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T year LOBs medicine > RESP ashtma > Flashcards

Flashcards in RESP ashtma Deck (142):
1

what are three characteristics of asthma?

1. airflow limitation
2. airway hyper-responsiveness
3. Bronchial inflammation

2

what causes inflammation in airways?

- Increase in mast cell mediated release of histamine, tryptase, PGD2 and cytokines
- increase eosinophils in the bronchial wall releasing LTC4
- Increase CD4

3

what are the results of lung function tests in asthma?

- peak expiratory flow rate before and after using a bronchodilator
- spirometry will show an obstructive condition

4

what is the step wise management of asthma?

1. SABA
2. + Low dose corticosteroids
3. +LABA
4. +high dose inhaled corticosteroids and regular bronchodilator
5.+ oral corticosteroid

5

how are SABAS used in asthma?

Salbutamol 100mg. Can be used in any step

6

when are inhaled low dose corticosteroids used in asthma treatment?

From step 2 (with SABA)

7

what are unwanted effects of inhaled corticosteroids?

oral candidiasis
hoarseness

8

What are signs of an asthma attack?

- inability to complete a sentence in one breath
- RR>25
- tachycardia >110
- PEFR<50%

9

what is management of an asthma attack?

Nebulised SABA
CXR to exclude causes
oral prednisolone

10

how does SABA work?

A beta 2 agonist
smooth muscle relaxation on the bronchi

11

what are the major side effects of SABA?

tachycardia
fight or flight effects
- palpitations
- anxiety
-tremor

12

how do leukotriene antagonists work?

- bronchodilator and anti inflammatory effect
- stop the formation of LTC4,LTD4,LTR4 which are all pro inflammatory

13

what drug should you not give an asthmatics?

NSAIDS especially COX 1 specific

Beta blockers (bronchoconstriction)

14

what is the emergency management for life threatening asthma?

Nebulised oxygen and salbutamol Hydrocortisone
Ipratropium
Magnesium sulphate if they get resp acidosis

15

what is the role of NIV in the management of acute asthma?

It has no place here

16

what are features of severe asthma?

- peak flow 33-50% of predicted
- RR>25
HR >110
- Can't complete sentences

17

what are features of life threatening asthma?

- peak flow <33% predicted
- oxygen sats <92%
- hypoxic
- silent chest cyanosis
- bradycardia
- hypotension
- exhaustion
- confusion

18

what is the emergency management of asthma for someone coming into A and E?

O- nebulised oxygen
S-salbutamol
H- hydrocortisone
I- ipratropium
M- magnesium sulphate if they get resp acidosis
T-theophiline

19

what symptoms are experienced by people with COPD?

- COB
-productive cough
- increased sputum
-frequent bronchitis
- pursed lipped breathing
- red faced

20

what are the systemic symptoms of COPD?

- cachexia
- increased CRP leading to increased CVS risk
- normochromic normocytic anaemia
- systemic inflammation

21

what clinical signs are found in people with COPD?

- nicotine stained fingers due to heavy smoking
- pursed lip breathing
- breathing with accessory muscles
- barrel chested
- reduced expansion
- crackles
- soft heart sounds
- hypercapnia
- hyperinflation
- liver problems if there is an AAT deficiency.

22

what anatomical changes are involved in the pathophys of COPD?

Proximal airways:
- trachea and cartilagenous airways become enlarged >2mm due to submucosal bronchial enlargment, squamous metaplasia of the airway epithelium and increased smooth muscle

The peripheral airways become <2mm as there is increased macrophages ND FIBROBLASTS.

- alveolour wall destruction and emphysema

23

where is centrilobular emphysema?

Main in the upper lobes associated with smokers.

24

what is panacinar emphysema?

Destruction of the acinus seen in AAT deficiency. affects the lower zomes

25

what are the three main processes in COPD development?

1. inflammation
2. protease and anti-protease imbalance
3. oxidant and anti oxidant imbalance

26

what is the inflammation seen in COPD?

1. cigarrete smoke activates macrophages and epithelial cells
2. release of chemotactic factors
3. recruitment of neutrophils and CD8 (CD8>CD4)
4. activation of fibroblasts
5. abnormal repair and bronchiolar fibrosis

27

What is the problem of the increased protease activity in COPD?

they lead to increased alveolour wall destruction and cause mucous release

28

what proteases are released from neutrophils in COPD?

elastase, cathepsin G, protease 3

29

what proteases come from macrophages in COPD?

cysteine protease
cathepsins EALS

30

what are the main ant proteases that you lack in COPD?

AAT#secretory leucoprotease inhibitor
tissue inhibitor of MMP

31

what causes the increased oxidative stress in COPD?

activation of antiproteases, stimulation of mucous production
oxidants come from cigRETTE SMOKE.

