Resp Flashcards
What changes in the lungs can amiodarone/ methotrexate lead to?
Pleural effusions, interstitial lung disease
What lung condition is common in miners, and how does it present?
Pneumoconiosis –> inflammation, coughing, fibrosis
What would be the results of spirometry in a patient with COPD:
- FEV 1
- FEV 1/FVC
- Bronchodilator reversibility
- Total lung volume
- FRC
- Residual volume
- Gas transfer (TLCO & kCO)
- decreased FEV 1
- decreased FEV 1/FVC
- minimal Bronchodilator reversibility (<15%)
- increased Total lung volume
- increased FRC
- increased Residual volume
- decreased Gas transfer (TLCO & kCO)
What treatments should patients experiencing a COPD exacerbation be considered for?
EDIT - PAGE 813
- Nebulized salbutamol + ipratropium w/ air
- Oral steroids
- Consider IV aminophylline if not improving with nebulisers
- NIV in pts w/ respiratory acidosis despite max medical TX
What is the definition of asthma?
Diurnal variation >20% on 3 or more days per week for 2 weeks
What would be the results of spirometry in a patient with asthma?
Obstructive pattern
- Decreased FEV1/FVC
- Increased RV
- > 15% increase in FEV after b2 agonists/ steroids
When should steroids be prescribed to a pt suffering from asthma?
Pts with an FEV less than 60% predicted who have had 2+ exacerbations per year requiring treatment with Abx or oral steroids. Use in combo w/ bronchodilator.
What is the treatment of an acute asthma attack?
- Supplementary oxygen (maintain at 94-98%)
- Salbutamol nebulised with oxygen
- If severe/life-threatening: add ipratropium to nebulisers
- Hydrocortisone IV or prednisolone PO
- If poor initial response: give single dose of magnesium sulfate IV the next day
What conditions must be met before a patient who has had an asthma attack is discharged?
- Must be stable on meds for 24 hours
- Peak flow rate >75% predicted
- Follow up appointments arranged
How does extrinsic allergic alveolitis present?
4 - 6 hours post-exposure: fevers, rigors, myalgia. dry cough, dyspnoea, crackles (NO wheeze!)
Is extrinsic allergic alveolitis obstructive or restrictive?
Restrictive
Name 3 things that might occur in chronic extrinsic allergic alveolitis.
- Type 1 respiratory failure
- Granuloma formation
- Obliterative bronchiolitis
What would you see on an CXR of someone with chronic extrinsic allergic alveolitis?
Upper-zone fibrosis; honeycomb lung
What would you see on an CXR of someone with acute extrinsic allergic alveolitis?
Upper zone mottling/ consolidation
A patient with resolving pneumonia develops a recurrent fever - what should you suspect? What would you see on CXR? How would you treat it?
Empyema. CXR suggests pleural effusion. Chest drain to treat.
How would empyema look like if you were to take a sample? Comment on other features it has
Yellow and turbid, pH <7.2, low glucose, LDH high
What would you hear on auscultation of someone with bronchiectasis?
Coarse, inspiratory crepitations.
What sort of pattern would bronchiectasis give on spirometry?
Obstructive pattern
Name 4 of the main organisms involved in bronhciestasis?
- H. influenzae
- Strep. pneumoniae
- Staph aureus
- Pseudomonas aeruginosa
What would you hear on auscultation of someone with cystic fibrosis?
Bilateral coarse crackles
How could you test pancreatic function in someone with cystic fibrosis?
Faecal elastase
What type of pattern would cystic fibrosis give on spirometry?
Obstructive pattern
How high would you expect sodium and chloride to be in the sweat of someone with cystic fibrosis?
> 60 mmol/L
Name some extra-pulmonary manifestations of cystic fibrosis?
DM, gallstones, cirrhosis, infertility, osteoporosis, arthritis, vasculitis, sinusitis, chronic pancreatitis
What treatments should be given to someone with cystic fibrosis?
- Physio (postural drainage)
- Mucolytics
- Bronchodilators
- Pancreatic enzyme replacement
Name the 3 most common organisms that cause community acquired pneumonia
- Streptococcus pneumoniae
- Haemophilus influenzae
- Mycoplasma pneumoniae
Name the 2 most common causes of hospital acquired pneumoniae
Gram negative enterobacteria
Staph aureus
What is the initial phase of TB treatment?
RIPE: 2 months on 4 drugs: rifampicin; isoniazid; pyrazinamide; ethambutol
What is the continuation phase of TB treatment?
RI: 4 months on 2 drugs: rifampicin and isoniazid
What are the side effects of rifampicin?
Raised LFTs (stop if bilirubin is raised)
Decreased platelets
Orange discolouration of urine, tears and contact lenses
Inactivation of the Pill
Flu symptoms
What are the side effects of isoniazid?
