Respiratory Flashcards
Name the different types of lung cancer
Non-small cell (80%) - Adenocarcinoma - Squamous cell carcinoma - Large cell carcinoma Small cell (20%)
Describe small cell lung cancers
Contain neurosecretory granules that release neuroendocrine hormones - multiple paraneoplastic syndromes
Give the signs and symptoms of lung cancer
SOB Cough - haemoptysis Clubbing Recurrent pneumonia Weight loss Lymphadenopathy - supraclavicular
What are signs of lung cancer on CXR?
Hilar enlargement
Peripheral opacity
Pleural effusion - unilateral
Collapse
What is the first line treatment for non-small cell lung cancer
Surgery - lobectomy or segmentectomy or wedge resection
Chemo or radiotherapy
What is the treatment for small cell lung cancer
Chemo or radiotherapy
Describe recurrent laryngeal nerve palsy
Hoarse voice - caused by the cancer pressing on or affecting the recurrent laryngeal nerve as it passes through the mediastinum
Describe phrenic nerve palsy
Compression causing diaphragm weakness and presents as SOB
Describe superior vena cava obstruction
Compression of the tumour on the superior vena cava
Presents with facial swelling, difficulty breathing and distended veins in the neck and upper chest
Describe Pembertons sign
SVC obstruction
Raising arms above head causes facial congestion and cyanosis
Describe Horner’s syndrome
Partial ptosis, anhidrosis and miosis
Associated with Pancoast tumour (pulmonary apex)
How does SIADH present?
Euvolemic hyponatraemia
Describe limbic encephalitis
Autoimmune antibodies to the limbic tissues causing inflammation and short term memory impairment, hallucinations, confusion and seizures
Associated with anti-HU antibodies
Describe lambert eaton myasthenic syndrome
Result of antibodies produced by the immune system against SCLC. They target voltage gated Ca channels on the presynaptic terminals in motor neurone leading to weakness of the proximal muscles and causes diplopia, ptosis, slurred speech and dysphagia. They also experience dry mouth, blurred vision, impotence and dizziness due to autonomic dysfunction
Reduced reflexes which become normal after a period of maximal contraction (post tetanic potentiation)
Describe mesothelioma
Lung mesothelial cells of the pleura
Strongly linked to asbestos and development of mesothelioma - 45years
Prognosis is poor and chemotherapy is palliative
Define hospital acquired pneumonia
Develops >48hrs of hospital admission
Describe the presentation of pneumonia
SOB Cough - haemoptysis Pleuritic chest pain Delirium Sepsis Tachycardia Tachypnoea Hypoxia Hypotension Fever Confusion
Bronchial breath sounds - harsh breath sounds on inspiration and expiration
Focal coarse crackles - air passing through sputum
Dullness to percussion - lung tissue collapse and or consolidation
What is the CURB 65 score
Prediction of the severity of pneumonia and helps guide treatment
Confusion Urea >7 RR >30 BP <90/60 Age >65
0 or 1 - home treatment
>2 - hospital admission
>3 - consider ICU
What are the common causes of pneumonia
Streptococcus pneumoniae
Haemophilus influenza
Moraxella catarrhalis
Pseudomonas aeruginosa
Staphylococcus aureus
What is an atypical pneumonia?
