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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
define extensive disease in NSCLC
tumour beyond the barriers of limited disease including malignant pericardial or pleural effusions
26
what is the treatment of limited SCLC?
combined chemoradiotherapy chemotherapy prophylactic cranial radiotherapy if no progression
27
what is the treatment of extensive SCLC?
combination chemoradiotherapy thoracic radiotherapy prophylactic cranial radiotherapy
28
what is the treatment of NSCLC?
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
29
define pneumonia
syndrome/condition, usually caused by infection, resulting in an inflammatory response within the lung parenchyma
30
what are the causes of pneumonia?
streptococcus pneumonia haemophilus influenza moraxella catarrhalis staphylococcus aureus legionella mycoplasma chlamydophila pneumoniae chlamydophila psittaci
31
what are the symptoms and signs of pneumonia?
``` 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 ```
32
what is the treatment of pneumonia?
ABx within 4 hours of attending hospital amoxicillin -/+ clarithromycin -> co-amoxiclav + clarithromycin doxycycline -> levofloxacin + clarithromycin ``` O2 fluids analgesia nutrition physiotherapy VTE prophylaxis ```
33
how should a patient with pneumonia be followed-up?
CXR after 6 weeks with persisting symptoms/signs and in those at high risk of underlying lung malignancy
34
define HAP
new radiographic infiltrate with evidence of infection at least 48hr after hospital admission or 2 weeks after discharge mostly caused by aspiration
35
what are the risk factors for developing HAP?
``` >70 yrs chronic lung disease reduced consciousness chest/abdominal surgery mechanical ventilation NG feeding previous antibiotic exposure poor dental hygiene steroids and cytotoxic drugs ```
36
who gets pneumothoraces?
tall, thin, young males older patients with underlying lung disease patients who have had trauma
37
describe primary pneumothoraces
spontaneous with no underlying lung disease | associated with Marfan's syndrome
38
what are the causes of secondary pneumothoraces?
``` COPD asthma cystic fibrosis pneumocystis pneumonia catamenial pneumothorax ```
39
what are the symptoms and signs of a pneumothorax?
``` sudden, ipsilateral, pleuritic type chest pain dyspnoea Hx of pneumothorax reduced breath sounds hyper resonant decreased vocal fremitis tachycardia hypoxia subcutaneous emphysema ```
40
what are the symptoms and signs of a tension pneumothorax?
tachycardia hypotension deviated trachea and apex beat (away)
41
what is the treatment of a tension pneumothorax?
large bore cannula inserted into 2nd intercostal space, midclavicular line then require a chest drain
42
what is the treatment of a primary pneumothorax?
<2cm high flow O2, discharge and review in 2-4 weeks | >2cm/dyspnoea aspirate with cannula
43
what is the treatment of a secondary pneumothorax?
>2cm/dyspnoea chest drain | 1-2cm aspirate with cannula
44
define a PE
obstruction in a pulmonary artery or one of its branches by material that originates somewhere else in the body thrombus, fat, amniotic fluid, air
45
what are the risk factors for developing a VT?
``` post-surgical obstetrics lower limb affections (fractures) malignancy Hx of VT HF HTN neurological impairment nephrotic syndrome chronic dialysis ```
46
what are the symptoms or signs of a PE?
``` 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 ```
47
what is the criteria of the Wells score?
``` recent immobilisation PE 1st diagnosis signs and symptoms of DVT tachycardia (>100) Hx PE or DVT haemoptysis malignancy ```
48
what investigation results indicate PE?
``` 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) ```
49
what is the treatment of a massive PE?
thrombolysis (alteplase 10mg bolus and 90mg over 2hr)
50
what is the treatment of a submissive PE?
oral/sc anticoagulation | dosing depends on weight and renal function
51
what are the causes of pleuritic chest pain?
``` pneumonia pneumothorax PE pericarditis lung cancers trauma autoimmune conditions ```
52
what are the causes of non-pleuritic chest pain?
``` cardiac MSK oesophageal spasm/rupture aortic dissection costochondritis gastritis pancreatitis anxiety ```
53
describe a respiratory chest pain
``` sharp shooting worse on inspiration shoulder pain (referred from diaphragm) located laterally or posteriorly ```
54
describe a cardia chest pain
``` dull pressure centre of chest radiates to arm, neck, jaw not affected by movement associated with nausea, sweating, dyspnoea ```
55
what are the causes of a PE?
