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Respiratory Flashcards

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1
Q

Wasting of hand muscles

A
  • Pancoast tumour (compresses brachial plexus –> hand weakness)
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2
Q

Bounding pulse

A
  • CO2 retention (stimulated chemoreceptions = increased cardiac output)
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3
Q

Features of Horner’s Syndrome

A
  • Miosis
  • Partial ptosis
  • Anhydrosis
  • Enophthalmos (opposite of exophthalmos)
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4
Q

Normal inspiratory: expiratory ratio

A
  • 1:2
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5
Q

Causes of increased vocal resonance vs decreased

A

Increased = increased lung density
- Consolidation
- Collapse
- Tumour

Decreased = decreased lung density
- Effusion
- Pneumothorax
- Emphysema

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6
Q

Causes of fine vs coarse crepitation

A

Fine
- Fibrosis
- Oedema

Coarse
- Consolidation
- Bronchiectasis
- COPD

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7
Q

Cause of monophonic vs polyphonic wheeze

A

Monophonic = single large airway
- Cancer
- Foreign body

Polyphonic = different-sized airways constricting at different times
- Asthma
- COPD
- Infection

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8
Q

Causes of pleural rub

A

Abnormal pleura rubbing each other causing friction
- Pleurisy
- Effusion
- Mesothelioma

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9
Q

How is Diffusion Capacity calculated?

A
  • Breathe in CO (crossed alveolar membrane) and helium (does not)
  • Amount of CO that crosses into blood = TLCO
  • Helium concentration breathed out is how much air in lungs to dilute it = total lung volume –> use to calculate KCO (gas transfer per unit volume)
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10
Q

MRC scale for breathlessness

A

1: strenuous exercise
2: slight hill
3: stop for breath walking flat
4: stop after 100m
5: when dressing

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11
Q

CXR sign of hyper-expansion

A

More than 6 anterior or 10 posterior ribs in the mid-clavicular line at the lung diaphragm level.

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12
Q

Indications for LTOT

A
  • PaO2 <7.3

OR PaO2 <8 and :
- Secondary polycythaemia
- Pulmonary HTN
- Cor pulmonale

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13
Q

Eligibility for LVRS in COPD

A
  • FEV1 <50%
  • SOB affects quality of life
  • Don’t smoke
  • 6min walk test >140m
  • (Ideally upper lobe emphysema)
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14
Q

Treatment for COPD

A
  • LAMA+LABA
  • LAMA+LABA+ICS if asthma features, eos >0.3
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15
Q

Eligibility for transplant in COPD

A
  • FEV1 <50%
  • SOB affects quality of life
  • Don’t smoke
  • Completed pulmonary rehabilitation
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16
Q

Contraindications for NIV in COPD exacerbation

A
  • Undrained pneumothorax
  • Confusion
  • Facial injuries
  • Upper airway obstruction
  • Upper GI surgery
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17
Q

Respiratory causes of clubbing

A

ABCDEF
Abscess (lung) and Asbestosis
Bronchiectasis
Cystic fibrosis
Dirty tumours (bronchogenic carcinoma, mesothelioma)
Empyema
Fibrosing alveolitis (IPF)

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18
Q

Causes of clubbing and creps

A

FAB you know this:
Fibrosing alveolitis (IPF)
Asbestosis
Bronchiectasis, Bronchogenic carcinoma.

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19
Q

HRCT signs of bronchiectasis

A
  • Cylindrical (advanced), saccular (cystic), varicose (irregular airways)
  • Bronchial thickening/dilation (“tram tracks”)
  • Lack of normal airway tapering–> see bronchi within 1cm of pleura
  • “Signet ring sign” = bronchi > 1.5 times larger than
    adjacent vessel
  • Mucus plugging in bronchioles
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20
Q

Causes of bronchiectasis

A
  • Congenital (CF, PCD, Young’s)
  • Childhood infection (pertussis, TB, measles)
  • Mechanical (cancer, granuloma, lymph node TB)
  • Immune underactive (congenital = hypogammaglobulin, acquired = AIDS)
  • Immune overactive (ABPA)
  • Aspiration (localised RLL)
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21
Q

CF diagnostic test

A
  • Sweat chloride >60mmol/L
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22
Q

Features of Young’s syndrome

A
  • Like CF but no abnormal sweat/pancreatic insufficiency
  • Diagnosed in middle-aged men who test for infertility
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23
Q

