Respiratory Flashcards
1
Q
FEV1:FVC < ? = airway obstruction?
A
0.7
2
Q
What values of FEV1 or FVC denote airway restriction?
A
normal FEV1, low FVC
3
Q
Type 1 respiratory failure
A
Low pO2
Low/normal pCO2
Most commonly caused by PE
(Type 1 think 1 change)
4
Q
Type 2 respiratory failure
A
Low pO2
High pCO2
Hypoventilation causes type 2
(type 2 = 2 changes)
5
Q
Signs of hypercapnoea (high CO2)
A
bounding pulse, flapping tremor, confusion, drowsiness, reduced consciousness
6
Q
Obstructive respiratory disease
A
FEV1:FVC < 0.7
Asthma, COPD, bronchiectasis
7
Q
Restrictive respiratory disease
A
FEV1:FVC >0.7, low FVC, lung volumes are small and most of breath is out in first second
Interstitial lung disease (pulmonary fibrosis, sarcoidosis)
8
Q
What is bronchiectasis?
A
Chronic inflammation of the bronchi and bronchioles –> permanent dilation and thinning of the airways, also excessive mucus production, recurrent bacterial infections ensue
9
Q
Main organisms causing bronchiectasis?
A
H.influenzae, Strep.pneumoniae, Staph. aureus
10
Q
Causes of bronchiectasis?
A
Cystic fibrosis, airway obstruction (tumour/foreign body), defective host defences (primary ciliary dykinesia), immunosuppression
11
Q
Px of bronchiectasis
A
Persistent cough, wheeze, copious purulent sputum, dyspnoea, wheezing
12
Q
Ix of bronchiectasis
A
Hx of recurrent respiratory infections, culture sputum, CXR (cystic shadows, thickened bronchial walls), CT scan (Gold standard)
13
Q
Mx of bronchiectasis
A
Airway clearance techniques and mucolytics, Abx, bronchodilators
14
Q
What is hypersensitivity pneumonitis? Px?
A
Inflammatory response to innocuous substances, usually associated with jobs/hobbies. Chronic cough, dyspnoea, fatigue
15
Q
Mx of hypersensitivity pneumonitis?
A
avoid the antigen, corticosteroids
16
Q
Occupational lung disorders
A
Lung diseases caused by exposure to agents at work, mx - avoid the antigen, corticosteroids
17
Q
Goodpasture’s syndrome aka
A
anti-glomerular basement membrane disease
18
Q
What is Goodpasture’s syndrome?
A
Rare autoimmune disease in which antibodies attack the BM in the lungs and kidneys
19
Q
Px of Goodpasture’s syndrome?
A
Symptoms of upper respiratory tract infection, cough, dyspnoea, haemoptysis, acute glomerulonephritis
20
Q
Dx of Goodpasture’s syndrome? Mx?
A
Renal and lung biopsy, anti-GBM, corticosteroids for immunosuppression
21
Q
Wegener’s granulomatosis was renamed?
A
granulomatosis with polyangiitis (due to associations with the Nazi party)
22
Q
What is Wegener’s granulomatosis?
A
ANCA-associated vasculitis, necrotising granulomatous inflammation with a predilection for the upper respiratory tract, lungs and kidneys
23
Q
Px of Wegener’s granulomatosis?
A
Saddle-shaped nose, cough, haemoptysis, signs of upper tract respiratory disease
24
Q
Dx and tx or Wegener’s granulomatosis?
A
cANCA +’ve, raised ESR/CRP
Corticosteroids, plasma exchange
25
What is pleural effusion?
Collection of fluid in the pleural space. Can be exudative (increased protein) or transudative (low protein count)
26
Exudative pleural effusion (>35g/L) causes
Increased pulmonary capillary leakage due to:
| infection, inflammation, malignancy (lung cancer, pneumonia, TB, RA)
27
Transudative pleural effusion (<25g/L) causes
Increased venous pressure:
| Congestive heart failure, hypoalbuminaemia, hypothyroidism, Meig's syndrome
28
What is Meig's syndrome?
