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RCSI Medicine > Respiratory > Flashcards

Respiratory Flashcards

1
Q

define ARDS

A

An acute inflammatory process occurring in the lungs which leads to increased pulmonary vascular permeability and a build up of fluid in the alveoli reducing aerated lung tissue

causes impaired gas exchange and hypoxaemic respiratory failure

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2
Q

What are the causes of Ards (8)

A

Aspiration of gastric or bowel contents into lungs
Chemical inhalation
Lung transplant
Infections e.g. pneumonia from any cause
Severe trauma (i.e. bilateral lung confusion, fat embolism)
Septic shock
Burns
Massive transfusion
Drugs (overdose) and alcohol
Must exclude cardiac cause (not ARDS if caused by cardiac failure)

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3
Q

What are the causes of Ards (8)

A

Aspiration of gastric or bowel contents into lungs
Chemical inhalation
Lung transplant
Infections e.g. pneumonia from any cause
Severe trauma (i.e. bilateral lung confusion, fat embolism)
Septic shock
Burns
Massive transfusion
Drugs (overdose) and alcohol
Must exclude cardiac cause (not ARDS if caused by cardiac failure)

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4
Q

ARDS complication <7>

A

Secondary pulmonary fibrosis (may be irreversible)
Pneuomothorax due to lung stiffness and reduced compliance (Barotrauma from PEEP of ~ > 35mmH2O)
Abnormal lung function
obstruction / restriction / reduced diffusing capacity
Infection
Venous thromboembolism – Pulmonary embolism
Cognitive dysfunction / memory loss as a result of prolonged hypoxaemia and sedation related to ICU stay
Death

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5
Q

what are you most likely to die from with ARDS

A

usually older in age, multiple medical comorbidities, concomitant hepatic failure, history of alcoholism

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6
Q

define asthma

A

Chronic inflammatory disease of the airways associated with reversible airflow limitation and characterised clinically by recurrent respiratory symptoms of dyspnoea, wheezing, chest tightness and/or cough

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7
Q

Ddx asthma (10)

A 
COPD 
Acute Bronchitis
Bronchiectasis
Inhaled foreign body
Lung cancer/endobronchial tumour
Vocal cord dysfunction (inspiratory stridor) 
Gastro-oesophageal reflux
Left ventricular failure
Pulmonary embolism
Pulmonary eosinophilia
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8
Q

therapeutic investigation for asthma

A

Flexible Bronchoscopy – Washings for mucus plugging.

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9
Q

Gina guidelines

A

Variability
is a difference of >20% between morning and evening PEF with bronchodilator usage

Reversibility
is reflected by an increase in PEF >15% after inhalation of a fast-acting ß2-agonist

In patients without bronchodilator use, a variability of >10% meets the definition of asthma

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10
Q

obstructive pattern on spirometry

A

= FEV1/FVC < 70%

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11
Q

what is reversibility on spirometry

A

Reversibility = an FEV1 must increase by > 12%

or > 200 mls

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12
Q

Broncoprovaction test

A

The provocative concentration is the amount of inhaled agonist required to drop the FEV1 by 20% from the baseline

The amount of metacholine required to do this in asthma is usually < 8 mg/min

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13
Q

complication of asthma

A 
Status asthmaticus
Pneumothorax
Respiratory failure
Pneumomediastinum
Subcutaneous emphysema
Theophylline toxicity
Hypoxic brain injury
Complications 20 steroid therapy
Mortality with life-threatening asthma
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14
Q

COPD definition

A

COPD is a preventable and treatable disease characterised by airflow obstruction that is not fully reversible

The airflow limitation is usually progressive and is associated with an enhanced inflammatory response of the lungs to noxious particles/gases, primarily tobacco smoke

Heterogenous disease
Chronic Bronchitis
Emphysema

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15
Q

Signs of CO2 retention

A

CO2 rentension

  • dilated veins and warm periphery
  • astarexis
  • bounding pulse
  • papilledema
  • chemosis
  • decrease LOC
  • palmar erythemosis (weak finding)
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16
Q

Egg findings suggestive of Cor pulmonate

A

ECG (Suggestive of Cor pulmonale)

