Resp Flashcards
1
Q
Pneumothorax
when does it occur
A
when air gets into the pleural space separating the lung from the chest wall
2
Q
Pneumothorax
Causes
A
- spontaneous
- trauma
- iatrogenic: lung biopsy, mechanical ventilation or central line insertion
- lung pathology: infection, asthma or COPD
3
Q
Pneumothorax
inx of choice for a simple pneumothorax
A
erect chest x-ray
4
Q
Pneumothorax
chest x-ray results
A
area between lung tissue and chest wall where there are no lung markings
line demarcating the edge of the lung where the lung markings ends and the pneumothorax begins
5
Q
Pneumothorax
how to measure the size of the pneumothorax according to BTS guidelines
A
measure horizontally from the lung edge to the inside of the chest wall at the level of the hilum
6
Q
Pneumothorax
what can be used to detect a small pneumothorax that is too small to see on CXR or be used to accurately assess the size of the pneumothorax
A
CT thorax
7
Q
Pneumothorax
mnx if no SOB and <2cm rim of air on CXR
A
no trx as it will spontaneously resolve
follow up in 2-4w
8
Q
Pneumothorax
mnx if SOB and/or >2cm rim of air on CXR
A
aspiration and reassessment
9
Q
Pneumothorax
what happens if aspiration mnx fails twice
A
it will require a chest drain
10
Q
Pneumothorax
who will require a chest drain
A
unstable patient
bilateral or secondary pneumothoraces
if aspiration fails twice
11
Q
Pneumothorax
what causes a tension pneumothorax
A
trauma to chest wall that creates a one-way valve that lets air in but not out of the pleural space
during inspiration, air is drawn into the pleural space and during expiration, the air is trapped in the pleural space
12
Q
Pneumothorax
why is lot of air in the pleural space dangerous in a tension pneumothorax
A
it creates pressure inside the thorax that will push the mediastinum across, kink the big vessels in the mediastinum and cause cardiorespiratory arrest
13
Q
Pneumothorax
signs of tension pneumothorax (5)
A
- tracheal deviation away from the side of pneumothorax
- reduced air entry to affected side
- increased resonant to percussion on affected side
- tachycardia
- hypotension
14
Q
Pneumothorax
mnx of a tension pneumothorax
A
insert a large bore cannula into the 2nd ICS in the midclavicular line
then chest drain for definitive mnx
15
Q
Pneumothorax
where are chest drains inserted
A
into the ‘triangle of safety’
obtain CXR to check positioning
16
Q
Pneumothorax
what forms the ‘triangle of safety’
A
- 5th ICS (or inferior nipple line)
- mix-axillary line (lateral edge of latissimus dorsi)
- anterior axillary line (lateral edge of pec major)
17
Q
Pneumothorax
why is the needle inserted just above the rib in a chest drain
A
to avoid the neurovascular bundle that runs below the rib
18
Q
Lung Function Tests
what test is used to establish objective measures of lung function
A
spirometry
19
Q
Lung Function Tests
what does spirometry involve
A
different breathing exercises into a machine that measures volumes of air and flow rates and produces a report
20
Q
Lung Function Tests
what does reversibility testing involve
A
giving a bronchodilator (eg salbutamol) prior to repeating the spirometry to see the impact this has on the results
21
Q
Lung Function Tests
what is FEV1
A
forced expiratory volume in 1 second
the amount of air a person can exhale as fast as they can in 1 sec
it will be reduced if there is any OBSTRUCTION to the air flow out of the lungs
22
Q
Lung Function Tests
what is FVC
A
forced vital capacity
the total amount of air a person can exhale after a full inhalation
measure of the total volume of air the person can take into their lung s
it will be reduced if there is any RESTRICTION on the capacity of their lungs
23
Q
Lung Function Tests
what will be reduced if there is any obstruction
A
FEV1
24
Q
Lung Function Tests
what will be reduced if there is any restriction
A
FVC
25
Lung Function Tests
how can obstructive lung disease be diagnosed
when FEV1 is less than 75% of FVC
FEV1 : FVC ratio <75%
26
Lung Function Tests
in asthma, what is the obstruction due to
narrowed airway due to bronchoconstriction
27
Lung Function Tests
in COPD, what is the obstruction due to
chronic airway and lung damage
28
Lung Function Tests
the difference between asthma and COPD
test for reversibility of the obstruction by giving a bronchodilator.
the obstructive picture is typically reversible in asthma
29
Lung Function Tests
how can restrictive disease be diagnosed
FEV1 and FVC are equally reduced
and FEV1 : FVC ratio > 75%
30
Lung Function Tests
what is restrictive lung disease
where there is restriction to the ability of the lungs to expand and take air in
31
Lung Function Tests
causes of restrictive lung disease (4)
- interstitial lung disease
- neurological (eg MND)
- scoliosis or chest deformity
- obesity
32
Lung Function Tests
what is a peak flow a measure of
the 'peak' or fastest point, of a person's expiratory flow of air
PEFR: peak expiratory flow rate
33
Lung Function Tests
what is the predicted peak flow based on
sex, height and age
34
COVID-19
where were the first cases reported
Wuhan, China
35
COVID-19
which animal did it originate
bats
36
COVID-19
clinical features (3)
- fever
- dry cough
- SOB
- nausea
- headache
- sore throat
- diarrhoea
- loss of smell/taste
37
COVID-19
how long is the incubation period
2-10d
38
COVID-19
severe covid disease pathogenesis
thought to be due to hyper-inflammatory response to the virus
raised inflammatory biomarkers (IL-2R, IL-6, IL-10 and TNFa)
39
COVID-19
what is death usually from
- respiratory failure
- multi-organ failure (heart, liver, kidney)
- neuro complications (stroke)
40
COVID-19
RFs for severe covid disease
- older age
- male sex
- comorbidities (chronic heart/lung disease, HTN, DM)
- high BMI
- lower socio-economic level
41
COVID-19
prognostic markers for severe covid disease
- present with tachypnoea, tachycardia, low paO2
- very low lymphocyte count <0.5 x 10(9)/ml
- raised CRP and ferritin (inflammatory markers)
- abnormal clotting: coagulopathy with increased D-dimers and fibrinogen, often leading to PE)
42
COVID-19
what predicts poor outcomes
hyperinflammation
43
COVID-19
distinct features of hyperinflammation
- earlier onset of ARDS
- prominent thrombo-embolic features
- relatively low levels of cytokines + ferritin
44
COVID-19
why is being male a RF for severe disease
- innate (adaptive) immune function enhanced in females
- ACE2 receptor distribution
- Male mice accumumlated inflammatory macrophages
45
COVID-19
what ethnicity is a RF for severe disease
South Asian
46
COVID-19
genetic factors contributing to critical illness
- OAS genes
- DPP9 gene variants
- low IFNAR2 and elevated TYK2
- Baricitinib
47
COVID-19
respiratory support for mnx of severe disease
- supplementary O2
- CPAP
- Mechanical ventilation
- Proning
- monitor for PE, secondary infection
48
COVID-19
medications for mnx of severe disease
- Dexamethasone
- Remdesivir (anti-viral therapy)
