Respiratory Flashcards
Treatment of pulmonary arterial hypertension
IF positive response to acute vasodilator testing then calclium channel blockers… but the majority are negative.
IF neg use prostacyclin analogues: treprostinil, iloprost
or Endothelin receptor antagonist: bosentan
Mechanism of action of endothelin receptor antagonist (eg bosentan)
reduce pulmonary vascular resistance leading to reduced right ventricular systolic pressure
Symptoms of pulmonary arterial hypertension
Progressive exertional dyspnoea,
Genetic testing of a gentleman with alpha 1 antitrypsin deficiency shows PiMZ, what is the prognosis
This is hetrozygous (normal is PiMM) homo is PiSS (50% normal levels) or PiZZ (10% normal levels)
Heterozygous are likely normal so usually 60% normal
Genetic testing of a gentleman with alpha 1 antitrypsin deficiency shows PiMZ, what is the prognosis
This is hetrozygous (normal is PiMM) homo is PiSS (50% normal levels) or PiZZ (10% normal levels)
Heterozygous are likely normal so usually 60% normal
Oxygen dissociation curve left Vs right
Shift Left .. Lower oxygen delivery - Lower acidity, temp, 2-3 DPG, HbF, carboxy/methaemoglobin levels
shift Right … Raised oxygen delivery - Raised acidity, temp 2-3 DPG, raised CO2
How do you diagnose pulmonary hypertension
Cardiac catheterisation, to measure right heart pressure
Raised if greater than 25mmHg at rest or 30mmHg after exercise
What is hering bruer reflex
Stretch receptors - distension causing slowing of resp rate
What is hering bruer reflex
Stretch receptors - distension causing slowing of resp rate
Most common occupational cause of asthma exacerbation
Isocyanates eg spray painting and foam moulding using adhesives
Most common lung cancer in non smokers
Adenocarcinoma
Treatment for latent TB
Three months of isoniazid and rifampicin
Or six months of isoniazid
Diabetic Thai gentleman with cough and progressive SOB. Extremely unwell. BC burkhoideria pseudomallei. Diagnosis and treatment
Melioidosis and iv ceftrazadine
Pneumonia after the flu causative organism.
Staphylococcus aureus or mycoplasma or legionella
Both bilateral consolidation. Mycoplasma usually younger and dry cough with erythema multiform.
Legionella hyponatremia
Legionella Vs Mycoplasma
Both treated with macrolides like erythromycin.
Both have flu like proceed and dry cough.
Legionella has hyponatremia
Mycoplasma has haemolytic anaemia and erythema multiform
Egg shell calcification of hilar LN is classic sign for
Silicosis (with multiple well rounded nodules in your zone)
Lung cancer with hyponatremia
Small cell… Occurs because of ectopic ADH secretion
when do you start LTOT with COPD
COPD - LTOT if 2 ABG measurements of pO2 < 7.3 kPa
OR to those with a pO2 of 7.3 - 8 kPa and one of the following:
secondary polycythaemia (so high Hb)
peripheral oedema
pulmonary hypertension
Which organism can cause cavitation lesions in pneumonia
Staphylococcus aureus can do, especially when caused by strains capable of making cytotoxin panton valentine leukocidin.
Klebsiella can too (alcoholism)
And TB (drawn out subacute presentation)
Squamous cell carcinoma (smoking history) other cancer too but not as much
Treatment for pneumocystis jirovecii
Co-trimoxazole (septrin) or IV pentamidine in servere cases
Prednisolone if hypoxic
What produces surfactant
Type 2 pneumocystes…
functioning component is dipalmitoyl phosphatidylcholine (DPPC) which reduces alveolar surface tension.
Treatment for end stage lung disease in alpha 1 anti trypsin
Lung volume reduction surgery
,-removes the worst affected part of the lungs in order to improve airflow and alveolar gas exchange in the remaining portion of the lung.
Patient in ED with multi drug resistant tb is trying to leave and has capacity
Tough! They can be detained under public health section.
Pneumothorax guidelines
If primary, under 2cm and no SOB then discharge
If not then aspirate
If that fails (>2 or still SOB) then chest drain
If secondary over 2cm and over 50yr then drain
If 1-2 aspirate and admit for 24hr.
