Respiratory Flashcards
Chlamydia Psittaci
- Treatment (1st Line and 2nd Line)
- How does it Present ?
1st Line = Doxycycline
2nd Line = Macrolides
Severe Pneumonia + Headaches + Organomegaly + Failure to respond to PENICILLIN base Antibiotics
Cystic Fibrosis Gene and Mutation
Delta F508 Deletion in Long Arm of Chromosome 7
Organisms that Colonize Cystic Fibrosis Patients ?
- Staphylococcus Aureus
- Pseudomonas Aeruginosa
- Burkholderia cepacia
- Aspergillus
pH<7.2 - Indication for placement of chest tube in Pleural Effusion.
PH <7.35 - Indication for ventilation and intubation in Asthma.
PO2<7.3 - Indication for LTOT.
FEV1 <1.5 - Contraindication for lung cancer resection
PaO₂ < 9.3 kPa in PCP - add corticosteroids in Tx.
Cystic Fibrosis Treatment
- Chest Physio
- High Fat diet
- Minimize Contact with other CF patients
- Creon
- Lumacaftor (More CFTR) /Ivacaftor (Potentiate existing CFTR) (Orkambi)
Contraindication for Lung Transplant in Cystic Fibrosis
Burkholderia cepacia
What type of Ventilation in :
COPD with Acidosis ?
T1RF
T2RF
NIV
CPAP
BiPAP
Allergic BronchoPulmonary Aspergillosis
- Treatment
- Features
- Corticosteroids
- Raised IgE + Eosinophilia + Positive IgG precipitins
(NOT as positive as in aspergilloma)
Recurrent Chest Infections and NOT RESPONDING TO ASTHMA TREATMENT
What is the X ray finding for ABPA ?
Fitting CXR - transient migratory pulmonary infiltrates
PROXIMAL Bronchiectasis
Panacinar vs Centri acinar in COPD
Aetiology
Centri-Acinar in Smokers and Coal Worker Pneumoconiosis
Panacinar - Alpha-1- Antitrypsin Deficiency
Causes of Bronchiectasis
‘A SICK AIRWAY’
Airway obstruction/ lesion
Sequestration
Infection/Inflammation
Cystic Fibrosis
Kartagener’ s Syndrome
ABPA
Immunodeficiencies(Hypogammaglobinemia,Myeloma,
Selective igA deficiency,Lymphoma )
William Campbell Syndrome
Aspiration
Yellow Nail Syndrome/Young Syndrome
Tram Track Sign on X ray defined as ?
Dilated Bronchi with Thickened Walls in the Lower Zone
Common Organism to colonize in CF
Psuedomonas in ADULTS
S.Aureus in CHILDREN
Most Common Organisms Colonizing Bronchiectasis patients
- Haemophilus influenzae
- Pseudomonas aeruginosa (Long History and PPI Use associated)
- Klebsiella spp.
- Streptococcus pneumoniae
Mnemonic for Upper Lobe Fibrosis
A TEA SHOP
ABPA
TB
Extrinsic Alveolar Alveolitis
AS
Sarcoidosis
Histiocytosis
Occupational (Silicosis and Berylliosis)
Coal Worker Pneumoconeosis
Mnemonic for Lower Lobe Fibrosis
IPAS-BM
Infection
A
Aspiration
Alpha 1 Antitrypsin
Asbestosis
S
Systemic Sclerosis
RA
Bronchiectasis
Medications - Busulfan Bleomycin Nitrofurantoin Hydralazine Methotrexate Amiodarone
or SCAR
Systemic Sclerosis
Cryptogenic Fibrosing Alveolitis (IPF)
Asbestosis
RA
Smoking Cessation
Varenicline - a nicotinic receptor partial agonist
Start 1 week before Target Stop Date
Start 1 week before Target to Stop Date and 12 weeks course (Only continued if stop attempted)
SELF HARM or SUICIDAL BEHAVIOR CONTRAINDICATED
Bupropion -
norepinephrine-dopamine reuptake inhibitor and nicotinic antagonist
Start 1 to 2 weeks before Target Stop Date
Seizures Risk –> CONTRAINDICATED IN EPILEPSY
Smoking Cessation in Pregnancy
Varenicline and Bupropion CONTRAINDICATED
Give CBT and Motivational Interviewing
Meigs Syndrome Triad ?
Ascites + Pleural Effusion, + Benign Ovarian Tumor
Right Sided Pleural Pneumothorax + Menstruating Women Think What ?
