Respiratory - Pleural and Pulmonary Vascular Diseases Flashcards
(262 cards)
1
Q
The structure of the pleura
A
The pleural space is bounded by the parietal and visceral membranes covered by a continuous layer of mesothelial cells
2
Q
What can result in the accumulation of excess pleural fluid
A
Disturbances in either formation or absorption
3
Q
When can we determine pleural fluid is an exudate - Light’s criteria
A
Pleural fluid proteins divided by serum proteins is >0.5
Pleural fluid LDH divided by serum LSD > 0.6
Pleural fluid LDH > 2/3 the upper limits of labs normal value for serum LDH
4
Q
Determining transudates vs exudates
A
Hx
Examinations
Ix
5
Q
Ix to help determine transudates vs exudates
A
Radiology Bloods - clotting screen, FBC, LFTs etc Light's criteria CT, PET Bx
6
Q
Most important examples of condns causing transudates
A
Usually caused by failures
HF
Liver cirrhosis
Nephrotic syndorme
Hypoalbuminaemic status
7
Q
Other condns causing transudates
A
Mitral stenosis
Meigs syndrome
Constrictive pericarditis
8
Q
Features of transudates
A
Slower time scale
Usually bilateral but R side may be larger - may find fluid in other areas e.g. ascites, pitting oedema
9
Q
Treatment of transudates
A
Treat the case- if pt fails to respond will need to reconsider dx
10
Q
Causes of pleural exudates
A
Parapenumonic effusions and empyema Malignancy Pulmonary infarction TB Drugs RhA
11
Q
Clinical assessment of pleural exudates
A
Risk factors (smoking, asbestos)
Red flag symptoms
A/c and subacute symtoms - timescale
Look for systemic signs (should be minimal) and effusion is often unilateral
12
Q
Examination findings of pleural exudates
A
Reduced chest expansion
Percussion - stony dullness
Absent breath sounds
13
Q
Use of ultrasound when determining between transudates and exudates
A
Fluid vs thickening - darker fluid. is usually transudate
Loculations
Guided thoracocentesis (Light’s criteria)
14
Q
What do we send pleural aspiration for
A
Cytology Protein LDH pH/ glucose Gram stain Culture & sensitivity Optional extras depending on likely cause
15
Q
Thoracoscopy
A
Placing camera in pleural space under anaesthetic
Can also take fluid from parietal pleura during this procedure
16
Q
Why should an ultrasound be done before a thoracospy
A
To guide needle placement
Should be above rib to avoid neurovasc bundle
17
Q
Ddx for complete white-out on CXR w/ trachea deviation
A
Complete lung collapse
Massive pleural effusion
Pneumonectomy
18
Q
Pleural plaques
A
Benign condn
Sign of asbestos exposure
19
Q
When might a pt develop diffuse pleural thickening
A
Heavy exposure to asbestos ** Previous haemothorax TB Chest surgery Radiation Infection drugs
20
Q
What can diffuse pleural thickening lead to
A
SOB, restricted lung function - requires follow up
21
Q
What are the majority of pleural effusions. (90%) caused by
A
Infection - treat w/ abx, CXR in 6-8 weeks (exudate)
HF - treat cause, don’t drain (transudate)
Malignancy (exudate)
PE (exudate)
22
Q
Clinical px of PTX pts
A
Hx - cigarette, cannabis smoking
PMH - lung disease
A/c onset symptoms - pleuritic chest pain, breathlessness
23
Q
Examination findings in PTX pts
A
Trachea/ mediastinum - pushed Reduced/ absent expansion Percussion - hyper resonant Reduced/ absent breath sounds Hypoxamia esp if underlying lung disease
24
Q
Hypoxaemia
A
Low levels of oxygen in blood nOT tissues
25
Causes of PTX
Primary spontaneous
Secondary spontaneous
Iatrogenic
Trauma
26
Which group of people do we tend to see primary sponatanoues PTX in
Taller pts
Alveoli at the lung apex in tall individuals are subject to significantly greater distending pressure than those at the base of the lung
