Respiratory Flashcards by Emmy Beever

What are the restrictive / obstructive patterns for FEV1 + FVC

Obstructive: FEV1 reduced / FEV1:FVC reduced

Restrictive: FVC and FEV1 reduced / FEV1:FVC normal

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What is Kco + TLco?

What can reduced Kco/TLco indicate?
What can it exclude?

Kco = diffusion capacity of lung per unit area for CO

TL = diffusion capacityt for total lung capacity for CO

A reduction can indicate a problem with gas exchange
= alveolar or vascular disease
= rules out chest wall / diaphragm probs

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What patient groups is pneumonia more common in? (5)

Male
Elderly
Smokers
Alcoholics
Chronic disease

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What are the clinical S+S of pneumonia? (5+8)

Acute systemic illness: fever/rigors/vom
Cough: initially dry then mucopurulent
SOB
Pleuritic pain (+ poss referred to shoulder / anterior abdo wall)
Confusion/delirium - in elderly pts (who may have v few symptoms)

Tachypnoea
Reduced chest expansion (affected side)
Dullness to percussion (affected side)
Coarse crackles
Bronchial breathing
Increased vocal resonance
?Pleural rub
?Upper abdo tenderness (if lower lobe)

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What is the definition of HAP?

Pneumonia developing 48hrs after admission (with no signs of incubation on admission)
OR
Someone hospitalised in the past 10d

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List the causative organisms for CAP (6)

Typical bact (60-80%):
S.Pneumoniae
H.influenzae

Atypical (10-20%):
mycoplasma / chlamydia / legionella

Viruses (10-20%):
influenza / parainfluenza

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What is seen on CXR for pneumococcal pneumonia?
Which patient group is most susceptible?

Which patient group is most susceptible to H.Influenzae

Classical lobar pneumonia + rust-coloured sputum
Immunosuppressed - vaccine given

COPD pts (the encapsulated strain)

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What is seen on CXR of mycoplasma pneumonia?
What patient group?
How does it present?

Widespread patchy consolidation across multiple lobes
Younger pts

Long H/o extra-pulm features:
Rash, Hepatitis, D+V, Pericarditis, Meningoencephalitis

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What is seen on CXR of legionella pneumonia?
What pt group?
What are some other features? (3)

Bilateral consolidation on lung bases

Smokers / recently returned from holiday (air conditioning units)

Proteinuria/haematuria (common)
Neuro involvement (CN palsies)
Hypernatraemia (SIADH)

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What pt groups are susceptible to Chlamydia pneumonia?

Infants (URTI) + Elderly (CAP)

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What Ix are done in pneumonia? (6+2)

Obs / sats assessment
FBC/UEs/CRP/LFTs
Blood cultures
Sputum sample (culture +/- mycoplasma PCR)
CXR
Urine in mod/severe (for L/S.pneumonia)

Serum mycoplasma IgG if suspect
Throat swab in viral transport medium if severe/suspect viral

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Describe the CURB65

Classify the severities

Confusion: AMT < 8
Urea >7
Resp rate >30
BP <90 SBP or <60 DBP
65yrs+

0-1 = non-severe
2 = moderately severe
>2 = severe

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Describe the treatment for CAP at diff severities

Non-severe: oral amoxi / doxi as outpatient

Mod severe: admit + oral amoxi/doxy + clarithro

Severe: admit HDU + IV co-amoxi + clarithro OR levofloxacin + vanco

ADD Metronidazole if aspiration suspected

PLUS chest physio for all for effective coughing

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Describe the management for HAP

Assess MRSA RFs:
Known/previous
Longterm indwelling line/catheter
From nursing home w. skin breaks

Mild = oral doxy
Severe = oral co-trimoxazole

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What are some complications of pneumonia? (4)

Parapneumonic effusion / empyema
Lung abscess (clubbing)
Bronchiectasis
Sepsis

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How and why are pts followed up after a pneumonia?

CXR 6wks after

Ensure resolved and not due to obstrn e.g. lung cancer

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What are the S+S of TB? (7+2)

Malaise / wt loss / anorexia / night sweats
Later: 
Mucoid wet cough
Pleural pain
Small haemoptysis

Fever / Apical crackles

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How is a pt with suspected active TB investigated? (4)

Sputum:
Microscopy - acid-fast bacilli (24hrs)
PCR
Culture - 6wks

IF sputum samples -ve
Bronchoscopy + biopsy
OR Broncho-alveolar lavage

CXR - upper lobe cavities / pleural effusions / lymphadenopathy

Ix extra-pulm if suspect

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How is latent TB investigated (eg contact tracing)? (3)

Mantoux test (inject TB Ag + size of reaction)
Interferon-y release assay (IGRA)
Standard bloods (FBC/UEs/LFTs) - rule out other causes/baseline

How is a pt with active TB managed?

If admitting - isolation
If not - specialist TB service
Assess RFs (prev TB Tx / adherence / contacts / HIV)

2m isoniazid (+pyridoxine) + rifampicin 
\+ ethambutol + pyrazinamide 
4m isoniazid (+pyridoxine) + rifampicin

How is latent TB managed?

3m - isoniazid (+ pyridoxine) + rifampicin

How is contact tracing done in confirmed cases of TB?

