Resp Flashcards

1
Q

what is hospital acquired pneumonia

A

pneumonia that has occurred 48 hrs after hospital admission

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2
Q

common causes of community acquired pneumonia

A

streptococcus pneumoniae (!)
mycoplasma pneumoniae
haemophilus pneumoniae

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3
Q

atypical organisms that cause pneumonia

A

mycoplasma pneumoniae
legionella pneumophilia
chlamydia psittaci
chlamydia pneumoniae

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4
Q

common causes of hospital acquired pneumonia

A

staphylococcus aureus
pseudomonas aeruginosa
klebsiella

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5
Q

causes of aspiration pneumonia

A

anaerobes from gut flora

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6
Q

risk factors for pneumonia

A

smoking
recent travel
immunocompromised
faulty air conditioning (legionella)
pet birds (chlamydia psittaci)

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7
Q

pneumonia symptoms (typical)

A

fever
SOB
productive cough (yellow/green sputum)
pleuritic chest pain

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8
Q

pneumonia symptoms (atypical)

A

dry cough
headache
diarrhoea
myalgia
hepatitis
confusion (legionella)

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9
Q

pneumonia signs (typical)

A

resp distress
cyanosis
reduced chest expansion
dull percussion over areas of consolidation
basal coarse crepitus
bronchial breathing
increased vocal resonance

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10
Q

pneumonia signs (atypical)

A

mycoplasma pneumoniae
- transverse myelitis
- erythema multiforme
- associated with AIHA

legionella
- hyponatraemia
- abnormal LFTs

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11
Q

pneumonia investigations

A

sputum MCS
FBC (high WCC)
high CRP
ABG (type 1 resp failure)

pleural fluid MCS via thoracentesis
CXR (consolidation with fluid levels)

atypical:
blood film
urinary antigens
LFTs

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12
Q

what would cxr show for pneumonia

A

lobar pneumonia
- consolidation within one lobe

bronchopneumonia
- consolidation all over the lungs

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13
Q

how is pneumonia severity assessed

A

CURB-65

confusion
urea > 7mmol/L
resp rate > 30
BP <90
age >65

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14
Q

mx of pneumonia

A

depends on CURB-65 score

1 = GP + oral antibiotics
2 = A&E + IV antibiotics
3+ = hospital admission + IV antibiotics + consider ITU

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15
Q

community acquired pneumonia antibiotics

A

typical:
- amoxicillin
- co-amoxiclav if severe

atypical:
- clarithromycin

typically amoxicillin and clarithromycin are given together if causative organism not yet identified

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16
Q

hospital acquired pneumonia antibiotics

A

staph aureus:
- flucloxacillin

MRSA:
- vancomycin

pseudomonas:
- tazocin + gentamicin

anaerobes:
- metronidazole and amoxicillin

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17
Q

special considerations when prescribing for pneumonia

A

if pt has penicillin allergy give doxycycline

in HIV pts give co-trimoxazole

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18
Q

pneumonia differentials

A

bronchitis
bronchiectasis
lung cancer

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19
Q

complications of pneumonia

A

pleural effusion
sepsis
ARDS

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20
Q

acute bronchitis typical organisms

A

rhinovirus
parainfluenza
influenza A or B
respiratory syncytial virus
coronavirus

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21
Q

risk factors acute bronchitis

A

smoking
cystic fibrosis
COPD

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22
Q

acute bronchitis signs and symptoms

A

non-productive or minimally productive cough
dyspnoea
MILD fever

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23
Q

acute bronchitis investigations

A

diagnosis based on clinical presentation
maybe CXR

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24
Q

Mx in acute bronchitis

A

otherwise healthy pts:
- paracetamol and ibuprofen as required
- hydration

cough persisting > 2 wks:
- inhaled corticosteroids
- inhaled beta 2 agonist may be useful if wheeze
- antitussives if cough interfering with sleep

pts with underlying lung pathology:
- oral abx (7 days of amoxicillin or doxycycline)

