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RW Year 6 > Respiratory > Flashcards

Respiratory Flashcards

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1
Q

Bilateral hilar lymphadenopathy

A

TB

Sarcoidosis

Lymphoma

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2
Q

Safe triangle borders

A

Anterior border of latissimus dorsi

Lateral border of pectoralis major

Line superior to horizontal level of nipple

Apex below axilla

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3
Q

X-ray changes in Heart Failure

A

ABCDE A – Alveolar oedema (Bat’s wing) B – Kerley B lines (interstitial oedema) C – Cardiomegaly D – Dilated upper lobe vessels (vessels in upper lobe appear bigger than in the lower lobe) E – Pleural effusion

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4
Q

DDx Consolidation

A

Pneumonia (alveoli with pus)

Malignancy (Alveolar cell carcinoma) (filled with cells)

Lymphoma (filled with lymph)

Pulmonary oedema (filled with fluid)

Pulmonary haemorrhage (filled with blood)

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5
Q

DDx Apical Fibrosis

A

(APENT)

Aspergillosis / ABPA

Pneumoconiosis (coal, silica)

Extrinsic allergic alveolitis

Negative sero-arthropathies (Ank Spond)

TB

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6
Q

DDx Basal Fibrosis

A

(STAIR)

Sarcoidosis (mid zone)

Toxins (BS NAME)

- Bleomycin, Bulsulfan, Amiodarone, Nitrofurantoin, Sulfaasalazine, Methotrexate

Asbestosis

Idiopathic pulmonary fibrosis

Rheum (Rheumatoid arthritis, SLE, SS, Sjogren’s, PM/DM)

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7
Q

T1RF vs T2RF (ABG findings, Pathogenesis, Aetiology, Tx)

A
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8
Q

Severity of Asthma

A
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9
Q

Definition of bronchodilator reversibility

A

Increase in FEV1 > 200ml or 12% of pre-test value

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10
Q

Diagnostic criteria for Asthma (in adults)

A

Symptomatic

AND

(1) +ve bronchodilator reversbility AND peak flow variability > 20%
(2) Based on FeNO levels AND (bronchodilator or peak flow variability)

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11
Q

Tx of acute asthma attack

A

Oxygen

Salbutamol (neb)

Hydrocortisone (IV)

Ipratropium Bromide (neb)

Magnesium Sulphate (IV)

Aminophylline (IV)

Ventilation

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12
Q

Long term Asthma treatment for Adults

A

(1) SABA
(2) SABA + ICS
(3) SABA + ICS + LTRA
(4) SABA + ICS + LABA
(5) SABA + MART (Low)
(6) SABA + MART (Moderate)
(7) Specialist

  • Muscarinic receptor antagonist
  • Theophylline
  • High dose ICS
  • Oral prednisolone
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13
Q

Spirometry: Obstructive vs Restrictive (FEV1, FVC, FEV1:FVC ratio)

A

Obstructive

  • ↓↓ FEV1 (<80% predicted)
  • ↓ FVC (but decreases by a lesser extent)
  • FEV1:FVC < 70% (predicted)

Restrictive

  • ↓ FEV1 (<80% predicted)
  • ↓ FVC (<80% predicted)
  • <-> FEV1:FVC ratio (>70%)
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14
Q

Definition of COPD

A

COPD = Chronic bronchitis + Emphysema

Characterised by progressively worsening irreversible airway obstruction (i.e. not fully reversible)

Chronic bronchitis = productive cough + mucus hypersecretion on most days for >3 months per year over consecutive years

Emphysema = permanent alveolar wall destruction, resulting in airway collapse and air trapping [histological diagnosis]

Small airways disease = fibrosis of the bronchiole (+ loss of alveolar attachments that hold airway open, not found in Asthma)

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15
Q

Diagnosis of COPD

A

Post-bronchodilator FEV1/FVC ratio < 0.70

(i.e. not reversible obstruction)

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16
Q

Staging system for COPD

A

GOLD staging system for COPD (based on FEV1)

