Respiratory I Flashcards
What respiratory pathology is indicated by these results? [1]
What changes to the face might suggest someone is suffering from sarcoidosis [1]
Bilateral parotid gland swelling
The most common radiological sign of tuberculosis on chest X-ray is [], which is seen in around 50-70% of cases.
he most common radiological sign of tuberculosis on chest X-ray is cavity formation, which is seen in around 50-70% of cases.
Cavity formation occurs due to necrosis and cavitation of the lung tissue as a result of the infection.
How do you differentiate between pleural plaques, mesothelioma and asbestosis? [3]
Mesothelioma
- pleural thickening
- haemoptysis
- As a rule of thumb, the pleurae should only be the thickness of a pencil line on a radiograph
- often presents with pleural effusion
- Clubbing
Pleural plaques
- asymptomatic and would not cause the dyspnoea, chest pain and cough
Asbestosis:
- is a form of lung fibrosis resulting from chronic, repeated asbestos exposure. It could cause the symptoms (dyspnoea, chest pain and cough) but will not cause the pleural thickening on the radiograph
Which factors make the Centor criteria? [4]
The Centor criteria are as follows:
* presence of tonsillar exudate
* tender anterior cervical lymphadenopathy or lymphadenitis
* history of fever
* absence of cough
A patient has PCP.
What is the standard treatment? [1]
Under what conditions do you add steroids to ^? [1]
Co-trixamazole
- Adjunctive steroids should be administered to patients with PaO2 ≤8 kPa and/or evidence of hypoxaemia e.g. oxygen saturations < 92%.
Which stages of sarcoidosis do you provide treatment for? [4]
What is the treatment? [4]
Bilateral hilar lymphadenopathy alone:
- Usually self-limiting and often does not require treatment
Acute sarcoidosis:
- Bed rest and NSAIDs for symptom control
Steroid treatment:
- Oral or intravenous, depending on the severity of the disease
Immunosuppressants
- Used in severe disease.
What is hypertrophic pulmonary osteoarthropathy (HPOA)? [2]
combination of clubbing and periostitis of the small hand joints
[] is associated with hypertrophic pulmonary osteoarthropathy (HPOA)
Squamous cell carcinoma
Small cell carcinoma
Adenocarcinoma
Large cell carcinoma
[] is associated with hypertrophic pulmonary osteoarthropathy (HPOA)
Squamous cell carcinoma
Small cell carcinoma
Adenocarcinoma
Large cell carcinoma
A patient presents with small cell lung cancer.
What is the main stay of treatment? [1]
Surgery plays little role in the management of small cell lung cancer, with chemotherapy (& radiotherapy) being the mainstay of treatment
A patient is diagnosed with small cell lunger cancer. What is the mainstay of treatment? [1]
Surgery plays little role in the management of small cell lung cancer, with chemotherapy being the mainstay of treatment
The patient has symptoms of a lung abscess further supported by foul smelling sputum, recurrent fever and a history of stroke (risk of aspiration due to impaired swallow).
[] is an additional clinical feature than can be seen in patients with recurrent lung abscesses
The patient has symptoms of a lung abscess further supported by foul smelling sputum, recurrent fever and a history of stroke (risk of aspiration due to impaired swallow).
Finger clubbing is an additional clinical feature than can be seen in patients with recurrent lung abscesses
What do you need to spefically look at on a blood test prior to treating a pneumothorax with a chest drain? [1]
Correct clotting abnormalities (INR ≥1.5 or platelets ≤50 x 10⁹/L) before inserting a chest drain in patients who are not critically unwell
What is the most common finding of an ABG of pneumothorax patient? [1]
respiratory alkalosis is the most common finding
Describe the location of chest drain procedure [4]
Chest drains are inserted in the “triangle of safety”. This triangle is formed by the:
- 5th intercostal space (or the inferior nipple line)
- Midaxillary line (or the lateral edge of the latissimus dorsi)
- Anterior axillary line (or the lateral edge of the pectoralis major)
The needle is inserted just ABOVE the rib to avoid the neurovascular bundle that runs just below the rib. Once the chest drain is inserted, obtain a chest x-ray to check the positioning.
What should you do to check positioning of chest drain? [1]
Once the chest drain is inserted, obtain a chest x-ray to check the positioning.
How long do most pneumothoraces resolve with a chest drain? [1]
What would you call it if after two days there was no resolution? [1]
Should resolve in 2-3 days
If not: called a persistent air leak - call the thoracic surgeons
How do you manage secondary pneumothorax persistent leak? [1]
Risk of surgery is greater: need to consider risk benefit:
- medical pleurodesis: put talc through chest drain (not as effective as surgical pleurodesis & painful)
- Abrasive / surgical pleurodesis (using direct physical irritation of the pleura)
- Open thoracotomy
You are a junior doctor on A+E and your patient has become acutely short of breath. On examination, you become convinced that this patient has a left tension pneumothorax.
