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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
Q

Pneumonia organisms

Klebsiella

A

Alcoholics

Diabetics

Red jelly sputum

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26
Q

Pneumonia organisms

Pneumocystis jiroveci

A

AIDS

Diagnosis = BAL

Tx = cotrimoxazole

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27
Q

CURB 65

A

New confusion

Urea over 7

RR over 30

BP systolic under 90, diastolic under 60

Age

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28
Q

Treatment for CURB 65 0-2

A

Amoxicillin

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29
Q

Treatment for CURB 65 over 3

A

IV co amoxiclav

AND

IV clarithromycin

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30
Q

Hospital acquired and aspiration pneumonia treatment

A

IV Amox, Met and Gent

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31
Q

Types of lung cancer

Adenocarcinoma

A

Commonest in everyone

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32
Q

Types of lung cancer

Small cell carcinoma

A

SIADH

Cushing syndrome

Lambert Eaton syndrome

Manage with chemotherapy

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33
Q

Types of lung cancer

Squamous cell carcinoma

A

PTH related protein -> hypercalcaemia

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34
Q

Investigations for lung cancer

A

CXR

CT staging scan

Biopsy - bronchoscopy (central lesion) or percutaneous transthoracic needle biopsy (peripheral lesion)

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35
Q

Mesothelioma.

A

Exposure to asbestos and recurrent pleural effusion

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36
Q

Risk factors for Pulmonary Embolism

A 
Immobility
Post op
Malignancy
COCP
HRT
Pregnancy
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37
Q

Investigations for pulmonary embolism

Name gold standard

A

Bloods, including D Dimer
ABG - resp alkalosis
ECG
CXR

GOLD STANDARD : CTPA

in pregnancy perfusion only V/Q scan

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38
Q

Management of PE

Provoked

A

3 months treatment

Rivaroxaban

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39
Q

Management of PE

Unprovoked

A

6 months treatment

Rivaroxaban

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40
Q

Management of PE

Active cancer

A

LMWH for 6 months

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41
Q

Management of PE

Massive

A

Ie. Hypotension

Give alteplase

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42
Q

Contraindications to surgery in lung cancer

A

SVC obstruction

FEV under 1.5

MALIGNANT pleural effusion

Vocal cord paralysis

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43
Q

Chest drain should be inserted where?

A

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

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44
Q

LTOT in COPD is given when pO2 is..

A

Under 7.3kPa

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45
Q

Pleural Effusion presentation

A

Dyspnoea
Non productive cough or chest pain

Stony dull to percuss
Reduced breath sounds
Reduced chest expansion

46
Q

Transudate Pleural Effusions

A

<30g/L protein

Heart failure
Hypoalbuminaemia (liver disease, nephrotic syndrome, malabsorption)
Meigs’ syndrome

47
Q

Exudate Pleural Effusions

A

> 30g/L protein

Infection
Connective Tissue Disease
Neoplasia
Pancreatitis
Pulmonary embolism
Dressler's syndrome
48
Q

Investigations for Pleural Effusions

A

PA CXR
USS
Contrast CT to investigate underlying cause, especially if exudate

49
Q

Characteristic pleural fluid findings

Low glucose

A

RA

TB

50
Q

Characteristic pleural fluid findings

Raised amylase

A

Pancreatitis

Oesophageal perforation

51
Q

Characteristic pleural fluid findings

Heavy blood staining

A

Mesothelioma
Pulmonary embolism
TB

52
Q

Management of recurrent Pleural Effusions

A

Recurrent aspiration
Pleurodesis
Indwelling pleural catheter
Drug management e.g. Opioids to relieve dyspnoea

53
Q

What is bronchiectasis and list some causes

A

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
Q

Management of bronchiectasis

A 
Physical training 
Postural drainage 
Abx for exacerbations and long term rotating abx in severe cases
Bronchodilators
Immunisations
55
Q

