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Resp Paces Flashcards

1
Q

Clinical signs of a lobectomy

A

Posterolateral thoracotomy scar or 3 scars (1 x 10cm in length + 2 port scars)
Reduced expansion and chest wall deformity
Lower lobectomy: dull percussion note over lower zone with absent breath sounds
Upper lobectomy: normal examination or hyperresonant percussion note over upper zone and dull base
CXR: raised hemidiaphragm
Ct chest

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2
Q

Indication for VATS

A

Lobectomy mainly for malignancy
Wedge resection for benign pathology
Bullectomy for recurrent pneumothoracices
Biopsy

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3
Q

Primary vs secondary spontaneous pneumothorax

A

Primary: no underlying lung disease, normally occurs in tall, slim men, smoker
Secondary: associated with underlying lung disease

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4
Q

Management of primary spontaneous pneumothorax

A

If asymptomatic and <2cm: supplementary O2 follow up CXR
If breathless or >2cm:
Supplementary O2, aspiration, if aspiration fails need chest drain

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5
Q

Management of secondary pneumothorax

A

If < 1cm and no breathlessness: supplementary O2, observe in hospital
If 1-2cm and no breathlessness: O2, aspirate, drain
If >2cm or symptomatic: O2, chest drain

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6
Q

Management of tension pneumothorax

A

Oxygen
Emergency needle decompression 2nd ICS mid clavicular line or midaxillary line 4th/5th ICS

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7
Q

Management of recurrent pneumothoracices or air leak

A

Bullectomy if Bullae present
Pleurectomy or talc pleurodesis

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8
Q

Advice to give patient post pneumothorax

A

Avoid air travel until full resolution
Avoid diving permanently unless has had bilateral surgical pleurectomy and normal lung function tests and Ct chest post- operatively

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9
Q

Risk factors for asthma

A

Cigarette smoke
Fumes
Work place exposure
Personal/family history of atopy
Resp infection in childhood
Obesity

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10
Q

Triggers for asthma exacerbation

A

Exercise
Infection
GORD
Drugs- aspirin, NSAIDs, b blockers
Poor medication compliance
Cold weather

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11
Q

Signs of chronic asthma

A

Tachypnoea
Wheezing
Hyperinflated chest
Nasal polyps
Atopic eczema

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12
Q

Diagnosis of asthma

A

History
Examination findings
Spirometry
- increased lung volumes
- Reduced FEV1
FEV1:FVC ratio <70%
- reversibility (at least 200ml)
Peak Flow diary
- >20% diurnal variability
- may also identify occupational asthma
- > 15% improvement with bronchodilator
FeNO
- conforms eosinophilic airway inflammation (FeNO level > 40 is positive in steroid naive adults)
Eosinophilia
Skin prick testing

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13
Q

Non pharmacological management of asthma

A

Education
Inhaler training
Weight loss
Smoking cessation
Peak flow monitoring
Annual follow up
Vaccination

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14
Q

Medical treatment of asthma

A
  1. Salbutamol prn + low dose ICS
  2. LABA + ICS
  3. Increase ICS dose + LABA + LTRA
  4. Specialist care
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15
Q

Moderate acute asthma

A

Sats > 92%
PEFR >50%
No signs of severe

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16
Q

Acute severe asthma

A

Sats >92
Can’t talk in full sentences
HR >110
RR>25
Peak flow 33-50%

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17
Q

Life threatening asthma

A

Sats <92
Silent chest
Poor resp effort
Exhaustion
Confusion
Cyanosis

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18
Q

Near fatal asthma

A

Raised pCO2

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19
Q

Management of asthma exacerbation

A

Nebs
Steroids
O2
Antibiotics if infection
Magnesium
Aminophylline
Monitor peak flows

Refer to ICU if deteriorating PEFR, worsening hypoxia, rising CO2/acidosis, exhaustion, altered consciousness

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20
Q

Criteria for discharging asthmatic

A

PEFR at least 75% predicted
Diurnal variation <25%
No nebs for 24 hours
Written asthma action plan
Follow up in next 30 days

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21
Q

Potential triggers for IPF

A

Acid reflux
Viruses - EBV, herpes, hep C
Dust, textiles, cattle farming
Genetic predisposition

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22
Q

Clinical features of IPF

A

SOB
Cough
Fatigue
Cyanosis
Finger clubbing
Fine end inspiratory crackles

Signs of steroid use

Look for differential diagnosis:
- joint deformity in RA
- evidence of systemic sclerosis
- skin discolouration if amiodarone

