Respiratory Flashcards
What does a bovine cough suggest?
Vocal cord palsy
At what SaO2 does central cyanosis start to become visible?
SaO2 <90%
Does COPD result in clubbing?
No
What are the cardiovascular causes of clubbing?
Cyanotic/congential heart disease and infective endocarditis
What are the respiratory causes of clubbing?
MOST COMMON: Lung cancer (but not usually small cell as it develops too quickly). Chronic pulmonary suppuration: bronchiactasis, lung abscess, empyema. Also idiopathic pulmonary fibrosis (and a lesser extent, other interstitial lung disease).
LESS COMMON: asbestosis, cystic fibrosis, pleural mesothelioma or pleural fibroma.
What are the GI causes of clubbing?
cirrhosis, IBD, coeliac disease
What is the name of the process that leads to clubbing that also can cause detectble arthropathy at the wrist?
Hypertrophic pulmonary oestoarthropathy. Presents as periosteal inflammation at the distal ends of long bones and can be detected by palpating the distal ends of the radial and ulnar bones, but also the ankles and metacarpal/metatarsal bones.
Other than asterixis, what might be found in the hypercapnoeaic patient?
Confusion, warm peripheries and bounding pulse.
What is the triad of signs that comprises a Horner’s syndrome?
Ptosis, miosis (pupil constriction) and anhidrosis of the affected side.
What is the cause of a Horner’s syndrome?
Hypothalamus lesion
Lateral medullary syndrome
C-spine disease
Lung malignancy
Lower brachial plexopathy
Carotid aneurysm
Thyroid lesions
Neck lymphadenopathy
What muscle closes the upper and lower lids and what innervates this muscle?
Orbicularis oculi. Innervated by the seventh (facial) nerve.
What muscle opens the upper eye lid and what innervates this muscle?
The levator palpedbrae superioris. Innervated by the third (occulomotor) cranial nerve.
What is Mullers muscle?
It’s the little muscle that opens the eye really wide when someone looks shocked. It’s innervated by the sympathetic nervous system, and becomes paralysed when the sympathetic chain is paralysed.
Horner’s syndrome is caused by what?
Unilateral defect of the sympathetic innervation of the head and neck. This can occur as a result of a lesion anywhere along this tract from the hypothalmus, into the brainstem, down the spine to the T1 level, then up through the sympathetic chain, via the neck along the carotid and jugular veins or in the face.
What is the differential cranial nerve deficit for a unilateral ptosis if not Horner’s syndrome?
CNIII nerve palsy, however this would also cause issues with extraocular muscles leading to a down and out appearance.
What pathologies lead to tracheal deviation towards the lesion?
Upper lobe collapse, upper lobe fibrosis, pneumonectomy
What pathologies lead to tracheal displacement away from the side of a lung lesion?
Massive pleural effusion or tension pneumothorax
What are the types of added breath sounds?
Wheezes (continuous),crackles (interrupted), and rubs.
What is the significance of polyphonic vs monophonic wheeze?
Polyphonic wheezes are the result of multiple foci of airway narrowing in say COPD or asthma. A monophonic wheeze suggests a single narrowing of an airway producing a single note - e.g. with a intrabronchial malignancy.
What is the significance of early, vs mid-late vs pan inspiratory crackles?
Early only crackles are heard in small airways, rather than alveolar, disease such as COPD and cease by mid inspiration. Mid-late or pansystolic crackles suggest disease isolated to the alveoli. These mid-late or pansystolic crackles can then be further characterised as fine, medium or coarse. Numerous fine crackles are classic of interstitial lung disease. Medium crackles are usually due to pulmonary oedema. Coarse crackles suggest signifcant intra-airway secretions impacting on normal alveolar function seen in diseases such as bronchiectasis or pneumonia.
What are the differentials for a pleural friction rub?
Pneumonia, pulmonary infarction. Rarely, malignancy, spontaneous pneumothorax.
