Respiratory

Asthma Bronchiectasis Consolidation COPD Cor Pulmonale and Pleural Rub Cystic Fibrosis Fibrosing Alveolitis Lung Cancer Old TB Pickwickian Syndrome Pleural Effusion Pneumothorax

THE ILLUSTRATED MRCP PACES PRIMER

Asthma
Wheeze differential
COPD LVF PAN Tumour Eosinophilic lung disease

Management of chronic asthma

Step 1. Occasional short acting Step 2. Short acting and steroid Step 3. Short acting + increase steroid or short acting + add long acting beta2 Step 4. Add other alternatives Step 5. Add oral steroid

Extrinsic asthma (kids) (Dermatophagoides pteronyssinus) Intrinsic asthma (late onset) Smoking related more severe and continuous

Chronic asthma
Wheeze Cough SOB

Diagnosis
PEFR >25% variable PEFR + FEV1 inc post neb Dec FEV1 Dec FEV1/ FVC ratio (<70%) Gas trapping

Triggers
Infection Emotion Exercise Drugs

Acute asthma
Severe H R >110 A BG pO2 <8 R R >25 P EFR <50% Life threatening PEFR <33% Exhaustion Bradycardia/ hypotension

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Bronchiectasis
(= chronic necrotising infection)

Types (Reids classification)

1. Cylindrical 2. Varicose 3. Cystic/ saccular Tests: CXR/ HRCT/ sputum culture Aetiology testing

Haemoptysis

Complications
Clubbing Sinusitis Haemoptysis Brain abscess Amyloidosis Effusion Pneumothorax Pneumonia

Bilateral coarse and end insp crackles coarse bronchiectasis. They clear with coughing

Causes
Congenital CF Kartageners Youngs Post-infective TB/ HIV Measles Pertussis Pneumonia ABPA Other Sarcoid Aspiration Hypogammaglob Idiopathic

Management
P hysio A ntibiotics B ronchodilator S urgery if restricted to a single lobe

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THE ILLUSTRATED MRCP PACES PRIMER

Consolidation
Causes of pneumonia
Community Typical S. pneumo H. influenzae Hospital Atypical Chlamydia pneumo Mycoplasma pneumo Legionella pneumo Chlamydia psittacii

Poor prognosis signs

Confusion and comorbidities Urea >7 RR >30 BP Sys <90/ Dias <60 Age >65

Extrapulmonary manifestations of mycoplasma

CNS/ PNS problems

DIC Pericarditis/ myocarditis

Hepatitis Haemolytic anaemia

Dec movement of affected side Bronchial BS (bronchial) Crackles ( ) Dec PN not stony dull (THUD)

Glomerulonephritis

Causes of recurrent pneumonia

Aspiration Antibiotics Cancer ChurgStrauss

Pulmonary eosinophilic disorders

Lfflers ABPA Chronic pulmonary eosinophilia

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COPD
(3 months cough/ year for 2+ years a combination of chronic bronchitis and emphysema)

Genetics in COPD
1. Alpha1 antitrypsin deficiency 2. TNF-alpha 3. Microsomal epoxide hydroxylase

Cricosternal distance <3 finger breadths

Classification
Mild FEV1 6080% Mod FEV1 4060% Sev FEV1 <40%

O BO

Hyperresonant (and loss of cardiac dullness) Decreased cricothyroid distance Decreased air entry

Treatment
Nebulisers/ inhalers/ O2 / antibiotics

Other treatments
Nutrition (diet high in n-3 fatty acids) Bullectomy: COPD with >1/3 of hemithorax taken up Lung transplantation: <60 yrs with no underlying systemic probs or cancer Lung volume reduction surgery

Long term O2 therapy

pO2 on air <7.3 pO2 7.38 with portal hypertension/ peripheral oedema/ nocturnal hypoxaemia FEV1 <1.5 L Normal or increased pCO2

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THE ILLUSTRATED MRCP PACES PRIMER

Cor Pulmonale
Mortality 50% at 5 years

Treatment
H E A V E P2 Click

Careful O2 Frusemide Venesect if HCT >55%

Heave/ raised JVP/ pansystolic murmur/ loud P2 Hepatomegaly and pedal oedema

Causes
Both obstructive and restrictive respiratory disease Pulmonary vascular disease

Pleural Rub
Causes
PE Infection RUB

Like shoes in the snow Doesnt clear on coughing Painful

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Cystic Fibrosis
7
RIP aged 30 from respiratory complications as predicted by FEV1 <30% gives 2 year survival

