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MBBS - Year 2 > Respiratory - Breathlessness: Airflow Obstruction > Flashcards

Respiratory - Breathlessness: Airflow Obstruction Flashcards

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1
Q

Overview of mechanical respiration

A

Inspiration & expiration
Gas conduction
Gas transfer
Exhalation

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2
Q

What does inhalation and exhalation require

A

Organised MSK function (diaphragm, IC muscles and rib cages) of the thorax to draw in air and return it to atmosphere
Function of pleural space to enable the expansion of the lung

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3
Q

What kind of things compromise inhalation and exhalation

A

Muscle wasting and neurodegenerative disease

Pleural disease - fibrosis, PTX

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4
Q

Where is the conducting zone

A

From nose to bronchioles

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5
Q

What is found in conducting zone

A

Resp type mucosa

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6
Q

Function of conducting zone

A 
Passage of air from environment to lungs 
Airways protection 
Air humidification and warming 
Smell 
Speech
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7
Q

How does the conducting zone protect the airway

A

Through mechanical and immunological removal of pathogens

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8
Q

How does the conducting zone allow the passage of air

A

Made of cartilage and muscle
Allows rigidity but flexibility of airways
Resistant to compression and collapse
Allows expansion during breathing

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9
Q

Why is the trachea C shaped

A

To allow swallowing

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10
Q

Mechanical (cellular) mechanisms of airway protection by the conducting zone

A

Cilla and mucus (mucocilliary escalator)

Physical barrier between external environment and tissue

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11
Q

Immunological mechanisms of airway protection by the conducting zone

A

Identification and removal of pathogens

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12
Q

Mechanical (anatomical) mechanisms of airway protection by the conducting zone

A

Reflex protection

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13
Q

How does nasal hair protect the airway

A

Remove larger particulate material

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14
Q

Movement of mucocilairy escalator

A

Moves mucus up the airways to pharynx to remove particles

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15
Q

What is cilia action independent of

A

Nervous control

May persist for several hrs after death

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16
Q

What is cilia rate dependent on

A

Temp (falls when colder)

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17
Q

Mucus secreting cells

A

Seromucinous glands within submucosa

Goblet cells within epithelium

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18
Q

Comparison of mucus produced by different cells

A

Seromucinous glands produce more watery, thin mucous whereas the goblet cells and mucous cells produce thicker mucous

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19
Q

When are neuroendocrine cells involved in the growth and envelopment of the airways

A

In utero

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20
Q

MALT

A

Mucosa Associated lymphoid Tissue

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21
Q

When is MALT acquired

A

In response to antigenic stimuli

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22
Q

Why can immunological identification and removal of pathogens occur in the nasopharynx

A

Dense lymphoid tissue

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23
Q

Serous cell secretions that destroy potential pathogens

A 
Lysosome 
Lactoferrin 
Antiprotease 
IgA 
Epithelial peroxidase
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24
Q

