Respiratory Flashcards
1
Q
Stepwise long-term management of Asthma
A
(1) SABA
(2) SABA + ICS
(3) SABA + ICS + LTRA
(4) SABA + ICS + LABA
+/- Continue LTRA depending on their response to LTRA
(5) SABA + MART (w/ Low-dose ICS)
(6) SABA + MART (w/ Moderate-dose ICS)
(7) Specialist
- Muscarinic receptor antagonist
- Theophylline
- High dose ICS
- Oral prednisolone
2
Q
Causes of upper lobe fibrosis
A
Tip: CHARTS
Coal workers pneumoconiosis
Hypersensitivity pneumonitis (= EAA)
Ank Spond + Aspergillosis (ABPA)
Radiation
TB
Sarcoidosis + Silicosis
3
Q
Causes of lower lobe fibrosis
A
- Asbestosis
-
Connective tissue disorders (except Ank Spond –> Aprical)
- RA
- SLE
- Scleroderma
- Sjogren’s
- Polymyositis / Dermatomyositis
- Idiopathic pulmonary fibrosis
-
Drug-induced pulmonary fibrosis (BS NAME)
- Bleomycin, Busulfan
- Amiodarone
- Nitrofurantoin
- Sulfasalazine
- Methotrexate
4
Q
Causes of drug related pulmonary fibrosis
A
Tip: BS NAME
- Bleomycin, Busulfan
- Amiodarone
- Nitrofurantoin
- Sulfasalazine
- Methotrexate
5
Q
Causes of bilateral hilar lymphadenopathy
A
- TB
- Sarcoidosis
- Lymphoma
- Pneumoconiosis
- Fungi (Histoplasmosis, Coccidioidomycosis)
6
Q
Classifying the different severities of Asthma
A
7
Q
Define
- Inspiratory capacity
- Vital Capacity
- Total Lung Capacity
- Functional residual capacity
- Residual Volume
- Tidal Volume
- Inspiratory Reserve Volume
- Expiratory Reserve Volume
A
8
Q
Borders of safe triangle
A
- Base of the Axilla
- Pectoralis major (lateral edge)
- 5th ICS
- Latissimus dorsi (anterior border)
9
Q
Where to insert the chest drain
A
In safe triangle
ABOVE the rib
10
Q
Obstructive pattern on spirometry is defined as
A
↓↓ FEV1 (<80% predicted)
↓ FVC (but decreases by a lesser extent)
FEV1:FVC < 70% (predicted) ==> Obstructive
11
Q
Causes of obstructive lung disease
A
Asthma
COPD
Bronchiectasis
Bronchiolitis obliterans
12
Q
Positive reversibility testing is defined as
A
↑ FEV1 which is > 200ml AND 12% of the pre-test value
13
Q
Classification of severity of COPD
Name of classification?
Based on what factor?
A
GOLD Classification - based on FEV1
Mild COPD: FEV1 > 80% (predicted) - i.e. normalises after medication
Moderate COPD: FEV1 50-79% (predicted)
Severe COPD: FEV1 30-49% (predicted)
Very severe COPD: FEV1 < 30% (predicted)
14
Q
Restrictive pattern on spirometry is defined as
A
↓ FEV1 (<80% predicted)
↓ FVC (<80% predicted)
FEV1:FVC ratio (>70%)
i.e. preserved ratio but absolute values for both FEV1 and FVC are both lower
15
Q
Causes of restritive lung disease
A
- Pulmonary fibrosis
- Pneumoconiosis / Asbestosis
- Extrinsic allergic alveolitis
- Neuromuscular conditions
- Sarcoidosis
- Kyphoscoliosis / Ankylosing spondyltitis
- Neuromuscular conditions (affecting diaphragm)
16
Q
Next investigation if
FEV1 < 80% predicted
reduced FVC
FEV1:FVC ratio < 0.7
A
Bronchodilator reversibility testing
Reversible –> Asthma (increase FEV1 by 200ml and 12%)
Irreversible –> COPD
17
Q
TLCO is defined as
A
Total factor of the Lung for Carbon Monoxide
= rate at which a gas will diffuse from the alveoli into the blood
Carbon monoxide is used to test the rate of diffusion
18
Q
Causes of increased and decreased TLCO
A
19
Q
Varenicline
Indication?
