Respiratory Flashcards
1
Q
What are some signs of hypercapnia?
A
- confusion
- reduced consciousness
- asterixis (flapping tremor)
- bounding pulse
2
Q
What are your differentials for type 2 respiratory failure?
A
- increased airway resistance (asthma, COPD)
- reduced breathing effort (drug effects, brainstem lesion)
- decreased area for gas exchange (chronic bronchitis)
- neuromuscular problems - Guillain-Barre Syndrome, MND
- deformity (ankylosing spondylitits, flail chest)
3
Q
What are some causes of RESPIRATORY ALKALOSIS?
A
Increased ventilation
- anxiety
- pain
- hypoxia
- PE
- pneumothorax
- iatrogenic *excess mechanical ventilation)
4
Q
A patient presents to A&E with a tight feeling in the chest, tingling around their fingers and mouth and shortness of breath. What is the most likely diagnosis?
A
Anxiety
Peri-oral tingling
5
Q
How does hyperventilation lead to perioral and peripheral paresthesia?
A
- increased respiration - respiratory akalosis - increased alkaline blood plasma - decrease in free ionised calcium - hypocalcaemia
- this results in the described symptoms
6
Q
How does sepsis result i metabolic acidosis?
A
Fever, hypotension and reduced end-organ perfusion can cause tissue hypoxia resulting in anaerobic respiration, increased lactic acid and therefore acidosis.
7
Q
What do you give for HAP?
A
Piperacillin with tazobactam (if more than 5 days into admission)
8
Q
What antibiotic do you give in an uncomplicated CAP?
A
Amoxicillin
Doxy if penicillin allergic
9
Q
What is the most common cause of pneumonia in an alcoholic? In a non-alcoholic?
A
Klebsiella
Strep pneumonia
10
Q
What ABG would you expect to see in a panic attack?
A
Hyperventilation - so low CO2, lower but normal O2, no metabolic changes
11
Q
What kind of drug is bupropion and what is it’s use?
A
Noradrenaline and dopamine reuptake inhibitor
Nicotine antagonist
Used in smoking cessation
12
Q
What medications can be offered in smoking cessation?
A
Varenicline
Bupropion
NRT (only one can use in pregnancy)
13
Q
What are common causes of respiratory alkalosis?
A
Salicylate poisoning Pregnancy Encephalitis PE Anxiety leading to hyperventilation Altitude
14
Q
What effects can small cell lung cancers have on the body?
A
Paraneoplastic syndromes - it’s a neuroendocrine tumour
Cushing’s syndrome, hyponatraemia
Lambert Eaton syndrome (autoimmune myasthenic-like symptoms)
15
Q
What can be used in the management of alpha-1-antitrypsin disease?
A
Stop smoking
Bronchodilators, physio
Surgery: volume reduction surgery
16
Q
What is first line treatment for sleep apnoea?
A
CPAP
weight loss, reduce alcohol intake, sleep on your side
17
Q
What are common symptoms in a patient presenting with sleep apnoea?
A
Daytime somnolence
Hypertension
Waking in the night struggling to breath
18
Q
What are risk factors for sleep apnoea?
A
Marfan’s
Large tonsils
Obesity
19
Q
Give some common causes of haemoptysis.
A
Lung cancer (smoking hx, malignancy sx)
Pulmonary oedema (dyspnoea, bibasal crackles, s3)
TB (night sweats, anorexia, weight loss)
PE (pleuritic chest pain, tachycardia, tachypnoea)
Bronchiectasis (cough history, sputum production)
Mitral stenosis (dyspnoea, AF, malar flush, mid-diastolic murmur)
Aspergilloma (past TB, severe, CXR - round opacity)
Granulomatosis with polyangiitis (URTI, LRTI, saddle-shaped nose deformity, glomerulonephritis)
Goodpasture’s syndrome (haemoptysis, systemically unwell, glomerulonephritis)
20
Q
What changes need to be made to asthma management during pregnancy?
A
Continue as normal for good asthma control
21
Q
What is your management for sarcoidosis?
A
Asymptomatic - no treatment
NSAIDs and bed rest
Steroids pred 40mg 4-6 weeks
Severe cases IV methylpred or immunosupressants (cyclosporine, methotrexate, cyclophosphamide)
22
Q
What is the most common organism causing infective exacerbations of COPD?
A
H. influenza
23
Q
What drugs have associations with respiratory symptoms?
