Respiratory Flashcards
(182 cards)
1
Q
What is a stridor and when does it occur?
A
- Monophonic wheeze
- Occurs in cough in pertussis or in laryngeal or tracheal obstruction
2
Q
List the questions asked relating to sputum
A
- Amount
- Character (serous is clear and frothy, mucoid is grey or white, purulent is pus, haemoptysis, muco-purulent)
- Viscosity
- Taste/odour
3
Q
What is mucous like sputum caused by?
A
- Chronic lung disease
4
Q
Describe sputum seen in pulmonary oedema
A
- Pink and frothy
5
Q
Describe types of haemoptysis and their causes
A
- Frank whole blood in TB, pulmonary infarction and bronchiectasis
- Pink in pulmonary oedema
- Blood stained in pneumonia, bronchial carcinoma, trauma from excessive coughing
- Rusty sputum is brown to yellow (due to breakdown of haem) due to pneumococcal pneumonia, bronchiectasis and lung abscesses
6
Q
What is a bovine cough?
A
- Non explosive
- Larygeal paralysis
7
Q
List the types of pain and their causes
A
- Laryngeal upper retrosternal mild/intermittent pain in tracheotomy, severe in TB or tumours
- Retrosternal pain is constrictive, like cardiac, but is not exertional. Radiates to the arms and back due to mediastinal lesions
- Pleural pain (pleurisy) is sharp, stabbing localised chest pain. Worse with breathing - especially deep breathing - can be worse on movement or exercise. If pulmonary effusion occurs then it subsides
8
Q
What is emphysema?
A
- Trapped air.
- Panacinar emphysema is due to alpha-1 antrypsin deficiency, suspected in young non-smokers
9
Q
What is kussmals breathing and when does it occur?
A
- Deep and fast
- Occurs in diabetic ketoacidosis
10
Q
Which lung conditions can be caused by birds?
A
- Psittacosis
- Extrinsic allergic alveolitis (bird fanciers lung)
11
Q
What is a pancoast tumour, and how does it affect nervous system?
A
- Apex of the lung
- Can compress superior sympathetic chain and cause horners (miosis, anhydrosis, ptosis)
12
Q
What is a flail chest?
A
Multiple broken ribs
13
Q
List the types of breath sounds and their causes
A
- Vesicular (normal - longer and slower inspiration, no pause then faster expiration)
- Bronchial - normal over the trachea, has a blowing quality (slower expiration, pause between inspiration and expiration. Due to fibrosis or consolidation)
- Extra - wheeze, crepitations (crackles are non musical, like walking on snow), rubs (leathery or crackling caused by pleura rubbing together)
14
Q
List the symptoms of pulmonary fibrosis, and the findings on spirometry testing
A
- Cough
- Crackles
- Clubbing
- Decreased total lung capacity and gas diffusion in the lungs (so decreased FVC, FEV1, DLCO but normal FEV1:FVC ratio)
15
Q
What causes tension pneumothorax?
A
- Trauma to the chest wall
- Entry of outside air into interpleural space
- Collapse of the affected lung causing absent breath sounds
16
Q
Define acute respiratory distress syndrome
A
Medical condition that occurs in critically ill patients characterised by widespread inflammation and non-cardiogenic pulmonary oedema
17
Q
List symptoms and signs of acute respiratory distress syndrome
A
- Dyspnoea
- Tachypnoea, tachycardia
- Peripheral vasodilation
- Crackles bilaterally
- Low oxygen sats
- Fever, cough, pleuritic chest pain
18
Q
How is acute respiratory distress syndrome diagnosed?
A
Berlin criteria
- Acute onset within 1 week of clinical insult with progression of symptoms and bilateral pulmonary infiltrates on Xray without alternate explaination
- Respiratory failure not fully explained by fluid overload or congestive heart failure
- Pa/FiO2 ratio less than 300 when patient given PEEP of 5cm H2O
19
Q
Describe symptoms of asthma
A
- Shortness of breath and wheezing due to bronchoconstriction, often worse at night or earlier in the morning (diurnal variation). History of cough
- Triggered by exercise, cold temperatures and allergens
- Obstructive pulmonary disease
- Presence of associated atopic conditions
- Symptoms exacerbated by some drugs
- Wheeze on auscultation
20
Q
List risk factors for pulmonary embolism
A
- DVT/ previous PE
- Malignancy
- Immobilisation
- Obesity
- Recent surgery
- Lower limb trauma or fracture
- Oestrogen, pregnancy
- Increasing age
- Varicose veins
21
Q
List symptoms of PE
A
- Chest pain that worsens on inspiration (pleuritic)
- Dyspnoea
- Dizziness or syncope
- Pain in leg, swelling
- Haemoptysis
22
Q
Define bronchiectasis
A
Bronchiectasis is a permanent dilatation and thickening of the airways associated with chronic cough, sputum production, bacterial colonization, and recurrent infection.
23
Q
What can be seen in streptococcus pneumoniae infection on X ray?
A
Lobar pneumonia (localised not patchy pulmonary infiltrates, only affecting one lobe)
24
Q
What can be seen in adenovirus infection on X ray?
A
Interstitial pneumonitis - interstitial rather than alveolar shadowing, bronchograms not visible
25
What can be seen in mycoplasma pneumoniae infaction on X ray?
- Bronchopneumonia but abscesses rarely seen
| - Patchy consolidation
26
What can be seen on saphylococcus aureus infection on X ray?
- Abscesses
- Bronchopneumonia
- Fluid level
27
Define sarcoidosis
- Multisystem granulomatous disease that may affect the skin, eyes, lungs, heart, liver and nervous system
- Frequently involves the lungs, often characterised by bilateral hilar adenopathy
- Can be asymptomatic
- May lead to fibrosis and restrictive lung disease
- Can cause neuropathies
28
What is chronic bronchitis?
- A form of COPD
- Productive cough for at least 3 months per year for at least 2 years
- Occurs with emphysema
29
What is the most common cause of community acquired pneumonia?
Streptococcus pneumoniae (encaspulated, gramp positive, diplococci, optochin sensitivie)
30
What is the golden S sign?
- Sign seen on x-ray indicative of a bronchogenic tumour
| - Commonly seen in right upper lobe collapse
31
What should be done to diagnose suspected haemothorax?