One that cannot be cultured in the normal way or detected using gram stain
Describe legionella pneumonophila
Caused by infected water supplies or air conditioning units
Causes a hyponatraemia - causing SIADH
Describe mycoplasma pneumoniae
Milder pneumonia
Erythema multiformed rash - target lesions formed by pink rings with pale centres - can also cause neurological symptoms in young patients
Describe coxiella burnetii
Q fever
Farmers - caused by contact with animals and body fluids
Describe chlamydia psittaci
Contracted from contact with infected birds
Describe fungal pneumonia
Pneumocystis jiroveci
Occurs in HIV patients
What is given to patients with fungal pneumonia
co-trimoxazole
What antibiotics are given to those with a mild CAP
5 day PO course - amoxicillin or macrolide
What antibiotics are given to those with moderate to severe CAP
7-10 day course of dual antibiotics - amoxicillin and macrolide
List some complications of pneumonia
Sepsis Pleural effusions Empyema Lung abscess Death
Describe FEV1
Forced expiratory volume in 1 second
The amount of air a person can exhale as fast as they can in 1 second
Will be reduced if there is any obstruction
Describe FVC
Forced vital capacity
The total amount a person can exhale after a full inhalation - measure of the total volume of air a person can take into their lungs
Reduced if any restriction to the capacity of the lungs
Describe obstructive disease
FEV1:FVC ratio <75%
What type of lung picture is asthma and COPD
Obstructive
Described restrictive disease
FEV1:FVC>75%
List some causes of restrictive lung disease
Interstitial lung disease Neurological - MND Scoliosis Chest deformity Obesity
Explain how to complete a peak flow
Stand up tall, take a deep breath in, make a good seal around the device with the lips and blow as hard and as fast as possible into the device - take 3 attempts and record the best one
What does peak flow vary with?
Age, Sex and height of the patient
What does peak flow measure
How much obstruction is in a patients lungs
List some triggers of asthma
Infection Night time or early morning Exercise Animals Cold/damp Dust Strong emotions
Describe features of a presentation suggesting asthma
Episodic symptoms Diurnal variability - worse at night Dry cough with wheeze and SOB History of other atopic conditions such as eczema, hay fever and food allergies Family history Bilateral widespread polyphonic wheeze
How is asthma diagnosed?
High probability- trial of treatment
Moderate probability - spirometry for reversibility testing
Low probability - referral and investigating for other causes
What are the first line investigations for asthma
Fractional exhaled nitric oxide
Spirometry with bronchodilator reversibility (>12% improvement)
Describe the long term management for Asthma
SABA
SABA + ICS
LABA or LTRA
Annual flu jab
Annual asthma review
Advise exercise
Stop smoking
Describe the mechanism of action of SABAs
Relax the bronchial smooth muscle causing bronchodilation
Describe the management of ICS
Reduce the inflammation and reactivity of the airways
Describe the mechanism of action of LAMAs
Block the acetylcholine receptors which are normally stimulated by the parasympathetic nervous system and cause inflammation, bronchoconstriction and mucus secretion
Describe the mechanism of action of theophylline
Relax bronchial smooth muscle and reduce inflammation
When is theophylline monitored
5 days after starting treatment
3 days after a dose change
List some features of severe acute asthma
PEF 33-50% best or predicted
RR >25
HR >110
Inability to complete sentences in one breath
List the features of life threatening asthma
PEFR <33% best or predicted
Oxygen sats <92%
Normal PCO2
Silent chest, cyanosis, feeble respiratory effort, bradycardia, dysrhythmia or hypotension, exhaustion, confusion or coma
List the features of moderate asthma
PEFR 50-75% best or predicted
Speech normal
RR <25/min
Pulse <110
Describe the treatment of a moderate asthma attack
Nebulised salbutamol and ipatropium bromide
Steroids - oral prednisolone for 5 days
Antibioitcs if sign of infection
Describe the treatment of severe asthma
Oxygen to maintain sats 94-98%
Aminophylline infusion
IV salbutamol
Describe the treatment of life threatening asthma
IV magnesium sulphate
Admission to HDU/ICU
Intubation in worst cases
Describe the initial ABG picture of a person with acute asthma
Respiratory alkalosis - tachypnoea causes a drop in CO2
What are some concerning ABG signs in acute asthma
Normal PCO2 or hypoxia - tiring and indicates life threatening asthma
Respiratory acidosis - high PCO2
How can you monitor the response of treatment in acute asthma
RR Respiratory effort Peak flow O2 sats Chest auscultation
Which electrolyte should you monitor when on salbutamol for acute asthma
Potassium - absorbed into cells with salbutamol
Which peripheral sign does COPD NOT cause?