A
Ramipril
Aspirin/NSAIDs
Beta blockers
Clopidogrel/ticagrelor
24
Q
How do you calculate pack years?
A
1 pack is 20 cigarettes
A 30 years pack history is 20 cigarettes a day for 30 years
25
What heart sound might be heard in pulmonary hypertension?
Loud P2
26
In what diseases does clubbing occur?
```
ILD
Asbestosis
Fibrosis
Lung cancer
Bronchiectasis
CF
```
27
What could crackles on lung examination indicate?
Fine - pneumonia, bronchiectasis, CF, fibrosis
| Coarse (Creps) - bronchiectasis, pleural effusion
28
What does a wheeze on respiratory examination indicate?
COPD or asthma
29
What is a good method to look at x-rays?
```
DETAILS - patient, time, date
RIPE - rotation, inspiration, penetration, exposure
Airway
Breathing
Circulation
Diaphragm
Everything (bone)
Foreign bodies
```
30
What are you indications for CPAP?
Sleep apnoea
Hypoxia
HF + Pulmonary oedema - drives the fluid out
31
What is your only indication for use of BiPAP?
Acidotic patients
Hypercapnoea
(T2RF)
32
Define the two different types of respiratory failure
Type 1 Respiratory Failure - Low PaO2, normal PaCO2
Type 2 Respiratory Failure - Low PaO2, low PaCO2
PaO2 <8.0kPa is respiratory failure
33
Give some causes of type 1 respiratory failure
Airflow obstruction - COPD, asthma
Failure to ventilate the alveoli - emphysema
Diffusion limitations - emphysema, ILD, sarcoidosis
V/Q mismatch - pneumonia, COPD
34
What is the pattern seen in obstructive lung diseases?
FEV is lower than FVC
| FEV1/FVC <80%
35
What is the pattern seen in restrictive lung disease?
FVC is proportionally lower than FEV1 so FEV1/FVC >80%
36
What are the two main pathologies behind COPD?
Emphysema
| Chronic bronchitis
37
What are risk factors in COPD development?
Smoking
Infection
Occupation (mining)
Alpha-1-antitrypsin disease
38
What signs might you see in a patient with COPD?
Barrel-chest (hyperinflation)
Quiet on auscultation
Chest may be resonant
Pursed lip breathing
39
How do you control an acute exacerbation of COPD?
```
Controlled O2 (be aware of saturation target)
Salbutamol nebulisers (SABA) and ipratropium (LAMA)
5-7 days course of prednisolone
```
40
What chronic management is seen in patients with COPD?
Home oxygen
SABA or LABA
Inhaled corticosteroids
Smoking cessation
41
What are the indications for home oxygen?
Resting PaO2 <7.3kPa
PaO2 <8kPa with peripheral oedema, PH or polycythaemia
Resting hypercapnia
42
What is the difference between chronic bronchitis and emphysema?
Chronic bronchitis - over secretion of mucous leading to productive cough, intermittent dyspnoea, infection risk and CO2 rention
Emphysema - loss of lung tissue, alveolar enlargement, bullous formation
43
What are the 4 key pathophysiological features behind asthma?
Bronchial hyperresponsiveness
Bronchoconstriction
Smooth muscle bronchospasms
Hypertrophy of mucosal glands
44
Give 3 triggers for asthma
Exercise
Cold weather
Night/early morning
Allergens
45
What investigations can be done in an asthmatic patient?
Peak Expiratory Flow - decreased, diurnal variation
Spirometry
DLCO/Transfer coefficient - may be raised
FBC
CXR
CRP
46
What is your management in an acute asthma attack?
Oxygen
Salbutamol (inhaler, nebs if possible run through with O2)
Hydrocortisone 100mg IV (max 200mg every 4hrs)
Ipratropium
Theophylline/Aminophylline (1.2-2g IV over 20 minutes) or MgCo4
47
What is standard escalation of asthma management?
```
Avoidance of trigger
SABA
Inhaled corticosteroid
LABA
LRA (Montelukast, preferred in younger children)
Muscarinic agonist
```
48
What is bronchiectasis?
Permanent abnormal dilation and thickening of bronchi and bronchioles
Failure of mucociliary clearance, inflammation and obstruction
49
What is cor pulmonale?
Right sided heart failure secondary to a pulmonary problem
50
What symptoms and signs might you expect to find in someone with bronchiectasis?
```
Dyspnoea
Haemoptysis
Chest pain
Sputum, productive cough
Finger clubbing, coarse inspiratory crackles
```
51
What respiratory diseases are obstructive?