If that fails then drain
If less than 1cm then admit for 24hr
Criteria for LTOT
pO2 <7.3 Or pO2 7.3 - 8 kPa and one of the following: secondary polycythaemia (high Hb) peripheral oedema pulmonary hypertension
Mantoux test 4mm diameter
Under 6 -negative, give BCG
6-15 positive, don’t give BCG
Above 15 tb infection
Bacteria related keeping birds
Chlamydia psittacosis
Atypical pneumonia
Organomegaly
Treat with tetracycline
diagnosis of adult w ?asthma
Adults with suspected asthma should have both a FeNO test and spirometry with reversibility
also referred to a specialist as possible occupational asthma if worse at work
Patient presents with Pneumonia and a Cold sore.. What is likely pathogen?
Streptococcus pneumoniae commonly causes reactivation of the herpes simplex virus resulting in ‘cold sores’
Patient with dry cough and target lesions
mycoplasma is associated with erythema multiforme - target lesions
Lower zone vs upper zone fibrosis causes
Extrinsic allergic alveolitis, tuberculosis, silicosis and sarcoidosis all predominantly cause upper zone fibrosis.
ACID causes lower, the rest upper
Asbestosis
Connective tissue disorders
Idiopathic pulmonary fibrosis
Drugs…… (Amiodarone, bleomycin, methotrexate).
Bacterial causes of extrinsic allergic alveolitis… Bird fancier lung is caused by…
Avian proteins
Bacterial causes of extrinsic allergic alveolitis… Farmers’ lung is caused by…
spores of Saccharopolyspora rectivirgula (formerly Micropolyspora faeni)…. From contaminated hey
Bacterial causes of extrinsic allergic alveolitis… Malt workers’ lung is caused by…
Aspergillosis clavatus
Bacterial causes of extrinsic allergic alveolitis… Mushroom workers’ lung is caused by…
thermophilic actinomycetes
Drug causes of lung fibrosis
Amiodarone (1-5% of patients)
Nitrofurantoin
Methotrexate
Bleomycin
Lower zone fibrosis
Increased risk of lung cancer in smoker with asbestos exposure
10 X 5 =50
What is main component of pulmonary surfactant?
dipalmitoyl phosphatidylcholine (DPPC)
Patient with upper-mid fibrosis, lymphocytosis on lavage and no eosinophils… diagnosis
Extrinsic allergic alveolitis
What occupation predisposes you to tb?
Silicosis predisposes, so jobs like mining slate works foundries potteries
After pleural aspirate what are the three reasons to leave a drain in to drain infected pleural fluid?
Turbid fluid
Growth from fluid
pH < 7.2
Most common organism cause of COPD infection
H influenza
Can also be strep pneumonia or moraxella catarrhalis
If there is consolidation on cxr then strep pneumoniae is most likely
What is alpha 1 anti trypsin
Protease inhibitor of neutrophilic elastase
Copd, no features of asthma, not controlled on salbutamol, next step?
LABA + LAMA
(Fluticasone or budesonide + tiotropium)
IF asthmatic features LABA + ICS
Pneumothorax guidelines
Primary pneumothorax :
< 2 and no symptom»_space; discharge and follow.
> 2 or symptom»_space;> first aspiration»_space; fails drain .
For secondary….admit all and:
<1cm, admit with oxygen
1-2cm »_space;> go with Aspiration»_space;> failed go with drain .
Age > 50 and >2cm or symp »_space;> straight to drain
Mnemonic for life threatening asthma
33 92 CHESt PEFR <33 SpO2 <92% Cyanosis, confusion, coma, CO2 falsely normal Hypotension. Exhaustion Silent chest
Patient with RA gets dyspnoea… Obstructive picture on spirometry
bronchiolitis obliterans
Fibrosis is restrictive
29yr Patient presents with chronic cough and haemoptysis. Urinalysis blood++
goodpastures… Pulmonary haemorrhages, longer history
Differences clues ….
1-Age : wegners 40+, churgs 50, good pasture <30 and then >60…
2- wegners epistaxis/sinusitis and renal failure, good pasture to pulmonary haemorrhage, churg eiosinophilia
Copd not controlled on salbutamol inhaler. No history of asthma.
