Respiratory Flashcards
1
Q
Pneumonia
Aetiology (4)
A
Community acquired pneumonia: primary or secondary to underlying disease, Strep pneumoniae –> Haemophilus influenzae –> Mycoplasma pneumoniae –> viruses account for 15%
Hospital acquired (nosocomial, >48hr after admission): gram -ve or Staph aureus
Aspiration: stroke, reduced consciousness, oesophageal disease
Immunocompromised patients
2
Q
Pneumonia
Signs + Symptoms (12)
A
Malaise Fever Riggers Dyspnoea Cough and purulent sputum Haemoptysis Pleuritic chest pain Cyanosis Confusion (may be only sign in elderly) Hypotension Signs of consolidation: reduced expansion, dull percussion, increased vocal resonance, bronchial breathing Pleural rub
3
Q
Pneumonia
Investigations (5)
A
CXR: lobar/multilobular infiltrates, pleural effusion
Assess saturation: O2 sats, ABG if severe, BP
Bloods: FBC, U&E, LFT, CRP, blood culture
Sputum: microscopy + culture
Legionella (sputum culture and urinary antigen) if severe
4
Q
Pneumonia
Severity (8)
A
Confusion (abbreviated mental test <8) Ureal (>7mmol/l) Respiratory rate (>30/min) BP (<90 systolic or <60 diastolic) Age >65
0-1: home with/without treatment
2: hospital therapy
3+: severe, consider ITU
5
Q
Pneumonia
Treatment (7)
A
CURB 0-1: oral amoxicillin or clarithromycin or doxycycline
CURB 2: oral amoxicillin + clarithromycin or doxycycline (IV may be required)
CURB 3+: co-amoxiclav IV or cephalosporin IV and clarithromycin IV, add flucloxacillin +/- rifampicin if Staph suspected or vancomycin if MRSA suspected
Analgesia for pleurisy
O2 if sats <94%
IV fluids
VTE prophylaxis
6
Q
Pneumonia
Complications (5)
A
Respiratory failure: aim sats 94-98%
Hypotension: due to dehydration and vasodilatation, give IV fluids
Pleural effusion: inflammation of pleura by adjacent pneumonia causing fluid exudation into pleural space
Empyema: pus in pleural space, suspect in patients with resolving pneumonia developing fever
Lung abscess
Septicaemia
7
Q
Cystic Fibrosis
Aetiology (3)
A
Mutations in CFTR gene on chromosome 7
Cl- channel defect leads to defective chloride secretion and increased sodium absorption across airway epithelium
Autosomal recessive
8
Q
Cystic Fibrosis
Signs + Symptoms (7)
A
In neonates: failure to thrive, meconium ileum, rectal prolapse
Cough
Wheeze
Recurrent infections
Cor pulmonale
Pancreatic insufficiency (diabetes, steatorrhoea)
Male infertility
9
Q
Cystic Fibrosis
Investigations (5)
A
Sweat test: sodium + chloride >60mmol/l Genetics screen Heel prick test (5 days old) CXR: hyperinflation, bronchiectasis Spirometry: obstructive pattern
10
Q
Cystic Fibrosis
Treatment (7)
A
Regular chest physio
Antibiotics for acute infective exacerbations and prophylaxis
Mucolytics eg. DNase
Bronchodilators
Pancreatic enzyme replacement
Vitamine supplements (ADEK)
If advanced: non-invasive ventilation/transplant
11
Q
Cystic Fibrosis
Common bacterial infections (2)
A
Pseudomonas aeruginosa in adulthood
Staph aureus + H.influenzae in children
12
Q
Bronchiectasis
Definition (1)
A
Chronic infection of the bronchi and bronchioles leading to permanent dilation
13
Q
Bronchiectasis Main organisms (4)
A
H. influenzae
Strep pneumoniae
Staph aureus
Pseudomonas aeruginosa
14
Q
Bronchiectasis
Aetiology (4)
A
Congenital: CF
Post infection: pneumonia, TB, HIV
Bronchial obstruction: tumour, foreign body
Allergic bronchopulmonary aspergillosis
15
Q
Bronchiectasis
Signs + Symptoms (4)
A
Persistent cough and sputum
Finger clubbing
Coarse inspiratory crepitations
Wheeze
16
Q
Bronchiectasis
Complications (3)
A
Pneumonia
Pleural effusion
Pneumothorax
17
Q
Bronchiectasis
Investigations (6)
A
Sputum culture
CXR: thickened bronchial walls
