Respiratory Flashcards
What is FEV1?
Forced expiratory volume in 1 second
What is FVC?
Forced vital capacity, the total amount of air forcibly expired.
What are the values for FVC in airways restriction?
Lower than 80% with a normal FEV1:FVC ratio
What are the values for Airway obstruction?
FEV1:FVC ratio is below 0.7
What are the 2 types of COPD?
Chronic bronchitis and emphysema
What is chronic bronchitis?
Increased mucus production due to irritants.
Pathophysiology of chronic bronchitis?
Mucus narrows airways, hypertrophy and hyperplasia in the mucus glands due to increased irritants.
Not as much O2 can come in and CO2 can’t get out due to the mucus.
What do patients with chronic bronchitis present with?
Hypercapnia and hypoxemia as the mucus plugs prevent O2 from entering the lungs and CO2 from leaving.
What is emphysema?
Increased breakdown of elastin in the lungs leading to reduced recoil of the lungs.
Pathophysiology of emphysema?
Macrophages phagocytose pollutants/particles, release cytokines, attracting neutrophils to the area.
Elastase is released which breaks down elastin.
Alveoli collapse due to lack of elastin.
What is alpha-1 antitrypsin?
An inhibitor of the enzyme elastase
What does this mean for patients with alpha-1 antitrypsin deficiency?
There is more elastase and therefore leads to the development of emphysema.
What are the risk factors for COPD?
Smoking, exposure to particles and pollutants.
Which patients are described as blue bloaters?
Patients with chronic bronchitis, commonly have a high BMI and cyanosis due to hypercapnia.
Which patients are described as the pink puffers?
Chronic emphysema, exhale through pursed lips to prevent alveolar collapse.
Presentations of chronic bronchitis?
Chronic productive cough, sputum, wheezing on expiration, inspiratory crackles, dyspnoea on exertion, hyper resonance to percussion.
Presentations of emphysema?
Weight loss, wheezing on expiration, hyper-resonance to percussion.
What are the gold standard tests for COPD?
Pulmonary function tests and spirometry. Do tests with and without bronchodilators if theres less than a 12% increase in FEV1 its likely to be COPD.
When should you start COPD on supplemental O2?
if O2 is less than 88%, if they have other conditions then start at 90%
What will you see on ABG in COPD?
Elevated CO2 low pH and low O2
What might a CXR show in COPD?
Can show a flat diaphragm, hyperinflation, air trapping and bullae (an air pocket due to emphysema)
Differential diagnoses for COPD?
Asthma, congestive heart failure, bronchiectasis.
Management of COPD generally?
Smoking cessation, influenza and pneumococcal vaccine.
Mild or intermittent COPD?
SAMA or SABA with a spacer
Moderate or severe COPD?
LAMA or LABA with corticosteroids.
Acute exacerbation of COPD?
IV methylprednisolone
Name a SAMA?
Ipratropium
Name a LAMA?
Tiotropium
Name a SABA?
Albutcol
Nama a LABA?
Salmeterol
How does a muscarinic receptor work?
ACH increases the amount of Ca2+ in the cell leading to bronchoconstriction.
How does a SAMA and a LAMA work?
Block ACH from being able to bind and causing less bronchoconstriction.
How do B2 receptors work?
When adrenaline or noradrenaline binds, increases the amount of cAMP leading to relaxation of smooth muscle.
How do SABA’s and LABAs work?
They are B2 receptor agonists, increasing the level of cAMP and therefore bronchodilation.
What is asthma?
A chronic inflammatory condition causing narrowing of the airways leading to difficulty breathing.
What is the age of onset for asthma?
3-5years
What are the risk factors for asthma?
Genetic predisposition, atopic triad, obesity, inner city environment, premature birth, socioeconomic deprivation.
What are asthma attacks commonly triggered by?
Air pollution, dust, dander, aspirin, beta blockers.
What happens during an asthma attack?
When a trigger enters the lungs eosinophils release their granules, this causes damage to cells lining the bronchioles leading to smooth muscle spasms and increased mucus production.
Symptoms of asthma?
Chest tightness, dyspnea, wheezing, coughing, mucus plugs in sputum. nocturnal coughing.
Signs of asthma?
Tachypnoea, audible wheeze, hyperinflated chest, decreased air entry and hyperresonant percussion note
What is the gold standard investigation for asthma?
Peak expiratory flow rate measured before and after a bronchodilator.
What questions should you ask to diagnose asthma?
Recent nocturnal waking, usual asthma symptoms in a day, interference with activities of daily living.
How to manage asthma?
Avoid contact with triggers, Immediate: O2 therapy, Nebulised salbutamol Prednisolone Daily: 1. Salbutamol when required 2. SABA plus inhaled corticosteroid 3. Add a LABA if not controlled.
What is a PE?
When an embolus becomes lodged in the pulmonary artery blocking blood flow to the lung.
What is the most common cause of a PE?
DVT - 95%
What are the risk factors for PE?
