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first year med > respiratory > Flashcards

respiratory Flashcards

1
Q

list symptoms of lung cancer

A
  • persistent cough
  • haemoptysis
  • unexplained weightloss
  • chest/shoulder pain
  • hoarse voice
  • SOB
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2
Q

list signs of lung cancer

A
  • chest pain
  • haemoptysis
  • fixed, monophonic wheeze
  • finger clubbing
  • subraclavicular lymphadenopathy / cervical lymphadenopathy

** signs of invasion / obstruction

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3
Q

list characteristics of small cell lung cancer

A
  • central
  • worst prognosis, rapidly metastasis
  • initially sensitive to chemotherapy
  • arise from APUD cells
  • rarely suitable for surgery
  • hyponatremia (low Na in blood)
  • associations: SIADH, Cushings syndrome, Lambert-Eaton syndrome
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4
Q

list characteristics of squamous cell lung cancer

A
  • central - hilum
  • most common
  • slow metastasis
  • antigen = p63
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5
Q

list characteristics of adenocarcinoma

A
  • peripheral - ‘mass in mid zone’
  • most common of non-smoker (most with it are tho)
  • arises from mucus-secreting glandular cells
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6
Q

give examples of squamous cell lung cancer

A
  • parathyroid hormone-related protein (PTHrP) - causes hypercalcaemia (BONES, STONES, MOANS,psychiatric groans)
  • hypertrophic pulmonary osteoarthropathy (HPOA) - causes periositis (inflammation of connective tissue over bone), finger clubbing, arthropathy of large joints
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7
Q

list characteristics of large cell lung cancer

A
  • peripheral
  • anaplastic (poor cellular differentiation)
  • poor prognosis
  • metastasises early
  • may secrete beta-hCG
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8
Q

investigations for lung cancer

A

1st line = CXR
2nd line = HRCT - for staging, do even if normal CXR

  • bronchoscopy - for biopsy
  • endobronchial US
  • PET - usually for NSCLC to see eligibility for curative treatment
  • bone mets - radionuclide bone scanning
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9
Q

treatment for lung cancer

A
  • surgery - VATS (lobectomy), thoracotomy

- high dose dexamethasone - improve short term, remove oedema

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10
Q

what is COPD

A

disease characterised by airflow limitation that is not fully reversible

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11
Q

what is COPD?

A

disease characterised by airflow limitation that is not fully reversible

  • bronchitis
  • emphysema
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12
Q

what is bronchitis?

A
  • inflammation (neutrophilic) - causes wall destruction + excess mucus secretion
  • hypertrophy - narrows lumen
  • mucus hypersecretion - narrows lumen
  • mucociliary dysfunction - prone to infections
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13
Q

what is emphysema?

A
  • destruction of alveolar walls
  • loss of lung elastic recoil - increase in TLC
  • less gas exchange - less o2 in blood
  • trapped dead air in large space (hyperinflation)
  • V/Q mismatch
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14
Q

what causes COPD in non-smokers?

A

alpha-1 antitrypsin deficiency - autosomal recessive

failure to breakdown neutrophil elatase

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15
Q

what are the 3 mechanisms of airflow limitation in small airways (<2mm in diameter?)

A
  1. loss of elasticity - due to emphysema
  2. inflammation and scarring
  3. mucus secretion - blocks airways

causing air trapping, hyperinflation, V/Q mismatch, increased work of breathing (SOB)

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16
Q

symptoms of COPD

A
  • productive cough - clear
  • wheeze
  • breathlessness
  • frequent infections
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17
Q

diagnosis of COPD

A

history

spirometry

  • FEV1/FVC <70%
  • FEV1 (post bronchodilator therapy)
    • mild >= 80%
    • moderate <80%
    • severe <50%
    • very severe <30%
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18
Q

management of COPD

A
  • smoking cessation
  • pulmonary rehab
  • vaccinations
  • bronchodilators
    • non-eosinophilic + infrequent exacerbator = LABA/LAMA
    • eosinophilic and/or frequent exacerbator = ICS/LABA or ICS/LABA/LAMA
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19
Q

give examples of LABAs

A
  • formoterol
  • salmeterol
  • indacaterol
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20
Q

give examples of LAMAs

A
  • tiotropium
  • aclidinium
  • ipratropium
  • oxitropium
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21
Q

how are corticosteroids prescribed in patients with moderate/severe COPD?

