Respiratory Flashcards
Which serum electrolyte is likely to be raised in a patient with active TB?
Increased serum calcium due to activated macrophages which produce calcitriol (active form of vit D)
What are causes of shortness of breath?
Respiratory Cardiac Anatomical Shock Anaemia
What is an expiratory wheeze?
Musical / whistling sound
Narrowing / obstruction of small airways
Causes: Inflammation - asthma, COPD, allergic reaction
Secretions blocking lumen - infection
Physical blockage - tumour, foreign body
What is stridor?
High-pitched, harsh, vibrating noise Inspiratory Turbulent airflow in large airways Trachea, larynx Emergency
What are your differential diagnoses for SOB?
Bronchial Inflammation: Infection / Pneumonia, Asthma, COPD, Bronchiectasis
Fluid in Airways: Pulmonary Oedema (heart failure)
Non-inflammatory Narrowing / Obstruction: Lung cancer, Pulmonary embolism, Inhaled foreign body
What are common pathogens which cause pneumonia?
S.pneumoniae
H.influenzae
Mycoplasma
What are symptoms of pneumonia?
Fever
Cough
Dyspnoea (acute / sub-acute)
Purulent sputum
What are pathological features of asthma?
Reversible airway obstruction
Bronchial muscle contraction
Mucosal swelling / inflammation
Increased mucus production
What are symptoms and features that would make you suspect asthma?
Childhood
Usually episodic, diurnal variation
Wheeze, dyspnoea
Non-productive nocturnal cough
What are features of COPD?
Progressive disorder of airway obstruction
Little / no reversibility or diurnal variation
Chronic bronchitis - clinical
Emphysema - histological
SMOKERS, Chronic cough, dyspnoea, wheeze and sputum, Age >35yrs
What is bronchiectasis?
Chronic infection of airways
Destroys muscular tissue so held dilated by lung parenchyma
Filled with purulent sputum
What are some causes of bronchiectasis?
Congenital: cystic fibrosis
Post-infection: measles, pertussis, TB
Airway obstruction: tumours
Immunosuppression
How can heart failure be a cause of SOB?
Impaired left ventricular function –blood backs up in pulmonary
circulation so Pulmonary Oedema
What are causes of heart failure?
Ischaemic heart disease
Cardiomyopathy
Myocarditis
What are non cardiac causes of fluid overload which could result in pulmonary oedema?
Excessive IV fluids
Renal failure
What questions in the history would you want to ask about someone’s cough?
When did it first start? Is it present all the time? Does it wake you up at night? Worse at any time of day? Does anything trigger it? Work? Exercise? Medication? Do you cough anything up? What colour? Any blood?
What questions in the history would you want to ask about someone’s SOB?
When did it first start? How quickly has it come on?
Is it present all the time? Is it only present when you exert yourself?
Before this started, how far could you walk on flat before getting breathless? And now?
Is it worse in certain positions? How many pillows do you use?
Does anything else trigger it?
What associated symptoms would you want to ask about in a patient who you suspect has asthma?
Acute onset
Rashes
Itchy skin
Watering eyes
What associated symptoms would you want to ask about in a patient who you suspect has bronchiectasis?
Fever
Progressive illness (or acute-on-chronic)
Weight loss
What past medical history questions are important in a patient who you suspect has bronchiectasis?
Chest infections? Especially as a child
Cystic fibrosis?
Previous TB?
What past medical history questions are important in a patient you suspect has heart failure?
Heart attacks?
Angina?
Kidney disease?
Which drugs might be particularly relevant to ask about in a patient presenting with SOB?
Steroids?
Immunosuppressants?
On home nebulisers or oxygen?
Multiple allergies / atopy?
What social history questions are important in a patient presenting with SOB?
Occupation? Change of job? Moved house? New pet? New hobby? SMOKING!! Pack years? Occupation? Time spent living abroad? TB contacts? Alcohol?
What family history questions are important in a patient presenting with SOB?
Asthma? Eczema? Hay fever? Bronchitis? Emphysema? Especially at an early age Cystic fibrosis? TB? Heart disease?
What end of the bed signs might you look for in a patient with SOB?
