Respiratory Flashcards
(181 cards)
1
Q
Give 4 symptoms of a PE
A
- SOB
- Cough
- Haemoptysis
- Pleuritic chest pain
2
Q
Give 4 signs of a PE
A
- Hypoxia
- Tachycardia
- Tachypnea (MOST COMMON FINDING)
- Low-grade fever
3
Q
What is seen on an ABG in a PE?
A
- Respiratory alkalosis
4
Q
What are the RF for a PE?
A
- Immobility
- Recent surgery
- Long-haul travel
- Pregnancy
- COCP or HRT
- Malignancy
- Polycythaemia
- SLE
- Thrombophilia
5
Q
How is a PE treated?
A
- Anticoagulation :
- 1st line = Apixaban : 10 mg twice daily for 7 days, then maintenance 5 mg twice daily.
- LMWH if eGFR <15
6
Q
what is defined as a massive PE and how is it treated?
A
- > 50% obstruction of pulmonary artery.
- Continuous infusion of unfractionated heparin and thrombolysis
7
Q
What long term anticoagulation is used following a PE?
A
- DOAC : avoid in severe renal impairment (creatinine clearance less than 15 ml/min)
- LMWH : 1st line in pregnancy
- Warfarin : 1st line in antiphospholipid syndrome
8
Q
How can differentiate between a respiratory alkalosis caused by hyperventilation sydrome and that caused by a PE ?
A
- In a PE low will be a low PaO2 as well as a low PaCO2.
- In panic /anxiety, there is no element of hypoxia, PaO2 is in fact high.
9
Q
what is the approach to investigation a PE
A
- PERC
- Well’s
- PE unlikely based on wells (<4) = d dimer if result within 4 hrs or interim anticoag
- PE likely based on wells (>4)= CTPA or interim anticoag
10
Q
If D dimer -ve
A
consider alternative diagnosis
11
Q
If d dimer +ve
A
CTPA or interim anticoag
12
Q
If CTPA +ve
A
PE diagnosed
13
Q
If CTPA -ve
A
consider proximal leg USS if DVT suspected
14
Q
what is the PERC
A
- Used in people with a low pre test probability of a PE
- All criteria have to be absent to rule our PE
15
Q
what are the components of the well’s criteria ?
A
- Clinical signs and symptoms of DVT (minimum of leg swelling and pain with palpation of the deep veins) = 3
- An alternative diagnosis is less likely than PE =3
- Heart rate > 100 bpm =1.5
- Immobilisation for more than 3 days or surgery in the previous 4 weeks = 1.5
- Previous DVT/PE = 1.5
- Haemoptysis = 1
- Malignancy (on treatment, treated in the last 6 months, or palliative)
16
Q
what are the ECG findings in a PE ?
A
- Large S wave in lead I, a large Q wave in lead III and an inverted T wave in lead III - ‘S1Q3T
- Sinus tachy
- RBBB with right axis deviation
17
Q
what is the length of anticoagulant following VTE ?
A
- Provoked = 3 mnths (3-6 if active cancer)
- unprovoked = 6 months
18
Q
what kind of hypersensitivity reaction is asthma ?
A
Type 1 hypersensitivity
IgE mediated
19
Q
what factors lead to the symptoms of asthma ?
A
- Chronic inflammation
- Bronchoconstriction
- Airway obstruction
20
Q
what are the symptoms of asthma ?
A
They are episodic with diurnal variation and worse at night
- SOB
- Chest tightness
- Dry cough, worse at night
- Wheeze
21
Q
what are the signs if asthma ?
A
- Widespread polyphonic wheeze on auscultation
- Reduced peak expiratory flow rate (PEFR)
22
Q
what can exaccerbate the symptoms of asthma. ?
A
- Infection
- Nighttime or early morning
- Exercise
- Animals
- Cold, damp or dusty air
- Strong emotions
23
Q
what are the two measurements used in spirometry ?
A
- FEV1: forced expiratory volume - volume that has been exhaled at the end of the first second of forced expiration
- FVC: forced vital capacity - volume that has been exhaled after a maximal expiration following a full inspiration
24
Q
what is seen on spirometry in asthma ?
A
- FEV1 - significantly reduced
- FVC - normal
- FEV1 (FEV1/FVC) < 70% = obstructive picture
25
Asthma diagnosis in >17
- Sprriometry with BDR test
- All pts = FeNO (>40 ppb is +ve)
- BDR (Increase in FEV1 >=>12% and increase in volume of 200ml = +ve)
26
Asthma diagnosis in 12-16
- Spirometry with BDR test.
