Respiratory Flashcards
Tools for measuring breathlessness?
NYHA Class
MRC breathlessness scale
WHO classification
Which patients would you want to keep below normal oxygen sats? What sats would you want in these?
Those at risk of hypercapnic respiratory failure ( those with chronic type 2 respiratory failure - e.g. severe COPD or nocturnal paroxysmal dyspnoea)
88-92%
Respiratory microbiology tests you can do
AFB Blood culture Pneumococcal antigen Legionella antigen (urine) PCR (mycoplasma, chlamydia) Procalcitonin (distinguishes between bacterial and viral - if low avoid abx)
Narcolepsy treatment
Daytime: Modafinil (stimulant)
Nighttime: Sodium Oxybate (powerful sedative)
Management of small cell lung cancer
Largely chemo and radiotherapy - surgery not appropriate
Surgery if T1-2a, N0, M0
Which lung cancer is proportionately more prevalent in non-smokers?
Adenocarcinoma (NSCLC)
Most common form of lung cancer, and where does it appear in the lung?
Adenocarcinoma
In lung peripheries in mucus-secreting cells
Where does squamous cell carcinoma usually appear and how does it present?
Central part of lung
Can present with pneumonia secondary to an obstructed bronchus
What is hypertrophic pulmonary osteoarthropathy (HPOA)?
TRIAD:
Periostitis
Arthropathy of large joints
Digital clubbing
What structures can a pancoast tumour compress, and thus what effects might it have?
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
Paraneoplastic syndromes that may occur in lung cancer
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)
When would you send a patient for an urgent referral or 2 week wait under suspicion of lung cancer?
Urgent: SVCO or stridor
2 week wait: CXR suggestive, unexplained haemoptysis >40
When would you consider an urgent CXR for lung cancer in patients over 40?
Lymphadenopathy Clubbing Thrombocytosis Chest signs Recurrent chest infections
2 of: appetite loss, weight loss, smoking/asbestos hx, cough, fatigue, SOB, chest pain
Possible diagnostic/staging tests for lung cancer
CXR
CT (staging)
PET scan
Tissue biopsy (endoscopy or video assisted thoracoscopic surgery) Cytology (from aspirates, washings, pleural fluid)
Squamous cell carcinoma histological findings
Kertain
Intercellular bridging
Necrosis
Interstitial lung disease characteristics and investigations
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
Interstitial lung disease treatment
Steroids
DMARDs, biologics
Sarcoidosis clinical features
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
What blood tests are useful to do for someone with suspected sarcoidosis?
FBC, U&Es, LFTs Bone profile (hypercalcaemia may be seen) Serum ACE (raised, levels show response to treatment)
Imaging findings for sarcoidosis
CXR: hilar lymphadenopathy, reticular opacities
High res CT: ground glass, diffuse nodularity, reticular changes
Fibrosis affecting upper lobes
What would you see on a bronchoalveolar lavage with biopsy for sarcoidosis?
Inversion of CD4/CD8 ratio
Raised lymphocytes
Non-caseating granulomas on biopsy
Staging system for sarcoidosis
0: normal CXR I: bilateral lymphadenopathy II: lymphadenopathy with pulmonary infiltrates III: infiltrates alone IV: pulmonary fibrosis
Indications for sarcoidosis treatment with corticosteroids?
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
What might you see in cutaneous sarcoidosis?
Papules on head or neck
Erythema nodosum
Lupus pernio (rash over nose and cheeks)
Most common causes of death in patients with sarcoidosis?
Pulmonary fibrosis
Cor pulmonale
Pulmonary hypertension
Myocardial disease
Bird fancier’s disease characteristics
Antigen mediated
Symptoms present during contact (e.g. while at work) but go away during holidays
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
What is sillicosis associated with?
