Respiratory Flashcards
(294 cards)
1
Q
what is finger clubbing?
A
- bogginess/ increased fluctuance of nail bed
- loss of concave nail fold angle
- ↑ longitudinal and transverse curvature
- soft tissue expansion at distal phalanx
2
Q
causes of clubbing
(cardiac)
A
CIA
Congenital cyanotica Heart disease
infective endocarditis
Atrial myxoma
3
Q
Respiratory causes of clubbing?
A
Carcinoma: Bronchial, Mesothelioma
Chronic lung suppuration: empyema, abscess, bronchiectasis, Cystic fibrosis
Fibrosis: Idiopathic pulmonary fibrosis, TB
4
Q
GI causes of clubbing?
A
Cirrhosis (liver)
Crohns/ UC
Coeliac Disease
Cancer: GI lymphoma
5
Q
other general causes of clubbing?
A
familial
thyroid acropachy
upper limb AVMs or aneurysms -> unilateral clubbing
6
Q
resp causes of cyanosis?
A
hypoventilation: COPD, MSK
decreased diffusion: Pulmonary oedema, fibrosing alveolitis
V/Q mismatch: PE, AVM
7
Q
cardiac causes of cyanosis?
A
congenital: Tetralogy of Fallot’s, TGA
low Cardiac output: LVF, Mitral stenosis
Vascular: DVT, Raynaud’s
8
Q
broncho vs lobar pneumonia?
A
Bronchopneumonia:
patchy consolidation of one or more lobes, of one or both lungs
(pus in many alveoli and adjacent air passages)
Lobar pneumonia:
acute inflammation of entire lobe
9
Q
what are the 4 stages of lobar pneumonia?
A
congestion -> red hepatization -> grey hepatization -> resolution
10
Q
what pathogens are mainly responsible for community acquired pneumonia?
A
strep pneumo
haemophilus influenzae
mycoplasma pneumo (esp in young adults- kids)
atypicals: moraxella, legionella, chlamydia
11
Q
what pathogens are mainly responsible for hospital acquired pneumonia?
A
Gram -ve enterobacteria: e.g. pseudomonas, klebsiella
Staph aureus (usually MRSA)
12
Q
what pathogens are mainly responsible for aspiration pneumonia?
A
anaerobes
13
Q
what increases risk of aspiration pneumonia?
A
unsafe swallow
- stroke, bulbar palsy, reduced GCS, achalasia, GORD
14
Q
what are the main pathogens causing pneumonia in an immunocompromised patient?
A
PCP
TB
Fungi e.g. Aspergillus, cryptococcus
CMV/ HSV
+ the usual suspects
15
Q
symptoms of pneumonia?
A
fever, rigors
malaise, anorexia
SOB
Cough, purulent sputum, haemoptysis
pleuritic pain
16
Q
Signs of pneumonia?
A
↑HR, ↑RR
cyanosis
confusion
Consolidation: coarse crackles, decreased air entry, decreased expansion, dull percussion, bronchial breathing, pleural rub, increased vocal fremitus
17
Q
Ix of pneumonia?
A
Bedside: Obs, Sputum Culture, Urine culture (Ag tests for legionella/ strep pneumo)
Bloods: FBC, U+E, WCC, CRP, Blood cultures, ABG (if SpO2 drops)
Imaging: CXR
Special:
- Paired serological Abs for atypicals (chlamydia, mycoplasma, legionella)
- Bronchoalveolar lavage
- pleural tap
- immunofluorescence (PCP)
18
Q
what is the severity scoring system of pneumonia?
A
CURB-65
Confusion (AMTS ≤ 8)
Urea >7 mM
Resp Rate ≥30/ min
BP < 90 or ≤60
Age≥65
19
Q
Mx of Pneumonia based on CURB65 risk stratification score?
A
0-1: outpatient care
2: inpatient / observation admission
≥ 3: inpatient admission, consider ITU
20
Q
Mx of pneumonia?
A
Antibiotics
O2: SpO2 94-98%
Fluids
Analgesia
Chest physio
Consider ITU if shock, hypoxia, hypercapnia
Follow up at 6 wks with CXR
21
Q
what empirical abx for mild CAP?
A
amoxicillin 500mg TDS PO for 5d
or
Clarithromycin 500mg BD PO 7d
22
Q
what empirical abx for moderate CAP?
A
amoxicillin 500mg TDS and clarithro 500mg BD PO/IV
7 days
23
Q
what empirical abx for severe CAP?
A
Co-amoxiclav 1.2g TDS IV (or cefuroxime)
AND Clarithro 500 mg BD IV
for 7-10 d
(add fluclox if staph suspected)
24
Q
what empirical abx for chlamydial pneumonia?
A
doxycycline
25
what empirical abx for PCP?
co-trimoxazole
120 mg/kg daily in 2–4 divided doses for 14–21 days.
26
what empirical abx for legionella pneumonia?
clarithromycin + rifampicin
27
empirical abx for mild Hospital acquired pneumonia?
Co-amoxiclav 625mg PO TDS for 7d
28
empirical abx for severe HAP?
Tazocin ± vanc ± gent for 7d
29
who should get pneumovax?
Age \>65
Immunosuppression: chemo, HIV, hyposplenism
DM
Chronic heart/ lung/ kidney/ liver failure
30
complications of pneumonia?
resp failure
hypotension + sepsis
AF
Pleural effusion
empyema
lung abscess
31
Type 1 vs Type 2 Respiratory Failure?
Type 1: PaO2 \< 8 kPa, PaCO2 \<6 kPa
Type 2: PaO2 \< 8 kPa, PaCO2 \> 6 kPa
32
what is empyema?
pus in the pleural cavity
33
tap of empyema will show?
turbid appearance
pH \< 7.2
low glucose
high LDH
34
mx of empyema?
US guided chest drain + ABx
35
causes of lung abscess?
aspiration
bronchial obstruction: tumour, foreign bodt
septic emboli: sepsis, IVDU, RH endocarditis
pulmonary infarction
subphrenic/ hepatic abscess
36
features of lung abscess?
swinging fever
cough, purulent sputum, haemoptysis
pleuritic pain
malaise, weight loss
clubbing
empyema
37
ix of lung abscess?
bedside: sputum MCS
bloods: FBC, CRP, cultures
imaging: CXR - cavity w fluid level
consider CT and bronchoscopy
38
mx of lung abscess
aspiration
surgical excision
39
what is SIRS?
Inflammatory response of
2 or more of:
temp: \>38 or \<36
HR \>90
RR \>20 or PaCO2 \< 4.6 kPa
WCC: \> 12 or \<4
40
what is sepsis?
SIRS + source of infection
41
what is severe sepsis?
sepsis w at least 1 organ dysfunction or hypoperfusion
42
what is septic shock?
severe sepsis with refractory hypotension
43
what is multiple organ dysfunction syndrome?
impairment of 2 or more organ systems
homeostasis cannot be maintained without therapeutic intervention
44
what is bronchiectasis?
airways of the lungs become abnormally widened, leading to a build-up of excess mucus that can make the lungs more vulnerable to infection.
chronic infection of bronchi -\> permanent dilatation, airway damage and recurrent infection
45
causes of bronchiectasis?
idiopathic - 50%
congenital:
CF, Kartagener's, Young's syndrome
Post-Infectious:
Measles, Pertussis, Pneumonia, TB, bronchiolitis
Immunodeficiency: brutons, CVID, IgA deficiency
46
what is young's syndrome?
azoospermia + rhinosinusitis + bronchiectasis
47
symptoms of bronchiectasis
persistent cough with purulent sputum
haemoptysis
fever, weight loss
48
signs of bronchiectasis?
clubbing
coarse inspiratory creps
wheeze
purulent sputum
Situs inversus -\> + Primary ciliary dyskinesia = Kartagener's
Splenomegaly: immune deficiency
49
complications of bronchiectasis?
pneumonia
pleural effusion
pneumothorax
pulmonary HTN
Massive haemoptysis
amyloidosis
50
ix of bronchiectasis?
