Week 8 Resp Flashcards

Question

Bronchodilators, muscarinics, methylxanthines

Answer 1

**B2 agonist:** Short acting B2 adrenoceptor agonist - Relaxes bronchial smooth muscle, causing bronchodilation - Inhibits pro-inf cytokines from mast cells decreasing airway inflammation - Stimulates cilia action, increasing mucus clearence Side effects: tremor, arrythmias, tachycardia, hypokalaemia SABA: salbutamol, terbutaline LABA: salmeterol, fometerol **Muscarinics:** Inhibits muscarinic (M1 and M3) receptors in lung leading to decreased parasympathetic mediated bronchoconstriction Reduces mucus secretion. Side effects: blurred vision, urinary retention, dry mouth SAMA: ipotropium bromide LAMA: tiotropium **Methylxanthines:** Theophylline, Aminophylline Phosphodiesterase inhibitor - bronchial smooth muscle relaxation Improves mucociliary clearence Side effects: hypokalaemia, arrthymias, narrow therapeutic window Indicated: adjunct to inhaled therapy in asthma, IV for severe exacebations

Answer 2

Montekulast Inhibits LTD4 (leukotriene D4) in smooth muscle cells in airways and airway macrophages leading to smooth muscle relaxation and decreased oedema Indicated: exercise induced asthma

Answer 3

**Omalizumab** Anti-IgE antibody For persistent, severe asthma Side effects: hypersensitivity **Mepolizumab** Anti-IL5 antibody Reduces eosinophils Side effects: headache Both given sub cut

Answer 4

Step 1: **Short acting B2 agonist (salbutamol)** Step 2: + **ICS** (Budesonide) Step 3: LABA (salmeterol) + ICS Add **LRTA (Montekulast)** or **theophylline** or oral B2 agonist Step 4: **high dose ICS + regular bronchodilator** e.g. nebs, anti-muscarinics Step 5: **Steroid tablet** **Omalizumbab** (anti-IgE), **Mepolizumab** (anti-IL-5), Entanercept (Anti-TNFa)

Answer 5

Asthma **Symptoms:** Recurring cough, wheeze, chest pain, breathlessness esp in night/early morning **Investigations:** FBC (raised eosinophils), CRP, Uand Es Sputum (esoinophils) PEFR Spirometry - obstructive, imrpoves \>400mL and 15% FEV1 after broncholdilator CXR - may have pneumothorax sputum culture - resp. viruses ABG **Treatment for acute exacerbation** 40-60% O2 aim \>94% sats Salbutamol and ipatropium bromide nebs Prednisolone Life threatning: IV Mg IV salbutamol If pt improving: 40-60% O2, prednisolone (at least 5 days), nebs salbutamol and ipatropium **Cell type involved:** CD4 T cells (secrete IL-4, 5, 13), eosinophils, mast cells **COPD** Symptoms: Chronic cough, sputum production, wheeze, exertional breathlessness Investigations: FBC (polycythaemia (increased Hb) if chronic hypoxaemia), CRP, U and Es Sputum culture, viral gargle Spirometry - obstructive. Little improvement after bronchodilator CXR - hyperinflation, consolidation Alpha 1 anti-trypsin genetic test ABG **Treatment acute exacerbation:** 24-28% O2, aim 88-92% sats Salbutamol and ipatropium bromide nebs Prednisolone Antibiotics if bacterial infection e.g. purulent sputum - amoxilicillin Non-invasive ventilation: for acidotic type II resp failiure **Cell types involved:** CD8 T cells, macrophages, neutrophils

Answer 6

Fluid in pleural space Clinical signs: decreased breath sounds, stony dull to percussion, decreased vocal fremitus

Answer 7

**Pleural effusion** \>300mL fluid Generally white appearence Blunting of costophrenic angles Mesnicus at upper edge Mediastinal shift away **Pneumothorax** Pleural line Hyperlucent (dark) lung Tracheal deviation away from affected side Depression of hemidiapragm

Answer 8

**Pleural effusion** Accumulation of fluid in pleural cavity Symptoms: SOB, pleuritic chest pain, referred pain to shoulder and abdomen Signs: Reduced breath sounds, stony dull percussion, reduced vocal fremitus, pleural rub Causes: Transudative: Cardiac failure (increased hydrostatic pressure) Cirrhosis, hypoalbuminaemia/nephrotic syndrome (decreased oncotic pressure) Exudative: Pneumonia (increased vascular permeability), malignancy (decresed lymphatic drainage), TB Investigations: Exam, history, CXR - transudate? - treat If not, pleural aspiration (with US). Transudate \<30 protein, \<2/3 LDH ULN, clear, bilateral Exudate \>30 protein, \>2/3 LDH ULN, cloudy, unilateral **Pneumothorax** Air in pleural cavity Breach in pleural cavity leads to collapse of lung **Causes:** Traumatic - rib fracture Iatrogenic - aspiration, pleural biopsy Spontaenous - primary (fit, healthy, development subpleural blebs which ruptures and tears visceral pleura leading to lung collapse. - secondary (underlying lung disease e.g. COPD - weakness in lung tissue, CF. asthma (increased airway pressure) Symptoms: SOB, pleuritic chest pain, resp distress **Signs:** Decreased vocal resonance, hyper-resonant to percussion, tracheal deviation if tension pneumo **Investigations:** Observe (via CXR) if small or asymptomatic Aspiration (if \>2cm in primary, or 1-2cm in secondary) Intercostal chest drain (if \>2cm in secondary) VATS (video assisted transthoracic surgery) Talc pleurodesis Tension pneumo: Medical emergency One way valve, air enters pleural space but doesn't leave Decreased venous return, CO, BP Treatment: aspiration, chest drain Empyema Pus in pleural cavity Treatment: IV antibiotics, DVT prophylaxis, fibrinolytics

