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Clinical Practice > Respiratory > Flashcards

Respiratory Flashcards

1
Q

what are the features of a tension pneumothorax?

A

absent breath sounds
increased JVP
hypotension

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2
Q

define COPD

A

progressive, persistent airflow limitation
associated with a chronic inflammatory response in the airways
not fully reversible

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3
Q

what is the treatment of COPD?

A 
smoking cessation
bronchodilators (SABA, LABA, inhaled steroid)
SAMA, LAMA, LRA (montelukast)
inflammation inhibitors
pulmonary rehab and oxygen therapy
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4
Q

what are the causes of COPD?

A 
smoking
airborne pollutants
alpha 1 antitrypsin deficiency
asthma
low birthweight
respiratory infections
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5
Q

describe emphysema

A

tissue fibrosis and smooth muscle hypertrophy
destruction and distention of alveolar walls
increased elastase activity
reduced alveolar surface area
impaired gas exchange
hypoxemia and hyperventilation -> hypoventilation and hypercapnia

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6
Q

describe bronchitis

A

cough and sputum production for at least 3 months in each of 2 consecutive years
inflammation and mucous hypersecretion
impaired ciliary function
thickening and narrowing of bronchial walls
alveolar macrophage function diminishes

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7
Q

describe the MOA of a SABA

A

relaxes smooth muscle in the bronchi leading to bronchodilation
binds to B2 adrenergic receptors

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8
Q

describe the MOA of a SAMA

A

inhibits ACh at muscarinic receptors on airway smooth muscle

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9
Q

define asthma

A

a common chronic disorder of the airways

airflow obstruction, bronchial hyper responsiveness, underlying inflammation

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10
Q

describe the pathophysiology of asthma

A

inhaled allergens are ingested by APCs
APCs present the allergens to TH0 cells
these transform into TH2 cells
TH2 cells activate the humeral immune system and produce antibodies
= inflammation, thickened airways, scarring, increased mucous production, more bronchospasm, oedema from microvascular leakage

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11
Q

define interstitial lung disease

A

heterogeneous group of diseases which affect the lung parenchyma
involving chronic inflammation of the lungs
leading to scarring and fibrosis

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12
Q

define idiopathic pulmonary fibrosis

A

interstitial lung disease for which no cause can be identified

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13
Q

what are the causes of ILD?

A 
idiopathic
occupational dusts
methotrexate
amiodarone
sulfasalazine
nitrofurantoin
hypersensitivity pneumonitis
smoking
COVID
sarcoid
RA
SLE
systemic sclerosis
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14
Q

what are the causes of basal lung fibrosis?

A 
radiation
RA
autoimmune
asbestosis
idiopathic 
drugs (amiodarone, methotrexate, nitrofurantoin, illicit drugs)
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15
Q

what are the causes of apical lung fibrosis?

A 
berylliosis
radiation
extrinsic allergic alveolitis
ankylosing spondylitis
sarcoidosis
TB
silicosis
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16
Q

what are the signs of pulmonary fibrosis?

A 
restrictive FEV1/FVC
finger clubbing
progressive cough and dyspnoea
bibasal fine crepitations
restrictive PFTs with low transfer factor
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17
Q

what is the treatment of pulmonary fibrosis?

A

ABx if infective exacerbation
exercise, weight loss, pulmonary rehab, smoking cessation
steroids
anti-fibrotic agents if FVC 50-80%
transplant
symptom management with palliative care input
long-term oxygen therapy

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18
Q

describe hypersensitivity pneumonitis

A

symptoms start 4-6 hours after allergen exposure
birds, farmers, mushrooms, malt, sugar cane
fever, rigors, myalgia, weight loss, dyspnoea
remove allergen, oral prednisolone, PPE, O2 therapy

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19
Q

describe sarcoidosis

A

multi-system granulomatous disease of unknown aetiology
erythema nodosum, CCF, uveitis, hepatosplenomegaly, dysrhythmias, arthralgia, polyneuropathy
60% recover spontaneously, steroids

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20
Q

what are the symptoms of lung cancer?

