Respiratory Flashcards
At what level does the trachea bifurcate?
T4
How many pulmonary veins do you have?
Do they carry deoxygenated or oxygenated blood?
4 pulmonary veins
They carry oxygenated blood.
Describe the passage of structures between the nose and the alveoli…
Nose
Pharynx
Larynx
Trachea
Bronchi
Bronchioles
Alveoli
What type of pneumocytes produce surfactant?
What does surfactant do?
Type II
Surfactant lowers the surface tension of the lungs.
What 6 structures are found at the hilum of the lung?
Pulmonary artery Pulmonary veins (2) Bronchi Pulmonary Plexus Lymphatics Bronchial vessels
What is the main cell type found in the upper airways?
What alternative cell type is found in bronchioles?
Pseudo stratified columnar cells
Cuboidal cells
What does the sympathetic nervous system do to the respiratory system?
What does the parasympathetic nervous system do to the respiratory system?
The sympathetic NS causes the bronchi to undergo dilation
The parasympathetic NS causes the bronchi to undergo constriction
How many lobes and fissures does the left lung have?
How many lobes and fissures does the right lung have?
Left Lung: 2 lobes and the oblique fissure
Right Lung: 3 lobes and the horizontal and oblique fissure
On what type of CXR can you diagnose cardiomegaly?
PA view
What is an acinus?
Functioning unit consisting of the terminal bronchioles and alveoli
What does the FEV/FVC and FVC values look like in an obstructive respiratory picture?
Obstructive Picture:
FEV/FVC < 70%
What does the FEV/FVC and FVC values look like in a restrictive respiratory picture?
FEV/FVC >70%
With FVC normally being low
What condition would cause the transfer coefficient to be higher than normal?
Pulmonary haemorrhage
In what conditions would the transfer coefficient be reduced?
COPD
Asthma (chronic severe)
Anaemia
The mneumonic BODE is used to stage patients with COPD.
What does it stand for?
BMI
O degree of airflow
D yspnoea
Exercise capacity
What is COPD?
What two conditions make it up?
COPD is a condition where you get an obstructive pattern on spirometry which is not fully reversible with a SABA
Emphysema and Chronic Bronchitis
What are some of the main causes of COPD?
Chronic smoking or exposure to smoke
Alpha 1 anti trypsin disease (? If young person non smoker has COPD like symptoms)
Occupational
What is the pathophysiology of COPD ?
Increased secretion by goblet cells
Infiltration of WBC leads to inflammation and scar tissue formation. This causes the airways to become more narrow.
Emphysema is dilation of the the lung tissue distal to the terminal bronchioles
Do people with COPD have an increased or decreased risk of getting lung cancer? Why?
Further progression of COPD can lead to metaplasia and thus increased cancer risk.
Describe what happens to the V/Q in COPD?
The V/Q undergoes mismatch. This means that there is eventually a rise in CO2 levels and thus the body becomes insensitive to CO2.
hypoxic drive commences
What is the typical presentation of someone with COPD?
Normally an ex smoker.
Dyspnoea, Chronic Productive Cough, Wheeze and has more frequent chest infections.
How do you diagnose COPD?
Spirometry- see an obstructive pattern aka FEV/FVC <70 and FEV<80
CXR
CT
ABG
Alpha 1 anti trypsin levels
What is the management of COPD?
- Smoking Cessation
- Start the patient on a SABA
- Start on a LAMA + LABA
- LAMA + LABA + steroid
Give 3 descriptions of asthma?
Reversible airflow limitation
Airway hyper responsiveness
Bronchial inflammation
Describe what intrinsic and extrinsic asthma means?
Intrinsic = non allergy induced i.e. smoke , cold, exercise
Extrinsic = allergy induced
What factors suggest that an acute asthma attack is
A. Severe
B. Life threatening
A. Severe is characterised by an inability to complete sentences . High HR and High RR
B. Silent chest, confusion, cyanosis and Bradycardia. With a PEFR <35
How do you manage chronic asthma?