A

prednisolone 30mg daily for 2 weeks
LFT before and after
if improvement
inhaled CS - beclametasone 40ug twice daily initially

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22
Q

management of COPD exacerbation

A
  • chest x-ray and ECG always done (differential diagnosis)
  • careful history
  • nebulised high dose salbutamol + ipratropium - oral
  • prednisolone 30mg for 5 days
  • antibiotic if consolidation/purulent sputum
    • amoxicillin 500mg tds
    • doxycycline 200mg 1st day, 100mg od for 5 days
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23
Q

what are the different types of pneumonia?

A

community acquired = developed outside hospital
hospital acquired = developed more than 48hr after hospital admission
aspiration = inhaling foreign material

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24
Q

symptoms of pneumonia

A
  • purulent sputum - pneumococcal = rusty
  • fever
  • haemoptysis
  • pleuritic chest pain - sharp and worse on inhalation
  • SOB
  • confusion
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25
Q

signs of pneumonia

A
  • tachypnoea (raised RR)
  • tachycardia
  • hypotension
  • bronchial breath sounds
  • reduced chest expansion
  • dull to percuss
  • focal crackles
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26
Q

what scoring assessment is used for pneumonia?

A 
C - new confusion
U - urea >7
R - respiratory rate >= 30/min
B - BP systolic <90 or diastolic <60
65 - age 65 or older

> 2 admit to hospital

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27
Q

investigations for pneumonia

A
  • CXR - consolidation
    • if normal repeat after 2-3 days
    • repeated after 6 weeks to rule out malignancy causing pneumonia
  • full blood count
  • urea + electrolytes (U&E)
  • CRP
  • blood and sputum culture (moderate/severe)
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28
Q

what pneumonia causing bacteria is common in COPD patients?

A

H. influenza

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29
Q

what pneumonia causing bacteria is common in people who inject drugs?

A

staph. aureus

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30
Q

what pneumonia causing bacteria is common in aspiration pneumonia?

A

GI bacteria eg enterococcus

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31
Q

how does mycoplasma pneumonia present?

A
  • usually younger people
  • dry cough

test via PCR

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32
Q

how does legionella present?

A
  • gives GI symptoms
  • spread via water - think air con, hot tubs

test via urine antigen test

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33
Q

where could someone get chlamydia psittaci from?

A

birds

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34
Q

how would you treat severe / non severe community acquired pneumonia?

A

non severe = amoxicillin (doxycycline if pen allergic)

severe = co-amoxiclav + doxycycline

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35
Q

how would you treat severe / non severe hospital acquired pneumonia?

A

non severe = amoxicillin (doxycycline if pen allergic)

severe = amoxicillin + gentamicin

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36
Q

how would you treat severe / non severe aspiration pneumonia?

A

non severe = amoxicillin + metronidazole

severe = amoxicillin + metronidazole + gentamicin

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37
Q

how would you treat pneumonia causing legionella + mycoplasma pneumoniae?

A

levofloxacin or clarithromycin

** does not respond to doxycycline

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38
Q

what would the spirometry results of an obstructive airway disease look like?

A

FVC - normal or low
FEV1 - low
FEV1/FVC - low

eg asthma, COPD
if all low - could be combination of obstructive and restrictive

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39
Q

what would the spirometry results of a restrictive lung disease look like?

A

FVC - low
FEV1 - low
FEV1/FVC - normal

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40
Q

what are the forces keeping alveoli open?

A
  • transmural pressure gradient - higher pressure inside alveoli than pleural cavity
  • pulmonary surfactant
  • alveolar interdependence - if starts to collapse, surrounding alveoli stretch then recoil exerting expanding force on alveoli
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41
Q

what effect does loss of elastic recoil have on residual volume and pulmonary compliance?

A

increases

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42
Q

what is pulmonary compliance?

A

change in lung volume per unit change in transmural pressure gradient across lung wall

  • less compliant = more work required for inflation
    decreased by - pneumonia, lung collapse, pulmonary fibrosis, pulmonary oedema
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43
Q

what are the consequences if perfusion > ventilation?