Answer 9

Pirmary tumour of pleura, due to asbestos exposure Epitheliod or sarcomatoid appearence

Answer 10

**EGFR** inhibitors: **Erlotinib** **Cetuximab** **Nivolumab** - inhibits **PD-L1** (receptor on tumour which binds to PD1 on T cells, stopping T cell from killing it) **ALK: Crizotinib** Inhibits ALK which inhibits EML4 ALK- fusion gene (leads to activation of tyrosine kinase, lead to cell proliferation)

Answer 11

Symptoms: cough, haemoptysis, weight loss, SOB, chest pain Signs: finger clubbing, pleural effusion, from metastases - cervical lymphadenopathy, cahexia, Horner's syndrome (Pancoast tumor), Cushingoid, oedema in face/arm (SVC obstruction) **Small cell carcinoma** - Chemotherapy, radiotherapy, no surgery Aggressive Central Appearence: small oval/spindle shaped cells, nuclear moudling, scant cytoplasm, finely granular nuclear chromatin (salt and pepper pattern) Limited or extensive **Non-small cell carcicnoma** Sugery Radiotherapy Chemo **Squamous cell carcnioma** Central Keratinized, intercellular bridges Can secrete PTHrP - p53 **Adenocarcinoma** Periphary TTF-1 (thyroid transcription factor) positive Glandular, mucin production Most common in female smokers, and non-smokers If EGFR +ve, can give EGFR inhibitors **Large cell carcinoma** Diagnosis of exclusion Undifferentiated malignant epithelial tumour with no features of small cell, squamous or adenocarcinoma Usually central **Carcinoid** Well diferentiated neuroendocrine tumour Better prognosis Yellow-brown tumor **Other treatments:** Endobronchial lasers/stents Palliative

Answer 12

**Malignant** Bronchial carcinoma Metastases **Benign:** Abcess TB Sarcoidosis

Answer 13

Blood vessels, trachea, oesophagus, thymus, thoracic duct, phrenic nerves

Answer 14

TB Sarcoidosis Lyphoma Malignancy

Answer 15

Suspect malignancy Also be mucus plug, foreign body Golden reverse S sign

Answer 16

Sail boat sign Can't see left hemidiaphragm Remainig left lung is hyperlucent (dark)

Answer 17

**Mediastinum central:** Pleural effusion Consolidation **Mediastinum towards:** Collapse Pneumectomy **Mediastinum away:** Pleural effusion

Answer 18

Weight loss Hypercalcaemia - increased PTHrP Cushing's - increased ACTH SIADH - increased ADH Eaton-Lambert syndrome Finger clubbing

Answer 19

SC compression Symptoms: leg weakness, reduced bladder/bowel control Signs: upper motor neuron signs in legs Treatment: high dose steroids, radiotherapy SVC obstruction Symptoms: oedema in face/arms, breathless Signs: raised JVP, dilated veins in arms Treatment: high dose steroids, radiotherapy/chemo

Answer 20

Unknown Sarcoidosis Idiopathic pulmonary fibrosis Known Occupation: Asbestos Drugs: Nitrofurantoin, methotrexate, cocaine Environment: Hypersensitivity pneumonitis Connective tissue diseaes: RA, Lupus

Answer 21

Multi-system inflammatory disease of unknown cause, mostly of lungs and intrathoracic lymph nodes. Diagnosis of exclusion. Characterised by non-necrotising granulomatous inflammation Causes: Borrelia Burgdorferi, TB Symptoms: fever, weight loss, night sweats, SOB on exertion, cough, chest pain Diagnosis: FBC (anaemia), LFTs (AST/ALT high)Ca (high), serum ACE (high) CXR: Stage 1: Bilateral lymphadenopathy without hilar infiltration Stage 2: Bilateral lymphadenopathy with hilar infiltration Stage 3: infiltration Stage 4: fibrotic bands, bullae

