asthma: - risk factors? 6 - three factors that contribute to airway narrowing?

- PMH atopic disease - FH atopic disease - exposure to tobacco smoke (or other lung irritants) - social deprivation - low birth weight - obesity 1) bronchial muscle constriction (triggered by a variety of stimuli) 2) mucosal swelling/inflammation (dt mast cell + basophil degranulation) 3) increased mucus production

asthma: - symptoms? 3 - common triggers? 8 - drugs which exacerbate? 2

- intermittent dyspnoea (diurnal variation) - wheeze - cough (often nocturnal) w sputum - cold air - exercise - emotions - allergens (dust mite, pollen, fur) - infection - smoking - passive smoking - pollution - NSAIDs - B blockers

asthma: - clinical signs? - conditions which often co-exist? - clinical testing/diagnosis?

- symptomatic wheeze on auscultation (- can get hyper inflated chest, but only if severe) - other atopic (hayfever, eczema) - gastric reflux - peak flow spirometry - FEV1/FVC ratio reduced (should be 90% in kids + 70% in adults) - FEV1 improves with salbutamol

differential diagnosis for asthma: - resp? 5 - cardiovascular? 3

resp: - COPD - bronchiectasis - large airway obstruction - pneumothorax - obliterative bronchiectasis (suspect in elderly) cardiac: - pulmonary oedema ('cardiac asthma') - PE - SVC obstruction (e.g. by tumour)

acute severe asthma: - presentation? - signs of severe attack? - signs of life-threatening attack?

- acute breathlessness + wheeze severe: - unable to complete sentences in one breath - RR >25 - pulse >110 - PEF 33-50% of predicted (or best) life threatening: - PEF <33% of predicted or best - silent chest, cyanosis, feeble respiratory effort - arrhythmia or hypotension - exhaustion, confusion, coma - poor ABG results

acute severe asthma: - management? - what to monitor? 3

- stay calm! - nebuliser salbutamol (keep going, can't really overdose) - oxygen - oral prednisalone - repeat salbutamol - continue reassessing - add ipratropium GET HELP!! - RR - pulse - O2 sats

COPD: - definition? - definition of chronic bronchitis? - factors which make COPD more likely than asthma? 5 - genetic risk factor?

progressive + prolonged airway obstruction - FEV1 35years - smoking (active or passive, or pollution related) - chronic dyspnoea - sputum production - minimal diurnal or day-to-day FEV1 variation - a1-antitrypsin deficiency

COPD: - symptoms? 4 - signs? 4

- cough - sputum - dyspnoea - wheeze - tachypnoea - use of accessory muscles - hyperinflation (barrel chest) - wheeze

COPD: - main investigation? - signs on x-ray? 2

- spirometry nb CXR may be normal if early/well-controlled - hyperinflation - flat hemidiaphragms (- may see bullae)

COPD: - non-pharm treatment? 3 - what is the general progression of inhalers? 3 - end-stage treatment?

- stop smoking - exercise - pneumococcal + flu vaccine 1) SABA or SAMA (short-acting muscarinic antagonist) 2) add LABA or LAMA 3) add inhaled steroid - long term oxygen therapy (LTOT) ^contraindicated in smokers nb can also consider surgery to remove bullae but rarely done

complications of COPD: - exacerbations? 2 - other? 5

- infective - non-infective - polycythaemia (dt prolonged hypoxia) - resp failure (1 or 2) - cor pulmonale - pneumothorax (ruptured bullae) - lung cancer

bronchial carcinoma - 4 types? - risk factors?

small cell - aka oat cell - worse prognosis - often have paraneoplastic syndromes (ACTH or ADH secretion) non-small cell - squamous - adenocarcinoma (commonest in non-smokers + asbestos) - large cell - tobacco smoking (90%) - passive smoking - asbestos - chromium - arsenic - iron oxides - radiation - pollution

bronchial carcinoma: - local symptoms? 4 - systemic symptoms? 3 - signs? 3

- persistent cough (80%) - haemoptysis (70%) - dyspnoea (60%) - chest pain (40%) - lethargy - anorexia - weight loss - cachexia - anaemia - clubbing nb can get other signs if mets or paraneoplastic syndromes - may auscultate an unresolved 'pneumonia' but not always

