Resp Flashcards
1
Q
What are the ABG findings in T1RF?
A
O2 <8 kPa
2
Q
What are the ABG findings in T2RF?
A
O2 <8 kPa, CO2 >6.5 kPa
3
Q
In summary, what sort of problem is T1RF?
A
Obstruction problem
4
Q
What is shunting?
A
Alveoli are perfused but not ventilated, eg due to ARDS or consolidation.
Hypoxia can’t be corrected by increasing FiO2 because poorly-ventilated alveoli will continue to lower systemic pO2
5
Q
Physiological causes of T1RF
A
Hypoventilation
V/Q mismatch
Shunting
Decrease in inspired pO2
6
Q
Causes of T1RF
A
Severe acute asthma
Pneumonia
PE
Pulmonary oedema
7
Q
Causes of T2RF
A
COPD
Asthma
Pneumonia
Pulmonary fibrosis
Obstructive sleep apnoea
Decreased respiratory drive: trauma, CNS trauma, sedatives
Neuromuscular: cervical cord lesion, MG, GBS, diaphragm paralysis
8
Q
Symptoms and signs of hypoxia
A
SOB, restless/ agitated, reduced GCS, cyanosis
9
Q
Symptoms and signs of hypercapnia
A
Headache, reduced GCS, tachycardia with bounding pulse, tremor in hands, peripheral vasodilatation, papilloedema
10
Q
Investigations for hypoxia?
A
ABG
Sputum/ spirometry
ABG
CXR
11
Q
Management of hypoxia
A
High-flow oxygen
Re-check ABGs
12
Q
What are the options for NON-invasive respiratory support?
A
Humidified supplemental O2 (for T1RF)
CPAP (for T1RF)
NIV (BIPAP) (for T2RF)
13
Q
Explain CPAP
A
Expiration against a resistance
opens up alveoli, forces out pulmonary oedema, decreases work of breathing
14
Q
Explain BIPAP
A
Positive pressure support for inspiration in addition to patient’s own breathing
(clears CO2, decreases work of breathing)
15
Q
How is INVASIVE mechanical ventilation different?
A
Can set a desired pressure, desired tidal volume, desired RR
16
Q
What are the indications for invasive mechanical respiration?
A
NIV not tolerated
Severe respiratory failure/ increased work of breathing
Airway protection (eg GCS <8 or burns)
Control pO2 and pCO2 in acute neurological disesase/ increased ICP
17
Q
Contraindications of invasive mechanical ventilation
A
Tension pneumothorax
Volutrauma, barotrauma
18
Q
How is invasive mechanical ventilation provided?
A
Most will have ETT (requires anaesthesia, sedation)
Long-term need tracheostomy (little/ no sedation, improved comfort, improved nursing/ oral care)
19
Q
4 types of pulmonary embolism
A
Thrombosis (usually distant vein)
Fat (fractures)
Amniotic fluid
Air (neck vein cannulation/ bronchial trauma)
20
Q
Presentation of PE
A
Large can cause sudden death/ small can be hard to diagnose
Symptoms: SOB, dyspnoea, chest pain (pleuritic or retrosternal), cough, haemoptysis
Signs: tachypnoea, tachycardia, hypotension hypoxia pyrexia pleuritic pain increased JVP, gallop rhythm
21
Q
Investigations for PE?
A
Two-level Wells Score:
LIKELY
CTPA + leg USS
anticoag to buy time
[if can’t have contrast/ renal impairment: V/Q spectroscopy]
If UNLIKELY: D-dimer
ABG Bloods: FBC, U&Es, baseline clotting, D-dimers, troponin + BNP may be raised due to strain ECG CXR Echo will show thrombus
Consider:
looking for ca (hx, CXR, mammogram, abdomino-pelvic CT)
antiphospholipid antibodies, thrombophilia screen
22
Q
How might a PE present on ECG?
A
Tachy
RBBB
R axis deviation
S1, Q3, T3
Large PE may show ST depression
23
Q
How do you manage PE?
A
Ideally LMWH or fondaparinux (at least 5 days whilst awaiting warfarin)
Warfarin for 3 months - INR 2-3
Maybe rivoraxaban (prophylactic) Surgical embolectomy/ IVC filters
24
Q
What are the signs of pulmonary oedema?
