Respiratory Flashcards
What are some signs of hypercapnia?
- confusion
- reduced consciousness
- asterixis (flapping tremor)
- bounding pulse
What are your differentials for type 2 respiratory failure?
- increased airway resistance (asthma, COPD)
- reduced breathing effort (drug effects, brainstem lesion)
- decreased area for gas exchange (chronic bronchitis)
- neuromuscular problems - Guillain-Barre Syndrome, MND
- deformity (ankylosing spondylitits, flail chest)
What are some causes of RESPIRATORY ALKALOSIS?
Increased ventilation
- anxiety
- pain
- hypoxia
- PE
- pneumothorax
- iatrogenic *excess mechanical ventilation)
A patient presents to A&E with a tight feeling in the chest, tingling around their fingers and mouth and shortness of breath. What is the most likely diagnosis?
Anxiety
Peri-oral tingling
How does hyperventilation lead to perioral and peripheral paresthesia?
- increased respiration - respiratory akalosis - increased alkaline blood plasma - decrease in free ionised calcium - hypocalcaemia
- this results in the described symptoms
How does sepsis result i metabolic acidosis?
Fever, hypotension and reduced end-organ perfusion can cause tissue hypoxia resulting in anaerobic respiration, increased lactic acid and therefore acidosis.
What do you give for HAP?
Piperacillin with tazobactam (if more than 5 days into admission)
What antibiotic do you give in an uncomplicated CAP?
Amoxicillin
Doxy if penicillin allergic
What is the most common cause of pneumonia in an alcoholic? In a non-alcoholic?
Klebsiella
Strep pneumonia
What ABG would you expect to see in a panic attack?
Hyperventilation - so low CO2, lower but normal O2, no metabolic changes
What kind of drug is bupropion and what is it’s use?
Noradrenaline and dopamine reuptake inhibitor
Nicotine antagonist
Used in smoking cessation
What medications can be offered in smoking cessation?
Varenicline
Bupropion
NRT (only one can use in pregnancy)
What are common causes of respiratory alkalosis?
Salicylate poisoning Pregnancy Encephalitis PE Anxiety leading to hyperventilation Altitude
What effects can small cell lung cancers have on the body?
Paraneoplastic syndromes - it’s a neuroendocrine tumour
Cushing’s syndrome, hyponatraemia
Lambert Eaton syndrome (autoimmune myasthenic-like symptoms)
What can be used in the management of alpha-1-antitrypsin disease?
Stop smoking
Bronchodilators, physio
Surgery: volume reduction surgery
What is first line treatment for sleep apnoea?
CPAP
weight loss, reduce alcohol intake, sleep on your side
What are common symptoms in a patient presenting with sleep apnoea?
Daytime somnolence
Hypertension
Waking in the night struggling to breath
What are risk factors for sleep apnoea?
Marfan’s
Large tonsils
Obesity
Give some common causes of haemoptysis.
Lung cancer (smoking hx, malignancy sx)
Pulmonary oedema (dyspnoea, bibasal crackles, s3)
TB (night sweats, anorexia, weight loss)
PE (pleuritic chest pain, tachycardia, tachypnoea)
Bronchiectasis (cough history, sputum production)
Mitral stenosis (dyspnoea, AF, malar flush, mid-diastolic murmur)
Aspergilloma (past TB, severe, CXR - round opacity)
Granulomatosis with polyangiitis (URTI, LRTI, saddle-shaped nose deformity, glomerulonephritis)
Goodpasture’s syndrome (haemoptysis, systemically unwell, glomerulonephritis)
What changes need to be made to asthma management during pregnancy?
Continue as normal for good asthma control
What is your management for sarcoidosis?
Asymptomatic - no treatment
NSAIDs and bed rest
Steroids pred 40mg 4-6 weeks
Severe cases IV methylpred or immunosupressants (cyclosporine, methotrexate, cyclophosphamide)
What is the most common organism causing infective exacerbations of COPD?
H. influenza
What drugs have associations with respiratory symptoms?
Ramipril
Aspirin/NSAIDs
Beta blockers
Clopidogrel/ticagrelor
How do you calculate pack years?