Bedside: Sputum MCS
Bloods: α1-AT level
Imaging: CXR - thickened bronchial walls
special: Spirometry - obstructive pattern
High resolution CT Chest
Bronchoscopy + mucosal biopsy: PCD
CF sweat test
51
what CXR findings with bronchiectasis?
thickened bronchial walls
'tramlines and rings'
52
what CT chest findings with bronchiectasis?
dilated and thickened airways
saccular dilatations in clusters w pools of mucus
53
mx of bronchiectasis?
Chest physio: expectoration, drainage, pulm rehab
Abx for exacerbations
Bronchodilators: nebulised B agonists
Tx underlying cause:
e.g. CF, ABPA (Steroids), immune deficiency (IVIg)
surgery may be indicated in severe localised disease
54
pathogenesis of cystic fibrosis?
autosomal recessive
mutation in CFTR gene on chr 7
-\> ↓ luminal Cl secretion and ↑ Na reabsorption -\> viscous secretions
in sweat glands: decreased Cl and Na reabsorption -\> salty sweat
55
features of CF in the neonate?
meconium ileus
FTT
rectal prolapse
56
features of CF in children/ young adults?
nasal polyps, sinusitis
recurrent chest infections, bronchiectasis
Pancreatic insufficiency: steatorrhoea, DM
gallstones
male infertility
57
signs of CF?
clubbing
cyanosis
bilateral coarse creps
58
what are the pathogens responsible for long term infections in CF?
pseudomonas aeruginosa
burkholderia cepacia
59
Diagnosis of CF?
Sweat Test: Na and Cl \> 60 mM
genetic screening for common mutations
faecal elastase (tests pancreatic exocrine function)
immunoreactive trypsinogen (neonatal screening)
60
Ix of Cystic Fibrosis?
Bedside: Sputum MCS
Bloods: FBC, LFTs, clotting, Vit A/D/E/K levels, glucose lvl
Imaging:
CXR- bronchiectasis
Abdo US- fatty liver, cirrhosis, pancreatitis
Special: Spirometry - obstructive defect
Aspergillus serology (20% develop ABPA)
61
Mx of cystic fibrosis?
MDT: specialist nurse, physio, GP, dietician
**Resp**:
Chest Physio
Abx
mucolytics e.g. hypertonic saline, dornase alfa
bronchodilators
Vaccinations
**GI:**
pancreatic enzyme replacement
A/D/E/K supplements
insulin
ursodeoxycholic acid for impaired hepatic function
**other:**
tx of complications
fertility and genetic counselling
DEXA osteoporosis screen
62
mx of advanced lung disease with Cystic fibrosis?
Oxygen
Diuretics (Cor pulmonale)
NIV
heart/ lung transplantation
63
aspergillus can cause what kinds of pulmonary conditions?
asthma
Allergic bronchopulmonary aspergillosis
aspergilloma
invasive aspergillosis
extrinsic allergic alveolitis
64
What is Allergic Bronchopulmonary Aspergillosis?
T1 and T3 hypersensitivity reaction to aspergillus fumigatus
airway inflammation -\> bronchiectasis
65
symptoms of Allergic bronchopulmonary aspergillosis?
wheeze
productive cough
dypsnoea
66
Ix of Allergic Bronchopulmonary Aspergillosis?
CXR: bronchiectasis
Aspergillus in sputum (black on silver stain)
Aspergillus skin test or IgE RAST
+ve Se precipitins (from previous exposure to aspergillus)
increased IgE and eosinophils
67
tx of allergic bronchopulmonary aspergillosis?
prenisolone 40mg/d + itraconazole for acute attacks
pred maintenance 5-10mg/d
bronchodilators for asthma
68
what is an aspergilloma?
fungus ball within a pre-existing cavity
e.g. TB or sarcoid
69
features of aspergilloma?
usually asymptomatic
can have haemoptysis
weight loss, lethargy
70
ix of aspergilloma?
CXR: round opacity - cavity, usually apical
sputum culture
+ve Se precipitins
Aspergillus skin test/ RAST
71
Mx of Aspergilloma?
consider excision for solitary lesions/ severe haemoptysis
72
complications of invasive aspergillosis
aflatoxins -\> liver cirrhosis and HCC
73
risk factors for invasive aspergillosis?
immuno compromised pts: HIV, leukaemia
Post broad spec abx
74
Ix of invasive aspergillosis?
CXR: consolidation, abscess
Sputum MCS
BAL
+ve Se precipitins
serial Galactomannan assay
75
Mx of invasive aspergillosis?
voriconazole
76
local complications of lung cancers?
recurrent laryngeal n palsy (hoarseness)
phrenic nerve palsy (diaphragm paralysis)
SVC obstruction
Horner's (Pancoast tumour)
AF
77
symptoms/ signs of SVC obstruction?
Pemberton's sign: raise hands above head-\> red face +/- blue + resp distress
Venous distention in the neck and distended veins in the upper chest and arms.
facial swelling / + upper limb oedema
collar of stokes (oedema of neck)
cough, difficulty breathing, headache
78
what is Horner's syndrome?
miosis + partial ptosis + apparent anhidrosis + apparent enophthalmos
79
what may Pancoast tumour affect?
compression of a brachiocephalic vein, subclavian artery,
phrenic nerve, recurrent laryngeal nerve, vagus nerve
sympathetic ganglion (the stellate ganglion) -\> Horner's syndrome.
80
what paraneoplastic syndromes may lung cancers cause? (hormones)
SIADH -\> low Na+ euvolaemic
PTHrP -\> high Ca, bone pain
ACTH -\> Cushing's syndrome
Serotonin -\> carcinoid (flushing, diarrhoea)
81
what is Trousseau's syndrome?
aka Trousseau sign of malignancy
medical sign involving episodes of vessel inflammation due to blood clots which are recurrent or appearing in different locations over time (thrombophlebitis migrans)
82
Imaging Ix of lung cancer?
**CXR** - lesion, hilar enlargement, consolidation/ collapse, effusion, bony secondaries
**Contrast CT** for staging
consider CT brain for mets
**PET-CT**: for distant mets
**radionucleotide bone scan**
83
Bedside/ Bloods Ix for Lung Ca?
Bloods: FBC (anaemia), U+E, Ca2+, LFTs
Sputum cytology
84
Special Test Ix for Lung Ca?
Biopsy:
- Bronchoscopy
- Percutaneous FNA
Lung Function tests:
assess treatment fitness
85
Coin Lesion on CXR differential
foreign body
abscess
Granuloma: TB, sarcoid, wegener's, RA
Neoplasia
Structural: AVM
86
what staging system used for NSCLC?
TNM Staging
87
Mx of Lung Ca?
