Respiration Flashcards
What does hyper resonance on percussion signify?
Tension pneumothorax
How should a tension pneumothorax be managed acutely?
Needle decompression with a wide bore cannula in the second intercostal space mid-clavicular line
How is a massive pneumothorax managed?
Wide bore chest drain
How is a massive PE managed?
Unfractionated heparin
Thrombolysis
What scores are used in PE?
Pulmonary embolism rule out criteria (PERC)
Wells score
What do you do if Wells gives unlikely?
D dimer
If positive then CTPA
What is sarcoidosis?
A chronic granulomatous disorder.
Granulomas are inflammatory nodules full of macrophages
Who is a typical sarcoidosis patient?
20-40 year old black female presenting with SOB and cough and erythema nodosum
What is erythema nodosum?
Modules of inflamed subcutaneous fat on the shins
What is screening test for sarcoidosis?
Serum ACE
What is raised in sarcoidosis?
Calcium
What is shown on a CXR in sarcoidosis?
Hilar lymphadenopathy
What is diagnostic for sarcoidosis?
US guided biopsy from bronchoscopy
Shows non-caseating granulomas with epithelial cells
What are the signs of sarcoidosis?
Lungs: mediastinal lymphadenopathy, pulmonary fibrosis, pulmonary nodules
Systemic symptoms: fever, weight loss, fatigue
Liver: nodules, cirrhosis, cholestasis
Eyes: uveitis, conjunctivitis, optic neuritis
CNS: nodules, diabetes insipidus, encephalopathy
Heart: BBB, heart block, myocardial muscle involvement
Kidneys: stones secondary to hypercalcaemia, nephrocalcinosis, interstitial nephritis
PNS: facial nerve palsy, mononeuritis multiplex
Bones: arthralgia, arthritis, myopathy
How is sarcoidosis managed?
- Oral steroids (add bisphosphonate)
- Methotrexate
What is Light’s criteria?
Pleural fluid protein/serum protein >0.5
Pleural fluid LDH/serum LDH >0.6
Pleural fluid LDH >2/3 of the normal upper limit of the serum LDH
Suggests exudative
What is an exudative pleural effusion?
High protein content >30g/L
What is a transudative pleural effusion?
Low protein content <30g/L
What causes an exudative pleural effusion?
Related to inflammation causing protein leaking out of tissues into the pleural space:
Cancer
Infection
RA
What causes a transudative pleural effusion?
Related to fluid moving across or shifting into the pleural space:
Congestive cardiac failure
Hypothyroidism
Hypoalbuminaemia
Meigs syndrom (benign ovarian tumour, pleural effusion, ascites)
Which way does trachea deviate in pleural effusion?
Away from
What are the CXR findings for a pleural effusion?
Blunting of the costophrenic angle
Fluid in the lung fissures
Tracheal deviation away from and mediastinal deviation
Why is a chest drain inserted in a pleural effusion with pH <7.2?
Suggests empyema
What is bronchiectasis?
Permanent dilation of the large airways due to chronic infection. Occurs due to damage to the airways
What causes bronchiectasis?
Idiopathic
Pneumonia
Whooping cough (pertussis)
TB
Alpha-1 anti trypsin deficiency
Rheumatoid arthritis
Cystic fibrosis
Yellow nail syndrome: yellow nails, bronchiectasis, lymphoedema
What are the signs of bronchiectasis on examination?
Clubbing
Signs of cor pulmonate: raised JVP and peripheral oedema
Scattered crackles
Scattered wheezes and squeaks
What is diagnostic for bronchiectasis?
High resolution CT
What is management for bronchiectasis?
Prolonged antibiotics, usually 7-14 days
Vaccines e.g. pneumococcal, influenza
Respiratory physio to help clear sputum
Long term antibiotics if >3 exacerbations per year
What are the most common infective pathogens in bronchiectasis?
Haemophilus influenzae
Pseudomonas aerguinosa
What are risk factors for OSA?
Obesity
Alcohol
Nasal polyps
Large adenoids
What is OSA?
Collapse of the pharyngeal airway
What are the signs of pulmonary hypertension on examination?