Chest X ray
32
Define COPD
- Obstructive airway disease associated with chronic tobacco use. Causes chronic bronchitis (narrowing of the airways with excessive secretions - chronic cough on most days for at least 3 months in the last 2 years) and emphysema (dilated terminal air spaces, loss of elastic recoil of alveoli)
- Elevated pCO2, pHCO3 and decreased pH
33
Define pleural effusion
Fluid between the pleura of the lungs, causing blunting of costophrenic angles on x-ray
34
Describe cheyne stokes breathing
- Oscillation between apnoea and hyperpnoea
| - Crescendo decreascendo pattern
35
List symptoms of mesothelioma
- Dyspnea
- Jaundice
- Chest wall pain (due to pleural effusion)
- Cough (usually dry)
- Fatigue
- Ascites
- Weight loss
- Fever
- Night sweats
- Anorexia
- Abdo pain and obstruction suggests peritoneal
36
Define mesothelioma
- A type of cancer in the mesothelium
| - Pleura, pericardium, sac of testes, chest wall
37
Describe investigations for mesothelioma
- CT scanning show pleural thickening/ effusion
- Sample of pleural fluid shows blood
- Biopsy using thorascopy
- CT CAP
38
Describe diagnosis of chronic bronchitis
- Presence of cough, producing sputum on most days of 3 months for 2 consecutive years
- Permanent largely irreversible shortness of breath
39
List risk factors for COPD
- Smoking
- Occupational exposure of lung irritants, pollution
- a1-antitrypsin deficiency (under 40)
- Age over 35
40
List signs of COPD
- Hyperexpanded chest
- Breathing through pursed lips + using accessory muscles
- Reduced cricosternal distance
- Central cyanosis
- Reduced air entry/chest expansion
- Prolongued expiratory phase
- Hyper-resonant percussion note
- Reduced breath sounds with wheeze
- Tar staining
- CO2 retention tremor (or fine due to salbutamol)
- Elevated JVP if cor pulmonale
- Cachectic
41
Define interstitial lung disease
- History of exposure to asbestos, silica, or coal (pneumoconioses), and drugs (methotrexate and amiodarone)
- Reduced FVC normal FEV
- Fine crackles heard over the lung, fibrosis
- Includes idiopathic pulmonary fibrosis, hypersensitivity pneumonitis, sarcoidosis, pneumoconiosis)
42
List signs of interstitial lung disease
- Clubbing
- Reduced air entry/chest expansion
- Late inspiratory, fine crackles (heard at bases or apices)
43
What is atelectasis?
- Alveolar collapse
- Pain sometimes stops patients breathing adequately to extract mucous from the lungs, leading to bronchioles becoming blocked and collapse of that area of the lung
44
How is post-operative atelectasis prevented?
- Analgesia
- Incentive spirometry
- Early mobilisation
45
How is atelectasis diagnosed?
- Chest radiograph
| - Look for collapse, consolidation (from pneumonia, oedema or pneumothorax)
46
How is atelectasis treated?
- Physiotherapy
- Analesia
- Oxygen
47
Describe management of asthma in the community
- Avoidance of triggers
- For reliever, SABA then can increase to formoterol if necessary
- For controller, start with low dose ICS if SABA alone not enough, then add LATRA, then increase SABA to LABA, then raise ICS dose.
- Reduction of immune response of the lungs (using inhaled or oral corticosteroids)
- Leukotriene receptor antagonist, LAMA
- Anti IgE and anti IL5
- Bronchial thermoplasty
- Oral prednisolone at late stage
48
Compare spirometery in asthma and COPD
- COPD, FEV1 and FER (FEV1:FVC) reduced (due to obstructed airways and lack of elasticity of the lungs meaning less air is exhaled)
- In asthma, usually only FER (FEV1:FVC)is affected as the speed air is moved in and out of the lungs is affected as opposed to volume of air
49
Describe management of COPD
- Smoking cessation
- Inhaled therapy (First line SABA or SAMA. If asthmatic features 2nd line is LABA and ICS, 3rd line triple therapy with LAMA, LABA, ICS. If no asthmatic features 2nd line LABA and LAMA, 3rd line triple therapy with LAMA, LABA, ICS)`
- Pulmonary rehabilitation (physiotherapy, exercise and education)
- Vaccination (influenza, one off pneummococcal)
- Long term oxygen (prevents cor pulmonale)
- Manage exacerbations (oral corticosteriods or prophlactic antibiotics, use of NIV, hospital at home/assisted discharge schemes, theophylline, mucolytic - carbocystine, PDE4 inhibitors)
- Rescue packs
50
How is type II respiratory failure in a COPD patient treated?
- Controlled oxygen therapy (not 100% as patients no longer rely on CO2 levels to stimulate breathing, 24% O2 blue venturi)
- Bronchodilators, steroids 30mg pret, antibiotics, paracetamol, IV aminophuline
- Improve ventillation with NIV (non-invasive ventillation)
- Treat underlying cause (pneumothorax, pneumonia, pulmonary oedema, PE, airway obstriction)
- If decompensated aim for sats 98%, ventillatory support (bi-level continuous airway support is non invasive option - BiPAP)
51
How is interstitial lung disease diagnosed?
- CT scan
| - Look for linear reticular opacities and ground-glass appearance
52
How is suspected malignancy investigated?
- Lymph node fine needle aspirate
- Chest radiograph
- Sample pleural effusion
53
What is respiratory failure?
Describe type 1 and 2 respiratory failure
- Impairment of pulmonary gas exchange sufficient to result in hypoxaemia or hypercapnia. Divided into 2 types based off whether CO2 is expelled or retained
- PO2 less than 8kPa
- Type 1 respiratory failure is a problem with oxygen alone (hypoxic)
- Type 2 respiratory failure is hypercapnic and hypoxaemic. Ventilatory failure, impairment of respiratory bellows resulting in alveolar hypoventilation occurs. Oxygenation of blood is reduced as CO2 builds up in the blood, so affinity for oxygen decreases and CO2 removal decreases.
