Respiratory Flashcards
clear and colourless sputum?
chronic bronchitis
yellow green sputum?
pneumonia
COPD exacerbation
frothy white/pink sputum?
pulmonary oedema
tidal volume
volume of air breathed in and out in a normal quiet breath
~500ml
inspiratory reserve volume
extra volume that can be inspired over and above the tidal volume
expiratory reserve volume
extra volume that can be expired over and below the tidal volume
residual volume
volume of air remaining in lungs after a maximal expiration
(forced) vital capacity
volume of air that can be exhaled after a maximal inspiration
TV + IRV + ERV
inspiratory capacity
TV + IRV
functional residual capacity
volume remaining in lungs after a quiet expiration
total lung capacity
total volume of air the lungs can hold
ie sum of all volumes
https://teachmephysiology.com/respiratory-system/ventilation/lung-volumes/
lung volumes
what is a normal FEV1/FVC ratio
~80%
what happens to the FEV1/FVC ratio in obstructive disease
FEV1 is reduced but FVC is normal so the ratio is <70%
what happens to the FEV1/FVC ratio in restrictive disease
FEV1 and FVC are both reduced but the ratio is >70%
what is the normal O2 sat target range for most people
94-98%
what is the normal O2 sat target for people with COPD
88-92%
describe type 1 resp failure
hypoxia
normal CO2
describe type 2 resp failure
hypoxia
hypercapnia
TLC and RV are increased/decreased in obstructive lung disease
increased in obstructive lung disease
decreased in restrictive lung disease
indications for bronchoalveolar lavage (BAL)
malignancy
pneumonia in immunosuppressed
TB
ILD
OSA can cause hyper/hypotension
hypertension
what is pneumonia
acute lower respiratory tract infection
what is community acquired pneumonia CAP and what are common causes
acquired in the community
most common cause - strep pneumoniae
HiB
mycoplasma
what are less common causes of CAP
staph legionella moraxella chlamydia coxiella anaerobes viral
what is hospital acquired penumonia HAP
pneumonia >48hr after hospital admission
what bugs cause HAP
gram negative enterobacteria staph pseudomonas klebsiella bacteroides clostridium
what is aspiration pneumonia
aspiration of gastric contents which enters the resp tract causing infection
RF for aspiration pneumonia
stroke myasthenia gravis bulbar palsies low GCS oesophageal disease
what bugs can cause pneumonia in immunocompromised people
PJP
fungi
viral
what bug is most likely to be the cause of pneumonia in a HIV patient and what is the treatment
PJP
co-trimoxazole
what bug is most likely to be the cause of pneumonia in PWID and what is the treatment
Staph A
flucloxacillin
(causes a bilateral cavitating bronchopneumonia)
what bug is most likely to be the cause of pneumonia in homeless/alcoholic/returned traveller/from asia and what is the treatment
TB
2 RIPE 4 RI antibiotics
what bug is most likely to be the cause of pneumonia in homeless/alcoholic/DM and what is the treatment
Klebsiella
cefotaxime / imipenem
causes a cavitating pneumonia
what bug is most likely to be the cause of pneumonia in bronchiectasis/CF/frequently hospitalised and what is the treatment
pseudomonas ticarcillin ciprofloxacin + gentamicin ceftazidine meropenem
what bug is most likely to be the cause of pneumonia in returned travellers (from spain) and what is the treatment
legionella
levofloxacin
clarithromycin
what bug is most likely to be the cause of pneumonia in someone with pet bird/parrot and what is the treatment
chlamydophila psittaci
tetracyclines
what bug is most likely to be the cause of pneumonia in children and young adults and what is the treatment
mycoplasma pneumoniae
macrolides / tetracyclines / fluoroquinolone
‘walking wounded’
what bug is most likely to be the cause of pneumonia in farmers
coxiella burnetti
symptoms and signs of pneumonia
fever cough malaise SOB purulent sputum pleuritic chest pain haemoptysis cyanosis confusion (delirium) tachycardia bronchial breathing signs of consolidation
potential investigations for pneumonia
ABCDE O2 if hypoxic IV access for FBC, U+E, LFT, CRP, blood cultures, amylase, troponins ECG erect CXR sputum culture CURB 65
