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Flashcards in Respiratory Deck (48):

What is a pleural effusion?

Fluid in the pleural space. Effusions can be divided by their protein concentration into transudates (less than 25g/L) and exudates (more than 35 g/L)


What causes transudates? (4)

1. Increased venous pressure (cardiac failure, constrictive pericarditis, fluid overload)
2. Hypoproteinaemia (cirrhosis, nephrotic syndrome, malabsorption)
3. Hypothyroidism
4. Meigs' syndrome (right pleural effusion and ovarian fibroma)


What causes exudates?

Mostly due to increased leakiness of pleural capillaries secondary to infection, inflammation or malignancy

Causes: pneumonia, TB, pulmonary infarction, rheumatoid arthritis, SLE, bronchogenic carcinoma, malignant metastases, lymphoma, mesothelioma, lymphangitis carcinomatosis


What signs can be seen in a pleural effusion? (3)

1. Decreased expansion, stony dullness on percussion and diminished breath sounds on affected side

2. Decreased tactile vocal fremitus and vocal resonance (inconsistent and unreliable)

3. There may be tracheal deviation AWAY from effusion if large


What investigations can be done in pleural effusions? (4)

1. CXR: blunting of costophrenic angles
2. US - identifies presence of pleural field and used in diagnostic/therapeutic aspiration
3. Diagnostic aspiration
4.Pleural biopsy


How are pleural effusions managed? (3)

1. Treat underlying cause!
2. Drainage if effusion is symptomatic (aspiration or intercostal drain)
3. Pleurodesis with tetracycline, bleomycin or talc for recurrent effusions


Define chronic bronchitis

Chronic sputum production every day for at least 3 months per year for 2 consecutive years


What are the lung function test features of a 'pink puffer'?

PaO2 - normal to slightly diminished
PaCO2 - normal to slightly diminished
TLC - increased
DLCO - diminished


What are the lung function test features of a 'blue boater'?

PaO2 - low
PaCO2 - elevated
Normal TLC and DLCO


What pathologic changes occur with smoking?

Upper lobe centrilobular emphysema


What is the pathologic change that occurs with alpha-1 antitrypsin disease?

Panacinar emphysema that favours the lower lobes


Which bacterial pathogens can cause community-acquired pneumonia in adults? (5)

Strep pneumonia - most common

Mycoplasma pneumoniae

Chlamydophila pneumoniae


HiB - less than 5%


How is pneumonia investigated?

CXR - usually establishes diagnosis
O2 saturation - (+/- ABG if severely ill)

Sputum Gram stain and culture appropriate if deep cough + collect specimen before commencing treatment


How is mild community-acquired pneumonia treated?


Amox 1g 8 hourly for 5 to 7 days

OR if mycoplasma, chlamydia or legionella suspected

Doxy 200mg for first dose then 100mg daily for further 3 days


What is the CORB tool?

Assesses severity of pneumonia based on most abnormal results obtained during initial 24 hours of inpatient stay

C = acute confusion
O = oxygen saturation 90% or less
R = resp rate 30 breaths or more per minute
B = SBP less than 90 or DBP 60 or less

Severe = the presence of at least 2 of these features


How do you treat moderate community-acquired pneumonia (nontropical regions)?

Nontropical regions - benpen IV + either oral doxy OR oral clarithro


How do you treat moderate community-acquired pneumonia (tropical regions with risk factors)?

Risk factors - diabetes, heavy alcohol consumption, chronic renal failure and chronic lung disease

ceftriaxone IV + gentamicin


How do you treat severe community acquired pneumonia? (non tropical)


azithromycin + ceftriaxone or benpen + gent or cefatoxime


How do you treat mild hospital-acquired pneumonia (in low risk of MDR organisms scenario)?

amox + clavulanate

OR if nil orally ben pen + gentamicin


How do you treat moderate/severe hospital-acquired pneumonia (in low risk of MDR organisms scenario)?



What Gram stain findings are associated with pneumococcal pneumonia?

Gram positive oval shaped diplococci


What Gram stain findings are associaed with S. aureus?

Gram-positive cocci in clusters, chains and pairs


What Gram stain findings are associated with N. meningitidis

Gram-negative cocci


What Gram stain findings are associated with H. influenzae pneumoniae?

Gram-negative coccobacilli and many PMNs


What are the most common causes of typical pneumonia?

S. pneumoniae

H. influenzae

M. Catarrhalis


What are the most common causes of atypical pneumonia?

