Respiratory Flashcards
What are the two main types of lung cancer and their subdivisions
Non small cell lung cancer
-Adenocarcinoma (40%)
-Squamous cell carcinoma (20%)
-Large cell carcinoma
Small cell lung cancer (neuroendocrine)
Mesothelioma is cancer of the pleura
What would be present in a superior vena cava obstruction in someone with lung cancer
Facial swelling, hard to breath, distended chest and neck veins, putting hands above head causes congestion - will have more of an acute onset than heart failure symptoms- is na emergency
What is Horner’s syndrome
Pancoast tumour pressing the sympathetic ganglion- triad of ptosis, anhidrosis and miosis (pupil constriction)
What is lambert-eaton myasthenia syndrome
Antibodies against small cell lung cancer damage calcium channels in motor neurones- proximal muscle weakness etc
What is the first line investigation for lung cancer
CXR
looking for hilar enlargement
Peripheral opacity
Pleural effusion
Collapse
CT CAP is used for staging
What signs would be present in pneumonia
Bronchial breath sounds (harsh inspiratory and expiratory)
Focal coarse crackles
Dullness to percussion
What scoring system is used for Pneumonia
CURB-65 in hosp and CRB-65 in community
C-Confusion
U-Urea
R-Resp rate >30
B-BP<90 systolic or <60 diastolic
65> 65 YRS
Score over 3 is high risk
What are the main organisms that cause pneumonia
-Steptococcus pneumonia
-Haemophilus influenza
What are the main causes of atypical pneumonia
Legionella- infected water inhalation, can cause SIADH- urine antigen screening test
Mycoplasma pneumonia - mild with target lesion rash
Chlamydophila pneumonia - children
Coxiella burnettic/ Q fever- body fluids to animals- flu like illness
Chlamydia psittaci - infected birds
Need macrolides (clarithromycin) to tetracycylines (doxy)
Pneumocytis jirovecii - fungal - immunocomp patients- give co-trimoxazole
What antibiotics are used in mild pneumonia
Oral amoxicillin, doxycycline/ clarithromycin for 5 days
What antibiotics are used in moderate/severe pneumonia
IV abx stepped down to oral
What are the features and causes of respiratory acidosis
Rentention of CO2 means more CO2 in the blood making it acidic
On an ABG if the bicarb is high then bicarb is trying to compensate for high CO2- this indicates CO2 retention is chronic
COPD patients
What are the features and causes of respiratory alkalosis
When a patient blows off too much CO2- anxiety / PE
If patient has anxiety they will have low PaC02 and high 02 - they are just hyperventilating
If patient has PE they will have low CO2 and low O2
What are the causes of metabolic alkalosis
Loss of hydrogen ions (acid)
-From GI tract- diarrhoea/vomiting
-From kidneys -increased aldosterone activity- Conn’s syndrome, liver cirrhosis, loop diuretics, thiazide diuretics
Will have raised Ph and raised Bicarb - no issues with CO2
What are the causes and features of metabolic acidosis
-Low pH and low Bicarb, no issues with CO2/O2
Can be caused by DKA- raised ketones
Raised lactate
Increased hydrogen ions in renal failure/ rhabdomyolysis, reduced bicarb in diarrhoea, renal failure
What respiratory support is given in acute respiratory distress syndrome
-ARDS causes collapse of alveoli (atelectasis) so low volumes and pressures are used to avoid overinflating the parts of the lungs that are still working
Positive end expiratory pressure is used to stop lungs collapsing further
What type of airway pressure is used in obstructive sleep apnoea
Continuous positive airway pressure - continuous pressure during each breath
What is bipap and when is it used
Bilevel positive airway pressure
Different air pressures for inhalation (IPAP) and exhalation (EPAP)
What would be seen on spirometry for an obstructive lung disease
FEV1/FVC <70% as FVC will have good volume but due to obstruction FEV1 is reduced- asthma and COPD
What would be seen for spirometry in a restrictive disease
Normal FEV1/FVC >70% as both FEV1 and FVC are equally reduced
-Sarcoidosis, interstitial lung disease, pulmonary fibrosis, obesity, motor neurone disease, scoliosis
What findings are relevant on a reversibility test for asthma
Greater than 12% increases in FEV1 will support an asthma diagnosis
What tests are done for asthma
- Fractional exhaled nitric oxide
- Spirometry with bronchodilator reversibility
Less important but keep a peak flow diary
What is the long term stepwise management of asthma
- Short acting Beta-2 agonist - salbutamol
- Inhaled corticosteroid low dose
- Leukotriene receptor antagonist- montelukast
- Long acting beta 2 agonist- salmeterol or combination of short and long acting inhaler
- High dose corticosteroid inhaler
How is an asthma exacerbation graded
Peak flow 50-75% of normal - moderate
Peak flow 33-49% of normal- severe
Peak flow<33%- life threatening
What is the management of a mild and moderate acute asthma exacerbation
Mild
Inhaled beta 2 agonists- via spacer
Quadrupled dose of inhaled corticosteroids for 2 weeks
Oral steroids
Abx
Moderate
Hosp admission
Nebulised beta-2 agonists
IV steroids
What is the management of a severe asthma exacerbation
- Hosp admission
- Oxygen sats>94-98%
- Nebulised ipatropium bromide
- IV magnesium sulfate
- IV salbutamol
- IV aminophylline
What is the staging of COPD
Stage 1- FEV1>80
Stage 2 - FEV1 50-79
Stage 3- FEV1 30-49
Stage 4- FEV1< 30
What is the stepwise medical management of COPD
- Short acting beta 2 agonist - salbutamol
- Short acting muscarinic antagonists (ipatropium bromide)
What is the treatment for asthma stepwise if there are asthma and steroid responsive features
Combination of long acting beta agonists and inhaled corticosteroids- symbicort
What is the treatment for asthma when there are no asthma or steroid responsive features
Long acting beat agonist combined with a long acting muscarinic antagonist
How is an acute exacerbation of COPD managed?
