Resp Flashcards
What are the 2 most common causes of acute cough
Upper respiratory tract infections (URI) and acute bronchitis are the most common causes of acute cough.
What are the 2 most common causes of sub-acute cough
Subacute cough is often a sequela of a URI (postinfectious cough) but can also be due to
1) chronic bronchitis
2) pneumonia.
What are the 2 most common causes of chronic cough
Chronic cough is often caused by rhinitis/sinusitis (upper airway cough syndrome), asthma, GERD, and ACE inhibitors.
Red flag symptoms of cough
SOB
Blood
Weight-loss
Fever
Which conditions can you see a nocturnal cough
Asthma and GERD
DDX for productive cough
pneumonia bronchitis bronchiectasis pulmonary edema tuberculosis
DDX for non-productive cough
asthma interstitial lung disease viral pneumonia (e.g., adenovirus. RSV, influenza virus)
What is the 3rd most common cause of cough
GERD
State some clinical features of PE
Acute onset of symptoms, often triggered by a specific event (e.g., on rising in the morning, sudden physical strain/exercise)
Dyspnea and tachypnea (> 50% of cases)
Sudden chest pain (∼ 50% of cases), worse with inspiration
Cough and hemoptysis
Possibly decreased breath sounds, dullness on percussion, split-second heart sound audible in some cases
Tachycardia (∼ 25% of cases), hypotension
Jugular venous distension
Low-grade fever
Syncope and shock with circulatory collapse in massive PE (e.g., due to a saddle thrombus)
Symptoms of DVT: unilaterally painful leg swelling
State 4 causes of pulmonary hypertension
1) COPD
2) Valvular heart disease-Mitral valve disease
3) chronic sleep apnea
4) idiopathic
What is the difference between cor pulmonale and pulmonary HTN
Pulmonary hypertension: chronically elevated mean pulmonary arterial pressure (mPAP) at rest ≥ 25 mm Hg (normal: 10–14 mm Hg) due to chronic pulmonary and/or cardiac disease or unknown reasons (idiopathic form)
Cor pulmonale: altered structure (hypertrophy, dilation) or impaired function of the right ventricle caused by pulmonary hypertension resulting from a primary disorder of the respiratory or pulmonary artery system
basically when Chronic lung disease CAUSES right-sided heart failure(it is called) cor pulmonale
State some signs you will see on physical examination for someone with pulmonary hypertension
Loud and palpable second heart sound (often split) Parasternal heave Nail clubbing Jugular vein distention Symptoms of right heart failure
What is the treatment for pulmonary hypertension
Treatment of the underlying cause
E.g., bronchodilators and inhalation corticosteroids for patients with COPD, CPAP for patients with obstructive sleep apnea
State some causes of heart failure-systolic or diastolic
Coronary artery disease, myocardial infarction
Arterial hypertension
Valvular heart disease
Diabetes mellitus (diabetic cardiomyopathy)
Renal disease
Infiltrative diseases (e.g., hemochromatosis, amyloidosis)
Cardiac arrhythmias
Dilated cardiomyopathy (e.g., Chagas disease, chronic alcohol use, idiopathic)
Myocarditis
Constrictive pericarditis
Restrictive or hypertrophic cardiomyopathy
Pericardial tamponade
Obesity
Smoking
COPD
Heavy drug (recreational and prescription) and alcohol abuse
The three major causes of heart failure are coronary artery disease, hypertension, and diabetes mellitus. Patients typically have multiple risk factors that contribute to the development of CHF.
Outline the management of PE patient
- go through stable patient
- unstable patient
Follow flow char on AMBOSS
PE ECG signs are:
Sinus tachycardia most commonly seen
Signs of right ventricular pressure overload
SIQIIITIII -pattern
New right bundle branch block
Bradycardia < 50 or tachycardia > 100 bpm
Right or extreme right axis deviation (30% of cases)
T negativity in leads V2and V3 (∼ 30%)
1st line treatment for PE-acute treatment
first line for haemodynamically stable PE/DVT Treatment- Apixaban (Direct Xa inhibitor) - remember do not use NOAC in renal impairment
eTG-Oral factor Xa inhibitors (eg apixaban, rivaroxaban) are preferred to dabigatran or warfarin to treat proximal DVT and PE because they do not require parenteral anticoagulation for initiation. Apixaban and rivaroxaban do not require routine anticoagulation monitoring; however, using the correct dose is vital because underdosing may not provide adequate anticoagulation.
