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Respiratory Flashcards

1
Q

Give some differentials for breathlessness of varying onset?

A

Few mins - PE, asthma exacerbation, pneumothorax, acute HF, inhaled FB

Mins to Hours - Pneumonia, COPD exacerbation

Hours to days - anaemia, pleural effusion, neuromuscular disorders

Chronic - Cancer, pulmonary fibrosis, COPD, Tuberculosis

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2
Q

What other symptoms could indicate respiratory pathology?

A 
Pleuritic chest pain
Cough - productive/dry/haemoptysis
Hyperventilation
Fever/unwell
Wheeze/stridor
Use of accessory muscles
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3
Q

What are some differentials for a cough?

A 
GORD
Pneumonia/TB
COPD/Asthma
HF
Pulmonary fibrosis
Drug induced
Lung Cancer
Psychogenic
FB
Cystic fibrosis
Thyroid enlargement
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4
Q

What are some differentials for a wheeze?

A

Sudden onset - FB and anaphylaxis

Fever - bronchitis/pneumonia/RTI

Previous atopy - Asthma

Adult - COPD/bronchiectasis/GORD

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5
Q

What is the difference in differentials for a monophonic/polyphonic wheeze?

A

Mono - Large airways

Poly - Multiple small airways

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6
Q

What are some causes for haemoptysis?

A 
PE
Vasculitis
Bronchiectasis
TB
Pneumonia
Trauma
Post intubation
CF
Cancers
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7
Q

What is blood streaked sputum indicative of?

A

Inflammation of the larynx/bronchi
Lung cancer
Ulcer

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8
Q

What is pink sputum indicative of ?

A

Blood from alveoli

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9
Q

What is green sputum indicative of?

A

Longstanding infection?

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10
Q

What other sputum changes may be seen and what may they indicate?

A

Yellow/purulent - contain pus

White/grey - dehydrated

White, milky, opaque - viral

Frothy pink - pulmonary oedema

Rust - pneumonia, PE, TB

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11
Q

What are the characteristics of asthma?

A

Reversible airflow limitation

Hyper responsive to range of stimuli

Bronchial inflammation

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12
Q

How is asthma investigated? What are the results of these investigations?

A

Peak flow - morning and night

Spirometry - obstructive pattern
- 12% improvement with bronchodilator (and 200ml increase in volume in adults)

Nitrous oxide - raised levels
Corticosteroid trial - 2 weeks should induce 15% improvement
Skin prick
Provacation test - inhale histamines and 20% will have transient airflow limitation

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13
Q

How is asthma diagnosed in children and adults?

A

Rare to diagnose <5 - clinical

5-16 - Bronchodilator reversibility. If negative or normal spirometry –> NO test

17y+:

  • ask if symptoms impacted by work days - occupational?
  • Spirometry with bronchodilator reversibility
  • NO test
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14
Q

What would constitute a positive nitric oxide test for asthma? Why does this occur?

A

> 40ppb in adults
35ppb in children

Inflammatory cells and in particular eosinophils have higher levels of NO synthases in them so NO is higher

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15
Q

How is asthma managed?

A

1 - SABA PRN
2 - SABA + low dose ICS
3 - SABA + ICS + LRTA
4 - SABA + ICS + LABA (+LRTA if effective)
5 - SABA + MART (fast acting LABA + low dose ICS) (+LRTA)
6 - increase MART dose to medium
7 - increase dose again, specialist advise or additional drug such as theophylline

Step up if symptoms 3+ times/week or night time waking

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16
Q

When is asthma treatment stepped down?

A

Consider every 3 months or so

Reduce steroid dose by 25-50%

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17
Q

What are the stages of an acute asthma attack?

A 
Mild
Moderate
Severe
Life-threatening
Near fatal
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18
Q

How is asthma ranked into stages?

A

Based on O2 Sats, RR, HR, Speech, Wheeze, PEFR

Mod - sats >92%, RR<25, HR<110, wheeze, PEFR 50-75%

Severe - sats <92%, RR and HR increase, not speaking in sentences, may not have wheeze, PEFR 33-50%

Life threatening - NORMAL pCO2!!. sats<92%/cyanosed, bradycardic, no resp effort, silent chest, PEFR <33%, hypotensive.

Near fatal - HIGH pCO2, req. mechanical ventilation with increased inflation pressures

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19
Q

How is acute asthma managed?