Major surgery, pregnancy, COPD, congestive heart failure, varicose veins, immobility, increasing age, malignant disease.
What are the common sources of a PE?
External iliac, femoral, deep femoral, popliteal
What are the CV affects of the PE?
An embolism lodged in a pulmonary artery causes an increase in pulmonary vascular pressure.
Increased right ventricular pressure leads to right sided HF.
What are the lung affects of PE?
V/Q mismatch due to obstruction of pulmonary artery.
Inflammation causes cytokine release and bronchoconstriction.
Hyperventilation, hypercapnia and respiratory acidosis.
What are the key presentations of a PE?
Dyspnoea, pleuritic chest pain, swollen leg and pain in the legs
What are the signs of a PE?
Tachycardia and hypotension
1st line investigations for a PE?
CXR to exclude pneumonia and pneumothorax
ECG to exclude MI and pericarditis.
Whats the gold standard investigation for a PE?
CT pulmonary angiogram
What would you do in a PE if the D-dimer was positive?
It could be a PE so CT pulmonary angiogram.
How to manage PE?
Oxygen, fluids, opiates for pain.
Anticoagulants used for a minimum of 3 months, Use heparin and Warfarin
Which is faster acting heparin or warfarin?
Heparin works immediately, warfarin takes 5 days to work.
What criteria is used to decide how likely it is a patient will have a PE?
Well’s criteria
What Wells score value indicates that a PE is likely?
Greater than 4
What is IPF?
The formation of scar tissue in the lungs with no known cause.
Epidemiolgy of IPF?
2/3 >60 M>F
What is the presentation of IPF?
Dyspnoea, dry cough, bibasal crackles
What investigations would you do in IPF?
High resolution CT, would show a ground glass appearance.
What is the pharmalogical treatment for IPF?
Pirfenidone and nintedanib
What is the non-pharmological treatment for IPF?
Smoking cessation, physiotherapy, vaccines up to date.
What is asbestosis?
The inhalation of asbestos
What are the presentations of asbestosis?
Dyspnoea on exertion, dry cough, normal chest on auscultation
How many years after exposure does asbestosis occur>
10 years after initial exposure
What investigations would you do for asbestosis?
CXR, Spirometry (showing restriction), High res CT
Treatment for asbestosis?
Remove exposure, smoking cessation, symptom treatment.
What are the complications of asbestosis?
Mesothelioma, pleural thickening
What is Goodpasture’s syndrome?
Autoimmune anti-glomerular basement membrane disease where antibodies attakc the basement membrane in the lungs and kidneys.
What is the presentation of goodpastures?
Haemoptysis, haematuria, dyspnoea, glomerulonephritis, chest pain, fever, fatigue.
What are the investigations for good pastures?
Lung and kidney biopsy for anti-GBM antibodies.
What is the treatment for goodpastures?
Prednisalone, immunosuppresents (cyclophosphamide), plasmapheresis.
What is hypersensitivity pneumonitis?
A type 3 hypersensitivity reaction causing alveolar and bronchial inflammation
What is the presentation of hypersensitivity pneumonitis?
Dyspnoea, cough, fever, malaise, weight loss
What investigations for hypersensitivity pneumonitis?
Bronchoalveolar lavage: raised lymphocytes and mast cells.
What is bronchoalveolar lavage?
Where water is washed into the lungs then collected again and sent for analysis.
What is the treatment for hypersensitivity pneumonitis?
Remove allergens and steroids.
What is granulomatosis with polyangiitis?
Systemic vasculitis involving small and medium vessels.
Classically ENT, lung and kidney involvement.
Associated with ANCA.
What is the general presentation of granulomatosis with polyangiitis?
Malaise, fatigue, fever, night sweats, arthralgias.
ENT symptoms of granulomatosis with polyangiitis?
Rhinorrhoea, chronic ear infections, conjunctivitis, scleritis, hoarseness.
Lung symptoms of granulomatosis with polyangiitis?
Cough, dyspnoea, wheeze
Kidney symptoms of granulomatosis with polyangiitis?
Haematuria
What investigations would you do for granulomatosis with polyangiitis?
ANCA, urinalysis and CT chest.
What treatment would you do for granulomatosis with polyangiitis?
Prednisalone, immunosuppression (rituximab, methotrexate) prophylactic antibiotics.
What is a pneumothorax?
Air in the pleural space
What are the most common causes of a pneumothorax?
Spontaneously, secondary to trauma, medical intervention, pathology e.g. asthma, COPD, infection.
What is the typical patient with a pneumothorax?
Young, tall and thin
What is a tension pneumothorax?
A one way valve into the pleura, the air can get in but can’t get out.
Progressively squashing the lung upon breathing
What would you see on CXR in a tension pneumothorax?
Tracheal deviation
1st line treatment of a tension pneumothorax?
Large bore cannula into the second intercostal space midclavicular line as a way for air to get out.
What are the key presentations of a pneumothorax?
Sudden shortness of breath, pleuritis chest pain, comes on when playing sports.
What’s the first line investigation for a pneumothorax?
