Phase 4 Question Knowledge > Respiratory > Flashcards

Respiratory Flashcards

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1
Q

Asthma

A
  • chronic reversible obstructive airway disease -> inflammation / bronchospasm
  • non/eosinophilic
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2
Q

Asthma RFs

A
  • atopy
  • maternal smoking, low birth weight, formula fed
  • air pollution
  • allergens, eg dust mites

Triggers

  • infection, nighttime, exercise, animals, cold/damp air, strong emotions

Occupational

  • workplace triggers - eg flour…
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3
Q

Asthma Px

A
  • episodic sx
  • diurnal variation - worse at night
  • SOB
  • chest tightness
  • dry cough
  • wheeze - widespread, polyphonic
  • reduced PEFR
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4
Q

Asthma Ix

A

Measure eosinophil count or fractional nitric oxide (FeNO)

Diagnose asthma, without further investigations if:
Eosinophil is above reference range
FeNO is ≥ 50 ppb

If asthma is not confirmed by the eosinophil count or FeNO
measure bronchodilator reversibility (BDR) with spirometry
diagnose asthma if:
the FEV1 increase is ≥ 12% and 200 ml or more from the pre-bronchodilator measurement, or
the FEV1 increase is ≥ 10% of the predicted normal FEV1
if spirometry is not available or it is delayed, measure peak expiratory flow (PEF) twice daily for 2 weeks
diagnose asthma if:
PEF variability (expressed as amplitude percentage mean) is ≥ 20%

If asthma is not confirmed by eosinophil count, FeNO, BDR or PEF variability but still suspected on clinical grounds:
refer for consideration of a bronchial challenge test
diagnose asthma if bronchial hyper-responsiveness is present

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5
Q

Asthma Dx

A

Initial Ix

  • FeNO
  • spirometry with bronchodilator reversibility

If dx uncertain

  • peak flow diary

If still uncertain

  • direct bronchial challenge
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6
Q

Asthma new joint guidelines

A

Step 1: a low-dose inhaled cordicosteroid (ICS)/formoterol inhaler to be taken as needed for symptom relief (anti-inflammatory reliever (AIR) therappy
If the patients presents highly symptomatic or with a severe exacerbatiion-
Start treatment with low-dose MART
Treat the acute symptoms as appropriate (a course of oral corticosteroids may be indicated)

Step 2:
A low dose MART- (ICS/formoterol combination for maintenance therpay as needed ie regularly and as required)

Step 3:
A moderate-dose MART

Step 4:
Check the fractional exhaled nitric oxide (FeNO) level if available, and the blood eosinophil count-
If either raised- specialist case
If neither raised- trial LTRA or a LAMA in addition to MART
If control has not improved stop LTRA or LAMA and start the alternative (LTRA or LAMA)

Step 5-
Reder people to a specialist in asthma care when asthma is not controlled despite treatment with moderate-dose MART, and trials of an LTRA and a LAMA

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7
Q

Asthma further Mx

A
  • ?occupational - refer to resp
  • yearly flu jab
  • yearly asthma review
  • consider stepping down tx every 3mo or so
  • reducing ICS dose - only by 25-30% at a time
  • regular exercise, avoid smoking, avoid triggers
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8
Q

Asthma drugs

A

SABA - salbutamol

LABA - salmeterol, formoterol

SAMA - ipratropium

LAMA - tiotropium

ICS - beclometasone / budesonide

MART - Fostair - beclometasone + formoterol

Trimbow - beclometasone + formoterol + glycopyrronium

LTRA - montelukast

Theophylline

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9
Q

Acute exacerbation of asthma

A
  • rapid deterioration in sx in asthma
  • triggers as chronic, may be infection
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10
Q

Acute asthma Px

A
  • SOB
  • Cough
  • Accessory muscle use
  • Tachypnoea
  • Global wheeze
  • Reduced air entry
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11
Q

Acute asthma grading

A

Moderate

  • PEF 50-75%

Acute severe

  • PEF 33-50% best
  • RR>25
  • HR>110
  • Unable to complete sentences

Life-threatening

  • PEF <33%
  • Sats <92%
  • Silent chest, cyanosis
  • Bradycardia, low BP
  • Exhaustion, confusion, coma

(Near fatal)

