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Resp Flashcards

1
Q

What pH is considered Alkalaemia?

A

pH>7.45

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2
Q

What can Alkalaemia cause?

A

Reduces free calcium causing Ca2+ ions to come out of solution, increasing neuronal excitability

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3
Q

What symptoms can Alkalaemia cause?

A

Paraesthesia and Tetany

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4
Q

What pH is considered Acidaemia?

A

pH<7.35

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5
Q

What can Acidaemia cause?

A

Increases plasma K+ concentration giving a risk of Arrythmia.
Also increases H+ concentrations, denaturing enzymes

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6
Q

Which ratio determines pH?

A

CO2:HCO3

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7
Q

What does arterial pCO2 depend on?

A

Respiration, controlled by chemoreceptors

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8
Q

What can disturb arterial pCO2?

A

Respiratory disease

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9
Q

What does arterial HCO3 depend on?

A

Renal excretion

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10
Q

What can disturb arterial HCO3?

A

Metabolic and Renal diseases

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11
Q

What is the primary role of HCO3 ions?

A

To buffer acids produced as a by-product of metabolism

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12
Q

Why aren’t HCO3 ions depleted when maintaining arterial pH?

A

The Kidneys both recover and produce HCO3

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13
Q

How is HCO3 produced in the PCT?

A

From amino acids, adding NH4 to urine

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14
Q

How is HCO3 produced in the DCT?

A

From CO2 and H2O

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15
Q

How does Metabolic Acidosis present?

A

pH <7.35
Lowered PaCO2
Lowered HCO3

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16
Q

How does Metabolic Alkalosis present?

A

pH>7.45
Increased PaCO2
Increased HCO3

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17
Q

How does Respiratory Acidosis present?

A

pH<7.35
Increased PaCO2
Increased HCO3

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18
Q

How does Respiratory Alkalosis present?

A

pH>7.45
Reduced PaCO2
Reduced HCO3

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19
Q

What are some causes of a low PaO2?

A

Hypoventilation
Diffusion Impairment
Shunt
V/Q Mismatch

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20
Q

When can it be useful to calculate the Alveolar - Arterial gradient?

A

If there is a suspected respiratory problem.

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21
Q

How is Alveolar O2 calculated?

A

P(Room Air) - (PaCO2/0.8)

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22
Q

What is the normal value for the partial pressure of room air?

A

20kPa

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23
Q

What should the A-a gradient be in healthy individuals?

A

<2kPa in younger patients

<4kPa IN OLDER PATIENTS

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24
Q

What does an A-a gradient of >4kPa suggest?