Tall P wave, RBBB, Right ventricular hypertrophy

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17
Q

in COPD what does the 6 minute walking test tell you

A

6 minute walk test

≤ 86% = indication for portable oxygen

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18
Q

when do you use NIV in acute exhasterbation of COPD

A

) if arterial pH < 7.35 and/or pCO2 > 6.5 kPa

fac

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19
Q

when is long term O2 therapy used

A

paO2 ≤ 7.3 kPa

paO2 < 8kPa with

  • pulmonary hypertension (clinical signs of cor pulmonale/right heart failure) or
  • echocardiogram showing a mean Pulmonary Artery Pressure (mPAP) > 20 mmHg
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20
Q

Surgery for COPD

A

Bullectomy

Lung Volume Reduction Surgery (LVRS)
Resection of the most severely affected areas of emphysematous lung
More beneficial in upper lobe emphysema

Lung transplantation

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21
Q

complication of COPD (11)

A

Acute exacerbations COPD
Hypoxia
Hypercapnia
Compensated Chronic Type II Hypercapnic Respiratory Failure
Acute acidotic hypercapnic respiratory failure
Pneumothorax 20 bullous rupture
Recurrent pneumonia
Cor pulmonale
Secondary Polycythaemia
Osteoporosis and diabetes 20 steroid therapy
Hearing impairment from azithromycin prophylaxis

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22
Q

Prognosis for COPD

A

uses the BODE score

  1. BMI
  2. Obstruction
  3. Dyspnea
  4. Exercise capacity
Approximate 4-year survival
0-2 points  = 80% 
3-4 points  = 67% 
5-6 points  = 57%
7-10 points = 18%
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23
Q

DDX of cOPD

A 
ABAC 
Asthma 
Bronchiectasis 
A1AT v
CCF

TB
Obliterated bronchiolitis

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24
Q

Ddx for CF

A

Non-CF Bronchiectasis

Common Variable Immunodeficiency (CVID)

Primary Ciliary Dyskinesia (Kartagener’s Syndrome)

Right middle lobe syndrome

Swyer-James Syndrome

Shwachman-Diamond Syndrome

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25
Q

Acute management of CF

A

Antimicrobial therapy tailored to known pathogens and sensitivies

Nebulised bronchodilators

Chest physiotherapy

Mucolytics; DNase (dornase-alpha)

Nutritional support

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26
Q

treatment for p. aeruginosa

A
  1. CIPROFLOXACIN PO _ ist isolate

2. exacerbation - treatment with B-lactam and amino glycoside

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27
Q

Burkholderia Cepacia complex

A

1 . ceftazidime

2. pip/tazo

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28
Q

Treatment of Macronodular Cirrhosis in CF

A

Ursodeoxycholic acid, taurine, seek specialist advice

Severe cases may need liver transplant

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29
Q

How do you treat complication CF arthropathy

A

NSAIDs, prednisolone +/- rheumatologist

st

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30
Q

drugs targeted to specific mutation

A 
Ataluren - class 1 mutation 
Lumacaftor - class 2 - delta508 
ivacaftor - class 3 - GG51D mutation
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31
Q

how often do you follow up CF patients

A

3 months for spirometry and sputum for cultures/sensitivity
6 months for nutritional screen/OGTT
1 year evaluation including CXR
2 yearly liver ultrasound and DEXA scans

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32
Q

when does a CF patient need a lung transplant

A

FEV1 < 30% predicted is an indication for referral for possible lung transplant

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33
Q

death in CF

A

Respiratory Failure
Pneumonia
Pneumothorax
Haemoptysis

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34
Q

Bronchiectasis

A

A disorder characterised by abnormal bronchial wall thickening and luminal dilatation of the central and medium-sized bronchi

Due to a vicious cycle of transmural infection and inflammation with mediator release

Prevalence increases with age

More common in females

Chronic cough, mucopurulent sputum

Haemoptysis, pleuritic pain, recurrent fever, wheeze and dyspnoea less frequent

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35
Q

Causes of bronchiectasis

A 
Idiopathic in 50% of adults and ~25% of children
Primary Ciliary Dyskinesia
Common Variable Immunodeficiency (CVID)
Cystic Fibrosis
Kartagener’s Syndrome
Post-infective causes-measles, pertussis, adenovirus, influenza
Mechanical obstruction
Pulmonary fibrosis
Right middle lobe syndrome
Swyer-James Syndrome
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36
Q

