Respiratory Flashcards
What are the 2 types of lung cancer
Non-small cell (squamous cell carcinomas, adenocarcinomas)
Small cell (cause neoplastic syndromes)
What are the risk factors for lung cancer
Smoking
Airflow obstruction
Increasing age
Family history
Exposure to carcinogens
What are the signs and symptoms of lung cancer
Shortness of breath
Cough
Haemoptysis
Finger clubbing
Recurrent pneumonia
Weight loss
Lymphadenopathy
Superior vena cava obstruction
Horner’s syndrome
What investigations are needed for lung cancer
CXR (hilar enlargement, opacity, pleural effusion, collapse)
Routine bloods + clotting
Staging CT with contrast
PET scan
Bronchoscopy with endobronchial ultrasound
Biopsy
What are the treatment options for lung cancer
Surgery
Radiotherapy
Chemotherapy
Palliative
What are the extrapulmonary manifestations of lung cancer
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…)
What is Lambert-Eaton myasthenic syndrome
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
What is mesothelioma
Lung malignancy affecting mesothelial cells of pleura
Strongly slinked to asbestos inhalation
Very poor prognosis
Usually need palliative chemo
How might pneumonia present
Shortness of breath
Cough with sputum production
Fever
Haemoptysis
Pleuritic chest pain (sharp, worse on inspiration)
Delirium
Sepsis
What are the signs of pneumonia
Deranged obs
Sepsis due to pneumonia: tachypnoea, tachycardia, hypoxia, hypotension, fever, confusion
Characteristic chest signs: bronchial breath sounds, focal coarse crackles, dullness to percussion
What is CURB-65
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
What are the common organisms that cause pneumonia
Strep pneumoniae
Haemophilus influenzae
Moraxella catarrhalis
Pseudomonas aeruginosa
Staphylococcus aureus
What are the organisms that cause atypical pneumonia
Legionella pneumonia
Mycoplasma pneumoniae
Chlamydophila pneumoniae
Coxiella burnetii (Q fever)
Chlamydia psittaci
Give an overview of fungal pneumonia
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)
What investigations are needed for pneumonia
CXR
Routine bloods
ABG (if low sats)
Atypical pneumonia screen (if high CURB score)
Sputum culture, blood cultures (in moderate/severe cases)
What are the differentials for CXR consolidation
Pneumonia
TB
Lung collapse
Lobar collapse
Haemorrhage
How long should antibiotics be given for in pneumonia
Mild CAP: 5 days oral
Moderate/severe CAP: 7-10 days dual therapy
What is involved in pneumonia followup
HIV test
Immunoglobulins
Pneumococcal IgG serotypes
Haemophilus influenzae B IgG
Follow up in clinic in 6 weeks (confirm resolution on CXR)
What are the causes of non-resolving pneumonia
CHAOS
Complications (empyema, lung abscess)
Host (immunocompromised)
Antibiotics (inadequate dose, poor oral absorption)
Organism (resistant, not covered by empirical antibiotics)
Secondary diagnosis (PE, cancer)
What are the complications of pneumonia
Sepsis
Pleural effusion
Empyema
Lung abscess
Death
What is asthma
Chronic inflammatory condition causing episodic exacerbations of bronchoconstriction
Reversible obstruction of airflow in and out of lungs
Due to hypersensitivity
What is the pathophysiology of asthma
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
What are the typical triggers of asthma
Infection
Night time/early morning
Exercise
Animals
Cold/damp
Dust
Strong emotions
Smoking
Pollen
Drugs (aspirin, beta blockers)
How might asthma present
Episodic symptoms
Usually worse at night
Dry cough
Wheeze
Shortness of breath
History of atopic conditions
Bilateral widespread ‘polyphonic’ wheeze
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)
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
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
What are the additional management strategies for asthma
Individual self-management programme
Yearly flue jab
Yearly asthma review
Exercise
Smoking cessation
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
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)
What is moderate asthma
PEFR 50-75% predicted
What is severe asthma
PEFR 33-55% predicted
Respiratory rate > 25
Heart rate > 110
Unable to complete sentences
What is life-threatening asthma
PEFR < 33%
Sats < 92%
Becoming tired
No wheeze (silent chest, so tight that no air entry)
Haemodynamic instability (shock)
What is near fatal asthma
Raised pCO2
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
What is the management for severe asthma
Oxygen
Maintain sate 94-98%
Aminophylline infusion
IV salbutamol or ipratropium
What is the management for life-threatening asthma
IV magnesium sulphate infusion
Admission to HDU/ITU
Intubation
IV salbutamol nebs
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
What monitoring is needed for acute asthma exacerbations
Respiratory rate
Respiratory effort
Peak flow
Oxygen saturations
Chest auscultation
Monitor serum potassium when using salbutamol
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
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
What are the causes of COPD
Smoking
Inherited alpha-1-antitrypsin deficiency
Industrial exposure
How might COPD present
Chronic shortness of breath
Cough
Sputum production
Wheeze
Recurrent respiratory infections
What are the differentials of COPD
Lung cancer
Fibrosis
Heart failure
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
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)
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
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
What investigations are needed for exacerbations of COPD
ABG
CXR
ECG
routine bloods
Sputum culture
Blood cultures
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)
What is the management of COPD exacerbations at home
Prednisolone (30 mg for 7-14 days)
