Respiratory Flashcards

Question

Outline the scoring system used for pneumonia severity - What it's an indicator of - What it is used for - What does CURB-65 stand for?

Answer 1

CURB-65 score - Predictor of mortality - Used to help decide whether a patient needs to be admitted for their pneumonia Confusion Urea > 7 Respiratory rate > 30 Blood pressure systolic < 90mmHg OR diastolic < 60 and > 65 yrs Mild score 0-1 = treat at home Moderate score 2 = admit to hospital Severe score 3-5 = intensive care

Answer 2

0-1 Mild = treat at home (oral abx) 2 Moderate = admit to hospital (oral abx) 3-5 Severe = admit to intensive care (IV abx) CURB-65 score can be used to estimate 30 day mortality rate from pneumonia e.g. CURB-65 of 1 = 3% mortality but CURB-65 of 5 = 57% mortality

Answer 3

Pathophysiology: - Embolus lodged within the pulmonary arteries - Main source is usually thrombus dislodged from a DVT Risk factors: - Previous DVT/PE - Prolonged immobilisation / long haul flights - Recent surgery - HRT/OC - Pregnancy - Malignancy - Polycythaemia Presentation: - Pleuritic chest pain - Haemoptysis - Cough - SOB - Tachycardia - Haemodynamic instability if large Investigations: 1. Calculate Wells' score If > 4 (likely) = CTPA If < 4 (unlikely) = d-dimer, if high then CTPA Management: - Immediate anticoagulation with LMWH e.g. Enoxaparin or Dalteparin - If massive PE, may do thrombolysis e.g. Streptokinase or Alteplase - Supportive: O2 or analgesia - Long-term DOACs (3 months if temporary cause, indefinitely if malignancy or unknown) e.g. Apixaban

Answer 4

Antibiotic issue - incorrect dose, poor absorption or abscess Emphysema Immunocompromised Organism - resistant or atypical Underlying/secondary diagnosis - e.g. PE

Answer 5

Wells' score DVT Likely if 2 or more Unlikely if less than 2 PE: Likely if 4 or more Unlikely if less than 4

Answer 6

- PE - Recent surgery - Pneumonia / infection - Pregnancy - Malignancy - Heart failure

Answer 7

Pathophysiology: - Mycobacterium tuberculosis bacteria - Inhaled through droplets of an actively infected individual - Spreads through the lymphatics and blood - TB can be active or latent Common extrapulmonary colonisation sites: - Lymph nodes - Pleura - Pericardium - GI system - Genitourinary system - Subcutaneous - CNS - Bones and joints Presentation: - Weight loss - Night sweats - Cough +/- haemoptysis - Lethargy - Erythema nodosum - Lymphadenopathy - Spinal pain (if spinal TB) Investigations: - Mantoux test or QuantiFERON gamma - Sputum cultures (if suspect active disease) - Chest x-ray (if suspect active disease) Management: Acute pulmonary TB: RIPE - Rifampicin - Isoniazid (plus Pyridoxine) - Pyrazinamide - Ethambutol Latent TB (at risk groups): 3 months of Rifampicin and Isoniazid OR 6 months of Isoniazid Other: - Test for other infectious disease e.g. HIV, Hepatitis - Notify Public Health - Contact tracing - Isolation in -ve pressure rooms

Answer 8

Pathophysiology: - Permanent dilation of the bronchi, with paradoxical narrowing due to decreased mucus clearance - Caused by chronic damage Causes: - Post-infection e.g TB - Recurrent childhood respiratory infections - Immune deficiency e.g. hypogammaglobinaemia - Genetic defects in mucus clearance e.g. cystic fibrosis Presentation: - Considerable productive cough (white) - Haemoptysis - Fatigue - SOB - History of risk factors/causes Investigations: - Sputum culture - High resolution CT (gold standard) = signet ring sign - Lung function tests - Autoimmune screen / genetic testing Management: - Pulmonary rehabilitation - Stop smoking - Up to date vaccinations - Long term O2 therapy - Mucolytic agents - Bronchodilators - Long term abx - Therapy for any underlying cause

Answer 9

Pathophysiology: - Autosomal recessive disease affecting CFTR - Impaired mucus clearance throughout body Presentation: - Meconium ileus at birth - Intestinal malabsorption - Recurrent respiratory infections - Pancreatitis / gallstones - Often found on newborn screening Investigations: - Newborn screening or family history PLUS - Positive sweat test or genotyping Management: - Newer therapies e.g. Kaftrio and Orkambi - Pulmonary physiotherapy - Mucolytics - Pancreatic enzyme replacement therapy - Up to date vaccinations - Fat soluble vitamin replacement

