Respiratory Flashcards
Epigastric pain and vomiting
Chest X-ray reveals bilateral infiltrates and a normal-sized cardiac silhouette
Heavy drinker, high lipase, high RR, low sats
What is feature of this complication the patient has developed?
ARDS - Diffuse alveolar damage with hyaline membrane formation (from acute pancreatitis)
Cardiothoracic ratio in ARDS with no signs of HF
<0.5
Anti-microbial causing high INR
Metronidazole (IV)
What is this asthma patient’s acid-base balance?
Low pH, low O2, high CO2, normal bicarb
Resp acidosis w no metabolic compensation
Conditions for discharge after acute asthma attack?
Stable on salbutamol inhaler for 24h
What type of hypersensitivity is asthma?
Type 1
Next step in asthma after using salbutamol v often
ICS 200mg
First-line asthma treatment if patient reports symptoms 2/3x week/night time waking
SABA + ICS
What position should you take peak flow in?
Sitting/standing
3rd line asthma treatment after SABA and ICS
LABA
Features of life-threatening asthma
O2 sats <90%
PEFR <33%
Silent chest, bradycardia, hypotension, exhaustion
Who gets pneumococcal vaccine?
Chronic heart failure
>65 y/o
What vaccines should patient with RA on methotrexate, folic acid, hydroxychloroquine receive?
Influenza and pneumococcal
What type of pneumonia is common in caves and Mid West US that causes bilateral hilar lymphadenopathy?
Histoplasma capsulatum
What is the treatment for someone w 3/more infective exacerbations per year already on optimal meds?
Long term prophylactic antibios
Management in bronchiectasis patient w high fever and raised resp rate
IV antibiotics
Cause of bronchiectasis in patient w dull on exp and resonant on insp and left lung base
Primary ciliary dyskinesia (normal percussion changes are right sided)
CF can cause issues w what organs?
All of them!!!!!!
O2 treatment in COPD exacerbation with CO2 retention
4/L min Venturi mask - target sats 88-92%
Why would you not use a nasal cannula in someone w type 2 resp failure?
It can’t supply controlled level of O2 (unlike Venturi mask)
Use of 15L/min non rebreathe?
Critically ill/severely hypoxic patients (<75-80% in COPD patient)
Right axis deviation/right vent heave/hypertrophy on ECG
Neg deflection lead 1
Pos deflection lead 2
What heart condition can result from long-term hypoxia e.g. COPD?
Right vent hypertrophy
COPD second-line treatment
LABA (+ICS if patient has asthmatic features or suggests steroid responsiveness)
Common ECG changes in COPD
RA deviation Prominent P waves in inf leads Inv P waves in high lateral leads (I, aVL) Low voltage QRS Delayed R/S transmission in V1-6 P pulmonale RV strain pattern RBBB Mutlifocal atrial tachycardia
Next step in COPD CO2 retainer acute exac
28% O2 Venturi mask - to prevent over-oxygenating
COPD w CO2 retention in ABGs
Incr HCO3
Base excess
Signs of CO2 narcosis
Reduced work of breathing
Looking calmer
Criteria for LTOT
PaO2 <7.3 or 7.3-8 PLUS periph oedema, pulm HT, nocturnal hypoxaemia, secondary polycythaemia
Second line treatment for COPD patients w asthma or steroid resp w persistent exac
LABA + ICS (budesonide + formeterol)
What test can confirm COPD diagnosis?
Spirometry
Chloride level indicating CF in sweat test?
> 60mmol/L
Drug to prescribe if patient has excess airway secretions that they are struggling to clear
Hyoscine butlbromide SC (anticholinergic agent)
Cause of massive haemoptysis, previous aspiration pneumo, foul sputum, fever
CXR right lower lobe consolidation and central cavitation w air-fluid level
Lung abscess
Features of aspergilloma
Secondary to chronic lung disease
Target-shaped lesion (upper lobe)
What are the features of Horner’s syndrome?
Miosis
Partial ptosis
Anhidrosis
(Caused by pancoast tumour in left apex invading symp chain)
Key features of SCLC
Perihilar and central lesions
Paraneoplastic syndrome e.g. Cushing’s excreting ACTH
Horner’s syndrome
Horner’s syndrome
Horner’s syndrome
Signs of compression of sympathetic chain
Partial ptosis and miosis of right eye
What lung cancer causes hypercalcaemia?
Squamous
What antibodies are commonly present in SCLC w paraneoplastic syndrome?