COPD
Asthma
Bronchiectasis
Malignancies
52
What is the genetic defect in cystic fibrosis?
Long arm of chromosome 7
delta F508 gene
CFTR transport protein
Normally moves chloride ions (and thus water and sodium)
53
In what ways might CF present?
Malabsorption, poor growth, pancreatic insufficiency, failure to thrive
Meconium ileus - failure to pass meconium
Reccurent respiratory infections
Infertility, atrophy of vas deferens
Steatorrhoea - offensive, greasy stool
54
What signs would you expect to see in a child with cystic fibrosis?
```
Hyperinflation of the chest
Coarse inspiratory creps, expiratory wheeze
Finger clubbing
Cyanosis
Hepatomegaly
```
55
What investigations can you do in cystic fibrosis?
Ion sweat tests (high chloride in sweat)
Serum immunoreactive trypsin (Guthrie)
Faecal elastase
56
What treatment options can you use to manage cystic fibrosis?
Anti-inflammatories - azithromycin, steroids, PPI
Prophylactic antibiotics - flucloxacillin
Physio
Mucolytics - DNases
Creon
57
What diet is recommended for cystic fibrosis sufferers?
High calorie, high fat diet
58
What might you see in CXR of someone with idiopathic pulmonary fibrosis?
Irregular nodular shadows, confluent markings
| Ground glass on CT
59
Describe what pneumoconiosis is and the two types.
Particulate inhalation - coal worker's
Symptoms include dyspnoea, cough and black sputum
Can be simple (small round opacities on CXR) or progressive (massive fibrotic nodules)
60
What is Caplan's syndrome?
The presence of rheumatoid arthritis and pneumoconiosis that manifests and pulmonary nodules
61
What is a major risk factor in mesotheliomas?
Asbestos
62
Give 2 different kids of extrinsic allergic alveolitis
Farmer's Lung - mouldy hay
Bird Fancier's Lung - bird faeces
Byssinosis - cotton fibres
Bagassosis - sugarcane fibres
63
What systemic diseases can result in lung fibrosis?
```
Goodpasture's Syndrome (collagen basement membrane antibodies, affects kidneys)
Wegner's Granulomatosis
Rheumatoid Arthritis
SLE
Systemic Sclerosis
```
64
What is sarcoidosis?
```
A multi-system granulomatous disease
Multisystemic
Respiratory symptoms - dry cough, chest pain, dyspnoea
Lymphadenopathy, hepatosplenomegaly
Malaise, weight loss, fatigue
Skin or eye lesions
```
65
What is seen on CXR of someone with sarcoidosis?
hilar lymphadenopathy
Fluffy opacities in the hilar region with clear lung fields
May be fibrosis
66
What are the different stages of sarcoidosis and how does this affect management?
Stage 0 - normal CXR
Stage 1 - BHL - bilateral hilar lymphadenopathy
Stage 2 - BHL + Infiltrated
Stage 3 - Peripheral pulmonary infiltrates alone
Stage 4 - Progressive pulmonary fibrosis + bulla
Stage 1 + 2 normally resolve spontaneously
Stage 3 + NSAIDs, steroids (prednisolone 40mg for 4-6 weeks)
Severe - IV methylprednislone or immunosuppressants (methotrexate)
67
What does sleep apnoea increase your risk of?
Stroke
Diabetes
CVD
HTN
68
How is sleep apnoea managed?
Weight loss
Avoidance of tobacco and alcohol
CPAP via nasal mask
Surgical options - mandibular advancement, tonsillectomy
69
What is someone with shortness of breath and inspiratory crackles presenting with? The chest x-ray shows alveolar shadowing (bat's wings) and bilateral effusions.
How do you treat?
Pulmonary oedema
Treat with furosemide
CPAP
70
Give 5 common differentials for haemoptysis?
```
Lung cancer
TB
PE
Goodpasture's Syndrome/Vascultitis/Granulomatosis with polyangiitis
Severe bronchiectasis or pneumonia
```
71
What are the different ways TB can present?
```
Miliary TB - disseminated small granulomas spread through various organs
CNS TB - cause of meningitis
Primary TB
Extra pulmonary
Secondary TB - after a latency period
```
72
Give 5 investigations you would do for someone with suspected TB and what you would expect to see on them?
