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Year 3 diagnosis and management > Respiratory > Flashcards

Respiratory Flashcards

1
Q

Symptoms and signs of ARDS?

A
  • SOB
  • Respiratory distress
  • Cough
  • Acute onset
  • Cyanosis
  • Tachypnoea
  • Tachycardia
  • Bilateral widespread fine inspiratory crackles
  • Hypoxia refractory to o2
  • Peripheral vasodilation
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2
Q

Diagnostic investigation for ARDS?

A

Diagnostic - CXR (bilateral infiltrates, interstitial shadowing, will see tracheostomy tube and central line)

  • Pulmonary capillary wedge pressure <19
  • Refractory hypoxaemia
  • Bloods
  • Echo (aortic/mitral valve dysfunction)
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3
Q

Symptoms and signs of asbestosis?

A

• Progressive dyspnoea

  • Clubbing
  • Fine end-inspiratory crackles
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4
Q

Symptoms and signs of mesothelioma?

A
  • SOB, diffuse chest pain
  • FLAWS
  • Bone pain
  • Bloody sputum
  • Clubbing
  • Lymphadenopathy, hepatomegaly etc.
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5
Q

Investigation for asbestosis?

A
  1. CXR - reticular-nodular shadowing +/- pleural plaques

2. Pulmonary function test

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6
Q

Investigations for mesothelioma? (3)

A
  1. CXR - pleural thickening/effusion
  2. CT with contrast (diagnostic)
  3. MRI + PET
    • Pleural biopsy - diagnosis, stain that reacts with calretinin
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7
Q

Describe the 3 types of Aspergillus lung disease: Aspergilloma, ABPA, Invasive Aspergillosis?

A

Aspergilloma
• Growth of A. fumigates mycetoma ball in pre-existing lung cavity

ABPA
• Colonisation of airways by A. f, IgE/G immune response

Invasive Aspergillosis
• Invasion into lung tissue and fungal dissemination
• Immunosuppresed patients of broad ABx therapy

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8
Q

Symptoms and signs of Aspergillus lung disease?

A

Aspergilloma
• Asymptomatic

ABPA
• Difficult to control asthma
• Recurrent pneumonia with wheeze

Invasive Aspergillosis
• Dyspnoea
• Rapid deterioration
• Septic picture

  • Tracheal deviation if large
  • Dullness
  • Reduced breath sounds
  • Cyanosis (invasive)
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9
Q

Investigation for Aspergilloma?

A
  1. CXR - round mass with crescent of air

2. CT/MRI if CXR is unclear

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10
Q

Investigations for ABPA? What would you see on CXR, CT and lung function test?

A
  1. Skin test
  2. IgE RAST test

CXR - transient patchy shadows, segmented collapse, distended mucous-filled bronchi
CT - lung infiltrates, central bronchiectasis
Lung function test - reversible airflow limitation

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11
Q

Investigation for Invasive Aspergillosis?

A
  1. CT - ground-glass (halo) from haemorrhage

• Broncheoalveolar lavage fluid or sputum may be used diagnostically

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12
Q

Symptoms and signs of asthma?

A
  • Episodic - dyspnoea, wheeze, cough (worse in morning and night), sputum
  • Worsened by cold air, virus, drugs, exercise, emotions etc.
  • History of atopic disease
  • Tachpnoea
  • Prolonged expiratory phase
  • Polyphonic wheeze
  • Hyperinflated chest
  • Hyper-resonant percussion note
  • Reduced air entry
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13
Q

What are the recorded signs of a moderate/severe/life-threatening asthma attack?

A

Moderate
• PEFR > 50-75% predicted

Severe
• PEFR 35-50% predicted
• Pulse > 110
• RR > 25
• Inability to complete sentences
Life-threatening attack
• PEFR < 33% predicted
• Silent chest
• Cyanosis
• Bradycardia
• Hypotension
• Confusion
• Coma
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14
Q

Investigations for acute asthma?

A
  1. Peak flow
  2. O2 sats
  3. ABG - normal/low PaO2, low PaCO2
  4. CXR - exclusion
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15
Q

Investigations for chronic asthma?