bronchial carcinoma: - imaging? - other tests?

``` CXR (nb if clear but smoker with haemoptysis send for CT as mediastinum may hide it) - peripheral nodule - hilar enlargement - (lung collapse or pleural effusion) ``` - fine needle aspiration or biopsy to identify + stage tumour - can send sputum or pleural fluid as well - bronchoscopy, to assess eligibility for surgery - PET CT for staging/mets

respiratory Flashcards by Maria Miles

asthma:

risk factors? 6
three factors that contribute to airway narrowing?

PMH atopic disease
FH atopic disease
exposure to tobacco smoke (or other lung irritants)
social deprivation
low birth weight
obesity

1) bronchial muscle constriction (triggered by a variety of stimuli)
2) mucosal swelling/inflammation (dt mast cell + basophil degranulation)
3) increased mucus production

How well did you know this?

Not at all

Perfectly

asthma:

symptoms? 3
common triggers? 8
drugs which exacerbate? 2

intermittent dyspnoea (diurnal variation)
wheeze
cough (often nocturnal) w sputum
cold air
exercise
emotions
allergens (dust mite, pollen, fur)
infection
smoking
passive smoking
pollution
NSAIDs
B blockers

How well did you know this?

Not at all

Perfectly

asthma:

clinical signs?
conditions which often co-exist?
clinical testing/diagnosis?

symptomatic wheeze on auscultation
(- can get hyper inflated chest, but only if severe)
other atopic (hayfever, eczema)
gastric reflux
peak flow

spirometry

FEV1/FVC ratio reduced (should be 90% in kids + 70% in adults)
FEV1 improves with salbutamol

How well did you know this?

Not at all

Perfectly

asthma:

suggested lifestyle changes? 3
pharmacological treatment ladder? (5 steps)

stop smoking
avoid precipitants
weight loss (if overweight)

1) occasional SABA as required

(if used >1 a day or at night then go step 2)

2) add daily inhaled steroid (e.g. beclomethasone)

(before step 3, check inhaler technique, adherence + removal of triggers)

3) change to LABA/inhaled steroid dual inhaler (don’t take LABA alone)
- if no response, stop LABA + increase inhaled steroid dose

4) raise inhaled steroid dose or add other agents:
- oral theophylline
- oral B2-agonists
- LTRA
* refer to specialist at this point*

5) add daily steroid tablets

How well did you know this?

Not at all

Perfectly

differential diagnosis for asthma:

resp? 5
cardiovascular? 3

resp:

COPD
bronchiectasis
large airway obstruction
pneumothorax
obliterative bronchiectasis (suspect in elderly)

cardiac:

pulmonary oedema (‘cardiac asthma’)
PE
SVC obstruction (e.g. by tumour)

How well did you know this?

Not at all

Perfectly

acute severe asthma:

presentation?
signs of severe attack?
signs of life-threatening attack?

acute breathlessness + wheeze

severe:

unable to complete sentences in one breath
RR >25
pulse >110
PEF 33-50% of predicted (or best)

life threatening:

PEF <33% of predicted or best
silent chest, cyanosis, feeble respiratory effort
arrhythmia or hypotension
exhaustion, confusion, coma
poor ABG results

How well did you know this?

Not at all

Perfectly

acute severe asthma:

management?
what to monitor? 3

stay calm!
nebuliser salbutamol (keep going, can’t really overdose)
oxygen
oral prednisalone
repeat salbutamol
continue reassessing
add ipratropium

GET HELP!!

RR
pulse
O2 sats

How well did you know this?

Not at all

Perfectly

differential diagnosis for acute asthma attack? 5

acute infective exacerbation of COPD
pulmonary oedema
upper resp tract obstruction
PE
anaphylaxis

How well did you know this?

Not at all

Perfectly

COPD:

definition?
definition of chronic bronchitis?
factors which make COPD more likely than asthma? 5
genetic risk factor?

progressive + prolonged airway obstruction

FEV1 <80% predicted
FEV1/FVC <0.7
with little or no reversibility
cough
sputum production on most days for 3 months of 2 successive years
symptoms improve if stop smoking
age of onset >35years
smoking (active or passive, or pollution related)
chronic dyspnoea
sputum production
minimal diurnal or day-to-day FEV1 variation
a1-antitrypsin deficiency

How well did you know this?

Not at all

Perfectly

COPD:

- difference between a pink puffer and a blue bloater?

blue bloater

mainly bronchitis
earlier
near normal PaO2
cyanosed
wheezing
overweight

pink puffer

mainly emphysema
later
low PaO2 and high CO2
severe breathless
quiet chest (hyper inflated lungs on x-ray)
cachexic

How well did you know this?

Not at all

Perfectly

COPD:

symptoms? 4
signs? 4

cough
sputum
dyspnoea
wheeze
tachypnoea
