respiratory Flashcards
(136 cards)
1
Q
list symptoms of lung cancer
A
- persistent cough
- haemoptysis
- unexplained weightloss
- chest/shoulder pain
- hoarse voice
- SOB
2
Q
list signs of lung cancer
A
- chest pain
- haemoptysis
- fixed, monophonic wheeze
- finger clubbing
- subraclavicular lymphadenopathy / cervical lymphadenopathy
** signs of invasion / obstruction
3
Q
list characteristics of small cell lung cancer
A
- central
- worst prognosis, rapidly metastasis
- initially sensitive to chemotherapy
- arise from APUD cells
- rarely suitable for surgery
- hyponatremia (low Na in blood)
- associations: SIADH, Cushings syndrome, Lambert-Eaton syndrome
4
Q
list characteristics of squamous cell lung cancer
A
- central - hilum
- most common
- slow metastasis
- antigen = p63
5
Q
list characteristics of adenocarcinoma
A
- peripheral - ‘mass in mid zone’
- most common of non-smoker (most with it are tho)
- arises from mucus-secreting glandular cells
6
Q
give examples of squamous cell lung cancer
A
- parathyroid hormone-related protein (PTHrP) - causes hypercalcaemia (BONES, STONES, MOANS,psychiatric groans)
- hypertrophic pulmonary osteoarthropathy (HPOA) - causes periositis (inflammation of connective tissue over bone), finger clubbing, arthropathy of large joints
7
Q
list characteristics of large cell lung cancer
A
- peripheral
- anaplastic (poor cellular differentiation)
- poor prognosis
- metastasises early
- may secrete beta-hCG
8
Q
investigations for lung cancer
A
1st line = CXR
2nd line = HRCT - for staging, do even if normal CXR
- bronchoscopy - for biopsy
- endobronchial US
- PET - usually for NSCLC to see eligibility for curative treatment
- bone mets - radionuclide bone scanning
9
Q
treatment for lung cancer
A
- surgery - VATS (lobectomy), thoracotomy
- high dose dexamethasone - improve short term, remove oedema
10
Q
what is COPD
A
disease characterised by airflow limitation that is not fully reversible
11
Q
what is COPD?
A
disease characterised by airflow limitation that is not fully reversible
- bronchitis
- emphysema
12
Q
what is bronchitis?
A
- inflammation (neutrophilic) - causes wall destruction + excess mucus secretion
- hypertrophy - narrows lumen
- mucus hypersecretion - narrows lumen
- mucociliary dysfunction - prone to infections
13
Q
what is emphysema?
A
- destruction of alveolar walls
- loss of lung elastic recoil - increase in TLC
- less gas exchange - less o2 in blood
- trapped dead air in large space (hyperinflation)
- V/Q mismatch
14
Q
what causes COPD in non-smokers?
A
alpha-1 antitrypsin deficiency - autosomal recessive
failure to breakdown neutrophil elatase
15
Q
what are the 3 mechanisms of airflow limitation in small airways (<2mm in diameter?)
A
- loss of elasticity - due to emphysema
- inflammation and scarring
- mucus secretion - blocks airways
causing air trapping, hyperinflation, V/Q mismatch, increased work of breathing (SOB)
16
Q
symptoms of COPD
A
- productive cough - clear
- wheeze
- breathlessness
- frequent infections
17
Q
diagnosis of COPD
A
history
spirometry
- FEV1/FVC <70%
- FEV1 (post bronchodilator therapy)
- mild >= 80%
- moderate <80%
- severe <50%
- very severe <30%
18
Q
management of COPD
A
- smoking cessation
- pulmonary rehab
- vaccinations
- bronchodilators
- non-eosinophilic + infrequent exacerbator = LABA/LAMA
- eosinophilic and/or frequent exacerbator = ICS/LABA or ICS/LABA/LAMA
19
Q
give examples of LABAs
A
- formoterol
- salmeterol
- indacaterol
20
Q
give examples of LAMAs
A
- tiotropium
- aclidinium
- ipratropium
- oxitropium
21
Q
how are corticosteroids prescribed in patients with moderate/severe COPD?