HRCT chest: assess extent and distribution of disease
Spirometry: obstructive pattern
Bronchoscopy: obtain samples, exclude obstruction
CF sweat test
18
Q
Bronchiectasis
Treatment (5)
A
Postural drainage Chest physio Antibiotics Bronchodilators if asthma, COPD, CF, allergic bronchopulmonary aspergillosis Corticosteroids if ABPA
19
Q
Pulmonary Aspergillus Infection
Effects of Aspergillus on the lung (5)
A
Asthma (type 1 hypersensitivity to fungal spores)
Allergic bronchopulmonary aspergillosis (causes bronchiectasis, give steroids)
Aspergilloma (fungus ball within pre-existing cavity)
Invasive aspergillosis
Extrinsic allergic alveoli’s
20
Q
Lung Cancer Risk factors (3)
A
Smoking
Asbestos
Radiation
21
Q
Lung Cancer
Pathology (2)
A
Non-Small Cell Lung Cancer: squamous, adenocarcinoma, large cell undifferentiated
Small Cell Lung Cancer: endocrine
22
Q
Lung Cancer
Signs + Symptoms (8)
A
Cough Haemoptysis Dyspnoea Chest pain Weight loss Anaemia Clubbing Metastatic signs (bone tenderness, hepatomegaly, confusion, fits)
23
Q
Lung Cancer
Sites of metastatic spread (4)
A
Liver
Adrenal glands
Brain
Bone
24
Q
Lung Cancer
Complications (3)
A
Recurrent laryngeal nerve palsy
Phrenic nerve palsy
SVC obstruction
25
Lung Cancer
| Investigations (6)
Cytology: sputum and pleural fluid
CXR: hilar enlargement, consolidation, collapse, pleural effusion
Fine needle aspiration or biopsy of peripheral lesions/superficial lymph nodes
CT: staging
PET: staging
Bronchoscopy: to give histology and assess operability
26
Lung Cancer
| Staging (11)
T1: <3cm
T2: >3cm
T3: close to carina or involving chest wall/diaphragm
T4: involves carina, mediastinum, heart, great vessels, trachea, oesophagus
N0: no nodes
N1: peribronchial and/or ipsilateral hilum
N2: ipsilateral mediastinum
N3: contralateral
M0: none
M1a: in other lung
M1b: distant metastases
27
Lung Cancer
| Treatment (3)
NSCLC: stage 1/2 surgery, curative radio if respiratory reserve is poor, chemo +/- radio if advanced
SCLC: chemo but relapse rate high and mortality high
Palliation: radio for bronchial/SVC obstruction or haemoptysis
28
Lung Cancer
| Prognosis (2)
NSCLC: 50% 2 year survival without spread, 10% with spread
SCLC: survive 3 months if untreated, 1-1.5 years if treated
29
Acute Respiratory Distress Syndrome
| Definition (2)
May be due to direct lung injury or secondary to severe systemic illness
Lung damage and release of inflammatory mediators cause increase in capillary permeability and pulmonary oedema, often associated with multi organ failure
30
Acute Respiratory Distress Syndrome
| Aetiology (4)
Pulmonary: pneumonia, injury, inhalation
Shock
Haemorrhage
Septicaemia
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Acute Respiratory Distress Syndrome
Risk Factors (6)
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Sepsis
Hypovolaemic shock
Trauma
Burns and smoke inhalation
Diabetic ketoacidosis
Pneumonia
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32
Acute Respiratory Distress Syndrome
| Signs + Symptoms (5)
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Cyanosis
Tachypnoea
Tachycardia
Peripheral vasoldilatation
Bilateral inspiratory crackles
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33
Acute Respiratory Distress Syndrome
| Investigations (3)
Bloods: FBC, U+E, LFT, amylase, clotting, CRP, blood cultures
ABG
CXR: bilateral pulmonary infiltrates
34
Acute Respiratory Distress Syndrome
| Treatment (5)
Admit to ITU
Respiratory support: CPAP/mechanical ventilation
Circulatory support: inotropes (eg. dobutamine), vasodilators, transfusion
Sepsis: identity organism and treat accordingly
Steroids for subacute
35
Asthma
| Definition (1)
