Respiratory Flashcards
What is the spirometry finding that indicates obstructive lung disease?
FEV1/FVC ratio <0.7
Name 3 clinical features that would suggest a high clinical probability of asthma.
Episodic symptoms of wheeze, chest tightness or cough exacerbated by allergens/cold/NSAIDs/beta blockers
Diurnal variation (worse night/early morning)
PMH or FH of atopy
Absence of Sx suggesting other diagnosis (e.g. extensive smoking history, coryzal symptoms)
If someone has a high probability of asthma, how is it diagnosed?
Trial of treatment, assess response and spirometry, confirm diagnosis of asthma if good response to treatment
How is asthma diagnosed in someone with intermediate probability of asthma?
Spirometry and bronchodilator reversibility
Other Ix may include PEF monitoring, challenge testing, skin-prick/serum IgE, inhaled NO
Outline the stepwise management of asthma
- SABA
- Inhaled corticosteroid
- LABA
- Increase corticosteroid dose
- Consider leukotriene receptor antagonist
What diagnosis should be suspected in a younger patient with emphysematous disease and liver disease?
Alpha-1 antitrypsin deficiency
What is the most common organism implicated in infective exacerbations of COPD?
Haemophilus influenzae
Which of emphysema and chronic bronchitis involves goblet cell hyperplasia?
Chronic bronchitis
What investigation supports the diagnosis of COPD? What are other investigations you may do?
Spirometry
May do a CXR, sputum sample
What is used to assess severity of airway obstruction in COPD?
FEV1 % predicted
Give 3 fundamental aspects of treating COPD, not including inhalers.
Smoking cessation, pneumococcal vaccination, influenza vaccination every year, physio and pulmonary rehab, optimise treatment of comorbidities
If all fundamental bases are covered, what is first line inhaler therapy for COPD?
SABA or SAMA
The second line treatment for COPD depends on FEV1 % predicted. What is the treatment if:
1) FEV1 >50%
2) FEV1 <50%?
1) LABA or LAMA, discontinue SAMA
2) LABA + ICS (or alternatively just offer a LAMA)
What are the only two interventions known to improve survival outcomes in COPD?
Smoking cessation and LTOT
Give 2 indications for LTOT.
- If hypoxaemic (PaO2 < 7.3kPa/resting sats <=92%) when stable (needs to be 8 weeks clear of an exacerbation)
- PaO2 <7.3-8.0kPa with secondary polycythemia, nocturnal hypoxaema, or pulmonary hypertension
Patients on LTOT should be using it for at least how many hours per day?
15
Is palliative oxygen therapy indicated in dyspnoeic patients with life-limiting illness?
No, not shown to have any benefit. Opioids and/or using a fan.
May be considered if there is still distressing breathlessness and other options haven’t helped
Recurrent infections, chronic cough with purulent sputum, bacterial infection secondary to irreversible dilataion of the airways are characteristics of what lung condition?
Bronchiectasis
Give 3 causes of bronchiectasis
Immunodeficiency (e.g. hypogammaglobulinaemia)
AI conditions (e.g.rheumatoid arthritis, IBD)
Genetic (Kartagener syndrome, Young syndrome)
Cystic fibrosis
Post-infectious states (e.g. pneumonia)
What is the gold standard investigation for bronchiectasis?
High-resolution CT scan
Other than CT, name 4 other investigations for bronchiectasis.
CXR, spirometry, sputum sample for MC&S, bloods (FBC, U&E, serum immunoglobulins), genetic testing (CF)
What is the characteristic HRCT appearance of bronchiectasis?
Signet ring pattern and tree bud appearance
Outline the management of non-cystic fibrosis bronchiectasis.
- Airway clearance (regular chest physio and mucolytic therapy e.g. acetylcysteine)
- Beta-2 agonists and anticholinergic bronchodilator therapy
- Empirical antibiotic therapy e.g. amoxicillin or clarithromycin
- Lung surgery or lung transplant
What gene and chromosome is affected in cystic fibrosis?
