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AC1 > Respiratory > Flashcards

Respiratory Flashcards

1
Q

What is transmural pressure in the lungs?

A

Pressure across a structure e.g. the pressure difference between inside the alveoli and the pleural space

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2
Q

For air-filled lungs what are the two main factors that determine the compliance of the lungs?

A

Intrinsic compliance of the lungs (mainly related to its elasticity) and the surface tension at the liquid-air surface

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3
Q

How does the intra-pleural pressure compare to the pressure of the atmosphere?

A

Negative i.e. pressure in the intrapleural space is less than atmospheric pressure

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4
Q

What creates the negative pressure in the lungs?

A

Negative pressure reflects the effects of two opposing forces: lungs elastic properties tending to collapse and the chest wall elastic properties tend to spring out. These two opposing forces create a vacuum in the intra-pleural space, which then opposes the forces producing it

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5
Q

What is a pneumothorax?

A

Presence of air in the intra pleural space

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6
Q

What effect does a pneumothorax have on the intra pleural pressure?

A

Intra-pleural pressure will increase (become less negative) and will eventually approach zero or even become positive

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7
Q

What effect does the change in intra pleural pressure in a pneumothorax have on the lungs?

A

Lack of negative intra-pleural pressure means the lungs collapse (natural tendency is to collapse but they are held open by the negative intra-pleural pressure)

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8
Q

What effect does the change in intra pleural pressure in a pneumothorax have on the chest wall?

A

Lack of negative intra-pleural pressure means that the chest wall tends to spring out (natural tendency of the chest wall is for it to spring out, but it is held in by the negative intra-pleural pressure)

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9
Q

What are the common causes of pneumothorax?

A

Spontaneous, idiopathic, secondary to an underlying lung disease e.g. COPD, TB, asthma, lung abscess, cystic lung disease, lung cancer or traumatic i.e. following injury to the chest wall

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10
Q

What are the common symptoms associated with pneumothorax?

A

Sudden onset, unilateral chest pain, which is pleuritic with acute dyspnoea

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11
Q

What clinical findings would you expect to see in a patient with a pneumothorax?

A

Reduced chest expansion of the affected side
Resonance or hyper-resonance on percussion over affected side
Absent breath sounds
Tracheal deviation

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12
Q

What are the 3 types of pneumothorax and what are common causes?

A

Closed: spontaneous
Open: Bronchopleural fistula or ruptured bulla or abscess
Tension: Bullae or following a penetrating injury

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13
Q

What can be a serious consequence of an open pneumothorax?

A

Risk of infection

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14
Q

What can be a serious consequence of a tension pneumothorax?

A

Acute cardiovascular compromise

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15
Q

What additional clinical signs are you more likely to see in a patient with a tension pneumothorax versus non-tension pneumothorax?

A

Tension pneumothorax will often have deviation of the trachea, tachycardia and hypotension

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16
Q

What changes would you see on an X-ray of a patient with pneumothorax? Why?

A

Collapsed lung edges can usually be identified very clearly
In the area of the pneumothorax there is complete translucency i.e. complete blackness with an absence of any lung markings. If it is tension type pneumothorax you could also see evidence of mediastinal shift. There may also be evidence of underlying lung disease e.g. COPD giving clues as to the likely underlying aetiology

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17
Q

What effect would fibrosis have on the lung tissue? Why?

A

Fibrosis is the replacement of normal tissue with scar tissue, this typically contains a high amount of collagen fibres and scanty elastic fibres. The lack of elastic fibres would decreased the compliance of the lungs

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18
Q

What features on examination would support a diagnosis of pulmonary fibrosis?

A

Digital clubbing can be seen and late, often fine, inspiratory crackles can be heard on auscultation of the lungs

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19
Q

What changes would you expect to see on chest x-ray in a patient with pulmonary fibrosis?

A

This disease is one of the interstitium and so evidence of involvement of the supporting tissue of the lung parenchyma resulting in fine or coarse reticular opacities or small nodules

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20
Q

What pattern of changes would you expect to see on lung function testing in a patient with a fibrotic lung disease?

A

Restrictive pattern of changes on lung function testing as in fibrotic tissue for a given change in pressure there will be smaller increase in volume compared to healthy lung tissue

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21
Q

What is the diagnostic golden standard criteria for diagnosis of bronchiectasis?

A

High-resolution CT (HRCT) scanning

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22
Q

What abnormalities would you expect to see on a CT scan of a patient with bronchiectasis?

A

Parallel tram track lines, or signet-ring appearance composed of a dilated bronchus cut in a horizontal section with an adjacent pulmonary artery representing the stone
Diameter of bronchus lumen is normally 1-1.5 times that of the adjacent vessel; a diameter greater than 1.5 times that of the adjacent vessel is suggestive of bronchiectasis
Varicose bronchiectasis has irregular or beaded bronchi, with alternating areas of dilatation and constriction
Cystic bronchiectasis has large cystic spaces and a honeycomb appearance; this contrasts with the blebs of emphysema, which have thinner walls and are not accompanied by proximal airway abnormalities

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23
Q

What two components of the respiratory system principally determine its compliance?