What does increased vocal resonance indicate?
Increased tissue density that is able to transmit higher pitch sounds. This usually indicates consolidation secondary to infection or other cause.
What components of the cardiac exam should be included routinely as part of respiratory exam?
JVP, palpate for right heart dysfunction (heaves and thrills), auscultate for P2, look at the legs for pulmonary oedema or evidence of DVT, examine the liver the displacement inferiorly due to COPD and tendorness or pulsatility due to right heart failure with TR.
Which way does the trachea go in unilateral atelechtasis?
Deviation towards the atelectasis
What is Light’s criteria?
Exudate criteria requires ONE of the following: 1. pleural fluid/serum protein >0.5, OR 2. pleural fluid/serum LDH >0.6, OR 3. pleural fluid LDH >2/3 normal upper limit for serum LDH.
Differentials for transudate pleural effusion?
Cardiac failre
Hypoalbuminaemia (e.g. secondary to nephrotic syndrome, liver disease or malignancy)
Hypothyroidism
Meig’s syndrome
Differentials for exudative pleural effusion?
Pneumonia
Malignancy
TB
Pulmonary infarction
Pancreatitis
Connective tissue disease including RA and SLE
Some cytotoxic medications
Radiotherapy
Trauma
Meig’s syndrome
Pseudo Pseudo Meig’s - raised CA125, ascites and pleural effusion in a pt with SLE.
What is Meig’s syndrome?
Benign ovarian tumour accompanied by exudative pleural effusion and ascites. The ascites and effusion resolve when the tumour is removed. Why ascites and pleural effusion accompany a benign ovarian tumour is not understood. Theories unclud thoraci ductal obstruction, tumour production of excess VEGF and other random things. It is a diagnosis of exclusion and can only be diagnosed after the tumour is removed and the third spaced fluid collections resolve.
Differentials for chylothorax?
Thoracic duct injury from trauma
Thoracic duct injury from malignancy
Empyema differentials
Pneumonia
Lung abscess
Bronchiectasis
TB
Penetrating chest wound
What is Yellow Nail Syndrome?
Rare condition caused by lymphatic system hypoplasia. It’s associated with pleural effusion, bronchiectasis and lower limb lymphoedema.
Causes of secondary pneumothorax?
Medical intervention
Emphysema bullae rupture - older pts
Asthma - when severe
Lung abscess
Eosinophilic granuloma
Lymphangioleimyomatosis - pre-menopausal women
Marfan’s syndrome
End stage pulmonary fibrosis
What the congential causes of bronchiectasis?
Cystic fibrosis
Primary ciliary dyskinesia
Congential hypogammaglobulinaemia
What are the acquired causes of bronchiectasis?
Recurrent childood infections (esp whoping cough, pneumonia or measles)
Localised disease such as foregin body aspiration, bronchial adenoma or TB
Allergic bronchopulmonary aspergillosis (ABPA - causes proximal bronchiectasis).
What is Hoover’s sign?
Paradoxical coming together of the thumbs over the sternum during inspiration. Sensitive and specific for COPD.
What diseases typically lead to upper lobe predominant pulmonary fibrosis?
SCART
S- silicosis and sarcoidosis
C - coal workers pneumoconiosis, cystic fibrosis, chronic allergic alveolitis, chronic eosinophilic pneumonitis
A - ankylosing spondylitis, alleric bronchopulmonary aspergillosis, alveolar haemorrhage syndromes
R - radiation
T - tuberculosis
What diseases typically lead to lower lobe predominant pulmonary fibrosis?
RASIO
R - rheumatoid arthritis
A - asbestosis, acute allergic alveolitis, acute eosinophilic pneumonitis
S - scleroderma
I - idiopathic intersitital fibrosis
O - other including drugs - amiodarone, nitrofuantoin, hydralazine, methotrexate, bleomycin, busulfan
What are the most likley endocrine phenomena associated with lung malignany?
