Respiratory Flashcards

Question

How is asthma diagnosed?

Answer 1

Diagnosis made based on a combination of the following: o Presence of more than one variable symptom of wheeze, cough, breathlessness and chest tightness o Personal/family history of other atopic conditions o The results of fractional exhaled nitric oxide testing (in over 17s, >40 parts per billion is a positive result, used to confirm eosinophilic airway inflammation) o Results of objective tests to detect airway obstruction, when the person is symptomatic:  Spirometry • FEV1/FVC ratio <70%, reduced • FVC normal • FEV1 significantly reduced  Bronchodilator reversibility • Improvement of FEV1 of >12% + increase in volume of >200ml following SABA or corticosteroids = positive result • In children, just FEV1 >12% = positive result  Variable peak expiratory flow (PEF) • >20% variability after monitoring twice daily for 2-4 weeks = positive result o Direct bronchial challenge test with histamine or methacholine (specialist centres)

Answer 2

use clinical judgement as child can’t perform objective tests

Answer 3

o High probability of asthma = try treatment o Intermediate probability of asthma = perform spirometry with reversibility testing o Low probability of asthma = consider referral and investigation for other causes

Answer 4

forced vital capacity = measures the amount of gas expelled when a person takes a deep breath and then forcefully exhales maximally and as rapidly as possible

Answer 5

forced expiratory volume = amount of air expelled during specific time intervals of the FVC test

Answer 6

the volume exhaled in the first second. Healthy individuals can exhale 80% of the FVC in one second.

Answer 7

decrease in both FEV1 and FEV1/FVC ratio

Answer 8

normal FEV1/FVC ratio

Answer 9

o Prominent systemic features e.g., myalgia, fever, weight loss o Unexpected clinical findings e.g., crackles, finger clubbing, cyanosis, cardiac disease, monophonic wheeze, stridor o Persistent non-variable breathlessness o Chronic sputum production o Unexplained restrictive spirometry o CXR shadowing o Marked blood eosinophilia

Answer 10

``` o Bronchiectasis o COPD o Ciliary dyskinesia o CF o Foreign body aspiration o GORD o HF o Interstitial ling disease e.g., asbestosis o Lung Ca o Pertussis o PE o TB ```

Answer 11

1. SABA PRN for infrequent wheezy episodes 2. + regular low dose inhaled corticosteroid 3. + oral montelukast (oral leukotriene receptor antagonist) 4. + LABA and continue only if the patient has a good response 5. Consider changing to a maintenance and reliever therapy (MART) regime 6. Increased inhaled corticosteroid to moderate dose 7. Consider increasing the inhaled corticosteroid to high dose or oral theophylline or an inhaled LAMA (tiotropium) 8. Refer to specialist

Answer 12

- Everyone should have an individual asthma self-management programme - Yearly flu jab - Yearly asthma review - Advise exercise and avoid smoking

Answer 13

Short acting beta 2 adrenergic receptor agonist (SABA) Salbutamol Reliver or rescue medication used PRN for acute exacerbations Dilation of bronchial smooth muscles ``` Tremor Arrhythmias Tachycardia Hyperglycaemia Hypokalaemia ```

Answer 14

Inhaled corticosteroid (ICS) Beclometasone Fluticasone Mometasone Maintenance or preventer used regularly Don’t take full effects until they’ve been used for 1 week ``` Oral thrush Hoarse/croaky voice Cough Nosebleeds Stunted growth in children ```

Answer 15

Long acting beta 2 adrenergic receptor agonist (LABA) Salmeterol Longer action than SABA, for long term maintenance therapy (taken every day regardless of symptoms) Dilation of bronchial smooth muscles ``` Tremor Arrhythmias Tachycardia Hyperglycaemia Hypokalaemia ```

Answer 16

Long acting muscarinic antagonist (LAMA) Tioptropium Blocks parasympathetic nervous system to cause bronchodilation Dry mouth Constipation Urinary retention

Answer 17

Leukotriene receptor antagonist Montelukast Prevents leukotrienes binding to receptors and causing bronchoconstriction/ inflammation Oral URTI Pharyngitis Headache Fever

Answer 18

Need to monitor plasma theophylline as it has a narrow therapeutic window, checked 5 days after starting and 3 days after dose changes

Answer 19

Maintenance and reliever therapy (MART) Low dose ICS and LABA combined Single inhaler for preventer and reliever

Answer 20

Methylprednisolone Prednisolone For severe persistent asthma ``` Cushings Osteoporosis Reduced growth Thin skin Immunosuppression Cataracts Oedema Suppressed HPA axis Teratogenic Emotional disturbance Rise in BP Obesity Increased hair growth Diabetes Striae ```

Answer 21

rapid deterioration of symptoms, could be triggered by any of the typical asthma triggers such as infection, exercise, or cold weather.

Answer 22

- Progressively worsening SOB - Use of accessory muscles - Tachypnoea - Symmetrical expiratory wheeze on auscultation - Chest sounds tight on auscultation, with reduced air entry

Answer 23

Moderate Severe Life threatening

Answer 24

o PEFR 50-75% predicted

Answer 25

o PEFR 33-50% predicted o Respiratory rate >25 o Heart rate >110 o Unable to complete sentences

Answer 26