- SABA
- SABA + ICS
- SABA + ICS + leukotriene receptor antagonist (montelukast)
- Above and add LABA
What assessment tool can judge a patient’s asthma severity?
RCP 3 form (nocturnal waking, interference with ADLS and how many times asthma symptoms have occurred.
What investigations could we do to determine if asthma is the allergic type?
Skin prick test
NO test.
What two lung diseases can asbestosis cause?
Benign pleural disease
Lung fibrosis
Mesothelioma
What condition does coal worker’s pneumoconiosis mimic?
COPD
What is Silicosis?
What occupations are it associated with?
What is the appearance on a Chest X Ray?
This is an occupational lung condition. That is commonly seen in pottery and ceramic workers.
You see a diffuse egg shell calcification pattern on CXR
Patient normally has dyspnoea and increased TB incidence
What is Extrinsic Allergic Alveolitis?
This is a respiratory condition that is a hypersensitivity Type 3 reaction.
Commonly known as bird fancier or pigeon fancier’s lung.
It causes there to be fibrosis of the lung.
There are 3 phases: Acute, Sub Acute and chronic
What are the 3 phase symptoms of Extrinsic Allergic Alveolitis (pigeon fancier lung) ?
Acute: dyspnoea, fever, malaise, rigors , dry cough and chest tightness.
Resolves generally 24-48 hours after. Note: occurs 4-6 hours post exposure.
Sub acute: less severe than above. normally occurs weeks to months post exposure
Chronic: normally they do not have symptoms (acute) but will suffer from cyanosis, weight loss, dyspnoea and clubbing.
What investigations would you like to do for EAA?
You would want to do a
Chest X Ray: show fibrotic shadow
Bronchoalveolar lavage (look at CD4 and lymphocyte count)
FBC will show a raised WCC and ESR.
What is the management of Extrinsic Allergic Alveolitis?
Acute: avoid exposure and give O2 and short term pred
Chronic: avoid exposure and give long term pred
What is bronchiectasis?
This is when you have chronic infection of the bronchi and bronchioles
This leads to permanent dilation and airways distortion
What are 4 causes of bronchiectasis?
Chronic infections i.e. pneumonia
Cystic Fibrosis
HIV
TB or whooping cough
What is the pathophysiology behind bronchiectasis?
The pathophysiology follows the idea that there is failed mucociliary clearance and impaired immune function. Leading to uncontrolled inflammation and WBC recruitment.
The airway dilation occurs secondary to inflammation and scarring
How does bronchiectasis normally present?
Chronic cough with Purulent sputum Dyspnoea Wheeze Finger clubbing Increased risk of further chest infections
Commonly affects the lower lobes
How would you diagnose bronchiectasis?
You would do a CXR which would show tram track opacities
You would do a HRCT (gold standard)
Sputum culture
? CF may want to do a sweat test.
How do you treat bronchiectasis?
You need to give an anti mucolytic such as Dornase Alfa
Chest Physio
Abx to treat ongoing infection. Some may require prophylactic abx
What channel does CF affect?
The CFTR channel.
This is a co transporter channel for Na+/Cl-
Most common mutation is F508
How can CF present?
Meconium ileus
Failure to thrive
Frequent infections
Rectal Prolapse and Nasal Polyps
Pancreatic insufficiency
Bronchiectasis , wheeze, dyspnoea
Males can also have atrophy of the vas deferens and epididymis
What diagnostic tests would you want to run on someone you queried CF in?
You would want to do
- newborn heel prick and genetic testing- in younger people
- older people teenage and above use the sweat test.
How would you treat CF?
You can’t treat it. However you can treat the symptoms:
Mucolytic agents: dornase alfa
Pancreatic enzyme replacement: Creon
High Fat and calorie diet.
