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Respiratory Flashcards

1
Q

Tools for measuring breathlessness?

A

NYHA Class
MRC breathlessness scale
WHO classification

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2
Q

Which patients would you want to keep below normal oxygen sats? What sats would you want in these?

A

Those at risk of hypercapnic respiratory failure ( those with chronic type 2 respiratory failure - e.g. severe COPD or nocturnal paroxysmal dyspnoea)

88-92%

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3
Q

Respiratory microbiology tests you can do

A 
AFB 
Blood culture 
Pneumococcal antigen 
Legionella antigen (urine)
PCR (mycoplasma, chlamydia)
Procalcitonin (distinguishes between bacterial and viral - if low avoid abx)
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4
Q

Narcolepsy treatment

A

Daytime: Modafinil (stimulant)

Nighttime: Sodium Oxybate (powerful sedative)

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5
Q

Management of small cell lung cancer

A

Largely chemo and radiotherapy - surgery not appropriate

Surgery if T1-2a, N0, M0

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6
Q

Which lung cancer is proportionately more prevalent in non-smokers?

A

Adenocarcinoma (NSCLC)

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7
Q

Most common form of lung cancer, and where does it appear in the lung?

A

Adenocarcinoma

In lung peripheries in mucus-secreting cells

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8
Q

Where does squamous cell carcinoma usually appear and how does it present?

A

Central part of lung

Can present with pneumonia secondary to an obstructed bronchus

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9
Q

What is hypertrophic pulmonary osteoarthropathy (HPOA)?

A

TRIAD:
Periostitis
Arthropathy of large joints
Digital clubbing

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10
Q

What structures can a pancoast tumour compress, and thus what effects might it have?

A

Subclavian vein
Cervical sympathetic trunk
Brachial plexus

Effects:
Horner’s syndrome
Shoulder pain that radiates to arm and hand
Atrophy of muscles and oedema of upper limb

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11
Q

Paraneoplastic syndromes that may occur in lung cancer

A

Hypercalcaemia

SIADH (cerebral oedema, hyponatraemia)

Hypertrophic pulmonary osteoarthropathy

Cushing’s syndrome (ACTH production)

Lambert-Eaton syndrome (antibodies to voltage gated calcium channels –> proximal and ocular muscle weakness)

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12
Q

When would you send a patient for an urgent referral or 2 week wait under suspicion of lung cancer?

A

Urgent: SVCO or stridor

2 week wait: CXR suggestive, unexplained haemoptysis >40

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13
Q

When would you consider an urgent CXR for lung cancer in patients over 40?

A 
Lymphadenopathy
Clubbing 
Thrombocytosis 
Chest signs 
Recurrent chest infections

2 of: appetite loss, weight loss, smoking/asbestos hx, cough, fatigue, SOB, chest pain

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14
Q

Possible diagnostic/staging tests for lung cancer

A

CXR
CT (staging)
PET scan

Tissue biopsy (endoscopy or video assisted thoracoscopic surgery)
Cytology (from aspirates, washings, pleural fluid)
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15
Q

Squamous cell carcinoma histological findings

A

Kertain
Intercellular bridging
Necrosis

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16
Q

Interstitial lung disease characteristics and investigations

A

Dry hacking cough
Dry crackles
Chronic hypoxaemia
Restrictive lung pattern

Lung function test: raised or normal FEV1/FVC
CXR: reticular and nodular
Biopsy (VATS)
High res CT: ground glass appearance

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17
Q

Interstitial lung disease treatment

A

Steroids

DMARDs, biologics

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18
Q

Sarcoidosis clinical features

A

Black females more at risk

Pulmonary: Bilateral hilar lymphadenopathy, fine insiratory crackles, breathlessness

Hypercalcaemia

Erythema nodosum (painful red nodules, shins)

Ocular: uveitis (iritis, intermediate, choroiditis), keratoconjunctivitis sicca (dry eyes), secondary glaucoma

Facial palsies
Carotid enlargement
Cardiac involvement

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19
Q

What blood tests are useful to do for someone with suspected sarcoidosis?

A 
FBC, U&Es, LFTs
Bone profile (hypercalcaemia may be seen)
Serum ACE (raised, levels show response to treatment)
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20
Q

Imaging findings for sarcoidosis

A

CXR: hilar lymphadenopathy, reticular opacities

High res CT: ground glass, diffuse nodularity, reticular changes

Fibrosis affecting upper lobes

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21
Q

What would you see on a bronchoalveolar lavage with biopsy for sarcoidosis?