- Tociluzamab (monoclonal antibody to IL-6)
- Anakinra (monoclonal antibody to IL-1 for hyper-inflammation)
- Antibody therapy (Regeneron/Ronapreve)
49
COVID-19
what can be given for pts developing lung fibrosis
additional high dose steroids
50
COVID-19
how long do covid symptoms last
Zoe data shows 1/10 are sick for 3w or more
51
COVID-19
what is the most common cause of 'breathlessness' after covid
dysfunctional breathing: umbrella term for hyperventilation, disordered breathing, mechanical changes
52
Pleural Effusion
what is it
a collection of fluid in the pleural cavity
it can be exudative or transudative
53
Pleural Effusion
exudative meaning
high protein count
| >3g/dL
54
Pleural Effusion
transudative meaning
there is a relatively lower protein count
| <3g/dL
55
Pleural Effusion
what causes it to be exudative
inflammation results in protein leaking out of the tissues into the pleural space (ex- meaning moving out of)
56
Pleural Effusion
exudative causes
inflammation causes:
- lung cancer
- pneumonia
- RA
- TB
57
Pleural Effusion
what causes it to be transudative
relate to fluid moving across into the pleural space (trans- meaning moving across)
58
Pleural Effusion
transudative causes
fluid shifting causes:
- congestive cardiac failure
- hypoalbuminaemia
- hypothyroidism
- Meig's syndrome
59
Pleural Effusion
what is Meig's syndrome
right sided pleural effusion with ovarian malignancy
60
Pleural Effusion
presentation (4)
- SOB
- dullness to percussion over the effusion
- reduced breath sounds
- tracheal deviation away from the effusion
61
Pleural Effusion
inx
- CXR
| - pleural fluid sample by aspiration or chest drain: protein count, cell count, pH, glucose, LDH, microbiology testing
62
Pleural Effusion
what will the CXR show
- blunting of the costophrenic angle
- fluids in the lung fissures
- larger effusions have a meniscus: curving upwards where it meets the chest wall and mediastinum
- tracheal and mediastinal deviation if massive effusion
63
Pleural Effusion
trx if small effusion
conservative mnx
will resolve with trx of underlying cause
64
Pleural Effusion
trx for larger effusions
pleural aspiration:
chest drain
65
Pleural Effusion
what does pleural aspiration involve
sticking a needle in and aspirating fluid
temporarily relieves pressure but the effusion may recur
repeated aspiration may be required
66
Pleural Effusion
what is an empyema
where there is an infected pleural effusion
67
Pleural Effusion
when should you suspect an empyema
in a pt who has improving pneumonia but new ongoing fever
68
Pleural Effusion
what would pleural aspiration show in empyema
pus
acidic pH <7.2
low glucose
high LDH
69
Pleural Effusion
how are empyemas treated
by chest drain to remove pus
abx
70
Interstitial lung disease
what is it
an umbrella term to describe conditions that affect the lung parenchyma causing inflammation and fibrosis
71
Interstitial lung disease
what is fibrosis
the replacement of the normal elastic and functional lung tissue with scar tissue that is stiff and does not function effectively
72
Interstitial lung disease
how to make a diagnosis
clinical features + high resolution CT scan of the thorax
when unclear, lung biopsy can be used for histology
73
Interstitial lung disease
what does high resolution CT scan show
ground glass appearance
74
Interstitial lung disease
what makes the prognosis poor
damage is irreversible
75
Interstitial lung disease
mnx
generally supportive:
- treat underlying cause
- home O2 if hypoxic at rest
- stop smoking
- physio + pulmonary rehab
- pneumococcal + flu vaccine
- advanced care planning and palliative care if appropriate
- lung transplant perhaps
76
Interstitial lung disease
sx of idiopathic pulmonary fibrosis
- insidious onset of SOB
| - dry cough >3m
77
Interstitial lung disease
whom does idiopathic pulmonary fibrosis usually affect
adults >50 years old
78
Interstitial lung disease
signs in idiopathic pulmonary fibrosis
- bibasal fine inspiratory crackles
| - finger clubbing
79
Interstitial lung disease
prognosis of idiopathic pulmonary fibrosis
poor with a life expectancy of 2-5yrs from diagnosis
80
Interstitial lung disease
which 2 medications are licensed that can slow the progression of the idiopathic pulmonary fibrosis
- Pirfenidone
| - Nintedanib
81
Interstitial lung disease
Idiopathic Pulmonary Fibrosis: what is Pirfenidone
an antifibrotic and anti-inflammatory
82
Interstitial lung disease
Idiopathic Pulmonary Fibrosis: what is Nintedanib
a monoclonal antibody targeting tyrosine kinase
83
Interstitial lung disease
what drugs can cause pulmonary fibrosis
MANC
- amiodarone
- cyclophosphamide
- methotrexate
- nitrofurantoin
84
Interstitial lung disease
what conditions can pulmonary fibrosis occur secondary to?
- alpha-1 antitripsin deficiency
- RA
- SLE
- systemic sclerosis
85
Interstitial lung disease
What is hypersensitivity pneumonitis?
aka extrinsic allergic alveolitis
a type III hypersensitivity reaction
to an environmental allergen
that causes parenchymal inflammation
and destruction in people that are sensitive to that allergen
86
Interstitial lung disease
Hypersensitivity Pneumonitis: what does bronchoalveolar lavage involve?
collecting cells from the airways during bronchoscopy
by washing the airways with fluid
then collecting that fluid for testing
87
Interstitial lung disease
Hypersensitivity Pneumonitis: what will the bronchoalveolar lavage show
raised lymphocytes and mast cells
88
Interstitial lung disease
Hypersensitivity Pneumonitis mnx
- removing the allergen
- giving oxygen where necessary
- steroids
89
Interstitial lung disease
Hypersensitivity Pneumonitis: reaction to bird droppings
Bird-fanciers lung
90
Interstitial lung disease
Hypersensitivity Pneumonitis: reaction to mouldy spores in hay
farmers lung
91
Interstitial lung disease
Hypersensitivity Pneumonitis: reaction to specific mushroom antigens
mushroom workers' lung
92
Interstitial lung disease
Hypersensitivity Pneumonitis: reaction to mould on barley
malt workers lung
93
Interstitial lung disease
what is Cryptogenic organising pneumonia
previously known as bronchiolitis obliterans organising pneumonia
focal area of inflammation of the lung tissue
94
Interstitial lung disease
Cryptogenic Organising Pneumonia: cause
```
idiopathic or
triggered by:
- infection
- inflammatory disorders
- medications
- radiation
- environmental toxins
- allergens
```
95
Interstitial lung disease
Cryptogenic Organising Pneumonia: presentation
very similar to infectious pneumonia:
- SOB
- cough
- fever
- lethargy
focal consolidation on CXR
96
Interstitial lung disease
Cryptogenic Organising Pneumonia: definitive inx
lung biopsy
97
Interstitial lung disease
Cryptogenic Organising Pneumonia: trx
systemic corticosteroids
98
Interstitial lung disease
what is asbestosis
lung fibrosis related to the inhalation of asbestos
99
Interstitial lung disease
Asbestosis: what makes it fibrogenic
it causes lung fibrosis.