Clubbing
Describe the MRC dyspnoea scale
Grade 1 - Breathless on strenuous exercise
Grade 2 - breathless on walking up a hill
Grade 3 - Breathless that slows walking on the flat
Grade 4 - Stop to catch their breath after walking 100m on the flat
Grade 5 - unable to leave the house due to breathlessness
Describe the spirometry picture of COPD
Obstructive
FEV1:FVC <0.7
No reversibility with SABA
Describe the severity of COPD
Stage 1: FEV1 >80% predicted
Stage 2: FEV1 50-79%
Stage 3: 30-49%
Stage 4: <30%
Describe type 1 respiratory failure
Low PaO2
Describe type 2 respiratory failure
Raised PCO2 despite low PaO2
Describe the ABG in someone with COPD
Acutely retaining CO2 - respiratory acidosis
The kidneys produce bicarbonate to try and normalise the pH
What are the target O2 sats for a COPD patient who chronically retains CO2
88-92%
Why is it dangerous to give too much O2 to a COPD patient?
These patients rely on their respiratory drive and therefore too much O2 will slow down their respiratory effort
Describe Venturi masks
Have holes in them - bigger the hole, the less O2
24% blue 28% white 31% orange 35% yellow 40% red 60% green
Describe the severity of COPD
Stage 1: FEV1 >80%
Stage 2: FEV1 50-79%
Stage 3: FEV1 30-49%
Stage 4 : FEV1 <30%
Describe the long term management of COPD
SABA or Short acting antimuscarinic
LABA plus LAMA or LABA plus ICS if asthmatic features
More severe cases - nebulisers, oral theophylline, oral mucolytic therapy (carbocisteine), long term prophylactic antibiotics (azithromycin), long term O2 therapy at home
Who is long term O2 therapy reserved for in COPD?
Chronic hypoxia
Polycythaemia
Cyanosis
heart failure secondary to pulmonary hypertension
Describe the medical treatment of a mild exacerbation of COPD
Prednisolone 30mg OD for 7-14 days
Regular inhalers or home nebulisers
Antibiotics
Describe the medical management of a moderate to severe COPD exacerbation
Nebulised bronchodilators - salbutamol or ipatropium
Steroids
Antibiotics
Physiotherapy
Describe the treatment of severe COPD exacerbations
IV aminophylline
NIV
Intubation and ventilation with admission to ITU
Doxapram
Describe BiPAP
Bilevel positive airway pressure - involves a cycle of high an low pressure to correspond to the patients inspiration and expiration. Used when type 2 resp failure and resp acidosis not responding to medical treatment
Describe CPAP
Continuous positive airway pressure
Provides continuous air being blown into the lungs to keep the airway open so air can travel in easily
Used to maintain the patients airway in conditions where it is prone to collapse
- Obstructive sleep apnoea
- Congestive cardiac failure
- Acute pulmonary oedema
Describe the presentation of idiopathic pulmonary fibrosis
Pt aged >50yo
Insidious onset SOB and dry cough > 3months
Finger clubbing and binasal crackles
Which drugs may lead to pulmonary fibrosis
Amiodarone
Cyclophosphamide
Methotrexate
Nitrofurantoin
Which conditions may lead to secondary pulmonary fibrosis
Alpha 1 antitrypsin deficiency
RA
SLE
Systemic sclerosis
Which drugs can be given in pulmonary fibrosis
Pirfenidone - antifibrotic and anti-inflammatory
Nintedanib - antibody targeting tyrosine kinase
Describe hypersensitivity pneumonitis (extrinsic allergic alveolitis)
Type 3 hypersensitivity reaction to environmental allergen that causes parenchymal inflammation and destruction in people sensitive to that allergen
How is EAA diagnosed?
Bronchoalveolar lavage - collecting cells from airway by washing airway with fluid during bronchoscopy
How is EAA managed?