Which clinical signs would best support this diagnosis?
Left hyper-resonance, left trachial deviation, absent JVP
Left hyper-resonance, left trachial deviation, raised JVP
Left hyper-resonance, right trachial deviation, raised JVP
Left hypo-resonance, left trachial deviation, absent JVP
Left hyper-resonance, right trachial deviation, absent JVP
You are a junior doctor on A+E and your patient has become acutely short of breath. On examination, you become convinced that this patient has a left tension pneumothorax.
Which clinical signs would best support this diagnosis?
Left hyper-resonance, right trachial deviation, raised JVP
How do you manage haemothoraxes? [4]
- Sufficient analgesia
- For trauma cases: tranexamic acid
- The majority of haemothorax require the insertion of a surgical chest drain, to evacuate the blood from the pleural cavity
- For patients with large volume blood loss (approx. >1500ml) or continuing moderate volume blood loss (approx. >200ml per hour), surgical exploration should be considered, in attempt to identify and stop the bleeding vessel - usually via VATS
Timing of VATS is crucial when evacuating a haemothorax, ideally being performed within 48-72 hours, to enable successful evaluation and early re-expansion of the lung.
State 5 drugs that cause exudative pleuritic effusion
nitrofurantoin
valproate
propylthiouracil
dantrolene (used for motor neurone)
methotrexate
Describe the clinical presentation of Meig’s syndrome [3]
TOM TIP: Meigs syndrome involves a triad of a :
- benign ovarian tumour (usually a fibroma)
- pleural effusion
- ascites.
This often appears in exams. The pleural effusion and ascites resolve with the removal of the tumour.
In some causes of pleural effusions, RBC might be found in the pleural fluid. State the causes where this could occur [4]
malignancy
trauma
parapneumonic effusions
pulmonary embolism
A raised lymphocyte count in pleural fluid would most likely indicate which two causes of pleural effusion? [2]
If the lymphocyte population is >90%, lymphoma and TB are the two most likely diagnoses.
How would pH analysis of pleural fluid help to determine cause? [3]
< 7.20 in complicated parapneumonic effusion & empyema, rheumatoid arthritis, or advanced malignancy
How would glucuose analysis of pleural fluid help to determine cause? [4]
Low glucose (< 3.3 mmol/L (60 mg/dL)) in empyema, rheumatoid arthritis, TB, and malignancy
How do you investigate for mesothelioma? [4]
-
CXR:
either a pleural effusion or pleural thickening - next step is normally a CT thorax
- if a pleural effusion is present fluid should be sent for MC&S, biochemistry and cytology (but cytology is only helpful in 20-30% of cases)
-
local anaesthetic thoracoscopy is increasingly used to investigate cytology negative exudative effusions as it has a high diagnostic yield (around 95%)
if an area of pleural nodularity is seen on CT then an image-guided pleural biopsy may be used
Describe the treatment algorithm for a patient with mesothelioma with inoperable disease [3]
1ST LINE – chemotherapy and/or immunotherapy
CONSIDER – radiotherapy
CONSIDER – palliative procedures + supportive care
- Therapeutic thoracentesis and pleurodesis may provide symptomatic relief.
In patients with inoperable or recurrent mesothelioma, chemotherapy and/or immunotherapy is often given in an attempt to improve quality of life and survival.
What is this? [1]
When is it indicated? [1]
Mandibular splint
If CPAP not tolerated
What is the most common surgery for sleep apnoea? [1]
Surgery is an option but involves significant surgical reconstruction of the soft palate and jaw. The most common procedure is called uvulopalatopharyngoplasty (UPPP).
Describe the pathophysiology of asthma
Airway inflammation:
- Immune cells activated by TH2, mast cells and eosinophils
- Causes pro-inflam mediators (cytokines, chemokines, histamines, leukotrines) to cause airway oedema, mucus production, and bronchoconstriction
Bronchoconstriction
- narrowing of the airways and obstruction of airflow.
Airway hyperresponsiveness
- airways exhibit excessive narrowing in response to various stimuli, such as allergens, irritants, and cold air
- mediated by several factors, including the release of inflammatory mediators, increased airway smooth muscle contractility, and impaired bronchodilator mechanisms
Mucus production and airway remodeling:
* Chronic inflammation causes airway remodeling
* Subepithelial fibrosis, increased smooth muscle mass, mucus gland hypertrophy, and angiogenesis.
What five steps should you educate / make on self management plans for patietns? [5]
How to use treatment
Self monitoring/assessment skills
Action plan with regard to goals
Recognition and management of exacerbations
Allergen/trigger avoidance
What are the different colours of venturi mask colours? [6]
What are the oxygen flow rate (L/min) for these different colours of venturi mask? [6]
What are the FiO2 (approx. oxygen) delivered for these different colours of venturi mask? [6]
Label A-F
A: Blue
B: White
C: Orange
D: Yellow
E: Red
F: Green
