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Respiratory Flashcards

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1
Q

What are the respiratory causes of clubbing?

A

Cancer - mesothelioma, bronchial
Chronic suppuration - bronchiectasis, CF, empyema, abscess
Fibrosis - IPF, TB

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2
Q

What are the cardiac causes of clubbing?

A

Atrial myxoma
Infective endocarditis
Congenital cyanotic heart disease

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3
Q

What are the GI causes of clubbing

A

Cirrhosis
Crohns/uC
Coeliac
Cancer

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4
Q

What are the miscellaneous causes of clubbing?

A

Idiopathic
Thyroid acropachy
Upper limb AVMs

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5
Q

What are the respiratory causes of cyanosis?

A

Hypoventilation - COPD, MSK
VQ mismatch - PE, AVM
Impaired gas diffusion - pulmonary oedema, fibrosing alveolitis

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6
Q

What are the cardiac causes of cyanosis?

A

Reduced output - HF, mitral stenosis
Congenital - Fallots, TGA
Vascular - Raynauds, DVT

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7
Q

Outline the CURB 65 score and interpret its results

A 
Confusion (AMTS less than 8)
Urea >7
Resp rate >30
BP <90/60
Age >65

0-1 - Home w. Abx
2 - Admit
3 or more - Consider ITU

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8
Q

What is the empirical antibiotic management for a mild CAP?

A

1st line; Amoxicillin 500mg TDS PO for 5 days

2nd line; Clarithromycin 500mg BD PO for 7 days

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9
Q

What is the empirical antibiotic management for a severe CAP?

A

Co-amox 1.2g TDS IV or Cefuroxime 1.5g TDS IV
AND
Clari 500mg BD IV for 7-10 days

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10
Q

How would you manage the three commonest atypical pneumonias?

A

Chlamydia - tetracycline
PCP - co-trimoxazole
Legionella - Clarithromycin + rifampicin

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11
Q

What is the antibiotic management of a mild and severe HAP?

A

Mild: Co-amox
Sev: Taz +-Vanc +- gent

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12
Q

What are some possible complications of a pneumonia?

A 
Respiratory failure
Hypotension
AF (usually resolves)
Pleural effusion
Empyema
Abscess
Sepsis
Jaundice
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13
Q

Define the following terms:

i) Sepsis
ii) Severe sepsis
iii) Septic shock

A

i) SIRS caused by infection
ii) Sepsis with at least 1 organ dysfunction
iii) Severe sepsis with refractory hypotension

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14
Q

Which organisms are commonly implicated in bronchiectasis?

A

H. influenzae
Pneumococcus
Pseudomonas
Staph

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15
Q

What are some causes of bronchiectasis?

A 
Idiopathic in 50%
Congenital - CF (upper lobes), Kartagener's
Post infectious
Hypogammaglobulinaemia
Obstruction (LNs, Ca, FB)
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16
Q

What are the clinical features of bronchiectasis?

A 
Purulent cough +- haemoptysis
Weight loss
Fever
Clubbing
Coarse creps
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17
Q

What are the Xray findings in bronchiectasis?

A

Thickened bronchial walls (tramlines and rings)

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18
Q

What other imaging technique might be used for bronchiectasis?

A

High Res CT

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19
Q

What is the management regime for bronchiectasis?

A

Chest physio
Abx for flare ups
Bronchodilators
specifics

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20
Q

What is the pathogenesis of cystic fibrosis?

A

CFTR gene mutation results in reduced luminal Cl and increased Na reabsorption leading to excessively viscous secretions

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21
Q

What are the clinical features of CF?

A

Resp: cough, wheeze, bronchiectasis, infections, haemoptysis, cor pulmonale

GI: Pancreatic insufficiency, GI obstructions, gallstones, cirrhosis
Other: nasal polyps, infertility, osteoporosis

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22
Q

What are some diagnostic tests for CF?

A

Sweat test: Na and Cl >60
Faecal elastase
Genetic screening
Immunoreactive trypsinogen (neonatal)

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23
Q

What is the management of CF?

A 
As for bronchiectasis +
Pancreatic enzyme replacement
ADEK supplements
Insulin
Ursodeoxycholic acid (stimulates bile secretion)
DEXA scanning
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24
Q

What is allergic bronchopulmonary aspergillosis (ABPA)?

