Respiratory Flashcards
What causes COPD?
smoking, occupation, environmental exposure
What is chronic bronchitis and emphysema?
Chronic bronchitis = inflammation in the bronchi –> cough and sputum
Emphysema = dilatation of the alveolar sacs and alveoli –> reduced SA for gas exchange
What is the difference between COPD and asthma?
COPD is minimally reversible with bronchodilators (both obstructive)
What would you see on spirometry with COPD?
FEV1:FVC ratio of <0.7 = obstructive
Little to no response to reversibility testing
How do you assess the severity of COPD?
Mild = FEV1 >80%
Moderate = FEV1 50-79%
Severe = FEV1 30-49%
Very severe = FEV1 <30%
What does a CXR show for those with COPD?
Hyperinflation, flattening of diaphragm and hyperlucent lung fields
Why do COPD patients have polycythaemia?
Chronic hypoxia –> raised Hb
When should we test for alpha-1 antitrypsin deficiency?
Young patient (<40) with COPD symptoms, unresponsive to treatments given
what is the iniital steps in medical management of COPD?
SABA or SAMA
If there are no asthmatic or steroid responsive features what is the 2nd step in treating COPD? (after SABA and SAMA)
LABA and LAMA
If there are asthmatic or steroid responsive features what is the 2nd step in treating COPD? (after SABA and SAMA)
LABA and ICS
What is the third stage of managing COPD?
LABA, LAMA and ICS
What is cor pulmonale?
Right sided heart failure caused by respiratory disease - pulmonary HTN limits RV pumping blood into pulmonary vessels –> back pressure
What are the symptoms of cor pulmonale?
SOB, oedema, breathlessness on exertion, syncope, chest pain
What is the most common bacterial cause of infective COPD exacerbation?
Haemophilus Influenzae
What is the management for acute COPD?
- regular nebulisers - salbutamol and ipratropium
- steroids - prednisolone 30mg OD for 5 days
- antibiotics if signs of infection
- oxygen - guided by ABG numbers
- may require escalating to ICU or NIV
Which type of NIV is used for what type of respiratory failure?
Type 1 = CPAP
Type 2 = BiPAP
What is the pathophysiology of asthma?
Chronic inflammation in airways due to smooth muscle hypersensitivity –> bronchoconstriction that is reversible with bronchodilators
When are symptoms worse with asthma?
Diurnal variation - typically worse early in mornings and at night
What would you see on spirometry in asthma?
FEV1:FVC ratio of <0.7 (obstructive)
Reversibility of this with bronchodilators (should increase by at least 12%)
What other tests can be done to diagnose asthma in those with normal spirometry?
Fractional exhaled nitric oxide, peak flow variability, direct bronchial challenge testing
What is the step wise approach for asthma management?
- SABA PRN
- ICS low dose
- LRTA (discontinue if no effect)
- LABA
- Consider MART
- Increase ICS to moderate dose
- Consider high dose ICS/LAMA/theophylline
- Refer
During acute exacerbation of COPD what occurs on the ABG?
Initially have respiratory alkalosis due to raised respiratory rate –> respiratory acidosis as it progresses (bad sign as shows they are getting tired)
What are the features of moderate asthma? (1)
50-75% peak flow
What are the features of severe asthma? (4)
Peak flow 33-50%
Resp rate >25
HR >110
Unable to complete full sentences
What are the features of life-threatening asthma?
Peak flow <33%
Sats <92%
PaO2 <8kPa
Becoming tired
Confusion or agitation
Silent chest
Haemodynamic instability
What is the stepwise approach for managing acute asthma?
- Oxygen
- Salbutamol nebulisers
- Ipratropium nebulisers
- IV Hydrocortisone/ PO prednisolone
- IV magnesium sulphate
- Aminophylline/IV salbutamol
What needs to be done following an acute asthma attack?
Optimise long term management, rescue pack of oral steroids, before discharge need to be stable on discharge meds for at least 12 hours
Which type of lung cancers causes paraneoplastic syndromeS?
SCLC
What is the most common sub type of lung cancer?
Adenocarcinoma
What symptoms occur in lung cancer?
SOB, cough, haemoptysis, clubbing, weight loss, lymphadenopathy (supraclavicular)
What can occur due to a pancoast tumour?
Horner’s syndrome due to tumour in apex pressing on the sympathetic ganglion - ptosis, anhidrosis and miosis
What paraneoplastic syndromes are associated with SCLC?
