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Respiratory Flashcards

1
Q

Restrictive disease

  1. FEV1
  2. FVC
  3. FEV1/FVC radio
  4. Examples
A
  1. < 80% predicted
  2. < 80% predicted
  3. > 70% normal
  4. Scoliosis, fibrosis, post-trauma, obesity, neuromuscular, asbestosis
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2
Q

Obstructive disease

  1. FEV1
  2. FVC
  3. FEV1/FVC radio
  4. Examples
A
  1. < 80% predicted
  2. Normal or low
  3. < 70% predicted
  4. COPD, asthma, bronchiectasis - partially reversible
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3
Q

Asthma - general

  1. 3 causes of airway narrowing
  2. Examination signs
  3. Precipitants - DIPLOMATS
  4. Longer term tests
  5. Important social aspects of history - ‘OPSA’
  6. Important HPC
  7. Management (steps 1-4)
  8. How often can treatment step down be considered
  9. How should ICS be reduced when stepping down
A
  1. Mucus production, bronchoconstriction, mucosal inflammation
  2. Tachycardia, tachypnoea, resonant percussion, hyperinflated chest with decreased wall movement, polyphonic expiratory wheeze
  3. Drugs (NSAIDs, beta blockers), infection, pollutants, laughter, oesophageal reflux, mites, allergens, temperature (cold), some exercise
  4. Skin prick, lung function
  5. Occupation, pets, smoking, allergens
  6. Attacks per week, exacerbations, previous ITU
  7. Step 1 (SABA e.g. salbutamol), step 2 if 3+ symptoms a week, or waking at night (add ICS e.g. beclomethasone), step 3 (add LTRA e.g. montelukast), step 4 (add LABA e.g. salmeterol, review LTRA)
  8. Every 3 months
  9. By no more than 50%
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4
Q

Asthma - classification

  1. Mild
  2. Moderate
  3. Severe
  4. Life threatening - ‘SHOCC 92’
A
  1. PEFR >75%
  2. PEFR 50-75%
  3. PEFR <50% RR >25, HR >110, CO2 low/normal, hypoxic, can’t complete sentences
  4. Silent chest, hypotension, peak flow one third, cyanosed, CO2 increased and acidotic, confused
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5
Q

Asthma - exacerbation (general)

  1. History
  2. Bedside tests
  3. When to do an ABG
  4. Other blood tests
  5. Initial management
  6. Full management - ‘O SHIT ME’
A
  1. Severity - SOCRATES, prevision admissions, inhaler compliance, rescue packs, home nebulisers
  2. Observations (RR, HR, SPO2, BP), peak flow, ECG
  3. SPO2 < 92%
  4. FBC, U+Es, CRP, infectious screen
  5. Salbutamol inhaler - can give 3 doses 5mg back to back then doses every 15 minutes
  6. Oxygen, Salbutamol (back to back, 5-10mg/hr), Hydrocortisone 100mg IV (/ prednisolone 40mg PO 5 days) , Ipratropium (500mcg nebuliser, 4-6 hourly), Theophylline (aminophylline infusion 1mg in 1L saline 0.5mg/hr, only in ITU as need daily levels, U+Es, cardiac monitoring), Magnesium sulphate (2g IV over 20 minutes, one off dose), Escalation to critical care
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6
Q

Indications for ITU in respiratory distress

A

Requiring ventilator support
Worsening hypoxia / hypercapnia / acidosis
Exhaustion
Drowsiness / confusion

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7
Q

Shortness of breath - causes

  1. Sudden respiratory
  2. Acute respiratory
  3. Chronic respiratory
  4. Cardiac
  5. Sudden systemic
  6. Acute on chronic systemic
A
  1. Pulmonary embolism, inhaled foreign body, pneumothorax
  2. COPD / asthma exacerbation, pneumonia
  3. Asthma, COPD, pulmonary fibrosis
  4. Heart failure, MI, angina, valve disease, arrhythmias
  5. Anaphylaxis, hyperventilation, anxiety
  6. Metabolic acidosis, thyrotoxicosis, fever, anaemia, obesity, neurological disease
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8
Q

Pneumonia

  1. CURB 65 score - components and interpretation
  2. Other factors increasing mortality risk (3)

CAP management

  1. Mild (CURB 0-1)
  2. Moderate (CURB 2)
  3. Severe (CURB 3)
  4. ABX to add if staph suspected
  5. ABX to add if MRSA suspected
  6. HAP management
  7. Aspiration pneumonia management
A
  1. Confusion, urea >7, RR >30, BP (systolic <90 / diastolic <60), age >65. 0-1 (PO abx/home treatment), 2 (hospital therapy), 3 (severe, consider ITU)
  2. Comorbidities, bilateral/multilobar, PaO2 <8 kPa
  3. PO amoxicillin / clarithromycin / doxycycline 5d
  4. PO amoxicillin and clarithromycin / doxycycline 7d
  5. IV clarithromycin and co-amoxiclav / cephalosporin e.g. cefuroxime 7d
  6. Flucloxacillin +/ rifampicin 10d
  7. Vancomycin / teicopleinin
  8. IV aminoglycoside and antipseudomonal penicillin / 3rd generation cephalosporin
  9. IV cephalosporin and metronidazole
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9
Q