A

1 High flow O2 and Nebulised salbutamol 5mg back to back
2 Nebulised ipratropium bromide 500mcg
3 Oral pred 40mg or IV hydrocortisone 100mg
4 IV Magnesium sulphate 2g
5 Senior support - can use IV salbutamol or aminophylline

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20
Q

What is the discharge criteria for asthma?

A

Stable on discharge meds for 12-24hr
Inhaler technique checked
PEFR >75%

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21
Q

What are the two main causes of COPD?

A

Alpha 1 antitrypsin deficiency

Smoking

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22
Q

How does COPD present? (Signs, symptoms, investigation findings)

A

Symptoms:

  • Cough
  • SOB

Signs:

  • Pursed lip breathing
  • Hyper-resonant
  • Reduced breath sounds and wheeze
  • Barrel chest

Spirometry:
Obstructive pattern with no reversibility

CXR:

  • Flat diaphragm
  • Hyperlucent lungs
  • Wheeze

Pulmonary HTN –> cor pulmonale –> large p waves on ECH

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23
Q

How is COPD categorised?

A

Using PEFR

Mild >80
Mod 50-79
Severe 30-49
V Severe <30

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24
Q

How is COPD investigated? What are the results of these investigations?

A

Post bronchodilator spirometry - FEV1/FVC remain <70
CXR - bullae can look like pneumothorax, flat diaphragm
FBC - rule out secondary polycythaemia
BMI

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25
Q

How is COPD managed?

A

Lifestyle:

  • Stop smoking
  • Pulmonary rehab
  • Annual influenza vaccine
  • One off pneumococcal vaccine
Drugs:
- SABA or SAMA
If previous atopy, eosinophilia or diurnal variation:
- LABA + ICS
- LABA + LAMA + ICS
If no asthmatic features:
- LABA + LAMA

Can consider lung reduction surgery

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26
Q

When is theophylline used in COPD?

A

After trials of LABA and LAMA

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27
Q

When is Abx prophylaxis offered in COPD? What antibiotic is given and what monitoring is required?

A

If >3 steroid requiring or 1 hospital requiring exacerbation

Azithromycin

  • LFT and ECG must be done (long QT)
  • CT thorax to exclude bronchiectasis
  • Sputum culture to exclude atypical/TB
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28
Q

Which organisms are typically responsible for infective exacerbations of COPD?

A

H Influenza - most common

Strep pneumoniae

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29
Q

When are mucolytics considered in COPD management?

A

Chronic productive cough

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30
Q

What are the features of cor pulmonale and how is it managed in COPD patients?

A

Peripheral oedema
Raised JVP
Systolic parasternal heave
Loud p2

Use loop diuretic and consider long term O2 therapy

ACEi, Ca blockers and alpha blockers not recommended

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31
Q

When is long term oxygen therapy considered in COPD? What happens in it?

A 
pO2 <7.3 OR
pO2 7.3-8 AND one of
- secondary polycythaemia
- pulmonary hypertension
- peripheral oedema

Not offered if pt. continue to smoke
Must do risk assessment - risk of fire/falling over equipment

Patients do at least 15 hours per day

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32
Q

Which patients would you assess for long term O2 therapy in COPD?

A 
Severe airflow obstruction
Cyanosis
Polycythaemia
Peripheral oedema
Raised JVP
O2 sats 92 or less
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33
Q

How is an acute exacerbation of COPD managed?

A

SABA + 5 days prednisolone + amoxicillin (IF prurulent sputum/ pneumonia signs)

or clarithromycin or doxycycline if penicillin allergy

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34
Q

What commonly causes pneumonia?

A

Community acquired - S pneumoniae, H Influenza

Hospital acquired - S Aureus (and IVDU), pseudomonas

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35
Q

Which individuals is klebsiella pneumonia common in? What are some classical features?

A

Alcoholics and diabetics

  • Red current jelly sputum
  • Cavitating upper lobe lesion
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36
Q

Which individuals commonly get legionella pneumonia? What are some classical blood findings?

A

Those near air conditioning units

Hyponatraemia and lymphopenia

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37
Q

What type of pneumonia is common in individuals with HIV? What are some characteristic features of this pneumonia?

