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Phase 1c: Conditions > Respiratory > Flashcards

Respiratory Flashcards

1
Q

What is COPD?

A

Airflow obstruction characterised by bronchitis (inflammatory process with increased mucous production, blocking airflow) and emphysema (destruction of alveolar wall); not reversible

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2
Q

What are the symptoms and signs of COPD?

A

Chronic productive cough
Exertional shortness of breath
Hyperinflation of chest (incomplete exhalation)
Tachypnoea (compensate for hypoxia)
Asterixis (CO2 retention)
Calf swelling (cor pulmonale and secondary pulmonary hypertension)
Fatigue (nocturnal cough, persistent hypoxia, and hypercapnia)
Weight loss (anorexia, use of respiratory muscles)
Headache (vasodilation caused by hypercapnia

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3
Q

What does COPD sound like on auscultation?

A

Distant breath sounds
Poor air movement (loss of lung elasticity and lung tissue breakdown)
Wheezing (airway inflammation and resistance)
Coarse crackles (mucous in airways)

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4
Q

What investigations are used for COPD?

A

Spirometry (FEV1/FVC < 0.7)
Pulse oximetry (low O2 saturation)
ABG (respiratory acidosis, hypercapnia, hypoxia)
CXR (hyperinflation)
FBC (increased haematocrit, increased WCC if infection)
ECG (to exclude ischaemic heart disease, may see RV hypertrophy due to pulmonary hypertension)

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5
Q

How is COPD managed?

A

Pulmonary rehabilitation
Pneumococcal and influenza vaccinations
SABA or SAMA if breathless (salbutamol or ipratropium)
IF EXACERBATIONS DESPITE TREATMENT:
LABA and ICS if asthmatic features (budesonide/formoterol)
LABA/LAMA or LABA/LAMA/ICS
Azithromycin prophylaxis in select patients

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6
Q

What organisms cause exacerbations of COPD?

A

H. influenzae (most common)
Streptococcus pneumoniae
Moraxella catarrhalis

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7
Q

How are acute exacerbations of COPD treated?

A

Oral prednisolone 30mg daily for 5 days
Amoxicillin or clarithromycin or doxycycline if clinical signs of pneumonia

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8
Q

What is bronchiectasis?

A

An obstructive lung disease; abnormal dilation of bronchi due to destruction of the elastic and muscular components of the bronchial wall - mucous plugs form due to abnormal clearance
Bacteria can become trapped in the mucous plug, causing recurrent pneumonias and chronic inflammation

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9
Q

What are the key diagnostic factors for bronchiectasis?

A

Chronic productive cough
Dyspnoea
Haemoptysis
Coarse crackles
Wheeze
May have clubbing

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10
Q

How does bronchiectasis sound on auscultation?

A

Crackles, high-pitched inspiratory squeaks and rhonchi
Wheezing

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11
Q

What are some risk factors for bronchiectasis?

A

Cystic fibrosis
Host immunodeficiency
Previous infections
Primary ciliary dyskinesia

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12
Q

What investigations are used for bronchiectasis?

A

High-resolution CT scan (shows thickened, dilated airways) - tram track and signet ring signs
CXR
FBC (high eosinophil count in bronchopulmonary aspergillosis, neutrophilia suggests superimposed infection/exacerbation)
Sputum culture
Spirometry

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13
Q

How is initial bronchiectasis treated?

A

Exercise and improved nutrition
Airway clearance therapy
Self-management plan
Consider inhaled bronchodilators

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14
Q

How is acute exacerbation of bronchiectasis treated?

A

Short-term oral antibiotic
Increased airway clearance
Continued maintenance therapy

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15
Q

What are the key diagnostic factors for acute bronchitis?

A

Productive cough (clear, white or discoloured sputum)
Duration of cough <30 days
No history of chronic respiratory illness
Fever
Wheezes and rhonchi (uncommon)

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16
Q

What investigations are used for acute bronchitis?

