Resp Flashcards
1
Q
which type of lung cancer is most common in people who have never smoked?
A
Adenocarcinoma
2
Q
Cause of a hoarse voice in a lung cancer patient?
A
Recurrent laryngeal nerve palsy
3
Q
- What are the components of Horner’s syndrome?
- What type of cancer is associated with Horner’s syndrome?
A
- Ptosis, Miosis, Anhidrosis
- Pancoast tumour at apex of lung (usually non-small cell)
4
Q
what are the three main types of lung cancer?
A
Adenocarcinoma (40%)
Squamous cell carcinoma (20%)
Small cell lung cancer (20%)
5
Q
diaphragmatic weakness and shortness of breath in lung cancer is caused by…
A
Phrenic nerve palsy- due to nerve compression
6
Q
Lung cancer patient presents with facial swelling, difficulty breathing and distended veins in the neck and upper chest.
1. Diagnosis?
2. name of sign when raising hands over head causes facial congestion and cyanosis?
A
- Superior vena cava obstruction
- Pemberton’s sign- this is a medical emergency
7
Q
Hyponatraemia in a patient with lung cancer could be due to…
A
SIADH, ectopic ADH secretion by a SCLC
8
Q
Cushing’s syndrome in a patient with lung cancer could be due to…
A
Ectopic ACTH secretion by a SCLC
9
Q
Hypercalcaemia in a lung cancer patient could be due to
A
ectopic PTH secretion from a squamous cell carcinoma
10
Q
lung cancer patient presents with short term memory impairment, hallucinations, confusion and seizures.
1. Diagnosis?
2. pathology
A
- Limbic encephalitis
- Small cell lung cancer causes immune system to make antibodies to tissues in the limbic system of the brain. Associated with Anti-Hu antibodies
11
Q
Patient with lung cancer presents with weakness of the proximal muscles, diplopia, slurred speech/dysphagia
1. Diagnosis?
2. Pathology
A
- Lambert Eaton Myasthenic syndrome
- Small cell lung cancer causes immune system to produce antibodies which target and damage voltage-gated calcium channels on the pre-synaptic terminals of motor neurones
12
Q
Lung cancer investigations:
1. First line investigation (and findings?)
2. Investigation for histological diagnosis
3. scan for increased metabolic activity in metastases?
A
- CXR, findings can include
- hilar enlargement
- ‘peripheral opacity’ - lesion visible in the lung field
- pleural effusion
- collapse - Histological diagnosis is by Bronchoscopy with Endobrachial Ultrasound (ultrasound guided biopsy)
- PET-CT scan
13
Q
- management- small cell lung cancer
- Prognosis better or worse than non-small cell?
A
- Chemotherapy and radiotherapy
- worse
14
Q
- Management of non-small cell lung cancer
A
- Surgery is offered first line where the lung cancer is isolated to a single area. Lobectomy=first line
- Radiotherapy can be curative if done early enough
15
Q
- cancer most commonly associated with ‘cannonball metastases’ in the lung?
- Other associated cancers?
A
- Renal Cell cancer
- breast, colorectal, prostate and bladder
16
Q
criteria for diagnosis of pneumonia
A
(1) clinical presentation of lower respiratory tract symptoms
AND
(2) focal chest signs (e.g. crackles) OR unexplained CXR shadowing
17
Q
most common cause of CAP
A
strep pneumoniae (80% of cases)
18
Q
most common cause of pneumonia in patients with COPD
A
H. Influenzae
19
Q
most common cause of pneumonia in patients following influenza infection
A
Staph Aureus
20
Q
- pneumonia which occurs secondary to infected air conditioning units. 2. Signs?
A
- Legionella pneumophiliae
- Hyponatraemia and lymphopenia
21
Q
pneumonia typically seen in Alcoholics
A
Klebsiella pneumoniae
22
Q
pneumonia seen in HIV patients.
