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Flashcards in Respiratory Deck (47):
1

What are the restrictive / obstructive patterns for FEV1 + FVC

Obstructive: FEV1 reduced / FEV1:FVC reduced

Restrictive: FVC and FEV1 reduced / FEV1:FVC normal

2

What is Kco + TLco?

What can reduced Kco/TLco indicate?
What can it exclude?

Kco = diffusion capacity of lung per unit area for CO

TL = diffusion capacityt for total lung capacity for CO

A reduction can indicate a problem with gas exchange
= alveolar or vascular disease
= rules out chest wall / diaphragm probs

3

What patient groups is pneumonia more common in? (5)

Male
Elderly
Smokers
Alcoholics
Chronic disease

4

What are the clinical S+S of pneumonia? (5+8)

Acute systemic illness: fever/rigors/vom
Cough: initially dry then mucopurulent
SOB
Pleuritic pain (+ poss referred to shoulder / anterior abdo wall)
Confusion/delirium - in elderly pts (who may have v few symptoms)

Tachypnoea
Reduced chest expansion (affected side)
Dullness to percussion (affected side)
Coarse crackles
Bronchial breathing
Increased vocal resonance
?Pleural rub
?Upper abdo tenderness (if lower lobe)

5

What is the definition of HAP?

Pneumonia developing 48hrs after admission (with no signs of incubation on admission)
OR
Someone hospitalised in the past 10d

6

List the causative organisms for CAP (6)

Typical bact (60-80%):
S.Pneumoniae
H.influenzae

Atypical (10-20%):
mycoplasma / chlamydia / legionella

Viruses (10-20%):
influenza / parainfluenza

7

What is seen on CXR for pneumococcal pneumonia?
Which patient group is most susceptible?

Which patient group is most susceptible to H.Influenzae

Classical lobar pneumonia + rust-coloured sputum
Immunosuppressed - vaccine given

COPD pts (the encapsulated strain)

8

What is seen on CXR of mycoplasma pneumonia?
What patient group?
How does it present?

Widespread patchy consolidation across multiple lobes
Younger pts

Long H/o extra-pulm features:
Rash, Hepatitis, D+V, Pericarditis, Meningoencephalitis

9

What is seen on CXR of legionella pneumonia?
What pt group?
What are some other features? (3)

Bilateral consolidation on lung bases

Smokers / recently returned from holiday (air conditioning units)

Proteinuria/haematuria (common)
Neuro involvement (CN palsies)
Hypernatraemia (SIADH)

10

What pt groups are susceptible to Chlamydia pneumonia?

Infants (URTI) + Elderly (CAP)

11

What Ix are done in pneumonia? (6+2)

Obs / sats assessment
FBC/UEs/CRP/LFTs
Blood cultures
Sputum sample (culture +/- mycoplasma PCR)
CXR
Urine in mod/severe (for L/S.pneumonia)

Serum mycoplasma IgG if suspect
Throat swab in viral transport medium if severe/suspect viral

12

Describe the CURB65
Classify the severities

Confusion: AMT < 8
Urea >7
Resp rate >30
BP <90 SBP or <60 DBP
65yrs+

0-1 = non-severe
2 = moderately severe
>2 = severe

13

Describe the treatment for CAP at diff severities

Non-severe: oral amoxi / doxi as outpatient

Mod severe: admit + oral amoxi/doxy + clarithro

Severe: admit HDU + IV co-amoxi + clarithro OR levofloxacin + vanco

ADD Metronidazole if aspiration suspected

PLUS chest physio for all for effective coughing

14

Describe the management for HAP

Assess MRSA RFs:
Known/previous
Longterm indwelling line/catheter
From nursing home w. skin breaks

Mild = oral doxy
Severe = oral co-trimoxazole

15

What are some complications of pneumonia? (4)

Parapneumonic effusion / empyema
Lung abscess (clubbing)
Bronchiectasis
Sepsis

16

How and why are pts followed up after a pneumonia?

CXR 6wks after
Ensure resolved and not due to obstrn e.g. lung cancer

17

What are the S+S of TB? (7+2)

Malaise / wt loss / anorexia / night sweats
Later:
Mucoid wet cough
Pleural pain
Small haemoptysis

Fever / Apical crackles

18

How is a pt with suspected active TB investigated? (4)

Sputum:
Microscopy - acid-fast bacilli (24hrs)
PCR
Culture - 6wks

IF sputum samples -ve
Bronchoscopy + biopsy
OR Broncho-alveolar lavage

CXR - upper lobe cavities / pleural effusions / lymphadenopathy

Ix extra-pulm if suspect

19

How is latent TB investigated (eg contact tracing)? (3)

Mantoux test (inject TB Ag + size of reaction)
Interferon-y release assay (IGRA)
Standard bloods (FBC/UEs/LFTs) - rule out other causes/baseline

20

How is a pt with active TB managed?

If admitting - isolation
If not - specialist TB service
Assess RFs (prev TB Tx / adherence / contacts / HIV)

2m isoniazid (+pyridoxine) + rifampicin
+ ethambutol + pyrazinamide
4m isoniazid (+pyridoxine) + rifampicin

21

How is latent TB managed?

3m - isoniazid (+ pyridoxine) + rifampicin

22

How is contact tracing done in confirmed cases of TB?

