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
2
Q
What does spirometry show in COPD?
A
An obstructive picture:
- FEV1:FVC ratio of less than 70%
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
4
Q
What is the initial medical management of COPD?
A
- SABA (salbutamol)
- SAMA (ipratropium bromide)
5
Q
What is the second line medical management of COPD that has asthmatic or steroid-responsive features?
A
Combination of:
- LABA (salmeterol)
- ICS
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)
7
Q
What is the third line medical management of COPD?
A
Combination of:
- LABA (salmeterol)
- LAMA (tiotropium bromide)
- ICS
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
9
Q
What is the most common causative organism of infective exacerbation of COPD?
A
H influenza
10
Q
What is Cor pulmonale?
A
- Right-sided heart failure caused by respiratory disease
- COPD is the most common cause
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)
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
- Wearing a full face mask/hood/tight nasal mask take forcefully blows air into the lungs to ventilate them
- Mid point between LTOT and mechanical ventilation
- Persistent respiratory acidosis despite treatment, based potential for recovery, based on patient preferences
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%)
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
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
16
Q
What are risk factors for pulmonary embolism?
A
- Long haul flights
- Surgery
- Periods of immobility
- Hormone therapy with oestrogen
- Pregnancy
- Malignancy
- Thrombophilia
17
Q
What features indicate PE?
A
- Pleuritic chest pain
- Tachy, hypotensive
- Beware the out of proportion hypoxic patient with a clear chest
18
Q
What is important to know about ECG/trop in PE?
A
Both can look like an MI
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
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)
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
22
Q
How long is anticoagulation continued for following VTE?
A
- 3 months - reversible cause of VTE
- > 3 months - unprovoked VTE, recurrent VTE
23
Q
What is given as VTE prophylaxis for hospital patients at high risk?
A
LMWH e.g. enoxaparin
24
Q
What are characteristic chest signs of pneumonia?
A
- Bronchial breath sounds
- Coarse crackles
- Dullness to percussion
25
What is the purpose of CURB-65?
Predicts mortality
26
What scores points in CURB-65? How does it differ for CAP and HAP?
- 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
27
How are CURB-65 scores used to guide management?
- Score 0/1: Consider treatment at home
- Score ≥ 2: Consider hospital admission
- Score ≥ 3: Consider intensive care
28
How is mild CAP managed?
5 days of oral abx:
- Amoxicillin
- Doxycycline
- Clarithromycin
29
What investigations may be used for patients admitted to hospital with pneumonia?
- FBC
- CRP
- CXR
- Renal profile
- Sputum cultures
- Blood cultures
30
What happens in asthma?
Smooth muscle in the airways is hypersensitive and responds to stimuli by constricting causing airflow obstruction
31
What might an asthma examination show?
Widespread polyphonic expiratory wheeze
32
What drugs can worsen asthma?
- Beta blockers
- NSAIDS
33
What does spirometry show in asthma?
An obstructive picture
- FEV1:FVC <70%
34
Reversibility testing can support a diagnosis of asthma. What is used? What is a positive result?
- Salbutamol
- A greater than 12% increase in FEV1
35
What initial investigations are recommended in patients with suspected asthma?
- Fractional exhaled nitric oxide
- Spirometry
36
What is Fractional exhaled nitric oxide testing? What can make the results of this test unreliable?
- 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
37
What are the BTS guidelines for long term asthma management?
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)
38
What will arterial blood gas show during an acute asthma exacerbation? What is a concerning sign?
- 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
39
What peak flow reading would indicate:
1. Moderate asthma exacerbation
2. Severe asthma exacerbation
3. Life threatening asthma exacerbation
1. 50-75% best or predicted
2. 33-50% best or predicted
3. <33%
40
What is 'silent chest'? What is it a sign of?
- When a wheeze disappears as the airways are so tight that there is no air entry
- Life threatening asthma exacerbation
41
What is the step-wise management of a mild asthma exacerbation?
1. SABA with spacer
2. Quadrupled dose of ICS
3. Oral steroids if insufficient
Follow up within 48 hrs
42
What is the step-wise management of a moderate asthma exacerbation?
1. Nebulised SABA
2. Steriods - oral prednisone/IV hydrocortisone
43
What is the step-wise management of a severe asthma exacerbation?
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
44
What are complications of salbutamol treatment?
- Hypokalemia
- Tachycardia
- Lactic acidosis
45
Why are the lungs the commonest site for TB infections?
