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Respiratory Flashcards

1
Q

Asthma Presentation

A

Recurrent episodes of cough, wheeze, SOB
Young children
Diurnal variability

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2
Q

Asthma Precipitants

A 
Cold air
Dustmites
Exercise
NSAIDs 
Beta Blockers
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3
Q

Investigations for Asthma and results

A

Peak flow

Spirometer - reduced FEV1, normal FVC

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4
Q

Samter’s Triad

A

Asthma
Nasal Polyps
Aspirin/NSAID sensitivity

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5
Q

Churg Strauss Vasculitis

A

Asthma
Eosinophilia
Mononeuritis Multiplex

Positive pANCA

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6
Q

Stages 1-4 of Asthma Management and examples of drug names

A
  1. SABA (salbutamol)
  2. SABA + ICS (salbutamol and beclometasone)
  3. SABA + ICS + LTRA (salbutamol, beclometasone and montelukast)
  4. SABA + ICS + LABA +/- LTRA (salbutamol, beclometasone, salmeterol/formoterol and montelukast)
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7
Q

Management on Acute Asthma

A

ABCDE
Nebulisers - salbutamol 5mg and ipatropium 500mcg
Steroids: Oral prednisolone/ IV Hydrocortisone
If life threatening add IV MgSO4 2g

ABG - pCO2 should be low. If high or normal means they are tiring. Worrying.

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8
Q

Presentation of COPD

A

Sputum production + cough on most days for 3 months for 2 consecutive years
Smoker
Cor pulmonale

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9
Q

How does Cor Pulmonale occur and what are the ECG changes

A

Chronic cascade, hypoxia, pulmonary vasoconstriction, pulmonary hypertension, cor pulmonale

ECG - peak P waves and right ventricular hypertrophy

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10
Q

Investigations and results in COPD

A

CXR - hyperinflation, flattened hemidiaphragms

ABG - compensated type 2 respiratory failure

Spirometry - obstructive. FEV1:FVC ratio under 0.7

Bloods - secondary polycythaemia due to hypoxia

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11
Q

Treatment of COPD

A
  1. SABA or SAMA
  2. FEV1 over 50% = LABA or LAMA
  3. FEV1 under 50% = LABA + ICS or LAMA
  4. Combo = LABA+ICS+LAMA
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12
Q

Treatment of Acute Exacerbation of COPD

A 
ABCDE
Nebulisers - salbutamol and ipraptropium
Steroids - predisolone/IV hydrocortisone
Antibiotics (amoxicillin/doxycycline)
No response - IV aminophylline

Respiratory acidosis, T2RF = Non invasive ventilation

pH under 7.26 = intubation

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13
Q

Presentation of ILD

A

Dry cough
Myalgia
SOBOE
fine inspiratory crackles

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14
Q

Investigations and expected results for ILD

A

CXR - diffuse infiltrates

Spirometry - restrictive pattern FEV1:FVC ratio over 0.7

ABG - type 1 respiratory failure

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15
Q

Management of ILD

A

Conservative
Oxygen
Pulmonary rehab
Steroids if exacerbation

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16
Q

Investigation for suspected pneumothorax

A

CXR

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17
Q

Management of primary spontaneous pneumothorax

A
  • if under 2cm and asymptomatic = discharge
  • if over 2cm or symptomatic = admit for aspiration
  • if aspiration fails = chest drain
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18
Q

Management of secondary spontaneous pneumothorax

A
  • if 0-1cm and asymptomatic = oxygen and admit for 24 hrs
  • if 1-2cm and asymptomatic = aspiration
  • if aspiration fails = chest drain
  • if over 2cm or symptomatic = chest drain
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19
Q

Investigations for pneumonia

A

CXR
Bloods
Blood cultures

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20
Q

Pneumonia organisms

Strep Pneumoniae

A

Most common

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21
Q

Pneumonia organisms

Haemophilia influenzae

A

COPD

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22
Q

Pneumonia organisms

Mycoplasma Pneumoniae

A

Atypical (tx = macrolide)

