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Respiratory Flashcards

1
Q

define asthma ?

A
  • chronic inflammatory airway disease leading to variable airway obstruction
  • bronchoconstriction is reversible with bronchodilators
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2
Q

name 3 respiratory emergencies

A

anaphylaxis
pneumothorax
pulmonary embolism

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3
Q

define ventilation

A

movement of air into and out of lungs during a single breathing cycle

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4
Q

what is alveolar ventilation and how do you calculate it?

A

total volume of air that reaches the alveoli and contributes to gas exchange

alveolar ventilation = RR x (tidal volume - dead space volume)

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5
Q

why is the concept of physiological dead space important?

A

physiological dead space = volume of lung that doesn’t eliminate CO2
- important because if this space increases (e.g. pneumonia) then patient needs to increase minute ventilation to maintain adequate gas exchange

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6
Q

what is hypoxic pulmonary vasoconstriction?

A

physiological response to alveolar hypoxia
- if PA02 decreases, pulmonary arterioles vasoconstrict to limit blood flow to hypoxic alveoli

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7
Q

what is the V/Q ration if ventilation is 4L/min and perfusion is 5L/min ?

A

4/5 or 0.8

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8
Q

what happens to V/Q ration if you decrease ventilation or perfusion?

A

decreased ventilation? V/Q ration decreases

increased ventilation? V/Q ratio increases

NB both V&Q are greater at the lung bases than apices

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9
Q

spirometry: what is FEV1?

A

Forced expiratory volume in 1 second (FEV1) = air a person can forcefully exhale in 1 second.

Measures how easily air can flow out of the lungs.
Reduced with airflow obstruction.

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10
Q

spirometry: what is FVC?

A

forced vital capacity = total air a person can exhale after a full inhalation

Measures volume of air someone can take into their lungs
Reduced with restricted lung capacity

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11
Q

when can we diagnose obstructive lung disease on spirometry?

A

Diagnosed when the FEV1 is less than 70% of the FVC = FEV1:FVC ratio of less than 70%

someone may have good lung volume but air can only move slowly in or out of lungs

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12
Q

causes of obstructive lung disease?

A
  • asthma
  • COPD
  • bronchiectasis
  • A1AT
  • CF
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13
Q

when can we diagnose restrictive lung disease on spirometry?

A
  • FEV1 and FVC are equally reduced
  • FEV1:FVC ratio greater than 70%

lungs have limited ability to expand and fill with air

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14
Q

causes of restrictive lung disease?

A

fibrosis
sarcoidosis
obesity
MND

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15
Q

asthma risk factors?

A
  • atopy (or FHx of atopy)
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16
Q

name 5 common asthma triggers?

A

Infection
Nighttime or early morning
Exercise
Animals
Cold, damp or dusty air
Strong emotions

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17
Q

name two medication classes that can worsen asthma symptoms?

A
  • Beta-blockers, particularly non-selective beta-blockers (e.g., propranolol)
  • NSAIDs (e.g., ibuprofen or naproxen)
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18
Q

what type o wheeze do you hear in asthma?

A

widespread “polyphonic” expiratory wheeze

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19
Q

asthma Px?

A
  • episodic sx
  • diurnal variation - worse at night
  • SOB
  • chest tightness
  • dry cough
  • wheeze - widespread, polyphonic
  • reduced PEFR
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20
Q

asthma Ix?

A

NICE recommend:
1. Fractional exhaled nitric oxide (FeNO)
2. Spirometry with bronchodilator reversibility

Others to add in:
3. peak flow diary
4. direct bronchial challenge - opposite of reversibility testing

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21
Q

what % increase of FEV1 on reversibility testing suggests asthma?

A

greater than 12% increase in FEV1

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22
Q

BTS asthma management?

A
  1. SABA - salbutamol
  2. Add ICS - low dose beclometasone
  3. Add LABA - salmeterol / maintenance and reliever therapy (MART)
  4. Increase ICS dose / add leukotriene receptor antagonist (LTRA) - montelukast
  5. Specialist mx - eg oral prednisolone
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23
Q

NICE asthma management?

A
  1. SABA - salbutamol
  2. Add ICS - low dose beclometasone
  3. Add LTRA - montelukast
  4. Add LABA - salmeterol
  5. Consider changing to MART
  6. Increase ICS dose
  7. Consider high dose ICS or additional drugs - LAMA / theophylline
  8. Specialist mx - eg oral prednisolone
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24
Q

what other things are involved with asthma management other than asthma medication?

A
  • ?occupational - refer to resp
  • yearly flu jab
  • yearly asthma review
  • consider stepping down tx every 3mo or so
  • reducing ICS dose - only by 25-30% at a time
  • regular exercise, avoid smoking, avoid triggers
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25
Q

what medications make up MART and Trimbow?

A

MART - Fostair - beclometasone (ICS) + formoterol (LABA)
Trimbow - beclometasone + formoterol + glycopyrronium

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26
Q

example of a SABA?

A

salbutamol, terbutaline

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27
Q

name a LABA?

A

salmeterol, formoterol

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28
Q

name a SAMA?

A

ipratropium

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29
Q

Name a LAMA?

A

tiotropium

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30
Q

name some ICS used in asthma ?

A

beclometasone / budesonide / fluticasone

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31
Q

what is an acute exacerbation of asthma?

