Respiratory Flashcards
What is the difference between transudative and exudative pleural effusion?
Transudative is more hydrostatic pressure or reduced plasma oncotic pressure. Exudative is more inflammatory.
What is empyema?
Pockets of pus that collect inside a cavity
What are the symptoms of pleural effusion?
- Pleuritic pain
- Worsening dysponea
- Cough
- Fever
- Rigors
- Appetite loss
- Weight loss
What causes a pleural effusion?
- PE
- Malignancy
- Yellow nail syndrome
What would you expect to find in a resporatory exam?
The breath sounds are uni- or bilaterally diminished or absent at the bases, and there is basal dullness to percussion. Tachypnea may be present if the effusion is large. A pleural rub can sometimes be heard in the initial stage of a parapneumonic effusion. In
What are some of the changes seen in the lungs in a pleural effusion?
Tracheal deviation
Meniscus is higher
What is the management of a pleural effusion?
Place a needle for aspiration 1-2 intercostal spaces above where the fluid is
What does this chest X ray show?
This is the classic ‘meniscus’ sign of a pleural effusion.
What does this X ray show?
Pleural plaques
These are the typical appearances of calcified pleural plaques secondary to asbestos exposure. This is different from asbestosis which is lung fibrosis secondary to asbestos exposure.
What does this X ray show?
There is no rotation; this is a good quality image in a patient with a thoracic spine scoliosis.
Increased density with air bronchogram in the left lower zone indicates consolidation. Compare with the clear right lower zone. A chest X-ray is not diagnostic of lung cancer and this diagnosis is very unlikely in this age group.
The costophrenic angles remain well-defined indicating there is no pleural effusion.
What does this chest X ray show?
The heart is not enlarged. There are no features of pectus and the right upper zone (the position of the azygos vein) appears unremarkable.
There is gas under the diaphragm, but this is in the stomach.
This is a beautifully normal chest X-ray.
What does this chest X ray show?
Increased density and air bronchogram in the right upper zone indicate consolidation, but no chest X-ray is in itself diagnostic of lung cancer or pneumonia. Compare with the normal left upper zone.
The lungs are hyperexpanded (green lines = predicted normal position) which explains the blunt appearance of the costophrenic angles; there is no pleural effusion.
Heart size is normal.
What does this chest x ray show?
The right heart border is not visible. This is not because of a right middle lobe pneumonia or rotation, but rather because the heart is displaced to the left due to pectus excavatum. The ribs are angled such that they take on more of a ‘7-shape’ rather than their normal ‘C-shape’.
Even if the right side of the heart was in line with the right edge of the spine, the heart size would still be within normal limits.
If you think your patient has pectus excavatum on the basis of a chest X-ray, then the diagnosis should be confirmed on clinical examination.
What does this chest X ray show?
Septal lines are a subtle but very useful sign. In the context of clinically suspected heart failure they indicate interstitial pulmonary oedema.
What is a PE?
Pulmonary embolism (PE) occurs when one or more emboli, usually arising from a thrombus (blood clot) formed in the veins, are lodged in and obstruct the pulmonary arteries.
When a PE is present, the lung tissue is ventilated but not perfused, resulting in an intra-pulmonary dead space and impaired gas exchange [Camm and Bunce, 2005; Tarbox, 2013; Konstantinides, 2014].
What are the signs of a PE?
Shortness of breath
Pain on breathing in
Rapid breathing
Light headedness
Coughing up blood
What are the risk factors for a PE?
About 30–50% of venous thromboembolism (VTE) episodes do not have an identifiable risk factor (unprovoked) [Di Nisio, 2016]. The remaining episodes are caused (provoked) by transient or persistent factors that increase the risk of VTE by inducing hypercoagulability, venous stasis, or vascular wall damage or dysfunction (known collectively as Virchow’s triad) [Di Nisio, 2016; BMJ, 2018]
Increasing age (older than 60 years of age).
The use of combined oral contraception or hormone replacement therapy (within the last 6 weeks to 3 months before diagnosis).
Obesity (body mass index greater than 30 kg/m2).
One or more significant medical comorbidities, for example, heart disease; metabolic, endocrine, neurological disability, or respiratory pathologies; acute infectious disease; or inflammatory conditions.
