Respiratory Flashcards
Asthmatic patient is using Salbutamol inhaler twice daily, should any management changes be suggested?
If using salbutamol more than once or day or experiencing night symptoms then should step up to:
Budesonide (steroid inhaler)
Resp causes of clubbing?
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Bronchial carcinoma (cancer)
Bronchiectasis (chronic supporative lung disease)
Cystic fibrosis (chronic supporative lung disease)
Idiopathic pulmonary fibrosis
Asthma Rx
Step 1 = short- b agonist
Step 2 = corticosteroid + short b agonist
What is step 3?
And if this doesn’t work?
Long- b agonist (salmeterol)
Not working? Stop it and increase steroids
Not working? Add Montelukast (leukotriene R antagonist)
What is the highest dose of inhaler corticosteroid given in asthma?
2000 micrograms/day
Acute asthma Rx?
Salbutamol 5mg NEB QRS (b2-agonist)
Ipratropium bromide 500mg NEB (anti-mACh R)
Prednisolone 40mg PO
1st line treatment for COPD?
20ug Ipratropium (anti-mACh R) QDS 100ug Salbutamol (b2-agonist) QDS
COPD patient is on ipratropium and salbutamol inhalers and is still breathless, what is 2nd line Rx for COPD?
Salmeterol 50ug INH (long b2-agonist)
Tiotropium 18ug INH (long anti m-ACh R)
What is the strongest combination of medications that can be given to someone with COPD?
Budesonide (steroid)
Formeterol (long acting anti mAChR)
Steroid
Salmeterol (long b2-agonist)
What FEV1/FVC values give the different stages of COPD?
Stage 1 mild: >0.8
Stage 2 moderate: 0.5-0.79
Stage 3 severe: 0.3-0.49
Stage 4 very severe:
What FEV/FVC values of COPD would you give tiotropium (anti m-ACh R) or salmeterol (long b2 agonist) for?
Mild to moderate- FEV/FVC above 0.5
What Rx should be started for stage 3/4 severe COPD?
Budesonide (steroid) + Fumeterol +LABA
Difference between janeway lesions and Osler’s nodes?
Osler’s (ow): Tender nodes on finger pulp
Janeways (way?? WAY!! High 5!!): red non-tender macules on palm
What is Quincke’s sign?
Visible pulsation in the nail bed related to aortic regurgitation
Low diastolic pressure > high stroke volume
What can cause a regularly irregular heart beat?
2nd degree heartblock
regular premature ventricular contractions
Radio-radial delay is a sign of?
Aortic arch aneurysm
What part of the brain is responsible for neurogenic hyperventilation?
Pontine lesions
What kind of drug overdose might lead to increased breathing?
Those causing metabolic acidosis:
Aspirin
What is the difference between bronchitis and bronchiectasis?
Bronchitis occurs in COPD where chronic inflammation leads to increased secretions And narrowing of airways.
Bronchiectasis is irreversible dilatation of bronchi and bronchioles secondary to recurrent infections as in cystic fibrosis and immunodeficiency
How is chronic bronchitis (of COPD) defined clinically?
Sputum production on most days
For 3 months
Of 2 successive years
What particular problems may be precipitated by SHORT COURSES of steroids in the elderly?
Name 3
- Steroid psychosis
- Congestive cardiac failure- from fluid overload
- Unmasking of diabetes
(And of course the normal issues, peptic ulcers etc)
What features of a patient in acute respiratory distress would make you think about non-invasive positive pressure ventilation?
- Patient is starting to tire
2. PH
What PaO2 on air, when stable would warrant oxygen for use at home (should be used 15 hours a day)
A PaO2 of below 7.3kPa
What puts hospitals off prescribing cephalosporins for elderly patients with pneumonia?
Clostridium difficile colitis complication risk.
If an elderly patient has had the flu, which bacterial cause of pneumonia is commoner. What Rx is good for this?
Staph aureus
Flucloxacillin- (you stacked it and absolutely FLU)
What are common causes of pleural effusion in the elderly?
Heart failure
Pneumonia- empyema
Pulmonary embolism
Malignancy- especially in ‘white-out’ on CXR
What are the different types of lung cancer?
20% Small cell (metastasises early)- platinum chemo
80% Non-small cell: squamous, adenocarcinoma, large cell- lobectomy
How is malignant mesothelioma diagnosed?
