Respiratory Flashcards
Mx of chlamydia pittsaci?
Tetracycles 1st line (doxycyline)
Macrolides 2nd line (erythromycin)
When to give abx in exacerbation of COPD?
‘if sputum is purulent or there are clinical signs of pneumonia’
When to admit for COPD exacerbation?
severe breathlessness
acute confusion or impaired consciousness
cyanosis
oxygen saturation less than 90% on pulse oximetry.
social reasons e.g. inability to cope at home (or living alone)
significant comorbidity (such as cardiac disease or insulin-dependent diabetes)
Which medication needs to be avoided in those with Esinophillic granulomatosis with polyangiitis (Churg-Strauss)?
Leukotriene receptor antagonists (eg montelukast)
Organisms in bronchiectasis?
Haemophilus influenzae (most common)
Pseudomonas aeruginosa
Klebsiella spp.
Streptococcus pneumoniae
What are some CIs for surgical managament of non-small cell lung ca?
assess general health
stage IIIb or IV (i.e. metastases present)
FEV1 < 1.5 litres is considered a general cut-off point*
malignant pleural effusion
tumour near hilum
vocal cord paralysis
SVC obstruction
CI for lung transplant in CF?
Burkholderia cepacia chronic infection
asthma
blood eosinophilia (e.g. > 10%)
paranasal sinusitis
mononeuritis multiplex
pANCA positive in 60%
What condition?
Eosinophillic granulomatosis with polyangitis (Churg-Strauss)
Causes of upper zone fibrosis?
CHARTS
C - Coal worker’s pneumoconiosis
H - Histiocytosis/ hypersensitivity pneumonitis
A - Ankylosing spondylitis
R - Radiation
T - Tuberculosis
S - Silicosis/sarcoidosis
Causes of lower zone fibrosis?
idiopathic pulmonary fibrosis
most connective tissue disorders (except ankylosing spondylitis) e.g. SLE
drug-induced: amiodarone, bleomycin, methotrexate
asbestosis
Lights criteria - what is it used for?
To distinguish between transudative and exudative pleural effusion
Prove please, please please this fluid is an exudate
P - pleural fluid
Pro - protein
Prove - 5 letters
pleural fluid protein divided by serum protein >0.5
P - pleural fluid
L - LDH
Please - 6 letters
pleural fluid LDH divided by serum LDH >0.6
PL L - Pleural and LDH
please please - 66 letters -> 0.66 (2/3)
pleural fluid LDH more than two-thirds the upper limits of normal serum LDH
If one of these is met suggests exudate
Sarcoidosis - what normally happens
The majority of patients with sarcoidosis get better without treatment
Key indications for NIV?
COPD with respiratory acidosis pH 7.25-7.35
type II respiratory failure secondary to chest wall deformity, neuromuscular disease or obstructive sleep apnoea
cardiogenic pulmonary oedema unresponsive to CPAP
weaning from tracheal intubation
Type 1 v Type 2 resp failure?
Type 1 - low o2
Type 2 - high co2
When for BiPAP v CPAP?
BiPAP - Type 2 resp failure
CPAP - Type 1 resp failure
radiographic evidence of dilated bronchi and thickened walls in the lower zones - what is this sign? which condition?
This is tram-track sign as seen in bronchiectasis
Conditions to fulfil before prophylactic abx in COPD and which abx?
Conditions:
- Optimised standard tx
- Not smoke
- CT Thorax - exclude bronchiectasis
- LFTs and ECG prior to abx due to risk of QT prolongation
Abx - Azithromycin
Inhaled corticosteroids during pregnancy?
Safe to use
progressive exertional dyspnoea associated with clubbing and a restrictive picture on spirometry
Suggestive of what?
Idiopathic pulmonary fibrosis
combination of parotid enlargement, fever, and anterior uveitis.
Diagnosis?
Heerfordt’s syndrome (uveoparotid fever) = subset of sarcoidosis
What increases and decreases TLCO?
raised: asthma, haemorrhage, left-to-right shunts, polycythaemia
low: everything else
Acute mountain sickness - prophylaxis?
Acetazolamide - carbonic anhydrase inhibitor
How to remember the indications for steroid use in sarcoidosis?