Regular inhalers and nebulisers
Consider antibiotics
What is the management of COPD exacerbations in hospital
Nebulised bronchodilators
Steroids
Antibiotics
Physiology
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)
What is involved in pulmonary rehabilitation
MDT 6-12 week programme
Supervised exercise
Unsupervised home activities
Nutritional advice
Disease education
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
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
What is interstitial lung disease
Conditions that cause inflammation and fibrosis of lung parenchyma
Replacement of normal elastic tissue with stiff scar tissue
What are some examples of interstitial lung disease
Usual interstitial pneumonia
Non-specific interstitial pneumonia
Extrinsic allergy alveolitis
Sarcoidosis
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)
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
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)
What is usual interstitial pneumonia
Most common cause of pulmonary fibrosis
Classical findings: clubbing, reduced chest expansion, fine inspiratory crackles, features of pulmonary hypertension
What are the causes of drug-induced pulmonary fibrosis
Amiodarone
Cyclophosphamide
Methotrexate
Nitrofurantoin
What are the causes of secondary pulmonary fibrosis
Alpha-1 antitrypsin deficiency
Rheumatoid arthritis
SLE
Systemic sclerosis
What is hypersensitivity pneumonitis
Type 3 hypersensitivity reaction to an environmental agent
Raised lymphocytes and mast cells
Management: remove allergens, give oxygen, give steroids
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
What is a pleural effusion
Collection of fluid in pleural cavity
Exudate: high protein count
Transudate: low protein count
What are the exudative causes of pleural effusion
Related to inflammation
Lung cancer
Pneumonia
Rheumatic arthritis
Pancreatitis
Lymphatic disorders
TB
HIV
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)
How might pleural effusion present
Shortness of breath
Dullness to percussion
Reduced breath sounds
Tracheal deviation/mediastinal shift
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)
What is the management for pleural effusion
Conservative management
Pleural aspiration (temporarily relieves pressure)
Chest drain (prevent recurrence)
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
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
What are the causes of pneumothorax
Spontaneous (primary, or secondary to lung pathology)
Trauma
Iatrogenic
What are the risk factors doe pneumothorax
Pre-existing lung disease
Height
Smoking
Cannabis use
Diving
Trauma
Chest procedures
Conditions (Marfan’s…)
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)
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
What are the indications for chest drain insertion in pneumothoraxes
Unstable patient
Bilateral pneumothorax
Secondary pneumothoraxes
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
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)
What are the risk factors for pulmonary embolism
Immobility
Recent surgery
Long haul flights
Pregnancy
Hormone therapy with oestrogen
Malignancy
Polycythaemia
SLE
Thrombophilia
What is involved in VTE prophylaxis
LMWH (enoxaparin…)
Antiembolic compression stockings
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)
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
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
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)
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
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
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)
How might pulmonary hypertension present
Shortness of breath
Syncope
Tachycardia
Raised JVP
Hepatomegaly
Peripheral oedema
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)
What is the management for pulmonary hypertension
IV prostanoids (epoprostenol)
Endothelin receptor antagonists
Phosphodiesterase-5 inhibitors (sildenafil0
Secondary: treat underlying cause
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
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)
What is Lofgren’s syndrome
A specific presentation of sarcoidosis
Triad of: erythema nodosum, bilateral hilar lymphadenopathy, polyarthralgia
What are the differentials for sarcoidosis
TB
Lymphoma
Hypersensitivity pneumonitis
HIV
Toxoplasmosis
Histoplasmosis
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
What is the management for sarcoidosis
If mild, self resolves
Oral steroids (6-24 months), give bisphosphonates
Methotrexate/azathioprine
Liver transplant
What is the prognosis for sarcoidosis
Spontaneously resolves in 6 months in 60%
Pulmonary fibrosis
Pulmonary hypertension
What is obstructive sleep apnoea
Collapse of pharyngeal airway during sleep
Stop breathing periodically for up to a few mins
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
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
What is the Epworth sleepiness scale
Assess symptoms of sleepiness associated with obstructive sleep apnoea
What is the management for obstructive sleep apnoea
Refer to ENT/sleep clinic
Correct reversible risk factors
CPAP
Surgery (reconstruct soft palate/jaw)
What is cystic fibrosis
Autosomal recessive
Mutation in CFTR gene
Multisystem disease, characterised by thickened secretions
How would cystic fibrosis present
Meconium ileus
Intestinal malabsorption
Recurrent chest infections
Newborn screening
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
What are the common complications of cystic fibrosis
Respiratory infections
Low body weight
Distal intestinal obstruction syndrome
CF related diabetes
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
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
