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Respiratory Flashcards

1
Q

Describe/draw the flow volume curves of normal, restrictive and obstructive lung disease

A
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2
Q

What is restrictive lung disease?

A

Pulmonary fibrosis that decreases lung volume and increases work of breathing with inadequate ventilation

  • Low FEV1
  • Low FVC
  • Normal FEV1/FVC ratio
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3
Q

Name some causes of restrictive lung disease

A
  • Pneumoconiosis
  • Pulmonary fibrosis
  • TB
  • Chest wall disease (kyphoscoliosis)
  • Weak respiratory muscles
  • Sarcoidosis
  • RA
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4
Q

What is obstructive lung disease?

A

Narrowing of airways due to excessive smooth muscle contraction

  • Normal FVC
  • Low FEV1
  • Low FEV1/FVC ratio (<0.7)
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5
Q

Name some causes of obstructive lung disease

A
  • Chronic bronchitis
  • COPD
  • Asthma
  • Bronchiectasis
  • CF
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6
Q

Describe/draw the spirometry curve of normal, obstructive and restrictive lung disease

A
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7
Q

What is respiratory failure?

A

When gas exchange in the lungs is inadequate which results in hypoxia. It is defined as pO2 < 8kPa. Divided into:

  • Type 1 - normal or low pCO2
  • Type 2 - high pCO2
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8
Q

Name some causes of Type 1 respiratory failure

A

Mainly ventilation perfusion mismatch

  • Pneumonia
  • Pulmonary oedema
  • PE
  • Asthma
  • Pneumothorax
  • Fibrosing alveolitis
  • ARDS
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9
Q

Name some causes of Type 2 respiratory failure

A

Alveolar hypoventilation

  • Pulmonary disease - COPD, fibrosis,
  • Reduced respiratory drive - Opiates, CNS tumour, trauma
  • Neuromuscular disease - Cervical cord lesion, diaphragmatic paralysis, myasthenia gravis
  • Thoracic wall disease - flail chest, kyphoscoliosis
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10
Q

Describe the effects of hypoxia (Type 1 and 2 respiratory failure)

A
  • Impaired CNS function
    • Confusion
    • Agitation
  • Dyspnoea
  • Restlessness
  • Central cyanosis
  • Pulmonary hypertension
  • Cardiac arrhythmia
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11
Q

Describe the effects of hypercapnia (Type 2 respiratory failure)

A
  • Headache
  • Peripheral vasodilation
  • Tachycardia
  • Bounding pulse
  • Tremor/flap
  • Papilloedema
  • Confusion
  • Drowsiness
  • Coma
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12
Q

How is respiratory failure investigated?

A
  • Bloods
    • FBC
    • U&E
    • CRP
    • ABG
  • CXR
  • Sputum culture (if febrile)
  • Spirometry
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13
Q

How is respiratory failure managed?

A
  • Treat underlying cause
  • Airway maintenance
  • Clearance of secretions
  • Oxygen by face mask
  • Assisted ventilation (CPAP/BIPAP) if pO2 < 8 kPa
  • Intubation
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14
Q

What is asthma?

A

A chronic inflammatory disorder characterised by increased responsiveness of the bronchi to various stimuli, causing reversible airway obstruction

  • Airway hyperresponsiveness
  • Increased mucosal inflammation
  • Hypersecretion of mucus
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15
Q

Describe the symptoms of asthma

A
  • Intermittent dyspnoea
  • Wheeze
  • Cough (often nocturnal)
  • Sputum production
  • Exercise intolerance
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16
Q

Name some asthma precipitants

A
  • Allergens (pollen, house dust mites, animals)
  • Smoke
  • Stress
  • Exercise
  • VIral infections
  • Drugs - NSAIDs, aspirin, beta blockers
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17
Q

Name the clinical signs of asthma

A
  • Tachypnoea
  • Audible polyphonic wheeze
  • Hyper-inflated chest
  • Hyper-resonant percussion
  • Diminished air entry
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18
Q

How is asthma investigated?

