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Respiratory Flashcards

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1
Q

Typical causative organisms of CAP

A 
Streptococcus pneumoniae (commonest), Haemophilus influenzae (common in COPD), Moraxella catarrhalis
Atypical: Mycoplasma pnuemoniae (dry cough), Staphylococcus aureus
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2
Q

Causative organisms of HAP

A

Gram neg enterobacteria
Staph aureus
Pseudomonas
Klebsiella

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3
Q

Investigations for pneumonia

A 
Oxygen saturation
ABG is sats are low
BP
Bloods - FBC, U+E, LFT, CRP
CXR
Sputum for microscopy and cultures
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4
Q

CAP severity scoring system

A 
CURB-65
Confusion (AMT =<8)
Urea >7
Resp rate >=30
BP <90 systolic (and/or diastolic 60)
Age >= 65
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5
Q

Management (acute and follow up) of CAP depending on severity

A

CURB65: 0-1 oral abx at home, 2 requires hospital therapy for IV abx, >=3 consider ITU

Abx, oxygen, IV fluids, VTE prophylaxis, analgesia
Follow up at 6 weeks (+/- CXR)

Abx guidelines: amoxicillin (doxycycline or erythromycin if pen allergic), co-amoxiclav if severe

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6
Q

Antibiotics for HAP

A

Co-amoxiclav

Tazocin if severe

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7
Q

Complications of pneumonia

A

Pleural effusion, empyema, lung abscess, resp failure, sepsis, brain abscess, pericarditis

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8
Q

Pneumonia in immunocomp patients

A

Pneumocystis jirovecii
Dry cough, exertional dyspnoea, reduced sats, fever, bilateral creps
Ix: induced sputum MCS, bronchoalveolar lavage
Mx: high dose co-trimoxazole, +/- steroids

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9
Q

What is bronchiectasis

A

Chronic inflamm of bronchi and bronchioles leading to permanent dilatation and thinning of the airways

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10
Q

Main organisms causing bronchiectasis

A

Haemophilus influenzae, Strep pneumonia, Staph aureus, Pseudomonas aeruginosa

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11
Q

Causes of bronchiectasis

A

Congenital: cystic fibrosis, primary ciliary dyskinesia, Kartageners
Post-infection: measles, pertussis, bronchiolitis, pneumonia, TB, HIV
Other: bronchial obstruction, allergic bronchopulmonary aspergillosis, RA, UC, idiopathic

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12
Q

Clinical features of bronchiectasis

A

Symptoms: persistent cough, copious purulent sputum, intermittent haemoptysis
Signs: clubbing, coarse inspiratory creps, wheeze (asthma, COPD, ABPA)

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13
Q

Complications of bronchiectasis

A

Pneumonia, pleural effusion, pneumothorax, haemoptysis, cerebral abscess, amyloidosis

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14
Q

Investigations for bronchiectasis

A

Sputum culture
CXR (cystic shadows, thickened bronchial walls (tramline and ring shadows)
HRCT chest (signet ring)
Spirometry (obstructive)
Bronchoscopy
Other tests - serum immunoglobulins, CF sweat test

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15
Q

Management of bronchiectasis

A

Chest physiotherapy
Flutter valve devices may air sputum removal
Mucolytics
Antibiotics in acute settings (ciprofloxacin if pseudomonas)
Salbutamol nebs (if asthma, COPD, CF, ABPA)
Prednisolone
Surgery if localised disease

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16
Q

Clinical features of cystic fibrosis (neonates –> children and young adults)

A

Failure to thrive, meconium ileus, rectal prolapse
Resp - bronchiectasis, recurrent chest infections, pneumothorax, haemoptysis, resp failure, cor pulmonale (finger clubbing, cyanosis, bilateral coarse crackles)
GI - DM, steatorrhoea, gallstones
Other - male infertility, osteoporosis, arthritis, vasculitis, nasal polyps

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17
Q

Management of cystic fibrosis

A

Antibiotics, postural drainage/ chest physiotherapy, pancreatic supplements (creon), high fat diet, bronchodilators, heart/lung transplant
Ivacaftor and lumacaftor target the CFTR protein

