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Resp Flashcards

1
Q

Signs of pulmonary fibrosis (6)

A

Clubbing
Central cyanosis
Tachypnoea
Fine end inspiratory crackles
Signs of autoimmune disease - RA, SLE, systemic sclerosis
Signs of treatment - cushingoid
Discoloured skin - amiodarone

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2
Q

Investigations for pulmonary fibrosis - bloods (3)

A

ESR
Rheumatoid factor
ANA

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3
Q

What will you see on CXR in pulmonary fibrosis? (3)

A

Reticulonodular changes
Loss of definition of heart border
Small lungs

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4
Q

Results of lung function tests in pulmonary fibrosis (3)

A

FEV1/FVC >0.8 (restrictive)
Low TLC
Reduced TLco and Kco

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5
Q

What investigations would you do for pulmonary fibrosis? (7)

A

Bloods: FBC, CRP, ESR, RhF, ANA
CXR
ABG
Lung function tests
Bronchoalveolar lavage
HRCT
Lung biopsy

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6
Q

Findings on HRCT in pulmonary fibrosis (3)

A

Bibasal subpleural honeycoming - UIP
Widespread groundglass - NSIP (autoimmune association)
Apical - sarcoidosis, ABPA, old TB, hypersensitivity pneumonitis, langerhans cell histiocytosis

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7
Q

Which diseases cause apical fibrosis ? (8)

A

Sarcoidosis
Radiation
ABPA
Ankylosing spondylitis
Old TB
Hypersensitivity pneumonitis
Histoplasmosis - fungal infection
Langerhans cell histiocytosis

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8
Q

What are treatment options for pulmonary fibrosis? (4)

A

Immunosuppression eg NSIP
Pirfenidone - UIP when FEV1 50-80%
NAC
Single lung transplant

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9
Q

Prognosis of pulmonary fibrosis - Highly cellular with ground glass infiltrate with response to immunosuppression

A

80% 5 year survival

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10
Q

Prognosis of pulmonary fibrosis - honeycombing on CT, no response to immunosuppression

A

80% 5 year mortality

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11
Q

What are causes of basal pulmonary fibrosis? (4)

A

UIP
Asbestosis
Connective tissue disease
Aspiration

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12
Q

Signs of bronchiectasis (8)

A

Cachexia
Tachypnoea
Clubbing
Mixed character crackles that alter with coughing
Occasional squeaks and wheeze
Sputum +++
Cor pulmonale - leg swelling, raised JVP, RV heave, loud P2
Yellow nail syndrome

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13
Q

Investigations for bronchiectasis (8)

A

Sputum culture and cytology
CXR - tramlines, ring shadows
HRCT - signet ring sign (thickened dilated bronchi larger than adjacent vascular bundle)
Immunoglobulins - hypogammaglobulinaemia
Aspergillus RAST or skin prick
Rheumatoid serology
Saccharine ciliary motility test - kartageners
Genetic screening - cystic fibrosis

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14
Q

Causes of bronchiectasis - congenital (2)

A

Kartageners
Cystic fibrosis

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15
Q

Causes of bronchiectasis - childhood infection (2)

A

Measles
TB

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16
Q

Causes of bronchiectasis - immune (2 over active, 2 under active)

A

ABPA
IBD associated
Hypogammaglobulinaemia
CVID

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17
Q

Causes of bronchiectasis (5)

A

Congenital - kartageners/CF
Childhood infection - measles/TB
Immune over activity - ABPA/ IBD
Immune under activity - hypogammaglobulinaemia/CVID
Aspiration - alcoholics, GORD, stroke

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18
Q

Treatment for bronchiectasis (5)

A

Chest physio
Abx for exacerbations
Low dose azithromycin 3 times per week long term
Bronchodilators/ICS if airflow obstruction
Surgery for localised disease

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19
Q

Complications of bronchiectasis (4)

A

Recurrent infections
Cor pulmonale
Secondary amyloidosis
Massive haemoptysis

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20
Q

Signs of old TB (6)