Raised LFTs
Decreased WCC
Stop if neuropathy
What are the side effects of ethambutol? What must you test as a result before and during treatment?
Optic neuritis (colour vision is 1st to deteriorate). Must test colour vision and acuity before and during treatment
Name 2 side effects of pyrazinamide
Hepatitis, arthalgia
Name 2 contraindications to a patient taking pyrazinamide
Acute gout; porphyria
A patient who is currently receiving treatment for TB presents to GP with orange urine - which medication is the likely cause?
Rifampicin
A patient who is currently receiving treatment for TB presents to GP and is pregnant despite being on the Pill! - which medication is the likely cause?
Rifampicin
A patient who is currently receiving treatment for TB presents to GP with deteriorating colour vision - which medication is the likely cause?
Ethambutol
A patient who is currently receiving treatment for TB presents to GP with joint pains - which medication is the likely cause?
Pyrazinamide
What signs would you see in a patient with pleural effusion?
- Decreased expansion
- Stony dull to percuss
- Decreased breath sounds
- Decreased tactile vocal fremitus
- ## Decreased vocal resonance (“repeat 99”)
What value of protein (in g/L) must a pleural effusion have below to be considered transudate?
Less than 25 g/L
Cardiac failure - does this cause a transudate or exudate pleural effusion?
Transudate
Constrictive pericarditis - does this cause a transudate or exudate pleural effusion?
Transudate
Cirrhosis - does this cause a transudate or exudate pleural effusion?
Transudate
Nephrotic syndrome - does this cause a transudate or exudate pleural effusion?
Transudate
Hypothyroidism - does this cause a transudate or exudate pleural effusion?
Transudate
Pneumonia - does this cause a transudate or exudate pleural effusion?
Exudate
Rheumatoid arthritis - does this cause a transudate or exudate pleural effusion?
Exudate
Mesothelioma - does this cause a transudate or exudate pleural effusion?
Exudate
SLE - does this cause a transudate or exudate pleural effusion?
Exudate
Bronchogenic carcinoma - does this cause a transudate or exudate pleural effusion?
Exudate
Generally, what is the cause of transudate pleural effusions?
Increased venous pressure or hypoproteinaemia
Generally, what is the cause of exudate pleural effusions?
Mostly due to increased leakiness of pleural capillaries secondary to infection, inflammation or malignancy
Generally, what is the cause of type 1 respiratory failure?
V/Q mismatch
Generally, what is the cause of type 2 respiratory failure?
Alveolar hypoventilation E.g. decreased respiratory drive (e.g. sedative drugs), neuromuscular disease (e.g. MG), thoracic wall disease
A patient gets short of breath when they walk up a hill but is otherwise fine - what is their MRC score?
2
What does an MRC score of 3 mean?
Walks slower than contemporaries on level ground because of breathlessness, or has to stop for breath when walking at own pace
A patient has to stop for breath after walking around 100m - what is their MRC score?
4
What does an MRC score of 5 mean?
The patient is too breathless to leave the house, or is breathless when dressing or undressing
Define chronic bronchitis
Cough, sputum production on most days for 3 months of 2 successive years.
How does the sputum in chronic bronchitis look like?
Clear and colourless
What is the pathophysiology behind emphysema?
Enlarged air spaces distal to terminal bronchioles, with destruction of alveolar walls
What does ABG of someone from an acute attack of asthma look like?
Usually shows normal/decreased PaO2 but decreased PaCO2 due to hyperventilation
Based on ABG, when should you consider transferring a patient suffering from an acute asthma attack to ITU?
If PaCO2 is normal or raised as this signifies failing respiratory effort
Name 4 side effects of salbutamol
Tachycardia, arrhythmias, tremor, hypokalaemia
What pattern on spirometry does interstitial lung disease give?
Restrictive pattern
In interstitial lung disease, which cells undergo hyperplasia?
Type II epithelial cells/pneumocytes
How does a pleural abscess present?
Swinging fever; purulent cough; pleuritic chest pain; haemoptysis; weight loss
What are the treatments available for pleural abscess?
- Abx (4-6 weeks)
- Postural drainage
- Repeated aspiration or surgical excision
What is the pathophysiology behind bronchiectasis?
Chronic infection of bronchi and bronchioles leading to permanent dilatation
How does bronchiectasis present?
Persistent cough; copious purulent sputum; intermittent haemoptysis; wheeze
What would you hear on auscultation of someone with bronchiectasis?
Coarse inspiratory crepitations
What would you see on the CXR of someone with bronchiectasis?
Thickened bronchial walls - tramline and ring shadows
What pattern would you see on spirometry of someone with bronchiectasis?
Obstructive
Why might you do bronchoscopy on someone with bronchiectasis?
To locate the site of haemoptysis and obtain samples for culture
What treatment is recommended for allergic bronchopulmonary aspergillosis (ABPA)?
