Respiratory Flashcards
What are the features of moderate acute asthma?
- Increasing symptoms
- Peak flow >50-75% best or predicted
- No features of acute severe asthma
What are the features of severe acute asthma?
Any one of the following:
- Peak flow 33-50% best or predicted;
- Respiratory rate ≥ 25/min;
- Heart rate ≥ 110/min;
- Inability to complete sentences in one breath.
What are the features of life-threatening acute asthma?
Any one of the following in a patient with severe asthma:
- Peak flow < 33% best or predicted;
- Arterial oxygen saturation (SpO2) < 92%;
- Partial arterial pressure of oxygen (PaO2) < 8 kPa;
- Normal partial arterial pressure of carbon dioxide (PaCO2) (4.6–6.0 kPa);
- Silent chest;
- Cyanosis;
- Poor respiratory effort;
- Arrhythmia;
- Exhaustion;
- Altered conscious level;
- Hypotension.
Which type of lung fibrosis typically affects the lower zones?
Idiopathic pulmonary fibrosis
Most connective tissue disorders (e.g. SLE)
Drug induced: Amiodarone, Bleomycin, Methotrexate
Asbestosis
Which types of lung fibrosis typically affect the upper zones?
- Hypersensitivity pneumonitis (also known as extrinsic allergic alveolitis)
- Coal worker’s pneumoconiosis/progressive massive fibrosis
- Silicosis
- Sarcoidosis
- Ankylosing spondylitis (rare)
- Histiocytosis
- Tuberculosis
- Radiation-induced pulmonary fibrosis
may develop following radiotherapy for breast or lung cancer
typically seen between 6 and 12 months following completion of radiotherapy course
What is the most common type of lung cancer?
Adenocarcinoma (non small cell carcinoma)
List some risk factors of lung cancer?
- Smoking
- Radiation exposure
- HIV
- Asbestos exposure
- Welding fumes
- Coal
- Organ transplant
What is the mode of transmission for TB?
Droplet inhalation
Give some risk factors for active TB?
Immunosuppression
Intravenous drug use
Drug and alcohol misuse
Homelessness
Ethnic minority background - particularly sub-saharan africa and south asia
Name the bacteria found on microscopy indicating TB
Acid fast bacilli
Define COPD
Irreversible, progressive obstruction of the airways
Give some potential findings on a chest X-Ray of a patient with COPD?
Hyperinflation
Bullae
Flattened hemidiaphragms
Decreased peripheral vascular markings
Give some signs of hypercapnia?
Confusion
Asterixis
Bounding pulse
Reduced consciousness
Risk factors for Aspiration pneumonia
Stroke,
Bulbar palsy,
Myasthenia gravis,
Alcoholism
Post-ictal state
Achalasia
GORD
What is the duration of anticoagulation therapy for PROVOKED PE?
3 months
What is the duration of anticoagulation therapy for UNPROVOKED PE?
6 months
What is the first-line treatment for massive PE?
IV Alteplase
What would you find on ECG indicating PE?
Sinus Tachycardia
S1Q3T3 (deep S waves in lead I, pathological Q waves in lead III and inverted T waves in lead III)
How do you define Acute Respiratory Distress Syndrome?
- Defined as non-cardiogenic pulmonary oedema and diffuse lung inflammation, typically secondary to an underlying illness.
- The pathophysiology includes diffuse alveolar damage with hyaline membrane formation
What are some causes of ARDS?
- Pneumonia
- Sepsis
- Aspiration
- Pancreatitis
- Transfusion reactions
- Trauma and fractures
- Fat embolism
What would you see on CXR for ARDS?
Reveals bilateral alveolar infiltrates, without other features of heart failure such as a cardiomegaly and Kerley B Lines
What is the management of ARDS?
- Transfer to ITU for Cardiorespiratory support
- Ventilatory support: A low tidal volume is associated with better outcomes
- Haemodynamic support (to maintain MAP >60mmHg)
- DVT prophylaxis
What is Asbestosis?
