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Respiratory Flashcards

1
Q

What is type 1 respiratory failure?

A

Hypoxaemia without hypercapnia (CO2 may be normal or low)

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2
Q

Give some causes of type 1 respiratory failure

A

Low ambient O2 (high altitude)
Vent-perf mismatch (PE)
Diffusion problem (pneumonia)
Shunt (R to L)

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3
Q

What is type 2 respiratory failure?

A

Hypoxaemia with hypercapnia

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4
Q

Give some causes of type 2 respiratory failure

A

Inadequate alveolar ventilation

  • Inc airway resistance (COPD, asthma, suffocation)
  • Dec breathing effort (opiates, brain lesion)
  • Dec in area of lung available for gas ex (bronchitis)
  • Chest wall deformity (kyphosis, ank spond, flail chest)
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5
Q

Give some examples of obstructive lung disease

A

Asthma
COPD
Bronchiectasis
Bronchiolitis obliterans

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6
Q

What lung function results would you expect to see in an obstructive lung disease?

A

FEV1 - significantly reduced
FVC - reduced or normal
FEV1% (FEV1/FVC) - reduced

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7
Q

Give some examples of restrictive lung disease

A 
Pulmonary fibrosis
Asbestosis
Sarcoidosis
Acute respiratory distress syndrome
Infant respiratory distress syndrome
Kyphoscoliosis
Neuromuscular disorders
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8
Q

What lung function results would you expect to see in a restrictive lung disease?

A

FEV1 - reduced
FVC - significantly reduced
FEV1% (FEV1/FVC) - normal or increased

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9
Q

Outline the Centor criteria

A

presence of tonsillar exudate
tender anterior cervical lymphadenopathy or lymphadenitis
history of fever
absence of cough

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10
Q

Give some examples of drugs that cause pulmonary fibrosis

A

amiodarone
cytotoxic agents: busulphan, bleomycin
anti-rheumatoid drugs: methotrexate, sulfasalazine, gold
nitrofurantoin
ergot-derived dopamine receptor agonists (bromocriptine

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11
Q

Outline the BTS guidelines for the management of chronic asthma

A

1) SABA. If used more than OD go to step 2.
2) Add inhaled steroid (beclo 200-800mcg/d)
3) Add LABA. If benefit but not complete inc dose steroid (800mcg/d). If no effect with LABA then stop LABA and inc steroid to 800 (leuk Rec antag or oral theophylline can be tried)
4) Consider trials of: steroid to 2000mcg/d; oral theophylline; oral BA; oral leuk rec antag
5) Add regular oral pred + refer to specialist

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12
Q

Outline the treatment of COPD

A

COPD care bundle (physio, rehab etc)

1) SABA or SAMA
2) Add LAMA or LABA (+/- ICS)
3) LTOT and surgery may be required

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13
Q

Give some causes of acute respiratory distress syndrome

A

Pneumonia, gastric aspiration, inhalation, injury, vasculitis, contusion
Shock, sepsis, haemorrhage, DIC, pancreatitis, acute liver failure, trauma, burns, drugs (aspirin, heroin)

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14
Q

What are the features of acute respiratory distress syndrome?

A 
Cyanosis
Tachypnoea
Tachycardia
Peripheral vasodilation
Bilateral fine inspiratory crackles
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15
Q

What investigations would you do in acute respiratory distress syndrome?

A

FBC, U+E, LFT, amylase, clotting, CRP, blood culture, ABG

Imaging - CXR (bilat pul infiltrates)

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16
Q

What are the diagnostic criteria for acute respiratory distress syndrome?

A

1) Acute onset
2) CXR shows bilateral infiltrates
3) PCWP <19
4) Refractory hypoxaemia

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17
Q

What’s the management for ARDS?

A

ITU!

  • CPAP or mechanical ventilation if O2 <8.3kPa
  • inotropes (dobutamine), vasodilators
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18
Q

What the management for type 1 respiratory failure?

A

Treat underlying cause
Give O2 (24-60%) by face mask
Assisted ventilation is PaO2 <8kPa despite 60% O2

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19
Q

What is the management in type 2 respiratory failure?

A

Treat underlying cause
Controlled O2 therapy - start at 24% O2
Recheck ABG at 20mins. If CO2 has inc then consider assisted ventilation

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20
Q

What do these results suggest:

  • pH = low
  • PaCO2 = normal/low
  • HCO3- = low
A

Metabolic acidosis

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21
Q

What do these results suggest:

  • pH = low
  • PaCO2 = high
  • HCO3- = normal/high
A

Respiratory acidosis

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22
Q

What do these results suggest:

  • pH = high
  • PaCO2 = normal/high
  • HCO3- = high
A

Metabolic alkalosis

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23
Q

What do these results suggest:

  • pH = high
  • PaCO2 = low
  • HCO3- = normal/low
A

Respiratory alkalosis

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24
Q

What are the clinical features of ILD?

