Respiratory conditions, signs, causes and differentials

Question 1

Signs of hypercapnia? (8)

• start from head downwards

Answer 1

1. coma
2. confusion
3. drowsiness
4. dilated pupils
5. bounding pulse
6. myoclonus
7. hand flap
8. tachypnea

Question 2

Signs of hypoxia?

Answer 2

1) Anxiety
2) Bradycardia
3) Confusion
4) Dyspnea
5) Cyanosis
6) Tachycardia
7) Tachypnea
8) Sweating

Question 3

Why does cor pulmonale happen? What is it?

Answer 3

Cor pulmonale AKA pulmonary heart disease, is abnormal enlargement of the right side of the heart.

It occurs because of diseases that causes retrograde pressure to be transmitted to the right heart. So it is a heart (cor) hypertension+insufficiency caused by a pulmonary cause (pulmonale)

Question 4

Signs of cor pulmonale?

Right sided heart enlargement

Answer 4

Raised RR - tachypnoea
Raised JVP
Bilateral lower limb oedema
Hepatomegaly

Cor pulmonale is the result of lung disease.
COPD often results in cor pulmonale.
Treatment is oxygen therapy and use of diuretics.

Question 5

Signs of an severe acute asthma attack?

Answer 5

Severe SOB - can’t complete a full sentence
Tachypnoea
Tachycardia
Silent chest (not enough air movement to produce wheezing)
Cyanosis
Collapse

Question 6

General signs of asthma?

Answer 6

Wheeze (polyphonic)
Dyspnoea
Hyperinflation 
Chest tightness
Tachypnoea

These signs will be:
Diurnal
Prompted by use of aspirin/beta blocker

(If condition is well handled there shouldn’t be any signs)

Question 7

What are possible differentials for a wheeze?

Answer 7

Asthma
COPD
Pulmonary disease
Cardiac failure
Foreign body aspiration
Eosinophilic lung disease

Question 8

Differentials for fine crackles heard by auscultation?

Answer 8

Broncholitis

Pulmonary oedema

Pulmonary fibrosis

Question 9

Differentials for coarse crackles heard by auscultation?

Answer 9

COPD

Pulmonary oedema

Pulmonary fibrosis

Lung abscess

TB: Tuberculosis lung cavities

Pneumonia (resolving)

Question 10

Differentials for a pleural rub heard on auscultation?

Answer 10

Consolidation

Pulmonary infarction

Question 11

Signs of a life-threatening asthma attack?

Answer 11

Cyanosis
Poor respiratory effort
Silent chest
Arrhythmia
Hypotension
Altered consciousness level
Exhaustion - Normal CO2 on ABG (no longer able to hyperventilate)

Question 12

Possible triggers of acute asthma exacerbation?

Answer 12

Stress

Exercise

Cold air

Allergens: dust mites, pollen, fur

Infection

Smoking/passive smoking

Pollution

NSAIDs

Beta-blockers

Question 13

What is the definition of asthma?

Answer 13

“Chronic recurrent episodes of dyspnoea, cough, wheeze caused by reversible airways obstruction”

Caused by:

1. Bronchial muscle contraction
2. Mucosal inflammation
3. Increased mucus production

Question 14

Signs of an acute asthma exacerbation on respiratory examination?

Answer 14

Increased RR

Tracheal tug (possibly) - “abnormal downwards motion of trachea during systole”

Intercostal recession

Question 15

Signs of pulmonary oedema in a respiratory examination?

Answer 15

Raised JVP

Crepitations/crackles on auscultation

Dullness to percussion

Decreased vocal fremitis

Peripheral oedema: ankles/lower limb and sacrum

Question 16

Signs of tension pneumothorax in a respiratory examination?

Answer 16

Signs of haemodynamic instability: pulses weak, hypotensive

Tracheal deviation

Hyperresonant to percussion

Absent breath sounds on auscultation

Question 17

What is the most likely cause of a unilateral silent lung field with a wheeze?