Presents with dry cough, exercise induced destaturations and absence of chest signs
A
Pneumocytis Jivorecii
23
Q
pneumonia seen in those around birds
A
chlamydia psittaci
24
Q
management- hospital acquired pneumonia
- non-severe
- Severe
- If MRSA is suspected
A
- If non-severe, co-amoxiclav. (doxycycline if penicillin allergic)
- If severe, treat with Piperacillin with Tazobactam (alternatives: Meropenem, cefuroxime, ceftriaxone)
- Add Vancomycin
25
management- community acquired pneumonia
1. mild/moderate
2. severe
1. Amoxicillin PO 5 days
Clarithro/doxy if penicillin allergic
Clarithro if atypical cause
2. 7-10 days dual abx therapy with (1) a stable beta lactamase (co-amoxiclav, ceftriaxone) AND (2) a macrolide (clarithromycin)
26
management options for aspiration pneumonia
clindamycin, levofloxacin, pip+taz
27
scoring system for severity of pneumonia + interpretation of scores in primary care
CURB 65
Confusion
(Urea >7- only used in secondary care)
RR greater than or equal to 30
BP: systolic less than 90 or diastolic less than 60
age 65
0= low risk
1-2= intermediate risk- consider hospital assessment
3-4= high risk (mortality risk 10%), urgent hospital admission
28
interpretation of CURB65 scores in hospital setting
0 or 1= home based care
2= ward based care
3+ = consider intensive care treatment
29
cause of pneumonia most commonly associated with a farmer with Q fever
Coxiella burnetti (treat with Doxy)
30
cause of pneumonia most commonly associated with a chronic wheezy child
Chlamydophilia (treat with Doxy or Azithromycin)
31
diagnostic tests for asthma (2)
1. Spirometry: FEV1:FVC ratio <0.7
2. FeNO (fractionated exhaled nitrous oxide): diagnosis confirmed if greater than 40ppb
Always do FeNO in adults (17+) with suspected asthma diagnosis, only do it in children if there is normal spirometry or obstructive spirometry with negative broncholidator reversibility (i.e. only do in children if there is doubt about the diagnosis)
32
First 4 steps in management of chronic asthma in adults and children
1. SABA
2. SABA + low dose ICS
3. SABA + low dose ICS + LTRA
4. SABA + low dose ICS + LABA +/- LTRA
In children always stop the LTRA at this point if it hasn't helped, in adults continuation of LTRA depends on patient's response to it
33
tiotropium is an example of a...
Long Acting Muscarinic Agonist
34
features of a life threatening asthma attack (6)
1. PEFR <33% best or predicted
2. Oxygen sats <92%
3. Normal pCO2 (4.6-6.0)
4. signs: silent chest, cyanosis or feeble respiratory effort
5. heart: Bradycardia, dysrhythmia or hypotension
6. exhaustion, confusion or coma
35
features of a severe asthma attack (4)
1. PEFR 33-50% best or predicted
2. Can't complete sentences
3. RR >25/min
4. Pulse >110 bpm
36
management of acute asthma
OSPITME
1. Admission if life threatening or severe and not responding to treatment
2. O2 if hypoxaemic
3. Salbumatol- nebulised if life-threatening, nebulised or standard inhaler if not life-threatening
4. Prednisolone 40-50mg PO for at least 5 days
5. Ipratropium bromide if severe/life-threatening asthma or not responding to treatment
6. thyophilline (aminophylline IV infusion) - considered by senior staff
7. Magnesium sulphate IV - given for life threatening/severe asthma but mixed evidence
8. Escalate to ITU/HDU (intubate/ventilate)
37
COPD:
1. Dyspnoea scale
2. Diagnostic test
3. Target sats when retaining CO2
1. MRC Dyspnoea scale
2. Spirometry, FEV1:FVC ratio <0.7
3. 88-92%
38
COPD management:
1. Step 1
2. Step 2 and 3 if asthmatic features?
3. Step 2 if no asthmatic features?
4. criteria for NIV?
1. SABA or SAMA
2. LABA + inhaled ICS
step 3: LABA + LAMA + ICS
3. add a LABA or a LAMA
if already taking a SAMA, switch this to a SABA
(SABA + LABA/LAMA)
4. pH <7.35 + PaCO2 >6 despite treatment
39
Idiopathic pulmonary fibrosis:
1. fingernail changes seen
2. Diagnostic test and results
3. life expectancy from diagnosis
4. Medication to slow disease progression?
5. Medications that can cause similar lung pathology
1. clubbing
2. High resolution CT- shows 'ground glass' appearance to the lungs
3. 2-5 years
4. Pirfenidone + Nintendanib
5. Amiodarone, Cyclophosphamide, Methotrexate, Nitrofurantoin
40
how to determine between transudative vs exudative pleural effusion
pleural fluid aspiration --> Light's criteria for protein measurement:
- Transudative= <30g/L (<3g/dL)
- Exudative= >30g/L (>3g/dL)
41
causes of exudative (>30g/L)
pleural effusion (6)
1. Lung cancer
2. Rheumatoid Arthritis, Lupus, TB
3. Pneumonia (most common cause)
4. Tuberculosis
5. PE
6. Pancreatitis
42
causes of transudative (<30g/L)
pleural effusion (4)