A

Clinical diagnosis (with predominant symptom being cough)
CXR (to exclude pneumonia)
Pulmonary function test (to evaluate for asthma)

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17
Q

How is acute bronchitis treated?

A

Analgesia
Adequate fluid intake
Doxycycline if patients are systemically unwell or have pre-existing co-morbidities
Amoxicillin for pregnant women and children aged 12-17

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18
Q

What are the key diagnostic factors of community-acquired pneumonia?

A

Cough with increasing sputum production
Dyspnoea
Pleuritic chest pain
Fever and night sweats/rigor (less common in older patients)
Tachypnoea
Confusion (older patients)

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19
Q

What are the chest signs of pneumonia?

A

Bronchial breath sounds - harsh breath sounds equally loud on inspiration and expiration (consolidation of lung tissue around the airway)
Focal coarse crackles - air passing through sputum in airways
Dullness to percussion - lung tissue collapse and/or consolidation

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20
Q

What are the key diagnostic factors of community-acquired pneumonia?

A

Cough with increasing sputum production (may be blood-stained)
Dyspnoea
Pleuritic chest pain
Fever and night sweats/rigor (less common in older patients)
Tachypnoea
Crackles, decreased breath sounds, dullness to percussion, and wheeze
Confusion (older patients)

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21
Q

What are the investigations for community-acquired pneumonia?

A

CXR (consolidation)
Pulse oximetry and ABG
Urea and electrolytes (inform disease severity)
FBC (leukocytosis)

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22
Q

What pathogens commonly cause CAP?

A

S. pneumoniae
Haemophilus influenzae
S. aureus
Mycoplasma pneumoniae
Chlamydophila pneumoniae

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23
Q

How are patients with CAP assessed for hospital admission?

A

CRB-65 (refer for patients with score >2)
Confusion
Respiratory rate (>30 breaths/min)
Systolic BP <90mmHg or diastolic BP <60mmHg
Age 65 or older

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24
Q

How is CAP managed?

A

Oxygen (if <94%)
Fluid resuscitation
Analgesia
Low-severity CAP: amoxicillin
Moderate-to-severe CAP: amoxicillin, hospital admission
High-severity CAP: clarithromycin, hospital admission

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25
Q

What is atypical pneumonia?

A

Pneumonia caused by an organism that cannot be cultured in the normal way or detected using a gram stain - treated with clarithromycin

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26
Q

What are the characteristics of Legionella pneumonia?

A

Hyponatraemia due to SIADH
Cheap hotel holiday - caused by air conditioning units or infected water

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27
Q

how is Legionella pneumonia investigated?

A

urinary antigen

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28
Q

What are the characteristics of Mycoplasma pneumonia?

A

Milder pneumonia
Erythema multiforme
Neurological symptoms in young patients

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29
Q

What are the characteristics of Chlamydophila pneumonia?

A

School aged child
Mild to moderate chronic pneumonia
Wheeze

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30
Q

What can cause a pulmonary embolism?

A

Blood clot, e.g. deep vein thrombosis
Fatty material from the marrow of a broken bone
Foreign material from an impure injection, e.g. during drug misuse
Amniotic fluid from pregnancy (rare)
Large air bubble in a vein (rare)
Tumour broken off from larger tumour
Mycotic emboli (material from the focus of fungal infection)

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31
Q

What are the key diagnostic factors for PE?

A

Dyspnoea
Acute onset pleuritic chest pain (usually localised to one side of the chest - pleural irritation)
Signs of concurrent DVT (typically pain and swelling in one leg)
Presence of risk factors
Hypoxaemia (O2 <94%)
PERC rule
Positive WELLS score
Cough
Tachypnoea (hyperventilation - respiratory alkalosis)

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32
Q

What is PERC rule?

A

PERC rule is used to rule out PE in patients which are low risk. It can be ruled out if none of the following are identified:
Age >50 years
Heart rate >100bpm
Oxygen saturation <95%
Haemoptysis
Oestrogen use
Prior DVT or PE
Unilateral leg swelling
Surgery/trauma in the last 4 weeks

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33
Q

What is the WELLS score?