  • Raised pCO2
  • mechanical ventilation, raised inflation pressures
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12
Q

Acute asthma Ix

A
  • ABG - resp alkalosis -> hypoxic -> normal pCO2
  • bloods, CXR
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13
Q

Acute asthma admit if

A
  • Life-threatening grade
  • Acute severe grade + unresponsive to tx
  • Previous near-fatal attack
  • Pregnancy
  • Occurring despite oral corticosteroid
  • Px at night
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14
Q

Acute asthma Mx

A
  • abx
  • O2
  • salbutamol - inhaler / nebs
  • PO prednisolone 40-50mg / IV hydrocortisone 5d (3d in paeds)
  • ipratropium - nebs
  • IV Mg
  • IV salbutamol
  • IV aminophylline
  • Intubation/ventilation, ECMO
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15
Q

Acute asthma criteria for discharge

A
  • Stable on discharge medication (no nebs / O2) for 12-24hrs
  • Inhaler technique checked + recorded
  • PEF >75%
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16
Q

COPD

A
  • Chronic irreversible progressive condition involving airway obstruction, emphysema, chronic bronchitis

Causes

  • smoking, A1AT deficiency, coal, cotton, cement…
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17
Q

COPD Patho

A
  • bronchitis - airway inflammation, fibrosis, mucus production
  • emphysema - parenchymal destruction, loss of elastic recoil, reduced SA for gas exchange
  • V/Q mismatch, lack of oxygenation, CO2 retention
  • increased pulmonary artery pressure -> PAH, RHF
  • some pts CO2 retainers
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18
Q

COPD Px

A
  • SOB, cough, sputum, wheeze
  • recurrent infections
  • minimal diurnal variation
  • accessory muscles
  • hyperinflation
  • decreased cricosternal distance
  • decreased expansion, hyperresonant
  • pursed lips
  • cyanosis, cachexia
  • cor pulmonale - peripheral oedema, raised JVP, SOBOE, syncope, chest pain
  • PP/BB
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19
Q

MRC SOB scale

A
  1. SOB on marked exertion
  2. SOB on hills
  3. Slow or stop on flat
  4. Exercise tolerance 100-200 yards on flat
  5. Housebound / SOB on minor tasks
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20
Q

COPD vs asthma

A
  • Younger onset in asthma
  • Smoking - in most with COPD
  • Asthma - sx vary, less so in COPD
  • Nocturnal sx in asthma
  • Persistent productive cough - COPD
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21
Q

COPD Ix

A
  • spirometry - FEV1/FVC<70%
  • CXR - hyperinflation, flat hemidiaphragms, bullae
  • FBC - anaemia/polycythaemia
  • ECG / ECHO
  • CT thorax
  • transfer factor for CO (TLCO)
  • ?A1AT levels
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22
Q

COPD severity

A

Stage 1 / mild - FEV1>80%
Stage 2 / moderate - FEV1 50-79%
Stage 3 / severe - FEV1 30-49%
Stage 4 - very severe - FEV1 <30%

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23
Q

COPD Mx

A
  • stop smoking, pneumococcal/flu jabs
  • pulm rehab
  • inhalers
  • oral theophylline
  • prophylactic abx - azithromycin
  • mucolytics
  • PDE-4 inhibitors - roflumilast
  • furosemide for cor pulmonale
  • LTOT - long-term O2 therapy
  • surgery - lung volume reduction surgery, bullectomy, lung transplant
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24
Q

COPD Inhaler Mx

A

1st step

  • SABA / SAMA

2nd step

Asthma/steroid-responsive features

  • previous dx asthma/atopy
  • variation FEV1 >400mls
  • diurnal variation PEF >20%
  • raised eosinophils
  • if no features -> LABA + LAMA (anoro ellipta)
  • if features - LABA + ICS (fostair)