Erect chest x-ray. Patient standing upright with their lungs fully expanded.
What is the gold standard investigation for pneumothorax?
CT thorax as it can detect smaller pneumothorax’s
Treatment of a pneumothorax less than 2cm in size?
Usuallt resolves spontaneously, just do a follow up CXR.
Pneumothorax greater than 2cm?
Aspiration?
When should you use a chest drain to treat a pneumothorax?
If aspiration fails twice or if its secondary to other conditions.
Whereabouts is a chest drain inserted?
The triangle of safety: 5th intercostal space mid axillary line, anterior axillary line Above the rib to above the neurovascular bundle.
What is a pleural effusion?
Fluid in the pleural space
What is an exudative pleural effusion?
Inflammation causing protein leaking into the pleural space
e.g. lung cancer, pneumonia, RA, TB
What is a transudative pleural effusion?
Caused by congestive heart failure, hypoalbulminaemia and hypothyroidism.
Low protein in fluid
What are the key presentations of pleural effusion?
Shortness of breath
Dullness to percuss, reduced breath sounds
What’s the 1st line investigation for pleural effusion?
CXR showing: blunting of costophrenic angle, fluid in the lung fissures, large effusions meniscus.
Gold standard for pleural effusions?
Sample of the pleural fluid by aspiration or chest drain.
Management of a larger effusion?
Aspiration or chest drain
What is sarcoidosis?
Granulomatous inflammatory condition.
What is the cause of sarcoidosis?
Unknown
Who is affected by sarcoidosis?
young adults and around age 60. women and black people more common.
What are granulomas?
Nodules of inflammation that are full of macrophages
What is erythrma nodosum?
Tender, red nodules on the shins.
Typical presentation of patient with sarcoidosis?
Young, black, female patient with dry cough and SOB, nodules on the shins
1st line investigation for sarcoidosis?
Serum ACE is raised anf serum calcium.
Gold standard investigation for sarcoidosis?
Histology, biopsy of the affected area showing non-caeseating granulomas with epithelioid cells.
What would sarcoidosis show on CXR?
Hilar lymphadenopathy
How to treat sarcoidosis?
condition usually resolves spontaneously but steroids can be given.
What causes TB?
Mycobacterium tuberculosis
How does TB work inside a macrophage?
Instead of being broken down by lysosomes, it is able to resist lysosomal degradation and multiply.
How to granulomas form in TB?
Immune cells surround the bacteria and wall it off forming a granuloma. The middle of the granuloma dies and this is caseous necrosis.
What happens when someone with latent TB becomes immunocompromised?
The bacteria can spread again, this time spreading to the upper lobes and potentially spreading systemically.
Key presentations of TB?
Fever, night sweats, weight loss, coughing up blood
1st line investigation of TB?
CXR to look for granuloma and signs of active TB
How to manage latent TB?
Isoniazid for 9months
How to manage an active TB infection?
Combination of antibiotics
What can you use to test for TB?
The PDD intradermal skin test.
What are the 2 types of lung cancer/
Small cell lung cancer and non small cell carcinoma
What are the risk factors for lung cancer?
Cigaretter smoking, asbestos, coal and products of coal combustion, radon exposure, PF, HIV, genetic factors.
Lung cancer symptoms of local disease?
Persistent cough, SOB, Haemoptysis, chest pain
What is a paraneoplastic change?
Where a tumour secretes a specific hormone
Can lung cancers undergo paraneoplastic changes?
yes
First line investigations for Lung cancer?
CXR, CT chest, liver and adrenals, sputum cytology .
What might you see on a CXR in lung cancer?
Central mass, hilar lymphadenopathy, pleural effusion.
What tests are diagnostic for lung cancer?
Biopsy and histology
Which lung cancer arises from endocrine cells?
Small cell lung cancer
What kinds of hormones does small cell lung cancer secrete?
Polypeptide hormones
Which lung cancer is most strongly associated with cigarette smoking?
Squamous cell carcinoma
Which cells does squamous cell carcinoma arise from?
Epithelial cells in the central bronchus
Which is the most common lung cancer in non-smokers?
adenocarcinoma
What types of cell do adenocarcinomas originate from/
Mucus-secreting glandular cells.
Whereabouts do lung cancers commonly metastise?
Liver, bone, adrenal glands, brain
What is pulmonary hypertension?
A disease of the small pulmonary arteries characterised by vascular proliferation and remodelling.
Progressive increase in pulmonary vascular resistance.
What are the causes of pulmonary hypertension?
Anything that increases PVR or increases pulmonary blood flow.
COPD, emphysema, LV failure etc
WHat are the clinical features of pulmonary hypertension/
Exertional dyspnoea, lethargy and fatigue, ankle swelling.
What are the signs of pulmonary hypertension?
Tricuspid regurgitation murmur
What is the diagnostic test for pulmonary HTN?
Right heart catheterisation
Treatment for pulmonary HTN?
Oral anticoags, dieuretics, supplemental oxygen, supervised exercise training, avoid pregnancy.
