Respiratory Flashcards
What is the MRC score?
Score used for breathlessness, graded 1-5:
1-not troubled by breathlessness unless strenuous exercise
2-SOB when hurrying or walking up slight hill
3-walks slower than normal due to breathlessness of has to stop to catch breath
4-stops for breath after walking 100m
5-SOB when dressing, struggles to leave house
What is bullous emphysema?
A condition where damaged alveoli distend to form large air spaces, it occurs in otherwise healthy adults and usually gets noticed when an abnormal air space ruptures, leaking air into the pleural space and causing a pneumothorax (it is not the same as pulmonary emphysema which is a complication of COPD).
What investigations would you do for a suspected pleural effusion?
CXR
Fluid aspiration
What is the difference between transudative and exudative pleural effusion?
Transudative - occurs due to increased hydrostatic pressure or decreased plasma osmotic pressure e.g. CHF, cirrhosis, nephrotic syndrome, PE, hypoalbuminaemia.
Exudative - occurs due to inflammation and increased capillary permeability e.g. Pneumonia, cancer, TB, viral infection, PE, autoimmune.
Name some causes of COPD.
Smoking - active or passive
Pollution
Alpha-1 antitrypsin deficiency
What are the most common causes of a pleural effusion?
Infection
Malignancy
What is the CURB-65 score used for and what do all the components stand for?
Used to estimate risk and guide management in community acquired pneumonia.
C-confusion
U-urea >7.0
R-RR>30/min
B-BP<90 systolic of <60 diastolic
65 - aged 65 years +
The higher the score, the worse the pneumonia
What is aspiration pneumonia?
Occurs when food, saliva, liquids or vomit is breathed into the lungs or large airways instead of being swallowed. If these things carry bacteria then this can cause pneumonia.
Name some causes of non-resolving pneumonia.
CHAOS
Complication - emphysema, lung access
Host - immunocompromised
Antibiotic - inadequate dose or poor oral absorption
Organism - resistant or unexpected
Second diagnosis - PE, cancer, organising pneumonia
What is empyema?
Pus in the pleural space, needs to be drained and cannot be treated with ABX as the pleural space has no blood supply
What is ‘honeycombing’ on a chest x-ray?
The radiological appearance seen with widespread fibrosis - appears as lots of white dots looking a bit like a honeycomb. These changes are seen in many end-stage interstitial lung diseases.
What are pleural plaques?
Areas of benign thickening of the lining of the lungs after prolonged asbestos exposure.
What is asbestosis?
Long term inflammation and scarring of the lungs due to exposure to and breathing in asbestos fibres.
When would you see an air bronchogram on a CXR?
Present in pneumonia - the airway is filled with air and surrounded by inflammatory exudates, therefore the airway shows up as dark.
What is the A-a gradient? What should a normal value be?
Alveolar arterial gradient, can be useful to work out if there is a respiratory problem as it is a measure of good gas exchange is. Should be <2kPa in healthy adults and <4kPa in older people. Anything >4kPa implies lung pathology
What is the equation to work out alveolar pO2?
PAO2 = PIO2 - PACO2/0.8
Where PIO2 is oxygen in room air (20kPa) and PACO2 is basically the same as arterial PaCO2.
What is the criteria for doing an ABG in an acute asthma patient?
If sats <92% on presentation.
What is the difference between CPAP and BIPAP?
CPAP is not a form of ventilatory support and provides constant positive pressure during inspiration and expiration, can be used for people with obstructive sleep apnoea.
BIPAP is a form of NIV (non-invasive ventilation) and has different positive pressures for inspiration and expiration, a form of ventilatory support.
What is chronic bronchitis?
Cough and sputum production on most days for 3 months of 2 successive years, caused by mucous hypersecretion.
What is emphysema?
Enlarged air spaces distal to the terminal bronchioles caused by destruction of alveolar walls.
Name some symptoms of COPD.
Coughing up sputum
Dyspnoea
Wheeze
Weight loss
Name some signs of COPD.
Tachypnoea Hyperinflation of lungs Use of accessory muscles Pursed lip breathing Wheeze Cor pulmonale - raised JVP, oedema Early-inspiratory crackles
What is alpha-1 antitrypsin deficiency and what can it lead to.
Genetic condition where there is a deficiency in the enzyme alpha-1 antitrypsin (A1A), can lead to lung and liver disease. A1A normally protects the lungs from inflammation caused by infection or inhaled irritants therefore a deficiency leads to lung damage. A1A is normally released by the liver but due to being abnormal the liver can’t release it. A build-up in the liver leads to liver damage.
What is the pink puffers and blue bloaters phenomenon?