Triad of R pleural effusion, ascites and ovarian fibroma
29
px of pleural effusion?
SOB, dyspnoea, pleuritic chest pain, dullness on percussion, decreased chest sounds
30
Ix of pleural effusion?
CXR - blunt costophrenic angle or meniscus
US
Diagnostic aspiration
31
MX of pleural effusion?
Treat underlying cause, pleuritic aspiration, chest drain
32
What is a pneumothorax? Typical px in?
Air in pleural space, tall thin young males
33
Causes of pneumothorax?
1. Spontaneous
2. Chronic lung disease - COPD, asthma
3. Infection - TB, pneumonia
4. Trauma
5. Carcinoma
6. Connective tissue disorders - Marfans
34
Px of pneumothorax
Dyspnoea, pleuritic pain, hyperresonance on percussion, asymptomatic, reduced expansion
35
Ix of pneumothorax
Erect CXR - area devoid of lung markings
36
Mx of primary pneumothorax
If SOB and/or >2cm --> aspirate, if not discharge and review in 2-4 weeks
37
Mx of secondary pneumothorax
If SOB or >2cm --> chest drain
38
Tension pneumothorax
Medical emergency, trauma to the pleura, one way valve, air drawn in upon inspiration and not released
39
Px of tension pneumothorax
respiratory distress, hypotension, tachycardia, deviated trachea
40
Mx of tension pneumothorax?
Insert a large bore cannula into the 2nd intercostal space, relieve pressure and then insert a chest drain
41
What is acute respiratory distress syndrome (ARDS)?
acute lung injury caused directly or secondary to a systemic illness. Lung damage and release of inflammatory mediators causes increased capillary permeability and non-cardiogenic pulmonary oedema
42
Pulmonary causes of ARDS
pneumonia, inhalation, injury, vasculitis
43
Px of ARDS
cyanosis, tachypnoea, tachycardia, peripheral vasodilation
44
Risk factors for ARDS
sepsis, hypovolaemic shock, trauma, pneumonia, DKA, pregnancy, massive transfusion, acute pancreatitis
45
What is Cor pulmonale?
R sided heart failure caused by underlying respiratory disease, most common = COPD, main presenting symptom = SOB
46
Physiology of Cor Pulmonale?
Lung disorder --> decreased O2 --> hypoxic vasoconstriction --> increased pressure and resistance within lungs --> pulmonary HTN --> difficult for R ventricle to pump --> back flow of pressure in R atrium and venous system
47
Px of Cor Pulmonale (SCRuFF)
SOB, cyanosis, raised JVP and heart rate (tachycardia), fatigue, fainting
48
Tx of Cor pulmonale
1. Treat underlying cause
2. Treat respiratory disease (oxygen supplementation)
3. Treat cardiac failure (diuretics)
49
What is sarcoidosis?
Rare granulomatous inflammatory condition. Granulomas = inflammatory nodules full of macrophages, unknown aetiology, thought to involve immune dysfunction and T cell overactivity, wide-ranging systemic manifestations, most commonly --> LUNGS
50
Classic patient with sarcoidosis?
Black female aged 20-40, presenting with a dry cough and SOB, may have nodules on shins
51
Pulmonary sarcoidosis?
Development of fibrosis (thickening of pulmonary interstitium), bilateral hilar lymphadenopathy and pulmonary nodules
52
Erythema nodosum sarcoidosis
tender red nodules caused by inflammation of the subcutaneous fat
53
Sarcoidosis that progresses with pulmonary fibrosis and pulmonary HTN may need treatment by?
Lung transplant
54
Common clinical features of interstitial lung diseases?
SOB, chronic cough, dyspnoea, abnormal breath sounds, restrictive pulmonary spirometry
55
How does acute sarcoidosis present? What is this eponymously named as?
