Respiratory Flashcards

Question

Cystic Fibrosis

Answer 1

Autosomal recessive disease Defect in CFTR gene on chromosome 7 - Most common defect = deltaF508 - Carrier rate = 1 in25 Defect in CFTR = chloride ions cannot leave cells = sodium and water reabsorption from mucus back into cells = thick viscous secretions Multisystem disorder - Nasal polyps - Bronchiectasis and recurrent chest infections - Diabetes (30% by age of 50) - Malabsorption/FTT - Biliary cirrhosis --> CLD (30%) - Delayed puberty - Infertility Most diagnosed in neonatal period but 5% diagnosed after age of 18

Answer 2

Haemophilus influenzae (early childhood) Staph Aureus Pseudomonas Aspergillus Burkholderia Cepacia = worst prognosis! - Contraindication to lung transplant

Answer 3

MDT Approach CONSERVATIVE - Daily chest physio and postural drainage - Optimise nutrition - Minimise contact with other CF pts (avoid cross infection) - Vitamin supplements - Pancreatic supplements PHARMACOLOGICAL - Treatment of pseudomonas colonisations with PO and nebulised antibiotics - Lumacaftor / Ivacaftor = indicated if homozygous delta F508 mutation. Increases number of CFTR proteins SURGICAL - Heart and lung transplant (5yr survival 60%) Median survival 32 years but is improving

Answer 4

Rare condition, unknown cause Triad of 1) Azoospermia 2) Bronchiectasis 3) Rhinosinusitis Often present in middle age with infertility

Answer 5

Rare condition, unknown cause Usually affects >50s 2 of the 3: 1) Slow growing hard yellow finger and toe nails 2) Lymphoedema 3) Recurrent Pleural effusions + bronchiectasis

Answer 6

Infection caused by mycobacterium tuberculosis Notifiable disease

Answer 7

Place of birth (Sub Sahara Africa & Asia) Increasing age HIV/AIDs Homelessness/Overcrowded living spaces e.g prisons Immunosuppression e.g. diabetes, chemo Malignancy Malnutrition

Answer 8

TB meningitis CNS tuberculoma Scrofuloderma (cervical LNs) Pericardial TB Pott's disease = spinal osteomyelitis Spinal TB Renal TB Miliary TB = haematogenous spread to any organ

Answer 9

Sputum samples x 3 for Ziehl Neelsen staining Early morning urine samples for AFB x 3 Tuberculin skin resting (Mantoux) - Can be false negative if immunosuppressed Interferon gamma Release Assay (Quantiferon) HIV CXR CT Chest ?Bronchoscopy ?Biopsy of extrapulmonary site e.g. LNs

Answer 10

Notifiable disease! Inform public health - contract tracing May need to have directly observed treatment if no fixed abode/non-compliant RIPE medications - Prior to starting, check LFTs and visual acuity/colour - Typical course is 6 months of R & I, 2 months of P &E RIFAMPICIN - Enzyme inducer, red urine, GI disturbance ISONIAZID - Hepatitis, peripheral neuropathy PYRAZINAMIDE - Hepatoxicity, peripheral neuropathy, gout ETHAMBUTOL - Optic neuritis

Answer 11

Tracheal deviation towards side of previous TB Phrenic nerve crush scar in supraclavicular fossa Chest deformity/asymmetry Thoracotomy/thoracoplasty (rib resection) scar Reduced chest expansion on TB side Dullness to percussion

Answer 12

Apical fibrosis Aspergilloma in old TB cavity Bronchiectasis secondary to LN obstruction Pleural effusion/thickening

Answer 13

CHARTS Coal Worker's pneumoconioses Histoplasmosis Hypersensitivity pneumonitis Histiocytosis X Ankylosing spondylitis ABPA Radiation TB Sarcoidosis Silicosis

Answer 14

RADIO Rheumatoid arthritis Asbestosis Drugs e.g. amiodarone, nitrofurantoin Idiopathic PF (IPF) Other e.g. bronchiectasis, CTD e.g. SLE or systemic sclerosis, sjogren's

Answer 15

"BBC is everyMANS Gold" Bleomycin Busulphan Cyclophosphamide Methotrexate Amiodarone Nitrofurantoin Sulphasalazine Gold

Answer 16

LAB - Routine bloods; ?eosinophilia on FBC (EAA) - Immunoglobulins (ABPA) - ACE (sarcoidosis) - CK (myositis) - Rheumatological screen e.g. ANA, RF, anti-DSNA, anti-Scl70, anti centromere FUNCTIONAL - Pulmonary function tests + DLCO (Restrictive pattern with low DLCO) - 6 minute walking test RADIOLOGICAL - CXR - HRCT is key test (Assess pattern, extent and distribution of fibrosis) INVASIVE - Bronchoscopy with Bronchoalveolar Lavage - ?Lung biopsy

Answer 17

Depends on underlying cause CONSERVATIVE - Pulmonary rehab PHARMACOLOGICAL - Corticosteroids - less likely to respond if male/late presentation/honeycombing on CT/BAL neutrophilia - Immunosuppression e.g. AZA/MTX - Supplemental Oxygen - Antifibrotics e.g. pirfenidone (Specialist MDT decision, FVC 50-80%) - Symptom Management e.g. benzos, opiates SURGICAL - Lung transplant may be suitable in some cases

