Resp Flashcards
COPD risk factors
Smoking Working with coal advanced age genetic factors white ancestry
What factors in history would make you consider TB
African Asian origin
HIV positive
Airway obstruction leading to bronchiectasis
Tumours
Foreign objects which lead to pneumonia and chronic inflammation
Why does lung appear as white out in atelectasis
Normally lung appears black due to proportion of air to tissue being much higher however in collapse there is no air
Causes of T2 resp failure
Local
CNS- spinal chord lesions, drug overdose, tumour, trauma
NMJ-Myasthenia gravis
What is most thing to ensure when administering ABx for CAP
Strep pneumoniae included
Eye involvement of sarcoid
Uveitis
Papilloedema
What can mainly give cannonball metastases in lungs
Renal cell carcinomas
Gastro cause of cough
GORD
When is only time you thrombolyse a PE
When very haemodynamically compromised
Why is CT done in lung cancer
Identify nature and location
Features of asthma cough
Chronic non productive cough
Nocturnal cough
Precipitated by common triggers
Most times comes before wheeze
Prognosis of invasive aspergillosis
Poor
What is fanncy name for collapsed lung
Atelectasis
What are miliary small nodules
Innumerable small nodules seen around lung hilum
Immediate investigations for PE
CXR
ECG
ABG
What type of drug is ipatropium bromide
Anit muscarinic
Long term management of pneumothorax
Pleurodesis
What is key investigation with suspected pneumonia
Get sputum and blood cultures to determine type of ABx to be given
What is main sign of worsening active sarcoid
Any sign of active inflammation
Very common cause of mixed rf
Acute asthma
Aetiology of tension pneumothorax
Ventilation
Trauma
Blocked chest drain
Lung conditions
Danger of tension pneumothorax in young people for doctors
Can appear fine but then drastically deteriorate
How does pneumothorax happen
When air from either alveoli or atmosphere gains access to pleural space. Pleural space has lower pressure than both of these so air will flow in until obstruction blocked or pressure equalises
Investigations for cancer post CXR
Bronchoscopy with biopsy
CT chest and abdo
Pathology of mesothelioma
Inhalation of asbestos fibres end up in pleural space leading to growth of pleural mesothelium that grows and encases lungs
How long should you be on warfarin post PE
3-6 months however permenant if recurrent PEs
What is FEV/FCV in obstructive resp diseases
Reduced- less than normal .7 or .8
Presentation of lung fibrosis
Dry cough
Clubbing
SOB
Symptoms of pneumothorax
Chest pain
SOB
Risk factors pneumothorax
Tall and slim
Male
Smoking
Underlying lung conditions
Auscultation sign of lung fibrosis
Late inspiratory creps
What part of resp system is responsible for T2 rf
Respiratory apparatus bringing air in and out
Key factor in nature of asthma
Temperamental, you see a lot of variation in sx depending on season for example
Management of PE
Anticoagulation
Oxygen if low sats
IV fluids
Risk factors for CAP
Over 65 Asthma and COPD Smoker Living in nursing home Alcohol use
Symptoms and signs of asbestos
Dyspnoea on exertion first sign
Non productive cough
Crackles at lung bases
Clubbing
How to definitively diagnose pneumothorax
PA erect CXR- identify rim and measure
Presentation of TB
Cough
Sputum
Weight loss
Night sweats
When will co2 be low in T1 rf
When hyperventilating
Brain stem T2 rf causes
Cva
Sol
Opiates
Benzodiazepine
What is defining feature of obstructed airway
Stridor
How does sarcoid present
Malaise Pyrexia Arthralgia Arthritis Erythema nodosum
What differentiates pneumonia from a LRTI
Consolidation on CXR
Investigations of bronchopulmonary aspergillosis
Positive aspergillus skin test
Raised IgE
Eosinophilia
Serum precipitins
Where do you do aspiration
2nd ICS MCL
What method can be used to prevent recurrence of pleural effusions
Installation of sclérosants into pleural space
What are diagnostic methods for mesotheliomas
Thoracoscopy with biopsy and histology of pleura
Investigations for asbestosis
Lung function tests- restrictive findings
CXR pa and lateral- show pleural thickening and interstitial fibrosis in lower zones bilaterally
What does reticular nodular shadowing
Nodular means nodule shaped
Reticular means net appearance
CAP on examination
Reduced air entry in affected lungs
Crackling on auscultation too
Dullness on percussion
Pathophysiology of T2 resp failure
Alveolar hypoventilation with or without VQ mismatch Reduced CNS output NMJ problems Chord lesions Thoracic wall problems
What is name of anti IgE AB in asthma treatment
Omalizumab
What condition is identical to sarcoid
Berylliosis
What could hypercalcaemia be confused with in sarcoid when lymphadenopathy
Lymphoma
Management of pneumonia patients
Use CURB 65 to assess mortality risk Confusion Urea over 7mmol/L RR over 30 Blood pressure below 90 SBP or 60DBP 65 age
Common asthma triggers
Exercise
Smoking
Cold air
Infections
What is FEV/FCV in restrictive diseases
Normal but FCV and FEV1 are reduced
What are 3 most common causes of atypical pneumonia
Legionella
Chlamydia
Mycoplasma
Haem findings sarcoid
Lymphocytosis
ACE
Alpha 1 hydroxylase
Calcium
Worse prognosis signs on HRCT
Honeycombing
Groundglass findings
Treatment of choice for mycetoma
Surgical removal
Drugs not helpful
How can resp failure be classified
Acute vs chronic
Type 1 vs type 2
Other name for pancoast tumour
Superior sulcus tumour
Prognostic factors sarcoid
Fibrosis extent
Pulmonary HTN
Lung function impairment
What would cause mediastinum to shift towards pneumothorax side
Lobar collapse on that side
What can cause fibrosis of lung bases
Asbestos
Connective tissue disorder
Idiopathic
Drugs such as methotrexate, amiodarone and nitreo- some antibiotic
What is alpha 1 antitrypsin
Protease inhibitor which inhibits elastase commonly produced by neutrophils. Neutrophils activity acting on lungs and liver have their activity increased therefore in the deficiency damage is caused
What test is used to determine if patient PE likely or not
WELLS
Peripheral examination sign of bronchiectasis
Clubbing due to hypoxia
How to differentiate sarcoid from TB
