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Respiratory Flashcards

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1
Q

What is type 1 respiratory failure?

A

Hypoxic on room air PaO2 < 8kPa and normal or low PaCO2. Ventilation profusion mismatch

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2
Q

What is type 2 respiratory failure?

A

Hypoxic on room air PaO2 < 8kPa and raised CO2 >6kPa. ventilatory failure

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3
Q

What are some causes of respiratory failure?

A

Acute asthma, exacerbation of COPD, PE, pneumonia, Pulmonary oedema, opiate or benzodiazepines overdose, guillian barre syndrome

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4
Q

What might you give in opiate overdose?

A

Naloxone 400mcg IV bolus ± IV Flumazenil 200mcg over 15s

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5
Q

What is a genetic cause of COPD?

A

Alpha 1 antitrypsin deficiency
A seriene protease inhibitor
Panacinar emphysema

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6
Q

What is Chronic Bronchitis?

A 
Production of sputum for most days for at least 3 months in at least 2 years. Productive cough and lots of mucus.
Elevated Hb (polycythaemia)
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7
Q

What type of respiratory failure happens in chronic bronchitis?

A

Type 2 - Low respiratory drive
hypoxic and hypercapnia. Loss of central sensitivity to CO2 and so reliant on hypoxia to stimulate breathing. aim for 88-92%

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8
Q

What is Emphysema?

A

Abnormal, permanent enlargement of the airspaces distal to the terminal bronchioles. Elasticity reduced and alveoli collapse - Air trapping

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9
Q

What type of respiratory failure occurs in emphysema?

A

Type 1 - hight respiratory drive
Hypoxia due to air trapping and hyperinflation of the chest - inefficient gas exchange.
Desaturate on exercise

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10
Q

What is panacinar emphysema?

A

Uniform enlargement from the level of the terminal bronchiole distally

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11
Q

What might be seen on spirometry in COPD?

A

Obstructive pattern

FEV1/FVC < 70%

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12
Q

What is first line in COPD management?

A

SABA - Salbutamol or

SAMA - Ipratropium

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13
Q

What other treatment would you give a COPD patient on SAMA or SABA who is still symptomatic?

A

Add LABA or
Stop SAMA and add LAMA
If further exacerbations - ICS - prednisolone or budesonide.
If further exacerbations consider -
Oral Theophylline, Roflumilast, azithromycin, Carbocisteine.

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14
Q

What is COPD?

A

Airflow obstruction that is usually progressive and not usually reversible, it does not change markedly over several months

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15
Q

What are some symptoms of an exacerbation of COPD?

A

Increasing cough, breathlessness, impaired consciousness, wheeze, decreased exercise capacity

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16
Q

What is the criteria for hospital admission in an exacerbation of COPD?

A

Marked increase in symptoms
New physical symptoms (cyanosis, peripheral oedema)
Significant co-morbidities
Not responding to initial management at home
> 70
Inadequate home support

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17
Q

In a COPD exacerbation, if there is no response to NIV or mechanical ventilation, what can you use?

A

Respiratory stimulant - Doxapram IV 1.5-4mg

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18
Q

How would you treat an acute exacerbation of COPD?

A
  1. Nebulised bronchodilators (Salbutamol 5mg/4h or ipratropium bromide 500mcg/6h)
  2. Controlled oxygen therapy - aim for 88-92%
  3. Steroids - IV hydrocortisone 50-100mg or oral prednisolone 30mg
  4. Antibiotics - amoxicillin 500mg/8h or clarithromycin 500mg or doxycycline 200mg
  5. Physiotherapy to aid sputum expectoration
    IF NO RESPONSE
  6. IV aminophylline
    IF NO RESPONSE
  7. a. NIV if RR > 30 pH < 7.35
    b. Intubation and ventilation if paCO2 still rising with NIV pH <7.26
  8. Consider a respiratory stimulant - Doxapram 1.5-4mg

also may need to give enoxaparin 40mg

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19
Q

What is asthma

A

Inflammation of the airways characterised by intermittent airflow obstruction, hyper-responsive airways and reversible airflow obstruction

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20
Q

How do you define reversible airflow obstruction.

A

An improvement in FEV1 of >/=15% or 400ml after 5mg of nebulised salbutamol

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21
Q

Define a positive bronchial hypersensitivity test.

A

A fall in FEV1 by 20% after less than 8mg/ml of methacholine (or histamine or mannitol)

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22
Q

How does salbutamol/terbutaline work and what are potential SE?

A

Relaxes bronchial smooth muscle via increasing cAMP.