CXR findings - differentials

  1. ‘White out’
  2. Pleural plaques
  3. Bilateral hilar lymphadenopathy (6)
  4. Lung nodules in context of rheumatoid arthritis and pneumoconiosis
  5. Double right heart
  6. Pleural mass/thickening/effusion with lobulated margin
  7. Walled cavity, often with fluid level
  8. Cystic shadows, thickened bronchial walls (tram line and ring shadows)
  9. Lobulated mass + calcification flecks (CT)
  10. Bilateral pulmonary infiltrates
  11. Normal, or oligaemia of affected segment, wedge shaped opacities or cavitation
  12. Area devoid of lung markings peripheral to edge of area of collapsed lung, potential tracheal deviation / mediastinal shift
  13. Costophrenic angle blunting if small, water-dense shadow with concave upper border if larger, ‘white out’
  14. Enlarged right atrium and ventricle, prominent pulmonary arteries
  15. Upper zone mottling/consolidation, hilar lymphadenopathy
  16. Air space shadowing (4)
  17. Bilateral interstitial shadowing (typically small, irregular, peripheral opacities - ‘ground-glass’, ‘honeycombing’
A
  1. Trachea away (effusion, diaphragm problem), trachea central (consolidation, pulmonary oedema), trachea towards (total lung collapse, pneumonectomy)
  2. Asbestosis
  3. Sarcoidosis, TB, mycoplasma, lymphoma, hypersensitivity pneumonitis, silicosis
  4. Caplan syndrome
  5. Advanced mitral stenosis causing left atrial enlargement
  6. Mesothelioma
  7. Empyma
  8. Bronchiectasis
  9. Hamartoma
  10. ARDS
  11. Pulmonary embolism
  12. Pneumothorax
  13. Pleural effusion
  14. Cor pulmonale
  15. Acute EAA
  16. Infection, lymphoma, alveolar cell carcinoma, haemorrhage
  17. Pulmonary fibrosis
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10
Q

Atelectesis - definition

A

Common post operative complication in which bronchial secretions obstruct airway, leading to basal alveolar collapse and respiratory difficulty

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11
Q

COPD

  1. Causes (2)
  2. Normal management (steps 1-4)
  3. Exacerbation management
  4. Long-term oxygen therapy - when to assess
  5. Long-term oxygen therapy - indications
A
  1. Smoking, a1 antitrypsin deficiency
  2. Step 1 (SABA/SAMA e.g. ipratropium), Step 2, if uncontrolled but FEV1 >50% (LABA or LAMA e.g. glycopyrrolium/tiotropium), Step 3, if uncontrolled and FEV1 <50% (LAMA or combined LABA/ICS e.g. symbicort (budesonide/formoterol) or seretide (fluticasone/salmeterol/)), Step 4 (triple therapy of LABA, ICS + LAMA)
  3. O SHIT (but controlled oxygen e.g. 24-28% through venturi, ABG after 15 minutes, and 1-2 weeks of steroids), maybe antibiotics, chest physiotherapy, BiPAP if can’t keep SPO2 at 88-92%
  4. FEV1 <30% predicted, or considered if FEV1 <50%, cyanosis, polycythaemia, raised JVP, peripheral oedema, PaO2 <92% on room air
  5. pO2 <7.3 kPa twice, 3 weeks apart, when well, or pO2 7.3-8 kPa with: secondary polycythaemia, nocturnal hypoxaemia, peripheral oedema, or pulmonary hypertension
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12
Q

Alpha 1 antitrypsin

  1. Location
  2. Function
  3. Deficiency presentation
  4. Deficiency management (lifestyle, supportive, surgical)
A
  1. Liver
  2. Protease inhibitor enzyme; protect cells from enzymes e.g. neutrophil elastase
  3. Lower lobe COPD (smoking causes upper lobe emphysema) and liver derangement at young age
  4. No smoking. Supportive - bronchodilators, physiotherapy, IV A1AT protein concentrates. Surgery -volume reduction surgery, lung transplantation
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13
Q

Pulmonary fibrosis

  1. Upper zone causes (CHARTS)
  2. Lower zone causes
  3. Clinical features
  4. CXR findings
  5. Bloods
  6. Idiopathic bloods
  7. Idiopathic diagnostic test
  8. Idiopathic management
A
  1. Coal workers pneumoconiosis, hypersensitivity pneumonitis, ankylosing spondylitis, radiation, TB, silicosis (miliary, egg shell hilar calcification) / (mid zone) sarcoidosis
  2. Idiopathic, connective tissue disease, drugs (amiodarone, methotrexate), asbestosis
  3. Progressively SOB, cyanosis, inspiratory fine crepitations, cough, clubbing, weight loss, arthralgia
  4. Bilateral interstitial shadowing (typically small, irregular, peripheral opacities - ‘ground-glass’)
  5. FBC, U+Es, LFTs, CRP, ANCA (vasculitis), ACE levels (sarcoidosis)
  6. ANA, rheumatoid factor
  7. CT
  8. Supportive, steroids (if diagnosis is in doubt), maybe azathioprine
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14
Q