MDT: resp physician, oncologist, radiologist, physio, OT, surgeon input, histopath, specialist nurses, palliative care
assess risk of operative mortality (co-morbidities, cardioresp function)
advise smoking cessation
tx depends on subtype of lung ca
88
What is Acute Respiratory Distress Syndrome?
life-threatening condition where the lungs can't provide the body's vital organs with enough oxygen.
inflammation due to infection/ injury -\> ↑ capillary permeability -\> pulmonary oedema -\> breathing is difficult
89
symptoms of acute respiratory distress syndrome
SOB
Tachypnoea
confusion
cyanosis
bilateral fine creps
SIRS
90
Ix of ARDS?
CXR: bilateral perihilar infiltrates
Bloods: FBC, U+E, LFTs, clotting, amylase, CRP, Cultures, ABG
91
Dx of ARDS?
acute onset
CXR shows bilateral infiltrates
no evidence of congestive cardiac failure
PaO2:FiO2 \<200
92
Mx of ARDS?
Admit to ITU for organ support and tx underlying cause
e.g. sepsis -\> abx
support ventilation and circulation and nutritional support (e.g. enteral nutrition)
93
ventilation mx of ARDS if indicated?
ie. PaO2 \<8 kPa despite 60% FiO2
or PaCO2 \> 6kPa
PEEP (positive end-expiratory pressure)
94
what is Type 1 Respiratory failure?
what is it due to?
PaO2 \< 8 and PaCO2 \< 6
V/Q mismatch and diffusion failure
95
What is Type 2 Respiratory failure?
What is it due to?
PaO2\<8 and PaCO2 \>6
alveolar hypoventilation +/- V/Q mismatch
e.g. COPD, asthma, bronchiectasis
96
acute features of hypoxia?
SOB
agitation
confusion
cyanosis
97
features of chronic hypoxia?
polycythaemia
cor pulmonale (abnormal enlargement of R heart due to lung disease)
98
features of hypercapnia?
headache
flushing and peripheral vasodilatation
bounding pulse
flap (asterixis)
confusion-\> coma
99
Mx of T1 resp failure?
tx underlying cause
give O2 to maintain SpO2 94-98%
assisted ventilation if PaO2 \<8kPa despite 60% O2
100
Mx of T2 Resp failure?
Controlled O2 therapy at 24% O2 aiming for SpO2 88-92% and PaO2\>8
Check ABG after 20 min
- if PaCO2 steady or lower can increase FiO2 if necessary
- if PaCO2 increases \> 1.5 kPa, and pt still hypoxic, consider NIV or respiratory stimulant e.g. doxapram
101
what is the target SpO2 for those at risk of hypercapnic respiratory failure?
88-92%
102
Mx of pts at risk of hypercapnic resp failure?
Start O2 therapy at 24% (Blue venturi @2-4L/ min) and do an ABG
103
nasal prongs can delivery oxygen at what rate?
1-4L/ min = 24-40% O2
104
non rebreather mask can deliver oxygen at what rate?
reservoir bag allows delivery of high concentrations of O2
60-90% O2 at 10-15L
105
venturi mask can delivery oxygen at what rate?
delivers a known oxygen concentration to pts on controlled oxygen therapy
Yellow: 5%
White: 8%
Blue: 24%
Red: 40%
Green: 60%
106
what is asthma?
episodic, reversible airway obstruction due to bronchial hyper-reactivity to a variety of stimuli
107
pathophysiology of acute asthma attack?
trigger causes Mast cell-Antigen interaction -\> histamine release
-\> bronchoconstriction, mucus plugs, airway mucosal swelling
108
triggers of asthma?
dust mites, pollen, animals
cold air, exercise, viral infection
smoking, pollution
Drugs: BB, NSAIDs
109
symptoms of asthma?
cough +/- sputum (often at night)
wheeze
SOB
diurnal variation w morning dipping
110
signs of asthma attack?
tachypnoea, tachycardia
decreased air entry, widespread polyphonic wheeze, hyperinflated chest
signs of steroid use
111
Ix of asthma?
Bloods: FBC (eosinophilia), high IgE, aspergillus serology
Bedside: PEFR monitoring/ diary (diurnal variation \>20%)
CXR: hyperinflation
Spirometry: FEV1:FVC \<0.75, 15% or more improvement in FEV1 w B-agonist
Atopy: Skin prick, RAST
112
Mx of asthma?
TAME
Technique for inhaler use
Avoidance: allergens, smoke, dust
Monitor: Peak flow diary (3x/d)
Educate: specialist nurse, need for tx compliance, emergency action plan
Drug ladder of asthma, start with SABA PRN
113
common clinical signs in PE?
Tachypnea (respiratory rate \>16/min) - 96%
Crackles - 58%
Tachycardia (heart rate \>100/min) - 44%
Fever (temperature \>37.8°C) - 43%
114
Ix based on Well's score-
if PE is likely (Wells \> 4) - Mx?
if PE not likely (wells 4 or \<) - Mx?
PE likely: immediate CTPA
if PE unlikely: D-dimer. if +ve -\> CTPA
(if pt allergic to contrast/ renal impairment -\> do V/Q scan)
if there is delay in ix, just give LMWH until scan is performed
115
classic ECG changes in PE?
sinus tachycardia
S1Q3T3
large S wave in lead I, a large Q wave in lead III and an inverted T wave in lead III
right BBB and right axis deviation are also associated with PE
116
risk factors for pseudomonas pneumonia?
bronchiectasis
CF
117
How to facilitate smoking cessation?
refer to specialist stop smoking service
Nicotine replacement:
- Gum
- Patches
Varenicline: selective partial nicotine receptor agonist
- Recommended by NICE
- 23% abstinence @ 1yr vs. 10% for placebo
- Start while still smoking
Bupropion: also an option
SpO2
118
definition of obstructive sleep apnoea?
intermittent closure/collapse of pharyngeal airway -\> apnoeic episodes during sleep
119
risk factors for obstructive sleep apnoea?
Obesity
male
smoker
alcohol
idiopathic pulm fibrosis
structural airway pathology: e.g. micrognathia
NM disease: e.g. MND
120
Ix of obstructive sleep apnoea?
SpO2
Polysomnography is diagnostic (sleep studies)
121
Mx of obstructive sleep apnoea?
↓wt.
Stop smoking
CPAP @ night via a nasal mask (1st line for mod/ severe)
intra-oral devices (e.g. mandibular advancement) if CPAP not tolerated and OSA mild
Surgery to relieve pharyngeal obstruction
- Tonsillectomy
- Uvulopalatpharyngoplasty
122
features of obstructive sleep apnoea?
_Nocturnal_
Snoring
Choking, gasping, apnoeic episodes
_Daytime_
Morning headache
Somnolence
↓ memory and attention
Irritability, depression
123
what is cor pulmonale?
RHF due to chronic Pulmonary HTN
124
symptoms of cor pulmonale?
dyspnoea
fatigue
syncope
125
signs of cor pulmonale?
raised JVP w prominent a wave
left parasternal heave (RVH)
loud P2 +/- S3
Murmurs:
- PR: Graham Steell EDM
- TR: PSM
Pulsatile Hepatomegaly
Fluid: ascites + peripheral oedema
126
ix of cor pulmonale?
Bloods: FBC, U+E, LFTs, ESR, ANA, RF
ABG: hypoxia +/- hypercapnoea
CXR: enlarged R atrium + ventricle, prominent pulmonary arteries
ECG: P pulmonale + RVH
Echo: RVH, TR, increased pulmonary artery pressure
Spirometry
Right heart catheterisation
127
Mx of cor pulmonale?