27
What are apical pleural blebs associated with
High risk of PTX
28
What should you ask spontaneous PTX pts about
Smoker - 12% risk of developing PTX
| Lung disease
29
Causes of secondary spontaneous PTX
```
COPD
PJP
CF
TB
Others - incl Marfan
```
30
PJP
Pnemoctitis jiroveci pneumonia
31
Tension PTX
Air trapped in between parietal and visceral pleura resulting in lung collapse, displacement of mediastinal structure and compromised cardiopulmonary function
32
Medical emergency - Tension PTX
Low BP and low HR
| Emergency needle decompression
33
Anterior border of safe triangle for chest drain
Lateral border of Pec Major
34
Superior border of safe triangle for chest drain
Base of axilla
35
Inferior border of safe triangle for chest drain
Line of 5th ICS
36
Lateral border of safe triangle for chest drain
Lateral edge of Lat Dor
37
Complications of Chest Drain
```
Infection/ pain
Drain dislodgement
Drain blockage
Visceral injury
Death
```
38
Methods of chest drain insertion
Seldinger technique
| Surgical blunt dissection approach
39
Suction recommendations for chest drain
High volume low-pressure suction systems
| Wall suction or digital suction system
40
Conservative mx of PTX
Shouldn't dive until definitive prevention strategy
Avoid air travel until 7/7 post PTX resolution
Smoking cessation
Organise follow up CXR to ,omit resolution
Manage comorbidities
41
Definitive prevention strategy for ptx
Surgical pleurectomy
42
Why do PTX pts need to stop smoking
Reoccurrence risk for smokers is 32%
| 8% in non-smokers
43
When should a follow up CXR be organised for a PTX
2 - 4 weeks
44
Risk factors for recurrence of SSP
Age
Pulmonary fibrosis
Emphysema
45
Surgical intervention to prevent recurrence of PTX
Medical Chemical Pleurodesis (Talc)
| Done for recurrent pneumothoraces and non-resolving PTX
46
When is melatonin secreted
As a result of darkness, from the pineal gland
| Retinal hyper thalamic pathway
47
Stages of sleep
REM (dream sleep)
| Non-REM - light sleep, slightly deeper, deep sleep
48
When do we experience non-REM sleep
First half of sleep
49
Which sleep refreshes cells
Deep sleep
50
Breathing in NREM sleep
Normal
| Regular muscle tone
51
Breathing in REM sleep
Breathing is erratic
| Muscles are atonic except diaphragm
52
Which stage of sleep generally exacerbates sleep apnoea
REM sleep
53
Sleep Disordered Breathing Classification
OSA
Central Sleep Apnoea
Mixed obstructive/ central apnoea
Obesity hypoventilation Syndrome
54
Most common pattern seen in Sleep disordered breathing
OSA
55
2nd most common pattern seen in sleep disordered breathing
Obesity Hypoventilation Syndrome
56
Hx and clinical px of OSA pts
```
Snoring
Witnessed apnoea
Excessive daytime sleepiness (EDS)
Nocturia
Unrefreshed sleep
Morning headaches
```
57
Witnessed apnoea in OSA
Bed partner will note pt stopped breathing and then took a v loud breath on inspiration
58
Nocturia
Urinating <4 a night
59
Things to ask about in hx of OSA pts
```
Occupation and riving
Medications
PMH
Trisomy 21
Past surgical hx
```
60
What medication can be a ppts factor in OSA
Opiod analgesics
61
What diseases should be screened for in PMH of OSA pts
Thyroid disease
DM
Systemic hTN
CDV and CBV disease
62
Why do we ask about trisomy 21 in OSA pts
High risk for OSA (reduced muscle tone)
63
What is relevant in the past surgical hx of OSA pts
Tonsillectomy
64
Measuring EDS
Epworth Sleepiness Scale
| Scores of 11/24 = EDS
65
Epworth Sleepiness Scale
Looks at high likely a pt is to fall asleep during following situations e.g sitting, watching TV, talking to someone, in a car