``` venous thrombosis in pelvis or legs RV thrombus (post MI) septic emboli (right sided endocarditis) fat air amniotic fluid neoplastic cells parasites ```
56
what are the risk factors for developing a PE?
``` recent surgery leg fracture thombophilia (antiphosphoplipid syndrome) pregnancy, postpardum OCP prolonged bed rest, reduced motility previous PE ```
57
what are the components of virchows triad?
hypercoaguability venous stasis endothelial injury
58
what are the symptoms and signs of a PE?
``` presyncope, syncope dyspnoea pleuritic chest pain haemoptysis pyrexia cyanosis tachyopnoea tachycardia signs of DVT hypotension raised JVP pleural rub pleural effusion ```
59
describe a PE on a CXR
``` normal oligaemia of affected segment dilated pulmonary artery linear atelectasis small pleural effusion wedge-shaped opacities ```
60
what are the components of the well's score
``` 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
what investigations are required to diagnose a PE?
CTPA | V/Q scan when contraindicated (pregnancy)
62
what is the treatment of a PE?
``` oxygen resuscitation supportive therapy anticoagulation thrombolysis embolectomy percutaneous catheter inferior vena cava filters ```
63
describe acute anticoagulation therapy in a PE
LWMH therapeutic dose warfarin DOAC
64
what are the consequences of thrombolysis in a PE?
rapidly restores pulmonary perfusion rapid recovery in cardiac function (less train placed on the right ventricle) large bleeding risk alongside anticoagulation
65
what are the prevention methods used against PE for inpatients?
``` prophylactic LMWH compression stockings early mobilisation stop OCP, HRT investigate for thrombophilia with FHx of thromboembolism ```
66
what are the symptoms and signs of pneumonia?
``` 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
what are the risk factors for developing pneumonia?
``` 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
what is seen on a CXR with pneumonia?
lobar is usually bacterial | diffuse is usually viral
69
what organisms cause pneumonia?
``` legionella pneumophila (hyponatraemic or GI upset) mycoplasma pneumoniae chlamydophila pneumoniae ```
70
what investigations are required to diagnose pneumonia?
CT chest, exclude abscess, empyema, malignancy | bronchopscopy, lavage, obtain sample and remove secretions
71
what are the components of the CURB65 score?
``` new onset confusion urea >7mmol/L respiratory rate >30 SBP <90mmHg or DBP <60mmHg age >65 ```
72
what is the treatment of pneumonia?
``` 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
define IHD
inadequate supply of blod and oxygen to a portion of the myocardium mainly caused by atherosclerosis
74
what are the risk factors for IHD?
``` hypercholesterolaemia (LDL) HTN smoking obesity diabetes FHx physical inactivity male asian race low weight at 1yr low social class stress reduced HDL cholesterol ```
75
what diseases are associated with smoking?
``` coronary artery disease malignant HTN ischaemic stroke sudden death peripheral vascular disease aortic aneursym thromboembolism ```
76
describe anginal pain
provoked by physical exertion, after meals, anger and excitement relieved by GTN spray and rest
77
what are the signs of coronary ischaemia on ECG?
T wave inversion | hyperacute T waves
78
what are the causes of troponin increase?
``` cardiac damage CKD infection hypotension PE AAA IE COPD hypertensive crisis GI bleeding SAH stroke seizure ```
79
what does ST depression mean?
sign of coronary insufficiency | significant if >1mm
80
what is the management of ACS?
``` oxygen analgesia (morphine sulphate or diamorphine) antiemetics (metoclopramide) antithrombotic therapy antianginal therapy reperfusion therapy ```
81
what is the treatment of NSTEMI?
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
what is the treatment of STEMI?
``` PCI within 12 hours of symptom onset antiplatelet analgesia thrombus aspiration (occasionally) thrombolysis (used infrequently, streptokinase, alteplase) ```
83
what are the complications of MI?
``` 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
what is used in the secondary prevention of ACS?
