Breathlessness- Examinations Flashcards

Question

Respiratory acidosis

Answer 1

• Acute respiratory acidosis= pH goes down, pCo2 goes up, Bicarbonate doesn’t change • Chronic respiratory acidosis= pH doesn’t change, pCo2 goes up, Bicarbonate goes up

Answer 2

Well patients stand postero-anterior , the x-ray beam travels from back to front. The arms are lifted to the side, so that the scapulae are lifted out of the lung fields. If the patients are too unwell a portable x-ray can be used, and an antero-posterior chest x-ray is taken in the sitting or lying position

Answer 3

RIPE • R- Rotation • I- Inspiration • P- Projection • E- Exposure

Answer 4

Rotation- the spinal processes should be aligned vertically. The medial ends of the clavicle should be equidistant from the spinous process Inspiration- poor inspiration may be seen in unwell patients i.e. due to pain, exhaustion. 5-6 ribs should be visible anteriorly above the diaphragm (10 ribs posteriorly). The patient is asked to take a derp breath for the chest x-ray.

Answer 5

Projection- describe the direction of the x-ray beam in relation to the patient. Anterior posterior (AP) or Poster-oanterior (PA), the standard position is PA. The scapulae overlies the lung field on AP film. Exposure- assessed by looking at the cardiac shadow. The vertebral bodies should only just be visible through the cardiac shadow. If very visible its an over penetrated film, low density lesions may be missed. If not visible, there is inadequate penetration, the lung fields will appear falsely white.

Answer 6

• Is the trachea central? • Carina: located at the point the trachea divides into the right and left main bronchi • Left main bronchus • Right main bronchus: steeper angle, shorter and wider than the left. Therefore foreign bodies more likely to lodge here • Hilar structure: pulmonary vessels, major bronchi and lymph nodes, should appear symmetrical in normal x-rays

Answer 7

• The pleura should not be visible in well individuals, it can be thickened in mesothelioma • Check that the lung markings extend all the way to the pleura (otherwise consider a pneumothorax) • Divide each lung into 3 zones: upper, middle and lower • Check that the lung markings cover the entire zone • Look for any areas of increased opacity, comparing sides

Answer 8

• Heart size: can only be assessed in PA films, the cardiothoracic ration should be <0.5 • Heart borders: on the right side it made up mainly on the right atrium, the left is predominantly the left atrium • Loss of definition of the left heart border is associated with lingular consolidation • Loss of definition of the right heart border is associated with middle lobe consolidation • The width of the heart should be less than half the width of the distance from the lateral edges of the lungs • Aorto-pulmonary window (the space between the aortic arch and the pulmonary arteries)- may be obscured by mediastinal lymphadenopathy is present • Aortic knuckle (the aortic arch crossing the left main bronchus)- can appear irregular in aortic aneurysm

Answer 9

• The right hemidiaphragm is higher than the left (normal is <3cm difference) • The diaphragm should not separate from the underlying liver – air below the diaphragm suggests visceral perforation • The costophrenic angles should be clearly defined with acute angles • Blurring of the costophrenic angles occurs with consolidation or pleural effusions

Answer 10

• Bones- any fractures or lytic lesions • Soft tissues- swellings or subcutaneous emphysema • Drains/ pacemakers/ lines/ tubes/ artificial valves

Answer 11

Discharge spreads from the SA node across the atrium to the AV node, There is a short pause before the conduction is spread to the ventricles via the bundle of His

Answer 12

• P wave- atrial depolarisation • QRS- depolarisation of the ventricles • T wave- repolarisation of the ventricles

Answer 13

• Limb leads: I, II, III, aVR, aVL, Avf • Chest leads: V1, V2, V3, V4, V5, V6 • Rhythm strip- recorded from lead 2

Answer 14

• Lateral part of the heart: I, aVL, V5, V6 • Anterior parts of the heart: V1, V2, V3 • Inferior part of the heart: II, III, aVF

Answer 15

• Rate, rhythm, axis • Abnormalities in the P wave, PR interval, QRS complex, ST segment and T wave

Answer 16

• Add up the number of large squares between each QRS complex • Divide 300 by that number to get the heart rate • So if there is 5 squares between each complex 300/5= 60, so the heart rate is 60

Answer 17

In normal sinus rhythm each QRS complex is preceded by a P wave with an equal distance between the QRS complex, this is the PR interval. Shows whether the rhythm is regular or irregular

Answer 18

• The predominant axis of the normal heart spreads from the right atrium to the left ventricle, on an ECG this is lead II • A normal axis is between 90 degrees and -30 degrees which is a big range • The QRS complex is negative in aVR and positive in lead II • If the QRS is positive in leads I and II then that means the axis is normal

Answer 19

P wave and PR interval= in sinus rhythm the length of the PR interval is consistent (normally between 3-5 small squares) ST segment: the flat line between the QRS complex and the start of the T wave, the interval between ventricular depolarisation and repolarisation. ST segment elevation or depression suggests either myocardial infarction or ischaemia

Answer 20

• Key waves are the part of the QRS complex that goes downwards, large key waves suggest a recent myocardial infarction. • The R wave is the first upwards deflection after the P wave and the S wave is the downwards deflection. • A normal QRS segment is less than 3 small squares, a broad complex is bigger then 3 squares and is either ventricular in origin or suggests a problem with conduction such as bundle branch block

Answer 21

• Represent ventricular repolarisation, changes in the T wave can occur in myocardial infarction, high or low levels of potassium, cardiomyopathy and in subarachnoid haemorrhage. • The distance between the Q wave and the end of the T wave is the QT interval, this distance is related to the heart rate. • The QT interval can lengthen with various metabolic and electrolyte issues, certain drugs or can be congenital. • Abnormally prolonged QT is associated with arrhythmias

