Respiratory

Briefly outline asthma- definition, symptoms

Heterogenous disease characterised by chronic airway inflammation

Reversible airflow limitation

SSx:
- wheeze
- breathlessness
- chest tightness
- cough
- worse at night
- triggered by allergen/exercise/cold air/aspirin/BB
- atopic features

List 5 different phenotypes of asthma

Allergic

Non-allergic

Adult-onset

Asthma with persistent airflow limitation

Asthma with obesity

Which clinical features make an asthma diagnosis LESS likely?

Dizziness, light-headedness or peripheral tingling

Productive cough in absence of wheeze/breathlessness

Normal examination when breathless

Voice disturbance

Smoking history (>20 pack years)

Cardiac disease

Normal PEF or FEV1 when symptomatic

List the differential diagnoses of wheeze

Asthma

COPD

Obstruction e.g. foreign body

Anaphylaxis

Pulmonary oedema

Outline the management of acute asthma

*O*xygen (high flow, aim for >92%

*S*albutamol

**H**ydrocortisone/prednisolone

**I**pratropium bromide

**T**heophylline

**!** Magnesium sulphate

Define chronic bronchitis

Presence of chronic productive cough and sputum for at least 3 months in each of two successive years

Define emphysema

Enlarged alveolar spaces and loss of alveolar walls

Define COPD

Common, preventable and treatable disease

Characterised by persistent respiratory symptoms + airflow limitation

Due to airway and/or alveolar abnormalities caused by significant exposure to noxious particles or gases

Risk factors- over 35 yrs, smoke/ex-smoker

How do you calculate pack years?

Number of packs (20) per day x years smoked

e.g. 1 pack a day for 30 yrs= 30

Describe the pathophysiology of COPD

***Chronic bronchitis***

* hypertrophy of mucus secreting glands :. more mucus= sputum cough
* infiltration of bronchial walls with inflammatory cells :. airway narrowing

***Emphysema***

* loss of elastic recoil :. airflow limitation + air trapping
* bulla formation (air filled space after alveoli walls break down)

Compare the inflammation in asthma and COPD

*ASTHMA:*
- triggered by sensitising agent
- CD4+ and t lymphocytes
- presence of eosinophils, macrophages + mast cells
- mostly REVERSIBLE

*COPD:*
- triggered by noxious agent
- CD8+ and T lymphocytes
- presence of macrophages + neutrophils
- mostly IRREVERSIBLE

Describe the classic symptoms of COPD

Exertional breathlessness

Chronic cough

Regular sputum production

Frequent winter bronchitis

Wheeze

Outline the clinical features of COPD

Tachypnoea

Use of accessory muscles

Hyperinflation

Reduced cricosternal distance (

How is the severity of COPD assessed?

Using MRC dyspnoea scale

Ranges from grade 0 (only breathless with strenuous exercise) to grade 4 (too breathless to leave house or when dressing)

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FEV1

What is Dahl's sign?

Hyperpigmentation seen above knees/elbows in COPD patients

List the smoking cessation drugs

Vareniciline (Champix)
- selective nicotine receptor partial agonist

Nicotine replacement therapy (patches, gums, spray, inhaler)

Bupropion (Zyban)
- atypical antidepressant

Outline the pharmacological treatment of stable COPD

Flu vaccines

SABA (salbutamol, terbutaline)

Anti-cholinergics (ipratropium bromide, aclidinium)

LABA (salmeterol, indacterol)

ICS

Phosphodiesterase inhibitors (theophyllines, roflumilast)

Outline the non-pharmacological treatment of stable COPD

Exercise training programmes

Long-term O2 therapy (>15 hrs a day)

Lung volume reduction surgery

Lung transplant

Outline the complications of COPD

Respiratory failure
(PaO2

List the investigations used to diagnosed COPD

O2 saturation

ABG

Sputum + blood cultures

CXR

ECG

Bloods- eosinophil count, U&E, CRP, theophylline, cardiac enzymes

CT/CTPA (rule out PE)

