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Phase 3B > Respiratory > Flashcards

Respiratory Flashcards

1
Q

What are the characteristics of asthma symptoms (wheeze, breathlessness, chest tightness and cough)?

A

Worse at night and early morning
In response to exercise, cold air, and allergen exposure
In response to aspirin or beta blockers
Occur apart from colds

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2
Q

What is the pathophysiology behind asthma?

A

Reversible obstructive airway inflammation and bronchial hyper-responsiveness

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3
Q

Describe the wheeze of asthma.

A

High pitched
Polyphonic
Expiration

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4
Q

What should a GP do if there is a high probability of asthma?

A

Move to a trial of treatment and reassess in 2-3 months

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5
Q

How is asthma diagnosed?

A

Spirometry: changes in PEFR or FEV1 10 minutes after bronchodilator
>12% improvement in lung function

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6
Q

What is the treatment of asthma?

A

1) SABA
2) ICS + SABA
3) LTRA, ICS + SABA
4) LABA, ICS + SABA
5) MART
6) MART, ↑dose ICS within the MART
7) MART, ↑dose ICS/theophylline

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7
Q

How do short acting beta agonists such as salbutamol or terbutaline work?

A

Act on beta-2 adrenoreceptor –> smooth muscle relaxation –> dilation of bronchial passages

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8
Q

How do inhaled corticosteroids such as beclomethasone dipropionate or budesonide work?

A

Reduce chronic inflammation and decreases reactivity of the airways

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9
Q

What are the indications of an inhaled corticosteroid?

A

Beta agonist being used >2 times per week
Symptoms disturb sleep >1 week
Exacerbation in last 2 years
All children with new diagnosis should be started on ICS.

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10
Q

How do leukotriene receptor antagonists such as Montelukast work?

What are leukotrienes?

A

Block the action of leukotriene D4 in the lungs –> decreases inflammation and relaxes smooth muscle

Leukotrienes are an immune molecule which promote bronchoconstriction, inflammation, microvascular permeability, and mucous secretion.

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11
Q

How do long acting beta agonists such as salmeterol and formoterol have a longer lasting effect?

A

Addition of a long lipophilic side chain that binds to an exosite on adrenergic receptors, allowing the active part of the molecule to continuously bind and unbind.

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12
Q

What is the condition characterised by partially reversible obstructive lung disease, associated with an abnormal inflammatory response of the lungs to noxious particles or gases?

A

COPD

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13
Q

Define airflow obstruction in COPD.

A

Reduced post bronchodilator FEV1/FVC ratio (less than 0.7)

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14
Q

What are the symptoms of COPD?

A

Asymptomatic in early stages

Exertional dyspnoea, chronic cough, regular sputum production, frequent winter bronchitis, wheeze.

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15
Q

What are the signs of COPD?

A 
Cachexia
Hyperinflated chest
Pursed lip breathing
Use of accessory muscles
Paradoxical movement of lower ribs
Wheeze/quiet breath sounds
Peripheral oedema
Cyanosis
Raised JVP
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16
Q

What is the main respiratory drive in COPD?

A

Hypoxia (rather than PaCO2)

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17
Q

How is COPD diagnosed?

A

Stage 1 mild: FEV1 >80% predicted
Stage 2 moderate: FEV1 50-79% predicted
Stage 3 severe: FEV1 30-49% predicted
Stage 4 very severe: FEV1 <30% predicted (or less than 50% with respiratory failure)

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18
Q

What other investigations are required in COPD?

A

CXR
FBC
BMI
Alpha-antitrypsin if early onset, family history, or minimal smoking

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19
Q

Which vaccinations do COPD patients receive?

A

Pneumococcal and influenza

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20
Q

What is the management of stable COPD?

A

1) SABA/SAMA (salbutamol or ipratropium)
* assess steroid responsiveness*
2) YES: ICS + LABA (+SABA) NO: LABA + LAMA (+SABA)
3) LABA + LAMA + ICS (+SABA)

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21
Q

What is a SAMA?

A

Short acting antimuscarinic

Ipratropium

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22
Q

What is a LAMA?

A

Long acting antimuscarinic

E.g. tiotropium or glycopyrronium bromide

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23
Q

What are the indications for oxygen in COPD?