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23
Q

Differential diagnosis for end insp crackles

A

Acute interstitial pneumonia
RA, IBD, systemic sclerosis
Drug related pulmonary fibrosis
- amiodarone, sulfasalazine, methotrexate, nitrofurantoin

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24
Q

Assessment/ diagnosis of IPF

A

ABG
ANA - elevated in 10-20%
RA - elevated in 10-20%
Anti CCP - normal
CXR- small lung volumes, interstitial shadowing most marked at bases and peripheries
HRCT
Lung function tests - FEV1/FVC >0.8, low TLC, reduced TLco and Kco
Bronchoalveolar lavage
- exclude infection prior to immunosuppression
- if lymphocytes > neuts likely better response to steroids
Lung biopsy

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25
Q

Management of IPF

A

Pulmonary rehab
Antifibrotic drugs eg. Pirfenidone
LTOT
Lung transplant

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26
Q

Causes of basal fibrosis

A

UIP
Asbestosis
Connective tissue diseases
Aspiration

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27
Q

Clinical signs of cystic fibrosis

A

Clubbing
Wet cough
Hyperinflated lungs reduced chest expansion
Coarse inspiratory crackles and wheeze
Portacath
PEG

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28
Q

What are the genetics of cystic fibrosis

A

Incidence of 1/2500 live births
Autosomal recessive chromosome 7q
Gene encodes CFTR (Cl- channel)

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29
Q

What is the Pathophysiology of cystic fibrosis

A

Secretions are thickens and block the lumens of various structures causing:
- bronchiectasis
- diabetes and loss of pancreatic exocrine function
- distal intestinal obstruction syndrome
- absence of vas deferens in males causing infertility
- subfertility in women due to affect of fallopian tubes

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30
Q

How is cystic fibrosis diagnosed

A

Screening with heel prick test (low immunoreative trypsin)
Sweat test (Na > 60mmol)
Genetic testing
CXR
CT

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31
Q

How is cystic fibrosis managed?

A

Physiotherapy
Antibiotics - both prophylactic and treatment
Monitor for diabetes
Pancrease and fat- soluble vitamins
Mucolytics
Immunisations
Lung transplant
Gene therapy is an ongoing area of research
Poor prognosis if becomes infected with Burkholderia cepacia

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32
Q

Most common pathogen is cystic fibrosis infection

A

Staph aureus in young children
Then H.influenza
Then pseudomonas aeruginosa in teenage years

33
Q

Contra-indications to lung transplant in CF

A

Burkholderia infection
Sepsis
Multi- organ dysfunction
History of non-adherence to treatment
Morbid obesity
Refractory GORD

34
Q

Clinical signs of double lung transplant

A

Scar - clamshell incision, central line, traceostomay
Clubbing which may indicate CF, bronchiectasis, pulmonary hypertension

35
Q

Indication for lung transplant

A

Chronic end stage lung disease and meet 3 criteria:
1. > 50% risk of death within 2 years
2. >80% chance of survival 90 days post transplant
3. >80% chance of survival 5 years post transplant

36
Q

Complications of lung transplant

A

Primary graft dysfunction (acute rejection) - very common
Chronic rejection usually secondary to bronchiolitis obliterans syndrome (BOS)
Infections
Malignancy
- post transplant lymphoproliferative disease
- skin cancer
Complications of immunosuppressants

37
Q

Contraindications to lung transplant

A

Malignancy in the last 5 years or 2 years of low risk of recurrence
Heart/liver/ kidney failure
Atheroscleorotic disease with end organ damage
Chronic infection with resistant organisms
Mycobacterium abscess
Chest wall or spinal deformity
Obesity or low BMI
Non- adherence to therapy
Psychiatric disease

38
Q

Clinical signs of bronchiectasis

A

Cachexia
Clubbing
Inspiratory coarse crackles
Wheeze
Sputum
Cor pulmonale

Yellow nail syndrome (yellow nails and lymphoedema

39
Q

Investigating suspected bronchiectasis

A

Sputum culture and cytology
CXR: tramlines and ring shadows
CT: signet ring sign

Tests for specific causes

40
Q

Investigating for specific cause of bronchiectasis

A

Immunoglobulins
HIV
Aspergillus RAST or skin prick testing
Rheumatoid serology
Saccharine ciliary motility test
Genetic screening for cystic fibrosis
Testing for IBD

41
Q

Causes of bronchiectasis

A

Congenital: kartageners and CF
Childhood infection: measles and TB
Immune over activity: allergic bronchopulmonary aspergillosis (ABPA) IBD
Immune under activity: hypogammaglobinaemia, CVID
Aspiration

