Respiratory Flashcards
1
Q
how can lung cancer be classified histologically? what % of total lung cancers are each of them?
A
- non-small cell lung cancer, 80%
- small cell lung cancer (SCLC), 20%
2
Q
3 main types of non-small cell lung cancer?
A
- adenocarcinoma (40%)
- squamous cell carcinoma (more likely in a non-smoker) (20%)
- large cell carcinoma
3
Q
which type of lung cancer can give rise to paraneoplastic syndromes? how?
A
- SCLC
- the cells have granules which secrete neuroendocrine hormones
4
Q
presentation of lung cancer? (6)
A
- SOB
- cough, haemoptysis
- finger clubbing
- recurrent pneumonia
- weight loss
- lymphadenopathy
5
Q
which lymph nodes are enlarged first typically in lung cancer?
A
supraclavicular ones
6
Q
first line investigation in lung cancer? what are the findings (4)?
A
CXR
- hilar enlargement
- peripheral opacity
- pleural effusion, usually unilateral
- collapse
7
Q
investigations in lung cancer?
A
- CXR
- CT chest, abdomen and pelvis to stage
- PET-CT
- bronchoscopy with endobronchial ultrasound (EBUS)
- biopsy and histology
8
Q
when is surgical management used in lung cancer? Types of surgery available?
A
- non-SCLC isolated in one area
- lobectomy
- segmentectomy (wedge resection)
- often done with adjuvant chemotherapy
9
Q
management of SCLC? prognosis?
A
- chemotherapy
- radiotherapy
- typically worse prognosis than non-SCLC
10
Q
palliative treatment options for lung cancer?
A
- palliative chemotherapy
- endobronchial stenting
- endobronchial debulking
11
Q
complications of lung cancer relating to compression (4) and hormone secretion (3) and immune (2)?
A
compression:
- recurrent laryngeal palsy
- phrenic nerve palsy
- SVCO
- horner’s syndrome
hormonal:
- SIADH
- cushing’s syndrome
- hypercalcaemia
Immune
- limbic encephalitis
- lambert-eaton myasthenic syndrome
12
Q
how can lung cancer cause nerve palsy? which nerves are commonly affected?
A
- tumour compresses them
- recurrent laryngeal nerve
- phrenic nerve
13
Q
presentation of SVC obstruction?
A
- facial swelling
- difficulty breathing
- distended veins in neck and upper chest
- pemberton’s sign
14
Q
what is pemberton’s sign? is it significant?
A
- raising the hands over the head causes facial congestion and cyanosis (as the thoracic inlet becomes obstructed)
- medical emergency!
15
Q
how can lung cancer cause horner’s syndrome?
A
pancoast tumour compressing the sympathetic ganglion
16
Q
presentation of horner’s syndrome?
A
triad:
- partial ptosis
- anhidrosis
- miosis
17
Q
what is a pancoast’s tumour?
A
tumour in the apex of the lung
18
Q
how can lung cancer cause SIADH? key finding on bloods?
A
- SCLC tumour secreting ectopic ADH
- hyponatraemia
19
Q
how can lung cancer cause cushing’s syndrome?
A
SCLC secreting ectopic ACTH
20
Q
how can lung cancer cause hypercalcaemia?
A
squamous cell carcinoma (non-SCLC) secreting ectopic PTH
21
Q
describe limbic encephalitis
(caused by? / pathophys?/ features?)
A
= paraneoplastic syndrome caused by SCLC
- immune reaction to the limbic system
- anti-Hu antibodies
- causes: memory impairment, confusion, hallucinations, seizures
22
Q
pathophysiology of lambert-eaton myasthenic syndrome?
A
antibodies created against SCLC cells ➡️ BUT also attack voltage-gated Ca channels in motor neurones
23
Q
presentation of lambert-eaton myasthenic syndrome?
A
- proximal muscle weakness, worse with prolonged use
- EYE - diplopia +ptosis
- slurred speech
- dysphagia
24
Q
top differential for lambert-eaton myasthenic syndrome?
A
- myasthenia gravis
- onset is more insidious and symptoms less pronounced in lambert-eaton
25
which cells are affected in mesothelioma?
mesothelial cells of the pleura
26
biggest risk factor for mesothelioma?
- asbestos inhalation / exposure
- latent period as long as 45 years
27
management of mesothelioma? prognosis?
- palliative chemotherapy
- very poor
28
finding on CXR in pneumonia?
consolidation
29
what is hospital acquired pneumonia (HAP)?
pneumonia which develops \>48h after hospital admission
30
different types of pneumonia?
- CAP
- HAP
- aspiration pneumonia
31
presentation of pneumonia?
