Respiratory Flashcards
(140 cards)
1
Q
Control of airway smooth muscle?
A
NA on β2 receptors = bronchodilation
ACh on M3 receptors = bronchoconstriction
2
Q
Muscles of passive inspiration vs forced inspiration vs expiration?
A
Passive inspiration = diaphragm, external intercostals
Forced inspiration = SCM, scalenes, pectoralis major
Expiration = internal intercostals, subcostals, transversus thoracis, anterior abdominal wall muscles
3
Q
Location of central vs peripheral chemoreceptors?
A
Central = medulla oblongata
Peripheral = carotid and aortic bodies
4
Q
Brain centres for inspiration, expiration, breath inhibition and prolongation?
A
Inspiration = dorsal (medullary) group
Expiration = ventral (medullary) group
Inhibition = pneumotaxic (pontine) centre
Prolongation = apneustic (pontine) centre
5
Q
What does the oxygen dissociation curve demonstrate?
A
Relationship between pO2 and SpO2%
6
Q
List causes of left shift on the oxygen dissociation curve (↑ O2 affinity,↓ O2 delivery).
A
HbF
Low pCO2
Low H
Raised pH
Low 2,3-DPG
Low temperature
7
Q
List causes of right shift on the oxygen dissociation curve (↓ O2 affinity,↑ O2 delivery).
A
Raised pCO2
Raised H
Low pH
Raised 2,3-DPG
Raised temperature
8
Q
List some gram +ve vs gram -ve cocci?
A
Gram +ve = staphylococcus, streptococcus
Gram -ve = neisseria meningitidis, neisseria gonnorhoeae, moraxella catarrhalis
9
Q
Classification of streptococci?
A
α = viridans and pneumoniae
β = pyogenes (group A) and agalactiae (group b)
γ = enterococci
10
Q
List some gram +ve vs gram -ve bacilli?
A
Gram +ve = bacillus, clostridium, corynebacterium, listeria, mycobacterium
Gram -ve = shigella, salmonella, legionella, klebsiella, E.coli, campylobacter, pseudomonas, haemophilus
11
Q
Cause of obstructive vs restrictive lung disease and examples?
A
Obstructive = reduced airflow
→ asthma, COPD, bronchiectasis
Restrictive = reduced expansion
→ IPF, sarcoidosis, pneumoconiosis
12
Q
FEV1, FVC and FEV1/FVC in obstructive lung disease?
A
FEV1 = significantly reduced
FVC = reduced or normal
FEV1/FVC = reduced (< 0.7)
13
Q
FEV1, FVC and FEV1/FVC in restrictive lung disease?
A
FEV1 = reduced
FVC = significantly reduced
FEV1/FVC = normal or increased (> 0.7)
14
Q
What is TV, IRV, ERV and RV?
A
TV = air breathed in/out during normal respiration
IRV/ERV = extra air breathed in/out after TV
RV = air left in lungs after maximum expiration
15
Q
IC, VC, FRC and TLC calculations?
A
IC = TV + IRV
VC = IC + ERV
FRC = ERV + RV
TLC = VC + RV
16
Q
ABG interpretation steps?
A
1st = PaO2 (hypoxic or not)
2nd = pH (acidosis, alkalosis)
3rd = PaCO2 (check if respiratory system causing acidosis/alkalosis or compensating)
4th = HCO3 (check if metabolic system causing acidosis/alkalosis or compensating)
5th = BE (> +2 = excess HCO3, < -2 = lack of HCO3)
17
Q
Examples of added breath sounds and associated conditions?
A
Wheeze (e.g. asthma)
Stridor (e.g. epiglottitis)
Coarse crepitations (e.g. bronchiectasis)
Fine end-inspiratory crackles (e.g. pulmonary fibrosis)
18
Q
Atopic triad and Ig mediator?
A
Asthma, allergic rhinitis, atopic eczema
→ IgE (type I hypersensitivity)
19
Q
Features of asthma?