A
  • rapid deterioration in sx in asthma
  • triggers as chronic, may be infection
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32
Q

how might acute asthma present?

A
  • SOB
  • Cough
  • Accessory muscle use
  • Tachypnoea
  • Global wheeze
  • Reduced air entry
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33
Q

acute asthma grading criteria: moderate versus severe?

A

Moderate
- PEF 50-75%

Acute severe
- PEF 33-50% best
- RR>25
- HR>110
- Unable to complete sentences

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34
Q

acute asthma severity: life threatening

A
  • PEF <33%
  • Sats <92%
  • Silent chest, cyanosis
  • Bradycardia, low BP
  • Exhaustion, confusion, coma

near fatal = raised pCO2

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35
Q

acute asthma Ix?

A
  • ABG - resp alkalosis -> hypoxic -> normal pCO2
  • bloods,
  • CXR
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36
Q

when to admit with acute asthma?

A
  • Life-threatening grade
  • Acute severe grade + unresponsive to tx
  • Previous near-fatal attack
  • Pregnancy
  • Occurring despite oral corticosteroid
  • Px at night
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37
Q

acute asthma Mx?

A

Oxygen
Salbutamol - inhaler / nebs
Hydrocortisone - 100mg IV or prednisolone 40mg oral
Ipratropium - nebulised
Aminophylline - IV
Magnesium - IV
Escalate care

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38
Q

criteria for acute asthma discharge?

A
  • Stable on discharge medication (no nebs / O2) for 12-24hrs
  • Inhaler technique checked + recorded
  • PEF >75%
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39
Q

why monitor serum potassium on salbutamol nebs?

A

salbutamol causes K+ to be absorbed from blood into cells leading to hypokalaemia

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40
Q

what is COPD?

A
  • Chronic irreversible progressive condition involving airway obstruction, emphysema, chronic bronchitis

Related to:
- smoking
- A1AT deficiency

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41
Q

COPD: what is bronchitis and what is emphysema?

A

Bronchitis = long-term symptoms of a cough and sputum production due to inflammation in the bronchi

Emphysema = damage and dilatation of the alveolar sacs and alveoli, decreasing the surface area for gas exchange

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42
Q

how might COPD present?

A

long-term smoker with persistent symptoms of:
- Shortness of breath
- Cough
- Sputum production
- Wheeze
- Recurrent respiratory infections, particularly in winter

NB COPD does NOT cause clubbing!v

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43
Q

MRC SOB scale?

A
  1. SOB on marked exertion
  2. SOB on hills
  3. Slow or stop on flat
  4. Exercise tolerance 100-200 yards on flat
  5. Housebound / SOB on minor tasks
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44
Q

COPD versus asthma?

A
  • Younger onset in asthma
  • Smoking - in most with COPD
  • Asthma - sx vary, less so in COPD
  • Nocturnal sx in asthma
  • Persistent productive cough - COPD
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45
Q

COPD Ix for diagnosis ?

A
  • clinical
  • spirometry - FEV1/FVC<70% with little/no response to reversibility testing
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46
Q

additional Ix you could do for COPD aside from spirometry?

A
  • CXR - hyperinflation, flat hemidiaphragms, bullae
  • FBC - anaemia/polycythaemia (raised Hb due to chronic hypoxia)
  • ECG / ECHO - look for HF
  • CT thorax - malignancy, bronchiectasis
  • transfer factor for CO (TLCO)
  • ?A1AT levels
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47
Q

how can we grade COPD severity - 4 stage scale

A

Using FEV1;
Stage 1 / mild - FEV1>80%
Stage 2 / moderate - FEV1 50-79%
Stage 3 / severe - FEV1 30-49%
Stage 4 - very severe - FEV1 <30%

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48
Q

COPD: conservative Mx?

A
  • smoking cessation
  • pneumococcal + flu jabs
  • pulmonary rehab
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49
Q

COPD - describe stepwise medical Mx ?

A

1st step
- SABA / SAMA

2nd step:
if asthma/steroid responsive?
- LABA/ICS
Eg Fostair, Symbicort and Seretide =LABA and ICS combination inhalers
if not asthma/steroid responsive?
- LABA/LAMA
Eg Anoro Ellipta, Ultibro Breezhaler and DuaKlir Genuair = LABA and LAMA combination inhalers.

3rd Step:
- LABA / LAMA / ICS combination inhaler
Eg Trimbow, Trelegy Ellipta and Trixeo Aerospher

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50
Q

COPD: who is eligible for long term oxygen therapy?

A

severe COPD with chronic hypoxia (sats < 92%), polycythaemia, cyanosis or cor pulmonale.

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51
Q

what is cor pulmonale? why does it happen?

A

Right-sided heart failure caused by respiratory disease
- increased pressure and resistance in the pulmonary arteries (pulmonary hypertension) limits the right ventricle pumping blood into the pulmonary arteries. This causes back-pressure into the right atrium, vena cava and systemic venous system

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52
Q

causes of cor pulmonale?

A

COPD (the most common cause)
Pulmonary embolism
Interstitial lung disease
Cystic fibrosis
Primary pulmonary hypertension

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53
Q

what is an infective exacerbation of COPD?

A
  • acute deterioration in sx in COPD pt
    Causes
  • bacterial - H influenzae, strep pneumoniae, M catarrhalis
  • Viral - human rhinovirus
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54
Q

IE-COPD Px?