Examples of reflex airway closure and removal of foreign bodies

A

Cough reflex
Swallow reflex
Gag reflex

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25
What are pulmonary irritant receptors stimulated by
Both mechanical (light touch) or chemical stimuli
26
Swallow reflex
Enables epiglottis to cover larynx to prevent aspiration
27
What nerve is involved in the cough reflex
Vagus nerve
28
Gag reflex (pharyngeal reflex or laryngeal spasm)
Reflex contraction of back of throat | Prevents foreign bodies entering upper wiarways
29
Stimulus of gag reflex
Touch from back of throat, tonsils, uvula, roof of mouth or base of tongue
30
Mucous involvement in smell
Dissolve odours to allow detection
31
Phases of speech
Respiration - lung function Phonation - laryngeal function Articulation - vocal tract (upper airways)
32
Where does the laryngeal cavity extend from
The tip of the epiglottis to the lower edge of the cricoid cartilage
33
False vocal cords vs true vocal cords
Resp epithelium vs squamous epithelium
34
Why do the true vocal cords adjust to a more robust epithelium
True vocal cords are subject to more mechanical trauma from phonation
35
Barriers to tumour spread in the larynx
Intrinsic and extrinsic connective tissue bands | Thyroid and cricoid cartilage
36
Intrinsic connective tissue bands in the larynx
Quadrangular membrane | Conus elastics
37
Extrinsic connective tissue bands in the larynx
Thyroid membrane | Cricothyroid membrane
38
What is the interstitium
Lungs connective tissue scaffolding
39
What does interstitial comprise of
``` Collagen Elastin fibres Fibroblasts Myofibroblasts Pericytes Histiocytes Mast cells Neuroendocrine cells ```
40
Where are Clara cells (bronchiolar exocrine cells) most numerous in
Terminal bronchioles
41
What are Clara cells important in modulating
Bronchiolar infl
42
What can Clara cells secrete
Endothelin - powerful broncho and vasoconstrictor | Protease inhibitors
43
Cells found in alveoli
``` Type 1 pneumocytes Type 2 pneumocytes Alveolar macrophages Pores of Kohn Lambert's canal ```
44
Pores of Kohn
Small gaps between alveoli
45
Lambert's canal
Tubular connections which connect terminal and resp bronchioles w. adjacent peri bronchial alveoli
46
Nuclei in pneumoncytes
Type 1 - flattened | Type 2 - larger, darker
47
What do Type 1 pneumocytes do
Thin for increased gas exchange | Forms a barrier to prevent fluid loss
48
What do Type 2 penumocytes do
Surfactant protection - reduced surface tension in order to facilitate lung expansion
49
Pulmonary vasculature
``` Pulmonary arteries Pulmonary capillaries Pulmonary veins Bronchial arteries Lymphatics ```
50
Where do pulmonary veins tend to be found
In the interlobar septa
51
Blood supply of lungs
Bronchial arteries arising from systemic circulation | Pulmonary arteries
52
What is the pleura
A pair of serous membrane lining the thoracic wall (parietal) and lungs (visceral)
53
Structure of pleura
Meosthelial cell lining | Connective tissue sub mesothelium
54
Elastin layer variation in visceral and parietal layers of pleura
Visceral layer is double and thicker - account for lung movement Parietal - single layer and thinner
55
What is the most readily preventable cause of death in humans
Smoking
56
Which components of tobacco have a carcinogenic effect
Tar Polycyclic aromatic hydrocarbons Nitrosamine
57
What causes the a/c effects of smoking
Nicotine - increase in HR and BP, CO and elevation of cardiac contractility
58
Effects of smoking in resp system
Mucosal irritant ---> bronchitis & RBILD/ DIP Destruction of alveolar walls ---> emphysema Carcinogenesis --> lung cancer
59
RBILD
Resp bronchial ILD
60
DIP
Desquamative interstitial pneumonia
61
What diseases are included in COPD
C/c bronchitis Emphysema (a/c obstructive bronchiolitis but diff pathology)
62
Main risk factor of COPD
Smoking - 80% of cases are smokers
63
Oher risk factors for COPD
Environmental/ occupational pollution Airway hyper-responsiveness Genetic factors
64
Zones affected in COPD
Conducting zone | Gas exchange zone
65
How is the conducting zone affected in COPD
C/c bronchitis - hypersecretory Obstructive bronchiolitis - obstructive These pathological processes may lead to cyanosis
66
How are large airways affected in c/c bronchitis
Mucus hyper secretion | Infl
67
How are small airways affected in c/c bronchitis
Peribronchiolar fibrosis Airway obstruction - infl thickening Goblet cell hyperplasia Loss of Clara cells
68
How is the gas exchange zone affected in COPD
Emphysema - loss of elastic recoil in alveoli
69
Symptoms of a blue bloater (c/c bronchitis)
``` C/c productive cough Purulent sputum Haemoptysis Cyanosis (due to hypoxia) Peripheral oedema Crackles, wheeze ```
70
Complications of c/c bronchitis
``` Pulmonary HTN Cor pulmonale (form c/c pulmonary HTN) ```
71
Symptoms of a pink puffer (emphysema)
``` Dyspnoea Minimal cough Pink skin, pursed lip breathing Accessory muscle use Cachexia Hyperinflation (barrel chest) Tachypnoea ```
72
Complications of emphysema
PTX (due to bullae) | Wt loss
73
Change in mucin type in c/c bronchitis
