Clinical Respiratory Flashcards
What part of the lungs are affected in Asthma?
Large and small airways
When does the greatest reduction in airflow occur in Asthma?
When breathing out
What is dynamic hyperinflation and what condition does it occur in?
Little bit of air from last breath remains in lungs when the next breath begins
occurs in asthma
What is likely to lead to an asthma attack?
Exposure to allergens, irritants, exercise or cold induced
What are the symptoms of an asthma attack? 4
1) Wheezing
2) Coughing
3) Tight chest
4) Shortness of breath
What are the clinical signs of an asthma attack? 5
1) Wheezing heard with stethoscope
2) Use of accessory muscles of respiration
3) Paradoxical pulse (pulse weaker during inhalation and stronger during exhalation)
4) Over inflation of the chest (seen on CXR)
5) Reduced FEV1
What drugs are used in the treatment of asthma?
1) Inhaled short acting B2 agonist (salbutamol)
2) Inhaled corticosteroids (beclometasone)
3) Long acting B2 agonist (salmeterol)
4) Oral prednisolone
5) Leukotriene antagonists
Which respiratory condition should aspirin be avoided in?
Asthma
What is the difference between a primary and secondary pneumothorax and what is a spontaneous pneumothrax?
Primary = occurs in healthy lungs Secondary = occurs in someone with lung disease (eg. COPD/CF) Spontaneous = occurs in the absence of trauma
In what kind of pneumothorax would tracheal deviation occur?
Tension pneumothorax
Is a CXR or CT scan always needed to make a diagnosis of pneumothorax?
No, in extreme cases the diagnosis can be made on examination eg. deviated trachea or hypoxia
In milder cases imaging is needed to make the diagnosis
If left untreated what may tension pneumothorax lead to?
Cardiac arrest
What is the treatment for pneumothorax?
1) Small spontaneous pneumothorax resolve by themselves
2) Moderate pneumothorax in healthy lungs are aspirated with a syringe
3) If aspiration doesnt relieve a moderate pneumothorax then a chest drain is used
4) In diseased lungs or large pneumothorax with significant symptoms or tension then a chest drain is used
What surgical treatment can be used to prevent future reoccurrences of pneumothorax?
Pleurodesis (sticking pleura together ie. lung to chest wall) to prevent reoccurrence
When can people fly following pneumothorax and why the restriction?
Patients should avoid significant changes in air pressure
In a non trauma - can fly after 7 days or CXR must confirm resolution
In trauma - wait full 2 weeks after radiographic resolution
What is surgical emphysema?
Rupture also in parietal pleura, air leaks out into the layer of sub cutaneous tissue
What kind of pneumothorax can lead to increased central venous pressure?
Tension pneumothorx - obstructs venous return to the heart
What sounds may be heard in pneumothorax?
Increased percussion note
Reduced breath sounds
What is the difference between a small and large pneumothorax?
Small = ring of air 2cm
What is the risk of recocurrence of pneumothorax after a 1st and 2nd primary pneumothorax?
After 1st primary pneumothorax - 10%
After 2nd primary pneumothorax - 40%
What are the risk factors for primary spontaneous pneumothorax? 2
1) Smoking
2) Family history
What are subpleural blebs?
Make people more susceptible to spontaneous pneumothorax, this is why family history can be important as people may be more susceptible to having blebs and to them rupturing
These subpleural blebs can rupture and lead to pneumothorax
What is the most common type of pneumonia?
Bacterial bronchopneumonia
What are the symptoms of pneumonia? 9
1) Productive cough
2) Fever
3) Rigors
4) Chills
5) Unilateral pleuritic chest pain (sharp stabbing)
6) Dyspnoea
7) Headache
8) Confusion
9) unsteadiness
What are the clinical signs of pneumonia (including sounds)? 8
1) Pyrexia
2) Green brown sputum
3) Tachypnoea
4) Tachychardia
5) Hypotension
6) Cyanosis if severe
7) Crackles
8) Bronchial breathing (harsh breath sounds)
What would a CXR of a patient with pneumonia show?
Consolidation and exudation of alveoli
What would a blood/sputum culture of a patient with pneumonia show?
