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**Clinical Med** UoL by SJC > Resp > Flashcards

Resp Flashcards

from UoL resp booklet

1
Q

Describe scoring of MRC Dysponea Score

A

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

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2
Q

Conditions to ask about specifically for resp PMH

A

• Asthma (previous hospitalisation / ITU) • COPD • DVT / PE • Nasal Polyps • Previous lung infections, including TB • Childhood lung infections • Surgery • Cardiovascular illness • Cancer

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3
Q

What to ask in respiratory social history besides smoking & alcohol

A

• 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

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4
Q

What are you checking eyes for in resp exam?

A

Horners syndrome

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5
Q

What are you looking at in the neck for resp exam?

A

JVP, Lymph nodes,

trachea

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6
Q

How can shadowing (white stuff) on CXR be described (4 different types)?

A

Shadowing can be complete (whiteout of whole lung field), dense / consolidation (affecting one or more zones), diffuse, alveolar (cotton wool like appearance)

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7
Q

What is increased cardio-thoracic ratio on CXR a sign of?

A

Cardiomegaly

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8
Q

What parts of total lung capacity make up vital capacity?

A

Inspiratory reserve volume + tidal volume (=inspiratory capacity) + expiratory reserve volume

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9
Q

What is the A-a gradient? What is normal value of it?

A

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 )

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10
Q

Give an overview of the stages of the immunological response in anaphylaxis

A

IgE → antigen → mast cell & basophils ‡ → histamine ↑ → body response

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11
Q

How do you treat laryngeal oedema?

A

NEB adrenaline

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12
Q

How do you treat bronchospasm?

A

NEB salbutamol

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13
Q

Vital signs of severe asthma

A

(Cannot complete sentences in 1 breath) Respiratory Rate > 25/min • Heart Rate >110/min

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14
Q

Would you expect pCO2 to be raised in an asthma attack?

A

Hopefully not! raised pCO2 is a sign of near fatal asthma

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15
Q

Signs of life threatening asthma

A

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 •

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16
Q

What O2 saturation are you aiming for when treating an asthma attack?

A

SpO2 94-98%

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17
Q

What medication would you consider giving in a SEVERE asthma attack ?

A

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])

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18
Q

What defines massive haemoptysis?

A

> 240mls in 24 hours OR • >100mls / day over consecutive days

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19
Q

What medication would you give for massive haemoptysis?

A

Oral Tranexamic Acid for 5 days or IV

consider Vit K, and add antibiotics if evidence of Respiratory Tract Infection

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20
Q

4 signs of tension pneumothorax

A

o hypotension
o tachycardia o deviation of the trachea away from the side of the pneumothorax
o Mediastinal shift away from pneumothorax

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21
Q

Symptoms of PE

A

– Chest pain (pleuritic) – SOB – Haemoptysis – Low cardiac output followed by collapse (if Massive PE)

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22
Q

2 imaging tests for PE

A

CT-PA
VQ scan (radionuclitide imaging of blood vessels)
(also echocardiography can show acute R heart strain if massive PE)

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23
Q

Absolute contraindications of thrombolysis

A 
Haemorrhagic stroke or Ischaemic stroke < 6 months 
 CNS neoplasia 
 Recent trauma or surgery 
 GI bleed < 1 month 
 Bleeding disorder 
 Aortic Dissection
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24
Q

Pharmacological management of massive PE

A

Consider thrombolysis with IV alteplase

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25
Q

Causes of wheeze, other than asthma or bronchitis!

A

• 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

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26
Q

Pathophysiology of asthma

A

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 •

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27
Q

Differentials for eosinophilia

A

• Airways inflammation (asthma or COPD) • Hayfever / allergies • Allergic Bronchopulmonary Aspergillosis • Drugs • Churg-Strauss / vasculitis • Eosinophilic Pneumonia • Parasites • Lymphoma • SLE • Hypereosinophilic syndrome

28
Q

Define emphysema

A

alveolar wall destruction causing irreversible enlargement of air spaces distal to the terminal bronchiole

29
Q

Causes of COPD in non-smokers

A
  • Inherited α-1-antitrypsin deficiency

* Industrial exposure, e.g. soot

30
Q

How much of the day does long term oxygen therapy have to be on?

A

At least 16 hours/day for a survival benefit

31
Q

Criteria for COPD patients to get Long Term Oxygen Therapy?

A

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

32
Q

What does pulmonary rehabilitation consist of?

A

MDT 6-12 week programme of supervised exercise, unsupervised home exercise, nutritional advice, and disease education

33
Q

Differentials of consolidation on CXR

A

• Pneumonia • TB (usually upper lobe) • Lung cancer • Lobar collapse (blockage of bronchi) • Haemorrhage

34
Q

Causes of non-resolving pneumonia

A
  • 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
35
Q

Differential Diagnosis of Haemoptysis

A

Infection: • Pneumonia • Tuberculosis • Bronchiectasis / CF • Cavitating lung lesion (often fungal) Malignancy: • Lung cancer • Metastases Haemorrhage: • Bronchial artery erosion • Vasculitis • Coagulopathy Others: • PE

36
Q

What investigations may be needed for pneumonia beyond the initial CXR, FBC, U&E, CRP & sputum culture?