A
  • SOB, cough, wheeze
  • increased sputum
  • hypoxia, acute confusion
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55
Q

IE-COPD Ix?

A
  1. ABG
  2. Chest x-ray - pneumonia or other pathology
  3. ECG - arrhythmias or evidence of heart strain
  4. FBC to look for infection (raised white blood cells)
  5. U&E to check electrolytes, which can be affected by infections and medications
  6. Sputum culture
  7. Blood cultures in patients with signs of sepsis (e.g., fever
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56
Q

what would you see on ABG for someone with acute exacerbation of COPD?

A
  • respiratory acidosis

Low pH indicates acidosis
Low pO2 indicates hypoxia and respiratory failure
Raised pCO2 indicates CO2 retention (hypercapnia)
Raised bicarbonate indicates chronic retention of CO2 - kidneys producing more bicarb to balance increased CO2 but cannot keep up with rate in exacerbation

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57
Q

IE-COPD Mx?

A
  1. regular inhalers (salbutamol / ipratropium)
  2. oxygen (+/- chest physio)
  3. 30mg prednisolone for 5d
  4. antibiotics

if severe …
5. IV aminophylline
6. NIV
7. Intubation and ventilation

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58
Q

what is asthma-COPD overlap syndrome?

A

clinical syndrome consisting of persistent airflow limitation (COPD) in someone >40 with a Hx of asthma/bronchodilator reversible airway disease

Mx = inhaled steroid + LABA

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59
Q

pneumonia - definition

A
  • infection of lung tissue causing inflammation in alveolar space

NB inflammation + pus - impairs gas exchange

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60
Q

types of pneumonia?

A

CAP - community
HAP - >48hrs in hospital
VAP - intubated
Aspiration - fromm aspiration of foods/fluids

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61
Q

typical bacterial causes of pneumonia?

A

Most common:
- Strep pneumoniae (most common)
- H influenzae (COPD)

others:
- Moraxella catarrhalis – COPD / immunocompromised
- Pseudomonas aeruginosa – CF / bronchiectasis
- S aureus – CF
- MRSA – HAP
- Klebsiella – alcoholics

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62
Q

atypical causes of pneumonia?

A

Atypical - cannot be cultured or gram stained in normal way

Legions – Legionella pneumophila = air con units
Psittaci – Chlamydia psittaci = contact with birds
M – Mycoplasma pneumoniae = erythema multiforme
C – Chlamydophila pneumonia = mild in children
Qs – Q fever (coxiella burnetii) = animal bodily fluid

Other
- Pneumocystis jirovecii pneumonia (PCP) – immunocompromised, eg HIV with low CD4 – dry cough, SOBOE, night sweats, co-trimoxazole to tx
- COVID-19

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63
Q

pneumonia symptoms?

A

Cough
Sputum production
Shortness of breath
Fever
Feeling generally unwell
Haemoptysis (coughing up blood)
Pleuritic chest pain (sharp chest pain, worse on inspiration)
Delirium (acute confusion)

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64
Q

signs of pneumonia on chest examination?

A
  • bronchial breathing
  • focussed coarse crackles
  • dull to percuss (lung filled with sputum)
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65
Q

CURB-65 scoring system?

A

C – confusion
U – urea >7mmol/L
R – resp rate >30
B – BP<90 systolic / 60 diastolic
65 – age >65yo

  • Score 0-1 – mild, consider home tx
  • Score 2– moderate, hospital admission
  • Score 3-5 – severe, admit, monitor, consider ITU
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66
Q

pneumonia Ix?

A
  1. Chest x-ray - look for focal consolidation
  2. Bloods (FBC, U&E, CRP)
  3. sputum cultures
  4. blood culture
  5. pneumococcal / legionella urinary antigen tests
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67
Q

pneumonia Mx?

A

Mild:
usually 5 days of amoxicillin / doxy / clari

Moderate / Severe?
- IV Abx
- respiratory support

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68
Q

acute bronchitis - Px, Ix and Mx?

A

self limiting URTI involving inflammation of bronchi
- usually viral

Px
- cough +/- sputum
- sore throat
- rhinorrhoea
- wheeze
- fever
DDx from pneumonia
- may have no sputum/wheeze/SOB
- no focal chest signs

Ix - clinical dx

Mx
1. smoking cessation
2. simple analgesia
3. ABx e..g doxy or amoxicillin

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69
Q

lung cancer RFs?

A
  • smoking, occupational (asbestos, coal, tar etc), radiation, pulm fibrosis, COPD
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70
Q

2 histological types of lung cancer?

A

Small cell lung cancer (SCLC) - 20%
- NE hormones released -> paraneoplastic

Non-small cell lung cancer (NSCLC) - 80%
- adenocarcinoma - 40% - often seen in non-smokers
- squamous cell - 20% - cavitating lesions
- large cell - 10%
- other - 10%

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71
Q

lung cancer Px?

A

Shortness of breath
Cough
Haemoptysis (coughing up blood)
Finger clubbing
Recurrent pneumonia
Weight loss
Lymphadenopathy – often supraclavicular nodes are the first to be found on examination

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72
Q

extra pulmonary manifestations of lung cancer: name 2 possible associated nerve palsies?

A

Recurrent laryngeal nerve palsy = hoarse voice. Caused by a tumour pressing on or affecting the recurrent laryngeal nerve as it passes through the mediastinum.