Catamenial Pneumothorax
Mnemonic for Pleural Cavities
CAVITY
Cancer - Lung SCC
Autoimmune -
RA , Wagener’s Granulomatosis
Vascular - Bland and Septic Emboli
Infection - PTB, Pulmonary Abscess
Trauma - Pneumatocele
Youth -
Congenital Airway Malformations
Bronchogenic Cysts
Red Flags for Chest Drain insertion ?
Hemodynamic Compromise
Severe Hypoxia
Bilateral Pneumothorax
Underlying Lung Disease
> /50 with Significant Smoking History
Hemopneumothorax
Discharge Advice for Patients treated for Pneumothorax
Scuba Diving - NEVER unless B/L Pleurectomy + Normal CT and PFT
Flying - 1 week post check X ray
LTOT offered in COPD if ?
2 ABG showing PO2<7.3
3 weeks apart
What type of Lung Cancer is Associated with Non Smokers ?
Adeno Carcinoma
Difference between Biopsy for EAA vs Sarcoidosis
EAA - Non Caseating Granuloma BUT LESS DENSE AND LESS DEFINED
Sarcoidosis - Non Caseating Granuloma BUT MORE DENSE AND DEFINED
EAA
- Pathophysiology
- Radiological Findings
- Clinical Progression
- Treatment
- Not IgE associated
Not Eosinophilia Associated
No Type 1 HSN
Acute (Type 3) and Chronic (Type 4) vs ABPA (TYPE 2)
- Upper / Middle Lobe Fibrosis
Honey Combing
Ground Glass - Fibrosis then Respiratory Failure then Hypoxemia
- Avoidance
Oral Glucocorticoids
Byssinosis
What exposure ?
Cotton / Flax / Textile
Monday Chest Tightness
Silo Fillers Lung
What Exposure ?
Nitric Oxide from Grain Dust in Silos
Type 1 HSN so Not EAA
When to give steroids in Sarcoidosis
Symptomatic + Stage II/III
Hypercalcemia
Ocular Neuro or Cardiac Involvement
In EAA Farmers Lung makes you have Emphysema (Obstructive Picture) but Bird Farmers Lung causes Fibrosis (Restrictive Picture)
So in EAA both Restrictive and Obstructive Picture can be seen
REMEMBER THIS
Pleural Plaques in Asbestosis are BENIGN
They increase risk of Pleural Effusion NOT MESOTHELIOMA
Remember this point
Inspiratory Capacity = ?
Functional Residual Capacity = ?
Residual Volume = ?
Expiratory Reserve Volume (ERV) Reduced by What ?
Vital Capacity = ?
Total Lung Capacity = ?
Tidal Volume + Inpiratory Reserve Volume
Expiratory Reserve Volume + Residual Volume
FRC - ERV
Obesity
Inspiratory Capacity + ERV
Treatment for IPF
Pulmonary Rehabilitation
Breathless on Exertion –> LTOT
Vaccinate Pneumococcus and Influenza
If FVC<50-80% = Antifibrinolytics
Radiological Findings
Stage 1: Lower zone lung opacification
Stage 2: Ground glass
Stage 3: Honeycomb
Causes of Exudative vs Transudative Pleural Effusion ?
Exudative
Malignancy
Pneumonia and Parapneumonic Effusions
Pancreatitis
Autoimmune ( RA Churgg Straus Pleurisy)
Post MI
Transudative
CHF Cirrhosis Nephrotic Syndrome
Peritoneal Dialysis
PE
Hypothyroidism
Lights Criteria
Exudative if 1 of
Pleural LDH/ Serum LDH >0.6
Pleural Protein/Serum Protein >0.5
Pleural LDH >2/3rd upper limit of Serum LDH
Why does HAPE and HACE occur ?
HAPE - High Altitude Pulmonary Edema
Uneven Pulmonary Vasoconstriction from Hypobaric Hypoxia
HACE - High Altitude Cerebral Vasodilation
Treatment for HACE and HAPE
HAPE
Descent and Oxygen
Nifedipine , Dexamethasone, Acetazolamide
PDE5i
HACE
Descent
Dexamethasone
Acute Mountain Sickness Preventative and Treatment
Acetazolamide -
Preventative by creating a primary metabolic acidosis and compensatory respiratory alkalosis –> improving RR
Treatment is DESCENT
Where is NIV not indicated ?
Bronchiectasis (a Trial only at best)
Limited by excessive secretions
Oxygen Dissociation Curve Mnemonic ?
