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respiratory Flashcards

1
Q

sarcoidosis presentation

A

20-40 year old black woman presenting with a dry cough and shortness of breath. They may have nodules on their shins suggesting erythema nodosum

lymphadenopathy

Lupus pernio (raised, purple skin lesions commonly on cheeks and nose)

eye + heart sx

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2
Q

what is sarcoidosis

A

granulomatous inflammatory condition.

Granulomas are nodules of inflammation full of macrophages.

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3
Q

what is lofgren’s syndrome

A

classical presentation of systemic sarcoidosis

classic triad of fever, erythema nodosum, and bilateral hilar lymphadenopathy
+polyarthralgia

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4
Q

Triad of Lofgren’s Syndrome

A

Erythema nodosum
Bilateral hilar lymphadenopathy
Polyarthralgia (joint pain in multiple joints)

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5
Q

blood tests for sarcoidosis

A

raised serum ACE

hypercalcaemia

Raised serum soluble interleukin-2 receptor

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6
Q

gold standard for sarcoidosis dx

A

histology from biopsy

= non-caseating granulomas with epithelioid cells.

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7
Q

tx for sarcoidosis

A

No treatment in px w no/mild sx - condition often resolves spontaneously.

Oral steroids 1st line where tx is req - for between 6 + 24 months
- bisphosphonates to protect against osteoporosis whilst on such long term steroids.

Second line options are methotrexate or azathioprine

Lung transplant is rarely required in severe pulmonary disease

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8
Q

COPD spirometry results

FEV1 according to stage

A

FEV1 <80% of predicted; FEV1/FVC <0.7
as OBSTRUCTIVE lung disease

Stage 1 Mild FEV1 ≥ 80% predicted

Stage 2 Moderate FEV1 50-79% of predicted

Stage 3 Severe FEV1 30-49% of predicted

Stage 4 Very Severe FEV1 <30% of predicted

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9
Q

CXR for COPD

A

Hyperinflated chest (>6 anterior ribs)

Bullae

Decreased peripheral vascular markings

Flattened hemidiaphragms

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10
Q

PE presentation

A

Sudden-onset shortness of breath
pleuritic chest pain
haemoptysis

signs of shock

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11
Q

PE ix

A

CT pulmonary angiogram

V/Q scan if renal impairment / preg/ contrast allergy

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12
Q

pneumothorax chest exam

A
  • reduced chest expansion of the affected side.
  • hyper-resonant percussion note on the affected side.
  • reduced or absent breath sounds on the affected side, with no added sounds.
  • vocal resonance (tactile vocal fremitus) is reduced on the affected side.

tension pneumothorax: signs of haemodynamic compromise (tachycardia and hypotension) and tracheal deviation to the contralateral side.

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13
Q

ix for pnuemothorax

A

urgent erect CXR (if no signs it is a tension pneumothorax)

CT thorax if too small to see on CXR

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14
Q

primary pneumothorax mx

A

No shortness of breath and less than a 2cm rim of air on the chest x-ray:
- No treatment is required as it will spontaneously resolve
Follow up in 2 – 4 weeks is recommended

Shortness of breath and/or more than a 2cm rim of air on the chest x-ray:
- Aspiration followed by reassessment
When aspiration fails twice, a chest drain is required

Emergency/earlier fails:
- Chest drain

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15
Q

what is the triangle of safety for insertion of a chest drain

A
  • The 5th intercostal space (or the inferior nipple line)
  • The midaxillary line (or the lateral edge of the latissimus dorsi)
  • The anterior axillary line (or the lateral edge of the pectoralis major)
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16
Q

signs of tension pneumothorax

A

Tracheal deviation away from side of the pneumothorax
Reduced air entry on the affected side
Increased resonance to percussion on the affected side
Tachycardia
Hypotension

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17
Q

mx of tension pneumothorax

A

Do not wait for ix.

