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3B > Respiratory > Flashcards

Respiratory Flashcards

1
Q

Asthma aetiology and triggers

A

Type 1 hypersensitivity

Maternal smoking
Atopy
Hygiene hypothesis
Viral illness
Occupation - Flour

Triggers - CHIPEES

  • Cold
  • House dust mites
  • Infection
  • Pets/pollen
  • Exercise
  • Emotion
  • Stress
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2
Q

Asthma pathophysiology

A

ATOPIC

Irritant allergen binds to IgE

Mast cells stimulate an increase in…

  • Leukotrines
  • Histamine
  • TNF-a

This causes…

  • Increased smooth muscle contractility
  • Hypersecretion of mucus
  • Increased vascular permeability

6 hours later…

  • Airway remodelling
  • Airway hypersensitivity
  • Increased goblet cells
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3
Q

Asthma presentation and investigations

A

Diurnal variation

  • Cough
  • Wheeze
  • Dyspnoea
  • Harrison’s sulci
  • Hyperinflation

Investigations - Spirometry - LuFTs

  • FEV1 / FVC < 70% - Obstructive
  • PEF diurnal variation > 20%
  • FEV1 bronchodilator reversibility > 12%
  • FeNO > 40ppb
  • CXR - Hyperinflation
  • Occupational asthma - Weekday/weekend PEF diary
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4
Q

Asthma management - Chronic

A

Try each for 3 weeks before escalating…

  1. SABA - Salbutamol
  2. SABA + ICS (Betamethasone)
  3. SABA + ICS + LTRA (Montelukast)
  4. SABA + ICS + LABA (Salmeterol)
  5. SABA + LTRA + MART (LABA + low-dose ICS)
  6. SABA + LTRA + MART (LABA + moderate-dose ICS)
  7. SABA + LTRA + MART + Theophylline
  8. Refer…

CI medications - NSAIDs / BBs

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5
Q

Asthma housekeeping

  • Severity
  • Questionnaire
  • Response to treatment
A

Assessing severity

  1. How many steroid courses in the past year
  2. How many hospital admissions
  3. ICU admissions

RCP3 questions - AST

  1. ADLs affected?
  2. Symptoms during the day?
  3. Trouble sleeping?
Poor response to treatment - ABCDE
Adherence (compliance)
Bad disease
Choice of drug
Diagnosis
Environment
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6
Q

Asthma attack severity

A

Moderate

  • PEF > 50% predicted
  • SpO2 > 92%
  • Able to speak in full sentences

Severe

  • PEF 33-50%
  • SpO2 < 92%
  • Unable to speak in full sentences

Life-threatening

  • PEF < 33% predicted
  • SpO2 < 92%
  • Silent chest / Brady / Cyanosis / Altered consciousness

PaCO2 normal = Exhaustion = Life-threatening

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7
Q

Asthma management - Acute

A

O SHIT ME

O2
Salbutamol - Nebulised - Repeat up to 3x
Hydrocortisone IV or Prednisolone PO (if tolerated)
Ipatropium - Nebulised - Repeat up to 3x

Theophylline IV (not used much)

Magnesium IV

Escalate - Anaesthetists - Intubation

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8
Q

COPD aetiology and presentation

A 
Smoking
A1AT deficiency
Coal
Cement
Cotton
Grain

Presentation

  • Cough - Productive
  • Dyspnoea
  • Recurrent infections

On examination

  • Wheeze
  • RHF - Cor pulmonale
  • Barrel chest
  • CO2 retention flap
  • Hyper-resonant chest
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9
Q

COPD investigations

A

Spirometry - LuFTS

Severity - FEV1

  • Mild > 80
  • Moderate 50-80
  • Severe 30-50
  • Very severe < 30

FEV1 / FVC < 70% - Obstructive

SpO2
ABG - Hypoxia, hypercapnia, respiratory acidosis
CXR - Hyperinflation, bullae, flattened hemidiaphragms
FBC - Exclude secondary polycythaemia