A

Inversion of CD4/CD8 ratio
Raised lymphocytes
Non-caseating granulomas on biopsy

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22
Q

Staging system for sarcoidosis

A 
0: normal CXR
I: bilateral lymphadenopathy
II: lymphadenopathy with pulmonary infiltrates
III: infiltrates alone
IV: pulmonary fibrosis
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23
Q

Indications for sarcoidosis treatment with corticosteroids?

A

Asymptomatic/I-III: no treatment

Symptomatic/IV: prednisolone (+osteoporosis prophylaxis if long-term) - reassess after 4-6 weeks

IF HYPERCALCAEMIA, EYE, HEART or NEURO involvement

Surgery for end-stage disease

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24
Q

What might you see in cutaneous sarcoidosis?

A

Papules on head or neck

Erythema nodosum

Lupus pernio (rash over nose and cheeks)

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25
Most common causes of death in patients with sarcoidosis?
Pulmonary fibrosis Cor pulmonale Pulmonary hypertension Myocardial disease
26
Bird fancier's disease characteristics
Antigen mediated | Symptoms present during contact (e.g. while at work) but go away during holidays
27
Asbestosis clinical features and treatment
>30 years exposure shipyards and construction Barbell bodies on biopsy Pleural plaques Mesothelioma Tx: stop smoking (patients have high mortality rate) Industrial compensation Surgery or chemo
28
What is sillicosis associated with?
Rock quarry and sand blasting TUBERCULOSIS
29
Causes of upper lobe fibrosis (CHARTS)
``` Coal workers' pneumoconiosis Hypersensitivity pneumonitis Aspergillosis Radiation TB Sarcoidosis/sillicosis ```
30
Causes of lower lobe fibrosis (CRABS)
``` C (idiopathic pulmonary fibrosis) RA Asbestosis Bleomycin SLE ```
31
Indicators for non-invasive ventilation
COPD with respiratory acidosis Type 2 resp failure secondary to chest wall deformity, neuromuscular disease, obstructive sleep apnoea Cardiogenic pulmonary oedema unresponsive to CPAP Weaning off tracheal intubation
32
What is a Ghon complex?
Ghon focus and hilar lymph nodes seen in primary TB infection
33
Bacteria most likely to cause aspiration pneumonia
Strep pneumonia H. influenzae Staph aureus Pseud. aeruginosa
34
Initial COPD management
Stop smoking one off pneumococcal vaccination annual influenza vaccination pulmonary rehab SABA and SAMA
35
What are asthmatic features/features suggesting steroid responsiveness?
Raised eosinophil count Variable FEV1 Diurnal PEF variation
36
What is the treatment of COPD after SABA/SAMA
Asthmatic features: ICS and LABA (+LAMA e.g. tiotropium if needed) No asthmatic features: LABA and LAMA
37
What abx prophylaxis do you give COPD patients and what investigation do you need to carry out for side effect?
Oral azithromycin (IF NON-SMOKER) ECG for prolonged QT
38
First line treatment in diagnosed asthma
ICS | SABA as required (unless on MART) - if using more than 3 times a week, consider next step
39
First line treatment for acute severe asthma
Nebulised salbutamol, nebulised ipratropium bromide, oral prednisolone IV magnesium sulphate and aminophyline (if initial treatment ineffective)
40
How do you give oxygen to COPD patient with acute exacerbation?
Venturi 28% | 15L non-rebreather high flow if critically hypoxic
41
How do you assess severity of stable COPD?
FEV1 (%predicted)
42
Causes of hemithorax white out
Trachea pulled towards whiteout: pneumonectomy, lung collapse, pulmonary hypoplasia Trachea central: consolidation, mesothelioma, pulmonary oedema (usually bilateral) Trachea pushed away from whiteout: pleural effusion, diaphragmatic hernia, large thoracic mass
43
Causes of multiple ill-defined opaque foci on a CXR?
``` RA Lung metastases Septic emboli Granulomatosis with polyangiitis (Wegners) Pulmonary infarcts ```
44