A
prednisolone 30mg daily for 2 weeks
LFT before and after
if improvement
inhaled CS - beclametasone 40ug twice daily initially
22
Q
management of COPD exacerbation
A
- chest x-ray and ECG always done (differential diagnosis)
- careful history
- nebulised high dose salbutamol + ipratropium - oral
- prednisolone 30mg for 5 days
- antibiotic if consolidation/purulent sputum
- amoxicillin 500mg tds
- doxycycline 200mg 1st day, 100mg od for 5 days
23
Q
what are the different types of pneumonia?
A
community acquired = developed outside hospital
hospital acquired = developed more than 48hr after hospital admission
aspiration = inhaling foreign material
24
Q
symptoms of pneumonia
A
- purulent sputum - pneumococcal = rusty
- fever
- haemoptysis
- pleuritic chest pain - sharp and worse on inhalation
- SOB
- confusion
25
signs of pneumonia
- tachypnoea (raised RR)
- tachycardia
- hypotension
- bronchial breath sounds
- reduced chest expansion
- dull to percuss
- focal crackles
26
what scoring assessment is used for pneumonia?
```
C - new confusion
U - urea >7
R - respiratory rate >= 30/min
B - BP systolic <90 or diastolic <60
65 - age 65 or older
```
> 2 admit to hospital
27
investigations for pneumonia
- CXR - consolidation
- if normal repeat after 2-3 days
- repeated after 6 weeks to rule out malignancy causing pneumonia
- full blood count
- urea + electrolytes (U&E)
- CRP
- blood and sputum culture (moderate/severe)
28
what pneumonia causing bacteria is common in COPD patients?
H. influenza
29
what pneumonia causing bacteria is common in people who inject drugs?
staph. aureus
30
what pneumonia causing bacteria is common in aspiration pneumonia?
GI bacteria eg enterococcus
31
how does mycoplasma pneumonia present?
- usually younger people
- dry cough
test via PCR
32
how does legionella present?
- gives GI symptoms
- spread via water - think air con, hot tubs
test via urine antigen test
33
where could someone get chlamydia psittaci from?
birds
34
how would you treat severe / non severe community acquired pneumonia?
non severe = amoxicillin (doxycycline if pen allergic)
severe = co-amoxiclav + doxycycline
35
how would you treat severe / non severe hospital acquired pneumonia?
non severe = amoxicillin (doxycycline if pen allergic)
severe = amoxicillin + gentamicin
36
how would you treat severe / non severe aspiration pneumonia?
non severe = amoxicillin + metronidazole
severe = amoxicillin + metronidazole + gentamicin
37
how would you treat pneumonia causing legionella + mycoplasma pneumoniae?
levofloxacin or clarithromycin
** does not respond to doxycycline
38
what would the spirometry results of an obstructive airway disease look like?
FVC - normal or low
FEV1 - low
FEV1/FVC - low
eg asthma, COPD
if all low - could be combination of obstructive and restrictive
39
what would the spirometry results of a restrictive lung disease look like?
FVC - low
FEV1 - low
FEV1/FVC - normal
40
what are the forces keeping alveoli open?
- transmural pressure gradient - higher pressure inside alveoli than pleural cavity
- pulmonary surfactant
- alveolar interdependence - if starts to collapse, surrounding alveoli stretch then recoil exerting expanding force on alveoli
41
what effect does loss of elastic recoil have on residual volume and pulmonary compliance?
increases
42
what is pulmonary compliance?
change in lung volume per unit change in transmural pressure gradient across lung wall
- less compliant = more work required for inflation
decreased by - pneumonia, lung collapse, pulmonary fibrosis, pulmonary oedema
43
what are the consequences if perfusion > ventilation?
