Respiratory Flashcards
What is the definition of emphysema?
Alveolar wall destruction leads to enlargement of distal airspaces - without sufficient antiprotease enzymes , proteases break down walls of alveoli causing bigger airspaces and reduce surface area available for gas exchanges
What is chronic bronchitis?
Persistent or recurrent productive cough due to mucus hypersecretion from goblet cells
Which lung function measure is lowered in COPD?
FEV1
Which enzyme usually counters inflammation in the lungs?
Antiproteases such as alpha-1-antitrypsin
What are the grades of COPD?
Mild: 80% or more than of predicted post bronchodilator FEV1
Moderate: 50-79%
Severe: 30 - 49%
Very severe: under 30%
What is the FEV1/FVC ratio in COPD?
Less than 0.7
What would be a sign in blood that there is COPD?
Polycythaemia
Anaemia
Which heart condition is associated with late stage COPD?
Cor pulmonale - right sided heart failure
What happens to hemidiaphragms in COPD?
They get flattened
Why is there an increase of VTE in COPD?
There can be increased blood viscosity due to polycythaemia which occurs because of chronic hypoxia and as a compensatory mechanism the body over produces erythropoietin which leads to increase in red cell production
What is empyema? + how would temp present?
Pus collects in pleural space - present with swinging fever
What is acute respiratory distress syndrome?
Non cardiogenic pulmonary oedema and diffuse lung inflammation may be secondary to lung injury
What criteria is used to define Acute respiratory distress syndrome (ARDS)?
Acute onset - less than a week
Chest - xray showing bilateral opacity
PaO2/FiO2 i 300 or less
What is pathophysiology of ARDS?
Diffuse bilateral alveolar injury so endothelial is disrupted and fluid leaks into the alveoli from pulmonary capillaries
Surfactant production decreases
What’s the presentation of ARDS?
Severe tachypnoea
Severe dyspnoea
Confusion/ presyncope
Creps
Use of accessory muscles
What anti-viral therapy can be used against influenza in COPD - and when is it best intiated?
Oseltamivir - within 48 hours of symptom onset
What is the definition of interstitial lung disease?
Group of diseases that cause inflammation and fibrosis of lung interstium
What are the two most common types of interstitial lung disease?
Idiopathic pulmonary fibrosis
Hypersensitivity pneumonia
What is hypersensitivity pneumonia?
Repeated exposures leads to ongoing inflammation and fibrosis
Triggers like: chemicals, agricultural dusts, woods, animal , fungi
What is farmer’s lung?
Type of hypersensitivity pneumonitis caused by mould spores an hay or straw
How is ILD classified?
By the zones it affects mainly
Upper zones: HART
Hypersensitivity pneumonitis
Ankylosing spondylitis
Radiotherapy
TB
Lower zones: RAIDS
Rheumatoid
Asbestosis
Idiopathic
Drugs
Sarcoidosis
How does ILD present?
Dry cough
SOB
reduced exercise tolerance
Fatigue
Anorexia
Weight loss
Clubbing
Fine end inspiratory crackles
What is seen with ILD on imaging?
Nodular shadowing
Honeycombing
Ground glass changes
Traction bronchiectasis
What is treatment of idiopathic Interstitial lung disease?
Antifibrotic: Pirfenidone and nintedanib
What’s the mechanism of action for nintedanib?
Tyrosine kinase inhibitor
What’s the mechanism of action for pirfenidone?
Reduces fibroblast proliferation
What is treatment for hypersensitivity pneumonitis?
Steroids
If steroids don’t work then: immunosuppression: cyclophosphamide and azathioprine
Which is correct stain for pneumonitis jirovecci pneumonia?
Silver stain
Which stain is for amyloid deposits?
Congo red
Which stain is for TB?
Ziehl - neelsen
Which stain is for cryptococcus neoformans?
India ink
What is a complication of amiodarone?
Inflammatory pneumonitis followed by chronic pulmonary fibrosis
Which drugs can cause pulmonary fibrosis?
Amiodarone
Nitrofurantoin
Methotrexate
Bleomycin
Busulfan
Sulfalazine
If pleural plaques are noted what can this indicate?
Asbestos exposure
What is the most common site of GI TB?
