Respiratory Flashcards
1
Q
What is the typical presentation of sarcoidosis?
A
Can affect many different systems, e.g.
respiratory (SoB, dry cough, hoarse voice)
systemic (weight loss, malaise, fever, fatigue)
skin (erythema nodosum)
eyes (uveitis)
MSK (polyarthralgia)
CNS (seizures, facial palsy)
renal (hypercalcaemia, hypercalciuria)
cardiovascular (arrhythmias)
2
Q
What is Lofgren’s syndrome?
A
acute form of sarcoidosis
triad: 1. arthralgia 2. erythema nodosum 3. hilar lymphadenopathy on CXR
absence of red flags!
3
Q
What is sarcoidosis?
A
multi-system granulomatous disease
formation of non-caseating granulomas in organs
4
Q
What is stage 1 of sarcoid?
A
hilar lymphadenopathy
likely to resolve spontaneously
5
Q
what is stage 2 of sarcoid?
A
hilar lymphadenopathy + parenchymal involvement
likely to resolve spontaneously
6
Q
what is stage 3 of sarcoid?
A
only parenchymal involvement (formation of reticular opacities)
likely to progress and require treatment
7
Q
what is stage 4 of sarcoid?
A
pulmonary fibrosis
likely to progress and require treatment
8
Q
what will CXR show in sarcoid?
A
hilar lymphadenopathy
diffuse infiltrates in lung fields
9
Q
what blood tests are typical/diagnostic in sarcoidosis?
A
ACE levels - raised
Calcium - raised
10
Q
what will biopsy of sarcoid show?
A
non-caseating granuloma with epithelioid cells
11
Q
what is the management for sarcoid?
A
conservative management - asymptomatic/mild symptoms
oral steroids - 6-24 months
methotrexate
12
Q
what is the indication for steroids in sarcoid?
A
PUNCH
Parenchymal Lung Disease
Uveitis
Neurological Involvement
Cardiac Involvement
Hypercalcaemia
CXR showing stage 2-3 and have symptoms (parenchymal lung disease)
hypercalcaemia
involvement of heart/eye/nervous system
13
Q
what investigations are used for sarcoid?
A
CXR
spirometry - might be restrictive
tissue biopsy - non-caseating granulomas
14
Q
what are the risk factors for sarcoid?
A
female
African descent
20-40 y.o.
15
Q
What factors are associated with poorer prognosis in sarcoidosis?
A
African descent
insiduous onset
symptoms lasting for 6+ months
absence of erythema nodosum
extrapulmonary manifestations (lupus pernio, splenomegaly)
stage 3-4 features on CXR
16
Q
What is bronchiectasis?
A
Chronic dilation of bronchi, leading to sputum collection and bacterial growth
17
Q
What is yellow nail syndrome? I.e. what are the main signs?
A
Yellow nails, lymphoedema, and bronchiectasis
18
Q
What respiratory condition is yellow nail syndrome associated with?
A
Bronchiectasis
19
Q
What are some causes of bronchiectasis?
A
CICA TYP:
Cystic fibrosis
Idiopathic
Connective tissue disorders
Alpha 1 antitrypsin deficiency
Tuberculosis
Yellow nail syndrome
Pertussis
20
Q
What are the key symptoms of bronchiectasis?
A
Chronic productive cough
Progressive SoB
Recurrent chest infections
Wheeze
Pleuritic chest pain
Red flag symptoms: Weight loss, fatigue, haemoptysis
21
Q
What signs on examination can you find in patients with bronchiectasis?
A
Coarse bi-basal crackles
Finger clubbing
Cachexia
Signs of cor pulmonale
Scattered wheeze and crackles
Sputum pot
Oxygen therapy
22
Q
What investigations should you do if you suspect bronchiectasis? And why?
A
Sputum culture - most common organisms are Haemophilus influenza, and Pseudomonas aeruginosa
CXR - tram track opacities, ring shadows
Bloods - FBC
Spirometry - assess severity of obstruction and identify any coexisting diagnoses
HRCT - best imaging - signet ring, dilated bronchi
Investigations to determine underlying cause,
e.g Tests for cystic fibrosis - e.g. sweat test
HIV serology
Immunoglobulin tests
23
Q
What organisms can you most commonly find in sputum culture of a patient with bronchiectasis?
