Respiratory Flashcards
Asthma - type of hypersentivity?
type 1
Investigations for asthma?
- spirometry (obstructive pattern - FEV1% reduced - <70%)
- bronchodilator reversibility test (>12% increase in FEV1%)
3.FeNO test (>/= 40ppd)
Treatment for asthma?
- SABA
- add ICS
- add leukotriene receptor agonist
- add LABA
*Start on ladder based on symptoms I.e. if newly diagnosed but asthma symptoms >3 times a week or woken up at night by asthma then start at step 2.
ICS examples?
beclometasone,
budesonide,
ciclesonide,
fluticasone,
mometasone.
Leukotriene receptor agonist (LTRA) examples?
Monteleukast,
zafirlukast
LABA examples?
salmetarol
formeterol
olodetarol
small cell lung cancer % of cases?
15%
lung cancer investigations?
- CXR (Hilar enlargement, peripheral opacity, pleural effusion, collapse)
- CT chest, abdo and pelvis - with contrast
- bronchoscopy
- transthoratic needle aspiration biopsy
small cell lung cancer treatment?
Chemotherapy + radiotherapy
if very early then surgery
SCLC or NSCLC - worse prognosis?
SCLC
SCLC metastasis to where?
brain
bone
liver
adrenal gland
paraneoplastic syndrome in SCLC - which hormones?
ADH
ACTH
types of NSCLC?
- adenocarcinoma (most common - 40%)
- squamous - 20%
- large cell - 10%
management of NSCLC?
Surgery if disease isolated to single area - Lobectomy - 1st line.
radiotherapy - can be curative when early enough.
Chemotherapy - certain patients to improve outcomes or palliative.
pneumothorax, simple (no SOB), <2cm management?
conservative - follow up in 2-4 weeks.
When would you consider going straight to chest drain instead of aspiration for pneumothorax?
Presence of high-risk characteristics:
- haemodynamic compromise (tension pneumothorax)
- significant hypoxia
- bilateral
- underlying lung disease
- >50 years with significant smoking history
pneumothorax, simple, >2cm, haemodynamically stable, management?
oxygen + aspiration (16G-18G cannula)
if this fails - chest drain
Tension pneumothorax manegement?
oxygen + needle decompression (2nd intercostal space - mid clavicular line) - once pressure relived then chest drain
Complication of pneumothorax and why?
cardiac arrest - due to increased intrathoracic pressure causing reduced venous return.
Additional long-term management options for asthmatics?
- yearly flu jab
- annual asthma review
- asthma care plan
PEFR Cut offs in acute asthma?
moderate - 50 - 75%
severe - 33-50%
life - threatening - <33%
moderate acute asthma treatment?
- salbutamol nebs 5mg PRN
- Ipratropium bromide nebs
- steroids, oral prednisolone, IV hydrocortisone (5DAYS)
- antibiotics if sign of infection
severe acute asthma treatment?
same as moderate + IV aminophyline + consider iv salbutamol
life threatening asthma treatment?
same as severe + IV magnesium sulphate + admit to HDU.
intubation is worse cases
investigations for COPD?
Spirometry - obstructive but no reversibility
FBC
CXR
What are the FEV1 cut offs for staging of severity of COPD?
stage 1 - >80% (mild)
stage 2 - 50 -79% (moderate)
stage 3 - 30-49% (severe)
stage 4 - <30% (very severe)
chronic treatment for COPD (non asthmatic )?
- SABA or SAMA
- LABA + LAMA
chronic treatment for COPD (asthmatic )?
- SABA or SAMA
- LABA + ICS
Prophylactic antibiotic of choice for COPD?
azithromycin
Acute management of COPD?
- steroids (oral prednisolone, IV hydrocortisone)
- inhalers / nebs
- antibiotics if infection signs
- chest physio
if severe - IV aminophylline.
What is cor pulmonale?
right heart failure secondary to lung disease - caused by pulmonary hypertension as result of hypoxia.
Non-pharmocological management of COPD?
- stop smoking
- pneumococcal + flu vaccines
- pulmonary rehab
what might you add if someone with COPD is still breathless after maximum treatment?
oral theophylline
or
mucolytic therapy (carbocisteine)
what is bronchiectasis?
chronic dilation of the airways
management of bronchiectasis?