A

Pneumocystis jiroveci

Dry cough
Exercise induced desaturations
Absence of chest signs

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38
Q

How does mycoplasma pneumonia present? What is seen in CXR? How is it diagnosed? What are some complications?

A

Flu like progressing to dry cough

CXR: Often bilateral consolidation

Diagnosis: +ve cold agglutination test

Complications: haemolytic anaemia, erythema mutliforme, any ‘itis’ eg nephritis, meningitis

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39
Q

How is pneumonia managed?

a) CAP
b) HAP
c) Mycoplasma
d) Pneumocystis

A

CAP - 5 days amoxicillin (mild). May need 10 days co-amoxiclav or Tazocin if severe

Hospital - IV co-amox

Mycoplasma - Erythromycin

Pneumocystis - co-trimoxazole

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40
Q

What investigations are recommended for pneumonia?

A 
Sputum MC&S
Blood culture 
FBC - raised WCC, ESR and CRP
CXR
ABG
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41
Q

How is pneumonia scored and what is the recommendation?

A

CURB65:

  • Confusion
  • Urea >7
  • RR >30
  • BP <90/60
  • > 65yo

If score 2+ –> hospital

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42
Q

What is the discharge criteria for pneumonia?

A

Don’t discharge if they have had 2+ of following in last 24 hr:

  • Temp >37.5
  • RR >24
  • HR >100
  • BP <90
  • Sats <90
  • Inability to eat unassisted
  • Abnormal mental status
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43
Q

What is the post discharge information given for pneumonia (in terms of how it will develop)?

A

1 wk - fever resolve
4 wk - chest pain and sputum should be v reduced
6 wk - cough and breathlessness should be v reduced
3 months - most symptoms resolved but mild fatigue
6 months - most people back to normal

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44
Q

What are some complications associated with pneumonia?

A 
Resp failure
Pneumothorax
Abscess
AF
Stroke
Pleural effusion
Sepsis
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45
Q

What is pulmonary fibrosis characterised by?

A

Scar tissue
Decreased compliance –> restrictive pattern
Honeycomb lung

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46
Q

What are the features of interstitial lung disease?

A

Dry cough
Dyspnoea
Digital clubbing
Diffuse inspiratory crackles

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47
Q

What are the risk factors for interstitial lung disease?

A 
Idiopathic - male and 50-70yo
Coal workers - asbestos exposure
Bird keepers - pigeon fanciers
Drugs - amiodarone, bleomycin, nitrofurantoin, methotrexate
Rheumatoid arthritis
Sarcoidosis
Goodpastures
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48
Q

How would you investigate lung fibrosis?

A

Spirometry - restrictive picture
Impaired transfer factor - TLCO
Imaging - CXR and CT

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49
Q

How is lung fibrosis managed?

A

Pulmonary rehab
Steroids
Pirfenidone may be useful - antifibrotic

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50
Q

What changes are seen on imaging in lung fibrosis?

A

Bilateral insterstitial shadowing
Ground glass appearance which progresses to honeycombing

CT gold standard and req. for diagnosis

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51
Q

Which causes of lung fibrosis predominantly affect the upper lobes?

A 
Hypersensitivity
Coal workers
Sarcoidosis
Ank spond
TB
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52
Q

Which causes of lung fibrosis typically affect the lower lobes?

A

Idiopathic pulmonary fibrosis
Drugs
Asbestosis
Lupus

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53
Q

How can asbestos affect the lungs?

A

Pleural plaques

Pleural thickening

Asbestosis - related to length of exposure, lower lobe fibrosis

Mesothelioma - Malignant disease of pleura

Lung cancer

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54
Q

What are the most common causes of bilateral hilar lymphadenopathy?

A

Sarcoidosis
TB

Others: lymphoma, pneumoconiosis, fungi

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55
Q

What is a mesothelioma?

A

Cancer of the mesothelial layer of the pleura

Highly associated with asbestos

Metastasise to contralateral lung and peritoneum

Right lung more often affected than left

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56
Q

How do mesothelioma’s present?

A 
Dyspnoea
Weight loss
Chest pain
Clubbing
30% - painless clubbing
Hx of asbestos exposure
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57
Q

How is mesothelioma investigated

A

CXR
CT
If pleural effusion - MC&S, biochem and cytology
Thoracoscopy for cytology negative exudates
Biopsy if pleural nodularity on CT

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58
Q

How are mesothelioma’s managed?