A
  1. Peak flow monitoring, at least 3/7 for several weeks
  2. Pulmonary function test pre/post-β2 agonist (gold standard)
  3. CXR - hyperinflation
  4. Bloods: IgE/eosinophilia
  5. Skin prick test
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16
Q

Management for acute asthma exacerbation?

A

ABCDE (resus)
• monitor O2, ABG, PEFR

  1. High flow O2 (venturi)
  2. Nebulised salbutamol and ipratropium every 20mins for 3 doses, then when required
  3. IV hydrocortisone, oral prednisolone
  4. IV magnesium sulphate if no improvement
  5. IV aminophylline if no improvement
  6. Anasethetic if exhausted
  7. Intubation and ventilation
  8. Treat underlying cause
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17
Q

What does a normal PaCO2 mean in someone with an asthma attack?

A
  • Bad sign
  • They should be hyperventilating and blowing off CO2
  • Normal PaCO2 = fatiguing
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18
Q

When can you discharge someone who’s been managed for acute exacerbation of asthma?

A
  • PEFR > 75% and diurnal variation < 25%
  • Check inhaler technique
  • Stable on medication for > 24 hours (patient has brochodilator and steroid therapy)
  • Patient owns PEF meter
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19
Q

Management for chronic asthma?

A
  1. SABA (salbutamol)
  2. Add low-dose ICS (budesonide)
  3. Add leukotriene receptor antagonist (LTRA)
  4. Add LABA (continue LTRA depending on response)
  5. Change ICS and LABA to MART (just combined)
  6. Change MART ICS to medium dose
  7. Increase ICS to high-dose, not as MART or refer
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20
Q

Symptoms and signs of bronchiectasis?

A
  • Persistent cough with copious purulent sputum
  • Worse when lying flat
  • Intermittent haemoptysis
  • Breathlessness
  • Malaise, fever, weight loss
  • Clubbing
  • Coarse inspiratory crackles (bases) shift when coughing
  • Wheeze
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21
Q

Investigation for bronchiectasis?

A
  1. CXR - dilated bronchi, fibrosis, may be normal
  2. Sputum culture - P. aeruginosa common
  3. High-resolution CT - DIAGNOSTIC
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22
Q

Management for bronchiectasis?

A
  1. Exercise + airway clearance therapy /postural drainage
  2. Oral ABx (P. aeruginosa - ciprofloxacin)
    ACUTE/3. - IV ABx
  3. Surgery
  4. Non-invasive ventilation

• Consider bronchodilators, inhaled corticosteroids, flu vaccination, prophylactic antibiotics if frequent exacerbations

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23
Q

What is COPD and what are the FEV1 and FEV1/FVC values?

A

Airflow obstruction with:
• Chronic bronchitis: chronic cough + sputum production on most days for > 3months/year for > 2 years
• Emphysema: permanent destructive enlargement of air spaces

FEV1 < 80%, FEV1/FVC < 0.7

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24
Q

What are the causes of COPD?

A
  • Environmental toxins
  • Rare: α1-antitrypsin deficiency (younger/non-smokers), may also result in liver disease
  • Chronic bronchitis
  • Emphysema
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25
Q

Symptoms and signs of COPD?

A
  • Chronic cough with sputum
  • Breathlessness
  • Wheeze
  • Reduced exercise tolerance
  • Accessory muscle use
  • Barrel chest
  • Cyanosis
  • Hyper-resonant
  • Quiet breath, prolonged expiration
  • Bound pulse, flapping tremor
  • Right sided heart failure
26
Q

Investigations of COPD? What would you seen on ECG?

A
  1. CXR - hyperinflation
  2. Spirometry and pulmonary function test (reduced PEFR and FEV1/FVC) - post-bronchodilator = diagnostic

ECG - cor pulmonale

27
Q

Management of chronic COPD?

A

• Conservative - stop smoking, vaccinations etc.
1. SABA or SAMA

  1. FEV1 > 50% (no asthmatic features) - LABA or LAMA
  2. FEV1 < 50% - LABA+ICS or LAMA
  3. LABA + LAMA + ICS
  • Pulmonary rehab
  • Oxygen therapy
28
Q

Give examples of SABA, SAMA, LABA, LAMA, ICS

A 
SABA - salbutamol
SAMA - ipratropium
LABA - salmeterol
LAMA - tiotropium
ICS - beclomethasone
29
Q

Management of acute exacerbation of COPD?

