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Respiratory Flashcards

1
Q

What are the normal range values for PaCO2 in an ABG sample?

A

4.8 - 6.0 kPa

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2
Q

What are the normal range values for PaO2 in an ABG sample?

A

10 - 13.5 kPa

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3
Q

What are the normal range values for HCO3- in an ABG sample?

A

23 - 27 mmol/L

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4
Q

What is the normal range value for base excess?

A

-3 to +3mmol/L

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5
Q

What is Type 1 respiratory failure?

A

Hypoxia- PaO2 <8kPa without hypercapnia.

May need long term O2 therary.

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6
Q

What is Acute Type 2 respiratory failure?

A

Hypoxia - PaO2 <8kPa with hypercapnia (PaCO2 >6kPa)
Presence of high CO2 concentration means more H+ ions= lower pH.

Kidneys have not yet compensated, so the base excess will be normal. Could be due to chest infection in COPD, exacerbation of respiratory disease.

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7
Q

What is Chronic Type 2 Respiratory Failure?

A

Where the raised PaCO2 (hypercapnia) persists, the kidneys will compensate (takes 3-5 days) by retaining HCO3-, which can mop up the excess H+ ions.
Here there will be a higher base excess.
Often seen in severe respiratory disorders eg. COPD.

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8
Q

Briefly outline the BTS guidelines for treatment of asthma.

A

Step 1 (Intermittent asthma): Short acting B2 agonist (SABA) eg. Salbutamol.

Step 2: Add Inhaled corticosteroid (ICS) eg. Beclomethasone

Step 3: Add Long-acting B2 agonist (LABA) eg. Salmeterol. If insufficient, increase the ICS dose.
No response, add a leukotrine receptor antagonist / Slow release theophylline.

Step 4: Trials of increased ICS. Add 4th drug if necessary, eg. oral B2 agonist. leukotrine receptor antagonist or SR theophylline.

Step 5: Low dose oral steroid (eg. prednisolone). Seek expert advice.

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9
Q

Name 3 causes of obstructive lung disease.

A
  1. COPD (emphysema, chronic bronchitis)
  2. Bronchiectasis
  3. Cystic fibrosis
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10
Q

Name 3 causes of restrictive lung disease

A
  1. Interstitial lung disease
  2. Scoliosis
  3. Sarcoidosis (small patches of red swollen inflammatory cells= granulomas, usually develops in lung first)
  4. Pulmonary fibrosis
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11
Q

What are the symptoms of carbon monoxide poisoning?

A 
Dizzyness 
Dull headache
Shortness of breath
Nausea due to gastric paresis (delayed gastric emptying) 
Vommitting
Weakness
Confusion
Cherry red appearance (Carboxyhaemoglobin absorbs blue-green light and reflects red light)
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12
Q

What happens in chronic carbon monoxide poisoning?

A

Chronic low oxygen status
Similar to high altitude
Heart rate and breathing rate increase to try and compensate
After 4-5 days, there is increased release of RBCs from bone marrow to try and increase oxygen carrying potential

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13
Q

How is oxygen transport and diffusion changed in anaemia?

A

Fewer Hb molecules or fewer oxygen binding sites = lower oxygen carrying capacity of the blood
PaO2 on ABG remains unchanged, as all RBCs are saturated, just a very low number of RBCs
Arteriolar dilation, increased heart rate and increased respiratory rate.
Principles of oxygen diffusion remain the same.

Giving these patients oxygen therapy has NO effect.

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14
Q

What are the main characteristic features of COPD?

A 
Irreversible
Obstructibe
Chronic airway inflammation
Mucus hypersecretion
Hyperinflation
Usually progressive
Difficult to fully expel air
Increased breathlessness
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15
Q

What are the risk factors for COPD?

A

Smoking
Age >50 years
Occupational hazards eg. paint, dust, fumes, chemicals, asbestos
Atmospheric pollution
Childhood chest infections
Alpha 1 antitrypsin deficiency (genetic) -WBCs harm the lungs

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16
Q

What are the signs and symptoms of COPD?