Cough is productive in TB
Treatment aim of sarcoid
Prevent fibrotic disease progression to
2 categories that lead to bronchiectasis
Airway obstruction
Primary ciliary dyskinesia
What to consider with calcified object obstructing airway
Swallowing bone from food
How does GORD present
Chronic dry cough Heart burn Indigestion Weird taste in mouth Remember to ask about these other Sx in cough history
What can treatment be escalated to after failure to respond to amoxicillin in relation to CAP
Include other bacteria so use erithomycin
Signs on examination of pneumothorax
Ipsilateral reduced air sounds
Ipsilateral hyper-resonant percussions and hyperinflations
What can give multiple ill defined focal opacities across the lung
Pulnomsry infarcts
Pulnomsry metastases
Rheumatoid arthritis
Septic emboli
How would Bullae appear on CXR
Can be bilateral
Air fluid level visible
What can cause a cavitating mass
Carcinoma of bronchus Squamous cell carcinoma metastasis Pulmonary infarct Bacterial lung abscess Fibrosing Wegners
What do coarse crackles indicate
Phlegm in airways
What would be indicated in recurrent pneumonia
Carcinoma
What would you suspect in a non smoker young person presenting with a chronic cough
Alpha 1 antitrypsin deficiency
Causes of T1 resp failure, 2 categories
Right to left cardiac shunt where deoxygenated blood bypasses pulmonary system
V/Q mismatch
After RIP what must do
Compare zones left to right looking if theyre the same and then if opacifications are either of the 4 possibiliites
Important thing to remember when thinking about possible lung cancer
Could be métastases from alternate site
What blood parameters can you use to monitor response to CAP treatment
WCC
Renal function
CRP
Distinguish between T1 and T2 resp failure
T1 low or normal co2
T2 high co2
Dangers of pneumothoraces
Air can collapse lung and compress mediastinum reducing flow into and out of heart. Collapse of lung leads to hypoxaemia and RDS
Management for mesothelioma
Symptoms treatment
Chemo can improve prognosis
Pleuroidesis or intra- pleural drain will also help with effusion
When is cough worse asthma
Nocturnal
Causes of deaths sarcoid
RF
Arrythmias
NMJ causes of T2 rf
Myasthenia gravis
Signs of cardiac sarcoid
AV block
Ectopics
Ventricular tachycardias
Wall abnormailities
Resp muscle causes of T2 rf
Mnd
Sx mycetoma
Haemoptysis
Weight loss
SOB
What is allergic bronchopulmonary aspergillosis
Type 1 and 3 hypersensitivity leading to recurrent asthma, bronchial damage and bronchiectasis
Symptoms of CAP
Dyspnoea Increasing productive cough Night sweats Fever Tachypnoea
What can cause pleuritic chest pain in lung cancer
Rib métastases and chest wall infiltration or inflammation affecting pleurs
What would reticular nodular shadowing be
Fibrosis
Main risk and danger with PE
Right ventricular failure with hyoptension
Treatting of sarcoid
High dose OCS
Low dose pred
Sometimes azathioprine or methotrexate
Hydroxychloroquine
Predictors of mortality sarcoid
Pulnomary HTN
Extensive fibrosis
Age
What can upper airway obstruction mimic
Asthma- can be treated in this manner originally
Pathology of asbestos
Asbestos fibres when inhaled deposit as alveolar bifurcations and cause alveolitis réaction leading to fibrosing reaction
In CAP what would you be worried about with a persistent fever
Empyema
What are most common lung cancers
Adenocarcinomas 40%
Squamous cell carcinoma 25-30%
Small cell carcinoma 15%
Large cell undifferentiated 10%
How long does it take for mesothelioma to develop after exposure
At least 20 years therefore important in history to identify specific job before then if want to help family get compensation
What is main cause of death with mesothelioma
Lung and pleural involvement
2 biggest causes of HAP
Staph aureus
Pseudomonas
Management of patient with consolidation seen in pneumonia
Order CXR for 6 weeks as pnuemonia can cover cancer
Defining mucous feature of bronchiectasis
It is bad smelling
How to differentiate obstructive causes
Salbutamol dependant
How often are ECG changes seen in PE
85%
Symptoms of mesothelioma
Chest pain
SOB
Récurrent pleural effusions
Whats FVC
Forced volume capacity- total amount of air produced in full effort expiration
What can cause fibrosis on lung apices
Berryliosis Radiation- common after breast cancer treatment Extrinsic allergic alveolitis Ankylosing spondylitis Sarcoid Tb
Cardinal respiratory symptoms
Cough Wheeze SOB Haemoptysis Chest pain
How do you differentiate between mass and nodule on lung
Mass is over 3cm
Name of TB mass
Cavitating coin lesion
DDx of sarcoid
Lymphoma
Important thing to do before administering TB drugs
Check sensitivities
Risk factors for sarcoid
Infectious Transplanted organs Bioaerosol inhalation Insecticides Agricultural exposures Hereditary North Europe Black people Autoimmune conditions such as SLE, UC
Signs of bronchiectasis
High pitched wheeze and crackles throughout inspiration
Rhonchi
Clubbing
What test must be done when cavitating mass evidence
CT to evaluate nature of mass for drainage
5 ways aspergillus can affect lung
Asthma- type 1 hypersensitivity Extrinsic allergic alveolitis Mycetoma Invasive aspergillosis Allergic bronchopulmonary aspergillosis
Can PE elevate troponin
Yes
Test for allergic bronchopulmonary aspergillosis
Aspergillus skin test
Why would you consider HIV infection in TB cases
Immunocompromised as should defend against it
Protective factors for sarcoid
Smoking
What are 4 approaches to managment of asthma
Controlled
Partly controlled
Uncontrolled
Exacerbation
Resp conditions associated with erythema nodosum
Strep infection
Sarcoid
Mycoplasma pneumonia
Psittacosis
What does worse pain on inspiration suggest
Pleuritic pain
How to diagnose chronic bronchitis
Productive cough of more than 3 months for over 2 annum
COPD symptoms
progressive shortness of breath wheeze cough sputum production haemoptysis
First line community approach to treating CAP
Amoxicillin
What are the hallmarks of TB
Cervical lymphadenopathy Erythema nodosum From endemic country Upper lobes affected Hilar lymphadenopathy Haemoptysis Weight loss Productive cough
