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Finals > Respiratory > Flashcards

Respiratory Flashcards

1
Q

What are the causes of pulmonary hypertension?

A 
Group 1.  Primary pulmonary HTN or SLE
Group 2. LHF due to MI or system  HTN
Group 3. Chronic lung disease e.g. COPD
Group 4. PE
Group 5. Sarcoidosis, haematological disorders
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2
Q

What are the signs and symptoms of Pulmonary HTN?

A

SOB is main

Other:
Syncope
Loud S2
Tachycardia
Raised A waves on JVP
Hepatomegaly
Peripheral odema
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3
Q

What are the investigations for pulmonary HTN?

A

ECG:

  • R ventricular hypertrophy
  • R axis deviation
  • RBBB

CXR:

  • dilated pulmonary arteries
  • R ventricular hypertrophy
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4
Q

What is the management of pulmonary HTN?

A

Primary pulmonary HTN:

  • IV prostanodids e.g. epoprostenol
  • Endothelin receptor antagonist e.g. macitentan
  • Phosphodiesterase-5 inhibitors e.g. sidenafil
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5
Q

What is the presentation of asthma?

A 
Episodic symptoms
Diurnal variation - worse at night
Dry cough with wheeze and SOB
Hx of other atopic conditions
FHx
Bilateral widespread polyphonic wheeze

Acute: respiratory alkalosis

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6
Q

What are the investigations for asthma?

A

First line:

  • fractional exhaled NO
  • spirometry with bronchodilator reversibility

Second line:

  • peak flow variability
  • direct bronchial challenge test
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7
Q

What is the management of asthma? (NICE)

A
  1. Salbutamol
  2. Add inhaled corticosteroid
  3. Add oral LTRA e.g montelukast
  4. Add LABA e.g. salmeterol
  5. Consider changing to MART regime
  6. Increase inhaled corticosteroid dose to moderate
  7. Increase inhaled corticosteroid to high dose or oral theophyline or tiotropium
  8. Refer to specialist
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8
Q

How is an asthma exacerbation graded?

A

Moderate:
- PEFR 50-75% predicted

Severe:

  • PEFR 33-50% predicted
  • RR > 25
  • HR > 110
  • Unable to complete full sentences

Life threatening:

  • PEFR <33%
  • Sats <92%
  • Becoming tired
  • Silent chest
  • Haemodynamically unstable
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9
Q

What is the treatment for an asthma exacerbation?

A 
Moderate:
Neb salbutamol
Neb ipratropium bromide
Steroids
Abs

Severe:
O2
Aminophyline infusion
Consider IV salbutamol

Life threatening:
IV magnesium sulfate infusion
Admission to ITU
Intubate

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10
Q

Give the presentation of COPD

A 
Chronic SOB
Cough
Sputum production 
Wheeze
Recurrent resp infections esp in winter
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11
Q

Describe the MRC Dyspnoea Scale

A 
Grade 1. Breathless on strenuous exercise
Grade 2. On walking up hill
Grade 3. SOB that slows walking on flat
Grade 4. Stop to catch breath after 100m
Grade 5. Unable to leave house
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12
Q

What is the diagnosis of COPD?

A

Based on clinical presentation plus spirometry

FEV1/FVC <0.7

FEV1 <80% of predicted

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13
Q

What is the long term management of COPD?

A

Stop smoking
Pneumococcal and annual flu vaccine

  1. Salbutamol or Ipratropium bromide
  2. Combined LABA+LAMA (if no asthmatic or steroid responsive features)
  3. If steroid responsive/asthma features = Combined LABA+ICS
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14
Q

How do you distinguish the different types of respiratory failure?

A

Low PO2 indicates hypoxia and respiratory failure
Normal PCO2 with low PO2 = type 1
Raised PCO2 with low PO@ = type 2

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15
Q

Oxygen therapy in COPD

A

If retaining CO2 aim for 88-92% titrated by venturi mask

If not retaining CO2 and bicarb normal, then give oxygen aim >94%

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16
Q

Give the histology of lung cancers

A

Non-small cell lung cancer (80%)

  1. Adenocarcinoma (40%)
  2. Squamous cell carcinoma (20%) (cavitating)
  3. Large cell carcinoma (10%)

Small cell lung cancer (20%)

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17
Q

What are the signs and symptoms of lung cancer?

A 
SOB
Cough
Haemoptysis
Finger clubbing
Recurrent pneumonia
Weight loss
Lymphadenopathy
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18
Q

What are the investigations for lung cancer?

A

CXR: first line

  • hilar enlargement
  • peripheral opacity
  • pleural effusion
  • collapse

Staging CT
PET CT
Bronchoscopy
Histological diagnosis

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19
Q

What are the treatment options for lung cancer?

A

Surgery = first line in non-small cell lung cancers
Radiotherapy - curative in NSCLC
Chemo

Tx for SCLC = radio and chemo

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20
Q

What are the extrapulmonary manifestations of lung cancers?

