Define asthma
Episodic, reversible airway obstruction due to bronchial hyper-reactivity to a variety of stimuli
- Hyper- responsiveness
- Air flow obstruction
- Inflammation
Outline the pathophysiology associated with asthma
ACUTE
- Mast cell Ag interaction
- Histamine release
- Bronchoconstriction, mucus plugs and mucosal swelling
CHRONIC
- Th2 cells release IL 3,4,5
- Mast cell, eosinophil and B cell recruitment
- Airway modelling
List the causes of asthma
- Atopy
- T1 hypersensitivity
- Dust mites, pollen, food, animals and fungus - Stress
- Cold air
- Viral UTI
- Exercise
- Emotion - Toxins
- Smoking
- Pollution
- Drugs ( NSAIDs, B-blockers)
Signs of asthma
Increased RR Increased HR Widespread polyphonic wheeze Hyper inflated chest Decreased air entry Signs of steroid use
Key features in an asthmatic hx
Precipitants Diurnal variation Exercise tolerance Life effect (sleep, work) Home and job environment
Outline the findings that would be seen on lung function tests
Spirometry
- Obstructive pattern c FEV1:FVC = <0/75
- > 15% improvement in FEV1 with B agonist
- PEFR monitoring diurnal variation and morning dipping
Management of asthma
- SABA as required
- low dose ICS
- Add LABA to ICS asa combined treatment
- Consider increasing the dose of ICS
- Add on therapies
- LTRA (Montelukast)
- Theophylline
- LAMA - Oral steriods at the lowest dose possible
Signs of life threatening asthma
- PEFR <33%
- SpO2 <92%, PaO2 <8kpa
- Cyanosis
- Hypotension
- Exhaustion, confusion
- Silent chest with poor resp effort
- Tachy/Brady/ arrhythmias
Define COPd
Chronic bronchitis (cough and sputum production on most days) Emphysema Airway obstruction FEV1<80%, FEV1:FVC<0.72
Signs of COPD
- Increase RR
- Hyperinflation
- Wheeze
- Cor pulmonale ( increase JVP, loud p2 )
PINK PUFFERs
Normal Po2, normal or low PaCO2
Type I resp failure
BLUE BLOATERs
Retainers, high Co2
Type II resp failure
Investigations for COPD
CXR
- Hyperinflation
- Prominent pulmonary arteries
- Peripheral oligaemia
ECG
- R atrial hypertrophy, p pulmonale
Spirometry
- FEV1 < 80%
- FEV:FVC 0.70
Management of COPD
- Stop smoking
- Offer pneumococcal and influenza vaccines
- Offer pulmonary rehabilitation if indicated
PHARMA
- Offer either a SABA ( salbutamol) or a SAMA ( ipratorpium)
- Offer either a LABA (salmeterol) or a LAMA (tiotorpium)
- Combine LABA and LAMA and ICS
- If the patients has asthma symptoms that respond to steroid add a ICS prior to adding in a LAMA
- If the steroid has no improvement revert to LAMA and LABA
- Also consider mucolyitics like carbocisteine
Guidelines with regards to LTOT in people with COPD
- Serious outflow obstruction FEV1 <30%
- Cyanosis
- Polycythemia
- Peripheral oedema
- Increased JVP
- O2 sats <92%
Classify pneumonia
- Community acquired pneumonia
- S.aureus, Moraxella, Chlamydia - Hospital Acquired pneumonia
- >48hrs post admission
- S aureus
- grm -ve enterobacteria - Aspiration
- Anaerobes - Immunocompromised
- PCP
- TB
- CMV/HSV
Sings of pneumonia on CXR
Consolidation Decreased expansion Dull percussion Bronchial breathing Decreased air entry Crackles Pleural rub
Name and discuss the scoring system for pneumonia
CURB-65
- Confusion
- Urea > 7mM
- Resp rate >30
- BP <90/60
- > 65 yres
Abx management of pneumonia
CAP
- Mild: Amoxicillin 500mg TDS 5 days
- Severe: Co-amoxiclav 1.2g TDS
HAP
1. Tazocin (+/- vanco +/- gent)
Aspiration
1. Co-amoxiclav 625mg PO TDS
PCP: Co-trimoxale
Legionella: Clarithromycin + rifampacin
List the complications of pneumonia
Respiratory failure Hypotension AF Pleural effusion Empyema Lung abscess (get swinging fevers with a lung abscess)
Describe the pathophysiology of bronchiectasis