Answer 10

1. Recurrent respiratory infections - Prophylactic antibiotics - Physiotherapy 2. Low BMI - Nutritional supplements - Pancreatic enzyme supplementation - May need NG / PEG feeding 3. Distal intestinal obstruction syndrome (DIOS) - Oral Gastrografin (osmotic) 4. Diabetes - Normal management

Answer 11

- Avoid other CF individuals - Avoid stables / hay (aspergillus) - Avoid hot tubs (pseudomonas) - Stay hydrated and have NaCl replacement in hot weather - Don't smoke - Up to date vaccinations

Answer 12

Pathophysiology: - Inflammation and fibrosis of the lung parenchyma - Leads to thickening of the basement membrane and impaired gas exchange, particularly O2 Presentation: - DRY cough - SOB - Fatigue/lethargy - Finger clubbing - Chest discomfort - History of causes/risk factors Investigations: - Routine bloods - High Resolution CT - Lung function tests including Spirometry Management: - Limited treatment options (damage is irreversible) - Manage any risk factors / underlying because - Smoking cessation - O2 therapy - Physiotherapy and pulmonary rehabilitation - Up to date vaccinations - Advanced care planning if appropriate - Perhaps lung transplant

Answer 13

Types/causes: 1) Idiopathic - Progressive pulmonary fibrosis with no clear because - Bibasal fine inspiratory crackles and finger clubbing 2) Drug-induced (MAN-C) - Methotrexate - Amiodarone - Nitrofurantoin - Cyclophosphamide 3) Secondary (R-ASS) - Secondary to other conditions - RA - Alpha-1 antitrypsin deficiency - SLE - Systemic sclerosis 4) Hypersensitivity pneumonitis Type 3 hypersensitivity reaction to an environmental allergen 4 main causes: - Bird fancier's lung (bird droppings) - Farmer's lung (mould in hay) - Mushroom worker's lung (specific mushrooms) - Malt worker's lung (mould on barley) 5) Cryptogenic organising pneumonia - Local inflammation of the lung (almost any trigger) - Similar presentation to pneumonia and on chest x-ray - Definitive diagnosis with lung biopsy 6) Asbestosis - From exposure to asbestos - Often takes 30-40 yrs to develop

Answer 14

- Chronic cough > 3 weeks - Haemoptysis - SOB - Finger clubbing - Lymphadenopathy (supraclavicular) - Recurrent chest infections - Weight loss - Lethargy - Night sweats BUT may have no symptoms

Answer 15

Cyanotic diseases Lung abscess Ulcerative colitis Bronchiectasis Brachial AV fistula Interstitial lung disease / infective endocarditis Neoplasia (incl. lung / fibroma / mesothelioma) Graves' disease

Answer 16

Pathophysiology: - Accumulation of fluid in the pleural cavity (between visceral and parietal pleura) - Can be transudate or exudate Presentation: - SOB only On examination: - Dull percussion and reduced breath sounds on auscultation - May have tracheal deviation if large Investigations: - Chest x-ray (blunted costophrenic angles, meniscus, tracheal deviation if large) - Need to sample fluid with chest drain or aspiration, for analysis Management: Dependent on cause - Small effusions = conservative management - Pleural aspiration, but may reoccur - Chest drain, prevents from recurring

Answer 17

Exudate (self-producing): - Pneumonia - TB - Lung cancer - RA Transudate (due to pressure): - Congestive heart failure - Hypoalbuminemia - Hypothyroidism - Meig's syndrome (ovarian malignancy) Empyema: - Infected pleural effusion - Suspect if pneumonia is improving but new/unresolving fever - Treat with chest drain and abx

Answer 18

Pathophysiology: - Infection of the pleural lining Most common organisms: - Strep pneumoniae - Strep pyogenes - Staph aureus Presentation: - Pleuritic chest pain (sharp and well localised) - Pain worse on inspiration - Fever - SOB - Cough with purulent sputum Investigations: - Chest x-ray which shows pleural effusions (from pneumonia) but with failure to improve Management: Variable! - Abx - Thoracentesis - Chest drain

Answer 19

Pathophysiology: - Collection of air within the pleural cavity, leading to disruption of the pleural seal Categories: - Simple vs tension - Primary vs secondary - Spontaneous vs iatrogenic Presentation: - Chest pain - SOB - Cough - Evidence of original cause e.g. trauma Investigations: - Erect chest x-ray, which shows 1. Hyperlucency 2. Lung border 3. Loss of lung markings CT thorax can be used if the pneumothorax is too small to be seen on chest x-ray On examination: - Hyperresonance - Decreased breath sounds - Reduced chest expansion - Tracheal deviation if large tension Management: - Conversative (if small and no SOB) with f/u in 2-4 w - Thoracentesis (if large OR SOB) - Chest drain (if large or haemodynamically unstable OR the thoracocentesis fails twice)