Left Shift - We have LEFT the tissue behind (Cells hold onto Hb)
Right Shift - Giving Oxygen to Tissues
Causes of Right and Left Shift in Oxygen Dissociation Curve
Right Shift (CADET)
Raised PCO2
Raised Acid
Raised 2,3-DPG
Raised Temperature
Left Shift
Low (ABOVE 5)
Hb F
Met Hb
Carboxyhemoglobin
Examples of Hemoglobin Structural Changes that make LEFT SHIFT
Changes to Heme Affinity -
Hb Kempsey (β99 Asp→Asn) - INCREASED O2 Affinity
Changes to Allosteric Regulators like 2,3-DPG
- Hb Rainier (β145 Tyr→His) - INCREASED O2 Affinity by making Hb more sensitive to regulators
HbS (Valine to Glutamate at C6)
Causes of Respiratory Alkalosis
Hyperventilation
PE (+ REDUCED PaO2)
Altitude
Pregnancy
CNS - Stoke Encephalitis SAH
Salicylate Poisoning (Early Resp alkalosis –> Metabolic Acidosis)
What causes a Raised TLCO ?
Watch Medicosis Video)
PELHAM for raised TLCO
P ulmonary haemorrhage, polycythaemia
E xercise
L eft to Right shunts
H yperkinetic states
A sthma (Late Stage Neovascularization)
M ale gender
Reduced DLCO
Reduced Perfusion
Systolic HF
Anaemia
Pulmonary Embolism
PAH (Narrowed)
Systemic Sclerosis (Damage to Pulmonary Artery)
ASBESTOSIS
Decreased Perfusion
INTRINSIC Restrictive Lung Disease
Medications
Emphysema
Dyspnea + Obstructive Pattern + RA = >
Bronchiolitis Obliterans
How does Bronchiolitis Obliterans Appear on CT
Centrilobular Nodules with Bronchial wall Thickening
Conditions with Raised KCO ?
KCO = TLCO / VA
VA roughly is lung volume or effective lung volume in compared to normal healthy lungs)
So Raised KCO means ether TLCO is increased or VA is reduced.
In here, Raised KCO is pretty much poor lung volume (Low VA)
ANK SPOND, Scoliosis, kyphosis = lung posture
NM weakness (Also reduced effective lung volume)
Lobectomy and pneumonectomy (again low lung volume).
*TLCO also known as DLCO on the web.
*KCO = DLCO/VA
*VA = effective lung volume
ERV is low in which patients and why ?
Obese because of decreased chest wall compliance
OSA Treatment ?
Weight Loss
CPAP
If not tolerated Oral mandibular devices
OSA Acid Base Picture ?
Compensated Respiratory Acidosis
LTRA Side Effects ?
Unmasking Churgg Strauss Syndrome
Hepatic and Neuropsychiatric
Poor Prognostic Factors for Sarcoidosis ?
Factors associated with poor prognosis
insidious onset, symptoms > 6 months
absence of erythema nodosum
extrapulmonary manifestations: e.g. lupus pernio, splenomegaly
CXR: stage III-IV features
black African or African-Caribbean ethnicity
PS - MOST Sarcoidosis resolves without treatment
Surgical Contraindication for NSCLC ?
Mediastinoscopy before CT TRO Mediastinal LN
Surgical Contraindications
- SVCO
- Vocal Cord Paralysis
- Tumor near Hilum
- Malignant Pleural Effusion
- FEV1<1.5 (<1.5 for Lobectomy and <2 for Pneumonectomy)
Cavitating Lesions Mnemonic
WAP RATS
(Wet Ass Pussy RATS)
Wegners, Abscess, PE
RA, Aspergillosis, TB, SCC
Alpha 1 Antitrypsin Deficiency
1. MOA
2. Inheritance
3. Treatment
Serine protease inhibitor (serpin) –> Inhibit Neutrophil Elastase —> Prevent Alveolar Breakdown
Autosomal Recessive / Co-Dominant
Chromosome 14
Alpha 1 Antitrypsin Concentrates
Lung Volume Reduction Surgery
A1AT Deficiency Genotypes
alleles classified by their electrophoretic mobility - M for normal, S for slow, and Z for very slow
normal: PiMM
heterozygous: PiMZ
evidence base is conflicting re: risk of emphsema
however, 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
How does Sarcoidosis Cause Hypercalcemia
Macrophages activate 1 Alpha Hydroxylase –> Activated Vitamin D3 –> Increase Calcium Absorption via Intestine DCT
Cherry Red Lesion on Bronchoscopy THINK WHAT ?
