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 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,
        o
       1 Spontaneous- tall, thin, male, smoker, 20-40                                                                 During summer (Hayfever) or throughout the
        o
       2 Spontaneous- COPD, male, >40                                                                                 year (Perennial rhinitis).
 Cause
        o
       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
        o
       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
                                                                                               100mcg children)
                                    Bronchoconstriction                                  STEP 3: ADD ON THERAPY: Adults / children > 5
                             Capillary Permeability (oedema)                            
                                                                                                   st
                                                                                                (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
                            Morning dipping
                                                                                         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 /
WILL WESTON                                                                                                                                             Page 1 of 8
                                                                                                                  4e972802-3f36-487b-85ca-69cd3a42c7aa.doc
 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
                 antitrypsin deficiency.
                                                                                                  (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,          TxObesity,  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
            JVP
                                                                                       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)
            Weight                                                                                                     Neoplasia
 V         Peripheral Oedema (may indicate Cor Pulmonale)                                                               Smoking
       PALPATION
 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
                               PO2,  PCO2
              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
                                                                                                                                                       Local lung
              CRP            
                                                                                                                                                       defences
 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
                                                                                                             4e972802-3f36-487b-85ca-69cd3a42c7aa.doc
 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
              B Cult         
                                                                                   PULMONARY OEDEMA
                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
        pneumophillia
                                                                                                                             
                                                                                   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
           pneumoniae                                                                                                        
                                                                                                                 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.
                 O2
                                                                                            Cyanosed, sweaty, pale.
                 Antibiotics….… Amoxicillin (Community)
                                                                                            Respiration:  + Use of accessory muscles.
                 Antibiotics….… Cefotaxime (Hospital)
                                                                                            Coughing, Wheezing.
                 IV fluids………..if anorexia / dehydration / shock
                                                                                            Sputum: Profuse, Frothy, Pink / Blood stained.
                 Analgesia……..Paracetamol
                                                                                            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
                                                                                   DDx
                                                                                   Inv   CXR       Ground glass appearance: alveolar oedema
 PLEURAL EFFUSIONS
                                                                                         ECG       MI?
 Def       Fluid in the pleural space
                                                                                         U&Es
           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.
           UNILATERAL                                                             Prog
           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
 Path     
 S&S     Asymptomatic, SOB (related to size), Pleuritic chest pain
         Chest Expansion         on Affected side
 (Often  Percussion             Stony dullness over Effusion

WILL WESTON                                                                                                                                         Page 3 of 8
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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;
                       dysfunction
                                                                                         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,
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 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
                                                                                                                      Benzylpenicillin
 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.
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               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
                                                                                              LOCAL EFFECTS:
          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
                                                                                                            Rib destruction
 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
                                                                                                               malignancy.
           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
           IONISING RADIATION
         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
                                                                                    PTH
                                   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
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                SUMMARY PARANEOPLASIA:                                                        Pneumonia
                     Neuro                                                                    Aspiration
                     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.
                                                          o
                         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)
                                                                                   DISEASE               Trauma
            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
                                                                                                         Haemophilia
                       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
                                                                                                 Pulmonary Infarct
                       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.
 COUGH                                                                             DDx
 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
                                                                                                                                     4e972802-3f36-487b-85ca-69cd3a42c7aa.doc
 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
             Fever                                                                                                  hypertension
             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
             Consciousness                                                                                                                               DYSPNOEA
             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
          ACUTE (HOURS-DAYS)

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)
ACUTE                                                           Cyanosis
                                                                                                            *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)
                                                                                                            exacerbation              bicarbonate
                                                                flapping tremor, bounding pulses)
PNEUMONIA          *Prodromal illness                                                                                                                                             CRP
                                                                Fever, confusion
                   *Fever                                                                                   *Pneumonic               PaCO2                                       WCC
                                                                *Pleural rub                                                                              Tachycardia
                   *Rigors                                                                                  consolidation             PaO2                                      Sputum & Blood
                                                                *Consolidation Cyanosis (only if severe)
                   *Pleurisy                                                                                                                                                     culture
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
                                                                                                                                      (H+ )




WILL WESTON                                                                                                                                                                        Page 8 of 8

				
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