TB bacteria have high oxygen demands
46
How can TB present?
- Lethargy
- Fever/night sweats
- Wt loss
- Cough +/- haemoptysis
- Lymphadenopathy
- Erythema nodosum
- Spinal pain in spinal TB
47
What 2 investigations are used to support a diagnosis of latent TB?
- 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
What does CXR show in primary TB?
Patchy consolidation, pleural effusion and hilar lymphadenopathy
49
What does CXR show in military TB?
'Millet seeds' uniformly distributed throughout the lung fields
50
What 2 investigations are used to support a diagnosis of active TB?
- CXR
- Cultures
51
What is the management of latent TB?
Either:
- Isoniazid and rifampicin for 3 months
- Isoniazid for 6 months
Otherwise healthy patients do not need treatment for latent TB
52
What is the management of active TB?
R – Rifampicin for 6 months
I – Isoniazid for 6 months
P – Pyrazinamide for 2 months
E – Ethambutol for 2 months
53
When patients are started on R, I, P, E for active TB, what else should they be prescribed? Why?
- Pyridoxine (vitamin B6)
- Isoniazid causes peripheral neuropathy, Pyridoxine is prescribed prophylactically to prevent this
54
What can rifampicin cause? What drugs can it interact with?
Red/orange discolouration of secretions ('red-an-orange-pissin’')
Contraceptive pills
55
What can isoniazid cause?
Peripheral neuropathy ('I’m-so-numb-azid')
56
What can pyrazinamide cause?
Hyperuricaemia resulting in gout
57
What can ethambutol cause?
Colour blindness and reduced visual acuity ('eye-thambutol')
58
What is pulmonary hypertension
- Increased resistance and pressure in the pulmonary arteries
- Defined as mean pulmonary arterial pressure >20mmHg
59
How can the causes of pulmonary hypertension be classified?
- 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
How does pulmonary hypertension present?
- SOB
- Syncope
- Tachycardia
- Raised JVP
- Hepatomegaly
- Peripheral oedema
61
How do you investigate pulmonary hypertension?
- ECG - indicates R heart strain (peaked P waves, R axis deviation, RBBB)
- CXR - dilated pulmonary arteries, RVH
62
What is the management of pulmonary hypertension?
Primary/idiopathic:
- Poor prognosis
- CCB
- IV prostaglandins
- Phosphodiesterase-5 inhibitors (sildenafil)
Secondary:
- Treat underlying cause
Supportive treatment:
- Oxygen
- Diuretics
63
What is pleural effusion?
A collection of fluid in the pleural space
64
How can pleural effusions be categorised?
- Exudative (protein >30g/L)
- Transudative (protein <30g/L)
65
What is Light's criteria used for?
- To establish an exudative effusion
- Uses protein or lactate dehydrogenase
- Compares pleural fluid level to serum level
66
What are exudative causes of pleural effusions?
- Cancer (lung cancer, mesothelioma, mets)
- Infection (pneumonia, TB)
- Connective tissue disease (RA, SLE)
- PE
- Pancreatitis
- Dressler's syndrome
67
What are transudative causes of pleural effusions?
- HF
- Hypoalbuminaemia (liver disease, nephrotic syndrome)
- Hypothyroidism
- Meigs syndrome
68
What examination findings suggest pleural effusion?
- Dullness to percussion
- Reduced breath sounds
- Reduced chest expansion
69
What findings of CXR indicate pleural effusion?
- Blunting of costophrenic angle
- Fluid lung fissures
- Tracheal and mediastinal deviation away from effusion (if massive)
70
What is the management of pleural effusion?
- 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
What is pneumothorax?
Accumulation of air in the pleural space resulting in partial or complete collapse of the affected lung
72
What is a tension pneumothorax?
A severe pneumothorax resulting in displacement of mediastinal structures that may result in severe respiratory distress and haemodynamic collapse
73
How can pneumothoraces be classified?
- Spontaneous pneumothorax
1) Primary - without underlying disease, tall, thin, young individuals
2) Secondary - pre-existing lung disease, marfans = rf
- Traumatic pneumothorax
- Iatrogenic pneumothorax
74
How does pneumothorax present?
- Dyspnoea
- Chest pain (pleuritic)
75
What examination findings indicate pneumothorax?
- Hyper-resonant lung percussion
- Reduced breath sounds
- Reduced expansion
- Tachypnoea
- Tachycardia
76
What is the management of pneumothorax?
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
What is the management of tension pneumothorax?