use of accessory muscles
hyperinflation (barrel chest)
wheeze

How well did you know this?

Not at all

Perfectly

COPD:

main investigation?
signs on x-ray? 2

spirometry

nb CXR may be normal if early/well-controlled

hyperinflation
flat hemidiaphragms
(- may see bullae)

How well did you know this?

Not at all

Perfectly

COPD:

non-pharm treatment? 3
what is the general progression of inhalers? 3
end-stage treatment?

stop smoking
exercise
pneumococcal + flu vaccine

1) SABA or SAMA (short-acting muscarinic antagonist)
2) add LABA or LAMA
3) add inhaled steroid

long term oxygen therapy (LTOT)
^contraindicated in smokers

nb can also consider surgery to remove bullae but rarely done

How well did you know this?

Not at all

Perfectly

complications of COPD:

exacerbations? 2
other? 5

infective
non-infective
polycythaemia (dt prolonged hypoxia)
resp failure (1 or 2)
cor pulmonale
pneumothorax (ruptured bullae)
lung cancer

How well did you know this?

Not at all

Perfectly

bronchial carcinoma

4 types?
risk factors?

small cell

aka oat cell
worse prognosis
often have paraneoplastic syndromes (ACTH or ADH secretion)

non-small cell

squamous
adenocarcinoma (commonest in non-smokers + asbestos)
large cell
tobacco smoking (90%)
passive smoking
asbestos
chromium
arsenic
iron oxides
radiation
pollution

How well did you know this?

Not at all

Perfectly

bronchial carcinoma:

local symptoms? 4
systemic symptoms? 3
signs? 3

persistent cough (80%)
haemoptysis (70%)
dyspnoea (60%)
chest pain (40%)
lethargy
anorexia
weight loss
cachexia
anaemia
clubbing

nb can get other signs if mets or paraneoplastic syndromes
- may auscultate an unresolved ‘pneumonia’ but not always

How well did you know this?

Not at all

Perfectly

bronchial carcinoma:

imaging?
other tests?

CXR
(nb if clear but smoker with haemoptysis send for CT as mediastinum may hide it)
- peripheral nodule
- hilar enlargement
- (lung collapse or pleural effusion)

fine needle aspiration or biopsy to identify + stage tumour
can send sputum or pleural fluid as well
bronchoscopy, to assess eligibility for surgery
PET CT for staging/mets

bronchial carcinoma:

ideal treatment?
other treatments?

lobectomy
radical radiotherapy
radiotherapy + chemo (for advanced)

very poor prognosis! (especially small cell)

differential diagnoses for nodules on the lung on a CXR:

respiratory? 8
other? 3

primary lung cancer
secondary lung cancer
carcinoid (neuroendocrine) tumours
abscess
granuloma
cyst
pulmonary hamartoma
encysted effusion (fluid, pus, blood)
Arterovenous malformation
foreign body
skin tumour (e.g. seborrheic wart)

differential diagnosis for haemoptysis:

commonest? 4
others? 4

bronchitis (26%)
neoplastic (23%)
pneumonia (10%)
TB (8%)
PE
foreign body
rare vasculitisis
bronchiectasis

pneumothorax:

commonest cause?
other causes?

spontaneous (in tall, young men)

chronic lung disease

asthma
COPD
CF
lung fibrosis
sarcoidosis

infection

TB
pneumonia
lung abscess

traumatic

trauma (incl rib fracture)
iatrogenic (e.g. lung biopsy, mechanical ventilation)

carcinoma

connective tissue disorder (e.g. marfans)

basically anything that affects the lung can cause a pneumothorax…

pneumothorax:

symptoms? 2
signs? 3
signs of a tension pneumothorax? 3

often asymptomatic in tall, young men

sudden onset
- dyspnoea
- pleuritic chest pain
(sudden deterioration in asthma/COPD patients)

on affected side:

reduced expansion
hyper resonant to percussion
diminished breath sounds

tension:

trachea deviation (away from pneumothorax)
hypotension
rapid deterioration/resp distress

pneumothorax:

imaging? 1
bloods? 1

CXR
- NOT in tension pneumothorax!!

ABG (if hypoxic or chronic lung disease)

pneumothorax:

management? 2
future advice? 2
treatment for recurrent? 1

aspiration
if unsuccessful (do CXR), or patient ill: intercostal chest drain
no air travel for 6 weeks after normal CXR
avoid diving permanently
pleurodesis

pleural effusion: - commonest causes of transudates? 2 - rare causes of transudates? 2 - causes of exudates? 3

- heart failure - hypoalbuminaemia (liver failure) (- hypothyroidism) (- meig's syndrome - ovarian fibroma) infection - pneumonia - TB inflammation - RS - SLE malignancy - bronchial carcinoma - mets - lymphoma - mesothelioma

pleural effusion: - symptoms? 2 - commonest signs? 3 - other signs? 3

asymptomatic if small - dyspnoea - pleuritic chest pain on affected side: - decreased expansion - stony dull to percussion - decreased breath sounds - bronchial breathing (above effusion dt compression) - tracheal deviation away from effusion, if large - signs of underlying cause (liver disease, clubbing, SLE rash etc)