Raised JVP
Hepatomegaly
Peripheral oedema
What does an ECG show in pulmonary hypertension?
P pulmonale (peaked p waves)
RV hypertrophy (tall R waves in V1 and V2)
Right axis deviation
R BBB
What does a chest X ray show in pulmonary hypertension?
Dilated pulmonary arteries
RVH
How do you treat idiopathic pulmonary hypertension?
CCB
IV prostaglandins
Endothelin receptor antagonist e.g macitentan
Phosphodiesterase-5 inhibitors
What are the groups of pulmonary hypertension?
Group 1 = idiopathic pulmonary HTN or connective tissue disease e.g. SLE
Group 2 = left HF due to MI or systemic HTN
Group 3 = chronic lung disease e.g. COPD or pulmonary fibrosis
Group 4 = pulmonary vascular disease e.g. PE
Group 5 = miscellaneous e.g. sarcoidosis, glycogen storage disease and haematological disorders
What is a pneumothorax?
When air enters the pleural space
What causes a pneumothorax?
Spontaneous
Secondary to trauma
Medical interventions “iatrogenic” due to lung biopsy, mechanical ventilation or central line insertion
Lung pathology e.g. infection, asthma, COPD
What investigations are performed for pneumothorax?
Erect CXR for simple pneumothorax
CT thorax
How is a pneumothorax managed?
If no SOB and <2cm on CXR: no treatment, follow up in 2-4 weeks
If SOB or >2cm: aspiration (when aspiration fails x2 then chest drain)
If unstable, bilateral or secondary: chest drain
How is a tension pneumothorax managed?
Large bore cannula into the second intercostal space in the midclavicular line
Chest drain for definitive management
What needs to be monitored with aminophylline?
ECG as can cause arrhythmias
Which type of X-ray can you assess cardiomegaly on?
PA
What do you look at for rotation on X-ray?
Clavicles and spinous vertebrae should be equidistant
What is in the hilar region?
Pulmonary arteries
Pulmonary veins
Lymph nodes
Are transudates more likely to be bilateral or unilateral?
Bilateral
Where should the tip of an NG tube be seen on a CXR?
Below the left hemidiaphragm
What are the types of lung cancer?
Small cell lung cancer (20%)
Non-small cell lung cancer:
Adenocarcinoma
Squamous cell carcinoma
Large cell carcinoma
What can be secreted from small cell lung cancers?
ADH
ACTH
Antibodies to voltage gated sodium channels (Lambert-Eaton syndrome)
Which is the most common lung cancer in non-smokers?
Adenocarcinoma
Which is the lung cancer causing cavitating lesions?
Squamous cell carcinoma
Which lung cancer is related to asbestos exposure?
Mesothelioma
What is the third most common cancer in the UK?
Lung
What are the causes of finger clubbing in lung disease?
Bronchiectasis
Lung cancer
Idiopathic pulmonary fibrosis
Asbestosis
What are complications for lung cancer?
Superior vena cava obstruction: facial swelling, distended neck and upper chest veins. Pemberton’s sign
Recurrent laryngeal nerve palsy: hoarse voice
Phrenic nerve palsy: diaphragm weakness and presents with SOB due to nerve compression
What is Pemberton’s sign?
Where raising the hands over the head causes facial congestion and cyanosis
What lung cancer is Horner’s syndrome?
Pancoast tumout
Which lung cancer secretes excess PTH and causes hypercalcaemia?
Squamous cell carcinoma
What is management of lung cancer?
Non-small cell: surgery, radiotherapy, chemotherapy
Small cell: chemotherapy, radiotherapy
What is limbic encephalitis?
Small cell lung cancer causes the immune system to make antibodies against tissues in the brain. Associated with anti-Hu antibodies
What are the surgical options for a lung tumour?
Segmentectomy or wedge resection
Lobectomy
Pneumonectomy
Can be thoracotomy or thoracoscopic
What are the most common bacterial causes of CAP?