- Physical training (inspiratory muscle training)
- Postural drainage
- Antibiotics for exacerbations
- Bronchodilators (not commonly)
- Immunisations
- Surgery in selected cases
Antibiotic of choice for acute bronchitis?
oral doxycyline
When do you consider antibiotic therapy for acute bronchitis?
- systemically very unwell
- pre-existing co-morbidities
-CRP 20-100 (delayed prescription)
-CRP >100
sleep apnoea diagnostic test?
polysomnography (sleep study)
sleep apnoea management?
- weight loss / cut down on alcohol / stop smoking
- CPAP
- surgery (uvulopalatopharyngoplasty (UPPP).)
indications for steroids in sarcoidosis?
- chest x-ray stage 2 or 3 disease who are symptomatic
- hypercalcaemia
-eye, heart or neuro involvement
classical examination findings in COPD?
hyper-reasonant percussion
hyperinflated lungs
use of accessory muscles
pursed breathing
Lung cancer associated with non-smokers?
adenocarcinoma
acute management of PE?
ABCDE
DOAC e.g. apixiban/ rivaroxaban
OR
LMWH (if DOAC unsuitable or in Antiphosphlipid syndrome) e.g. enoxoparin/delteparin
thrombolysis (Alteplase/streptokinase/tenecteplase) if patient haemodynamically unstable or massive PE
anticoagulation
Transudate pleural effusion protein level?
<30g/L
Exudate pleural effusion protein level?
> 30g/L
Investigations for pleural effusion?
PA CXR
Ultrasound
contrast CT - to investigate underlying cause
pleural aspiration
Low glucose in pleural fluid findings suggestive of?
RA or TB
Raised amylase in pleural fluid findings suggestive of?
pancreatitis or oesophageal perforation
heavy blood staining in pleural fluid finding suggestive of?
mesothelioma, pulmonary embolism, tuberculosis
Exudative causes of pleural effusion?
- Infection - pneumonia / TB
- malignancy - bronchial carcinoma, mesothelioma or metastases
- inflammatory conditions - rheumatoid arthritis, lupus, or acute pancreatitis.
- Pulmonary infarct (for example secondary to a pulmonary embolism) and trauma.
Transudative causes of pleural effusion?
- Congestive heart failure
- hypoalbuminaemia
- hypothyroidism
- Meig’s syndrome (right sides pleural effusion with ovarian malignancy)
Transudative plueral effusion is more likely to be bilateral/unilateral?
bilateral
Exudative plueral effusion is more likely to be bilateral/unilateral?
Unilateral
What is empyema?
pus in pleural space (infected pleural effusion)
PaCO2 > 6.0 kPa suggests?
respiratory acidosis (or respiratory compensation for a metabolic alkalosis)
PaCO2 < 4.7 kPa suggests?
respiratory alkalosis (or respiratory compensation for a metabolic acidosis)
Bicarbonate < 22 mmol/l (or a base excess < - 2mmol/l) suggests?
a metabolic acidosis (or renal compensation for a respiratory alkalosis)
Bicarbonate > 26 mmol/l (or a base excess > + 2mmol/l) suggests?
metabolic alkalosis (or renal compensation for a respiratory acidosis)
What does the ‘ROME’ mnemonic for ABG’s refer to?
Respiratory = opposite
(low pH + high PaCO2 i.e. acidosis, or
high pH + low PaCO2 i.e. alkalosis)
Metabolic = equal
(low pH + low bicarbonate i.e. acidosis, or
high pH + high bicarbonate i.e. akalosis)
Risk factors for PE?
Immobility
Recent surgery
Long haul flights
Pregnancy
Hormone therapy with oestrogen
Malignancy
Polycythaemia
Systemic lupus erythematosus
Thrombophilia
Scoring system for predicting likelihood of PE/DVT?
WELLS
If PE is likely on the WELLS score then what investigation?
CT pulmonary angiography
If PE is ‘less likely’ on the Wells score then what investigation?
D-dimer and if +ve then CT angiography
PE ABG result?