It is a diffuse interstitial lung fibrosis that develops in patients with pleural plaque disease who have been exposed to asbestos.
What are the signs and symptoms of Asbestosis?
- Dyspnoea
- Chronic cough
- Crepitations on auscultation
- Finger clubbing
- Cyanosis
- Reduced Chest expansion
What might a CXR show in someone with Asbestosis?
- Linear interstitial fibrosis
- Pleural plaques
- Pleural thickening
- Atelectasis
What should you do when a person with asbestosis dies?
Report to the coroner
What investigations could you do for aspiration pneumonia?
- CXR: To visualise any infiltrates or consolidation
- Sputum culture: To identify the causative organism
- Blood tests: To assess the severity of the infection and the patients overall health status
What is the most common cause of Aspiration pneumonia?
Streptococcus pneumoniae
What type of lung disease is Asthma?
A chronic inflammatory disease which is a type of obstructive lung disease
What is the pathophysiology of asthma?
Occurs because of reversible airway obstruction.
- Involves a Type 1 hypersensitivity reaction.
What are some risk factors for Asthma?
- Family history
- Personal history of atopy
- Maternal smoking
- Viral infections
- Lower socioeconomic status
On a peak flow diary what is diagnostic of asthma?
Variability of >20% is diagnostic
What would you see on spirometry in asthma?
FEV1/FVC <0.7 (obstructive spirometry)
What is Step 1 of management for Asthma?
Start Short acting beta 2 agonist
What is Step 2 of management for Asthma?
Start ICS and then use SABA as reliever
What is Step 3 of management for Asthma in adults?
SABA (as reliever) +ICS + Start Long acting Beta 2 agonist
What is Step 3 of management for Asthma in Children?
In children aged five and over, an inhaled long-acting β₂ agonist or a leukotriene
receptor antagonist can be considered as initial add-on therapy.
Add on to SABA + ICS
What is Step 4 of management for Asthma in Adults?
If asthma control remains suboptimal after the addition of an inhaled long-acting
β₂ agonist then:
* increase the dose of inhaled corticosteroids from low dose to medium dose
in adults or from very low dose to low dose in children (5-12 years), if not
already on these doses.
or
* consider adding a leukotriene receptor antagonist.
What is required for a patient with acute exacerbation of asthma to be discharged?
Stable on Salbutamol inhaler for 24 hours
What are some causes of Bilateral hilar lymphadenopathy on CXR?
- Inflammatory: Sarcoidosis
- Infective: TB and mycoplasma
- Neoplastic: Bronchial carcinoma and lymphoma
- Interstitial lung disease
What is Bronchiectasis?
Permanent dilation of the bronchi and bronchioles following direct damage to the airway walls.
This leads to mucus plugging and further recurrent infections
What are the causes of Bronchiectasis?
Use the mnenmonic I CRAM:
Immune OVER-response – allergic bronchopulmonary aspergillosis (ABPA)
Immune UNDER-response – HIV, inherited immunodeficiencies, bone marrow suppression
Congenital – cystic fibrosis, Kartagener syndrome, primary ciliary dyskinesia, Young syndrome, yellow nail syndrome
*almost all patients with cystic fibrosis will ultimately develop severe bronchiectasis
Childhood infection – tuberculosis, measles, pertussis, pneumonia
Respiratory disease – COPD, pulmonary fibrosis
pulmonary fibrosis causes a ‘traction bronchiectasis’
as the interstitium fibroses, it contracts, thereby pulling the bronchiolar walls apart
Aspiration pneumonia
Mechanical obstruction – foreign body, tumour, lymph node, external compression
What are the symptoms of Bronchiectasis?
- Productive cough - large amounts of purulent sputum
- Dyspnoea
- Haemoptysis
- Pleuritic pain
What signs would you expect to see on on CXR in a patient with Bronchiectasis?
- Thickened bronchial walls and cystic appearance, otherwise known as tramline and ring shadows
What is the diagnostic investigation for bronchiectasis?
