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PACES > Respiratory > Flashcards

Respiratory Flashcards

1
Q

Causes of ILD

A

Immune mediated

  • hypersensitivity pneumonitis
  • connective tissue disease associated
  • sarcoid
  • occupational exposure
  • drug causes: methotrexate, amiodarone, nitrofurantoin

Non-immune mediated
- IPF

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2
Q

Upper zone fibrosis causes

A 
APHAT
Aspergillosis 
Pneumoconiosis e.g. coal / silica
Hypersensitivity pneumonitis
Ankylosing spondylitis 
TB
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3
Q

Mid zone fibrosis causes

A

Sarcoid

Radiotherapy

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4
Q

Lower zone fibrosis causes

A 
DAIR
Drugs e.g. methotrexate, nitrofurantoin, amiodarone
Asbestosis
Idiopathic pulmonary fibrosis
Rheumatic
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5
Q

Asthma management (chronic)

A

1) SABA
2) SABA + low dose ICS
3) SABA + low dose ICS + montelukast
4) SABA + low dose ICS + LABA (+/- montelukast if it had any effect)
5) SABA (+/- montelukast) & maintenance and reliever LABA/ICS combo
6) Increase steroid dose
7) Increase steroid dose further OR add LAMA OR theophylline

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6
Q

COPD management (chronic)

A

1) SABA / SAMA (iptrotropium)
2) LABA (salmeterol) + ICS (if asthmatic features)
OR LABA + LAMA (tiotropium) (if no asthmatic features)
3) LABA + LAMA + ICS
4) Roflumilast (>2 exacerbations in a year, despite triple inhaled therapy, where FEV1 is less than 50% of predicted)
Others
- oral theophylline
- mucolytics e.g. carbocysteine
- lung volume reduction surgery

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7
Q

VATS indications

A

Parenchymal

  • lung biopsy
  • wedge resection
  • lobectomy
  • bullectomy

Pleural

  • decortication of chronic empyema
  • pleurectomy / pleurodesis e.g. recurrent pneumothoraces
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8
Q

Thoracotomy indications

A

Cancer (CI if malignant pleural effusion / SV obstruction / paralysis vocal cords / tumour near hilum)

  • lobectomy (FEV1 >1.5L)
  • pneumonectomy (FEV1 >2L)

Lobectomy (non-cancer)

  • traumatic lung injury
  • vascular malformations
  • lung abscess
  • bronchiectasis
  • aspergilloma

Lung volume reduction surgery (COPD)

Bullectomy

Pleural procedures including pleurectomy for recurrent pleural effusions

Atypical approaches to the thoracic aorta

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9
Q

Lung transplant indications

A

Aetiologies

  • CF
  • bronchiectasis
  • ILD
  • COPD
  • pulmonary vascular disease

Prognosis

  • > 50% death within 2 years
  • otherwise few co-morbidities

Contraindications

  • malignancy
  • smokers / illicit drug users
  • non-compliance with clinic / medications
  • poor social support systems
  • extremes of BMI
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10
Q

Complications of transplant

A

Acute

  • surgical complications (pain / bleeding / infection / neurovascular injury)
  • acute rejection

Chronic

  • rejection
  • opportunistic infection
  • post transplant diabetes (in part related to glucocorticoids)
  • malignancy
    • > skin cancer (azathioprine / immunosuppression)
    • > post transplant lymphoproliferative disorder
    • > graft versus host
  • disease recurrence

Other complications of immunosuppression

  • cushing’s
  • calcineurin kidney toxicity
  • gum hypertrophy (ciclosporin)
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11
Q

Causes of clubbing

A

Idiopathic / familial

Respiratory

  • ILD e.g. IPF
  • chronic suppurative lung disease e.g. CF, bronchiectasis, TB, empyema, abscess
  • cancer (non-small cell, mesothelioma)
  • part of hypertrophic pulmonary osteoarthropathy

Abdo

  • IBD
  • cirrhosis of the liver

Cardio

  • subacute infective endocarditis
  • congenital cyanotic heart disease

Endocrine
- thyroid acropachy of Graves

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12
Q

Management of pneumothorax

A

Primary
asymptomatic / <2cm - consider discharge
>2cm or symptomatic - aspiration -> chest drain if residual >2cm