Rock quarry and sand blasting
TUBERCULOSIS
Causes of upper lobe fibrosis (CHARTS)
Coal workers' pneumoconiosis Hypersensitivity pneumonitis Aspergillosis Radiation TB Sarcoidosis/sillicosis
Causes of lower lobe fibrosis (CRABS)
C (idiopathic pulmonary fibrosis) RA Asbestosis Bleomycin SLE
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
What is a Ghon complex?
Ghon focus and hilar lymph nodes seen in primary TB infection
Bacteria most likely to cause aspiration pneumonia
Strep pneumonia
H. influenzae
Staph aureus
Pseud. aeruginosa
Initial COPD management
Stop smoking
one off pneumococcal vaccination
annual influenza vaccination
pulmonary rehab
SABA and SAMA
What are asthmatic features/features suggesting steroid responsiveness?
Raised eosinophil count
Variable FEV1
Diurnal PEF variation
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
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
First line treatment in diagnosed asthma
ICS
SABA as required (unless on MART) - if using more than 3 times a week, consider next step
First line treatment for acute severe asthma
Nebulised salbutamol, nebulised ipratropium bromide, oral prednisolone
IV magnesium sulphate and aminophyline (if initial treatment ineffective)
How do you give oxygen to COPD patient with acute exacerbation?
Venturi 28%
15L non-rebreather high flow if critically hypoxic
How do you assess severity of stable COPD?
FEV1 (%predicted)
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
Causes of multiple ill-defined opaque foci on a CXR?
RA Lung metastases Septic emboli Granulomatosis with polyangiitis (Wegners) Pulmonary infarcts
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
Causes of miliary shadowing on x-ray
TB Lung mets Sarcoidosis Occupational lung disease Extrinsic allergic alveolitis
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
What are the characteristics of allergic bronchopulmonary aspergillosis
Eosinophilia
Serum precipitins
Raised IgE
Positive aspergillus skin test
Management of primary pneumothorax
If <2cm rim of air and no SOB - discharge
ASPIRATE
if still >2cm or SOB then CHEST DRAIN
Avoid smoking
Common causes of respiratory alkalosis (low CO2)
Pregnancy PE Anxiety CNS disturbances (stroke, encephalitis) Salicylate poisoning Altitude
Staging of COPD
FEV1 predicted
1: >80%
2: 50-79%
3: 30-49%
4: <30%
Features of A1AT disease?
Emphysema of lower lobes (COPD picture with worsening SOB, chest pain, cough)
Liver cirrhosis or cholestasis in children
Management of A1AT
No smoking
Bronchodilators and physio
IV alpha-1 antitrypsin protein
Lung volume reduction surgery/transplant
A1AT disease inheritance pattern
Autosomal recessive/co-dominant
Definition of ARDS
Bilateral pulmonary infiltrates, severe hypoxaemia
in absence of cardiogenic pulmonary oedema (normal pulmonary capillary wedge pressure)
CXR looks like pulmonary oedema
Causes of ARDS
Acute pancreatitis Sepsis Trauma Lung injury Long bone fracture Head injury
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
Features of ARDS
Acute dyspnoea and hypoxaemia (P/A <200) hours/days after event
Multi organ failure
Rising ventilatory pressures
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
Causes of transudate pleural effusion
CHF
Cirrhosis
Gastrosis
Nephrosis
Causes of exudative pleural effusion
Malignancy
Pneumonia
TB
PE
What would you see in a pleural effusion in TB
Lymphocytosis (also in cancer)
Ada
When is thoracentesis contraindicated in pleural effusion?
Too small (<1cm)
Loculated (septations or lobes)
CHF (use diuretics instead if they have CHF)
Management of loculated pleural effusion
Thoracostomy
Thoracotomy if that fails
Pleural effusion imaging
PA CXR
Ultrasound: guides aspiration, can identify fluid septations
CT: underlying disease
Organisms that most commonly cause infective exacerbations of COPD?
First-line treatment?
