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Flashcards in Resp Session 8 Deck (79):
1

What is the pathogenesis of interstitial lung disease (diffuse parenchymal lung disease)?

Start in intersticium --> surrounding structures involved --> acini, alveoli lumen, bronchioles lumen, bronchioles involved --> hypoxia and hypercapnia

2

How are ventilation, diffusion and perfusion affected in interstitial lung disease?

Ventilation decreased due to decreased compliance
Diffusion decreased due to barrier to gas exchange
Perfusion decreased due to damage/destruction of alveolar capillaries

3

What pattern on lung function tests is seen in interstitial lung disease?

Restrictive

4

What cells are involved in interstitial lung disease?

Epithelial
Endothelial
Mesenchymal
Macrophages
Recruited inflammatory cells

5

What is seen on CXR in interstitial lung disease?

Loss of silhouette sign
Increased reticular and nodular shadowing

6

What is seen on CT scan in interstitial lung disease?

Fibrosis visible as patchy white/grey areas

7

What is the classic Hx in interstitial lung disease?

Insidious onset with gradual decline SoB

8

What are the S/S of interstitial lung disease?

Progressive SoB on exertion +/- non-productive cough
Clubbing
Peripheral/central cyanosis
Tachycardia
Tachypnoea
Decreased chest movement
Course crackles
Signs of cor pulmonale

9

What are the 5 types of interstitial lung disease?

Occupational
Tx related
CT disease
Immunological
Idiopathic

10

What can cause CT disease leading to interstitial lung disease?

Rheumatoid arthritis
SLE
Polymyositis
Schleroderma
Sjorgen's

11

At what age do immunological interstitial lung disease pts typically present?

20 or 60-70 y.o.

12

At what age does idiopathic pulmonary fibrosis typically present?

60-80 y.o.

13

What is the problem with new therapies for idiopathic pulmonary fibrosis?

Slow mortality and decline in FVC but have significant drug toxicity

14

What effects can asbestos exposure have in the lungs?

Asbestos plaques
Diffuse pleural thickening
Benign asbestos pleural effusions
Mesothelioma
Bronchogenic lung cancer
Rounded atelectasis

15

What is asbestosis?

Interstitial lung disease and asbestos exposure

16

How is sarcoidosis usually identified?

Incidentally as vast majority indolent

17

What is found on biopsy in sarcoidosis?

Non-caseating granulomas

18

What are differentials for sarcoidosis following biopsy?

Lymphoma
TB

19

What are the Tx options for sarcoidosis?

None
Steroids
Methotrexate (2nd line for steroid sparing)

20

How is pleural fluid in the reabsorbed in the pleural cavity?

Via stomata on parietal pleural surface --> lymphatic drainage

21

What can cause increased production of pleural fluid?

Increase in lung interstitial fluid
Hydrostatic pressure increases
Permeability increases
Oncotic pressure decreases
Peritoneal fluid seeps through diaphragm
Thoracic duct disruption so no drainage

22

What can cause decreased absorption of pleural fluid?

Lymphatic blockage
Increased systemic venous pressures

23

What does Light's criteria state?

Pleural fluid is exudate if:
Pleural fluid protein/serum protein > 0.5
Pleural fluid or serum LDH > 0.6
Pleural fluid LDH > 2/3 upper normal lab limits

24

What are causes of transudate pleural effusion?

Heart failure
Cirrhosis
Hypoalbuminaemia
Atelectasis
Nephrotic syndrome
Constrictive pericarditis
Meigs syndrome

25

What are causes of exudate pleural effusion?

Infection
Malignancy
Rheumatoid arthritis
PE
Asbestos related
Pancreatitis

26

What can cause haemothorax?

Trauma
Iatrogenic e.g. central line

27

What can cause chylothorax?

Lymphatic interruption
Lymphoma
Iatrogenic

28

How does chylothorax appear?

Milky

29

What indicates empyema?

Decreased pH, decreased glucose and infection
CT and US show septations

30

What are risk factors for empyema?

Alcoholism
Immunocompromise

31

What is the Tx of empyema?

Abx +/- drainage

32

What is the intersticium?

Potential space between alveolar membrane and capillary across which gas can move

33

What pts develop primary pneumothorax?

Otherwise healthy people, tend to be taller males

34

Which pts can develop secondary pneumothroax?

Those with underlying lung disease e.g. Cancer or COPD

35

What are the S/S of pneumothorax?

Pleuritic chest pain
Dyspnoea if large

36

What is iatrogenic pneumothorax?

Caused by procedures e.g. Central lines

37

How are small and large pneumothoracies differentiated on CXR?

Small 2cm

38

What are the treatment options for pneumothorax?

Small, closed w/o significant SoB: observation, discharge and early review
If admittance for obs needed: high flow O2
Pts with SoB: simple aspiration
Recurrent cases: open thoracotomy and pleurectomy

39

What treatment option is available for pneumothorax pts who do not want surgery?

Chemical pleurodesis via surgical talk into drain to cause irritation of visceral and parietal pleura --> inflammation --> adhesion

40

How should a tension pneumothorax be diagnosed?