A 
Dyspnoea on exertion
Non-productive paroxysmal cough 
Abnormal breath sounds
Abnormal CXR or CT
Restrictive spirometry
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25
Q

What are the pathological features of ILD?

A

Fibrosis and remodelling of the interstitium
Chronic inflammation
Hyperplasia of the Type 2 epithelial cells

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26
Q

What is the underlying pathology of bronchiectasis?

A

Chronic inflammation of the bronchi and bronchioles leading to permanent dilatation and thinning of the airways. Main organism is H. Influenzae, strep pneumoniae, staph aureus

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27
Q

What are the causes of bronchiectasis?

A

Congenital - CF, ciliary dyskinesia
Post-infective - measles, bronchiolitis, pneumonia, TB
Other - bronchial obstruction (tumour), allergic bronchopulmonary aspergillosis, RA, UC

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28
Q

What are the symptoms of bronchiectasis?

A

Persistent cough
Purulent sputum
Haemoptysis

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29
Q

What are the signs of bronchiectasis?

A

Finger clubbing
Coarse inspiratory crepitations
Wheeze

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30
Q

What are the complications of bronchiectasis?

A 
Pneumonia
Pleural effusion
Pneumothorax 
Haemoptysis
Cerebral abscess
Amyloidosis
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31
Q

What examination findings would you expect in consolidation

A

Dull to percussion
Bronchial/dec breath sounds
Inc vocal resonance

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32
Q

What examination findings would you expect in lung collapse?

A

Mediastinal shift towards the affected side
Dull to percussion
Dec/absent breath sounds
Dec/absent vocal resonance

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33
Q

What examination findings would you expect in a pleural effusion?

A

Mediastinal shift away (if big)
Stony dull to percussion
Dec/absent breath sounds
Dec/absent vocal resonance

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34
Q

What examination findings would you expect in a pneumothorax?

A

Mediastinal shift away (if tension)
(hyper) Resonant to percussion
Dec/absent breath sounds
Dec/absent vocal resonance

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35
Q

What are the signs of hyperinflation?

A

Inc AP diameter
Intercostal drawing (Hoover’s sign)
Apex not palpable
Hyper-resonant to percussion

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36
Q

Causes of ILD

A
  1. Idiopathic - fibrosing alveolitis
  2. Inhaled antigen - bird fancier’s lung
  3. Inhaled irritant - asbestosis, silicosis, coal worker’s pneumoconiosis
  4. Systemic disease - SLE, RA, sarcoid, systemic sclerosis
  5. Drug-induced - methotrexate, amiodarone
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37
Q

Causes of Horner’s syndrome

A

Central lesion - stroke, tumour, MS
T1 root lesion - spondylosis
Brachial plexus lesion - Pancoast tumour, cervical rib
Neck lesion - tumour, carotid a. aneurysm

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38
Q

Features of bronchial breathing

A

Loud and blowing
Length of inspiration = expiration
Audible gap between insp and exp
Reproducible by steth on trachea

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39
Q

Causes of bibasal crepitations

A

Fine - pulmonary oedema, ILD

Coarse - bronchiectasis, CF, bibasal pneumonia

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40
Q

Causes of a pleural effusion with protein <30 g/L

A

Transudate:

  • LVF
  • vol. O/L
  • Hypoalbuminaemia
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41
Q

Causes of a pleural effusion with protein >30 g/L

A

Exudate:

  • Infection (pneumonia, TB)
  • Infarction (PE)
  • Inflammation (RA, SLE)
  • Malignancy
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42
Q

What investigations would you do for bronchiectasis?

A

Bedside: normal obs
Lab: sputum culture, serum Igs
Imaging: CXR (cystic shadows, thickened bronchial walls), high res CT, bronchoscopy

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43
Q

What are the management options for bronchiectasis?

A

Airway clearance and mucolytics - chest physio, saline nebs
Abx: pseudomonas = ciprofloxacin
Bronchodilators

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44
Q

What is Kartagener’s Syndrome also known as?

A

Primary ciliary dyskinesia

45
Q

What are the features of Kartagener’s Syndrome (1’ ciliary dyskinesia)?