A

A hypersensitivity reaction to A. fumigatus, causing bronchoconstriction and eventually bronchiectasis

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25
What are the investigation findings of ABPA?
CXR - bronchiectasis Aspergillus in sputum Aspergillus skin test Raised IgE and eosinophils
26
What are the features and Xray findings of an aspergilloma?
Commonly silent, haemoptysis, lethargy, weight loss | Well defined, round opacity in apical zone
27
What are some key differences between small cell and non-small cell lung cancers (SCC, adeno, large cell)?
Site - SCLC and SCC central, adeno are peripheral Smoking - All are associated with smoking except for adenocarcinomas Adenocarcinomas are common in non smoking asian women SCC causes paraneoplastic hypercalcaemia SCLC is very chemosensitive but has a poor prognosis due to late presentation
28
What are the complications of lung cancer?
Local, paraneoplastic, metastatic Local - Laryngeal nerve palsy, Horners, SVC obstruction, AF Paraneo - ADH (SIADH), ACTH (Cushings), Serotonin (Carcinoid), PTHrP (SCC only) Metastatic - Pathological fractures, liver failure, neuro, Addison's
29
What investigations would you do for a suspected lung cancer?
Bloods - FBC, LFT, Ca2+, U&E Cytology - sputum, pleural fluid Imaging CXR - coin lesion, hilar enlargement, collapse, effusion CT contrast for staging PET - distant mets Biopsy - pFNA, bronchoscopy, mediastinoscopy Lung function tests
30
What are the differentials for a coin lesion on CXR?
FANGS ``` Foreign body Abscess - aspergilloma, klebsiella, TB, staph Neoplasm Granuloma - TB, sarcoid, Wegener's, RA Structural - AVM ```
31
Which stands better chance of being cured, SCLC or NSCLC?
NSCLC (SC=slim chances)
32
What are the clinical features of ARDS?
Tachypnoea Cyanosis Bilateral fine creps SIRS (Tx, tachycardia, tachypnoea, raised WCC)
33
What are the Xray findings of ARDS?
Bilateral perihilar infilatrates
34
Does ARDS have a sudden or insidious onset?
Sudden
35
How would you manage ARDS?
``` Ventilation support Invasive BP monitoring Inotropes Abx if septic TPN ```
36
What are the differential diagnoses of pulmonary oedema?
Transudates vs exudates Transudates Increased capillary hydrostatic pressure - CCF, fluid overload, renal failure Reduced capillary oncotic pressure - liver failure, nephrotic syndrome, malnutrition, protein losing enteropathy Increased interstitial pressure - blocked lymphatic drainage Exudates ARDS
37
Define type 1 and type 2 respiratory failure
Type 1 - Hypoxia only | Type 2 - Hypoxia and hypercapnoea
38
What are the mechanisms for oxygen delivery and how much do they deliver/
Nasal cannulae - 1-4 L Simple facemask Venturi mask - 5-60% depending on colour Non-rebreathe - up to 100%
39
What might you find on examination of an asthmatic patient?
Inspection: paraphernalia, may be cushingoid, oral thrush Chest: Harrison's sulcus, usually normal auscultation or wheeze Sig Negatives: CO2 retention, cor pulmonale, clubbing
40
What are some important history questions to ask an asthmatic?
``` Symptoms Diurnal variation Limitations Exacerbations Control (Med use and Hosp admissions) ```
41
What investigations might you do in an asthmatic?
``` Bedside - PEFR Bloods - FBC (eosin), IgE, Aspergillus CXR - hyperinflation Spirometry - obstructive (Low FEV1 with Low FEV1:FVC ratio PEFR monitoring/diary ```
42
Define a severe asthma attack
``` Any one of: PEF 33-50% expected RR>25 HR >110 Incomplete sentences ```
43
Define a lifethreatening asthma attack
``` PEFR <33% exp SpO2 <92% or T2RF Cyanosis Hypotension Exhaustion or confusion Silent chest/poor effort Arrhythmias ```
44
What is the management of acute severe asthma?