54
List causes of type 1 respiratory failure
- Caused by reduced oxygen entry into the blood (lack of ventilation or lack of exchange at the alveolar membrane)
- Asthma, COPD, pneumonia, pulmonary fibrosis
- Ventilation perfusion mismatch
55
List causes of type 2 respiratory failure
- Decreased respiratory drive (opiates, central neurological problems eg. stroke/trauma)
- Impaired lung movements eg. reduced compliance and increased dead space in COPD, chest wall deformity, neuromuscular impairment (motor neuron disease) and obesity
56
Describe presentation of respiratory syncytial virus
- Bronchiolitis (LRTI)
- Wheezing, cough
- Fusion of endothelial cells to form cyncitia
- Tachypnoea, congestion, rinorrhoea
- Fever
- Hypoxaemia
57
What is the most common cause of childhood pneumonia?
Respiratory syncytial virus
58
Which type of tumour is most likely to have neuroendocrine function?
List other characteristics of this tumour.
- Small cell carcinoma
- Also occur centrally in large airways and have cells that resemble lymphocytes
- Poor prognosis as it is highly metastatic
59
Define pulmonary embolism
A disease characterized by an embolus to the pulmonary vasculature commonly associated with deep venous thrombosis
60
Define obstructive sleep apnea
- Reversible intermittent obstruction of the upper airway at night
- During sleep, muscle tone decreases and the pharynx collapses and can obstruct the airway
- CO2 accumulates in blood until it arouses the patient to wake up
- Absence of air flow during sleep
61
List symptoms and signs of obstructive sleep apnoea
- Recent unintentional weight gain (obesity is a big risk factor)
- Excessive daytime sleepiness
- Snoring
62
How is obstructive sleep apnoea diagnosed?
- Overnight sleep study
- Electroencephalogram
- Questionnaire (epworth sleepyness scale score over 12 means clinically sleepy)
63
Define pneumoconiosis
Interstitial lung disease caused by inhaling dust, for example coal dust particles. Causes fibrosis due to macrophages ingesting dust
64
Define croup
- Infection in infants causing a characteristic barking cough and stridor.
- Upper airways affected, causes inflammation and swelling and possibly fever
65
How is croup investigated
Neck x ray shows a steeple sign in the trachea, providing evidence of tracheal swelling
66
How is croup treated?
- Give oral dexametasone to reduce swelling of the trachea
| - Treatment of then supportive and the condition resolves within a few days
67
List symptoms of viral upper respiratory tract infections
- Sore throat
- Malaise
- Non-productive cough
- Low grade fever
68
How is URTI diagnosed?
Sputum culture
69
How is URTI treated?
Symptomatic support
70
Define pulmonary fibrosis
An over-deposition of collagen within the interstitium of the lung
71
Which pattern of calcification is associated with malignancy?
Eccentric or stippled
72
List causes of haemoptysis (surgical sieve)
- Vascular (PE, left ventricular failure, bleeding diathesis, arteriovenous malformation, vascular bronchial fistula)
- Accident/trauma (iatrogenic, wounds)
- Neoplasm (primary or metastatic lung cancer)
- Inflammatory (granulomatosis, goodpastures syndrome, SLE, hereditary haemorrhagic telangiectasia, polyarteritis nodosa, microscopic polyangitis)
- Septic (TB, bronchitis, pneumoia, lung abscess, mycetoma)
- Hereditary/haematological (warfarin use)
- Endocrine
- Degenerative (bronchiectasis)
73
Define lung cancer
Cancer in the lungs including small cell lung cancer and
| non-small cell lung cancer (adenocarcinoma, squamous cell carcinoma, large cell carcinoma).
74
List risk factors for lung cancer
- Tobacco smoke.
- Exposure to radon.
- Exposure to asbestos.
- Exposure to other cancer-causing agents in the workplace.
- Taking certain dietary supplements.
- Previous radiation therapy to the lungs.
75
Describe epidemiology of lung cancer
- Over 43,000 new lung cancers are diagnosed each year in the UK.
- A full time GP is likely to diagnose approximately one person with lung cancer each year.
- The 5 year survival is below 10%.
- SCLC and squamous cell linked with smoking
- Adenocarcinoma most common in females and non-smokers
- Most common and most deadly cancer in the world
76
List presenting symptoms of lung cancer
- Cough (haemoptysis)
- Fatigue.
- Shortness of breath.
- Chest pain.
- Weight loss.
- Appetite loss.
- Bovine cough if affecting the recurrent laryngeal nerve, and paraesthesiae (pancoast)
77
List signs of lung cancer on examination
- Clubbing
- Hoarse voice
- Cachexia
- Hypotonia, hyporeflexive, weak arms (metastasis to bone)
- Horners syndrome (pancoast tumour)
- Jaundice (lung involvement)
- Cervical lymphadenopathy, vircows node
- Tracheal deviation
- Asymmetrical lung expansion
- Dullness to perfussion
- Stridor
- Hepatomegaly (liver involvement)
78
List investigations performed in suspected lung cancer
Urgent X ray
- Look for mass/lesion
- Look for hilar lymphadenopathy
- Look for pulmonary infultrates
- Lobar collapse (sail sign - left lower lobe collapse)
- Multiple coin shaped lesions if metastatic
Confirmed with cytology of sputum and bronchoscopic washings, and tissue biopsy (via CT-guided fine needle biopsy or bronchoscopy). Staged with CT scan and bone scan.
- Squamous PTH related peptide
- Endocrine tests
79
Define TB
- Tuberculosis (TB) is an infection caused by bacteria of the Mycobacterium tuberculosis complex. People are infected by inhaling the bacterium in respiratory droplets that are released when a person with pulmonary or laryngeal TB coughs.
- Active disease describes symptomatic or progressive disease of the lung (most common) and/or other organs (extrapulmonary TB).
- Latent disease occurs when there is no clinically active TB (the person is asymptomatic and not infectious).
80
List risk factors for TB
- Being born in high prevalence areas
- Children
- Previous untreated infection
- Being in close contact with active TB
- Immunosuppressive conditions (HIV) or drugs
- Some under-served groups.
- South asian, india, bangladesh
81
List symptoms of TB
- Weight loss
- Fever
- Night sweats
- Anorexia
- Malaise.
- Pulmonary involvement may present with persistent productive cough, breathlessness, and haemoptysis.
