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Respiratory Flashcards

1
Q

Wasting of hand muscles

A
  • Pancoast tumour (compresses brachial plexus –> hand weakness)
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2
Q

Bounding pulse

A
  • CO2 retention (stimulated chemoreceptions = increased cardiac output)
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3
Q

Features of Horner’s Syndrome

A
  • Miosis
  • Partial ptosis
  • Anhydrosis
  • Enophthalmos (opposite of exophthalmos)
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4
Q

Normal inspiratory: expiratory ratio

A
  • 1:2
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5
Q

Causes of increased vocal resonance vs decreased

A

Increased = increased lung density
- Consolidation
- Collapse
- Tumour

Decreased = decreased lung density
- Effusion
- Pneumothorax
- Emphysema

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6
Q

Causes of fine vs coarse crepitation

A

Fine
- Fibrosis
- Oedema

Coarse
- Consolidation
- Bronchiectasis
- COPD

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7
Q

Cause of monophonic vs polyphonic wheeze

A

Monophonic = single large airway
- Cancer
- Foreign body

Polyphonic = different-sized airways constricting at different times
- Asthma
- COPD
- Infection

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8
Q

Causes of pleural rub

A

Abnormal pleura rubbing each other causing friction
- Pleurisy
- Effusion
- Mesothelioma

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9
Q

How is Diffusion Capacity calculated?

A
  • Breathe in CO (crossed alveolar membrane) and helium (does not)
  • Amount of CO that crosses into blood = TLCO
  • Helium concentration breathed out is how much air in lungs to dilute it = total lung volume –> use to calculate KCO (gas transfer per unit volume)
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10
Q

MRC scale for breathlessness

A

1: strenuous exercise
2: slight hill
3: stop for breath walking flat
4: stop after 100m
5: when dressing

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11
Q

CXR sign of hyper-expansion

A

More than 6 anterior or 10 posterior ribs in the mid-clavicular line at the lung diaphragm level.

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12
Q

Indications for LTOT

A
  • PaO2 <7.3

OR PaO2 <8 and :
- Secondary polycythaemia
- Pulmonary HTN
- Cor pulmonale

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13
Q

Eligibility for LVRS in COPD

A
  • FEV1 <50%
  • SOB affects quality of life
  • Don’t smoke
  • 6min walk test >140m
  • (Ideally upper lobe emphysema)
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14
Q

Treatment for COPD

A
  • LAMA+LABA
  • LAMA+LABA+ICS if asthma features, eos >0.3
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15
Q

Eligibility for transplant in COPD

A
  • FEV1 <50%
  • SOB affects quality of life
  • Don’t smoke
  • Completed pulmonary rehabilitation
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16
Q

Contraindications for NIV in COPD exacerbation

A
  • Undrained pneumothorax
  • Confusion
  • Facial injuries
  • Upper airway obstruction
  • Upper GI surgery
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17
Q

Respiratory causes of clubbing

A

ABCDEF
Abscess (lung) and Asbestosis
Bronchiectasis
Cystic fibrosis
Dirty tumours (bronchogenic carcinoma, mesothelioma)
Empyema
Fibrosing alveolitis (IPF)

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18
Q

Causes of clubbing and creps

A

FAB you know this:
Fibrosing alveolitis (IPF)
Asbestosis
Bronchiectasis, Bronchogenic carcinoma.

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19
Q

HRCT signs of bronchiectasis

A
  • Cylindrical (advanced), saccular (cystic), varicose (irregular airways)
  • Bronchial thickening/dilation (“tram tracks”)
  • Lack of normal airway tapering–> see bronchi within 1cm of pleura
  • “Signet ring sign” = bronchi > 1.5 times larger than
    adjacent vessel
  • Mucus plugging in bronchioles
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20
Q

Causes of bronchiectasis

A
  • Congenital (CF, PCD, Young’s)
  • Childhood infection (pertussis, TB, measles)
  • Mechanical (cancer, granuloma, lymph node TB)
  • Immune underactive (congenital = hypogammaglobulin, acquired = AIDS)
  • Immune overactive (ABPA)
  • Aspiration (localised RLL)
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21
Q