Prophylactic abx, regular supply of chest physio
Amiloride: inhibits Na+ and leads to less thick mucous!
What is sarcoidosis and where does it affect?
Sarcoidosis is a multi system granulomatous disease that is an interstitial lung disease.
What is the typical presentation of sarcoidosis?
You get Bilateral hilar lymphadenopathy.
Pulmonary infiltrates
Skin and Eye lesions
Is Sarcoidosis more common in men or women ?
Women
Note: it is often detected on routine CXR
How does sarcoidosis present?
Generally presents incidentally after a routine CXR with no symptoms prior
However, it its acute phase it can present with polyarthralgia, fever, fatigue, weight loss and erythema nodosum
What are some of the respiratory symptoms of sarcoidosis?
Dry Cough
Dyspnoea
Bilateral Hilar lymphadenopathy
Does sarcoidosis affect the skin?
Yes it does
It can cause cutaneous lesions and also leads to facial numbness, conjunctivitis and Bell’s palsy
How would you diagnose Sarcoidosis?
- CXR
- ACE levels + inflammatory markers
- Bronchoscopy and Tissue biopsy
How do you acutely treat sarcoidosis?
How is it treated when chronically?
Acutely: give bed rest and NSAIDs
Chronically: give prednisolone and methotrexate
What is the most common type of Interstitial Lung Disease?
Idiopathic Pulmonary Fibrosis
Who is idiopathic pulmonary fibrosis more common in- males or females?
Males
What is the pathophysiology behind IPF?
Well it is unknown
However, normally the alveolar epithelium can repair damage on its own. But in IPF it can’t do this so you get uncontrolled wound healing and deposition of extra cellular matrix and fibrosis.
This loss of lung parenchyma means that you loose elasticity and the ability to perform gas.
What is seen on the clinical presentation of IPF?
It will affect the lower lobes mainly and be patchy in nature
The patient will have exertional dyspnoea and a dry cough.
Malaise and Weight loss
Arthalgia, Cyanosis and Finger clubbing
What will you hear when listening to the chest with someone with IPF?
You will hear fine bilateral inspiratory crackles
What investigations would you do on someone you suspect IPF in ?
You will do: HRCT (gold standard) will show honeycombing
Spirometry: restrictive pattern
Generally ABG will show a T1RF picture.
How do you treat IPF?
You do
Pulmonary rehab
Give oxygen therapy
Start an anti-fibrinolytic agent such as pirfenidone this slows down the rate of FVC decline.
What causes pulmonary hypertension?
It is caused by an increase in pulmonary vascular resistance.
Defined as a MAP above 25mmHg
What are some of the causes of pulmonary hypertension?
Give 2 Resp, 1 MSK and 2 other
Resp: Pulmonary Embolism and COPD
MSK: polio or kyphosis
Other: obstructive sleep apnoea and obesity
What does pulmonary hypertension do to the heart?
It causes there to be increased pulmonary vascular distance and as such the right ventricle needs to pump harder to get past this resistance.
This causes RVH
What is the clinical presentation of pulmonary hypertension?
The presentation is the same as someone who has R Heart failure.
As such the patient will be:
SOB, fatigue
Ankle swelling
Hepatomegaly, Ascites and syncope
What is the management of pulmonary hypertension?
The management of pulmonary hypertension is
Phosphodiesterase inhibitors and Warfarin
Diuretics
Vasoconstrictors like prostanoid
What is a pleural effusion?
What are the two types?
A pleural effusion is when you get fluid in the pleural space.
Transudate (low protein) commonly caused by heart, liver and kidney failure.
Exudate (high protein): normally due to malignancy, infection or inflammation.
How do pleural effusions present?
The can be asymptomatic especially in those with malignancy and long standing disease.
Normally SOB on exertion
Pleuritic chest pain
Cough
Reduced chest expansion on one side. In a large Pleural effusion you will see that the trachea deviates towards the lesion.