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18
Q

Subtypes of non-small cell lung cancer and their typical features

A

NSCLC is more common than SCLC
Squamous cell lung cancer - central, PTHrP (hypercalcaemia), finger clubbing, HPOA
Adenocarcinoma - peripheral, most common for non-smokers (although majority of cases are smokers), gynaecomastia, HPOA.
Large cell lung carcinoma - peripheral, poor prognosis, poor differentiation, may secrete beta-HCG

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19
Q

Features of small cell lung cancer

A

Central, arise from APUD cells, associated with ADH (hyponatraemia) and ACTH secretion (Cushings), Lambert-Eaton syndrome
The ACTH can cause bilateral adrenal hyperplasia and hypokalaemic alkalosis due to cortisol

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20
Q

Features of lung cancer

A

Persistent cough, haemoptysis, dyspnoea, chest pain, weight loss, anorexia

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21
Q

Complications of lung cancer

A

Superior vena cava obstruction, hoarseness (recurrent laryngeal nerve palsy), Horners (pancoast tumour), rib erosion, pericarditis, AF, mets to brain, bone, liver, adrenals

Lambert eaton, hypercalcaemia (PTHrP), Cushings (ACTH secretion), hyponatraemia (ADH secretion)

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22
Q

Investigations for lung cancer

A 
CXR (usually the first investigation)
CT (investigation of choice)
Bronchoscopy (allows for biopsy)
PET scan (usually for NSCLC)
Bloods (raised platelets)
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23
Q

referral criteria for lung cancer

A

2-week-wait referral if: CXR suggests lung cancer, or aged 40+ with unexplained haemoptysis

offer 2-week-wait if: 40+ with 2+ unexplained symptoms (or 1+ and a smoker): cough, fatigue, dyspnoea, chest pain, weight loss, anorexia

Consider 2-week-wait if: 40+ with persistent or recurrent chest infections, or finger clubbing, or lymphadenopathy, or chest signs suggestive of lung cancer, or thrombocytosis

