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Internal Medicine > Respiratory > Flashcards

Respiratory Flashcards

1
Q

Type 1 Respiratory Failure

A

Low O2, low CO2

Emphysema, astham, pneumonia, pulmonary oedema, PE

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2
Q

Type 2 Respiratory Failure

A

Low O2, high CO2

Chronic bronchitis, COPD, life-threatening asthma, Guillain-Barre with respiratory failure

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3
Q

Asthma

A

Chronic inflammatory disorder of the airways. Often with family history of atopy (asthma, allergic rhinitis, eczema). Occupational asthma also present.

Triggers
- URTI, allergens, irritants, drugs (NSAIDs, B-blockers)

Signs
- Dyspnea, wheezing, chest tightness, nocturnal cough, sputum

Partly controlled asthma:

  • Daytime: >2/wk
  • Night-time: any
  • Limitations of activity: any
  • Reliever treatment: >2/wk
  • Exacerbation: >1/yr

Investigations

  • O2 sats
  • ABGs
  • Pulmonary function test

Treatment:

  • Education, avoid triggers
  • Pharmacological: SABA, inhaled corticosteroids, LABA, anti-IgE

Hospital admission:

  • Require bronchodilator more than 3 hourly
  • Persisting oxygen desat at <92%

Emergency management

1) inhaled SABA
2) systemic steroids
3) anticholinergic therapy + Mg
4) intubation in life threatening cases
5) SC adrenaline
6) corticosteroid therapy at discharge

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4
Q

Chronic obstructive pulmonary disease

A

Progressive and irreversible condition of the lung. 2 types: chronic bronchitis and emphysema

Bronchitis:

  • chronic productive cough, purulent sputum, hemoptysis, mild dyspnea
  • cyanosis, peripheral edema from cor pulmonale, crackles, wheeze, prolonged expiration

Emphysema:

  • dyspnea, minimal cough, tachypnea, decreased exercise tolerance
  • pink skin, pursed lip breathing, accessory muscle use, hyperinflation, decreased breath sounds

Treatment
Prolong survival: smoking cessation, vaccination, home oxygen
Symptomatic relief: bronchodilators (SA: ipratropium/salbutamol, LA: tiotropium/salmeterol), corticosteroids, lung transplant.

Acute exacerbations of COPD

  • Causes: viral URTI, bacteria, air pollution, CHF, PE, MI
  • Management: O2 (88-92% for CO2 retainers), bronchodilators, systemic corticosteroids, antibiotics (amoxicillin, cefaclor, erythromycin)
  • ICU admission for life threatening exacerbations

Complications:

  • Polycythemia secondary to hypoxemia
  • Pulmonary HTN due to vasoconstriction
  • Cor pulmonale
  • Pneumothorax
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5
Q

Bronchiectasis

A

Irreversible dilatation of airways due to inflammatory destruction of airway walls by persistently infected mucous.
P. aeruginosa, S. aureus, H. influenza are common pathogens.

Features: chronic cough, purulent sputum, hemoptysis, recurrent pneumonia, local crackles, wheezes, clubbing.

Treatment:

  • Vaccination, influenza, pneumonia
  • Abx and inhaled corticosteroids for acute exacerbations
  • Chest physiotherapy, breathing exercises, physical exercise
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6
Q

Cystic fibrosis

A

Chloride transport dysfunction, thick secretions from exocrine glands (lung, pancreas, skin, reproductive organs) and blockage of ducts.

Features: chronic bronchitis, pancreatic insufficiency, diabetes, azoospermia.

Infections: S.aureus, P. aeruginnosa, B. cepacia, Aspergillus fumigatus

Investigations:

  • Sweat chloride test >60 mmol/L in children
  • PFTs, ABGs, CXR

Treatment

  • Chest physiotherapy and postural drainage
  • Bronchdilators
  • Inhaled mucolytic, hypertonic saline DNase
  • Inhaled tobramycin
  • Abx: ciprofloxacin
  • Pancreatic enzyme replacement
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7
Q

Interstitial lung disease

A

Inflammatory and/or fibrosing process in the alveolar walls, distortion and destruction of normal alveoli. Associated with lung restriction, decreased lung compliance, impaired diffusion, hypoxemia (V/Q mismatch), pulmonary HTN or cor pulmonale

