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Y4 Medicine > Respiratory > Flashcards

Respiratory Flashcards

1
Q

Pathophysiology of asthma

A

Chronic inflammation (due to IgE release from mast cells) of the airways causing episodic bronchoconstriction leading to reversible airflow limitation.

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2
Q

Describe the chronic remodelling/histological changes of airways seen in asthma

A

Thickening of sub-basement membrane
sub epithelial fibrosis
airways smooth muscle hypertrophy + hyperplasia
Mucus gland hyperplasia + hyper secretion

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3
Q

Common triggers in asthma

A

Cold air
Exercise
NSAIDs / Aspirin
Beta-blockers
Infection
Animals
Dust
Moulds

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4
Q

Clinical Features of asthma

A

Episodic symptoms + Diurnal variation
Bilateral widespread polyphonic wheeze
Dry cough
History of atopy / exposure to trigger

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5
Q

1st line investigations for asthma

A

Fractional exhaled NO + Spirometry
>40 parts NO is diagnostic + spirometry must demonstrate 12% increase in FEV1 or PEFR following bronchodilator use

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6
Q

2nd line investigations for asthma

A

PEFR diary or Bronchial provocation test

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7
Q

Management of Asthma (Age >12yrs)

A
  1. SABA prn
  2. SABA + low dose ICS
  3. SABA + low dose ICS + LTRA
  4. SABA + low dose ICS + LABA (+/- LTRA if helped)
  5. SABA + MART (ics + laba)
  6. SABA + Med dose ICS + LABA
  7. Refer - for consideration of high dose ICS or adding in Theophylline/Aminophylline
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8
Q

MOA and Example of LTRA

A

Montelukast
MOA = Leukotreine antagonist. reduces inflammation, bronchoconstriction and mucus secretions.

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9
Q

What monitoring is needed for theophylline

A

Plasma levels 5 days after initiation and 3 days after each dose change (due to low therapeutic index)

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10
Q

Definition of COPD

A

Progressive, irreversible long term airflow obstruction caused by damage to lung tissue.

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11
Q

What are the 2 conditions outlined by COPD

A

Emphysema + Chronic Bronchitis

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12
Q

RF for COPD

A

Smoking
Age
FHx
A1AT deficiency
Exposure to dust
Sulphur dioxide exposure

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13
Q

Histological changes in COPD

A

Narrowing of airways
Airways remodelling (pseudo stratified columnar epithelium –> Squamous cell)
Increased number of goblet cells
Mucus gland hyperplasia
Vascular bed changes –> Pulmonary HTN

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14
Q

What is emphysema?

A

Enlargement of alveolar airspace due to breakdown of elastin and destruction of alveolor walls leading to loss of lung elastic recoil + small airways collapse resulting in air trapping.

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15
Q

What is chronic bronchitis

A

Chronic productive cough due to goblet cell hyperplasia and fibrosis + thickening of airways resulting in airflow limitation

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16
Q

How to differentiate between Emphysema + Chronic bronchitis subtypes

A

Emphysema = ‘Pink puffers’ - barrel chest, SOB, pursed lip breathing, weight loss, accessory muscle use

Bronchitis = ‘Blue bloaters’ - chronic cough, ascites, ankle oedema, cor pulmonale, cyanosis, polycythemia

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17
Q

Clinical Signs of COPD

A

Hypoxemia
Asterixes
Distant breath sounds
Tachypnoea
R sided HF signs

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18
Q

MRC dyspnoea scale

A

1 = Breathless on strenuous exercise
2 = Breathless on walking uphill
3 = Breathless that slows on walking flat
4 = Needs to stop + catch breath after walking 100m on flat
5 = unable to leave house due to SOB

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19
Q

Investigations for COPD

A

Clinical Features + Spirometry (Obstructive pattern reduced FEV1:FVC)

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20
Q

Classification of COPD severity

A

Mild = FEV1 >80%
Moderate = FEV1 50-79%
Severe = FEV 30-49%
Very severe = FEV1 <30%