32

what are some causes of COPD?

AAT1 deficiency
smoking
ashtma/ airway hyperactivity
recurrent infections
dust mining

33

what spirometry figures are for mild airflow obstruction in COPD?

FEV 50-80%

34

what spirometry figures are for moderate airway obstruction in COPD?

FEV: 30-49%

35

what spirometry figures are for severe airway obstruction in COPD?

FEV <30%

36

what may be seen in a chest xray of a COPD patient?

hyperinflation of the lungs
flattening of the diaphragm
bullae
large proximal vessels

37

what can be seen in the ECG of a COPD patient?

RVH
right axis deviation
big P waves

38

what main drugs are used in smoking cessation?

bupropion/zyban
varenicline/ chantix
Cytisine

39

what is bupropion?

Used for smoking cessatation and reduces cravings

40

what are side effects of bupropion?

dry mouth
problems sleeping
behaviour changes

41

who shouldn't take bupropion?

pregnant
under 18

42

what is varenicline?

Oral partial agonist of nicotonic Ach receptor to reduce withdrawal and craving.

43

what are types of bronchodilators?

Beta agonists
Anti cholinergics

44

what are examples of SABA used in COPD?

anti cholinergic: ipratropium
Beta 2: albuterol

45

why are corticosteroids used in COPD?

to improves symptoms, lung function and aid chronic inflammation

46

what is the problem of giving corticosteroids in COPD?

increased risk of pneumonia

47

what is theophyline?

A bronchodilator that blocks conversion of Camp.

48

what are adverse effects of theophylline?

nausea
hypokalaemia
abdominal pain
headache
diarrhoea

49

what are complications of COPD?

Cor pulmonale
Depress
Resp failure
Increased infections
Polycythaemia
Pulmonary hypertension

50

what causes cor pulmonale in COPD?

Pulmonary hypertension due to peripheral vascular constriction. this leads to right ventricular hypertrophy.

51

what is the main organism respinsible for infection in COPD?

haemophillus influenzae B

52

why can COPD patients get polycythaemia?

COPD causes hypoxia causes excess EPO leading to increased red blood cells

53

what is the emergancy maanagement in a patient presenting with IECOPD?

1. sit up
2. stop any sedatives
3. salbutamol (bronchodilator)
4. ipratropium
5. antibiotics
6. corticosteroids

54

what is the oxygen target in COPD?

88-92%

55

what organisms are common in COPD patients?

haemophilus influenzae B
Strep pneumonia
moraxella catarhallis

56

what are the consequences of hypoxia?

Polycythaemia
cerebral ischaemia
myocardial ischaemia
tumour angiogenesis
pulmonary vasoconstriction
Peripheral vessel vasodilation

57

what are the consequences of hypercapnia?

acidosis
cerebral vasodilation
hypoxia
mild: increased RR
severe: decreased RR

58

what is type 1 resp failure?

oxygen below 8kpa

59

what is type 2 resp failure?

oxygen below 8
carbon dioxide above 6

60

what are the three areas of the brain that control breathing?

1. inspiratory centre
2. pneumotaxic centre
3. expiratory centre

61

what are symptoms and signs of pulmonary TB?

long term cough
pleurisy
haemoptysis
pleural effusion
systemic symptoms

62

what is the microbiology of TB?

ziehl neelsen or auramine rhodamine staining
nucleic acid amplification

63

what is the pathophys of pulmonary TB?

inhalation of the bacteria
ingestion of the bacteria by alveolour macrophages
bacteria will proliferate in the macrophages
release of neutrophil chemoattractants and cytokines
inflammatory cell infiltrate will reach the lung and hilar lypmh nodes
macrophages present to T cells
cellular response of a delayed hypersensitivity reaction
tissue necrosis and granuloma formation

64

what is a granuloma lesion in TB?

there is a central necrotic caseation surrounded by epitheliod cells and langhans giant cells both from macrophages

65

how do you investigate TB?

- ziehl nelson stainin
- culture
- nucleic acid amplification
- CXR
- sputum smear for acid fast bacilli
- mantoux testing

66

what is the size needed of the mantoux testing area for TB?

>5mm if there are risk factors
>15mm if there are no risk factors

67

what drugs are used to treat TB?

Rifampicin
Isoniazid
Pyrazinamide
Ethambutol

68

how is rifampicin given for TB?

2 months intensive and 4 months continuation

69

when should rifampicin be stopped?

when it causes more than 3x elevation of bilirubin or transferases

70

what are side effects of isoiazid?

- polyneuropathy if causing a B6 deficiency
- hepaitits so give with pyridoxine

71

when should you change the dose of pyrazinamide?

