Resp Flashcards
1
Q
what are the different types of lung CA
A
- Small Cell Lung CA
- Non-small Cell Lung CA
- Mesothelioma
2
Q
what are the two types of Non-small Cell Lung CA
A
- squamous cell carcinoma
- adenocarcinoma
3
Q
What does small cell lung CA contain and what do they cause
A
neurosecretory granules that release neuroendocrine hormones = multiple PARA-NEOPLASTIC SYNDROMES
4
Q
What are the common signs of lung CA
A
- SOB
- cough
- haemoptysis
- clubbing
- weight loss
- recurrent pneumonia
- lymphadenopathy
5
Q
what is the first line Ix for ?lung CA
A
CXR
6
Q
what XR findings may indicate Lung Ca
A
- hilar enlargement
- peripheral opacity
- pleural effusion (consolidation on XR)
- collapsed lung
7
Q
What other Ix are used in the diagnosis of lung CA
A
- staging CT
- PET-CT
- Bronchoscopy with endobronchial US (US guided biopsy)
- Histology
8
Q
What system in used to stage lung CA
A
TNM staging
9
Q
Mx options for non-small cell lung Ca
A
MDT management
- surgery first line (Lobectomy)
- radiotherapy
- chemotherapy
10
Q
Mx options for small cell lung Ca
A
MDT management
- chemotherapy
- radiotherapy
11
Q
Which lung Ca has the worse prognosis
A
small cell lung cancer
12
Q
What can be done in the palliative management of lung cancer
A
- palliative chemotherapy
- endobronchial treatment (stents/debulking)
13
Q
How else might a pt first present with lung Ca
A
extrapulmonary manifestation or paraneoplastic syndrome
14
Q
define paraneoplastic syndromes
A
a group of rare disorders that are triggered by an abnormal immune response to a neoplasm
15
Q
which paraneoplastic syndromes are associated with small cell lung cancer
A
- Syndrome of inappropriate ADH
- Cushings syndrome
- limbic encephalitis
- Lambert-Eaton Myasthenic Syndrome
16
Q
how does SIADH present
A
hyponatraemia
17
Q
which paraneoplastic syndrome is associated with squamous cell lung cancer
A
Hypercalcaemia of malignancy
18
Q
What are the extrapulmonary manifestations of lung CA
A
- Recurrent laryngeal nerve palsy (HOARSE VOICE)
- Phrenic nerve palsy (SOB-diaphragm weakness)
- Superior vena cave obstruction
19
Q
How does Superior vena cave obstruction present
A
- facial swelling
- difficulty breathing
- distended veins in the neck and upper chest
- Pemberton’s sign
20
Q
What is Pemberton’s sign
A
when raising the pts arms above their head causes facial congestion and cyanosis
= MEDICAL EMERGENCY
21
Q
what is the main cause of extrapulmonary manifestations?
A
compression from the tumour
22
Q
what is a Pancoast tumour
A
tumour in the pulmonary apex
23
Q
what paraneoplastic syndrome does a pancoast tumour cause
A
Horner’s syndrome
24
Q
what is the classic Horner’s triad
A
- ptosis
- anhidrosis
- miosis
25
what is limbic encephalitis
when the CA causes the immune system to create antibodies against the limbic system = INFLAMMATION in these areas
26
How does limbic encephalitis present
- short term memory impairment
- hallucinations
- confusion
- seizures
27
which antibody is limbic encephalitis associated with
anti-Hi antibodies
28
What is Lambert-Eaton Myasthenic Syndrome
when antibodies that target the small cell lung CA are target voltage-gated Ca channels on the presynaptic terminals in motor neurones
29
How does Lambert-Eaton Myasthenic Syndrome present
- proximal muscle weakness which gets worse with prolonged use
- diplopia
- ptosis
- slurred speech
- dysphasia
30
which muscles are affected in Lambert-Eaton Myasthenic Syndrome to cause the eye symptoms
- intraocular muscles (Diplopia)
| - levator muscles (ptosis)
31
What is mesothelioma
malignancy of the mesothelial cells of the pleura
32
what is mesothelioma associated with
asbestos inhalation
33
what is the prognosis with mesothelioma
Poor - Mx mainly palliative
34
define COPD
long-term non-reversible deterioration in air flow
35
what lung diseases are found in COPD
- emphysema
| - chronic bronchitis
36
common differentials for COPD
- heart failure
- lung CA
- fibrosis
37
what are the respiratory causes of clubbing