M. pneumoniae

C. pneumoniae


Viruses - influenza, parainfluenza and adenovirus


What is the daily regimen for drug-susceptible tuberculosis?

Rifampicin - 6 months
Isoniazid - 6 months
Pyrazinamide - 2 months
Ethambutol - 2 months


What are the typical symptoms of active TB?

Night sweats, fever, weight loss and cough, developing over 2-3 weeks or more


How is suspected active TB investigated? (3)

1. CXR
2. Sputum cultures x3
3. Acid-fast microscopy using Ziehl-Neelsen stain


What is the Mantoux test?

Aka tuberculin skin test

Assesses inflammation in dermis following intradermal injection of tuberculin protein. Test needs to be read 48-72 hours after administration.


When can false positive Mantoux tests occur?

Previous BCG vaccination and exposure to environmental Mycobacterium spp.


Obstructive lung disease - spirometry results

FEV reduced more than FVC therefore, FEV/FVC ratio is decreased


Restrictive lung disease - spirometry results

FEV/FVC ratio is normal or increased


In which type of COPD patient should supplemental oxygen be given with care?

Blue bloaters - respiratory centres are insensitive to CO2, rely on hypoxic drive to maintain respiratory effort


What is Type 1 respiratory failure?

Hypoxia with normal or low PaCO2. Caused by V/Q mismatch - pneumonia, pulmonary oedema, PE, asthma


What is type 2 respiratory failure?

Hypoxia with hypercapnia (PaCO2 > 6 kPa). Caused by alveolar hypoventilation, with or without V/Q mismatch - reduced respiratory drive, neuromuscular disease (diaphragmatic paralysis, poliomyelitis), thoracic wall disease (flail chest, kyphoscoliosis), pulmonary disease (asthman, COPD, pneumonia, OSA)


How is respiratory failure managed?

Type 1 - treat underlying cause, give oxygen

Type 2 - treat underlying cause, be more careful about giving oxygen


What is the most common cause of interstitial lung disease?

Idiopathic pulmonary fibrosis


Which condition(s) are early inspiratory crackles suggestive of?

COPD/bronchiectasis - often cleared by cough


Which condition(s) are late inspiratory crackles suggestive of?

Pulmonary fibrosis


What constitutes mild, moderate and severe COPD?

FEV/FVC for all 0.7 (post-bronchodilator)

Mild - FEV = 60-80% predicted
Moderate - FEV = 40-59% predicted
Severe - FEV less than 40% predicted


What non-pharmacological interventions should be considered in COPD management? (5)

1. Risk reduction: smoking cessation, influenza and pneumococcal immunisation handbook

2. Optimise function: encourage physical activity, review nutrition, provide education

3. Consider co-morbidities: osteoporosis, coronary disease, anxiety and depression

4. Refer to pulmonary rehab (once moderate severity)

5. Once severe: Consider oxygen therapy, surgery, palliative care and advanced care directive


What pharmacological interventions should be considered in the management of COPD? (3)

1. Short-acting reliever medication: e.g. ventolin

2. In moderate severity: Symptom relief e.g. long-acting muscarinic antagonist or long-acting beta agonist

3. Exacerbation prevention: when FEV below 50% predicted AND patient has had 2 or more exacerbations in the previous 12 months - ICS/LABA ccombination therapy e.g. seretide (fluticasone and salmeterol) or symbicort (budesonide and eformeterol)


What is Seretide?

Combination therapy - ICS/LABA

Fluticasone and salmeterol


What is symbicort?

Combination - ICS/LABA

Budesonide and eformeterol


How does one interpret and increase vs a decrease in tactile fremitus?

Increase = there is a direct solid communication from the bronchus through the lung out to the chest wall e.g. consolidation

Decrease = a process is preventing communication e.g. bronchial obstruction or lung is displaced from chest wall by air or fluid in the pleural space


What are the classical ECG changes for PE?


1. S wave in lead 1
2. Q wave and T wave inversion in lead III
3. T wave inversion in leads V1 to V4


What causes clubbing?

Cyanotic heart disease
Lung disease (Abscess, Bronchiectasis, Cystic fibrosis, DON"T SAY COPD, Empyema, Fibrosis)
UC/Crohn's disease
Biliary cirrhosis
Birth defect (harmless)
Infective endocarditis
Neoplasm (esp. Hodgkins)
GI malabsorption (e.g. Coeliac)