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50 Cards in this Set
- Front
- Back
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What is honeycombing? and when do you see it? |
Honeycombing refers to the computed tomographic (CT) manifestation of diffuse pulmonary fibrosis (usual interstitial pneumonia). CT demonstrates clustered cystic air spaces (between 0.3-1.0 cm in diameter), which are usually subpleural and basal in distribution. Honeycombing is an irreversible finding in interstitial lung disease and associated with a poor prognosis.Differential diagnosisair-space consolidation in the presence of pulmonary emphysema can mimic this appearance. |
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What are the pneumoconioses? |
The pneumoconioses are a group of interstitial lung diseases caused by the inhalation of certain dusts and the lung tissue’s reaction to the dust. The principal cause of the pneumoconioses is work-place exposure; environmental exposures have rarely given rise to these diseases.The primary pneumoconioses are asbestosis, silicosis, and coal workers’ pneumoconiosis. As their names imply, they are caused by inhalation of asbestos fibers, silica dust, and coal mine dust. |
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What is asbestosis? |
Asbestosis is a chronic inflammatory and fibrotic medical condition affecting the parenchymal tissue of the lungs caused by the inhalation and retention of asbestos fibers. It usually occurs after high intensity and/or long-term exposure to asbestos (particularly in those individuals working on the production or end-use of products containing asbestos) and is therefore regarded as an occupational lung disease. People with extensive occupational exposure to the mining, manufacturing, handling, or removal of asbestos are at risk of developing asbestosis. Sufferers may experience severe dyspnea (shortness of breath) and are at an increased risk for certain malignancies, including lung cancer and, less commonly, mesothelioma. Asbestosis specifically refers to interstitial (parenchymal) fibrosis from asbestos, and not pleural fibrosis or plaquing. Asbestos exposure may cause: Benign disease: pleural plaques, pleural thickening, benign pleural effusions Interstitial lung disease: asbestosis Malignant disease: particularly mesothelioma and lung cancer |
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What is Pickwickian syndrome? |
= Obesity Hypoventilation Syndrome Often presents with early morning headaches and daytime somnolence as a result of nocturnal hypoventilation, hypercapnia and intermittent episodes of sleep apnoea and waking. Patients classically have episodes of snoring followed by episodes of upper airway obstruction and apnoea. They should be encouraged to lose weight and may benefit from non-invasive ventilation at night which maintains the patency of the upper airway and thus oxygenation, whilst avoiding the apnoea and hypercapnia. |
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What symptoms would be suggestive of an atypical pneumonia? |
- dry, non-productive cough - type 1 respiratory failure - hyponatraemia - mild renal impairment This picture is highly suggestive of an atypical pneumonia and in particular, Legionella pneumophila infection The diagnosis would be confirmed by the presence of urinary antigens. Atypical pneumonia caused by M.Pneumoniae and Legionella Pneumophilia can be associated with multi-systemic involvement e.g. renal impairment, haemolytic anaemia, hepatitis and hyponatraemia with SIADH. Both strains are sensitive to the macrolide group of antibiotics. Radiographic presentations are not usually as remarkable as clinical presentations. |
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What are the important ‘giveaway’ signs of idiopathic pulmonary fibrosis? |
- finger clubbing - restrictive pattern on spirometry - type 1 respiratory failure intitially, but over time a more diffuse fibrotic picture and subsequent type II failure. Investigations required = HRCT - high resolution CT thorax |
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What is the classic appearance of pulmonary oedema on chest radiograph? |
bat wing appearance |
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What are the similarities in presentation between pulmonary oedema and pulmonary embolism? |
Both present with type 1 respiratory failure and metabolic (lactic) acidosis due to tissue hypoxia. Also present with hypotension (although pulmonary oedema initially presents as a hypertensive emergency) |
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What are the features of squamous cell carcinoma? |
- cavitating lung lesion - central location - hypercalcaemia (parathyroid type hormone secretion) |
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Which type of lung cancer most commonly cavities? |
