Respiratory 2 Flashcards
List some differentials for finger clubbing:
Increased soft tissue swelling, with loss of the hyponychial angle
Thoracic :
- TB
- Emphysema
- Cystic fibrosis
- Lung cancer
- Pulmonary fibrosis
Cardio:
- Infective heart disease
- Congenital heart disease
G.I
- Inflammatory bowel disease
- Cirrhosis
- celiac disease
- lymphoma
Endocrine:
- thyroid disease
List some causes of haemoptysis:
Lung cancer Acute bronchitis TB Pulmonary infarction Goodpastures disease Granulomatous polyangiitis Acute left ventricular failure
What investigations should be done into haemoptysis?
Bloods:
- FBC
- Coagulation screen
Orifices:
- sputum smear
- Bronchoscopy
X-ray:
- CXR
- CT
Following an x-ray of a pleural infusion, what next test should be done to establish it?
Ultrasound
What is light’s criteria?
> 30g protein
Pleural protein: Serum Protein >0.5
Pleural LDH: Serum LDH >0.6
Pleural LDH upper 1/3rd of normal
What are the general causes of restrictive lung diseases?
Interstitial disease
Thoracic cage reduction
- Kyphosis
Neuromuscular conditions
Name some symptoms and clinical signs that are seen with interstitial lung disease:
Progressive dyspnoea
Dry cough
Reduced exercise capacity
Finger clubbing
Restrictive pattern
Prior to discharge of an asthma attack what must the patient have?
>75% PEF On discharge medication for 24 hours Inhaler technique checked GP follow up in 2 days Respiratory clinic in 1 month
When diagnosing COPD and there is evidence of Cor pulmonale, what additional tests should be ordered?
Echocardiogram
ECG
When can long term O2 therapy be started in COPD?
kPa O2 <7.3
- need 2 separate occasions to be seen for this
kPa O2 <8 + polycythemia, cor pulmonale,
What are some features of cor pulmonale?
Peripheral oedema
Raised JVP
Right ventricular heave
Second heart sound
When someone comes in with an exacerbation of COPD what questions do you want to know?
usual treatment at home and adherence
Normal exercise tolerance
Allergies to medication
Has this occurred before - and if so what was the treatment course?
Signs of hypercapnia?
Hand flapping Flushing Vasodilation Bounding pulse confusion Coma Papilloedema
What is the target PEF for asthma?
> 80%
What is the lung cancer called the develops in the apex of the lung and may cause lung erosion:
Pancoast tumour
What may cause round lesions to appear on the lung xray?
Primary lung cancer Metastatic lung cancer - renal cell carcinoma Rheumatoid nodules TB Sarcoidosis Abscess
What investigations should be done to diagnose lung cancer?
Bloods:
- LFTs (Mets in liver and bone)
- U&Es (hyponatramia)
- Bone profile (mets + Ca2+ level for paraneoplastic)
X-rays:
CT/ US guided biopsy
Bronchoscopy for biopsy or wash for cytology
PET Scan
CT Chest/ Abdo/ Pelvis
- check adrenals
List the causes of atypical pneumonia:
Legionella Pneumophila
Chlamydia Psittaci (birds)
Chlamydia Pneumoniae
Mycoplasma Pneumoniae
Coxiella Burnetii
What are the indications that lung tumours are operable?
Unilateral
No involvement of the major vessels
Non - distant metastasis
Not within 2cm of the main bronchus
What are the clinical finding of sarcoidosis?
Lupus Pernio Erythema nodosum Anterior uveitis Lymphadenopathy Hepatosplenomegaly Cor pulmonale
What features are taken into account when assessing lung function?
Height
sex
Age
Why are investigations are necessary in lung cancer?
- Stage the extent of lung cancer
- To make tissue diagnosis
- To assess fitness of patient - for treatment
Whats the most common cancer to metastasis to the lung?
No.1 Breast
Colon cancer
Renal cell carcinoma
What are some signs of primary lung cancer?
Dyspnea Finger clubbing Weight loss Weakness Horner syndrome Shoulder pain Chest pain
Where does lung cancer spread to?