Recurrent episodes of dyspnoea, cough and wheeze caused by reversible airway obstruction
36
Asthma
| Pathology (3)
Bronchial muscle contraction, triggered by a variety of stimuli
Mucosal swelling/inflammation, caused by mast cel and basophil degranulation resulting in release of inflammatory mediators
Increased mucus production
37
Asthma
| Symptoms (6)
Intermittent dyspnoea, wheeze, cough (often nocturnal) and sputum
Precipitants: cold air, exercise, allergens (home dust mite, pollen, fur), smoking, B-blockers
Diurnal variation
Disturbed sleep
Acid reflux
Other atopic disease eg. eczema, hay fever
38
Asthma
| Signs (7)
Tachypnoea
Wheeze
Hyperinflated chest
Hyperresonant percussion
Severe attack: inability to complete sentences, pulse >110bpm, RR >25
Life-threatening attack: silent chest, confusion, exhaustion, cyanosis, bradycardia
Near fatal: high PaCO2
39
Asthma
| Investigations for chronic (4)
PEF monitoring
Spirometry: obstructive defect (low FV1/FVC)
CXR: hyperinflation
Skin prick test may help identify allergens
40
Asthma
| Investigations for attack (5)
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PEF
Sputum culture
Bloods: FBC, U&E, CRP, cultures
ABG
CXR: to exclude infection/pneumothorax
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Asthma
Chronic treatment (5)
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Step 1: SABA as required (unless using MART), consider starting low-dose ICS
Step 2: regular preventer (low-dose ICS) + SABA as required
Step 3: initial add-on therapy (add inhaled LABA to low-dose ICS- fixed dose or MART) + SABA as required
Step 4: additional controller therapies (increase ICS to medium dose or add LTRA), if no response to LABA then stop + SABA as required
Step 5: specialist therapies (high dose ICS + oral steroids)
42
Asthma
| Treatment of attack (4)
Immediate treatment: nebulised salbutamol, IV hydrocortisone +/- oral prednisolone, start O2 if sats <92%
If life-threatening: salbutamol nebulisers every 15 minutes, add ipratropium to nebulisers, single dose IV magnesium sulfate
If no improvement: consider ventilatory support and intensification of medical therapy eg. aminophylline, IV salbutamol (ITU)
If improving within 15-30 mins: nebulised salbutamol every 4 hours, prednisolone oral for 5-7 days
43
COPD
| Definition (2)
Progressive disorder characterised by airway obstruction with little/no reversibility
FEV1 <80%
44
COPD
| Pathology (1)
Chronic bronchitis (clinical diagnosis- cough + sputum) + emphysema (histological diagnosis- enlarged air spaces distal to terminal bronchioles with destruction of alveolar walls)
45
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COPD
Pink puffers (5)
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Increased alveolar ventilation
Near normal PaO2
Normal/low PaCO2
Breathless but not cyanosed
May progress to type 1 respiratory failure
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46
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COPD
Blue bloaters (5)
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Reduced alveolar ventilation
Low PaO2
High PaCO2
Cyanosed but not breathless
May develop cor pulmonale
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47
COPD
| Signs + symptoms (6)
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Cough + sputum
Dyspnoea + tachypnoea
Wheeze
Use of accessory muscles of respiration
Reduced expansion
Resonant percussion
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48
COPD
| Complications (5)
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Acute exacerbations +/- infection
Respiratory failure
Cor pulmonale
Pneumothorax
Lung cancer
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49