A 
FEV1<30%
Cyanosis
Polycythaemia
Peripheral oedema
Raised JVP
Saturations <92%
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24
Q

What is the management of an exacerbation of COPD?

A

Increase dose/frequency of SABA
Prednisolone 30mg OD 7-14d
Salbutamol/ipratropium nebs

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25
Q

What are the most common causes of infective exacerbations of COPD?

A

Rhinovirus
Influenza
Adenovirus
Bacterial - Hib, strep pneumoniae

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26
Q

If bacterial exacerbation of COPD is suspected (purulent sputum, signs of consolidation), which antibiotics should be prescribed?

A

Amoxicillin

Doxycycline

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27
Q

What is the cause of cystic fibrosis?

A

Mutation in the CF transmembrane conductance regulator (CFTR) gene on chromosome 7

Delta F508 mutation

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28
Q

What is the pathophysiology of CF?

A

CFTR: ATP responsive chloride channel so does not absorb chloride ions, which remain in the lumen and prevent sodium absorption.
High sodium sweat, pancreatic insufficient, reduce mucociliary clearance in the airway

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29
Q

What are the symptoms of CF

A 
Recurrent LRTI with chronic sputum production
Bowel obstruction with meconium ileus
Rectal prolapse
Nasal polyps
Bronchiectasis
Male infertility
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30
Q

Why are males with CF infertile?

A

Congenital bilateral absence of vas deferens

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31
Q

What are the signs of CF?

A

Finger clubbing
Crackles and wheeze
FEV1 shows obstruction

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32
Q

How is CF diagnosed?

A

Immunoreactive trypsinogen on Guthrie test

Sweat testing chloride >60mmol/L, lower sodium (pilocarpine)
Molecular genetic testing
ard X-Ray/CT - opacification of the sinuses
Stool elastase for pancreatic insufficiency

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33
Q

How is CF treated?

A

Twice daily chest physiotherapy
Regular physical exercise
Prophylactic antibiotics

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34
Q

How are the following treated in CF:

1) Nasal polyps
2) Pancreatic insufficiency
3) Thickened mucus

A

1) nasal steroids/polypectomy
2) pancreatic enzymes
3) rhDNAse or mannitol dry powder

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35
Q

What are the indications of azithromycin in CF?

A

As an immunomodulator: deteriorating lung function, repeated exacerbations

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36
Q

What are the complications of CF?

A

Bronchiectasis

Cor pulmonale

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37
Q

When does respiratory failure occur?

A

Disease of the heart or lungs leads to hypoxia +/- hypercapnia

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38
Q

What is Type 1 respiratory failure and what are the causes?

A

Hypoxia <8kPa and normal/low PaCO2

COPD, pneumonia, p.fibrosis, asthma, PE, ARDS, bronchiectasis

39
Q

What is Type 2 respiratory failure and what are the causes?

A

Hypoxia <8kPa and hypercapnia (PaCO2>6kPa)

COPD, asthma, myasthenia, polio, head/neck injuries, pulmonary oedema

40
Q

What are the symptoms of respiratory failure?

A 
S+S of underlying cause
Confusion and reduced GCS
Tachycardia and arrhythmias from hypoxia and acidosis
Cyanosis
Polycythaemia if long standing hypoxia
41
Q

How is respiratory failure diagnosed?

A

ABG
CXR
FBC

42
Q

How is respiratory failure treated?

A

ICU and resuscitation
oxygen (unless patients rely on their hypoxic drive. elevation of PaO2 may reduce ventilation rate so Co2 rises dangerously)
Assisted ventilation

43
Q

What is a pneumothorax?

A

Collection of air in the pleural cavity resulting in collapse of the lung on the affected side

44
Q

What is a tension pneumothorax?

A

Pleural pressure > alveolar pressure

Air passes through the valve on inspiration, but cannot escape on exhalation

45
Q

What are the causes of primary pneumothoraces?

A

Rupture of subpleural bleb and bullae
Penetrating chest wound
Lung biopsy
Thoracic endometriosis

46
Q

What are the signs and symptoms of tension pneumothoraces?

A

Sudden pain, dyspnoea, sweating, cyanosis, hypotension

Trachea deviated away from collapse, hyperresonance on percussion, reduced breath sounds

47
Q

How is a pneumothorax diagnosed?