CF diagnostic test

A
  • Sweat chloride >60mmol/L
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22
Q

Features of Young’s syndrome

A
  • Like CF but no abnormal sweat/pancreatic insufficiency
  • Diagnosed in middle-aged men who test for infertility
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23
Q

Cause and mechanism of CF

A
  • Autosomal recessive disease due to defect in CFTR gene on chromosome 7
  • CFTR found in all exocrine tissues (hence sinusitis and pancreatitis)
  • Stops Chloride moving out of cells–> Na follows to keep isoelectric–> water follows into cells –> thick secretions
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24
Q

CF bug which can lead to increased worsening of lung function

A
  • Burkholderia cepacia ‘complex’ (Gram -ve)
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25
Q

Signs of old TB

A
  • Supraclavicular scar (phrenic nerve crush)
  • Thoracotomy
  • Chest deformity/missing ribs (thoracoplasty = remove 2 ribs so anterior chest wall collapses into affected side)
  • Tracheal deviation to fibrosis in old TB site
  • Dull percussion
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26
Q

Investigation signs of old TB

A
  • Apical fibrosis
  • Pleural scarring
  • Aspergilloma in old TB cavity
  • Kyphosis (Pot’s Disease)
  • Bronchiectasis (lymph node obstruction causing distal bronchiectasis)
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27
Q

Investigations for TB

A
  • 3 sputum samples (including early morning): culture and auramine stain for AFB
  • Nucleic acid amplification test (NAAT)
  • IGRA (previous TB)
  • HIV test!!!
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28
Q

CXR findings of TB

A
  • Hilar/paratracheal lymphadenopathy
  • Pulmonary nodules/infiltrates
  • Upper lobe cavitation
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29
Q

Management of TB

A
  • Notify PHE and contact trace
  • Before treatment: LFTs, acuity, colour blindness
  • If fully sensitive: RIPE for 2 months –> RI for 4 more months
  • Give pyridoxine (B6)
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30
Q

Side effects of TB meds

A
  • Rifampicin: liver enzyme inducer (COCP, anti-epileptics)
  • Isoniazid: peripheral neuropathy
  • Pyrazinamide: gout
  • Ethambutol: optic neuritis

They ALL cause hepatitis!

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31
Q

Squeaks on auscultation

A
  • Hypersensitivity pneumonitis
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32
Q

Causes of upper zone fibrosis

A

CHARTS
- Coal worker’s pneumoconiosis
- Hypersensitivity pneumonitis (fibrotic EAA)
- Ank spond/ABPA
- Radiation
- Tuberculosis
- Sarcoidosis/Silicosis

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33
Q

Causes of lower zone fibrosis

A

RATIO
- Rheumatoid arthritis
- Asbestosis
- Tissue disease connective (scleroderma, Sjögren’s, SLE)
- IPF
- Other - chemicals (lead, paraquat, dry-cleaning fluids) or drugs

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34
Q

Causes of asymmetrical fibrosis

A
  • Old TB
  • Cancer/radiotherapy
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35
Q

Iatrogenic causes of fibrosis

A

BBC is MANS Gold
- Bleomycin
- Cyclophosphamide
- Methotrexate
- Amiodarone
- Nitrofurantoin
- Sulphasalzine
- Gold (used to treat RA)

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36
Q

List different idiopathic interstitial pneumonias

A
  • UIP: in IPF, not steroid responsive, poorer prognosis
  • NSIP: more steroid responsive
  • Desquamative Interstitial Pneumonia (DIP): due to smoking, steroid-responsive
  • Cryptogenic Organizing Pneumonia (COP): resembles pneumonia but does not respond to abx– give steroids for 6-12months (happens in inflammatory conditions e.g. RA)
  • Acute Interstitial Pneumonia (Haman-Rich Syndrome): rapid ARDS, supportive treatment may respond to steroids
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37
Q

Antibody for limited systemic sclerosis

A
  • Anti-centromere
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38
Q

Antibody for diffuse systemic sclerosis

A
  • Anti-topoisomerase (anti-Scl 70)
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39
Q

