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Core Conditions > Respiratory > Flashcards

Respiratory Flashcards

1
Q

What are the causes of Asthma? (3)

A

Caused by a Reversible airway obstruction
Cause unknown exactly- combination of:
Environmental factors
Genetic factors

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2
Q

What 3 factors contribute to airway narrowing in Asthma? (3)

A

Bronchial muscle contraction (triggered by variety of stimuli)
Mucosal swelling/inflammation (caused by mast cell and basophil degranulation resulting in the release of inflammatory mediators)
Increased mucus production

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3
Q

What are the risk factors for Asthma? (7)

A 
Gender (male more likely than female)
Family History 
Atopic allergies (eczema/hayfever)
Smoking 
Obesity 
Viral respiratory infections in infancy and childhood
Air pollution
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4
Q

What are the symptoms of Asthma? (4)

A

Intermittent dyspnoea
Wheeze
Cough (often nocturnal)
Sputum

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5
Q

What are the signs of Asthma on examination? (6)

A 
Tachypnoea
Audible wheeze
Hyperinflated chest
Hyper resonant percussion note
Decreased air entry
Polyphonic wheeze
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6
Q

What are the possible differential diagnoses of Asthma? (4)

A

COPD
Pulmonary oedema
Large airway obstruction
Superior Vena Cava obstruction

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7
Q

What investigations could be done to diagnose Asthma? (4)

A

Peak expiratory flow
Sputum culture
Blood tests (FBC, U&Es, CRP, cultures)
ABG (showing normal/slightly low PaO2 and low PaCO2 due to hyperventilation)

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8
Q

What drugs can be used to treat Asthma?

A
  • B2-adrenoreceptor agonists (relax bronchial smooth muscle by increasing cAMP, act in minutes, eg Salbutamol)
  • Corticosteroids (⬇️ bronchial mucosal inflammation, act over days, eg beclometasone)
  • Aminophylline (inhibits phosphodiesterase, thus ⬇️ bronchoconstriction by ⬆️ cAMP)
  • Anticholinergics (⬇️ muscle spasm synergistically with B2 agonists, eg ipratropium)
  • Leukotriene receptor antagonists (block the effects of cysteinyl leukotrienes in the airways by antagonising the CystLT1 receptor, eg montelukast)
  • Anti-IgE monoclonal antibody (used in persistent allergic asthma, eg omalizumab)
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9
Q

How common is COPD?

A

Affects 10-20% of >40s

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10
Q

What is COPD?

A

COPD is a common progressive disorder characterised by airway obstruction with little or no reversibility.

It includes chronic bronchitis and emphysema.

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11
Q

What is a “pink puffer” and a “blue bloater”?

A

PINK PUFFER: have increased alveolar ventilation, normal PaO2 and low/normal PaCO2. They are breathless but not cyanosed. They may progress to T1 Respiratory failure.

BLUE BLOATER: have decreased alveolar ventilation, low PaO2 and high PaCO2. They are cyanosed but not breathless. They may go on to develop cor pulmonale. Their respiratory centres are relatively insensitive to CO2. They rely on hypoxic drive to maintain respiratory effort. (Therefore O2 given with care).

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12
Q

What causes COPD?

A

Smoking

The lining of the lungs becoming inflamed which can lead to scarring. This can be caused by smoking and exposure to smoke and air pollution.

Alpha-1 antitrypsin deficiency can cause COPD as if there is a deficiency in A1AT then elastase breaks down elastin and in the lungs this leads to the destruction of alveolar walls and emphysematous change. Smoking can accelerate this very quickly.

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13
Q

What are the risk factors for COPD?

A

Smoking
Air pollution
Occupation (dusts, chemicals, vapours, irritants, fuels)
Frequent LRTIs in childhood

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14
Q

What are the symptoms of COPD? (4)

A

Cough
Sputum
Dyspnoea
Wheeze

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15
Q

What are the signs of COPD on examination? (10)

A

Tachypnoea
Use of accessory muscles during respiration
Hyperinflation
Decreased cricosternal distance (

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16
Q

What are the possible differential diagnoses of COPD? (6)

A 
Asthma
Bronchiectasis
CCF
Lung cancer
Obliterative bronchiolitis
Bronchopulmonary dysplasia
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17
Q

What investigations are necessary to diagnose COPD? (2)

A

Spirometry

  • Mild (stage 1) COPD is FEV1 at least 80% of predicted value
  • Moderate (stage 2) COPD is FEV1 between 50% and 79% of predicted value
  • Severe (stage 3) COPD is FEV1 between 30% and 49% of predicted value
  • Very severe (stage 4) COPD is FEV1 of less than 30% of predicted value

Chest X-Ray (necessary to exclude other diagnoses)

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18
Q

What are the possible treatments of COPD?

