Respiratory Med Flashcards
1
Q
What symptoms are indicative of pneumothorax?
A
Sudden onset
SOB
Decreased breath sounds
COPD as risk factor
2
Q
What is pulmonary oedema?
A
Fluid overload in the lung secondary to underlying cause e.g. MI
3
Q
What are the three sections under HPC?
A
Symptom characteristic
Associated symptoms
DDx and RFs
4
Q
What associated symptoms are important to ask in a resp history?
A
Cough
Sputum
Haemoptysis
Weight loss
5
Q
What questions should you ask when considering PE?
A
Immobile Previous surgery Recent travel FH of DVT Malignancy - PMH or FH
6
Q
What conditions are associated with different onsets of SOB?
A
Onset - seconds/minutes/days-weeks
Seconds - foreign body, PE, pneumothorax
Minutes - asthma exacerbation (inflammation), acute heart failure (fluid), infection (pus)
Weeks - Plural effusion, anaemia, chronic heart failure
7
Q
How do we treat pneumothorax?
A
Oxygen
Primary
<2cm - discharge, repeat CXR
> 2cm/SOB - aspiration, if unsuccessful chest drain
Secondary
<2cm - aspiration
>2cm - chest drain
8
Q
What do we mean by primary vs. secondary pneumothorax?
A
Secondary is when there is underlying lung disease
9
Q
Pt. with pneumothorax improves after chest drain insertion but 2 hours later has recurrent SOB, why?
A
re-expansion pulmonary oedema
fluffy shadowing seen on CXR
10
Q
What makes it more likely to be a tension pneumothorax?
A
Tracheal deviation
Trauma
Unlikely to see CXR since its an emergency
11
Q
What do you see on an ECG in AF?
A
no P-waves
12
Q
Which leads would should an inferior MI on an ECG?
A
II, III, aVF
ST elevation
13
Q
How can we determine the axis?
A
Look at I and II - are either of them overall more negative
Yes - axis deviation
Is aVL overall positive?
Yes - left axis deviation
No - right axis deviation
14
Q
How do you know if there is a RBBB?
A
MarrowW
V1 - M
V6 -W
RBBB
15
Q
How do you know if there is a LBBB?
A
WilliaM
V1 - W
V6 - M
16
Q
Why might a patient presenting with SOB have RBBB?
A
Pulmonary hypertension
PE causing strain on the right side of the heart
17
Q
What is a cause of LBBB?
A
Acute coronary syndrome
Ischaemia
18
Q
What is the treatment for PE?
A
If haemodynamically stable:
Anti-coagulate with Apixaban or Rivaroxiban. LMWH if unsuitable.
19
Q
What is vanishing lung syndrom?
A
Large bullae - do NOT put in a chest drain
if in doubt need a chest drain
20
Q
On CXR what would you see in pulmonary oedema?
A
Air-space shadowing
21
Q
On CXR what would you see in pulmonary fibrosis?
A
Reticular/nodular shadowing
22
Q
What are some obstructive lung diseases?
A
COPD
Asthma
FEV1/FVC < 70%
23
Q
What is asbestosis?
A
Pulmonary fibrosis
not
Asbestos plaques
24
Q
Signs of COPD on CXR?
A
Hyperexpansion
Flat diaphragm
Raised clavicle
25
How do you present a chest xray?
This is PA/AP CXR of:
Name and DOB
Taken at time
Commenting on the quality of the film:
Rotation
Inspiration
Penetration (look at appearance of vertebrae)
Compare Left and Right
Look for shadowing
Look at the peripheral margins
26
How can you tell the difference between a large effusion and lung collapse?
Where the trachea is deviated to
27
What are the causes of pleural effusion?
Infection
Inflammation
Malignancy
28
What is reticulonodular shadowing indicative of?
Restrictive/Fibrotic disease
29
Why shouldn't you use cardiomegaly, what term should you use instead?
Increased cardiac shadow
Do not know if it fluid around the heard or cardiomegaly
30
What is homogenous shadowing?
White
| Pleural effusion
31
How can breathlessness be characterised?
Air hunger- gas exchange
| Wheeze - obstruction, inflammation
32
What can be some triggers for breathlessness?
Exertion
Exercise
Laying flat
How far can you walk? MRC Breathlessness scale
33
Define tension pneumothorax
Life threatening condition defines as
1. air trapped in the pleural cavity
2. under a positive pressure
3. causing cardiopulmonary compromise
34
What is the treatment for a tension pneumothorax?
Emergency needle decompression (2nd ICS at MCL)
High flow oxygen
Chest drain
35
How are pneumothoracies managed?
Determine whether it is primary or secondary
Categorise the size and if >2cm aspirate
If <2cm they can go home
But if secondary they need chest drain and admission
36
What is a pulmonary embolism?
Venous thrombi that pass into the pulmonary circulation causing occulsion
Normally arise from DVTs
37
How are PEs diagnosed?