SE - tremor, hypokalaemia, hyperglycaemia, muscle cramps

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23
Q

What is the management options in asthma?

A
  1. SABA
  2. SABA + low dose ICS
  3. SABA + low dose ICS + LABA
  4. SABA + LABA + Medium dose ICS
  5. SABA + LABA + high dose ICS
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24
Q

How so SA and LA muscarinic antagonists work?

A

Works on M1 and M3
M1 counteracts bronchconstriction directly
M3 causes NO release - vasodilation
Nebulised risk of Acute angle closure glaucoma

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25
Q

What are methylxanthines MoA?

A

Relax bronchial smooth muscle, improve mucocillary clearance and have an anti-inflammatory effect

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26
Q

In an acute asthma attack 2g of magnesium sulphate may be given over 2 min. What is its MoA?

A

relaxes bronchial smooth muscle. Blocks histamine production from mast cells, reduces Ach production from nerve endings
SE. hypermagnesamia, muscle weakness, respiratory failure.

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27
Q

What monoclonal antibodies can be used as maintenance drugs in asthma?

A

Omalizumab - anti IgE - reduces circulating IgE. SC injection every 4 weeks
Mepolizumab - anti- IL5, reduces circulating eosinophils. SC injection every 4 weeks.

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28
Q

Given an example of the maintenance drug Leukotriene receptor antagonist and its MoA?

A

Montelukast and Zafirlukast

Reduces airway oedema and smooth muscle contraction

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29
Q

How would you manage life threatening asthma?

silent chest, low respiratory effort, PEF <33% predicted, sats <92%, altered consciousness, agitation/confusion

A

O SHIT ME

  1. High flow oxygen - aim >/=92%
  2. Nebulised salbutamol 500mg
  3. IV hydrocortisone 100mg or oral prednisolone 40mg
  4. Ipratropium bromide 500mcg
  5. Theophylline IV
  6. Magnesium sulphate 2g over 2 min
  7. Escalate care - intubation and ventilation

If chest infection suspected - Doxycycline 200mg Oral

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30
Q

What is brittle asthma?

A

A rare form of severe asthma that is hard to control due to being unstable or unpredictable.
Type 1: wide variation of PEF despite intense and regular therapy
Type2: sudden severe asthma attacks on a background of apparently well controlled asthma

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31
Q

What is near fatal asthma?

A

Raised PaCO2 ± the need for mechanical ventilation with raised inflation pressures.

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32
Q

What are some characteristics of severe asthma?

A 
PaO2 <92%
PEF 33-50% predicted 
Too breathless to talk or feed
RR >30 HR >125
use of accessory muscle
audible wheeze
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33
Q

What are some characteristic of life threatening asthma,s?

A

PaO2 <92%
PEF < 33% predicted
Silent chest, agitated, confused, cyanotic, poor respiratory effort, altered consciousness, exhaustion

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34
Q

What are some antibiotics that can be takes in a suspected chest infection in an asthmatic?

A

Amoxicillin 500mg/8h Orally or 1g/8h IV. Caution in renal problems as renal excreted.
Co-moxiclav 625mg/8h Orally or 1.2g/8h IV. Caution in Renal impairment as renal excreted
Clarithromycin 500mg /12h orally (IV causes phlebitis). Caution in hepatic impairment and renal impairment. Risk of adverse drug reactions - Can’t Give with methlyxanthines, cardiac caution (QT prolongation)
Doxycyline 200mg then 100mg orally - Caution in hepatic impairment. Avoid in children or pregnant women

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35
Q

What symptomatic triad may be present in acute severe asthma?

A

Wheeze
Increasingly breathless
Cough

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36
Q

What is obstructive sleep apnoea?

A

Recurrent episodes of complete or partial upper airway (pharyngeal) obstruction during sleep, with intermittent hypoxia and sleep fragmentation

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37
Q

Define apnoea.

A

Cessation or near cessation of airflow. 4% o2 desaturation lasting >/=10s

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38
Q

Define hypoapnoea

A

Reduction of airflow to a degree insufficient to meet the criteria for apnoea

39
Q

What is Respiratory related arousal?

A

Arousals associated with a change in airflow that does not meet the criteria for apnoea or hypoapnoea

40
Q

What is the apnoea hypo apnoea index.

A

Calculated by the number of apnoeas and hypo apnoeas divided by the total hours of sleep
>30 is severe
>/=15 is OSA

41
Q

What fungus may cause fungal meningitis?