CHEST:
- SOB
- productive cough +/- haemoptysis
- pleuritic chest pain
SYSTEMIC
- fever
- Sepsis
OTHER:
- delirium
32
findings in a set of obs in pnuemonia?
- tachypnoea
- tachycardia and hypotension (shock)
- hypoxia
- fever
- confusion (GCS)
33
lung signs on examination in pneumonia?
- bronchial breathing
- increased tactile vocal fremitus
- focal coarse crackles
- dullness to percuss
34
describe bronchial breathing
harsh breathing, equally loud on inspiration and expiration
35
scoring system for severity and risk of mortality from pneumonia in hospital? in community?
- CURB-65 in hospital
- urea not checked out of hospital (CRB-65)
36
different parts of CURB-65?
- Confusion, new onset
- Urea \>7
- RR \>30
- BP \<90 systolic, \<60 diastolic TO REMEMBER ➡️”69 😉”
- 65 or above years old
37
which CURB-65 score determines which treatment?
- 0-1 = home treatment
- 2 = hospital admission
- 3 or more = ICU care
38
commonest bacterial causes of pneumonia?
- strep pneumoniae (50%)
- H. influenzae (20%)
39
which organism causes pneumonia in immunocompromised / COPD patients?
moraxella catarrhalis
40
which organisms cause pneumonia in CF patients?
- pseudomonas aeruginosa
- staph aureus
41
who is at higher risk of pneumonia from pseudomonas aeruginosa?
- CF patients
- bronchiectasis patients
42
define atypical pneumonia
pneumonia caused by an organism which cannot be cultured in the normal way or detected by gram stain
43
which ABx should be used on atypical pneumonia?
macrolides
44
organisms which cause atypical pneumonia?
\*\*REMEMBER - “legions of psittaci MCQs”
- legionella pneumophila
- mycoplasma pneumoniae
- chlamydophila pneumoniae
- coxiella burnetii
- chlamydia psittaci
45
how is legionella pneumophila contracted? how does it present?
- infected water supply, dodgy air con
- pneumonia
- hyponatraemia (it causes SIADH)
46
how does mycoplasma pneumoniae infection present?
- mild pneumonia
- additional features = COLD-type AIHA
- erythema multiforme ("target" lesions) (= a COMPLICATION)
47
which demographic typically gets chlamydia pneumoniae infection? how does it present?
- school aged children
- chronic cough and wheeze
- (be careful because this is a common presentation!)
48
another name for coxiella burnetii infection? how does it spread?
- Q fever
- animal bodily fluids
- e.g. "farmer with a flu"
49
Legions of psittaci MCQs: 5 causes of atypical pneumonia?
- legionella
- psittaci (chlamydia)
- Mycoplasma pneumoniae
- Chlamydophila pneumoniae
- Q fever (coxiella burnetti)
50
which organism could cause a fungal pneumonia?
pneumocystis jiroveci
51
which patients are at risk of pnuemocystis jiroveci pneumonia?
- immunocompromised
- e.g. HIV+ with low CD4 count
52
presentation of fungal pneumonia?
- dry cough
- SOBOE
- night sweats
53
management of fungal pneumonia?
- co-trimoxazole (trimethoprim + sulfamethoxazole)
54
how can fungal pneumonia be prevented?
all HIV+ pts with CD4 count \<200 are given prophylactic co-trimoxazole alongside their regular ART
55
investigations for pneumonia? findings?
- CXR (consolidation)
- FBC (raised WCC)
- UEs (urea for CURB-65)
- CRP (raised)
56
extra investigations done in severe pneumonia? (3)
- sputum cultures
- blood cultures
- legionella and pneumococcal urinary antigens
57
when might CRP be low in pneumonia? why?
- immunocompromised patients
- they can't mount an immune response
58
management of severe pneumonia?
- hospital admission
- IV ABx (check local guidelines to choose)
- switch to oral once improving
59
management of mild CAP?
5 day oral course of either:
- amoxicillin
- macrolide
60
management of mod-sev CAP?
7-10 day course of BOTH amoxicillin AND a macrolide
61
SPELD: complications of pneumonia?
- sepsis
- pleural effusion
- lung abscess
- death
62
3 outcome measures of lung function tests?
- spirometry
- FEV1
- FVC
63
in spirometry, what is reversible testing?
giving a bronchodilator (salbutamol) before doing the breathing exercises
64
what is FEV1? when is it reduced?
- forced expiratory volume in 1 second
- volume of air a person can forcefully exhale in 1 second
- reduced in lung obstruction
65
what is FVC? when is it reduced?