Insert a large bore cannula into the second intercostal space in the midclavicular line. (needle decompression)

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18
Q

abx prophylaxis for COPD

A

azithromycin

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19
Q

what are the ECG changes in a PE

A

large S wave in lead I, a large Q wave in lead III and an inverted T wave in lead III - ‘S1Q3T3’

but not always

may also see:
RBBB
right axis deviation
sinus tachycardia

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20
Q

CXR in PE

A

may be normal but cld show wedge shaped opacification

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21
Q

PE tx

A

Thrombolysis (alteplase)
thrombolysis is now recommended as the first-line treatment for MASSIVE PE where there is circulatory failure (e.g. hypotension)

If not + usually :
Apixaban as first line mx (DOAC)

if the patient has active cancer
- DOAC (prev guidelines said LMWH)

if renal impairment is severe (e.g. < 15/min) then LMWH, unfractionated heparin or LMWH followed by a VKA

if the patient has antiphospholipid syndrome then LMWH followed by a VKA should be used

anticoag for at least 3 months (6 months if unprovoked)

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22
Q

what is bronchiectasis?

A

permanent dilation of the airways secondary to chronic inflammation or infection

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23
Q

what are the causes of bronchiectasis

A
  • post-infective: tuberculosis, measles, pertussis, pneumonia
  • cystic fibrosis
  • bronchial obstruction e.g. lung cancer/foreign body
  • immune deficiency: selective IgA, hypogammaglobulinaemia
  • allergic bronchopulmonary aspergillosis (ABPA)
  • ciliary dyskinetic syndromes: Kartagener’s syndrome, Young’s syndrome
  • yellow nail syndrome
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24
Q

s + sx bronchiectasis

A

sx
- persistent productive cough
- dyspnoea
- haemoptysis

s
- coarse crackles, wheeze
- clubbing

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25
Q

ix for bronchiectasis

A

CXR: sometimes normal
if severe: tram lines + ring shadows

GS = CT chest - bronchial dilation

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26
Q

what increase of FEV1 is indicative of asthma (after inhalation of SABA)

A

12%

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27
Q

what blood result might be seen in lung cancer

A

raised platelets

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28
Q

ix for lung cancer

A

CXR

CT IS GS

bronchoscopy for biopsy

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29
Q

pulmonary HTN presentation

A

Shortness of breath is the main presenting symptom. Others include:

Syncope (loss of consciousness)
Tachycardia
Raised jugular venous pressure (JVP)
Hepatomegaly
Peripheral oedema

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30
Q

ECG signs in pulmonary HTN

A

indicate R sided heart strain

P pulmonale (peaked P waves)
Right ventricular hypertrophy (tall R waves in V1 and V2 and deep S waves in V5 and V6)
Right axis deviation
Right bundle branch block

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31
Q

what cancer is most assoc w asbestos exposure

A

Mesothelioma - cancer of the mesothelial layer of the pleural cavity

there is a substantial latent period between exposure + dev

chemo can help, but is palliative

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32
Q

characteristic chest signs of pneuomonia

A

bronchial breath sounds - harsh inspiratory + expiratory breath sounds due to consolidation around the airways
focal course crackles due to air passing through sputum in the airways
dullness to percussion due to lung tissue filled w sputum or collapsed

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33
Q

sx of pneumonia

A

Cough
Sputum production
Shortness of breath
Fever
Feeling generally unwell
Haemoptysis
Pleuritic chest pain
Delirium )

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34
Q

what can indicate sepsis secondary to pneumonia

A

Tachypnoea (raised respiratory rate)
Tachycardia (raised heart rate)
Hypoxia (low oxygen)
Hypotension (shock)
Fever
Confusion

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35
Q

severity assessment for pneumonia + what it means

A

CURB-65
C – Confusion (new disorientation in person, place or time)
U – Urea > 7 mmol/L
R – Respiratory rate ≥ 30
B – Blood pressure < 90 systolic or ≤ 60 diastolic.]
65 – Age ≥ 65

The CURB-65 score predicts mortality. NICE state 0/1 is low risk (under 3%), 2 is intermediate risk (3-15%), and 3-5 is high risk (above 15%):
Score 0/1: Consider treatment at home
Score ≥ 2: Consider hospital admission
Score ≥ 3: Consider intensive care

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36
Q

most common causes of typical pneumonia

A

Streptococcus pneumoniae (most common)
Haemophilus influenzae

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37
Q

other causes of typical pneumonia

A
  • Moraxella catarrhalis in immunocompromised patients or those with COPD
  • Pseudomonas aeruginosa in patients with cystic fibrosis or bronchiectasis
  • Staphylococcus aureus in patients with cystic fibrosis
  • Methicillin-resistant Staphylococcus aureus (MRSA) in hospital-acquired infections
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38
Q

causes of Legionella pneumophila (Legionnaires’ disease)

A

inhaling infected water from infected water systems, such as air conditioning units

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39
Q

what can Legionnaires’ disease cause

A

syndrome of inappropriate ADH (SIADH), resulting in hyponatraemia

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40
Q

initial screening test for Legionnaires’ disease

A

urine antigen test

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41
Q

Mycoplasma pneumoniae presentation

A

causes a milder pneumonia
erythema multiforme - varying-sized ‘target lesions’ formed by pink rings w pale centres
can cause neuro sx in young px

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42
Q

how do you get chlamydia psittaci pneumonia

A

typically contracted from contact with infected birds.