A
Haemophilus influenza
Pseudomonas aeruginosa
24
Q
What will CXR show in bronchiectasis?
A
tram track opacities, ring shadows
25
what will HRCT show in bronchiectasis?
signet ring sign, dilatation of bronchi
26
What is the management of bronchiectasis?
physical training/pulmonary physiotherapy
bronchodilators (in some cases)
smoking cessation
vaccination
surgery (very rare - only if localised)
27
what are the potential complications of bronchiectasis?
exacerbations (deterioration in 3+ symptoms for 48+ hrs)
pneumonia
cor pulmonale
respiratory failure
recurrent pleurisy
28
What is interstitial lung disease?
umbrella term
inflammation and fibrosis of lung parenchyma
29
What are some types of interstitial lung disease?
Idiopathic pulmonary fibrosis
Cryptogenic organising pneumonia
Hypersensitivity pneumonitis
Asbestosis, silicosis
ILD of connective tissue dissease
30
What are the key presenting features of interstitial lung disease?
gradual SoB (esp. on exertion)
dry cough
fatigue
31
What examination findings will you find in idiopathic pulmonary fibrosis?
Bi-basal fine-end inspiratory crackles
finger clubbing
32
What are the risk factors for interstitial lung disease?
occupational exposure to asbestos, silica
bird keeper
IPF: male, smoker, older
CTD: younger, female, connective tissue disease
certain drugs (bleomycin - chemo; amiodarone - anti-arrhythmic; nitrofurantoin - ATB; methotrexate - anti-inflammatory)
33
How is interstitial lung disease/IPF diagnosed?
clinical features and Hx
HRCT - ground glass appearance -> honeycombing
spirometry - restrictive pattern or normal
34
What are the spirometry findings in patients with interstitial lung disease/IPF?
FEV1 normal or reduced
FVC can be reduced
FEV1/FVC normal or restrictive
transfer factor (TLCO) - reduced - impaired gas exchange
35
What is the gold standard imaging for idiopathic pulmonary fibrosis?
HRCT - ground glass/honeycombing
36
What is the management of interstitial lung disease?
if underlying cause - remove/treat
medications - steroids (if inflammatory cause), antifibrotics if fibrotic (pirfenidone, nintedanib)
hypoxia - o2 therapy
smoking cessation
pulmonary rehabilitation
vaccinations
advanced care planning, palliative care
lung transplantation
37
How is IPF managed?
pulmonary rehabilitation
anti-fibrotics - pirfenidone, nintedanib - to slow the progression
supplementary o2
lung transplantation
38
What is the prognosis of IPF?
poor - typically 3-4 years (can be a bit higher with treatment)
39
What drugs can cause ILD?
chemotherapy - bleomycin
anti-arrhythmic - amiodarone
ATBs (long-term) - nitrofurantoin
anti-inflammatory - methotrexate
40
What is asthma?
Chronic inflammatory airway disease secondary to type 1 hypersensitivity
Hypersensitive smooth muscle causes bronchospasm, leading to airway obstruction.
The bronchospasm is reversible with bronchodilators.
Symptoms are variable - diurnal variation
41
What are the main types of asthma? (onset)
childhood onset
adult onset
occupational asthma - flour, isocyanates
42
What are the risk factors for developing asthma?
Hx or Fx of atopy
low birth weight
maternal smoking, viral infections during pregnancy
respiratory infections in infancy
(parental) exposure to tobacco smoke
exposure to high concentrations of allergens
air pollution
43
What is the pathophysiology of asthma?
IgE antibodies sensitised and released by plasma cells in response to environmental triggers
IgE antibodies bind to mast cells - degranulation
Release of cytokines, histamine, prostaglandins and leukotriens -> leads to bronchospasm - airway obstruction
Th2 lymphocytes - production of interleukins -> sustain inflammation
Leads to airway hypersensitivity and hyper-responsiveness
44
What are some common triggers of asthma attacks/worsening of asthma symptoms?