- forced vital capacity
- total volume of air a person can exhale after inspiration
- reduced in lung restriction (because capacity of lung is being restricted)
66
how is obstructive lung disease diagnosed?
FEV1/ FVC \<0.75
67
examples of obstructive lung disease?
- asthma (bronchoconstriction)
- COPD (chronic damage leading to obstruction)
- bronchiectasis
68
FEV1/FVC in restrictive lung disease? explain this
- FEV1/FVC \>0.75 (normal or raised)
- they're both equally reduced, so the ratio doesn't change
69
describe restrictive lung disease
restriction in lung's ability to expand
70
examples / causes of restrictive lung diseases? 6
- pulmonary fibrosis (or other ILD)
- asbestosis
- sarcoidosis
- obesity
- MND / other neuro disorders
- scoliosis (e.g. in ank spond)
71
when is peak flow (PEFR) useful?
to demonstrate obstruction in asthma
72
how is peak flow measured?
- stand tall and take a deep breath in
- make a good seal with the device
- blow hard and fast ;)
- 3 attempts, take the best one
73
how is the peak flow result interpreted?
- predicted peak flow obtained from chart
- record it as % of actual over predicted
74
factors taken into account in predicted peak flow?
- sex
- height
- age
75
what is asthma?
chronic inflammatory condition where there is bronchoconstriction in exacerbations
76
how does asthma cause obstruction? is this reversible?
- smooth muscles of bronchi contract
- airway gets narrowed
- obstructs airflow
- reversible
77
how is obstruction in asthma reversed?
bronchodilator (salbutamol)
78
triggers of bronchoconstriction in asthma?
- infection
- time of day (night or early morn)
- exercise
- animals
- cold / damp / dust
- strong emotions
79
presentation of asthma? (5 symps; 2 Hx)
- episodic symptoms in Hx
- diurnal variation
- dry cough
- wheeze
- SOB
- Hx of atopy (eczema, hayfever, food allergy)
- FHx
80
what is heard on auscultation in asthma?
bilateral widespread polyphonic wheeze
81
what are the first line investigations in asthma diagnosis according to NICE?
- fractional exhaled nitric oxide (FeNO)
- spirometry with bronchodilator reversibility
82
second line investigations in asthma diagnosis?
- peak flow variability
- direct bronchial challenge with histamine / methacholine
83
full form of SABA? how long does the effect of a SABA last? what is the inhaler commonly called? example?
- short acting beta 2 agonist
- only lasts 1-2 hours
- "reliever", "rescue"
- salbutamol
84
example of an ICS? how do they work? what is the inhaler commonly called?
- beclometasone, budesonide, fluticasone
- reduces inflammation in airway
- "maintenance", "preventer"
85
full form of LABA? example? what is the difference between LABA and SABA?
- long acting beta 2 agonist
- salmeterol
- same MOA but LABA lasts much longer
86
full form of LAMA? example? how does it work?
- long acting muscarinic antagonist
- tiotropium
- blocks ACh receptors, causing bronchodilation
87
full form of LTRA? example? how does it work?
- leukotriene receptor antagonist
- montelukast
- blocks leukotriene action
88
what are the effects of leukotrienes?
- inflammation
- bronchoconstriction
- mucus secretion
89
how does theophylline work?
- relaxes bronchial smooth muscle
- reduces inflammation
90
why does theophylline need to be monitored? how is it monitored?
- narrow therapeutic window, can cause toxicity
- check blood theophylline levels 5 days after starting treatment
- check 3 days after each dose change
91
what does MART stand for in asthma treatment? why is it useful?
- maintenance and reliever therapy
- one inhaler with a low dose ICS and LABA in it
- replaces all other inhalers
- convenient
92
step 1 in NICE asthma treatment ladder?
SABA (salbutamol), PRN
93
step 2 in NICE asthma treatment ladder?
add low dose ICS (beclometasone)
94
step 3 in NICE asthma treatment ladder? how does SIGN/BTS differ here?
- NICE: add LTRA (montelukast)
- BTS: add LABA (salmeterol)
95
step 4 in NICE asthma treatment ladder? (VS BTS)
NICE
Add LABA inhaler (e.g. salmeterol). Continue the LABA only if the patient has a good response.
BTS
consider adding one of these:
- LTRA (montelukast)
- theophylline
- PO SABA (salbutamol)
- LAMA (tiotropium)
96
step 5 in NICE asthma treatment ladder? (VS BTS)
Consider changing to a maintenance and reliever therapy (MART) regime.
BTS…
Titrate inhaled corticosteroid up to “high dose”. Combine additional treatments from step 4. Refer to specialist.
97
step 6 in NICE asthma treatment ladder? (Vs BTS)
Increase the inhaled corticosteroid to a “moderate dose”.