Is it AD, AR, X-linked?
CFTR gene on chromosome 7
Autosomal recessive inheritance
What causes intestinal obstruction in neonates with CF?
Meconium ileus
Why are males with CF infertile?
Absence of ductus deferens bilaterally
What is the best initial test if cystic fibrosis is suspected?
Describe how this is carried out.
Sweat test.
Pilocarpine applied topically to stimulate sweating, sample collected
What is diagnostic in a sweat test for cystic fibrosis?
Chloride ion concentration >60mmol/L on two different occasions
Give 4 investigations that would be done in a patient with CF (other than sweat test), and why.
CXR, HRCT, spirometry- assess lung function
Sputum microscopy and culture- to target treatment of infections
Bloods (FBC, U&Es, LFTs, vit ADEK levels)- to pick up any deficiencies and to have baseline bloods
Give 4 aspects management for respiratory disease in CF
- Chest physio
- SABA PRN
- Mucolytics
- Nebulised tobramycin (if >6 and affected by P aeruginosa)
- Oral/IV antibiotics and corticosteroids for an exacerbation
- Prophylactic antibiotics for P aeruginosa
What antibiotic is used for prophylaxis of P aeruginosa in patients with CF?
Azithromycin
Name 3 aspects of management for GI problems in CF
- Pancreatic enzyme (Creon) supplementation
- Fat-soluble vitamin supplementation
- High calorie meals and optimised nutrition
- Ursodeoxycholic acid in hepatobiliary disease
- Stool softeners, laxatives, adequate hydration
Give 3 conditions to screen/monitor for in a patient with CF.
Depression, diabetes, infertility, osteoporosis
Name two drugs that are commonly associated with lung fibrosis.
Methotrexate, amiodarone, bleomycin
True/false: IPF causes finger clubbing
True- not always, but can cause finger clubbing
Does IPF cause an obstructive or restrictive picture on pulmonary function tests?
Restrictive.
What is the gold standard investigation for IPF and what is the characteristic finding?
HRCT of the thorax, demonstrates a ground glass appearance
What is the management of IPF?
What two drugs are recommended in guidelines?
Pulmonary rehabilitation and supportive care
Tyrosine kinase inhibitor (nintedanib) or pirfenidone
Some pts may be offered lung transplant
What is the average life expectancy from diagnosis of IPF?
3-5 years
What is the histologically characteristic of sarcoidosis?
Non-caseating granulomas
What organ system is most commonly affected by sarcoidosis and what symptoms does it cause?
Lungs, causes dry cough, dyspnoea. May have flu-like illness and may be pyrexial
Give 5 non-pulmonary symptoms/signs sarcoidosis can cause?
Cutaneous- maculopapular rash, erythema nodosum Dry eyes and anterior uveitis Bell palsy Polyarthritis Hypercalcaemia Liver cirrhosis, deranged LFTs Kidney- interstitial nephritis Heart - heart block
How is sarcoidosis staged and what are the stages?
CXR 1= bilateral hilar lymphadenopathy only 2= bilateral hilar lymphadenopathy and infiltrates 3= infiltrates only 4= fibrosis
True/false: crackles are commonly found on examination of someone with sarcoidosis.
False- often the respiratory exam is normal in pulmonary sarcoidosis
What blood test is often used as a screening test for sarcoidosis?
What electrolyte abnormality is found?
What other investigations would you do to check for other organ involvement?
Serum ACE
Hypercalcaemia
LFTs, U&Es, urine dipstick (proteinuria–>nephritis), opthalmology review, ECG and ECHO for heart involvement.
US abdo for liver and kidney if bloods show abnormalities.
What is the gold standard for diagnosing sarcoidosis?
Tissue biopsy (may require bronchoscopy) and histology. Shows non-caseating granulomas with epithelioid cells
What are the 3 characteristic features of Löfgren syndrome and what is it?
How is it managed?
Bilateral hilar lymphadenopathy, erythema nodosum, and/or polyarthralgia/bilateral ankle arthritis.
