PNEUMOTHORAX Persistent obstruction of nostrils with
Def Collection of air b/w visceral and parietal pleura sniffing, sneezing, and nasal discharge.
PP 20 000 spontaneous ./ year Allergic Conjunctivitis- redness / swelling,
1 Spontaneous- tall, thin, male, smoker, 20-40 During summer (Hayfever) or throughout the
2 Spontaneous- COPD, male, >40 year (Perennial rhinitis).
1 SPONTANEOUS NB: Most atopic pts have +ve skin tests to
Most common type common allergens (house dust mite, pollen,
Tx recommended after 2nd time animal danders), eosinophilia, IgE.
Med- insertion of Bleomycin / Talc Paeds Moderate if:
- Abrasion of Pleural lining Aged < 2 Audible wheezing
2 SPONTANEOUS Still feeding
Disorders disrupting lung architecture Accessory muscles
Asthma, COPD, TB, Pneumonia, CF, Marfans Sats: >92%
> Serious than Primary due to respiratory reserve Severe if:
TRAUMATIC / IATROGENIC RR 50 / min, HR 140, PF 50% predicted.
Trauma- RTA, Stabbing, Rib Fracture Too breathless to speak / feed.
Iatrogenic- Pleural Aspiration, Bx, Central Line Insert Sats: <92%
… TENSION Life Threatening if:
Air pleural cavity faster than removed PF 50% predicted, Cyanosis, Silent chest,
…leading to mediastinal shift, compression of functioning lung Fatigue / Exhaustion, Agitation / LOC.
… venous return CO Shock DDx Pulmonary oedema, HF, MI, Pneumonia, Bronchiolitis, Acute
S&S Asymptomatic bronchitis, COPD, Hypersensitivity pneumonia, Upper airway
Dyspnoea, Pleuritic Pain, Distended neck veins, obstruction, Pneumothorax, PE, Angiooedema, Anxiety attack
Subcutaneous emphysema (body swelling) PAEDS: Foreign body, Pertussis, Croup, Epiglottitis, Pneumonia,
Chest Expansion, Hyperresonance, Tactile Fremitus, Hyperventilation
Cyanosis, Trachea moving from affected side Inv / General Compatible Hx (+/- atopy)
Breath Sounds Dx Freq of S&S? How affecting child? School
DDx COPD exacerbation, Asthma, Pulmonary Embolus, MI, Pericarditis, missed? Sport N? Sleep disturbed? Longest
Aortic Dissection, MS chest pain, Pleuritis symptom free period?
Inv / CXR (Not for tension due to time) Broncho- Demonstration of airflow obstruction- 15%
Dx Exp film dilator after bronchodilator
Look for pleural line and vasculature PFTs FEV1, TLC, RV
Tracheal deviation PEFR N= 400-600, Mod= 100-300, Sev = <100
ABGs PO2 (PCO2) May be used in children >5.
ECG Tachycardia, T wave inversion CXR Hyperinflation, Exclude Pneumothorax
Tx O2 + Analgesia ABGs (acute) Resp Alkalosis (Due to PCO2)
SMALL CXR in week Severe = PO2
<30% hemithorax Send home if no significant symptoms Tx Attack Tx
MEDIUM Aspirate O2 (Neb) + FBC, ABGs, ECG
>50% hemithorax Check CXR afterwards Salbutamol (Neb) Bronchodilation
LARGE Chest Tube Hydrocortisone/ Prednisolone (IV) Inflammation
TENSION Immediate needle decompression Ipratropium Bromide Muscle spasm
Chest Tube Mg Sulphate Bronchodilation
Antibiotics) If signs of infection
ASTHMA (Aminophylline #...) Bronchoconstriction
Def Chronic airway inflammation characterised by 3 elements: Intubate If still failure to respond
Chronic airway secretions and inflammation NB: Nebulise with O2 for Asthma, with Air for COPD
Bronchial hyperactivity As with any O2 [except*], after starting O2, ABGs / oximetry should be
Reversible airway obstruction repeated adjusting inspired oxygen concentration to achieve PaO2
PP FHx; 7% adults, 15% children; >59mmHg (7.8kPa) / SaO2 > 90%.
Childhood: ♂>♀. Adolescence ♂=♀. *COPD: Hypoxic drive
10-20% Acute Paediatric (1-16) admissions *Premature Infants: Risk of retrolental fibroplasias, which may
15 child deaths / year. blindness. Condition is caused by blood vessels growing
Prevalence if: weight / passive smoking / bottle fed. into vitreous fibrosis. Low birth weight v. premature infant is
Geography: > in NZ, Australia, UK. < in China, Malaysia. at risk 44/52. Level of PaO2 required to retinal damage
Cause TRIGGER FACTORS: unknown, but umbilical PaO2 of 60-90mmHg (8-12kPa) is safe
Extrinsic- Hypersensitivity to allergen: Attack is > severe if # …if failure to respond to
…pollen, dust mites Pulse > 110 bronchodilator: ECG & Electrolyte
Intrinsic- Non immune triggers: RR > 25 monitoring needed since S/Es
…aspirin (10%), pollution, cold, stress, exercise, B- PEFR < ½ Normal include tachycardia. Don’t give if
blockers, infections, smoking, wood dust. Reflux from already taking since narrow T-W.
stomach. Mx Educate Pt: Avoid Triggers, Inh techn, S&S of …Step up Tx:
Path Inhalation of Antigen 2 phase response: Steps 1-3: Aims to Abolish S&S, Permit unrestricted exercise,
Phase 1: Early reaction in minutes (Bronchoconstriction) Prevent exacerbations.
Phase 2: Later reaction- 3-5 hrs (Oedema & Mucous): Steps 4-5: Aims to: Prevent best possible & most stable PEF,
Improve S&S & exercise capacity, Need for bronchodilator
Environmental Factors Genetic Predisposition drug use as far as possible, With < S/E for the drugs used.
STEP 1: MILD INTERMITTENT ASTHMA: All
Bronchial Inflammation B2 agonist: Short acting- Salbutamol- (PRN) (> 3x/52, waking
, exacerbation in last 2 yrs 2)
Bronchial Hyperactivity + TRIGGER FACTORS STEP 2: REGULAR PREVENTER THERAPY: All
(Mast cells [via IgE mech] Histamine + prostaglandins) 1 + Low dose steroid-Beclomethasone (Bd 200mcg adults/ Bd
Bronchoconstriction STEP 3: ADD ON THERAPY: Adults / children > 5
Capillary Permeability (oedema)
(1 ) 1 to B2 agonist: Long acting- Salmetarol (Bd 400mcg
Mucous production adults/ Bd 200mcg children >5 +/- spacer)
(2nd) No response +/- LABA (depending if helping or not) +
Airway narrowing 2 (800mcg, 400mcg / day)
(3rd) Still No response Leukotriene R antagonist /
Symptoms Theophylline / Slow release B2 tabs (Latter: Adults only)
> 2 Leukotriene R antagonist
S&S NORMAL Wheeze, SOB, Cough (Esp ), Tight chest, < 2 Refer
STEP 4: ADDITION OF 4TH DRUG:
SEVERE + Accessory muscles, Hyperinflated chest (if long
Stop 3 + 2 (2000mcg, 800mcg / day) / Leukotriene receptor
standing…Harrison’s sulci, pectus carinatum),
antagonist (esp children < 5) / Theophylline / Slow release B2 tabs
tachypnoic, pulsus paradoxus ( pulse pressure (lat in adults only
on insp), sweating, can’t speak
Refer to Specialist
VERY + Cyanosis, airflow so much no more rhonchi,
STEP 5: ORAL STEROIDS:
SEVERE silent chest, bradycardia
Monitor growth, cataracts.