- Extrapulmonary involvement may present with organ-specific symptoms and signs (eg. colicky abdo pain, painless lymph node enlargement, bony tenderness, CNS meningitis, genitourinary dysuria, frequency, loin pain, addisons, infertility)
- Generally asymptomatic in the latent stage, then reactivation. Miliary is lymphohaematogenatous dissemination - all over body
82
List signs of TB on examination
- Tachycardia
- Consolidation (reduced chest expansion, dullness to percussion, reduced breath sounds, crackles, increased vocal resonance - pleural effusion)
83
List investigations for TB
- Raised WCC and raised CRP
- A chest X-ray and three spontaneously-produced respiratory (sputum) samples, particularly if chest X-ray appearances suggest TB infection.
- Sputum screened for acid fast bacilli, and cultured for sensitivity testing
- Unilateral hilar lymphadenopathy, effusion
- Nucleic acid amplification test (direct detection by DNA or RNA amplification)
- Look for organ involvement
- Caseating granumolas on lymph node biopsy
- Latent: tuberculin skin testing, interferon gamma release assays
84
List respiratory causes of clubbing
- Pulmonary fibrosis
- Suppurative lung diseases (abscess, empyema, CR, bronchiectasis)
- Bronchial carcinoma
- Mesothelioma
- TB
85
List risk factors for bronchiectasis
- Cystic fibrosis – the most common cause in developed countries
- Bordetella pertussis infections (Whooping Cough) can sometimes cause bronchiectasis later in life
- Ciliary dysfunction syndromes (primary ciliary dyskinesia)
- Primary hypogammaglobuminaemia
- Congenital abnormalities (usually rare ones)
- TB – this is the most common cause worldwide
- Pneumonia, measles, pertussus
- Lung cancer
- Obstruction
- Immunodeficiency
86
Describe epidemiology of bronchiectasis
- 5 in every 1000 adults in UK
| - More common in women
87
List symptoms of bronchiectasis
- Cough with large volumes of purulent sputum
- Breathlessness.
- Haemoptysis.
- Chest pain that is present between exacerbations and is usually non-pleuritic.
88
List signs of bronchiectasis
- Coarse crackles during early inspiration.
- Wheeze.
- Large airway rhonchi (low pitched snore-like sound).
- Clubbing
89
List investigations performed in suspected bronchiectasis
- A chest X-ray to exclude other causes of chronic cough (such as lung cancer).
- High resolution CT showing signet ring sign (best test)
- Sputum, sweat tests for CF, FBC, CRP, ABG
- Spirometry to assess the degree of airway obstruction.
- Sputum culture to identify colonizing pathogens.
90
List signs on x ray of bronchiectesis
- Thickened bronchial walls
- Ring shadows (thickened airways seen end-on)
- Volume loss secondary to mucous plugging
- Air-fluid levels may be visible within dilated bronchi
91
What is first line treatment for pneumonia?
Amoxicillin for typical, and clarithromycin for atypical (combined therapy)
92
Describe epidemiology of asthma
The British Lung Foundation states that 5.4 million people in the UK are receiving treatment for asthma.
93
List signs of asthma on examination
Widespread wheeze (bilateral, predominantly expiratory)
94
List risk factors for asthma
- Atopic conditions
- Family history
- Bronchiolitis
- Exposure to tobacco smoke as a child
- Mother smoking during pregnancy
- Being born prematurely (before 37 weeks) or with a low birthweight
95
Describe investigations for asthma
- Fractional exhaled nitric oxide (FeNO) testing >40ppb, spirometry FEV1:FVC <70%
- Bronchodilator reversibility (BDR) Improvement of 60L/min following SABA
- Variable peak expiratory flow (PEF - ask to keep diary) readings. Diurnal variation of over 20% on 3/7 days for 2 weeks.
- Direct bronchial challenge testing with histamine or methacholine.
96
Describe epidemiology of COPD
- Second most common lung disease in the UK, after asthma. Around 2% of the whole population – 4.5% of all people aged over 40 – live with diagnosed COPD.
- 4th leading cause of death worldwide
97
List symptoms of COPD
- Exertional breathlessness
- Chronic/recurrent cough
- Regular sputum production
98
What is prognosis of COPD
- There is no cure currently
- Prognosis varies due to severity of exacerbations, smoking, severity of symptoms, hospital admissions and multimorbidity
99
List complications of COPD
- Reduced quality of life, increased morbidity and mortality
- Depression and anxiety
- Cor pulmonale (right sided heart failure)
- Chest infections
- Secondary polycythaemia
- Respiratory failure
- Pneumothorax
- Lung cancer
- Muscle wasting and cachexia
100
Describe epidemiology of sarcoidosis
- 10-20 per 100000 affected
- Black africans followed by scandinavians at highest risk
- Genetic component (10% cases familial, associated with HLA-DRB1 and DQB1)
- Typical presentation 25-45, more common in women
101
List symptoms of sarcoidosis
- Up to 50% asymptomatic
- Dry cough
- Chest pain
- Fever
- Dyspnoea (usually progressive, decreased exercise tolerance)
- Fatigue
- Malaise
- Weight loss
- Weakness, polyarthralgia
- Decline in lung function
- Uveitis, keratoconjunctivitis
- Can cause any neurological sign, sometimes bells palsy
- Erythema nodosum, lupus pernio
102
List signs of sarcoidosis
- A restrictive pattern may be seen on spirometry
- Lymphadenopathy
- Crackles on auscultation
- Hepatomegaly, splenomegaly, lymphadenopathy, Bell’s palsy, uveitis, conjunctivitis and cataracts, renal stones
Skin
- Papules – often resembling Rosacea, or the malaria rash seen in SLE
- Plaques that may mimic psoriasis
- Erythema nodosum
103
List risk factors for sarcoidosis
- Sarcoidosis can occur at any age, but often occurs between the ages of 20 and 60 years.
- Women are slightly more likely to develop the disease.
- People of African descent and those of Northern European descent have a higher incidence of sarcoidosis. African-Americans are more likely to have involvement of other organs along with the lungs.
- Family history (HLA DRB1 and DQB1)
- Insecticides, agricultural esposures
- Smoking is protective
104
Define pneumonia
- An infection of the lung tissue in which the air sacs in the lungs become filled with microorganisms, fluid, and inflammatory cells, affecting the function of the lungs.