100
Interstitial lung disease
Asbestosis: what makes it oncogenic
it causes cancer
101
Interstitial lung disease
Asbestosis: what problems does asbestos inhalation cause
- lung fibrosis
- pleural thickening and pleural plaques
- adenocarcinoma
- mesothelioma
102
PE
what is it
where a blood clot (thrombus) forms in the pulmonary arteries
103
PE
what are DVTs and PEs collectively known as
VTE
104
PE
what are the RFs for developing a DVT or PE (9)
- immobility
- recent surgery
- long haul flights
- pregnancy
- hormone therapy with oestrogen
- malignancy
- polycythaemia
- SLE
- thrombophilia
105
PE
if pts are at increased risk of VTE, what should they receive
prophylaxis with LMWH e.g. enoxaparin
anti-embolic compression stockings
106
PE
when would LMWH (e.g. enoxaparin) be contraindicated
- active bleeding
| - existing anticoagulation with warfarin or NOAC
107
PE
what is the main CI for compression stockings
significant peripheral arterial disease
108
PE
presenting features
- SOB
- cough with or without blood
- pleuritic chest pain
- hypoxia
- tachycardia
- reduced RR
- low grade fever
- haemodynamic instability causing hypotension
109
what score predicts the risk of a pt actually having a DVT or PE
Wells Score
110
VTE
if the Wells score is 'likely', what next?
perform a CT pulmonary angiogram
111
VTE
if the Wells score is 'unlikely', what next?
perform a d-dimer and if +ve, perform a CTPA
112
PE
what are the 2 main options for establishing a definitive dx
1. CTPA
or
2. ventilation perfusion scan
113
PE
when would you use a VQ scan instead of a CTPA
in pts with renal impairment, contrast allergy or at risk from radiation
114
PE
what may the ABG show and why
respiratory alkalosis
high RR causes them to 'blow off' extra CO2 so the blood becomes alkalotic
115
what are the only 2 causes of respiratory alkalosis
1. PE
| 2. hyperventilation syndrome
116
on an ABG, what is the difference between a PE and hyperventilation syndrome
PE will have a low pO2 whereas pts w/ hyperventilation syndrome will have a high pO2
117
PE
initial mnx
apixaban or rivaroxaban started immediately if suspected VTE
before confirming dx
alternative: LMWH (enoxaparin, dalteparin) if unsuitable or in antiphospholipid syndrome
118
PE
what are the options for long term anticoagulation in VTE
warfarin, NOAC or LMWH
119
PE
when switching to warfarin, how long should you continue LMWH for
5 days
or until the INR is 2-3 for 24 hours
120
PE
what are the main DOACs
apixaban
dabigatran
rivaroxaban
121
PE
what is the 1st line trx in pregnancy or cancer
LMWH
122
PE
how long should pt continue long term anticoagulation if there is an obvious reversible cause
3m
123
PE
how long should pt continue long term anticoagulation if the cause is unclear; there is recurrent VTE or there is an irreversible cause such as thrombophilia
beyond 3m (6m in practice)
124
PE
how long should pt continue long term anticoagulation if pt has active cancer
6m (then review)
125
PE
mnx for a massive PE with haemodynamic compromise
thrombolysis: streptokinase, alteplase, tenecteplase
126
PE
which 2 ways can thrombolysis be performed
- IV using a peripheral cannula
| - directly into pulmonary arteries using a central catheter (catheter-directed thrombolysis)
127
Pulmonary Hypertension
causes: group 1
Primary pulmonary hypertension or connective tissue disease
128
Pulmonary Hypertension
causes: group 2
L heart failure due to MI or systemic HTN
129
Pulmonary Hypertension
causes: group 3
chronic lung disease such as COPD
130
Pulmonary Hypertension
causes: group 4
pulmonary vascular disease such as PE
131
Pulmonary Hypertension
causes: group 5
miscellaneous causes: sarcoidosis, glycogen storage disease + haem disorders
132
Pulmonary Hypertension
main presenting sx
SOB
133
Pulmonary Hypertension
signs and sx
- SOB
- syncope
- tachycardia
- raised JVP
- hepatomegaly
- peripheral oedema
134
Pulmonary Hypertension
ECG changes (3)
- R ventricular hypertrophy
- R axis deviation
- RBBB
135
Pulmonary Hypertension
how does R ventricular hypertrophy present on an ECG
larger R waves on the R sided chest leads (V1-3)
S waves on the L sided chest leads (V4-6)
136
Pulmonary Hypertension
CXR changes (2)
- dilated pulmonary arteries
| - R ventricular hypertrophy
137
Pulmonary Hypertension
what blood test result may indicate R ventricular failure
a raised NT-proBNP
138
Pulmonary Hypertension
what inx can be used to estimate pulmonary artery pressure
Echo
139
Pulmonary Hypertension
what can primary pulmonary hypertension be treated with? (3)
1. IV prostanoids e.g. epoprostenol
2. Endothelin receptor antagonists (e.g macitentan)
3. Phosphodiesterase-5 inhibitors (e.g. sildenafil)
140
Pulmonary Hypertension
mnx of secondary pulmonary hypertension
treat underlying cause such as PE or SLE
141
PE
ECG changes
- S1Q3T3
- RBBB + right axis deviation
- sinus tachycardia
142
PE
what is S1Q3T3
- large S wave in lead I
- large Q wave in lead III
- inverted T wave in lead III
143
ipsilateral Horner's syndrome + thoracic outlet syndrome (shoulder pain radiating down arm, motor weakness of the intrinsic hand muscles)
cause?
Pancoast tumour
invasive apical lung cancer invading the sympathetic plexus and brachial plexus.
can also cause a hoarse voice and bovine cough if it is affecting the laryngeal nerve.
144
smoke inhalation
mnx for all pts
endotracheal tube
| + analgesia + anxiety trx: morphine, propofol
145
smoke inhalation
mnx for CO poisoning
high-flow supplemental oxygen
146
what does a CO-Hb level >15% indicate
| carboxyhaemoglobin
CO poisoning
147
COVID medication mnx
- dexamethasone
- IL-6 inhibitor: tocilizumab, sarilumab
- Remdesivir
148
Acute Asthma
presentation
- progressively worsening SOB
- use of accessory muscles
- tachycardia
- symmetrical expiratory wheeze on auscultation
- chest can sound 'light' on auscultation with reduced air entry
149
Acute Asthma
moderate PEFR
50-75% predicted
150
Acute Asthma
severe signs?
