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PACES > Respiratory > Flashcards

Respiratory Flashcards

1
Q

What are they key symptoms of asthma?

A

Wheeze, often with clear triggers, reversibility with bronchodilators.
Chest tightness.
Cough.
Atopy.

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2
Q

What are the investigations for suspected asthma?

A

Peak flow.
Spirometry.
CXR if atypical presentation.

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3
Q

What are the investigations for an acute exacerbation of asthma?

A

ABG (O2, CO2, PH)
Peak flow (% best or predicted to assess severity).
CXR if diagnosis not clear.

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4
Q

What is the severity grading of acute exacerbation of asthma?

A

Moderate acute asthma
Increasing symptoms;
Peak flow > 50-75% best or predicted;
No features of acute severe asthma.

Severe acute asthma
Any one of the following:
Peak flow 33-50% best or predicted;
Respiratory rate ≥ 25/min;
Heart rate ≥ 110/min;
Inability to complete sentences in one breath.

Life-threatening acute asthma
Any one of the following in a patient with severe asthma:
Peak flow < 33% best or predicted;
Arterial oxygen saturation (SpO2) < 92%;
Partial arterial pressure of oxygen (PaO2) < 8 kPa;
Normal partial arterial pressure of carbon dioxide (PaCO2) (4.6–6.0 kPa);
Silent chest;
Cyanosis;
Poor respiratory effort;
Arrhythmia;
Exhaustion;
Altered conscious level;
Hypotension.

Near-fatal acute asthma
Raised PaCO2 and/or the need for mechanical ventilation with raised inflation pressures.

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5
Q

What is the management of an acute asthma exacerbation?

A

O2
Salbutamol nebs, can be repeated, can use ipratropium if salbutamol not effective.
Oral prednisolone, Continue inhaled steroids
Aminophylline or IV magnesium are not evidence based.
Early escalation to ITU if life threatening features.

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6
Q

What is the management of chronic asthma?

A

Stepwise approach:
1) SABA eg salbutamol
2) Add inhaled corticosteroid if needing reliever 3x per week or more.
3) Add in leukotriene receptor antagonist eg montelukast or add in LABA eg salmeterol, fometerol (or combination inhaler).
4) Add in the other one not tried above.
5) Consider tiptropium; speicalist referral.
6) Under specialist guidance, mAbs eg omalizumab

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7
Q

What extra pulmonary signs might there be in asthma?

A

Tremor (salbutamol)
Tachycardia (salbutamol)
Thin skin, easy bruising, cushingoid appearance - steroids.

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8
Q

What are the features of a moderate acute exacerbation of asthma?

A

Increased symptoms
peak flow 50-70% of predicted
No features of acute severe asthma

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9
Q

What are the features of a severe acute exacerbation of asthma?

A

Peak flow 33-50% of predicted
OR
Respiratory rate >/=25/min
OR
Heart rate >/=110bpm
OR
Inability to complete sentences

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10
Q

What are the features of a life-threatening acute exacerbation of asthma?

A

Peak flow <33% predicted
OR
normal PaCO2
OR
Sats<92%
OR
Pa02<8
Or silent chest/cyanosis/poor respiratory effort/arrhythmia/exhaustion/altered level of consciousness

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11
Q

What are the features of a near-fatal acute exacerbation of asthma?

A

High PCO2 and/or need for mechanical ventilation

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12
Q

What is bronchiectasis?

A

A chronic condition of abnormal, permanent thickening of the bronchi and bronchioles due to repeated infection, impaired draining, airway obstruction or abnormal immune response

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13
Q

What are some common symptoms of brochiectasis?

A

Shortness of breath
Chronic productive cough
Repeated infections
Haemoptysis
Pleuritic chest pain
Childhood infections

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14
Q

What are the top three causes of bronchiectasis?

A

Post-infective
COPD
Cystic fibrosis

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15
Q

What signs of an underlying cause for bronchiectasis should you look for on physical examination?

A

Cystic fibrosis - young, thin patient. PEG/permanent line, signs of chronic liver disease
Kartageners - Dextrocardia/situs inversus
Connective tissue disease - peripheral polyarthropathy, lupus skin changes

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16
Q

What are some differential diagnoses for a patient with lung crepitations and finger clubbing?

A

Bronchiectasis - generally fine late-inspiratory that don’t improve with coughing but do on leaning forwards
Lung cancer - signs of malignancy inc tar staining, cachexia
Abscess

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17
Q

How is the severity of bronchiectasis determined?

A

MRC dyspnoea scale - severe if >4
Number of bronchopulmonary segments involved
Lung function assessment

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18
Q

What is Youngs syndrome?

A

Includes bronchiectasis, male infertility and sinustitis. Thought to be due to genetic factors or mercury exposure in childhood

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19
Q

What signs may be seen on a chest xray of a person with bronchiectasis?

