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Flashcards in Respiratory Deck (48):
1

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)

2

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)

3

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

4

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

5

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

6

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

7

Define chronic bronchitis

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

8

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

9

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

PaO2 - low
PaCO2 - elevated
Normal TLC and DLCO

10

What pathologic changes occur with smoking?

Upper lobe centrilobular emphysema

11

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

Panacinar emphysema that favours the lower lobes

12

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

Strep pneumonia - most common

Mycoplasma pneumoniae

Chlamydophila pneumoniae

Legionella

HiB - less than 5%

13

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

14

How is mild community-acquired pneumonia treated?

Outpatient

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

15

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

16

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

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

17

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

18

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

IV

azithromycin + ceftriaxone or benpen + gent or cefatoxime

19

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

amox + clavulanate

OR if nil orally ben pen + gentamicin

20

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

ceftriaxone

21

What Gram stain findings are associated with pneumococcal pneumonia?

Gram positive oval shaped diplococci

22

What Gram stain findings are associaed with S. aureus?

Gram-positive cocci in clusters, chains and pairs

23

What Gram stain findings are associated with N. meningitidis

Gram-negative cocci

24

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

Gram-negative coccobacilli and many PMNs

25

What are the most common causes of typical pneumonia?

S. pneumoniae

H. influenzae

M. Catarrhalis

26

What are the most common causes of atypical pneumonia?

M. pneumoniae

C. pneumoniae

Legionella

Viruses - influenza, parainfluenza and adenovirus

27

What is the daily regimen for drug-susceptible tuberculosis?

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

28

What are the typical symptoms of active TB?

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

29

How is suspected active TB investigated? (3)

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

30

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.

31

When can false positive Mantoux tests occur?

Previous BCG vaccination and exposure to environmental Mycobacterium spp.

32

Obstructive lung disease - spirometry results

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

33

Restrictive lung disease - spirometry results

FEV/FVC ratio is normal or increased

34

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

35

What is Type 1 respiratory failure?

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

36

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)

37

How is respiratory failure managed?

Type 1 - treat underlying cause, give oxygen

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

38

What is the most common cause of interstitial lung disease?

Idiopathic pulmonary fibrosis

39

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

COPD/bronchiectasis - often cleared by cough

40

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

Pulmonary fibrosis

41

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

42

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

43

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)

44

What is Seretide?

Combination therapy - ICS/LABA

Fluticasone and salmeterol

45

What is symbicort?

Combination - ICS/LABA

Budesonide and eformeterol

46

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

47

What are the classical ECG changes for PE?

"S1Q3T3"

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

48

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)