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Respiratory Flashcards

1
Q

What are the causes of a pleural transudate?

A

Heart failure Hypoalbuminaemia Hypothyroidism Meigs syndrome

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2
Q

What defines a transudate?

A

<30g/L protein

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3
Q

What defines an exudate?

A

>30g/L protein

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4
Q

What are the causes of a pleural exudate?

A

Infection (pneumonia, TB, abscess) Connective tissue disease Neoplasia Pancreatitis PE Dressler’s syndrome Yellow nail syndrome

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5
Q

What is acute bronchitis?

A

Inflammation of the bronchi

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6
Q

What causes bronchitis?

A

Viruses (influenze, RSV, rhinoviruses) Bacteria (pneumococcus, H.influenzae, staph aureus)

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7
Q

What are the symptoms of acute bronchitis? How long does it last?

A

Main= cough SOB, wheeze, sputum Cough lasts 7-10d but can be up to 3 weeks

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8
Q

What is the treatment for bronchitis?

A

Reassurance Analgesia/antipyretics DOES NOT NEED ANTIBIOTICS

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9
Q

What are the risk factors for bronchitis?

A

Smoking Damp

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10
Q

What family of viruses causes influenza?

A

Orthomyxoviridae

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11
Q

What are the 3 types of influenza and what are the differences between them?

A

Influenza A- most common, more virulent. Causes most local outbreaks. Influenza B- often co-circulates with A, less severe illness. Influenza C- mild/asymptomatic infection

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12
Q

What is the management of influenza in health individuals vs those who are “at risk”?

A

Healthy- rest, paracetmaol/ibuprofen, adequate fluids, stay off until worst sx resolved (~1 week) At risk- antivirals (oseltamivir or zanamivir) within 48hr of sx

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13
Q

Which groups are “at risk” of complications from influenza?

A

Chronic disease (lung/heart/kidney/neuro) Diabetics Obese Immunosuppressed >65 years <6 months Pregnant (or up to 2 weeks postpartum)

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14
Q

What are the complications of flu?

A

Bronchitis, sinusitis, otitis media, exacerbation of COPD/asthma, pneumonia

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15
Q

What is laryngotracheobronchitis?

A

Croup

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16
Q

What are the symptoms of croup?

A

Seal-like barking cough Stridor Hoarse voice Respiratory distress Worse at night Preceded by 12-48hr cough, fever, rhinorrhoea

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17
Q

What determines if croup is mild/mod/severe?

A

Mild- cough, no stridor or recession Moderate- cough with stridor or recession at rest, no agitation/lethargy Severe- cough, stridor, recession with agitation/lethargy

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18
Q

What are the signs of impending respiratory failure in croup?

A

Increasing airway obstruction Recession (can decrease as child tires!) Asynchronous chest/abdo movements Fatigue Pallor Cyanosis Decreased consciousness

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19
Q

What is the management of croup and where should patients be managed?

A

Single dose oral dexamethasone 0.15mg/kg Paracetamol/ibuprofen for pain Mild- home Moderate/severe- hospital admission

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20
Q

In which circumstances would you admit a child with mild croup?

A

<3 months Inadequate oral fluids Chronic lung disease Congenital heart disease NM disease Immunodeficient

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21
Q

How long does croup normally last?

A

48 hrs

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22
Q

What is the most common causative organism for croup?

A

Parainfluenza viruses

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23
Q

What is the most common causative agent of bronchiolitis?

A

RSV

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24
Q

What are the symptoms of bronchiolitis?

A

Coryzal prodrome 1-3d Persistent cough Tachypnoea/recession Wheeze/crackles Fever (<39 usually) Poor feeding Apnoea

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25
Q

How long does bronchiolitis usually last?

A

3-7d, cough 3 weeks

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26
Q

What is the management for bronchiolitis?

A

Self-care Paracetamol/ibuprofen if distressed by fever Oral fluids

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27
Q

What is the vaccination for bronchiolitis called and who receives it?

A

Palivizumab SCID/premature/chronic lung disease/congenital heart disease

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28
Q

What would prompt referral of a child with bronchiolitis to hospital?

A

O2 <92% RR >70 Cyanosis Apnoea Respiratory distress (grunting/severe recession)

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29
Q

What is the management of CAP?