A

Erect CXR in inspiration

48
Q

What is the treatment of a tension pneumothorax?

A

Tension: needle decompression mid clavicular line, 2nd IC space.

49
Q

What is the treatment of a normal pneumothorax (if short of breath)?

A

<1cm: admit, give oxygen, review in 24h
1-2cm: aspirate
>2cm: insert chest drain (anterior/mid axillary line, 5th IC space)

50
Q

What is the safe triangle of chest drain insertion?

A

Latissimus dorsi, pectoralis major, line superior to the nipple, and apex at the axilla.

51
Q

What are the types of pulmonary fibrosis?

A

Replacement fibrosis secondary to lung damage
Focal fibrosis in response to irritants
Diffuse parenchymal lung disease which occurs in IPF and EAA.

52
Q

What are the s+s of idiopathic pulmonary fibrosis?

A 
Dyspnoea
Persistent dry cough
Bilateral inspiratory crackles
Clubbing
Systemically unwell, weight loss
Extra-articular features such as arthralgia
53
Q

How is IPF diagnosed?

A

High resolution CT - pattern of usual interstitial pneumonia - honeycombing, basal predominance, reticular pattern

CXR, spirometry, gas transfer

54
Q

What is the treatment of IPF?

A

Physiotherapy and oxygen
Pirfenidone
Nintedanib

55
Q

What is nintedanib?

A

Intracellular tyrosine kinase inhibitor

antifibrotic and anti-inflammatory

56
Q

What is extrinsic allergic alveolitis?

A

Diffuse granulomatous inflammation of parenchyma and airways in people who have been sensitised by repeated inhalation of antigens in dusts.

Hypersensitivity reaction

57
Q

Name three types of EAA and the allergen.

A

Farmer’s lung: mouldy hay
Bird fancier’s lung: avian proteins
Cheese worker’s lung: mouldy cheese

58
Q

How does EAA present?

A

Acute: starts 4-8h post exposure, resolve within days. flu-like, tight chest, dry cough, dyspnoea, anorexia, crackles

Chronic: gradual decrease in exercise tolerance, cyanosis, clubbing, hypoxia, PHTN.

59
Q

How is EAA diagnosed?

A

High resolution CT
LFTs (restrictive if acute, mixed if chronic)
CXR
Inhalation challenge

60
Q

How is EAA treated?

A

Oxygen
Avoid allergen
Corticosteroids

61
Q

In pleural effusions, how are transudates and exudates differentiated?

A

Transudates: protein <30g/L
Exudates: protein >30g/L

If pleural protein is 25-35g/L, apply Light’s criteria

62
Q

What are the causes of bloody pleural fluid (>1%)?

A

Malignancy
Trauma
PE

63
Q

Give some examples of transudate pleural effusions.

A 
Heart failure
Cirrhosis
Hypoalbuminaemia
Peritoneal dialysis
Nephrotic syndrome
64
Q

Give some examples of exudate pleural effusions.

A

Pneumonia
Malignancy
Autoimmune disease
TB

65
Q

What are the symptoms of alpha-antitrypsin deficiency?

A

Cirrhosis and HCC in adults
Cholestasis in children
Basal emphysema (COPD=apical emphysema)

66
Q

What occurs if a COPD patient is given too much oxygen?

A

Acute respiratory acidosis on top of chronic resp acidosis with metabolic compensation

67
Q

What are the symptoms of sarcoidosis?

A 
Bilateral hilar lymphadenopathy
Cough
Low grade/swinging fever
Erythema nodosum
Facial palsies
Ocular problems
Parotid enlargement
Hypercalcaemia
68
Q

When stepping down asthma treatment, how should you reduce the dose of inhaled steroids?

A

By 25-50% at a time

69
Q

What is atelectasis?

A

Common post-operative complication in which basal alveolar collapse can lead to respiratory difficulty

70
Q

What occurs in lung function tests in obstructive lung disease and give examples?

A

FEV1 reduced
FVC reduced/normal
FEV1:FVC reduced

Asthma, COPD, bronchiectasis

71
Q

What occurs in lung function tests in restrictive lung disease and give examples?