Answer 22

Medical screening test- registers amount of air a subject inhales or exhales, rate at which air is moved into or out of the lungs, performed using a spirometer. Spirometers- wedge bellows, rotating vane, pneumotachographs, ultrasonic

Answer 23

• Bellows mounted in a box • Bellows expand pushing the stylus upwards when patient expires • Stylus moves across a pressure sensitive paper and makes a recording • Bellows are calibrated so the stylus moves the appropriate distance to record the correct volume on the chart paper • Electric motor drives the chart horizontally to give a record of volume against time • Advantages: simple, reliable, accurate • Disadvantages: expired measurements only, big and bulky. Recalibration requires specialist medical engineer, inside cannot be cleaned

Answer 24

• RVC (litres) Relaxed Vital Capacity: max volume expired from full inspiration, but done at a relaxed or steady pace • FEV1 (litres) Forced Expiratory volume in 1 second: maximum volume of air expired from the lungs in the first second of a forced • FVC (litres) Forced Vital Capacity: maximum volume of air expired from the lungs during a forced and complete expiration from full inspiration

Answer 25

• FEV1 / VC% • FEV1 expressed as a percentage of VC • Largest acceptable FEV1 divided by largest acceptable VC multiplied by 100

Answer 26

• Detect presence or absence of disease • Quantify the extent of known disease • Monitor deterioration of disease • Measure effects of therapy • Assess risk for surgical procedures

Answer 27

• Recent MI (within 1 month) • Pneumothorax • Recent thoracic, abdominal or eye surgery • Haemoptysis of unknown origin • Vomiting, generally unwell • Confusion, dementia

Answer 28

• Short-acting bronchodilators for 4 hrs Long-acting bronchodilators for 12 hrs • Short-acting antichollinergics for 6 hrs • Long-acting antichollinergics for 24 hrs • Performing vigorous exercise 30mins • Smoking 24hrs • Wearing tight-fitting clothing • Alcohol consumption 4hrs •Eating a substantial meal 2hrs

Answer 29

Should be performed with the patient sitting upright in a chair with both feet on the floor. Hold the spirometer in one hand, don’t have the other arm folded across chest

Answer 30

• Take in as deep a breath as possible through the mouth • Place lips and teeth around the mouthpiece to make a tight seal • Blow out at a steady speed until completely empty • Needs to be repeated until 3 relaxed manoeuvres that match within 5% or 100ml are performed. Up to 4 attempts should be made to achieve reproducibility

Answer 31

• Take in as deep a breath as possible through the mouth • Place lips and teeth around the mouthpiece to make a tight seal • Blow out as fast and forcefully as possible and to keep on blowing for as long as possible • Fast start and expiration time >6 seconds • Tests needs to be repeated until 3 forced manoeuvres that match FEV and FVC within 5% or 100ml are performed. Up to 9 attempts should be made to achieve reproducibility

Answer 32

• A leak at the mouth • An obstructed mouthpiece due to tongue or teeth • A poorly co-ordinated start to the test so that the blow starts slowly and “builds up” to a high flow. • A cough within the first second of the test – may give spuriously high FEV1 • A cough during the test that is deemed to interfere with the blow • Early termination of the blow – every subject should try to keep blowing for a minimum of 6 seconds • The subject did not inspire fully – watch out for the “Ted Heath” who raises his shoulders but does not take a breath in!! • The expiratory effort was submaximal. • Unable to reproduce best effort

Answer 33

Asthmatics may struggle doing repeated tests due to bronchoconstriction • Largest FVC & Largest FEV1 from different efforts can be reported (as long as within 5% or 100ml) • Examine RVC & FVC- use whichever is largest to calculate ratio & call this VC Calculating % Predicted= (Measured / Predicted) x 100

Answer 34

• FEV >80% • FVC >80% • FEV/VC >70%-80% (depends on age)

Answer 35

• FEV1- low • FVC- normal/low • FEV1/VC- <70%

Answer 36

• FEV1- low • FVC- low • FEV1/VC >70%

Answer 37

Narrowing of the airways due to: contraction of smooth muscle (bronchoconstriction), inflammatory changes and mucus secretions.

Answer 38

• Reduced Expiratory ratio (FEV1/VC%) • Reduced FEV1 • Maintained VC • Increased exhalation time • Late or no plateau on volume-time curve • Diseases: COPD, asthma, bronchiectasis, Sarcoidosis, Bronchial tumours

Answer 39

• Reduced VC and FEV1 • Normal or elevated expiratory ratio (FEV1/VC %) • Reduced exhalation time • Early plateau on volume time curve • Intra pulmonary conditions: Pulmonary fibrosis, Sarcoidosis, Asbestosis, Fibrosing Alveolitis • Extrapulmonary conditions: Kyphoscoliosis, Ankylosing spondylitis, Lung volume reduction surgery, Muscle weakness

Answer 40

A persons maximum speed of expiration as measured with a peak flow meter, a small hand-held device used to monitor a persons ability to breathe out air. It measures the airflow through the bronchi and thus the degree of obstruction in the airways.

Answer 41

• Peak flow is useful when you are considering obstructive airway conditions such as asthma. • Due to the longer term obstructive nature of COPD, spirometry is of more value in the diagnosis of this.

Answer 42

Diurnal variability of peak expiratory flow rate (PEFR) greater than 20% for at least three days in a week for two weeks is typical of asthma. OR Improvement in PEF: • 10 minutes after high-dose bronchodilator through a spacer. • After a six-week course of inhaled steroids. • After 14 days of 30 mg prednisolone.