A
  • increased co2 in alveoli - dilation of airways, airflow increases
  • decreased o2 in alveoli - constriction of blood vessels, blood flow decreases
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44
Q

what are the 4 factors that influence rate of gas exchange across alveolar membrane?

A
  1. partial pressure (pressure gas would exert if only gas) gradient of o2 and co2 - increase results in increase rate of transfer
  2. diffusion coefficient (solubility of gas in membranes) for o2 and co2 (co2 20 times that of o2) - increase results in increase rate of transfer
  3. surface area of alveolar membrane - increase results in increase rate of transfer, exercise increases surface area
  4. thickness of alveolar membrane - increase results in DECREASE rate of transfer, thickness increased by pulmonary oedema, pneumonia
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45
Q

describe the shape of an haemoglobin oxygen saturation curve

A

sigmoid

  • Flat upper portions means that moderate fall in alveolar PO2 will not much affect oxygen loading
  • Steep lower part
    means that the peripheral tissues get a lot of oxygen for a small drop in capillary PO2
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46
Q

describe cooperativity of haemoglobin

A

The binding of one oxygen molecule to deoxyhaemoglobin increases the oxygen affinity of the
remaining binding sites

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47
Q

what is the Bohr effect?

A

a shift in the oxygen saturation curve to the right due to increased release of o2 (reduced affinity)

due to:

  • increased pCO2
  • increased [H+]
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48
Q

give characteristics of myoglobin (Mb)

A
  • present in skeletal and cardiac muscles
  • one haem group
  • no cooperative binding of o2
  • dissociation curve hyperbolic
  • releases o2 at very low pO2
  • provides short-term storage of o2 for anaerobic conditions
  • presence of myoglobin in blood indicates muscle damage
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49
Q

what is the Haldane effect?

A

removing o2 from Hb increases ability of Hb to pick up co2 and co2 generated H+

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50
Q

what are the neural steps to inspiration?

A
  • rhythm generated by Pre-Botzinger complex in medulla
  • excites dorsal respiratory group neurones (inspiratory)
  • fire in bursts
  • firing leads to contraction of inspiratory muscle = inspiration

when firing stops = passive expiration

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51
Q

what are the neural steps to “active” expiration during hyperventilation?

A

increased firing of dorsal neurones excites a second group = ventral respiratory group neurones

excites internal intercostals, abdominals etc = forceful expiration

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52
Q

how can the rhythm of breathing be modified?

A

the rhythm generated in the medulla can be modified by neurones in the pons

  • pneumotaxic centre - stimulated when dorsal respiratory neurones fire, inhibits inspiration
  • apneustic centre - their impulses excite inspiratory area of medulla, prolong inspiration
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53
Q

what events occur in lung development in the embryonic stage?

A

26days - 6weeks

  • respiratory diverticulum forms
  • initial branching to give lungs, lobes and segments
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54
Q

what event occurs in lung development in the pseudoglandular stage?

A

6-16weeks

14 more generations of branching: terminal bronchioles

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55
Q

at what stage do terminal sacs form and capillaries establish close contact?

A

saccular stage - 28-36weeks

as terminal sacs form, epithelial cells differentiate into 2 main cells: type I + II

56
Q

what are the 2 types of cells that line alveoli walls?

A

type I = thin squamous epithelium

  • form blood-air barrier - capillary network form close connections
  • most of surface area of terminal sacs

type II = cuboidal
- produce surfactant

57
Q

what is respiratory acidosis / alkalosis?

A

respiratory acidosis = increase [H+] due to increase pCO2

respiratory alkalosis = decrease [H+] due to decrease pCO2

58
Q

what is metabolic acidosis / alkalosis?

A

metabolic acidosis = increase [H+] due to decrease HCO3-

metabolic alkalosis = decrease [H+] due to increase HCO3-

59
Q

how does metabolism compensate for respiratory acidosis?

A

(too much CO2)

kidneys excrete H+ + simultaneously regenerates bicarbonate

60
Q

name the cartilages of the larynx

A
  • epiglottis - lid which stops food going down airways
  • thyroid
  • 2 arytenoid (posterior)
  • cricoid
61
Q

where is the rima glottidis?

A

larynx - narrowest part

  • where air passes from URT to LRT
  • where foreign bodies get stuck
  • vocal cords are ligament which surround it
62
Q

how is air warmed, humidified and cleaned?

