Respiratory Flashcards
What are symptoms of pulmonary fibrosis?
SOB
DRY cough
Fatigue
Weight loss
What are signs of pulmonary fibrosis?
End-inspiratory crackles (bibasal)
Clubbing
Cyanosis
Reduced chest expansion
What is seen on CXR in pulmonary fibrosis?
Widespread infiltrates, interstital shadowing
What is seen on CT in pulmonary fibrosis?
Ground glass opacification, honeycombing, mosaicism
What drugs cause pulmonary fibrosis?
MADNEsS
Methotrexate Amiodarone Dopamine agonists Nitrofurantoin Sulfasalazine
What are causes of ARDS?
Pulmonary causes of ARDS: Sepsis Aspiration Pulmonary contusion (bruise in or on lungs – caused by force to the chest) TRALI
Non-pulmonary causes: Non-chest sepsis Acute pancreatitis DIC Drug overdose
What is the stepwise management of asthma?
- SABA
- Add daily low dose ICS
- Add montelukast
- LABA
- Increase dose of ICS
What is the staging of COPD?
By FEV1 Stage 1 = >80% Stage 2 = 50-79% Stage 3 = 30-49% Stage 4 = <30%
What is seen on ECG in pulmonary HTN?
P mitrale
How do you determine the management of pneumonia?
CURB65 or CRB65 (in general practice)
Confusion Urea > 7 RR > 30 BP systolic <90 or diastolic <60 >65
If CURB65 of 0/1 and CRB65 of 0 = Oral Amoxicillin/Doxy/macrolide
If CURB65 of 2 or CRB65 of ½ = 2 Antibiotics
If CURB65 of 3-5 or CRB65 ¾ - Admit for IV Co-Amox + Another oral
How is aspiration pneumonia treated?
IV Cephalosporin + IV Metronidazole
What is seen on CXR in lung cancer?
Nodule
Pleural effusion
Consolidation
Hilar lymphadenopathy
What is seen on ECG in PE?
Sinus tachycardia
S1Q3T3
Deep S in lead I
Pathological Q in lead III
Inverted T in lead III
Where do you aspirate a pneumothorax?
16-18G cannula placed in the 5th intercostal space mid-clavicular line.
Where do you place a chest drain?
5th intercostal space mid-axillary line
Where do you decompress a tension pneumothorax?
Wide bore cannula 2nd intercostal space mid clavicular line
How to analyse pleural effusion fluid analysis?
Protein (g/L) > 35 = Exudative, <25 = Transudative.
If between 25-35.. Light's criteria: Exudative if meets one of these criteria 1) Pleural protein:Serum protein >0.5 2) Pleural LDH:Serum LDH >0.6 3) Pleural LDH >2/3 upper limit for serum LDH
Which malignancies are most likely to cause pleural effusions?
Adenocarcinoma
Mesothelioma
What are side effects of pyrazinamide?
Hyperuricaemia leading to gout
Liver toxicity
What are features of Kartagener’s syndrome?
Complete situs invertus Bronchiectasis Recurrent sinusitis Subfertility Right testicle hangs lower
What is atelectasis? How does it present?
Basal alveolar collapse
Common post-operative complication
Dyspnoea + Hypoxia at around 72 hrs post -op
What is correct inhaler technique?
1) Remove cap and shake
2) Breathe out gently
3) Put mouthpiece in mouth, as you begin to breathe in , slow and deep, press canister down and continue to inhale steadily
4) Hold breath for 10 seconds
5) For a second dose wait for approx 30 seconds
When to use CPAP vs. BiPAP?
BiPAP is used in T2RF - eg in a COPD exacerbation
Helpful in COPD patients who retain CO2
CPAP is used in cardiogenic pulmonary oedema eg Heart failure which has not responded to Furosemide
Also used in hypoxia, pneumonia and obstructive sleep apnoea
How is a NSCLC managed?
Lobectomy
How is a SCLC managed?
Palliative chemo
What can raised amylase on pleural aspirate suggest?
Pancreatitis
Oesophageal perforation
What can heavy blood staining on pleural aspirate suggest?
Mesothelioma
TB
PE
What is the management of obstructive sleep apnoea?
CPAP
How can sleepiness be assessed in obstructive sleep apnoea?
Epworth sleepiness scale
How and when can you step down asthma management?
If a patient has not had to use their salbutamol can trial stepping down steroids by 50%
What is the most common cause of pneumonia after a recent influenza infection?
Staph aureus
How to decide what type of oxygen to give?
Critically ill?
- Yes - 15L NRM
Not critical - any conditions predisposing them to T2RF?
- Yes - Venturi lowest dose to maintain 88-92%
- No - Nasal cannual lowest dose to maintain 94-98%
What causes tracheal deviation TOWARDS problem?
Pneumonectomy
Lung collapse
Lung hypoplasia
What causes tracheal deviation AWAY from problem?
Tension pneumothorax
massive pleural effusion
When should you consider azithromycin prophylactically in patients with COPD?
If they…
- do not smoke and
- have optimised non-pharmacological management and inhaled therapies, relevant vaccinations and (if appropriate) have been referred for pulmonary rehabilitation and continue to have 1 or more of the following, particularly if they have significant daily sputum production:
- frequent (typically 4 or more per year) exacerbations with sputum production
- prolonged exacerbations with sputum production
- exacerbations resulting in hospitalisation.
What advice must you give someone post-pneumothorax?
- Stop smoking
- No scuba diving for life
- No flying for 1 week post check x-ray
What to consider when a young person presents with COPD symptoms?
Alpha-1 anti-trypsin
How much does spirometry need to improve by for a diagnosis of asthma?