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24
Q

Management for NSCLC

A

Only 20% eligible for surgery

Curative or palliative radiotherapy

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25
Contraindications for surgery in lung cancer
Assess general health, stage 3b/4 (mets), FEV1 <1.5L, malignant pleural effusion, tumour near hilum, vocal cord paralysis, SVCO
26
Malignant mesothelioma cause, mx, prognosis
Cause - asbestos Mx - palliative chemo Prognosis is poor (<2y)
27
Allergic bronchopulmonary aspergillosis (ABPA) - what is it - who does it affect
type 1 and 3 hypersensitivity reaction to Aspergillus fumigatus Asthmatics and CF patients at risk
28
Allergic bronchopulmonary aspergillosis (ABPA) symptoms
Bronchoconstriction then permanent damage, causing bronchiectasis -> wheeze, cough, purulent sputum, dyspnoea
29
Allergic bronchopulmonary aspergillosis (ABPA) investigations
CXR (transient segmental collapse, consolidation, bronchiectasis) Aspergillus in sputum Eosinophilia Serum IgE (raised)
30
Allergic bronchopulmonary aspergillosis (ABPA) management
Prednisolone Itraconazole Bronchodilators
31
Important questions to ask in asthma history
Symptoms Precipitants - cold, exercise, emotion, allergens, pollution, NSAIDs, beta blockers Diurnal variation Exercise tolerance (quantify) Disturbed sleep (quantify as nights/week) Acid reflux? Other atopic disease - eczema, hayfever, allergy, family history Home - pets, carpet, feather pillow/duvet, floor cushions? Job Days/week off school/work
32
Investigations for asthma
Spirometry (measures vol and speed of air) - obstructive FEV1 significantly reduced, FVC normal, FEV1% <70% reversible obstruction following bronchodilators Fractional exhaled nitric oxide (FeNO) - rises in inflam cells, so levels will be high in asthma Consider CXR if old and hx of smoking
33
Chronic asthma management in children >5
SABA (salbutamol) - >Low dose ICS (budesonide) - >Oral LTRA (montelukast) - > Stop LTRA and start LABA (salmeterol) - >MART (ICS+LABA)
34
Side effects of asthma drugs
SABA and LABA - tremor ICS - oral candidiasis, stunted growth LTRA - GI discomfort, sleep/movement disorders
35
Asthma management in adults
SABA +ICS +LTRA +LABA (dont stop LTRA) SABA + LTRA + MART (ICS + LABA)
36
Acute asthma management in children
Mild-mod: salbutamol via spacer give 1 puff every 30-60 sec up to 10 puffs, if symptoms not controlled then refer to hospital Prednisolone should be given to all children with an asthma exacerbation (3-5 days)
37
Acute asthma severities
Moderate - PEFR 50-75% of best/predicted, normal speech, RR <25, Pulse <110, sats >92 Severe - PEFR 33-50%, cant complete sentences, RR>25, pulse>110, sats <92 Life-threatening - PEFR<33%, silent chest, cyanosis, feeble resp effort (normal pCO2), bradycardia, dysrhythmia, hypotension, exhaustion, confusion, coma
38
Treatment of acute asthma (severe or life threatening)
``` O2 (maintain 94-98%) 5mg salbutamol nebs 40-50mg oral prednisolone 500 micrograms ipratropium bromide nebs Consider 2g magnesium sulfate IV ```
39
Follow up for acute severe asthma
GP should be notified within 24hours of discharge and should review the patient within 48 hours Check inhaler technique Review treatment Resp specialist should follow up all patients admitted with a severe asthma attack for at least one year
40
COPD includes which two lung conditions
``` Chronic bronchitis (chronic cough and sputum production) Emphysema (enlarged alveoli with destruction of alveolar walls) ```
41
Pink puffers vs. blue bloaters
Pink puffer - increased alveolar ventilation, near normal pO2 and normal/low pCO2, breathless but not cyanosed. May develop type 1 resp failure Blue bloater - reduced alveolar ventilation, low pO2 and high pCO2, cyanosed but not breathless and may go on to develop cor pulmonale. Rely on hypoxic drive to maintain resp effort (88-92%) type 2 resp failure.
42
Investigations for COPD
Spirometry (obstructive, irreversible) ABG (low pO2 +/- hypercapnia) CXR (hyperinflation, flat hemidiaphragm, large central pulmonary arteries, reduced peripheral vascular markings) CT (bronchial wall thickening, air space enlargement) ECG (right atrial and ventricular hypertrophy if cor pulmonale)