Antibody for dermatomyositis

A
  • Anti-Jo 1
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40
Q

Which ILD conditions have high lymphocytes in BAL

A
  • Hypersensitivity pneumonitis
  • Sarcoidosis
  • Organizing pneumonia
  • Lymphocytic interstitial pneumonia (LIP)
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41
Q

5 respiratory complications of RA

A
  • Pleural effusion
  • Nodules
  • Fibrosis
  • Caplan Syndrome (pneumoconiosis and RA)
  • Obliterative bronchiolitis (bronchiole inflammation –> necrotizing fibrosis)
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42
Q

How much effusion do you need to get symptoms

A
  • > 500ml
  • Need >1L for tracheal deviation away
  • Need 300ml to see on PA CXR (25ml on lateral film)
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43
Q

Cause of transudate effusions

A

CHAM
- CCF
- Hypoalbumin (nephrotic syndrome)
- All failures (inc cirrhosis)
- Meig’s Syndrome (ovarian fibroma)

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44
Q

Cause of exudative effusions

A

PINTS
- Pneumonia
- Infarction (PE)
- Neoplasm
- TB/trauma
- Sarcoid/scleroderma

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45
Q

Differential for dull bases

A
  • Collapse
  • Consolidation
  • Fibrosis
  • Raised diaphragm (phrenic nerve palsy, hepatomegaly)
  • Pleural thickening
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46
Q

Why take blood test at same time as pleural aspirate

A
  • So serum LDH and albumin can be taken for Light’s criteria
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47
Q

Definition of transudate vs exudate

A

Protein concentration
- Exudate >35g/L
- Transudate <25g/L

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48
Q

Light’s criteria for pleural effusion

A

Exudate:
- Pleural albumin: serum albumin > 0.5
- Pleural LDH: serum LDH > 0.6
- Pleural LDH > 2/3rds upper normal limit of serum LDH

25 % of patients with transudates are mistakenly identified as having exudates by Light’s criteria

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49
Q

Definition of empyema

A
  • pH <7.2 (and glucose <2)
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50
Q

What is normal glucose level in effusion

A
  • > 2mmol/L
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51
Q

Causes of low glucose effusions

A

MEAT:
- Malignancy
- Empyema
- Arthritis (rheumatoid)
- TB

52
Q

Diagnostic criteria for haemothorax

A
  • Hct effusion/Hct serum > 0.5
53
Q

Cause of chylothorax

A

Lymph seeps into pleural space
- Post-pneumonectomy
- Lymphoma/cancer
- Trauma

54
Q

Diagnostic criteria for chylothorax

A
  • Triglycerides >1.3mmol/L
55
Q

Other calculation for exudate effusion

A

Serum albumin - pleural albumin = <1.2g/dL

56
Q

Simple vs complicated parapneumonic effusion

A

Complicated
- Empyema (pH <7.2)
- Culture positive fluid

57
Q

Definition of apnoea

A
  • No breathing for 10 seconds
58
Q

Definition of hyponoea

A
  • Breathing <50% below baseline AND desaturation or sleep arousal
59
Q

Components of a sleep study (i.e. diagnostic tests)

A
  • EEG
  • EMG
  • Electro-oculogram (EOG)- determines sleep stage/REM
    (Do 2nd study with CPAP pressure titration if diagnosis confirmed)
  • Need 5 episodes/hour to diagnose OSA
60
Q

How is OSA severity calculated (and what is severe)

A

Apnoea-hypopnea index (number of event per hour of sleep)
- >30 is severe

61
Q

Causes of OSA

A

Upper airway obstruction
- Obesity
- Macroglossia (Down’s/hypothyroid)
- Mandibular deficiency (micrognathia or retrognathia)

Reduced upper airway tone
- Neurological issue

62
Q

Causes of central sleep apnoea

A
  • Cheynes-Stokes apnoea: stroke, heart failure
  • Brainstem lesion
  • Opioid use
63
Q

Hoarse voice- relevance to respiratory?

