Respiratory Flashcards

(47 cards)

0
Q

What are the causes of bronchiectasis?

A

Congenital - impaired microcilary transport
Cystic fibrosis, Young’s syndrome, primary ciliary dyskinesia, Kartagener’s syndrome

Acquired - 
Post infection: measles, pertusis, bronchiolitis, pneumonia, TB, HIV
Bronchial obstruction: foreign body, tumour
Allergic broncopulmonary aspergillosis, 
Hypogammaglobulinaemia, 
RA
UC
Idiopathic
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1
Q

What is bronchiectaisis?

A

Abnormal permanently dilated airways with inflamed thickened bronchial walls.

On CT see signet ring sign and on CXR see tramline and ring shadows

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2
Q

What are the clinical features of bronchiectasis?

A

Persistent cough, copious purulent sputum, intermittent haemoptysis,
Clubbing, coarse inspiratory crackles, wheeze,

Complications - pneumonia, pleural effusion, pneumothorax, cerebral abscess, amyloidosis

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3
Q

Describe the illness cystic fibrosis:

A

Autosomal recessive condition
Mutation in 7q31.2 results in defect in cystic fibrosis transmembrane conduction regulator (Chlorine channel)
Failure of opening of the channel when cAMP increases in the cells, leads to a decrease in chlorine excretion into the airway lumen. This leads to an increase in the reabsorption of Na into the epithelial cells, which is followed by water, so there is less water excreted which increases the viscosity of the secretions.

The result of the increased viscosity of the secretions is an increase in respiratory infections leading to chronic lung disease, infections and bronchiectasis.

Patients also have pancreatic insufficiency leading to malnutrition and diabetes

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4
Q

What are the clinical features of cystic fibrosis at the different ages?

A

Neonate - Meconium ileus

Children and young adults -
Respiratory: cough, wheeze, chronic infections, etc Pts start with staph aureus and strep pneumonia infections and then develop chronic pseudomonas and burkholderia cepacia later on.

GI: energy needs increase by 130%, pancreatic insuffieceny requires enzymes, diabetes, GI obstruction more common

Other: infertility, osteoporosis, arthritis, vasculitis,

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5
Q

What result on the sweat test would diagnosis CF?

A

> 60mmol/l with chloride > Sodium

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6
Q

What are the three characteristics of asthma?

A

Airflow limitation - reversible
Airway hyperesponsiveness
Bronchial inflammation : T and Mast cells, plasma exudation, oedema, muscle hypertrophy, matrix deposition, mucus plugging

There are three factors that contribute to the airway narrowing:

  1. bronchial muscle contraction
  2. mucosal swelling
  3. increased mucus production
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7
Q

What are the steps in asthma management?

A

Step 1: inhaled short acting B2 agonist

Step 2: Add inhaled corticosteriod 200-800 ug/ day

Step 3: Add inhaled long acting B2 agonist
if good response from LABA cont
if response to LABA but inadequte control increase steroid to 800ug if not yet on
if no response to LABA stop it and increase steroid. if still inadequate consider adding leukotriene receptor agonist or SR theophylline

Step 4: increased steroid to 2000ug/day
think of adding a fourth drug (leukotriene receptor agonist, SR theophylline or B agonist tablet

Step 5: use daily steroid tablet - refer for specialist care

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8
Q

What are the different levels of acute asthma?

A

Moderate asthma:
increasing symptoms
PEF >50 - 70% best or predicted

Severe asthma:
PEF 33-50% best or predicted 
RR >25
HR >110
inability to complete full sentences 
Life threatening asthma:
PEF <8 
normal pCO2 
Silent chest 
Cyanosis 
Poor respiratory effort 
Arrhythmia 
Exhaustion, altered LOC
Hypotension 

Near Fatal:
Increased PaCO2

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9
Q

How do you treat acute asthma?

A

Oxygen:
Maintain stats between 94-98%
Use oxygen to drive nebuliser

Salbutamol:
2.5 - 5mg nebuliser - back to back if not helping
Can use IV but only in patients not responsive to nebs

Ipratropium Bromide:
0.5 mg neb 4-6hrly

Steroids:
100mg IV hydrocortisone or 30mg pred PO STAT
continue 40-50mg pred for 5 days post attack

Magnesium sulphate
IV 1.2-2g over 20mins (need to be on cardiac monitor)

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10
Q

When do you need to refer an asthmatic patient to ITU?

A

ANY ONE WHO HAS ACUTE OR LIFE THREATENING ASTHMA

need to refer early!!

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11
Q

What is a significant diurnial variation when diagnosing asthma?

A

> 20% difference in peak flow on >3days a week for 2 weeks.

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13
Q

What are the three commonest causes of a chronic cough with a normal chest xray?

A

Asthma
Sinusitis and post nasal drip
Reflux oesophagitis

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14
Q

What are the differences between community acquired, hospital acquired and aspiration pneumonia?