Bloods: CRP/ESR (raised), raised calcium, white cells, high platelets
Mantoux Tuberculin skin test - positive
Microbiological culture - specify TB as this is not routinely done, mycobacterium culture, Lowenstein-Jensen slope
CXR - cavitation, consolidation, patchy nodular shadows in the upper zones
73
What are the 4 drugs used to treat TB and the length of time each is given?
Rifampicin - 6m
Isoniazid - 6m
Ethambutol - 2m
Pyrazinamide - 2m
74
What are side effects of each of the TB drugs used?
Rifampicin - red urine, hepatic toxicity
Isoniazid - peripheral neuropathy, N+V
Ethambutol - optic neuritis
Pyrazinamide - hepatotoxicity, arthralgia
75
What are the 5 features of an acute SEVERE asthma attack?
Inability to complete full sentences
PEFR 33-50% of best or predicted
RR >25/min
HR >110 bpm
```
Life threatening
O2 <92%
PEFR <33%
Silent chest, cyanosis, poor respiratory effort
Hypotension, bradycardia
```
76
Give the name of some restrictive lung diseases?
```
Pulmonary fibrosis
Asbestosis
Sarcoidosis
ARDS
Kyphoscoliosis
Neuromuscular disorders
```
77
What is the order of drugs to be prescribed in asthma in children?
SABA
SABA + ICS
SABA + ICS + LTRA
SABA + ICS + LABA (LTRA continued depending on response)
78
What would you expect to find in an empyema expiration?
Empyema - turbid effusion - high protein, low pH, low glucose - exudate
pH <7.2
Low glucose
High LDL
79
Give some causes of exudate effusions?
Infection
Neoplasia
Pancreatisis
PE
>30g/L protein
80
What do you expect to see on CXR in heart failure?
```
Alveolar oedema (bat's wings)
Kerley B lines (interstitial oedema)
Cardiomegaly
Dilated prominent upper lobe vessels
Effusion (pleural)
```
81
What are the classic 4 features of idiopathic pulmonary fibrosis (cryptogenic fibrosing alveolitis)
Dyspnoea
Bibasal fine end-inspiratory creps
Dry cough
Clubbing
82
Give 4 signs you might see in a patient presenting with a pneumothorax.
Tracheal tug
Hyperresonance
Decreased breath sounds
Asymmetric chest sounds/expansion
83
What is your management of a spontaneous pneumothorax?
Occlusive dressing
Give oxygen
Chest drain
84
Where should chest drains be inserted?
Mid-axillary triangle, 5th intercostal space, lateral edge of pectoralis major, base of azilla and lateral edge of latissimus dorsi
85
Where is the needle thoracocentesis inserted?
2nd intercostal space, midclavicular line
86
Where can secondary lung cancers originate from?
```
Breast
Kidney
Ovary
Uterus
Testes
Thyroid
```
87
What are the different types of lung cancer?
Small cell lung cancer
| Non-small cell - adenoma, squamous and large cell
88
What is the biggest risk factor in the development of lung cancer? What are other risk factors that exist?
SMOKING
Asbestos
Carcinogenic products - coal mining, silica, heavy metals
89
What are the two different types of small cell lung cancer and how does treatment differ?
Limited - chemotherapy extends prognosis to 1 year
| Extensive - chemotherapy extends life expectancy to 8 months
90
What systemic effects can SCLC have?
Cushings
| Addison's- hyponatraemia
91
What kind of lung cancer is most common in smokers?
Squamous Cell Lung Cancer
92
What complications can arise as a result of metastatic spread of lung cancers?
Chest wall - can infringe on nerves
| Pancoast's Tumour - Horner's Syndrome
93
Give 5 key symptoms of patients presenting with lung cancer.
Cough, sometimes with haemoptysis
Chest pain
Malaise and weight loss
94
What might you see on a CXR in suspected lung cancer?
```
Lung collapse
Masses
Bony secondaries
Pleural effusion
Hilar enlargement
Consolidation
```
95
What side effects might patients on chemotherapy experience?
```
Alopecia
N+v
Peripheral neuropathy
Fatigue
Diarrhoea
Infertility
```
96
How might a mesothelioma present?
Progressive breathlessness
History of asbestos exposure
Finger clubbing + bilateral end-inspiratory crackles (fibrosis signs)
On CXR: dark streaks and a honeycomb appearance
97
What are the 5 different types of pulmonary hypertension?
```
Pulmonary artery HTN
Pulmonary HTN due to left heart disease
Pulmonary HTN due to lung disease
Pulmonary HTN due to blood clots
Pulmonary HTN due to blood
```
98
What is pulmonary hypertension a complication of?