A
  • Left laryngeal nerve palsy (passes along trachea)
64
Q

Hand features of Horner’s Syndrome

A
  • Weakness/atrophy of intrinsic muscles (T1)
  • Pain/paraesthesia at 4th/5th digits (C8) and medial forearm (T1)
65
Q

Clubbing and pain at wrist/ankles

A
  • Hypertrophic pulmonary osteoarthropathy: subperiosteal bone formation (periosteum is layer above bone)
  • Any lung cancer type, esp squamous and adenocarcinoma
66
Q

Features of Lambert-Eaton Syndrome

A
  • Proximal muscle weakness- improves with exercise
  • Reduced tendon reflexes- improves with exercise (check reflexes before and after testing power)
  • Cranial nerve involvement (ptosis, diplopia)
67
Q

Lambert-Eaton Syndrome in which lung cancer

A
  • Small cell lung cancer
68
Q

Pathophysiology of Lambert-Eaton Syndrome

A
  • Antibodies against voltage-gated calcium channels–> reduced acetylcholine release from presynaptic nerve terminals (so adjacent muscle does not depolarise)
69
Q

Difference between Myasthenia Gravis and Lambert-Eaton Syndrome

A
  • Myasthenia: antibodies against acetylcholine-receptor
  • Lambert-Eaton: antibodies against voltage-gate calcium channel
70
Q

Paraneoplastic syndromes in lung cancer

A

Neurological:
- Lambert-Eaton (small cell)
- Peripheral neuropathy

Musculoskeletal
- Hypertrophic pulmonary osteoarthropathy (SCC, adenocarcinoma)

Endocrine
- Hypercalcaemia (PTH-related peptide) (SCC)
- SIADH (small cell)
- Ectopic ACTH (small cell)

Skin
- Acanthosis nigricans
- Thrombophlebitis migrans

71
Q

Presenting features of SIADH

A
  • Confusion
  • Hyponatraemia– with raised urine osmolarity/low serum osmolarity, raised urine sodium
72
Q

Treatment of SIADH

A
  • Fluid restrict if euvolaemic
  • Tolvaptan (vasopressin receptor antagonist)
  • Demeclocycline (tetracycline which reduces responsiveness of collecting tubule to ADH)
  • Slow sodium chloride tablets
73
Q

Staging classification for small cell cancer

A
  • Limited = same hemithorax (15-20months)
  • Extensive = outside of hemithorax (8-13months)
74
Q

WHO performance status

A
  • 0: asymptomatic
  • 1: light work
  • 2: bed <50% of day, can self-care but not work
  • 3: bed >50% of day, limited self-care
  • 4: bedridden
  • 5: dead
75
Q

Eligibility criteria for lung cancer surgery

A
  • FEV1 >2L for pneumonectomy and >1.5L for lobectomy
  • Ideally DLCO >80% and pre-op VO2 max >15ml/min/kg
76
Q

Features of Superior Vena Cava Obstruction

A
  • Pemberton’s sign: lifting arms above head worsens signs (thyroid compressed against thoracic inlet, which contains the SVC)
  • Facial plethora
  • Facial/upper body oedema
  • SOB
  • Hoarse voice
  • Fixed elevated JVP
  • Stridor if severe
77
Q

Causes of Superior Vena Cava Obstruction

A

Disease of right lung/lymph nodes/mediastinum
- Small cell lung cancer
- Non-Hodgkin’s Lymphoma
- Thymoma

78
Q

Treatment of Superior Vena Cava Obstruction

A
  • Dexamethasone 8mg BD with PPI cover
  • Stenting
  • If not stentable: emergency radiotherapy
79
Q

Symptoms of metastatic spinal cord compression

A
  • New back pain/worse than usual back pain
  • Limb weakness–> difficulty walking
  • Incontinence/retention
80
Q

Management of metastatic spinal cord compression

A
  • 16mg dexamethasone STAT –> 8mg BD (0800 and 1200)—with PPI cover
  • STRICT bed rest until neurosurgeons confirm if spine stable
  • Surgery + post-op radiotherapy (or only radiotherapy in non-surgical candidates)
81
Q

Treatment of hypercalcaemia of malignancy

A
  • STOP calcium supplements!
  • 2-6L over 24hrs initially
  • STAT zolendronic acid –> consider another dose at day 5 (adjust dose if Cr clearance <60)
  • Denosumab if zolendronic doesn’t work
82
Q

Trachea deviation in lobectomy?

