Respiratory Flashcards by Daniah Thomas

What are the clinical signs of pulmonary fibrosis?

Clubbing
Central cyanosis
Fine end inspiratory crackles
Signs of associated autoimmune disease
Signs of steroid treatment
Discoloured skin secondary to amiodarone

How well did you know this?

Not at all

Perfectly

How would you investigate a patient with suspected pulmonary fibrosis?

Bloods - ESR, rheumatoid factor, eosinophils
CXR - reticulonodular changes, loss of definition of heart border, small lungs
ABG - type 1 respiratory failure
Lung function tests - FEV1/FVC > 0.8 (restrictive), low total lung capacity, reduced transfer factors
Bronchoalveolar lavage to exclude infection prior to starting treatment
High resolution CT scan
Lung biopsy

How well did you know this?

Not at all

Perfectly

What is the treatment of pulmonary fibrosis?

Immunosuppression if inflammatory
Pirfenidone for usual interstitial pneumonia when FEV1 50-80% predicted
N-acetylcysteine
Single lung transplantation

How well did you know this?

Not at all

Perfectly

What is the prognosis of pulmonary fibrosis?

Variable as depends on aetiology
Increased risk of bronchogenic carcinoma

Highly cellular with ground glass infiltrates and responds to immunosuppression has 80% 5 year survival

Honeycombing with no response to immunosuppression has 80% 5 year mortality

How well did you know this?

Not at all

Perfectly

What are the causes of basal fibrosis?

Usual interstitial pneumonia
Asbestosis
Rheumatoid arthritis
Aspiration

How well did you know this?

Not at all

Perfectly

What are the causes of an apical fibrosis?

Substances: Berylliosis, pneumoconiosis, sillicosis, radiation

Infective/immune: Extrinsic allergic alveolitis, Allergic bronchopulmonary aspergillosis, TB

Sarcoidosis
Ankylosing spondylitis
Psoriasis

How well did you know this?

Not at all

Perfectly

What are the respiratory causes of clubbing?

Interstitial lung disease
Cancer
Mesothelioma 
Bronchiectasis
Cystic fibrosis
Lung abscess
Empyema
Tuberculosis

How well did you know this?

Not at all

Perfectly

What are the clinical signs of bronchiectasis?

Cachexia
Clubbing
Crackles that alter with coughing
High sputum load
Cor pulmonale
Yellow nail syndrome

How well did you know this?

Not at all

Perfectly

How would you investigate a patient with suspected bronchiectasis?

Sputum culture and cytology
CXR - tramlines and ring shadows
High resolution CT - signet ring sign

Immunoglobulins
Aspergillus RAST
Rheumatoid serology
Saccharine ciliary motility 
Genetic screening

How well did you know this?

Not at all

Perfectly

What are the causes of bronchiectasis?

Congenital - Kartagener’s and cystic fibrosis
Childhood infection - measles and TB
Immune over activity - ABPA, inflammatory bowel disease
Immune under activity - hypogammaglobulinaemia, common variable immunodeficiency
Aspiration

How well did you know this?

Not at all

Perfectly

How would you manage a patient with bronchiectasis?

Physiotherapy
Prompt antibiotics for infections
Low dose azithromycin prophylaxis
Bronchodilators and inhaled corticosteroids
Surgery may be used for localised disease
Ensure up to date vaccinations
Long term oxygen therapy in advanced cases
Lung transplantation in cystic fibrosis

How well did you know this?

Not at all

Perfectly

What are the possible complications of bronchiectasis?

Sepsis
Cor pulmonale
Secondary amyloidosis
Massive haemoptysis due to mycotic aneurysm

How well did you know this?

Not at all

Perfectly

What are the most common pathogens in patients with bronchiectasis?

Staphylococcus aureus
Haemophillus influenzae
Pseudomonas
Streptococcus pneumoniae
Klebsiella
Aspergillus

How well did you know this?