Answer 17

Foreign body aspiration

• totally occludes some airways stopping noise
• partially occludes some airways causing the wheeze

Question 18

What are the causes of pleural effusion?

Answer 18

Malignancy

Empyema

TB

Pleuritis

Fungal infection

Lupus pleuritis

Chylothorax

Urinothorax

Oesophageal rupture

Haemothorax

Peritoneal dialysis

Question 19

Upon sampling a pleural effusion via thoracentesis, you notice that the fluid is bloody:

What are your differentials?

Answer 19

Malignancy

Asbestosis

Pulmonary infarction

Post cardiac injury syndrome

Question 20

Upon sampling a pleural effusion via thoracentesis, you notice that the fluid is milky white:

What are your differentials?

Answer 20

This is a lipid effusion:

Chylothorax (- lymph from the digestive tract is called chyle, this is caused by disruption of drainage by the thoracic duct)

Cholesterol effusion (- due to TB or rheumatoid pleurisy)

Question 21

Upon sampling a pleural effusion via thoracentesis, you notice that the fluid is black:

What are your differentials?

Answer 21

Aspergillus

Question 22

Upon sampling a pleural effusion via thoracentesis, you notice that the fluid is yellow/green:

What are your differentials?

Answer 22

Rheumatoid pleurisy (uncommon)

Question 23

Upon sampling a pleural effusion via thoracentesis, you notice that the fluid is dark green:

What are your differentials?

Answer 23

Bilothorax (- presence of bile fluid in the pleural space, most often due to biliary surgery or trauma)

Question 24

Upon sampling a pleural effusion via thoracentesis, you notice that the fluid is like fish paste:

What are your differentials?

Answer 24

Amebic liver abscess (- most common extraintestinal manifestation of entamoeba infection)

Question 25

Upon sampling a pleural effusion via thoracentesis, you notice that the fluid has pus in it: What are your differentials?

Answer 25

Empyema

Question 26

What are the main three organs causing a transudate pleural effusion?

Answer 26

Kidney failure Liver failure Heart failure

Question 27

Which conditions override the hypoxic pulmonary vasoconstriction?

Answer 27

Sepsis Pneumonia COPD Pulmonary fibrosis

Question 28

What is a shunt?

Answer 28

The pathological process where deoxygenated blood entering the lungs perfuses alveoli that aren’t ventilated. This results in deoxygenated blood reentering circulation without oxygenation, and reducing the overall oxygen concentration of blood in the body. Can occur in an area of infection in the lung e.g. pneumonia, or all over in copd

Question 29

What is wasted ventilation AKA alveolar dead space?

Answer 29

This is when there is an obstruction in the pulmonary capillary or in a larger pulmonary vessel, that prevents blood flow from the pulmonary artery to the pulmonary vein. This occurs in PE.

Question 30

Why is a thickening of the alveoli wall a pathological process?

Answer 30

The gap between the pulmonary capillaries and the air of the alveoli is only 1mm thick - very thing. If this thickened, the diffusion of gases is obstructed! This causes shunt.

Question 31

What is respiratory failure?

Answer 31

The lungs produce an inadequate supply of oxygen to the body +/- an inability to clear carbon dioxide from the body Type 1 = hypoxaemic failure; low oxygen Caused by lung pathology Type 2 = ventilatory failure; low oxygen and high co2 Can be compensated (BE >+3) or decompensated (BE <0) Caused by: Gas trapping (COPD, severe asthma) Chest wall deformities Muscle weakness Respiratory depression (opioids etc)

Question 32

What is COPD?

Answer 32

Chronic obstructive pulmonary disease A smoking related disease characterised by airflow obstruction - FEV1/FVC <0.7 1. Normally the adjacent alveoli help to hold airways open. 2. As the airways become scarred and damaged due to smoking, the alveoli walls break down, and the airways lose their integrity. 3. This means the airways collapse, trapping air in certain alveoli. 4. This means parts of lungs don’t contribute to respiration, so the patient has to fight to get get enough air. 5. This leads to hyperinflation.

Question 33

The major differential for COPD is asthma, how can we differentiate?