1. Heart failure
2. Hypothyroidism
3. Hypoalbuminaemia (liver disease, nephrotic syndrome, malabsorption)
4. Meig's syndrome
43
1. What is empyema?
2. pH of pleural fluid with empyema
3. Management
1. infected pleural effusion. Should be suspected when a patient who has an improving pneumonia suddenly develops new or ongoing fever
2.pH <7.2
3. Chest drain and antibiotics
44
tracheal deviation in massive pleural fusion is usually ____ the side of the lesion
away from
45
management of pleural effusions
1- if small effusion, conservative management
2- if large effusion, pleural aspiration with a needle or chest drain insertion
46
difference between a tension pneumothorax and a simple pneumothorax?
- tension pneumothorax is a medical emergency caused by trauma, where there is a one way valve created which lets air in and doesn't let air out of the pleural space, causing increased pressure. If not managed, it can cause cardiorespiratory arrest
- simple pneumothorax is non expanding. It can occur spontaneously, due to medical interventions (e.g. lung biopsy, mechanical venilation, central line insertion) or secondary to disease (infection, asthma, COPD)
47
investigations for pneumothorax (non-tension)
1. Erect CXR - shows area between lung tissue and chest wall with no lung markings and a line demarcating the edge of the lung where the lung markings end and the pneumothorax begins
2. If diagnostic uncertainty, can also do a CT thorax
48
management of a primary pneumothorax (pneumothorax with no underlying lung disease)
- If no SOB and <2cm rim of air: no tx required (usually spontaneously resolve). Follow-up at 2-4 weeks is recommended
- If SOB and/or >2cm rim of air: Needle Aspiration --> if it fails twice, then chest drain insertion
- If unstable or bilateral pneumothoraces, chest drain is normally required
49
management of secondary pneumothorax (pneumothorax in the presence of underlying lung disease)
- If patient is >50yrs and the rim of air is greater than 2cm AND/OR patient is SOB, a chest drain should be inserted
- If rim of air is 1-2cm, patient <50 and no SOB, then aspiration should be attempted
- If less than 1cm, give O2 and admit for 24hrs
50
management of tension pneumothorax (2)
emergency- do not wait for results of any investigations
1. First decompress with needle decompression- 2nd intercostal space mid clavicular line
2. Chest drain insertion in the triangle of safety - 5th intercostal space mid clavicular line
51
components of the DVT Wells Score + interpretation of score
Score 2 or more= DVT likely
Score 1 or less= DVT unlikely
○ Active cancer (tx ongoing, within 6mo, or palliative) - 1pt
○ Paralysis, paresis or recent plaster immobilisation of the lower extreemities - 1pt
○ Recently bedridden for 3 days or more or major surgery within 12wks requiring general or regional anaesthesia - 1pt
○ Localised tenderness along the distribution of the deep venous system - 1pt
○ Entire leg swollen- 1pt
○ Calf swelling at least 3cm larger than asymptomatic side - 1pt
○ Pitting oedema confined to the symptomatic leg- 1pt
○ Collateral superficial veins (non-varicose) - 1pt
○ Previously documented DVT - 1pt
○ An alternative diagnosis is at least as likely as DVT - -2pts
52
DVT Well's score less than 2
(1) - perform a D-Dimer within 4 hours. If not available within 4 hours, interim anticoagulation should be given with DOAC
- if the result is negative then DVT is unlikely and alternative diagnoses should be considered
- if the result is positive then a proximal vein US should be carried out within 4 hours. If not available within 4 hours, give interim anticoagulation
(2) If D-Dimer is positive and US is negative, stop interrim anticoag and repeat US 6-8 days later
53
DVT Well's score 2 or more
(1) Proximal leg US should be carried out within 4 hours. If not available within 4 hours then interim anticoagulation should be offered
- if result is positive then diagnose DVT and start DOAC
- if the result is negative do D-Dimer
- If D dimer and US are both negative then consider alternative diagnosis
- If US is negative and D Dimer is positive then stop interrim anticoag and repeat US 6-8 days later
54
DVT management:
1. First line
2. If the patient has active cancer
3. If renal impairment is severe (eGFR <15/min)
4. If patient has phospholipid syndrome
1. DOAC
2. DOAC
3. LMWH + VKA (warfarin)
4. LMWH + VKA (warfarin)
55
components of the PE Well's score and interpretation of score
Score 5 or more= PE likely
Score 4 or less= PE unlikely (do D Dimer)
○ Signs/Sx of a DVT (leg swelling and pain on palpitation) - 3pts
○ Alternative Dx is less likely than PE - 3pts
○ HR >100 bpm - 1.5pts
○ Immobility for more than 3 days in last 4wks - 1.5pts
○ Previous DVT/PE - 1.5pts
○ Haemoptysis - 1pt
○ Malignancy (on Tx, treated 6mo or palliative) - 1pt
56
PE Well's score of 5 or more
1. Do CTPA. If delay in getting CTPA then interim DOAC
If CTPA is positive, DOAC
2. If CTPA is negative, consider proximal leg US if DVT is suspected
57
PE Well's score of 4 or less
Do a D-Dimer
If positive, arrange a CTPA
If D-Dimer is negative, consider an alternative diagnosis
58
PE management:
1. first line
2. If pregnant
3. if haemodynamically unstable
4. If repeat PEs despite anticoag
1. DOAC
2. Low Molecular Weight Heparin. Warfarin should not be used in pregnancy as risk of haemorrhage but can be started 5 days postpartum
3.Thrombolysis (e.g. Alteplase)
4. If patient gets repeat PEs despite anticoagulation, consider patient for an IVC filter
59
Pulmonary hypertension:
1. 5 groups of causes
2. clinical signs (4)