- increased co2 in alveoli - dilation of airways, airflow increases
- decreased o2 in alveoli - constriction of blood vessels, blood flow decreases
44
what are the 4 factors that influence rate of gas exchange across alveolar membrane?
1. partial pressure (pressure gas would exert if only gas) gradient of o2 and co2 - increase results in increase rate of transfer
2. diffusion coefficient (solubility of gas in membranes) for o2 and co2 (co2 20 times that of o2) - increase results in increase rate of transfer
3. surface area of alveolar membrane - increase results in increase rate of transfer, exercise increases surface area
4. thickness of alveolar membrane - increase results in DECREASE rate of transfer, thickness increased by pulmonary oedema, pneumonia
45
describe the shape of an haemoglobin oxygen saturation curve
sigmoid
- Flat upper portions means that moderate fall in alveolar PO2 will not much affect oxygen loading
- Steep lower part
means that the peripheral tissues get a lot of oxygen for a small drop in capillary PO2
46
describe cooperativity of haemoglobin
The binding of one oxygen molecule to deoxyhaemoglobin increases the oxygen affinity of the
remaining binding sites
47
what is the Bohr effect?
a shift in the oxygen saturation curve to the right due to increased release of o2 (reduced affinity)
due to:
- increased pCO2
- increased [H+]
48
give characteristics of myoglobin (Mb)
- present in skeletal and cardiac muscles
- one haem group
- no cooperative binding of o2
- dissociation curve hyperbolic
- releases o2 at very low pO2
- provides short-term storage of o2 for anaerobic conditions
- presence of myoglobin in blood indicates muscle damage
49
what is the Haldane effect?
removing o2 from Hb increases ability of Hb to pick up co2 and co2 generated H+
50
what are the neural steps to inspiration?
- rhythm generated by Pre-Botzinger complex in medulla
- excites *dorsal* respiratory group neurones (inspiratory)
- fire in bursts
- firing leads to contraction of inspiratory muscle = inspiration
when firing stops = passive expiration
51
what are the neural steps to "active" expiration during hyperventilation?
increased firing of dorsal neurones excites a second group = *ventral* respiratory group neurones
excites internal intercostals, abdominals etc = forceful expiration
52
how can the rhythm of breathing be modified?
the rhythm generated in the medulla can be modified by neurones in the pons
- pneumotaxic centre - stimulated when dorsal respiratory neurones fire, inhibits inspiration
- apneustic centre - their impulses excite inspiratory area of medulla, prolong inspiration
53
what events occur in lung development in the embryonic stage?
26days - 6weeks
- respiratory diverticulum forms
- initial branching to give lungs, lobes and segments
54
what event occurs in lung development in the pseudoglandular stage?
6-16weeks
14 more generations of branching: terminal bronchioles
55
at what stage do terminal sacs form and capillaries establish close contact?
saccular stage - 28-36weeks
as terminal sacs form, epithelial cells differentiate into 2 main cells: type I + II
56
what are the 2 types of cells that line alveoli walls?
type I = thin squamous epithelium
- form blood-air barrier - capillary network form close connections
- most of surface area of terminal sacs
type II = cuboidal
- produce surfactant
57
what is respiratory acidosis / alkalosis?
respiratory acidosis = increase [H+] due to increase pCO2
respiratory alkalosis = decrease [H+] due to decrease pCO2
58
what is metabolic acidosis / alkalosis?
metabolic acidosis = increase [H+] due to decrease HCO3-
metabolic alkalosis = decrease [H+] due to increase HCO3-
59
how does metabolism compensate for respiratory acidosis?
(too much CO2)
kidneys excrete H+ + simultaneously regenerates bicarbonate
60
name the cartilages of the larynx
- epiglottis - lid which stops food going down airways
- thyroid
- 2 arytenoid (posterior)
- cricoid
61
where is the rima glottidis?
larynx - narrowest part
- where air passes from URT to LRT
- where foreign bodies get stuck
- vocal cords are ligament which surround it
62
how is air warmed, humidified and cleaned?
warmed - via arterial blood supply of respiratory mucosa lining walls of nasal cavity
Humidified – via mucous produced by respiratory mucosa providing moisture
Cleaned – via sticky mucous trapping potentially infected particles
63
how many ribs are there?