BTS
add oral steroids
98
other than regular medication, what else is part of asthma management? (1 medical? 1 follow up? 2 conservative)
- yearly flu jab
- yearly asthma review
- advice on exercise and smoking
- all patients should have a personalised plan
99
presentation of acute asthma exacerbation?
- progressively worsening SOB
- use of accessory muscles
- tachypnoea
100
signs on auscultation in acute asthma exacerbation?
- symmetrical expiratory wheeze
- "tight" chest sounds (reduced air entry)
101
how are acute asthma exacerbations graded?
- moderate
- severe
- life-threatening
102
features of a moderate acute asthma exacerbation?
- peak flow 50-75% of predicted
- normal speech
- RR \<25/min
- pulse \<110/min
103
features of a severe acute asthma exacerbation?
- peak flow is 33-50% of predicted
- RR \>25
- HR \>110
- unable to complete a sentence
104
features of a life-threatening acute asthma exacerbation? 5
- peak flow isn \<33% of predicted
- O2 sats \<92%
- becoming tired
- silent chest (no wheeze)
- haemodynamic instability (shock)
105
management of a moderate acute asthma exacerbation?
- nebulised salbutamol 5mg, repeat as much as needed
- nebulised ipratropium bromide
- PO pred or IV hydrocortisone for 5 days
- ABx if bacterial cause suspected
106
management of a severe acute asthma exacerbation?
- O2 to maintain sats of 94-98%
- aminophylline infusion
- consider IV salbutamol
107
management of a life-threatening acute asthma exacerbation?
- IV magnesium sulphate infusion
- HDU / ICU admission
- intubation if extreme severity
108
ABG findings in an acute asthma exacerbation? why?
- respiratory alkalosis (drop in CO2 from tachypnoea)
- normal pCO2 means they are tiring and retaining more CO2
109
why is respiratory acidosis a worrying finding on ABG in asthma?
it means they have high CO2 because they're not blowing any of it off
110
how is treatment response monitored in acute asthma exacerbations? (5)
- RR
- resp effort
- peak flow
- O2 sats
- chest auscultation
111
which electrolyte needs to be monitored in patients on salbutamol? why?
- serum K+
- salbutamol causes K+ to move from blood into cells
112
define COPD
non-reversible, long term obstruction in air flow through the lungs caused by damage to lung tissue
113
presentation of COPD?
- chronic SOB
- cough with sputum
- wheeze
- recurrent resp infections
114
main risk factor for COPD?
smoking
115
how can breathlessness be assessed?
MRC dyspnoea scale
116
describe the 5 grades of the MRC dyspnoea scale
- 1 = breathless on strenuous exercise
- 2 = breathless on walking uphill
- 3 = breathessness that slows walking on the flat
- 4 = stops to catch breath after walking 100m on the flat
- 5 = unable to leave the house due to breathlessness
117
how is COPD diagnosed?
both of:
- clinical picture
- spirometry showing: FEV1/FVC \<0.7
118
results of spirometry reversibility testing in COPD?
no dramatic reversal with salbutamol
119
how can the severity of obstruction in COPD be assessed?
look at the FEV1 compared to the predicted value
120
investigations (other than spirometry) and findings in COPD? (9)
* CXR (hyperinflated, exclude: cancer)
* CT thorax (exclude: fibrosis, cancer, bronchiectasis)
* echocardiogram - cor pulm
* ECG (cor pulmonale findings),
* BMI (weight loss if COPD is severe, gain from steroids)
* FBC (polycythaemia due to chronic hypoxia)
* sputum culture (chronic infection)
* serum A1AT (may be deficient)
* TLCO (low)
121
what is TLCO?
transfer factor for carbon monoxide
122
non-drug management of COPD (2)? (+prevention (2))
- smoking cessation
- pulmonary rehab
- pneumococcal vaccine
- annual flu jab
123
step 1 in drug management of COPD?
SABA (salbutamol) or SAMA (ipratropium)
124
step 2 in COPD management with NO features of asthma / response to steroids?
- combined inhaler
- includes LABA and a LAMA
125
which add-on meds can be used in COPD management?
- PO theophylline
- PO mucolytics (carbocisteine)
- long term prophylactic ABx (azithromycin)
- O2 therapy at home
126
what determines step 2 of COPD medical management?
- whether they have features of asthma
- whether it is steroid-responsive
127
step 2 in COPD management with features of asthma / response to steroids? if this fails?
- combined inhaler
- LABA + ICS
- if this fails: LABA + ICS + LAMA inhaler
128
indications for long-term O2 therapy use in COPD?