Breathlessness Resp rate Accessory muscle use Sputum pots Inhalers / nebulisers Oxygen masks/tubing Cachexia
What examination findings might you see in a patient with SOB?
Peripheral cyanosis Clubbing Tar staining CO2 retention flap Central cyanosis Pitting oedema
What are respiratory causes for clubbing?
A – abscess B – bronchiectasis (incl CF) C – cancer (bronchial + mesothelioma) D – decreased oxygen (hypoxia) E – empyema F – fibrosing alveolitis
What is cor pulmonale? What are symptoms of this?
Right sided heart failure due to long term pulmonary hypertension or chronic low oxygen conditions - COPD, CF
Symptoms: SOB during activity, tachycardia, palpitations, chest pain, syncope, cyanosis, raised JVP
What are the descriptors for abnormal percussion of a lung?
Pleural Effusion: stony dull
Consolidation: dull
Collapse: dull
Pneumothorax: hyper resonant
Which conditions may increase or decrease vocal resonance?
Consolidation: increased vocal resonance
Effusion and pneumothorax: decreased vocal resonance
What are bronchial breath sounds?
Tubular, hollow sounds heard over large airways
Louder and higher pitched than vesicular breath sounds
What are crackles? If they are head in early or late phases of breathing what does that signify?
Early inspiratory and expiratory: chronic bronchitis
Late inspiratory: pneumonia, CHF, atelectasis
What is a pleural rub?
Creaking or grating sound like standing on snow
Produced by two inflamed surfaces sliding on one another - pleurisy
What is pleurisy?
Inflammation of the pleurae which impairs their lubricating function and causes pain when breathing
What additional investigations might you want to do after an examination of a patient with SOB?
Peak flow
Sputum Pot
Oxygen saturation
ABG
How might a patient describe pleuritic chest pain?
Usually lateral Sudden Sharp, stabbing On deep inhalation Severe
What are the 5 Ps which might cause pleuritic chest pain?
Pneumonia Pulmonary embolus (PE) Pneumothorax Pericarditis Pneumomediastinum
What are causes for haemoptysis?
Pneumonia, upper respiratory tract infection Pulmonary embolism Coagulopathy Coughing Malingering Vasculitis Bronchial carcinoma
What questions in the history would you want to ask about a patients pleuritic chest pain?
Where is it?
When did it start? Over how long? What were you doing?
How would you describe it?
Does it go anywhere else?
Is it there all the time or does it come and go?
Does anything make it worse? Breathing? Position?
Where is it on a scale of 1-10?
What questions in the history would you want to ask about a patients haemoptysis?
What exactly happens? Are you really coughing blood?
When did it first start?
How often does it happen? Per day?
Fresh blood or clot?
How much is there? Streak? Teaspoon? More?
What additional symptoms would you want to ask a patient about who presents with pleuritic chest pain?
Leg pain? Leg swelling? Fever? Purulent sputum? Unintentional weight loss? Longstanding cough?
What aspects of a patients past medical history would you want to ask about if they present with pleuritic chest pain?
Previous DVT/PE? Recent immobility? Recent surgery? Recent travel? Pregnancy? History of cancer? Immunocompromise?
Which specific drugs would you want to ask about in a patient presenting with pleuritic chest pain?
Oral contraceptive?
Steroids?
Immunosuppressants?
What family history would you want to ask about in a patient presenting with pleuritic chest pain?
DVT?
PE?
History of lung cancer?
What social history would you want to ask about in a patient presenting with pleuritic chest pain?
Level of activity? Occupation? Home environment? Occupation? Smoking? Pack years?
What signs would you look for from the end of the bed in a patient with pleuritic chest pain?
In pain Shallow, rapid breaths Sputum pots Oxygen Inhalers Chest expansion
What examination signs might you look for in a patient with pleuritic chest pain?
Peripheries cold Oxygen saturations Peripheral cyanosis Clubbing Tar staining Conjunctival pallor Fever Calf swelling/ tenderness
What is the mechanism that leads to clubbing in lung conditions?