A

Crytococcus neoformans.
Inhaled opportunistic infection usually in people with HIV.
2 weeks of IV amphotericin B 250mcg/kg daily for meningitis
For non-CNS like lungs - Fluconazole 400mg daily PO/IV or Flucytosine 200mg/kg IV

42
Q

What is allergic bronchopulmonary aspergillosis?

A

An allergic reaction to a fungal infection with aspergillum fumigatus.
Prednisolone 50-80mg PO 5 days

43
Q

What is invasive pulmonary aspergillosis?

A

When the fungal infection becomes systemic and spreads throughout the body. In immunocompromised. IV amphotericin B 3mg/kg daily or voriconazole 200-400mg/12 hours for first 2 doses then 100-200mg/12h

44
Q

What is an aspergillioma?

A

A fungal ball that develops in an area of past lung disease or scarring like an abscess. Do not treat unless bleeds - surgery

45
Q

How would you treat pneumocystic pneumonia and what organism causes it?

A

Pneumocystic jivoreci
Co-trimoxazole 120mg/kg or if intolerant or contraindicated
Trimethroprim 5mg/kg/6-8h

46
Q

How do the antifingals -azole work? E.g. fluconazole, voriconazole, ketoconazole

A

They inhibit the synthesis of ergosterol which is a component of the fungal plasma membrane

47
Q

What are some possible signs of PE?

A

Breathlessness, syncope, pleuritic chest pain, haemoptysis

Hypotension, tachycardia, tachypnoea, raised JVP, reduced Ox sats

48
Q

Define a massive PE?

A

PE associated with SBP < 90mmHg or there is a drop in SBP by >40mmHg from baseline for >15min that can’t be explained by another cause (hypovolaemia, new arrhythmia or sepsis)

49
Q

How would you manage a massive confirmed heamodynamically unstable PE?

A

IV unfractioned heparin bolus (5000 units) then infusion 18Units/kg/hr until APTT 1.8-2.8 (in pts getting anticoagulant normal is 1.5-2.5)
O2, IV fluids, inotropic support?
Alteplase IV 10mg over 1-2min then 90mg over 2 hours
If persistent hypotension and CTPA confirms or echo shows RV dilation or dysfunction

50
Q

What are some signs of pneumothorax?

A 
Pleuritic chest pain
Breathlessness, respiratory distress
Hyper-resonant to percuss, reduced vocal resonance
Ipislateral reduced air entry 
Treacheal deviation away if tension
Reduced breath sounds
51
Q

Describe the pathophysiology of a primary pneumothorax.

A

Subpleural bleb or bullae at the lung apex.
Spontaneous rupture causes a tear in the visceral pleura.
Air flows from airways into pleura space, increasing pressure in intrapleural space.
Elastic lung collapses

52
Q

How would you manage a large (>2cm) primary sponaneous pneumothorax and (1-2cm) secondary?

A

Aspirate with a small bore cannula (16-18G) 2nd intercostal space midclavicular line

53
Q

In a large 2ndary Pneumothorax, >2cm, that fails to respond to a chest drain, what would you do?

A

VATS - video assisted thoracic surgery if not resolves in 5 days
Talc pleurodesis

54
Q

What are some physiological problems in tension pneumothorax?

A

Reduced venous return and so reduced CO and so BP fall –> Hypotensive, tachycardia, sweating, cyanotic, distressed, tachypnoea

55
Q

Why does transudate occur?

these are causes of pleural effusion

A

Increased hydrostatic pressure or low plasma oncotic pressure
Nephrotic syndrome, congestive heart failure, hypothyroidism, cirrhosis, sarcoidosis

56
Q

Why does Exudate occur?

causes are causes of pleural effusion

A

Inflammation and increased capillary permeability

Malignancy, pneumonia, TB, AI, pericarditis, pancreatitis, mets, viral infection

57
Q

What type of lung cancer does smoking increase your risk of?

A

Squamous cell and Small cell (these are centrally located- arise in and around the hilum)

58
Q

What is the most aggressive type of lung cancer?

A

Small cell - mets early and widely
From APUD neuroendocrine cells
Nuclear moulding, oval to spinal shaped cells, scant cytoplasm

59
Q

What scoring system Is used in pneumonia?

A 
CURB65
Confusion
Urea > 7mmol/L
RR >/=30
DBP = 60 or SBP =90
>/=65 years old
60
Q

What antibiotic(s) would you give for a CURB65 score of 1?

A

PO 500mg/8hourly Amoxicillin 7 days

OR
200mg stat then 100mg daily PO Doxycycline 7 days
Or
500mg/12 hourly Clarithromycin 7 days

61
Q

What antibiotic(s) would you give for a CURB65 score of 2?

