Respiratory Flashcards
LENT score
For malignant pleural effusion (prognostic scoring system)
- Pleural fluid LDH, ECOG, neutrophil-tolymphocyte ratio, tumor type
Diagnosis of mesothlioma
- Pleural biopsy via thoracoscopy (highest diagnostic yield) -> histology and immunohistochemistry
- Serum mesothelin and fibulin 3: markers (mesothelin more diagnostic, fibulin more prognostic information)
Work up for FEV1/FVC < LLN
VC ≥ LLN: obstruction VC < LLN - TLC ≥ LLN: obstruction - TLC < LLN: mixed defect If obstruction - DLCO ≥ LLN: asthma, Chronic bronchitis - DLCO < LLN: emphysema
Work up for FEV1/FVC ≥ LLN
If VC ≥ LLN: normal -> - DLCO ≥ LLN: normal - DLCO < LLN:: PV disorders If VC < LLN - TLC ≥ LLN: obstruction - TLC < LLN: restriction (if DLCO ≥ LLN -> CW and NM disorders; if DLCO < LLN -> ILD, pneumonitis)
Extrathoracic obstruction
- Vocal cord paralysis
- Vocal cord dysfunction
Oxygen dissociation curve
percentage saturation of Hb (y) at various partial pressure of oxygen (x) Shift L (lower O2 delivery to tissues): lower H+, lower temp, lower 2,3DPG Shift R (higher O2): higher H2, higher temp, higher 2,3DPG
RAPID score
- Clinical risk score for identifying risk for poor outcome with pleural effusion
Renal - urea, Age, Purulence, Infection source, Dietary factors - albumin
Evidence for intrapleural tissue plasminogen activator and Dornase alfa (DNase)
improve fluid drainage and reduce frequency of surgical referral and the duration of hospital stay (MIST 2)
Indications for pleural space drainage
- Large free flowing pleural effusion more than 50% hemithorax OR
- Positive culture OR
- Positive gram stain OR
- pH < 7.2 suggesting presence of pus
ILD resolve with smoking cessation
Distal interstitial pneumonia (DIP)
Respiratory associated bronchiolitis associated ILD
Biomarkers for guarded prognosis from covid 19 pneumonia
- D-dimer, cardiac trop I, serum ferritin, LDH, IL-6 NOT lymphocyte (baseline higher in survivors than non-survivors)
Pulmonary rehab in COPD
Improve - Emotional function - Exertional dyspnea - QoL - Exercise tolerance But NOT lung function
Mechanism of hyperCa in sarcoidosis
Main mechanism
- Increased intestinal Ca absorption induced by high serum calcitriol concentration
- Activated mononuclear cells (esp macrophages) in the lung and LN in sarcoidosis and other granulomatous disease -> produce calcitriol from calcidiol independent of PTH
Other mechanism: PTHrP secreted from granulomatous tissue
Lofgren syndrome
Subtype of acute sarcoidosis (good prognosis, >90% disease resolution within 2 years) Triad of - Erythema nodosum - Bilateral hilar adenopathy - Arthritis
PET scan
3 clinical settings
1) solitary pulmonary nodules - distinguish benign vs malignant (not useful when lesion <1cm)
2) Carcinoma staging
3) surveillance - great sens and spec for detecting recurrence or persistent malignant disease from changes caused by radiation or surgery
Hyperglycaemia can reduce intracellular uptake of radioactive substrate FDG
S/E of LAMA
- Dry mouth (most frequently reported)
Dyspepsia, gastroenteritis, insomnia, irritation affecting nasal and throat passages
Cautious with narrow-angle glaucoma and urinary retention, renal impairment
Prognosis for SCLC, NSCLC and carcinoid
Carcinoid > NSCLC > SCLC
Clinical tool - highest accuracy of predicting patients requiring intensive respiratory and ventilatory support (IRVS)
SMART-COP ≥ 3 - 92% who received IRVS
Index for mortality, hospital readmission from 3 months to 1 year after discharge
in COPD patients
CODEX index (comorbidity, obstruction, dyspnea, previous severe exacerbations)
systemic thrombolysis vs Catheter directed thrombolysis
- No difference in 30 day mortality rate
- No difference in-hospital mortality
- Increase risk of major haemorrhage
Rivaroxaban > dabigatran
If history of dyspepsia
Age adjustment D-dimer