A

Symptomatic
Industrial compression
Surgery/chemo

Poor prognosis - median 1 yr survival

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59
Q

What are some risk factors for a pulmonary embolus?

A 
Age
Varicose veins
Recent foreign travel
Immobility
Recent surgery
Cancer
Oestrogen/COCP
Factor V leiden, 
Infection
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60
Q

How does a pulmonary embolus present?

A 
Breathlessness
Acute pleuritic chest pain - worse on inspiration
Haemoptysis
Tachycardia
Palpitations
Dizziness/syncope
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61
Q

What is in the well’s score?

A 
3 - Clinical signs of DVT
3 - Other diagnosis unlikely
1.5 - Recent immobility >3 days - 
1.5 - Previous hx of DVT/PE
1.5 - Tachycardia 
1 - Malignancy 
1 - Haemoptysis

Score >4 - likely PE - do CTPA/VQ scan and start treating
Score <4 - PE unlikely, do D Dimer - if + CTPA

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62
Q

How is a pulmonary embolus managed?

A

Start treatment dose rivaroxaban while waiting for scan results if wells >4

Manage with DOAC’s in normal and cancer

If severe renal impairment - LMWH then warfarin

Haemodynamically unstable - thrombolyse

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63
Q

How long are patients with a pulmonary embolus anti coagulated for?

A

Provoked - 3 months
Active cancer - 3-6 months
Unprovoked - 6 months

Weight up with HASBLED score

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64
Q

What can be used in individuals who have recurrent pulmonary embolisms?

A

IVC filter however weak evidence

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65
Q

Which pulmonary embolism patients can be managed as outpatients?

A

Those who are classified as low risk.

BTS recommend use of PESI score for risk stratification

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66
Q

What ECG changes are seen in pulmonary embolism?

A

Typically sinus tachycardia

Can see S1Q3T3 - deep S wave, path Q wave, t wave invert

RBBB and Right axis deviation

67
Q

What would a CXR show in a pulmonary embolism?

A

Typically normal - done to exclude other pathology

May find wedge shaped opacification

68
Q

What can cause a VQ mismatch on a scan?

A

PE
AV malformation
Vasculitis
Previous radio

69
Q

Where may a CTPA fail to pick up a pulmonary embolus?

A

Emboli in the sub segmental arteries

70
Q

What happens in tuberculosis?

A

When a non immune individual is exposed to M. Tuberculosis, a primary infection leading to a Ghon focus develops.

In immunocompetent people, this heals by fibrosis and remain dormant but in immunocompromised, it may lead to disseminated infection

If a patient later becomes immunocompromised, the dormant TB can reactivate in secondary TB.

This can spead locally or to distant sites.

71
Q

What forms a Ghon complex?

A

Tubercle-laden macrophages - Ghon focus

Hilar lymph nodes

72
Q

Where can secondary tuberculosis spread?

A 
CNS - tuberculous meningitis
Vertebral body - Pott's disease
Cervical lymph nodes - scrofuloderma
Renal
GI tract
73
Q

What screening tools are used for TB?

A

Mantoux test - tuberculin skin test

Interferon gamma

74
Q

What does the tuberculin skin test tell you?

A

If positive - whether a patient has had exposure to TB (active or latent)

Negatives can be false negatives - military TB, sarcoid, HIV, lymphoma, v young age

75
Q

What is the advantage to interferon gamma over the tuberculin skin test?

A

Increased ability to detect latent TB in BCG vaccinated individuals

Neither good at determining between active and latent

76
Q

How is tuberculosis investigated?

A

CXR - upper lobe cavitation and bilateral hilar lymphadenopathy

Sputum culture - gold standard

Sputum smear - 3 samples - Ziehl Neilson

NAAT - rapid diagnosis

FBC and LFT’s

77
Q

How does tuberculosis present?

A 
Fever
Cough
Night sweats
Weight loss
Haemoptysis
Malaise
Pleural effusion
78
Q

How is active tuberculosis managed?

A

RIPE
6 months of Rifampicin and Isoniazid (with pyridoxine)
2 months of Pyrazinamide and Ethambutol

79
Q

How is latent tuberculosis managed?

A

3 months Isoniazid (with pyridoxine) and rifampicin
OR
6 months Isoniazid (with pyridoxine)

80
Q

Who may directly observed therapy be used in for tuberculosis?

