Resp Flashcards
________ most commonly causes a cavitating pneumonia in the upper lobes, mainly in diabetics and alcoholics
+ other features of this
Klebsiella
may occur following aspiration
‘red-currant jelly’ sputum
steroids during tx for acute asthma - what route?
oral pred
stable COPD management
- SABA/SAMA
if no asthmatic features
- add LABA + LAMA
discontinue SAMA and replace with SABA
if asmathic features
- LABA + ICS + LAMA
switch SAMA to SABA
Persistent productive cough +/- haemoptysis in a young person with a history of respiratory problems →
?bronchiectasis
what confirms that the chest drain is located in the pleural cavity?
water seals rises on inspo, falls on expo
as the patients expands their thoracic cavity at the start of inspiration, the pressure in the pleural space becomes increasingly more negative - drawing air into the lungs from the outside, and simultaneously it will also cause the water level of the underwater seal to rise inside the bottle
male 50-70, finger clubbing, dry cough, weight loss
pulmonary fibrosis
BiPAP vs CPAP - which is preferred in COPD?
BiPAP: forcing air in with variable pressure (high/low). Useful to keep lungs from collapsing, and also for forcing air into lungs. Hence useful in COPD - forces O2 in and forces CO2 out.
CPAP: continuous pressure that keeps lungs open continuously, prevents collapse in conditions like obstructive sleep apnoea.
In idiopathic pulmonary fibrosis, ________ is the investigation of choice
high resolution CT
Subacute productive cough, foul-smelling sputum, night sweats →
?lung abscess
Pneumothorax: if needle aspiration and rim of air is greater than __cm, insert chest drain
2
Tx to reduce multiple COPD exacerbations
roflumilast (oral PDE-4 inhibitors)
After smoking cessation,________ is one of the few interventions that has been shown to improve survival in COPD
long-term oxygen therapy (LTOT)
multiple rounded lesions on CXR are suggestive of ____
lung mets
consolidation at the right base + neurological injury + no fever =
aspiration
non-small-cell lung carcinoma with squamous appearing tumour cells - What paraneoplastic syndrome is most commonly associated with this patient’s cancer?
PTHrP
paraneoplastic features of:
- small cell
- squamous cell
- adenocarcinoma
- small cell: ADH, ACTH, Lamber-Eaton
- squamous: PTH-rp causing hypercalcaemia, hyperthyroidism
- adenocarcinoma: gynaecomastia
excessive daytime sleepiness + snoring + RFs like obesity, HTN, DM - what is the Dx? What is the main Ix?
Dx: OSA
Ix: polysomnography (sleep studies)
What is Light’s criteria?
criteria to determine if pleural effusion is transudate or exudate
a pleural effusion is an exudate if:
- Effusion lactate dehydrogenase (LDH) level greater than 2/3 the upper limit of serum LDH
- Pleural fluid LDH divided by serum LDH >0.6
- Pleural fluid protein divided by serum protein >0.5
basically raised LDH = exudate
what type of exudate will the following cause:
- liver disease
- haemothorax
- HF
- nephrotic syndrome
- liver disease: transudate, hypoalbuminaemia
- haemothorax: exudate
- HF: transudate
- nephrotic syndrome: transudate
Late stage COPD/alpha-1 antitrypsin deficiency Mx - what is life-prolonging tx?
lung volume reduction surgery
exposure to contaminated water + fever + headache + chills + muscle aches + jaundice from liver involvement - Dx?
leptospirosis (caused by leptospira)
how does lung abscess present?
- secondary to aspiration pneumonia
- acute Sx: fever, productive cough, foul-smelling sputum
chronic cough can indicate
lung cancer
The most common organism causing infective exacerbations of COPD is
Haemophilus influenzae
Aspiration pneumonia: most common XRAY finding?
