Resp Flashcards
from UoL resp booklet
Describe scoring of MRC Dysponea Score
Grade of breathlessness related to activities: 1 Not troubled by breathlessness except on strenuous exercise 2 Short of breath when hurrying or walking up a slight hill 3 Walks slower than contemporaries on level ground because of breathlessness, or has to stop for breath when walking at own pace 4 Stops for breath after walking about 100m or after a few minutes on level ground 5 Too breathless to leave the house, or breathless when dressing or undressing
Conditions to ask about specifically for resp PMH
• Asthma (previous hospitalisation / ITU) • COPD • DVT / PE • Nasal Polyps • Previous lung infections, including TB • Childhood lung infections • Surgery • Cardiovascular illness • Cancer
What to ask in respiratory social history besides smoking & alcohol
• Occupational History – specifically asbestos • Pets – specifically cats, birds (budgies, parrots, pigeons) – also friends / neighbours • Recent Foreign Travel • Immobility – flights / long car or bus journeys • Activities of daily living – self care, cooking, cleaning, shopping, type of accommodation, helpers / carers
and performance status for cancer pts
What are you checking eyes for in resp exam?
Horners syndrome
What are you looking at in the neck for resp exam?
JVP, Lymph nodes,
trachea
How can shadowing (white stuff) on CXR be described (4 different types)?
Shadowing can be complete (whiteout of whole lung field), dense / consolidation (affecting one or more zones), diffuse, alveolar (cotton wool like appearance)
What is increased cardio-thoracic ratio on CXR a sign of?
Cardiomegaly
What parts of total lung capacity make up vital capacity?
Inspiratory reserve volume + tidal volume (=inspiratory capacity) + expiratory reserve volume
What is the A-a gradient? What is normal value of it?
Alveolar-arterial gradient, in young healthy people should be less than 2 kPa, and less than 4 kPa in older people (>4 kPa implies lung pathology )
Give an overview of the stages of the immunological response in anaphylaxis
IgE → antigen → mast cell & basophils ‡ → histamine ↑ → body response
How do you treat laryngeal oedema?
NEB adrenaline
How do you treat bronchospasm?
NEB salbutamol
Vital signs of severe asthma
(Cannot complete sentences in 1 breath) Respiratory Rate > 25/min • Heart Rate >110/min
Would you expect pCO2 to be raised in an asthma attack?
Hopefully not! raised pCO2 is a sign of near fatal asthma
Signs of life threatening asthma
hreatening (if any one of the following): • PEFR < 33% of best or predicted
• Sats <92% or ABG pO2 < 8kPa
• Cyanosis, poor respiratory effort, near or fully silent chest
• Exhaustion, confusion, hypotension or arrhythmias •
What O2 saturation are you aiming for when treating an asthma attack?
SpO2 94-98%
What medication would you consider giving in a SEVERE asthma attack ?
Nebulised Ipratropium Bromide 500 micrograms
and consider back to back salbutamol nebs
(for acute asthma mangement you will have already given 5mg neb salbutamol & 40mg oral prednisolone [or IV hydrocortisone])
What defines massive haemoptysis?
> 240mls in 24 hours OR • >100mls / day over consecutive days
What medication would you give for massive haemoptysis?
Oral Tranexamic Acid for 5 days or IV
consider Vit K, and add antibiotics if evidence of Respiratory Tract Infection
4 signs of tension pneumothorax
o hypotension
o tachycardia o deviation of the trachea away from the side of the pneumothorax
o Mediastinal shift away from pneumothorax
Symptoms of PE
– Chest pain (pleuritic) – SOB – Haemoptysis – Low cardiac output followed by collapse (if Massive PE)
2 imaging tests for PE
CT-PA
VQ scan (radionuclitide imaging of blood vessels)
(also echocardiography can show acute R heart strain if massive PE)
Absolute contraindications of thrombolysis
Haemorrhagic stroke or Ischaemic stroke < 6 months CNS neoplasia Recent trauma or surgery GI bleed < 1 month Bleeding disorder Aortic Dissection
Pharmacological management of massive PE
Consider thrombolysis with IV alteplase
Causes of wheeze, other than asthma or bronchitis!
