RESPIRATORY Flashcards
PNEUMONIA
Name 3 pathogens that can cause community acquired pneumonia (CAP)
- Streptococcus pneumoniae (most common)
- Haemophilus influenzae
- s.aureus
PNEUMONIA
Name 3 pathogens that can cause hospital acquired pneumonia (HAP)
mainly gram negative
- Pseudomonas aeruginosa
- E.coli
- Staphylococcus aureus
PNEUMONIA
What is the treatment for someone with Legionella pneumoniae?
Fluoroquinolone + clarithromycin
PNEUMONIA
What is the treatment for someone with Pseudomonas aeruginosa pneumonia?
IV ceftazidime + gentamicin
BRONCHIECTASIS
What can cause bronchiectasis?
- Congenital = Cystic fibrosis
- Idiopathic (50%)
- Post infection - (most common)
- pneumonia,
- TB,
- whopping cough
- Bronchial obstruction
- RA
- Hypogammaglobulinaemia
BRONCHIECTASIS
Which bacteria might cause bronchiectasis?
- Haemophilus influenza (children)
- Pseudomonas aeruginosa (adults)
- Staphylococcus aureus (neonates often)
BRONCHIECTASIS
what are the symptoms of bronchiectasis?
- Chronic productive cough
- Purulent sputum
- Intermittent haemoptysis
- Dyspnoea
- Fever, weight loss
BRONCHIECTASIS
what are the signs of bronchiectasis?
- Finger clubbing
- Coarse inspiratory crepitate (crackles)
- Wheeze
- rhonchi (low-pitched snore-like sound)
BRONCHIECTASIS
what are the investigations?
CXR - dilated airways with thickened walls (tram-tracks)
High resolution CT (gold standard) - bronchial dilation + wall thickening
sputum cultures
FBC
spirometry - obstructive pattern (FEV1/FVC <70%)
Describe the treatment for bronchiectasis
1st line
- treat underlying cause
- chest physio
- annual flu vaccine
- antibiotics ofr exacerbations
2nd line
- mucoactive agent (carbocisteine)
- bronchodilator
- nebulised isotonic/hypertonic saline
- long term antbiotics (azithromycin)
long term oxygen
LUNG CANCER
which cancers most commonly metastasise to the lungs?
breast
bowel
kidney
bladder
LUNG CANCER
Give examples of paraneoplastic syndromes due to lung cancer
- ↑PTH -> Hyperparathyroidism
- ↑ADH -> SIADH
- ↑ACTH -> Cushing’s disease
- lambert-eaton myasthenic syndrome
ASTHMA
What are the signs of a life threatening asthma attack?
- Hypoxia = PaO2 <8 kPa, SaO2 <92%
- Silent chest
- Bradycardia
- Confusion
- PEFR < 33% predicted
- Cyanosis
ASTHMA
What is the long-term guideline mediation regime for asthma?
- low dose ICS/formoterol combination inhaler (AIR therapy) or if very symptomatic start low dose MART
- low dose MART
- moderate dose MART
- check FeNO + eosinophil level (if either is raised, refer to specialist).
- If neither are raised = LTRA or LAMA in addition to moderate dose MART
- if still not controlled, stop LTRA or LAMA and try other drug option (LTRA/LAMA) - refer to specialist
COPD
What can cause COPD?
- Genetic = alpha 1 antitrypsin deficiency
- Smoking = major cause
- Air pollution
- Occupational factors = dust, chemicals
COPD
Give 4 signs of COPD
- Tachypnoea
- Barrel shaped chest
- Hyperinflantion
- Cyanosis
- Pulmonary hypertension
- Cor pulmonale
COPD
What investigations might you do to diagnose someone with COPD?
Spirometry = FEV1:FVC < 0.7
CXR = hyperinflation, bullae, flat hemi-diaphragms, large pulmonary arteries
CT = Bronchial wall thickening, enlarged air spaces
ECG = RA and RV hypertrophy
ABG = decreased PaO2 +/- hypercapnia
COPD
What are the treatments for COPD?
