Respiratory Flashcards
Which type of lung cancer is responsible for multiple paraneoplastic syndromes and why?
SCLC because the cells contain neurosecretory hormones which secrete neuroendocrine hormones
What are the signs and symptoms of lung cancer?
Shortness of breath Cough Haemoptysis Finger clubbing Recurrent pneumonia Weight loss Lymphadenopathy
What investigations should be done for lung cancer?
Chest x-ray
Staging CT scan
PET-CT
Bronchoscopy
Histology
What may be seen on a chest x-ray of lung cancer?
Hilar enlargement
Peripheral opacity
Pleural effusion
Collapse
What can a hoarse voice in the context of lung cancer suggest?
Recurrent laryngeal palsy
What is pemberton’s sign and what does it suggest?
When raising hands over the head causes facial congestion and cyanosis. It is a sign of superior vena cava obstruction
Which tumour causes Horner’s syndrome?
Pancoast’s tumour. Presses on the sympathetic ganglion
Why can small cell lung cancer cause lambert-eaton?
Antibodies are produced against the SCLC, they also target and damage voltage-gated calcium channels on the presynaptic terminals in the motor neurones
How is pneumonia seen on chest x-ray?
Consolidation
How is pneumonia labelled as either community or hospital?
If it is acquired outside of hospital then it is labelled as community. If it is acquired >48 hours after admission to hospital then it is hospital acquired pneumonia
What are the chest signs of pneumonia?
bronchial breath sounds
Focal coarse crackles
Dullness to percussion
What scoring assessment is used in pneumonia to estimate the mortality?
CURB-65
What are the common causes of pneumonia?
Streptococcus pneumoniae (50%) haemophilus influenzae (20%)
How does legionella pneumonia present?
Hyponatraemia because it causes SIADH
Which bacteria causes a pneumonia which presents alongside target lesions?
Mycoplasma pneumoniae. Causes erythema multiforme which leads to the target lesions on the skin. May also cause neurological symptoms in a younger patient
What can cause pneumonia in those who are immunocompromised?
Pneumocystis jirovecii (PCP). Usually occurs in those who have poorly controlled or new HIV with a low CD4 count
What does obstructive lung disease show on spirometry?
FEV1 less than 75%, FEV1:FVC <75%
What does restrictive lung disease show on spirometry?
FEV1 and FVC are equally reduces so the FEV1:FVC is >75%
Is asthma obstructive or restrictive?
Obstructive
Give some examples of typical triggers for asthma
Infection Night time or early morning Exercise Animals Cold/damp Dust Strong emotions
What type of wheeze is heard in asthma?
Bilateral widespread “polyphonic” wheeze
What are the first line investigations for asthma?
Fractional exhaled nitric oxide
Spirometry with bronchodilator reversibility
Give an example of a LABA
Salmeterol
Give an example of a LAMA
Tiotropium
Give an example of a leukotriene receptor antagonist
Montelukast
What is the monitoring for theophylline?
Levels after 5 days and 3 days after any dose changes
What is the stepwise management of asthma (8 steps)
- SABA
- SABA+ ICS
- leukotrine receptor agonist
- +LABA
- Change to MART
- Increase ICS to moderate dose
- Increase ICS to high or theophylline or LAMA
- Refer to specialist
What is MART regime?
A combination inhaler containing a low dose inhaled ICS and a fast acting LABA
What does a PEFR of 50-75% of predicted suggest?
Moderate acute asthma
What does a PEFR of 33-50% of predicted suggest?
Severe acute asthma
What does a PEFR of <33% suggest?
Life threatening asthma
How is moderate acute asthma managed?
Nebulised salbutamol
Nebulised ipratropium bromide
Steroids
Oxygen
How is severe acute asthma managed?
Oxygen to maintain sats at 94-98%
Aminophylline infusion
IV salbutamol
How is life threatening asthma managed?
IV magnesium sulphate
Intubation
What does an ABG in acute asthma show?
Respiratory alkalosis due to tachypnoea causing a drop in CO2
What needs to be monitored when salbutamol is used?
Serum potassium. Causes serum hypokalaemia
Also causes tachycardia
What are the 5 stages of the MRC dyspnoea scale?
1- breathless on strenuous exercise
2- breathless on walking up hill
3- breathless that slows walking on the flat
4- stop to catch breath after 100m on the flat
5- unable to leave house due to breathlessness
How is a diagnosis of COPD made?
By clinical presentation and spirometry
FEV1:FVC <0.7
What is the management of COPD?
SABA or short acting antimuscarinics (ipatropium bromide)
Plus either:
LABA and LAMA if no asthmatic features
OR
LABA and ICS if asthmatic features
What are the features of type 1 respiratory failure?
Normal pCO2 with low PO2
What are the features of type 2 respiratory failure?
Raised pCO2 and low PO2
What is the O2 sats target in patients who are retaining CO2?