A

Lung pathology

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25
What is a Pulmonary Embolus?
Thrombus entering the Right side of the heart and pulmonary arteries
26
Where do Pulmonary Emboli normally originate from?
DVT in the Popliteal/Pelvic veins
27
What are some risk factors for a PE?
``` Pregnancy Prolonged immobilisation Previous VTE Long haul travel Cancer HF Obesity Smoking ```
28
What are some symptoms of a PE?
Pleuritic CP SOB Haemoptysis Low Cardiac Output leading to collapse
29
What are some physical signs of a PE?
Obvious Dyspnoea Tachycardia Low BP Raised JVP
30
A PE presents with RV overload. What is the pathophysiology behind this presentation?
Pulmonary artery pressure rises giving RV dilatation and strain. Inotropes are also released giving pulmonary vasoconstriction
31
When should an ABG be performed with a suspected PE?
Evidenc of Hypoxia needing Oxygen
32
What is a CXR needed for with a suspected PE?
To exclude other diagnoses
33
What may an ECG show with a PE?
RV Strain
34
What is D-Dimer?
A fibrin degredation product
35
When can a normal D-Dimer rule out PE?
In patients at low risk of a PE
36
When should a D-Dimer not be used?
If the patient is high risk
37
What is the investigation of choice for a suspected PE?
CT-PA
38
What are some recommended management steps for a confirmed PE?
``` ABCDE O2 if Hypoxic Fluid resuscitation if Hypotensive Anticoagulation Thrombolysis if signs of massive PE ```
39
Which Thrombolytic agent is recommended with a massive PE?
IV Alteplase
40
What are some Absolute contraindications to Thrombolysis with a massive PE?
``` Stroke less than 6 months ago CNS Neoplasia Recent Trauma/Surgery GI bleed less than 1 month ago Bleeding disorder Aortic Dissection ```
41
What are some Relative contraindications to Thromboysis with a massive PE?
Warfarin Pregnancy Advanced liver disease Infective endocarditis
42
What is Pneumonia?
Inflammation of lung alveoli due to a respiratory tract infection
43
What are some cardinal symptoms of Pneumonia?
Fever Cough Pleuritic CP SOB
44
What are the two primary types of Pneumonia?
Community Acquired Pneumonia (CAP) | Hospital Acquired Pneumonia (HAP)
45
What is Community Acquired Pneumonia (CAP)?
Pneumonia that was acquired prior to admission
46
What is Hospital Acquired Pneumonia (HAP)?
Pneumonia that develops over 48h post admission
47
What are some symptoms of CAP?
``` SOB Cough +/- Yellow/Brown sputum Fever Rigors Pleuritic CP Malaise N+V ```
48
What are some signs of CAP?
``` Pyrexia Tachycardia Tachypnoea Cyanosis Dullness to Percussion Tactile Vocal Fremitus Bronchial Breathing Crackles ```
49
What are some appropriate investigations for CAP?
``` FBC U+E CRP ABG CXR ```
50
Which samples are appropriate in suspected CAP?
``` Sputum Blood cultures Bronchoalveolar Lavage Nose and Throat swabs Urine Serum antibodies ```
51
Which score can be used to assess suspected CAP?
CURB - 65
52
Which CURB-65 score suggests admittance would be appropriate with CAP?
>2
53
What is the "C" of CURB-65?
Confusion - MMT score 2 or more worse than their usual score
54
What is the "U" of CURB-65?
Urea >7mmol/L
55
What is the "R" of CURB-65?
Respiratory Rate >30/min
56
What is the "B" of CURB-65?
Blood Pressure: <90mmHg Systolic <60mmHg Diastolic
57
What is the "65" in CURB-65?
65 years of age or older
58
For every positive CURB-65 factor, how many points does the patient get?
1
59
What management is appropriate for confirmed CAP?
ABCDE If septic, commence sepsis 6 Use local guidelines and CURB-65 score to guide choice of Abx
60
What are some common causative organisms of CAP?
S.pneumonia H.influenzae Legionella
61
What are some common causative organisms of HAP?
``` Staph Aureus Enterobacteriaciae Pseudomonas H. Influenzae Fungi ```
62
What is Anaphylaxis?
A serious allergic reaction as a result of a sensitised individual being exposed to a specific antigen
63
Where can anaphylactic antigens come from?
Insect bites/stings Foods Medications
64
What is the immunological response responsible for anaphylaxis?
Mast Cell and Basophil production in response to an antigen leading to increased Histamines giving the symptoms seen.
65
What are some signs/symptoms of anaphylaxis?
``` Pruritis Urticaria and Angioedema Hoarseness Stridor and Bronchial Obstruction Wheeze Chest Tightness ```
66
What should the immediate management of suspected anaphylaxis be?