A 
cough
haemoptysis
dyspnoea
chest pain
weight loss
bone pain, hypercalcaemia
vomiting
headache
visual disturbances
hemiparesis
cranial nerve deficit
seizures
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21
Q

describe some specific presentations of lung cancer

A

SVCO (fullness in head, distended neck veins, plethoric faces)
pan coast tumour (shoulder pain, atrophy of small hand muscles, Horner’s syndrome)
paraneoplastic phenomena
hypercalcaemia
hyponatraemia (SIADH)
Cushing’s syndrome
Lambert-Eaton syndrome

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22
Q

describe NSCLC

A

80%

includes squamous cell carcinoma, adenocarcinoma, lepidic adenocarcinoma

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23
Q

describe SCLC

A

15%
more aggressive
usually metastasised at time of presentation

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24
Q

define limited disease in SCLC

A

confined to the ipsilateral hemithorax

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25
Q

define extensive disease in NSCLC

A

tumour beyond the barriers of limited disease including malignant pericardial or pleural effusions

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26
Q

what is the treatment of limited SCLC?

A

combined chemoradiotherapy
chemotherapy
prophylactic cranial radiotherapy if no progression

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27
Q

what is the treatment of extensive SCLC?

A

combination chemoradiotherapy
thoracic radiotherapy
prophylactic cranial radiotherapy

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28
Q

what is the treatment of NSCLC?

A

surgery for small, localised tumours with little/no lymph node involvement
radiotherapy (SABR/SBRT)
radio frequency ablation
chemotherapy (locally advanced malignancy)
non-radical/palliative
SACT/combination chemotherapy
TKIs for EGFR and ALK mutations
immune checkpoint inhibitors for PDL1 expression

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29
Q

define pneumonia

A

syndrome/condition, usually caused by infection, resulting in an inflammatory response within the lung parenchyma

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30
Q

what are the causes of pneumonia?

A

streptococcus pneumonia
haemophilus influenza
moraxella catarrhalis
staphylococcus aureus

legionella
mycoplasma
chlamydophila pneumoniae
chlamydophila psittaci

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31
Q

what are the symptoms and signs of pneumonia?

A 
fever
cough
sputum
dyspnoea
pleuritic chest pain
headaches
muscle aches
anorexia
tachypnoea
tachycardia
hypotension
coarse crepitations
reduced air entry
bronchial breathing
reduced chest expansion
reduced percussion note
increased vocal resonance
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32
Q

what is the treatment of pneumonia?

A

ABx within 4 hours of attending hospital

amoxicillin -/+ clarithromycin -> co-amoxiclav + clarithromycin

doxycycline -> levofloxacin + clarithromycin

O2
fluids
analgesia
nutrition
physiotherapy
VTE prophylaxis
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33
Q

how should a patient with pneumonia be followed-up?

A

CXR after 6 weeks with persisting symptoms/signs and in those at high risk of underlying lung malignancy

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34
Q

define HAP

A

new radiographic infiltrate with evidence of infection at least 48hr after hospital admission or 2 weeks after discharge
mostly caused by aspiration

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35
Q

what are the risk factors for developing HAP?

A 
>70 yrs
chronic lung disease
reduced consciousness
chest/abdominal surgery
mechanical ventilation
NG feeding
previous antibiotic exposure
poor dental hygiene
steroids and cytotoxic drugs
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36
Q

who gets pneumothoraces?

A

tall, thin, young males
older patients with underlying lung disease
patients who have had trauma

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37
Q

describe primary pneumothoraces

A

spontaneous with no underlying lung disease

associated with Marfan’s syndrome

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38
Q

what are the causes of secondary pneumothoraces?

A 
COPD
asthma
cystic fibrosis
pneumocystis pneumonia
catamenial pneumothorax
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39
Q

what are the symptoms and signs of a pneumothorax?

A 
sudden, ipsilateral, pleuritic type chest pain
dyspnoea
Hx of pneumothorax
reduced breath sounds
hyper resonant
decreased vocal fremitis
tachycardia
hypoxia
subcutaneous emphysema
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40
Q

what are the symptoms and signs of a tension pneumothorax?

A

tachycardia
hypotension
deviated trachea and apex beat (away)

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41
Q

what is the treatment of a tension pneumothorax?

A

large bore cannula inserted into 2nd intercostal space, midclavicular line
then require a chest drain

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42
Q

what is the treatment of a primary pneumothorax?

