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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
Q

What are the NICE guidelines for diagnosis of asthma

A

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)

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26
Q

What is the long term management for asthma

A

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

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27
Q

What is the NICE asthma stepwise ladder

A

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

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28
Q

What are the additional management strategies for asthma

A

Individual self-management programme

Yearly flue jab

Yearly asthma review

Exercise

Smoking cessation

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29
Q

What is an acute asthma exacerbation

A

Rapid deterioration

Could be triggered by normal asthma triggers

NICE guidelines: refer to specialist after 2 exacerbations in 12 months

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30
Q

How might an acute asthma exacerbation present

A

Progressive worsening shortness of breath

Use of accessory muscles

Tachypnoea

Symmetrical expiratory wheeze

Chest sounds ‘tight’ on auscultation (reduced air entry)

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31
Q

What is moderate asthma

A

PEFR 50-75% predicted

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32
Q

What is severe asthma

A

PEFR 33-55% predicted

Respiratory rate > 25

Heart rate > 110

Unable to complete sentences

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33
Q

What is life-threatening asthma

A

PEFR < 33%

Sats < 92%

Becoming tired

No wheeze (silent chest, so tight that no air entry)

Haemodynamic instability (shock)

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34
Q

What is near fatal asthma

A

Raised pCO2

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35
Q

What is the management for moderate asthma

A

Nebulised beta 2 agonist (repeat as often as needed)

Nebulised ipratropium bromide

Steroids (oral prednisolone/IV hydrocortisone for 5 days)

Antibiotics

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36
Q

What is the management for severe asthma

A

Oxygen

Maintain sate 94-98%

Aminophylline infusion

IV salbutamol or ipratropium

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37
Q

What is the management for life-threatening asthma

A

IV magnesium sulphate infusion

Admission to HDU/ITU

Intubation

IV salbutamol nebs

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38
Q

What are the criteria for discharge after an acute asthma exacerbation

A

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

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39
Q

What monitoring is needed for acute asthma exacerbations

A

Respiratory rate

Respiratory effort

Peak flow

Oxygen saturations

Chest auscultation

Monitor serum potassium when using salbutamol

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40
Q

What is COPD

A

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

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41
Q

What is the pathophysiology of COPD

A

2 main features: emphysema, chronic bronchitis

Mucous gland hyperplasia

Loss of ciliary function

Chronic inflammation and fibrosis of small airways

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42
Q

What are the causes of COPD

A

Smoking

Inherited alpha-1-antitrypsin deficiency

Industrial exposure

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43
Q

How might COPD present

A

Chronic shortness of breath

Cough

Sputum production

Wheeze

Recurrent respiratory infections

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44
Q

What are the differentials of COPD

A

Lung cancer

Fibrosis

Heart failure

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45
Q

What is the dyspnoea scale

A

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
Q

How is COPD diagnosed

A

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
Q

What is the outpatient management for COPD

A

COPD care bundle

Smoking cessation

Bronchodilators

Antimuscarinics

Steroids

Mucolytics

Diet

Long term oxygen therapy if needed

Lung volume reduction

48
Q

What is the long term management for COPD

A

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
Q

What investigations are needed for exacerbations of COPD

A

ABG

CXR

ECG

routine bloods

Sputum culture

Blood cultures

50
Q

Give an overview of oxygen therapy in COPD

A

Too much oxygen can depress respiratory drive (slows down breathing, retain more CO2)

Use venturi masks (gives a percentage of oxygen)

51
Q

What is the management of COPD exacerbations at home

A

Prednisolone (30 mg for 7-14 days)

Regular inhalers and nebulisers

Consider antibiotics

52
Q

What is the management of COPD exacerbations in hospital

A

Nebulised bronchodilators

Steroids

Antibiotics

Physiology

53
Q

What is the management of severe COPD exacerbations that do not respond to first line management

A

IV aminophylline

NIV

Intubation and ventilation

Consider admission to ITU

Doxapram (respiratory stimulant, when NIV/intubation not appropriate)