- chronic hypoxia
- polycythaemia
- cyanosis
- cor pulmonale
129
significant contraindication for O2 therapy?
smoking! fire hazard
130
presentation of COPD exacerbation?
acute worsening of:
- cough
- SOB
- sputum production
- wheeze
131
what causes a COPD exacerbation?
viral / bacterial infection
132
ABG findings in someone acutely retaining CO2? why? what is this called?
- low pH
- the breakdown product of CO2 is acidotic
- respiratory acidosis
133
ABG findings in someone chronically retaining CO2? why?
- raised bicarbonate
- kidneys compensate for the acid by producing something alkaline
134
ABG findings in type 1 resp failure?
- low pO2
- normal pCO2
135
ABG findings in type 2 resp failure?
- low pO2
- high pCO2
136
investigations in COPD exacerbation? (6)
- ABG
- CXR
- ECG
- UEs
- sputum culture
- blood cultures if septic
137
why does O2 therapy need careful monitoring if someone is retaining CO2? how is it done?
- too much O2 can depress their resp drive
- repeat ABGs
- use venturi masks to tightly control O2 flow
138
target O2 sats in CO2 retainers?
88-92% titrated by venturi mask
139
target O2 sats in COPD patient NOT retaining CO2?
\>94%
140
treatment of COPD exacerbation at home?
- pred 30mg for 7-14 days
- regular inhalers / nebulisers
- ABx if signs of infection
141
treatment of COPD exacerbation in hospital? (5)
- nebulised salbutamol + ipratropium (bronchodilators)
- steroids (either hydrocortisone or pred)
- O2 via venturi mask
- ABx if signs of infection
- physio to clear sputum
142
management of COPD exacerbation not responding to first line treatment? (4)
- IV aminophylline
- NIV
- intubation and ventilation
- doxapram (resp stimulant)
143
what are the types of non-invasive ventilation (NIV)?
- BiPAP
- CPAP
144
what does BiPAP stand for? when is it indicated?
- bilevel positive airway pressure
- type 2 resp failure
- patient must have resp acidosis despite medication
145
contraindications for BiPAP?
- untreated pneumothorax
- any other serious pathology affecting face / airway / GI tract
146
imaging done before BiPAP? why?
- CXR
- to rule out pneumothorax
147
what does CPAP stand for?
continuous positive airway pressure
148
indications for CPAP?
- obstructive sleep apnoea
- congestive cardiac failure
- acute pulmonary oedema
149
describe interstitial lung disease (ILD)
- an umbrella term
- conditions which affect lung parenchyma to cause inflammation
- results in fibrosis
150
diagnostic investigation for ILD? findings?
- high-res CT (HRCT)
- ground glass appearance
151
prognosis in ILD?
- poor
- the fibrosis is irreversible
152
management of ILD? hint (7): supportive
remove / treat underlying cause
SUPPORTIVE
* O2 at home if hypoxic at rest
* Stop smoking
* physio, pulmonary rehab
* advanced care planning / palliative where needed
VAX = pneumococcal and flu jab
SURGERY lung transplant (rare)
153
what is idiopathic pulmonary fibrosis?
- pulmonary fibrosis without a clear cause
- type of interstitial lung disease
154
typical demographic for idiopathic pulmonary fibrosis?
those aged \>50 years old
155
presentation of idiopathic pulmonary fibrosis?
- insidious onset over \>3 months
- SOB
- dry cough
156
signs O/E in idiopathic pulmonary fibrosis?
- bibasal fine inspiratory crackles
- finger clubbing
157
prognosis in idiopathic pulmonary fibrosis?
- poor
- life expectancy of 2-5 years
158
2 medications which can slow progression of idiopathic pulmonary fibrosis?
- pirfenidone (*antifibrotic + anti-inflammatory)*
- nintedanib *(nintedanib - mAb targeting tyrosine kinase)*
159
drugs which can cause pulmonary fibrosis? 4
- amiodarone
- cyclophosphamide
- methotrexate
- nitrofurantoin
160
which conditions can pulmonary fibrosis be secondary to? (5)
- A1AT
- RA
- SLE
- systemic sclerosis
- sarcoidosis
161
what is the other name for extrinsic allergic alveolitis (EAA)?
hypersensitivity pneumonitis
162
describe EAA?
- type III (delayed) hypersensitivity reaction to environmental antigen
- causes inflammation in parenchyma
163
investigation in EAA? (\*1st line investigation + findings)
* - bronchoalveolar lavage
* raised lymphocytes
* ^ eosinophils
* raised mast cells
164
what does bronchoalveolar lavage involve? when is it used?
- washing out the airways during bronchoscopy and collecting the fluid to test
- used in EAA diagnosis
165
4 specific causes of EAA? what is each one called?