People with emphysema are pink puffers - they have increased alveolar ventilation and are breathless but not cyanosis.
People with chronic bronchitis are blue bloaters - they have decreased alveolar ventilation and are cyanosis but not breathless.
What is cor pulmonale?
When the right side of the heart is enlarged due to pulmonary disease, can lead to heart failure with signs such as raised JVP and oedema.
How can COPD lead to polycythaemia?
Hypoxia can cause erythrocytosis.
What would spirometry show for COPD?
Increased TLC
Increased residual volume
FEV1:FVC < 70%
What medication can be used for COPD?
Mucolytics e.g. Carbocisteine to increase viscosity of sputum and make it easier to bring up.
SABA, SAMA, ICS (see notes of when to give each).
What is asthma?
Reversible airway obstruction caused by bronchial hypersensitivity to a variety of stimuli - consists of bronchoconstriction, mucosal inflammation and increased mucous production.
Name 3 causes of asthma.
Atopy
Stress e.g. Cold air, exercise, viral URTI, emotion
Toxins e.g. Smoking, pollution, beta-blockers, aspirin
What are the features of severe acute asthma?
Any one of: PEFR <50% predicted RR>25 HR>110 Can't complete sentence in one breath
What are the features of life-threatening asthma?
Any one of: PEFR<33% predicted CHEST: -cyanosis -hypotension -exhaustion/confusion -silent chest/poor respiratory effort -tachycardia/bradycardia/arrhythmia
Where exactly should an aspiration needle/drain be inserted for a tension pneumothorax?
2nd intercostal space, mid-clavicular line
What is the therapeutic treatment for a tension pneumothorax?
Needle aspiration first to remove air. If it’s a large pneumothorax then chest drain insertion may be needed.
Name some recognised causes of a pneumothorax.
Rib fracture Central line insertion Mechanical ventilation Asthma COPD Marfan's Syndrome
What ECG changes can sometimes be seen with a pulmonary embolism?
Sinus tachycardia
T wave inversion in leads V1-V4, II, III and aVF - this is caused by right ventricular strain.
May also see the classic SITIIIQIII but this is less common.
What is the gold-standard imaging for diagnosis of a PE? Is this the same for pregnant women?
CTPA
Ventilation-perfusion (VQ) scan if there is contraindications to CTPA e.g. Renal failure, contrast allergy, pregnancy.
Why is active malignancy a risk factor for PE?
An active malignancy causes hypercoagulable blood.
It is only a risk factor if the malignancy is active i.e. Not if the patient is in remission.
Name some risk factors for a PE.
Factors related to immobility - recent surgery, long-haul flights, bed-bound.
Factors related to hypercoagulability - contraception/HRT, cancer, inherited coagulation diseases, smoking
Name some causes of a raised troponin other than an MI.
Sepsis
CKD
Heart failure
Myocarditis
What is the definitive treatment for a PE?
Anticoagulate the patient with LMWH or fondaparinux unless contraindications.
If it is a massive PE then fibrinolysis is required (ateplase) unless there are contraindications e.g. Recent haemorrhagic stroke.
The patient is likely to also need longer term anticoagulation.
Name some symptoms and signs of idiopathic pulmonary fibrosis.
Symptoms - dry cough, exertional dyspnoea, arthralgia, weight loss and malaise.
Signs - finger clubbing, cyanosis and fine end-inspiratory crackles.
What is the management for idiopathic pulmonary fibrosis?
Supportive care - smoking cessation advice, pulmonary rehabilitation, O2 therapy and palliative care. Only cure is a lung transplantation.
What would you see on a CT scan in a patient with idiopathic pulmonary fibrosis?
Honeycombing
Name 4 drugs that can cause interstitial lung disease.
Methotrexate
Sulfasalazine
Nitrofurantoin
Amiodarone
Name the histological subtypes of lung cancer.
Small-cell carcinoma
Non-small-cell carcinoma (squamous cell carcinoma, adenocarcinoma and large-cell carcinoma)
Why do some people with lung cancer present with hoarseness of voice?
Tumour can compress on either the vocal cords or the recurrent laryngeal nerve (which hooks under the arch of the aorta on the left side).
Why do some people with lung cancer present with Horner’s syndrome?
A pancoast can damage sympathetic nerves leading to miosis, partial ptosis and ipsilateral anhydrosis.
What is the management for lung cancer?
SCLC - usually disseminated at presentation, may respond to chemo but high chance or relapse.
NSCLC - surgical resection if no metastatic spread, radiotherapy if unable to undergo surgery, or chemotherapy if disease is more advanced.
What type of epithelium lines the respiratory tract?
Pseudostratified ciliated columnar epithelium