- SABA or SAMA as required
if NO asthmatic features:
2. SABA as required, LABA + LAMA regularly
if asthmatic features:
2. SABA or SAMA as required, LABA + ICS regularly
- SABA as required, LABA + LAMA + ICS regularly
PLEURAL EFFUSION
what are the causes of a transudate pleural effusion?
fluid movement (systemic causes)
- Heart failure
- fluid overload
- Peritoneal dialysis
- Constrictive pericarditis
- hypoproteinaemia
- cirrhosis
- hypoaluminaemia
- nephrotic syndrome
PLEURAL EFFUSION
Name 3 causes of a exudate pleural effusion
inflammatory (local causes)
- Pneumonia
- Malignancy
- TB
- pulmonary infarction
- lymphoma
- mesothelioma
- asbestos exposure
- MI
PNEUMOTHORAX
What is the treatment for a primary pneumothorax?
PRIMARY
- small (<2cm) + asymptomatic = consider discharge
- if >2cm or breathless = aspirate with 16-18G needle
- if successful consider discharge + follow-up
- If unsuccessful insert chest drain + admit
SARCOIDOSIS
what are the symptoms?
- non-productive cough
- gradual onset dyspnoea
- polyarthralgia
- uveitis (red eye, photophobia)
- fever
- fatigue
- weight loss
SARCOIDOSIS
How can you stage sarcoidosis?
Using CXR
Stage 1 = bilateral hilar lymphadenopathy (BHL)
Stage 2 = pulmonary infiltrates with BHL
Stage 3 = pulmonary infiltrates without BHL
Stage 4 = progressive pulmonary fibrosis, bulla formation and bronchiectasis
SARCOIDOSIS
How do you treat sarcoidosis?
asymptomatic non-progressive = observation
symptomatic or progressive = 1st line - corticosteroids, 2nd line - immunosuppressants
IDIOPATHIC PULMONARY FIBROSIS
what are the risk factors of idiopathic pulmonary fibrosis?
- cigarette smoking
- infectious agents - CMV, Hep C, EBV
- occupational dust exposure
- drugs - methotrexate, imipramine
- GORD
- genetic predisposition
IDIOPATHIC PULMONARY FIBROSIS
What is the treatment for idiopathic pulmonary fibrosis?
SUPPORTIVE CARE
- pulmonary rehab
- long term oxygen
- pneumonia + flu vaccines
ANTI-FIBROTIC AGENTS
- pirifenidone
- nintedanib
LUNG TRANSPLANTATION
PULMONARY HYPERTENSION
what are the causes of pulmonary hypertension
- pre-capillary
- multiple small PE’s
- left-to-right shunts
- primary
- capillary
- emphysema
- COPD
- Post-capillary
- backlog of blood causes secondary hypertension
- LV failure
- chronic hypoxaemia
- living at high altitude
- COPD
PULMONARY HYPERTENSION
What are the investigations?
Initial tests:
- CXR - Enlarged main pulmonary artery, enlarged hilar vessels and pruning.
- ECG - right ventricular hypertrophy,right axis deviation, right atrial enlargement. (A normal ECG does not rule out the presence of significant pulmonary hypertension)
- TTE - (trans-thoracic echocardiogram)
Diagnostic test: Right heart catheterisation
PULMONARY HYPERTENSION
Describe the treatment of pulmonary hypertension
1st line
- CCBs
- pulmonary vasodilators e.g. prostacyclin, sildenafil
- diuretics
- oxygen therapy
- anticoagulation (warfarin or NOAC)
2nd line
- lung transplant
- balloon atrial septostomy
TB
Give 2 potential side effects of Pyrazinamide
- Hepatitis
- Gout
- Neuropathy
PLEURAL EFFUSION
what are the risk factors for pleural effusion?
- Previous lung damage
- Asbestos exposure
PNEUMOTHORAX
what are the risk factors for pneumothorax?
Smoking
Family history
Male
Tall and slender build
Young age
Presence of underlying lung disease
PNEUMONIA
which bacteria causes rusty sputum in pneumonia?
strep pneumoniae
PNEUMONIA
what are the common organisms that cause atypical pneumonia?
Mycoplasma pneumoniae,
Chlamydophila pneumoniae,
Legionella pneumophila
coxiella burnetii
BRONCHIECTASIS
what antibiotics are used for bronchiectasis?
- pseudomonas aeruginosa = oral ciprofloxacin
- h.influenzae = oral amoxycillin, co-amoxyclav or doxycycline
- staph aureus = flucloxacillin
LUNG CANCER
where does squamous cell carcinoma of the lung arise from?
- epithelial cells typically in the central bronchus
LUNG CANCER
where does adenocarcinoma arise from?
mucus-secreting glandular cells
ASTHMA
which drugs can trigger asthma attacks?
