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Respiratory > Resp - Pneumothorax, Pleural Effusion, Pneumonia, Pulmonary HTN, Sarcoidosis, PE > Flashcards

Resp - Pneumothorax, Pleural Effusion, Pneumonia, Pulmonary HTN, Sarcoidosis, PE Flashcards

1
Q

Pneumothorax - what is it?

A

Pneumothorax - is when air gets in the pleural space separating the lung from the chest wall

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2
Q

Pneumothorax - what are 4 causes?

A
  1. Spontaneous
  2. Trauma
  3. Iatrogenic e.g. lung biopsy
  4. Pathology - infection, COPD
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3
Q

Pneumothorax - what is the investigation of choice?

A

Erect chest x-ray

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4
Q

Pneumothorax - what would you see on a chest x-ray?

A

Area between lung tissue and chest wall with no lung markings

Line demarcating lung edge, where lung markings end and pneumothorax begins

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5
Q

Pneumothorax - what is the stepwise management for a primary pneumothorax and a secondary pneumothorax?

A

Primary:

  1. if the rim of air is < 2cm and the patient is not short of breath then discharge should be considered - DISCHARGE
  2. otherwise, aspiration should be attempted - ASPIRATE
  3. if this fails (defined as > 2 cm or still short of breath) then a chest drain should be inserted - CHEST DRAIN

Secondary:

  1. if the patient is > 50 years old and the rim of air is > 2cm and/or the patient is short of breath then a chest drain should be inserted - CHEST DRAIN
  2. otherwise aspiration should be attempted if the rim of air is between 1-2cm. If aspiration fails (i.e. pneumothorax is still greater then 1cm) a chest drain should be inserted. All patients should be admitted for at least 24 hours - 1 to 2cm, ASPIRATE, FAILS -> CHEST DRAIN
  3. if the pneumothorax is less the 1cm then the BTS guidelines suggest giving oxygen and admitting for 24 hours - ADMIT AND O2
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6
Q

Pneumothorax - what is a tension pneumothorax?

A

Tension pneumothorax caused by trauma to chest wall creating one way valve:

Air can get into pleural space during inspiration
Air can’t escape during expiration

So more air drawn into pleural space with each breath, can’t escape, pressure builds inside mediastinum, pushes mediastinum across (away from TP), kinks big vessels, can cause cardiorespiratory arrest

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7
Q

Pneumothorax - signs of tension pneumothorax on examination and obs?

A

Reduced air entry to affected side

Tachycardic

Hypotension

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8
Q

Pneumothorax - what would a tension pneumothorax show on XRAY?

A

Tracheal deviation away from pneumothorax side

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9
Q

Pneumothorax - management of tension pneumothorax?

A

Insert a large bore cannula into the second intercostal space in the midclavicular line

Once pressure is relieved with cannula, do chest drain fro definitive management

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10
Q

Pleural effusion - what is it?

A

Collection of fluid in pleural cavity

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11
Q

Pleural effusion - what are the two types of fluid it can be?

A

Exudative - high protein count >3g/dL

Transudative <3g/dL

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12
Q

Pleural effusion - what are exudative causes?

A

Exudative causes related to inflammation

Inflammation results with protein leaking out of tissues into pleural space

‘EX’udative - meaning moving out

Lung cancer
Pneumonia
Rheumatoid A
TB

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13
Q

Pleural effusion - what are transudative causes?

A

Transudative causes relate to fluid moving into the pleural space

‘TRANS’udative - meaning moving across

Congestive Cardiac Failure
Hypothyroidism
Hypoalbuminaemia - liver disease, less protein in blood so reduced oncotic pressure, so fluid moves out of blood vessels as oncotic pressure from albumin (protein), isn’t there to keep fluid in

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14
Q

Pleural effusion - what are the symptoms?

A
  1. SoB
  2. Pleuritic pain
  3. Non-productive cough
  4. Extra-pulmonary symptoms depending on underlying cause e.g. weight loss in malignancy
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15
Q

Pleural effusion - what are the signs?

A

Stony dull percussion over effusion

Reduced breath sounds

Tracheal deviation away from effusion if massive (>1000ml)

Reduced chest expansion

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16
Q

Pleural effusion - what imaging do you do and what do you see?

A

Chest X-Ray

Blunting of costophrenic angles
Meniscus if big effusion
Fluid in lung fissures
Tracheal deviation away from effusion

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17
Q

Pleural effusion - what other investigation can you do?

A

Pleural paracentesis and analysis

Analyse for protein count, pH, glucose, lactate dehydrogenase, microbiology testing

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18
Q

Pleural effusion - management

A

Should be directed towards underlying cause

  1. Small effusion - conservative management may be appropriate, as may resolve by fixing underlying cause
  2. Large effusion - pleural aspiration, effusion may recur, may need to repeat aspiration
  3. Chest drain - used to drain effusion and prevent it recurring
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19
Q

Pneumonia - what is it?