Gold standard - CT Pulmonary Angiogram
Ventilation/Perfusion Scan - will demonstrate perfusion defects
Scoring tools
38
How are PEs managed?
ABCDE - haemodynamicaly stable?
```
Unstable
Oxygen, fluids
Urgent thrombolysis - local or systemic
OR
Percutaneous embolectomy
```
Stable
Risk stratification
Low risk - LMWH (cancer), DOAC and Warfarin for 3 months
Moderate to high - admit
39
What are signs of pulmonary oedema on CXR?
Alveolar oedma - white dots at peripheries
Kerley B lines
Cardiomegaly
Dilated upper lobe vessels
40
What are signs symptoms of pulmonary oedema?
Pitting odema
Breathlessness
Raised JVP
41
What is pulmonary oedema?
Acute accumulation of fluid within the lung parenchyma
| Results in impaired gas exchange
42
What are the causes of pulmonary oedema?
Cardiogenic - HF, Arrythmia, MI
Renal - Acute, severe kidney failure
ARDS - lung injury, infection e.g. covid
43
What is the management of acute cardiogenic pulmonary oedema?
Give O2 if hypoxic
High dose IV diuretics - Furosemide bolus
Treat cause e.g. beta blockers for arrhythmia
NO improvement - then
Nitrate infusion e.g GTN if BP is high enough >100mg systolic
Consider CPAP
44
What does CPAP do?
recruits alveoli
| drives fluid out of alveolar spaces
45
What are signs of life threatening asthma?
CHEST
```
Cyanosis
Hypotension
Exhaustion
Silent chest
Tachy/Brady/Arrhythmias
```
46
What is conservative management for an asthma attack?
O2 aim for 98% sats
Bronchodilators
Steroids
If they improve:
Wean 02
Daily PEF
TAME (technique, avoid triggers,
47
What is CAP?
Acute lower resp tract infection associated with fever and chest signs
48
What will you find on auscultation in CAP?
Coarse crepitations
Dullness to percussion
Increased vocal fremitus
49
How do we assess severity of CAP?
```
CURB 65
Confusion
Urea > 7
Resp rate > 30bpm
B - SBP < 90mmHh
65 age
```
50
What is whooping cough a common cause of?
Bronchiectasis in adulthood after whooping cough in childhood is commone
51
What is bronchiectasis?
Permanent dilation of bronchi/bronchioles due to chronic inflammation
52
What are the causes of bronchiectasis?
Congenital - CF, Primary ciliary dyskinesia, young's syndrome
Acquired - post infection, aspergillosis, inflammatory diseases e.g. RA or UC
53
How do we diagnose brochiectasis?
High res CT is gold standard
Bloods - Ig, HIV, FBC, autoimmune screen
Sputum - will commonly grow pseudomonas
Spirometry - obstructive pattern
54
How do we treat bronchiectasis?
Chest physio
Mucolytics, ABx, Inhaled steroids, bronchodilators
Surgery on indicated in severe disease with haemoptysis
55
What discharge advice should be give to people with small pneumothoraces?
Avoid smoking
No air travel for 2 weeks after successful drainage
Diving should be avoided unless bilateral surgical pleuroectomy has been performed
56
What some RFs for pneumothorax?
Pre-existing lung disease e.g. COPD, asthma, CF
Connective tissue disease e.g. Marfans, RA
Ventilation e.g. NIV
Tall and slender build
< 40 years old
57
What are the symptoms of pneumothorax?
```
dyspnoea
chest pain: often pleuritic
sweating
tachypnoea
tachycardia
```
58
How does a spontaneous pneumothorax from?
Bullae breaks
| Bullae form from air leaks from alveoli
59
How does a traumatic pneumothorax form?
e.g. gunshot or stab wound
rips through parietal pleura
Air enters the pleural space
60
What are clinical signs of pneumothorax?
Reduced breath sounds
| Hyper-resonant when percussed
61
What are some symptoms of PE?
```
chest pain
typically pleuritic
dyspnoea
haemoptysis
tachycardia
tachypnoea
```
62
What criteria is used to investigate PE?
2-level PE Wells score
63
What features are present on a 2-level PE Wells score?
Clinical signs and symptoms of DVT (minimum of leg swelling and pain with palpation of the deep veins) - 3
An alternative diagnosis is less likely than PE - 3
Heart rate > 100 beats per minute - 1.5
Immobilisation for more than 3 days or surgery in the previous 4 weeks - 1.5
Previous DVT/PE - 1.5
Haemoptysis - 1
Malignancy (on treatment, treated in the last 6 months, or palliative) - 1
64
What is the threshold score for the 2-level PE Wells score?
PE likely - more than 4 points (arrange CTPA, interim anticoag if waiting)
PE unlikely - 4 points or less
(check D-dimer and if pos do CTPA)
65
What are the ECG changes seen in PE?