Rated from 0 (would never dose) - 3 (high chance)
66
Limitations of ESS
Pt may be worried to accurately report lapse in judgement e.g. driving
Timescale - values may may change by the time the pt is seen
67
Possible sleep questionnaires
Pittsburgh sleep quality index index (PSQ1)
ESS
STOP BANG (pre-op screening)
4 variable screening tool used in Norfolk
68
Examination for OSA
Obesity - BMI >30kg/m2, measure waist circumference
Upper airways -
Look for signs of acromegaly, hypothyroidism, Cushing's syndrome
Look for cranial abnormalities
69
What do you look for in upper airways when examining OSA pts
Enlarged tonsils esp in younger pts
70
Which craniofacial abnormalities should you look for in OSA pts
Micrognathia (small jawline)
Retrognathia (receding jawline)
These can cause smaller airways
71
Mallampati Score
Class I (Complete visualisation of soft palate) to Class IV (soft palate is covered)
72
Desaturation in apnoea
Cessation of breathing for 10s or more
| Usually scored w/ >4% desaturation (SpO2)
73
Hypoapnoea
Reduction in the airflow (nasal flow) by 50% or more
74
Does hypoapnoea always cause O2 desaturations
No - may not cause O2 desaturation
75
Apnoea Hypoapnoea Index scores for OSA
2-15 - mild OSA
15 - 30 - moderate OSA
>30 severe OSA
76
Desaturation index criteria fro OSA
>4%
77
OSAS
OSA syndrome
78
OSA vs OSAS
Abnormal Sleep study and EDS - OSAS
| Abnormal Sleep Study and no EDS - OSA
79
Measurements in sleep disordered breathings
```
Nocturnal oximetry
Resp Polygraphy (Home Sleep Test)
Polysomnography - Gold standard
```
80
Treatment of sleep disordered breathing
Lifestyle modifications - mild OSA/ OSAS
Wt reduction
Sleep Hygiene - excessive caffeine
Positional training
81
Mandibular advancement devices
Used in mild OSA(S)
| Boil and bite devices - pushes lower jaw forward creating more room at back of throat
82
CPAP
Continuous Positive Airway Pressure
83
When is CPAP given for OSAS
Definitive treatment - moderate/ severe disease
Given after attempting lifestyle modification and mandibular advancement devices
Relieves symptoms majorly
84
Driving and sleep apnoea
Pts have to declare dx to DVLA
CPAP compliance > 4hrs/ night
HGV/ public transport drivers need to inform employers and occupational health - asked not to drive unless established in treatment
85
Obesity Hyperventilation Syndrome
Morbid obesity BMI > 35kg/m2
Mean SpO2 < 90% in sleep study
Need to measure time spent <90% SpO3 - shallow breathing, reduced TV
86
ABG of pts w/ obesity Hypoventilation Syndrome
Day time CO2 retention and/or elevated HCO3 (.27mmol/L)
87
Mx of Obesity Hypoventilation Syndrome
Wt loss
| NIV (+ve pressure)
88
Co-existent lung disease in sleep disordered breathing
Asthma and OSA
| COPD/ emphysema: overlap syndrome of OSA/COPD
89
Consequences of SDB (sleep disordered breathing)
Systemic HTN
AF
MI, CVA
Pulmonary arterial hypertension
90
Ventilation
Rate at which air enters or leaves the lungs
91
Minute ventilation
Volume of air moving in and out per unit time
92
Alveolar ventilation
Amount of air utilised for gas exchange (VT - dead space) x RR
93
Perfusion (Q)
Movement of blood in to lungs through pulmonary capillaries
94
V/Q ratio
Alveolar ventilation/ pulmonary blood flow
95
When do we see hypoxaemia
```
Reduction in altitude
Hypoventilation
Diffusion
Shunts
VQ mismatch
```
96
When are V and Q matched
When pulmonary blood flow is proportionally matched to the pulmonary ventilation
Results in greatest efficiency for gas exchange
97
VQ ratio for single alveolus
Alveolar ventilation/ capillary blood flow
98
How many zones are there for perfusion and ventilation in the lungs