54
Q

What is involved in pulmonary rehabilitation

A

MDT 6-12 week programme

Supervised exercise

Unsupervised home activities

Nutritional advice

Disease education

55
Q

What is BiPAP

A

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
Q

What is CPAP

A

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
Q

What is interstitial lung disease

A

Conditions that cause inflammation and fibrosis of lung parenchyma

Replacement of normal elastic tissue with stiff scar tissue

58
Q

What are some examples of interstitial lung disease

A

Usual interstitial pneumonia

Non-specific interstitial pneumonia

Extrinsic allergy alveolitis

Sarcoidosis

59
Q

How is interstitial lung disease managed

A

Clinical features

HRCT (ground glass appearance)

If diagnosis unclear, biopsy

Bloods (ANA, ENA, Rh F, ANCA, anti-GBM, ACE, IgG to HIV)

60
Q

What is the management for interstitial lung disease

A

Treat underlying cause

Home oxygen (if hypoxic at rest)

Smoking cessation

Physiotherapy

Pneumococcal and flu vaccine

Advanced care and palliative planning

Lung transplant

61
Q

What is idiopathic pulmonary fibrosis

A

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
Q

What is usual interstitial pneumonia

A

Most common cause of pulmonary fibrosis

Classical findings: clubbing, reduced chest expansion, fine inspiratory crackles, features of pulmonary hypertension

63
Q

What are the causes of drug-induced pulmonary fibrosis

A

Amiodarone

Cyclophosphamide

Methotrexate

Nitrofurantoin

64
Q

What are the causes of secondary pulmonary fibrosis

A

Alpha-1 antitrypsin deficiency

Rheumatoid arthritis

SLE

Systemic sclerosis

65
Q

What is hypersensitivity pneumonitis

A

Type 3 hypersensitivity reaction to an environmental agent

Raised lymphocytes and mast cells

Management: remove allergens, give oxygen, give steroids

66
Q

What is cryptogenic organising pneumonia

A

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
Q

What is a pleural effusion

A

Collection of fluid in pleural cavity

Exudate: high protein count

Transudate: low protein count

68
Q

What are the exudative causes of pleural effusion

A

Related to inflammation

Lung cancer

Pneumonia

Rheumatic arthritis

Pancreatitis

Lymphatic disorders

TB

HIV

69
Q

What are the transudative causes of pleural effusion

A

Due to fluid shifting

Congestive heart failure

Cirrhosis

Hypoalbuminaemia

Hypothyroidism

Mitral stenosis

PE

Meig’s syndrome (right pleural effusion with ovarian malignancy)

70
Q

How might pleural effusion present

A

Shortness of breath

Dullness to percussion

Reduced breath sounds

Tracheal deviation/mediastinal shift

71
Q

What investigations are needed in pleural effusion

A

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
Q

What is the management for pleural effusion

A

Conservative management

Pleural aspiration (temporarily relieves pressure)

Chest drain (prevent recurrence)

73
Q

What is empyema

A

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
Q

What is a pneumothorax

A

Air gets into pleural space, separating lung from chest wall

Typical in young thin men with sudden onset breathlessness and pleuritic chest pain

75
Q

What are the causes of pneumothorax

A

Spontaneous (primary, or secondary to lung pathology)

Trauma

Iatrogenic

76
Q

What are the risk factors doe pneumothorax

A

Pre-existing lung disease

Height

Smoking

Cannabis use

Diving

Trauma

Chest procedures

Conditions (Marfan’s…)

77
Q

What imaging is needed for pneumothorax

A

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
Q

What is the management for pneumothorax

A

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
Q

What are the indications for chest drain insertion in pneumothoraxes

A

Unstable patient

Bilateral pneumothorax

Secondary pneumothoraxes

80
Q

Give an overview of tension pneumothoraxes

A

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
Q

Where should large bore canulae and chest drains be placed in pneumothoraxes

A

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
Q

What are the risk factors for pulmonary embolism

A

Immobility

Recent surgery

Long haul flights

Pregnancy

Hormone therapy with oestrogen

Malignancy

Polycythaemia

SLE

Thrombophilia

83
Q

What is involved in VTE prophylaxis

A

LMWH (enoxaparin…)

