Respiratory Flashcards
(118 cards)
1
Q
What level of pO2 is severe respiratory failure?
A
<8kpa
2
Q
What is the presentation of respiratory failure?
A
*SOB
*Anxiety
*Tachypnoea
*Confusion
*Cardiac dysfunction
3
Q
What investigations should be carried out in suspected respiratory failure?
A
*Pulse oximetry
*ABG
*FBC, D dimer, serum bicarbonate
* ECG
*Pulmonary funciton tests
4
Q
What is type 1 resp failure
A
Low oxygen, normal CO2
5
Q
What are the causes of type 1 respiratory failure?
A
*Pulmonary oedema
*COPD
*Asthma
*PE
*Pneumothorax
*Pulmonary fibrosis
6
Q
What is type 2 respiratory failure?
A
Low oxygen, high Co2
7
Q
What are the causes of type 2 respiratory failure?
A
*COPD
*Chest wall abnormalities
*Muscle weakness
*CNS depression
8
Q
What is the management of respiratory failure?
A
*ABCDE
*Oxygen
*Management of underlying cause
9
Q
What are the features of COPD?
A
*Productive cough
*Dyspnoea
*Wheeze
*Recurrent respiratory infection
10
Q
Grade 1 MRC
A
Breathless on strenuous exericse
11
Q
Grade 2 MRC
A
Breathless on walking up a hill
12
Q
Grade 3 MRC
A
Breathless that slows walking on the flat
13
Q
Grade 4 MRC
A
SOB after 100m
14
Q
Grade 5 MRC
A
Unable to leave the house due to SOB
15
Q
What investigations should be carried out in COPD?
A
*Spirometry
*Chest X ray
*FBC
*Consider an ABG if acutely unwell
16
Q
What is the typical spirometry for someone with COPD?
A
*FEV1/FVC<0.7
*Obstructive picture
*Not fully reversible
17
Q
What are the signs of COPD on X Ray?
A
*Hyperinflation
*Bullae
*flat hemidiaphragm
18
Q
What may be seen on a FBC in someone with COPD?
A
*Polycythaemia
*Anaemia
*Leucocytosis
19
Q
Stage 1 COPD
A
FEV1>80% - must also have symptoms
20
Q
Stage 2 COPD
A
Moderate, FEV1 50-79%
21
Q
Stage 3 COPD
A
Severe, FEV1 30-49%
22
Q
Stage 4 COPD
A
FEV1 <30%, very severe
23
Q
What is the non-pharmaceutical management of COPD
A
*Smoking cessation
*Annual influenza vaccine
*One off pneumococcal vaccine
*Pulmonary rehabilitation
24
Q
What is step 1 of pharmaceutical management of COPD?
A
SABA (salbutamol) or SAMA (ipratropium bromide)
25
What is step 2 of pharmaceutical management of COPD?
* If there is a steroid response then LABA+ ICS (fostair)
* If no steroid response then LABA and LAMA
26
What is the treatment of an exacerbation of COPD?
* Prednisolone
* Inhalers and nebulisers
* Antibiotics if evidence of infection
* Physiotherapy
27
What is the treatment of a severe exacerbation of COPD?
* IV aminophylline
* Non-invasive ventilation
* Intubation and ventilation ->ICU
* Doxapram as a respiratory stimulant
28
What is step 3 of pharmaceutical management of COPD?
Oral theophylline
29
When should mucolytics be considered in COPD
In those with a chronic productive cough
30
What antibiotic can be used as prophylaxis in COPD?
Azithromycin
31
Before giving LTOT, what investigation do you have to do?
2 ABGs at least 3 weeks apart
32
Which patients should be offered LTOT?
* pO2 <7.3kPa
* pO2 7.3 to 8 AND one of:
- secondary polycythaemia
- oedema
- pulmonary hypertension
33
Immunoglobulin asthma
IgE
34
What is the presentation of asthma?
* Episodic symptoms
* Diurnal variation
* Dry cough, wheeze and SOB
* History of atopy
* Bilateral widespread polyphonic wheeze
35
What investigations should be carried out for asthma?