Answer 22

Form of chornic fibrosing interstital pneumonia of unknown aetiology. Characterised by scar tissue in lungs and progressive dyspnoea. **Symptoms:** progressive breatlessness, cough, bilateral crackles Signs: weight loss, finger clubbing Complications: cor pulmonale Causes: Abestos, methotrexate, amiodarone, lupus, RA, sarcoid, idiopathic **Diagnosis**: Made by clinical diagnosis, with restrictive pattern and XR changes Spirometry - **restrictive** diseasse (both FEV1 and FVC reduced, TLC reduced, CO gas transfer reduced) **ABG** (type I resp failure) **CXR:** basilar reticular opacities High Res CT - subpleural **reticular abnormalities,** honey combing - thick walled cysts in bronchioles Lung biospy - temporal heterogenity: areas of fibrosis and healthy tissue **fibroblastic foci** Macroscopically - fibrotic areas of lung - firm, rubbery, white **Pathogenesis**: Agent leads to abnormal activation of epithelial cells - abnormal repair - inflammation - formation of fibroblastic foci **Cell types involved:** **Damaged epithelial cells - release TGFB1** **Fibroblasts - secrete collagen** Type I pneumocytes reduced MUC5B gene assoc with familial IPF **Treatment** Pirfenidone: anti fibrotic, anti-inflammatory Nintedenib: inhiibtor of tyrosine kinases Long term O2, antibiotics, lung transplant

Answer 23

Recurreing partial/complete airway obstruction during sleeping, leading to intermittent hypoxia OSAS - daytime sleepliness Symptoms: Snoring, daytime sleepliness, fatigue, disruptive sleep, witness apnoeas Assessment: History (and from partner), BMI, BP, Neck circumference, craniofacial appearences Epsworth sleepiness score Investigations Limited sleep polysomnography Full polysomnography Apnoea-hypoapnoea index: no. of apnoeas (stopping of airflow) and hypoapnoeas (reduced airflow) divded by total hrs slept AHI \>15 = diagnositc OSA Oxygen desaturation index: no. of times per hour that SpO2 \>4% drop below baseline Treatment: Weight lossReduce triggers e.g. alcohol CPAP - mask over nose directs air in, keeps airway open Mandicbular advancement device Sleep position traineres - vibration when pt on back to change position - for supine OSA

Answer 24

Increased risk of CVA Accidents at work RTA Need to inform DVLA (if without daytime sleepiness, can still drive)

Answer 25

FBC, CRP, LFTs, UEs CXR CT chest and upper abdomen - look for mets Bronchoscopy (endoscope to see airway) Others: US guided aspiration biopsy of supraclavicular lymph nodes CT-PET - look for mets **Aim of investigations:** To diagnose - whether small cell or non small cell To stage To assess fitness for treatment

Answer 26

Lung function tests FEV1 \> 1.5L ECG, echo - cardiac disease

Answer 27

Lymph nodes - mediastinal (obstructs SVC), cerivcal Liver Bone - can cause SC compression

Answer 28

Metabolic Endocrine - ectopic ACTH (Cushing's) - ectopic ADH - water retention - hyponatraemia (sIADH) - PTHrP (hypercalcaemia) Neuro - Lambert-Eaton Syndrome

Answer 29

**Spinal cord compression** Symptoms: leg weakness and numbness, incontinence Signs: UMN signs in legs **SVC obstruction** - due to mediastinal nodes, compressing SVC Symptoms: SOB, oedema in face and arms Signs: Raised JVP Treatment: high dose steroids

Answer 30

Type **2** resp failure "**blue** bloater" - loss of CO2 sensitivity rely on hypoxic drive to stimulate breathing Low resp drive, Low PaO2 and **high PaCO2** cyanosis, flapping tremor, oedema, right sided heart failure Type 1 resp failure "pink puffer" High resp drive, decreased PaO2 and Pa CO2 Weight loss, pursed lip breathing, use accessory muscles,

Answer 31

MRC Dyspnoea scale (assesses level of breathlessness) used to assess prognosis Other: smoking cessation, pulmonary rehabilitation, vaccinations (influenza, pneumococcus) Long term O2 therapy: In COPD pts who have PaO2 \< 7.3 or 7.3 - 8 AND pulmonary oedema, pulmonary hyptertension and non-smokers for 3 months Resp failure: PaO2 \< 8kPa on room air (21%)

Answer 32

**Mod exacerbation** Increasing symptoms **Acute Severe** RR \>25 HR\> 110 Inabiliy to complete sentences in one breathe **Life threatning** PEF \<33% Normal PaCO2 **Near fatal** Raised PaCO2 and/or requires mechiancal ventilation

Answer 33

Sustained worsening of pts symptoms from usual, stable state and acute onset. Common symptoms: worsening breathlessness, increased sputum production, change in sputum colour. Change in symptoms ususally needs change in medication

Answer 34

FBC, UEs, LFTs, ESR (raised in 1st hr), CRP (normal) Immunology ANA ANCA **Serum ACE** (sarcoidosis) Serum immunoglobulins **(raised in active sarcoid)** **ABG** - type 1 resp. failure - due to V/Q mismatch PaCO2 normal or low (due to hypoventilation) Six minute walk test - test desaturation **Echo** - pulm hypertension **CXR** - ground glass changes (increased hazy areas in lung due to alveolar wall inflammation, visible bronchial markings), irregular reticulonodular shadowing **CT** - subpleural abnormalities honeycombing (thick walled cysts in resp bronchioles)

Week 8 Resp Flashcards

(63 cards)