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MRCP > Respiratory > Flashcards

Respiratory Flashcards

1
Q

Lights criteria

A

Pleural:serum protein >0.5

Pleural:serum LDH >0.6

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

GLUCOSE NOT USED

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2
Q

Lung volumes -typical values

A

TV - 500ml M and 359ml F - vol inspired and expired at normal breathing at rest

IRV 2-3L - total vol inspired at end of normal tidal insp

ERV - 750ml - max vol of air expired at end of normal
Tidal resp

RV 1.2L - vol air remaining in lungs after max expiration - increases with age

VC - 4,500 M and 3,500 F - max vol air expired after max inspiration - decreases with age - = inspiratory capacity + ERV

TLC = viral capacity + residual Vol

Physiological dead space = TV* (PaCO2 - PeCO2/PaCO2)

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3
Q

Bilateral
Hilar LN
- Please Helen Lick My Popsicle Stick

A 
-p-rimary TB
H-istioplasmosis
L-ymphoma
M- Malignancy/Mets
P- pneumocnoiosis 
S- Sarcoid

Fungi - histoplasmosis and coccidiodimycosis

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4
Q

COPD - LTOT

A

Assess if:

  • FEV1 <30% (consider between 30-40)
  • cyanosis
  • polycythaemia
  • peripheral oedema
  • Raised JVP
  • 02
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5
Q

Indications for chest tube insertion in pleural infection

A
  • frankly purulent or turbid/cloudy fluid
  • presence of organisms on Gstain or culture
  • pleural fluid pH <7.2
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6
Q

Pleural effusion protein levels

A

<25 - transudateb

> 35 - exudate

Between 25–35 —> lights criteria

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7
Q

Smoking cessation

A
  • NRT, vareniciline Or bupropion

NRT:

  • s/e - N/V, headaches, flu like symptoms.
  • prescribe 2 weeks

Vareniciline:

  • nicotinic receptor PARTIAL agonist
  • 3/4 weeks
  • start 1 week before due to stop.
  • nausea/headaches/ insomnia / vivid dreams
  • DONT USE IF DEPRESSION
  • DONT USE IF PREG OR BREASTFEEDING

Bupropion:

  • norepinephrine and dopamine reuptake inhibtor.
  • contraindicated in EPILEPSY/ PREG / BREASTFEED

Pregnant women:

  • all should be tested for smoking with CO detector.
  • if smoke or stopped smoking last 2/52 or CO >7 —> refer to stop smoking

Mx:

  • 1st - CBT
  • NRT I’d above fail -> patches to be removed prior to bed
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8
Q

Lung carcinoid

A

CHERRY RED LESION

40-50yrs

Smoking not RF

Slow growing

Carcinoid syndrome - rare

Mx:
Surgical
If no met —> good survivals

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9
Q

Cryptogenic organising pneumonia

A

Pneumonia type presentation that doesn’t respon to abx

Weeks history

ILD

Raised leukocytes, ESR and CRP

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10
Q

Cavitating lung lesions

A

Abscess

Squamous cell Ca

TB

WEgners

PE

RA

aspergillosis, histoplasmosis, coccididiomycosis

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11
Q

contraindications to surgical of lung Ca

A

FEV1 <1.5 lobectmy or FEV1 <2.0 if oneumonectomy.

Malignant pleural effusion

Vocal cord paralysis

SVCO

Tumour near hilum

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12
Q

Surfactant

A

secreted by type 2 pneumocytes

acitive ingredient - DPPC

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13
Q

Pousielles Law

A

R = 8nL/Pie*R^4

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14
Q

Ohms Law

A

airflow = Pressure gradient/airway resistance

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15
Q

Pulm perfusion

A

Low pressure system 15-30mmHg
Pulm vasc = 1/10th resistance of systemic

Get Hypoxic VC –> Shunt blood away from low ventilated areas.

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16
Q

Respiratory centre

A

Poorly definned nervous system in pons and medulla -

can eb OVERIDDEN by cortex

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17
Q

Chemoreceptors

A

Central:

  • Ventral surface of medilla
  • Responds to H+/inc PCO2

Peripheral:

  • Carotid and aortic bodies
  • Repsond to low PO2 and H+/CO2

In normal lung most improtant factor = CO2 howevr eif chronic CO2 retainer then relies on hypoxic drive.

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18
Q

Cheyne stokes breathing

A

Apnoea alt w/ tachypnoea

seen in:

  • Brain damage
  • Altitude
  • HFx
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19
Q

Pulm Fn Tests

A

PEFR:
- Asthma

Spirometry:

  • Obstructive - Asthma/COPD
  • Restrictive: Pulm fibrosis, neuromusc, obesity, pleural disaease.