List the differentials for COPD

Pneumonia

Pneumothorax

Malignancy

PE

HF/ACS

Define pneumonia

Symptoms and signs consistent with an acute lower respiratory tract infection associated with new radiographic shadowing

British Thoracic Society

Outline the symptoms of pneumonia

Fever

Shivers

Malaise

Dyspnoea

Cough

Sputum

Pleuritic pain

Haemoptysis

Outline the signs of pneumonia

Pyrexia

Cyanosis

Confusion (elderly)

Tachypnoea/tachycardia

Consolidation (reduced expansion, dull percussion, increased fremitus, bronchial breathing)

Pleural rub (raspy breathing)

List the lung defence mechanisms

Filtration in upper airways

Cough reflex

Mucociliary clearance

Alveolar macrophages

Humoral and cellular immunity

Oxidative metabolism of neutrophils

Outline the different investigations for pneumonia

Diagnosis:
- CXR
- FBC/CRP

Severity:
- U&E
- FBC/CRP/LFT
- ABG

Target therapy:
- blood + sputum cultures
- Pneumococcal urinary antigen
- Legionella urinary antigen + sputum culture
- viral PCR

What is CURB65?

A scoring system for pneumonia


Confusion
Urea (>7mmol/l)
Respiratory rate (>30/min)
Blood pressure (

How does the CURB65 scoring affect the management of pneumonia?

0-1: treat at home

2: short admission, oral antibiotics

3: senior urgent review

4-5: critical care

Outline the general management of pneumonia

O2 (aim for 94-98%)

Antibiotics

IV fluids, analgesia, DVT prophylaxis

Chest physio

Nutritional support

Smoking cessation

Name the pathogen that causes Tb

Mycobacterium Tuberculosis

Outline the risk factors of Tb

Immunosuppression e.g. HIV infection, silicosis (inhaling silica dust), substance abuse, severe kidney disease, low BMI, transplant, cancer, diabetes

Homelessness

Imprisonment

Outline the presentation of Tb

Respiratory:
- cough
- sputum
- haemoptysis

Systemic:
- fever
- malaise
- loss of appetite
- night sweats
- weight loss
- lymphadenopathy

Describe the pathogenesis of Tb

Inhaled particles deposited in alveoli →

invade and replicate in alveolar macrophages →

epithelial reaction to bacteria →

encapsulation of bacteria (tubercle) →

bacteria continue to replicate or become latent →

causes destruction and fibrosis of tissue

Compare primary and post-primary Tb

*Primary:*
- Tb with no pre-existing immunity
- non-infectious
- high mortality in vulnerable (children, elderly)
- often outside lung
- HIV coinfection

*Post-primary:*
- with pre-existing immunity
- infectious
- forms cavities in lungs
- young adults
- immunocompetent immune system

Outline the diagnosis of Tb

*Sputum*- PCR, culture

*CXR*- segmental/lobar consolidation, hilar or mediastinal lymphadenopathy, pleural effusion

*Inflammatory markers*- ESR, CRP

*Histology*- granuloma, caseation, histocytes, giant cells, lymphocytes

Outline the treatment of Tb

4 antibiotics for 2-4 months intensive

Rifampicin
Isoniazid
Pyrazinamide
Ethambutol

What is sarcoidosis? Who does it affect?

A multisystem granulomatous disorder of unknown cause

Highest prevalence in Northern Europe

Adults 20-40yrs

Caucasians

HLA-DRB1 + DBQ1 alleles

Outline the clinical features of sarcoidosis

Fever

Erythema nodosum

Polyarthralgia

Bilateral hilar lymphadenopathy

Dry cough

Dyspnoea

Low exercise tolerance

Chest pain

Red eyes

Thirst, polyuria (hypercalcaemia)

Skin lesions

How is sarcoidosis diagnosed?