- lung Ca
- pulmonary fibrosis
- CF
- bronchiectasis
- lung abscess
- interstitial lung disease
38
What is the grading scale of dyspnoea
Medical Research Council (MRC) scale
Grade 1: breathless of strenuous exercise
Grade 2: breathless on walking up hill
Grade 3: Breathlessness that slows walking on flat
Grade 4: Stop to catch breath after 100m on flat
Grade 5: unable to leave house due to breathlessness
39
How is COPD diagnosed
clinical presentation
40
what Ix can be used for COPD
spirometry
41
What will spirometry show
obstructive picture with minimal/no reversibility with a beta-2-agonist
- FEV1/FVC ratio < 0.7
42
What is FVC
Forced Vital Capacity
- overall lung capacity
43
What is FEV1
Forced Expiratory Volume in 1 second
44
how can the severity of COPD be assessed
using the FEV1
45
what are the different levels of severity for COPD
stage 1: FEV1 > 80% predicted
stage 2: FEV1 50-79%
stage 3: FEV1 30-49%
stage 4 FEV1 < 30% predicted
46
what other Ix may be done for ?COPD
- CXR (exclude Ca)
- FBC (exclude polycythaemia/anaemia)
- BMI (assess if any weight loss)
- Sputum culture (exclude chronic infections)
- ECG/ECHO
- CT thorax (exclude Ca, fibrosis, bronchiectasis)
- Serum alpha-1 antitrypsin (look for deficiency)
- transfer factor for CO
47
what does deficiency in Serum alpha-1 antitrypsin cause
early onset and increased severity of COPD
48
what can transfer factor for CO (TLCO) show
this is decreased in COPD and can be used to assess the severity of the disease
49
what lifestyle advice is given for COPD
- smoking cessation
- annual flu vaccinations
- pneumococcal vaccine
- nutritional support
- pulmonary rehab/physio
50
what is the pharmacological Mx for COPD (long-term)
1. beta-2 agonist (salbutamol) or short acting antimuscarinic (ipratropium bromide)
2. LABA + LAMA (if not steroid responsive)/ ICS (if steroid responsive)
3. LABA + LAMA + ICS
51
give an example of a LABA+LAMA inhaler
anoro ellipta
52
give an example of a LABA+ICS inhaler
symbicort
53
give an example of a LABA+LAMA+ICS inhaler
Trimbo
54
Mx of sever COPD
- nebulisers
- oral theophylline
- oral mucolytic therapy to break down sputum (carbocisteine)
- long term prophylactic abx (azithromycin)
- long term O2 therapy
55
what is oral theophylline
a phosphodiesterase inhibitor - inhibitory effect of cAMP on immune cell function = ANTI-INFLAMMATORY EFFECT
56
What ABG result indicates T1RF
- low O2
| - low/normal CO2
57
what ABG result indicates T2RF
- low O2
| - high CO2
58
What SpO2 are you aiming for in T2RF
88-92%
59
how may a pt present with acute exacerbation of COPD
- acute increase SOB
- cough
- sputum production
- wheeze
60
what Ix are done for ?acute exacerbation of COPD
- CXR
- Sputum + blood cultures
- ECG
- FBC
- U&E
61
Mx of acute exacerbation in the community
- prednisolone (30mg OD 7-14days)
- regular inhalers/at home nebs
- antibiotics (if evidence of infection)
62
Mx of acute exacerbation in Hospital
- nebulised bronchodilators (salbutamol)
- steroids (200mg hydrocortisone)
- abx
- chest physio
63
Mx of acute exacerbation if pt continues to deteriorate
- IV aminophylline
- Non-invasive ventilation
- intubation
- doxapram (respiratory stimulation where NIV/intubation not appropriate)
64
define chronic bronchitis
hypertrophy and hyperplasia of the mucus glands in the bronchi
65
define emphysema
enlargement of air spaces and destruction of alveolar walls
66
what are the clinical signs of COPD
- using accessory muscles to breath
- tachypnoea
- hyperinflation
- reduced chest expansion
- hyper-resonant percussion
- decreased breath sounds
- wheeze
- cyanosis
- cor pulmonale
67
what signs may suggest COPD on a CXR
- hyperinflation
- bullae
- decreased peripheral vascular markings
- flattened hemidiaphragms
68
what are the indications for long term oxygen therapy
- PaO2 < 7.3 kPa on 2 reading more than 3wks apart
- PaO2 7.3-8kPa plus (1 of)
- nocturnal hypoxia
- polycythaemia
- peripheral oedema
- pulmonary HTN
MUST BE NON-SMOKERS! FIRE HAZARD!!!
