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Respiratory Flashcards

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1
Q

Describe the key features of a pneumonia caused by Klesbiella

A

Klesbiella

  • common in alcoholics and following aspiration
  • atypical cavitating pneumonia in upper lobes
  • can lead to lung abcsess formation
  • currant jelly-like sputum
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2
Q

What does normocapnia (a normal PaCO2) in an acute asthma attack indicate?

A

exhaustion - the patient is tiring and the asthma should be classified as life-threatening
- more likely to need to intubate and ventilate

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3
Q

When are ABGs recommended in acute asthma?

A

for patients with oxygen sats < 92%

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4
Q

What would be classified as a moderate asthma attack?

A

PEFR 50-75% best or predicted
Speech normal
RR < 25 / min
Pulse < 110 bpm

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5
Q

What would be classified as a severe asthma attack?

A

PEFR 33 - 50% best or predicted
Can’t complete sentences
RR > 25/min
Pulse > 110 bpm

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6
Q

What would be classified as a life-threatening asthma attack?

A

PEFR < 33% best or predicted
Oxygen sats < 92%
‘Normal’ pC02 (4.6-6.0 kPa)
Silent chest, cyanosis or feeble respiratory effort
Bradycardia, dysrhythmia or hypotension
Exhaustion, confusion or coma

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7
Q

What are the criteria for referral to hospital for an acute asthma attack?

A

patients with features of severe acute asthma should be admitted if they fail to respond to initial treatment

all patients with life-threatening should be admitted

other admission criteria include a previous near-fatal asthma attack, pregnancy, an attack occurring despite already using oral corticosteroid and presentation at night

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8
Q

What is the criteria for discharge following an acute asthma attack?

A

PEF >75% of best or predicted
Been stable on their discharge medication (i.e. no nebulisers or oxygen) for 24 hours
Inhaler technique checked and recorded
Triggers in the patient environment considered
Follow up in community in 2 working days and specialist care within 2 weeks

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9
Q

What is the stepwise tx for an acute asthma attack?

A

Oxygen
Salbutamol (nebulised)
Ipratropium bromide (nebulised)
Hydracortisone IV or Oral Prednisolone
Magnesium sulphate IV
Aminophylline/ IV salbutamol

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10
Q

What is the most appropriate treatment for a non-acute asthma exacerbation?

A

a short course of oral prednisolone (the BNF recommend 40-50mg od)

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11
Q

When should abx therapy be considered in bronchitis? Which drug is first line?

A

if patients:
are systemically very unwell
have pre-existing co-morbidities
have a CRP of 20-100mg/L (offer delayed prescription) or a CRP >100mg/L (offer antibiotics immediately)

Doxcycline first line unless pregnant/child

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12
Q

What is the most common organism causing infective exacerbations of COPD? Tx?

A

Haemophilus influenzae

increase frequency of bronchodilator use and consider giving via a nebuliser
give prednisolone 30 mg daily for 5 days
Only give antibiotics if purulent sputum or clinical signs of pneumonia
(first-line antibiotics are amoxicillin or clarithromycin or doxycycline)

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13
Q

Acute respiratory distress syndrome is non-cardiogenic pulmonary oedema. It can be caused by infection, blood transfusion and acute pancreatitis, amongst other things. How does it present?

A

Clinical features are typically of an acute onset and severe:

dyspnoea and high RR
low oxygen saturations
bilateral lung crackles
alveolar shadowing on xray

Acute respiratory distress syndrome can only be diagnosed in the absence of a cardiac cause for pulmonary oedema (i.e. the pulmonary capillary wedge pressure must not be raised)

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14
Q

What is allergic bronchopulmonary aspergillosis? Give the key features on investigation and treatment.

A

allergy to aspergillus spores

patients often have a hx of asthma and bronchiectasis

On Investigation:
- eosinophilia and fungal hyphae on sputum microscopy
- positive radioallergosorbent (RAST) test for Aspergillus
- raised IgE

Oral glucocorticoids are the treatment of choice

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15
Q

If you see COPD symptoms in a young person - think alpha-1 antitrypsin (A1AT) deficiency.

What are the features in the lungs and in the liver?

How is it investigated and how is it managed?