Features: SOB, nonproductive cough, fine crackles, clubbing, cor pulmonale features

Unknown etiology:

  • Idiopathic interstitial pneumonias
  • Sarcoidosis
  • Langerhans-cell histocytosis
  • Pulmonary infiltrates with eosinophilia

Known etiology:

  • Systemic rheumatic disorders: scleroderma, RA, SLE, polymyositis, mixed connective disease
  • Environmental: hypersensitivity pneumonitis, pneumoconioses
  • Drugs/treatment
  • Pulmonary vasculitis: Wegener’s granulomatosis, Goodpasture’s syndrome, idiopathic pulmonary hemosiderosis
  • Inherited disorders: familial IPF, neurofibromatosis, tuberous sclerosis, Gaucher’s disease
  • Alveolar filling disorders: chronic eosinophilic pneumonia, pulmonary alveolar proteinosis
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8
Q

Idiopathic pulmonary fibrosis

A

Progressive, irriversible fibrosis of the lung parenchyma with no known cause.

Features: commonly presents >50 yrs with SOB and dry cough

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9
Q

Causative agents of interstitial lung disease

A

Hypersensitivity pneumonitis

  • extrinsic allergic alveolitis, due to sensitisation to inhaled agents.
  • Farmer’s lungs, Bird Fancier’s lung, Humidifier lung
  • Presents 4-6h after exposure in acute, insidious onset in chronic presentation.

Pneumoconioses

  • Reaction to inhaled organic dust
  • Asbestosis: lower lobes, calcified pleural plaques, round atelectasis, mesothelioma
  • Silicosis: upper lobes, nodular disease
  • Coal worker’s pneumoconiosis: upper lobe, coal macule

Drug induced ILD

  • Antineoplastic: methotrexate, cyclophosphamide, chlorambucil
  • Antibiotics: nitrofurantoin, penicillin, sulfonamide
  • Cardiovascular: amiodarone
  • Illicit: heroin, methadone

Radiation-induced

  • early pneumonitis ~wks
  • late fibrosis 6-12 months
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10
Q

Sarcoidosis

A

Idiopathic non-infectious granulomatous multisystem with lung involvement.

Features: cough, dyspnea, fever, arthralgia, malaise, erythema nodosum, chest pain.

Investigations:

  • FBC
  • Serum U&E, Ca (vit D activation by granulomas)
  • Elevated ACE
  • CXR predominantly nodular opacities in upper lung zones + bilar adenopathy
  • PFT

Diagnosis:
- Biopsy

Treatment:

  • Earlier stages may resolve spontaneously
  • Steroids, methotrexate and other immunosuppressives may be used
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11
Q

Pulmonary hypertension

A

MAP of pulmonary artery >25 mmHg or systolic >40 mmHg.

Mechanisms:
Hypoxic vasoconstriction - down regulation of NO synthase and alteration of endothelium leading to vasoconstriction
Decreased area of pulmonary vascular bed - rise in resting pulmonary arterial pressure
Volume and pressure overload - excessive volume overload.

Classifications
I) Pulmonary arterial HTN - idiopathic, collagen vascular disease, Eisenmenger syndrome, portopulmonary HTN, HIV infection, sickle cell disease
II) Pulmonary HTN due to left heart disease - LV dysfunction, aortic stenosis, mitral stenosis
III) Pulmonary HTN due to lung disease/hypoxia - parenchymal lung disease, chronic alveolar hypoxia
IV) Chronic thromboembolic pulmonary HTN - thromboembolic obstruction of pulmonary arteries
V) Pulmonary HTN with unclear mechanisms - hematologic disorders, systemic, metabolic disorders

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12
Q

Idiopathic pulmonary arterial hypertension

A

Features: young women 20-40yrs, sporadic, present with dyspnea, fatigue, syncope, exertional chest pain , Raynaud’s pheonmenon.