tests for legionella pneumonia
sputum culture
urinary antigen / culture
what is the CURB 65 score
list its components
used to assess severity of pneumonia, one point for each of the following: Confusion Urea >7 RR >30 BP S <90 or D <60 65yr or older
approach to pneumonia depending on CURB 65 score
0-1: at home
2: hospital
>=3: severe, hospital admission and IV treatment
management of pneumonia in hospital
PO/IV antibiotics IV fluids antiemetics analgesia oxygen if hypoxic CXR (and follow up at 6 weeks)
complications of pneumonia
sepsis pleural effusion empyema lung abscess resp failure - type 1 hypotension AF
who is eligible for the pneumococcal vaccine
elderly immunocompromised - chemo, HIV, steroids chronic heart/liver/renal/lung disease COPD asthma hyposplenism DM
what antibiotics should those with a CURB65 score of 0-2 for CAP receive
amoxicillin PO 5 days
allergic: doxycycline or clarithromycin
what antibiotics should those with a CURB65 score of 3-5 for CAP receive
IV co-amoxiclav + doxycycline
allergic: levofloxacin
what antibiotics should those with non-severe HAP receive
PO amoxicillin 5 days
allergic: doxycycline
what antibiotics should those with severe HAP receive
IV amoxicillin and gentamicin
allergic: IV co-trimoxazole + gentamicin
what antibiotics should those with non-severe aspiration pneumonia receive
PO amoxicillin + metronidazole
allergic: doxycycline + metronidazole
what antibiotics should those with severe aspiration pneumonia receive
IV amoxicillin + metronidazole + gentamicin
allergic: replace amox with doxycycline/clarithromycin
when do you give antibiotics for COPD exacerbations
increased purulent sputum and symptomatic
antibiotics for COPD exacerbation
amoxicillin
allergic: doxycycline
what is the most common type of pneumonia
pneumococcal pneumonia (strep pneumoniae)
diagnosis of mycoplasma pneumoniae
PCR sputum or serology
complications of mycoplasma pneumoniae
erythema multiforme
SJS
meningoencephalitis
GBS
features of legionnaire’s disease
dry cough SOB water tank coloniser flu like symptoms bi basal consolidation deranged LFTs abdominal pain hyponatraemia
commonest viral cause of pneumonia
influenza
features of PJP pneumonia
SOB
dry cough
insidious onset
exertional dyspnoea
features of COVID-19 virus
SOB cough ansomia loss of taste fatigue
what is SARS
severe acute respiratory syndrome
caused by SARS-CoV virus
features of empyema on aspiration
bright yellow
pH <7.2
low glucose and high LDH
flucloxacillin and co-amoxiclav can cause jaundice, true or false
true
what is bronchiectasis
persistent abnormal dilatation of the airways
features of bronchiectasis
recurrent infections with: HiB, strep pneumoniae, staph a, pseudomonas copious purulent sputum haemoptysis finger clubbing wheeze
causes of bronchiectasis
idiopathic CF Primary ciliary dyskinesia post infection ABPA RA UC
in bronchiectasis, spirometry shows an obstructive/restrictive pattern
obstructive
what is cystic fibrosis
AR condition causing a mutation in the CFTR gene on chromosome 7 leading to defective chloride secretion and increased Na absorption across airway epithelium
changes in airway surface liquid predispose to recurrent chronic infections and bronchietasis
features of CF
meconium ileus failure to thrive cough wheeze nasal polyps recurrent infections resp failure haemoptysis pancreatic insufficiency - DM, failure to absorb fat gallstones male infertility osteoporosis sinusitis finger clubbing
how can aspergillus affect the lungs
- asthma - type 1 hypersensitivity to fungal spores
- allergic bronchpulmonary aspergillosis - type 1 + 3 hypersensitivity
- aspergilloma
- invasive aspergillosis
- extrinsic allergic alveolitis
RF for lung cancer
smoking
age
asbestos
radiation
what are the different types of lung cancer
Small cell (SCLC) Non-small cell (NSCLC) - squamous - adenocarcinoma - large cell
symptoms of lung cancer
chronic cough >3months SOB chest pain haemoptysis lethargy, malaise, fatigue weight loss hoarse voice (RLN palsy)
signs of lung cancer
cachectic anaemia finger clubbing paraneoplastic syndromes lymphadenopathy
small cell lung cancer is a neuroendocrine type tumour?
