Respiratory Flashcards
(114 cards)
1
Q
3 key features of asthma?
A
- airflow limitation which is reversible
- airway hyper-responsiveness to a wide range of stimuli
- inflammation of the bronchi
2
Q
symptoms of asthma
A
cough often worse at night
dyspnoea
wheeze
chest tightness
3
Q
signs on spirometry of asthma
A
FEV1 significantly reduced
FVC normal
therefore FEV1/FVC <70%
shows bronchoconstriction
4
Q
Mx of asthma
A
SABA e.g. salbutamol
SABA + ICS e.g. budenoside 400mcg OD or beclomethasone
SABA + ICS + LTRA (leukotriene receptor antagonist) e.g. Montelukast
SABA + ICS + LABA e.g. salmeterol (can continue LTRA)
SABA +/- LTRA + MART (maintenance and reliever therapy- contains low dose ICS and LABA)
Trial of long-acting muscarinic antagonist or theophylline
increase ICS
5
Q
SEs of ICS?
A
oral candidiasis and stunted growth in children
6
Q
when should children with asthma be given a paediatric ICS?
A
Not controlled with SABA
OR
Newly-diagnosed asthma with symptoms >= 3 / week or night-time waking
7
Q
what are the steps after SABA + pICS for childhood asthma?
A
- add leukotriene receptor antagonist
- then stop LTRA and add LABA (different to adult guidance)
- SABA + MART
8
Q
What is MART
A
a form of combined ICS and LABA
used for both daily maintenance therapy and the relief of symptoms as required
9
Q
signs of life-threatening of acute asthma?
A
PEFR <33% O2 sats <92% Silent chest, cyanosis or feeble respiratory effort bradycardia, dysrhythmia, hypotension exhaustion, confusion, coma
10
Q
signs of severe acute asthma?
A
PEFR 33-50%
Can’t complete sentences
RR >25/min
Pulse >110 bpm
11
Q
mx of acute severe asthma?
A
salbutamol nebs prednisolone or IV hydrocortisone magnesium sulphate 1.2-2g IV over 20 mins IV aminophylline IV salbutamol
12
Q
causes of COPD?
A
Smoking
alpha-1 antitrypsin deficiency
13
Q
causes of IECOPD?
A
H.influenza
Strep pneumoniae
Moraxella catarrhalis
14
Q
features of COPD?
A
Cough: often production
dyspnoea
wheeze
Right heart failure
15
Q
Ix of COPD?
A
airflow obstruction- FEV1/FVC ratio <70%
CXR
FBC-exclude polycythaemia
16
Q
FEV1 severity of COPD?
A
>80%= stage 1- mild 50-79%= stage 2- moderate 30-49%= stage 3- severe <30%= stage 4- very severe
17
Q
general management of COPD?
A
stop smoking
annual influenza vaccination
one-off pneumococcal vaccine
pulmonary rehab
18
Q
drug management of COPD
A
- SABA or SAMA is first line
- if not steroid responsiveness- LAMA (tiotropium)+ LABA
- if steroid responsiveness- LABA (salmeterol) + ICS (beclomethasone 200mcg BD)
- Consider adding theophylline
others- azithromycin (oral prophylactic antibiotic therapy), mucolytics
19
Q
who shouldn’t you offer LTOT for COPD?
A
If people continue to smoke
20
Q
who should get LTOT?
A
Long-term O2 therapy- >15 hours a day. Used in patients with pO2 <7.3kPa or 7.3-8kPa and one of:
- very severe airflow obstruction (FEV1 <30%)
- cyanosis
- polycythaemia
- peripheral oedema
- raised JVP
- O2 sats <92%
21
Q
What is a well’s score?