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25
acute bronchitis differentials
asthma pneumonia
26
acute bronchitis complications
pneumonia chronic bronchitis sinusitis
27
pulmonary embolism risk factors
cancer, chemo, cardiac failure, COPD, factor c deficiency trauma, thrombocytosis, travel stasis, surgery, factor S deficiency varicose veins, virchow's triad, factor V Leiden pill (OCP), pregnancy, previous VTE, polycythaemia, paraprotein deposition
28
signs and symptoms of PE
depends on severity pleuritic chest pain dyspnoea collapse if severe central crushing pain haemoptysis CXR can show Westermark's sign
29
what would ecg show PE
S1Q3T3 pattern right axis deviation right bundle branch block sinus tachycardia
30
PE ix
depends on wells score wells score < 4: low risk, d-dimer wells score 4+: high risk, CTPA (except if pregnant)
31
PE Mx
depends on whether pt is haemodynamically stable stable: (subacute/ chronic) - resp support - anticoagulation > fondaparinux/heparin for 5 days > warfarin for 3 months unstable: SBP <90 (massive PE) - resp support - 1st line: thrombolysis - 2nd line: embolectomy IV thrombolytics: alteplase, streptokinase, rt-PA
32
VTE prevention
everyone must be VTE assessed within 24 hrs of hospital admission compression stockings (TED stockings) LMWH (eg tinzaparin)
33
classifying pneumothorax
traumatic: damage to parietal pleura spontaneous: damage to visceral pleura primary: young and otherwise healthy pt secondary: pre-existing lung pathology, elderly
34
risk factors pneumothorax
male smoking Marfan's
35
pneumothorax Ix
CXR - look for loss of lung markings FBC, clotting screen - correct clotting abnormalities before inserting chest drain
36
pneumothorax Mx
primary: <2cm, no SOB: discharge and OPD review >2cm or SOB: needle aspirate - aspiration unsuccessful: chest drain - aspiration successful: observe + O2 secondary: <1cm, no SOB: observe + O2 1cm-2cm, no SOB: needle aspirate: - aspiration unsuccessful: chest drain - aspiration successful: observe + O2 >2cm or SOB: chest drain
37
Tension pneumothorax signs and symptoms
MEDICAL EMERGENCY lung compression - severe dyspnoea - tracheal deviation away from lesion - silent chest, hyperresonance, reduced expansion mediastinal shift - hypotension - tachycardia
38
Mx of tension pneumothorax
insert large bore cannula (orange or grey) in 2nd ICS, MCL just above 3rd rib to avoid neurovascular bundle of the 2nd rib
39
What is ARDS (+Berlin's criteria)
non-cardiogenic pulmonary oedema Berlin's criteria: - no alternative cause for pulmonary oedema - rapid onset < 1 week - dyspnoea - bilateral signs on CXR
40
Causes of ARDS
hypoxaemic acute lung injury: - sepsis - pneumonia - ventilation - severe burns - acute pancreatitis - transfusion reactions - drug overdose - COVID-19 body responds with profound inflammatory response - vascular permeability increased - alveolar collapse
41
ARDS Ix
bilateral diffuse opacities on chest x-ray ABG (type 2 resp failure) sputum culture blood culture
42
ARDS Mx
refer to ICU ventilator intubation draining effusions consider proning to improve oxygenation
43
what receptor does SARS-CoV-2 bind to
ACE2
44
covid symptoms
dyspnoea fever altered smell and taste headache GI disturbances
45
covid Ix
RT-PCR: +ve for viral DNA pulse oximetry: low o2 sats bloods: ABG, FBX, TFTs, glucose, CRP, ESR, cardiac biomarkers, coagulation screen, u+e CXR,CCT: ground glass opacity, consolidation
46
covid Mx
mild/moderate: bed rest, paracetamol, ibuprofen, hydration, monitor O2 sats severe: hospital admission, O2 therapy, VTE prophylaxis, dexamethasone, remdesivir, IL-6 inhibitor, consider ICU for ventilation, JAK inhibitor, ECMO
47
asthma signs and symptoms
SOB, dry cough, chest tightmess expiratory polyphonic wheeze work of breathing nasal polyps
48
asthma risk factors
fhx of asthma fhx or personal history of atopy GORD can make asthma worse
49
asthma investigations