3. ECG changes (3)
4. CXR signs (2)
5. Raised blood test?
6. Management
1. causes:
1- primary pulmonary hypertension
2- left sided heart failure
3- chronic lung disease e.g. COPD
4- pulmonary vascular disease (e.g. pulmonary embolism)
5- misc e.g. sarcoidosis
2. Clinical signs: tachycardia, raised JVP, hepatomegaly, peripheral oedema
3. ECG changes: right ventricular hypertrophy, right axis deviation, right bundle branch block
4. CXR: dilated pulmonary veins, right ventricular hypertrophy
5. NT-pro BNP
6. Anticoagulants, diuretics, oxygen, CCBs, digoxin if heart failure
60
30 year old black woman with a dry cough and breath
1. Diagnosis- what is it?
2. What are granulomas?
3. tender lumps on shins?
4. screening blood test?
5. electrolyte abnomality?
6. CXR finding?
7. Gold-standard investigation?
8. first line treatment?
1. Sarcoidosis- development of granulomas in multiple body tissues
2. nodules of inflammation full of Macrophages
3. Erythema nodosum
4. Serum ACE
5. Hypercalcaemia
6. Hilar Lymphadenopathy
7. Histology (biopsy)
8. Steroids
61
Obstructive sleep apnoea:
1. risk factors (3)
2. key symptoms (3)
3. Scale
4. Refer to?
5. Step after correcting risk factors?
1.Obesity, smoking, alcohol
2. morning headache, daytime somnolence, snoring
3. Epworth sleepiness scale
4. ENT/sleep clinic
5. CPAP machine use during sleep
62
Bronchiectasis:
1. What is it?
2. causes? (4)
3 Most common associated organism?
4. sputum or no sputum? other symptoms?
5. management? (4)
1. Permanent dilatation of the airways, usually secondary to chronic infection or inflammation
2. causes:
1- infection- pneumonia, TB, pertussis, measles
2- allergic bronchopulmonary aspergillosis
3- Bronchial obstruction e.g. lung cancer
4- cystic fibrosis
3. H.Influenzae
4. large volumes of sputum. Dyspnoea, haemoptysis, coarse crackles, clubbing. Tram-track sign on CXR
5. management:
1- physical training e.g. inspiratory muscles
2- postural drainage
3 - antibiotics for exacerbations (long term for severe cases)
4- surgery or bronchodilators for select cases
63
tuberculosis- investigation for latent TB
Mantoux test
64
tuberculosis- gold standard investigations for active TB
- CXR: upper lobe cavitation + bilteral hilar lymphadenopathy
- sputum culture
65
standard treatment for active tuberculosis
- first two months: RIPE
- continuation period for next four months: Rifampicin + Isoniazid
- steroids for extrapulmonary disease
66
treatment of latent TB
either isoniazid + Rifampicin for 3 months
OR
isoniazid for 6 months
67
Wegener's granulomatosis (Granulomatosis with polyangitis) - presentation:
1- Upper respiratory features
2- lower respiratory tract features
3- renal feature
4- nasal deformity
5- other features
1 - upper respiratory tract: epistaxis, sinusitis, nasal crusting
2- lower respiratory tract: dyspnoea, haemoptysis
3- rapidly progressive glomerulonephritis ('pauci-immune', 80% of patients)
4- saddle-shape nose deformity
5- also: vasculitic rash, eye involvement (e.g. proptosis), cranial nerve lesions
68
Wegener's granulomatosis (Granulomatosis with polyangitis) - investigations:
1- antibodies
2- CXR signs
3- renal biopsy
1- cANCA positive in > 90%, pANCA positive in 25%
2- chest x-ray: wide variety of presentations, including cavitating lesions
3- renal biopsy: epithelial crescents in Bowman's capsule
69
Management- Wegener's granulomatosis (Granulomatosis with polyangitis) (4)
1. steroids
2. cyclophosphamide (90% response)
3. plasma exchange
4. median survival = 8-9 years
70
cystic fibrosis:
1. mode of inheritance
2. Pathology
1. autosomal recessive
2. due to a defect in the cystic fibrosis transmembrane conductance regulator gene (CFTR), which codes a cAMP-regulated chloride channel.