42
Q

Treatment of bronchiectasis

A

Physiotherapy
Antibiotics for acute infection
Low dose azithromycin for prophylaxis
Mucolytics

43
Q

Complications of bronchiectasis

A

Cor pulmonale
Secondary amyloidosis
Massive haemoptysis

44
Q

Resp diseases associated with yellow nail syndrome

A

Pleural effusions
Bronchiectasis
Chronic sinusitis
Chronic bronchitis
Recurrent pneumonia

45
Q

Treatment of yellow nail syndrome

A

Topical vitamin E

46
Q

Clinical signs of lung cancer

A

Cachexia
Clubbing and tar staining
Lymphadenopathy
Tracheal deviation - towards collapse or away from effusion
Reduced expansion
Dull percussion note
Increased vocal resonance in collapse or consolidation
Reduced tactile vocal fremitus in effusion
Evidence of mets
Evidence of treatment (lobectomy scar or radiotherapy tattoo
Evidence of complications
- SVCO
- recurrent laryngeal nerve palsy
- horners and wasted small muscles of the hand
- neurological
- dermatomyositis, Gottrons papules or acanthosis nigricans

47
Q

Types of lung cancer

A

Small cell
Non small cell
- squamous - typically central, most associated with smoking
- adenocarcinoma
- large cell
- alveolar

48
Q

Investigation of lung cancer

A

CXR
CT
Sputum cytology
Bronchoscopy/percutanous needle CT guided/ pleural tap
Staging CT
Lung function tests to aide treatment decisions

49
Q

Endocrine complications of lung cancer

A

Non small cell lung ca: increased PTHrP causing hypercalcaemia (typically squamous cell)
SCLC: increased ACTH (cushings) and SIADH

50
Q

Treatment of lung cancer

A

NSCLC: lobectomy or pneumonectomy, radiotherapy, chemotherapy
Surgery considered for stage 1 or 2 disease or potentially stage 3 if no mediastinal lymphadenopathy
SCLC: chemotherapy

New targeted treatments

51
Q

Baseline FEV1 to consider pneumonectomy and lobectomy

A

> 2L for pneumectomy
1.5L for lobectomy

52
Q

Indications for pneumonectomy

A

Large centrally located tumours or those that impinge the proximal bronchial tree

53
Q

Clinical signs of pneumonectomy

A

Thoracotomy scar
Reduced expansion on affected side
Tracheal deviation towards pneumonectomy
Dull percussion note
Absent tactile fremitus
Bronchial breathing in the upper zone with reduced breath sounds throughout the rest of the hemi thorax

54
Q

Natural progression post pneumonectomy

A

The pneumonectomy space fills with fluid over 3 months and you will see an air fluid level which will then be completely opaque after around 3 months

55
Q

What are the complications post pneumonectomy?

A

Bronchopleural fistula: Bronchial stump breaks down and the pneumonectomy space becomes infected with resp organisms

Pneumonectomy empyema: complication of bronchopleural fistula and required drainage

56
Q

Clinical signs of pleural effusion

A

Asymmetrically reduced expansion
Trachea pushed away from side of effusion
Stony dull percussion note
Absent tactile vocal fremitus
Reduced breath sounds
Bronchial breathing above

57
Q

Signs that may indicate cause of pleural effusion

A

Cancer: clubbing, lymphadenopathy, mastectomy
CCF: raised JVP, peripheral oedema
Chronic liver disease
Chronic renal failure (evidence of RRT)
Connective tissue disease (rheumatoid hands, butterfly rash of SLE)

58
Q

Causes of dull lung bases

A

Consolidation
Collapse
Previously lobectomy
Pleural thickening (normal tactile fremitus)
Raised hemidiaphragm

59
Q

Causes of pleural effusion

A

Transudate (protein <30)
- CCF, liver or renal failure
Exudate (protein >30)
- cancer
- infection
- infarction
- RA/SLE

60
Q

Differentiating transudate from exudate

A

If 25-35g/L of protein, use Lights criteria

An exudate is indicated by:
Effusion protein : plasma protein > 0.5
Effusion LDH : plasma LDH >0.6
Effusion LDH > 2/3 of upper limit of normal serum LDH

Empyema: low glucose and pH <7.2

61
Q

What is an empyema

A

Collection of pus in the pleural space
Most frequent organisms are anaerobes, staph, gram -ve
Associated with bronchial obstruction, recurrent aspiration, poor dentition, alcohol dependency

