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Flashcards in Respiratory Deck (80):
1

Bilateral hilar lymphadenopathy is most commonly seen in which conditions?

Sarcoidosis
TB

2

A px presents with dyspnoea and a primary pneumothorax of 1.5cm is diagnosed. How should this be managed?

Attempt aspiration as they are symptomatic
(Only aspirate primary pneumothorax if >2cm or if px symptomatic, if this fails then insert a chest drain)

3

How should a secondary pneumothorax be managed in patients if it is:
i) less than 1cm
ii) 1-2cm
iii) more than 2cm

i) if less than 1cm give Ow and admit for 24 hours
ii) aspirate if 1-2cm and admit for at least 24 hours, insert chest drain if aspiration fails
iii) if >50 years old and air is >2cm and/or px is symptomatic, chest drain should be inserted

4

Why can primary TB become reactivated in the host?

If they become immunocompromised e.g. use of steroids, HIV, malnutrition

5

Cannonball metastases in the lungs are most commonly seen with which cancer?

Renal cell carcinoma

6

With a tension pneumothorax, will the trachea deviate towards or away from the affected side?

Pushed away from affected side
(Only with tension, not simple, pneumothorax)

7

What organism is the most common cause of infective exacerbation of COPD?

Haemophilius influenzae
(Then strep pneumoniae and moraxella)

8

What is severity of COPD based upon?

FEV1

(NOT FEV1/FVC ratio)

9

What is the investigation of choice to confirm a diagnosis of idiopathic pulmonary fibrosis?

HRCT

(Can show shadowing and honeycombing)

10

What pathology can cause the trachea to deviate away from the affected lung?

Tension pneumothorax
Pleural effusion

11

What pathology can cause the trachea to deviate towards the affected lung?

Collapsed lung

12

What is the pathophysiology behind the airway obstruction in the bronchi that is seen in asthma?

- bronchial smooth muscle contraction due to triggering stimuli
-mucosal swelling due to inflammatory mediators
-mucous plugging due to increased number of goblet cells

13

What spirometry pattern would asthma show?

FEV1/FVC <70%
Will show reversibility, 12% improvement after a bronchodilator

14

What features characterise a severe attack of asthma?

RR > 25
Pulse > 110
Can’t complete sentences

15

What features characteristic of a life threatening attack of asthma?

Exhaustion
Cyanosis
Silent chest
Sats <92
Bradycardia
PEF < 33% predicted

16

What is the first step of the BTS stepladder to manage asthma?

PRN SABA

Move to next step if using more than 3x per week

17

What is the 2nd step of the BTS asthma management step ladder?

Add low dose ICS e.g. beclametasone

18

What are some examples of LABAs?

Salmeterol
Formoterol

19

What are some side effects of beta agonists?

Fine tremor
Headache
Tachyarrhythmias

20

If an asthmatics symptoms fail to be controlled using a SABA and low dose ICS, what treatment is next?

Change to LABA with ICS
(usually a combination inhaler e.g. symbicort)

21

If a symbicort inhaler is failing to control symptoms in an asthmatic patient, what treatment option can be trialled next?

Higher dose ICS
Can consider adding LTRA, theophylline, LAMA, or beta agonist tablet

22

How would you manage an acute asthma attack?

ABCDE
Salbutamol 5mg nebulised with O2 (every 15 minutes)
100% O2 (aim for sats >94)
Hydrocortisone IV 10pmg, or prednisolone orally 40mg
If rising CO2, refer to ITU
If life threatening severity, give magnesium sulphate IV

23

What is the spirometry pattern in COPD?

FEV1/FVC <0.7
FEV1 <80%

24

What are some signs of COPD that may be visible of examination?

Pursed lip breathing
Hyperinflated chest
Reduced chest expansion
Accessory muscle use when breathing
Hyperresonant percussion
Quiet breath sounds
Tachypnoea

25

What is the FVC1 value in mild COPD?

>80%

26

What is polycythaemia?