A

Homeless people with active TB
People with poor compliance
All prisoners

81
Q

What are the adverse effects associated with tuberculosis management?

A

Immune reconstitution disease - enlarged lymph nodes 3-6wks post treatment

Rifampicin - orange secretions, hepatotoxicity, CYP inhibitor
Isoniazid - peripheral neuropathy, hepatitis, CYP inducer
Pyrazinamide - Arthralgia, gout, hepatitis
Ethambutol - optic neuritis

82
Q

What is bronchiectasis?

A

Chronic inflammation of the bronchi and bronchioles leading to permanent dilation and thinning

83
Q

What causes bronchiectasis?

A
  • Post infective - TB, Measles, pertussis, pneumonia
  • Cystic fibrosis
  • Bronchial obstruction - FB or tumour
  • Immune deficiency - selective IgA, hypogammaglobulinaemia
  • Allergic bronchopulmonary aspergillosis
  • Kartageners/youngs syndrome
  • Yellow nail syndrome
84
Q

What happens in bronchiectasis?

A

Poor mucus clearance so predisposed to infection by:

  • H Influenzae
  • S Pneumoniae
  • Klebsiella
  • Pseudomonas
85
Q

How does bronchiectasis present?

A

Persistent cough
Copious sputum
Intermittent haemoptysis

Clubbing
Coarse inspiratory creps
Wheeze

86
Q

How is bronchiectasis diagnosed?

A

High resolution CT - cystic shadows and thickened bronchial walls

87
Q

How is bronchiectasis managed?

A

Airway clearance techniques
Mucolytics
Postural drainage
Abx - rotate! if pseudomonas - ciprofloxacin
Supportive measures - flu vaccines and bronchodilators

Surgery can be considered

88
Q

What is cystic fibrosis?

A

Autosomal recessive mutation of the CFTR gene leading to defective chloride secretion and increased sodium absorption

89
Q

What are the features of cystic fibrosis?

A 
Recurrent infections
Chronic sinusitis
Nasal polyps
Infertility in males
Malabsorption - failure to thrive, Steatorrhoea
Abnormal sweat
Liver disease - portal hypertension, gallstones
Osteoporosis
Arthropathy
Distal intestinal obstruction syndrome
Diabetes mellitus
90
Q

Which bacteria commonly colonise in cystic fibrosis patients?

A

Staph aureus
Pseudomonas
Aspergillus
Burkholderia

91
Q

How is cystic fibrosis diagnosed?

A

Usually picked up on skin prick testing at birth
Can do sweat testing

Diagnosis:
- Positive hx in sibling or newborn screening result AND
one of
- >60mmol/L chloride conc on sweat test
- 2 CF mutations
- abnormal nasal epithelium ion transport

92
Q

How does cystic fibrosis present in the neonatal period?

A

Meconium ileus

Prolonged jaundice

93
Q

What is are the common causes for a negative sweat test?

A

Main - Skin Oedema - pancreatic exocrine insufficiency

Others - malnutrition, glycogen storage disease, adrenal insufficiency, nephrogenic diabetes insipidus, G6PD, hypothyroid/parathyroid, ectodermal dysplasia

94
Q

How does meconium ileus present?

A

Bilious vomit
Abdo distension
Delay in meconium passage

95
Q

How is cystic fibrosis managed?

A 
Chest physio and postural drainage
Abx prophylaxis
Mucolytics
Creon - Vit ADEK
High fat high calorie diet
Regular diabetic and osteoporosis screening
Vaccination - annual flu

Lifestyle:

  • avoid smoking
  • avoid jacuzzi’s
  • avoid other people with CF or those with cold’s
  • clean and dry nebulisers fully
  • NaCl tablets in hot weather
96
Q

What causes pleural effusions?

A

Exudative - protein >35 - infections, inflammation, malignancy

Transudative - protein <25:

  • high venous pressure - heart failure, fluid overload, constrictive pericarditis
  • low protein - Cirrhosis, nephrotic syndrome, malabsorption
  • other - hypothyroid, PE, meig’s syndrome (ovarian fibroma)
97
Q

How are pleural effusions managed?

A

Exudative - drain

Transudative - manage underlying cause

98
Q

If the protein level of a pleural effusion is between 25-35, what do you do?