Infection
Nighttime and early morning
Exercise
Animals
Some medications (non-selective beta blockers e.g. propranolol, NSAIDs e.g. aspirin)
Cold air
Strong emotions
45
How do patients with asthma typically present?
Dry cough, often worse at night
SoB
Wheeze
Chest pain/tightness
Diurnal variation in symptoms (worse in the morning and at night)
Reversibility with bronchodilators
46
What are examination finding in asthma?
Can be normal if between attacks
Widespread polyphonic expiratory wheeze (NOT monophonic!)
47
What could a localised monophonic wheeze suggest?
Inhaled foreign body
Tumour
Mucus plug
48
What investigations are used when you suspect asthma?
Spirometry with bronchodilator reversibility
Fractional exhaled nitric oxide FeNO
Peak flow variability
Direct bronchial challenge test (inhaled histamine)
49
What will spirometry show in ashtma?
Obstructive picture
FEV1 significantly reduced
FEV1/FVC < 70%
50
What will a positive reversibility test show in asthma?
Increase in FEV1 of 12% or more
51
What will a positive FeNO test show in asthma?
40 ppb or higher
52
Why is FeNO used in asthma diagnosis?
NO is a marker of airway inflammation
53
How is peak flow variability measured?
Keeping a peak flow diary with readings at least 2x a day
For 2-4 weeks
54
What is a positive peak flow variability?
If peak flow variability is more than 20%
55
What classes of drugs are used in asthma? Give 1 example for each
Short-acting beta agonists (SABA) - salbutamol
Inhaled corticosteroids (ICS) - beclomethasone
Long-acting beta agonists (LABA) - salmeterol
Leukotriene receptor antagonists - monteleukast
Long-acting muscurinic receptor antagonists (LAMA) - tiotropium
Maintenance and reliever therapy (MART) - combination of ICS and fast-acting LABA (formoterol)
56
How does SABA (and LABA) work?
Adrenalin binds to beta 2 adrenergic receptors on smooth muscle in the airway. This leads to relaxation of the smooth muscle and bronchodilation.
SABA and LABA stimulate the same receptor and cause bronchodilation.
57
How does LAMA work?
block acetylcholine receptors, preventing contraction of bronchial smooth muscle, and leading to bronchodilation
58
Which medications aim to reduce the inflammation in the airways in asthma?
Inhaled corticosteroids (ICS) - e.g. beclomethasone
Leukotriene receptor antagonists - e.g. monteleukast
Theophylline - also caused bronchodilation
59
What is step 1 in asthma management?
SABA
60
What is step 2 in asthma management? When do you step up from step 1?
When not controlled on step 1 (symptoms 3+ times a week) OR new asthma with symptoms more than 3 times a week
SABA + ICS
61
What is step 3 in asthma management?
SABA + ICS + leukotriene receptor antagonist
62
What is step 4 in asthma management?
SABA + ICS + LABA (+/- LTRA - based on the response to LTRA)
63
What is step 5 in asthma management?
SABA + low-dose ICS MART (+/- LTRA)
64
What is step 6 in asthma management?
SABA + medium-dose ICS MART (+/- LTRA)
65
What is step 7 (final) in asthma management?
SABA +/- LTRA and either of the following:
- high-dose ICS (fixed dose, not MART)
- trial of an additional drug - e.g. LAMA (tiotropium), theophylline
- specialist management
66
What are the additional management recommendations in asthma?
individual self-management plan
yearly flu vaccination
yearly asthma review
regular exercise
avoid smoking
avoid triggers when possible
67
What are the three stages of acute asthma?
Moderate
Severe
Life-threatening
68
What are the features of acute asthma?
Progressive SoB
Use of accessory muscles
Tachypnoea
Cough
symptoms not improving with salbutamol
Symmetrical expiratory wheeze
Reduced air entry on auscultation
69
What are the features of moderate acute asthma?
PEFR of 50-75% best or predicted
able to complete sentences
RR < 25
HR < 110
70
What are the features of severe acute asthma?