What treatment can be given to a patient with mesothelioma? How is it usually diagnosed?
Injection of sclerosant substances to prevent reaccumulation of pleural effusion Diagnosed with thoracoscopy with histology of pleura
45
Causes of miliary shadowing on x-ray
``` TB Lung mets Sarcoidosis Occupational lung disease Extrinsic allergic alveolitis ```
46
What 5 ways can aspergillus affect the lung?
Type I hypersensitivity in asthma Allergic bronchopulmonary aspergillosis - type I and III hypersensitivity with recurrent asthma and bronchiectasis Mycetoma (aspergilloma) - fungus ball forming in pre-existing lung cavity Invasive aspergillosis (in immunosuppressed) - high mortality Extrinsic allergic alveolitis - dry cough, dyspnoea and fibrosis
47
What are the characteristics of allergic bronchopulmonary aspergillosis
Eosinophilia Serum precipitins Raised IgE Positive aspergillus skin test
48
Management of primary pneumothorax
If <2cm rim of air and no SOB - discharge ASPIRATE if still >2cm or SOB then CHEST DRAIN Avoid smoking
49
Common causes of respiratory alkalosis (low CO2)
``` Pregnancy PE Anxiety CNS disturbances (stroke, encephalitis) Salicylate poisoning Altitude ```
50
Staging of COPD
FEV1 predicted 1: >80% 2: 50-79% 3: 30-49% 4: <30%
51
Features of A1AT disease?
Emphysema of lower lobes (COPD picture with worsening SOB, chest pain, cough) Liver cirrhosis or cholestasis in children
52
Management of A1AT
No smoking Bronchodilators and physio IV alpha-1 antitrypsin protein Lung volume reduction surgery/transplant
53
A1AT disease inheritance pattern
Autosomal recessive/co-dominant
54
Definition of ARDS
Bilateral pulmonary infiltrates, severe hypoxaemia in absence of cardiogenic pulmonary oedema (normal pulmonary capillary wedge pressure) CXR looks like pulmonary oedema
55
Causes of ARDS
``` Acute pancreatitis Sepsis Trauma Lung injury Long bone fracture Head injury ```
56
Management of ARDS
Treat underlying cause ABx if sepsis Diuretics SMALL, SHALLOW, FAST BREATHS (avoid CO2 accumulation) Mechanical ventilation using low tide volumes Positive end expiratory pressure or prone ventilation
57
Features of ARDS
Acute dyspnoea and hypoxaemia (P/A <200) hours/days after event Multi organ failure Rising ventilatory pressures
58
What is Lights criteria?
LDH fluid >2/3 LDHf/LDHs >0.6 TPf/TPs >0.5 Protein >30g/L Any ONE positive = exudate All negative = transudate
59
Causes of transudate pleural effusion
CHF Cirrhosis Gastrosis Nephrosis
60
Causes of exudative pleural effusion
Malignancy Pneumonia TB PE
61
What would you see in a pleural effusion in TB
Lymphocytosis (also in cancer) | Ada
62
When is thoracentesis contraindicated in pleural effusion?
Too small (<1cm) Loculated (septations or lobes) CHF (use diuretics instead if they have CHF)
63
Management of loculated pleural effusion
Thoracostomy Thoracotomy if that fails
64
Pleural effusion imaging
PA CXR Ultrasound: guides aspiration, can identify fluid septations CT: underlying disease
65
Organisms that most commonly cause infective exacerbations of COPD? First-line treatment?
1. H influenzae Strep pneumoniae Tx: amox or co-amox Clarithromycin or doxycycline if pen allergy
66
Causes of widening mediastinum on CXR?
``` Lymphoma Retrosternal goitre Teratoma Thoracic aortic aneurysm Tumour of the thymus ```
67
Difference between severe and life-threatening asthma attack
Severe: >110 bpm, 33-50% PEF, can't speak in full sentences, RR>25 Life-threatening: <33% PEF, silent chest, pO2<92%, cyanosis, bradycardia
68
Wegener's vs Churg-Strauss
Wegeners: renal failure, epistaxis, haemoptysis, cANCA Churg-Strauss: asthma, eosinophilia, pANCA Both: vasculitis, sinusitis, dyspnoea
69
Management of asthma attack - guidelines for escalation
1. Oxygen 2. Salbutamol nebs 3. Ipratropium nebs 4. IV hydrocortisone or oral pred 5. IV magnesium sulphate 6. aminophyline or IV salbutamol