- bird droppings (bird-fanciers lung)
- mould spores in hay (farmers lung)
- mushroom antigens (mushroom workers lung)
- mould spores in barley (malt workers lung)
166
what is asbestosis?
**lung fibrosis** caused by inhaling asbestos
167
conditions caused by asbestos inhalation? 4
- lung fibrosis
- pleural thickening and plaques
- adenocarcinoma
- mesothelioma
168
what is a pleural effusion?
collection of fluid in the pleural space
169
what is an exudative pleural effusion?
there is \>3g/L (high) protein in the fluid
170
causes of exudative pleural effusion? (hint: inflammation)
think inflammation:
- lung cancer
- pneumonia
- RA
- TB
171
what is a transudative pleural effusion?
there is \<3g/L (low) protein in the fluid
172
causes of transudative pleural effusion? (hint: fluid shift)
think of things causing fluid to move:
- CCF
- hypoalbuminaemia (nephrotic syndrome)
- hypothyroidism
- Meig's syndrome
173
what is Meig's syndrome?
R-sided pleural effusion with ovarian malignancy
174
presentation (including O/E) of pleural effusion? (4)
*(key symp, resp exam, trachea position)*
- SOB
- dull to percuss over the area
- reduced breath sounds
- tracheal deviation away from effusion if massive
175
findings on CXR in pleural effusion? (4)
- blunting of costophrenic angle
- fluid in lung fissures
- meniscus in larger effusions
- tracheal + mediastinal deviation if massive
176
what can be tested for in a sample of pleural effusion fluid? (6)
- protein count
- cell count
- pH
- glucose
- LDH
- microbiology testing
177
management of pleural effusion?
- conservative if small
- pleural aspiration
- chest drain
178
what is empyema? when should you suspect it?
- an infected pleural effusion
- when someone comes in with pneumonia-like signs but they are not responding to ABx
179
findings on aspiration of empyema? (4)
- pus
- acidic pH (\<7.2)
- low glucose
- high LDH
180
management of empyema?
- chest drain
- ABx
181
describe pneumothorax
air in the pleural space separating the lung from the chest wall
182
causes of pneumothorax?
- spontaneous
- trauma
- iatrogenic
- lung pathology
183
what are the iatrogenic causes of pneumothorax? 3
- lung biopsy
- mechanical ventilation
- central line insertion
184
which lung pathologies could cause a pneumothorax?
- infection
- asthma
- COPD
185
investigations in pneumothorax?
- erect CXR
- CT thorax ( for smaller ones not seen on CXR)
186
management of pneumothorax where there is no SOB and there is a \<2cm rim of air on CXR?
- nothing
- will resolve spontaneously
- follow up in a month
187
management of pneumothorax where there is SOB +/- rim of air is \>2cm on CXR?
- needle aspiration and reassess
- if aspiration fails twice, chest drain
- talc pleurodesis if recurrent
188
what is a tension pneumothorax? what causes it?
- one-way valve forms in chest wall, which lets air in but not out
- emergency
- caused by trauma
189
signs (including O/E) of tension pneumothorax? (5)
- tracheal deviation away from side of pneumothorax
- reduced air entry on affected side
- increased resonance on percussion of affected side
- tachycardia
- **hypotension**
190
main complication of tension pneumothorax?
cardiorespiratory arrest
191
management of tension pneumothorax?
- insert a large bore cannula into the 2nd IC space in the midclavicular line
- once some pressure is relieved, insert chest drain
- do NOT wait for investigations
192
describe the borders of the "triangle of safety". why is this space important?
- 5th IC space
- mid-axillary line
- anterior axillary line
- this is where chest drains are inserted
193
what is a pulmonary embolism (PE)?
- a blood clot in the pulmonary arteries
- usually secondary to a DVT which has travelled
194
risk factors for developing VTE? (8)
- recent surgery
- long haul flights
- pregnancy
- oestrogen therapy
- malignancy (hypercoagulable state!)
- polycythaemia
- SLE
- thrombophilia
195
what prophylaxis is offered to patients at risk of VTE?
- LMWH (enoxaparin)
- compression stockings
196
main contraindication for compression stockings?
peripheral arterial disease
197
contraindications for LMWH?
- active bleeding
- anyone on warfarin / NOAC (anticoag)
198
presentation of PE? (8)
- cough +/- blood
- pleuritic chest pain
- hypoxia
- tachycardia
- tachypnoea
- low grade fever
- haemodynamic instability
- hypotension
199
what can be calculated if you suspect a PE?
wells score
200
which factors are taken into account for wells score? (5)
- HR \>100
- immobilisation
- prev DVT / PE
- haemoptysis
- malignancy
201
how is the wells score outcome interpreted in suspected PE?
