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Year 4 > Medicine - Respiratory > Flashcards

Medicine - Respiratory Flashcards

1
Q

Describe the features and causes of T1RF

A 
Lung issue (issue with gas exchange and the ability of the lungs to add O2/remove CO2 from the lungs)
Low oxygen (<8kPa) but normal CO2

Causes:

  • pneumonia
  • pulmonary oedema
  • PE
  • shunt
  • pneumothorax…

VENTILATION PERFUSION MISMATCH

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2
Q

Describe the features and causes of T2RF

A 
Pump issue = lungs are working at removing CO2/adding O2, but there is an issue getting air into/out of the lungs in the first place!
Low O2 (<8kPa) and high CO2 (>6kPa)

Causes:

  • COPD
  • asthma
  • neuromuscular issue
  • analgesia
  • drugs
  • CNS trauma

ALVEOLAR HYPOVENTILATION

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3
Q

Signs/symptoms of hypoxia?

A

SCCAR

  • SOB
  • cyanosis
  • confusion
  • agitated
  • restless
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4
Q

Signs/symptoms of hypercapnia?

A 
headache
tachycardia
bounding pulse
tremor/flap
peripheral vasodilation
confusion
drowsy
papilloedema
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5
Q

Why must caution be taken when prescribing O2 to a patient with T2RF?

A

If they are a chronic CO2 retained then their respiratory centre relies on HYPOXIA for respiratory drive (rather than high CO2) therefore give O2 carefully as too much can depress respiratory drive

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6
Q

What is the most common cause of metabolic acidosis?

A

diarrhoea (loss of HCO3)

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7
Q

What is the most common cause of metabolic alkalosis?

A

Vomiting (loss of H+)

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8
Q

What is anion gap and why is it used?

A

Used to work out the cause of a metabolic acidosis
Calculated by cations (Na+ and K+) - anions (HCO3- and CL-)

  • raised AG = presence of XS acid!
  • normal AG = metabolic acidosis due to HCO3- loss!
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9
Q

Definition of COPD

A

FEV1/FVC <70%
% predicted FEV1 <80%
CB and E

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10
Q

Describe features of blue bloaters and pink puffers

A

BB = CB
- mild late SOB, copious sputum, cor pulmonale, T2RF, cyanosis, flapping tremor

PP = E
- severe early SOB, scanty sputum, no cor pulmonale, T1RF, wheeze and use of accessory muscles

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11
Q

What ECG features might you find in COPD?

A

R heart strain = S1 (large S waves in V1), Q3 (Q waves present in V3) and T3 (T wave inversion in V3)

Also seen in a PE!

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12
Q

What are the GOLD stages of COPD and why are they used

A 
Used to guide treatment, based on FEV1 % of predicted
stage 1 (mild) = >80%
stage 2 (moderate) = 50-79%
stage 3 (severe) = 30-49%
stage 4 (v severe) = <30%
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13
Q

Describe the investigations for COPD

A 
CXR
Bloods (high PCV, ?a1-antitryptase deficiency)
spirometry (diagnostic)
ABG
CT
ECG
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14
Q

Describe the treatment of COPD

A

1 - lifestyle

2 - pharmacological:

  • SABA/SAMA first
  • if FEV1 >50% add LABA/LAMA OR if <50% add LABA+ICS
  • then consider theophyllines/mucolytics

3 - pulmonary rehabilitation

4 - LTOT (use >15hrs/day for benefit)

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15
Q

What is the treatment for an acute COPD exacerbation?

A 
Increase bronchodilator use
Steroids
Abx
Oxygen
Ben salbutamol/ipratropium
Oral pred
?Diuretics
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16
Q

Describe the pharmacological treatment of asthma:

A

SABA + low dose ICS
Add LTRA
Add LABA
change ICS to high dose

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17
Q

Describe asthma and the features of airway remodelling you would find

A

thicker smooth muscle
thickened mucosa
increased goblet cell secretions
increased leukocyte recruitment and cell degranulation

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18
Q

How do you monitor an acute asthma attack?