A

CAP - pneumonia developed in the community
Strep pneumoniae is the most common, followed by haemeophilus influenzae

HAP - pneumonia developed >48hrs after hospital admission.
Gram -ve enterobacteria or staph aureus most common

Aspiration - results from aspiration of oropharyngeal organisms.
More common in patients with stroke, myasthenia, low consciousness, oesophageal disease

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15
Q

What is the CURB 65 score?

A

A scoring system to help guide if hospital management of pneumonia is needed.

Confusion (AMTS 7 = 1 point)
Respiratory rate (>30 = 1 point)
BP (systolic 3 indicates severe disease inform ITU
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16
Q

Which pneumonia is most commonly complicated by influenza?

A

Staphylococcal

Causes bilateral cavitating bronchopneumonia

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17
Q

Where does Klebsiella pneumonia usually affect?

A

The upper lobes

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18
Q

Which pathogens cause atypical pneumonia, and what is atypical about them?

A

Mycoplasma pneumonia
occurs in epidemics every 4 years
has insidious onset with flu like symptoms followed by dry cough
CXR usually looks worse than the symptoms suggest Autoimmune haemolytic anaemia may occur as a result of cold agglutinins
Associated with skin rashes

Legionella pneumophilia
Colonizes water tanks and air conditioning units
Flu like symptoms preceed a dry cough and SOB.
Extra pulmonary features - anorexia, D+V, hepatitis, renal failure, confusion
CXR - bibasal consolidation
Lymphopenia, hyponatraemia
Urine - haematuria,

Chlamydophila pneumoniae
Biphasic illness: pharyngitis followed by pneumonia

Chlamydophila psittaci
Acquired from parrot
Headache, fever, ,dry cough, lethargy, arthralgia,
Extra pulmonary - menigoencephalitis, infective endocarditis, hepatitis, nephritis, rash, splenomegaly

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19
Q

Who gets PCP?

A

Patients are are immunocompromised
Now called pneumocystis jiroveci

Dry cough, exertional dyspnoea, fever. bilateral creps

20
Q

What are the causes of PE?

A

Clot breaking off from a pre-existing venous thrombosis

RARE:
Right ventricular thrombus (post MI)
Septic emboli (right sided endocarditis)
Fat, air or amniotic fluid embolism 
Neoplastic cell
Parasites
21
Q

What risk factors increase the chance of developing a PE?

A
Recent surgery - espc abdominal/ pelvic or ortho
Thrombophilia
Leg #
Prolonged bed rest 
Malignancy 
Pregnancy, the pill, HRT 
Previous PE
22
Q

What are the symptoms, signs and results seen in PE?

A

Acute breathlessness and chest pain
Haemoptysis
Dizziness and syncope

Pyrexia, cyanosis, tachypnoea, tachycardia, hypotension, raised JVP, pleural rub
Signs of a DVT

Low PaO2 and PaCO2
Normal CXR
ECG - sinus tachy with signs of right heart strain or SI, QIII TIII
-ve d-dimer rules out, a +ve one does NOT rule it in

23
Q

How do you treat a PE

A

LMWH + warfarin until INR is stable for 3months if provoked
If unprovoked then longer than 3 months depending on risks

If cardiovascularly unstable may need to thrombolyse

24
Q

What is the scoring system used to classify patients risk of developing a VTE?