``` o PEFR <33% o Sats <92% o Becoming tired o No wheeze, this occurs when the airways are so tight that there is no air entry at all. ‘Silent chest’ o Haemodynamic instability – shock ```

Answer 27

respiratory alkalosis due to tachypnoea causing CO2 drop. A normal pCO2 or hypoxia is concerning as it means the person is tiring = life threatening asthma. Respiratory acidosis due to high CO2 = very bad sign

Answer 28

``` o RR o Respiratory effort o Peak flow o O2 saturations o Chest auscultation ```

Answer 29

1. Moderate o Nebulised short acting beta 2 agonist (salbutamol) – repeated as often as required : WATCH THEIR SERUM POTASSIUM (salbutamol = hypokalaemia) o Nebulised ipratropium bromide o Steroids – oral prednisolone / IV hydrocortisone (continue for 5 days) o Abx if bacterial infection 2. Severe o Oxygen o Aminophylline infusion o IV salbutamol 3. Life threatening o IV magnesium sulphate infusion o Admission ITU/HDU o Intubation

Answer 30

Symptoms of both asthma and COPD | Significantly worse respiratory symptoms, poorer quality of life and increased risk of exacerbations/hospital admissions

Answer 31

permanent dilation of the airways secondary to chronic infection or inflammation.

Answer 32

- Post infective – TB, measles, pertussis, pneumonia - Cystic fibrosis - Bronchial obstruction e.g., lung cancer, foreign body - Immune deficiency – selective IgA, hypogammaglobinaemia - Allergic bronchopulmonary aspergillosis - Ciliary dyskinetic syndrome – Kartagener’s syndrome, Young’s syndrome - Yellow nail syndrome

Answer 33

* Cough * Sputum production (daily) * Crackles, high pitched inspiratory squeaks and rhonchi * Dyspnoea * Fever * Fatigue * Haemoptysis * Weight loss * Pleuritic chest pain * Rhinosinusitis

Answer 34

``` CXR Chest CT Sputum culture and sensitivities FBC Spirometry ```

Answer 35

o Tram track opacities o Air fluid levels o Ring shadows o Dilated rhonci and bronchioles

Answer 36

o Thickened, dilated airways o Air fluid levels o Cysts

Answer 37

1. Influenza and pneumococcal vaccine 2. Pulmonary rehabilitation 3. Stop smoking 4. Airway clearance therapy 5. Inhaled bronchodilator – salbutamol 6. Nebulised hypertonic saline 7. Abx for acute exacerbations

Answer 38

inflammation and infection in the bronchioles, the small airways of the lungs. Childhood disease.

Answer 39

respiratory syncytial virus (RSV) [Other causes – mycoplasma and adenoviruses]

Answer 40

Common in the winter in children under 1 year (most common in children <6 months old)

Answer 41

: small size of airways in children means that a small amount of inflammation and mucus in the airway can cause great effect on the infants ability to circulate air to the alveoli = wheeze and crackles.

