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Bpt > Respiratory > Flashcards

Respiratory Flashcards

1
Q

Where is the central area for stimulation of inspiration

A

medulla- dorsal respiratory group

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2
Q

Where are the central chemoreceptors

A

Near ventral surface of the medulla

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3
Q

Anion Gap Equation

A

ANION GAP:
= Na – (Cl + HCO3) – 12
Normal anion gap = 12mmol/L +/- 2

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4
Q

Osmolar gap equation

A

OSMOLAR GAP: calculate if anion gap is increased and unclear cause
Difference in measured and calculated osmolality
Should be <10

Calculated osmolality =
(2xNa) +Glucose +Urea

Measured osmolality – calculated osmolality = Osmolar gap

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5
Q

Lung volume at which pulmonary vascular resistance is lowest

A

FRC

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6
Q

Definition of pulsus paradoxus

A

an inspiratory drop in blood pressure of 10mmHg or more during normal breathing

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7
Q

A-A Gradient equation

A

• PA02 = (Patm – Pwater)FiO2 – PaCO2/0.8
= 150 – PaCO2/0.8
• A-a gradient = PA02 – Pa02
= 150 – PaCO2/0.8 – PaO2

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8
Q

Indirect Bronchoprovocation drugs

A

Mannitol, adenosine monophosphate, eucapnic hyperventialtion

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9
Q

Direct Bronchoprovocation drugs

A

methacholine, histamine

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10
Q

Which histo subtype of malignant mesothelioma has the worst/best prognosis

A

Sarcomatoid - worst

Papillary mesothelioma -best

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11
Q

Mx of mesothelioma

A

Unresectable - Platinum +Pemetrexed

+/- bevacizumab

If progess on first line: Gemcitabine

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12
Q

Causes of Upper Lung Fibrosis

A 
Upper lobe
	- Coal miners pneumoconiosis
	- Hypersensitivity pneumonitis (extrinsic allergic alveolitis)/ Histiocytosis
	- Ank Spond
	- Radiation
	- TB
Silicosis/Sarcoidosis
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13
Q

Left shift in O2 curve

A 
↓H+ (↑pH) and CO2
↓Temperature
↓DPG-phosphate from metabolism
COHb 
MetHb
↑HbF
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14
Q

Right shift in O2 curve

A 
↑H+ (↓pH) and CO2
↑Temperature
↑2-3 DPG-phosphate from metabolism
Cyanide 
↓HbF
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15
Q

Right shift in O2 curve

A 
↑H+ (↓pH) and CO2
↑Temperature
↑2-3 DPG-phosphate from metabolism
Cyanide 
↓HbF
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16
Q

Flow Volume loop: Flat bottom

A

Dynamic extrathoracic obstruction

Cause:
Structural or functional vocal fold abnormalities
Laryngomalacia
Tracheomalacia of the extrathoracic trachea

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17
Q

Flow Volume loop: Flat top

A

Dynamic intrathoracic obstruction

Cause:
Tracheomalacia of intrathoracic airway
Bronchogenic cysts
Malignant tracheal lesions

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18
Q

Flow Volume loop: Flat both top and bottom

A

Fixed obstruction

Cause:
Firm tracheal lesions (e.g. tracheal stenosis)
Extraluminal Tracheal Obstruction (goitre)

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19
Q

Flow Volume loop: Sawtooth

A

Cause:
OSA
NMD
Parkinsons

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20
Q

Methaemoglobinaemia

A
  • Iron is in Fe3+ state rather than Fe2+, so reduced oxygen affinity for Hb while remaining O2 bound to normal Hb binds tighter (left shift)
  • Can be congenital (eg. Haemoglobin M disease or acquired (eg. Dapsone)
  • Cyanosis with normal PaO2.
  • Treatment: methylene blue
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21
Q

Lights Criteria

A
  • Pleural fluid protein/serum ratio >0.5
  • Pleural fluid LDH/serum LDH ratio >0.6
  • Pleural fluid LDH > 2/3 the upper limits of the laboratory’s normal serum LDH
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22
Q

Transudative pleural effusion

A

 Serum: Pleural protein - >31g/L most likely transudative
 If <31 g/L consider measuring albumin gradient (particularly if hepatic hydrothorax is likely)
• >12 g/L most likely transudate
• Ratio <0.6 the most sensitive for transudate

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23
Q

Mesothelioma malignancy markers

A

– Mesothelin, Fibulin 3; SMRP (Serum mesothelin related protein good for sarcomatoid mesothelioma), Calcretin