- PEFR 33-50% predicted
- RR>25
- HR >110
- unable to complete sentences
151
Acute Asthma
life-threatening signs
- PEFR <33%
- Sats <92%
- becoming tired
- no wheeze
- haemodynamic instability
152
Acute Asthma
what is silent chest
in life threatening asthma
airways are so tight that there is no air entry at all
153
Acute Asthma
mnx for moderate acute asthma
- neb salbutamol 5mg repeat as often as required
- neb ipratropium bromide
- PO prednisolone or IV hydrocortisone (continued for 5d)
154
Acute Asthma
mnx for severe acute asthma
- O2 if required to maintain sats 94-98%
- aminophylline infusion
- consider IV salbutamol
155
Acute Asthma
mnx for life-threatening acute asthma
- IV magnesium sulphate infusion
- admission to ICU/HDU
- intubation in worst cases
156
Acute Asthma
initially what will ABG show and why
respiratory alkalosis as tachypnoea causes a drop in CO2
157
Acute Asthma
which ABG results is a very bad sign
resp acidosis due to high CO2
158
Acute Asthma
when an ABG has normal pCO2 or hypoxia, what does it mean
a concerning sign as it means they are tiring and indicates life threatening asthma
159
Acute Asthma
what needs to be monitored when on salbutamol and why
serum K as salbutamol causes K to be absorbed from the blood into the cells
160
COPD
does it cause clubbing
NO
161
COPD
what is used to assess the impact of their breathlessness
MRC (Medical Research Council) Dyspnoea Scale
162
COPD
MRC Dyspnoea Scale: grade 1
Breathless on strenuous exercise
163
COPD
MRC Dyspnoea Scale: grade 2
Breathless on walking up hill
164
COPD
MRC Dyspnoea Scale: grade 3
Breathless that slows walking on the flat
165
COPD
MRC Dyspnoea Scale: grade 4`
Stop to catch their breath after walking 100 meters on the flat
166
COPD
MRC Dyspnoea Scale: grade 5
Unable to leave the house due to breathlessness
167
COPD
dx
clinical presentation plus spirometry.
168
COPD
spirometry findings in COPD
FEV1/FVC ratio <0.7
| obstructive
169
COPD
how is severity graded
using FEV1
170
COPD
stage 1 in severity
FEV1 >80% of predicted
171
COPD
stage 2 in severity
FEV1 50-79% of predicted
172
COPD
stage 3 in severity
FEV1 30-49% of predicted
173
COPD
stage 4 in severity
FEV1 <30% of predicted
174
COPD
mnx if they do not have asthmatic or steroid responsive features
stop smoking
1) salbutamol / ipratropium bromide
2) LABA + LAMA
e. g. “Anoro Ellipta”, “Ultibro Breezhaler” and “DuaKlir Genuair
175
COPD
mnx if they have asthmatic or steroid responsive features
stop smoking
1) salbutamol / ipratropium bromide
2) LABA + ICS
e. g. “Fostair“, “Symbicort” and “Seretide”
3) LABA + ICS + LAMA
e. g. “Trimbo” and “Trelegy Ellipta
176
COPD
mnx in more severe cases
- Nebulisers (salbutamol and/or ipratropium)
- Oral theophylline
- Oral mucolytic therapy to break down sputum (e.g. carbocisteine)
- Long term prophylactic antibiotics (e.g. azithromycin)
- Long term oxygen therapy at home
177
COPD
indications for long term O2 therapy
severe COPD that is causing problems such as:
- chronic hypoxia
- polycythaemia
- cyanosis
- heart failure secondary to pulmonary hypertension (cor pulmonale).
178
COPD
why can't smokers use long term O2 therapy
oxygen plus cigarettes is a significant fire hazard.
179
COPD
ABG: what does low pH with a raised pCO2 suggest
they are acutely retaining more CO2 and their blood has become acidotic.
respiratory acidosis.
180
COPD
ABG: what does a raised bicarbonate suggest
they chronically retain CO2 and their kidneys have responded by producing more bicarbonate to balance the acidic CO2 and maintain a normal pH.
181
COPD
target O2 saturation If not retaining CO2 and their bicarbonate is normal (meaning they do not normally retain CO2)
> 94%
182
COPD
target O2 saturation If retaining CO2 aim for oxygen saturations
88-92% titrated by venturi mask
183
COPD
medical trx of an exacerbation if they are well enough to remain at home
- prednisolone 30mg OD for 7-14d
- regular inhalers or home nebs
- abx if evidence of infections
184
COPD
medical trx of an exacerbation if in hopsital
- neb bronchodilators (salbutamol 5mg/4h + ipratropium 500mcg/6h
- steroids (200mg hydrocortisone or 30-40mg PO prednisolone)
- abx if evidence of infection
- physio
185
COPD
medical trx of an exacerbation in severe cases not responding to first line treatment
- IV aminophylline
- NIV: BiPAP
- Intubation and ventilation with admission to intensive care
- Doxapram can be used as a respiratory stimulant where NIV or intubation is not appropriate
186
Lung cancer
what is the biggest cause
smoking
187
Lung cancer
types
- non small cell lung cancer (80%)
| - small cell lung cancer (20%)
188
Lung cancer
type of non-small cell lung cancer
- Adenocarcinoma (~40%)
- Squamous cell carcinoma (~20%)
- Large-cell carcinoma (~10%)
- Other types (~10%)
189
Lung cancer
signs + sx
- SOB
- Cough
- Haemoptysis (coughing up blood)
- Finger clubbing
- Recurrent pneumonia
- Weight loss
- Lymphadenopathy
190
Lung cancer
what nodes are often found first on examination
supraclavicular nodes
191
Lung cancer
1st line inx
CXR
192
Lung cancer
findings on CXR
- Hilar enlargement
- “Peripheral opacity”
- Pleural effusion – usually unilateral in cancer
- Collapse
193
Lung cancer
CXR: what is peripheral opacity
a visible lesion in the lung field
194
Lung cancer
what inx is used to stage and check for lymph node involvement and metastasis
contrast enhanced CT scan of chest, abdomen and pelvis
195
Lung cancer
when are PET-CT scans useful
in identifying areas that the cancer has spread to by showing areas of increased metabolic activity suggestive of cancer
196
Lung cancer
what is involved in a PET-CT scan
injecting a radioactive tracer
and taking images using a a CT scanner and a gamma ray detector
to visualise how metabolically active various tissues are.
197
Lung cancer
which inx is used for detailed assessment of the tumour and US guided biopsy
Bronchoscopy with endobronchial ultrasound (EBUS)
| endoscopy of the bronchi with US on the end of the scope
198
Lung cancer
what trx is offered 1st line in non-small cell lung cancer to patients that have disease isolated to a single area with intention to cure the cancer
Surgery - lobectomy
radiotherapy can also be curative if early on enough
199
Lung cancer
when is chemo offered
- in addition to surgery or radiotherapy in certain patients to improve outcome (adjuvant chemo)
- palliative treatment to improve survival and QoL in later stages of non-small cell lung cancer.