12 pairs
- true = 1-7
- false = 8-10 (attach to common carilage - costal margin)
- floating = 11+12 - no attachment to sternum
64
what are the joints of the thoracic skeleton?
sternocostal joint
- between sternum and costal cartilage
- synovial
costochondral joint
- between rib and costal cartilage
- v limited movement
65
where is the neurovascular bundle found?
intercostal space - between internal and innermost inter coastal muscle layers
66
describe the role of conchae
conchae greatly increase the surface area of the lateral walls of the nasal cavities
conchae produce turbulent flow bringing the air into contact with the walls
67
at what point does the larynx and pharynx become the trachea and oesophagus respectively?
C6 vertebra
68
what are the posterior and anterior blood supplies to the intercostal spaces?
posterior
- thoracic aorta
- azygous vein
anterior
- internal thoracic artery
- internal thoracic vein
69
where does the muscular part of the diaphragm attach peripherally to?
- the sternum
- the lower 6 ribs and costal cartilages
- L1-L3 vertebral bodies
70
what are the phrenic nerves and where are they found?
the combined anterior rami of cervical spinal nerves C3, 4, 5 (keeps diaphragm alive)
found in
- neck on the anterior surface of scalenus anterior muscle
- chest (thorax) descending over lateral aspects of heart
71
what does the phrenic nerve supply?
- supplies somatic sensory and sympathetic axons to the diaphragm and fibrous pericardium
- supplies somatic motor axons to the diaphragm
72
at what point does the subclavian vein and artery become the axillary vein and artery?
once they pass the 1st rib
73
where would abnormal fluid in the pleura drain to?
costodiaphragmatic recess (most inferior)
- located between diaphragmatic parietal pleura and costal parietal pleura
- left base descends into here during FULL inspiration
74
where do you auscultate the lung apex?
root of the neck - superior to medial third of clavicle
75
where do you auscultate the middle lobe?
between ribs 4 and 6 in the mid-clavicular and midaxillary lines
76
where do you auscultate the lung base?
in the scapula line (posterior) at T11 vertebral level
77
which cranial nerves sensory receptors are stimulated in sneexing?
CN V or CN IX
78
which cranial nerves sensory receptors are stimulated in coughing?
CN IX or CN X
79
what are carotid sheaths and what do they contain?
protective tubes of cervical (neck) deep fascia - attach superiorly to the bones of the base of the skull
contains:
- vagus nerve
- internal carotid artery
- common carotid artery
- internal jugular vein
80
list the 3 steps of inspiration mechanics
1. diaphragm contracts and descends - increases vertical chest dimension
2. intercostal muscles contract elevating ribs - increases A-P and lateral chest dimensions
3. chest wall pulls the lungs outwards with them (pleura) - creates -ve pressure so air flows into lungs
81
what are the 3 muscles of normal inspiration?
1. external intercostal
2. internal intercostal
3. innermost intercostal
82
what are the accessory muscles of forced inspiration?