Streptococcus pneumoniae
What are the atypical pneumonias? 4
1) Mycoplasma pneumoniae
2) Haemophilus
3) Influenza
4) Chlamydia pneumoniae
What is the treatment of bacterial pneumonia? 4
1) O2
2) Fluids (IV if low BP)
3) Abx
4) If severe assisted ventilation may be required
What respiratory condition is the leading cause of death in the young, elderly and chronically ill?
Pneumonia
What is pneumonia?
Inflammatory disease of bronchi and alveoli, get consolidation and exudation of alveoli
What pneumonia-causing bugs can we vaccinate against?
Flu
Pneumococcal pneumonia
What cancer is the most common cause of cancer mortality?
Lung cancer
How common is lung cancer in people under 45 or men over 65?
Uncommon in people under 45
Most common cancer in men over 65
What factor in terms of diagnosis contributes to lung cancer having the lowest survival rate of all cancers?
2/3 diagnosed late stage
What are the 2 main types of lung cancer?
1) Small cell
2) Non small cell (squamous, adenocarcinoma, large cell)
What are the symptoms of lung cancer? 12
1) Cough
2) Wheeze
3) Haemoptysis
4) Dyspnoea
5) Disphonia (hoarse voice)
6) Dysphagia
7) Chest pain
8) Cachexia
9) Anorexia
10) Bone pain
11) Neurological symptoms
12) Stridor (harsh sound when breathing)
What are the clinical signs of lung cancer? 8
1) Anorexia/ weight loss
2) Clubbing
3) Tachypnoea
4) Signs of collapse, consolidation, effusion
5) Lymphadenopathy
6) SVC obstruction
7) Horner’s syndrome
8) Signs from metastatic spread eg. neurological symptoms or bone pain
What is Horner’s syndrome (a clinical sign of lung cancer)?
Triad of: 1) Upper eyelid drooping 2) Pupillary constriction 3) Absence of sweating These only occur on one side and occur due to damage to the sympathetic trunk
What are the risk factors for lung cancer? 4
1) 90% caused by smoking
2) Asbestos exposure
3) Radioactive minerals/radon gas
4) Pyrene, arsenic, nickel, napthalenes
What is the difference between transudate and exudate pleural effusion and what are their causes?
Transudate = low protein content of fluid
Caused by heart failure/nephrotic syndrome
Exudate = rich in cellular elements
Caused by malignancy/infection
What are paraneoplastic disorders?
Disorders that are caused by or resulting from the presence of cancer in the body but not the physical presence of cancerous tissue in the organ affected
What are the para- neoplastic disorders associated with lung cancer? 3
1) Hypercalcemia
2) Lambert-eaton myasthenic syndrome
3) Syndrome of inappropriate anti-diuretic hormone production (SIADH)
4) Pancoast tumours - tumours in the apex of the lung may invade the local part of the SNS and alter sweating patterns and eye muscle control (Horner’s syndrome and muscle weakness in hands due to invasion of the brachial plexus)
5) Horner’s syndrome
What investigations should be carried out in suspected lung cancer? 7
1) CXR - shadow or lung collapse
2) CT/PET Scan - show lymphadenopathy or metastisis
3) Bronchoscopy - visualise tumour obstruction
4) Biopsy - shows malignancy
5) Mediastinoscopy
6) VATS
7) CT bone/head
What are common sites of metastises for lung cancer?
1) Brain
2) Bone
3) Adrenal glands
4) Contra lateral lung
5) Liver
6) Pericardium
7) Kidneys
What percentage of people diagnosed have no symptoms on diagnosis and are picked up by a routine CXR?
10%
What is the difference in treatment for small cell and non small cell lung cancer?
Small cell - chemotherapy and radiotherapy
Non small cell - surgery (lobectomy, pneumonectomy), radiotherapy, chemotherapy
What is COPD?
Bronchitis with emphysema
When is the greatest reduction in air flow in COPD?
On exhalation
Other than Asthma when else might dynamic hyperventilation occur?
COPD
What are the 4 risk factors for COPD?
