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2a > Resp > Flashcards

Resp Flashcards

1
Q

What is the difference between chronic bronchitis and emphysema?

A
  • Chronic bronchitis: refers to long-term symptoms of a cough and sputum production due to inflammation in the bronchi
  • Emphysema: involves damage and dilatation of the alveolar sacs and alveoli, decreasing the surface area for gas exchange
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2
Q

What does spirometry show in COPD?

A

An obstructive picture:
- FEV1:FVC ratio of less than 70%

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3
Q

How can COPD severity be graded?

A

Using FEV1:
- Stage 1 - FEV1 more than 80% of predicted
- Stage 2 - FEV1 50-79% of predicted
- Stage 3 - FEV1 30-49% of predicted
- Stage 4 - FEV1 less than 30% of predicted

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4
Q

What is the initial medical management of COPD?

A
  • SABA (salbutamol)
  • SAMA (ipratropium bromide)
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5
Q

What is the second line medical management of COPD that has asthmatic or steroid-responsive features?

A

Combination of:
- LABA (salmeterol)
- ICS

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6
Q

What is the second line medical management of COPD that doesn’t have asthmatic or steroid-responsive features?

A

Combination of:
- LABA (salmeterol)
- LAMA (tiotropium bromide)

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7
Q

What is the third line medical management of COPD?

A

Combination of:
- LABA (salmeterol)
- LAMA (tiotropium bromide)
- ICS

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8
Q

When is LTOT indicated in COPD? What is a contraindication to LTOT?

A
  • Chronic hypoxia (sats < 92%)
  • Polycythaemia
  • Cyanosis
  • Cor pulmonale

Contraindication = smoking due to fire hazard

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9
Q

What is the most common causative organism of infective exacerbation of COPD?

A

H influenza

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10
Q

What is Cor pulmonale?

A
  • Right-sided heart failure caused by respiratory disease
  • COPD is the most common cause
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11
Q

What would an arterial blood gas show during an acute exacerbation of COPD?

A

Respiratory acidosis
- High pH - indicates acidosis
- Low O2 - indicates hypoxia and respiratory failure
- High CO2 - indicates CO2 retention
- High bicarbonate - indications chronic CO2 retention (kidneys produce more HCO3 to balance high CO2, during an exacerbation despite blood remains acidotic despite high HCO3 levels)

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12
Q

Non-invasive ventilation (NIV)
1. What does it involve?
2. What is it a middle point between?
3. When is it considered?

A
  1. Wearing a full face mask/hood/tight nasal mask take forcefully blows air into the lungs to ventilate them
  2. Mid point between LTOT and mechanical ventilation
  3. Persistent respiratory acidosis despite treatment, based potential for recovery, based on patient preferences
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13
Q

What are the 4 most common types of lung cancer?

A
  • Adenocarcinoma (40%)
  • SCC (20%)
  • Small cell lung cancer (20%)
  • Large cell lung cancer (10%)
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14
Q

What might a CXR show in lung cancer?

A
  • Hilar enlargement
  • Peripheral opacity (a visible lesion in the lung field)
  • Pleural effusion (usually unilateral in cancer)
  • Collapse
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15
Q

What findings indicate 2ww for lung cancer?

A
  • Clubbing
  • Lymphadenopathy (supraclavicular or persistent abnormal cervical nodes)
  • Recurrent or persistent chest infections
  • Raised platelet count (thrombocytosis)
  • Chest signs of lung cancer
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16
Q

What are risk factors for pulmonary embolism?

A
  • Long haul flights
  • Surgery
  • Periods of immobility
  • Hormone therapy with oestrogen
  • Pregnancy
  • Malignancy
  • Thrombophilia
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17
Q

What features indicate PE?

A
  • Pleuritic chest pain
  • Tachy, hypotensive
  • Beware the out of proportion hypoxic patient with a clear chest
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18
Q

What is important to know about ECG/trop in PE?

A

Both can look like an MI

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19
Q

How does a Wells score determine further investigation?

A
  • Likely: perform a CT pulmonary angiogram (CTPA)
  • Unlikely: perform a d-dimer, and if positive, perform a CTPA
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20
Q

What is the management of a confirmed pulmonary embolism? How is a massive PE with haemodynamic compromise managed?