Mnemonic PUNCH
P - Parenchymal Lung Disease
U- Uveitis
N- Neurological Involvement
C- Cardiac Involvement
H - Hypercalcaemia
Definition of pulmonary arterial HTN?
Raised PAP >20mmHg
What is Lofgrens syndrome?
Acute form of sarcoidosis characterised by the triad of erythema nodosum, bilateral hilar lymphadenopathy, and polyarthritis
COPD - still breathless despite using SABA/SAMA and no asthma/steroid responsive features
What is the next step?
Add LAMA + LABA
Dyspnoea, obstructive pattern on spirometry in patient with rheumatoid
Dx?
bronchiolitis obliterans
A high-resolution CT scan of the chest shows mosaic attenuation (centrilobular nodules) and bronchial wall thickening.
is suggestive of?
Bronchiolitis obliterans
What is Caplans syndrome and when is it seen?
massive fibrotic nodules with occupational coal dust exposure
Seen with RA
What is farmers lung? what is it caused by?
Farmers lung is a type of extrinsic allergic alveolitis
Caused by Saccharopolyspora rectivirgula - contaminated hay
What causes malt workers lung and what is this?
malt workers lung is a type of extrinsic allergic alveolitis
Caused by Aspergillus clavatus
What are the CIs for lung cancer surgery?
Surgery For Very Malignant Voices
S: Superior vena cava (SVC) obstruction
F: FEV < 1.5 liters
V: Vocal cord paralysis
M: Malignant pleural effusion
What effect does 2,3 DPG have on O2 dissociation curve?
Right shift at higher levels
What are the paraneoplastic features of squamous cell ca of lungs?
PTHrp -> hyperca, clubbing, HPOA, hyperthyroidism due to ectopic TSH
What are the paraneoplastic features of small cell ca (APUD cells) of lungs?
ADH -> hyponatraemia
ACTH -> Cushings syndrome, bilateral adrenal hyperplasia -> can lead to hypokalaemic alkalosis
Lambert-Eaton syndrome
CXR staging of sarcoidosis?
1 = BHL
2 = BHL + infiltrates
3 = infiltrates
4 = fibrosis
What are the high risk characteristics that determine the need for chest drain in pneumothorax mx?
Haemodynamic compromise (suggesting a tension pneumothorax)
Significant hypoxia
Bilateral pneumothorax
Underlying lung disease
≥ 50 years of age with significant smoking history
Haemothorax
What is catamenial pnneumothorax? What causes it?
Catamenial pneumothorax is the cause of 3-6% of spontaneous pneumothoraces occurring in menstruating women
Thought to be caused by endometriosis in the thorax
Signs of life-threatening asthma attack?
CHESS 33 -
Cyanosis,
Hypotensive,
Exhaustion,
Silent chest,
Sats<92%,
PEFR<33%
What can over rapid aspiration / drainage of pneumothorax lead to? What factors predispose to this?
re-expansion pulmonary oedema (RPE) - normally 1-2 hours post but can develop up to 24h after
Risk factors for RPE include:
1. Longer duration of lung collapse
2. Larger volume of lung collapse
3. Rapid drainage of pleural fluid/air
4. Application of negative pleural pressure (suction)
5. Younger age of patient
What is Churg Strauss syndrome also known as? what can unmask this?
Eosinophilic granulomatosis with polyangiitis (EGPA)
Use of montelukast can unmask tis
What part of lung is most affected in idiopathic pulmonary fibrosis?
Lung bases - reticular changes, honeycombing, traction bronchiectasis and less so ground glass opacities
How to calculate Functional residual capacity?
Expiratory reserve volume + Residual volume
Patients with high oxygen-affinity haemoglobin variants
What is the risk of this?
Can lead to tissue hypoxia and compensatory polycythaemia.
This theoretically increases the thrombotic risk, although this has not been properly delineated. To reduce this risk patients with high oxygen-affinity variants may be managed by:
> low-dose aspirin
> venesection
Management of high altitude cerebral edema ?