What is the long term prophylaxis for PE
Long term anti-coagulation
- First-line- Apixaban
- DVT or PE provoking factor that is no longer present- anticoagulant therapy for 3 months
- Otherwise, assess risks and benefit.
Pregnancy VTE is
LMWH
Bronchial breath sounds in the lung parenchyma
Pneumonia
Bronchodilator reversibility/post-bronchodilator test
What findings need to be there in the test that allows differentiating between reversible obstruction from irreversible destruction
An increase in FEV1 by 200ml or 15% of the initial value indicates reversible airway obstruction(bronchial asthma)
3A’s of Klebsiella
Aspiration pneumonia
Alcoholics and diabetics
Abscess in lungs
Risk factors for melioidosis induced pneumonia
- what is the organism
- state risk factors
Risk factors
1) T2DM
2) Alcohol
3) Hazardous alcohol consumption
4) CKD
5) Chronic lung disease
6) Immunosuppressive therapy
What is the eTG management for pneumonia
Management- First is to assess Pneumonia severity, using CURB 65, SMART COP and clinical judgement. Essentially assess the degree of the derangement of vitals + lactate, confusion, multilobar involvement.
Empirical therapy
Low-severity- Out-patient (SMART-COP 0-2)
Mono- Amoxicillin (only if review possible within 48 hours),OR Combination- Amoxicillin, Doxycycline
Moderate severity - Hospital (SMART-COP 3-4)
Benzylpenicillin+ Doxycycline
High severity - ICU (SMART-COP >5)
Ceftriaxone + azithromycin
What is the eTG management for pneumonia in the wet climate
eTG- A repeat chest X-ray is recommended for adults 6 to 8 weeks after the episode of pneumonia to confirm resolution.
If in tropical region-
Low severity- Same as above
Moderate Severity- three drug regime
Ceftriaxone + Gentamicin + Doxycycline( the last one is a consideration)
High Severity
Wet- Meropenem or PipTaz + Azithromycin
Dry Season- Azithomycin + Ceftriaxone
All high severity cases we have to add Azithromycin(marcolide)
Complications of pneumonia-SLAP HER
- Respiratory failure
- Hypotension
- Atrial fibrillation( common in elderly)
- Pleural effusion( inflammation of the pleura by adjacent pneumonia may casue fluid exudation into the pleural space)
- Empyema( pus in the pleural space)
- Lung abscess
- Septicaemia
- Pericarditis and myocaridits
- Jaundice
Which location and what characteristics do small cell lung cancer(SCLC) posses
Location- central
Strong correlation with cigarette smoking
Pulmonary neuroendocrine tumour; associated with several paraneoplastic syndromes
Very aggressive; early metastases
Associated mutations: l-myc
What are the two main types of non-small cell lung cancer, which one is more common
Adenocarcinoma- More common
SCC
What are the characteristics of an adenocarcinoma-NSLC
Most common type of lung cancer overall and in women
Most common lung cancer in non-smokers
Associated mutations: EGFR , ALK , and KRAS
Distant metastases are common
Noninvasive subtype: bronchioloalveolar carcinoma
SCC in NSLC- state some characteristics
Strong association with smoking!