Hypercalcaemia secondary to PTH like protein (most common in squamous cell carcinomas), hyponatraemia secondary to ADH release (most common in small cell carcinoma), ectopic ACTH secretion (small cell carcinoma), carinoid syndrome secondary to 5-HT secretion from NET tumours, gynaecomastia secondary to gonadotrophin secretion from squamous cell carcinomas, and rarely hypoglycaemia from insulin-like peptide secretion from squamous cell carcinomas.
What is Eaton-Lambert syndrome? How does it relate to cancer?
Progessive muscle weakness that improves on repeititve movements due to an antibody targeting pre synaptic voltage gated calcium at the neuromuscular junction - causes reduced ACh release and muscle weakness. Associated with small cell carcinoma or thymoma.
What paraneoplastic neurological syndromes or muscular diseases are associated with small cell lung cancer?
Lambert-Eaton syndrome, retinal blindness, peripheral neuropathy, subactue cerebellar degeneration, polymyositis.
What haematoligcal paraneoplastic phenomona are associated with lung cancer?
Migrating venous thrombophlebitis
DIC
Anaemia
What are the pulmonary features of sarcoidosis?
80% have pulmonary disease
Hilar lymphadenopathy
ILD - upper lobe predominant
Non-caseating granulomas
What the extrapulmonary signs of sarcoidosis?
Skin - lupus pernio (violaceous patches on the face, nose fingers or toes), pink nodules and plaques in old scars, erythema nodosum on the shins.
Eyes: anterior uveitis
Lymp nodes: generalised adenopathy
Liver and spleen: enlarged
Parotids: enlarged
CNS - cranial nerve lesions. The most commonly affected is nerve VII.
MSK - arthralgia, dactylitis
Heart - heart block, cor pulmonale
Endocrine - hypercalcaemia
Name this flow volume loop
Normal flow volume loop
Describe this - what could cause it?
Variable extrathoracic obstruction leading to normal expiratory FEV1 and FVC with flat with slow inspiratory flow with normal inspiratory volume. Causes include vocal cord paralysis, tracheomalacia of the extrathoracic trachea, large airway neoplasm.
Describe this - what could cause it?
Variable intrathoracic obstruction. Occurs with tracheal or large airway masses that collapse with forced expiration. Can also be the behavious of tracheomalacia.
Describe this - what could cause it?
Fixed upper airway obstrction (can be intrathoracic or extrathoracic). Flow limitation throughout inspiration and expiration.
Describe this - what could cause it?
Peripheral or lower airways obstruction - the ‘scooped out’ pattern. Typical of uncontrolled asthma or COPD.
Decribe this imaging
a) Right middle lobe bronchiectasis. Note the increased lung markings and the thickened bronchial walls (arrow). (b) CT scan of the chest of a patient with bronchiectasis. Note the thickened bronchial walls (arrow).
Describe this imaging
Right upper lobe fibrosis. Note the loss of volume and increased lung markings (arrow)
Describe this imaging
CT scan of chest showing pulmonary haemorrhage in a patient with Goodpasture’s syndrome.
Describe the finding in this imaging
Retrosternal goitre
Describe the findings in this imaging
Retrosternal mass thoracic aortic aneurysm (1) and pulmonary metastases (2).
Describe the imaging findings
(a) Chest X-ray showing granulomatosis with polyangiitis (GPA, or Wegener’s granulomatosis). Note infiltrates and destructive changes. (b) Lateral view. Note infiltrates and destructive changes.
Describe the imaging
Large left pleural effusion (arrow). Note previous left mastectomy.
Describe the imaging
(a) Sarcoidosis basal infiltrate (arrows). (b) Hilar lymphadenopathy (arrow)
What’s this?
Pleural effusion. Note the steep meniscus.
What’s this?
Hydropneumothorax. Note the loss of meniscus - flat line on top of the pleural effusion.