A

Wells Score

for PE:
Clinical signs of DVT
Is PE the most likely diagnosis 
HR >100
Immbolisation for >3days or surgery in previous 4 weeks
Haemoptysis 
Malignancy 
for DVT:
Paralysis or casting of leg
Bed ridden for 3 days or surgery in previous 4 weeks
Swelling of entire leg
Calf swelling >3cm compared to other leg
Greater pitting odeama in symptomatic leg
Collateral non varicose veins
Malignancy 
Other diagnosis more likely (-2 points)
25
What is sarcoidosis and what are the features of it?
Multisystem granulomatous disorder of unknown cause. Associated with HLA DRB1 and DQB1 alleles Bilateral hilar lymphadenopathy, cough, dyspnoea, chest pain Lymphadenopathy, hepatomegaly, splenomegaly Uveitis, conjunctivits, keratoconjuctivitis sicca, gluacoma Terminal phalangeal bone cysts Enlargment of lacrimal and parotid glands Bell's palsy Erythema nodsum Lupus pernio - chronic plaques on the nose, ears, lips and cheeks Hypercalcaemia, hypercalcuria
26
What are the stages of sarcodosis?
Stage 0 = normal Stage 1 = bilateral hilar lymphadenopathy Stage 2 = BHL + peripheral pulmonary infiltrates Stage 3 = pulmonary infiltrates alond Stage 4 = progressive pulmonary fibrosis, bulla formation, pleural involvement
27
What are the indications for giving steriods in sarcoidosis?
Parenchymal lung disease Uveitis Hypercalcaemia Neurological or cardiac involvement
28
What are the common causes for pneumothorax?
``` Primary = Spontaneous - due to rupture of a sub pleural bulla. Secondary = Asthma, COPD, TB, pneumonia, lung abscess, carcinoma, C, lung fibrosis, sarcoidosis, connective tissue disorders, trauma, iatrogenic - CVP insertion, pacemaker,) ```
29
What is the safe triangle to insert a chest drain?
4th-6th intercostal space (above the nipple) | Anterior to mid axillary line, posterior to pec major.
30
What is the pathogenesis of Obstructive Sleep Apnoea?
Intermittent closure of the pharyngeal airway causing apnoeic episodes in sleep. The respiratory muscles decrease activity during REM, so the diaphragm is the only muscle working. The airway at the back of the throat is sucked closed. Apnoea causes hypoxia, which results in increased effort and then the patient wakes up.
31
What are the complications of sleep apnoea?
Pulmonary hypertension, T2 resp failure, hypertension
32
What are the two different types of pleural effusions, how are they different and what causes each of them?
Transudates vs Exudates Transudates have 200 IU/l LDH caused by pneumonia, carcinoma, TB, rheumatic diseases due to increased leakiness of the pleural capillaries
33
What lung function tests suggest obstructive lung disease?
FEV1
34
What radiologically is hyperinflation?
>6 anterior ribs on the CXR in the mid clavicular line
35
What is the criteria for long term oxygen therapy in COPD?
PaO2 15hrs per day | non smokers clinically stable with Pa02
36
What treatment can help patients with COPD?
Ipratropium and B agonist and steroid inhalers Theophyline has a role in advanced disease
37
How does the zone of fibrosis help you distinguish the cause?
``` Upper zone: TB Extrinsic allergic alveolitis Ankylosing spondylitis Radiotherapy Sarcoidosis ``` Mid Zone: Progressive massive fibrosis Lower Zone: Idiopathic pulmonary fibrosis Asbestos
38
How can interstitial lung disease be classified?
Chronic inflammation/ fibrosis - dyspnoea, non productive cough, abnormal CXR and CT can be divided into: ``` Those with a know cause: Occupational/ environmental Drugs Hypersensitivity Infections ``` Those associated with systemic disorders: Sarcoidosis RA SLE, systemic sclerosis, connective tissue diseases, sjogrens UC, renal tubular acidosis, autoimmune thyroid disease Idiopathic Idiopathic pulmonary fibrosis Cryptogenic organizing pneumonia Lymphocytic interstitial pneumonia
39
How does the zone of fibrosis help you distinguish the cause?
``` Upper zone: TB Extrinsic allergic alveolitis Ankylosing spondylitis Radiotherapy Sarcoidosis ``` Mid Zone: Progressive massive fibrosis Lower Zone: Idiopathic pulmonary fibrosis (commonest cause) Asbestos
40
How can interstitial lung disease be classified?
Chronic inflammation/ fibrosis - dyspnoea, non productive cough, abnormal CXR and CT can be divided into: ``` Those with a know cause: Occupational/ environmental Drugs Hypersensitivity Infections ``` Those associated with systemic disorders: Sarcoidosis RA SLE, systemic sclerosis, connective tissue diseases, sjogrens UC, renal tubular acidosis, autoimmune thyroid disease Idiopathic Idiopathic pulmonary fibrosis (commonest cause) Cryptogenic organizing pneumonia Lymphocytic interstitial pneumonia
41
What are the main causes of extrinsic allergic alveoltitis?
Bird fancier's lung and pigeon fancier's lung - the protein in the droppings Farmers and mushroom worker's lung Malt workers lung Bagassosis or sugar workers lung
42
What does restrictive diseases show on lung function?
Low FEV1 Low FVC Normal or high FEV1/FVC Normal peak flow
43
What are the main causes of extrinsic allergic alveoltitis?
Bird fancier's lung and pigeon fancier's lung - the protein in the droppings Farmers and mushroom worker's lung Malt workers lung Bagassosis or sugar workers lung **Long term steroids can help, whereas in IPF they do not**
44
Name some risk factors for acute respiratory distress syndrome:
``` Sepsis Hypovolaemic shock Trauma Pneumonia DKA Gastric aspiration Pregnancy Eclampsia Amniotic fluid embolus Drugs/ toxins Pulmonary contorsion Massive transfusion Burns Smoke inhalation Near drowning Acute pancreatitis DIC Head injury Increased ICP Fat embolus Heart/ lung bypass Tumour lysis syndrome Malaria ```
45
What are the diagnostic criteria for ARDS?
1 acute onset 2 CXR: bilateral infiltrates 3 pulmonary capillary wedge pressure
46
What does exposure to asbestos do to the lungs?
Pulmonary fibrosis Pleural plaques increases risk of bronchial adenocarcinoma and mesothelioma
47
What is cor pulmonale?
Right heart failure caused by chronic pulmonary arterial hypertension.