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21
Q

CXR findings in COPD

A

Lung hyperinflation, bullae, flattened diaphragm

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22
Q

Special tests in suspected COP

A

Echocardiogram + ECG (if suspecting cor pulmonale)
TLCO = decreased
Genetic testing (for A1AT deficiency)

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23
Q

Management pathway for COPD

A
  1. SABA or SAMA (e.g ipratropium)
  2. If steroid responsive/asthma features = LABA +ICS
  3. If not steroid responsive = LABA + LAMA (make sure to stop SAMA)
  4. LABA + LAMA + ICS
  5. Add theophylline / azithromycin / Carbocystine
  6. Consider LTOT or lung volume reduction surgery
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24
Q

What monitoring is needed prior to azithromycin treatment

A

LFTs
ECG - can cause prolonged QT interval (tdp)

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25
Q

Indications for long term oxygen therapy in COPD patients

A

2 ABGs at least 3 weeks apart showing SpO2 < 7.3
FEV1 <30%
Polycythemia
Peripheral oedema
Raised JVP
Sp02 < 92% on air

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26
Q

Which condition is characterised by Bronchiectasis + emphysema + Liver cirrhosis

A

Alpha-1 Antitrypsin deficiency

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27
Q

What is the inheritance of A1AT deficiency

A

Autosomal recessive mutation to the SERPINA1 gene on chromosome 14

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28
Q

Which type of lung cancer is most common

A

NSCLC - Squamous cell

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29
Q

Which type of lung cancer has the strongest associated with smoking?

A

Squamous cell

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30
Q

Which type of lung cancer is most common in non-smokers

A

Adenocarcinoma

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31
Q

Which type of lung cancer originates in neuroendocrine cells - APUD/Kulchitsky cells?

A

SCLC

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32
Q

Which lung cancer is caused by undifferentiated tumour cells?

A

Large cell

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33
Q

Cavitating lesions with central necrosis on CXR is indicative of which type of lung cancer?

A

Squamous cell

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34
Q

What are the paraneoplastic extramanifestations of pancoast tumours

A
  1. Recurrent laryngeal nerve palsy
  2. Phrenic nerve palsy
  3. SVC obstruction
  4. Brachial plexus palsy
  5. Horner’s syndrome
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35
Q

Signs + Symptoms of SVC obstruction

A

Facial swelling
SOB
Distended neck veins
Pemberton’s sign - facial congestion + cyanosis when hands raised above head

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36
Q

Hypercalcemia, Hyperthyroidism and Hypertrophic pulmonary osteoarthropathy are parenoplastic manifestations of which type of lung cancer?

A

Squamous cell carcinoma

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37
Q

Gynaecomastia is associated with which type of lung cancer?

A

adenocarcinoma

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38
Q

What are the paraneoplastic manifestations associated with SCLC?

A
  1. SIADH
  2. Cushing’s
  3. Hypercalcemia
  4. Lambert-eaton syndrome
  5. Limbic encephalitis
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39
Q

Management of SCLC

A

Radiotherapy + Chemotherapy

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40
Q

Management for NSCLC

A

Surgery (Lobectomy) + neoadjuvant chemotherapy

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41
Q

Contraindications to surgery in Squamous cell lung cancer

A

Stage IIIb or IV
FEV1 <1.5
Malignant pleural effusion
Tumour near the hilum
Vocal cord paralysis
SVC obstruction

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42
Q

Clinical Features of mesothelioma

A

History of asbestos exposure
SOB
chest pain
SOB
Clubbing
Painless pleural effusion

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43
Q

1st line investigation for mesothelioma

A

CXR: shows pleural effusion / pleural thickening / pleural plaques
Next step = Pleural CT and consider a pleural aspirate if effusion is present

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44
Q

Most common cause of pneumonia in general population

A

Streptococcus pneumoniae

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45
Q

Most common cause of pneumonia in COPD patients

A

Haemophilius influenzae

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46
Q

Main cause of Hospital acquired pneumonia

A

Staph aureus

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47
Q

Which patients tend to get Morazella catarrhalis pneumonia?