A

General

  • smoking cessation
  • encourage exercise
  • diet (treat poor nutrition or obesity)
  • influenza & pneumococcal vaccinatio
  • pulmonary rehabilitation
  • PRN short acting antimuscarinics (ipratropium) or B2 agonist (salmeterol)

Mild/moderate
- inhaled long-acting antimuscarinic (tiotropium) or B2 agonist

Severe
- Combination long-acting B2 agonist & corticosteroids

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19
Q

How common is Bronchial Carcinoma?

A

Approximately 95% of all primary lung tumours are bronchial carcinomas
Bronchial carcinomas account for approximately 19% of all cancers

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20
Q

Who does Bronchial carcinoma affect?

A

Mostly affects smokers

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21
Q

What are the risk factors for Bronchial Carcinoma? (6)

A

Smoking
Increased age
COPD
Past history of head and neck cancer
Industrial dust diseases, asbestos, chromium, arsenic, iron oxide, radiation
Epidermal growth factor receptor tyrosine kinase (EGFR-TK) mutation

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22
Q

What are the symptoms of Bronchial Carcinoma? (8)

A 
Cough
Haemoptysis
Dyspnoea
Chest pain
Recurrent/slowly resolving pneumonia
Lethargy
Anorexia
Weight loss
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23
Q

What are the signs of Bronchial Carcinoma on examination? (3)

A 
General signs:
Cachexia
Anaemia
Clubbing
Hypertrophic pulmonary osteoarthropathy (HPOA) 
Supraclavicular or axillary nodes
Chest signs: 
None
Consolidation
Collapse
Pleural effusion
Metastases:
Bone tenderness
Hepatomegaly
Confusion
Fits
Focal CNS signs
Cerebellar syndrome
Proximal myopathy
Peripheral neuropathy
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24
Q

What are the possible differential diagnoses of Bronchial Carcinoma? (10)

A 
Secondary malignancy
Arteriovenous malformation
Pulmonary hamartoma
Bronchial adenoma
Abscesses
Granuloma
Encysted effusion 
Cyst
Foreign body
Skin tumour
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25
Q

What investigations are necessary to diagnose Bronchial carcinoma? (5)

A 
Cytology - sputum and pleural fluid
Chest X-Ray:
- peripheral nodule
- hilar enlargement
- consolidation
- lung collapse
- pleural effusion
- bony secondaries

Bronchoscopy
CT - to stage the tumour
PET scan

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26
Q

What are the treatments for Bronchial Carcinoma? (4)

A

Non-small cell:

  • Excision
  • Curative radiotherapy
  • Chemotherapy +/- radiotherapy

Small cell

  • almost always disseminated at presentation
  • may respond to chemo but will invariably relapse
  • palliative radiotherapy
  • analgesic drugs
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27
Q

What are the types of pneumothorax? (3)

A

Primary spontaneous pneumothorax - pneumothorax occurring in healthy people
Secondary spontaneous pneumothorax - associated with underlying lung disease, worse consequences
Tension pneumothorax - MEDICAL EMERGENCY!!

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28
Q

How common is a pneumothorax?

A

PSP - 24/100,000/year in males

- 9.9/100,000/year in females

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29
Q

Who does pneumothorax affect?

A 
Young, tall, thin, males
People with other lung diseases
- Asthma
- COPD
- Cystic Fibrosis
- Tuberculosis
- Whooping cough

PSP occurs most often in the 20s and rarely over age of 40
SSP typically occurs between 60-65

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30
Q

What causes a pneumothorax?

A

Spontaneous due to rupture of sub-pleural bulla

Lung diseases:

  • asthma
  • COPD
  • TB
  • pneumonia
  • CF
  • lung fibrosis
  • sarcoidosis

Connective tissue disorders

Trauma

Iatrogenic

31
Q

What are the risk factors for pneumothorax?

A

Tall, young, thin males

Smoking

Family history of pneumothorax

Underlying lung conditions

32
Q

What are the symptoms of a pneumothorax? (4)

A

Sudden onset dyspnoea

Pleuritic chest pain

Pts with asthma/COPD may present with sudden deterioration

May be asymptomatic

33
Q

What are the signs of a pneumothorax on examination? (4)

A

Reduce chest expansion unilaterally

Hyper-resonance on percussion

Reduced breath sounds unilaterally

Deviated trachea

34
Q

What are the possible differential diagnoses of a pneumothorax? (3)

A

Pleural effusion- tends to be slower onset and there is dullness on percussion

Chest pain: a pleuritic pain may give sensation of breathlessness

Pulmonary Embolism - may produce haemoptysis and more commonly affects lower lungs

35
Q

What investigations are necessary to diagnose pneumothorax? (4)

A

Chest X-Ray

Ultrasound

CT

ABG - show hypoxia

36
Q

What are the treatments for a pneumothorax?