A

Chest deformity / absent ribs
Thoracoplasty scar
Tracheal deviation towards fibrosis
Reduced expansion
Dull percussion but present tactile vocal fremitus
Crackles and bronchial breathing

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21
Q

Historical treatment for TB (6)

A

Plombage - polystyrene balls
Phrenic nerve crush
Thoracoplasty - rib removal, lung not resected
Apical lobectomy
Recurrent medical pneumothoraces
Streptomycin

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22
Q

Side effects of TB drugs (4)

A

Isoniazid - peripheral neuropathy and hepatitis
Rifampicin - hepatitis and increased contraceptive pill metabolism
Ethambutol - retro bulbar neuritis and hepatitis
Pyrazinamide - hepatitis

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23
Q

What to council TB patients before starting treatment regarding side effects (5)

A

If jaundice - stop tablets and call nurse
If red becomes less bright - call nurse
If tingling in toes - tell dr at next visit
Secretions will turn orange / red - don’t wear contacts
If on OCP - use barrier contraception

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24
Q

Signs of lobectomy (5)

A

Reduced expansion and chest wall deformity
Thoracotomy scar
Central trachea
If lower lobectomy - dull percussion note lower zone, absent breath sounds
If upper lobectomy - normal or hyper-resonant percussion upper zone, dull percussion at base - elevated diaphragm

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25
Q

Signs of pneumonectomy (7)

A

Thoracotomy scar
Reduced expansion on side of op
Trachea deviated to side of op
Dull percussion note through hemi thorax
Absent tactile vocal fremitus beneath scar
Bronchial breathing in upper zone
Reduced breath sounds in rest of hemi thorax

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26
Q

Signs of single lung transplant (3)

A

Thoracotomy scar
Normal exam on side of scar
Clinical signs on opposite side

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27
Q

Indications for single lung transplant (2)

A

COPD
Pulmonary fibrosis
(“Dry” lung conditions)

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28
Q

Signs of double lung transplant (1)

A

Clamshell incision

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29
Q

Indications for double lung transplant (3)

A

CF
Bronchiectasis
Pulmonary HTN
(“Wet” lung conditions)

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30
Q

Signs of COPD on inspection (4)

A

Nebuliser or inhalers at bedside
Sputum pot
Dyspnoea
Pursed lips

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31
Q

Signs of COPD in hands (3)

A

CO2 retention flap
Bounding pulse
Tar stained fingers

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32
Q

Chest signs in COPD (4)

A

Hyper expanded lungs
Percussion note resonant
Expiratory polyphonic wheeze
Reduced breath sounds at apices

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33
Q

Signs of cor pulmonale (5)

A

Raised JVP
Ankle oedema
RV heave
Loud P2
Pansystolic murmur of TR

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34
Q

Causes of clubbing - chest (7)

A

Bronchial carcinoma
Bronchiectasis
Cystic fibrosis
Lung abscess /empyema
Mesothelioma
Idiopathic pulmonary fibrosis
TB

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35
Q

Causes of COPD (3)

A

Smoking
Industrial dust exposure (apical)
Alpha 1 anti trypsin (basal)

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36
Q

Spirometry result in COPD

A

Low FEV1
FEV1/FVC ratio <0.7 obstructive
Gas transfer low T CO

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37
Q

GOLD classification of COPD

A

GOLD 1 - mild: FEV1 ≥80% predicted
GOLD 2 - moderate: 50% ≤ FEV1 <80% predicted
GOLD 3 - severe: 30% ≤ FEV1 <50% predicted
GOLD 4 - very severe: FEV1 <30% predicted

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38
Q

Treatment of COPD (9)

A

Smoking cessation / NRT
Mild - Beta agonists
Moderate - Tiotropium and beta agonist
Severe - Moderate plus ICS if no pneumonia
Pulmonary rehab
Nutrition
Vaccinations - pneumococcal and influenza
LTOT
Surgical - bullectomy, endobronchial valve replacement, lung reduction surgery, single lung transplant

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39
Q

LTOT inclusion criteria (4)

