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Respiratory Flashcards

1
Q

What are the 2 types of lung cancer

A

Non-small cell (squamous cell carcinomas, adenocarcinomas)

Small cell (cause neoplastic syndromes)

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2
Q

What are the risk factors for lung cancer

A

Smoking

Airflow obstruction

Increasing age

Family history

Exposure to carcinogens

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3
Q

What are the signs and symptoms of lung cancer

A

Shortness of breath

Cough

Haemoptysis

Finger clubbing

Recurrent pneumonia

Weight loss

Lymphadenopathy

Superior vena cava obstruction

Horner’s syndrome

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4
Q

What investigations are needed for lung cancer

A

CXR (hilar enlargement, opacity, pleural effusion, collapse)

Routine bloods + clotting

Staging CT with contrast

PET scan

Bronchoscopy with endobronchial ultrasound

Biopsy

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5
Q

What are the treatment options for lung cancer

A

Surgery

Radiotherapy

Chemotherapy

Palliative

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6
Q

What are the extrapulmonary manifestations of lung cancer

A

Recurrent laryngeal nerve palsy

Phrenic nerve palsy

Superior vena cava obstruction

Horner’s syndrome (miosis, partial ptosis, anhidrosis)

SIADH

Cushing’s syndrome

Hypercalcaemia

Limbic encephalitis (a paraneoplastic syndrome, antibodies against the brain, short term memory impairment, hallucinations, confusion…)

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7
Q

What is Lambert-Eaton myasthenic syndrome

A

Antibodies against small cell lung cancer

Antibodies damage voltage-gated calcium channels

Get: weakness (proximal muscles), diplopia, ptosis, slurred speech, dysphagia

Weakness worse with prolonged muscle use

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8
Q

What is mesothelioma

A

Lung malignancy affecting mesothelial cells of pleura

Strongly slinked to asbestos inhalation

Very poor prognosis

Usually need palliative chemo

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9
Q

How might pneumonia present

A

Shortness of breath

Cough with sputum production

Fever

Haemoptysis

Pleuritic chest pain (sharp, worse on inspiration)

Delirium

Sepsis

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10
Q

What are the signs of pneumonia

A

Deranged obs

Sepsis due to pneumonia: tachypnoea, tachycardia, hypoxia, hypotension, fever, confusion

Characteristic chest signs: bronchial breath sounds, focal coarse crackles, dullness to percussion

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11
Q

What is CURB-65

A

Predicts mortality due to pneumonia

Confusion (new)

Urea (>7)

Respiratory rate (>30)
Blood pressure, (<90, <60)

65

In hospital: CRB-65

0 - 1: consider home treatment
2: consider hospital admission
3+: consider intensive care treatment

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12
Q

What are the common organisms that cause pneumonia

A

Strep pneumoniae

Haemophilus influenzae

Moraxella catarrhalis

Pseudomonas aeruginosa

Staphylococcus aureus

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13
Q

What are the organisms that cause atypical pneumonia

A

Legionella pneumonia

Mycoplasma pneumoniae

Chlamydophila pneumoniae

Coxiella burnetii (Q fever)

Chlamydia psittaci

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14
Q

Give an overview of fungal pneumonia

A

Pneumocystis jiroveci

In immunocompromised patients (especially new HIV)

Presentation: dry cough without sputum, shortness of breath, sweating

Treatment: co-trimoxazole (consider prophylaxis in patients with low CD4 count)

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15
Q

What investigations are needed for pneumonia

A

CXR

Routine bloods

ABG (if low sats)

Atypical pneumonia screen (if high CURB score)

Sputum culture, blood cultures (in moderate/severe cases)

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16
Q

What are the differentials for CXR consolidation

A

Pneumonia

TB

Lung collapse

Lobar collapse

Haemorrhage

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17
Q

How long should antibiotics be given for in pneumonia

A

Mild CAP: 5 days oral

Moderate/severe CAP: 7-10 days dual therapy

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18
Q

What is involved in pneumonia followup

A

HIV test

Immunoglobulins

Pneumococcal IgG serotypes

Haemophilus influenzae B IgG

Follow up in clinic in 6 weeks (confirm resolution on CXR)

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19
Q

What are the causes of non-resolving pneumonia

A

CHAOS

Complications (empyema, lung abscess)

Host (immunocompromised)

Antibiotics (inadequate dose, poor oral absorption)

Organism (resistant, not covered by empirical antibiotics)

Secondary diagnosis (PE, cancer)

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20
Q

What are the complications of pneumonia

A

Sepsis

Pleural effusion

Empyema

Lung abscess

Death

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21
Q

What is asthma

A

Chronic inflammatory condition causing episodic exacerbations of bronchoconstriction