  • older children/ young adults
  • haemolytic anaemia + erythema multiforme/nodosum
  • Diagnosis = serology
  • CXR shows patchy consolidation of one lower lobe
  • flu like symptoms such as headache, arthralgia and myalgia followed by dry cough
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23
Q

Pneumonia organisms

Legionella

A

Atypical (tx = macrolide)

Travel/water

Hyponatraemia

Diagnosis = urinary antigen

Flu like symptoms, D&V

Bibasal consolidation on CXR

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24
Q

Pneumonia organisms

Staph Aureus

A

After influenza A

IVDU

Young, elderly or underlying disease such as leukaemia or cystic fibrosis

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25
Pneumonia organisms Klebsiella
Alcoholics Diabetics Red jelly sputum
26
Pneumonia organisms Pneumocystis jiroveci
AIDS Diagnosis = BAL Tx = cotrimoxazole
27
CURB 65
New confusion Urea over 7 RR over 30 BP systolic under 90, diastolic under 60 Age
28
Treatment for CURB 65 0-2
Amoxicillin
29
Treatment for CURB 65 over 3
IV co amoxiclav AND IV clarithromycin
30
Hospital acquired and aspiration pneumonia treatment
IV Amox, Met and Gent
31
Types of lung cancer Adenocarcinoma
Commonest in everyone
32
Types of lung cancer Small cell carcinoma
SIADH Cushing syndrome Lambert Eaton syndrome Manage with chemotherapy
33
Types of lung cancer Squamous cell carcinoma
PTH related protein -> hypercalcaemia
34
Investigations for lung cancer
CXR CT staging scan Biopsy - bronchoscopy (central lesion) or percutaneous transthoracic needle biopsy (peripheral lesion)
35
Mesothelioma.
Exposure to asbestos and recurrent pleural effusion
36
Risk factors for Pulmonary Embolism
``` Immobility Post op Malignancy COCP HRT Pregnancy ```
37
Investigations for pulmonary embolism | Name gold standard
Bloods, including D Dimer ABG - resp alkalosis ECG CXR GOLD STANDARD : CTPA in pregnancy perfusion only V/Q scan
38
Management of PE Provoked
3 months treatment Rivaroxaban
39
Management of PE Unprovoked
6 months treatment Rivaroxaban
40
Management of PE Active cancer
LMWH for 6 months
41
Management of PE Massive
Ie. Hypotension Give alteplase
42
Contraindications to surgery in lung cancer
SVC obstruction FEV under 1.5 MALIGNANT pleural effusion Vocal cord paralysis
43
Chest drain should be inserted where?
5th intercostal space Mid Axilliary line Bordered by anterior edge latissimus dorsi, lateral border of pec major, line superior to the horizontal level of the nipple, apex below the axilla
44
LTOT in COPD is given when pO2 is..
Under 7.3kPa
45
Pleural Effusion presentation
Dyspnoea Non productive cough or chest pain Stony dull to percuss Reduced breath sounds Reduced chest expansion
46
Transudate Pleural Effusions
<30g/L protein Heart failure Hypoalbuminaemia (liver disease, nephrotic syndrome, malabsorption) Meigs' syndrome
47
Exudate Pleural Effusions
>30g/L protein ``` Infection Connective Tissue Disease Neoplasia Pancreatitis Pulmonary embolism Dressler's syndrome ```
48
Investigations for Pleural Effusions
PA CXR USS Contrast CT to investigate underlying cause, especially if exudate
49
Characteristic pleural fluid findings Low glucose
RA | TB
50
Characteristic pleural fluid findings Raised amylase
Pancreatitis | Oesophageal perforation
51
Characteristic pleural fluid findings Heavy blood staining
Mesothelioma Pulmonary embolism TB
52
Management of recurrent Pleural Effusions
Recurrent aspiration Pleurodesis Indwelling pleural catheter Drug management e.g. Opioids to relieve dyspnoea