Hilar lymph nodes Brain Adrenals Bone Liver
What is the staging for lung cancer and what does the TNM staging in lung cancer refer to?
Squamous cell: TNM
Small cell: Limited, Extensive
Tumour size
Nodal status
Metastasis
What are the symptoms of horners?
Miosis
Ptosis
Anhidrosis
How is superior vena cava syndrome managed?
Head elevation + diuretics
Stents + radiotherapy
palliative
What are some signs of cor pulmonale?
Oedema Right ventricular heave Loud Pulmonary second sound Raised JVP Enlarged liver
What drugs can be used to reduce secretion/ mucus production? and are especially helpful with COPD?
Carbocysteine
Physiotherapy chest
Neb Saline
- used short term and usually in hospital
What is pulmonary rehabilitation?
Retraining how someone breathes. usually in obstructive conditions people breath shallow and fast.
Retraining to take deep inhaled breathes and slow down the breathing
When can long term oxygen therapy be started in COPD?
PaO2 <7.3
or
paO2 7.3-8 with polycythemia, pulmonary oedema or hypertension
What are some additional therapeutics effects for COPD outwith inhalers?
Vaccines
Sensation of breathlessness
- Pulmonary rehabilitation
- Dihydrocodeine
Secondary polycythemia
- venesection
Surgery
- bullectomy
- Lung reduction volume surgery
Why are COPD patients more likely to get pneumothoraces?
due to the bullae formation - which is essentially large amounts of alveoli clumped together. this increase tension and leads to an increased likelihood of rupture.
During COPD exacerbation what should the venturi mask oxygen sats be at?
24%
What are poor prognostic factors in COPD?
Age
FEV1
What drug can be used as a CNS stimulator in obstructive sleep apnea?
Modafinil
List some causes of restrictive lung disease:
Parenchymal:
- IPF
- Sarcoidosis
Pleural:
- Pleural effusion
Chest wall:
- Kyphoscoliosis
- AS
Neuromuscular:
- Myasthenia gravis
- MND
- Guillain Barre syndrome
Vascular:
- Vasculitis - Anti- GBM
What are the histological findings on sarcoidosis?
Non-caseating granulomas with well defined borders
How does a pleuritic rub differ from a pericardial rub?
It only has a biphasic rub whereas cardiac has triphasic
What are the complications of sarcoidosis?
Interstitial lung disease
Cor pulmonale
What is the acute presentation of sarcoidosis?
Lofgren syndrome
Bilateral lymphadenopathy
Fever
Poly arthropathy
Eyrthema nodosa
What is described to have egg-shell hilar lymph nodes on x-ray?
Silicosis
What are the contraindications to BiPAP?
Facial trauma
Pneumothorax
Patient wishes
+/-
Cardiac disease
Excessive sputum production
Which type of empysema is most associatted with COPD?
Centroacinar - dilation is more centred around the terminal bronchioles
Panacinar is more associated with Alpha 1 antitrypsin deficiency
What are the three mechanisms by which there is airflow limitation in COPD?
Loss of elasticity
Mucus plugging
Inflammation and scarring of the small airways
What are the signs of COPD?
Tachypnoeic
Prolonged expiration
Intercostal indrawing during inspiration
Pursing of lips during exhalation
Poor chest expansion
Loss of normal cardiac and liver dullness
Findings of cor pulmonale:
Right Ventricular Heave
Loud pulmonary second sound
JVP raised
Tall P wave
How long does oxygen therapy need to be given for in COPD to provide a significant impact on mortality?
19 hours daily
What are the mechanisms behind reduced oxygen saturations during sleep - which can significant impact on COPD patients?
Inhibition of accessory muscles such as the intercostals and sternocleidomastoid muscle during REM
Shallow breathing - especially during REM
Increased upper airway obstruction due to loss of tone
What are the guidelines regarding receiving oxygen?
COPD <7.3paO2
Cystic fibrosis <7.3 paO2
Neuromuscular disorders
Pulmonary malignancy
Heart failure <7.3paO2
What two sets of people get obstructive sleep apnea?
Overweight middle aged men
Children with enlarged adenoids
Symptoms of sleep apnea?