A

Immunocompromised patients or those with chronic lung diseases

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48
Q

Which organism causes pneumonia in cystic fibrosis patients

A

Pseudomonas auerginosa

49
Q

Cause of pneumonia in a patient with red current jelly sputum + Epyema + Cavitating lesions in upper lobes

A

Klebsiella

50
Q

Klebsiella pneumonia is common in which patients

A

Chronic alcoholics
Diabetics
Aspiration pneumonia

51
Q

Which type of pneumonia is commonly caused by air-con or infected water

A

Legionella

52
Q

Clinical Signs / Features of Pneumonia

A

Sx = Productive cough + purulent sputum / SOB / Pleuritic chest pain / fever
Signs = Bronchial breath sounds / Focal coarse crackles / Dullness to percussion / Whispering pectroloquy

53
Q

Severity assesment in pneumonia

A

CURB 65
Confusion
Urea >7
RR >30
BP <90
Age >65

54
Q

Management of pneumonia

A

CURB score 0-1 = Amoxicillin 5 days at home (or doxy/clarith/eryth)
2 = Amoxicillin + Macrolide for 10 days (in hosp)
3-5 = IV Co-amoxiclav + fluids + O2

55
Q

What monitoring is required in patients with pneumonia to indicate recovery

A

WBC + CRP

56
Q

Complications of pnuemonia

A

Sepsis
Pleural effusion
Respiratory failure
Lung abscess
Empyema

57
Q

Symptoms of Legionairres disease

A

Flu like symptoms + Dry cough + SIADH + Confusion + deranged LFTs

58
Q

Investigation for legionairres disease

A

Urinary antigen

59
Q

Psittacosis

A

Often caused by contact with birds
Sx = pneumonia + severe headache
Invx = CXR + Atypical pneumonia screen

60
Q

Atypical causes of pneumonia

A

Legionella
Psittacosis
Mycoplasma pneumoniae
Chlamdoyphilia pneumonia
Coxiella (Q fever)

61
Q

Which cause of atypical pneumonia has a prolonged & gradual onset and causes erythema multiforme / erythema nodosum

A

Mycoplasma pneumoniae

62
Q

Cold aha / Guillian barre / Bullous myringitis / Pericarditis and GN are complications of which atypical pneumonia?

A

Mycoplasma pneumoniae

63
Q

When to suspect Q fever

A

Pt with pneumonia symptoms + working as a farmer/in an abattoir

64
Q

Management of Pneumocystosis jiroveci (PCP)

A

Co trimoxazole

65
Q

Clinical Presentation of Bronchiectasis

A

Productive cough
Daily production of sputum (often thick, foul smelling green mucus)
Haemoptysis
Wheeze
Clubbing

66
Q

CT chest showing thickened dilated bronchi + cysts at the end of bronchioles (bunch of grapes pattern) is indicative of what respiratory disease

A

Bronchiectasis

67
Q

Causes of Upper zone fibrosis

A

C - Coal workers pneumoconiosis
H - Hypersensitivity pneumonitis / Histiocytosis
A - Ankylosing spondylitis
R - Radiation
T - TB
S - Silicosis / Sarcoidosis

68
Q

Causes of lower zone fibrosis

A

B - Bronchiectasis
I - Intersitial pneumonia / infection
S - Systemic sclerosis / SLE / RA
A - Aspiration / A1AT deficiency / Asbestosis
M - Medications (BANS ME)

69
Q

Medications causing lower zone fibrosis

A

Bleomycin
Amiodarone
Nitrofuantoin
Sulfalazine
Methotrexate

70
Q

Clinical Presentation of Fibrosis

A

Insidious onset
Progressive exertional dyspnoea
Weight loss
Clubbing
Bi-basal fine end-inspiratory crackles

71
Q

CXR showing reduced lung volume, bilateral interstitial shadowing + lung honeycombing is indicative of what

A

Lung fibrosis

72
Q

Ground glass appearance on CT is indicative of what

A

Lung fibrosis

73
Q

Features of sarcoidosis

A

Erythema nodosum
Bilateral hilar lymphadenopathy
Swinging fever
Polyarthralgia
Fibrosis (SOB + Cough + Weight loss)
Lupus pernio
Hypercalcemia
Non-caseating granulomas

