Resp Flashcards
FEV1 definition?
forced expiratory vol in 1 sec
an increase of ? or more in ? 10-20 mins after inhalation of short-acting B2 agonist is compatible with diagnosis of asthma
increase of 15% or more in FEV1
name 2 interstitial lung diseases
asbestosis, silicosis etc drug induced hypersensitivity pneumonitis TB, viral, fungi GORD sarcoid RA, SLE, SS, UC idiopathoic pulm fib
kyphoscoliosis
deformity of the spine
curvature in sagittal AND coronal plane
describe FEV1 and FVC in obstructive lung disease
FEV1/FVC less than 80%
describe FEV1 and FVC in restrictive lung disease
FEV1/FVC >80%
lung volume reduced, most air blown out in 1st second as airways not narrowed
2 conditions under umbrella term of COPD
chronic bronchitis
emphysema
bronchiectasis - most obstructive or restrictive?
mostly obstructive but can get some restrictive scarring
describe bronchiectasis
dilated bronchi w/ pool secretions
copious purulent sputum
3 atopic conditions
hay fever
asthma
eczema
major complications of bronchoscopy
pneumonia
pneumothorax
heamorrhage
stridor definition
harsh vibrating noise when breathing, caused by obstruction of windpipe or larynx
presentation of PE
breathlessness/haemoptysis
pleuritic chest pain
acute massive: v. sudden circulatory collapse, life-threatening emergency
describe pleuritic chest pain
hurts when patients breathes in or coughs
pain from pleura due to infarct
causes of acute breathlessness
asthma
pneumonia
PE
pneumothorax
How many lobes in L and R lungs?
left lung 2
right lung 3
normal areas to show up on PET scan
heart
kidneys
bladder
what is the CURB-65 score?
scoring system in community acquired pneumonia - home Abx/ hospital Abx/ mortality
what are the 5 criteria of CURB-65 score?
confusion urea >7 resp rate >30 BP >90/60 age >65
RA & the lungs - complications with immunosuppression?
PCP
TB reactivation with anti-TNF
lung problems caused by RA
pleural effusions fibrosing alveolitis bronchiectasis obliterative bronchiolitis methotrexate > lung fibrosis immunosuppression > TB/PCP
Guillain–Barré syndrome definition
acute neuropathy
usually inflammatory demyelinating
often preceded by resp infection [CMV, EBV]
limb weakness, resp failure
ABPA [allergic bronchopulmonary aspergillosis] definition
hypersensitivity/exaggerated immune response to aspergillus fungus
[often asthma/ CF patients]
what is goodpastures’s syndrome?
antibodies to type 4 collagens in basement membrane of lung & kidney after some viral infections
myaesthenia gravis
autoimmune
muscle weakness without atrophy
defect in ACh at neuromuscular jn.s
how do diffuse parenchymal lung diseases present?
SOB on exertion
persistent non-productive cough
how does sarcoidosis present & appear on CXR
skin or eye lesions
coughing/SOB
bilateral hilar lymphadenopathy &/or pulmonary infiltrations
treatment of sarcoidosis
[just hilar lymphadenopathy > no Tx]
prednisolone
steroid sparing/long-term: methotrexate/azathioprine/cyclophosphamide
treatment for wegener’s granulomatosis
remission with corticosteroids and cyclophosphamide
[plasmapheresis]
2nd line: rituximab
treatment for microscopic polyangiitis
corticosteroids
immunosuppressive drugs: azathioprine, cyclophosphamide
treatment for churg-strauss syndrome
corticosteroids
immunosuppressive drugs: azathioprine, cyclophosphamide
microscopic polyangiitis causes what in relation to the kidney?
haematuria
proteinuria
renal failure
2 main organs affected by microscopic polyangiitis
lungs
kidneys
3 main areas affected by wegener’s granulomatosis lesions
lungs
kidneys
upper resp tract
diagnosis of microscopic polyangiitis
renal biopsy
serum pANCA
cANCA is associated with which disease?
wegener’s
pANCA is associated with which diseases?