PEFR of 33-50% best or predicted
unable to complete sentences
RR > 25
HR > 110
71
What are the features of life-threatening acute asthma?
PEFR of <33% best or predicted
O2 saturation <92%
Becoming fatigued
Absence of wheeze / silent chest
Cyanosis
Signs of shock
Confusion, agitation
Normal pCO2
72
What will ABG show initially in acute asthma?
respiratory alkalosis - hyperventilation will decrease pCO2
73
Why is respiratory acidosis a bad sign in acute asthma?
it means the pCO2 is high - patient very fatigued, almost stopping breathing
74
How is mild asthma exacerbation managed?
inhaled SABA via a spacer
quadrupled dose of ICS for up to 4 weeks
oral steroids (e.g. prednisolone) if ICS not adequate
ATB - if evidence of bacterial infection
follow-up within 48 hrs
75
How should moderate acute asthma be managed?
Hospital admission
Nebulised SABA
Steroids - oral prednisolone, IV hydrocortisone
76
How should severe exacerbation of asthma be managed?
Hospital admission
Oxygen to maintain pO2 >94%
salbutamol nebuliser
Nebulised ipratropium bromide
IV magnesium sulphate
IV salbutamol
IV aminophylline
77
How should life-threatening astma be managed?
"Oh Shit I Have Mad Asthma"
Hospital admission
Oxygen to maintain pO2 >94%
salbutamol nebuliser
Nebulised ipratropium bromide
IV magnesium sulphate
IV salbutamol
IV aminophylline
HDU/ICU admission
intubation and ventilation
78
What are criteria for discharge after an acute exacerbation of asthma?
stable on discharge medication (e.g. no oxygen, no nebulisers) for 12-24 hrs
checked and recorded inhaler technique
PEFR > 75% best or predicted
79
What do you need to monitor when administering IV salbutamol and why?
serum potassium - IV salbutamol can cause hypokalaemia as it promotes absorption of potassium from blood into cells
80
What is the management/follow up after an acute asthma exacerbation?
optimising long-term asthma management
individual self-management plan
rescue pack of oral steroids
specialist referral if 2 attacks in 12 months
81
What is obstructive lung disease? What are the findings on spirometry?
Asthma, COPD, bronchiectasis
FEV1 significantly reduced
FVC reduced or normal
FEV1/FVC - reduced
82
What is restrictive lung disease? What are the findings on spirometry?
pumonary fibrosis, obesity, asbestosis
FEV1 reduced
FVC significantly reduced
FEV1/FVC - normal or increased
83
What is COPD?
long-term respiratory condition involving airway obstruction, chronic bronchitis and emphysema
84
What are the common features of COPD?
productive cough
SoB
wheeze
signs of cor pulmonale can be seen
recurrent respiratory infections
winter exacerbations
85
What are some of the common signs of COPD?
tar staining
chest hyper-inflation
pursed lip breathing
use of accessory muscles of respiration
peripheral oedema
wheeze
crackles
86
What are the risk factors for COPD?
smoker / passive smoking
40+ y.o.
male
cannabis (COPD at younger age)
alpha 1 antitrypsin deficiency
87
What is Alpha-1 antitrypsin deficiency?
Inherited condition caused by a lack of protease inhibitor (produced by liver)
Protease inhibitor protects cells from elastase.
A1AT causes COPD in young non-smokers
88
What are some features of A1AT?
symptoms of COPD
abnormal LFTs - liver cirrhosis, hepatocellular carcinoma, cholestasis
89
What is Grade 1 on MRC Dyspnoea Scale?
SoB on strenuous exercise
90
What is Grade 2 on MRC Dyspnoea Scale?
SoB when walking uphill
91
What is Grade 3 on MRC Dyspnoea Scale?
SoB that slows walking on flat ground
92
What is Grade 4 on MRC Dyspnoea scale?
SoB stops them from walking more than 100m on flat ground
93
What is Grade 5 on MRC Dyspnoea Scale?
