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AKT > Respiratory > Flashcards

Respiratory Flashcards

1
Q

What is Pemberton’s sign?

A

Pemberton’s sign” is where raising the hands over the head causes facial congestion and cyanosis. This is a medical emergency.

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2
Q

SIADH and lung cancer cause

A

Syndrome of inappropriate ADH (SIADH) caused by ectopic ADH secretion by a small cell lung cancer and presents with hyponatraemia.

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3
Q

Cushing’s syndrome and lung cancer cause

A

Ectopic ACTH release from small cell lung cancer

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4
Q

SCC on histology

A

Malignant epithelial tumour showing keratinisation and/or intercellular bridges or squamous cell marker expression

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5
Q

Hypercalcaemia and lung cancer cause

A

Ectopic PTH

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6
Q

What is Limbic encephalitis?

A

This is a paraneoplastic syndrome where the small cell lung cancer causes the immune system to make antibodies to tissues in the brain, specifically the limbic system, causing inflammation in these areas. This causes symptoms such as short term memory impairment, hallucinations, confusion and seizures. It is associated with anti-Hu antibodies.

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7
Q

What is Lambert-Eaton Myasthenic Syndrome?

A

Lambert-Eaton myasthenic syndrome is a result of antibodies produced by the immune system against small cell lung cancer cells. These antibodies also target and damage voltage-gated calcium channels sited on the presynaptic terminals in motor neurones.

This leads to weakness, particularly in the proximal muscles but can also affect intraocular muscles causing diplopia (double vision), levator muscles in the eyelid causing ptosis and pharyngeal muscles causing slurred speech and dysphagia (difficulty swallowing). Patients may also experience dry mouth, blurred vision, impotence and dizziness due to autonomic dysfunction.

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8
Q

Signs and symptoms of Lambert-Eaton?

A

Weakness, particularly in the proximal muscles but can also affect intraocular muscles causing diplopia (double vision), levator muscles in the eyelid causing ptosis and pharyngeal muscles causing slurred speech and dysphagia (difficulty swallowing).

Dry mouth, blurred vision, impotence and dizziness due to autonomic dysfunction.

Reduced tendon reflexes. A notable finding is that these reflexes become temporarily normal for a short period following a period of strong muscle contraction. For example, the patient can maximally contract the quadriceps muscle for a period, then have their reflexes tested immediately afterwards, and display an improvement in the response. This is called post-tetanic potentiation.

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9
Q

In older smokers with symptoms of Lambert-Eaton syndrome consider

A

Small cell lung cancer

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10
Q

Mesothelioma is strongly linked to

A

Asbestos inhalation

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11
Q

Characteristic chest signs of pneumonia

A

Bronchial breath sounds. These are harsh breath sounds equally loud on inspiration and expiration. These are caused by consolidation of the lung tissue around the airway.

Focal coarse crackles. These are air passing through sputum in the airways similar to using a straw to blow in to a drink.

Dullness to percussion due to lung tissue collapse and/or consolidation.

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12
Q

CURB65

A

C – Confusion (new disorientation in person, place or time)
U – Urea > 7
R – Respiratory rate ≥ 30
B – Blood pressure < 90 systolic or ≤ 60 diastolic.
65 – Age ≥ 65

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13
Q

Common causes of pneumonia

A

Streptococcus pneumoniae (50%)
Haemophilus influenzae (20%)

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14
Q

Definition of atypical pneumonia

A

Pneumonia caused by an organism that cannot be cultured in the normal way or detected using a gram stain.

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15
Q

Atypical bacteria antibiotics

A

They don’t respond to penicillins and can be treated with macrolides (e.g. clarithomycin), fluoroquinolones (e.g. levofloxacin) or tetracyclines (e.g. doxycycline).

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16
Q

Legionella pneumophila (Legionnaires’ disease) caused by and causes

A

This is typically caused by infected water supplies or air conditioning units. It can cause hyponatraemia (low sodium) by causing an SIADH. The typical exam patient has recently had a cheap hotel holiday and presents with hyponatraemia.

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17
Q

Mycoplasma pneumoniae presentation

A

This causes a milder pneumonia and can cause a rash called erythema multiforme characterised by varying sized “target lesions” formed by pink rings with pale centres. It can also cause neurological symptoms in young patient in the exams.

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18
Q

Coxiella burnetii AKA “Q fever” presentation

A

This is linked to exposure to animals and their bodily fluids. The MCQ patient is a farmer with a flu like illness.

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19
Q

Chlamydia psittaci presentation

A

This is typically contracted from contact with infected birds. The MCQ patient is a from parrot owner.

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20
Q

Treatment for pneumocystis jirovecii

A

Treatment is with co-trimoxazole (trimethoprim/sulfamethoxazole) known by the brand name “Septrin”. Patients with low CD4 counts are prescribed prophylactic oral co-trimoxazole to protect against PCP.

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21
Q

Obstructive lung disease can be diagnosed when

A

FEV1 is less than 75% of FVC (FEV1:FVC ratio < 75%).