A

warmed - via arterial blood supply of respiratory mucosa lining walls of nasal cavity

Humidified – via mucous produced by respiratory mucosa providing moisture

Cleaned – via sticky mucous trapping potentially infected particles

63
Q

how many ribs are there?

A

12 pairs

  • true = 1-7
  • false = 8-10 (attach to common carilage - costal margin)
  • floating = 11+12 - no attachment to sternum
64
Q

what are the joints of the thoracic skeleton?

A

sternocostal joint

  • between sternum and costal cartilage
  • synovial

costochondral joint

  • between rib and costal cartilage
  • v limited movement
65
Q

where is the neurovascular bundle found?

A

intercostal space - between internal and innermost inter coastal muscle layers

66
Q

describe the role of conchae

A

conchae greatly increase the surface area of the lateral walls of the nasal cavities

conchae produce turbulent flow bringing the air into contact with the walls

67
Q

at what point does the larynx and pharynx become the trachea and oesophagus respectively?

A

C6 vertebra

68
Q

what are the posterior and anterior blood supplies to the intercostal spaces?

A

posterior

  • thoracic aorta
  • azygous vein

anterior

  • internal thoracic artery
  • internal thoracic vein
69
Q

where does the muscular part of the diaphragm attach peripherally to?

A
  • the sternum
  • the lower 6 ribs and costal cartilages
  • L1-L3 vertebral bodies
70
Q

what are the phrenic nerves and where are they found?

A

the combined anterior rami of cervical spinal nerves C3, 4, 5 (keeps diaphragm alive)

found in

  • neck on the anterior surface of scalenus anterior muscle
  • chest (thorax) descending over lateral aspects of heart
71
Q

what does the phrenic nerve supply?

A
  • supplies somatic sensory and sympathetic axons to the diaphragm and fibrous pericardium
  • supplies somatic motor axons to the diaphragm
72
Q

at what point does the subclavian vein and artery become the axillary vein and artery?

A

once they pass the 1st rib

73
Q

where would abnormal fluid in the pleura drain to?

A

costodiaphragmatic recess (most inferior)

  • located between diaphragmatic parietal pleura and costal parietal pleura
  • left base descends into here during FULL inspiration
74
Q

where do you auscultate the lung apex?

A

root of the neck - superior to medial third of clavicle

75
Q

where do you auscultate the middle lobe?

A

between ribs 4 and 6 in the mid-clavicular and midaxillary lines

76
Q

where do you auscultate the lung base?

A

in the scapula line (posterior) at T11 vertebral level

77
Q

which cranial nerves sensory receptors are stimulated in sneexing?

A

CN V or CN IX

78
Q

which cranial nerves sensory receptors are stimulated in coughing?

A

CN IX or CN X

79
Q

what are carotid sheaths and what do they contain?

A

protective tubes of cervical (neck) deep fascia - attach superiorly to the bones of the base of the skull

contains:

  • vagus nerve
  • internal carotid artery
  • common carotid artery
  • internal jugular vein
80
Q

list the 3 steps of inspiration mechanics

A
  1. diaphragm contracts and descends - increases vertical chest dimension
  2. intercostal muscles contract elevating ribs - increases A-P and lateral chest dimensions
  3. chest wall pulls the lungs outwards with them (pleura) - creates -ve pressure so air flows into lungs
81
Q

what are the 3 muscles of normal inspiration?

A
  1. external intercostal
  2. internal intercostal
  3. innermost intercostal
82
Q

what are the accessory muscles of forced inspiration?

A
  • pectoralis major - attaches between sternum + humerus
  • pectoralis minor - pull ribs 3-5 up
  • sternocleidomastoid - attaches between clavicle and mastoid process
  • scalenus anterior, medius and posterior - under sternocleidomastoid, attach between cervical vertebrae and rib 1+2
  • use of accessory muscles is a sign of dyspnoea
83
Q

list the steps of coughing

A
  1. STIMULATION of sensory receptors in mucosa
  2. deep inspiration using diaphragm (phrenic nerves), intercostal muscles and accessory muscles
  3. adduction of vocal cords to close the rima glottidis (vagus nerve)
  4. contraction of anterolateral abdominal wall muscles to build up intra-abdominal pressure which pushes the diaphragm superiorly and builds up pressure un chest inferior to adducted vocal cords
  5. vocal cords suddenly abduct to open the rima glottidis
  6. soft palate tenses (CN V) and elevates (vagus nerve) to close entrance to nasopharynx so goes through oral cavity as cough n not nasal as sneeze
84
Q

list the steps of expiration mechanics

A
  1. diaphragm relaxes and rises - decreases vertical thoracic dimension
  2. intercostal muscles relax lowering ribs - decreases A-P and lateral chest dimensions
  3. elastic tissue of lung recoils - pushes air out of lungs
85
Q

list the anterolateral abdominal wall muscles

A

left and right:

  • rectus abdominis
  • external oblique
  • internal obligue
  • transverse abdominus
  • used in forced expiration
86
Q

at what point does the LRT begin?

A

C6 vertebra

87
Q

what is an anatomical landmark for cardiopulmonary resuscitation?

A

xiphoid process

88
Q

what carries deoxygenated blood, drains into superior vena cava and arches round right main bronchus?

A

azygous vein

89
Q

what carries oxygenated blood and are sited inferoposteriorly within lung root?

A

pulmonary vein

90
Q

where is the horizontal fissure?

A

right 4th rib

91
Q

where is the carina?

A

rib 2 level

92
Q

where is the oblique fissure posteriorly and anteriorly?

A

posteriorly - T3 vertebra

anteriorly - rib 6

93
Q

what stage of lung maturation happens at 16-28 weeks and what happens?

A

canalicular

- branching of terminal bronchioles into respiratory bronchioles and then alveolar ducts

94
Q

which germ layer forms the lining of the trachea and bronchial tree?

A

endoderm

95
Q

what does the visceral mesoderm form in the respiratory system?

A

cartilage and smooth muscle in the thorax

96
Q

what type of cells line the roof of the nasal cavity?

A

olfactory epithelium

- involved in smell and taste

97
Q

what type of cells line the main bronchi?

A

pseudostratified ciliated columnar epithelium and goblet cells with hyaline cartilage rings and cartilage plates

98
Q

what do cuboidal epithelium and non-ciliated clara cells line?

A

terminal bronchioles

99
Q

what are clara cells?

A

a non-ciliated cell found in terminal bronchioles

  • act as an immune modulator and stem cell
  • able to produce surfactant
100
Q

what is subcutaneous omalizumab?

A

a monoclonal antibody against IgE that also reduces IgE receptor expression

101
Q

what is a synthetic glucocorticoid used to prevent inflammation in chronic asthma?

A

inhaled beclometasone

102
Q

what does law of LaPlace state?

A

smaller alveolar radius = higher tendecy to collapse

103
Q

what is daltons law?

A

total pressure of a mixture of gases = sums of partial pressures of each component gas

104
Q

what is henrys law?

A

the amount of a gas dissolved in a given type and volume of liquid at constant temperature is proportional to the partial pressure of the gas in equilibrium with the liquid

105
Q

how is most co2 transported?

A

as bicarbonate

106
Q

what is the difference between SAMA/LAMA and SABA/LABA?

A

muscarinic receptor antagonists

  • reduce bronchospasm
  • decrease mucus secretion

beta2-adrenoreceptor agonist
- bronchodilator

107
Q

what can peripheral chemoreceptors detect?

A

arterial oxygen partial pressure - when stimulated they cause hyperventilation and increased cardiac output

  • can compensate for metabolic acidosis
108
Q

list extrinsic factors that could present as a restrictive lung disease

A 
THORACIC:
obesity
kyphoscoliosis
ascites 
diaphragmatic palsy

NEUROPATHY: motor neurones

PLEURAL DISEASES: mesothelioma

109
Q

what is a normal mPAP?

what value would imply pulmonary hypertension?

A

normal = 12-20mmHg

pulmonary hypertension = 25mmHg

110
Q

give examples of DOACs

A

rivaroxaban

apixaban

111
Q

what is tidal volume?

A

amount of air inspired or expired in a normal breath at rest (0.5)

112
Q

what is FVC?

A

(forced) vital capacity - volume of air exhaled after forced/maximal expiration

113
Q

what is FEV1?