53
What is bronchiectasis and list some causes
A permanent dilatation of the airways secondary to chronic infection or inflammation Post infective - TB, measles, pneumonia Cystic fibrosis Bronchial obstruction - lung cancer/ foreign body Immune deficiency - selective IgA, hypogammaglobulinaemia Allergic bronchopulmonary aspergillosis Ciliary dyskinesia syndrome e.g. kartageners or Young's
54
Management of bronchiectasis
``` Physical training Postural drainage Abx for exacerbations and long term rotating abx in severe cases Bronchodilators Immunisations ```
55
Bronchiectasis - Imaging
CXR - parallel lines - tram track CT bronchiole wider than neighbouring arteriole - signet ring sign
56
Acute Asthma Attack Signs of moderate
PEFR 50-75% best or predicted Speech normal RR under 25 Pulse under 110bpm
57
Acute Asthma Attack Severe
PEFR 33-50% best or predicted Can't complete sentences RR over 25 Pulse over 110
58
Acute Asthma Attack Life Threatening
PEFR under 33% best or predicted Oxygen Satan under 92% Silent chest, cyanosis or feeble respiratory effort Bradycardia, dysrhythmia or hypotension Exhaustion, confusion or coma
59
Type 1 respiratory failure
Hypoxaemia without hypercapnia
60
Type 2 respiratory failure
Hypoxaemia with hypercapnia Caused by inadequate alveolar ventilation
61
Standard therapy for active TB
Initial phase - first 2 months (RIPE) Rifampicin Isoniazid Pyrazinamide Ethambutol Continuation phase - next 4 months Rifampicin Isoniazid
62
Treatment for latent TB
3 months isoniazid with pyridoxine and rifampicin (To people under 35 if hepatotoxicity is a concern) Or 6 months of isoniazid with pyridoxine (People with HIV or transplant)
63
Pulmonary oedema on CXR
ABCDE Alveolar bats wings Kerley B lines Cardiomegaly Dilated prominent upper lobe vessels Pleural effusion
64
Pneumonia Organisms Pseudomonas Aeruginosa
common pathogen in bronchiectasis and CF Common as HAP, especially in patients on ventilator Ground glass attenuation on CT
65
Conditions causing predominantly fibrosis of the upper lobes
CHARTS ``` Coal workers pneumonitis Histiocytosis/hypersensitivity pneumonitis Ankylosing spondylitis Radiation Tuberculosis Silicosis/sarcoidosis ```
66
CXR interpretation
``` ABCDE AIRWAY is trachea deviated, carina and bronchi, hilar structures BREATHING Inspect lungs zones and pleura CARDIAC assess heart size and borders DIAPHRAGM Costophrenic angles EVERYTHING ELSE mediastinal contours, bones, soft tissues, tubes/valves/pacemakers ```
67
Causes of bilateral hilar enlargement
Sarcoidosis Tuberculosis Lymphoma Lymph node metastases
68
Skin manifestations of sarcoidosis
Erythema nodosum Lupus pernio Macular or papillae sarcoidosis
69
Pulmonary fibrosis aetiologies
``` BREASTCA Bleomycin Radiation Extrinsic allergic alveolitis Ank spond Sarcoidosis Tuberculosis Cryptogenic fibrosing alveolitis (idiopathic pulmonary fibrosis) Asbestosis ```
70
Sarcoidosis | Some presenting complaints
``` Bilateral hilar lymphadenopathy Erythema nodosum Granulomas Fatigue Uveitis Weight loss Hypercalcaemia ``` Tends to be 20-40 year old black woman - AfroCarribbeans
71
Sarcoidosis management
Steroids if... CXR Stage 2 or 3 disease with moderate to severe or progressive symptoms Hypercalcaemia Eye, heart or neuro involvement
72
Asbestosis
Blue asbestosis is the most fibrogenic Progressive dyspnoea, clubbing, fine end inspiratory crackles Pleural plaques, increased risk of bronchial carcinoma and mesothelioma
73
Offer LTOT to patients with...