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43
Q

how do you get Coxiella burnetii pneumonia

A

or Q fever
linked to exposure to the bodily fluids of animals. The typical exam patient is a farmer with a flu-like illness.

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44
Q

5 causes of atypical pneumonia (cannot be tx by penicillin)

A

Legions – Legionella pneumophila
Psittaci – Chlamydia psittaci
M – Mycoplasma pneumoniae
C – Chlamydophila pneumoniae
Qs – Q fever (coxiella burnetii)

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45
Q

what fungal pneumonia commonly occurs in immunocompromised px + how does it present

A

Pneumocystis jirovecii pneumonia (PCP)

px w poorly controlled HIV + low CD4 count - at risk

usually presents w dry cough
SOB on exertion
night sweats

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46
Q

PCP tx

A

Co-trimoxazole (trimethoprim/sulfamethoxazole)

brand name Septrin

px with a low CD4 count are prescribed prophylactic co-trimoxazole to protect against PCP. (under 200)

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47
Q

pneumonia tx

A

Mild community-acquired pneumonia is typically treated with 5 days of oral abx, eg:
Amoxicillin
Doxycycline
Clarithromycin

Moderate or severe pneumonia is usually treated initially with IV abx and stepped down to oral antibiotics as the condition improves.
- dual abx - amoxicillin + a macrolide (clarithromycin) 7-10 days
Respiratory support (e.g., oxygen or intubation and ventilation) is also used.

V high severe
co-amoxiclav/tazocin + mactolide

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48
Q

what is exudate

A

a high protein content (more than 30g/L)

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49
Q

what is transudate

A

a lower protein content (less than 30g/L)

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50
Q

when would you start steroids in sarcoidosis

A

parenchymal lung disease
uveitis
hypercalcaemia
neurological or cardiac involvement

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51
Q

what ph does someone benefit most from NIV

A

7.25-7.35

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52
Q

what is a restrictive respiratory pattern

A

FVC and FEV1 are reduced proportionately so the FEV1/FVC ratio is normal

FVC < 70%
FEV1 reduced

usually has a reduced transferred factor for CO2 reflecting impaired gas exhange

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53
Q

examples of restrictive lung disease

A

where lung vol is reduced
pulmonary fibrosis
scoliosis

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54
Q

what is an obstructive resp pattern

A

FVC and FEV1 are reduced disproportionately so the FEV1/FVC ratio is reduced (<70%)
FVC normal or reduced
FEV1 reduced <80%

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55
Q

examples of obstructive lung disease

A

airways are obstructed due to diffuse airway narrowing of any cause
COPD
cystic fibrosis
asthma
bronchiectasis
airway obstruction due to lung tumours

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56
Q

CXR for PCP

A

bilateral interstitial pulmonary infiltrates

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57
Q

moderate asthma attack

A

PEFR 50-75% best or predicted
Speech normal
RR < 25 / min
Pulse < 110 bpm

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58
Q

severe asthma attack

A

PEFR 33 - 50% best or predicted
Can’t complete sentences
RR > 25/min
Pulse > 110 bpm

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59
Q

life-threatening asthma attack

A

PEFR < 33% best or predicted
Oxygen sats < 92%
‘Normal’ pC02 (4.6-6.0 kPa)
Silent chest, cyanosis or feeble respiratory effort
Bradycardia, dysrhythmia or hypotension
Exhaustion, confusion or coma

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60
Q

near-fatal asthma

A

raised pC02 and/or requiring mechanical ventilation with raised inflation pressures

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61
Q

first line treatment for Allergic bronchopulmonary aspergillosis (ABPA)

A

oral glucocorticoids - pred

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62
Q

Refer people using a suspected cancer pathway referral (for an appointment within 2 weeks) for lung cancer if they:

A

have chest x-ray findings that suggest lung cancer
are aged 40 and over with unexplained haemoptysis