Strep pneumonia
Haemophilus influenza
Moraxella catarrhalis in immunocompromised or COPD
Pseudomonas aeurginosa in CF or bronchiectasis
Staph aureus in CF
MRSA in hospital acquired
What rash is associated with mycoplasma pneumonia?
Erythema multiforme
What are causes of atypical pneumonia?
Legions of psittaci MCQs:
Legionella penumophila: can cause SIADH. Do urinary antigen test
Chlamydia psittaci (bird exposure)
Mycoplasma pneumonia
Chlamydophila pneumoniae
Coxiella brunette/Q fever: farmer
What is found on examination in pneumonia?
Bronchial breath sounds
Focal coarse crackles
Dullness to percussion
How do you interpret CURB 65?
0-1 = low risk, treat at home
2 = hospital admission for oral antibiotics and supportive measures
3-5 = consider intensive care
Which pathogen for pneumonia is common in alcoholics?
Klebsiella pneumoniae
Red current jelly sputum
What do blood tests show in Legionella pneumophila?
Low sodium
Derange LFTs
Lymphopenia
What is a sign of mycoplasma pneumonia?
Haemolytic anaemia
What should all cases of pneumonia have as follow up?
Repeat in 6 weeks
What is used to treat a mild CAP?
Amoxicillin
Doxycycline
Clarithromycin
What is the most common pneumonia pathogen in COPD patients?
Haemophilus influenzae
What are the investigations for asthma?
Spirometry with reversibility testing
Fractional exhaled nitric oxide (not smoking can lower this)
Direct bronchial challenge testing (give histamine)
What is the management of chronic asthma?
- SABA
- ICS low dose e.g. budesonide
- Leukotriene receptor antagonist
- LABA
- MART
- Increase dose of ICS to moderate
- ICS high dose or LAMA/theophylline
- Special management e.g. corticosteroids
What causes a transudative effusion?
Increased hydrostatic pressure or low oncotic pressure
What is asthma?
Chronic inflammatory airway disease leading to variable airway obstruction
The smooth muscle in the airways is hypersensitive and responds to stimuli by constricting (bronchoconstriction)
When do you use Light’s criteria?
When borderline protein 25-35g/L
What is percussion like in pleural effusion?
Stony dullness
What is diagnostic for a exudative pleural effusion?
US guided pleural aspirate
How do beta 2 agonists work?
Stimulates the adrenalin receptors to dilate the bronchioles and revers the bronchoconstriction
How do LAMAs work?
Blocking acetylcholine receptors which are stimulated by the parasympathetic nervous system, reversing bronchoconstriction
What does a MART contain?
ICS
Fast and long-acting beta-agonist e.g. formoterol
How does theophylline work?
Relaxing the bronchial smooth muscle and reduce inflammation
Can be toxic
What is the SE of pyrazinamide?
Hyperuricaemia (gout)
How do you step down ICS?
25-50% reduction
What is the triangle of safety?
5th intercostal space, midaxillary line (lateral edge of latissimus dorsi), anterior axillary line (lateral edge of pectoralis major)
Where is the needle inserted in a chest drain?
Above the rib to avoid the neurovascular bundle
How do you know a chest drain is treating a pneumothorax?
Place end of the tube in water and will get “swinging”
What are surgical options for persistent pneumothorax?
Abrasive pleurodesis: direct physical irrational of the pleura
Chemical pleurodesis: chemicals e.g. talc powder to irritate
Pleurectomy: removal of the pleura
What is the investigation of choice in interstitial lung disease?
High resolution CT
Ground glass appearance before progressing to honeycombing
Reduced lung volume
What is the spirometry pattern in interstitial lung disease?
FEV1 reduced
FVC reduced
FEV1:FVC normal or high
What are examples of interstitial lung disease?
Idiopathic pulmonary fibrosis
Secondary pulmonary fibrosis
Hypersensitivity pneumonitis
Cryptogenic organising pneumonia
Asbestosis
What are the examination findings of idiopathic pulmonary fibrosis?
Bibasal fine end inspiratory crackles
Finger clubbing
Which medications can slow the progression of idiopathic pulmonary fibrosis?
Pirfenidone
Nintedanib (inhibits tyrosine kinase)
What are secondary causes of pulmonary fibrosis?