- If 48 hours after hospital admission termed hospital acquires
105
Compare causes of transudative pleural effusion and exudative
- Transudative pleural effusions are low in protein. They are defined as effusions that are caused by factors that alter hydrostatic pressure, pleural permeability, and oncotic pressure (congestive heart failure, liver cirrhosis, severe hypoalbuminaemia, nephrotic syndrome)
- Exudative pleural effusions are caused by changes to the local factors that influence the formation and absorption of pleural fluid. They are high in protein (malignancy, pneumonia, TB, trauma, pulmonary infarction, pulmonary embolism, sarcoidosis, RA)
106
Describe normal pleural fluid
```
Appearance: clear
pH: 7.60-7.64
Protein: < 2% (1-2 g/dL)
White blood cells (WBC): < 1000/mm³
Glucose: similar to that of plasma
LDH: <50% plasma concentration
Amylase: 30-110 U/L
Triglycerides: <2 mmol/l
Cholesterol: 3.5–6.5 mmol/l
```
107
Compare diagnostic criteria for pleural effusion
- Transudate protein <30g/L
- Exudate protein >30g/L
Exudate - lights criteria (one of these present)
- The ratio of pleural fluid to serum protein is greater than 0.5
- The ratio of pleural fluid to serum LDH is greater than 0.6
- The pleural fluid LDH value is greater than two-thirds of the upper limit of the normal serum value
108
Compare spirometry in obstructive and restrictive lung disease
- Obstructive FEV1 reduced (less than 80% predicted), FVC closer to normal. Reduced FEV1 to FVC ratio (less than 0.7)
- Restrictive both FEV1 and FVC less than 80% of normal, FEV1 to FVC ratio is normal (more than 0.7)
109
Describe pathophysiology of COPD
- Imbalance between the antioxidants and antiproteases
- Neutrophil infiltration linked with over production of antiproteases and reduced antioxidants
- Increased build up of damaging products from cigarette smoke, contributing towards epithelial cell injury and increased mucous production resulting in chronic bronchitis
- Reduced antiproteinases results in emphysema as lung is broken down, also linked to increased mucous production
- Combined results in COPD
110
Describe pharmacological management of COPD
- SABA (100mcg/puff start off with 2 puffs as needed, max 2 puffs 4 times a day) or SAMA as needed
- LABA and LAMA if no asthmatic features suggesting steroid responsiveness if still limited by symptoms
- LAMA and ICS if features suggesting steroid responsiveness
- LAMA, LABA and ICS if still not working
111
Define asthma
Chronic respiratory condition associated with airway inflammation and hyper-responsiveness
112
List what is looked for in general inspection in resp exam
- Accessory muscle use, pursed lips breathing
- Obvious chest wall deforminties
- Scars
- Medical paraphernalia
- Cigarettes
113
List what is looked for in inspection of hands in resp exam
- Clubbing
- Peripheral cyanosis
- Tar staining
- Tremor
- Capillary refill
- Small muscle wasting
- Mention or assess CO2 retention flap
114
List what is looked for in the face in resp exam
- Horners syndrome
- Conjunctival pallor
- Central cyanosis
- Hydration status
115
List what is looked for in closer inspection of the chest in resp exam
- Scarring
| - Pectus excavatum or carinatum
116
How is stepping up in asthma treatment determined?
- Symptoms 3 times a week
- SABA 3 times a week
- Waking once per week with symptoms
117
Describe severity of asthma attack
Moderate acute
- Increasing symptoms
- PEF 50-75% best
- No features of acute severe asthma
Acute severe asthma
- PEF 33-50% best
- Resp rate more than 25 per min
- Heart rate more than 110 per min
- Inability to complete sentences in one breath
Life threatening
- PEF<33%
- SpO2<92
- PaO2<8
- Normal PaCO2
- Altered conscious level, exhaustion, arrhythmia, hypotension, cyanosis, silent chest, poor respiratory effort
Near fatal
- Raised PaCO2 and/or requiring mechanical ventilation
118
How are asthma exacerbations managed in the community?
- Increase salbutamol use
- Quadrupule ICS for 14 days
- Oral prednisolone (for everyone)
- Check inhaler technique
- Follow up 48 hrs
- If lifethreatening must have hospital transfer
119
How is acute asthma managed in hospital?
- Sit patients up
- Oxygen, aiming for sats 94-98% (15L through non-rebreathe mask)
- Steroid therapy (IV or oral prednisolone 40mg)
- B agonist bronchodilator
- Anticholinergic broncodilator (ipatropium bromide)
- Other agents eg. antibiotics, assisted ventilation, magnesium sulphate, aminophyline (requires heart monitoring for hypokalaemia)
- Continue 5-7 days and monitor on the ward. Wean off O2 and discharge once PEF over 75%
120
List investigations performed in COPD
- Post-bronchodilator spirometry (FEV1:FVC less than 0.7), FEV1 less than 80% with scooped out low volume loop
- CXR (barrel chest - flattened diaphragm, more than 6 anterior ribs)
- CT thorax (fibrosis or bronchiectasis)
- FBC (high WCC, polycythaemia)
- ABG (Raised bicarb indicating chronic CO2 retention, type 2 resp failure)
- Sputum culture
- ECG for cor pulmonale
- MRC breathlessness scale
- Theophyline level in exacerbation
121
Describe treatment of exacerbation of COPD
- Oral steroids (prednisolone 30mg 5 days)
- Nebulised salbutamol ever 15 mins, ipatropium cant give over 3 in a row
- Oral antibiotics, amoxicillin, doxocycline, clarithromycin/ IV
- IV fluids
- Oxygen (30-40% target sats 88-92%, due to loss of hypercapnic drive - hypoxic drive instead)
- NIV (BiPAP, lower pressure makes it easier to breathe out CO2)
122
Describe end stage COPD treatment
- Relief of symptoms and QOL
- Advanced care plan
- MDT
- Optimise treatment based on symptoms
123
Describe managment of bronchiectesis
- Prophylactic antibiotics if over 3 exacerbations
- Pulmonary rehab
- Smoking cessation
- Immunisation (influenza and s.pneumoniae)
- Education for infective exacerbation
- Physiotherapy (airway clearance)
- Specialist follow up (deterioration)
124
Describe CURB-65
Determined need for hospital admission with pneumonia
- Confusion
- Urea over 7mmol/L
- Raised resp rate
- Low BP (diastolic less than 60 or systolic less than 90)
- Age over 65
Score 0-1 no risk factors manage at home
Score 0-1 with risk factors hospital admission on oral antibiotics
Score 2 hospital admission and consider IV antibiotics
Score 3+ hospital admission and IV antibiotics
125
List risk factors for poor prognosis with pneumonia
- Co-existing chronic illness eg. bronchiectasis
- Oxygen sats less than 92%
- PaO2 less than 8kPa
- Acidosis
- Bilateral or multilobar changes
- Emphyema on CXR
126
Describe management of pneumothorax
Primary
- <2cm discharge, repeat CXR. Tell to avoid strenuous exercise.