Answer 33

COPD; all have smoking history Onset >35 Cough is productive Breathlessness is constant Asthma; onset <35 Nocturnal dyspnoea and wheeze Diurnal and day-to-day variability in symptoms

Question 34

How does the body compensate for respiratory failure type 2?

Answer 34

Kidneys reabsorb more bicarbonate

Question 35

What are the signs of hypercapnia? (As in respiratory failure type 2)

Answer 35

``` Coma Confusion Drowsiness Dilated pupils(SNS) Bounding pulse Myoclonus Hand flap ```

Question 36

Why do people with COPD develop complications?

Answer 36

COPD is an inflammatory process, the inflammatory agents spill over in to the system, combined with the decreased physical activity and hypoxia, it leads to: ``` Osteopenia Skeletal muscle weakness Depression Metabolic disease - diabetes Cardiovascular diseases ```

Question 37

What are the cardinal symptoms of acute exacerbation of COPD?

Answer 37

Cough Purulent sputum Fever

Question 38

What are the most common causes of acute exacerbation of COPD?

Answer 38

Rhinovirus and other viruses = 50% H.Influenzae (80%) and streptococcus pneumoniae and other bacteria = 50%

Question 39

What is pneumonia?

Answer 39

An acute infection of the lung parenchyma MOA: Neutrophil infiltration Inflammatory exudate in the interstitium (drawn out by neutrophils) Alveolar oedema and haemorrhaging - causing the inflammation, swelling and bleeding in the lungs, which is why CXR shows consolidation The next step after infection, is either resolution, or incomplete resolution: abscess formation or fibrosis

Question 40

What is the different between typical and atypical bacterial pneumonias?

Answer 40

Typical organisms are extracellular and can be cultured in the laboratory by standard methods. Atypical organisms are intracellular, and cannot cultured by standard methods. They also require antibiotics that can get in to the intracellular space. (Ciprofloxacin, and the macrolides: azithromycin, clarithromycin)

Question 41

What is the commonest cause of viral pneumonia?

Answer 41

Haemophilus influenza A and B Diagnosed via PCR

Question 42

What is the most common cause of fungal pneumonia?

Answer 42

Pneumocystis Jirovecii Mainly seen in those with altered immunity (e.g. HIV and immunosuppression) but also in those with severe underlying respiratory condition (COPD, CF).

Question 43

What is hospital acquired pneumonia?

Answer 43

New onset symptoms with compatible X-ray, which develop more than 48 hours after admission to hospital. It’s still CAP if it’s within 48 hours of admission. Types of HAP: Early onset = within 4/5 days of admission, requires cefuroxime Late onset = >5 days after admission, and is likely to be antibiotic-resistant, so requires pipericillin and tazobactam Causes: Enterobactericae and staph A

Question 44

What is community acquired pneumonia?

Answer 44

Signs of a lower respiratory tract infection (fever, cough, phlegm, crepitations, bronchial breathing) with CXR changes. Diagnosis then requires CURB-65 score to be taken to check danger of death. (Confusion, blood urea, resp rate, low BP and 65+) ``` Causes: S pneumoniae Haem Influenzae Moraxella catarrhalis Viruses (Influenza A/B, human metpneumovirus and respiratory syncytial virus) ``` Atypical - mycoplasma pneumoniae and Legionella pneumophilia

Question 45

What are the atypical causes of pneumonia?

Answer 45

Bacteria: Mycoplasma pneumoniae Legionella pneumophilia ``` Fungi: Aspergillosis fumigatus Zygomycetes Pneumocystis jirovecii Histoplasmosis capsulatam ```

Question 46

What type of organism causes pneumonia in the immunocompromised?

Answer 46

Pneumocystis jirovecii

Question 47

How can you differentiate chlamydia psittaci from other pneumonias?

Answer 47

Expect the patient to have contact with birds - often parrots. Chest X-ray will show patchy consolidation.

Question 48

How can you differentiate chlamydophilia pneumoniae from other pneumonias?

Answer 48

A biphasic disease: First - the ears, pharynx and throat are affected; otitis, pharyngitis and hoarseness Second - Pneumonia occurs Early phase and late phase Second most common cause of CAP

Question 49

What may make you suspect Legionella pneumophilia may be the cause of pneumonia?

Answer 49

Occurs in outbreaks, especially at hotels Hyponatremia Lymphopenia Deranged LFT’s Urine test shows haematuria CXR shows bilateral basal consolidation Complications: Renal failure, confusion, coma,

Question 50

How can you differentiate mycoplasma pneumoniae from other pneumonias?

Answer 50

Occurs as epidemics CXR occurs in ONE lobe, in the lower lobe

Question 51

How can you differentiate pseudomonas from other pneumonias?

Answer 51

Patients will have underlying condition cystic fibrosis or bronchiectasis

Question 52

How can you differentiate staphylococcal pneumonia’s from other pneumonias?

Answer 52

Chest X-ray will show BILATERAL cavitating bronchopneumonia (most common organism to cause cavitation) - showing as a subtle area of radiolucency superimposed on a region of consolidation

Question 53

What is the most common cause of COPD exacerbation and infection in bronchiectasis?

Answer 53

H. Influenzae The mucus pools form a nidus for bacterial colonisation in both

Question 54

What is bronchiectasis?

Answer 54

Dilation of the bronchi due to inflammation, causing bronchial wall oedema and increased mucus production The mucus pools form a nidus for bacterial colonisation

Question 55

What are the general symptoms of pneumonia?

Answer 55

