Respiratory Flashcards
What some key features in the pathophysiology of asthma?
Smooth muscle spasm and hypertrophy, mucus hyper secretion and goblet cell hyperplasia, release of inflammatory mediators, basement membrane thickening
What investigations can be used to diagnose asthma?
Peak flow, spirometry with reversibility, FeNO, bronchial challenge test
Why can we use an FeNO test in asthma?
FeNO is produced as a result of asthmatic inflammation
What is the first line management for asthma?
a low dose inhaled ICS/formoterol combination inhaler taken as needed for symptoms relief
If someone was just using a SABA to control there asthma what would make you consider moving onto the next level of treatment?
If they are using more than three puffs a week, symptoms aren’t under control
What are the benefits of using a spacer?
Increased drug deposition in the lungs, less deposited in the mouth or swallowed, no coordination required
What questions are good to ask when monitoring asthma?
Any night time/ day time symptoms?
How is asthma affecting usual activities?
How often are you using reliever?
What are some side effects of using a steroid inhaler?
Most common: Oral thrush, hoarseness of voice
Less common: increased risk of T2DM, adrenal suppression
Which asthma medications are safe for use in pregnancy and breastfeeding?
All asthma medications
What is the correct treatment for a suspected primary pneumothorax greater than 2cm?
Simple aspiration
What is the correct treatment for a suspected primary pneumothorax less than 2cm and without associated SOB?
Consider discharge and review in ODP in a few weeks
What is the suggested treatment for a suspected secondary pneumothorax greater than 2cm or with associated breathlessness?
Chest drain
What is the suggested treatment for a suspected secondary pneumothorax between 1-2cm?
Simple aspiration
What is hepatic hydrothorax?
Presence of a pleural effusion in a patient with cirrhosis who has no other reason for a pleural effusion
What are diagnosing features of moderate acute asthma?
Increasing symptoms, PEF 50-75%
What features would give a diagnosis severe acute asthma?
PEF 33-50%, RR >25, HR >110, inability to complete sentences in one breath
What features are diagnostic of near fatal asthma?
Raised PaCO2 or requiring mechanical ventilation with raised inflation pressures
What are some diagnostic features of life-threatening asthma?
PEF <33%, SpO2 <92%, PaO2 <8kPa, normal PaCO2
What are some features of mycobacterium tuberculosis?
Small rod shaped, slow growing, acid fast bacilli
What can increase a patients susceptibility to tuberculosis infection?
Crowded living, malnutrition, alcohol + drug abuse, HIV infection, immigration from counter with high rates
What are symptoms of active TB?
Cough, fever, malaise, night sweats, loss of appetite, weight loss, SOB (late symptom)
What can be seen on CXR in TB?
A cavitating lesion most commonly seen in upper lobes
Which lab test fro TB are screening test which can show exposure to TB/ latent but aren’t diagnostic for active TB?
TST (tuberculin skin test) and interferon gamma release assay
Which tests are used to diagnose active TB?
Microscopy culture (of sputum), nucleic acid amplification
What is the treatment for TB? (RIPE)
Isoniazid, rifampicin, pyrazinamide, ethambutol
All four for 2 month, then just R+I for next 4 months
If there is CNS involvement in TB how does this effect length of treatment?
Treatment is 9 months
What is XDR-TB?
A TB infection resistant to at least 4 of the core anti TB drugs
What main feature distinguishes a massive PE?
A systolic BP <90 for more than fifteen minutes
What is the treatment for a massive PE?
Thrombolysis (Alteplase)
What are the clinical features of PE listed from most frequent?
Dyspnoea, tachypnoea, pleuritic chest pain, apprehension, tachycardia, cough, haemoptysis
What is a PESI score?
Pulmonary embolism severity index- a risk stratification tool to determine mortality of patients with newly diagnosed PE
What is sarcoidosis?
A multi systemic, chronic inflammatory condition characterised by granuloma formation
What are the ages of peak incidence of sarcoidosis in men and women?
Men: 30-50
Women: 50-60
What are the symptoms of sarcoidosis?
Most cases are asymptomatic.