- >2cm OR SOB oxygen, aspiration 2nd ICS MCL, if unsuccessful chest drain
Secondary
- <2cm aspirate
- >2cm OR breathless chest drain
127
List causes of hilar lymphadenopathy
- TB (unilateral usually)
- Sarcoidosis (bilateral usually)
- Lymphoma (unilateral usually)
128
Define pneumothorax
- An abnormal collection of air in the pleural space – between the lung and the chest wall. They can be:
- Primary – no underlying lung disease.
- Secondary – to underlying lung disease – such as COPD
- They can also separately be classified as spontaneous or traumatic.
- Tension air in pleural space keeps getting larger
129
Describe epidemiology of pneumothorax
Primary
- Incidence form 4-40 per 100000 per year
- More common in men M:F 2.5:1
- Recurrence 20-25%
- Patients typically in their 20s
- Tension pneumothorax 1-2% of cases
130
List risk factors for pneumothorax
Primary
- Smoking (including smoking cannabis) – about 90% of cases occur in smokers – smoking probably increases the risk by causing airway inflammation. The risk is proportional to the amount smoked
- Family history – 25% of cases have an associated FHx
- Marfan Syndrome
- Homocystinurea
- Male
Secondary
- COPD
- Cystic fibrosis
- Lung malignancy
- Pneumonia
- TB
131
List symptoms of pneumothorax
- Sudden onset of SOB and pleuritic chest pain
| - More severe if secondary
132
List signs of pneumothorax
- Reduced breath sounds
- Hyperresonance to percussion
- Hypoxia with no hypercapnia
- Hypotensive, tachycardic, elevated resp rate if haemodynamically unstable
- Decreased chest expansion
- Tracheal deviation in tension
- Tactile vocal fremitus decreased
133
Describe investigation of pneumothorax
- Clinical diagnosis (dont wait for C ray)
- Simple air in pleural space with volume not increasing. Trachea not deviated, lung collapse may be visible
- Tension volume continuing to increase, trachea deviated away from side of lesion, obvious collapse
- Reduced lung markings
- Blood gases - hypoxia, respiratory alkalosis
134
List complications of pneumothorax
- Increased intrathoracic pressure
- Reduced venous return to the heart
- Cardiac arrest if not treated quickly
- Haemorrhage
- Respiratory failure
- Arrythmia
135
Describe prognosis of pneumothorax
- Small spontaneous resolve on their own
| - Secondary 1-17% mortality
136
What is compensated and decompensated respiratory failure?
- pH normal in compensated respiratory failure
| - pH low in decompensated respiratory failure - requires ventillation support
137
Describe investigation of PE
- Wells score over 4 CTPA, wells score under 4 D dimer firsst
- CT pulmonary angiogram, spiral is diagnostic
- Ventilation/perfusion scan to demonstrate perfusion defects and V/Q mismatch (used in patietns who cannot tolerate contrast)
- Use scoring system eg. wells score (>2 suggests may be PE, d dimer high also suggests may be PE)
- X ray (atelectasis, pleural effusion, elevation of hemidiaphragm), ECG
- Doppler of lower limbs
138
Describe management of PE
- ABCDE
- If haemodynamically unstable give oxgen and fluids, admit for thrombolysis (systemic or local using percutaneous embolectomy)
- If stable, risk stratify. If low risk, discharge with apixaban or rivaroxaban. If not suitable, LMWH followed by dabigatran or edoxaban, or if not suitable LMWH with vitamin K antagnoists
139
Describe x ray in pulmonary oedema
- Loss of costophrenic angles
| - White fluffy appearance bilaterally
140
Describe epidemiology of obstructive sleep aponea
In the UK
- 8 million stop breathing over 5 times an hour (24.5%)
- 1.5 million stop breathing over 15 times an hour (4.8%)
- 4% middle age men and 2% middle age women
141
Describe treatment of obstructive sleep apnoea
- CPAP (continuous positive airway pressure)
- Used if moderate - severe
- Generalised sleep therapy
- Engagement
- Goal setting
- Expectation management
- Alternatively, mandibular advancement split, positional devices to prevent sleeping on the back
142
List risk factors for obstructive sleep apnoea
- Male sex (the male to female ratio is 2–3:1).
- Obesity.
- Neck circumference greater than 43 cm.
- Family history of OSAS.
- Smoking.
- Alcohol intake before bed.
- Sleeping supine.
- Hypothyroidism.
- Craniofacial abnormalities
- Acromegaly
- In children adenotonsilar hypertrophy, obesity, congenital conditions
143
List signs of PE
- Tachycardia
- Tachypnoea
- Fever
- Hypoxia
- Elevated JVP
- Gallop rhythm, split second heart sound, tricuspid regurg
- Pleural rub
- Hypotension
144
Describe epidemiology of PE
- DVT and PE incidence of 100-200 per 100000 people
- Third most common cardiovascular disease
- PE 60-70 per 100000
145
List complications of PE
- Chronic thromboembolic pulmonary hypertension
| - Mortality
146
Describe prognosis of PE
- If untreated, high risk of death
- Following treatment, risk of recurrence especially if unprovoked
- If clinically massive, 20% death following treatment
147
List licensed biologics for use in severe asthma
- Anti IgE omalizmab
- Anti Il5 and anti Il5r (mepolisumab, esilizuman, benralizumab)
- Anti Il4R
148
Define severe asthma
- Requires treatment with high dose ICS plus a second controller to prevent from being uncontrolled or remains uncontrolled despite this therapy
- Frequent exacerbations, attacks and symptoms
149
Describe investigations of sarcoidosis
- Lymph node biopsy showing non-caseating granulomas (DIAGNOSTIC)
- Serum ACE raised in 60%, raised calcium, raised ESR
- CXR (symmetrical bilateral hilar lymphadenopathy, calcification around the borders of lymph nodes)
- Lung function tests - may show restrictive defect and reduced volume
- FBC
- Serum urea
- Raised calcium, LFTs, lymphocytes, ESR
- Exclude alternative diagnosis
- Bronchoscopy and biopsy
- ECG (arythmias, bundle branch block)
150
What causes increased/ reduced tactile vocal fremitus?