Investigations:

  • CXR: enlarged central pulmonary arteries
  • ECG: RVH/strain
  • Cardiac catheterization

Treatment:
- Trial of CCB

Prognosis:
- 2-3yr mean survival

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13
Q

Pulmonary embolism

A

Risk factors:

  • Stasis: immobilisation, obesity, CHF, chronic venous insufficiency
  • Endothelial damage: post-operative, trauma
  • Hypercoagulable states: malignancy, cancer treatment, estrogen, pregnancy, prior DVT/PE, nephrotic syndrome, coagulopathies, increasing age

Investigations:

  • Pulmonary angiogram
  • D-dimer
  • CT angiogram
  • Venous duplex US or Doppler
  • ECG (S1Q3T3)
  • CXR (atelectasis, pleural effusion

Treatment

  • Oxygen
  • Analgesia
  • Acute anticoagulation: IV heparin, enoxapain
  • Long term anticoagulation: warfarin, enoxaparin (pregnancy, active cancer)
  • IV thrombolytic therapy/interventional thrombolytic therapy,
  • IVC filter for absolute CI to anticoagulants

Thromboprophylaxis

  • LMWH
  • Fonaparinux
  • Warfarin
  • Dabigatran
  • Heparin
  • TED stockings
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14
Q

Pulmonary vasulitis

A

Wegner’s Granulomatosis

  • systemic vasculitis of med/small arteries
  • necrotising granulomatous lesions of upper and lower resp tract
  • GN, focal necrotising lesions
  • C-ANCA positive

Churg-Strauss Syndrome

  • multisystem disorder characterised by allergic rhinitis, asthma, prominent peripherla eosinophilia
  • asthma, infiltrates
  • life threatening systemic vasculitis

Goodpasture’s Disease

  • disorder chrarcterised by diffuse alveolar hemorrhage and glomerulonephritis (anti-GBM antibodies)
  • hemoptysis
  • anemia, glomerulonephritis

SLE
RA
Scleroderma

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15
Q

Mediatinal masses

A

Anterior compartment

  • Thymoma
  • Thyroid enlargement
  • Teratoma
  • Thoracic aneurysm
  • Tumours: lymphoma, parathyroid, esophageal angiomatous

Middle compartment

  • Pericardial cyst
  • Bronchogenic cyst/tumour
  • Lymphoma
  • Lymph node enlargment
  • Aortic aneurysm

Posterior compartment

  • Neurogenic tumours
  • Meningocele
  • Enteric cysts
  • Lymphoma
  • Diaphragmatic hernias
  • Esophageal tumour
  • Aortic aneurysm

Signs

  • Asymptomatic 50%
  • Chest pain, cough, dyspnea, recurrent respiratory infections
  • Hoarseness, dysphagia, Horner’s syndrome, SVC compression
  • Paraneoplastic syndromes (myarthenia gravis)
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16
Q

Mediatinitis

A

Most commonly caused by post-op complications of cardiovascular or thoracic surgery.

Signs

  • Fever, substernal pain
  • Pneumomediastinum, mediastinal compression
17
Q

Pleural effusions

A

Light’s criteria
Transudate: p:s protein ratio <0.5, p:s LDH ratio <0.6, pleural LDH <2/3 ULN of serum LDH
Exudate: p:s protein ratio >0.5, p:s LDH ratio >0.6, pleural LDH >2/3 ULN of serum LDH

Transudative effusion

  • Increased capillary hydrostatic pressure: CHF, PE
  • Decreased plasma oncotic pressure: cirrhosis, nephrotic syndrome

Exudative effusion

  • Infectious: bacterial pneumonia, empyema, TB pleuritis, viral infection
  • Malignancy: lung carcinoma, lymphoma, metastases
  • Inflammatory: RA, SLE, PE, post CABG, drug reaction
  • Intra-abdominal: sub-phrenic abcess, pancreatic disease, Meig’s syndrome
  • Intra-thoracic: esophageal perforation
  • Trauma: chylothorax, hemothorax, pneumothorax

Investigations:

  • PA CXR seen >200mL
  • lateral CXR seen >50mL

Treatment:

  • Thoracentesis
  • Chest drain
18
Q

Empyema

A

Pus in pleural space due to infection.