Bronchiectasis - Imaging

A

CXR - parallel lines - tram track

CT bronchiole wider than neighbouring arteriole - signet ring sign

56
Q

Acute Asthma Attack

Signs of moderate

A

PEFR 50-75% best or predicted

Speech normal

RR under 25

Pulse under 110bpm

57
Q

Acute Asthma Attack

Severe

A

PEFR 33-50% best or predicted

Can’t complete sentences

RR over 25

Pulse over 110

58
Q

Acute Asthma Attack

Life Threatening

A

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
Q

Type 1 respiratory failure

A

Hypoxaemia without hypercapnia

60
Q

Type 2 respiratory failure

A

Hypoxaemia with hypercapnia

Caused by inadequate alveolar ventilation

61
Q

Standard therapy for active TB

A

Initial phase - first 2 months (RIPE)

Rifampicin
Isoniazid
Pyrazinamide
Ethambutol

Continuation phase - next 4 months
Rifampicin
Isoniazid

62
Q

Treatment for latent TB

A

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
Q

Pulmonary oedema on CXR

A

ABCDE

Alveolar bats wings

Kerley B lines

Cardiomegaly

Dilated prominent upper lobe vessels

Pleural effusion

64
Q

Pneumonia Organisms

Pseudomonas Aeruginosa

A

common pathogen in bronchiectasis and CF

Common as HAP, especially in patients on ventilator

Ground glass attenuation on CT

65
Q

Conditions causing predominantly fibrosis of the upper lobes

A

CHARTS

Coal workers pneumonitis
Histiocytosis/hypersensitivity pneumonitis
Ankylosing spondylitis
Radiation
Tuberculosis
Silicosis/sarcoidosis
66
Q

CXR interpretation

A 
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
Q

Causes of bilateral hilar enlargement

A

Sarcoidosis
Tuberculosis
Lymphoma
Lymph node metastases

68
Q

Skin manifestations of sarcoidosis

A

Erythema nodosum
Lupus pernio
Macular or papillae sarcoidosis

69
Q

Pulmonary fibrosis aetiologies

A 
BREASTCA
Bleomycin
Radiation
Extrinsic allergic alveolitis
Ank spond
Sarcoidosis
Tuberculosis
Cryptogenic fibrosing alveolitis (idiopathic pulmonary fibrosis)
Asbestosis
70
Q

Sarcoidosis

Some presenting complaints

A 
Bilateral hilar lymphadenopathy
Erythema nodosum
Granulomas
Fatigue
Uveitis
Weight loss
Hypercalcaemia

Tends to be 20-40 year old black woman - AfroCarribbeans

71
Q

Sarcoidosis management

A

Steroids if…

CXR Stage 2 or 3 disease with moderate to severe or progressive symptoms

Hypercalcaemia

Eye, heart or neuro involvement

72
Q

Asbestosis

A

Blue asbestosis is the most fibrogenic

Progressive dyspnoea, clubbing, fine end inspiratory crackles

Pleural plaques, increased risk of bronchial carcinoma and mesothelioma

73
Q

Offer LTOT to patients with…

A

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
Q

Clinical features of obstructive sleep apnoea

A

Middle aged obese men

Loud snoring
Daytime somnolence
Poor sleep quality
Morning headache
Decreased libido
Cognitive performance is decreased
75
Q

Complications of obstructive sleep apnoea

A

Pulmonary HTN
Type 2 respiratory failure
Independent risk factor for HTN

76
Q

Management of obstructive sleep apnoea

A

Weight reduction
Avoidance of tobacco and alcohol
CPAP for moderate to severe
Surgery for pharyngeal obstruction occasionally needed

77
Q

Alpha-1 antitrypsin deficiency

A

Symptoms of COPD in young person

No smoking
Supportive: bronchodilators, physiology
IV alpha1 antitrypsin protein concentrates
Surgery: volume reduction, lung transplantation

Panacinar emphysema

78
Q

Cor pulmonale - description and some causes

A

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
Q

Cor pulmonale - clinical features

A

Dyspnoea
Fatigue
Syncope

Signs - cyanosis, tachycardia, raised JVP, RV heave, loud P2, pansystolic murmur (tricuspid regurg), hepatomegaly, oedema