Atopy S&S Eczema (1/3 children have it at some point)
Allergic rhinitis (1/2 have S&S) – Recurrent /
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COPD 3: Acute on C
Def GENERAL Tx Acute Tx: O SHIDA
Progressive Irreversible airway obstruction (usually due to O2- 24%... Progressively , aiming for PO2 > 50mmHg
smoking). FEV1 is <80 predictive value. (6.6kPa) or SpO2 of 85-90%.
CHRONIC BRONCHITIS Salbutamol Bronchodilator
Coughing up of sputum on most days of at least 3 consecutive Hydrocortisone Inflammation
months for more than 2 successive years (provided other causes Ipratropium* Bronchodilator e.g. Atrovent
have been excluded.) Diuretics (Furosemide + Spironolactone) / ACEi (If
EMPHYSEMA JVP and Oedema present)
Pathological process of a permanent destructive enlargement of the Antibiotics Amoxicillin / Tetracycline
airspaces distal to the terminal bronchioles. Physiotherapy Aids sputum clearance
PP Aminophylline See cautions in CCC- Asthma
Cause Cigarettes-90%, Pollution, Biomass and Solid fuels, Alpha 1 Nasal Ventilation Non Invasive Positive Pressure Ventilation
(NAPPV)- When breath taken, air forced down need pt awake,
Risk: FHx-4.7% if sibling has it. Low birth weight.
non confused. OR Intubate: if reversible cause (pneumonia,
Path Persistent airway inflammation
aspiration). If on ventilator and no reversible and then ventilator
switched off, pt will stop breathing (since relying on O2 to breath).
Hypertrophy of mucous secreting glands
Monitor: Rpt ABGs every 20mins. RR, BP.
Goblet cells + Ciliated cells NB: Nebulise with O2 for Asthma, with Air for COPD
*Combined with S=Combivent
Less efficient transport of the amount of mucous in airways. Mx MANAGEMENT ***FEV1 (% PREDICTED)
Looking to straighten PEFR curve with no morning dips. Everyone
AIRWAY OBSTRUCTION… should have Mx plan: If PEFF , then steroids, then H.
*** Signs & Symptoms Treatment
…Mechanical Obstruction in smaller airways. 100 Healthy Stop smoking
…Loss of pulmonary elastic recoil. 80 Smoker Cough, Little / Tx acute infections
…Loss of alveolar attachments around airways > liable to Dyspnoea, abnormal S&S.
collapse during expiration. 60 Dyspnoea on exertion, Inh Anticholinergic + PRN B2
S&S: (Blue Bloaters: Blue from hypoxia, bloater from ascites -RHF) Cough & Sputum, Some agonist
Main Pc is SOB as opposed to Asthma where the complaint is cough. COPD 50 abnormal S&S. Reg B2 agonist. Flu vacc
patients are used to coughing due to smoking. 40 Dyspnoea on mild exertion, Pulmonary Rehab. ID and
Predominant PINK PUFFERS- BLUE BLOATERS- Hyperinflation & cyanosis, TxObesity, nutrition,
Disease Emphysema Chronic Bronchitis Wheeze & Cough. depression, social isolation
Body Size Thin Obese 20 Death Amb O2 + inh steroids
Hyperinflation Marked + barrel chest Present Comp Bullae (Thin walled air spaces caused by rupture of alveolar
Post mortem Panacinar Centrilobar emphysema walls), Pneumothorax (Rupture of bullae), Respiratory Failure,
finding emphysema Cor Pulmonale
Cor pulmonale Absent Present Prog Inversely related to age
2o Polycythaemia Directly related to post bronchodilator FEV1.
Cyanosis Absent Centrally Poor prognostic conditions: Pulmonary HT, PaCO2 that
Corpulmonale No Yes- oedema reverts to N on recovery (assoc with survival of 3 years).
Dyspnoea Severe Exertional
Cough Productive- esp mornings PNEUMONIAS
due to regen of cilia Df Lower respiratory tract infection associated with
Blood gases PCO2 / N PCO2 Inflammation, Alveolar exudates, Consolidation
Severe: Reflect … P 10% pts admitted to H RISK FACTORS:
I …Pulmonary hyperinflation, hypoxaemia, cor pulmonale, polycythaemia. P Incidence:1-3/1000 Immunosupression
INSPECTION Neurological impairment of cough reflex
C COMMUNITY ACQUIRED (Dysphagia, OH, Epilepsy Aspiration)
F Flapping tremor (Hypercapnia)
1. Strep pneumoniae (65%) Secretion retention
Pursed lip breathing- physiological response to air trapping
A 2. Haemophilus influenzae Pulmonary Oedema
3. Mycoplasma Pneumonia I
Accessory muscles of respiration: Sternomastoid, Scalenes.
U 4. Staphylococcus Aureus Resp Tract Infection
Excavation of Suprasternal fossae, Supraclavicular fossae.
Tracheal tug on inspiration Antibiotics
S Indrawing of Costral margins, Intercostal spaces. S Tracheal instrumentation (Surgery)
AP diameter of chest relative to lateral diameter loss of cardiac HOSPITAL ACQUIRED Impaired alveolar macrophages
E dullness on CXR E 1. Staphylococcus Aureus Other eg Age (Elderly, Children <5)
V Peripheral Oedema (may indicate Cor Pulmonale) Smoking
E Length of trachea palpable above sternal notch
PATHOGENESIS OF HOSPITAL ACQUIRED INFECTION
Bounding pulse (Hypercapnia Peripheral Vasodiliation)
R RV heave
PERCUSSION Hospitalisation Broad Spectrum Consciousness
E Hyperinflation of lungs. ABs (drugs, CVA)
AUSCULTATION Swallowing difficulty,
Rhronchi esp. on forced expiration vomiting
Loud pulmonary second sound Immobility and debility
Tricuspid regurgitation Gram negative bacilli colonise Instrumentation (NG
DDx Respiratory Failure: Asthma, PE, Pnemothorax, LVF, Lung C, nasopharynx tubes)
Upper airway obstruction.
Inv / Dx FBC WCC, Polycythaemia
ECG Rule out MI Aspiration of nasopharyngeal Gastro Oesophageal
ABGs Especially if Sats <92% secretions Aspiration
CXR Diaphragm flat, hyperventilation, prominent
pulmonary a, bullae Cough Reflex (eg.
Not Dx, but excludes other pathology. Infected ventilators / Drugs, pain)
PFTs FEV1 < 80% (Normal FEV1 excludes Dx) nebulisers
Dx Mild 60-80, Mod 40-60, Sev <40 Direct access to lower
FEV1 /VC ratio < 70% respiratory tract Mucociliary
Lung Volumes and FRC (endotracheal / clearance
Sputum Send for culture trachesotomy)
A1 AntiT A1 Antitrypsin Deficiency
Resp F ph PCO2 PO2 HCO3 Pleural effusions as in
1 N N N any pneumonia but
2: Acute N especially Staph aureus
2: Chronic N and Strep pneumoniae
WILL WESTON Page 2 of 8
S&S Haemoptysis, Purulent Sputum, Pleuritic Chest Pain (may be over before Breath Sounds or Absent over Effusion
stomach), Fever, Rigors, Sweating, Chills, Fatigue, Anorexia, N&V PE) Vocal Resonance or Absent over Effusion
May be no sputum if pneumonia is interstitial rather than the > Tracheal Deviation Away from Effusion if large
common bronchial. DDx
Tachypnoea, Chest dull on percussion, Tactile & Vocal fremitus / Inv / Only detected: CXR when volume > 300 ml; Clinically when >500 ml
resonance, Pleural rub, Bronchial Breathing, Cyanosis, Confusion, Dx CXR Effusions (dense uniform opacities) at costophrenic angles
Hypotension, Expansion (sign of consolidation) US Examination for tumours and diaphragm
DDx Asp Pleural Aspiration + Bx (US guided). As well as determining
Inv / CXR Consolidation, Shadowing, Pleural Effusions, protein levels, Test for Glucose, Cytology, Culture. Glucose
Dx Petchy Shadows, Pneumatoceles, Lung Cavitation, may be in RA / SLE / TB / Malignancy.