VEGF induces vascular hyperplasia, oedema, and fibroblast or osteoblast proliferation at a peripheral level in the nails
In primary pulmonary conditions such as lung cancer, this is the operative mechanism
What are the stages of clubbing?
Nail bed fluctuation Loss of nail bed angle Increase curvature of nail fold Thickened distal phalanx/ Drumstick appearance Hypertrophic osteoarthropathy
What is Virchows triad for DVT risk?
Stasis
Endothelial damage
Hypercoagulability
What initial investigations might you want to do to determine the cause of a patients pleuritic chest pain?
ECG D-dimer (Wells score) White cells (FBC) C-reactive protein Urea and electrolytes Chest X-ray
What is your basic management for a patient with a PE?
Stabilise the patient: Oxygen, Fluids, Senior help
Treat the symptoms: Analgesia
Stop further clots: Anticoagulation (e.g. enoxaparin)
Which arachidonic acid metabolite is inhibited by montelukast and is used to treat severe asthma and COPD?
Leukotrienes
Give reasons for a hemithorax white out on X-ray
Trachea pulled to opacified side: total lung collapse, pneumonectomy, pulmonary agenesis
Trachea central: consolidation, pulmonary oedema/ARDS, pleural mass (mesothelioma), chest wall mass
Trachea pushed away: pleural effusion, diaphragm hernia, large mass
What is the acute management for a severe asthma attack?
High flow oxygen
5mg salbutamol nebulised
500 micrograms ipratropium nebulised
100mg IV hydrocortisone
What is the acute management for pneumonia?
High flow oxygen
IV fluid as required
Antibiotics according to curb 65 score and local guidelines
What are differences between type 1 and type 2 respiratory failure?
Type 1: low pO2 due to ventilation perfusion mismatch
Type 2: high pCO2 due to lack of ventilation
What is lights criteria for diagnosing an exudative effusion?
Pleural fluid protein:serum protein >0.5
Pleural fluid LDH:serum LDH >0.6
Pleural fluid LDH >2/3 upper limit normal for serum
Name some causes of a transudative effusion
Heart failure Hypoproteinaemia (nephrotic syndrome) Constrictive pericarditis Hypothyroidism Ovarian tumours producing right sided pleural effusion
You have treated a patient for pneumonia but they still appear ill. What could be reasons for this?
Pleural effusion
Empyema
Respiratory failure
Septicaemia
Name some causes of an exudative pleural effusion
Bacterial pneumonia Carcinoma of bronchus TB Autoimmune rheumatic disease Mesothelioma Sarcoidosis Familial Mediterranean fever
In a patient with a suspected PE, what is the appropriate immediate treatment?
Low molecular weight heparin unless eGFR is less than 30, then unfractioned should be considered
What are some features of severe asthma?
Peak flow 33-50% predicted
Resp rate over 25
Heart rate above 110
Inability to complete sentences
What are some features of life threatening asthma?
Peak flow
Name some causes of atypical pneumonia
Legionella pneumophila
Mycoplasma pneumoniae
Chlamydophila pneumoniae
What should be used to treat atypical pneumonia?
Macrolide - clarithromycin, erythromycin
Tetracycline
Fluoroquinolone
Name some risk factors for lung cancer
Smoking
Industrial hazards: asbestos, arsenic, uranium
Air pollution
Describe the molecular basis of the development of lung cancer
Stepwise accumulation of oncogenic driver mutations until the hallmarks of cancer are acquired
What types of lung cancer are there?
Small cell carcinoma and
Non small cell: adenocarcinoma, squamous cell carcinoma, large cell carcinoma
Bronchial carcinoids
Mesenchymal
What precursor lesions to SCC in the lung can occur?
Squamous metaplasia
Squamous dysplasia
Squamous cell carcinoma in situ
What are patterns of growth of squamous cell carcinoma of the lung?
Exophytic: ulcerate, bleed and obstruct
Endophytic: infiltrate along airways and can present late
Where do squamous cell carcinoma of the lung tend to grow?
Central airways
Sometimes in periphery
Where do adenocarcinomas of the lung tend to grow?
Peripheries
Tend to be smaller than other forms of lung cancer
What are precursor lesions of adenocarcinoma of the lung?