A

Infection of the lung tissue

Causes inflammation of lung tissue and sputum filling the airways and alveoli

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20
Q

Pneumonia - what are the three classifications of pneumonia?

A

COMMUNITY ACQUIRED PNEUMONIA - pneumonia developed outside of hospital

HOSPITAL ACQUIRED PNEUMONIA - develops >48 hours after hospital admission

ASPIRATION PNEUMONIA - develops as a result after inhaling foreign material

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21
Q

Pneumonia - what is the presentation?

A 
SoB
Productive cough
Fever
Haemoptysis
Pleuritic chest pain
Confusion
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22
Q

Pneumonia - what are the signs (obs)?

A 
Tachypnoea
Tachycardia
Hypoxia
Hypotension
Fever
Confusion

These obs can indicate sepsis secondary to pneumonia

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23
Q

Pneumonia - what are the signs on chest examination?

A

Bronchial breath sounds - heard on inspiration and expiration

Focal coarse crackles - this is the sound of air passing through the sputum

Dullness to percussion

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24
Q

Pneumonia - CRB65 and CURB65

A

CRB65 out of hospital

CURB65 in hospital

In CRB65, if score is anything other than 0, consider referral to hospital

Score predicts mortality, used to help guide whether to admit patient to hospital

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25
Q

Pneumonia - what are the parameters of CURB65?

A 
C - confusion
U - urea >7
R - resp rate >30
B - <90 systolic <60 diastolic
65 - age >65
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26
Q

Pneumonia - CURB65 scores

A

0/1 - consider home treatment
>2 consider hospital admission
>3 consider ICU assessment

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27
Q

Pneumonia - common causes

A

50% streptococcus pneumoniae

20% haemophilus influenzae

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28
Q

Pneumonia - what two headings can community acquired pneumonia be divided into, and what are the features of each?

A

Typical - classical symptoms

Atypical - insidious onset
- extrapulmonary symptoms
- caused by an organism that can’t be cultured in the
normal way or detected using gram stain
- don’t respond to penicillins
- treated with macrolides, tetracyclines

29
Q

Pneumonia - investigations and diagnosis

A 
Bedside:
Obs
Sputum sample
Urinary sample
ECG
Bloods:
FBC
U&Es
CRP
Blood cultures

Imaging:
Chest X-ray

30
Q

Pneumonia - management of CAP

A

Always follow local area guidelines

CAP:
Mild - 5 day course oral amoxicillin or macrolide (if allergic to pencillin)

Moderate - 7 to 10 day course of dual antibiotics, amoxicillin and macrolide
(Doxycycline if allergic to penicillin)

Severe - IV co-amoxiclav and a macrolide, 7-10 days, may be extended to 14-21

31
Q

Pneumonia - management of HAP

A

Follow local area guidelines

Mild - co-amoxiclav 625mg TDS

Severe - IV Tazocin 4.5g TDS

32
Q

Pulmonary HTN - what is it?

A

It is increased resistance and pressure of blood in the pulmonary arteries, which causes strain on the right side of the heart trying to pump blood through lungs

Causes a back pressure of blood into systemic venous system

33
Q

Pulmonary HTN - what are the causes?

A

COPD
SLE
PE
Sarcoidosis

34
Q

Pulmonary HTN - what is main presenting symptom?

A

SoB

35
Q

Pulmonary HTN - what are the signs?

A

Raised JVP
Hepatomegaly
Peripheral oedema
Tachycardia

36
Q

Pulmonary HTN - Investigations

A

ECG

Chest X-Ray

Echo - used to estimate pulmonary artery pressure

37
Q

Pulmonary HTN - what changes do you see on the ECG?

A

Right ventricular hypertrophy

Right axis deviation

Right bundle branch block

38
Q

Pulmonary HTN - what changes do you see on Chest X-Ray?

A

Dilated pulmonary arteries

Right ventricular hypertrophy

39
Q

Pulmonary HTN - management of primary pulmonary HTN

A

Treating underlying cause like SLE or PE

IV prostanoids - epoprostenol

Endothelin receptor antagonists (potent vasoconstrictor of vascular smooth muscle) - macitentan

Phosphodiesterase -5 inhibitors - sildenafil

40
Q

Sarcoidosis - what is it?

A

It is a granulomatous inflammatory condition

Usually chest symptoms, but has multiple extra-pulmonary manifestations

41
Q

Sarcoidosis - what are granulomas?

A

Granulomas are nodules of inflammation full of macrophages

42
Q

Sarcoidosis - what is the cause of these granulomas?