Exposure to which toxin is associated with it?
High resolution CT scan may identify it but definite diagnosis needs:
Pleural Biopsy
Asbestos exposure
Causes of pulmonary fibrosis?
IE. FS (fu** sake)
Idiopathic (cryptogenic fibrosing alveolitis)
Exposure- Occupation, drugs (amiodarone antiarrhythmic, nitrofurantoin Abx, gold RHEUM)
Focal- TB, radiotherapy
Secondary- connective tissue disease, sarcoid
Patient has headache, vomiting, breathless. Is not cyanosed but PaO2 is 7kPa, Sats are 99% . Mucous membranes in the mouth are bright red.
Diagnosis?
Tests?
Carbon monoxide poisoning
IHx:carboxyhaemaglobin
Swinging pyrexia with shortness of breath and sputum suggests?
Collection of pus:
Para-pneumonic
Empyema (pleural space)
Cavity of pus
In acute asthma who would you consider giving magnesium sulphate to?
Those who do not have a good initial response to bronchodilators
Or life-threatening asthma
What peak flow readings should be aimed for before discharging asthma patients?
> 75% normal
What histological cell type of lung cancer is associated with ectopic hormone synthesis?
Small cell
-may secrete ADH leading to hyponatraemia
In lung function tests how do you test for reversibility of airway constriction (more asthma than COPD)?
More than a 15% change in FEV1 following 2 weeks of steroids
Indicates ongoing use of inhaled steroids
Normally long term oxygen therapy is given for COPD patients when their PaO2 goes below 7.3kPa but it is also indicated for below 8kPa if one of the following conditions are fulfilled:
Secondary Polycythaemia
Pulmonary hypertension
Peripheral oedema
Nocturnal hypoxaemia
If someone is under 40 and presenting with Lung Function Tests suggesting an obstructive picture without reversibility, what test should be done?
Serum a1-antitrypsin levels
What are acquired and congenital causes of bronchiectasis?
Aquired:
Local
obstruction- tumour, enlarged lymph node, foreign body
Post-infective -measles, whooping cough, TB
Systemic
Immunodeficiency- AIDs
Congenital
Local
Ciliary dyskinesia- primary, Kartagener’s, Young’s
Systemic
Cystic fibrosis
Immunoglobulin deficiencies- IgA selective, hypogammaglobulinaemia
A CF patient is treated for a pneumonia and given Flucloxacillin but the sputum remains green after antibiotics are given. What could be causing the infection and how should it be treated?
Pseudomonas aeruginosa (gram negative) Ciprofloxacin
More likely if hospital acquired or pneumonia is very severe
How is cystic fibrosis diagnosed?
Sodium level in sweat >60mmol/L
Gene analysis CFTR gene on chromosome 7
Absent vas deferens + epididymus
Patient has pneumonia and red cell agglutination on blood film. What may be the causative organism?
Mycoplasma pneumoniae (agglutination due to cold agglutinins) IgM shoots up
If pneumonia is severe with PaO2 below 8kPa what tests should be sent off?
Send urine off for legionella and pneumococcal (strep pneumo) antigen testing.
PCR sputum, serology for atypical organisms, viral serology
Under what circumstances would a pneumonia more likely to be due to anaerobic organism requiring metronidazole?
In comatosed aspiration pneumonia or when the patient has been on ITU
How do strep pneumo and staph pneumonias look different on CXR?
Strep pneumo- lobar consolidation
Staph aureus- bilateral cavitating bronchopneumonia
Which pneumonia may complicate an influenza infection?
Staphylococcal pneumonia
Staphylococcal pneumonia is found to be MRSA positive, which medications won’t work?
Can’t use flucloxacillin- try vancomycin
Patient has a cavitating upper lobe pneumonia, not responding to antibiotic treatment, what might be the causative organism?
Klebsiella- gram negative
Which pneumonia causes flu-like symptoms and then on xray has reticular-nodular shadowing/patchy consolidation?
How is it diagnosed?
Mycoplasma pneumoniae
PCR sputum/serology
What are the potential complications of mycoplasma pneumoniae infections?
Cold agglutinins > autoimmune haemolytic anaemia Erythema multiforme (target lesions on limbs)
Steven Johnson syndrome
Meningoencephalitis
Guillain-Barré syndrome
Patient with cough and green sputum and SOB
CXR: reticular nodular shadowing
EHx: difficulty standing up from a chair, weakness getting more distal
What’s the diagnosis?