A
Resp distress: pale, sweaty, tachypnoeic, tachycardic
May be cyanosed, low sats <90% RA
May be signs of associated cause
Basal or widespread crackles
Cardiogenic shock: hypotension, oliguria, low CO2
25
Investigations for pulmonary oedema
Bloods: FBC, U&Es, glucose, cardiac enzymes
ECG
CXR
Echo (to establish LV function once stable)
26
How does pulmonary oedema appear on CXR?
Bilateral patchy shadowing
Kerley B lines
Batwings (increased vascular shadowing)
Pleural effusions
If cardiogenic, maybe cardiomegaly
27
How do you manage pulmonary oedema?
Depends on cause but...
Fluid balance
28
What is a pneumothorax?
Air in pleural space
29
What are the causes of pneumothorax?
SPONTANEOUS: rupture of pleural pleb (congenital weakness) - tall, slim males - often apical
SECONDARY: COPD (emphysematous bullae), TB, pneumonia, bronchial Ca, sarcoidosis, CF, trauma
30
Causes of pulmonary oedema: lymphatic obstruction
Mediastinal carcinamatosis
| Silicosis
31
Causes of pulmonary oedema: neurogenic
Status epilepticus
Head injury
Cerebrovascular insult
These happen within a few hours
32
Causes of pulmonary oedema: increased capillary permeability
```
ARDS
Increased altitude
Inhaled/ aspirated toxins
Radiation
Liver failure
Fat/ amniotic embolus
```
33
Causes of pulmonary oedema: increased pulmonary capillary pressure
Heart: MI/ ACS, valvular disease (regurg or severe AS), cardiomyopathy, PE, acute arrhythmia, tamponade, dissection, right-output HF (septicaeia, thyrotoxicosis, anaeia)
Renal: AKI, CKD, renal artery stenosis
Iatrogenic: fluid overload
34
Causes of pulmonary oedema: airway obstruction
Acute or chronic upper airway obstruction
35
What is ARDS?
Non-cardiogenic pulmonary oedema - 30-45% mortality
36
What are the causes of ARDS?
Pulmonary causes: mechanical ventilation, trauma, near drowning, smoke inhalation, gastric contents aspiration, infection
Extrapulmonary causes: Gram-negative septicaemia, pancreatitis, burns, CABG, perforated viscus, DIC, O2 toxicity, drug OD
37
Management of ARDs
```
Identify cause + support
-ve fluid balance, as in pulm oedema
PEEP: prevent alveolar walls from collapsing during expiration
Vasodilators
Steroids (late stages)
```
38
Presentation of pneumothorax
Asymptomatic - esp if small or they're healthy
or
Sudden unilateral chest pain, SOB, sudden deterioration of existing lung problem
39
How does pneumothorax present on examination?
Reduced chest expansion on that size - hyperresonance - reduced, absent breath sounds
40
How does pneumothorax present on CXR?
Are of increased lucency without lung markings, edge of lung may be visible away from chest wall
41
Management of pneumothorax
Small: often no treatment, r/v 7-10 days
Large: admit for aspiration
42
Common causes of tension pneumothorax
Positive pressure ventilation, stab, rib fracture
43
Management of tension pneumothorax
Large-bore cannula, 2nd ICS, MCL
44
How does tension pneumothorax present on examination?
Tracheal deviation (pulled to contralateral side)
Hyperresonance
Absence of breath sounds
Widened ICS spaces on contralateral side
45
How does tension pneumothorax present?
As pressure increases, venous return to heart is impaired:
| Dyspnoea, chest pain, cyanosis, even cardiac arrest
46
What is a tension pneumothorax?
A chest or lung wall injury allowing air into the pleural space. The air rises above atmospheric pressure, compressing the lung and venous return to the heart. Air enters but doesn't leave.
47
Which side do aspirated foreign bodies go?
R
48
Presentation of foreign body aspiration?
Upper airway: stridor, respiratory distress, cyanosis, resp arrest
Beyond carina: recurrent cough, pneumonia, SOB, haemoptysis
49
Management of foreign body aspiration
Heimlich - suction - bronchoscopy - abx to treat/ prevent pneumonia
50
Investigations for foreign body aspiration
Bloods (inflammatory response) - CXR (if radio-opaque, if pneumonia) - bronchoscopy (direct visualisation)
51
What is OSA?