A

WELLS is used to determine the likelihood of suspected PE:
Clinical signs/symptoms of DVT
PE is most likely diagnosis
Tachycardia >100bpm
Immobilization/surgery in the past 4 weeks
Prior DVT/PE
Haemoptysis
Active malignancy

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34
Q

What are the first line investigations for PE?

A

CT pulmonary angiogram (definitive confirmation; avoid with other methods if possible in younger patients) - may also show right ventricular hypertrophy
Echocardiogram (if CTPA not possible)
D-dimer (low specificity)
FBC (thrombocytopenia/anaemia increase risks of anticoagulants)
ECG

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35
Q

How is PE investigated if Wells score <4?

A

D-dimer
If D-dimer is positive, CTPA - interim DOAC if delay in CTPA

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36
Q

How is PE investigated if Wells score >4?

A

CTPA
If CTPA is negative, arrange proximal leg vein ultrasound scan if DVT suspected

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37
Q

What is the management plan for confirmed PE?

A

DOAC (e.g. apixaban) for 3 months if provoked - recent surgery, immobilization
DOAC for 6 months if unprovoked
DOAC for 3-6 months if malignancy
thrombolyis if massive PE and hypotension

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38
Q

What are the ECG changes seen in PE?

A

S1Q3T3 - only in 20% of patients
Right BBB
Right axis deviation
Sinus tachycardia

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39
Q

What occurs in a tension pneumothorax?

A

Air enters the pleural space, but cannot leave, due to the presence of a one-way valve. Over time, air can build up, increasing pressure and compressing the heart and lungs, making them less functional.

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40
Q

What are the key diagnostic factors for a pneumothorax?

A

Pleuritic chest pain
Dyspnoea (due to inability of lung to expand as much)
Ipsilateral reduced breath sounds
Hypoxia (late sign)
Cardiopulmonary deterioration (tension pneumothorax, sudden in onset)
Trachea shifted to contralateral side
Sweating

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41
Q

What are the risk factors for pneumothorax?

A

Smoking
Family history
Tall, young, thin male
Lung disease (infection, asthma, COPD, CF)
Structural abnormalities (Marfan’s, Ehler’s-Danlos)
Trauma
Ventilated patients

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42
Q

What are the features of cardiopulmonary deterioration?

A

Hypotension (suggests imminent cardiac arrest)
Respiratory distress
Low oxygen saturations
Tachycardia
Shock
Loss of consciousness

43
Q

What investigations are considered for pneumothorax?

A

Erect CXR (no lung markings and visible rim between lung margin and chest wall)
CT chest (if diagnosis is uncertain on CXR)
ABG (hypoxia)

44
Q

How is primary pneumothorax treated?

A

If rim of air is <2cm and no SOB, consider discharge
Otherwise aspiration
If this fails, chest drain

45
Q

How is secondary pneumothorax treated?

A

If rim of air <2cm, aspiration (if this fails, chest drain)
If rim of air >2cm, immediate chest drain

46
Q

How is a suspected tension pneumothorax treated?

A

Immediate needle decompression of the second intercostal space, midclavicular line - 14G cannnula
chest tube insertion

47
Q

What are the key diagnostic factors for asthma?

A

Widespread polyphonic expiratory wheezing
Dry night-time cough
Dyspnoea on exertion
Chest tightness
Symptoms worse at night!

48
Q

What investigations are used for asthma?

A

Spirometry (FEV1/FVC <0.7)
Peak expiratory flow rate
CXR (normal or hyper-inflated)
FBC (eosinophilia)
Bronchodilator reversibility >12%
Exhaled NO (>35ppb in children, >40ppb in adults)

49
Q

How is asthma treated?

A

Maintenance therapy: inhaled corticosteroid (budesonide) first, leukotriene receptor antagonist (montelukast) if insufficient
Acute symptomatic relief: beta-2 agonists (salbutamol),

50
Q

What are the symptoms of lung cancer?