Lung Carcinoid
Why give Corticosteroids in COPD ?
Reduce Frequency of Exacerbations
Isocyanates associated with which Cancer
Polyvinyl Chloride ?
Aromatic Amines ?
Squamous Cell Carcinoma
Angiosarcoma of Liver
Bladder Ca
Occupational Asthma Diagnostic Investigation
Serial Peak Flow at Home and Work
Most Common Chemical Associated with Occupational Asthma
Isocyanates
Squamous Cell Cancer
Most Common Cancer in UK
Cavitates
PTHrP
HPOA and Clubbing
Central
Sarcoidosis CXR Classification ?
Sarcoidosis CXR
1 = BHL
2 = BHL + infiltrates
3 = infiltrates
4 = fibrosis
Bronchiectasis and Bilateral Hilar Lymphadenopathy NOT caused by ????
Amyloidosis
B/L Hilar Lymphadenopathy Causes ?
Berylliosis
Histoplasmosis
Coccidioidomycosis
Subfertility + Recurrent Chest Infections + Quiet Heart Sounds ?
Kartagener Syndrome
Do Sweat Test TRO Cystic Fibrosis (Absence of Vas Deferens - Normal Sperms but just less
PAH Diagnostic Criteria
Pulmonary Arterial Pressure >20
Primary Spontaneous Pneumothorax Management
OP Follow up every 2-4 days ambulatory
Secondary Spontaneous Pneumothorax Management
Inpatient
OP Follow-up once stable in 2-4 weeks
Hertford Syndrome Triad
Lofgren Syndrome Triad
CHRONIC Fever + Triad of 1. Parotitis
2. Anterior Uveitis
3. Facial Palsy
ACUTE Fever + Triad of
1. Erythema Nodosum
2. Migratory Polyarthritis
3. B/L Hilar Lymphadenopathy
Jüngling’s disease what is it ?
Chronic Sarcoidosis with Cystic Bony Lesions in Acral Region (Fingers)
Mnemonic for Occupational Asthma Chemicals ?
GF works at PEPSI factory and comes home daily with Asthma symptoms
GF— Glutaraldehyede. Flour
PEPSi :
Platinum salt
Epoxy resins
Proteolytic enzymes
Soldering flux resins
Isocyanates
Mat Worker Lung Organism
Mushroom Worker Lung
Farmers Lung
Aspergillus clavatus
Thermophilic actinomycetes
Saccharopolyspora rectivirgula
Is Coal Dust Associated with Lung Cancer ?
NO !
Do we need follow-up for Pleural Plaques on CXR ?
NO they aren’t premalignant
Cystic Fibrosis Features
short stature
DM
delayed puberty
rectal prolapse (due to bulky stools)
nasal polyps
male infertility, female subfertility
ARDS Diagnostic Criteria
2012 Berlin definition: remember as ABCD
A: Acute onset (within 1 week of lung injury)
B: bilaterafl infiltrates on CXR
C: (not) cardiogenic
D: Decreased PaO2:FiO2 (mild <300, mod <200, severe <100)
HYPOXIC despite Oxygenation
Mechanism of Action of LTRA
Binds to CysLT1 Receptors
Blocking action of cysteinyl leukotrienes in Bronchial Tissue which are released by Immune System to increase mucus secretion, bronchoconstriction etc …
Investigation of Choice for Fixed Upper Airway (Tumor, Goiter etc… )
Flow - Volume Loops
Asthma workup (New Guidelines) for >16
- Eosinophilia or FeNO (>40ppb)
- BDR (FEV1>12% or 200mls Pre and Post BD OR >10% of Predicted)
If Unavailable then PEFR
3.Twice Daily for 2 weeks (20% variability) - Bronchial Challenge Test
If NO for BDR Test then Straight to Bronchial Challenge Test
Asthma Workup for 5-16 y/o
SAME as above but
FeNO > 35ppb
NO Eosinophilia
1, 2, 3 same but 4 is
- Skin Prick for House Mite OR Total IgE raised
If Yes –> Eosinophils >0.5*10^9 ? –> If NO then Refer for 2nd Opinion and Bronchial Challenge Test
Asthma Workup for <5y/o
Any Preschooler with 1 hospital admission OR >/= 2 ED admissions WITHIN 12 months