A
  • 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

37
Q

What tests besides routine bloods and sputum culture would you do for TB

A

HIV test
Vitamin D levels
+/- CT chest
MRI brain/spine, followed by LP if miliary TB suspected

38
Q

Why is it particularly important to do LFTs when investigating TB?

A

TB treatments Rifampicin, Isoniazid and Pyrazinamide can cause hepatitis

39
Q

Why is it important to test visual acuity before treating TB?

A

Ethambutol can cause Retrobulbar neuritis

40
Q

What is bronchiectasis?

A

Chronic dilatation of one or more bronchi. The bronchi exhibit poor mucus clearance and there is predisposition to recurrent or chronic bacterial infection

41
Q

What is the Gold standard diagnostic test for bronchietasis?

A

High Resolution CT

42
Q

What is Kartagener syndrome?

A

triad of bronchiectasis, sinusitits, and situs inversus

43
Q

Causes of bronchietasisi

A
  • 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
44
Q

Common organisms in bronchietasis

A

• Haemophilus influenzae • Pseudomonas aeruginosa • Moraxella catarrhalis • Stenotrophomonas maltophilia • Fungi – aspergillus, candida • Non-tuberculous mycobacteria • Less common - Staphylococcus aureus (think about CF)

45
Q

How is CF diagnosed

A

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)
46
Q

How does CF present? (4 ways)

A

Meconium ileus
Intestinal malabsoprtion
Recurrent chest infections
Newborn screening

47
Q

What causes intestinal malabsorption in CF?

A

The main cause is a severe deficiency of pancreatic enzymes.

48
Q

What are the most common causes of Distal Intestinal Obstruction Syndrome (in CF)?

A

Most often due to insufficient prescription of pancreatic enzymes or non-compliance, also salt deficiency / hot weather

49
Q

Whats the difference between pleural plaques and pleural thickening?

A

Pleural plaques = discrete fibrous areas which are localised while pleural thickening = larger areas scarring/ calcification causing thickening which can often be widespread

50
Q

Risk factors for pneumothorax

A
  • Pre-existing lung disease - Height - Smoking/ Cannabis - Diving - Trauma/ Chest procedure - Association with other conditions e.g. Marfan’s syndrome
51
Q

When would you actively manage a primary pneumothorax?

A

If symptomatic and rim of air >2cm on CXR give O2 and aspirate

52
Q

What is Light’s criteria used for when analysing pleural fluid?

A

If pleural fluid protein level between 25 and 35 g/L (i.e. borderline) can be used to decide if fluid exudate or transudate

53
Q

What are Light’s criteria?

A

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

54
Q

Causes of exudate effusions besides infection and malignancy

A 
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)
55
Q

Causes of transudate effusions

A

 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)

56
Q

Types / causes of interstitial lung disease

A
  • Usual Interstitial Pneumonia (UIP commest type)
  • Non-specific Interstitial Pneumonia (NSIP)
  • Extrinsic Allergic Alveolitis
  • Sarcoidosis
57
Q

What are the classical findings in Usual Interstitial Pneumonia?

A
  • 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
58
Q

How long does it typically take acute Extrinsic Allergic Alveolitis / Hypersensitivity Pneumonitis to resolve?

A

Spontaneously settle 1-3 days

59
Q

What histological finding is present in sarcoidosis?

A

Non-caseating granulomas

60
Q

Why might you need to do a CT/MRI head for a patient with sarcoidosis?

A

If they are getting headaches this is a sign of neuro sarcoid

61
Q

What is the 5 year survival rate for lung cancer?

A

5 year survival approximately 13%

62
Q

List paranoplastic signs of lung cancer

A

clubbing, hypercalcaemia, anaemia, SIADH, Cushing’s syndrome, Lambert-Eaton myasthenic syndrome, thrombo-embolic disease

63
Q

What type of scan is mainly used for staging lung cancer?

A

Spiral CT Thorax and Upper Abdomen

PET if CT suggests low stage +/- surgical candidate

64
Q

Most common types of lung cancer?

A

Small cell

Non-small cell e.g. squamous cell, adenocarcinoma, and large cell carcinoma, bronchoalveolar cancer

65
Q

Median survival time for untreated small cell lung cancer

A

4-12 weeks

66
Q

What is CPAP?

A

CPAP is an airway device supplies constant positive pressure during inspiration and expiration (is therefore not a form of ventilatory support.)

**Clinical Med** UoL by SJC (10 decks)

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