Respiratory Flashcards
What are the respiratory causes of clubbing?
Cancer - mesothelioma, bronchial
Chronic suppuration - bronchiectasis, CF, empyema, abscess
Fibrosis - IPF, TB
What are the cardiac causes of clubbing?
Atrial myxoma
Infective endocarditis
Congenital cyanotic heart disease
What are the GI causes of clubbing
Cirrhosis
Crohns/uC
Coeliac
Cancer
What are the miscellaneous causes of clubbing?
Idiopathic
Thyroid acropachy
Upper limb AVMs
What are the respiratory causes of cyanosis?
Hypoventilation - COPD, MSK
VQ mismatch - PE, AVM
Impaired gas diffusion - pulmonary oedema, fibrosing alveolitis
What are the cardiac causes of cyanosis?
Reduced output - HF, mitral stenosis
Congenital - Fallots, TGA
Vascular - Raynauds, DVT
Outline the CURB 65 score and interpret its results
Confusion (AMTS less than 8) Urea >7 Resp rate >30 BP <90/60 Age >65
0-1 - Home w. Abx
2 - Admit
3 or more - Consider ITU
What is the empirical antibiotic management for a mild CAP?
1st line; Amoxicillin 500mg TDS PO for 5 days
2nd line; Clarithromycin 500mg BD PO for 7 days
What is the empirical antibiotic management for a severe CAP?
Co-amox 1.2g TDS IV or Cefuroxime 1.5g TDS IV
AND
Clari 500mg BD IV for 7-10 days
How would you manage the three commonest atypical pneumonias?
Chlamydia - tetracycline
PCP - co-trimoxazole
Legionella - Clarithromycin + rifampicin
What is the antibiotic management of a mild and severe HAP?
Mild: Co-amox
Sev: Taz +-Vanc +- gent
What are some possible complications of a pneumonia?
Respiratory failure Hypotension AF (usually resolves) Pleural effusion Empyema Abscess Sepsis Jaundice
Define the following terms:
i) Sepsis
ii) Severe sepsis
iii) Septic shock
i) SIRS caused by infection
ii) Sepsis with at least 1 organ dysfunction
iii) Severe sepsis with refractory hypotension
Which organisms are commonly implicated in bronchiectasis?
H. influenzae
Pneumococcus
Pseudomonas
Staph
What are some causes of bronchiectasis?
Idiopathic in 50% Congenital - CF (upper lobes), Kartagener's Post infectious Hypogammaglobulinaemia Obstruction (LNs, Ca, FB)
What are the clinical features of bronchiectasis?
Purulent cough +- haemoptysis Weight loss Fever Clubbing Coarse creps
What are the Xray findings in bronchiectasis?
Thickened bronchial walls (tramlines and rings)
What other imaging technique might be used for bronchiectasis?
High Res CT
What is the management regime for bronchiectasis?
Chest physio
Abx for flare ups
Bronchodilators
specifics
What is the pathogenesis of cystic fibrosis?
CFTR gene mutation results in reduced luminal Cl and increased Na reabsorption leading to excessively viscous secretions
What are the clinical features of CF?
Resp: cough, wheeze, bronchiectasis, infections, haemoptysis, cor pulmonale
GI: Pancreatic insufficiency, GI obstructions, gallstones, cirrhosis
Other: nasal polyps, infertility, osteoporosis
What are some diagnostic tests for CF?
Sweat test: Na and Cl >60
Faecal elastase
Genetic screening
Immunoreactive trypsinogen (neonatal)
What is the management of CF?
As for bronchiectasis + Pancreatic enzyme replacement ADEK supplements Insulin Ursodeoxycholic acid (stimulates bile secretion) DEXA scanning
What is allergic bronchopulmonary aspergillosis (ABPA)?
A hypersensitivity reaction to A. fumigatus, causing bronchoconstriction and eventually bronchiectasis
What are the investigation findings of ABPA?
CXR - bronchiectasis
Aspergillus in sputum
Aspergillus skin test
Raised IgE and eosinophils
What are the features and Xray findings of an aspergilloma?
