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Respiratory Flashcards

1
Q

Respiratory causes of clubbing

A
  1. Idiopathic pulmonary fibrosis
  2. Lung cancer
  3. Suppurative lung diseases - cystic fibrosis, bronchiectasis, lung abscess
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2
Q

Causes of pulmonary fibrosis

A
  1. Idiopathic - CLUBBED!
  2. Drug induced
  3. Occupational lung disease
    - coal miner’s lung: simple pneumoconiosis + progressive massive fibrosis
  4. Associated with systemic disease
  5. Extrinsic allergic alveolitis
  6. Granulomatous disease - TB, sarcoid
  7. Radiotherapy
  8. Chemicals - steel, lead, paraquat
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3
Q

Systemic diseases that are associated with pulmonary fibrosis

A

All lower zone fibrosis EXCEPT Ank Spond

  • RA
  • And Spond
  • Sjogrens
  • UC
  • Autoimmue thyroid disease
  • Polymyositis
  • Dermatomyositits
  • Systemic sclerosis
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4
Q

Drugs that cause pulmonary fibrosis

A
  1. Immunosuppression:
    - MTX
    - Cyclophosphamide
    - Sulphasalazine
  2. Cardiac:
    - Amiodarone
  3. Antibiotics
    - Nitrofurantoin
  4. Chemotherapy
    - Bleomycin
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5
Q

Different types of extrinsic allergic alveolitis

A
  • Farmer’s lung
  • Bird fancier’s lung
  • Mushroom lung
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6
Q

Caplan’s syndrome

A

Coal miner’s lung + rheumatoid nodules

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7
Q

Clinical features of Sarcoidoisis by system

A
  1. Resp
    - bilateral hilar lymphadenopathy
    - pulmonary fibrosis
  2. Skin
    - erythema nodosum
    - lupus pernio
    - cutaneous sarcoid
  3. Ophthal
    - anterior uveitis
    - keratoconjunctivitis sicca
  4. Cardiac:
    - conduction issues - ECG!!
  5. Endocrine:
    - hypercalcaemia
  6. Neuro:
    - bilateral facial nerve palsies
    - psychosis
  7. GI:
    - hepatosplenomegaly
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8
Q

5 causes of cavitating lung lesions

A 
Cancer
Autoimmune e.g. granulomatosis with polyangiitis
Vasculitis
Infection - TB, staph, klebsiella
Sarcoid
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9
Q

Causes of lower zone fine inspiratory crackles

A 
Idiopathic pulmonary fibrosis
Pulm fibrosis secondary to systemic conditions
- RA
- sjogrens
- granulomatosis with polyangiitis
- SLE
- polymyositis/dermatomyositis
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10
Q

Causes of middle zone fine inspiratory crackles

A

Progressive massive fibrosis

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11
Q

Causes of upper zone fine inspiratory crackles

A 
TB
Ank Spond
Radiotherapy
Sarcoid
Extrinsic allergic alveolitis
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12
Q

Causes of expiratory wheeze

A 
Small Airway disease:
Asthma
COPD
Churg-strauss (eosinophilic granulomatosis with polyangiitis)
Aspirin 
Viral wheeze

Large airway disease
Epiglottitis
Foreign object

Pulmonary oedema

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13
Q

Causes of obstructive airway disease

A 
COPD
Asthma
CF
Bronchiectasis
Alpha 1 anti-trypsin deficiency
Obliteran bronchiolitis - follows lung transplantation with graft versus host disease, follows viral illness
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14
Q

7 classes of causes of bronchiectasis

A
  1. Genetic - cystic fibrosis
  2. Post infection
  3. Immune deficiency
  4. Mucociliary clearance abnormalities - primary ciliary dyskinesia
  5. Toxins - aspiration, inhalation
  6. Mechanical insults - foreign body, extrinsic lymph node compression intrinsic obstructing tumour
  7. Systemic disease associations
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15
Q

5 post infectious causes of bronchiectasis

A
  1. TB
  2. Whooping cough
  3. Severe pneumonia
  4. Non TB mycobacterium
  5. Allergic bronchopulmonary aspergillosis
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16
Q