All household - trace / assess for latent
Casuals - only trace if infectious (10%+ of close develop TB) or if contact eg HIV

23

What are the main SEs for:
Isoniazid
Rifampicin
Pyrazinamide
Ethambutol

Ison - neuropathy/enceph (pyridoxine prevents)
Rifamp- deranged LFTs
Etham- optic neuritis
Pyraz- hepatotoxic

24

What are the common sites + features of non-pulmonary TB (6)

Joints/spinal - mono arthritis
Cutaneous - lupus vulgaris/erythema nodosum
Meningitic TB
Renal - sterile pyuria
Pericarditis - chest pain

25

What are the S+S of a pneumothorax

Asymp (small one + young)
Sudden unilateral pleuritic pain w. Progressive dyspnoea

Reduced expansion
Hyperesonance on percussion
Reduced vocal resonance
Reduced breath sounds

26

How is a tension pneumothorax clinically differentiated from a normal?

Trachea deviated from affected side
Neck veins dilated (venous return)
+ poss haemodynamic compromise
NB check chest drain - could be blocked

27

How is a tension pneumothorax treated?

100% oxygen
Large bore cannula ics2 mid-clav
CXR
Insert chest drain

28

How is a pneumothorax treated?

If <2cm air rim or not SOB:
discharge + fortnightly CXR + advise smoking cessation

If >2cm or SOB:
Aspirate or chest drain if fails

If recurrent (>2) or not resolving within 5d - surgery indicated (pleurectomy/ talc pleurodesis)

29

List the causes of transudative pleural effusion (5)

Cardiac failure: hydrostatic backpressure from LHF
Liver failure: reduced protein prodn = reduced oncotic pressure
Renal failure: nephrotic synd reduced oncotic pressure
Peritoneal dialysis
Hypothyroidism (rare)
Ovarian tumours (Meig's)

30

List the causes of exudative pleural effusion (5 - A PAIN)

Infections
Neoplasm
PE (pulm infarct)
Autoimmune (RA/SLE)
Abdo disease: pancreatitis, subphrenic abscess

31

Describe the S+S of pleural effusion (3+6)

Asymp
SOB
Pleuritic pain

Reduced expansion
Dull to percussion
Reduced vocal resonance
Reduced breath sounds
Bronchial breathing

32

List the RFs for COPD (6)

SMOKING
Occupational dust exposure
a1-antitrypsin defc
Recurrent childhood chest infections
Low socioeconomic status
Asthma / atopy

33

Describe the typical presenting features of COPD (3)

Productive morning cough (after yrs of smokers cough)
Increased freq of LRTIs
Slow progressive dyspnoea w. wheeze

34

What may be seen O/E in mild/severe?

Mild: widespread wheeze
Severe:
O - tachypnoea / cyanosis / flap
I - hyperinflation / recession / tug / pursing / accessorys
P - poor expansion
P - hyperresonant
A - reduced breath sounds / prolonged expiration / polyphonic wheeze

35

List the complications of COPD (6)

Acute exacerbations
Polycythaemia
Resp failure
Cor pulmonale
Pneumothorax (ruptured bullae)
Lung carcinoma

36

What Ix/Further tests will be done in suspected COPD (3+4) and why is each one done

Post-bronchodilator spirometry (Dx / severity)
CXR (exclude other pathology)
FBC (ID anaemia / polycythaemia)

Sputum culture (abnormal orgs suggest bronchiectasis)
ECG (RA/RVH)
ABG (resp failure)
DLCO (diffusion capacity of lung for CO - reduced in emphysema)

37

Describe the management for stable COPD (4)

Specialist referral if Dx uncertain / deteriorating

Patient education
Action plan for exacerbations (steroids/Abx)
Lifestyle advice (diet / exercise / smoking)
Meds/inhalers

38

What is the main SE of:
Rifampicin
Isoniazid
Pyrazinamide
Ethambutol

R: deranged LFTs
I: neuropathy/enceph
P: hepatotoxic
E: optic neuritis

39

Causes of a normal anion gap in metabolic acidosis (4)

Causes of a raised anion gap in metabolic acidosis (4)

Normal = HCO3- loss
Renal tubular acidosis
Diarrhoea
Intestinal fistula
Drugs (acetozolamide)

Raised = Acid prodn
DKA
Urate (renal failure)
Lactic (hypoxia/shock)
Drugs (NSAIDs/metformin/ethanol)

40

What are the features of Pancoast syndrome (4)

Horners
Shoulder pain → arm
Hand/arm mm atrophy
Oedema (vv congestion)

41

List some metastatic manifestations specific to lung cancer

Recurrent laryngeal nn palsy
Phrenic nn palsy
SVC obstrn
Adrenal mets (Addison's)
Pericarditis
AF
Pancoast syndrome (Horners/brachial neuralgia/oedema)
Dermatomyositis
Acanthosis nigracans
Lambert-Eaton
SIADH
Cushing
HyperPTH/Cal
Hypertrophic pulmonary osteoathropathy

42

Causes of Restrictive lung disease

ENDOGENOUS:
Idiopathic**
Autoimm/CTDs

EXOGENOUS:
Drugs
Infections (weird) / Hypersensitivity (EAA)
Occupational

43

What Ix can be done in restrictive lung disease of unknown cause?

Bloods: FBC / ANA / RF
Orifices: Spirometry
Imaging: CXR / CT
Invasive: Bronchoalv lavage / Biopsy

44

What are the complications of lung fibrosis (restrictive disease)? (3)

Pulm HTN
T2RF
Lung cancer risk

45

How can lung fibrosis (restrictive disease) be managed?

Most unresponsive

O2 – for attacks
Prednisolone (20% respond)
Lung transplant

46

What are the complications of OSAS? (3)

Cor pulmonale
HTN
T2RF

47

What are the indications for Lobectomy? (4)

Lung cancer
TB / Chronic abscess
Fungal infection
Bronchiectasis (localised)