3rd step

  • LABA + LAMA + ICS (trimbow)
  • do not prescribe LAMA with SAMA (change to SABA)
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25
Long term O2 therapy
Assess by measuring 2 ABGs >3wks apart in stable COPD pts on optimum mx, carry out if - FEV1<30%, cyanosis, polycythaemia, peripheral oedema, raised JVP, sats <92% Indication Offer LTOT if pO2 <7.3, or pO2 7.3-8 and any of: - secondary polycythaemia - peripheral oedema - PAH
26
COPD Cx
- acute exacerbation, resp failure - secondary polycythaemia - PAH, cor pulmonale - PTX - lung ca - exercise limitation - reduced QoL
27
IECOPD
- acute deterioration in sx in COPD pt Causes - bacterial - H influenzae, strep pneumoniae, M catarrhalis - Viral - human rhinovirus
28
IECOPD Px
- SOB, cough, wheeze - increased sputum - hypoxia, acute confusion
29
IECOPD Ix
- Bloods - FBC, U/E, CRP, cultures - ABG - resp acidosis (raise bicarb indicates chronic retainer) - CXR - ECG - sputum culture
30
IECOPD admit if
- Severe SOB - Acute confusion, impaired consciousness - Cyanosis - Low sats - Social reasons - eg unable to cope at home - Significant comorbidities
31
IECOPD Mx
- O2 - salbutamol / ipratropium - 30mg prednisolone for 5d / IV hydrocortisone - abx - amoxicillin / clarithromycin / doxycycline - chest physio severe - IV aminophylline - NIV - biPAP - intubation / ventilation - doxapram
32
Pneumonia
- infection of lung tissue - inflammation in alveolar space - inflammation + pus - impairs gas exchange - neutrophils - cytokines - inflammatory response + fever
33
Pneumonia types
CAP - community HAP - >48hrs in hospital VAP - intubated Aspiration - form aspiration of foods/fluids
34
Pneumonia causes
Bacterial - Strep pneumoniae (most common), H influenzae (COPD) - Moraxella catarrhalis – COPD / immunocompromised - Pseudomonas aeruginosa – CF / bronchiectasis - S aureus – CF - MRSA – HAP - Klebsiella – alcoholics Atypical - cannot be cultured in normal way - Legionella – air conditioning units, causes SIADH (hyponatraemia) – urine antigen test to screen - Mycoplasma pneumoniae – mild pneumonia, erythema multiforme rash – target lesions, neuro sx in young pts - Chlamydophila pneumoniae – mild chronic pneumonia + wheeze in school children - Coxiella burnetiid / Q fever – bodily fluids of animals – eg farmer - Chlamydia psittaci – contact with infected birds – eg parrot owner Other - Pneumocystis jirovecii pneumonia (PCP) – immunocompromised, eg HIV with low CD4 – dry cough, SOBOE, night sweats, co-trimoxazole to tx - COVID-19
35
Pneumonia Px
- cough, sputum +/- blood, SOB, fever, malaise, myalgia, pleuritic chest pain - delirium - dull to percussion - bronchial breath sounds - coarse focal crackles, reduced AE - raised RR, tachycardia, hypoxia, hypotension
36
CURB-65
C – confusion U – urea >7mmol/L R – resp rate >30 B – BP<90 systolic / 60 diastolic 65 – age >65yo - Score 0-1 – mild, consider home tx - Score 2– moderate, hospital admission - Score 3-5 – severe, admit, monitor, consider ITU
37
Pneumonia Ix
- bloods - FBC, U/E, CRP, cultures, ABG - CXR - focal consolidation - sputum culture - pneumococcal / legionella urinary antigen tests
38
Pneumonia Mx
- Abx - amoxicillin / doxy / clari / co-amox / IV / tazocin - O2 - IV fluids - intubation / ventilation - rpt CXR in 6wks
39
Acute bronchitis
- infection / inflammation of trachea/bronchi - viral often Px - cough +/- sputum - sore throat - rhinorrhoea - wheeze - fever DDx from pneumonia - may have no sputum/wheeze/SOB - no focal chest signs Ix - clinical dx - bloods, CXR etc Mx - doxy / amoxicillin
40
Aspiration pneumonia
- inhalation of stomach contents/secretions, leading to URTI - chemical pneumonitis, obstruction of resp tract, bacterial infection - usually R lower/middle lobes RFs - impaired GCS, swallowing disorder, poor mobility, older age, NBM, COPD Mx - bronchoscopy - remove, send to MC+S - tracheal suction - intubation/ventilation - abx - amoxicillin/doxy/clari/erythro / co-amox/ levofloxacin - chest physio, bronchodilators, fluids - SALT referral