Delta 508 mutation

Clubbing

Bibasal creps

Cyanosis

Treatment
Physio Antibiotics Bronchodilators Heart-lung transplantation High dose ibuprofen Aerosolised human recombinant DNase Improve hydration of secretions with amiloride, triphosphate nucleotide Immunisation

Treatment of steatorrhoea
Low fat diet Pancreatic supplement H2 receptor antagonist

Chest infection bacteria

S. aureus H. influenzae Burkholderia cepaciae Pseudomonas aeruginosa

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THE ILLUSTRATED MRCP PACES PRIMER

Fibrosing Alveolitis
Types
UIP DIP NSIP LIP GIP usual desquamative non-specific lymphoid giant-cell

Causes
RA/ SLE/ UC/ CAH/ SS/ dermatomyositis EAA Chronic pulmonary oedema Occupational lung disease

Investigations
CXR/ ABG/ PFT/ HRCT Inc ESR/ Inc Ig/ Inc ANA/ RF BAL: Lymphocytic = good prognosis

Features

Treatment
6/52 steroids Cyclophosphamide for steroid non-responders Lung transplantation has a 60% 1 year survival

Finger clubbing Cyanosis Bilateral fine late inspiratory creps (velcro)

Clubbing and creps differential

Bronchogenic Ca Bronchiectasis Asbestosis Fibrosing alveolitis Lymphocytosis Little fibrosis

Prognostic factors
Young Female Predominantly ground glass changes Little fibrosis Predom lymphocytosis

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Lung Cancer
Extrapulmonary
Gynaecomastia TSH raised PTH raised

Lung cancer types

Squamous (SQ) and small cell (SM) central Adenocarcinoma (AD) peripheral

Treatment
Small cell chemotx Non-small cell surgery/radiotx

Extrapulmonary
SiADH Carcinoid ACTH EatonLambert

General extrapulmonary manifestations of lung cancers

CVS AF Pericarditis Marantic endocarditis Endocrine As above Skeletal Clubbing HPOA Cutaneous Herpes zoster Dermatomyositis Neuro EatonLambert Neuropathies Horners Cerebellar degeneration Vasc DIC

Inoperable disease
FEV1 <1.5 L Current IHD Malignant pleural effusion Mediastinal LN Carinal involvement

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THE ILLUSTRATED MRCP PACES PRIMER

Old TB
Features
Trachea pulled over May have obvious scar Creps upper zone

Pulmonary TB diagnosis
If sputum positive AFB: isolation for 2 weeks can self isolate at home Investigate contacts by enquiry re BCG/ do CXR/ Heaf test Give chemoprophylaxis if Heaf positive but CXR negative Early TB diagnosis done by PCR

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Pickwickian Syndrome
Features
Sleepy Cyanosed Short of breath Micrognathia possibly

Obese

Right heart failure

Treatment
CPAP Tonsillectomy Correction of GH/ TSH/ Other Weight loss Mandibular surgery Tracheostomy

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THE ILLUSTRATED MRCP PACES PRIMER

Pleural Effusion
Pleural effusion types
Exudate (Serum albumin: pleural gradient >1.2 g/dL = exudate) Lung Ca/ mesothelioma Secondaries (breast/ lung/ ovary/ panc) Pneumonia/ TB RA/ SLE Transudate CCF Liver failure Hypothyroid Nephrotic Empyema Chylous Haemothorax Decreased movement Tracheal deviation to opposite side Stony dull Decreased vocal resonance and breath sounds (sounds travel badly through water)

Investigations
C ytology: white cells >50 000 parapneumonia; Lymph Ca/ TB/ sarcoid/ collagen P rotein/ pH: If pH <7.2 suggests empyema G L ucose: glu/ LDH TB/ Ca/ RA/ SLE; glu or LDH in Ca poor prognosis Chol E sterol: <60 g/dL in transudates U R F: RF and ANA increased in SLE A lbumin/ ANA/ amylase: Boerhaaves/ bact pneumonia / adenoCa/ pan L DH

Use of USS
To differentiate thickening from effusion For drain placement For loculation

Causes of dullness at the lung base

Pleural effusion Pleural thickening Raised right hemidiaphragm Consolidation and collapse

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Pneumothorax
Causes
Spontaneous Trauma Asthma COPD Ca lung CF TB Ventilation Marfans EhlersDanlos

BTS grading
Small (<2 cm rim on CXR) Medium Complete Tension Dec movement affected side Inc PN Deviated trachea Dec breath sounds If hypotensive/ tachycardic = tension

Thoracotomy if ...
a. More than three episodes of spontaneous pneumothorax b. Bilateral pneumothoraces c. Failure of lung to expand after thoracostomy for first episode

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