Respiratory Flashcards
Firstline antibiotic for neutropenic sepsis?
Taz
DAH and SLE?
DAH (diffuse alveolar haemorrhage) is rare complication of SLE. Sudden onset SOB and fall in haematocrit. BAL fluid is haemorrhagic. Get high DLCO as alveolar blood can absorb CO. Biopsy shows pulmonary capillaritis. Clinically resembles ARDS
What can low complement be suggestive of?
SLE flare
Causes of high DLCO?
DAH, polycythaemia, asthma, after exercise, L-R shunts
What does BAL containing CD4 cells indicate?
Sarcoidosis
Main lab findings in SIADH?
Hyponatraemia, concentrated urine (sodium >40), hypo-osmolality of serum
Why no oedema or HTN in SIADH?
Body retains water but loses sodium (natriuresis)
Where does neurovascular bundle lie in relation to ribs?
Just below inferior border so aim just above the rib below
Protein level for transudate vs exudate?
Below 25g/L is transudate (hydrostatic increased or oncotic decreased);>35 is exudate (increased capillary permeabilility)
Features of histoplasmosis?
Exposed to pigeon droppings. Have pulmonary nodules and mediastinal LNs on CT chest. May have cavitation.
What is plastic bronchitis?
Formation of rigid or gelatinous casts in airways and coughing them up e.g. Hoffman’s bronchitis, cast bronchitis. Seen n asthma, CF, bronchiectasis.
Blood supply of lungs and significance?
Is dual i.e. bronchial arteries and pulmonary artery. So embolus of small pulmonary artery if have adequate bronchial circulation is minimal significance.
What does oblique fissure separate?
R lower and middle lobs; 6th rib roughly follows
Gold standard test for CF?
Pilocarpine sweat test (measure chloride content)
S. aureus pneumoniae?
Usually affects the elderly, typically after influenza, can produce cavitating lesions
NIV in ECOPD?
Should be considered if have persisting resp. acidosis after 1 hour of standard medical therapy. If pH<7.25 then ITU and intubation may be preferable.
When is NIV not indicated in COPD?
If have impaired GCS, severe hypoxaemia, copious respiratory secretions
Features of sarcoidoisis?
Multisystem granulomatous disorder, peaks 20-30, F>M, Afro-Caribb. Most common xray finding is BHL. May have EN, anterior uveitis.
Managing sarcoidosis?
Acute sarcoidosis with BHL and EN usually resolves spontaneously wihtout any treatment. Chronic requires steroids, monitoring lung function, ESR, CRP, ACE (all usually elevated)
Complication of anti-TNF antibody?
I.e. infliximab; increases risk of Tb (should get clinical exam, CXR and tuberculin test done before starting)
Lung findings in rheumatoid lung disease?
Basal fibrosis (blood borne) and pulmonary nodules
Causes of calcified hilar nodes?
Sarcoidosis, tuberculosis, histoplasmosis. Nodes enlarged but not calcified in cancer
Gold standard investigation for active Tb?
Sputum samples (at least three) for culture and microscopy
Features of bronchiolitis obliterans?
Dry cough, SOB, fatigue, wheeze. Can be caused by HSCT, heart or lung transplant, infections e.g. influenza, adenovirus, Mycoplasma, CTD (SLE, RA). CT shows air trapping. Obstructive spirometry (see above)
NIV in tension?
Disastrous!
Lung findings in silicosis?
Small numerous opacities in upper zones with hilar lymphadenopathy
Features of Klebsiella pneumonia?
Most common inpatients with conditions e.g. alcoholism, DM, chronic lung disease. Spread person-to-person or through devices e.g. ventilator so hospital stay is a risk. Presents as consolidation, most commonly RUL, can be multilobar, may get cavitation or abscess formation.
Treating klebsiella?
Carbapenams, at least 14 days.
When might V/Q be preferred to CTPA?
Pregnancy, renal impairment (does not use nephrotoxic contrast), contrast allergy
Bloods in vitamin D deficiency?
Low calcium, low phosphate, high ALP
Tb drugs and VDD?
Rifampicin and isoniazid can cause VDD
4Cs of Tb?
Cough, cavitation, calcification, caseation
Side effects of Tb meds?
Rifampicin = pissing orange = orange urine
Ethambutol can cause optic neuritis (EYEthambutol)
Lung cancer that is hilar and associated with hypercalcaemia?
SCC
Indications for LTOT in COPD?
Polycythaemia, peripheral oedema, raised JVP, sats below 92% on RA, very severe airflow obstruction i.e. <30% predicted FEV1
What % improvement in FEV1 with BD supports asthma?
12%
What % variability in PEFR supports asthma?
> 20%
Causes of BHL?
Sarcoidosis, Tb, lymphoma, LN mets
Three skin manifestations of sarcoidosis?
EN, lupus pernio, macular or papular sarcoidosis
5 causes of erythema nodosum?
