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Respiratory Flashcards

1
Q

What is COPD?

A

Chronic obstructive pulmonary disease - a group of lung disorders that cause airflow obstruction, not fully reversible.

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2
Q

What is the pathophysiology of COPD?

A

Emphysema

Chronic bronchitis

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3
Q

What is emphysema?

A

Abnormal, permanent enlargement of alveoli. Air cannot be effectively expelled out.

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4
Q

What is chronic bronchitis?

A

Inflammation of the airways leading to mucous production, lymphocyte invasion, scarring and fibrosis.

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5
Q

What type of respiratory failure does COPD result in?

A

Type 2

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6
Q

What are some of the causes of COPD?

A

Smoking
Occupational dust/chemical exposures
Pollution
Cystic fibrosis

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7
Q

What are the pathophysiological obstructive mechanisms in COPD?

A

Loss of elasticity
Inflammation and scarring
Mucous secretion

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8
Q

What are the symptoms of COPD?

A

Cough with sputum
Wheeze
Dyspnoea
Tired and lack of energy

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9
Q

What are the signs of COPD?

A

Raised BP
Use of accessory muscles
Hyperinflation - barrel chest
Frequent infections

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10
Q

What is the mechanism of the ‘pink puffer’ in COPD?

A

Increased alveolar ventilation, normal oxygen, normal/low CO2, not cyanosed, breathless –> due to emphysema

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11
Q

What is the mechanism of the ‘blue bloater’ in COPD?

A

Decreased alveolar ventilation, low oxygen, high CO2, cyanosed –> due to chronic bronchitis

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12
Q

What is the FEV/FVC ratio post bronchodilator to diagnose COPD?

A

<0.7

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13
Q

What investigations should be carried out in COPD?

A

Spirometry
Chest X-Ray
DLCO

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14
Q

What does a chest X-Ray show in COPD?

A

Hyperinflation, depressed diaphragm.

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15
Q

What does a DLCO test show?

A

The extent to which CO2 is diffusing in and out of alveoli.

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16
Q

What are the differential diagnoses for COPD?

A

Heart failure
Pulmonary embolism
Pneumonia
Asthma

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17
Q

What is the general lifestyle advice for COPD?

A

Smoking cessation
Physical activity
Flu vaccine - to avoid exacerbations
Pulmonary rehabilitation

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18
Q

What pharmacological therapies are available in COPD?

A

2 - Long acting muscarinic antagonists or long acting beta agonists.
3 - Long acting beta agonist and inhaled corticosteroid
4 - long acting beta agonist and ICS and short acting muscarinic antagonist.

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19
Q

What is an example of a short acting muscarinic antagonist?

A

Ipratropium

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20
Q

What is an example of a long acting muscarinic antagonist?

A

Tiotropium

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21
Q

What is an example of a short acting beta agonist?

A

Salbutamol

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22
Q

What is an example of a long acting beta agonist?

A

Salmeterol

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23
Q

What are the target oxygen sats for a patient

A

88-92%

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24
Q

What is the difference between asthma and COPD?

A

COPD is not as variable
COPD has a later age of onset typically
COPD has a more relentless progression
COPD is not fully reversible unlike asthma