3
99
Pressures in zone I (apex) for perfusion and ventilation
PA > Pa > Pv
A - systemic arteries
a - alveoli
v - pulmonary vein
100
Pressure in zone II for V & Q
Pa > PA > Pv
A - systemic arteries
a - alveoli
v - pulmonary vein
101
Pressures in zone III
Pa > Pv > PA
A - systemic arteries
a - alveoli
v - pulmonary vein
102
How does V/Q vary in diff zones of the lung
Highest in apex and lowest in base (but has higher O2 content)
Clinical rel - certain infections attack apex as less aerobic than base
103
Shunt
Physiological phenomena where deoxygenated blood mixes w/ oxygenated blood
Occurs when there's an intracardiac defect - doesn't participate in gas exchange
104
Pulmonary shunt
Mixing of blood without participating in the gas exchange at level of pulmonary capillaries
105
When do we see a pulmonary shunt
Occurs when alveoli are perfused like normal but ventilation fails to supply perfused region - pathological condn (VQ = 0)
106
Examples of intrapulmonary shunting
Fluid in alveoli e.g. pulmonary oedema & pneumonia
107
Shunt fraction
% of blood pumped by heart that is not ventilated (oxygenated)
108
When is the shunt fraction increased
Greater in pulm contusion or haemorrhage even at breathing 100% oxygen
109
What can minimise shunt fraction
Vasoconstriction - compensatory mechanisms of hypoxaemia
110
What can cause a VQ mismatch
```
Dead space (physiological) - ventilation of poorly perfused alveoli (V > Q)
Shunts; perfusion of poorly ventilated alveoli (V < Q)
```
111
Pathologies resulting in VQ mismatch - low VQ ratio
```
Pneumonia
Pulmonary oedema
ILD/ pulm fibrosis
Asthma
Mucous plugging
Airway obstruction
```
112
Pathologies resulting in AQ mismatch - high VQ
PE
| Emphysema
113
What does a VQ mismatch respond to
100% oxygen
114
Normal VQ in healthy lung
0.8
115
Aa gradient
Alveolar to capillary oxygen gradient
116
Mechanisms of hypoxaemia
```
Shunt
Diffusion impairment
VQ mismatch
Hypoventilation
Low ambient oxygen
```
117
Aetiology of primary pleural malignancy
Mesothelioma
118
Aetiology of secondary pleural malignancies
Lung - 1st most common
Breast - 2nd most common
Lymphoma - 3rd most common
But almost any cancer can metastasise to the pleura
119
What do pleural malignancies commonly cause
Malignant pleura effusions and/or pleural thickening
120
Pathology of exudative effusion caused by pleural malignancy
Tumour dissemination
Angiogenesis - w/ vasc hyperpermeability
Tumour secreted vasoactive mediators (VEGF)
121
Asbetsos-related resp disease
```
Asbestosis
Malignant pleural mesothelioma
Pleural plaques
Benign pleural thickening
Benign pleural effusion
```
122
Why is asbestos considered an ILD
Asbestos in lung tissue --> fibrosis and scarring
123
When can pts get compensation for benign pleural thickening after asbestosis exposure
If disabled by SOB
124
Epidemiology of pleural malignancy
Common - incidence about 30,000/ yr
Breast cancer commonest in women and lung cancer commonest cause in men
Increasing incidence w/ age (max at 80-85)
125
Ddx of pleural effusion
```
Transudative pleural effusion - cardiac, renal or hepatic failure
Pleural infection
PE
CTD
Benign asbestos pleural disease
```
126
What should be asked in the hx of a pt w/ pleural malignancy
```
Symptoms spp to effusion
Constitutional symptoms
Symptoms of other malignancy
PMH - previous malignancies
SH
```
127
Symptoms spp to effusion in pts w/ pleural malignancy
Breathlessness, cough, dull chest pain
| Time course: months - weeks
128
Constitutional symptoms seen in pts w/ pleural malignancy
Wt loss
Loss of appetite
Fatigue
129
Symptoms of the malignancies that may be seen in pts w/ pleural malignancy
