Medicine - Respiratory Flashcards
Lung Cancer Types: Symptoms: Paraneoplastic Syndromes (6): Risk factors: Investigations: Management: Met locations:
Types:
- Non-small cell, eg. squamous cell, adenocarcinoma
- Small cell - very aggressive, surgical options not available, paraneoplastic syndromes
Symptoms: SOB, Cough, Haemoptysis, Weight loss, Supraclavicular lymphadenopathy
Paraneoplastic Syndromes: Phrenic nerve impingement (SOB), Recurrent Laryngeal Nerve palsy (Hoarse Voice), SVC obstruction (Facial swelling/distended veins), Horner’s syndrome in a Pancoast tumour, SIADH, Cushing’s syndrome, Hypercalcaemia (PTHrP OR lytic bone lesions), Lambert-Eason myaesthenic syndrome
Risk factors: Smoking, Increasing Age, FH, Asbestos
Investigations: CXR, Staging CT, US-Guided FNA for biopsy, Endobronchial ultrasound, PET-CT for mets
Management: Non-small cell = Lobectomy
Radiotherapy is first line after this - can be radical or palliative
Combination chemo-radiotherapy can work in small cell, but rarely
Palliative = Airway stents, Radiotherapy, Anxiolytics
Met locations: Cervical lymph nodes, Liver, Bones, Adrenal Glands
COPD Pathophysiology: Chronic changes: Causes: Symptoms: Signs: Risk factors: Investigations: Management: Complications:
Pathophysiology: Airflow obstruction that is progressive and not fully reversible. Encompasses emphysema and chronic bronchitis.
Chronic changes: Mucous gland hyperplasia and loss of cilia function, emphysematous change, fibrosis and remodelling of the airways
Causes: Smoking, A-1 antitrypsin, occupational exposure
Symptoms: Cough with sputum production
Signs: CO2 retention tremor, pursed lip breathing, hyperresonance, barrel chest, expiratory wheeze, ankle oedema due to pulmonary hypertension
Investigations: Spirometry (FEV1/FVC ratio <70%), ABG for respiratory failure, CXR for hyperinflation, a-antitrypsin
Management:
Outpatient: Smoking cessation, Pulmonary rehabilitation (6-12 week programme), Bronchodilators, Steroids, Mucolytics, Influenza vaccine/Pneumococcal, LTOT
Complications: Acute exacerbation of COPD
How do you calculate pack years? (eg. 30 a day for 35 years)
20/day for 1 year = 1 pack year
1.5*35
What are the stages of the MRC Dyspnoea scale?
- Breathless only with strenuous exercise
- Breathless when hurrying on a level ground or walking up a hill
- Walks slower than normal people or needs to stop for breath at own pace on level ground
- Stops for breath after 100m
- Too breathless to go outside or get dressed
Acute Exacerbation of COPD
Presentation:
Management:
Presentation: Severe SOB, Fever, Chest Pain, Raised WCC
Management:
- Aim for 88-92% O2, controlled oxygen
- Nebulised salbutamol and ipratropium
- Oral prednisolone (then OD for 7 days)
- Antibiotics
- ABG
- NIV if Type 2 Respiratory Failure
Asthma: Chronic Pathophysiology: Presentation: Common triggers: Investigations: Management:
Pathophysiology: - Hypersensitivity reaction leading to eosinophil release, mast cell degranulation, histamine and leukotriene release, leading to smooth muscle contraction
- Leads to: Goblet cell hyperplasia -> more mucous production/mucous plug, smooth muscle hyperplasia and hypertrophy, mucosal swelling, airway remodelling in long-term asthma
- Expiratory outflow obstruction
Reversible
Presentation: Dry cough, wheeze, breathlessness, chest tightness
Common triggers: Smoking, Allergens, dust mites, cold, exercise, aerosols
Investigations: Peak flow <70% (Obstructive)
Management:
Step 1: SABA (Salbutamol)
Step 2: SABA + ICS (Beclomethosone)
Step 3: SABA + ICS + Leukotriene receptor antagonist (Montelukast)
Step 4: SABA + LTRA + LABA/ICS combined (Salmeterol)
Acute Asthma
BTS Asthma Severity Guidelines:
Treatment of acute asthma attack:
Asthma severity:
- Mild - >75% PEFR
- Moderate - 50-75% PEFR
- Severe - 33-50% PEFR, Cannot complete sentences in one breath, RR>25, HR >110