What are two diagnostic tests that you would do for someone with a suspected Pleural effusion?
- Chest X Ray
2. Diagnostic aspiration and then send that off for cytology.
What are the management of pleural effusions?
Transudate: you need to treat the underlying cause i.e heart failure
Exudate: if symptomatic it may be appropriate to drain the excess fluid and if recurrent a pleuraldesis may be indicated
What is a pneumothorax?
This is when you get air in the pleural space leading to a partial or a fully collapsed lung.
What are some of the causes/ RF for a pneumothorax?
Cause: spontaneous pneumothorax (common in tall, thin, men who smoke)
Or by trauma
How do pneumothorax’s present?
They present acutely. They are normally presented by
A person who has acute onset SOB and chest pain. This can lead to tachycardia and pallor. They may have a low BP too
How do you treat a simple pneumothorax?
How do you treat a tension pneumothorax?
Simple pneumothorax: insert a chest drain
Tension pneumothorax: needles aspiration (2nd intercostal space) followed by a chest drain.
What is the most common malignant tumour in the world?
Bronchial tumour
This is more common in men and those that smoke
What are 3 RF of bronchial carcinoma?
Smoking
COPD
Asbestosis
What are the two types of Bronchial Carcinoma?
Non small cell lung cancer: most common type of bronchial cancer. In those that are non smokers it is common for the histology to be adenocarcinoma. In those that smoke it is common for histology to show squamous cell
Small cell lung cancer: this is associated with smoking
What are 3 areas that lung cancer can metatasise to?
Bone
Liver
Brain
Adrenal Gland
What lung cancer is associated with an increased risk of paraneoplastic syndrome?
Small Cell Lung Cancer: increased risk of paraneoplastic syndrome and thus secretion of PTH and ADH.
How do you diagnose bronchial carcinomas?
- CXR
- CT
- Bronchoscopy
What is the management of NSCLC ?
Surgery
Radiotherapy
What is the treatment of SCLC?
- Chemo and Radio
Which Bronchial carcinoma has an increased risk of SVC obstruction?
SCLC
Increased risk of SVC obstruction. Management is to give radiotherapy + dexametasone
What exposure is associated with mesothelioma?
Asbestos
When do mesothelioma typically present ?
When the person is in their 40-70s
What is the clinical presentation of someone with mesothelioma?
- SOB
- Weight loss
- Cough
- Recurrent pleural effusions
Bone pains, abdominal pain
What type of biopsy do you normally take in mesothelioma ?
Pleural Biopsy
Is mesothelioma responsive to chemotherapy and radiotherapy?
No . Really resistant.
Sometimes if the condition is localised it can be useful to do surgery
What type of hypersensitivity reaction is Goodpasture’s syndrome?
Type 2
What two organs does Goodpasture’s syndrome commonly affect?
- Kidneys
2. Lungs
What circulating antibodies are found in Goodpasture’s syndrome?
- Anti glomerular basement membrane (anti-GBM)
How does Goodpasture’s disease normally present?
- Symptoms of URTI (sneezing, nasal discharge, congestion and fever)
- Cough, intermittent haemoptysis and tiredness
- Anaemia (from acute glomerulonephritis and persistent pulmonary bleeds!)
What are 3 investigations you would want to do on someone with suspected Goodpasture’s syndrome?
- Chest X Ray will show pulmonary infiltrates
- Kidney Biopsy
- Presence of anti- glomerular basement membrane (anti- GBM)
What is the management of Goodpasture’s syndrome?
- Vigorous immunosupressive treatment: prednisolone and plasmapheresis.
What are some of the classical features of gramulomatous with Polyangitis?
Saddle nose deformity + severe rhinorrhoea
Glomerulonephritis
Cough, haemoptysis and pleuritic chest pain
What type disorder is granulomatous with Polyangitis?
