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Respiratory Flashcards

1
Q

What is the difference between Stridor and Stertor?

A
  • Stridor= harsh. Indicates partial obstruction of laryngeal/ tracheal airways
  • Stertor= snoring-like breathing. Obstruction of nasopharynx/ oropharynx
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2
Q

Management of airways obstruction

A
  1. Airway manoevers/suction/ adjuncts
  2. Intubation
  3. Cricothyroidotomy/ tracheostomy
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3
Q

Anaphylaxis presentation

A
  • Oedema- larynx, eyelids, lips, tongue
  • Wheeze/stridor
  • Itching
  • Capillary leak
  • Urticaria
  • D+V
  • Sweating
  • Erythema
  • Cyanosis
  • Shock- SBP<90 and evidence of end organ hypoperfusion
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4
Q

Acute management of anaphylaxis

A
  1. ABCDE!
  2. Secure airway. Raise feet
  3. Remove cause
  4. Adrenaline 0.5mg 1:1000 IM
  5. Secure IV access
  6. Chlorphenamin 10mg IV + hydrocortisone 200mg IV
  7. IVT stat
  8. ?wheeze –> salbutamol NEBS
  9. Still hypotensive –> ICU. ?IV adrenaline/aminophylline
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5
Q

Presentation of PE

A
  • Acute SOB
  • Pleuritic chest pain
  • Haemoptysis
  • Sudden collapse
  • Signs of DVT
  • High RR, HR. Low BP
  • Cyanosis
  • RV Heave
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6
Q

Well’s score for PE

A
  • Signs/ Sx of DVT (3)
  • PE most likely Dx (3)
  • HR >100 (1.5)
  • >3 days immobilisation/ surgery <4w (1.5)
  • Prev. DVT/ PE (1.5)
  • Haemoptysis (1)
  • Malignancy- current/ Tx <6m ago (1)
  • ==> 4 or less= low risk –> d-dimer –> ?CTPA
  • >4= High risk –> CTPA
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7
Q

PE Ix

A
  • Bedside- O2 sats, ECG (tachy, RBBB, inverted T waves, S1Q3T3)
  • Bloods- d-dimer, ABG
  • Imaging- CTPA, USS of leg, ?V/Q scan
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8
Q

PE Tx

A
  1. ABCDE + o2 + IVT
  2. Morphine + metoclopramide
  3. LMWH (tinzaparin)/ fondaparinux
  4. ?Alteplase/ embolectomy
  5. (Vena cava filter)
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9
Q

Presentation of Pneumothorax

A
  • Chest pain (unilat)
  • Worsening SOB
  • Tracheal deviation AWAY
  • Resp. distress
  • Cyanosis
  • O/E Reduced expansion, hyper-resonance, reduced breath sounds
  • Tension: Shocked, mediastinal shift, raised JVP
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10
Q

Investigations and management of pneumothorax

A
  • Ix: ABG, CXR (lung markings not to edges)
  • ABCDE + o2
  • Primary pneumothorax:
    • <2cm- discharge. r/v 2-4w
    • >2cm- 2x aspiration attempts –> chest drain
  • Secondary pneumothorax:
    • Always treat
    • 1-2cm: aspirate
    • >2cm/ SOB/ >50y: chest drain
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11
Q

Pleural effusion: Difference between transudate and exudate and causes

A
  • Transudate= Protein <25, LDH <0.6. FAILURE
    • Increased venous return- CHF, cirrhosis
    • Decreased proteins- Nephrotic syndrome, hypoalbuminaemia
  • Exudate= Protein >35, LDH >0.5. INFECTION/ INFLAMMATION/ MALIGNANCY
    • Malignancy
    • Pneumonia
    • TB
    • PE
    • Pancreatitis
    • Oesophageal rupture
    • AI
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12
Q

Presentation of Pleural Effusion

A
  • Sx: ASx, SOB, chest pain
  • Stony dull percussion
  • Reduced expansion
  • Reduced breath sounds
  • Reduced vocal resonance
  • Tracheal deviation (large)
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13
Q

Pleural effusion: Ix and Tx

A
  • Ix:
    • CXR- blunted costophrenic angle, dense shadowing with fluid level
    • USS- Diagnosis and guiding drain
    • Pleural fluid aspirate
    • Pleural biopsy
  • Tx:
    • Pleural fluid drainage (?repeated)
    • Pleuradhesis- tetracycline, bleomycin, talc
    • Surgical
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14
Q