A
  • Peak expiratory flow monitoring
  • Obstructive spirometry result
    • Improvement of FEV1 by 12% with beta agonist
  • CXR
  • Skin prick test - identify triggers
  • Fractionated exhlaed FeNO test (>40)
  • Bronchial provocation - inhalation of increase dose of histamine until FEV1 declines by 20%
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19
Q

Describe the guidelines to treating chronic asthma

A
  1. Short acting inhaled B2 agonist
  2. Add inhaled low dose steroid (beclometasone 100-400microg/12hrs)
  3. Add leukotriene receptor antagonist (montelukast)
  4. Add long acting B2 agonist (salmeterol 50microg/12hrs)
  5. Increase dose of steroids (up to 1000) / oral theophylline / oral B2 agonist / oral leukotriene receptor antagonist

Continue until no daytime symptoms, no limitations on activity, no exacerbations, no night-time awakening and normal lung function

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20
Q

Describe the emergency treatment of acute severe asthma

A
  • Oxygen via non-rebreathe bag (15L)
    • Aim for 94-98% sats
  • Salbutamol 5mg delivered with oxygen
  • Hydrocortisone 100mg IV or prednisolone 30mg PO
    • Continue for 5 days
  • Add ipatropium bromide 0.5mg nebuliser
  • CXR to exclude pneumothorax
  • If life-threatening: add magnesium sulphate 1.2-2mg IV over 20 min
  • Salbutamol nebulisers every 15 min
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21
Q

Name some ADRs of B2 agonists

A
  • Muscle tremor
  • Tachycardia
  • Palpitations
  • Arrhythmias
  • Hypokalaemia
  • Headache
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22
Q

What is chronic bronchitis?

A

Chronic mucosal inflammation, mucus gland hypertrophy and mucus hypersecretion

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23
Q

What is emphysema?

A

Progressive destruction of the alveolar septa and capillaries producing enlarged spaces (bullae) with decreased compliance and increased collapsibility

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24
Q

What is COPD?

A

An irreversible expiratory airflow obstruction. hyperinflation, mucus hypersecretion and increased work of breathing. Includes chronic bronchitis and emphysema.

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25
Q

What signs differentiate COPD with asthma?

A
  • Age of onset > 35
  • Smoking related
  • Chronic dyspnoea
  • Sputum production
  • No diurnal variation
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26
Q

What are pink puffers and blue bloaters?

A

Pink puffers:

  • Purse lipped breathing
  • Normal PO2 and normal/low CO2
  • Barrel chest
  • Dyspnoea

Blue bloater:

  • Dec alveolar ventilation
  • Low PO2 and high PCO2
  • Cyanosed but not breathless
  • Rely on hypoxic drive
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27
Q

Name some symptoms of COPD

A
  • Cough
  • Sputum production
  • Dyspnoea
  • wheeze
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28
Q

Name some signs of COPD

A
  • Use of accessory muscles
  • Hyperinflation
  • Dec. expansion
  • Resonant on percussion
  • Cyanosis
  • Cor pulmonale
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29
Q

What are the risk factors for developing COPD?

A
  • Male
  • Age > 50
  • Smoking
  • Asthma
  • Childhood chest infections
  • Low SES
  • A1 anti trypsin deficiency
  • Heavy metal exposure
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30
Q

Describe some investigations into COPD

A
  • CXR
    • Hyperinflation (>6 ant. ribs seen above diaphragm in mid-clavicular line)
    • Flat hemidiaphragm
    • Large pulmonary arteries
  • ECG - cor pulmonale (hypertrophy)
  • ABG - low PO2 +/- high PCO2
  • Spirometry - irreversible airway obstruction (FEV1/FVC < 0.7)
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31
Q

Name some complications of COPD

A
  • Acute exacerbations
  • Infection
    • H influenzae most common in COPD
  • Polycythaemia
  • Cor pulmonale
  • Respiratory failure
  • Lung cancer
  • Pneumothorax
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32
Q

How is the severity of COPD assessed?