Symptoms include- fatigue, weight loss, aches and pains, arthritis, SOB, dry eyes
What sign on CXR would indicate sarcoidosis?
Bilateral hilar lymph node enlargement
What are some signs of sarcoidosis?
Rash, hepatomegaly, arrhythmia, anaemia, nerve palsy, enlarged parotid, erythema nodosum, enlarged lymph nodes
How can you diagnose sarcoidosis?
CXR, lung function tests, raised serum calcium and ACE levels
Why is serum calcium raised in sarcoidosis?
- Uncontrolled synthesis of active vitamin D by macrophage leads to increased absorption of calcium from gut
- Increased resorption of bone
In what three conditions is it possible to see bilateral hilar enlargement on CXR?
Sarcoidosis, TB and lymphoma
What treatment is used in sarcoidosis?
Only treated if treatment is indicated.
Treatment includes NSAIDs and consider steroids
How may a patient with brochiectasis present?
Several months with shortness of breath and chronic productive cough
What features on physical examination are seen in bronchiectasis?
Coarse crackles, wheeze, clubbing, weight loss
What are symptoms patients with brochiectasis can experience other than chronic cough and SOB?
Rhinosinusitis, fatigue, haemoptysis, thoracic pain
What scan is diagnostic for bronchiectasis?
High resolution CT chest
What features of bronchiectasis are seen on CT?
Lack of tapering of bronchioles (tram-track sign), increased bronchio-arterial ratio (signet ring sign)
What is the main cause of secondary pneumothorax?
COPD
What is the difference between primary and secondary pneumothorax?
Secondary is where there is pre-existing lung disease
What is the main indication for intervention in pneumothorax?
Significant breathlessness
How can a patient with pneumothorax typically present?
Short of breath, pleuritic chest pain, decreased breath sounds, lack of movement on affected side
What is first line investigation for pneumthorax?
CXR
What are causes of cavitating lesions? (CAVITY)
Carcinoma, autoimmune (RA, wegner’s granulomatosis), vascular (septic PE), infection (abscess, TB), Trauma (pneumatocoele), youth (CPAM-congenital malformation)
How does COVID pneumonia appear on CXR?
Bilateral peripheral shadowing
How does ILD look on a CXR?
Reticulo-nodular shadowing
What is the pathogenesis of interstitial Lund disease?
Epithelial activation followed by dysregulated repair and fibrosis is promoted
What drugs can cause ILD?
Amiodarone, methotrexate, nitrofurantoin, bleomycin, cyclophosphamide
What are some clinical signs and symptoms features seen in ILD?
Progressive SOB, dry cough, reduced exercise tolerance, fine inspiratory crackles, finger clubbing (small percentage), cyanosis
What are some occupations associated with ILD?
Ship workers (abestosis), coal workers (pneumoconiosis), pigeon workers (hypersensitivity pneumonitis)
What are some diseases associated with ILD?
RA, SLE, scleroderma
What treatments are used for ILD?
Removal of exposure, immunosuppressants, anti fibrotic drugs, pulmonary rehab
A patient presents with hyponatraemia, productive cough and fever following a cheap hotel holiday. What is likely atypical cause of their pneumonia?
Legionella pneumophila
A patient presents with productive cough and low grade fever, they also have a rash made up of target lesions. What is a likely cause of their atypical pneumonia?
Mycoplasma pneumoniae
A farmer presents with a flu-like illness. He is found to have an atypical pneumonia, what is the likely causative organism?
Coxiella burnetti (Q fever)
A parrot owner presents with shortness of breath, productive cough and fever. He is found to have an atypical pneumonia. What is the likely cause?
Chlamydia psittaci
Why are patient with low CD4 counts given prophylactic oral co-trimoxazole?
To protect them from pneumocystis jiroveci (PCP) as they are at high risk
Is WCC or CRP better for monitoring a patient’s improvement with pneumonia?
WCC
- as CRP shows delayed response so may spike a couple days later despite treatment improving patient’s condition
What organisms are more commonly seen to cause pneumonia in cystic fibrosis?