A
Shows likelihood of DVT
Active cancer (treatment ongoing, within 6 months, or palliative)
- Paralysis, paresis or recent plaster immobilisation of the lower extremities
- Recently bedridden for 3 days or more or major surgery within 12 weeks requiring general or regional anaesthesia
- Localised tenderness along the distribution of the deep venous system
- Entire leg swollen
- Calf swelling at least 3 cm larger than asymptomatic side
- Pitting oedema confined to the symptomatic leg
- Collateral superficial veins (non-varicose)
- Previously documented DVT (-2)
> 2= DVT likely
1 or less= unlikely
An alternative diagnosis is at least as likely as DVT
22
Q
what to do if DVT is likely?
A
proximal leg vein USS
if negative-> D-dimer
23
Q
what to do if DVT unlikely?
A
D-dimer
if positive -> arrange USS asap
if can’t do USS in 4 hours -> LMWH
24
Q
Mx of DVT?
A
LMWH or fondaparinux- continued until INR >2 for at least 24 hours
Give a vitamin K antagonist i.e. warfarin for 3 months
At 3 months clinicians should assess the risks and benefits of extending treatment.
If unprovoked DVT- full physical examination, CXR, bloods (FBC, serum calcium, LFTs) and urinalysis
25
what needs doing in patients over 40 with first unprovoked DVT/PE?
investigate for malignancy with abdo-pelvic CT scan
26
features of PE?
```
Chest pain (pleuritic)
dyspnoea
haemoptysis
tachycardia
tachypnoea
```
27
mx of PE?
Same as DVT
thrombolysis if massive PE where there is circulatory behaviour
IVC filters if repeat PE
28
causes of upper zone fibrosis
```
CHARTS
Coal worker's pneumoconiosis
Hypersensitivity pneumonitis
Ankylosing spondylitis
Radiation
TB
Silicosis/sarcoidosis
```
29
diagnosis of lung fibrosis
restrictive picture: FEV1 normal/decreased, FVC decreased, FEV1/FVC increased
CXR- ground-glass appearance, progresses to opacities
CT-diagnostic
30
what is coal-workers' pneumoconiosis?
caused by long term exposure to coal dust particles, can be a long lead time 1st exposure and development of disease
caused by accumulation of macrophages in the alveoli which starts an immune response, causing damage to the lung tissue
31
what can coal-workers' pneumoconiosis lead to?
Simple pneumoconiosis- opacities in lungs, can be asymptomatic
Progressive massive fibrosis- dust exposure causes patients to develop round fibrotic masses which can be several cms. Symptomatic with SOB, cough, black sputum
32
What are the effects of asbestos on the lung?
1. pleural plaques
2. pleural thickening
3. asbestosis- lower lobe fibrosis
4. mesothelioma- malignant disease of the pleura
5. lung cancer
33
which type of lung cancer has the worst prognosis?
SCLC
34
What are the main types of non small cell LC?
squamous (35%)
adenocarcinoma (30%)
large cell (10%)
35
features of SCLC?
Arises from APUD cells
Associated with ectopic ADH, ACTH secretion
ADH-> hyponatraemia
ACTH -> cushing's syndrome, bilateral adrenal hyperplasia
Lambert-Eaton syndrome: antibodies to voltage gated calcium channels causing myasthenic like syndrome
36
mx of SCLC?
usually mets at time of diagnosis
surgery
chemoradiotherapy
37
features of NSCLC?
SCC-
typically central, associated with PTHrP secretion -> hypercalcaemia + finger clubbing
HPOA- hypertrophic pulmonary osteoarthropathy
Adenocarcinoma-
typically peripheral
most common type in non-smokers, can cause HPOA and gynaecomastia
large cell- typically peripheral, poorly differentiated tumours with a poor prognosis, may secrete bHCG
38
mx of NSCLC?
Only 20% suitable for surgery
| curative or palliative radiotherapy
39
2 week wait criteria for lung cancer
```
CXR features that suggest lung cancer
over 40 with unexplained haemoptysis
over 40 with 2 of the following:
- cough
- fatigue
- SOB
-chest pain
- weight loss
- appetite loss
```
Consider if over 40 and persistent chest infections, clubbing, supraclavicular lymphadenopathy, thrombocytosis
40
what is bronchiectasis?
a permanent dilatation of the airways secondary to chronic infection or inflammation
41
causes of bronchiectasis?
post-infective- TB, measles, pertussis, pneumonia
CF
Bronchial obstruction
Immune deficiency- selective IgA, hypogammaglobulinaemia
ABPA
42
What is a transudate and exudate?