A

Dextrocardia
Bronchiectasis
Recurrent sinusitis
Subfertility

46
Q

Describe the staining of mycobacterium tuberculosis

A

Gram stain: weak positive

Ziehl-Neelson stain: strong positive

47
Q

Name a steroid with minimal mineralocorticoid activity

A

Dexamethasone

48
Q

Triad of symptoms associated with PE

A

SOB
Pleuritic chest pain
Haemoptysis

49
Q

Other symptoms (not triad) that make a PE more likely

A

Tachypnoea (RR>16)
Crackles
Tachycardia (>100)
Fever

50
Q

Outline the PE Wells score for PE

A 
Clinical symptoms and signs of DVT - 3
Alternative diagnosis less likely than PE - 3
HR >100 - 1.5
Immobilisation >3d or recent surgery - 1.5
Previous DVT/PE - 1.5
Haemoptysis - 1
Malignancy - 1
(>4 PE is likely)
51
Q

What is psittacosis?

A

Atypical pneumonia caused by chlamydia psittaci (spread via parrots, poultry, sheep)

52
Q

49yo female with pneumonia who has some parrots. Causative organism

A

Chlamydia psittaci (give tetracycline)

53
Q

Cause of currant jelly sputum? Who gets it and how do you treat it?

A

Klebsiella pneumonia
Typically seen in alcoholics
Treat with meropenem

54
Q

COPD management

A

1) SABA or SAMA
Not adequate?
2a)FEV1 >50 -> LABA or LAMA
2b)FEV1 <50 -> LABA + ICS, or LAMA
Not adequate?
3) if taking LABA swap to LAMA + ICS, otherwise give LAMA and LABA/ICS combo
(Theophylline is recommended after trials of S or LA bronchodilators)o

55
Q

List the lung diseases associated with asbestos exposure

A 
Pleural plaques
Pleural thickening
Asbestosis
Mesothelioma
Lung cancer
56
Q

Describe pleural plaques

A

Benign form of asbestos-related lung disease.

Generally occur after a latent period of 20-40yrs

57
Q

Describe asbestosis

A

Severity of asbestosis is related to length of exposure.
Latent period is between 15-30yrs
Typically causes lower lobe fibrosis (SOB)

58
Q

When can a treated pneumothorax be discharged?

A

If following aspiration the rim of air is <2cm and the breathing has improved. Discharge with outpt XR

59
Q

Outline the expected recovery in pneumonia from week 1 to month 6.

A 
Week 1: fever resolves
Week 4: chest pain and sputum dec
Week 6: cough and SOB signif dec
Month 3: most symptoms resolved 
Month 6: normal
60
Q

Asthma control in pregnancy?

A

Inhalers can be taken as normal

61
Q

Outline the criteria for LTOT

A 
FEV1 <30% predicted
Cyanosis
Polycythaemia
Peripheral oedema
Raised JVP
O2 <92% on air
62
Q

ABG result for offering LTOT

A

2 ABGS pO2 < 7.3

63
Q

B criteria for CURB 65

A

Systolic <90
And/or
Diastolic <60

64
Q

Define stage 1 COPD

A

Post broncho FEV1/FVC <0.7

FEV1 >80% predicted

65
Q

Define stage 2 COPD

A

Post broncho FEV1/FVC <0.7

FEV1 50-79% predicted

66
Q

Define stage 3 COPD

A

Post broncho FEV1/FVC <0.7

FEV1 30-49% predicted

67
Q

Define stage 4 COPD

A

Post broncho FEV1/FVC <0.7

FEV1 <30% predicted

68
Q

Criteria for moderate asthma exac

A

PEFR 50-75% best
Speech normal
RR <25
Pulse <110

69
Q

Criteria for severe asthma exac

A

PEFR 33-50% best
Can’t complete sentences
RR >25
HR >110

70
Q

Criteria for life-threatening asthma

A 
PEFR <33% best
O2 <92%
Silent chest, cyanosis or feeble resp effort
Bradycardia, dysrhythmia or hypotension
Exhaustion, confusion, coma
71
Q

When is thrombolysis recommended in PE? What should be done if it’s not recommended?

A

Recommended in circulatory failure (hypotension)
LMWH or fondaparinux should be given otherwise
Warfarin

72
Q

1wk post PE, INR is 1.3. What do you do?

A

Inc warfarin to 6mg and start LMWH

73
Q

Management of O2 sats 52%

A

High flow O2 via non-rebreath mask (regardless of COPD or not)

74
Q

Essential investigation in PE before CTPA

A

CXR

75
Q

Management of asthma exacerbation after acutely stabilised

A

Pred 40mg OD for 5days

76
Q

Diagnostic criteria for diagnosing COPD

A

FEV1/FVC <70% plus symptoms of COPD

77
Q

White-out X-ray with tracheal deviation towards.