Reversible obstruction of airflow in and out of lungs

Due to hypersensitivity

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22
Q

What is the pathophysiology of asthma

A

Airway epithelial damage, shedding of subepithelial fibrosis, basement membrane thickening

Inflammatory reaction: eosinophils, Th2 cells, mast cells, histamine, leukotriene, prostaglandins

Cytokines amplify inflammatory response

Increased mucus secretion, smooth muscle hyperplasia and hypertrophy

Mucus plugging in fatal and severe asthma

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23
Q

What are the typical triggers of asthma

A

Infection

Night time/early morning

Exercise

Animals

Cold/damp

Dust

Strong emotions

Smoking

Pollen

Drugs (aspirin, beta blockers)

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24
Q

How might asthma present

A

Episodic symptoms

Usually worse at night

Dry cough

Wheeze

Shortness of breath

History of atopic conditions

Bilateral widespread ‘polyphonic’ wheeze

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25
What are the NICE guidelines for diagnosis of asthma
Assess and treat patient at a diagnostic hub First line investigations: functional exhaled nitric oxide, spirometry with bronchodilator reversibility Follow up investigations: peak flow variability, direct bronchial challenge test (histamines, methacholine)
26
What is the long term management for asthma
Short acting beta 2 adrenergic receptor agonist (rescue inhaler) Inhaled corticosteroids (preventer inhaler) Long acting beta 2 agonists Long acting muscarinic antagonists Leukotriene receptor antagonists Theophylline
27
What is the NICE asthma stepwise ladder
Add SABA as required for infrequent wheezy episodes Add regular dose inhaled corticosteroid Add oral leukotriene receptor antagonist Add LABA inhaler Consider changing to maintenance and reliever therapy Increase inhaled corticosteroid to moderate dose Consider increasing inhaled corticosteroid to high dose Refer to specialist
28
What are the additional management strategies for asthma
Individual self-management programme Yearly flue jab Yearly asthma review Exercise Smoking cessation
29
What is an acute asthma exacerbation
Rapid deterioration Could be triggered by normal asthma triggers NICE guidelines: refer to specialist after 2 exacerbations in 12 months
30
How might an acute asthma exacerbation present
Progressive worsening shortness of breath Use of accessory muscles Tachypnoea Symmetrical expiratory wheeze Chest sounds 'tight' on auscultation (reduced air entry)
31
What is moderate asthma
PEFR 50-75% predicted
32
What is severe asthma
PEFR 33-55% predicted Respiratory rate > 25 Heart rate > 110 Unable to complete sentences
33
What is life-threatening asthma
PEFR < 33% Sats < 92% Becoming tired No wheeze (silent chest, so tight that no air entry) Haemodynamic instability (shock)
34
What is near fatal asthma
Raised pCO2
35
What is the management for moderate asthma
Nebulised beta 2 agonist (repeat as often as needed) Nebulised ipratropium bromide Steroids (oral prednisolone/IV hydrocortisone for 5 days) Antibiotics
36
What is the management for severe asthma
Oxygen Maintain sate 94-98% Aminophylline infusion IV salbutamol or ipratropium
37
What is the management for life-threatening asthma
IV magnesium sulphate infusion Admission to HDU/ITU Intubation IV salbutamol nebs
38
What are the criteria for discharge after an acute asthma exacerbation
PEFR > 75% Stop regular nebs 24 hrs before Inpatient asthma review and inhaler assessment Provide peak flow metre Give written asthma action plans At least 5 days oral prednisolone GP follow up in 2 days Respiratory clinic follow up in 4 weeks
39
What monitoring is needed for acute asthma exacerbations
Respiratory rate Respiratory effort Peak flow Oxygen saturations Chest auscultation Monitor serum potassium when using salbutamol
40
What is COPD
Non-reversible, long term deterioration in air flow through lungs Due to damage to lung tissue Usually due to smoking Lungs prone to developing infections Usually progressive Not fully reversible
41
What is the pathophysiology of COPD
2 main features: emphysema, chronic bronchitis Mucous gland hyperplasia Loss of ciliary function Chronic inflammation and fibrosis of small airways
42
What are the causes of COPD
Smoking Inherited alpha-1-antitrypsin deficiency Industrial exposure
43
How might COPD present
Chronic shortness of breath Cough Sputum production Wheeze Recurrent respiratory infections
44
What are the differentials of COPD
Lung cancer Fibrosis Heart failure
45