Ileocecal TB - which can present with the presence of a Right lower quadrant mass and abdo pain
How many apnoeic episodes per hour allows for a diagnosis of sleep apnea?
5 or more
What is the definition of a lung abscess?
Necrosis of lung tissue
Which smoking cessation drug is contraindicated in epileptics? and why?
Bupropion - decreases the seizure threshold
What is mechanism of bupropion?
Inhibits reuptake of dopamine and noradrenaline
How is bupropion taken?
Once a day for 6 days then twice a day 7-9 weeks
When is bupropion contraindicated?
Epilepsy
Bipolar
pregnant
breast feeding
Brain tumour
Eating disorder
What is the mechanism of action of varenicline?
Partial nicotinic receptor agonist
How is varenicline taken?
Started 1-2 weeks before quit date, then continued for 12 weeks
What are key side effects to be aware of with varenicline?
Suicidal ideation, depression, hallucination
When is varenicline contraindicated?
Pregnant
End stage renal failure
What’s a classic finding on chest x-ray in patients with sarcoidosis?
Bilateral hilar lymphadenopathy
What is the inheritance pattern of primary ciliary dyskinesia?
Autosomal recessive
What is primary ciliary dyskinesia?
Dysfunctional cilia
What is a key feature of primary ciliary dyskinesia that means that left lung base would be dull?
Situs invertus
What type of pneumonia is common from contaminated water, air conditioning - esp in hotels.?
Legionnaire’s disease
What type of bacteria is legionella?
Gram negative bacilli
How does legionnaire’s disease present?
Dry cough
Confusion
Hyponatraemia
Lethargy
Muscle aches
What must the ABG results be in order to meet criteria for long term oxygen therapy?
PaO2 less than 7.3 on two separate readings more than 3 weeks apart - non smokers
OR PaO2 of 7.3-8 WITH nocturnal hypoxia, polycythaemia, peripheral oedema and pulmonary hypertension
What is caplan’s syndrome?
Multiple pulmonary nodules that rapidly occur in lung periphery in patients with rheumatoid - causes swelling and scarring of lungs
Why can idiopathic pulmonary arterial hypertension be exacerbated in pregnancy?
Because the pulmonary vascular resistance can’t be reduced to accommodate increasing Cardiac output like in normal pregnant women therefore causing a early diastolic murmur - pulmonary regurg
What causes type 2 respiratory depression?
Can be due to opiate overdose
Causing:
Decreased paO2 but increased paCO2 due to alveolar hypoventilation
What is treatment of T1RF vs T2RF?
T1: CPAP
T2: NIV (BIPAP)
What is a complication type 2 diabetics are at risk of getting post influenza?
Pneumococcal pneumonia
What chemical is in contract for CTPA that people may be allergic to?
Iodine
Other than iodine allergy when else may a V/Q be preferred over CTPA?
Pregnant
Renal impairment
What is gold standard investigation for allergies?
Food challenge test
What is heparin induced thrombocytopenia?
Life threatening auto-immune reaction to heparin whereby patients have reduced platelets and hypercoagulable state
How is heparin induced thrombocytopenia treated?
Cessation of heparin
Argatroban
What type of bacteria can cause pneumonia after influenza?
Staph aureus
What bacteria is a common cause of hospital acquired pneumonia?
Klebsiella
What does sputum of klebsiella look like?
Red-currant jelly
Which patients are more likely to get pseudomonas aeruginosa?
CF
COPD
What is treatment for TB?
RIPE for 2 months followed by RI (or called rifinah) for 4 months
R:ifampicin
Isoniazid
Pyrazinamide
Ethambutol
Which intervention can reduce mortality in ARDS?
Low tidal volume mechanical ventilation
Which medication is usually given for aspiration pneumonia?
IV metronidazole as aspiration pneumonia is most likely due to oropharyngeal anaerobes
Which anti-microbial can cause INR to rise?
Metronidazole
Which sound is heard on COPD lungs?
Wheeze
Is MS obstructive or restrictive lung disease?
Restrictive so a normal FEV1/FVC - more than 0.7 and normal BUT reduced FEV1 and FVC values
When is spironolactone used vs furosemide?
Furosemide is used first then if symptoms persist then spironolactone is used
What type of hypersensitivity reaction is farmer’s lung (a type of extrinsic allergic alveolitis)?