A
  • DOAC - apixaban or rivaroxaban
  • Alternative is LMWH
  • Continuous infusion of unfractionated heparin +/- thrombolysis (e.g. IV alteplase)
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21
Q

What are options for long term anticoagulation in VTE?

A
  • DOAC
  • Warfarin - first line in anti-phospholipid syndrome
  • LMWH - first line in pregnancy
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22
Q

How long is anticoagulation continued for following VTE?

A
  • 3 months - reversible cause of VTE
  • > 3 months - unprovoked VTE, recurrent VTE
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23
Q

What is given as VTE prophylaxis for hospital patients at high risk?

A

LMWH e.g. enoxaparin

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24
Q

What are characteristic chest signs of pneumonia?

A
  • Bronchial breath sounds
  • Coarse crackles
  • Dullness to percussion
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25
Q

What is the purpose of CURB-65?

A

Predicts mortality

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26
Q

What scores points in CURB-65? How does it differ for CAP and HAP?

A
  • C – Confusion
  • U – Urea > 7 mmol/L
  • R – Respiratory rate ≥ 30
  • B – Blood pressure < 90 systolic or ≤ 60 diastolic
  • 65 – Age ≥ 65

CRB-65 is recommended for CAP

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27
Q

How are CURB-65 scores used to guide management?

A
  • Score 0/1: Consider treatment at home
  • Score ≥ 2: Consider hospital admission
  • Score ≥ 3: Consider intensive care
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28
Q

How is mild CAP managed?

A

5 days of oral abx:
- Amoxicillin
- Doxycycline
- Clarithromycin

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29
Q

What investigations may be used for patients admitted to hospital with pneumonia?

A
  • FBC
  • CRP
  • CXR
  • Renal profile
  • Sputum cultures
  • Blood cultures
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30
Q

What happens in asthma?

A

Smooth muscle in the airways is hypersensitive and responds to stimuli by constricting causing airflow obstruction

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31
Q

What might an asthma examination show?

A

Widespread polyphonic expiratory wheeze

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32
Q

What drugs can worsen asthma?

A
  • Beta blockers
  • NSAIDS
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33
Q

What does spirometry show in asthma?

A

An obstructive picture
- FEV1:FVC <70%

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34
Q

Reversibility testing can support a diagnosis of asthma. What is used? What is a positive result?

A
  • Salbutamol
  • A greater than 12% increase in FEV1
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35
Q

What initial investigations are recommended in patients with suspected asthma?

A
  • Fractional exhaled nitric oxide
  • Spirometry
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36
Q

What is Fractional exhaled nitric oxide testing? What can make the results of this test unreliable?

A
  • Measures the concentration of nitric oxide exhaled
  • Nitric oxide is a marker of airway inflammation
  • A level above 40 ppb is a positive test result
  • Smoking lowers the FeNO making the result unreliable
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37
Q

What are the BTS guidelines for long term asthma management?

A
  1. SABA (salbutamol)
  2. ICS
  3. LABA (salmeterol) or maintenance and reliever therapy (MART)
  4. Increase ICS or add a LTRA (montelukast)
  5. Specialist management (e.g. oral corticosteroids)
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38
Q

What will arterial blood gas show during an acute asthma exacerbation? What is a concerning sign?

A
  • Respiratory alkalosis as raised resp rate causes a drop in CO2
  • A normal pCO2 or pO2 is a concerning sign as it indicates they are getting tired
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39
Q

What peak flow reading would indicate:
1. Moderate asthma exacerbation
2. Severe asthma exacerbation
3. Life threatening asthma exacerbation

A
  1. 50-75% best or predicted
  2. 33-50% best or predicted
  3. <33%
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40
Q

What is ‘silent chest’? What is it a sign of?

A
  • When a wheeze disappears as the airways are so tight that there is no air entry
  • Life threatening asthma exacerbation
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41
Q

What is the step-wise management of a mild asthma exacerbation?

A
  1. SABA with spacer
  2. Quadrupled dose of ICS
  3. Oral steroids if insufficient

Follow up within 48 hrs

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42
Q

What is the step-wise management of a moderate asthma exacerbation?

A
  1. Nebulised SABA
  2. Steriods - oral prednisone/IV hydrocortisone
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43
Q

What is the step-wise management of a severe asthma exacerbation?

A

Oxygen to maintain sats 94-98%

  1. Nebulised SABA
  2. Steriods - oral prednisone/IV hydrocortisone

May be additional treated with:
- Nebulised ipratropium bromide (SAMA)
- IV magnesium sulphate
- IV salbutamol
- IV aminophylline

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44
Q

What are complications of salbutamol treatment?