What is the dyspnoea scale
Grade 1: breathlessness on strenuous exercise Grade 2: breathless on walking uphill Grade 3: breathless that slows walking on flat ground Grade 4: stop to catch their breath after walking 100m on flat ground Grade 5: unable to leave house due to breathlessness
46
How is COPD diagnosed
Clinical presentation Spirometry: FEV1:FVC < 70% (not improved with bronchodilators) CXR (exclude other things) FBC (raised Hb in chronic hypoxia) Transfer factor for carbon monoxide (TLCO - decreased in COPD)
47
What is the outpatient management for COPD
COPD care bundle Smoking cessation Bronchodilators Antimuscarinics Steroids Mucolytics Diet Long term oxygen therapy if needed Lung volume reduction
48
What is the long term management for COPD
Smoking cessation Pneumococcal and flu vaccines Step 1: short acting bronchodilators (SABA/short acting antimuscarinics) Step 2: combined LABA and long acting muscarinic agonist, combined LABA and ICS Additional: nebulisers, oral theophylline, oral mucolytic therapy, long term prophylactic antibiotics, LTOT
49
What investigations are needed for exacerbations of COPD
ABG CXR ECG routine bloods Sputum culture Blood cultures
50
Give an overview of oxygen therapy in COPD
Too much oxygen can depress respiratory drive (slows down breathing, retain more CO2) Use venturi masks (gives a percentage of oxygen)
51
What is the management of COPD exacerbations at home
Prednisolone (30 mg for 7-14 days) Regular inhalers and nebulisers Consider antibiotics
52
What is the management of COPD exacerbations in hospital
Nebulised bronchodilators Steroids Antibiotics Physiology
53
What is the management of severe COPD exacerbations that do not respond to first line management
IV aminophylline NIV Intubation and ventilation Consider admission to ITU Doxapram (respiratory stimulant, when NIV/intubation not appropriate)
54
What is involved in pulmonary rehabilitation
MDT 6-12 week programme Supervised exercise Unsupervised home activities Nutritional advice Disease education
55
What is BiPAP
Bilevel positive airway pressure Cycle of high and low pressure Used in type 2 respiratory failure Criteria: respiratory acidosis despite adequate medical treatment Contraindications: untreated pneumothorax, structural abnormalities affecting face/airway/GI tract Inspiratory positive airway pressure: air forced into lungs Expiratory airway positive pressure: pressure during expiration so airways don't collapse
56
What is CPAP
Continuous positive airway pressure Keeps airways expanded so that air can travel in and out Used in conditions where lungs are prone to collapse Indications: obstructive sleep apnoea, congestive heart failure, acute pulmonary oedema
57
What is interstitial lung disease
Conditions that cause inflammation and fibrosis of lung parenchyma Replacement of normal elastic tissue with stiff scar tissue
58
What are some examples of interstitial lung disease
Usual interstitial pneumonia Non-specific interstitial pneumonia Extrinsic allergy alveolitis Sarcoidosis
59
How is interstitial lung disease managed
Clinical features HRCT (ground glass appearance) If diagnosis unclear, biopsy Bloods (ANA, ENA, Rh F, ANCA, anti-GBM, ACE, IgG to HIV)
60
What is the management for interstitial lung disease
Treat underlying cause Home oxygen (if hypoxic at rest) Smoking cessation Physiotherapy Pneumococcal and flu vaccine Advanced care and palliative planning Lung transplant
61
What is idiopathic pulmonary fibrosis
Progressive fibrosis with no clear cause Insidious onset shortness of breath and dry cough for > 3 months Usually > 50s Examination: bibasal fine inspiratory crackles, finger clubbing Poor prognosis Medications to sow progression: pirfenidone (antifibrotic and antiinflammatory agent), nintedanib (monoclonal antibody targeting tyrosine kinase)
62
What is usual interstitial pneumonia
Most common cause of pulmonary fibrosis Classical findings: clubbing, reduced chest expansion, fine inspiratory crackles, features of pulmonary hypertension
63
What are the causes of drug-induced pulmonary fibrosis
Amiodarone Cyclophosphamide Methotrexate Nitrofurantoin
64
What are the causes of secondary pulmonary fibrosis
Alpha-1 antitrypsin deficiency Rheumatoid arthritis SLE Systemic sclerosis
65
What is hypersensitivity pneumonitis
Type 3 hypersensitivity reaction to an environmental agent Raised lymphocytes and mast cells Management: remove allergens, give oxygen, give steroids
66
What is cryptogenic organising pneumonia
Focal area of inflammation in lung tissue Presentation: shortness of breath, cough, fever, lethargy Focal consolidation on CXR Biopsy for definitive diagnosis Treatment: systemic corticosteroids