74
Q

Management of Sarcoidosis

A

Oral prednisolone - should be stated when stage 2/3 or hypercalcemia

75
Q

Lofgren’s syndrome

A

Acute form of sarcoidosis characterised by BHL + Erythema nodosum + Fever + polyarthralgia

76
Q

Hereford’s syndrome

A

Parotid enlargement + fever + uveitis (associated with Sarcoidosis)

77
Q

Causes of Hypersensitivity pneumonitis (Extrinsic allergic alveolitis)

A

Farmers lung - wet hay
Bird-fanciers lung - bird droppings
Malt workers lung - mould on barley (aspergillus)
Mushroom lung

78
Q

Clinical presentation of Hypersensitivity pneumonitis

A

SOB + dry cough + fever acutely.
After weeks/months = Lethargy + SOB + Anorexia + weight loss

79
Q

Investigations + Special tests for hypersensitivity pneumonitis

A

FBC = No eosinophilia
Imaging = Upper/mid zone honeycomb lung/fibrosis
Special tests = bronchealveolar lavage shows raised lymphocytosis + mast cells

80
Q

Pt presents with a new wheeze + cough + SOB.
The patient has a PMH of bronchiectasis.
FBC shows eosinophilia
CXR shows new infiltrates
+Ve RAST test
Diagnosis?

A

Allergic bronchopulmonary aspergillosis

81
Q

CT scan findings in Allergic bronchopulmonary aspergillosis

A

Bronchocoeles
(finger in glove appearance)

82
Q

Special tests for allergic bronchopulmonary aspergillosis

A

RAST test to aspergillus
IgE raised
+ve IgG precipitans

83
Q

Management of Allergic bronchopulmonary aspergillosis

A

Oral prednisolone

84
Q

Idiopathic pumonary fibrosis + Features

A

Essentially fibrosis without any other clear cause.
Typically men aged 50-70yrs
Features = exertional SOB + Weight loss + Bibasal fine end-inspiratory crackles
Reduced TCLO
Fibrosis on CXR

85
Q

Risk Factors for PE

A
  1. Vessel wall damage (Surgery / Previous DVT / Trauma)
  2. Venous stasis (Age >40 / Bed rest / long haul flight / General anesthetic / Paralysis)
  3. Hypercoagulability (Pregnancy / COCP / HRT / Cancer / Polycythemia / SLE / Obesity)
86
Q

Clinical Presentation of PE

A

SOB + Pleuritic chest pain + Haemoptysis
Tachycardia + Tachypnoea + Hypotension + Pleural rub

87
Q

Causes of Transudative Pleural effusion

A

= < 25g/L protein + Low LDH
Heart failure
Renal failure
Constrictive pericarditis
Liver disease / Hypoalbuminemia
Hypothyroidism
Meig’s syndrome

88
Q

Meig’s syndrome

A

Ovarian cancer + R sided pleural effusion

89
Q

Causes of Exudative Pleural effusion

A

> 30g/L protein + High LDH
Pneumonia
Lung cancer / TB
Connective tissue disease (RA/SLE)
Acute pancreatitis
Dressler’s syndrome
Mesothelioma

90
Q

Light’s Criteria

A

Useful for when protein is 25-30g/L
An exudative is likely if:
> Pleural fluid protein/Serum protein is >0.5
> Pleural fluid LDH/Serum LDH is >0.6
> Pleural fluid LDH is >2/3rds more than normal serum LDH

91
Q

Examination findings in a patient with a pleural effusion

A

Stony dullness to percussion
Quiet breath sounds
Reduced chest expansion
Decreased/absent tactile vocal fremitus

92
Q

If pleural fluid aspirate shows heavy blood staining what are the most likely causes of the pleural effusion

A

Mesothelioma
PE
TB

93
Q

Empyema

A

= Purulent fluid in the pleural space (infected pleural effusion)
Pleural aspirate = Pus, pH <7.2, Low glucose, High HDL

94
Q

Diagnostic test for OSA

A

Polysomnogrphy

95
Q

Management of acute bronchitis

A

Consider doxycycline (if systemically unwell or CRP >100)

96
Q

Kartagner’s syndrome

A

Dextrocardia + Bronchiectasis + Recurrent sinusitis + Subfertility

97
Q

Small volume complexes in lateral leads or Quiet heart sounds may indicate what?