Stage 1: > 80%

Stage 2: 50-80%

Stage 3: 30-50%

Stage 4: < 30%

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17
Q

Features of exacerbation of COPD

A

Triad = Increase in SOB, Sputum volume and sputum purulence

Signs of respiatory distress

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18
Q

Examination findings in COPD

A

Inspection: signs of respiratory distress, pursed lip breathing (increase PEEP)

Palpation: symmetrically reduced chest expansion, reduced cricosternal distance, apex beat not palpable

Percussion: Hyper-resonance

Auscultation: reduced breath sounds, wheeze, coarse crackes

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19
Q

Tx of acute exacerbation of COPD

A

OSHINIVA (Oxygen, Salbutamol, Hydrocortisone, Ipratropium, NIV, ABx)

Controlled oxygen

  • Via 28% Venturi mask

Nebuliser

  • Nebulised Salbutamol
  • or Nebulised Ipratropium

Steroids

  • Oral Prednisolone or IV Hydrocortisone

Non-invasive ventilation

  • BiPAP

+/- Antibiotics (if infective exacerbation)

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20
Q

Inhaler Tx of COPD

A

(1) 1 drug = SABA
(2) 2 drugs = SABA + (LABA or LAMA)
(3) 3 drugs = SABA + (LABA/ICS or LABA/LAMA)
(4) 4 drugs = SABA + LABA/LAMA/ICS

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21
Q

Long term Tx of COPD

A

Conservative

  • Smoking cessation
  • Pulmonary rehabilitation
  • Vaccination

Medical

  • Inhaler therapy
    • SABA
    • SAMA
    • LABA
    • LAMA
    • ICS
  • +/- Long term Oxygen therapy (LTOT)
  • +/- Mucolytics
  • Rescue pack
    • +/- Oral Antibiotics
    • +/- Oral corticosteroids

Surgical

  • Manage pneumothoraces
  • Bullectomy
  • Lung volume reduction surgery
  • Lung transplant
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22
Q

Bronchiectasis - causes

A

Post-infectious (most common)

Cystic fibrosis

alpha-1 antitypsin deficiency

Kartagener’s syndrome (bronchietasis, sinusitis, situs invertus)

Yellow-nail syndrome (bronchiectasis, yellow nails, pleural effusion)

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23
Q

Bronchiectasis - Sx

A

Productive cough with sputum

Fever

SOB

Wheeze

Coase crackles

Clubbing

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24
Q

Bronchiectasis - Ix (best)