Flow Vol loops:
- See note book

Gas Transfer:

  • Measure using CO as completely diffusion dependant:
  • Increased: Asthma, pulm haemorrhage, polycythaemia, L–> R shunt.
  • Decreased: everything else
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20
Q

O2 dissoiation curve

A 
x-axis = pO2
y-axis = % saturation

Right shift: raised H+/CO2/Temp/ 2-3 DPG - increas O2 offload

Left shift: opposite of abive + Foetal Hb + carboxyhaemoglobin

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21
Q

Altitude related disorders.

A

decrease pO” - approx 1/2 at 18,000ft

stimulates periph chemoreceptors
get metabolic alkalosis –> increase renal HCO3- secretion

Physiological changes:
Increase Hb
Increase 2,3-DPG
increase renal exc of HCO3
hypoxic VC (as prev) --> can lead to increase pulm vasc R --> RV fhypetrophy

Pulm and cerebral oedema.

3 syndromes:

  • acute mountain sickness
  • HACE
  • HAPE
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22
Q

acute moutnain sickness Mx

A

Prophylactic acetazolamide

- Descent

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23
Q

HACE

A

DEXAMETHASONE

descent

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24
Q

HAPE

A

descent, Dex, nifedipine, PDE-4 inhib, acetozolamide.

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25
Q

Astham - See revision notes

A

Remember in chronic mx - 3rst step now LTRA

Acute Mx: MgSO4- if not settled with steroid + NEbs –> ten theophylline

Referral to ITU:

  • deterirating PEFR
  • persistent or worsening hypoxia
  • increas pCO2
  • exhaustion
  • GCS
  • resp arrest
Discharge criteria:
- settlef off neb for 24hr
PEFR>75% of baseline
diurnal variability <25%
written astham plan
f/u in 30 days
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26
Q

Astham pathiphysiology

A

NArroawing by:

  • Mucosal oedema
  • SM contraction
  • Mucus plugging

chronic asthma:
- thicken BM
- Coblet cell hyperplasia
SM hypertrophy

inflamm cells
mast cells/ mac/ T cells/ neutrophils/ eosinophils

these cells release cytokines:
Histamine/bradykinin/ leukotriene/ PGs/ PAF

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27
Q

Astham diagnosis

A 
FEV1 decrease
FEV 1 increase post bronchodilator >400ml or PEFR post >15%
FEV1:FVC <70%
histamine provocation test <8mg/ml
FENO >325 part per billion 
sputume eosinophillia >2%

if >17yrs:
FENO + PFTs with reversibility

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28
Q

alpha-1 antitrypsin deficiency

A

Pz of COPD type illness in young or no smoking history.

it is a protease inhibitor.

PIMM - 50% still active
PiZZ = 10%
piMZ = 35%

PIMM an PiMZ –> you dont need active treatment no LT

MX - SMOKIN CESSATUIB

  • lung transplant
  • counselling
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29
Q

NIV

A

initiall setings IPAP:EPAP

10:5

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30
Q

Invasive ventillation

A 
Type 2 RF 
PAralysis 
Trauma --> Chest/cpine
Mult orga dysfn
low GCS
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31
Q

CAP

A

Causes:

Strep - most common
Staph post viral infection - IVDU –> ABSCESS
Mycoplasma - Atypical. Long prodrome.
Legionella - TRAVEL - urinary Ag. - Clarithromycin

CURB 65 - =>3 = severe

Curb 65 <3 = Po Amox + clari
=> IV Co-amox + macro

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32
Q

HAP

A

Causes:

  • Staph A:
  • G- - Klebsiella (EtOH), Pseudomonas, E.Col
  • Anaerobes
  • Funghi

Mx:

  • Co-amox or Taz
  • pen allergc –> Levoflox.
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33
Q

Aspiration

A

Get Abscess + Empyema

Mx: Metroniazole + 3rd gen ceph

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34
Q

Lung Abscess

A

suspect if non-improving infection +/- swinging fever

RF:

  • imunnocomp
  • bronchial ca
  • dental procedure
  • pneumonia
  • septic emboli - Right I.E.

Causes:

  • Staph
  • Klebsiella
  • legionella
  • psuedomonas
  • anaerobes
  • Mycobacter
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35
Q

Empyema

A
  • pleurla aspirate pH <7.2

Urgent drainage + IV Abx –> Fx (intraplueral tPA + DNAse) –> Fx –> Thoracotomy +/- decortication

36
Q

Bronchiectasis

A

causes: SEE NOTES.
- idiopathic
- post infectious - measles, TB, pneumo, pertussis
- congenital - marfans, williams.
- ABPA
- CF
- PCD, Kategeners, Youngs
- Alpha1 antitrypsin

px: chronic sputum prouction +/- haemoptsis.
assoc. conditions
w/L, fatiue, clubbing, malaise.