Voltage-gated Ca channel antibodies (VGCC)
Symptoms of Cushing’s
Hyperpigmentation
Hypertension
Impaired glucose tolerance
Perhaps hypokalaemia
Most common occupational exposure pleual tumour
Asbestos
Features of mesothelioma on CXR
Pleural thckening
Some distinct plaques
Where would a cancer with monophonic wheeze be?
Central (squamous cell)
Common symptoms w lung adenocarcinoma
Clubbing
Hypertrophic pulm osteoarthropathy (painful wrist swelling)
Drug for reduction of swelling in SVCO caused by lung cancer
Dexamethasone
First line treatment of hypercalcaemia
IV fluids and then IV phosphates as they take 2-4 days to respond
Carcinoid syndrome features
Facial flushing
Diarrhoea
Asthma
Lung nodule (demarcated opacification)
Investigation for carcinoid syndrome
Urinary 5-HIAA excretion (ID serotonin metabolite)
Which lung cancer causes hyponatraemia?
Small cell (SIADH)
How can stroke influence lung abscess?
Risk of aspiration due to impaired swallow causing infection in lung
Most common microbe in abscesses
Anaerobic bacteria esp w impaired swallow
Which sex is more affected by OSA?
Males
What scoring is used for OSA?
Epworth Sleepiness Scale
What test may be used before polysomnography in OSA?
Overnight pulse oximetry
What is Meig’s syndrome?
Ovarian tumour + pleural effusion + ascites
What change in pulm cap pressure can cause pleural effusion?
High pressure
Leads to transudation of fluid into pleural cavity
Causes of transudate vs exudate
Transudate (incr intravasc pressure/reduced osmotic pressure)
Exudate (inflam, infection, neoplasm)
Exudative pleural effusion w fatigue/MSK pain/rash/erythemous rash of nose/oral ulcers
Systemic lupus erythematosus
Incr ANA
Low complement
What type of effusion can hypothyroidism cause?
Transudative
What type of effusion can lung adenocarcinoma cause?
Exudative
Light’s criteria
Exudative effusion if:
The ratio of pleural fluid to serum protein is greater than 0.5
The ratio of pleural fluid to serum LDH is greater than 0.6
The pleural fluid LDH value is greater than two-thirds of the upper limit of the normal serum value
Glucose levels in patient w pleural effusion secondary to RA
Low glucose (<3.3mmol/L)
First line investigation of pleural fluid in empyema
pH analysis
<7.2 suggests empyema
Fevers following pneumonia
Empyema
Positive hepato-jugular reflex indicates?
Congestive heart failure
First line HF treatment w pleural effusion
Furosemide (treat the cause!!!!!)
When is pleural fluid aspirate not required in PEff?
When there is clear evidence of congestive HF
Best diagnostic test for HF
Transthoracic echocardiogram
Pneumonia causing low sodium
Legionella
HAP due to pseudomonas treatment?
IV Ciprofloxacin
Treatment of severe pneumonia from staph areus
IV co-amoxiclav + clarithromycin + flucloxacillin
Stain to use in pneumocystis diagnosis
Silver stain
Signs of pneumonia on auscultation
Incr tactile vocal fremitus
Dull precussion note
Gm+ cocci in clusters pneumonia?
Staphylococcus aureus pneumonia
First line antibio for staph pneumonia
Flucloxacillin
Antibio for gm- pneumonia e.g. strep
Amoxicillin
First line investigation for legionella
Urine antigen enzyme immunoassay test
Hotel air conditioning pneumonia?
Legionella
Confusion score on CURB-65
<8/10
Antibio if penicillin allergy
Clarithromycin
CURB-65 score 2 means?
Immediate risk of death
Admit to hosp for treatment and close observation
Microbe causing flu-like illness, erythema (target-shaped), and anaemia symptoms in pneumonia
Mycoplasma pneumonia
Lymphopenia plus hyponatraemia in pneumonia?
Legionella
CAP with rusty sputum, fast onset symptoms, high fever
Strep pneumonia
Treatment of empyema
Chest drain under radiological guidance
Pneumonia assoc w AI haemolytic anaemia?
Mycoplasma pneumonia
What type of pneumothorax if patient has asthma?
Secondary pneumothorax
Marfan’s increases risk of which aortic pathology?
Acute aortic dissection
What recreational drug can incr risk of pneumothorax?
Cannabis
Pneumothroax management if there is mediastinal shift or haemodynamic compromise
Needle aspiration
Immediate management of tension pneumo with noisy breathing and GCS 8
Airway manoeuvres (intubate if this fails)
V/Q ratio in pneumothorax?