Features of acute severe asthma attack

A
  • PEFR 33-50%
  • RR >25
  • HR >110
  • Unable to speak in full sentences
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15
Q

Features of acute life-threatening asthma attack

A
  • PEFR <33%
  • Silent chest
  • Cyanosis
  • Hypotension
  • Arrhythmia
  • Exhaustion/ confusion/ coma
  • ABG: CO2 >4.6, pO2 <8kpa/92%
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16
Q

Investigations of chronic and acute asthma

A
  • Chronic: PEFR, spirometry, bloods, CXR, IgE skin prick, sputum culture
  • Acute: NEWS, PEFR, bloods, ABG, CXR
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17
Q

BTS guidlines of chronic asthma management

A

INH SABA PRN. ?Step up >3 times/w

  1. INH SABA PRN- salbutamol
  2. Low dose ICS- beclometasone
  3. INH LABA eg salmeterol. If ineffective, stop and increase dose of ICS
  4. High dose ICS (upto 2000 micrograms/d). Consider addition of B2 agonist PO, motelukast, SR theophylline
  5. Prednisolone PO/ continue high dose ICS. Specialist care
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18
Q

Management of acute asthma attack

A
  • ABCDE + 02
  • Salbutamol 5mg NEB. Repeat every 15-30 mins
  • Ipratropium bromide 0.5mg/6h NEBS
  • Magnesium sulfate 1.2-2g IV over 20 mins
  • Not improving –> ICU ?ventilation ?aminophylline ?IV salbutamol
  • Improving 15-30 mins –> Continue salbutamol NEBS 4-6h, PO prednisolone 5-7d
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19
Q

Presentation of COPD

A
  • SOB (++ exercise)
  • Wheeze
  • Nocturnal cough
  • Sputum (white)
  • Fatigue
  • Plethora
  • Cyanosis
  • Raised JVP
  • Tremor
  • Hyperresonance
  • ??Smoker
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20
Q

Spirometry: Obstructive vs Restrictive

A
  • Obstructive- Reduced FEV1 and FEV1:FVC
  • Restrictive- Reduced FVC (?raised FV1:FVC)
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21
Q

Staging of COPD

A

Gold Classification

  1. Mild- FEV1 80-100%
  2. Moderate- FEV1 50-80%
  3. Severe- FEV1 30-50%
  4. V severe- FEV1 <30%
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22
Q

Management of chronic COPD

A

Conservative- smoking cessation, good diet, pulmonary rehab, vaccinations

  1. SABA (salbutamol) or SAMA (ipratropium) PRN
  2. FEV >50%: LABA (salmeterol) or LAMA (tiotropium) + stop SAMA. FEV<50%: LABA + ICS or LAMA
  3. LAMA + LABA/ICS combined (symbicort/ seretide)
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23
Q

Acute management of COPD

A

ABCDE

  1. NEBS- salbutamol, ipratropium bromide
  2. Controlled o2 (88-92%)
  3. Steroids- prednisolone/ hydrocortisone
  4. ABx- amoxicillin/ clarithromicin/doxycycline
  5. Chest physio
  6. No response to NEBS –> IV aminophylline
  7. NIV
  8. Doxapram
  9. ??Intubation
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24
Q

Indications for NIV in acute COPD

A
  • RR >30
  • pH <7.35
  • PaCO2 >6.5 and rising despite Tx
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25
Q

Contraindications of NIV

A
  • Unable to maintain airway- impaired swallow/cough, low GCS
  • Facial trauma/ burns
  • Pneumothorax
  • Cardio/pulmonary arrest
  • Relative- extreme anxiety, dementia, morbid obesity, multiple organ failure
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26
Q

COPD CXR

A
  • Hyperinflation: >6 ribs visible above diaphragm
  • Flattened hemidiaphragms
  • Large central pulmonary arteries
  • Reduced vascular markings
  • Bullae
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27
Q

Presentation of Pneumonia

A
  • Productive cough
  • SOB
  • Pleuritic chest pain
  • Haemoptysis
  • Fever +/- rigors
  • Confusion (esp elderly)
  • Reduced chest expansion
  • Dull percussion
  • Crackles
  • Bronchial breathing
  • ??SEPSIS
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28
Q