All household - trace / assess for latent

Casuals - only trace if infectious (10%+ of close develop TB) or if contact eg HIV

What are the main SEs for:
Isoniazid
Rifampicin
Pyrazinamide
Ethambutol

Ison - neuropathy/enceph (pyridoxine prevents)
Rifamp- deranged LFTs
Etham- optic neuritis
Pyraz- hepatotoxic

What are the common sites + features of non-pulmonary TB (6)

Joints/spinal - mono arthritis
Cutaneous - lupus vulgaris/erythema nodosum
Meningitic TB
Renal - sterile pyuria 
Pericarditis - chest pain

What are the S+S of a pneumothorax

Asymp (small one + young) Sudden unilateral pleuritic pain w. Progressive dyspnoea Reduced expansion Hyperesonance on percussion Reduced vocal resonance Reduced breath sounds

How is a tension pneumothorax clinically differentiated from a normal?

Trachea deviated from affected side Neck veins dilated (venous return) + poss haemodynamic compromise NB check chest drain - could be blocked

How is a tension pneumothorax treated?

100% oxygen Large bore cannula ics2 mid-clav CXR Insert chest drain

How is a pneumothorax treated?

If <2cm air rim or not SOB: discharge + fortnightly CXR + advise smoking cessation If >2cm or SOB: Aspirate or chest drain if fails If recurrent (>2) or not resolving within 5d - surgery indicated (pleurectomy/ talc pleurodesis)

List the causes of transudative pleural effusion (5)

Cardiac failure: hydrostatic backpressure from LHF Liver failure: reduced protein prodn = reduced oncotic pressure Renal failure: nephrotic synd reduced oncotic pressure Peritoneal dialysis Hypothyroidism (rare) Ovarian tumours (Meig's)

List the causes of exudative pleural effusion (5 - A PAIN)

``` Infections Neoplasm PE (pulm infarct) Autoimmune (RA/SLE) Abdo disease: pancreatitis, subphrenic abscess ```

Describe the S+S of pleural effusion (3+6)

Asymp SOB Pleuritic pain ``` Reduced expansion Dull to percussion Reduced vocal resonance Reduced breath sounds Bronchial breathing ```

List the RFs for COPD (6)

``` SMOKING Occupational dust exposure a1-antitrypsin defc Recurrent childhood chest infections Low socioeconomic status Asthma / atopy ```

Describe the typical presenting features of COPD (3)

Productive morning cough (after yrs of smokers cough) Increased freq of LRTIs Slow progressive dyspnoea w. wheeze

What may be seen O/E in mild/severe?

Mild: widespread wheeze Severe: O - tachypnoea / cyanosis / flap I - hyperinflation / recession / tug / pursing / accessorys P - poor expansion P - hyperresonant A - reduced breath sounds / prolonged expiration / polyphonic wheeze

List the complications of COPD (6)

``` Acute exacerbations Polycythaemia Resp failure Cor pulmonale Pneumothorax (ruptured bullae) Lung carcinoma ```

What Ix/Further tests will be done in suspected COPD (3+4) and why is each one done

Post-bronchodilator spirometry (Dx / severity) CXR (exclude other pathology) FBC (ID anaemia / polycythaemia) Sputum culture (abnormal orgs suggest bronchiectasis) ECG (RA/RVH) ABG (resp failure) DLCO (diffusion capacity of lung for CO - reduced in emphysema)

Describe the management for stable COPD (4)

Specialist referral if Dx uncertain / deteriorating Patient education Action plan for exacerbations (steroids/Abx) Lifestyle advice (diet / exercise / smoking) Meds/inhalers

``` What is the main SE of: Rifampicin Isoniazid Pyrazinamide Ethambutol ```

R: deranged LFTs I: neuropathy/enceph P: hepatotoxic E: optic neuritis

Causes of a normal anion gap in metabolic acidosis (4) Causes of a raised anion gap in metabolic acidosis (4)

``` Normal = HCO3- loss Renal tubular acidosis Diarrhoea Intestinal fistula Drugs (acetozolamide) ``` ``` Raised = Acid prodn DKA Urate (renal failure) Lactic (hypoxia/shock) Drugs (NSAIDs/metformin/ethanol) ```

What are the features of Pancoast syndrome (4)

Horners Shoulder pain → arm Hand/arm mm atrophy Oedema (vv congestion)

List some metastatic manifestations specific to lung cancer

``` Recurrent laryngeal nn palsy Phrenic nn palsy SVC obstrn Adrenal mets (Addison's) Pericarditis AF Pancoast syndrome (Horners/brachial neuralgia/oedema) Dermatomyositis Acanthosis nigracans Lambert-Eaton SIADH Cushing HyperPTH/Cal Hypertrophic pulmonary osteoathropathy ```

Causes of Restrictive lung disease

ENDOGENOUS: Idiopathic** Autoimm/CTDs EXOGENOUS: Drugs Infections (weird) / Hypersensitivity (EAA) Occupational

What Ix can be done in restrictive lung disease of unknown cause?

Bloods: FBC / ANA / RF Orifices: Spirometry Imaging: CXR / CT Invasive: Bronchoalv lavage / Biopsy

What are the complications of lung fibrosis (restrictive disease)? (3)

Pulm HTN T2RF Lung cancer risk

How can lung fibrosis (restrictive disease) be managed?

Most unresponsive O2 – for attacks Prednisolone (20% respond) Lung transplant

What are the complications of OSAS? (3)

Cor pulmonale HTN T2RF

What are the indications for Lobectomy? (4)

Lung cancer TB / Chronic abscess Fungal infection Bronchiectasis (localised)