Pseudomonas aeruginosa and staphylococcus aureus
What organism is more likely to be a cause of pneumonia in patients with bronchiectasis?
Pseudomonas aeruginosa
What are the categories that make up the CURB-65 scoring? What is this used for?
Confusion, urea (>7), Resp rate (>30), blood pressure (<90 sys, <60 dys), age (>65)
Used to guide whether to admit a patient with pneumonia
At what CURB-65 score would you consider hospital admission?
2 or above
What are some examination findings that may be present in a patient with pneumonia?
focal coarse crackles, bronchial breath sounds, dullness on percussion,
What are some side effects of ethambutol?
Optic neuropathy and reduced visual acuity
What are some side effects of rifampicin?
Urine/tears turn orange and drug induced hepatitis
What are some side effects of isoniazid?
Peripheral neuropathy, colour blindness, drug-induced lupus
What are the most common cause of community acquired pneumonia?
strep pneumoniae, haemophilia influenzae, M. Catarrhalis
What 3 clinical features do patients with covid-19 who require hospitalisation often have?
Hypoxia, lymphopenia, bilateral lower zone changes on CXR
What are some findings on CXR which can suggest cancer?
Hilar enlargement, peripheral opacity, pleural effusion, atelectasis
What are some extra-pulmonary manifestations of lung cancer caused by compression of neurovasculature?
Recurrent laryngeal palsy, phrenic nerve palsy, superior vena cava obstruction, Horner’s syndrome
What clinical sign can you look for if you suspect superior vena cava obstruction? What does it involve?
Pemberton’s sign
When patient raises their hands above their head it causes facial congestion and cyanosis
Which scale would you use to help identify obstructive sleep apnoea?
Epworth sleepiness scale
What are some features suggesting steroid responsiveness in COPD?
Previous asthma or atopy diagnosis
High blood eosinophil count
Variation in FEV1 over time (at least 400ml)
Substantial diurnal variation in peak flow
Which of myasthenia gravis and Lambert-Eaton syndrome improves with muscle use?
Lambert-Eaton
On CXR there is a loss of the silhouette of the left hemidiaphragm. Which is the most likely area of pathology e.g atelectasis or pneumonia?
Left lower lobe
On CXR there is a loss of the silhouette of the right hemidiaphragm. Which is the most likely area of pathology e.g atelectasis or pneumonia?
Right lower lobe
On CXR there is a loss of the silhouette of the right heart border. Which is the most likely area of pathology e.g atelectasis or pneumonia?
Right middle lobe
On CXR there is a loss of the silhouette of the left heart border. Which is the most likely area of pathology e.g atelectasis or pneumonia?
Lingula
Unable to complete full sentences is a parameter for which stage of acute asthma?
Severe
‘PEFR 50-75% of predicted’ is a parameter for which stage of acute asthma?
Moderate
‘PEFR 33-50% of predicted’ is a parameter for which stage of acute asthma?
Severe
‘PEFR <33% of predicted’ is a parameter for which stage of acute asthma?
Life-threatening
‘Oxygen saturations <92%’ is a parameter for which stage of acute asthma?
Life-threatening
Haemodynamic instability, fatigue and no wheeze are parameters for which stage of acute asthma?
Life-threatening
‘HR >110 and RR >25’ are parameters for which stage of acute asthma?
Severe
Which electrolyte should be monitored when giving lots of salbutamol?
Potassium
What medications are used in the treatment of acute asthma? (O shit me)
O-oxygen S- salbutamol (5mg nebulisers) H- hydrocortisone I- ipratropium bromide (nebulised) T- theophylline/aminophylline M- magnesium sulphate E- escalate care
What forms the triangle of safety used for chest drain insertion?
5th intercostal space, anterior axillary line and mid axillary line
What s the immediate treatment for tension pneumothorax?
Insert large bore cannula into the second intercostal space mid-clavicular line
When inserting a needle into the thorax do you go just above or just below the rib?
Just above to avoid the neruovascular bundle that runs below the ribs
What paraneoplastic syndromes are associated with small cell lung cancer?