- pectoralis major - attaches between sternum + humerus
- pectoralis minor - pull ribs 3-5 up
- sternocleidomastoid - attaches between clavicle and mastoid process
- scalenus anterior, medius and posterior - under sternocleidomastoid, attach between cervical vertebrae and rib 1+2
* use of accessory muscles is a sign of dyspnoea
83
list the steps of coughing
1. STIMULATION of sensory receptors in mucosa
2. deep inspiration using diaphragm (phrenic nerves), intercostal muscles and accessory muscles
3. adduction of vocal cords to close the rima glottidis (vagus nerve)
4. contraction of anterolateral abdominal wall muscles to build up intra-abdominal pressure which pushes the diaphragm superiorly and builds up pressure un chest inferior to adducted vocal cords
5. vocal cords suddenly abduct to open the rima glottidis
6. soft palate tenses (CN V) and elevates (vagus nerve) to close entrance to nasopharynx so goes through oral cavity as cough n not nasal as sneeze
84
list the steps of expiration mechanics
1. diaphragm relaxes and rises - decreases vertical thoracic dimension
2. intercostal muscles relax lowering ribs - decreases A-P and lateral chest dimensions
3. elastic tissue of lung recoils - pushes air out of lungs
85
list the anterolateral abdominal wall muscles
left and right:
- rectus abdominis
- external oblique
- internal obligue
- transverse abdominus
* used in forced expiration
86
at what point does the LRT begin?
C6 vertebra
87
what is an anatomical landmark for cardiopulmonary resuscitation?
xiphoid process
88
what carries deoxygenated blood, drains into superior vena cava and arches round right main bronchus?
azygous vein
89
what carries oxygenated blood and are sited inferoposteriorly within lung root?
pulmonary vein
90
where is the horizontal fissure?
right 4th rib
91
where is the carina?
rib 2 level
92
where is the oblique fissure posteriorly and anteriorly?
posteriorly - T3 vertebra
| anteriorly - rib 6
93
what stage of lung maturation happens at 16-28 weeks and what happens?
canalicular
| - branching of terminal bronchioles into respiratory bronchioles and then alveolar ducts
94
which germ layer forms the lining of the trachea and bronchial tree?
endoderm
95
what does the visceral mesoderm form in the respiratory system?
cartilage and smooth muscle in the thorax
96
what type of cells line the roof of the nasal cavity?
olfactory epithelium
| - involved in smell and taste
97
what type of cells line the main bronchi?
pseudostratified ciliated columnar epithelium and goblet cells with hyaline cartilage rings and cartilage plates
98
what do cuboidal epithelium and non-ciliated clara cells line?
terminal bronchioles
99
what are clara cells?
a non-ciliated cell found in terminal bronchioles
- act as an immune modulator and stem cell
- able to produce surfactant
100
what is subcutaneous omalizumab?
a monoclonal antibody against IgE that also reduces IgE receptor expression
101
what is a synthetic glucocorticoid used to prevent inflammation in chronic asthma?
inhaled beclometasone
102
what does law of LaPlace state?
smaller alveolar radius = higher tendecy to collapse
103
what is daltons law?
total pressure of a mixture of gases = sums of partial pressures of each component gas
104
what is henrys law?
the amount of a gas dissolved in a given type and volume of liquid at constant temperature is proportional to the partial pressure of the gas in equilibrium with the liquid
105
how is most co2 transported?
as bicarbonate
106
what is the difference between SAMA/LAMA and SABA/LABA?
muscarinic receptor antagonists
- reduce bronchospasm
- decrease mucus secretion
beta2-adrenoreceptor agonist
- bronchodilator
107
what can peripheral chemoreceptors detect?
arterial oxygen partial pressure - when stimulated they cause hyperventilation and increased cardiac output
* can compensate for metabolic acidosis
108
list extrinsic factors that could present as a restrictive lung disease
```
THORACIC:
obesity
kyphoscoliosis
ascites
diaphragmatic palsy
```
NEUROPATHY: motor neurones
PLEURAL DISEASES: mesothelioma
109
what is a normal mPAP?
what value would imply pulmonary hypertension?
normal = 12-20mmHg
pulmonary hypertension = 25mmHg
110
give examples of DOACs
rivaroxaban
| apixaban
111
what is tidal volume?
amount of air inspired or expired in a normal breath at rest (0.5)
112
what is FVC?