- 'Insert a large bore cannula into the second intercostal space in the midclavicular line'
- Chest drain is definitive management
78
What is interstitial lung disease?
Conditions that cause inflammation and fibrosis of the lung parenchyma (lung tissue)
79
What conditions come under interstitial lung disease?
- Idiopathic pulmonary fibrosis
- Secondary pulmonary fibrosis
- Hypersensitivity pneumonitis
- Cryptogenic organising pneumonia
- Asbestosis
80
What happens in lung fibrosis?
Elastic and functional lung tissue is replaced with non-functional scar tissue
81
How does interstitial lung disease present?
- SOB on exertion
- Dry cough
- Fatigue
82
How do you investigate interstitial lung disease?
- High-resolution CT of the thorax (ground glass appearance)
- Spirometry (restrictive pattern)
- If doubt of dx -> lung biopsy, bronchoalveolar lavage
83
What is the general management of interstitial lung disease?
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
What is idiopathic pulmonary fibrosis? How does it present? Key examination findings? What is the prognosis?
- 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
What medications are used to slow the progression of idiopathic pulmonary fibrosis?
- Pirfenidone
- Nitedanib
Both reduce fibrosis and inflammation
86
What are causes of secondary pulmonary fibrosis?
- Drugs - amiodarone, methotrexate, nitrofurantoin
- RA
- Alpha-1 antitrypsin
- SLE
- Systemic sclerosis
- Sarcoidosis
87
What is hypersensitivity pneumonitis also called?
Extrinsic allergic alveolitis
88
What happens in hypersensitivity pneumonitis?
Inhalation of allergens causes an immune response -> leading to inflammation and damage to the lung tissue
89
How is hypersensitivity pneumonitis investigated?
- Bronchoalveolar lavage during a bronchoscopy procedure
- Raised lymphocytes suggests hypersensitivity pneumonitis
90
What is the management of hypersensitivity pneumonitis?
- Remove allergen
- Oxygen if needed
- Steriods
91
What are specific examples of hypersensitivity pneumonitis?
- 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
What is asbestosis?
- Lung fibrosis related to asbestos exposure
- Asbestos is fibrogenic (causes fibrosis) and oncogenic (causes cancer)
93
What are complications of asbestosis inhalation?
- Lung fibrosis
- Pleural thickening and plaques
- Adenocarcinoma
- Mesothelioma
94
What is sarcoidosis?
- A chronic granulomatous disorder
- Granulomas are inflammatory nodules full of macrophages (cause of granulomas is unknown)
95
Describe a typical exam patient with sarcoidosis?
20-40 year old black female presenting with dry cough and SOB
96
How does sarcoidosis present?
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
What sign is specific to sarcoidosis?
- Lupus pernio
- Pts present with raised purple skin lesions, often on cheeks and nose
98
What is Lofgren's syndrome?
Specific presentation of sarcoidosis with a classic triad of symptoms:
- Erythema nodosum
- Bilateral hilar lymphadenopathy
- Polyarthralgia
99
What are differentials for sarcoidosis?
- TB
- Lymphoma
- Hypersensitivity pneumonitis
- HIV
- Toxoplasmosis
100
How do you investigate sarcoidosis?
- 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
What is the management of sarcoidosis?
- 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
What is the prognosis of sarcoidosis?
- Resolves spontaneously in 1/2 of pts (within 2 yrs)
- In some pts it progresses to pulmonary fibrosis and hypertension
103
What happens in bronchiectasis?
Permanent dilation of the bronchi -> sputum collects and organisms grow -> chronic cough, continuous sputum production, recurrent infections
104
What can cause bronchiectasis?
- Idiopathic
- Pneumonia
- Whooping cough
- TB
- Cystic fibrosis
- Yellow nail syndrome
105
What is yellow nail syndrome?
- Yellow finger nails
- Bronchiectasis
- Lymphoedema
Pts are stable -> good for OSCE
106
How does bronchiectasis present?
- SOB
- Chronic cough
- Recurrent chest infections
- Wt loss
107
What signs are present in bronchiectasis?
- 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
How do you investigate bronchiectasis?
- Sputum culture - common organisms = H influenza, pseudomonas aeruginosa
- CXR - tram-track opacities, ring shadows
- High-resolution CT - to confirm dx
109
How are infective exacerbations of bronchiectasis managed?
- Extended course of abx (7-14 days)
- Ciprofloxacin = choice if pseudomonas