- If normal spiro or obstructive spiro with no BDR = FeNO
- FeNO >=35ppb = +ve
- Spiro : BDR >=12% = +ve
27
Based on the NICE guidelines, what is the stepwise long term management of asthama
Add drug at each stage
1. SABA (salbutamol)
2. SABA + Low dose ICS
3. SABA + ICS + LTRA (montelukast)
4. SABA + ICS + LABA (salmeterol) - continue LTRA based on response
5. SABA +/- LTRA AND MART (combined ICS and LABA)
6. SABA +/- LTRA with moderate dose ICS MART
7. SABA +/-LTRA with high dose ICS or additional drugs (LAMA or theophylline)
8. Specialist management
28
what are the presenting symptoms of pneumonia ?
- Cough (purulent rust coloured / blood stained sputum)
- SOB
- Pleuritic chest pain
- Fever
- Malaise
29
what are characteristic chest signs of pneumonia ?
- High fever, tachy, hypo, confusion
- Tachypnoea
- Hypoxia
- Focal coarse crackles, bronchial breathing, reduced breath sounds
- Dullness to percussion (fluid)
30
what is used to assess the severity of someone with pneumonia ?
- Community : CRB65
- Hospital : CURB65
- C : Confusion
- U : Urea (>7mmol/L
- R : RR >=30
- B : BP (<90/60)
- >=65
- Score of greater than 0 = hospital admission
31
most common bacterial causes of pneumonia.
- Streptococcus pneumoniae (most common cause of CAP)
- Haemophilus influenza (common in COPD, bronchiectasis)
32
Atypical cause of pneumonia in a pt recentyl been on holiday presenting with symptoms of penumonia and hyponatraemia
- Legionella pneumophilia
- Causes pneumonia and SIADH (low sodium)
- Urine antigen is initial screening test
33
What are the 5 causes of atypical pneumonia
Legions of Psittaci MCQs
- Legionella pneumophila
- Psittaci : chlamydia psittaci (=parrot owner)
- M : mycoplasma pneumoniae (= causes erythema multiforme)
- C : Chlamydophila pneumoniae (= affects children)
- Qs : Q fever (Coxiella burnetii) = farmer with flu like illness
34
what is a cause of pneumonia in immunocomprimised pts, particularly those with HIV
- Penumocystis jirovecii
- Fungal
- Druy cough, SOB, night sweats
- Tx : Co-trimoxazole (trimethoprim/sulfamethoxazole)
35
what investigations are done for pneumonia when admitted to hospital (5)
- CXR = consolidation
- Full blood count (raised white cell count)
- Renal profile (urea level for the CURB-65 score and acute kidney injury)
- CRP (raised in inflammation and infection)
- Sputum / blood cultures
36
CURB-65 of 0-2
- 5 days oral antibiotics
- 1st line = Amoxicillin +/- PO clarithromycin
IF CI
- PO doxycycline or levofloxacin
37
CURB-65 score 3-5
- 7 to 10 days
- IV co-amoxiclav + PO/IV Clarithromycin
IF CI
- IV Teicoplanin + PO/IV Levofloxacin
38
when should all cases of pneumonia have a repeat CXR ?
6 wks after clinical resolution
39
Management of legionella pneumophila
- 1st line = PO/IV Levofloxacin or clarithrromycin
- 2nd line = PO Azithromycin
40
Complications of pneumonia (7)
Pleural effusion
Empyema
Pneumothorax
Pulmonary embolism
Lung abscess
ARDS
Sepsis with multi-organ failure
41
How can lung cancer be histologically divided
1. Small cell (SCLC)
2. Non small cell (NSCLC) - 80%
42
What are the subtypes of NSCLC ?
1. Adenocarcinoma : most common
2. Squamous
3. Large cell
4. Alveolar cell carcinoma
5. Bronchial adenoma
43
what type of lung cancer is associated with asbestos exposure ?
Mesothelioma
44
what are the common presenting features of lung cancer (8)
SOB
Persistent cough
Haemoptysis
Recurrent pneumonia
Weight loss and anorexia
Chest pain
Hoarseness
Superior vena cava syndrome
45
what tumour is associated with hoarsness and why ?
- Pancoast
- Presses on recurrent laryngeal nerve
46
What can be seen on examination in lung cancer ?