A

PSP

  • aspiration
  • observe

SSP

  • supplementary O2 as relieves hypoxia and accelerates reabsorption of the pneumothorax compared to breathing air
  • most pts will need chest drain
  • If persistent air leak then pt needs referring to thoracic surgeons
37
Q

What is a pleural effusion?

A

Fluid in the pleural space

38
Q

How can you divide pleural effusions and what is the difference?

A

By their protein concentrations:
- Transudates (35g/L)

Examples:
Haemothorax= blood in pleural space
Empyema= pus in pleural space
Chylothorax = lymph (with fat) in the pleural space
Haemopneumothorax= blood and air in pleural space

39
Q

What causes pleural effusion?

A 
Transudates: 
May be due to ⬆️ venous pressure
-cardiac failure
-constrictive pericarditis
-fluid overload
Hypoproteinaemia
-cirrhosis
-nephrotic syndrome
-malabsorption

Exudates:
Mostly due to ⬆️ leakiness of pleural capillaries secondary to:
-infection (pneumonia)
-inflammation
-malignancy (most commonly lung and breast cancer)

40
Q

What are the symptoms of pleural effusion? (3)

A

Asymptomatic
Dyspnoea
Pleuritic chest pain

41
Q

What are the signs of pleural effusion on examination? (6)

A

Decreased chest expansion

Stony dull percussion note

Reduced breath sounds on affected side

Tactile vocal fremitus and vocal resonance are decreased.

Bronchial breathing may be present above effusion where lung is compressed

Tracheal deviation away from effusion in large pleural effusions

42
Q

What are the possible differential diagnoses of pleural effusion?

A 
Transudates:
CCF
Cirrhosis with hepatic hydrothorax
Nephrotic syndrome
Hypoproteinaemia
Glomerulonephrotis
SVC obstruction
CSF leak to pleural space
Exudates:
Malignancy
Pneumonia
Tuberculosis
PE
Fungal infection
43
Q

What tests are necessary to diagnose pleural effusion? (4)

A

Chest X-Ray

  • small effusions blunt costophrenic angles
  • large effusions seen as water dense shadows with concave upper borders

Ultrasound

Diagnostic aspiration

Pleural biopsy

44
Q

How do you treat/manage pleural effusion?

A

Drainage

45
Q

What are the two classifications of pneumonia? (2)

A

Lobar pneumonia

  • form of pneumonia infection that only involves a single lobe of the lung
  • often due to streptococcus pneumoniae

Bronchopneumonia

46
Q

How common is CAP?

A

0.5-1% in UK every year

47
Q

What causes lobar pneumonia?

A

Most often streptococcus pneumoniae

Other causes:
Haemophilus influemzae
Moraxella catarrhalis
Mycobacterium tuberculosis

48
Q

What are the risk factors for lobar pneumonia?

A

Age - young children and elderly

Lifestyle - smoking and alcohol

Preceding viral infections - eg influenza predisposing to streptococcus pneumoniae infection

Immunosuppression

IV drug abuse - associated with staph aureus infection

Hospitalisation - often with Gram -ve organisms

Underlying predisposing disease - DM, cardiovascular disease

49
Q

What are the symptoms of lobar pneumonia?

A 
Fever
Rigor
Malaise
Anorexia
Dyspnoea
Cough
Purulent sputum
Haemoptysis
Pleuritic pain
50
Q

What are the signs of lobar pneumonia on examination?

A 
Pyrexia
Cyanosis
Confusion
Tachypnoea
Tachycardia
Hypotension
Signs of lung consolidation:
- diminished chest expansion
- dull percussion note
- increased tactile vocal fremitus/resonance
- bronchial breathing
Pleural rub
51
Q

What are the possible differential diagnoses of lobar pneumonia?

A 
Pulmonary oedema
Pleural effusion
Pneumothorax
PE
Asthma
COPD
Bronchiectasis
Fibrosing alveolitis
Neoplasm
Sarcoidosis
52
Q

What investigations would you do to diagnose lobar pneumonia?

A

Chest X-Ray
SpO2
ABG
BP
Blood tests- FBC, U&Es, CRP, LFT, blood cultures
Sputum microscopy and culture
Aim to identify pathogen and assess severity

CURB 65 scoring system

53
Q

What is the CURB 65 scoring system for pneumonia?

A

C - confusion
U- urea >7mmol/L
R - respiratory rate >/= 30 breaths/min
B - Blood pressure (65 years

54
Q

How do you manage a pt with lobar pneumonia?