Answer 20

Spontaneous: - Subpleural blebs Secondary / pre-existing conditions: - COPD - Asthma - Bronchiectasis / cystic fibrosis - Lung cancer - Lung infections e.g. TB / pneumonia - RA - Marfan's syndrome / Ehler's Danlos syndrome Traumatic: - Stab wound - Needle wound - Fractured rib Iatrogenic: - Chest drain - Central line - Any other procedure near the lungs (including apices)

Answer 21

Signs: - Tracheal deviation (to unaffected side) - Reduced air entry on affected side - Hyperresonance - Haemodynamically unstable (hypotension and tachycardia) Management: 1) Thoracocentesis (immediate management) - Large bore cannula into 2nd intercostal space, midclavicular line 2) Chest drain (definitive management)

Answer 22

1. 5th intercostal space 2. Mid-axially line 3. Anterior axillary line Insert needle above the ribs avoid the neurovascular bundle

Answer 23

Pathophysiology: - Collapse and obstruction of the pharyngeal airway during sleep - Apnoea episodes where the patient stops breathing completely for up to a few minutes - Leads individual to wake many times during the night (often reported by partner) Risk factors: - Obesity - Smoking - Alcohol - Middle age - Male Presentation: - Snoring reported by partner - Reduced O2 sats at night Problems with tiredness as a result of disrupted sleep - Poor concentration - Daytime tiredness / fatigue - Morning headache Investigations: - Referral to ENT specialist or specialist sleep clinic for: Sleep studies Management: - Weight loss if appropriate - Stop smoking / alcohol - CPAP overnight - If severe, surgery is UPPP (uvulopharyngoplasty to restructure soft palate and jaw) *Consider occupation and whether it's high risk e.g. HGV driver = require urgent referral

Answer 24

Obstructive Causes: - COPD - Asthma FEV1:FVC ratio - < 0.75 (FEV1 reduced) Restrictive Causes: - ILD e.g. pulmonary fibrosis - Obesity - Sarcoidosis - Scoliosis - Motor neurone disease FEV1:FVC ratio - > 0.75 (FEV1 and FVC reduced)

Answer 25

BiPAP (bilevel positive airway pressure) - Positive pressure during inspiration to force air into lungs - Less positive pressure during expiration to allow air to leave Use: type 2 respiratory failure, with respiratory acidosis that doesn't respond to treatment CPAP (continuous positive airway pressure) - Pressure that is continuous to keep airways open, for airways that are prone to collapse Use: obstructive sleep apnoea, congestive heart failure and acute pulmonary oedema

Answer 26

Pathophysiology: - Viral infection classified by haemagglutinin (H) and neuraminidase (N) surface antigens - Spread through direct contact or via respiratory droplets Presentation: - Fever and chills - Headache - Rhinorrhoea - Cough - SOB - Myalgia - Arthralgia - Fatigue / malaise Investigations: - Only test for influenza if it will change outcomes or if patients are at high risk of complications from influenza - PCR tests Management: - Manage pt in a side room - Usually supportive e.g. analgesia, fluids, O2 if required - Oseltamivir if required

Answer 27

Pathophysiology: - Viral coronavirus infection - Spread through direct contact or via respiratory droplets Presentation: - Fever and chills - Continuous cough - Loss / change sense of smell or taste - SOB - Sore throat - Rhinorrhoea - Myalgia - Arthralgia - Fatigue / malaise - Headache - Diarrhoea Investigations: - Rapid antibody test - PCR test Management: - Manage pt in a side room - Usually supportive e.g. analgesia, fluids, O2 if required - Dexamethasone / corticosteroids - Monoclonal antibody treatment (Casirivimab/Imdevimab)

Answer 28

Pathophysiology: - Increased pressures in the pulmonary vasculature - Can be either primary or secondary to pulmonary disease - Often leads to cor pulmonale Presentation: May be asymptomatic - SOB - Syncope - Chest pain Signs - Raised JVP - Peripheral oedema - Reduced O2 sats / cyanosis - Hepatomegaly Common causes: - Primary pulmonary hypertension - Large PE - Interstitial lung disease e.g. pulmonary fibrosis - COPD - Cystic fibrosis Management: - Treat the underlying cause - Long-term O2

