Respiratory Flashcards

Question

LTOT

Answer 1

Arterial PaO2 < 7.3kPa Arterial PaO2 < 8kPa with any of -Pulmonary hypertension -Peripheral oedema -Secondary polycythaemia

Answer 2

Respiratory failure Pneumonia Pneumothorax Polycythaemia/anaemia Depression

Answer 3

One or more emboli usually arising from a thrombus break off and obstruct within the pulmonary arteries Usually arises from a DVT

Answer 4

Predominant therapy of development of VTE is Virchow’s triad -Venous stasis -Endothelial injury -Hypercoagulable state Occlusion of one or more of the pulmonary arteries leads to absence of perfusion to that area of the lung -V/Q mismatch because ventilation is unaffected -May lead to hypoxia and clinical features of breathlessness -Area of lung may undergo infarction (usually prevented by the bronchial circulation)

Answer 5

Dyspnoea Pleuritic chest pain Cough Haemoptysis Dizziness Syncope Leg pain and swelling

Answer 6

Tachycardia (> 100 bpm) Low grade fever (>37.5) Hypoxia (sats < 94%)

Answer 7

Routine bloods D-dimer ECG - sinus tachycardia, S1Q3T3 pattern CXR, V/Q scan, lower limb USS, echo CTPA

Answer 8

PE - series of seven criteria are used that given a score between 0-12.5 Clinical signs and symptoms of DVT (+3) PE is #1 diagnosis/equally likely (+3) HR > 100 (1.5) Immobilisation at least 3 days or surgery in the previous 4 weeks (+1.5) Previous, objectively diagnosed PE/DVT (+1.5) Haemoptysis (+1) Malignancy with treatment within 6 months/palliative (+1) PE likely (score > 4) = straight to CTPA, if not available, interim anticoagulation if safe PE unlikely (score < 4) d-dimer blood test within 4 hours, if positive = CTPA

Answer 9

Stable - offer apixaban/rivaroxaban Haemodynamic instability - consider thrombolysis & heparin-based anticoagulation according to local guidelines Active cancer - consider DOAC (edoxaban) Renal impairment - if CrCl 15-50ml/min, offer apixaban/rivaroxaban or LMWH for 5 days then edoxaban/warfarin, if CrCl <15ml/min, offer LMWH/UFH as per local guidance

Answer 10

Thrombolysis - use of recombinant tissue plasminogen activator (fibrinolytic drug that breaks down clots) -Cardiac arrest with confirmed or suspected PE -Confirmed PE with deterioration despite anticoagulation -Haemodynamic instability & high clinical suspicion of PE/confirmed PE within 14 days

Answer 11

Long-term management - patients are advised to continue anticoagulation for a minimum period of 3 months After this patients should be referred to a specialist anticoagulation clinic & discuss whether to continue anticoagulation

Answer 12

High mortality (20%) in patients with haemodynamic instability Maternal death in pregnancy Chronic thromboembolic pulmonary hypertension & associated right sided HF

Answer 13

Caused by bacteria of the mycobacterium tuberculosis complex & is one of the world’s most common and deadly infective diseases Latent TB - refers to individuals infected with TB, who suppressed the initial infection, have no active diseases & not infectious Active TB - refers to symptomatic/progressive disease Primary TB - initial infection, often subclinical, suppressed in the majority of individuals Progressive-primary TB - primary infection is not suppressed & prolonged infection occurs Post-primary TB - occurs in patients with latent TB, frequently due to immunocompromised (may be pulmonary/extra-pulmonary)

Answer 14

Inhaled bacilli find their way into alveoli & begin dividing In some individuals -> may be immediately cleared, in others primary TB develops Once a critical mass is reached a host immune response is elicited with mycobacterium producing a strong immune response Ghon complex may develop -Ghon focus - small caseating granuloma -Ipsilateral mediastinal lymph node After 2-10 weeks a sufficient cell-mediated response halts the proliferation of the bacilli in the majority of individuals - these patients develop latent TB (may have a Ranke complex = calcified Ghon’s complex) Small proportion of patients do not halt the primary infection & develop primary-progressive TB (linked to patients with inadequate T-cell immunity)

Answer 15

Pulmonary TB - cough, fever, weight loss Lymph node - enlarged, firm, non-tender (most commonly affects cervical and supraclavicular nodes) Genitourinary TB - sterile pyuria, salpingitis, epididymo-orchitis, renal abscess Miliary TB - disseminated haematogenous spread of bacilli CNS TB - TB meningitis: fever, malaise and headache