Respiratory alkalosis
Acute bronchitis, CRP >100 management?
doxycycline unless pregnant then amoxicillin
Cystic fibrosis inheritance type + which gene affected?
autosomal recessive
CF transmembrane conductance regulator (CFTR) gene
How is cystic fibrosis diagnosed?
Neonatal heel prick day between day 5 and day 9
Sweat test: sweat sodium and chloride >60mmol/L
Faecal elastase: this can provide evidence for abnormal pancreatic exocrine function.
Genetic screening: This can identify CF mutations
Common organisms in bronchiectasis?
Haemophilus influenzae (most common)
Pseudomonas aeruginosa
Klebsiella spp.
Streptococcus pneumoniae
Lung cancer extra-pulmonary manifestations?
- recurrent laryngeal nerve palsy
- phrenic nerve palsy
- superior vena cava obstruction
- Horner’s syndrome
- syndrome of inappropriate ADH
- cushing’s syndrome
- Lambart eaton myasthenic syndrome
Lung cancer associated with asbestos?
mesothelioma
Definition of hospital acquired pneumonia?
Pneumonia which develops >48hrs after hospital admission
What is the pneumonia scoring system and what does it consist of?
C - confusion
U - Urea >7
R - RR>/= 30
B - BP <90 systolic or </= 60 diastolic
65 - age =/>65y
if >1 then consider admission
Common causes of pneumonia?
Streptococcus pneumoniae (50%)
Haemophilus influenzae (20%)
Pneumonia in immunocompromised patient / chronic pulmonary disease likely cause?
Moraxella catarrhalis
Pneumonia in patient with CF or bronchiectasis likely cause?
Haemophilus influenzae - most common cause.
Pseudomonas aeruginosa
Staphylococcus aureus - CF
pneumonia after travel + hyponatraemia - most likely cause?
Legionella pneumophila (Legionnaires’ disease)
Pneumonia + erythema multiforme (‘target lesions’) + neurological symptoms - likely cause?
Mycoplasma pneumoniae
Pneumonia after animal contact - likely cause?
Coxiella burnetii
Pneumonia after contact with infected birds - likely cause?
Chlamydia psittaci
Treatment for atypical pneumonia?
macrolides (e.g. clarithomycin), fluoroquinolones (e.g. levofloxacin) or tetracyclines (e.g. doxycycline).
Treatment for fungal (Pneumocystis jiroveci) pnuemonia?
Co-trimoxazole
How does Pneumocystis jiroveci pneumonia usually present?
- immunocompromised patient
dry cough without sputum
SOB on exertion
night sweats
Investigations for pneumonia?
CXR
FBC
U&E’S
CRP
If moderate/severe then:
sputum culture
blood culture
Legionella and pneumococcal urinary antigens
Investigations for interstitial lung disease?
High resolution CT - shows ‘ground glass’ appearance.
Treatment of idiopathic pulmonary fibrosis?
Pirfenidone - antifibrotic and anti-inflammatory
Nintedanib - monoclonal antibody targeting tyrosine kinase
Prognosis of Idiopathic pulmonary disease?
poor - life expectancy 2-5years
Medications which cause drug-induced pulmonary fibrosis?
- Amiodarone
- Cyclophosphamide
- Methotrexate
- Nitrofurantoin
Secondary pulmonary fibrosis can occur secondary to which conditions?
- Alpha-1 antitripsin deficiency
- Rheumatoid arthritis
- Systemic lupus erythematosus (SLE)
- Systemic sclerosis
What is hypersensitivity pneumonitis?
AKA extrinsic allergic alveolitis
Type III hypersensitivity reaction to an environmental allergen that causes parenchymal inflammation and destruction in people that are sensitive to that allergen.
Investigations for hypersensitivity pneumonitis?
Bronchoalveolar lavage - collecting cells from the airways during bronchoscopy by washing the airways with fluid then collecting that fluid for testing.
This shows raised lymphocytes and mast cells in hypersensitivity pneumonitis.
Management of hypersensitivity pneumonitis?
- remove the allergen
- give oxygen
- steroids
Examples of specific causes of hypersensitivity pneumonitis (4)?