An increased concentration of Hb in the blood
(Either due to reduced plasma volume, or increased number of red cells)

27

Why does polycythaemia result due to conditions e.g. COPD and obstructive sleep apnoea?

Due to chronic hypoxaemia, so increased EPO production by the kidneys is stimulated

28

What is the long term management of COPD?

Conservative: smoking cessation, pulmonary rehabilitation, exercise, weight loss if obese, annual influenza and one of pneumococcal vaccinations

Medical: PRN SABA or SAMA, if still symptomatic try LAMA, then if not try LABA + ICS, if not try LAMA+LABA+ICS

29

How is long term oxygen therapy given?

For 15 hours per day
Via a 2L/min nasal cannula

30

When should a COPD px be recommended oxygen therapy?

When Disease is stage 3 severe (FEV1 30-49% of predicted)
Hypoxic

31

What is ipatropium?

Short acting muscarinic antagonist

32

What is an example of a LAMA?

Tiotropium

33

How would you manage an exacerbation of COPD?

“O SHIT”
Oxygen (CONTROLLED at 24-28%)
Salbuatmol 5mg nebuliser
Hydrocortisone or prednisolone course
Ipatropium nebuliser
Theophylline IV
(consider NIV if O2 on ABG not improving)

34

When should Light’s criteria be applied?

For pleural fluid samples with a protein content between 25-35g/L

(Exudate likely if LDH is high)

35

Where would you insert a large bore cannula to decompress a tension pneumothorax?

2nd ICS MCL

36

What is the FEV1 of somebody who has moderate COPD?

50-79% of predicted

37

Which type of pneumonia has a vaccine available?

Strep pneumoniae, pneumococcal vaccine

38

Which organism is likely to cause pneumonia in patients with HIV?

Pneumocystitis jiroveci

PCP = pneumocystitis pneumonia

39

What are common causes of HAP?

Staph aureus
Pseudomonas aeruginosa

40

Which is a common causative organism of pneumonia in COPD patients?

Haemophilius infleuenzae

41

What investigations would you do a px with suspected pneumonia?

CXR
FBC (WCC, CRP usually Raised)
U&Es (look for dehydration, Raised urea is scored for in CURB65)
O2 sats
ABG if sats are low
Sputum culture
Legionella urine antigen

42

What is looked at in the CURB65 score?

Confusion scoring 8 or above on mini mental exam
Urea above 7mmol/L
Resp rate above 30
Blood pressure below 90 systolic, 60 diastolic
65 (aged above)

43

What Abx are used in community acquired pneumonia?

Amoxicillin and clarithromycin (a macrolide) or doxycycline

Course of 5 days
Add meropenem IV if very severe

(If mild CAP, 5 day course of oral amoxicillin will do, or use doxy if pen allergic)

44

What Abx are used to treat HAP?

Meropenem and co-amoxiclav or tazocin

45

What are some symptoms of TB?

Weight loss
Fever
Night sweats
Productive cough
+/- haemoptysis
Fatigue

46

How many sputum samples must be sent off for suspected respiratory TB?

3
One to be an early morning sample (reflects overnight secretions that accumulated in the chest)

47

What drugs are used in TB and for how long?

Rifampicin and isoniazid for 6/12
Pyrazinamide and ethambutamol for 3/12

48

Which TB drug can cause optic neuritis?

Ethambutamol

49

What are some side effects of Rifampicin?

Orange secretion
Liver toxicity (monitor LFTs)
CYP450 inducer

50

Which TB drug can cause arthralgia and myalgic as a known wide effect?

Pyrazinamide

51

Which TB can cause agranulocytosis?

Isoniazid

52

What are some causes of type 1 respiratory failure?

V/Q mismatch: PE, pneumonia, pulmonary oedema, fibrosis, high altitude, asthma, COPD

53

What are some causes of type 2 respiratory failure?

Sedative drugs
Flail chest
Guillain Barre syndrome
Kyphoscoliosis
Severe COPD, asthma

54

What are some signs of hypercapnia?