Atypical adenomatous hyperplasia
Adenocarcinoma in situ
What type of mutations are found in 10-40% lung adenocarcinomas?
EGFR
What is the most aggressive form of lung cancer?
Small cell carcinoma
Typically disseminated at time of diagnosis
High grade
Which form of lung cancer are commonly associated with ectopic hormone secretion?
Small cell carcinoma
What is the cell type involved in large cell carcinoma?
Undifferentiated malignant neoplasm
Poorly differentiated adeno or squamous carcinoma
Carcinosarcoma
Large cell neuroendocrine carcinoma
What patterns of metastasis are associated with lung cancer?
Lymph nodes: hilar, mediastinal, paratrachel, supraclavicular
Haematogenous: liver, brain, bone, adrenals
Tumours in the lung cause obstruction to air and mucus flow. What can this cause?
Partial obstruction: focal emphysema
Total obstruction: atelectasis
Infection: severe suppurative bronchitis, bronchiectasis, abscesses
What changes can occur in the surrounding tissues of a lung cancer due to infiltration?
SVC obstruction Recurrent laryngeal nerve compression Phrenic nerve invasion (pointing sign) Pulmonary veins and artery Narrowing of oesophagus (dysphagia) Vertebral body erosion Pleural effusion Pericardial effusion
What aspects of a lung tumour are used to stage it?
T: size, pleural involvement, main stem bronchus involvement, multifocal, distal changes
N: hilar/peribronchial, mediastinal/subcarinal, contra lateral/scalene/supraclavicular
M: mets
What are the different stages of lung cancer?
I: localised, no nodes
II: local nodes or large tumour
III: extensive nodal disease
IV: presence of mets
What clinical presentations might occur with a lung cancer?
Cough Haemoptysis Chest pain Pneumonia, abscess, lobe collapse Pleural effusion Hoarseness Dysphagia Diaphragm paralysis Rib destruction SVC syndrome Horners Pericarditis, tamponade
What paraneoplastic syndromes can occur with lung cancer?
ADH: hyponatraemia ACTH: Cushing's Parathyroid hormone: raised calcium Calcitonin: hypocalcaemia Serotonin and bradykinin: carcinoid syndrome
In which type of lung cancer is hypercalcaemia most prevalent?
Squamous cell carcinoma
In which type of lung cancer is ADH and ACTH ectopic release most prevalent?
Small cell carcinoma
What is lambert eaton myasthenic syndrome?
Autoanitibodies to neuronal calcium channel
Mostly as a result of paraneoplastic syndrome from small cell lung cancer
What is acanthosis nigricans?
Brown to black, poorly defined, velvety hyperpigmentation of the skin usually found in body folds such as the posterior and lateral folds of the neck, the armpits, groin, navel, forehead, and other areas
Can occur as a paraneoplastic syndrome
What is a CT scan used for in lung cancer?
Presence of lesion Local extent of tumour Local nodal disease Distant mets Suitability for different types of tissue diagnosis Background changes
What different types of tissue diagnosis can be used in lung cancer?
Bronchoscopy: biopsy and bronchoalveolar lavage
Percutaneous needle biopsy
Node biopsy
Sputum cytology if unfit for procedures
What can be used to assess a patients fitness for resection in lung cancer?
Pulmonary function tests
What can be used for symptom control in lung cancer?
Painkillers
Radiotherapy
Laser ablation
Stenting
What are management options for lung cancer?
Surgical resection of early stage disease (N0)
Radical radiotherapy alone for early stage
Surgery plus chemo/radiotherapy for N1
Radical radiotherapy/chemo if unfit for surgery
Palliative chemo
Tyrosine kinase inhibitors if EGFR positive
In a patient with a recent influenza infection, which organism is likely to have causes a pneumonia?
Staph aureus
In a patient with COPD, which organism is likely to have caused their pneumonia?
Haemophilus influenzae
In a patient with a dry cough, atypical chest signs, hyponatraemia and Lymphopenia, what is the likely causative organism of their pneumonia?