Cause and mechanism of CF

A
  • Autosomal recessive disease due to defect in CFTR gene on chromosome 7
  • CFTR found in all exocrine tissues (hence sinusitis and pancreatitis)
  • Stops Chloride moving out of cells–> Na follows to keep isoelectric–> water follows into cells –> thick secretions
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24
Q

CF bug which can lead to increased worsening of lung function

A
  • Burkholderia cepacia ‘complex’ (Gram -ve)
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25
Signs of old TB
- Supraclavicular scar (phrenic nerve crush) - Thoracotomy - Chest deformity/missing ribs (thoracoplasty = remove 2 ribs so anterior chest wall collapses into affected side) - Tracheal deviation to fibrosis in old TB site - Dull percussion
26
Investigation signs of old TB
- Apical fibrosis - Pleural scarring - Aspergilloma in old TB cavity - Kyphosis (Pot's Disease) - Bronchiectasis (lymph node obstruction causing distal bronchiectasis)
27
Investigations for TB
- 3 sputum samples (including early morning): culture and auramine stain for AFB - Nucleic acid amplification test (NAAT) - IGRA (previous TB) - HIV test!!!
28
CXR findings of TB
- Hilar/paratracheal lymphadenopathy - Pulmonary nodules/infiltrates - Upper lobe cavitation
29
Management of TB
- Notify PHE and contact trace - Before treatment: LFTs, acuity, colour blindness - If fully sensitive: RIPE for 2 months --> RI for 4 more months - Give pyridoxine (B6)
30
Side effects of TB meds
- Rifampicin: liver enzyme inducer (COCP, anti-epileptics) - Isoniazid: peripheral neuropathy - Pyrazinamide: gout - Ethambutol: optic neuritis They ALL cause hepatitis!
31
Squeaks on auscultation
- Hypersensitivity pneumonitis
32
Causes of upper zone fibrosis
CHARTS - Coal worker's pneumoconiosis - Hypersensitivity pneumonitis (fibrotic EAA) - Ank spond/ABPA - Radiation - Tuberculosis - Sarcoidosis/Silicosis
33
Causes of lower zone fibrosis
RATIO - Rheumatoid arthritis - Asbestosis - Tissue disease connective (scleroderma, Sjögren’s, SLE) - IPF - Other - chemicals (lead, paraquat, dry-cleaning fluids) or drugs
34
Causes of asymmetrical fibrosis
- Old TB - Cancer/radiotherapy
35
Iatrogenic causes of fibrosis
BBC is MANS Gold - Bleomycin - Cyclophosphamide - Methotrexate - Amiodarone - Nitrofurantoin - Sulphasalzine - Gold (used to treat RA)
36
List different idiopathic interstitial pneumonias
- UIP: in IPF, not steroid responsive, poorer prognosis - NSIP: more steroid responsive - Desquamative Interstitial Pneumonia (DIP): due to smoking, steroid-responsive - Cryptogenic Organizing Pneumonia (COP): resembles pneumonia but does not respond to abx-- give steroids for 6-12months (happens in inflammatory conditions e.g. RA) - Acute Interstitial Pneumonia (Haman-Rich Syndrome): rapid ARDS, supportive treatment may respond to steroids
37
Antibody for limited systemic sclerosis
- Anti-centromere
38
Antibody for diffuse systemic sclerosis
- Anti-topoisomerase (anti-Scl 70)
39
Antibody for dermatomyositis
- Anti-Jo 1
40
Which ILD conditions have high lymphocytes in BAL
- Hypersensitivity pneumonitis - Sarcoidosis - Organizing pneumonia - Lymphocytic interstitial pneumonia (LIP)
41
5 respiratory complications of RA
- Pleural effusion - Nodules - Fibrosis - Caplan Syndrome (pneumoconiosis and RA) - Obliterative bronchiolitis (bronchiole inflammation --> necrotizing fibrosis)
42
How much effusion do you need to get symptoms
- >500ml - Need >1L for tracheal deviation away - Need 300ml to see on PA CXR (25ml on lateral film)
43
Cause of transudate effusions
CHAM - CCF - Hypoalbumin (nephrotic syndrome) - All failures (inc cirrhosis) - Meig's Syndrome (ovarian fibroma)
44
Cause of exudative effusions
PINTS - Pneumonia - Infarction (PE) - Neoplasm - TB/trauma - Sarcoid/scleroderma
45
Differential for dull bases
- Collapse - Consolidation - Fibrosis - Raised diaphragm (phrenic nerve palsy, hepatomegaly) - Pleural thickening