A

Lungs and chest wall

24
Q

65 y/o M comes in complaining of SOB when walking up hill. Given a salbutamol inhaler last week but it hasn’t helped. Been breathless getting up stairs for last 2 years. Advised to give up smoking but doesn’t want to. Has been smoking 20 cigarettes a day for last 40 years. Coughs every day, usually in mornings and always produces yellow sputum. This has been going on for years and is no worse this week than at any other time. He has no fever or chest pain. What is the likely diagnosis?

A

Chronic obstructive pulmonary disease

25
Q

4 y/o boy brought to clinic by his parents because he is miserable, lethargic and complaining of a sore left ear. They have not noticed any ooze from the ear, but he has had a temperature on and off for 48 hours. He had a runny nose last week but is usually well with no past medical history. They do not have a thermometer at home, but he has felt hot. They have been giving him paracetamol and fluids. His temperature is 38.4, pulse and oxygen saturations normal. The external auditory canal looks normal, but the tympanic membrane is bulging on the left. What is the likely diagnosis?

A

Otitis media

26
Q

What is the most common infective cause of otitis media?

A

Viral - particularly respiratory viruses

27
Q

What are risks of antibiotic therapy if it is not clinically indicated?

A

To the patient: allergic reaction, gastrointestinal problems, risk of resistant organisms which are harder to treat in future
To community: increased antibiotic resistance

28
Q

84 y/o F with left leg red and painful. Known to have venous leg ulcers and district nurses attend her regularly for dressings. She has osteoarthritis and has had a previous right sided total hip replacement and is house-bound. She is on medication for hypertension and AF. Been getting more sore for 3 days and now feels hot. She feels shivery and unwell. She has no chest pain, SOB or urinary symptoms. Her temperature is 38.4, blood pressure 150/80 and pulse 90. Marked erythaema around an ulcer on medial aspect of her left leg which extends above her knee and is hot and tender.
What is the likely diagnosis?

A

Cellulitis

Should also consider deep vein thrombosis in unilateral swollen leg

29
Q

What antibiotic would you give for MRSA causing cellulitis in a patient who is not in hospital?

A

Prescribe an agent shown to be active against the MRSA, which can be given in the community (not gentamicin). In practice use doxycycline as it is easier to take than tetracycline
Fusidic acid and rifampicin should never be used as single agents for treatment of infection as bacteria can evolve to resistance with a single point mutation. They may be useful as part of a combination therapy

30
Q

What antibiotics would you give for sepsis of unknown origin?

A

Amoxicillin
Metronidazole
Single dose gentamicin

31
Q

What are common causes of meningitis?

A

Streptococcus pneumoniae is the commonest cause in older age group
Neisseria meningitidis (meningococcus) common cause in young people
Haemophilus influenzae: Hib
Listeria common in pregnancy

32
Q

What is the treatment regimen for meningitis?

A

Ceftriaxone: covers H. Influenzae, strep pneumoniae, Neisseria meningitides
Amoxicillin: covers listeria
Aciclovir: covers viral

33
Q

What would you expect the protein and glucose results to be if there is bacterial meningitis suggested by cloudy CSF?

A

Raised CSF protein (>0.4g/L)

Low CSF glucose (

34
Q

Who other than your medical team and the microbiology lab need to know about a case of meningitis?

A

Public Health England: acute meningitis is a statutorily notifiable condition (by the clinician caring for the patient)
In practice, single case of pneumococcal meningitis, there is no public health action needed

35
Q

What is sarcoidosis?

A

Multisystem granulomatous disorder
Noncaseating granulomas in lungs
Arthritis, erythema nodosum, fever, bilateral hilar adenopathy on chest X-ray
Dyspnoea, cough, chest discomfort, wheeze

36
Q

Describe the embryology of how the lungs develop

A

At beginning of 4th week, tracheal buds form off oesophagus
By end of 4th week, bronchial buds form off trachea
These develop until 8 weeks at which point the basic lobar structure of the lungs is complete

37
Q

What is the nerve supply to the upper airway?

A

Cranial Nerves V, IX, X
Glossophayngeal: posterior part of tongue and pharynx – gag reflex
Terminal branches of Ophthalmic and Maxillary division of V supply nasopharynx and turbinates
Lingular branch of Mandibular division of V supplies anterior 2/3 of tongue

38
Q

What is the Pterygopalatine ganglion?

A

Parasympathetic ganglion in pterygopalatine fossa
Innervated by greater petrosal branch of facial nerve
Axons project to lacrimal glands and nasal mucosa

39
Q

What important airway reflexes are there? Which nerves control these?