What is problem with mantoux test
Cant differentiate between latent and active TB
Conditions causing cervical lymphadenopathy
Infective mononucleosis
TB
Sarcoid
Lymphoma
Pathophysiology of T1 resp failure
Ventilation perfusion mismatch
What bacteria does abcess formation in CAP suggest
Staph aureus
Symptoms of bronchiecstasis
Productive cough with copious amounts mucous- purulent
SOB
What test should be discussed with patient when has TB
HIV
What is most likely diagnosis of someone with COPD with sudden onset SOB
Pneumothorax
Problem with lung function declining over time
Get hypoxia so pulnomary vasculature constricts to divert blood away to un damaged parts of lungs however if damage widespread then get widespread constriction leading to pulmonary hypertension so cor pulmonale
What do you have to give with chest drain and aspiration
Paracetemol 1g or Ibupofen QDS
Oxygen if needed
Suggested aetiology of sarcoid
Infectious Transplanted organs Bioaerosol inhalation Insecticides Agricultural exposures
What does bright green phlegm indicate
Pseudomonas infection
How would bullae present
Chronic SOB
Cough
Pain
Heavy smoker
Things need to know about a previous TB infection
Sensitvities of drugs
Adherance
What drugs
Why is abdominal CT done for suspected lung cancer
Staging
What are categories of things affecting resp apparatus
Brain stem Nervous system NMJ Resp muscle Chest wall movement
Whats FEV1
The forced expiratory volume in 1 second
Tests needed for acute severe asthma attack
ECG
Peak flow
BG
UAO on spirometry
Straight diagonal line
What are most common causes of CAP
Strep pneumoniae 40% Chlamydia pneumoniae 13% Viral 13% Mycoplasma pneumoniae 11% H influenzae 5%
Contraindications of thrombolytics
Recent surgery Recent trauma and bleed anywhere Suspected aortic dissection Severe HTN Peptic ulcer disease Allergy to streptokinase
How does lyme disease present initially
Rash and then get arthritis afterwards
Lung conditions causing clubbing
Cancer
Fibrosis
Bronchiectasis
Empyema
When is peak flow worse asthma
Morning
Daignosies of sarcoid
Right clinical pattern such as eryhtema nodosum
Histology non caseating granulomas
Compatible radiological findings
Exclusion of other diagnoses
Why is co2 normal in T1 rf
More soluble than o2 so even if exchange impaired will still be able to be exchanged more readily
What electrolyte is elevated in sarcoid
calcium
Main complications of sarcoid
Progressive lung fibrosis which leads to shortened life expectancy
Aspergillosis
Diagnosis for mesothelioma
Thoracoscopy with biopsy- histology for complete diagnosis
Differentiation between TB and sarcoid
TB unilateral lymph node calcified whereas sarcoid bilateral
Histologically TB is caseating
Where can mesotheliomas spread
Often spread through one pleural cavity to another so from pleural to peritoneal and pericardial.
Can spread to hilar nodes via lymphatics
MAINLY SPREAD TO LUNGS AND LIVER
What finding on CXR in CAP would indicate an underlying pathology
Reduced lung volume on affected side
What disease type is Bird fanciers disease
Extrinsic allergic alveolitis
When is S1 Q3 T3 seen
Acute massive PE not minor
How many sputum samples for TB
3
2 fates of sarcoid granulomas
Chronic fibrosis
Resolves completely
Treatment for PE
Give LMWH, do CTPA then start warfarin and only remove LMWH when INR in range.
Tests done to check hyperreactivity to antigens
Skin prick test
PE ECG changes
A fib Sinus tachy 1st degree heart block RBBB S1 Q3 T3
What does nocturnal cough indicate
Asthma
Questions to ask in asthma history
Night time awakenings
Interference with every day life
How often use medication
Peak flow if known
How does lymphoma of lung appear on CXR
Mediastinal node enlargement
What to think if in question says keeps pidgeons
Either psittacosis- chlamydia infection that is an atypical pneumonia
Or bird fanciers disease- a type of EAA that presents with fibrosis
How does mycoplasma tend to present
Fatigue
Dry cough
Invasive effects of pancoast tumour
Horners syndrome from sympathetic chain involvement
Brachial plexus involvement
Cord compression
Invasion of recurrent laryngeal nerve- hoarse voice
What would be Homogenous shadowing
Effusion- can be bilateral or unilateral
Pneumectomy
4 opacities on CXR types
Alveolar shadowing
Reticular nodular shadowing
Homogenous shadowing
Masses
Which occupations were put at risk of asbestosis
Boilermakers
Heating engineers
Electrical engineers or anyone in building work
Signs of patient deteriorating from PE
Any sign on right sided heart failure of cardiac arrest
Hyoptenion, syncope and tachycardia
Other organs involved in sarcoid
Cardiac
Skin
Lymphatics
Nervous system causes of T2 rf
Guillain barre
Trauma
What else could present with numerous masses across lungs other than metastases
Vasculitis
Who does invasive aspergillosis occur in
Immunocompromised
Textbook chlamydia pneumonia presentation
Sx feeds birds in spare time
Confused
Diarrohoea
Factors showing how well asthma is controlled
Limits activity Daytime sx Nightime sx Need for relief Lung function- less than 80% predicted or best Exacerbations
What can lead to changing your asthma classification
Exposure to allergens
Incorrect medication or use
Poor adherance
What enzyme is elevated in sarcoid
Alpha 1 hydroxylase
ACE
Risk factors PE
Age Obesity Previous surgery recently Bed ridden and lack of activity DVT diagnosis recently
What is name for chlamydia psittaci disease
Psittacosis- parrot fever
Differentials for singular masses
Primary malignancy
Abcess
Infarct
Metaseses
What are granulomas in sarcoid
Non-caseating
Other investigations for a PE
D-dimer
Right ventricle showing signs of enlargement on Echo
FBC to determine if thrombocytopaenic or anaemic
What is a tension pneumothorax
Medical emergency that occurs when pressure in pleura becomes greater than that of atmosphere so air can only flow into pleura in a valve like mechanism
What is a common non lung related cause of chest pain in lung cancer
presence of metastases in the rib bones causing a ‘pleuritic’ type of pain, which may be sharp, well localised and is worse with movement.