Thicker, more viscous | Increased seromucinous glands
74
Change to goblet cells in c/c bronchitis
Hyperplasia - reduced capacity to remove mucus (increased susceptibility to infection)
75
Emphysema
Irreversible abnormal increase in the size of air spaces beyond the terminal bronchioles w/ destruction of air space walls w/ out obvious fibrosis
76
What do proteases cause
Tissue degeneration
77
What does elastase do
Break down elastin
78
Why must there be a balance between proteases and antiproteases
Allows any tissue damage which may have occurred to be removed and repaired in a controlled manner whilst limiting damage to surrounding tissue
79
Pathogenesis of emphysema
Smoking causes antiprotease inactivation and causes uncontrolled activity of proteases --> destruction of elastin causes alveoli to become brittle preventing deflation on expiration
80
Process of emphysema development
Harmful particles from smoking trapped in alveoli Infl response triggered Infl chemicals dissolve alveolar septum Large air cavity filled w/ carbon deposits formed
81
Patterns of emphysema
Centrilobular Paracinar Paraseptal Irregular
82
Centrilobular emphysema
Central/ proximal alveolar unit involved, distal alveoli spared Most commonly seen in smokers More severe in upper lobes
83
Paracinar emphysema
Whole alveolar unit involved More commonly in lower lobes Associated w/ alpha1-antitrypsin deficiency
84
Paraspetal emphysema
Proximal alveolar unit normal, emphysematous change more evident near the pleura, along septa and margins of lobules Seen in upper half of lungs
85
Emphysema histology
Airspace enlargement Fractured alveolar walls +/- infl
86
Smoking related ILD
Resp bronchiolitis Resp bronchiolitis associated ILD DIP
87
Resp bronchiolotis vs resp bronchiolitis associated ILD
Pts may not be symptomatic w/ resp bronchiolitis and wont always develop RBILD Pts are symptomatic w/ resp bronchiolitis associated ILD - persistent cough and/ or mild breathless
88
Lung function test in resp bronchiolitis associated ILD
Normal or mildly restrictive defect
89
Mx of resp bronchiolitis associated ILD
Resolves completely on quitting smoking | May require corticosteroids
90
Typical pts of DIP
Middle-aged cigarette smokers who complain of breathlessness and cough of insidious onset
91
Prognosis of DIP
Responds well to steroid and smoking cessation but can progress to interstitial fibrosis
92
Effects of tobacco in epthelial lining of resp tract
Metaplasia Dysplasia Carcinogenesis
93
Metaplasia in the resp tract
Noxious tobacco smoke not tolerated by columnar epithelium | Squamous epithelium more resistant to thermal and chemical damage
94
Consequences of metaplasia in resp tract
Reduced function | Increased propensity for malignant transformation
95
Is metaplasia in the resp tract reversible
Yes on smoking cessation
96
What is squamous dysplasia in the resp tract a precursor lesion for
Squamous cell carcinomas
97
What is squamous dysplasia in the resp tract characterised by
The presence of disordered squamous epithelium w/ loss of pleomorphism
98
Most frequently diagnosed major cancer in the world
Lung cancer | Also most common cause of cancer mortality worldwide
99
What % of lung cancers are in active smokers or those who've stopped recently
80%
100
What age is lung cancer most common in
40 and 70yrs w/ peak incidence in 50s/60s
101
Prognosis of lung cancer
Poor - survival <50%
102
Other factors affecting lung cancer
``` Industrial exposure - asbestos, uranium , arsenic, nickel Radiation Air pollution Molecular genetics EGFR mutations ```
103
Types of lung tumours
90-95% are carcinomas 5% carcinomas 2% mesenchymal and other types
104
Classical features of squamous cell carcinomas
Malignant cells w/ keratinisation and intercellular bridges
105
Pathological feature for lung adenocarcinomas
Gland or duct formation w/ mucin
106
Lung tumours of seromucinous glands
Salivary type tumours such as mucoepidermoid carcinoma and adenoids cystic carcinoma
107
Lung tumours of blood vessels
Haemoangiomas
108
Lung tumours of mesothelium
Mesothelioma
109
Determining if a lung mass is a metastasis
Lung is a common site | Can see single lesions but often multiple, well circumscribed nodules
110
Common cancers that may metastasise to lung
``` Colorectal Renal Breast Melanoma Direct spread from oesophagus ```
111
Dx of lung cancer
Bronchial washings and brushings EBUS TBNA Lung biopsy Bronchial biopsy
112
EBUS TBNA
Endobronchial ultrasound guided transbronchial (fine) needle aspirations
113
Reporting of lung excisions - providing prognostic info
``` Type of tumour Size Margins Pleural involvement Vascular invasion Involvement of adjacent structures e.g. hearts, pericardium, diaphragm Lymph node involvement ```
114
Types of air movement in lung
Convection | Diffusion
115
What part of the conducting zone is most susceptible to collapse during expiration
Bronchioles and alveolar ducts
116
What does the pulmonary arteries carry
Deoxygenated mixed venous blood from RV to alveoli of lungs
117
Where does blood drain from the lungs