46
Why take blood test at same time as pleural aspirate
- So serum LDH and albumin can be taken for Light's criteria
47
Definition of transudate vs exudate
Protein concentration - Exudate >35g/L - Transudate <25g/L
48
Light's criteria for pleural effusion
Exudate: - Pleural albumin: serum albumin > 0.5 - Pleural LDH: serum LDH > 0.6 - Pleural LDH > 2/3rds upper normal limit of serum LDH 25 % of patients with transudates are mistakenly identified as having exudates by Light’s criteria
49
Definition of empyema
- pH <7.2 (and glucose <2)
50
What is normal glucose level in effusion
- >2mmol/L
51
Causes of low glucose effusions
MEAT: - Malignancy - Empyema - Arthritis (rheumatoid) - TB
52
Diagnostic criteria for haemothorax
- Hct effusion/Hct serum > 0.5
53
Cause of chylothorax
Lymph seeps into pleural space - Post-pneumonectomy - Lymphoma/cancer - Trauma
54
Diagnostic criteria for chylothorax
- Triglycerides >1.3mmol/L
55
Other calculation for exudate effusion
Serum albumin - pleural albumin = <1.2g/dL
56
Simple vs complicated parapneumonic effusion
Complicated - Empyema (pH <7.2) - Culture positive fluid
57
Definition of apnoea
- No breathing for 10 seconds
58
Definition of hyponoea
- Breathing <50% below baseline AND desaturation or sleep arousal
59
Components of a sleep study (i.e. diagnostic tests)
- EEG - EMG - Electro-oculogram (EOG)- determines sleep stage/REM (Do 2nd study with CPAP pressure titration if diagnosis confirmed) - Need 5 episodes/hour to diagnose OSA
60
How is OSA severity calculated (and what is severe)
Apnoea-hypopnea index (number of event per hour of sleep) - >30 is severe
61
Causes of OSA
Upper airway obstruction - Obesity - Macroglossia (Down's/hypothyroid) - Mandibular deficiency (micrognathia or retrognathia) Reduced upper airway tone - Neurological issue
62
Causes of central sleep apnoea
- Cheynes-Stokes apnoea: stroke, heart failure - Brainstem lesion - Opioid use
63
Hoarse voice- relevance to respiratory?
- Left laryngeal nerve palsy (passes along trachea)
64
Hand features of Horner's Syndrome
- Weakness/atrophy of intrinsic muscles (T1) - Pain/paraesthesia at 4th/5th digits (C8) and medial forearm (T1)
65
Clubbing and pain at wrist/ankles
- Hypertrophic pulmonary osteoarthropathy: subperiosteal bone formation (periosteum is layer above bone) - Any lung cancer type, esp squamous and adenocarcinoma
66
Features of Lambert-Eaton Syndrome
- Proximal muscle weakness- improves with exercise - Reduced tendon reflexes- improves with exercise (check reflexes before and after testing power) - Cranial nerve involvement (ptosis, diplopia)
67
Lambert-Eaton Syndrome in which lung cancer
- Small cell lung cancer
68
Pathophysiology of Lambert-Eaton Syndrome
- Antibodies against voltage-gated calcium channels--> reduced acetylcholine release from presynaptic nerve terminals (so adjacent muscle does not depolarise)
69
Difference between Myasthenia Gravis and Lambert-Eaton Syndrome
- Myasthenia: antibodies against acetylcholine-receptor - Lambert-Eaton: antibodies against voltage-gate calcium channel
70
Paraneoplastic syndromes in lung cancer
Neurological: - Lambert-Eaton (small cell) - Peripheral neuropathy Musculoskeletal - Hypertrophic pulmonary osteoarthropathy (SCC, adenocarcinoma) Endocrine - Hypercalcaemia (PTH-related peptide) (SCC) - SIADH (small cell) - Ectopic ACTH (small cell) Skin - Acanthosis nigricans - Thrombophlebitis migrans
71
Presenting features of SIADH
- Confusion - Hyponatraemia-- with raised urine osmolarity/low serum osmolarity, raised urine sodium
72
Treatment of SIADH
- Fluid restrict if euvolaemic - Tolvaptan (vasopressin receptor antagonist) - Demeclocycline (tetracycline which reduces responsiveness of collecting tubule to ADH) - Slow sodium chloride tablets
73
Staging classification for small cell cancer
- Limited = same hemithorax (15-20months) - Extensive = outside of hemithorax (8-13months)