Commonly silent, haemoptysis, lethargy, weight loss
Well defined, round opacity in apical zone
What are some key differences between small cell and non-small cell lung cancers (SCC, adeno, large cell)?
Site - SCLC and SCC central, adeno are peripheral
Smoking - All are associated with smoking except for adenocarcinomas
Adenocarcinomas are common in non smoking asian women
SCC causes paraneoplastic hypercalcaemia
SCLC is very chemosensitive but has a poor prognosis due to late presentation
What are the complications of lung cancer?
Local, paraneoplastic, metastatic
Local - Laryngeal nerve palsy, Horners, SVC obstruction, AF
Paraneo - ADH (SIADH), ACTH (Cushings), Serotonin (Carcinoid), PTHrP (SCC only)
Metastatic - Pathological fractures, liver failure, neuro, Addison’s
What investigations would you do for a suspected lung cancer?
Bloods - FBC, LFT, Ca2+, U&E
Cytology - sputum, pleural fluid
Imaging
CXR - coin lesion, hilar enlargement, collapse, effusion
CT contrast for staging
PET - distant mets
Biopsy - pFNA, bronchoscopy, mediastinoscopy
Lung function tests
What are the differentials for a coin lesion on CXR?
FANGS
Foreign body Abscess - aspergilloma, klebsiella, TB, staph Neoplasm Granuloma - TB, sarcoid, Wegener's, RA Structural - AVM
Which stands better chance of being cured, SCLC or NSCLC?
NSCLC (SC=slim chances)
What are the clinical features of ARDS?
Tachypnoea
Cyanosis
Bilateral fine creps
SIRS (Tx, tachycardia, tachypnoea, raised WCC)
What are the Xray findings of ARDS?
Bilateral perihilar infilatrates
Does ARDS have a sudden or insidious onset?
Sudden
How would you manage ARDS?
Ventilation support Invasive BP monitoring Inotropes Abx if septic TPN
What are the differential diagnoses of pulmonary oedema?
Transudates vs exudates
Transudates
Increased capillary hydrostatic pressure - CCF, fluid overload, renal failure
Reduced capillary oncotic pressure - liver failure, nephrotic syndrome, malnutrition, protein losing enteropathy
Increased interstitial pressure - blocked lymphatic drainage
Exudates
ARDS
Define type 1 and type 2 respiratory failure
Type 1 - Hypoxia only
Type 2 - Hypoxia and hypercapnoea
What are the mechanisms for oxygen delivery and how much do they deliver/
Nasal cannulae - 1-4 L
Simple facemask
Venturi mask - 5-60% depending on colour
Non-rebreathe - up to 100%
What might you find on examination of an asthmatic patient?
Inspection: paraphernalia, may be cushingoid, oral thrush
Chest: Harrison’s sulcus, usually normal auscultation or wheeze
Sig Negatives: CO2 retention, cor pulmonale, clubbing
What are some important history questions to ask an asthmatic?
Symptoms Diurnal variation Limitations Exacerbations Control (Med use and Hosp admissions)
What investigations might you do in an asthmatic?
Bedside - PEFR Bloods - FBC (eosin), IgE, Aspergillus CXR - hyperinflation Spirometry - obstructive (Low FEV1 with Low FEV1:FVC ratio PEFR monitoring/diary
Define a severe asthma attack
Any one of: PEF 33-50% expected RR>25 HR >110 Incomplete sentences
Define a lifethreatening asthma attack
PEFR <33% exp SpO2 <92% or T2RF Cyanosis Hypotension Exhaustion or confusion Silent chest/poor effort Arrhythmias
What is the management of acute severe asthma?
- Sit patient up
- 100% O2 via non rebreathe mask
- Nebulised salbutamol and ipratropium
- Hydrocortisone IV or Pred PO or both
- Write ‘no sedation’ on drug chart
- If not improving, escalate to Aminophylline, switch nebs to IV, and inform ITU
What additional measures should be taken in the event of life threatening asthma?