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24
Q

Pleural pH when testing for empyema

A

• Pleural pH is only reliable if checked within 1 hour of obtaining otherwise it begins to rise; pleural glucose <2.2 is just as sensitive as pH and can be stable for up to 24 hours

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25
Q

Management of pleural infection

A

IVABx
Drainage

Treatment Failure:
-Surgical: VATS/Thoracotomy

Not a surgical candidate:
-TPA and DNase

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26
Q

Mx of malignant pleural effusions:

A
  1. USS guided thoracocentesis
  2. If NO lung expansion:
    - Survival >1 week Consider IPC
    - Survival <1 week then palliate and consider repeat thoracocentesis
  3. If Lung expansion occurs:
    - IPC (indwelling pleural catheter - improved length of hospital stay, increased risk of infections)
    - VATS pleurodesis
    - Combo IPC and talc (increased rate of pleurodesis in 35 days)
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27
Q

Varenicline (Champix)

A

Partial agonist of nicotinic receptors

o Most effective monotherapy
o CIs: Pregnancy, psychiatric disease, CVD, reduce dose in renal disease, SEs: Nausea

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28
Q

Bupropion (Zyban)

A

o Antidepressent with uncertain mechanism

o CI: bipolar, seizures, pregnancy, MAO-I use

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29
Q

AAT Pathophysiology

A

• Emphysema thought to result from imbalance between neutrophil elastase (destroys elastin) and elastase inhibitor (AAT) – toxic loss of function
o Pathogenesis of liver disease is a “toxic gain of function” – accumulation of AAT within hepatocyte

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30
Q

CF PAthogenesis

A

• Pathogenesis – CFTR protein dysfunction: functions as cAMP-regulated Cl- channel (also other ions)
o Located on apical plasma membranes in lungs (regulates secretions)

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31
Q

CF Genetics

A

AR

Delta F508 mutation with deletion of phenylalanine at position 508

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32
Q

Kalydeco/Ivakaftor

A

Oral active inhibitor for G551d stop mutation in CF

Potentiates CFTR channel

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33
Q

Definition of classic CF

A

homozygous mutations or positive sweat test with >1 organ system affected

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34
Q

Non Classical CF Definition

A

Milder symptoms with either heterozygote or no mutations detected

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35
Q

ABPA diagnostic Criteria

A

Major Criteria:
o Clinical: Asthma
o Radiographic: Pulmonary opacities (transient or chronic); central bronchiectasis
o Immune: Eosinophilia; immediate skin reactivity to Aspergillus antigen; serum IgE > 1000 IU/ml

Minor Criteria
o Fungal elements in sputum; expectoration of brown plugs/flecks; delayed skin reactivity to fungal antigens

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36
Q

ABPA Mx

A

Steroids; Itraconazole as second line

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37
Q

ABPA XR

A

Finger in glove appearance

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38
Q

Sarcoid PFTs

A

Restrictive pattern, decreased DLCO

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39
Q

Pulm HTN Classification

A

o Group 1: PAH (eg. idiopathic, heritable (BMPR2, ALK1), drugs (eg. Amphetamines, IFN), CTD
o Group 2: Left heart disease (most common): Elevated LA pressure (mLAP >14mmHg)
o Group 3: Lung disease (+/- hyoxaemia) Eg. COPD, ILD
o Group 4: CTEPH - V/Q best screening test, special phase CTPA gold-standard
o Group 5 – Multifactorial - Eg. Chronic haemolytic anaemia, myeloproliferative disorders, sarcoid

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40
Q

STOP BANG Screening OSA

A

o Snoring, Tiredness, Observed apnea, Pressure (BP), BMI, Age, Neck circumference, Gender; Score 3 or more = 88-93% sensitivity

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41
Q

Diagnosis of OSA

A

Clinical diagnosis – AHI >5/hr plus 1 symptom or AHI of >15/hr
o Symptoms: fatigue, insomnia, PND, snoring, breathing interruptions HTN, mood disorder, cognitive dysfunction, CAD, stroke, CCF, AF, T2DM

• General consensus – AHI <5 is normal, 5-15 mild, 15-30 moderate and >30 severe

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42
Q

Strongest correlation with CVS events in OSA

A

oxygen desaturation index of 4% - number of times oxygen dips by 4% from baseline per hour of sleep