- Increased in consolidation, fibrosis
| - Decreased in pneumothorax, pleural effusion, blocked airway
151
Describe stages of sarcoidosis on CXR
- Stage 1 bilateral hilar and right paratracheal symmetrical lymph nodes
- Stage 2 additional parenchymal disease (peripheral pulmonary infiltrates)
- Stage 3 parenchymal disease with no lymph nodes
- Stage 4 fibrosis, bulla formation, pleural involvement
152
How is disease activity measured in sarcoid?
- Imaging (HRCT, FDG PET)
- Lymphocytosis on lavage
- Serum markers
- Serial lung function tests
153
Describe appearance of the liver in right sided heart failure
- Hepatomegaly
- Nutmeg liver
- Due to conslidation
154
List investigations for pneumonia
- Chest x-ray (consolidation, cavitation, pleural effusion) - FIRST LINE
- Pulse oximetry (low O2)
- Arterial blood gas (ABG)
- Urea and electrolytes
- Urine dip
- Full blood count
- C-reactive protein (CRP)
- Liver function tests
- Sputum culture/bronchoscopy/ bronchoalveolar lavage
- Blood culuture
- CT
- Chest ultrasound
- PCR
- If PE occurs, pleural fluid MCS by thoracentesis
155
Describe treatment of pneumonia
- Supportive care (fluids, analgesia, vasopressor, oxygen to keep PaO2 over 8kpa/ sats over 94%, VTE prophylaxis)
- CURB-65 0 oral amoxicillin
- CURB-65 1 or 2 hospital referral, co-amoxiclav if severe
- CURB-65 3 or 4 urgent hospital referral
- Atypical - clarithromycin
- Staph - flucloxacillin
- MRSA- vancomycin
- Pseudomonas - tazocin and genamicin
156
Describe epidemiology of pneumonia
- LRTI 3 million deaths 2016
- Annual incidence of CAP 1.54-1.7 per 10000 UK
- 5-11 per 100000
- Pneumococcal 5% deaths
- HAP is more common in patients in the intensive care unit, those who have recently had major surgery, and those who have been in hospital for a long time.
- It is associated with high morbidity and mortality because these patients are usually critically ill and have multiple comorbidities or severe frailty
157
List complications of pneumonia
CA
- Septic shock
- Acute respiratory distress syndrome (ARDS)
- Antibiotic-associated Clostridium difficile colitis
- Heart failure
- Acute coronary syndrome
- Cardiac arrhythmias short term
- Necrotising pneumonia
- Pleural effusion
- Lung abscess (swinging fever, persistent pneumonia and foul smelling sputum more common in staph)
- Pneumothorax
HA
- Empyema or lung abscess
- Systemic inflammatory response syndrome (SIRS) or sepsis with multi-organ system failure
- Pulmonary embolism/infarction variable
- Clostridium difficile colitis due to broad-spectrum antibiotic use
158
Describe prognosis of pneumonia
- CAP admitted to hospital 5-10% mortality. ICU 20-50%
- CAP readmission 7-12%
- HAP 30-70% mortality
159
List risk factors for hospital acquired pneumonia
- Poor infection control/hand hygiene
- Intubation and mechanical ventilation
- Multidrug-resistant bacteria
- Aspiration
- Acid-suppression drugs
- Depressed consciousness
- Chest or upper abdominal surgery
160
Describe treatment of hospital acquired pneumonia
Severe disease
- Intravenous antibiotics
- MRSA antibiotic cover (vancomycin)
- Supportive care
- Switch to pathogen-targeted therapy
Mild to moderate symptoms/signs and not at higher risk of resistance
- Oral antibiotics (amoxicillin)
- Supportive care
- Switch to pathogen-targeted therapy
161
Describe treatment of type 1 respiratory failure
CPAP
162
List signs of PE on ECG
- S1Q3T3
- Deep S in lead 1, deep q in lead 3, inverted T in lead 3
- RBBB
- Right axis deviation
- AF
163
Compare acute and chronic PE
- Acute massive collapse, central crushing pain and severe dyspnoea
- If acute submassive or small incomplete occlusion, pleuritic chest pain, haemoptysis and dyspnoea
- If chronic occlusion of microvasculature causing exertional dyspnoea
164
Describe epidemiology of acute respiratory distress syndrome
- 10-15% of patients in intensive care meet the criteria for ARDS
- 64 per 100000 people or 190000 per year in US
- Increased incidence in mechanically ventillated patients
- Mortality 30-50%
165
List risk factors for acute respiratory distress syndrome
- Trauma
- Pneumonia
- COVID
- Drugs
- Burns
- Acute pancreatitis
- DIC and sepsis
- Aspiration
- Blood transfusions
166
List investigations performed for acute respiratory distress syndrome
- Chest x-ray (bilateral infiltrates)
- Arterial blood gases (low O2)
- Sputum culture
- Blood culture
- Urine culture
- Amylase and lipase (pancreatitis as cause)
- Brain natriuretic peptide (BNP - low, exclude HF)
- Echocardiography
- Pulmonary artery catheterisation to measure pulmonary capillary wedge pressure (low indicates no HF)
- Bronchoalveolar lavage or endotracheal aspirate
- CT scan of the thorax
167
Describe epidemiology of TB
- 9.6 million new cases each year, of which 37% are underreported/diagnosed
- 3.3% of new cases and 20% of previously treated cases are drug resistant
- Co infection with HIV in 12% of new cases
- Leading cause of death worldwide, 1.5 mil annually
- UK 8000 cases per year, around 12 per 100000. 73% from outside UK, 70% deprived areas
168
List risk factors for drug resistant TB
- Previous treatment for TB
- Previous residence in area of high prevalence
- Contact with case of HIV/AIDS and TB
- Male gender
- Recent residence in London
169
Define aspergillus lung disease
- Aspergillus species are ubiquitously found as soil inhabitants. Inhalation of the aerosolised conidia (spores) causes the infection.