Bronchiectasis si ass. w/ (II CD MAM)

A 
Infertility
Inflammatory Bowel Disease (IBD)
Connective Tissue Disorders
Diffuse panbronchiolitis
Malignancy
AATD
Mercury poisoning
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37
Q

Radiological findings in bronchiectasis

A

Internal bronchial diameters 1.5 times greater than that of the adjacent pulmonary artery (signet ring sign)

Lack of bronchial tapering

Bronchial wall thickening, ‘tram lines’

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38
Q

upper lobe causes of fibrosis

A 
Upper Lobe Predominant
(SCHA-ARTS)
Silicosis
Coal worker’s lung
Histiocytosis X
Ankylosing Spondylitis
ABPA
Radiotherapy
TB
Sarcoidosis
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39
Q

Lower Lobe Predominant

A 
(RRASCO)
Rheumatoid Arthritis
Radiotherapy
Asbestosis
Scleroderma
Cryptogenic Fibrosing Alveolitis
Other (Methotrexate, Amiodarone, Nitrofurantion, Bleomycin, Busulfan)
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40
Q

when do you take a lung Bx when a patient has ILD

A 
Atypical progressive disease 
< 50yrs old
Fever
Weight loss
Haemoptysis
Vasculitis
Unexplained pulmonary hypertension
Cardiomegaly
Rapid deterioration
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41
Q

Complication iLD

A

Pulmonary Hypertension

Right Ventricular Failure/Cor pulmonale

Respiratory Failure

Secondary infections while on steroid or immunosuppressive therapy

~ 5% patients with LIP (Lymphoid Interstitial Pneumonia) progress to Pulmonary Lymphoma

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42
Q

IPF

A

chronic progressive fibrotic disorder of lower part of the rest tract , age > 40

43
Q

CXR IPF

A

Bibasilar
Reticulonodular
Infiltrates

Volume loss

Poorly defined pleural-
Parenchymal borders

44
Q

HRCT Thorax:

IPF

A

Subpleural fibrosis

Volume loss

Traction bronchiectasis

45
Q

HRCT Thorax:

NSIP

A

Ground-glass appearance

No significant volume loss

46
Q

Treatment of IPF vs. NSIP

A

NSIP - steroids 1mg.kg .day

NO STEROIDS for IPF 
1. Oxygen 
2. pulm rehabilitation 
3. vaccine 
Trial of sedenfil
47
Q

COP - CXR finding

A

CXR: multiple ground-glass or consolidative opacities
PFTs: restrictive ventilatory defect with reduced DLCO
Bronchoalveolar lavage to rule out infection/haemorrhage/malignancy
+/- Transbronchial biopsy +/- lung biopsy

48
Q

PULMONARY LYMPHANGIOLEIOMYOMATOSIS (LAM)

A

Rare Interstitial Lung disease

Young women of child-bearing age

Multiple cysts

Complications of pneumothorax and chylothorax

Affects 30% of women with Tuberous Sclerosis

No proven therapies; supportive treatment with bronchodilator therapy, oxygen and pulmonary rehabilitation

49
Q

median survival for IPF and NSIP

A

IPF is 2 -3 years from diagnosis

NSIp - 5 years

50
Q

what radiotherapy cancer’s make you increased risk of getting lung cancer

A

Radiotherapy for other malignancies
Breast cancer
Hodgkin’s Lymphoma

51
Q

Paraneoplastic syndromes of lung cancer

A

Hypercalcaemia (SquamCCa)
Syndrome of Inappropriate ADH secretion (Small CLC)
Ectopic ACTH secretion (Small CLC)
Cerebellar Syndrome (Small CLC)
Lambert-Eaton Myasthenic Syndrome (Small CLC)

52
Q

DDX of lung cancer

A 
Pneumonia
Exacerbation of COPD
Parapneumonic effusion
Tuberculosis
Carcinoid
Mesothelioma
Metastatic lung disease
Benign lung disease
53
Q