Answer 18

<65 years old TLCO<40% predicted Fall in FVC > 10% over 6 months

Answer 19

1) Pleural effusions/pleurisy 2) Pulmonary nodules - Can precede arthritis 3) Fibrotic Lung disease - Lower zone 4) Caplan Syndrome = coal worker's pneumoconioses & RA 5) Obliterative Bronchiolitis - Small airways obstructions --> necrotising bronchiolitis - Linked to Gold & penicillamine

Answer 20

1) Transudates - Raised hydrostatic or low oncotic pressures 2) Exudates - Increased capillary permeability 3) Chylothorax - Disruption of lymphatic ducts 4) Empyema - Infection of pleural space 5) Haemothorax - Bleeding into pleural space

Answer 21

Pleural protein < 20g/L CHAM C- CCF H - Hypoalbuminaemia / Hypothyroidism A - All failures (liver, renal) M - Meig's syndrome (= benign ovarian fibroma & right sided effusion)

Answer 22

Pleural protein >30g/L PINTS P -Pneumonia I - Infarction (PE) N - Neoplasia e.g. mesothelioma, metastases T - TB/Trauma S - Sarcoidosis/Scleroderma

Answer 23

Used if pleural protein level equivocal e.g. 25g/L Pleural effusion is an EXUDATE if ... 1) Pleural Albumin/Serum Albumin > 0.5 2) Pleural LDH/Serum LDH > 0.6 3) Pleural LDH > 2/3 of ULN of serum LDH HOWEVER - 25% of transudates mistakenly identified as exudates using light's criteria

Answer 24

Sputum MC&S +/- AFB Bloods - Routine - ?Blood cultures - Serum albumin and LDH CXR - >300mL to be seen on PA film - >1000mL if mediastinal shift seen USS ?CT thorax ?Bronchoscopy ?CT guided biopsy ?VATS PLEURAL ASPIRATE TESTS Pleural Fluid - Cell Count - Cytology - Albumin & LDH (Light's) - Glucose - pH (<7.2 = empyema!) - Amylase (if suspicious of pancreatitis/oesophageal rupture) - Lipids (if suspicious chylothorax)

Answer 25

Malignancy Empyema Arthritis (RA) TB

Answer 26

Base of axilla Lateral edge of pectoralis major Lateral edge of latissimus dorsi 5th Intercostal Space

Answer 27

Emergency! A to E 14 - 16 gauge cannula into 2nd or 3rd intercostal space, midclavicular line Chest drain (safety triangle)

Answer 28

Primary pneumothorax = no history of underlying lung disease. Usually young, tall, thin men A to E assessment If <2cm and asymptomatic = supportive e.g. pain relief and oxygen therapy If >2cm or symptomatic = aspirate with cannula in 2nd-3rd ICS - If unsuccessful, chest drain

Answer 29

Secondary pneumothorax = due to underlying respiratory disease e.g. Asthma, COPD If <50 & <2cm & asymptomatic = Supportive +/- aspirate If > 50 & > 2cm +/- symptoms = chest drain

Answer 30

Avoid smoking (increases risk of pneumoT) No flying in 7 days after treatment Avoid scuba diving for rest of life (unless undergo bilateral surgical pleurectomy)

Answer 31

Persistent air leak Repeat pneumothorax - 1st contralateral - 2nd ipsilateral Bilateral spontaneous pneumothoraces

Answer 32

3 of 1) OSA 2) Hypercapnia 3) Restrictive PFTs

Answer 33

Epworth Sleepiness Scale Overnight Polysomnography - Measures ECG, EMG, resp effort and oxygenation overnight - Number of apnoeas overnight FBC (polycythaemia) TFTs (?hypothyroidism) Morning ABG

Answer 34

CONSERVATIVE - Advise weight loss if overweight (only 50% of OSA pts are obese) - Stop smoking - Reduce alcohol intake MEDICAL - CPAP = 1st line Rx but issues with compliance - LTOT Surgical intervention rare

Answer 35

HTN IHD & MIs Arrhythmias Stroke Pulmonary HTN OHS

Answer 36

NON SMALL CELL LUNG CANCER - Most common, 75-80% - 3 main subtypes = SCC > adenocarcinoa > large cell SMALL CELL LUNG CANCER - 20-25% of lung cancers - Arise from APUD cells - Rapidly growing with early metastases

Answer 37

Brain Liver Adrenal Glands Bone - osteolytic appearance, often in vertebral bodies

Answer 38

Lung Function Tests - Suitability for surgical intervention Sputum Cytology - Positive in 20% Bloods - Routine (Na+ for SIADH, LFTs) Imaging CXR can be useful in first instance CT CAP - Evaluate tumour location & size, LNs & ?mets - Identify site for biopsy PET-CT scan - More accurate at identifying mediastinal disease (?site for EBUS) TISSUE SAMPLING EBUS - nodal disease CT guided biopsy - of mets or peripherally located cancer Flexible bronchoscopy Mediastinoscopy VATS & pleural biopsy