Tx underlying condition
decreased pulmonary vascular resistance:
- long term o2 therapy
- CCB e.g. nifedipine
- Sildenafil (PDE-5 inhibitor)
- prostacycline analogues
Cardiac failure: ACEi + BB (caution if asthma), diuretics
heart- Lung transplant
128
definition of pulmonary HTN?
PA pressure \> 25 mmHg
129
Causes of pulmonary Hypertension?
**_Left heart disease:_**
- mitral stenosis
- mitral regurg
- left ventricular failure
- L-\>R shunt
**_Lung Parenchymal Disease:_**
- chronic hypoxia -\> hypoxic vasoconstriction, perivascular parenchymal changes
- COPD
- Asthma: severe, chronic
- interstitial lung disease
- CF, bronchiectasis
**_Pulmonary Vascular Disease:_**
- idiopathic pulm HTN
- pulm vasculitis: SLE, scleroderma, Wegener's
- Sickle cell
- PE
- Portal HTN
**_Hypoventilation_**:
Obstructive sleep apnoea
morbid obesity
Thoracic cage abnormality: kyphosis, scoliosis
Neuromuscular: MND, MG, polio
130
Ix of Pulm HTN?
ECG: P pulmonale, RVH, R Atrial Deviation
Echo: Severity of TR, RA/RV enlargement, ventricular dysfunction, valve disease
Right heart catheterisation: Gold St
131
what is the gold st ix for pulmonary HTN?
right heart catheterisation
- mean pulmonary artery pressure
- pulmonary vascular resistance
- Cardiac Output
- vasoreactivity testing to guide tx
132
what is extrinsic allergic alveolitis?
acute allergen exposure in sensitised pts
chronic exposure -\> granuloma formation and obliterative bronchiolitis
133
causes of extrinsic allergic alveolitis?
Bird Fancier's lung: proteins in bird droppings
farmer's / mushroom worker's
Malt worker's lung: Aspergillus clavatus
134
features of extrinsic allergic alveolitis?
4-6h post exposure:
fever, rigors, malaise
dry cough, dyspnoea
crackles (no wheeze)
chronic:
- increasing dyspnoea
- weight loss
- T1RF
- cor pulmonale
135
mx of extrinsic allergic alveolitis?
avoid exposure
steroids: acute/ long-term
compensatoin may be payable
136
ix of extrinsic allergic alveolitis?
bloods: neutrophilia, raised ESR, +ve se precipitins
CXR: upper zone fibrosis -\> honeycomb lung
Spirometry: Restrictive defect
Bronchoalveolar lavage: raised lymphocytes and mast cells
137
features of coal workers pneumoconiosis?
progressive massive fibrosis
presents as progressive dyspnoea and chronic bronchitis
CXR: upper zone fibrotic masses
138
features of silicosis
assoc w quarrying, sand blasting
upper zone reticular shadowing and egg shell calcification of hilar nodes
139
Features of asbestosis?
demolition and ship building
basal fibrosis, pleural plaques
increased risk of mesothelioma
140
featiueres of mesothelioma?
chest pain, weight loss, clubbing, recurrent effusions, dyspnoea
CXR: pleural effusions, thickening
Dx by histology of pleural biopsy
141
diagnosis of mesothelioma?
histology of pleural biopsy
142
epidemiology of idiopathic pulmonary fibrosis?
commonest cause of interstitital lung disease
middle age
M\>F 2:1
assoc w other AI disease in 30%
143
presentation of idiopathic pulmonary fibrosis?
signs:
clubbing
cyanosis
crackles: fine, end inspiratory
symptoms:
dyspnoea
dry cough
malaise, weight loss
arthralgia
obstructive sleep apnoea
144
complications of idiopathic pulmonary fibrosis?
increased risk of lung ca
T2RF and cor pulmonale
145
Ix for idiopathic pulmonary fibrosis
Bloods:
raised CRP, raised IG, ANA+ (30%), RF+ (10%)
ABG- low PaO2, high PCO2
CXR:
decreased lung vol, bilat lower zone reticulonodular shadowing
honey comb lung
High resolution CT: - more sensitive, diagnostic
Spirometry: restrictive defect, decreased transfer factor (impaired gas exchange)
BAL: may indicated disease activity
raised lymphocytes: good prognosis
raised polymorphonuclear cells or eosinophils: poor
146
mx of idiopathic pulmonary fibrosis?
supportive care:
stop smoking
pulmonary rehabilitation
pirfenidone (an antifibrotic agent) may be considered
o2 therapy
palliation
tx symptoms of HF
lung transplant offers only cure
147
principal features of interstitial lung disease?
dyspnoea
dry cough
abnormal CXR/ CT
Restrictive spirometry
148
causes of interstitial lung disease?
environmental: silicosis, asbestosis
Drugs: Bleomycin, Amiodarone, Nitrofurantoin, Sulfasalazine, methotrexate
Hypersensitivity: EAA
Infection: TB, viral, fungi
systemic disease: RA, sarcoidosis, SLE, UC, ank spond
Idiopathic: IPF
149
interstitial lung disease
which causes mainly affect the upper zone?
A PENT(house)
Aspergillosis: ABPA
Pneumoconiosis: coal, silica
Extrinsic allergic alveolitis
Negative, sero-arthropathy
TB
150
interstitial lung disease
what causes lower zone fibrosis?
STAIR(case down)
Sarcoidosis (mid zone)
Toxins: Bleomycin, Amiodarone, Nitrofuran, Sulfasalazine, Methotrexate
Asbestosis
Idiopathic pulm fibrosis
Rheum: RA, SLE, Scleroderma, Sjogrens,
151
what is sarcoidosis?
multisystem granulomatous disorder of unknown cause
age: 20-40
F\>M
Afro caribbean
152
features of sarcoidosis?
may present incidentally on CXR
acute sarcoidosis: fever, polyarthralgia, erythema nodosum, LNs
GRANULOMAS
General: fever, anorexia, weight loss, fatigue, Lymphadenopathy
Resp: fibrosis
Arthalgia: polyarthralgia, dactylitis
Neuro: polyneuropathy e.g. Bell's
Urine: high Ca -\> renal stones
Low hormones: pituitary dysfunction
Opthal: uveitis, keratoconjunctivitis, sicca/sjogrens
Myocardial: restrictive cardiomyopathy secondary to granulomas + fibrosis
Abdo: hepato splenomegaly + cholestatic LFTs
Skin: Erythema nodosum, Lupus pernio
153
Differentials for Bilateral hilar lymphadenopathy?
Sarcoidosis
Infection: TB, mycoplasma
malignancy: lymphoma, carcinoma
interstitial disease: EAA, silicosis
154
Bilateral Hilar Lymphadenopathy
155
Ix of Sarcoidosis?
Bloods:
high ESR, Ca, Serum ACE, Ig, LFTs
CXR, CT, MRI
Spirometry: restrictive
tissue biopsy: diagnostic- non caseating granulomas
opthal assessment
156
mx of Sarcoidosis?
if Bilateral Hilar Lymphadenopathy but asymptomatic
no tx
157
mx of acute sarcoidosis?
usually resolves spontaneously
bed rest and NSAIDs
158
mx of chronic sarcoidosis?
Steroids: pred 40mg/d for 4-6 wks
additional immunosuppression: methotrexate, ciclosporin, cyclophosphamide
159
how to classify pleural effusion as exudate or transudate?