Medications e.g. amiodarone (blue/grey skin)
Cyclophosphamide
Methotrexate
Nitrofurantoin
Other:
SLE
Rheumatoid arthritis
Systemic sclerosis
Sarcoidosis
Alpha-1 antitrypsin
What are the types of hypersensitivity pneumonitis?
Bird fancier’s lung
Farmer’s lung
Mushroom worker’s lung
Malt worker’s lung
Which type of hypersensitivity is hypersensitivity pneumonitis?
Type III and type IV
How is hypersensitivity pneumonitis investigated?
Bronchioalveolar lavage is performed during a bronchoscopy procedure. The airways are washed with sterile saline to gather cells, after which the fluid is collected and analysed
Raised lymphocytes
Is asbestos fibrogenic or oncogenic?
Both
Which cancers can asbestos cause?
Adenocarcinoma
Mesothelioma
How is bronchiolitis obliterates (aka cryptogenic organising pneumonia) diagnosed?
Biopsy
How is bronchiolitis obliterates (aka cryptogenic organising pneumonia) managed?
Systemic corticosteroids
What is COPD?
Long term progressive condition involving airway obstruction, chronic bronchitis and emphysema.
What is emphysema?
Damage and dilatation of the alveolar sacs and alveoli, decreasing the surface area for gas exchange
What symptoms does COPD not cause?
Clubbing
Haemoptysis
Chest pain
How can dyspnoea be graded?
Grade 1: breathless on strenuous exercise
Grade 2: breathless on walking uphill
Grade 3: breathlessness that slows walking on the flat
Grade 4: breathlessness stops them from walking more than 100 metres on the flat
Grade 5: unable to leave the house due to breathlessness.
How is COPD graded?
FEV1:
Stage 1 (mild): >80%
Stage 2 (moderate): 50-79%
Stage 3 (severe): 30-49%
Stage 4 (very severe): <30%
Why do you get raised Hb in COPD?
Chronic hypoxia
What is TLCO (transfer factor for carbon monoxide) in COPD?
Low
Which vaccines are given in COPD?
One off pneumococcal
Annual flu
What is the management of chronic COPD?
- SABA OR SAMA
- Determined by if asthmatic features or not
If asthmatic features: LABA, ICS e.g. Fostair, Seretide, Symbicort
If no asthmatic features: LABA, LAMA - LABA + LAMA + ICS combination inhaler e.g. Trimbow
What are asthmatic signs in COPD?
Previous diagnosis of asthma or atopy
Variation in FEV1 >400mls
Diurnal variation in peak flow >20%
Raised blood eosinophil count
What is carbocisteine?
Anti mucolytic agent
Which antibiotics are used in an infective exacerbation of COPD?
Amoxicillin
Clarithromycin
Doxycyline
Which prophylactic antibiotic is given in COPD?
Azithromycin
Shouldn’t smoke
>3 exacerbations in the last year
At least one exacerbation in the last year requiring hospital admission
When is LTOT used in COPD?
Chronic hypoxia (sats <92%)
Polycythaemia
Cyanosis
Cor pulmonale (raised JVP, peripheral oedema)
What does a raised bicarbonate mean in COPD?
They chronically retain CO2
How is oxygen delivered in COPD patients?
Venturi mask 28% (normal air is 21%)
How is an acute exacerbation of COPD managed?
Regular inhalers or nebulisers e.g. salbutamol or ipratropium
Steroids e.g. prednisone for 5 days
Antibiotics if infective
IV aminophylline
NIV: BIPAP
Intubation and ventilation with admission to IT
Doxapram as a respiratory stimulant where NIV or intubation is not appriopriate
When is NIV used in COPD?
pH < 7.35 and paCO2 > 6
What is the main CI to NIV?
Untreated pneumothorax
What is cor pulmonale?
Right sided HF secondary to pulmonary hypertension
What causes cor pulmonale?
COPD (most common)
PE
Interstitial lung disease
Cystic fibrosis
Primary pulmonary hypertension
What is found on examination in cor pulmonale?