41
Lung cancer
- cancer of lungs - 95% of primary are bronchial carcinomas - mets more common than primary - kidney, prostate, bone, GI tract, cervix, ovary
42
Lung cancer RFs
- smoking, occupational (asbestos, coal, tar etc), radiation, pulm fibrosis, COPD
43
Lung cancer types
Small cell lung cancer (SCLC) - 20% - NE hormones released -> paraneoplastic Non-small cell lung cancer (NSCLC) - 80% - adenocarcinoma - 40% - often seen in non-smokers - squamous cell - 20% - cavitating lesions - large cell - 10% - other - 10%
44
Lung cancer Px
- SOB, cough, chest pain, haemoptysis - monophonic wheeze - finger clubbing - recurrent pneumonia - wt loss, lethargy - lymphadenopathy (supraclavicular) - mets - bone pain, headache, seizures, hepatic/abdo pain
45
Lung cancer extrapulmonary / paraneoplastic changes
- Recurrent laryngeal nerve palsy - hoarse voice - Phrenic nerve palsy - SOB (diaphragm weakness) - SVC obstruction - facial swelling, difficulty breathing... - Horner's syndrome - Pancoast tumour - SIADH - ectopic ADH from SCLC - hyponatraemia - Cushing's syndrome - ectopic ACTH from SCLC - HTN, hyperglycaemia, hypokalaemia, alkalosis - Hypercalcaemia - ectopic PTH from SCC - Limbic encephalitis - SCLC causes immune system to produce ABs against limbic system - short-term memory impairment, hallucination, confusion, seizures - Lambert-Eaton myasthenic syndrome - ABs against SCLC also target Ca channels in presynaptic motor neurons - Gynaecomastia - AC - Hypertrophic pulmonary osteoarthropathy (HPOA) - AC / SCC
46
Lung cancer referral criteria
2ww for ?lung ca if - CXR suggesting lung ca - >40yo + unexplained haemoptysis Offer urgent 2wk CXR in >40yo non-smoker and 2 of the following, or smoker and 1 of: - Cough, fatigue, SOB, chest pain, weight loss, appetite loss Consider urgent CXR if >40yo with - Persistent / recurrent chest infection - Finger clubbing - Lymphadenopathy - Chest signs of cancer - Thrombocytosis
47
Lung cancer Ix
- bloods - CXR - hilar enlargement, peripheral opacity, pleural effusion, collapse - CT TAP + contrast - bronchoscopy - PET scan - TNM
48
Lung cancer Mx
SCLC - chemo / radio - stents / debulking surgery - poor prognosis NSCLC - surgery - segmentectomy/wedge resection, lobectomy, pneumonectomy - radiotherapy - chemo
49
Mesothelioma
- Tumour of mesothelial cells - 80-90% in pleura - other sites are peritoneum, pericardium, testes - asbestos - 45yr latent period - high-grade, may invade intercostal nerves, severe pain
50
Mesothelioma Px
- chest pain - SOB - wt loss - finger clubbing - recurrent pleural effusions - mets - lymphadenopathy, hepatomegaly, bone pain/tenderness, abdo pain/obstruction
51
Mesothelioma Ix
- CXR/CT - unilateral pleural thickening/effusion - pleural aspiration - bloody - pleural biopsy
52
Mesothelioma Mx
- resistant to surgery/chemo/radio - palliative chemo
53
PE
thrombus (blood clot) in pulmonary arteries - venous thrombus, usually from DVT - obstructs RV outflow - sudden increase in pulmonary vascular resistance - acute RHF - lung tissue ventilated, not perfused - V/Q mismatch
54
PE RFs
- Immobility - Recent surgery - Long-haul flight - Pregnancy - Oestrogen therapy - cOCP, HRT - Malignancy - Polycythaemia - SLE - Thrombophilia
55
VTE prophylaxis
- Assess for VTE risk - LMWH (enoxaparin) if higher risk - CI - active bleeding, warfarin/DOAC - Anti-embolic compression stockings - CI - PAD
56
PE Px
- SOB - Cough - Haemoptysis - Pleuritic chest pain - Hypoxia - Tachycardia - Raised RR - Low-grade fever - Hypotension - May have DVT sx
57
PE Ix
- PERC rule - PE Wells score If PE likely (>4) CTPA - positive - dx - negative - consider leg USS Delay to CTPA - interim DOAC/LMWH PE unlikely (<4) D dimer - positive - CTPA - negative - stop anticoagulation, alt dx V/Q scanning - maybe if renal impairment Other Ix - CXR - ?wedge-shaped opacification - ECG - S1Q3T3, RBBB, right axis deviation, sinus tachy - ABG - low O2/CO2
58
PE Mx