A

Cause of granulomas developing is unknown

43
Q

Sarcoidosis - what is the typical incidence?

A

Young adulthood

Again aged round 60

44
Q

Sarcoidosis - what is the classic ‘exam’ patient

A

20-40 year old black woman presenting with dry cough and SoB, may have nodules on shins

45
Q

Sarcoidosis - what organs are affected?

A

Can affect almost any organ in the body:

Lungs (90%)
Heart
Eyes
Skin
Kidneys
Bones
CNS/PNS
46
Q

Sarcoidosis - how are lungs affected?

A
  1. Mediastinal lymphadenopathy
  2. Pulmonary fibrosis
  3. Pulmonary nodules
47
Q

Sarcoidosis - how is liver affected?

A

Liver nodules

Cirrhosis

Cholestasis

48
Q

Sarcoidosis - how are the eyes affected?

A
  1. Uveitis
  2. Conjunctivitis
  3. Optic neuritis
49
Q

Sarcoidosis - how is the skin affected?

A
  1. Erythema Nodosum - red nodules on shins caused by inflammation of subcut fat
  2. Lupus pernio - raised purple lesions commonly on cheek and nose
50
Q

Sarcoidosis - how is the heart affected?

A
  1. Bundle branch block
  2. Heart block
  3. Myocardial muscle involvement
51
Q

Sarcoidosis - how are the kidneys affected?

A
  1. Kidney stones - due to hypercalcaemia
  2. Nephrocalcinosis
  3. Interstitial nephritis
52
Q

Sarcoidosis - how is the CNS affected?

A
  1. Encephalopathy

2. Nodules

53
Q

Sarcoidosis - how is the PNS affected?

A
  1. Facial nerve palsy

2. Mononeuritis multiplex

54
Q

Sarcoidosis - how are the bones affected?

A
  1. Arthralgia

2. Arthritis

55
Q

Sarcoidosis - What is Lofgren’s syndrome?

A

Specific presentation of sarcoidosis, triad of:

  1. Erythema nodosum
  2. Bilateral hilar lymphadenopathy
  3. Polyarthralgia
56
Q

Sarcoidosis - what investigations do you do?

A

Blood tests

Chest XRAY

Histology from biopsy - gold standard

57
Q

Sarcoidosis - what blood tests do you do and what findings do you get from them?

A

Serum ACE - raised

Hypercalcaemia - key finding

Serum soluble interleukin-2 recepetor - raised

CRP - raised

58
Q

Sarcoidosis - what do you see on chest Xray?

A

Shows hilar lymphadenopathy

59
Q

Sarcoidosis - what characteristic finding do you get with histology?

A

Biopsy made from mediastinal lymph nodes

Non-caseating granulomas with epitheloid cells

60
Q

Sarcoidosis - what is the treatment?

A

Mild/no symptoms - no treatment, should resolve spontaneously

When treatment is required - 1st line oral steroids, 6-24 months, also give bisphosphonates to protect bones

2nd line - methotrexate, azathioprine

61
Q

Sarcoidosis - mnemonic off passmed that encompasses main points of condition

A

‘A Bug’s Life (with Sarcoid)’

A - Arthopathy
B - Bell's Palsy
U - Uveitis
G - Granulomas, non-caseating
S - Serum calcium/ ACE elevated
L - Lupus Pernio
I - Interstitial fibrosis
F - Fever, swinging
E - Erythema Nodosum
62
Q

Pulmonary Embolism (PE) - what is it?

A

Condition where a blood clot forms in the pulmonary arteries

Usually as a result of a DVT from the pelvis or leg and travelled to pulmonary arteries

63
Q

PE - what happens when thrombus is in pulmonary arteries?

A

Blocks blood flow to lung tissue, creates strain on right side of heart

64
Q

PE - what are the symptoms?

A 
Dyspnoea
Pleuritic chest pain
Cough with or without blood
Unilateral, painful, swollen leg
Dizziness
Syncope
65
Q

PE - what are the signs? (obs)

A

Tachycardia (>100bpm)

Low grade fever

Low O2 sats <94%

Hypotension <90mmHg

66
Q

PE - what are the steps in diagnosis?

A
  1. Perform a wells score
  2. If score>4 PE likely, straight for CTPA
  3. If score<4 PE unlikely, d-dimer within 4 hours, then if positive, then do CTPA
67
Q

PE - what other investigations can you do?

A

ECG, echo, troponin - markers to assess right ventricular strain/failure

ABG - pO2 low
pCO2 low - high resp rate, blow off extra CO2, low blood CO2, causes respiratory alkalosis

68
Q

PE - initial management

A

Anticoagulation:

Apixaban or Rivaroxaban

LMWH (dalteparin) when NOACs aren’t suitable

Respiratory (8 decks)

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