T stages for lung cancer

A

tx - no assessed
t1 - <3cm - DOESN’t involve the main bronchus
T2 - 3-5cm + involves
- main bronchus
- visceral
- ass/ w/ atelectasis, obstructive penumonititis
T3 - 5- 7cm or has direct invasion with
1. chest wall
2. pleural Nerve
3. partial pericardium
4. tumour nodules
T4 - > 7 cm - or invades one of the following
- diaphragm , mediastinum
- heart, great vessels
- trachea , recurrent LN, esophagus
- vertebral body
- carina
- separate tumour nodules or ipsilateral lobe of primary

54
Q

N staging for Lung cancer

A

N1 - ipsilateral peribronchial ± ipsilateral hilar LN Plus intrapulmonary nodules

N2 - ipsilateral mediastinum ± subcarnial LN

N3: contralateral mediastinum
Contralateral hilar
ipsilateral or contralateral scalene or supraclavicular LN

55
Q

M staging for lung cancer

A

M - no distant mets
M1 - distant mets
M1a - separate tumour nodule in CL lobe
tumour with pleural or pericardial node
malignant pleural or pericardial effusion
M1b - extrathroacic mets in single organ
M1c - multiple extra thoracic mets in one or several organs

56
Q

Limited staging vs. extensive staging

A

Limited - confined to ipsilateral hemithroax and regional LN

Extensive - distant mets contralateral SC and hilar LN , pericardial or pleural involvement

57
Q

treatment for limited staging SCLC

A

CHEMO + thoracic RTX (platinum based chemo and etoposide)

Prophylactic cranial irradiation

58
Q

treatment for extensive staging SCLC

A
  • Palliative chemo
  • increase survival 2-10 months
  • whole brain RTX for brain mets
  • palliative care
59
Q

NSCLC treatment

A

T1,2,3

  • SURGERY ( thoracotomy for lobectomyy and pneumonectomy OR VATS for wedge decision, lobectomy)
  • CHEMO
    • platinum doublet ± bevacizumab
    • non squamous type - pemtrexed
  • RTX / ST RTX
  • TKI - ertotinib, Gefitinib (if EGFR oncogene)
  • ALK TK inhibitors if ALk fusion oncogene +
    - crizotinib
60
Q

ECOG performance

A

Performance status is a scoring system used to identify a cancer patient’s general wellbeing and activities of daily living

61
Q

PANCOAST TUMOUR/SUPERIOR SULCUS TUMOUR

A

Defines a tumour located at the apical pleuropulmonary groove, adjacent to the subclavian vessels

62
Q

Pancoast Syndrome

A

Shoulder and arm pain (C8, T1, T2 dermatomes)
Horner’s Syndrome
Wasting and weakness of the small muscles of the hand

63
Q

Lung cancer

A 
Pleural effusion
Post-obstructive Pneumonia
Pulmonary Embolism
Pericardial effusion
Brain Metastases
Bone Metastases
Hypercalcaemia
Superior Vena Cava Obstruction
SIADH
Ectopic ACTH production
Pancoast Tumour
Lambert-Eaton Myasthenic Syndrome
Cerebellar Syndrome
64
Q

influenza vaccine indication (8)

A 
age > 65 years
Institutionalisation
chronic cardiac diseases
chronic pulmonary diseases
unstable diabetes mellitus
chronic renal diseases
Immuno-compromised persons
Women in the second or third trimester of pregnancy during the influenza season
65
Q

Pneumococcal vaccine (9)

A 
recommended for persons at risk for pneumococcal disease
age > 65 years
institutionalisation
cerebrovascular disease, dementia, seizure disorders
congestive heart failure
chronic obstructive pulmonary disease
history of prior pneumonia
chronic liver disease
diabetes mellitus
chronic cerebrospinal fluid leakage
66
Q

Acute complication of pneumonia

A 
Pleural effusion
Empyema
Pulmonary haemorrhage
Septicaemia, septic shock
Type 1 or 2 respiratory failure
Acute Respiratory Distress Syndrome (ARDS)
Mortality
67
Q

chronic complication of pneumonia

A

Bronchiectasis

Cavitation-classically staphylococcal and klebsiella pneumonia

68
Q

systemic complication of pneumonia

A

SIADH
Deranged LFTs/biochemical hepatitis

Mycoplasma
Stevens – Johnson syndrome 	
Haemolytic anaemia 
Pericarditis , myocarditis 
headache

Legionella

  • hypoNa
  • GI . diarrhea, abdo pain
  • ARF
69
Q

high risk of asbestosis exposure

A 
Asbestos miner
Shipyard worker
Textile mill worker
Firefighter
Insulators
Construction workers
Boiler repair workers
70
Q

Ddx of mesothelioma

A

Pleural effusion from any other cause.
Benign asbestos related pleural thickening.
Primary bronchogenic carcinoma.
Pleural fibrosis from infection or inflammation (e.g. tuberculosis, actinomycetes).
Pleural metastases (pleural carcinomatosis).
Solitary fibrous tumour of pleura.

