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DPD interactive cases > Respiratory (2) > Flashcards

Respiratory (2) Flashcards

1
Q

The Symbicort inhaler consists of which two drugs?

A

Budesonide (steroid)

Formeterol (lond-acting beta agonist)

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2
Q

Name an anti-muscarinic drug that is used to treat COPD.

A

Tiotropium

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3
Q

List causes of raised JVP.

A

Tricuspid regurgitation
Right heart failure (and congestive heart failure)
Constrictive pericarditis
Lung pathology e.g. PE –> RH strain

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4
Q

What is an important complication of COPD?

A

Pulmonary hypertension

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5
Q

How is COPD a risk factor for pneumothorax?

A

COPD leads to the formation of bullae (an air pocket that replaces lung tissue) - DO NOT INSERT TUBE INTO BULLOUS

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6
Q

List causes of sudden-onset breathlessness (within seconds).

A

PE
Pneumothorax
Foreign body (Child, or OA - dentures)
NOTE: anxiety can also cause sudden-onset breathlessness

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7
Q

List causes of breathlessness that develops over minutes/hours.

A

Problems with the airways (inflammation/obstruction)
Pus in the interstitium (due to chest infection (e.g. pneumonia))
Fluid in the interstitium (due to acute heart failure)
Blood in the lungs (pulmonary haemorrhage)

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8
Q

List causes of breathlessness that develops over days/weeks.

A 
Interstitial lung disease 
Malignancy
Large pleural effusion
Neuromuscular 
Anaemia/thyrotoxicosis 
Chronic variations of acute e.g. multiple small PE
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9
Q

What is CPAP and what is it used for?

A

Continuous positive airway pressure
It provides positive airway pressure that keeps the airways open
It IMPROVES OXYGENATION
It is used in people with type 1 respiratory failure
E.g. if someone has pulmonary oedema and is not getting better, you may give them CPAP

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10
Q

Describe the management of a primary pneumothorax that is:

i) <2cm
ii) >2cm

A 
< 2 cm
Discharge and repeat CXR 
> 2 cm
Aspiration 
If that fails, insert a chest drain
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11
Q

Describe the management of secondary pneumothorax that is:

i) <2cm
ii) >2cm

A

< 2cm
Aspiration
> 2 cm
Chest drain

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12
Q

What important feature of the chest drains must the patient be made aware of when they have on put in?

A

There is an underwater seal and it should be bubbling as the air comes out
It should be kept below waist height

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13
Q

State a cause of homogenous white shadowing in the lung field on CXR.

A

Pleural effusion

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14
Q

State a cause of reticulo-nodular shadowing on CXR.

A

Interstitial lung disease (e.g. pulmonary fibrosis)

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15
Q

State causes of fluffy white shadowing on CXR.

A

Pus – e.g. pneumonia

Fluid – e.g. pulmonary oedema

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16
Q

What is the first step in the acute management of a patient with PE?

A

High flow oxygen

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17
Q

State three ECG changes that may be seen in a patient with PE.

A

S1Q3T3
RBBB (RH strain)
Right axis deviation

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18
Q

How do you determine axis deviation on an ECG?

A

Look at leads I and II – are either of them overall negative?
If either of them is overall negative – there is axis deviation
Then look at lead aVL
- +ve = LAD
- -ve = RAD

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19
Q

What are RBBB and Right Axis Deviation signs of?

A

Right sided heart strain

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20
Q

What is the next step in the acute management of a patient with PE if they are haemodynamically stable?

A

Low molecular weight heparin (e.g. enoxaparin, tinzaparin, dalteparin)
CTPA - if confirmed –> continue LMWH (+ Warfarin)

21
Q

Explain BiPAP.

A

Form of non-invasive ventilation
Provides positive pressure outside the lungs at the beginning of inspiration (iPAP) so that air goes into the lungs
When the patient expires, the pressure doesn’t drop down to zero, it is maintained at an expiratory positive airway pressure (ePAP)
NOTE: if iPAP = ePAP then it is CPAP

22
Q

In what condition is BiPAP used?

A

Respiratory acidosis

NOTE: COPD can cause CO2 retention and respiratory acidosis

23
Q

Why is it important to continue LMWH for a few days once warfarin has been started?

