RESPIRATORY Flashcards
1
Q
What is the characteristic finding on high resolution CT thorax with Interstitial Lung disease?
A
Ground glass appearance
May also be described as honeycombing
2
Q
What is the prognosis of interstitial lung disease?
A
Prognosis is poor as damage is irreversible
Management is mainly supportive
3
Q
How does Idiopathic Pulmonary Fibrosis present?
A
Insidious onset
dry cough
Shortness of breath
over more than 3 months
4
Q
Define pulmonary embolism
A
Where a thrombus forms in the pulmonary arteries.
Usually result of DVT that has developed in legs and embolised (moved from one part of circulation to another) through the venous system
5
Q
How does pulmonary embolism affect blood flow?
A
Once in pulmonary arteries, blocks blood flow to lung tissue.
Creates strain on R side of heart
6
Q
Risk factors for PE?
A
Immobility / long flights Pregnancy Obesity (>29 kg/m2) Recent surgery (>30min procedures) DVT or previous VTE Contraception - OCP, hormone therapy with oestrogen Tumours Thrombophillia Polycythemia SLE (as SLE is an inflammatory condition). Age (40+)
Booklet has it grouped as follows:
1) Surgery - Abdo, pelvic; Knee, hip replacement, post-op
2) Obstetris - late pregnancy, C section
3) LL - fracture, varicose veins
4) Malignancy - Abdo, pelvic, mets, advanced
5) Reduced mobility
6) Previous VTE.
7
Q
Presentation of PE?
Give symptoms and signs
A
Symptoms :
Dyspnoea / SOB - most common.
Pleuritic chest pain
Cough +/- haemoptysis
Signs:
Hypoxia Tachycardia Hypotension - haemodynamic instability Raised RR Low grade fever
Note: may have S+S of a DVT - unilateral leg swelling, tenderness.
8
Q
What scoring system can be used when patient presents with S+S of PE?
A
Wells score
9
Q
What does Wells score predict?
A
The risk of a patient presenting with symptoms ACTUALLY having a DVT or PE.
Ca
10
Q
Criteria in Wells score for PE?
A
Clinical S+S of DVT?
Is PE top differential?
HR >100?
Immobilised for 3 days or surgery in last 4 weeks?
Previous PE or DVT?
Haemoptysis?
Malignancy w/ treatment within 6 months or have palliative care for it?
11
Q
Causes of bronchiectasis?
A
Post infective- Whooping cough/TB
Immune deficiency- Hypogammaglobulinaemia
Genetic- CF, primary cilary kinesia, young’s syndrome, kartagener syndrome
Obstruction- foreign body, tumour
Toxic insult- gastric aspiration,
Secondary immune deficiency- HIV
12
Q
Next step if Wells score outcome is: Unlikely?
A
D-dimer. If this is positive - then do CTPA
13
Q
Conditions that cause raised d-dimer?
A
DVT, PE Pneumonia Malignancy Heart Failure Surgery Pregnancy
14
Q
Investigations for suspected PE?
A
CTPA - IV contrast highlights pulmonary arteries
VQ scan - compare ventilation with perfusion. Used if CTPA is unsuitable. In PE, there will be deficit in perfusion.
D-dimer
Echocardiogram (if pt can not have CTPA)
FBC - thrombocytopenia, or anaemia, polycythaemia.
ECG
U+Es - for renal fuction to assess what drugs to use, and whether contrast can be used in CTPA
Coag screen - baseline before staring anticoagulant
LFTs - help choice of anticoagulant
15
Q
ABG shows respiratory alkalosis for PE. So does hyperventilation. How to differentiate these two differentials?
A
PE = resp alkalosis with low pO2.
Hyperventilation = resp alkalosis with high pO2
16
Q
Appearance of bronchiectasis on CT?
A
Signet rings
17
Q
What is Young’s syndrome?
A
Triad of bronchiectasis, sinusitis, and reduced fertility
18
Q
Methods of thrombolysis for PE?
A
IV - use peripheral cannula
Catheter-directed thrombolysis = directly into pulmonary arteries using central catheter
19
Q
Risk of catheter-directed thrombolysis in PE?
A
Damage to pulmonary arteries
20
Q
Bronchiectasis common organisms?
A
Haemophilius influenzae Non- tuberculous mycobacteria Fungi- aspergillus, candida Pseudomonas aeruginosa Moraxella catarrhalis Stenotrophomonas maltophilia
21
Q
Management of bronchiectasis?
A
Treat underlying cause
Antibiotics/ IV for severe infection
Flu and Covid vaccines
Bronchodilators
Antibiotic prophylaxis for those with recurrent infections
Physiotherapy for mucus/airway clearance
Pulmonary Rehab – MRC Dyspnoea Score >3
22
Q
What is the MRC dyspnoea score?
A
Used to assess the degree of baseline functional disability due to dyspnoea.
Breatheless with strenuous exercise-0
Breathless when walking up slight hill 1
Walk slower than people their age due to breathlessness/ has to stop walking due to breathlessness 2
Stop walking after 100m as am breathless 3
Too breathless to leave the house/ breathless when dressing/ undressing- 4
23
Q
How to identify pt with acute exacerbation of bronchiectasis
A
A person with bronchiectasis with a deterioration in 3 or more key symptoms for at least 48 hours:
Cough
Sputum volume and / or consistency
Sputum purulence
Breathlessness and / or exercise tolerance
Fatigue
Haemoptysis
24
Q
Management of PE
A
ABCDE
Oxygen if hypoxic
Analgesia if pain
Subcut LMWH (enoxaparin, dalteparin) whilst awaiting CTPA
Confirmed PE on CTPA - long term anticoagulant needed (warfarin, doac, LMWH).
25
Pt has massive PE. What is management?
```
ABCDE
Oxygen if hypoxic
Analgesia
Subcut LMWH while waiting for CTPA
Thrombolysis with IV alteplase
```
26
What is thrombolysis?
Inject fibrinolytic meds that break down clot rapidly.
27
Risk of thrombolysis?
Bleeding risk
| There is 4% risk of an intracranial bleed
28
Examples of thrombolytic agents?
Alteplase
Streptokinase
Tenecteplase
29
What is Allergic Bronchopulmonary Aspergillosis (ABPA)
Caused by aspergillus fumigatus exposure
| Combination of Type 1 and 3 hypersensitivity reactions following inhalation of fungal spores
30
What can ABPA cause?
Bronchiectasis
31
Who is at risk of ABPA?
Asthma, bronchiectasis and CF
32
How do you diagnose ABPA?
Dry cough, wheeze,
| Raised Aspergillus IgE level, high Total IgE and high eosinophils
33
Risk of catheter-directed thrombolysis?
Damage to pulmonary arteries
34
Absolute contraindications for thrombolysis?
```
Haemorrhagic stroke or ischaemic stroke within 6 months
CNS neoplasia
Recent trauma/surgery
GI bleed less than 1month ago
Bleeding disorder
Aortic dissection
```
35
Relative contraindications for thrombolysis?
Warfarin/DOAC use
Pregnancy
Advanced liver disease
Infective endocarditis
36
Presentation of pleural effusion?