Descent + dexamethasone
Causes of transudative (<30g/L pro) pleural effusion?
all the failures (hypothroid, heart failures, liver failure, liver failure,low albumin) + meigs syndrome…. it kinda works
Causes of exudative (>30g/L pro) pleural effusion?
infection
-pneumonia (most common exudate cause),
-tuberculosis
-subphrenic abscess
connective tissue disease
-rheumatoid arthritis
-systemic lupus erythematosus
neoplasia
-lung cancer
-mesothelioma
-metastases
pancreatitis
pulmonary embolism
Dressler’s syndrome
yellow nail syndrome
What are the recommended initial settings for bi-level pressure support in COPD?
Expiratory Positive Airway Pressure (EPAP): 4-5 cm H2O
Inspiratory Positive Airway Pressure (IPAP): RCP advocate 10 cm H20 whilst BTS suggest 12-15 cm H2O
back up rate: 15 breaths/min
back up inspiration:expiration ratio: 1:3
Ix for occupational asthma?
Serial peak flow measurements at work and at home
Most common cause of occupational asthma?
isocyanates - the most common cause
example occupations include spray painting and foam moulding using adhesives
Also (platinum salts, soldering flux resin, glutaraldehyde, flour, epoxy resins, proteolytic enzymes)
COPD - still breathless despite using SABA/SAMA and asthma/steroid responsive features → ???? Next steps
COPD - still breathless despite using SABA/SAMA and asthma/steroid responsive features → add a LABA + ICS
When to consider LTOT in COPD?
pO2 of < 7.3 kPa
OR to those with a pO2 of 7.3 - 8 kPa and one of the following:
> secondary polycythaemia
> peripheral oedema
> nocturnal hypoxaemia
> pulmonary hypertension
How can you interpret A1 antitrypsin deficiency genetics?
M is normal, S is slow, and Z for very slow → PiMM is the normal genotype
heterozygous: PiMZ - if non-smoker low risk of developing emphsema but may pass on A1AT gene to children
homozygous PiSS: 50% normal A1AT levels
homozygous PiZZ: 10% normal A1AT levels
patients who manifest disease usually have PiZZ genotype
Bupropion is used to help people stop smoking - MoA?
Atypical antidepressant - Norepinephrine and dopamine reuptake inhibitor, and nicotinic antagonist
Small risk of seizures - CI in epilepsy, pregnancy + breast feeding
What is Varenicline’s MoA and use? Caution in?
MoA - partial nicotinic receptor agonist used in smoking cessation
caution in patients with a history of depression or self-harm
CI in pregnancy + breastfeeding
Major and minor criteria for allergic bronchopulmonary aspergillosis?
Major criteria for the diagnosis are:
Clinical features of asthma
> Proximal bronchiectasis
> Blood eosinophilia
> Immediate skin reactivity to Aspergillus antigen
> Increased serum IgE (>1000 IU/ml)
Minor criteria:
> Fungal elements in sputum
> Brown flecks in sputum
> Delayed skin reactivity to fungal antigens
CT T showing abnormal widening + thickening of bronchi
Dx? Most likely causative organism?
Bronchiectasis
H. Influenzae
Tx of choice for allergic bronchopulmonary aspergillosis?
oral glucocorticoids
itraconazole is sometimes introduced as a second-line agent
Extrinsic allergic alveolitis Fibrosis loacation?
Upper / mid zone fibrosis
How to distinguish between obstructive and restrictive lung disease?
Obstructive - FEV1:FVC ratio of less than 70%
Restrictive - FEV1 and FVC are equally reduced, hence FEV1:FVC ratio greater than 70%
Examples of restrictive lung disease?
Restrictive lung disease includes conditions that limit how well the chest wall and lungs can expand, for example:
Interstitial lung disease, such as idiopathic pulmonary fibrosis
Sarcoidosis
Obesity
NM disorders eg Motor neurone disease
Scoliosis eg ank spond
ARDS
Examples of obstructive lung disease?
In asthma, the obstruction is a narrowed airway due to bronchoconstriction.
In COPD, there is chronic airway and lung damage, causing obstruction.
You can test the reversibility of this obstruction by giving a bronchodilator (e.g., salbutamol).
The obstructive picture is typically reversible in asthma but less so in COPD.
Also Bronchiectasis + Bronchiolitis obliterans
What proportion of lung ca CXR is normal o reporting?
10%
Most common causes of BHL? other causes?