- Fixed, monophonic wheeze may be noted
- Supraclavicular lymphadenopathy or persistent cervical lymphadenopathy
- Clubbing
47
what paraneoplastic features can be seen in SCLC?
- Cushing's : ectopic ACTH
- SIADH : ectopic ADH -> hyponatraemia
- Lambert-Eaton
- Limbic encephalitis -> anti-Hu antibodies - STM impairment, hallucinations, confusion, seizures
48
what paraneoplastic features are seen in squamous cell lung cancers ?
- Hypercalcaemia -> ectopic PTH
- Clubbing
- Hyperthyroidism -> ectopic TSH
- HPOA
49
what is the triad of horner's syndrome ?
- Ptosis
- Miosis
- Anhidrosis
50
what paraneoplastic features are seen in adenocarcinomas of the lung ?
- Gynaecomastia
- HPOA
51
How does superior vena cava obstruction present ?
- Facial swelling, difficulty breathing, distended neck & upper chest veins
- Pemberton's sign : raising hands over head causes facial congestion and cyanosis
52
when is a two week wait CXR done for suspected lung cancer ? (five)
Pts >40 with :
- Clubbing
- Lymphadenopathy (supraclavicular or persistent abnormal cervical nodes)
- Recurrent or persistent chest infections
- Raised platelet count (thrombocytosis)
- Chest signs of lung cancer
53
When is CXR also offered for unexplained symptoms of lung cancer ?
- 2 or more in pts >40 who have never smokes
- 1 or more in pts >40 who have smoked or had asbestos exposure
Cough
Shortness of breath
Chest pain
Fatigue
Weight loss
Loss of appetite
54
Explain type 1 and type 2 resp failure on ABG
- > Normal PaCO2 with low PaO2 indicates type 1 respiratory failure
-> Raised PaCO2 with low PaO2 indicates type 2 respiratory failure
55
what suggests a person is a chronic retainer of CO2 on ABG
- Raised bicarbonate
- In an acute exacerbation -> they will become acidotic with raised CO2 despite the raised bicarbonate
56
Give 2 causes of respiratory alkalosis
- Hyperventilation : high PaO2, low PaCO2 and alkalosis
- PE : LOW PaO2, Low PaCO2 and alkalosis
57
Moderate acute exacerbation of asthma
-> PEFR : 50-75% best or predicted
58
Severe acute exacerbation of asthma
- Peak flow 33-50% best or predicted
- Respiratory rate above 25
- Heart rate above 110
- Unable to complete sentences
59
Life threatening acute exacerbation of asthma
- Peak flow less than 33%
- Oxygen saturations less than 92%
- PaO2 less than 8 kPa
- Becoming tired
- Confusion or agitation
- No wheeze or silent chest
- Haemodynamic instability (shock)
- Normal PCO2
60
Neat fatal acute astma
Raised pCO2 and / or requiring mechanical ventilation with raised inflation pressures
61
management of mild asthma exacerbation
- Inhaled beta-2 agonists (e.g., salbutamol) via a spacer
- Quadrupled dose of their inhaled corticosteroid (for up to 2 weeks)
- Oral steroids (prednisolone) if the higher ICS is inadequate
- Antibiotics only if there is convincing evidence of bacterial infection
- Follow-up within 48 hours
62
Management of moderate asthma exacerbation
- Consider hospital admission
- Nebulised beta-2 agonists (e.g., salbutamol)
- Steroids (e.g., oral prednisolone or IV hydrocortisone)
63
Management of severe asthma exacerbation
- Hospital admission
- Oxygen to maintain sats 94-98%
1. Nebulised salbutamol.
2. Corticosteroids
3. Nebulised ipratropium bromide
4. IV magnesium sulphate
5. IV aminophylline
6. ITU
64
what is the criteria for discharge following asthma exacerbation ?
- Stable on their discharge medication (i.e. no nebulisers or oxygen) for 12–24 hours
- Inhaler technique checked and recorded
- PEF >75% of best or predicted
65
what needs monitoring with salbutamol treatment ?
- Serum potassium
- Can cause hypokalaemia
66
what is acute bronchitis
- Chest infection associated with inflammation of trachea and major bronchi
67
Typical presentation of acute bronchitis
- cough: may or may not be productive
- sore throat
- rhinorrhoea
- wheeze
- Low grade fever
68
Normally supportive management BUT when would Abx be offered for acute bronchitis and what is first line ?