Too SoB to leave the house
94
What investigations are recommended in suspected COPD?
post-bronchodilator spirometry showing obstructive picture (FEV1/FVC <70%)
CXR
FBC - exclude secondary polycythaemia
BMI
CT thorax
alpha 1 antitrypsin - if young and non-smoker
ECG, echo - assess for cor pulmonale
TLCO - reduced
95
What will CXR show in COPD?
lung hyperinflation
bullous emphysema
flat hemidiaphragm
smaller heart size
horizontal ribs
96
What is Stage 1 COPD? What is the FEV1?
Mild - FEV1 > 80% predicted
97
What is Stage 2 COPD? What is the FEV1?
Moderate - FEV1 50-79% predicted
98
What is Stage 3 COPD? What is the FEV1?
Severe - FEV1 30-49% predicted
99
What is Stage 4 COPD? What is the FEV1?
Very severe - FEV < 30%
100
What is the gold standard investigation for COPD diagnosis?
spirometry post-bronchodilator
101
What is the long-term non-pharmacological management of COPD?
- smoking cessation
- annual vaccinations - influenza, pneumococcal
- physiotherapy, pulmonary rehabilitation
102
What smoking cessation drugs can be offered to COPD patients?
nicotine replacement therapy
varenicline - nicotinic partial agonist
bupropion - atypical antidepressant
103
What is step 1 in COPD treatment? Give examples of drugs
SABA (salbutamol) or SAMA (ipratropium)
104
How do you determine whether a COPD patient has asthmatic features?
Hx of asthma or atopy
increased eosinophil count
significant variation in FEV1 over time (>400ml)
significant diurnal variation in peak expiratory flow (>20%)
105
What is step 2 in COPD treatment in patients with asthmatic features?
SABA/SAMA as required
LABA + ICS combination - Symbicord, Seretide
106
What is an example of LABA + ICS combination inhaler?
Symbicord, Seretide, Fostair
107
What is step 2 in COPD treatment in patients without asthmatic features?
SABA as required (switch to SABA if on SAMA)
LABA + LAMA combination - Anoro Ellipta, DuaKlir Genuair
108
What is an example of LABA?
salmeterol, formoterol
109
What is an example of LAMA?
tiotropium, glycopyrronium
110
What is an example of SAMA?
ipratropium
111
What is step 3 (final) in inhaler therapy of COPD?
SABA as required (if using SAMA - switch to SABA)
combination of LAMA + LABA + ICS - Trimbow, Trellegy Ellipta, Trixeo
112
What is an example of combination of LAMA + LABA + ICS?
Trimbow, Trellegy Ellipta, Trixeo
113
What are some oral add-ons to COPD therapy?
theophylline
carbocysteine - mucolytic
corticosteroids - prednisolone
ATBs - azithromycin
PDE-4 inhibitor - e.g. roflumilast
114
What is the "rescue pack" in COPD?
short course of oral corticosteroids and antibiotics
offered if 1> exacerbation in the last year
115
What is important to do before and during treatment with azithromycin?
ECG - to rule out QT prolongation
LFTs - to assess liver function
116
When is long-term oxygen therapy offered to COPD patients?
- chronic hypoxia (<92% / 7.3 on air) - on 2 separate occasions
- secondary polycythaemia
- cyanosis
- cor pulmonale
117
What medication should be used in patients with cor pulmonale?
loop diuretics - e.g. furosemide
118
What are the most common infective causes of COPD exacerbation?
Bacterial - Haemophilus influenzae, Streptococcus pneumoniae
Viral - human rhinovirus
119
What are the features of acute COPD exacerbation?
choryzal symptoms
increase in SoB, cough, wheeze
increase in sputum - infective
120
What are the investigations in suspected acute COPD exacerbation?
CXR
gas exchange assessment
ECG
bloods
sputum culture
121
How do you manage acute COPD exacerbation?
if hypoxic - O2 therapy
- nebulised bronchodilator - salbutamol, ipratropium
- oral corticosteroids (prednisolone 30mg daily for 5 days)
- ATB - if positive sputum culture - amoxicillin, clarithromycin, doxycycline
122
What is the name, dose and duration of oral corticosteroids in acute COPD exacerbation?
prednisolone - 30mg once daily for 5 days
123
What additional treatment can you use in acute COPD exacerbation in secondary care?