Seek immediate help - crash call if appropriate Removal of trigger, maintainance of airway 100% O2
67
What Pharmacological intervention for anaphylaxis is appropriate?
IM Adrenaline 0.5mg every 5 mins as required IV Hydrocortisone 200mg IV Chlorpheniramine 10mg
68
If a patient in anaphylaxis is hypotensive, what is the recommended treatment?
Lie them flat and fluid resuscitate
69
Which treatment is recommended for Bronchospasm due to anaphylaxis?
Nebulised Salbutamol
70
Which treatment is recommended for Laryngeal oedema due to anaphylaxis?
Nebulised Adrenaline
71
How is massive Haemoptysis defined?
>240mls of Blood in 24h | >100ml of blood per day for consecutive days
72
What is the management of massive haemoptysis
ABCDE assessment If the site of lesion is known, lie the patient on the affected side Stop NSAIDS, Aspirin, Anticoagulants
73
What pharmacological intervention can be indicated with massive haemoptysis?
Tranexamic Acid PO for 5/7 or IV | Vitamin K
74
Which imaging is indicated in cases of massive haemoptysis?
CT - Aortagram with a view to possible interventional Bronchial artery embolisation.
75
What does the WHO performance status help to quantify?
Lung Ca status
76
How many stages are there in the WHO performance status for Lung Ca?
6
77
What criteria for Stage 0 of the WHO Lung Ca Performance status are there?
Patient is fully active without restriction
78
What criteria for Stage 1 of the WHO Lung Ca Performance status are there?
Patient is restricted in physically strenuous activity, but ambulatory and able to carry out light work
79
What criteria for Stage 2 of the WHO Lung Ca Performance status are there?
Ambulatory and capable of all self-care, but unable to carry out any work activities. Up and about more than 50% of waking time
80
What criteria for Stage 3 of the WHO Lung Ca Performance status are there?
Capable of only limited self-care, confined to bed or chair more than 50% of waking hours
81
What criteria for Stage 4 of the WHO Lung Ca Performance status are there?
Completely disabled. Cannot care for self. Totally confined to bed or chair.
82
What criteria for Stage 5 of the WHO Lung Ca Performance status are there?
Patient is deceased as a result of Lung Ca
83
What is Asthma?
A chronic inflammatory airway disease characterised by intermittent airway obstruction and hyper-reactivity
84
Which cells are activated in asthma?
Th2 cells
85
How does the activation of Th2 cells in asthma lead to symptoms?
Th2 cells produce Cytokines which activate mast cells and eosinophils, giving inflammation
86
What does the inflammation in Asthma lead to?
Mucosal oedema due to vascular leakage Bronchial wall thickening Mucous over-production leading to mucosal plugs Smooth muscle contraction
87
What are some triggers of Asthma?
``` Allergens Cold air Exercise Fumes Cigarette smoke Perfumes Chemicals NSAIDs Beta blockers Emotional distress ```
88
What are some clinical features of asthma?
``` Acute breathlessness +/- Wheeze/Cough Reduced Peak Flow/FEV1 Tachypnoea Tachycardia Anxiety ```
89
How is the body able to compensate for mild asthma?
Through hyperventilation of better ventilated areas
90
How does mild asthma present?
Low pCO2 and pO2 - Type 1 Respiratory Failure
91
How does Severe/Life threatening asthma present?
Low pO2, raised pCO2 - Type 2 Respiratory Failure
92
What pattern does asthma demonstrate on a Flow-Volume Loop?
Obstructive pattern
93
How will FEV1 change in asthmatic patients after administration of Bronchodilators?
Improve
94
What is the first stage in Pharmacological management of asthma?
Short Acting β2 Agonist
95
What is an example of a Short-Acting β2 Agonist?
Salbutamol
96
How do short-acting β2 agonists improve symptoms in asthma?
Reverses/Prevents bronchoconstriction
97
Why should short-acting β2 agonists only be used infrequently?
Regular use can increase mast cell degranulation, worsening symptoms
98
What are some common side-effects of short-acting β2 agonists?
Tachycardia Palpitations Tremor
99
What is the second stage in Pharmacological management of asthma?
Regular Preventer therapy through inhaled corticosteroids
100
Name a commonly used Inhaled Corticosteroid in treatment of asthma?
Beclamethasone
101
When is use of a regular preventer corticosteroid in asthma indicated??
If using β2 agonist >3 times a week If getting symptoms >3 times a week If waking with symptoms >once a week If they've had an exacerbation needing steroids in the last two years
102