A
  • Mild = FEV1 60-80% predicted
  • Moderate = FEV1 40-59% predicted
  • Severe = FEV1 < 40% predicted
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33
Q

Describe the guidelines to treating chronic COPD

A
  • Non pharmacological - smoking cessation, regular exercise, diet, flu vaccine
  • Pulmonary rehabilitation
  • Oxygen therapy
  • Long acting inhaled B2 agonists (salmeterol)
  • Inhaled steroid if FEV1 < 50%
  • Inhaled ipatromium (LAMA)
  • Surgery
    • Lung volume reduction
    • Transplant
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34
Q

Name some side effects of steroids

A

CUSHINGOID

  • Cataracts
  • Ulcers
  • Skin: striae, bruising, thinning
  • Hypertension / hirsutism / hyperglycaemia
  • Infections
  • Necrosis (avascular necrosis of the femoral head)
  • Glycosuria
  • Osteoporosis / obesity
  • Immunosuppression
  • Diabetes
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35
Q

What is cor pulmonale?

A

Right heart failure caused by chronic pulmonary hypertension

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36
Q

How is pulmonary hypertension investigated?

A
  • Bloods - Hb, ABG, LFTs, autoantibodies, HIV
  • CXR
    • Enlarged right atrium and ventricle
    • Prominent pulmonary artieries
    • Parenchymal disease?
  • ECG
    • RIght axis deviation
    • Right ventricular hypertrophy
  • Echo
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37
Q

What is sarcoidosis?

A

Multi system immune deposits characterised by non-caseating granulomas and an abnormal, antigen-triggered CD4 T cell response.

Unknown aetiology.

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38
Q

Name some clinical features of sarcoidosis

A
  • Acute = erythema nodosum, arthralgia, fever, bihilar lymphadenopathy
  • Constitutional = fatigue, malaise, weight loss
  • Resp = Non productive cough, dyspnoea, pain, decrease exercise tolerance
  • Eye = uveitis, conjunctivitis
  • Neuro = neuropathy, meningitis
  • Cardiac = arrhythmia, heart failure
  • Gastro = hepato/splenomegaly
  • Renal impairment
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39
Q

How is sarcoidosis diagnosed?

A
  • CXR - bihilar lymphadenopathy, upper lobe fibrosis, pulmonary infiltrates
  • Tissue biopsy - non-caseating granuloma
  • Bloods - FBC, biochemistry, Ca, LFT, SACE
  • Lung function test - normal or restrictive
  • Mantoux - exclude TB
  • Slit lamp examination
  • Bronchoalveolar lavage - Inc lymphocytes
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40
Q

How is sarcoidosis managed?

A
  • Acute - bed rest, NSAIDs
  • Steroids (4-6 weeks) if:
    • Parenchymal lung disease
    • Uveitis
    • Hypercalcaemia
    • Neuro or cardio involvement
  • Immunosuppression (methotrexate, azathioprine, cyclosporin)
  • Transplant
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41
Q

Name some differentials for granulomatous diseases

A
  • TB
  • Sarcoidosis
  • Vasculitis (Wegeners)
  • Crohns
  • Extrinsic allergic alveolitis
  • Syphilis
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42
Q

How can PEs be prevented?

A
  • Compression stockings
  • Heparin to all immobile patients
  • Stop HRT / OCP
  • Investigations for thrombophilia
  • Encourage mobilisation
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43
Q

What is interstital lung disease?

A

Inflammation and/or fibrosis of the pulmonary intersitium caused by inhalation of allergens which provokes a hypersensitivity reaction or is idiopathic.

With chronic exposure, granulomas and obliterative bronchiolitis occur

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44
Q

How is interstital lung disease classified?

A
  1. Idiopathic Interstital Pneumonias
    • Usual Interstital Pneumonias / Idiopathic Pulmonary Fibrosis = minimal inflammation with fibrosis
    • Non-Usual Interstital Pneumonias = more diffuse pulmonary involvement with less fibrosis
  2. Non-idopathic causes
    • Drug-induced = nitrofurantoin, bleomycin, amiodarone
    • Hypersensitivity (extrinsic allergic alveolitis)
    • Connective Tissue Disease = RA/vasculitis
    • Occupational lung disease = pneumoconiosis/asbestosis
  3. Granulomatosis (sarcoidosis)
  4. Other causes
    • Infiltrative (amyloidosis)
    • Malignant
    • Post-infective (HIV)
45
Q

What are the clinical features of ILD?

