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Flashcards in Resp Session 6 Deck (66)
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1
Q

What two conditions is COPD a combination of?

A

Emphysema and chronic bronchitis

2
Q

What is the pathogenesis of chronic bronchitis?

A

Inflammation in large always causes:
Remodelling and narrowing of airways
Hyper secretion of mucus and proliferation of goblet cells
Chronic productive cough and frequent infections

3
Q

What is the pathogenesis of emphysema?

A

Terminal bronchioles and distal airspaces destroyed causing:
Loss of elastic tissue –> hyperinflation
Small airways collapsing on expiration
Bullae due to large redundant air spaces

4
Q

What causes COPD?

A

Smoking

Alpha-1 antitrypsin deficiency (esp

5
Q

What are the S/S if COPD?

A
Cough with sputum
Purse lip breathing
SoB
Use of accessory muscles in breathing
Tachypnoea
Wheeze --> quiet breath sounds --> silent chest
6
Q

What are the S/S of more advanced cases of COPD?

A
Silent chest
Peripheral +/- central cyanosis
CO2 retention flap
Cor pulmonale
Oedema
7
Q

What are the 5 stages of the MRC dyspnoea score used to assess COPD?

A
  1. SoB on strenuous exercise only
  2. SoB on hurrying/walking up slight hill
  3. Walks slower due to SoB
  4. Stops for breath after walking ~100m on level ground
  5. Too SoB to leave house/SoB on dressing
8
Q

What investigations can be used in COPD?

A
Spirometry
CXR
HRCT
ABG
Alpha-1-antitrypsin blood test
9
Q

Why is HRCT used in investigation of COPD?

A

Gives detailed assessment of macroscopic alveolar destruction in emphysema, useful if considering surgery

10
Q

Why is CXR mandatory in COPD investigation?

A

To exclude other diagnoses

11
Q

What do NICE guidelines state are mild, moderate and severe levels of airflow obstruction detectable by spirometry?

A

Mild: FEV1 = 50-80%
Moderate: FEV1 = 30-49%
Severe: FEV1

12
Q

How is COPD diagnosed?

A

Hx: smoker, >40 y.o. with onset of symptoms later in life, chronic productive cough, persistent and progressive SoB
AND
obstructive pattern on spirometry

13
Q

How is stable COPD managed?

A
Smoking cessation
Pulmonary rehabilitation
Bronchodilators
Antimuscarinics
Steroids
Mucolytics
Dietary review
Supportive Tx
Long term O2 and surgery if appropriate
14
Q

What is the cycle of reconditioning seen in stable COPD pts?

A

Feel SoB –> avoid activities that worsen SoB –> do less –> muscles weaken –> worsened SoB –> feel depressed –> avoid activities etc.

15
Q

What are some of the S/E associated with treatment of stable COPD?

A

Beta-2 agonist: tachycardia, anxiety, hypokalaemia, tremor
Antimuscarinics: urinary difficulty, dry mouth, URT, glaucoma
Steroidal S/E

16
Q

How is an acute COPD exacerbation managed?

A

Aim for sats of 88-92% with titrated O2 therapy
Nebulised bronchodilators
Oral steroids
Abx if blood tests indicate infection
Consider IV bronchodilator
Repeat ABG to assess need for ventilation

17
Q

How can COPD generally be distinguished from asthma by using clinical features?

A

Pts tend to be smokers
S/S >65 y.o.
Chronic productive cough
Persistent and progressive SoB
Night time waking with cough/wheeze uncommon
Diurnal pattern/day-to-day variability uncommon

18
Q

What characterises COPD?

A

Airflow obstruction which is usually progressive, not fully reversible and does not change markedly over several months

19
Q

What are common microbial flora of the URT?

A

Viridans streptococci
Neisseria sp.
Candida sp.

20
Q

What are URTIs most commonly caused by?

A

Self limiting viruses

21
Q

Why can viral URTI lead to secondary bacterial infection?

A

Due to viral action on cilia

22
Q

Give some examples of common URTIs.

A
Rhinitis
Tracheitis
Pharyngitis
Sinusitis
Laryngitis
Otitis media
23
Q

What deferences does the respiratory tract have against infection?

A
Nasal hairs
Ciliated columnar epithelium
Cough+sneeze reflexes
Respiratory mucosa
Lymphoid follicles of pharynx and tonsils
Alveolar macrophages
Secretory IgA and IgG
24
Q

Give some examples of LRTIs.

A
Bronchitis
Pneumonia
Bronchiolitis
Empyema
Bronchiectasis
Lung abscess
25
Q

How does a poor swallow lead to aspiratory pneumonia?

A

Allows secretory pool in pharynx which can enter LRT

26
Q

What is acute bronchitis?

A

Inflammation of medium sized airways often seen in smokers

27
Q

What are the S/Sof acute bronchitis?

A
Cough
Fever
Increased sputum production
Sob due to exudation
Pulmonary oedema and cellular infiltration
28
Q

How does a CXR appear in acute bronchitis?

A

Normal as terminal bronchioles and air sacs are not affected

29
Q

What can cause acute bronchitis?

A

Viruses
S.pneumoniae
H.influenzae
M.catarrhalis

30
Q

What is the treatment for acute bronchitis?

A

Bronchodilation
Physiotherapy
Abx if absolutely necessary

31
Q

What is penumonitis?

A

Non-infective inflammatory disease

32
Q

What is chronic bronchitis?