Acute presentation of sarcoidosis, with a good prognosis
Treated with bed rest and NSAIDs
In sarcoidosis with moderate symptoms that requires treatment, what is first line?
What is second line?
PO corticosteroids (+bisphophonate cover) PO methotrexate (or azathioprine)
What criteria are used to diagnose ARDS?
What 3 features have to be fulfilled in order for ARDS to be diagnosed?
Berlin criteria
1) Acute onset (<1 week)
2) Bilateral infiltrates on CXR
3) Non-cardiogenic pulmonary oedema
Using pulmonary capillary wedge pressures is very helpful in diagnosing ARDS. Does an elevated or lowered PCWP indicate ARDS over cardiogenic pulmonary oedema?
Lowered
What is the management of ARDS?
Optimise oxygenation (may need to be lain prone), fluid balance, DVT prophylaxis, treat underlying sepsis.
Farmer’s lung, bird fancier’s lung, Malt worker’s lung, mushroom worker’s lung are all examples of what disease?
Extrinsic allergic alveolitis (hypersensitivity pneumonitis)
How is acute EAA managed?
How is chronic EAA managed?
Acute= supportive, removal of antigen Chronic= supportive, removal of antigen (may need change of job), may require corticosteroids
What type of lung disease is associated with coal workers?
Pneumoconiosis
This is a notifiable disease! Patients may be eligible for financial compensation
Name 2 asbestos-related lung diseases
Benign pleural plaques, asbestosis, mesothelioma
3 investigations for mesothelioma?
CXR, CT scan, pleural biopsy
What is the time frame for a pneumonia to be classed as HAP?
Presents after at least 48 hours in a hospital setting
What is the management of aspiration pneumonia?
IV antibiotics and supportive care
What organism causes pneumonia as an opportunistic infection in HIV patients and what is the treatment?
Pneumocytis jirovecii pneumonia
Co-trimoxazole is treatment
Hyponatraemia and deranged LFTs are features in pneumonia caused by which organism?
Legionella
How is legionella tested for?
Urinary antigen test
What score is used to determine severity of CAP and help guide treatment?
What are the components?
CURB-65 Confusion (AMT <8) Urea (>7) Resp rate (>30) BP (<90 SBP or <60 DBP) 65 (Age >=65)
A patient’s CURB65 score is 1. How should their CAP be treated? Give route and length of course.
5 days of amoxicillin or clarithromycin, PO
A patient’s CURB score is 2. How should their CAP be treated? Route and length of course
Inpatient. 7 days of amoxicillin and clarithromycin (IV or PO)
CURB score of 3, how should their CAP be treated?
Inpatient, 7 days IV co-amoxiclav and clarithromycin.
Consider ITU involvement
Give 3 reasons a patient with pneumonia may not be improving a few days after treatment has been commenced?
Incorrect/missed diagnosis Other source of infection as well as pneumonia Complication e.g. abscess, empyema Inappropriate antibiotic Unexpected antigen Impaired immunity
What does follow up of pneumonia involved?
CXR follow up (6-8 weeks) to ensure full resolution
Vaccinations: annual influenza, pneumococcal (elderly, significant comorbidities, impaired immunity)
Give 4 questions to ask to assess risk of life-threatening exacerbation of asthma.
How many times in last 12 months have you needed a course of steroids from GP/A&E?
How many visits to A&E?
How many admissions?
Have you ever been on ITU for asthma?
Have you ever been ventilated for asthma?
Give 3 questions to assess day to day control of asthma.
RCP 3 questions e.g.
In the last week have you had the usual asthma symptoms in the day?
Have you had asthma symptoms in the night? E.g. night time waking
Has asthma caused any limitation of what you’re able to do?
Also, how often do they have to use their rescue/blue inhaler?
What is the classic finding on examination of asthma?
Polyphonic wheeze
Briefly outline the two main phenotypes of asthma
Eosinophilic/allergic/TH2 high type
Non-atopic/TH2 low type
What pattern in a patient’s temperature might you expect with a lung abscess?