A
  • Hypokalemia
  • Tachycardia
  • Lactic acidosis
45
Q

Why are the lungs the commonest site for TB infections?

A

TB bacteria have high oxygen demands

46
Q

How can TB present?

A
  • Lethargy
  • Fever/night sweats
  • Wt loss
  • Cough +/- haemoptysis
  • Lymphadenopathy
  • Erythema nodosum
  • Spinal pain in spinal TB
47
Q

What 2 investigations are used to support a diagnosis of latent TB?

A
  • Mantoux test - indicates previous immune response to TB from previous vaccination, latent or active TB
  • Interferon-Gamma Release Assays - used to confirm diagnosis of latent TB
48
Q

What does CXR show in primary TB?

A

Patchy consolidation, pleural effusion and hilar lymphadenopathy

49
Q

What does CXR show in military TB?

A

‘Millet seeds’ uniformly distributed throughout the lung fields

50
Q

What 2 investigations are used to support a diagnosis of active TB?

A
  • CXR
  • Cultures
51
Q

What is the management of latent TB?

A

Either:
- Isoniazid and rifampicin for 3 months
- Isoniazid for 6 months

Otherwise healthy patients do not need treatment for latent TB

52
Q

What is the management of active TB?

A

R – Rifampicin for 6 months
I – Isoniazid for 6 months
P – Pyrazinamide for 2 months
E – Ethambutol for 2 months

53
Q

When patients are started on R, I, P, E for active TB, what else should they be prescribed? Why?

A
  • Pyridoxine (vitamin B6)
  • Isoniazid causes peripheral neuropathy, Pyridoxine is prescribed prophylactically to prevent this
54
Q

What can rifampicin cause? What drugs can it interact with?

A

Red/orange discolouration of secretions (‘red-an-orange-pissin’’)

Contraceptive pills

55
Q

What can isoniazid cause?

A

Peripheral neuropathy (‘I’m-so-numb-azid’)

56
Q

What can pyrazinamide cause?

A

Hyperuricaemia resulting in gout

57
Q

What can ethambutol cause?

A

Colour blindness and reduced visual acuity (‘eye-thambutol’)

58
Q

What is pulmonary hypertension

A
  • Increased resistance and pressure in the pulmonary arteries
  • Defined as mean pulmonary arterial pressure >20mmHg
59
Q

How can the causes of pulmonary hypertension be classified?

A
  • Group 1 - idiopathic pulmonary HTN/connective tissue disease
  • Group 2 - LHF
  • Group 3 - chronic lung disease (COPD/fibrosis)
  • Group 4 - pulmonary vascular disease (PE)
  • Group 5 - miscellaneous (e.g. sarcoidosis)
60
Q

How does pulmonary hypertension present?

A
  • SOB
  • Syncope
  • Tachycardia
  • Raised JVP
  • Hepatomegaly
  • Peripheral oedema
61
Q

How do you investigate pulmonary hypertension?

A
  • ECG - indicates R heart strain (peaked P waves, R axis deviation, RBBB)
  • CXR - dilated pulmonary arteries, RVH
62
Q

What is the management of pulmonary hypertension?

A

Primary/idiopathic:
- Poor prognosis
- CCB
- IV prostaglandins
- Phosphodiesterase-5 inhibitors (sildenafil)

Secondary:
- Treat underlying cause

Supportive treatment:
- Oxygen
- Diuretics

63
Q

What is pleural effusion?

A

A collection of fluid in the pleural space

64
Q

How can pleural effusions be categorised?

A
  • Exudative (protein >30g/L)
  • Transudative (protein <30g/L)
65
Q

What is Light’s criteria used for?

A
  • To establish an exudative effusion
  • Uses protein or lactate dehydrogenase
  • Compares pleural fluid level to serum level
66
Q

What are exudative causes of pleural effusions?

A
  • Cancer (lung cancer, mesothelioma, mets)
  • Infection (pneumonia, TB)
  • Connective tissue disease (RA, SLE)
  • PE
  • Pancreatitis
  • Dressler’s syndrome
67
Q

What are transudative causes of pleural effusions?

A
  • HF
  • Hypoalbuminaemia (liver disease, nephrotic syndrome)
  • Hypothyroidism
  • Meigs syndrome
68
Q

What examination findings suggest pleural effusion?