How do inhaled corticosteroids improve symptoms in asthma?
Reduce inflammation
103
What can be added on to inhaled corticosteroids in asthma if symptoms persist?
Long-Acting β2 agonist
104
Name a long-acting β2 agonist for asthma?
Formoterol
105
When is a long-acting β2 agonist indicated in asthma?
If symptoms are not being controlled with 400mcg per day of inhaled corticosteroid
106
Can Formoterol be prescribed on its' own?
No, must be prescribed with an inhaled corticosteroid i.e. Beclamethosone + Formoterol
107
What are some alternatives to Formoterol as an add-in therapy for Asthma?
Leukotriene Antagonists - Montelukast Long Acting Anticholinergics - Tiotropium Bromide Methylxanthines - Theophylline
108
What biological therapies are available for the treatment of asthma?
Anti IgE - Omalizumab | Anti IL5 - Mepolizumab
109
Which symptoms indicate an acute severe asthma attack in adults?
``` Any one of: Unable to complete sentences Pulse >110bpm RR>25/min Peak Flow ```
110
Which features of an asthma attack suggest it is life-threatening?
``` SpO2<92% PaO2<8kPa PaCO2>4.5kPa Silent chest Cyanosis Feeble respiratory effort Hypotension Bradycardia Arrythmia ```
111
What is the recommended treatment for an acute severe/life threatening asthma attack?
High Flow O2 - Aim for sats of 94-98 Nebulised Salbutamol 40mg Prednisolone PO for 10-14 days Nebulised Ipratroprium/IV Aminophylline if needed
112
What is COPD?
An umbrella term encompassing both Emphysema and Chronic Bronchitis
113
How is COPD characterised?
Progressive airway obstruction, usually due to smoking
114
What is Emphysema?
Pathological destruction of terminal bronchioles and distal air spaces reducing alveolar surface area and leading to development of bullae.
115
How does the destruction of bronchioles in COPD affect gaseous diffusion?
Destruction of supporting tissues of small airways leads to collapse during expiration Also gives lung hyperinflation
116
What is Chronic Bronchitis?
Inflammation of large airways leading to mucus hypersecretion through proliferation of mucus producing cells. Leads to airway narrowing and obstruction
117
What are some common causes of COPD?
Smoking Alpha-1-Antitrypsin deficiency Occupational exposure Pollution
118
What are some symptoms of COPD?
Cough and Sputum Production | Progressive breathlessness
119
How are COPD patients assessed?
MRC Dyspnoea score
120
What are some clinical signs of COPD?
``` Pursed-lip breathing to prevent small airway collapse Tachypnoea Use of accessory muscles Hyperinflation Wheeze on auscultation Cyanosis and signs of CO2 retention Reduced FEV1 ```
121
How can the airway obstruction in COPD be characterised?
Mild Moderate Severe
122
How is FEV1 affected in Mild COPD?
50-80% of predicted best
123
How is FEV1 affected in Moderate COPD?
30-49% of predicted best
124
How is FEV1 affected in Severe COPD?
<30% of predicted best
125
What are some management options for COPD?
``` Smoking cessation Pulmonary rehabilitation Bronchodilators Anti-muscarinics Steroids Mucolytics Diet modification Flu Vaccine Long-Term Oxygen Therapy Lung Volume reduction Non-invasive ventilation ```
126
What is MRC Dyspnoea score 1?
Not troubled by breathlessness except on strenuous exercise
127
What is MRC Dyspnoea score 2?
SOB when hurrying/walking uphill
128
What is MRC Dyspnoea score 3?
Walks slower than contemporaries on level ground due to breathlessness, or must stop for breath when walking at own pace
129
What is MRC Dyspnoea score 4?
Stops for breath after walking 100m or a few minutes on level ground
130
What is MRC Dyspnoea score 5?
Too breathless to leave the house
131
How can COPD exacerbations be qualified?
Infective | Non-Infective
132
How do infective exacerbations of COPD present?
Change in sputum colour/volume Fever Raised WCC +/- CRP
133
What are the generalised management steps for a COPD exacerbation?
ABCDE Oxygen Bronchodilators Steroids
134
How should Oxygen be given to COPD exacerbation patients?
Through a fixed performance mask due to the risk of CO2 retention
135
What are the target SATS of COPD patients?
88-92%
136
What nebulisers should be given to patients with an exacerbation of COPD?
Nebulised Salbutamol and Ipratroprium
137
How much steroids should be given to patients with an exacerbation of COPD?
30mg Prednisolone Stat, OD for 7/7
138
When should NIV be considered with an exacerbation of COPD?
Type 2 Respiratory failure and pH 7.25-7.35
139