Intermittent and repeated upper airway collapse during sleep
52
What should you look for when examining for OSA?
No specific signs
Look for: neck fat deposition, small mouth, big tongue, polyps etc
53
Gold standard for OSA?
Ix
Mx
Ix Polysomnography (electrodes on eyes and chin)
Mx CPAP
54
What are the risks associated with OSA?
HTN, CVD, obesity, DM, asthma
55
What are the options for treating OSA?
Lifestyle/ avoid supine sleeping
CPAP
Consider:
Modafinil for sleepiness
Surgery
56
What is central sleep apnoea?
Airway patent but no respiratory effort
Causes hypercapnia that arouses pt
57
What are the causes of pulmonary hypertension?
COPD, interstitial lung disease, others
L cardiac disease, secondary to congenital heart disease
Portal HTN
Idiopathic is rare - poor prognosis - associated with CREST/ autoimmune
58
How does pulmonary HTN present?
Non-specific insidious signs (often diagnosed late)
SOB, malaise, presyncopal
Often picked up as signs of cor pulmonale
59
How is pulmonary HTN investigated?
R heart catheterisation confirms
PAH diagnosed by exclusion: ECG, echo, CXR, CT chest, autoantibodies
60
How is pulmonary HTN managed?
Warfarin to minimise risk of thrombosis
CCBs to decrease pressure of pulmonary vasculature
HF should be treated aggressively
Poor prognosis (2-3 years) - death usually due to RHF
61
Incidence of asthma
20% kids
| 5% adults
62
Define asthma
Reversible airflow obstruction, airway hyper-responsiveness, inflamed bronchi
63
What is extrinsic vs intrinsic asthma?
EXTRINSIC: atopic childhood asthma, remits in teens
INTRINSIC: usually adult, progressive, less responsive to treatment
64
How to diagnose asthma?
at least 15% improvement in FEV1 after bronchodilator use
There will be an obstructive picture (FEV1/ forced vital capacity reduced)
Residual volume may be increased due to air trapping
65
Management of asthma (adults and children over 5)
Avoid triggers!
STEP 1: inhaled short-acting beta2 agonist - PRN
STEP 2: add inhaled steroid (200-800 mcg) - 400 usually ideal, but titrate
STEP 3: Add LABA
Good response: continue!
Quite good response: continue/ ensure steroids at 800 mcg
No response: steroids at 800 mcg, stop LABA
From this step eligible for SMART (single maintenance and reliever therapy)
STEP 4: add leukotriene receptor antagonist, theophylline, beta2 agonist pill
steroids up to 2000 mcg/day
STEP 5: add daily oral steroid (+ 2000 mcg/day inhaled)
TRY TO STEP DOWN WHERE POSSIBLE
66
What should every asthmatic have?
Asthma action plan
67
Definition COPD
airflow obstruction with little or no reversibility
68
Incidence of COPD
5-15% industrialised countries
69
What should be considered cause of COPD in under 40s?
alpha-1-antitrypsin deficiency (proteases overwhelm antiproteases = increased compliance)
panacinar picture
70
What are the traditional forms of COPD?