Effusion Protein \< 25 g/L = transudate
Effusion protein \> 35 g/L = exudate
Between 25-35: apply Light's Criteria
Lights criteria
- an exudate has one of:
1. Effusion: serum protein ratio \> 0.5
2. Effusion: serum LDH ratio \> 0.6
3. Effusion LDH is 0.6 x ULN
160
what is acute respiratory distress syndrome?
caused by the increased permeability of alveolar capillaries leading to fluid accumulation in the alveoli, i.e. non-cardiogenic pulmonary oedema
mortality ~ 40%
161
causes of ARDS (acute resp distress syndrome)?
infection; sepsis, pneumonia
massive blood transfusion
trauma
smoke inhalation
pancreatitis
cardio-pulm bypass
162
Key Ix of Acute Resp Distress Syndrome?
ABG
CXR: pulmonary oedema (bilat infiltrates)
non cardiogenic (Pulm art wedge pressure if in doubt)
163
Mx of acute resp distress syndrome?
due to severity of condition -\> ITU
oxygen/ ventilation to treat low O2
General organ support: e.g. vasopressors
tx of underlying cause e.g. abx for sepsis
164
what is Light's criteria?
to determine if pleural effusion is transudate or exudate if in doubt ( protein = 25-35 g/L)
an exudate has one of:
effusion: serum protein ratio \> 0.5
effusion: serum LDH ratio \> 0.6
effusion LDH is 0.6 x upper limits of normal serum LDH
165
causes of exudative pleural effusion?
due to increased cap permeability
infection: pneumonia, TB
neoplasm: bronchial, lymphoma, mesothelioma
Inflammation: RA, SLE
infarction
166
causes of transudative pleural effusion?~
due to increased cap hydrostatic or decreased oncotic pressure
CCF
Renal failure
low albumin: nephrotic synd, liver failure, enteropathy
hypothyroidism
Meig's Syndrome: right Pleural effusion, ascites, ovarian fibroma
167
Ix of Pleural effusion?
Imaging: PA CXR
US recommended: increases likelihood of successful pleural aspiratoin and is sensitive for detecting pleural fluid septations
contrast CT: to ix underlying cause
Pleural aspiration:
sent for pH, protein, LDH, cytology and microbiology
168
raised amylase in pleural effusion aspiration suggests?
pancreatitis
oesophageal perforation
169
heavy blood staining in pleural effusion aspiration suggests?
mesothelioma,
PE
TB
170
low glucose in pleural effusion aspiration suggests?
RA, TB
171
Mx of pleural infection?
pleural effusion in assoc w sepsis or pulmonic illness need diagnostic pleural fluid samplng
- if fluid is purulent or tubid/ cloudy -\> chest tube to allow drainage
- if fluid is clear but pH\<7.2 -\> chest tube should be placed
172
mx of recurrent pleural effusion?
recurrent aspiration
pleurodesis
indwelling pleural catheter
drug mx to alleviate symptoms e.g. opioids to relieve dyspnoea
173
mx of pleural effusion?
tx underlying cause
may use drainage if symptomatic
- w repeated aspiration or chest tube
chemical pleurodesis if recurrent malignant effusion
persistent effusions may require surgery
174
features of pleural effusion?
symptoms: asymptomatic, SOB, pleuritic chest pain
Signs:
tracheal deviation away from effusion, decreased expansion
stony dull percussion
decreased breath sounds, bronchial breathing just above effusion
decreased vocal fremitus
signs of underlying cause e.g. cancer, HF
175
definition of pneumothorax?
accumulation of air in the pleural space w secondary lung collapse
176
types of pneumothorax?
closed: intact chest wall. air from lung -\> pleural cavity
open: defect in chest wall. exterior -\> pleural cavity
tension: air enters pleural cavity through one way valve and cannot escape -\> mediastinal compression
177
Causes of pneumothorax?
Spontaneous:
1º - no underlying lung disease. young thin men (ruptured subpleural bulla), smokers
2º - underlying lung disease
e. g. COPD, marfans, ehlers danlos, pulm fibrosis, sarcoidosis
trauma: penetrating, blunt +/- rib fractures
iatrogenic: subclavian CVP line insertion, Positive pressure ventilation
178
features of pneumothorax?
symptoms:
sudden onset SOB, pleuritic chest pain
signs:
chest: reduced expansion, resonant percussion, decreased breath sounds, low vocal resonance
tension: raised JVP, mediastinal shift
179
ix of pneumothorax?
ABG
US
CXR: expiratory film
- Translucency + collapse (2cm rim = 50% vol loss)
- Mediastinal shift (away from PTX)
- Surgical emphysema
- Cause: rib #s, pulmonary disease (e.g. bullae)
180
Mx of tension pneumothorax?
A-\> E approach
Resus
no CXR
straight up large bore venflon into 2nd ICS, Mid clavicular line
insert chest drain
181
mx of traumatic pneumothorax?
A to E resus
analgesia: e.g. morphine
3 sided wet dressing if sucking
insert chest drain
182
Mx of primary pneumothorax?
A to E approach
CXR
- \> SOB and or rim bigger than 2 cm?
- \> NO -\> discharge
- \> yes -\> aspiration successful? -\> Yes -\> discharge
- \> NO (\>2cm or still SOB): Chest drain
183
Mx of secondary pneumothorax?
A to E resus
CXR
SOB and \>50 yo and rim \>/= 2 cm? -\> yes -\> intercostal drain
- \> no -\> aspiration successful? -\> no -\> intercostal drain
- \> yes -\> admit for 24h
184
Causes of pulmonary embolism?
usually from DVTs in proximal leg or iliac veins
rarely: septic emboli in right sided endocarditis, or RV post MI
185
risk factors of PE?
Sex: female
pregnancy
increased age
surgery
malignancy
oestrogen: OCP/ HRT
immobility
past hx
colossal size
antiphospholipids abs
lupus anti coagulant
186
features of PE?
symptoms: dyspnoea, pleuritic pain, haemoptysis, syncope
signs: fever, tachycardia, tachypnoea
RHF: hypotension, raised JVP, loud P2
187
Ix for PE?
Bloods
ABG
CXR
ECG: sinus tachycardia, RBBB, Right ventricular strain (rarely S1Q3T3)
Doppler US for DVT
CTPA
188
diagnosis of PE?
assess probability using Wells Score
low probability -\> perform D dimers
negative -\> excludes PE
+ve -\> CTPA
high probability -\> CTPA
189
prevention of PE?
risk assessment of all pts
TEDS
prophylactic LMWH
early mobilisation after surgery
avoid OCP/ HRT if @ risk
190
Mx of PE?
A to E approach
Airway: Sit up, 100% O2 via non rebreather mask
Analgesia: morphine + metoclopramide
if critically ill w massive PE -\> consider thrombolysis (e.g. alteplase 50mg bolus stat)
LMWH e.g. enoxaparin SC
Circulation: \<90 -\> fluid bolus
If BP still low: consider inotropes (ie. Dobutamine, Norad)
cont LMWH until INR \>2
target INR 2-3
duration of warfarin: remedial cause 3 mo
no identifiable cause 6 mo
on going cause: indefinite
191
Causes of acute exacerbation of COPD?
viral URTI
bacterial infections
192
features of acute exacerbation of COPD?
cough + sputum
breathlessness
wheeze
193
ix of acute exacerbations of COPD?