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10
Q

COPD management

A 
Stop smoking
Vaccinations - Influenza / Pneumococcal
Pulmonary rehab
Prophylactic abx - Azithromycin (can cause long QT)
Mucolytics - Acetylcysteine
  1. SABA (Salbutamol) or SAM (Ipatropium)
  2. Switch SAMA to SABA
    Non-steroid responsive - LABA (Salmeterol) + LAMA (Tiotropium)
    Steroid responsive - LABA + ICS (Beclamethasone) ± LAMA
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11
Q

COPD steroid responsive features

A

FEV variation over time > 400ml
Diurnal PEF variation
Eosinophils ^
Atopy / Asthma

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12
Q

COPD indications for LTOT

A

2 ABG readings 3 weeks apart

PaO2 < 7.3

OR

PaO2 7.3-8.0 + One of the following…

  • Secondary polycythaemia
  • Nocturnal hypoxia
  • Pulmonary HTN
  • Peripheral oedema suggestive of CCF
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13
Q

COPD common infections / exacerbation management / complications

A

HiB - Most common
Moraxella catarrhalis
Strep pneumonia

Exacerbation management

  • Increase SABA dose
  • Short course of corticosteroids
  • Abx if indicated
  • In hospital - Give O2 and nebulisers

Complications

  • Recurrent infections / exacerbations
  • Depression
  • Type 2 RF
  • Secondary polycythaemia
  • Pulmonary HTN - Cor pulmonale
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14
Q

Bronchiectasis aetiology

A

Previous infection

  • Pneumonia
  • TB
  • Bordetella
  • Measles

RA
IBD
CF
Kartagener’s

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15
Q

Bronchiectasis presentation

A 
Productive cough
Clubbing
Crackles
Haemoptysis
Weight loss

Recurrent infections

  • HiB
  • Strep pneumonia
  • Klebsiella
  • Pseudomonas
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16
Q

Bronchiectasis investigations and management

A

FEV1 / FVC decreased - Obstructive
CT - Dilated bronchioles
Sputum culture
Bronchoscopy - Rule out malignancy

Management

  • Mucolytics - Carbocysteine
  • PT
  • Vaccinations - Influenza / Pneumococcal
  • Bronchodilators - Salbutamol
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17
Q

PE risk factors and presentation

A 
OCP
Pregnancy
Malignancy
Recent immobility - Surgery
Thrombotic disorder - Thrombophilia

Presentation

  • Sharp pleuritic chest pain - Worse on inspiration
  • Dyspnoea
  • Cough (+ Haemoptysis)
  • Tachycardia
  • Tachypnoea
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18
Q

PE investigations

A

Wells score > 4 - Request CTPA - Gold standard
(VQ scan is alternative)

Wells score < 4 - D-dimer
D-dimer positive - Request CTPA

CXR - Rule out differential
ECG - Rule out differential - Sinus tachycardia (S1Q3T3)

PERC score - Should all be NEGATIVE to rule out PE

  • Age > 50
  • HR > 100
  • SpO2 < 94%
  • Previous DVT/PE
  • Recent surgery or trauma < 4 weeks
  • Haemoptysis
  • Unilateral leg swelling
  • Oestrogen use
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19
Q

Wells score

A

PAD THAI

Previous VTE
Alternative diagnosis not likely
DVT signs/symptoms
Tachycardia > 100bpm
Haemoptysis
Active malignancy
Immobilisation for 3/7 or surgery in the last 4/52
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20
Q

PE management

A

DOAC - Do not wait if Wells > 4 and CTPA not immediately available
Renal impairment - LMWH

Alteplase - If haemodynamically unstable

Continue DOAC on discharge…

  • 3 months if PE provoked
  • 6 months if PE unprovoked
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21
Q

Pneumonia causative organisms

A

Typical

  • GBS
  • Listeria
  • HiB
  • Strep P
  • TB
  • Klebsiella - Alcoholics
  • Pneumocystitis pneumoniae

Atypical

  • Mycobacterium pneumoniae
  • Legionella
  • Chlamydia pneumonia
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22
Q

Pneumonia presentation and investigations

A

Cough - Productive
Dyspnoea
Systemic features - Fever, tachycardia, tachypnoea

Investigations - CURB-65

  • Confusion - AMT < 8/10
  • Urea > 7
  • RR > 30
  • BP < 90/60
  • Age > 65
Sputum sample - MC&S
CXR - Consolidation
Septic screen?
Urinary antigen for Legionella
Serum electrolytes - Hyponatraemia in Legionella
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23
Q