- O2
- IV theophylline - if not responding to nebulised bronchodilators
- IV hydrocortisone (sometimes used instead of oral prednisolone)
- intubation and ventilation
124
When would you consider non-invasive ventilation?
- persistant respiratory acidosis despite maximal medical treatment
- potential to recover
- acceptable to the patient
125
What would raised bicarbonate on ABG suggest in a COPD patient?
chronic retention of CO2
126
What is the most common cause of pneumonia? What are other possible causes?
Bacterial is most common
Other causes include viral and fungal (e.g. Pneumocystis jirovecii)
127
What are the most common causative organisms of pneumonia?
Streptococcus pneumoniae
Klebsiella pneumoniae
Staphylococcus aureus
Haemophilus influenzae
128
What are some atypical causative organisms of pneumonia?
Mycoplasma pneumoniae
Legionella pneumophilia
Pneumocystis jirovecii
129
Which organism is typically seen in HIV patients presenting with pneumonia?
Pneumocystis jirovecii
130
Which organism is typically seen in COPD patients presenting with pneumonia?
Haemophilus influenzae
131
What is the typical presentation of pneumonia?
productive cough
haemoptysis
sputum production
SoB
chest pain (pleuritic)
fever
confusion
132
What are some examination signs of pneumonia?
systemic signs of inflammation - fever, tachycardia
reduced oxygen saturation
reduced breath sounds
bronchial breathing
dullness to percussion
focal coarse crackles
133
What investigations would you do if you suspect pneumonia?? And what results would you expect?
CXR - consolidation
FBC - neutrophilia
U&E - urea
CRP - raised
sputum cultures
ABG - if low O2 sats
134
What is the basic management of pneumonia?
antibiotics
IV fluids if dehydrated
O2 therapy if hypoxic
135
What scoring tool is used to assess severity of pneumonia in primary care?
CRB65
Confusion
Resp rate > 30
Blood pressure (systolic < 90 / diastolic < 60)
65+ y.o.
136
How is CRB65 used to stratify the risk?
Score 0: low risk - treatment at home
Score 1-2: intermediate risk (1-10% mortality risk) - consider hospital assessment
Score 3-4: high risk (10%+ mortality risk) - urgent hospital admission
137
What scoring tool is used to assess severity of pneumonia in secondary care?
CURB65
Confusion
Urea > 7mmol/L
Resp rate > 30
Blood pressure (systolic < 90 / diastolic < 60)
65+ y.o.
138
How is CURB65 used to stratify the risk?
Score 0-1: low risk - treatment at home
Score 2+: intermediate risk (3-15% mortality risk) - hospital-based care
Score 3+: high risk (15%+ mortality risk) - intensive care assessment
139
What is the management for low-severity CAP? (Medication)
5 day course of ATB
amoxicillin (macrolide or tetracycline if allergy)
140
What is the management of moderate and high severity pneumonia? (pharmaceutical)
dual ATB therapy - amoxicillin and macrolide
7-10 day course
141
What is hospital acquired pneumonia?
pneumonia that develops after more than 48 hours in a hospital
142
What will sputum culture of someone with tuberculosis show?
acid-fast bacilli that stain red with Zeihl-Neelsen stain
143
What can happen once M.tuberculosis is in the body?
1. immediate clearance of the bacteria
2. Primary active tuberculosis - active infection after exposure
3. Latent tuberculosis - presence of bacteria without being infectious or symptomatic
4. Secondary tuberculosis - reactivation of latent tuberculosis, usually due to immunosuppression
144
What is miliary tuberculosis?
disseminated and severe form of active tuberculosis
145
What are the risk factors for tuberculosis?
close contact with active tuberculosis
immigration from area with high TB prevalence
immunocompromised - HIV, immunosuppressant medications
malnutrition
homeless
drugs
146
What is the Mantoux test?