Pulmonary sarcoidosis

  1. Classic patient
  2. Associated alleles
  3. Acute presentation (Lofgren syndrome)
  4. Blood findings
  5. CXR findings
  6. Non-pulmonary signs
  7. ECG findings
  8. Diagnostic test
  9. Ultrasound finding
  10. Bone x-ray finding
  11. Bronchiolar lavage finding
  12. Management
A
  1. Black 20-40yo progressive SOB, chest pain, dry cough
  2. HLA-DRB1 /DQB1
  3. Erythema nodosum on shins, fever, polyarthralgia, CXR changes
  4. ACE, ESR, LFT, Ca2+, immunoglobulins up
  5. Bilateral hilar lymphadenopathy +/- pulmonary infiltrates / fibrosis
  6. Lymphadenopathy, hepatosplenomegaly, nodules, eye problems, neurological problems, high blood/urine Ca2+
  7. Arrhythmias / bundle branch block
  8. Tissue biopsy
  9. Nephrocalcinosis
  10. Punched out lesion in terminal phalange
  11. Lymphocyte in active disease, neutrophil in fibrosis
  12. Bed rest, NSAIDs, prednisolone if significant lung disease, uveitis, high Ca2+, neurological/cardiac involvement
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15
Q

Bronchiectasis

  1. Definition
  2. Causes
  3. Main organisms
  4. Symptoms
  5. Signs
  6. Complications
  7. CXR findings
  8. If culture pseudomonas, which therapy
  9. When to consider long-term ABX
  10. General management
A
  1. Chronic inflammation and infection of bronchial walls leading to permanent airway dilation
  2. Cystic fibrosis, primary ciliary dyskinesia, Kartagener’s syndrome, post-infection e.g. measles, TB
  3. Haemophilus influenzae, pseudomonas, strep pneumonia, klebsiella
  4. Persistent cough, copious purulent sputum, intermittent haemoptysis
  5. Finger clubbing, coarse inspiratory creps, wheeze
  6. Pneumonia, pleural effusion, pneumothorax, cerebral abscess, amyloidosis
  7. Cystic shadows, thickened bronchial walls (tram line and ring shadows)
  8. Oral ciprofloxacin / other IV
  9. 3+ exacerbations / year
  10. Airway clearance techniques, antibiotics, bronchodilators, prednisolone, surgery if localised / severe haemoptysis
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16
Q

Cough - causes

  1. Acute
  2. Mucus-producing
  3. Bloodstained
  4. Chronic non-productive
A
  1. Inhaled foreign object, goitre / tumour pressing on larynx, post nasal drip, URTI
  2. Pneumonia, bronchiectasis, COPD exacerbation
  3. TB, cancer, PE, HF (pink frothy)
  4. Asthma, pulmonary fibrosis, GORD, ACE-i, ANCA positive
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17
Q

Respiratory system - questions

A 
SOB
Cough
Wheeze
Chest pain
Haemoptysis
Weight loss / fever / night sweats
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18
Q

Chronic cough - investigations

  1. Bloods
  2. Bedside
  3. Non-bedside
A
  1. FBC, CRP / ESR, U+Es, TFTs, ANCA
  2. PEFR, sputum sample and culture
  3. Spirometry, CXR, echocardiogram
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19
Q

Cyanosis

  1. Central - causes
  2. Central - key test
  3. Peripheral - causes
  4. Peripheral - need to exclude
A
  1. Chronic lung disease, congenital heart disease, PE, abnormal haemoglobin
  2. ABG
  3. Central causes, + Reynaud’s, slow circulation, vascular occlusion
  4. Vascular occlusion
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20
Q

Bilateral lung conditions - common locations

  1. Upper lobe predominant
  2. Lower lobe predominant
A
  1. Cystic fibrosis, ankylosing spondylitis, sarcoidosis, TB

2. Bronchiectasis, asbestosis, interstitial pneumonia

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21
Q

Haemoptysis

  1. Respiratory causes
  2. Systemic causes
  3. HPC questions
  4. PMH questions
  5. Associated symptoms
  6. Blood tests
  7. Bedside tests
  8. Imaging
A
  1. Infection (pneumonia, TB), trauma, PE, malignancy
  2. Granulomatus polyangiitis, goodpasture’s disease
  3. How much, what colour, mixed with sputum, B symptoms
  4. Kidney disease, clotting disorders, occupation, smoking
  5. Chest pain, SOB, cough, nose bleed
  6. FBC, U+Es, CRP, ANCA (GPA), Clotting screen, Anti-GBM antibodies (goodpasture’s)
  7. ECG, urine dip/culture, urinary antigens (atypical pneumonia), sputum sample
  8. CXR, echocardiogram, fibreoptic bronchoscopy, CT, CTPA (if suspected PE)
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22
Q