Pulmonary vein and azygous vein | Minority of blood in bronchial veins
118
Systems innervating resp tract
Cholinergic Adrenergic Peptidergic
119
Cholinergic effect on smooth muscle of bronchioles
Constrict
120
Adrenergic effect on smooth muscle of bronchioles
Dilate
121
Petidergic effect on smooth muscle of bronchioles
Dilate
122
Spirometry
Method for studying pulmonary ventilation
123
Tidal volume
Volume of air inspired or expired w/ each normal breath (500ml)
124
Inspiratory reserve volume
Extra volume of air that can be inspired over and over normal TV (2500ml)
125
Expiratory reserve volume
Extra volume of air that can be expired by forceful expiration after end of normal TV (1100ml)
126
Residual volume
Volume of air remaining in lungs after most forceful expiration (1200ml)
127
Calculating total lung capacity
IRV + TV + ERV + RV
128
Factors affecting IRV
``` Current lung volume Lung compliance Muscle strength Comfort Flexibility of the skeleton Posture ```
129
Lung compliance
Measurement of lung expandability
130
Does all the air that is breathed in reach gas exchange area
No - some fills resp passages | Dead air space - 150mls
131
Intrapulmonary pressure
Pressure in alveoli, which rises and falls during respiration but always equalises w/ atmospheric pressure
132
Muscles that arise from the rib cage
External IC Sternocleoimastoid Anterior serrati (lift many ribs) Scaleni (lift 1st 2 ribs)
133
Muscles moving lower rib cage
Abdominal recti | Internal IC
134
In which ways can lungs be expanded and contracted
Downward (inspiration) and upward (expiration) movement of diaphragm Elevation and depression of the ribs to increase the diameter of chest cavity
135
Transpulmonary pressure
Pressure difference between alveoli and pleura
136
What is lung compliance determined by
Elastic force of the lung tissue itself | Elastic fibres caused by surface tension of fluid lining alveoli
137
Lung compliance in pulmonary fibrosis (restrictive lung disease)
Decreased --> smaller changes in lung volume for small changes in trans pulmonary pressure
138
How does decreased lung compliance affect pts breathing
More shallowly and rapidly
139
How does decreased lung compliance affect spirometry measurements
Decreases seen in RV, FRC, TLC
140
How does lung compliance change in emphysema
Increases --> larger changes in lung volume for small changes in trans pulmonary pressures
141
How does increased lung compliance affect pts breathing
Pts breathe more slowly and deeply
142
How does increased lung compliance affect spirometry measurements
Increases seen in RC, FRC, TLC
143
Lung compliance in c/c bronchitis
Normal but will still see increases in RV, FRC and TLC
144
If 2 alveoli are connected but have diff diameters, where will the air flow
From small to large
145
Alveolar macrophages and surfactant
Help degrade surfactant | Type II pneumocytes take up rest and recycle or destroy it
146
Role of lung surfactant
Increased lung compliance so easier to inflate Reduces pressure and fluid accumulation in alveoli Helps keep alveoli's size relatively uniform during resp cycle
147
How does airway resistance change w/ disease
Increases in disease | At any given lung volume, resistance in COPD is higher
148
What is the glottis formed by
Vocal cords (folds)
149
How are food and saliva prevented from entering resp tract
Sphinchteric action of vocal chords and epiglottis
150
What is the pharynx nerve supply
Nerves from pharyngeal plexus
151
Innervation of laryngeal muscles
Recurrent laryngeal nerve (except cricothyroid)
152
Which nerve provides sensation to the glottis and sub glottis
Recurrent laryngeal nerve
153
Which nerve provides sensation to supra glottis
Superior laryngeal nerve
154
What is the larynx adapted to act as in phonation
A vibrator | Vibrating element is vocal folds (vocal cords)
155
Position of vocal cords during normal breathing
Wide open
156
What happens to the vocal cords during phonation
Cords move together so passage of air between them causes vibrations
157
What is our pitch determined by
Degree of stretch of cords
158
Which organs of articulation allows us to change sound
Lips Tongue Soft palate
159
Which organs act as resonators
Mouth Nose and associated nasal sinuses Pharynx Chest cavity
160
Allergens responsible for asthma
``` Pets Eosinophils Dust mites Fungus Pollen ```
161
Mediators of asthma attack
B lymphocyte produces IgE which causes release of histamine, leukotriene, bradykinins, prostaglandins which cause immediate allergic symptoms
162
What happens to the airways in asthma
Airways get inflamed and constricted
163
Pathological changes in asthma
``` Thickening of basement membrane Mucous gland hyperplasia Desquamation of epithelium Hypertrophy of smooth muscle Oedema of mucosa and submucosa - due to infiltration Mucosal plug ```
164
Symptoms seen in asthma
Wheeze Cough Breathlessness
165
Things to look for in the hx of an asthma pt
Fhx of atopy Samter's triad Occupation (work related/ exacerbated asthma)
166
What might come up in Fhx of atopy for asthma pts