Severity scoring of CAP

A

CURB-65

  • Confusion
  • Urea >7mmol/L
  • RR >30
  • BP <90/60
  • Age >65 years

1-2= Mild. 2= Moderate, hospital. 3= Severe ?ICU

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29
Q

Common pathogens causing pneumonia

A
  • Strep. pneumoniae
  • H. Influenzae
  • Moraxella catarrhalis
  • Klebsiella
30
Q

Management of CAP

A
  • Mild: 5d course of amoxicillin (or clarithromycin or doxycycline)
  • Mod: 7-10d course of amoxicillin + clarithromycin
  • Severe: 7-10d Tazocin/Co-amox + clarithromycin
31
Q

Management of HAP

A
  • Tx within 4 hours
  • 5-10d coure of tazocin/ co-amoxiclav IV
32
Q

Different types of lung cancer and their key features

A
  • Small cell lung cancer (20%)- AGGRESSIVE. Central/ hilar. Met early. Neuroendocrine cells –> paraneoplastic syndromes
  • Non-small cell cancer
    • Squamous (35%)- **SMOKERS**. Proximal bronchi. Local spread. Met late. Hypercalcaemia
    • Adenocarcinoma (27%)- Peripheral. Glandular cells. ++mets: pleura, LN, brain, bone, adrenal glands
    • Large cell (10%)
    • Alveolar cell carcinoma (<1%)
33
Q

Presentation of Lung Cancer

A
  • Chest pain
  • Persistent cough
  • Haemoptysis
  • Weight loss and anorexia
  • Lethargy
  • Chest signs- Consolidation, collapse, pleural effusion
  • ?Tar staining
  • Clubbing
  • Signs of complications
34
Q

2 week wait criteria for Lung Cancer

A
  • X-Ray finding
  • >40y + unexplained haemoptysis
  • Urgent CXR if >40y and 2 of following Sx (or smoker +1): Cough, fatigue, SOB, chest pain, weight loss, anorexia
  • ?Urgent CXR if >40y with any of: Persistent chest infection, clubbing, lymphadenopathy, chest signs, thrombocytosis
35
Q

Complications of Lung Cancer

A
  • Local- SVCO, pleural effusion, pericarditis, phrenic n palsy, hoarse voice, Horner’s (ptosis, myosis, anhydrosis), pain, rib erosion
  • Mets: LNs (supraclavicular, axillary, mediastinal), skin, adrenals, bone (fracture), brain (ICP)
  • Endocrine: SIADH (low Na+, high ADH), hyperparathyroidism –> hypercalcaemia **squamous**, Cushing’s (ACTH) **SCLC**
  • Neurological: Fits, cerebellar syndrome, neuropathy, proximal myopathy, polymyositis, Lambert-Eaton syndrome
36
Q

Lung cancer investigations

A
  • Bedside- Lung function, sputum cytology
  • Bloods- FBC, U+Es, LFTs, Ca2+, LDH (tumour lysis)
  • Imaging- CXR, CT, ?PET, ?bronchoscopy
    • CXR- Nodules, hilar enlargement, consolidation, collapse, pleural effusion, bony mets
  • Special- FNA/ Biopsy/ Pleural fluid analysis
37
Q

What are the pulmonary signs and symptoms of TB?

A
  • ASx
  • Cough
  • Sputum
  • Malaise
  • Weight loss
  • Night sweats
  • Pleurisy
  • Haemoptysis
  • Pleural effusion
38
Q

What are the extrapleural signs and symptoms of TB?

A
  • Miliary= Disseminated haematogenous spread
  • GU= Dysuria, frequency, loin/back pain, haematuria
  • Bone= Vertebral collapse
  • Skin= Jelly like nodules
  • Cardiac= Chronic pericardial effusion/ pericarditis
  • TB meningitis
39
Q

Diagnosis of TB

A
  • Latent= Mantoux test –> ?Quantiferon gold
  • Active
    • CXR- Consolidation, cavitation, fibrosis, calcification
    • Sputum- C+S with Ziehl-Neelson stain ?acid fast bacilli
    • Histology- Caseating granulomata
  • ??HIV
40
Q

TB Treatment and SE

A
  • Rifampicin- orange fluids, less effective OCP
  • Isoniazid- Peripheral neuropathy
  • Pyrazinamide- Gout, photosensitivity, hepatitis
  • Ethambutol- Optic neuritis, reduced acuity, loss of colour vision
  • 4 drugs for 2 months, 2 drugs (R + I) for 4 months
41
Q

What is Bronchiectasis?