Dysphagia
Change in bowel habits
Lumps
130
Relevant SH in pts w. pleural malignancy
Smoking
Asbestos exposure
Perfomance status
131
ECOG performance status
```
Looks at effects of malignancy on pts lifestyle
From 0 (fully active, able to carry on pre-disease performance) to 4 (completely disabled, cannot cary on self-care)
```
132
Why is ECOG performance status important for pleural malignancy
Helps determining what ix the pt is fit for e.g <2 fit for thoracoscopy
Helps determine mx, 4 is usually disseminated and not fit for treatment
133
Examination of pts w/ pleural malignancy
Increased RR
Cachexic
not usually hypoxic
Decreased air entry, decreased lung expansion, dull percussion note, decreased vocal resonance
Other signs of malignancy e.g. breast lumps, testiuclar lumps, lymphadenopathy
134
Main ix for pleural malignancy
Bloods - U&Es, FBC, CRP, clotting, PSA
| CXR
135
Addn ix for pleural malignancy
Thoracic ultrasound
CT
Pleural aspiration
Thoracoscopy
136
What might you see in a thoracic ultrasound in pleural malignancy
Pleural effusion
Pleural thickening
Pleural modularity
137
Difference in CT scan for men and women for suspected pleural malignancy
CT scans in men of chest and upper abdomen
| For women also do pelvis
138
What do you send pleural aspiration for in suspected pleural malignancy
Biochem: total protein, LDH (malignant effusions typical transudative)
MC&S - excl infection
Cytology - +ve in 90% MPE, only 20% in mesothelioma
139
MPE
Malignant Pleural effusion
140
Main procedures done in thoracoscopy
Fluid drainage and pleural biopsy
| After procedure can perform pleurodesis (using sterile talc), IPC insertion
141
IPC
indwelling pleural catheter
142
Complication of thoracosocpy
Re explosion pulmonary oedema
143
Making a dx of pleural malignancy - role of MDT
Team reviews hx and ix
Make a dx - radiological or definitive
Mx plan
144
Possible mx plans for pleural malignancy
Further biopsies
Cancer treatment
Watch and wait
Palliative care
145
Treatment for pleural malignancy
```
Treat underlying malignancy - lymphoma, small cell lung cancer, breast cancer
Therapeutic aspiration
Chest drain and pleurodesis
IPC insertion
Pleurectomy
```
146
Chest drain and pleurodesis for pleural malignancy
Inpt 2-5 days
Seldinger chest drain and underwater seal
~75% success rate
147
Why is talc used in pleurodesis
4g talc creates infl causing pleura to fuse together
148
What can pts be left w/ after chest drain and pleurodesis
Residual pleural thickening --> breathlessness
149
IPC for pleural malignancy treatment
Day case
intermittent drainage at home using vacuum bags, 3x/ week initially
Definitive treatment
Can give talc to perform pleurodesis
150
What IPC the treatment of choice for
Trapped lung
| Failed pleurodesis
151
Risk associated w/ IPC
Blockage
| Infection
152
Trapped lung
Thickened visceral pleura so unable to expand fully
153
Pulmonary HTN
Pathophysiological disorder that may involve multiple clinical condns, where mPAP > 20 mmHg
154
mPAP
Mean pulmonary artery pressure
155
What can pulmonary HTN complicate
Majority of CDV and resp diseases
156
What kind of symptoms are seen in pulm HTN
Non-spp
157
What does pulmonary HTN dx and classification require
R heart catheterisation
158
Calculating PVR
80(mPAP - PAWP)/ CO
159
PAWP
Pulm artery wedge pressure
160
Normal pulmonary artery pressure
14 mmHg +/- 3.3 mmHg at rest
161
Criteria for Pulm HTN
Precapillary PH mPAP > 20mmHg, PVR > 3 WU and PAWP < 15mmHg
Combined pre and post capillary PH - mPAP > 20mmHg, PVR > 3 WU, PAWP > 15
162
WU
Wood units
163
Classification of pulm HTN
```