A 
↑  breathlessness
Wheezing
Chest tightness
Frequent coughing with/ without sputum
Loss of appetite, weight loss, swollen ankles
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17
Q

What are the key characteristics of emphysema?

A

PINK PUFFER: Breathless not cyanoses

Progressive destruction of alveolar septa and capillaries
Overproduction elastase = elastin destruction
Enlarged airways
Distal airway collapse during expiration
Less elastic recoil
Air trapped in alveoli on expiration

V/Q mismatch- High ratio, as pulmonary capillaries are lost.

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18
Q

What are the key characteristics of chronic bronchitis?

A

Cough with sputum production for most days of 3 months of 2 successive years.

Mucosal inflammation, Mucus gland hypertrophy, Mucus hypersecretion
Bronchospasm
Daily morning cough
Hypoxaemia leads to polycythaemia (↑ red cell production)
Pulmonary hypertension due to hypoxic pulmonary vasoconstriction
Can lead to cor pulmonale
BLUE BLOATER: Cyanosed not breathless, HIGH PCO2

V/Q ratio affected: low V/Q- airways partly blocked by bronchoconstriction, inflammation or secretions.

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19
Q

Outline the stages of treatment for COPD

A

Stage 1: Short acting B2 agonist (SABA) eg. Salbutamol OR Short Acting Muscarinic Antagonist (SAMA) Ipatorpium Bromide

Stage 2: If FEV1 >50% then Long acting B2 agonist (LABA) eg. Salmeterol OR Long acting muscarinic antagonist (LAMA) eg. Tiotropium
If FEV1 <50% then Long acting B2 agonist eg. Salmeterol WITH Inhaled corticosteroid (ICS) eg. Beclomethasone

Stage 3: LABA with ICS or
LABA with LAMA with ICS

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20
Q

How do Short acting B2 agonists (SABAs) work?

A

eg. Salbutamol.

Selective B2 agonist, ↑ cAMP which ↓ intracellular Ca2+, and causes bronchus smooth muscle relaxation.
Also increases mucociliary clearance.

Side effects: shaking, headaches, palpitations

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21
Q

How do Short acting muscarinic antagonists (SAMAs) work?

A

eg. Ipatropium bromide

Non-selectively BLOCKS muscarinic cholinergic receptor. Causes ↓ cGMP, which affects intracellular Ca2+ and ↓ smooth muscle contractility.

Side effects: sinusitis, headaches

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22
Q

What type of drug is Salmeterol?

A

Long acting B2 agonist (LABA)

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23
Q

What type of drug is Tiotropium?

A

LAMA

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24
Q

How do inhaled corticosteroids (ICSs) work?

A

eg. Beclamethosone

Anti-inflammatory. Inhibits leukocyte infiltration at inflammatory site. Reduction in oedema and scar tissue.

Side effects: dry mouth, headache.