Blue bloaters: CHRONIC BRONCHITIS - small airways obstructed by mucus plugs & bacterial colonisation - crackles/ wheeze - peripheral oedema
Pink puffers: EMPHYSEMA - proteases overwhell=m antiproteases - cachectic, pursed-lip breathing, accessory muscles, barrel chest, decreased breath sounds
71
Signs of COPD
I: central cyanosis - barrel chest - use of accessory muscles - pursed lip breathing - flapping tremor - tachypnoea - persistent cough - chronic sputum production - weight loss
P: tacycardia - tracheal tug - reduced expansion
P: hyperresonant lung fields (unless consolidation)
A: wheeze - prolonged expiration
72
Investigations for COPD
```
Spirometry (severity based on FEV1)
Pulse oximetry
Sputum
Bloods: FBC, alpha1-antitrypsin level
CXR
ECG/ Echo for cor pulmonale
```
73
Management of COPD
Yearly influenza jab, 5-yearly pneumococcus jab
Pulmonary rehab: 6-12 weeks, work on exercise tolerance
Medications (these are all symptomatic so only continue if iprovement after 4 weeks):
STEP 1 (breathlessness or exercise limitation): SABA or SAMA
STEP 2 (exacerbations or persistent breathlessness)
FEV > 50% - LABA/ LAMA
FEV < 50% - LABA + ICS / or LAMA (combination inhaler - ICS not used alone in COPD)
STEP 3
LABA --> LABA + ICS
Others --> LAMA + LABA + ICS
ORAL: theophylline, carbocisteine (mucolytic), rescue pack abx
SEVERE/ END-STAGE: home O2 (15h/ day)
Lung transplant an option
74
Complications of COPD
Acute worsening (usually infection, eg influenza or haemophilus influenzae)
T2RF
cor pulmonale
75
Example SABA
Salbutamol
76
Example SAMA
Ipratropium
77
Example LABA
Salmetarol
78
Example LAMA
Tiotropium
79
Definition cor pulmonale
Impairment of right ventricular function as a result of respiratory disease - leading to increased resistance to blood flow in the pulmonary vasculature
80
General two types of pathology leading to interstitial lung disease
Granulomatous or fibrosis
81
Define pulmonary fibrosis
The irreversible end-stage of many respiratory diseases, characterised by scarring of lung tissue which decreases compliance.
An example of interstitial lung disease
82
Symptoms of pulmonary fibrosis
Progressively breathless
| Dry, non-productive cough
83
Findings on examination of pulmonary fibrosis
Lung expansion is reduced
| Fine end-inspiratory crackles
84
Investigations of pulmonary fibrosis
CXR may show infiltration in basal area
Gold standard is HRCT: honeycomb, ground-glass appearance (needs specialised radiologist)
Biopsy useful but many patients too frail
Lung function tests show restrictive pattern - good to monitor disease progression
85
Management of pulmonary fibrosis
Avoid triggers
Pulmonary rehab
Steroids may dampen inflammatory response
Home oxygen may help
86
Define the pneumoconioses
An example of interstitial lung disease. A group of disorders caused by inhalation of mineral or biological dusts - incidence is decreasing as working conditions improve
Examples are coal worker's pneumoconiosis and asbestosis
87
What is extrinsic allergic alveolitis?
An example of interstitial lung disease. A hypersensitivity pneumonitis (type III reaction). Results from individual already being sensitised to the inhaled antigen.
Eg farmer's lung (mouldy hay) and bird fancier's (bird faeces)
88
What is the pathogenisis of extrinsic allergic alveolitis?
Neutrophils infiltrate small airways and alveolar walls after antigen exposure
Lymphocytes and macrophages then infiltrate, forming non-caseating granulomas
May resolve, or lead to pulmonary fibrosis
89
Investigations for extrinsic allergic alveolitis
Bloods: polymorph leucocyte count, precipitating antibodies (evidence of exposure, not disease)
Lung function tests show restrictive pattern
CXR: nodular shadowing
HRCT may show disease if CXR normal
Bronchoalveolar lavage
90
Management of extrinsic allergic alveolitis
/most will regress if exposure to antigen prevented
CS may speed up recovery
91
Clinical features of extrinsic allergic alveolitis
Cough, SOB
Malaise, fever
Coarse end-inspiratory crackles
92
3 pathological features of asthma
Bronchospasm - mucus plugging - smooth muscle hypertrophy
93
Describe the early and late responses in asthma
EARLY RESPONSE:
release of preformed mediators (predominantly mast cells) causes vascular leakage and smooth muscle contraction within about 15 mins
(1-2 hours to return to baseline)
LATE RESPONSE:
influx of inflammatory cells (predominantly eosinophils) - these release inflammatory mediators that that cause airway narrowing in 3-4 hours
(maximally at 6-12 hours)
94
When is the annual influenza epidemic?
Autumn/ winter
95
When is influenza infective?
1 day prior to symptoms
96
When do influenza symptoms resolve?
After about 1 week
97
Common complications of influenza
Secondary bacterial pneumonia (Staph aureus)
Otitis media
Sinusitis
Encephalitis
98
Groups most at risk of influenza
```
Children under 2
Elderly
Underlying lung disease
Heart disease
Diabetes
Immunocompromised
```
99
How is influenza diagnosed during pandemics?