```
transudate= <30g/L of protein
exudate= >30g/L of protein
```
43
causes of transudate pleural effusion?
heart failure
hypoalbuminaemia (liver disease, nephrotic syndrome, malabsorption)
Meig's syndrome
44
causes or exudate pleural effusion?
```
Infection e.g. pneumonia. TB subphrenic abscess
connective tissue disease- RA, SLE
neoplastic
pancreatitis
PE
Dressler's syndrome
yellow nail syndrome
```
45
features of pleural effusion?
dyspnoea
| non-productive cough or chest pain
46
Ix of pleural effusion?
CXR
Pleural aspiration- USS guided
contrast CT
47
How to distinguish between transudate and exudate pleural effusion?
Light's criteria if the protein level is between 25-35g/L
an exudate is likely if at least one of the following criteria are met:
- pleural fluid protein/ serum protein >0.5
- pleural fluid LDH/ serum LDH >0.6
- pleural fluid LDH more than 2/3 the upper limits of normal serum LDH
48
what diagnosis is likely if pleural effusion has blood staining?
Mespthelioma
PE
TB
49
what diagnosis is likely if pleural effusion is purulent or turbid/cloudy?
infection (needs chest drain)
50
how to manage a recurring pleural effusion?
recurrent aspiration
pleurodesis
indwelling pleural catheter
opioids to relieve dyspnoea
51
what is sarcoidosis?
a multisystem disorder of unknown aetiology characterised by non-caseating granuloma
52
RFs of sarcoidosis?
young adults
| African descent
53
features of sarcoidosis?
Acute- erythema nodosum, bilateral hilar lymphadenopathy, swinging fever, polyarthralgia
Insidious- dyspnoea, non-productive cough, malaise, weight loss
Skin- lupus pernio
Hypercalcaemia
54
Ix of sarcoidosis
```
clinical Dx
ACE levels- 60% sensitive and 70% specific
high calcium, high ESR
CXR
Spirometry- restrictive defect
tissue biopsy- non-caseating granuloma
```
55
mx of sarcoidosis?
steroids if CXR stage 2 or 3, hypercalcaemia, eye, heart or neuro involvement
56
common organisms for aspiration pneumonia?
Streptococcus pneumoniae
staph aureus
H. influenzae
pseudomonas aeruginosa
57
Common organisms causing pneumonia?
Streptococcus pneumoniae
H.influenzae (esp if COPD)
Staph aureus
Mycoplasma pneumoniae- atypical pneumonia- presents as dry cough and atypical chest signs/CXR
Legionella pneumophilia- secondary to air conditioning units. Hyponatraemia and lymphopenia common
Klebsiella pneumoniae
PCP- HIV patients
58
how does PCP present
HIV patients
| dry cough, exercise-induced desaturations and the absence of chest signs
59
S+S of pneumonia?
cough, sputum, dyspnoea, chest pain, fever
reduced breath sounds, bronchial breathing
reduced O2 sats
60
Ix for pneumonia?
```
CXR
Bloods- FBC, U&Es, CRP
ABG
Blood and sputum cultures
Pneumococcal and legionella urinary antigen tests
```
61
how are patients assessed for pneumonia?
```
CURB65
Confusion (AMT <8)
Urea (>7mmol/L)
Resp rate >30/min
Blood pressure: SBP <90 or DBP <60
65 years plus
```
0- manage in community
1- SaO2 assessed which should be >92% to be safely managed in the community and CXR performed
2- manage in hospital
62
mx of low severity CAP?
Amoxicillin- 5 days
| if allergic macrolide or tetracycline
63
mx of moderate and high severity CAP?