Lobar / Multilobar More ESR, Amylase, Albumin, TFTs, BC,
FBC WCC ( WCC = poor prognosis) Tx Drain or Repeated Tap (+ CXR to check for iatrogenic
LFTs Legionella / Mycoplasma infection pneumothorax). Don’t’ remove > 1000 ml at one time.
CRP Pleurodesis e.g. Bleomycin if malignant effusion.
ABGs PO2 Mx
Serol Sputum gram stain Comp
RADIOGRAPHIC FEATURES OF PNEUMONIA Def 1 of 3 forms of cardiac dyspnoea (2 others: Angina & CHF)
Diffuse extravascular accumulation of fluid in pulmonary tissues
and air spaces due to changes in hydrostatic forces in
Homogenous Patchy shadows capillaries or to capillary permeability.
(lobar) seen in many PP
consolidation as pneumonias but Cause Capillary LHF: Atrial, e.g. MS; Ventricular, e.g. MI, HT
seen in 80% Strep especially Pressure Pulmonary venous obstruction
Pneumoniae Mycoplasma IV fluid overload, e.g. from blood transfusion
pneumoniae Capillary Pneumonia, DIC, Renal F, ARDS
(50%) Permeability Toxins (inh) e.g. Chlorine, Mustard Gas
Toxins (circ) e.g. Histamine, Septicaemia
Progression of Oncotic Any cause of hypoalbuminaemia e.g. Nephrotic
shadowing to both Pneumatocoeles Pressure Syndrome, Liver Cirrhosis
lungs especially in as seen with Lymphatic Any Obstruction e.g. Tumour,Parasitic Infections
Strep pneumoniae Staph aureus Other Causes ICP, PE, PIH, High Altitude, Heroin OD
and Legionella infection Path In Left ventricular diastolic pressure
LHF Pressure in LA, Pulmonary veins, Pulmonary capillaries.
Pleural effusions Lung cavitation When hydrostatic pressure of pulmonary capillaries > oncotic
as in any often in pressure of plasma (25-30mmHg), fluid moves from capillaries to
pneumonia but pneumonia causes alveoli
especially Staph by Staph aureus
aureus and Strep and aspergillus Vagus nerve and Hering Breuer reflex
Rapid shallow respiration
Tx Admit if > CURB-65: Confusion (Mental Test score < 8), Urea
S&S SOB: Alleviated by sitting upright or standing (reduces
(>7), RR (>30), BP, >65 Years.
congestion at apices of lungs), Orthopnoea, PND.
Unable to speak, distressed, agitated.
Cyanosed, sweaty, pale.
Antibiotics….… Amoxicillin (Community)
Respiration: + Use of accessory muscles.
Antibiotics….… Cefotaxime (Hospital)
IV fluids………..if anorexia / dehydration / shock
Sputum: Profuse, Frothy, Pink / Blood stained.
Extensive crepitations and rhonchi.
Mx PREVENTION: Offer pneumococcal vaccine to those with:
Signs of Right heart failure e.g. JVP
Chronic heart conditions, Lung conditions, Cirrhosis, Cheyne stokes if severe: waxing and waning ventilation,
Nephrosis, Dm, Immunosuppression
sometimes with periods of apnoea, that occur in cycles. Due to
Comp Pleural Effusions, Empyema, Lung Abscesses, Meningitis,
delay in medullary chemoreceptor response to blood gas .
Respiratory F, Septicaemia, Pericarditis, Cholestatic Jaundice
Inv CXR Ground glass appearance: alveolar oedema
Def Fluid in the pleural space
TRANSUDATIVE (Protein content < 25 g / L)
ABGs PaCO2 Due to hyperventilation; Usually a PaO2
Hydrostatic pressure or osmotic pressure
PFTs Not appropriate in emergency: restrictive ventilatory
As seen in Cardiac / Liver / Renal F
impairment: VC and FEV1 in proportion. forced
Ovarian Tumours (Meig’s synrome)
expiratory ratio is N or > than normal.
SVC Obstruction, Cons Pericarditis, Hypothyroidism
Mx SIT UP PATIENT
EXUDATIVE (Protein content > 25 g / L)
O2: High flow 100% (So long as no COPD)
Microvascular permeability due to disease of MORPHINE: Alleviates SOB. Reverses peripheral
pleural surface itself / injury in adjacent lung… vasoconstriction reflex (so long as no COPD)
Infective: Pus / Pneumonia DIURETIC: Furosemide (Vasodilating action)
Inflammatory: TB / SLE / RA / PAN. NITRATE: GTN until clinical improvement or BP by 10mm.
Malignant: Bronchial / Mesothelioma / Myeloma / HL If above Fails:
Misc: Pulmonary Infarct / Pancreatitis / Uraemia. Inotropic agents: To stimulate heart…or
Drugs: Methotrexate, Sulphonamides Vasodilators (more powerful): Left ventricular load.
BILATERAL often occurs in: Cardiac failure, Connective tissue
disorders, Hypoproteinuria. PULMONARY EMBOLISM
CAUSE TYPE OF FLUID PREDOMINANT FLUID CELLS Def Occurs when clot from vein, originating in venous sinuses of calf /
CARDIAC Transudate Few serosal cells femoral vein / pelvis, detaches Lodged in pulmonary arterial tree.
TB Exudates Lymphocytes PP Present in 60-80% with DVT, even though > ½ asymptomatic.
MALIGNANT Exudates (+ Blood) Serosal cells & lymphocytes Third most common cause of death in hospitalized patients
Often clumps of malignant cells Cause
PULMONARY Exudate (rarely RBCs, Eosinophils
INFARCTION transudate) (+/- Blood)
RA Exudates Lymphocytes
SLE Exudates Lymphocytes and serosal cells
PANCREATITIS Exudates (+/- Blood) No cells predominate
S&S Asymptomatic, SOB (related to size), Pleuritic chest pain
Chest Expansion on Affected side
(Often Percussion Stony dullness over Effusion
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CHANGES IN THE VESSEL WALL: ECG Arrhythmias, Bundle BB.
Previous thrombo-embolism PFTs May be N. May show lung volumes, impaired gas
> 40 years transfer and restrictive ventilator defect.
Smoking Bx Dx: Shows noncaseating granulomata (May be
Local trauma taken from lung, liver, lymph nodes, skin nodules,
Obesity lacrimal glands).
Lavage Bronchoalveolar Lavage: Shows lymphocytes
inactive disease. Neutrophils with pulm fibrosis
BLOOD COAGULABILITY BLOOD FLOW / STASIS
Malignancy Surgery US Nephrocalcinosis, Splenomegaly
Oestrogen: Immobility Bone XR: Punched out lesions at terminal phalanges
OCP, HRT Bed rest RadioA Gallium, Thallium Scans may indicate distribution of
Pregnancy Paralysis active granulomata
Blood disorders: Obesity CT/MR Assessing severity of pulmonary disease or
Polycythaemia Cardiac failure neurosarcoidosis.
Thrombocythaemia Dehydration Opthal Slit lamp / Flurescein angiography in ocular disease.
Anti-phospholipid syndrome Mx BHL needs no Tx as most recover spontaneously.
Acute: Bed rest, NSAIDS, Corticosteroids.