Answer 16

CXR - demonstrate consolidation, cavitation (typically upper lobe) & effusion -Miliary TB - appearance of millet seeds throughout the lung fields Latent TB -Mantoux test - intradermal injection of tuberculin -If patient has had exposure to TB they exhibit a delayed hypersensitivity reaction -Previous BCG vaccination affects results Interferon-gamma release assay - assays detect the bodies cellular immune response (tests for the T-cell interferon-gamma response to M. tuberculosis) -Unaffected by previous BCG and non-tuberculous mycobacterium Active TB -Microbial - microscopy & culture, cytology & histology, nucleic acid amplification -Imaging

Answer 17

Latent TB - advise treatment in those younger than 65 -6 months of isoniazid with pyridoxine OR -3 months of isoniazid and rifampicin Active TB - combination antibiotics for 6-12 months -Without CNS involvement - managed with isoniazid (with pyridoxine), rifampicin, pyrazinamide & ethambutol for 2 months followed by rifampicin and isoniazid for 4 months -With CNS involvement - treated with isoniazid & rifampicin for 12 months whilst pyrazinamide & ethambutol are given for the first 2 months --Adjunctive steroids - offered dexamethasone or prednisolone at the start of treatment which is then weaned over 4-8 weeks

Answer 18

Irreversible and abnormal dilatation of the airways

Answer 19

Immune deficiency Mechanical obstruction Mucociliary clearance dysfunction Congenital airway defects Other causes - rheumatic diseases, allergic bronchopulmonary aspergillosis, COPD, inflammatory bowel disease

Answer 20

Infective insults combined with defective mucociliary clearance, airway obstruction or impaired host immunity Infective pathogens promote an inflammatory response involving the activation of neutrophils and release of inflammatory mediators -> results in damage to elastic & muscular components of the airway -> dilated airways Abnormal dilatation of the airways further predispose patients to infections -> leads to a cycle of infection & worsening bronchiectasis

Answer 21

Persistent sputum production Persistent cough Dyspnoea Haemoptysis Weight loss

Answer 22

Crackles High pitched inspiratory squeaks Wheeze Clubbing (rare)

Answer 23

Bloods - FBC, renal function, serum immunoglobulins Cultures - sputum cultures, blood cultures Imaging - CXR (tram track airways & ring shadows), thin section CT (signet ring) Aspergillus fumigatus - serum total IgE, sensitisation assessment

Answer 24

1) airway clearance - respiratory physiotherapist will teach airway clearance techniques 2) mucoactives - (help the clearance of mucus from the airways), isotonic and hypertonic saline may be used & have been shown to improve quality of life 3) prophylactic antibiotics - patients with recurrent exacerbations (> 3 per year) should be considered for long term abx P. aeruginosa: inhaled colistin & gentamicin, oral azithromycin/erythromycin can be considered in those who don’t tolerate inhaled therapy Non-P. aeruginosa: azithromycin/erythromycin may be used 4) bronchodilators 5) surgery - lung resection may be considered in patients with localised disease with uncontrolled symptoms

Answer 25

Infective exacerbation Chronic respiratory failure Haemoptysis Cor pulmonale Pneumothorax Chest pain

Answer 26

Autosomal recessive multi-system disease predominantly characterised by respiratory features

Answer 27

Caused by mutations to the cystic fibrosis transmembrane conductance regulator (CFTR) gene found on chromosome 7 CFTR gene encodes for a epithelial chloride channel regulated by cyclic AMP

Answer 28

In the lungs, CFTR channels are found on the apical surface of epithelial cells Defects in normal ion transport leads to dehydration & depletion of airway surface liquid Resultant mucociliary dysfunction causes reduced mucus clearance, airway obstruction & predisposition to infection Recurrent infection leads to chronic bronchitis, damage to the bronchi and eventual bronchiectasis -> permanent dilation of bronchi secondary to damage to the elastic and muscular components of the bronchial wall