Pulm arterial HTN (PAH)
Left heart disease - PAWP > 15
Lung disease
CTEPH
Unclear/ multifactorial
```
164
Epidemiology of pulmonary HTN
Global PH incidence data is poor
In the UK, prevalence of 97/1,000,000
F:M ratio of 1.8
L heart disease believed to be most common cause
165
How is clinical presentation of Pulm HTN classed
```
By functional class
From Class I (nob symptoms w/ exercise or rest) to Class IV (symptomatic at rest, syncope and fatigue)
```
166
Determinants of prognosis in pulmonary HTN
Clinical signs of R heart failure
Progression of symptoms
Syncope
WHO functional class
Cardiopulmonary exercise testing
NT-proBNP plasma levels - higher is worse
Imaging - increased RA area, pericardial effusion
167
General mx of pulmonary HTN
```
Avoid pregnancy
Influenza and pneumococcal vaccinations
Psychosocial support
Pulm/ cardiac rehab
Diuresis if evidence of volume overload
LTOT if pO2 consistently less than 8kPa
Correct anaemia
```
168
Spp mx for pulm HTN
Group I - depends on functional class, assess severity
Group 2 - targeted therapy not currently licensed
Group 3 - no targeted therapy
Group 5 - v difficult to mx
169
CTEPH
C/c thromboembolic pulmonary HTN
170
What is CTEPH
Fibrotic transformation of a pulmonary arterial thrombosis, causing fixed mechanical obstruction of pulmonary arteries
Microvascular remodelling causing a progressive increase in PVR
171
What % of CTEPH pts lack a hx of a/c PE
~25%
172
Treatment for CTEPH
PEA (pulmonary endarterectomy) surgery - removing central obstructing lesions
BPA (Balloon pulmonary angioplasty)
173
CTEPH prognosis
In operable pts, treated w/ drugs, 3 yrs survival varies from 41-805
3-yr survival of 89% in operated PEA pts and 70% in non operated pts
174
Drugs given for CTEPH
IV prostacyclin analogues or oral PAH targeted drugs
175
What does BPA in non-operable CTEPH pts show significant improvement in
```
Functional status
QoL
Pulm pressure
Exercise capacity
PVR
```
176
Causes of cardiac chest pain
MI/ infarction
Pericarditis
Aortic dissection (pleurite chest pain)
177
Resp causes of chest pain
PE
PTX
Pneumonia
Pleural infl (pain happens even at rest)
178
GI causes of chest pain
Oesophageal spasm
Dysmotility/ reflux
Oesophageal rupture (Boerhavve's)
179
MSK causes of chest pain
Rib frature/ metastasis
Muscle spasm/ strain
Costochondritis (localised pain - can be elicited)
180
Psychological states causing chest pain
Panic attack
| Hyperventilation
181
Ix for differentiating between causes of chest pain
Bloods - FBC, CRP/ESR, LFT, D-dimer etc
ECG - cardiac causes, arrhythmia
CXR +/- further imaging
182
What is a PE
Occlusion of a segment of pulmonary arterial circulation through embolism from a distant source - lower limbs
183
Embolic material that can cause a PE
Commonly blood clots
May be fat embolism - following major trauma
Air embolism following invasive procedures e.g. central line insertion
184
Causes of a PE
Virchow's triad
Hypercoagulable stae
Stasis (local/ systemic) - VV, immobilisation
Endothelial damage - c/c infl
185
What can cause a hyper coagulable state --> PE
Factor V Leiden, Protein S/C deficiency
Malignancy
Loss of proteins incl clotting factors - myeloma
186
Major risk factors for a PE
```
Recent immobility
Major surgery incl obstetric
Leg fracture
Previous DVT/ PE
Thrombotic disorder
Metastatic cancer
```
187
Minor risk factors for PE
```
Oestrogen
Travel
Known thrombophilia
Obesity
Minor surgery
```
188
Presentation of a PE
```
SOB
Pleuritic chest pain
Cough
Leg swelling/ pain
Haemoptysis
```
189
Well's score for PE - criteria
```
Previous VTE
Tachycardia
Recent surgery/ immobilisation