Answer 42

- Coryzal symptoms (URTI) – snotty nose, sneezing, mucus in throat, watery eyes - Signs of respiratory distress - Dyspnoea - Heavy laboured breathing - Tachypnoea - Poor feeding - Mild fever (under 39) - Apnoeas - Wheeze and crackles on auscultation - Grunting - Stridor - Course of infection = URTI with coryzal symptoms, half get better and half get worse. Chest symptoms develop 1-2 days later, most fully recover in 2-3 weeks.

Answer 43

``` Raised respiratory rate o Accessory muscle use o Intercostal and subcostal recessions o Nasal flaring o Head bobbing o Tracheal tugging o Cyanosis – due to low oxygen saturation o Abnormal airway noises ```

Answer 44

- <3 months old - Pre-existing condition – prematurity, Down’s syndrome, cystic fibrosis - 50-75% or less of their normal milk intake - Clinical dehydration - Respiratory rate above 70 - Oxygen sats below 92% - Moderate to severe respiratory distress = deep recessions, head bobbing - Apnoeas - Parents not confident in managing at home / difficulty accessing medical help from home

Answer 45

- Supportive - Adequate intake – oral, NG or IV fluids - Saline nasal drops and nasal suctioning - Supplementary oxygen - Ventilatory support: high flow oxygen, CPAP, intubation and ventilation - PALIVIZUMAB – monoclonal antibody against RSV, given as a monthly injection to prevent bronchiolitis in high risk children (ex-premature/congenital heart disease)

Answer 46

- Increased risk of viral induced wheeze during childhood

Answer 47

non reversible long-term deterioration in air flow through the lungs caused by damage to lung tissue, which is almost always the result of smoking.

Answer 48

- Long term smoking - Chronic SOB - Cough - Sputum production - Wheeze - Recurrent respiratory infections – particularly in winter - DOES NOT CAUSE CLUBBING. Haemoptysis and chest pain is unusual

Answer 49

- 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 breath after walking 100m on flat - Grade 5 – unable to leave house due to breathlessness

Answer 50

1. Clinical presentation 2. Spirometry: o Obstructive = FEV1/FVC <70% o No dramatic response to reversibility testing 3. CXR – to exclude lung cancer 4. FBC – polycythaemia or anaemia 5. BMI to assess later weight loss 6. Sputum culture 7. ECG and echocardiogram 8. CT thorax – to exclude fibrosis, lung cancer and bronchiectasis 9. Serum alpha-1 antitrypsin – if there’s deficiency = early onset and more severe disease 10. Transfer factor for carbon monoxide (TLCO) – decreased in COPD (indication of disease severity & raised in asthma)

Answer 51

Severity grading by FEV1: - 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

Answer 52

1) SABA = salbutamol OR SAMA = ipratropium bromide 2) If they do not have asthmatic or steroid responsive features = LABA and LAMA e.g., ellipta, ultibro breezhaler and duaklir genuair 3) If they have asthmatic/steroid responsive features = LABA and ICS e.g., fostair, Symbicort, Seretide 4) LABA + LAMA + ICS = trimbo, trelegy ellipta 5) Other options: a. Nebulisers – salbutamol/ipratropium b. Oral theophylline c. Oral mucolytic therapy e.g., carbocisteine d. Long term abx e.g., azithromycin e. Long term oxygen therapy at home

Answer 53

if chronic hypoxia, polycythaemia, cyanosis or heart failure secondary to pulmonary HTN (cor pulmonale)

Answer 54

- Stop smoking | - Pneumococcal and influenza vaccine

Answer 55

acute worsening of symptoms e.g., cough, SOB, sputum production and wheeze. Usually triggered by viral or bacterial infection.

Answer 56

``` - ABG = o Raised pCO2 = respiratory alkalosis o Raised bicarbonate as they chronically retain CO2 so the kidneys produce more bicarbonate to compensate - CXR - ECG - FBC - U&E - Sputum culture - Blood culture ```

Answer 57

- Venturi masks are used to give oxygen as they can deliver a specific percentage concentration – some oxygen leaks out the side of the mask and normal air can be inhaled alongside the oxygen - Venturi masks deliver: o 24% blue o 28% white o 31% oxygen o 35% yellow o 40% red o 60% green - If retaining CO2, aim for 88-92% on sats titrated on venturi mask - If not retaining CO2 and normal bicarbonate, aim for >94% sats