Phrenic nerve palsy, due to nerve compression, causes diaphragm weakness and SOB

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73
Q

what triad makes up Horner’s syndrome and what tumour can cause it?

A
  • partial ptosis, anhidrosis and miosis
  • Pancoast tumour - pressing on sympathetic ganglion
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74
Q

extra pulmonary manifestation caused by ectopic ADH secretion by SCLC? ectopic ACTH by SCLC?

A
  • SIADH - ectopic ADH from SCLC - Px with hyponatraemia
  • Cushing’s syndrome - ectopic ACTH from SCLC - HTN, hyperglycaemia, hypokalaemia, alkalosis
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75
Q

why could lung cancer manifest with hypercalcaemia?

A

Hypercalcaemia can be caused by ectopic parathyroid hormone secreted by squamous cell carcinoma.

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76
Q

lung cancer patient with proximal weakness, diplopia and ptosis - what might have happened?

A

Lambert-Eaton myasthenic syndrome
- ABs against SCLC also target Ca channels in presynaptic motor neurons

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77
Q

name 5 key signs/symptoms that warrant a 2ww CXR in patients over 40

A

Clubbing
Lymphadenopathy (supraclavicular or persistent abnormal cervical nodes)
Recurrent or persistent chest infections
Raised platelet count
Chest signs of lung cancer

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78
Q

NICE guidelines surrounding unexplained symptoms and CXR for possible lung cancer referrals?

A

Two or more unexplained symptoms in patients that have never smoked
One or more unexplained symptoms in patients that have ever smoked or had asbestos exposure

unexplained Sx:
Cough
Shortness of breath
Chest pain
Fatigue
Weight loss
Loss of appetite

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79
Q

lung cancer Ix?

A
  • CXR
  • staging CT
  • peT scan
  • bronchoscopy
  • biopsy + histology
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80
Q

CXR findings suggesting lung cancer?

A

Hilar enlargement
Peripheral opacity (a visible lesion in the lung field)
Pleural effusion (usually unilateral in cancer)
Collapse

81
Q

lung cancer Mx?

A

SCLC
- chemo / radio
- stents / debulking surgery
- poor prognosis

NSCLC
- surgery - segmentectomy/wedge resection, lobectomy, pneumonectomy
- radiotherapy
- chemo

82
Q

mesothelioma - definition?

A
  • Tumour of mesothelial cells - 80-90% in pleura - other sites are peritoneum, pericardium, testes
  • associated w asbestos - 45yr latent period
  • high-grade, may invade intercostal nerves, severe pain
83
Q

mesothelioma Px?

A
  • chest pain
  • SOB
  • wt loss
  • finger clubbing
  • recurrent pleural effusions
  • mets - lymphadenopathy, hepatomegaly, bone pain/tenderness, abdo pain/obstruction
84
Q

mesothelioma Ix?

A
  • CXR/CT - unilateral pleural thickening/effusion
  • pleural aspiration - bloody
  • pleural biopsy
85
Q

mesothelioma Mx?

A
  • resistant to surgery/chemo/radio
  • palliative chemo
86
Q

PE - definition and patho?

A

thrombus (blood clot) in pulmonary arteries

  • venous thrombus, usually from DVT
  • obstructs RV outflow - sudden increase in pulmonary vascular resistance - acute RHF
  • lung tissue ventilated, not perfused - V/Q mismatch
87
Q

PE risk factors?

A
  • Immobility
  • Recent surgery
  • Long-haul flight
  • Pregnancy
  • Oestrogen therapy - cOCP, HRT
  • Malignancy
  • Polycythaemia
  • SLE
  • Thrombophilia
88
Q

VTE prophylaxis options

A
  • Assess for VTE risk
  • LMWH (enoxaparin) if higher risk - CI - active bleeding, warfarin/DOAC
  • Anti-embolic compression (stockings CI - PAD
89
Q

PE Px?

A
  • SOB
  • Cough
  • Haemoptysis
  • Pleuritic chest pain
  • Hypoxia
  • Tachycardia
  • Raised RR
  • Low-grade fever
  • Hypotension
  • May have DVT sx
90
Q

PE: what is PERC rule and when is it used?

A

PERC is used when the clinician estimates less than a 15% probability of a pulmonary embolism to decide whether further investigations for a PE are needed

91
Q

PE: what is Wells score used for?

A

predicts the probability of a patient having a PE - used when PE is suspected.

92
Q

PE Ix?

A
  • PERC rule
  • PE Wells score

If PE likely (>4) then CTPA
- positive = dx
- negative = consider leg USS

if PE unlikely (<4) then D dimer
- positive = CTPA
- negative = stop anticoagulation, alt dx

can perform V/Q scanning - maybe if renal impairment

93
Q

Possible ABG findings in PE patient?

A
  • respiratory alkalosis

hypoxia = raised RR –> blow off CO2 –> makes blood alkaloid

94
Q

PE Mx/

A
  • oxygen, analgesia

haemodynamically stable?
- DOAC (apixaban/rivaroxaban) for 3 months
- if CI? LMWH

haemodynamically unstable?
- unfractionated heparin whilst considering thrombolysis
- thrombolysis (streptokinase/alteplase)
- post thrombolysis - switch to DOAC

95
Q

anticoagulation Tx length after PE?

A

Anticoagulation length
- all pts - 3mo
- provoked - stop after 3mo (3-6mo if active cancer)
- unprovoked - 6mo total
- ORBIT score - assess bleeding risk

96
Q

what is a pleural effusion?