A 
1. Nebulised SABA 
• O2 therapy - venturi mask
• Nebulised ipratropium
• IV hydrocortisone or oral prednisolone
• ABx - amoxicillin

If no improvement - IV aminophylline, BiPAP, ventilation

30
Q

Symptoms and signs of acute extrinsic allergic alveolitis?

A 
Reversible
• Dry cough
• Dyspnoea
• Malaise
• Fever
• Myalgia
  • Rapid shallow breathing
  • Pyrexia
  • Inspiratory crackles
31
Q

Symptoms and signs of chronic extrinsive allergic alveolitis?

A
  • Slowly increasing breathlessness
  • Decreased exercise tolerance
  • Weight loss
  • Fine inspiratory crackles
  • Clubbing
32
Q

Causes of extrinsic allergic alveolitis?

A
  • Farmer’s lung - mouldy hay with thermophilic actinomycetes
  • Pigeon Fancier’s lung - blood on bird feathers and excreta
  • Maltworker’s lung - barley/maltings with Aspergillus clavatus
  • Bagassosis or sugar worker’s lung - Thermoactinomyces sacchari
33
Q

Investigations for extrinsic allergic alveolitis? What would you see on a pulmonary function test?

A
  1. CXR - reticular nodular
  2. High-res CT - ground glass, diagnostic

Pulmonary function test - normal/high FEV1/FVC due to reduced lung capacity

34
Q

Symptoms and signs of idiopathic pulmonary fibrosis?

A
  • Gradual onset dyspnoea on exertion
  • Dry irritating cough
  • post-viral infection
  • Fatigue/weight loss
  • Clubbing
  • Bi-basal fine late inspiratory crepitations
  • Right heart failure
35
Q

Investigations for idiopathic pulmonary fibrosis?

A
  1. CXR - reticulonodular shadowing
  2. High-res CT - better
  3. Pulmonary function test - reduced FEV1 and FVC, preserved or increased FEV1/FVC
  4. Lung biopsy - gold standard (but not needed)
36
Q

Symptoms and signs of lung cancer?

A

Primary
• Haemoptysis
• Chest pain

Local invasion
• Shoulder/arm pain
• Hoarse voice
• Horner's
• Arrhythmias

Metastatic
• Weight loss, fatigue
• Fractures, bone pain

  • May be no signs
  • Cachexia
  • Clubbing
  • Anaemia
37
Q

Investigation for lung cancer?

A
  1. CXR
  2. CT
  3. CT/MRI - staging
    • Sputum/pleural fluid cytology
    • CT/US guided percutaneous biopsy
    • Lymph node biopsy
    • Lung function tests
    • Bloods - hypercalcaemia
38
Q

Types of lung cancers?

A 
Small cell (15%)
- central, associated with SIADH (3rd most common)

Non-small cell
• Adenocarcinoma - peripheral, more common in non-smokers (most common lung cancer)
• Carcinoid
• Large cell - poor prognosis
• Squamous cell - hilar location, cavitating lesion on CXR, PTHrp release (2nd most common)

39
Q

Symptoms and signs of obstructive sleep apnoea?

A
  • Excessive daytime sleepiness
  • Morning headaches
  • Dry mouth
  • Irritable
  • Large tongue
  • Enlarged tonsils
  • Thick uvula
  • Retrognathia
  • Large neck
40
Q

Investigations for obstructive sleep apnoea?

A

Diagnostic - polysomnography (sleep study)

• 15 or more episodes of apnoea/hypopnoea during 1 hour of sleep

41
Q

What is pneumoconiosis?

A

Fibrosing interstitial lung disease caused by chronic inhalation of mineral dust

42
Q

What are the 3 types of pneumoconiosis?

A
  • Simple - Coalworker’s / silicosis - asymptomatic
  • Complicated - loss of lung function
  • Abestosis - diffuse parenchymal fibrosis due to prolonged asbestos exposure
43
Q

Symptoms and signs of pneumoconiosis?