Confusion
Drowsiness
Flapping tremor
Headache
Bounding pulse

55

How would you treat type 1 respiratory failure?

Tx cause
Oxygen 24-60% via a face mask
(CPAP if sats still low despite oxygen)

56

How would you tx type 2 respiratory failure?

*controlled oxygen therapy as respiration may now be driven by hypoxia and we want to avoid further hypercapnia!*

Tx cause
Controlled oxygen starting at 24%, check ABG after 20 mins and if CO2 steady or reduced, up oxygen to 28%)
Try assisted ventilation
If not, intubation and ventilation

57

What is the Epworth scale used to assess?

Completed by px +/- partner to assess sleepiness
Score >9 indicates obstructive sleep apnoea

58

How can obstructive sleep apnoea be managed?

Weight loss
Smoking cessation
Reduce alcohol
Mandibular advancement device
If severe, CPAP
Remove tonsils if enlarged

59

What is the protein content in transudates and exudates?

Transudate <25g/L
Exudate>35g/L

60

What are some causes of a transudate pleural effusion?

Heart failure
Hypoalbuminaemia (Liver cirrhosis, nephrotic syndrome, malabsorption)
Hypothyroidism

61

What are some causes of an exudate pleural effusion?

Infection: pneumonia, TB
Malignancy (lung Ca, mesothelioma, metastases)
CT disease: SLE, RA

62

What signs on examination would indicate pleural effusion?

Stony dull percussion
Reduced breath sounds
Reduced vocal resonance
Reduced chest expansion

63

How are pleural effusions managed?

Tx underlying cause
Aspiration for diagnosis
Drainage if persistent
If recurrent, pleurodesis with talc

64

What drugs can cause pulmonary fibrosis?

Amiodarone
Methotrexate
Azathioprine

65

Extrinsic allergic alveolitis affects which lung zones?

Upper zones

66

Idiopathic pulmonary fibrosis predominantly affects which lung zones?

Lower zones

67

Drug induced pulmonary fibrosis predominantly affects which lung zones?

Lower zones

68

What are some features usually present on examination for a patient with idiopathic pulmonary fibrosis?

Clubbing
Dry cough
Exertional dyspnoea
Bibasal crackles
Restrictive spirometry pattern

69

What is bronchiectasis?

Permanent dilation of the airways causing chronic infection and inflammation

70

What signs on HRCT are indicative of bronchiectasis?

Tram track signs
Signet ring signs

71

What are some causes of bronchiectasis?

-post infection: TB, pneumonia, measles
-cystic fibrosis
-bronchial obstruction e.g. lung Ca
-yellow nail syndrome
-immune deficiency

72

How is bronchiectasis managed?

Tx cause
Pulmonary physio to clear mucus
Postural drainage
Abx for infection

73

How would a patient with bronchiectasis typically present?

Productive cough
Purulent sputum
Haemoptysis
Dyspnoea
Inspiratory crepitations
+/- clubbing

74

What spirometry pattern would bronchiectasis show?

Obstructive

75

What is the inheritance pattern of cystic fibrosis?

Autosomal recessive

76

What gene is mutated in cystic fibrosis?

CFTR gene (regulating a Cl- channel)

77

What are some effects of cystic fibrosis on the body?

Frequent chest infections
Bronchiectasis
Steatorrhea
Diabetes Mellitus
Male infertility

78

How can cystic fibrosis be diagnosed?

Sweat test will have abnormally high chloride
Can also genetically screen
Faecal elastase can test for exocrine pancreas dysfunction

79

How is cystic fibrosis managed?

At least 2x day cheats physio and postural drainage
Vitamin supplements
Pancreatic enzyme replacement
Mucolytics
No smoking
Avoid other CF px
Abx for acute infective exacerbations

80

What is sails sign?

Indicates left lower lobe collapse on CXR
Appears like a double left heart border, and the left hemidiaphragm can’t be followed to the spine