• Pulmonary oedema • PE • Vocal cord dysfunction • Gastro-oesophageal reflux • Foreign body • Allergy • Hyperventilation / psychosocial • Cardiac disease • Vasculitides – Churg-Strauss syndrome, polyarteritis nodosa, Granulomatosis with Polyangiitis (Wegener’s granulomatosis) • Carcinoid syndrome with hepatic metastases – release of HIAA
Pathophysiology of asthma
Increased numbers of mucus secreting goblet cells and smooth muscle hyperplasia and hypertrophy.
Airway epithelial damage – shedding and subepithelial fibrosis, basement membrane thickening • An inflammatory reaction characterised by eosinophils, T-lymphocytes (Th2) and mast cells. Inflammatory mediators released include histamine, leukotrienes, and prostaglandins • Cytokines amplify inflammatory response •
Differentials for eosinophilia
• Airways inflammation (asthma or COPD) • Hayfever / allergies • Allergic Bronchopulmonary Aspergillosis • Drugs • Churg-Strauss / vasculitis • Eosinophilic Pneumonia • Parasites • Lymphoma • SLE • Hypereosinophilic syndrome
Define emphysema
alveolar wall destruction causing irreversible enlargement of air spaces distal to the terminal bronchiole
Causes of COPD in non-smokers
- Inherited α-1-antitrypsin deficiency
* Industrial exposure, e.g. soot
How much of the day does long term oxygen therapy have to be on?
At least 16 hours/day for a survival benefit
Criteria for COPD patients to get Long Term Oxygen Therapy?
pO2 consistently below 7.3 kPa, or below 8 kPa with cor pulmonale
• Patients must be non-smokers and not retain high levels of CO2
What does pulmonary rehabilitation consist of?
MDT 6-12 week programme of supervised exercise, unsupervised home exercise, nutritional advice, and disease education
Differentials of consolidation on CXR
• Pneumonia • TB (usually upper lobe) • Lung cancer • Lobar collapse (blockage of bronchi) • Haemorrhage
Causes of non-resolving pneumonia
- Complication – empyema, lung abscess
- Host – immunocompromised
- Antibiotic – inadequate dose, poor oral absorption
- Organism – resistant or unexpected organism not covered by empirical antibiotics
- Second diagnosis – PE, cancer, organising pneumonia
Differential Diagnosis of Haemoptysis
Infection: • Pneumonia • Tuberculosis • Bronchiectasis / CF • Cavitating lung lesion (often fungal) Malignancy: • Lung cancer • Metastases Haemorrhage: • Bronchial artery erosion • Vasculitis • Coagulopathy Others: • PE
What investigations may be needed for pneumonia beyond the initial CXR, FBC, U&E, CRP & sputum culture?
- If high CURB-65 score need Atypical pneumonia screen – serology and urine legionella test • ABG if low sats
- HIV test • Immunoglobulins • Pneumococcal IgG serotypes • Haemophilus influenzae b IgG
• Follow up in clinic in 6 weeks with a repeat CXR to ensure resolution
What tests besides routine bloods and sputum culture would you do for TB
HIV test
Vitamin D levels
+/- CT chest
MRI brain/spine, followed by LP if miliary TB suspected
Why is it particularly important to do LFTs when investigating TB?
TB treatments Rifampicin, Isoniazid and Pyrazinamide can cause hepatitis
Why is it important to test visual acuity before treating TB?
Ethambutol can cause Retrobulbar neuritis
What is bronchiectasis?
Chronic dilatation of one or more bronchi. The bronchi exhibit poor mucus clearance and there is predisposition to recurrent or chronic bacterial infection
What is the Gold standard diagnostic test for bronchietasis?
High Resolution CT
What is Kartagener syndrome?