```
SOB - gradual
Pleuritic chest pain
Non productive cough - not as common
(productive cough - only if due to pneumonia)
Tachycardia
```
37
Investigations for pleural effusion?
Imaging: PA CXR. USS . Contrast CT (good for exudative effusions). ECHO (if suspect HF)
Pleural aspiration: fluid sent for pH, protein, MC&S, glucose.
Bloods: FBC. CRP, blood culture, U+Es, LFTs, bone profile, LDH, clotting
Sputum: sputum gram stain and culture
38
RF for pleural effusion?
CCF
Malignancy
Pneumonia
Weaker RF:
SLE, RA, recent MI, renal failure, nephrotic syndrome, drug induced - e.g. nitrofurantoin,
39
Management for pleural effusion?
Ultrasound guided pleural aspiration
Conservative management if small
Chest drain
40
Examination findings/ signs in pleural effusion?
```
Reduced chest movement on affected side
Stony dull percussion
Reduced/absent breath sounds
Reduced vocal resonance
Tracheal deviation
```
41
Define exudate and transudate classification of pleural effusion
Exudate: Pleural protein concentration more than 30g/L
Transudate: less than 30g/L protein.
42
Transudate causes of pleural effusion?
Transudative = fluid moving across into the pleural space
```
Heart Failure
Hypoalbuminaemia (nephrotic syndrome or peritoneal dialysis)
Liver cirrhosis
Hypothyroidism
Pulmonary embolism
Mitral stenosis
```
Rare:
Meigs' syndrome (triad of benign ovarian tumor with ascites and pleural effusion that resolves after resection of the tumor).
Constrictive pericarditis
Superior vena cava obstruction
43
Exudate causes of pleural effusion?
Exudative = inflammation related - causes protein to leak out of tissue and into pleural space
Infection - pneumonia, TB, subphrenic abscess, TB. HIV (kaposi's).
Malignancy - lung cancer, mets
Inflammatory causes - Connective tissue disease, RA, SLE, Pancreatitis, lymphatic disorders, PE
Rare: yellow nail syndrome, fungal infections, drugs
Z2F : main ones - lung cancer, pneumonia, RA, Tb
44
Define empyema
Infected pleural effusion.
Z2F: suspect when pt has improving pneumonia but new or ongoing fever.
Pleural aspiration shows pus, acidic <7.2, low glucose and high LDH
45
How is empyema managed?
* Chest drain - remove pus.
* antibiotics based on sensitivity - usually for 3 weeks
* supportive care - pain relief, IV fluids, early mobilisation.
| bmj bes practice
46
What can CF be diagnosed based on?
One or more characteristic phenotypic features OR history of CF in a sibling OR positive newborn screening test result
PLUS:
Increased sweat chloride concentration (>60mmol/L Na+, Cl-) in sweat test
OR
Identify of two CF mutations - genotyping
OR
Demonstration of abnormal nasal epithelial ion transport
Note: Quesbook says the following:
- Neonatal heel prick day between day 5 and day 9
- Sweat test: sweat sodium and chloride >60mmol/L
- Faecal elastase: this can provide evidence for abnormal pancreatic exocrine function.
- Genetic screening: This can identify CF mutations
47
Pathophysiology of CF?
Autosomal receive condition.
Mutation in CFTR gene (which usually regulates sodium channel called ENAC)
Mutation in CFTR gene
—> increases Na+ absorption
—> get abnormal Chloride secretion (as CFTR usually codes cAMP regulated chloride channel) in epithelial cells lining the airways,
—>less water secreted
—> OVERALL: get thicker mucus= impair cilia function
48
Presenting features of CF?
Presenting features:
- Meconium ileus:
is in newborns, bowel is blocked by sticky secretions. Have signs of intestinal obstruction soon after birth - billows vomiting, abdominal distension, delay in passing meconium.
- Intestinal malabsorption:
main cause is severe deficiency of pancreatic enzymes
- Recurrent chest infections
- Newborn screening
49
Respiratory features of CF?
```
Chronic sinusitis
Nasal polyps
Cough
Wheeze
Haemoptysis
Recurrent LRTI
Bronchiectasis
Pneumothorax
Cor pulmonale
Respiratory failure
```
50
Apart from respiratory system, CF causes multi-organ damage. What are features of damage in:
1. GI system?
1. Pancreatic insufficiency, so have DM and/or steatorrhea
Cirrhosis
Portal HTN
Gallstones
51
Apart from respiratory system, CF causes multi-organ damage. What are features of damage in:
2.. Reproductive system?
2. Male infertility
52
Apart from respiratory system, CF causes multi-organ damage. What are features of damage in:
3. MSK?
3. Clubbing
Arthritis
Osteoporosis
53
Investigations in known CF patients (to monitor disease aseverity, assess symptoms etc)?
```
Sputum culture - chest infection
Glucose tolerance test - assess DM
Bloods - FBC, U+Es, coat screen, vitamins, blood sugar, bone profile
Spirometry: obstructive defect
Aspergillus skin prick test or serology
```
Imaging: CXR - bronchiectasis, hyperinflation
Abdominal ultrasound - Distal Intestinal Obstruction, liver cirrhosis, chronic pancreatitis
54
Lifestyle advice for pts with CF?
No smoking
Avoid other CF pts
Avoid friends/relatives with colds and infections
Avoid jaccuzis (pseudomonas)
Clean and dry nebulisers thoroughly
Avoid stables, compost or rotting veg - Aspergillus inhalation
Annual flu vaccine
Sodium chloride tablets in hot weather/exercise
55
Medical management for infective exacerbation of CF?
* Antibiotics, although for patients with recurrent chest infections prophylactic long-term antibiotics may be prescribed.
* Nebulised mucolytics (Dornase Alfa)
* Bronchodilators (Inhaled corticosteroids or B2-agonists)
56
Medical management for pancreatic insufficiency in CF?
Insulin replacement
Creon - exocrine enzymatic replacement
Vitamins - A, D, E, K
57
Medical management for worsening progressive lung disease in CF?
Oxygen therapy
Ventilation
Diuretics (especially if have cor pulmonale)
58
Presentation of asthma:
a) Symptoms?
b) Signs?
```
a) Symptoms:
Wheeze
Dyspnoea
Cough (may be nocturnal)
Chest tightness
Diurnal variation (symptoms often worse in the morning)
```
```
b) Signs:
Tachypnoea
Hyperinflated chest
Hyper-resonance on chest percussion
Decreased air entry (sign of severe illness: silent chest)
Wheeze on auscultation
```
59
Investigations for suspected asthma?
1. Peak flow: variability >20%
2. Fractional exhaled nitric oxide (FeNO): >40 ppb in adults or >35 ppb in children
3. Spirometry with bronchodilator reversibility: FEV1/FVC < 0.7 (obstructive spirometry). Improvement of FEV1 > 12% after bronchodilator therapy is diagnostic
5. Bloods - FBC, U+Es, ABG
6. CXR
60
Non - pharmacological management of asthma? (not an acute attack)
Smoking cessation
Avoidance of precipitating factors (eg. known allergens - dust, animal hair, cold air etc)
Review inhaler technique
61
Pharmacological management of asthma? (not an acute attack)
Step 1: short-acting inhaled B2-agonist (eg. Salbutamol)
Step 2: add low-dose inhaled corticosteroid steroid (ICS)
Step 3: add long-acting B2-agonist (eg. Salmeterol). If no benefit, stop this and increase ICS dose; if benefit but inadequate control, continue and increase ICS dose.