Treatment:

  • Chest drain
  • Antibiotics for 4-6wks
19
Q

Pneumothorax

A

Air in pleural space

Etiology:

  • Traumatic: chest injuries
  • Iatrogenic: central venous catheter, thoracentesis, mechanical ventilation
  • Spontaneous: primary in young healthy males, secondary due to underlying lung disease

CXR: separation of visceral and parietal pleura, increased density and decreased lung volume on affected side

Treatment:

  • small, will resolve spontaneously
  • large chest drain with underwater seal
  • repeated requires pleurodesis or apical bullectomy
20
Q

Hypoxemic respiratory failure

A

Types

1) Low FiO2: high altitude, PaCO2 normal, A-a gradient normal, give oxygen therapy
2) Hypoventilation: drug overdose, PaCO2 high, A-a gradient normal, give oxygen and ventilation
3a) Shunt: pneumonia, ARDs, PaCO2 normal, A-a gradient high, improve cardiac output
3b) Shunt (right to left): pulmonary hypertension, PaCO2 normal, A-a gradient high, ventilation and increase cardiac output worsens breathing
4) Low mixed venous O2 content: shock, PaCO2 low, A-a gradient high, give oxygen and improve cardiac output
5) V/Q mismatch: COPD, PaCO2 high, A-a gradient high, give oxygen and ventilation
6) Diffusion impairment: ILD, emphysema, PaCO2 normal, A-agradient high, give oxygen and CPAP

21
Q

Hypercapnic respiratory failure

A

Types:

1) high inspired CO2
2) Low total ventilation: COPD, asthma, CF, brainstem stroke, Guillain-Barre
3) High deadspace ventilation: PE, shock
4) High CO2 production: fever, sepsis, acidosis

Treatment

  • reverse underlying pathology
  • suction of secretions, bronchodilators, treatment of infections
  • oxygenation, careful with chronic CO2 retainers
22
Q

Acute respiratory distress syndrome

A

Severe pulmonary distress, hypoxemia, non-cardiogrnic pulmonary edema.
Disruption of alveolar capillary membranes, leading to interstital pulmonary edema, reducing compliance, increase shunting, hypoxemia and pulmonary hypertension.

Clinical course

  • Exudative phase: first 7 days
  • Fibroproliferative phase: improves but may develop fibrotic lungs.

Causes:

  • Direct lung injury: aspiration, pneumonia, inhalation injury
  • Indirect lung injury: shock, sepsis, trauma, head trauma, intracranial hemorrhage, drug overdose
23
Q

Lung cancer

A

Bronchogenic cancers:
Small cell lung cancer - smoking correlation, centrally located with dissemination, oat cells, neuroendocrine cells
Non-small cell lung cancer:
- Squamous - most common, smoking correlation, central location with local invations, keratin, intercellular bridges
- Adenocarcinoma - poor smoking correlation, peripheral location with early distant metastasis, glandular, mucin producing
- Large cell cancer

Benign

  • Papillomas
  • Adenomas

2/3 of primary lung cancer is found in the upper lobes, 2/3 of metastases occur in the lower lung.

Primary lesion
- cough, dynpnea, chest pain, hemoptysis, clubbing

Metastasis

  • lung: pleural effusion, atelectasis, wheezing
  • pericardium: pericarditis, pericardial tamponade
  • esophageal compression: dysphagia
  • phrenic nerve: paralyzed diaphragm
  • recurrent laryngeal nerve: hoarsness
  • SCV syndrome: facial swelling, dilated neck veins, Pemberton’s sign
  • Pancoast tumour: Horner’s syndrome, brachial plexus palsy (C8 and T1)
  • rib and vertebrae: erosion
  • paraneoplastic syndromes

Paraneoplastic syndromes
Bronchogenic cancer: acanthosis nigricans, dermatomyositis
Squamous cell carcinoma: PTHrP
Small cell carcinoma: ectopic ACTH, SIADH, Lambert-Eaton syndrome, polymyositis

24
Q

Solitary Pulmonary nodules

A

Benign
- Infectious granuloma: TB
- Other infections: abcess, aspergilloma
Benign neoplasms: hamartoma, lipoma, fibroma
- Vascular: AV malformation, pulmonary varix
- Developmental: bronchogenic cyst
- Inflammatory: Wegener’s, rheumatoid, sarcoidosis

Malignant

  • Bronchogenic carcinoma
  • Metastatic lesions
  • Pulmonary carcinoid

Management:

  • Compare with previous CXR
  • CT thorax if appears malignant or changed
  • Repeat CXR in 3-6m if appears benign
25
Q

Sleep apnea

A

Obstructive

  • transient episodic obstruction of upper airway
  • weight loss, decreased alcohol/sedatives, nasal decongestion
  • CPAP, postural therapy

Central

  • transient episodic decrease in CNS drive to breathe
  • nasal BiPAP/CPAP

Internal Medicine (12 decks)

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