Corticosteroids
What would happen to tactile vocal fremitus/ vocal resonance in pneumonia?
Increased
In severe cases of pneumonia, what might you check for and which investigations would you do?
- Legionella: sputum culture, urine antigen
- Atypical organism/ viral serology (PCR sputum)
- Check for pneumococcal antigen in urine
What does CURB 65 stand for?
Confusion (abbreviated mental test 8 or less)
Urea over 7 mmol/L
Respiratory rate 30 or more/min
BP 90 or less systolic +/- 60 or less diastolic
65: if over this age
If someone scores 1 of CURB 65, where should the patient be treated?
At home
If someone scores 2 of CURB 65, where should the patient be treated?
Hospital
If someone scores 3 of CURB 65, where should the patient be treated?
Consider ITU
List 7 groups that should be offered the pneumococcal vaccine
- Over 65 year olds
- Those suffering from chronic heart/ liver/ renal or lung conditions
- DM
- Immunosuppression
What investigations should be done on patients with suspected active TB?
CXR
Sputum samples (3 or more with 1 early morning sample before starting TX if possible) and send for MC&S and AFB
PCR allows rapid identification of rifampicin resistance
What test can you do to check for latent TB? If the result is positive, what should you then consider doing?
Mantoux test
If positive - consider interferon gamma testing
How should you treat someone with asymptomatic TB?
Prophylaxis: 1/2 anti-TB drugs for shorter periods of time
How is the tuberculin skin test carried out?
TB antigen is injected intradermally. There is a cell-mediated response @ 48 - 72 hours. Positive result = immunity or previous exposure.
Strong positive result = active TB
When might you get a false negative result for a tuberculin skin test?
In immunosuppression
A patient with suspected TB gets the results back from their sputum culture and it is negative - what should you do?
Continue if histology and clinical picture are consistent with TB
Is public health notification necessary for TB?
Yes
Is contact tracing necessary for TB?
Yes
By what means does military TB occur?
Haematogenous spread
What should you look out for in bone TB?
Vertebral collapse and Pott’s vertebrae
What effect can TB have on the pericardium?
Chronic pericardial effusion and constrictive pericarditis
What is the pathophysiology of spontaneous pneumothoraxes in young thin men?
Rupture of a subpleural bulla
What first treatment should be offered to someone with a 3cm primary pneumothorax that is short of breath?
Aspiration
What first treatment should be offered to a 30 year old man that is short of breath with a 4cm secondary pneumothorax?
Aspiration
Would be a chest drain if he was 50 or older
What treatment should be offered to someone with a 1cm primary pneumothorax that is not short of breath?
Consider discharge
What treatments and investigation should you do with someone with a tension pneumothorax?
1) Insert large-bore needle with syringe into 2nd ICS midclavicular line
2) Then CXR
3) Then chest drain
How does a large pleural effusion look like on chest x ray?
Water-dense shadows with concave upper borders
How does a pneumothorax look on CXR?
Completely flat horizontal upper border
What options are there for recurrent pleural effusions?
Pleurodesis (e.g. with tetracycline/talc) for recurrent effusions, surgery
How would the pleural fluid look like in someone with mesothelioma?
Bloody
What treatment can you offer someone with mesothelioma?
Pleurodesis and indwelling intra-pleural drain
Chemo can improve survival
Name 3 consequences of long-term hypoxia?
Polycythaemia; pulmonary HTN; cor pulmonale
List some symptoms of hypercapnia
Headache; peripheral vasodilation; tachycardia; bounding pulse; tremor/flap; papilledema; confusion
How can sarcoidosis present?
Erythema nodosum, non-productive cough, arthralgia, bilateral hilar lymphadenopathy, hypercalcaemia
Which measurement in spirometry is significantly reduced in obstructive lung disease?
FEV 1
Which measurement in spirometry is significantly reduced in restrictive lung disease?
FVC
Which pattern would you see on spirometry of someone with Acute Respiratory Distress Syndrome?
Restrictive lung disease
What is KCO?
KCO AKA transfer coefficient
= TLCO (Transfer Factor of the Lung for Carbon Monoxide) / alveolar volume
It measures how efficient gas exchange is relative to the alveolar-capillary surface to volume ratio
What would the KCO be in someone with chest wall disease?
It would be increased as there is a small alveolar volume, so in proportion to the alveolar volume, there is increased pulmonary blood flow (SA to volume ratio)
Which pattern would you see on spirometry of someone with Alpha-1 antitrypsin deficiency?
Obstructive
What would you see on chest x-ray of someone with ARDS?
Bilateral pulmonary infiltrates
What causes atelectasis?
Airways becoming obstructed by bronchial secretions
What treatment is available for someone with Atelectasis?
Chest physio with mobilisation and breathing exercises
What would you hear on auscultation of someone with Atelectasis?
Fine crackles