A
Wheeze
Breathlessness
Chest tightness
Cough (often worse at night)
Diurnal variation of symptoms
PMH or FH of atopy e.g. eczema
20
Q
Investigations for asthma?
A
Peak expiratory flow rate (PEFR)
Spirometry (FEV1/FVC)
Bronchodilator reversibility test (BDR)
Fraction of expired nitric oxide (FeNO)
21
Q
BDR, PEFR and FeNO results indicative of asthma?
A
BDR = ≥12% FEV1 improvement
PEFR = ≥20% variability
FeNO = > 40 ppb (adults) or > 35 ppb (kids)
22
Q
Investigation if asthma diagnosis unclear?
A
Fraction of expired nitric oxide (FeNO)
23
Q
Drugs which can worsen asthma?
A
Aspirin
Other NSAIDs (e.g. ibuprofen)
Beta blockers (e.g. bisoprolol)
24
Q
Drug options for asthma (adult)?
A
1st line = SABA + ICS
2nd line = SABA + ICS + LABA
3rd line = ↑ ICS or SABA + ICS + LTRA
25
Drug options for asthma (kids)?
1st line = SABA
2nd line = SABA + very low dose ICS (≥ 5) or SABA + LTRA (< 5)
3rd line = SABA + very low dose ICS + LABA/LTRA (≥ 5) or SABA + very low dose ICS + LTRA (< 5)
4th line = ↑ ICS or specialist referral
26
Outline good inhaler technique?
- Remove cap and shake well
- Sit/stand straight with chin tilted up
- Exhale slowly until lungs empty
- Make a tight seal around mouthpiece
- Press inhaler whilst inhaling slowly until lungs full
- Remove inhaler and hold breath for 10 seconds
- Exhale and wait 30 seconds if 2nd dose needed
- Wash mouth out if inhaler contains steroid
27
Indication for step-up asthma treatment?
SABA used 3 or more times a week
28
ICS dosage in step-down asthma treatment?
Reduce by 25-50%
29
Key signs of a severe vs life-threatening asthma attack?
Severe = PEFR 33-50%, SaO2 < 92%, can't talk
Life-threatening = PEFR < 33%, SaO2 < 92%, pCO2 normal, silent chest, confusion, poor resp effort
30
Hospital management of asthma attack?
15L/min O2 via non-rebreather then:
1st line = nebulised salbutamol/ipratropium
2nd line = oral prednisolone or IV hydrocortisone
3rd line = IV magnesium sulphate
4th line = IV aminophylline
N.B. give antibiotics if infective exacerbation
31
Main cells involved in asthma vs COPD?
Asthma = mast cells, eosinophils, T helper cells (CD4+)
COPD = neutrophils, cytotoxic T cells (CD8+)
32
Example of a SABA, LABA, SAMA, LAMA, ICS and LTRA.
SABA = salbutamol
LABA = salmeterol
SAMA = ipratropium
LAMA = tiotropium
ICS = beclamethasone
LTRA = montelukast
33
Pathology of chronic bronchitis and emphysema?
Chronic bronchitis = goblet cell proliferation and mucus hypersecretion
Emphysema = permanent alveoli hyperinflation and membrane loss
34
Types of emphysema, location and their associated cause?
Centriacinar (upper lobes) = tobacco smoking
Panacinar (lower lobes) = A1AT deficiency
35
Features of COPD?
Cough (often productive)
Breathlessness
Chest hyperinflation
Accessory muscle use
Smoking history
36
Complications of COPD?
Pneumothorax (ruptured bulla)
Cor pulmonale (PHTN)
Polycythaemia (chronic hypoxia)
Infection (reduced ciliary clearance)
37
CXR features of COPD?
Hyperinflation (> 6 ribs visible)
Pulmonary bullae
Loss of lung markings
Flattened hemidiaphragms
38
Type 1 vs type 2 respiratory failure and cause?
Type 1 = hypoxia without hypercapnia
→ V/Q mismatch (low oxygen but well perfused)
Type 2 = hypoxia with hypercapnia
→ alveolar hypoventilation
39
Pathogenesis of CO2 retention?