yes
paraneoplastic syndromes associated with SCLC
SIADH: hyponatraemia
^ACTH secretion: Cushing’s syndrome
LEMS: antiCa channel Ab
paraneoplastic syndromes associated with squamous cell lung cancer
PTHrp
paraneoplastic syndromes associated with adenocarcinoma
HPOA
hypertrophic pulmonary osteoarthropathy
pathophysiology behind squamous cell lung cancer
smoking results in metaplasia of columnar glandular lung tissue to stratified squamous cells (protective) which then becomes cancerous
complications of lung cancer
recurrent laryngeal nerve palsy - from compression of nerve hooking around hilum/aorta phrenic nerve palsy SVC obstruction Horner's syndrome rib erosion AF metastases: brain, bone, liver, lungs
what is a Pancoast tumour and what is a potential complication
apical lung cancer
Horner’s syndrome from compression of the sympathetic nerves
what is Horner’s syndrome
ptosis - partial
miosis - pupil constriction
anhydrosis - ipsilateral
adenocarcinomas are more likely to be found centrally/peripherally
peripherally
management of the following lung cancers:
SCLC
NSCLC
SCLC - chemotherapy
NSCLC - excision for peripheral tumours, radiotherapy, chemotherapy
small cell lung cancer is more likely to metastasise fast/slow
fast
more likely to have disseminated disease early on
what lung diseases can asbestos cause
pleural plaques
mesothelioma
D.Dx of a lung nodule in a CXR
malignancy abscess granuloma carcinoid tumour cyst hamartoma
symptoms of asthma
SOB dry cough nocturnal/early morning symptoms wheeze atopy tight chest triggers: cold weather, exercise, NSAIDs, allergens
stepwise approach to asthma therapy
- inhaled SABA - salbutamol
- ICS
- inhaled LABA
- increase dose of ICS
- consider leukotriene antagonist
management for exercise induced asthma
leukotriene receptor antagonist
LABA
sodium cromoglicate
theophyllines
when would you consider stepping up treatment wise in asthma
if using SABA >3 times a week
asthma shows a restrictive/obstructive pattern on spirometry
obstructive
management of acute asthma
ABCDE PEFR to determine severity O2 if hypoxic nebulised SABA steroid: PO pred / IV hydrocortisone nebulised ipratropium bromide IV magnesium sulphate IV aminophylline
symptoms of COPD
exertional dyspnoea
chronic cough (productive)
wheeze
exacerbations
what red flags must you ask about in COPD
unintentional weight loss chest pain peripheral oedema fatigue occupational hazards haemoptysis
investigations for COPD
spirometry
CXR
FBC
BMI
what comprises COPD
emphysema and chronic bronchitis
management of COPD
lifestyle modifications: smoking cessation, exercise, pulmonary rehab, vaccination SABA/SAMA ICS LAMA/LABA - non-asthmatic features ICS/LABA - asthmatic features ICS/LABA/LAMA PO steroids PO theophylline
antibiotic of choice for prophylaxis in COPD
azithromycin
indications for long term O2 therapy in COPD
FEV1<30% cyanosis polycythaemia peripheral oedema raised JVP SaO2 <92% MUST NOT BE A SMOKER
what is a cardiac complication of COPD
cor pulmonale
right heart failure secondary to lung disease
what is acute respiratory distress syndrome ARDS
acute lung injury which may be caused by direct lung injury or secondary to systemic disease
lung damage and release of inflammatory mediators results in a non-cardiogenic pulmonary oedema often accompanied by multi-organ failure
causes of ARDS
pneumonia vasculitis contusion shock sepsis DIC pancreatitis acute liver failure eclampsia drugs
what is respiratory failure
inadequate gas exchange results in hypoxia
what is type 1 resp failure
hypoxia only
what is type 2 resp failure
hypoxia and hypercapnia
T1RF is mainly caused by?
VQ mismatch e.g. pneumonia pulmonary oedema PE asthma emphysema pulmonary fibrosis ARDS
T2RF is mainly caused by?
alveolar hypoventilation e.g.
pulmonary disease: asthma, COPD, OSA, pneumonia
reduced resp drive: opiates, CNS tumour, trauma
neuromuscular disease
thoracic wall disease
clinical features of hypoxia
SOB restlessness agitation confusion cyanosis
clinical features of hypercapnia
headache peripheral vasodilatation tachycardia bounding pulse tremor / flap papilloedema confusion
what is a pulmonary embolus (PE) and list its causes
clot that has broken off and lodged in the pulmonary circulation can arise from: DVT - most common right ventricular thrombus septic emboli fat air amniotic fluid tumour
RF for PE/DVT
immobility recent surgery pregnancy contraception long haul flight cancer thrombophilia previous PE
clinical features of PE
swollen hot leg SOB chest pain haemoptysis dizziness tachycardia tachypnoea hypotension hypoxia
investigations for PE
FBC, U+E, LFT, CRP, d dimer, coagulation screen ABG ECG CXR leg USS CTPA / VQ scan ECHO
d dimer is a good test for DVT/PE?
no
it is sensitive but not specific ie if it is raised it does not confirm PE but if it is low it can exclude
What is the Wells score
scoring system to estimate the probability of a PE
a Wells score of ? is likely to be a PE
what is the management
> 4
arrange hospital admission for CTPA
a Wells score of ? is not likely to be a PE
what is the management
<=4
arrange a d dimer with results available within 4 hours
ECG patterns in PE
tachycardia
S1Q3T3
RBBB
treatment of PE in hospital
- DOAC
2. thrombolysis (alteplase) for a massive PE and patient is haemodynamically unstable
what is a pneumothorax
air in the pleural space
RF for pneumothorax
tall thin men CTD - Marfan's, Ehler-Danlos smokers asthma COPD trauma iatrogenic - chest drain
clinical features of pneumothorax
acute SOB
pleuritic chest pain
reduced breath sounds
hyperresonant percussion
what makes a tension pneumothorax different from a pneumothorax
tracheal deviation
mediastinal shift
with a tension pneumothorax, the trachea will be deviated away/towards the affected side
AWAY!!!