Answer 29

Respiratory disease - productive cough & recurrent chest infections -Children - staph aureus & haemophilus influenza -Older age groups - colonisation with pseudomonas aeruginosa -Recurrent infections -> bronchiectasis Pancreatic disease - fatty stools, malabsorption, diabetes, recurrent acute pancreatitis & eventual chronic pancreatitis -Thick secretions block the outflow of exocrine digestive enzymes -Autolysis destroys the pancreatic islets Gastrointestinal disease - meconium ileus in infants, constipation, DIOS Malignancies - increased risk of gastrointestinal malignancies -Large and small bowel -Pancreas -Biliary tract -HCC

Answer 30

Diagnosis is now commonly made after a positive heel prick test (newborn screen) followed by confirmatory testing -Immuno-reactive trypsin test - used at newborn screening, a positive test is indicative but further confirmation testing is needed -Sweat test - can be used in children of any age Sweat chloride > 60mmol/L is considered positive for CF, 30-59mmol/L is inconclusive & <30mmol/L is considered negative -Genetic testing - common mutations are screening for, where not found, sequencing of the entire CFTR gene may be completed

Answer 31

Pulmonary disease - encouraging clearance of secretions & treating/preventing infections -Airway clearance techniques -Mucoactive agents - rhDNase, hypertonic sodium chloride, mannitol dry powder for inhalation -Pulmonary infection --Staph aureus - oral flucloxacillin can be offered as prophylaxis up to 6 --Pseudomonas aeruginosa - patients with a new infection are treated with eradication therapy with oral/IV antibiotics & inhaled antibiotics --Other infections - specific treatments -Lung transplantation

Answer 32

Nutrition and pancreatic insufficiency -Nutritional assessment forms a key part of the management -Pancreatic insufficiency is common resulting in malabsorption and steatorrhoea -> patients with CF should be tested for this Liver disease -Should be screened regularly for liver disease thorough history, examination & LFTs -Ursodeoxycholic acid may be given to those with abnormal liver function with the aim to improve biliary flow CF-related diabetes -Often results in diabetes through damage to the pancreatic islets -Screen annually from the age of 10 & at any times where symptoms are suggestive or the clinical situation demands

Answer 33

Family of conditions with shared characteristics of interstitial inflammation, fibrosis and/or cellular changes in the absence of infection and malignancy Idiopathic pulmonary fibrosis = progressive pulmonary fibrosis with no clear cause

Answer 34

Majority of cases of IPF occur spontaneously without known cause Familial pulmonary fibrosis Hermansky-pudlak syndrome Telomeropathies

Answer 35

Exertional dyspnoea Dry cough Fatigue

Answer 36

Bilateral inspiratory crackles Clubbing Acrocyanosis

Answer 37

(for ILD - HRCT ‘ground glass’ appearance) Bloods - FBC, renal function, LFTs & CRP Lung function tests - spirometry, lung volumes and diffusing capacity of the lung for carbon monoxide (DLCO) Imaging -CXR - key investigation in any patient presenting with shortness of breath/chronic cough -High resolution CT - honeycombing, reticular opacities, traction bronchiectasis, emphysema and loss of lung volume -> changes predominantly seen in the bases & peripheries Biopsy and cytology -Bronchoalveolar lavage and/or transbronchial biopsy -Surgical lung biopsy

Answer 38

Supportive care Pulmonary rehab Oxygen therapy Disease modifying medical therapies - pirfenidone & nintedanib -Pirfenidone = anti-inflammatory & anti-fibrotic whose mechanism of action is incompletely understood -Nintedanib = acts on 3 growth factor receptors implicated in the development of IPF Lung transplant

Answer 39

Adenocarcinoma SCC Large cell

Answer 40

Smoking Exposure -Asbestos - more strongly associated with mesothelioma, asbestos is linked with adenocarcinoma of the lung -Radon gas, released from naturally occurring uranium, is also a recognised cause of lung cancer

Answer 41

Non-small cell lung cancer -Adenocarcinoma - cancer of the mucus-secreting cells --Tends to occur in lung peripheries -Squamous cell - second most common form of lung cancer --Second most common form of lung cancer --Typically occurring in the central parts of the lungs -> can present with pneumonia secondary to an obstructed bronchus -Large cell - undifferentiated neoplasms accounting for 5% of lung cancers, tend to metastasise Small cell lung cancer -Fast doubling time, aggressive nature & early metastasis -Cancer of the APUD cells, a neuroendocrine cell

Answer 42

Fever Malaise Nausea Cough Haemoptysis Hoarseness (due to involvement of the recurrent laryngeal nerve) Weight loss