Lowered ratio
Standard length of PE treatment
3 months
Length of treatment in provoked/unprovoked PE
3 months provoked if cause is treated
>3 months if unprovoked
Investigation to confirm(!!!!) PE
CT pulm angio (CTPA)
Prescription of anticoag for PE post-op
LMWH as it is shorter acting in case there’s pos-op bleeding
Absolute contraindication to thrombolysis
Past haemorrhagic stroke AT ANY TIME
Anti-phospholipid syndrome incr risk of…
Venous thromboembolism/PE and prg-related morbidity
Treatment of symptomatic suspected PE
DOAC (direct oral anticoag) instead of waiting until investigation results
IPF spirometry results
Restrictive
Treatment of UTIs that can cause pulm fibrosis
Nitrofuratoin
Changes in FVC and FEV1 in PF
Both decr
Gradual symp onset, clubbing, fine insp crackles
IPF
RA causes fibrosis in what area of lungs?
Lower lobes
Lower lobe fibrosis caused by…
RA IPF Asbestosis SLE Scleroderma Drugs e.g. methotrexate and bleomycin
TLCO in IPF
Reduced
Disease-modifying drug for IPF (long-term management)
Pirfenidone and nintedinab
Cor pulmonale features
Pulm HT symptoms plus RH failure symptoms
Investigation for pulm HT due to chronic thromboembolism (recurrent PEs)
Right heart catheterisation
Auscultation signs in cor pulmonale
Split S2 w loud pulm component
Bosentan side effects
Deranged LFTs
What ABG result would panic attack cause?
Resp alkalosis w good O2 sats
Treatment of type 2 resp failure w low pH and rising PaCO2
Non-invasive vent (NIV)
Raised serum ACE indicates
Sarcoidosis
Which ion is incr in sarcoidosis?
Calcium (hypercalcaemia)
Treatment of symptomatic sarcoidosis
Oral prednisolone
Bilateral parotid gland swelling?
Sarcoidosis
Diagnostic test for sarcoidosis
Bronchoscopy w transbronchial lung biopsy
Drug which can cause pulm fibrosis and restrictive spirometry
Methotrexate
IgE mediated activ of mast cells type hypersensitivity
Type 1 hypersensitivity (asthma)
Red urine side effect of which urine treatment?
Rifampicin (R for red)
Best investigation for TB diag
Early morning sputum samples
Best investigation for TB diag
Early morning sputum samples
Peripheral neuropathy side effect of which TB drug?
Isoniazid (nia=neuro)
Stain used in TB testing
Sputum acid-fast bacilli smear (AFB)
Visual disturbance side effect of which TB drug?
Ethambutal (E for eyes)
TB on CXR
Patchy opacification across both upper zones
Treatment of theophylline toxicity
Activated charcoal
The Haldane Effect
Oxygenated Hb releases CO2 more readily
Lower V/Q in bases compared to apices means that base PO2 and PCO2 are..
Lower PO2
Higher PCO2
Increase in ventilation rate causes alveolar ventilation rate to…
Decrease by same proportion
Hypercalcaemia has what effect on muscle and nervous system?
Depresses both
PTH secreting tumour has what effect?
Incr abs of Ca and phosphate
Limb weakness improving with movement assoc with lung cancer?
Lambert-Eaton syndrome
- small cell cancer
- voltage-gated calcium channel (VGCC) antibodies
Characteristic finding of mesothelioma on CXR
Plaque formation and pleural thickening
CXR findings in asthma
Nothing specific
Hyperinflation
COPD/asthma patient with acute exacerbation and chest infection with penicillin allergic?
Theophylline and macrolide antibiotics can interact and cause arrhythmias
- monitor theophylline levels v closely
Bronchiectasis would show which spirometry pattern
Obstructive pattern (decr ratio)
Low FEV1 and low FVC but normal FEV1/FVC ratio is suggestive of?
Restrictive lung disease
IRA causes of pulmonary fibrosis
Idiopathic
Rheumatoid arthritis
Amiodarone/asbestosis
First line investigation of cor pulmonale
Echocardiogram
How would you manage CA pneumonia with a penicillin allergy?
IV levofloxacin 500mg bd
Which lung cancer of the mid-zone is most common in non-smokers?
Adenocarcinoma
Cushing’s syndrome is caused by which lung cancer?
Small cell lung cancer
Diagnosis of asthma
Peak flow: variability >20%
Fractional exhaled nitric oxide (FeNO): >40 ppb adults or >35 ppb children
Spirometry: FEV1/FVC <70% (obstructive spirometry)
Gold standard diagnostic test for PCP
Bronchoalveolar lavage