200
Lung cancer
trx for small cell lung cancer
chemo + radio
201
Lung cancer
which has a worse prognosis: small cell or non small cell
small cell
202
Lung cancer
palliative trx to relieve bronchial obstruction
endobronchial trx w/ stents or debulking
203
Lung cancer
extrapulmonary manifestations (9)
1. recurrent laryngeal nerve palsy
2. phrenic nerve palsy
3. superior vena cava obstruction
4. horner's syndrome
5. SIADH
6. Cushing's syndrome
7. Hypercalcaemia
8. Limbic encephalitis
9. Lambert-Eaton myasthenic syndrome
204
Lung cancer
extrapulmonary manifestations: how does recurrent laryngeal nerve palsy present
hoarse voice
205
Lung cancer
extrapulmonary manifestations: cause of recurrent laryngeal nerve palsy
the cancer pressing on or affecting the recurrent laryngeal nerve as it passes through the mediastinum
206
Lung cancer
extrapulmonary manifestations: how does phrenic nerve palsy present
SOB
| diaphragm weakness
207
Lung cancer
extrapulmonary manifestations: how does superior vena cava obstruction present
medical emergency!
- facial swelling
- difficulty breathing
- distended veins in the neck and upper chest
- “Pemberton’s sign”
208
Lung cancer
what is Pemberton's sign
a sign of superior vena cava obstruction
raising the hands over the head causes facial congestion and cyanosis
209
Lung cancer
what is Horner's syndrome caused by
a Pancoast’s tumour (tumour in the pulmonary apex) pressing on the sympathetic ganglion
210
Lung cancer
what is SIADH caused by
ectopic ADH secretion by a small cell lung cancer
211
Lung cancer
what is cushing's syndrome caused by
ectopic ACTH secretion by a small cell lung cancer.
212
Lung cancer
what is hypercalcaemia caused by
ectopic parathyroid hormone from a squamous cell carcinoma.
213
Lung cancer
what is limbic encephalitis
a paraneoplastic syndrome
the small cell lung cancer causes the immune system to make antibodies to tissues in the brain
specifically the limbic system, causing inflammation in these areas.
214
Lung cancer
sx of limbic encephalitis
- short term memory impairment
- hallucinations
- confusion
- seizures
215
Lung cancer
what antibodies is limbic encephalitis associated with
anti-Hu antibodies
216
Lung cancer
what is Lambert-Eaton myasthenic syndrome
antibodies produced by the immune system against small cell lung cancer cells also target and damage voltage-gated calcium channels sited on the presynaptic terminals in motor neurones.
217
Lung cancer
presentation of Lambert-Eaton myasthenic syndrome
- weakness in proximal muscles
- diplopia
- ptosis
- slurred speech
- dysphagia
- autonomic: dry mouth, blurred vision, impotence, dizziness
218
Lung cancer
what is a notable finding on examination of someone with Lambert-Eaton myasthenic syndrome
post-tetanic potentiation
reflexes become temporarily normal for a short period following a period of strong muscle contraction
219
Lung cancer
old patient who smokes and sx of Lambert-Eaton syndrome
what do you consider
small cell lung cancer
220
Lung cancer
what is mesothelioma
a lung malignancy affecting the mesothelial cells of the pleura
221
Lung cancer
what is mesothelioma strongly linked to
asbestos inhalation
222
Lung cancer
is there a huge latent period between exposure to asbestos and the development of mesothelioma
yes - up to 45 years!
223
Lung cancer
prognosis of mesothelioma
poor
chemo may help but it is essentially palliative
224
Pneumonia
definition of hospital acquired pneumonia
If it develops more than 48h after hospital admission
225
Pneumonia
definition of aspiration pneumonia
If it develops as a result of aspiration
meaning after inhaling foreign material such as food
226
Pneumonia
presentation
- SOB
- Cough productive of sputum
- Fever
- Haemoptysis
- Pleuritic chest pain
- Delirium
- Sepsis
227
Pneumonia
characteristic chest signs
- bronchial breath sounds
- focal coarse crackles
- dullness to percussion
228
Pneumonia
what are bronchial breath sounds
harsh breath sounds equally loud on inspiration and expiration
caused by consolidation of the lung tissue around the airway
229
Pneumonia
what causes focal coarse crackles
air passing through sputum in the airways
230
Pneumonia
why is there dullness to percussion
lung tissue collapse and/or consolidation.
231
Pneumonia
signs (which could indicate sepsis secondary to pneumonia)
```
Tachypnoea
Tachycardia
Hypoxia
Hypotension
Fever
Confusion
```
232
Pneumonia
what is the severity assessment called
CURB-65
233
Pneumonia
what does CURB-65 stand for
C – Confusion (new disorientation in person, place or time)
U – Urea > 7
R – Respiratory rate ≥ 30
B – Blood pressure < 90 systolic or ≤ 60 diastolic.
65 – Age ≥ 65
234
Pneumonia
CURB-65 score of 0 or 1
Consider treatment at home
235
Pneumonia
CURB-65 score of 2
Consider hospital admission
236
Pneumonia
CURB-65 score of 3 or more
Consider intensive care assessment
237
Pneumonia
common organisms
- Streptococcus pneumoniae (50%)
| - Haemophilus influenzae (20%)
238
Pneumonia
cause in immunocompromised patients or those with chronic pulmonary disease
Moraxella catarrhalis
239
Pneumonia
cause in patients with cystic fibrosis or bronchiectasis
Pseudomonas aeruginosa
240
Pneumonia
cause in patients with cystic fibrosis
Pseudomonas aeruginosa
Staphylococcus aureus
241
Pneumonia
definition of atypical pneumonia
pneumonia caused by an organism that cannot be cultured in the normal way or detected using a gram stain.
They don’t respond to penicillins
242
Pneumonia
what can atypical pneumonias be treated with
- macrolides (e.g. clarithromycin)
- fluoroquinolones (e.g. levofloxacin)
- tetracyclines (e.g. doxycycline)
243
Pneumonia
Legionella pneumophila (Legionnaires’ disease) key points
- infected water supplies or air conditioning units
| - can cause SIADH --> hyponatraemia
244
Pneumonia
Mycoplasma pneumoniae key points
- milder pneumonia
- erythema multiforme: target lesions
- neuro sx
245
Pneumonia
Chlamydophila pneumoniae key points
school aged child with a mild to moderate chronic pneumonia and wheeze
246
Pneumonia
Coxiella burnetii AKA “Q fever” key points
- linked to exposure to animals and their bodily fluid
| - farmer with a flu like illness
247
Pneumonia
Chlamydia psittaci key points
- typically contracted from contact with infected birds
248
Pneumonia
what are the 5 causes of atypical pneumonia
“Legions of psittaci MCQs''
- Legionella pneumophila
- Chlamydia psittaci
- Mycoplasma pneumoniae
- Chlamydophila pneumoniae
- Q fever (coxiella burnetii)
249
Pneumonia
name a fungal pneumonia
Pneumocystis jiroveci (PCP)
250
Pneumonia
whom is Pneumocystis jiroveci (PCP) common in
the immunocompromised
poorly controlled or new HIV with a low CD4 count
251
Pneumonia
presentation of fungal pneumonia
subtle
| dry cough without sputum, SOB on exertion and night sweats
252
Pneumonia
treatment of Pneumocystis jiroveci (PCP)
Septrin: co-trimoxazole (trimethoprim/sulfamethoxazole)
253
Pneumonia
what are patients with low CD4 counts prescribed
prophylactic oral co-trimoxazole to protect against PCP.