- Life threatening - <33%, <92% sats, Cyanosis/Poor respiratory effort, exhaustion, confusion, hypotension, normal pCO2
- Near Fatal - Raised pCO2/Need a ventilator
Asthma treatment:
- Oxygen, aiming for 94-98% titrated via ABG
- Salbutamol nebuliser
- Oral Prednisolone/IV Hydrocortisone
- Ipratropium Bromide nebulisers
- ITU
- Magnesium Sulphate
Pneumothorax Pathophysiology: Causes: Symptoms: Signs: Risk factors: Investigations: Management:
Pathophysiology: Communication between pleural space and the atmosphere, air flows from the atmosphere, into the pleural cavity - loss of elastic recoil of the lung (due to loss of pleural seal)
Causes: Primary: Commonly in young, tall men who smoke - bulla bursts
Secondary: COPD, Asthma, Bronchiectasis, Lung cancer, Trauma, Pneumonia
Symptoms: SOB, Chest Pain, Cough (dry)
Signs: Tracheal deviation (tension-only), dyspnoea, hyper-resonant, tachycardia, reduced lung expansion, absent breath sound
Risk factors: Male, Smoking, Lung disease, Being tall, Marfan’s disease, Mechanical Ventilation
Investigations: X-ray
Management: Oxygen, Aspirate, Chest Drain in 5th intercostal space, mid-axillary line
Tension Pneumothorax
Pathophysiology:
Symptoms:
Management:
Pathophysiology: When air can enter the pleural cavity, but cannot escape because of a flap, causing pressure to increase
Symptoms: SOB, hypotension, tachycardia, silent breath sounds, tracheal deviation, pleuritic chest pain
Management: Venflon into the second intercostal space, mid-clavicular line and chest drain
Interstitial Lung Disease Name 5 types of ILD: Pathophysiology: Symptoms: What drugs cause ILD (2):
Types: Idiopathic pulmonary fibrosis, hypersensitivity pneumonitis, sarcoidosis, asbestosis, non-specific pneumonitis
Pathophysiology: Restrictive pattern on spirometry, reduced compliance but increased elastic recoil, leading to reduced lung volume
Symptoms: Exertional SOB, dry cough, clubbing, weight loss, dry inspiratory wheeze, fine crackles
ILD drugs: Methotrexate, Amiodarone, Ciprofloxacin, Nitrofurantoin
Sarcoidosis Pathophysiology: Symptoms: Investigations: Management:
Pathophysiology: Multisystem inflammatory condition with non-caseating granulomas, causes lung fibrosis when granulomas heal
Symptoms: Erythema nodosum, SOB, cough, clubbing, fine crackles
Investigations: Peak flow, CXR (BILATERAL HILAR LYMPHADENOPATHY), Renal Function, Calcium (hypercalcaemia occurs), ECG
Management: 80% go into remission spontaneously, only treat if signs of skin disease, uveitis, persistent hypercalcaemia - then give corticosteroids
Name 3 causes of Bilateral Hilar Lymphadenopathy on an X-ray
- Sarcoidosis
- Tuberculosis
- Lymphoma
Pulmonary Embolism Causes: Symptoms: Signs: Risk factors: Investigations: Wells Score: Management: Complications:
Symptoms: Tachycardia, SOB, DVT. low BP, Sats drop, Haemoptysis
Signs: Raised JVP, hypotension, DVT
Risk factors: Surgery, Immobilisation, Pregnancy, Malignancy, Varicose Veins, Obesity, COCP
Investigations: CTPA, CXR, ABG, ECG, D-dimer, Wells Score
Management: Oxygen, Fluid resuscitation, enoxaparin, thrombolysis if massive PE, continued DOAC for 3 months if identified cause, or lifelong if not
Wells Score - define:
Wells Score: Can Not Treat If Surgical PE, Help ME Clinical suspicion of PE - 3 No other likely differential - 3 Tachycardia - 1.5 Immobilisation or Surgery - 1.5 PE/DVT in the past - 1.5 Haemoptysis - 1 Malignancy - 1
> 4 PE likely
Name the 5 signs of PE on an ECG:
- Sinus tachy
- S1Q3T3
- RBBB
- RV Strain
- Right Axis Deviation
Thrombolysis
Contraindications:
Complications:
Contraindications: Haemorrhagic stroke within 6 months, CNS neoplasia, recent surgery, recent GI bleed, aortic dissection
Complications: Haemorrhage, Hypotension, Systemic embolisation of thrombi, Allergy
Pleural Effusion Pathophysiology: Causes (Exudate and Transudate): Symptoms: Signs: Investigations:
Pathophysiology: Dysfunction of either production or absorption
Causes (Exudate and Transudate):