1) Smoking
2) Repeated chest infections
3) Family history
4) Exposure to dust in a workplace
What are the symptoms of COPD? 5
1) Dyspnoea
2) Ankle swelling
3) Wheeze
4) Cough
5) Sputum production
What are the clinical signs of COPD and what would you see on examination? 6
1) Tachypnoea
2) Hyperinflated chest
3) Wheeze heard
4) Decreased breath sounds
5) Pursed lips - to prolong expiration
6) CO2 flap (hypercapnic flap)
What may suggest that a patient is having an exacerbation of their COPD? 3
1) Increased dyspnoea
2) Increased sputum production (green)
3) Increased cough
What would the blood gases of a patient with COPD show?
Hypercapnia and hypoxaemia
What would happen to the FEV1 of a patient with COPD?
Reduced (unreversible - reversible in Asthma)
What would the CXR of a patient with COPD show?
Hyper inflated lungs
What is a pack year?
1 pack year = 20 cigarettes per day for 1 year
smoked 40 a day for 10 years = (40/20x10) = 20 pack years
What is the effect of stopping smoking on COPD?
Leads to a slower decline in FEV1 and a longer life expectancy compared to if you carried on smoking
What is the difference between a pink puffer and a blue bloater in COPD?
Pink puffer = maintain normal blood gases at the expense of breathlessness, often with skeletal muscle wasting
Blue bloater = less breathlessness but at the expense of abnormal blood gases and right heart failure
Why shouldn’t COPD patients be put on high flow O2?
Healthy patients rely on hypercapnic drive to make you breathe but in patients with COPD they have persistent hypercapnia so have adapted to this and as a consequence rely on their hypoxic drive to make them breathe. Give them high flow O2 and suppress breathing - O2 induced CO2 retention
What is the drug treatment for COPD? 7
1) Abx for episodes of infective bronchitis
2) Long acting B2 agonist (salmeterol)
3) Anticholinergic bronchodilator therapy
4) Inhaled steroids (budesonide)
5) Oral steroid (prednisolone)
6) Anti-inflammation therapy in bad episodes of wheezing
7) Theophyllines
What vaccination is often given to COPD patients?
Influenza vaccine
Other than drug treatment what other therapy may be given to COPD patient?
1) Low flow, non invasive ventilation
2) LTOT (if needed)
3) Pulmonary rehabilitation
4) Surgery - in bullous disease (lung volume reduction
What is respiratory disease in rheumatoid arthritis likely to be?
Interstitial pneumonitis or fibrosis
When does respiratory disease in rheumatoid arthritis often present?
Late in disease when symptoms are present
How can respiratory disease in rheumatoid arthritis present?
Can present with acute interstitial pneumonia (Hamman Rich syndrome)
What are the symptoms of rheumatoid arthritis respiratory disease? 2
1) Progressive breathlessness
2) Persistent non productive cough
What are the clinical signs of respiratory disease associated with rheumatoid arthritis?
1) Fine inspiratory crackles
2) Clubbing
What drugs are patients that develop respiratory disease associated with rheumatoid arthritis often taking? 2
1) Methotrexate
2) Steroids
Is respiratory disease associated with rheumatoid arthritis obstructive or restrictive?
Restrictive (increased or normal FEV1/FVC)
What is rheumatoid arthritis?
Chronic, systemic inflammatory disorder, get joint destruction due to erosion of cartilage and bone
What is methotrexate lung?
Hypersensitivity pneumonia
What are the side effects of steroid therapy? 4
1) Thrush
2) Bruising
3) Increased weight
4) Cushing
5) Increased infection risk
6) Osteoporosis
What is bronchiectasis?
Chronic dilatation and inflammation of one or more bronchi which are easily collapsible resulting in obstruction of airflow and poor mucous clearance and disposition to bacterial infection.
Is bronchiectasis a restrictive or obstructive lung disease?
Obstructive (Reduced FEV1/FVC ratio)
Name a congenital cause of bronchiectasis? 2
1) Ciliary dyskinesia (Kartagener’s syndrome)
2) Alpha 1 anti trypsin deficiency
What would a CT scan of a bronchiectasis patient show? 2
1) Dilated airways
2) Signet ring signs (normally blood vessel bigger than airway, in bronchiectasis it is the other way round)
What are the symptoms of chronic bronchiectasis? 10
1) Persistent purilent green-yellow sputum production
2) Haemoptysis
3) Halitosis
4) Dyspnoea
5) Wheeze
6) Sinusitis and nasal symptoms
7) Weight loss
8) Pleurisy (inflammation of the pleura, causes pain when breathing)
9) Repeated chest infections
10) Nasal polyps
What are the clinical signs of chronic bronchiectasis? 3
1) Clubbing
2) Coarse crepitations (crackles)
3) Wheeze
What would the blood gases of a patient with bronchiectasis show?>
Hypoxaemia and Hypercapnia
With what medical history is bronchiectasis commonly associated?