- are systemically very unwell
- have pre-existing co-morbidities
- have a CRP of 20-100mg/L (offer delayed prescription) or a CRP >100mg/L (offer antibiotics immediately)
- Doxycyline for 5 days
69
Typical presentation of COPD
Long term smoker with :
- SOB
- Cough
- Sputum production
- Wheeze
- Recurrent respiratory infections, particularly in winter
70
How is COPD diagnosed >
- Clinical presentation and spirometry results
- Spirometry will show obstructive picture = FEV1:FVC ratio of <70%
71
How is the severity of COPD staged ?
-> Stage 1 (mild): FEV1 more than 80% of predicted
-> Stage 2 (moderate): FEV1 50-79% of predicted
-> Stage 3 (severe): FEV1 30-49% of predicted
-> Stage 4 (very severe): FEV1 less than 30% of predicted
72
what can be used to assess the degree of breathlessness in COPD ?
-> MRC dyspnoea scale
- Grade 1: Breathless on strenuous exercise
- Grade 2: Breathless on walking uphill
- Grade 3: Breathlessness that slows walking on the flat
- Grade 4: Breathlessness stops them from walking more than 100 meters on the flat
- Grade 5: Unable to leave the house due to breathlessness
73
what general advice is given to all pts with COPD ?
1. smoking cessation advice:
2. Annual influenza vaccination
3. One-off pneumococcal vaccination
4. Pulmonary rehabilitation to all people who view themselves as functionally disabled by COPD (usually Medical Research Council [MRC] grade 3 and above)
74
1st line treatment of COPD
Salbutamol or ipatropium bromide
75
what is the second line treatment for COPD if no asthmatic features / features suggesting steroid responsiveness
- > Add a long-acting beta2-agonist (LABA) + long-acting muscarinic antagonist (LAMA)
- > if already taking a SAMA, discontinue and switch to a SABA
76
what is the second line treatment for COPD if there IS asthmatic features / features suggesting steroid responsiveness
- > LABA + inhaled corticosteroid (ICS)
-> if patients remain breathless or have exacerbations offer triple therapy i.e. LAMA + LABA + ICS
- > if already taking a SAMA, discontinue and switch to a SABA
- > NICE recommend the use of combined inhalers where possible
77
if required, what prophylactic antibiotics can be offered to pts with COPD and what needs to be monitored
-> Azithromycin
-> ECG (can prolong QT interval ) and LFTs
78
what is cor pulmonale and the most common cause
- Right-sided heart failure caused by respiratory disease
- COPD
79
what are the features of cor pulmonale
- Peripheral oedema
- Raised JVP
- Systolic parasternal heave
- Loud P2
- Hypoxia
- Cyanosis
80
How is cor pulmonale managed
- Loop diuretics
- Long term oxygen therapy
81
when is LTOT offered in COPD ?
- Assess ABG on 2 occasions, 3 wks apart
- Offer LTOT if : pO2 of < 7.3 kPa or to those with a pO2 of 7.3 - 8 kPa and one of the following:
- secondary polycythaemia
- peripheral oedema
- pulmonary hypertension
82
what is the most common infective cause of a COPD exacerbation
- Bacteria : haemophilus influenzae
83
how is COPD exacerbation not requiring admission managed ?
- Increase the frequency of bronchodilator use and consider giving via a nebuliser
- Give prednisolone 30 mg daily for 5 days
84
what can be given in more severe COPD exacerbations
- Nebulised bronchodilators
- IV hydrocortisone
- IV theophylline if no response to nebs
- NIV (most benefit when pH is between 7.25-7.35)
85
what is bronchiectasis and some common causes ?
- Permanent dilation of the bronchi
- Post-infective: TB, measles, pertussis, pneumonia
- CF
- Bronchial obstruction e.g. lung cancer/foreign body
- Immune deficiency: selective IgA, - hypogammaglobulinaemia
- Allergic bronchopulmonary aspergillosis (ABPA)
- Ciliary dyskinetic syndromes: Kartagener's syndrome, Young's syndrome
- Yellow nail syndrome
86
What is yellow nail syndrome characterised by ?
- Yellow fingernails
- Bronchiectasis
- Lymphoedema
87
Features of bronchiectasis
- Persistent productive cough. Large volumes of sputum may be expectorated and possible haemoptysis.
