Resp Flashcards by Rishi Banerjee

Signs of COPD in the hands

CO2 retention flap
Tar staining
Bounding pulse

How well did you know this?

Not at all

Perfectly

Signs of hyper expansion seen in a patient with COPD

 ↓ cricosternal distance
 Loss of cardiac dullness on percussion
 Palpable liver edge

How well did you know this?

Not at all

Perfectly

What are signs of cor pulmonale?

 ↑JVP
 Left parasternal heave: RV hypertrophy
 LoudP2±S3
 MDM of pulmonary regurg
 Ascites and pulsatile hepatomegaly
 Peripheral oedema

How well did you know this?

Not at all

Perfectly

Definition of COPD

Is used to define two conditions:

Chronic bronchitis: Cough productive of sputum on most days for ≥3mo on ≥2 consecutive years

Emphysema: Histological description of alveolar wall destruction with air collapse and air trapping

How well did you know this?

Not at all

Perfectly

4 features you would see on spirometry of a patient with COPD?

 ↑ TLC and residual volume (RV)
 FEV1 <80%
 FEV1:FVC <0.7
 ↓ transfer factor

How well did you know this?

Not at all

Perfectly

How can you determine the prognosis of a patient with COPD?

Bode index

Looks at:
 BMI
 Obstruction: FEV1
 Dyspnoea: MRC score
 Exercise capacity: 6 min walk

How well did you know this?

Not at all

Perfectly

Gold Classification COPD

Global Initiative for Obstructive Lung Disease) - allows you to tailor therapy to the patient

Looks at:

 mMRC dyspnoea score (modified medical research council)
 Airflow limitation
 No. of exacerbations per year

How well did you know this?

Not at all

Perfectly

Conservative management of COPD (4)

MDT
 GP, dietician, physio, resp physician, specialist nurses
 Regular review 1-2x / yr

Smoking Cessation: single most important intervention
 Specialist nurse and support programme
 Nicotine replacement therapy
 Varenicline: partial nicotinic agonist

Pulmonary Rehabilitation Therapy
 Tailored exercise programme
 Disease education
 Psychosocial support

Co-morbidities
 Nutritional assessment and dietary support
 CV risk Mx
 Vaccination: pneumococcal and seasonal influenza

How well did you know this?

Not at all

Perfectly

Medical Management of COPD

Principal Therapies
 Anti-muscarinics: short- or long-acting
 β-agonists: short- or long-acting
 Inhaled corticosteroids: in combination ̄c β-B

Other Therapies
 Theophylline or Roflumilast: PDIs 
 Carbocisteine: mucolytic
 Home emergency pack for acute exacerbations 
 LTOT

How well did you know this?

Not at all

Perfectly

Surgical Management of COPD

 Used for recurrent pneumathoraces or large bullae

 Bullectomy
 Lung reduction surgery (removing damaged parts of the lungs)

How well did you know this?

Not at all

Perfectly

Definition of asthma

Episodic, reversible airway obstruction due to bronchial hyper-reactivity to a variety of stimuli.

How well did you know this?

Not at all

Perfectly

Conservative management of Asthma

M TAME

General
 MDT: GP, specialist nurses, respiratory physician
 Technique for inhaler use
 Avoidance: allergens, smoke (ing), dust
 Monitor: Peak flow diary (2-4x/d)
 Educate
        Liaise  ̄c specialist nurse 
        Need for Rx compliance 
        Emergency action plan

How well did you know this?

Not at all

Perfectly

Management of acute asthma exacerbations

Immediate

Sit-up
100% O2 via non-rebreathe mask (aim for 94-98%)
Nebulised salbutamol (5mg) and ipratropium (0.5mg) 4. Hydrocortisone 100mg IV or pred 50mg PO (or both) 5. Write “no sedation” on drug chart

Life threatening
 Inform ITU
 MgSO4 2g IVI over 20min
 Nebulised salbutamol every 15min (monitor ECG)

IV Rx if No Improvement in 15-30min:
 Nebulised salbutamol every 15min (monitor ECG)
 Continue ipratropium 0.5mg 4-6hrly
 MgSO4 2g IVI over 20min
 Salbutamol IVI 3-20ug/min
 Consider aminophylline
          Load: 5mg/kg IVI over 20min
          Monitor Levels
ITU for intubation

How well did you know this?