Inx : CT –> signet rings - can sometimes be sen on CXR#
PFT = obstructive pattern.

Test for underlying causes

Mx:

mosy important= PHYSIOTHERAPY
- mucolytics
nebs
prophylactic abx:
- =.>3 exac in 1 yr --> azithromycin 
surgery if sev localised.
37
Q

CF

A

chromsome 7
transmembrane chlroide channel

poor sweat cl- reabs
poor airway Cl- secretion –> Na reabs.

Inx: CL- sweat test
Genetic analysis
Neonate –> Guthries.

Pulm dx

GI dx 
- Pancretic exocrine fn - Vit ADEK 
- Child - meconium ileus 
- adult - SBO 
- biliary obstruction 
gallstones
- peptic ulcer 
- pajncreatitis.

Renal:

  • Renal stones = oxalate
  • Aminoglycloside –> Renal tubule dysfn.

Infertility

Mx:
- MDT 
- Pseudomonas prophlaxis - Azithromycin 
mucolytics
nebs. 
Pancreatic enzyme replace. 
NIPPV if type  2 RF --> Dbl lung transplantation.
38
Q

Aspergillus - 4 Types

A

ABPA

  • assoc. asth,a
  • sensitivity rx - IgE IgG
  • fleeting CXR signs
    • Skin/RAST to Aspergillus
  • serum IgE >1000
  • EOSINOPHILLIA

Chronic pulm Aspergillus

  • pt mildly immunocomp
  • Culture + Aspergillus PCR
  • radiograph –> Tree-in–bud apearance.
  • Mx - PO Antifungal.

Invasive Aspergilliosis

  • Rapdly spreading –> granulomas/necrosis/suppuratve
  • pt is sig. immunocomp
  • GALACTOMANNAN
  • Sputum + BAL for fungal
  • CT Thorax –> halo sign

Apergilloma

  • Fungal ball - often in sited of old TB/CF/ sarcoid/ neoplasm
  • typical cause = A. Fumigatabs
  • can get massive heamoptysis –> Req bronchial A Embolisation.
  • CXR diagnostic
39
Q

Asbestosis

A

Q stem - Shipbuilder/deck worker/builder.

Pleural effusions

Pleural plaques:

  • not premalignant
  • Asx

Diffuse pleural thickening:

  • Lung bases
  • SOBOE
  • PFTs = restrictibe
  • reduced TLC
  • KCO normal

Asbestosis

  • Fibrotic changes at lower lobe
  • Inx - HRCT
  • KCO reduces

Mesothelioma

  • malignancy
  • Inx: CXR –> pleural effusion analysis or CT
  • Cytology neg –> LA thoracoscopy

COMPENSATION

40
Q

Coal workers pneumoconiosis

A
  • Dust exposure
  • UZ
  • initially small nodules (<1cm) –> further exposure –> aggregate (>1cm)
  • PFT = mixed obstructive and restrictive + Reduced KCO

Caplan syndrome - assoc with RA - NODULES IN PERIPHERY of lung

41
Q

Silicosis

A

Quarry/miner
UZ –> silicotic nodules –> pofressive massive fibrosis

  • EGG SHELL CALCIFICATION around enlarged hilar glands
  • PFT as prev

ASSOC WITH TB

42
Q

Berryliosis

A

Acute –> Acute alveolitis
Chronic – non-caseating granulomas

CXR - Bilat perihilar LN

43
Q

Byssinosis

A

Cotton

Q stem - worse sx 1st day back after a break

Ft - FEV1 reduced –> more marked first day of the week/

44
Q

Extrinsic allergic alveolitis

A

IgG relating

UZ

45
Q

Extrinsic allergic alveolitis

A

IgG related

Initially type 3 hypersensitivity

UZ

CXR - generalised haze

PFT: restictive + low KCO

Histology: mononuclear cell infiltrates + non-caseating granulomas.