A

Assess severity of attack
oxygen, salb nebs, IV hydrocortisone, oral pred
Monitor ECG (?arrhythmias)
Consider ipratropium/IV magnesium

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19
Q

How do you define a severe asthma attack?

A

PEF 33-50% predicted
unable to speak in complete sentences
RR >25
HR >110

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20
Q

How do you define a life threatening asthma attack?

A

PEF <33% predicted
confusion/silent chest
bradycardia
low O2 sats

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21
Q

What is the most likely causative agent/s of a CAP?

A
  • strep pneumoniae
  • haemophilus influenza
  • staph aureus (common after the flu)
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22
Q

What is the most likely causative agent/s of a HAP?

A
  • staph aureus (common after the flu)

- pseudomonas aeruginosa (ventilators!)

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23
Q

What is the likely causative infectious agent in a young pt presenting with few clinical findings but their CXR shows a much worse than expected pneumonia, and they have been feeling generally unwell and possibly have erythema multiforme rash?

A

mycoplasma pneumoniae

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24
Q

What is the most likely cause of pneumonia in a patient who has recently been travelling and may have drunk contaminated drinking water, with multi-system derangement (low Na, high CK, D&V, LFT derangement?)

A

legionella pneumoniae

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25
Q

Which type of pneumonia is commonly associated with birds and present with fever, epistaxis and joint pain?

A

chlamydophila psittaci

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26
Q

Which type of pneumonia is commonly associated with farmers/sheep/goats and present with Q-fever (flu-like symptoms)

A

coxiella burnetti

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27
Q

Define acute and chronic Q fever

A 
acute = 2-3 week incubation period, flu-like symptoms
chronic = endocarditis, hepatitis and osteomyelitis
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28
Q

Which type of pneumonia is commonly associated with alcoholics/poor dental hygiene?

A

klebsiella pneumoniae

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29
Q

What two types of pneumonia-infections are common in patients who are immunocompromised?

A

PCP (pneumocystis jirovecci)

Aspergillosis

30
Q

What is the CURB65 score used for and describe its components

A 
Confusion
Urea >7
RR >/=30
BP <90 syst / <60 dias
65yrs +++

Used for CAP to guide treatment

31
Q

What antibiotics are commonly used to treat CAP?

A

amox
clarithromycin
levofloxacin

32
Q

What antibiotics are commonly used to treat HAP?

A

doxycycline
co-amox
gent

33
Q

What antibiotics are commonly used to treat aspiration pneumonia?

A

metronidazole

34
Q

What antibiotics are commonly used to treat mycoplasma legionella?

A

macrolide (arythromycin) or tetracycline

35
Q

What medicine/s are commonly used to treat PCP?

A

co-trimoxazole

36
Q

What are the risk factors for PE? - think of the PERC score

A

PERC = pulmonary embolism rule-out criteria
(use this score if you have a LOW suspicion of PE, and if none of the components are present than the probability of a PE is <2%)

H - hormone therapy (HRT/COCP)
A - age >50
D - prev DVT/PE
C - coughing up blood (haemoptysis)
L - leg swelling discrepancy
O - O2 sats <94%
T - tachycardia >100
S - surgery/trauma in last 4 weeks
37
Q

What are the components of Virchow’s triad?

A

1) vessel injury
2) venous stasis
3) activation of the clotting system

38
Q

Describe 3 signs/symptoms of PE?

A

Signs:

  • pleural rub
  • AF
  • lung crackles

Symptoms:

  • pleuritic chest pain
  • SOB
  • haemoptysis
39
Q

What is the treatment for a PE?

A

Carry out the 2 level Well’s score

Score >4 = PE likely
-> immediate CTPA with interim DOAC, if CTPA positive then PE diagnosed, if CTPA negative then consider USS for DVT

Score = 4 = PE unlikely -> do D-dimer within 4hrs, positive D-dimer then do CTPA, negative D-dimer then consider alternative diagnosis

Patient unstable -> thrombolyse with alteplase
Patient stable ->
- Provoked DVT = 3 months DOAC
- Unprovoked DVT = 6 months DOAC

40
Q

What are the 5 types/causes of a pneumothorax?

A 
Spontaneous - primary/secondary
Traumatic - iatrogenic/chest wall injury
Closed
Open
Tension
41
Q

What are the treatment options for a pneumothorax?