A
  • Dullness to percussion
  • Reduced breath sounds
  • Reduced chest expansion
69
Q

What findings of CXR indicate pleural effusion?

A
  • Blunting of costophrenic angle
  • Fluid lung fissures
  • Tracheal and mediastinal deviation away from effusion (if massive)
70
Q

What is the management of pleural effusion?

A
  • Conservative - small effusions will resolve w tx of underlying cause
  • Pleural aspiration - can temporarily relieve the pressure, effusion may recur
  • Indwelling pleural catheter
  • Drugs - to alleviate symptoms if recurrent e.g. opioids for dyspnoea
71
Q

What is pneumothorax?

A

Accumulation of air in the pleural space resulting in partial or complete collapse of the affected lung

72
Q

What is a tension pneumothorax?

A

A severe pneumothorax resulting in displacement of mediastinal structures that may result in severe respiratory distress and haemodynamic collapse

73
Q

How can pneumothoraces be classified?

A
  • Spontaneous pneumothorax
    1) Primary - without underlying disease, tall, thin, young individuals
    2) Secondary - pre-existing lung disease, marfans = rf
  • Traumatic pneumothorax
  • Iatrogenic pneumothorax
74
Q

How does pneumothorax present?

A
  • Dyspnoea
  • Chest pain (pleuritic)
75
Q

What examination findings indicate pneumothorax?

A
  • Hyper-resonant lung percussion
  • Reduced breath sounds
  • Reduced expansion
  • Tachypnoea
  • Tachycardia
76
Q

What is the management of pneumothorax?

A
  1. Not SOB and < 2cm rim of air on CXR
    - No tx required
  2. SOB/>2cm rim of air on CXR
    - Aspiration
    - Where fails -> chest drain
  3. Unstable/bilateral or secondary pneumothoraces
    - Chest drain
  4. Persistent/recurrent pneumothorax
    - Video-assisted thoracoscopic surgery (VATS) for pleurodesis +/- bullectomy
77
Q

What is the management of tension pneumothorax?

A
  • ‘Insert a large bore cannula into the second intercostal space in the midclavicular line’
  • Chest drain is definitive management
78
Q

What is interstitial lung disease?

A

Conditions that cause inflammation and fibrosis of the lung parenchyma (lung tissue)

79
Q

What conditions come under interstitial lung disease?

A
  • Idiopathic pulmonary fibrosis
  • Secondary pulmonary fibrosis
  • Hypersensitivity pneumonitis
  • Cryptogenic organising pneumonia
  • Asbestosis
80
Q

What happens in lung fibrosis?

A

Elastic and functional lung tissue is replaced with non-functional scar tissue

81
Q

How does interstitial lung disease present?

A
  • SOB on exertion
  • Dry cough
  • Fatigue
82
Q

How do you investigate interstitial lung disease?

A
  • High-resolution CT of the thorax (ground glass appearance)
  • Spirometry (restrictive pattern)
  • If doubt of dx -> lung biopsy, bronchoalveolar lavage
83
Q

What is the general management of interstitial lung disease?

A

Tx is primarily supportive
- Remove or treat underlying cause
- Home oxygen if hypoxia
- Stop smoking
- Physio and pulmonary rehabilitation
- Flu vaccine
- Lung transplant - risks and benefits need careful consideration

84
Q

What is idiopathic pulmonary fibrosis? How does it present? Key examination findings? What is the prognosis?

A
  • Progressive pulmonary fibrosis w no apparent cause
  • Insidious onset SOB and dry cough over 3 months
  • Bibasal fine end-inspiratory crackles and finger clubbing (common OSCE pt)
  • Poor prognosis, 2-5 yr life expectancy from dx
85
Q

What medications are used to slow the progression of idiopathic pulmonary fibrosis?

A
  • Pirfenidone
  • Nitedanib

Both reduce fibrosis and inflammation

86
Q

What are causes of secondary pulmonary fibrosis?

A
  • Drugs - amiodarone, methotrexate, nitrofurantoin
  • RA
  • Alpha-1 antitrypsin
  • SLE
  • Systemic sclerosis
  • Sarcoidosis
87
Q

What is hypersensitivity pneumonitis also called?

A

Extrinsic allergic alveolitis

88
Q

What happens in hypersensitivity pneumonitis?