A

HR-CT

  • Tramtrack sign / opacities
  • Signet ring sign
  • Dilated bronchi
  • Mucus plugs
  • Lung collapse
  • Fibrosis
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25
Bronchiectasis - Tx
* **Treat underlying cause** * **Diet and Exercise** * **Chest physiotherapy** * +/- Bronchodilators * +/- Inhaled mucolytics (inhaled hypertonic saline) * +/- Prophylactic antibiotics * +/- Surgery * +/- Resection of bronchiectatic areas * +/- Lung transplant
26
**Recurrent respiratory infections** **Steatorrhoea** **Pancreatitis** **Diabetes mellitus** **Infertility** **Clubbing** Diagnosis?
Cystic fibrosis
27
Ix for Cystic fibrosis
Guthrie test (newborn screening): measure serum immunoreactive trypsinogen (IRT) If +ve Guthrie test --\> Sweat test (measure Cl-) - HIGH in CF
28
Long term Tx of Cystic fibrosis
Respriatory disease * (1) Chest physiotherapy * +/- Bronchodilators * +/ Mucolytics * +/- ICS * +/- Prophylactic ABx * +/- CFTR modulator (Ivacaftor, Orkambi) * (2) Lung transplant GI disease * Dietary advice (HIGH fat, HIGH calorie) * Pancreatic enzyme replacements * Fat-soluble Vitamin supplements (A, D, E, K) * +/- Ursodeoxycholic acid (oral bile acids) * If GORD --\> Antacid +/- PPI +/- H2 antagonist
29
Drugs which cause pulmonary fibrosis
BSNAME * Bleomycin, Busulfan * Sulfasalazine * Nitrofurantoin * Amiodarone * MEthotrexate
30
Types of Pneumoconiosis
Asbestosis Silicosis Coalworker's pneumoconiosis Chornic beryllium disease
31
Characteristic CXR changes in pneumoconiosis
**Silicosis** * Egg shell calcification * Micro-nodular opacities (100s) (upper zones) **Coalworker's pneumoconiosis** * Micro-nodular opacities (100s) (upper zones) **Asbestosis** * Pleural thickening * Interstitial fibrosis (lower zones)
32
Tx of pneumoconiosis
(1) Pulmonary rehabilitation Smoking cessation +/- Oxygen Treat complications (COPD, Pneumonia, TB, Cor pulmonale) (2) Lung transplant
33
**Progressive SOB** **Dry cough** **Clubbing** **Bibasal fine inspiratory crackles** **No wheeze** Diagnosis?
Idiopathic pulmonary fibrosis
34
Ix for idiopathic pulmonary firbosis
* HR-CT (diagnostic) * Ground glass opacities * Honeycombing * Traction bronchiectasis * CXR: * Reticulonodular opacities * Spirometry: restrictive lung disease * low FEV1, low FVC, normal FEV1:FEVC ratio
35
Tx for idiopathic pulmonary fibrosis
Acute exacerbation * **High dose corticosteroids** Long term * Conservative * **Smoking cessation** * **Pulmonary rehabilitation** * Medical * (1) **Anti-fibrotic therapy** * **Pirfenidone** * **Nintedanib** * +/- Oxygen * Surgical * * (2) Lung transplant *
36
Organisms for pneumonia
37
Typical vs Atypical pneumonia organisms
38
**Fever** **Productive cough** **SOB** **Pleuritic chest pain** **Reduced chest expansion (unilateral)** **Dullness to percussion** **Increased breath sounds** **Coarse crepitations** Diagnosis?
Pneumonia
39
Most common cause of pneumonia
*Streptococcus pneumoniae*
40
Most common cause of pneumonia in smokers
Haemophilus influenza Moraxella catarrhalis
41
Most common cause of pneumonia in COPD
Haemophilus influenza Moraxella catarrhalis
42
Most common cause of pneumonia in Alcoholics
Klebsiella pneumoniae
43
Most common cause of pneumonia in IVDU
S aureus
44
Pneumonia and Erythema multiforme
Mycoplasma pneumoniae
45
Pneumonia and Water
Legionella pneumophila
46
Pneumonia and Hyponatraemia / Confusion
Legionella pneumophilia
47
Pneumonia and unsafe swallow
Anaerobes
48
Pneumonia with rusty coloured sputum
Streptococcus pneumoniae
49
Typical and atypical causes of pneumonia
50
CXR changes in pneumonia
Consolidation ====\> Lobar pneumonia - typical organisms ====\> Patchy shadowing (Bronchopneumonia) - atypical organisms +/- Air bronchograms +/- Cavitation (S aureus)
51
CURB-65 score
52
Empiral ABx in CAP
