Respiratory Gap Flashcards
Factors associated with poor prognosis of Sarcoidosis
insidious onset, symptoms > 6 months
absence of erythema nodosum
extrapulmonary manifestations: e.g. lupus pernio, splenomegaly
CXR: stage III-IV features
black African or African-Caribbean ethnicity
Indication of NIV in COPD
NIV should be considered in all patients with an acute exacerbation of COPD in whom a respiratory acidosis (PaCO2>6kPa, pH <7.35 ≥7.26) persists despite immediate maximum standard medical treatment
What type of NIV is used in COPD
BiPAP
BC
CPAP used in
It is used in conditions where the principal pathophysiology is type 1 respiratory failure i.e. pulmonary oedema/covid pneumonitis. It will not be effective in this scenario as the patient needs support with ventilation as well as oxygenation and therefore needs bilevel (i.e. oxygenation and ventilation) support.
also, OSA
HLA associations:
HLA-DR1: bronchiectasis
HLA-DR2: systemic lupus erythematous (SLE), Goodpasture
HLA-DR3: autoimmune hepatitis, primary Sjogren syndrome, type 1 diabetes Mellitus, SLE
HLA-DR4: rheumatoid arthritis, type 1 diabetes Mellitus
HLA-B27: ankylosing spondylitis, postgonococcal arthritis, acute anterior uveitis
Situations where oxygen therapy should not be used routinely if there is no evidence of hypoxia
Myocardial infarction and acute coronary syndromes
stroke
obstetric emergencies
anxiety-related hyperventilation
Oxygen therapy for COPD patients
Prior to availability of blood gases, use a 28% Venturi mask at 4 l/min and aim for an oxygen saturation of 88-92% for patients with risk factors for hypercapnia but no prior history of respiratory acidosis
adjust target range to 94-98% if the pCO2 is normal
Color of venturi mask
BLUE = 2-4L/min = 24% O2
WHITE = 4-6L/min = 28% O2
YELLOW = 8-10L/min = 35% O2
RED = 10-12L/min = 40% O2
GREEN = 12-15L/min = 60% O2
Causes of Bilateral Hilar Lymphadenopathy
The most common causes of bilateral hilar lymphadenopathy are sarcoidosis and tuberculosis.
Other causes include:
lymphoma/other malignancy
pneumoconiosis e.g. berylliosis
fungi e.g. histoplasmosis, coccidioidomycosis
ABPA story
Allergic bronchopulmonary aspergillosis results from an allergy to Aspergillus spores. In the exam questions often give a history of bronchiectasis and eosinophilia.
Features
bronchoconstriction: wheeze, cough, dyspnoea. Patients may have a previous label of asthma
bronchiectasis (proximal)
Investigations
eosinophilia
flitting CXR changes
positive radioallergosorbent (RAST) test to Aspergillus
positive IgG precipitins (not as positive as in aspergilloma)
raised IgE
Management
oral glucocorticoids
itraconazole is sometimes introduced as a second-line agent
What is ABPA
Allergic bronchopulmonary aspergillosis results from an allergy to Aspergillus spores. In the exam questions often give a history of bronchiectasis and eosinophilia.
Features of ABPA
bronchoconstriction: wheeze, cough, dyspnoea. Patients may have a previous label of asthma
bronchiectasis (proximal)
Rx of ABPA
oral glucocorticoids
itraconazole is sometimes introduced as a second-line agent
high-risk characteristics for Pneumothorax
Haemodynamic compromise (suggesting a tension pneumothorax)
significant hypoxia
bilateral pneumothorax
underlying lung disease
≥ 50 years of age with significant smoking history
haemothorax
Fitness to fly advice for Pneumothorax
absolute contraindication, the CAA suggest patients may travel 2 weeks after successful drainage if there is no residual air. The British Thoracic Society used to recommend not travelling by air for a period of 6 weeks but this has now been changed to 1 week post check x-ray
NICE recommendation for Smoking cessation
Nicotine replacement therapy (NRT)
Varenicline
Bupropion
What is Buproprion
a norepinephrine-dopamine reuptake inhibitor and nicotinic antagonist
unlike many antidepressants it has a minimal effect on serotonin
should be started 1 to 2 weeks before the patient’s target date to stop
small risk of seizures (1 in 1,000)
contraindicated in epilepsy, pregnancy and breast feeding. Having an eating disorder is a relative contraindication
Buproprion contraindicated in
contraindicated in epilepsy, pregnancy and breast feeding. Having an eating disorder is a relative contraindication
who to refer to NHS Stop Smoking Service in Pregnancy
All women who smoke, or have stopped smoking within the last 2 weeks, or those with a CO reading of 7 ppm or above should be referred to NHS Stop Smoking Services.
