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Scott's Notes > Respiratory > Flashcards

Respiratory Flashcards

1
Q

What are the respiratory causes of clubbing?

A

Cancer - mesothelioma, bronchial
Chronic suppuration - bronchiectasis, CF, empyema, abscess
Fibrosis - IPF, TB

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2
Q

What are the cardiac causes of clubbing?

A

Atrial myxoma
Infective endocarditis
Congenital cyanotic heart disease

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3
Q

What are the GI causes of clubbing

A

Cirrhosis
Crohns/uC
Coeliac
Cancer

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4
Q

What are the miscellaneous causes of clubbing?

A

Idiopathic
Thyroid acropachy
Upper limb AVMs

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5
Q

What are the respiratory causes of cyanosis?

A

Hypoventilation - COPD, MSK
VQ mismatch - PE, AVM
Impaired gas diffusion - pulmonary oedema, fibrosing alveolitis

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6
Q

What are the cardiac causes of cyanosis?

A

Reduced output - HF, mitral stenosis
Congenital - Fallots, TGA
Vascular - Raynauds, DVT

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7
Q

Outline the CURB 65 score and interpret its results

A 
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

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8
Q

What is the empirical antibiotic management for a mild CAP?

A

1st line; Amoxicillin 500mg TDS PO for 5 days

2nd line; Clarithromycin 500mg BD PO for 7 days

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9
Q

What is the empirical antibiotic management for a severe CAP?

A

Co-amox 1.2g TDS IV or Cefuroxime 1.5g TDS IV
AND
Clari 500mg BD IV for 7-10 days

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10
Q

How would you manage the three commonest atypical pneumonias?

A

Chlamydia - tetracycline
PCP - co-trimoxazole
Legionella - Clarithromycin + rifampicin

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11
Q

What is the antibiotic management of a mild and severe HAP?

A

Mild: Co-amox
Sev: Taz +-Vanc +- gent

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12
Q

What are some possible complications of a pneumonia?

A 
Respiratory failure
Hypotension
AF (usually resolves)
Pleural effusion
Empyema
Abscess
Sepsis
Jaundice
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13
Q

Define the following terms:

i) Sepsis
ii) Severe sepsis
iii) Septic shock

A

i) SIRS caused by infection
ii) Sepsis with at least 1 organ dysfunction
iii) Severe sepsis with refractory hypotension

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14
Q

Which organisms are commonly implicated in bronchiectasis?

A

H. influenzae
Pneumococcus
Pseudomonas
Staph

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15
Q

What are some causes of bronchiectasis?

A 
Idiopathic in 50%
Congenital - CF (upper lobes), Kartagener's
Post infectious
Hypogammaglobulinaemia
Obstruction (LNs, Ca, FB)
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16
Q

What are the clinical features of bronchiectasis?

A 
Purulent cough +- haemoptysis
Weight loss
Fever
Clubbing
Coarse creps
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17
Q

What are the Xray findings in bronchiectasis?

A

Thickened bronchial walls (tramlines and rings)

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18
Q

What other imaging technique might be used for bronchiectasis?

A

High Res CT

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19
Q

What is the management regime for bronchiectasis?

A

Chest physio
Abx for flare ups
Bronchodilators
specifics

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20
Q

What is the pathogenesis of cystic fibrosis?

A

CFTR gene mutation results in reduced luminal Cl and increased Na reabsorption leading to excessively viscous secretions

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21
Q

What are the clinical features of CF?

A

Resp: cough, wheeze, bronchiectasis, infections, haemoptysis, cor pulmonale

GI: Pancreatic insufficiency, GI obstructions, gallstones, cirrhosis
Other: nasal polyps, infertility, osteoporosis

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22
Q

What are some diagnostic tests for CF?

A

Sweat test: Na and Cl >60
Faecal elastase
Genetic screening
Immunoreactive trypsinogen (neonatal)

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23
Q

What is the management of CF?

A 
As for bronchiectasis +
Pancreatic enzyme replacement
ADEK supplements
Insulin
Ursodeoxycholic acid (stimulates bile secretion)
DEXA scanning
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24
Q

What is allergic bronchopulmonary aspergillosis (ABPA)?

A

A hypersensitivity reaction to A. fumigatus, causing bronchoconstriction and eventually bronchiectasis

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25
Q

What are the investigation findings of ABPA?

A

CXR - bronchiectasis
Aspergillus in sputum
Aspergillus skin test
Raised IgE and eosinophils

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26
Q

What are the features and Xray findings of an aspergilloma?

A

Commonly silent, haemoptysis, lethargy, weight loss

Well defined, round opacity in apical zone

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27
Q

What are some key differences between small cell and non-small cell lung cancers (SCC, adeno, large cell)?

A

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

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28
Q

What are the complications of lung cancer?

A

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

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29
Q

What investigations would you do for a suspected lung cancer?