- squamous cell carcinoma |
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What is 1 pack year? |
Smoked 1 pack (20 cigarettes) every day for 1 year |
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What would cause a tracheal shift towards the problem? |
1) spontaneous pneumothorax (collapsed lung, such as one caused by a bleb) 2) pneumonectomy (lung removed) - tracheal shift toward the problem |
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What respiratory problem would cause no movement of trachea? |
1) pulmonary consolidation (pneumonia, pulmonary oedema) 2) mesothelioma |
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What would cause a tracheal shift away from the problem? |
1) pleural effusion - fluid buildup in the pleural cavity surrounding one area of the lung 2) haemothorax - buildup of blood in area of the lung 3) tension pneumothorax - accumulation of air in the pleural sac; air can get into the sac but not out. The increased pressure may push trachea away from the problem |
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What is the definition of sepsis? |
Sepsis is defined as SIRS in response to a proven or presumed infection. The mortality rate = ~10% SIRS (systemic inflammatory response syndrome) requires at least 2 of the following: - body temperature less than 36 or greater than 38.3 - heart rate greater than 90/min - respiratory rate greater than 20 breaths per minute - blood glucose >7.7 mmol/L in the absence of known diabetes - white cell count less than 4 or greater than 12 SIRS may occur as a result of an infection (bacterial, viral or fungal) or in response to a non-infective inflammatory cause, for example burns or pancreatitis. |
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What are red flag signs in regards to Sepsis? |
- recommended to start the ‘sepsis six’ if any of the following ‘red flag signs’ are present: - systolic blood pressure <90 mmHg or >40 mmHg fall from baseline - mean arterial pressure <65 mmHg - heart rate >131 per minute - respiratory rate >25 per minute - AVPU = V, P or U |
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What is severe sepsis and septic shock? |
severe sepsis = sepsis with end organ dysfunction or hypo perfusion (indicated by hypotension, lactic acidosis or decreased urine output or others) septic shock = severe sepsis with persistently low blood pressure which has failed to respond to the administration of intravenous fluids |
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What is the management of a patient with sepsis? |
If any of the red flags are present, the ‘sepsis six’ should be started straight away: 1) Administer high flow oxygen 2) Take blood cultures 3) Give broad spectrum antibiotics 4) Give intravenous fluid challenges 5) Measure serum lactate and haemoglobin 6) Measure accurate hourly urine output |
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What are some examples of obstructive lung diseases? |
- asthma - COPD - bronchiectasis |
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What are some examples of restrictive lung diseases? |
- pulmonary fibrosis - asbestosis - sarcoidosis - acute respiratory distress syndrome - infant respiratory distress syndrome - kyphoscoliosis - neuromuscular disorders |
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What is the normal FEV1/FVC ratio? |
normal = >75% (~80) a ratio of <70% implies obstructive disease |
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What is idiopathic pulmonary fibrosis? |
IPF (previously termed cryptogenic fibrosing alveolitis) is a chronic lung condition characterised by progressive fibrosis of the interstitium of the lungs. Whilst there are many causes of lung fibrosis (e.g. medications, connective tissue disease, asbestos) the term IF is reserved when no underlying cause exists. IPF is typically seen in patients aged 50-70 years and is twice as common in men. |
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What are the features of idiopathic pulmonary fibrosis? |
IPF is typically seen in patients aged 50-70 years and is twice as common in men. Features: - progressive exertional dyspnoea - bibasal crackles on auscultation - dry cough - clubbing |
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How do you diagnose idiopathic pulmonary fibrosis? |
- spirometry - classically a restrictive picture (FEV1 normal/decreased, FVC decreased, FEV1/FVC increased) - impaired gas exchange: reduced transfer factor (TLCO) - imaging - bilateral interstitial shadowing (typically small, irregular, peripheral opacities - ‘ground-glass’ later progressing to ‘honeycombing’) may be seen on a chest x-ray but CT is the Ix of choice and required for diagnosis - ANA positive in 30%, rheumatoid factor positive in 10% (does not mean the fibrosis is secondary to a connective tissue disease) |