GFR <30

72

what are effects of ethambutol?

retrobulbar neuritis
colour blindness
change in visual acuity

73

what is primary TB?

the first infection with the myobacterium.

74

what factors are involved in the reactivation of latent TB?

HIV, immunosuppresion, diabetes, end stage CKD, malnutrition, ageing.

75

what is the mantoux test?

A screening test for TB
if positive will cause a delayed hypersensitivity reaction and raised skin lesion

76

why does a positive mantoux test cause a raised skin lesion?

Previous infection means T cells are sensitised and will be recruited to the injection site.
T cells will cause release of lymphokines which cause vasodilation, oedema, fibrin deposition and recruitment

77

what are indications for the BCG vaccine?

- all infants where the annual incidence is greater than 40/100,000

- all infants with a parent or grandparent born in a country where the risk is greater than 40/100,000

- occupational risk

- travel risk

78

what are features of a tension pneumothorax?

- sudden onset unilateral -pleuritic chest pain
- SOB
-chest tightness
- hypotension
- tachycardia
- distended neck veins
- tracheal deviation

79

what is the emergency management of a tension pneumothorax?

- rapid decompression in the 2nd intercostal mid clavicular line

- thoracostomy in the 5th intercostal space mid auxillary line

80

what are causes of a pneumothorax?

- trauma
- spontaneous in tall, thin people
- ashtma
- COPD
- cystic fibrosis
- carcinomas
-connective tissue disorders

81

what investigations should be done for a pneumothorax?

- CXR
- reduced breath sounds
- hyperesonant on percussion
- ABG

82

what is the management of a pneumothorax?

- no SOB and <2cm = conservative watch and wait

- SOB and air space >2cm--> needle aspiration in the 2nd intercostal space mid clavicular line

chest drain if unsuccessful

83

what are signs of pneumonia?

fever, chills
increased sputum production, SOB, pleuritic pain
-crackles
- cyanosis
- dull percussion
- pleuritic chest pain
- myalgia

84

what pneumonia causes rust coloured sputum?

pneumococcal

85

what are risk factors for CAP?

- aged under 16 or over 65
- Co morbidities such as D.M, CKD, malnutrition
- respiratory conditions
- smoking, alcohol, IV drugs
- immunosuppresed

86

what are the main causes of pneumonia CAP?

- strep pneumoniae
- haemophillus
- staph aureus

87

what are the main causes of HAP?

- gram negatives
- staph aureus

88

what causes atypical lower resp infections?

- chlamydia pneumoniae
- mycoplasma pneumoniae
- legionella pneumoniae

89

what signs suggest an atypical is responsible for pneumonia?

-symptoms emerge slower
- low grade fever
- dryer cough
- more mild

90

how do you determine the severity of pneumonia?

CURB 65?

91

what is CURB 65?

1. confusion using AMTS score
2. urea >7
3. resp rate >30
4. BP <90/60
5. aged 65 or over

92

what do different CURB 65 scores mean?

0-1 = outpatient treatment
2= admit to hospital
3= consider intensive care

93

why can a urine sample be helpful in pneumonia diagnosis?

check for legionella and pneumococcal antigens

94

what antibiotics are effective against strep pneumoniae?

penicillin
erythromycin

95

what antibiotic is helpful in aspiration pneumonia?

metronidazole

96

what antibiotics are often used for HAP?

- aminoglycoside with penicillin/ 3rd gen cephalosporin

97

what antibiotics are often used for legionella?

fluoroquinolone with rifampicin or clari

98

what antibiotics is often given for chlamydiophilia pneumoniae?

tetracycline

99

who should get the pneumococcal vaccine?

All adults over 65
chonic heart, liver or renal conditions
- DM
- immunosupresion

100

what are signs and symptoms of a DVT?

- asymptomatic
- PE features
- calf pain
- warmth on the site
- homans sign
- mild fever
- pitting oedema

101

what are risk factors for DVT/PE?

- malignancy or treatment
- age >60 years
- long distance flight
- known thrombophilia
- BMI>30
- Personal history/ family history of VTE
- varicose veins with phlebitis
- pregnancy and childbirths
- COCP

102

what is in wells score?

1, active cancer or treatment within the last 6 months
3. Paralysis, paresis or immobilisation of the leg.
4. Recently bedridden for over 3 days or major surgery in the last 12 weeks
5. Local tenderness along distribution of leg venous system
6. Entire leg swollen
7. Calf swelling >3cm compared with asymptomatic leg
8. Pitting oedema
9. Collateral superficial veins
10. Previously documented DVT
11. The alternative diagnosis is at least as likely as DVT

103

what investigations do you do for a suspected DVT?

