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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
Q

What are the major characteristics of asthma?

A

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

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26
Q

What two things try to make the lungs move inwards?

A

Surface tension of alveoli, which is partially reduced by surfactant

Elastic recoil of alveoli due to elastic fibres

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27
Q

How is Stage 1 COPD classified?

What about Stage 2?

A

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

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28
Q

How are stage 3 and 4 COPD classified?

A

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)

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29
Q

What are the features of lung adenocarcinoma?

A

NSCLC, usually peripheral, glands and mucin,
Weaker smoking association.
TTF1 positive
Prognosis good if discovered early; poor if fewer glands.

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30
Q

Which type of lung cancer is usually centrally located, with kertinisation and intracellular bridges, and may have cavities?

A

Squamous cell carcinoma

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31
Q

What is the prognosis of squamous cell carcinoma?

A

Good if discovered early; poor if less keratin

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32
Q

What is the most common type of lung cancer?

A

Adenocarcinoma (35%)

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33
Q

Which type of lung cancer has poor prognosis, cells with low amounts of cytoplasm, and innapropriate hormone secretion?

A

Small cell carcinoma

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34
Q

Which type of lung cancer appears benign, has well differentiated cells, but behaves malignantly?

A

Carcinoid tumour

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35
Q

What is centrilobular emphysema?

A

Associated with smoking, affects upper lobes and ends of each terminal bronchiole.

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36
Q

What is pan acinar emphysema?

A

Associated with alpha 1 antitrypsin deficiency

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37
Q

Dyspnoea on exertion, Dry cough, Fine end inspiratory crackles, Clubbing, cyanosis
and malaise are the clinical features of which lung disease?

A

Interstitial lung disease

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38
Q

Honeycombing and reticulonodular shadowing are features of which lung disease on chest Xray?

A

Interstitial lung disease

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39
Q

Give examples of causes of interstitial lung disease.

A
  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
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40
Q

What is hypersensitivity pneumonitis also known as?

A

Extrinsic Allergic Alveolitis

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41
Q

Granulmoas, foamy macrophages and giant cells can be found in which lung disease which also presents with clubbing, cough and fever?

A

Extrinsic Allergic Alveolitis (Hypersensitivity Pneumonitis)

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42
Q

What is the commonest cause of Interstitial Lung Disease?

A

Idiopathic Pulmonary Fibrosis

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43
Q

Which drugs can cause ILD?

A

Nitrofurantoin, Bleomycin, Sulfasalazine, Amiodarone, Busulfan

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44
Q

What can Coal Worker’s Pneumoconiosis progress to?

A

Progressive massive fibrosis; progressive dyspnoea, cor pulmonale

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45
Q

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?

A

Silicosis

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46
Q

How does asbestosis affect the pleura?

A
  1. Pleural thickening
  2. Pleural effusions
  3. Pleural plaques made of collagen
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47
Q

How does acute sarcoidosis often present (4 features)?

A
  1. Fever
  2. Bilateral hilar lymphadenopathy
  3. Polyarthralgia
  4. Erythema nodosum

Also… Dry cough, progressive dyspnoea, hypercalcaemia, raised serum ACE levels

48
Q

What are the differential diagnoses for bilateral hilar lymphadenopathy on Xray?

A
  1. Sarcoidosis
  2. Lymphoma
  3. Silicosis
  4. Coal workers pneumoconiosis
  5. Lung metastases
  6. TB
49
Q

What are the systemic features of sarcoidosis?

A

Splenomegaly
Hepatomegaly
Lymphadenopathy

50
Q

What are the Lung causes of cor pulmonale?

A

COPD
Bronchiectasis
Pulmonary fibrosis
Chronic asthma

51
Q

What are the pulmonary vascular causes of cor pulmonale?

A 
PE
Pulmonary vasculitis
Primary pulmonary hypertension
ARDS
Sickle cell
52
Q

What are the non-respiratory causes of cor pulmonale?

A 
Kyphosis
Scoliosis
Myasthenia gravis
Motor neurone disease
Sleep apnoea
53
Q

What are the clinical features of cor pulmonale?

A 
Raised JVP
Peripheral oedema
Dyspnoea
Syncope
RV heave
Fatigue
Tricuspid regurgitation
54
Q

What are the clinical features of sleep apnoea?