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What is the management and prognosis of idiopathic pulmonary fibrosis? |
prognosis = poor, average life expectancy is around 3-4 years Management = pulmonary rehabilitation - some evidence that pirfenidone (an antifibrotic agent) may be useful in selected patients - many patients will require supplementary oxygen and eventually a lung transplant |
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How do you calculate someone’s pack year in terms of cigarettes? |
Divide the number of cigarettes smoked per dayby 20 (the number of cigarettes in a pack) – Then multiply by the number of years smoked |
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What is the lower threshold of risk of smoking in terms of pack years? |
5 below 5 pack years - risk of extra risk of lung cancer from smoking is very small (i.e. 20 cigarettes a day for 5 years, 10 a day for 10 years, 5 a day for 20 years etc.) |
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If there is a “white-out” of a hemithorax, and the trachea is pulled towards the white out, what is the cause? |
- pneumonectomy - complete lung collapse e.g. endobronchial intubation - pulmonary hypoplasia |
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If there is a “white-out” of a hemithorax, and the trachea is central, what is the cause? |
- consolidation - pulmonary oedema (usually bilateral) - mesothelioma |
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If there is a “white-out” of a hemithorax, and the trachea is pushed away from the white out, what is the cause? |
- pleural effusion - diaphragmatic hernia - large thoracic mass |
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What are the grades in the modified MRC scale for breathlessness? |
Grade O No breathlessness except with strenuous exercise Grade 1 Breathlessness when hurrying on the level or walking up a slight hill Grade 2 Walks slower than contemporaries on level ground due to breathlessness, or has to stop for own breath when walking at own pace Grade 3 Stops for breath after walking about 100m or after a few minutes on level ground Grade 4 Too breathless to leave the house, or breathless when dressing or undressing |
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What is the most important intervention in patients with COPD? |
- smoking cessation. |
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What factors may improve survival in patients withs stable COPD? |
- smoking cessation - the most important intervention in patients who are still smoking - long term oxygen therapy in patients who fit criteria (hypoxic patients) - lung volume reduction surgery in selected patients |
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What is the general management of a patient with COPD? |
- smoking cessation advice - annual influenza vaccination - one-off pneumococcal vaccination |
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What is the treatment of COPD? (bronchodilator therapy) |
1st line- a short acting beta-2 agonist (SABA) or short-acting muscarinic antagonist (SAMA) For patients, who remain breathless or have exacerbations despite using short acting bronchodilators the next step is determined by the FEV1 FEV1>50% - long-acting beta-2 agonist (LABA) e.g. salmeterol OR - long-acting muscarinic antagonist (LAMA), e.g. tiotropium FEV1 <50% - LABA + inhaled corticosteroid in a combination inhaler OR - LAMA For patients with persistent exacerbations or breathlessness: - if taking a LABA then switch to a LABA + ICS combination inhaler - otherwise give a LAMA and a LABA + ICS combination inhaler - oral theophylline is only recommended after trials of short and long-acting bronchodilators or to people who cannot use inhaled therapy - mucolytics - should be ‘considered’ in patients with a chronic productive cough and continued if symptoms improve |
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What are the typical causative pathogens that result in infective endocarditis? |
Typical microorganism consistent with IE from 2 separate blood cultures, : • viridans streptococci, Streptococcus bovis or • community-acquired Staphylococcus aureus or enterococci |
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1st step in a spontaneous pneumothorax (no tension) |
Needle aspiration should be performed under sterile conditions. A large-bore cannula is inserted into the second intercostal space, mid-clavicular line, and the air is aspirated to dryness. If this is successful, the patient is discharged with X-ray follow-up |
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Patient hit by car; decreased air entry into the left chest with a resonant percussion note and evidence of mediastinal shift to the right. 1st step? |