12%
What medication can be used to prevent altitude sickness?
Acetozolamide
Why can the chest become hyper-resonant in an acute asthma attack?
Air trapped in narrow airways
How does Klebsiella pneumonia appear on XR?
cavitating lesions in the upper zone
How much prednisolone is it safe for breastfeeding women to take?
Up to 40mg daily
How to differentiate type of compensation from an ABG?
if pH is normal but on lower side of normal = kidneys compensated for respiratory acidosis
If pH is normal but on higher side of normal = lungs compensated for metabolic alkalosis
What are contraindications to chest drain insertion?
INR > 1.3
Platelet count <75
Pulmonary bullae
Pleural adhesions
Why does type 1 respiratory failure occur?
Ventilation-perfusion mismatch (V/Q mismatch)
Asthma, congestive heart failure, PE, pneumonia, pneumothorax
Why does type 2 respiratory failure occur?
Alveolar hypoventilation
COPD, pulmonary fibrosis, opiates, neuromuscular disease
When is oxygen given in an acute asthma exacerbation and what oxygen is given?
If sats drop below 94%
15L via non-rebreather mask
Common infective organisms in those with cystic fibrosis?
Strep pneumonia
H influenzae
P aeruginosa
Burkholderia cepacia
Risk factors for obstructive sleep apnoea
Obesity Acromegaly Enlarged tonsils Nasal polyps Alcohol
Risk factors for lung cancer
Smoking (tobacco and cannabis) Passive smoking Occupation exposure (asbestos, silica, welding fumes, coal) HIV Organ transplantation Radiation exposure (X-ray, gamma rays). Beta-carotene supplements in smokers.
Causes of bronchiectasis
CF Kartagener’s Lung cancer Allergic bronchopulmonary aspergillosis TB
Should you insert a chest drain above or below the rib and why?
ABOVE the rib - due to avoiding the neurovascular bundle immediately beneath the ribs.
What are indications for long term oxygen in COPD?
PaO2 < 7.3 on two readings more than 3 weeks apart
paO2 7.3-8 plus one of: Nocturnal hypoxia, polcythaemia, peripheral oedema, pulmonary HTN
PATIENT NEEDS TO BE A NON-SMOKER
Causes of pulmonary HTN?
COPD Asthma Interstitial lung disease Bronchiectasis Cystic fibrosis
Pulmonary causes of clubbing?
Lung cancer
Bronchiectasis
Pulmonary fibrosis
Where does lung cancer most commonly metastasise?
Brain
Breast
Bone
Adrenals
Biopsy: TB vs. Sarcoidosis
TB = caseating granuloma Sarcoidosis = non-caseating granuloma
How does acute sarcoidosis present?
Erythema nodosum
Bilateral hilar lymphadenopathy – dry cough, SOB
Polyarthralgia
Fever
How does chronic sarcoidosis present?
Pulmonary: cough, Dyspnoea
Systemic: fatigue, weight loss, Arthralgia, fever, lymphadenopathy
Ocular: uveitis, conjunctivitis, optic neuritis
Dermatological: erythema nodosum, lupus pernio (purple rash on face)
Which pleural effusions need draining with a chest drain?
If the fluid is purulent or turbid/cloudy
if the fluid is clear but the pH is less than 7.2
What is the 2WW criteria for lung cancer?
Any age with CXR findings suggestive of lung cnacer
>40 with unexplained haemoptysis
What are features of granulomatosis with polyangitis? (Wegener’s)
Kidney and respiratory tract problems Chronic sinusitis Epistaxis Saddle-nose deformity Cough Haemoptysis Pleuritic Haematuria Proteinuria
What paraneoplastic syndromes are associated with small cell lung cancer?
Cushing’s
SIADH –> Hyponatraemia
Lambert-Eaton
What paraneoplastic syndromes are associated with squamous cell carcinoma?
Raised PTH mimic –> Hypercalcaemia
HPOA
What paraneoplastic syndromes are associated with adenocarcinoma?
Gynaecomastia
HPOA
4 examples of extrinsic allergic alveolitis?
bird fanciers’ lung: avian proteins from bird droppings
farmers lung: spores of Saccharopolyspora rectivirgula from wet hay (formerly Micropolyspora faeni)
malt workers’ lung: Aspergillus clavatus
mushroom workers’ lung: thermophilic actinomycetes*
What is the most common cause of pneumoconiosis and what does it cause?
Coal workers pneumoconiosis
leads to upper lobe fibrosis
What is Allergic bronchopulmonary aspergillosis, what marker is it associated with and how is it managed?
Allergy to Aspergillus spores
Eosinophilia
Management = oral prednisolone
What is re-expansion pulmonary oedema?
Complication of drainage of pleural effusion
Causes pulmonary oedema due to rapid fluid output
To prevent - Drain tubing should be clamped regularly - should not exceed 1L of fluid over a short period of time.
What are options for smoking cessation?
NRT
Varenicline
Bupropion
What are side effects of NRT?
Nausea and vomiting
Headache
Flu-like symptoms
What is the most common SE of Varenicline and when should it be avoided?
SE: Nausea
CI: Pregnancy, history of depression or self harm
What is the main SE of Bupropion?
Increased risk of seizures - avoid in those with epilepsy
Also CI in pregnancy
When should you consider NIV in someone with an acute COPD exacerbation/
Hypoxia + pH <7.35
What are the asthma diagnostic criteria?
FeNO > 40 parts per billion Post-bronchodilator improvement of 200ml Post-bronchodilator improvement in Fev1 of 12% Peak flow variability of 20% or more FEV1/FVC ratio <0.7