A

forced expiratory volume - volume that has be exhaled after the first second of forced expiration

114
Q

give an example of a leukotriene receptor antagonist (LTRA) and list uses / possible side effects

A

montelukast

  • patients with allergic rhinitis and asthma
  • abdominal pain + headaches
115
Q

give an example of a xanthine and list uses / possible side effects

A

theophylline

  • increased mucus clearing - asthma
  • N+V, abdo discomfort, headaches
116
Q

give an example of a monoclonal antibody treatment and list uses / possible side effects

A

omalizumab - against IgE

  • allergic asthma
  • abdo pain, pyrexia
117
Q

give examples of short and long acting muscarinic Ach antagonists

A

SAMA = ipratropium (non-selective)

LAMA = tiotropium (selective for M3 receptors)

118
Q

give examples of both inhaled and oral corticosteroids

A

inhaled = beclomethasone

oral = prednisolone

119
Q

what would sodium cromoglicate be used for?

A

allergic asthma and allergic rhinitis

in kids

120
Q

give examples of short and long acting beta2-adrenoceptors

A

SABA = salbutamol

LABA = salmeterol, formoterol

121
Q

what happens in type I hypersensitivity reaction?

A

Allergic

  • immediate response after exposure
  • IgE stimulates overproduction of mast cells, basophils and eosinophils
  • results in rapid degranulation - release of vasoactive + inflammatory substances
  • IgE mediated (adaptive - Th2>Bcells>IgE)
  • innate - mast cells, eosinophils
122
Q

what happens in type II hypersensitivity reaction?

A

Bound antigens to antiBodies

  • mins/hours
  • IgM/IgG mediated
  • these react with cell surface antigens stimulating inflammatory response + tissue damage
  • mediated by complement system proteins (MAC), phagocytes, natural killer cells

example = goodpastures syndrome - lungs (pulmonary alveolar haemorrhage, kidney disease
- plasmapheresis

123
Q

what is empyema?

A

A collection of pus in the pleural space, which can be seen on a chest X-ray as a D-shaped abnormality.

124
Q

The commonest cause of bronchiolitis. Diagnosis is by PCR on throat or pernasal swabs. Treatment is supportive.

A

Respiratory syncytial virus

125
Q

what happens in a type III hypersensitivity reaction?

A

immune Complex

  • few hours after exposure (flu-like)
  • antibody binds to antigen(soluble) forming lots of immune complexes
  • antigens come from inhaled particles - farmers/bird lung
  • can circulate or gather in spaces (joints(arthritis), small vessels(vasculitis))
  • presence of immune complexes attract neutrophils which cause damage (also complement proteins)

example = systemic lupus erythematosus

126
Q

what happens in a type IV hypersensitivity reaction?

A

Delayed

  • T cell mediated activation of macrophages (no antibodies) - CD4+>Th1>macrophage recruitment
  • takes daysss
  • granulomas
  • lots of macrophages at reaction site
127
Q

what does pulmonary oedema do to lung compliance?

A

reduces lung compliance

128
Q

what effect does pulmonary oedema have on hydrostatic and interstitial pressure respectively?

A

both are increased

129
Q

what is the most posteriorly located structure in the lung root?

A

vagus nerve

130
Q

how do the pulmonary arteries respond to the presence of hypoxia?

A

constrict

131
Q

which gas law is relevant in respiratory distress syndrome of premature new born babies?

A

insufficient surfactant

Law of La Place
–> it states that the tension exerted on a spherical wall of set pressure is inversely proportional to that sphere’s thickness

132
Q

Which neurotransmitter acts on muscarinic receptors and what is its action in the airways?

A

Acetylcholine, constriction of the airways

–> hence the use of muscarinic antagonists like ipratropium and tiotropium in asthma and COPD to reverse this effect

133
Q

what is the difference between foetal and adult haemoglobin?

A

foetal haemoglobin has 2alpha +2 gamma subunits instead of beta subunits causing it to have a high affinity for oxygen that adult Hb

134
Q

where is the horizontal fissure anatomically?

A

anterior aspect of rib 4

135
Q

features of life-threatening asthma

A 
PEFR < 33%
oxygen sats < 92%
silent chest, cyanosis
brady cardia, dysrhythmia, hypotension
exhaustion, confusion, coma
136
Q

features of severe asthma

A

PEFR 33-55%
can’t complete sentences
RR > 25/min
pulse >110 bpm

first year med (15 decks)

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