basic obs (should be normal unless asthma attack) FEV1 reduced FEV1/FVC < 0.7 with BDR peak flow diary (>20% variability over 2-4 wks) FeNO 40+
50
asthma mx
learn this
51
COPD risk factors
childhood resp disease or infection malnourishment or poor development smoking genetics resp infections susceptibility to inflammation environmental exposures a1-antitrypsin deficiency
52
copd signs and symptoms
dyspnoea, exercise induced, progressive chronic cough, may be productive weight loss, fatigue, anorexia can be seen in severe disease ankle swelling secondary to cor pulmonale tripod, flared nostrils, accessory muscles hypercapnia wheeze barrel chest hoovers sign
53
COPD risk factors
increasing age childhood resp disease or infection malnourishment smoking genetics fhx susceptibility to inflammation, environmental exposures a1-antitrypsin deficiency
54
COPD investigations
gold standard: - spirometry post-bronchodilator FEV1/FVC < 0.7 with no BDR basic obs: low sats CXR: hyper-expansion, air trapping FBC: exclude anaemia
55
COPD management
1) educate 2) reduce risk factors: - smoking cessation - pneumococcal and influenza vaccines - develop personal COPD plan 3) if breathless with exercise limitation (CAT score): - SABA or SAMA prn 4) if symptoms continues or has exacerbations: - reduce risk factors or review adherence 5) asthmatic features (hx of asthma, eosinophils, peak flow variability > 20%): - no: LABA + LAMA, if no success after 3 month review then add ICS. review after 3 months and if ICS doesn't help then remove ICS - yes: LABA + ICS, LABA + LAMA + ICS
56
when to consider long term oxygen therapy for COPD
if pt has: PaO2 < 7.3 when stable or PaO2 between 7.3 and 8 kPa when stable with 1+ of: - secondary polycythaemia - peripheral oedema - pulmonary hypertension also non smoker
57
what is idiopathic pulmonary fibrosis
lung scarring of an unknown cause
58
risk factors for idiopathic pulmonary fibrosis
older (>65) males smoking Fhx
59
idiopathic pulmonary fibrosis signs and symptoms
progressive SOB exertional dyspnoea dry cough may have weight loss, fatigue, malaise slow insidious onset clubbing (not common) bi-basal fine end inspiratory crepitations
60
Ix for idiopathic pulmonary fibrosis
MDT approach rule out common mimics: - CXR - spirometry and gas transfer: (restrictive FEV1:FVC > 0.7 with reduced gas transfer) rule in pulmonary fibrosis with imaging: - HRCT to show IPF pattern of fibrosis (bi-basal sub-pleural fibrosis) rule out any other cause of pulmonary fibrosis: - i.e other ILDs (exposure history, ANA panel, rheumatoid factor, anti CCP and myositis panel for collagen vascular disease) bronchoalveolar lavage +/- lung biopsy if MDT aren't sure
61
IPF management
monitoring and assess for treatment: - baseline, 6mo, 12mo: spirometry and gas transfer, 6 min walking test, SO2, and QoL specialist care: - pulmonary rehab - supportive care - ambulatory or long term o2 antifibrotics: pirfenidone or nintedanib if FVC is between 50-80% predicted lung transplant
62
typical pt profile for sarcoidosis
black woman with cough and skin patch on her shin
63
what is sarcoidosis
systemic non-caseating granulomas deposited around the body causing disease. affects lungs and other organs
64
sarcoidosis risk factors
infection (eg TB) FHx Scandinavian Afro-Caribbean (esp extrapulmonary) woman 20-40 yrs
65
sarcoidosis signs and symptoms
chronic dry cough progressive SOB with exertional dyspnoea disproportionate chronic fatigue joint pain skin lesion (lupus pernio and erythema nodosum) eye problems wheeze rhonci serum biochem - high calcium and ACE cardiac involvement most common cause of death
66
What is Lofgrens syndrome
self resolving pulmonary manifestation of sarcoidosis bilateral hilar lymphadenopathy erythema nodosum arthralgia fever
67
staging Lofgrens syndrome
stage 1: bilateral hilar lymphadenopathy stage 2: bilateral hilar lymphadenopathy + pulmonary infiltrates stage 3: pulmonary infiltrates alone stage 4: extensive fibrosis with distortion
68