pleural effusion: - imaging? 1 - other investigation? 1

- CXR (blunted costophrenic angles is first sign) | - USS guided pleural fluid aspiration (unless obvious it's heart failure)

pleural effusion: - treatment of transudates? 1 - treatment of exudates? 1 - treatment of recurrent pleural effusions? 1

- treat underlying cause in transudates - drain in exudates (or if symptomatic) - nb also treat underlying cause!! - pleurodesis

pneumonia: | - definition?

an acute LRTI associated with fever, symptoms + signs in the chest AND abnormalities on the CXR

pneumonia: - commonest organism in CAP? - other typical CAP organisms? - atypical CAP organisms?

strep pneumoniae (commonest) typical - Haemophilus influenzae (common w COPD) - moraxella catarrhalis atypical - mycoplasma pneumoniae - staph aureus (IVDU) - legionella (water borne) - chlamydia nb 15% are caused by viruses

hospital acquired pneumonia: - definition? - 2 most common causative organisms? - 4 rarer ones?

>48hours after hospital admission + gram negative enterobacteria + staph aureus - pseudomonas - kleibsiella - bacteroides - clostridia

pneumonia: - resp symptoms? 4 - other symptoms? 4

- productive cough (w green sputum) - dyspnoea - pleuritic pain - haemoptysis - fever - rigors - anorexia - malaise

pneumonia: - sign most commonly seen in elderly? - score used to assess severity?

confusion (can be only sign in elderly) CURB-65 ``` C - confusion U - urea (in blood) R - RR B - BP 65 - over the age of 65 ``` score 1 for each! determines whether treatment as outpatient or admitted

pneumonia: - imaging? - bloods? 4 - other bedside tests? 2

CXR - FBC (raised WBCs) - U+E (look for urea) - LFTs (just cos) - CRP (severity) - O2 sats - BP (see if getting septic)

pneumonia Abx treatment: - first line if CAP with low CURB? - first line if CAP with high CURB? - first line if CAP with penicillin allergy? - if caused by MRSA?

low CURB - amoxicillin (initially 5 days) high CURB - co-amoxiclav (initially 7 days) (- add clarithromycin if not clearing!) penicillin allergy - clarithromycin nb always consult trust guidelines nb above are for typical organisms - atypicals use other things (check guidelines) - vancomycin if hospital acquired, culture + treat organism

Pneumonia: - non-Abx medication? 3 - follow up required?

- analgesia - fluids - oxygen (to keep up sats) ^all depend on severity also physio to help cough CXR in 6 weeks

pneumonia: | - main resp DDx? 3

- PE - pulmonary oedema - bronchial carcinoma

PE: - commonest cause? - rare causes? 4

emboli from DVT in legs or pelvis - RV thrombus (post-MI) - septic emboli (R infective endocarditis) - fat, air or amniotic fluid emboli - neoplastic cells

PE: - risk factors which increase hypercoaguability? 5 - risk factors which increase stasis? 2 - risk factors which damage blood vessels? 2

hypercoaguable - pregnancy (+ 6 wks postpartum) - COCP (HRT, but less so) - cancer - thrombophilia (e.g. antiphospholipid syndrome) - previous PE stasis - prolonged bed rest/reduced mobility (incl air travel) - recent surgery (esp pelvic, hip or knee) damaged blood vessels - obesity - over 60 also FH

PE: - symptoms? 5 - signs? 6

nb small emboli may be asymptomatic - acute breathlessness - pleuritic chest pain - haemoptysis - dizziness - syncope - tachypnoea - tachycardia (see on ECG) - hypotension - raised JVP - pleural rub - SIGNS OF DVT

PE: - score used to work out likelihood of PE? - investigation if this is low? - investigation if this is high? - other investigations? (incl bloods) 3

WELLS score - uses clinical signs as well as risk factors low WELLS score = do D-Dimer - if negative, consider alternative diagnosis - if positive, do CTPA (or empirical LMWH treatment if delay) high WELLS score = do CTPA or treat empirically with LMWH if delay - bloods, incl clotting - ECG (rule out ACS) - CXR (rule out other DDx)

PE: - treatment if haemodynamically unstable? - treatment if haemodynamically stable? - investigations needed if unprovoked PE (i.e. no real risk factors)?

unstable - thrombolyse (alteplase) stable - LMWH (unfractioned if renal probs) then introduce NOACs or warfarin (target INR = 2-3) investigate for possible underlying malignancy - full Hx + exam - CXR, Ca2+, LFTs if over 40, consider abdominal-pelvic CT + mammography for women consider antiphospholipid + thrombophilia testing if FH positive