consolidation in the right lung
tension pneumothorax can cause ________ shock
obstructive (mechanical obstruction of pulmonary arteries or aorta)
Mx of CAP
- amoxicllin
- if allergic use macrolide/tetracycline
- 5 days
if severe CAP
- consider co-amoxiclav
- dual abx therapy with amoxicillin + macrolide to cover for atypical pathoegns
causes of exudate and transudate
exudate:
- infection (pneumonia**, TB, abscess)
- connective tissue disease (RA, SLE)
- neoplasia
- pancreatitis
- PE
transudate (all begin with H)
- HF**
- hypoalbuminaemia (liver disease, nephrotic disease, malabsorption)
- hyperthyroidism
asthmatic features/features suggesting steroid responsiveness in COPD
- previous diagnosis of asthma or atopy
- a higher blood eosinophil count
- substantial variation in FEV1 over time (at least 400 ml)
- substantial diurnal variation in peak expiratory flow (at least 20%)
what is actelectasis + tx
common postoperative complication in which basal alveolar collapse can lead to respiratory difficulty. It is caused when airways become obstructed by bronchial secretions.
it should be suspected in the presentation of dyspnoea and hypoxaemia around 72 hours postoperatively
positioning the patient upright
chest physiotherapy: breathing exercises
sarcoidosis: most patients __________ without treatment
get better
A negative result on spirometry (not showing bronchodilator reversibility) ___________
does not exclude asthma, do FeNO testing
benign ovarian tumour + ascites + pleural effusion =
Meig’s syndrome
asbestosis:
- typically affects ______ zones
- ________ is the most dangerous form
- severity is linked to _______
- _______ may develop following minimal exposure
- pleural plaques are ________
- typically affects lower zones
- blue (crocidolite) is the most dangerous form
- severity is linked to length of exposure
- mesothelioma may develop following minimal exposure
- pleural plaques are benign
_________ can be used to guide whether patients with acute bronchitis require abx
CRP level (doxycycline)
dry cough for 3-4 days which becomes productive, then resolved within 3 weeks, sore throat, wheeze, rhinorrhoea - Dx?
acute bronchitis
prior to discharge following an acute asthma attack PEF should be _______
> 75% of best/predicted
CT chest shows intralobular, small, rounded and branching opacities; thickened interlobular septa, pleural plaques - Dx?
asbestosis lung disease
pleural effusion - after confirmed on PA CXR, what is the next step?
pleural aspiration with US guidance
lung abscess is not improving with IV abx - what is the next step?
percutaneous drainage
(abx may not be able to penetrate the walls of the abscess)
causes of respiratory alkalosis
- anxiety –> hyperventilation
- PE
- salicylate poisoning
- CNS disorders: stroke, SAH, encephalitis
- altitude
- pregnancy
abx given as prophylaxis in COPD pts?what is the criteria for prophylactic abx?
azithromycin
pt no longer smokes, has tried rehab, has 4 or more acute exacerbations in the past year
what is associated with poor prognosis in CAP?
urea >7
Allergic bronchopulmonary aspergillosis (ABPA): 1st and 2nd line Tx
1st: oral glucorticoids (prednisolone)
2nd: itraconazole
asthma, blood eosinophilia, nasal polyps, cough and wheeze, pulmonary infiltrates - Dx?
Churg-Strauss syndrome - pANCA +ve
Alpha-1 antitrypsin deficiency is a risk factor (hint: yellowing eyes)
hepatocellular carcinoma
________ can be an indicator of lung cancer (blood tests)
Raised platelets
In acute asthma, the BTS guidelines recommend ABGs for patients with ______________
oxygen sats < 92%
Painful shin rash + cough →
sarcoidosis
In patients with severe acute respiratory distress syndrome (ARDS) who are receiving mechanical ventilation,__________ has been demonstrated to improve oxygenation and decrease mortality rates
prone positioning
ground glass appearance on CXR - what is it? what drug can cause it?
lower zone lung fibrosis
amiodarone
Bronchiectasis: most common organism =
Haemophilus influenzae
COPD stages by severity
use FEV1 to compare
1: >80
2: 50-79
3: 30-49
4: <30
sarcoidosis: ____ is raised
serum calcium
__________ in COPD can mimic pneumothorax
emphysematous bullae (air spaces in the lung measuring >1cm in diameter when distended)
Investigating suspected PE: if the CTPA is negative then consider a _________
proximal leg vein ultrasound scan if DVT is suspected
Empyema: Turbid effusion with pH _______, ______ glucose, ______LDH
<7.2
low glucose
high LDH
Mining occupation, upper zone fibrosis, egg-shell calcification of hilar nodes → ?
silicosis
severe inflammation of the inner lining of the large intestine, most commonly caused by c diff - what is this called? how does it present on sigmoidoscopy?
pseudomembranous colitis
yellow plaques on the intraluminal wall of the colon
Patients diagnosed with pneumonia who have COPD should be given ________ even if no evidence of the COPD being exacerbated
corticosteroids
pleural plaques identified - what do you do?
nothing, they are benign
Pulmonary embolism and renal impairment → Ix of choice?