microscopic polyangiitis
churg-strauss
IBD
what 3 things make up the triad of Churg-Strauss syndrome?
eosinophilia
asthma
systemic vasculitis [peripheral nerves & skin]
which infections may trigger Guillain-Barre syndrome?
campylobacter jejuni
EBV
CMV
Management of Guillain-Barre syndrome
IV immunoglobulin [reduce paralysis duration & severity]
heparin [reduce thrombosis risk]
physio [prevent contracture]
diagnosis of Guillain-Barre syndrome
clinical features
nerve conduction studies [slow motor conduction]
mciroorganism that causes PCP
pneumocystis jirovecii
individuals susceptible to PCP [opportunistic infection]
on immunosuppressive drugs
HIV
cancer
organ transplant
scoring system for PE/ DVT
Wells
frothy white-pink sputum indicates what ?
pulmonary oedema
commonest organism to cause CAP & one other typical
strep pneumoniae
haemophilus influenzae
individuals/ conditions at risk of aspirating
stroke M gravis bulbar palsy post ictal intoxicated reflux/ achalasia poor dental hygiene
give 4 symptoms of pneumonia
SOB pleuritic chest pain fever/rigors cough w/sputum malaise anorexia haemoptysis
give 4 clinical signs of pneumonia
pyrexia ^RR dull chest percussion creps / pleural rub / bronchial breathing tachycardia hypoTN confusion cyanosis
how will the curb65 score affect how you give your Abx?
0-1 home Tx, PO unless vomiting
2 hospital, PO unless vomiting
>2 IV
3 = severe - consider ITU
Mx of pneumonia
ABx O2 VTE prophylaxis IV fluids [analgesia if pleurisy]
complications of pneumonia
pleural effusion empyema [in pleura] abscess [in lung] resp failure sepsis brain abscess pericarditis myocarditis cholestatic jaundice
Abxs for severe pneumonia (curb65>3) e.g.
co-amox + clarithromycin
OR e.g. cefuroxime + clarith
IV
Abxs for aspiration pneumonia
IV cephalosporin e.g. cefuroxime
+ metronidazole
at risk groups who should have a pneumococcal vaccine
imm comp - AIDS, chemo, steroids
DM [non- diet controlled]
>65
liver/ heart/ renal/ lung chronic disease
commenest patient groups for pneumonia
elderly post splenectomy alcoholics immunosuppressed HF lung disease
Mx of type 1 resp failure as a complication of pneumonia
high flow O2 60%
ABGs
consider ITU if hypoxia not improving with O2 or PaCO2 >6
aim for sats 94-98%
pneumonia can lead to AF in the elderly. Usually resolves with Tx of the pneumonia. What drugs may be needed to slow the ventricular response rate in the short term
BB, digoxin
walled cavity and fluid level seen on xray.
cough, fever, foul smelling purulent sputum.
diagnosis?
lung abscess
describe the pathology of bronchiectasis
chronic inflammation of bronchi + bronchioles leads to dilatation
causes of bronchiectasis
CF post infection [bronchiolitis, pneumonia, measles] RA UC bronchial tumour/ foreign body
Sx of bronchiectasis
+ signs
cough
^^^ purulent sputum
haemoptysis
clubbing
inspiratory creps, wheeze
name 3 complications of bronchiectasis
pneumonia pleural effusion pneumothorax haemoptysis cerebral abscess amyloidosis
CXR findings in bronchiectasis
thickened bronchial walls [tramline/ring shadows]
cystic shadows
give 4 Ix in bronchiectasis
sputum CXR spirometry [obstructive] high res CT bronchoscopy CF sweat test
Mx of bronchiectasis
chest physio/ airway clearance
ABx [based on sensitivities]
bronchodilators [neb salb]
genetic cause of CF
auto rec mutation of CFTR gene on chromosome 7 a Cl- channel. Leads to ^Cl- secretion + Na+ absorption across airway epithelium. Leads to bronchiectasis.
how is CF diagnosed?