- The clinical spectrum varies from colonisation, allergy (e.g., allergic bronchopulmonary aspergillosis), asthma, or aspergilloma (fungal ball) to invasive disease, depending on host immune impairment.
- Neutropenia and compromised T-lymphocyte/macrophage function are key immune deficiencies predisposing to tissue invasion.
170
Describe epidemiology of aspergillus lung disease
- In US 2.4 cases per 100000 per year
Occurs in:
- Allogeneic stem cell transplantation (25%)
- Haematological malignancy (28%)
- Solid organ transplantation (9%)
- Pulmonary disease (9%)
- AIDS (8%)
- Autologous stem cell transplantation (7%)
- Immunosuppressive therapy (6%)
- Other underlying conditions (6%)
- Non-compromised hosts (2%).
171
Describe aetiology of aspergilous lung disease
- Environmental mould from soil
- Humans routinely inhale the aerosolised conidia.
- The conidia are promptly eliminated from the respiratory tract, or may lead to colonisation or infection dependent on the underlying local and general immune status of the host.
- Aspergillus fumigatus is the most common pathogenic species, accounting for 50% to 70% of the aspergillosis syndromes.
172
List symptoms of aspergilous lung disease
- Pleuritic chest pain
- Cough
- Headache
- Fever
- Congestion
- Haemoptysis
- Dyspnoea
- Facial pain
- Seizure
- Altered mental status
- Malaise
- Weight loss
- Cranial nerve palsy (invasive - space occupying lesion)
173
List risk factors for aspergillus lung disease
- Allogeneic stem cell transplantation
- Prolonged severe neutropenia (>10 days)
- Immunosuppressive therapy
- Chronic granulomatous disease (CGD)
- Solid organ transplantation (SOT)
- Acute leukaemia
- Aplastic anaemia
- Pre-existing cavity (aspergilloma)
- Advanced chronic lung disease
- Influenza infection
- Primary immunodeficiency
- HIV infection
- Diabetes mellitus
- Cystic fibrosis
- Severe burns
- Malnutrition
- Multiple myeloma
- Immunocompetent patients
- Age >55 years
- Smoking
- Asthma
174
List signs of aspergillus lung disease
- Fever
- Sinus tenderness
- Pleural rub
- Nasal ulcer
- Skin rash (erythematous slightly tender, raised lesion)
175
List investigations of aspergillus lung disease
- CXR (nodules, consolidation, non-specific infiltrates)
- High-resolution chest CT scan (nodules with a halo sign or air crescent sign)
- High-resolution sinuses CT scan (opacity or mass within the sinus cavity, bone erosion)
- High-resolution brain CT scan (space-occupying lesions with oedema, abscesses, haemorrhage)
- MRI sinuses
- MRI brain
- Serum Aspergillus galactomannan (GM) antigen by enzyme immunoassay (EIA) (2 positive results of optical index ration 0.5 or greater in the same blood culture)
- Sputum culture/ smear
- BAL Aspergillus galactomannan (GM) antigen
- Bronchoscopy with bronchoalveolar lavage (BAL) fungal stain
- Bronchoscopy with BAL fungal culture
- Polymerase chain reaction
- Serum (1-3)-beta-D-glucan
- Serum IgG, elevated IgE and eosinophilia
- Tissue biopsy (acute angular branching, filamentous septate hyphae with angioinvasion, tissue necrosis)
- Tissue fungal culture
- Tissue fungal stain
176
List possible consequences of aspergillous lung disease
- Asthma – type I hypersensitivity
- Allergic bronchopulmonary aspergillosis – type I and III hypersensitivity with recurrent asthma and bronchial damage and bronchiectasis.
- Mycetoma (aspergilloma) – fungus ball forming in a pre-existing lung cavity
- Invasive aspergillosis (in the immunosuppressed) with high mortality
- Extrinsic allergic alveolitis – recurrent dyspnoea and dry cough and ultimately fibrosis
177
List types of lung cancer and their proportion
- Adenocarcinoma approx 40%
- Squamous cell carcinoma approx 25-30%
- Small cell carcinoma approx 15%
- Large cell undifferentiated approx 10%
- Rare types are bronchoalveolar carcinoma and carcinoid, both approx 1% of all tumours, and unrelated to smoking
178
Define COPD acute exacerbation
Sustained worsening of the patients symptoms for his or her usual state, which is beyond normal day to day varitions and acute in onset. Commonly worsening breathlessness, cough, increased sputum production and change in sputum
179
Describe X ray appearances of TB
- Apical opacification
- Miliary TB (disseminated, all over the lung, white splotches)
- Fibrosis in chronic disease
- Calcification
- Cavitation
- Pleural effusion
- Hilar lymphadenopathy (usually unilateral)
180
List the most common cause of pneumonia in COPD patients
Haemophilius influenzae
181
Describe acronym for criteria of life threatening asthma
A basic method to remember most of the criteria for life-threatening asthma is the mnemonic "33 92 CHEST":
33: PEFR below 33% predicted.
92: Pulse oximetry below 92%
C: Cyanosis
H: Hypotension
E: Exhaustion
S: Silent chest (on auscultation)
T: Tachycardia (not always included under "life-threatening")
182
Describe abnormal tuberculin skin test result
Induration ≥5 mm:
- HIV patients
- Immunocompromised patients
- Person with recent contact with someone with active TB
- Person with fibrocystic changes on chest x-ray consistent with old TB
Induration ≥10 mm:
- Travel to country with high prevalence of TB within the past 5 years
- Injection drug user
- Resident or employee of high-risk setting (hospitals, prisons, homeless shelter, mycobacteriology lab)
- Children <4 years old
- Children exposed to adults with high-risk exposure
Induration ≥ 15 mm:
- Healthy person with no risk factors