- Dyspnoea
- Recurrent chest infection
88
what might be seen on examination in bronchiectasis ?
- Weight loss (cachexia)
- Finger clubbing
- Signs of cor pulmonale (e.g., raised JVP and peripheral oedema)
- Scattered crackles throughout the chest that change or clear with coughing
- Scattered wheezes and squeaks
89
Explain the testing done in bronchiectasis
- Sputum culture : haemophilus influenza & pseudomonas aeruginosa most common
- CXR : tram-track opacities & signet rings
- High-resolution CT (HRCT) : test of choice for diagnosis
90
General management of bronchiectasis
- Vaccines (e.g., pneumococcal and influenza)
- Respiratory physiotherapy to help clear sputum
- Pulmonary rehabilitation
- Long-term antibiotics (e.g., azithromycin) for frequent exacerbations (e.g., 3 or more per year)
- Long-acting bronchodilators may be considered for breathlessness
- Long-term oxygen therapy in patients with reduced oxygen saturation
91
what do infective exacerbations in bronchiectasis require ?
- Sputum culture (before antibiotics)
- Extended courses of antibiotics, usually 7–14 days
- Ciprofloxacin is the usual choice for exacerbations caused by Pseudomonas aeruginosa
92
Explain the categories of pleural effusion
= Fluid in the pleural space
- Exudative : high protein (>30g/l)
- Transudative : low protein (<30g/l)
If a pleural effusion fluid protein/serum protein ratio is >0.5, the effusion is an exudate
93
what criteria is used for establishing an exudative effusion
Light's criteria
-> Pleural fluid protein / serum protein greater than 0.5
-> Pleural fluid LDH / serum LDH greater than 0.6
-> Pleural fluid LDH greater than 2/3 of the normal upper limit of the serum LDH
94
What are the causes of an exudative pleural effusion
Related to inflammation resulting in protein leaking out of the tissue (7) :
- Infection
pneumonia (most common exudate cause), TB, subphrenic abscess
- Connective tissue disease : RA, SLE
- Neoplasia : lung cancer, mesothelioma, metastases
- Pancreatitis
- Pulmonary embolism
- Dressler's syndrome
- Yellow nail syndrome
95
What are the transudative causes of a pleural effusion ?
Related to fluid shifting into pleural space
- Congestive cardiac failure
- Hypoalbuminaemia
- Hypothyroidism
- Meigs syndrome
96
Main presenting symptom of pleural effusion ?
SOB
97
Three examination findings in pleural effusion
- Dullness to percussion over the effusion
- Reduced breath sounds
- Tracheal deviation away from the effusion in very large effusions
98
CXR findings in pleural effusion
- Blunting of the costophrenic angle
- Unilateral, solid white area
- Tracheal and mediastinal deviation away from the effusion in very large effusions
99
Possible management options of a pleural effusion
- Conservative = small effusions
- Pleural aspiration
- Chest drain
100
What is an empyema and what would be seen on pleural aspiration ?
- Infected pleural effusion
- Aspiration : pus, low pH, low glucose, high LDH
101
When should empyema be suspected and how is it managed ?
- Improving pneumonia but new or ongoing fever
- Chest drain and antibiotics
102
Define a pneumothorax and the possible underlying causes
-> Air in the pleural space
-> PSP : no underlying cause. Tall, young male playing sport.
-> SSP : Pre-existing lung disease
-> Iatrogenic : complication of medical procedures
-> Traumatic : penetrating or blunt chest trauma
103
Presenting symptoms of pneumothorax
Sudden onset SOB and pleuritic chest pain
104
Five signs of a pneumothorax
- Hyper-resonance to percussion
- Decreased breath sounds
- Decreased chest expansion
- Tachypnoea
- Tachycardia
105
Imaging for a pneumothorax
Erect CXR
106
Management of persistent / recurrent pneumothorax
- Video-assisted thoracoscopic surgery (VATS) WITH
- Abrasive or chemical pleurodesis +/- pleurectomy
107
where is a chest drain inserted in a pneumothorax
Triangle of safety
- 5th intercostal space (or the inferior nipple line)
- Midaxillary line (or the lateral edge of the latissimus dorsi)
- Anterior axillary line (or the lateral edge of the pectoralis major)
ABOVE the rib to avoid the neurovascular bundle
108
Discharge advice following a pneumothorax
- > Stop smoking : most important advice to reduce risk of further pneumothoraces
-> Can fly 2 wks later if no residual air
-> Avoid scuba diving
109
Cause and signs of a tension pneumothorax
- Trauma to the chest wall = creating a one way valve letting air in but not out of pleural space
- Tracheal deviation away from affect side
- Reduced air entry and increased resonance on affected side
- Tachycardia and hypotension
110
Management of tension pneumothorax
- Insert a large bore cannula (14G) into the second intercostal space in the midclavicular line
- Once pressure relieved, chest drain
111
what is pulmonary HTN ?