A

Lung collapse

78
Q

How does miliary TB spread?

A

Through the pulmonary venous system

79
Q

Chest drain insertion location

A

5th IC space, mid axillary line

80
Q

pH range that will achieve the most benefit of NIV in COPD

A

7.25-7.35 (<7.25 consider invasive)

81
Q

Management of a pneumothorax with air rim <2cm and pt not SOB

A

Consider discharge

82
Q

Management of pneumothorax >2cm, or <2cm with SOB

A

Attempt aspiration

If this fails then insert chest drain

83
Q

Likely ABG result in PE

A

Respiratory alkalosis - inc ventilation -> Dec CO2

84
Q

Which vaccinations should a pt with COPD receive?

A

Annual influenza and one-off pneumococcal

85
Q

Test to confirm idiopathic pulmonary fibrosis

A

High res CT

86
Q

Strongest indicator of a need for intubation in asthma attack

A

pH <7.35 as this is likely to represent CO2 retention

87
Q

When would you treat a PE whilst waiting for a scan?

A

Wells score >4 and delayed CTPA scan

Give tinzaparin

88
Q

What is TLCO?

A

Total gas transfer using CO

89
Q

Give some causes of a raised TLCO

A 
Asthma
Pul haemorrhage
L-R cardiac shunts
Polycythaemia
Male gender
90
Q

Give some causes of a decreased TLCO

A 
Pul fibrosis
Pneumonia
PE
Pul oedema
Emphysema
Anaemia
Low CO
91
Q

Briefly outline the pathophysiology of asthma

A

Reversible airway obstruction due to:

  • bronchial muscle contraction
  • mucosal swelling and inflammation (mast cell degranulation)
  • inc mucus production
92
Q

XR findings in pt with pneumonia and swinging temperature

A

Swinging temp indicates a collection of pus

May be an effusion, empyema, or a cavity of pus with a fluid level

93
Q

Discharge after asthma exac

A

Pts with PEFR >75% within 1h of initial treatment can be discharged if there’s no other reason to admit.
Otherwise pts must have:
- been stable on discharge meds for 24h
- had inhaler technique checked
- PEFR >75%
- steroid (inhaled AND oral) and bronchodilator therapy
- their own PF meter with written management plan
- GP apt in 2d
- resp clinic apt within 4w

94
Q

Advice to pts if asthma attack

A
  1. Take reliever immediately
  2. Sit and loosen clothing - don’t lie down
  3. If no immediate improvement, take 1 puff every 5min or until symptoms improve
  4. If no improvement in 5min - call ambulance
  5. Take 1 puff every min until help arrives
95
Q

Management of acute COPD with signs of hypercapnia

A

NIV

96
Q

Atypical pneumonia seen in immunocompromised people

A

Pneumocystis

97
Q

XR features of coal workers pneumoconiosis

A

Large fibrotic masses in upper zones

98
Q

XR features of emphysema

A

Multiple bullae in upper zones

99
Q

XR features of silicosis

A

Nodular pattern in upper and mid zones

100
Q

XR features of pulmonary fibrosis

A

Reticulo-nodular shadowing in the lower zones

101
Q

Alcoholic pt with consolidation which is cavitating in the RUL

A

Klebsiella pneumonia

102
Q

Investigation of PE in renal impairment

A

V/Q scans (contrast media in CTPA is nephrotoxic)

103
Q

Pt presents with fatigue, SOB on exertion, cough producing yellow sputum, 20 pack-year smoking Hx. Bloods show raised ALT and AST. Diagnosis?

A

Alpha-1 antitrypsin deficiency

104
Q

Diagnostic criteria for COPD

A

FEV1/FVC <70% + symptoms suggestive of COPD

105
Q

Indications for surgery in bronchiectasis

A

If CT shows disease is localised to one lobe

106
Q

CXR features of bronchiectasis

A

Parallel line shadows (due to dilated bronchi due to peribronchial inflammation and fibrosis)

107
Q

Describe the presentation of aspergilloma

A

Often past Hx of TB
Haemoptysis may be severe
CXR shows rounded opacity

108
Q

Presentation of granulomatosis with polyangiitis

A

URT: epistaxis, sinusitis, nasal crusting
LRT: dyspnoea, haemoptysis
GN
Saddle-shape nose deformity

109
Q

Treatment of thyrotoxic storm

A

B-blockers
Carbimazole
Hydrocortisone

Finals (25 decks)

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