S&S SOB, Pleuritic Chest Pain, Haemoptysis, Dizziness, Syncope Indications for corticosteroid Tx: Parenchymal Lung disease,
Right Ventricular Strain: JVP, Central Cyanosis, RV heave, Uveitis, Hypercalcaemia, Neurological / Cardiac involvement.
Tachycardia, Hypotension, AF Prog 60%: Pts with thoracic sarcoidosis spontaneous resolution
Pleural effusion: AE, Crackles; Pyrexia, Pleural Rub within 2 years. 20%: Respond steroid Tx. 20%: Improvement.
DDx CHF, Aortic dissection, Pericarditis, Cardiac Tamponade, Pneumonia, Likelihood of regression for pulmonary disease correlates with
Bronchitis, COPD, Asthma, Pleural Effusions, Pneumothorax, MS extent of parenchymal disease, as noted by CXR stage.
Chest pain, Anxiety, GORD
Inv / FBC HB? Need to know if anticoagulant Tx TUBERCULOSIS
Dx Platelets: clotting? Def Disease caused by infection with mycobacterium tuberculosis
WBC: Cellulitis? PP WORLDWIDE: 1.7 B infections, and 2M deaths / year.
U&E PREVALENCE: Countries of Asia e.g. India, China, Indonesia,
CXR Dilated pulmonary A, small pleural effusions, Pakistan and Bangladesh have largest number of cases.
Wedge shaped infarct INCIDENCE: in parallel with a global epidemic of HIV. in
ECG Often No Change! May only be Tachycardia. UK from 120, 000 in 1913 5,000 in 1987 7000 in 2002.
V1: Tall R Waves RISK IN DEVELOPED WORLD: Alcoholics, Undernourished,
V1-3: T Wave Inversion Ethnic Communities, Elderly, HIV, Pts after gastrectomy for PU.
Inf: P Pulmonale (Peaked P Waves) SEX: Young: F>M. Older: M>F
RBBB, R axis deviation AGE: > 60% aged 25-64 years but risk highest in over 65s.
Deep waves in: Si / Qiii / T(inversion) iii Path ORG: Mycobacterium tuberculosis (Humans are only known
ABGs PO2, PCO2, ( pH) reservoir)
D Dimers Use to Exclude PE / DVT. Also DIC, Post OP SPREAD: Airborne droplet
In many situations RESIDENCE: Droplets deposited within terminal airspaces.
+PV: 44%, -PV: 98% Upon encountering bacilli, macrophages ingest & transport
VQ / Spiral CT / (CTPA: not used so much anymore) bacteria to regional lymph nodes.
Tx O2 & IV Access FATE OF TB- One of four choices:
Morphine 1) Killed by immune system
LMW Heparin 2) Multiply and cause primary TB
Immediate Surgery: If severe causing CV Collapse. 3) Become dormant and remain asymptomatic, or
BP: <90: Colloid infusion Dobutamine Thrombolysis 4) Proliferate after a latency period (reactivation
BP: >90: Warfarin disease). Reactivation may occur following 2 or 3.
Mx Don’t fly / dive for 2 weeks GROWTH: Slow-growing, requiring 4-8 /52 for visible growth on
Wear Thromboembolism Stockings solid medium
Stop Hep when INR > 2 INFECTIVITY:
Continue Warfarin for 3-6/12 –Aim for INR of 2-3 Prev BCG vaccination 80% protection 15 years when given in schools
Comp programme, but in older patients there is < evidence for effectiveness.
S PULMONARY TB:
SARCOIDOSIS Y Typical: Productive cough, fever, and weight loss
Def Multisystem granulomatous disorder of unknown cause that M Occasional: Haemoptysis / chest pain
predominantly affects lungs and intrathoracic lymph nodes P Systemic: Anorexia, fatigue, or night sweats.
PP Prevalence: 10-20/105. Often Adults 20-40. Black > White. M>F (2:1) T TUBERCULOUS MENINGITIS:
Path O Headache- Intermittent / Persistent for 2-3 weeks.
S&S AYSYMPTOMATIC: M Mental status changes Coma over days to weeks.
20-40%...Dx incidentally on CXR S Fever may be low-grade or absent
ACUTE SARCOIDOSIS: SKELETAL TB:
Erythema nodosum +/- polyarthralgia. Spine is most common site (Pott disease). Back Pain Or
PULMONARY DISEASE: Stiffness. Lower extremity paralysis (50%)
90% abnormal Xray with bilateral hilar lymphadenopathy (BHL) Arthritis: Usually involves 1 joint only. Hip / Knee > Ankle,
+/- Pulmonary infiltrates, Fibrosis. elbow, wrist, and shoulder
S&S: Dry cough, Progressive SOB, Exercise tolerance, Pain may precede XR by weeks - months.
chest pain. GENITOURINARY TB:
In 10-20%, S&S progress with deterioration in lung function. Flank pain, dysuria, frequency.
NONPULMONARY MANIFESTATIONS In men, genital TB S&S: Epididymitis or scrotal mass.
SWOLLEN Lymphadenopathy, Hepatomegaly, Splenomegaly In women, genital TB S&S may mimic PID. TB 10% sterility
EYES Uveitis, Conjunctivitis, Keratoconjuctivitis sicca, in women worldwide and 1% in industrialized countries.
Glaucoma GASTROINTESTINAL TB:
BONE Terminal phalangeal bone cysts Any site along GI Tract may be infected. S&S relate to site.
Nonhealing ulcers of mouth or anus;
GLANDS Enlarged lacrimal / parotid glands; Pituitary
Difficulty swallowing with oesophageal disease;
Abdo pain mimicking PUD with stomach / duodenal infection;
NEURO Bell’s palsy, Neuropathy, Meningitis, Brainstem /
Malabsorption with infection of small intestine;
Spinal syndromes, Space occupying lesion
Pain, diarrhoea, or hematochezia with infection of colon.
SKIN Erythema nodosum, Lupus pernio, Subcut nodules
TUBERCULOUS LYMPHADENITIS (scrofula):
HEART Cardiomyopathy, Arrhythmias
Most common site is in neck along sternocleidomastoid muscle.
RENAL Hypercalcaemia, Renal Stones Usually unilateral, with little or no pain.
DDx Advanced disease may suppurate and form draining sinus.
Inv / Bloods ESR, Lyphopenia, Abnormal LFTs, ACE, Igs CUTANEOUS TB:
Dx Urine Ca Direct inoculation may Ulcer or wartlike lesion.
CXR Abnormal in 90%. Staging as follows: Contiguous spread from infected lymph node Draining sinus.
0: Normal Haematogenous spread Reddish brown plaque on face /
1: BHL (Bilateral Hilar Lymphadenopathy) extremities (lupus vulgaris) / tender nodules or abscesses.
2: BHL + Peripheral Pulmonary Infiltrates S PULMONARY TB: Abnormal breath sounds, esp over upper
3: Only Peripheral Pulmonary Infiltrates I lobes or areas involved.
4: Progressive pulmonary fibrosis; bullae formation G EXTRAPULMONARY TB: Differ depending on tissues involved.
(honeycoming); pleural involvement. N May include confusion, coma, neurologic deficit, chorioretinitis,
WILL WESTON Page 4 of 8
S lymphadenopathy, cutaneous lesions (as described above). Organisms most commonly involved are aerobic and
DDx Bronchiectasis, Crohn Disease, Histoplasmosis, Lung Abscess, Lung anaerobic streptococci, Staphylococcus aureus and variety of
Cancer, Miliary TB, Pericarditis- Constrictive, Pneumonia- Fungal, different gram-negative organisms.
Sarcoidosis. Anaerobes normally found in oral cavity occur exclusively in
Inv / Hx Suspect Pulmonary TB with >3/52 unexplained cough esp if 60% of cases - inc Bacteroides, Fusobacterium, Peptococcus.