- H influenzae
Strep pneumoniae
Tx: amox or co-amox
Clarithromycin or doxycycline if pen allergy
Causes of widening mediastinum on CXR?
Lymphoma Retrosternal goitre Teratoma Thoracic aortic aneurysm Tumour of the thymus
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
Wegener’s vs Churg-Strauss
Wegeners: renal failure, epistaxis, haemoptysis, cANCA
Churg-Strauss: asthma, eosinophilia, pANCA
Both: vasculitis, sinusitis, dyspnoea
Management of asthma attack - guidelines for escalation
- Oxygen
- Salbutamol nebs
- Ipratropium nebs
- IV hydrocortisone or oral pred
- IV magnesium sulphate
- aminophyline or IV salbutamol
1 pack year?
25 cigs per day for one year
Parallel line shadows (tram lines) on x-ray
Bronchiectasis
Long-term changes on FBC in COPD
Polycythaemia (raised haematocrit due to prolonged hypoxia and increased EPO production)
Stepwise management of asthma
- SABA
- SABA and ICS
- SABA and ICS and LTRA
- LABA
- switch ICS and LABA for MART
- medium dose ICS MART
- change MART to high dose ICS or add antimuscarinic/theophyline or refer to specialist
Most common causes of bilateral hilar lymphadenopathy
Sarcoidosis and TB
Lymphoma
Pneumoconiosis
Fungi
Features of Klebsiella pneumonia
Red-currant jelly sputum
Alcoholics and diabetics
Following aspiration
Affects upper lobes
Management of low-severity CAP
Oral amox 5 days (macrolide if allergy)
Management of mod and high-severity CAP
Amox and macrolide
Consider co-amox/ceftriaxone with macrolide and tazobactam
Where do you treat a pneumonia patient with:
CURB 2 or more?
CURB 3 or more?
> 2: admit
>3: intensive care
Diagnostic investigation for asbestosis?
Thoracoscopy and histology (usually following a CXR and pleural CT)
What pH should an aspirate from an NG tube be before it is safe to use?
<5.5
In which patients should you avoid clarithromycin in?
Long QT syndrome
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
Emergency aspiration for pneumothorax - landmark?
Mid-clavicular, 2nd intercostal space
Chest drain triangle of safety?
Base of axilla, lateral edge of pec, 5th intercostal space, anterior border of latissimus dorsi
Indications for surgery in bronchiectasis?
Localised disease
Uncontrolled haemoptysis
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
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
Contraindications to lung cancer surgery?
SVC obstruction FEV <1.5 Vocal cord paralysis Malignant pleural effusion Tumour near hilum
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%
CXR findings in heart failure
Alveolar oedema (bat wings) B Kerley B lines Cardiomegaly Dilated upper lobe vessels Effusion (pleural)
When to give patients with URTI abx?
Otorrhoea
Meet Centor criteria for tonsilitis
<2 years with bilateral acute otitis media
Pneumothorax differential in smokers with COPD?
Emphysematous bullae
Appear lucent without a visible war and >1cm
What is the main criteria for a COPD patient being offered LTOT?
Two ABG readings <7.3kPa oxygen
Lung cavitation differentials
Abscess (Klebsiella, Staph, pseudomonas) Wegener's TB SCC RA PE Aspergillosis
Management of secondary pneumothorax (if underlying lung disease)
> 2cm CHEST DRAIN
1-2cm ASPIRATE
<1cm oxygen and admit for 24 hours
Three stages of Churg-Strauss disease, and what antibody is associated?
- Allergy, rhinitis, asthma
- Eosinophilia
- Vasculitis, renal failure, petechial rash
pANCA
What drugs can cause secondary pulmonary fibrosis?
Amiodarone
Nitrofurantoin
Methotrexate
Investigation for obstructive sleep apnoea?
Polysomnography
Identifying anatomical basis: cinematic MRI and sleep endoscopy
Most common pulmonary manifestation of SLE?
Pleuritis with exudative pleural effusion