PRecipitants - measure SPECIFIC IgG response

if think pulm fibrosis –> HRCT

46
Q

Types of EAA

A

Farmer lung - Saccharopolyspora rectivirgula

Bird fanciers - Avian proteins

MAlt workers lung - Aspergillus clavitus

Mushroom workers: Thermophilic actinomycetes

47
Q

Lung Ca

A

Adenocarcinoma

  • 30%
  • peripheral lung
  • assoc gynaecomastia

Sq cel Ca - 35%

  • PTH like peptide
  • best survival
  • Ectopic TSH

SCC ca:

  • Neuroendicrine
  • SIADH
  • ACTH
  • LEMS - presynaptic MG like
  • met at px –> CHEMO
  • Cerebellar Syndrome

Pancoast tumour::

  • pain in C8/T1 dermatome
  • Wasting of small muscles of hand
  • Horners.
  • CT + CT guided biopsy
48
Q

Sarcoid

A

Multisystem granulamatous disease = MAc + Lymphocytes + epithelioid cells –> aggregated –> Multinucleate giant cells

Affects : West indian + Asian

hyperCa –> Due to increased activation of Vit D

Q - Stem - YOung pt from above origine with BHL + ERYTHEMA NODOSUM

PFT - restrictive + low KCO

Heerfordt-waldenstrom:

  • Parotid gland enlargement
  • ant. uveitis
  • Temp raised
  • CN Palsy

LoffGRens - groaning from arthralgia whilst going into loft :

  • Athralgia
  • BHL + EN
  • raised temp

Inx:

  • Thoracic CT
  • BIopsy
49
Q

Sarcoid Mx

A

Ca restrict diet

if Ca restrict fx –> Steroids.

50
Q

idiopathic pulm fibrosis

A

80% of ILD

Characterised by UIP:

  • Honeycombing
  • minimal celluar inflamm
  • Fibroblastic foci

haziness –> peripheral + basal lung.

Px: fine END INSP crackles.

HRCT = gold standard to look for characteristic findings above.

Mx:
- NAC
- if FVC 50-80% - Perfenidone = reduces the fall in FVC
<65yrs –> Single lung transplant

51
Q

Types of ILD

A

Steroid responsice:

  • NSIP
  • DIP
  • RBILD

non-steroid responsive:
- AIP
LIP

52
Q

Drug causes of pulm fibrosis:

A CAR carrying a BIKE, followed by a BUS and a TRUCK with a LOUD SPEAKER and a DRONE flying above

A

Carmustine

Cyclophosphamide

Buslphan

Methotraxate

Bleomycin

Amiodarone

53
Q

Causes of UZ pulm fibrosis:

A TEA SHOP

A

ABPA

TN

EAA

Ank spond

Sarcoid

Histiocytosis

OCcupational

Pneumoconiosis

54
Q

Granulomatosis w/ polyangitis

Wegners granulomatosis

A

cANCA

Small/med vasculitis

Glomerulonephritis

Eye + Joint

Vasculitic rash + Mono-neuritis

CXR: –> large rounded shadow can CAVITATE

Mx:
- Cyclophosphamide + Steroid

55
Q

Eosinophillic granulamotosis with polyangitits

CHurg strauss

A 
Asthm
Blood eosinophillia
paranasal sinusitis 
mono-neuritis multiplex
pANCA

exac by LRTA

56
Q

Pulmonary eosinophillia

A

EGwP (churg strauss)

Lofflers syndrome:

  • assoc with parasitic infection - strongyloides/ascan’s lumbracoides
  • lasta <2/52
  • spont resolves or bendazole

Chronic eosinophilia pneumonia

  • > 8/52
  • CXR –> reverse batwing
  • Mx - Steroids

Hyperesonophillic syndrome:

  • V.high eosinophils
  • can have hepatosplenomegaly & LN
  • cardiac involvement –> arrythmia + Death
  • VTE

Mx = I.S. + steroids.

57
Q

Cryptogenic organising pneumonia

A

Diffuse ILD

Pneumoia picture with bilateral infiltates and NOT RESPONDING TO ABX

Cough, SOB, Malaise, fever

Watch and wait –> if v.sev high dose steroid

58
Q

ABPA MAjor criteria

A 
proximal bronchiectasis 
Clinical ft of asthma 
Blood eosinophillia
Serum IgE >1000
immediate skin rection to aspergillus antigen
59
Q

intubation criteria in COpd

A

pH <7.6 or pCO2 rising on NIV

60
Q

Respiratory alkalosis causes

A 
Anxiety 
PE
Pregnancy 
CNS - Haemorrhage/encephalitis
Salicylate poisoning 
Altitude
61
Q

Middle easter respiratory syndrome

A

Patient returns from middle eastern country wth cough coryza and fever

Caused by MERS - CoV

Incubation 2-14 days

Contact with camels + Camel products

62
Q

Treatments of flu

A

Tami flu - PO med:

  • nueramidase inhibitor - stop viral particle release
  • s.e = n/V and headaches

Zanamivir:

  • Inhsaled med
  • same mechanism of action
  • Can cause bronchospasm in asthmatics.
63
Q

Diagnosis of COPD

A

FEV1:FVC <0.7 + Symptoms

64
Q

NSAIDS exac of Asthma MOA

A

Inhibits cox –> inhibits THromboxan + PG

therefore arachidonic acid goes dow lipoxygenase pathway –> pro inflamm LKTR !!