74
WHO performance status
- 0: asymptomatic - 1: light work - 2: bed <50% of day, can self-care but not work - 3: bed >50% of day, limited self-care - 4: bedridden - 5: dead
75
Eligibility criteria for lung cancer surgery
- FEV1 >2L for pneumonectomy and >1.5L for lobectomy - Ideally DLCO >80% and pre-op VO2 max >15ml/min/kg
76
Features of Superior Vena Cava Obstruction
- Pemberton's sign: lifting arms above head worsens signs (thyroid compressed against thoracic inlet, which contains the SVC) - Facial plethora - Facial/upper body oedema - SOB - Hoarse voice - Fixed elevated JVP - Stridor if severe
77
Causes of Superior Vena Cava Obstruction
Disease of right lung/lymph nodes/mediastinum - Small cell lung cancer - Non-Hodgkin's Lymphoma - Thymoma
78
Treatment of Superior Vena Cava Obstruction
- Dexamethasone 8mg BD with PPI cover - Stenting - If not stentable: emergency radiotherapy
79
Symptoms of metastatic spinal cord compression
- New back pain/worse than usual back pain - Limb weakness--> difficulty walking - Incontinence/retention
80
Management of metastatic spinal cord compression
- 16mg dexamethasone STAT --> 8mg BD (0800 and 1200)—with PPI cover - STRICT bed rest until neurosurgeons confirm if spine stable - Surgery + post-op radiotherapy (or only radiotherapy in non-surgical candidates)
81
Treatment of hypercalcaemia of malignancy
- STOP calcium supplements! - 2-6L over 24hrs initially - STAT zolendronic acid --> consider another dose at day 5 (adjust dose if Cr clearance <60) - Denosumab if zolendronic doesn’t work
82
Trachea deviation in lobectomy?
- Only in upper lobectomy = towards lobectomy (may be central in other lobectomies)
83
Breath sounds in pneumoectomy
- Usually decreased (thoracic cavity fills with gelatinous stuff) - May have bronchial breathing in upper zones due to deviation of trachea towards the pneumonectomy
84
Types of pneumonectomy
- Simple: lung - Extrapleural (mesothelioma): lung, diaphragm, parietal pleura and pericardium (these linings replaced with Gore-Tex surgical patches)
85
Operative mortality for pneumonectomy and lobectomy
- Lobectomy: 2-4% - Left pneumonectomy: 3% - Right pneumonectomy: 10% (complications are higher)
86
Complications of pneumonectomy
- Post-pneumonectomy syndrome (right pneumonectomy): hyperinflation of other lung--> compresses distal trachea and mainstem bronchus--> symptoms a few months after surgery --> needs re-do surgery - Bronchopleural fistula - Pulmonary oedema
87
Signs of pulmonary HTN
- Left parasternal heave (RV hypertrophy) - Loud P2 and palpable - Wide splitting of S2 - Tricuspid regurg (RV dilation)--> pansystolic murmur left sternal edge loudest on inspiration
88
Definition of cardiomegaly on CXR
- Cardiac silhouette: thoracic cavity >0.5
89
CXR signs of pulmonary HTN
- Cardiomegaly (cardiac silhouette: thoracic cavity >0.5) - Enlarged pulmonary trunk, with prominent peripheral vessels
90
ECG signs of pulmonary HTN
- Prominent p waves (p pulmonale) due to RA enlarged - Right axis deviation - RBBB
91
Diagnostic definition of pulmonary HTN
- Mean pulmonary artery pressure > 25mmHg with a pulmonary capillary wedge pressure/left atrial pressure <15mmHg
92
List the 5 classes of pulmonary HTN
- 1: Pulmonary arterial hypertension - 2: Left-sided cardiac disease - 3: Lung disease (hypoxaemia) - 4: CTEPH - 5: Others (sarcoid, Langerhans cell histiocytosis)
93
How to palpate for parasternal heave
- Heel of hand vertical along left sternal edge - Heave = hand lifted off the chest with each systole
94
BAL feature of fibrosis which suggests steroid-responsiveness
- Lymphocytes > neutrophils
95
CT features of UIP
- Bibasal subpleural honey-combing - Traction bronchiectasis - Heterogenous distribution
96
CT features of NSIP
- Ground-glass shadowing - Reticular opacities
97
One lung normal breath sounds, other lung has fine creps-- diagnosis?