A

CURB 0-1 amoxicillin 500mg TDS for 5d CURB1-2 consider adding clarithromycin 500mg BD 7-10d

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30
Q

What is the main cause of CAP?

A

Strep pneumoniae

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31
Q

What is required to diagnose pneumonia?

A

Cough + 1 of: sputum/wheeze/SOB/pleuritic pain + systemic feature (fever, myalgia, sweats) +/- temp >38

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32
Q

What is CURB65?

A

Scoring system for pneumonia C- new confusion U- urea >7 R- RR>30 B- BP <90 systolic or <60 diastolic 65- Over 65yrs of age

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33
Q

What follow up is needed after pneumonia?

A

Repeat CXR in 6/52

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34
Q

What are the complications of pneumonia?

A

Pleural effusion Empyema Lung abscess Sepsis Systemic infection

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35
Q

What is pneumoconiosis?

A

Restrictive lung disease Coal workers- 15-20yr lag

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36
Q

What would show a restrictive pattern on spirometry plus opacities on CXR?

A

Pneumoconiosis

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37
Q

What are the symptoms of pneumoconiosis?

A

Breathlessness on exertion Cough +/- Black sputum

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38
Q

What is the pathophysiology of pneumoconiosis?

A

Coal dust inhaled, reaches terminal bronchioles and engulfed by alveolar and interstitial macrophages. The dust is removed from the body as mucus. With many years of exposure, system is overwhelmed and macrophages accumulate in alveoli causing immune response and damage to lung tissue.

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39
Q

What is the safe triangle for chest drain insertion?

A

The triangle is located in the mid axillary line of the 5th intercostal space. It is bordered by: Anterior edge latissimus dorsi, the lateral border of pectoralis major, a line superior to the horizontal level of the nipple, and the apex below the axilla.

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40
Q

Features of klebsiella pneumonia

A

Red-currant jelly sputum Cavitations Often affects upper lobes More common in alcoholics/diabetics May occur following aspiration

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41
Q

Features of lung Ca

A

Peristent cough Haemoptysis Dyspnoea Chest pain Weight loss Anorexia

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42
Q

Lung Ca exam findings

A

fixed monophonic wheeze Supraclavicular/cervical lymphadenopathy Clubbing

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43
Q

Spirometry for COPD

A

FEV1/FVC less than 0.7

44
Q

MRC dyspnoea scale

A

Grade 1: breathless only on strenuous exertion Grade 2: SOB when hurrying on level ground/slight incline Grade 3: walks slower than contemporaries due to breathlessness or has to stop for breath at own pace Grade 4: stops for breath after 100m/few minutes of walking Grade 5: breathless on dressing/undressing, too breathless to leave house

45
Q

COPD severity

A

1- mild, FEV1 >80% predicted 2- moderate, FEV1 50-79% predicted 3- severe, FEV1 30-49% predicted 4- very severe, FEV1 <30% predicted or <50% with respiratory failure

46
Q

COPD symptoms

A

Exertional breathlessness Cough (chronic) Wheeze Regular sputum production Recurrent chest infections Others; weight loss, exercise intolerance, ankle swelling, fatigue

47
Q

Signs on examination for COPD

A

Cyanosis Raised JVP Cachexia Pursed lip breathing Hyperinflated chest Use of accessory muscles Wheeze or quiet breath sounds Peripheral oedema

48
Q

Features of cor pulmonale

A

Sx/signs are due to back up of blood:

Fatigue, SOB, fainting

Peripheral oedema

Raised JVP

Hepatomegaly

Systolic parasternal heave

Loud pulmonary second HS (over 2nd left intercostal space)

Widened descending pulmonary artery on CXR

Right ventricular hypertrophy on ECG

49
Q

Investigations for COPD

A

Post bronchodilator spirometry CXR FBC (check for anaemia/secondary polycythaemia) +/- pulse oximetry, ECG, sputum culture

50
Q

Fundamentals of COPD care

A

Stop smoking Pneumococcal and influenza vaccines Pulmonary rehab Optimise co-morbidities

51
Q

Asthmatic features/features of steroid responsiveness

A

Previous asthma/atopy High eosinophil count Substantial FEV1 variation (at least 400ml) Diurnal variation in peak flow (at least 20%)