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63
Q

OFFER an urgent chest x-ray (to be performed within 2 weeks) to assess for lung cancer if:

A

they are 40+ + have 2+ of the following unexplained sx, or if they have ever smoked and have 1+:

cough
fatigue
shortness of breath
chest pain
weight loss
appetite loss

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64
Q

CONSIDER an urgent chest x-ray (to be performed within 2 weeks) to assess for lung cancer in people:

A

aged 40 and over with any of the following:

persistent or recurrent chest infection
finger clubbing
supraclavicular lymphadenopathy or persistent cervical lymphadenopathy
chest signs consistent with lung cancer
thrombocytosis

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65
Q

lung abscess sx

A

sim features to pneumonia but more SUBACUTE - sx may dev over wks
may get systemic features such as night sweats and weight loss
fever
productive cough - often w foul smelling sputum
sometimes haemoptysis
chest pain
dypsnoea

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66
Q

lung abscess signs

A

bronchial breathing
dull percussion
maybe clubbing

hx aspiration pneumonia

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67
Q

lung abscess CXR

A

fluid filled space w area of consolidation
usually see an air-fluid level

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68
Q

lung abscess mx

A

intravenous antibiotics
if not resolving percutaneous drainage may be required and in very rare cases surgical resection

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69
Q

when might you get Legionnaire’s disease from Legionella pneumophilia

A

It typically colonizes water tanks and hence questions may hint at air-conditioning systems or foreign holidays (often SPAIN).

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70
Q

features of Legionnaire’s disease

A

flu-like symptoms including fever (present in > 95% of patients)
dry cough
relative bradycardia
confusion
lymphopaenia (low WBCs)
HYPONATRAEMIA
deranged liver function tests
pleural effusion: seen in around 30% of patients

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71
Q

dx of Legionnaire’s disease

A

urinary antigen

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72
Q

tx of Legionnaire’s disease

A

erythromycin/clarithromycin

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73
Q

what is bronchitis

A

self-limiting chest infection

result of inflammation of the trachea + major bronchi -> oedematous large airways and the production of sputum

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74
Q

bronchitis presentation

A

an initial dry cough over 3-4 days followed by a productive cough that usually resolves within 3 weeks

mild bilateral wheeze with no other findings

low grade fever

75
Q

when to use abx in bronchitis and which one is used

A

CRP>100mg/L

doxycycline

76
Q

what criteria does a px have to have to be discharged following asthma attack

A

stable on their discharge medication for at least 12 hours
PEFR >75% best or predicted
have a good inhaler technique

77
Q

what are the causes of pleural effusion with transudate (< 30g/L protein)

A

related to fluid moving across or shifting into pleural space
mostly fails (heart, renal, liver)

HEART FAILURE (most common)
HYPOALBUMINAEMIA
liver disease
nephrotic syndrome
malabsorption
HYPOTHYROID
MEIGS’ syndrome

78
Q

what are the causes of pleural effusion with exudate (> 30g/L protein)

A

related to inflammation -> protein leaking out of tissues into pleural space (EX = moving out)
or anything that causes cell death in the lungs

infection
- PNEUMONIA (most common),
- tuberculosis
- subphrenic abscess
connective tissue disease
- RA
- SLE
neoplasia
- lung CANCER
- mesothelioma
- metastases
pancreatitis
pulmonary embolism
Dressler’s syndrome
yellow nail syndrome

79
Q

what is meigs syndrome

A

triad of
- benign ovarian tumour (usually a fibroma)
- pleural effusion
- ascites.

The pleural effusion and ascites resolve with the removal of the tumour.

80
Q

pleural effusion sx

A

SOB

81
Q

pleural effusion examination findings

A

dullness to percussion over effusion
reduced breath sounds
tracheal deviation away from effusion if v large

82
Q

pleural effusion ix

A

CXR =
blunting of costophrenic angle
fluid in lung fissures
larger ones have meniscus
tracheal and mediastinal deviation away if large

US / CT if smaller

pleural fluid analysis (take sample by aspiration or chest drain)

83
Q

pleural effusion tx

A

dx + tx underlying cause
conservative if small
pleural aspiration
chest drain

84
Q

what is empyema

A

infected pleural effusion

Suspect an empyema in a patient with improving pneumonia but a new or ongoing fever.

