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Respiratory Flashcards

1
Q

Signs/Symptoms of Lung Cancer

A

SOB

Hemoptysis

Finger Clubbing

Recurrent Pneumonia

Weight Loss

Lymphadenopathy (Supraclavicular)

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2
Q

Investigations for lung cancer

A

Chest XRAY (Hilar enlargement, Peripheral Opacity, Unilateral Pleural Effusion)

Staging CT (Contrast enhanced)

PET-CT (Areas of increased activity (Warburg’s Effect))

Bronchoscopt with endobronchial ultrasound (EBUS)

Biopsy/histological Analysis

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3
Q

Treatment for non-small cell lung cancer?

A

Lobectomy/Wedge Resection

Radiotherapy (Early DIagnosis)

Adjuvant Chemotherapy

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4
Q

Treatment of small cell lung cancer?

A

Chemotherapy/Radiotherapy

Prognosis is worse for small cell than non-small cell

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5
Q

Extrapulmonary manifestations of Lung Cancer?

A

Recurrent Laryngeal Nerve Palsy => hoarse voice

Phrenic Nerve Palsy => diagpram weakness/SOB

Superior Vena Cava Obstruction => Facial Swelling, difficulting breathing, distended neck veins. Elicited with Pemberton’s Sign in which riading the hands over the head causes facial congestion and cyanosis

Horner’s Syndrome: triad of ptosis, anhidrosis and miosis. Caused by a Pancoast tumor (pulmonary apex) pressing on sympathetic ganglion

Cushing’s Syndrome: ectpic ACTH secretions from Small Cell Lung Cancer

Hypercalcemia: ectopic PTH from Squamous Cell Carcinoma

Limbic Encephalitis: Small Cell Lung Cancer causes immune system to make antibodies targetting the limbic system => memory impairment, hallucinations, confusion/seizures (anti-HU antibodies)

Lambertg Eaton Myasthenic Syndrome: Small Cell Lung Cancer causes immune system to make antibodies targetting voltage gated calcium channels => proximal muscles weakness (better with use)

  • Proximal Muscle Weakness
  • Diplopia
  • Ptosis
  • dysphagia/slurred speach
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6
Q

Characteristics of Lambert-Eaton Syndrome and when to suspect it?

A

Lambertg Eaton Myasthenic Syndrome: Small Cell Lung Cancer causes immune system to make antibodies targetting voltage gated calcium channels => proximal muscles weakness (better with use)

  • Proximal Muscle Weakness
  • Diplopia
  • Ptosis
  • dysphagia/slurred speach

Suspect Small Cell Lung Cancer in older smokers with any of the above symptoms

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7
Q

Presentation/Chest Signs of Pneumonia

A

Presentation
* SOB
* COugh w/ Sputum
* Fever
* Hemoptysis
* Pleuritic chest pain (Sharp chest pain worse on inhalation)
* Delerium (Acute confusion associated with infection)
* Sepsis

Chest Signs
* Bronchial Breath Sounds (harse sounds heard equally on insp/exp. Cuased by consolidaiton in lungs)
* Focal Coarse Crackles
* Dullness to Percussion (Collapse/Consolidation)

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8
Q

Severeity Assessment of Pneunmonia?

A

CRB-65 Out of Hospital (>0 refer to hospital)

CURB-65 in Hospital :
* Confusion
* Urea >7
* Respiratory rate ≥ 30
* Blood pressure <90 systolic or ≥60 diastolic
* Age > 65

CURB-65 predicts mortality (1=5%, 3=15%, 4/5 >25%)
- 0/1: treat at home
- ≥2 hospital admission
- ≥3 ICU Assesment

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9
Q

Typical Common causes of Pneumonia

A

Streptococcous Pneumonia (50%)
Hemophilus Influenza (20%)
Pseudomona (Cystic FIbrosis/Bronchiectasis)
Staphylococcus Aureus (Cystic Fibrosis)

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10
Q

Atypical causes of Pneumonia?