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25
What is asthma?
A reversible cause of obstructive airways disease due to bronchial hypersensitivity.
26
What respiratory failure does asthma cause?
Type 1
27
What is the pathophysiological basis of allergic asthma?
Type 1 hypersensitivity reaction resulting in an IgE inflammatory response - leading to bronchoconstriction and smooth muscle contraction.
28
What are the two types of asthma?
Allergic (eosinophilic) | Non-allergic
29
What are conditions associated with asthma? Why?
Hayfever, aczema. These are other atopic conditions, which often occur together.
30
What are the exacerbating features of asthma?
Cold Exercise Allergens Infection
31
What are the symptoms of asthma?
Intermittent dyspnoea Wheeze Cough (often nocturnal) Often worse in the morning (diurnal variation)
32
What are the signs of asthma?
``` Other atopic disease Raised RR Audible wheeze Decreased air entry Precipitated by triggers ```
33
How do you investigate chronic asthma?
``` Spirometry Peak flow monitoring Chest X-Ray Skin prick tests Exhaled nitric oxide test ```
34
What does spirometry show in asthma?
FEV/FVC <0.7 | >15% increase in FEV post bronchodilator
35
What do peak flow tests show in asthma?
Diurnal variation >20%
36
What does an exhaled nitric oxide test show in asthma?
Increased amount of exhaled nitric oxide due to the inflammation of the airways.
37
What investigations should be carried out in chronic asthma?
Peak flow Cultures ABG
38
What is a sign that respiratory failure is occurring in an acute asthma attack?
Normal or raised CO2 - hyperventilation would usually produce a low CO2 level.
39
What are the differential diagnoses of asthma?
Pulmonary oedema COPD Large airways obstruction
40
What general advice should be given to an asthmatic patient?
Smoking cessation | Avoid allergens and triggers
41
What is the pharmacological ladder of treatment for asthma?
``` 1 - SABA 2 - SABA + ICS (+/- leukotriene) 3 - SABA + ICS + LABA 4 - Increase dose of steroid 5 - Consider biologics 6 - Oral steroid Move onto next stage of 3/4 time a week. ```
42
What is the action of beta agonists? What are their side effects?
Relax bronchial smooth muscle. | Tachycardia, tremor, anxiety, hypokalaemia
43
What is an example of an inhaled corticosteroid? What is its action?
Beclometasone. | Reduce bronchial inflammation.
44
What are the side effects of long term steroid use?
Osteoporosis, adrenal suppression, cataracts
45
What are the requirements for an acute asthma attack?
Peak flow 33-50% RR > 25 HR > 110 Can't complete sensible
46
What are the requirements for a life threatening asthma attack?
Peak flow < 33% O2 < 92% Altered consciousness
47
What is the treatment for an acute asthma attack?
Salbutamol Prednisolone Oxygen - according to sats MONITOR closely
48
What is hypersensitivity pnuemonitis?
Inflammation of small airways and alveoli caused by an allergic reaction to an inhaled allergen.
49
What is the pathogenesis of hypesensitivity pneumonitis?
Chronic inflammation Interstitial granulomas Interstitial fibrosis
50
Give 3 examples of hypersensitivity pneumonitis?
Farmer's lung - from mouldy hay Bird fancier's lung - handling pigeons Maltworker's lung
51
What are the symptoms of hypersensitivity pneumonitis?
Malaise Dyspnoea Cough Weight loss
52
What are the signs of hypersensitivity pneumonitis?
Inspiratory squeaks | Bilateral fine crackles
53
What investigations can be carried out in suspected hypersensitivity pneumonitis?
Chets X-Ray Lung function tests Serum antibodies
54
What type of airways disease foe hypersensitivity pneumonitis cause?
Restrictive
55
What are the differential diagnoses of hypersensitivity pneumonitis?
Asthma | Interstitial lung disease
56
What is the management of hypersensitivity pneumonitis?
Avoid exposure | Steroids
57
What are the lung conditions that can be included in occupational lung disorders?
``` Bronchitis Fibrosis Occupational asthma Hypersensitivity pneumonitis Carcinoma ```
58
What type of materials can cause occupational lung diseases?
Dusts Vapours Fumes
59
Give an example of materials that can cause occupational lung disease?
Silicon | Asbestos
60
What is bronchiectasis?
Irreversible dilatation of bronchioles due to recurrent damage.
61
What are possible causes of bronchiectasis?
Tuberculosis Obstructions Complication from other conditions - cystic fibrosis, COPD
62
What is the pathophysiology of bronchiectasis?
Damage to the airways causes scarring and inflammation. Result in airways widening, excess mucous production.
63