``` smoking cessation regular exercise diet control statin aim BP <140/85mmHg ACEi beta blocker antiplatelet ```
85
describe asthma
reversible airway obstruction | recurrent episodes of dyspnoea, (nocturnal) cough and wheeze
86
what factors contribute to airway narrowing in asthma?
bronchial muscle contraction mucosal swelling/inflammation increased mucous production
87
what are the precipitants of an asthma attack?
``` cold air exercise emotion allergens infection smoking pollution NSAIDs beta blockers ```
88
what are the signs of asthma?
``` 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
what is the treatment of acute asthma?
salbutamol 5mg nebulised with O2 hydrocortisone 100mg IV or prednisolone 40-50mg ABG aim for sats 94-98%
90
what is the treatment of life-threatening asthma?
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
what is the treatment of acute/life threatening asthma that is improving?
neb salbutamol every 4 hours prednisolone 40-50mg PO OD for 5-7 days monitor peak flow aim for sats 94-98%
92
define chronic bronchitis
chronic cough with sputum production for >3 months in 2 successive years
93
define emphysema
alveolar wall destruction leading to abnormal and permanent enlargement of airspaces distal to the terminal bronchioles
94
what are the causes of COPD?
smoking industrial dust exposure alpha 1 antitrypsin deficiency
95
what are the symptoms and signs of COPD?
``` 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
what is the treatment of COPD?
``` 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
what is the treatment of an acute exacerbation of COPD?
controlled O2 via venturi mask (monitored) bronchodilators steroids / 7 days antibiotics
98
what are the signs of hypercapnia?
``` reduced GCS drowsiness/coma confusion bounding pulse headache repsiratory arrest peripheral vasodilatation tachycardia tremor/flap papilloedema ```
99
describe the pathology of cardiac failure
``` 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
what are the causes and consequences of LSHF?
``` IHD hypertensive heart disease valvular heart disease cardiomyopathy myocarditis ``` venous congestion pulmonary oedema
101
define pneumothorax
collection of air in the pleural cavity resulting in a collapsed lung on the affected side
102
what are the types of pneumothorax?
traumatic spontaneous (primary and secondary) tension
103
what are the symptoms and signs of a pneumothorax?
``` 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
what are the risk factors for a pneumothorax?
``` 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
what is the management of a pneumothorax?
<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
define respiratory failure
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
what are the causes of type 1 respiratory failure?
``` V/Q mismatch pneumonia pulmonary oedema PE asthma emphysema pulmonary fibrosis ARDS ```
108
what are the causes of type 2 respiratory failure?
asthma COPD ES pulmonary fibrosis CNS tumour/trauma Guillian Barre syndrome myasthenia gravis
109
what are the signs of hypoxia?
``` dyspnoea restlessness agitation confusion central cyanosis ``` polycythaemia pulmonary HTN cor pulmonale
110
what is the management of type 1 respiratory failure?
treat underlying cause give oxygen 35-60% assisted ventilation if O2 < 8kPa despite 60% oxygen
111
what is the management of type 2 respiratory failure?
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
what are the symptoms and signs of lung cancer?
``` 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
what are the complications of lung cancer?
``` 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
what is the differential diagnosis of a lung nodule on CXR?
``` primary or secondary malignancy abscess cyst granuloma foreign body carcinoid tumour pulmonary hamartoma arterio-venous malformation encysted effusion (blood, pus, fluid) ```
115
what are the causes of transudative pleural fluid?
``` heart failure hypoalbuminaemia cirrhosis hypothyroidism peritoneal dialysis PE Meig’s syndrome ```
116
what is the treatment of NSCLC?
surgical resection post-operative adjuvant chemotherapy radical XRT for those that are inoperable
117
what is the treatment of SCLC?
combination radiotherapy and platinum-based chemotherapy prophylactic cranial irradiation (reduce brain metastases) airway stenting laser therapy
118
what are the symptoms and treatment of mesothelioma?
chest pain dyspnoea weight loss pleural effusion
119
what are the causes of oedema?
``` cardiac failure nephrotic syndrome liver failure NSAIDs amlodipine corticosteroids ```
120
what are the risk factors for lung cancer?
``` smoking asbestos chromium COPD alpha 1 antitrypsin deficiency idiopathic pulmonary fibrosis ```

Clinical Practice (14 decks)

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