Clinically

41

What are S/S of tension pneumothorax?

Tachycardia
Hypotension
Decreased chest expansion with hyper resonance and absent breath sounds on one side
Mediastinal shift --> tracheal displacement and shift of apex beat
Hypoxaemia

42

What is the Tx for tension pneumothorax?

Immediate cannula into affected side
Oxygen
Intercostal chest drain
Resp/thoracic surgical referral to prevent repeat

43

What congenital chest wall diseases can lead to hypoxia and hypercapnia?

Pectus deformities
Scoliosis
Kyphosis
Muscular dystrophy

44

What acquired chest wall diseases can lead to hypoxia and hypercapnia?

Trauma
Iatrogenic
Ankylosing spondylitis
Motor neurone disease

45

What is a radiograph?

Electromagnetic wave of high energy and short wavelength passed through body --> different tissues absorb different amounts --> levels of contrast on grey scale

46

Why is CXR appropriate for almost all pts?

Low dose of radiation

47

What two different projections can be used for CXR?

PA projection (conventional, back to front)
AP projection

48

When are AP CXR used?

For pts who are too unwell to stand

49

What are the potential problems with using AP CXR?

Heart magnified
Lungs under inflated due to sitting position
Scapula over lung fields

50

What is checked for when assessing inclusion on a CXR?

1st rib
Lateral margin of ribs
Costophrenic angle

51

How is rotation assessed on CXR?

Spinous processes should be directly in the middle of medial ends of clavicles

52

Taken during inspiratory phase
At point of intersection of diaphragm and MCL should see 5-7 anterior ribs

How is lung volume assessed on CXR?

53

What on CXR indicates incomplete inspiration?

Big heart --> increased lung markings

54

What indicates exaggerated expansion caused by obstructive airway disease on CXR?

Flattened diaphragm

55

What effects lung volume filling on CXR?

Pt and radiographer factors e.g. explanation, inspiratory effort

56

How is penetration assessed on CXR?

Vertebrae should be just visible through heart and complete left hemidiaphragm should be visible

57

What can manipulate penetration on CXR if it is inadequate?

Digital manipulation

58

What is an artefact on CXR?

External/iatrogenic material that obstructs view e.g. Clothes, buttons, hair, surgical or vascular lines, pacemaker

59

Give 10 areas of thoracic anatomy which should be examined when assessing a CXR.

Trachea
Hila - L should be higher than R
Lungs
Diaphragm
Heart
Aortic knuckle
Ribs
Scapulae
Breasts
Bowel gas

60

When might the nipples not show equally on CXR?

Penetration is not equal

61

Give a systematic approach to assessing a CXR.

Pt demographics
Projection
Adequacy: RIP
Airway
Breathing
Circulation
Diaphragm and dem bones

62

List review areas in CXR where pathology is commonly missed.

Apices
Thoracic inlet
Paratracheal stripe
AP window
Hila
Behind heart
Below diaphragm
Bones
Edge of films

63

What is the silhouette sign?

Adjacent structures of differing density give crisp silhouette and loss of this contour indicates pathology esp. consolidation

64

What causes mediastinal shift on CXR?

Push= increase in volume or pressure e.g. pleural effusion or tension pneumothroax
Pull= decreased volume or pressure e.g. lung collapse

65

What signs of pneumothorax are visible on CXR?

Visible pleural edge with no visible lung markings

66

What is visible on CXR in pleural effusion?

Uniform white area visible
Loss of costophrenic angle
Hemidiaphragm obscured
Meniscus of fluid at upper border

67

What can cause lobar lung collapse?

Aspirated foreign material
Mucus plugging
Iatrogenic
Bronchogenic carcinoma
Compression by adjacent mass

68

How does lobar lung collapse appear on CXR?

Raised epsilateral hemidiaphragm
Crowding of ipsilateral ribs
Shift of mediastinum due to atelectasis
Crowding of pulmonary vessels
Luftsichel sign in left upper lobe

69

How does consolidation appear on CXR?

Dense opacification +/- air bronchogram

70

What can cause consolidation in lung cancer?

Cells

71

What differentiates a nodule from a mass when assessing a SoL on CXR?

Nodule 3cm

72

What causes SoLs?

Malignancy - primary will be single SoL, metastases often have multiple
Benign mass lesion
Inflammation
Congenital

73

What can a SoL mimic on CXR?

Bone lesion
Cutaneous lesion
Nipple shadow

74

What additional sign may be visible on CXR in SoL if phrenic diaphragm is implicated?

Raised hemidiaphragm

75

What should the cardiac index be on PA image?

76

What is indicated if the heart is the wrong way round on CXR with the apex on R?

Dextrocardia

77

What is indicated if heart is the wrong way round and liver and gastric bubble are on the opposite side to normal?

Situs inversus

78

What are CT scans which give much more information than CXR not suitable for all pts?

Deliver much higher doses of radiation, esp if a contrast is used

79

Why might CT not be appropriate for lactating women?

Sensitivity of breasts to radiation