88-92%
What is a contraindication for biPAP?
Pneumothorax
Which investigation is used to diagnose interstitial lung disease? What is the finding?
HRCT and it shows a ground glass appearance
What can be found on examination in idiopathic pulmonary fibrosis?
Bibasal fine inspiratory crackles and finger clubbing
Which two medications can be used to slow the progression of idiopathic pulmonary fibrosis?
Pifenidone
Nintedanib
Which drugs can cause pulmonary fibrosis?
Amiodarone
Cyclophosphamide
Methotrexate
Nitrofurantoin
What type of hypersensitivity reaction in hypersensitivity pneumonitis?
Type III
How is hypersensitivity pneumonitis diagnosed
Bronchoalveolar lavage which shows raised lymphocytes and mast cells
What are the two types of pleural effusion and what is the difference?
There is exudative and transudative
Exudative means there is a high protein count >3g/dL
Transudative means there is a lower protein count <3g/dL
What causes exudative pleural effusion?
Lung cancer
Pneumonia
Rheumatoid arthritis
Tuberculosis
What causes transudative pleural effusion?
Congestive cardiac failure
Hypoalbuminaemia
Hypothyroidism
Meig’s syndrome
What is the presentation of pleural effusion?
SOB
Dullness to percussion
Reduces breath sounds
Tracheal deviation away from the effusion
What is seen on a chest X-ray of a pleural effusion?
Blunting of the costophrenic angle
Fluid in the lung fissures
Larger effusions have a meniscus
Tracheal deviation
What is the management of pleural effusion?
Conservative if small
Pleural aspiration
Chest drain
What is seen on pleural aspiration in empyema?
Pus, acidic pH (<7.2), low glucose, high LDH
What is the investigation of choice in pneumothorax?
Erect chest x-ray
What is the management for a pneumothorax with a <2cm rim of air
No treatment is required, should resolve spontaneously
What is the management for a pneumothorax with a >2cm rim of air and SOB?
Aspiration
If aspiration fails twice then chest drain
What are the signs of tension pneumothorax?
Tracheal deviation away from the side of the pneumothorax Reduces air entry to affected side Increased resonance on affected side Tachycardia Hypotension
What is the management of a tension pneumothorax?
Insert a large bore cannula into the second intercostal space in the midclavicular line
Where should chest drains be inserted?
The triangle of safety made up by:
5th intercostal space
Mid axillary line
anterior axillary line
What is the main contraindication for compression stockings?
Peripheral arterial disease
What should patients at risk of DVT or PE be given?
LMWH for example enoxaparin
What is the presentation of PE?
SOB Cough, woith or without haemoptysis Pleuritic chest pain Hypoxia Tachycardia Raised respiratory rate Low grade fever
What does the outcome of a well’s score suggest?
If likely do a CT pulmonary angiogram/ proximal vein ultrasound, if unlikely to a d-dimer and if positive do a CTPA/ proximal vein ultrasound
Which investigation for PE should be done if a CTPA is contraindicated?
Ventilation-perfusion scan (VQ scan)
What is the initial recommended treatment for PE?
Apixaban or rivaroxaban
In which disease are DOACs contraindicated?
Antiphospholipid syndrome. LMWH should be used instead
How long should anticoagulation be continued after PE?
3 months if there is an obvious reversible cause
Beyond 6 months if the cause is unclear, there is recurrent VTE or there is an irreversible underlying cause
6 months in active cancer
What is seen on an ECG in pulmonary hypertension?
Right ventricular hypertrophy
Right axis deviation
RBBB
What is seen on x-ray in pulmonary hypertension?
Dilated pulmonary arteries
Right ventricular hypertrophy
How can primary pulmonary hypertension be managed?
IV prostanoids
Endothelin receptor agonists
Phosphodiesterase-5 inhibitors (sildenafil)
What are granulomas?
Nodules of inflammation full of macrophages
What are the extra-pulmonary manifestations of sarcoidosis?
Erythema nodosum and lymphadenopathy
Fever
Fatigue
Weight loss
What are the pulmonary manifestations of sarcoidosis?
Lymphadenopathy
Pulmonary fibrosis
Pulmonary nodules
What is the presentation of lofgren’s syndrome?
Bilateral hilar lymphadenopathy
Polyarthralgia
Erythema nodosum
What is seen on bloods in someone with sarcoidosis?
Raised serum ACE Hypercalcaemia raised serum soluable interleukin-2 receptor Raised CRP Raised IgG
What is the gold standard test for sarcoidosis and what does it show?
Histology showing non-caseating granulomas with epitheliod cells
What is the management of sarcoidosis?
Often resolves in 6 months
Oral steroids
Lung transplant in very serious lung disease
What causes obstructive sleep apnoea?
Collapse of the pharyngeal airway during sleep
Which scale is used to assess OSA?
Epworth sleepiness scale
What is the management of OSA?
lose weight
CPAP or surgery