What cancer causes cavitating mass
Squamous cell cancer
How to describe percussion for pleural effusion
Stony dull
Symptoms of PE
Pleuritic chest pain due to infarct- normally on one side of chest not central Tachypnoea Signs of DVT Hypoxaemia Haemoptysis
Treatment for asthma
Steroids
Salbutamol
Long term b2 agonist
How can TB present on CXR
Diffuse nodular infiltrates
Cavitation
Lymphadenopathy
Nodular densities
What will atelectasis presnent with
Wheeze
Dry cough
SOB
What could alveolar shadowing be
Fluid- HF oedema bilaterally
Pus- pneumonia
Blood- vasculitis haemorrhage rare
Abdo exam finding sarcoid
Hepatosplenomegaly
What is used to monitor sarcoid progression
FDG PET
What is main risk of chest drain
Re-expansion pulmonary oedema
Drugs used in asthma treatment
Short acting beta agonists Long acting eta agonists Muscarinic antagonists GCS Leukotriene receptor antagonists Theophylline oral pills
Complications associated with asbestosis
Increased adénocarcinoma risk
Mesothelioma
Pleural plaques
What is respiratory failure
Where the blood doesn’t have enough O2 or too much CO2
PaO2 of less than 8kPa
PaCO2 of greater than 6.7kPa
Signs of COPD on examination
Barrel chest
Wheeze
Reduced air entry
Coarse crackles
What is a pneumothorax
When air accumulates or gains access to pleural space
What conditions can show miliary shadowing
Sarcoidosis
Métastases
Occupational lung diseases
Extrinsic allergic alveolitis
Management of COPD
Bronchodilators Corticosteroid treatment Comination of 2^ Cessate smoking Influenza and pnuemonococcal vaccines
What is different about treating patients with severe CAP in relation to administration
Must be IV
What does pleurodesis do
Seals pleura to chest wall or lung
Coarse crackles vs fine crackles
Coarse sounds like bubbling- much more low pitched
Fine crackles sounds like fire crackling- higher pitched
What would you suspect in a non drinker young person presenting with cirrhosis
Alpha 1 antitrypsin deficiency
What conditions are included within COPD
Emphysema
Chronic bronchitis
Chest drain site
4-6th ICS MAL
How to investigate mesothelioma
CXR or CT that will show pleural thickening and effusion quite often bloody effusion
CXR findings TB
Upper lobes affected
Cavitating lesion
Bilateral lymphadenopathy
Complications of mycoplasma pneumonia
Transverse myelitis
RBC agglutination
What can cause atelectasis
- blockage of bronchus
- reduced surfactant
How to see collapsed lung CXR
Mediastinal shift and appears as white out or air
What is affected in type 1 resp failure
Gas exchange
RFx for mycetoma
Cancer
Sarcoid
TB
What is test for TB in clinical setting
Acid fast bacillus test- Ziehl–Neelsen stain. Only takes 48 hours
How to differentiate between inhaled object and bronchus obstruction on CXR
CXR shows consolidation for obstruction of bronchus
Investigations for COPD
Spirometry
Pulse oximetry
ABG
Causes of V/Q mismatch
Not well ventilated Acute asthma Pulnomary oedema Ards Pneumonia Pneumothorax Fibrosing alveolitus
Not well perfused
PE
What does cavitation on chest indicate about patients health
Immunocompromised
Differentiate between asthma and COPD
Symptomatically COPD much more continuous whereas asthma is related to attacks of coughing and wheezing.
COPD gets progressively worse
COPD responds better to anti-cholinergic drugs and asthma to B2 agonists
What area of lungs does TB affect
Upper lobe
Textbook legionella presentation
Sx plumber or stays in hotels a lot with ACed rooms
Other than rheumatic fever what is another complication post strep infection
Post strep reactive arthritis
Tests to confirm asthma
Spirometry with salbutamol and ipatropium
CXR
Skin prick demonstrating atopy
Trial them on budenoside and see if Sx improve or peak flow
Non lung symptoms of mesothelioma
Métastases
Hepatomegaly
Bone pain
Abdo pain and obstruction from peritoneal malignant mesothelioma
How to tell if something consolidation
Will see air filled bronchus which appears as a black line- air bronchogram
Principles of asthma management
Well controlled asthma should lead to better control and the ability to move to a lower stage
Define sarcoid
Systeminc disorder of unkown cause leading to noncaseating granulomas in majortiy of cases
What is best test for likely PE
CTPA
What does bronchial breathing sound like
High pitch, louder sounds where inspiration and expiration sound the same
Immediate management of PE
Depends on size
CTPA required then if massive immediate thrombolysis or thrombectomy if available
If small sub cut LMWH
Risk factors PE
Immobility
Malignancy
Recent surgery
FH of clot
Differences in pain PE central vs lateral
Central implies massive PE affecting main arteries
Lateral will be smaller artery and will get pleuritic pain
What does persistent type 3 HS reaction to aspergillus lead to
Bronchiectasis
Bronchectasis on CXR
Crowded bronchial markings extending to lung peripheries
Reduced volume
What is another cause of hyperesonant breath sounds
Bullae- where walls between alveoli break down thus forming multiple to join together
Investigations of sarcoid
CT
CXR
Bronchoscopic histology
What does type 1 hypersensitivity reaction to aspergillus lead to
Asthma
What would you be thinking with eye problems in a resp case
Sarcoid
Commonest PE ECG finding
RBBB and RAD
May also see large R in V1
What is mixed resp failure
Progression of T1 to T2 rf from hyperventilation leading to tiring of muscles
When will consolidation have disappeared in 95 % of CAP
6 weeks
Where is appropriate place for TB patient
Negative pressure isolation room
Signs of tension pneumothorax
Signs of cardiac deterioration- hypotension, hypoxic, tachycardia and resp distress