A

<2cm high flow O2, discharge and review in 2-4 weeks

>2cm/dyspnoea aspirate with cannula

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43
Q

what is the treatment of a secondary pneumothorax?

A

> 2cm/dyspnoea chest drain

1-2cm aspirate with cannula

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44
Q

define a PE

A

obstruction in a pulmonary artery or one of its branches by material that originates somewhere else in the body
thrombus, fat, amniotic fluid, air

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45
Q

what are the risk factors for developing a VT?

A 
post-surgical
obstetrics
lower limb affections (fractures)
malignancy
Hx of VT
HF
HTN
neurological impairment
nephrotic syndrome
chronic dialysis
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46
Q

what are the symptoms or signs of a PE?

A 
haemoptysis
dyspnoea
chest pain
swollen (unilateral) painful limb
cough
exertion dyspnoea
pre/syncope
impending sense of doom
sweating
obstructive shock
SBP <90mmHg for >15 mins (massive embolism)
tachycardia
hypotension
hypoxic
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47
Q

what is the criteria of the Wells score?

A 
recent immobilisation
PE 1st diagnosis
signs and symptoms of DVT
tachycardia (>100)
Hx PE or DVT
haemoptysis
malignancy
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48
Q

what investigation results indicate PE?

A 
tachycardia
T wave inversion inferior and anterior leads
incomplete RBBB
D-dimer positive
BNP (indicating RSHF)
troponin (cardiomyocyte damage)
pulmonary artery dilation
Westermark sign
CTPA (gold standard)
V/Q perfusion imaging
US lower limb (non-compressible)
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49
Q

what is the treatment of a massive PE?

A

thrombolysis (alteplase 10mg bolus and 90mg over 2hr)

50
Q

what is the treatment of a submissive PE?

A

oral/sc anticoagulation

dosing depends on weight and renal function

51
Q

what are the causes of pleuritic chest pain?

A 
pneumonia
pneumothorax
PE
pericarditis
lung cancers
trauma
autoimmune conditions
52
Q

what are the causes of non-pleuritic chest pain?

A 
cardiac
MSK
oesophageal spasm/rupture
aortic dissection
costochondritis
gastritis
pancreatitis
anxiety
53
Q

describe a respiratory chest pain

A 
sharp
shooting
worse on inspiration
shoulder pain (referred from diaphragm)
located laterally or posteriorly
54
Q

describe a cardia chest pain

A 
dull
pressure
centre of chest
radiates to arm, neck, jaw
not affected by movement
associated with nausea, sweating, dyspnoea
55
Q

what are the causes of a PE?

A 
venous thrombosis in pelvis or legs
RV thrombus (post MI)
septic emboli (right sided endocarditis)
fat
air
amniotic fluid
neoplastic cells
parasites
56
Q

what are the risk factors for developing a PE?

A 
recent surgery
leg fracture
thombophilia (antiphosphoplipid syndrome)
pregnancy, postpardum
OCP
prolonged bed rest, reduced motility
previous PE
57
Q

what are the components of virchows triad?

A

hypercoaguability
venous stasis
endothelial injury

58
Q

what are the symptoms and signs of a PE?

A 
presyncope, syncope
dyspnoea
pleuritic chest pain
haemoptysis
pyrexia
cyanosis
tachyopnoea
tachycardia
signs of DVT
hypotension
raised JVP
pleural rub
pleural effusion
59
Q

describe a PE on a CXR

A 
normal
oligaemia of affected segment
dilated pulmonary artery
linear atelectasis
small pleural effusion
wedge-shaped opacities
60
Q

what are the components of the well’s score

A 
PE is the most likely diagnosis
clinical signs/symptoms of DVT
tachycardia
immbolisation in the last 4 weeks
prior DVT/PE
haemoptysis
active malignancy (treatment within 6 months)
61
Q

what investigations are required to diagnose a PE?

A

CTPA

V/Q scan when contraindicated (pregnancy)

62
Q

what is the treatment of a PE?

A 
oxygen resuscitation
supportive therapy
anticoagulation
thrombolysis
embolectomy
percutaneous catheter
inferior vena cava filters
63
Q

describe acute anticoagulation therapy in a PE

A

LWMH therapeutic dose
warfarin
DOAC

64
Q

what are the consequences of thrombolysis in a PE?