Tx as outpatient if - stable, no comorbidities, support at home - Pulmonary Embolism Severity Index (PESI) score to stratify risk - O2, analgesia Anticoagulation - DOAC - apixaban/rivaroxaban (1st line / active cancer) - LMWH, then dabigatran / edoxaban - LMWH, then warfarin - renal impairment - LMWH / heparin / LMWH then warfarin - APL - LMWH then warfarin Anticoagulation length - all pts - 3mo - provoked - stop after 3mo (3-6mo if active cancer) - unprovoked - 6mo total - ORBIT score - assess bleeding risk Unstable - thrombolysis - alteplase - surgical thrombectomy - IVC filter
59
Pleural effusion
- fluid in pleural space - empyema - pus - chylothorax - lymphatic fluid - trauma / carcinoma infiltration
60
Pleural effusion causes
Transudative (<30g/L protein) – tend to be issue with flow - Heart failure (most common) - Hypoalbuminaemia - liver disease, nephrotic syndrome, malabsorption - Hypothyroidism - Meigs’ syndrome – benign ovarian tumour, pleural effusion, ascites Exudative (>30g/L protein) – tend to be inflammation - Infection – pneumonia, TB, subphrenic abscess - RA, SLE - Neoplasia – lung ca, mesothelioma, mets - Pancreatitis - PE - Dressler’s syndrome
61
Pleural effusion Px
- SOB - Non-productive cough - Chest pain - Dull to percussion - Reduced breath sounds - Reduced chest expansion - Large effusion - tracheal deviation away from effusion
62
Pleural effusion Ix
- CXR - blunting of costophrenic angles, fluid in lung fissures, meniscus, tracheal deviation - USS - contrast CT - pleural aspiration - send for pH, protein, LDH, cytology, micro
63
Pleural aspiration interpretation
- Low glucose - RA, TB - Raised amylase - pancreatitis, oesophageal perf - Blood - mesothelioma, PE, TB - Empyema - pus, low pH, low glucose, high LDH
64
Light's criteria
Differentiate between transudate / exudate where protein 25-35. Exudate likely if at least one of the following is met: - Pleural fluid protein / serum protein >0.5 - Pleural fluid LDH / serum LDH >0.6 - Pleural fluid LDH >2/3 upper limit normal of normal serum LDH
65
Pleural effusion Mx
- tx cause - pleural aspiration - chest drain Empyema - chest drain - Abx Recurrent - recurrent aspiration - pleurodesis - indwelling pleural catheter - opioids for SOB
66
PTX
- air in pleural cavity, can collapse lung
67
PTX types
Primary spont PTX (PSP) - no underlying disease Secondary spont PTX (SSP) - COPD, asthma, CF, cancer, PCP, Marfan's Traumatic - blunt / penetrating Iatrogenic - eg thoracentesis, CVC, ventilation Tension PTX - BP drops...
68
PTX Px
- sudden onset SOB - pleuritic CP - hyper-resonant - reduced AE - reduced chest expansion - tachypnoea, tachycardia - surgical emphysema - tension - resp distress, tracheal deviation, hypotension
69
PTX Ix
- CXR - CT chest
70
PTX Mx
If no sx - conservative mx If sx - assess for high risk characteristics - haemodynamic compromise - significant hypoxia - bl PTX - underlying lung disease - >50yo, smoker - haemothorax If high risk characteristics + safe to intervene (>2cm) -> seldinger chest drain If no high risk - choice of intervention - conservative - IP/OP with clinic follow up - ambulatory device - Rocket Pleural vent - needle aspiration - if unsuccessful, then chest drain
71
Persistent/recurrent PTX Mx
- video-assisted thoracoscopic surgery (VATS) for mechanical / chemical (talc) pleurodesis +/- bullectomy / pleurectomy
72
PTX discharge advice
- avoid smoking - if ptx persists - cannot fly - avoid scuba diving - unless undergone bl surgical pleurectomy, normal PFTs/chest CT post-op
73
Tension PTX Mx
- needle decompression - 2nd ICS MCL, or 4/5th ICS just anterior to mid-axillary - then chest drain
74
Bronchiectasis
- permanent dilatation + thickening of bronchi after chronic inflammation - impaired mucociliary transport - chronic cough, excessive sputum, recurrent infections - main orgs - H influenzae, strep pneumoniae, S aureus, pseudomonas
75
Bronchiectasis causes
- post-infective - TB, measles, pertussis, pneumonia - CF - cancer/TB - immune deficiency - allergic bronchopulmonary aspergillosis - ciliary dyskinetic syndromes - yellow nail syndrome