First line for smoking cessation in pregnancy
CBT
Varenicline
a nicotinic receptor partial agonist
should be started 1 week before the patients target date to stop
the recommended course of treatment is 12 weeks (but patients should be monitored regularly and treatment only continued if not smoking)
has been shown in studies to be more effective than bupropion
nausea is the most common adverse effect. Other common problems include headache, insomnia, abnormal dreams**
varenicline should be used with caution in patients with a history of depression or self-harm. There are ongoing studies looking at the risk of suicidal behaviour in patients taking varenicline
contraindicated in pregnancy and breastfeeding**
Varenicline is contraindicated in
contraindicated in pregnancy and breastfeeding
Which one of the following pathophysiological changes is most responsible for emphysema?
Destruction of alveolar walls secondary to Proteinases
COPD management
photo
criteria to determine whether a patient has asthmatic/steroid responsive features:
- any previous, secure diagnosis of asthma or of atopy
- a higher blood eosinophil count - note that NICE recommend a full blood count for all patients as part of the work-up
- substantial variation in FEV1 over time (at least 400 ml)
- substantial diurnal variation in peak expiratory flow (at least 20%)
Asthma Exacerbation class
Moderate:
PEFR 50-75% best or predicted
Speech normal
RR < 25 / min
Pulse < 110 bpm
Severe:
PEFR 33 - 50% best or predicted
Can’t complete sentences
RR > 25/min
Pulse > 110 bpm
Life-Threatening:
PEFR < 33% best or predicted
Oxygen sats < 92%
‘Normal’ pC02 (4.6-6.0 kPa)
Silent chest, cyanosis or feeble respiratory effort
Bradycardia, dysrhythmia or hypotension
Exhaustion, confusion or coma
Predisposing factors for OSA
obesity
macroglossia: acromegaly, hypothyroidism, amyloidosis
large tonsils
Marfan’s syndrome
Rx for OSA
Management
weight loss
continuous positive airway pressure (CPAP) is first line for moderate or severe OSAHS
intra-oral devices (e.g. mandibular advancement) may be used if CPAP is not tolerated or for patients with mild OSAHS where there is no daytime sleepiness
the DVLA should be informed if OSAHS is causing excessive daytime sleepiness
limited evidence to support use of pharmacological agents
Genotype for A1AT Deficiency
For anyone who cannot remember the PiMM, PiSS, PiZZ, remember in an alphabet list, M comes first then S and last Z so… PiMM = normal., PiSS = 50% and PiZZ = Zero.
Also this:
Normal PiMM > PiMS > PiMZ > PiSS > PiSZ > PiZZ Abnormal
PIZZ - last letter in the alphabet - therefore the worst.
PIMM - the best, no carrier, not ill
PiSS – Slow on electrophoresis. Unlikely to be symptomatic.