- Mean pulmonary arterial pressure of >20mmHg
- There is increased resistance and pressure in the pulmonary artery
- This causes strain on the right side of the heart
- There is back pressure through the right side of the heart and into systemic venous system
112
What are the 5 groups of pulmonary HTN dependent on cause ?
-> Group 1 – Idiopathic pulmonary hypertension or connective tissue disease (e.g., systemic lupus erythematous)
-> Group 2 – Left heart failure, usually due to myocardial infarction or systemic hypertension
-> Group 3 – Chronic lung disease (e.g., COPD or pulmonary fibrosis)
-> Group 4 – Pulmonary vascular disease (e.g., pulmonary embolism)
-> Group 5 – Miscellaneous causes such as sarcoidosis, glycogen storage disease and haematological disorders
113
Main presenting symptom of pulmonary HTN
- SOB
114
Four signs of pulmonary HTN
- Peripheral oedema
- Raised JVP
- Tachycardia
- Hepatomegaly
115
4 ECG changes that indicate right-sided heart strain
- P pulmonale (peaked P waves)
- Right ventricular hypertrophy (tall R waves in V1 and V2 and deep S waves in V5 and V6)
- Right axis deviation
- RBBB
116
2 CXR changes in pulmonary HTN
Dilated pulmonary arteries
Right ventricular hypertrophy
117
What is sarcoidosis and who is it more common in ?
- Multisystem disorder characterised by non-caseating granulomas
- Young females of african descent
118
Common features seen in sarcoidosis
-> Lung : bilateral hilar lymphadenopathy, PF and pulmonary nodules (=SOB)
-> Skin : erythema nodosum on the shins, lupus pernio (raised purple lesions on cheeks and nose)
-> Systemic : fever, fatigue, weight loss
-> Kidneys : kidney stones (due to HYPERCALCAEMIA)
119
Bloods seen in sarcoidosis
- Raised angiotensin-converting enzyme (ACE) (often used as a screening test)
- Raised calcium (hypercalcaemia)
120
Staging of sarcoidosis based on CXR
stage 0 = normal
stage 1 = bilateral hilar lymphadenopathy (BHL)
stage 2 = BHL + interstitial infiltrates
stage 3 = diffuse interstitial infiltrates only
stage 4 = diffuse fibrosis
121
First and second line treatment for sarcoidosis
- Oral steroids (6-24mnths) with bisphosphonates
- Methotrexate second line
2/3rds = gett better without treatment !!
122
5 RF for OSA
Middle age
Male
Obesity
Alcohol
Smoking
123
what is used to assess sx associated with OSA and then what is done to confirm diagnosis ?
-> Epworth sleepiness scale
-> Sleep studies
124
How is OSA managed ?
1. Address reversible RF
2. CPAP to maintain airway
3. Surgery
125
what is allergic bronchopulmonary aspergillosis and the common features
- An allergy to aspergillus spores
- Bronchoconstriction : wheeze, cough and SOB
- Proximal bronchiectasis
126
what is seen on investigations in allergic bronchopulmonary aspergillosis ?
- eosinophilia
- flitting CXR changes
- positive radioallergosorbent (RAST) test to Aspergillus
- positive IgG precipitins (not as positive as in aspergilloma)
- raised IgE
127
How is allergic bronchopulmonary aspergillosis managed ?
Oral glucocorticoids
128
what is interstitial lung disease and 5 causes ?
- Inflammation and fibrosis on lung parenchyma
1. Idiopathic pulmonary fibrosis (the most important to remember)
2. Secondary pulmonary fibrosis
3. Hypersensitivity pneumonitis
4. Cryptogenic organising pneumonia
5. Asbestosis
129
3 key presenting features of ILD
Shortness of breath on exertion
Dry cough
Fatigue
130
2 key findings on examination in idiopathic pulmonary fibrosis
- Bibasal fine end-inspiratory crackles
- Finger clubbing
131
What 3 things are used for a diagnosis of ILD ?