Chronic infection of the bronchi or bronchioles leads to permanent dilatation Airway damage and recurrent infection - H influenza - Pneumococcus - S aureus - Pseudomonas
Causes of bronchiectasis
Congenital Post infections (measles, TB) Immunodeficiency (hypogammaglobulinaemia)
Signs of bronchiectasis
Clubbing
Coarse inspiratory crackles
Wheeze
Purulent sputum (pneumococcus) (pseudomonas)
Investigations for bronchiectasis
Sputum MCS Blood - Se Ig, Aspergillus, RF CXR - Thickened bronchial walls (tramlines and rings) Spirometery - Obstructive pattern HRCT - Dilated thickened airways
Management of bronchiectasis
Chest physio
Abx for exacerbations (ciprofloxacin 7-10days)
Bronchodilators
Outline the pathophysiology associated with CF
Autosommal recessive condition Mutation in the CFTR gene on Chr7 Defective CFTR protein is unresponsive to cAMP Transported of chloride ions is impaired Decrease in luminal Cl- secretion Increase in NA reabsortion Results in viscous secretions Salty sweat
CF is a multi system disease. Outline which systems are involved and how they are affected
Nasal: polyps
Resp: wheeze, cough, infections, pneumothorax
GI: Pancreatic insufficiency, gallstones, cirrohosis
Infertility
Low BMI
Key organisms that affect CF patients
Early disease
- s.aureus
- h.influenza
Late
- P.aeruginosa
- b.cepacia
Diagnosis of CF
- Sweat test NA and Cl > 600mM
- Genetic screening
- Faecal elastase
- Immunoreactive trypsinogen
Management of CF patients
CHEST
- physio
- abx for infections
- mucolytics (dnase)
GI
- Creon
- ADEK supplements
- Insulin
- Ursodeoxycholic acid, stimulate biles secretion
Gene therapy
List the types of lung cancers
- SCC
- Adeno
- Large cells
- Small cell
Discuss the pathology and behaviour of the following lunch cancers
- SCC
- Adeno
- Large cells
- Small cell
SSC
- Centrally located
- Keratinisation
- Locally invasive
- Metastasise late
- Secrete PTHrP
Adeno
- Peripherally located
- Glandular differentiation
- Mucin production
- More common in females
- Present with mets
Large cell
- Large poorly differentiated cells
- Poor prognosis
Small cell
- Central located
- Near bronchi
- V chemosensitive but v poor prognosis
- ectopic hormone secretion
Test in the investigations of lung cancer
Bloods (BC UEs Ca LFTs0 CXR - Coin lesion - Hilar enlargement - Consolidation - Effusion Contrast enhanced Volumetric CT PET CT Radio nucleotide bone scan Biopsy
CXR coin lesion differentials
Foreign body Abscess Neoplasia Granuloma Structural (AVM)
Management of lung ca
MDT NSCLA - Surgical resection - Curative radiotherapy - Chemo
SCLA
- Palliative radio
- Rx obstruction
- Analgesia
Complications associated with lung cancer
- Local
- recurrent laryngeal N.palsy
- SVC obstruction
- Horner’s syndrome - Paraneoplastic
- Endo
SIADH
Cushings
Carcinoid
PTHrP
- Rheum
Polymyositis
-Neuro
Peripheral neuropathy
- Derm
Acanthosis nigricans - Metastatic
Path #
Hepatic failure
Addisons
Classify pleural effusion and name the classy the criteria used to differentiate between the groups
- Transudates: effusion protein <25g/L
- Exudate: effusion protein > 35g/L
Between apply Lights
Exudate must have one of
- serum protein ratio > 0.5
- serum LDH ration > 0/6
- LDH os 0.6 x ULN
List the causes of exudates pleural effusion
Increased capillary permeability Infection; pneumonia, Tb Neoplasm: bronchial, lymphoma Inflammation: RA, SLE Infarction
List the causes of transudates
Increase capillary hydrostatic or decrease oncotic pressure CCF Renal failure Decrease albumin Hypothyroidism Meig's syndrome - Right pleural effusion - Ascites - Ovarian fibroma
Presentation of pleural effusion
Can be asymptomatic or can present with dyspnoea and pleuritic pain Tracheal deviation Decreased expansion Stony dullness Decrease air entry