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25
What are the major characteristics of asthma?
Narrowing of airways Hypersensitiveness to range of normally harmless stimulu (cold air, irritants, pollutants) Increased mucosal inflammation Recruitment of inflammatory cells (eosinophils, mast cells, neutrophils) to airways Hhypersecretion of mucus Epithelial shedding= whorls of epithelial cells Remodelling of airways = increased bronchial smooth muscle
26
What two things try to make the lungs move inwards?
Surface tension of alveoli, which is partially reduced by surfactant Elastic recoil of alveoli due to elastic fibres
27
How is Stage 1 COPD classified? | What about Stage 2?
FEV1 to FVC ratio is below 0.7, with FEV1 over 80% of expected FEV1 to FVC ratio is below 0.7, with FEV1 between 50-79% of expected
28
How are stage 3 and 4 COPD classified?
FEV1 to FVC ratio is below 0.7, with FEV1 30-49% of expected (for stage 3) FEV1 below 30% of expected (for stage 4)
29
What are the features of lung adenocarcinoma?
NSCLC, usually peripheral, glands and mucin, Weaker smoking association. TTF1 positive Prognosis good if discovered early; poor if fewer glands.
30
Which type of lung cancer is usually centrally located, with kertinisation and intracellular bridges, and may have cavities?
Squamous cell carcinoma
31
What is the prognosis of squamous cell carcinoma?
Good if discovered early; poor if less keratin
32
What is the most common type of lung cancer?
Adenocarcinoma (35%)
33
Which type of lung cancer has poor prognosis, cells with low amounts of cytoplasm, and innapropriate hormone secretion?
Small cell carcinoma
34
Which type of lung cancer appears benign, has well differentiated cells, but behaves malignantly?
Carcinoid tumour
35
What is centrilobular emphysema?
Associated with smoking, affects upper lobes and ends of each terminal bronchiole.
36
What is pan acinar emphysema?
Associated with alpha 1 antitrypsin deficiency
37
Dyspnoea on exertion, Dry cough, Fine end inspiratory crackles, Clubbing, cyanosis and malaise are the clinical features of which lung disease?
Interstitial lung disease
38
Honeycombing and reticulonodular shadowing are features of which lung disease on chest Xray?
Interstitial lung disease
39
Give examples of causes of interstitial lung disease.
1. Occupational-asbestosis, silicosis 2. Drugs- Nitrofurantoin, Bleomycin, Amiodarone, Sulfasalazine, Busulfan 3. Infection- TB 4. Systemic disoder- RA, SLE, Sarcoidosis, UC 5. Idiopathic pulmonary fibrosis 6. Hypersensitivity reactions eg. Hypersensitivity pneumonitis
40
What is hypersensitivity pneumonitis also known as?
Extrinsic Allergic Alveolitis
41
Granulmoas, foamy macrophages and giant cells can be found in which lung disease which also presents with clubbing, cough and fever?
Extrinsic Allergic Alveolitis (Hypersensitivity Pneumonitis)
42
What is the commonest cause of Interstitial Lung Disease?
Idiopathic Pulmonary Fibrosis
43
Which drugs can cause ILD?
Nitrofurantoin, Bleomycin, Sulfasalazine, Amiodarone, Busulfan
44
What can Coal Worker's Pneumoconiosis progress to?
Progressive massive fibrosis; progressive dyspnoea, cor pulmonale
45
Collagen nodules in the upper and posterior lung and egg shell calcification of hilar lymph noes can be found on Xrays in which lung disease?
Silicosis
46
How does asbestosis affect the pleura?
1. Pleural thickening 2. Pleural effusions 3. Pleural plaques made of collagen
47
How does acute sarcoidosis often present (4 features)?
1. Fever 2. Bilateral hilar lymphadenopathy 3. Polyarthralgia 4. Erythema nodosum Also... Dry cough, progressive dyspnoea, hypercalcaemia, raised serum ACE levels
48
What are the differential diagnoses for bilateral hilar lymphadenopathy on Xray?
1. Sarcoidosis 2. Lymphoma 3. Silicosis 4. Coal workers pneumoconiosis 5. Lung metastases 6. TB
49
What are the systemic features of sarcoidosis?
Splenomegaly Hepatomegaly Lymphadenopathy
50
What are the Lung causes of cor pulmonale?
COPD Bronchiectasis Pulmonary fibrosis Chronic asthma
51
What are the pulmonary vascular causes of cor pulmonale?