Answer 43

Lymphadenopathy Stridor Wheeze Clubbing Hypertrophic pulmonary osteoarthropathy (fibrovascular proliferation that results in periostitis of the long bones, arthralgia and clubbing) Signs of pleural effusion (exudative) Dull (‘stony dull’) percussion -Reduced vocal fremitus -Reduced breath sounds

Answer 44

Causes engorgement of vessels in the neck and face, shortness of breath & ‘fullness’ of the head

Answer 45

Horner’s syndrome Pain in the shoulder that radiates into the arm and hand Atrophy of muscles of the upper limb Oedema of the upper limb

Answer 46

Bone - bone pain, raised ALP Brain - focal and non-focal neurology Liver - abnormal LFTs Adrenal glands - normally asymptomatic

Answer 47

Hypercalcaemia - bony metastasis, tumour secretion of PTHrP or calcitriol -50% SCC, 20% adenocarcinoma, 15% small cell carcinoma SIADH -10% small cell lung cancer Cushing’s syndrome - lung cancers produced ectopic ACTH driving an increase in glucocorticoids Lambert-eaton syndrome - antibodies to voltage-gated calcium channels -1-3% of small cell lung cancer -Characterised by both proximal and ocular muscle weakness Hypertrophic osteoarthropathy -Clubbing and periostitis -Symmetrical, painful arthropathy affecting the distal joints

Answer 48

Bloods Imaging -CXR - focal lesion, pleural effusion, widened mediastinum -CT chest - solitary pulmonary nodule, lymph node involvement -PET-CT - radioactive tracer taken up preferentially into more metabolically active cells -CT/MRI brain - ordered to exclude cerebral metastasis Bronchoscopy Lung function tests Histology & cytology

Answer 49

2 week wait referral for: Suggestive CXR findings Unexplained haemoptysis and aged over 40 Urgent CXR for: Persistent/recurrent chest infection Clubbing Supraclavicular lymphadenopathy/persistent cervical lymphadenopathy Chest signs indicative of lung cancer Thrombocytosis

Answer 50

Characterised by episodes of complete or partial upper airway obstruction during sleep

Answer 51

Occurs if the upper airway at the back of the throat is sucked closed when the patient breathes in Occurs during sleep because the muscles that hold the airway open are hypotonic Airway closure continues until the patient is woken up by the struggle to breathe against a blocked throat

Answer 52

Apnoea episodes during sleep Snoring Morning headache Waking up unrefreshed from sleep Daytime sleepiness Concentration problems Reduced oxygen saturation during sleep

Answer 53

Polysomnography (PSG) - ENT specialist perform sleep studies: monitor their oxygen sats, HR, RR & breathing, extent of snoring Portable multichannel sleep tests Awake fiberoptic endoscopy

Answer 54

Epworth sleepiness scale = how likely they are to fall asleep in eight specific situations Sitting and reading Watching TV Sitting in a public place Sitting in a care as a passenger without a break Lying down to rest Sitting and talking to someone Sitting quietly after lunch without alcohol In a car, while stopped for a few minutes in traffic

Answer 55

Correct reversible risk factors - stop drinking, stop smoking and lose weight Continuous positive airway pressure (CPAP) - provides a continuous pressure to maintain the patency of the airway Surgery - surgical restructuring of the soft palate and jaw (uvulopalatopharyngoplasty)

Answer 56

Hypertension Ischaemic heart disease Cerebrovascular disease Pulmonary hypertension AF Depression

Answer 57

Abnormal collection of fluid within the pleural space

Answer 58

Transudate - fluid with minimal protein or cellular content, occurs due to alteration in hydrostatic and oncotic pressures leading to the fluid being ‘squeezed’ into the pleural space Exudate - fluid with a high protein and cellular content, develops due to a variety of inflammatory conditions that affect vessel permeability and/or lymphatic drainage

Answer 59

Heart failure Hypoalbuminaemia Cirrhosis Constrictive pericarditis Nephrotic syndrome Peritoneal dialysis Meigs’ syndrome - ascites and pleural effusion in association with a benign ovarian tumour

Answer 60

Parapneumonic effusion (secondary to pneumonia) Malignancy (breast/lung) Tuberculosis Pulmonary embolism Pancreatitis Radiation pleuritis Systemic inflammatory condition (eg. SLE, RA) Trauma