- PE likely: CT pulmonary angiogram (CTPA)
- PE unlikely: D-dimer
202
what is the next investigation in suspected PE if D-dimer is positive? hint: different for renal impairment
- CTPA
- if renal impairment: VQ scan
203
diagnostic investigations for PE?
- CTPA
- VQ scan (ventilation-perfusion)
204
what does the ABG pH show in PE? why?
- resp alkalosis (high pH)
- tachypnoea means they blow off their CO2
- low CO2 makes blood alkalotic
205
2 main causes of resp alkalosis?
- PE
- hyperventilation syndrome
206
supportive management in PE?
- hosp admission
- O2 as required
- analgesia as required
- monitor for deterioration
207
medical management of PE?
- IV fluids / oxygen if needed
- start off with rivaroxaban + LMWH (dalteparin)
- then long-term anticoag (warfarin or NOAC) for 3 months
- carry on for longer if unsure of cause / malignancy present
208
is D-dimer sensitive / specific to VTE?
- sensitive but not specific
- if low, unlikely to be VTE but if raised can be something else
209
causes of a raised D-dimer?
- VTE
- pneumonia
- malignancy
- HF
- surgery
- pregnancy
210
management of a massive PE with haemodynamic instability? which agents can be used for this?
- IV or catheter-directed thrombolysis
- streptokinase
- alteplase
- tenecteplase
211
causes of pulmonary hypertension?
- primary (caused by nothing else)
- connective tissue disease (SLE)
- LSHF
- chronic lung disease (COPD)
- lung vascular disease (PE)
- sarcoidosis
- glycogen storage disorders
- haematological causes
212
presentation of pulmonary HTN?
- SOB (main one)
- syncope
- tachycardia
- raised JVP
- hepatomegaly
- peripheral oedema
213
investigations for pulmonary HTN?
- ECG
- CXR
- NT-proBNR (cor pulmonale)
- echo (to check pulmonary artery pressure)
214
ECG changes in pulmonary HTN?
- RV hypertrophy
- R axis deviation
- RBBB
215
CXR changes seen in pulmonary HTN?
- dilated pulmonary arteries
- RV hypertrophy
216
prognosis in pulmonary HTN?
- poor
- 30% life expectancy at 5 years post-diagnosis
217
treatment for primary pulmonary HTN?
- IV prostanoids (epoprostenol)
- endothelial receptor antagonists (macitentan)
- phosphodiesterase-5 inhibitors (sildenafil)
218
complications of pulmonary HTN?
- cor pulmonale
- resp failure
- arrhythmias
219
management of secondary pulmonary HTN?
manage the underlying cause
220
what is sacrdoidosis?
- granulomatous inflammatory condition
- gives chest signs and extrapulmonary signs
221
what do the granulomas in sarcoidosis contain?
macrophages
222
demographics affected by sarcoidosis?
- 2 spikes in incidence
- young adulthood and 60s
- F\>M
- Black people more affected
223
organs affected by sarcoidosis? (hint: literally everything)
- lungs
- liver
- eyes
- skin
- heart
- kidneys
- CNS and PNS
- bones
224
what can sarcoidosis cause in the lungs?
- mediastinal lymphadenopathy
- pulmonary fibrosis
- pulmonary nodules
225
what can sarcoidosis cause in the liver?
- nodules
- cirrhosis
- cholestasis
226
what can sarcoidosis cause in the eyes?
- uveitis
- conjunctivitis
- optic neuritis
227
what can sarcoidosis cause on the skin?
- erythema nodosum
- lupus pernio
- granulomas
228
systemic signs of sarcoidosis?
- fever
- fatigue
- weight loss
229
what can sarcoidosis cause in the heart?
- bundle branch block
- heart block
- myocardial muscle involvement
230
what can sarcoidosis cause in the kidneys?
- stones (hypercalcaemia)
- nephrocalcinosis
- interstitial nephritis
231
what can sarcoidosis cause in the nervous system? (hint: split into central and peripheral)
central:
- diabetes insipidus (pituitary)
- encephalopathy
peripheral:
- bell's palsy
- mononeuritis multiplex
232
what can sarcoidosis cause in the bones?
- arthralgia
- arthritis
- myopathy
233
what is lofgren's syndrome?
a specific presentation of sarcoidosis
234
presentation of lofgren's syndrome? hint: triad
- erythema nodosum
- bilateral hilar lymphadenopathy
- polyarthralgia (joint pain)
235
differentials for sarcoidosis?
- TB
- lymphoma
- EAA
- HIV
- toxoplasmosis
- histoplasmosis
236
investigations and findings for sarcoidosis?