85
Q

pleural aspiration in empyema

A

pus
low pH
low glucose
high LDH

86
Q

what is Kartagener’s syndrome (primary ciliary dyskinesia)

A

dextrocardia (heart on RHS)
bronchiectasis
recurrent sinusitis
subfertility

87
Q

mx of asthma attack

A

oxygen
SABA - salbutamol (nebs)
Corticosteroid -Oral Prednisolone or Hydrocortisone IV
SAMA - ipratropium bromide (nebs)
IV magnesium sulphate
IV aminophylline
senior critical care support
- intubation + ventilation

88
Q

how to dx adults w suspected asthma

A

Fractional exhaled nitric oxide (FeNO) test + spirometry w bronchodilator reversibility

if uncertain then test peak flow variability

if stilll uncertain then do direct bronchial challenge test with histamine or methacholine

px should be asked if their symptoms are better on days away from work/during holidays. If so, patients should be referred to a specialist as possible occupational asthma

89
Q

what is acute respiratory distress syndrome (ARDS)

A

caused by the increased permeability of alveolar capillaries leading to fluid accumulation in the alveoli, i.e. non-cardiogenic pulmonary oedema.

Mortality of 40% + assoc with significant morbidity in those who survive

90
Q

causes of acute respiratory distress syndrome (ARDS)

A

infection: sepsis, pneumonia
massive blood transfusion
trauma
smoke inhalation
acute PANCREATITIS
Covid-19
cardio-pulmonary bypass

91
Q

features of acute respiratory distress syndrome (ARDS)

A

cute onset and severe:
dyspnoea
elevated respiratory rate
bilateral lung crackles
low oxygen saturations

92
Q

ix acute respiratory distress syndrome (ARDS)

A

CXR - bilateral infiltrates
- non cardiogenic (pulmonary artery wedge pressure needed if doubt)

ABG - uncompensated resp acidosis

93
Q

tx acute respiratory distress syndrome (ARDS)

A

ITU

94
Q

what is the difference between primary + secondary pneumothorax

A

primary if there is no underlying lung disease and secondary if there is

95
Q

secondary pneumothorax mx

A

> 50 >2cm/SOB = chest drain
1-2cm = aspiration attempt. if fails = chest drain. admit all px for at least 24 hrs
<1cm = give O2 + admit for 24 hrs

96
Q

pneumothorax and flying

A

absolute CI
can travel 2 wks after successful drainage if there is no residual air
1 wk post check XR

97
Q

pneumothorax + scuba diving

A

permanently avoided
unless the patient has undergone bilateral surgical pleurectomy and has normal lung function and chest CT scan postoperatively.

98
Q

what might be the cause of pneumonia in an alcoholic

A

Klebsiella pneumoniae

99
Q

2 broad types of lung cancer

A

Small-cell lung cancer (SCLC) (around 20%)
Non-small-cell lung cancer (around 80%)

100
Q

types of non-small-cell lung cancer

A

Adenocarcinoma (around 40% of total lung cancers)
Squamous cell carcinoma (around 20% of total lung cancers)
Large-cell carcinoma (around 10% of total lung cancers)
Other types (around 10% of total lung cancers)

101
Q

presentation of lung cancer

A

Shortness of breath
Cough
Haemoptysis (coughing up blood)
Finger clubbing
Recurrent pneumonia
Weight loss
Lymphadenopathy – often supraclavicular nodes are the first to be found on examination

102
Q

what can SCLC cause

A

various paraneoplastic syndromes as the cells contain neurosecretory granules that release neuroendocrine hormones

103
Q

presentation of recurrent laryngeal nerve palsy

A

hoarse voice

caused by tumour pressing on recurrent laryngeal nerve as it passes through mediastinum

104
Q

presentation phrenic nerve palsy

A

due to nerve compression

causes diaphragm weakness -> SOB

105
Q

what innervates diaphragm

A

The phrenic nerve - originates from C3 - C5 nerve roots

106
Q

presentation superior vena cava obstruction + why can you get it

A

can be a comp of lung cancer
med emergency

presents w facial swelling, difficulty breathing, distended neck + upper chest veins

pemberton’s sign = raising the hands over the head causes facial congestion + cyanosis