Bloods
Sputum culture
PEFR
CXR
ECG
194
discharge mx for acute exacerbation of COPD?
spirometry
establish optimal maintenance therapy
GP and specialist follow up
prevention using home oral steroids and abx
pneumococcal and flu vaccine
home assessment
195
mx of acute exacerbation of COPD?
A to E approach
Airway: sit up, 24% O2 via Venturi mask (aim SpO2 88-92)
nebulised bronchodilators: salbutamol + ipratropium bromide air driven via nasal specs
Steroids: IV hydrocortisone then PO prednisolone 30 mg for 7-14 days
Abx if evidence of infection
NIV if no response: if PH \< 7.35 and or RR \>30
consider invasive ventilation if pH \<7.26
196
definition of COPD?
airway obstruction: FEV1 \<80%, FEV1:FVC \<0.70
Chronic bronchitis: cough and sputum production on most days for 3 mo of 2 successive years
Emphysema: histological diagnosis of enlarged air spaces distal to terminal bronchioles w destruction of alveolar walls
197
causes of COPD?
smoking
pollution
a1 antitrypsin
198
signs of COPD?
tachypnoea
prolonged expiratory phase
hyperinflation: decreased cricosternal distance (normal = 3 fingers), loss of cardiac dullness, displaced liver edge
wheeze
may have early inspiratory crackles
cyanosis
cor pulmonale: raised JVP, oedema, loud P2
signs of steroid use
199
features of emphysema?
pink puffers
increased alveolar ventilation -\> breathless but not cyanosed
normal or near normal PaO2
normal or low PaCO2
Progress -\> T1RF
200
Features of chronic bronchitis?
Blue bloaters
low alveolar ventilation -\> cyanosed but not breathless
low PaO2 and high PaCO2: rely on hypoxic drive
progress -\> T2RF and cor pulmonale
201
complications of COPD?
acute exacerbations +/- infection
polycythaemia
pneumothorax (ruptured bullae)
cor pulmonale
lung ca
202
what is the mMRC dyspnoea score?
1. Dyspnoea only on vigorous exertion
2. SOB on hurrying or walking up stairs
3. Walks slowly or has to stop for breath
4. Stops for breath after \<100m / few min
5. Too breathless to leave house or SOB on dressing
203
Ix of COPD?
BMI
Bloods: FBC, a1-AT, ABG
CXR: hyperinflation (\>6 ribs anteriorly), prominent pulm arteries, bullae
ECG: P Pulmonale, RVH, RAD
Spirometry: FEV1\<80%, FEV1:FVC \<0.70
echo: pulm HTN
204
how to determine severity of COPD?
Mild: FEV1 \>80% (but FEV/FVC \<0.7 and symptomatic)
Mod: FEV1 50-79%
Severe: FEV1 30-49%
Very Severe: FEV1 \< 30%
205
Mx of COPD?
general mx:
stop smoking
pulmonary rehabilitation
annual Influenze and one off pneumococcal vaccine
Review 1-2x/ yr
Mucolytics: if chronic productive cough
e.g. carbocisteine
SABA and or SAMA (ipratropium) PRN
does pt have asthmatic features?
-no asthmatic features: add LABA and LAMA
Asthmatic features/features suggesting steroid responsiveness -\>
LABA + inhaled corticosteroid (ICS) or
triple: LAMA + LABA + ICS
206
what general measures should be instigated in mx of COPD?
**_Stop smoking:_**
- Specialist nurse
- Nicotine replacement therapy
- Bupropion, varenicline (partial nicotinic agonist)
- Support programme
Pulmonary rehabilitation / exercise
Rx poor nutrition and obesity
Screen and Mx comorbidities e.g. cardiovasc, lung Ca, osteoporosis
Influenza and pneumococcal vaccine
Review 1-2x/yr
Air travel risky if FEV1\<50%
207
When is long term oxygen therapy used in COPD?
aim: PaO2 ≥8 for ≥15h / day (↑ survival by 50%)
Clinically stable non-smokers w PaO2 \<7.3 (stable on two occasions \>3wks apart)
PaO2 7.3 – 8 + PHT / cor pulmonale / polycythaemia / COPD
/ nocturnal hypoxaemia
Terminally ill pts.
208
when is surgery indicated in COPD?
Recurrent pneumothoraces
Isolated bullous disease
Lung volume reduction
209
Mx of persistent exacerbations or breathless in COPD?
LABA+LAMA+ICS
Roflumilast / theophylline (PDIs) may be considered
Consider home nebs
210
Mx of exacerbations or persistent breathlessness of COPD?
FEV1 ≥50%: LABA or LAMA (tiotropium) (stop SAMA)
FEV1 \<50%: LABA+ICS combo or LAMA
211
hx of acute severe asthma?
Precipitant: infection, travel, exercise?
Usual and recent Rx?
Previous attacks and severity: ICU?
Best PEFR?
Medication compliance
212
Ix in acute asthma?
PEFR
ABG
- PaO2 usually normal or slightly ↓
- PaCO2 ↓
- If PaCO2 ↑: send to ITU for ventilation
FBC, U+E, CRP , blood cultures
213
features of severe asthma?
any one of:
- PEFR \<50%
- RR\>25
- HR \>110
- Can’t complete sentence in one breath
214
features of life threatening asthma?
any one of:
PEFR \<33%
SpO2 \<92%, PCO2 \>4.6kPa, PaO2 \<8kPa
Cyanosis
Hypotension
Exhaustion, confusion
Silent chest, poor respiratory effort
Tachy-/brady-/arrhythmias
215
admission criteria for acute asthma attack?
Life-threatening attack
Feature of severe attack persisting despite initial Rx
May discharge if PEFR \> 75% 1h after initial Rx
216
Mx of Acute Asthma?
A to E approach
1. Sit-up
2. 100% O2 via non-rebreathe mask (aim for 94-98%)
3. Nebulised salbutamol (5mg) and ipratropium (0.5mg)
4. Hydrocortisone 100mg IV or pred 50mg PO (or both)
5. Write “no sedation” on drug chart
217
mx if life threatening asthma?
after O2, salbutamol, ipratropium, hydrocort have been given
Inform ITU
MgSO4 2g IVI over 20 min
Nebulised salbutamol every 15 min (monitor ECG)
218
mx of acute asthma after acute mx and improving?
monitor SpO2 @ 92-94, PEFR
Continue Prednisolone 50mg OD for 5 days
Nebulised salb every 4 hrs
219
what mx of acute asthma if no improvement after treatment?
**IV mx:**
Nebulised salbutamol every 15min (monitor ECG)
Continue ipratropium 0.5mg 4-6hrly
MgSO4 2g IVI over 20min
Salbutamol IVI 3-20ug/min
Consider aminophylline
- Load: 5mg/kg IVI over 20min, Unless already on theophylline
- Continue: 0.5mg/kg/hr
- Monitor levels
ITU transfer for invasive ventilation
220
Asthma Treatment Ladder for adults?
1. inhaled SABA reliever therapy PRN
2. is use SABA 3x/wk or nocturnal symptoms -\> inhaled corticosteroid as preventer therapy
ie. low dose beclometasone 100-400 mcg bd
3. if uncontrolled, offer oral Leukotriene receptor antagonist w ICS
or LABA (Salmeterol) w ICS
\*if LTRA not effective, -\> LABA
4. if LABA w ICS ineffective -\> maintenance and reliever therapy (MART)
a single inhaler containing both ICS and a fast-acting LABA, which is used for both daily maintenance therapy and the relief of symptoms as required.