What are the symptoms of bronchiectasis?
Persistent cough Large sputum production Dyspnoea Haemoptysis - due to infection.
64
What are the possible signs of bronchiectasis?
Course crackles on auscultation | Clubbing of fingers
65
What is a complication of bronchiectasis?
Recurrent infections - due to less clearance of the airways.
66
What investigations can be carried out in bronchiectasis?
CT | Chest X-Ray
67
What is the general lifestyle advice in bronchiectasis?
Smoking cessation Vaccinations - to minimise future infection risk Chest physiotherapy
68
What are the pharmacological management options in bronchiectasis?
Antibiotics | Steroids
69
What are the possible complications of bronchiectasis?
Pneumonia Pleaural effusion Pneumothorax Haemoptysis
70
What is the inheritance of cystic fibrosis?
Autosomal recessive
71
What is the genetic mutation in cystic fibrosis?
CF transmembrane protein of chromosome 7 mutation
72
What is the pathophysiology of cystic fibrosis?
CFTR protein is a chloride channel, a mutation results in low chloride secretion and increased sodium absorption. This causes thick mucous to clog ducts.
73
What areas of the body does cystic fibrosis primarily affect?
Respiratory | Gastrointestinal
74
What are the respiratory symptoms of cystic fibrosis?
Wheeze Cough Recurrent infections Bronchiectasis
75
What are the gastrointestinal symptoms of cystic fibrosis?
Pancreatic insufficiency Gallstones Steathorrea
76
What are the investigations for cystic fibrosis?
Sweat test - sodium and chloride >60mmol/l Genetic screening Feacal elastase - a marker of pancreatic dysfunction
77
What is the management of cystic fibrosis?
``` Physiotherapy to aid airways clearance Antibiotics for exacerbations Mucinlytics to air clearance Bronchodilators. Pancreatic enzyme replacement ```
78
What is a pleural effusion?
Accumulation of fluid in the pleural space
79
What are the two type of fluids that can accumulate in a pleural effusion?
Transudate | Exudate
80
What is a transudate fluid?
Low protein <25g/l
81
What is an exudate fluid?
High protein >35g/l
82
What are the causes of a transudate fluid build up in pleural effusion?
Increased venous pressure - cardiac failure, constrictive pericarditis. Hypoprotienaemia - cirrhosis, nephrotic syndrome
83
What are the causes of an exudate fluid build up in pleural effusion?
Damage to the pleura - Pneumonia TB Cancer
84
What are the symptoms of pleural effusion?
Dyspnoea | Pleuritic chest pain
85
What are the signs of a pleural effusion?
Decreased expansion on the affected side Stony, dull percussion Diminished breath sounds.
86
What investigations can diagnose a pleural effusion?
Chest X-Ray - white shows fluid (if dense so absorbs) | Diagnostic aspiration to examine the pleural fluid.
87
What is the management of a pleural effusion?
Drainage. | If very recurrent - pleurodesis can glue layers together and stop collection.
88
What other types of fluid can be found in a pleural effusion?
Blood - haemothorax Pus - empyema Chyle - chylothorax
89
What is a pneumothorax?
An accumulation of air in the pleural space
90
Why does a pneumothorax cause the lung to deflate?
Pressure in the pleural space is usually negative to keep the lung inflated. If air enters then it is no longer negative and the elastic recoil of the lung causes it to deflate.
91
What are the causes of a pneumothorax?
Trauma Spontaneous rupture of a ab-pleural bulla Secondary lung damage - COPD, asthma, TB
92
What are the symptoms of a pneumothorax?
``` Sudden onset Dyspnoea Pleuritic chest pain Worse breathing in Onse sided. ```
93
What are the signs of a pneumothorax?
Reduced expansion on the affected side Hyper-resonance on percussion of affected side Diminished breath sounds of affected side.
94
What investigation can diagnose a pneumothorax and what does it show?
Chest X-Ray - black areas show air presence (low density so rays pass through)
95
What is the management of a pneumothorax?
If small and spontaneous - can often self heal Aspiration Chets drain
96
What is a tension pneumothorax?
A pneumothorax in which air can only move from the lung to pleural space (ie. the hole acts as a one way valve).
97
What is the pathophysiology of a tension pneumothorax?
Air accumulated rapidly in the pleural space, trachea begins to deviate towards collapsed lung. There is a risk of vein compression.
98
What is the management for tension pneumothorax?
Chest drain ASAP.
99
How are lung cancers divided?
Small cell | Non-small cell
100
Are lung small cell or non-small cell cancers more common?
Non-small cell