Step 4: Trial oral leukotriene receptor antagonist, high-dose steroid, oral B2-agonist
(from Quesmed - see NICE guidelines too)
62
Investigations for acute asthma attack?
ABG: type 2 respiratory failure (low PaO2 and high PaCO2) is a sign of a life-threatening attack.
Routine blood tests (including FBC, CRP): to look for precipitating causes of an asthma attack, such as an infection.
Chest x-ray: to exclude differentials and possibly identify a precipitating infection.
63
Management of acute asthma attack?
- ABCDE - Ensure a patent airway
- Ensure oxygen saturations of 94-98%, ABG if O2 sats <92%
- Nebulisers: Salbutamol 5mg (can repeat after 15mins).
- Steroids: oral Prednisolone 40mg STAT or IV Hydrocortisone (if PO not possible)
64
Differential diagnosis for asthma?
```
Bronchiectasis
COPD
CF
Foreign body aspiration (especially in children)
GORD
HF
Interstitial lung disease
Lung cancer
Pertussis
```
65
2 Main types of lung cancer?
Small cell- 15% of cases and worse prognosis
| Non-small cell- more common
66
Types of non-small cell lung cancer?
Adenocarcinoma
Squamous cell carcinoma
Large cell carcinoma
67
Most common type of lung cancer?
Adenocarcinoma
68
Symptoms of lung cancer?
```
Persistent cough
Haemoptysis
Dyspnoea
Chest pain
Weight loss and anorexia
SVC obstruction
```
69
What type of tumour causes a hoarse voice?
Pancoast tumour pressing on the recurrent laryngeal nerve
70
Sign of lung cancer?
Cachexia
Finger Clubbing
Hypertrophic pulmonary osteoarthropathy
Anaemia
Horner's syndrome (if the tumour is apical)
Enlargement of supraclavicular and axillary lymph nodes
Paraneoplastic syndromes: Cushing's syndrome, SIADH, and Lambert-Eaton syndrome (suggest small-cell), hyperparathyroidism (suggests squamous cell)
71
On auscultation of the lungs, how might lung cancer sound?
Features of consolidation (pneumonia); collapse (absent breath sounds, ipsilateral tracheal deviation); pleural effusion (Stony dull percussion, decreased vocal resonance and breath sounds)
72
Features of squamous cell carcinoma?
Typically central tumour
Associated with PTHrP- hypercalcaemia, finger clubbing and hypertrophic pulmonary osteoarthropathy
May also get hyperthyroidism due to ectopic TSH
73
Features of large cell carcinoma?
Peripheral
Usually anaplastic and poorly differentiated with poor prognosis
May secrete B-hCG
74
Features of small cell carcinoma?
Associated with ectopic ADH--> hyponatraemia
ectopic ACTH--> hyperglycaemia, hypertension, hypokalaemia, alkalosis, muscle weakness--> may get bilateral hyperplasia of the adrenal glands
Lambert- Eaton syndrome
75
What is Lambert- Eaton syndrome?
Antibodies to voltage gated calcium channel--> myasthenic like symptoms
76
What is SVC obstruction?
Oncological emergency
| Compression of the SVC most commonly due to lung cancer
77
Features of SVC obstruction?
```
Dyspnoea
Swelling of face and neck, conjunctival and periorbital oedema
Headache- often worse in the morning
Visual disturbance
Pulseless jugular venous distension
```
78
Management options for SVC obstruction?
Dependent on pt, options range from:
endovascular stenting for symptoms relief
Radical chemo or chemo-radio therapy
Glucocorticoids are usually given but evidence is weak
79
Investigations in suspected lung cancer?
Cxr- may see nodules, lung collapse, pleural effusion, consolidation, and bony metastases
CT- confirm diagnosis and to stage it, ensure adrenals and liver are also scanned to have a look
Bronchoscopy- allow biopsy to be taken
PET scanning- usually in non-small cell lung cancer--> eligibility for curative treatment. Uses 18-fluorodeoxygenase which is preferentially taken up by neoplastic tissue
80
Management of small cell lung cancer?
Most pts will be on palliative chemo
| May try chemo-radiotherapy for some patients, however prognosis is poor
81
Management of Non-small cell lung cancer?
Only 20% suitable for surgery, before surgery mediastinoscopy performed as CT doesn't always show mediastinal involvement
Curative or palliative radiotherapy
Chemo may be offered palliatively
82
Ddx for lung cancer?
pneumonia, bronchitis, exacerbation of COPD, mets from another site, sarcoidosis, TB
83
What blood abnormality would you most likely see in lung cancer?
Raised platelets
84
What is a pneumothorax?
When air gets into the pleural space separating lung from chest wall
85
Whats the difference between primary and secondary pneumothorax?
Primary- no underlying lung pathology
| Secondary- if there is underlying lung disease
86
Causes of pneumothorax?
Spontaneous
Trauma
Iatrogenic- lung biopsy, mechanical ventilation, central line insertion
Lung pathology- asthma, COPD
87
What is catamenial pneumothorax?
Due to endometrisosis in the thorax. Occurs during/ after menstruation
88
Presentation of pneumothorax?
```
Sudden onset:
Dyspnoea
chest pain: often pleuritic
sweating
tachypnoea
tachycardia
```
89
Investigations for pneumothorax?
Erect Cxr
| CT thorax for small pneumothorax and can accurately asses the size of the pneumothorax
90
How do you manage a primary pneumothorax?
rim of air is < 2cm and the patient is not short of breath then discharge should be considered
otherwise, aspiration should be attempted
if this fails (defined as > 2 cm or still short of breath) then a chest drain should be inserted
91
How do you manage a secondary pneumothorax?
patient is > 50 years old and the rim of air is > 2cm and/or the patient is short of breath then a chest drain should be inserted.
otherwise aspiration should be attempted if the rim of air is between 1-2cm.
If aspiration fails a chest drain should be inserted.
All patients should be admitted for at least 24 hours
if the pneumothorax is less the 1cm then the BTS guidelines suggest giving oxygen and admitting for 24 hours
92
Where do you insert a chest drain?
```
Safe triangle:
5th IC space
Mid axillary line
anterior axillary line
within this triangle
```
93
What is a tension pneumothorax?
One way valve, not allowing air to escape, leading pressure to rise
94
Typical pneumothorax pt?
Young, tall and thin man presenting with SOB
95
Signs of tension pneumothorax?
```
Tracheal deviation AWAY from side of the pneumothorax
Reduced air entry on affected side
Increased resonance on affected side
Tachycardia
Hypotension
```
96
Management of tension pneumothorax?
Insert a large bore cannula into the second IC space mid clavicular line
Then use a chest drain for definitive management
97
How does a patient with COPD present? divide into symptoms and signs
```
Symptoms:
Productive cough sputum
Wheeze
Dyspnoea
Reduced exercise tolerance
```
```
Signs :
Accessory muscle use
Tachypnoea
Hyperinflation
Reduced cricosternal distance
Reduced chest expansion
Hyper-resonant percussion
Decreased/quiet breath sounds
Wheeze
Cyanosis
Cor pulmonale (signs of right heart failure)
```
98
what DDx should you consider when thinking about COPD
Lung cancer
Heart failure
lung fibrosis
99
What might you see on examination of a pt with COPD?