NSAIDs and aspirin
beta blockers - results in bronchoconstriction which results in airflow limitation and potential attack
PHARMACOLOGY
give 2 examples of LABAs
- salmeterol
- formoterol (full agonist)
PHARMACOLOGY
give an example of a SAMA
ipratropium
PHARMACOLOGY
give an example of a LAMA
tiotropium
PHARMACOLOGY
what are the side effects of ICS?
Loss of bone density
Adrenal suppression
Cataracts
Glaucoma
LUNG CANCER
what are the extra-pulmonary manifestations of lung cancer?
Recurrent laryngeal nerve palsy - hoarse voice
Superior vena cava obstruction - facial swelling, distended veins in neck and upper chest, Pemberton’s sign
Horner’s syndrome - ptosis, miosis, anhidrosis
PNEUMONIA
which bacteria is associated with causing pneumonia in COPD patients?
h.influenzae
PNEUMONIA
which bacteria is associated with aspiration pneumonia?
klebsiella pneumoniae
PNEUMONIA
what is the management of HAP?
low severity = oral co-amoxiclav
high severity = broad spectrum abx (IV tazocin or ceftriaxone)
CYSTIC FIBROSIS
how does orkambi work?
- LUMACAFTOR - increases number of CFTR proteins transported to cell membranes
- IVACAFTOR - potentiates CFTR proteins on cell surface, increases chance channel will open
ASTHMA
what is the management of a severe/life-threatening asthma exacerbation?
- oxygen
- nebulised bronchodilator (salbutamol)
- corticosteroid (40-50mg prednisolone)
- ipratropium bromide
- IV magnesium sulfate
- IV aminophylline
PNEUMOTHORAX
what is the management for a secondary spontaneous pneumothorax?
SMALL (1-2cm)
- aspirate with 16-18G needle
- admit with high flow oxygen
LARGE (>2cm) or breathless
- insert chest drain
- admit with high flow oxygen
PNEUMOTHORAX
where is the needle for aspiration of a spontaneous pneumothorax placed?
- 2nd intercostal space midclavicular line
PNEUMOTHORAX
what are the indications for surgical management?
- 2nd ipsilateral pneumothorax
- 1st contralateral pneumothorax
- bilateral spontaneous pnemothorax
- persistent air leak after 5-7 days chest drain
- pregnancy
- at risk profession e.g. pilots + divers
SARCOIDOSIS
what are the signs?
- cervical + submandibular lymphadenopathy
- lupus pernio (lupus-type rash)
- erythema nodosum (dusky coloured nodules on shins)
PULMONARY HYPERTENSION
what are the signs?
- right parasternal heave
- loud 2nd heart sound
- pulmonary or tricuspid regurgitation
- raised JVP
- signs of underlying condition
PNEUMOCONIOSIS
what is the pathophysiology?
- when dust particles are inhaled, they reach terminal bronchioles + are ingested by interstitial + alveolar macrophages
- dust particles are carried by macrophages + expelled as mucus
- if exposed for a long time these systems no longer function
- macrophages accumulate in alveoli resulting in immune system activation + lung tissue damage
PNEUMOCONIOSIS
what are the different types?
- coal workers pneumoconiosis (coal miners)
- silicosis (quarry workers, silica miners)
- berylliosis (aerospace industry, beryllium miners)
- asbestosis (construction workers, plumbers)
PNEUMOCONIOSIS
what are the investigations?
- CXR - opacities in upper lobes, eggshell calcification of hilar lymph nodes
- SPIROMETRY - restrictive pattern (FEV1/FVC>0.7)
- HIGH RESOLUTION CT CHEST - interstitial fibrosis
PNEUMOCONIOSIS
how is it staged?
using CXR
- 0 = small rounded opacities absent
- 1 = small rounded opacities but few in number
- 2 = numerous small rounded opacities but normal lung markings
-3 = numerous small rounded opacities + obscured lung markings
PNEUMOCONIOSIS
what is the management?
- smoking cessation
- avoidance of exposure
- pulmonary rehab
- supplementary oxygen
- corticosteroids
- lung transplant
HYPERSENTIVITY PNEUMONITIS
what is it?
type III + IV hypersensitivity reaction to an environmental allergen
HYPERSENTIVITY PNEUMONITIS
give some examples of causes
- bird fanciers lung (bird droppings)
- farmers lung (mould spores in hay)
- mushroom workers lung (mushroom antigens)
- malt workers lung (mould on barley)
HYPERSENTIVITY PNEUMONITIS
what are the investigations?