1. Clinical features
2. High resolution CT = "ground glass" appearance
3. Spirometry : FEV1 and FVC equally reduced with ration >70%
132
2 medications used to slow progression of idiopathic pulmonary fibrosis
- Pirfenidone reduces fibrosis and inflammation through various mechanisms
- Nintedanib reduces fibrosis and inflammation by inhibiting tyrosine kinase
133
4 drugs that can cause PF
Amiodarone (also causes grey/blue skin)
Cyclophosphamide
Methotrexate
Nitrofurantoin
134
what kind of reaction is hypersensitivity pneumonitis
- Type II and type IV
135
Diagnosis and management of hypersensitivity pneumonitis
- Bronchoalveolar lavage = lymphocytosis
- Management : remove allergen, O2 and steroids
136
Give 4 specific causes of hypersensitivity pneumonitis
-> Bird-fancier’s lung is a reaction to bird droppings
-> Farmer’s lung is a reaction to mouldy spores in hay
-> Mushroom worker’s lung is a reaction to specific mushroom antigens
-> Malt worker’s lung is a reaction to mould on barley
137
4 complications of asbestos expsoure
Lung fibrosis
Pleural thickening and pleural plaques
Adenocarcinoma
Mesothelioma
138
Cryptogenic organising pneumonia : what, cause, presentation, diagnosis and treatment
- Focal area of lung tissue inflammation
- SOB, cough, fever, lethargy and inspiratory crackles
- Definitive investigation : lung biopsy
- Tx : systemic corticosteroids
139
Diagnostic criteria for ARDS
- acute onset (within 1 week of a known risk factor)
- pulmonary oedema: bilateral infiltrates on chest x-ray ('not fully explained by effusions, lobar/lung collapse or nodules)
non-cardiogenic (pulmonary artery wedge pressure needed if doubt)
- pO2/FiO2 < 40kPa (300 mmHg)
140
Diagnostic investigation for pulmonary fibrosis
high resolution CT - 'honeycombing' appearance
141
Explain the steps for inhaler technique
1. Remove cap and shake
2. Breathe out gently
3. Put mouthpiece in mouth and as you begin to breathe in, which should be slow and deep, press canister down and continue to inhale steadily and deeply
4. Hold breath for 10 seconds, or as long as is comfortable
5. For a second dose wait for approximately 30 seconds before repeating steps 1-4.
142
causes of upper zone ling fibrosis
C - Coal worker's pneumoconiosis
H - Histiocytosis/ hypersensitivity pneumonitis
A - Ankylosing spondylitis
R - Radiation
T - Tuberculosis
S - Silicosis/sarcoidosis
143
causes of lower zone lung fibrosis
A: Asbestos
C : Connective tissue disorders (eg. SLE)
I : Idiopathic pulmonary fibrosis
D : Drugs (Bleomycin, MTX, Amiodarone, Nitrofurantoin, Cyclophosphamide)
144
criteria for LTOT in a pt with COPD
COPD - LTOT if 2 measurements of pO2 < 7.3 kPa
145
COPD symptoms in young person
A1AT deficiency
146
Hypercalcaemia + bilateral hilar lymphadenopathy on CXR + normal bloods and no evidence of malignancy
Sarcoidosis
147
CI to surgery for lung cancer (6)
- stage IIIb or IV (i.e. metastases present)
- FEV1 < 1.5 litres is considered a general cut-off point*
- malignant pleural effusion
- tumour near hilum
- vocal cord paralysis
- SVC obstruction
148
How is mesothelioma diagnosed ?
- Thoracoscopy + histology
149
what is atelectasis ?
- Basal alveolar collapse postoperatively
- Presents with SOB and hypoxaemia around 72 hrs after surgery
- Treat with chest physio and breathing exercise
150
Causes of upper lobe fibrosis
CHARTS
- C : Coal worker pneumoconiosis
- H : Histiocytosis
- A : Ank spond / APBA
- R : Radiation pneumonitis
- T : TB
- S : Sarcoidosis / Silicosis
151
Causes of lower lobe fibrosis
BAD RASH
- B : Bronchiectasis; Bronchiolitis Organising Pneumonia
- A : Asbestosis
- D: Drugs (Amiodarone; Hydralazine; Nitrofurantoin)
- R : Rheumatological diseases
- A : Aspiration
- S : Scleroderma
- H : Harmen Reich (Eponym for Interstitial Pulmonary Fibrosis)
152
Klebsiella pnneumonia : bacteria, presentation of CXR and likely affected
- Gram negative rod
- Cavitating pneumonia
- DM and alcoholics
153
what are the high-risk characteristics for a pneumothorax that wiuld immediately require chest drain over attempted aspiration ?