Secondary
<1cm: oxygen / admit for observation
1-2cm: aspiration -> chest drain if residual >1cm
>2cm: chest drain

Recurrent

  • pleurodesis
  • pleurectomy (VATS or thoracotomy)
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13
Q

Causes of pleural effusion

A

Transudate (protein <25g/dL or -ve Light’s criteria)

  • heart failure
  • liver failure (including hepatic hydrothorax)
  • renal failure
  • hypoalbuminaemia (including dietary / severe disease associated)
  • Meig’s syndrome - benign ovarian tumour + pleural effusion)

Exudate (protein >35g/dL or +ve Light’s criteria)

  • empyema (frank pus, ph <7.2, low glucose,
  • parapneumonic
  • malignancy
  • rheumatological (serositis e.g. SLE, RA)
  • pancreatitis
  • TB -> low glucose, raised adenosine deaminase
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14
Q

Light’s criteria

A

Exudative effusion if

  • pleural / plasma LDH > 0.6
  • pleural LDH > 2/3 upper limit of serum normal range
  • pleural / plasma protein > 0.5
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15
Q

Non-small cell lung cancer features

A

Adenocarcinoma

  • 40%
  • most common type for non-smokers (but smoking still increases risk)
  • peripheral tumours

Squamous

  • 25%
  • highly smoking associated
  • central lesions
  • PTHrP secretion -> hypercalcaemia

Large cell

  • 10%
  • aggressive
  • Bhcg secretion

NETs

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16
Q

Non-small cell lung cancer management

A

Depends on stage at diagnosis

Stage 1/2 (no distant metastases, limited nodal disease)

  • curative lobectomy / pneumonectomy +/- adjuvant chemoradiotherapy
  • OR radical radiotherapy

Late stage / inoperable
- chemoradiotherapy

17
Q

Small cell lung cancer features & treatment

A 
Aggressive with early metastases 
Paraneoplastic syndromes common
- SIADH
- Lambert Eaton
- ACTH secretion (ectopic cushing's)

Surgery: rarely indicated as picked up post mets
Local disease: chemoradiotherapy
Extensive disease: palliative chemotherapy

18
Q

Causes of bronchiectasis

A

Recurrent respiratory infections (childhood or adulthood)
Genetic
- CF
- Kartagener’s (situs invertus, primary ciliary dyskinesia)
Chronic lung disease e.g. COPD
Connective tissue disease e.g. RA
Chronic inflammatory disease e.g. IBD
Allergic bronchopulmonary aspergillosis
Immunodeficiency e.g. hypogammaglobulinaemia

19
Q

Bronchiectasis managment

A

MDT

  • PT / OT
  • chest physiotherapy including postural drainage / assisted clearance
  • mucolytics
  • prompt treatment of infections guided by sputum mcs
  • vaccinations
  • LTOT if needed
  • surgical excision of severely affected lung
  • transplant
20
Q

Causes and definition of pulmonary hypertension

A

Mean pulmonary artery pressure >20mmHg

Group 1 = pulmonary arterial hypertension
- idiopathic
- connective disease associated
- cirrhosis portopulmonary syndrome 
Mx
- treat cause
- CCBs if vasoreactive
- PDE5i/ER antagonist if not
Group 2 = left heart disease associated
- HFrEF / HFpEP
- valvular heart disease (often mitral)
Mx 
- diurese / optimise heart failure medication
- treat the cause (e.g. valvular)
Group 3 = lung disease / hypoxia related
- e.g. COPD / ILD 
Mx
- supportive
- LTOT 
- treat the cause 
Group 4 = pulmonary artery obstructions
- e.g. chronic venous thromboembolism
Mx
- anticoagulation
- pulmonary thromboendarterectomy

Group 5 (miscellaneous)

21
Q

Signs of pulmonary hypertension / cor pulmonale

A

Loud P2
RV heave (cor pulmonale)
Raised JVP
Peripheral oedema

22
Q

Asthma severity

A

Moderate

  • peak flow >50-75%
  • increasing symptoms
  • no greater features

Acute severe

  • peak flow 33-50%
  • RR >25
  • HR >110
  • inability to complete sentences in one breath

Life threatening

  • peak flow <33%
  • spo2 <92%
  • pao2 <8
  • normal pco2
  • exhaustion
  • silent chest / poor respiratory effort
  • hypotension
  • decreased gcs

PACES (6 decks)

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