sarcoidosis investigations
CXR HCRT - ground glass (reversible) - cystic (irreversible) PFTs: obstructive or restrictive BAL lung biopsy skin biopsy ECG urea and creatinine AST high high serum calcium and high ACE
69
sarcoidosis management
done by specialist not all need treatment currently revolves around corticosteroids and later immunosuppressants (azathioprine, methotrexate)
70
sleep apnoea pathology
complete or partial collapse of upper airway
71
sleep apnoea risk factors
things that make you more overweight or thicken airway soft tissue -obesity -Cushing's -acromegaly -menopause
72
sleep apnoea presentation
assess risk using STOP-BANG score: snoring tired observed apnoea pressure (BP) BMI>35 age>35 neck circumference>40cm gender - male scores > 3 should be referred for polysomnography
73
sleep apnoea Ix
night time in lab polysomnography Apnoea Hypopnoea Index is the average number of obstructive events per hour mild: AHI 5-14 moderate: AHI 15-30 severe: AHI > 30
74
sleep apnoea mx
all: address risk factors mild asymptomatic: intra-oral mandibular advancement device mild/moderate/severe symptomatic: CPAP
75
occupational lung disease particulates
coal, silica, asbestos etc
76
asbestos related lung disease signs and symptoms
clubbing reduced expansion asbestos wart bibasal crackles RHF
77
types of asbestos related diseases
asbestos disease - presence of asbestosis with no symptoms or CXR findings pleural plaques - thick calcified pleura on CXR, restrictive lung disease asbestosis - lung fibrosis 5-10 yrs after heavy exposure, severe restrictive lung disease, reduced gas transfer, progressive dyspnoea mesothelioma - pleural effusion, chest pain, SOB, 20-40 yrs after exposure asbestos related lung cancer - usually 10+ yrs after first exposure
78
asbestos related lung disease investigations
hx of exposure and exclusion of other conditions CXR restrictive: low FEV1, low FVC, low residual vol normal or high fev1/FVC alveolar damage: reduced DLCO ABG if acute may show hypoxia HRCT: - basal diffuse reticulonodular infiltrates - shaggy heart border - ground glass and diffuse interstitial fibrosis lung biopsy
79
asbestos related lung disease Mx
no specific mx compensation available if they apply within 3 yrs of diagnosis corticosteroids support groups
80
causes of cavitating lung lesions
CAVITY: Cancer: - lung cancer (ie squamous cell carcinoma) - pulmonary metastasis Autoimmune: - granulomatosis with polyangiitis - rheumatoid arthritis (rheumatoid nodules) Vascular: - bland and septic pulmonary emboli Infection: - abscess - tuberculosis Trauma: - pneumatoceles Youth: - congenital pulmonary airway malformation - pulmonary sequestration - bronchogenic cyst
81
what is bronchiectasis
abnormal irreversible dilation of bronchi and bronchioles
82
causes of bronchiectasis
tuberculosis (worldwide) cystic fibrosis (western world)
83
bronciectasis risk factors
post infection chronic aspiration immunodeficiency chronic aspiration chronic inflammation chronic airway inflammation congenital disease eg CF, Youngs, a1-antitrypsin deficiency, Kartagener's, primary ciliary dyskinesia underlying chronic lung condition
84
Kartagener's syndrome/PCD triad
bronchiectasis sinusitis situs inversus
85
resp causes of clubbing
bronchiectasis ILD lung cancer lung abscess empyema TB CF
86
bronchiectasis signs and symptoms
chronic daily productive cough >8wks -large amounts -mucopurulent (pus) sputum -foul smelling -green/yellow if infection, white otherwise haemoptysis dyspnoea, SOB weight loss non pleuritic chest pain recurrent resp infections clubbing course crackles in lower lung and maybe wheeze
87
bronchiectasis ix
basic obs sputum MCS FBC, u+e, high crp, lft, abg x-ray (tram tracking) HRCT gold standard imaging tests for underlying cause sweat test (CF) genetic test skin prick/serun IgE (ABPA) serum immunoglobulin
88
classic bronchiectasis feature on imaging
signet ring sign
89
bronchiectasis mx