52
Q

Indications for long-term oxygen therapy in COPD

A

Oxygen saturation 92% or less FEV1 less than 30% Cyanosis Secondary polycythaemia Peripheral oedema Raised JVP

53
Q

Treatment for acute exacerbation of COPD

A

Oral prednisolone 30mg OD 7-14d Oral amoxicillin 500mg TDS 5d (or dox 200mg first day then 100mg for 4 more days)

54
Q

Indications for admission in acute exacerbation of COPD

A

Severe breathlessness, rapid onset of symptoms, acute confusion, cyanosis, worsening peripheral oedema, impaired consciousness Unable to cope or lives alone Reduction in activities, confined to bed, or on long-term oxygen Significant comorbidity Oxygen saturation less than 90%

55
Q

Definition of end-stage COPD

A

FEV1 less than 30% predicted/MRC dyspnoea scale grade 4/5 and unresponsive to medical treatment and life expectancy of less than 6-12 months

56
Q

Drug treatment for breathlessness in end-stage COPD

A

Opioid first line (immediate release oral morphine) Benzodiazepines (diazepam, lorazepam or midazolam) Short burst oxygen therapy

57
Q

Complications of COPD

A

Disability and impaired quality of life Depression and anxiety Cor pulmonale Frequent chest infections Secondary polycythaemia Type II respiratory failure Lung cancer

58
Q

Chronic Bronchitis

A

Chronic cough with mucus for at least three months for two consecutive years Shortness of breath which can become worse with exercise

59
Q

Emphysema

A

Dilation/destruction of lung parenchyma Mild cough, severe constant dyspnoea

60
Q

Symptoms of asthma

A

Wheeze- widespread, bilateral, predominantly expiratory Breathlessness Chest tightness Cough Worse at night/early morning Associated with exercise/cold air/allergens/NSAIDs/beta blockers

61
Q

Investigations for asthma

A

FeNO testing (those over 17yrs) Spirometry (all over 5yrs) - FEV1/FVC <0.7 Bronchodilator reversibility (all over 17, consider in ages 5-16)- FEV1 improvement of 12% or more + increase in volume of 200ml Peak flow- if diagnostic uncertainty

62
Q

Positive FeNO level in steroid-naive adults

A

40 ppb

63
Q

To dx asthma you need

A

Postive FeNO + bronchodilator reversibility or peak flow variability or bronchial hyperreactivity

64
Q

Asthma management (according to NICE)

A

1) SABA alone 2) low dose ICS (if use SABA >3/week or sx 3/week or woken at night 1/week) 3) consider LTRA 4) Add LABA 5) MART (maintainer and reliever) regimen with low dose ICS 6) Increase dose of ICS

65
Q

Asthma management for ages 5-16 according to NICE

A

1) SABA 2) low dose ICS 3) LTRA 4) stop LTRA, add LABA 5) MART 6) increase dose ICS

66
Q

Salbutamol and terbutaline are…

A

SABAs

67
Q

Salmeterol and formetorol are…

A

LABAs

68
Q

Budesonide, beclometasone, ciclesonide, fluticasone and mometasone are

A

Inhaled corticosteroids

69
Q

Montelukast and zafirlukast are…

A

LTRAs

70
Q

Ipratropium bromide and tiotropium are

A

Muscarinic agents Ipratropium- SAMA Tiotropium- LAMA

71
Q

Hx for near drowning

A

Mechanism and duration of submersion Type/temperature of water Time until CPR Time to first spontaneous breath Time to return of spontaneous cardiac output Vomiting Likelihood of associated trauma Other precipitants e.g. Arrythmia, MI, seizure, non-accidental

72
Q

Examination in near drowning

A

Temp, O2 sats Cardiac rhythm Respiratory pattern Any evidence of pulmonary oedema Head/neck injuries Intra-abdominal/thoracic injuries (if fall from height) Neurological status

73
Q

Investigations for near drowning

A

ECG- check for ischaemia, J waves= hypothermia Bloods- ABG, U&Es, glucose, osmolarity, alcohol level, FBC, LFTs, coag, cultures CXR +/- C-spine/CT head