A

Po 500mg/8h Amoxicillin AND
Either 200mg stat then 100mg doxycycline
Or 500mg/12h clarithromycin 7 days

if penicillin allergy
just clarithromycin 7 days

62
Q

What antibiotic(s) would you give for a CURB65 score of 3+ plus sepsis?

A

IV or oral clarithromycin 500mg/12h
and either IV Amxocillin 1g/8h or
IV co-amoxiclav 1.2g/8h

if true penicillin allergy:
IV or oral Levofloxacin 500mg/12h 7-10d
14d if atypical

63
Q

What is interstitial lung disease?

A

non-infective, non-malignant infiltrations of the lung parenchyma.
Cause restrictive lung disease with a reduced transfer factor

64
Q

What is Sarcoidosis?

A

A multi-system granulomatous disorder of unknown cause, that predominantly affects the lungs and intrathoraic LN, characterised by non-necrotising granulomas.
Asteroid bodies on histology

65
Q

What are some clinical signs of sarcoidosis?

A

Fever, anorexia, night sweats, uveites, conjunctivitis, organomegaly, restrictive cardiomyopathy, chest pain, dry cough, CN palsies, peripheral neuropathy, reduced exercise tolerance, weight loss, Diabetes insidious (cranial)

66
Q

What is extrinsic allergic alveolitis or hypersensitivity pneumonitis?

A

Immune mediated (T cell) inflammatory reaction in the alveoli and respiratory bronchioles

67
Q

What are the borders of the triangle of safety in a thoracocentesis?

A

Base of the axilla (top)
Lateral edge of pectorals major (anterior)
Lateral edge of latissimus dorsi (posterior)
5th intercostal space (inferior)

68
Q

How can you tell the difference between collapse, consolidation and effusion on CXR?

A

Collapse - uniform soft tissue density and smaller affected lobe, tracheal pulled towards collapse
Effusion - uniform SFD, meniscus sign, trachea pushed
Consolidation - Non-uniform STD blotchy white, perihilar air bronchograms visible

69
Q

What causes a cough?

A

Acute or chronic sinusitis, Post nasal drip
GORD, pharyngeal pouch, oesophageal dysmobility
Mediastinal mass, ACEi, Ipratropium, CNS disease leading to impaired swallowing/ aspiration
URTI/LRTI/TB, chronic bronchitis, OSA, ILD, foreign body, lung cancer, CF, Asthma COPD, HF, LA enlargement

70
Q

What are causes of a chronic cough?

A

Allergic rhinitis, post-nasal drip, lung cancer, COPD, GORD, smoking, HF, ACEi

Acute - Rhinovirus, pneumonia, COVId, PE

71
Q

What is central bronchiectasis and what are the signs seen on HR CT?

A

Dilated bronchi with thickened walls. Chronic productive cough due to recurrence –> scarring
Tram track sign and signet rings on CT

72
Q

What are the fat soluble vitamins and their functions.

A

Vit A - Important in vision, reproduction, bone health and immune system
Vit D- bone strength and calcium absorption
Vit E - Immune function - an antioxidant
Vit K - role in blood clotting

73
Q

What should be done before discharging a patient after a severe asthma attack?

A

Asthma review - optimise inhaled therapy and inhaler technique assessed
Stable on discharge medication for >24 hours
PEFR > 75% predicted
Short course of oral and inhaled corticosteroids
PEF meter and asthma action plan

74
Q

What is pulmonary HTN?

A

Increased pressure and resistance of blood flow in the pulmonary arteries. Causes right heart strain, also causes back pressure of blood into the systemic venous system.

Pul arterial pressure >25mmHg at rest and > 30 with exercise of a systolic pulart >40mmHg at rest

Assess with right heart catheterisation

75
Q

What are the 5 groups of causes of pulmonary hypertension?

A

Group 1: Primary pulmonary arterial hypertension or due to a connective tissue disease. (idiopathic, hereditary, drug to toxin induced, HIV, schistosomiasis, SLE)
Group 2: MOST COMMON - left heart failure due to MI or systemic HTN
Group 3: Chronic lung disease e.g. COPD, or hypoxia
Group 4: pulmonary vascular disease such as PE
Group 5: miscellaneous - sarcoidosis, haematological disorders, glycogen storage disorder.

76
Q

What is cor pulmonale?