A pO2 of under 7.3 on 2 occasions 3 weeks apart OR ``` A pO2 of 7.3-8 AND Secondary polycythaemia Nocturnal hypoxaemia Peripheral oedema Pulmonary hypertension On 2 occasions 3 weeks apart ```
74
Clinical features of obstructive sleep apnoea
Middle aged obese men ``` Loud snoring Daytime somnolence Poor sleep quality Morning headache Decreased libido Cognitive performance is decreased ```
75
Complications of obstructive sleep apnoea
Pulmonary HTN Type 2 respiratory failure Independent risk factor for HTN
76
Management of obstructive sleep apnoea
Weight reduction Avoidance of tobacco and alcohol CPAP for moderate to severe Surgery for pharyngeal obstruction occasionally needed
77
Alpha-1 antitrypsin deficiency
Symptoms of COPD in young person No smoking Supportive: bronchodilators, physiology IV alpha1 antitrypsin protein concentrates Surgery: volume reduction, lung transplantation Panacinar emphysema
78
Cor pulmonale - description and some causes
Right heart failure caused by chronic pulmonary arterial HTN Causes Lung disease - severe/chronic asthma, COPD, bronchiectasis, pulmonary fibrosis, lung resection Pulmonary vascular disease - PE, pulmonary vasculitis, ARDS, sickle cell disease Thoracic cage abnormality - kyphosis, scoliosis Neuromuscular disease - myasthenia gravis, MND Hypoventilation - sleep apnoea Cerebrovascular disease
79
Cor pulmonale - clinical features
Dyspnoea Fatigue Syncope Signs - cyanosis, tachycardia, raised JVP, RV heave, loud P2, pansystolic murmur (tricuspid regurg), hepatomegaly, oedema
80
Cor pulmonale investigations
FBC - hb and heamocrit increased - secondary polycythaemia ABG - hypoxia with or without hypercapnia CXR - enlarged right side of heart, prominent pulmonary arteries ECG - p pulmonale, right axis deviation, right ventricular hypertrophy
81
What is extrinsic allergic alveolitis
In sensitised individuals the inhalation of allergens (fungal spores or avian proteins) provoke a hypersensitivity reaction Acutely the alveoli are infiltrated with acute inflammatory cells With chronic exposure there is granuloma formation and obliteragive bronchiolitis occurs
82
Causes of extrinsic allergic alveolitis
Bird fanciers and pidgeon fanciers lung Farmers and mushroom workers lung Malt workers lung Bagassosis or sugar workers lung
83
Clinical features of extrinsic allergic alveolitis and treatment Acutely
4-6 hours post exposure Fever, rigors, myalgia, dry cough, dyspnoea, crackles (no wheeze) Remove allergen, give 35-60% O2 then oral pred
84
Clinical features of extrinsic allergic alveolitis Chronic
Increasing dyspnoea, weight loss, exertions dyspnoea, T1RF, cor pulmonale
85
Features of Kartageners Syndrome
Primary ciliary dyskinesia Dextrocardia or complete situs inversus Bronchiectasis Recurrent sinusitis Subfertility (secondary to diminished sperm motility and defective ciliary action in Fallopian tubes)
86
What is ARDS
Acute respiratory distress syndrome caused either by direct lung injury or secondary to severe systemic illness. Lung damage and release of inflammatory mediators cause increased capillary permeability and non cardiogenic pulmonary oedema often accompanied by multi organ failure
87
Risk factors for ARDS
``` Sepsis Hypovolaemic shock Trauma Pneumonia Diabetic ketoacidosis Gastric aspiration Pregnancy Eclampsia Amniotic fluid embolus Drugs/toxins (Paraquat, aspirin, heroin) Pulmonary contusion Massive transfusion Burns Smoke inhalation Near drowning Acute pancreatitis DIC head injury Increased ICP Fat embolus Heart/lung bypass Tumour lysis syndrome Malaria ```