Bird-fanciers lung - bird droppings
Farmers lung - mouldy spores in hay
Mushroom workers’ lung - mushroom antigens
Malt workers lung - mould on barley
Examples of conditions which can be caused by asbestos?
- Lung fibrosis
- Pleural thickening and pleural plaques
- Adenocarcinoma
- Mesothelioma
Management of mesothelioma?
Palliative chemotherapy
very poor prognosis - median survival is 8-14 months
Treatment of empyema?
Chest drain + antibiotics
Treatment of pleural effusion?
- Conservative - if small
- pleural aspiration - may temporarily relieve symptoms but may come back
- chest drain
Which criteria to distinguish exudative and transudative causes of pleural effusion?
Light’s criteria
Investigation for PE if patient has renal impairment, contrast allergy or at risk of radiation?
Ventilation-perfusion (VQ) scan
How long do you continue anti-coagulation for after a PE?
3 months - if obvious cause
6 months - cause unclear or irreversible cause (e.g. thrombophilia, cancer)
Causes of pulmonary hypertension (5 groups)?
Group 1 – Primary pulmonary hypertension or connective tissue disease such as systemic lupus erythematous (SLE)
Group 2 – Left heart failure usually due to myocardial infarction or systemic hypertension
Group 3 – Chronic lung disease such as COPD
Group 4 – Pulmonary vascular disease such as pulmonary embolism
Group 5 – Miscellaneous causes such as sarcoidosis, glycogen storage disease and haematological disorders
Investigations for pulmonary hypertension?
ECG
CXR
raised NT-proBNT
echo
Management of pulmonary hypertension?
Primary:
- IV prostanoids (e.g. epoprostenol)
- Endothelin receptor antagonists (e.g. macitentan)
- Phosphodiesterase-5 inhibitors (e.g. sildenafil)
What is sarcoidosis?
Granulomatous inflammatory condition. Granulomas are nodules of inflammation full of macrophages.
How does sarcoidosis present / which organs affected?
LUNGS (90%)
- mediastinal lymphadenopathy
- Pulmonary fibrosis
- pulmonary nodules
SYSTEMIC:
- fever
- fatigue
- weight loss
LIVER (20%)
- liver nodules
- cirrhosis
- cholestasis
EYES (20%)
- uveitis
- conjunctivitis
- optic neuritis
SKIN (15%)
- erythema nodosum
- lupus pernio
HEART (5%):
- BBB
- heart block
- myocardial muscle involvement
KIDNEY (5%)
- kidney stone (hypercalcaemia)
- nephrocalcinosis
- interstitial nephritis
CNS (5%)
- pituitary involvement
- encephalopathy
- facial nerve palsy
BONES (2%)
- arthralgia
- arthritis
- myopathy
Which is Lofgren’s syndrome?
This is a specific presentation of sarcoidosis. It is characteristic by a triad of:
Erythema nodosum
Bilateral hilar lymphadenopathy
Polyarthralgia (joint pain in multiple joints)
Investigations for sarcoidosis?
- raised serum ACE - screening test
- hypercalcaemia - key finding
- raised serum soluble IL-2 receptor
- raised CRP
- raised immunoglobulins
- CXR
- CT
- histology from biopsy (bronchoscopy) - GOLD STANDARD
Histological appearance of sarcoidosis?
non-caseating granulomas with epithelioid cells.
Management of sarcoidosis?
- Conservative - first line in patients with no or mild symptoms.
- Oral steroids - first line where treatment is required (between 6 and 24 months course) + bisphosphonates
- methotrexate or azathioprine - 2nd line
What is obstructive sleep apnoea?
Collapse of the pharyngeal airway during sleep.
What is used to assess symptoms of sleep apnoea?
The Epworth Sleepiness Scale
What is ARDS?
Acute respiratory distress syndrome (ARDS) is defined as non-cardiogenic pulmonary oedema and diffuse lung inflammation, typically secondary to an underlying illness. The pathophysiology includes diffuse alveolar damage with hyaline membrane formation.
acute resp failure within 7 days of the onset of lung injury
Causes of ARDS?
