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