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43
Q

Mx OSA

A

o Weight loss can reduce severity of OSA and in some cases eliminate OSA altogether
 Calorie counting, Very low energy diet, Bariatric intervention
o Positional treatment – efficacious in 25% of patients with OSA when laying on back
o Mandibular splint – For mild to moderate OSA; Brings lower jaw forward; 75% efficacious
o CPAP – Most effective Tx
 RCT for severe OSA and CPAP use: NO improvement in CVS event rates (maybe reduces stroke rate, but post hoc analysis)
 Reduced BP and actually increases weight due to reduced WOB
o Uvulolaryngopharyngeal plasty – Not usually done; only 40% undergoing this have resolution or major improvement in OSA

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44
Q

Cause of narcolepsy

A

Loss of neuropeptides (orexin A and B aka Hypocretin 1 and 2); ?Autoimmune component (Assoc with HLADQB1*06:02 in >90% of people with Type 1)

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45
Q

Diagnosis of narcolepsy

A

Multi-sleep latency test – Mean latency <8 minutes and 2 or more naps associated with REM sleep

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46
Q

Mx of narcolepsy

A

Modafinil 1st line

47
Q

Idiopathy hypersomnolence

A

Typical presentation – young adult with chronic and disabling excessive daytime sleepiness
Multi-sleep latency test – Mean latency <8 minutes BUT number of naps with REM sleep <2
Pathophysiology unclear
Generally treat the same as narcolepsy

48
Q

Subtypes of OHS

A
  • OHS in the context of obstructive sleep apnoea; this is confirmed by the occurrence of 5 or more episodes of apnoea, hypopnea or respiratory-related arousals per hour (high apnea-hypopnea index) during sleep.
  • OHS primarily due to “sleep hypoventilation syndrome”; this requires a rise of CO2 levels by 10 mmHg (1.3 kPa) after sleep compared to awake measurements and overnight drops in oxygen levels without simultaneous apnoea or hypopnea
49
Q

Cause and Mx of restless leg syndrome

A
  • Iron defiency is most common cause (it is a co-factor for dopamine, and defiencies of DA transport are thought to be key in pathogenesis)
  • Treatment: Dopamine agonists – PRAMIPEXOLE or gabapentin and pregabalin
50
Q

Causes of REM behavior disorder

A

LBD/MSA (alpha syneuclein neurodegeneration)

Mx: Melatonin

51
Q

PJP Prophylaxis

A

o Bactrim 160/800 daily or 3 times per week

 If contraindicated: Dapsone 100 mg daily

52
Q

Role for adaptive servo ventilation in CSA

A

Cannot be used with decreased LVEF as increases mortality

-Better to treat underlying CCF

53
Q

Primary ciliary dyskinesia

A

AR
Dx - Examination of ciliary ultrastructure is the definitive test
–Low levels of nasal NO are suggestive of need for further investigation

54
Q

Diagnosis of CF

A

Clinical feature os CF or FHx of CF AND EITHER

  • 2 CF causing mutations
  • Positive sweat chloride on 2 occasions (60mmol/L)
  • Nasal potential difference tracing typical for CF
55
Q

Lumacaftor-Ivacaftor

A

CFTR Corrector and potentiator

For homozygous Phe508del

Small improvement in FEV1, decrease in pulmonary exacerbations

56
Q

Role for macrolides in CF

A

Inhibits biofilm
Modifies mucus production
Suppresses inflammatory mediators

Always rule out nontuberculous myobacteria before starting as it can cause resistance when started

57
Q

Definition for pulm arterial HTN

A

mPAP >25 mmHg

58
Q

PASP (Pulm arterial systolic pressure)

A

PASP=RVSP=tricuspid pressure gradient +CVP (in the absence of RV outflow obstruction or pulmonary stenosis)

59
Q

RVSP

A

RVSP >40 mmHg = estimated mPAP >25 mmHg

60
Q

mPAP severity rating

A

mild = 25-40
Mod=41-55
Severe >55

61
Q

PCWP indicative of LHF as cause of increased PAP

A

PCWP = LVEDP

> /=15 mmHg suggest LHF

62
Q

PBS listed treatment for IPF that have shown to slow progression of disease

A

Pirfenidone

Nintendanib

63
Q

Diagnosis of IPF

A

Confirmed at MDT

  • No tissue needed
  • Radiological features of UIP pattern IPF + Combined with appropriate clinical features
64
Q

HRCT Findings of UIP pattern

A
  • Subpleural and basal predominance
  • Reticular abnormality
  • Honeycombing (with or w/o traction bronchiectasis)
  • Absence of features listed as inconsistent with UIP (mid or upper zone, peribronchovascular changes, extensive ground glass opacity, profuse micronodules, cysts, mosaic attenuation, consolidation)
65
Q