- Loss of elastic recoil means lungs can't fully empty CO2
- Chronic hypercapnia makes respiratory centre less sensitive to PaCO2 so relies on PaO2
- Giving O2 will ↓ respiratory drive and ↑ PaCO2
40
Drug options for COPD?
1st line = SABA or SAMA
2nd line = SABA + LABA + LAMA (no asthmatic features) or SABA/SAMA + LABA + ICS (asthmatic features)
3rd line = SABA + LABA + LAMA + ICS
41
Most important management for survival in COPD?
Smoking cessation
42
Smoking cessation management options?
Normal = NRT or bupropion or varenicline
Pregnant = NRT
43
When to commence NRT, bupropion and varenicline?
NRT = on quit day
Bupropion/varenicline = 7-14 days before quit day
44
Indications for LTOT in COPD?
2 readings of PaO2 < 7.3 or PaO2 7.3-8 with COPD complications e.g. PHTN
45
Indication for NIV (BiPAP) in COPD?
Respiratory acidosis pH 7.25-7.35
46
COPD severity categories and associated FEV1?
Mild (FEV1≥ 80%)
Moderate (FEV1 50-79%)
Severe (FEV1 30-49%)
Very severe (FEV1 < 30%)
47
Management of a COPD exacerbation?
4L/min O2 via Venturi 24-28% then:
1st line = nebulised salbutamol/ipratropium
2nd line = oral prednisolone or IV hydrocortisone
3rd line = IV theophylline
N.B. give antibiotics if infective exacerbation
48
Target SpO2 for COPD exacerbation before vs after ABG results?
Before = 88-92%
After = 94-98% (if pCO2 normal)
N.B. if very hypoxic high-flow O2 given regardless
49
Vaccination advice for COPD patients?
One-off pneumococcal + annual influenza
50
Most common bacterial cause of COPD and bronchiectasis exacerbations and antibiotic options?
Haemophilus influenzae
1st line = amoxicillin
2nd line = doxycycline
51
Antibiotic prophylaxis for recurrent COPD and bronchiectasis exacerbations and screening test?
Azithromycin
ECG (can cause QT prolongation)
52
Features of bronchiectasis?
Productive cough (LOTS of sputum)
Recurrent infections
Breathlessness
Finger clubbing
53
Investigation for bronchiectasis and key feature?
High-resolution CT (HRCT)
Signet ring appearance
54
Outline α1-antitrypsin (A1AT) deficiency effect on the lungs?
- A1AT is an antiprotease which inhibits neutrophil elastase
- Deficiency allows neutrophil elastase to destroy alveolar walls (emphysema)
55
Malignancy associated with α1-antitrypsin deficiency?
Hepatocellular carcinoma
56
Features of PHTN?
Breathlessness
Tachycardia
Raised JVP
Peripheral oedema
Hepatomegaly
57
Investigation for PHTN and diagnostic value?
Right heart catheterisation
Pulmonary arterial pressure = ≥25mmHg
58
Management options for PHTN?
CCBs e.g. nifedipine
PDE-5 inhibitors e.g. sildenafil
Prostacyclin analogues e.g. iloprost
Endothelin receptor antagonists e.g. bosentan
59
Causes of chronic pulmonary infection?
Hypogammaglobuminaemia
Ciliary dysfunction
Cystic fibrosis
Immunosuppression
Allergic bronchopulmonary aspergillosis (ABPA)
60
Management of allergic bronchopulmonary aspergillosis?
1st line = oral steroids
2nd line = oral itraconazole
61
Medical name for a typical cough?
Acute bronchitis
62
CRP level needing antibiotic for chest infection and options?
CRP > 100
1st line = amoxicillin
2nd line = doxycycline
63
Most common cause of noisy breathing in children?
Laryngomalacia
64
Most common cause of coryza (common cold)?
Rhinovirus
65
Influenza known to cause pandemics?
Influenza A
66
Advice for influenza management?
Only treat those at risk of complications
Must be initiated within 48 hours of onset
→ oseltamavir
→ zanamivir
67
Age at first dose, type and live/inactivated influenza for young vs elderly?