Pneumonia management

A

0-1 - Treat in community - PO Amox
2 - Consider admission - PO Amox + Clari
3-5 - ICU admission - IV Co-amox + Clari

Pen allergy - Doxy or Clari
Atypical - Clari

HAP - As per local policy

  • Co-amox
  • Taz
  • Cefuroxime
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24
Q

Pneumothorax aetiology

A

Primary

  • Male
  • Sport

Secondary

  • RA
  • IBD
  • COPD - Bullae
  • Cancer
  • Asthma
  • CF
  • Ventilation
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25
Q

Pneumothorax presentation and investigations

A

Dyspnoea
Chest pain - Pleuritic
Cough

Absent breath sounds
Hyper-resonance
Unequal chest expansion

Tension pneumothorax - Deviated trachea - Respiratory distress

Investigations

  • CXR - Radiolucency
  • ECG - Rule out differentials
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26
Q

Pneumothorax management and complications

A

Primary
0-2cm - OPD CXR
> 2cm - Aspirate
Failed - Chest drain

Secondary
0-1cm - Monitor 24 hours - IP CXR
1-2cm - Aspirate
> 2cm or failed - Chest drain

Tension pneumothorax
Immediate aspiration - 14G cannula

Flail chest - Good knowledge but unsure why this is here
- 3 or more ribs broken in 2 or more places
OR
- More than 5 adjacent rib fractures

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27
Q

Pulmonary fibrosis aetiology

A

Upper zone - SCRATcHES

  • Sarcoidosis
  • Coal-workers pneumoconiosis
  • Radiation
  • Anky spond
  • TB
  • c
  • Histiocytosis
  • Extrinsic allergic alveolitis
  • Silicosis

Lower zone - RAID

  • RA
  • Asbestosis
  • Idiopathic pulmonary fibrosis
  • Drugs - Bleomycin, Amiodarone, Methotrexate
28
Q

Pulmonary fibrosis presentation and investigations

A

DDDD

  • Dyspnoea
  • Dry cough
  • Diffuse inspiratory crackles
  • Digital clubbing

Investigations -Investigate cause

  • high resolution CT - Ground glass appearance
  • FEV1/FVC > 80% - Restrictive
  • Reduced transfer factor
  • CXR - Shaggy heart border
29
Q

Pulmonary fibrosis management and complications

A

Treat cause!

  • Pulmonary rehab
  • Vaccinations
  • Pirfenidone
  • LTOT
  • Transplant

Complications

  • P.HTN
  • Type 2 RF
  • Cachexia
  • Depression
30
Q

Sarcoidosis

A

Type IV hypersensitivity

  • Afro-Caribbean
  • 20-40

Presentation

  • Lungs - Fibrosis upper
  • Lymphadenopathy
  • Eyes - Anterior uveitis
  • MSK - Arthralgia
  • Skin - Lupus pernio and erythema nodosum
  • Other - Cardiomyopathy, Bells palsy, parotitis

Investigations

  • CXR - Bilateral hilar lymphadenopathy, upper zone fibrosis
  • ACE ^
  • Serum calcium ^
  • Biopsy - Non-caseating granuloma

Management

  • Asymptomatic - Bed rest
  • Moderate / Severe - Pred PO
31
Q

TB aetiology / presentation

A

Mycobacterium Tuberculosis

RF - Homelessness

Presentation

  • Night sweats
  • Fever
  • Cough + Haemoptysis
  • Weight loss
32
Q

TB investigations

A

CXR - Bilateral hilar lymphadenopathy and upper zone fibrosis
Biopsy - Caseating granuloma
Sputum sample - ZN stain for AFB

Mantoux test
< 6mm - Never exposed
6-15mm - Previous exposure
> 15mm - Active TB

PCR - NAAT
Culture - Lowenstein Jensen

LFTs + ^Ca
Visual acuity

33
Q

TB management and side-effects

A

RIPE

Rifampicin - 6 months

  • Orange secretions
  • Flu-like symptoms
  • CP450 inducer
  • Hepatitis

Isoniazid - 6 months

  • CP450 inhibitor
  • Hepatitis
  • Peripheral neuropathy

Pyrazinamide - 4 months

  • Hepatitis
  • Arthralgia
  • Gout

Ethambutol - 4 months
- Optic neuritis

34
Q

Lung cancer aetiology and presentation

A

Smoking!