Hyperventilation

  1. Respiratory causes
  2. Cardiac causes
  3. Metabolic causes
  4. Other
A
  1. Pneumonia, asthma, PE, pneumothorax
  2. Cardiac failure, anaemia, valve disease, MI
  3. Sepsis, DKA
  4. Anxiety
23
Q

Clubbing

  1. Respiratory causes
  2. Cardiac causes
  3. ‘Other’ causes
A
  1. Pulmonary fibrosis, malignancy, cystic fibrosis, bronchiectasis, TB, asbestosis
  2. Bacterial endocarditis, cyanotic congenital heart disease (tetralogy of Fallot, TGA)
  3. Crohn’s, hepatic cirrhosis, primary biliary cirrhosis, Grave’s disease
24
Q

Pleural effusion

  1. Transudate vs exudate protein level
  2. Transudate cause
  3. Exudate cause
  4. Criteria to use if borderline protein level
  5. Symptoms
  6. Signs
  7. CXR findings
  8. Tests - aspirate
  9. Chylothorax diagnostic criteria
  10. Aspirate if empyema (pH, glucose, LDH)
  11. Management
A
  1. T < 30 g/L, E > 30 g/L
  2. Increased venous pressure (cardiac failure, fluid overload) or hypoproteinaemia (hepatic failure, nephrotic syndrome
  3. Increased leakiness of pleural capillaries due to infection (e.g. TB, para-pneumonic), inflammation (e.g. RA, SLE), or malignancy (e.g. carcinoma)
  4. Light’s criteria
  5. Can be asymptomatic, dyspnoea, pleuritic chest pain
  6. Decreased chest expansion / breath sounds / vocal fremitus, stony dull percussion, mediastinal shift away if large
  7. Costophrenic angle blunting if small, water-dense shadow with concave upper border if larger, ‘white out’
  8. Protein, glucose, WBC, amylase, cytology, culture, lipids
  9. Aspirate triglycerides > 1.1 g/L
  10. Turbid, yellow, low pH/glucose, high LD
  11. Conservative if small (will go away by itself), if large then surgical drain, talc pleurodesis if recurrent
25
Q

Pneumothorax

  1. Primary causes
  2. Secondary causes
  3. Signs
  4. What denotes ‘small’ pneumothorax on CXR
  5. Large pneumothorax management
A
  1. Trauma, iatrogenic
  2. COPD, asthma, carcinoma, cystic fibrosis, connective tissue disease
  3. Tachypnoea, decreased lung expansion, hyporesonant on percussion, absent vocal fremitus, tracheal deviation + mediastinal shift away in tension
  4. < 2 cm
  5. Intercostal drain
26
Q

Pneumonia - organisms associated with

  1. Alcoholics/diabetics
  2. Recent hotel stay (+ specific test)
  3. Dehabilitated / IVDUs
  4. Parrot owners
  5. Community acquired
  6. Aspiration-associated
  7. Hospital acquired
  8. Atypical bacteria - examples
  9. ABX management
A
  1. Klebsiella
  2. Legionella, urine specific antigen
  3. Staphylococcus aureus
  4. Chlamydia psittaci
  5. Streptococcus pneumoniae, haemophilus influenzae, moraxella catarrhlis, mycoplasma pneumoniae
  6. Gram negative bacilli (pseudomonas aeruginosa, serratia marcescens, E.coli, klebsiella), streptococcus pneumoniae, coxiella burnetii, anaerobes
  7. Gram negative bacilli, (enterobacteriaceae) pseudomonas aeruginosa, anaerobes, staphylococcus aureus
  8. Legionella, psittaci, mycoplasma, Q fever (coxiella)
  9. Macrolide (clarithromycin), quinolone (levofloxacin), tetracycline (doxycycline)
27
Q

Auscultation sounds

  1. Inspiratory stridor - cause
  2. Expiratory stridor - cause
  3. Biphasic stridor - cause
  4. Stertor - definition and cause
  5. Wheeze - definition and cause
  6. Stridor - acute management
A
  1. Laryngeal obstruction
  2. Tracheobronchial obstruction
  3. Subglottic or glottic obstruction
  4. Low pitched snoring sound due to stenosis between nasopharynx and supraglottic region
  5. Polyphonic expiratory airway sound caused by lower airway narrowing
6. Stabilise - high flow O2, involve senior
Suction secretions / clear foreign body
Adrenaline + steroids - IV or inhaled
Bloods including an ABG
May need a surgical airway
28
Q

