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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
What is atypical pneumonia?
Pneumonia caused by an organism that cannot be cultured in the normal way or detected using a gram stain - treated with clarithromycin
26
What are the characteristics of Legionella pneumonia?
Hyponatraemia due to SIADH Cheap hotel holiday - caused by air conditioning units or infected water
27
how is Legionella pneumonia investigated?
urinary antigen
28
What are the characteristics of Mycoplasma pneumonia?
Milder pneumonia Erythema multiforme Neurological symptoms in young patients
29
What are the characteristics of Chlamydophila pneumonia?
School aged child Mild to moderate chronic pneumonia Wheeze
30
What can cause a pulmonary embolism?
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)
31
What are the key diagnostic factors for PE?
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)
32
What is PERC rule?
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
33
What is the WELLS score?
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
34
What are the first line investigations for PE?
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
35
How is PE investigated if Wells score <4?
D-dimer If D-dimer is positive, CTPA - interim DOAC if delay in CTPA
36
How is PE investigated if Wells score >4?
CTPA If CTPA is negative, arrange proximal leg vein ultrasound scan if DVT suspected
37
What is the management plan for confirmed PE?
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
38
What are the ECG changes seen in PE?
S1Q3T3 - only in 20% of patients Right BBB Right axis deviation Sinus tachycardia
39
What occurs in a tension pneumothorax?
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.
40
What are the key diagnostic factors for a pneumothorax?
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
41
What are the risk factors for pneumothorax?
Smoking Family history Tall, young, thin male Lung disease (infection, asthma, COPD, CF) Structural abnormalities (Marfan's, Ehler's-Danlos) Trauma Ventilated patients
42
What are the features of cardiopulmonary deterioration?
Hypotension (suggests imminent cardiac arrest) Respiratory distress Low oxygen saturations Tachycardia Shock Loss of consciousness
43
What investigations are considered for pneumothorax?
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
How is primary pneumothorax treated?
If rim of air is <2cm and no SOB, consider discharge Otherwise aspiration If this fails, chest drain
45
How is secondary pneumothorax treated?
If rim of air <2cm, aspiration (if this fails, chest drain) If rim of air >2cm, immediate chest drain
46
How is a suspected tension pneumothorax treated?
Immediate needle decompression of the second intercostal space, midclavicular line - 14G cannnula chest tube insertion
47
What are the key diagnostic factors for asthma?
Widespread polyphonic expiratory wheezing Dry night-time cough Dyspnoea on exertion Chest tightness Symptoms worse at night!
48
What investigations are used for asthma?
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
How is asthma treated?
Maintenance therapy: inhaled corticosteroid (budesonide) first, leukotriene receptor antagonist (montelukast) if insufficient Acute symptomatic relief: beta-2 agonists (salbutamol),
50
What are the symptoms of lung cancer?
Cough Haemoptysis Shortness of breath Weight loss Fatigue
51
What clinical features show local invasion of lung cancer?
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
What are the types of lung cancer?
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
How is lung cancer investigated?
CXR (unilateral pleural effusion, hilar enlargement) Contrast CT Bronchoscopy with endobronchial ultrasound PET-CT for staging FBC (raised platelets)
54
What are the symptoms of asbestosis?
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
How is asbestosis investigated?
CXR (lower lobe fibrosis) Spirometry (restrictive pattern) High-resolution CT (pleural thickening and plaques) Lung biopsy for malignancy
56
How is asbestosis treated?
Smoking cessation Pulmonary rehabilitation and oxygen therapy Pleural decortication or lung transplant Immunisation against influenza and pneumococcal vaccine
57
What are the symptoms of sarcoidosis?
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
What are the risk factors for sarcoidosis?
Age 20-40 Family history Female gender
59
How is sarcoidosis investigated?
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
How is sarcoidosis treated?
Asymptomatic patients do not need treatment Oral prednisolone or inhaled budesonide 2nd line: azathioprine or methotrexate Lung transplant for end-stage lung disease
61
What are the risk factors for tuberculosis?
Exposure to infection Immunosuppression Silicosis Malignancy Birth in an endemic country
62
What are the symptoms of tuberculosis?
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
How is TB investigated?
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
How is TB treated?
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
What are the side effects of TB medication?
Rifampicin: red/orange secretions, decreases INR Isoniazid: hepatitis, drug-induced lupus, peripheral neuropathy Pyrazinamide: hepatitis or gout Ethambutol: optic neuritis, avoid in CKD
66
What are the risk factors for idiopathic pulmonary fibrosis?
Family history Cigarette smoking Older age Male sex
67
What are the symptoms of pulmonary fibrosis?