injection of tuberculin (collection of TB proteins) into intradermal space on the forearm
Test is read after 72 hrs
Positive - induration of 5+mm
147
How does tuberculosis typically present?
symptoms are usually chronic and gradually worsening
cough
haemoptysis
lethargy
fever
night sweats
weight loss
lymphadenopathy
erythema nodosum
cold abscess (in the neck)
spinal pain
148
What is the typical onset and progression of TB symptoms?
symptoms are usually chronic and gradually worsening
149
What is pleuritic chest pain?
worse when inhaling/breathing
150
What is pneumothorax?
air entering the pleural space, separating the lung from the chest wall
151
Tall, thin young male presents with sudden SoB and pleuritic chest pain. What is the likely cause?
pneumothorax
152
What is the classification of pneumothoraces based on the cause?
Spontaneous (primary and secondary)
Trauma
Iatrogenic (e.g. due to lung biopsy, mechanical ventilation or central line insertion)
153
What is primary spontaneous pneumothorax?
without underlying lung disease, often in tall, thin, young individuals
associated with the rupture of subpleural blebs or bullae
154
What is secondary spontaneous pneumothorax?
in patients with pre-existing lung disease, such as COPD, asthma, cystic fibrosis, lung cancer, Pneumocystis pneumonia
certain connective tissue diseases such as Marfan's syndrome are also a risk factor
155
What are the main signs and symptoms of pneumothorax? (Hx and exam findings)
SoB
(pleuritic) chest pain
hyper-resonant on percussion
reduced breath sounds
reduced lung expansion
tachypnoea
tachycardia
156
What are some additional signs and symptoms of a tension pneumothorax?
respiratory distress
tracheal deviation away from the side of the pneumothorax
hypotension
157
What is the management of tension pneumothorax?
needle thoracostomy - inserting a cannula into the second intercostal space in the midclavicular line on the affected side
followed by the placement of a chest drain (tube thoracostomy) in the safe triangle of the chest
158
How are patients with pneumothorax with no or minimal symptoms managed?
conservative management
159
What are "high risk" characteristics in pneumothorax?
haemodynamic compromise (suggests tension pneumothorax)
significant hypoxia
bilateral pneumothorax
underlying lung disease
haemothorax
160
How are patients with pneumothorax with high-risk characteristics managed?
if safe to intervene -> chest drain
161
How are patients with pneumothorax without high-risk characteristics managed?
if not safe to intervene -> conservative management
if safe to intervene -> depends on patient's main priority:
if procedure avoidance: conservative care
if rapid symptom relief as outpatient: pleural vent ambulatory device
if rapid symptom relief with short-term drainage: needle aspiration / chest drain
162
What is pleural vent ambulatory device?
catheter inserted into the pleural space attached to a device stuck to the upper chest
allows air to exit, but not to enter
patient can wear it as an outpatient until the pneumothorax has resolved
163
What is the triangle of safety? What are the borders?
place where chest drains are inserted
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)
164
How do you know a chest drain for pneumothorax is working?
bubbling (will disappear when pneumothorax resolves)
swinging of the water in the drain with respiration
CXR - to check positioning
165
What are the two main complications of chest drains?
air leaks around the drain site
surgical emphysema
166
When is surgical management required in patients with pneumothorax?
if chest drain fails to correct the pneumothorax
if there is a persistent air leak in the drain
if it's a recurrent pneumothorax
167
What is the surgical procedure to correct a pneumothorax?
VATS - video assisted thoracoscopic surgery
- abrasive pleurodesis - direct physical irritation of pleura
- chemical pleurodesis - using chemicals to irritate the pleura
- pleurectomy - removal of pleura
168
What is pleurodesis? Why is it performed?
creating an inflammatory reaction in the pleural lining so the pleura sticks together and the pleural space becomes sealed
prevents further pneumothoraces from developing.