69
indications for surgery with sever COPD
- upper lobe predominant emphysema
- FEV1 > 20%
- PaCO2 < 7.3kPa
- TLCO > 20%
70
define asthma
chronic inflammatory condition of the lung that causes episodic exacerbations of bronchoconstriction
71
what are the common triggers for asthma
- infection
- night time/early morning
- cold/damp air
- animals
- exercise
- dust
- strong emotions
72
how do asthmatic pts typically present
- SOB
- episodic symptoms
- dry cough/wheeze
- Hx of atopic conditions
- FHx
- bilateral widespread 'polyphonic' wheeze
73
what is the atopic triad
- asthma
- eczema
- hayfever
74
what are the first line Ix for ?asthma
- spirometry with bronchodilator reversibility
| - fractional exhaled nitric oxide
75
what other Ix can be used for ?athma
- peak flow variability
| - direct bronchial challenge test (histamine)
76
Name a Short acting beta 2 adrenergic receptor agonist (SABA)
Salbutomol
77
how do Short acting beta 2 adrenergic receptor agonist (SABA) work
promote the release of adrenalin that acts on the smooth muscles of the airway to cause relaxation
78
how are Short acting beta 2 adrenergic receptor agonist (SABA) used
short term
- "rescue" or "reliever"
79
Name an Inhaled corticosteroid (ICS)
beclomethasone
80
how do Inhaled corticosteroid (ICS) work
reduce the inflammation and reactivity of the airway
81
how are Inhaled corticosteroid (ICS) used
"maintenance" or "preventer"
82
name a long-acting beta 2 agonist (LABA)
salmeterol
83
how do long-acting beta 2 agonist (LABA) work
promote the release of adrenalin that acts on the smooth muscles of the airway to cause relaxation, but has a much longer action
84
Name a long-acting muscarinic antagonist (LAMA)
tiotropium
85
How do long-acting muscarinic antagonist (LAMA) work
block the acetylcholine receptors causing bronchodilation
86
Name a Leukotriene receptor antagonist
montelukast
87
how do Leukotriene receptor antagonists work
by blocking the affects of leukotrienes
88
what do leukotrienes cause
they are produced by the immune system and cause
- inflammation
- bronchoconstriction
- mucus secretion
89
how does theophylline work
relaxes the brachial smooth muscle and reduce inflammation
90
what do you have to be careful of when using theophylline
its narrow therapeutic window
- must monitor plasma theophylline levels in blood
91
when is are plasma theophylline levels checked
- 5 days after starting
| - 3 days after every dose change
92
what is maintenance and reliever therapy (MART)
a combination of ICS and LABA
93
what is the pharmacological Mx of asthma
1. SABA
2. + ICS
3. + low dose Leukotriene
4. + LABA
5. if still not controlled change ICS + LABA to MART
6. increase ICS dose
7. theothylline
8. refer to specialist
94
what is the non-pharmacological Mx of asthma
- annual flu jab
- annual asthma review
- advise exercise and avoid smoking
95
what characterises an acute asthma attack
rapid deterioration of symptoms
96
how does an acute asthma attack present
- progressively worsening SOB
- use of accessory muscles
- tachypnoeic
- symmetrical expiratory wheeze
- reduced air entry
97
what are the different severitys of an acute asthma attack
- moderate
- severe
- life-threatening
98
what defines a moderate asthma attack
- PERF 50-75% predicted
99
what defines a severe asthma attack
- PERF 33-50%
- RR > 25
- HR > 110
- unable to complete sentences
100
what defines a life-threatening asthma attack
- PERF < 33%
- Stats < 92%
- silent chest
- pt becoming tired (respiratory acidosis - normal/high pCO2)
- haemodynamic instability (SHOCK)
101
Mx of a moderate asthma attack
- Nebulised SABA (salbutamol)
- Nebulised ipratropium bromide
- steriods
- abx (if evidence of infection)
102
Mx of a severe asthma attack
- O2
- aminophylline infusion
- consider IV salbutamol
103
Mx of a life-threatening asthma attack
- IV Magnesium sulphate infusion
- admission to HDU/ICU
- intubation in worst case scenario
104
Why is Magnesium sulphate infusion in acute asthma attacks