101
What is a characteristic feature of small cell lung cancer presentation?
Usually present with a very high grade - mestastatic
102
What are the types of non-small cell lung cancers?
Adenocarcinoma Squamous cell carcinoma Large cell carcinoma
103
What is the most common location for a lung cancer?
Bronchus
104
What are the causes of lung tumours?
Cigarette smoke Asbestos Radon Nickel
105
What are the symptoms of a bronchial carcinoma?
``` Cough Haemoptysis Dyspnoea Chest pain Recurrent infections ```
106
What are the signs of bronchial carcinoma?
Weight loss Anaemia Finger clubbing Supraclavicular/axillary node enlargement.
107
What are the investigations for lung cancer?
Chest X-Ray Cytology of sputum Bronchoscopy Biopsy
108
What determines the treatment of lung cancer?
Tumour type and grade?
109
What are the treatment options for non-small cell tumours?
Low grade - excision or curative radiotherapy | High grade - chemotherpy
110
What are the treatment options for small cell tumours?
Nearly always metastatic at presentation so usually palliative management.
111
What are the differential diagnoses for a lung nodule on chest X-Ray?
``` Malignancy Abscess Granuloma Cyst Foreign body ```
112
What are the common primary site for lung metastases to originate from?
Kidney Prostate Breast Bone
113
What is a mesothelioma?
Cancer of the pleura
114
What is the most common cause of a mesothelioma?
Asbestos
115
What is the management of a mesothelioma?
Often present at a very late stage - so mostly palliative.
116
What in pneumonia?
Inflammation of the lungs due to infection?
117
What are the four different classifications of pneumonia|?
Community-acquired Hospital-acquired Aspiration Immunocomprimised patients
118
What is the commonest causative organism of pneumonia?
Streptococcus pneumonia
119
What is the appearance of strep. pneumonia on gram stain?
Gram positive diplococci
120
What are the most common causes of hospital acquired pneumonia?
Gram negative enterobacteria - E.coli, salmonella, shigella, klebsiella, proteus. Staph aureua.
121
What is a more unusual cause of pneumonia?
Legionellas
122
What are the symptoms of pneumonia?
``` Fever Rigors Malaise Dyspnoea Cough Haemoptysis Pleuritic pain ```
123
What are the signs of pneumonia?
``` High temperature (pyrexia) Tachycardia High respiratory rate Confusion Hypotension Diminished expansion Pleural rub. ```
124
What investigations should be carried out in pneumonia?
Chest X-Ray | Sputum culture and microscopy to find organism.
125
What is the system used to grade the severity of pneumonia?
``` Confusion Urea >7 Respiratory rate >30 BP <90/<60 Age >65 CURB65 ```
126
What does the CURB65 score mean to a patients treatment?
Higher score = higher mortality Score 1 - outpatient Score 2 - hospital inpatient Score 3 - hospital and consider ITU
127
What is the supportive treatment required in pneumonia?
IV fluids Oxygen Analgesia
128
What are the standard antibiotic therapies for community acquired pneumonia?
Mild - oral amoxicillin Moderate - oral amoxicillin and clarithromycin Severe - IV co-amoxiclav and clarithromycin
129
What is the antibiotic treatment for Legionellas?
fluoroquinolone and clarithromycin
130
What is the antibiotic treatment for S. aureus?
Flucloxacillin
131
Who should be offered the pneumococcal vaccine?
Vulnerable groups - >65, chronic conditions, diabetes.
132
What are the possible complications of pneumonia?
``` Pleural effusion Lung abscess Respiratory failure Septicaemia Hypotension ```
133
What is the causative organism of tuberculosis?
Mycobacterium tuberculosis
134
How is TB detected?
Ziehl-Neelson stain - shows as an acid fast bacilli
135
How is TB spread?
Aerosol from an effected individual - cough/spit etc. | Bovine TB from cows milk
136
When first infected with TB what are the possible outcomes?
Primary TB develops in 5% | The TB lies latent
137
What occurs in primary TB?
Granulomas develop - mostly in the lung apex = primary focus. Mediastinal lymph nodes enlarge
138
What is the primary (Ghon) complex?
Primary focus and mediastinal lymph node enlargement.
139
What are the general symptoms of active tuberculosis?
Weight loss Night sweats Fever Fatigue
140
What are the respiratory symptoms of active tuberculosis?
Persistent cough Chest pain Haemoptysis
141
What are the extra-pulmonary symptoms of active tuberculosis?
Lymph node swelling Bone pain and swelling Meningitis
142
What is miliary TB?
Granulomata everywhere!
143
How may a Chest X-Ray suggest TB?
Cavitation Fibrosis Calcification
144
How do you diagnose active TB?