A 
Recurrent laryngeal nerve palsy
Phrenic nerve palsy
Superior vena cava obstruction
Horners syndrome
SIADH - SCLC
Cushing's syndrome - SCLC
Hypercalcaemia - Squamous cell carcinoma
Lambert eatorn myasthenic syndrome
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21
Q

What is the lambert-eaton myasthenic syndrome?

A

A result of antibodies produced by the immune system against SCLC cells.

antibodies damage the voltage gated calcium channels on the presynaptic terminal in motor neurones leading to proximal muscle weakness, diplopia, ptosis.

Patients have reduced tendon reflexes

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22
Q

What is a mesothelioma?

A

Lung malignancy affecting mesothelial cells fo the pleura. Strongly linked to asbestos inhalation.

May have lag of up to 45 years between exposure and diagnosis

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23
Q

Difference between exudative and transudative pleural effusion

A

Exudative means high protein count >3g/dl

Transudative means low protein count <3g/dl

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24
Q

What are the exudative causes of pleural effusion?

A

Related to inflammation. Inflammation results in protein leaking out of tissues.

Lung cancer
Pneumonia
Rheumatoid arthritis
Tb

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25
Q

What are the transudative causes of pleural effusion?

A

Relate to fluid moving across into the pleural space.

Congestive heart failure
Hypoalbuminaemia
Hypothyroidism
Meig’s syndrome

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26
Q

What are the investigations and findings on pleural effusion

A

CXR:

  • blunting of the costophrenic angle
  • Fluid in the lung fissures
  • larger effusions will have a meniscus
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27
Q

What is the treatment for pleural effusion?

A

Conservative management
Pleural aspiration
Chest drain

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28
Q

What is empyema?

A 
Where there is infected pleural effusion
Improving pneumonia but new or ongoing fever
Pleural aspiration shows pus
Acidic pH
Low glucose, high LDH

Treat with chest drain and abs

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29
Q

What are the causes of pneumothorax?

A

Spontaneous
Trauma
Iatrogenic
Lung pathology

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30
Q

What is the management of pneumothorax?

A

If no SOB and <2cm rim of air on CXR = no treatment and follow up in 2-4 weeks

If SOB and/or >2cm rim of air on CXR then require aspiration and assessment

If aspiration fails twice it will require chest drain

Unstable patients or bilateral or secondary pneumothoraces require chest drain

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31
Q

What is the management of tension pneumothorax?

A

Insert a large bore canula into the second intercostal space in the midclavicular line

Definitive management = chest drain in the triangle of safety in the mid-axillary line

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32
Q

What is the presentation of pneumonia?

A 
SOB
Cough productive of sputum
Fever
Haemoptysis
Pleuritic chest pain
Delirium
Sepsis
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33
Q

What are the characteristic signs of pneumonia?

A

Bronchial breathing
Focal coarse crackles
dullness to percussion

34
Q

What tool is used to assess severity of pneumonia?

A

CURB-65

Confusion
Urea >7
RR > 30
Blood pressure <90 systolic or <60 diastolic
Age >65
35
Q

What is fungal pneumonia and the treatment?

A

Pneumocystis jiroveci (PCP) occurs in patients that are immunocompromised. Particularly important in patients with poorly controlled or new HIV.

Treatments with co-trimoxazole

36
Q

What are the risk factors for pulmonary embolism?

A 
immobility
recent surgery
long haul flights
pregnancy
hormone therapy with oestrogen
37
Q

What is VTE prophylaxis?

A

Given to all patients that are at risk of a VTE in hospital.

LMWH such as enoxaparin given unless active bleeding or existing anti coagulation

Anti-embolic compression stockings unless significant peripheral arterial disease

38
Q

What is the presentation of PE

A 
SOB
Cough ± haemoptysis
Pleuritic chest pain
Hypoxia
Tachycardia
Raised RR
Low grade fever
39
Q

What are the investigations and their findings for PE

A
  1. Wells score

If likely: CTPA
Unlikely: D-Dimer and if positive = CTPA

Definitive diagnosis = CTPA

ABG = respiratory alkalosis

40
Q

How long do you anticoagulate following a PE?

A

If there is an obvious reversible cause: 3 months
If the cause unclear, recurrent or irreversible: 6 months
In active cancer: 6 months

41
Q

What is obstructive sleep apnoea?

A

Caused by collapse of the pharyngeal airway during sleep.

Characterised by apneoa episodes during sleep where the person will periodically stop breathing for a few minutes

42
Q

What are the risk factors for obstructive sleep apnoea

A 
Middle age
Male
Obesity
Alchohol
Smoking
43
Q

What are the features of obstructive sleep apnoea?

A 
Apnoea episodes during sleep (reported by partner)
Snoring
Morning headache
Waking up tired
Daytime sleepiness
Concentration problems
Reduced O2 sats during sleep
44
Q

What tool is used to assess obstructive sleep apnoea?

A

Epworth sleepiness scale

45
Q

What is the management for obstructive sleep apnoea?

A

Referral to ENT or specialist sleep clinic

Correct reversible risk factors

CPAP

Surgery

46
Q

What is the typical exam question for sarcoidosis?

A

Black woman aged 20-40 with dry cough and SOB. May also have nodules on their shins suggesting erythema nodosum.