Bloods: high ESR, lymphopenia, high Ca2+, high Ig,

Biopsy: non-caseating granuloma

Bone XR: 'punched out' lesions in distal phalanges

Why do oxygen prescriptions need to be monitored?

Oxygen toxicity leads to free radicals

:. seizures + unconsciousness

Also results in constriction of pulmonary circulation

What's the O2 saturation target for COPD patients?

88-92%

What's the general O2 saturation target?

Above 94%

Briefly outline the 4 ways O2 is administered

***Venturi mask:*** delivers fixed O2 concentration

5-10 L/min, 35-60% FIO2, type 1 resp failure

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***Non-rebreather reservoir bag:*** critical/trauma patients, 70-80% FIO2, effecting for short term treatment

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***Nasal cannulae:*** 2-5L/min, 24-50% FIO2, suitable for most patients with type 1 and 2 resp failure, comfortable

What is humidified O2 and when is it prescribed?

Reduces dryness in upper airways

Should be humidified if O2 is being delivered for more than 24hrs

How does the BTS classify acute asthma?

Life-threatening asthma mnemonic

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==**33, 92 CHEST:**==

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PEFR **

Define a pneumothorax

Air in the pleural space leading to lung collapse

Outline the different types of pneumothoraxes

**Spontaneous:** primary (normal lung) or secondary to pre-existing lung disease

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**Non-spontaneous:** traumatic or iatrogenic

Diagnosis?

Large left pneumothorax

Diagnosis?

Outline the causes of secondary pneumothorax

Outline the symptoms of pneumothorax

**Sudden** onset/ acute

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Pleuritic chest pain

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SOB

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Cough

Outline the differentials of pneumothorax

==Respiratory==- __PE__, pneumonia, acute exacerbation of respiratory disease

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%%Cardiovascular%%- __ACS, MI__, pericarditis, aortic dissection, aneurysm rupture, cardiac tamponade

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Other- MSK, GORD, panic attack

Outline the signs of pneumothorax

**Reduced** expansion

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**Hyper-resonant** percussion

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**Quiet** breath sounds

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Tachycardia

Outline the management of a pneumothorax

A-E assessment

History and examination

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Where is the safe triangle?

Location used when aspirating pneumothorax

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Needle inserted right above rib to avoid neurovascular bundle

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Boundaries: latissimus dorsi, pec major, line superior to nipple + apex at axilla

Describe tension pneumothorax

Increasing pressure in thoracic cavity

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Hole in visceral pleura is letting air in on inspiration

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On breathing out, air isn’t being let out :. one-way valve

Outline the clinical features of tension pneumothorax

Severe breathlessness

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Tachycardia

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Pulsus paradoxus (exaggerated fall in systolic pressure during inspiration >10mm/Hg)

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Distended jugular veins

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Tracheal deviation (AWAY)

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Ipsilateral reduced/absent breath sounds

Outline the emergency management of a tension pneumothorax

No CXR

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Needle decompression

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Large bore cannula in MCL 2nd ICS

Advice to prevent recurrence of pneumothorax

No diving

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Stop smoking

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No aeroplane travel for 2-6 weeks

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Pregnancy can increase risk

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Return immediately if SOB

Epidemiology of PE

Outline the risk factors for VTE- major and non major

Outline the clinical features of a minor PE

**Symptoms:**

* May be asymptomatic
* SOB
* Pleuritic chest pain
* Haemoptysis

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**Signs:**

* Tachypnoea
* Low grade fever
* Sinus tachycardia or new AF
* Hypoxia
* Localised pleural rub
* DVT

Outline the clinical features of a massive PE

Hypotension

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Collapse

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Cardiac arrest

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Sudden death

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Hypoxia

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Acute right heart strain

* loud P2, wide splitting of 2nd heart sound, gallop rhythm, tricuspid regurgitation

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RHF

* low cardiac output, raised JVP, low BP

Outline the diagnostic tests for PE

Describe the Well’s score for PE

How does a PE present on a CXR?