1 pack is 20 cigarettes
A 30 years pack history is 20 cigarettes a day for 30 years
What heart sound might be heard in pulmonary hypertension?
Loud P2
In what diseases does clubbing occur?
ILD Asbestosis Fibrosis Lung cancer Bronchiectasis CF
What could crackles on lung examination indicate?
Fine - pneumonia, bronchiectasis, CF, fibrosis
Coarse (Creps) - bronchiectasis, pleural effusion
What does a wheeze on respiratory examination indicate?
COPD or asthma
What is a good method to look at x-rays?
DETAILS - patient, time, date RIPE - rotation, inspiration, penetration, exposure Airway Breathing Circulation Diaphragm Everything (bone) Foreign bodies
What are you indications for CPAP?
Sleep apnoea
Hypoxia
HF + Pulmonary oedema - drives the fluid out
What is your only indication for use of BiPAP?
Acidotic patients
Hypercapnoea
(T2RF)
Define the two different types of respiratory failure
Type 1 Respiratory Failure - Low PaO2, normal PaCO2
Type 2 Respiratory Failure - Low PaO2, low PaCO2
PaO2 <8.0kPa is respiratory failure
Give some causes of type 1 respiratory failure
Airflow obstruction - COPD, asthma
Failure to ventilate the alveoli - emphysema
Diffusion limitations - emphysema, ILD, sarcoidosis
V/Q mismatch - pneumonia, COPD
What is the pattern seen in obstructive lung diseases?
FEV is lower than FVC
FEV1/FVC <80%
What is the pattern seen in restrictive lung disease?
FVC is proportionally lower than FEV1 so FEV1/FVC >80%
What are the two main pathologies behind COPD?
Emphysema
Chronic bronchitis
What are risk factors in COPD development?
Smoking
Infection
Occupation (mining)
Alpha-1-antitrypsin disease
What signs might you see in a patient with COPD?
Barrel-chest (hyperinflation)
Quiet on auscultation
Chest may be resonant
Pursed lip breathing
How do you control an acute exacerbation of COPD?
Controlled O2 (be aware of saturation target) Salbutamol nebulisers (SABA) and ipratropium (LAMA) 5-7 days course of prednisolone
What chronic management is seen in patients with COPD?
Home oxygen
SABA or LABA
Inhaled corticosteroids
Smoking cessation
What are the indications for home oxygen?
Resting PaO2 <7.3kPa
PaO2 <8kPa with peripheral oedema, PH or polycythaemia
Resting hypercapnia
What is the difference between chronic bronchitis and emphysema?
Chronic bronchitis - over secretion of mucous leading to productive cough, intermittent dyspnoea, infection risk and CO2 rention
Emphysema - loss of lung tissue, alveolar enlargement, bullous formation
What are the 4 key pathophysiological features behind asthma?
Bronchial hyperresponsiveness
Bronchoconstriction
Smooth muscle bronchospasms
Hypertrophy of mucosal glands
Give 3 triggers for asthma
Exercise
Cold weather
Night/early morning
Allergens
What investigations can be done in an asthmatic patient?
Peak Expiratory Flow - decreased, diurnal variation
Spirometry
DLCO/Transfer coefficient - may be raised
FBC
CXR
CRP
What is your management in an acute asthma attack?
Oxygen
Salbutamol (inhaler, nebs if possible run through with O2)
Hydrocortisone 100mg IV (max 200mg every 4hrs)
Ipratropium
Theophylline/Aminophylline (1.2-2g IV over 20 minutes) or MgCo4
What is standard escalation of asthma management?
Avoidance of trigger SABA Inhaled corticosteroid LABA LRA (Montelukast, preferred in younger children) Muscarinic agonist
What is bronchiectasis?
Permanent abnormal dilation and thickening of bronchi and bronchioles
Failure of mucociliary clearance, inflammation and obstruction
What is cor pulmonale?
Right sided heart failure secondary to a pulmonary problem
What symptoms and signs might you expect to find in someone with bronchiectasis?
Dyspnoea Haemoptysis Chest pain Sputum, productive cough Finger clubbing, coarse inspiratory crackles
What respiratory diseases are obstructive?
COPD
Asthma
Bronchiectasis
Malignancies
What is the genetic defect in cystic fibrosis?