A

Tramlines when diseased bronchi seen side on
Signet rings when diseased bronchi seen end-on
Hyperinflation

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20
Q

What pattern would be seen on lung function tests in a patient with bronchiectasis?

A

Obstructive pattern

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21
Q

How should bronchiectasis be managed?

A

MDT approach including physio
Educate patient
Stop smoking
Postural drainage
Vaccines optimise nutrition
Treat the cause
Rescue abx
Steroids
Mucolytics
Bronchodilators

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22
Q

What are some complications of bronchiectasis?

A

Pulmonary: haemoptysis, recurrent infections, empyema or abscess, cor pulmonale
Extra-pulmonary: Anaemia, secondary amyloidosis

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23
Q

What are some extra-pulmonary manifestations of cystic fibrosis?

A

Pancreatic insufficiency
Male infertility
Distal intestinal obstruction syndrome
Gallstones
Biliary cirrhosis and portal hypertension
Sinus disease
Intestinal malabsorption
Diabetes

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24
Q

What are some differential diagnoses for bilateral lower-zone crackles?

A

Pulmonary oedema
Pulmonary fibrosis
Bronchiectasis
Bilateral pneumonia

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25
Q

How is the severity of COPD classified?

A

GOLD criteria based on FEV1
Mild = FEV1 >80% with symptoms
Moderate= FEV1 50-79%
Severe = FEV1 30-49%
Very severe = FEV1 <30%

26
Q

What signs may be found on physical examination of a patient with COPD?

A

Widespread wheeze
Hyperinflated chest
Reduced chest expansion
Reduced breath sounds over bullae
Hyperresonant percussion
Bronchodilator tremor
Pursed lip breathing/using accessory muscles

27
Q

When should alpha1 antitrypsin deficiency be considered in a patient who appears to have copd?

A

Young patient
Family history of COPD/bronchitis
Non-smoker
Icteric with hepatosplenomegaly

28
Q

What is the inheritance pattern of alpha 1 antitrypsin deficiency?

A

Autosomal codominant
S allele produces little A1AT, Z allele produces very little so people with ZZ homozygous have very high risk of lung and liver disease. SS have high risk, but especially if they smoke

29
Q

What features should you comment on in a patient who you suspect has COPD?

A

Evidence of complications such as respiratory failure (LTOT, CO2 flap, cyanosis) or cor pulmonale (oedema, raised JVP)
Signs of malignancy ie cachexia, radiotherapy tattoos
Signs of treatment, ie oxygen therapy, steroids causing cushingoid appearance, scars from lung reduction surgery

30
Q

What test is most diagnostic of COPD?

A

Spirometry with FEV1/FVC ratio <0.70 with minimal reversibility with bronchodilators

31
Q

How should COPD be managed?

A

MDT approach
Stop smoking
Optimise nutrition
Pulmonary rehab
Vaccinations
SABA/SAMA/LAMA/LABA +steroids if FEV1<50%
LTOT if needed
NIV if needed

32
Q

What are the indications for LTOT in a patient with COPD?

A

PaO2 <7.3kPa on two consecutive readings at least 3 weeks apart or 7.3-8kpa in a patient with cor pulmonale

33
Q

When should surgical interventions be offered for a patient with COPD?

A

Symptomatic patients with large bullae and FEV1 <50% predicted - bullectomy
Upper zone dominant emphysema, FEV1>20% predicted and PaCO2<7.3kpa - lung reduction surgery

34
Q

What is the difference between an empyema and a complicated parapneumonic effusion?

A

Empyema is pus in the pleural cavity with pH,7.2
Complicated parapneumonic effusion is clear fluid with pH<7.2
Parapneumonic effusion has pH>7.2

35
Q

How can consolidation be differentiated from a pleural effusion on clinical examination?

A

Tactile vocal fremitus - Increased transmission through tissue, ie consolidation and decreased through fluid, ie effusion
Whispering pectoriloquy - if whispers are heard clearly through affected lung tissue then there is consolidation present

36
Q

What is Light’s criteria used for?

A

Determining whether a pleural effusion is exudative or transudative

37
Q

What is an exudative effusion and give some examples of conditions which may cause an exudative pleural effusion?

A

Fluid with high cellular and protein content due to increased permeability of blood vessels, usually due to inflammation.
Seen in infection, inc. empyema, malignancy and in pulmonary infarction

38
Q

What is a transudative effusion and give some examples of conditions which may cause a transudative effusion?

A

Fluid pushed through extracellular space to due to increased hydrostatic or oncotic pressure. Seen in CCF, cirrhosis and nephrotic syndrome

39
Q

What parameters are needed to calculate Light’s criteria?

A

Serum and fluid protein
or serum and fluid LDH

40
Q

What changes are seen on CXR in sarcoidosis?