74
Q

Treatment of near drowning

A

Resuscitation + intubation if needed Oxygen Treat hypothermia, hypoglycaemia, seizures, hypovolaemia and hypotension if they occur NG tube +/- catheter May need CPAP, PEEP or ECMO If awake/alert, observe for at least 6hrs

75
Q

Acute onset severe sore throat and fever

Muffled voice

Drooling

Stridor

A

Epiglottitis

76
Q

Management of epiglottitis

A

Usually IV or oral antibiotics

Intubation may be needed

Tracheostomy if intubation not possible

77
Q

Catarrhal phase- malaise, conjunctivitis, nasal discharge, sore throat, dry cough, mild fever for 1-2 weeks

At least 2 weeks of paroxysmal cough (dry, hacking) associated with whoops or post cough vomiting

Convalescent phase- may last additional 2 months, gradual improvement in sx

A

Whooping cough (pertussis)

78
Q

If suspicious of whooping cough, you need to…

A

Send a notification form to PHE within 3 days

79
Q

Management of whooping cough

A

Admit if unwell

Macrolide antibiotic e.g. clarithromycin, azithromycin, erythromycin

Rest, fluid intake, paracetamol/ibuprofen

Children/HC workers to stay off until 48hr abx

Close contacts may need prophylactic abx

80
Q

Define empyema

A

Collection of pus in the pleural space

81
Q

Causes of empyema

A

Pneumonia (not treated fully)

Bronchiectasis

Pulmonary infarct

Surgery/endoscopy

Chest injury

TB

82
Q

Symptoms of empyema

A

Fever

Night sweats

Fatigue

Difficulty breathing

Weight loss

Chest pain

Cough, coughing up mucus

83
Q

Management of empyema

A

Chest drain

Antibiotics

+/- fibrinolytics and DNase’s

84
Q

Definition of OSA

A

A clinical condition in which there is intermittent and repeated upper airway collapse during sleep. This results in irregular breathing at night and excessive daytime sleepiness.

85
Q

Symptoms suggestive of OSA

A
  • Excessive daytime sleepiness.
  • Impaired concentration.
  • Snoring.
  • Unrefreshing sleep.
  • Choking episodes during sleep.
  • Witnessed apnoeas.
  • Restless sleep.
  • Irritability/personality change.
  • Nocturia.
  • Decreased libido.
86
Q

Assessment and management of OSA

A

Epworth scale- if >10 investigations recommended

Polysomnography to dx, >5 apnoeas is mild

Management:

Lifestyle- weight loss, smoking cessation, avoid evening alcohol, sleep on side. Assess CV risk and diabetes, regular monitoring of BP.

CPAP- need to wear for minimum 4hr/night. Maintains patency of upper airway.

intraoral devices

87
Q
A
88
Q

Cor pulmonale and its pathophysiology

A

Cor pulmonale is right sided heart dysfunction caused by lung dysfunction

Can lead to right heart failure

Pathophysiology:

Lung dysfunction leads to hypxoia, resulting in hypoxic vasoconstriction, which increases resistance and leads to pulmonary hypertension.

In chronic lung disease, this causes right ventricular hypertophy which results in less ventricular space and therefore diastolic failure. The thickened muscle increases oxygen demand which leads to ischaemia and systolic failure.

89
Q

Treatment for cor pulmonale

A

LTOT/NOT if sats <88%

Diuretics e.g. furosemide for oedema

90
Q

PE risk factors

A

DVT

Previous DVT/PE

Active cancer

Recent surgery

Lower limb trauma

Recent immobilsation

Pregnancy/6 weeks postpartum

COCP/HRT

Thrombophilia

Long distance travel

Obesity

Increasing age

91
Q

Clinical features/signs of PE

A

Symptoms:

  • Dyspneoa
  • Chest pain
  • Cough
  • Haemoptysis
  • DVT (lef pain and swelling)
  • Lower abdo pain
  • Redness
  • Increased temperature
  • Dizziness
  • Syncope

Tachycardia

Hypoxia

Pyrexia

Raised JVP

Gallop rhythm

Pleural rub

Hypotension

Shock

92
Q

Investigations for PE

A

2 level Wells score:

  • <4 = PE unlikely. Do D-dimer. If raised do CTPA.
  • 4+ = PE likely. Do CTPA. If delay give LMWH or fondaparinux.