COPD
| Investigations (5)
CXR: hyperinflation, flat hemidiaphragms, bullae
ECG: cor pulmonale
ABG: low PaO2 +/- hypercapnia
Spirometry: obstructive pattern (FEV1 <80% of predicted)
Trial of steroids
50
COPD
| Severity (4)
Stage 1 mild: FEV1 >80% of predicted
Stage 2 moderate: FEV1 50-79% of predicted
Stage 3 severe: FEV1 30-49% of predicted
Stage 4 very severe: FEV1 <30% of predicted
51
COPD
| Treatment of stable COPD (5)
General: stop smoking, pulmonary rehav, vaccinate against influenza, SAMA (ipratropium)/SABA
Mild/moderate: LAMA (tiotropium)
Severe: LABA + corticosteroids (eg. Symbicort- budesonide + formoterol) or tiotropium
If still symptomatic: tiotropium + ICS + LABA, refer to specialist, consider steroid trial, home nebulisers, theophylline, long term O2 therapy
Indications for specialist referral: rapid FEV1 decline, cor pulmonale, assessment for oral corticosteroids/nebulisers/home O2
52
COPD
| Treatment of acute exacerbation (6)
Nebulised bronchodilators (salbutamol, ipratropium)
O2 therapy
IV hydrocortisone + oral prednisolone
Antibiotics if infection: amoxicillin, clarithromcyin, doxycycline
If no response to nebulisers + steroids, consider IV aminophylline
If no response: non-invasive ventilation --> intubation + ventilation
53
Pulmonary Embolism
| Aetiology (2)
Venous thrombosis in pelvis/legs pass through veins and right side of heart before lodging in the pulmonary circulation
Right ventricular thrombus (post MI)
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Pulmonary Embolism
Risk factors (7)
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Recent surgery
Thrombophilia
Leg fracture
Prolonged bed rest/reduced mobility
Malignancy
Pregnancy, post-partum, OCP, HRT
Previous PE
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55
Pulmonary Embolism
| Signs + symptoms (8)
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Acute breathlessness
Pleuritic chest pain
Haemoptysis
Dizziness/syncope
Cyanosis
Tachypnoea + tachycardia
Hypotension
Raised JVP
```
56
Pulmonary Embolism
| Investigations (6)
Bloods: FBC, U&E, baseline clotting, D-dimer (high sensitivity but low specificity)
CXR: may be normal or show dilated pulmonary artery
CTPA: 1st line imaging
ABG: low PaO2, low PaCO2
V/Q scan: rarely done
ECG: normal, tachycardia, right bundle branch block, SIQIIITIII pattern (deep S waves in I, pathological Q waves in III, inverted T waves in III)
57
Pulmonary Embolism
| Treatment (7)
Oxygen
Morphine
IV unfractionated heparin or SC LMWH
If systolic <90 start colloid infusion but if remains low consider IV noradrenaline
If systolic >90 start warfarin
If PE is massive then thrombolyse (alteplase)
Stop heparin when INR >2 and continue warfarin for minimum 3 months
58
Pneumothorax
| Aetiology (4)
Spontaneous primary: weight of lung inducing apical blebs that rupture
Spontaneous secondary: pre-existing disease, eg. CF, COPD
Traumatic non-iatrogenic: penetrating or blunt injury
Traumatic iatrogenic: pleural aspiration/biopsy, subclavian vein cannulation
59
Pneumothorax
| Pathology (1)
Breach of visceral/parietal pleura with entry of air, lung collapses due to elastic recoil
60
Pneumothorax
| Signs + symptoms (7)
```
Asymptomatic if small
Acute breathlessness
Pleuritic chest pain
Reduced breath sounds
Tracheal deviation (non tension to affected side, tension away from affected side)
Reduced expansion
Hyperresonant percussion
```
61
Pneumothorax
| Treatment (3)
Tension: chest drain 2nd intercostal space
Chest drain if any trauma
For others try aspirating before chest drain
62
Pleural Effusion
| Definition (3)
Fluid in the pleural space
Transudates <30g/l protein conc.
Exudates >30g/l protein conc.