Sarcoidosis and TB
lymphoma/other malignancy
pneumoconiosis e.g. berylliosis
fungi e.g. histoplasmosis, coccidioidomycosis
Main cause of extrinsic allergic alveolitis acutely + chronically?
Acute = (type III hypersensitivity)
Chronic = delayed hypersensitivity (type IV)
Causes of bronchiectasis?
Mnemonic: A SICK AIRWAY
Airway Obstruction/lesion
Sequestration
Infection/Inflammation
Cystic Fibrosis
Kartageners
ABPA
Immunodeficiencies (Hypogammaglobinemea, Myeloma, lymphoma)
William Campbell Syndrome
Aspiration
Yellow Nail Syndrome/Young Syndrome
Features of Kartageners syndrome?
dextrocardia or complete situs inversus
bronchiectasis
recurrent sinusitis
subfertility (secondary to diminished sperm motility and defective ciliary action in the fallopian tubes)
Causes of resp alkalosis?
CHEAPS causes Respiratory Alkalosis
CNS Disorders,
Height (Altitude),
Embolism (Pulmonary),
Anxiety,
Pregnancy
Salicylate overdose - mixed resp alkalosis + met acidosis
Peripheral tingling during episodes of dyspnoea - feature of asthma?
No this makes a diagnosis of asthma less likley
HLA-DR1 is associated with what?
Bronchiectasis
Resp alkalosis in hyperventilation, what happens to O2?
O2 levels are normal
Mx of asymptomatic pneumothoax?
- 1ry pneumothorax»_space;> discharge & FU ‘outpatient’
- 2ry pneumothorax»> conservative TTT + monitored ‘inpatient’
Mx of symptomatic pneumothorax with no high risk features?
- Conservative Care
- Needle Aspiration
- Ambulatory Device (Rocketµ Pleural Vent)
Before Needle aspiration or chest drain, Pneumothorax what needs to be fulfilled?
- Has to be ≥ 2 cm laterally or apically on CXR or
- Can be accessed with CT-guided intervention
Mx of recurrent pneumothorax?
VATS for pleurodesis +/- bullectomy.
What can be considered in mx of COPD pneumothorax?
Talc pleurodesis may be considered in 1st episode pneumothorax
Mx of pneumothorax in ventilated pts?
Chest drain
Pneumothorax discharge advice?
Scuba diving is avoided permanently unless pleurectomy and Normal PFTs
Patients may travel 2 weeks after successful drainage if no residual air.
advised to avoid smoking to reduce the risk of further episodes - the lifetime risk of developing a pneumothorax in healthy smoking men is around 10% compared with around 0.1% in non-smoking men
Lung Adenocarcinoma paraneoplastic features?
gynaecomastia
hypertrophic pulmonary osteoarthropathy (HPOA)
Which one of the following markers is most useful for monitoring the progression of patients with chronic obstructive pulmonary disease?
FEV1
most important in the long term control of his symptoms in Bronchiectasis?
inspiratory muscle training + postural drainage
Predisposing factors for OSA / hypopnoea?
obesity
macroglossia: acromegaly, hypothyroidism, amyloidosis
large tonsils
Marfan’s syndrome
Bloods show a leukocytosis and an elevated ESR and CRP. Imaging typically shows bilateral patchy or diffuse consolidative or ground glass opacities. Lung function tests are most commonly restrictive but can be obstructive or normal. The transfer factor is reduced.
Non responsive to abx
dx?
Cryptogenic organizing pneumonia (COP)
is a diffuse interstitial lung disease that affects the distal bronchioles, respiratory bronchioles, alveolar ducts and alveolar walls.
Causes of pulmonary eosinophillia?
WEgener’s
Loffler’s (transient rxn to parasites eg Ascaris lumbricoides, self limiting)
ABPA
Tropical pulm eosinophilia
Churg-Strauss
Hypereosinophilic syndrome
Eosinophilic pneumonia
Drugs - nitro, sulfonamides
What is tropical pulmonary eosinophilia associated with?
associated with Wuchereria bancrofti infection
Mx of Acute eosinophilic pneumonia?
highly responsive to steroids
How is COPD severity characterised?
Based on FEV1
> 80 - mild hence need sx of COPD for diagnosis
50-79 - moderate
30-49 - severe
<30 - v severe
When should chest tube be inserted for pleural effusion?