254
Pneumonia
inx in hospital
- CXR
- FBC: raised WCC
- U+Es: urea
- CRP: raised
255
Pneumonia
inx in hospital for moderate or severe cases
- Sputum cultures
- Blood cultures
- Legionella and pneumococcal urinary antigens (send a urine sample for antigen testing)
256
Pneumonia
what can be helpful in monitoring the progress of the patient towards recovery.
Inflammatory markers such as white blood cells and CRP
257
Pneumonia
mnx
depends on local area guidelines
mild CAP: 5d PO amoxicillin or macrolide
mod-severe CAP: 7-10d dual abx (amox + macrolide)
258
Pneumonia
complications
- Sepsis
- Pleural effusion
- Empyema
- Lung abscess
- Death
259
what is the most common form of lung cancer in non smokers
Lung adenocarcinoma
260
centrally located cavitating mass in the left upper lobe
and smoker
what type of lung cancer is this
squamous cell carcinoma
261
what is acute respiratory distress syndrome
inflammation of the lung due to infective or other causes
fluid accumulation in the alveoli
262
what is the 4 diagnostic criteria for ARDS
1. bilateral diffuse infiltrates seen on a CXR or chest CT
2. acute onset (within 1 week of a known risk factor)
3. non-cardiogenic (pulmonary artery wedge pressure needed if doubt)
4. pO2/FiO2 < 40kPa (200 mmHg)
263
causes of ARDS
- infection: sepsis, pneumonia
- massive blood transfusion
- trauma
- smoke inhalation
- acute pancreatitis
- cardio-pulmonary bypass
264
features of ARDS
- dyspnoea
- elevated respiratory rate
- bilateral lung crackles
- low oxygen saturations
265
key inx for ARDS
CXR + ABG
266
mnx fo ARDS
- ITU
- oxygenation/ventilation
- treatment of the underlying cause e.g. antibiotics for sepsis
- prone
267
mnx of acute exacerbation of COPD and PaCO2 is rising
NIV
268
pleural effusion: what is light's criteria
an effusion is an exudate if:
- pleural fluid to serum protein ratio is >0.5,
- pleural fluid to serum LDH ratio is >0.6,
- or the pleural fluid LDH is >2/3 the upper reference limit for serum LDH.
269
Non Invasive Ventilation
when is it used
as an alternative to full intubation and ventilation to support the lungs in respiratory failure due to obstructive lung disease
270
what does intubation and ventilation involve
giving the patient a general anaesthetic, putting a plastic tube into the trachea and ventilating the lungs artificially.
271
Non Invasive Ventilation
what does it involve
using a full face mask or a tight fitting nasal mask to blow air forcefully into the lungs and ventilate them without having to intubate them
272
Non Invasive Ventilation
what types can it be
BiPAP or CPAP.
273
Non Invasive Ventilation
what is BiPAP
bilevel positive airway pressure
a cycle of high and low pressure to correspond to the patients inspiration and expiration
274
Non Invasive Ventilation
when is BiPAP used
where there is type 2 respiratory failure typically due to COPD
275
Non Invasive Ventilation
what is the criteria for initiating BiPAP
Respiratory acidosis (pH < 7.35, PaCO2 >6)
despite adequate medical treatment.
276
Non Invasive Ventilation
what are the CIs
an untreated pneumothorax or any structural abnormality or pathology affecting the face, airway or GI tract
277
Non Invasive Ventilation
what is needed prior to NIV
CXR to exclude pneumothorax where this does not cause a delay
278
Non Invasive Ventilation
what plan should be in place in case it fails
whether the patient should proceed to intubuation and ventilation and ICU or whether palliative care is more appropriate.
279
Non Invasive Ventilation
BiPAP: what is IPAP
inspiratory positive airway pressure
the pressure during inspiration. This is where air is forced into the lungs.
280
Non Invasive Ventilation
BiPAP: what is EPAP
expiratory positive airway pressure
the pressure during expiration.
This provides some pressure during expiration so that the airways don’t collapse and it helps air to escape the lungs in patients with obstructive lung disease.
281
Non Invasive Ventilation
BiPAP: what must be done after initiation
ABG 1 hour after every change and 4 hours after that until stable
IPAP is increased by 2-5 cm increments until the acidosis resolves.
282
Non Invasive Ventilation
what is CPAP
continuous positive airway pressure
continuous air being blown into the lungs that keeps the airways expanded so that air can more easily travel in and out.
used to maintain the patient’s airway in conditions where it is prone to collapse.
283
Non Invasive Ventilation
indications for CPAP
- Obstructive sleep apnoea
- Congestive cardiac failure
- Acute pulmonary oedema
284
Sarcoidosis
what is it
a granulomatous inflammatory condition
285
Sarcoidosis
what are granulomas
nodules of inflammation full of macrophages
286
Sarcoidosis
when are the 2 spikes in incidence
young adulthood
again around age 60
287
20-40 year old black woman presenting with a dry cough + SOB.