What is ICS
Inhaled corticosteroid
Causes of bronchiectasis
UK- Cystic fibrosis
Worldwide- TB
What happens when is V/Q mismatch
Either alveoli are getting a good air supply but not a good blood supply or vice versa
How does mass within cavity appear
Air surrounding opacification
What do fine crackles indicate
exudates in airways such as fluid from pneumonia
Why is calcium elevated in sarcoid
Ectopic alpha 1 hydroxylase produced
Can you get contralateral lobar collapse tension pneumthorax
Yes
What is a mycetoma
Or aspergilloma. Fungus ball forming in a pre existing cavity
How do arterio- venous malformations appear on CXR
Smaller well defined masses
Possible complications of bronchectasis
Infections recurrently
Cor pulmonale
Haemoptysis
How does GORD cause a cough
When reaches pharynx
Features of GORD cough
Dry
Nocturnal
Infections causing cavitating mass
TB
Klebsiella
Staph aureus
Which infection probably is causing cavitating mass in alcoholics
Klebsiella
What does bilateral basal lung opacities suggest of the aetiology
Of blood borne source as this is where perfusion is greatest
What to do in management of effusion
Take sample and send off for cytology, protein count and micro
How to differentiate between consolidation and effusion on examination
Consolidation increases vocal fremitus whereas effusion reduced
Difference between COPD and asthma
Asthma shows reversibility with 2 week steroid reversibility
What is fast test for legionella
Urinary antigen
Tests used to diagnose all atypical pneumonias
Serology
Categories of exudate pleural effusion
Malignancy
Inflammation- rheum, SLE, vasculitis
Infection
Rare PE ECG finding
S1 Q3 T3
S1 Q3 T3 on ECG
Deep S wave in lead I
Pathological Q in lead III
Inverted T wave in lead III
Why do we aim for a lower oxygen target range in COPD patients
These patients rely on hypoxic drive to drive respiration as resp centre insensitve to CO2. Too much oxygen will cause drop in respiratory drive so deterioration
What do COPD patients present with on ABG
T2 RF due to respiratory drive insensitivity to CO2
Resp acidosis with long term metabolic compensation as hypercapnic
Resp causes of clubbing
Cancer Mesothelioma Fibrosis Bronchiectasis Abcess
Most common lung cancer seen in non-smokers
Adenocarcinoma
Auscultation finding lung fibrosis
Bilateral reduced air entry
Fine crackles inspiratory
Causes of pneumothorax
Spontaneous in young men Lung pathology Connective tissue disorder Iatrogenic Trauma
Management of PE
Even when just suspected subcut LMWH and warfarin with INR range 2-3
Management of recurrent PEs
Warfarin lifelong
If from malignancy heparin
Classifications of causes of cor pulmonale
Lung disease Pulmonary vascular disease Thoracic cage abnormality Neuromuscular Hypoventilation
Why does in asthma exacerbations volume in pulse falls
Decreased left atrial filling- compromised airways exacerbate negative pressure in chest so blood pools in lungs
What happens in EEA
Hypersensitivity to inhlalation of organic allergens that leads to hypersensitivity reactions in alveoli. Chronic leads to fibrosis
What are formed in EEA
Non caseating granulomas
Main causes of EEA
Farmers lung- mouldy hay
Bird fanciers
Mushroom pickers lung
Malt workers lung- barley
Acute EEA presentation
Fever
Rigors
Dry cough
SOB
Chronic EEA presentation
Weight loss
Exertional SOB
Dry cough
What is pneumoconiosis
Occupational lung diseases caused by inhalation of dust
What cells is it thought small cell carcinomas arise from
Neuroendocrine cells
What do you think when lung Sx and hyponatraemia
Small cell carcinoma
How is COPD categorised
All less than 0.7 ratio Mild- FEV1 above 80 Moderate- FEV1 50-80 Severe- FEV1 30-50 Very severe less than 30
When should oxygen therapy be started
Evidence of cyanosis Polycythaemia Severe airflow obstruction Peripheral oedema Raised JVP
What asthma drug can cause hypokalaemia
Salbutamol
What is ARDS
Damage to lung results in release of acute ohase proteins leading to increased capillary permeability so get noncardiogenic pulmonary oedema
Causes of ARDS classification
Pulmonary- any systemic illness or injury to lung
Extra pulmonary- septic shock, DIC, multiple transfusions
Diagnosis of ARDS 4 criteria
Acute onset
Bilateral CXR infiltrates
Pulmonary capillary wedge pressure under 19
Refractory hypoxaemia
What must do with antibiotics when suspect aspiration pneumonia
Cover anaerobes
How to determine examination needed for PE
Do wells score
If under 4 do D-dimer
If 4 or over do CTPA
What are categories for acute asthma based on
PEF
What is fatal sign of asthma attack
Raised PaCO2
Immediate asthma attack treatment
O2 Neb salbutamol 5mg Neb ipatropium bromide 0.5mg 100mg hydrocrotisone IV Then 40-50mg PO pred for 5 days
What is senior supportive treatment for asthma attacks
IV magnesium sulphate
IV aminophylline
What colour is sputum in COPD
White
What are crackles in COPD
Coarse
When are coarse crackles heard
COPD
Pneumonia
When are fine crackles heard
Interstitial lung disease
What is best way to manage COPD
Smoking cessation
How does COPD lead to polycythaemia
Hypoxia leads to EPO production
How can COPD patients present with very low RR
Given too much oxygen
Managemnt of COPD exacerbation
Neb salbutamol 5mg
Neb ipatropium bromide 0.5mg
200mg hydrocrotisone IV
Then 40-50mg PO pred for 5 days
Further management of COPD
BiPAP
Why is BiPAP used for COPD
Reduced expiratory pressure allows some CO2 to leave- in COPD patients they chronically retain CO2 so not letting some out would further exacerbate his resp acidosis
What is new name of EAA
Hypersensitivity pneumonitis