Exudate (>30g/L of protein): Pneumonia/TB, RA/SLE, Malignancy, Pancreatitis, Pericarditis
Transudate: Heart Failure, Hypoalbuminaemia (cirrhosis/nephrotic syndrome), PE, Meig’s syndrome (fibroma)
Symptoms: Breathlessness, chest pain, cough, gradual onset
Signs: Tracheal deviation, dyspnoea, reduced lung expansion, stony dull percussion, reduced vocal resonance
Investigations: CXR, Echo, ECG, Thoracentesis (USS-guided chest drain)
Pneumonia Pathophysiology: CAP Organisms: HAP Organisms: Atypical Oraganisms: Symptoms: Signs: Investigations: Management: Complications:
Pathophysiology: Inflammation of the lung parenchyma due to infection
CAP: Strep pneumoniae, H influenzae, Moraxella Catarrhalis
HAP: Staph aureus
Atypical: Legionella, Mycoplasma, Chlamydia
Symptoms: Fever, cough/sputum production, pleuritic chest pain, SOB, vomiting/malaise
Signs: Crackles, pyrexia, tachycardia, tachypnoea, cyanosis, bronchial breathing
Investigations: CURB-65 score, ABG, CXR, FBC, U&Es, CRP
Management: Amoxicillin or Co-Amoxiclav if >3 CURB-65, Flu/Pneumococcal vaccine
Complications: Sepsis, Lung Abscess, Pleural Effusion, Empyema, Resp Failure, Pneumothorax
CURB-65 - define:
- Confusion
- Urea >7mmol/L
- Respiratory rate > 30
- BP <90 or <60
- Over 65
> 3 = IV Co-amoxiclav
Tuberculosis Pathophysiology: Causes of reactivation: Symptoms: Signs: Investigations: Latent TB detection: Management:
Pathophysiology: Mycobacterium tuberculosis - must write pulmonary TB in the exam. Macrophages engulf mycobacterium and form primary focus. TB can drain out of this and into lymph nodes to cause systemic TB. Mostly develops into latent TB. 10% reactivate, 5% within 2 years.
Causes of reactivation: HIV, IVDU, Organ transplants, Diabetes
Symptoms: Fever, Night sweats, weight loss and anorexia, cough, pleural effusion
Signs: Erythema Nodosum, Meningitis, Pericardial effusion
Investigations: CXR, Acid fast bacilli, HIV test
Latent TB: Tuberculin (Mantoux) (measures cell response to tuberculin from mycobacterium cell wall) via hypersensitivity reaction if previously exposed. False positive with BCG, False negative in immunosuppressed.
QuantiFERON/IGRA: Detects interferon and T-cell response. Cannot tell the difference between latent and active TB, but not affected by BCG.
Management: Rifampicin, Isoniazid, Pyrazinamide, Ethambutol - All for 2 months, then Rifampicin and Isoniazid for 4 months, compliance must be monitored eg. directly observed therapy, Notify authorities as notifiable disease
Name 5 systemic signs of TB
- Miliary TB - wide dissemination of TB nodules via the lymph nodes
- Tuberculous meningitis
- Pericardial effusion
- Swollen lymph nodes/Scrofula
- Potts Disease
12 months treatment + steroids for CNS TB meningitis, 6 months + steroids for pericardial effusion
Bronchiectasis Pathophysiology: Causes: Organisms: Symptoms: Investigations: Management: Complications:
Pathophysiology: Chronic dilation of the bronchi, exhibiting poor mucous clearance and increased disposition
Causes: TB/Pertussis, Hypogammaglobulinaemia, CF, Young’s syndrome (bronchiectasis, sinusitis, reduced fertility), Primary ciliary dyskinesia, Kartagener’s (bronchiectasis, sinusitis, situs inversus), RA
Organsisms: Pseudomonas aeruginosa, Haemophilus influenzae
Symptoms: Recurrent infections, daily productive cough, breathlessness, intermittent haemoptysis
Investigations: High resolution CT thorax - signet ring sign
Management: Physiotherapy to help with mucous clearance, sputum sampling and prophylactic antibiotics, hypertonic saline nebuliser, flu vaccine, pulmonary rehabilitation if MRC Dyspnoea > 3
What type of X-ray is used to look at the lungs?
PA
What two conditions cause mediastinal push away?
What is the definition of a “large” pneumothorax?
What sound will be heard on percussion of a pleural effusion?
1: Pleural effusion, tension pneumothorax
2: >2cm away from the lung walls
3: Dull sound/Stony dull