Answer 61

Breathlessness Non-productive cough Pleuritic pain Extra-pulmonary symptoms based on underlying caus

Answer 62

Reduced chest expansion Reduced breath sounds Stony dull percussion Reduced vocal resonance Trachea deviation Extra-pulmonary signs - depending on the underlying cause

Answer 63

Increased fluid entry -Increased vasculature permeability - loss of fluid and macromolecules from ‘leaky’ vessels -Increased microvascular pressure - increased venous pressure affects hydrostatic pressure forcing fluid out -Decreased plasma oncotic pressure - hypoproteinaemia -> favour accumulation of the fluid in the pleural space Decreased fluid exit -Alteration in lymphatic drainage -Intrinsic factors - inflammatory mediators, infiltration, damage -Extrinsic factors - physical compression, limitation by respiratory motion, decreased intrapleural pressure

Answer 64

CXR - PA with approximately 200ml of pleural fluid, blunting of the costophrenic angle, meniscus Ultrasound, CT and MRI Pleural paracentesis and analysis Pleural aspiration - biochemistry, microbiology, cytology

Answer 65

Pleural fluid is an exudate if one or more of the following criteria are met: Pleural fluid protein divided by serum protein is > 0.5 Pleural fluid LDH divided by serum LDH is > 0.6 Pleural fluid LDH > ⅔ the upper limits of laboratory normal value for serum LDH

Answer 66

Address underlying cause Pleural aspiration and/or chest drains -Therapeutic paracentesis - involves the removal of 1-1.5L of pleural fluid via a special drainage kit -Chest drain insertion - involves the insertion of a tube into the pleural space to allow drainage over hours to days --Connected to an underwater seal to prevent backflow of air/fluid into the pleural space --Complications: re-expansion pulmonary oedema, pneumothorax, infection, bleeding, damage to thoracic viscera, subcutaneous emphysema Pleurodesis - procedure to obliterate the pleural space and prevent re-accumulation of fluid or air Surgical intervention

Answer 67

A collection of air within the pleural space Spontaneous - occurring without prior trauma, normally in older patients with underlying lung disease/younger patients with apical blebs Traumatic - occuring in the setting of trauma, may be open or closed

Answer 68

Primary spontaneous pneumothorax - occur spontaneous in a previously non-pathological lung, typically seen in tall thin young men Secondary spontaneous pneumothorax - occur in previously diseased lungs (common causes = COPD & asthma)

Answer 69

Symptoms Dyspnoea Pleuritic chest pain - pain worse on deep inspiration, usually unilateral Signs Normal Tracheal deviation Reduced chest expansion Reduced breath sounds Hyperresonant percussion Absent tactile fremitus (vibration intensity) Absent vocal resonance (sound intensity)

Answer 70

eCXR - allows size of pneumothorax to be estimated USS - therapeutically may be used to aid drain placement CT chest - can be considered the gold standard

Answer 71

Large (>2cm) or breathless: Active intervention Needle aspiration (14-16G needle) is typically advised first (stop after 2.5L has been aspirated) If needle aspiration fails, small bore chest drain can be inserted Small (<2cm) and asymptomatic: Observation with outpatient follow-up Advised to return if they develop breathlessness

Answer 72

Large (>2cm) or breathless: Small bore chest drain Size 1-2cm: Needle aspiration is typically advised first Size < 1cm Admit and observe for at least 24h, consider supplemental oxygen

Answer 73

Administer high flow oxygen and carry out urgent needle decompression, imaging should not be awaited Placing a large-bore cannula in the 2nd intercostal space midclavicular line

Answer 74

Type 1 respiratory failure - characterised by hypoxaemia and a normal or low CO2 Type 2 respiratory failure - characterised by hypoxaemia and hypercapnia

Answer 75

Pneumonia COPD Asthma Pulmonary oedema Pneumothorax PE Obesity

Answer 76

COPD Asthma Chronic neurological disorders Chronic neuromuscular disorders Chest wall diseases Obesity hypoventilation syndrome

Answer 77

All patients with a pleural effusion in association with sepsis or a pneumonic illness require diagnostic pleural fluid sampling - if the fluid is purulent or turbid/cloudy a chest tube should be placed to allow drainage - if the fluid is clear but the pH is less than 7.2 in patients with suspected pleural infection a chest tube should be placed

Respiratory Flashcards

(101 cards)