A

Gag reflex: Protects upper airway! Sensory input from Glossopharyngeal, efferent from Vagus
Glottis closure reflex: Protects Upper airway, Sensory- Superior laryngeal nerve, Efferent- recurrent laryngeal nerve, Severe form of this is laryngospasm
Cough Reflex: mediated by Vagus to protect lower airways

40
Q

What are the functions of the upper airway?

A 
Protects against aspiration
Humidifies dry air from atmosphere to its saturated vapour pressure by the time it reaches alveoli
Heats up air to body temperature
Filters off particles 
Immunological function
41
Q

What infra glottic airway devices are available?

A

Endotracheal tubes
Endo-bronchial tubes
Cricothyrodotomy
Tracheostomy

42
Q

What are advantages and disadvantages of laryngeal masks and i-gels?

A 
Ensures patent airway
Minimal or no training  
Frees up both hands
Can ventilate patient (with caution)
Does not protect against aspiration
43
Q

What are differences between first and second generation supra glottic airway devices?

A

First gen: Do not have a separate portal that communicates
with gastric passages. No bite blocks
Second gen: Have a gastric portal to minimise chances of aspiration. Has a bite block. Can withstand higher pressures during ventilation because of their unique design

44
Q

What are advantages and disadvantages of intubation?

A

Nasal or oral
Protection against aspiration, definitive airway
Best for controlled ventilation
Requires training
Be aware of potential pit falls and complications

45
Q

What are indications for intubation?

A

Unconscious unresponsive patients with a GCS of 8 or under
Cardiac arrest to maximise oxygenation and protect airway from aspiration
Emergency surgery (full stomach aspiration risk)
Major Surgery (blood loss, Muscle relaxation)
Prolonged surgery (Lasting over 4 hours)
Head and Neck surgery (sharing of site, blood in airway, potential loss of airway)
Patient position e.g. prone, change of position
Premature/infants/neonates (deoxygenate quickly, high resistance to ventilation)

46
Q

What specific tests can be performed as part of an airway assessment?

A

Mallampati: distance from from tongue base to roof of mouth
Thyromental distance: thyroid notch to tip of jaw with head extended
Wilson’s test: weight, head and neck movement, jaw movement, mandibular size, prominence of upper incisors
X-rays/scans

47
Q

What does lemons stand for in an airway assessment for intubation?

A 
Look
Evaluate: 3:3:2 rule, Three fingers in mouth, Three fingers in Thyromental distance, Two fingers between hyoid and laryngeal notch
Mallampati
Obstruction
Neck mobility
Saturation
48
Q

What might you do in an obese patient to aid intubation?

A

Ramping

Prop their head up with cushions so that ear and sternum are parallel

49
Q

Describe the technique for oral intubation

A 
GA mostly ( in rare cases Awake)
Full monitoring/trained assistant
Position of head vs neck
Laryngoscope held in left hand
Move tongue to left
Advance scope till tip in valeculla
Lift forward and upward
Do not lever back on the teeth
50
Q

When might you use nasal intubation as opposed to oral?

A 
Smaller tubes/dedicated tubes
More comfortable for awake/sedated patient
ENT/Maxillifacial/neck surgery
Ideal for awake fibreoptic intubation
Long term intubation on ICU
Paediatrics
51
Q

What are potential problems with nasal intubation?

A

Risk of torrential bleeding
Infection
Avoid in base of skull fracture

52
Q

How can you confirm correct position after intubation?

A

Direct vision, see tubes pass through the cords
Auscultation
Misting
End tidal CO2: max conc of CO2 at end of exhaled breath
X-ray

53
Q

What are potential complications of intubation?

A 
Direct trauma: Lips, teeth, tongue, pharynx, cords, trachea
Sore throat, Bleeding (tumours)
Cuff pressure – Ischaemia to mucosa
Stricture (narrowing)
Hypoxia
Bronchial intubation
Oesophageal intubation
Aspiration
Difficult or failed intubation
54
Q

When maxillofacial, cervical spine, head or soft tissue injuries are present, what factors may prevent ventilation?

A

Gross distortion
Airway obstruction
Massive emesis
Significant hemorrhage

55
Q

Describe the procedure of an emergency cricothyroidotomy

A

Stabilise larynx with one hand
Uing a scalpel or haemostat, cut or poke through cricothyroid membrane
A rush of air may be felt through the opening
Insert end of ET tube into trachea directed towards lungs and inflate
the cuff with 5-10 ml of air
Advance tube no more than 2-3 inches; further intubation could result in right main stem broncus inubation only

56
Q

What are potential complications of emergency cricothyroidotomy?

A 
Incorrect tube placement
Blood aspiration
Oesophageal laceration
Haematoma
Tracheal wall perforation
Vocal cord paralysis, hoarseness

AC1 (18 decks)

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