A
  • Asymptomatic - picked up on routine CXR
  • Insidious onset SOB
  • Dry cough
  • Melanoptysis (black sputum)
  • Pleuritic chest pain
  • Normal
  • Simple - decreased breath sounds
  • Asbestosis - fine end-inspiratory crackles, clubbing
  • Pleural effusion or RHF (cor pulmonale)
44
Q

Investigation for pneumoconiosis?

A
  1. CXR - diagnostic (infiltrative patches “honeycombing”)
  2. Spirometry
  3. High-res CT (more sensitive, but only used for further characterisation)
45
Q

Main cause of CAP and HAP?

A

CAP - Strep. pneumoniae

HAP - G- enterobacteria (pseudomonas)

46
Q

Signs of pneumonia on examination?

A
  • Reduced chest expansion
  • Dull percussion
  • Increased vocal fremitus
  • Bronchial breathing
  • Coarse crepitations
47
Q

Investigations for pneumonia?

A

Diagnostic - CXR (lobar shadowing)
• Bloods
• Sputum/pleural fluid MC+S
• Urine antigen test

48
Q

How do you calculate CURB-65 score?

A 
Confusion AMT ≤ 8
Urea > 7
RR ≥ 30
BP < 90/61
Age ≥ 65
49
Q

Management for pneumonia?

A

CURB-65

Mild, 0-1: home treatment if possible
• Oral amoxicillin

Moderate, 2: hospital therapy
• IV/oral amoxicillin + clarithromycin

Severe, ≥3: Consider ICU
• IV co-amoxiclav + clarithromycin
• Cephalosporin if penicillin allergic

50
Q

What shows a high risk of re-admission and mortality in discharged pneumonia patients?

A

2 or more features of clinical instability (e.g. tachycardia, tachypnoea, pyrexia etc.)

51
Q

What are the 3 causes (types) of pneumothorax?

A
  • Spontaneous - tall, thin males, rupture of subpleural bleb
  • Secondary - pre-existing lung disease
  • Traumatic - often iatrogenic
52
Q

Symptoms and signs of pneumothorax? How is a tension pneumothorax different?

A
  • Sudden-onset breathlessness
  • Pleuritic chest pain
  • Distress with rapid shallow breathing
  • Reduced expansion on affected side
  • Hyper-resonant
  • Reduced breath sounds

Tension
• Tachycardia, distended neck veins, hypotension
• Tracheal deviation away

53
Q

Management for tension pneumothorax?

A

Emergency

  1. Large bore needle in MCL, 2nd ICS
  2. High O2 therapy
  3. Chest drain

• Follow up CXR

54
Q

Management for primary and secondary pneumothorax (including age +/-50)

A

Primary and < 50 years
< 2cm - discharge, repeat CXR
>2cm - aspiration (drain if unsuccesful)

Secondary or > 50 years
< 1cm - High flow O2
< 2cm - aspiration
> 2cm - chest drain

(number cm = rim of air on CXR)

55
Q

Investigations for sarcoidosis?

A
  1. CXR
    • Stage 0: clear
    • Stage 1: bilateral hilar lymphadenopathy
    • Stage 2: + pulmonary infiltration and paratracheal node enlargement
    • Stage 3: peripheral pulmonary infiltration alone
    • Stage 4: pulmonary infiltration and fibrosis, bulla formation, pleural involvement
  • High-res CT
  • Tuberculin skin test (negative)
  • Pulmonary function test
56
Q

What are the 3 types of TB?

A
  • Primary - initial infection pulmonary or GI
  • Miliary - haematogenous dissemination (multi-organ)
  • Post-primary - reinfection or reactivation
57
Q

Who is the highest TB risk group in the UK?

A

Asians

58
Q

Investigations for TB?

A
  1. CXR
  2. Sputum acid-fast bacilli smear
  3. Sputum culture (GOLD STANDARD) - can take 6 weeks
59
Q

What is the hall mark of TB?

A

Caseating granulomas

60
Q

Management for TB?

A

RIPE
• Rifampicin, isoniazid, pyrazinamide and ethambutol started at same time
• R, I for 6 months
• P, E for 2 months

• Sputum cultures repeated during treatment until 2 consecutive negatives

Year 3 diagnosis and management (9 decks)

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