Choice of oxygenation method for T1RF

A

HFNP better than NIV except in APO when CPAP/NIV are beneficial

66
Q

Contraindications to Lung Tx

A
  • End stage concurrent organ disease
  • Active malignancy
  • Active IVDU
  • Active untreated infection
67
Q

Treatment of PJP

A

IV Bactrim
OR
-Clinda + Primaquine OR IV pentamadine

If Severe (PaO2 <70 mmHg) add stress pred/hydrocort

68
Q

CMV Prophylaxis in Tx

Recipient +ve

A

IV ganciclovir for first 7 days
Change to oral valganciclovir 450mg BD

Duration 5-11 months
High risk: lifelong

69
Q

CMV Prophylaxis in Tx

Recipient -ve/ Donor +ve

A

IV ganciclovir for first 7 days + CMV immunoglobulin for first 3 days then weekly for a month
Change to oral valganciclovir 450mg BD

Duration 11-17 months

70
Q

CMV Prophylaxis in Tx D-ve/R-ve

A

3 months valganciclovir

71
Q

Most common type of Lung Tx rejection

A

Acute cellular rejection

-T cell mediated via HLA

72
Q

Mx of Lung Tx Acute cellular rejection

A

Azithromycin for immunomodulatory properties 3x/wk

Increase immunosuppression

73
Q

Diagnosis and Mx of AMR in lung transplant

A

AMR usually hyperacute rejection and due to DSAs

Definite AMR: Allograft dysfunction (drop in FEV1) plus DSA plus histological (neutrophil capillaritis) and immunological (C4d positivity) changes on lung biopsy. ACR and AMR can be concurrent but other causes have been excluded.

Mx:
MMF, IVIG, increase immunosuppression dependent on stage of rejection

Bortezomib if refractory

74
Q

CLAD Definition

A

Chronic lung allograft dysfunction

Two types:
Bronchiolitis obliterans syndrome (obstructive)
OR
Restrictive allograft syndrome

Definition:
Substantial or persistent decline of >20% FEV1 from baseline
If it persists for >3 months then it is definitive

75
Q

Pathogenesis of IPF

A

Perpetuated by abberant wound healing rather than by chronic inflammation

76
Q

Pirfenidone Evidence

A

Combined activity as antifibrotic, antiinflammatory, and antioxidant

Unknown MOA

Evidence:

  • Reduced FVC, 6MWT
  • Improved progression free survival
  • No reduction in dyspnea or death though
77
Q

Pirfenidone SE

A

Photosensitivity
Rash
N+D

78
Q

Nintedanib MOA and evidence

A

TKI

Evidence

  • Reduction in FVC decline
  • No change to time to first exacerbation
  • No difference in QOL
79
Q

Nintedanib SE

A

GI upset

N+D

80
Q

Prognosis for NSIP vs UIP

A

NSIP has a better prognosis

81
Q

RAPID Score

A

Assessing outcome in pleural infection

  • Renal: Urea
  • Age
  • Purulence of fluid (more better)
  • Infection source (CAP vs HAP)
  • Dietary factors: Albumin <27
82
Q

Serum neurone specific enolase is assosciated with?

A

Small cell Lung Cancer

83
Q

Major indication for Thrombolysis in PE

A

Cardiogenic shock/persistent hypotension

84
Q

ILD type associated with sjogren’s

A

Lymphocytic interstitial pneumonitis

85
Q

Risk factors for Spontaneous primary pneumothorax

A 
Smoking
FHx
Marfa's
Homocytinuria
Thoracic endometriosis
86
Q

Risk factors for spontaneous secondary pneumothorax

A 
COPD
PCP
AIDS
CF
TB
87
Q

Which type of ILD resolves with smoking cessation

A

Respiratory associated Bronciolitis Associated ILD (RBILD)

DIP - Distal interstitial pneumonia

88
Q

Tx of choice for a lung abscess

A

IV Clindamycin

89
Q

Riociguat

A

Soluable guanylate cyclase stimulator

for Pulm HTN associated with CTEPH

90
Q

Best measure to predict mortality in patients with IPF

A

DLCO and FVC

91
Q

PSP Mx

A

<2 cm - O2 and observe for 6 hours and repeat CXR

> 2 cm or symptomatic - Fine needle aspiration/chest tube

Unstable - chest tube or emergency cannula

92
Q

Most common causes of chylothorax

A
  • Malignancy is typically the leading cause of nontraumatic chylothorax while thoracic surgery is the major cause of traumatic chylothorax