Investigations for asthma
Peak flow
FeNO
Spirometry
What is FeNO
Frequency of expired NO- signs of inflammation in lungs
Steps to asthma management
SABA SABA+ICS SABA+ICS+LTRA SABA+ICS+LTRA+LABA SABA+MART+LTRA
What is MART
Management and reliever therapy- ICS+LABA
What is montelukast therapy
Leukotriene receptor antagonists
CAP pneumonia tx
Co-amoxiclav
Atypical CAP tx
Clarithomycin
HAP treatment
Tazocin
Most common gram pos organisms you are faced with
Staph
Strep
C.difficile
What is given for gram positive if has penicillin allergy
Macrolides
Give 2 macrolides
Clarithomycin
Erythomycin
3 categories of ABx to treat gram pos
Beta lactams
Glycopeptides
Oxazolidinones
3 beta lactams categories
Penicillins
Cephalosporins
Carbapenems
Example of cephalosporins
Ceftriaxone
Examples of carbapenems
Meropenem
Ertapenem
Examples of glycopeptides
Vancomycin
Examples of penicillins
Amoxicillin
Flucloxacillin
Tazocin
Most common gram neg organisms have to deal with
Salmonella
E.Coli
Klebsiella pneumoniae
Pseudomonas
Who is at risk of aspiration
Neurological disorder
Altered mental state
LOC
Categories of Abx for gram negs
Aminoglycosides
Fluroquinones
Examples of aminoglycosides
Gentamicin
Amikacin
Examples of fluoroquinones
Ciprofloxacin
Levofloxacin
What abx used for intracellular pathogens
Tetracycline
Examples of tetracyclines
Doxycycline
Tigecyclin
Examples of intracellular pathogens
Chlamydia
Mycoplasma
What abx are used to cover anaerobes
Nitroimidazoles
Examples of nitroimidazoles
Metronidazole
Tinidazole
When are you worried about anaerobes
STIs
Pneumonia
What is nitrofurantonin used for
UTIs as concentrates in the bladder
Management of PE
Immediately give LMWH or DOAC
Then do wells score to determine if D-dimer or CTPA needed
How long do you anticoagulate for post PE
If provoked 3 months
If unprovoked 6 months
What criteria is used to classify pleural effusions
Lights criteria
What is the lights criteria
pleural fluid/serum protein ratio of greater than 0.5
pleural fluid/serum LDH ratio of greater than 0.6
What does very elevated LDH in pleural fluid suggest
TB or cancer
Wheeze in young person differentials
Asthma
Foregin object
Antitrypsin
What can present with persistent greenish sputum cough and occasional haemoptysis
Bronchiectasis
What is the chest pain in resp conditions
Tight
What is the chest pain in cardio conditions
Crushing
What infections can often precede sarcoidosis
Lyme
TB
What is uveitis a inflammation of
Pigmented layer
What is affected in erythema nodosum
Fat
How can kidney be affected in sarcoid
Nephrocalcinosis- so have to do 24hr urine collection
Which patients are at specific risk of aspiration pneumonia risk
Dementia
Which lobe is most commonly affected in aspiration pneumonia
Right middle
What is use of spirometry
Longer term test
Differentials of wedge infarct
PE
What is problem of CTPAs
Lots of radiology and contrast
Antibiotics for TB given for first 2 months assuming all sensitive
Rifampicin
Isoniazad
Pyrazinamide
Ethambutol
Management of TB patient
Negative pressure room
Cultures to test sensitivity of patients TB to antibiotics- this can take 4 months to come back so start the patient on all 4 abx then if sensitivities all come back positive only keep on the isoniazad and rifampicin
What determines if primary or secondary pneumothorax
Lung dx
50 year old smoker
For primary pneumothoraces what determines if needle aspirate or not
If SOB or if greater than 2cm
With primary pneumothorax what do you do if asymptomatic or less than 2cm
Discharge and outpatient review
If aspiration is successful in primary pneumothorax what do you do
Observe and give O2
If aspiration is unsuccessful in pneumothorax what do you do
Put in chest drain
In secondary pneumothoraces what determines pathway
Greater than 2cm or SOB
If greater than 2cm or SOB what do with secondary pneumothoraces
Chest drain
If between 1-2cm in secondary pneumothoraces what do
Needle aspiration
If successful observe and O2
If unsuccessful chest drain
If pneumothorax less than 1cm in secondary pneumothoraces what do
Observe and O2
Presentation of acute massive PE
Collapse
Central crushing pain
Severe dyspnoea
What can be CXR finding of PE
Westermarks sign
Dilation of pulmonary vessels
Massive PE on ECG
RAD
S1Q3T3
RBBB
In small likely to be kust tachycardia
Management of massive PE vs submassive PE
Determined by if haemodynamically unstable
Massive
Resp support
1st line thrombolysis
2nd line embolectomy
Submassive
Resp support
Anticoagulation
What 2 IV thrombolytics are used in massive PE
Alteplase
Streptokinase
What can be general inspection finding in asthma
Nasal polyps
Criteria for diagnosing asthma
FEV1/FVC ratio less than 0.7
12% or more reversibility with SABA
FeNO over 40parts per billion
If move on from stage 5 asthma what is next step
Tiral of-
Theophylline
LAMA
If trials of theophylline and LAMA dont work what is given
Oral corticsteroids
Name of LTRA
Montelukast
Name of budenoside and formoterol
Symbicort
What is defined as a moderate acute asthma and waht do you do
50-75
Send home
What is defined as an acute severe asthma and what do you do
33-50
Admit if no response
What is defined as a life threatening acute asthma and waht do you do
Less than 33
Admit
What is defined as a near fatal acute asthma and waht do you do
Rised Co2 on ABG
Admit
COPD history
SOB
Productive cough- white
Some wheeze
Treatment for simple COPD infective
Amoxicillin
Which conditions can cause COPD in younger people
Alpha-1-antitrypsin
CF
What will post bronchodilator FEV1/FVC be in all COPD categories
Less than 0.7
Mild severity COPD
FEV1 over 80 compared to expected