A
  • Only in upper lobectomy = towards lobectomy (may be central in other lobectomies)
83
Q

Breath sounds in pneumoectomy

A
  • Usually decreased (thoracic cavity fills with gelatinous stuff)
  • May have bronchial breathing in upper zones due to deviation of trachea towards the pneumonectomy
84
Q

Types of pneumonectomy

A
  • Simple: lung
  • Extrapleural (mesothelioma): lung, diaphragm, parietal pleura and pericardium (these linings replaced with Gore-Tex surgical patches)
85
Q

Operative mortality for pneumonectomy and lobectomy

A
  • Lobectomy: 2-4%
  • Left pneumonectomy: 3%
  • Right pneumonectomy: 10% (complications are higher)
86
Q

Complications of pneumonectomy

A
  • Post-pneumonectomy syndrome (right pneumonectomy): hyperinflation of other lung–> compresses distal trachea and mainstem bronchus–> symptoms a few months after surgery –> needs re-do surgery
  • Bronchopleural fistula
  • Pulmonary oedema
87
Q

Signs of pulmonary HTN

A
  • Left parasternal heave (RV hypertrophy)
  • Loud P2 and palpable
  • Wide splitting of S2
  • Tricuspid regurg (RV dilation)–> pansystolic murmur left sternal edge loudest on inspiration
88
Q

Definition of cardiomegaly on CXR

A
  • Cardiac silhouette: thoracic cavity >0.5
89
Q

CXR signs of pulmonary HTN

A
  • Cardiomegaly (cardiac silhouette: thoracic cavity >0.5)
  • Enlarged pulmonary trunk, with prominent peripheral vessels
90
Q

ECG signs of pulmonary HTN

A
  • Prominent p waves (p pulmonale) due to RA enlarged
  • Right axis deviation
  • RBBB
91
Q

Diagnostic definition of pulmonary HTN

A
  • Mean pulmonary artery pressure > 25mmHg with a pulmonary capillary wedge pressure/left atrial pressure <15mmHg
92
Q

List the 5 classes of pulmonary HTN

A
  • 1: Pulmonary arterial hypertension
  • 2: Left-sided cardiac disease
  • 3: Lung disease (hypoxaemia)
  • 4: CTEPH
  • 5: Others (sarcoid, Langerhans cell histiocytosis)
93
Q

How to palpate for parasternal heave

A
  • Heel of hand vertical along left sternal edge
  • Heave = hand lifted off the chest with each systole
94
Q

BAL feature of fibrosis which suggests steroid-responsiveness

A
  • Lymphocytes > neutrophils
95
Q

CT features of UIP

A
  • Bibasal subpleural honey-combing
  • Traction bronchiectasis
  • Heterogenous distribution
96
Q

CT features of NSIP

A
  • Ground-glass shadowing
  • Reticular opacities
97
Q

One lung normal breath sounds, other lung has fine creps– diagnosis?

A
  • Unilateral lung transplant in fibrosis
98
Q

Counselling needed after starting TB meds

A
  • Get sclera everyday– if yellow, stop TB meds and call TB nurse
  • If red colour less bright, ring TB nurse
  • COCP may not work
  • Don’t wear contact lenses as may turn orange
99
Q

Signs of upper vs lower lobectomy

A
  • Upper: hyper-resonant upper with dull base (raised diaphragm)– or could be normal examination!
  • Lower: dull percussion and absent breath sounds at bases
100
Q

CXR signs of lobectomy

A
  • Could be normal!
  • Raised hemidiaphragm (note right should normally be above left)
101
Q