70
1 pack year?
25 cigs per day for one year
71
Parallel line shadows (tram lines) on x-ray
Bronchiectasis
72
Long-term changes on FBC in COPD
Polycythaemia (raised haematocrit due to prolonged hypoxia and increased EPO production)
73
Stepwise management of asthma
1. SABA 2. SABA and ICS 3. SABA and ICS and LTRA 4. + LABA 5. switch ICS and LABA for MART 6. medium dose ICS MART 7. change MART to high dose ICS or add antimuscarinic/theophyline or refer to specialist
74
Most common causes of bilateral hilar lymphadenopathy
Sarcoidosis and TB Lymphoma Pneumoconiosis Fungi
75
Features of Klebsiella pneumonia
Red-currant jelly sputum Alcoholics and diabetics Following aspiration Affects upper lobes
76
Management of low-severity CAP
Oral amox 5 days (macrolide if allergy)
77
Management of mod and high-severity CAP
Amox and macrolide Consider co-amox/ceftriaxone with macrolide and tazobactam
78
Where do you treat a pneumonia patient with: CURB 2 or more? CURB 3 or more?
>2: admit | >3: intensive care
79
Diagnostic investigation for asbestosis?
Thoracoscopy and histology (usually following a CXR and pleural CT)
80
What pH should an aspirate from an NG tube be before it is safe to use?
<5.5
81
In which patients should you avoid clarithromycin in?
Long QT syndrome
82
When would you give a COPD patient azithromycin prophylaxis?
DON'T SMOKE Optimised vaccinations and referred for pulmonary rehab Continue to have >4/year exacerbations with sputum, prolonged exacerbations or hospitalisation
83
Emergency aspiration for pneumothorax - landmark?
Mid-clavicular, 2nd intercostal space
84
Chest drain triangle of safety?
Base of axilla, lateral edge of pec, 5th intercostal space, anterior border of latissimus dorsi
85
Indications for surgery in bronchiectasis?
Localised disease | Uncontrolled haemoptysis
86
Which COPD patients should you assess for long-term oxygen therapy?
``` Polycythaemia Severe airflow obstruction (PEF <30%) Peripheral oedema Raised JVP Sats <92% on room air Cyanosis ```
87
What does LTOT assessment entail?
Two ABGs two weeks apart pO2 <7.3kPa or pO2 7.3-8kPa with one of: Secondary polycythaemia Peripheral oedema Pulmonary hypertension
88
Contraindications to lung cancer surgery?
``` SVC obstruction FEV <1.5 Vocal cord paralysis Malignant pleural effusion Tumour near hilum ```
89
Criteria for asthma diagnosis?
Exhaled FeNO >40 parts per billion Diurnal PEF variation of >20% Post-bronchodilator FEV1 improvement of >12% or 200mL lung volume FEV1/FVC <70%
90
CXR findings in heart failure
``` Alveolar oedema (bat wings) B Kerley B lines Cardiomegaly Dilated upper lobe vessels Effusion (pleural) ```
91
When to give patients with URTI abx?
Otorrhoea Meet Centor criteria for tonsilitis <2 years with bilateral acute otitis media
92
Pneumothorax differential in smokers with COPD?
Emphysematous bullae | Appear lucent without a visible war and >1cm
93
What is the main criteria for a COPD patient being offered LTOT?
Two ABG readings <7.3kPa oxygen
94
Lung cavitation differentials
``` Abscess (Klebsiella, Staph, pseudomonas) Wegener's TB SCC RA PE Aspergillosis ```
95
Management of secondary pneumothorax (if underlying lung disease)
>2cm CHEST DRAIN 1-2cm ASPIRATE <1cm oxygen and admit for 24 hours
96
Three stages of Churg-Strauss disease, and what antibody is associated?
1. Allergy, rhinitis, asthma 2. Eosinophilia 3. Vasculitis, renal failure, petechial rash pANCA
97
What drugs can cause secondary pulmonary fibrosis?
Amiodarone Nitrofurantoin Methotrexate
98
Investigation for obstructive sleep apnoea?
Polysomnography Identifying anatomical basis: cinematic MRI and sleep endoscopy
99
Most common pulmonary manifestation of SLE?
Pleuritis with exudative pleural effusion

Phase 3b (18 decks)

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