Eczema Allergic rhinitis Nasal polyps Aspirin intolerance
167
Samter's triad
Asthma Nasal polyps Aspirin sensitivity/ intolerance
168
Why is occupation important for asthma pts
Could be cause of late onset asthma
169
Reversibility testing
Way of measuring if pt has asthma or not Ask pt to stop taking all med and take an FEV1 measurement then give them 2 puffs of salbutamol through a spacer and see if FEV1 improves FEV1 should improve by 400ml or 12%
170
What is usually used for reversibility testing
``` Short-acting beta 2 agonists or ICS for longer reversibility tests (6-8 weeks) Oral steroids (30mg pred for 2/52) ```
171
How can we measure airway infl
Sputum differential counts | Exhaled nitric oxide (FeNO) > 40
172
Allergy testing for asthma
Skin prick test Blood - RAST Total IgE & IgA for seasonal and perennial allergens Blood eos > 1
173
Measuring disease control in asthma
RCP Asthma Control Questionnaire (ACQ) Asthma Control Test (ACT) Mini-asthma QoL Questionnaire (AQLQ)
174
Things to consider in difficult asthma
If the dx is really asthma? Pts adherence If both these things are fine, you must increase therapy in a step wise fashion
175
Ddx for asthma
``` Vocal cord dysfunction (paradoxical vocal cord movement) Dysfunctional breathing (hyperventilation syndrome) GORD (reflux related cough/ breathelessness) ```
176
Types of bronchodilators
SABA LABA LAMA
177
SABA's
Short acting beta 2 agonists
178
Examples of SABAs
Salbutomol | Terbutaline
179
LABA
Long acting beta 2 agonists
180
Examples of LABAs
Salmeterol Formoterol Vilanterol
181
LAMA's
Long acting muscarinic antagonist
182
Examples of a LAMA
Tiotropium
183
How should drug powder inhalers be taken
Fast and furious
184
ICS used in asthma mx
Beclomethasone Fluticasone Budesonide Ciclesonide
185
Aetiology of asthma
Asthma gene complexes - ADAM 33, DPP10 | Hygiene hypothesis
186
Epidemiology of COPD
3rd leading cause off death worldwide | Worldwide prevalence of 10.1%
187
What is COPD characterised by
C/c resp Symptoms Structural pulmonary abnormalities (airway and/or alveolar abnormalities) Lung function impairment (primarily airflow limitation that is poorly reversible)
188
Host risk factors for COPD
Genetic | Lung growth, low BW, age
189
Risk factors for COPD - exposure
``` Tobacco smoke Biomass fuels, open fires Occupational dusts and exposures C/c uncontrolled asthma Lower socioeconomic status ```
190
Dx of COPD
Hx and symptoms e.g. SOB/ wheeze, c/c cough, sputum production Possible risk factors Spirometry
191
Measurements in spirometry
``` FEV1 FVC FEV1/ FVC ratio PEFR FEF 25%-75% ```
192
FEV1
Forced expired volume in 1 seconds
193
FVC
Forced vital capacity
194
PEFR
Peak expiratory flow rate
195
FEF 25-75%
Forced expiratory flow between 25-75% of the vital capacity
196
How does spirometry measures change according to height
Tall people have large lungs
197
How does spiromtry measures change according to age
Resp function decline w/ age
198
How do spirometry measures change w/ sex
Lung volumes smaller in females
199
How does spirometry measures change w/ race
Black people and asians have smaller lung volumes (-12%)
200
How does spirometry measures change w/ posture
Little difference between sitting and standing | Reduced in supine
201
How long to wait when giving a SABA for bronchodilatory reversibility testing
20 mins before retesting
202
How long to wait when giving a LABA for bronchodilatory reversibility testing
2hrs before retesting
203
Criteria for GOLD 1
FEV1 > 80% predicted
204
Criteria for GOLD 2
50% < FEV1 < 80% predicted
205
Criteria for GOLD 3
30% < FEV1 < 50% predicted
206
Criteria for GOLD 4
FEV1 < 30% predicted
207
Key indicators for a dx of COPD
``` Dyspnoea C/c cough C/c sputum production Recurrent LRTI Hx of risk factors Fhx of COPD ```
208
Dyspnoea in COPD
Progressive over time Characteristically worse w/ exercise Persistent
209
C/c cough in COPD
May be intermittent and may be unproductive | Recurrent wheeze
210
Intrathoracic causes of c/c cough
``` Asthma Lung cancer TB Bronchiectasis Left HF ILD CF Idiopathic cough ```
211
Extrathoracic causes of c/c cough
C/c allergic rhinitis PND Syndrome GORD Medication e.g. ACEi
212
What should be looked for in initial assessment of COPD pts
``` FEV1 - GOLD 1-4 Exacerbation hx Smoking Alpha1-antitrypsin Comorbidities ```
213
Initial mx of COPD pts
``` Smoking cessation Vaccination Active lifestyle and exercise Initial pharmacotherapy Self-mx education Mnage comorbidities ```
214
Self-mx education for cOPD
Risk factor mx Inhaler technique Breathlessness Written action plan
215
How do we aim to reduce symptoms in stable COPD
By relieving symptoms Improving exercise tolerance Improving health status
216
How do we aim to reduce risk in stable COPD
Prevent disease progression Prevent and treat exacerbations Reduce mortality
217
What needs to be taken into account for mx of COPD
Degree of airflow obstruction Exacerbation Symptoms
218
Initial pharmacological treatment of COPD for those w/ no exacerbation hx
SABA or LAMA | LABA or LAMA if CAT < 10
219
When would you consider giving a LAMA and LABA for COPD