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22
Q

Restrictive lung disease can be diagnosed when

A

FEV1 and FVC are equally reduced and FEV1:FVC ratio > 75%

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23
Q

Asthma diagnosis

A

Fractional exhaled nitric oxide

Spirometry with bronchodilator reversibility

If there is diagnostic uncertainty after first line investigations these can be followed up with further testing:

Peak flow variability measured by keeping a diary of peak flow measurements several times per day for 2 to 4 weeks

Direct bronchial challenge test with histamine or methacholine

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24
Q

Inhaled corticosteroid example

A

Beclomethasone

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25
Q

Long-acting beta 2 agonists (LABA) example

A

Salmeterol

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26
Q

Asthma NICE guidelines - stepwise process

A

Add short-acting beta 2 agonist inhaler (e.g. salbutamol) as required for infrequent wheezy episodes.

Add a regular low dose inhaled corticosteroid.

Add an oral leukotriene receptor antagonist (i.e. montelukast).

Add LABA inhaler (e.g. salmeterol). Continue the LABA only if the patient has a good response.

Consider changing to a maintenance and reliever therapy (MART) regime.

Increase the inhaled corticosteroid to a “moderate dose”.

Consider increasing the inhaled corticosteroid dose to “high dose” or oral theophylline or an inhaled LAMA (e.g. tiotropium).
Refer to a specialist.

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27
Q

Types of acute asthma

A

Moderate
PEFR 50 – 75% predicted

Severe
PEFR 33-50% predicted
Resp rate >25
Heart rate >110
Unable to complete sentences

Life-threatening
PEFR <33%
Sats <92%
Becoming tired
No wheeze. This occurs when the airways are so tight that there is no air entry at all. This is ominously described as a “silent chest”.
Haemodynamic instability (i.e. shock)

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28
Q

Treatment for moderate acute asthma

A

Nebulised beta-2 agonists (i.e. salbutamol 5mg repeated as often as required)
Nebulised ipratropium bromide
Steroids. Oral prednisolone or IV hydrocortisone. These are continued for 5 days
Antibiotics if there is convincing evidence of bacterial infection

29
Q

Treatment for severe acute asthma

A

Oxygen if required to maintain sats 94-98%
Aminophylline infusion
Consider IV salbutamol

30
Q

Treatment for life threatening acute asthma

A

IV magnesium sulphate infusion
Admission to HDU / ICU
Intubation in worst cases – however this decision should be made early because it is very difficult to intubate with severe bronchoconstriction

31
Q

What needs to be monitored on salbutamol?

A

Monitor serum potassium when on salbutamol as it causes potassium to be absorbed from the blood into the cells. Salbutamol also causes tachycardia (fast heart rate).

32
Q

Type 1 vs type 2 respiratory failure

A

Type 1 respiratory failure occurs when the respiratory system cannot adequately provide oxygen to the body, leading to hypoxemia.

Type 2 respiratory failure occurs when the respiratory system cannot sufficiently remove carbon dioxide from the body, leading to hypercapnia.

33
Q

Why is it bad to treat someone with O2 if they retain CO2

A

Can depress their respiratory drive. This slows down their breathing rate and effort and leads to them retaining more CO2.

Needs to be carefully balanced to optimise their pO2 whilst not increasing their pCO2.

34
Q

Venturi mask colours

A

Environmental air contains 21% oxygen. Venturi masks deliver 24% (blue), 28% (white), 31% (orange), 35% (yellow), 40% (red) and 60% (green) oxygen.

35
Q

Oxygen aims for patients with COPD

A

If retaining CO2 aim for oxygen saturations of 88-92% titrated by venturi mask

If not retaining CO2 and their bicarbonate is normal (meaning they do not normally retain CO2) then give oxygen to aim for oxygen saturations > 94%

36
Q

Non-invasive ventilation involves

A

Using a full face mask or a tight fitting nasal mask to blow air forcefully into the lungs and ventilate them without having to intubate them

37
Q

What is BiPAP

A

Bilevel positive airway pressure. This involves a cycle of high and low pressure to correspond to the patients inspiration and expiration.

38
Q

When is BiPAP used?

A

BiPAP is used where there is type 2 respiratory failure, typically due to COPD. The criteria for initiating BiPAP are:

Respiratory acidosis (pH < 7.35, PaCO2 >6) despite adequate medical treatment.

39
Q

Contradictions to BiPAP

A

The main contraindications are an untreated pneumothorax or any structural abnormality or pathology affecting the face, airway or GI tract.

40
Q

What is CPAP?

A

CPAP stands for continuous positive airway pressure. It provides continuous air being blown into the lungs that keeps the airways expanded so that air can more easily travel in and out. It is used to maintain the patient’s airway in conditions where it is prone to collapse.

41
Q

Diagnosis of interstitial lung disease

A

Requires a combination of clinical features and high resolution CT scan of the thorax

42
Q

Insidious pulmonary fibrosis presentation

A

It presents with an insidious onset of shortness of breath and dry cough over more than 3 months. It usually affects adults over 50 years old. Examination can show bibasal fine inspiratory crackles and finger clubbing.