67
What is a pleural effusion
Collection of fluid in pleural cavity Exudate: high protein count Transudate: low protein count
68
What are the exudative causes of pleural effusion
Related to inflammation Lung cancer Pneumonia Rheumatic arthritis Pancreatitis Lymphatic disorders TB HIV
69
What are the transudative causes of pleural effusion
Due to fluid shifting Congestive heart failure Cirrhosis Hypoalbuminaemia Hypothyroidism Mitral stenosis PE Meig's syndrome (right pleural effusion with ovarian malignancy)
70
How might pleural effusion present
Shortness of breath Dullness to percussion Reduced breath sounds Tracheal deviation/mediastinal shift
71
What investigations are needed in pleural effusion
CXR (blunted costophrenic angles, fluid in fissures, meniscus, tracheal deviation) Aspiration (protein count, cell count, pH, glucose, LDH, microbiology testing) ECG Routine bloods ECHO (if suspecting heart failure) Staging CT (if suspect exudative cause)
72
What is the management for pleural effusion
Conservative management Pleural aspiration (temporarily relieves pressure) Chest drain (prevent recurrence)
73
What is empyema
Infected pleural effusion Suspect in: unimproving pneumonia, new/ongoing fever Pleural aspiration shows: pus, acidic pH, low glucose, high LDH Management: chest drain, antibiotics
74
What is a pneumothorax
Air gets into pleural space, separating lung from chest wall Typical in young thin men with sudden onset breathlessness and pleuritic chest pain
75
What are the causes of pneumothorax
Spontaneous (primary, or secondary to lung pathology) Trauma Iatrogenic
76
What are the risk factors doe pneumothorax
Pre-existing lung disease Height Smoking Cannabis use Diving Trauma Chest procedures Conditions (Marfan's...)
77
What imaging is needed for pneumothorax
Erect CXR for simple pneumothorax (shows area between lung tissue ending and chest wall starting) CT thorax (if too small to see on CXR)
78
What is the management for pneumothorax
If no SOB/small: no treatment, follow up in 2-4 weeks If SOB/large: give O2, aspirate, reassess, may need drain If have lung pathology, low threshold for chest drain insertion If lasts > 5 days, refer to thoracic surgeons
79
What are the indications for chest drain insertion in pneumothoraxes
Unstable patient Bilateral pneumothorax Secondary pneumothoraxes
80
Give an overview of tension pneumothoraxes
Trauma to chest wall creates a one-way valve: air gets into pleural space, not able to get out Increasing pressure can cause mediastinal shift and compress big vessels, causing cardiorespiratory arrest Signs: tracheal deviation away from side of pneumothorax, reduced air entry, increased resonance on percussion, tachycardia, hypotension Management: large bore cannula insertion, chest drain
81
Where should large bore canulae and chest drains be placed in pneumothoraxes
Large bore cannula: 2nd ICS, midclavicular line Chest drain: into triangle formed by - 5th ICS, midaxillary line, anterior axillary line Go just above ribs (avoid neurovascular bundle)
82
What are the risk factors for pulmonary embolism
Immobility Recent surgery Long haul flights Pregnancy Hormone therapy with oestrogen Malignancy Polycythaemia SLE Thrombophilia
83
What is involved in VTE prophylaxis
LMWH (enoxaparin...) Antiembolic compression stockings
84
How might pulmonary embolism present
Shortness of breath Cough Haemoptysis Pleuritic chest pain Hypoxia Tachycardia Raised respiratory rate Low grade fever Haemodynamic instability Symptoms of DVT (unilateral leg swelling, calf tenderness)
85
What is the Well's score
Risk of a patient presenting with symptoms actually having a DVT/PE Takes into account risk factors and clinical findings
86
How is pulmonary embolism diagnosed
Perform Well's score If likely, do CTPA If unlikely, do D-dimer (if positive, do CTPA) Definitive diagnosis by CTPA Ventilation-perfusion (VQ) scan
87
What is the management for pulmonary embolism
Supportive: admit, oxygen, analgesia, monitor Initial: DOAC, LMWH Long term anticoagulation: warfarin, DOAC, LMWH (first line in pregnancy)
88
How long is anticoagulation continued after pulmonary embolism
3 months: obvious reversible cause Beyond 3 months: cause unclear, recurrent VTEs, irreversible underlying cause 6 months: active cancer
89
What is pulmonary hypertension
Increased resistance and pressure of blood in pulmonary arteries Causes right heart strain and back pressure of blood into systemic nervous system
90
What are the causes of pulmonary hypertension