A

lungs: panacinar emphysema, most marked in lower lobes
liver: cirrhosis and hepatocellular carcinoma in adults, cholestasis in children

Investigations
-A1AT concentrations
-spirometry: obstructive picture

Management
- supportive: bronchodilators, physiotherapy
- IV alpha1-antitrypsin protein concentrates
- surgery: lung volume reduction surgery, lung transplantation

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16
Q

What is the most common form of asbestos related lung disease?

A

Pleural plaques - benign

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17
Q

What are the main diagnostic tests for asthma?

What patient group can be diagnosed based on clinical features alone?

A

Spirometry with a bronchodilator reversibility test - 12% increase in FEV1 with bronchodilator is diagnostic

FeNO test (done on all adults and children with negative spirometry but strong clinical suspicion of asthma)

Children under 5

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18
Q

What is the most common cause of occupational asthma? How is it diagnosed?

A

isocyanates

Serial peak flow measurements at work and at home are used to detect occupational asthma

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19
Q

What change to tx should be considered if asthma is well controlled?

A

Review every 3 months
Step down ICS dose by 25-50%

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20
Q

Atelectasis is a common postoperative complication in which basal alveolar collapse can lead to respiratory difficulty. How should it be managed?

A

Management
- positioning the patient upright
- chest physiotherapy: breathing exercises

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21
Q

Give key symptoms and signs of bronchiectasis

A

Symptoms
- persistent productive cough. Large volumes of yellow sputum
- dyspnoea
- haemoptysis

Signs
- Coarse crackles and low pitched wheeze (widespread- helps distinguish from cancer)
- thickened airways
- fingernail clubbing (also seen in lung cancer but NOT COPD)

Sometimes a childhood hx of TB

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22
Q

What complication are you screening for in a FBC of a COPD patient?

A

Secondary polycythaemia is a complication of COPD- can cause worsening breathlessness, pins and needles, and plethoric complexion

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23
Q

How is COPD severity classified using FEV1?

A

Mild COPD can have normal FEV1 results, as long as symptoms are present and FEV1/FVC is <0.7.

Moderate has an FEV1 50-70%, severe is 30-49%, and very severe is <30%.

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24
Q

When is long term oxygen therapy recommended in COPD?

A

Offer LTOT to patients with 2 pO2 readings of < 7.3 kPa

OR to those with a pO2 of 7.3 - 8 kPa and one of the following:

secondary polycythaemia
peripheral oedema
pulmonary hypertension

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25
What is the first line pharmacological management of COPD?
a SABA or SAMA
26
In a COPD patient who is still breathless despite using SABA/SAMA and has asthma/steroid responsive features (e.g. eosinophilia, diurnal variation in PEF or substantial variation in FEV1 over time ) ...
→ add a LABA + ICS
27
When is insertion of a chest drain contraindicated?
INR > 1.3 Platelet count < 75 Pulmonary bullae Pleural adhesions
28
What is the safe triangle for chest drain insertion bordered by?
Anterior edge of latissimus dorsi, the lateral border of pectoralis major, a line superior to the horizontal level of the nipple, and the apex below the axilla.
29
How do you know if a chest drain is in the right place (without reviewing Xray)?
Chest drain swinging: water level rises on inspiration, falls on expiration- shows drain is in right place
30
What typically causes cannonball mets? (well circumscribed, large, circular lesions)
RCC may also occur secondary to choriocarcinoma and prostate cancer
31
Give the causes of upper lobe lung fibrosis
CHARTS Coal workers’ pneumoconiosis Histiocytosis Ankylosing spondylitis/Allergic bronchopulmonary aspergillosis Radiation TB Silicosis (progressive massive fibrosis), sarcoidosis
32
What is Eosinophilic granulomatosis with polyangitis (EGPA) / Churg- Strauss Syndrome? Give 3 key features and 3 things seen on investigation.
Small - medium vessel vasculitis associated with ANCA Features: -asthma -paranasal sinusitis- runny and blocked nose -mononeuritis multiplex - type of peripheral neuropathy Investigations: +ve pANCA can help to diagnose blood eosinophilia pulmonary infiltrates on CXR
33
Idiopathic pulmonary fibrosis is a progressive lung disease typically seen in patients aged 50-70 years that is twice as common in men. Give 2 symptoms and 2 signs. What will be seen on spirometry?
Symptoms progressive exertional dyspnoea dry cough Signs bibasal fine end-inspiratory crepitations on auscultation clubbing spirometry: classically a restrictive picture impaired gas exchange: reduced transfer factor (TLCO)
34
What are the key points of good inhaler technique?
After inhaling hold breath for 10 seconds Wait 30 seconds before repeating
35
What is Kartagener's syndrome? How can it be differentiated from CF?
primary ciliary dyskinesia Features: -dextrocardia or complete situs inversus -bronchiectasis -recurrent sinusitis -subfertility Negative sweat test rules out CF
36
What is Lambert-Eaton syndrome?
antibodies to voltage gated calcium channels causing myasthenic like syndrome in SC lung cancer patients
37
Most common lung cancer in non smokers ?
adenocarcinoma
38
Causes of lower zone lung fibrosis?
AIDS - asbestosis - idiopathic pulmonary fibrosis - drug-induced: amiodarone, bleomycin, methotrexate - most connective tissue disorders (except ankylosing spondylitis) e.g. SLE
39
What are the 4 Ts (for most common causes of mediastinal mass)?
teratoma, terrible lymphadenopathy, thymic mass and thyroid mass
40
Which cancer is most strongly linked to asbestos exposure? How is it diagnosed? Prognosis?
Mesothelioma suspicion is normally raised by a chest x-ray showing either a pleural effusion or pleural thickening Diagnosis is made on histology, following a thoracoscopy Prognosis is relatively poor
41
When is non invasive ventilation indicated in COPD ?
respiratory acidosis pH 7.25-7.35
42
How is sleep apnoea diagnosed? What are the complications if it goes untreated?
Diagnosed using sleep studies (polysomnography) daytime somnolence compensated respiratory acidosis hypertension
43
What are O2 sats targets for different patient groups?
Oxygen saturation targets acutely ill patients: 94-98% patients at risk of hypercapnia (e.g. COPD patients): 88-92% Target saturations in COPD are 94-98% if CO2 is normal on ABG because not defined as 'at risk of hypercapnia'
44
What is classified as transudate on the lungs? Give 4 causes
Pleural fluid with < 30g/L protein heart failure (most common transudate cause) hypoalbuminaemia (liver disease, nephrotic syndrome, malabsorption) hypothyroidism Meigs' syndrome
45
What is classified as an exudate on the lungs? Give 6 causes
pleural fluid with > 30g/L protein infection: pneumonia (most common exudate cause), TB, subphrenic abscess connective tissue disease: RA, SLE neoplasia: lung cancer, mesothelioma, metastases pancreatitis pulmonary embolism Dressler's syndrome
46
Describe empyema fluid
Turbid effusion with pH <7.2, Low glucose, High LDH
47
First line tx for atypical pneumonia?
Clarithromycin
48
What is classed as a hospital acquired pneumonia? Tx?
Pneumonia that occurs ≥ 48 hours after admission is defined as a hospital-acquired pneumonia- tx is co-amoxiclav
49
When should a chest Xray be carried out on a discharged pneumonia patient?
6 weeks after clinical resolution in ALL patients
50
Tx of pscittacosis?
1st-line: tetracyclines e.g. doxycycline 2nd-line: macrolides e.g. erythromycin
51
Painful shin rash + cough →
sarcoidosis
52
Sarcoidosis is a multisystem disorder characterised by non-caseating granulomas. It is more common in young adults and in people of African descent. Give some acute and insidious features. What can be seen on investigation?