1. Bilateral hilar lymphadenopathy (BHL)
2. Polyarthralgia
3. Erythema nodosum
Löfgren's syndrome
56
Extra-pulmonary signs of sarcoidosis
Hepatomegaly, uveitis, conjunctivitis, arrhythmias, renal stones
57
Ix of sarcoidosis
1. Spirometry - restrictive
2. Bloods - raised ESR/CRP, raised serum ACE, raised Ca2+
3. CXR - BHL, fibrosis
4. Biopsy - diagnostic
58
Mx of sarcoidosis
1. Spontaneously resolves
2. Acute sarcoidosis - NSAIDs and bed rests
3. Corticosteroids (prednisolone) - parenchymal lung disease, uveitis, hypercalcaemia
59
What is idiopathic pulmonary fibrosis (IPF)?
Interstitial lung disease, inflammatory cell infiltrate of unknown cause
60
Px of IPF?
dry cough, dyspnoea, weight loss, malaise, arthralgia, cyanosis
61
Complications of IPF?
Respiratory failure, increased risk of lung cancer
62
Ix of IPF?
1. Bloods (ABG - low PaO2), raised CRP, increased Ig
2. Imaging - honeycomb lung
3. Spirometry - restrictive
63
Mx of IPF
Supportive care, palliative care, opiates, pulmonary rehabilitation
64
What is meconium ileus?
Neonatal bowel obstruction of the distal ileum due to abnormally thick and impacted meconium. Unlike in the meconium plug syndrome, the meconium is abnormal in consistency, suspect CF in neonates with MI
65
What is CF?
autosomal recessive condition causing a mutation on the CFTR gene leading to a faulty CFTR channel affecting the transport of Cl- ions, predominantly affects the lungs
66
How does CF affect the CFTR transporters in the GIT, lungs and pancreas?
Faulty CFTR --> lack of Cl- secretion, therefore thick mucus, impaired mucociliary clearance, biliary/pancreatic duct blockage --> cysts --> infection
67
When does CF present? When is it screened for?
Infants/children, in newborns - positive heel prick test
68
Px of CF (CF PANCREAS)
Cough, wheeze
Failure to thrive
Pancreatic insufficiency (steatorrhoea)
Absence/atresia of vas deferens --> male infertility
Neonatal intestinal obstruction
Clubbing
Recurrent infections (--> bronchiectasis)
Elevated electrolytes in sweat
A(malignancies)
Sputum - infected with S.aureus, H.influenzae
69
Ix of CF?
1. Sweat test - Na+ and Cl- >60mmol/L
2. Genetic screening
3. Newborn heel prick test
4. other ix e.g. spirometry, faecal elastase, CXR
70
Mx of CF?
1. Physiotherapy for airway clearance
2. Mucoactive agents
3. ABx
4. Lung transplantation
5. Vitamin supplements, pancreatic enzyme replacement
6. Liver reviews
7. Diabetes - glucose testing
71
Why patients treated with RIPE drugs for TB have regular LFTs?
Because 3 of the drugs (RIP) are hepatotoxic
72
Define COPD
Progressive disorder characterised by airway obstruction with little/no reversibility, umbrella term for chronic bronchitis and emphysema
73
What is chronic bronchitis?
Chronic productive cough for >3 months over 2 years, inflammation of the bronchi
74
Emphysema?
Pathological term referring to structural lung changes, abnormal air space enlargement, alveoli destruction --> hypoxia
75
What is the biggest risk factor for COPD?
Smoking
76
Genetic disease causing COPD?
Alpha-1 antitrypsin deficiency (lack of elastase inhibition, alveoli elastin broken down)
77
Difference between inflammatory cell infiltration in chronic bronchitis and asthma?
```
CB = neutrophils
Asthma = eosinophils
```
78
Pathological changes in chronic bronchitis?
Mucus hypersecretion, goblet cell hyperplasia, airway narrowing, chronic inflammation and fibrosis
79
How might Cor Pulmonale result from COPD?
Chronic hypoxia in alveoli due to decreased ventilation and air trapping --> decreased perfusion/vasoconstriction --> pulmonary HTN --> backs up pressure in R side of heart
80
Signs of COPD?