A
  • Dyspnoea
  • Dry cough
  • Weight loss
  • Type 1 respiratory failure
  • Clubbing
  • RHF and hypoxaemia if advanced
46
Q

How is ILD diagnosed?

A
  • History - drugs, occupation, CTD, sarcoidosis
  • Bloods - rheumatoid factor, Inc ESR, neutrophilia
  • Serology - positive precipitans
  • Pulmonary function tests - Restrictive deficit with dec TLC, dec FRC and dec RV
  • CXR - mid-zone mottling/consolidation, hilar lymphadenopathy, upper-zone fibrosis, honeycomb lung
  • Decreased gas transfer
  • Broncholaveolar Lavage - inc lymphocytes and mast cells
  • Biopsy (non-IUP)
47
Q

How is ILD treated?

A
  • Oxygen therapy
  • Pulmonary rehab
  • Smoking cessation
  • Avoid allergens
  • Pharmacological
    • Steroids (non-IUP)
    • Immunosuppressants (azathioprine / methotrexate)
  • Lung transplant

NB: non-IUP = low dose prednisolone, azathioprine, N-acetylcysteine

48
Q

Name some causes of hypersensitivity pneumonitis / EAA

A
  • Mouldy hay (thermophilic actinomycetes) - Farmers Lung
  • Compost - Mushroom Workers Lung
  • Feathers / excreta - Pigeon Fanciers Lung
  • Contaminated water (klebseilla) - Humidifiers Fever
49
Q

Describe Coal Worker’s Pneumoconiosis

A

Inflammatory reaction to the presence of coal dust in the lungs

  • Weakens bronchiolar walls to cause emphysema
  • Irreversible airflow limitation
    • Dec TLC
    • Dec compliance
    • Dec gas transfer
  • Limited treatment
50
Q

Describe asbestosis

A

Fibrosing lung disease caused by inhalation of asbestos particles

  • Presents with progressive dyspnoea, inspiratory basal crackles and clubbing
  • Restrictive deficit with dec gas transfer
  • Predisposes to mesothelioma
  • No treatment available
51
Q

Describe the x-ray appearance of asbestosis

A
  • Diffuse streaky shadows
  • Thickened visceral pleura
  • Honeycombing in lower lobes
52
Q

Descrbe the x-ray appearance of extrinsic allergic alveolitis / hypersensitivity pneumonitis

A
  • Fluffy nodular shadowing
  • Ground glass opacity
  • Honeycomb lung
53
Q

Name some indications for mechanical ventilation

A

Prevent type 2 respiratory failure:

  • Surgery
  • Respiratory centre depression (PCO2 > 7-9kPa)
    • Head injury
    • Opiate overdose
    • Raised intracranial pressure
  • Lung disease
    • Pneumonia
    • ARDS
    • Severe asthma
    • Exacerbation of COPD
  • Cervical cord damage above C4
  • Neuromuscular disorders
  • Chest wall disorders
  • Cardiac arrest
54
Q

Describe the different types of mechanical ventilation

A
  • Intermittent Positive Pressure Ventilation = air is driven into lungs by raising airway pressure via a tracheostomy tube
    • Expiration = pressure falls to 0
  • Positive End-Expiratory Pressure = IPPV but positive airway pressure is maintained during expiration
  • Continuous Positive Airway Pressure = standing pressure applied to a facemask during spontaneous breathing
  • Biphasic Positive Airway Pressure = maintains pressure during inspiration and expiration
  • Non-Invasive Intermittent Positive Pressure Ventilation - IPPV delivered by face/nasal mask
55
Q

Name some complications of using mechanical ventilation

A
  • During intubation
    • Aspiration of gastric contents
    • Laryngospasm
  • Of intubation
    • Intubation of oeseophagus / bronchus
    • Laryngeal / tracheal damage or stenosis
  • Sedation
    • Cardiac depression
    • Respiratory depression
  • Mechanical ventilation
    • Barotrauma
    • Pneumothorax
56
Q

Name some indications for the use of oxygen therapy

A
  • Cardiac / respiratory arrest
  • Hypoxia (pO2 < 8kPa)
  • Hypotension (systolic BP < 100mmHg)
  • Low cardiac output
  • Metabolic acidosis (bicarp < 18mmol/L)
  • Respiratory distress (RR > 24)
57
Q

What blood concentration of oxygen is aimed for?