acute: swinging fever, papular rash on nose, lips and forehead, bilateral hilar lymphadenopathy, polyarthralgia, erythema nodosum insidious: dyspnoea, non-productive cough, malaise, weight loss Raised serum ACE and hypercalcaemia
53
Indications for corticosteroid treatment for sarcoidosis are:
parenchymal lung disease, uveitis, hypercalcaemia and neurological or cardiac involvement
54
How should you investigate a tension pneumothorax?
A tension pneumothorax should not be investigated if suspected but should be immediately decompressed with a needle (14G needle, 2nd intercostal space)
55
What are the 3 cardinal signs of Meig's syndrome?
Benign ovarian tumour, ascites, and pleural effusion
56
What is the appropriate management for a large unilateral pleural effusion of unknown cause?
Diagnostic aspiration before symptomatic drainage-differential diagnosis includes malignancy and infection (diagnostic aspiration should be performed with a green 21G needle and a 50ml syringe)
57
What is the next step in management for a patient with suspected/ known lung cancer and a mass showing on X-ray?
Contrast-enhanced CT scan of the chest, liver and adrenals
58
What can be recommended to certain COPD patients who have continuous exacerbations? What tests must you do before prescribing it?
Azithromycin prophylaxis do an ECG (to rule out prolonged QT interval) and baseline liver function tests
59
What are the 2 major ectopic secretions for SCLC and their consequences?
ADH → hyponatraemia ACTH → Cushing's syndrome
60
When presented with a large secondary pneumothorax > 2cm and/or a patient who is short of breath, what tx should be recommended?
Chest drain insertion
61
What are the main contraindications to lung cancer surgery?
SVC obstruction, FEV < 1.5, MALIGNANT pleural effusion, and vocal cord paralysis
62
What are the two main indications for surgery in bronchiectasis?
uncontrollable haemoptysis and localised disease
63
Subacute productive cough, foul-smelling sputum, night sweats →
?lung abscess
64
What is the management of : 1. High Altitude Cerebral Oedema (HACE) 2. High altitude pulmonary oedema (HAPE)
Management of HACE descent dexamethasone Management of HAPE descent nifedipine, dexamethasone, acetazolamide, phosphodiesterase type V inhibitors* oxygen if available
65
Bronchiectasis: most common organism =
Haemophilus influenzae
66
Features of COPD on CXR?
hyperinflation flattened hemidiaphragms hyperlucent lung fields
67
Give some causes of white-out on CXR with: 1. Trachea pulled toward white out 2. Central trachea 3. Trachea pushed away from white out
1. Pneumonectomy Complete lung collapse e.g. endobronchial intubation Pulmonary hypoplasia 2. Consolidation Pulmonary oedema (usually bilateral) Mesothelioma 3. Pleural effusion Diaphragmatic hernia Large thoracic mass
68
In which type of lung cancer are cavitating lesions most commonly seen?
Squamous cell carcinoma
69
The transfer factor describes the rate at which a gas will diffuse from alveoli into blood. Give some causes of a raised TLCO (total gas transfer)
asthma pulmonary haemorrhage (Wegener's, Goodpasture's) left-to-right cardiac shunts polycythaemia hyperkinetic states male gender, exercise
70
Give some causes of a low TLCO (total gas transfer)
pneumonia pulmonary emboli pulmonary fibrosis pulmonary oedema emphysema anaemia low cardiac output
71
How do you check if an NG tube is positioned correctly?
CXR Tip of the tube should be sub-diaphragmatic
72
What CXR findings would you expect in HF?
Alveolar oedema (bat’s wings) Kerley B lines (interstitial oedema) Cardiomegaly Dilated prominent upper lobe vessels Effusion (pleural)
73
How is asthma diagnosed in adults in terms of: FeNO result FEV1:FVC Post bronchodilator improvement PEFR variability
An exhaled FeNO of 40 parts per billion or greater An FEV1/FVC ratio <70% (it is an obstructive lung disease) A post-bronchodilator improvement in lung volume of 200 ml or in FEV1 of 12% or more A peak expiratory flow rate variability of 20% or more
74
Name 4 drugs that can induce pulmonary fibrosis
MANC Methotrexate Amiodarone Nitrofurantoin Cyclophosphamide
75
What two medications are licensed to slow the progression of idiopathic pulmonary fibrosis?
Pirfenidone - an antifibrotic and anti-inflammatory Nintedanib - a monoclonal antibody targeting tyrosine kinase
76
Name the 5 causes of pulmonary hypertension
Group 1 – Primary pulmonary hypertension or connective tissue disease such as SLE Group 2 – Left heart failure usually due to myocardial infarction or systemic hypertension Group 3 – Chronic lung disease e.g COPD Group 4 – Pulmonary vascular disease e.g. PE Group 5 – Miscellaneous causes such as sarcoidosis, glycogen storage disease and haematological disorders
77
5 causes of atypical pneumonia?
“legions of psittaci MCQs”: Legions – Legionella pneumophila Psittaci – Chlamydia psittaci M – Mycoplasma pneumoniae C – Chlamydydophila pneumoniae Qs – Q fever (coxiella burnetii)
78
Mining occupation, upper zone fibrosis, egg-shell calcification of hilar nodes →
? silicosis

Y3 Medicine (9 decks)

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