A
  • fluid in pleural space
  • empyema - pus
  • chylothorax - lymphatic fluid - trauma / carcinoma infiltration
97
Q

definition of a exudative pleural effusion?

A

high protein content (more than 30g/L)

98
Q

give 3 causes of exudative pleural effusion?

A
  • related to inflammation - inflammation results in protein leaking out of the tissues into the pleural space

Cancer (e.g., lung cancer or mesothelioma)
Infection (e.g., pneumonia or tuberculosis)
Rheumatoid arthritis

99
Q

definition of transudative pleural effusion?

A

lower protein content (less than 30g/L)

100
Q

causes of transudative pleural effusion?

A

relates to fluid moving across or shifting into the pleural space
- Congestive cardiac failure
- Hypoalbuminaemia
- Hypothyroidism
- Meigs syndrome

101
Q

what is meig’s syndrome?

A

triad of:
- benign ovarian tumour (usually a fibroma)
- pleural effusion
- ascites

102
Q

pleural effusion Px?

A
  • sob
  • chest pain
  • Dullness to percussion over the effusion
  • Reduced breath sounds
  • Tracheal deviation away from the effusion in very large effusions
103
Q

pleural effusion Ix?

A
  • CXR
  • USS
  • contrast CT
  • pleural aspiration - send for pH, protein, LDH, cytology, micro
104
Q

4 pleural effusion CXR findings?

A
  • blunting of costophrenic angle
  • fluid in lung fissures
  • tracheal / mediastinal deviation
  • large effusionnn? may see meniscus
105
Q

interpreting pleural aspiration

A
  • Low glucose - RA, TB
  • Raised amylase - pancreatitis, oesophageal perf
  • Blood - mesothelioma, PE, TB
  • Empyema - pus, low pH, low glucose, high LDH
106
Q

what is Lights criteria?

A

Differentiate between transudate / exudate where protein 25-35. Exudate likely if at least one of the following is met:
- Pleural fluid protein / serum protein >0.5
- Pleural fluid LDH / serum LDH >0.6
- Pleural fluid LDH >2/3 upper limit normal of normal serum LDH

107
Q

pleural effusion Mx?

A
  • tx cause
  • pleural aspiration
  • chest drain

Empyema
- chest drain
- Abx

Recurrent
- recurrent aspiration
- pleurodesis
- indwelling pleural catheter
- opioids for SOB

108
Q

PTX definition?

A
  • air in pleural cavity causing lungs to separate from chest wall , can collapse lung
109
Q

4 causes of PTX?

A

Primary spontaneous PTX (PSP) - no underlying disease

Secondary spontaneous PTX (SSP) - COPD, asthma, CF, cancer, PCP, Marfan’s

Traumatic - blunt / penetrating

Iatrogenic - caused by medical intervention eg thoracentesis, CVC, ventilation

110
Q

what is a tension PTX?

A

PTX caused by trauma to the chest wall that creates a one-way valve that lets air in but not out of the pleural space –> air is trapped and pressure in thorax increases

111
Q

4 signs of a tension PTX?

A
  • Tracheal deviation away from the side of the pneumothorax
  • Reduced air entry on the affected side
  • Increased resonance to percussion on the affected side
  • Tachycardia
  • Hypotension
112
Q

Mx of tension PTX?

A

Insert a large bore cannula into the second intercostal space in the midclavicular line

113
Q

PTX Px?

A
  • sudden onset SOB
  • pleuritic CP
  • hyper-resonant
  • reduced AE
  • reduced chest expansion
  • tachypnoea, tachycardia
  • surgical emphysema
114
Q

PTX Ix?

A
  • CXR
  • CT thorax
115
Q

what can make a PTX patient high risk?

A

haemodynamic compromise, bilateral pneumothorax,
hypoxia
underlying lung disease

116
Q

PTX Mx?

A

If no sx = conservative mx

low risk and PTX < 2cm = conservative

PTX > 2cm = conservative / pleural vent / needle aspiration / chest drain

117
Q

management of recurrent / persistent PTX?

A
  • video-assisted thoracoscopic surgery (VATS) for mechanical / chemical (talc) pleurodesis +/- bullectomy / pleurectomy
118
Q

what makes up the chest drain triangle of safety?

A
  • 5th intercostal space (or the inferior nipple line)
  • Midaxillary line (or the lateral edge of the latissimus dorsi)
  • Anterior axillary line (or the lateral edge of the pectoralis major)
119
Q

key info to give on discharge after PTX?

A
  • avoid smoking
  • if ptx persists - cannot fly
  • avoid scuba diving - unless undergone bl surgical pleurectomy, normal PFTs/chest CT post-op
120
Q

bronchiectasis - definition + patho

A

Permanent dilation of the bronchi, the large airways that transport air to the lungs
- Sputum collects and organisms grow in the wide tubes, resulting in a chronic cough, continuous sputum production and recurrent infections

121
Q

bronchiectasis causes?

A

Idiopathic (no apparent cause)
Pneumonia
Whooping cough (pertussis)
Tuberculosis
Alpha-1-antitrypsin deficiency
Connective tissue disorders (e.g., rheumatoid arthritis)
Cystic fibrosis
Yellow nail syndrome

122
Q

OSCE: what triad makes up yellow nail syndrome ?