Answer 58

1. If they can be treated at home: a. Prednisolone 30mg OD 7-14 days b. Regular inhalers or home nebulisers c. Abx if infection 2. In hospital a. Nebulised bronchodilators e.g., salbutamol and ipratropium b. Steroids (IV hydrocortisone or oral prednisolone) c. Abx if infection d. Physiotherapy to clear sputum 3. Severe cases a. IV aminophylline b. NIV c. Intubation and ventilation – ITU/HDU d. Doxapram – respiratory stimulant where NIV/intubation isn’t indicated

Answer 59

``` Hereditary clubbing Cyanotic heart disease Infective endocarditis Cystic fibrosis TB Inflammatory bowel disease Liver cirrhosis ```

Answer 60

autosomal recessive disorder causing increased viscosity of secretions (e.g., in the lungs and pancreas). Due to a defect in the cystic fibrosis transmembrane conductase regulator gene (CFTR) on chromosome 7, which codes a cAMP-regulated chloride channel.

Answer 61

1. Autosomal recessive genetic condition 2. Genetic mutation on cystic fibrosis transmembrane conductance regulatory gene 3. Chromosome 7 4. Most common mutation = delta-F508 mutation 5. The gene codes for cellular channels – particularly chloride channels 6. 1 in 25 are carriers of the mutation 7. 1 in 2500 children have CF

Answer 62

- Thick pancreatic and biliary secretions that cause blockage of the ducts = lack of digestive enzymes e.g., pancreatic lipase - Low volume thick airway secretions that reduce airway clearance = bacterial colonisation and susceptibility to airway infections - Congenital bilateral absence of vas deferens in males = healthy sperm but no way of ejaculating healthy sperm causing male infertility

Answer 63

1. Screened at birth with newborn blood spot test 2. Meconium ileus – meconium is stuck in the bowel causing obstruction = no meconium passed, abdominal distention and vomiting 3. Childhood = recurrent LRTI, failure to thrive or pancreatitis

Answer 64

- Chronic cough - Thick sputum production - Recurrent RTI - Loose, grey stools (steatorrhoea) due to a lack of lipase enzymes - Abdominal pain and bloating - Salty taste when kissing the child - Failure to thrive - Nasal polyps - Finger clubbing - Crackles and wheeze on auscultation - Abdominal distention

Answer 65

1) Newborn blood spot testing 2) Sweat test = gold standard o Pilocarpine applied to skin, electrodes either side and small current is passed causing the skin to sweat o Sweat is absorbed with lab gauze and tested for chloride concentration o CF = chloride concentration >60 mmol/L 3) Genetic testing for CFTR gene – amniocentesis or chorionic villous sampling or after birth blood test

Answer 66

- Staphylococcus aureus – long term prophylactic flucloxacillin - Pseudomonas aeruginosa – difficult to get rid of, can become resistant to multiple abx. Increases morbidity and mortality. Children with CF to avoid others with CF to prevent spread of pseudomonas aeruginosa. Tx: long term nebulised tobramycin and oral ciprofloxacin. - Haemophilus influenza - Krebsiella pneumoniae - E coli - Burkhodheria cepacia

Answer 67

* Chest physiotherapy – multiple times daily to clear mucus * Exercise * High calorie diet – due to malabsorption * CREON tablets – for pancreatic insufficiency * Prophylactic flucloxacillin – for staph aureus colonisation * Treat chest infections * Bronchodilators * Nebulised DNase (dornase alfa) – easier to clear respiratory secretions * Nebulised hypertonic saline * Vaccinations – pneumococcal, influenza and varicella * Lung transplantation * Liver transplantation * Fertility treatment * Genetic counselling

Answer 68

- Respiratory colonisation - Diabetes - Osteoporosis - Vitamin D deficiency - Liver failure

Answer 69

conditions that affect the lung parenchyma causing inflammation and fibrosis.

Answer 70

high resolution CT chest = ground glass appearance. Can do lung biopsy if diagnosis unclear

Answer 71

- Remove/treat underlying cause - Home oxygen if chronically hypoxic - Stop smoking - Physiotherapy and pulmonary rehabilitation - Pneumococcal and influenza vaccines - Advanced care planning / palliative care - Lung transplant

Answer 72