```
Tacchypnoea
Resp distress
accessory muscle use
intercostal retraction
barrel chest
wheezing
coarse crackles
cyanosis
Right sided heart failure (+ neck veins, heptatomegaly, LL oedema)
Asterexis -hypercapnia
```
100
Pneumonia on a chest xray?
Consolidation and air bronchogram
101
Signs of pneumonia
```
Usually signs of sepsis:
Tachycardia
Tachypnoea
Hypoxia
Hypotension
Fever
Confusion
```
102
Chest signs of pneumonia
Bronchial breath sounds-
Focal coarse crackles
Dullness to percussion
103
Severity assessment for pneumonia
```
CURB-65 (CRB-65 in community)
C- Confusion
U- Urea> 7
R- RR> 30
B- BP < 90 systolic or < or equal to 60 diastolic
65- age greater than or equal to 65
```
104
What is atypical pneumonia?
Pneumonia caused by organisms that cannot be cultured by gram staining
105
What are bronchial breath sounds?
In pneumonia- harsh breath sounds equally loud on inspiration and expiration
106
What are focal coarse crackles?
Air passing through sputum in airways similar to using a straw blow air through a drink
107
What is CURB-65 for?
Predicts mortality: (1= 5% 3= 15%, score 4/5= 25%) and whether pt should be treated at hospital
0/1- consider treatment at home
greater than/equal to 2- consider treatment at hospital
greater than/equal to 3- consider intensive care assessment
108
How do you get Legionnaires' disease?
Infected water supply or air condition units
109
What complication can Legionnaires' disease cause?
| i.e. note on bloods as a clue
Hyponatraemia--> SIADH
| Lymphopenia
110
Typical Legionnaires' exam patient?
Cheap hotel holiday and presents with hyponatraemia and lymphopenia
111
What are some investigations you might do for lung abscess?
CXR :
- Fluid-filled space within an area of consolidation
- air-fluid level is typically seen
sputum and blood cultures
112
Complications of mycoplasma pneumoniae?
```
haemolytic anaemia
Erythema multiforme
meningioenchepalitis
Guillan barre syndrome
bullous myringitis: painful vesicles on the tympanic membrane
pericarditis/myocarditis
gastrointestinal: hepatitis, pancreatitis
renal: acute glomerulonephritis
```
113
Causative organism for fungal pneumonia?
Pneumocystis jiroveci
114
Who is at risk of fungal pneumonia?
Immunocompromised- esp HIV patients with low CD4 count
115
How does fungal pneumonia present?
Dry cough with sputum production
SOB on exertion
Night sweats
116
What are RF for empyema ?
recent pneumonia
iatrogenic intervention in the pleural space
thorax trauma
Immunocompromised e.g. diabetes, HIV , chemo, malnutrition
co-morbidities make pneumonia more likely aspiration - stoke/NG tube
lung disease
male sex
young or old age
alcohol abuse
117
In a pt w/ symptoms and signs of infection + a significant pleural effusion what must be done urgently?
thoracentesis (pleural aspiration)
118
Complications of pneumonia?
```
Sepsis
Pleural effusion
Empyema
Lung abscess
Death
```
119
Causes of pneumonia?
Streptococcus pneumoniae (accounts for around 80% of cases)
Haemophilus influenzae
Staphylococcus aureus: commonly after influenza infection
atypical pneumonias (e.g. Due to Mycoplasma pneumoniae)
120
What are the most common bacterial organisms that cause infection exacerbations of COPD?
Haemophilus influenzae (most common cause)
Streptococcus pneumoniae
Moraxella catarrhalis
121
What would you see on CXR with a patient with COPD?
hyperinflation
Bullae: if large, may sometimes mimic a pneumothorax
flat hemidiaphragm
122
What is a lung abscess?
well-circumscribed infection within the lung parenchyma
123
What are the causes / RF for a lung abscess?
Secondary to aspiration pneumonia e.g.
Poor dental hygiene
stroke (reduced consciousness)
infective endocarditis - haematogenous spread
direct extension - empyema
Bronchial osbtruction (secondary to lung tumour)
124
What are some of the microbial causes of lung abscess?
often polymicrobial
Monomicrobial causes:
Staphylococcus aureus
Klebsiella pneumonia
Pseudomonas aeruginosa
125
What are some of the symptoms of lung abscess?
Develop over weeks (like subacute pneumonia)
```
Systemic: night sweats / weight loss
Fever
productive cough (foul sputum, rarely haemoptysis)
chest pain
SOB
```
126
What are some of the signs you would see on examination of a lung abscess?
dull percussion
bronchial breathing
clubbing may be seen
127
What are some investigatioins you might do for lung abscess?
CXR :
- Fluid-filled space within an area of consolidation
- air-fluid level is typically seen
sputum and blood cultures
128
How would you manage a lung abscess?
IV antibiotics
Percutaneous drainage may be required
Rare: surgical resection
129
What is an empyema?
Empyema is defined as the presence of frank pus in the pleural space
130
What is a Parapneumonic effusion?
Parapneumonic effusions are effusions caused by an underlying pneumonia.
Simple - not infected
Complicated- effusion develops once infection has spread to the pleural space.
131
How is empyema, a simple parapneumonic effusion and complicated parapneumonic effusion related?
Three conditions = a spectrum of pleural inflammation in response to infection.
From a simple parapneumonic effusion to empyema.
132
What are RF for empyema ?
```
recent pneumonia
iatrogenic intervention in the pleural space
thorax trauma
Immunocompromised e.g. diabetes
co-morbidities make pneumonia more likely
lung disease
male sex
young or old age
alcohol abuse
```
133
If empyema or a complicated parapneumonic effusion is diagnosed what must be done urgently?
Insert a chest drain
+ long course of AB
if no improvement with AB and drainage - surgery or fibrinolytics
134
How do causative pathogens differ from comminity acquired and hospital acquired empyema?
Community: Streptococcus pneumoniae, and staphylococci
Hospital: staphylococci (particularly MRSA)
135
How would a pt with empyema present?
Constitutional symp:
Malaise, anorexia, weight loss, fatigue
Pyrexia
Rigors
```
Examination:
dullness at the lung base
reduced breath sounds
reduced vocal resonance
signs of sepsis
```
136
What investigations for empyema?
Bloods:
Blood cultures - AB choice
FBC - WCC count
CRP
Imaging:
CXR - see effusion, loculated effusion suggests empyema. consolidation due to pneumonia.
```
Special tests:
Thoracentesis : pleaural fluid:
appearance; pus diagnostic
Odor: putrid - anaerobic
PH: <7.2
total protein context > 30 g/l
LDH level >2-3 x upper limit of serum
Glucose
WCC - lymphocytes -TB / malignancy
MC&S
```
137
What is type 1 respiratory failure?
Pa02<8kPa; PaC02 Normal
138
Causes of type 1 respiratory failure?