Type 3 its a hypersensitivity pneumonitis
What’s the most common form of lung cancer in non smokers?
Adenocarcinoma
What’s the most common subtype of lung cancer?
SCC
What can cause wrist pain in lung adenocarcinoma?
hypertrophic pulmonary osteoarthropathy
Which nerves are invaded in pancoast tumour that can cause horner’s?
Brachial plexus
What AMTS score in setting of pneumonia and calculating CURB-65 indicates confusion?
Less than 8
How is CURB65 calculated?
C: confusion?
Urea over 7
Resp rate: 30 or over
B: BP systolic under 90 or diastolic under 60
65 - are they 65 or older
What does a CURB-65 score of over 3 indicate?
Mortality within 30 days
What is p pulmonale on ecg?
Right atrial abnormality on ecg seen as tall peaked p waves can be due to pulmonary hypertension as it’s a cause of right atrial enlargement
What size cannula should be used to aspirate pneumothorax?
18-18G
Where is cannula placed in pneumothorax on chest?
2ICS on affected side if this fails do an open thoracostomy
After initial emergency decompression a chest drain should be inserted
Which patients would require a chest drain over a 16-18G cannula for pneumothorax first?
High risk feature patients:
Significant hypoxia
Bilat penumothoraces
Underlying lung disease
50 or older with significant smoking history
Haemopneumothorax
What is a normal cardiothoracic ration?
Less than 0.5 - above 0.5 can indicate cardiomegaly
What is best diagnostic investigation for heart failure?
Transthoracic echo
What would a pH of below 7.2 in pleural fluid indicate?
Empyema
What’s a common form of pneumonia in young adults?
Mycoplasma pneumonia
What rash can be seen with mycoplasma pneumonia?
Erythema multiforme
How would mycoplasma pneumonia present?
Haemolysis
Elevated reticulocytes
Cold agglutinin and positive coombs
Erythema nodusm rash
What does a positivie coomb’s test indicate?
Antibodies that act against red blood cells
What is cold agglutinin test show?
Detects presence of cold agglutinins which are antibodies that cause RBC to clump together in cold temperatures
Which asthma patients should be offered preventer therapy?
Patients with symptoms more than twice a week
History of exacerbations in the past year
Pt who need SABA more than 3 times a week
What is 1st line treatment for COPD patient with breathless on activity?
SABA or SAMA
Give me an example of a SAMA?
Ipratropium
If after a SABA or LAMA things are not improving in copd what else is given?
LABA + ICS OR LABA + LAMA - use this combo first
What ICS is used in COPD?
Beclamethasone
What LAMA is used in COPD?
Tiotropium
What is bronchiectasis?
Chronic lung disease characterised by irreversible dilation of bronchi and bronchioles due to chronic inflammation and infection
What’s the initial management of bronchiectasis?
Chest physio - helps removes secretions
Inhaled bronchodilators - improve airflow
Antibiotics
When is metronidazole helpful in treating pneumonia?
Gram negative infections
When is vancomycin used in pneumonia?
If there is concern for MRSA
What is treatment for TB meningitis?
RIPE for 2 months
RI for 10 months
What is the gram staining of klebsiella?
Gram negative anaerobic rod
Which electrolyte imbalance is present in legionella?
Hyponatraemia
What is the gram staining of legionella?
Gram negative aerobic rods
What is a transudate vs exudate?
Transudate are pleural fluids with a protein level less than 25g/L
Exudates are pleural fluid with protein level more than 35g/L
What does light’s criteria say about exudates?
Ratio of pleural to serum protein is more than 0.5
Ratio of pleural to serum LDH is more than 0.6
Pleural fluid LDH is more than 2/3s the upper limit of normal value
What are transudative causes of effusions?
Heart failure - usually bilat
Nephrotic syndrome
Cirrhosis
Hypoalbuminaemia
What are exudative causes of pleural effusions?
Pneumonia - so a parapneumonic effusion
Malignancy
TB
PE
RA
SLE
Pancreatitis
Trauma
How many days would a chest drain be expected to clear and allow for chest re-expansion?
3-5 days of chest drain insertion
What is important to remember about methotrexate?
It can cause pneumonitis - fibrosis, restrictive lung disease
Which pneumonia is associated with alcoholics?