A 
Loud snoring
Poor sleep quality
Daytime sleepiness
Morning headaches
Nocturia
55
Q

What are the symptoms of Typical CAP?

A

Purulent sputum
Fever
Chest pain

56
Q

Which organisms cause typical CAP?

A
  1. Strep pneumoniae
  2. Haem Influenzae
  3. Moraxella
57
Q

Which organisms cause atypical CAP?

A
  1. S aureus
  2. Chlamydia
  3. Mycoplasma
  4. Legionella

atypicals can cause deranged LFTs

58
Q

What are the symptoms of atypical CAP?

A

Cough
Dyspnoea
Systemic features
Minimal sputum

59
Q

Which bacteria is the most common cause of CAP?

A

Strep pneumoniae

60
Q

Which antibiotics are given for Strep pneumoniae CAP?

A

Amoxicillin / Clarithromycin

61
Q

Which bacteria cause hospital acquired pneumoniae?

A
  1. Gram negative: E.coli, Klebsiella
  2. S. aureus
  3. Pseudomonas
62
Q

What does the CURB 65 Score stand for?

A 
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
Q

What are the complications of pneumonia?

A 
Pleural effusion
Empyema
Abscess
Resp failure
Sepsis
Pericarditis
64
Q

What is a transudate (pleural effusion)?

A

Fluid in the pleural cavity, with protein <25g/L

Caused by increased venous pressure or hypoproteinaemia

65
Q

What are the causes of a transudate (pleural effusion)?

A
  1. Increased venous pressure- Heart failure, LVF,Fluid overload
  2. Hypoproteinaemia- Nephrotic syndrome, Cirrhosis
  3. Hypothyroidism
  4. Constrictive pericarditits
66
Q

What is an exudate (pleural effusion)?

A

Fluid in the pleural cavity due to increased leakiness of pleural capillaries, secondary to infection, inflammation or malignancy. Protein content >35g/L

67
Q

What are the causes of an exudate (pleural effusion)?

A
  1. Infection- parapneumonic effusion, TB
  2. Pulmonary infarction
  3. Inflammation- RA, SLE
  4. Malignancy
68
Q

If a pleual effusion contains neutrophils what may this suggest?

A

Parapneumonic effusion

69
Q

If a pleual effusion contains lymphocytes what may this suggest?

A

TB, malignancy

70
Q

What would suggest a pleural effusion on examination?

A 
Stony dull percussion
Reduced vocal resonance
Reduced breath sounds
Decreased expansion
Tracheal deviation AWAY if large
71
Q

What is the management of a primary pneumothorax?

A

If >2cm then aspirate (2nd ICS or triangle or safety)

If unsuccessful, chest drain.

72
Q

What is the management of a secondary pneumothorax?

A

If >2cm then chest drain.

73
Q

What are the clinical features of a PE?

A 
Acute SOB
Pleuritic chest pain
Haemoptysis
Syncope
Tachycardia
Hypotension
Raised JVP
74
Q

What may an unprovoked PE suggest?

A

Underlying malignancy

75
Q

What are the Well’s criteria?

A

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
Q

Which conditions can cause a V/Q mismatch as seen in Type 1 respiratory failure?

A 
PE
Pulmonary oedema
Pulmonary fibrosis
ARDS
Asthma
Emphysema
Pneumonia
77
Q

Which conditions can cause Type 2 respiratory failure?

A
  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
Q

What are the clinical features of hypercapnia?

A
  1. Bounding pulse
  2. Flap/ tremor
  3. Headache
  4. Peripheral vasodilation
  5. Tachycardia
79
Q

How should oxygen be administered in Type 1 respiratory failure?

A

Via facemask (24-60%)

Assisted ventilation only if PaO2 remains <8KPa despite use of 60% Oxygen

80
Q

How should oxygen be administered in Type 2 respiratory failure?

A

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
Q

What is ARDS?

A

Acute Respiratory Distress Syndrome
Lung damage, release of inflammatory mediators causes widespread non cardiogenic pulmonary oedema
Often has multi organ failure

82
Q

What are the clinical features of ARDS?

A 
Cyanosis
Tachycardia
Tachypnoea
Peripheral vasodilation
Bilateral fine inspiratory crackles
83
Q

What 3 criteria are present to diagnosis Acute Severe Asthma?