```
Asthma
Congestive HF
Pulmonary Embolism
Pneumonia
Pneumothorax
```
139
What is type 2 respiratory failure?
Pa02<8kPa; PaC02 > 6kPa
140
Causes of type 2 respiratory failure?
Obstructive lung disease e.g. COPD
Restrictive lung disease e.g. IDL
Depression of respiratory centre e.g. opiates
NMJ disease e.g. Guillan barre syndrome, MND
Thoracic wall disease- rib fracture
141
What is ARDS?
Increased permeability of alveolar capillaries--> fluid accumulation in alveoli- non-cardiogenic pulmonary oedema
142
Causes of ARDS?
Pulmonary: chest sepsis, aspiration, pneumonia, trauma, smoke inhalation
Non-pulmonary: DIC, acute pancreatitis, drug OD
143
Presentation of ARDS?
Acute onset respiratory failure which fails to improve with supplemental O2.
Symptoms of severe dyspnoea, tachypnoea, confusion and presyncope
144
Examination findings in ARDS?
fine bibasal crackles but no other signs of HF
145
Investigations for ARDS?
Cxr with bilateral alveolar infiltrates w/o any other features of HF
146
Management of ARDS
```
V serious
ICU
Ventilatory support
Haemodynamic support
DVT prophylaxis
Abx only if infectious cause for ARDS
```
147
Characteristics of asthma? i.e. what is it?
Chronic inflammation disease of the airways
Obstructive but reversible (spontaneously or w treatment)
Increased airway responsiveness (i.e. narrowing) to variety of stimuli.
148
Pt has a wheeze. What are most likely/common differentials?
Acute asthma exacerbation
Bronchitis - bacterial or viral
```
Less common:
Pulm oedema
PE
GORD
Allergy
Hyperventilation
Cardiac disease
Churg-Strauss syndrome
```
149
# Define MILD asthma exacerbation based on:
1) PEFR %
| 2) features of severe asthma
1) >75%
| 2) no features of severe asthma
150
# Define MODERATE asthma exacerbation based on:
1) PEFR %
| 2) features of severe asthma
1) 50-75%
| 2) no features of severe asthma
151
# Define SEVERE asthma exacerbation based on:
1) PEFR %
| 2) features of severe asthma
1) 33-50%
2) Cannot complete sentences in one breath
RR>25
HR>110
(ANY ONE OF THESE PRESENT = SEVERE ASTHMA ATTACK)
152
# Define LIFE THREATENING asthma exacerbation based on:
1) PEFR %
| 2) features of severe asthma
1) <33%
2) Sats<92% or ABG pO2<8kPa
Cyanosis, poor response effort, silent chest
Exhaustion, confusion
Hypotension, arrythmias
normal pCO2
153
Define NEAR FATAL asthma exacerbation based on features of severe asthma
RAISED pCO2
154
Management of SEVERE (PEFR 33-50%) asthma attack?
Same as acute asthma attack
- ABCDE - Ensure a patent airway
- Ensure oxygen saturations of 94-98%, ABG if O2 sats <92%
- Nebulisers: Salbutamol 5mg (can repeat after 15mins).
- Steroids: oral Prednisolone 40mg STAT or IV Hydrocortisone (if PO not possible)
PLUS:
- Nebulised ipratropium bromide 500micrograms
- back to back salbutamol if needed
155
Management of LIFE THREATENING (PEFR <33%) asthma attack?
Same as acute asthma attack PLUS
- urgent ITU or anaesthetist assessment
- Urgent portable CXR
- IV aminophylline
- Consider IV salbutamol if nebuliser route is ineffective.
156
Criteria for safe asthma discharge after exacerbation?
PEFR >75%
Stop nebulisers 24hrs before discharge
Inpatient asthma nurse review to reassess inhaler technique and adherence
Provide PEFR meter and written asthma action plan
At least 5 day course of oral prednisolone
GP follow up within 2 working days
Resp clinic follow up within 4 weeks
Psychosocial factors considered before discharge
157
Differentials of eosinophilia?
```
Airway inflammation = COPD or asthma
Hayfever/allergies
Multiple courses of abx for chronic infections
Eosinophillic pneumonia
Parasites
Lymphoma
SLE
```
158
Asthma triggers?
```
Smoking
Cold air
Allergens - dust, pollen, pets
URTI - mainly viral
Occupational irritants
Pollution
Drugs - aspirin, Bblocker
Food and drink - dairy, alcohol, orange juice
Stress
```
159
How to manage chronic asthma?
Use BTS stepwise management guidelines
Assess and teach inhaler technique
Self management plans
Avoid triggers
160
Management of CF?
```
Physio airway clearance
Exercise
Mucolytic treatment
Pancreatic enzyme replacement therapy
Fat soluble vitamin replacement
Long term abx
Optimise CF related DM - insulin therapy
Novel CFTR modulators = Kaftrio
Long term monitoring for CF related DM, CF related liver disease, osteoporosis.
```
161
(SARS-CoV-2) can cause viral pneumonia. What is the triad of symptoms hospitalised patients get?
Hypoxia
Lymphopenia
Bilateral, lower zone changes on CXR
162
What is hospital management for SARS-CoV-2?
1. O2 supplementation
some may need CPAP / invasive ventilation
2. Dexamethasone ( consider Tocilizumab +/- Remdesivir)
3. AB may be needed if superadded bacterial infection
163
What is Influenza?
Flu
Single stranded RNA virus.
most common cuaes of viral pneumonia in immunocompromised adults
164
What serotypes of inluenza are there?
Three serotypes of influenza - A, B and C
Serotype- determined by surface antigens haemagglutinin and neuraminidase. These are rearranged in host organisms e.g. birds /animals = different strains e.g. Influenza A H5N1 (avian influenza)
165
How is influenza transmitted?
via respiratory secretions
VVV contagious
166
How long is incubation period for influenza?
typically 1-4 days
167
How long is a pt infectious for with influenza after incubation period ?
patients can remain infectious for 7-21 days
168
What are the symptoms of influenza?
Fever ≥ 37.8°C
Non-productive cough
Myalgia
Headache
Malaise
Sore throat
Rhinitis
169
What are some pulmonary complications of Influenza?
Viral pneumonia,
secondary bacterial pneumonia,
worsening of chronic conditions e.g. COPD and asthma
170
What are some Cardiovascular complications of Influenza?
Myocarditis
Heart failure
171
What are some neurological complications of Influenza?
Encephalopathy
172
What are some GI complications of Influenza?
Anorexia and vomiting are common
173
How do you diagnose Influenza?
Routine viral culture
Rapid reverse transcriptase PCR tests are now available.
174
What is the management of Influenza?
1. Supportive (analgesia, antipyretic, fluids, oxygen)
2. Antiviral treatment with neuraminidase inhibitors e.g. Oseltamivir ('Tamiflu')
3. Infection control and respiratory isolation to prevent onward transmission
175
What are the vaccine options for Influenza? Who is it recommended for?
1. Inactivated vaccine tailored each year according to recent outbreaks.
It provides partial protection against influenza
2. those over 65, with chronic conditions. Healthcare workers and nursing home residents.
176
What are some general clinical features of TB?