107
Q

horners syndrome triad

A

ptosis
anhidrosis
miosis

108
Q

what can cause horner’s syndrome

A

pancoast tumour (tumour in pulmoary apex) pressing on sympathetic ganglion

109
Q

ectopic cause of SIADH

A

SCLC
ectopic ADH secretion

110
Q

ectopic cause cushing’s syndrome

A

SCLC
ectopic ACTH

111
Q

what hormone can squamous cell carcinoma release

A

ectopic parathyroid hormone
-> hypercalcaemia

112
Q

what is limbic encephalitis

A

paraneoplastic syndrome where SCLC causes the immune system to make antibodies to tissues in the brain (mostly limbic system) -> inflam in these areas
-> short term memory impairment, hallucinations, confusion, seizures

113
Q

what arethe antibodies in limbic encephalitis

A

anti-Hu antibodies

114
Q

what is lambert-Eaton myasthenic syndrome

A

caused by antibodies against SCLC cells
they also target + damage VG Ca channels on the presynaptic terminals in motor neurones

-> proximal muscle weakness

115
Q

CXR findings suggesting cancer

A

hilar enlargement
peripheral opacity (a visible lesion in the lung field)
pleural effusion (usually unilateral in cancer)
collapse

116
Q

first line tx in non-small cell lung cancer

A

surgery - in all px w disease isolated to a single area

117
Q

types of lung tumour removal

A

Segmentectomy or wedge resection involves removing a segment or wedge of lung (a portion of one lobe)
Lobectomy involves removing the entire lung lobe containing the tumour (the most common method)
Pneumonectomy involves removing an entire lung

118
Q

typical examination findings with idiopathic pulmonary fibrosis

A

Bibasal fine end-inspiratory crackles
Finger clubbing

119
Q

what is interstitial lung disease

A

incs conditions that cause inflam + fibrosis of lung parenchyma

120
Q

types of interstitial lung disease

A

Idiopathic pulmonary fibrosis (the most important to remember)
Secondary pulmonary fibrosis
Hypersensitivity pneumonitis
Cryptogenic organising pneumonia
Asbestosis

121
Q

key presenting features of interstitial lung disease

A

Shortness of breath on exertion
Dry cough
Fatigue

122
Q

dx interstitial lung disease

A

clinical features

spirometry
= restrictive pattern
FEV1 and FVC are equally reduced
FEV1:FVC ratio greater than 70%

HIGH RES CT SCAN OF THORAX
= GROUND GLASS appearance
- ix of choice to confirm dx

123
Q

general mx of interstitial lung disease

A

Remove or treat the underlying cause
Home oxygen where there is hypoxia
Stop smoking
Physiotherapy and pulmonary rehabilitation
Pneumococcal and flu vaccine
Advanced care planning and palliative care where appropriate
Lung transplant is an option, but the risks and benefits need careful consideration

124
Q

what is idiopathic pulmonary fibrosis + how does it present

A

progressive pulmonary fibrosis w no apparent cause
insidious onset SOB + dry cough over >3 months
adults > 50
poor prog 2-5 yrs LE from dx

125
Q

medications which can slow progression of idiopathic pulmonary fibrosis

A

PIRFENIDONE reduces fibrosis and inflammation through various mechanisms

NINTEDANIB reduces fibrosis and inflammation by inhibiting tyrosine kinase

126
Q

what drugs can cause 2ndary pulmonary fibrosis

A

amiodarone (also causes grey/blue skin)
cyclophosphamide
methotrexate
nitrofurantoin

127
Q

pulmonary fibrosis can occur secondary to which conditions

A

alpha-1 antitrypsin deficiency
RA
SLE
systemic sclerosis
sarcoidosis

128
Q

what is hypersensitivity pneumonitis (/extrinsic allergic alveolitis)

A

involves type III + type IV hypersensitivity reaction to an environmental allergen
inhalation of allergens in px sensitised -> immune res -> inflam + damage to lung tissue

129
Q

what is bronchoalveolar lavage

A

performed in bronchoscopy
airways are washed w sterile saline to gather cells + the fluid is collects + analysed

130
Q

Bronchoalveolar lavage result in hypersensitivity pneumonitis

A

raised lymphocytes

131
Q

mx hypersensitivity pneumonitis

A

remove allergen
oxygen
steroids

132
Q

Bird-fancier’s lung

A

Hypersensitivity Pneumonitis reaction to bird droppings

133
Q

Farmer’s lung

A

Hypersensitivity Pneumonitis reaction to mouldy spores in hay

134
Q

mushroom worker’s lung

A

Hypersensitivity Pneumonitis reaction to specific mushroom antigens

135
Q

malt worker’s lung

A

Hypersensitivity Pneumonitis reaction to mould on barley

136
Q

what is asbestosis

A

lung fibrosis related to asbestos exposure

137
Q

what problems does asbestos inhalation cause

A

lung fibrosis
pleural thickening + pleural plaques
adenocarcinoma
mesothelioma

138
Q

what is asthma

A

chronic inflammatory airway disease -> variable airway obstruction
smooth muscle in the airways is hypersensitive + responds to stimuli by constricting + causing airflow obstruction