A

Inhalation of allergens causes an immune response -> leading to inflammation and damage to the lung tissue

89
Q

How is hypersensitivity pneumonitis investigated?

A
  • Bronchoalveolar lavage during a bronchoscopy procedure
  • Raised lymphocytes suggests hypersensitivity pneumonitis
90
Q

What is the management of hypersensitivity pneumonitis?

A
  • Remove allergen
  • Oxygen if needed
  • Steriods
91
Q

What are specific examples of hypersensitivity pneumonitis?

A
  • Bird-fancier’s lung - bird droppings
  • Farmer’s lung - mould spores in hay
  • Mushroom worker’s lung - specific mushroom antigens
  • Malt worker’s lung - mould on barley
92
Q

What is asbestosis?

A
  • Lung fibrosis related to asbestos exposure
  • Asbestos is fibrogenic (causes fibrosis) and oncogenic (causes cancer)
93
Q

What are complications of asbestosis inhalation?

A
  • Lung fibrosis
  • Pleural thickening and plaques
  • Adenocarcinoma
  • Mesothelioma
94
Q

What is sarcoidosis?

A
  • A chronic granulomatous disorder
  • Granulomas are inflammatory nodules full of macrophages (cause of granulomas is unknown)
95
Q

Describe a typical exam patient with sarcoidosis?

A

20-40 year old black female presenting with dry cough and SOB

96
Q

How does sarcoidosis present?

A

Can affect almost any organ in the body, the lungs are most commonly affected:
- Mediastinal lymphadenopathy
- Pulmonary fibrosis
- Pulmonary nodules

Extra-pulmonary manifestations to remember for exams:
- Erythema nodosum
- Lymphadenopathy

97
Q

What sign is specific to sarcoidosis?

A
  • Lupus pernio
  • Pts present with raised purple skin lesions, often on cheeks and nose
98
Q

What is Lofgren’s syndrome?

A

Specific presentation of sarcoidosis with a classic triad of symptoms:
- Erythema nodosum
- Bilateral hilar lymphadenopathy
- Polyarthralgia

99
Q

What are differentials for sarcoidosis?

A
  • TB
  • Lymphoma
  • Hypersensitivity pneumonitis
  • HIV
  • Toxoplasmosis
100
Q

How do you investigate sarcoidosis?

A
  • Bloods - raised ACE (often screening test), raised Ca
  • CXR - hilar lymphadenopathy
  • Bronchoscopy with US guided biopsy of mediastinal lymph nodes - histology shows non-caveating granulomas w epithelial cells
101
Q

What is the management of sarcoidosis?

A
  • Conservative if mild symptoms
  • Oral steroids - first line where treatment is needed (for 6-24 months)
  • Methotrexate - 2nd line
  • Lung transplant - if severe pulmonary disease
102
Q

What is the prognosis of sarcoidosis?

A
  • Resolves spontaneously in 1/2 of pts (within 2 yrs)
  • In some pts it progresses to pulmonary fibrosis and hypertension
103
Q

What happens in bronchiectasis?

A

Permanent dilation of the bronchi -> sputum collects and organisms grow -> chronic cough, continuous sputum production, recurrent infections

104
Q

What can cause bronchiectasis?

A
  • Idiopathic
  • Pneumonia
  • Whooping cough
  • TB
  • Cystic fibrosis
  • Yellow nail syndrome
105
Q

What is yellow nail syndrome?

A
  • Yellow finger nails
  • Bronchiectasis
  • Lymphoedema

Pts are stable -> good for OSCE

106
Q

How does bronchiectasis present?

A
  • SOB
  • Chronic cough
  • Recurrent chest infections
  • Wt loss
107
Q

What signs are present in bronchiectasis?

A
  • Sputum pot by bedside
  • Oxygen
  • Wt loss (cachexia)
  • Finger clubbing
  • Signs of cor pulmonale
  • Scattered crackles throughout chest that change/clear with coughing
  • Scattered wheezes and squeaks
108
Q

How do you investigate bronchiectasis?

A
  • Sputum culture - common organisms = H influenza, pseudomonas aeruginosa
  • CXR - tram-track opacities, ring shadows
  • High-resolution CT - to confirm dx
109
Q

How are infective exacerbations of bronchiectasis managed?

A
  • Extended course of abx (7-14 days)
  • Ciprofloxacin = choice if pseudomonas

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