A

Recurrent bouts of SoB associated with but not caused by infection (not primarily infective)

33
Q

What is pneumonia?

A

Inflammation of the lung alveoli, terminal bronchioles and lung parenchyma

34
Q

What are the S/S if pneumonia?

A
Fever
Cough
Pleuritic chest pain
SoB
Opacities on CXR
35
Q

How is pneumonia classified?

A

Clinical setting
Presentation (acute->bacterial/viral, chronic->TB)
Causative organism
Lung pathology - lobar, broncho (patchy), interstitial

36
Q

What is the pathogenesis of pneumonia?

A

Acute inflammatory response –> exudation of fibrin rich fluid, neutrophil and macrophage infiltration –> fluid filled air sacs –> heavy, stiff lung –> red hepatisation –> grey hepatisation

37
Q

What factors may help identify the causative agent in pneumonia?

A
Pre-existing lung disease
Immunocompromise
Geography
Seasons
Epidemics
Travel
Animal exposure
Recent ventilation
38
Q

How long does grey hepatisation take to develop following red hepatisation in pneumonia?

A

2-3 days

39
Q

What are the typical causative agents of CAP?

A

S.pneumoniae

H.influenzae

40
Q

What are atypical causes of CAP?

A

Legionella
Mycoplasma
Coxiella bunetti (livestock)
Chlamydia psittaci (birds)

41
Q

What are the S/S of CAP?

A
SoB
Cough +/- sputum (yellow, rusty, recurrent jelly)
Fever
Rigors
Pleuritic chest pain
Malaise
Nausea
42
Q

What causative agent does recurrent jelly sputum suggest?

A

Klebsiella

43
Q

What is detected O/E in CAP?

A
Pyrexia
Tachycardia
Bronchial breathing
Tachypnoea
Cyanosis
Crackles
Dullness to percussion
Tactile vocal fremitus
44
Q

What investigations are used to support diagnosis and assess severity of CAP?

A
FBC
U&Es
CRP
ABG
CXR
45
Q

What methods can be used to collect samples for sputum and blood culture to identify the causative agent in CAP?

A

Broncho alveolar lovage fluid
Nose and throat swabs
Urine antigen tests
Serum antibody test

46
Q

When are urine antigen tests or serum antibody tests used to investigate CAP?

A

Atypical causes due to difficulty in culture

47
Q

What are the criteria included in the CURB-65 score used to assess severity of CAP?

A

Confusion
Urea > 7 mmol per litre
RR > 30
Blood pressure

48
Q

What does a CURB-65 indicate?

A

Severe pneumonia, consider admittance to hospital

49
Q

What is the empiric Tx for CAP?

A

Mild-moderate: amoxicillin (doxycycline or erythromycin for penicillin allergic pts)
Moderate-severe: co-amoxiclav (clarithromycin/doxycycline for penicillin allergic pts and to cover atypical penicillin resistant causes)

50
Q

How can CAP lead to chronic lung disease?

A

Resolution of infection with fibrous scarring

51
Q

What complications can arise following CAP?

A

Lung abscess –> empyema

Bronchiectasis –> recurrent infections

52
Q

What is atypical pneumonia?

A

Pneumonia caused by organisms without a cell wall

53
Q

What additional features are seen in atypical pneumonia?

A

Extra-pulmonary features e.g. hepatitis, hyponatraemia

54
Q

What is the Tx for atypical pneumonia?

A

Agents that work on protein synthesis: macrolides and tetracyclines

55
Q

What is the pathogenesis of viral pneumonia?

A

Immune cells and virus cause damage to epithelial cells –> necrosis/haemorrhage into lung parenchyma –> acute hypoxia –> ARDS

56
Q

How is viral pneumonia identified on CXR?

A

Patchy/diffuse ground glass opacity on CXR

57
Q

What causes viral pneumonia?

A

Influenza
Parainfluenza
Respiratory syncytial virus
Adenovirus

58
Q

What is the definition of hospital acquired pneumonia?

A

Onset within 48hrs of being in hospital

59
Q

What causative agents are associated with hospital acquired pneumonia?

A
G-ve:
Staph aureus
Enterobacteriaciae
Pseudomonas sp.
H.influenza
Acinetobacter baumannii 
Candida sp.
60
Q

What is the Tx for HAP?

A

1st line: co-amoxiclav

2nd line: pipperacillin/Tazobactam/meropenem

61
Q

What method is used to distinguish causative agent of HAP form UR flora?

A

Bronchial lava he

62
Q

What is aspiration pneumonia?

A

Exogenous material/endogenous secretions –> resp tract seen in dysphagia, epilepsy, alcoholics, drowning

63
Q

What is the causative agent for aspiration pneumonia?

A

Mixed infection as you can’t selectively aspirate certain organisms, commonly viridans streptococci and anaerobes

64
Q

What is the treatment for aspiration pneumonia?

A

Co-amoxiclab

65
Q

What causative agents are seen in immunosuppression associated LRTI?

A

HIV: PCP, TB, atypical mycobacteria
Neutropenia: fungi
BM transplant: CMV
Splenectomy: encapsulated organisms e.g. S.pneumoniae, H.influenzae, malaria

66
Q

How is LRTI associated with immunosuppression prevented?

A

Flu vaccine every year
Pneumococcal vaccine every 5 years
Lifelong amoxicillin in asplenic
Smoking advice