Answer 29

Pathophysiology: - Right-sided heart failure, secondary to respiratory disease (leading to pulmonary hypertension) Presentation: Symptoms - May be asymptomatic - SOB - Syncope - Chest pain Signs - Raised JVP - Peripheral oedema - Reduced O2 sats / cyanosis - Hepatomegaly Common causes: - Large PE - Primary pulmonary hypertension - Interstitial lung disease e.g. pulmonary fibrosis - COPD - Cystic fibrosis Management: - Treat the underlying cause - Long-term O2

Answer 30

1) Primary pulmonary hypertension or connective tissue disease (e.g. SLE) 2) Left-sided cardiac failure or systemic hypertension 3) Chronic lung conditions e.g. COPD 4) Vasculature issues e.g. PE 5) Miscellaneous e.g. sarcoidosis, haematological disorders

Answer 31

Grade 1: breathless only on strenuous exertion Grade 2: breathless when hurrying on the flat / walking up a slight hill Grade 3: breathless after 15 minutes walking / walk slower than most people Grade 4: breathless after a few minutes on the flat / breathless after walking 90m Grade 5: breathless after undressing / too breathless to leave the house

Answer 32

1. SMOKING CESSATION 2. Long term O2 therapy (used for > 15 hrs per day) 3. Lung volume reduction surgery

Answer 33

- ACEi - CCB - DMARDs

Answer 34

Pathophysiology: - Multi-system disease characterised by granuloma formation (nodules of inflammation full of macrophages) - Cause is unknown - Usually associated with chest symptoms, but can also have multiple extra-pulmonary manifestations e.g. erythema nodosum and lymphadenopathy Who commonly develops it? - Young adulthood and aged 60 - Women - Black ethnicity Presentation: - Dry cough - SOB - Lymphadenopathy - Arthralgia (young black woman, presenting with dry cough and SOB) Investigations: - Serum ace - Chest x-ray (hilar lymphadenopathy) - HRCT (pulmonary nodules) - PET scan (active areas of inflammation) - Histology = gold standard (skin biopsy or bronchoscopy) shows non-caseating granulomas Management: May spontaneously resolve in 6 months in 60% of patients - No treatment needed if no/mild symptoms (often resolves spontaneously) - Oral corticosteroids (6-24 months) - Methotrexate or Azathioprine if above doesn't work

Answer 35

Lungs (mainly): - Pulmonary fibrosis - Nodules - Mediastinal lymphadenopathy Systemic: - Fever - Weight loss - Fatigue Liver: - Nodules - Cirrhosis - Cholestasis Eyes: - Uveitis - Conjunctivitis - Optic neuritis Skin: - Erythema nodosum - Lupus pernio Heart: - Heart block - Heart failure Kidneys: - Kidney stones (hypercalcaemia) - Calcium deposits - Interstitial nephritis CNS: - Nodules e.g. in brain - Pituitary involvement e.g. diabetes insipidus - Encephalopathy PNS: - Bell's palsy

Answer 36

Lung adenocarcinoma

Answer 37

Small cell carcinoma

Answer 38

- Pneumonia - Aspiration pneumonia - Sepsis - Major trauma - Pancreatitis

Answer 39

Pathophysiology: - Non-cardiogenic pulmonary oedema developing acutely within 1 week - Usually occuring after an injury or illness affecting the lungs Presentation: - Tachypnoea - SOB / severe dyspnoea - Chest pain - Cyanosis / low O2% / confusion - Bilateral crackles - Dullness to percussion over affected areas - Sudden onset respiratory failure Investigations: - Bedside = sputum culutre, ABG, viral swabs e.g. covid-19 - Bloods = infection screen, BNP (?cardiac cause), blood cultures - Imaging = chest x-ray (bilateral opacities) - Procedures = brocheolar Management: Aim to resolve underlying cause - Ventilatory support (low flow to prevent damage) - Nutritional support e.g. NG tube - DVT prophylaxis whilst immobile

Answer 40

1. Klebsiella pneumoniae 2. Streptococcus pneumoniae

Answer 41

- Sepsis - ARDS (acute respiratory distress syndrome) - Empyema / lung abscess - Parapneumonic effusion - Death

Answer 42

- Malignancy (lymphoma) - Infective (TB) - Inflammatory (sarcoidosis) - Pneumoconiosis (e.g. silicosis from fibre inhalation)

Answer 43

- Pulmonary fibrosis / asbestosis / sarcoidosis - Chest wall abnormalities / kyphosis - Myasthenia gravis / MND - Obesity

Answer 44

- COPD - Asthma (with reversibility) - Cystic fibrosis / bronchiectasis - Foreign body / malignancy of the airway

Respiratory Flashcards

(71 cards)