newborn screening
sweat test- Na + Cl
common genetic mutations screen
faecal elastase
list 4 complications on CF
meconium ileus pancreatic insuff steattorhoea pancreatitis [acute/chron] DM infective exac haemop resp failure male infertility nasal polyps clubbing
Tx of CF
fat soluble vitamins panc enzyme replacement chest physio bronchodilators mucolytic nebs Abx lung transplant [new mutation specific therapies]
small cell lung cancers arise from what type of cells
endocrine (Kulchitsky)
of small and non-small cell lung cancers, which is the commoner and which is often disseminated at presentation/ worse porgnosis
NSCLC more common (80%)
SCLC often disseminated at presentation
name 4 Sx of lung cancer
cough haemoptysis SOB weight loss chest pain recurrent/not resolving pneumonia lethargy anorexia back pain
name 3 examination findings in lung CA
supraclavicular/axillary lymph node enlargement
cachexia
CHEST: none/ consolidation/ effusion/ collapse
METS: hepatomeg/ bone tenderness/ confusion/ fits
CXR findings in Lung CA
peripheral nodule consolidation hilar enlargement pleural effusion bony involvement collapse
list 4 local and 4 systemic/metastatic complications of Carcinoma of bronchus
LOCAL: recurrent laryngeal nerve palsy phrenic nerve palsy SVC obstruction horners syndrome rib erosion pericarditis AF
mets: brain, bone, liver, adrenals hypercalcaemia cushings anaemia neuro: myopathy, neuropathy, cerebellar degeneration
describe the difference between type 1 and type 2 resp failure
type 1 = low O2, normal CO2
type 2 = low O2 and high CO2
why do you aim for lower O2 targets in type 2 resp failure
if you give them lots of O2, then the CO2 keeps rising which just worsens the resp acidosis
what non invasive ventilation do you use in type 1 and type 2 resp failure
type 1 - CPAP
type 2 - bipap [need to draw out CO2 as well as driving O2 in]
what Ix might you consider in lung CA
CXR pleural fluid aspiration + cytology sputum cytology biopsy [lymph node/ bronchoscopy/ peripheral] CT/PET [staging] lung fn test bone scan [mets]
clinical features of mesothelioma
SOB chest pain weight loss clubbing pleural effusion [mets - lymphadenopathy, hepatomeg, bone pain]
differentials of lung nodule on CXR
malignancy - prim/mets infection granuloma abscess arterio-venous malformation carcinoid tumour cyst foreign body skin tumour e.g. seb wart
non metastatic extrapulm manifestations of bronchial CA - endocrine
ectopic secretion of hormones by the tumour: cushings (ACTH) dilutional hyponatraemia (ADH) hypercalcaemia (PTH) gynaecomastia (HCG)
non metastatic extrapulm manifestations of bronchial CA - neuro
cerebellar degeneration
myopathy
polyneuropathy
myasthenic syndrome
non metastatic extrapulm manifestations of bronchial CA - vascular/ haem
thrombophlebitis migrans
anaemia
DIC
Mx of NSCLC
lobectomy
radiotherapy
+ chemo for more advanced
cetuximab
what manifestations/ complications of palliative SCLC might be helped by palliative radiotherapy?
SVC obstruction haemoptysis bronchial obstruction bone pain cerebral mets
give 5 aspects of SCLC Mx
surgery in less advanced chemo + radio if well enough palliative care SVC stent tracheal stent dexamethasone pleural drainage analgesia antiemetics bronchodilators antidepressants
what is allergic bronchopulmonary aspergillosis
type 1 + 3 hypersens rn. to aspergillus fumigatus. affects asthmatics and CF. Caused constriction then bronchiectasis
Mx of allergic bronchopulmonary aspergillosis
pred
bronchodilators for asthma
itraconazole
bronchoscopic aspiration of mucus plugs
difference between asthma and copd
asthma is reversible
asthma Sx
SOB wheeze chest tightness cough [often nocturnal] sputum precipitants e.g. exercise /allergens
asthma precipitants
cold air exercise emotion allergens [house dust mite, pollen, fur] infection smoking/passive pollution NSAIDs BBs
what time of day is it commoner for asthmatics to have worse peak flow
morning
examination findings/signs in asthma
^RR wheeze [audible + auscult] hyperinfated chest ^resonance on percussion reduced air entry
signs that indicate a life threatening asthma attack
silent chest confusion cyanosis exhaustion bradycardia
clinical features that increase probability of asthma
wheeze chest tightness SOB diurnal precipitants:exercise, cold, allergens aspirin/BB induced Hx of atopy FH of asthma/atopy wheeze on auscult low peak flow eosinophilia
Ix in asthma
peak flow/ spirom CXR sputum culture FBC/U&E/CRP cultures ABG
what might an ABG show in asthma attack
normal or low O2 + low CO2 [hypervent]
a normal or raised CO2 indicates failing resp effort > HDU/ITU
differentials of asthma
obstruction [foreign body/ CA] pneumothorax LRTI COPD pulm oedema ["cardiac asthma"] SVC obstruction PE bronchiectasis obliterative bronchiolitis
lifestyle Mx of asthma
weight loss
stop smoking
avoid allergens
Mx of chronic asthma, stepwise
- salbutamol inhaler PRN
- beclometasone inhaler od
- salmeterol inhaler BD / ^beclo dose
try montelukast (LRA), oral theophylline - ^steroid, oral theoph, oral B2 ag, oral monte
- PO pred od
in asthma, when would you move from PRN salb to step 2 (inhaled steroid)?
used more than od
night time Sx
side effects of B2 agonists [salbutamol]
tachyarrhythmias hypokalaemia tremor anxiety [long acting - paradoxical bronchospasm]
mouth should be rinsed after using inhaled steroids for asthma. Why?
prevent oral candidiasis
aminophylline, metabolised to theophylline, has a narrow therapeutic ratio. What SEs?
arrhythmia GI upset fits anxiety tremor
if IV aminophylline is used in acute asthma, what Ix should you do after administration [bearing in mind its narrow therapeutic ratio]
ECG
theophylline levels
COPD Sx
cough
sputum
SOB
wheeze
signs in COPD
wheeze ^RR accessory muscles hyperinflation reduced expansion resonant/hyperres cyanosis quiet breath sounds
complications of COPD
infective exacerbation polycythaemia resp failure cor pulmonale [oedema] pneumothorax carcinoma
Ix in COPD
FBC [^haematocrit] CXR CT ECG [R hypetrophy] ABG [low O2 +/- ^CO2] spirom
CXR signs in COPD
hyperinflation flat hemidiaphragms large central pulm arteries reduced peripheral vascular markings bullae
Mx of chronic stable COPD
SABA/SAMA [ipratropium] LABA LAMA ICS home O2 CPAP/BIPAP
SMOKING CESSATION
flu + pneumococcal vaccines
what happens to the lungs in acute resp distress syndrome
^cap permeability > oedema
pulmonary causes of ARDS
pneumonia aspiration inhalation vasculitis injury/contusion
non-pulmonary causes of ARDS
sepsis/shock/haemorrhage/DIC multiple transfusions pancreatitis ALF trauma head injury burns eclampsia drugs [aspirin/heroin]
clinical features of ARDS
^RR
cyanosis
tachycardia
crackles
Ix for ARDS
CXR FBC, U+E, clotting, amylase, CRP, LFT cultures ABG sputum pulm artery catheter [cap wedge pressure]
diagnostic criteria for ARDS
- acute onset
- CXR - bilateral infiltrates
- refactory hypoxaemia
what is pulmonary capillary wedge pressure?
estimate of LA pressure
measured by placing balloon catheter in pulm. artery
Mx of ARDS
admit ITU treat cause e.g. sepsis O2, CPAP intubate + ventilate inotropes [dobutamine] vasodilators blood transfusion
what is pneumoconiosis
industrial lung disease ass. with dust e.g. coal miners
give signs / Sx of hypoxia
SOB restlessness agitation confusion central cyanosis
give 4 signs/sx of hypercapnia
headache peripheral vasodilatation tachycardia bounding pulse tremor/flap papilloedema confusion drowsy coma
Ix in respiratory failure
ABG CXR FBC, U+E, CRP sputum cultures spirometry
where do PEs usually arise from?
a venous thrombosis in the pelvis or legs
risk factors for PE
recent surgery (especially abdo/pelvic, hip/knee replacement) thrombophilia e.g. antiphospholipid syndrome leg fracture prolonged bed rest / reduced mobility malignancy pregnancy/post partum COCP, HRT previous PE
PE Sx
SOB
pleuritic CP
haemoptysis
dizzy, syncope
PE signs
tachypnoea pyrexia cyanosis pleural rub tachycardia hypoTN ^JVP pleural effusion [DVT- red hot swollen leg]
Ix in PE
FBC, U+E, clotting, D-dimer ABG [low O2, low CO2] CXR CTPA ECG
CXR findings in PE
may be normal oligaemia of affected segment dilated pulmonary artery linear atelectasis small pleural effusion wedge shaped opacity/ cavitation [rare]
ECG findings in PE
may be normal tachycardia RBBB RV strain [R axis deviation, dominant R wave, inverted T wave or ST depression V1-V4] (rarely SIQIIITIII)
PE Mx
O2 morphine + antiemetic LWWH/ fondaparinux fluid bolus if low BP vasopressors e.g. dobutamine/noradrenaline thrombolysis [alteplase] long term anticoag [noac] VC filter
what ix.s might you carry out in a Pt with an unprovoked PE [unknown cause]
?malignancy - breast exam and mammography,
CXR
FBC, Ca2+, LFTs
urinalysis
abdo-pelvic CT
antiphospholipid + thrombophilia testing if FH +ve
name 5 causes of pneumothorax
spontaneous [young thin men] asthma, COPD TB pneumonia lung abscess carcinoma CF lung fibrosis sarcoidosis marfans/EDS trauma iatrogenic [biopsy/line] ventilation
presentation of pneumothorax
may be asymptomatic
sudden onset SOB, pleuritic CP
asthma/COPD sudden deterioration
hypoxia
examination findings in pneumothorax
^resonance [percussion]
reduced air entry/ breath sounds
reduced expansion
tracheal deviation in tension
Mx pneumothorax
aspiration
chest drain
O2 in secondary
what is the difference between transudate and exudate pleural effusions?
protein concentration
transudate less, exudate more protein
what do you call a) pus in the pleural space. b)blood in the pleural space. c) blood and air in the pleural space ?
a) empyema
b) haemothorax
c) haemopneumothorax
causes of transudate pleural effusion
^ venous pressure: [HF, constrictive pericarditis, fluid overload]
low blood protein: [nephrotic syndrome, cirrhosis, malabsorption]
hypothyroidism
causes of an exudate pleural effusion
pneumonia, TB
pulmonary infarction
RA, SLE
bronchogenic carcinoma, mets, lymphoma, mesothelioma
Sx of pleural effusion
asymptomatic or
dyspnoea, pleuritic CP
exam findings in pleural effusion
reduced expansion stony dull to percussion diminished breath sounds may be bronchial breathing above effusion large > tracheal deviation
Ix in pleural effusion
CXR
US
aspiration
pleural biopsy
CXR findings in pleural effusion
blunting of costophrenic angles
larger > water-dense shadows with cancave upper border
Mx of pleural effusion
drainage
pleurodesis [with talc]
surgery
treat the cause
define obstructive sleep apnoea
intermittent closure/collapse of pharyngeal airway causing apnoeic episodes during sleep terminated by partial arousal
presentation of ob. sleep apnoea
falling asleep during the day loud snoring poor sleep quality morning headache reduced libido nocturia reduced cognitive performance
complications of obstructive sleep apnoea
pulm HTN
type 2 resp failure
HTN
investigations in obstructive sleep apnoea
video recording
pulse ox
polysomnograph [during sleep: O2, airflow, ECG, abdo wall movement, EMG chest]
sleep apnoea Mx
weight loss stop smoking + alcohol mandibular advancement device CPAP surgery [polyectomy/tonsillectomy] rarely
causes of cor pulmonale [name 4]
COPD, bronchiectais, pulm fibrosis, asthma, resection
PE, vasculitis, pulm HTN, ARDS
myasthenia gravis, MND, stroke
kyphosis, scoliosis
sleep apnoea
most common age range, gender and ethnicity affected by sarcoidosis
20-40
female
african-caribbean
clinical features of sarcoidosis.
Name 2 for acute sarcoidosis, 2 for pulmonary, 5 non-pulmonary.
acute: fever, erythema nodosum, hilar lymphadenopathy,polyarthralgia
pulm: SOB, dry cough, CP
non-pulm: lymphadenopathy hepatosplenomeg uveitis/conjunctivitis/glaucoma terminal phalynx bone cysts bells palsy/neuropathy/mengingitis/space-occ lesion erythema nodosum renal stones hypercalcaemia arrhythmia/cardiomyopathy
bloods findings in sarcoidosis
^ESR lymphopenia ^LFTs ^ACE ^Ca2+ ^imm.glob.s
what findings in 24 hours urine in sarcoidosis
^ urine ca2+
CXR findings in sarcoidosis
bilat. hilar lymphadenopathy infiltrates fibrosis bulla pleural
Ix in sarcoidosis
CXR ECG lung Fn tests bloods: ESR, FBC, LFT, Ca2+, imm.globs tissue biopsy bronchoalveolar lavage transbronchial biopsy UA bone xray CT/MRI
results found on tissue biopsy in sarcoidosis [lung/liver/lymph node/skin nodule]
non-caseating granulomata
Mx of sarcoidosis
acute: bed rest, nsaids
pred 4-6 weeks
severe: IV methylpred/ methotrex/ hydroxychloroquine/ciclosporin/ cyclophosphamide
anti TNFa
lung transplant
name 4 differentials for graulomatous disease
TB, leprosy, syphilis sarcoidosis fungi [cryptococcus] primary biliary cholangitis extrinsic allergic alveolitis vasculitis: GCA, polyarteritis nodosa, wegeners] crohns silicosis
differentials of bilateral hilar lymphadenopathy on CXR
sarcoidosis TB, mycoplasma lymphoma pneumoconiosis mets mediastinal tumour
Sx of interstitial lung disease
+ spirometry picture
dry cough
SOB
restrictive
name 3 causes of intersitial lung disease
occupational: asbestos, silica
drugs: nitrofurantoin, amiodarone
hypersensitivity rn [pneumonitis]
infection: TB, fungi, viral
GORD
idiopathic pulmonary fibrosis
give some systemic disorders which cause, or are associated with, interstitial lung disease
RA, SLE, systemic sclerosis, sjogrens sarcoidosis UC renal tubular acidosis autoimmune thyroid disease
Mx of extrinsic allergic alveolitis
remove allergen
give o2
PO pred
differentials for upper zone fibrotic shadowing on CXR
TB hypersensitivity pneumonitis ank spond radiotherapy progressive massive fibrosis
Sx of idiopathic pulmonary fibrosis
dry cough SOB malaise weight loss arthralgia
signs of idiopathic pulm. fibrosis
cyanosis
fine end-resp creps
clubbing
complications of idiopathic pulm. fibrosis
resp faulire
^risk of lung CA
Ix for idiopathic pulm. fibrosis
ABG CRP imm glob ANA, Rh. factor CXR, CT spirom bronchoalveolar lavage lung biopsy
Mx of idiopathic pulm. fibrosis
O2 pulmonary rehab opiates palliative lung transplant
Differentials for bilateral hilar lymphadenopathy
Lymphoma (primarily hodgkins)
Sarcoidosis
Silicosis
TB
metabolic disturbace caused by aspirin od
resp alkalosis [hyperventilaiton]
can APTT be used to monitor unfractionated heparins and LMWH
yes for unfractionated because its intrinsic, not for LMWH which act on factor Xa
causes of COPD other than smoking
industrial exposures e.g. coal dust, grain/flour, silica
alpha-1-antitrypsin deficiency