A

Use LIGHT’s criteria to determine whether it is an exudate or not:

  • pleural fluid:serum protein ratio >0.5
  • pleural fluid:serum LDH ratio >0.6
  • pleural fluid LDH >2/3 of the normal
99
Q

How are pleural effusions investigated?

A

PA CXR
USS
Contrast CT

Pleural fluid aspiration

100
Q

What would low glucose in a pleural effusion indicate?

A

Rheumatoid arthritis

TB

101
Q

What would raised amylase in a pleural effusion indicate?

A

Pancreatitis

Oesophageal perforation

102
Q

What would heavy blood staining in a pleural effusion indicate?

A

Mesothelioma
TB
PE

103
Q

How should pleural effusions be managed?

A

Turbid/cloudy –> drainage

Clear but pH <7.2 - drain placed

104
Q

How can recurrent pleural effusions be managed?

A

Recurrent aspiration
Pleurodesis
Indwelling catheter
Drugs to alleviate symptoms

105
Q

What is obstructive sleep apnoea?

A

Intermittent closure of the pharyngeal airway causing apnoea episodes when sleeping.

106
Q

What can cause obstructive sleep apnoea?

A

Already small pharynx:

  • fatty infiltration/fat pressure
  • Large tonsils
  • Craniofacial abnormalities
  • Macroglossia - hypothyroid, acromegaly, amyloidosis

Excessive narrowing:

  • Neuromuscular disease
  • Muscle relaxants
  • Excessive
107
Q

How does obstructive sleep apnoea present?

A 
Obese middle aged men
Loud snoring
Daytime tiredness
Morning headache
Loss of libido
Nocturia

Can cause hypertension and compensated respiratory acidosis

108
Q

How is obstructive sleep apnoea diagnosed?

A

Night time pulse ox
Video recordings
Polysomnography

109
Q

What scoring system is used for obstructive sleep apnoea?

A

Epworth sleepiness scale

Multiple sleep latency test

110
Q

How is obstructive sleep apnoea managed?

A

Lifestyle - weight loss and decrease alcohol before bed
CPAP
Mandibular advancement device
Surgery

Inform DVLA if excessive daytime tiredness

111
Q

What are the types of pneumothorax?

A

Primary - no lung disease
Secondary - underlying lung pathology
Iatrogenic
Tension

112
Q

What are some risk factors for pneumothorax?

A 
Lung disease
Tall
Smoking cannabis
Scuba diving
Trauma
113
Q

How is a pneumothorax managed?

A

Primary:

  • Asymptomatic or <2cm - Observe and review in clinic in 2 wks or needle aspirate
  • Symptomatic or >2cm air rim - Chest drain

Secondary:

  • > 50yo and symptomatic/air rim>2 - chest drain
  • air rim 1-2cm - aspirate. drain if fails
  • air rim <1cm - O2 and observe
  • All pt’s admitted for 24hr
114
Q

What guidance is given regarding scuba diving in patients who have had a pneumothorax?

A

Permanently avoid unless undergone bilateral pleurectomy and normal resp function and CT post op

115
Q

How are iatrogenic pneumothoraxes managed?

A

Less likely to recur
Most resolve under observation. If not aspirate

Ventilated patients or those with COPD may need a chest drain

116
Q

What is the difference between type 1 and type 2 respiratory failure?

A

T1 - Low pO2, normal or low pCO2
T2 - Low pO2, high pCO2

T2 due to reduced respiratory drive

117
Q

What are the signs/symptoms of hypoxia?

A 
Dyspnoea
Agitation
Restlessness
Confusion
Central cyanosis

Long standing –> polycythaemia and pulmonary hypertension

118
Q

What are the signs/symptoms of hypercapnia?

A 
Headache
Peripheral vasodilation
Tachycardia
Bounding pulse
CO2 flap
Papilloedema
119
Q

How is respiratory failure managed?

A

Treat underlying cause
Give O2
Assist ventilation

If type 2 - controlled O2 starting at 24%

120
Q

What are the indications for non-invasive ventilation?

A
  • COPD with respiratory acidosis pH 7.25-7.35 (req. HDU if more acidotic)
  • T2 resp failure secondary to chest trauma, neuromuscular disease or obstructive sleep apnoea
  • Cardiogenic pulmonary oedema unresponsive to CPAP
  • Weaning from tracheal intubation
121
Q

What is non-invasive ventilation?