76
Bronchiectasis Px
- persistent cough - sputum, purulent - SOB - intermittent haemoptysis - recurrent chest infections - coarse crackles / wheeze on auscultation - finger clubbing - wt loss
77
Bronchiectasis Ix
- sputum culture - CXR - tram-track opacities, ring shadows - HRCT - dilated/thickened bronchi, signet ring sign - spirometry - obstructive - bronchoscopy
78
Bronchiectasis Mx
- vaccines - chest physio, postural drainage - extended abx course for exacerbations (7-14d) - pseudomonas - cipro - H influenzae - amoxicillin, co-amox, doxy - S aureus - fluclox - long-term abx - azithromycin - if 3+ exacerbations/yr - bronchodilators - surgical resection - lung transplant
79
Obstructive sleep apnoea (OSA)
- collapse of pharyngeal airways whilst asleep leading to apnoeas
80
OSA RFs
- middle aged, male - obesity - alcohol - smoking - macroglossia - large tonsils - Marfan's
81
OSA Px
- Partner may report excessive snoring, periods of apnoeas - Morning headache - Waking up unrefreshed from sleep - Daytime sleepiness - Concentration problems - Reduced O2 sats during sleep - Severe - HTN, HF, increased risk of MI / stroke
82
OSA Ix
- Epworth sleepiness scale - Multiple Sleep Latency Test (MSLT) - sleep studies (polysomnography)- diagnostic test
83
OSA Mx
- reduce alcohol, stop smoking, lose weight - CPAP - intra-oral devices - eg mandibular advancement - surgery - uvulopalatopharyngoplasty (UPPP) - inform DVLA if daytime sleepiness
84
Occupational lung disorders
Inhaling something at work, leads to: - acute bronchitis, oedema - Pulmonary fibrosis - Occupational asthma - Hypersensitivity pneumonitis - Bronchial carcinoma
85
Occupational asthma
- asthma sx worse at work - peak flow diary to compare work/home
86
Pneumoconiosis
- inhalation of coal dust, fibrosis occurs - coal mine workers -> coal-workers pneumoconiosis (CWP) - particles ingested by alveolar macrophages - die, release enzymes, cause fibrosis - simple pneumoconiosis / progressive massive fibrosis (PMF)
87
Silicosis
- inhalation of silica particles - fibrogenic - upper zone fibrosis, egg-shell calcification of hilar lymph nodes - eg stonemasons, sandblasters, pottery - massive airways restriction
88
Asbestos and the lung
Pleural plaques - benign - discrete fibrous / partially calcified thickened area Pleural thickening - extensive thickening of pleura - fibrosis - can lead to restrictive lung disease Asbestosis - lung fibrosis from asbestos exposure - an ILD - Px - SOB, clubbing, bl end-insp crackles, restrictive Mesothelioma Lung cancer - most common form of cancer from asbestos exposure
89
Byssinosis
- inhalation of textile fibre dust - chest tightness, cough, SOB - Sx worse first day back at work after break
90
Berylliosis
- inhalation of copper alloy - aerospace, electrical devices - progressive SOB, pulm fibrosis
91
Pulmonary siderosis
- inhalation of metallic particles - metal grinding, welding - little effect on lung function
92
Pulmonary fibrosis
- diseases that cause lung fibrosis - scarring of lungs, loss of elasticity - an interstitial lung disease (ILD)
93
ILD
Disease which causes inflammation + fibrosis of lung parenchyma - Idiopathic pulmonary fibrosis - secondary pulmonary fibrosis - EAA - cryptogenic organising pneumonia - asbestosis
94
Pulm fibrosis patho
- fibrosis may be secondary to lung damage, focal in response to irritants, or diffuse parenchymal disease Idiopathic pulm fib (IPF) - progressive PF, no apparent cause Secondary pulm fib - drugs - amiodarone, methotrexate, nitrofurantoin - conditions - A1AT, RA, SLE, SSc, sarcoidosis
95
Pulm fibrosis Px
- SOBOE - Dry cough - fatigue - IPF - bibasal find end insp crackles, finger clubbing
96
Pulm fibrosis Ix
- bloods - eg CRP, ANA, RF - spirometry - restrictive - FEV1 + FVC reduced, FEV1:FVC >70% - HRCT - ground-glass appearance - TLCO test - reduced transfer factor - lung biopsy - bronchoalveolar lavage
97
Pulm fibrosis Mx