In the UK 80% of CF cases are due to delta F508 on the long arm of chromosome 7. Cystic fibrosis affects 1 per 2500 births, and the carrier rate is c. 1 in 25
71
cystic fibrosis- management (6)
1. regular (at least twice daily) chest physiotherapy and postural drainage. Parents are usually taught to do this. Deep breathing exercises are also useful
2. high calorie diet, including high fat intake*
3. patients with CF should try to minimise contact with each other to prevent cross infection with Burkholderia cepacia complex and Pseudomonas aeruginosa
4. vitamin supplementation
5. pancreatic enzyme supplements taken with meals
6. lung transplantation
chronic infection with Burkholderia cepacia is an important CF-specific contraindication to lung transplantation
72
Asbestosis:
1. is risk related to length of asbestos exposure?
2. latent period
3. lung changes
4. management
1. yes- severity of disease is associated with length of exposure (unlike mesothelioma)
2. 15-30 years
3. lower lobe fibrosis
4. Treat conservatively- no interventions offer a significant benefit
73
Mesothelioma:
1. What is it?
2. which form of asbestos is most dangerous?
3. Management
4. Prognosis?
1. malignant disease of the pleura
2. blue (crocidolite) asbestos is most dangerous
3. Patients are usually offered palliative chemotherapy and there is also a limited role for surgery and radiotherapy
4. Prognosis is very poor, with a median survival from diagnosis of 8-14months
74
How to differentiate between pneumonia and acute bronchitis?
History: Sputum, wheeze, breathlessness may be absent in acute bronchitis whereas at least one tends to be present in pneumonia.
Examination: No other focal chest signs (dullness to percussion, crepitations, bronchial breathing) in acute bronchitis other than wheeze. Moreover, systemic features (malaise, myalgia, and fever) may be absent in acute bronchitis, whereas they tend to be present in pneumonia.
75
Bronchitis management
1. analgesia
2. good fluid intake
3. consider antibiotic therapy if patients:
are systemically very unwell
have pre-existing co-morbidities
have a CRP of 20-100mg/L (offer delayed prescription) or a CRP >100mg/L (offer antibiotics immediately)
NICE Clinical Knowledge Summaries/BNF currently recommend doxycycline first-line
4. doxycycline cannot be used in children or pregnant women
alternatives include amoxicillin
76
Goodpasture's syndrome
1. Aka? What is it?
2. associated antibodies and HLA-type?
3. Features? (2)
4. Investigations? (2)
5. management?
6. associated complication?
1. Anti-glomerular basement membrane (anti-GBM) disease, a small vessel vasculitis associated with both pulmonary haemorrhage and rapidly progressive glomerulonephritis.
2. associated with anti-glomerular basement antibodies against type IV collagen. Associated with HLA DR2
3. Features:
1- pulmonary haemorrhage
2- rapidly progressive glomerulonephritis- typically results in rapid onset of AKI and nephritis progresses to proteinuria + haematuria
4. Investigations:
1- renal biopsy: linear IgG deposits along the basement membrane
2- raised transfer factor secondary to pulmonary haemorrhages
5. Management:
plasma exchange (plasmapheresis)
steroids
cyclophosphamide
6. One of the main complications is pulmonary haemorrhage. Factors that increase the likelihood of this include:
smoking
lower respiratory tract infection
pulmonary oedema
inhalation of hydrocarbons
young males
76
Goodpasture's syndrome
1. Aka? What is it?
2. associated antibodies and HLA-type?
3. Features? (2)
4. Investigations?
5. management?
1. Anti-glomerular basement membrane (anti-GBM) disease, a small vessel vasculitis associated with both pulmonary haemorrhage and rapidly progressive glomerulonephritis.
2. associated with anti-glomerular basement antibodies against type IV collagen. Associated with HLA DR2
3. Features:
