Resp Flashcards
What can cause upper zone lung fibrosis
TB extrinsic allergic alveolitis sarcoidosis silicosis ank spond
What can cause lower zone lung fibrosis
IPF
drugs
asbestosis
What drugs can cause lower zone lung fibrosis
amiodarone
methotrexate
bleomycin
nitrofurantoin
What is idiopathic pulmonary fibrosis
progressive fibrosis of the interstitial alveolar tissue
excessive collagen deposition
no known cause
Who is IPF most common in
men aged 50-70
smokers
What are the symptoms of IPF
dry cough
SOB
What are the signs of IPF
fine end-inspiratory bibasal crackles
clubbing
How should a patient with suspected IPF be investigated?
Bedside Bloods: ABG, ANA, CRP Micro: Imaging: CXR, HRCT, Special tests: spirometry, TLCO
What are the common findings on CXR in IPF
reticular shadowing
small, irregular, peripheral opacities - ground-glass
decreased lung volume
honeycombing
What are the common findings on HRCT in IPF
reticular opacities
honeycombing
essential for diagnosis!
What are the common findings on spirometry in IPF
reduced FVC
reduced FEV1
FEV1/FVC normal/increased
What What are the common findings on TLCO in spirometry
reduced transfer factor
impaired gas exchange
What is the management of IPF
pulmonary rehabilitation
oxygen
clinical trial
lung transplant
What is the prognosis in IPF
50% 5 year survival rate
What investigations should be carried out in suspected COPD
Bedside: BMI, ECG Bloods: FBC, Micro Imaging: CXR Special tests: post bronchodilator spirometry
State the MRC Dyspnoea Scale grades
1 = not breathless 2 = breathless on walking up hill 3 = walks slowly 4 = breathless after 100 metres/ few mins 5 = unable to leave house
How are the stages of COPD defines
perventage predicted of FEV1
State the stages of COPD defined by the FEV1
>80% = mild 50-79% = moderate 30-49% = severe <30% = very severe
What are the signs of COPD on CXR
increased lung volume
flattened diaphragm
bullae
Describe the steps in the pharmacological management of stable COPD
- LABA/LAMA
- if FEV1 >50% = LABA/LAMA
if FEV1 <50% = LABA+ICS/LAMA - if LABA -> LABA+ICS
if LAMA -> LABA+ICS + LAMA
What general measures are involved in the management of COPD
pulmonary rehabilitation
stop smoking
influenza vaccine
pneumococcal vaccine
What bacteria are most commonly present in acute exacerbation of COPD
Haemophilus influenzae
Streptococcus pneumoniae
Moraxella catarrhalis
Descrebe the steps in management of an acute exacerbation of COPD
admit nebulised salbutamol and ipatropium oxygen - if known hypercapnic, 28% venturi(white) at 4l IV hydrocortisone and oral presnisolone Abx if sputum purulent - doxycycline
What is the rationale behind LTOT in COPD
maintaining PaO2 >8kPa for >15hours per day increases the 3yr survival rate by 50%
What are the criteria for LTOT in COPD
PaO2 <7.3 on two separate occasions greater then 3 weeks apart
PaO2 7.3-8 + evidence of pulmonary hypertension, polycythaemia, peripheral oedema, nocturnal hypoxia on two separate occasions greater then 3 weeks apart
Which patients with COPD should be assessed for LTOT
very severe airflow obstruction (FEV1 < 30% predicted), ‘considered’ for patients with severe airflow obstruction (FEV1 30-49% predicted)
cyanosis
polycythaemia
peripheral oedema
raised JVP
oxygen saturations less than or equal to 92% on room air
What are the diagnostic criteria should be used when assessing a patient with suspected COPD?
FEV1/FVC <70%
symptoms!
What is the difference between a primary and secondary pneumothrax?
primary = no underlying disease secondary = occurs in presence of underlying disease`
What is the difference between a pneumothorax and a tension pneumothorax?
tension = trachea deviated away from affected side.
Air cannot leave pleural cavity during expirations due to valve like flap in parietal pleura.
What tests should be done in suspected pneumothorax?
ABG
CXR
What is the management of a primary pneumothorax?
> 2cm or breathless = aspiration.
successful (<2cm)
= discharge, r/v OPD in 2-4wks
unsuccessful = admit, chest drain
<2cm, not breathless
= discharge, OPD in 2-4wks
What is the management of a secondary pneumothorax?
> 2cm, breathless
= chest drain
1-2cm
= aspirate.
success (<1cm) = admit, oxygen, observe 24h
unsuccessful = chest drain
<1cm = admit, oxygen, observe 24h
How do you aspirate a pneumothorax
14-16G cannula
2nd ICS in midclavicular line (superior to 3rd rib)
remove needle
connect cannula to 3 way tap and 50ml syringe
aspirate!
CXR to confirm resolution
What are the signs of a working chest drain?
swinging
bubbling
water bottle below patient!
What is the bacterium involved in TB
Mycobacterium tuberculosis
What are the characteristics of the Mycobacterium tuberculosis
aerobe
rod shaped
waxy - acid fast
Describe how the ghon focus forms in TB
Macrophages phagocytose bacteria Tb can inhibit phagosome and lysosome fusing TB proliferates granuloma forms caseous necrosis
What are the cells in a granuloma
epitheloid histiocytes
What is a Ghon complex
ghon focus plus hilar lymph node involvement
What is a Ranke complex
fibrosis and calcification of Ghon complex
What can cause dormant TB to become reactivated
steroids HIV malnutrition chronic renal failure solid organ transplantation with immunosuppression IVDU haematological malignancy anti-TNF treatment
Where is TB often located in the lungs?
upper lobes
Where can TB spread to?
brain - meningitis kidneys - sterile pyuria spine - Pott's adrenal - addison's liver - hepatitis
What investigations should be done in suspected TB
sputum cultures - 3x
CXR
What are the features of TB on CXR
hilar lymphadenopathy consolidation in upper lobes Ghon focus upper zone fibrosis pleural effusion in primary
What is the treatment for active TB
Rifampicin
Isoniazid
Pyramidazole
Ethambutol
R+I for 6m, P+E for first 2 months
What is the treatment for latent TB
Rifampicin and Isoniazid for 3m
Isoniazid for 6m
What are the side effects of rifampicin
hepatitis, orange secretions
What are the side effects of isoniazid
peripheral neuropathy
hepatitis,
agranulocytosis
What are the side effects of pyrazinamide
hyperuricaemia causing gout
arthralgia,
myalgia
hepatitis
What are the side effects of ethambutol
optic neuritis
What tests do you need to do before initiating treatment of TB
LFTs
visual acuity
FBC
What is the difference between acute bronchitis and pneumonia?
acute bronchitis is a transient inflammation of the trachea and major bronchi associated with oedema and mucus production
pneumonia is an acute infection of the lung parenchyma
State the most common causes of CAP
Streptococcus pneumoniae
Haemophilus influenzae
Staphylococcus aureus
What are some atypical causes of CAP
Mycoplasma pneumoniae
Klebsiella pneumoniae
Legionella pneumophilia
Pneumocystis jiroveci
What are the common features of pneumonia causes by Streptococcus pneumoniae
fever
rapid onset
pleuritic chest pain
cold sores!
Which group of people is Klebsiella pneumoniae most common in?
alcoholics
Which bacterial cause of pneumonia often follows influenza?
staph aureus
What chsnegs are often seen in teh blood results of a patient with Legionella pneumophilia?
lymphopaenia
hyponatraemia
deranged LFTs
What are the classical features of Pneumocystis jiroveci
HIV positive
dry cough
no chest signs
desaturate on exercise
What are the most common causes of HAP
gram negative enterobacteria
staph aureus
Moraxella catarrhalis
What are the most common causes of pneumonia in an immunocompromised patient?
Strep pneumoniae Haemophilus influenzae Staph aureus Moraxella catarrhalis Mycoplasma pneumoniae Pneumocystis jiroveci CMV HSV
What investigations are carried out in suspected pneumonia?
urine testing for pneumococcal antigen
FBC, U+E, LFTs, CRP
blood cultures, sputum cultures
CXR
What is the immediate management of a patient with penumonia
O2 if desaturated
IV fluids if dehydrated
analgesia for pleuritic pain
antibiotics!
What are the values used for CURB-65
Confusion Urea >7 RR >30 BP <90/60 >65
How does management change depending on the CURB-65 score?
<=1 manage at home
>=2 admission to hospital
>=3 consider ITU/HDU
What is antibiotic treatment for mild/moderate pneumonia
amoxicillin 500mg-1g/8h oral for 5 days
What is antibiotic treatment for severe pneumonia
7-10days of co-amoxicav 1.2g/8g IV + clarithromycin 500mg/12h IV
What is antibiotic treatment for hospital acquired pneumonia
gentamicin plus ceftriaxone
What is the most common cause of PE
DVT
What are the most common signs of PE
increased RR
increased HR
crackles on auscultation
pyrexia
What investigations should be carried out in suspected PE
Well’s score
ECG
FBC, U+E, clotting, ABG
CXR to exclude other diagnoses
State how to calculate the PE Well’s score
Clinical signs and symptoms of DVT (minimum of leg swelling and pain with palpation of the deep veins) 3
An alternative diagnosis is less likely than PE 3
Heart rate > 100 beats per minute 1.5
Immobilisation for more than 3 days or surgery in the previous 4 weeks 1.5
Previous DVT/PE 1.5
Haemoptysis 1
Malignancy (on treatment, treated in the last 6 months, or palliative) 1
How does the Wells score for PE change the investigation of PE
> 4 = PE likely. urgent CTPA needed
<=4 = PE unlikely. do d-dimer.
if negative, d-dimer ruled out
if positive, d-dimer not ruled out. arranged CTPA
What is the management of a confirmed PE
LMWH - enoxaparin 1.5mg/kg/24h plus warfarin
stop LMWH when INR 2-3 for over 24hrs
warfarin for 3m if provoked, 6m if unprovoked
What is the management of a massive PE
SENIOR HELP oxygen IV access morphine and antiemetic IV colloids thrombolysis
What is a massive PE
PE with presence of circulatory failure
When would V/Q testing be used in investigation of PE
if severe renal failure or allergy to contrast
Describe the pathophysiology of asthma
chronic inflammation of the airways due to a hypersensitivity reaction.
infiltration of eosinophils, TH2 cells and mast cells into the mucosa
release of histamine, leukotrienes and prostaglandins
leading to bronchoconstriction and increased mucus production
airway hypersensetivity
in the long term, there is mucosal oedema and thickened basement membrane
What are soem of the risk factors for asthma
developed country history of atopy urban areas premature viral infection early in life
What are the symptoms of asthma
cough - dry, worse at night
chest tightness
breathlessness
What are the potential triggers of asthma exacerbation
dust, pet hair, pollen
air pollutants, smoking, cold air
aspirin, B blockers
occupation
What are the signs of chronic asthma
increased RR hyperinflated chest use of accessory muscles intercostal recession expiratory high pitched wheeze
What investigations should be carried out in suspected chronic asthma
peak flow monitoring
spirometry with bronchodilator reversibility test
fractional exhaled nitric oxide
What are the expected findings on peak flow monitoring in asthma
diurnal variation - morning dipping
What are the expected findings on spirometry with bronchodilator reversibility testing in asthma
FEV1/FVC <70% pre bronchodilator
improvement of >=12% post bronchodilator
What is a fractional exhaled nitric oxide test?
measurement of nitric oxide synthases in breath
there are 3 types of nitric oxide synthases (NOS) - One of the types is inducible (iNOS) and levels tend to rise in inflammatory cells, particularly eosinophils.
Levels of NO therefore typically correlate with levels of inflammation.
What are the expected findings on fractional exhaled nitric oxide test in asthma
raised levels due to inflammation
What are the steps in management of chronic asthma according to NICE
- SABA reliever therapy
- low dose ICS
- LTRA
- LABA
- lose dose MART
- medium dose MART
- high dose ICS or LAMA or theophylline
What is a LTRA
leukotriene receptor antagonist eg. monteleukast
reduced smooth muscle cell constriction, mucus production and eosinophils
What is a MART
Maintenance and reliever therapy
= combined ICS and LABA treatment in which a single inhaler, containing both ICS and a fast-acting LABA, is used for both daily maintenance therapy and the relief of symptoms as required
Define a moderate acute asthma attack
PEFR 50-75% best or predicted
Speech normal
RR < 25 / min
Pulse < 110 bpm
Define a severe acute asthma attack
PEFR 33 - 50% best or predicted
Can’t complete sentences
RR > 25/min
Pulse > 110 bpm
Define a life threatening asthma attack
any one of:
PEFR < 33% best or predicted Oxygen sats < 92% Silent chest, cyanosis or feeble respiratory effort Bradycardia, dysrhythmia or hypotension Exhaustion, confusion or coma
Define a near fatal asthma attack
rise in PaCO2 or requiring ventilation
What investigations should be carried out in acute asthma attack
PEFR, ECG, pulse oximetry ABG FBC, U+E, CRP, cultures ?CXR
What is the management of severe acute asthma
O2 if sats <92%
salbutamol 5mg nebulised with o2 ervy 15 mins
hydrocortisone 100mg IV
ipatropium bromide if response to beta agonists is poor
Abx if due to infection
magnesium sulphate IV if poor response
What monitoring needs to be done with salbutamol therapy in acute asthma
ECG - tachyarrythmias
potassium - hypokalaemia
peak flows!
ABGs
What are the indications for admission to ITU in severe asthma attack?
rising PaCO2 low PaO2 exhaustion, drowsiness, coma respiratory arrest not responding to therapy
When would it be right to admit a patient with a moderate acute asthma exacerbation to hospital?
if they have had a previous near fatal asthma attack
When would you consider stepping up chronic asthma therapy
using SABA three times a week or more,
being symptomatic three times a week or more,
experiencing night-time symptoms at least once a week,
has had an asthma attack in the last 2 years.
Describe the pathophysiology of bronchiectasis
chronic infection and inflammation leads to dilation of the bronchial walls and bronchioles
What are some causes of bronchiectasis
infections: pneumonia, TB, whooping cough, measles
CF
bronchial obstruction e.g. lung cancer/foreign body
immune deficiency: selective IgA, hypogammaglobulinaemia
allergic bronchopulmonary aspergillosis (ABPA)
ciliary dyskinetic syndromes: Kartagener’s syndrome, Young’s syndrome
What are the symptoms of bronchiectasis
cough
sputum
haemoptysis
What are the signs of bronchiectasis
clubbing anaemia coarse crackles on inspiration cor pulmonale - raised JVP, peripheral oedema smelly breath - foetor
What investigations need to be carried out for bronchiectasis
CXR, HRCT
spirometry with reversibility
bronchoscopy
What are the typical findings on CXR for bronchiectasis
tram lines
What are the typical findings on HRCT for bronchiectasis
signet ring sign
What is the management of bronchiectasis
chest physio - twice daily postural drainage
antibiotics in exacerbation (may need to be long term if severe)
bronchodilators if they help
surgery if localised disease
What are some complications of bronchiectasis
pleural effusion
pneumothorax
pneumonia
cerebral abscess
What are the most common organisms found in the sputum of bronchiectasis
Haemophilus influenzae (most common)
Pseudomonas aeruginosa
Klebsiella spp.
Streptococcus pneumoniae
Name the types of lung cancer
small cell
squamous cell
adenocarcinoma
large cell
Which lung cancer is more common in non-smokers
adenocarcinoma
Which lung cancer is PTHrP released in
squamous cell
Which lung cancer is ADH released in
small cell
Which lung cancer is ACTH released in
small cell
Which lung cancer is clubbing more common in
squamous
Which lung cancers metastasise early and late
early = small and large late = squamous and adeno
What are the most common symptoms of lung cancer
cough hamoptysis dyspnoea chest pain weight loss recurrent pneumonia
What are the signs of lung cancer
cachexia
clubbing
supraclavicular/axillary lymph nodes
What are some potential complications of lung cancer
SVC obstruction phrenic nerve palsy recurrent laryngeal nerve palsy Horner's oesophagel compression
What are the features of SVC obstruction
swelling of face and upper limbs
dilated veins
What are the features of phrenic nerve palsy
raised hemidiaphragm on CXR
dyspnoea
What are the features of recurrent laryngeal nerve palsy
hoarse voice
aspiration
What causes Horner’s syndrome in lung cancer
palsy of sympathetic chain from Pancoast tumour in apex of lung
What are the features of Horner’s syndrome
hemifacial anhidrosis
miosis - small pupil
ptosis
What investigations should be carried out in suspected lung cancer
CXR FBC, U+E, bone profile, ACTH and cortisol levels, LFTs, INR CXR staging CT PET scan to look for metastasis
What is the WHO performance status scale
0 = normal activity 1 = symptomatic, but ambulatory 2 = >50% normal activity, some help with care 3 = <50% normal activity, needs nursing care 4 = bed bound
What is the treatment, according to stage, of lung cancer
I or II = curative surgery
IIIa = curative surgery + adjunct chemo
III or IV + performance status 0-2 = chemo
others palliative
What kind of things can be done for palliative care in lung cancer
radiotherapy - reduce size of tumour
SVC stent
What are the common adverse effects of salbutamol
angiooedema tremor palpitations nausea headache taste alteration risk of hypokalaemia
Why might salbutamol be contraindicated?
hypokalaemia
hypersensetivity
pre-eclampsia
What is the mechanism of action of theophylline
xanthine
relaxes smooth muscle - acting mainly as a bronchodilator and vasodilator
What can affect the plasma-theophylline concentration
plasma-theophylline concentration is increased in:
heart failure,
hepatic impairment
viral infections.
The plasma-theophylline concentration is decreased:
in smokers
by alcohol consumption.
Differences in the half-life of theophylline are important because the toxic dose is close to the therapeutic dose.
What problems can theophyline cayse
hypokalaemia
overdose can be fatal
What is the presentation of theophylline overdose
vomiting (which may be severe and intractable), agitation, restlessness, dilated pupils, sinus tachycardia, hyperglycaemia.
More serious effects are haematemesis, convulsions supraventricular and ventricular arrhythmias. Severe hypokalaemia may develop rapidly.
What are the key side effects if glucocorticoids?
diabetes osteoporosis avascular necrosis of the femoral head. infections Muscle wasting (proximal myopathy) can also occur. peptic ulceration and perforation. Psychiatric reactions may also occur.
What should you tell a patient when presciribing prednisolone?
increased risk of infections - see doctor straighwaay
steroid treatment card
if diabetic, check blood more frequently
some immunisatoins might not be suitable - check!
see doctor if any worrying side effects
Describe the pathophysiology of COPD
progressive airflow obstruction due to mucous gland hyperplasia and loss of cilial functon
emphysema = alveolar wall destruction causing irreversible enlargement of airspaces distal to teh terminal bronchioles bronchitis = chronic inflammation and fibrosis of small airways due to lymphocytes and macrophages
Why do people with COPD develop ankle oedema
hypoxic vasocontriction in lungs pulmonary hypertension and venous congestion increased pressure in right ventricle increased preload venous
Why might uncontrolled oxygen therapy be dangerous in COPD
chronic hypercapnia - compensated for by HCO3-
switch to hypoxic respiratory drive
increased oxygen leads to decreased ventilation
worsens hypercapnia
What key questions would you ask a patient asthma when reviewing them
cough SOB how often using inhalers inhaler technique nocturnal sx exposure to tobacco smoke school/work/home interference asthma attacks steroids? do they have self-management plan
What should be monitored in those taking long term steroids?
Blood pressure.
Urine or blood sugar (measured by HbA1c).
Cholesterol.
Bone mineral density.
Vision (to assess for cataracts and glaucoma).
What is Allergic Bronchopulmonary Aspergillosis
allergic reaction to Aspergillus fumigatus spores
hypersensitivity reaction I or III
What are the features of Allergic Bronchopulmonary Aspergillosis
first bronchoconstriction - wheeze, cough, SOB
then bronchiectasis - sputum
What are the findings on investigation of Allergic Bronchopulmonary Aspergillosis
eosinophilia
rasied serum IgE
aspergillus in sputum
positive radioallergosorbent (RAST) test to Aspergillus
CXR: transient segmental collapse or consolidation, bronchiectasis
What is an asthma managemnt plan
written plan for helping patients to:
recognise worsen asthma - sx or peak flow
initiate changes to treatment when symptoms change eg. seeking emergency help, starting oral steroids, restarting or temporarily increasing inhaled corticosteroid
know how and when to access medical help
What are some systemic complications of CAP
sepsis
brain abscess
pericarditis
cholestatic jaundice
What are some local complications of CAP
pleural effusion
empyema
lung abscess
respiratory failure
What is the differential diagnosis for a pleural effusion associated with CAP
empyema’
secondary to lung cancer
What is a pleural effusion
collection of excess fluid in the pleural space
What is the pathophysiology of a transudate pleural effusion
increased hydrostatic or decreased oncotic pressure leading to too much fluid leaving capillaries and entering pleural space
What are some causes of a transudate pleural effusion
heart failure
cirrhosis
nephrotic syndrome
What defines a transudate or an exudate
the amount of protein in the fluid
transudate = <30g/L exudate = >30g/L
What is the pathophysiology of an exudate pleural effusion
inflammation of the pulmonary capillaries leads to fluids, immune cells and proteins leaking out into the pleural space
What causes an exudate pleural effusion
infection
malignancy
systemic inflammation - RA, SLE, pancreatitis
When is Light’s criteria used?
to decide if a pleural effusion is an exudate or a transudate when protein levels are 25-35g/L
State Light’s criteria
fluid protein:serum protein >0.5
fluid LDH:serium LDH >0.6
fluid LDH > 2/3 normal upper limit serum LDH
What are the symptoms of pleural effusion
pain on inspiration
SOB
cough
What are the signs of pleural effusion
dull to percussion
reduced chest expansion
reduced breath sounds
bronchial breathing
What investigations should be done in pleural effusion
urine dipstick ECG
FBC, U+E, LFTs, CRP
CXR, echo, contrast staging CT if ?malignant
US guided Pleural aspiration
What are the signs on CXR of pleural effusion
blunting of costophrenic angles
meniscus sign
What should the fluid collected on pleural aspiration from pleural effusion be tested for?
biochen: protein, LDH, pH
cytology
microbiology
immunology: RF, ANA
What is the management of pleural effusion
treat the underlying cause
?drain using chest time
What can be done for recurrent pleural effusions
recurrent aspiration
pleurodesis
indwelling permanant catheter
State the pathophysiology of sarcoidosis
multisystem granulomatous condition with unknown aetiology
Who is sarcioidosis most common in
females
20-40y
afro-caribbean
What are the features of acute sarcoidosis
erythema nodosum
arthralgia
bilateral hilar lymphadenopathy
How many cases of acute sarcoidosis resolve spntaneously within a year
80%
What are the features of chronic sarcoidosis
progressive breathlessness
malaise
weight loss
What investigation sshould be done in sarcoidosis
FBC, ESR, calcium
CXR
transbronchial biopsy
What are the blood test findings in sarcoidosis
decreased lymphocytes
low platelets
raised ESR
raised calcium - due to abnormal vit D metabolism
What are the CXR stages of sarcoidosis
0 = no change
1 - BHL
2 - BHL + pulmonary infiltrates’
3 - pulmonary infiltrates, no BHL
What is seen on histology in sarciodosis
non-caseaeting granulomas
What is the treatment of sarciodosis
pain relief - NSAIDs if good prognosis (BHL + erythema nodosum)
steroids
chloroquine
When are steroids used in teh treatment of sarciodosis
if:
stage 2/3 + moderate/severe or progessive symptoms
eye, heart or neurological involvement
raised Calcium
What is the stepwise management of paediatric asthma (5-17y) according to NICE
SABA \+ paed low dose ICS \+LTRA \+ LABA stop LABA, atart MART (paed medium) increase MART to high dose or start theophylline SR.