If highly symptomatic
220
When would you consider giving ICS and LABA for COPD
If Eos > 100
221
Effects of LABA/ LAMA combinations in COPD pts
Increases FEV1 Reduces symptoms Reduces exacerbation rates
222
Non-pharma mx of COPD
``` Smoking cessation Pulmonary rehab Nutrition incl vit D supplementation Vaccinations Candidate for long-term oxygen therapy ```
223
What is an exacerbation of COPD defined by
Increase in dyspnoea Increase in cough Increase in sputum volume/ purulence WITH or WITHOUT symptoms of an URTI
224
What % of COPD exacerbations are bacterial
30-50% - H.influenza, strep pneumonia
225
What % of COPD exacerbations are viral
30% - rhinovirus, influenza
226
Mx of a/c exacerbations of COPD
Regular nebulisers - bronchodilators Abx Steroids (30mg pred for 5/7 - 7/7) Consider need for non-invasive ventilation in more severe exacerbations
227
When would you give abx for a/c exacerbations of COPD
Usually for pts w/ hx of more purulent sputum, otherwise only if consolidation on CXR or clinical signs of pneumonia
228
Drug treatments used in resp med
``` Bronchodilators - anti-chilergics, beta-agonists Corticosteroids Leukotriene receptor antagonists Cromones Monoclonal antibodies - asthma Methylxanthines Phosphodiesterase inhibitors Mucolytics ```
229
SE of beta-2 agonists
Tremor Tachycardia. palpitations Decreased K
230
Ultra long-acting B2 agonists
Indacaterol (Onbrez) - COPD Vilanterol Olodaterol
231
Examples of short acting anticholinergics
Ipratropium
232
Examples of long acting anticholinergics
Tiotropium Glycopyrronium Alidinium
233
Role of administration for anticholinergics
Inhaled
234
Indications for Anticholinergics
COPD | Severe asthma
235
Beneficial effects of corticosteroids in resp system
Reduce infl mediators Increases anti-infl mediators Reduce eosinophils, macrophages, lymphocytes
236
Examples of combination inhalers
``` Seretide Symbicort Fostair Relval lepta Anoro elllipta ```
237
Components of Symbicort
Budesonide & formoterol
238
Components of Fostair
Beclomethaosne & formoterol
239
Components of Flutiform
Fluticasone & formaterol
240
Examples of leukrotriene receptor antagonists
Montekulast Zafirkulast Pranlukast
241
Indication for leukotriene inhibitors
Aspirin sensitive asthma
242
Infl effects of leukotrienes in the airways
Increased mucus secretion Epithelial cell damage Eosinophil recruitment Increased release of bradykinins
243
What are cromones
Mast cell stabilisers
244
Administration of cromones
Inhaled | QDS
245
Which group of people are cromones usually given to
Children
246
Omalizumab
Monoclonal antibody - binds circulating IgE | Given in anaphylaxis and uncontrolled allergic asthma
247
Mepolizumab
Monoclonal antibody - blocks IL-5 | Reduces exacerbations but no change in symptoms
248
Administration of mepolizumab
4 weekly injections
249
Administration of Xanthines
Oral or IV
250
Examples of xanthines
Theophylline | Aminophylline
251
Effects of xanthines
Inhibit phosphodiesterase | Have bronchodilatory and anti-infl effects
252
SE of xanthines
Nausea | Drug interactions - low therapeutic range
253
PDE4 inhibitors
New gen "theophyllines"
254
Admin of PDE4 inhibitors
Po
255
Example of PDE4 inhibitors
Roflumilast
256
SE of PDE4 inhibitors
Nausea
257
Examples of mucolytics
Carbocysteine Erdosteine Mecysteine
258
Administration of mucolytics
po
259
Indication for mucolytics
Pts w/ c/c bronchitis
260
Asthma treatment cascade
Allergen/ irritant exposure -- avoidance Infl -- anti-infl Infl mediator please - mediator blockers Bronchoconstriction - bronchodilators
261
Inh vs po drugs
Inhaled drug delivers drugs where required Reduced systemic exposure Reduced systemic adverse effects
262
Types of inhalers - structural
Nebuliser Metered dose inhaler Dry powder inhaler
263
Advantages of spacers
Helps co-ordination Less oropharyngeal deposition Improved lung delivery Comparable efficacy to nebulisers
264
Disadvantages of spacers
Size Cost Assembling - older people Electrostatic - increased delivery in primed or used spacers
265
Phases of coughing
Irritation Inspiration Compression Expulsion
266
Presentation of influenza
``` Fever Non-productive cough Myalgia Headaches Malaise Sore throat Rhinitis ```
267
Mx of influenza
``` Analgesia Antipyretics Fluids O2 Antivirals Resp isolation ```
268
What does alpha-antitrypsin do
Neutralises proteases
269
What properties do lysosomes and lactoferrin
Bactericidal
270
Examples of URTI
``` Pharyngitis A/c laryngitis Bacterial epiglottis Sinusitis Common cold Influenza Croup Pertussis ```
271
Pharyngitts
Inflammation of the nasopharyngeal mucosa with reactive inflammation of the lymph nodes and tonsils. 
272
Non infective causes of pharyngitis
Allergic rhinitis | Irritative pharyngitis
273
Complications of pharyngitis
Abcess formation and tonsil hypertrophy = airway obstruction A/c rheumatic fever ReA
274
Features of pharyngitis
``` Sore throat - worse when swallowing Neck pain and swelling Fever Headache Swollen tonsils ```
275
Symptoms in bacterial vs viral pharyngitis