``` Sputum samples (>3) microscopy and culture If extra pulmonary try pleura, urine, ascites, peritoneum etc. ```
145
What does a blood test show in active tuberculosis?
Anaemia, raised platelets, raised ESR and CRP, decreased albumin.
146
How do you diagnose latent TB?
Mantoux test - skin response test to Tb antigen, shows a memory to TB (ie, a previous infection has been experienced.
147
What are the downfalls of the Mantoux test?
Will be positive if had the BCG vaccine. | Will be positive even if the infection is completely eradicated - could lead to unnecessary treatment.
148
What is the standard treatment for active TB?
``` Rifampicin Isoniazid Pyrazinamide Ethambutol 2 months of all 4 and 4 more months of RI only. ```
149
What is a side effect of Rifampicin?
Red urine
150
What is a side effect of Isoniazid?
Peripheral neuropathy
151
What is a side effect of Pyrazinamide?
Hepatitis
152
What is a side effect of Ethambutol?
Optic neuritis
153
Why is adherence critical in treatment of TB?
If not then resistant TB may develop and this is much harder to treat.
154
What is the treatment regime for latent TB?
6mo isoniazid or 3mo isoniazid and rifampicin.
155
What must also occur on a diagnosis of tuberculosis?
Notification of public health england.
156
What can be done to reduce TB?
BCG vaccine to newborns | Contact tracing of TB contacts.
157
What organism causes whooping cough?
Bordatella pertussis
158
How is influenza transmitted?
Aerosol - coughs and sneezes.
159
What causes seasonal epidemics of influenza?
Antigenic drift
160
What causes pandemics of influenza?
Antigenic shift
161
What is the definition of respiratory failure?
Inability of the lungs to adequately oxygenate arterial blood and/or eliminate CO2 from venous circulation.
162
What is type 1 respiratory failure?
PaO2 < 8kPa | Normal/low CO2
163
What is type 2 respiratory failure?
PaO2 <8kPa | PaCO2 >6kPa
164
What are the causes of respiratory failure?
``` Decreased FiO2 V/Q mismatch - asthma, pneumonia, PE etc. Increased shunt Diffusion impairment Alveolar hypoperfusion ```
165
What is the primary cause of type 2 respiratory failure?
Alveolar hypoperfusion - ie. obstruction, COPD, sleep apnoea.
166
What are the signs of type 1 respiratory failure?
``` Cyanosis Tachypnoea Use of accessory muscles Tachycardia Confusion ```
167
What are the signs of type 2 respiratory failure?
``` Think hypercapnia Bounding pulse Flapping tremor Confusion Drowsiness Reduced consciousness ```
168
What is the treatment of type 1 respiratory failure?
Target O2 94-98% Treat cause If this does not work - CPAP
169
What is the treatment of type 2 respiratory failure?
O2 target 88-92% Medication for 1 hour - bronchodilators, steroids Not worked - ventilate
170
Why are O2 target sats lower in type 2 respiratory failure?
Drive to breathe has changed from carbon dioxide to oxygen, so may reduce the hypoxic drive if it rises too high.
171
What is the cause of a pulmonary embolism?
``` Deep vein thrombus RV thrombus Tumour Fat Foreign material - IVDU ```
172
What are the risk factors for pulmonary embolism?
Recent surgery Leg fracture Immobility Malignancy
173
What is dead space?
When alveoli are perfused but not ventilated - the V/Q ratio is large/infinite.
174
What are the symptoms of a pulmonary embolism?
Sudden onset dyspnoea Pleuritic chest pain Haemoptysis
175
What are the signs of pulmonary embolism?
Pyrexia Cyanosis Tachypnoea Tachycardia
176
What are the investigations for a pulmonary embolism?
Blood tests Chest X-Ray ABG serum D-dimer - NOT specific (rises in inflammation and infection)
177
What is the management of a pulmonary embolism?
Oxygen if hypoxic Analgesia LMWH and warfarin Continue warfarin for 6 months if a spontaneous cause.
178
What action can be taken to prevent pulmonary embolism?
Compression stockings LMWH for prophylaxis in the high risk Anticoagulation post incident.
179
What is the pathophysiology of acute respiratory distress syndrome?
Damage to the lungs causes release of inflammatory mediators, increase in vascular permeability and pulmonary oedema -- fibrosis.
180
What is the cause or ARDS?
Pneumonia, injury, shock, haemorrhage.
181
What are the signs of ARDS?
Cyanosis Tachypnoea Tachycardia Peripheral vasodilation
182
What is the management of ARDS?
Supportive and treat cause
183
What is cor pulmonale?
Right heart failure caused by pulmonary arterial hypertension.
184
What are the causes of cor pulmonale?
COPD Bronchiectasis Emboli

Phase 2a - conditions (11 decks)

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