Respiratory Flashcards

Question

Cor pulmonale Definition Pathophysiology

Answer 1

Changes in the cardiovascular system resulting from the chronic hypoxia (and usually hypercapnia) of chronic lung disease, mainly PHT and fluid retention. Results from following sequence: - Lung disease causes hypoxia, cyanosis, and sometimes polycythaemia - Hypoxia is sensed both within the kidney and via the carotid body, generating increases in sympathetic activity and renal vasoconstriction - Increased sympathetic activity (and other mechanisms) leads to renal retention of salt and water - This extra salt and water is mainly held in the capacitance vessels (the large veins), often with a raised JVP - If vascular permeability rises (particularly when the PaCO2 rises, producing peripheral vasodilatation and an increase in capillary pressure), extra fluid accumulates in dependent tissues, mainly the ankles - A raised JVP and ankle oedema in this setting are NOT due to impaired RV function, but to fluid overload and increased vascular permeability.

Answer 2

Clinical features - The underlying disease causing the hypoxia, e.g. COPD/bronchiectasis - Easily visible veins and a raised JVP - Cyanosis and a suffused conjunctiva (polycythaemia and vessel dilatation from the raised CO2) - Sometimes marked polycythaemia, very rare consequences - Peripheral vasodilatation, with a ‘bounding’ pulse and warm peripheries - Ankle swelling and pitting oedema - RV hypertrophy (sternal heave uncommon, masked by hyperinflated lung between heart and chest wall; more often seen with the higher pressures of IPAH - Tricuspid incompetence (not usually severe) Investigations - CXR—enlarged pulmonary arteries/underlying lung disease - FBC—may have polycythaemia - Oximetry—cor pulmonale is unlikely if awake SaO2 >92% - Blood gases—cor pulmonale progressively more likely as PaO2 drops below 8kPa (equivalent SaO2 ≈ 91%) and PaCO2 rises above 6kPa - ECG—may indicate right axis deviation (RAD), p pulmonale (right atrial hypertrophy), and right bundle branch block (RBBB) - Echo—dilated or hypertrophied RV, tricuspid regurgitation (TR), providing estimate of PAP, and exclude other diagnoses such as a patent ASD • Overnight oximetry—to reveal unexpected degrees of hypoxia, e.g. from OSA, obesity, neuromuscular disease.

Answer 3

URTI - Sinusitis - Tonsilitis LRTI - Bronchitis - Pneumonia - Empyema - Bronchiectasis - Lung abscess Causes: - Poor swallow (CVA, muscle weakness, alcohol) - Abnormal ciliary function (smoking, viral infection, Kartagener's) - Abnormal mucus (CF) - Dilated airways: bronchiectasis - Defects in host immunity (HIV, Immunosuppression)

Answer 4

Typical 1. Streptococcus pneumonia (30-50% of CAP - Gram +ve diplococci; alpha haemolysis; bile solubility - OVeR PS: Optochin Viridans Resistant, Pneumococci sensitive - Acute onset - severe, fever, rigours, lobar consolidation - Almost always penicillin sensitive - Urine antigen test available for severe CAP 2. Haemophilus Influenzae (15-35% of CAP) - gram -ve cocco-bacilli; beta lactamase producing; choc agar - Associated with COPD 3. Moraxella cattarrhalis - gram -ve coccus - associated with smoking 4. S.aureus - gram +ve cocci (clusters) - ?cavitation - associated with recent viral infection - i.e. flu 5. Klebsiella pneumonia - gram -ve rod - elderly; alcohol - haemopytsis +/- cavitation Atypical 1. Legionella pneumophilia - Choc agar - Aerosol spread - Dx = antigens in urine, antibody in serum - Associations: Diarrhoea, confusion, abdo pain (hepatitis), lymphopenia, hyponatraemia - Rx: Macrolides 2. Coxiella Burnetti (Q-fever - animal exposure) - Flu like illness --> hepatitis, pneumoniyis - Rx: Doxycycline 3. Chlamydia psitacci - Bird exposure - Associations: Splenomegaly, rash, haemolytic anaemia - Rx: Macrolides 4. Mycoplasma (epidemics every 4 yrs) - Systemic symptoms - Joint pain; eruythma multiforme - Cold agglutination test - AIHA, SJS risk

Answer 5

Inflammation of lung alveoli ``` Fever Cough SOB Pleuritic chest pain Tachycardia/pnoea Often localising signs - dullness to percussion; crackles abnormal CXR ``` CAP or HAP

Answer 6

>48h into hospital stay. Commonly gram -ve Need BAL 1st line: Ciprofloxacin + Vancomycin ITU/2nd line: Piptizobactam + Vancomycin Pseudomonas: Tazocin OR Ciprofloxacin + Gentamicin