A

Antibiotics (mild-mod= amoxicillin OR clarythromycin severe= co-amoxiclav OR Cephalosporin e.g. Cefuroxime )

  • Oxygen - keep PaO2 >8 and SpO2 >94%
  • IV fluids and VTE prophylaxis
  • Analgesia for pleuritic pain
55
Q

How common is a PE?

A

1/1000 people/year have a DVT

If untreated about 1/10 people with a DVT will develop a PE

56
Q

What causes PE?

A

Results from obstruction within pulmonary arterial tree

Emboli can be caused by:

  • thrombosis (DVT - causes most PEs)
  • fat
  • amniotic fluid
  • air
57
Q

What are the risk factors for a PE?

A 
Surgery 
Obstetrics
Lower limb problems
Malignancy
Reduced mobility
Previous venous thromboembolism
58
Q

What are the symptoms of a PE?

A

Dyspnoea
Pleuritic chest pain (sharp stabbing pain when breathing in)
Retrosternal chest pain
Cough
Haemoptysis
Any chest symptoms in a pt with symptoms suggesting a DVT

59
Q

What are the signs of PE on examination?

A

Tachypnoea
Tachycardia
Hypoxia - leading to anxiety, restlessness, agitation and impaired consciousness
Pyrexia
Elevated JVP
Galloping heart rhythm, widely split heart sounds, tricuspid regurg murmur
Pleural rub
Systemic hypertension and cardiogenic shock

60
Q

What are the possible differential diagnoses of PE?

A

Other causes of collapse, chest pain or dyspnoea:

Acute coronary syndromes
Aortic dissection
Cardiac tamponade
Pneumonia
Pneumothorax
Sepsis
61
Q

What investigations are necessary to diagnose a PE?

A

Baseline obs: O2 sats, FBC, biochem, clotting screen
ECG
Chest X-Ray
ABG - may show reduced PaO2 and PaCO2 due to hyperventilation
Echocardiogram
Cardiac troponins
D-dimers- fibrin D-dimer is a degradation product of cross-linked fibrin, conc increases in patients with acute VTE and provides a very sensitive test to exclude acute DVT or PE

Specific investigations for VTE:
Coronary angiography
Leg ultrasound
Isotope lung scanning
CPTA
62
Q

What are the treatments of PE?

A

Anticoagulation therapy:
Starts as soon as PE is suspected
Medications or tablets

Low molecular weight heparins
In pregnant women regular heparin instead or warfarin

63
Q

What are the causes of pulmonary fibrosis?

A

Replacement fibrosis secondary to lung damage

Extrinsic allergic alveolitis (bird fanciers lung)

Granulomatous diseases eg sarcoidosis

Radiation exposure

64
Q

What are the risk factors of pulmonary fibrosis?

A 
Drugs and environmental causes
Smoking
GORD
Infectious agents
Genetic factors
65
Q

What are the symptoms of pulmonary fibrosis?

A

Gradual onset of SOB

Chronic non productive cough

Wheezing

Haemoptysis

Chest pain

Non-specific fever, myalgia

Finger clubbing

66
Q

What is the treatment for pulmonary fibrosis?

A 
Smoking cessation
Avoidance of other cause
Influenza and pneumococcal vaccination
O2 therapy for significant hyperaemia
Immunosuppressive therapy
67
Q

How common is Asthma? (3)

A

Affects 5-8% of population
3rd most common Hospital Admission in children
5-10% of adults have severe asthma

68
Q

Define type 1 respiratory failure

A

PaO2 ⬇️

PaCO2 normal

69
Q

Define type 2 respiratory failure

A

PaO2 ⬇️

PaCO2 ⬆️

70
Q

What organism causes cavitating pneumonia ?

A

Klebsiella

71
Q

Local complications of bronchial carcinoma ?

A
  • recurrent laryngeal nerve palsy
  • phrenic nerve palsy
  • SVC obstruction
  • horners syndrome (pancoasts tumour)
  • rib erosion
  • pericarditis
72
Q

Causes of type 1 respiratory failure

A

V/Q mismatch:

  • pneumonia
  • pul oedema
  • PE
  • asthma
  • emphysema
  • pulmonary fibrosis
73
Q

Causes of type 2 respiratory failure ?

A

Alveolar hypoventilation with or without v/q mismatch

  • pul disea: COPD, obstructive sleep apnoea, asthma
  • reduced respiratory drive: sedatives, CNS tumour
  • neuro muscular disease: myasthenia gravis, G-B
  • thoracic wall disease: flail chest, kyphoscoliosis
74
Q

When to consider ABG ?

A
  • any unexpected deterioration in ill patient
  • acute exacerbations of chronic chest conditions
  • impaired consciousness or impaired resp effort
  • signs if co2 retention
  • cyanosis, confusion

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