A

Primary pneumothorax:
<2cm and pt not SOB = self-resolve
>2cm or pt SOB = aspiration
If still >2cm or pt SOB after aspiration = chest drain

Secondary pneumothorax:
<1cm = give O2 and admit for 24hrs
1-2cm = aspirate
>2cm or failed aspiration = chest drain

42
Q

What are the subtypes of lung cancer?

A

SCLC

  • from neuroendocrine cell line
  • chemosensitive
  • normally not fit for surgery as mets at presentation

NSCLC

  • from epithelial cell line
  • squamous cell, large cells, adenocarcinoma, mesothelioma
  • less chemosensitive but better candidates for surgery
43
Q

What are the investigations and treatment options for lung cancer?

A 
CXR
CT
Sputum cytology
Bloods
Bone scan
Bronchoscopy

Treatment

  • surgery
  • radiotherapy
  • chemotherapy (better for SCLC)
  • palliative
44
Q

Define and describe the pathophysiology of a pleural effusion

A

accumulation of an abnormal volume of fluid in the pleural space
rate of accumulation > removal

hydrostatic pressure > osmotic

45
Q

Describe the causes and features (in Light’s criteria) of a exudate:

A
  • occur when local factors are altered e.g. inflammation/inflammation, increased capillary permeability
  • > high protein (>30g/L), LDH >2/3rds ULN, protein ratio in pleural fluid to serum is >0.5
  • > usually unilateral
  • > clear, cloudy, blood stained fluid

causes:

  • pneumonia
  • malignancy
  • TB
46
Q

Describe the causes and features (in Light’s criteria) of a transudate:

A
  • occur when systemic factors are altered e.g. high hydrostatic pressure, low protein
  • > low protein (>30g/L), LDH <2/3rds ULN, protein ratio in pleural fluid to serum is <0.5
  • > usually bilateral
  • > usually clear fluid

causes:

  • HF
  • cirrhosis
  • renal failure
47
Q

What investigations would you do for a suspected pleural effusion?

A

Bloods, CXR, aspiration and send for:

  • cytology
  • immunology
  • bacteriology
  • microscopy and culture
48
Q

Describe the pathophysiology of OSA:

What are the signs and symptoms of OSA?

A
  • recurrent episodes of partial/complete airway obstruction during sleep
  • caused by narrowing of upper airway (anatomical, obesity, neuromuscular dysfunction)

S/Sx:

  • snoring, witnessed apnoea
  • choking, sweating, dry mouth
  • autonomic sympathetic response: vasoconstriction (HTN) and cardiac arrhythmias
  • reduced libido
  • fatigue
  • nocturia
  • poor concentration/mood
  • morning headache
49
Q

What investigations are carried out for OSA?

A
  • good Hx
  • examination: Mallampati score, BP, BMI, tonsils, ?nasal polyps, sleep questionnaire
  • polysomnography
  • epworth sleepiness scale
  • TOSCA (transcutaneous O2/CO2 assessment)
50
Q

What are the treatment options for OSA?

A 
weight loss
mandibular advancement device
avoid smoking and alcohol
sleep position trainers
CPAP
Inform DVLA!
51
Q

Describe the three categories of interstitial lung disease:

A

1 - Those with a known cause: drugs, occupational, infections…
2 - Those associated with systemic disorders: sarcoidosis, RA, renal tubular acidosis…
3 - Idiopathic: IPF, non-specific interstitial pneumonitis

52
Q

Define and describe the pathophysiology of IPF:

A
  • the commonest cause of interstitial lung disease
  • a type of progressive fibrosing interstitial pneumonia
  • causes can be: occupational, drug induced, genetic, idiopathic, viral
  • scarring and fibrosis affects the blood/gas barrier limiting O2 perfusion into the blood
53
Q

Describe bronchiectasis and its causes:

A

abnormal dilation of bronchi
chronic inflammation -> permanent dilatation -> sputum production increases -> scarring

Can be congenital, post-infectious or other causes
CONGENITAL:
- CF, ciliary dyskinesia
POST-INF:
- pneumonia, measles, pertussis, bronchiolitis, TB…
OTHER:
- caused by bronchial obstruction (by a tumour/foreign body)
- allergic aspergillosus
- RA
- UC
- idiopathic

54
Q

What are the main causative organisms of bronchiectasis?