``` Cough; purulent or haemoptysis Fever Rigors Anorexia Chest pain; pleuritic and sudden onset Dyspnoea Abdominal pain; epigastric ```

Question 56

What are the general signs of pneumonia?

Answer 56

``` Pyrexia Tachypnoea Focal crackles, bronchial breathing, whispering pectoriloquy (whispered sounds are louder), and aegophony (voice sounds are more resonant)on auscultation Dull to percussion Confusion ```

Question 57

Which type of organism is more likely to affect someone with B cell lymphoma?

Answer 57

S pneumoniae - because the B cells are absent, which means there is limited humoral immune protection, and favours a capsular bacteria like this. Capsular bacteria are classic bacteria, therefore humoral immunity defends against them. Unlike viral or fungal organisms, which are dealt with by cell-mediated (T-cell: learning cells)

Question 58

Why are fungal and atypical bacteria more likely to cause pneumonia in a patient with HIV?

Answer 58

The cell mediated immune system is made up of T cells, this recognises viral and fungal organisms. In HIV patients, their T cells are destroyed.

Question 60

Who should be give the pneumococcal vaccine or the influenza vaccine?

Answer 60

Pneumococcal: single dose to those over 65, and those under 1 ``` Influenza: Chronic resp disease Chronic heart disease Chronic kidney disease Chronic neurological disease Chronic liver disease DM Immunosuppression Asplenic people Pregnant women Morbidly obese 40kgm2+ Children age 2-10 Residential home dwellers All healthcare workers All those over 65 ```

Question 61

What is TB?

Answer 61

A mycobacterium that is usually pulmonary (50%), generally tuberculosis or bovis. MOA: Infection occurs by droplets inhaled, infects macrophages, causing a small primary lung lesion, and then spreads via blood, the lesions (granuloma) heal once the immune system adapts causing a latent stage, then reactivation can occur. Causing a set of signs that are fever, anorexia, night sweats, clubbing, erythema nodosum (dark patches) and weight loss (similar to HIV/cancer). Then depends on the site of infection: (50%) Pulmonary - cough, pleurisy, pleural effusion, cavitation/pneumothorax/atelactasis on cxr (destructive inflammation) (20%) Lymphadenitis - cervical lymph node enlargement, firm, non tender (9%) Intrathoracic but not pulmonary (6.9%) Pleural Can occur in ANY part of body except kidneys. (3%) Other types: GI, Spinal (bony), Miliary (loads of little ones on lungs - millet; bird seed), CNS (meningitis), GU, Cardiac or skin