V/Q scan
what are the oxugen saturations target for a COPD patient?
88-92%
Once COPD on 100% high-flow oxygen and his sats improve, what do yo switch the oxygen to? (if blood gases show that theyre a CO2 retainer)
a 28% Venturi mask at 4 l/min and aim for an oxygen saturation of 88-92%
A 55-year-old man presents with progressive weakness and dyspnoea and a full examination is performed. Massive hepatomegaly is detected and on further investigation, his renal function is reduced with heavy proteinuria however his liver function tests appear to be normal. He is a type 2 diabetic and was just this year diagnosed with chronic obstructive pulmonary disease (COPD). There is no ongoing family history of any conditions.
Dx?
amyloidosis (esp bc of the breathlessness + hepatosplenomegaly)
Alpha 1-antitrypsin deficiency - will it cause proteinurea?
no
How do you Dx amyloidosis?
- Congo red staining: apple-green birefringence
- serum amyloid precursor (SAP) scan
- biopsy of skin, rectal mucosa, or abdominal fat
an air-fluid level is typically seen in
Lung abscess
CAP with CURB-65 score of 0 - Mx?
send home with amoxicillin
when do you offer delayed abx therapy?
pneumonia or bronchitis with CRP 20-100mg/L
ABG in someone with PE will show
respiratory alkalosis due to hyperventilation
______________ causes pulmonary fibrosis predominantly affecting the lower zones
Asbestosis
DAIM for lower zone: drugs, asbestosis, idiopathic and most connective tissue except AS
CHARTS: coal-workers, histocytes, AS, radiotherapy, TB, silicosis/sarcoidisis
Strong suspicion of PE but a delay in the scan:
offer treatmen dose of rivaroxaban
Indications for corticosteroid treatment for sarcoidosis are:
Indications are PUNCH
-Parenchymal Lung Disease
- Uveitis
- Neurological involvement or
- Cardiac involvement
- HyperCa
tension vs simple pneumothorax: how to differentiate?
BP: tension will be hypo
The criteria for reversibility in the diagnosis of asthma is a ______ change in FEV1, which must also be an absolute increase in FEV1 of ____
> 12%
200ml
Pleural fluid with a protein level ____ is indicative of an exudate
> 30g/L
most common organism causing bronchiectasis
H.influenzae
Obstructive sleep apnoea can cause hypertension/hypotension?
hypertension
the patient has a negative sputum microscopy and culture, and a normal chest radiograph. However, the patient has a positive interferon-gamma release assay and a positive Mantoux test –> what does this mean
latent TB, needs Tx but cant be spread
Mycoplasma pneumoniae
Mycoplasma pneumoniae
Massive PE + hypotension - tx?
thrombolyse w alteplase, not DOAC
what e- abnormality does sarcoidosis cause?
Sarcoidosis is known to cause hypercalcaemia due to macrophages inside the granulomas causing an increased conversion of vitamin D to its active form
What are differential Dx for post-op SoB?
atelectasis, pneumonia and pulmonary embolism (PE, although this would typically be expected to occur later on)
what is atelectasis? how does it present and how do you treat it?
Atelectasis is a common postoperative complication in which basal alveolar collapse can lead to respiratory difficulty. It is caused when airways become obstructed by bronchial secretions.
Features
it should be suspected in the presentation of dyspnoea and hypoxaemia around 72 hours postoperatively
Management
positioning the patient upright
chest physiotherapy: breathing exercises
paraneoplastic features of lung cancers:
1. small cell
2. squamous cell
3. adenocarcinoma
- small cell: AD, ACTH, Lambert-Eaton syndrome
- squamous cell: PTH-rp, clubbing
- adenocarcinoma: gynaecomastia
dry cough, erythema multiforme (symmetrical target shaped rash with a central blister) and reticulo-nodular shadowing in bacterial pneumonia points to whoch organism?
mycoplasma pneumoniae
Legionella pneumophila - another atypical, lymphopenia and hyponatraemia, recent holiday (air conditioning units), diagnose with urinary antigen.