- Inform ITU
- MgSO4 2g IV infusion over 20 mins
- B2B salb nebs
What is the drug ladder for chronic asthma?
- SABA PRN
- Add LD Beclometasone inh
- Add LABA (salmeterol)
- Consider upping steroid dose if improvement but control still poor)
- Trials of LTRA, theophylline, oral Beta agonist
- Oral steroids (pred 5-10mg OD)
What is the pulmonary function picture of COPD?
FEV1 <80%
FEV1:FVC <0.70
What are the signs of COPD?
Tachypnoea Prolonged expiratory phase Hyperinflation Wheeze Early inspiratory crackles Cyanosis Cor pulmonale (Raised JVP, oedema, loud P2)
Pink puffers vs. Blue bloaters
Pink puffers in emphysema are breathless but not cyanosed, with normal/low PaCO2
Blue bloaters in chronic bronchitis are hypercapnic, thus rely on hypoxic drive
What are the complications of COPD?
Polycythaemia Acute (infective) exacerbations Pneumothorax Cor pulmonale Lung carcinoma
What is the general management approach of COPD?
Stop smoking
Annual IFV
One off pneumococcal vaccince
Pulmonary rehab
What features might indicate that a patient is steroid responsive?
Any previous atopic diagnosis
Eosinophilia
Substantial variation in FEV1 over time
Substantial diurnal variation in PEF
What is the medical management of COPD?
- SABA or SAMA
- (not steroid responsive) - LAMA + LABA
- (steroid responsive) - LABA + ICS
- Oral theophylline
Prophylactic azithromycin in certain patients (Do LFT and ECG on commencement)
Which factors may improve survival in patients with stable COPD?
- Smoking cessation
- LTOT
- Lung volume reduction surgery
What criteria must be filled for a COPD patient to be placed on LTOT?
pO2 <8 AND 1 of:
i) Secondary polycythaemia
ii) Peripheral oedema
iii) Pulmonary hypertension
How would you manage an acute exacerbation of COPD?
O2: Sit up, 24% O2 Venturi aiming for 88-92%, aim for PaO2 >8
BronchoNebs: Air driven Salbutamol 5mg and Ipratropium 0.5mg
Steroids: IV Hydrocortisone and PO prednisolone (>7 days)
Abx: If evidence of infection then Doxy 200mg PO STAT then 100mg OD PO for 5 days
NIV: BiPAP if pH<7.35 and or RR>30
What are the ECG features of a PE?
Sinus rhythm Sinus tachy RBBB RV strain (T inversion in V1-4) S1Q3T3
What are the components of Well’s score/
Signs and symptoms of DVT PE is leading differential HR >100 Immobilised in 3 days or surgery in 4 weeks Hx of DVT or PE Haemoptysis Malignancy w. treatment within 6 months
How would you manage a confirmed PE?
Sit up, 100% O2
Morphine + metoclopramide if distressed
If critically ill consider Alteplase 50mg bolus stat
LMWH e.g. Enoxaparin 1.5mg/kg/24hr SC - till INR>2
Fluids/inotropic support if hypotensive
What are the clinical features of sarcoidosis?
GRANULOMAS
General
Fever, anorexia, wt loss, fatigue, lymphadenopathy
Respiratory
Upper - otitis, sinusitis
Lower - Dry cough, SOB, chest pain, BHL, fibrosis
Arthralgia
Neuro
Polyneuropathy (esp Bell’s), meningitis, transverse myelitis, SOL
Urine
Stones, nephrocalcinosis, DI
Low hormones
Pituitary dysfunction
Ophthalmological
Uveitis, Sjogrens, keratoconjunctivitis
Myocardial
Restrictive cardiomyopathy, pericardial effusion
Abdominal
HSM
Skin
Erythema nodosum, Lupus pernio
What investigations (and findings) are relevant in sarcoidosis?
Bloods - raised ESR, hypercalcaemia, lymphopaenia, raised ACE, HyperIg, deranged LFTs
CXR, CT, MRI
PFT - Restrictive pattern with reduced transfer factor
Biopsy - non-caseating granulomata
What is the management of acute and chronic sarcoidosis?