A

Cough
Haemoptysis
Shortness of breath
Weight loss
Fatigue

51
Q

What clinical features show local invasion of lung cancer?

A

Brachial plexus: upper limb paraesthesia or weakness
Cervical sympathetic chain: Horner’s syndrome
Phrenic nerve: paralysis of ipsilateral hemidiaphragm
Recurrent laryngeal nerve: hoarse voice
SVC: Pemberton’s sign

52
Q

What are the types of lung cancer?

A

Small cell lung cancer (worse prognosis, ADH, ACTH, Lambert-Eaton Syndrome)
Adenocarcinoma (most common, non-smokers, gynaecomastia)
Squamous cell carcinoma (smokers, ectopic PTH-rp, TSH)
Large cell cancer

53
Q

How is lung cancer investigated?

A

CXR (unilateral pleural effusion, hilar enlargement)
Contrast CT
Bronchoscopy with endobronchial ultrasound
PET-CT for staging
FBC (raised platelets)

54
Q

What are the symptoms of asbestosis?

A

Onset >10 years after exposure - may be asymptomatic or progressive SOB
Dyspnoea on exertion (increases with progression of disease)
Dry cough
Bilateral end-inspiratory crackles
Clubbing (advanced disease)

55
Q

How is asbestosis investigated?

A

CXR (lower lobe fibrosis)
Spirometry (restrictive pattern)
High-resolution CT (pleural thickening and plaques)
Lung biopsy for malignancy

56
Q

How is asbestosis treated?

A

Smoking cessation
Pulmonary rehabilitation and oxygen therapy
Pleural decortication or lung transplant
Immunisation against influenza and pneumococcal vaccine

57
Q

What are the symptoms of sarcoidosis?

A

Non-productive cough
Gradual onset dyspnoea
Chronic fatigue
Arthralgia
Wheezing and rhonchi
Lymphadenopathy (enlarged, non-tender)
Uveitis (photophobia, red painful eye, blurred vision)
Erythema nodosum
Lupus pernio
Facial palsy
May cause hypercalcaemia

58
Q

What are the risk factors for sarcoidosis?

A

Age 20-40
Family history
Female gender

59
Q

How is sarcoidosis investigated?

A

CXR (may show bilateral hilar lymphadenopathy)
Bronchoscopy with biopsy (non-caseating granulomas)
FBC (aneamia and leukopenia)
U&Es (hypercalcaemia, urea raised if renal involvement)

60
Q

How is sarcoidosis treated?

A

Asymptomatic patients do not need treatment
Oral prednisolone or inhaled budesonide
2nd line: azathioprine or methotrexate
Lung transplant for end-stage lung disease

61
Q

What are the risk factors for tuberculosis?

A

Exposure to infection
Immunosuppression
Silicosis
Malignancy
Birth in an endemic country

62
Q

What are the symptoms of tuberculosis?

A

Cough lasting 2-3 weeks, initially dry, becomes productive
Low-grade fever
Anorexia and weight loss
Malaise
Night sweats
Pleuritic chest pain
Cervical and hilar lymphadenopathy

63
Q

How is TB investigated?

A

sputum culture (gold standard, but takes 1-3 weeks)
sputum spear and acid-fast bacilli (Ziehl-Neelson stain) - least sensitive, rapid, inexpensive
nucleic acid amplification test (NAAT) - rapid diagnosis, less sensitive than sputum culture
Mantoux test for latent tuberculosis

64
Q

How is TB treated?

A

Latent TB: isoniazid and rifampicin
Active TB: rifampicin, isoniazid, pyrazinamide, ethambutol - give R and I for whole 6 months, P and E for just first 2 months
Pyridoxine (vit B6) given to prevent peripheral neuropathy caused by isoniazid

65
Q

What are the side effects of TB medication?