MOA?
C/I
A
Varenicline
Indication: Smoking cessation
MOA: ACh receptor agonist –> reduced cravings of nicotine
C/I in Pregnancy, Breastfeeding
Caution: increased suicidal thoughts
20
Q
Bupropion
Indication
MOA
C/I
A
Bupropion
Indication: Smoking cessation
MOA: NA and Dopamine re-uptake inhibitor (atypical antidepressant)
C/I in Pregnancy and Breastfeeding
S/E: Seizures
21
Q
Pulsus paradoxus
Definition
Causes
A
Pulsus paradoxus = difference between sBP on inspiration and expiration > 20mmHg
Causes
- Severe asthma
- Cardiac tamponade
22
Q
PERF variability
cut off?
indicates?
A
PEFR variability = (highest PEFR - lowest PEFR) / (average PEFR)
Uncontrolled asthma have ↑ variability in PEFR (worse in morning)
Values > 20% variability suggests asthma
23
Q
Ix for diagnosis of (stable) Asthma
if High probability
if Intermidiate probability
A
High probability –> Trial treatment + Spirometry (FEV1 or serial PEFR)
Intermediate probability –> Spirometry + Bronchodilator reversibility
Obstructive pattern on spirometry
- ↓↓ FEV1 < 80% (predicted or best)
- ↓ FVC
- FEV1:FVC ratio < 70% (predicted or best)
+ve bronchodilator response
- ↑ FEV1 which is > 200ml AND 12% of the pre-test value
24
Q
Ix to exclude Asthma if -ve Spirometry and -ve PEFR variability
A
Bronchial challenge test (using Histamine)
Negative test excludes Asthma
25
Asthma attack given nebulised salbutamol
ECG changes show?
Salbutamol
**S**/E: **Hypokalaemia**
ECG changse: **TWI + U waves + long QU interval**
26
Severe Asthma given IV MgSO4
S/E?
IV MgSO4
## Footnote
**Hypotension**
27
Severe asthma started on IV aminophylline
S/E?
Monitoring?
**IV Aminophylline**
cardiac arrhythmias
Requires cardiac monitor
28
Examples of asthma therapy
SABAs
LABAs
ICS
LTRA
SABAs
* Salbutamol
* Terbutaline
LABAs
* Salmeterol
* Formeterol
ICS
* Beclometasone dipropionate / Clenil
* Budesonide
LTRA
* Montelukast
29
Signs of well controlled asthma
Signs of well controlled asthma
* **No daytime symptoms or waking at night**
* **No exacerbations**
* No need for reliver inhaler
* Ideally, 1 SABA inhaler should last \> 1 year
* **No limitations on activity** (including exercise)
* **No asthma attacks**
* Normal lung function (**PEFR \> 80%** of predicted or best)
* **Minimal S/E from medication**
30
Kartagener's syndrome triad
**Kartagener's syndrome**
bronchiectasis
sinusitis
situs inversus
31
Causes of bronchiectasis
* **Post-infection** (**Haemophilus influenzae** - most common)
* Genetic
* **Cystic fibrosis**
* **a1 antitrypsin**
* **Kartagener syndrome** (ciliary dyskinetic syndrome)
* **Yellow nail syndrome**
32
CXR signs in bronchiectasis
CXR signs in bronchiectasis
* Dilated bronchi / **Tramtrack opacities**
* **Caose, thickened bronchidal markings**
* **Ring shadows** (mainly in upper lobes)
* **Fibrosis**
* **Atelelactasis**
33
Ix for bronchiectasis
**HR-CT**: [best diagnostic method for bronchiectasis]
* **Dilated airways**
* +/- thickened wall
* **Mucus plugs**
* Tram-track sign
* Signet ring sign
34
Management of bronchiectasis
Acute
* Antibiotics
* Bronchodilators
* Hypertonic 3% saline nebs
Long term
* **Chest physiotherapy** --\> postural drainage