2 immune deficiency causes of bronchiectasis

A
  1. Primary - hypogammaglobinuaemia
  2. Secondary
    - HIV
    - CLL
    - Nephrotic syndrome
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17
Q

Primary ciliary dyskinesia - 6 features

A
  1. Autosomal recessive
  2. Situs invertus = Kartagener’s syndrome
  3. Persistent wet cough
  4. Hearing deficits
  5. Clubbing
  6. Infertility
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18
Q

6 systemic diseases associated with bronchiectasis

A
  1. SLE
  2. RA
  3. Sjogren’s
  4. Marfan’s
  5. IBD
  6. Chronic sinusitis
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19
Q

Bronchiectasis - further investigations

A
  1. CXR
  2. HRCT
  3. Sputum MC+S - specifically looking for S aureus, pseuomonas, haemophilus
  4. Serum Ig
  5. Sweat test
  6. Autoimmune antibody screen - anti-CCP, ANA, anti-Ro and anti-La
  7. Nasal brushings- Kartenger’s syndrome
  8. Tuberculin skin test, early morning
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20
Q

Clinical findings COPD

A 
End of bed:
- SOB
- wheeze
- inhaler
Hands:
- NO clubbing
- tar stained fingers
- CO2 retention flap (acutely unwell)
- bounding pulse (CO2 retention)
- peripheral cyanosis
Arms:
- nicotine patch
- brusing secondary to long term steroid use
Neck:
- raised JVP if cor pulmonale
Face:
- cushing secondary to steroids
Mouth;
- central cynaosis
- oral candiasis secondary in ICS
- pursed lips
Chest inspection
- hyperinflated chest
- use of accessory muscles
- tracheal tug
Chest percussion
- hyper-resonate
- reduced hepatic + cardiac dullness
Chest ausculation
- prolonged expiration 
- polyphonic wheeze
- course crackles
Legs
- pedal oedema secondary to Cor Pulmonale

Extra:
Features of Cor Pulmomale - raised JVP, tricuspid regurgitation, peripheral oedema, hepatomegaly + pulsatile
Steroid use: cushing, bruising, buffalo hump, moon face

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21
Q

COPD - investigations

A

CXR
Sputum MC+S
Peak flow
Spirometry
- obstructive picture without reversibility
Alpha 1 anti-trypsin levels
Bloods - FBC (polycythaemia), albumin (chronic disease)

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22
Q

Smoking cessation options

A
  1. Behavioural treatment
  2. Nicotine replacement therapy including vaping
  3. Buproprion
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23
Q

COPD treatment

A
  1. Stop smoking
  2. Inhalation therapies
    - beta agonist - short acting + long acting
    - antimuscurinic - short (ipratropium) + long (tiotropium)
    - steroid
  3. Mucolytics
  4. Oral steroids
  5. Theophylline
  6. LTOT
  7. Pulmonary rehab
  8. NIV
  9. Surgery - lung reduction to remove bullae
  10. Lung transplant
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24
Q

Clinical findings bronchiectasis

A 
End of bed:
- SOB
- productive cough
- cachetic 
Hands:
- clubbing
- cyanosis
- bruising secondary steroids
- rheumatoid hands
- tar staining --> lung cancer --> bronchiectasis
Arms:
- bruising
- PICC line - long term Abx
Neck:
- raised JVP 2nd to Cor Pulmonale
- lymphadenopathy 2nd leukaemia/HIV
Face:
- periorbital oedema - Nephrotic syndrome
- moon face --> cushing --> steroid use
- Horner's syndrome (meiosis, ptosis, anhydrosis) --> lung cancer 
Mouth:
- high arched palate - Marfan's
- ulcers - IBD
- angular stomatitis --> B12 deficiency --> IBD
Chest inspection:
- thoracoomy --> lung Ca, lung abscess
- hyperexpanded
Chest percussion
- hyper-resonant
Chest ausculation
- inspiratory crackles - course, late
- expiratory wheeze
Heart sounds
- Dextrocardia!
25
Q

Congenital causes of bronchiectasis

A
  1. Cystic fibrosis
  2. Yellow nail syndrome - yellow nails, pleural effusion, lymphoedema
  3. Kartenger’s syndrome
    Young’s syndrome - similar to CF but no CF mutation - appears in middle aged men
26
Q