A

Atypical organisms cannot be cultured nromally or detected using gram stain and dont respond to penicillins

  • Legionella
  • Mycoplasma (Milder, ass with rashcalled ertyhma multiforme characterised by target lesions and neurological symptoms in young pts)
  • Chlamydophilia Pneumonea
  • Coxiella Burnetii (Farmer)
  • Chlamydia psittaci (Parrots)
  • PCP (Immunocompromised, low CD4, presents as dry couh without sputum, SOB on exertion and NIGHT SWEATS) - treated with co-trimoxazole

Otehr than PCP trated with Macrolides, Fluroquinilones, Tetracyclines

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11
Q

Pneumonia Investigations?

A

Chest X Ray
FBC (Raised WBC)
U/E’s (Urea)
CRP
Sputum CUltures
Blood Cutlures
Legionella/Pneumococal Urinary Antigens

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12
Q

Treatment of Pneunomia?

A

Mild: 5 days of Amoxicillin OR Macrolide
Moderate/Severe: 7-10 days Amoxicillin AND Macoloide

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13
Q

What pathology causes a reduced FEV1?

A

Obstructive Lung Disease (FEV1:FVC ratio < 75%)
- Asthma
- COPD

Obstruction slowing passage of air getting ouit of the lungs

Test for reversibility by giving bronchodialator (salbutamol) asthma reversible, COPD not

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14
Q

What pathology causes equally reduced FEV1 and FVC?

A

Restrictive Lung Disease (FEV1 and FVC reduced & FEV1:FVC ratio > 75%)
* Interstitial lung disease (Pulmonary Fibrosis)
* Sarcoidosis
* Obesity
* Motor Neuron Disease
* Scoliosis

Lungs are resicted from expanding

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15
Q

Presentation of Asthma

Diagnosis?

A

Dinural variability (Worse at night)
Atopic conditions (Ecsema, hayfever, food allergies)
Bilateral widepread “polyphonic wheeze”

Diagnosis:
- Spriomettry with bronchoduialator reversibility
- Birect bronchial challenge with histamine or metacholine
- Peak Expiratory Flow Rate (PEFR): using a flow meter, 3 attempts and record best result. Recrod as percent of predicted (based off age, sex height)

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16
Q

Long Term Asthma Management

A

SABA (Salbutamol)
- Act on smooth muscles => relaxation
- Reliever/rescue medicaiton
- Monitor Serum Potassium, causes k+ to be absorbed into cells

Inhaled Corticosteroids (Beclomtasone)

  • Reduce inflaamtion/raectivity of airways
  • Maintencne/preventer medications

Leukotriene Receptor Antagonist (Montelukast)
- Leukotrienes produced by imun system =>inflamation, bronchoconstriction and mucus secretion)

LABA (Salmeterol)

  • Act on smooth muscles => relaxation
  • Longer action than SABA

LAMA (Tiotropium)
- Block acytylcholine receptors of ariway => bronchodialation

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17
Q

Grading Asthma?

A

Moderate (Peak Expiratory FLow Rate (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%
- Tired/Confused
- NO WHEEZE (Silent Chest)
- Shock

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18
Q

Management of Moderate Acute Asthma?

A

Moderate (Peak Expiratory FLow Rate (PEFR) 50-75% predicted)
- Nebulized beta-2 agonist (Salbutamol 5mg repeated asoften as required)
- Nebulized Ipatropium Bromide (LAMA)
- Steroids (oral predisolone or IV hydrocortisone (5 Days)

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19
Q

Management of Severe Acute Asthma?

A

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

Managed with:
- Oxygen if required to maintain sats 94-98%
- Aminophylline infusion
- IV Salbutamol (SABA)

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20
Q

Management of Life Threatening Acute Asthma?

A

Life Threatening
- PEFR <33%
- Sats <92%
- Tired/Confused
- NO WHEEZE (Silent Chest)
- Shock

Management
- IV magnesium Sulphate Infusion
- Admission to ICU
- Intubation (Worst case)

21
Q

ABG’s in Asthma?

A

Respiratory Alkylosis (Initial Tachynea => drop in CO2)

Normal PCO2 or Hypoxia VERY concerning, means pt is tiring => life threatening

Respiratory Acidosis due to HIGH CO2 is very bad sign

22
Q

Investigations/Staging of COPD?