Not at all

Perfectly

Explain the pathophysiology of cystic fibrosis

Autosomal recessive condition that occurs in 1 in 2500
Defect in chromosome 7 that encodes the CFTR gene
Respiratory manifestations - nasal polyps, bronchiectasis
GI - malabsorption, meconium ileus, gallstones
Non-erosive arthropathy and infertility

How well did you know this?

Not at all

Perfectly

What are the side effects of tuberculosis medications?

Isoniazid - peripheral neuropathy, hepatitis
Rifampicin - hepatitis, enzyme inducer
Ethambutol - hepatitis, retro-bulbar neuritis
Pyrazinamide - hepatitis

How well did you know this?

Not at all

Perfectly

What are the indications for a single lung transplantation?

COPD, pulmonary fibrosis

How well did you know this?

Not at all

Perfectly

What are the indications for a double lung transplantation?

Cystic fibrosis
Bronchiectasis
Pulmonary hypertension

How well did you know this?

Not at all

Perfectly

What are the clinical signs of COPD?

CO2 retention flap, bounding pulse
Hyper- expanded chest
Resonant percussion with loss of cardiac dullness
Expiratory polyphonic wheeze
Cor pulmonale

How well did you know this?

Not at all

Perfectly

What are the causes of COPD?

Smoking
Industrial dust exposure
Alpha 1 antitrypsin deficiency

How well did you know this?

Not at all

Perfectly

How would you investigate a patient with COPD?

CXR - hyperexpanded, pneumothorax 
ABG - type 2 respiratory failure 
Bloods - look for infection, alpha 1 antitrypsin 
Spirometry - low FEV1, FEV1/FVC <0.7
Reduced gas transfer factor

How well did you know this?

Not at all

Perfectly

What is the treatment of COPD?

Smoking cessation is single most beneficial intervention
Long term oxygen therapy
Pulmonary rehabilitation 
Beta agonists
Tiotropium
Inhaled corticosteroids 
Vaccinations

How well did you know this?

Not at all

Perfectly

What are the inclusion criteria for long term oxygen therapy?

Non smoker
PaO2 <7.3 on air (<8 if cor pulmonale)
PaCO2 that does not rise excessively on oxygen
Improves average survival by 9 months

How well did you know this?

Not at all

Perfectly

What are the differential diagnoses of a wheezy chest?

COPD
Granulomatous polyangitis
Obliterative bronchiolotis
Rheumatoid arthritis

What are the clinical signs of a pleural effusion?

Asymmetrically reduced expansion
Trachea deviated away from effusion
Stony dull percussion
Absent tactile vocal fremitus
Reduced breath sounds

What are the causes of a pleural effusion?

``` Cancer Heart failure Liver failure Renal failure Connective tissue disease Infection ```

How would you differentiate between a transudative and an exudative effusion?

Transudate protein count <30 | Exudate protein count >30

What would you look for in pleural aspiration?

Protein (compare effusion albumin and plasma albumin) LDH Glucose pH

What is an empyema?

Collection of pus within the pleural space Anaerobes, staphylococci and gram negative organisms most commonly Associated with bronchial obstruction (cancer) and recurrent aspiration

How would you classify lung cancer?

Small cell and non-small cell Squamous is the most common type, associated with smoking Small cell more common in non-smokers Small cell usually disseminated at presentation and therefore not amenable to radical surgical treatment

What are the treatment options for non-small cell lung cancer?

Surgery (lobectomy or pneumonectomy) Radiotherapy Chemotherapy

What is the definition of COPD?

Progressive and irreversible (or partially reversible) airflow obstruction due to chronic bronchitis and emphysema

What is the definition of chronic bronchitis?

Cough productive of sputum most days for 3 months during two consecutive years

What is the definition of emphysema?

Abnormal and permanent enlargement of air spaces distal to the terminal bronchioles associated with destruction of their walls without obvious fibrosis

What is the appearance and composition of normal pleural fluid?