Management of CF

A

General measures:

  1. Optimize nutrition
    - calorie supplement
    - pancreatic enzyme
  2. Stop smoking
  3. Vaccinations
  4. Sputum clearance physiotherapy

Medical treatment:

  1. Antibiotics - cover pseudomonas
    - may need prophylactic
  2. Bronchodilators
  3. Inhaled steroids
  4. Mucolytics
  5. Genetic treatment - introduction of normal CFTR gene
27
Q

Pathogenesis of CF

A

Mutation in CFTR gene - loss of chloride movement across cell membranes - raises osmotic pressure inside cells keeping extracellular space dehydrated - thick mucous production

28
Q

Which system affected by CF

A
  1. Respiratory
  2. Endocrine pancreas - type 1 diabetes
  3. Exocrine pancreas - malabsorption
  4. Focal biliary cirrhosis
29
Q

Complications of bronchiectasis

A

Pulmonary

  1. Haemoptysis
  2. Recurrent infections
  3. Empyema/abscess
  4. Cor pulmonale

Extra-pulmonary

  1. Metastatic infections
  2. Anaemia
  3. Secondary amyloidosis
30
Q

Old TB clinical findings

A

End of bed:
- not SOB

Hands:
- not clubbed

Arms:
- nil

Neck:
- supra-clavicular scar from phrenic crush

Face:
- nil

Mouth;
- nil

Chest inspection

  • thoracotomy scars
  • rib resections
  • chest deformity
  • tracheal deviation TOWARDS side of thoracotomy scar
  • reduced expansion on side of resection

Chest percussion
- dullness to percuss over resection

Chest ausculation
- bronchial breathing over resection site
- fine end inspiratory crepitations due to fibrosis
OR course inspiratory crackles due to bronchiectasis

EXTRA
- kyphosis may be sign of spinal TB (Pott’s disease)

31
Q

TB investigations

A
  1. CXR
  2. HRCT
  3. Sputum for Ziehl-Neelson staining - acid fast bacilli. Need 3 samples
  4. Early morning urine for AFB - x3 consecutive samples
  5. Mantoux test
    - injection of TB - assess for type 4 hypersensitivity
    FALSE negatives in immunosuppressed
  6. HIV test
  7. Bronchoscopy for BAL
32
Q

TB risk factors

A
  1. Place of birth
  2. Age
  3. HIV
  4. Homeless
  5. Sex worker
  6. Co-morbidities e.g. diabetes
  7. Immunosuppression - anti-TNF medications
33
Q

Pulmonary fibrosis - investigations

A
  1. Laboratory:
    - ABG - hypoxia + hypocapnia (secondary to hyperventilation
    - Eosinophilia - Eosinophilic granulomatosis with polyangiitis
    - ANA —> SLE
    - anti-CCP/RA –> RA
    - anti-centromere antibody –> limited systemic sclerosis
    - anti-Scl 70 –> diffuse systemic sclerosis
    - anti Jo1 –> dermatomyositis
    - serum immunoglobulins –> bronchiectasis secondary to immunoglobulin deficiency (primary or secondary), IgE for ABPA
    - serum ACE –> sarcoid
    - CK –> myositis
  2. Functional tests
    - lung function tests with diffusion capacity
    - -> restrictive pattern with reduced diffusion capacity (indicates loss of alveolar function)
    - 6 minute walk test
  3. Radiological
    - HRCT
  4. Echo
    - assess pulmonary artery pressures
  5. Bronchoscopy
    - BAL +/- biopsy
34
Q

What is Hammah Rich Syndrome

A

Acute rapidly progressive lung fibrosis also known as acute interstitial pneumonia

35
Q

Rheumatoid arthritis pulmonary manifestations

A
  1. Rheumatoid nodules
    - mainly asymptomatic
    - can become infected
  2. Pleurisy/pleural effusions
    - RF +ve effusions
  3. Fibrotic lung disease
    - lower zone
36
Q