High Resolution CT scan
What happens to the PaO2 and PaCO2 in type 2 respiratory failure?
Low PaO2 and raise PaCO2
What electrolyte abnormality is commonly seen in sarcoidosis?
Hypercalcaemia
What happens to the PaO2 and PaCO2 in type 1 respiratory failure?
Low PaO2 and normal PaCO2
What value defines pulmonary hypertension?
A mean pulmonary arterial pressure of more than 20mmHg
What lung function test outcome indicates obstructive lung disease?
A FEV1:FVC ratio of less than 70%
What are the top causes of transudative pleural effusions?
- Congestive cardiac failure
- Hypoalbuminaemia
- Hypothyroidism
- Meigs syndrome
What is the usual first-line medication for treating sarcoidosis?
Oral steroids
What scoring system is used to assess sleepiness associated with obstructive sleep apnoea?
Epworth Sleepiness Scale
What is the name for minimally invasive “keyhole” surgery to treat lung pathology, such as cancer?
Video-assisted thoracoscopic surgery (VATS)
What are the criteria for using non-invasive ventilation to treat an exacerbation of COPD?
- Persistent respiratory acidosis (pH<7.35 and PaCO2>6) despite maximal medical treatment
- Potential to recover
- Acceptable to the patient
What lung function test outcome is used to determine the severity of COPD?
FEV1
What is the most common organism causing COPD exacerbations?
Haemophilus influenzae
How does a tension pneumothorax occur?
A pleural flap acts as a one way valve allowing air to enter but not leave the pleural space
What picture would you see on an ABG in heroin overdose?
They would have hypoventilation and therefore a respiratory acidosis
What investigation can you do after a negative result with spirometry
FeNO
What is the first line management for OSA?
CPAP
What is the diagnostic test for obstructive sleep apnoea?
Polysomnography
What is the presentation of Pneumocystis Jirovecii?
A patient who is immunocompromised with a dry cough and exercise induced desaturations.
What is the investigation of choice for PE in patients with significant renal impairment?
V/Q scans as the contrast media used during CTPAs in toxic
What is OSA caused by?
Collapse of the pharyngeal airway. Characterised by episodes of apnoea during sleep.
What are some of the risk factors of OSA?
Middle age
Male
Obesity
Alcohol
Smoking
What do you use to assess OSA?
Epworth sleepiness scale
What is Pulmonary hypertension?
Refers to increased resistance and pressure in the pulmonary arteries. It causes strain on the right side of the heart as it tries to pump blood through the the lungs
Defined as a Mean pulmonary arterial pressure of more than 20mmHg
What are the groups of pulmonary hypertension?
Group 1 – Idiopathic pulmonary hypertension or connective tissue disease (e.g., systemic lupus erythematous)
Group 2 – Left heart failure, usually due to myocardial infarction or systemic hypertension
Group 3 – Chronic lung disease (e.g., COPD or pulmonary fibrosis)
Group 4 – Pulmonary vascular disease (e.g., pulmonary embolism)
Group 5 – Miscellaneous causes such as sarcoidosis, glycogen storage disease and haematological disorders
What would an ECG should in pulmonary hypertension?
P pulmonale (peaked P waves)
Right ventricular hypertrophy (tall R waves in V1 and V2 and deep S waves in V5 and V6)
Right axis deviation
Right bundle branch block
What would an CXR should in pulmonary hypertension?
- Dilated pulmonary arteries
- Right ventricular hypertrophy
What is the treatment of idiopathic pulmonary hypertension?
Calcium channel blockers
Intravenous prostaglandins (e.g., epoprostenol)
Endothelin receptor antagonists (e.g., macitentan)
Phosphodiesterase-5 inhibitors (e.g., sildenafil)
When would Long term oxygen therapy be offered to a patient?
Offer LTOT to patients with a pO2 of < 7.3 kPa or to those with a pO2 of 7.3 - 8 kPa and one of the following:
secondary polycythaemia
peripheral oedema
pulmonary hypertension