SIADH, Lambert-Eaton, cushings
What paraneoplastic syndromes are associated with squamous cell lung cancer?
Hypercalcaemia from PTH production
What blood test may be abnormal in sarcoidosis?
Calcium may be raised
What features of sarcoidosis require treatment with steroids?
Pulmonary fibrosis, hypercalcaemia, involvement of eyes, cardiac or neurological system
Why would a patient with COPD have polycythaemia?
Secondary response to chronic hypoxia
What is the acute management of an infectuve exacerbation of COPD?
Prednisone one 30mg
Salbutamol and ipratropium
Antibiotics (co-amoxiclav for 5 days)
Mucolytics (nebulised saline in acute setting can help break up mucus)
When do you consider NIV in severe COPD?
If type 2 respiratory failure and pH 7.25-7.35
What are microscopic changes in 1) gastric cancer, 2) UC 3) Crohn’s 4) coeliac disease?
Signet ring cells
Cryst abscess and goblet cell hypoplasia
Granulomatous inflammation in all layers from mucosa to serosa
Villous atrophy, crypt hyperplasia and increase in intraepithelial lymphocytes
What is initial management of hepatic encephalopathy (build up of ammonia secondary to liver cirrhosis)?
Lactulose
What criteria is used to assess whether a UC flare is mild to moderate to severe?
True love and Witts criteria
How would you treat severe UC flare?
IV hydrocortisone
How would you treat mild/moderate UC flare?
Mesalazine (topical +/- oral)
What skin rash can be seen in sarcoidosis?
Erythema nodosum
Why is calcium high in sarcoidosis?
Uncontrolled synthesis of vitamin D in macrophages which increases calcium absorption in intestines
Is sarcoidosis self limiting?
Most will have spontaneous remission within two years however some will need treatment if particular symptoms are present
What are some indications for treatment in sarcoidosis?
Progressive pulmonary disease, uveitis, end organ involvement, neurological involvement, persistent hypercalcaemia
What are main causes of bilateral hilar lymphadenopathy?
Sarcoidosis, TB, lymphoma
Common causes of pleural effusion?
CCF, malignancy, TB, pneumonia
Why can you get hypercalcaemia with lung cancer?
Release of PTH related protein from squamous cell carcinoma, osteolytic activity at sites of skeletal metastatase
What blood test should patients presenting with TB also have?
HIV testing
Risk factors for pneumothorax?
Male, smoking, existing lung disease, mechanical ventilation, marfan’s
What are asthmatic features or features of steroid responsiveness in COPD?
Previous asthma diagnosis, raised eosinophil count, substantial variation in FEV1 over time, diurnal variation in peak flow (not routinely measured in COPD)
which pneumonia causing bacterial pathogen is associated with cold sores?
strep pneumoniae
how do we treat sarcoidosis and when would we treat it?
treated with glucocorticoids.
steroids indicated in patients with stage 2/3 disease who are symptomatic, have hypercalcaemia or heart/eye/neuro involvement
what is a ghon complex in TB?
the lung lesion and affected lymph nodes in TB
what staining technique is used to identify mycobacterium?
Ziehl-Neelsen stain
what is the order of tests we use to diagnose asthma in adults and young people (over 16)?
blood eosinophils or FeNO
Bronchodilator reversibility with spirometry
peak flow variability
bronchial challenge
preceeding influenza predisposes to pneumonia caused by what bacteria?
staph aureus
what is the management of latent TB?
3 months isoniazid and rimfampicin
or 6 months isoniazid
what is likely to have happened in a patient who has a sudden deterioration following ventilation?
iatrogenic tension pneumothorax
what are causes of lower lobe lung fibrosis with mneumonic ACID?
asbestos
connective tissue disorders
idiopathic pulmonary fibrosis
drugs e.g methotrexate, nitrofurantoin
what is Eosinophilic granulomatosis with polyangiitis otherwise known as?
Churg Strauss syndrome
what syndrome should be considered in patients with asthma, nasal congestion, peripheral neuropathy, and signs of renal involvement such as haematuria and proteinuria?
churg strauss syndrome
what