(forced) vital capacity - volume of air exhaled after forced/maximal expiration
113
what is FEV1?
forced expiratory volume - volume that has be exhaled after the first second of forced expiration
114
give an example of a leukotriene receptor antagonist (LTRA) and list uses / possible side effects
montelukast
- patients with allergic rhinitis and asthma
- abdominal pain + headaches
115
give an example of a xanthine and list uses / possible side effects
theophylline
- increased mucus clearing - asthma
- N+V, abdo discomfort, headaches
116
give an example of a monoclonal antibody treatment and list uses / possible side effects
omalizumab - against IgE
- allergic asthma
- abdo pain, pyrexia
117
give examples of short and long acting muscarinic Ach antagonists
SAMA = ipratropium (non-selective)
LAMA = tiotropium (selective for M3 receptors)
118
give examples of both inhaled and oral corticosteroids
inhaled = beclomethasone
oral = prednisolone
119
what would sodium cromoglicate be used for?
allergic asthma and allergic rhinitis
| in kids
120
give examples of short and long acting beta2-adrenoceptors
SABA = salbutamol
LABA = salmeterol, formoterol
121
what happens in type I hypersensitivity reaction?
Allergic
- immediate response after exposure
- IgE stimulates overproduction of mast cells, basophils and eosinophils
- results in rapid degranulation - release of vasoactive + inflammatory substances
- IgE mediated (adaptive - Th2>Bcells>IgE)
- innate - mast cells, eosinophils
122
what happens in type II hypersensitivity reaction?
Bound antigens to antiBodies
- mins/hours
- IgM/IgG mediated
- these react with cell surface antigens stimulating inflammatory response + tissue damage
- mediated by complement system proteins (MAC), phagocytes, natural killer cells
example = goodpastures syndrome - lungs (pulmonary alveolar haemorrhage, kidney disease
- plasmapheresis
123
what is empyema?
A collection of pus in the pleural space, which can be seen on a chest X-ray as a D-shaped abnormality.
124
The commonest cause of bronchiolitis. Diagnosis is by PCR on throat or pernasal swabs. Treatment is supportive.
Respiratory syncytial virus
125
what happens in a type III hypersensitivity reaction?
immune Complex
- few hours after exposure (flu-like)
- antibody binds to antigen(soluble) forming lots of immune complexes
- antigens come from inhaled particles - farmers/bird lung
- can circulate or gather in spaces (joints(arthritis), small vessels(vasculitis))
- presence of immune complexes attract neutrophils which cause damage (also complement proteins)
example = systemic lupus erythematosus
126
what happens in a type IV hypersensitivity reaction?
Delayed
- T cell mediated activation of macrophages (no antibodies) - CD4+>Th1>macrophage recruitment
- takes daysss
- granulomas
- lots of macrophages at reaction site
127
what does pulmonary oedema do to lung compliance?
reduces lung compliance
128
what effect does pulmonary oedema have on hydrostatic and interstitial pressure respectively?
both are increased
129
what is the most posteriorly located structure in the lung root?
vagus nerve
130
how do the pulmonary arteries respond to the presence of hypoxia?
constrict
131
which gas law is relevant in respiratory distress syndrome of premature new born babies?
insufficient surfactant
Law of La Place
--> it states that the tension exerted on a spherical wall of set pressure is inversely proportional to that sphere’s thickness
132
Which neurotransmitter acts on muscarinic receptors and what is its action in the airways?
Acetylcholine, constriction of the airways
--> hence the use of muscarinic antagonists like ipratropium and tiotropium in asthma and COPD to reverse this effect
133
what is the difference between foetal and adult haemoglobin?
foetal haemoglobin has 2alpha +2 gamma subunits instead of beta subunits causing it to have a high affinity for oxygen that adult Hb
134
where is the horizontal fissure anatomically?
anterior aspect of rib 4
135
features of life-threatening asthma
```
PEFR < 33%
oxygen sats < 92%
silent chest, cyanosis
brady cardia, dysrhythmia, hypotension
exhaustion, confusion, coma
```
136
features of severe asthma
PEFR 33-55%
can't complete sentences
RR > 25/min
pulse >110 bpm