PE
COPD
Heart problems - HF
99
What is a normal pulmonary artery pressure?
Pulmonary artery pressure >25mmHg
100
What are transudative causes of pleural effusion?
Renal failure
| Heart failure
101
What is the most common cause of a exudative pleural effusion?
Pneumonia
102
What is your step-wise management for chronic COPD?
SABA/SAMA
FEV1>50% predicted - LAMA/LABA
FEV1<50% predicted - LAMA or LABA + Steroid
Continued: triple therapy: LABA, Corticosteroid, LAMA
103
What is pneumonia?
An infection of the airway leading to inflammation of the distal airways
104
What are common causes for bacterial pneumonia?
Strep pneumonia
Haemophilus influenza
Klebsiella - neonates, smokers
Atypical - chlamydia, legionnaires disease (Spain, air conditioning)
105
How long must a patient be in hospital before it's considered a hospital acquired pneumonia?
48 hours post-admission
106
Give 4 signs you might see on someone with a pneumonia?
```
Cough
Stony dullness in chest, coarse crackles on auscultation
Tachycardia
Fever
Tachypnoea
Low BP
Decreased air entry
Bronchial breathing, increased vocal resonance
```
107
What test is used for legionella?
Urine antigen test
Na is low in legionella
108
What is your way of determining management of community acquired pneumonia?
CURB 65
Confusion Urea >7 RR >30 BP systolic <90 diastolic <60 65 age
0-1 home management
2 - IV amoxicillin + clarithromycin
3 - Co-amoxiclav
109
What is your management option of choice for an atypical CAP?
Doxy + macrolide (azithromycin or clarithromycin) 500mg IV/PO
110
What is a pleural effusion?
The presence of fluid in the pleural space of the lungs
111
What indicates an empyema on pleural tap?
White colour
Low glucose (bacterial), high protein
pH - low
112
What are symptoms of pleural effusion?
dull to percussion
reduced or absent breath sounds
respiratory distress
113
The protein count in a transudate is...?
Low <25g/L
| Causes include organ failure, low albumin
114
A patient present with a sharp stabbing chest pain and shortness of breath has an abnormal ECG and raised D-Dimer. What might you see on ECG and is the raised D-Dimer significant? What test will you follow up with?
PE - S1Q3T3 - deep S wave, q-wave in lead III, inverted t-wave, sinus tachycardia
Raised D-Dimer >500ng/ml - a d-dimer is sensitive but not specific, it can also be raised in malignancy, RA, prengnacy. D-dimer measures the breakdown products of a fibrin clot
V/Q scan if renally impaired but otherwise gold standard is a CTPA
115
What features exist in a Wells Score?
```
Clinically expected DVT
PE most likely diagnosis
Tachycardia >100bpm
Immobilisation >3 days or previous surgery in past 4 weeks
History of DVT or PE in past
Haemoptysis
Malignancy
```
116
The acute management of a PE is...?
Thombolysis - alteplase in haemodynamically unstale patients
| LMWH for 5 days, then warfarin with INR aimed 2-3
117
What is severe acute respiratory syndrome?
SARS
Severe pulmonary inflammation occurring due to a non-respiratory stimuli
Results in diffuse alveolar capillary wall damage through inflammation
118
What sign do you see in DVT?
Homan’s sign – pain in the calf on dorsiflexion of the foot
119
What is your management in a massive PE?
IV Heparin – rapid onset, used to cover
| PO Warfarin – warfarin has to reach a therapeutic level before effective, usually 3 days
120
How does SCLC cause hypercalcaemia?
Bone metastasis
| PTH-related peptic secretion
121
What are some indications for home oxygen?
Severe airflow obstruction FEV1 <30% predicted
SpO2<92%
pO2 <7.3kPa or 7.3-8kPa with secondary polycythaemia, peripheral oedema or pulmonary hypertension
122
How does CURB 65 affect your antibiotic management?
Low severity – amoxicillin
Moderate to high – amoxicillin and a macroline (co-amox)
Severe- clarithromycin
123
Describe correct inhaler technique
- Remove cap and shake
- Breathe out gently
- Put mouthpiece in mouth, press canister down and breath in slowly
- Hold breath for 10 seconds
- Wait 30 seconds before repeating
124
What would you recommend to a patient post-pneumothorax?
Avoid scuba diving
| Stop smoking