Young = 2-3 years, intranasal, live
Elderly = 65 and over, vaccine, inactive
68
Medication contraindicating a child's influenza vaccine and why?
Aspirin
Risk of Reye's syndrome
69
Main cause of epiglottitis, croup, bronchiolitis and whooping cough?
Epiglottitis = haemophilus influenzae
Croup = parainfluenza virus
Bronchiolitis = RSV
Whooping cough = bordatella pertussis
70
CXR finding in acute epiglottitis vs croup (laryngotracheobronchitis)?
Acute epiglottitis = thumbprint sign
Croup = steeple sign
71
Features and management of acute epiglotittis?
Generally unwell (e.g. fever)
Inspiratory stridor
Drooling
Tripod position
Management = secure airway + IV antibotic e.g. ceftriaxone
72
Features and management of croup?
Generally unwell (e.g. fever)
Barking cough
Inspiratory stridor
Management = don't upset child, oral dexamethasone (1st line), nebulised budesonide, nebulised adrenaline (2nd line)
73
Features and management of bronchiolitis?
Generally unwell (e.g. fever)
Dry cough
Breathlessness
Wheeze, fine inspiratory crackles
Poor feeding
Management = supportive
74
Features and management of pertussis?
Generall unwell (e.g. fever)
Paroxymal cough worse at night
Post-tussive vomiting
Apnoeic spells
Management = oral macrolide if onset < 21 days
75
School exclusion for children with pertussis?
48 hours after starting antibiotics
21 days after onset if no antibiotics
76
When is a pertussis vaccine offered to pregnant women?
16-32 weeks
77
List causes of bilateral hilar lymphadenopathy?
Sarcoidosis
Tuberculosis
Lymphoma
Fungal infections
Pneumoconiosis
78
Features of Kartagener's syndrome?
Bronchiectasis (ciliary dysfunction)
Dextrocardia
Situs inversus
Sinusitis
Infertility
79
Features of cystic fibrosis?
Recurrent chest infections
Chronic sinusitis
Meconium ileus
Failure to thrive
Infertility
Pancreatic insufficiency
Liver disease
Malabsorption
80
Ions affected in cystic fibrosis and diagnostic test result?
Chloride (Cl) and sodium (Na)
→ Cl sweat levels > 60
81
Management of CF?
Chest physiotherapy (at least twice a day)
High calorie/high fat diet
Pancreatic enzyme supplements
Vitamin supplements
Lung transplantation
82
Specific CF drug and indication?
Lumacaftor/ivacaftor (Orkambi)
→ those homozygous for delta F508 mutation
83
CAP vs HAP?
CAP = outside hospital or within 48 hours admission
HAP = 48 hours after admission
84
CURB65 and management plan per score?
Confusion
Urea > 7
Respiratory rate > 30
Blood pressure < 90 systolic OR < 60 diastolic
65 or over
0-1 = home management, 2 = consider hospital, 3-5 = hospital/ITU admission
85
Follow-up CXR post-pneumonia?
6 weeks
86
Pneumonia organisms most linked to CAP, COPD, CF, post-flu, air-con, alcoholics/diabetics, HIV, bird contact, red jelly sputum, dry cough, SIADH, erythema multiforme, cold AIHI, exertional SOB?
CAP = strep pneumoniae
COPD = haemophilus influenzae, moraxella
CF = psuedomonas
Post-flu = staph aureus
Air-con/dry cough/SIADH= legionella
Alcoholics/diabetics/red jelly sputum = klebsiella
HIV/exertional SOB = pneumocystic jiroveci
Bird contact = chlamydia psitacci
Dry cough/erythema multiforme/cold AIHI = mycoplasma
87
Specific test for Legionella infection?
Urinary antigen enzyme immunoassay
88
Most common area affected in aspiration pneumonia?
Right lower (or middle) lobe
89
Clinical features, pleural aspirate features and management of empyema?