PIMZ: carrier and unlikely to develop emphysema if a non-smoker
A1AT Features
located on chromosome 14
inherited in an autosomal recessive / co-dominant fashion*
Features
Lungs: panacinar emphysema, most marked in lower lobes
Liver: cirrhosis and hepatocellular carcinoma in adults, cholestasis in children
Investigations
A1AT concentrations
spirometry: obstructive picture
Management:
- no smoking
- supportive: bronchodilators, physiotherapy
- intravenous alpha1-antitrypsin protein concentrates
** - surgery: lung volume reduction surgery, lung transplantation**
Klebsiella pneumoniae is a Gram——— bacilli?/cocci? that is part of the normal ——
Klebsiella pneumoniae is a Gram-negative rod that is part of the normal gut flora
Red currant Jelly sputum is caused by
Klebsiella
Klebsiella is common in
Alcoholics and Diabetics
Spirometry in A1At
Obstructive
Causes of Upper zone pulmonary fibrosis:
Causes of upper zone pulmonary fibrosis:
CHARTS
Coal workers pneumoconiosis
Hypersensitivity pneumonitis, histiocytosis
Ankylosing spondylitis
Radiation
Tuberculosis
Silicosis, sarcoidosis
Causes of lower zone pulmonary fibrosis
ACID
Asbestosis
C- connective tissue diseases (e.g. rheumatoid arthritis)
Idiopathic pulmonary fibrosis
Drugs (e.g. methotrexate)
Type of hypersensitivity in Extrinsic Allergic Alveolitis
It is thought to be largely caused by **immune-complex mediated tissue damage (type III hypersensitivity) **although delayed hypersensitivity (type IV) is also thought to play a role in EAA, especially in the chronic phase.
Examples of Extrinsic Allergic Alveolitis
bird fanciers’ lung: avian proteins from bird droppings
farmers lung: spores of Saccharopolyspora rectivirgula from wet hay (formerly Micropolyspora faeni)
malt workers’ lung: Aspergillus clavatus
mushroom workers’ lung: thermophilic actinomycetes*
BAL Finding of Extrinsic Allergic Alveolitis
Blood finding of EAA
bronchoalveolar lavage: lymphocytosis
blood: NO eosinophilia
What is TLCO
The transfer factor describes the rate at which a gas will diffuse from alveoli into blood. Carbon monoxide is used to test the rate of diffusion. Results may be given as the total gas transfer (TLCO) or that corrected for lung volume (transfer coefficient, KCO)
Relation Between TLCO and KCO
TLCO = KCO x Alveolar volume (VA)
Granulomatosis with Polyangitis also known as
Wegner’s Granulomatosis
It commonly affects the;
upper respiratory tract (chronic sinusitis)
lungs (haemoptysis due to pulmonary haemorrhage, leading to raised TLCO), and kidneys (glomerulonephritis causing proteinuria and haematuria). The presence of c-ANCA is strongly associated with GPA
Causes of a raised TLCO
asthma
pulmonary haemorrhage (e.g. granulomatosis with polyangiitis, Goodpasture’s)
left-to-right cardiac shunts
polycythaemia
hyperkinetic states
male gender, exercise
blood flow barabe jara lungs e tara shobai TLCO barabe
Causes of a lower TLCO
pulmonary fibrosis
pneumonia
pulmonary emboli
pulmonary oedema
emphysema
anaemia
low cardiac output
active lung volume jodi kome jay- or blood flow jodi kome
Features of ASD
The fixed splitting of the second heart sound and the systolic murmur at the left upper sternal edge are classic clinical signs of an ASD
TLCO in chronic bronchitis- normal/raised/decreased
Normal
TLCO in emphysema- normal/raised/decreased
Decreased
Relation of TLCO vs KCO
TLCO = KCO x Alveolar volume (VA)
Small Cell Lung Cancer Associated with
Hyponatremia
How to diagnose Asthma in Children
Children 5-16 years
all children should have spirometry with a bronchodilator reversibility (BDR) test
+
a FeNO test should be requested if there is normal spirometry or obstructive spirometry with a negative bronchodilator reversibility (BDR) test
i am a simple man, i see cherry red lesion i choose ———-
i see alcoholic or diabetic with pneumonia i choose ——–
i see pneumonia in immunosupprssed, without or with less chest findings i ——-
i see fever, retroorbital headache, rash, thrombocytopenia, in a travellar i choose ——
i see pleural plaques i choose ——
i see….
i seee….
i am a simple man, i see cherry red lesion i choose lung carcinoid.
i see alcoholic or diabetic with pneumonia i choose klebsiella.
i see pneumonia in immunosupprssed, without or with less chest findings i choose pneumocystis jiroveci.
i see fever, retroorbital headache, rash, thrombocytopenia, in a travellar i choose** dengue.
i see pleural plaques i choose no follow up.**
i see….
i seee….