63
Pleural Effusion
| Aetiology (2)
Transudates: increased venous pressure (cardiac failure, fluid overload), hypoproteinaemia (cirrhosis, nephrotic syndrome)
Exudates: increased leakiness of pleural capillaries secondary to infection, inflammation or malignancy (pneumonia, TB, RA, SLE)
64
Pleural Effusion
| Signs + symptoms (8)
```
May be asymptomatic
Dyspnoea
Pleuritic chest pain
Reduced expansion
Stony dull percussion note
Reduced breath sounds
Reduced vocal resonance
If large, tracheal deviation away from effusion
```
65
Pleural Effusion
| Investigations (4)
CXR: effusions visible
Ultrasound: identifies pleural fluid
Diagnostic aspiration
Pleural biopsy if aspiration inconclusive
66
Pleural Effusion
| Treatment (3)
Drainage if symptomatic
Pleurodesis for recurrent effusions
Surgery for persistent collections and increasing pleural thickness
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Sarcoidosis
Definition (1)
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Multisystem granulomatous disorder of unknown cause
68
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Sarcoidosis
Risk factors (3)
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Age 20-40
Women
Afro-Caribbean affected more frequently and severely
69
Sarcoidosis
| Signs + symptoms (7)
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Often asymptomatic
Acute sarcoidosis often presents with erythema nodosum +/- polyarthralgia and resolves spontaneously
Dry cough
Progressive dyspnoea
Chest pain
Lymphadenopathy
Hepatmegaly + splenomegaly
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70
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Sarcoidosis
Investigations (6)
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Bloods: high ESR, high LFT, high serum ACE, high Ca, high immunoglobulins
24h urine: high Ca
CXR: bilateral hilar lymphadenopathy --> pulmonary infiltrates --> pulmonary fibrosis --> bulla formation
ECG: arrhythmias or bundle branch block
Bronchoalveolar lavage: high lymphocytes
CT/MRI: to assess severity of pulmonary disease
71
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Sarcoidosis
Treatment (2)
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Acute sarcoidosis: bed rest, NSAIDs
| Indications for corticosteroids: uveitis, hypercalcaemia, neuro/cardiac involvement
72
Interstitial Lung Disease
| Definition (2)
A number of conditions that primarily affect the lung parenchyma
Characterised by chronic inflammation and/or progressive interstitial fibrosis
73
Interstitial Lung Disease
| Signs + symptoms (2)
Dyspnoea on exertion
| Non productive paroxysmal cough
74
Interstitial Lung Disease
| Investigations (3)
CXR
HRCT
Spirometry: restrictive patten
75
Interstitial Lung Disease
| Classification (3)
Those with known cause: occupational (asbestosis), drugs (nitrofuratnoin, sulfasalazine), hypersensitivity reactions (extrinsic allergic alveolitis), infections, GORD
Those associated with systemic disorders: sarcoidosis, RA, SLE, systemic sclerosis, Sjogren's, ulcerative colitis
Idiopathic: idiopathic pulmonary fibrosis
76
Extrinsic Allergic Alveolitis
| Aetiology (2)
Proteins in bird droppings
| Farmer's lung (Micropolyspora faeni)
77
Extrinsic Allergic Alveolitis
| Signs + symptoms (2)
Post-exposure: fever, rigors, dry cough, dyspnoea, crackles
| Chronic: increased dyspnoea, weight loss, type 1 respiratory failure, cor pulmonale
78
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Extrinsic Allergic Alveolitis
Acute investigations (4)
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Bloods: FBC (neutrophilia), increased ESR
ABG
CXR: upper-zone consolidation, hilar lymphadenopathy
Spirometry: reversible restrictive pattern
79
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Extrinsic Allergic Alveolitis
Chronic Investigations (4)
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Bloods
CXR: upper zone fibrosis
Spirometry: persistent restrictive pattern
Bronchoalveolar lavage: increased lymphocytes and mast cells
80
Extrinsic Allergic Alveolitis
| Treatment (2)
Acute: remove allergen, give O2, oral prednisolone
Chronic: avoid allergen or wear protective equipment, long term steroids
81
Industrial Lung Disease
| Silicosis (4)
Caused by inhalation of silica particles
Associated jobs: metal mining, pottery/ceramic manufacture
Signs + symptoms: progressive dyspnoea, increased incidence of TB