Clinical signs of DVT - 3 point
Haemoptysis
Cancer
```
190
Bloods for a PE
ABG
D-dimer
FBC/ clotting profile
191
ECG for PE
Sinus tachycardia
Fast AF
S1Q3T3
May also be normal
192
Ix for PE
```
Bloods
ECG
CXR - doesn't excl/ confirm dx
CTPA
V/Q
```
193
D-dimer for PE
Highly sensitive
High -ve predictive value
Used in combo w/ probability score
194
What is D-dimer commonly elevated in
Pts w/ infl states, infection, ACS, malignancy recent surgery
195
What might you see on a CXR for for PE
Pulmonary infarct
| Pleural effusion
196
CTPA
CT pulmonary angio
Gold standard for PE
Involves higher dose of ionising radiation and risk of nephrotoxicity w/ contrast
Embolus is dark grey - found in white area
197
VQ scan for a PE
Compares radioactive material uptake in lungs via inhalation and iV injection
Reported as probability risk
198
Pulmonary angio for PE
Invasive
Superseded in a/c setting by CTPA
Relevat in dx CTEPH
199
Echo for PE
Looks for evidence of R heart dilatation/ strain
Relevant in a/c setting/ peri-arrest situation
To screen for 2' pulmonary HTN
200
Treatment of a/c PE
Heparin - LMWH, unfractionated heparin (IV)
Warfarin
Anticoagulants for 3/12
201
Massive PE
PE w/ evidence of systemic compromise - central/ proximal/ multiple clots
Hypotension, R heart strain
202
Thrombolysis of a massive PE
Dissolution of a clot
Improvement of physiological parameter
Reduce risk of death
203
Follow up for PE
Echo
Consider VTE risk factors and their modification
Consider lifelong anticoagulants
204
Who gets lifelong treatment after a PE
Idiopathic PE - cause unknown
First episode and ongoing risk factors
2 or more VTE events - IVC filter
205
Canonball metastases on CXR
Discrete lesion, multiple opacities
206
Mx of tension PTX
Urgent needle decompression
| Chest drain and admission
207
Ddx of whole lung field white out
Collapse
Large pleural effusion
Pneumonectomy
Consolidation
208
Pneumonectomy
Surgical removal of lung or part of lung
209
What direction does the trachea move in lung collapse
Pulls trachea towards it
210
What direction does a large pleural effusion push the mediastinum
Away
211
Why might you see a white out on a CXR following a pneumonectomy
Fluid fills up space where lung has been taken out
212
What direction does a pneumonectomy move the mediastinum
Moves in or may be normal
213
When do you see a meniscus sign on a CXR
Pleural effusion
214
What do we see in hydro PTX on CXR
Fluid line
215
What side do you normally see surgical emphysema in
The side of the chest drain
216
Pancoasts tumour
Apical lung tumour
| May cause denervation
217
Signs in Horner's syndrome
Anhydrosis
Ptosis
Miosis
218
What does it mean if the cricothyroid distance is <3 fingers
Hyperinflation of the chest
219
What types of crackles do we hear
Coarse (infection and bronchiectasis) and fine end inspiratory (pulm fibrosis)
220
Features of vesicular breathing
Normal breathing
Longer inspiratory phase (2:1)
Gentle sound
221
Features of bronchial breathing
Seen in infections
Longer espiratrxy phase (1:3)
Break in between inspiratory and expiratory phases
Louder sound
222
Features of rhonci
Sounds similar to snoring
Can be cleared by coughing
Combination of wheeze and crackles - low pitched
223
Cause of rhonci
Build up of secretions
224
Features of a wheeze
Heard in expiratory
High pitched
Whistling/ musical tone
225
When do we hear a pleural rub
Pleurisy
226
Added breath sounds
```
Crackles
Bronchial breathing
Wheeze
Stridor
Rhonci
Pleural rub
```
227
Signs of anaphylaxis
V quick onset
Stridor (inspiratory wheeze)
Angiodema
Urticarial rash
Crash call should be put out
228
Where do we aspirate PTXs from