- Unilateral lung transplant in fibrosis
98
Counselling needed after starting TB meds
- Get sclera everyday-- if yellow, stop TB meds and call TB nurse - If red colour less bright, ring TB nurse - COCP may not work - Don't wear contact lenses as may turn orange
99
Signs of upper vs lower lobectomy
- Upper: hyper-resonant upper with dull base (raised diaphragm)-- or could be normal examination! - Lower: dull percussion and absent breath sounds at bases
100
CXR signs of lobectomy
- Could be normal! - Raised hemidiaphragm (note right should normally be above left)
101
Indication for bullectomy in COPD
- Bullus >1L and compresses surround lung
102
Wheeze in a rheumatoid arthritis patient
- Obliterative bronchiolitis (also occurs after lung transplant)
103
Causes of empyema
- Staph and strep - Anaerobes - Psuedomonas (fusobacterium)
104
Treatment for pancreatic CF disease
- Creon (lipase, protease, amylase) - Fat-soluble vitamins (ADEK) - because CF can't absorb fat so don't absorb the vitamins normally dissolved in fat
105
Causes of false positive sweat test for CF
- Hypothyroidism - Addison's
106
Urine tests in pneumonia
- Legionella antigen - Pneumococcal antigen - Haemaglobin: mycoplasma causes cold agglutins (IgMs against RBCs--> haemolysis)
107
Bug which commonly causes bacterial IECOPD
- Haemophilus influenzae (Gram -ve)
108
What additional antibiotic would you add if severe pneumonia
- Metronidazole to cover anaerobics
109
Adjunct to antibiotics/chest drain for empyema
- Intrapleural fibrinolytics (dornase alfa/alteplase for 3 days)- because bacteria cause fibrin net in Fibrinopurulant stage of empyema
110
Which pneumonia covers right heart border
- RML
111
Why are CF men infertile
- Congenital Bilateral Absence of Vas Deferens (carries sperm out of testes)
112
Definition of PEFR variability in asthma
- Varies by 20% for 3 days a week for 2 weeks
113
Stages of sarcoidosis
- 1: bilateral hilar lymphadenopathy - 2: bilateral hilar lymphadenopathy + infiltrates - 3: infiltrates only - 4: fibrosis (mid-zone)
114
Skin manifestations of sarcoidosis
- Lupus pernio - Erythema nodosum - Maculopapular lesions/plaques - Subcutaneous nodules
115
Other conditions which cause raised serum ACE
- Pulmonary TB - Lymphoma - Asbestosis So use serum ACE to check response to treatment in sarcoidosis
116
When do d-dimer if suspect PE
- If Well's score <4 but you still suspect PE - (If Well's score >4, you are not meant to check d-dimer!)
117
Thrombolysis criteria in PE
- Cardiac arrest - SBP <90 with end-organ hypoperfusion (or needing vasopressors to maintain SBP 90) - SBP drop >40 for 15mins, not caused by something else
118
Alteplase doses for PE thrombolysis
- Cardiac arrest: 50mg - Others: 10mg bolus --> 90mg over 2hrs --> heparin infusion until stable enough for LMWH
119
How to use salbutamol in asthma attack and when to call 999
- 1 puff every 30 seconds up to max of 10 puffs - Then call 999 if not feeling better - Can take another 10 puffs after 10mins if ambulance not there yet
120
Chest expansion - Where to measure - What is normal - What is pathologically low
- 4th ICS - 5cm - <2.5cm
121
Pattern of arthritis caused by sarcoidosis
- Symmetrical oligoarthritis
122
2 ways in which sarcoidosis affects kidneys
- Glomerulonephritis - Stones (high calcium)
123
Primary Ciliary Dyskinesia triad
- Bronchiectasis - Sinusitis - Situs inversus
124
Breathless patient- what 2 important things need to ask in history
- PND and orthopnoea!
125
Mode of inheritance cystic fibrosis and gene/chromosome involved
- Autosomal recessive - CFTR gene on chromosome 7
126
Tests in returning traveller
- Malaria blood film x3 and rapid diagnostic test - Stool MC&S with ova, cysts and parasites - AFB x3 - Extended respiratory viral screen - Blood-bourne viruses with HIV - Serology tests (Dengue, leptospirosis, chikungunya)

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