Tb, IBD, streptococcal infection, sarcoidosis, drugs e.g. oral contraceptives and sulphonamides
Xray signs of HF?
Bilateral pleural effusions, Kerley B lines, upper lobe venous diversion, cardiomegaly, interstitial shadowing
Using LABA without ICS?
Very dangerous - linked with life-threatening exacerbations
Clinical course of Tb?
Get initial infection (usually in lung apices) called Ghon focus (single, scarred, often calcified granuloma). Years later, get immunosuppression and re-infection (post-primary Tb) and may see classic findings of bilateral enlarged hila, patchy upper zone markings, round opacity in upper zone, or pleural effusion, or miliary Tb.
Where does aspiration pneumonia most commonly present?
Right middle or lower, or left lower. Give cover for anaerobes.
Two conditions where cavitation of upper zones is found?
Tb and Ank. spond.
Site for thoracocentesis in tension?
Second intercostal space, mid clavicular, just above the third rib
Site for chest drain?
Fifth IC, mid-axillary
NIV and massive haemoptysis?
Contraindicated due to risk of aspiration of blood and disturbance of clot formation with pressure
Immediate treatment of suspected CO poisoning?
High flow oxygen (reduces half life of carboxyhaemoglobin). Later do hyperbaric oxygen if severe.
Key finding in CO poisoning?
Resp distress with normal oxygen saturations (pulse oximeter cannot differentiate carboxyhaemoglobin and oxyhaemoglobin
Conditions assoc. with OSA?
Obesity, smoking, high levels of alcohol consumption. Male gender.
Clinical features of pleural effusion?
- Trachea central or deviated away
- Reduced chest expansion on affected side
- Reduced tactile vocal fremitus on affected side
- Stony dull percussion
- Reduced air entry/breath sounds
- Reduced vocal resonance
Presence of which bacteria makes a patient ineligible for lung transplant?
Burkholderia cenocepacia (accelerates lung decline)
Below what FEV1 threshold are COPD patients eligible for lung transplant?
<25% predicted
Which respiratory infection is associated with the “air crescent” sign?
Aspergillus - neutrophils invade to clear necrotic tissue, air fills space
PO2 and PaO2 in right-to-left shunt?
Means blood (if complete) is bypassing lungs completely so PO2 in lungs will be fine (alveolar PO2) but arterial blood PaO2 will be low, and increasing inspired oxygen will have no effect.
What are the five causes of hypoxaemia?
- Hypoventilation
- VQ mismatch
- Right-to-left shunt
- Low-inspired oxygen
- Diffusion abnormalities
What PEFR would indicate sub-optimal therapy?
Average should be >80% of best reading
What is extrinsic allergic alveolitis?
Type III HS condition, leads to inflammation within airways. Get SOB, reticulo-nodular shadowing on CXR. A type of pulmonary fibrosis. Exposures to Aspergillus in hay causes farmer’s lung, to avian proteins causes bird fancier’s lung
Features of bronchiectasis?
Copious sputum often with haemoptysis, recurrent chest infections. O/E clubbing, cyanosis, coarse creps which move with coughing.
Features of Legionnaires?
Pneumonia caused by Legionella. Inhale aerosols from contaminated water (often AC systems, showers, hot tubs). Get severe pneumonia assoc. with N&V, diarrhoea, hyponatraemia, raised transaminses. Does not respond to B-lactams!
Characteristics of EGPA?
Asthma, peripheral and tissue eosinophilia, extravascular granulomas, vasculitis of multiple organ systems
Histology in EGPA?
Affects small and medium sized arteries, capillaries, veins, venules. Get granulomatous reactions in tissues or walls of vessels, with infiltration of eosinophils.
Manifestations of EGPA?
- Non-specific manifestations e.g. fever, weight loss.
- Pulmonary (severe asthma, pulmonary infiltrates)
- Mononeuritis multiplex (painful, asymmetrical motor and sensory neuropathy
- Skin lesions inc. purpura and nodules
- Allergic rhinitis and sinusitis
Bloods in EGPA?
Dramatic eosinophilia, signs of inflammation e.g. raised ESR/fibrinogen/alpha 2 globulin
Why is SCLC the most associated with hormonal paraneoplastic syndromes e.g. ectopic ACTH and SIADH?
Small cells are neuroendocrine derivatives so have propensity to produce hormones
Aetiologies of pulmonary fibrosis (BREASTCA)?
Bleomycin Radiation EAA Ank. spond. Sarcoidosis Tb Cryptogenic fibrosing alveolitis Asbestosis
What is yellow nail syndrome?
Triad of yellow deformed nails, lymphoedema, exudative pleural effusion/resp. involvement. Seen in PLE, nephrotic syndrome, thyroid disease
CXR in PE?
Wedge-shaped opacity
Needle gauge for aspiration of pneumothorax?
16-18G
Differentiating IPF and EAA?
In EAA, as allergens are airborne get apical changes. In IPF, get lower zone changes
Features of idiopathic pulmonary fibrosis?