A
  • Normal patients = SaO2 of 94-98%
  • Risk of type 2 respiratory failure = SaO2 of 88-92%
    • COPD
    • If increased, risk of CO2 retention, dec ventilation and acidosis
58
Q

Describe the different delivery methods of oxygen and which groups of patients they are appropriate for

A
  • High dose (>60%) by non-rebreathe, resvoir mask at 10-15 L/min
    • Cardiac arrest
    • Shock
    • Sepsis
    • CO poisoning
  • Moderate dose (40-60%) by nasal cannulae at 2-6 L/min
    • Pneumonia
  • Low dose (24-28%) by Venturi mask
    • CO2 retention
    • COPD
    • Neuromuscular disease
    • Cystic fibrosis
59
Q

What are the risks of using oxygen therapy?

A
  • CO2 retention
    • COPD patients
  • Rebound hypoxaemia (if suddenly withdrawn)
  • Absorption collapse / atelectasis
  • Toxicity
    • ARDS
    • Coronary / cerebro vasospasm
  • Burns (in smokers)
  • Cerebral vasoconstriction and epileptic fits (Paul-Bert effect)
60
Q

What are the classifications of pneumonia?

A
  • Community acquired - within 48 hours of hospital admission in patients that had not been hospitalised for 14 days
  • Hospital acquired - > 2 days after admission
  • Aspiration (stroke, myasthenia gravis, dec. consciousness, oesophageal disease)
  • Opportunistic - immunosuppressed patients
  • Recurrent - CF, bronchiectasis
61
Q

Name some risk factors for contracting pneumonia

A
  • Age > 65
  • Chronic disease
    • Diabetes
    • COPD
  • Immunosuppression/compromised
    • Steroids
  • Alcohol dependency
  • Malnutrition
  • Mechanical ventilation
  • Post-operative
  • IVDU
62
Q

Name the commin causative agents of CAP

A
  • Strep pneumoniae
  • Haemophilus influenza
  • Klebsiella pneumoniae
  • Influenza
  • Mycoplasma
  • Aspergillus
63
Q

What are the clinical features of pneumonia?

A
  • General - fever, malaise, rigors, myalgia
  • Chest - dyspnoea, pleurisy, cough, haemoptysis
  • Cyanosis
  • Tachypnoea
  • Tachycardia
  • Confusion
  • Auscultation - focal dullness, crepitations, bronchial breathing, pleuritic rub
  • Hypotension
64
Q

What investigations are needed for pneumia?

A
  • Bloods - FBC, CRP, LFTs, ABG, U&Es, cultures
  • CXR - lobar infiltrates, cavitations, pleural effusion
  • O2 sats
  • Other cultures - sputum, pleural fluid, bronchoalveolar lavage
  • Serology (virus/atypical organism)
65
Q

How is the severity of pneumonia assessed?

A

CURB 65 score

  • Confusion (mental test < 8)
  • Urea > 7 mmol/L
  • RR > 30/min
  • Systolic BP <90 or diastolic BP < 60
  • Age > 65

Score > 1 indicates severe pneumonia

66
Q

What is the general management of pneumonia?

A
  • Antibiotics
  • Oxygen (keep pO2 > 8kPa and sats > 92%)
  • IV fluids
  • Paracetemol if pleurisy
  • Sputum clearance
  • Ventilatory support (CPAP)
  • ITU if severe or failure to imrpove, shock or hypercapnic
67
Q

Describe the antibiotic treatment regimes for the different types of pneumonia

A
  • CAP - amoxicllin 500mg/8hr or erythromycin 500mg/6hr
  • Severe - IV Co-amoxiclav or cephalosporin AND erythromycin
  • Legionella - clarithromycin 500mg/12hr
  • Chlamydia - tetracycline
  • Gram negative - IV aminoglycoside
68
Q

Name some complications of pneumonia

A
  • Respiratory failure
  • Hypotension due to dehydration / septic vasodilation
  • Atrial fibrillation
  • Pleural effusion
  • Empyema
  • Lung abscess (cavitating area of infection)
  • Sepsis
  • Pericarditis
69
Q

What are the risks of developing hospital acquired pneumonia?