Mycoplasma

  1. Presentation
  2. Specific blood test result
  3. CXR findings
  4. Diagnosis
  5. Complications
  6. Management
A
  1. Insidious with flu-like symptoms (headache, myalgia, arthralgia), then dry cough, haemolytic anaemia
  2. Cold agglutins (can cause autoimmune haemolytic anaemia)
  3. Reticular/nodular shadowing / patchy consolodation in one lower lobe, worse than signs suggest
  4. PCR sputum / serology
  5. Erythema multiforme, Stevens-Johnson syndrome, meningoencephalitis / myelitis, GBS
  6. Clarithromycin / doxycycline / fluroquinolone
29
Q

Pneumococcal vaccine - at risk groups

  1. Age
  2. Chronic disease (4 organs)
  3. DM if
  4. Immunosuppressed
  5. Contraindicated in
A
  1. > 65yo
  2. Heart, liver, renal, lung
  3. On medication i.e. not controlled by diet
  4. Low spleen function, AIDS, active chemotherapy, on high dose >20mg/d prednisolone
  5. Pregnancy/breastfeeding, fever, previous anaphylaxis to vaccine/one of its components
30
Q

Pneumococcal pneumonia

  1. When it occurs
  2. Specific clinical findings
  3. X-ray findings
  4. Management
A
  1. Commonest bacterial
  2. Fever, pleurisy, herpes labialis
  3. Lobar consolidation
  4. Amoxicillin, benzypenicillin, cephalosporin
31
Q

Staphylococcal pneumonia

  1. When it occurs
  2. X-ray findings
  3. Management
A
  1. Complication of flu, young, elderly, IVDU, comorbid from leukaemia / lymphoma / cystic fibrosis
  2. Bilateral cavitating bronchopneumonia
  3. Flucloxacillin +/- rifampicin, if MRSA consider vancomycin
32
Q

Klebsiella pneumonia

  1. When it occurs
  2. X-ray findings
  3. Management
A
  1. Alcoholics/diabetics
  2. Upper lobe cavitating pneumonia
  3. Cefotaxime / imipenem
33
Q

Psuedomonas pneumonia

  1. At risk groups
  2. Management
A
  1. Bronchiectasis, cystic fibrosis, HAP on ITU / post-op

2. Anti-pseudomonal penicillin / ceftazidine / meropenem / ciprofloxacin and aminoglycoside (consider dual therapy)

34
Q

Legionella pneumophilia

  1. Colonises (therefore places at risk)
  2. Respiratory symptoms
  3. Extra-pulmonary features
  4. CXR findings
  5. Blood test findings
  6. Urine tests
  7. Management
A
  1. Water tanks <60 degrees (e.g. hotel air conditioning, hot water systems)
  2. Flu like (fever, malaise, myalgia), then dry cough and dyspnoea
  3. Anorexia, D+V, hepatitis, renal failure, confusion, coma
  4. Bibasal consolidation
  5. Lymphopaenia, low Na+, deranged LFTs
  6. Dipstick (haematuria), urine antigen/culture
  7. Fluroquinolone / clarithromycin
35
Q

Chlamydophila

Pneumoniae (commonest)

  1. Clinical symptoms
  2. Diagnostic test (2)

Psittaci

  1. Caught from
  2. Causes
  3. Respiratory symptoms
  4. Extra-pulmonary symptoms
  5. Severe extra-pulmonary features
  6. CXR findings
  7. Diagnosis
  8. Management (both types)
A
  1. Biphasic illness: pharyngitis/hoarseness/otitis, then pneumonia
  2. Chlamydophila complement fixation test, PCR invasive samples
  3. Parrots
  4. Psittacosis, orthinosis
  5. Dry cough,
  6. Headache, fever, lethargy, arthralgia, anorexia, D+V
  7. Meningoencephalitis, infective endocarditis, hepatitis, nephritis, splenomegaly
  8. Patchy consolidation
  9. Chlamydophila serology
  10. Doxycycline / clarithromycin
36
Q

Pneumocystic pneumonia

  1. Patient cohort
  2. Responsible organism
  3. Symptoms
  4. CXR findings
  5. Diagnosis
  6. Management
  7. Indications for prophylaxis
A
  1. Immunosuppressed
  2. Pneumocystis jirovecii
  3. Dry cough, exertional dyspnoea, low PaO2, fever, bilateral crepitations
  4. Normal / bilateral perihilar interstitial shadowing
  5. Organism visualisation via induced sputum / bronchoalveolar lavage / lung biopsy
  6. High dose co-trimoxazole / pentamidine slow IV if severe, + steroids if severely hypoxaemic
  7. CD4 count < 200, or after 1st attack
37
Q

Avian flu

  1. Suspect if
  2. Diagnosis
  3. Management
A
  1. Chest symptoms, fever > 38, CXR consolidation, conjunctivitis, contact with birds
  2. Viral culture +/- reverse transcriptase PCR with H5/N1 specific primers
  3. Isolate, O2/ventilatory support, antiviral e.g. oseltamivir
38
Q