Chronic cough, sputum production, breathlessness, recurrent bronchitis, wheeze, barrel chest
81
Diagnosis of COPD
Confirm obstruction on spirometry (FEV1 reduced and FEV1:FVC <0.7) and does NOT reverse following inhalation of bronchodilator
82
5 things to differentiate COPD from asthma?
1. Smoker/Hx
2. Older
3. Productive cough
4. Breathlessness
5. COPD - no night time cough
83
CXR findings for COPD?
hyperinflation, flat hemidiaphragms
84
Inhaled therapy for stable COPD? (think ice cream parlour)?
1. SABA/SAMA PRN
2. LABA + LAMA (if steroid unresponsive)
LABA + ICS (if steroid responsive)
3. Triple therapy - LABA + LAMA + ICS
85
Oral therapy for COPD
Corticosteroids, mucolytics, Abx, theophylline (bronchodilator)
86
Complications of COPD?
Respiratory failure, pneumonia, pneumothorax, polycythaemia, anaemia, depression
87
Signs and symptoms of pneumonia?
Malaise, confusion, fever, rigor, tachycardia, tachypnoea, dyspnoea, cough (CAN be productive), haemoptysis, dull percussion, reduced breath sounds
88
Risk factors for pneumonia?
Elderly, smoker, malnourishment, underlying lung disease, recent respiratory infection, immunocompromised
89
lower respiratory tract is sterile - true or false? How?
true - alveolar macrophages and mucociliary clearance (mucus contains IgA antibodies)
90
Common bacteria causing pneumonia?
Strep. pneumoniae
| Haemophilus influenzae
91
Common viral causes of pneumonia?
Influenza, RSV
92
Streptococcus pneumoniae
Gram +'ve
Alpha-haemolytic
Most common cause of community acquired pnuemonia, presenting with a cough, pleuritic pain and fever
Classically gives rust coloured sputum
93
What type of body fluid test can detect Strep. pneumoniae infection? Is it affected by Abx?
Urinary antigen test, unaffected by antibiotics
94
Mycoplasma pneumoniae
Rod shaped bacterium, lacking a cell wall, tends to affect young.
Causes pneumonia with a prolonged, insidious onset with extra-pulmonary features
95
Legionella pneumophilia
L. pneumophila is a gram-negative coccobacillus that may cause the atypical CAP (typically lobar) Legionnaire’s disease. It is encountered in those exposed to contaminated cooling systems, humidifiers and showers. Chest symptoms may be preceded by several days of myalgia, headache and fever
96
Causative agents of hospital acquired pneumonia?
(gram-negative)
| Pseudomonas, anaerobes
97
Pseudomonas aeruginosa
Gram -'ve bacilli that typically cause HAP, causes pneumonia in immunosuppressed patients and those with chronic lung disease, may affect MANY body systems, sputum characteristically green
98
Pulmonary complications of pneumonia
pneumothorax, pleural effusion, empyema, lung abscess, respiratory failure
99
Extra-pulmonary complications of pneumonia
Sepsis, AF
100
Define pneumonia
Acute lower respiratory tract infection associated with fever, chest sign and symptoms and CXR abnormalities (inflammation of lung parenchyma)
101
Pathological changes in pneumonia?
Fluid filled alveoli, narrowed airways, increased mucus
102
What is meant by lung consolidation? What part of a lung does it usually occupy?
Process that fills the alveoli with fluid, pus, blood --> lobar opacity; occupies a lobe of the lung
103
Classifying pneumonia by location in lung? Difference?
Lobar, broncho
Lobar pneumonia starts distally and spreads proximally (starts in the alveoli and fills lobe)
Broncho affects patches throughout the lungs and spreads from the airways -- distally
104
Scoring systems to help stratify patients with pneumonia --> risk of mortality
CRB-65 and CURB-65, point scored for each category
105
CRB-65
```
Aid judgement to assess need --> hospital admission, calculated in primary care
C - confusion
R - respiratory rate >30
B - BP (low)
65 - age>65?
0 - outpatient
1-2 - admission
3 - urgent admission
```
106
CURB-65
```
Calculated when a patient presents to hospital, includes a urea measurement
C - confusion
U - urea >7
R - respiratory rate >30
B - BP low
65 - age>65?