Mycoplasma pneumoniae pneumonia with Guillain Barré onsetting (proximal weakness)
What abnormal blood results are associated with Legionella pneumonia?
U+E: low Na
FBC: low lymphocytes
LFTs: abnormal
How is legionella pneumonia diagnosed?
CXR: bi-basal consolidation
Urine antigen/culture
Which pneumonia organism is associated first with ear infection, hoarse voice and pharyngitis?
Chlamydiophilia psittaci
HIV +ve gentleman drops his saturations dramatically during exercise and is noted to have bilateral crepitations and a fever, CXR is normal. What could it be?
Pneumocystis jiroveci pneumonia
CXR may be normal or have bilateral perihilar interstitial shadowing
How does an empyema form?
Pus may accumulate in the pleural cavity as bacteria spreads in severe pneumonia
Or if an abscess ruptures
Which skin rash is associated with TB?
Erythema nodosum
Painful blue bruise-like lesions over two weeks
Rx of TB?
2 months:
Rifampicin
Isoniazid
Pyrazinamide
Ethambutol
4 months:
Rifampicin
Isoniazid
If miliary TB is suspected from xray, what further investigation should you do to check extent of infection?
Lumbar puncture to check for blood-bourne spread to meninges
Under what circumstances should patients be given TB treatment in hospital?
The patient:
Is ill
Unlikely to comply with treatment
The infection:
Is infectious (sputum smear is positive)
Or multi-drug resistant
How long should you give anti-TB treatment to someone who contracts TB meningitis?
12 months
9 months for boney TB
How long should you give TB treatment to those with boney TB?
9 months (of RIP at least)
12 for TB meningitis
What are the commonest causes of interstitial lung disease?
Sarcoid
Cryptogenic fibrosing alveolitis (pulmonary fibrosis)
What are the features of sarcoid on examination and investigation?
EHx:
Skin- erythema nodosum (acute), lupus pernio
Eyes- uveitis, conjunctivitis, keratoconjunctivitis sicca, glaucoma
Neuro- Bell’s, meningitis, neuropathy
Heart- cardiomyopathy, arrhythmias
IHx: bilateral hilar lymphadenopathy
How does tissue biopsy differentiate between TB and sarcoid?
TB- caseating granulomas
Sarcoid- non-caseating granulomas
What kind of lung cancer do you get a central cavitating lesion with typically?
Squamous cell carcinoma
For those with borderline personality disorder, what are the commonest defence mechanisms?
Acting out
Emotional hypochondriasis (noone can understand my pain!)
Splitting
Long term nitrofurantoin is know to cause what complication in some patients?
Lung fibrosis
Which UTI antibiotic causes a rise in potassium?
Trimethoprim
(Blocks epithelial Na channels, so less Na uptaken from urine into blood in exchange for K+
What condition is frothy white pink sputum associated with?
Pulmonary oedema
Patient has SaO2 of 7.6 and SaCO2 of 5.8. What type of respiratory failure is this?
Type 1
Type 1 is 02 6kPa (two things wrong)
Causes of restrictive picture of lung defect (FVC is lowered, but FEV1/FVC is normal)
Idiopathic
Infection- interstitial pneumonia, effusion
Autoimmune- sarcoid, connective tissue, pneumoconiosus (dust)
Mechanical- obesity, kyphosis, neuromuscular problems
CURB score?
Confusion (AMTS 7
RR>30
BP
Elderly patient with consolidation of the lung has an AMTS score of 8, urea 8mmol, RR 27, BP 80mmHg and is 70 years old. CURB score and corresponding action?
Score 4
1 = AMTS 7
1 = BP 30
3+ consider ITU
Which conditions are associated with reduced or absent spleen function?
Which vaccine should they recieve to prevent pneumonia?
Splenectomy/aplenia
Sickle cell
Coeliac disease
Pneumococcal vaccine
What antibiotics may be needed if MRSA is complicating a pneumonia?
Vancomycin or Teicoplanin
pneumonia causes of cavitating xray consolidation?
Bilateral cavitating bronchial: Staph
Upper lobe cavitating: Klebsiella
Pneumonia causes of bilateral consolidation on xray?