* Spirometry
* Chest X ray to exclude other pathologies
* FBC
* Consider IgE immunoassay
* Consider fractional exhaled nitric oxide
36
Spirometry in asthma
* Obstructive picture
* FEV1/FVC <80%
* Reversibility over 12%
37
FBC in asthma
May be normal, may see raised eosinophils and/or neutrophilia
38
What is the management of asthma?
* SABA - salbutamol
* ICS - beclometasone dipropionate
* LABA - salmeterol
* Leukotriene receptor antagonist - montelukast
39
Moderate acute asthma
* Peak flow 50-75%
* Normal speech
40
Acute severe asthma
* Peak flow 33-50%
* Unable to complete sentences in one breath
* Signs of respiratory distress
* Resp rate >25
* Heart rate >110
41
Life threatening asthma
* Peak flow <33%
* Saturations <92%
* Exhaustion and poor respiratory effort
* Hypotension
* silent chest
* Cyanosis
* Altered consciousness/confusion
42
What is the management of moderate acute asthma?
* Nebulised SABA and SAMA
* Steroids (oral prednisolone or IV hydrocortisone)
43
What is the management of acute severe asthma?
* Nebulised SABA and SAMA, steroids
* Oxygen to maintain SATs
* Aminophylline
* Consider IV salbutamol
44
What is the management of life threatening asthma?
* IV magnesium sulfate
* HDU admission
45
Pneumonia on chest X ray
* Consolidation
46
What is the presentation of pneumonia?
* Shortness of breath
* Productive cough
* Fever
* Haemoptysis
* Pleuritic chest pain
* Delerium
47
What are the signs of pneumonia?
* Tachycardia and tachypnoea
* Hypoxia
* Hypotension
* Fever
48
What are the characteristic chest signs of pneumonia?
* Bronchial breath sounds
* Focal coarse crackles
* Dullness to percussion
49
What is the assessment for pneumonia?
CURB-65
50
Explain the result of a CURB-65 score
* 0/1 manage at home
* ≥2 hospital
* ≥3 ICU
51
Explain CURB 65
C- confusion
U - urea >7
R - respiratory rate ≥ 30
B - blood pressure <90 systolic or ≤60 diastolic
65 - aged ≥65
52
What is the most common cause of pneumonia?
Streptococcus pneumoniae
53
What is a common cause of pneumonia in those with COPD?
Haemophilus influenzae
54
What cause of pneumonia is seen in those with HIV?
Pneumocystis jiroveci
55
What is the treatment for pneumonia caused by pneumocystis jiroveci?
Co-trimoxazole
56
What is a hospital acquired pneumonia?
48 hours + after admission
57
What investigations should be carried out in suspected pneumonia?
* FBC - neutrophilia if bacterial
* U+Es (For urea, look for dehydration also)
* CRP
* Chest X Ray
* Sputum (and blood) cultures
58
What is the management of a low severity pneumonia?
5 day course of amoxicillin
59
What is the management of a moderate/high severity pneumonia?
7 day course of amoxicillin and a macrolide
60
What are the complications of pneumonia?
* Pleural effusion
* Empyema
* Lung abscess
* Sepsis
61
What are the risk factors for PE
* Immobility
* Recent surgery
* Long haul travel
* Pregnancy
* Oestrogen: HRT or oral contraceptive pill
* Polycythaemia
* SLE
* Thrombophilia
* Malignancy
62
What is the presentation of DVT?
* unilateral swelling
* Oedema
* Tender calf
* Colour changes
* Dilated superficial veins
63
What is the presentation of PE?
* Tachypnoea >20
* Crackles
* Tachycardia
* Fever
* Signs of PE
64
Results of WELLS score
* ≥4 means PE is likely, immediate CTPA, if there is a delay, anticoagulate. If negative, carry out proximal leg USS
* <4 arrange a D-dimer
65
What are the ECG changes due to PE?
* Large S wave in lead I
* Large Q wave in lead III
* Inverted t wave in lead III
* RBBB and right axis deviation
* Sinus tachycardia
66
What investigations should you carry out in suspected PE?