A

Spirometry (Obstructive Picture):
- FVC: Total lung capacity
- FEV2: forved air expiration in 1 second
- FEV1/FVC < .7
- Staging with FEV1: Stage 1 >80%, Stage 2 50-79%, Stage 3 30-49%, Stage 4 <30%

Other Investigations
- Chest XRay (cancer)
- FBC (Polycythemia, raised Hemoglobin, secondary to chronic hypoxia)
- Sputum Culture
- ECG/Echo
- CT Thorax (Fibrosis, cancer, bronchiectasis)
- Serum 1 antitrypsin
- Trasnsfer Factor for Carbon Monoxide (TLCO reduced in COPD, severity indicator)

23
Q

Management of COPD

A

Step 1: SABA (salbutamol/Terbutaline) or SAMA (Ipratropium Bromide)
Step 2: LABA + Inhaled Corticosteroid Combo (Fostair, Symbicort)

Long term oxygen therapy for severe COPD causing polycythemia, cyanosis of hcor pulmonary

24
Q

ABG’s in COPD?

A

Repiratotoary Acidosis (low pH with raised pCO2)

Raised bicarb indicated chronic retention of CO2

25
Types of Respiratory Failure?
Low pO2 indicates Hypoxia + Respiratory Failure **Type 1 Respiratory Failure**: NORMAL pCO2 with LOW pO2 (1 Affected) **Type 2 Respiratory Failure**: RAISED pCO2 with LOW pO2 (2 Affected)
26
Causes of Type 1 Respiratory Failure?
**NORMAL pCO2 with LOW pO2** (1 Affected) Pulmonary Edema Pneumonia PE Pulmonary Fibrosis
27
Causes of Type 2 Respiratory Failure?
**RAISED pCO2 with LOW pO2** COPD Resp center depression Resp muscle weakness
28
Considerations when delivering O2 to pt with COPD
Cannot have oxygen when smoking Too much O2 => depressed respiratory drive **Venturi Masks** deliver specific O2 percentages - Retaining CO2 (88-92%) - Not retaining CO2 (>94%)
29
Indications for BiPAP
Used for Type 2 Respiratory Failure (RAISED pCO2 with LOW pO2) Criteria for initiating BiPAP: **Repiratory Acidosis (pH < 7.35, PaCO2 > 6)** despite medical treatment Contraindidations: phenomothorax
30
Indications for CPAP
Obstructive Sleep Apnea Congestive Cardiac Failure Acute Pulmonary Edema
31
Diagnosis of Instersitial Lung Disease?
CT Scan: Ground Glass Apearance Finger Clubbing Bibasal fine inspiratory crackles
32
Casues of pulmonary fibrosis?
Drugs: * Amiodarone * Cyclophosphamide * Methotrexate * Nitrofuratoin Seconary Pulmonary Fibrosis: - Alpha1-antitrypsin deficiency - Rehamatoid Arthritis - SLE - Systemic Sclerosis Hypersensitivity Pneumonitis (Diagnosed with bronchoalveolar lavage showing INC WBC and Mast Cells) Asbesthosis
33
Pleural Effusion w/ >30 g/L of Protein?
**Exudative** (Inflamation=> protein leaking out of tissue into pleural space): - Lung Cancer - Pneumonia - Rheamatoiid Arthritis - TB
34
Pleural Effusion w/ <30 g/L Protein
**Transudative** (Fluid moving across into pleural space) - Congestive Heart Failure - Hypoalbuminemia - Hypothyroidism - Meig's Syndrome (right sided plerual effusion w. Ovarian Malginancy)
35
Presentation of Pleural Effusion?
SOB Dullness to Percussion Reduced brachial Sounds Tracheal Deviations AWAY from large effusion
36
Investigations for Pleural Effusion - XRAY - Aspirate
XRay FIndings - Blunting of costophrenic angle - FLuid in lung fissures - Meniscus (curving where it meets chest wall/mediatinum) - Tracheal Deviation (Massive effusion) Aspiration Sample - Protein Count (>30 Exudative, <30 Transudative) - Cell Count - pH - Glucose - LDH - Culture
37
Criteria to determine if plerual effusion is transudative or exudative?
**Light's Criteria** More likely to be EXUDATE if: - Pleural Fluid/protein ratio >.5 - Pleural fluid LDH >200 - Pleural fluid::Serum LDH >.6
38
When to suspect empeyema? Pleural aspiration findings?