A

Providing resp. support through sealed face masks, nasal masks, mouth pieces, visors etc. without intubating.

Can be CPAP, BiPAP or Negative pressure

122
Q

How do obstructive and restrictive patterns appear on lung function tests?

A

Obstructive: Normal FVC, FEV1:FVC <0.7

Restrictive: FVC low, FEV1:FVC >0.7

123
Q

What does an anion gap show?

A

If increased - increased acid production/ingestion metabolic acidosis (DKA, lactic acidosis, aspirin OD)

If reduced - reduced acid excretion (GI loss of bicarb in diarrhoea), addison’s

124
Q

What is allergic bronchopulmonary aspergillosis?

A

Allergy to aspergillus spores - usually on background of bronchiectasis and eosinophilia

125
Q

What are the features of bronchopulmonary aspergillosis?

A

Bronchoconstriction - wheeze, cough, dysnpnoea

Proximal bronchiectasis

126
Q

How would you investigate allergic bronchopulmonary aspergillosis?

A 
FBC - eosiniphilia
CXR
RAST test - positive for aspergillus
IgG precipitins - increased
Increased IgE
127
Q

What imaging changes are seen in allergic bronchopulmonary aspergillosis?

A

CXR:

  • Ring shadowing and tram track opacificties –> bronchiectasis
  • Hilar mass

CT:
- Branching lesion with finger in glove appearance - bronchocoele

128
Q

How is allergic bronchopulmonary aspergillosis managed?

A

Oral glucocorticoids

Itraconazole 2nd line

129
Q

What are the types of altitude related disorders?

A

Acute motion sickness
High altitude pulmonary oedema
High altitude cerebral oedema

All due to chronic hypobaric hypoxia

130
Q

How does acute motion sickness present?

A

Headache, nausea, fatigue when over 2500-3000m

Develop over 6-12hr and last a few days

Self-resolve

131
Q

How can acute motion sickness be managed?

A

Descent

Don’t climb by more than 500m per day

Can give prophylactic acetazolamide

Risk is associated with physical fitness

132
Q

When do high altitude pulmonary/cerebral oedema develop? How do they present?

A

Over 4000m

HAPE - classic pulmonary oedema
HACE - headache, ataxia, papilloedema

133
Q

How are high altitude pulmonary/cerebral oedema managed?

A

Descent

HAPE - Nifedipine, dexamethasone, acetazolamide, phosphodiesterase V inhibitors, O2

HACE - dexamethasone

134
Q

What are some differentials for cavitating lung lesions on chest X-ray?

A 
Abscess
TB
PE
Squamous cell cancer
Asbestosis
Wegners granulomatosis
Rheumatoid arthritis
Aspergillosis, histoplasmosis
135
Q

What can cause lung collapse? What signs are seen on CXR?

A 
Common:
- Lung cancer
- Asthma
- Foreign body
CXR:
- Tracheal deviation and mediastinal shift to side of collapse
- Elevated hemi-diaphragm
136
Q

What commonly causes lung metastases?

A 
Breast
Colorectal
Renal
Bladder
Prostate
137
Q

How do renal cell cancers that metastasise to the lungs present?

A

Cannonball metastases

Can also occur secondary to choriocarcinoma and prostate cancer

138
Q

Which lung metastases may show calcification?

A

Chondrosarcoma

Osteosarcoma

139
Q

What can cause mediastinal widening?

A 
Vascular problems - thoracic aorta aneurysm
Lymphoma
Retrosternal goitre
Teratoma
Tumour of thymus
140
Q

What are the signs of pulmonary oedema on chest xray?

A 
Interstitial oedema
Batwing appearance
Kerly B lines
Cardiomegaly
Pleural effusions
141
Q

Give some causes of clubbing

A 
Cardiac:
- Cyanotic congenital heart defects
- Bacterial endocarditis
- Atrial myxoma
Respiratory:
- Lung cancer
- Pyogenic lesions - CF, bronchiectasis, empyema, abscess
- TB
- Asbestosis/mesothelioma
- Fibrosing alveolitis

Others - graves, Crohn’s, cirrhosis

142
Q

What happens in coal workers pneumoconiosis?

A

Coal dust inhaled and enter terminal bronchi. Enguled by alveolar and interstitial macrophages. Normally removed by mucocilliary escalators.