Answer 7

1. Allergic bronchopulmonary aspergillosis - Chronic wheeze, eosiniphillia - Bronchiectasis - Recurrent pneumonia 2. Aspergilloma - Fungal ball often in pre-existing cavity - May cause haemoptysis - -> Infection, infarction, malignancy 3. Invasive aspergillosis - Immunocompromised - Rx: Amphotericin B

Answer 8

``` Confusion Urea >7 RR>/= 30 BP <90 S or 60 d 65 or over ``` 0-1 home rx 2 hospita; rx 3 or more severe - ?ITU Mild: Orla amoxicillin Mod: Oral/IV Amoxicillin + Clarithromycin Severe: IV Co-amoxiclav + Clarithromycin

Answer 9

LUNG - T1 resp failure - Pleural effusion - Empyema (pus in pleural space) - Lung abscess HEART - AF - Pericarditis, Myocarditis ?Other - Sepsis - Hypotension - Cholestatic jaundice - Brain abscess

Answer 10

Pathology 1) Chronic bronchitis: cough and sputum most days for 3 months of 2 consecutive years 2) Emphsema (histological diagnosis) = dilation of air spaces distal to terminal bronchioles with destruction of the alveoli ``` Symptoms • Dyspnoea • Chronic cough, may be productive • Decreased exercise tolerance • Wheeze • Weight loss and peripheral muscle weakness/wasting may occur ``` ``` Signs • Central cyanosis • Tachypnoea • Expiratory time >5s, with pursed lip • Hyperexpanded/barrel • Accessory muscle use • Intercostal indrawing • ?basal crepitations • Signs of cor pulmonale and CO2 retention (ankle oedema, raised JVP, warm peripheries, plethoric conjunctivae, bounding pulse, polycythaemia. Flapping tremor if CO2 acutely raised) ``` On palpation • Tachycardia • Tracheal tug • Reduced expansion On percussion • Hyper resonant lung fields On auscultation • Quiet breath sounds (esp. in lung apices)  wheeze • Possible basal crepitation • Quiet heart sounds (due to overlying inflated lungs) MRC dyspnoea scale (1-5) 1. Not troubled by breathlessness except on strenuous exercise 2. SOB when hurrying or walking up a slight hill 3. Walks slower than contemporaries on level ground because of breathlessness or has to stop for breath when walking at own pace 4. Stops for breath after walking about 100m or after a few mins on level ground 5. Too breathless to leave the house, or breathless when dressing or undressing

Answer 11

``` Spirometry: gold standard o FEV1/FVC of <0.7 confirms persistent airflow limitation and thus COPD Mild: FEV1>80% Mod: FEV1 50-79% Sev: 30-49% V sev: <30% ``` Other tests – helpful but not essential for diagnosis • Pulse oximetry • CXR: Classically hyperinflated lung fields, with flattened hemidiaphragms • FBC • Sputum culture (identify persistent organisms) • Alpha-1-antitrypsin level (consider in young pts) • ECG/Echo: may be useful in end-stage COPD with features of cor-pulmonale ``` Management Conservative - Stop smoking - Yearly influenza, 5-yearly pneumococcal - Improve nutrition/ activity ``` Pulmonary rehab - Essential outpatient team - strategies to help cope with SOB Medication 1) SABA (salbutamol) or SAMA (ipratropium) for symptoms 2) Add a LABA (salmeterol) + LAMA (tioptropium) 3) Change LABA to combined LABA + ICS ( seretide) If asthmatic features: 2) Is LABA + ICS 3) LABA + LAM +ICS - any previous, secure diagnosis of asthma or of atopy - a higher blood eosinophil count - note that NICE recommend a full blood count for all patients as part of the work-up - substantial variation in FEV1 over time (at least 400 ml) - substantial diurnal variation in peak expiratory flow (at least 20%) Oral medications • Theophylline • Carbocisteine (mucolytic) • Rescue pack antibiotics ``` LTOT (end stage) considerin - Non smokers - PaO2 <7.3 when stable - PaO2 7.3-8 with one of: 1_ Polycythaemia 2) Nocturnal hypoxaemia (<90%) 3) Peripheral oedema 4) Pulmonary HTN ```

Answer 12

1) Regular preventer = Low-dose ICS 2) Initial add on inhaled LABA to low dose ICS (fixed dose or MART) 3) Consider increasing ICS to medium dose or Adding LTRA. If no response to LABA consider stopping LABA 4) Specialist therapies NB: SABA as required from before step 1 (unless using MART) Step up If using 3 doses a week or more

Answer 13

``` breast cancer colorectal cancer renal cell cancer - most common bladder cancer prostate cancer ``` CT abdomen PSA

Answer 14

Pathogenesis dynein arm defect results in immotile cilia ``` Features dextrocardia or complete situs inversus bronchiectasis recurrent sinusitis subfertility (secondary to diminished sperm motility and defective ciliary action in the fallopian tubes) ``` Normally, the left testicle hangs lower than the right. However, patients with Kartageners syndrome it is reversed. This is due to the patient having situs inversus. Cystic fibrosis can also present similarly if they were not diagnosed at a young age. However, they would have other symptoms such as diabetes, diarrhoea and fat-soluble vitamin deficiencies. Although some antibiotics may impair sperm function and motility, there is nothing in the history to suggest he is currently taking them

Answer 15