Group 1: primary, connective tissue disease Group 2: left heart failure Group 3: chronic lung disease Group 4: pulmonary vascular disease Group 5: miscellaneous causes (sarcoidosis, glycogen storage disease, haemolytic disorders)
91
How might pulmonary hypertension present
Shortness of breath Syncope Tachycardia Raised JVP Hepatomegaly Peripheral oedema
92
What investigations are needed for pulmonary hypertension
ECG (right ventricular hypertrophy, right axial deviation, right bundle branch block) CXR (dilated pulmonary arteries, right ventricular hypertrophy) NT-proBNP (raised)
93
What is the management for pulmonary hypertension
IV prostanoids (epoprostenol) Endothelin receptor antagonists Phosphodiesterase-5 inhibitors (sildenafil0 Secondary: treat underlying cause
94
What is sarcoidosis
Granulomatous inflammatory condition (involves macrophages) Associated with chest symptoms and extra-pulmonary manifestations Spikes in young adulthood and 60s F>M More common in black people
95
What are the extra-pulmonary symptoms of sarcoidosis
Systemic symptoms Lungs (mediastinal lymphadenopathy, pulmonary fibrosis, pulmonary nodules) Liver (liver nodules, cirrhosis, cholestasis) Eye (uveitis, conjunctivitis, optic neuritis) Skin (erythema nodosum, lupus pernio) Heart (bundle branch block, heart block, myocardial muscle involvement) Kidney (kidney stones, nephrocalcinosis, intestinal nephritis) CNS (nodules, pituitary involvement, encephalopathy) PNS (facial nerve palsy, mononeuronitis) Bones (arthralgia, arthritis, monopathy)
96
What is Lofgren's syndrome
A specific presentation of sarcoidosis Triad of: erythema nodosum, bilateral hilar lymphadenopathy, polyarthralgia
97
What are the differentials for sarcoidosis
TB Lymphoma Hypersensitivity pneumonitis HIV Toxoplasmosis Histoplasmosis
98
What investigations are needed for sarcoidosis
Bloods (high ACE, hypercalcaemia, raised CRP, high immunoglobulins) Imaging (CXR, HRCT, MRI, PET) Biopsy (histology gold standard - non-caseating granulomas with epithelioid cells) Test for other organ involvement
99
What is the management for sarcoidosis
If mild, self resolves Oral steroids (6-24 months), give bisphosphonates Methotrexate/azathioprine Liver transplant
100
What is the prognosis for sarcoidosis
Spontaneously resolves in 6 months in 60% Pulmonary fibrosis Pulmonary hypertension
101
What is obstructive sleep apnoea
Collapse of pharyngeal airway during sleep Stop breathing periodically for up to a few mins
102
What are the risk factors for obstructive sleep apnoea
Middle age M>F Obesity Alcohol Smoking Undersized/set back mandible Fat in pharyngeal tissue Large tonsils Craniofacial abnormalities Extra submucosal tissue
103
What are the features of obstructive sleep apnoea
Apnoea episodes during sleep Snoring Morning headaches Wake unrefreshed from sleep Daytime sleepiness Concentration problems Reduced O2 sats during sleep Severe cases: hypertension, heart failure, increased risk of MI/stroke
104
What is the Epworth sleepiness scale
Assess symptoms of sleepiness associated with obstructive sleep apnoea
105
What is the management for obstructive sleep apnoea
Refer to ENT/sleep clinic Correct reversible risk factors CPAP Surgery (reconstruct soft palate/jaw)
106
What is cystic fibrosis
Autosomal recessive Mutation in CFTR gene Multisystem disease, characterised by thickened secretions
107
How would cystic fibrosis present
Meconium ileus Intestinal malabsorption Recurrent chest infections Newborn screening
108
What are the signs and symptoms of cystic fibrosis
Chronic sinusitis Nasal polyps Abnormal sweat secretions Pancreatic insufficiency Finger clubbing Osteoporosis Male infertility Arthropathy/arthritis Steatorrhoea Distal intestinal obstruction syndrome Liver disease Portal hypertension Gallstones Bronchiectasis Repeat LRTIs
109
What are the common complications of cystic fibrosis
Respiratory infections Low body weight Distal intestinal obstruction syndrome CF related diabetes
110
How is cystic fibrosis diagnosed
One from each group Group 1: one or more phenotypic features, CF in siblings, positive newborn screening test Group 2: increased sweat chloride concentration, 2 mutations on genotyping, abnormal nasal epithelial ion transport
111
What is the lifestyle advice given to patient with cystic fibrosis
No smoking Avoid other CF patients Avoid contact with people with colds/infections Avoid jacuzzis (pseudomonas) Clean and dry nebulisers Avoid stables/farms Flu vaccine Sodium chloride tablets in hot weather

Medicine (9 decks)

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