may have nodules on their shins (erythema nodosum)
what is it
sarcoidosis
288
Sarcoidosis
what is the most commonly affected organ
lungs
289
Sarcoidosis
what are the lung problems
- Mediastinal lymphadenopathy
- Pulmonary fibrosis
- Pulmonary nodules
290
Sarcoidosis
systemic sx
- fever
- fatigue
- weight loss
291
Sarcoidosis
what are the liver problems
Liver nodules
Cirrhosis
Cholestasis
292
Sarcoidosis
what are the eye problems
Uveitis
Conjunctivitis
Optic neuritis
293
Sarcoidosis
what are the skin problems
- Erythema nodosum
- Lupus pernio
- Granulomas develop in scar tissue
294
Sarcoidosis
what is erythema nodosum
tender, red nodules on the shins caused by inflammation of the subcutaneous fat
295
Sarcoidosis
what is lupus pernio
raised, purple skin lesions commonly on cheeks and nose
296
Sarcoidosis
what are the heart problems
- Bundle branch block
- Heart block
- Myocardial muscle involvement
297
Sarcoidosis
what are the kidney problems
- Kidney stones (due to hypercalcaemia)
- Nephrocalcinosis
- Interstitial nephritis
298
Sarcoidosis
what are the CNS problems
- Nodules
- Pituitary involvement (diabetes insipidus)
- Encephalopathy
299
Sarcoidosis
what are the peripheral nervous system problems
- Facial nerve palsy
| - Mononeuritis multiplex
300
Sarcoidosis
what are the bone problems
- Arthralgia
- Arthritis
- Myopathy
301
Sarcoidosis
What is Lofgren's Syndrome
specific presentation of sarcoidosis:
1. Erythema nodosum
2. Bilateral hilar lymphadenopathy
3. Polyarthralgia
302
Sarcoidosis
Ddx
- TB
- Lymphoma
- Hypersensitivity pneumonitis
- HIV
- Toxoplasmosis
- Histoplasmosis
303
Sarcoidosis
screening inx
raised serum ACE
304
Sarcoidosis
will calcium be raised
yes
305
Sarcoidosis
what other blood tests (apart from Ca + ACE)
- Raised serum soluble interleukin-2 receptor
- Raised CRP
- Raised immunoglobulins
306
Sarcoidosis
what will CXR show
hilar lymphadenopathy
307
Sarcoidosis
what will high resolution CT thorax show
hilar lymphadenopathy and pulmonary nodules
308
Sarcoidosis
what can MRI show
CNS involvement
309
Sarcoidosis
what can PET scan show
active inflammation in affected areas
310
Sarcoidosis
what is the gold standard for confirming dx
histology from biopsy
by doing bronchoscopy with US guided biopsy of mediastinal lymph nodes
311
Sarcoidosis
what will histology show
non-caseating granulomas with epithelioid cells.
312
Sarcoidosis
1st line trx in patients with no or mild symptoms
none as the condition often resolves spontaneously
313
Sarcoidosis
1st line trx in patients with sx
1st line: PO steroids (+ bisphosphonates)
2nd: methotrexate or azathioprine
314
Sarcoidosis
prognosis
spontaneously resolves within 6 months in around 60% of patients
315
Sarcoidosis
what does it progress to in a small number of pts
pulmonary fibrosis and pulmonary hypertension
potentially requiring a lung transplant
316
Sarcoidosis
what is death due to usually
when it affects the heart (causing arrhythmias) or the CNS
317
Obstructive Sleep Apnoea
what is it caused by
collapse of the pharyngeal airway during sleep
318
Obstructive Sleep Apnoea
characteristic feature
apnoea episodes during sleep where the person will stop breathing periodically for up to a few minutes
319
Obstructive Sleep Apnoea
RFs (5)
- Middle age
- Male
- Obesity
- Alcohol
- Smoking
320
Obstructive Sleep Apnoea
features
- Apnoea episodes during sleep (reported by partner)
- Snoring
- Morning headache
- Waking up unrefreshed from sleep
- Daytime sleepiness
- Concentration problems
- Reduced oxygen saturation during sleep
321
Obstructive Sleep Apnoea
what can severe cases cause
- hypertension
- heart failure
- can increase the risk of MI and stroke
322
Obstructive Sleep Apnoea
what is uses to assess sx of sleepiness associated with OSA
Epworth Sleepiness Scale
323
Obstructive Sleep Apnoea
what do patients that need to be fully alert for work, for example heavy goods vehicle operators, require
urgent referral and may need amended work duties whilst awaiting assessment and treatment.
324
Obstructive Sleep Apnoea
who do you refer to
ENT specialist or a specialist sleep clinic
325
Obstructive Sleep Apnoea
inx
sleep studies : monitor O2 sats, HR, RR + breathing
326
Obstructive Sleep Apnoea
1st step in mnx
correct reversible risk factors
- stop drinking alcohol
- stop smoking
- lose weight
327
Obstructive Sleep Apnoea
2nd step in mnx
CPAP machine
provides continuous pressure to maintain the patency of the airway.
328
Obstructive Sleep Apnoea
last line mnx
surgery: uvulopalatopharyngoplasty (UPPP)
restructuring of the soft palate + jaw
329
Asthma
BTS/Sign Guidelines on Diagnosis
- High probability of asthma clinically: Try treatment
- Intermediate probability of asthma: Perform spirometry with reversibility testing
- Low probability of asthma: Consider referral and investigating for other causes
330
Asthma
NICE Guidelines on Diagnosis
specifically advise not to make a diagnosis clinically and require testing (1st line inx):
- Fractional exhaled nitric oxide
- Spirometry with bronchodilator reversibility
331
Asthma
NICE Guidelines on Diagnosis: if uncertainty after 1st line inx, what further testing can be done?
- peak flow diary
| - Direct bronchial challenge test with histamine or methacholine
332
Asthma
how do SABAs work (Short acting beta 2 adrenergic receptor agonists)
Adrenalin acts on the smooth muscles of the airways to cause relaxation
333
Asthma
name an example of an ICS
beclomethasone
334
Asthma
name an example of a LABA
salmeterol
335
Asthma
how does LABA work
same way as short acting beta 2 agonists but have a much longer action.
(Adrenalin acts on the smooth muscles of the airways to cause relaxation)
336
Asthma
name an example of a LAMA
tiotropium
337
Asthma
how do LAMAs work
they block the ACh receptors which leads to bronchodilation
338
Asthma
name an example of a LTRA (Leukotriene receptor antagonists)
montelukast
339
Asthma
how do LTRAs work
Leukotrienes are produced by the immune system and cause inflammation, bronchoconstriction and mucus secretion in the airways.
LTRAs block the effects of leukotrienes
340
Asthma
how does theophylline work
relaxing bronchial smooth muscle and reducing inflammation
341
Asthma
why is monitoring of plasma theophylline needed
it has a narrow therapeutic window and can be toxic in excess
342
Asthma
when is plasma theophylline monitored
5 days after starting treatment and 3 days after each dose change
343
Asthma
what is a MART (Maintenance and Reliever Therapy)
a combination inhaler containing a low dose ICS + fast acting LABA
This replaces all other inhalers and the patient uses this single inhaler both regularly as a “preventer” and also as a “reliever” when they have symptoms.
344
Asthma
BTS/SIGN Stepwise Ladder of mnx
1. SABA
2. SABA + ICS
3. SABA + ICS + LABA
4. trial of PO LTRA/SABA/theophylline or inh LAMA
5. step 4 + high dose ICS + refer
6. + low dose PO steroid
345
Asthma
NICE Guidelines mnx
1. SABA
2. SABA + ICS
3. SABA + ICS + LTRA
4. + LABA (continue only if good response)
5. consider changing to MART
6. change to moderate dose ICS
7. change to high dose ICS or PO theophylline or inh LAMA
8. refer
346
Asthma
additional mnx
- individual asthma self-management programme
- Yearly flu jab
- Yearly asthma review
- Advise exercise and avoid smoking
347
what is Samter's triad
three conditions which commonly cluster together:
- asthma
- nasal polyps
- aspirin sensitivity
348
what is a Positive hepato-jugular reflux
(distension of neck veins when pressure is applied over the liver) is a major Framingham criteria for the diagnosis of heart failure.