Antiembolic compression stockings

84
Q

How might pulmonary embolism present

A

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
Q

What is the Well’s score

A

Risk of a patient presenting with symptoms actually having a DVT/PE

Takes into account risk factors and clinical findings

86
Q

How is pulmonary embolism diagnosed

A

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
Q

What is the management for pulmonary embolism

A

Supportive: admit, oxygen, analgesia, monitor

Initial: DOAC, LMWH

Long term anticoagulation: warfarin, DOAC, LMWH (first line in pregnancy)

88
Q

How long is anticoagulation continued after pulmonary embolism

A

3 months: obvious reversible cause

Beyond 3 months: cause unclear, recurrent VTEs, irreversible underlying cause

6 months: active cancer

89
Q

What is pulmonary hypertension

A

Increased resistance and pressure of blood in pulmonary arteries

Causes right heart strain and back pressure of blood into systemic nervous system

90
Q

What are the causes of pulmonary hypertension

A

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
Q

How might pulmonary hypertension present

A

Shortness of breath

Syncope

Tachycardia

Raised JVP

Hepatomegaly

Peripheral oedema

92
Q

What investigations are needed for pulmonary hypertension

A

ECG (right ventricular hypertrophy, right axial deviation, right bundle branch block)

CXR (dilated pulmonary arteries, right ventricular hypertrophy)

NT-proBNP (raised)

93
Q

What is the management for pulmonary hypertension

A

IV prostanoids (epoprostenol)

Endothelin receptor antagonists

Phosphodiesterase-5 inhibitors (sildenafil0

Secondary: treat underlying cause

94
Q

What is sarcoidosis

A

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
Q

What are the extra-pulmonary symptoms of sarcoidosis

A

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
Q

What is Lofgren’s syndrome

A

A specific presentation of sarcoidosis

Triad of: erythema nodosum, bilateral hilar lymphadenopathy, polyarthralgia

97
Q

What are the differentials for sarcoidosis

A

TB

Lymphoma

Hypersensitivity pneumonitis

HIV

Toxoplasmosis

Histoplasmosis

98
Q

What investigations are needed for sarcoidosis

A

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
Q

What is the management for sarcoidosis

A

If mild, self resolves

Oral steroids (6-24 months), give bisphosphonates

Methotrexate/azathioprine

Liver transplant

100
Q

What is the prognosis for sarcoidosis

A

Spontaneously resolves in 6 months in 60%

Pulmonary fibrosis

Pulmonary hypertension

101
Q

What is obstructive sleep apnoea

A

Collapse of pharyngeal airway during sleep

Stop breathing periodically for up to a few mins

102
Q

What are the risk factors for obstructive sleep apnoea

A

Middle age

M>F

Obesity

Alcohol

Smoking

Undersized/set back mandible

Fat in pharyngeal tissue

Large tonsils

Craniofacial abnormalities

Extra submucosal tissue

103
Q

What are the features of obstructive sleep apnoea

A

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
Q

What is the Epworth sleepiness scale

A

Assess symptoms of sleepiness associated with obstructive sleep apnoea

105
Q

What is the management for obstructive sleep apnoea

A

Refer to ENT/sleep clinic

Correct reversible risk factors

CPAP

Surgery (reconstruct soft palate/jaw)

106
Q

What is cystic fibrosis

A

Autosomal recessive

Mutation in CFTR gene

Multisystem disease, characterised by thickened secretions

107
Q

How would cystic fibrosis present

A

Meconium ileus

Intestinal malabsorption

Recurrent chest infections

Newborn screening

108
Q

What are the signs and symptoms of cystic fibrosis

A

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
Q

What are the common complications of cystic fibrosis

A

Respiratory infections

Low body weight

Distal intestinal obstruction syndrome

CF related diabetes

110
Q

How is cystic fibrosis diagnosed

A

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
Q

What is the lifestyle advice given to patient with cystic fibrosis

A

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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