Coronaviruses

  1. SARS cause
  2. SARS clinical findings
  3. MERS cause
  4. MERS symptoms
  5. Incubation period
A
  1. SARS-CoC virus
  2. Fever >38, chills, rigors, myalgia, LOW WCC
  3. MERS CoV - camel transmitted
  4. Fever, cough, SOB, GI upset
  5. 14 days
39
Q

Pneumonia - CXR findings, likely organism

  1. Lobar consolidation
  2. Bilateral cavitating bronchopneumonia
  3. Upper lobe cavitating
  4. Reticular nodular shadowing / patchy consolidation of one lower lobe
  5. Bi-basal consolidation
  6. Patchy consolidation (general)
  7. Normal / bilateral perihilar interstitial shadowing
A
  1. Pneumococcal
  2. Staphylococcal
  3. Klebsiella
  4. Mycoplasma
  5. Legionella
  6. Chlamydopgila psittaci
  7. Pneumocystis jirovecii
40
Q

Pneumonia - complications

  1. Respiratory
  2. Cardiovascular
  3. Post-antibiotic therapy (flucloxacillin / co-amoxiclav)
A
  1. T1 respiratory failure, (ITU if PaCO2 >6 kPa), pleural effusion, empyma (recurrent fever in resolves pneumonia), lung abscess
  2. Hypotension, atrial fibrillation (usually resolves when pneumonia goes), pericarditis, myocarditis
  3. Cholestatic jaundice
41
Q

Lung abscess

  1. Causes (6)
  2. Clinical features
  3. Blood tests
  4. CXR findings
  5. Other tests
  6. Management
A
  1. Inadequately treated pneumonia, aspiration, bronchial obstruction, pulmonary infarction, septic emboli, subphrenic/hepatic abscess
  2. Swinging fever, cough, purulent sputum, pleuritic chest pain, haemoptysis, weight loss
  3. FBC (low Hb, high WCC), ESR, CRP, cultures
  4. Walled cavity, with fluid level
  5. Sputum microscopy, culture, sensitivities
  6. ABX (4-6w), postural drainage, maybe surgical incision
42
Q

Cystic Fibrosis

  1. Inheritance pattern
  2. Cause
  3. Neonatal features
  4. Respiratory features
  5. GI features
  6. Other features
  7. Diagnosis (3)
  8. CXR findings
  9. Other tests
  10. Management
A
  1. Autosomal recessive
  2. Mutation on CFTR mutation (chromosome 7)
  3. Failure to thrive, meconium ileus, rectal prolapse
  4. Cough, wheeze, recurrent infection, bronchiectaiss, pneumothorax, haemoptysis, cyanosis, finger clubbing, bilateral coarse crackles
  5. Pancreatic insuffiency (DM, steattorhoea) so malabsorption, GORD, distal intestinal obstruction, gallstones, cirrhosis
  6. Male infertility, osteoporosis (DEXA screening), arthritis, vasculitis
  7. Neonatal sweat test (sweat Na+ and Cl- >60, Cl- usually higher than Cl-), genetic mutation screening, faecal elastase (exocrine pancreatic dysfunction)
  8. Hyperinflation, bronchiectasis
  9. Annual GTT, cough swab/sputum culture, abdominal USS (fatty livier, cirrhosis, pancreatitis), faecal fat analysis
  10. Chest (physio, ABX, bronchodilators, mucolytics, annual CXR), pancreatic enzyme replacement, fat-soluble vitamin supplement
43
Q

Lung cancer - general

  1. Which cancers metastasise to the lungs
  2. Where to lung cancers metastasise to
  3. Symptoms
  4. Examination signs
  5. Differential diagnosis of nodule on CXR
  6. Complications (local, metastatic, non-M neurological)
A
  1. Breast, kidney, testes, bladder
  2. Lymph nodes, brain, bone, liver, adrenal glands
  3. Cachexia, anaemia, clubbing, HPOA (hypertrophic pulmonary ostearthropathy, causing wrist pain), supraclavicular/axillary nodes, consolidation, collapse, pleural effusion
  4. Clubbing, cyanosis, consolidation, expansion asymmetry, lymphadenopathy
  5. TB, pneumonia, secondary tumour, abscess
  6. Local (RL/phrenic nerve palsies, SVC obstruction, Horner’s syndrome from pancoast tumour), metastatic (brain, bone if pain, anaemia, high Ca2+, liver, adrenals if Addison’s), neurological (confusion, fits, cerebellar syndrome, Lambert-Eaton syndrome)
44
Q

Lung cancer - types

  1. Non-small cell (NSCLC)
  2. Small cell (oat cell) - arise from
  3. Commonest in non-smokers
  4. NSCLC management
  5. SCLC management
  6. SVC obstruction - symptoms
  7. SVC obstruction - management
A
  1. Squamous (35%, central), adenocarcinoma (27%, peripheral), large cell (10%), adenocarcinoma in situ (<1%)
  2. Kulchitsky (endocrine) cells
  3. Adenocarcinoma
  4. Lobectomy if fit/curative, parenchymal sparing if borderline fitness/small tumours. Radical radiotherapy stages 1-3, add chemo for stage 4. Platinum based monoclonal antibodies
  5. Surgery if limited, chemo + radio if well enough.
  6. SOB, headache, facial/arm swelling, stridor
  7. SVC stent, radiotherapy, dexamethasone, O2
45
Q