(1) **Amoxicillin** (2) If allergic --\> **Doxycycline** or Clarithromycin +/- Macrolide for atypical cover (Azithromycin, Clarithromycin, Erythromycin)
53
Empirical ABx for CAP
(1) Amoxicillin (2) If allergic --\> Doxycycline +/- Macrolide for atypical cover (Azithromycin, Clarithromycin, Erythromycin)
54
Empirical Abx for Atypical pneumonia
(1) Macrolides - Azithromycin - Clarithromycin - Erythromycin (2) Fluoroquinolone (Levofloxacin)
55
Empiral ABx for HAP
(1) CIprofloxacin +/- Vancomycin
56
Empirical ABx for MRSA
Vancomycin
57
Empiral ABx for Pseudomonas
Tazocin (Piperacillin and Tazobactam)
58
Empirical anti-fungal for PCP
Co-trimoxazole
59
Definition of ARDS
Acute onset (non-cardiogenic) pulmonary oedema with hypoxaemia, most commonly caused by sepsis
60
Bibasal fine inspiratory crackles Pink frothy sputum
Pulmonary oedema
61
CXR findings in ARDS
White lung Lung or Lobar collapse Once ARDS improves --\> underlying reticular pattern
62
Tx of ARDS
ABCDE * Oxygen * Intubation + Ventilation (**low tidal volume ventilation**) * Fluid management Treat underlying cause
63
CXR changes in TB
Fibronodular opacities in upper lobes Consolidation Bilateral hilar lymphadenophy
64
Dx of TB
Sputum =\> ZN statin =\> Acid fast bacilli or Culture or NAAT/PCT Histology =\> Caseating granuloma
65
Screening for TB
**Tuberculin skin test** (TST) Does not DDx Latent vs Active TB vs BCG vaccination **Interferon-gamma release assay** (IGRA) Does not DDx Latent vs Active TB
66
Tx of TB
6 months * 4 months RIPE * 2 months RI Rifampicin Isoniazid (+ Pyridoxine) Pyrazinamide Ethambutol
67
S/E of TB drugs
68
DDx causes of Pleural effusions
Transudative * Congestive cardiac failure * Cirrhosis * Renal failure (nephrotic syndrome --\> hypoalbuminaemia) Exudative * Infection (Pneumonia, TB) * inflammation (Rheumatoid arthritis, SLE) * Malignancy
69
How to DDx type of Pleural Effusion
(1) Pleural USS + Pleurocentesis
70
Tx of pleural effusion
Transudative * **Furosemide** * **+/- Physiotherapy** * If symptomatic * **+/- USS-guided thoracentesis** * **+/- Oxygen** Exudative * **IV Antibiotics** * **+/- Physiotherapy** * If symptomatic * **+/- USS-guided thoracentesis** * **+/- Oxygen** * **Treat underlying cause** If recurrent pleural effusion * **Pleurodesis** (using sclerosing agent e.g. talc) * *_or_* **Pleural catheter drainage**
71
Tx of Empyema
(1) **Chest drain** (URGENT) **+ IV Antibiotics** + Supportive (Analgesia, IV Fluids)
72
Tx of tension pneumothorax
Immediate large-bore needle decompression (2nd ICS MCL) Then, chest drain
73
Tx of pneumothorax
If primary pneumothorax * If **\< 2cm** and **asymptomatic** ==\> **Oxygen** and **Observation** * If **\> 2cm** or **SOB** ==\> (1) **Aspiration**, (2) **Chest drain** If secondary pneumothorax * If **\< 1cm** ==\> **Oxygen** and **Observation** * If **1-2 cm** ==\> (1) **Aspiration**, (2) **Chest drain** * If **\> 2cm** or **SOB** ==\> (1) **Chest drain**
74
Wells score
7 criteria
75
ECG in PE
Sinus tachycardia new RBBB S1Q3T3 --- Deep S wave in Lead 1 --- Deep Q wave in Lead 3 --- Inverted T wave in Lead 3
76
Investigation algorithmn for PE
If Well's score _\<_ 4 * (1) D-dimer * If -ve --\> excludes PE (high -ve predictive value) * if +ve --\> (2) CTPA If Well's score \> 4 * (1) CTPA
77
Tx of PE
(1) **LMWH + Warfarin** * If provoked --\> Continue Warfarin for 3 months * If unprovoked --\> Continue Warfarin for 6 months **+ Oxygen** **+ Analgesia** If shock * (1) **Thrombolytics** * (2) **Open pulmonary embolectomy** if recurrent PE or anticoag is C/I --\> **IVC filter**
78
Monitoring and Reversal of Unfractionated Heparin
Monitor **APTT** Reverse with **Protamine**
79
Chest drain insertion
**5th ICS** in **mid-axillary line** **_ABOVE_ the rib**
80
DDx Scar
81
DDx Scar
82
PEFR for severity of Asthma

RW Year 6 (13 decks)

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