If unprovoked, need investigations for possible malignancy incl:

  • Hx/examination
  • CXR
  • Bloods incl. FBC, Calcium, LFTs
  • Urinalysis
  • Consider referral for further investigationswith CT if >40 and above normal
  • Consider antiphospholipid testing
  • Consider thrombophilia testing if 1st degree relative has had PE/DVT
93
Q

Management of PE

A

Initial resuscitation: O2, IV access, analgesia if required, assess circulation

Anticoagulation with LMWH/fondaparinux for at least 5d or until INR is 2 or more for at least 24hr

(or unfractionated heparin if increased bleeding risk/CKD)

Thrombolysis e.g. rt-PA if massive PE

Mechanical intervention e.g. IVC filters (if cannot have anticoagulation or recurrent PE despite anticoag)

Long Term:

3 months anticoagulation for unprovoked (with warfarin/NOAC)

6 months if provoked

94
Q

ECG signs in PE

A

sinus tachycardia
non-specific ST-segment and T-wave abnormalities
right axis deviation
incomplete or complete RBBB
T-wave inversion in leads V1–V3
P pulmonale
classical S1, Q3, T3 (S wave in lead 1, Q wave in lead 3, and T-wave inversion in lead 3).

95
Q

CXR signs in PE

A

atelectasis, pleural effusion, or elevation of a hemidiaphragm

96
Q

Light criteria for pleural effusion- differentiates transudates and exudates if pleural fluid proteinis 25-35g/L

A

Measure LDH and protein in pleural fluid and serum

Fluid is considered exudative if one of the following criteria is present:

Pleural fluid-to-serum protein ratio >0.5; or

Pleural fluid-to-serum LDH ratio >0.6; or

Pleural fluid LDH >2/3rds upper limit of normal for serum LDH

97
Q

Symptoms of pleural effusion

A

SOB

Cough

Pleuritic chest pain

Features of malignancy

98
Q

Investigations for pleural effusion

A

CXR 1st line

US (more sensitive, detects small effusions)

CT/MRI

Pleural fluid analysis (if exudative need to do this)

99
Q

Pleural fluid analysis

A
  • Transudate vs exudate
  • Bloody?- causes are malignancy, PE with infarct, trauma, asbestos
  • If bloody measure haematocrit ?haemothorax
  • pH. low= infection, rheumatoid, SLE, TB, malignancy, oesophageal rupture
  • Cytology
  • Cholesterol/triglycerides- chylothorax triglyceride >1.24, cholesterol <5.18
  • Glucose- low glucose in empyema, rheumatoid, SLE, TB, malignancy, oesophageal rupture
  • Differential WCC- lymphocytosis in malignancy and TB
100
Q

Management of plueral effusion

A

Treat underlying cause

Pleural tap/chest drain

Pleurodesis if malignant effusion

101
Q

Definition of pneumothorax

A

collection of air in the pleural cavity (between the lung and the chest wall) resulting in collapse of the lung on the affected side

102
Q

Types of pneumothorax

A

Primary (spontaneous)

Secondary- associated with underlying lung disease

Traumatic

Tension- emergency

Iatrogenic

103
Q

Treatment for tension pneumothorax

A

Large bore needle/cannula into pleural space through 2nd intercostal space in the mid-clavicular line

Oxygen

104
Q

Symptoms and signs of pneumothorax

A

Symptoms — collapse, sudden-onset pleuritic pain, breathlessness.

Signs — reduced chest wall movements, reduced breath sounds, reduced vocal fremitus, and increased resonance of the percussion note on the affected side.

Tension pneumothorax can result in a rapid development of severe symptoms associated with tracheal deviation away from the pneumothorax, tachycardia, and hypotension.

105
Q

Investigations and management of pneumothorax

A

Investigations:

  • CXR
  • CT if uncertain/complex case
  • ABG (if O2 sats <92%)

Management:

Secondary pneumothorax- admit, observe, O2

Primary- if asymptomatic and small, discharge. If breathless- needle aspiration (14-16G), or chest drain if large

Pleurodesis if recurrent

106
Q
A

PA (12 decks)

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