Dual abx therapy with amoxicillin and a macrolide -7-10 day course
if high severity- use co-amoxiclav instead
64
what is FEV1?
volume of air exhaled in 1 second
65
what is FVC?
Maximum volume of air a person can exhale
66
What spirometry readings does thoracic kyphosis produce?
restrictive disease
| means air can leave the lungs quickly but due to poor lung expansion FVC is low so ratio is higher
67
what is TLCO?
Total gas transfer
an overall measure of gas transfer for the lungs from the alveoli into the capillaries and reflects how much O2 is taken up into the red cells
68
what medications are given to help smoking cessation?
nicotine replacement therapy
varenicline- nicotine receptor partial agonist (start 1 week before stop date)
bupropion- NA and DA reuptake inhibitors
target stop date needed
69
SEs of NRT?
n&v, headaches, flu-like symptoms
70
SEs of varenicline?
nausea, headaches, insomnia, abnormal dreams
| CI- pregnancy and breast feeding
71
SEs of bupropion?
risk of seizures
| CI- epilepsy, pregnancy and breast feeding
72
S&S of pneumothorax?
```
dyspnoea
chest pain: often pleuritic
sweating
tachypnoea
tachycardia
```
73
what is a tension pneumothorax?
lung parenchymal flap is formed following trauma
| trachea shift and hyper-resonance on affected side
74
tx of tension pneumothorax?
needle decompression and chest tube
75
mx of pneumothorax?
if the rim of air is <2cm and the patient is not SOB -> discharge
otherwise, aspiration
chest drain if not successful
76
RFs for pneumothorax?
pre-existing lung disease
connective tissue disease- marfan's, RA
ventilation
catamenial pneumothorax (spontaneous in menstruating women)
77
what meds to give in hospital acquired pneumonia of <5 days?
co-amoxiclav or cefuroxime
78
what meds to give in hospital acquired pneumonia of >5 days?
piperacillin with tazobactam or broad spec cephalosporin e.g. ceftazidime
79
what is ARDS?
Acute respiratory distress syndrome (ARDS) is caused by the increased permeability of alveolar capillaries leading to fluid accumulation in the alveoli, i.e. non-cardiogenic pulmonary oedema
80
causes of ARDS?
```
infection: sepsis, pneumonia
massive blood transfusion
trauma
smoke inhalation
acute pancreatitis
cardio-pulmonary bypass
```
81
features of ARDS?
dyspnoea
elevated respiratory rate
bilateral lung crackles
low oxygen saturations
82
Ix of ARDS?
CXR
| ABG
83
mx of ARDS?
due to the severity of the condition patients are generally managed in ITU
oxygenation/ventilation to treat the hypoxaemia
general organ support e.g. vasopressors as needed
treatment of the underlying cause e.g. antibiotics for sepsis
certain strategies such as prone positioning and muscle relaxation have been shown to improve outcome in ARDS
84
What are the 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
85
what is tidal volume?
volume inspired or expired with each breath at rest
| 500ml in males, 350ml in females
86
causes of respiratory acidosis?
COPD
decompensation in other respiratory conditions e.g. life-threatening asthma / pulmonary oedema
neuromuscular disease
obesity hypoventilation syndrome
sedative drugs: benzodiazepines, opiate overdose
87
causes of respiratory alkalosis?
```
anxiety leading to hyperventilation
pulmonary embolism
salicylate poisoning*
CNS disorders: stroke, subarachnoid haemorrhage, encephalitis
altitude
pregnancy
```
88
criteria for steroid-responsiveness in COPD (asthmatic features)
prev diagnosis of asthma
higher blood eosinophil count
sustainable variation in FEV1 over time
substantial diurnal variation in peak expiratory flow (at least 20%)
89
what type of asbestos is the most serious form?
crocidolite (blue)
90
what is mesothelioma and symptoms?
malignant disease of the pleura
- progressive SOB
- chest pain
- pleural effusion
91
mx of mesothelioma?
palliative chemo
92
review areas in a CXR?
behind the heart
under diaphragm
apices
costophrenic angles
93
predisposing factors for pneumothorax?