Clinical features of pleural effusion

A 
End of bed:
- SOB
- cachetic ?malignancy
- cough
Hands:
- malignancy: clubbing, tar stains, wasting of small muscles of hand (pancoast tumour - T1 paralysis)
- RA: rheumatoid hands.
Arms:
- dialysis access 
Neck:
- raised JVP - SVCO obstruction, heart failure
- lymphadenopathy - if present then palpate for axillary LNs
- goitre: hypothyroidism
- dialysis access

Face:

  • SLE - butterfly rash
  • peri-orbital oedema –> nephrotic syndrome

Mouth;
- mucositis - on chemo

Chest inspection

  • radiotherapy tattoos
  • mastectomy
  • spider naevi - hypoalbuminaemia secondary to liver disease
  • trachea deviated away from effusion (large volumes)
  • reduced chest expansion

Chest percussion
- dull to percuss

Chest ausculation

  • reduced air entry +/- crackles
  • reduced vocal resonance
37
Q

Define Light’s criteria for pleural effusion

A

Exudative effusion if one of the following:

  1. Pleural protein: serum protein >0.5
  2. Pleural LDH: pleural LDH >0.6
  3. Pleural LDH >0.6 or 2/3 of normal upper limit of serum LDH
38
Q

Caveats with Lights criteria and further calculation to perform

A

20-25% of patients with transudative effusions diagnosed as exudates

If you think patient has transudate i.e. has CCF but Lights criteria is positive for exudate then perform following calculation:
serum albumin - pleural albumin
if >1.2g/dL then = transudate

39
Q

Management of pleural effusion

A
  1. Supportive
    - oxygen
  2. Treat underlying cause
    - antibiotics
    - diuretics
  3. Pleural drainage under USS guidance
  4. Pleurodesis if recurrent
    - medical via pleural drain
    - surgically via VATS
  5. Long term pleural drain i.e. malignancy
  6. Pleural-peritoneal shunt
40
Q

Pleural effusion classifications

A
  1. Transudate
  2. Exudate
  3. Haemothorax
  4. Chylothorax
  5. Empyema
  6. Drug induced pleural effusions
41
Q

Drugs that can cause pleural effusion

A
  1. Drugs associated with drug-induced lupus e.g. quinidine, procainamide, anti-TNF,
  2. Dopamine agonist - bromocriptine
  3. DMARDS e.g. MTX
  4. Anti-migraine - methysergide
  5. Antibiotics - nitrofurantoin
  6. Chemotherapy - procarbazine
42
Q

3 types of pneumothorax

A
  1. Traumatic
  2. Spontaneous
    - primary (no lung disease) - tall young men, Marfan’s
    - secondary (lung disease) - COPD, asthma
  3. Tension pneumothorax
43
Q

Obesity hypoventilation syndrome/Pickwickian syndrome

- 3 components

A
  1. Obstructive sleep apnoea
  2. Hypercapnia
  3. Restrictive pulmonary function test
44
Q

Clinical features of Pickwickian syndrome

A 
End of bed:
- obese
-dyspnoeic
- sleepy
- shallow breathing
Hands:
- nil obvious
Arms:
- check for raised BP
Neck:
- large neck circumference
- raised JVP secondary to pulmonary hypertension
Face:
- facial plethora - due to secondary polycythaemia
Mouth;
- maxillary/mandibular hypoplasia
- crowded oropharynx
Chest inspection
- features of pulmonary hypertension with heart failure

Chest percussion
- features of pulmonary hypertension with heart failure

Chest ausculation
- features of pulmonary hypertension with heart failure

45
Q

Complications of direct lung cancer extension

A
  1. Hoarse voice - recurrent laryngeal nerve palsy
  2. Stridor - tracheal invasion
  3. Horner’s syndrome + weakness/atrophy of intrinsic small muscles of hand - Pancoast tumour invading in to paravertebral sympathetic chain
  4. Superior vena cava obstruction
46
Q

Paraneoplastic malignancy syndromes by system

A
  1. MSK
    - Hypertrophic pulmonary osteoarthropathy
    - Polymyositis
  2. Neurological
    - Lambert Eaton myasthenic syndrome - associated with small cell lung cancer
    - Proximal myopathy
    - Cerebellar syndrome
    - Peripheral neuropathy
  3. Endocrine
    - Hypercalcaemia
    - SIADH
    - Ectopic ACTH secretion –> cushing’s, pigmentation.
  4. Dermatological
    - Thrombophlebitis migrans
    - Acanthosis nigrans
    - Dermatomyositis
47
Q