* +/- Prophlactic ABx (**Azithromycin**)
* +/- Surgical resection +/- Lung transplant
35
**a1 anti-trypsin deficiency**
Mode of inheritence
Clinical features
**a1 anti-trypsin deficiency**
Autosomal recessive (**PIZZ** homozygous)
Presents with **COPD** in yougng people + **Liver cirrhosis**
36
IECOPD - causes
IECOPD - causes
* Viral URTI (30%)
* **Rhinovirus** (most common viral cause)
* Bacterial infection
* **Haemophilus influenzae** (most common bacterial cause)
* **Streptococcus pneumoniae**
* **Moraxella catarrhaslia**
37
Diagnosis of COPD
Spirometry
## Footnote
**_Post-bronchodilator_ FEV1/FVC ratio \< 0.70** on spirometry is **diagnostic for COPD**
38
Tx options which improve survival in COPD
ONLY **smoking cessation + oxygen supplementation**
have been shown to ↑ survival in COPD
39
Stepwise management of COPD
Stepwise management of COPD
1. **SABA / SAMA**
2A. If Asthmatic features or steroid responsiveness --\> **LABA + ICS**
2B. If no asthmatic features or steroid responsiveness --\> **LABA + LAMA**
3. **LABA + LAMA + ICS**
40
**Cystic fibrosis**
- mode of inheritance
_Cystic fibrosis_
**Autosomal recessive**
Mutation in **CFTR**
**ΔF508** is the most common mutation in the UK
41
Most common organsisms in cystic fibrosis
_cystic fibrosis_
## Footnote
In Children --\> **S. aureus** & H. influenzae
In Adults --\> **Pseudomonas aeruginosa** (85%) + **Burkholderia species**
42
Ix for Cystic fibrosis
Ix for Cystic fibrosis
* **Guthrie test**: +ve = ↑ immunoreactive Trypsinogen (IRT) at birth
* Part of UK newborn heel prick test performed @ 5-8 days olD
* *_If +ve Guthrie test_*
* **Sweat test**: Give Pilocarpine + measure [Cl-]
* *_Genetic testing_*: confirm patient's genotype +/- family testing
43
Acute Tx for meconium ileus due to cystic fibrosis
(1) Gastrografin enemas + Lactulose
(2) Surgery +/- NG decompression
44
Long term management of CF
* Chest physiotherapy
* +/- Salbutamol +/- ICS +/- Mucolytic +/- Prophylactic ABx
* +/- CFTR modulator
* **Ivacaftor** (not effective for F508del)
* **Orkambi** (if **F508del homozygous**)
* +/- Lung traplant
* HIGH calorie + HIGH fat diet
* Pancreatic enzymes
* Fat-soluble Vitamin supplementation (ADEK)
45
Cystic fibrosis - presentation
Cystic fibrosis
* Newborns
* **Meconium ileus** (distal small bowel obstruction)
* **Recurrent respiratory infections** --\> Bronchiectasis
* Prolonged neonatal jaundice
* Failure to thrive
* **Steatorrhoea**
* Young children
* **Rectal prolapse**
* Nasal polyps
* Teenagers
* Delayed puberty
* **Diabetes mellitus**
* **Pancreatitis**
* Distal intestinal obstructural syndrome (DIOS)
* **Infertility**
46
Obstructural sleep apnoea
Ix?
Tx?
Cx?
**_Obstructural sleep apnoea_**
Ix: **Polysomnography** [diagnostic]
Epworth Sleep Scale
Tx: **Weight loss** +/- **CPAP +/- Oral appliance therapy**
Complications: **Respiratory acidosis**
47
Ix for pulmonary fibrosis
**High-resolution CT** [diagnostic]
* **Reticular opacities**
* Worse at the bases + sub-pleural
* (initially) **Ground glass opacities**
* (later) **Honeycombing**
* **Traction bronchiectasis**
48
**EAA** - definition
CXR
Tx?