43
Management of chronic COPD
Stop smoking, exercise, diet advice If asthmatic features of features of steroid responsiveness: 1. SABA or SAMA 2. LABA + ICS (if already on SAMA discontinue and switch to SABA) 3. LABA + ICS + LAMA If no asthmatic features or no features of steroid responsiveness: 1. SABA or SAMA 2. LABA + LAMA (if already taking SAMA, discontinue and switch to SABA) Flu and pneumococcal vaccinations Long term oxygen therapy (+ NIV if hypercapnic) Consider surgery
44
what is type 1 resp failure and what are some examples
pO2<8kPa with normal/low paCO2 Ventilation/perfusion mismatch, hypoventilation, abnormal diffusion, or right to left cardiac shunts V/Q mismatch: pneumonia, pulm oedema, PE, asthma, emphysema, pulm fibrosis, ARDS
45
what is type 2 resp failure and what are some examples
pO2 <8kPa with paCO2 >6kPa Alveolar hyperventilation +/- V/Q mismatch Examples: asthma, COPD, pneumonia, end-stage pulm fibrosis, OSA, sedation, cervical cord lesion, MG, GBS, kyphoscoliosis
46
Management of type 1 resp failure
Treat underlying cause Oxygen (24-60%) via face mask Assisted ventilation if pO2 <8kPa despite 60% O2
47
Management of type 2 resp failure
Treat underlying cause Controlled O2: start at 24% via venturi Recheck ABG after 20 min - if pCO2 is steady or lower then increase O2 conc to 28%, if pCO2 has increased by >1.5kPa consider assisted ventilation (non-invasive positive pressure ventilation), if this fails consider intubation and ventilation
48
Symptoms of PE
Acute breathlessness, pleuritic chest pain, haemoptysis, dizziness, syncope
49
Signs of PE
Pyrexia, cyanosis, tachypnoea, tachycardia, hypotension, raised JVP, pleural rub, pleural effusion, check for DVT
50
Investigations for PE
D-Dimer +/- CTPA or V/Q scan FBC, U+E, baseline clotting ABG CXR ECG (normal, or tachycardia, RBBB, inverted T in V1-V4, S1Q3T3)
51
Criteria for suspecting PE
``` Well's Score- Clinical signs and symptoms of DVT (=3) Tachycardia (=1.5) Recently bed ridden or major surgery (=1.5) Previous DVT or PE (=1.5) Haemoptysis (=1) Cancer (=1) Alternative diagnosis less likely than PE (=1) ``` Score <4 = unlikely Score >4 = likely
52
How to investigate PE based on Well's score
<4 (unlikely) -> D-Dimer If D-dimer +ve then do CTPA or empirical LMWH If D-dimer -ve then consider other diagnoses >4 (likely) -> immediate CTPA or treat empirically with LMWH fi there will be a delay in CTPA
53
PE treatment
If haemodynamically unstable -> thrombolyse for massive PE (alteplase) If haemo stable - LMWH (unfractionated if renal impairment) for 5 days then start DOAC or warfarin (with warfarin stop LMWH when INR 2-3)
54
Pneumothorax causes
Spontaneous in young thin men asthma, COPD, TB, pneumonia, lung abscess, cancer, CF, lung fibrosis, sarcoidosis, connective tissue disorders, trauma, iatrogenic
55
Symptoms of pneumothorax
May be asymptomatic | Sudden onset dyspnoea, pleuritic chest pain
56
Signs of pneumothorax
Unilateral: Reduced expansion, hyper-resonance to percussion, diminished breath sounds Tension pneumothorax - trachea deviated away from affected side
57
Investigations for pneumothorax
CXR (dont bother if tension pneumothorax - delays treatment) | ABG
58
Types of pneumothorax
Primary - spontaneous, no other lung conditions (young thin male) Secondary - lung comorbidities Tension - air drawn into pleural space with each inspiration and no route for escape during expiration (one way valve). EMERGENCY.
59
Management for non-tension pneumothorax
Primary: SOB or >2cm on CXR -> aspiration (chest drain if unsuccessful) Primary: <2cm and no SOB -> O/P review in 2-4 weeks Secondary: SOB or >2cm on CXR -> chest drain Secondary: <2cm and no SOB -> aspiration if >1cm (chest drain if unsuccessful), if <1cm then admit and observe for 24h with O2
60
Management of tension pneumothorax
Needle decompression and chest tube insertion. Insert a large bore (14-16G) needle with a syringe, partially filled with 0.9% saline, into the 2nd intercostal space midclavicular line on the affected side. Withdraw plunger to allow air to to bubble through saline in syringe. Then insert a chest tube. (5th intercostal mid axillary line)