Remove allergen
O2 where appropriate
Describe cryptogenic organising pneumonia
Used to be called bronchiolitis obliterans organising pneumonia
Focal areas of inflammation of lung tissue
Idiopathic or triggered by infection, inflammatory disorders, medications, radiation or environmental toxins and allergens
Presentation is very similar to infectious pneumonia so delayed diagnosis
Treatment is with systemic corticosteroids
What is the long term effects of asbestosis
Lung fibrosis
Pleural thickening and pleural plaques
Adenocarcinoma
Mesothelioma
How is interstitial lung disease diagnosed
Ground glass appearance on High resolution CT scan
What is interstitial lung disease
Umbrella term for the conditions that affect the lung parenchyma causing inflammation and fibrosis
What is a pleural effusion
Fluid in the pleural space
What is a transudative pleural effusion
Fluid moving across into the pleural space
List some causes of transudative pleural effusion
Congestive cardiac failure
Hypoalbuminemia
Hypothyroidism
Meigs syndrome
What is Meigs syndrome
Right sided pleural effusion with an ovarian malignancy
What is an exudative pleural effusion
Related to inflammation
Protein leaking out of the tissue into the pleural space
List the causes of exudative pleural effusion
Lung cancer
Rheumatoid arthritis
Pneumonia
Tuberculosis
Describe the signs and symptoms of pleural effusions
Shortness of breath
Dullness to percussion over the effusion
Reduced breath sounds
Deviation of the trachea away from the effusion if massive
Describe the CXR appearance of pleural effusion
Blunting of the costophrenic angles
Tracheal and mediastinal deviation away from the pleural effusion if massive
Fluid in the lung fissures
Larger effusions have a meniscus
Describe the treatment of pleural effusion
Conservative - treat underlying cause
Pleural aspiration - aspirate the fluid
Chest drain - drain the effusion and prevent it from occurring
What is an empyema and when is it suspected?
Infected pleural effusion
Suspected when pneumonia is resolving but patient has a new and ongoing fever
What does pleural aspiration show in empyema
pH <7.2
Low glucose
High LDH
How is empyema treated
Chest drain and antibiotics
What is a pneumothorax
Air in the pleural space separating the lung from the chest wall
What causes a pneumothorax?
Spontaneous
Trauma
Iatrogenic
Secondary to lung pathology
How is pneumothorax diagnosed
Erect CXR
How is the size of a pneumothorax measured
Measure horizontally from the lung edge to the inside of the chest wall at the level of the hilum
How is pneumothorax managed
If <2cm rim of air on CXR and no SOB - spontaneous resolution and OP follow up in 2-4 weeks
If SOB and/or >2cm rim on CXR then aspirate and reassessment
If aspiration fails twice then chest rain
Unstable patients of bilateral or secondary pneumothoraxes generally require a chest drain
Describe a tension pneumothorax
Trauma to chest wall that reates a one way valve that lets air in but not out of the pleural space
One way valve means more air is pulled in with each inspiration and the air becomes trapped. Pressure in the thorax keeps building, pushes the mediastinum across, kinks the big vessels and can cause cardiorespiratory arrest
List some signs of tension pneumothorax
Tracheal deviation away from side of pathology
Reduced air entry to affected side
Increased reasonant to percussion on afected side
Tachycardia
Hypotension
Describe the management of a tension pneumothorax
Insert a large bore cannula into the 2nd ICS mid clavicular line
Chest drain is definitive treatment
Where is the chest drain inserted
Triangle of safety
Describe the borders of the triangle of safety
5th ICS - inferior nipple line
Mid axillary line - latissimus dorsi
Anterior axillar line - lateral edge of pectoris major
Where is the needle inserted when putting in a chest drain
Just above the rib to avoid the neurovascular bundle
Describe the gas picture in someone with a PE
Respiratory alkalosis - blowing off the CO2 (low CO2 and low O2)
Who is a V/Q scan performed in?