* CTPA (echo if haemodynamically unstable)
* D dimer
* FBC
* ECG
* UEs to check baseline renal function
* LFTs to check baseline function
* Coagulation studies
67
What is the management of PE?
* Apixaban or rivaroxaban
* PESI score to risk stratify
68
How long should you coagulate after PE?
* At least 3 months if there is a reversible cause
* >3 if cause unclear
* 3-6 months in active cancer
69
What is Budd Chiari syndrome?
Clot in the hepatic vein causing acute hepatitis
70
What is a pneumothorax?
Air in the pleural space
71
What are the causes of pneumothorax?
* Spontaneous
* Trauma
* Iatrogenic: lung biopsy, mechanical ventilation, central line insertion
* Lung pathology: infection, asthma, COPD
72
What is the investigation for pneumothorax
Xray
73
What is the management of pneumothorax?
* If no SOB and <2cm air then no treatment and follow up in 2-4 weeks
* If SOB or >2cm air, aspirate and if it fails twice then insert a chest drain
* If unstable then chest drain
74
What is the presentation of pneumothorax?
* Chest pain
* Dyspnoea
* Ipsilateral reduced breath sounds
* Cough
* Hyper-resonance on percussion
75
Where is the safe space for aspiration?
Either 2nd intercostal space in mid clavicular line or the 4th/5th intercostal space in the mid axillary line (lateral dorsi, pectoralis major lateral edges)
76
Where is triangle of safety for chest drain?
4th/5th intercostal space in the mid axillary line (lateral dorsi, pectoralis major lateral edges)
77
What is a tension pneumothorax
A pneumothorax in which there is continual entrance of air with trapping in the pleural space causing haemodynamic compromise
78
What are the types of lung cancer?
* Non small cell: adenocarcinoma, squamous, large cell
* Small cell
* Mesothelioma
79
What is the presentation of lung cancer?
* SOB
* Cough
* Haemoptysis
* Finger clubbing
* Recurrent pneumonia
* Weight loss
* Lymphadenopathy
80
What are the extrapulmonary manifestations of lung cancer?
* Recurrent laryngeal palsy
* Phrenic nerve palsy
* Superior vena cava obstruction
* Horner's syndrome
* SIADH: SCLC ectopic ADH secretion
* Cushing's: SCLC ectopic ACTH
* Hypercalcaemia: squmous cell carcinoma secreting PTH
* Limbic encephalitis: antibodies against small cell lung cancer causing inflammation in the brain
* Lamert-Eaton mysathenic syndrome: antibodies against voltage calcium channels
81
Presentation of limbic encephalitis
* Short term memory impairment
* Hallucination
* Confusion
* Seizures
82
What is the presentation of lambert-eaton myasthenic syndrome?
* Proximal weakness
* Diplopia
* Dysphagia
* Slurred speech
83
What is the presentation of superior vena cava obstruction?
* Facial swelling
* Difficulty breathing
* Distended veins
* Pemberton's sign (hands above head ->cyanosis)
84
Referral criteria for suspected lung cancer in >40s
* Clubbing
* Lymphadenopathy
* Recurrent or persistent chest infection
* Raised platelet count
* Chest signs of lung cancer
* 2 week wait
85
Referral criteria for suspected lung cancer in <40s
* Refer if a smoker with one of the following or a non smoker with two of:
* Cough
* SOB
* Fatigue
* Chest pain
* Weight loss
* Loss of appetite
86
What are the investigations for suspected lung cancer?
* CXR
* CT staging and PET-CT
* Bronchoscopy with endobronchial US
* Histology via bronchoscopy or percutaneous biopsy
87
What are the signs of lung cancer on CXR?
* Hilar enlargement
* Peripheral opacity
* Unilateral pleural effusion
* Collapse
88
What is the treatment of lung cancer?
* Surgery 1st line for non small cell
* Radiotherapy
* Chemotherpay
* Small cell: chemo and radio
* Endobronchial treatment for bronchial obstruction
89
What are the exudative causes of pleural effusion
Due to inflammation:
- Lung cancer, mesothelioma, metastases
- Pneumonia
- Rheumatoid arthritis, SLE
- Tuberculosis
90
What are the transudative causes of pleural effusion?