A

Rifampicin: red/orange secretions, decreases INR
Isoniazid: hepatitis, drug-induced lupus, peripheral neuropathy
Pyrazinamide: hepatitis or gout
Ethambutol: optic neuritis, avoid in CKD

66
Q

What are the risk factors for idiopathic pulmonary fibrosis?

A

Family history
Cigarette smoking
Older age
Male sex

67
Q

What are the symptoms of pulmonary fibrosis?

A

Exertional dyspnoea
Chronic dry cough (>3 months)
Bi-basal fine inspiratory crackles
Weight loss, fatigue, malaise
Clubbing
Poor prognosis: 2-5 years from diagnosis

68
Q

How is pulmonary fibrosis investigated?

A

High resolution CT (honeycombing, ground glass appearance)
CXR (bilateral lower zone reticulo-nodular shadowing)
Spirometry (restrictive pattern, FEV1/FVC slightly increased)

69
Q

How is idiopathic pulmonary fibrosis treated?

A

Pirfenidone (anti-fibrotic, anti-inflammatory)
Nintedanib (monoclonal antibody targetting tyrosine kinase)
Smoking cessation
Pulmonary rehabilitation
Oxygen

70
Q

How is an acute exacerbation of idiopathic pulmonary fibrosis treated?

A

High-dose prednisolone

71
Q

What drugs can induce pulmonary fibrosis?

A

Amiodarone
Cyclophosphamide
Methotrexate
Nitrofurantoin

72
Q

What diseases can cause pulmonary fibrosis?

A

Alpha-1 antitripsin deficiency
Rheumatoid arthritis
Systemic lupus erythematosus (SLE)
Systemic sclerosis

73
Q

What is extrinsic allergic alveolitis?

A

Type III hypersensitivity reaction to an allergen - causes parenchymal inflammation and destruction

74
Q

How is extrinsic allergic alveolitis investigated?

A

CXR: upper/mid-zone fibrosis
Bronchoalveolar lavage: raised lymphocytes and mast cells
FBC: NO eosinophilia

75
Q

How does extrinsic allergic alveolitis present?

A

Acute: dyspnoea, dry cough, fever
Chronic: lethargy, dyspnoea, productive cough, anorexia and weight loss

76
Q

How is extrinsic allergic alveolitis treated?

A

Avoid precipitating triggers
Oral glucocorticoids

77
Q

How is a pleural effusion classified as transudative or exudative?

A

Exudates have protein level of >30g/L, transudates <30g/L
LIGHTS CRITERIA if between 25-35g/L
Exudates have:
Pleural fluid/serum protein >0.5
Effusion LDH/serum LDH ratio >0.6

78
Q

What are some causes of exudative pleural effusion?

A

Inflammation causes protein to leak from tissues into pleural space - lung cancer, pneumonia, rheumatoid arthritis, tuberculosis

79
Q

What are some causes of transudative pleural effusion?

A

Fluid moves into the pleural space:
Congestive cardiac failure
Hypoalbuminaemia (liver disease, nephrotic syndrome, malabsorption)
Hypothyroidism
Meig’s syndrome (right sided pleural effusion with ovarian malignancy)

80
Q

How does pleural effusion present on examination?

A

Shortness of breath
Dullness to percussion over effusion
Reduced breath sounds
Tracheal deviation away from effusion if it is large
Decreased tactile vocal fremitus

81
Q

How does pleural effusion present on CXR?

A

Blunting of the costophrenic angle
Fluid in the lung fissures
Meniscus
?tracheal and mediastinal deviation

82
Q

What is empyema?

A

Infected pleural effusion - suspected in patients with improving pneumonia but new or ongoing fever
Pleural aspiration shows pus, acidic pH (<7.2), low glucose, high LDH

83
Q

How is pleural effusion investigated?

A

Pleural aspiration - pH, protein, LDH, cytology and microbiology

84
Q

How is empyema treated?

A

If fluid is purulent/turbid, chest drain
If fluid is clear but pH is <7.2, chest drain
Antibiotics

85
Q

What is silicosis?