Investigations: CXR, spirometry (restrictive defect)
82
Industrial Lung Disease
| Asbestosis (2)
Types of asbestos: chrysotile (white), crocidolite (blue), amosite (brown)
Signs + symptoms: progressive dyspnoea, clubbing, crackles
83
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Industrial Lung Disease
Malignant mesothelioma (5)
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Definition: tumour of mesothelial cells that usually occurs int he pleura
Aetiology: asbestos
Signs + symptoms: chest pain, dyspnoea, weight loss, clubbing
Investigations: CXR/CT show pleural thickening/effusion, thoracoscopy allows histological diagnosis
Treatment: pemetrexed + cisplatin chemo but prognosis is poor
84
Idiopathic Pulmonary Fibrosis
| Definition (2)
A type of idiopathic interstitial pneumonia
| Commonest cause of interstitial lung disease
85
Idiopathic Pulmonary Fibrosis
| Signs + symptoms (7)
```
Dry cough
Exertional dyspnoea
Malaise
Weight loss
Cyanosis
Clubbing
Crepitations
```
86
Idiopathic Pulmonary Fibrosis
| Investigations (6)
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Bloods: high CRP, high immunoglobulins
ABG: low PaO2, if severe high PaCO2
CXR: reduced lung volume
CT
Spirometry: restrictive pattern
Bronchoalveolar lavage: high lymphocytes (good prognosis), high neutrophils (poor prognosis)
```
87
Idiopathic Pulmonary Fibrosis
| Treatment (2)
Best supportive care: oxygen, pulmonary rehabilitation, opiates
Lung transplant
88
Pulmonary Hypertension
| Definition (2)
Normal pulmonary arterial pressure 12-16mmHg
| Hypertension >25mmHg
89
Pulmonary Hypertension
| Pathology (3)
Walls of pulmonary arteries become thickened and stiff, and can't expand as well
Can lead to right heart failure
Commonly due to heart/lung condition
90
Pulmonary Hypertension
| Signs + symptoms (4)
Dyspnoea
Chest pain
Palpitations
Oedema/ascites
91
Pulmonary Hypertension
| Investigations (6)
Echo
Right heart catheterisation
Bloods: BNP
CXR: enlarged right ventricle/pulmonary arteries, emphysema, fibrosis
V/Q scan: check for blood clots as this may be the cause or can be a complication
92
Pulmonary Hypertension
| Treatment (5)
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Treat underlying condition
Anticoagulation: warfarin
Oxygen
Diuretics: to treat oedema due to heart failure
Digoxin: slows down heart rate
```
93
Cor Pulmonale
| Definition (1)
Right heart failure caused by chronic pulmonary arterial hypertension
94
Cor Pulmonale
| Aetiology (3)
Lung disease: COPD, bronchiectasis, pulmonary fibrosis, severe asthma
Pulmonary vascular disease: pulmonary emboli, pulmonary hypertension, acute respiratory distress syndrome
Thoracic cage abnormality: scoliosis, kyphosis
95
Cor Pulmonale
| Signs + symptoms (8)
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Dyspnoea
Fatigue
Syncope
Cyanosis
Tachycardia
Elevated JVP
RV heave
Pansystolic murmur (tricuspid regurgitation)
```
96
Cor Pulmonale
| Investigations (4)
FBC: high Hb and haematocrit (secondary polycythaemia)
ABG: hypoxia
CXR: enlarged right atrium and ventricle, prominent pulmonary arteries
ECG: P pulmonale, right axis deviation
97
Cor Pulmonale
| Treatment (4)
Treat underlying cause
Treat respiratory failure: oxygen
Treat cardiac failure
Consider heart-lung transplant in young patients as prognosis is poor
98
Sleep Apnoea
| Definition (1)
Intermittent closure/collapse of the pharyngeal airway, causing apnoeic episodes during sleep
99
Sleep Apnoea
| Signs + symptoms (5)
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Loud snoring
Daytime somnolence
Poor sleep quality
Morning headache
Reduced cognitive performance
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100
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Sleep Apnoea
Risk factors (3)
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Obesity
Alcohol
Enlarged tonsils
101
Sleep Apnoea
| Complications (2)
Pulmonary hypertension
| Type II respiratory failure
102
Sleep Apnoea
| Investigations (3)
Overnight pulse oximetry
Polysomnography (O2sats, air flow, ECG, EMG chest + abdo movement)
Epworth sleep survey
103
Sleep Apnoea
| Treatment (4)
Weight reduction
Avoid tobacco and alcohol
CPAP for moderate-severe disease
Surgery to relieve pharyngeal obstruction (eg. tonsillectomy)
104
Sleep Apnoea
| Severity based on Epworth Sleep Survey (3)
0-10 normal
11-15 excessive daytime sleepiness
16-24 severe daytime sleepiness