A

Dextrocardia

98
Q

Wegners vasculitis - features + Invx

A

Granulomatosis with polyangitis
Features = Epistaxis + sinusitis + nasal crusting + saddle shaped nose deformity + haemoptysis + SOB + Glomerulonephritis + vasculitic rash
Invx = cANCA +ve
Renal biopsy = Epithelial crescents in the bowman’s capsule

99
Q

Management of Wegner’s granulomatosis

A

Steroids + Cyclophosphamide + Plasma exchange

100
Q

Churg-Strauss vasculitis - Features & invx

A

Eosinophilic granulomatosis with polyangitis
Features = asthma + paranasal sinusitis + mononeuritis multiplex
Bloods = eosinophilia
Invx = pANCA +Ve

May be precipitated by montelukast

101
Q

Red staining with ziehl-nielson stain on sputum sample indicates what organism

A

TB

102
Q

CXR findings in TB

A

Upper zone consolidation
Bilateral hilar lymphadenopathy
Ghon focus (in primary infection)

103
Q

Gold standard investigation for TB

A

Sputum culture

104
Q

Rapid diagnostic test for TB

A

NAAT

105
Q

TB Screening

A

Mantoux test - used among high risk population.
<6mm induration = consider BCG vaccine
>6mm induration = DO NOT GIVE BCG VACCINE!
If >15mm = active infection

106
Q

Management of TB

A

Rifampicin - 6 months
Isoniazid - 6 months
Pyrazinamide - 2 months
Ethambutol - 2 months

107
Q

Rifampicin

A

MOA = Inhibits bacterial DNA dependent RNA polymerase
CYP450 inducer
SE’s = Hepatitis, Red-orange secretions , Flu-like symptoms

108
Q

Isoniazid

A

MOA = inhibits mycolic acid synthesis
SEs = Peripheral neuropathy / Hepatitis / Agranulocytosis / Sideroblastic anemia
CYP450 inducer

*Prescribe pyroxidine (B6) with it to prevent neuropathy

109
Q

Pyrazinamide

A

MOA = Inhibits fatty acid synthesis
SEs = Gout / arthralgia / hepatitis

110
Q

Ethambutol

A

MOA = inhibits arabinosyl transferase
SEs = Optic neuritis

111
Q

Acute mountain sickness

A

Sx start around 2500-3000m and last a few days
Sx = Headache / Nausea / Fatigue

112
Q

Which drug can prevent acute mountain sickness

A

Acetazolamide - works by causing a metabolic acidosis and compensatory respiratory alkalosis which increases the RR.

113
Q

Management of acute mountain sickness

A

descent

114
Q

High altitude pulmonary oedema

A

develops > 4000m
SOB + Orthopnoea + Haemoptysis + PND
Management = descent + dexamethasone

115
Q

High altitude cerebral oedema

A

Develops >4000m
Sx = Headache + ataxia + papillodema

116
Q

Management of HACE (High altitude cerebral oedema)

A

Descent
Nifedipine + Dexamethasone + Acetazolamie + Sildenafil + Oxygen

117
Q

Egg shell calcification of hilar lymph nodes

A

Silicosis

118
Q

Management of pneumothorax

A

< 2cm and no SOB = discharge + review in 2-4weeks
> 2cm or SOB = Aspirate + reassess. If aspiration fails or patient is >50yrs insert chest drain

If a secondary pneumothorax (i.e there is existing lung disease) = Aspirate if < 2cm + Chest drain if >2cm.

Recurrent ones = Pleurodesis +/- Bullectomy

119
Q

Most common cause of occupational asthma

A

Isocyanates - spray painting

Y4 Medicine (22 decks)

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