Respiratory IM Flashcards
Presentation of PE?
Dyspnea (73%)
Pleuritic chest pain (66%)
Cough (37%)
High RR (>70%)
Crackles (51%)
Tachycardia (30%)
Fever, cyanosis
Massive PE shows syncope, hypotension, PEA, CCF
Clinical diagnosis of tension pneumothorax?
Hypotension
Neck vein distension
Severe respiratory distress
Deviated trachea
Subcutaneous emphysema
Hypotension confirms pneumothorax is a tension pneumothorax
Neck veins may be flat due to hypotension
Small bilateral effusions with other clinical and XR manifestations of fluid overload, are usu due to fluid overload itself. Most other effusions should undergo _____
Undergo diagnostic pleural tap, unless cause is obvious.
How to classify effusion as exudate or transudate?
Light Criteria
Based on its protein and LDH.
Effusion is exudative if 1/3 is positive:
1. pleural fluid protein/serum protein >0.5
2. Pleural LDH/serum LDH >0.6
3. Pleural LDH exceeds 2/3 of upper normal limit for serum.
Causes of ILD?
Exposure-related = asbestosis, silicosis, hypersensitivity pneumonitis
**Drug-related **= amiodarone, methotrexate etc
**Rheum-related **= scleroderma, RA
Primary diffuse parenchymal lung disease
Reid classification for bronchiectasis?
Normal
Cylindrical
Varicose
Cystic
Commonest cause is post-infective
Light criteria for transudative vs exudative pleural effusion?
Pleural fluid protein/serum protein ratio = above or below 0.5?
Pleural fluid LDH/serum LDH ratio = above/below 0.6?
Pleural fluid LDH = above/below 2/3 the upper limit of normal serum LDH?
If below the stated parameters, then transudative.
If above the stated
Causes of transudative effusions?
Congestive HF
Hepatic cirrhosis
Nephrotic syndrome
Protein-losing enteropathy
CKD (Na+ retention)
How much pleural fluid do u need to be symptomatic?
300ml
4 stages of pleural effusion?
Transudative stage
Exudative stage
Fibrinopurulent stage
Organization stage
Grading for severity of dyspnea?
mMRC Grade 0 = SOB with strenuous exercise
Grade 1 = SOB on hurrying up a slope
Grade 2 = I am slow or i have to stop for breath when walking up slope
Grade 3 = Stop for breath after walking 100m or after a few minutes on slope
Grade 4 = Too breathless to leave the house or ADLs.
What is fibronodular change of lungs a/w?
Higher risk of developing TB reactivation
Causes of Spontaneous pneumothorax?
- Primary = Ruptured subpleural apical blebs
- Secondary = COPD/Infection/cystic fibrosis/Marfan/Malignancy
Secondary causes of spontaneous pneumothorax?
COPD (smoking) = ruptured bullae in emphysema
Infection = TB, pneumocystis pneumonia
Cystic fibrosis = Bronchiectasis with obstructive emphysema +bleb/cyst rupture
Marfan
Malignancy
How long for orthopnea to manifest and recover?
Occurs rapidly within 1-2 mins of recumbency.
Can occur in any condition in which vital capacity is low e.g. COPD/diaphragmatic weakness
What is bullae?
Emphysema is a type of COPD that damages walls of alveoli.
This causes large air pockets called bullae, which hinder gas exchange
Diagnosis of OSA?
STOP BANG score
4 or more = high risk for OSA
Snoring
Tired in day?
Anyone observed u stopping breathing?
High BP
BMI >35
Age >50
Neck circumference >40cm
Male gender
COPD Assessment score?
How often u cough
How much mucus in cough/chest
How much tightness in chest
How breathless u feel after uphill
How much COPD limits home activities
How comfortable u feel leaving home with COPD
How well u sleep
How much energy u have
0-9 = Low
10-20 = Medium
21-30 = High
31-40 = Very high
Examples of Obstructive lung diseases
Asthma
Bronchiectasis
COPD
Examples of restrictive lung disease
ILD
Asbestosis
Chest wall e.g. AS, Scoliosis
Drug ADRs e.g. MTX
Nm disorders e.g. GBS, MG
In what cases do u not do spirometry?
Post-MI, dont do for one month
Dont do post-abdo surgery
Dont do in pneumothorax
What is SMART therapy for asthma?
Single maintenance and reliver therapy
Budesonide + Formoterol
Symbicort
Max dose 12 a day, but IRL usu dont exceed 4 a day
Seretide vs Symbicort?
Seretide is more potent and has higher proportion of ICS, but cannot use as reliever due to its Salmeterol slow onset.
Formoterol in symbicort is fast-acting
Symbicort can also be used in kids. from 7yo onwards. Cuz formoterol can use in kids, but salmeterol cannot
When to use mMrc dyspnea score vs CAT scoring?
mMrc only discusses breathlessness.
If pt has no SOB but has other COPD features, use CAT.
What does low PaO2 and P/F ratio show?
Low PaO2 means ARDS
P/F ratio shows degree of hypoxaemia
Signs of hyperinflated lungs on XR?
Flattened hemidiaphragm
Lungs extends past 6th rib anteriorly, 10th rib posteriorly
flattened hemidiaphragm is easier to catch on XR
In what position does neuromuscular disease worsen dyspnea?
When supine. Abdo contents are pushed up, restricting thoracic cavity expansion.
In which 2 situations do you do ABG?