Cavitary lesions are common
Direct spread to hilar lymph nodes
↑ Parathyroid hormone-related protein (PTHrP) leads to hypercalcemia (See Hypercalcemia of malignancy)
↑ Parathyroid hormone-related protein (PTHrP) leads to hypercalcemia (See Hypercalcemia of malignancy)
Squamous cell carcinoma in NSLC
What are some extrapulmonary symptoms of lung cancer
1) Constitutional symptoms (weight loss, fever, weakness)
2) Clubbing of the fingers and toes
3) Signs or symptoms of tumour infiltration or compression of neighbouring structures
4) Paralysis of the recurrent laryngeal nerve: hoarseness
5) Paralysis of the phrenic nerve: results in diaphragmatic elevation and dyspnea
6) Malignant pleural effusion: dullness on percussion, reduced breath sounds on the affected side
Which lung cancer types give paraneoplastic sydrome and what are they
- Clinical syndrome due to chemical product by tumour (not tumour itself)
- 3-10% of lung cancers have this and it’s common in small cell carcinomas
- Small Cell Carcinoma
o Ectopic adrenocorticotropic hormone (ACTH) syndrome: usually results only in weight loss and weakness, but thin skin, wasting of the extremities, central obesity, hirsutism, menstrual irregularities, hypogonadism, bruising, and acne may rarely occur
o SIADH (Syndrome of Inappropriate Antidiuretic Hormone Secretion): excess ADH secretion, hypovolaemia and hyponatraemia
- Squamous Cell Carcinoma
o Hypercalcaemia – PTHrP secretion (or may indicate malignant bone metastases) - Adenocarcinoma
o Hypertrophic Pulmonary Osteoarthropathy (HPOA)/Finger Clubbing
What is the cut off for solitary pulmonary nodule to not be worried about
Less than 4mm if there is no clinical symptoms
If there are follow up in 12 months
What are signs of CXR that point to malignancy
Solitary nodule
Indirect signs: atelectasis, post-obstructive pneumonia, pleural effusion (particularly unilateral), mediastinal widening, cavitary lesions
Definition for pleural effusion
Pleural effusion is an accumulation of fluid in the pleural cavity between the lining of the lungs and the thoracic cavity (i.e., the visceral and parietal pleurae).
2 types of pleural effusion are
1) Transductive
2) Exudative
Pathophysiology for transductive pleural effusion
-state 3 causes
Increase in hydrostatic pressure
Decrease in oncotic pressure
Causes-
Congestive heart failure
Hepatic cirrhosis
Nephrotic syndrome
Pathophysiology for exudative pleural effusion
Increase in capillary permeability
Causes-
1) Infection
2) Malignancy
3) PE
4) Autoimmune
What is the criteria for pleural effusion
Light’s criteria
Pleural fluid with blood indicated
Malignancy
What is the treatment for pleural effusion
Treat underlying condition (e.g., loop diuretics for acute congestive heart failure, antibiotics for pneumonia).
Therapeutic thoracentesis to remove fluid
A chest x-ray should be performed after each of these procedures in order to rule out iatrogenic pneumothorax!
What is the life-threatening variant of pneumothorax
Tension pneumothorax
P-THORAX
Pleuritic pain Tracheal deviation Hyperresonance Onset sudden Reduced breath sounds (and dyspnea) Absent fremitus X-rays show collapse.
Tension pneumothorax the trachea shifts to the vs spontaneous pneumothorax the trachea shifts to the
In spontaneous pneumothorax, a shift may occur toward the ipsilateral side.
TP-Tracheal deviation towards the contralateral side
COPD
- what does treatment depend on
- what is the mainstay treatmtn
Treatment depends on the GOLD stage but is mainly comprised of
-short and long-acting bronchodilators (beta-agonists and parasympatholytics) and glucocorticoids.
3 main complications of COPD
1) Pulmonary hypertension
2) Exacerbation of COPD
3) Respiratory failure
Alveolar hypoventilation → hypoxic pulmonary vasoconstriction → pulmonary hypertension → cor pulmonale
Chronic bronchitis vs Emphysema
Chronic bronchitis: productive cough (cough with expectoration) for at least 3 months each year for 2 consecutive years
Emphysema: permanent dilatation of pulmonary air spaces distal to the terminal bronchioles. The condition is caused by the destruction of the alveolar walls and of the pulmonary capillaries required for gas exchange.
O2 therapy for COPD patients should be given with care why?
Their respiratory centres are relatively insensitive to CO2 and they rely on hypoxic drive to maintain respiratory effort —supplemental oxygen should be given with care.
FEV1/FVC has to be less than how much in COPD
70%
Post-bronchodilator test–> asthma vs COPD
FEV1 does not increase significantly (ΔFEV1 ≤ 12%)→ Irreversible bronchoconstriction → COPD more likely
FEV1 increases significantly → Reversible bronchoconstriction → Asthma more likely
What supplementation is needed for COPD
Vitamin D3 and calcium in cases of deficiency
Aspirin-induced asthma: mechanisms
Aspirin-induced asthma: NSAID inhibition of COX-1 → ↓ PGE2 → ↑ leukotrienes and inflammation → submucosal edema → airway obstruction