A

Upper zone fibrosing lung disease due to inhalation of silica - mining, slate works, foundries, potteries
Shows ‘egg-shell’ calcification of hilar lymph nodes on CXR

86
Q

How does coal miner’s pneumonoconiosis present on investigation?

A

Upper zone fibrosis
Spirometry: restrictive picture (normal/slightly reduced FEV1 and redcued FVC)

87
Q

How does progressive massive fibrosis present?

A

Dyspnoea on exertion
Cough
Black sputum

88
Q

What are the risk factors for obstructive sleep apnoea?

A

Middle age
Male
Obesity
Alcohol
Smoking

89
Q

What are the symptoms of OSA?

A

Apnoea episodes during sleep (reported by partner)
Snoring
Morning headache
Waking up unrefreshed from sleep
Daytime sleepiness
Concentration problems
Reduced oxygen saturation during sleep

90
Q

How is OSA investigated?

A

Epworth Sleepiness Scale - assess symptoms of sleepiness

91
Q

How is OSA managed?

A

Correct reversible risk factors: smoking cessation, weight loss
CPAP: maintain patency of the airway

92
Q

What are the types of respiratory failure?

A

Type 1: hypoxia - failure of oxygenation (gas exchange, V/Q mismatch)
Type 2: hypoxia and hypercapnia - hypoventilation, so inadequate oxygenation and elimination of CO2

93
Q

What are the causes of type 2 respiratory failure?

A

Airway obstruction: COPD, severe asthma
Chest wall abnormalities: obesity, rib fractures, kyphoscoliosis
Weak respiratory muscles: Duchenne Muscular Dystrophy, Guillan Barré, MND
Drugs: opiates (respiratory depressant)

94
Q

What are the causes of type 1 respiratory failure?

A

PE (V/Q mismatch, decreased perfusion)
Pulmonary oedema
Pneumonia
Pneumothorax
Lung collapse
Low inspired oxygen

95
Q

What are the clinical features of hypoxia?

A

Tachypnoea
Dyspnoea
Cyanosis
Pleuritic chest pain

96
Q

What are the clinical features of hypercapnia?

A

Hypoventilation
Headache
Anxiety
Papilloedema
Asterixis

97
Q

What are some causes of fibrosis affecting upper zones of lungs?

A

hypersensitivity pneumonitis (also known as extrinsic allergic alveolitis)
coal worker’s pneumoconiosis/progressive massive fibrosis
silicosis
sarcoidosis
ankylosing spondylitis (rare)
histiocytosis
tuberculosis
radiation-induced pulmonary fibrosis

98
Q

What are some causes of fibrosis affecting lower zones of lungs?

A

idiopathic pulmonary fibrosis
most connective tissue disorders (except ankylosing spondylitis) e.g. SLE
drug-induced: amiodarone, bleomycin, methotrexate
asbestosis

99
Q

What is mesothelioma?

A

Cancer of the mesothelial layer of the pleural cavity; strongly associated with asbestos exposure

100
Q

What are the features of mesothelioma?

A

Dyspnoea, weight loss, chest wall pain
Painless pleural effusion
Clubbing
Pleural friction rub on auscultation
Cough
Haemoptysis

101
Q

What are the features of allergic bronchopulmonary aspergillosis?

A

Eosinophilia
Proximal bronchiectasis
Bronchoconstriction: wheeze, cough, dyspnoea
Raised IgE

102
Q

How is allergic bronchopulmonary aspergillosis managed?

A

Oral glucocorticoids (prednisolone)

103
Q

what are the features of pulmonary hypertension?

A

dyspnoea
fatigue
syncope
raised JVP
parasternal heave
loud P2
S3 sound
pansystolic murmur (tricuspid regurgitation)

104
Q

what are the investigation findings for pulmonary hypertension?

A

right heart catheterisation (gold standard) - mean pressure >25mmHg
ECG: p pulmonale, right ventricular hypertrophy, right axis devation

Phase 1c: Conditions (18 decks)

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