0-1 - outpatient
2- secondary care
3 - ICU
```
107
Mx of pneumonia?
1. Oxygen
2. IV fluids
3. Antibiotics
4. Analgesics
108
Ix for pneumonia?
1. CXR - lobar/ patchy consolidation
2. Sputum for microscopy
3. Urine - check for urinary antigens
4. Blood tests - raised ESR/CRP, LFTs, FBC, U&Es
109
Empirical Abx used in pneumonia to target gram positive and negative bacteria?
Amoxicillin (penicillins) +'ve
| Clarithromycin (-mycins) -'ve
110
Beta lactams Abx
Target cell wall of bacteria (e.g. amoxicillin, target staph species)
111
What is community acquired pneumonia (CAP)?
pneumonia acquired outside a hospital in a patient who is not immunocompromised
112
What is hospital acquired pneumonia? (HAP)
Pneumonia contracted >48hrs after hospital admission that was not incubating at the time of admission
113
Typical CAP
Strep. pneumoniae most common cause, common symptoms - fever, cough, pleuritic chest pain
114
Likely organisms causing HAP?
Gram -'ve bacilli (pseudomonas aeruginosa), staph. aureus, legionella pneumophila
115
What are aspiration pneumonias?
Caused by inhalation of oropharyngeal or gastric contents which brings bacteria into the lungs
116
What sort of px is aspiration pneumonia seen in?
- Reduced conscious level (stroke, post-ictal, drunk)
- NM disorders (MG)
- Oesophageal conditions (reflux)
- Mechanical interventions e.g. endotracheal tubes
117
Hospitalised patients on which medication are seen to suffer with HAP pneumonia more (aspiration)?
PPIs
118
Organisms causative of pneumonia in immunocompromised patients?
1. More bacterial pathogens
2. Fungal pathogens
3. Viral pathogens - varicella zoster
4. Parasitic - almost exclusive to aspiration pneumonias
119
Bacteria classically causing pneumonia in alcoholics?
Klebsiella pneumophilia
| Symptoms - cough, fever, flu, red-currant jelly sputum
120
3 cardinal symptoms of pneumonia
cough, SOB, signs of consolidation
121
What is TB?
infectious disease caused by the mycobacterium complex, commonly presents in lungs
122
Latent TB
Suppression of initial TB infection, but later re-activated
123
Active TB
Symptomatic, contagious, progressive - often presents with malaise, fever, weight loss
124
Staining TB?
Bright red with Zelhl-Neelsen stain
125
What is a Ghon focus? What is a Ghon complex?
Granuloma of phagocytosed TB, caseous necrosis occurs inside = Ghon focus
Ghon complex = Ghon focus + nearby involved lymph node
126
3 cardinal symptoms of TB
weight loss
fever
malaise
127
Mantoux test for TB
Intradermal injection of tuberculin (TB proteins) - type IV hypersensitivity reaction if exposed to TB, diagnosis based on degree of epidermal reaction
128
Interferon gamma release assay test for TB
Patients blood mixed with TB antigens. If previously exposed to TB, WBCs with release interferon gamma
129
Ix of active TB?
1. CXR - millet seeds, patches, pleural effusions
2. Cultures (sputum, blood)
3. Nucleic acid amplification
130
BCG vaccine?
Live attenuated (weakened) vaccine, required a -'ve mantoux test if >6 to rule out exposure to TB
131
Mx of active pulmonary TB (RIPE)
1. Rifampicin
2. Isoniazid
3. Pyrazinamide
4. Ethambutol
132
SE of each of the abx used in TB? (RIPE)
Rifampicin - red-orange body fluids
Isoniazid - neuropathy (give pyridozine = vitB6)
Pyrazinamide - gout
Ethambutol - optic neuropathy
133
Tx for extra-pulmonary disease of TB?
corticosteroids
134
Mx of latent TB
1. 6 months of isoniazid (+pyridoxine)
| 2. 3 months of isoniazid (+ pyridoxine) + rifampicin
135
Abx used in HAP?
co-amoxiclav
136
Define asthma
Chronic inflammation disorder of the airway, characterised by recurrent episodes of dyspnoea, cough, wheeze caused by reversible airway obstruction (airway hyperresponsiveness)
137
3 factors contributing to airway narrowing in asthma?