``` PE Pulmonary vasculitis Primary pulmonary hypertension ARDS Sickle cell ```
52
What are the non-respiratory causes of cor pulmonale?
``` Kyphosis Scoliosis Myasthenia gravis Motor neurone disease Sleep apnoea ```
53
What are the clinical features of cor pulmonale?
``` Raised JVP Peripheral oedema Dyspnoea Syncope RV heave Fatigue Tricuspid regurgitation ```
54
What are the clinical features of sleep apnoea?
``` Loud snoring Poor sleep quality Daytime sleepiness Morning headaches Nocturia ```
55
What are the symptoms of Typical CAP?
Purulent sputum Fever Chest pain
56
Which organisms cause typical CAP?
1. Strep pneumoniae 2. Haem Influenzae 3. Moraxella
57
Which organisms cause atypical CAP?
1. S aureus 2. Chlamydia 3. Mycoplasma 4. Legionella atypicals can cause deranged LFTs
58
What are the symptoms of atypical CAP?
Cough Dyspnoea Systemic features Minimal sputum
59
Which bacteria is the most common cause of CAP?
Strep pneumoniae
60
Which antibiotics are given for Strep pneumoniae CAP?
Amoxicillin / Clarithromycin
61
Which bacteria cause hospital acquired pneumoniae?
1. Gram negative: E.coli, Klebsiella 2. S. aureus 3. Pseudomonas
62
What does the CURB 65 Score stand for?
``` C- Confusion U- Urea >7 R- Resp rate >30 B- BP <90 systolic or <60 diastolic Age > 65 ``` 2+ need hospital, 3+ need ITU
63
What are the complications of pneumonia?
``` Pleural effusion Empyema Abscess Resp failure Sepsis Pericarditis ```
64
What is a transudate (pleural effusion)?
Fluid in the pleural cavity, with protein <25g/L Caused by increased venous pressure or hypoproteinaemia
65
What are the causes of a transudate (pleural effusion)?
1. Increased venous pressure- Heart failure, LVF,Fluid overload 2. Hypoproteinaemia- Nephrotic syndrome, Cirrhosis 3. Hypothyroidism 4. Constrictive pericarditits
66
What is an exudate (pleural effusion)?
Fluid in the pleural cavity due to increased leakiness of pleural capillaries, secondary to infection, inflammation or malignancy. Protein content >35g/L
67
What are the causes of an exudate (pleural effusion)?
1. Infection- parapneumonic effusion, TB 2. Pulmonary infarction 3. Inflammation- RA, SLE 4. Malignancy
68
If a pleual effusion contains neutrophils what may this suggest?
Parapneumonic effusion
69
If a pleual effusion contains lymphocytes what may this suggest?
TB, malignancy
70
What would suggest a pleural effusion on examination?
``` Stony dull percussion Reduced vocal resonance Reduced breath sounds Decreased expansion Tracheal deviation AWAY if large ```
71
What is the management of a primary pneumothorax?
If >2cm then aspirate (2nd ICS or triangle or safety) | If unsuccessful, chest drain.
72
What is the management of a secondary pneumothorax?
If >2cm then chest drain.
73
What are the clinical features of a PE?
``` Acute SOB Pleuritic chest pain Haemoptysis Syncope Tachycardia Hypotension Raised JVP ```
74
What may an unprovoked PE suggest?
Underlying malignancy
75
What are the Well's criteria?
Assesses probability of a PE: ``` Signs/symptoms of DVT HR >100 Recently bed ridden/ major surgery Haemoptysis Previous PE or DVT Cancer An alternative diagnosis is less likely than PE ```
76
Which conditions can cause a V/Q mismatch as seen in Type 1 respiratory failure?
``` PE Pulmonary oedema Pulmonary fibrosis ARDS Asthma Emphysema Pneumonia ```
77
Which conditions can cause Type 2 respiratory failure?
1. COPD 2. Asthma 3. Obstructive sleep apnoea 4. Respiratory depression- morphine, trauma, CNS tumour 5. Flail chest 6. Neuromuscular disease: GBS, Myasthenia Gravis
78
What are the clinical features of hypercapnia?
1. Bounding pulse 2. Flap/ tremor 3. Headache 4. Peripheral vasodilation 5. Tachycardia
79
How should oxygen be administered in Type 1 respiratory failure?
Via facemask (24-60%) Assisted ventilation only if PaO2 remains <8KPa despite use of 60% Oxygen
80
How should oxygen be administered in Type 2 respiratory failure?
Controlled oxygen therapy (eg, Use Venturi mask) 24-60%. Start at 24%. Respiratory drive via hypoxia, so give oxygen with care. Recheck PaO2 on ABG after 20 mins, if PaCO2 is lowering, then increase oxygen to 28%. If PaCO2 rises then consider Non Invasive Ventilation