Dx additional: Haemoptysis, SOB, Appetite , Weight , Fever Organisms may be introduced through:
& Sweats (Nocte), Fatigue, Swollen glands… URGENT… Aspiration (Most common cause. See risks.)
CXR Antecedent primary bacterial infection (Pneumonia, TB)
Always compare previous XR if possible: Septic emboli (Endocarditis, Thrombophlebitis from systemic)
Primary TB: < half of patients show Neoplasia ( Drainage, Distal atelectasis, Aspiration of blood
radiological abnormalities. Hilar lymph and tumour fragments Infection And Abscess formation)
node enlargement; subsides as Other factors: Foreign body, CF, Bronchiectasis, Trauma
immunity to tubercle bacillus develops. Patterns:
hilar nodes or Ghon focus may be Aspiration: More common on RHS, Single.
calcified Pneumonia / Bronchiectasis: Mutliple, Basal, Diffuse.
Post-Primary TB: Patchy solid lesions, Septic Emboli: Multiple, Any area.
cavitated solid lesions, streaky fibrosis, S&S S&S OF PNEUMONITIS: Shivers, Fever, Pleuritic Chest Pain,
flecks of calcification, solitary General Systemic Upset, Malaise And Fatigue
tuberculoma presenting as a coin DISCHARGE INTO BRONCHUS: Cough, Sputum (copious, foul
lesion, hilar node enlargement smelling- Initially blood stained green / brown)
Miliary TB: Millet-sized nodules present OTHER S&S
throughout lung fields. In practice, CXR Fever And Malaise in a chronic lung abscess
often normal. Clubbing, which may develop rapidly
SPT Ziehl-Nielsen / Auramine staining of sputum smear may Pleural effusion or consolidation
demonstrate presence of acid-fast bacilli Pleural rub
Bx Dx may be based on histological view: Caseating granuloma Symptoms relating to metastatic abscesses e.g. cerebral
TT Tuberculin Test (Mantoux test): Hypersensitivity to tubercle DDx
bacillus is developed about 3 weeks after initial infection Inv / Blood WBC, ESR
Mx Specialist Care. E.g. 6 / 12 isoniazid + rifampicin supplemented Dx Sputum Gram stain & Culture for aerobic + anaerobic
in first 2 months with pyrazinamide + ethambutol. Determine antibiotic sensitivity
Comp Pleural effusion, Empyema, Pneumothorax, Laryngitis Examine for acid fast bacilli
Enteritis, Mycetoma with aspergillus fumigatus in healed cavity CXR One or more circular lesions of almost any size
Cor pulmonale 2o to extensive fibrosis, Death which may cavitate and show fluid levels
Prog TB can mimic congenital syphilis or CMV infection. Chst US Can ID a fluid collection. May allow aspiration.
Case-fatality rate was 50% for untreated patients before ABx. Endos Fibre-optic bronchoscopy: Permits sampling for
Worldwide Mortality is 25-30% bacteriology and histological Dx of lesions, e.g.
UK Mortality is 5% neoplasms or foreign bodies
Mortality highest in S.E Class, those with Multidrug-resistant Tx Postural drainage: Position determined by CXR.
tuberculosis (MDR-TB) and immunocompromised (though ABx (Org Dependant). Often successful but may take weeks.
ChemoTx provides cure in almost all immunocompromised). Blind cover:
Relapse Rate is 1-2%; Rate highest amongst poor compliers. Gentamicin: Monitor for Toxic S/Es
SUPPURATIVE LUNG DISEASE Metronidazole: Covers anaerobic organisms
SUPPURATION: Formation of, conversion into, or process of discharging pus. Definitive treatment, for example:
Examples: Bronchiectasis, Lung Abscess (localized area of suppuration) Flucloxacillin for staphylococcus. Medical
BRONCHIECTASIS treatment is often successful but healing
Def Permanent dilation of bronchi. May be localised to a lobe of may take several weeks.
generalised throughout the bronchial tree. There is impaired Percutaneous drainage reserved when abscess cavity does
clearance of bronchial secretions with 2o bacterial infections. not communicate with bronchus or when ABx & fail.
PP Mainly in childhood. Incidence in all age groups due to ABs. Comp If prompt Tx, most experience few long term sequelae. Extreme:
Cause CF is the most common cause. Others include: Severe bronchopneumonia, malnutrition and death may occur.
IDIOPATHIC: Progressive bronchiectasis- No underlying case. EMPYEMA (PLEURAL)
INFLAMMATORY: Infective processes e.g. measles, Def Empyema: Accumulation of pus in a cavity (Pleural Cavity)
whooping cough, Klebseilla pneumonia, may damage and PP
weaken bronchial wall dilation and ciliary damage. Cause Most common is bacterial pneumonia (pneumococcal pneumonia).
OBSTRUCTION: Proximal obstruction of an airway e.g. Staph and H. influenzae pneumonias important causes in children.
inhaled foreign body, enlarged turbuculous lymph nodes, Others: Lung abscess, Bronchiectasis, Pulm Infarction, Sx Comp.
leads to distal accumulation of secretions which then become S&S High, swinging fever
infected, resulting in localised bronchiectasis. Night sweats
CONGENITAL FACTORS: Other than CF…Kartagener’s Chest pain
syndrome, Ig deficiencies which recurrent infections. Signs of a pleural effusion
S&S Cough & Sputum (Severe: Sputum- Copious amounts, Thick, If Chronic: Clubbing, Weight , Anaemia, Signs of
Green, Foul smelling) extensive pleural thickening
Haemoptysis (may be massive & life threatening) DDx
SOB, Wheeze. Inv / FBC WBC : Polymorphonuclear leucocytosis
Clubbing, Coarse crackles over affected area (N @ bases). Dx Asp Pleural Fluid Aspiration: May be diagnostic:
DDx WBCs, Culture / Gram stained orgs, Gluc, pH
Inv / CXR May be N. Dilated bronchi with thickened bronchial walls. CXR Generally posterior & lateral, above diaphragm
Dx May be multiple cysts containing fluid. Initially appearance identical to pleural effusion
Sputum Essential during infective exacerbation. Common orgs: Later fluid may become loculated
C S. Aureus, Pseudomonas Aeruginosa, H. Influenzae. Tx ABX: Depends on Aspirate: Often metronidazole as organisms
CT Inv of choice as may show bronchial wall thickening not may not be revealed by culture
shown on CXR. (Sliced at 1 & 2mm instead of 10mm) DRAIN PLEURAL FLUID - If not possible Sx indicated (Sx
Others Where underlying cause suspected. Serum Igs, Sweat T. evacuation and lung decortication so that it may be fully
Tx : Daily postural drainage is vital. Teach pt to do @ home. expanded and so obliterate pleural space)
ABs: Mild- Intermittent ChemoTx: Ceraclor (500mg tds) INTRAPLEURAL STREPTOKINASE may be required to break
Abs: Best Tx for Staph. aureus on sputum C = Flucloxacillin down adhesions if empyema is loculated
Abs: Psudomonas Aeruginosa (Persistant sputum despite Tx)
= Ceftazidime CRYPTOGENIC FIBROSING ALVEOLITIS (+ OTHER FIBROSIS)
Bronchodilators: Used for demonstrable airflow limitation. Def Initially cellular alveolar infiltrate Acute S&S
Steroids (PO): May rate of progression Later fibrosis of alveolar walls Decline in Lung function
Sx: Reserved for v small minority with localised disease. Lung function deteriorates progressively (norm years). A rapidly
Severe disease may require heart-lung transplant. progressive form Death in months (Hamman-Rich syndrome).