Age X 10 in patients > 50 years
Asthma-COPD overlap syndrome
Airflow limitation is not fully reversible, but often with current or historical variability
Endobronchial valve placement
Procedures: with bronchoscopy, valve prevent air inflow during insp and allow air and mucus to exit during expiration
Beneficial for severe heterogeneous emphysema
- Improve lung function, dyspnea, exercise tolerance and QoL, safety profile
AVOID in severe bronchiectasis, fibrosis, severe paraseptal emphysema -> poor prognosis
Long term O2 therapy for COPD
Indication: severe resting hypoxaemia - PaO2 ≤ 55mmHg or SpO2 ≤ 88%
at least 15 hours to proven beneficial
HFNP vs NIV for acute hypoxemic respiratory failure
- Increase patient comfort
- Modest reduction in intubation
- Modest reduction in hospital acquired pneumonia
- Large reduction in all cause mortality
- NOT reduced length of ICU stay
Triple therapy for COPD
For patients already using LAMA/LABA dual therapy and have ongoing symptoms and risk for exacerbation
Those with ≥ 2 % (or 150 absolute) eosinophils on blood do better with addition of ICS
ICS withdrawal and ICS continuation in COPD
- Both decrease in absolute FEV1 (greater in withdrawal group)
Possible reduce rates of pneumonia and minor infections e.g. oropharyngeal candidiasis
Management of COPD that improves survival
- Smoking cessation
- Long term O2 therapy
- Lung transplant
- Lung volume reduction therapy
NOT ICS and LABA
Ix of Kartagener syndrome
- Molecular testing for mutations in DNAI1 and DNAH5 (38% of primary ciliary dyskinesia)
- Bronchoscopy: mucosal inflammation and mucopurulent secretions
- Nasal biopsy (Brush or curettage)
- Digital high speed video imaging (DHSV) of ciliary beat pattern
Kartagener syndrome (subunit of primary ciliary dyskinesia)
Autosomal recessive disorder with genetic heterogeneity
Caused by ciliary immotility/ dysmotlity due to ultrastructural abnormalities of resp cilia and flagella of spermatozoa and fallopian tube
Clinical: situs invertus, resp distress of various severity -> chronic sinusitis and bronchiectasis. Flagella defects of spermatozoa and fallopian tube -> infertility/subfertility
How to measure respiratory muscle weakness in motor neurone disease?
Measure maximal inspiratory pressure (MIP), maximal sniff nasal inspiratory pressure (SNIP) and maximal expiratory pressures (MEP)
- MIP and SNIP reflect the strength of the diaphragm and other inspiratory muscles (if record low MIP -> confirm with SNIP)
- MEP reflects the strength of abdominal muscle and other expiratory muscle
Evidence of mandibular splint advancement
Suitable for mild to moderate disease or 2nd line who cannot tolerate CPAP
Significant improvement in AHI and other indices a/w OSAS including snoring volume
Severity of OSA
Mild: AHI 5-15
Moderate: AHI 15-30
Severe: ≥ 30
How to calculate pulmonary ventilation?
Ventilation = RR X TV
Riociguat - useful in which group of PHTN
Guanylate cyclase stimulators
Dual mode of action: directly stimulate soluble guanylate cyclase independently of NO, increase sensitivity of soluble guanylate cyclase to NO -> increase level of cyclic guanosine monophosphate -> vasorelaxation and antiproliferative and antifibrotic effects
In group IV: it improve exercise capacity and pulmonary vascular resistance in CTEPH (CHEST-1 trial)
Selexipag - benefits and s/e
Use: pulmonary arterial hypertension
Oral selective IP prostacyclin receptor agonist
Reduce risk of hospitalisation and delay disease progression (Griphon study NEJM 2015)
Most common s/e: headache
Boyle’s law and the importance in diving
Behavior of gases under varying amount of atmospheric pressure. If diver holds his breath at 100 feet, continues holding while rising to 10 feet then the gas in his lungs increase 4 times -> if forget to exhale on way up, lung explode