``` Idiopathic pulmonary fibrosis Drug induced pulmonary fibrosis Secondary pulmonary fibrosis Hypersensitivity pneumonitis Crytogenic organising penumonia Asbestosis ```

Answer 73

replacement of normal elastic lung tissue with scar tissue that is stiff and doesn’t function effectively

Answer 74

Progressive pulmonary fibrosis with no clear cause SOB Dry cough Clubbing Bibasal fine inspiratory crackles Pirfenidone Nintedanib

Answer 75

- Amiodarone - Cyclophosphamide - Methotrexate - Nitrofurantoin

Answer 76

- Alpha 1 antitripsin deficiency - RA - SLE - Systemic sclerosis

Answer 77

Type III hypersensitivity reaction to environmental allergens that causes parenchymal inflammation Examples: - Bird fanciers lung - Farmers lung - Mushroom workers lung - Malt workers lung

Answer 78

bronchiolitis obliterans Focal area of inflammation of the lung tissue ``` SOB Cough Fever Lethargy Focal consolidation on CXR ``` Need lung biopsy (gets mistaken for pneumonia) Tx = systemic corticosteroids

Answer 79

seasonal influenza, outbreaks occur in the winter. It’s an RNA virus. There are 3 types: A, B and C (A and B are most common).

Answer 80

- Fever - Coryzal symptoms - Lethargy and fatigue - Anorexia - Muscle and joint aches - Headache - Dry cough - Sore throat

Answer 81

* Clinical diagnosis | * Viral nasal or throat swabs for PCR analysis

Answer 82

- Public health monitor case numbers - Self care, adequate fluids and rest - If at risk of complications (start within 48 hrs of symptom onset) = o Oral oseltamivir 5 days o Inhaled zanamivir 5 days - Can give oseltamivir and zanamivir to high risk patients after exposure as prophylaxis

Answer 83

- Otitis media, sinusitis and bronchitis - Viral pneumonia - Secondary bacteria pneumonia - Worsening COPD and HF - Febrile convulsions in young children - Encephalitis

Answer 84

1. It’s given intranasally 2. First dose is given at 2-3 years old, then annually after that 3. It’s a live vaccine 4. More effective than injectable vaccine 5. Only children aged 2-9 years that haven’t had a vaccine before need 2 doses

Answer 85

- Immunocompromised - Aged <2 years - Current febrile illness or blocked nose - Current wheeze - Egg allergy - Pregnancy/breastfeeding - Child is taking aspirin e.g., for Kawaski disease – risk of Reye’s syndrome (swelling of liver and brain)

Answer 86

1. Inactivated vaccine 2. Can get fever and malaise – lasts for 1-2 days 3. Stored at 2-8 degrees, shielded from light 4. Cis: egg hypersensitivity 5. Takes 10-14 days for antibodies to reach protective levels

Answer 87

- Over 65s - Chronic respiratory disease - Chronic heart disease - Chronic kidney disease - Chronic liver disease - Chronic neurological disease - DM - Immunosuppressed - Asplenia or splenic dysfunction - Pregnant women - >40 BMi - Health and social care staff - People in long stay residential care homes - Carers

Answer 88

1. Small cell lung cancer – 20% 2. Non-small cell lung cancer – 80% a. Adenocarcinoma (most common) – seen in non-smokers b. Squamous cell carcinoma c. Large cell carcinoma d. Other types

Answer 89

contain neurosecretory granules that release neuroendocrine hormones = paraneoplastic syndromes.

Answer 90

- SOB - Cough - Haemoptysis - Finger clubbing (squamous cell carcinoma) - Recurrent pneumonia - Weight loss - Lymphadenopathy – often supraclavicular nodes - Fixed monophonic wheeze

Answer 91

- Recurrent laryngeal nerve palsy – hoarse voice - Phrenic nerve palsy – diaphragm weakness = SOB - Superior vena cava obstruction – facial swelling, difficulty breathing and distended neck veins o Pemerton’s sign = raising hands over the head causes facial congestion and cyanosis = medical emergency

Answer 92

- Horner’s syndrome – ptosis, anhidrosis and miosis (Pancoast tumour in pulmonary apex compressing the sympathetic ganglion)