- blood tests (lots)
- CXR (hilar lymphadenopathy)
- HRCT thorax (HL and pulmonary nodules)
- MRI (CNS changes)
- PET scan (inflammation)
237
findings of blood tests in sarcoidosis?
- raised serum ACE (screening)
- raised Ca
- raised IL-2 receptor
- raised CRP
- raised Ig
238
gold standard investigation to diagnose sarcoidosis?
biopsy and histology
239
what is seen on histology in sarcoidosis?
non-caseating granulomas with epithelioid cells
240
management of asymptomatic / mild sarcoidosis?
- nothing
- resolves spontaneously
241
1st line treatment of symptomatic sarcoidosis? 2nd line?
- PO steroids for 6-24 months
- give bisphosphonates concurrently (stops osteoporosis)
- 2nd line: methotrexate or azathioprine
- lung transplant if severe lung disease
242
prognosis of sarcoidosis?
- good
- 60% resolve spontaneously in 6 months
- in some patients goes on to cause pul fibrosis / HTN
243
what causes obstructive sleep apnoea (OSA)?
collapse of the pharyngeal airway in sleep
244
risk factors for OSA?
- middle age
- male
- obesity
- alcohol
- smoking
245
features of OSA?
- apnoeic episode, noticed by partner
- snoring
- morning headache
- waking up unrefreshed from sleep
- daytime sleepiness
- reduced concentration
- reduced O2 sats in sleep
246
describe an apnoeic episode
- the person stops breathing for a few minutes
- typically unaware of this themselves
247
complications of OSA?
- HTN
- HF
- increased risk of MI and stroke
248
investigations for OSA?
- sleep studies
- done by ENT specialists or sleep clinics
249
management of OSA?
- stop drinking
- stop smoking
- lose weight
- CPAP at night
- surgery (UPPP)
250
ECG changes seen in PE?
- sinus tachycardia
- R-axis deviation
- complete / partial RBBB
- S waves in lead I
- Q waves in lead III
- T wave inversion in lead III
251
what is ARDS? explain the pathophysiology of it
- acute respiratory distress syndrome
- a non-cardiac cause of pulmonary oedema (e.g. alveolar damage)
- gives acute resp failure
252
risk factors for ARDS? hint: most common first and there's a LOT
- sepsis
- major trauma with shock
- hypovolaemic shock
- pneumonia
- gastric aspiration
- smoke inhalation
- burns
- DKA
- pregnancy and eclampsia
253
features of ARDS?
- worsening dyspnoea
- cyanosis
- tachypnoea
- tachycardia
- peripheral vasodilation
254
signs O/E of ARDS?
- cyanosis
- bilateral fine inspiratory crackles
255
management of ARDS?
- ITU admission
- CPAP in early disease
- mechanical ventilation when more severe
- monitor BP with arterial line
- treat underlying cause (e.g. ABx for sepsis)
256
differentials for a "white out" on CXR?
- consolidation
- pleural effusion
- collapse
- pneumonectomy
- tumours
- fluid (pulmonary oedema)
- hernia
257
differentials for a "white out" on CXR where the trachea is central?
- consolidation
- pulmonary oedema
- mesothelioma
258
differentials for a "white out" on CXR where the trachea is PULLED towards it?
- pneumonectomy
- complete lung collapse
- pulmonary hypoplasia
259
differentials for a "white out" on CXR where the trachea is PUSHED away from it?
- pleural effusion
- diaphragmatic hernia
- large thoracic mass
260
poor prognostic factor in CF?
chronic infection with either:
- pseudomonas
- burkholderia
261
indications for corticosteroids in sarcoidosis?
- parenchymal lung disease
- uveitis
- hypercalcaemia
- neurological signs
- cardiac signs
262
what is bronchiectasis?
permanent dilation of bronchi / bronchioles from chronic infection
263
main causative organisms of pts affected by bronchiectasis?
- H. influenzae
- pseudomonas aeruginosa
- streptococcus pneumoniae
- staph aureus
264
causes of bronchiectasis?
- post-infection (TB, HIV, measles, pertussis, pneumonia)
- foreign body / tumour obstructing bronchioles
- CF
- idiopathic
265
presentation of bronchiectasis?
- cough with large amounts of purulent sputum
- haemoptysis
- finger clubbing
- coarse inspiratory crackles
- dyspnoea
- wheeze
266
findings on spirometry in bronchiectasis?
obstructive pattern
267
findings on CXR in bronchiectasis?
- tramlines
- ring shadows
268
features of legionnaire's disease?
- muscle aches
- headache
- dry cough
- high fever