- stop smoking, physio, pulm rehab, vaccines - home O2 if hypoxic - lung transplant IPF - pirfenidone - nintedanib
98
Extrinsic allergic alveolitis (EAA)
- hypersensitivity pneumonitis - diffuse granulomatous inflammation of lung parenchyma due to inhalation of organic antigens - an ILD - T3 and T4 hypersensitivity Bird-fancier’s lung – reaction to bird droppings Farmer’s lung – reaction to mouldy spores in hay Mushroom worker’s lung – reaction to specific mushroom antigens Malt workers lung – reaction to mould on barley
99
EAA Px
Acute (4-8hrs post-exposure) - SOB, dry cough, fever, rigors, chest tightness - crackles on ausc - resolves after Ag removed Chronic (wks/months) - lethargy - SOB - productive cough - anorexia, wt loss
100
EAA Ix
- CXR / CT - upper/mid zone fibrosis - Bloods - assay for specific IgG - Spirometry - restrictive - bronchoscopy + bronchoalveolar lavage - biopsy
101
EAA Mx
- remove allergen - O2 - steroids - oral prednisolone
102
Pulmonary arterial hypertension (PAH)
- increased pulmonary artery pressure + resistance, >20mmHg
103
PAH patho
- hypoxic vasoconstriction, inflammation, endothelium damage - vasoconstrictor release, increased pressure - right heart strain, back pressure into venous system - RV pumps harder -> RVH, RHF - thrombosis tendency
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PAH causes
- Idiopathic - Connective tissue disease, eg SLE - LHF - usually due to MI / HTN - COPD, pulmonary fibrosis - PE - Sarcoidosis, glycogen storage disease, haem disorders
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PAH Px
- SOB - Syncope - Cough - Tachycardia - Raised JVP - Hepatomegaly - Peripheral oedema - Hypotension
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PAH Ix
- ECG - RH strain, RAD, RBBB, RVH, p pulmonale - CXR - RVH, dilated pulmonary arteries - pulm function tests - ECHO - HRCT / cardiac MRI - 6min walking distance - BNP raised - right heart catheterisation
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PAH Mx
- diuretics, anticoagulants, LTOT if hypoxic, tx anaemia - tx cause - CCB - nifedipine, diltiazem, amlodipine - cause vasodilation - endothelin receptor antagonist - bosentan - prevent vasoconstriction - phospohdiesterase type 5 inhibitor - sildenafil - reduce pulm BP - prostacyclin / prostaglandin analogues - iloprost - vasodilate - balloon atrial septostomy - lung transplant
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Sarcoidosis
- Chronic multisystem granulomatous disorder (nodule full of macrophages) of unknown cause - F, 20-39yo/60yo, black ethnic origin - can affect any organ - tends to be lungs/thorax
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Sarcoidosis Px
Acute sarcoidosis - fever, erythema nodosum, polyarthralgia, BHL Pulm disease - dry cough, SOB, decreased exercise tolerance, chest pain Other sx - lupus pernio - hepatomegaly, deranged LFTs, cholestasis, cirrhosis - lymphadenopathy, wt loss, splenomegaly, fatigue - salivary gland, eye, face, CNs, pituitary, renal, cardiac sx Lofgren's syndrome - erythema nodosum + BHL + polyarthralgia
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Sarcoidosis Ix
- raised Ca, ACE - CXR, HRCT, MRI, PET - biopsy - non-caseating granulomas with epithelioid cells - other Ix for organ involvement - U/E, LFTs, ophthalmoscopy, ECG, ECHO, US liver/kidney
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Sarcoidosis Mx
- mild sx - conservative - oral steroids - prednisolone + bisphosphonates - methotrexate, anti-TNF - lung transplant
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Lung abscess
- well-circumscribed infection within lung parenchyma, contains pus - after aspiration pneumonia, IE, lung tumour... - S aureus, Klebsiella, Pseudomonas, but typically polymicrobial
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Lung abscess Px
- pneumonia sx, but more subacute - fever, night sweats, wt loss - productive cough - foul sputum - haemoptysis - chest pain, SOB - dull to percussion, bronchial breathing - clubbing