A
  • Bronchiectasis is chronic infection of bronchi and bronchioles –> permenant dilatation. Underlying causes.
  • Common organisms- S. pneumonia, H. Influenzae, pseudomonas
42
Q

What are the main causes of Bronchiectasis?

A
  • Congenital- CF
  • Post-infective: Measles, pertussis, bronchiolitis, pneumonia, TB, HIV
  • Other- Idiopathic, RA, UC, bronchial obstruction eg tumour
43
Q

What are the signs and symptoms of Bronchiectasis?

A
  • Persisent cough
  • ++ purulent sputum
  • Intermittent haemoptysis
  • Clubbing
  • Coarse inspiratory crepitations
  • Advanced –> cyanosis, RHF
44
Q

What investigations would you do for Bronchiectasis?

A
  • Bedside- sputum sample, CF breath test, spirometry
  • Bloods- immunoglobulins, FBC, CRP
  • Imaging-
    • CXR- Tramline and ring shadows. Cystic shadows, dilated airways, thickened bronchial walls
    • HRCT- Extent and distribution (CF upper lobe, all rest lower)
  • Special- ?Biopsy
45
Q

Treatment of Bronchiectasis

A
  • Conservative- Chest physio and postural drainage
  • Medical- ABx, ?bronchodilators, ?steroids
  • Surgical- Localised, haemoptysis
46
Q

Types of respiratory failure and their causes

A
  1. PaO2 <8kPa = V/Q mismatch. PE, pulm. oedema, asthma
  2. PaO2 <8kPa + PaCO2 >6kPa. Hypoventilation- COPD, pneumonia, MND, opiates, chest wall damage
47
Q

Patients at risk of hypoventilation

A
  • Chest wall deformity
  • COPD
  • Obstructive sleep apnoea
  • Muscle disease eg DMD
  • Spinal injury
  • Diaphragm paralysis
48
Q

Hypoventilation investigations

A
  • Bedside- NEWS, transcutaneous CO2
  • Bloods- ABG= Respiratory acidosis (hypoxia, hypercapnia)
  • Imaging- CXR
  • Special- Pulmonary function tests (spirometry, resp muscle strength
49
Q

What is obstructive sleep apnoea and how does it present?

A
  • OSA= Intermitted collapse of pharyngeal airway –> apnoeic eps. Terminated by rousal.
  • Typical patient= middle aged obese male.
  • Sx: Loud snoring, nocturia, daytime somnolence, poor cognitive performance, morning headache.
50
Q

Investigations and treatment of obstructive sleep apnoea

A
  • Ix: Pulse oximetry (desats), Epworth sleep scale, chest wall movement, flow, snoring. ??EEG. (Somnography)
  • Tx: Weight loss, CPAP, ?surgery to remove obstruction
51
Q

What is interstitial lung disease? What are it’s symptoms and Ix?

A
  • Umbrella term for conditions primarily affecting the parenchyma diffusely. Chronic inflammation/ fibrosis
  • Sx: Dry cough, exertional dyspnoea, abnormal breath sounds.
  • Ix: Abnormal CXR/ HRCT, spirometry= restrictive, ABG= type 1 respiratory failure.
52
Q

Categorise the causes of interstitial lung disease

A
  • Known cause:
    • Occupational/ environmental eg asbestosis, silicosis
    • Drugs- nitrofurantoin, bleomycin, amiodarone
    • Hypersensitivity pneumonitis
    • Infections- TB, viral, fungi.
  • Secondary to systemic disorder- RA, SLE, Sarcoidosis
  • Idiopathic pulmonary fibrosis
53
Q

Presentation of idiopathic pulmonary fibrosis (IPF)

A
  • Dry cough
  • SOB (worse on exercise)
  • Malaise
  • Weight loss
  • CLUBBIN (2/3)
  • Cyanosis
  • Reduced expansion
54
Q

Investigations and management of idiopathic pulmonary fibrosis

A
  • Ix: NEWS, CRP, immunoglobulins, HRCT (reticular nodular shadowing/ honeycomb), restrictive spirometry, ?biopsy
  • Tx: O2, pulm rehab, palliation, antifibrotics (eg perfenidone), ??transplant
55
Q

What is hypersensitivity pnuemonitis?