Comp Pneumonia, Haemoptysis (may be life threatening), Cerebral PP Highest incidence in late middle age. M>F (2:1)
abscess. Most pts with severe disease Respiratory failure. Cause Unknown: But thought there is alteration in cell-mediated immunity,
LUNG ABSCESS perhaps activated T lymphocytes fibroblastic activity
Def Confined area of suppuration within lung parenchyma. It is Assoc Polyarthritis - 10% of cases have RA (RF +ve in 35%).
PP More common in: Alcoholics, Elderly, Debilitated (prone to Autoimmune chronic hepatitis in 5 - 10% of cases
aspiration), IV Drug abusers. M>F (Slight) Thyroid disease, SLE, Systemic Sclerosis, Dermatomyositis
Incidence due to ABx Tx of Lower RTI, Childhood TB. S&S Panting SOB
Cause Infection and necrotic tissue Development of abscess.
WILL WESTON Page 5 of 8
Exhaustion on effort (amount needed decreases) Giant cell carcinoma
Dry cough Clear cell carcinoma
S&S: Hypoxia, Cardiac F, Bronchopulmonary infection MISCELLANEOUS TUMOURS
Terminal Stages: Respiratory failure and pulmonary embolism Bronchial carcinoid carcinoma
Dyspnoea And Tachypnoea (Cyanosis if severe) Bronchial gland carcinomata:
Clubbing (> 50% cases) Adenoid cystic carcinoma
Auscultation: Fine Crepitations marked at end of inspiration Muco-epidermoid carcinoma
('velcro-like' crackles). Wheezes are rare. Others
DDx Bronchiectasis: Longstanding productive cough + purulent sputum. Stage Staging important in determining: Prognosis, Appropriate Tx
Transfer factor is not . Usually airway obstruction and dyspnoea. Non-small cell lung tumours staged using TNM model.
Causes of Upper Zone Fibrosis…BREAST! Most important are S&T: Small cell lung tumours are staged differently:
Berylliosis, Radiation, Extrinsic Allergic Alveolitis (e.g. Stage 0: Carcinoma In Situ I.e.
Farmer’s Lung): Hx of exposure to organic dusts, Ankylosing Stage IA: T1N0M0
Spondylitis, Sarcoid, TB No Nodes
Stage IB: T2N0M0
Causes of Lower Zone Fibrosis…Connective Tissue Disorders: Stage IIA: T1N1M0
SLE, RA, Sceroderma. Nodes
stage IIB: T2N1M0, T3N0M0
Drugs: Cytotoxics, Amiodarone, Nitrofurantoin. Stage IIIA: T3N1M0, T1N2M0, T2N2M0, T3N2M0
Occupational lung diseases: Silicosis, Asbestosis. > Growth.
Stage IIIB: T4N0M0, T4N1M0, T4N2M0,
Inv / CXR Main: Ground glass haze at lung bases. > Nodes
T1N3M0, T2N3M0, T3N3M0, T4N3M0
Dx Others: Streaky wisps of shadow with elevation of Stage IV: M1 with any T or N Mets
diaphragms suggesting basal collapse. Miliary mottling.
S&S Lung should be suspected in any pneumonia which is slow to
Honeycomb lung develops as condition progresses
resolve / recurrent, or who presents with a pyrexia of unknown origin.
and lung function lost
Bloods ESR , Gamma-globulin
INTRA-PULMONARY: Invasion of Tissue…
Anti-nuclear factor +ve in 45%, RF in 35%
Cough, Poorly localised chest pain, Haemoptysis
CT Sensitive for diagnosis and monitoring
INTRA-PULMONARY: Airway Obstruction…
Bronch- Neutrophils +/or Eosinophils
Dyspnoea, Wheeze / stridor, Pneumonia,
oscopy Lymphocytes may also
Bronchiectasis, Lung abscess, Lobar collapse
PFTS & RESTRICTIVE DEFECT INTRA-THORACIC INFILTRATION: Apex
Lung Volumes . Lung Compliance
Horner's syndrome due to sympathetic ganglion
ABGs Blood Gases N until advanced disease when there invasion by pancoast's tumour
may be arterial hypoxaemia and hypocapnia
Tx OXYGEN: Palliates S&S of breathlessness.
Arm pain & weakness due to brachial plexus invasion
STEROIDS (Prednisolone): S&S in ½. Lung function in ¼.
INTRA-THORACIC INFILTRATION: Left hilum:
IMMUNOSUPPRESSIVE Tx (Azathioprine)
Hoarseness due to recurrent laryngeal nerve invasion
LUNG TRANSPLANT: Consider is no response to above
INTRA-THORACIC INFILTRATION: Mediastinum:
steps. Survival after 1 year: 80%; Survival after 3 years: 55%
ANTIFIBROTICS (pirfenidone): May improve survival but more Cardiac tamponade or pericardial invasion
evidence needed. Arrhythmias
Dysphagia due to oesophageal invasion
LUNG CARCINOMA Diaphragmatic palsy due to phrenic nerve invasion
Def Bronchial carcinomata so common that lung & bronchial Central chest pain due to chest wall invasion
INTRA-THORACIC INFILTRATION: Chest wall invasion:
carcinoma appear synonymous. Further confusion due to fact that not
all bronchial carcinomata derived from bronchi, e.g. Pleural effusion, Pleuritic chest
bronchioloalveolar carcinomata found peripherally and derived from INTRA-THORACIC INFILTRATION: Right paratracheal:
bronchioles. Clinically lung divided: Small cell & Non-small cell. Superior VC obstruction (SVC compression / invasion)
PP Common: Accounts for 1 in 8 cases and 17% of cancer deaths. EXTRA-THORACIC METASTASES
Relative risk of death related to no of cigarettes smoked / day: Anorexia, Weight and Lethargy frequently indicate
Non-smokers: 0.07 lung cancer deaths/year/1000 disseminated disease. Distant metastasis is…
> Common with, SCC followed by
1-14 cig/day: 0.78 lung cancer deaths/year/1000
adenocarcinoma & LCC.
14-24 cig/day: 1.27 lung cancer deaths/year/1000
< Common with squamous carcinoma.
> 24 cig/day: 2.51 lung cancer deaths/year/1000
Secondary spread may occur to virtually any part of
M>F (7:1); Ratio as incidence of bronchial C in ♀ .
body. Most common sites are: Brain BALL: Brain,
Peak in 70s (♂) & 80s (♀). Rare < 25.
Bone, Adrenals, Lymph nodes (Lymph), Liver.
> 90% Patients are symptomatic at Dx.
Marrow involvement occurs in 10-20% of cases of
Cause SMOKING: Most important cause: 90% ♂ & 80% ♀. Others…
advanced small cell carcinoma and may leuco-
ASBESTOS: Blue asbestos (Crocidolite) poses greatest risk.
erythroblastic anaemia. However, anaemia in lung
Assoc with pleural mesothelioma and bronchial carcinoma
DUST: Containing arsenics, dichromates, chromates, nickel is usually due to due to non-specific effects of
COAL: Tar and products of coal combustion
CHRONIC INFLAMMATION: NON - METASTATIC : ENDOCRINE
Predisposes to Alveolar cell carcinoma
Small Hypercalcaemia: 6-7% tumours. Usually Ca of
malignancy. In squamous cell carcinoma, may be due
Associated with adenocarcinoma of the lung
ADH, to PTH-like peptides
Tumours assoc occupational factors are > likely adenocarcinomas.
ACTH Dilutional hyponatraemia: 10% of small cell
carcinoma. Due to ADH-like peptides
Path Lungs are common site for met spread from distant 1o neoplasms.