Clinical = failure to respond to antibiotics, swinging fever
Pleural aspirate = low pH (<7.2), low glucose, high LDH
Management = drainage + IV antibiotics
90
Types of pleural effusion, value and most common cause?
Transudate (< 30g/L protein)
→ heart failure
Exudate (> 30g/L protein):
→ pneumonia
91
Light's criteria?
Used if protein content is borderline (25-35 g/L)
Effusion is an exudate if serum:protein > 0.5 or pleural LDH is > 2/3rd upper limit for serum LDH
92
Meigs syndrome triad?
Pleural effusion
Ascites
Benign ovarian tumour
93
Acute surgical management of a tension pneumothorax?
Needle decompression
94
Management of a primary pneumothorax?
< 2cm and not breathless = discharge and 2-4 week OP review
> 2cm or breathless = aspiration (1st line), chest drain (2nd line)
95
Management of a secondary pneumothorax?
< 1cm and not breathless = 24 hour observation
1-2 cm and not breathless = aspiration (1st line), chest drain (2nd line)
> 2cm, > 50 or breathless = chest drain
96
Management for persistent air leaks or recurrence of pneumothorax?
Thoracic surgery referral for VATS pleurodesis
97
Insertion site for needle decompression vs aspiration/drain?
Needle decompression = 2nd intercostal space, mid-clavicular line
Aspiration/drain = 5th intercostal space, mid-axillary line
98
What is atelectasis and management?
Collapse of basal alveoli caused by obstruction
Management = sit patient upright + breathing exercises
99
What is a Pancoast tumour, give a complication and explain?
Mainly NSCLC tumour at the lung apex
Horner's syndrome (ptosis, miosis, anhydrosis)
Loss of sympathetic innervation to one side of face due to sympathetic trunk damage
100
Investigation for pulmonary fibrosis and key feature?
High-resolution CT (HRCT)
Honeycomb appearance
101
Conditions which cause upper zone fibrosis?
CHARTS:
Coal worker's pnuemoconiosis
Histiocytosis/Hypersensitivity pneumonitis
Ankylosing Spondylitis
Radiation-induced fibrosis
Tuberculosis
Sarcoidosis/Silicosis
102
Conditions which cause lower zone fibrosis?
Idiopathic pulmonary fibrosis
Drugs (e.g. amiodarone)
Asbestosis
CTDs (except ankylosing spondylitis)
103
List medications which cause pulmonary fibrosis?
Amiodarone
Bleomycin
Methotrexate
Nitrofurantoin
104
What is hypersensitivity pneumonitis and give some examples?
Reaction to inhaled allergen:
Bird-fancier's lung
Farmer's lung
Hot-tub lung
105
What is pneumoconiosis and give some examples?
Reaction to inhaled metal or dust:
Silicosis
Asbestosis
Coal miner's lung
106
Egg shell calcification of hilar lymph nodes and increased TB risk?
Silicosis
107
Caplan's syndrome?
Rheumatoid arthritis + pneumoniosis
108
Features of acute sarcoidosis (Löfgren syndrome)?
Fever
Polyarthralgia
Erythema nodosum
Bilateral hilar lymphadenopathy
109
Blood test and pathological findings in sarcoidosis?
Bloods = raised ACE, ESR and Ca, low lymphocytes
Pathology = non-caseating granulomas
110
Management of sarcoidosis?
Mostly self-limiting
Steroids
Immunosuppressants
111
Outline latent vs active TB?
Latent = mycobacterium engulfed by macrophages, move to hilar lymph nodes and are surrounded by granulomas (primary TB)
Active = inability to fight initial exposure (miliary TB) or reactivation of pathogen (secondary TB)
112
Ghon complex?
Ghon focus (primary TB lesion) + nearby lymphadenopathy
113
Commonest extrapulmonary manifestation of TB?
Pott's disease of the spine
114
Main test for latent vs active TB?
Latent = Mantoux test
Active = sputum culture
115
Treatment for latent vs active TB?
Latent = 3 months of RIP or 6 months of IP
Active = 2 months of RIPE + 4 months of RI
116
Side effects of RIPE drugs?