Klebsiella - highly associated with lung abscesses in alcoholic patients
When is vocal resonance reduced?
Pleural effusion or lung collapse
What about spirometry would allow for a diagnosis of asthma?
Reversibility of 12% or more in the FEV1 with bronchodilator use
Which is the diagnostic investigation for chronic thromboembolism pulmonary hypertension?
Right heart catheterisation
Which measure should be monitored monthly when starting bosentan (endothelin A receptor antagonist)
LFTs
What medication can be prescribed for pulmonary hypertension?
Bosentan
What would empyema present with?
Persistent foul smelling sputum and low pleural fluid pH
What is defined as pulmonary hypertension?
Pressure over 25
What happens to residual lung volume in COPD?
There is an increase in residual lung volume as body can’t exhale all air properly due to dynamic hyperinflation
What feature on the hands can be seen with recurrent lung abscesses?
Finger clubbing
What’s the best diagnostic investigation for mycoplasma pneumonia?
Blood serology
Which pneumonia is urinary antigens useful in?
Legionnaire’s disease
Which heart sound can indicate right sided heart failure due to long term lung disease?
Split second heart sound with loud pulmonary component
What is percussion like in pleural effusion?
Stony dull
What is meig syndrome triad?
Ovarian benign tumour
Ascites
Pleural effusion
Which side do pleural effusions usually happen in Meig’s syndrome?
Right sided
Which organism causes pneumonia with rust coloured sputum?
Streptococcus
What is acute bronchitis normally caused by?
Respiratory virus
Why is D dimer not useful in pregnancy?
Because D dimer is naturally increased in pregnancy - so the test would produce false positives
Which pneumonia is most commonly associated with cold haemolytic anaemia?
Mycoplasma pneumonia
How does cold haemolytic anaemia present?
Fatigue
Blue fingers and toes when cold
Sweating
Weakness
Pale
Drained skin
When someone has had a stroke and come in with pneumonia like symptoms what should you start thinking?
Aspiration pneumonia - bcos impaired swallow
Which type of bacteria is most commonly causing lung abscess?
Anaerobic bacteria
What is most likely test for pulmonary fibrosis?
CT of chest
Which UTI medication can cause pulmonary fibrosis if multiple courses are taken?
Nitrofurantoin
What is seen on chest X-ray for PE?
Wedge shaped opacification in left middle zone
What is common sighting on X-ray for TB?
Upper zones - patchy opacifications - can be described as fibronodular
What well’s score indicated high likelihood of PE?
Over 4
What is Spirometry values in osbstructive disease?
Low FEV1
Reduced FEV1/FVC
Preserved FVC
What is the oral antibiotic regime for patients with CAP?
Amoxicillin 500mg 3 times a day for 5 days
What follow up do patients with pneumonia need?
Repeat chest X-ray 6-8 weeks after to screen for underlying lung cancer
Which lung lobes does farmer’s lung (extrinsic allergic alveolitis) tend to go got?
Upper lobes
What FVC must a patient have to consider an anti-fibrinolytic?
50-80%
Which pneumonia patients are suitable for home treatment?
CURB65 - is 0 or 1 .
Any CRUB over 2 needs hospital admission
What is seen with an INITIAL ABG in aspirin overdose?
Respiratory alkalosis
What is the most common gram positive aerobic bacteria that causes aspiration pneumonia?
Streptococcus
What indications make a COPD patient suitable for lung reduction surgery?
Predominant upper lobe emphysema
What’s the definitive test for pneumocystis pneumonia?
Bronchoscopy with bronchoalveolar lavage
Which drug should be held when clarithromycin is used and why?
Simvastatin - statins are metabolised by the CYp3a4 pathways and clarithromycin increases plasma levels of statins - increases the risk of myopathy
What type of hypersensitivity reaction is asthma?
Type 1
What does signet ring sign on CT signify?
Bronchiectasis - bronchus is dilated
What is postural drainage?
Type of chest physio - done twice a day to help drain mucous to prevent infective exacerbations of bronchiectasis
What’s recommended first line antibiotic for HAP? why what does it act against?
Pip and taz
Pseudomonas cover and MRSA cover
What type of fibrosis does TB cause?
Apical fibrosis