A

rapidly restores pulmonary perfusion
rapid recovery in cardiac function (less train placed on the right ventricle)
large bleeding risk alongside anticoagulation

65
Q

what are the prevention methods used against PE for inpatients?

A 
prophylactic LMWH
compression stockings
early mobilisation
stop OCP, HRT
investigate for thrombophilia with FHx of thromboembolism
66
Q

what are the symptoms and signs of pneumonia?

A 
cough
dyspnoea
sputum production (purulent)
fever
pleuritic chest pain
tachypnoea
low oxygen saturations
tachycardia
reduced expansion
dull percussion note
focal coarse crackles
increased vocal resonance
bronchial breathing
pleural rub
67
Q

what are the risk factors for developing pneumonia?

A 
contact with infected people
poor nutrition
underlying lung disease
immunosuppression
age >65
smoking
co-morbidities
exposure to children (strept pneumoniae carriers)
aspiration risk
recent viral illness (pneumococcus vector)
excess alcohol
inpatient stay
68
Q

what is seen on a CXR with pneumonia?

A

lobar is usually bacterial

diffuse is usually viral

69
Q

what organisms cause pneumonia?

A 
legionella pneumophila (hyponatraemic or GI upset)
mycoplasma pneumoniae
chlamydophila pneumoniae
70
Q

what investigations are required to diagnose pneumonia?

A

CT chest, exclude abscess, empyema, malignancy

bronchopscopy, lavage, obtain sample and remove secretions

71
Q

what are the components of the CURB65 score?

A 
new onset confusion
urea >7mmol/L
respiratory rate >30
SBP <90mmHg or DBP <60mmHg
age >65
72
Q

what is the treatment of pneumonia?

A 
use local antibiotic guidelines
penicillin or cephalosporin and macrolide
oxygen
IV fluids
nutritional support
physiotherapy
follow up CXR
smoking cessation team
respiratory clinic follow up
vaccine prevention given to high risk groups (influenza and pneumococcal)
73
Q

define IHD

A

inadequate supply of blod and oxygen to a portion of the myocardium mainly caused by atherosclerosis

74
Q

what are the risk factors for IHD?

A 
hypercholesterolaemia (LDL)
HTN
smoking
obesity
diabetes
FHx
physical inactivity
male
asian race
low weight at 1yr
low social class
stress
reduced HDL cholesterol
75
Q

what diseases are associated with smoking?

A 
coronary artery disease
malignant HTN
ischaemic stroke
sudden death
peripheral vascular disease
aortic aneursym
thromboembolism
76
Q

describe anginal pain

A

provoked by physical exertion, after meals, anger and excitement
relieved by GTN spray and rest

77
Q

what are the signs of coronary ischaemia on ECG?

A

T wave inversion

hyperacute T waves

78
Q

what are the causes of troponin increase?

A 
cardiac damage
CKD
infection
hypotension
PE
AAA
IE
COPD
hypertensive crisis
GI bleeding
SAH
stroke
seizure
79
Q

what does ST depression mean?

A

sign of coronary insufficiency

significant if >1mm

80
Q

what is the management of ACS?

A 
oxygen
analgesia (morphine sulphate or diamorphine)
antiemetics (metoclopramide)
antithrombotic therapy
antianginal therapy
reperfusion therapy
81
Q

what is the treatment of NSTEMI?

A

aspirin 300mg initially then 75mg daily after
with
clopidogrel 300mg initially then 75mg daily after (less bleeding risk)
or
ticagrelor 180mg initially then 90mg BD (more effective)
and
enoxaparin 1mg/kg BD (provided not already on anticoagulant)

82
Q

what is the treatment of STEMI?

A 
PCI within 12 hours of symptom onset
antiplatelet
analgesia
thrombus aspiration (occasionally)
thrombolysis (used infrequently, streptokinase, alteplase)
83
Q

what are the complications of MI?

A 
pericarditis
conduction defects
ventricular thrombus and systemic embolism (week 1-3)
cardiac rupture (day 4-10)
VSD with septal rupture
Dressler’s syndrome
late VT/VF
left ventricular aneurysm
papillary muscle dysfunction and mitral regurgitation
84
Q

what is used in the secondary prevention of ACS?