139
Q

auscultation finding w asthma

A

widespread “polyphonic” expiratory wheeze

140
Q

differentials for a localised wheeze

A

inhaled foreign body
tumour
thick sticky mucus plug obstructing an airway

141
Q

typical asthma triggers

A

Infection
Nighttime or early morning
Exercise
Animals
Cold, damp or dusty air
Strong emotions

142
Q

what Fractional exhaled nitric oxide (FeNO) is a positive result supporting asthma dx

A

above 40 ppb

(smoking can lower it making results unreliable)

143
Q

what level of peak flow variability is a positive result supporting asthma dx

A

more than 20%

144
Q

what is Maintenance and reliever therapy (MART)

A

a combination inhaler containing an inhaled corticosteroid and a fast and long-acting beta-agonist (e.g., formoterol).

replaces all other inhalers

145
Q

general asthma mx for adults NICE guidelines

A
  1. Short-acting beta-2 agonist SABA - salbutamol as reliever (as req)
  2. Inhaled corticosteroid (low dose) as maintenance
  3. Leukotriene receptor antagonist LRTA - montelukast take reg
  4. Long-acting beta-2 agonists LABA - salmeterol take reg
  5. Consider changing to MART
  6. Increase steroid dose to moderate
  7. Increase steroid dose to high (or + LAMA / + theophylline)
  8. Specicalist mx
146
Q

additional asthma mx

A

Individual written asthma self-management plan
Yearly flu jab
Yearly asthma review when stable
Regular exercise
Avoid smoking (including passive smoke)
Avoiding triggers where appropriate

147
Q

ABG in acute asthma attack

A

respiratory alkalosis initially
(increased RR blows of CO2)

Hypoxia is concerning sign
Resp acidosis is v bad sign
- means px is getting tired

148
Q

what is COPD

A

a long-term, progressive condition involving airway obstruction, chronic bronchitis and emphysema.

result of smoking

149
Q

COPD presentation

A

a long-term smoker with persistent symptoms of:

Shortness of breath
Cough
Sputum production
Wheeze
Recurrent respiratory infections, particularly in winter

150
Q

MRC Dyspnoea Scale

A

Grade 1: Breathless on strenuous exercise
Grade 2: Breathless on walking uphill
Grade 3: Breathlessness that slows walking on the flat
Grade 4: Breathlessness stops them from walking more than 100 meters on the flat
Grade 5: Unable to leave the house due to breathlessness

151
Q

vaccines in COPD

A

pneumococcal and annual flu vaccine

152
Q

first line tx COPD

A

Short-acting beta-2 agonists SABA (e.g., salbutamol)
OR
Short-acting muscarinic antagonists SAMA (e.g., ipratropium bromide)

153
Q

how to know if a px w COPD has asthmatic/steroid responsive features

A

any previous, secure diagnosis of asthma or of atopy
a higher blood EOSINOPHIL count - note that NICE recommend a FBC for all patients as part of the work-up
substantial variation in FEV1 over time (at least 400 ml)
substantial diurnal variation in peak expiratory flow (at least 20%)

154
Q

next tx in COPD when there is no asthma features

A

combo of Long-acting beta agonist (LABA) + Long-acting muscarinic antagonist (LAMA)

if already taking SAMA, stop + switch to SABA

155
Q

next tx in COPD when there is asthma features

A

combo of Long-acting beta agonist (LABA) +
Inhaled corticosteroid (ICS)

if already taking SAMA, stop + switch to SABA

156
Q

final step tx COPD

A

triple therapy: LABA, LAMA and ICS

157
Q

what do px taking azithromycin need

A

ECG and liver function monitoring before and during treatment

158
Q

when to use long-term oxygen therapy in COPD

A

used for severe COPD with chronic hypoxia (sats < 92%), polycythaemia, cyanosis or cor pulmonale.