5. If MART ineffective -\> increase inhaled steroid to moderate maintenance dose
6. consider a trial of an additional drug (for example, a muscarinic receptor antagonist or theophylline)
or high dose inhaled steroids
7. oral steroids
221
mx of bronchiectasis?
Bronchiectasis describes a permanent dilatation of the airways secondary to chronic infection or inflammation. After assessing for treatable causes (e.g. immune deficiency) management is as follows:
## Footnote
- physical training (e.g. inspiratory muscle training) - has a good evidence base for patients with non-cystic fibrosis bronchiectasis
- postural drainage
- antibiotics for exacerbations + long-term rotating antibiotics in severe cases
- bronchodilators in selected cases
- immunisations
- surgery in selected cases (e.g. Localised disease)
222
most common organism isolated from pts w bronchiectasis?
haemophilus influenzae
223
indications for surgery in bronchiectasis?
uncontrollable haemoptysis
localised disease
224
ix that supports diagnosis of asthma?
fractional exhaled nitric oxide (FeNO) testing:
level of 40 parts per billion (ppb) or higher
Spirometry:
FEV1/FVC ratio \<70% suggests airflow limitation
Bronchodilator reversibility:
improvement in FEV1 of 12% or \>, together with an increase in vol of at least 200 mL in response to beta-2 agonists or corticosteroids is regarded as a positive result
Variable peak expiratory flow (PEF) readings:
more than 20% variability
225
ix of pneumonia according to curb score?
chest x-ray
in intermediate or high-risk patients NICE recommend blood and sputum cultures, pneumococcal and legionella urinary antigen tests
CRP monitoring is recommend for admitted patients to help determine response to treatment
226
mx of high-severity community acquired pneumonia?
NICE recommend considering a beta-lactamase stable penicillin such as co-amoxiclav, ceftriaxone or piperacillin with tazobactam and a macrolide
227
what is Lofgrens syndrome?
Lofgren's syndrome is an acute form of the disease characterised by bilateral hilar lymphadenopathy (BHL), erythema nodosum, fever and polyarthralgia. It usually carries an excellent prognosis
228
what is Mikulicz syndrome?
In Mikulicz syndrome\* there is enlargement of the parotid and lacrimal glands due to sarcoidosis, tuberculosis or lymphoma
229
what is Heerfordt's syndrome?
Heerfordt's syndrome (uveoparotid fever) there is parotid enlargement, fever and uveitis secondary to sarcoidosis
230
231
mx of COPD when symptoms not controlled on SABA/SAMA?
No asthmatic features/features suggesting steroid responsiveness
add a long-acting beta2-agonist (LABA) and a long-acting muscarinic antagonist (LAMA)
232
mx of COPD when not controlled on SABA/ SAMA?
Asthmatic features/features suggesting steroid responsiveness
LABA + inhaled corticosteroid (ICS)
if patients remain breathless or have exacerbations offer triple therapy i.e. LAMA + LABA + ICS
233
mx of COPD after trials of short and long-acting bronchodilators or to people who cannot used inhaled therapy?
oral theophylline
234
mx of cor pulmonale secondary to COPD?
use a loop diuretic for oedema, consider long-term oxygen therapy
235
what is considered low dose of inhaled corticosteroid?
what is high?
For adults:
## Footnote
\<= 400 micrograms budesonide or equivalent = low dose
400 micrograms - 800 micrograms budesonide or equivalent = moderate dose
\> 800 micrograms budesonide or equivalent= high dose.
236
features of granulomatosis w polyangiitis (aka Wegener's)?
upper respiratory tract: epistaxis, sinusitis, nasal crusting
lower respiratory tract: dyspnoea, haemoptysis
rapidly progressive glomerulonephritis ('pauci-immune', 80% of patients)
saddle-shape nose deformity
also: vasculitic rash, eye involvement (e.g. proptosis), cranial nerve lesions
237
ix of Granulomatosis w polyangiitis?
cANCA+ve
CXR: cavitating lesions
renal biopsy: epithelial crescents in Bowman's capsule
238
mx of granulomatosis w polyangiitis?
steroids
cyclophosphamide (90% response)
plasma exchange
239
prevention of acute mountain sickness?
gain altitude at no more than 500 m per day
acetazolamide (a carbonic anhydrase inhibitor) is widely used to prevent AMS and has a supporting evidence base
treatment: descent
240
mx of high altitude cerebral oedema?
descent
dexamethasone
241
mx of high altitude pulmonary edema?
descent
nifedipine, dexamethasone, acetazolamide, phosphodiesterase type V inhibitors\* (by reducing systolic pulmonary artery pressure)
oxygen if available
242
white out of hemithorax but tracheal central?
Consolidation
Pulmonary oedema (usually bilateral)
Mesothelioma
243
white out of hemithorax w trachea pulled towards white out?
Pneumonectomy
Complete lung collapse e.g. endobronchial intubation
Pulmonary hypoplasia
244
white out of hemithorax w trachea pushed away from the white out?
Pleural effusion
Diaphragmatic hernia
Large thoracic mass
245
features of bronchiectasis?
may have a history of previous infections (e.g. Tuberculosis, measles), bronchial obstruction or ciliary dyskinetic syndromes e.g. Kartagener's syndrome
affected pts may produce large amounts of purulent sputum
Clubbing
246
when should long term oxygen therapy be offered to COPD pts?
a pO2 of \< 7.3 kPa
or to those with a pO2 of 7.3 - 8 kPa and one of the following:
secondary polycythaemia
nocturnal hypoxaemia
peripheral oedema
pulmonary hypertension
247
what interventions improve survival in COPD?
smoking cessation
LTOT in those who fit criteria
lung volume reduction surgery in selected patients
248
contraindications to lung cancer surgery?
stage IIIb or IV (i.e. metastases present)
FEV1 \< 1.5 litres is considered a general cut-off point\*
malignant pleural effusion
tumour near hilum
vocal cord paralysis
SVC obstruction
249
what are the oxygen saturation targets for an acutely ill pt w COPD?
94-98%
250
ACE levels in sarcoidosis?
high
251
what ectopic hormones are small cell lung ca assoc w?
ectopic ADH, ACTH secretion
ADH -\> hypoNa
ACTH -\> Cushings
Lambert-Eaton syndrome: antibodies to voltage gated calcium channels
252
mx of small cell lung ca?
patients with very early stage disease (T1-2a, N0, M0) are now considered for surgery
most patients with limited disease receive a combination of chemotherapy and radiotherapy
patients with more extensive disease are offered palliative chemotherapy
253
most common organism causing acute exacerbation of COPD?
haemophilus influenzae
then sometimes: strep pneumo, moraxella catarrhalis
254
when are oral abx indicated during acute exacerbation of COPD
if sputum is purulent or there are clinical signs of pneumonia'
255
reason for inhaled corticosteroid therapy in COPD?
reduced frequency of exacerbations
256
features of Eosinophilic granulomatosis with polyangiitis
(aka Churg- Strauss)
ANCA associated small-medium vessel vasculitis.
asthma
blood eosinophilia (e.g. \> 10%)
paranasal sinusitis
mononeuritis multiplex
pANCA positive in 60%
Leukotriene receptor antagonists may precipitate the disease
257
mx of ascites in pts with cirrhosis?