1. Sit patient up 2. 100% O2 via non rebreathe mask 3. Nebulised salbutamol and ipratropium 4. Hydrocortisone IV or Pred PO or both 5. Write 'no sedation' on drug chart 6. If not improving, escalate to Aminophylline, switch nebs to IV, and inform ITU
45
What additional measures should be taken in the event of life threatening asthma?
1. Inform ITU 2. MgSO4 2g IV infusion over 20 mins 3. B2B salb nebs
46
What is the drug ladder for chronic asthma?
1. SABA PRN 2. Add LD Beclometasone inh 3. Add LABA (salmeterol) 4. Consider upping steroid dose if improvement but control still poor) 5. Trials of LTRA, theophylline, oral Beta agonist 5. Oral steroids (pred 5-10mg OD)
47
What is the pulmonary function picture of COPD?
FEV1 <80% | FEV1:FVC <0.70
48
What are the signs of COPD?
``` Tachypnoea Prolonged expiratory phase Hyperinflation Wheeze Early inspiratory crackles Cyanosis Cor pulmonale (Raised JVP, oedema, loud P2) ```
49
Pink puffers vs. Blue bloaters
Pink puffers in emphysema are breathless but not cyanosed, with normal/low PaCO2 Blue bloaters in chronic bronchitis are hypercapnic, thus rely on hypoxic drive
50
What are the complications of COPD?
``` Polycythaemia Acute (infective) exacerbations Pneumothorax Cor pulmonale Lung carcinoma ```
51
What is the general management approach of COPD?
Stop smoking Annual IFV One off pneumococcal vaccince Pulmonary rehab
52
What features might indicate that a patient is steroid responsive?
Any previous atopic diagnosis Eosinophilia Substantial variation in FEV1 over time Substantial diurnal variation in PEF
53
What is the medical management of COPD?
1. SABA or SAMA 2. (not steroid responsive) - LAMA + LABA 2. (steroid responsive) - LABA + ICS 3. Oral theophylline Prophylactic azithromycin in certain patients (Do LFT and ECG on commencement)
54
Which factors may improve survival in patients with stable COPD?
1. Smoking cessation 2. LTOT 3. Lung volume reduction surgery
55
What criteria must be filled for a COPD patient to be placed on LTOT?
pO2 <8 AND 1 of: i) Secondary polycythaemia ii) Peripheral oedema iii) Pulmonary hypertension
56
How would you manage an acute exacerbation of COPD?
O2: Sit up, 24% O2 Venturi aiming for 88-92%, aim for PaO2 >8 BronchoNebs: Air driven Salbutamol 5mg and Ipratropium 0.5mg Steroids: IV Hydrocortisone and PO prednisolone (>7 days) Abx: If evidence of infection then Doxy 200mg PO STAT then 100mg OD PO for 5 days NIV: BiPAP if pH<7.35 and or RR>30
57
What are the ECG features of a PE?
``` Sinus rhythm Sinus tachy RBBB RV strain (T inversion in V1-4) S1Q3T3 ```
58
What are the components of Well's score/
``` Signs and symptoms of DVT PE is leading differential HR >100 Immobilised in 3 days or surgery in 4 weeks Hx of DVT or PE Haemoptysis Malignancy w. treatment within 6 months ```
59
How would you manage a confirmed PE?
Sit up, 100% O2 Morphine + metoclopramide if distressed If critically ill consider Alteplase 50mg bolus stat LMWH e.g. Enoxaparin 1.5mg/kg/24hr SC - till INR>2 Fluids/inotropic support if hypotensive
60
What are the clinical features of sarcoidosis?
GRANULOMAS General Fever, anorexia, wt loss, fatigue, lymphadenopathy Respiratory Upper - otitis, sinusitis Lower - Dry cough, SOB, chest pain, BHL, fibrosis Arthralgia Neuro Polyneuropathy (esp Bell's), meningitis, transverse myelitis, SOL Urine Stones, nephrocalcinosis, DI Low hormones Pituitary dysfunction Ophthalmological Uveitis, Sjogrens, keratoconjunctivitis Myocardial Restrictive cardiomyopathy, pericardial effusion Abdominal HSM Skin Erythema nodosum, Lupus pernio
61
What investigations (and findings) are relevant in sarcoidosis?
Bloods - raised ESR, hypercalcaemia, lymphopaenia, raised ACE, HyperIg, deranged LFTs CXR, CT, MRI PFT - Restrictive pattern with reduced transfer factor Biopsy - non-caseating granulomata