A

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

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30
Q

What are the differentials for a coin lesion on CXR?

A

FANGS

Foreign body
Abscess - aspergilloma, klebsiella, TB, staph
Neoplasm
Granuloma - TB, sarcoid, Wegener's, RA
Structural - AVM
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31
Q

Which stands better chance of being cured, SCLC or NSCLC?

A

NSCLC (SC=slim chances)

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32
Q

What are the clinical features of ARDS?

A

Tachypnoea
Cyanosis
Bilateral fine creps
SIRS (Tx, tachycardia, tachypnoea, raised WCC)

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33
Q

What are the Xray findings of ARDS?

A

Bilateral perihilar infilatrates

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34
Q

Does ARDS have a sudden or insidious onset?

A

Sudden

35
Q

How would you manage ARDS?

A 
Ventilation support
Invasive BP monitoring
Inotropes
Abx if septic
TPN
36
Q

What are the differential diagnoses of pulmonary oedema?

A

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

37
Q

Define type 1 and type 2 respiratory failure

A

Type 1 - Hypoxia only

Type 2 - Hypoxia and hypercapnoea

38
Q

What are the mechanisms for oxygen delivery and how much do they deliver/

A

Nasal cannulae - 1-4 L
Simple facemask
Venturi mask - 5-60% depending on colour
Non-rebreathe - up to 100%

39
Q

What might you find on examination of an asthmatic patient?

A

Inspection: paraphernalia, may be cushingoid, oral thrush

Chest: Harrison’s sulcus, usually normal auscultation or wheeze

Sig Negatives: CO2 retention, cor pulmonale, clubbing

40
Q

What are some important history questions to ask an asthmatic?

A 
Symptoms
Diurnal variation
Limitations
Exacerbations
Control (Med use and Hosp admissions)
41
Q

What investigations might you do in an asthmatic?

A 
Bedside - PEFR
Bloods - FBC (eosin), IgE, Aspergillus
CXR - hyperinflation
Spirometry - obstructive (Low FEV1 with Low FEV1:FVC ratio
PEFR monitoring/diary
42
Q

Define a severe asthma attack

A 
Any one of:
PEF 33-50% expected
RR>25
HR >110
Incomplete sentences
43
Q

Define a lifethreatening asthma attack

A 
PEFR <33% exp
SpO2 <92% or T2RF
Cyanosis
Hypotension
Exhaustion or confusion
Silent chest/poor effort
Arrhythmias
44
Q

What is the management of acute severe asthma?

A
  1. Sit patient up
  2. 100% O2 via non rebreathe mask
  3. Nebulised salbutamol and ipratropium
  4. Hydrocortisone IV or Pred PO or both
  5. Write ‘no sedation’ on drug chart
  6. If not improving, escalate to Aminophylline, switch nebs to IV, and inform ITU
45
Q

What additional measures should be taken in the event of life threatening asthma?

A
  1. Inform ITU
  2. MgSO4 2g IV infusion over 20 mins
  3. B2B salb nebs
46
Q

What is the drug ladder for chronic asthma?

A
  1. SABA PRN
  2. Add LD Beclometasone inh
  3. Add LABA (salmeterol)
  4. Consider upping steroid dose if improvement but control still poor)
  5. Trials of LTRA, theophylline, oral Beta agonist
  6. Oral steroids (pred 5-10mg OD)
47
Q

What is the pulmonary function picture of COPD?

A

FEV1 <80%

FEV1:FVC <0.70

48
Q

What are the signs of COPD?

A 
Tachypnoea
Prolonged expiratory phase
Hyperinflation
Wheeze
Early inspiratory crackles
Cyanosis
Cor pulmonale (Raised JVP, oedema, loud P2)
49
Q

Pink puffers vs. Blue bloaters

A

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

50
Q

What are the complications of COPD?

A 
Polycythaemia
Acute (infective) exacerbations
Pneumothorax
Cor pulmonale
Lung carcinoma
51
Q

What is the general management approach of COPD?

A

Stop smoking
Annual IFV
One off pneumococcal vaccince
Pulmonary rehab

52
Q

What features might indicate that a patient is steroid responsive?

A

Any previous atopic diagnosis
Eosinophilia
Substantial variation in FEV1 over time
Substantial diurnal variation in PEF

53
Q

What is the medical management of COPD?

A
  1. SABA or SAMA
  2. (not steroid responsive) - LAMA + LABA
  3. (steroid responsive) - LABA + ICS
  4. Oral theophylline

Prophylactic azithromycin in certain patients (Do LFT and ECG on commencement)

54
Q

Which factors may improve survival in patients with stable COPD?

A
  1. Smoking cessation
  2. LTOT
  3. Lung volume reduction surgery
55
Q

What criteria must be filled for a COPD patient to be placed on LTOT?