A

FEV1: reduced/normal
FVC: reduced
FEV1:FVC: normal/increased

IPF, ARDS, kyphoscoliosis.

72
Q

What is the name of the condition characterised by permanent dilatation and thickening of the airways, secondary to chronic infection or inflammation?

A

Bronchiectasis

73
Q

Why does bronchiectasis develop?

A 
Post-infective: TB, pneumonia, measles
Immunodeficiency
Cystic fibrosis
Ciliary dyskinetic syndrome e.g. Kartagener's syndrome
Lung cancer
74
Q

How is bronchiectasis diagnosed?

A

CXR: tramlines
CT: tramlines and signet ring signs

75
Q

What are the features of Kartagener’s syndrome?

A

Dextrocardia/situs inversus
Bronchiectasis
Recurrent sinusitis
Subfertility

76
Q

What are the types of lung cancer?

A

Small cell: 15%, worse prognosis

Non-small cell: usually squamous or adenocarcinoma

77
Q

Which lung cancer is not related to smoking?

A

Alveolar cell carcinoma/adenocarcinoma

78
Q

What are the signs and symptoms of lung cancer?

A 
Persistent cough
Haemoptysis
Dyspnoea
Chest pain
Weight loss and anorexia
Fixed monophonic wheeze
Clubbing
Hoarseness
79
Q

What extra features are associated with small cell lung cancer?

A

Ectopic ADH (hyponatraemia) or ACTH (Cushing’s, hypokalaemic alkalosis) secretion

80
Q

How does squamous cell carcinoma of the lung result in hypercalcaemia?

A

Associated with parathyroid hormone related protein secretion

81
Q

What is acute respiratory distress syndrome?

A

Non-cardiogenic pulmonary oedema

Increased permeability of alveolar capillaries leading to fluid accumulation in the alveoli

82
Q

What are the causes of ARDS?

A 
Sepsis, pneumonia
Massive blood transfusion
Trauma
Smoke inhalation
Acute pancreatitis
83
Q

How is occupational asthma diagnosed?

A

Peak flow diary = home and work

84
Q

What are the components of the CURB score?

A

1 point for:

Confusion (new, or abbreviated mental test score (AMTS) <8)
Blood urea nitrogen >7mmol
RR>=30
Systolic BP<90, or diastolic BP<=60
Age >=65
85
Q

What is Lambert-Eaton myasthenic syndrome?

What are the symptoms?

A

Paraneoplastic syndrome associated with small cell lung cancer of the lung

Difficulty walking and muscle tenderness from autoimmune destruction of calcium channels on the presynaptic motor neurone terminal.

86
Q

Which organisms cause atypical pneumonia (dry cough)

A

Legionella pneumophilia
Mycoplasma pneumonia
Chlamydia psittaci
Coxiella burnetti

87
Q

What are the symptoms of atypical pneumonia?

A

Dry cough and dyspnoea
Type 1 respiratory failure
Nausea, vomiting, diarrhoea
SIADH - hyponatraemia
Transient hepatitis (raised aminotransferases)
Rashes (erythema multiforme, rose spots)
Confusion, drowsiness (presents like meningo-encephalitis)

88
Q

How may atypical pneumonia be treated?

A

Rifampicin
Erythromycin
Tetracycline

Treat as CAP until culture confirms diagnosis i.e. amoxicillin and macrolide

89
Q

What is the respiratory aspect of management of Guillain Barre syndrome?

A

4-6 hourly spirometry

Any significant reduction in FEV1 = assisted ventilation

90
Q

What results suggest a COPD patient is a chronic CO2 retainer?

A

Elevated serum bicarbonate - partial compensation for respiratory acidosis

91
Q

Hyperventilation leading to hypoxia may lead to…

A

Respiratory alkalosis

92
Q

Lymphoid =

Myeloid =

A

leucocytes

Everything else - neutrophils basophils

93
Q

2 pharmacological treatments to maintain sobriety.

A

Antabuse (disulfiram) - makes you feel sick when you drink

Acamprosate - stops cravings

94
Q

What are the differentials for nocturnal cough?

A

Asthma
Congestive cardiac failure
Sinusitis with post nasal drip
Gastro-oesophageal reflux

Phase 3B (20 decks)

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