Snoring Daytime sleepiness Unrefreshed sleep Restless sleep Morning headache Nocturnal choking Morning drunkness
What endocrine disorder may be implicated with obstructive sleep apnea?
Acromegaly
On a pulse oximetry used for sleep apnea, what would you expect to see?
Saw tooth appearance
What is a differential for obstructive sleep apnea?
Central Sleep apnea
What may be seen on CXR of bronchiectasis?
Tram track lining
Ring shadows
Cysts
Name a drug used to help quit smoking and its mechanism of action:
Varenicline
- partial nicotinic partial receptor agonist
- contraindicated in pregnancy and breast feeding
Bupropion
- noradrenaline and Serotonin uptake inhibitor
- contraindicated in pregnancy and epilepsy
Which two types of pneumonia have antigens in the urine?
Pneumococcal
Legionella
How long following pneumonia are people usually back to normal?
6 months
What are the three main types of asthma?
Extrinsic
- childhood
- atopy
Intrinsic
- Adulthood
- does not repsond well to treatment
Occupational
What are the key features of asthma?
Hyperresponsiveness of the bronchi
Bronchi inflammation
Airflow limitation
What are some triggers for asthma:
Beta blockers
Aspirin
Cold
Exercise
Dust
Infection **
Perfumes
Cold Damp
What are the associated symptoms of asthma?
Atopy
- eczema
- Hayfever
Night time symptoms
Acid reflux
Disturbed sleep
What are the main investigations into asthma?
Fractional Exhaled Nitric oxide (eosinophils produce lots of NO)
Spirometry with reversibility
PEF variability - diurnal variation
Histamine provocation
Outwith inhalers and medication what other treatments should be given to patients with asthma?
Yearly flu jab Education / inhaler technique Stop smoking Avoidance of triggers exercise programs
What are the side effects of ICS?
Oral Candidiasis
Hoarseness
Throat infection
Osteoporosis - in high dose
What are your differentials for acute asthma?
Pulmonary oedema - cardiac wheeze P.E Pneumothorax Pneumonia COPD
What factors is PEF flow based upon?
Age
Height
Sex
What is a new inhaler can be used as maintain and reliever and what does it contain?
Maintenance and reliever therapy inhaler
- LABA
- ICS
If there is a lung tumour is within a certain distance of the main bronchi it is deemed inoperable, what is this distance and how is it viewed?
2cm proximity of the main bronchus deems the node inoperable.
View via bronchoscope usually
What is the main complication of percutaneous biopsy?
Pneumothorax
What investigations are wanted into lung cancer?
Bloods:
- FBC - anaemia
- U&Es - Hyponatraemia
- Calcium - Hypercalcaemia
Orifices:
- Bronchial lavage with cytology
X-rays:
- CXR
- CT - staging. Includes adrenals
- PET Scan
Special tests:
- Bronchoscopy with biopsy
0r
- CT guided biopsy
Assessment of fitness for surgery:
- Stress Echo
- Lung functioning - for other lung to deal with
What are the treatment options for lung cancer?
Surgery
- with curative intent
Radiation therapy for cure
- used in early NSCLC
- Continually hyperfractionated accelerated Regimes (CHARTS)
Chemotherapy
- biological therapy
What therapeutic interventions can be done for lung cancer in patients that are palliative?
Laser therapy
- vaporise parts of protruding tumour
Tracheobronchial stenting
- metal springs
Endobronchial brachytherapy
- used from compressional symptoms
Name some benign tumours of the lungs:
Pulmonary hamartoma
Bronchial carcinoid
Tracheal tumours
What investigations are done on pleural fluid?
Biochemistry
Immunology
Cytology
Cultures
What FBC would you find in sarcoidosis?
Leukopenia
- markedly reduced T cell circulation.
This has no effect on immunity
What are the differentials for perihilar mass?
Lymphoma
Sarcoidosis
TB
Bronchial carcinoma
Main differentials for sarcoidosis:
Idiopathic pulmonary fibrosis
Tuberculosis
Pneumoconiosis
Lung cancer
What are the drugs that can cause interstitial lung disease:
Nitrofurantoin
Methotrexate
Sulphasalazine
Amiodarone
ACE inhibitors
Methadone
Radiotherapy