Add combined LABA LAMA
(Fluticasone or budesonide + tiotropium)
If asthma history then add LABA + ICS
Lower Vs upper zone fibrosis causes
ACID causes lower, the rest upper
Asbestosis
Connective tissue disorders
Idiopathic pulmonary fibrosis
Drugs…… (Amiodarone, bleomycin, methotrexate)
Occupational causes of asthma
GF works at PEPSI factory and comes home every day with asthma symptoms
GF— Glutaraldehyede. Flour PEPSi : Platinum salt Epoxy resins Proteiolytic enzymes Soldering flux resins Isocynayes
Diagnosis of asthma
Over 17yr everyone should have Spiro w reversibility AND FeNO
Altitude, pulmonary oedema, treatment
Descent and nifedipine / dex/ acetazolamide
Treatment for allergic bronchopulmonary aspergillosis (ABPA)
Prednisolone
Oral antifungals are often used as an adjunct
most common cause of secondary pneumothorax
COPD 50-70% of cases
‘red-currant jelly’ sputum
Klebsiella
asthma who are not controlled with a SABA + ICS
Leukotriene R antagonist
Lambert-Eaton syndrome. Diagnosis
Small cell
Also ADH
Asthma, ulnar nerve palsy, eosinophilia
churg Strauss, aka Eosinophilic Granulomatosis with Polyangiitis
What drug can trigger chrurg Strauss
Leukotriene receptor antagonists
Remember can be mononeuritis
Treatment for sarcoid
Oral corticosteroids
Treat if hypercal
Eye, heart or neuro inv
stage 2 or 3 disease on XR who are symptomatic
1 = BHL 2 = BHL + infiltrates 3 = infiltrates 4 = fibrosis
NIV settings
IPAP 10 EPAP 5
Contraindications to lung cancer surgery
SVC obstruction,
FEV < 1.5
MALIGNANT pleural effusion
vocal cord paralysis
Bronchiectasis: most common organism
H influenza
Lofgren’s syndrome
Acute form of sarcoidosis
- erythema nodosum
- bilateral hilar lymphadenopathy (BHL)
- polyarthralgia or polyarthritis
Thought to be caused by Ascaris lumbricoides
allergic bronchopulmonary aspergillosis features
Asthma-like Proximal bronchiectasis Blood eosinophilia Immediate skin reactivity to Aspergillus antigen Increased serum IgE (>1000 IU/ml)
Heerfordt syndrome
subset of sarcoidosis
Combo of:
parotid enlargement, fever, and anterior uveitis
investigation of choice for upper airway compression
Flow volume loop
A normal flow volume loop is often described as a ‘triangle on top of a semi circle’
Varenicline MOA
nicotinic receptor partial agonist
Causes nausea, Contra with suicide, breast feeding/preg
Bupropion MOA
a norepinephrine and dopamine reuptake inhibitor, and nicotinic antagonist
also Contra in breast feeding/preg
And epilepsy
Vital capacity
- maximum volume of air that can be expired after a maximal inspiration
4,500ml in males, 3,500 mls in females
When might you get Calcification in lung metastases
uncommon EXCEPT in the case of chondrosarcoma or osteosarcoma.
Chest drain triangle of safety
base of the axilla
lateral edge pectoralis major
5th intercostal space
anterior border of latissimus dorsi
What affects transfer factor
raised: asthma, haemorrhage (wegeners), left-to-right shunts, polycythaemia
low: everything else
anything that reduces alveolar surface area will reduce TLCO… Except asthma
Management of bronchiectasis (non CF)
inspiratory muscle training + postural drainage
What is not a risk factor for lung cancer….?
Coal dust!
Does cause pneumoconiosis/progressive massive fibrosis though
erythema nodosum in sarcoidosis
Is good prognostic factor
Transfer factor
Rate of diffusion blood to air
So fibrosis/scarring /restrictive would be reduced
Pulmonary haemorrhage, hyperaemia, hyperkinetic increases. Asthma
Asbestos cancers
Mesothelioma, but also bronchial carcinoma, laryngeal cancer and ovarian cancer.
Patient with HIV and PCP. Severe infection
usually Co-trimoxazole
But if severe IV pentamidine
Also give prednisolone if severe hypoxaemia
Can give pentamidine aerosol as prophylaxis but there is risk of pneumothorax
flu-like symptoms preceding a dry cough, bilateral consolidation on x-ray,
erythematous lesions on his limbs and trunk
Mycoplasma (rash was erythema multiforme)
Patient from home w HIV.. SOB, productive cough, septic. coarse crackles on R chest. XR consolidation on RLZ. organism?
Streptococcus pneumoniae (CAP)
Remember Pneumocystis jiroveciitends to present w very few chest signs and bilat consolidation