**Extrinsic allergic alveolitis**
= **Hypersensitivity pneumonitis**
= Interstitial inflammatory disease of the alveoli due to **inhalation of organic dusts**
* Farmer’s lung = Mouldy hay
* Pigeon fancier’s lung = Bird droppings
* Mushroom worker’s lung = Compost (contains thermophilic actinomycetes)
* Humidifier lung = Water-containing bacteria & amoeba
* Maltworker’s lung
* Barley or maltings (contains Aspergillus clavatus)
CXR: reticulonodular opacities with ground glass appearance
Tx: Avoid allergn +/- Prednisolone
49
Tx and Cx of pulmonary fibrosis
_Pulmonary fibrosis_
**Pulmonary rehabilitation**
**Anti-fibrotic therapy**
* **Perfendione**
* ****C/I: eGFR \< 30
* **Nintedanib**
**+/- Lung transplant**
Complications: **Pulmonary hypertension,** Lung cancer
50
**CXR Pleural plaques**
Management?
None required as do NOT undergo malignant change
## Footnote
**Do NOT require follow up**
51
CXR shows egg shell calcification of hilar lymph nodes in upper lobes
Dx?
Silicosis
52
Tx for mesothelioma
_Tx for mesothelioma_
(1) **Surgery**
(2) Chemotherapy
53
Types of aspergillus lung disease
**Aspergilloma**
* pre-existing lung cavity
**Allergic broncho-pulmonary aspergillosis (ABPA)**
* Type I and III Hypersensitivity reaction to Aspergillus spores
**Invasive aspergillosis**
* invades lung tissue --\> fungal dissemination
54
Definitive diagnosis of invasive aspergillosis
**Galactomannan ELISA test**
Definitive diagnosis of invasive aspergillosis
55
Tx for aspergilloma
Tx for ABPA
Tx for invasive aspergillosis
Tx for aspergilloma
* (1) **Surgical resection**
* (2) Radiological embolisation
Tx for ABPA
* **Oral prednisolone**
Tx for invasive aspergillosis
* **Voriconazole**
* **Lipsomal Amphotericin B**
56
Common organisms causing pneumonia
57
Productive, **rusty coloured sputum**
Cause
Streptococcus pneumoniae
58
COPD + Pneumonia
Cause
Haemophilus influenza
59
60
Alcoholic + Pneumonia
Klebsiella pneumoniae
61
**Dry cough**
**Flu-like symptoms**
**Erythema multiforme**
**Young adult / Children**
Ix? Dx?
**Mycoplasma pneumoniae** (atypical CAP)
Mycoplasma serology
62
**Stagnant water systems**
**Dry cough**
**Flu-like symptoms**
**Confusion**
**Hyponatraemia**
Diagnosis? Ix?
**Legionella pneumophila**
Ix: Urinary Legionella antigen
63
**Dry cough**
**Flu like symptoms**
**Rose spots**
**Hepatosplenomegaly**
**Hepatitis**
Dx? Risk factor?
**Chlamydia psittaci**
Birds
64
ABx for atypical pneumonia
Usually --\> (1) **Macrolide**
* **Azithromycin**
* **Clarithromycin**
* **Erythromycin**
**Chlamydia psittaci** *_or_* **Coxiella burnetii** (Q fever) --\> (1) Tetracycline (**Doxycycline**)
65
Dx of TB
**Sputum MC&S for TB** --\> Smear microscopy + **staining for AFB**
* Ziehl-Neelson stain (operator dependent)
* Auramine-Rhodamine stain (look for fluorescent AFBs, better sensitivity)
or
**Bronchoscopy + Biopsy + Histology**
* **Caseating granuloma** (hallmark of TB)
66
Paradoxical transient worsening of TB symptoms and lesions following anti-TB therapy
* Fever
* Worsening of CXR
* Lymphadenopathy
* Pleural effusions
Diagnosis?