triad of bronchiectasis, sinusitits, and situs inversus
Causes of bronchietasisi
- Post infective – whooping cough, TB
- Immune deficiency – Hypogammaglobulinaemia • Genetic / Mucociliary clearance defects – Cystic fibrosis, primary ciliary dyskinesia, Young’s syndrome (triad of bronchiectasis, sinusitis, and reduced fertility), Kartagener syndrome
- Obstruction – foreign body, tumour, extrinsic lymph node
- Toxic insult – gastric aspiration (particularly post lung transplant), inhalation of toxic chemicals/gases
- Allergic bronchopulmonary aspergillosis
- Secondary immune deficiency – HIV, malignancy
- Rheumatoid arthritis
- Associations – inflammatory bowel disease; yellow nail syndrome
Common organisms in bronchietasis
• Haemophilus influenzae • Pseudomonas aeruginosa • Moraxella catarrhalis • Stenotrophomonas maltophilia • Fungi – aspergillus, candida • Non-tuberculous mycobacteria • Less common - Staphylococcus aureus (think about CF)
How is CF diagnosed
One or more of the characteristic phenotypic features -
• Or a history of CF in a sibling
• Or a positive newborn screening test result
And
- An increased sweat chloride concentration (> 60 mmol/l) – SWEAT TEST
- Or identification of two CF mutations – genotyping
- Or demonstration of abnormal nasal epithelial ion transport (nasal potential difference)
How does CF present? (4 ways)
Meconium ileus
Intestinal malabsoprtion
Recurrent chest infections
Newborn screening
What causes intestinal malabsorption in CF?
The main cause is a severe deficiency of pancreatic enzymes.
What are the most common causes of Distal Intestinal Obstruction Syndrome (in CF)?
Most often due to insufficient prescription of pancreatic enzymes or non-compliance, also salt deficiency / hot weather
Whats the difference between pleural plaques and pleural thickening?
Pleural plaques = discrete fibrous areas which are localised while pleural thickening = larger areas scarring/ calcification causing thickening which can often be widespread
Risk factors for pneumothorax
- Pre-existing lung disease - Height - Smoking/ Cannabis - Diving - Trauma/ Chest procedure - Association with other conditions e.g. Marfan’s syndrome
When would you actively manage a primary pneumothorax?
If symptomatic and rim of air >2cm on CXR give O2 and aspirate
What is Light’s criteria used for when analysing pleural fluid?
If pleural fluid protein level between 25 and 35 g/L (i.e. borderline) can be used to decide if fluid exudate or transudate
What are Light’s criteria?
Light’s criteria dictates pleural fluid is exudate if it meets one or more of the following:
– Pleural fluid/Serum protein >0.5
– Pleural fluid/Serum LDH >0.6
– Pleural fluid LDH > 2/3 of the upper limit of normal
Causes of exudate effusions besides infection and malignancy
Inflammatory (rheumatoid arthritis, pancreatitis, benign asbestos effusion, Dressler’s, pulmonary infarction/pulmonary embolus), Lymphatic disorders, Connective tissue disease (Rare: Yellow nail syndrome, fungal infections, drugs)
Causes of transudate effusions
Heart failure
Cirrhosis
Hypoalbuminaemia (nephrotic syndrome or peritoneal dialysis)
Less common:
Hypothyroidism, mitral stenosis, pulmonary embolism
(Rare: Constrictive pericarditis, superior vena cava obstruction, Meig’s syndrome)
Types / causes of interstitial lung disease
- Usual Interstitial Pneumonia (UIP commest type)
- Non-specific Interstitial Pneumonia (NSIP)
- Extrinsic Allergic Alveolitis
- Sarcoidosis
What are the classical findings in Usual Interstitial Pneumonia?
- clubbing, reduced chest expansion
- Auscultation – fine inspiratory crepitations (like pulling Velcro slowly) – usually best heard basal / axillary areas
- Cardiovascular – may be features of pulmonary hypertension
How long does it typically take acute Extrinsic Allergic Alveolitis / Hypersensitivity Pneumonitis to resolve?
Spontaneously settle 1-3 days
What histological finding is present in sarcoidosis?
Non-caseating granulomas
Why might you need to do a CT/MRI head for a patient with sarcoidosis?
If they are getting headaches this is a sign of neuro sarcoid
What is the 5 year survival rate for lung cancer?
5 year survival approximately 13%
List paranoplastic signs of lung cancer
clubbing, hypercalcaemia, anaemia, SIADH, Cushing’s syndrome, Lambert-Eaton myasthenic syndrome, thrombo-embolic disease
What type of scan is mainly used for staging lung cancer?
Spiral CT Thorax and Upper Abdomen
PET if CT suggests low stage +/- surgical candidate
Most common types of lung cancer?
Small cell
Non-small cell e.g. squamous cell, adenocarcinoma, and large cell carcinoma, bronchoalveolar cancer
Median survival time for untreated small cell lung cancer
4-12 weeks
What is CPAP?
CPAP is an airway device supplies constant positive pressure during inspiration and expiration (is therefore not a form of ventilatory support.)