- To confirm presence of respi failure
- Diagnose acid-base disturbance.
E.g. pt is on room air, but suddenly desaturates. Low O2 doesnt mean pure T1/T2 respi failure, hence need ABG.
So if pt is on room air, no need ABG.
Type 1 vs Type 2 respi failure?
T1 = hypoxic drive
T2 = hypercapnic
But in T2, they assume T1 is already present.
Common causes of chronic cough?
GERD
Smoking exposure
ACE-Is
Asthma / COPD
Upper airway cough syndrome
UACS previously known as post nasal drip
How to differentiate btw tension and normal pneumothorax?
Tracheal deviation
Hemodynamic compromise
Tension pneumo is mostly secondary
Severity of RSV infection?
Usu causes bronchitis and prolonged wheezing.
Usu no pneumonia or haemotypsis
Bronchoscopy vs IR-guided biopsy?
Bronchoscopy only used for staging, to see more central lesions OR to see peripheral lesions with dilated airways leading to them.
IR-guided biopsy is for peripheral lesions without airways leading to them
What is organization pneumonia?
Pneumonia without active inflammation.
Can be primary with no known cause
Can be secondary e.g. underlying cancer
Most patients respond to steroids. If unresponsive, suspect others like superimposing infections
Strict diagnosis of exclusion
What does alpha-1-trypsin deficiency cause?
Affects liver and lungs
Causes COPD - mostly lower zone emphysema
Complicated vs Uncomplicated parapneumonic effusion?
Uncomplicated = no bacterial activity inside effusion
Complicated = bacterial activity. AKA EMPYEMA!!
Lung exudate obtained in suspected TB. What 4 things to check for?
Exudate obtained via thoracentesis
Gram stain
AFB
TB PCR
Adenosine Deaminase for TB (ADA)
What does ABG monitor for?
development of Respi failure or acid-base disturbances
How does asthma cause pulsus paradoxus?
Only in acute exacerbation!
During asthma attack, sides of the lungs swell and cause airways to narrow. When there is trouble getting air into lungs, lungs respond by overinflating. This overinflation puts pressure on arteries and can cause pulsus paradoxus.
What is sarcoidosis?
Multisystem inflammatory disorder. Non-caseating granulomas form most commonly in lungs and hilar LNs.
Mostly asymptomatic. Can present with constitutional symptoms, cough, dyspnea.
Cause thought to be related to environmental exposure in genetically predisposed pt.
Screen with CXR.
Treat with pred only if severe.
What characteristic of effusion in pneumonia indicates empyema?
Empyema is a collection of pus in pleural cavity
Parapneumonic effusion with pleural pH of 7.2/7.3 indicates empyema.
This is due to leukocyte phagocytosis and bacterial metabolism.
Bone mets from lung is usually?
Bone mets from lung usu osteolytic and not osteoblastic.
How can bronchogenic CA present in eyes?
It can cause ptosis by impinging on sympathetic trunk
Best test to visualize PE?
CT pulmonary angiogram.
NOT D-dimer!!! D-dimer is to exclude PE
Common pathogens for COPD exacerbation?
Strep pneumo
Moraxella Catarrhalis
Typical invx for COPD exacerbation?
ABG, CXR
Occupational hazard suggests what pathology?
Mesothelioma
Bilateral infiltrates.
Lymphopenia.
These point to what patho?
Viral pneumonia!!
bacterial pneumonia unlikely.
What hormones are secreted by SCLC?
ADH and ACTH.
SCLC cells show neuroendocrine differentiation
Curb-65 score for pneumonia?
Confusion
BUN >7mmol/L
Respi rate >30/min
BP = systolic below 90 or diastolic <60
Age >65 yo
2 points = consider admission
3 points = admit inpatient.
4 or 5 = consider ICU
How to pulmonary infarct due to PE show in imaging?
Wedge-shaped opacity
GOLD spirometric grades for COPD?
Postbronchodilator FEV1% of predicted value.
GOLD 1 = mild, >80%
GOLD 2 = moderate, 50-79%
GOLD 3 = severe, 30-49%
GOLD 4 = very severe, <30%
GOLD grouping for pharm treatment guiding?
GOLD A/B = 0 or 1 exacerbation with none leading to hospital admission
GOLD A = If mMRC 0-1, CAT <10
GOLD B = mMRC 2-4, CAT ≥10
GOLD E = 2 or more exacerbations OR at least 1 leading to hospital admission
COPD vs Asthma, which is a clinical diagnosis and which needs spirometry numbers for diagnosis?
Asthma can be diagnosed clinically.
COPD must have spirometry done showing obstructive picture.
5 types of pulmonary HTN?
- Pulmonary arterial HTN
- Pulm HTN due to L Heart disease
- Pulm HTN due to lung disease
- Pulm HTN due to chronic lung thromboembolism
- Idiopathic
Cutoff for bronchodilator reversibility?
Rise of 12%
AND
200ml rise in FEV1
Management of acute sinusitis?
Symptoms should end in 10 days.
Do not offer abx + symptomatic treatment
If symptoms over 10 days, consider high-dose nasal steroid. No abx yet.
If VERY unwell + red flags, offer immediate abx + refer out
What 4 signs significantly raise likelihood of pneumonia?
Dementia
Dullness to percussion
Bronchial breath sounds
Vocal resonance
How to treat Pulmonary embolism?
Anticoagulants.
In severe PE, give tPA for thrombolytic therapy.