1. Fever
2. Night sweats
drenching)
3. Weight loss (weeks – months)
4. Malaise
177
What are some clinical features of Respiratory TB?
cough ± purulent sputum/haemoptysis
pleural effusion
178
What are some clinical features of NON- Respiratory TB?
Skin (erythema nodosum)
Lymphadenopathy;
Bone/joint; (stiffness, abscess, swelling)
Abdominal; (pain/diarrhoea/distention)
CNS
(meningitis);
Genitourinary; (flank pain, dysuria, polyuria)
Miliary (disseminated);
Cardiac (pericardial effusion)
179
What are you differentials for Haemoptysis : infection related?
Pneumonia
Tuberculosis
Bronchiectasis / CF
Cavitating lung lesion (often fungal
180
What are you differentials for Haemoptysis : Malignancy related?
Lung cancer
metastases
181
What are you differentials for Haemoptysis : Haemorrhage related?
Bronchial artery erosion
Vasculitis
Coagulopathy
182
What are some differentials for Haemoptysis? Other (resp = clue)
PE!
183
List some RISK FACTORS for TB ?
Past history of TB
TB contact
Born in a country with high TB incidence
Travel to country with high incidence of TB
Immunosuppression–e.g. IVDU, HIV, organ transplant, renal failure/
dialysis, malnutrition/ low BMI, DM, alcoholism
184
What are the immediate management principals for a pt with Resp TB (before investigations)
ABCDE approach
Admit to side room + start infective control measure (e.g. masks + negative pressure room.)
185
What are the management principals for a pt with Resp TB (lab investigations)
1. Productive cough - 3 x sputum samples (acid-fast Ziehl-Neelsen stain) + TB culture
2. NO productive cough - consider bronchoscopy
3. Routine bloods
LFTs + HIV test + vit D levels
186
What are the management principals for a pt with Resp TB (imaging)
- CXR
| - Consider CT chest if suspect pulmonary TB (CXR normal / no clinical features)
187
What to do if your diagnosis is split between pneumonia and TB?
Start Antibiotics for pneumonia as per CURB-65
188
What should you do if pt is critically unwell and there is a likelihood of TB?
Start TB treatment AFTER samples sent
189
How long does TB culture take? What does this mean?
Culture takes 6-8 weeks.
Means treatment often started before confirmed diagnosis.
Novel PCR test (Gene Xpert) available in some centre - gives immediate info on drug sensitivites / resistance.
190
What role do specialist nurses play in TB management?
Notify pt cases to specialist nurses as they:
support pt during investigation, treatment, pubic health issues AND initiate contact tracing!
191
What is standard Anti-TB therapy regimen?
FIRST 2 MONTHS:
4: (Rifampicin, Isoniazid, Pyrazinamide, Ethambutol)
NEXT 4 MONTHS
2: (Rifampicin, Isoniazid)
TOTAL: 6 months minimum (can vary)
192
Why is weight important in Anti-TB therapy?
dose of anti-TB is weight dependant.
193
Which bloods is it essential to check before commencing anti-TB treatment?
LFTS
194
Which anti-malarial drug requires eye test?
Ethambutol (E for eyes)
need to check visual acuity before giving.
Side effect - can cause Retrobullar neuritis
195
What strategies can be used to ensure compliance ?
Directly observed Therapy (DOT)
196
What investigation if suspect CNS TB?
MRI Brain
197
What are major side effects of Rifampicin?
Hepatitis
rashes
febril reactions
orange / red secretions - sweat / urine / contact lenses
Drug interactions - warfarin / COCP
198
What are major side effects of Isoniazid?
Hepatitis
rashes
peripheral neuropathy
psychosis
199
What are major side effects of Pyrazinamide?
Hepatitis
rashes
vomitting
arthralgia
200
What is pathophysiology of COPD?
Eemphysema and chronic bronchitis
Mucous gland (goblet cells) hyperplasia
Loss of cilial function
Emphysema – alveolar wall destruction causing
irreversible enlargement of air spaces distal to the
terminal bronchiole
```
Chronic inflammation (macrophages and
neutrophils) and fibrosis / remodelling of small airways
```
201
What is the definition of COPD?
COPD is characterised by airflow obstruction. Airflow obstruction is progressive, not fully reversible and does not change markedly over several months.
The disease is predominantly caused by smoking
202
What are the cuases of COPD?
Smoking
Inherited - α-1-antitrypsin deficiency
Industrial exposure - e.g. soot from coal
203
What is outpatient COPD Management?
* ‘COPD Care Bundle’
* SMOKING CESSATION
* Pulmonary Rehabilitation
* Bronchodilators
* Antimuscarinics
* Steroids
* Mucolytics
* Diet
* LTOT if appropriate
* Lung Volume reduction if appropriate
204
What does the 'COPD care Bundle’ involve?
Assessment of inhaler technique
Provision of a written patient self-management action plan
(where appropriate) an emergency drug pack
The offer of referral for support to stop smoking
Access to a treatment programme that can help people with a lung condition stay active (pulmonary rehabilitation)
Appropriate follow-up arrangements.
205
Who is in the multidisciplinary team for COPD patient care?
```
Physicians
GPs
specialist nurses
Physiotherapists
pharmacists
Occupational therapsits
Dieticians.
```
206
What are the indications for long term oxygen therapy for a patient with COPD?
pO2 below 7.3 kPa, or 8 kPa (cor pulmonale)
Non-smokers
Balance loss of
independence/ reduced activity
Note: 02 not a treatment for breathlessness; to prevent organ hypoxia
207
Why is long term oxygen therapy good for COPD patients?
Hypoxia can causes renal and cardiac damage - LTOT reduces this
208
How long do COPD pts need to use long term oxygen therapy for a day to get a survival benefit ? (LTOT)
at least 16 hours a day
209
What is pulmonary rehabilitation?
MDT 6-12 week programme:
supervised
exercise
unsupervised home exercise
nutritional advice
disease education
210
Why is pulmonary rehabilitation good for COPD pts?
COPD pts avoid exercise / physical activity as breathless.
Leads to vicious cycle of increasing social isolation, depression, muscle weakness and inactivity making symptoms worse
211
How would you judge a pt with COPD to be in the midst of an infective exacerbation ?
Change in sputum volume / colour
Fever
Raised WCC +/- CRP
212
How would you manage a pt with COPD who is having an exacerbation?
ABCDE approach
O2- aim for 94-98% but if evidence of (raised pCO2 on ABG) or Type 2 Resp Failure, then target SaO2 88-92%
NEBs – Salbutamol and Ipratropium
Steroids – Prednisolone 30mg STAT and OD for 7
days
Antibiotics if raised CRP / WCC or purulent sputum
CXR
Consider IV aminophylline
Non invasive ventilation if Type 2 respiratory failure and pH
7.25-7.35
pH <7.25 consider ITU referral
213
What is interstitial lung disease?
Umbrella term describing a number of conditions that affect the lung parenchyma in a diffuse manner. an umbrella term used for a large group of diseases that cause scarring (fibrosis) of the lungs.
214
What are some examples of interstitial lung disease?
Usual Interstitial Pneumonia (UIP)
Non-specific Interstitial Pneumonia (NSIP)
Extrinsic Allergic Alveolitis
Sarcoidosis
Several other conditions
215
What are important things to cover in hx taking from a pt with ILD? Why?