Legionella pneumophillia
In a patient with a history of HIV, dry cough, exercise induced desaturations and the absence of chest signs, what is the likely causative organism of their pneumonia?
Pneumocystis jiroveci
What would protein concentrations be in transudate and exudate?
Transudate: less than 25g/L
Exudate: >35g/L
What is lights criteria for transudates and exudates?
If protein concentration falls between 25 and 35, fluid is likely to be exudate if:
Pleural fluid protein/serum is >0.5
Pleural fluid LDH/serum is >0.6
Pleural fluid LDH is >2/3 upper limit of normal for serum
What are causes of exudate?
Malignancy
Infection: parapneumonic or empyema
Oesophageal rupture
Inflammatory: SLE or RA
What are causes of transudate?
Cardiac failure
Renal failure
Liver failure
Hypoalbuminaemia
Under what circumstances is atelectasis commonly seen?
After prolonged operations After upper abdominal surgery Elevated intra abdominal pressure Obese patients Smokers
In which patients is pneumonia a common problem following major surgery?
Smokers
Obese
COPD
Emergency operations
What type of wheeze is present in asthma?
Expiratory
What is lofgrens syndrome?
Sarcoidosis triad of bilateral hilar lymphadenopathy, acute polyarthritis, erythema nodosum
Why would a patient with active TB have raised plasma calcium levels?
Activated macrophages produce calcitriol (active vit D) which increases absorption in the small intestine and increase reabsorption of calcium in renal parenchyma
What are some transudative causes of a pulmonary effusion?
HF Nephrotic syndrome Constrictive pericarditis Hypothyroidism Ovarian tumour
What are some exudative causes of pleural effusion?
Bacterial pneumonia Carcinoma of bronchus TB Autoimmune rheumatic disease Post MI Acute pancreatitis Mesothelioma Sarcoidosis Familial Mediterranean fever
What can cause a chylothorax?
Leakage from thoracic duct following trauma or infiltration by carcinoma
What are 3 important differentials for mediastinal lymphadenopathy?
TB
Sarcoidosis
Lymphoma
What are some causes of pneumothorax?
Spontaneous: pleural bleb COPD Bronchial asthma Carcinoma Lung abscess breakdown leading to bronchopleural fistula Pulmonary fibrosis with cyst formation
At what rate will a pneumothorax be reabsorbed?
1.25% of hemithorax volume per day
Why are copd patients at risk of clots?
Polycythaemia
What are differentials for chronic cough?
COPD Asthma GORD Catarrh / post nasal drip Drugs - ace inhibitors Lung cancer
What are differentials for chronic cough?
COPD Asthma GORD Catarrh / post nasal drip Drugs - ace inhibitors Lung cancer
What are some clinical features of legionella?
Diarrhoea
Pneumonia
Confusion
Hyponatraemia
What is the likely organism responsible for hospital acquired pneumonia?
Staph aureus
A 32 year old female smoker presents with acute severe asthma. Sats are 91% on 15L oxygen. pO2 is 8.2. There is widespread expiratory wheeze throughout chest. She is given IV hydrocortisone, 100% oxygen, 5mg nebulised salbutamol and 500 micrograms nebulised ipratropium with little response. Nebs are repeated back to back but she remains tachypnoeic with wheeze but good air entry. What is the next step in your management?
IV magnesium
What can differentiate mycoplasma pneumoniae from other causes of pneumonia?
Slow progression of symptoms
Positive blood test for cold haemagglutinins
What are causes of clubbing?
Bronchial ca Lung fibrosis Bronchiectasis Mesothelioma Atrial myxoma Infective endocarditis Cyanotic heart disease Cirrhosis Inflammatory bowel disease
What are some causes for CO2 retention?
Alveolar hypoventilation
Hypercapnia
Acute resp failure: pulmonary oedema, pneumothorax, PE, sepsis
Chronic resp failure: COPD
How do you manage respiratory acidosis?
Treat cause: nebs, naloxone, chest drain, diuretics
Non invasive ventilation: BIPAP
Invasive ventilation
Chronic: CPAP
How do you treat acute pulmonary oedema?
Oxygen
IV furosemide
IV morphine
IV nitrates