Bilateral cavitating bronchial= Staph
Bi-basal: legionella
Bilateral perihilar interstitial shadowing: Pneumocystis
Pneumonia causes of patchy consolidation:
Reticular nodular + patchy: Mycoplasma
Patchy: chlamydia psittai
Bilateral perihilar interstitial shadowing: Pneumocystis
How does staph, strep pneumo and mycoplasma look different on CXRs?
Bilateral cavitating bronchial: Staph
Lobar: strep pneumo
Reticular nodular + patchy: Mycoplasma
Patient has type 1 respiratory failure, when would you consider transferring them to ITU?
When for BP stabilising?
Pa02 doesn’t improve with oxygen or PaCO2 above 6kPa
If BP remains below 90mmHg despite fluids (ITU can give inotropes, adrenaline, noradrenaline)
Patient had a pneumonia and was recovering but had recurrent fever, on aspiration of their pleural effusion it was yellow, PH of 7.15, low glucose and LDH. Likely cause?
Empyema (effusion becomes infected = pus)
PH below 7.2, LDH + glucose low
Patient takes antibiotics for her pneumonia and becomes jaundice, what could be the cause?
Flucloxacillin
Co-amoxiclav
Xray findings of bronchiectasis on CXR?
Tramline and ring shadows or thickened bronchial walls.
What fungal infection are cystic fibrosis sufferers at risk of?
CF patient has recurrent pneumonia, how would you test for it?
Aspergillus fumigatus
IHx: CXR- consolidation, segment collapse, bronchiectasis
Aspergillus sputum
Aspergillus skin test or IgE RAST
Cystic fibrosis patient with aspergillus fulmgatus infection, Rx?
Due to hypersensitivity reaction so prednisolone 30mg for acute attacks.
Patient has come in coughing up blood feeling unwell, they recently finished treatment for their TB, on xray there is a round opacity in a cavity. Likely cause?
Aspergilloma- fungal ball colonising a pre-existing cavity from TB.
Giving antifungals has limited success
What is the problem with IV amphoteracin (antifungal)?
SO MANY POSSIBLE SIDE EFFECTS:
Anaphylaxis
Nephrotoxicity
Low K+, low Mg2+
What types of lung cancer make secrete ectopic hormones and which ones?
Small cell: ADH or ACTH (Cushing’s)
Squamous cell: PTCH
What cancer is associated with lambert eaton syndrome and what is the pathophysiology of this?
Small cell lung cancer
Antibodies against voltage gated Ca2+ channels causes reduced ACh release and muscle weakness
Features of severe asthma?
HR, RR, Peak flow etc
HR > 110
RR > 25
PEF 33-50%
Unable to complete sentences
Features of life-threatening asthma
Silent chest
Confusion, exhuastion
PaO2 below 8kPa with SpO2
What sign suggests an asthma attack has gone from being life threatening to nearly fatal?
Rising PaCO2
Normally hyperventilation keeps CO2 low
PaO2 below 8kPa means life threatening
Where in the treatment ladder for asthma is theophylline used? What is the problem with it?
SSLL (short b2, short steroid, long b2, leukotriene i, long steroid
Theophylline may be tried after increasing short steroid dose (step 3) instead of a leukotriene inhibitor
Narrow therapeutic range, can lead to fits + arrhythmias
What is the difference between progressive massive fibrosis and simple coal-worker’s pneumoconiosis?
PMF is a severe complication that may arise from SCWP or silicosis for example.
In SCWP focal disposition of coal and macrophages form macules, these may aggregate to form large nodules and fibrosis (PMF).
TB and rheumatoid may predispose to PMF
Which lung tumour often generates carcinoid tumours?
Bronchial adenomas
Pathophysiology of acute respiratory distress syndrome?
Lung damage > inflammatory mediators > capillary permeability > non-cardio pulmonary oedema
Causes: pneumonia, vasculitis, DIC… A multitude
What 4 things are required for a diagnosis of acute respiratory distress syndrome?
- Acute onset
- CXR- bilateral infiltrates
- Pulmonary capillary wedge pressure
A V/Q mismatch meaning inadequate perfusion for the level of ventilation occurs in which type of respiratory failure typically?
Type 1- low O2, normal CO2
(CO2 can be lost even with abit of arterial access to the lungs
Type 2- more to do with hypoventilation ± V/Q mismatch
What kind of a rise in PaCO2 after giving oxygen therapy in type 2 respiratory failure would make you consider non-invasive positive pressure ventilation?