Raised JVP
Peripheral oedema
Parasternal heave
Loud second heart sound
Murmurs e.g. pan systolic in tricuspid regurgitation
Hepatomegaly due to back pressure in the hepatic vein (pulsatile in MR)
What bacteria causes TB?
Mycobacterium tuberculosis
A small rod shaped bacteria (bacillus)
What can happen when TV enters the body?
Immediate clearance of the bacteria (in most cases)
Primary active tuberculosis (active infection after exposure)
Latent tuberculosis (presence of the bacteria without being symptomatic or contagious)
Secondary tuberculosis (reactivation of latent tuberculosis to active infection).
How is TB spread?
Saliva
What is miliary tuberculosis?
When the immune system cannot control the infection, disseminated and severe disease can develop.
Where is extra pulmonary TB?
Lymph nodes
Pleura
Central nervous system
Pericardium
Gastrointestinal system
Genitourinary system
Bones and joints
Skin (cutaneous tuberculosis).
What are the risk factors for TB?
Close contact with active tuberculosis (e.g., a household member)
Immigrants from areas with high tuberculosis prevalence
People with relatives or close contacts from countries with a high rate of TB
Immunocompromised (e.g., HIV or immunosuppressant medications)
Malnutrition, homelessness, drug users, smokers and alcoholics
Silicosis.
What are signs of TB?
Lymphadenopathy
Erythema nodosum
Spinal pain in spinal TB (Pott’s disease)
What staining is used in TB?
M. tuberculosis has a waxy coating that makes gram staining ineffective. They are resistant to the acids used in the staining procedure, described as “acid-fast”, making them acid-fast bacilli. Special staining is required, using the Zeihl-Neelsen stain, which turns them bright red against a blue background.
What are the tests for TB?
Mantoux: inject tuberculin into the intradermal space on the forearm (induration of 5mm or more is positive)
Interferon-gamma release assay: mixing a blood sample with antigens from M. tuberculosis bacteria
What is shown on a CXR in TB?
Primary tuberculosis: patchy consolidation, pleural effusions and hilar lymphadenopathy.
Reactivated tuberculosis: patchy or nodular consolidation with cavitation (gas-filled spaces), typically in the upper zones
Disseminated miliary tuberculosis gives an appearance of millet seeds uniformly distributed across the lung fields with many small (1-3mm) nodules disseminated throughout the lung fields.
How many sputum cultures are taken in TB?
3
How can you get a culture sample for TB?
Sputum cultures (3 separate sputum samples are collected)
Mycobacterium blood cultures (require special blood culture bottle)
Lymph node aspiration or biopsy
If they cannot produce enough sputum:
Sputum induction with nebulised hypertonic saline
Bronchoscopy and bronchoalveolar lavage (saline is used to wash the airways and collect a sample).
What are the advantages of NAAT testing in TB?
It provides information about the bacteria faster than traditional culture, including drug resistance. NAAT is used for:
Diagnosing tuberculosis in patients with HIV or aged under 16
Risk factors for multidrug resistance (where the results would alter management).
Is the TB vaccine live?
Yes
What is injected in the BCG vaccine?
Mycobacterium bovis bacteria
What happens before somebody is vaccinated for TB?
Tested with the Mantoux test and only given the vaccine if this test is negative.
Assessed for the possibility of immunosuppression and HIV due to the risks related to a live vaccine.
How is latent TB treated?
Isoniazid and rifampicin for 3 months
Isoniazid for 6 months.
What is the treatment for active TB?
R: Rifampicin for 6 months
I: Isoniazid for 6 months
P: Pyrazinamide for 2 months
E: Ethambutol for 2 months.
What is co-prescribed with isoniazid?
Pyridoxine (vitamin B6)
What is used in hospitals to prevent air born spread?
Negative pressure rooms have ventilation systems that actively remove air to prevent it from spreading onto the ward.
What is the side effect of rifampicin?
Red/orange discolouration of secretions, such as urine and tears.
It is a potent inducer of the cytochrome P450 enzymes and reduces the effects of drugs metabolised by this system, such as the combined contraceptive pill.