88
Clinical features of ARDS
Cyanosis, tachycardia, tachypnoea, peripheral vasodilation, bilateral fine inspiratory crackles
89
Investigations of ARDS
FBC, U&Es, LFT, amylase, clotting, CRP, blood cultures, ABG CXR shows bilateral pulmonary infiltrates
90
Diagnostic criteria of ARDS
1. Acute onset 2. CXR bilateral infiltrates 3. PCWP under 19 or lack of clinical congestive heart failure 4. Refractory hypoxaemia
91
5 ways aspergillus affects the lungs
1. Asthma - type 1 hypersensitivity reaction to spores 2. Allergic bronchopulmonary aspergillosis (ABPA) - type 1 and 2 hypersensitivity 3. Aspergilloma - fungus ball within pre existing cavity 4. Invasive aspergillosis - immunocompromised or after broad spectrum abx 5. Extrinsic allergic alveolitis - malt workers lung
92
What is CF
Cystic fibrosis - autosomal recessive Defect leading to combination of defective chloride secretion and increased sodium absorption across airway epithelium Changes in composition of airway surface liquid predisposes the lung to chronic pulmonary infections and bronchiectasis
93
Clinical features of CF
Neonates - failure to thrive, meconium ileus, rectal prolapse Children and young adults - cough, wheeze, recurrent infections bronchiectasis, pneumothorax, haemoptysis, resp failure, cor pulmonale - pancreatic insufficiency, gall stones, cirrhosis - male infertility, osteoporosis, arthritis, vasculitis, nasal polyps, sinusistis - finger clubbing, cyanosis, bilateral coarse crackles
94
Diagnosis of CF
Sweat test Genetics Faecal elastase
95
Spirometry in obstructive lung disease
FEV1 is reduced more than FVC Ratio FEV1/FVC is under 75% Eg. Asthma, COPD
96
Spirometry in restrictive lung disease
FVC is reduced FEV1/FVC ratio is the same or increased. Eg. Fibrosis, sarcoidosis, pleural effusion, obesity, connective tissue diseases
97
What is stridor
Loud high pitched crowing Usually heard on inspiration Caused by obstruction in upper airway Immediate attention
98
What is wheeze
High pitched sound heard on exhalation usually Doesn't change with coughing Airflow blocked More severe can be heard on inspiration
99
Fine crackles
Usually heard in lung bases Walking in snow ``` Occur in restrictive diseases such as Pulmonary fibrosis Asbestosis Silicosis Heart failure Pneumonia ```
100
Coarse crackles
Sound like bubbling or gargling as air moves through secretions Occur in COPD Bronchiectasis Pulmonary oedema Severely ill patients who can't cough
101
Preferred view for CXR
PA
102
Cells types found in BAL Haemosiderin laden macrophages
Alveolar bleeding
103
Cells types found in BAL High CD4
Sarcoidosis
104
Cells types found in BAL Eosinophils
ABPA etc
105
Cells types found in BAL Neutrophils
Pneumonia ILD
106
Cells types found in BAL Marked lymphocytosis
Hypersensitivity pneumonitis
107
Lights Criteria
1. Protein pleural:serum ratio over 0.5 2. LDH pleural : LDH serum over 0.6 3. LDH pleural more than 2/3 the upper limit of normal LDH serum Meeting any one of the three criteria indicates exudative
108
Side effect of Rifampicin
Red/orange urine and tears Hepatotoxicity Rashes
109
Side effects of ethambutol
Optic neuritis | Red green colour blindness
110
Side effects of Isoniazid
Peripheral neuropathy Concomitant treatment with pyridoxine (vit B6) can help to reduce risk
111
Farmers lung triad
Interstitial inflammation Chronic bronchiolitis Non necrotising granuloma

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