A
  • yellow fingernails
  • bronchiectasis
  • lymphoedema
123
Q

bronchiectasis: key symptoms?

A

Shortness of breath
Chronic productive cough
Recurrent chest infections
Weight loss

124
Q

bronchiectasis signs on examination?

A

Sputum pot by the bedside
Oxygen therapy (if needed)
Weight loss (cachexia)
Finger CLUBBING
Signs of cor pulmonale (e.g., raised JVP and peripheral oedema)
Scattered crackles throughout the chest that change or clear with coughing
Scattered wheezes and squeaks

125
Q

bronchiectasis Ix?

A
  1. sputum culture
  2. CXR - tram-track opacities, ring shadows
  3. HRCT - dilated/thickened bronchi, signet ring sign
  • spirometry - obstructive
  • bronchoscopy
126
Q

most common infective organisms in bronchiectasis?

A

Haemophilus influenza
Pseudomonas aeruginosa

127
Q

bronchiectasis Mx?

A
  • vaccines
  • chest physio, postural drainage
  • long-term abx - azithromycin - if 3+ exacerbations/yr
  • bronchodilators
  • surgical resection
  • lung transplant
128
Q

management of infective exacerbation of bronchiectasis?

A
  • extended abx course for exacerbations (7-14d)
  • pseudomonas - cipro
  • H influenzae - amoxicillin, co-amox, doxy
  • S aureus - fluclox
129
Q

obstructive sleep apnoea?

A
  • collapse of pharyngeal airways whilst asleep leading to apnoeas
130
Q

OSA RFs?

A
  • middle aged, male
  • obesity
  • alcohol
  • smoking
  • macroglossia
  • large tonsils
  • Marfan’s
131
Q

OSA Px?

A
  • Partner may report excessive snoring, periods of apnoeas
  • Morning headache
  • Waking up unrefreshed from sleep
  • Daytime sleepiness
  • Concentration problems
  • Reduced O2 sats during sleep
  • Severe - HTN, HF, increased risk of MI / stroke
132
Q

OSA Ix?

A
  • Epworth sleepiness scale
  • Multiple Sleep Latency Test (MSLT)
  • sleep studies
133
Q

OSC Mx?

A
  • reduce alcohol, stop smoking, lose weight
  • CPAP
  • intra-oral devices - eg mandibular advancement
  • surgery - uvulopalatopharyngoplasty (UPPP)
  • inform DVLA if daytime sleepiness
134
Q

name some occupational lung disorders?

A

Inhaling something at work, leads to:
- acute bronchitis, oedema
- Pulmonary fibrosis
- Occupational asthma
- Hypersensitivity pneumonitis
- Bronchial carcinoma

135
Q

what is occupational asthma?

A
  • asthma sx worse at work
  • peak flow diary to compare work/home
136
Q

what is pneumoconiosis? who is affected?

A
  • inhalation of coal dust, fibrosis occurs
  • coal mine workers -> coal-workers pneumoconiosis (CWP)
137
Q

what is silicosis?

A
  • inhalation of silica particles - fibrogenic
  • upper zone fibrosis, egg-shell calcification of hilar lymph nodes
  • eg stonemasons, sandblasters, pottery
  • massive airways restriction
138
Q

what iis asbestosis?

A

lung fibrosis related to asbestos exposure
asbestos inhalation causes:
- Lung fibrosis
- Pleural thickening and pleural plaques
- Adenocarcinoma
- Mesothelioma

NB can get lung cancer

139
Q

what might you see on CXR of someone with asbestos related lung diseasE?

A
  • pleural plaques - these have no potential for malignancy
  • effusion
140
Q

Byssinosis

A
  • inhalation of textile fibre dust
  • chest tightness, cough, SOB
  • Sx worse first day back at work after break
141
Q

Berylliosis

A
  • inhalation of copper alloy
  • aerospace, electrical devices
  • progressive SOB, pulm fibrosis
142
Q

Pulmonary siderosis

A
  • inhalation of metallic particles - metal grinding, welding
  • little effect on lung function
143
Q

what is pulmonary fibrosis?

A
  • diseases that cause lung fibrosis - scarring of lungs, loss of elasticity
  • an interstitial lung disease (ILD)
144
Q

what is ILD?

A

ILD includes many conditions that cause inflammation + fibrosis of lung parenchyma

Examples:
- Idiopathic pulmonary fibrosis
- secondary pulmonary fibrosis
- EAA
- cryptogenic organising pneumonia
- asbestosis

145
Q

idiopathic pulmonary fibrosis Px?

A
  • SOBOE
  • dry cough
  • fatigue

O/E bibasal fine end-inspiratory crackles, clubbing

146
Q

ILD Ix?

A
  • Clinical features
  • High-resolution CT scan (HRCT) of the thorax (showing a typical “ground glass” appearance)
  • Spirometry –> FEV1&FVC reduced, FEV1:FVC >70%

If in doubt:
- lung biopsy
- bronchoalveolar lavage

147
Q

Mx of ILD?

A
  • Remove or treat the underlying cause
  • Home oxygen where there is hypoxia
  • Stop smoking
  • Physiotherapy and pulmonary rehabilitation
  • Pneumococcal and flu vaccine
  • Advanced care planning
148
Q

what are 2 medications licensed to slow progressive of idiopathic pulmonary fibrosis?