What is the side effect of isoniazid?
Peripheral neuropathy
What is the side effect of ethambutol?
Colour blindness and reduced visual acuity
What is the side effect of Pyrazinamide?
Hyperuricaemia resulting in gout and kidney stones
How does CO2 make the blood acidic?
Breaks down carbonic acid
Where is bicarbonate produced?
Kidneys
What is the likely ABG in PE?
Respiratory alkalosis
What causes metabolic acidosis?
Raised lactate
Raised ketones (DKA)
Increased hydrogen ions (renal failure, type 1 renal tubular acidosis, rhabdomyolysis)
Reduced bicarbonate (diarrhoea, renal failure, type 2 renal tubular acidosis).
What is the bicarbonate like in metabolic acidosis?
Low
What causes metabolic alkalosis?
Loss of H+ ions from:
GI tract (vomiting)
Kidneys (increased aldosterone due to Conn’s, liver cirrhosis, HF, loop diuretics, thiazide diuretics)
How do you approach ABGs?
ROME
R espiratory = O pposite
Low pH + high PaCO2
High pH + low PaCO2
M etabolic = E qual
Low pH + low bicarbonate
High pH + high bicarbonate
What is first line in acute bronchitis?
Doxycycline
Amoxicillin in pregnant women and children
What does alpha-1 antitrypsin deficiency cause?
COPD and bronchiectasis in the lungs
Dysfunction, fibrosis and cirrhosis of the liver
How is alpha-1 antitrypsin deficiency inherited?
Autosomal co-dominant pattern (both genes contribute to the outcome)
SERPINA 1 gene on chromosome 13
What is the pathophysiology of alpha-1 antitrypsin deficiency?
Inhibits neutrophil elastase which helps to keep tissues flexible and elastic
Where is alpha-1 antitrypsin produced?
Liver
What can alpha-1 antitrypsin deficiency be associated with?
Panniculitis (inflammation of subcutaneous fat)
Granulomatosis with polyangitis (small and medium sized vasculitis)
What is shown on liver biopsy in alpha-1 antitrypsin deficiency?
Periodic acid-Schiff positive staining globules in hepatocytes, resistant to disease treatment. these represent a buildup of the mutant proteins
What can asbestos cause in the lungs?
Benign pleural plaques (most common)
Pleural thickening
Asbestosis (lower lobe fibrosis)
Mesothelioma
What is the most common form of cancer associated with asbestos?
Lung cancer not mesothelioma.
Which occupations are at risk of silicosis?
Mining
Slate works
Foundries
Potteries
What is shown on imaging in silicosis?
Upper zone fibrosis lung disease
“Egg shell” calcification of hilar lymph nodes
Why is a Venturi mask used in COPD?
At risk of losing hypoxic drive
What are signs of consolidation on examination?
Reduced chest expansion
Dull percussion note
Increased tactile vocal fremitus
Increased vocal resonance
Bronchial breathing
What causes erythema nodosum?
TB
Sarcoidosis
IBD
Idiopathic
Strep infection
Chlamydia Leprosy
What causes bronchiectasis?
Idiopathic
Post infective
Post obstructive (tumour, foreign body)
Immunodeficiency
Alpha 1 antitrypsin deficiency
RA
UC
What are complications of bronchiectasis?
Pneumonia
Septicaemia
Recurrent LRTI
Haemoptysis
Respiratory failure
Cor pulmonale
Pneumothorax
What shows on ECG in cor pulmonale?
Right axis deviation
P pulmonale
Dominant R wave in V1
Inverted t waves in chest leads
What is seen on imagine in cor pulmonale?
Dilated RA
Enlarged RV
Prominent pulmonary arteries
What are SE of long term steroids?
Adrenal suppression
Hyperglycaemia
Skin bruising
Skin thinning
Osteoporosis
Avascular of the femoral head
Hypertension
Susceptibility to infection
Peptic ulcers
What tests are performed on a pleural aspirate?
Microscopy
Culture and sensitivities
Cytology
Glucose
Amylase
pH
Ziehl-Neelsen staining for acid fast bacilli