-Target oxygen sats -88-92% due to CO2 retention
- Regular inhalers/ nebulisers
- Steroids - red 30mg, once daily for 5 days
3.Antibiotics
If severe
-IV aminophylline
-non-invasive ventilation
-intubation and ventilation
What investigations are done for suspected bronchiectasis
-Sputum culture- haemophilus influenza/ pseudomonas aeruginosa
CXR will show tram track opacities
Diagnosis done with a high res CT
What are the main features of bronchiectasis
Recurrent infection , finger clubbing, pseudomonas auerginosa, if exacerbation- need 7-14 days on abx,
If caused by pseudomonas aeruginosa give ciprofloxacin
What is the treatment for idiopathic pulmonary fibrosis
-Progressive with no cause
-Medications to slow disease progression - pirfenidone and nintedanib
What are the causes of secondary pulmonary fibrosis
Drugs- amiodarone, cyclophosphamide, methotrexate, nitrofuratonin
Alpha-1-antitrypsin deficiency
RA
SLE
Systemic sclerosis
Sarcoidosis
Asbestos
Cyrptogenic organising pneumonia
What are the features of hypersensitivity pneumonitis in pulmonary fibrosis
Type 3 and 4 hypersensitivity reactions
Raised lymphocytes in bronchoalveloar lavage
bird fanciers lung, farmers lung etc
Treatment- remove allergen, oxygen, steroids
What are the risk factors for a PE
Immobility
Surgery
Long haul travel
Pregnancy
Hormone therapy with oestrogen
Malignancy
Polycythaemia
SLE
Thrombophilia
What is the main VTE prophylaxis
LMWH- Enoxaparin and anti embolic stockings
What score is used for risk of PE
Well’s score
How is a PE diagnosed
- Calculate Well’s score
- If PE likely- Do CTPA
- If PE unlikely do a d-dimer and if that is positive do a CTPA
Can also do a VQ scan
What are the treatment options for a PE
1st line anticoagulant with apixaban/rivaroxaban started as soon as suspected even if there is a delay in scan
If haemodynamically unstable- give continuous infusion of unfractionated heparin and IV thrombolysis with streptokinase
What is the long term treatment for a PE
DOACs first line unless antiphospholipid syndrome or pregnancy then give warfarin
If cause was reversible- anticoagulant for 3 months
If PE was unprovoked, recurrent or active cancer- anticoagulant for 6 months
What are the main causes of pulmonary hypertension
Group 1- Idiopathic/ CT disease (SLE)
Group 2- Left sided HF due to MI or systemic HTN
Group 3- Chronic lung disease (COPD, Pul fibrosis)
Group 4- Pulmonary Vascular disease (PE)
Group 5 - Miscellaneous (sarcoid etc)
What are the main features of sarcoidosis
Granulomas, erythema nodosum, lymphadenopathy, lupus perno (skin lesions on face)
Lungs -Mediastinal lymphadenopathy, pulmonary fibrosis, pulmonary nodules
Systemic- fever, fatigue, weight loss
Liver- cirrhosis, cholestasis
Eyes- uveitis, conjunctivitis
CNS involvement, Kidney involvement, PNS involvement (facial nerve plasy), bones
Lofgren’s syndrome- erythema nodosum, bilateral hilar lymphadenopathy, polyarthraglia
What investigations are done in sarcoidosis
Blood tests- screening- Raised ACE
-Raised calcium
CXR- Bilateral hilar lymphadenopathy
Bronchoscopy- non caseating granulomas
What is the management of sarcoidosis
Oral steroids 6-24 months
Bisphosphates to protect against osteoporosis while on steroids
Methotrexate second line