SIADH, Cushing’s, hypercalcaemia, Lambert-eaton, limbic encephalitis
Lung cancers can put pressure on surrounding structures which can lead to ..?
Recurrent laryngeal nerve palsy, phrenic nerve palsy, SVC obstruction
What does a CXR show in someone with lung cancer?
Hilar enlargement, peripheral opacity, unilateral pleural effusion, lobe collapse
What investigations are done in lung cancer?
CXR = 1st line (done in 2ww clinic), staging CT, PET scan, bronchoscopy with endobronchial USS biopsy
What is the treatment for someone with SCLC?
Chemotherapy + adjuvant radiotherapy
What is the treatment for someone with early non-small cell lung cancer?
Surgery or radiotherapy can both be curative in early disease
What two things increase survival rates in those with COPD?
Smoking cessation and LTOT
What is the criteria for 2ww referral for lung cancer?
Over 40 and: clubbing, lymphadenopathy, recurrent/persistent chest infection, raised platelet count or CXR findings
Where is aspiration pneumonia likely to be in the lungs?
Right middle or lower lobe - due to right main bronchus being more vertical
What symptoms would you see in pneumonia?
Cough, sputum production, SOB, fever, pleuritic chest pain
What do you score a point for on the CURB-65?
C- confusion
U- urea>7mmol/l
R- RR>30
B- BP<90 systolic
65 - age >65
What are the most common causes of bacterial pneumonia?
Strep pneumoniae and haemophilus influenzae
What investigations would you do in pneumonia?
Sputum cultures, blood cultures, antigen tests for atypical
What are the standard antibiotics for pneumonia?
Amoxicillin + clarithromycin/doxycycline for atypical
How is TB spread?
Inhaling saliva droplets from infected individuals
What are the risk factors for TB?
Close contacts with active TB, immigrants, immunocompromised, neglect, IVDU
What are the presenting symptoms in TB?
Chronic symptoms: cough, haemoptysis, tiredness, weight loss, lymphadenopathy
What investigations would you do to diagnose TB?
3 sputum cultures, CXR (patchy consolidation, pleural effusions and hilar lymphadenopathy)
What tests can be used to check for previous TB infection?
Mantoux test and interferon-gamma release assay
What are the 4 treatments used for TB and their common side effects?
Rifampicin 6 months - red secretions, P450 inducer
Isoniazid 6 months - peripheral neuropathy
Pyrazinamide 2 months - gout and kidney stones
Ethambutol 2 months - colour blindness
What are the risk factors for PE?
Immobility, recent surgery, long haul travel, oral oestrogen, malignancy, polycythaemia
What is the classic presentation of PE?
Hypoxic patient, clear chest, tachycardia
May also have pleuritic chest pain and haemoptysis
What is the initial and gold standard investigation for PE?
D-dimer initial test done if wells score says PE is unlikely
CTPA/VQ scan - gold standard done in those where Wells score says PE is likely
What are the first and second line treatment options for PE?
1st line = apixiaban/rivaroxaban
2nd line = LMWH
What treatments are used to prevent PE?
Stockings and LMWH (prophylactic dose)
What is the treatment for a massive PE with haemodynamic compromise?
Continuous unfractionated heparin infusion
What is bronchiectasis?
Permanent dilatation of the bronchi
What are the symptoms associated with bronchietasis?
SOB, chronic productive cough, recurrent chest infections, weight loss
What is the gold standard for diagnosing bronchiectasis?
High resolution CT
How do you treat bronchiectasis?
LTOT, LABA, chest physio, prophylactic abx
How is CF inherited and on what chromosome is the mutation?
Autosomal recessive
Chromosome 7
What symptoms are common in CF?
chronic cough, thick sputum, recurrent LRTI, steatorrhoea, failure to thrive
How is CF diagnosed?
Newborn blood spot test, sweat test = gold standard, genetic testing during pregnancy
How do they treat pseudomonas colonisation in CF?
Nebulised tobramycin and oral ciprofloxacin
What are exudative causes of pleural effusion? (high protein)
Cancer, infection, rheumatoid arthritis, pulmonary embolism
What are the transudative causes of pleural effusion? (low protein)
Heart failure, hypoalbuminaemia, hypothyroidism, meig’s syndrome
What examination findings are present in pleural effusions?
Dullness to percussion, reduced breath sound, tracheal deviation away from effusion (if big)
What CXR findings are present in pleural effusions?