43
Q

Two medications are licensed that can slow the progression of insidious pulmonary fibrosis

A

Pirfenidone is an antifibrotic and anti-inflammatory
Nintedanib is a monoclonal antibody targeting tyrosine kinase

44
Q

Drugs that can cause pulmonary fibrosis

A

Amiodarone
Cyclophosphamide
Methotrexate
Nitrofurantoin

45
Q

First line treatment for PE in cancer and pregnancy

A

LMWH long term is first line treatment in pregnancy or cancer.

46
Q

20-40 year old black woman presenting with a dry cough and shortness of breath. They may have nodules on their shins suggesting erythema nodosum.

A

Sarcoidosis

47
Q

Symptoms and signs of sarcoidosis

A

Lungs (affecting over 90%)
Mediastinal lymphadenopathy
Pulmonary fibrosis
Pulmonary nodules

Systemic Symptoms
Fever
Fatigue
Weight loss

Liver (affecting around 20%)
Liver nodules
Cirrhosis
Cholestasis

Eyes (affecting around 20%)
Uveitis
Conjunctivitis
Optic neuritis

Skin (affecting around 15%)
Erythema nodosum (tender, red nodules on the shins caused by inflammation of the subcutaneous fat)
Lupus pernio (raised, purple skin lesions commonly on cheeks and nose)
Granulomas develop in scar tissue

Heart (affecting around 5%)
Bundle branch block
Heart block
Myocardial muscle involvement

Kidneys (affecting around 5%)
Kidney stones (due to hypercalcaemia)
Nephrocalcinosis
Interstitial nephritis

Central nervous system (affecting around 5%)
Nodules
Pituitary involvement (diabetes insipidus)
Encephalopathy

Peripheral Nervous System (affecting around 5%)
Facial nerve palsy
Mononeuritis multiplex

Bones (affecting around 2%)
Arthralgia
Arthritis
Myopathy

48
Q

Lofgren’s Syndrome

A

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)

49
Q

Blood Tests for sarcoidosis

A

Raised serum ACE. This is often used as a screening test.
Hypercalcaemia (rasied calcium) is a key finding.
Raised serum soluble interleukin-2 receptor
Raised CRP
Raised immunoglobulins

50
Q

Sarcoidosis on CXR

A

Hilar lymphadenopathy

51
Q

Sarcoidosis histology

A

Characteristic non-caseating granulomas with epithelioid cells.

52
Q

Treatment for sarcoidosis

A

Oral steroids are usually first line where treatment is required and are given for between 6 and 24 months.

Patients should be given bisphosphonates to protect against osteoporosis whilst on such long term steroids.

Second line options are methotrexate or azathioprine

53
Q

The most common organism causing infective exacerbations of COPD is

A

Haemophilus influenzae

54
Q

Side effects of inhaled corticosteroids in asthma

A

Candida albicans and loss of taste

55
Q

First line treatment for COPD

A

A short-acting beta2-agonist (SABA) or short-acting muscarinic antagonist (SAMA) is first-line treatment

56
Q

The most common organism found in infective exacerbations of bronchiectasis is

A

Haemophilus influenzae .

57
Q

Bronchiectasis on CXR

A

dilated bronchi and thickened walls in the lower zones (‘tram-track sign’)

58
Q

Patient with acute asthma who do not respond to full medical treatment and are becoming acidotic should be

A

Intubated and ventilated, rather than given BiPAP/CPAP

59
Q

Idiopathic pulmonary fibrosis predominately affects which zones of the lungs?

A

Lower zones

60
Q

First line treatment for obstructive sleep apnoea

A

Following weight loss, CPAP is the first-line treatment for moderate/severe obstructive sleep apnoea

61
Q

This is a typical history of idiopathic pulmonary fibrosis

A

A male patient aged 50-70 years presenting with progressive exertional dyspnoea associated with clubbing and a restrictive picture on spirometry,

62
Q

Are pleural plaques a concern?

A

No they are benign

63
Q

COPD - still breathless despite using SABA/SAMA and asthma/steroid responsive features →

A

Add a LABA + ICS

64
Q

What is TLco?

A

Gas transfer test is sometimes known as a TLco test. TLco refers to the transfer capacity of the lung

65
Q

DVT investigation: if the scan is negative, but the D-dimer is positive →

A

Stop anticoagulation and repeat scan in 1 week

66
Q

Diagnosis of mesothelioma

A

Diagnosis of a mesothelioma is made on histology, following a thoracoscopy

67
Q

Four ways asthma is diagnosed with numbers

A

An exhaled FeNO of 40 parts per billion or greater

A post-bronchodilator improvement in lung volume of 200 ml

A post-bronchodilator improvement in FEV1 of 12% or more

A peak expiratory flow rate variability of 20% or more

68
Q

COPD does not cause

A

Finger clubbing

AKT (16 decks)

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