Spironolactone- aldosterone antagonist
258
Nasogastric tube
- feeding NG tube used for enteral nutrition
- fine bore and is soft unlike the Ryle's NG tube which is wide bore
indicated in oesophageal obstruction
contraindicated in: basal skull fracture, facial traume or pt refusal
259
Endotracheal tube
indicated: to acquire a definitive airway in elective/ emergency situations
features: cuffed - secured tube + prevents aspiration
uncuffed- children, avoid damaging larynx
size: female- 7.5, male - 8.5
double lumen: allow single lung ventilation, used in thoracic surgery
radio-opaque line: blue
260
iGel: laryngeal mask airway
non definitive airway, may also be used in emergency situation
provide an anatomical impression fit over the laryngeal inlet
(inflatable cuff to create a seal)
method:
cuff is deflated and lubricated w aquagel
inserted w open end pointing down towards the tongue
sits in orifice over the larynx
cuff inflated and tube secured w tape
complications: dislodgement, leak, pressure necrosis in airway, aspiration
261
Guedel Airway (oropharyngeal)
airway adjunct used in pts w impaired LOC to maintain a patent airway
measure from incisors to angle of mandible
insert upside down and rotated once in the oral cavity
complications: oropharyngeal trauma, gagging -\> vomiting
262
nasopharyngeal airway
- airway adjunct used in pts w impaired LOC to maintain patent airway
method: sized lateral edge of nostril to trigus of ear
safety pin and flared end prevents the tube becoming irretrievable
complications: bleeding (trauma to nasal mucosa), intracranial placement
contraindications: absolutely contraindicated in pts w facial injuries or evidence of basal skull #
263
Ryles nasogastric tube
indicated for draining the stomach (drip and suck), pts w persistent vomiting e.g. pancreatitis
features: wire bore, stiffer, radio opaque line
264
3 way irrigation foley catheter
- indication: irrigate bladder in pts at risk of clot retention e.g. pts w haematuria or after TURP
features: 3 ports = balloon inflation, drainage (middle), irrigation
265
causes of horners syndrome?
Central (anhidrosis of face, arm and trunk):
syringomyelia
MS
Brain tumour
stroke
Preganglionic (anhidrosis of face):
cervical rib
pancoast tumour
trauma (Klumpkes)
Postganglionic (no anhidrosis):
carotid artery aneurysm/ dissection
cavernous sinus thrombosis
266
267
most common cause of infective exacerbations of COPD?
Haemophilus influenzae
tx: amoxicillin or a tetracycline together with prednisolone.
268
key indications for non invasive ventilation?
COPD with respiratory acidosis pH 7.25-7.35\*
type II respiratory failure secondary to chest wall deformity, neuromuscular disease or obstructive sleep apnoea
cardiogenic pulmonary oedema unresponsive to CPAP
weaning from tracheal intubation
269
270
Assessment of sleepiness in obstructive sleep apnoea?
Epworth Sleepiness Scale - questionnaire completed by patient +/- partner
Multiple Sleep Latency Test (MSLT) - measures the time to fall asleep in a dark room (using EEG criteria)
271
monitoring of which marker determines response of pts w pneumonia to treatment?
CRP
272
diagnosis of occupational asthma?
Serial measurements of peak expiratory flow are recommended at work and away from work.
273
Indications for steroid treatment in sarcoidosis?
patients with CXR stage 2 or 3 disease who have moderate to severe or progressive symptoms.
hypercalcaemia
eye, heart or neuro involvement
274
what disease marker might have a role in monitoring disease activity of sarcoidosis?
ACE levels
275
CXR of sarcoidosis may show different stages?
stage 0 = normal
stage 1 = bilateral hilar lymphadenopathy (BHL)
stage 2 = BHL + interstitial infiltrates
stage 3 = diffuse interstitial infiltrates only
stage 4 = diffuse fibrosis
276
Respiratory features of Cystic fibrosis?
recurrent infections
cough, wheeze
bronchiectasis
pneumothorax
haemoptysis
resp failure, cor pulmonale
277
GI features of cystic fibrosis?
Pancreatic insufficiency -\> diabetes, steatorrhoea
meconium ileus in neonates
gallstones
cirrhosis
278
diagnosis of cystic fibrosis?
sweat test \> 60 mmol/L of NaCl
Faecal elastase decreased: exocrine pancreatic dysfunction
279
Mx of resp features in cystic fibrosis?
postural drainage
bronchodilators
IV/PO abx for infective exacerbations/ prophylaxis
280
Mx of GI features of Cystic fibrosis?
pancreatic enzyme replacement
fat soluble vitamin replacement therapy
ursodeoxycholic acid tx if impaired liver fn
281
Which organisms cause chronic infection of lungs in Cystic fibrosis?
Pseudomonas aeruginosa (80%)
Burkholderia cepacia (3.5%)
282
what drugs are assoc with pulmonary fibrosis w long term use?
Bleomycin
amiodraone
bulsulfan
methotrexate
sulfasalazine
nitrofurantoin
283
Ix recommended in pts w suspected COPD?
post-bronchodilator spirometry to demonstrate airflow obstruction: FEV1/FVC ratio \< 70%
CXR: hyperinflation, bullae, flat hemidiaphragm. + exclude lung cancer
FBC: exclude secondary polycythaemia
BMI calculation
284
How to categorise COPD severity?
using FEV1
_Stage 1 Mild:_
Post bronchodilator FEV1/FVC: \<70%
FEV1 \>**80%** of predicted
_Stage 2 -Moderate:_
Post bronchodilator FEV1/FVC: \<70%
FEV1 **50-79%** of predicted
_Stage 3 - Severe:_
Post bronchodilator FEV1/FVC: \<70%
FEV1 **30-49%** of predicted
_Stage 4 - Very severe:_
Post bronchodilator FEV1/FVC: \<70%
FEV1 \<**30%** of predicted
285
Tx of aspergillus infection?
Amphotericin B
286
SEs of ethambutol?
optic neuritis
red green colour blindness
peripheral neuropathy
vertical nystagmus
287
Diagnosis of ARDS involve which criteria?
all four of:
1. Acute Onset
2. bilat infiltrates present on CXR
3. Pulm cap wedge pressure \< 19mmHg or lack of clinical congestive HF
4. refractory hypoxaemia with PaO2:FiO2\<200
288
most common organism causing infective exacerbations of COPD?
1. haemophilus influenzae
2/3: strep pneumo, moraxella
289
most common causes of bilateral hilar lymphadenopathy?
sarcoidosis and tuberculosis
290
what NIV is used mainly for T2RF and what is mainly used for T1RF?
T2RF: BiPAP
T1RF: CPAP
291
Features of Kartagener's Syndrome?
aka primary ciliary dyskinesia (immotile cilia)
dextrocardia or complete situs inversus
bronchiectasis
recurrent sinusitis
subfertility (secondary to diminished sperm motility and defective ciliary action in the fallopian tubes)
292
RFs for aspiration pneumonia?
Poor dental hygiene
Swallowing difficulties
Prolonged hospitalization or surgical procedures
Impaired consciousness
Impaired mucociliary clearance
293
Mx of post op atelectasis?
Chest physiotherapy with mobilisation and breathing exercises
294
most common organisms causing aspiration pneumonia?
Streptococcus pneumoniae
Staphylococcus aureus
Haemophilus influenzae
Pseudomonas aeruginosa