- bronchoalveolar lavage = raised lymphocytes
HYPERSENTIVITY PNEUMONITIS
what is the management?
- removal of allergen
- oxygen
- corticosteroids
RESPIRATORY FAILURE
what are the causes of type 1 respiratory failure?
- pneumonia
- heart failure
- asthma
- PE
- high altitude pulmonary oedema
RESPIRATORY FAILURE
what are the causes of type 2 respiratory failure?
- opiate toxicity
- iatrogenic
- neuromuscular disease (MND, GBS)
- reduced chest wall compliance (Obesity)
- increased airway resistance (COPD)
INFLUENZA
what is the management?
- not treatment required for majority
- if at risk or have severe flu, offer anti-virals (zanamivir, oseltamivir)
ACUTE BRONCHITIS
what is the management?
- analgesia
- good fluid intake
- antibiotics (DOXYCYCLINE (or AMOXICILLIN if contraindicated))
consider antibiotics if:
- systemically unwell
- have pre-existing co-morbidities
- delayed abx prescription if CRP 20-100
- immediate abx if CRP >100
PLEURAL EFFUSION
what is the light’s criteria?
exudate is likely if:
- pleural fluid to serum protein ratio >0.5
- pleural fluid LDH to serum LDH ratio >0.6
- pleural fluid LDH >2/3 upper limits of normal serum LDH
PLEURAL EFFUSION
what does low glucose in pleural fluid indicate?
- rheumatoid arthritis
- tuberculosis
PLEURAL EFFUSION
what does a raised amylase in pleural fluid indicate?
- pancreatitis
- oesophageal perforation
PLEURAL EFFUSION
what does heavy blood staining in pleural fluid indicate?
- mesothelioma
- PE
- tuberculosis
PLEURAL EFFUSION
what are the indications of a pleural infection?
- purulent or turbid/cloudy fluid
- clear fluid but pH <7.2 (chest drain must be inserted)
PULMONARY FIBROSIS
what are the causes of upper lobe pulmonary fibrosis?
SCART
- sarcoidosis
- coal miners pneumoconiosis
- ankylosing spondylitis
- radiation
- TB
PULMONARY FIBROSIS
what are the causes of lower lobe pulmonary fibrosis?
RASIO
- Rheumatoid
- Asbestosis
- Scleroderma
- Idiopathic pulmonary fibrosis (most common)
- other
COPD
what is the criteria for LTOT?
pO2 <7.3
pO2 7.3-8kPa and one of the following:
- secondary polycythaemia
- peripheral oedema
- pulmonary hypertension
do not offer LTOT to people who continue to smoke despite being offered smoking cessation
PNEUMONIA
what is the most common cause of pneumonia in alcoholics?
klebsiella
ASTHMA
what are the investigations for asthma in adults?
1st line = FeNO or eosinophil levels
2nd line = bronchodilator reversibility with spirometry
3rd line = peak expiratory flow variability
4th line = skin prick or total IgE
ASTHMA
what are the investigations for asthma in children aged 5-16?
1st line = FeNO (asthma = >35)
2nd line = bronchodilator reversibility with spirometry
3rd line = peak expiratory flow variability
4th line = skin prick or total IgE
if still in doubt = bronchial challenge test
ASTHMA
what are the 3 drugs and their doses that should be immediately administered in an acute asthma exacerbation?
- oxygen - 15L via non-rebreather
- salbutamol nebuliser 2.5-5mg
- IV hydrocortisone 20mg or 40-50mg oral prednisolone
LUNG CANCER
what paraneoplastic features are associated with small cell lung cancer?
- ADH
- ACTH (cushing’s)
- Lambert Eaton syndrome
LUNG CANCER
what are the paraneoplastic features of squamous cell lung cancer?
- parathyroid hormone-related protein (PTH-rp)
- clubbing
- hypertrophic pulmonary osteoarthropathy (HPOA)
- hyperthyroidism
LUNG CANCER
what are the paraneoplastic features of adenocarcinoma lung cancer?
- gynaecomastia
- hypertrophic pulmonary osteoarthropathy (HPOA)
COPD
how is a mild exacerbation of COPD managed?
- increase bronchodilator use + consider nebuliser
- 30mg oral prednisolone for 5 days
- only give antibiotics if sputum is purulent or signs of infection
- 1st line abx = amoxicillin, clarithromycin or doxycycline
PNEUMONIA
what are the CURB65 criteria?
C = confusion
U = urea >7
R = resp rate >30
B = BP systolic <90, diastolic <60
65 = >65