Not at all

Perfectly

What are some of the causes of PF?

Upper (PENTA):
 Pneumoconiosis: Coal, Silica
 Extrinsic allergic alveolitis
 Negative, sero-arthropathy (ank spond)
 TB
 Aspergillosis : ABPA

Lower (STAIR):
 Sarcoidosis (mid zone)
 Toxins: BANS ME
 Asbestosis
 Idiopathic pulmonary fibrosis
 Rheum: RA, SLE, SS, Sjogren’s, PM/DM

TOXINS (BANS ME):
 Bleomycin, Busulfan
 Amiodarone
 Nitrofurantoin
 Sulfasalazine
 MEthotrexate

How well did you know this?

Not at all

Perfectly

Spirometry results for PF?

 ↓TLC ̧ ↓RV, ↓FEV and ↓FVC
 FEV1:FVC >0.8
 ↓ transfer factor

How well did you know this?

Not at all

Perfectly

Management of PF

MDT: GP, pulmonologist, physio, psych, palliative care,
specialist nurses, pts. family

Anti fibrotic: e.g. perfenidone

Rx specific cause:
 EAA: steroids
 Sarcoidosis: steroids
 Connective tissue disease: steroids

Supportive care:
Stop smoking: single most beneficial strategy Pulmonary rehabilitation
LTOT
Symptomatic: anti tussive such as codeine phosphate

How well did you know this?

Not at all

Perfectly

Ddx for bronchiectasis

COPD
Asthma
Pneumonia

Causes of bronchiectasis

Congenital
 CF
 PCD / Kartagener’s
 Young’s: azoospermia + bronchiectasis
 Hypogammaglobulinaemia: XLA, CVID, SAD

Acquired
 Idiopathic
 Post-infectious: pertussis, TB, measles
 Obstruction: tumour, foreign body
 Associated: RA, IBD (esp. UC), ABPA

Ix for bronchiectasis

Sputum

Blood
 FBC: ACD
 Serum Ig: may do provocative testing
 Aspergillus: RAST, precipitins, ↑IgE, eosinophilia  RA: anti-CCP, RF, ANA

Spirometry
 Obstructive

HRCT
 Signet ring sign: thickened dilated bronchi + smaller adjacent vascular bundle
 Pools of mucus in saccular dilatations

CXR
 tramlines and ring shadows (bunch of grapes)

Management of bronchiectasis

Conservative
 MDT: GP, pulmonologist, physio, dietician, immunologist
 Physio: postural drainage, active cycle breathing, pulmonary rehabilitation

Medical
 Abx
 Exacerbations: e.g. cipro for 7-10d
 May use prophylactic azithromycin
 Bronchodilators: nebulised β agonists
 Treat underlying cause
 CF: DNAase, pancreatin (Creon), ADEK vitamins
 ABPA: Steroids
 Immune deficiency: IVIg
 Vaccination: flu, pneumococcus

Surgical
 May be indicated in severe localised disease or obstruction

Organs affected by CF

 Bronchioles → bronchiectasis
 Pancreatic ducts → DM, malabsorption
 GIT → Distal Intestinal Obstruction Syndrome
 Liver → gallstones, cirrhosis
 Fallopian tubes → ↓ female fertility
 Seminal vesicles → male infertility

Causes of pleural effusion

Transudate

CCF
Renal failure
↓ albumin
Hypothyroidism
Meig’s syn.

Exudate

Infection: pneumonia, TB -Ca:1O or2O
Inflammation: RA, SLE
Infarction: PE
Trauma

What are the types of lung malignancy?