A

Non smoker
PaO2 <7.3 on air
PaCO2 does not rise excessively on O2
PaO2 <8 if cor pulmonale

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40
Q

COPD exacerbation prognosis

A

15% in hospital mortality

41
Q

Wheezy chest differential (4)

A

COPD/asthma
Granulomatous polyarteritis
Rheumatoid arthritis (obliterative bronchiolitis)
Post transplant - chronic rejection

42
Q

Signs of pleural effusion (6)

A

Asymmetrically reduced expansion
Trachea or mediastinum displaced away from side of effusion
Stony dull percussion note
Absent tactile vocal fremitus
Reduced breath sounds
Bronchial breathing above

43
Q

Signs to indicate cause of pleural effusion - cancer (3)

A

Clubbing
Lymphadenopathy
Mastectomy - breast cancer

44
Q

Signs that indicate cause of pleural effusion - heart failure (2)

A

Raised JVP
Peripheral oedema

45
Q

Signs that indicate cause of pleural effusion - chronic liver disease (3)

A

Leuconychia
Spider naevi
Gynaecomastia

46
Q

Signs that indicate cause of pleural effusion - renal failure (1)

A

AV fistula

47
Q

Causes of chronic pleural effusion (5)

A

Cancer
Congestive heart failure
Chronic liver disease
Chronic renal failure
Connective tissue disease

48
Q

Signs of cause of pleural effusion - connective tissue disease (2)

A

RA hands
Butterfly rash of SLE

49
Q

Causes of a dull lung base (6)

A

Effusion
Consolidation - bronchial breathing and crackles
Collapse - tracheal deviation, reduced breath sounds
Lobectomy - reduced lung volume
Pleural thickening - similar to pleural effusion but normal tactile vocal fremitus, scars from VATs pleuradesis
Raised hemidiaphragm - hepatomegaly

50
Q

Causes of a transudative pleural effusion (3)

A

CCF
Renal failure
Liver failure

51
Q

Causes of exudative pleural effusion (4)

A

Neoplasm
Infection
Infarction
Inflammation - RA/SLE

52
Q

What pleural effusion aspirate findings suggest exudate? (4)

A

Protein: >35g/L or lights criteria
Pleural fluid albumin/plasma albumin >0.5
LDH: effusion LDH/plasma LDH >0.6
Or >2/3 normal value

53
Q

What pleural effusion aspirate findings are suggestive of empyema? (3)

A

Exudate
Low glucose
pH <7.2

54
Q

What is an empyema?

A

Collection of pus in pleural space
Most frequently anaerobes, staph and gram negatives
Associated with bronchial obstruction - carcinoma, recurrent aspiration, poor dentition, alcohol dependence

55
Q

What is the treatment for empyema? (4)

A

Pleural drainage
IV abx
Intrapleural DNAse plus TPA
Surgical decortication

56
Q

Clinical signs of lung cancer (11)

A

Cachexia
Clubbing
Tar staining
Lymphadenopathy
Tracheal deviation - if collapse or effusion
Reduced expansion
Dull percussion - if collapse or effusion
Absent tactile vocal fremitus - if effusion or increased resonance if consolidation
Auscultation - crackles or reduced breath sounds
Hepatomegaly if mets
Bony tenderness if mets

57
Q

What signs of lung cancer treatment might you find? (3)

A

Lobectomy scar
Radiotherapy burn
Radiotherapy tattoo

58
Q

What are complications of lung cancer? (9)

A

SVCO
Recurrent laryngeal nerve palsy
Horners sign
Wasted small muscles of hands
Gynaecomastia
Lambert Eaton myasthenia
Dermatomyositis
SIADH
Hypercalcaemia

59
Q

What are the different types of lung cancer and how common? (5)

A

Squamous 35%
Small (oat) 24%
Adeno 21%
Large 19%
Alveolar 1%

60
Q

How do you diagnose lung cancer? (7)

A

CXR: collapse, mass, hilar lymphadenopathy
CT thorax
Induced sputum cytology
Biopsy by bronchoscopy if central
Percutaneous CT guided needle if peripheral lesion and FEV1 >1L
Staging CT/EBUS/thoracoscopy/PET
Lung function tests for operability assessment

61
Q

What is important for staging of different lung cancers?