349
what hypersensitivity reaction is asthma
type 1: IgE antibodies
350
what can be seen on histology if a pt has asthma
Curschmann spirals: when shed epithelium becomes whorled mucous plugs
351
CXR: right lower lobe consolidation with central cavitation with an air-fluid level
what is it
lung abscess
352
stony dull to percussion
what is it
pleural effusion
353
A 76y: recurrent fever, productive cough with foul smelling sputum and dyspnoea. PMH of middle cerebral artery stroke. Finger clubbing. what could it be
lung abscess
354
why may a PMH of stroke indicate lung abscess
risk of aspiration due to impaired swallow
355
constipation and bone pain
finger clubbing and an inspiratory monophonic wheeze
what is it
Squamous cell lung cancer
hypercalcaemia from PTH or bony mets!
356
sx of carcinoid syndrome
facial flushing, diarrhoea and asthma
357
what could a well demarcated opacification is found in the right upper lobe be
a carcinoid tumour
358
diagnostic inx for a carcinoid tumour
identifying the serotonin metabolite 5-HIAA in a 24 hour urinary collection
359
1st line trx for pneumonia if CURB 0 or 1
amoxicillin
if allergic:
doxycycline
360
1st line trx for pneumonia if CURB 2
amoxicillin + clarithromycin
if allergic:
doxycycline + clarithromycin
361
1st line trx for pneumonia if CURB 3-5
co-amoxiclav + clarithromycin
if allergic:
levofloxacin
362
Bronchiectasis
what is it
permanent dilation of the bronchi and bronchioles due to chronic infection
363
Bronchiectasis
main organisms patients are infected by
Haemophilius Influenzae, Pseudomonas aeruginosa, Streptococcus Pneumoniae, Staphylococcus aureus.
364
Bronchiectasis
causes
- Post-Infection: TB; HIV; Measles; Pertussis; Pneumonia
- Obstruction by foreign body or tumour
- Allergic Bronchopulmonary aspergillosis (ABPA)
Congenital: CF; Kartagener's syndrome; Primary ciliary dyskinesia; Young syndrome
- Hypogammaglobulinaemia
- Idiopathic
365
Bronchiectasis
sx
- Productive Cough
- Large amounts of purulent sputum
- Haemoptysis
366
Bronchiectasis
signs
- Finger clubbing
- Coarse inspiratory crepitations
- Dyspneoa
- Wheeze
367
Bronchiectasis
diagnostic investigation
High-resolution CT
368
Bronchiectasis
what may CXR show
thickened bronchial walls, and cystic appearance aka tramline and ring shadows
369
Bronchiectasis
what will spirometry show
obstructive pattern
370
Bronchiectasis
what inx identify pathogens and guide management with antibiotics
sputum culture
371
Bronchiectasis
what inx can locate areas of obstruction, haemoptysis or sample tissue for culture
Bronchoscopy
372
Bronchiectasis
conservative mnx
- Patient Education
- Support Group
- Chest Physio – Postural drainage at least BD to aid mucous drainage
- Smoking Cessation
373
Bronchiectasis
medical mnx
- abx
- bronchodilators
- Carbocysteine - Mucolytic which reduces the viscosity of sputum
374
Bronchiectasis
surgical mnx
- Surgical excision of localized area of disease or cessation of haemoptysis.
- Lung transplant may be indicated in certain patients
375
what will histology show in small cell lung cancer
dense neurosecretory granules.
376
chest pain, SOB, weight loss
CXR: pleural effusion and pleural thickening
what is it
mesothelioma
377
what is the PERC
PE rule out criteria. All features must be absent for the likelihood of it being a PE <2% . If not, move to Well's
378
what are the features of PERC
- ≥50y
- HR ≥ 100
- O2 sats ≤ 94%
- previous DVT or PE
- recent surgery or trauma in the past 4w
- haemoptysis
- unilateral leg swelling
- oestrogen use (HRT, contraceptives)
379
what is the Wells score criteria
CHIMPAH
Clinical signs + sx of DVT (minimum of leg swelling + pain with palpation of deep veins)
Haemoptysis
Immobilisation >3d or surgery in the previous 4w
Malignancy (on treatment, treated in last 6m, or palliative)
Previous DVT/PE
An alternative diagnosis is less likely than PE
HR > 100 bpm
380
What is the score to estimate the prognosis of PE in 30 days?
Pulmonary embolism severity index (PESI)
381
what 4 things to do before discharging pt on anticoagulants
1. arrange appropriate anticoag monitoring/follow up
2. provide written and verbal info on new anticoagulant drug
3. provide written and verbal info on PE
4. give pt an anticoagulant alert card
382
how do you define an acute exacerbation of COPD
Anthonisen criteria
- 2 major symptoms
- or 1 major + 1 minor symptom
383
Anothonisen criteria major symptoms
- dyspnoea
- increased sputum volume
- increased sputum purulence
384
Anothonisen criteria minor symptoms
- cough
- wheeze
- nasal discharge
- sore throat
- pyrexia
385
what is the most common bacterial organisms that cause infective exacerbations of COPD
H. Influenzae
386
what is the 11 clinical criteria of the PESI score
- Age
- Sex
- History of cancer
- History of heart failure
- History of chronic lung disease
- Heart rate ≥110
- Systolic BP <100 mmHg
- RR ≥30
- Temperature <36°C
- Altered mental status (disorientation, lethargy, stupor, or coma)
- O2 saturation <90%
387
mnx of high-severity community acquired pneumonia
co-amoxiclav + clarithromycin
388
mnx of moderate severity community acquired pneumoni
amoxicillin + clarithromycin
389
what would make you admit a pneumonia patient for outreach or ICU
- resp failure requiring mechanical ventilation
- septic shocl requiring vasopressors
- score 3-5 on CURB-65
- class V on pneumonia severity score
390
two pathological features of the airways in asthma
1. airway hyperresponsiveness
| 2. inflammation and remodelling (causing bronchoconstriction)
391
What receptor does salbutamol attach to
Beta 2 Adrenergic Receptors
392
mnx if pt has a sub-massive pulmonary
| embolus but is also at risk of haemorrhage.
IV heparin as it can be stopped and reversed in event of recurrent bleeding
393
Which is the most appropriate method for providing analgesia during the early
postoperative period after major abdo surgery if they have resp disease?
Epidural is best because it can be topped up and titrated
opioid, by whatever route, should be avoided
394
what inx to confirm pulmonary fibrosis
High resolution CT scan of chest
395
If a patient presents with signs or symptoms of PE carry out an assessment of their general medical history, a physical examination
and a ___to exclude other causes.
CXR
| then CTPA/D-dimer