People with contrast allergy
Renal impairment
Pregnancy (however higher risk of leukaemia in the child)
If the Wells score for PE is likely what is the next step?
CTPA
If the Wells score for PE is unlikely, what is the next step
D-dimer and if positive then CTPA
Describe the Wells score
Predicts the likelihood of someone presenting with symptoms of a PE actually having a PE
- Haemoptysis
- Tachycardia
- RF
What are the RF for PE
Immobility Recent surgery HRT with oestrogen Polycythaemia SLE Pregnancy COCP Malignancy
Describe VTE prophylaxis
LMWH - enoxaparin
Compression stockings
Who are compression stockings CI in?
Peripheral arterial disease
Describe the initial treatment of PE
Oxygen PRN
Analgesia PRN
Apixaban or rivaroxaban
LMWH (enoxaparin or Dalteparin) -if waiting for a scan or if apixaban or rivaroxaban not suitable/antiphospholipid syndrome
Describe the long term anticoagulation in PE
Warfarin, DOAC or LMWH
Target INR for warfarin is 2-3
Warfarin plus LMWH for 5 days until INR in range for 24hrs as warfarin as prothrombotic properties to begin with
LMWH long term in pregnancy or cancer
Continue for 3 months if obvious reversible cause, beyond 3 months if the cause is unclear, irreversible underlying cause or active cancer (6 months)
Describe the use of thrombolysis in PE
Massive PE - haemodynamic compromise
Fibrinolytic agent - streptokinase, Alteplase or Tenecteplase
2 ways of giving it - IV or directly into the pulmonary arteries using a central catheter (catheter directed thrombolysis)
Catheter directed thrombolysis - delivered into the venous system through the right side of the heart into the pulmonary artery - inject the agent directly into the clot
What is pulmonary hypertension
Increased resistance and pressure of blood in the pulmonary arteries
Causes strain on the right side of the heart trying to pump blood through the lungs - causes back pressure of blood on the systemic venous system
List the causes of pulmonary hypertension
Group 1 - primary pulmonary hypertension or connective tissue disease (SLE)
Group 2 - left heart failure due to MI or systemic hypertension
Group 3 - chronic lung diseases such as COPD
Group 4 - pulmonary vascular disease - PE
Group 5 - sarcoidosis, glycogen protein disorder, haematological disorders
List the symptoms of pulmonary hypertension
Syncope
Tachycardia
Raised JVP Hepatomegaly
Peripheral oedema
Describe the ECG changes in pulmonary hypertension
Right ventricular hypertrophy - Larger R waves on the Right sided chest leads (V1-3) and S waves on the left sided chest leads (V4-6)
Right axis deviation
Right bundle branch block
Describe the CXR signs of pulmonary hypertension
Dilated pulmonary arteries
Right ventricular hypertrophy
Describe the management of pulmonary hypertension
Primary - IV prostenoids (epoprostenol), Endothelin receptor antagonists (macitentan), phosphodiesterase 5 inhibitors (sildenafil)
Secondary pulmonary hypertension - treat underlying cause
Supportive therapy for complications
Describe the typical sarcoidosis patient
Young black female presenting with dry cough, SOB and may have nodules on their shins
What is sarcoidosis
Granulomatous inflammatory condition - nodules of inflammation full of macrophages develop
Describe how sarcoidosis affects the lungs
Mediastinal lymphadenopathy
Pulmonary fibrosis
Pulmonary nodueles
List the systemic symptoms of sarcoidosis
Fever
Fatigue
Weight loss
List the liver symptoms of sarcoidosis
Liver nodules
Cirrhosis
Cholestasis
List the eye symptoms of sarcoidosis
Uveitis
Conjunctivitis
Optic neuritis
List the skin conditions caused by sarcoidosis
Erythema nodosum - tender red nodules on shins by inflammation in the subcutaneous fat