Fluid MCS for chylothorax: lots of lymphocytes, chylomicrons, and triglycerides

93
Q

Extrinsic allergic alveolitis/Hypersensitivity pneumonitis

A

Will need trigger - bird’s, farmer

Abrupt onset
fever, chills, malaise, nausea, cough, chest tightness, and dyspnea without wheezing. With removal from exposure to the inciting antigen, symptoms subside within 12 hours to several days and clinical and radiographic findings resolve completely within several weeks

CXR: fleeting, micronodular pattern

94
Q

ABPA

A
  • Major Criteria:
    o Clinical: Asthma
    o Radiographic: Pulmonary opacities (transient or chronic); central bronchiectasis
    o Immune: Eosinophilia; immediate skin reactivity to Aspergillus antigen; serum IgE > 1000 IU/ml
  • Minor Criteria
    o Fungal elements in sputum; expectoration of brown plugs/flecks; delayed skin reactivity to fungal antigens
  • Management: Steroids; Itraconazole as second line
95
Q

COPDX

Confirm the diagnosis

A

Sx and spirometry

RF:
§ Smoking!!
§ Organic and inorganic dust and fume exposure
§ Smoke from cooking (solid fuel fires)
§ Bronchial hyper responsiveness
§ Respiratory infections/mucus hypersecretion
Genetic: alpha 1 antitrypsin deficiency

96
Q

COPD Severity based on FEV1

A

Mild: FEV1 60-80%
Mod: 40-59%
Severe: <40%

97
Q

COPDx

Optimise function

A

Essentially.

  1. Start SABA
  2. Mod: Add LAMA/LABA or both
  3. Severe: Add ICS to above
98
Q

Indication for Long term O2 therapy in COPD

A
  • PO2 <55 mmHg
  • PO2 <60 mmHg w/ Pulmonary HTN/RHF
          § Mortality benefit only if greater than 16 hours use per day No benefit of LTOT in COPD with moderate resting or exercise induced O2 therapy
99
Q

Lung volume reduction surgery for COPD

A

® Overall increase early mortality and no change at 2 years, increased exercise capacity
Predominantly upper lobe emphysema benefitted the most

100
Q

COPD X

Prevent Deterioration

A

Vaccines
Smoking cessation
Mx for comorbidities

101
Q

COPDX

Develop Supports

A 
○ Self management plans
		○ Education - exacerbations, Sx Mx
		○ Exercise
		○ Psychological support
		○ Manage anxiety and depression
		○ Overall improves QoL and respiratory admissions
102
Q

COPDX

Exacerbations

A
  1. Bronchodilators
    - SABA - No evidence for nebulizer more efficacious than MDI and spacer
    - Mixed evidence for adding ipratropium
  2. Steroids ® Improve symptoms, FEV1, PaO2 ® Reduce treatment failure, relapse and length of stay
    - No advantage of IV except speed of onset
  3. ABx
    If Increased SOB, Sputum volume, purulence, and ?CRP
  4. O2 therapy
    -Sats 88-92%
    ◊ High flow O2 associated with: HDU admission, increased use of NIV, and Increased length of stay
103
Q

NIV indication in COPD exacerbation

A

Hypercapnic respiratory failure

Consider early when RR >30 and blood pH <7.35

104
Q

BODE Index

A

Better predicts: Mortality, hospitalization, survival post LVRS)
◊ BMI ◊ Obstruction ◊ Dyspnea (MMRC)
-Exercise (6MWD)

105
Q

SABA

A
  • Salbutamol

Terbutaline

106
Q

SAMA

A

Ipratropium

107
Q

LABA

A
  • Indacaterol
  • Formoterol
    Salmeterol
108
Q

LAMA

A
  • Tiotropium
  • Umeclidinium
    Glycopyrronium
109
Q

ICS

A
  • Fluticasone
  • Ciclesonide
  • Budesonide
    Beclometasone
110
Q

Kalydeco/Ivacaftor

A

For G551D mutation in CF

Ivacaftor isCFTR potentiator

111
Q

Lumacaftor/Ivacaftor

A

CTFR corrector and potentiator

For homozygous Phe508del

112
Q

Endothelin receptor antagonists

A

Bosentan

113
Q

Phosphodiesterase inhibitors

A

Tadalifil

114
Q

Prostanoids

A

Iloprost

Bpt (15 decks)

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