A
  1. Unable to complete sentence in 1 breath
  2. RR >25
  3. HR >110
  4. PEF 33-50% predicted/best
84
Q

How is acute severe asthma managed?

A
  1. Oxygen
  2. Salbutamol/ Terbutaline nebuliser
  3. Hydrocortisone IV or Prednisolone oral
85
Q

What are the key clinical signs of bronchiectasis?

A
  1. Clubbing
  2. Haemoptysis (intermittent)
  3. Coarse inspiratory crackles
  4. Cough
  5. Purulent sputum
86
Q

What are the main infectious organisms in bronchiectasis?

A
  1. Strep pneumoniae
  2. Haemophilus influenzae
  3. S. aureus
  4. Pseudomonas
87
Q

Which 2 methods can be used to diagnose LATENT TB?

A
  1. Tuberculin skin test (Mantoux test)

2. Interferon gamma release assay

88
Q

Which 4 methods can be used to diagnose ACTIVE pulmonary TB?

A
  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
Q

What is an inverted papilloma and what are the causes?

A

Benign nasal mucous membrane tumour, inverted so grows into underlying bone, may become malignant.

Causes: Smoking, pollution, allergens

90
Q

What condition has coarse inspiratory crackles?

A

Bronchiectasis

91
Q

Which conditions have fine crackles?

A

Pulmonary oedema

92
Q

Which cancer has the highest mortality rate in the UK?

A

Lung cancer

93
Q

Who should have the Pneumococcus (Strep.pneumococcus) vaccine?

A
  1. Babies
  2. Age >65
  3. COPD
  4. Splenectomy
  5. Other health conditions eg. Congenital heart disease
  6. Diabetes not controlled by diet
94
Q

Which signs in the mouth distinguish bacterial vs viral pharyngitis?

A

White spots
Swollen uvula
Grey furry tongue

95
Q

Which 2 organisms usually cause sinusitis?

A

Staph aureues

Haem influenza

96
Q

Which organism usually causes epiglottitis?

A

Haem influenza

97
Q

Which type of organisms can cause deranged LFTs in a pneumonia patient?

A

Atypicals:

Legionella
Chlamydia
Mycoplasma
Staph aureus

98
Q

What is a common finding in bloods of a patient with EBV?

A

Increased numbers of lymphocytes

>10% are atypical

99
Q

If IgG against EBV is found in a patient, what does this suggest?

A

Past EBV infection

100
Q

If IgM against EBV is found in a patient, what does this suggest?

A

Current EBV infection

101
Q

What does an air-fluid level on chest X ray suggest?

A
  1. Abscess

2. Cavitation of tumour

102
Q

What is SARS caused by?

A

SARS CoV virus- a corona virus

103
Q

What is MERS caused by?

A

Coronavirus

104
Q

What is a pneumatocele?

A

Air filled cyst

105
Q

What are the potential causes of lung abscess?

A
  1. Pneumonia (untreated)
  2. Aspiration
  3. Pulmonary infarct
  4. Septic emboli (IVDU, endocarditis)
  5. Bronchial obstruction
106
Q

How would bronchiectasis appear on chest X ray?

A
  1. Dilated airways

2. Bronchial wall thickening (tramlines and ring shadows)

107
Q

Emphysema can lead to which type of respiratory failure?

108
Q

If a pleural effusion has raised amylase what might this suggest?

A

Pancreatitis
Oesophageal rupture
Bacterial pneumonia
Cancer

109
Q

Fibrotic shadows in the upper zone of lungs on chest X ray can be caused by………..

110
Q

Fibrotic shadows in the mid zone of lungs on chest X ray can be caused by………..

A

Sarcoidosis

111
Q

Fibrotic shadows in the lower zone of lungs on chest X ray can be caused by………..

A

Asbestosis

Idiopathic pulmonary fibrosis

112
Q

Which antibiotic used for TB can cause red urine as a side effect?

A

Rifampicin

113
Q

cANCA is positive in which condition?

A

Granulomatosus with polyangiitis

114
Q

pANCA is positive in which condition?

A

Microscopic polyangitiis

115
Q

Lambert Eaton syndrome is associated with which type of lung cancer?

A

Small cell lung cancer

116
Q

Epithelioid histiocytes are activated macrophages found in which granulomatous condition?

Year 3 (22 decks)

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