Swinging fevers
How are lung abscesses managed?
IV broad-spectrum antibiotics
If refractory to medical therapy may need surgical resection
Give 3 extra-pulmonary manifestations of TB?
Arthritis, meningitis, Pott spine, erythema nodosum, finger clubbing
Within which type of cells in the body does mycobacteria replicate?
Alveolar macrophages
How is TB diagnosed?
At least 3 sputum samples (with one early morning sample)
What stain is used to look for TB organisms and what does it show?
Ziehl-Neelsen stain, shows acid fast bacilli
Give two methods of investigating for latent TB infection?
Tuberculin skin test (Mantoux) or interferon gamma release assays
Outline the steps in managing a patient with TB
1) Isolate patient, seek specialist input, assess HIV status
2) Drug therapy (2 months RIPE, 4 months RI
3) Contact tracing
For each of the 4 main TB drugs, give their main side effect.
Rifampicin= red urine, hepatitis Isoniazid= peripheral neuropathy, agranulocytosis, hepatitis Pyrazinamide= hepatitis, myalgia, hyperuricaemia/gout Ethambutol= optic neuritis, renal impairment
Allergic bronchopulmonary aspergillosis is more commonly seen in what two groups of patients?
Asthma or cystic fibrosis
How is ABPA diagnosed?
Give 3 features found on blood tests of ABPA.
How is it treated?
CXR, CT
Elevated IgE, eosinophilia, Aspergillus serum precipitins
Oral corticosteroids (may need for up to 6 months) and itraconazole. Manage asthma/CF.
Investigations for ABPA
CXR and CT scan
Blood tests- eosinophilia, IgE elevated, Aspergillus serum precipitins
Check sputum or skin test for Aspergillus
Pleural effusions can be divided into transudates and exudates. What is the classification for each?
Transudates have protein content <25g/L
Exudates have protein content >35g/L
Give 2 causes of a transudate pleural effusion
Heart failure, liver failure, hypoalbuminaemia, Meig syndrome
Give 2 causes of exudate pleural effusion
Pneumonia, TB, lung cancer
In cases of suspected pleural effusion, should you perform a AP or PA CXR?
Posterior-anterior
What determines whether to performa aspiration of a pleural effusion?
If you ascertain from history and clinical picture that it’s a transudate, don’t perform aspiration. Particularly if it’s bilateral
If exudate is suspected, performa aspiration
All patients with effusion and superimposed infective condition (e.g. pneumonia) require sampling
Transudates have a protein content <25 g/L and exudates have a protein content >35g/L. What can you measure to determine whether a pleural effusion is an exudate if the protein content is 25-35g/L?
What criteria is this from?
Effusion protein/serum protein ratio >0.5
Effusion LDH/serum LDH ratio >0.6
Effusion LDH more than 0.6 x upper limit of normal
This is using the Light criteria
You have obtained a sample of pleural fluid from a pleural effusion. Give 4 things to test it for.
Protein, LDH, Gram stain, cytology and microbiological culture
How to manage a pleural effusion?
Tapping pleural fluid, treat underlying cause, may need chest drain, may need pleurodesis in refractory cases e.g. malignant or recurrent
A pleural fluid <7.2 should prompt suspicion of what two conditions?
What is the management for both of these?
Empyema or para-pneumonic effusion
Both require antibiotics and chest tube drainage
What are the anatomical landmarks for placement of a chest drain?
The safe triangle= base of axilla, lateral edge of pectoris major, lateral edge of latissimus dorsi, 5th intercostal space
What investigation is appropriate for a suspected pneumothorax?
PA CXR
What three features of a spontaneous pneumothorax help determine management?
Size e.g. bigger–> aspirate or chest drain
Breathless vs not breathless
Primary or secondary
When is it inappropriate to do a CXR with a pneumothorax?
If suspected tension pneumothorax
Management of a tension pneumothorax?
