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 LTOT?
Long Term Oxygen therapy (LTOT)
Needed for 15 hours per day
What is NIV?
Non-invasive ventillation
Acidotic
High CO2
Bipap
What is some surgery linked to COPD?
Bullectomy
Lung volume reduction - 20% of effected lung removed
Lung transplantation
What are some complications of COPD?
Pulmonary hyeprtension/ constriction due to hypoxaemia
Infection
Polycythemia
Hyperinflation
Collapse
What are some epidiemiological facts linked to COPD?
5TH biggest killer in UK
Most likely respiratory disease in hospital
What is the most effective treatment for COPD?
Smoking cessation
(Others are LTOT, NINV, pulonary rehabilitation)
What is reexpansion pumonary oedema?
The mechanism of re-expansion pulmonary oedema is thought to be due to lung interstitial damage plus hydrostatic imbalance that occur following rapid expansion of the underlying collapsed lung.
How should newly diagnosed asthma be treated?
Newly diagnosed adult with asthma (symptoms < 3 times/weeks) - add a SABA
What happens in pulmonary fibrosis?
Pulmonary fibrosis is a restrictive condition in which gas exchange is impaired, therefore the results should show <80% of the predicted values for FEV1 and FVC, a FEV1:FVC ratio of >70%, and reduced TLCO. As a result, ‘FEV1 = 2.79, FVC = 3.34, TLCO = Decreased’ is the correct answer. TLCO is gas transfer and is decreased
What are the different types of asthma?
ModerateSevereLife-threatening
PEFR 50-75% best or predicted
Speech normal
RR < 25 / min
Pulse < 110 bpmPEFR 33 - 50% best or predicted
Can’t complete sentences
RR > 25/min
Pulse > 110 bpmPEFR < 33% best or predicted
Oxygen sats < 92%
‘Normal’ pC02 (4.6-6.0 kPa)
Silent chest, cyanosis or feeble respiratory effort
Bradycardia, dysrhythmia or hypotension
Exhaustion, confusion or coma
Which type of lung cancer is more common in smokers?
Small cell lung cancer
What are the two types of pneumothorax?
Tension and spontaneous
What is a spontaneous pneumothroax
A relatively common condition in which air escapes from lungs into pleura.
What is a primary pneumothorax?
No underlying lung disease e.g. in a tall male with Marfans
What is a secondary pneumothorax?
Underlying lung disease is known
What is the difference between a small and large pneumothorax?
A space of 2cm or greater between the lung wall and the chest border at the level of the hilum.
How is a tension pneumothorax treated?
Wide bore needle (14-16G) in the 2nd ICS at the MCL.
How do you treat a primary pneumothorax that is less than 2cm in size and not causing symptoms?
Disharge a review in DPD in 2-4 weeks time
How do you treat a primary pneumothorax that is more than 2cm in size and is causing symptoms?
Needle drainage in safety triangle
What do you do for secondary pneumothorax?
Admit and high flow oxygen
What is Trimbow?
COPD - still breathless despite using SABA/SAMA and a LABA + ICS → add a LAMA
What is Fostair?
Formeterol (LABA) and beclomethasone
What is Spireva?
Ipratropium a SAMA
What is Ciclesonide?
ics red inhaler
What are signs of life threatening asthma?
A normal carbon dioxide, despite silent chest and cyanosis
What treatment should all COPD patients get with exacerbations of 3 or more per year?
In the 2010 NICE guidelines, there is a recommendation that patients who have frequent exacerbations of COPD should be given a home supply of corticosteroids and antibiotics. It is, of course, good practice to ask the patient to contact you if they are required to use them, at least to ensure that no further action is required. An antibiotic should be only be taken if the patient is coughing up purulent sputum.
What is sarcoidosis?
Sarcoidosis, dubbed by some ‘the great imitator’, can be difficult to diagnose. Sarcoidosis should be a differential to keep in mind with patients presenting with a persistent cough and a painful shin rash. This rash is most likely erythema nodosum, inflammation of the subcutaneous fat usually found on the shins (but can present on the thighs and forearms). Sarcoidosis can also affect the kidneys, giving hypercalcaemia, the lymphatic system, giving lymphadenopathy, and other organs/systems. It is more common in people of Scandinavian or African descent.
What sign normally appears with PE?
Sinus tachycardia
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?

How should COPD be managed with an acute exacerbation?
NICE only recommend giving oral antibiotics in an acute exacerbation of COPD in the presence of purulent sputum or clinical signs of pneumonia
Conservative management for asthma.
Smoking cessation
Avoid triggers
Weight loss

Acute treatment for acute asthma
OBSIMIA
Oxygen
Beta agonist
Steroids
Ipratropium bromide
Magnesium
IV aminophylline
Triggers for asthma
Isocyanates
Dust mites
Pollens
Dander
Short acting vs long acting beta agonist names.
SalBUTamol and terBUTaline
vs
Formeterol and salmeterol
(seretide is a mix of salmeterol and fluticasone)
ICS examples.
Beclometasone (Qvar® or Clenil® brand specified) • Fluticasone (Flixotide®) • Budesonide (Pulmicort®)
What is seretide?
Combination of salmeterol and fluticasone

How should the lungs be imaged in IPF? What would be expected?
Honey comb + ground glass –> CT scan
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
CF symptoms?
Infertility
Pancreatic insufficiency
malaborsption
When should patients be offered LTOT?
Offer LTOT to patients with a pO2 of < 7.3 kPa or to those with a pO2 of 7.3 - 8 kPa and one of the following:
secondary polycythaemia
peripheral oedema
pulmonary hypertension
What is the target for a patient with PE on warfarin?
As the patient suffers from recurrent pulmonary embolisms, her target INR is 3.5. Therefore the patients warfarin dose should be increased to 5.5mg.