Cough + Haemoptysis
Pleuritic chest pain
Weight loss
Clubbing

Apical tumour

  • SVCO
  • T1 wasting
  • Hoarse voice
  • Horner’s syndrome

Metastases

  • Bone
  • Brain
  • Liver
  • Adrenals
35
Q

Lung cancer types

A

Small-cell carcinoma

  • Lambert-Eaton syndrome (MG)
  • ADH - SiADH - Hyponatraemia
  • ACTH - Cushing’s

Squamous cell carcinoma - 35%

  • PTH
  • Hyperthyroid
  • HPOA

Adenocarcinoma - Not related to smoking

  • Gynaecomastia
  • HPOA
  • Peripheral features

Large-cell carcinoma

  • bHCG
  • Peripheral features*******
36
Q

Lung cancer investigations and management

A

CXR
CT + Biopsy
PTH and calcium profile

Sodium - LES in SC
Dexamethasone suppression - ACTH
Desmopressin test - SiADH

Management

  • Non-SC - Surgial excision / Pneumonectomy
  • SC - Surgery only in T1 N0 M0
37
Q

ARDS aetiology and presentation

A

Alveolar oedema due to increased vascular permeability

Pancreatitis
Shock - Sepsis
Trauma
DIC
Burns

Presentation

  • Dyspnoea
  • Tachypnoea
  • Persistent low SpO2 despite ventilation / oxygenation
  • Bibasal crackles
38
Q

ARDS criteria and management

A

pANiC

  1. pO2 < 40
  2. Acute
  3. Not attributed to cardiogenic cause
  4. CXR - Pulmonary oedema

Management - Treat cause

  • B1 agonist - Dobutamine
  • CPAP - Mechanical ventilation
  • ITU ventilation
39
Q

Pleural effusion aetiology

A

Transudate - Protein < 30

  • HF
  • Cirrhosis
  • Hypoalbuminaemia - Nephrotic
  • Hypothyroid
  • Meig’s syndrome

Exudate - Protein > 30

  • Malignancy
  • TB
  • Connective tissue - RA
  • Pancreatitis
  • Pneumonia
  • PE
40
Q

Pleural effusion criteria and presentation

A

Light’s criteria - Protein 25-35 - More likely to be exudate if…

  • Pleural protein / Serum protein > 0.5
  • Pleural LDH / Serum LDH > 0.6
  • Pleural LDH > 2/3 upper limit
Pleuritic chest pain
Dyspnoea
Cough
Dullness on percussion
Decreased breath sounds
41
Q

Pleural effusion investigations and management

A

CXR - Blunted costophrenic angles

USS + Pleuritic tap

  • LDH
  • Protein
  • Cytology
  • Gram staining

Investigate cause!

Management - Treat cause + Observe

  • Pleural tap - Diagnostic and therapeutic
  • Chest tube - If purulent or pH < 7.2
  • O2 if sats < 94%
  • Pleurodesis - Talc
42
Q

Asbestos related disease presentation

A 
Pleural plaques - 20-40 years latency
Pleural thickening
Asbestosis - Lower zone fibrosis - 15-30 years
Mesothelioma
Lung cancer

Fibrosis symptoms - DDDD

  • Dyspnoea
  • Dry cough
  • Diffuse end inspiratory crackles
  • Digital clubbing
43
Q

Asbestos related disease investigations and management

A

CT - Fibrosis and pleural plaques

Management

  • Pulmonary rehab
  • Vaccinations
  • Pirfenidone
  • LTOT
  • Transplant
44
Q

Mesothelioma

A

Aetiology - Asbestos

Presentation

  • Pleural effusions
  • Pleuritic chest pain
  • Dyspnoea
  • Cough + Haemoptysis
  • Weight loss

Investigations

  • CXR - Effusion
  • CT + Biopsy

Management - Palliative (+ Compensation)
Prognosis - 8-14 months

Notify the coroner!