conservative - exercise, diet - vaccinations - smoking cessation - airway clearance (chest physio, nebulised hypertonic saline, high freq oscillation device) pharm - steroids, bronchodilators - IV ABx in acute exacerbation - oral ABx - ciprofloxacin (pseudomonas) surgery indicated in massive haemoptysis
90
complications of bronchiectasis
recurrent infections cor pulmonale (RHF) resp failure
91
organism causing TB
mycobacterium tuberculosis
92
latent TB vs active TB
latent TB: - not transmissible - TB contained in caseating granulomas active TB: - transmissible - pt requires treatment 10% risk reactivation in immunocompromised or aging
93
TB risk factors
HIV overcrowding homeless immunosuppressive meds sub-sahara africa, india, bangladesh travel
94
signs and symptoms of TB
productive cough dyspnoea/SOB +haemoptysis (late) pleural effusion low grade fever gradual weight loss lymphadenopathy erythema nodosum
95
extrapulmonary TB examples
TB can affect any organ Meningitis erythema nodosum clubbing Pott's disease addison's disease sterile pyuria etc
96
active TB Ix
basic obs sputum MCS (x3 samples, one in early morning) - microscopy (AFB stain > Ziehl-Neelsen) !!! FBC( high wcc, anaemia) high CRP ABG HIV Chest x-ray (bi-hilar lymphadenopathy) lymph node biopsy (caseating granuloma)
97
latent TB ix
Tuberculin skin test (Mantoux test) interferon gamma release assay if either test positive order CXR
98
what would you see on TB CXR
consolidation bi-hilar lymphadenopathy upper lobe scarring cavitating lesions pleural effusions miliary TB: (nodular shadowing)
99
TB management
RIPE Rifampicin Isoniazid Pyrazinamide Ethambutol R+I = 6mo P+E = 2mo
100
side effects of TB drugs
all cause hepatotoxicity red/orange secretions peripheral neuropathy + vit B6 deficiency > give pyridoxine hyperuricaemia (gout) optic neuritis (reversible red-green colour blindness)
101
where does lung cancer metastasise to
bone brain liver
102
lung cancer signs and symptoms
cough (dry or productive) haemoptysis SOB FLAWS bone (bone pain, fractures) brain (headaches, blurry vision) liver (hepatomegaly) lymphadenopathy clubbing tar staining dull percussion crepitations increased vocal resonance
103
lung cancer risk factors
smoking asbestos exposure (esp SqCC)
104
lung cancer sub-types
small cell lung cancer (15%) non-small cell lung cancer (85%) - adenocarcinoma - squamous cell carcinoma - large cell carcinoma
105
small cell lung cancer cell type and associations
Kulchitsky endocrine cells SIADH, ectopic ACTH, Lambert-Eaton syndrome central lung
106
adenocarcinoma cell type and associations
goblet cells peripheral lung periostitis clubbing arthropathy of large joints
107
squamous cell carcinoma cell type and associations
squamous epithelial cells PTHrp central lung cavitating
108
large cell carcinoma cell type and associations
epithelial cells peripheral + central lung
109
Pancoast syndrome signs and symptoms
Horner's syndrome sympathetic trunk (miosis, partial ptosis, anhidrosis) branchial plexus (shoulder/arm pain, paraesthesia) recurrent laryngeal nerve (hoarse voice +/- bovine cough) can cause SVC syndrome if tumour in right lung apex
110
SVC syndrome signs and symptoms
+ve Pemberton sign pooling of blood oedema facial flushing
111
lung cancer Ix
basic obs sputum cytology FBC calcium (possibly high) ALP (possibly high) LFTs (possibly deranged) CXR CT chest, abdo, pelvis PET (staging) biopsy (TNM staging)
112
Lung cancer CXR findings
primary lung cancer: - consolidations - bi-hilar lymphadenopathy - pleural effusion - cavitating lesion secondary lung cancer: - coin shaped lesions (cannonball mets)
113
RF for mesothelioma
asbestos exposure (20-50 yrs latency)
114
mesothelioma signs and symptoms
dry cough clubbing FLAWS pleural friction rub on auscultation
115
definitive way to diagnose mesothelioma
thoracoscopy and histology
116
mesothelioma Ix
sputum cytology pleural fluid cytology via thoracentesis FBC calcium ALP LFT CXR CT chest abdo pelvis PET scan pleural lining biopsy