71
Q

Signs of poor prognosis mesothelioma (8)

A

ABG. Possibility of needing supplemental O2
LDH (> 500 IU/L associated with poor prognosis)
FBC for platelet count. (> 400,000/microL = poor prognosis)
Non-epithelial histology.

Age >75
Poor ECOG
Chest pain present
Pleural involvement

72
Q

Complication of mesothelioma

A

Symptomatic pleural effusion
Respiratory failure due to lung encasement or pleural thickening
Chest pain due to direct tissue / organ infiltration
Facial and swelling due to superior vena cava obstruction (SVC syndrome)
Dysphagia
Paraneoplastic disease (hypercalcaemia, DIC et cetera)
Death

73
Q

Survival for mesothelioma

A

8-14 mon - pleural mediastinum

7 mon - peritoneal mediastinum

74
Q

Define mesothelioma

A

Malignant neoplasm which arises from the mesothelial cells in the pleural cavity.
Less commonly can arise from peritoneal cavity or pericardium.

75
Q

OSA definition

A

Reurrent collapse of the pharyngeal airway during sleep resulting in complete / near complete cessation of airflow despite normal breathing effort.
Leads to intermittent disturbance in gas exhange and fragmented sleep due to associated arousals.

76
Q

OSA risk factors

A 
Male gender
Advancing age
Obesity and increased neck circumference
Cranio-facial and upper airway abnormalities
Retrognathia 
Large tonsils obstructing upper airway
Acromegaly 
Hypothyroidism
Nasal congestion
77
Q

Crowded airway

A 
Narcolepsy
Depression
Hypothyroidism
Seizures
Periodic limb movement disorder / restless leg syndrome
Drugs
SSRIs, beta blockers, sedatives, alcohol
Shift worker syndrome
Sleep deprivation (quantity of sleep)
Fragmented sleep (quality of sleep)
Insomnia
Primary snoring
78
Q

OSA on polysomography

A

5 or more respiratory events per hour of sleep and associated symptoms or typical history: AHI > 5 per hour

Apnoea-Hypopnoea Index (AHI) greater than 15 per hour regardless of symptoms or comorbidities

79
Q

OSA complications

A

Untreated OSA can lead to cardiovascular events such as stroke, arrhythmias and myocardial infarction

Potentiates pre-existing hypertension

Road traffic accidents due to sleepiness while driving

Reduced quality of life

Memory issues

80
Q

Ddx of pleural effusion

A 
Parapneumonic pleural effusion
Malignant pleural effusion
Empyema
Lung mass
Congestive Cardiac Failure
Nephrotic Syndrome
Cirrhosis
Hypothyroidism
Acute pancreatitis
Sarcoid
Meig’s Syndrome
81
Q

how do you perform a pleural aspiration under US

A 
Sterile dressing pack
Sterile gloves
Antiseptic solution
1% lignocaine
50ml syringe
3 x 20 ml universal containers
ABG needle
Sterile dressing
82
Q

Lights criteria

A

Pleural fluid protein: Serum protein > 0.5

Pleural fluid LDH: Serum LDH > 0.6

Pleural fluid LDH> 2/3 upper limit normal blood LDH

83
Q

Criteria to put in a drain

A

Complicated para-pneumonic pleural effusion
Empyema; frankly purulent pleural fluid or pleural fluid pH < 7.2
Malignant pleural effusion +/- combined with talc pleurodesis
Symptomatic relief of large pleural effusion
Traumatic haemopneumothorax

84
Q

complication of pleural effusions

A

REC FT

Empyema
Recurrence of pleural effusion
Fibrothorax
Trapped Lung
Complications secondary to drain insertion
Infection
Bleeding
Haemopneumothorax
Subcutaneous emphysema
85
Q

causes of pleural effusion

A

CANCER:
Bronchogenic carcinoma
Mesothelioma
Metastatic disease (lung, breast, lymphoma, ovary, pancreas)