Nasopharyngeal aspirate
100
Define pneumonia
The presence of symptoms and signs consistent with acute LRTI in association with new radiographic shadowing for which there is no alternative explanation.
UK's fifth leading cause of death
101
Common risk factors for pneumonia
Related to processes that impair lung's natural immune defences
Age: v young/ old
Lifestyle: smoking, alcohol
Preceding viral infection
Respiratory: any existing disease
Immunosuppression
IV drug use (Staph aureus)
Hospitalisation
Underlying predisposing disease: DM, CVD
Swallowing impairment (aspiration pneumonia)
102
What differentiates diagnosis of HAP from CAP?
Been in hospital over 48hrs (nursing home acquired is an important sub-type)
103
Common causes of CAP
```
Streptococcus pneumoniae
Haemophilus influenzae
Mycoplasma pneumoniae
Chlamydophila pneumoniae
Respiratory viruses
```
104
Common causes of HAP
Staph aureus
Gram negative enterobacteria
Klebsiella
Pseudomonas
105
Common causes of aspiration pneumonia
Anaerobes
Gram-negative enterobacteria
Staph aureus
106
Common causes of pneumonia in the immunocompromised
```
CAP organism
HAP organisms
Viruses (CMV, VZV)
Fungi (aspergillus)
Mycobacteria
```
107
Atypical pneumonia: Mycoplasma pneumoniae
Epidemics every 3-4 years
Young patients
Flu-like symptoms, followed by persistent dry, hacking cough
Extrapulmonary features: haemolytic anaemia, GBS...
Usually resolves spontaneously over few weeks
108
Atypical pneumonia: Legionella pneumophila
Severe pneumonia with high mortality
| Extrapulmonary features: D&V, neurological deficit (including focal), hepatitis, hyponatraemia
109
How does pneumonia present on examination?
Obs: pyrexial, tachycardic, tachypnoeic
(diagnosis unlikely if no focal chest signs and obs normal)
Resp exam: lung expansion is reduced, dull to percuss, creps, pleural rub, may be coarse crackles as resolves
Confusion (esp elderly)
Look for extrathoracic signs if atypical suspected
110
Ix for pneumonia
If managed in community, usually not needed
AMTS
Sputum: examination and culture
ABG if signs of respiratory failure
ECG: AF common
Urine: pneumococcal and legionella urinary antigen tests
```
Bloods:
FBC
CRP/ ESR
U&Es (dehydration common)
LFTs (can become deranged in atypicals)
```
Cultures: if pyrexial
CXR (plus follow-up in 6 weeks after recovery)
Consider aspiration of pleural fluid
111
Assessing whether CAP needs hospital admission
CRB-65
AMTS 8 or less, or new disorientation in person, place or time
RR above 30
Systolic BP below 90 (or diastoilc below 60)
65 years +
Consider hospital admission if 2 or more
112
Management of CAP in community
Rest, drink lots, no smoking
| Seek advice if no improvement in 72h
113
Management of CAP in hospital
Oxygen for hypoxia
Fluids for dehydration
NSAIDs and paracetamol for mild pleuritic pain
Nebulised saline may help
114
Antibiotics for low-severity CAP
5-day course amoxicillin (macroglide or tetracycline if allergic)
Add flucloxacillin if staphylococcal infection suspected
115
Name of atypical pneumonia caused by exposure to ill birds
Chlamydophila psittaci
116
Atypical pneumonia: Chlamydia pneumoniae
Gradual onset, biphasic (may improve then get worse again)
Incubation 3-4 weeks
Initial non-specific URTI followed by bronchitic symptoms
Most ppl are quite well
Scanty sputum, hoarseness, headache
Symptoms may persist for weeks/ months
117
Complications of pneumonia
```
Pleural effusion (usually sterile)
Empyema
Lung abscess
DVT
Septicaemia and its spread to cause pericarditis, endocarditis, osteomyelitis, septic arthritis, cerebral abscess, meningitis etc.
Post-infective bronchiectasis
AKI
```
118
Define TB
A chronic granulomatous disease caused by bacteria of the Mycobacterium tuberculosis complex (M. tuberculosis, M. bovis and M. africanum)
119
Describe the difference between secondary TB and miliary TB
Secondary is due to subsequent reactivation of semi-dormant M.tuberculosis. Usually reactivated by impaired immune function. Reactivation usually occurs in the lung apex and can spread locally or to distant sites.