Acute: NSAIDs and bed rest
Chronic: Steroids +- additional immunosuppression
What are the differentials for BHL?
Sarcoid
TB
Lymphoma
Interstitial lung disease (EAA)
What are the differentials for granulomatous disease?
Infection: TB, syphillis Autoimmune: PBC Vasculitic: GCA, PAN, GwP Idiopathic: Crohns, Sarcoid Interstitial disease: EAA
What are the iatrogenic causes of interstitial lung disease?
BANS ME
Bleomycin Amiodarone Nitrofurantoin Sulfasalazine MEthotrexate
How might you categorise the causes of interstitial lung disease?
By location
Upper zone = A PENT Aspergillosis Pneumoconiosis EAA Negative seroarthropathy TB
Lower zone = STAIR Sarcoid Toxins (drugs) Asbestosis IPF Rheum (lots)
What is the pathophysiology of extrinsic allergic alveolitis?
Acute allergen exposure in sensitised patients causes T3HS reaction.
Chronic exposure leads to granuloma formation and obliterative bronchitis
Give three causes of EAA
Bird fancier’s lung
Farmer’s lung
Malt worker’s lung
What are the clinical features of EAA?
Acute: Fever, rigors, malaise, dry cough, dyspnoea, crackles
Chronic: Dyspnoea, weight loss, T1RF, cor pulmonale
What are the features of IPF?
Dry cough, dyspnoea, arthralgia, malaise, OSA, cyanosis, fei crackles, clubbing
What are the complications of IPF?
Lung cancer risk
T2RF and cor pulmonale
What are the CXR findings in IPF?
Reduced lung volume
Bilateral lower zone reticulonodular shadowing
Honeycomb lung
What are some causes of pulmonary hypertension?
Left heart disease - MS, MR, LVF
Parenchymal lung disease - COPD, asthma, CF, bronchiectasis
Pulmonary vascular disease - Idiopathic pulmonary hypertension, vasculitis, PE, portal HTN
Hypoventilation - OSA, obesity, thoracic cage abnormalities, neuromuscular disease
What is cor pulmonale?
Right heart failure secondary to chronic pulmonary hypertension
What are the signs seen in cor pulmonale?
Raised JVP Left parasternal heave Loud P2 +- S3 Murmurs - Pulm Regurg, Tric Regurg Pulsatile hepatosplenomegaly Fluid - ascites, oedema
What are the investigations and findings relevant to cor pulmonale?
Bloods ABG - T2RF CXR - enlarged right side of heart with prominent pulmonary vessels ECG - p pulmonale + RVH Echo - RVH, TR Spirometry Right heart catheterisation
How would you manage cor pulmonale?
Treat the underlying condition
Options to reduce pulmonary vascular resistance include LTOT, Ca channel blockers, Sildenafil, prostacyclin analogues
HF management is ACEi + beta blocker + diuretics
Which two medications can be offered to aid smoking cessation and how do they work?
Varenicline - selective partial nicotine receptor agonist
Bupropion - SNRI
What scars might indicate pneumo/lobectomy?
Clamshell= double lung transplant
Lateral thoracotomy = lobe/pneumonectomy
What might explain a lobectomy scar but normal lungs?
Thoracotomy - abscess, empyema, biopsy
Transplant
What are some indications for lobe/pneumonectomy?
90% for non-disemminated bronchial carcinoma
Bronchiectasis
COPD
TB
What are the complications of old TB?
Aspergilloma
Bronchiectasis (LN compression or traction from fibrosis)
Scarring -> bronchial Ca
What are the side effects of the 4 TB medications?
Rifampicin - Orange secretions, hepatitis, enzyme induction
Isoniazid - peripheral sensory neuropathy
Pyrazinamide - Hepatitis, arthralgia
Ethambutol - Optic neuritis
How might you diagnose latent and active TB?
Latent: Tuberculin skin test/IGRA
Active: CXR, 3x positive sputum cultures, L-J culture