```
COPD
asthma
pulmonary fibrosis
cystic fibrosis
trauma
iatrogenic- central venous line obstruction, mechanical ventilation
```
94
description of pulmonary fibrosis on CXR?
diffuse reticulonodular shadowing
95
causes of upper lobe fibrosis?
```
BREAST
Berylliosis
Radiation fibrosis
EAA
AS
Sarcoidosis
TB
```
96
causes of lower lobe fibrosis?
connective tissue disease
asbestosis
cryptogenic fibrosing alveolitis
drug-induced- amiodarone, methotrexate
97
causes of unilateral pleural effusions?
```
malignant tumours
parapneumonic
PE
infarction
rheumatoid disease
```
98
3 most common causes of left lower lobe collapse (sail sign)
1. central hilar or endobronchial mass
2. endobronchial foreign body esp children
3. endobronchial mucus plug e.g. asthma
Ix= bronchoscopy and CT thorax
99
scenario: acute on chronic SOB in a young person?
cystic fibrosis with new pneumothorax
100
what does pulmonary oedema look like on CXR?
bat wing sign
101
causes of pulmonary oedema with and without cardiomegaly?
with CM- HF
| without CM- acute renal failure, ARDS, after aggressive fluid resuscitation, massive acute PE, SAH
102
differentials for a large globular heart and what to ask about in history?
congenital cardiac disease
cardiomyopathy
pericardial effusion
(ask about childhood illness and FH cardiac disease)
103
signs of mitral valve disease on CXR?
moderately enlarged heart
prominence of left atrial appendage
double RHB- enlargement of left atrium
104
causes of clubbing?
resp- pulmonary fibrosis, LC, abscess, bronchiectasis, CF
cardio- IE, cyanotic heart diseases
GI- IBD, coeliac, cirrhosis
thyroid- hyperthyroidism
105
causes of interstitial lung disease?
occupational- asbestosis, sarcoidosis, coal dust, birds, hay, fungus
meds- radiation, methotrexate, amiodarone, nitrofurantoin
idiopathic pulmonary fibrosis
connective tissue disease- RA, systemic sclerosis, AS, dermatomyositis/polymyositis
others but learn these main ones!
106
differential diagnosis of unilateral hilar enlargement vs bilateral hilar enlargement?
```
Unilateral:
bronchial carcinoma
TB
lymphoma
metastatic mediastinal lymph node disease
```
```
Bilateral:
Sarcoidosis
Lymphoma
Pulmonary hypertension
Metastatic nodal disease
```
107
differential for a cavitating lung lesion?
```
bronchial carcinoma
TB
cavitating pneumonia
lung abscess
rheumatoid nodule
vasculitic disease e.g. Wegener's granulomatosis
```
108
signs of left upper lobe collapse on CXR?
volume loss of left hemithorax (lung) with veil sign (opacification over whole lung)
may have increased density indicating a mass around the left hilum
trachea and mediastinum may be deviated to the left
109
if there is lobe collapse, is the trachea deviated towards or away?
towards
110
If there is a 'white-out' of a hemithorax it is useful to assess the position of the trachea - what does central, pushed or pulled tell you?
1. Towards- Pneumonectomy, complete lung collapse e.g. endobronchial intubation, Pulmonary hypoplasia
2. Central- Consolidation, Pulmonary oedema (usually bilateral), Mesothelioma
3. Away- Pleural effusion, Diaphragmatic hernia, Large thoracic mass
111
differentials for an anterior mediastinal mass?
trachea deviated away
thyroid enlargement, thymoma, teratoma, lymphoma
CT- guided biopsy
112
what cancer can causes cannon-ball mets in a CXR?
renal cell carcinoma
others inc testicular malignancy and choriocarcinoma
do CT chest, abdo, pelvis
113
if the R heart border is not visible, what lobe is affected?
right middle lobe
114
what follow up to do after a lobar pneumonia?
CXR 6 weeks after Abx treatment
| could be an underlying carcinoma