D dimer
doppler ultrasound
- venogram

104

what is the MOA of LMWH?

inhibits thrombin and factor X

105

what is the MAO of warfarin?

inhibits hepetic production of vitamin K dependant clotting factors

106

what makes a patient moderate risk for DVT/PE for travel?

- previous history of DVT/PE
- surgery in the past 2 months but not in the past 4 weeks
- pregnant/postpartum
- cardiac disease
- HRT/COCP
- BMI >30
- Varicose veins with phlebitis
- first degree relative with a thromboembolism history
- polycythaemia
- lower limb fracture in plaster
-

107

what advise is given to people travelling at moderate risk of DVT/PE?

- General advise
- compression stockers

108

what puts patients at high risk of a DVT/PE when travelling?

- surgery in the past four week
- known thrombophilia
- cancer

109

what adive is given to high risk patients of DVT/PE when travelling?

recommend delaying/ cancelling
- general advise
- compression stockings
- LMWH

110

what are symptoms/signs of a PE?

- sudden SOB
- tachycardia
- elevated JVP
- pleuritic chest pain
- haemoptysis
- syncope
- hypotension
- gallop rhythm

111

what imaging is helpful in suspected PE?

- V/Q scanning
- CTPA

112

what are the clinical featuers of a massive PE?

severe central chest pain
shocked, pale and sweating
syncope
raised JVP
right ventricular heave

113

what is the management of PE?

- high flow oxygen
- anticoagulation with fondaparinux or LMWH
- thrombolysis with alteplase

114

what is the clinical definition of COPD?

progressive airway obstruction which doesn't change over months, persistant and poorly reversible

115

what is the definition of chronic bronchitis?

cough productive of sputum for 3 consecutive months for 2 consecutive years with no other cause

116

what is emphysema?

permanent dilatation of the airways distal to the terminal bronchiole, dilations due to destruction of alveolour walls

117

how does smoking effect the bronchi?

hyperplasia of mucus producing glands in the submucosa and hyperplasia of goblet cells on the surface epithelium meaning increased sputum production

118

how does smoking affect smaller airways?

chronic inflammation leads to fibrosis healing causing stenosis

119

in COPD there is destruction of alveolour walls, what are the two main effects of this destruction?

- loss of pulmonary surface area leading to hypoxia
- loss of elastic tissue in the terminal airways leading to a loss of natural recoil meaning reduction in airflow

120

what are causes of acute exacerbations fo COPD?

- infection
- pneumothorax
- PE
= LVF
- lung carcinoma

121

what are the common causes of infective exacarbations of COPD?

h. influenzae
M. catarrhalis
S pneumonia
virus

122

why can COPD cause pulmonary hypertension?

- emphysema
- hypoxia causes pulmonary vasoconstriction
- increased EPO MEANING INCREASED BLOOD VISCOSITY

123

what is pulmonary hypertension?

an increase in blood pressure in the pulmonary vasculature above 25

124

what is pneumonia?

inflammation of the lung parenchyma due to infection

125

what is bronchopneumonia?

widespread patchy inflammation centred on the airways often bilateral

126

what is lobar pneumonia?

diffuse inflammation affecting the entire lobes or lobe.

127

what is the most common cause of mild CAP?

s.pneumoniae

128

what are important causes of severe CAP?

s.pneumoniae
legionella
s.aures

129

what are diffuse parenchymal lung disease?

conditions characterised by inflammation centres on the interstitum of alveolour walls

130

Pneumoconioses are a cause of DLPD what does this mean?

That it is caused by inhaled inorganic dusts often mineral for example coal dust, silica or asbestosis

131

extrinsic allergic alveolitis are a cause of DLPD what does this mean?

inhaled organic particles are to blame for example pigeon poo or farmers lung

132

what multisystem diseases can cause DLPD?

Sarcoid, SLE,RA, scleroderma, sjogrens, polymyositis, dermatomyositis

133

how do you diagnose DPLD?

- CXR
- CT shows reticulation
- lung biopsy

134

what are long term complications of DLPD?

cor pulmonale
pulmonary heart failure

135

what are the majority of lung cancers?

Adenocarcinoma

136

what is the most common sit of metastatic caner?

The lung

137

what lung cancers have a strong association with smoking?

Small cell (strongest association)
squamous cell

138

where dpes squamous cell carcinoma tend to arise?

larger airways near the hilum

139

what is the most common type of lung cancer in non smokers?

adenocarcinoma

140

what gene can adenocarcinomas be assoicated with?

EGFR

141

where do adenocarcinomas tend to arise?

peripheral smaller airways

142

where do small cell carcinomas tend to arise?

centrally