Respiratory Flashcards
Zero to finals resp
What is the most common type of lung cancer?
Non-small cell lung cancer = 80% of lung cancers. of these, 40% are adenocarcinomas, 20% are SCC and 10% are LCC.
What is small cell lung cancer?
20% of lung cancers. Secrete neurosecretory granules that can release neuroendocrine hormones. This makes SCLC responsible for multiple paraneoplastic syndromes.
How does lung cancer present?
Shortness of breath Cough Haemoptysis (coughing up blood) Finger clubbing Recurrent pneumonia Weight loss Lymphadenopathy – often supraclavicular nodes are the first to be found on examination
What investigations would you do for lung cancer and what would they show?
- CXR -
Hilar enlargement
“Peripheral opacity” – a visible lesion in the lung field
Pleural effusion – usually unilateral in cancer
Collapse - Contrast CT chest abdo pelvis - staging, LN involvement, mets.
- PET-CT - radioactive tracer attached to glucose molecules, pictures taken using CT scanner + gamma ray detector. Shows how metabolically active tissues are –> identify mets.
- Bronchoscopy with endobronchial ultrasound (EBUS) - assessment of tumour and uss guided biopsy
- Biopsy for histology - bronchoscopy or percutaneously
How is non small cell lung cancer managed?
MDT
- Surgery - lobectomy, segmentectomy, wedge resection
- radiotherapy can be curative if early enough
- adjuvant chemotherapy - palliative or improve outcomes.
How is small cell lung cancer managed?
MDT
- Chemo
- Radiotherapy
- Endobronchial treatment - stents/debulking palliative treatment to relieve obstruction.
Which type of lung cancer has the worst prognosis?
Small cell.
Give 5 extrapulmonary manifestations of lung cancer.
Recurrent laryngeal nerve palsy- hoarse voice caused by the cancer pressing on or affecting the recurrent laryngeal nerve as it passes through the mediastinum.
Phrenic nerve palsy - due to nerve compression causes diaphragm weakness, SOB
Superior vena cava obstruction (SVCO)
Horner’s syndrome
SIADH (ectopic ADH - SCLC)
Cushing’s syndrome (ectopic ACTH - SCLC)
Hypercalcaemia (ectopic PTH - squamous cell carcinoma)
Limbic encephalitis.
Lambert-Eaton myasthenic syndrome.
What is Pemberton’s sign?
Raising the hands over the head causes facial congestion and cyanosis. –> SVCO - medical emergency.
What is Horner’s syndrome?
Partial ptosis, anhidrosis and miosis. It is caused by a Pancoast’s tumour (tumour in the pulmonary apex) pressing on the sympathetic ganglion.
Why does lung cancer lead to hyponatraemia and what type does this?
Syndrome of inappropriate ADH (SIADH) caused by ectopic ADH secretion by a small cell lung cancer –> hyponatraemia.
What type of lung cancer leads to hypercalcaemia?
Squamous cell carcinoma –> ectopic PTH
What would anti-Hu antibodies in someone with lung cancer mean?
Limbic encephalitis: Paraneoplastic syndrome where the small cell lung cancer causes the immune system to make antibodies to tissues in the brain, specifically the limbic system, causing inflammation in these areas. This causes symptoms such as short term memory impairment, hallucinations, confusion and seizures. It is associated with anti-Hu antibodies.
What is Lambert-Eaton Myaesthenic syndrome?
=LEMS: antibodies produced by the immune system against SCLC cells.
These antibodies also target and damage voltage-gated calcium channels (VGCCs) on the presynaptic terminals in motor neurones. This leads to weakness, esp proximal muscles, also intraocular muscles causing diplopia (double vision), levator muscles in the eyelid causing ptosis and pharyngeal muscles causing slurred speech and dysphagia. Also autonomic –> dry mouth, blurred vision, impotence, dizziness.
Reduced tendon reflexes with post-tetanic potentiation: they become temporarily normal for a short period following a period of strong muscle contraction. For example, the patient can maximally contract the quadriceps muscle for a period, then have their reflexes tested immediately afterwards, and display an improvement in the response.
Think sclc in older smokers with LEMS symptoms
What type of lung cancer is linked to asbestos inhalation?
Mesothelioma - mesothelial cells of the pleura. Latent period between exposure and cancer up to 45 years. Poor prognosis, chemotherapy can improve survival but it is essentially palliative.
What is the definition of community acquired pneumonia?
Pneumonia developed outside of hosp
What is hospital acquired pneumonia?