A

Pirfenidone - reduces fibrosis and inflammation

Nintedanib - reduces fibrosis and inflammation by inhibiting tyrosine kinase

149
Q

name 4 drugs that can cause secondary pulmonary fibrosis?

A

Amiodarone (also causes grey/blue skin)
Cyclophosphamide
Methotrexate
Nitrofurantoin

150
Q

which conditions are associated with pulmonary fibrosis?

A

Alpha-1 antitrypsin deficiency
Rheumatoid arthritis
Systemic lupus erythematosus (SLE)
Systemic sclerosis
Sarcoidosis

151
Q

what is hypersensitive pneumonitis / Extrinsic allergic alveolitis (EAA)?

A

type III and type IV hypersensitivity reaction to an environmental allergen - leads to lung inflammation and damage
- form of ILD

Bird-fancier’s lung – reaction to bird droppings
Farmer’s lung – reaction to mouldy spores in hay
Mushroom worker’s lung – reaction to specific mushroom antigens
Malt workers lung – reaction to mould on barley

152
Q

EAA Px

A

Acute (4-8hrs post-exposure)
- SOB, dry cough, fever, rigors, chest tightness
- crackles on ausc
- resolves after Ag removed

Chronic (wks/months)
- lethargy
- SOB
- productive cough
- anorexia, wt loss

153
Q

EAA Ix?

A
  • CXR / CT - upper/mid zone fibrosis
  • Bloods - assay for specific IgG
  • Spirometry - restrictive
  • bronchoscopy + bronchoalveolar lavage = lymphocytes in hypersensitivty pneumona
154
Q

EAA Mx?

A
  1. avoid trigger
  2. steroids - oral prednisone
  3. O2 if necessary
155
Q

what is pulmonary hypertension?

A
  • increased resistance and pressure in the pulmonary arteries
  • causes strain on the right side of the heart as it tries to pump blood through the lungs
  • results in back pressure through the right side of the heart and into the systemic venous system.

defined as mean pulmonary arterial pressure of > 20  mmHg

156
Q

what causes PAH?

A

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

157
Q

how might PAH Px?

A
  • SOB
  • Syncope
  • Cough
  • Tachycardia
  • Raised JVP
  • Hepatomegaly
  • Peripheral oedema
  • Hypotension
158
Q

PAH Ix?

A
  • ECG - RH strain, RAD, RBBB, RVH, p pulmonale
  • CXR - RVH, dilated pulmonary arteries
  • ECHO
  • BNP raised
159
Q

PAH Mx options?

A

Idiopathic pulmonary hypertension may be treated with:
- Calcium channel blockers
- Intravenous prostaglandins (e.g., epoprostenol)
- Endothelin receptor antagonists (e.g., macitentan)
- Phosphodiesterase-5 inhibitors (e.g., sildenafil

secondary PAH?
- Tx cause e.g. COPD, PE, SLE

160
Q

what is sarcoidosis?

A
  • Chronic multisystem granulomatous disorder of unknown cause
  • granulomas = inflammatory nodules full of macrophages

NB can have non pulmonary manifestations e.g. erythema nodosum

161
Q

sarcoidosis risk factors?

A
  • Aged 20-39 or around 60
  • Women
  • Black ethnic origin
162
Q

possible skin features of sarcoidosis?

A
  • erythema nodosum
  • lupus pernio - raised purple lesions on nose/cheeks
163
Q

how might acute sarcoidosis present?

A
  • cough
  • SOB
  • fatigue
  • fever
  • weight loss
  • arthralgia
  • erythema nodosum
164
Q

which organ is most commonly affected by sarcoidosis?

A

lungs - in over 90% patients

165
Q

name 3 organs (except lungs) that might be affected by sarcoidosis and explain how?

A

liver: nodules, cirrhosis, cholestasis
eyes: uveitis, conjunctivitis, optic neuritis
heart: BBB, heart block, myocardial involvement
kidneys: stones, interstitial nephritis

166
Q

what is Lofgren syndrome?

A

specific presentation of sarcoidosis with a classic triad of symptoms:

  • Erythema nodosum
  • Bilateral hilar lymphadenopathy
  • Polyarthralgia
167
Q

key blood test findings in sarcoidosis?

A
  • Raised ACE - often used as screening test
  • Raised calcium
168
Q

what might a lymph node biopsy show in sarcoidosis?

A

non-caseating granulomas with epithelioid cells.

169
Q

what imaging can you do for sarcoidosis? what might you seE?

A

Chest x-ray may show hilar lymphadenopathy
High-resolution CT scanning may show hilar lymphadenopathy and pulmonary nodules
MRI can show central nervous system involvement
PET scan can show active inflammation in affected areas

170
Q

sarcoidosis Mx?

A
  • mild sx - conservative
    1. oral steroids for 6-24m - prednisolone + bisphosphonates
    2. methotrexate
    3. lung transplant

NB spontaneous resaves in 50% patients

171
Q

lung abscesses? most common causative organism?

A
  • well-circumscribed infection within lung parenchyma, contains pus
  • RFx: necrotising pneumonia, septic emboli, tumours, aspiration
  • S aureus, Klebsiella, Pseudomonas, but typically polymicrobial
172
Q

Px of lung abscess?

A
  • swinging fevers
  • foul tasting purulent sputum
  • cough
  • pleuritic pain
  • haemoptysis
  • tachypnoea
  • clubbing
173
Q

Ix of lung abscess?