A

Non small cell - TNM staging to assess operability
Small cell - assess limited or extensive disease

62
Q

What is ideal FEV1 value for lobectomy and pneumonectomy?

A

Lobectomy FEV1 >1.5L
Pneumonectomy >2L

63
Q

What might bloods show in lung cancer that show complications? (6)

A

Deranged LFTs - mets
Hypercalcaemia - mets or non small cell
Low Hb - mets
Raised PTHrP - non small cell
Raised ACTH - small cell
SIADH - small cell

64
Q

What are treatment options for lung cancer - non small cell? (4)

A

Surgery - lobectomy or pneumonectomy
Radiotherapy
Chemo - eGFR positive - erlotinib
MDT approach

65
Q

What are treatment options for small cell lung cancer? (2)

A

Chemo
MDT approach

66
Q

What are palliative treatment options for lung cancer and its complications ? (5)

A

Dex and radiotherapy for brain mets or SVCO
Stent for SVCO
Radiotherapy for haemoptysis, bone pain, cough
Chemical pleurodesis for effusion
Opiates for pain, cough

67
Q

What are signs of CF? (8)

A

Small stature
Clubbed
Tachypnoea
Sputum pot with purulent sputum
Hyperinflated chest with reduced expansion
Coarse crackles and wheeze
Portacath or Hickman lines/scars
PEG

68
Q

What are the genetics of CF?

A

1/2500 live births
Autosomal recessive
Chromosome 7q
CFTR gene
Chloride channel
Delta 508 deletion most common

69
Q

What is the pathophysiology of CF and which organs does it affect?

A

Secretions thickened and block lumens of various structures:
Bronchioles - bronchiectasis
Pancreatic ducts - loss of endo and exocrine function
Gut - distal intestinal obstruction syndrome in adults
Seminal vesicles - male infertility
Fallopian tubes - reduced female fertility

70
Q

What are investigations for CF? (3)

A

Screened at birth- heel prick - low immunoreactive trypsin
Sweat test - Na >60
Genetic screening

71
Q

What can cause a false positive sweat test for CF?

A

Hypothyroidism
Addisons

72
Q

What are treatments for CF? (9)

A

Physiotherapy - postural drainage and active cycle breathing
Abx for infections
Pancrease
Fat soluble vitamin supplements
Mucolytics- nebulised DNAse
Immunisations
Double lung transplant
Gene therapy under development
Kaftrio for certain mutations

73
Q

What is the prognosis in CF?

A

Median survival 35 years but rising
If double lung transplant - 50% survival at 5 years
Poor prognosis if burkholderia cepacia infection

74
Q

What are signs of pneumonia? (8)

A

Tachypnoea
Oxygen requirement
Sputum pot with purulent or rusty sputum
Reduced expansion
Dull percussion note
Focal coarse crackles
Increased vocal resonance
Temperatures

75
Q

What investigations would you do for pneumonia? (6)

A

CXR: consolidation with air bronchogram, effusion
Bloods: raised WCC, CRP, urea, atypical serology, immunoglobulins
Blood cultures
Sputum culture
Atypical serology in urine - legionella, pneumococcal antigens
Haemoglobulinuria

76
Q

Which pneumonia causes cold agglutinins leading to haemolysis?

A

Mycoplasma

77
Q

What are most common organisms causing CAP? (4)

A

Strep pneumoniae 50%
Mycoplasma pneumoniae 6%
Haemophilus influenzae - COPD
Chlamydia pneumoniae

78
Q

What are first line abx for pneumonia? (2)

A

Penicillin or cephalosporin
+
Macrolide

79
Q

What bugs might immunosuppressed people be at risk of causing pneumonia and what are treatments? (4)

A

Fungal - amphotericin
Multi resistant mycobacteria
Pneumocystis carinii- co-trimox or pentamidine
CMV - ganciclovir

80
Q

What bug commonly causes pneumonia post influenza and what is treatment?