A

Oropharyngeal colonisation with enteric gram negative bacteria due to:

  • Immobilisation
  • Impaired consciousness
  • Instrumentation
  • Poor hygiene
  • Inhibition of gastric acid (aspiration)
70
Q

Name some common organisms for HAP

A
  • Staph aureus
  • CAP organisms
  • MRSA
  • Gram negative bacilli
71
Q

Name some causes of pneumothorax

A
  • Primary (idiopathic) mainly in young men
  • Secondary
    • COPD
    • Asthma
    • TB
    • Pneumonia
    • HCTD
    • Carcinoma
    • Fibrosis
  • Traumatic
72
Q

What are the clinical features of pneumothorax?

A
  • Sudden breathlessness
  • Sharp pleuritic pain
  • Reduced air entry
  • Hyperresonant percussion
  • Cyanosis
  • Tachycardia
  • Respiratory failure
  • Hypertension
73
Q

How is pneumothorax investigated?

A
  • CXR (if tension not suspected) = area devoid of lung markings
  • ABG = respiratory failure
74
Q

How is pneumothorax managed?

A
  • Oxygen
  • Analgesia
  • If >2cm and/or breathless = aspirate in 2nd intercostal space mid-clavicular with 16-28G cannula
  • If unsuccessful - chest drain in 5th intercostal space in axilla
75
Q

Describe the pathogenesis of TB

A
  • Primary = inital infection by inhaling acid-fast bacill (mycobacterium tuberculosis) affecting the upper lobes
    • Granuloma (Ghon focus) and enlarged hilar lymph nodes = Ghon complex
  • Post-primary = if Ghon focus fails to heal due to poor defences or following immunocompromised reactivation (HIV, malignancy, diabetes, steroids)
    • Lung lesions fibrose
    • Local dissemination
    • Bloodborne spread
76
Q

What are the clinical features of pulmonary TB?

A
  • Primary
    • Fever
    • Erythema nodosum
    • Small pleural effusions
    • Lymphadenopathy
    • Wheeze
  • Post-primary
    • Malaise
    • Weight loss
    • Night sweats
    • Productive cough
    • Dyspnoea
    • Chest pain
    • Haemoptysis
    • Pneumonia
77
Q

How is TB diagnosed?

A
  • Sputum sample for MC+S (acid fast bacillus / Ziehl-Neilson stain)
  • Other relevant samples for culture - pleural fluid, urine, pus, ascites etc
  • Histology - caseating granuloma
  • CXR - consolidation, cavitation, fibrosis, calcification
  • Immunological tests
    • Mantoux (>10mm)
    • Tuberculin skin test - cell-mediated response to intradermal TB antigen
    • Heaf (screening)
  • Bloods - anaemia, dec Na+, inc Ca2+
78
Q

How is TB managed?

A
  • Isolation
  • Notify communicable diseases practitioner
  • Inital antiobiotics (RIPE) for 2 months
    • Rifampicin
    • Isoniazid (+ pyridoxine / vit B6)
    • Pyrazinamide
    • Ethambutol
  • Continuation antibiotics (4 months)
    • Rifampicin
    • Isoniazid (+ pyridoxine / vit B6)
79
Q

Name some side effects of the antibiotics treatment of TB. How are these monitored?

A
  • Rifampicin - hepatitis, orange discolouration of urine and tears (contact lens staining), inactivation of OCP
    • LFTs
  • Isoniazid - hepatitis, neuropathy, vit B6 deficiency
  • Ethambutol - optic neuritis
    • Ishihara (colour) chart
  • Pyrazinamide - hepatitis, arthralgia
80
Q

Name some complications of TB

A
  • Reactivation when immunocompromised
  • Bronchiectasis
  • Lung cavities
  • Cranial nerve lesions
  • Renal tract obstruction
  • Multi-drug resistance
81
Q

How do you present a chest x-ray?

A

DRSABCDE

  1. Details - Patient details, type of film (AP) date and time
  2. RIE (image quality) - rotation, inspiration (5-6 ant. ribs) exposure
  3. Soft tissues and bones
  4. Airway
  5. Breathing
  6. Circulation
  7. Diaphragm
  8. Extras
82
Q

What is looked for in ‘soft tissue and bones’ of CXR?