All patients with a pleural effusion in association with sepsis or a pneumonic illness require diagnostic pleural fluid sampling
if the fluid is purulent or turbid/cloudy a chest tube should be placed to allow drainage
if the fluid is clear but the pH is less than 7.2 in patients with suspected pleural infection a chest tube should be placed
Causes of cavitating leisons on CXR?
WAP RATS (Wet Ass Pussy RATS)
Wegners, Abscess, PE
RA, Aspergillosis, TB, SCC
Why does sarcoidosis lead to hypercalcaemia?
Increased concentrations of calcitriol, the active component of vitamin D.
This is as a result of increased activity of 1α hydroxylase produced by the sarcoid macrophages.
What is vital capacity in men and women?
4,500ml in males, 3,500 mls in females
most suitable way of assessing compression of the upper airway?
Flow volume loop
When do patients with symptomatic primary pneumothorax need to be f/u if mx conservatively?
2-4 days!!!
COPD - reason for using inhaled corticosteroids?
Reduced exacerbation frequency
When are cannonball mets typically seen in the lungs?
most commonly seen with renal cell cancer but may also occur secondary to choriocarcinoma and prostate cancer
When is Calcification in lung mets seen?
chondrosarcoma or osteosarcoma.
Inheritance of CF?
AR
RFs for lung ca?
Smoking
Asbestos - increases risk of lung ca by a factor of 5
arsenic, radon, nickel, chromate, aromatic hydrocarbon
cryptogenic fibrosing alveolitis
Causes of COPD?
Smoking!
Alpha-1 antitrypsin deficiency
Other causes
cadmium (used in smelting)
coal
cotton
cement
grain
Asthmatic features/features suggesting steroid responsiveness in COPD:
previous diagnosis of asthma or atopy
a higher blood eosinophil count
substantial variation in FEV1 over time (at least 400 ml)
substantial diurnal variation in peak expiratory flow (at least 20%)
Dietary advice for CF?
High calorie and high fat with pancreatic enzyme supplementation for every meal
Features of CF?
MAIN
neonatal period (around 20%): meconium ileus, less commonly prolonged jaundice
recurrent chest infections (40%)
malabsorption (30%): steatorrhoea, failure to thrive
other features (10%): liver disease
OTHERS
short stature
diabetes mellitus
delayed puberty
rectal prolapse (due to bulky stools)
nasal polyps
male infertility, female subfertility
Situations where oxygen therapy should not be used routinely if there is no evidence of hypoxia?
myocardial infarction and acute coronary syndromes
stroke
obstetric emergencies
anxiety-related hyperventilation
Criteria for ARDS?
remember as ABCD
A: Acute onset (within 1 week of lung injury)
B: bilateral infiltrates on CXR
C: (not) cardiogenic
D: Decreased PaO2:FiO2 (mild <300, mod <200, severe <100)
Features of silicosis?
upper zone fibrosing lung disease
‘egg-shell’ calcification of the hilar lymph nodes
NB it is a RF for development of TB
high altitude pulmonary oedema (HAPE) main sx + mx?
mechanism: hypobaric hypoxia → uneven hypoxic pulmonary vasoconstriction → uneven blood flow in the lungs → areas of the lung receiving more blood experience an increase in capillary pressure → more fluid leakage.
Hypoxia may also directly increase capillary permeability, exacerbating fluid leakage into the alveolar space.
presents with classical pulmonary oedema features
MX:
descent
nifedipine, dexamethasone, acetazolamide, phosphodiesterase type V inhibitors*
oxygen if available
Which one of the following chest x-ray findings develops first in patients with idiopathic pulmonary fibrosis?
Small, peripheral opacities in the lower zones (ground glass) -> can progress to honeycombing
What is atelectasis and when to suspect?
common postoperative complication in which basal alveolar collapse can lead to respiratory difficulty
Caused by airway obstruction secondary to bronchial secretions - suspect why dyspnoeic and hypoxaemic 72h post op
Mx of atelectasis?
positioning the patient upright
chest physiotherapy: breathing exercises
Main way of reducing ca risk in asbestos exposure?
Stop smoking - synergistic effect!