Significant childhood infection
What prior infections can lead to bronchiectasis? 5
1) Bordetella Pertussis (measles)
2) Whooping cough
3) Childhood bacterial pneumonia
4) TB
5) Allergic bronchopulmonary aspergillosis
With what immunodeficiencies may bronchiectasis be associated? 4
1) HIV
2) Lung transplant
3) late onset idiopathic Ig deficiency
4) Selective immunoglobulin deficiency
What toxic and mechanical causes are there associated with bronchiectasis?
1) Toxic - aspiration
2) Mechanical - tumour, lymph node, foreign body
What is the relationship between asthma and allergic bronchopulmonary aspergillosis?
People with asthma can get allergic reactions to broncho pulmonary aspergillosis and this can lead to a chest infection and ultimately bronchiectasis
What pathogens may cause an exacerbation of bronchiectasis? 5
1) Streptoccocus Pneumonia
2) Staph aureus
3) Haemophilus influenza
4) Pseudomonus aerurginosa
5) Aspergillus
What is the treatment for broncheictasis? 6
1) Physiotherapy
2) Education
3) Abx
4) IV Abx as required
5) Annual flu vaccine
6) Dietetics
What investigatins should be carried out in someone with expected bronchiectasis? 8
1) History - childhood diseases
2) Genetics/Sweat test
3) Cilliary beat frequency/saccharin test
4) Auto Ab screen
5) Sputum culture
6) Aspergillosis serology
7) Lung function
8) Routine bloods/CRP
What are the symptoms of CF? 7
1) Weight loss
2) Cough
3) Sputum production
4) Dyspnoea
5) Fatty stools
6) Repeated chest exacerbations
7) Haemoptysis
What are the signs of CF? 9
1) Clubbing
2) Coarse crackles
3) Wheeze
4) Salty skin
5) Cyanosis
6) Poor weight gain
7) Azoospermia
8) Hypoxia
9) Pulmonary hypertension
What are the main features of CF? 11
1) Repeated Chest infections
2) Pancreatic insufficiency
3) Bronchiectasis
4) Chronic sinusitis
5) Nasal polyps
6) Clubbing
7) Steatorrhoea
8) Male infertility
9) Osteoporosis
10) Abnormal sweat secretions
11) CF-related diabetes
What percentage of patients with CF die from respiratory failure?
95%
What is a pulmonary exacerbation in CF?
1) Increased cough
2) Increased sputum production
3) Change in sputum colour
4) Fever/malaise
What therapy is used to treat CF?
1) Physiotherapy
2) Staph prophylaxis
3) Pulmozyme
4) Bronchodilators
5) Azithromycin
6) Vit ADEK
7) Pancreatic enzymes
8) IV Abx
9) Insulin
10) Transplant
Why could loss of vision occur in CF?
Vit A deficiency - fat soluble vitamin
What investigations would be needed to make a diagnosis of CF?
1) Sweat test
2) Obstructive lung function
3) Genetic testing
4) Sputum cultures +ve for staph aureus/haemophilus/pseudomas aeruginosis
Name 2 respiratory conditions resulting in type 1 respiratory failure?
1) PE
2) Rheumatoid arthritic fibrotic lung
What is Type 2 respiratory failure and what is it typically caused by?
Decreased PaO2 ( 6kPa) pH decreased (Respiratory acidosis)
Caused by reduced breathing effort in (fatigued patient) or decrease in area of lung available for gas exchange (eg. COPD)
In which type of respiratory failure do you get hypercapnia?
Type 2
What is a paradoxical pulse and in which respiratory condition would it be a clinical sign?
Pulse that is weaker on inhalation and stronger on exhalation
Clinical sign of Asthma attack