Lupus pernio - raised, purple skin lesions commonly on the cheeks and nose
Granulomas form in scar tissue
List the heart conditions caused by sarcoidosis
Bundle branch and heart block
Myocardial muscle involvement
List the kidney conditions caused by sarcoidosis
Kidney stones (hypercalcaemia)
Nephrocalcinosis
Interstitial nephritis
List the CNS sarcoidosis problems
Nodules
Pituitary involvement - diabetes insipidus
Encephalopathy
List the PNS sarcoidosis problems
Facial nerve palsy
Mononeuritis multiplex
List the bone problems caused by sarcoidosis
Arthralgia
Arthritis
Myopathy
Describe Lofgren’s syndrome
Bilateral hilar lymphadenopathy
Erythema nodosum
Polyarthralgia
What investigations would you do to diagnose sarcoidosis
Serum ACE Calcium (high) Serum soluble IL-2 receptor (high) CRP (high) Immunoglobulins (high) CXR - hilar lymphadenopathy HRCT - hilar lymphadenopathy and pulmonary nodules MRI - CNS involvement PET scan - active inflammation
Biopsy - non-caseating granulomas with epithelioid cells - bronchoscopy with USS guided biopsy of the mediastinal lymph nodes
Describe the treatment of sarcoidosis
No treatment if no or mild symptoms
Oral steroids between 6-24months
Second line is methotrexate or azathioprine
Lung transplant if severe pulmonary disease
Describe the prognosis of sarcoidosis
Spontaneously resolves within 6 months in 60% patients. Small number develop pulmonary fibrosis and pulmonary hypertension
List the RF for obstructive sleep apnoea
Male Middle aged Obesity Alcohol Smoking
Describe features of obstructive sleep apnoea
Daytime sleepiness Morning headache Snoring Apnoea episodes during sleep Concentration problems Waking unrefreshed
What can severe cases of sleep apnoea cause
Heart failure
Hypertension
Increased risk of MI and stroke
What tool can be used to assess for symptoms of sleepiness associated with obstructive sleep aponeoa
Epworth sleepiness scale
Describe the management of obstructive sleep apneoa
Lifestyle - lose weight, stop smoking and drinking
CPAP - continous positive pressure during sleep to maintain patency of airway
Surgery - UPPP
How does lung Cancer cause chest pain
Chest wall involvement
Rib mets
Where does mesothelioma spread to?
Other pleural cavity
Hilar lymph nodes
Lung
How is mesothelioma diagnosed?
Thoracoscopy with biopsy and histology of pleura
What can be injected to prevent re-accumulation of pleural effusions in mesothelioma?
Sclerosant substances
What is the test for TB
Acid fast bacilli sputum
Where should patients with active TB be treated?
Negative pressure isolation room
What is a mycetoma
Fungus ball forming in a pre-existing lung cavity
What investigations would you do for aspergillus?
Skin test (positive in 30%)
Serum precipitins
Sputum culture
Which anti-TB drug can cause hepatitis?
Rifampicin
Which anti-TB drug can cause optic neuritis
Ethambutol
Why is pyridoxine supplementation recommended with isoniazid therapy
Isoniazid therapy can cause peripheral neuropathy due to vitamin depletion
What is an air bronchogram
Consolidated lung outlining an air filled bronchus
List the radiographical changes associated with bronchiectasis
Thickened bronchial walls
Ring shadows - thickened airways seen end on
Volume loss secondary to mucous plugging
Air fluid levels within dilated bronchi
List some causes of bronchiectasis
Aspergillosis Cystic fibrosis Immunodeficiency Sarcoidosis TB
Which antibiotic is given to serious gram negative infections
Gentamicin
Which antibiotic is given to pneumocystis jirovecci
Co-trimoxazole
List the four drugs used to treat TB
Rifampicin
Isoniazid
Pyrazinamide
Ethambutol
Which type of organism is the most common cause of aspiration pneumonia
Anaerobic