- Haemodynamic compromise (suggesting a tension pneumothorax)
- Significant hypoxia
- Bilateral pneumothorax
- Underlying lung disease
- ≥ 50 years of age with significant
- Smoking history
- Haemothorax
154
Hospital acquired pneumonia
- 48hrs OR within 30 days of admission
155
what is the most appropriate non invasive ventilation option in a pt with COPD exacerbation who develops type 2 resp failure
Bipap
156
explain the management of CAP
CRB65
- 0 = treat in the community with oral amoxicillin
- 1 or 2 = intermediate risk -> hospital assessment should be considered (
- 3 or 4 = urgent admission to hospital
157
complication of high pressure non invasive ventilation (CPAP)
Pneumothorax
158
RF for aspiration pneumonia
Recent intubation on ITU
159
Pulmonary function test results in pulmonary fibrosis
- Pulmonary fibrosis = restrictive
- FEV1:FVC normal or increased (>70)
- TLCO reduced due to impaired gas exchange
- Transfer factor reduced
160
Common exam presentation of bronchiectasis
- Persistent productive cough +/- haemoptysis in a young person with a history of respiratory problems
161
First steps in determining management of a pneumothorax
- No or minimal symptoms -> conservative are, regardless of pneumothorax size !
- Symptomatic -> assess for high-risk characterisits
162
Next step in assessing management of a pneumothorax if they are symptomatic
ARE THEY HIGH RISK =
- Haemodynamic compromise (suggesting a tension pneumothorax)
- Significant hypoxia
- Bilateral pneumothorax
- Underlying lung disease
- ≥ 50 years of age with significant smoking history
- Haemothorax
163
Management of pneumothorax if high risk
- Chest drain if safe to intervene
164
Next step in assessing management of pneumothorax if symptomatic but not high risk
conservative care
ambulatory device
needle aspiration
165
when is conservative care used in symptomatic but non high risk pneumothorax pt
1. Primary spontaneous pneumothorax that is managed conservatively should be reviewed every 2-4 days as an outpatient
2. Patients with a secondary spontaneous pneumothorax that is managed conservatively should be monitored as an inpatient
166
Management of occupational asthma presenting to GP
- Advice a diary of peak flow readings in and out of work
- Referral to resp specialist if suspected occupational asthma
167
Common presentation of a lung abscess
- Cough + offensive smelling sputum that may be blood tinged.
- Fever ! Night sweats.
- Sputum sample : multiple bacteria
- Possible Hx of unsafe swallow as aspiration is a common cause
168
what is seen on CXR in lung abscess
- Well-circumscribed lesion with air-fluid level present.
- No mediastinal lymphadenopathy
169
Low severity CAP (CURB65 - 1)
Oral amoxacillin
170
CAP scoring a 2 on CURB65
Oral amoxacillin + erythromycin
171
CAP score 3 or above on CURB65
IV co-amoxiclav + erythromycin
172
when would a pt with a moderate acute asthma attack be admitted to hospital
Previous near fatal attack
173
when do the BTS recommend ABGs for pts with acute asthma attacks
Oxygen sats <92%
174
what can cause a negative mantoux test despite presence of TB
Sarcoidosis
175
what are the 3 indications for steroids in sarcoidosis
- Patients with chest x-ray stage 2 or 3 disease who are symptomatic.
- Hypercalcaemia
- Eye, heart or neuro involvement
176
What 5 factors are associated with poor prognosis in sarcoidosis
- Insidious onset, symptoms > 6 months
- Absence of erythema nodosum
- Extrapulmonary manifestations: e.g. lupus pernio, splenomegaly
- CXR: stage III-IV features
- Black African or African–Caribbean ethnicity
177
Cause of pneumonia in alcoholics
Klebsiella pneumoniae
178
2 investigations done for pneumocystitis jiroveci pneumonia and their findings
1. CXR : bilateral interstitial pulmonary infiltrates
2. Exercise induced desaturation
179
common complication of pneumocystitis jiroveci pneumonia
Pneumothorax
180
what is raised following an acute episode of anaphylaxis ?
Tryptase
181