Non-metastatic extra-pulmonary manifestations of bronchial cancer

  1. Endocrine
  2. Neurological
  3. Vascular
  4. Cutaneous
  5. Skeletal
A
  1. Ectopic secretion: ACTH (Cushing’s - small cell), ADH (dilutional hyponatraemia - small cell), PTH (hypercalcaemia - squamous cell), HCG (gynaecomastia - large cell)
  2. Cerebellar degeneration, myopathy, polyneuropathy, myasthenic syndrome (Lambert-Eaton, when immune cells attack NMJs)
  3. Thrombophlebitis migrans, anaemia, DIC
  4. Dermatomyositis, herpes zoster, acanthosis nigricans
  5. Clubbing, HPOA
46
Q

Acute Respiratory Distress Syndrome

  1. Pathophysiology
  2. Bloods
  3. CXR findings
  4. Diagnostic criteria (4)
  5. Management
A
  1. Lung damage / inflammatory mediator release leads to increased capillary permeability, non-cardiogenic pulmonary oedema, and associated multi-organ failure
  2. FBC, U+E, LFT, CRP, amylase, clotting, cultures, ABG
  3. Bilateral pulmonary infiltrates
  4. Acute onset, bilateral pulmonary infiltrates on CXR, pulmonary capillary wedge pressure (from pulmonary artery catheter) <19 / no clinical congestive heart failure, refractory hypoxaemia (PaO2:FiO2 <200)
  5. ITU, CPAP/mechanical ventilation if PaO2 <8.3 kPa despite 60% O2, inotropes (e.g. dobutamine), vasodilators (e.g. nitric oxide for pulmonary vasoconstriction), treat sepsis, enteral feeding
47
Q

Respiratory Failure

  1. Definition
  2. Type 1 - definition
  3. Type 1 - pathophysiology
  4. V/Q mismatch - examples
  5. Type 2 - definition
  6. Type 2 - pathophysiology
  7. Type 2 - causes (4 main groups)
A
  1. PaO2 <8 kPa
  2. Hypoxia with normal/low CO2
  3. V/Q mismatch, hypoventilation, right to left cardiac shunts
  4. Pneumonia, pulmonary oedema, PE, asthma, emphysema, pulmonary fibrosis, ARDS
  5. Hypoxia with high CO2 (PaCO2 >6 kPa)
  6. Alveolar hypoventilation, with or without V/Q mismatch
  7. Respiratory disease (asthma, COPD, pulmonary fibrosis, obstructive sleep apnoea), reduced respiratory drive (sedative drugs, brain tumour/trauma), neuromuscular disease (cervical cord lesion, MG, GBS), thoracic wall disease (flail chest, kyphoscoliosis)
48
Q

Hypoxia

  1. Acute signs
  2. Chronic signs

Hypercapnia
1. Signs

A
  1. Dyspnoea, restlessness, agitation, confusion, central cyanosis
  2. Polycythaemia, pulmonary HTN, cor pulmonale
  3. Headache, peripheral vasodilation, tachycardia, bounding pulse, tremor/flap, papilloedema, confusion, drowsiness, coma
49
Q

Pulmonary Embolism

  1. Causes
  2. Symptoms
  3. Signs
  4. ABG findings
  5. CXR findings
  6. ECG signs
  7. Features of modified Wells Criteria
  8. Acute treatment - score >4 + unstable
  9. Well’s score >4 + haemodynamically stable
  10. Well’s score <4
  11. Long-term management
  12. Unprovoked - subsequent investigations and indications
  13. Prevention
A
  1. Venous thrombosis, RV thrombus (post-MI), septic emboli (right sided endocarditis)
  2. Acute SOB, pleuritic chest pain, haemoptysis, dizziness, syncope
  3. Pyrexia, cyanosis, high HR/RR, hypotension, raised JVP, pleural rub/effusion
  4. Low PaO2 and low PaCO2
  5. Normal, or oligaemia of affected segment, wedge shaped opacities or cavitation
  6. Normal, or tachycardia, RBBB, RV strain (e.g. large S in 1, Q in 3, inverted T in V1-4)
  7. DVT signs/symptoms (pain), HR >100, recent immobility, previous DVT/PE, haemoptysis, cancer, alternative less likely
  8. Thrombolyse with alteplase 10mg IV 1 min, then 90mg IVI over 2 hours
  9. Immediate CTPA or empirical LMWH if delay (unfractioned if renal impairment) for 5 days
  10. D-dimer, then if positive same as above
  11. DOAC or warfarin (for warfarin, stop heparin when INR 2-3) for 3 months (provoked) / 6 months (unprovoked)
  12. For malignancy - (full exam including breast, CXR, FBC, calcium, LFTs, urinalysis - CTAP/mammography if F >40), antiphospholipid/thrombophilia testing if FH positive
  13. Heparin to all immobile patients, stop HRT/COCP pre-op
50
Q