Mg competes with Ca at calcium-mediated smooth muscle binding sites resulting in bronchodilation
105
what is used to monitor a pts response to Tx in an acute asthma attack
- RR
- Resp effort
- Peak flow
- SpO2
- check auscultation
106
what must you measure when prescribing salbutamol
serum K - can cause hypokalaemia
107
What are the two types of Venous Thromboembolism (VTE)
- PE
| - DVT
108
Risk factors for VTE disease
- immobility
- recent surgery
- long haul flights
- pregnancy
- Oestrogen HRT
- Malignancy
- Polycythaemia
- SLE
- Thrombophilia
109
presentation of a DVT
- pain along the deep veins
- unilateral swelling of the calf/thigh
- pitting oedema
- distention of superficial viens
- raised skin temperature
- skin discolouration
- a palpabale cord (hard, thickened vein)
110
what are the differentail diagnosis of a DVT
- traume
- post-thrombotic syndrome
- venous/lymphatic obstruction
- vasculitis
- Ruptured Baker's cyst (@popliteal fossa)
- Cellulitis
- Septic arthritis
- Compartment syndrome
111
first line Ix for DVT
d-dimer
112
What is the diagnostic Ix for DVT
- US
113
What scoring system is used to assess the pts risk of DVT
Well's Score
114
how does a PE present (symptoms)
- dyspnea
- cough
- haemoptysis
- pleuritic chest pain
- dizziness/syncope - Right HF signs in SEVERE cases
**look out for Sx of DVT**
115
what are the types of VTE prohpylaxis
- LMWH (enoxaparin)
| - anti-embolic compression stockings
116
what are the contra-indications for using LMWH prophylaxis
- pt is already on a blood thinner
- pt has active bleeding
- pt has had a previous bad reaction
117
what is the main contra-indication for compression stockings
- peripheral arterial disease
118
what scoring system is used to assess a pts risk of a PE
Well's score
119
what can the emboli in a PE be made up of
- thrombosis
- fat (following long bone fracture/orthopaedic surgery)
- amniotic fluid
- air (following neck vein cannulation or bronchial trauma)
120
what are the signs of a PE
- hypoxia
- tachycardia
- tachypnoea
- pyrexia
- elevated jugular venous pressure
- pleural rub
- haemodynamic instability causing hypotension
121
what cardiac signs may be present with a PE
- gallop heart rhythm
- widely split second heart sound
- tricuspid regurgitant murmur
122
Differential diagnosis for PE
- ACS
- Aortic dissection
- Cardiac tamponade
- Pneumonia
- Pneumothorax
- Sepsis
123
what Ix are performed for a PE
depends upon Well's score
LIKELY - CT pulmonary angiogram
UNLIKELY - d-dimer and if that comes back positive CT pulmonary angiogram
124
how is the d-dimer test used?
it has high sensitivity so if it is negative Drs can be pretty confident the pt has not had a PE/DVT.
If it is positive if is not necessarily indicative of a PE?DVT
125
what can cause a raised d-dimer
- pneumonia
- malignancy
- HF
- surgery
- pregnancy
126
what other Ix can be used to establish a definitive diagnosis of PE
V/Q mismatch scan
127
what result is found on an ABG with PE
respiratory alkalosis
128
how is an unprovoked PE defined
PE in a person with no recent major clinical risk factor for PE, who is not taking the combined oral contraceptive pill or hormone replacement therapy
129
what Ix are done for unprovoked PE
Ix for CA
- CXR
- FBC
- U&E
- serum Ca
- PT & APTT
- LFTSs
- Urinalysis
130
according to the well's score what is a likely PE
>4 points
131
what Ix may be done for a PE
- ECG
- CXR
- ABG
- ECHO
- Cardiac troponins
132
Mx of PE
- O2
- IV access
- Analgesia (morphine)
- Monitoring
- LMWH
133
name two LMWH
- enxoaparin
| - dalteparin
134
what long term anticoagulants can be used in VTE
- Warfarin
- LMWH
- NOAC or DOACs
135
how does Warfarin work
Vit K antagonist
136
what is the target INR for warfarin
between 2 and 3
137
name 3 NOAC/DOAC
- apixaban
- dabigatran
- rivaroxiban
138
when are LMWH first line for long-term management
pregnancy or CA
139
how long should the pt stay on anti-coagulants for with VTE
- 3 mths if obvious reversable cause
- >3mths if cause unclear
- 6mths if active CA
