Resp key questions Flashcards
68 y/o male, 40 pack year history, breathlessness on exertion. productive cough of white sputum over last four months.
F
FEV1/FVC ratio 51%, minimal reversibility after 2 week trial of oral steroids.
likely diagnosis?
Chronic obstructive pulmonary disease (COPD)
FEV1/FVC indicates obstructive defect.
Describe what an FEV1/FVC ratio of less than 80% indicates?
obstructive defect
seen in COPD and asthma
Describe what an FEV1/FVC ratio of more than 80% indicates?
restrictive defect
seen in lung fibrosis
Type 1 respiratory failure may show
- Fluid accumulation
- -> water —-> pulmonary oedema
- -> pus —-> pneumonia
- -> blood —-> haemorrhage - Hypoxemia
- -> oxygen can’t diffuse
Type 2 respiratory failure may show
- Obstruction
- -> asthma, COPD
- -> Flail chest, guillain barre - CO2 collects thus hypercapnic
54 y/p, weight loss, loss of appetite, shortness of breath. resp rate 19, oxygen on air 94%.
On examination, there is reduced air entry and dullness to percussion on lower to mid zones of the right lung.
Reduced chest expansion on right.
what might she have?
Pleural effusion
- reduced air entry
- dullness to percussion in lower and midzones
Typically patients with COPD exhibit what type of respiratory failure?
- type 2 resp failure
- caused by alveolar hypoventilation
- longstanding hypercapnia
- resulting in respiratory acidosis
- over time will be compensated by kidneys retaining more bicarb
- in order to normalise pH levels
Bronchiectasis
chronic infection of bronchi and bronchioles.
leading to permanent dilation of these airways.
Clinical signs in patients with COPD
- carbon dioxide retention tremor
- peripheral cycanosis
- tar staining in finger tips
28 y/o male, A+E, acute onset of pleuritic chest pain and shortness of breath while playing football. oxygen sats are 93% . resp rate 20, temp 37.1
decreased expansion on LHS chest. hyper-resonant to percussion and reduced air entry on left.
most likely diagnosis is:
LHS pneumothorax
- pleuritic chest pain
- acute onset
What are pancoast’s tumours?
- defined as tumours arising from lung apex
- as it grows can compress structures
e. g.
- —> brachiocephalic vein
- —> subclavian artery
- —> recurrent laryngeal n.
- —> vagus, phrenic
- —> Horner’s syndrome
compress of what may result in Horner’s syndrome?
Sympathetic ganglion
- Miosis (pupil constriction)
- Ptosis (drooping eye)
- Ipsilateral anhydrosis
50 y/o afro-carribean male, no PMH, 4 month history of dry cough and shortness of breath one exertion.
blood tests reveal rasied ESR and [ACE]/
CXR shows bilateral hilar lyphaedenopathy.
Indicative of…
Sarcoidosis
- multisystem granulomatous disorder
Briefly recap the pathophysiology of Sarcoidosis?
- unknown antigen detected by CD4+ T Helper cells
- cytokine release
- non-infection noncaseating granulomas
- macrophages in granuloma
- release 1-a-hydroxylase
- thus HYPERVITAMINOSIS D
- calcium kidney stones
- sudden severe pain
69 y/o male, dyspnoae, cyanosis, finger clubbing.
CXR shows bilateral lower zone reticulo-nodular shadowing.
honey combing of lung on CXR
likely diagnosis
Pulmonary fibrosis
In advanced fibrotic disease. honeycombing of lung may be seen.
25 y/o severe exacerbation of asthma. resp rate 30, 95% oxygen sats, temp 37.2. as you feel peripheral pulse, volume falls as patient inspires.
describe the pathophys between the falling volume of the pulse?
- narrowing of airways
- thus when patient inspires
- sudden increase in negative intrathoracic pressure
- causes dilatation of pulmonary vasculature
- pooling of blood in lungs
- diminished pulmonary venous return to left atrium
- reduced stroke volume
- BP falls , volume of pulse falls.
Empyema
presents with:
Pus in pleural space
- transient fever
- SoB
- pleural effusion
78 y/o female, hyponatraemia, weight loss and haemoptysis.
mass lesion detected on CT chest scan.
suspicious of bronchogenic carcinoma.
what type of bronchogenic carcinoma would explain the patients above symptoms?
Small cell carcinomas.
May lead to ectopic hormone production.
resulting in paraneoplastic syndromes.
Likely daignosis: Syndrome of inappropriate ADH secretion (SIADH)
56 y/o male, three month history of productive ocugh, blood tinged sputum following return from India.
lethargy, nigh sweats, decreased appetite.
patients chest has good air entry bilaterally, no added sounds.
sputum sample reveals fast growth of bacilli.
likely diagnosis?
Tubercolosis.