Insertion of large bore cannula into second intercoastal space at mid-clavicular line, then subsequent chest drain insertion
How does a tension pneumothorax cause haemodynamic instability?
Increasing pressure leads to ipsilateral lung collapse, then mediastinal shift to contralateral side, and kinking of veins which impairs venous return to the heart
What two types of lung cancer are generally centrally located tumours?
SCLC and squamous cell
SCLC and Squamous cell lung cancer are S-entrally located
What syndrome is SCLC associated with and why?
Cushing syndrome, due to ectopic ACTH secretion
SCLC is extremely sensitive to chemotherapy, however prognosis is poor. Why?
Because it proliferates rapidly and has often metastasised by the time of diagnosis
What is the most common subtype of lung cancer in non-smokers?
Adenocarcinoma (also in people with asbestos exposure)
Which type of lung cancer is associated with ectopic PTH secretion? Therefore how may they present?
Squamous cell carcinoma.
May present with elevated serum calcium
A hoarse voice and bovine cough may indicate what nerve involvement with lung cnacer?
Recurrent laryngeal nerve
A Pancoast lung tumour affects which part of the lung?
What two syndromes might it cause and why?
Lung apex
Can cause Horner syndrome if compresses the superior cervical ganglion
Can cause Thoracic Outlet Syndrome if there is compression of the brachial plexus
A patient with lung cancer presents to A&E with acute-onset dyspnoea, neck and face swelling, and dilated superficial veins. What complication of the lung cancer is likely to have caused this presentation?
What sign is positive in this condition?
Superior vena cava obstruction.
Positive Pemberton sign. Ask pt to raise both arms above head, positive –> facial congestion, cyanosis and resp distress
What are the NICE 2WW referral guidelines for suspected lung cancer?
> = 40, smoker and has 1 of unexplained: cough, fatigue, SOB, weight loss, appetite loss, chest pain
Or is a non-smoker with 2 of those.
A PA CXR is performed and lung cancer confirmed in a patient. What is the next investigation to arrange?
Contrast-enhanced CT
What methods are used to obtain a tissue sample in lung cancer?
Either bronchoscopy and biopsy for central lesions
Or CT/US-guided needle biopsy for peripheral lung lesions
Management options for NSCLC?
- Risk score e.g. Thorascore to evaluate risk if surgery considered
- Surgical resection (Stage 1 or 2 disease). Treatment of choice for curative intent
- Radical radiotherapy (Stage 1, 2, 3)
- Chemo (stage 3 or 4) to improve survival and QoL
- Multi modality therapy (MDT decision)
What test should be done prior to radical radiotherapy for NSCLC?
PFTs
Management of SCLC?
- Combo chemotherapy first line (multi-drug regimen)
- Concurrent radiotherapy
Give 2 contraindications to surgery for lung cancer
- Disseminated disease or malignant pleural effusion
- FEV1 < 1.5L
- Vocal cord paralysis or local infiltration
- SVCO
What is the traditional ECG finding of PE, and what is more commonly found clinically?
S1Q3T3
Sinus tachycardia
What score is used to assessed likeliness of PE?
PE Wells score
If a PE is clinically likely, what is the next investigation to do?
CTPA
Why might a patient not be suitable for CTPA? Give 2 reasons
Allergy to contrast media
Renal failure
Unsuitable to receive radiation
What would you consider to investigate a PE if a CTPA was CI?
A V/Q SPECT scan
What test do you do if a PE is unlikely following assessment using PE Wells? How does a negative/positive result affect management?
Do a D-dimer. If D-dimer is negative, consider an alternative diagnosis. If positive, arrange CTPA
What is the management of a massive PE in a patient with haemodynamic instability, acute breathlessness and features of shock?
Thrombolysis
What is the first line therapy for PE?
What about in severe renal impairment?
What is the minimum length of anticoagulation following a) provoked and b) unprovoked PE?
A DOAC e.g. rivaroxaban or apixaban
LMWH
Min length of anticoagulation is 3 months if provoked, 6 months if unprovoked.