Long arm of chromosome 7
delta F508 gene
CFTR transport protein
Normally moves chloride ions (and thus water and sodium)
In what ways might CF present?
Malabsorption, poor growth, pancreatic insufficiency, failure to thrive
Meconium ileus - failure to pass meconium
Reccurent respiratory infections
Infertility, atrophy of vas deferens
Steatorrhoea - offensive, greasy stool
What signs would you expect to see in a child with cystic fibrosis?
Hyperinflation of the chest Coarse inspiratory creps, expiratory wheeze Finger clubbing Cyanosis Hepatomegaly
What investigations can you do in cystic fibrosis?
Ion sweat tests (high chloride in sweat)
Serum immunoreactive trypsin (Guthrie)
Faecal elastase
What treatment options can you use to manage cystic fibrosis?
Anti-inflammatories - azithromycin, steroids, PPI
Prophylactic antibiotics - flucloxacillin
Physio
Mucolytics - DNases
Creon
What diet is recommended for cystic fibrosis sufferers?
High calorie, high fat diet
What might you see in CXR of someone with idiopathic pulmonary fibrosis?
Irregular nodular shadows, confluent markings
Ground glass on CT
Describe what pneumoconiosis is and the two types.
Particulate inhalation - coal worker’s
Symptoms include dyspnoea, cough and black sputum
Can be simple (small round opacities on CXR) or progressive (massive fibrotic nodules)
What is Caplan’s syndrome?
The presence of rheumatoid arthritis and pneumoconiosis that manifests and pulmonary nodules
What is a major risk factor in mesotheliomas?
Asbestos
Give 2 different kids of extrinsic allergic alveolitis
Farmer’s Lung - mouldy hay
Bird Fancier’s Lung - bird faeces
Byssinosis - cotton fibres
Bagassosis - sugarcane fibres
What systemic diseases can result in lung fibrosis?
Goodpasture's Syndrome (collagen basement membrane antibodies, affects kidneys) Wegner's Granulomatosis Rheumatoid Arthritis SLE Systemic Sclerosis
What is sarcoidosis?
A multi-system granulomatous disease Multisystemic Respiratory symptoms - dry cough, chest pain, dyspnoea Lymphadenopathy, hepatosplenomegaly Malaise, weight loss, fatigue Skin or eye lesions
What is seen on CXR of someone with sarcoidosis?
hilar lymphadenopathy
Fluffy opacities in the hilar region with clear lung fields
May be fibrosis
What are the different stages of sarcoidosis and how does this affect management?
Stage 0 - normal CXR
Stage 1 - BHL - bilateral hilar lymphadenopathy
Stage 2 - BHL + Infiltrated
Stage 3 - Peripheral pulmonary infiltrates alone
Stage 4 - Progressive pulmonary fibrosis + bulla
Stage 1 + 2 normally resolve spontaneously
Stage 3 + NSAIDs, steroids (prednisolone 40mg for 4-6 weeks)
Severe - IV methylprednislone or immunosuppressants (methotrexate)
What does sleep apnoea increase your risk of?
Stroke
Diabetes
CVD
HTN
How is sleep apnoea managed?
Weight loss
Avoidance of tobacco and alcohol
CPAP via nasal mask
Surgical options - mandibular advancement, tonsillectomy
What is someone with shortness of breath and inspiratory crackles presenting with? The chest x-ray shows alveolar shadowing (bat’s wings) and bilateral effusions.
How do you treat?
Pulmonary oedema
Treat with furosemide
CPAP
Give 5 common differentials for haemoptysis?
Lung cancer TB PE Goodpasture's Syndrome/Vascultitis/Granulomatosis with polyangiitis Severe bronchiectasis or pneumonia
What are the different ways TB can present?
Miliary TB - disseminated small granulomas spread through various organs CNS TB - cause of meningitis Primary TB Extra pulmonary Secondary TB - after a latency period
Give 5 investigations you would do for someone with suspected TB and what you would expect to see on them?