The following features would indicate a diagnosis of:
- acute onset within past day
- on background of known risk factor (e.g. pneumonia)
- bilateral pulmonary oedema
- crackles, CXR changes
- hypoxia despite oxygen therapy
acute respiratory distress syndrome
acute respiratory distress syndrome caused by
- increased permeability of alveolar capillaries
- leading to fluid accumulation in alveoli
70 y/o with small cell lung cancer. weakness in limbs worse in legs, gets slightly less weak the more he moves. no pain anywhere else and no other symptoms.
most likely to have:
Lambert-Eaton syndrome
- weakness in prox arms and legs
- weakness worse in legs (unlike in myasthenia gravis)
1 pack year defined as
20 cigarettes per day for 1 year.
crackles on auscultation would indicate…
pulmonary fibrosis
chronic productive cough in the absence of wheeze or breathlessness may indicate…
- bronchiectasis
- inhaled foreign body
- obliterative bronchioitis
- large airway stenosis
42 y/o smoker, chronic cough and shortness of breath. brings up copious amounts of sputum.
CXR shows numerous parallel line shadows
Bronchiectasis
- parallel line shadows common
- may indicate dilated bronchi
- due to peribronchial inflammation and fibrosis
71 y/o recurrent collapse during exertion, presents with shortness of breath. HR and BP okay.
syncope from aortic stenosis
73 y/o male SoB. smokes 20/day. Spirometry reveals restrictive picture
pulmonary fibrosis
multiple rounded lesions o CXR are highly suggestive off…
lung metastases
haematocrit
ratio of volume of red blood cells to total volume of blood
patient with long term COPD might have increased concentration of haematocrit on their FBC. why?
- increased [haematocrit] known as polycythaemia
- due to long term hypoxia present in COPD
- results in increased erythropoietin production
- by kidneys
- thus h.globin levels rise
thrombocythaemia
- raised platelet count
- can be caused by infection, malignancy or any form of inflammation
leukopenia
- reduced white cell count
bilateral hilar lymphadenopathy seen mainly in what conditions?
- sarcoidosis
2. tuberculosis
24 y/o female afro-carribean, facial weakness, fever, painful red eyes. LHS facial palsy, tender swelling of parotids. hypercalcaemic.
most likely diagnosis?
Sarcoidosis
- multisystem
- granulomas (abnormal collection of inflam cells)
55 y/o male progressively worse SoB, worse when walking, dry cough. bibasal crackles. evidence of finger clubbing.
spirometry done, clearly restrictive pattern.
typical history of
idiopathic pulmonary fibrosis
- progressive exertional dysponea
- dry cough
- finger clubbing
- bilateral basal crackles
- restrictive lung pattern
- CXR interstital shadowing
- high res CT ‘honey comb’ lungs
panic attacks result in…
- hyperventilation
- respiratory alkalosis
- oxygen will be normal
- no metabolic compensation as panic attacks resolve rapidly
Pneumonia assessment criteria
CRB65
C - confusion
R - resp rate (>30/min)
B - BP
65 - (>65 y/o)
notes:
patients with asthma who are not controlled with a SABA + ICS should have a leukotriene receptor antagonist added before LABA
patients with asthma who are not controlled with a SABA + ICS should have a leukotriene receptor antagonist added before LABA
67 y/o male admitted to surgical unit with acute abdominal pain. found to have RHS pneumonia.
Nursing staff give him oxygen.
after 30 mins patient is moribund, sweaty and agitated.
ABG reveals acute resp acidosis.
why?
- COPD patient who has recieved too much oxygen.
- patients lose hypoxic drive for respiration
- thus retain CO2
- subsequently hypoventilate
- leading to resp arrest
Meig’s syndrome
- benign ovarian tumour
- ascites
- pleural effusion
64 y/o male Bangladeshi , bloody sputum, breathlessness, signs of malaise, fever.
sputum samples and CXR are done. what other test should be offered?
- suspected TB patient
- should also be given a HIV test
- as latent TB often pushed into active disease by immunosuppresion
- most common cause of immunosuppression is HIV
COPD patients tend to retain…
- CO2
- thus chronically raised bicarb
remember!
Type 1 resp failure: low oxygen and no CO2 retention
Type 2 resp failure: low oxygen, high co2
paraneoplastic Cushing’s syndrome
- vast majority caused by small cell bronchial carcinoma
- neuroendocrine tumour which can secrete hormones / antibodies
- in Paraneoplastic cushing’s there is ectopic ACTH production
- syndrome results in: muscle weakness, hypertension, hypokalaemia, oedema
most common infective organism in exacerbations of COPD
Haemophillus influenza
Kartagener’s syndrome
- primary ciliary dyskinesia
- dynein arm defects results in immotile cilia
deficiency in what protein is a risk factor for hepatocellular carcinoma
alpha-1-antitrypsin
how might you distinguish between tension pneumothorax and simple pneumothorax?
- hypotension will occur in tension pneumothoraces as a result of cardiac outflow obstruction
- thus measure BP