How long is initial treatment for a PE provoked by active cancer?
3-6 months
Other than renal impairment, what other condition would cause a pt to receive LMWH anticoagulation for PE?
Antiphospholipid syndrome (triple positive)
What are the 5 group classifications for pulmonary hypertension?
I- idiopathic
II- secondary to left heart disease (most common)
III- secondary to lung disease and hypoxia
IV- chronic thromboembolic pulmonary HTN
V- pulm HTN due to miscellaneous causes e.g. sarcoidosis
What investigation confirms the diagnosis of pulmonary hypertension?
Right heart catheterisation
Give 2 examples of pulmonary vasodilator medications.
Calcium channel blockers Prostacyclin analogues (iloprost) Endothelin receptor antagonists Phosphodiesterase inhibitors (sildenafil)
What are the 3 components of supportive/background therapy for pulmonary hypertension?
Oxygen
Diuretics
Anticoagulation
What is pulmonary hypertension defined as?
Pulmonary artery pressure >=25mmHg at rest or >=35mmHg with exercise
When are calcium channel blockers indicated in pulmonary hypertension?
Only works in idiopathic pulmonary hypertension and if the acute vasodilator testing (done during right heart catheterisation) is positive
What is cor pulmonale and what most commonly causes it?
Alteration of structure and function of right ventricle secondary to lung disease, most commonly COPD and pulmonary hypertension
Management components of cor pulmonale?
Treatment of underlying cause LTOT- improves survival Diuretics Long-acting CCBs e.g. nifedipine Transplantation in severe, intractable disease
What is the first line investigation in allergy?
Skin prick test
What two investigations can be done following skin prick test for allergy if symptoms persist or aetiology is unclear?
Radioallergosorbent (RAST) or enzyme-linked immunosorbent assay (ELISA)
Apart from avoiding the allergen, what is first line treatment for allergic rhinitis?
Oral or intranasal antihistamines PRN
Intranasal faster acting and more effective. Azelastine hydrochloride only licensed intranasal antihistamine for allergic rhinitis
What is second line treatment for allergic rhinitis?
Intranasal corticosteroids (particularly if nasal blocking and polyps are significant)
What treatment can be used as an adjunct to pharmacotherapy in allergic rhinitis?
Nasal douching with normal saline
Give an example of an intranasal antihistamine and 2 oral antihistamines
Azelastine
Cetirizine and loratidine (non-drowsy). Piriton= chlorphenamine (drowsy)
What is the diagnosis of sinusitis based on?
History- rhinorrhoea, post-nasal drip, headache, nasal blockage, impaired sense of smell
Examination- facial pain typically over affected sinus
What is the management of sinusitis?
Analgesia- paracetamol or ibuprofen
Irrigate nose with saline and apply warm face packs
Antibiotic only if acute bacterial sinusitis
Intranasal corticosteroids only if prolonged and severe symptoms
When should a GP refer to ENT for sinusitis?
Patients with frequent, recurrent episodes of sinusitis (more than 3 eps requiring antibiotics in a year)
Give 3 associated conditions with obstructive sleep apnoea
Obesity, diabetes, PCOS, Marfan’s, macroglossia (hypothyroidism, acromegaly), large tonsils
What is the greatest risk factor for OSA?
Other risk factors?
Obesity
Smoking, deviated nasal septum, sedative drug and alc use
What tool can be used to assess daytime sleepiness when investigating OSA?
Epworth Sleepiness Scale
What is the gold standard investigation for OSA? What is diagnosis based on?
Polysomnography (sleep studies).
Apnoea/hypopnoea index (AHI)= number of apnoea or hyppnoea episodes divided by number of hours
Describe the management options for OSA
First line= Lifestyle modification- losing weight, optimising RFs
Mandibular splints may help in moderate OSA
CPAP= gold standard therapy
Name 2 conditions someone with OSA is more likely to develop/
Hypertension, AF, MI, stroke, diabetes