Miliary occurs when primary infection is inadequately contained and it invades the bloodstream, resulting in severe disease
120
Most common site of extrapulmonary TB
Genitourinary, presenting with pyuria
121
Presentation of primary TB
Often asymptomatic or general malaise, fever etc.
122
CXR findings in TB
Patchy or nodular shadows in the upper zones, loss of volume, fibrosis, cavitation
Primary TB: central apical portion with a L lower lobe infiltrate + pleural effusion
Reactivated TB: central apical lesion, no pleural effusion
Severe: miliary TB (uniform 1-10 mm shadows throughout lungs)
Extrapulmonary: may still have evidence or original lesion
123
Investigations for TB
Sputum MC&S with Ziehl-Neelson stain: at least 3 samples, including early morning - ideally before treatment or within 7 days
(If unable to give, consider broncholavage)
CXR
Bloods: check HIV, hep B and hep C status
124
Management of TB
Start and complete meds if clinical signs and symptoms, regardless of sputum culture results
```
RIPE
Rifampicin - 6 months
Isoniazid - 6 months
Pyrazinamide - 2 months
Ethambutol - 2 months
```
If co-existing HIV, see HIV guidance
Give prophylactic 10 mg pyridoxine if risk factors for peripheral neuropathy (worsened by isoniazid)
LFTs should be monitored: RIP cause hepatic toxicity, monitor more frequently if alcoholic - expect R to cause some disturbances in first 2 months
U&Es ethambutol should be avoided in renal failure
Visual acuity, colour blindness + visual fields should be checked - ethambutol
Notifiable disease
Contact tracing: Mantoux test for all close contacts - may be positive if had BCG, so interferon gamma testing is second-line
125
Who is offered the BCG?
Newborns in high-risk areas
Health workers
New immigrants from countries with high levels of TB
Close contacts of pts with pulmonary TB
126
Signs and symptoms of lung abscess
Acute: malaise, anorexia, fever, productive cough, copious foul-smelling sputum
Chronic: dullness to percus, pallor due to anaemia, clubbing
127
Causes of lung abscess
Aspiration of infected material
Complication of pneumonia, bronchiectasis or TB
Bronchial obstruction
Pulmonary infarction
128
Define suppurative lung disease
range of lung diseases characterised by a chronic wet cough and progressive lung damage
129
Clinical features of bronchiectasis
Cough - often productive of foul-smelling sputum
Haemoptysis
Clubbing
Crackles on auscultation - usually lower lobes affected
130
Define bronchiectasis
Abnormal and permanent dilation of bronchi
131
Causes of bronchiectasis
Acquired:
usually caused by severe childhood illness (pneumonia, measles, whooping cough),
bronchial obstruction followed by infection distal to obstruction (foreign object, tumour, lymph nodes)
bronchopulmonary aspergillosis
Congenital:
problems with ciliary function (eg Kartanger's)
IgA and other primary antibody deficiency
132
Who should be investigated for bronchiectasis?
In adults:
persistent productive cough, esp if young and associated with haemoptysis
pts with COPD who are non-smokers or have frequent exacerbations
133
Investigations for bronchiectasis
```
Sputum MC & S
Spirometry (obstructive pattern)
Tests for CF
Check immunoglobulins (may demonstrate deficiency)
Aspergillus-specific Ig
```
CXR: may show bronchial wall thickening, cystic spaces if advanced
HRCT
Consider bronchoscopy:
?foreign object
Bronchoalveolar lavage
134
Management of bronchiectasis
Control of infection
| Bronchodilators may be helpful
135
Incidence of CF
Prevalence of heterozygous carriers is 4%
1:2000 births
136
CF sufferers prone to which infection?
Psuedomonas aerginosa
137
Clinical presentation of CF
In infancy, GI manifestations: meconium ileus, malabsorption
As older, problems with lungs occur - increasingly more infections - then clubbing and dyspnoea
Almost all men infertile, women subfertile
138
Investigations for CF
```
Genetic screening if family hx
CVS or amnioscentesis prenatally
Guthrie test
Immunoreactive trypsin test or Sweat Test
CXR
```
139
How does sarcoidosis present?