- comprehensive occupational / environmental history
e. g.
inhalation of dust - Silicosis
Inhalation of asbestos - Asbestosis
Pneumoconioisis (coal workers)
216
What results to do you get in PFTs for ILD?
Typically restrictive lung diseases on PFT’s
217
What autoimmune / immunological investigations do you need to do for ILD?
(Looking for conditions associated with developing ILD)
ANA – connective tissue disease OR SLE
ENA – connective tissue disease
Rh F – Rheumatoid Arthritis
ANCA – Vasculitis
Anti-GBM – Pulmonary Renal disease
ACE – Sarcoidosis
Ig G to serum precipitins e.g. pigeon, budgie – Extrinsic Allergic Alveolitis
HIV
218
What is the most common ILD causing lung fibrosis?
Usual Interstitial Pneumonia (UIP)
often idiopathic
219
What findings do you see with Usual Interstitial Pneumonia (UIP) and ILD?
`Examination : clubbing, reduced chest expansion
Auscultation: fine inspiratory crepitations (pulling Velcro slowly) – best heard basal / axillary areas
Cardiovascular – features of pulmonary
hypertension
(note L (UIP) is a form of lung disease characterised by progressive scarring of both lungs - interstitial lung disease)
220
What is Extrinsic Allergic Alevolitis? (ILD)
Also known as Hypersensitivity Pneumonitis
Inhalation of organic antigen to which the individual has been sensitised
221
How does Extrinsic Allergic Alevolitis? (ILD) present acutely?
short period from exposure - 4-8 hrs.
Usually reversible - spontaneously settle 1-3 days.
Can reocur
222
How does Extrinsic Allergic Alevolitis? (ILD) present Chronically?
chronic exposure (months – years). Less reversible.
223
What are some drug causes of ILD? Extrinsic Allergic Alevolitis?
```
Amiodarone
Bleomycin
Methotrexate
Nitrofurantoin
Penicillamin
```
224
What is Sarcoidosis ? (ILD)
| What do you see on histology?
Multisystem (often resp) inflammatory condition of unknown cause
50% remission, 50% progressive disease
Non-caseating granulomas on Histology
225
What investigations for Sarcoidosis?
Definitive: tissue biopsy (e.g., lung, lymph nodes), which typically reveals non-caseating granulomas
Bedside: PFTs: restrictive pattern (fibrosis) -(obstructive- an early sign)
Bloods:
* raised ESR
* ACE (not specific or diagnostic)
* U&Es
* raised calcium levels
* lymphocytes may be reduced
Imaging:
* CXR: 4 stages of changes from Sarcoid
Cardiac involvement:
* ECG, 24 tape, ECHO, cardiac MRI
* CT/MRI head: headaches – Neuro sarcoid
226
What are ILD treatment principals?
Remove trigger exposure e.g. occupational / environment
Stop smoking
MDT approach – Pirfenidone to slow progression
Treatment of infective exacerbations
Oxygen if respiratory failure
Palliative care
Transplantation
227
Stages of sarcoidosis on CXR?
Stage 1 - Bilateral hilar lymphadenopathy (BHL)
Stage 2 - BHL with peripheral infiltrates
Stage 3 - Peripheral infiltrates alone
Stage 4 - Pulmonary fibrosis
228
What is sarcoidosis?
Sarcoidosis is a multi-system disease that is characterised by the formation of granulomas, leading to widespread inflammatory changes and complications across multiple body systems.
229
Clinical definition of obstructive sleep apnoea?
Upper airway narrowing, provoked by sleep, causing sufficient sleep fragmentation. Results in daytime sleeping
230
Signs and symptoms of Acute Sarcoidosis?
Signs and symptoms of acute sarcoidosis, also known as Löfgren syndrome, include:
Fever
Polyarthralgia
Erythema nodosum
Bilateral hilar lymphadenopathy
231
Characteristic physical features of pt with obstructive sleep apnoea?
Male
Upper body obesity - collar size >17inches
Undersized/set back mandible
232
Common manifestations of Chronic Sarcoidosis?
| Involving other organs / systems
* Pulmonary: Dry cough, dyspnoea, reduced exercise tolerance, and crepitations on examination
* Constitutional: Fatigue, weight loss, arthralgia, low-grade fever, lymphadenopathy, and enlarged parotid glands
* Neurological: Meningitis, peripheral neuropathy, bilateral Bell's palsy
* Ocular: Uveitis, keratoconjunctivitis sicca
* Cardiac: Arrhythmias, restrictive cardiomyopathy
* Abdominal: Hepatomegaly, splenomegaly, renal stones
* Dermatological: Erythema nodosum, lupus pernio
233
Definition and Pathophysiology of obstructive sleep apnoea?
Obstructive sleep apnoea (OSA) is a sleep disorder caused by recurrent episodes of complete or partial collapse of the upper airway, causing obstruction of airflow and therefore apnoeic episodes.
It is normal for muscle tone to reduce when asleep, in these patients the innate tone of the pharynx is overcome, which causes it to collapse on itself, obstructing the airway. This induces hypoxia and therefore a reactive episode of transient arousal to reopen the airway. Overall overnight ventilation is impaired and CO2 levels increase.
234
Management of sarcoidosis?
* Bilateral hilar lymphadenopathy alone: Usually self-limiting and often does not require treatment
* Acute sarcoidosis: Bed rest and NSAIDs for symptom control
* Steroid treatment: Oral or intravenous, depending on the severity of the disease
* Immunosuppressants: Used in severe disease.
235
Causes of small pharyngeal size?
| Obstructive Sleep apnoea
Fatty infiltration of pharyngeal tissues and external pressure from increased neck fat/muscle bulk
Large tonsils
Craniofacial abnormalities
Extra submucosal tissue = e.g in myxoedema
236
Causes of excessive narrowing of the airway during sleep?
Obesity
Neuromuscular disease with pharyngeal involvement - leads to greater loss of dilator muscle tone e.g stroke, myotonic dystrophy, motor neurone disease
Muscle relaxants - sedatives, alcohol
Increasing age
237
Clinical features (signs and symptoms) of obstructive sleep apnoea?
Unrefreshed sleep
Snoring and apnoea attacks witnessed by partner
Excessive daytime sleepiness
Nocturia
Less common in booklet: Nocturnal sweating, reduced libido, oesophageal reflux
238
What is Epworth sleepiness scale?
A questionnaire completed by patient +/- partner to assess chance of having obstructive sleep apnoea. 0 = would not doze. 1 = slight chance. 2 = moderate chance. 3 = high chance. 0-3 given for each question, score out of 24 given.
239
What kind of questions are asked in Epworth sleepiness scale?
Sleep when:
1. sitting and reading
2. watching tv
3. sitting in public place
4. passenger in a car for an hour
5. lying down to rest in the afternoon
6. sitting and talking
7. sitting quietly after lunch without alcohol
8. in a car, while stopped in traffic
240
What sleep studies can be done to diagnose obstructive sleep apnoea?
Overnight oximetry alone
Limited sleep study
Full polysomnography
241
What is included in limited sleep study to diagnose obstructive sleep apnoea?