Blunting of the costophrenic angle, fluid in lung fissures, may have meniscus
Who are the typical patients in primary sponatenous pneumothoraces?
Tall, thin, young male who smoke and play sport
What is the management of primary pneumothroax <2cm and no SOB?
No treatment required - follow up in 2-4 weeks
What is the management of primary pnuemothorax >2cm or SOB?
Aspiration with 16G cannula, if reamins >2cm or the patient remains SOB following this a chest drain should be inserted
Which pneumothorax patients require a chest drain insertion instead of aspiration?
Unstable patients, bilateral and secondary pneumothroaces >2cm
What are the signs of tension pneumothorax on examination?
Tracheal deviation away from pneumothorax, reduced air entry, increased resonance to percussion on affected side
What is the management for tension pneumothorax?
Insert large bore cannula into 2nd IC space midclavicular line - needle decompression
Followed by chest drain = definitive management
What is pulmonary hypertension?
Increased pressure in the pulmonary arteries >20mmHg
What ECG would you expect in right sided heart strain caused by pulmonary disease?
Tall R waves in V1 and V2, deep S waves in V5 and V6, right axis deviation and RBBB
What treatments are used for pulmonary hypertension
sildenafil, epoprostenol, iloprost
What is the typical patient for sarcoidosis?
Black, woman aged 20-39 with erythema nodosum
What results of spirometry would you expect in interstitial lung disease?
Restrictive =
FEV1 reduced-normal
FVC reduced
FEV1:FVC >0.7
What blood test results are associated with sarcoidosis?
Raised ACE, raised calcium
What does a CXR show in sarcoidosis?
Bilateral hilar lymphadenopathy
What treatments are available for sarcoidosis?
Steroids and methotrexate
What are the key features of interstitial lung disease?
Symptoms and exam findings
SOBOE, dry cough, fatigue, bi-basal inspiratory crackles, finger clubbing
What treatments are available for idiopathic pulmonary fibrosis?
Pirfenidone, nintedanib
What are the typical features of someone with anti-GBM/good pastures syndrome?
Acute kidney failure and coughing up blood
What management is required for secondary pneumothoraxes with rim of air 1-2cm?
Aspiration with 16G cannula, if this fails chest drain
What is the management of someone with secondary pneumothorax <1cm?
Oxygen and admit for observation for 24 hours
What organism commonly causes pneumonia in alcoholics and diabetics?
Klebsiella pneumoniae - causes cavitating lesions in upper lobes and currant jelly-like sputum
Which type of pneumonia commonly causes erythema multiforme?
Mycoplasma pneumoniae
What organisms are associated with hospital acquired pneumonia?
E.coli, staph, Klebsiella
How is legionnaire’s diseases treated?
Clarithromycin
What is the treatment of hospital acquired pneumonia?
Within 5 days of admission = co-amoxiclav or cefuroxime
More than 5 days after admission = tazocin
What is atelectasis?
Post op complication that results in basal alveolar collapse
What are the features of a lung abscess?
Subacute presentation (weeks to months)
Persistent cough with foul smelling sputum, fever, dullness to percussion, SOB
What are the causes of lung abscess?
Most commonly aspiration pneumonia, but can also spread from blood, or come from bronchial obstruction e.g. lung cancer
Which kind of lung cancer are cavitating lesions most commonly found?
Squamous cell carcinoma
Which subtype of lung cancer is most commonly found in non-smokers?
Adenocarcinoma
When are steroids indicated to treat sarcoidosis?
Symptomatic, hypercalcaemia or have heart/eye/neuro involvement
Give an example of the common types of inhalers - SABA, SAMA, LAMA, LABA
SABA - salbutamol
SAMA - ipratropium
LABA - salmeterol
LAMA - tiotropium
What is the criteria for LTOT in COPD patients?
pO2 <7.3 or between 7.3 and 8 + one of the following:
secondary polycythaemia, peripheral oedema, pulmonary hypertension
Following a case if pneumonia what follow up should a patient have?
Repeat CXR in 6 weeks
What are the findings that someone is tiring in severe asthma attacks?
CO2 retention and therefore low pH
How does legionnaire’s disease present and how is it diagnosed?
Severe pneumonia, hyponatraemia and deranged LFTs
Can be diagnosed on urinary antigen
Which lung cancer is associated with gynaecomastia?
Adenocarcinoma