A
  • Ribs, sternum, spine, clavicles – symmetry, fractures, dislocations, lytic lesions, density
  • Soft tissues – looking for symmetry, swelling, loss of tissue planes, subcutaneous air, masses
  • Breast shadows
  • Calcification – great vessels, carotids
83
Q

What is looked for in ‘airway’ of CXR?

A
  • Trachea – central?
  • Carina & RMB/LMB
  • Mediastinal width <8cm on PA film
  • Aortic knob
  • Hilum – T6-7 IV disc level, left hilum is usually higher (2cm) and squarer than the V-shaped right hilum.
  • Check vessels, calcification.
84
Q

What is looked for in ‘breathing’ of CXR?

A

Lung fields:

  • Vascularity – to ~2cm of pleural surface (~3cm in apices), vessels in bases > apices
  • Pneumothorax – don’t forget apices
  • Lung field outlines – abnormal opacity/lucency, atelectasis, collapse, consolidation, bullae
  • Pulmonary infiltrates – interstitial vs alveolar pattern
  • Coin lesions
  • Cavitary lesions

Pleura

  • Pleural reflections
  • Pleural thickening
85
Q

What is looked for in ‘circulation’ of CXR?

A
  • Heart position –⅔ to left, ⅓ to right
  • Heart size – measure cardiothoracic ratio on PA film (normal <0.5)
  • Heart borders – R) border is R) atrium, L) border is L) ventricle & atrium
  • Heart shape
  • Aortic stripe
86
Q

Describe this x-ray

A
  • Visible pleural edge
  • Lung markings not visible beyond this point
  • Rib fracture

Diagnosis = left pneumothorax due secondary to rib fracture

Tracheal and mediastinal structures are not deviated so no ‘tension’

87
Q

Describe this x-ray

A
  • The left lower zone is uniformly white
  • At the top of this white area there is a concave surface - meniscus sign
  • The left heart border, costophrenic angle and hemidiaphragm are obscured
  • Slight blunting of the right costophrenic angle indicates a small pleural effusion on that side

Diagnosis - large left pleural effusion

88
Q

Describe this x-ray

A
  • The right heart border (right atrial edge) is obscured
  • Consolidation (asterisk) is limited above by a crisp line, formed by the horizontal fissure
  • The pathology must therefore involve the right middle lobe
  • More extensive shadowing also involves the right and left peri-hilar regions

Diagnosis = pneumonia involving the right middle lobe

89
Q

Describe the x-ray

A
  • The horizontal fissure (white line) has been displaced upwards from its original position (red line)
  • Dense opacification (asterisk) of the medial part of the right upper zone
  • Enlarged right hilum

Diagnosis = right upper lobe collapse

90
Q

Describe the x-ray

A
  • Large, round, thick-walled lung cavity
  • The cavity is in the left middle zone, close to the hilum

Diagnosis = Left lower lobe lung cavity, possible due to a squamous cell carcinoma

91
Q

Describe this x-ray

A
  • Both costophrenic angles are blunt due to lung hyper-expansion
  • The hemidiaphragms are flattened indicating hyperexpansion
  • The lung markings are distorted bilaterally

Diagnosis = COPD

92
Q

Describe this x-ray

A
  • The lungs are normal
  • The diaphragm is crisply defined on both sides (arrowheads)
  • Air under the diaphragm (asterisks) is seen as crescents of relatively low density (black)
  • Black air can be seen on both sides of the bowel wall (blue line) – this is known as the double-wall sign or Rigler’s sign (usually only seen on abdominal X-rays)

Diagnosis = perforated duodenal ulcer (pneumoperitoneum)

93
Q

Describe this x-ray

A
  • Cardiomegaly CTR = 18/30 (>50%)
  • Upper zone vessel enlargement (1) – a sign of pulmonary venous hypertension
  • Septal (Kerley B) lines (2) – a sign of interstitial oedema – see next picture
  • Airspace shadowing (3) – due to alveolar oedema – acutely in a peri-hilar (bat’s wing) distribution
  • Blunt costophrenic angles (4) – due to pleural effusions