Beaware of associated disease CA Liver disease RA SLE Hypothyroidism
Define pulmonary hypertension
PA pressure > 25mmHg
List the causes of pHTN
- Left heart disease
- mitral stenosis
- mitral regurgitation
- l - r shunt - Lung parenchymal disease
- COPD
- Asthma
- Interstitial lung disease
- CF - Pulmonary Vascular disease
- Scleroderma
- SLE
- Wegners
- Sickle cell
- Portal hypertension
Investigations of pHTN
ECG
- P Pulmonale
- RVH
- RAD
Echo
- Tricuspid regurgitation
Right heart catheterisation
- Gold standard
Define Cor pulmonale
RHF due to pHTN
List the signs of cor pulmonate on examination
Increased JVP with a wave Left parasternal heave Loud P2 Murmur Pulsatile hepatomegaly
List the management of pHTN
Decrease pulmonary resistance
- LTOT
- CCB (nifedipine)
- Sildenafil (PDE-5 inhibitors)
Cardiac failure
- ACEi
- Diuretics
Classify the different types of pneumothorax
- Closed
Intact chest wall, air leak from the lung to the pleural cavity - Open
Defect in the chest wall allows communication between the PTX and the exterior - Tension
Air enters pleural cavity through a one way valve and can’t escape
List the causes of a pneumothorax
Spontaneous
- No underlying disease, seen in young men and smokes
- Underlying lung disease such as COPD, marinas, EDS,
Trauma
Iatrogenic
- Central line insertion
- PP ventilation
- Biopsy
Cause of mesothioloma
Asbestos exposure
Note prognosis is very poor, presents in a similar way to lung cancer.
It is important to notify patients of the compensation scheme that is available to them.
Define Goodpastures disease
Acute glomerulonephritis and alveolar haemorrhage
Type II antigen-antibody reaction
Presence of antiglomerular basement membrane antibodies (Anti-GBM abs)
Bind to the kidney basement membrane and the alveolar membrane.
Complement cascade is activated
Attackes type IV collagen of basement membranes
Key investigations for Goodpastures
Bloods
- ESR
- ANCA-ve
- Anti- GBM antibodies (ELISA)
CXR
- infiltrates pulmonary haemorrhage
- patchy consolidation
Kidney biopsy
- crescentric glomerulonephritis
Treatment for Goodpastures
- Remove circulating abs via plasmapheresis
- Place on high dose corticosteroids
- IV methylprednisolone + cyclophosphamide
List the potential causes of hypersensitivity pneumonitis
- Bird’s fanciers lung
- Farmer’s and mushroom workers lung
- Malt workers lung
- Sugar workers lung
Outline the CXR findings in hypersensitivity pneumonitis
Upper zone mottling
Hilar lymphadenopathy
Honey comb lung in acute cases
Classify the different types of lung disease
- Associated with systemic disease
- Enviromental triggers
- Granulomatous disease
- Idiopathic
- Other
Define sarcoidosis
Multi system granulomatous disorder of unknown cause
Mass of macrophages forming giant cells
Non caesating
Outline the systems affect by sarcoidosis
Pulmonary
- Bilateral hilar lymphadenopathy
- Cough
- Dyspnoea
Non pulmonary
- Hepatomegaly
- Splenomegaly
- Conjunctivitis
- Cardiomyopathy
- Nephrocalcinosis
- Enlargement of the paratoid glands
- Bell’s palsy
Outline the radiological staging of sarcoidosis
Stage 0: Normal Stage 1: BHL Stage 2: BHL + pulmonary inflitrates Stage 3: as above Stage 4: Progressive pulmonary fibrosis
Biopsy will reveal non casting granulomatous
Treatment for patients with sarcoidosis
Acute
- Bed rest
- NSAIDs
Chronic
1. Steroids (prednisalone)
Clinical features of pulmonary fibrosis
Dry cough Excertional dyspnoea Weight loss Cyanosis Finger Clubbing Fine end inspiratory crackles
How does rheumatoid arthritis affect the lungs
Pleural adhesions
Fibrosing alveolitis
Rheumatoid nodules
Obliterative disease of the small bronchioles