A

Right heart failure due to chronic pulmonary arterial hypertension. Causes:
Lung disorders: COPD, Pul fibrosis, bronchiectasis
Pul Vascular: sickle cell, PE, Pul vasculitis, ARDS
Neuro - Myasthenia gravis, MND, poliomyelitis
Skeletal - scoliosis, kyphosis

77
Q

What are some causes of bronchiectasis and what are some organisms that cause it?

A

Obstruction - Tumour, foreign body
Post -Infection - TB, pneumonia, pertussis, allergic bronchopulmonary aspergillosis, measels
Impaired defence - Hypogammaglobulinaemia, CF, ciliary dysfunction
S.aureus, H.influenza, strep pneumonia, pseudomonas aeruginosa

78
Q

What are some causes of Horners syndrome?

A

Brainstem stroke, pan coast tumour, demyelination diseases, inflammation of LN of neck

79
Q

Describe the SNS supply that is interrupted in Horners.

A 
1st order neurone, originated from posteriolateral hypothalamus and descends via brainstem to terminate in ciliospinal centre in C8-T2
2nd order (preganglionic), exits into paravertebral sympathetic chain, over the lung apex and terminates in superior cervical ganglia at ~C4 - Angle of mandible and bifurcation of common carotid 
3rd (postganglioic) forms a plexus around internal carotid and then into cavernous sinus - eye. some follows external carotid for face supply
80
Q

Define respiratory failure.

A

When gas exchange becomes significantly impaired. Diagnosed by a ABG

81
Q

What are some causes of respiratory failure?

A

Breathing centre affected - stroke, drug overdose
Blood flow to lungs affected - PE
Weak breathing muscles - MG, GB, SC injury
Ventilation to lungs affected - COPD, asthma, CF
Failure of gas exchange - pneumonia, ARDS

82
Q

What scoring tools can you use in PE?

A

Wells score, revised Geneva, D-dimer, PERC

83
Q

How would you manage a suspected PE?

A

O2 therapy ± analgesia
LMWH until CTPA result

If confirms - switch to DOAC for 3 months

84
Q

What drugs are used to reduce exacerbations in COPD and what are their MoA?

A

Roflumilast - inhibits hydrolysis of cAMP in inflam cells - Inc IC cAMP - reduces release of pro-inflam mediators and cytokines
Azithromycin - macrolide abx - inhibits pro-inflam AP-1, NFkappaB and mucin release
Carbocysteine - reduces sputum viscosity, facilitating mucocilary clearance

85
Q

What is the classes in MRC dyspnoea scale?
1- mild
2,3 - moderate
4,5 - severe

A

1 - breathless only on strenuous exercise
2 - breathless when hurrying or walking up a slight hill
3 - Walks slower than others their age on level ground or has to stop for a breath when walking at own pace
4 - Stops for a breath after walking 100m
5 - too breathless to leave the house, breathless while dressing

86
Q

An atypical bacteria causing pneumonia is called mycoplasma pneumonia, what are some Sx and complications of this?

A

Fever, breathless, pleuritic chest pain, cough
Malaise, headache, myalgia *
complications - arthritis, haemolytic anaemia (cold agglutinant) **, Gillian barre, erythema multiform

penicillin resistant

87
Q

An atypical bacteria causing pneumonia is called legionella pneumonia, what are some Sx and a test of this?

A

fever, cough, pleuritic chest pain, breathlessness
myalgia, malaise, headache, deranged LFTs, hypoNa** due to SIADH
Neurological Sx

Got by inhaling contaminated water mist - so ask about if they have been exposed to water - hot tub?
Legionella urinary antigen test!!
penicillin resistent

88
Q

Abx treatment in pneumonia?

A

CURB65 0-1 = ORAL Amox 500mg/8h or doxycycline 200mg then 100mg or clarithromycin 500mg/12h 7 days
2 = ORAL Amox + dox or clarith OR if penicillin allergy just clarithromycin 7 days
>/=3 or sepsis = clarithromycon 500mg/12 + either IV amoxicillin 1g/8 or co-amox 1.2g/8h OR if penicillin allergy levofloxacin 500mg/12h
7-10d if atypical 14d

89
Q

What might a swinging pyrexia with pneumonia mean?

A

A cavitation lesion or collection of pus somewhere with and effusion- empyema?

90
Q

What might cause pneumonia in an immunocompromised person?

A

Pneumocytic jivorecii

91
Q

What classes a HAP over CAP?

A

Got with 48hr of admission or 5 days with leaving

92
Q

What cause pneumonia in alcoholics?

A

Klebsiella as they aspirate

Red current sputum

93
Q

What bacteria that causes pneumonia is associated with parrots?

A

Chalymdiophile Psittaci

year 4 (14 decks)

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