A 
smoking cessation
regular exercise
diet control
statin
aim BP <140/85mmHg
ACEi
beta blocker
antiplatelet
85
Q

describe asthma

A

reversible airway obstruction

recurrent episodes of dyspnoea, (nocturnal) cough and wheeze

86
Q

what factors contribute to airway narrowing in asthma?

A

bronchial muscle contraction
mucosal swelling/inflammation
increased mucous production

87
Q

what are the precipitants of an asthma attack?

A 
cold air
exercise
emotion
allergens
infection
smoking
pollution
NSAIDs
beta blockers
88
Q

what are the signs of asthma?

A 
diurnal variation of >20% PF
obstructive defect in spirometry
>15% improvement in FEV1 with steroid or beta 2 agonist trial
hyperinflation
skin prick
FENO
aspergillus serology
89
Q

what is the treatment of acute asthma?

A

salbutamol 5mg nebulised with O2
hydrocortisone 100mg IV
or
prednisolone 40-50mg

ABG
aim for sats 94-98%

90
Q

what is the treatment of life-threatening asthma?

A

give salbutamol neb every 15 minutes
add ipratropium 0.5mg to neb
give single dose magnesium sulphate 1.2-2g IV / 20 minutes

inform ICU and seniors

91
Q

what is the treatment of acute/life threatening asthma that is improving?

A

neb salbutamol every 4 hours
prednisolone 40-50mg PO OD for 5-7 days
monitor peak flow
aim for sats 94-98%

92
Q

define chronic bronchitis

A

chronic cough with sputum production for >3 months in 2 successive years

93
Q

define emphysema

A

alveolar wall destruction leading to abnormal and permanent enlargement of airspaces distal to the terminal bronchioles

94
Q

what are the causes of COPD?

A

smoking
industrial dust exposure
alpha 1 antitrypsin deficiency

95
Q

what are the symptoms and signs of COPD?

A 
dyspnoea
exertional breathlessness
chronic cough with sputum production
central cyanosis
pursed lips
CO2 retention flap
bounding pulse
tar-stained fingers
hyper-expanded chest
expiratory polyphonic wheeze
reduced breath sounds at apices
raised JVP
ankle oedema
RV heave
tricuspid regurgitation murmur
recurrent chest infections
96
Q

what is the treatment of COPD?

A 
smoking cessation
nicotine replacement therapy
varenicline
pulmonary rehab
nutrition
vaccinations (influenza and pneumococcal)
beta agonist (mild)
tioropium and beta agonist (moderate)
inhaled corticosteroids (severe)
theophylline
long-term oxygen therapy
bullectomy
endobronchial valve placement
lung reduction surgery
single lung transplant
97
Q

what is the treatment of an acute exacerbation of COPD?

A

controlled O2 via venturi mask (monitored)
bronchodilators
steroids / 7 days
antibiotics

98
Q

what are the signs of hypercapnia?

A 
reduced GCS
drowsiness/coma
confusion
bounding pulse
headache
repsiratory arrest
peripheral vasodilatation
tachycardia
tremor/flap
papilloedema
99
Q

describe the pathology of cardiac failure

A 
decreased cardiac output
decreased renal perfusion
RAAS activation
angiotensin II promotes vasconstriction
aldosterone promotes fluid retention
sympathetic nervous system promotes vasoconstriction, positive inotropy and tachycardia
ADH is released
this increased preload and afterload
resulting in hypertrophy, myocyte loss, interstitial fibrosis and dilatation
100
Q

what are the causes and consequences of LSHF?

A 
IHD
hypertensive heart disease
valvular heart disease
cardiomyopathy
myocarditis

venous congestion
pulmonary oedema

101
Q

define pneumothorax

A

collection of air in the pleural cavity resulting in a collapsed lung on the affected side

102
Q

what are the types of pneumothorax?

A

traumatic
spontaneous (primary and secondary)
tension

103
Q

what are the symptoms and signs of a pneumothorax?

A 
pleuritic chest pain
rapid, progressive dyspnoea of sudden onset
reduced chest movement
trachea central (small), away from affected lung (tension) or towards affected lung (large)
reduced tactile vocal fremitus
hyper-resonant percussion note
reduced breath sounds
reduced vocal resonance
thin/marfoid habitus
104
Q

what are the risk factors for a pneumothorax?