Pneumonia developed more than 48h after hospital admission.
How does pneumonia present?
Shortness of breath Cough productive of sputum Fever Haemoptysis Pleuritic chest pain (sharp chest pain worse on inspiration) Delirium Sepsis
Give 5 signs of sepsis secondary to pneumonia.
Tachypnoea Tachycardia Hypoxia Hypotension Fever Confusion
What would you find on examination in pneumonia?
Bronchial breath sounds - harsh breath sounds equally loud on inspiration + expiration caused by consolidation.
Focal coarse crackles. These are air passing through sputum in the airways similar to using a straw to blow in to a drink.
Dullness to percussion due to lung tissue collapse and/or consolidation.
What’s in the CURB65 score and what does the result mean?
C – Confusion (new disorientation in person, place or time)
U – Urea > 7
R – Respiratory rate ≥ 30
B – Blood pressure < 90 systolic or ≤ 60 diastolic.
65 – Age ≥ 65
Predicts MORTALITY (score 1 = under 5%, score 3 = 15%, score 4/5 = over 25%).
Score 0/1: Consider treatment at home
Score ≥ 2: Consider hospital admission
Score ≥ 3: Consider intensive care assessment
What is the most common causative organism of pneumonia in adults?
50% streptococcus pneumoniae
20% haemophilus influenzae (smokers)
What causes pneumonia in patients with COPD/immunocompromised?
Moraxella catarrhalis
Give 2 organisms which cause pneumonia in patients with CF?
P aeruginosa (also bronchiectasis), staph aureus
What are 5 causes of atypical pneumonia? Give one associated feature for each.
Legions of psittaci MCQs -
Legionella pneumophilia - SIADH –> hyponatraemia, infected air conditioning units/water supplies (cheap hotels)
Chlamydia psittaci - birds/parrots
Mycoplasma pneumoniae - erythema multiforme (target lesions), neuro symptoms
Chlamydophila pneumoniae - school age, wheeze
Coxiella burnetii (Q fever) - animals/farmers
What causes pneumonia in patients with low CD4 count?
Pneumocystis jiroveci (PCP) pneumonia. Dry cough without sputum, SOBOE, night sweats. Patients with low CD4 counts are prescribed prophylactic oral co-trimoxazole to protect against PCP.
How is pneumonia investigated?
CRB 2 or more - hosp admission –>
CXR- consolidation
FBC - raised WCC
U+Es - urea
CRP - raised. Nb not in immunocompromise.
Sputum cultures, blood cultures, urinary antigens for legionalla/pneumococcal.
How is pneumonia managed?
Abx for local area guidelines.
Mild: 5 days oral amoxicillin OR macrolide
Mod/severe: IV 7-10 days of BOTH. changed to oral guided by clinical improvement or improvement in WCC.
Give 5 complications of pneumonia.
Sepsis Pleural effusion Empyema Lung abscess Death
What is reversibility testing?
Doing spirometry before and after giving a bronchodilator eg salbutamol. Eg asthma is reversible but COPD is not.
What is the FEV1? What does reduction in FEV1 mean?
Forced expiratory volume in 1 second - reduced in obstruction to air flow out of the lungs.
What is FVC? What does reduction in FVC mean?
Forced vital capacity - total amount of air a person can exhale after a full inhalation. Reduced in restriction on the capacity of the lungs.
What type of pattern is seen on spirometry for obstructive lung disease? Give an example.
FEV1: FVC ratio <75% - air can go in but not out.
Eg COPD, asthma. Asthma is reversible with bronchodilators.
What type of pattern is seen on spirometry in restrictive lung disease? Give an example.
Reduced FVC AND FEV1, with normal FEV1:FVC ratio (>75%).
Eg interstitial lung disease, neurological eg MND, scoliosis or chest deformity, obesity.
What is peak flow?
Peak or fastest point of expiration. Asks Peak Expiratory Flow Rate (PEFR).
Demonstrates how much obstruction is present.
Varies between people so % predicted is used.
What is asthma?
Chronic inflammatory condition of airways causing episodic bronchoconstriction. Reversible airway obstruction. Caused by hypersensitivity.
Give 5 potential triggers for asthma.
Infection Night time or early morning Exercise Animals Cold/damp Dust Strong emotions
Give 5 features that would help you differentiate between asthma and another diagnosis eg viral induced wheeze.
Asthma: episodic, diurnal variability, worse at night, dry cough, wheeze, SOB, atopy, FHx, bilateral widespread polyphonic wheeze
Reconsider diagnosis: wheeze related to coughs and colds (VIW), isolated or productive cough, normal Ix, no response to treatment, unilateral wheeze (focal lesion/infection).