Commonest ILD. Get lower zone inflammation. Dry cough, SOB, fatigue.
O/E get find end inspiratory crackles throughout. Restrictive spirometry. CXR shows reduced lung volume, increased interstitial markings bilaterally and in lower zone. On HRCT, get honeycombing and microcysts. Do not need biopsy if imaging typical.
Treating idiopathic pulmonary fibrosis?
Lung transplant only cure. Treatment otherwise is domiciliary oxygen, pulmonary rehab, palliative care. Steroids not indicated.
Where in the lung does sarcoidosis affect?
Typically middle and upper
Treating ECOPD (not IECOPD)?
Oral steroids, short-acting bronchodilators.
Investigating OSA?
Do overnight polysomnographic study
What might decrease sensitivity of V/Q scan?
Current or previous lung disease
What does phrenic nerve involvement in lung cancer cause?
Raised hemidiaphragm
What drugs make up the continuation phase of Tb treatment?
Rifampicin and isoniazid
Causes of nocturnal cough?
GORD, asthma, CHF, sinusitis with post-nasal drop
Mechanism behind primary tuberculosis?
Granulomatous disease with type IV HS reaction
Recommended first investigation for pleural effusion?
Pleural aspiration (can classify as trans/ex and guide management)
Horner’s triad?
Meiosis, ptosis, anhidrosis (compression of sympathetic nerves)
What do if have clinical suspicion of PE and VQ shows low probability?
Do CTPA!
Classic features of IPF?
Clubbing, fine end-inspiratory crackles, CXR with bi-basal reticular nodular shadowing
Which type of lung tumour most commonly cavitates?
SCC. Also tends to be central and release PTH-RP
Causes of cavitating lesions?
Primary lung cancer, septic emboli, Tb, bacterial pneumonia e.g. S. aureus, rheumatoid nodules
Signs of hypercapnia?
Reduced GCS, flapping tremor, palmar erythema, bounding pulse (vasodilation)
Presentations of tension pneumo?
Severe respiratory compromise, asymmetrical chest movement, tracheal deviation, hyper-resonant hemithorax, absent breath sounds, cardiac arrest
“Algorithm” for pleural fluid protein?
If <30g/L = transudate, if >30 = exudate. If between 25 and 35, apply Light’s criteria.
What is Lofgren syndrome?
Presentation of acute sarcoidosis; get triad of erythema nodosum, BHL, arthralgia
Histology of sarcoidosis?
Non-caseating granulomas
Organisms causing interstitial lung infections?
Mycoplasma, pneumocystis, RSV or CMV, fungal like histoplasmosis
Extra-pulmonary manifestations such as haemolytic anaemia, erythema multiforme, GBS, myocarditis or cerebellar ataxia are associated with which organism?
Mycoplasma
Cause of early and late stages of allergic asthma?
- Early is caused by mast cell degranulation after allergen-specific IgE binds, leading to release of histamine, leukotrienes and prostaglandins
- Late is caused by APCs carrying Ag that present to Th1 and Th2 cells, causing mucosal inflammation and oedema and therefore persistent symptoms
Why avoid warfarin and heparin together in patients who have had large PE?
Means if need to thrombolyse them then are at high risk of haemorrhage - better to just use IV heparin or LMWH
Indications for thrombolysis in PE?
- Systolic below 90mmHg for 15 minutes despite fluid resusc
- > 40mmHg drop in baseline systolic for >15 minutes despite fluid resusc
- Imminent or actual cardiac arrest
- Presence of right heart thrombus
Pneumothorax and PE in CF?
Pneumo likely, PE unlikely
What is Meig’s?
Benign ovarian tumour and transudative pleural effusion (which resolves when tumour is removed)
Central line insertion route and pneumothorax?
Subclavian is higher risk than IJV. Get portable CXR and then insert chest drain.
Two reasons why IJV route is preferable to SCV for central line?
Lower risk of iatrogenic pneumothorax, and if accidentally puncture artery then direct pressure can be applied
Complications of central line insertion?
- Infection (local site and systemic)
- Arterial puncture
- Haematomas
- Thrombosis
- Air embolus
- Dysrhythmias
- Atrial wall puncutre
- Lost guidewire
- Anaphylaxis (if catheter is antibiotic impregnated)
- Chylothorax
Typical CXR in PCP?
Bat-wing diffuse infiltrates
What does peak flow measure the calibre of?
Medium and large airways
PEF in the diagnosis of COPD?
Has no role
What defines a large pneumothorax?
Collapse >2cm at level of hilum
Gold-standard test in pulmonary fibrosis?
HRCT
Factors indicating Legionnaire’s disease?
Flu-like symptoms, dry cough, bibasal consolidation. Bloods show lymphopenia, hyponatraemia, deranged LFTs
Who gets S. aureus pneumonia?
Post-influenza, the young, the elderly, IVDU. Can cause bilateral cavitating bronchopneumonia