Immediate needle thoracocentesis. This is an emergency as the patient has evidence of a tension pneumothorax. Air will hiss out under pressure through the cannula. After this immediate treatment, a chest drain must be inserted. |
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Patient stabbed in the right chest; he is breathless and has evidence of a simple pneumothorax. 1st step? |
Chest drain in fifth intercostal space, mid-axillary line. Unlike a spontaneous pneumothorax, needle aspiration is not recommended in trauma. A chest drain should be inserted. The recommended site is in the fifth intercostal space, mid-axillary line. |
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Large sponaneous pneumothorax; 5 litres of air are aspirated but the chest x-ray is unchanged. Next step? |
Chest drain in the fifth intercostal space, mid-axillary line. Aspiration has failed and the next step is a chest drain. |
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Man has been impaled by a spike through his right chest; he removed the spike but now has a hole in his chest wall through which air is seen to pass. Next step? |
Chest drain in fifth intercostal space, mid-axillary line. This is an open pneumothorax. The initial management is a dressing taped on three sides over the hole to act as a valve and only let air out. A chest drain should be inserted (not through the wound) and then the wound can be closed. |
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small spontaneous pneumothorax; pain but not breathless. Next step? |
No itnervention except regular X-ray. Nothing to be gained from aspiration, and he should just be monitored as an out-patient with x-rays. Advise not to fly or dive and to return if the situation deteriorates. A chest x-ray should be performed at 48hours or sooner if he returns with increasing symptoms. |
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What type of asbestos is the most likely to produce asbestosis and mesotheloma? |
crocidolite |
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What might ahistory of shortness of breath and a chest x-ray revealing reticulo-nodular shadowing point to? |
Pulmonary fibrosis. This condition has many causes including: - exposure to inorganic dusts e.g. asbestosis, beryllium (commonly used in the aerospace industry) - organic dusts e.g. mould hay, avian protein - drugs e.g. nitrofurantoin, sulphasalazine, penicillamine, amiodarone, methotrexate - systemic disease e.g. systemic sclerosis, systemic lupus erythematosus, ankylosing spondylitis, Sjogren’s syndrome, rheumatoid arthritis, vasculitis, sarcoidsosis, lymphoma. NSAIDs are not linked to pulmonary fibrosis |
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What are some features that would strongly suggest Legionella infection? |
- recent foreign travel - flu-like symptoms - hyponatraemia - pleural effusion |
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What are the flu-symptoms? |
Flu can give you any of the following symptoms:a sudden fever – a temperature of 38C (100.4F) or abovea dry, - - chesty cough - a headache - tiredness and weakness - chills - aching muscles - limb or joint pain - diarrhoea or abdominal (tummy) pain - nausea and vomiting - a sore throat - a runny or blocked nose - sneezing - loss of appetite - difficulty sleeping |
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What is Legionella and what are the features of it? |
Legionnaire’s disease is caused by the intracellular bacterium Legionella pneumophilia. It typically colonizes water tanks and hence questions may hint at air conditioning systems or foreign holidays. Person-to-person transmission is not seen. Features - flu-like symptoms including fever (present in >95% of patients) - dry cough - relative bradycardia - confusion - lymphopaenia - hyponatraemia - deranged liver function tests - pleural effusion: seen in around 30% of patients |
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How do you diagnose Legionella and what is the treatment? |
Diagnosis: urinary antigen Management: - treat with erythromycin |
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How do you treat an acute exacerbation of COPD? |
Non-invasive ventilation. Doxapram is a respiratory stimulant which may be used if the patient is not suitable for non-invasive ventilation. |
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What are the causes of transudate pleural effusions. |
Transudates have a protein level of <30 but if the pleural fluid protein is between 25 and 35 , Light’s criteria should be applied. Transudates are largely caused by ‘systemic’ illnesses, whereas exudates tend to be due to local causes. Transudate causes can be remembered by the word FAILURE - cardiac failure - renal failure - liver failure - endocrine failure (hypothyroidism) - nutritional failure (hypoalbuminaemia) |