- Oximetry
- Snoring
- body movement
- HR
- oronasal flow
242
What simple approaches can you suggest for obstructive sleep apnoea managed?
Note: Treatment is based on symptoms/QofL. Need to consider livelihood too
Simple approaches: Weigh loss, sleep on side (decubitus), not supine. Avoid or reduce evening alcohol intake
243
How to manage mild obstructive sleep apnoea/ snorers?
Mandibular advancement devices
| Consider pharyngeal surgery
244
How to manage significant obstructive sleep apnoea?
Nasal CPAP, consider gastric bypass.
| Rare: tracheostomy
245
How to manage severe obstructive sleep apnoea and CO2 retention?
Non-invasive ventilation before CPAP if acidotic.
| Note: compensated CO2 may reverse with CPAP only. (So treatment here is individualised).
246
What is CPAP in obstructive sleep apnoea?
Continuous positive airway pressure - helps keep airway open so prevents sleep apnoea
247
How is CPAP delivered?
| What is air pressure?
Via nasal mask. Can also use mouth and nose mask.
| Air pressure is 10cm H2O pressure = this splints open the upper airways.
248
Benefit of CPAP for obstructive sleep apnoea?
Prevents airways collapse
Prevents fragmented sleep
Prevents daytime somnolence
Opens collapsed alveoli - improves V/Q match
249
CPAP (continous positive airway pressure) vs NIV (non-invasive ventilation)?
Biggest contrast:
CPAP supplies constant positive pressure in inspiration and expiration = so is NOT a form of ventilatory support.
NIV has two levels of positive pressure - one for inspiration and one for expiration = so IS A form of ventilatory support.
Additional from booklet:
CPAP can be used in patients with acute respiratory failure (palm oedema) to help oxygenation,
NIV can be set up with back up rates so the machine operates when RR drops below a certain level.
250
How is pleural effusion diagnosed (1st line)?
Do CXR
| Ultrasound guided pleural aspiration
251
What is the only indication for an urgent chest drain in pleural effusion?
If there is an underlying empyema
252
pH of pleural fluid in empyema plural effusion?
pH <7.2
253
From a US guided pleural aspiration, what is tested?
Biochemistry —> protein, pH, LDH
Cytology
Microbiology (including acid alkali fast bacteria)
254
Disadvantage of draining all fluid from pleura without understanding Dx?
Draining all the fluid = prevents opportunity to take pleural biopsies.
255
Options available to biopsy pleura (e.g. if malignancy is found in cytology from aspiration sample|)?
Thoracoscopy
| CT pleural biopsy
256
How to manage pleural effusion that is found to be transudate?
Treat underlying cause
257
Pt has transudative pleural effusion. You have treated the underlying cause but pt still has effusion. What is appropriate next step?
Effusion has persisted even after treating underlying cause - so now need to use therapeutic aspiration/drainage
258
When is Light's criteria used?
If pleural protein level is between 25-35g/L
259
Lights criteria to identify exudative pleural effusion?
Pleural fluid/Serum protein >0.5
Pleural fluid/ Serum LDH >0.6
Pleural fluid LDH >2/3rds of the upper limit of normal
260
What type of shock can PE lead to ?
Mechanical shock
261
What is pathophysiology of mechanical shock from a massive PE?
Embolus occludes the large pulmonary artery.
Pulmonary artery pressure is high. Occlusion means RV can not empty, and central venous pressure increases.
So, get reduced return of blood to the left side of the heart and there is limited filling of the left heart.
Left atrial pressure is low, so arterial BP is low, leading to shock.
262
Context:Pt has lung cancer.
| What scale is used to interpret a patient's level of fitness?
WHO scale to find out performance status
263
WHO scale for fitness level in pts with lung cancer is from 0 to 5. Describe each level.
0 - normal fitness - fully active without restriction
1 - restricted in physically strenuous activity. Ok with light work e.g. office work, light house work
2 - capable of all self care, ambulatory but can not carry out work activities. Active (up and about ) over 50% of waking hours
3 - capable of only limited self care. Confined to bed or chair for more than 50% of waking hours
4 - completely disabled. Can no self care. Totally confined to bed or chair.
5 - dead.
264
Gold standard investigation for bronchiectasis?
High resolution (1/2) CT (1/)
265
Salbutamol side effects?
Hypokalaemia
266
X-ray findings for ILD?
Fluffy appearance- reticulonodular shadowing
267
Causes of ILD?
```
Medication e.g. amiodarone, bleomycin, methotrexate, nitrofurantoin
Sacroidosis
Hypersensitivity pneumonitis
coal worker's pneumoconiosis
TB
```
268
Indication for LTOTs?
paO2<7.3
paO2<8 in cor pulmonale
Not smoking
269
What is a restrictive pattern on spirometry?
FEV1:FVC ratio the same >0.7 but the FEV1:FVC values have decreased
270
Causes of non-resolving pneumonia?
CHAOS
Complication - empyema, lung abscess
Host - immunocompromised
Antibiotics - inadequate dose or poor oral absorption
Organism - resistant or unexpected, so empirical abx did not cover this organism
Second diagnosis - PE, cancer, organising pneumonia
271
ECG findings for a PE?
Sinus tachycardia
"S1Q3T3” pattern of acute cor pulmonale is classic; this is termed the McGinn-White Sign.
—> A large S wave in lead I, a Q wave in lead III and an inverted T wave in lead III together indicate acute right heart strain
272
Which oxygen delivery device is commonly used in patients with COPD, and why?
Venturi masks are calibrated to deliver Fio2 between 24% and 50%, allowing Po2 to be titrated.
minimising the risk of CO2 retention (hypercarbia) associated with uncontrolled oxygen therapy
273
How should beta-2 agonists be delivered in patients with hypercapnia, in the context of acute COPD exacerbation?
Use a nebuliser driven by compressed air rather than oxygen (to avoid worsening hypercapnia).
274
Describe the management of acute COPD exacerbation if there is no response to an initial dose of a bronchodilator
Repeat doses of salbutamol at 15-30 minute intervals
Give continuous nebulised salbutamol at 5-10 mg/hour
275
When are oral corticosteroids indicated in an acute exacerbation of COPD and what is the recommended prescription?
Consider oral corticosteroids for people with a significant increase in breathlessness that interferes with daily activities.
Offer 30mg oral prednisolone once daily for 5 days
276
Describe the management of patients with acute COPD exacerbation that do not respond to first or second-line drug treatments
Escalate the patient’s care to senior medical staff to consider further management, including:
Non-invasive ventilation (NIV) for persistent hypercapnic respiratory failure.
Respiratory stimulants and intravenous theophylline.
277
Describe the GOLD staging criteria
Used for staging COPD
4 categories based on the FEV1
Stage 1 is classed as an FEV1 >80%
Stage 2 50-79%,
Stage 3 30-49%
Stage 4 <30%.
| see Geeky medics - COPD
278
Name four complications of COPD
Cor pulmonale
Pneumothorax
Secondary polycythemia
Hypercapnic respiratory failure
| Cor pulmonale is right-sided heart failure due to high pressure in the p
279
Name three clinical signs associated with cor pulmonale
* Distended neck veins
* Hepatomegaly
* Peripheral oedema