If paCO2 rises by 1.5kPa whilst the patient is still hypoxic
What provides the definitive diagnosis in sarcoidosis?
Biopsy of lung, lymph nodes, skin nodules, lacrimal gland
= non-caseating granulomata
How does bronchiolar lavage indicate the stage or activity of sarcoidosis?
Raised lymphocytes indicate active disease (granulomatous)
Raised neutrophils indicate fibrosis (stage 4 disease)
Rx of acute sarcoid
Indications for steroids?
NSAIDs - acute
Steroids if: fibrosis, uveitis, high Ca, neuro/cardiac involvement
On CXR what differentiates coal worker’s pneumoconiosis from progressive massive fibrosis (the step along)?
CWP: round opacities
What is the problem in type 1 respiratory failure?
V/Q mismatch
Pulmonary oedema, PE etc
What is the problem in type 2 respiratory failure?
02 < 8kPa, CO2 > 6.6kPa
Alveolar hypoventilation
COPD, kyphosis, obesity etc
What causes pulmonary haemorrhage?
Vasculitidies
If a patient has bilateral effusions what is it most likely to be?
Most likely to be a failure
Heart failure- give trial of diuretics
Renal
Hepatic
If unilateral could be indicate of malignancy, parapneumonic etc-
Unilateral pleural effusion, what investigation would you do?
US guided pleural effusion
Then CT
If you suspect a lung cancer what investigations would you perform?
Wait until any pneumonic changes have resolved (6 weeks)
then CT»_space; PET»_space; biopsy
Can PET + biopsy if >1cm
What else will light up bright on a PET scan in the lung, aside from a malignancy?
Pleuritis- connective tissue disease
Pneumonia- inflammation
Which type of lung cancer is nastiest?
Small cell lung cancer- very likely to respond to chemo but also to reoccur
What kind of therapy is small cell carcinoma very sensitive to?
Chemo- likely to reoccur
In terms of DLCO and K, what changes would you expect in obesity
DLCO= diffusion capacity of lung (how well gases are absorbed)
KCO= diffusion adjusted for lung volume
Normal lung function in terms of diffusion but squashed lung so when adjusted for volume
Normal or reduced DLCO
Raised KCO because a normal DLCO in a small lung will cause a high absorption when adjusted for size. Obesity squashes the lungs.
What kPa of oxygen defines severe hypoxia?
<8kPa
Caused of a restrictive picture in spirometry tests?
Fibrosis (idiopathic, radiotherapy, past ARDS, connective tissue)
Sarcoid
Pneumoconiosis
Rare infiltrative causes (eosinophilic pneumonia, amyloid)
Kyphoscoliosis, neuromuscular problems, obesity
Which type of lung conditions need a high resolution CT with thin sections to diagnose them?
Interstitial lung diseases (fibrosis, sarcoid, pneumoconiosis, hypersensitivity pneumonitis)
Bronchiectasis
What are the indications of bronchoscopy?
Diagnostic: suspected malignancy, interstitial lung disease, pneumonia + immunosuppressed, slow resolving pneumonia
Therapeutic: remove mucus plug causing lobar collapse or foreign body, stenting or treating tumours (lasers)
What tests need to be done before doing a bronchoscopy?
FBC, pulse oximetry
CXR, Spirometry
Clotting if due biopsy and recent anti-coagulation
What change in spirometry results would make asthma more likely than COPD following bronchodilator therapy?
> 12% change in FEV1 or more than 0.2L
How can spirometry be used to determine neuromuscular weakness as a cause of hypoxia?
Check lung function when sitting or lying supine, if diaphragmatic muscles are paralysed then on lying, without gravity there will be a large decrease in vital capacity (25%)
Which medications can prompt symptoms in an adult with undiagnosed asthma?
NSAIDs or beta-blockers
In a patient with wheeze and shortness of breath that you are considering a diagnosis of asthma for, what symptoms are red flags or indications of other diagnoses?
(Think symptoms, findings and investigations)
Symptoms- non-variable breathlessness, chronic sputum
Systemic features- weight loss, fever, myalgia
Clinical findings- clubbing, cyanosis, crackles, cardiac disease
IHx- restrictive spirometry, CXR shadowing
If a patient with asthma is using their short acting b2 blocker more than how many times a week would you consider stepping up their treatment?
3 times a week