``` Features Dyspnoea, weight loss, chest wall pain Clubbing 30% present as painless pleural effusion Only 20% have pre-existing asbestosis History of asbestos exposure in 85-90%, latent period of 30-40 years ``` Basics Malignancy of mesothelial cells of pleura Metastases to contralateral lung and peritoneum Right lung affected more often than left Investigation/diagnosis CXR: either a pleural effusion or pleural thickening the next step is normally a pleural CT if a pleural effusion is present fluid should be sent for MC&S, biochemistry and cytology (but cytology is only helpful in 20-30% of cases) Local anaesthetic thoracoscopy is increasingly used to investigate cytology negative exudative effusions as it has a high diagnostic yield (around 95%) = BEST If an area of pleural nodularity is seen on CT then an image-guided pleural biopsy may be used ``` Management Symptomatic Industrial compensation Chemotherapy, Surgery if operable Prognosis poor, median survival 12 month ```

Answer 16

Eosinophillia on bloods Previous diagnosis of asthma or atopy FEV1 varies over time (at least 400ml) Substantial diurnal variation in PEF (20%)

Answer 17

Features usually central arise from APUD* cells associated with ectopic ADH, ACTH secretion ADH → hyponatraemia ACTH → Cushing's syndrome ACTH secretion can cause bilateral adrenal hyperplasia, the high levels of cortisol can lead to hypokalaemic alkalosis Lambert-Eaton syndrome: antibodies to voltage gated calcium channels causing myasthenic like syndrome Management U sually metastatic disease by time of diagnosis patients with very early stage disease (T1-2a, N0, M0) are now considered for surgery. NICE support this approach in their 2011 guidelines However, most patients with limited disease receive a combination of chemotherapy and radiotherapy patients with more extensive disease are offered palliative chemotherapy

Answer 18

Refer people using a suspected cancer pathway referral (for an appointment within 2 weeks) for lung cancer if they: have chest x-ray findings that suggest lung cancer are aged 40 and over with unexplained haemoptysis ``` Offer an urgent chest x-ray (to be performed within 2 weeks) to assess for lung cancer in people aged 40 and over if they have 2 or more of the following unexplained symptoms, or if they have ever smoked and have 1 or more of the following unexplained symptoms: cough fatigue shortness of breath chest pain weight loss appetite loss ``` Consider an urgent chest x-ray (to be performed within 2 weeks) to assess for lung cancer in people aged 40 and over with any of the following: persistent or recurrent chest infection finger clubbing supraclavicular lymphadenopathy or persistent cervical lymphadenopathy chest signs consistent with lung cancer thrombocytosis

Answer 19

Eye, heart or neuro involvement Hypercalcaemia CXR stage 2 or 3 who are symptomatic

Answer 20

Clinical diagnosis but can be supported by any of: An exhaled FeNO of 40 parts per billion or greater A post-bronchodilator improvement in lung volume of 200 ml A post-bronchodilator improvement in FEV1 of 12% or more A peak expiratory flow rate variability of 20% or more An FEV1/FVC ratio <70% (it is an obstructive lung disease)

Answer 21

* Resuscitation with intravenous (IV) fluids and oxygen. * Intramuscular (IM) adrenaline 0.5 mL of 1:1000. * Chlorphenamine (an antihistamine) 10 mg IM or slow IV infusion. * Hydrocortisone 200 mg IM or slow IV infusion.

Answer 22

``` Amiodarone Methotrexate, Sulfasalazine Cytotoxic's: busulphan, bleomycin Nitrofurantoin Ergot-derived dopamine receptor agonists (bromocriptine, cabergoline, pergolide) ```

Answer 23

``` Rifampicin mechanism of action: inhibits bacterial DNA dependent RNA polymerase preventing transcription of DNA into mRNA - Potent liver enzyme inducer - Hepatitis - Orange secretions - fFu-like symptoms ``` ``` Isoniazid MOA inhibits mycolic acid synthesis - Peripheral neuropathy: prevent with pyridoxine (Vitamin B6) - Hepatitis - Agranulocytosis - Liver enzyme inhibitor ``` MOA: converted by pyrazinamidase into pyrazinoic acid which in turn inhibits fatty acid synthase (FAS) I - Hyperuricaemia causing gout - Arthralgia, myalgia - Hepatitis Ethambutol MOA: inhibits the enzyme arabinosyl transferase which polymerizes arabinose into arabinan - Optic neuritis: check visual acuity before and during treatment -Dose needs adjusting in patients with renal impairment

Respiratory Flashcards

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