In chronic exposure, system overwhelmed and start to accumulate in alveoli and cause inflammatory damage

143
Q

How does coal workers pneumoconiosis present?

A

Simple - asymptomatic, increased risk of COPD

Progressive massive fibrosis:

  • round fibrotic masses in upper zones
  • mixed obstructive/restrictive picture
  • breathlessness on exertion
  • cough - productive (black)
144
Q

How is coal workers pneumoconiosis managed?

A

Avoid coal dust and other irritates (smoking)
Manage chronic bronchitis
May be eligible for compensation under industrial injuries act

145
Q

What is Churg-Strauss syndrome?

A

Eosinophilic granulomatosis and polyangitis

ANCA associated small-medium vessel vasculitis

146
Q

What are the features of Churg-Strauss syndrome?

A 
Asthma
Blood eosinophilia - >10%
Paranasal sinusitis
Mononeuritis multiplex
pANCA positive - 60%
147
Q

How does Churg-Strauss syndrome vary with Wegeners granulomatosis?

A

CS is eosinophilic and associated with pANCA

W is associated with cANCA, renal failure and epistaxis
Wegeners associated with glomerulonephritis, saddle shape nose deformity

148
Q

What are the features of wegeners granulomatosis?

A 
Upper RT - epistaxis, sinusitis
Lower RT - dysnpnoea, haemoptysis
Rapidly progressive glomerulonephritis
Saddle nose deformity
Vasculitic rash, eye involvement, CN lesions
149
Q

How would you investigate wegeners granulomatosis?

A

cANCA - >90%
CXR - multiple presentations - caveatting lung lesions
Renal biopsy - epithelial crescents on bowman’s capsule

150
Q

How is wegeners granulomatosis managed?

A

Steroids
Cyclophosphamide (90% response)
Plasma exchange

Survival 8-9 years

151
Q

What is kartageners syndrome?

A

Dextrocardia
Recurrent sinusitis
Bronchiectasis
Subfertility - sperm dysmotility

152
Q

What are the features of klebsiella pneumonia?

A

Red currant jelly sputum
Common in alcoholics and diabetics
May occur after aspiration
Upper lobes

Commonly causes lung abscess and empyema

153
Q

What shifts the oxygen dissociation curve to the right?

A

Acidosis
High temperature
Raised 2,3-DPG

154
Q

What can salicylate poisoning cause?

A

Mixed metabolic acidosis and respiratory alkalosis

Early stimulation of resp. centre –> resp alkalosis

Later the effects of salicylate + renal failure –> metabolic acidosis

155
Q

What is the centor criteria?

A

Tonsillar exudate
Fever >38
No cough
Tender cervical lymphadenopathy

156
Q

How long do respiratory tract infections tend to last?

A 
Otitis media - 4 days
Sore throat/tonsilitis/pharyngitis - 7 days
Common cold - 1.5 weeks
Rhinosinusitis - 2.5 weeks
Cough/bronchitis - 3 weeks
157
Q

What are some respiratory manifestations of rheumatoid arthritis?

A 
Pulmonary fibrosis
Pleural effusion
Pulmonary nodules
Bronchiolitis obliterans
Complications of drug therapy
Pleurisy
Caplan's syndrome - fibrotic lung nodules
Infection secondary to immunosuppression
158
Q

How is smoking cessation managed?

A

Offer nicotine replacement therapy, varenicline or bupropion

Have a target stop date

Max 2 weeks after stop date

Don’t offer again within 6 months if fails

159
Q

How is nicotine replacement therapy given in those with high level of dependence?

A

Offer NRT patch and one other form of nicotine (gum, inhalator, lozenge, nasal spray)

160
Q

What can be offered for smoking cessation in pregnancy?

A

Only nicotine replacement therapy

Varenicline and Bupropion contraindicated

161
Q

Which conditions can increase transfer factor?

A 
Asthma
Pulmonary haemorrhage
Left and right cardiac shunts
Polycythaemia
Hyperkinetic states
Male
Exercise
162
Q

Which conditions reduce transfer factor?

A 
Pulmonary fibrosis
Pneumonia
PE
Pulmonary oedema
Emphysema
Anaemia
Low cardiac output
163
Q

When in COPD is BiPAP indicated?

A

Respiratory acidosis with low pO2

Finals (16 decks)

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