When should an exacerbation of COPD be referred to ITU?
If pH <7.25
140
What is TB?
A respiratory infection caused by bacteria of the Mycobacterium Tuberculosis complex
141
How is TB transmitted?
Droplets produced during coughing, sneezing. | Must be prolonged exposure
142
What are the two forms of TB infection?
Clinical - Primary/Active TB | Subclinical - Latent TB
143
How does TB present pathologically?
Caseating Granulomas within lung parenchyma/mediastinal lymph nodes.
144
What are some risk factors for TB?
PMHx TB Known history of TB contact Originally from a country of high TB incidences Foreign travel to a country with a high incidence of TB Evidence of immunosuppression
145
What are some symptoms of TB?
``` Fever Night sweats W/loss and anorexia Tiredness and Malaise Cough Haemoptysis Breathlessness ```
146
Which investigations are appropriate with suspected TB?
``` CXR 3 sputum samples - Test via Ziel-Niellson stain Induced sputum Bronchoscopy Routine bloods inc LFTs, HIV, Vitamin D CT Chest ```
147
What are some non-respiratory manifestations of TB?
``` Skin Lymphadenopathy Bone/Joint Abdominal CNS Genitourinary Miliary ```
148
What are some management steps for TB?
ABCDE approach Send samples/cultures If high suspicion and patient unwell, commence anti TB treatment once samples are sent Notify TB nurses
149
Which medications are the treatment of choice for TB
Rifampicin, Isoniazide - 6 month course | Pyazinamide, Ethambutol - 2 month course initially
150
What are some important side effects of TB treatment?
Rifampicin - Orange/Red secretions Ethambutol - Retrobulbar Neuritis Hepatitis Peripheral neuropathy
151
What is important to consider before starting TB treatment?
Baseline visual acuity and LFTs, then monitor throughout treatment
152
What is Bronchiectasis?
Chronic dilatation of 1/more bronchi. These exhibit poor mucus clearance and there is a predisposition to recurrent/chronic bacterial infection
153
What are some causes of Bronchiectasis?
``` Post-Infective - Whooping Cough/TB Primary Immune Deficiency Secondary Immune Deficiency - HIV, Malignancy Genetic - CF Obstruction - FB, Tumour Toxic Insult - Gastric aspiration, inhalation of gases Bronchopulmonary Aspergillosis RA ```
154
What are some common organisms that can cause infection in Bronchiectasis?
Haemophilus Influenzae Pseudomonas aeruginosa Aspergillus Candida
155
What is the investigation of choice with suspected Bronchiectasis?
High Resolution CT
156
What are some management steps for Bronchiectasis/Infection?
``` Treat underlying cause Physio - Mucus clearance Abx of sensitive organism Flu Vaccine, Bronchodilators Pulmonary Rehab if MRC >3 ```
157
What is Cystic Fibrosis?
An autosomal recessive disease leading to mutations in the Cystic Fibrosis Transmembrane Conductance Regulator (CFTR) gene leading to a multisystem disease characterised by thickened secretions
158
How is Cystic Fibrosis diagnosed?
1/more phenotypic features, Hx of CF in sibling or +ve screening test AND Increased Sweat Cl- concentration of 60mmol/L Identification of 2 CF mutations Demonstration of abnormal nasal epithelial ion transport
159
What are some common presentations suggestive of Cystic Fibrosis?
Meconium Ileus Intestinal Malabsorption Recurrent Chest Infections Newborn Screening
160
What is Meconium Ileus?
Newborn patients present with an intestinal obstruction due to thick secretions. Found in 15-20% of newborn CF patients
161
What are some clinical features suggestive of CF?
``` Chronic Sinusitis Nasal polyps Recurrent LRTIs Abnormal sweat secretions Bronchiectasis Liver disease Diabetes Finger Clubbing Steatorrhoea Osteoporosis Male infertility Arthropathy ```
162
How are Respiratory Infections in CF patients managed?
Aggressive Physio and Abx | Often given Prophylactic Abx
163
How is low body weight in CF patients managed?
Careful monitoring | High calorie intake and additional supplements
164
What is Distal Intestinal Obstruction Syndrome (DIOS)?
Faecal obstruction in ileocaecum due to thick contents in distal ileum. Presents as a palpable RIF mass in CF patients
165
What lifestyle advice should be given to CF patients?
``` No smoking Avoid other CF patients Avoid friends with colds/infections Avoid Jacuzzis - Pseudomonas Clear and dry nebulisers thoroughly Avoid stables, compost and rotting vegetation Annual Flu Vaccine NaCl tablets in hot weather/after vigorous exercise ```
166