Usually normal

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May be signs of:

* pulmonary hypertension (enlarged vessels)
* pleural effusions
* Westermark’s sign- focal hyperlucency
* Hampton’s hump- wedge-shaped infarcts

How does PE present on an ECG?

Non-specific ST and T wave abnormalities

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Sinus tachycardia

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New AF

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Right axis deviation

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RBB

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S1Q3T3 (large S wave in lead I, Q wave in III, inverted T in III- classic cor pulmonale presentation)

When is a V/Q scan indicated in suspected PE?

Only used if:

* normal CXR
* no concurrent symptomatic CVD
* inconsistent with clinical suspicion

How is PE managed in pregnancy?

Well’s score and D-dimer unhelpful

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1. Start LMWH (continue for 6 wks postnatal)
2. CXR (with lead protection for foetus)
3. ECG
4. Bilateral leg ultrasound
5. Half-dose VQ scan

Outline the general management of PE

LMWH or fondaparinux or UFH

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If major PE:

* open pulmonary embolectomy (surgical removal)
* IVC filter (traps fragmented thromboemboli on way to pulmonary circulation)

Briefly outline the features of the different types of lung cancer

Small cell lung cancer (SCLC)- 10%

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Non small cell lung cancer (NSCLC)

* Squamous cell carcinoma 20-30%
* adenocarcinoma 40-50%
* large cell carcinoma 10-15%

Outline the staging and diagnostic investigations of lung cancer

* staging CT of chest and upper abdomen
* blood tests
* bronchoscopy
* CT guided biopsy
* PET scan
* MRI scan for Pancoast tumours
* bone scan
* brain CT/MRI

Describe the TNM staging of lung cancer

List the treatment options for lung cancer

1. ==Surgical== (for localised tumours that have not metastasised)

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2. ==Radical Radiotherapy== (useful in squamous cell carcinoma where surgery is not possible)

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3. ==Palliative Radiotherapy== (to relieve symptoms)

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4. ==Chemotherapy or immunotherapy==

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5. ==Adjuvant/neo-adjuvant chemotherapy== (chemo given __after surgery__ to reduce recurrence OR chemo given __before surgery__ to ensure cancer is well controlled)

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6. Other ==palliative measures== and counselling

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List the paraneoplastic syndromes of SCLC

Outline the paraneoplastic features of squamous cell carcinoma

1. PTH- related protein secretion causing hypercalcaemia
2. clubbing
3. hypertrophic pulmonary osteoarthropathy (HPOA)


1. proliferative periostitis affecting long bones
4. hyperthyroidism due to ectopic TSH

Outline the paraneoplastic features of adenocarcinoma

1. gynaecomastia
2. hypertrophic pulmonary osteoarthropathy (HPOA)

Define Type 1 RF

A partial pressure of oxygen below 8 kPa

Define Type 2 RF

A partial pressure of O2 below 8 kPa

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AND PaCO2 greater than 6.5 kPa

Describe the mechanisms of hypoxia

**Hypoventilation** (asthma, COPD, motor neurone disease, obesity)

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**Diffusion abnormality** (pulmonary fibrosis, sarcoidosis, COPD)

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**V/Q mismatch** (lobar pneumonia, asthma, PE, pneumothorax)

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**Right to left cardiac shunt** (patent truncus arteriosus)

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**Low inspired O2** (high altitude, air-flight)

Describe LTOT

Describe CPAP

Define Obstructive Sleep Apnoea

Repetitive episodes of partial or complete upper airway obstruction during sleep

Outline the details needed in a sleep history for OSA

How is the severity of OSA assessed?