Depends on organ
90% have pulmonary involvement: dyspnoea, chest pain, dry cough
Non-specific: fatigue, malaise, weight loss, lymphadenopathy
140
Common extrapulmonary manifestations of sarcoid
Skin: erythema nodosum/ lupus pernio
Arthralgia
Uveitis
Cranial nerve palsies (neurosarcoid)
141
How is sarcoid investigated?
Spirometry: restrictive
Bloods: FBC, U&Es, LFTs, bone profile, ESR
Rule out RA and SLE
CXR: hilar lymphadenopathy
HRCT
GOLD STANDARD: biopsy showing epithelioid non-caseating granulomas
142
How does Goodpasture's present?
Haemoptysis (pulmonary haemorrhage), anaemia, haematuria
143
How does Wegener's granulomatosis present?
affects nose, lungs and kidneys
Rhinorrhea, cough, haemoptysis, dyspnoea
wonky nose
144
How does Churg-Strauss Disease present?
Triad: late-onset asthma, eosinophilia, small-vessel vasculitis
Vasospasm common: risks of MI, PE, DVT
145
Respiratory manifestation of RA
```
10-15% have lung involvement
Diffuse pulmonary fibrosis
Pleural fibrosis
Pleural effusions
Rheumatoid nodules in lung
Others
```
146
Respiratory manifestation of SLE
Pleurisy, with or without effusion
147
Respiratory manifestation of systemic sclerosis
Pulmonary fibrosis - rapidly-progressing pulmonary hypertension
148
Respiratory manifestation of ankylosing spondylitis
Apical lung fibrosis
149
Lung Ca common sites of metastisis
```
Lymph nodes
Bone
Liver
Adrenals
Brain (personality change, epilepsy, focal neurology)
```
150
What % smokers get lung cancer?
1 in 5
151
Types of bronchial carcinoma?
Which type has best survival rates?
Non-small cell: squamous cell - adenocarcinoma - large cell
Small cell
Best survival: squamous cell/ least likely to metastisise
152
Which bronchial ca may present as paraneoplastic syndrome?
Squamous cell
Adenocarcinoma
Small-cell
153
Which bronchial ca doesn't often present with obstructive symptoms?
Adenocarcinoma
Non-smoking old women from East Asia
Often peripheral
154
Which bronchial ca is usually diagnosed by process of elimination?
Large-cell anaplastic
No typical clinical or radiological findings
155
How does small-cell carcinoma present?
Obstructive symptoms
Paraneoplastic
Mets (via lymphatics)
156
What paraneoplastic syndromes are associated with bronchial ca?
SIADH
ectopic ACTH
hypercalcaemia (SCC unless bone mets)
hypertrophic pulmonary osteoarthropathy
gonadotrophins (large cell): gynaecomastia + testicular atrophy
157
Pancoast's tumour is usually which sub-type?
66% SCC
158
Who should be referred under TWR?
Anyone over 40 with unexplained haemoptysis
| Suspicious CXR findings
159
Which lung ca has no staging?
Malignant mesothelioma as so aggressive
160
How does COPD affect Hb?
Chronic hypoxia causes secondary polycythaemia - Hb raised
161
When may eosinophils be decreased?
Steroid therapy
162
How can streptococcal infection be confirmed?
ASO titre (anti-streptolysin O)
163
How does salbutamol affect U&Es?
Hyperkalaemia
164
How might bronchial ca cause hyperkalaemia?
ACTH-secreting tumour
165
Which lung disease affects ACE?
Sarcoid
166
When might calcium be raised
SCC of lung
Sarcoid
Bone mets
167
How is GA avoided in flexible bronchoscopy?
Topical lidocaine to pharynx and vocal cords
168
Differentiating between transudates and exudates
Tran- clear - heart failure, liver failure, kidney failure
| Exudates- cloudy - lung ca, pneumonia
169
Normal ABG values
pH 7.35 to 7.45
paCO2 35 to 45
HCO3 22 to 26
170
Causes of respiratory acidosis
IMPAIRED VENTILATION
asthma, COPD, pneumonia, sleep apnoea, acute PE, severe obesity, neuromuscular problems, scoliosis, sedative OD, arrest
171
Causes of respiratory alkalosis
HYPERVENTILATION
heart attack, pain, asthma, fever, COPD, infection, PE, pregnancy
172
Causes of metabolic acidosis
DKA, lactic acidosis, renal tubular acidosis, severe diarrhoea
173
Causes of metabolic alkalosis
excess vomiting, diuretics, adrenal crisis, alcohol abuse, excess sweating
174
Give 3 key facts to encourage smokers to quit
Half will die of smoking-related disease
10 years before non-smokers
Slow, painful deaths like COPD
175
How many weeks of stop smoking therapy?