Bacterial - sudden onset, tonsils exudes and fever Viral - cough, nasal congestion, coryza, oral ulcers Symptoms resolve in 3-5days in viral and 5-7 days in bacterial
276
Symptoms of a/c laryngitis
Flu like: fever, cough, malaise, enlarged lymph nodes, Stridor, hoarseness, pain.
277
Dx of laryngitis
Laryngoscopy shows swollen, red vocal folds Biopsy Blood culture
278
Mx of laryngitis
Analgesics NSAIDs Abx Voice rest
279
What is bacterial epiglottis caused by
Caused by inflammatory cell accumulation = airway narrows = airway obstruction Haemophilus influenzae, Streptococcus pneumoniae, Staph aureus. 
280
Complications of bacterial epiglottis
Airway obstruction, Oropharyngeal secretion aspiration Cardiopulmonary arrest Death may occur due to occluded airway
281
Features of bacterial epiglottis
``` Dysphagia Distress Tachypnoea Cyanosis Sore throat Fever Individual refuses to lie down ```
282
Ix for bacterial epiglottis
Laryngoscopy: swollen, red epiglottis X-ray: shadow of enlarged epiglottis Lab results: Increased WBC, CRP, Culture.
283
Risk factors for sinusitis
Allergies Dental infections spreading to maxillary sinus Tumours Genetic disorders (Kartagener's CF)
284
Complications of sinusitis
Meningitis Cavernous sinus thrombosis Abcess
285
Features of bacterial sinusitis
``` Fever Headache Pain when leaning forward Voice change Lasts > 10 days ```
286
Features of viral sinusitis
``` Self limiting Painful sinus on leaning forward Discharge Lasts <10 days PND irritate larynx and causes cough ```
287
Croup
Laryngobronchitis | Usually seen in children
288
Viruses causing croup
``` Parainfluenza virus RSV Influenza A and B Rhinoviruses Adenovirus Measles ```
289
Px of croup
Child develops harsh, barking cough w/ URTI which may progress to stridor
290
Mx of croup
Often no treatment required but some children develop more severe LRTI ---> intubation and ventilation Oral pred can be used
291
Duration of acute cough
<3/52
292
Duration of subacute cough
3/52 - 8/52
293
Duration of c/c cough
8/52 +
294
Diurnal variation of asthma symptoms
Worse at night/ early morning
295
Stridor vs wheeze
Stridor comes from upper airway (obstruction) and is heard on inspiration Wheeze comes from lower airways and is heard on expiration
296
Examination findings for asthma
``` Use of accessory muscles Tracheal tug Expiratory wheeze High RR Tremor, tachy (salbutamol) Subcostal and IC recession ```
297
How to take a peak flow measurement
Ask pt to stand up Take a deep breathe in and out Take another deep breath in Purse lips around peak flow meter and breathe out as fast as they can
298
CXR findings of COPD
``` Extra long lungs Flattened diaphragm (hyperinflation) Prominent vascular markings ```
299
Stages of lung maturation and development
Pseudoglandular (5-17 weeks) Canalicular (16-25 weeks) Saccular (terminal sac) (24 weeks to birth) Alveolar (late foetal period to ~8yrs)
300
Clinical problems w/ lung surfactant production
``` Adequate amounts of surfactant not produced until ~32nd week Premature infants (up to prenatal 7 months) – respiratory distress syndrome (RDS) = insufficient surfactant Resulting in increased surface tension = collapse of alveoli (atelectasis) ```
301
Types of movement of air in resp system
Conduction in larger airways | Diffusion in smaller airways
302
Calculating minute ventilation
Tidal volume x RR
303
Alveolar ventilation
(Tidal volume - dead volume) x RR | Determine O2 and CO2 conc in blood
304
Functional residual capacity
Volume of air already in lung before inspiration
305
Vital capacity
Air that can be drawn in from residual volume
306
Hysteresis
Difference in compliance between inspiration and expiration | If lungs fill w/ water, the gradient increases as lungs will be more compliant and hysteresis disappears
307
What happens when the vagus nerve is stimulated
Bronchoconstriction - parasympathetic fibres
308
What does sympathetic innervation of beta2 adrenergic receptors cause in smooth muscle
Bronchodilation
309
Oxygen content vs oxygen saturation
Content - amount of O2 carried by 1L of blood | Sat - % of O2 carrying sites on Hb occupied by O2 (should be 100%)
310
Drugs exacerbating asthma
NSAIDs | BB
311
What is the physiological mechanism of breathlessness in COP
Increased Residual Volume - all the air cannot be expelled due to hyperinflation and gas trapping
312
How does Total Lung Capacity change in emphysema
Increases
313
How does Forced Vital Capacity change in lung diseases
Normal COPD | Decreased in ILD
314
How many measurements should be taken on a peak flow meter
3
315
Peak flow diary
Usually kept for 2+ weeks Aim to take measurements QDS Look for diurnal variation
316
Calculating PEF variability
(PEFmax - PEFmin)/ (1/2 (PEFmax + PEFmin)) | Variability > 20% - asthma
317
FEV1/FVC ration in obstructive lung disease
<70%
318
Why is Asthma worse at night
Low cortisol at night
319
Asthma mx algorithm
SABA - reliever and low dose ICS (preventer) Add LABA to ICS (combi inhaler) Increase ICS to medium dose or add LTRA
320
When are LABA/ LAMA inhalers most used
COPD
321
Characteristics of moderate a/c asthma