**Immune reconstitution inflammatory syndrome** (IRIS)
Tx: Continue anti-TB therapy and anti-retrovirals, consider steroids
67
S/E of TB medications
68
Sputum culture grows Mycobacterium malmoense
Next Ix?
**Repeat sputum culture**
At least 2 samples if from a non-sterile source (as may be contamination)
69
High Altitude \> 2500 m
**Headache**
**Nausea**
**Fatigue**
Dx? Tx? Prevention?
**Acute mountain sickness (AMS)**
Tx: **Descent**
Prevention: Acetazolamide
70
Altitude \> 4000 m
Signs of pulmonary oedema
* SOB
* Productive cough
* Pink, frothy sputum
* Bibasal crackles
Dx? Tx?
**High altitude pulmonary oedema**
Descent +/- Oxygen
71
**Altitude \> 4000 m**
**Headache**
**Ataxia**
**Papilloedema**
Dx? Tx?
**High altitude cerebral oedema (HACE)**
Tx: Descent + Dexamethasone
72
**Progressive SOBOE**
**Fatigue**
**Loud P2**
Dx?
Ix for screening? Ix for diagnosis? Ix for management?
**Pulmonary hypertension**
Screening Ix --\> **TTE**
Diagnostic Ix --\> **R heart catherisation** (pulmonary arterial pressure \> 25mmHg)
Management Ix --\> **Vasodilator testing** (Epoprostenol)
* +ve response --\> **CCBs** (Nifedipine)
* -ve response
* **PDE-5 inhibitor** (Sildenafil)
* **Endothelin receptor antagonist** (Ambrisentan)
* **Prostacyclin analogue** (Epoprostenol, Iloprost)
* **Guanylate cyclse stimulator** (Riociguat)
*_Complications_*: VTE (Tx: **+ Warfarin**), RVH, R heart failure
73
**Progressive SOBOE**
**Fatigue**
**Loud P2**
Dx?
Ix for screening? Ix for diagnosis? Ix for management?
**Pulmonary hypertension**
Screening Ix --\> **TTE**
Diagnostic Ix --\> **R heart catherisation** (pulmonary arterial pressure \> 25mmHg)
Management Ix --\> **Vasodilator testing** (Epoprostenol)
* +ve response --\> **CCBs** (Nifedipine)
* -ve response
* **PDE-5 inhibitor** (Sildenafil)
* **Endothelin receptor antagonist** (Ambrisentan)
* **Prostacyclin analogue** (Epoprostenol, Iloprost)
* **Guanylate cyclse stimulator** (Riociguat)
*_Complications_*: VTE (Tx: **+ Warfarin**), RVH, R heart failure
74
Classification of pleural effusion
75
Causes of pleural effusion
76
Diagnosis of pleural effusion
**Pleural USS + Pleurocentesis**
| (diagnostic for pleural effusion)
77
Tx of pleural effusion
Transudative
* **Furosemide**
* If symptomatic --\> **USS-guided Thoracentesis**
Exudative
* +/- Antibiotics
* If symptomatic --\> **USS-guided Thoracentesis**
* If empyema **--\> Chest drain**
If recurrent
* Pleurodesis
* Pleural catheter drainage
78
Thoracentesis: Turbid effusion with pH \< 7.2, ↓ glucose and ↑ LDH
Diagnosis?
Tx?
**Empyema**
Chest drain + IV Antibiotics
79
Tx for stable pneumothorax
_Primary pneumothorax in \< 50 years old_
* **\< 2cm** _AND_ **asymptomatic**
* (1) **Observation** +/- Oxygen + OP CXR
* * **\> 2cm** _or_ **symptomatic**
* (1) **Aspiration +/- repeat aspiration**
* (2) **Chest drain**
_Secondary pneumothorax_ or _\> 50 years old_
* **\< 1cm** _AND_ **asymptomatic**
* (1) **Observation** +/- Oxygen + OP CXR
* * **1-2cm** _AND_ **asymptomatic**
* ****(1) **Aspiration**
* (2) **Chest drain**
* * **\> 2cm** _or_ **symptomatic**
* (1) **Chest drain**