Long-distance sedentary travel.
Varicose veins.
Superficial venous thrombosis.
Known thrombophilias (thrombotic disorders).
Other factors, such as indwelling central vein catheter, nephrotic syndrome, chronic dialysis, myeloproliferative disorders, paroxysmal nocturnal haemoglobinuria, or Behçet’s disease.
How is a susepected PE diagnosed?
For all other people, use the two-level PE Wells score to estimate the clinical probability of PE:
Clinical features of deep vein thrombosis (DVT; minimum of leg swelling and pain with palpation of the deep veins) — plus 3 points.
Heart rate greater than 100 beats per minute — plus 1.5 points.
Immobilization for more than 3 days or surgery in the previous 4 weeks — plus 1.5 points.
Previous DVT or PE — plus 1.5 points.
Haemoptysis — plus 1 point.
Cancer (receiving treatment, treated in the last 6 months, or palliative) — plus 1 point.
An alternative diagnosis is less likely than PE — plus 3 points. Alternative conditions to consider include:
Respiratory conditions, such as pneumothorax, pneumonia, and acute exacerbation of chronic lung disease.
Cardiac causes, such as acute coronary syndrome, acute congestive heart failure, dissecting or rupturing aortic aneurysm, and pericarditis.
Musculoskeletal chest pain. Note that chest pain with chest wall palpation occurs in up to 20% of people with confirmed PE.
Gastro-oesophageal reflux disease.
Any cause for collapse, such as vasovagal syncope, orthostatic (postural) hypotension, cardiac arrhythmias, seizures, and cerebrovascular disorders.
For people with a Wells score of more than 4 points (PE likely),
How is a PE treated?
If interim therapeutic anticoagulation is required:
Offer apixaban or rivaroxaban first line, and if these are not suitable, low molecular weight heparin (LMWH) for at least 5 days followed by dabigatran or edoxaban, or LMWH concurrently with a vitamin K antagonists for at least 5 days.
Take into account comorbidities, contraindications and the person’s preferences when choosing anticoagulation treatment.
What are the key stages of reading a chest X ray?
Demographics
Rotation: The clavicles should appear symmetrical and be seen as equal length.
Inspiration: On good inspiration, the diaphragm should be seen at the level of the 8th – 10th posterior rib or 5th – 6th anterior rib.
Position: PA, AP, or lateral view? The standard chest X-Rays consists of a PA and lateral chest X-Ray.The normal lateral chest x-ray view is obtained with the left chest against the cassette.
Exposure / Penetration: Ideally, you should be able to see the heart, the blood vessels, and the intervertebral spaces. Exposure should be adequate if you are able to see approximately T4 vertebra and spinal process.
A – AIRWAY. The trachea, carina and both main bronchi are called the upper airway and should all be visible on an AP view (Figure-8). Look for if there is any deviation of the trachea away from the midline.
What does this chest X ray show?
Why does lung cancer cause pain?
Chest pain is associated with complication of a primary lung nodule – chest wall involvement and presence of metastases in the bones causing a ‘pleuritic’ type of pain, which may be sharp, well localised and is worse with movement.
What does CTPA stand for?
CT pulmonary angiogram
What does this image show?
Left sided lung collapse/ consolidation
What is mesothelioma?
A pleural tumour that encases the lungs
What percentage of smokers acquire COPD?
20% (but 80-85% of COPD cases are linked with smoking)
What enzyme helps to reduce the protease activity of neutrophils?
Alpha 1 antitrypsin
How is chronic bronchitis defined?
A progressive cough or mucus for more than 3 months for at least two consecutive years
What is PERC?
PE rule out criteria
<2% risk
What is the 2-level Wells test?
Clinical probability simplified scores
PE likely - more than 4 points
PE unlikely - 4 points or less
How is mesothelioma diagnosed?
Conservative management for asthma.
Smoking cessation
Avoid triggers
Weight loss
What is seretide?
Combination of salmeterol and fluticasone
What are the features of bronchiectasis on CT?
Signs described on CT include:
tram-track sign
signet ring sign
string of pearls sign 9
bunch of grapes sign 9