159
Q

CI to long-term oxygen therapy

A

smoking as fire risk

160
Q

Cor Pulmonale

A

right-sided heart failure caused by respiratory disease. The increased pressure and resistance in the pulmonary arteries (pulmonary hypertension) limits the right ventricle pumping blood into the pulmonary arteries. This causes back-pressure into the right atrium, vena cava and systemic venous system.

161
Q

causes of Cor Pulmonale

A

COPD (the most common cause)
Pulmonary embolism
Interstitial lung disease
Cystic fibrosis
Primary pulmonary hypertension

162
Q

Signs of cor pulmonale on examination

A

Hypoxia
Cyanosis
Raised JVP (due to a back-log of blood in the jugular veins)
Peripheral oedema
Parasternal heave
Loud second heart sound
Murmurs (e.g., pan-systolic in tricuspid regurgitation)
Hepatomegaly due to back pressure in the hepatic vein (pulsatile in tricuspid regurgitation)

163
Q

ABG in acute exacerbation COPD

A

typically causes a respiratory acidosis involving:

Low pH indicates acidosis
Low pO2 indicates hypoxia and respiratory failure
Raised pCO2 indicates acute CO2 retention (hypercapnia)
Raised bicarbonate indicates chronic retention of CO2

164
Q

target sats in COPD px who are chronic CO2 retainers

A

88-92

165
Q

reasons for CO2 retention in COPD when tx w O2

A

ventilation-perfusion mismatch
haemoglobin binding less well to CO2 when also bound to oxygen = Haldane effect

166
Q

which masks to use that deliver a specific % conc O2

A

Venturi masks

167
Q

mx of COPD acute exacerbation

A

Regular inhalers or nebulisers (e.g., salbutamol and ipratropium)
Steroids (e.g., prednisolone 30 mg once daily for 5 days)
Antibiotics if there is evidence of infection

If severe:
IV aminophylline
Non-invasive ventilation (NIV) - usually BiPAP
Intubation and ventilation with admission to intensive care

168
Q

when to consider NIV in COPD

A

Persistent respiratory acidosis (pH < 7.35 and PaCO2 > 6) despite maximal medical treatment
Potential to recover
Acceptable to the patient

decision made by reg or above
CI = untx pneumothorax / stuctural abnormality

169
Q

what is obstructive sleep apnoea caused by

A

collapse of the pharyngeal airway

170
Q

RFs obstructive sleep apnoea

A

Middle age
Male
Obesity
Alcohol
Smoking

171
Q

presentation obstructive sleep apnoea

A

Episodes of apnoea during sleep (reported by a partner)
Snoring
Morning headache
Waking up unrefreshed from sleep
Daytime sleepiness
Concentration problems
Reduced oxygen saturation during sleep

172
Q

what is important to ask about in obstructive sleep apnoea + why

A

daytime sleepiness and occupation

px that need to be fully alert for work, such as heavy goods vehicle operators, require an urgent referral and may need amended work duties while awaiting assessment and treatment.

173
Q

what is used to assess sx assoc w obstructive sleep apnoea

A

Epworth Sleepiness Scale

174
Q

dx obstructive sleep apnoea

A

sleep studies
e.g. simple sleep study wearing an oxygen saturation monitor overnight at home.
or respiratory polygraphy
or complex sleep study staying at a centre overnight w polysomnography

175
Q

mx obstructive sleep apnoea

A

Reversible risk factors
Continuous positive airway pressure (CPAP) machines
Surgical reconstruction of the soft palate and jaw - usually uvulopalatopharyngoplasty (UPPP).

176
Q

when to repeat a CXR after clinical resolution of pneumonia

A

6 weeks

177
Q

most common cause of HAP

A

aerobic gram -ve bacilli
- Pseudomonas aeruginosa
- Klebsiella pneumoniae

178
Q

most common cause of COPD exacerbation

A

Haemophilus influenzae

179
Q

which type of lung cancer causes hoarseness in voice + why

A

Pancoast tumours pressing on the recurrent laryngeal nerve

180
Q

high-risk characteristics in pneumothorax + what do you do

A

haemodynamic compromise (suggesting a tension pneumothorax)
significant hypoxia
bilateral pneumothorax
underlying lung disease
≥ 50 years of age with significant smoking history
haemothorax

-> chest drain

181
Q

GS for mesothelioma ix

A

thoracoscopy and biopsy

182
Q

tx massive PE + hypotension

A

thrombolysis w alteplase

183
Q

tx haemothorax

A

wide bore chest drain

finals (27 decks)

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