-Pneumonia (most common cause)
-Sepsis
-Aspiration
-Pancreatitis
-Transfusion reactions
-Trauma and fractures
- Fat embolism
Management of ARDS?
Transfer to ITU
Ventilatory support - a low tidal volume is associated with better outcomes.
Haemodynamic support to maintain mean arterial pressure >60 mmHg.
DVT prophylaxis.
Nutritional support with enteral/parenteral means if necessary.
Regular repositioning of patient for pressure ulcer prophylaxis.
Note that antibiotics need only be administered if an infectious cause for the ARDS is identified (such as pneumonia or sepsis).
Investigations for bronchiectasis?
- spirometry - obstructive
- sputum culture
- CXR
- High-resolution CT - diagnostic
- bronchoscopy
Management of CF?
Infective exacerbations - antibiotics, bronchodilators, neb mucolytics
pancreatic insufficiency - insulin replacement, exocrine enzymatic replacement (creon), vitamin A,D,E,K
abnormal LFT - ursodeoxycholic acid
What is Horner’s syndrome?
Characterised by ptosis, miosis (small pupil ) with or without anhydrosis (loss of sweating on one side of face), enophthalmos (sunken eye)
Can be caused by pancoast tumour, stroke or carotid artery dissection
Definition of Type 1 and Type 2 respiratory failure?
Type 1 Respiratory Failure = PaO2 <8 kPa; PaCO2 Normal
Type 2 Respiratory Failure: PaO2 < 8 kPa; PaCO2> 6 kPa
What is Type 1 respiratory caused by?
Due to a ventilation- perfusion (V/Q) mismatch. The volume of air passing in and out of the lungs is comparatively smaller than the volume of blood perfusing the lungs.
Causes include asthma, congestive cardiac failure, PE, pneumonia, pneumothorax.
What is Type 2 respiratory caused by?
Due to alveolar hypoventilation. This means that the lungs fail to effectively oxygenate and blow off carbon dioxide.
Causes:
- Obstructive lung disease
- restrictive lung disease
- depression of resp system
- neuromuscular disease
- thoracic wall dsiease
What is tuberculosis caused by?
Mycobacterium tuberculosis.
What is primary, secondary and miliary TB?
Primary - Bacteria is engulfed by macrophages and localised in hilar lymph nodes where it is eliminated or encapsulated by a barrier of granulation tissue (dormant state)
Secondary - active TB (usually in immunocompromised patients) - usually in apex of lungs but can spread.
Miliary - when patient is unable to contain primary infection and it disseminates into bloodstream
Investigations for TB?
- CXR
-sputum smear - 3 samples, stained with ziehl-Neelsen or auramine staining
-sputum culture - GOLD STANDARD, can take 1-3 weeks. - Mantoux test - screening test - checks for latent disease also.
Management of TB?
Isoniazid, rifampicin, ethambutol, and pyrazinamide for 2 months, then Isoniazid and rifampicin for a further 4 months.
Most important side effects of TB drugs?
Isoniazid - peripheral neuropathy, liver toxicity
Rifampicin - Liver toxicity, hepatic enzyme inducer, turns bodily fluids red/orange
Ethambutol - visual disturbance
Pyrazinamide - liver toxicity
Management of allergic rhinitis?
- allergen avoidance
- mild/moderate - oral/intranasal antihistamines
- moderate/severe persistant symptoms - intranasal corticosteroids
Management of influenza?
- Largely supportive (analgesia, antipyretic, fluids, oxygen)
- Antiviral treatment with neuraminidase inhibitors e.g. Oseltamivir (‘Tamiflu’)
- Infection control and respiratory isolation to prevent onward transmission
Cancers which commonly metastasise to the lungs?
breast
colon
rectum
head and neck
kidney, testicular
uterine
lymphomas.
When would you offer long-term oxygen therapy for COPD?
To patients with a pO2 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
Which scale is used to assess severity of COPD?
MRC Dyspnoea Scale
PE + renal impairment - investigation of choice?
V/Q perfusion scan
Indications for thoracotomy in haemothorax?
> 1.5L blood initially or losses of >200ml per hour for >2 hours