Pleural fluid analysis

  1. Clear, straw coloured (2)
  2. Turbid, yellow (2)
  3. Haemorrhagic (3)

Cytology

  1. Neutrophils
  2. Lymphocytes
  3. Mesothelial cells
  4. Mutinucleated giant cells
  5. Glucose <3, pH <7.2, high LDH
  6. High amylase
A
  1. Transudate, exudate
  2. Empyema, parapneumonic
  3. Trauma, malignancy, pulmonary infarct
  4. Parapneumonic, PE
  5. Malignancy, TB, SLE, RA, sarcoid
  6. Pulmonary infarct, mesothelioma if abnormal cells
  7. Rheumatoid arthritis
  8. Empyema, malignancy, TB, RA, SLE
  9. Pancreatitis, carcinoma, bacterial pneumonia, oesophageal rupture
51
Q

Obstructive sleep apnoea

  1. What is it
  2. Typical history
  3. Complications (2)
  4. Investigations, including scale
  5. When is it classified as ‘significant’
  6. Management - conservative
  7. Management - 1st line if moderate/severe
  8. Management - if mild and can’t tolerate above
A
  1. Intermittent closure/collapse of pharyngeal airway
  2. Obese middle aged man, snoring, daytime somnolence, morning headache, partner reports apnoeic episodes
  3. Pulmonary hypertension, type 2 respiratory failure
  4. Epworth sleep scale, Pulse oximetry and video recordings often sufficient; polysomnography diagnostic
  5. 15+ episodes of apnoea/hyponoea in 1 hour of sleep
  6. Weight reduction, avoid tobacco/alcohol
  7. Sleep CPAP
  8. Mandibular advancement device
52
Q

Cor pulmonale

  1. What is it
  2. Respiratory causes
  3. Pulmonary vascular disease causes
  4. ‘Other’ causes
  5. Clinical features
  6. CXR findings
  7. ECG findings
  8. Blood results
  9. Management
A
  1. Right heart failure caused by chronic pulmonary arterial hypertension
  2. COPD, bronchiectasis, fibrosis, severe asthma, resection
  3. Emboli, vasculitis, primary pulmonary HTN, ARDS, sickle cell
  4. Thoracic cage abnormality (kyphosis, scoliosis), neuromuscular (myaesthenia gravis, poliomyelitis, MND) hypoventilation (sleep apnoea, large adenoids in children), cerebrovascular disease
  5. Dyspnoea, fatigue, syncope, cyanosis, tachycardia, raised JVP with prominent A+V waves, RV heave, loud P2 pansystolic murmur (tricuspid regurgitation), early diastolic Graham Steell murmur, hepatomegaly, oedema
  6. Enlarged right atrium and ventricle, prominent pulmonary arteries
  7. P pulmonale, right axis deviation, right ventricular hypertrophy (R/S ratio >1 in V1) / strain (ST depression/T wave inversion in right leads e.g. V1-3, II, III, aVF
  8. Secondary polycythaemia (high Hb and haematocrit)
  9. Treat underlying cause, acute respiratory failure, cardiac failure (furosemide 40-160mg po or spironolactone), venesection if haematocrit >55%, heart-lung transplant in young patients
53
Q

Interstitial lung disease

  1. Generic name for
  2. Clinical features
  3. Pathological features
  4. Causes (occupational, drugs, infection, systemic, idiopathic, other)
A
  1. Condition diffusely affecting lung parenchyma
  2. Exertional dyspnoea, paroxysmal dry cough, restrictive spirometry
  3. Interstitial fibrosis/remodelling, chronic inflammation, hyperplasia of type 2 epithelial cells/pneumocytes
  4. Asbestosis, nitrofurantoin, bleomycin, amiodarone, sulfasalazine, TB, GORD, hypersensitivity reaction, IPF
54
Q

Extrinsic allergic alveolitis

  1. Causes
  2. Acute exposure features
  3. Acute test results (blood, CXR, lung function)
  4. Chronic features
  5. Chronic blood results
  6. Management
A
  1. Bird / farmer (hay) / mushroom / malt workers
  2. Fever, rigors, myalgia, dry cough, SOB, fine bibasal crackles - hours after exposure to antigen
  3. Raised WCC / ESR / antibodies, upper zone mottling/consolidation/BHL on CXR, reversible restrictive defect
  4. Clubbing, worsening SOB, weight loss, T1 RF
  5. Serum antibodies, nodules / ground glass appearance / extensive fibrosis on CXR
  6. Remove/avoid allergen, O2 if required (acute) PO prednisolone

Medical School (28 decks)

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