Moderate severity COPD
FEV1 50-80% compared to expected
Severe severity COPD
FEV1 30-49% compared to expected
Very severe COPD
FEV1 less than 30% compared to expected
Initial COPD management
SABA or SAMA
In second line COPD what determines what drug is given
Whether asthma symptoms or not- diurnal cough, wheeze and SOB worsened by triggers
If asthmatic signs in COPD what is given
LABA and ICS
If no asthmatic signs in COPD what is given
LABA and LAMA
Final line treatment for COPD
LABA
LAMA
ICS
General management of COPD
Smoking cessation
Annual influenza vaccination
Pneumococcal vaccination
Improved survival methods for COPD
Smoking cessation
Long term O2
Lung volume reduction surgery
When is long term O2 given in COPD
PO2 of less than 7.3
PO2 7.3-8 and PCV, nocturnal hypoxaemia, peripheral oedeama or pulm HTN
Terminally ill
What can cause idiopathic fibrosis
Methotrexate
Amiodarone
IPF history
SOBOE
Dry cough
What is gold standard test for IPF
Biopsy
In first presentation what is first only imaging will see changes
HR-CT- ground glass
Later on will see CXR- reticulonodular, cor pulmonale, honeycombing
What causes atelectasis in asthma
Mucous plugs
CXR findings IPF
Only seen late
Honey-combing, reticulonodular, cor pulmonale, honeycombing
Hypersensitivity pneumonitis history
SOBOE
Dry cough
Fever
X-ray changes seen in Hypersensitivity pneumonitis
Often none but will be superior reticulonodular changes
HR-CT early changes hypersensitivity pneumonitis
Ground glass
Investigations do hypersensitivity pneumonitis
CXR
HRCT
BAL
Spirometry
What is BAL finding of Hypersensitivity pneumonitis
Increased ceullularity
Pneumoconiosis history
Dry cough
SOBOE
How is pneumoconiosis classified
Simple
Complicated
Investigations for pneumoconiosis
CXR
HRCT
Spirometry
CXR finding pneumoconiosis
In simple disease will see micronodular mottling
HRCT finding pneumoconiosis
Bilateral lower zone reticulonodular shadowing
Pleural plaques
What is different about asbestos HRCT to all other pneumoconiosis’
Fibrotic changes seen
What is history of sleep apnoea
Snoring
Unrefreshed sleep
Chronic fatigue
What is common profession seen in sleep apnoea
Truck driver who does very little moving
Risk factors for sleep apnoea
Obesity
Smoker
Alcohol
Investigations for sleep apnoea
Sleep study (polysomnography) TFTs and IGF-1 to rule out acromegaly and goitre
What can cause obstructive sleep apnoea
Obesity
Goitre
Acromegaly
Associations of legionella
Hyponatraemia
Abnormal LFTs
Pneumonia with abnormal LFTs
Legionnella
Symptoms of atypical pneumonias
Dry cough Headache Diarrorhoea Myalgia Hepatitis
2 tests for atypical pneumonia legionella
Urine antigen test
LFTs
Test for mycoplasma atypical pneumonia
Blood film- cold agglutins
What are 2 types of findings seen on CXR pneumonia
Lobar
Bronchopneumonia
If patient scores 1 CURB 65 what do
GP
If patient scores 2 CURB 65 what do
Short A&E score
If patient scores 3 CURB 65 what do
Admission
Treatment for pseudomonas pneumonia
Tazocin and gentamicin
Treatment for MRSA pneumonia
Vancomycin
Treatment for CAP
Amoxicillin
Co-amoxiclav if severe
Complications of pneumonia
Pleural effusion
Abscess
Sepsis
Empyema
How does lung abscess present
Swinging fevers
Persistent pneumonia
Foul smelling sputum
What is post primary TB
When TB is reactivated probably due to immunocompromise- normally presents with severe disease
What is miliary TB
Lymphohaemaotogenous dissemination of TB
Extra pulmonary problems of TB
Addisons Potts disease Meningitis Tuberculomas Granuolmas in kidney or colon
What is potts disease
Osteomyelitis and arthrits of spine associated with TB
Initial tests for TB
Sputum MCSx3 Ziehl neelsen stain Blood culture HIV test Lymph node biopsy Mantoux test but cant differentiate between latent and active
If question asks for next step management in resp what must always do
Look if needs oxygen
Non mililary TB findings on CXR
Bi hilar lymphadenopathy Patchy consolidation Pleural effusions Cavitating lesions Upper lobe scarring
Miliary TB finding CXR
Nodular shadowing
Congenital causes of bronchiectasis
Cystic fibrosis
Youngs syndrome
Kartageners (primary ciliary dyskinesia)
Acquired causes of bronchiectasis
Recurrent infections TB Measles Pertussis Lung cancer Aspergillosis
Presentation of bronchiectasis
Chronic cough of copious sputum Haemoptysis occasionally SOB Fever Weight loss
4 things that give basal creps
HF
Pneumonia
Bronchiectasis
IPF
Investigations for bronchiectasis
Bedside - sputum sample for microscopy - sweat test for cystic fibrosis - genetic testing for PCD and youngs Bloods - FBC - CRP - ABG - blood culture Imaging - CXR - HR-CT
Classic feature of bronchiectasis HR-CT
Signet ring
Triad of youngs syndrome
Bronchiectasis
Sinusitis
Infertility
Management of bronchiectasis
Conservative - exercise and good diet - influenza vaccination - physio - hypertonic saline nebs Pharm - oral prophylactic ABx - IV if acute infection Surgical - resection
What is prophylactic antibiotic given in bronchiectasis
Azithromycin
Complications of bronchiectasis
Recurrent infections
Cor pulmonale
Resp failure
Common sites of primary tumours causing breast mets
Breast
Colorectal
Causes of primary lung cancer and %
Non-small cell - Adenocarcinoma 40 - squamous cell 25 - large cell 5 Small cell - small cell carcinoma 15
Which cells does each lung cancer originate from
Adenocarcinoma- goblet cells
Squamous cell carcinoma- squamous epithelial cells
Small cell- NET
Large cell- epithelial cell
What can small cell carcinomas produce ectopically
SIADH
ACTH
Where in lung do adenocarcinomas grow
Peripheral
Which lung tumour produces PTH
SqCC