What are some causes of a Non-Resolving Pneumonia?
``` Complication - Empyema, lung abscess Host - Immunocompromised Antibiotic - Inadequate dose, poor absorption Organism - Resistant, unexpected course Second Diagonsis - PE/Cancer ```
167
What are some infective causes of Haemoptysis?
Pneumonia TB Bronchiectasis/CF Cavitating lung lesion
168
What are some malignant causes of Haemoptysis?
Lung Ca | Metastases
169
What are some haemorrhagic causes of Haemoptysis?
Bronchial Artery erosis Vasculitis Coagulopathy
170
What is the Pleural Cavity?
A potential space created by pleural surfaces which contains pleural fluid
171
What is a Pneumothorax?
Air in the Pleural cavity
172
What is a Pleural Effusion?
Fluid in the Pleural cavity
173
What is an Empyema?
Infected fluid in the pleural cavity
174
What types of Pneumothorax are there?
Spontaneous Traumatic Tension Iatrogenic - Post central line/pacemaker
175
What types of Spontaneous Pneumothorax are there?
Primary - No Lung Disease | Secondary - Lung Disease
176
What are some risk factors for a Pneumothorax?
``` Pre-existing lung disease Height Smoking/Cannabis Diving Trauma/Chest procedure Other conditions e.g Marfans ```
177
What is the recommended management for a Primary Pneumothorax?
If symptomatic and the rim of air measures more than 2cm on CXR then give O2 and aspirate. Insert a chest drain if unsuccessful
178
What is the recommended management for a Secondary Pneumothorax?
Consider a drain insertion earlier than with a Primary Pneumothorax
179
What advice should a Pneumothorax patient be given?
No flying or diving until resolved
180
What investigations are appropriate with a suspected Pleural Effusion?
``` CXR ECG FBC, U+E, LFTs, CRP, Bone Profile ECHO if ?HF Staging CT if ?Malignancy USS Guided Pleural aspiration ```
181
What defines a Transudate Effusion?
Protein content <30g/L
182
What are some causes of a transudate pleural effusion?
``` HF Cirrhosis Hypoalbuminaemia PE Hypothyroid ```
183
What treatment is recommended for a transudate pleural effusion?
Treat underlying cause | If effusion persists, then aspirate/drain
184
What defines an Exudate Effusion?
Protein content >30g/L
185
What are some causes of an exudate pleural effusion?
``` Malignancy Infection Inflammatory Fungal infections Drugs ```
186
What does Lights Criteria determine?
Whether the fluid is a transudate or exudate
187
What is Interstitial Lung Disease?
An umbrella term describing a number of conditions that affect the lung parenchyma in a diffuse manner
188
What are some examples of interstitial lung diseases?
Usual Interstitial Pneumonia (UIP) Non-Specific Interstitial Pneumonia (NSIP) Extrinsic Allergic Alveolitis
189
How do Interstiatial lung diseases affect Peak Flow?
Usually demonstrate a restrictive pattern
190
How does Usual Interstitial Pneumonia present?
Clubbing Reduced chest expansion Fine Inspiratory Crepitations (Velcro) Features of Pulmonary Hypertension
191
What is Extrinsic Allergic Alveolitis?
Inhalation of an organic antigen to which the individual has been sensitised
192
How can Extrinsic Allergic Alveolitis present?
Acute - Short period from exposure, usually reversible | Chronic - Less reversible, longer exposure
193
What is Sarcoidosis?
Multisystem inflammatory condition of unknown cause. Forms non-caseating granulomas, leads to an immunological response
194
What investigations are useful with suspected Sarcoidosis?
``` Peak Flow CXR Renal Function and Calcium ECG, ECHO, Cardiac MRI if ?Cardiac Involvement CT/MRI head if headaches ```
195
What are some treatment options for interstitial lung diseases?
``` Remove exposure Stop causative drug Stop smoking Lung transplantation Treatment of infections Oxygen Palliation ```
196
What are some risk factors for Lung Ca?
``` Large number of Pack Years Airflow Obstruction Increasing Age FHx Exposure to carcinogens e.g. Asbestos ```
197
What are some clinical features of Lung Ca?
``` Asymptomatic - Incidental finding Respiratory symptoms SVC obstruction Horners Syndrome Paraneoplastic - SIADH ```
198
What are some appropriate investigations for suspected Lung Ca?
``` FBC, U+E, Calcium, LFTs, INR CXR Staging CT Chest and Upper Abdo CT Biopsy PET Scan ```
199
What are the most common histological types of Lung Ca?
Small-Cell Lung Ca | Non-Small Cell Lung Ca - Squamous Cell, Adenocarcinoma, Large cell Carcinoma

Year 3 Medicine (8 decks)

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