A

pO2 <8 AND 1 of:

i) Secondary polycythaemia
ii) Peripheral oedema
iii) Pulmonary hypertension

56
Q

How would you manage an acute exacerbation of COPD?

A

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

57
Q

What are the ECG features of a PE?

A 
Sinus rhythm
Sinus tachy
RBBB
RV strain (T inversion in V1-4)
S1Q3T3
58
Q

What are the components of Well’s score/

A 
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
59
Q

How would you manage a confirmed PE?

A

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

60
Q

What are the clinical features of sarcoidosis?

A

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

61
Q

What investigations (and findings) are relevant in sarcoidosis?

A

Bloods - raised ESR, hypercalcaemia, lymphopaenia, raised ACE, HyperIg, deranged LFTs

CXR, CT, MRI

PFT - Restrictive pattern with reduced transfer factor

Biopsy - non-caseating granulomata

62
Q

What is the management of acute and chronic sarcoidosis?

A

Acute: NSAIDs and bed rest
Chronic: Steroids +- additional immunosuppression

63
Q

What are the differentials for BHL?

A

Sarcoid
TB
Lymphoma
Interstitial lung disease (EAA)

64
Q

What are the differentials for granulomatous disease?

A 
Infection: TB, syphillis 
Autoimmune: PBC
Vasculitic: GCA, PAN, GwP
Idiopathic: Crohns, Sarcoid
Interstitial disease: EAA
65
Q

What are the iatrogenic causes of interstitial lung disease?

A

BANS ME

Bleomycin
Amiodarone
Nitrofurantoin
Sulfasalazine
MEthotrexate
66
Q

How might you categorise the causes of interstitial lung disease?

A

By location

Upper zone = A PENT
Aspergillosis
Pneumoconiosis
EAA
Negative seroarthropathy
TB
Lower zone = STAIR
Sarcoid
Toxins (drugs)
Asbestosis
IPF
Rheum (lots)
67
Q

What is the pathophysiology of extrinsic allergic alveolitis?

A

Acute allergen exposure in sensitised patients causes T3HS reaction.

Chronic exposure leads to granuloma formation and obliterative bronchitis

68
Q

Give three causes of EAA

A

Bird fancier’s lung
Farmer’s lung
Malt worker’s lung

69
Q

What are the clinical features of EAA?

A

Acute: Fever, rigors, malaise, dry cough, dyspnoea, crackles

Chronic: Dyspnoea, weight loss, T1RF, cor pulmonale

70
Q

What are the features of IPF?

A

Dry cough, dyspnoea, arthralgia, malaise, OSA, cyanosis, fei crackles, clubbing

71
Q

What are the complications of IPF?

A

Lung cancer risk

T2RF and cor pulmonale

72
Q

What are the CXR findings in IPF?

A

Reduced lung volume
Bilateral lower zone reticulonodular shadowing
Honeycomb lung

73
Q

What are some causes of pulmonary hypertension?

A

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

74
Q

What is cor pulmonale?

A

Right heart failure secondary to chronic pulmonary hypertension

75
Q

What are the signs seen in cor pulmonale?

A 
Raised JVP
Left parasternal heave
Loud P2 +- S3
Murmurs - Pulm Regurg, Tric Regurg
Pulsatile hepatosplenomegaly
Fluid - ascites, oedema
76
Q

What are the investigations and findings relevant to cor pulmonale?

A 
Bloods
ABG - T2RF
CXR - enlarged right side of heart with prominent pulmonary vessels
ECG - p pulmonale + RVH
Echo - RVH, TR
Spirometry
Right heart catheterisation
77
Q

How would you manage cor pulmonale?

A

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

78
Q

Which two medications can be offered to aid smoking cessation and how do they work?

A

Varenicline - selective partial nicotine receptor agonist

Bupropion - SNRI

79
Q

What scars might indicate pneumo/lobectomy?

A

Clamshell= double lung transplant

Lateral thoracotomy = lobe/pneumonectomy

80
Q

What might explain a lobectomy scar but normal lungs?

A

Thoracotomy - abscess, empyema, biopsy

Transplant

81
Q

What are some indications for lobe/pneumonectomy?

A

90% for non-disemminated bronchial carcinoma
Bronchiectasis
COPD
TB

82
Q

What are the complications of old TB?

A

Aspergilloma
Bronchiectasis (LN compression or traction from fibrosis)
Scarring -> bronchial Ca

83
Q

What are the side effects of the 4 TB medications?

A

Rifampicin - Orange secretions, hepatitis, enzyme induction

Isoniazid - peripheral sensory neuropathy

Pyrazinamide - Hepatitis, arthralgia

Ethambutol - Optic neuritis

84
Q

How might you diagnose latent and active TB?

A

Latent: Tuberculin skin test/IGRA

Active: CXR, 3x positive sputum cultures, L-J culture

Scott's Notes (21 decks)

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