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Lung abscess Ix
- CXR - fluid-filled space, air-fluid level - sputum + blood cultures - sepsis workup
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Lung abscess Mx
- IV abx - percutaneous drainage - surgical resection
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TB
- infection caused by Mycobacterium tuberculosis - acid-fast bacilli - see with ZN stain - bright red cells on blue background
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TB patho
- spread by saliva droplets, then several possible outcomes: Immediate clearance - most cases Primary active TB - Ghon focus (lung lesion) develops - granuloma forms (collection of epithelioid histiocytes) - heals by fibrosis - T4 hypersensitivity Latent TB - immune system encapsulates bacteria, stops disease progression Secondary TB - reactivation of latent TB to active infection - cavity erodes into airways Miliary TB - disseminated + severe disease Extrapulmonary TB - disease in other areas Drug-resistant TB - resistant to tx
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TB RFs
- close contact - household member - immigrants relatives from high prevalence areas - immunocompromised - malnutrition, homelessness, drug users, smokers, alcoholics
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BCG vaccine
- intradermal, live attenuated M bovis - generates immune response - test with Mantoux test first - only give if negative
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TB Px
Systemic sx - fever, lethargy, night sweats, wt loss, lymphadenopathy Pulm sx - cough, haemoptysis, chest pain, consolidation, pleural effusion Extrapulmonary sx - Bone – bone pain, Pott’s - Abdo – ascites, lymph nodes, ileal malabsorption - GU – epididymitis, LUTS, pyuria - CNS – meningitis, sx of raised ICP - Cardiac – pericarditis, pericardial effusion - Skin – lupus vulgaris (red/brown lesions), erythema nodosum
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TB Ix
For immune response - previous infection, latent TB, active TB - mantoux test - IGRA For active disease - CXR - patchy consolidation, hilar lymphadenopathy, pleural effusions, upper lobe cavitation, millet seed appearance - cultures - sputum (3x), blood, lymph node aspiration/biopsy - caseating granuloma on histology - NAAT
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TB Mx
- MDT, notify PHE, isolate, test for other IDs Active TB - Rifampicin - 6mo - Isoniazid (with pyridoxine vit B6) - 6mo - Pyrazinamide - 2mo - Ethambutol - 2mo Latent TB - 3mo isoniazid (and vit B6) + rifampicin - OR 6mo isoniazid (and vit B6) Meningeal TB - Tx for >12mo - add steroids - may need direct observed therapy
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Influenza
- acute resp illness from infection with influenza virus - A/B/C serotypes, H/N Ags - un/complicated - droplet infection/contact - vaccinate - >65yo, pregnant, young children, healthcare workers
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Influenza Px
- 1-4d incubation period - Fever - Lethargy - Anorexia - Myalgia, joint pain - Headache - Dry cough - Sore throat - Coryzal sx
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Influenza Ix
- clinical dx - POCT / viral PCR to monitor outbreaks
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Influenza Mx
- self-care - antivirals - tamiflu (oseltamivir), inhaled zanamivir - start <48hrs for it to be effective
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ARDS
- severe inflammatory reaction in lungs - alveolar collapse, pulm oedema, inflammatory exudate, decreased lung compliance, fibrosis of lung tissue Causes - sepsis, pneumonia, trauma, massive blood transfusion, smoke inhalation, pancreatitis Px - resp distress, SOB, elevated RR - bl lung crackles - hypoxia Ix - CXR - bilateral infiltrates - ABG - hypoxia, resp failure Mx - resp support - prone positioning - ITU - PEEP
Phase 4 Question Knowledge
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