Diagnosis = left ventricular failure with pulmonary oedema

94
Q

Describe this x-ray

A
  • Dense airspace shadowing is due to alveolar oedema caused by fluid filling the alveoli and small airways
  • In the acute setting this airspace shadowing radiates from the hilar regions in a ‘bat’s wing’ distribution and then becomes more generalised

Diagnosis = alveolar pulmonary oedema

95
Q

Describe this x-ray

A
  • Sternal wires and aortic valve prosthesis (arrowhead)
  • Massive aortic knuckle (red line)
  • Displaced trachea (arrow)
  • Widened, tortuous descending aorta (blue lines)

Diagnosis = chronic thoracic aortic aneurysm (treated with surgical repair of the aortic root)

96
Q

Describe this x-ray

A
  • No patient rotation - the spinous processes (red line) are central between the medial clavicles (blue lines)
  • Trachea (asterisk) shifted to the left of the midline
  • Soft tissue mass mainly to the right of the trachea
97
Q

What is Acute Respiratory Distress Syndrome?

A

An acute, diffuse inflammatory lung injury in response to a variety of direct (inhaled) or indirect (bloodborne) insults.

98
Q

Name some causes of ARDS

A

Direct:

  • Infection
  • Trauma
  • Near-drowning
  • Gas inhalation

Indirect:

  • Sepsis
  • Burns
  • Haemorrhage
  • Post-arrest
99
Q

What are the clinical features of ARDS?

A
  • Dyspnoea and tachypnoea
  • Central cyanosis
  • Hypoxic confusion
  • Bilateral fine inspiratory crepitations
  • Peripheral vasodilations
    *
100
Q

What is the diagnostic criteria for ARDS?

A
  1. Acute onset
  2. Bilateral infiltrates on CXR
  3. Pulmonary capillary wedge pressure (PCWP) < 19mmHg
  4. Hypoxaemia
101
Q

How is ARDS managed?

A
  • Treat underlying cause
  • Respiratory support
    • CPAP / PEEP with 40-60% O2
  • Circulatory support
    • Inotropes
    • Vasodilators
    • Blood transfusion
  • Sepsis - empirical broad spectrum
  • Nutritional support
102
Q

What is bronchiectasis?

A

Chronic infection (staph aureus, h influenzae, strep pneumoniae, pseudomonas aeruginosa) of the bronchi and bronchioles leading to permenant dilation of these airways

103
Q

Name some causes of bronchiectasis

A
  • Congenital - cystic fibrosis
  • Post-infection - measles, pertussis, pneumonia, TB, HIV
  • Bronchial obstruction - tumour, foreign body
  • RA
  • UC
  • Idiopathic
104
Q

What are the clinical features of bronchiectasis?

A
  • Persistent cough
    • Copious purulent sputum
    • Intermittent haemoptysis
  • Clubbing
  • Coarse inspiratory crepitations
  • Wheeze
105
Q

How is bronchiectasis investigated?

A
  • Sputum culture
  • CXR
    • Cystic shadows
    • Thickened bronchial walls
  • High-resolution CT
  • SPirometry - obstructive
106
Q

How is bronchiectasis managed?

A
  • Postural drainage twice a day
  • Chest physiotherapy
  • Antibiotics
  • Bronchodilators (nebulised salbutamol)
  • Surgery
107
Q

Name the different types of lung tumour

A
  • Non-small cell
    • Squamous
    • Adenocarcinoma
    • Large cell (poorly differentiated)
  • Small cell - neuroendocrine tumour with poorer prognosis
  • Mesothelioma
108
Q

Name the guidelines for urgent CXR guidelines in suspected lung cancer

A

Aged over 40 if 2 or more OR ever smoked with 1:

  • Cough
  • Fatigue
  • Shortness of breath
  • Chest pain
  • Weight loss
  • Appetite loss
109
Q

Describe the guidelines for prescribing LTOT in a COPD patient

A
  • pO2 < 7.3 kPa
  • pO2 7.3-8.0 kPa if:
    • Secondary polycythaemia
    • Nocturnal hypoxaemia
    • Peripheral oedema
    • Pulmonary hypertension

IPE (13 decks)

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