2nd IC space, mid clavicular
229
Where do we insert a chest drain for PTX
5th IC space mid axillary
230
How do we measure a PTX
From edge of lung to hilum
231
Mx of PSP
If >2cm and/or breathless - aspirate
| If no success, insert chest drain and admit
232
Mx of SSP
Insert chest drain if >2cm and/or breathless
| Aspirate if 1-2cm
233
Which hilum is higher
L
234
What can a cavitating mass be caused by
Carcinoma of bronchus
SCC metastasis
Pulm infarct
Bacterial abscess
235
Definition of apnoea
Cessation of breathing for 10 seconds, causing 4% destauration
236
Ideal V/Q ratio
1 for maximally efficient pulmonary function
237
Usual VQ ratio
0.84 overall
| Diff ratios for diff areas due to where area lies in relation to heart
238
How does VQ ratio change at the apex and base of lung
When standing up straight, ratio is 3.3 in apex and only 0.63 in base
V > Q in apex
V < Q in base
239
Examples of diseases causing Class I PHTN
Idiopathic/ heritable PAH - pts usually px quite young
| PAH 2' to drugs of CTD
240
Examples of diseases causing Class II PHTN
LV systolic/ diastolic dysfunction
| Valvular disease e.g. MS, MR
241
Examples of diseases causing Class III PHTN
COPD
| ILD
242
Examples of disease causing Class V PHTN
Sarcoidosis
| Sickle cell anaemia
243
What mutation causes familial PAH
BMPR2
244
PAH
Pulm arterial HTN
245
Symptoms of Pulm HTN
```
(Non-spp)
Progressive exertion dyspnoea
Syncope
Fatigue
Limb swelling
Chest pain
Haemoptysis
```
246
Examination findings for pulm HTN
Looking for associations w/ CTD e.g. Raynaud's, calcinosis, telangiectasia, sclerodactyly
247
Main ix for pulm HTN
R heart catheterisation
Echo
ECG
Bloods - NTproBNP, FBC (anaemic pts have worse prognoses)
Cardiac MRI
6 in walking test (stamina and desaturations)
248
Why do we measure glucose in pleural aspirate
To rule out Rh effusion when glucose is low
249
What is the pleural effusion most likely to be if the pH of the aspirate is below 7.2
Acidotic fluid implies parapneumonic effusion or empyema
| Chest drain must be inserted ASAP (5th IC space)
250
What can be done for a PTX pt if a chest drain has not worked
Insert large bore cannula
Surgery
Talc pleurodesis
251
Key mechanism of hypoxaemia in pE
Physiological dead space - no gas supply to alveoli
252
Key mechanism of hypoxaemia in pleural effusion
Physiological shunting
253
What must HGV and public transport drivers do after a dx of OSA is made
Declare to DVLA and stop driving ASAP
| Once established on treatment for 2-3/52, and assessed, they can resume
254
Indications for CPAP
ESS 11/24 and moderat/severe apnoea
| Mild apnoea but CDV risk factors
255
Which CTD is most likely to cause heart failure
SScl
| Specifically R heart
256
h
257
Example of a drug that may cause PAH
Fenfluramine - anti-epileptic
258
Drug therapy for PAH
Sildenafil
Bosentan
Both venodilators
259
Absolute contraindications for thrombolysis in PE
```
Haemorrhage stroke
Ischaemic stroke within 3/12
Recent head injury
Recent surgery
Current active bleeding
Bleeding disorder
```
260
Mechanism of tension PTX
The opening in the pleura creates a flap that acts as a one-way valve
This allows air to enter the cavity during inspiration but stops it from leaving during expiration
261
Mechanism of a spontaneous PTX
Small bleb/ weakness ruptures - more common in tall pts
Air in pleural space can results in pain - variable in intensity
Feeling breathless - dependent on air leak
Air in pleural space may result in the lung collapsing
262
Key landmark for insertion of a needle in a tension PTX
2nd IC space in the mid-clavicular line (urgent needle decompression)