How is asthma diagnosed?
NICE guidelines 2017 advise definitive testing at a ‘diagnostic hub’, with:
Fractional exhaled nitric oxide (FENO),
Spirometry with bronchodilator reversibility.
If uncertain can go on to PF diary, direct bronchial challenge test with histamine or methacholine.
However the BTS and SIGN guidelines only suggest testing when there is clinical uncertainty.
Describe the long-term management of asthma.
- SABA (salbutamol) - reliever, blue PRN
- ICS (beclomethasone) - preventer, brown
- LRA (montelukast)
- LABA (salmeterol)
- Consider Maintenance and reliever therapy (MART) = ICS + LABA.
- Increase corticosteroid
- LAMA (tiotropium)/theophylline
- Refer to specialist
lifestyle - exercise, avoid smoking
check adherence+ technique
yearly review + flu jab
NICE 2017 (BTS/sign is different)
How does acute asthma present?
Progressively worsening shortness of breath
Use of accessory muscles
Fast respiratory rate (tachypnoea)
Symmetrical expiratory wheeze on auscultation
The chest can sound “tight” on auscultation with reduced air entry
How is moderate acute asthma defined and managed?
PEFR 50 – 75% predicted
Nebulised salbutamol 5mg repeated as often as required (‘back to back’). Monitor K+ as salbutamol causes hypokalaemia.
Nebulised ipratropium bromide
Oral prednisolone or IV hydrocortisone 5 days
Antibiotics if bacterial infection
How is severe acute asthma defined and managed?
PEFR 33-50% predicted
Resp rate >25
Heart rate >110
Unable to complete sentences
Senior input
Oxygen if required to maintain sats 94-98%
Aminophylline infusion
IV salbutamol
Remember OSHITME for treating asthma attack: Oxygen Salbutamol Hydrocortisone IV Ipratropium (senior) Theophylline (senior) Mag sulphate (senior) Escalate
How is life-threatening asthma defined and managed?
33, 92 CHEST
PEFR <33% Sats <92% Cyanosis Hypotension Exhaustion/Tiring Silent chest: airways are so tight that there is no air entry at all. Tachycardia
IV magnesium sulphate infusion
HDU / ICU
Intubation in worst cases, but decide early because difficult to intubate with severe bronchoconstriction
What would ABG show in acute asthma?
Resp alkalosis due to ‘blowing off CO2’.
Tiring –> normal CO2 or hypoxia.
Resp acidosis = high CO2, very bad sign
How would you monitor the response to treatment in acute asthma?
Respiratory rate Respiratory effort Peak flow Oxygen saturations Chest auscultation
What is COPD?
non-reversible, long term obstructive airway disease caused by damage to lung tissue (usually smoking)
How does COPD present?
chronic SOB cough sputum wheeze recurrent RTIs esp in winter often smoker. Differential - cancer, fibrosis, heart failure. COPD does NOT cause clubbing, haemoptysis or chest pain
MRC Dyspnoea scale is recommended by NICE - give the grades and what they mean.
Grade 1 – Breathless on strenuous exercise
Grade 2 – Breathless on walking up hill
Grade 3 – Breathless that slows walking on the flat
Grade 4 – Stop to catch their breath after walking 100 meters on the flat
Grade 5 – Unable to leave the house due to breathlessness
What would be seen on spirometry in COPD?
Obstructive picture - FEV1/FVC ratio <0.7, not reversible with bronchodilators.
How is COPD staged?
Stage 1: FEV1 >80% of predicted
Stage 2: FEV1 50-79% of predicted
Stage 3: FEV1 30-49% of predicted
Stage 4: FEV1 <30% of predicted
What investigations would you do for COPD?
CXR - exclude cancer etc
FBC - polycythaemia (hypoxia -> more EPO -> more Hb) or anaemia.
BMI as a baseline to later assess weight loss (e.g. cancer or severe COPD) or weight gain (e.g. steroids).
Sputum culture to assess for chronic infections such as pseudomonas.
ECG and echocardiogram to assess heart function.
CT thorax for alternative diagnoses such as fibrosis, cancer or bronchiectasis.
Serum alpha-1 antitrypsin to look for alpha-1 antitrypsin deficiency. Deficiency leads to early onset and more severe disease.
Transfer factor for carbon monoxide (TLCO) is decreased in COPD. It can give an indication about the severity of the disease and may be increased in other conditions such as asthma.