A
  • CXR - walled cavity +/- fluid level
  • sputum + blood cultures
  • sepsis workup
174
Q

lung abscess Mx?

A
  • IV abx
  • bromchoscopic drainage
  • surgical resection
175
Q

what is TB?

A
  • infection caused by Mycobacterium tuberculosis
  • acid-fast bacilli - see with zeihl Neilson stain - bright red cells on blue background
176
Q

TB pathophysiology - how is is spread? what are the 4 possible outcomes once bacteria is in bodY?

A
  • spread by saliva droplets, then several possible outcomes:
  1. Immediate clearance
    - most cases
  2. Primary active TB - active infection after exposure
  3. Latent TB - presence of bacteria without being symptomatic or contagious
  4. Secondary TB - reactivation of latent TB to active infection
177
Q

what is miliary TB?

A

when immune system can’t control infection and disseminated and severe disease develops

178
Q

RFs of TB?

A
  • close contact - household member
  • relatives from high prevalence areas
  • immunocompromised
  • malnutrition, homelessness, drug users, smokers, alcoholics
179
Q

what is the BCG vaccine?

A
  • intradermal, live attenuated M bovis bacteria
  • generates immune response
  • test with Mantoux test first - only give if negative
  • NOT part of routine vaccine schedule
180
Q

TB Px (systemic, pulmonary and extrapulmonary symptoms)

A

Systemic sx
- fever, lethargy, night sweats, wt loss, lymphadenopathy

Pulm sx
- cough, haemoptysis, chest pain, consolidation, pleural effusion

Extrapulmonary sx
- Bone – bone pain, Pott’s
- Abdo – ascites, lymph nodes, ileal malabsorption
- GU – epididymitis, LUTS, pyuria
- CNS – meningitis, sx of raised ICP
- Cardiac – pericarditis, pericardial effusion
- Skin – lupus vulgaris (red/brown lesions), erythema nodosum

181
Q

TB Ix - for immune response and active disease

A

For immune response - previous infection, latent TB, active TB
- mantoux test
- IGRA

For active disease
- CXR
- cultures - sputum (3x), blood, lymph node aspiration/biopsy - caseating granuloma on histology
- NAAT

182
Q

what might you see on a TB CXR?

A
  • primary TB: patchy consolidation, pleural effusions and hilarious lymphadenopathy
  • reactivated TB: nodule consolidation
  • disseminated miliary TB: ‘millet seeds’ (small nodules) distributed across lungs
183
Q

Latent TB Mx?

A

Either:
Isoniazid and rifampicin for 3 months (with pyridoxine vit B6)
Or
Isoniazid for 6 months (with pyridoxine vit B6)

184
Q

why prescribe pyridoxine / vitamin B6 with isoniazid?

A

isoniazid causes peripheral neuropathy

185
Q

active TB mx?

A

R – Rifampicin for 6 months
I – Isoniazid for 6 months
P – Pyrazinamide for 2 months
E – Ethambutol for 2 months

  • isolate patient and inform UKHSA
186
Q

common S/E of rifampicin?

A
  • red/orange discolouration of secretions, such as urine and tears
  • induced cytochrome P450 enzymes so reduces effect of COCP
  • hepatic
187
Q

common S/E of pyrazinamide?

A

hyperuricaemia (high uric acid levels), resulting in gout and kidney stones
- hepatotoxic

188
Q

common S/E of ethambutol?

A
  • colour blindness and reduced visual acuity
  • hepatotoxic
189
Q

influenza?

A
  • acute resp illness from infection with influenza virus
  • RNA virus with 3 subtypes (A, B and C)
  • A strains can be divided in H and N subtypes e.g. H1N1 (Spanish flu)
190
Q

who is eligible for free flu vaccines?

A

Aged 65 and over
Young children
Pregnant women
Chronic health conditions, such as asthma, COPD, heart failure and diabetes
Healthcare workers and carers

191
Q

influenze Px?

A
  • 1-4d incubation period
  • Fever
  • Lethargy
  • Anorexia
  • Myalgia, joint pain
  • Headache
  • Dry cough
  • Sore throat
  • Coryzal sx
192
Q

how can we clinically differentiate between common cold and flu?

A
  • flu more abrupt onset
  • flu typically has fever
  • feel ‘wiped out’ with flu + muscle aches
193
Q

influenza Ix?

A
  • clinical dx
  • POCT / viral PCR to monitor outbreaks
194
Q

influenza Mx?

A
  • self-care

if at risk of complications?
- antivirals - tamiflu (oseltamivir), inhaled zanamivir - start <48hrs of sx onset for it to be effective

195
Q

ARDS - Px?

A
  • resp distress, SOB, elevated RR
  • bl lung crackles
  • hypoxia
196
Q

what is ARDS?

A

acute respiratory distress syndrome
characterised by:
1. onset within 7 days of triggering event
2. bilateral opacities seen on CXR/CT
3. respiratory failure

197
Q

causes of ARDS?

A
  • sepsis, pneumonia, trauma, massive blood transfusion, smoke inhalation, pancreatitis
198
Q

ARDS - Ix and Mx?

A

Ix
- CXR - bilateral infiltrates
- ABG - hypoxia, resp failure

Mx
1. Tx trigger e.g. sepsis/trauma
2. oxygen
3. CPAP + O2
4. mechanical ventilation
5. prone positioning

finals (19 decks)

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