A

Varies with severity.
Usually bilateral hilar lymphadenopathy +/- pulmonary infiltrates or fibrosis

41
Q

What are the common pulmonary presenting signs of sarcoidosis?

A

Shortness of breath
Reduced exercise tolerance
Dry cough

42
Q

What are some extra pulmonary manifestations of sarcoidosis?

A

Lymphadenopathy
Hepatomegaly
Splenomegaly
Lupus pernio
Uveitis
Erythema nodosum
Cardiomyopathy
Hypercalcaemia
Renal stones

43
Q

What is the definition of sarcoidosis?

A

Idiopathic multisystem granulomatous disorder

44
Q

Clinical features of sarcoidosis

A

Pulmonary disease - in 90%
Lymphadenopathy, hepatosplenomegaly
Neurological syndromes - lymphocytic meningitis, seizures, cerebellar, brainstem, space occupying lesion, neuropathy
Cardiac - cardiomyopathy, arrhythmias
Eyes - uveitis, conjunctivitis, keratoconjunctivitis sicca, glaucoma - in >20%
Skin - lupus pernio, erythema nodosum, papules
Heerfordt’s syndrome - Salivary gland enlargement, Bell’s palsy, uveitis
Constitutional - fever, night sweats, weight loss, malaise

45
Q

What are the lab tests for sarcoidosis?

A

ESR - raised
Lymphopenia
Raised LFT
Raised ACE in 60%, normalisies with treatment response
Raised Ca (blood and urine)
Raised Igs
Usually negative tuberculin skin test

46
Q

What is the CXR grading of pulmonary sarcoid disease?

A

0-normal
1-Bilateral hilar lymphadenopathy
2-BHL and peripheral pulmonary infiltrates
3-Pulmonary infiltrates alone
4-pulmonary fibrosis

47
Q

What is the management of sarcoidosis?

A

If Bilateral hilar lymphadenopathy only, no treatment required as most self-resolve.
Steroids if: parenchymal lung disease, uveitis, hypercalcaemia, neuro or cardiac involvement.
Steroid sparing agents eg MTX, hydroxychloroquine, ciclosporin, cyclophosphamise in severe illness.
Anti-TNF if unpresponsive
Bisphosphonates but not calcium and Vit D (risk of hypercalcaemia)

48
Q

What is the prognosis of sarcoidosis?

A

60% of thoracic sarcoidosis resolves over 2 years, 20% respond to steroids, improvement unlikely in the rest.
Prognosis is poorer in African Carribean patients.

49
Q

DDX for bilateral hilar lymphadenopathy

A

Sarcoidosis
Infection eg TB
Malignancy
Organic dust disease - silicosis, berylliosis
Extrinsic allergic alveolitis
Histiocytosis X

50
Q

Upper zone fibrosis causes

A

Berylliosis, radiation, EAA, ankylosing spondylitis, sarcoidosis, TB

51
Q

Lower zone fibrosis causes

A

RA, other connective tissue diseases, idiopathic, drugs, asbestos

52
Q

Interstitial lung disease treatments

A

Smoking cessation
Pulmonary rehab
LTOT
Antifibrotic agents for patients with usual interstitial pneumonia pattern - pirfenidone and nintedanib

53
Q

Which organisms are often found in the sputum of patients with CF?

A

H. influenzae, Staph aureus, Moraxella catarrhalis, Strep pneumoniae, mycobateria, Aspergillus fumigatus
Burkholderia cepacia, pseudomonas and mycobacterium abscessus are poor prognostic indicators.

54
Q

What are the types of lung cancer?

A

Small cell (15%)
Adenocarcinoma (35-40%)
Squamous cell (25-30%)
Large cell (10-15%)

55
Q

What paraneoplastic syndromes are associated with SCLC?

A

SIADH, Cushings
Lambert-Eaton

56
Q

What paraneoplastic syndromes are associated with lung adenocarcinoma?

A

Hypertrophic pulmonary osteoarthropathy

57
Q

What paraneoplastic syndromes are associated with lung SCC?

A

PrPTH secretion resulting in hypercalcaemia

58
Q

Dermatomyositis classical skin findings

A

Gottron’s papules (knuckes)
Heliotrope rash (eyes)

59
Q

Dermatomyositis key symptoms

A

Patchy rashes with purple or red discolorations, malar rash
Nail changes/cuticle changes
Proximal muscle weakness, Muscle tenderness;
Weight loss;
Arthralgia;
Arthritis;
Dyspnea;

60
Q

Dermatomyositis associations

A

Interstitial lung disease
Cardiac disease
Malignancy

61
Q

Dermatomyositis investigations

A

CK, autoantibodies (anti-Jo)
Imaging eg HR CT chest
EMG
Muscle and skin biopsy

PACES (6 decks)

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