45
Q

Extrinsic allergic alveolitis aetiology and presentation

A

Type 3 hypersensitivity

  • Farmer’s lung
  • Malt worker’s lung
  • Bird fancier’s lung
  • Mushroom worker’s lung

Presentation - The 4 Ds

  • Dyspnoea
  • Dry cough
  • Diffuse end inspiratory crackles
  • Digital clubbing
46
Q

EAA / Coal worker’s lung

Investigations and management

A

Restrictive picture - FEV1/FVC > 80%
CXR/CT - Upper zone fibrosis - Ground glass with honeycombing

Management

  • Remove allergen
  • O2 therapy if acute
  • Prednisolone
  • Advice - Eligible for compensation
47
Q

Coal worker’s lung aetiology and presentation

A 
Coal dust particles ingested by macrophages
Macrophages die and release enzymes
Enzymes cause fibrosis
May progress to massive pneumoconiosis
- Round fibrotic masses
- Black sputum

Presentation - The 4 Ds!

  • Dyspnoea
  • Dry cough
  • Diffuse end inspiratory crackles
  • Digital clubbing
48
Q

Goodpasture’s

A

Aetiology

  • Anti-GBM antibodies
  • Destroy type 4 collagen
  • Associated with HLA-DR2

Presentation - Blood

  • Haemoptysis
  • Haematuria

Investigations

  • Anti-GBM
  • U&Es
  • Renal biopsy
  • CXR - Rule out other causes of haemoptysis

Management

  • Steroids
  • Plasma exchange
49
Q

Silicosis

A

Aetiology

  • Construction workers
  • Pottery workers
  • Miners

Presentation - 4 D’s

Investigations

  • Egg shell calcification of hilar lymph nodes
  • CXR - Ground glass and honeycombing
  • Restrictive picture - FEV1/FVC > 80%

Management

  • Pulmonary rehab
  • Vaccinations
  • Pirfenidone
  • LTOT
  • Transplant
50
Q

Allergic bronchopulmonary aspergillosis

A

Aetiology - Allergic to aspergillus fumigatus
- Associated with atopy and bronchiectasis

Presentation

  • Cough
  • Dyspnoea
  • Wheeze

Investigations

  • Eosinophils ^
  • IgE ^
  • RAST - Aspergillus
  • CXR - Tram track opacities

Management

  • Itraconazole
  • Steroids
51
Q

Pulmonary HTN

A

mPAP > 25

Aetiology

  • COPD
  • Fibrosis
  • CVD

Presentation

  • Progressive SOBOE
  • Exertional syncope
  • Symptoms of RHF

Examination

  • Raised JVP
  • Loud S2
  • Right ventricular heave
  • Tricuspid regurgitation

Investigations - Pulmonary arterial pressures

Management - Vasodilator testing
+ve - CCB
-ve - Sildenafil / Prostacyclin analogue (Iloprost)

52
Q

Oxygen delivery methods

A

Nasal cannulae - 24-30%

  • 1-4L
  • Non-acute or mildly hypoxic patients

Venturi mask - 24-60%

  • Blue - 2-4L - 24%
  • White - 4-6L - 28%
  • Yellow - 8-10L - 35%
  • Red - 10-12L - 40%
  • Green - 12-15L - 60%

Non-rebreather - 85-90%

  • 15L
  • Acutely unwell patients

Intubation - GCS < 8

53
Q

CPAP vs BiPAP

A

CPAP - Uses your own respiratory rate

  • Pneumonia
  • Type 1 RF
  • Obstructive sleep apnoea
  • Heart failure

BiPAP - Patients too weak to breathe out

  • COPD
  • Atelectasis
54
Q

Respiratory acidosis

A

Hypoventilation - Unable to blow off CO2

COPD
Asthma attack
Opioids
Obesity
GBS
MG
55
Q

Respiratory alkalosis

A

Hyperventilation - Blowing off too much CO2

Anxiety
Hypoxia
Acute pulmonary insult
Pneumonia
Asthma attack
Pulmonary oedema
56
Q

Metabolic acidosis

A 
Increased anion gap = Acid added to body
MUDPILES
- Methanol
- Uraemia
- DKA
- Propylene glycol
- Iron / Isoniazid
- Lactate
- Ethylene glycol
- Salicylates