Non-Small Cell Lung Cancer
SCC: 35%
 Highly related to smoking 
 Centrally located
 PTHrP → ↑ Ca2+

Adenocarcinoma: 25%
 RF: female non-smokers
 Peripherally located
 80% present ̄c extrathoracic mets

Large-cell: 10%

Small Cell Lung Cancer: 20%
       Highly related to smoking
       Central location
       80% present  ̄c advanced disease
       Ectopic hormone secretion

Outline the CURB 65 score and how would you interpret the result

Severity: CURB-65 (only if x-ray changes)

 Confusion (AMT ≤8) 
 Urea >7mM
 Resp. rate >30/min 
 BP <90/60
 ≥65

Score
0-1 → home Rx
2 → hospital Rx
≥ 3 → consider ITU

How do you treat TB and what are some of the side effects of the drugs?

 RMP: hepatitis, orange urine, enzyme induction  INH: peripheral sensory neuropathy, ↓PMN  PZA: hepatitis, arthralgia (CI: gout, porphyria)  EMB: optic neuritis → loss of colour vision first

Causes of obstructive lung disease

``` Asthma COPD Bronchiectasis Bronchiolitis obliterans Alpha 1 Antitrypsin deficiency ```

Causes of restrictive lung disease

Pulmonary fibrosis Asbestosis Sarcoidosis ``` Acute respiratory distress syndrome Infant respiratory distress syndrome Kyphoscoliosis e.g. ankylosing spondylitis Neuromuscular disorders Severe obesity ```

Causes of apical lung fibrosis

``` C- Coal worker's pneumoconiosis H - Histiocytosis/ hypersensitivity pneumonitis A - Ankylosing spondylitis R - Radiation T - Tuberculosis S - Silicosis/sarcoidosis ```

Causes of lower lobe lung fibrosis

``` Sarcoid Toxins Asbestosis Idiopathic PF Rheumatological ``` Most connective tissue disorders (except ankylosing spondylitis) e.g. SLE Drug-induced: amiodarone, bleomycin, methotrexate

Ddx for coarse crackles

Pneumonia Bronchiectasis (can be mixed) Pulmonary oedema Discontinuous, brief, popping sounds. They have also been described as a bubbling sound. More common during inspiration.

Ddx for fine end-inspiratory crackles

Fine end-inspiratory crackles are associated with pulmonary fibrosis Brief, discontinuous, popping sounds that are high-pitched. Similar to wood burning in a fireplace. More commonly heard during inspiration.

How can you tell the difference between fine and coarse crackles?

Fine are usually smaller airways and normally on inspiration Coarse usually on inspiration and expiration and may change if you ask the patient to cough

Features O/E of lung collapse?

Trachea deviation towards affected side Reduced breath sounds Dull to percussion

4 causes of pulmonary hypertension?

``` Chronic thromboembolic disease/recurrent PEs Chronic lung disease Congenital heart disease Left sided heart disease HTN ```

Causes of trachea pulled toward the white-out on xray?

Pneumonectomy Complete lung collapse e.g. endobronchial intubation Pulmonary hypoplasia

Causes of Trachea pushed away from the white-out on xray?

Pleural effusion Diaphragmatic hernia Large thoracic mass

Causes of trachea central on white-out CXR?

Consolidation Pulmonary oedema (usually bilateral) Mesothelioma

Causes of exudative pleural effusion?

The Boys In the NYPD Choir were singing Exudate: ``` TB Infection (pneumonia, abscess) Neoplasm Yellow nail syndrome PE, Pancreatitis Dressler's syndrome Connective tissue: RA & SLE ```

Findings on lung function test of restrictive conditions?

Reduced FEV1 Significantly reduced FVC Normal/increased FEV1/FVC ratio

Findings on lung function test of obstructive conditions?

FEV1 - significantly reduced FVC - reduced or normal FEV1% (FEV1/FVC) - reduced