``` Clear ultrafiltrate of plasma pH 7.6-7.64 Protein <1.2g/litre WCC <1000 LDH <50% of plasma concentration Glucose similar to plasma concentration ```

What are Light’s criteria for an exudate?

Pleural fluid protein:serum protein > 0.5 Pleural fluid LDH:serum LDH > 0.6 Pleural fluid LDH >2/3 of the upper limit of the normal serum value

What are the causes of high LDH in pleural fluid?

Empyema Malignant effusion Rheumatoid effusion

What are the causes of low glucose in a pleural effusion?

``` Malignancy Empyema Tuberculosis Oesophageal rupture Rheumatoid arthritis SLE ```

What are the indications for pleurodesis?

Recurrent malignant pleural effusion | Recurrent pneumothoraces

What agents can be used for chemical pleurodesis?

``` Talc Doxycycline Bleomycin Zinc sulphate Quinacrine hydrochloride ```

What is the most common type of non small cell lung cancer?

Adenocarcinoma (50%) Squamous cell (30%) Bronchoalveolar Large cell (least common)

What are the endocrine paraneoplastic manifestations of lung cancer?

``` SIADH Cushing’s syndrome Hypercalcaemia Hyperthyroidism Hypoglycaemia ```

What are the neurological paraneoplastic manifestations of lung cancer?

Lambert-Eaton myasthenic syndrome Sensory neuropathy Limbic encephalopathy

What are the musculoskeletal paraneoplastic manifestations of lung cancer?

Polymyositis Dermatomyositis Clubbing Hypertrophic pulmonary osteoarthropathy

What are the cutaneous paraneoplastic manifestations of lung cancer?

Acanthosis nigricans Gynaecomastia Thrombophlebitis Herpes zoster

What are the possible indications for a lobectomy?

``` Bronchiectasis Malignancy Solitary pulmonary nodule Cystic fibrosis Tuberculosis Lung abscess ```

What are the possible indications for a pneumonectomy?

Bronchiectasis Malignancy Tuberculosis

What are the clinical features of old tuberculosis infection?

``` Apical fibrosis Thoracoplasty Pneumonectomy Lobectomy Phrenic nerve crush (left supraclavicular scar) Recurrent pneumothoraces ```

What is the prevalence of tuberculosis?

2 billion individuals worldwide, with 8 million new diagnoses every year

What are the risk factors for developing tuberculosis?

``` Immigrant population Immunocompromised Elderly patients Alcoholics Malnutrition Homeless individuals Occupational exposure ```

What are the acute complications of tuberculosis?

Respiratory: Pneumothorax, Pleural effusion, Empyema, Collapse, ARDS, respiratory failure Tubulointerstitial nephritis Tuberculous meningitis Miliary TB

What are the chronic complications of tuberculosis?

``` Pulmonary fibrosis Bronchiectasis Cor pulmonale Aspergilloma Reactivation ```

How would you investigate a patient with suspected tuberculosis?

Blood tests including HIV serology CXR: upper lobe cavitating lesion, mediastinal lymphadenopathy Sputum: three samples, Ziehl-Neilson staining for acid-alcohol fast bacilli CT scanning Bronchoscopy

How would you treat pulmonary tuberculosis?

Rifampicin, isoniazid, pyrizinamide and ethambutol for 2 months followed by rifampicin and isoniazid for 4 months If multi-drug resistant, treatment with at least three different drugs should be continued until the sputum culture becomes negative, and then at least two different drugs should be continued for 12-24 months

What are the causes of a pneumothorax?

Primary | Secondary (respiratory disease, connective tissue disease, lung cysts, iatrogenic, trauma, )

What are the BTS guidelines on the management of a spontaneous primary pneumothorax?

Minimal symptoms and air rim of <2cm can be allowed home with repeat CXR in 7 days

How would you manage a secondary pneumothorax?

Observation alone (<1cm or isolated apical pneumothorax in an asymptomatic patient) Aspiration if <50, asymptomatic or <2cm Chest drain if >50, symptomatic or >2cm