Due to fluid shift (<3g/dL)
- congestive cardiac failure
- hypoalbuminaemia
- hypothyroidism
- Meig's syndrome (R sided pleural effusion with ovarian malignancy)
91
What is the presentation of pleural effusion?
- SOB
- Dullness to percussion
- Reduced breath sounds
- tracheal deviation away from the effusion if massive
92
What are the investigations for pleural effusion?
- Chest X ray
- pleural aspiration or sample from the drain
93
What is the management of pleural effusion?
- conservative if small
- pleural aspiration
- chest drain
94
What is empyema?
Infected pleural effusion
95
Diagnosis of empyema
* Suspect in patients with improving pneumonia with new or ongoing fever
* Pleural aspiration: pus, acidic pH, low glucose, high LDH
96
What is Light's criteria?
If protein is 25-30g/L it is likely to be exudative if any one of the following is true:
- Pleural fluid protein/serum protein >0.5
- Pleural fluid LDH/serum LDH >0.6
- Pleural fluid >2/3 upper limits of normal serum LDH
97
What is the management of empyema?
Chest drain and antibiotics
98
What is the presentation of obstructive sleep apnoea
* Episodes of apnoea
* Excessive daytime sleepiness
* Chronic snoring
* Morning headache and problems concentrating
99
What are the risk factors of Obstructive Sleep apnoea?
- obesity
- male
- smoker
- maxillomandibular anomalies
100
What are the investigations for suspected obstructive sleep apnoea?
Polysomnography
101
Results of polysomnography
≥15: diagnose (moderate)
5-15 diagnose if also experiencing symptoms
>30 is severe OSA
102
What are the complications of obstructive sleep apnoea?
- Cardiovascular disease
- depression
- impaired glucose metabolism
- motor vehicle accidents
103
What is interstitial lung disease?
Umbrella term for lung disease affecting the lung parenchyma causing inflammation and fibrosis
104
What are the different types of interstitial lung disease?
- idiopathic pulmonary fibrosis
- Drug induced pulmonary fibrosis
- Asbestosis
- Hypersensitivity pneumonitis
105
What is idiopathic pulmonary fibrosis?
Progressive pulmonary fibrosis with no clear cause
106
What is the presentation of pulmonary fibrosis?
- progressive dyspnoea
- (non-productive) cough
- basilar crackles
107
Investigation for idiopathic pulmonary fibrosis
- Chest XRay: opacities
- High resolution CT scan: honeycombing
108
Management of idiopathic pulmonary fibrosis
- Pirfenidone
109
What are the causes of drug induced pulmonary fibrosis?
- Amiodarone
- Cyclophosphamide
- Methotrexate
- Nitrofuratoin
110
What does asbestosis cause?
- Lung fibrosis
- Pleural thickening and plaques
- Adenocarcinoma
- Mesothelioma
111
What is hypersensitivity pneumonitis?
Inflammation of the alveoli and distal bronchioles caused by an immune response to inhaled allergens: avian, mould, chemicals
112
What is the presentation of hypersensitivity pneumonitis?
- cough
- dyspnoea
- fevers/chills
- malaise
- weight loss
113
Investigation for hypersensitivity pneumonitis
- Chest X-ray
- CT chest
- Serum IgG: raised
- Pulmonary function tests
114
Management of hypersensitvity pneumonitis
- Avoidance of antigen
- smoking cessation
- pulmonary rehabilitation
- oxygen
- consider steroids
115
What is bronchiectasis?
Abnormal dilation of the bronchioles in response to destruction of the elastic and muscular components of the bronchial wall. Usually due to recurrent infection secondary to an underlying disorder
116
What is the presentation of bronchiectasis?
- Cough
- sputum production (haemoptysis in 50%)
- crackles, high pitched inspiratory squeaks, rhonci
- dyspnoea
- fever
- fatigue
- rhinosinusitis (nasal discharge, obstruction and facial pressure)
117
Investigation for bronchiectasis
- High resolution CT chest
- Chest X-ray
- FBC, CRP, autoimmune screen, genetic testing
- Sputum culture and sensitivity
118
Investigation for cystic fibrosis
Sweat chloride test