65
Q

Pulonary arterial hypertension

A

> 25 mmHg

Vasodilator test –> + –> CCB

VD test –> neg :

  • Prostacyclin analogu - iloptost, treprostinil
  • Endothelin receptor anatag - bonsentan, ambrisentan
  • PDEI - Sildenafil
66
Q

Re-expansion pulmonary oedema

A

complciation of over rapid re-expansion fo lung after tx for effusion or pneumothorax

RF:

  • Longer duration of lung collapse
  • larger vol of lung collapse
  • rapid drainage
  • applicaton of suction
  • Younger pt
67
Q

COPD who to offer LTOT

A

Need 2 ABGs at least 3/52 apart

pO2 <7.3

or

pO2 7.3-8.0

  • polycythaemia
  • perpheral oedema
  • pulm HTN
68
Q

Indications for Steroid therapy in sarcooidosis

A
  • Parenchymal lung involvement
  • Cardiac involvement
  • Neurosarcoid
  • hypercalcaemia
  • Uveitis.
69
Q

Legionella indicators in Q stem

A

Flu - like prodrome
Foreign travel
Effusions
Hyponatraemia

tx:
- Erythomycin/clarithromycin

70
Q

Mycoplasma pneumonia

A

Raised LDH
Cold agglutinins

Drycough, fever, malaise

can present with AUTOIMMUNE HAEMOLYTIC ANEAMIA

Mx:
- Macrolides

71
Q

Rheumatoid pleural effusion

A

LDH high

Pleural glucose <1.6

PH <7.2

High cholesterol

High rheumatoid factor

72
Q

PCP management - when to use steroids.

A

Evidence of sev. hypoxia - Steroids

73
Q

Lung mets that calcify

A

Chondrosarcomas and osteosarcomas

74
Q

Mycoplasma

A

Cold agglutinin +ve
Flu like illness
Erythema nodosum

Ezithromycin/claarithromycin

75
Q

Primary pneumothorax

A

Rim of air <2cm (30%) and no sx –> discharge

Sx or >2cm –> Aspirate –> Fx –> chest drain

Following aspiration if air <2cm –> discharge with outpatient review.

Post - No fly 2 weeks.

Stop smoking (RR of recurrence 10% vs 0.1%)

76
Q

Secondary pneumothorax

A

50 + >2cm +/or SOB –> Chest drain

Otherwais if >1cm –> aspirate –> chest drain (>1cm)

All should be admitted for 24 hrs.

<1cm –> Admit and observe + O2 for 24 hrs

AVOID SCUBA

77
Q

Iatrogenic pneumothorax

A

less likely recurrence

seen in ventilated patients

oserve

78
Q

Altitiude sickness

A

Prevention:

  • Slow ascent
    = Carbonic anhydrase inhibitor - Acetazolamide
HAPE:
- O2
Descent
PDE Type V inhib 
Acetazolamide
Nifedipine 
Dex

HACE:

  • Descent
  • Dex
79
Q

What factors iprove COPD survival

A

Smoking cessation - most important

LTOT

Lung vol reduction surgery

80
Q

Churg strauss

A

Eosinophillic granulomatosis with polyangitis

small-medium vessel vasculitis

pANCA +ve

Px:

  • Asthma
  • Eosinophilia
  • Paranasal sinusitis
  • mononeuritis multiplex

LTRA –> precipitate disease

81
Q

Staph pneumonia

A

Follows Flu like illness.
CAVITATING

Sen in:

  • IVDU
  • Pt wth central line
  • Leukaemia/lmphoma
  • CF
82
Q

most important antigen presenting cells in sensitisation

A

Dendritic cells.

83
Q

What is alpha-1 anitrypsin

A

Elastase inhibitor (helos prevent emphysema)

84
Q

Most common respiratory complication of SLE?

A

Pleural effusions

85
Q

EAA Investigation

A

IgG !!

despite its name its not allergic therefore dont commony get eosinophillia

86
Q

COPD management despite inhalers

A

FEV1 >50%:
- LABA or LAMA

FEV1 <50%
- LABA + ICS or LAMA

MRCP (20 decks)

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