Rifampicin = hepatitis, p450 inducer, orange/red secretions
Isoniazid = hepatitis, p450 inhibitor, peripheral neuropathy
Pyrazinamide = hepatitis, gout
Ethambutol = visual disturbances
117
Drug which reduces the risk of isoniazid-induced peripheral neuropathy?
Pyridoxine (vitamin B6)
118
Broad summary of lung cancer types?
Small cell (SCLC)
Non-small cell (NSCLC) = adenocarcinoma, squamous cell, large cell
119
Paraneoplastic features of small cell lung cancer?
Increased ACTH → Cushing's
SIADH → hyponatraemia
Lambert-Eaton syndrome
120
Paraneoplastic features of squamous cell carcinoma?
Increased PTHrp → hypercalcemia
Increased TSH → hyperthyroidism
Hypertrophic pulmonary osteoarthropathy (HPOA)
121
Paraneoplastic features of adenocarcinoma?
Gynaecomastia
Hypertrophic pulmonary osteoarthropathy (HPOA)
122
Investigations for lung cancer?
CT chest, liver and adrenals
Bronchoscopy with EBUS + biopsy
123
Management of SCLC vs NSCLC?
SCLC = chemo + radiotherapy
NSCLC = surgery (e.g. lobectomy) + radiotherapy + chemo
124
Lung cancer associated with non-smokers, poorest prognosis, cavitating?
Non-smokers = adenocarcinoma
Poorest prognosis = SCLC
Cavitating = squamous cell carcinoma
125
Mesothelioma association and CXR findings?
Asbestos exposure
Pleural thickening and pleural effusion
126
Most common pleural manifestation of asbestos exposure?
Pleural plaques (benign)
127
Pathology of ARDS vs NRDS?
ARDS = inflammation of alveoli leads to type II alveolar destruction and surfactant loss
NRDS = prematurity means immature type II alveoli and insufficient surfactant production
128
CXR finding in ARDS and NRDS?
Bilateral pulmonary infiltrates
129
Management of RDS?
Supportive care
High-flow oxygen
Assisted ventilation
Surfactant (NRDS)
130
Prevention of NRDS?
If mum at risk of premature birth, IM corticosteroids to stimulate foetal lung maturation
131
Features of eosinophilic granulomatosis with polyangitis (Churg-Strauss)?
pANCA +ve
Small vessel vasculitis
Recurrent sinusitis
Pulmonary disease
Asthma/eosinophilia
132
Features of granulomatosis with polyangitis (Wegener's)?
cANCA +ve
Small vessel vasculitis
Recurrent sinusitis
Pulmonary disease
Epistaxis/haemoptysis
Rapidly progressive glomerulonephritis
133
Features of Goodpasture's syndrome?
Anti-GBM +ve
Pulmonary haemorrhage
Rapidly progressive glomerulonephritis
134
Features of obstructive sleep apnoea?
Snoring
Morning headache
Daytime sleepiness
Inability to concentrate
135
Investigations and management of obstructive sleep apnoea?
Investigations = epworth sleepiness scale, polysomnography (sleep study)
Management = lifestyle changes, CPAP
136
Management of choking?
Able to breathe = encourage to cough
Unable to breathe = 5 back blows then 5 abdominal thrusts (repeat)
Unconscious = call 999, start CPR
137
Features of anaphylaxis?
Urticaria
Angioedema
Breathlessness
Wheeze, stridor
Abdominal pain
138
Test to confirm anaphylaxis and time-frame?
Serum mast cell tryptase
→ within 6 hours of the event
139
Adrenaline dosage for < 6 months, 6 months-6 years, 6-12 years and > 12 years?
< 6 months = 100-150 mcg
6 months-6 years = 150 mcg
6-12 years = 300 mcg
> 12 years = 500 mcg (0.5 ml 1 in 1,000)
140
Refractory anaphylaxis and management?
Respiratory and/or cardiovascular problems persisting after 2 doses of IM adrenaline
Management = IV adrenaline + IV fluid bolus