A 
asthma
COPD
lung fibrosis
CF
chest trauma
Marfan’s syndrome
Ehlers-Danlos syndrome
HIV
positive pressure ventilation
pleural aspiration
central line insertion
recent surgery
105
Q

what is the management of a pneumothorax?

A

<2cm supportive management
>2cm or asymptomatic pleural aspiration attempted
chest drain insertion with underwater seal
surgical pleurodesis or pleurectomy

tension (urgent needle decompression, large bore cannula with syringe into 2nd intercostal space midclavicular line)

106
Q

define respiratory failure

A

inadequate gas exchange resulting in hypoxia
PaO2 < 8kPa

type 1 (low PaO2 with normal/low PaCO2)
type 2 (low PaO2 with hypercapnia/PaCO2 > 6kPa)
107
Q

what are the causes of type 1 respiratory failure?

A 
V/Q mismatch
pneumonia
pulmonary oedema
PE
asthma
emphysema
pulmonary fibrosis
ARDS
108
Q

what are the causes of type 2 respiratory failure?

A

asthma
COPD
ES pulmonary fibrosis

CNS tumour/trauma
Guillian Barre syndrome
myasthenia gravis

109
Q

what are the signs of hypoxia?

A 
dyspnoea
restlessness
agitation
confusion
central cyanosis

polycythaemia
pulmonary HTN
cor pulmonale

110
Q

what is the management of type 1 respiratory failure?

A

treat underlying cause
give oxygen 35-60%
assisted ventilation if O2 < 8kPa despite 60% oxygen

111
Q

what is the management of type 2 respiratory failure?

A

treat the underlying cause
controlled oxygen therapy (start at 24%)
ABG after 20 minutes
if PaCO2 is steady/lower increase O2
if PaCO2 rises by 1.5kPa and O2 is steady consider NIV
if NIV fails consider ventilation/intubation

112
Q

what are the symptoms and signs of lung cancer?

A 
cough
haemoptysis
dyspnoea
chest pain
recurrent/slowly resolving pneumonia
lethargy
anorexia
weight loss
hoarseness
cachexia
Horner’s syndrome (pancoast tumour)
SVCO
lymphadenopathy
hypertrophic pulmonary osteoarthropathy
pleural effusion
pneumothorax
anaemia
consolidation
tracheal deviation
113
Q

what are the complications of lung cancer?

A 
recurrent laryngeal nerve palsy
phrenic nerve palsy
Horner’s syndrome
SVCO
rib erosion
pericarditis
AF
bone pain
anaemia
raised calcium
addison’s
cushing’s (ACTH increase)
SIADH (low sodium)
jaundice
itch
encephalopathy
seizures
confusion
cerebellar syndrome
proximal myopathy
neuropathy
polymyositis
lambert-eaton syndrome
114
Q

what is the differential diagnosis of a lung nodule on CXR?

A 
primary or secondary malignancy
abscess
cyst
granuloma
foreign body
carcinoid tumour
pulmonary hamartoma
arterio-venous malformation
encysted effusion (blood, pus, fluid)
115
Q

what are the causes of transudative pleural fluid?

A 
heart failure
hypoalbuminaemia
cirrhosis
hypothyroidism
peritoneal dialysis
PE
Meig’s syndrome
116
Q

what is the treatment of NSCLC?

A

surgical resection
post-operative adjuvant chemotherapy
radical XRT for those that are inoperable

117
Q

what is the treatment of SCLC?

A

combination radiotherapy and platinum-based chemotherapy
prophylactic cranial irradiation (reduce brain metastases)
airway stenting
laser therapy

118
Q

what are the symptoms and treatment of mesothelioma?

A

chest pain
dyspnoea
weight loss
pleural effusion

119
Q

what are the causes of oedema?

A 
cardiac failure
nephrotic syndrome
liver failure
NSAIDs
amlodipine
corticosteroids
120
Q

what are the risk factors for lung cancer?

A 
smoking
asbestos
chromium
COPD
alpha 1 antitrypsin deficiency
idiopathic pulmonary fibrosis

Clinical Practice (14 decks)

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