Improving pneumonia w/ New/Ongoing Fever Aspirations: - Pus - Acidic (pH<7.2) - LOW Glucose - HIGH LDH
39
Investigations for Pneumonthorax?
Erect XRay (Area w/ no lung markings) CT Thorax (Smaller/ asses size)
40
Management of Pneumothrorax?
No SOB and <2cm air then no treatment required SOB and >2cm air (Aspiraton and Re-Assesment) Unstable (Chest Drain)
41
Danger/Signs/ Management of Tension Pneumothorax
Tension pneumothorax caused by trauma creating one-way valve. Pushes mediateiunum across, kinking large vessels => Cardiovacular Arrest Signs: - Tracheal deviation AWAY from side of pneumothroax - Reduced air entry on affected side - Increased resonance to percussion on affected side - Tachycardia - Hypotension Management: - **"Insert a large bore cannula into the 2nd intercostal space in the midclavicular line"** - once perssure relieved, then chest drain is required for definitive management
42
Chest Drain Insertion?
Inserted into the **Triangle of Safety** - **5th intercostal space** (inferior to nipple line) - **Mid Axillary Line** (lateral edge of Latissimus Dorsi) - **Anterior Axillary Line** (lateral edge of Pectoralis Major) Inserterd ABOVE rib to avoid neurovascular bundle running beneath, after insertion chest xray to check positioning
43
Risk Factors for DVT/PE?
Immobility (Long Flights) Recent Surgery Pregnangy Estrogen Therapy Malignangy Polycythemia SLE Thrombophilia
44
Prophylaxis for VTE? Contraindications?
LMWH (Enoxaparin) (*Unless Active bleeding or on Warfarin/DOACs*) Compression Stocking (*Unless Peripheral Artery DIsease*)
45
Presentation/Diagnosis of PE?
SOB Pleuritic Chest Pain Hypoxia Tachycardia Raised Resp Rate Low grade fever **Perform Well's Score** (Predicts risk of pt having PE) - Likely => CTPA (VQ if contraindicated) - Unlikely => d-dimer (95% sensitive, not specific), if positive then CTPA Deifinitive Diagnosis of PE: - **CT Pulmonary Angiogram (CTPA)**: chest CT w/ intravenmous contrast highlighting pulmonary arteries - **Ventilation-Perfusion (VQ) Scan)** radioactive isotypes and gama camera to compare ventilation with perfusion of lungs. Used in pts with renal impairment, contrast allergy or at risk of radiation
46
Conditions leading to elevated d-dimer?
VTE Pneumnonia Malignancy Heart Failure Surgery Pregnancy
47
Management of PE
Initital: - LMWH Imediately started if delay w/ scan - If Massive PE w/ hemodynamic compromise => Catheter-Directed Thrombolysis (Streptokinase, Altepolase, Tenectoplase) Long term: Warfarin, DOAC, LMWH
48
Pulmonary Hypertension - Signs/Symptoms - Investigations? - Mangement
Signs/Symtoms - SOB - Syncope - Tachycardia - Raised JVP - Hepatomegaly - Peripheral edema ECG Changes - **Right Ventricular Hypertrophy** (Large R-waves on right chest leads (V1-3); Large S-waves on Left leads (V4-6)) - **Right Axis Deviation** - **Right BBB** Chest XRay Changes - **Dialated Pulmonary Arteries** - **Right Ventricular Hypertrophy** Others - **Raised NT-proBNF**= Right heart failure Poor prognosis (30-40% 5 year survival). Treatable with IV Prostanoids, Phosphodiesterase Inhibiots (Sildenafil)
49
Investigations for Sarcoidosis?
Blood - **INC serum ACE** - **Hypercalcemia** - INC serum coluable interleukin-2 recepto - Raised CRP Imaging - Chest XRay: **Hilar Lymphadenopathy** - HIgh Resolution CT: **Hilar Lymphadenopathy** and **Pulmonary Nodules** - MRI: CNS Involvement - PET Scan: shows areas of active inflamation Histology (GOLD STANDARD) - **Non-Caseating granulomas w/ epitheliod cells)**

Clinical Medicine (8 decks)

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