- ANCA associated vasculitis (small and medium vessels)
2. Particularly affects the kidney and lungs.
Can you get skin nodules and neuropathy in granulomatous with polyangitis?
YES
What are 3 tests you would like to do in Granulomatous with Polyangitis?
- C ANCA positive, high ESR and CRP
- Chest X Ray : masses and infiltrates will be evident
- Urine dipstick (++ protein and ++ blood) and a renal biopsy
How do you treat granulomatous with polyangitis?
A. Maintenance: methotrexate and azathioprine
B. Prednisolone and cyclophosphamide
Explain the passage of a DVT to the lung:
- Clot breaks off in one of the deep veins of the leg.
- Travels in the venous system up the body through the Inferior Vena Cava
- To the RHS of the Heart.
- This then travels through the pulmonary arteries to the lung.
What are 3 physiological factors that predispose someone to a clot?
- Hyper viscosity
- Endothelial damage
- Stasis (circulatory)
How would a Pulmonary Embolism present?
Sudden onset chest pain and breathlessness
They may become tachycardia, low BP, dizzy and faint.
Haemoptysis
What is the gold standard test for a pulmonary embolism?
CT pulmonary angiogram (CTPA
How do you treat an active DVT or PE?
How do you treat prophylactically?
Active treatment: DOAC like apixaban
Massive PE: may be indicated to do thrombolysis or alternative surgery
Prophylactically: LMWH via SC injection.
What are 3 common viruses that lead to URTI?
- Rhinovirus
- RSV
- Influenza + Parainfluenza
What are some causative bacterial organisms for URTI?
Strep Pneumoniae
Staph aureus
What scoring system would you use on a patient that presents with suspected tonsillitis?
Fever Pain Score
What is the most common organism that causes tonsillitis?
Group A Beta Haemolytic Streptococci
What is the abx you would use to treat tonsillitis first line?
Penicillin V
If allergic to penicillin give Erythromycin
What is a sign that sinusitis is typically bacterial and not viral?
What are two causative bacteria that lead to sinusitis?
Unilateral purulent nasal discharge
Bacteria: strep pneumonia and H influenza
Commonest pathogen to cause LRTI in neonates?
- Group B Streptococcus
2. Neisseria Gonorrhoea or Chlamydia
Commonest cause of Community Acquired Pneumonia?
- Strep Pneumoniae
- H influenzae
- Mycoplasma Pneumoniae
Commonest cause of Hospital Acquired Pneumonia?
- Gram negative organisms
E. coli, Klebsiella and Pseudomonas
What antibiotics would you use to treat CAP?
- Amoxicillin
- Amoxicillin + Doxy
- Co amoxiclav + Doxy
What abx would you use to treat HAP?
- Co amoxiclav
What stain would you do on a sputum sample to diagnose TB?
What culture would you do?
Sputum Stain: Ziehl Neelson stain
Culture: Lowstein Jenson agar
How would you test for latent TB?
- Interferon Gamma Release Assays
2. Matnoux Tests
What is the treatment for active TB?
- Report to PHE
- Rifampicin (red urine) Isoniazid for 6 months
- Pyrazinamide and Ethambutol (optic neuritis) for first 2 months
How do you treat latent TB?
Give Rifampicin (red urine)
Give Isoniazid
Both for 3 months
How many cm signify a positive Mantoux test?
> 5cm
O2 Dissociation Curve:
What does a RHS shift mean?
It means you will have low pH, high PO2
As such the Hb will move out O2 more readily.
What is Henry’s Law?
When a gas is dissolved in a liquid
Its partial pressure = the same as the concentration
What is a cause of Metabolic Acidosis?
Renal Failure
What is a cause of metabolic alkalosis?
Vomiting
What are blue Bloaters?
What are pink puffers?
Blue Bloaters: chronic Bronchitis
Pink Puffers: emphysema
Which lobes of the lungs does bronchiectasis commonly affect?
The lower lobes