A

Because warfarin causes a transient procoagulant phase due to the inhibition of protein C and protein S
LMWH needs to be continued for a few days until INR remains within the target range for > 24 hours

24
Q

What are the indications for thrombolysis in a case of PE?

A

Massive PE and blood pressure has dropped (haemodynamic compromise)

25
Q

What is the main diagnostic test for PE?

A

CTPA (clot; no distal filling)

CXR may show slightly darker area (underperfusion - oligaemia)

26
Q

What important type of medication should patients a pneumothorax requiring a chest drain be put on?

A

Regular analgesia (the chest drain is very painful)

27
Q

What is a bulla?

A

A thin-walled air-filled space within the lung, arising congenitally or in emphysema. It may cause trouble by rupturing into the pleural space causing a pneumothorax.

28
Q

Describe the difference in FEV1/FVC for restrictive and obstructive lung disease.

A

Obstructive: < 70%
Restrictive: > 70%

29
Q

Describe the differential diagnosis of reticulo-nodular shadowing on CXR.

A

Idiopathic fibrosing alveolitis
Connective tissue disease (e.g. SLE, scleroderma)
Drugs (e.g. methotrexate, nitrofurantoin)
Asbestosis (ship builder?) = pulm fibrosis; =/= asbestos plaques
EAA

30
Q

Define asbestosis.

A

Pulmonary fibrosis due to asbestos

NOTE: the presence of plaques of asbestos does NOT constitute asbestosis

31
Q

How many anterior ribs must be visible to consider the lungs as being hyperinflated? What else can you see on CXR?

A

7 ribs

Flattened diaphragm

32
Q

What causes hyperinflation of the lungs?

A

COPD

33
Q

Which parts of the lungs does pulmonary TB tend to affect most?

A

Upper lobes

34
Q

What respiratory condition is keeping pigeons a risk factor for?

A

Extrinsic allergic alveolitis

35
Q

What features of an X-ray are important to comment on when presenting an X-ray?

A 
PA/AP X-ray
Name and DOB
Date and time 
Rotation – ends of clavicles + spinous processes should be equidistant from the two ends of the clavicles 
Inspiration
Penetration (too white = under)
36
Q

What is a classic feature of right middle lobe pneumonia on CXR?

A

You cannot see the right heart border (pneumonia = alveolar shadowing)

37
Q

What should you always be able to see behind the heart on CXR?

A

Right hemidiaphragm

If you can’t see it then consider collapse and consolidation

38
Q

What does homogenous white shadowing on a CXR indicate?

A

Pleural effusion, fluid, collapse (look at trachea)

39
Q

What does fluffy white shadowing on CXR indicate?

A

Pulmonary oedema

If bilateral - batwings = HF

40
Q

What does reticulo-nodular shadowing show on CXR?

A

Pulmonary fibrosis (interstitial lung disease)

41
Q

State two conditions that can cause total white shadowing across an entire lung field.

A

Massive pleural effusion

Lung collapse

42
Q

What feature of the CXR would help you differentiate between these collapse and pleural effusion?

A

Deviation of the trachea
Pleural effusion – away from the affected side
Collapse – towards the affected side

43
Q

State three causes of a cavitating lung lesion with an air-fluid level.

A

Infection (e.g. TB, Klebsiella, TB, S. aureus)
Inflammation (e.g. rheumatoid arthritis/Granulomatosis w/ Polyangiitis)
Malignancy (e.g. squamous cell carcinoma)

44
Q

Describe the appearance of a pericardial effusion on CXR.

A

The heart has a globular appearance (fluid around)

It will be homogenous white

45
Q

List three causes of bilateral hilar lymphadenopathy.

A

TB
Sarcoidosis (+fibrosis)
Lymphoma

46
Q

What might happen after a chest drain?

A

Re-expansion pulmonary oedema (very rare)

47
Q

What else to look out for on CXR

A

Masses, Cavitation, pacemaker+leads, mastectomy (if mass ?mets)

48
Q

What does multiple pleural plaques show?

A

Asbestos plaques = exposure

DPD interactive cases (8 decks)

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