& 1o Tumours of lung divided into following however to simplify…
(Think Cushing's syndrome: Ectopic ACTH-like peptide
AA tits commonly produced by small cell tumours but
Class Small Cell (SCLC.. 70% Mets) / Non Small Cell (NSCLC..40% Mets): are
BENIGN TUMOURS symptomatic < 1% of cases.
small) Hyperpigmentation due to ectopic MSH production.
Hamartoma (Most common): --------
Often discovered incidentally on CXR [1-3cm Clubbing: > 50% of squamous cell tumours. Unusual
Sqam in small cell tumours.
diameter, ‘coin lesion’]. Mesenchymal in
origin & usually composed of mature, hyaline Hypertrophic pulmonary osteoarthropathy
cartilage. PP: Middle / Elderly Men. Gynaecomastia
Rarely symptomatic. Tx: Sx- Resection. NON - METASTATIC : NEUROLOGIC
Prog: V Good Uncommon, occurring in < 2% of cases. Most often
Others (Rare): Lipomas, Leiomyomas, Neural tumours due to small cell carcinoma.
BRONCHIAL TUMOURS: Four Groups… > Common: Peripheral neuropathy, Cerebellar
Squamous cell carcinoma (40 % of all lung cancers): degeneration / ataxia
Spindle cell (squamous) carcinoma Rare: Encephalomyositis, polymyositis /
Small cell carcinoma (20-30 %): dermatomyositis, Lambert-Eaton myasthenia gravis
Oat cell carcinoma DERMATOLOGIC Associations
Intermediate cell type Erythema gyratum repens (Irregular wavy bands)
Combined oat cell carcinoma Acanthosis nigricans (Dark hyperplasia of creases)
Adenocarcinoma (20%): Erythroderma (Generalised redness of the skin)
Bronchial derived adenocarcinoma: SUMMARY LOCAL:
Acinar adenocarcinoma Hoarseness
Papillary adenocarcinoma Cough
Solid carcinoma with mucus formation SOB (obstruction / pleural effusion)
Bronchioloalveolar carcinoma Haemoptysis
Þ Large cell carcinoma (10-15%):
WILL WESTON Page 6 of 8
SUMMARY PARANEOPLASIA: Pneumonia
Skin Congestive HF
Weight , Bone pain, Seizure, Ascites, Pulmonary embolism
Lymphadenopathy CHRONIC COUGH
DDx Post nasal drip secondary to nasal or sinus disease.
Inv / CXR Posteroanterior and lateral films. Asthma
Dx Histo / Cyt Confirmation of diagnosis: Histological diagnosis; GORD: May require ambulatory pH monitoring / anti reflux Tx.
Cytology of sputum and bronchoscopic washings Pertussis
Bx Confirmation of diagnosis: Intrabronchial tumour
Proximal lesions - Bronchoscopy Foreign body
Peripheral lesions - Percutaneous biopsy C Serous Pulmonary Oedema
Pleural effusions - Aspiration and biopsy O Bronchoalvelola cell carcinoma
Lymph nodes L Mucoid Chronic Bronchitis
Tissue Dx required in majority, esp those under 70 yr, O COPD
in order that appropriate Tx can be given. U Asthma
Confirmation of diagnosis: R Purulent Infection
CT scan - Assessment of spread: Useful for showing in Rusty Pneumococcal Pneumonia
mediastinum, e.g. local spread of tumour, enlarged Assoc Stridor Indicates partial obstruction of major airway. Eg.
lymph nodes, and for showing 2 spread to opposite Laryngeal oedema / Tumour / Inhaled foreign body
lung which may be too small to see on CXR
Barium Assessment of spread: May show oesophageal HAEMOPTYSIS
Swallow compression by enlarged mediastinal nodes Def A clear Hx must be taken to maintain that there is true
Bone scan Assessment of spread haemoptysis and NOT epitaxis (nosebleed).
Bloods: May help to indicate disseminated disease Always assume there is a serious cause until following have
FBC, U+E, Small cell tumours may secrete substances e.g. been ruled out: Bronchial , Thromboembolic disease, TB etc
2+ Causes *: More Common Causes
LFTs, Ca ADH hyponatraemia…ACTH Cushing's.
ADH, Squamous cell carcinomas may secrete PTH- BRONCHIAL Carcinoma*- (Hx & appears streaky)
ACTH like substances producing hypercalcaemia DISEASE Acute bronchitis*
Mx: Treatment for NSCLC: Sx Excision: Bronchiectasis*(may cause catastrophic bronchial
NICE Lobectomy [I-II] hemorrhage)
Pneumonectomy [II-III]) Bronchial adenoma
+/- Radiotherapy [I-III] Foreign body
+/- Chemotherapy [III - IV]. PARENCHYMAL Tuberculosis* (& chronic fever & weight loss)
Limited Resection / Radical Radio Tx for pts who would not tolerate Suppurative pneumonia (rusty coloured sputum)
lobectomy due to comorbid disease or pulmonary compromise. Actinomycosis
Treatment for SCLC: SCLC metastasise early Sx not indicated. Lung abscess
Radiotherapy and Combo Chemotherapy is indicated. Aspergilloma (may cause catastrophic bronchial
For most cases treatment is palliative: hemorrhage)
RadioTx used to ease pain / bronchial obstruction. Parasites (e.g. hydatid disease, flukes)
Pleurodesis indicated for recurrent pleural effusions. LUNG Pulmonary infarction*
Palliative endoscopic laser Tx of obstructive lesions of VASCULAR Idiopathic pulmonary
large airways may also be effective. DISEASE Polyarteritis nodosa
Prog 80% 1 year mortality from lung cancer after Tx. Haemosiderosis
5 year survival is only about 5%. Goodpasture’s syndrome
5-year survival after Sx of NSMLC is ~ 25%. CARDIO- Acute left ventricular failure*
Small cell tumours carry the worst prognosis: VASCULAR Aortic aneurysm
Untreated - 1-2 months median survival
DISEASE Mitral stenosis
Treated - 12 months median survival BLOOD Leukaemia
Untreated median survival times for other tumours include: DISORDERS Anticoagulants
Adenocarcinoma: 12 months
Risk Immobilisation, Malignant disease of any organ, CF, Pregnancy
Squamous carcinoma: 8 months
TNM Prognosis: S&S Melaena if enough blood swallowed.
Clubbing: bronchial carcinoma & bronchiectasis.
Stage I: 80-90% 5 yr survival
Cachexia, Hepatomegaly, Lymphadenopathy:
Stage II: 40-50% 5 yr survival
Fever, Signs Of Consolidation, Pleurisy: Pneumonia /
Stage IIIA: 30-40% 5 yr survival
Stage IIIB: 9-12 months median survival DVT In Legs: Pulmonary Infarct
Stage IV: 6-9 months median survival Rash, Purpura, Haematuria, Splinter haemorrhages, Lymphad-
enopathy, Splenomegaly: Uncommon systemic disease.
Def Tussis Inv / CATASTROPHIC ACUTE HAEMOPTYSIS
Path Form of violent exhalation by which irritant particles in airways may Mx Haemodynamic resuscitation
be expelled. Stimulation of cough reflexes epiglottis being kept Bronchoscopy Rigid- allows optimal bronchial suction.
shut until a high expiratory pressure has built up which is then under GA: Allows adequate ventilation during GA
suddenly released. May be need for: Angiography, Bronchial arterial embolization,
Cause Stimulation of sensory nerves in mucosa of: Pharynx, Larynx, Emergency pulmonary surgery.
Trachea, Bronchi MAJORITY OF CASES, NOT SERIOUS
Cause S&S CXR May give clear evidence of lesion including:
ORIGIN COMMON CAUSES NATURE Pulmonary infarct, Tumour- malignant or
Pharynx Post Nasal Drip Usually persistent benign, Pneumonia, TB
Larynx Laryngitis, tumour, Harsh, barking, painful, persistent, FBC and other blood tests including clotting screen
whooping cough, associated with stridor Bronchoscopy Necessary to exclude bronchial carcinoma
croup (invisible on CXR)
Trachea Tracheitis Painful Provides tissue diagnosis in other cases of
Bronchi Bronchitis & acute Dry or productive, worse in morning suspected bronchial neoplasia.