Indication for bullectomy in COPD

A
  • Bullus >1L and compresses surround lung
102
Q

Wheeze in a rheumatoid arthritis patient

A
  • Obliterative bronchiolitis (also occurs after lung transplant)
103
Q

Causes of empyema

A
  • Staph and strep
  • Anaerobes
  • Psuedomonas (fusobacterium)
104
Q

Treatment for pancreatic CF disease

A
  • Creon (lipase, protease, amylase)
  • Fat-soluble vitamins (ADEK) - because CF can’t absorb fat so don’t absorb the vitamins normally dissolved in fat
105
Q

Causes of false positive sweat test for CF

A
  • Hypothyroidism
  • Addison’s
106
Q

Urine tests in pneumonia

A
  • Legionella antigen
  • Pneumococcal antigen
  • Haemaglobin: mycoplasma causes cold agglutins (IgMs against RBCs–> haemolysis)
107
Q

Bug which commonly causes bacterial IECOPD

A
  • Haemophilus influenzae (Gram -ve)
108
Q

What additional antibiotic would you add if severe pneumonia

A
  • Metronidazole to cover anaerobics
109
Q

Adjunct to antibiotics/chest drain for empyema

A
  • Intrapleural fibrinolytics (dornase alfa/alteplase for 3 days)- because bacteria cause fibrin net in Fibrinopurulant stage of empyema
110
Q

Which pneumonia covers right heart border

A
  • RML
111
Q

Why are CF men infertile

A
  • Congenital Bilateral Absence of Vas Deferens (carries sperm out of testes)
112
Q

Definition of PEFR variability in asthma

A
  • Varies by 20% for 3 days a week for 2 weeks
113
Q

Stages of sarcoidosis

A
  • 1: bilateral hilar lymphadenopathy
  • 2: bilateral hilar lymphadenopathy + infiltrates
  • 3: infiltrates only
  • 4: fibrosis (mid-zone)
114
Q

Skin manifestations of sarcoidosis

A
  • Lupus pernio
  • Erythema nodosum
  • Maculopapular lesions/plaques
  • Subcutaneous nodules
115
Q

Other conditions which cause raised serum ACE

A
  • Pulmonary TB
  • Lymphoma
  • Asbestosis

So use serum ACE to check response to treatment in sarcoidosis

116
Q

When do d-dimer if suspect PE

A
  • If Well’s score <4 but you still suspect PE
  • (If Well’s score >4, you are not meant to check d-dimer!)
117
Q

Thrombolysis criteria in PE

A
  • Cardiac arrest
  • SBP <90 with end-organ hypoperfusion (or needing vasopressors to maintain SBP 90)
  • SBP drop >40 for 15mins, not caused by something else
118
Q

Alteplase doses for PE thrombolysis

A
  • Cardiac arrest: 50mg
  • Others: 10mg bolus –> 90mg over 2hrs –> heparin infusion until stable enough for LMWH
119
Q

How to use salbutamol in asthma attack and when to call 999

A
  • 1 puff every 30 seconds up to max of 10 puffs
  • Then call 999 if not feeling better
  • Can take another 10 puffs after 10mins if ambulance not there yet
120
Q

Chest expansion
- Where to measure
- What is normal
- What is pathologically low

A
  • 4th ICS
  • 5cm
  • <2.5cm
121
Q

Pattern of arthritis caused by sarcoidosis

A
  • Symmetrical oligoarthritis
122
Q

2 ways in which sarcoidosis affects kidneys

A
  • Glomerulonephritis
  • Stones (high calcium)
123
Q

Primary Ciliary Dyskinesia triad

A
  • Bronchiectasis
  • Sinusitis
  • Situs inversus
124
Q

Breathless patient- what 2 important things need to ask in history

A
  • PND and orthopnoea!
125
Q

Mode of inheritance cystic fibrosis and gene/chromosome involved

A
  • Autosomal recessive
  • CFTR gene on chromosome 7
126
Q

Tests in returning traveller

A
  • Malaria blood film x3 and rapid diagnostic test
  • Stool MC&S with ova, cysts and parasites
  • AFB x3
  • Extended respiratory viral screen
  • Blood-bourne viruses with HIV
  • Serology tests (Dengue, leptospirosis, chikungunya)

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