AHI

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RDI

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Epworth Sleepiness Scale (OSA= score >10/24)

Outline the treatment options for OSA

Weight loss

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CPAP (for moderate-severe OSA)

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Avoiding alcohol and sedatives

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Non-supine sleep

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Tonsillectomy

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Mandibular advancement splints

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Maxillofacial splints

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Treat underlying cause e.g. Cushing’s

Briefly outline the steps in asthma management (adults)

1. Newly diagnosed→ SABA
2. Not controlled or more symptoms→ SABA + low dose ICS
3. SABA + low dose ICS + LTRA
4. SABA + low dose ICS + LABA
5. SABA +/- LTRA


1. switch ICS/LABA for maintenance and reliever therapy (includes ICS)
6. SABA +/- LTRA + medium dose ICS MART
7. SABA +/- LTRA plus one of


1. high dose ICS
2. LAMA or theophylline
3. seek specialist advice

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Describe bronchiectasis and its causes

Permanent __dilatation of the airways__ secondary to chronic infection or inflammation

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**Causes:**

* post-infective e.g. Tb, measles, pertussis, pneumonia
* CF
* bronchial obstruction e.g. lung cancer, foreign body
* immune deficiency e.g. selective IgA, hypogammaglobulinemia

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ECG showing tramlines (bronchial wall thickening), prominent in left lower zone

List the causes of upper zone fibrosis

Fine inspiratory crackles on auscultation

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==**CHART**==

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**C**oal worker’s pneumoconiosis

**H**istiocytosis/ hypersensitivity pneumonitis

**A**nkylosing spondylitis

**R**adiotherapy

**T**b

**S**ilicosis/ sarcoidosis

List the causes of lower zone fibrosis

==**I Don’t Care Actually**==

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**I**PF

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**D**rug-induced e.g. amiodarone, methotrexate

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**C**onnective tissue disorders e.g. systemic lupus erythematous (SLE)

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**A**sbestosis

List 3 consequences of OSA

Daytime somnolence

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Compensated respiratory acidosis

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Hypertension

Name the most likely causative agent of an infective exacerbation of COPD

Haemophilus influenzae

Outline the inhaler technique guideline recommended by the BTS

1. Remove cap and shake

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2. Breathe out gently

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3. Put mouthpiece in mouth and as you begin to breathe in, which should be slow and deep, press canister down and continue to inhale steadily and deeply

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4. Hold breath for 10 seconds, or as long as is comfortable

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5. For a second dose wait for approximately 30 seconds before repeating steps 1-4

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Only use the device for the number of doses on the label, then start a new inhaler.

Briefly outline the management of low-severity CAP

==**Amoxicillin**== first-line

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If penicillin allergic, then use macrolide (erythromycin) or tetracycline

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**5 day course** of antibiotics

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Repeat CXR at 6wks

Briefly outline the management of moderate and high-severity CAP

==**Dual antibiotic therapy**== with amoxicillin and a macrolide

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**7-10 day course**

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NICE recommend considering beta-lactamase stable penicillin such as **co-amoxiclav, ceftriaxone or piperacillin with tazobactam and a macrolide** in high-severity CAP

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Repeat CXR at 6wks

List the indications for a chest drain insertion

(Tube inserted into pleural cavity which creates a one-way valve, allowing movement of air or liquid out)

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* pleural effusion
* pneumothorax not suitable for conservative management or aspiration (therapeutic and diagnostic)
* empyema
* haemothorax
* haemopneumothorax
* chylothorax (accumulation of lymph from GIT in lungs)

List the contraindications of a chest drain insertion

* **INR > 1.3** (greater risk of bleeding and complications)
* platelet count

Outline the staging of COPD

1. Mild: FEV1 >80%
2. Moderate: FEV1 50-79%
3. Severe: FEV1 30-49%
4. Very severe: FEV1

Outline the LTOT criteria for COPD patients

lungS POP

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Secondary polycythaemia

Peripheral oedema

Oxygen 7.3-8

Pulmonary hypertension

Describe bronchiectasis and what its most common organism is

==**Permanent dilatation of airways**== secondary to chronic infection

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Commonly caused by **Haemophilus influenzae**