Answer 93

- SiADH – hyponatraemia (ectopic ADH from SCLC) - Cushing’s syndrome (ectopic ACTH from SCLC) - Limbic encephalitis – short term memory impairment, hallucinations, confusion and seizures (SCLC causes autoantibodies against tissues in the brain: anti-Hu antibodies) - Lambert-Eaton myasthenic syndrome – proximal muscle weakness, intraocular muscle weakness = diplopia, ptosis, pharyngeal muscle weakness = slurred speech and dysphagia & autonomic dysfunction (dry mouth, blurred vision, impotence & dizziness) – SCLC causes autoantibodies against voltage gated calcium channels on presynaptic terminals in motor neurones.

Answer 94

- Gynaecomastia

Answer 95

- Hypercalcaemia (ectopic PTH from squamous cell carcinoma)

Answer 96

- Clubbing - Lymphadenopathy (supraclavicular or persistent abnormal cervical nodes) - Recurrent or persistent chest infections - Raised platelets = thrombocytosis - Chest signs of lung cancer ``` - Or in over 40’s: 2+ unexplained symptoms in non-smokers/1+ unexplained symptom in smoker – o Cough o SOB o Fatigue o Chest pain o Weight loss o Loss of appetite ```

Answer 97

1. CXR 2. Staging CT CAP (contrast enhanced) 3. PET-CT 4. Raised platelets on bloods 5. Bronchoscopy with endobronchial ultrasound (EBUS) & biopsy 6. Histological diagnosis – bronchoscopy or percutaneous biopsy

Answer 98

o Hilar enlargement o Peripheral opacity – visible lesion in lung field o Pleural effusion – usually unilateral in cancer o Collapse

Answer 99

o Surgery o Radiotherapy o Chemotherapy – in addition to surgery/radiotherapy or palliative

Answer 100

o Chemotherapy o Radiotherapy o Worse prognosis o Endobronchial treatment with stents or debulking to relieve obstruction

Answer 101

1. Options to remove tumour: a. Segmentectomy or wedge resection b. Lobectomy – absent breath sounds in one zone c. Pneumonectomy (entire lung) – no breath sounds on one side 2. Types of surgery a. Thoracotomy – open surgery with an incision and separation of the rib cage to assess the thoracic cavity b. Video assisted thorascopic surgery – minimally invasive keyhole surgery c. Robotic surgery

Answer 102

a. Anterolateral thoracotomy – front and side b. Axillary thoracotomy – axilla c. Posterolateral thoracotomy – incision around the back and side (most common)

Answer 103

caused by collapse of the pharyngeal airway. It is characterised by episodes of apnoea during sleep, where the person stops breathing periodically for up to a few minutes. The partner usually reports this happening, and the patient is unaware of the episodes.

Answer 104

- Middle age - Male - Obesity - Alcohol - Smoking

Answer 105

- Episodes of apnoea during sleep (reported by their partner) - Snoring - Morning headache - Waking up unrefreshed from sleep - Daytime sleepiness - Concentration problems - Reduced oxygen saturation during sleep - Hypertension, - heart failure - increase the risk of myocardial infarction and stroke.

Answer 106

Epworth Sleepiness Scale The Epworth Sleepiness Scale is used to assess symptoms of sleepiness associated with obstructive sleep apnoea. - Daytime sleepiness - Occupation / driving - Asks how likely you are to sleep in certain situations

Answer 107

* referral to an ENT specialist or a specialist sleep clinic to perform sleep studies * correct reversible risk factors by advising them to stop drinking alcohol, stop smoking and lose weight * continuous positive airway pressure (CPAP) machine that provides continuous pressure to maintain the patency of the airway * Surgery = significant surgical reconstruction of the soft palate and jaw. The most common procedure is called uvulopalatopharyngoplasty (UPPP).

Answer 108

Coal workers pneumoconiosis – coal dust particles cause fibrosis Investigations: 1. Chest x-ray: upper zone fibrosis 2. Spirometry: restrictive lung function tests - a normal or slightly reduced FEV1 and a reduced FVC Management: - Avoid exposure to coal dust and other respiratory irritants (e.g. Smoking). - Manage symptoms of chronic bronchitis - Patients may be eligible for compensation via the Industrial Injuries Act.