2 weeks and then reassess
176
Which stop smoking method for kids and pregnant/ breastfeeding?
NRT
177
What is bupropion?
Zyban
Antidepressant with cessation effects
8 week course
178
Contraindications of NRT?
Severe cardiovascular disease, recent CVA (inc TIA)
179
Contraindications of Zyban?
eating disorders
| epilepsy/ risk factors for seizures
180
What is varenicline?
Champix
Nicotinic Ach receptor with cessation effects
12 week course
181
Contraindications of Champix?
Hx of psych illness - needs v close monitoring
| Suicide ideation
182
How are beta agonist nebs usually driven?
O2 for asthma
| Air for COPD
183
What are the issues with e-cigarettes and vaping?
Often contain nicotine
Maybe safer than cigarettes
Long-term effects of vapour unknown
Unregulated so not sure what inhaling
No proof they can help stop smoking
184
Average duration of cough
3 weeks
185
Average duration of common cold
1.5 weeks
186
Features of clubbing
beaked nails
loss of angle between nail bed and finger
increased AP width of finger tip
sponginess of proximal nail bed
187
Resp causes of clubbing
common:
```
lung cancer (not small cell cancer)
chronic pulomnary suppuration
bronchiectasis
lung abscess
empyema
Idiopathic pulmonary fibrosis
cystic fibrosis
asbestosis
pleural mesothelioma or fibroma
```
uncommon:
Cystic fibrosis
Asbestosis
Pleural mesothelioma (benign fibrous type) or pleural fibroma
188
Features more in keeping with asthma than COPD
Chronic unproductive cough
Diurnal or day-to-day variation of breathlessness
Waking at night due to SOB/ wheeze
189
Features of poor asthma control
Needing SABA 3+ days/week
| 1+ night per week up at night due to asthma
190
Illustrative examples of V/Q mismatch
High, eg asthma
| Low, eg PE
191
What do tramtrack marks on CXR signify?
Bronchiectasis
192
Most common organism implicated in IECOPD?
Haemophilus influenzae
193
Pneumonia mx based on CURB
CURB 0-1:
amoxicillin 500 mg TDS or clarithromycin 500 mg BD for 5 days
CURB 2: inpatient
amoxicillin 500 mg TDS AND clarithromycin 500 mg BD for 7 days (oral or IV)
CURB 3: consider ITU
co-amoxiclav 1.2 g TDS AND clarithromycin 500 mg BD for 7 days (IV)
194
Causes of lung abscess
Primary disease: existing pneumonia/ untreated pneumonia or lung disease
Secondary disease: aspiration, alcoholics, septic emboli from R-sided infective endocarditis
195
Presentation of lung abscess
Swinging fevers, night sweats, productive cough with purulent sputum
196
TB drug side-effects
RED-fampicin: reddish orange secretitions, hepatitis
Iso-NEURO-azid: peripheral neuropathy, granulocytosis, hepatitis
Pyr-OUCH-zinamide: hyperuricaemia (causing gout), myalgia, hepatitis
EYE-thambutol: optic neuritis, renal impairment
197
How to avoid peripheral neuropathy with isoniazid?
Supplement with vit B6
198
Most commonly implicated organism in Aspergillus-related lung disease
Aspergillus fumigatus
199
Presentation aspergillosis
haemoptysis, large amount of blood
200
mx aspergilloma
surgical removal and long-term itraconazole
201
Triad of Meig syndrome
R-sided pleural effusion (transudate), ascites, benign ovarian tumour
202
Which pleural effusions should be aspirated?
Exudates (suspect from hx)
203
where to insert large-bore cannula in tension pneumothorax?
2nd ICS, MCL
204
where to insert chest drain?
3-5th ICS, MAL