61
Pleural effusion transudate vs exudate causes
Transudate (<25g/L protein) - cardiac failure, constrictive pericarditis, fluid overload, cirrhosis, nephrotic Exudate (>35g/L protein) - infection (pneumonia, TB), inflammation (RA, SLE), malignancy
62
Pleural effusion signs
Decreased expansion, stony dull percussion, diminished breath sounds on affected side Reduced vocal resonance There may be tracheal deviation in large effusions
63
Pleural effusion investigations
``` CXR Ultrasound Contrast CT Diagnostic aspiration Pleural biopsy ```
64
Management of pleural effusion
Recurrent aspiration Pleurodesis Indwelling pleural catheter Drugs to alleviate symptoms
65
What is obstructive sleep apnoea syndrome?
Intermittent closure/collapse of the pharyngeal airway causing apnoeic episode during sleep. terminated by partial arousal from sleep
66
Clinical features of obstructive sleep apnoea
``` Obese, middle aged man Snoring Tiredness Poor sleep quality Morning headache Decreased libido Nocturia Reduced cognitive performance ```
67
Investigations for obstructive sleep apnoea
Epworth sleepiness scale | Diagnostic sleep studies
68
Management for obstructive sleep apnoea
Weight loss CPAP Intra-oral devices (mandibular advancement) if CPAP is not tolerated Inform DVLA if excessive daytime sleepiness
69
What is cor pulmonale and what are some causes
Right heart failure due to chronic pulmonary artery hypertension Causes - chronic lung disease, pulmonary vascular disorders, neuromuscular and skeletal diseases
70
Clinical features of cor pulmonale
Dyspnoea, fatigue, syncope | Signs: cyanosis, tachycardia, raised JVP, RV heave, loud P2, pansystolic murmur (tricuspid regurg), hepatomegaly, oedema
71
Sarcoidosis population group
More common in african-caribbean women aged 20-40
72
Acute sarcoidosis clinical features
Fever, erythema nodosum, polyarthralgia, bilateral hilar lymphadenopathy
73
Pulmonary features of sarcoidosis
Bilateral hilar lymphadenopathy, fibrosis | Dry cough, progressive dyspnoea, reduced exercise tolerance, chest pain
74
Non-pulmonary features of sarcoidosis
lymphadenopathy, hepatomegaly, splenomegaly, uveitis, conjunctivitis, dry eyes, glaucoma, bells palsy, erythema nodosum, arrhythmias, hypercalcaemia, renal stones
75
Investigations for sarcoidosis
Tissue biopsy is diagnostic and shows non-caseating granulomata Bloods - raised ESR, lymphopenia, deranged LFTs, raised serum ACE, hypercalcaemia, raised immunoglobulins 24hr urine - high calcium CXR ECG - arrhythmias, BBB Lung function tests - restrictive bronchoalveolar lavage ultrasound bone x-rays - punched out lesions in terminal phalanges CT/MRI
76
CXR sarcoidosis staging
``` 0- normal 1- BHL 2- BHL + peripheral pulm infiltrates 3- diffuse pulm infiltrates alone 4- progressive pulmonary fibrosis, honey comb, pleural involvement ```
77
Management of sarcoidosis
BHL alone requires no treatment, most recovers spontaenously. Acute sarcoidosis - bed rest, NSAIDs Consider corticosteroids or immunosuppression.
78
Clinical features of interstitial lung disease
Dyspnoea on exertion, non-productive paroxysmal cough, abnormal breath sounds, abnormal CXR or HRCT, restrictive pulmonary spirometry
79
Examples of interstitial lung disease associated with a known cause
``` Occupational (asbestosis, siliocosis, cotton workers lung, coal workers pneumonconiosis) Drugs (bleomycin, nitrofurantoin, etc) Hypersensitivity pneumonitis (aka. EAA) Infection (TB, fungi, viral) GORD ```
80
Examples of interstitial lung disease associated with systemic disorders
Sarcoidosis, RA, SLE, Sjögrens, UC, autoimmune thyroid
81
Idiopathic examples of interstitial lung disease
Idiopathic pulmonary fibrosis Cryptogenic organising pneumonia Non-specific interstitial pneumonitis
82
What is extrinsic allergic alveolitis (EAA)?
In sensitised inderviduals, repetitive inhalation of allergens provokes a hypersensitivity reaction (acute or chronic phases)
83
Causes of extrinsic allergic alveolitis