47
Q

Which organs are affected in sarcoidosis?

A

Lungs (90%)

  • mediastinal lymphadenopathy
  • pulmonary fibrosis
  • pulmonary nodules

Liver (20%)

  • Liver nodules
  • Cirrhosis
  • Cholestasis

Eyes (20%)

  • uveitis
  • conjuctivitis
  • optic neuritis

Others

48
Q

What is lofgren’s syndrome?

A

A specific presentation of sarcoidosis. Triad of:

  • erythema nodosum
  • bilateral hilar lymphadenopathy
  • polyarthralgia
49
Q

What do the blood tests show in sarcoidosis?

A 
Raised serum ACE (screening tool)
Hypercalcaemia
Raised IL-2 receptor
Raised CRP
Raised immunoglobulin
50
Q

Findings on imaging in sarcoidosis?

A

CXR - hilar lymphadenopathy
High resolution CT: hilar lymphadenopathy and pullmonary nodulles
MRI: CNS involvement

51
Q

What is the gold standard test for sarcoidosis?

A

Non-caseating granulomas with epithellioid cells on histology

52
Q

What is the treatment for sarcoidosis?

A
  1. no treatment
  2. steroids (+ bisphosphonates)
  3. methotrexate or axathioprine
    4, lung transplant
53
Q

What is interstitial lung disease?

A

An umbrella term to describe conditions that affect the lung parenchyma causing inflammation and fibrosis.

54
Q

What is the diagnosis of interstitial lung disease?

A

Combination of clinical features on high resolution CT scan of the thorax: shows ground glass appearance.

55
Q

What is the management for interstitial lung disease?

A

Mostly supportive to not make things worse.

  • remove or treat underlying cause
  • home oxygen
  • stop smoking
  • physiotherapy
56
Q

What is idiopathic pulmonary fibrosis?

A

Condition where there is progressive pulmonary fibrosis with no clear cause

57
Q

How does idiopathic pulmonary fibrosis present?

A

Insidious onset of SOB and dry cough for over 3 months

Usually affects over 50yr olds

58
Q

What is seen on examination for idiopathic pulmonary fibrosis?

A

Bibasal fine inspiratory crackles and finger clubbing

59
Q

What is the management of idiopathic pulmonary fibrosis?

A

pirfenidone

nintedanib

60
Q

Which drugs can cause pulmonary fibrosis?

A

Amiodarone
Cyclophosphamide
Methotrexate
Nitrofurantoin

61
Q

What causes secondary pulmonary fibrosis

A

Alpha 1 antitripsin deficiency
Rheumatoid arthritis
SLE
Systemic sclerosis

62
Q

What is hypersensitivity pneumonitis?

A

type 3 hypersensitivity reaction to an environmental allergen.

e.g. farmers lung, bird fanciers lung, mushroom workers lung

Tx: oxygen, remove allergen and steroid

63
Q

What is bronchiectasis?

A

Describes a permanent dilation of the airways secondary to chronic infection or inflammation

64
Q

What are the causes of bronchiectasis?

A

Post-infective
CF
Bronchial obstruction e.g. lung ca/foreign body
Immune deficiency

65
Q

What is the management of bronchiectasis?

A 
Physical training 
Postural drainage
Antibiotics for exacerbation
Bronchodilators
Immunisations
Surgery
66
Q

What is the most common causative organism of bronchiectasis?

A

Haemophilus influenzae

67
Q

What are the features of carbon monoxide toxicity?

A 
Headache
N+V
Vertigo
Confusion
Subjective weakness
68
Q

What are the investigations and results for carbon monoxide poisoning

A

O2 sats: falsy high
ABG
ECG

69
Q

What is the management of patients with CO poisoning?

A

100% high flow oxygen via a non-rebreather mask

Hyperbaric oxygen

70
Q

What is seen on CXR in asbestosis?

A

Honey combing of lung with parenchymal bands and pleural plaques

71
Q

Investigation of choice for unprovoked DVT?

A

CT abdo and pelvis

72
Q

Which tube provides protection for lungs from regurgitated stomach contents?

A

Tracheal tube

73
Q

What is the most common post COVID complication?

A

PE

74
Q

Which the most common causative organism of COPD exacerbation?

A

Haemophilus influenza

75
Q

Preceding influenza predisposes to which causative organism in pneumonia?

A

Staph aureus

76
Q

Which normal acute procedure is contraindicated in haemoptysis?

A

Non invasive ventilation due to aspiration risk

77
Q

What is the presentation of legionella penumonia?

A 
Flu-like symptoms
Dry cough
Relative bradycardia
Confusion
Hyponatraemia
78
Q

What is recommended for COPD patients with 4 or more exacerbations despite optimised control?

A

Azithromycin prophylaxis

79
Q

What is the measurement of exudative and transudative pleural effusion in terms of protein ratio?

A

Pleural effusion protein/ serum protein ration >0.5 = exudative

80
Q

What is an alternative presentation of lower lobe pneumonia?

A

Upper quadrant abdominal pain

Finals (20 decks)

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