Superior vena cava obstruction - Clinical findings

A

End of bed:

  • SOB
  • hoarse voice - tumour invasion in to recurrent laryngeal nerve
  • stridor - tumour invasion into upper airway
  • cachectic

Hands:

  • clubbing - cancer
  • tar stains - smoking –> cancer
  • wasting of small muscles of hand –> pancoast tumour

Arms:
- ?PICC line - on chemo

Neck:

  • Fixed raised JVP
  • distended superficial neck veins

Face:

  • facial plethora
  • odematous
  • suffusion of eyes
  • PEMBERTON’S SIGN* - symptoms get worse if raise arms above head

Mouth;
- nil obvious

Chest inspection

  • thoracotomy scars
  • radiotherapy tattoos
  • engorged chest veins
  • mastectomy

Chest percussion
- ?pleural effusion/dullness

Chest ausculation
- crackles/reduced air entry etc ?cancer ?lung resection ?previous radiotherapy

48
Q

Common causes of SVCO

A

Right lung pathology

  • lung cancer
  • lymphoma

Lymph nodes

  • metastatic LNs
  • primary lymphoproliferative diseases

Mediastinal pathology:

  • thymoma
  • mediastinal germ cell cancers
  • thoracic artery aneurysm

SVC intrinsic pathology
- stenosis or thrombosis following central line, pacemaker lines, etc

49
Q

Management of SCVO

A
  1. ABC
  2. Steroids in malignancy
  3. SCVO stenting under IR
  4. Radiotherapy
  5. Chemo if chemo sensitive i.e. small cell, lymphoma
50
Q

Thoracotomy scars - clues for underlying diagnosis

A
  1. Old TB - Phrenic nerve crush scar - supraclavicular
  2. Lung cancer - clubbing, tar stains, inhaler for COPD, radiotherapy tattoo, radiotherapy burns.
  3. Bronchiectasis - clubbing, sputum pot, productive cough, coarse crackles
51
Q

Reasons to perform a pneumectomy or lobectomy

A
  1. Resection of malignancy
    - primary NSCLC
    - solitary metastases
  2. Infections:
    - Old TB - prior to modern anti-TB medications
    - Aspergilloma
  3. Bullectomy for large empyseamtous bullae
  4. Localised bronchiectasis with uncontrolled symptoms e.g. haemoptysis
52
Q

Treatment of asthma

A

Step wise approach as per BTS

  1. Inhaled short acting beta 2 agonist
  2. Inhaled steroids
  3. Inhaled steroids + long acting beta 2 agonist
  4. Leukotriene antagonist - montelukast
53
Q

Differentiate between asthma and COPD

A
  1. Smoking history
  2. Spirometry - reversibility of obstructive picture
    - change in PEF and/or FEV1 in response to inhaled beta 2 agonist
    - 200ml change in FEV1 or 15% change in comparison to baseline
  3. Age
54
Q

Investigations for asthma

A
  1. Bloods - eosinophil count and IgE level
  2. Peak flow diary looking for diurnal variation
  3. Spirometry - obstructive picture (decreased FEV1 and preserved FVC with reduced ratio <0.8) that is reversible
55
Q

Benefits of VATS over thoracotomy

A
  1. Reduced pain
  2. Reduce healing time
  3. Reduced hospital length of stay
56
Q

FVC limits for 1) lobectomy 2) pneumonectomy

A

1) >1.5L 2) >2L

57
Q

Lung transplant clinical findings

A
  1. Clam shell scar
  2. Multiple chest drain site
  3. Possible tracheostomy scars
  4. CVC scars
58
Q

Indications for lung transplant

A
  1. Bronchiectasis
  2. Idiopathic lung fibrosis
  3. Pulmonary vascular disease
  4. COPD
59
Q

Complications of lung transplant

A

Rejection (acute and chronic) including bronchiolitis obliterans syndrome
Infection e.g. CMV, HSV, aspergillus, PCP, bacterial pneumonia
Immunosuppression therapy side effects

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