62
Q

What should pleural fluid be sent for

A

LDH and protein
Glucose and pH
MC&S
Cytology

If suspicious of Chylothorax send triglycerides

A glucose level <1.6 are seen in effusions due to RA

63
Q

Clinical signs of COPD

A

Nebs, inhalers, sputum pot, dyspnoea, central cyanosis, pursed lips
Co2 retention flap, bounding pulse
Tar- stained fingers
Hyper- expanded
Percussion note resonant with loss of cardiac dullness
Expiratory polyphonic wheeze
Cor pulmonale signs (raised JVP, ankle oedema, RV heave, loud P2, tricuspid regurgitation)

64
Q

Aetiology of COPD

A

Smoking
Air pollution
Low birthweight and low socioeconomic status
Dust exposure
Alpha- 1 - antitrpsin deficiency

65
Q

Lung functions tests in COPD

A

Diagnosis: FEV1:FVC <0.7

Severity (FEV1)
Mild >80%
Moderate 50-79%
Severe 30-49%
Very severe <30%

Patient also have large TLC and reduced diffusion capacity (DLCO)

66
Q

Investigating COPD

A

CXR- hyperexpanded, R/O pneumothorax
ABG
Spirometry
Alpha- 1 - antitrypsin if younger, minimal smoking hx or FHx
ECG: p-pulmonale, right axis deviation, RBBB
Sputum culture - most commonly H.influenza, streptococcus

67
Q

Medical management of COPD

A

Smoking cessation
Beta agonist
LABA+LAMA
LABA + ICS if evidence of steroid responsivity
Triple therapy (LABA, LAMA, ICS)
Vaccination
Nutrition and exercise
LTOT
Pulmonary rehab

68
Q

Surgical management of COPD

A

Bullectomy (if bullae greater than 1L and compressing surrounding lung)
Transplantation if:
FEV1 and DLCO <20%
History of hospitalisation with an exacerbation with T2RF
Pulmonary hypertension/ cor pulmonale

69
Q

Criteria for LTOT

A

Non smoker
PaO2 <7.3 on air
PaO2 < 8 on air if cor pulmonale
PaCO2 that does not significantly rise on O2
O2 for at least 16hours a day
Improved average life expectancy by 9 months

70
Q

DECAF score

A

Dyspnoea
- too breathless to leave house (1)
- too breathless to wash/dress (2)
Eosinophils <0.05
Consolidation on CXR (1)
Acidaemia (1)
A Fibrillation (1)

Score 3 or me = indicated increased risk of inpatient mortality

71
Q

Clinical signs of old tuberculosis

A

Chest deformity and absent ribs, thoracotomy scar
Tracheal deviation towards side of fibrosis
Reduced expansion
Dull percussion but present tactile vocal fremitus
Crackles and bronchial breathing

72
Q

Side effects of TB drugs

A

Isoniazid: peripheral neuropathy (co prescribe pyridoxine) and hepatitis
Rifampicin: hepatitis, increased COCP metabolism, orange urine
Ethambutol: retro-bulbar neuritis and hepatitis
Pyrazinamide: hepatitis

73
Q

Historical management of TB

A

Plombage: insertion of polystyrene balls into the thoracic cavity
Phrenic nerve crush
Thoracoplasty (rib removal)

74
Q

What to tell patient before starting TB medication

A

If yellow sclera- urgent review
If red colour less bright - urgent review
Watch out for peripheral neuropathy
Orange/red secretions will dye contact lenses
Don’t rely on COCP

75
Q

Investigating suspected TB

A

FBC
CRP
LFTs
HIV and hepatitis screen
Sputum
Urine AFB
Quantiferon test
CXR
CT (upper lobe fibrosis, traction bronchiectasis)
Bronchoscopy
Biopsy extra pleural site for culture

76
Q

Causes of upper zone fibrosis

A

TB
Radiation
Ankylosing spondylitis/ABPA
Sarcoidosis, silicosis
Histoplasmosis
Extrinsic allergic alveolitis

77
Q

Causes of lower zone fibrosis

A

RA
Asbestosis
Scleroderma, SLE, sjogrens
IPF
Drugs

78
Q

When to refer patients for lung transplant

A

UIP on diagnosis of no CI

ILD with FVC < 80% or transfer factor <40% or O2 requirement
May be listed if FVC drop >10% in 6 months

In CF if FEV1 <30%, poor exercise tolerance, pulmonary arterial hypertension, high exacerbation frequency, recurrent pneumothoracices, haemoptysis

COPD: bode index score >7 (fev1, 6 min walk distance, dyspnoea scale, BMI)

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