Answer 39

Parathyroid-hormone Related Protein Secretions - Raised PTHrP = hypercalcaemia - SCC Hypertrophic Pulmonary Osteoarthropathy - Clubbing and pain at wrist and ankles due to new bone formation - Adenocarcinoma & SCC BCG Secreting Tumour - Gynaecomastia - Adenocarcinoma & large cell

Answer 40

Lung Cancer MDT Consider if suitable for surgical resection - Stage I or II TNM - FEV1 >2L (if pneumonectomy); FEV1 > 1.5L (if lobectomy) Radiotherapy - Stage I - III if inoperable Chemotherapy - Post op or on its own - Stage III-IV Palliative Chemo/Radiotherapy if stage IV Advanced Care Planning Symptom control

Answer 41

Stage IIIb/IV (mets present) FEV1<1.5L Malignant pleural effusion Tumour near hilum Vocal cord paralysis SVCO Left recurrent laryngeal nerve palsy

Answer 42

Ectopic ADH secretion - = SIADH, with low sodium Ectopic ACTH Secretion - Cushing's syndrome = HTN, raised glucose, hypokalaemia, muscle weakness Lambert-Eaton Myasthenic Syndrome (LEMS) - Antibodies against VGCC - Can precede diagnosis of lung cancer

Answer 43

Staged as either: 1) Limited = disease confined to ipsilateral hemithorax = 15-20 months median survival 2) Extensive = metastatic disease outside ipsilateral hemithorax = 8-13 months median survival MDT Approach Unlikely to be suitable for surgical intervention Combination of radiotherapy and chemotherapy

Answer 44

Tumour in lung apex Most commonly NSCLC (and usually SCC) Invasive! - chest wall/ribs/brachial plexus/cervical sym nerves PANCOAST'S SYNDROME = Shoulder and arm pain along C8-T1 dermatomes Horner's Syndrome = miosis, ptosis, enophthalmos & anihydrosis Hand muscle weakness & wasting

Answer 45

Superior Vena Cava Obstruction Oncological emergency! Most common in lung cancer (SCLC>NSCLC) and lymphoma FEATURES - Cough, SoB - Headache, worse on bending forwards - Syncope - Hoarse voice - Facial & upper limb oedema - Facial plethora - Superficial vein distension of upper body - Fixed elevated JVP - Inspiratory stridor - Pemberton's sign = facial swelling on lifting of both arms

Answer 46

A to E assessment Inform anaesthetic team and oncology team Corticosteroids mainstay of treatment - If evidence of respiratory compromise = IV dexamethasone ?Endovascular stenting ?Chemo/Radiotherapy (if unable to lie flat, unlikely to be able to tolerate radiotherapy)

Answer 47

Resection of lung malignancy - NSCLC mainly (25% suitable) Localised bronchiectasis with uncontrolled symptoms Old TB (prior to pharmacological Rx) Fungal infections e.g. aspergilloma Traumatic lung injury Large emphysematous bullae CF

Answer 48

FEV1 > 1.5L

Answer 49

Lobectomy & pneumonectomy (less invasive) Pleural biopsy Lung parenchymal biopsy Bullectomy & lung volume reduction for emphysema Correction of spontaneous primary pnemothorax Pleurodesis Wedge resection

Answer 50

Minimally invasive - Reduce need for muscle division & rib spreading/fractures Quicker recovery Reduced length of stay in hospital Earlier mobilisation Lower doses opiates/analgesics required All adds up to reduce risks associated with hospital admissions e.g. HAI, delirium

Answer 51

ILD Advanced COPD (usually single) CF Emphysema secondary to alpha1AT Pulmonary HTN Single = if >65 years old Double = <60 years old CRITERIA - >50% chance of death within 2 years if no transplant - >80% chance of survival >90 days - >80% chance of 5yr survival

Answer 52

Severe organ dysfunction e.g. cardiac failure Acute Critical Illness Severe malnutrition/obesity Smoking in last 6 months Malignancy in last 5 years Poor exercise tolerance/unable to walk

Answer 53

= removal of giant bullae Can help improve symptoms and lung function (restores mechanical linkage between chest wall and lungs) Indications 1) Progressive SoB despite maximal Rx AND 2) FEV1<50% AND 3) Bullae>1/3 of hemithorax

Answer 54

= enlargement and failure of right side of heart due to increased vascular resistance secondary to respiratory disorder e.g. COPD Fluid retention & pulmonary HTN --> increased strain on RV --> RV failure Best treatment = prevention! Will likely need LTOT & diuretics

Answer 55

Oxygen therapy Sputum pots Inhalers Likely young if CF Wet cough, ?cachexia Clubbing, ?yellow nails Midline/central line/portacath (?long term abx therapy) ?lymphadenopathy Non deviated trachea Coarse crackles ?Scars from previous lobectomy/wedge resection

Answer 56

FEV1/FVC < 0.7 Severity: FEV1 0.8 - 1.0 = mild FEV1 0.5 - 0.8 = moderate FEV1 0.3 - 0.5 = severe FEV1 <0.3 = very severe

Respiratory Flashcards

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