INFECTIOn:
Pneumonia (parapneumonic)
TB
Empyema

OTHER:
Pulmonary infarct (post PE)
Asbestosis

RA
SLE

Dressler’s syndrome
Yellow-nail syndrome (VERY RARE)

86
Q

Conditions that have an elevated D-dimer

A

PULMONARY EMBOLISM
Heart failure
Pneumonia
95% of patients with recent surgery or malignancy

87
Q

Consider iv unfractionated heparin when there is

A

Persistent hypotension SBP < 90mmHg in a massive PE ( may need to proceed to thrombolysis)
Increased risk of bleeding
Concern about subcutaneous malabsorption (morbid obesity)

88
Q

Indication for thrombolysis in PE

A 
Indications for Thrombolysis in PE	
massive PE
cardiogenic shock
hemodynamic instability
Transit thrombus seen on ECHO in right ventricle
89
Q

indication for IVC filter in acute TE

A

An absolute contraindication to therapeutic anticoagulation

Failure of anticoagulant therapy when there is acute proximal venous thrombosis

90
Q

when do you do an embolectomy in pt with PE

A

Considered when a patient’s presentation is severe enough to warrant thrombolysis, but thrombolytic therapy either fails or is contraindicated.

91
Q

Risk of embolectomy for PE

A

Requires cardiopulmonary bypass - carries high risk in mortality

Much better to have IR do the embolectomy but not always offered in hospital

92
Q

complication pulm embolism

A

Pulmonary infarction (May resemble pneumonia on CXR)
Arrhythmias
Pleural effusion
Pulmonary Hypertension (Chronic Thromboembolic Pulmonary Hypertension = CTEPH)
Right ventricular failure
Bleeding complications 20 anticoagulation
Thrombocytopaenia 20 anticoagulation
Cardiorespiratory arrest and sudden death

93
Q

what is prophylactic dosage of tinazeparin and enozaparin for PE in surgical patients

A

Tinazeparin 300 IU od sc

Enoxaparin 90mg od sc

94
Q

what study looks at the efficiency of CTPA for PE

A

PIOPED study

95
Q

prophylactic dose of PE

A

Tinzaparin 3500 iu od subcutaneously (4500 iu od dosing in patients with malignancy)
Prophylactic Enoxaparin 40 mg od subcutaneously

96
Q

Sarcoidosis

A

A multisystem granulomatous disorder of unknown aetiology characterised by the development of non-caseating granulomas within an organ

97
Q

lupus pernio

A

raised indurated hardened lesion of skin often in purple colour

98
Q

Ddx sarcoidosis

A 
Tuberculosis
Lymphoma
Granulomatosis with polyangiitis (formerly Wegener’s Granulomatosis)
Churn-Strauss syndrome
CVID
Fungal infections; e.g. histoplasmosis
Brucellosis, Chlamydia
Chronic Beryllium Disease
99
Q

Lofgren’s Syndrome

A

Erythema nodosum, bilateral hilar lymphadenopathy, arthralgia and fever
Usually resolves spontaneously

100
Q

Mikulicz’s Syndrome

A

Parotid and salivary gland enlargement in conjuction with lacrimal gland involvement

101
Q

Indications for systemic treatment

A

Progressive dyspnoea
Worsening pulmonary infiltrates
Fall in FVC and/or DLCO
Anterior or posterior uveitis unresponsive to topical therapy
Active cardiac involvement
Hypercalcaemia
CNS involvement (Facial Nerve / CN VII in 50%)

102
Q

Complication of Sarcoidosis

A

Pulmonary fibrosis
Pulmonary hypertension
Respiratory failure
Lung transplantation
Cardiac arrhythmia, sudden cardiac death 20 to ventricular fibrillation
Hypercalcaemia
Chronic renal failure 20 to Renal sarcoid
Glaucoma and visual loss
Obstructive hydrocephalus 20 to Neurosarcoid

103
Q

what test do you do to follow up patient with sarcoidosis

A
  • PFT
  • ACE
  • CXR

RCSI Medicine (6 decks)

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