62
What is the management of acute and chronic sarcoidosis?
Acute: NSAIDs and bed rest Chronic: Steroids +- additional immunosuppression
63
What are the differentials for BHL?
Sarcoid TB Lymphoma Interstitial lung disease (EAA)
64
What are the differentials for granulomatous disease?
``` Infection: TB, syphillis Autoimmune: PBC Vasculitic: GCA, PAN, GwP Idiopathic: Crohns, Sarcoid Interstitial disease: EAA ```
65
What are the iatrogenic causes of interstitial lung disease?
BANS ME ``` Bleomycin Amiodarone Nitrofurantoin Sulfasalazine MEthotrexate ```
66
How might you categorise the causes of interstitial lung disease?
By location ``` Upper zone = A PENT Aspergillosis Pneumoconiosis EAA Negative seroarthropathy TB ``` ``` Lower zone = STAIR Sarcoid Toxins (drugs) Asbestosis IPF Rheum (lots) ```
67
What is the pathophysiology of extrinsic allergic alveolitis?
Acute allergen exposure in sensitised patients causes T3HS reaction. Chronic exposure leads to granuloma formation and obliterative bronchitis
68
Give three causes of EAA
Bird fancier's lung Farmer's lung Malt worker's lung
69
What are the clinical features of EAA?
Acute: Fever, rigors, malaise, dry cough, dyspnoea, crackles Chronic: Dyspnoea, weight loss, T1RF, cor pulmonale
70
What are the features of IPF?
Dry cough, dyspnoea, arthralgia, malaise, OSA, cyanosis, fei crackles, clubbing
71
What are the complications of IPF?
Lung cancer risk | T2RF and cor pulmonale
72
What are the CXR findings in IPF?
Reduced lung volume Bilateral lower zone reticulonodular shadowing Honeycomb lung
73
What are some causes of pulmonary hypertension?
Left heart disease - MS, MR, LVF Parenchymal lung disease - COPD, asthma, CF, bronchiectasis Pulmonary vascular disease - Idiopathic pulmonary hypertension, vasculitis, PE, portal HTN Hypoventilation - OSA, obesity, thoracic cage abnormalities, neuromuscular disease
74
What is cor pulmonale?
Right heart failure secondary to chronic pulmonary hypertension
75
What are the signs seen in cor pulmonale?
``` Raised JVP Left parasternal heave Loud P2 +- S3 Murmurs - Pulm Regurg, Tric Regurg Pulsatile hepatosplenomegaly Fluid - ascites, oedema ```
76
What are the investigations and findings relevant to cor pulmonale?
``` Bloods ABG - T2RF CXR - enlarged right side of heart with prominent pulmonary vessels ECG - p pulmonale + RVH Echo - RVH, TR Spirometry Right heart catheterisation ```
77
How would you manage cor pulmonale?
Treat the underlying condition Options to reduce pulmonary vascular resistance include LTOT, Ca channel blockers, Sildenafil, prostacyclin analogues HF management is ACEi + beta blocker + diuretics
78
Which two medications can be offered to aid smoking cessation and how do they work?
Varenicline - selective partial nicotine receptor agonist Bupropion - SNRI
79
What scars might indicate pneumo/lobectomy?
Clamshell= double lung transplant | Lateral thoracotomy = lobe/pneumonectomy
80
What might explain a lobectomy scar but normal lungs?
Thoracotomy - abscess, empyema, biopsy Transplant
81
What are some indications for lobe/pneumonectomy?
90% for non-disemminated bronchial carcinoma Bronchiectasis COPD TB
82
What are the complications of old TB?
Aspergilloma Bronchiectasis (LN compression or traction from fibrosis) Scarring -> bronchial Ca
83
What are the side effects of the 4 TB medications?
Rifampicin - Orange secretions, hepatitis, enzyme induction Isoniazid - peripheral sensory neuropathy Pyrazinamide - Hepatitis, arthralgia Ethambutol - Optic neuritis
84
How might you diagnose latent and active TB?
Latent: Tuberculin skin test/IGRA Active: CXR, 3x positive sputum cultures, L-J culture

Scott's Notes (21 decks)

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