Bloods: CRP/ESR (raised), raised calcium, white cells, high platelets
Mantoux Tuberculin skin test - positive
Microbiological culture - specify TB as this is not routinely done, mycobacterium culture, Lowenstein-Jensen slope
CXR - cavitation, consolidation, patchy nodular shadows in the upper zones
What are the 4 drugs used to treat TB and the length of time each is given?
Rifampicin - 6m
Isoniazid - 6m
Ethambutol - 2m
Pyrazinamide - 2m
What are side effects of each of the TB drugs used?
Rifampicin - red urine, hepatic toxicity
Isoniazid - peripheral neuropathy, N+V
Ethambutol - optic neuritis
Pyrazinamide - hepatotoxicity, arthralgia
What are the 5 features of an acute SEVERE asthma attack?
Inability to complete full sentences
PEFR 33-50% of best or predicted
RR >25/min
HR >110 bpm
Life threatening O2 <92% PEFR <33% Silent chest, cyanosis, poor respiratory effort Hypotension, bradycardia
Give the name of some restrictive lung diseases?
Pulmonary fibrosis Asbestosis Sarcoidosis ARDS Kyphoscoliosis Neuromuscular disorders
What is the order of drugs to be prescribed in asthma in children?
SABA
SABA + ICS
SABA + ICS + LTRA
SABA + ICS + LABA (LTRA continued depending on response)
What would you expect to find in an empyema expiration?
Empyema - turbid effusion - high protein, low pH, low glucose - exudate
pH <7.2
Low glucose
High LDL
Give some causes of exudate effusions?
Infection
Neoplasia
Pancreatisis
PE
> 30g/L protein
What do you expect to see on CXR in heart failure?
Alveolar oedema (bat's wings) Kerley B lines (interstitial oedema) Cardiomegaly Dilated prominent upper lobe vessels Effusion (pleural)
What are the classic 4 features of idiopathic pulmonary fibrosis (cryptogenic fibrosing alveolitis)
Dyspnoea
Bibasal fine end-inspiratory creps
Dry cough
Clubbing
Give 4 signs you might see in a patient presenting with a pneumothorax.
Tracheal tug
Hyperresonance
Decreased breath sounds
Asymmetric chest sounds/expansion
What is your management of a spontaneous pneumothorax?
Occlusive dressing
Give oxygen
Chest drain
Where should chest drains be inserted?
Mid-axillary triangle, 5th intercostal space, lateral edge of pectoralis major, base of azilla and lateral edge of latissimus dorsi
Where is the needle thoracocentesis inserted?
2nd intercostal space, midclavicular line
Where can secondary lung cancers originate from?
Breast Kidney Ovary Uterus Testes Thyroid
What are the different types of lung cancer?
Small cell lung cancer
Non-small cell - adenoma, squamous and large cell
What is the biggest risk factor in the development of lung cancer? What are other risk factors that exist?
SMOKING
Asbestos
Carcinogenic products - coal mining, silica, heavy metals
What are the two different types of small cell lung cancer and how does treatment differ?
Limited - chemotherapy extends prognosis to 1 year
Extensive - chemotherapy extends life expectancy to 8 months
What systemic effects can SCLC have?
Cushings
Addison’s- hyponatraemia
What kind of lung cancer is most common in smokers?
Squamous Cell Lung Cancer
What complications can arise as a result of metastatic spread of lung cancers?
Chest wall - can infringe on nerves
Pancoast’s Tumour - Horner’s Syndrome
Give 5 key symptoms of patients presenting with lung cancer.
Cough, sometimes with haemoptysis
Chest pain
Malaise and weight loss
What might you see on a CXR in suspected lung cancer?
Lung collapse Masses Bony secondaries Pleural effusion Hilar enlargement Consolidation
What side effects might patients on chemotherapy experience?
Alopecia N+v Peripheral neuropathy Fatigue Diarrhoea Infertility
How might a mesothelioma present?
Progressive breathlessness
History of asbestos exposure
Finger clubbing + bilateral end-inspiratory crackles (fibrosis signs)
On CXR: dark streaks and a honeycomb appearance
What are the 5 different types of pulmonary hypertension?
Pulmonary artery HTN Pulmonary HTN due to left heart disease Pulmonary HTN due to lung disease Pulmonary HTN due to blood clots Pulmonary HTN due to blood
What is pulmonary hypertension a complication of?