______________ may arise in a lung cavity that developed secondary to previous tuberculosis
An aspergilloma
chest x-ray containing a rounded opacity. A crescent sign may be present
___________ can cause a false negative Mantoux test
Sarcoidosis
________________ are used to treat Legionella
Macrolides such as clarithromycin
Breathing problems with clear chest, think
pulmonary embolism
meniscus sign on CXR =
Mx:
pleural effusion
Aspirate!
pleural effusion findings:
low glucose:
raised amylase:
heavy blood staining:
- rheumatoid arthritis, tuberculosis
- pancreatitis, oesophageal perforation
- mesothelioma, pulmonary embolism, tuberculosis
how does mesothelioma present?
- Hx of asbestosis exposure
- pleural opacity, reduction in lung volume or pleural effusion
Tx for acute bronchitis if Pt has co-morbidities or raised CRP?
doxycycline
__________is used to assess drug sensitivities in TB
Sputum culture
Thick and thin blood smears are thr gold standard diagnosis test for
malaria
causes of transudative pleural effusion
All Hs
- HF
- hypoalbuminaemia (liver disease, nephrotic syndrome, malabsorption)
- hypothyroidism
- Her issues (Meig’s syndrome)
bilateral fluffy opacities
pulmonary oedemas
bilateral consolidation + erythema multiforme =
gold standard Ix =
mycoplasma pneumoniae
serology
Over rapid aspiration/drainage of pneumothorax can result in _____________
re-expansion pulmonary oedema
sarcoidosis - indications to Tx w steroids?
Indications include splenic/hepatic/renal/cardiac involvement, lupus pernio, hypercalcemia, eye/CNS involvement or deteriorating pulmonary function tests or deteriorating chest x-ray changes
patient has presented following a traumatic accident with respiratory distress, hypotension, jugular venous distension, and absent lung sounds –>
What cardiac complication can this cause?
tension pneumothorax
PEA, reversible
criteria for asthma discharge
- stable on discharge meds for 12-24h
- inhaler technique checked and recorded
- PEF >75% best or predicted
Dx extrinsic allergic alveolitis
- imaging: upper/mid-zone fibrosis
- bronchoalveolar lavage: lymphocytisius
- IgG serology
- NO eosinophilia
Tx with glucocorticoids
Tx for Wegner’s?
steroids
cyclophosphamide
plasma exchange
Aspergilloma Px
- Often past history of tuberculosis.
- Haemoptysis may be severe
- Chest x-ray shows rounded opacity
klebsiella pneumonia commonly causes ____________ and typically follows ___________
lung abscess formation and empyema
aspiration
A ____________may be noted on bloods in lung cancer
thrombocytosis
cavitating lesions are most common in which type of lung cancer
squamous
Other characteristic pleural fluid findings:
- low glucose:
- raised amylase:
- heavy blood staining:
- low glucose: rheumatoid arthritis, tuberculosis
- raised amylase: pancreatitis, oesophageal perforation
- heavy blood staining: mesothelioma, pulmonary embolism, tuberculosis
Tx for pleural effusions (recurrent)
- recurrent aspiration
- pleurodesis
- indwelling pleural catheter
- drug management to alleviate symptoms e.g. opioids to relieve dyspnoea
All cases of pneumonia should have a
repeat chest X-ray at 6 weeks
diagnostic test for pancoast tumour
CT chest
Mnemonic: assessing for LTOT - The 4 Bs
Blue (cyanosis, sp02 <92%)
Breathing (severe airway obstruction, FEV1 <30%)
Blood (secondary polycythaemia)
Ballooning (peripheral oedema, raised JVP, hepatomegaly)
TLCO in pulmonary fibrosis?
reduced
Pneumothorax: persistent air leak or recurrent episodes →
consider referral for VATS to allow for mechanical/chemical pleurodesis +/- bullectomy