169
What organism does commonly cause pneumonia with upper lobe cavitations, and is more common in diabetics and alcoholics?
klebsiella pneumoniae
170
What is pulmonary hypertension?
increased resistance and pressure in the pulmonary arteries
mean pulmonary arterial pressure > 20mmHg
171
What is the complication of pulmonary hypertension?
causes right sided heart strain - back pressure into the venous system
172
What are the causes of pulmonary hypertension?
idiopathic / connective tissue disease
left heart failure - due to MI/systemic HTN
chronic lung disease - e.g. COPD
pulmonary vascular disease - e.g. PE
others - e.g. sarcoidosis
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What are the signs and symptoms of pulmonary hypertension?
SoB
syncope
tachycardia
raised JVP
hepatomegaly
peripheral oedema
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How is pulmonary hypertension investigated?
ECG - shows signs of right heart strain
CXR
raised NT-proBNP
echocardiogram
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What will ECG show in pulmonary hypertension?
signs of right sided heart strain:
- P pulmonale (peaked P waves)
- RV hypertrophy (tall R in V1,2 ; deep S in V5,6)
- R axis deviation
- R bundle branch block
176
What will CXR show in pulmonary hypertension?
dilated pulmonary arteries
RV hypertrophy
177
What is the prognosis in idiopathic pulmonary hypertension?
2-3 years after diagnosis if untreated
178
How is idiopathic pulmonary hypertension treated?
Calcium channel blockers
Intravenous prostaglandins (e.g., epoprostenol)
Endothelin receptor antagonists (e.g., macitentan)
Phosphodiesterase-5 inhibitors (e.g., sildenafil)
179
How is secondary pulmonary hypertension managed?
treating the cause
supportive treatments - oxygen therapy, diuretics
180
If needle aspiration of pneumothorax is unsuccessful, what is the next step?
chest drain
181
What is CPAP? When is it used?
Continuous positive airway pressure
treatment for obstructive sleep apnoea
182
What is BiPAP? When is it used?
Bilevel positive airway pressure
form of non-invasive ventilation
183
What are the causes of upper zone lung fibrosis?
CHARTS
C - Coal worker's pneumoconiosis
H - Histiocytosis/ hypersensitivity pneumonitis
A - Ankylosing spondylitis
R - Radiation
T - Tuberculosis
S - Silicosis/sarcoidosis
184
What smoking cessation therapy is appropriate in pregnant women? Which is contraindicated?
appropriate - nicotine replacement therapy
contraindicated - varenicline, bupropion
185
What is allergic bronchopulmonary aspergillosis?
result of allergy to Aspergillus spores
can have Hx of bronchiectasis and eosinophilia
186
What are the features of allergic bronchopulmonary aspergillosis?
bronchoconstriction - wheeze, cough, dyspnoea, possible Hx of asthma
(proximal) bronchiectasis
187
What will investigations show in allergic bronchopulmonary aspergillosis?
eosinophilia
CXR changes
positive RAST test to Aspergillus
positive IgG precipitins
raised IgE
188
How is allergic bronchopulmonary aspergillosis managed?
oral glucocorticoids
second-line - itraconazole (antifungal)
189
What are some predisposing factors for obstructive sleep apnoea?
obesity
macroglossia - acromegaly, hypothyroidism, amyloidosis
large tonsils
Marfan's
190
What are some features of obstructive sleep apnoea?
excessive snoring
periods of apnoea
results in:
daytime somnolence
compensated respiratory acidosis
HTN
191
What are the diagnostic tests for obstructive sleep apnoea?
sleep studies (polysomnography) - ECG, respiratory airflow, thoraco-abdominal movement, snoring, pulse oximetry
192
How is obstructive sleep apnoea managed?
weight loss
CPAP
intra-oral devices (e.g. mandibular advancement) - if not tolerating CPAP, no daytime sleepiness
inform DVLA if severe daytime sleepiness
193
What is silicosis?
type of interstitial (fibrosing) lung disease
due to inhalation of silica
risk factor for TB
194
What are the risk factors for silicosis?
occupational exposures:
mining
slate works
foundries
pottery
195
What are the features of silicosis?
symptoms of fibrosis
upper zone fibrosing lung disease on CXR
egg-shell calcification of hilar lymph nodes on CXR
196
What follow up should be organised for patients with pneumonia? and when?
CXR 6 weeks after resolution
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