A

Pseudomonas aeruginosa
H influenza
Strep pneumoniae
Staph aureus

55
Q

Define cor-pulmonale

A

RV dysfunction secondary to chronic respiratory disease

Leads to pulmonary HTN and RV failure/enlargement/hypertrophy

56
Q

What are the causes of cor-pulmonale

A

Obstructive

  • COPD
  • asthma
  • bronchiectasis

Vascular

  • primary pulmonary HTN
  • vasculitis
  • PE
  • ARDS

Restrictive

  • IPF
  • drugs
  • anatomy
  • neuromuscular

Central

  • OSA
  • obesity
57
Q

What might you hear when you listen to the heart of a patient with cor-pulmonale?

A

1) pansystolic murmur (TR)
2) S2 splitting (AV valve closes slightly before PV due to increased pulmonary pressure)
3) Gallop rhythm = tachycardia + 3/4th HS
- > 3 HS = physiological in children
- > 4 HS = pathological

58
Q

How is cor-pulmonale managed?

A

Oxygen (LTOT)
Furosemide
Use of vasodilators

59
Q

Define pulmonary oedema and its causes

A

Fluid accumulation in lung tissues and alveoli
Can be cardiogenic or non-cardiogenic

cardiogenic = heart failure! failure to remove blood from pulmonary circulation leading to increased hydrostatic pressure in pulmonary capillaries which pushes fluid into the lungs

non-cardiogenic = ARDS, chronic high altitude, AKI/CKD, PE

60
Q

What are the presenting features of pulmonary oedema?

A 
Hamoptysis: bloody, frothy sputum
SOB, orthopnoea and PND
Reduced exercise tolerance
Leg and abdominal swelling
Cyanosis
JVP
Bibasal creps
Displaced apex beat
RV heave
tachycardia and 3/4th heart sounds
61
Q

Describe sarcoidosis and how it may present

A

A multi-system disease
Non-necrotising granulomatous inflammatory disease
Mainly affects lungs and intra-thoracic LNs

Presents with dry cough, SOB, chest pain, splenomegaly, hepatomegaly, erythema nodosum and BHL (bilateral hilar lymphadenopathy)

Raised ACE and Ca

62
Q

Name causes of a raised AG

A 
MUDPILES
methanol
uric acid (uricaemia)
DKA
Paraldehyde
Iron/isoniazide
Lactic acid
Ethanol
s aSpirin/salycilates
63
Q

Name causes of a normal AG

A

diarrhoea

renal tubular acidosis

64
Q

What is the only cause of increased vocal resonance?!

A

consolidation (pneumonia)

65
Q

What are the 5 MRC stages of dyspnoea?

A 
1 - breathless on strenuous exercise
2 - breathless when walking up a hill
3 - breathless walking on flat ground
4 - breathless when walking <100m
5 - too breathless for ADL
66
Q

Name a complication of quickly treating pneumothorax

A

re expansion pulmonary oedema

67
Q

Name some complications of lung cancer

A
  • local mets
  • SVC obstruction
  • non-metaplastic paraneoplastic syndromes
  • > cushings (ACTH secreting)
  • > SIADH (ADH secreting)
  • > hypercalcaemia (PTH secreting)
68
Q

What is Meig’s syndrome?

A

R sided pleural effusion + ovarian fibroma

69
Q

How is IPF investigated?

A

Bloods (all normal + autoimmune condition screen)
Imaging (CXR and CT - honeycomb)
PFTs (restrictive pattern)
Bronchoscopy -> BAL/biopsy
Video-assisted lung biopsy
Others: urinary Ca excretion (?sarcoidosis)

70
Q

Name causes of fibrosis predominantly in the upper lobes of the lungs

A 
CHARTS
coal workers (pneumoconiosis)
hypersensitivity pneumonitis
ankylosing spondylitis
radiation
TB
sarcoidosis

Year 4 (28 decks)

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