A

Staph aureus - flucloxacillin

81
Q

What are complications of pneumonia? (4)

A

Lung abscess - Staph aureus, klebsiella, anaerobes
Para pneumonic effusion or empyema
Haemoptysis
Septic shock and organ failure

82
Q

What are risk factors for asthma? (10)

A

Atopy
FH of asthma or atopy
Inner city environment
Socio-economic deprivation
Obesity
Prematurity and low birth weight
Viral infections in early childhood
Smoking
Maternal smoking
Early exposure to broad-spectrum antibiotics

83
Q

What are investigations for asthma? (6)

A

Peak flow diary
Spirometry with reversibility testing
FeNO - elevated levels suggest inflammation
CXR to exclude other causes if atypical
FBC for eosinophilia
Allergen testing IgE

84
Q

What are steps for managing asthma? (9)

A

Identify and remove triggers, remember occupational
SABA only if intermittent and mild
Add ICS if frequent symptoms
Add montelukast +/- LABA
Increase steroid dose
Change to MART
Add LABA if not before +/- SR theophylline
Oral steroids
Omalizumab if IgE mediated poorly controlled

85
Q

What is the most likely underlying pathology of a pancoasts tumour?

A

Squamous cell carcinoma

86
Q

What are respiratory indications for VATS? (5)

A

Lobectomy/Wedge resection/segmentectomy
Bullectomy / volume reduction
Recurrent pneumothorax pleurodesis
Decortication/pleurectomy
Biopsy

87
Q

What are BTS guidelines for pneumothorax?

A

If patient is symptomatic, do they have high risk characteristics?
If yes, then drain
If no and pneumothorax large enough (>2cm), patient can choose conservative, ambulatory device or therapeutic aspiration
If aspiration does not resolve it, then drain

88
Q

What are indications for pleurodesis? (3)

A

Malignant pleural effusion
Recurrent or persistent pneumothorax
Recurrent pleural effusion

89
Q

What are causes of airflow obstruction ? (4)

A

Asthma
COPD
Bronchiectasis
Obliterative bronchiolitis: viral, pollutants, graft vs host

90
Q

What defines reversible airflow obstruction?

A

FEV1 200ml or 15% change in response to bronchodilation

91
Q

Who can have anti fibrotics in IPF?

A

FVC 50-80% predicted

92
Q

Which bacteria confers poor prognosis in cystic fibrosis?

A

Burkholderia cepacia
Rapid decline in lung function, contraindication to transplant

93
Q

What is the most common cause of chronic lung transplant rejection?

A

Bronchiolitis obliterans

94
Q

What are contraindications to lung transplant? (10)

A

History of malignancy in last 5 years
Untreatable significant other organ dysfunction
Uncorrected atherosclerotic disease
Acute illness
Chronic infection with resistant organisms
Chest wall or spinal deformity
BMI >35
Non adherence to therapies
Poor functional status
Substance abuse: alcohol, smoking

95
Q

Which condition carries worst prognosis for lung transplant?

A

ILD

96
Q

What are signs of hyper inflation on examination? (7)

A

Prolonged expiration
Tracheal tug
Cricosternal distance less than 3 finger widths
Indrawing of inter and subcostal spaces
Reduced expansion
Quiet breath sounds
Hyper resonance to percussion

97
Q

What respiratory involvement can occur in rheumatoid arthritis? (8)

A

ILD - UIP or NSIP
Treatment related ILD
Pulmonary nodules
Pleural effusion
Pleuritis
Obliterative bronchiolitis
Infections related to immunosuppression
Raised hemidiaphragm

98
Q

What does groundglass appearance on CT suggest?

A

Inflammation - likely to respond to steroids/immunosuppressants

99
Q

What does honeycomb appearance on CT mean?

A

Fibrosis
Not ammenable to steroids /immunosuppressants

PACES (6 decks)

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