Increasing symptoms | Increasing PEF >50-75% best or predicted
322
Characteristics of a/c severe asthma
``` Any one of: PEF 33-50% best or predicted RR > 25 HR > 110 Inability to complete sentences in one breath ```
323
Clinical signs of life-threatening asthma
``` Altered conscious level Exhaustion Arrhythmia Hypotension Cyanosis Silent chest Poor resp effort ```
324
Measurements in life-threatening asthma
PEF < 33% best predicted PaO2 < 92% Normal PaCO2 (4.6-6.0kPa)
325
Characteristics of near-fatal asthma
Raised PaCO2 and/or requiring mechanical ventilation
326
Medications for a/c asthma
SABA (nebuliser) 5mg - 2 puffs QDS as well as prn Ipratropium 500 microgram QDS Corticosteroids (IV or po) Oxygen (if sats below 94%) Continue w/ usual asthma drugs
327
Corticosteroid dosage for a/c asthma
``` 40mg Pred (give in the AM) - 0.5/kg of bw IV hydrocortisone 100mg ```
328
FEV1/ FVC ratio in restrictive lung disease
>70%
329
Example of primary concordance
Pt doesn't redeem prescription
330
Example of secondary concordance
Pt not taking medication as prescribed
331
What does adherence and compliance look at
Pts behaviour and attitudes
332
Concordance
Process entertaining pt views on medication-taking; agreement btwn patient + clinician
333
Triggers for asthma
``` Viral infections SMoking Pets Occupation GORD Drugs - NSAIDs and BB OSA Pregnancy Anapylaxis ```
334
How do we quantify breathlessness
MRC dyspnoea scale Grades 1 - 5 Not troubled by breathlessness except on strenuous exercise to too breathless to leave the house/ breathless when dressing
335
When is it suggested to measure alpha1 antitrypsin in pts
Younger pts w/ COPD (<40)
336
Why might you see elevated Hb (polycythemia) in COPD
Hypoxia stimulated formation of erythropoietin in kidneys
337
Inhaled therapies for COPD
SABA or SAMA LABA + LAMA or LABA + ICS (if features suggest steroid responsiveness) LABA + LAMA + ICS
338
What is most likely to kill COPD pts
Hypoxia (resp failure)
339
Type 1 resp failure
Hypoxaemia only | Treat w/ O2
340
Type 2 resp failure
Hypoxaemia AND hypercapnia | Treat w/ O2 and NIV
341
Why does HCO3 rise in resp failure
Attempted compensation by kidneys
342
Contraindications of lung function tests
``` Pts who are acutely unwell PTX (until 6/52 recovery) Infection Haemoptysis MI/PE Major surgery ```
343
TLCO
Measure of gas transfer
344
When is TLCO < 80%
Emphysema
345
How does ILD affect TLC
Reduces it
346
Conditions w/ an obstructive picture on spirometer
Asthma COPD CF Bronchiectasis
347
When do we see normal Spiro readings and low TLCO
Early ILD | Pulmonary arterial HTN (PAH)
348
Acidotic ABG
pH < 7.35
349
Alkalotic ABG
pH > 7.45
350
Metabolic acidosis on ABG
CO2 < 4.5 (low) | Bicarb < 22 (low)
351
Resp acidosis on ABG
CO2 > 6.0 (high) | Bicarb > 26 (high)
352
Resp alkalosis on ABG
CO2 < 4.5 (low) | BIcarb < 22 (low)
353
Metabolic alkalosis on ABG
CO2 > 6.0 (high) | Bicarb > 26 (high)
354
Causes of resp acidosis
Alveolar hyperventilation Skeletal - kyphoscoliosis Critical airway obstruction - asthma, COPD Mechanical/ neuromuscular - musculodystrophy. myasthenia gravis
355
Causes of metabolic acidosis
``` M - methanol U - uraemia (CKD)* D - DKA P - propylene glycol I - infection, iron, isoniazid*, inborn errors of metabolism L - lactic acidosis E- ethylene glycol S - salicylates, sepsis* ```
356
Anion gap
(Na + K) - (Cl + HCO3) => 16
357
Cause of normal anion gap depsite deranged ABG
Bicarb losses from gut (diarrhoea) | Renal tubular acidosis
358
Causes of raised anion gap
``` Ketoacidosis Renal failure Lactic acidosis Salicylate toxicity Methanol Ethylene glycol ```
359
Causes of metabolic alkalosis
Loss of acid e.g. vomiting Diuretics* Milk-alkali syndrome Hyperaldosteronism
360
When do you see a mixed picture ABG
Cardiac arrest | Resp failure
361
pO2 in resp failure
< 8.0
362
What are target sats in type 2 resp failure
88-92% Loses hypoxic drive if given O2 Will retain more CO2
363
Timeframe of metabolic compensation on ABG
Takes weeks to change (c/c condn) but CO2 compensation is v quick
364
When is acute on chronic resp acidosis seen
Seen in exacerbations of COPD
365
Features of acute on chronic acidosis on ABG
Low pH (acidotic) Raised CO2 Extremely elevated bicarb
366
When do we achieve 100% FiO2
15L of oxygen - max that can be given
367
FiO2
Fraction of inspired oxygen
368
Why would you given high flow O2 in an emergency despite type 2 resp failure
Hypoxia kills faster than hypercapnia | Redo ABG after
369
Signs of hyperinflation on CXR
Flattened hemidiaphrgam Thin heart Increase in anterior ribs seen (5-7)
370
Causes of stridor
Upper airway obstruction - croup, epiglottitis, inhalation of foreign body
371
What pathological changes will occur if asthma is not treated
Thickening of basement membrane due to hypertrophy of smooth muscle Mucous gland hyperplasia Desquamation of epithelium
372
Criteria for LTOT
Pt must be stable and on maximal therapy PaO2 < 7.3 PaO2 7.3-7.8 w/ co-existing pulmonary disease

MBBS - Year 2 (20 decks)

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