1. Bronchial muscle contraction
2. Mucosal swelling/inflammation
3. Increased mucus production
138
What causes mucosal swelling/inflammation in asthma?
Mast cell and basophil degranulation --> inflammatory mediators
139
Atopic asthma?
Genetic predisposition to IgE mediated allergen sensitivity
140
Why are the airways hyperresponsive in asthma?
Increased eosinophils in mucus, increased mast cells and neutrophils in lamina propria
141
Classic symptoms of an asthmatic?
Intermittent dyspnoea, wheeze, cough (often nocturnal), chest tightness
142
Precipitants of asthma?
Cold air, exercise, emotion, allergens, smoking, pollution, NSAIDs, beta-blockers
143
Diurnal variation asthma?
Symptoms/ peak expiratory flow vary throughout the day - markedly worse at night
144
Hygiene hypothesis asthma
Reduced exposure to infectious pathogens at a young age predisposes individuals to asthma
145
Pathophysiology of the early phase of asthma
Inhalation of allergens --> type 1 hypersensitivity reaction (allergic). Allergen exposure causes the release of IgE antibodies (due to increased sensitivity) from plasma cells. IgE bind to high affinity receptors on mast cells --> degranulate --> histamine --> bronchoconstriction
146
Acute asthma attack?
Worsening of symptoms, can't complete sentences, tachycardia, exhaustion, tachypnoea, reduced PEF (<33%)
147
Asthma and spirometry
Performed at time of diagnosis, reduced FEV1, FEV1:FVC <0.7, reversibility after bronchodilator inhalation
148
Asthma and PEFR (peak expiratory flow rate)
Classically varies throughout the day
149
Fractional exhaled nitric oxide (FeNO)
- Offered at the same time as spirometry
- Tests for eosinophilic airway inflammation (NO produced by eosinophils = messenger)
- >25ppb at 50ml/sec = 70-80% of patients
150
What value for FeNO is supportive of a diagnosis for asthma?
>40ppb
151
tests for asthma variability?
1. Reversibility testing with spirometry
| 2. PEFR
152
Tests for eosinophilic inflammation to help diagnose asthma?
1. FeNO
2. Blood eosinophilia
3. Skin prick test (IgE)
153
mx of asthma (think nutella sandwich)
SABA - PRN
1. ICS
2. + LABA
3. ^ICS or LTRA
4. specialist referral
154
SABA
short-acting beta-2 agonist, acts in airways to stimulate bronchodilation
E.g. =salbutamol
SE - tachycardia, tremor, palpitations
155
ICS
inhaled corticosteroids, beclomethasone, reduced inflammation
SE - osteoporosis, HTN
156
LABA
long acting beta-2 agonist
157
LTRA
leukotriene receptor antagonist
| E.g.=montelukast
158
Initial mx of an acute asthma attack?
1. Nebulised salbutamol
2. Oxygen
3. Steroids (prednisolone)
4. Ipratropium bromide nebuliser (anticholinergic)
159
Salbutamol is associated with hypo-?
Hypokalaemia
160
Tx for interstitial lung disease?
Remove underlying cause, stop smoking, physiotherapy and respiratory rehabilitation, pneumococcal and flu vaccine
161
What condition gives a honeycomb appearance on CXR?
idiopathic pulmonary fibrosis
162
Drugs that can cause pulmonary fibrosis?
Amiodarone, cyclophosphamide, methotrexate, nitrofurantoin
163
Conditions that can cause secondary pulmonary fibrosis? (ARSE)
Alpha-1 anti-trypsin deficiency
RA
Systemic sclerosis
(SL)E
164
Hypersensitivity pneumonitis (extrinsic allergic alveolitis) = type ??? hypersensitivity reaction?
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