management of a spontaneous pneumothorax >2cm
chest aspiration with cannula
if not improving or is a secondary pthx, insert a chest drain and admit
small vs large pneumothorax?
small <2cm
large >2cm
management of a tension pneumothorax
immediate call for help
needle decompression in 2nd ICS mid clavicular line on affected side
then a chest drain
what is a pleural effusion
fluid in the pleural space
pleural effusions can be transudate or exudate, what does this mean
transudate: <30g protein
organ failure, fluid overload, hypoproteinaemia, hypothyroidism, Meig’s syndrome
exudate: >30g protein
infection, cancer, inflammation
what is a:
haemothorax
empyema
chylothorax
blood in the pleural space
pus in the pleural space
chyle in the pleural space
clinical features of pleural effusion
asymptomatic
pleuritic chest pain
stony dull to percuss
reduced breath sounds
large effusions can cause the trachea to deviate away/towards the affected side on CXR
away from affected side
CXR feature of pleural effusion
blunting of costophrenic angle
management of pleural effusion
chest drain / aspiration
what is sarcoidosis
a multisystem non-caseating granulomatous disorder of unknown origin
clinical features of sarcoidosis
asymptomatic SOB cough erythema nodosum arthralgia bihilar lymphadenopathy hepatomegaly hypercalcaemia high serum ACE
management of sarcoidosis
BHL alone - nothing
acute - bed rest, NSAIDs
Steroids: symptomatic, eye disease, ^Ca, neuro/cardiac involvement
D.Dx for bihilar lymphadenopathy BHL
Cancer
sarcoidosis
infection - TB, mycoplasma
EAA
what is ILD
interstitial lung disease is a generic term to describe diffuse lung disease / fibrosis / inflammation
clinical features of ILD
SOB
cough non productive
abnormal breath sounds
ILD is restrictive/obstructive
restrictive
classification of ILD
known cause
associated with systemic disease
idiopathic
known causes of ILD
occupational e.g. asbestosis, silicosis drugs e.g. nitrofurantoin, bleomycin, amiodarone, sulfasalazine hypersenstivity e.g. EAA infection GORD
systemic diseases causing ILD
RA sarcoidosis SLE SS MCTD Sjogrens UC
idiopathic causes of ILD
idiopathic pulmonary fibrosis
What is Caplan’s syndrome
associated with RA, pneumoconiosis, and pulmonary rheumatoid nodules
what is OSA
obstructive sleep apnoea is characterised by intermittent closure of pharyngeal airway causing episodes of apnoea during sleep
RF for OSA
Male
obesity
macroglossia
Downs syndrome
clinical features of OSA
daytime somnolence loud snoring poor sleep quality morning headache decreased cognitive performance HTN change in personality
complications of OSA
pulmonary HTN
type 2 resp failure
HTN
Scoring system for OSA
Epworth sleepiness scale
management of OSA
weight loss
avoid smoking and alcohol
CPAP at night
what is cor pulmonale
right heart failure caused by chronic arterial pulmonary hypertension
ABCDE of heart failure on CXR
A - Alveolar oedema (Batwing opacities) B - kerley B lines (interstitial oedema) C - Cardiomegaly D - Dilated prominent upper lobe vessels E - pleural Effusions
what is the TLCO test
Transfer factor for CO
assesses gas transfer of oxygen from lungs into blood
idiopathic pulmonary fibrosis will have a low/high FEV1/FVC ratio and a low/high TLCO
high ratio
low TLCO
what does a reduced TLCO mean?
reduced ability of the lungs to perform gas exchange
what test is widely used for latent TB
Mantoux / tuberculin skin test
if you have had the BCG vaccine, can you have a reaction to the Mantoux test?
yes, you may have a mild reaction
this does not necessarily mean you have TB
what is IGRA
blood test for TB used following a positive Mantoux test
causes of haemoptysis
lung cancer / metastases lung abscess PE bronchiectasis / CF vasculitides: GPA, EGPA, Goodpasture's trauma AVM post surgery
pulmonary causes of breathlessness
airway obstruction - tumour, infection, foreign body, asthma, COPD, bronchiectasis, cancer
parenchyma - fibrosis, sarcoid, TB, tumour, pneumonia
circulation - PE, vasculitis, pul HTN
pleural - effusion, pneumothorax
chest wall - scoliosis, kyphosis
neuromuscular - MG, GBS, MND
non-pulmonary causes of breathlessness
anaemia obesity pregnancy metabolic acidosis (DKA) left HF psychogenic