Bird-fanciers and pigeon-fanciers lung Farmers and mushroom-workers lung Malt workers lung
84
Clinical features of EAA (acute and chronic)
Acute (4-6h post exposure): fever, rigors, myalgia, dry cough, dyspnoea, fine bibasal crackles Chronic: finger clubbing, increasing dyspnoea, weight loss, exertional dyspnoea, type 1 resp failure, cor pulmonale
85
Acute phase investigations for EAA
FBC (netrophilia), high ESR, ABG, serum antibodies CXR (upper zone consolidation) Lung function tests (reversible restriction)
86
Chronic phase investigations for EAA
``` Bloods, serum antibodies CXR (upper zone fibrosis, honeycomb) CT chest (nodules, ground glass) Lung function tests (restrictive) Bronchoalveolar lavage (increased lymphocytes and mast cells) ```
87
Management of EAA
Acute: remove allergen, give O2, oral prednisolone Chronic: avoid allergen, wear face mask or positive pressure helmet, long term steroids, compensation
88
Idiopathic pulmonary fibrosis population group
typically seen in patients aged 50-70 years, twice as common in men Commonest type of interstitial lung disease
89
Features of idiopathic pulmonary fibrosis
Progressive exertional dyspnoea | Bibasal fine end-inspiratory crepitations, dry cough, clubbing
90
Diagnosing idiopathic pulmonary fibrosis
High resolution CT chest diagnostic investigation of choice (honeycombing, traction bronchiectasis, ground glass) Spirometry - restrictive, FEV1 normal/decreased, FVC decreased, FEV1% increased Impaired gas exchange - reduced transfer factor (TLCO) CXR - bilateral interstitial shadowing (ground glass, honeycombing) ANA positive in 30%, RhF positive in 10%
91
Management and prognosis of idiopathic pulmonary fibrosis
Pulmonary rehabilitation Supplementary oxygen Lung transplant Poor prognosis (3-4 year life expectancy)
92
TB primary disease
non-immune host exposed to mycobacterium tuberculosis -> small lung lesion (Ghon focus develops), composed of tubercle-laden macrophages. In immunocompetent people then initial lesion usually heals by fibrosis. Those who are immunocompromised may develop disseminated disease (miliary TB)
93
TB secondary disease
Host becomes immunocompromised and the initial infection becomes reactivated, generally at lung apex
94
Clinical features of TB
``` Low grade fever, anorexia, weight loss, malaise, night sweats, clubbing, erythema nodosum Cough, haemoptysis Enlarged lymph nodes Bone tenderness TB meningitis UTI symptoms Pericarditis, pericardial effusion ```
95
Diagnostic tests for latent TB
Tuberculin skin test - intradermal injection of purified protein derivative tuberculin. Size of skin induration is used to determine positivity depending on vaccination history and immune status Interferon gamma release assays - measure amount of interferon-gamma released from T cells reacting to TB antigen. More sensitive than TST
96
Diagnosing active pulmonary TB
CXR - fibronodular/linear opacities in upper zone usually Sputum smear (three specimens) stained for acid-fast Sputum culture (takes 1-3 weeks) Nucleic acid amplification test
97
Management of TB
ACTIVE: Rifampicin and isoniazid for 6 months. Pyrazinamide and ethambutol for the first 2 months LATENT: 3 months of isoniazid (with pyridoxine) and rifampicin
98
Side effects of TB meds
Rifampicin - enzyme inducer, altered liver function, orange-red urine Isoniazid - peripheral neuropathy (give pyridoxine to prevent), hepatitis Pyrazinamide - hepatotoxicity Ethambutol - colour blindness, reduced visual acuity, optic neuritis
99
Inhaler technique for metered dose inhalers
``` Remove cap and shake Breath out gently Put mouthpiece in mouth and as you begin to breath in (slowly and deep), press cannister down and continue to inhale steadily and deeply Hold breath for 10 seconds Wait 30sec before next dose ```
100
Causes of clubbing
Cardiac - cyanotic congenital heart disease, bacterial endocarditis, atria myxoma Resp - lung cancer, CF, bronchiectasis, abscess, empyema, TB, asbestosis, mesothelioma, fibrosing alveolitis Others - Crohns, cirrhosis, PBC, Graves, Whipples, coeliacs

Medicine (15 decks)

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