Normal anion gap…

  • Retaining H+ - Renal tubular acidosis, Addisons
  • Losing HCO3- - Diarrhoea
57
Q

Type 1 RF

A

1 gas abnormal
O2 = LOW
CO2 = NORMAL

V/Q mismatch

Low V/Q - Perfused but not ventilated - Airway obstruction

  • Mucus plug - Asthma
  • COPD
  • Airway collapse in emphysema

High V/Q - Ventilated but not perfused
- PE

CO2 normal because venilated/perfused areas can blow off extra CO2 by increasing ventilation rate
O2 is low as extra oxygen cannot be absorbed - Maximum amount is already absorbed under normal circumstances

58
Q

Type 2 RF

A

2 gases abnormal
O2 = LOW
CO2 = HIGH

Alveolar hypoventilation

  • O2 can’t get in
  • CO2 can’t get out
Obstructive lung disease - COPD
Restrictive lung disease
Decreased respiratory drive
Neuromuscular disease
Thoracic wall disease
59
Q

Lactic acidosis

A

Product of anaerobic metabolism

Type 1 - Hypoxic - Producing too much lactic acid

  • DKA
  • Starvation
  • CV / Resp depression

Type 2 - Non-hypoxic - Cannot breakdown lactic acid

  • Secondary to metformin
  • Poisoning

LDH - Increased in tissue breakdown/turnover

  • Muscle trauma
  • Stroke / MI
  • Haemolysis
  • Cancer
  • Acute pancreatitis
  • HIV
  • Meningitis / Encephalitis
60
Q

Wegener’s

A

Granulomatosis with polyangitis

Autoimmune
Necrotising granulomatous vasculitis

Affects respiratory tract + Kidneys

61
Q

Wegener’s clinical features

A

URT - Epistaxis, sinusitis, nasal crusting
LRT - Dyspnoea, haemoptysis
Rapidly progressive glomerulonephritis - Haematuria
Saddle-shaped nose deformity

Fatigue / Malaise
Fever / Night sweats
Anorexia / Weight loss

Cutaneous - Vasculitic rash
Ocular - Redness, pain, proptosis, diplopia, blurring
MSK - Myalgia, arthralgia, swelling
Neuro symptoms
VTE
62
Q

Wegener’s investigations / management / prognosis

A

Urinalysis - Haematuria
cANCA positive (90%)
pANCA +ve (25%)
CXR/CT - Cavitating lesions

FBC - Anaemia
Creatinine ^
ESR ^
Renal biopsy - Epithelial cells in Bowman’s capsule

Steroid - Pred
Cyclophosphamide
Plasma exchange

Prognosis - 8-9 years

63
Q

CF aetiology

A

AR

Defect in CFTR gene
Coding for cAMP-regulated chloride channel
Delta-F508 on Chromosome 7

Sodium/Chloride pump affected
Sodium reabsorption = Water retention
= Increased viscosity of secretions

64
Q

CF - Clinical features

A

Neonates

  • Meconium ileus (24 hours)
  • Prolonged jaundice

Recurrent chest infections

  • Staph A
  • Pseudomonas aeruginosa
  • Burkholderia
  • Aspergillus

Malabsorption

  • Steatorrhoea
  • FTT

Liver disease

Short stature
DM
Delayed puberty 
Rectal prolapse - Bulky stools
Nasal polyps
Male infertility
Female subfertility
65
Q

CF diagnosis

A

Sweat test - Chloride > 60 mEg/L

False positives…

  • Skin oedema - Hypoalbuminaemia - Pancreatic exocrine insufficiency
  • Malnutrition
  • Adrenal insufficiency
  • Glycogen stores disease
  • Nephrogenic DI
  • Hypothyroid
  • Hypoparathyroid
  • G6PD
  • Ectodermal dysplasia
66
Q

CF management

A

Chest PT - Twice daily

  • Postural drainage
  • Deep breathing exercises

Vaccines!

Bronchodilator - Salbutamol
Mucolytic - Dornase Alfa
Diet - High calorie with high fat
Minimise contact with other CF patients
Vitamin supplements - Fat soluble - ADEK
Pancreatic enzyme supplements - Pancreatin
Lung transplant - not in burkholderia/ not isolating from CF patients

3B (23 decks)

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