81
What is ARDS?
Acute Respiratory Distress Syndrome Lung damage, release of inflammatory mediators causes widespread non cardiogenic pulmonary oedema Often has multi organ failure
82
What are the clinical features of ARDS?
``` Cyanosis Tachycardia Tachypnoea Peripheral vasodilation Bilateral fine inspiratory crackles ```
83
What 3 criteria are present to diagnosis Acute Severe Asthma?
1. Unable to complete sentence in 1 breath 2. RR >25 3. HR >110 4. PEF 33-50% predicted/best
84
How is acute severe asthma managed?
1. Oxygen 2. Salbutamol/ Terbutaline nebuliser 3. Hydrocortisone IV or Prednisolone oral
85
What are the key clinical signs of bronchiectasis?
1. Clubbing 2. Haemoptysis (intermittent) 3. Coarse inspiratory crackles 4. Cough 5. Purulent sputum
86
What are the main infectious organisms in bronchiectasis?
1. Strep pneumoniae 2. Haemophilus influenzae 3. S. aureus 4. Pseudomonas
87
Which 2 methods can be used to diagnose LATENT TB?
1. Tuberculin skin test (Mantoux test) | 2. Interferon gamma release assay
88
Which 4 methods can be used to diagnose ACTIVE pulmonary TB?
1. CXR: Upper lobe (most o2) opacitites, coin lesions 2. Sputum smear X3 3. Sputum culture (can take weeks) 4. Nucleic acid amplification test
89
What is an inverted papilloma and what are the causes?
Benign nasal mucous membrane tumour, inverted so grows into underlying bone, may become malignant. Causes: Smoking, pollution, allergens
90
What condition has coarse inspiratory crackles?
Bronchiectasis
91
Which conditions have fine crackles?
Pulmonary oedema
92
Which cancer has the highest mortality rate in the UK?
Lung cancer
93
Who should have the Pneumococcus (Strep.pneumococcus) vaccine?
1. Babies 2. Age >65 3. COPD 4. Splenectomy 5. Other health conditions eg. Congenital heart disease 6. Diabetes not controlled by diet
94
Which signs in the mouth distinguish bacterial vs viral pharyngitis?
White spots Swollen uvula Grey furry tongue
95
Which 2 organisms usually cause sinusitis?
Staph aureues | Haem influenza
96
Which organism usually causes epiglottitis?
Haem influenza
97
Which type of organisms can cause deranged LFTs in a pneumonia patient?
Atypicals: Legionella Chlamydia Mycoplasma Staph aureus
98
What is a common finding in bloods of a patient with EBV?
Increased numbers of lymphocytes | >10% are atypical
99
If IgG against EBV is found in a patient, what does this suggest?
Past EBV infection
100
If IgM against EBV is found in a patient, what does this suggest?
Current EBV infection
101
What does an air-fluid level on chest X ray suggest?
1. Abscess | 2. Cavitation of tumour
102
What is SARS caused by?
SARS CoV virus- a corona virus
103
What is MERS caused by?
Coronavirus
104
What is a pneumatocele?
Air filled cyst
105
What are the potential causes of lung abscess?
1. Pneumonia (untreated) 2. Aspiration 3. Pulmonary infarct 4. Septic emboli (IVDU, endocarditis) 5. Bronchial obstruction
106
How would bronchiectasis appear on chest X ray?
1. Dilated airways | 2. Bronchial wall thickening (tramlines and ring shadows)
107
Emphysema can lead to which type of respiratory failure?
Type 1
108
If a pleural effusion has raised amylase what might this suggest?
Pancreatitis Oesophageal rupture Bacterial pneumonia Cancer
109
Fibrotic shadows in the upper zone of lungs on chest X ray can be caused by...........
TB EAA PMF
110
Fibrotic shadows in the mid zone of lungs on chest X ray can be caused by...........
Sarcoidosis
111
Fibrotic shadows in the lower zone of lungs on chest X ray can be caused by...........
Asbestosis | Idiopathic pulmonary fibrosis
112
Which antibiotic used for TB can cause red urine as a side effect?
Rifampicin
113
cANCA is positive in which condition?
Granulomatosus with polyangiitis
114
pANCA is positive in which condition?
Microscopic polyangitiis
115
Lambert Eaton syndrome is associated with which type of lung cancer?
Small cell lung cancer
116
Epithelioid histiocytes are activated macrophages found in which granulomatous condition?
TB

Year 3 (22 decks)

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