 2nd iCS MCL** once stable cxr and drain
51
Define Pleural effusion
Accumulation of fluid in pleural space
52
Two types of pleural effusion and causes
1. **_Transudate_**
* Clear
* Low protein
* Failures (Heart, Liver, Renal)
* Hypo-albuminemia
1. **_Exudate_**
* cloudy
* high protein
* Infection (paraneumonic, empyema, TB)
* Malignancy
* PE
* Inflammatory
53
Presentation of px with pleural effusion
SOB, pleuritic chest pain, cough + symptoms reld to cause
54
Diagnostic investigation of pleural effusion
**CXR + USS to confirm presence**
USS may show loculated effusion = empyema
CT not routinely done
**Pleural tap/fluid aspiration/thoracentesis under USS guide**
* Send sample for biochem, microbiology and cytology
* Protein \<25 trans, \>35 ex. Inbetween use lights criteria
*
55
Management of transudate pleural effusion
Treat underlying cause
56
Management of exudate pleural effusion where cause is infection (para-pneumonic)
Parapneumonic - effusion is assd with underlying lung infection
FLUID ITSELF IS STERILE SO NO NEED TO DRAIN
Treat with abx long course
may therapeutic drain if px symptom bad
57
Management of exudate pleurla effusion when cause is infection (empyema)
URGENT DRAIN because fluid is infectious
long course abx
consider surgery/ct thorax
58
Management of exudate pleural effusion when cause is infection (TB)
Likely that pleural tap results inconclusive so need to do **ct thorax and PLEURAL biopsy**
Dont need to drain unless for px
long course tb treatment
59
Management of exudate pleural effusion when cause is malignancy
May be primary pleural malignancy or mets
Pleural tap may not show + cytology but do CT TAP (mets)
if thats inconclusive or suggestive of primary pleural malignancy do a pleural biopsy
**treat malignancy, therapeutic tap, may need to do pleurodesis (stick) or catheter if recurring (common to)**
60
Define a pulmonary embolism
Embolus from thrombus usually of deep veins in leg or pelvis, that lodges in pulmonary arteries
61
RF for PE
1. Recent surgery
2. History of VTE
3. Oral contraceptive
4. Pregnancy
5. Coag disorders
6. Malignancy
7. Obesity
8. Age \> 60
9. long haul travel
62
Presentation of PE
* sudden onset SOB, inc RR
* Pleuritic Chest pain
* haemoptysis
* may have cough
* calf pain DVT signs inconsistent
MASSIVE PE (hypotensive)
* RH signs (raised JVP, oedema)
* Hypotensive, shock
* Syncope
MAY have chronic - lots of little ones
* gradual dyspnoea -\> pul hypertension
63
Investigating PE
* Wells score for PE
* \<=4 do a D dimer
* if D dimer negative, rule out PE
* all else -\> CTPA or V/Q but not specific
64
Management of a PE
1. If massive PE: clot buster (alteplase)
2. Otherwise: anticoag (fondaparineux or LMWH)
3. Then may have longterm DOAC (-ban) or VKA (warfarin)
65
Define TB
A curable bacterial infection caused by mycobacterium tuberculosis that is contageous when effcting lungs.
Results in granulomatous inflammation
66
Pathophysiology of TB
Macrophages engulf enhaled TB
These fuse -\> Giant cells
Granuloma = Langhan giant cells, macrophages and central caseous necrosis containing some free TB
Calcified granuloma = Ghon focus on XR (typically upper lobe)
Ghon complex = focus + lymph node
67
Types of TB
Primary - first hit in children, immunosuppressed individuals -\> active infection
Secondary - reactivation of latent infection due to decline in health/immunity
Can have latent for life
68
Latent tb screening
Tuberculin skin test -\> positive = type 4 cell mediated hypersensitivity reaction
IGRA -\> interferon gamma released to blood sample
BUT these can be positive for both active and latent tb so history needed
69
Presentation of TB
* Fever
* Weight Loss + fatigue
* Night sweats
May also get cough, haemoptysis, abdo pain, headache, back pain bc tb can effect everywhere
**nb dd cancer**
70
Miliary TB
Millet seed pattern throughout lung parenchyma
Signifies systemic dissemination of TB
71
Causes of granulomatous inflammation other than TB
1. Sarcoidosis
2. Crohns
3. GPA (vasculitis)
4. Infection
5. Foreign body
72
Management of TB and SE
6 months NB 9-24 if drug resistant
**2 months RIPE**
**R**ifampicin (orange)
**I**soniazid (peripheral neuropathy)
**P**yrazinamide (hepattox)
**E**thambutol (eyes)
**4 months RI**
73
How is TB diagnosed
**Auramine** stain on sputum. fluorescent yellow
**Ziehl Neelson** stain requires culture. shows up red on blue, can see morphology
solid culture (most sensitive)
QUICKER:
**TB PCR** straight from sputum + test rifampicin resistance
New dev: WGS for drug sensitivity
74
What is sore throat and the main infectious causes
Pharyngitis +- tonsilitis
Mostly viral
**important bac cause**: Group A strep
75
Group A Strep Pharyngitis inv, management and complications
gram + bacterial cause of sore throat
NB not your typical cough, rhinorrhoea, sore throat- viral
Throat **swab**-\> blood culture-\> beta haemolysis, complete
Centor criteria indicates whether to start abx for sore throat, may involve doing a **rapid antigen t**est if ambiguous
Manage: oral penicillin V for 10 days, clarithromycin if allergy
Consequence: scarlet fever, quinsy, rheum fever and post infection glomerulonephritis
76
What is diptheria, complications and mangement
gram + aerobic bacterial toxin-mediated that rarely causes pharyngitis/tonsilitis in UK
adherent to membrane -\> obstruction
toxin can also -\> myocarditis and neuropathy
Manage: penicillin/erythromycin, antitoxin, secure airway
77
What is glandular fever/infectious mononucleosis, presentation, diagnosis, management
mainly ebv mediated cause of pharyngitis in Uk
Presents: malaise,fever, sore throat, lymphadenopathy, splenomegaly, rash if given amoxicillin
Diagnosis: Serology (igM, igG, EBNA)
Treat symptoms and avoid contact sports for 6 weeks -\> spleen rupture
78
Organisms causing sinusitis/otitis media
same organisms that cause URTi
1. Viruses (majority)- RSV, rhinovirus
2. Bacteria - pneumococcus, haemophilus influenza
79
Presentation of otitis media + sinusitis
Acute, usually young children (shorter eustachian tube)
Pain, malaise, fever, coryza
hearing issues, dizziness
Can -\> sinusitis
nasal congestion/smell , face pressure ( can be referred to forehead, eyes, upper jaw, teeth)
80
Management of OM/sinusitis and complications of sinusitis
Decongestants, rarely abx
Grommet for recurrent OM
**Complications of sinusitis:**
Mastoiditis
Meningitis (pneumococcal)
Intracranial abscess
81
What is epiglottitis, cause, presentation, diagnosis, management
Acute inflammation of epiglottis
Rare because vaccinate against
Cause: bac haemophilus influenza type B
Present: dysphonia, dysphagia, drooling, distress
Diagnose: blood culture NOT swab
Manage: fix airway, tracheostomy + IV abx (ceftriaxone)
82
What is whooping cough, cause, presentation, diagnosis, management
Highly infectious bacterial infection caused by Bordetella Pertussis. rare = vaccine
**Present**:
1. 2 weeks: standard virus symptoms, coryza BUT highly infectious
2. 2-6 weeks: intense cough
3. chronic cough
**Diagnose**: PCR swab
**Manage:** a macrolide abx
**Consequence:** fail thrive, apnoea, pneumothorax, subcut emphysema, brain damage
83
What is croup, cause, presentation, diagnosis, management
UR/LRTi - larynx/trachea caused by viruses eg RSV
Present: young children esp 18months, **barking cough/seal,** hypoxic, tachypnoeic
Diagnosis: clinical
NB dont forget epiglottis, bac tracheitis and aspiration in kids
Manage: dexamethasone, paracetamol, ox
usually self limiting
84
Flu - causes, symptoms, diagnosis, complications, management
Lots of viruses: RSV, coronas, para/influenza,adeno
Type A and B (human only, cant cause pandemic) HN
Symptoms: fever, malaise, myalgia, headache, coryza, cough, sore throat
Diagnosis: Swab and PCR
complications: viral pneumonia or secondary bac pneumonia
Manage: neuraminidase inhibitors, oseltamavir, zanamivir (less resistance)
85
What is bronchiolitis, cause, pres, diagnosis + outcomes
Infection of smaller airways, usually in children (6m). Most common cause of adm \<1yr
Causes: viruses eg RSV
Presentation: snuffles, fever, mild cough, worse @ night, difficulty feeding. can -\> resp distress (admission)
Diagnose: PCR swab
outcomes: recovery 10 days, mortality, secondary bac pneumonia
86
Define exacerbation of COPD
change in baseline in 2/3 of:
* Volume of sputum
* character of sputum
* breathlessness/wheeze
87
Organisms causing acute exac of COPD
**Bacterial:**
* pneumococcus
* haemophilus
* moraxella catarrhalis
* ecoli, klebsiella
**Viral:**
* RSV/rhino/flu/adeno
**Non infective**
88
Management of COPD exac
Bronchodilation: salbutamol + ipratropium
Steroid: prednisalone
May need abx
89
Interstitial lung disease definition, causes, presentation and tx
scarring at interstitium
Causes:
1) idiopathic
2) infection
3) secondary to exposure
Present with SOB
Treat steroids but poor prognosis
90
CC2
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