COPD V/Q scan Helpful in establishing Dx of suspected
Asthma Dry or productive, worse in night pulmonary thromboembolytic disease.
Bronchial carcinoma Persistent- often with haemoptysis. CT pulmonary angiography may be
Lung TB Productive- often with haemoptysis. necessary with pre existing lung disease
Parenchyma Pneumonia Dry initially, productive later (interpretation of VQ scan can be difficult).
Bronchiectasis Productive, changes in posture CT Particularly useful in Inv peripheral lesions
induce sputum production seen on CXR which may not be accessible to
Pulmonary Oedema Often at night, may be pink frothy bronchoscopy & facilitates accurate
sputum percutaneous needle Bx where indicated
Interstitial Fibrosis Dry, irritant, distressing
Onset ACUTE COUGH DYSPNOEA
Viral induced lower respiratory tract infection Def Shortness of breath, difficult or laboured breathing
Post nasal drip from rhinitis or sinusitis Unpleasant subjective awareness of the sensation of breathing
Throat clearing secondary to laryngitis or pharyngitis
WILL WESTON Page 7 of 8
PP Asthma, Respiratory tract infection, Lung tumours, Pleural
Path Pts usually perceive discomfort from either: effusions, Metabolic acidosis.
VENTILATORY RATE, PROVOKED BY: CHRONIC (MONTHS- YEARS)
Pa CO2 eg. COPD COPD, Cardiac failure, Fibrosing alveolitis, Anaemia,
Pa O2 eg. Cyanotic congen heart disease, asthma, COPD Arrhythmia, Valvular heart disease, Chest wall derformities,
Exercise Neuromuscular disorders, Cystic fibrosis, Pulmonary
VENTILATORY RATE, PROVOKED BY: Inv /
Lung vol (Restrictive lung disease) eg Pneumonia, Dx
Pulmonary oedema, Interstitial lung disease Mx
Pleural pain Prog
RESISTANCE TO AIR FLOW:
eg. Asthma, COPD, Upper airway or laryngeal obstruction. CAUSES OF DYSPNOEA BY SYSTEM
S&S ASSESS SEVERITY, RATE OF ONSET: ACUTE DYSPNOEA AT REST CHRONIC EXERTIONAL
Central Cyanosis (degree) C Pulmonary Oedema Chronic heart failure
Anaphylaxis (angioedema, Urticaria) V Ischaemia (angina Myocardial ischaemia
Patency of Upper airway. equivalent (angina equivalent
Ability to speak R Asthma (Acute severe) *COPD
PMH OF: E COPD (Acute *Chronic asthma
LHF, Asthma, COPD S exacerbation) Bronchial carcinoma
ALSO: P Pneumothorax Interstitial lung disease
Renal disease, Dm, Anaemia Pneumonia (sarcoidosis, fibrosing
Inhaled foreign body? Pulmonary embolus alveolitis, extrinsic allergic
Acute epiglottitis? Acute RDS alveolitis, pneumoconiosis)
CARDIOVASCULAR STATUS: Inhaled foreign body Chronic pulmonary
SYMPTOMS: Chest pain, Palpitations, Sweating, Nausea (especially in the child) thromboembolism
SIGNS: Rate and rhythm, BP, Peripheral perfusion, Leg Lobar collapse Lymphatic carcinomatosis
swelling may indicate CF or venous thrombosis. Laryngeal oedema (e.g. (may cause intolerable
RESPIRATORY SYSTEM: anaphylaxis) dyspnoea)
SYMPTOMS: Cough, Wheeze, Haemoptysis, Stridor Large pleural effusion(s)
SIGNS: Rate, Evidence of CO2 retention, Breathing pattern, O Metabolic acidosis (e.g. Severe anaemia
Tracheal position, Chest expansion (Degree, Symmetry) T diabetic ketoacidosis Obesity
Percussion (Hyper resonant, Dull), Breath sounds (Chest, H Lactic acidosis, uraemia,
Bases), PEFR measured if possible. E overdose of salicylates,
Digital clubbing: Anaemia, Polycythaemia R ethylene glycol poisoning)
Clinical features of: Dm, Renal failure, Other chronic disease Phsychogenic
DDx SUDDEN (SECS- MINS) hyperventilation (anxiety
Pneumothorax, Pulmonary oedema, Pulmonary embolism, or panic-related
Aspiration, Anaphalaxis, Anxiety, Chest trauma
DIFFERENTIAL DIAGNOSIS OF ACUTE SEVERE DYSPNOEA: * denotes a valuable discriminatory feature; = Hypoxia, = Hypercapnea = Plasma bicarbonate
CONDITION Hx SIGNS CXR ABGs ECG OTHER
LEFT Central cyanosis JVP or ) Cardiomegaly
Chest pain Sinus tachycardia
VENTRICULAR Murmurs *Upper zone vessel Echo ( left
Orthopnoea Pa02 *Signs of
FAILURE *Sweating enlargement ventricular
Palpitations or N Pa CO2 MI
Cool extremities *Overt oedema/ pleural function)
*Previous cardiac history Arrhythmia
*Dullness and Crepitations at bases effusions
MASSIVE Severe central cyanosis Sinus tachycardia
Recent surgery or other risk factors May be subtle changes *Echo
PULMONARY *Elevated JVP S1Q2T3 pattern
Chest pain Previous pleurisy only Prominent hilar Pa02 *V/Qscan
*Absence of S&S in lung (unless T (V1—V4)
EMBOLUS *Syncope vessels Pa CO2 *CT pulmonary
previous pulmonary infarction) Shock Right bundle- Branch
*Dizziness *oligaemic lung fields angiography
(tachycardia, blood pressure) block
ACUTE SEVERE Tachycardia and pulsus paradoxus Sinus tachycardia
*Hyperinflation only PaO2
ASTHMA *History of previous Cyanosis (late) (bradycardia with
(unless complicated PaCO2
episodes, asthma medications, wheeze *JVP severe hypoxaemia
by pneumothorax) (until late)
peak flow, rhonchi —late)
*Hyperinflation or Pa02
EXACERBATION *Signs of COPD Nil, or signs of
*Previous Episodes (Admissions) Signs of In type II failure
(barrel chest, intercostal indrawing, right ventricular
OF COPD If in type II respiratory failure, may not Emphysema. Signs of PaCO2 , with
pursed lips, tracheal tug) failure (in cor
be distressed events precipitating [H+] and
*Signs of CO2 retention (warm periphery, pulmonale)
flapping tremor, bounding pulses)
PNEUMONIA *Prodromal illness CRP
*Fever *Pneumonic PaCO2 WCC
*Pleural rub Tachycardia
*Rigors consolidation PaO2 Sputum & Blood
*Consolidation Cyanosis (only if severe)
METABOLIC Fetor (ketones)
ACIDOSIS *Evidence of diabetes/renal disease *Hyperventilation without physical signs *PaO N
in heart or lungs Normal PaCO2
*Overdose of aspirin or ethylene glycol *Dehydration pH (H+)
Air hunger (Kussmaul’s respiration)
PSYCHOGENIC *Pao N
*Not cyanosed End-tidal PaCO2
(A Dx Previous episodes PaCO2
*No heart signs Normal *Low exercise
Symptoms mainly at rest, but not sleep. *pH N or
OF EXCLUSION) *No lung signs Carpopedal spasm tolerance test
WILL WESTON Page 8 of 8