A
  • AKA Extrinsic allergic alveolitis
  • In sensitised individuals, inhalation of allergens provokes hypersensitivity reaction.
  • Eg Farmer’s lung, pigeon fancier’s lung etc
56
Q

Presentation of hypersensitivity pneumonitis

A
  • Acute: flu-like. Fever, myalgia, drug cough, squeak/squark
  • Chronic: SOB, weight loss, type 1 resp failure, cor pulmonale
57
Q

Investigations and managment of hypersensitivity pneumonitis

A
  • Ix: NEWS, ABG, CXR (honeycomb, upper lobe consolidation), HRCT, spirometry (restrictive).
  • Tx: Remove allergen, O2, PO Pred
58
Q

What is sarcoidosis and how does it present?

A
  • Sarcoidosis= multisystem granulomatous disorder of unknown cause. Predominantly affects the lung
  • Lung Sx- Hilar lymphadenopathy, SOB, dry cough, chest pain, poor lung function
  • Non-pulmonary Sx- Erythema nodosum, neuropathy, polyarthralgia, lupus pernio, arrhythmias, glaucoma, uveitis/ conjunctivitis, hypercalcaemia, hepatosplenomegaly
59
Q

What is Lofgren’s syndrome?

A

Sarcoidosis associated with arthralgia and hilar lymphadenopathy –> NSAIDs

60
Q

How would you investigate sarcoidosis?

A
  • Bedside- 24h urine, ECG
  • Bloods- FBC, ESR, serum ACE (increased in 60%), immunoglobulins
  • Imaging- CXR (bilateral hilar lymphadenopathy + pulmonary infiltrates), CT/MRI, USS of liver/ spleen
  • Special- biopsy (non-caseating granuloma), restrictive spirometry, BAL
61
Q

Sarcoidosis treatment

A
  • Acute- bed rest, NSAID
  • PO prednisolone
  • Severe- IV methylprednisolone, immunosuppression (methtrexate, hydroxychloraquin, ciclosporin).
62
Q

Differentials of hilar/ mediastinal lymphadenopathy

A
  1. Sarcoidosis (usually young and healthy)
  2. Lymphoma (fever and night sweats)
  3. Carcinoma (smoker and haemoptysis_
  4. TB
63
Q

What is pneumoconiosis and what might cause it?

A
  • Lung disease caused by inhalation of mineral dust. Fibrosis –> restrictive lung disease.
  • Might be caused by coal/silica/asbestos
  • Silicon- Fibrosis. Diffuse nodules –> large lumpy areas in upper zone. Sparkley birefringent pattern on biopsy
  • Coal- deposition around terminal bronchioles.
  • Asbestosis= fibrosis. Plaques (holly leaf).
  • Asbestost can also cause malignant mesothelioma (pleura) 40-50y after exposure.
64
Q

Causes of Respiratory Acidosis

A
  • = Hypoventilation
  • Opiates
  • Neuromuscular- Guillain-Barre, MND, DMD
  • Asthma
  • COPD
  • Iatrogenic (ventilator)
65
Q

Causes of Respiratory Alkalosis

A
  • = Hyperventilation
  • Anxiety
  • Pain
  • Hypoxia
  • PE
  • Pneumothorax
  • Iatrogenic
66
Q

Causes of Metabolic Acidosis

A
  • Determined by Anion Gap= Na+ - (Cl- + HCO3-)
  • High anion gap= increased acid production- DKA, lactic acidosis, aspirin OD
  • Low anion gap= decreased acid excretion or loss of HCO3-: Diarrhoea, ileostomy, Addison’s, renal tubular acidosis
67
Q

Causes of Metabolic Alkalosis

A
  • GI loss of H+ (D+V)
  • Renal loss of H+: loop/thiazide diuretics, HF, nephrotic syndrome, cirrhosis, Conn’s
  • Iatrogenic- Addition of alkali
68
Q

Management of smoking cessation

A
  • NB Hx to ask Pt about smoking and best way to support them.
  • Advise best way to quit, provide details of where to get help.
  • Refer to specialist smoking cessation service
  • Medical:
    • Nicotine replacement- gum, patches
    • Varencline- partial nicotine receptor agonist. Reccommended by NICE. Start whilst still smoking –> high rates of abstinence
    • Alt= bupropion
69
Q

What is the DECAF score?

A

= Predicts in hospital mortality in acute exacerbation of COPD.

  • Dyspnoea - MRCD 5a/b (1-2)
  • Eosinopenia - <0.05x109/L (1)
  • Consolidation (1)
  • Acidaemia- pH <7.3 (1)
  • Fibrillation (AF) (1)

Score >3 = high risk!

Finals!!! (19 decks)

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