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
How is pulmonary fibrosis investigated?
High resolution CT (honeycombing, ground glass appearance) CXR (bilateral lower zone reticulo-nodular shadowing) Spirometry (restrictive pattern, FEV1/FVC slightly increased)
69
How is idiopathic pulmonary fibrosis treated?
Pirfenidone (anti-fibrotic, anti-inflammatory) Nintedanib (monoclonal antibody targetting tyrosine kinase) Smoking cessation Pulmonary rehabilitation Oxygen
70
How is an acute exacerbation of idiopathic pulmonary fibrosis treated?
High-dose prednisolone
71
What drugs can induce pulmonary fibrosis?
Amiodarone Cyclophosphamide Methotrexate Nitrofurantoin
72
What diseases can cause pulmonary fibrosis?
Alpha-1 antitripsin deficiency Rheumatoid arthritis Systemic lupus erythematosus (SLE) Systemic sclerosis
73
What is extrinsic allergic alveolitis?
Type III hypersensitivity reaction to an allergen - causes parenchymal inflammation and destruction
74
How is extrinsic allergic alveolitis investigated?
CXR: upper/mid-zone fibrosis Bronchoalveolar lavage: raised lymphocytes and mast cells FBC: NO eosinophilia
75
How does extrinsic allergic alveolitis present?
Acute: dyspnoea, dry cough, fever Chronic: lethargy, dyspnoea, productive cough, anorexia and weight loss
76
How is extrinsic allergic alveolitis treated?
Avoid precipitating triggers Oral glucocorticoids
77
How is a pleural effusion classified as transudative or exudative?
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
What are some causes of exudative pleural effusion?
Inflammation causes protein to leak from tissues into pleural space - lung cancer, pneumonia, rheumatoid arthritis, tuberculosis
79
What are some causes of transudative pleural effusion?
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
How does pleural effusion present on examination?
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
How does pleural effusion present on CXR?
Blunting of the costophrenic angle Fluid in the lung fissures Meniscus ?tracheal and mediastinal deviation
82
What is empyema?
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
How is pleural effusion investigated?
Pleural aspiration - pH, protein, LDH, cytology and microbiology
84
How is empyema treated?
If fluid is purulent/turbid, chest drain If fluid is clear but pH is <7.2, chest drain Antibiotics
85
What is silicosis?
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
How does coal miner's pneumonoconiosis present on investigation?
Upper zone fibrosis Spirometry: restrictive picture (normal/slightly reduced FEV1 and redcued FVC)
87
How does progressive massive fibrosis present?
Dyspnoea on exertion Cough Black sputum
88
What are the risk factors for obstructive sleep apnoea?
Middle age Male Obesity Alcohol Smoking
89
What are the symptoms of OSA?
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
How is OSA investigated?
Epworth Sleepiness Scale - assess symptoms of sleepiness
91
How is OSA managed?
Correct reversible risk factors: smoking cessation, weight loss CPAP: maintain patency of the airway
92
What are the types of respiratory failure?
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
What are the causes of type 2 respiratory failure?
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
What are the causes of type 1 respiratory failure?
PE (V/Q mismatch, decreased perfusion) Pulmonary oedema Pneumonia Pneumothorax Lung collapse Low inspired oxygen
95
What are the clinical features of hypoxia?
Tachypnoea Dyspnoea Cyanosis Pleuritic chest pain
96
What are the clinical features of hypercapnia?
Hypoventilation Headache Anxiety Papilloedema Asterixis
97
What are some causes of fibrosis affecting upper zones of lungs?
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
What are some causes of fibrosis affecting lower zones of lungs?
idiopathic pulmonary fibrosis most connective tissue disorders (except ankylosing spondylitis) e.g. SLE drug-induced: amiodarone, bleomycin, methotrexate asbestosis
99
What is mesothelioma?
Cancer of the mesothelial layer of the pleural cavity; strongly associated with asbestos exposure
100
What are the features of mesothelioma?
Dyspnoea, weight loss, chest wall pain Painless pleural effusion Clubbing Pleural friction rub on auscultation Cough Haemoptysis
101
What are the features of allergic bronchopulmonary aspergillosis?
Eosinophilia Proximal bronchiectasis Bronchoconstriction: wheeze, cough, dyspnoea Raised IgE
102
How is allergic bronchopulmonary aspergillosis managed?
Oral glucocorticoids (prednisolone)
103
what are the features of pulmonary hypertension?
dyspnoea fatigue syncope raised JVP parasternal heave loud P2 S3 sound pansystolic murmur (tricuspid regurgitation)
104
what are the investigation findings for pulmonary hypertension?
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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