80
Q

Cor pulmonale investigations

A

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
Q

What is extrinsic allergic alveolitis

A

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
Q

Causes of extrinsic allergic alveolitis

A

Bird fanciers and pidgeon fanciers lung

Farmers and mushroom workers lung

Malt workers lung

Bagassosis or sugar workers lung

83
Q

Clinical features of extrinsic allergic alveolitis and treatment

Acutely

A

4-6 hours post exposure

Fever, rigors, myalgia, dry cough, dyspnoea, crackles (no wheeze)

Remove allergen, give 35-60% O2 then oral pred

84
Q

Clinical features of extrinsic allergic alveolitis

Chronic

A

Increasing dyspnoea, weight loss, exertions dyspnoea, T1RF, cor pulmonale

85
Q

Features of Kartageners Syndrome

A

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
Q

What is ARDS

A

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
Q

Risk factors for ARDS

A 
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
Q

Clinical features of ARDS

A

Cyanosis, tachycardia, tachypnoea, peripheral vasodilation, bilateral fine inspiratory crackles

89
Q

Investigations of ARDS

A

FBC, U&Es, LFT, amylase, clotting, CRP, blood cultures, ABG

CXR shows bilateral pulmonary infiltrates

90
Q

Diagnostic criteria of ARDS

A
  1. Acute onset
  2. CXR bilateral infiltrates
  3. PCWP under 19 or lack of clinical congestive heart failure
  4. Refractory hypoxaemia
91
Q

5 ways aspergillus affects the lungs

A
  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
Q

What is CF

A

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
Q

Clinical features of CF

A

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
Q

Diagnosis of CF

A

Sweat test
Genetics
Faecal elastase

95
Q

Spirometry in obstructive lung disease

A

FEV1 is reduced more than FVC

Ratio FEV1/FVC is under 75%

Eg. Asthma, COPD

96
Q

Spirometry in restrictive lung disease

A

FVC is reduced

FEV1/FVC ratio is the same or increased.

Eg. Fibrosis, sarcoidosis, pleural effusion, obesity, connective tissue diseases

97
Q

What is stridor

A

Loud high pitched crowing
Usually heard on inspiration

Caused by obstruction in upper airway

Immediate attention

98
Q

What is wheeze

A

High pitched sound heard on exhalation usually

Doesn’t change with coughing

Airflow blocked

More severe can be heard on inspiration

99
Q

Fine crackles

A

Usually heard in lung bases

Walking in snow

Occur in restrictive diseases such as 
Pulmonary fibrosis 
Asbestosis
Silicosis
Heart failure
Pneumonia
100
Q

Coarse crackles

A

Sound like bubbling or gargling as air moves through secretions

Occur in COPD
Bronchiectasis
Pulmonary oedema
Severely ill patients who can’t cough

101
Q

Preferred view for CXR

A

PA

102
Q

Cells types found in BAL

Haemosiderin laden macrophages

A

Alveolar bleeding

103
Q

Cells types found in BAL

High CD4

A

Sarcoidosis

104
Q

Cells types found in BAL

Eosinophils

A

ABPA etc

105
Q

Cells types found in BAL

Neutrophils

A

Pneumonia

ILD

106
Q

Cells types found in BAL

Marked lymphocytosis

A

Hypersensitivity pneumonitis

107
Q

Lights Criteria

A
  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
Q

Side effect of Rifampicin

A

Red/orange urine and tears
Hepatotoxicity
Rashes

109
Q

Side effects of ethambutol

A

Optic neuritis

Red green colour blindness

110
Q

Side effects of Isoniazid

A

Peripheral neuropathy

Concomitant treatment with pyridoxine (vit B6) can help to reduce risk

111
Q

Farmers lung triad

A

Interstitial inflammation

Chronic bronchiolitis

Non necrotising granuloma

Revision lectures (15 decks)

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