PE
COPD
Heart problems - HF
What is a normal pulmonary artery pressure?
Pulmonary artery pressure >25mmHg
What are transudative causes of pleural effusion?
Renal failure
Heart failure
What is the most common cause of a exudative pleural effusion?
Pneumonia
What is your step-wise management for chronic COPD?
SABA/SAMA
FEV1>50% predicted - LAMA/LABA
FEV1<50% predicted - LAMA or LABA + Steroid
Continued: triple therapy: LABA, Corticosteroid, LAMA
What is pneumonia?
An infection of the airway leading to inflammation of the distal airways
What are common causes for bacterial pneumonia?
Strep pneumonia
Haemophilus influenza
Klebsiella - neonates, smokers
Atypical - chlamydia, legionnaires disease (Spain, air conditioning)
How long must a patient be in hospital before it’s considered a hospital acquired pneumonia?
48 hours post-admission
Give 4 signs you might see on someone with a pneumonia?
Cough Stony dullness in chest, coarse crackles on auscultation Tachycardia Fever Tachypnoea Low BP Decreased air entry Bronchial breathing, increased vocal resonance
What test is used for legionella?
Urine antigen test
Na is low in legionella
What is your way of determining management of community acquired pneumonia?
CURB 65
Confusion Urea >7 RR >30 BP systolic <90 diastolic <60 65 age
0-1 home management
2 - IV amoxicillin + clarithromycin
3 - Co-amoxiclav
What is your management option of choice for an atypical CAP?
Doxy + macrolide (azithromycin or clarithromycin) 500mg IV/PO
What is a pleural effusion?
The presence of fluid in the pleural space of the lungs
What indicates an empyema on pleural tap?
White colour
Low glucose (bacterial), high protein
pH - low
What are symptoms of pleural effusion?
dull to percussion
reduced or absent breath sounds
respiratory distress
The protein count in a transudate is…?
Low <25g/L
Causes include organ failure, low albumin
A patient present with a sharp stabbing chest pain and shortness of breath has an abnormal ECG and raised D-Dimer. What might you see on ECG and is the raised D-Dimer significant? What test will you follow up with?
PE - S1Q3T3 - deep S wave, q-wave in lead III, inverted t-wave, sinus tachycardia
Raised D-Dimer >500ng/ml - a d-dimer is sensitive but not specific, it can also be raised in malignancy, RA, prengnacy. D-dimer measures the breakdown products of a fibrin clot
V/Q scan if renally impaired but otherwise gold standard is a CTPA
What features exist in a Wells Score?
Clinically expected DVT PE most likely diagnosis Tachycardia >100bpm Immobilisation >3 days or previous surgery in past 4 weeks History of DVT or PE in past Haemoptysis Malignancy
The acute management of a PE is…?
Thombolysis - alteplase in haemodynamically unstale patients
LMWH for 5 days, then warfarin with INR aimed 2-3
What is severe acute respiratory syndrome?
SARS
Severe pulmonary inflammation occurring due to a non-respiratory stimuli
Results in diffuse alveolar capillary wall damage through inflammation
What sign do you see in DVT?
Homan’s sign – pain in the calf on dorsiflexion of the foot
What is your management in a massive PE?
IV Heparin – rapid onset, used to cover
PO Warfarin – warfarin has to reach a therapeutic level before effective, usually 3 days
How does SCLC cause hypercalcaemia?
Bone metastasis
PTH-related peptic secretion
What are some indications for home oxygen?
Severe airflow obstruction FEV1 <30% predicted
SpO2<92%
pO2 <7.3kPa or 7.3-8kPa with secondary polycythaemia, peripheral oedema or pulmonary hypertension
How does CURB 65 affect your antibiotic management?
Low severity – amoxicillin
Moderate to high – amoxicillin and a macroline (co-amox)
Severe- clarithromycin
Describe correct inhaler technique
- Remove cap and shake
- Breathe out gently
- Put mouthpiece in mouth, press canister down and breath in slowly
- Hold breath for 10 seconds
- Wait 30 seconds before repeating
What would you recommend to a patient post-pneumothorax?
Avoid scuba diving
Stop smoking