Risk factors for lung cancer
Smoking
Asbestos
Other than mesothelioma which tumour can asbestos predispose to
SqCC
What happens to vocal resonance in cancer
Increased
Local invasions of lung cancer
Horners
Left recurrent laryngeal nerve-> bovine cough and hoarse voice
SVC obstruction
Where does lung cancer often metastasise to
Bone
Brain
Liver
Questions for bone mets lung cancer
Fractures
Bone pain
Questions for brain mets lung cancer
Headache
Blurry vision
Investigations for lung cancer
Bedside - sputum cytology Bloods - FBC - U&Es - calcium - LFTs Imaging - CXR - CTAP - PET Biopsy - bronchoscopy - transthoracic needle
Why measure clacium in lung cancer
Bone mets
Ectopic PTH from SqCC
Why do LFTs lung cancer
ALP for bone mets
Liver mets
Complications of lung cancer
Atelectasis Pleural effusion Mets SVC obstruction Nervous infiltration
What is sail sign
When LLL collapse
Symptoms of mesothelioma
Cough dry
LAWS
SOB
Sign of mesothelioma on auscultation
Pleural friction rub
What does pleural friction rub suggest
Mesothelioma
Investigations for mesothelioma
Bedside - sputum cytology - thoracocentesis for pleural fluid cytology Bloods - FBC - U&Es - calcium - LFTs Imaging - CXR - CTAP - PET Biopsy - thoracoscopy to get pleural lining biopsy
Definitive test for mesothelioma
Thoracoscopy
CXR finding for mesothelioma
Pleural thickeing
Effusions
Pleural plaques
CXR findnings bronchiectasis
Thickened bronchial walls
Volume loss
Ring shadows
Fluid air levels from dilated airways
Why do you get volume loss in bronchectasis
Mucous plugs
What can lead to reduced lung volume
Bronchial cancer
Bronchiectasis
What is chance patient will have allergic reaction to a cephalosporin if allergic to penicillin
10%
Sore throat differentials
Cold Influenza Glandular fever Strep throat Haematological cancer
Presentation of influenza flu
headache, weakness, fatigue, myalgia, fever and dry cough
Presentation of cold
rhinorrhoea, nasal congestion and cough
Presentation of strep throat
suggested by acute onset, fever, presence of exudate and absence of cough
Presentation of EBV
sore throat of greater than 7 days’ duration, adenopathy and splenomegaly
What would worry you about haem malignancy in sore throat
fatigue, weightloss, petechial rash, bruising, adenopathy and fever
What would prompt referral to ENT about removal of tonsils
7 or more tonsilitis in a year
What is delayed prescription of antibiotics
Delayed means that can access them after a few days giving them a few days to attempt self care
Fever pain score of 2-3
Delayed prescription of penicillin
Fever pain score of 4-5
Immediate prescription of penicillin
What to bear in mind with feverpain for vulnerable groups ie on steroids
Move the parameters
What is main complication of inhaled ICS
Thrush
Are inhaled ICS ok for pregnancy
Yes
What is alternative steroid to betclamethasone
Fluticasone
Significance of sore throat for rheumatic fever
Strep A
Scarlet fever also presents with sore throat
What is main complication of tonsilitis
Peritonsilar abscess
What is first thing must establish if presenting with haemoptysis
If truly from lungs or from GI, nose or gums
Ways to determine if haemoptysis truly haemoptysis
Colour- brown suggests GI
History of nosebleeds, nausea, gastric disease or alcoholism
INVITED MD for haemoptysis
Infective- TB, abscess, mycetoma, pneumonia Neoplastic- metastases, primary tumour Vascular- PE, heart failure Inflammatory- wegners, goodpastures, microscopic polyangiitis, Lupus, haemorrhagic telengiectasia Trauma- rib Endocrine- no Degenerative- bronchiectasis Metabolic- no Drugs- warfarin
What does blood streaked sputum suggest
Infective cause like pneumonia
Bronchiectasis
What does frothy bloody sputum suggest
Pulmonary oedema from HF or mitral stenosis
What does sudden onset haemoptysis suggest vs chronic
Sudden- PE, tumour
Chronic- bronchiectasis
What does productive cough alongside haemoptysis suggest
Pneumonia
Bronchiectasis
What would oligouria suggest about haemoptysis
Pulmonary renal syndrome- Lupus, vasculitides, good pastures
What does hoarse voice suggest with haemoptysis
Lung cancer
What does muscle wasting in hand suggest about haemoptysis
Pancoast tumour infiltrating the brachial plexus
What does a purpuric rash or petechiae suggest about haemoptysis
Vasculitide
What does swollen face suggest about haemoptysis
SVC syndrome
What does jaundice or hepatomegaly suggest about haemoptysis
Liver cancer thats spread to lungs or vice versa
What does tracheal deviation suggest about haemoptysis
Collapse of lung secondary to tumour or abscess
Maligant pleural effusion
Bloods ordered for haemoptysis
FBC- malignant anaemia, WCC CRP Clotting screen- easy bleeding U&Es- pulmonary renal syndrome Clacium- hypercalcaemia LFTs- liver involvement
Investigations after lung cancer suggested
Sputum for cytology
Biopsy from bronchoscopy or CT guided percutaneous fine needle biopsy
What obs recording would discount PE
Tachypnoea
Why are PCD sufferes infertile
Spermatazoa cant swim properly
People with primary ciliary dyskinesia often suffer with that conditions
Sinusitis as cant clear noses Male infertility Bronchiectasis Situs invertus Otitis media as cant clear mucous from middle ear
When is lights criteria used
If pleural protein less than 25g/L then is exudate
If over 35g/L then is transudate
If between these then do lights criteria
Which cancers most commonly metastasise to lung
Colon
Renal
Gynae
Breast
Extra pulmonary manifestation of lung cancer
Bone mets
LEMS
Hypercalcaemia from ectopic PTHrp
Ectopic ACTH
DDx for coin lesion
TB Sarcoid Abscess Harmatoma Foreign object Tumour Mycetoma