Large S wave in Lead I
Large Q wave in Lead III
Inverted T wave in Lead II
S1Q3T3
Only in 20% of patients
66
Why is a CXR done in suspected PE, what is seen?
To exclude other pathology
Typically normal
Wedge shape opacification
67
What is CTPA?
Computed tomography pulmonary angiogram
68
What are some DOACs?
Apixiban
| Rivaroxiban
69
What are used first-line in the treatment of PE?
DOACs
| Anticoagulation for 3 months at least
70
What is used if DOACs are not suitable in PE?
LMWH
71
When might DOACs be unsuitable for the treatment of PE?
Severe renal impairment <15mlmin
If pt has antiphospholipid syndrome
72
What is provoked vs. unprovoked VTE?
Provoked - result of precipitating event e.g. surgery
Unprovoked - absence of precipitating event
3 further months of anti-coag
73
What is the management of PE with haemodynamic instability?
thrombolysis - where there is circulatory failure (e.g. hypotension)
74
What do thrombolytic drugs do?
Activate plasminogen to form plasmin
| Degrades fibrin and breaks up thrombin
75
What are some examples of thrombolytic drugs?
alteplase
tenecteplase
streptokinase
76
Why is DVT more common in pregnancy?
pregnancy is a hypercoagulable state
| majority occur in last trimester
77
How do you manage DVT in pregnancy?
warfarin contraindicated
| S/C low-molecular weight heparin preferred to IV heparin (less bleeding and thrombocytopenia)
78
How does pleural effusion usually present?
```
Breathlessness
Cough
Pleuritic chest pain
Dullness to percussion
Decreased tactile fremitus
Quieter breath sounds
```
79
What do you see on a CXR in pleural effusion?
>200ml of fluid
80
What can US or CT be used for in pleural effusion?
Whether fluid is free-lowing or loculated
81
What is the definitive treatment of pleural effusion?
Therapeutic thoracentesis
82
Define pleural effusion
Fluid collects between the parietal and visceral surfaces of the thorax
83
What are the RFs for pleural effusion?
Congestive HF
Pneumonia
Malignancy
Recent CABG
84
What investigations are used in pleural effusion?
```
PA CXR
Pleural US
LDH and protein in fluid and serum
Cytology/Culture/Glucose/pH of fluid
BNP
```
85
What is the significance of exudate and transudate?
Exudate = fluid/serum protein ratio >0.5
OR
protein < 30g/L
Caused by infection, malignancy
Transudate
Caused by factors altering hydrostatic pressure etc.
Protein > 30g/L
86
What are the typical findings of normal pleural fluid?
```
Appearance: clear
pH: 7.60-7.64
Protein: < 2% (1-2 g/dL)
White blood cells (WBC): < 1000/mm³
Glucose: similar to that of plasma
LDH: <50% plasma concentration
Amylase: 30-110 U/L
Triglycerides: <2 mmol/l
Cholesterol: 3.5–6.5 mmol/l
```
87
What are some causes of transudative pleural effusions?
Congestive heart failure
Liver cirrhosis
Severe hypoalbuminemia
Nephrotic syndrome
88
What are some causes of exudative pleural effusions?
```
Malignancy
Infection (e.g. empyema due to bacterial pneumonia)
Trauma
Pulmonary infarction
Pulmonary embolism
```
89
What is the criteria used to diagnose exudative pleural effusion?
The ratio of pleural fluid to serum protein is greater than 0.5
The ratio of pleural fluid to serum LDH is greater than 0.6
The pleural fluid LDH value is greater than two-thirds of the upper limit of the normal serum value
90
What is the management for pleural effusion in HF?
Diuretic
Physio
+/- therapeutic thoracentesis
91
Define asbestosis?
diffuse interstitial fibrosis of the lung as a consequence of exposure to asbestos fibres
92
What are presenting features of asbestosis?
```
Occupational exposure
Smoking
Dyspnoea on exertion
Cough
Crackles
```
93
What investigations are done for asbestosis?
PA CXR
| Pulmonary function tests (mixed obstructive/restrictive changes)
94
What is the management of asbestosis?
Smoking cessation guidance
Supportive care e.g. ABs if signs of infection
Pulmonary rehab
Lung transplant
95
What is pleurisy?
Pain on breathing
96
What causes pain on inspiration?
Virus - flu most commonly
bacterial infections e.g. pneumonia or tuberculosis
PE
injury – if the ribs are bruised or fractured, the pleura can become inflamed
lung cancer
autoimmune conditions e.g. rheumatoid arthritis and lupus
97
What are some causes of cyanosis?
```
COPD
Bronchiolitis
Acute 'life-threatening' asthma
Congenital heart disease
Acute HF
```
98
What exposures are risks for occupational asthma?
Isocynates (spray paint)
Flour
Resins
Proteolytic enzymes
99
What is the management for occupational asthma?
Avoidance of irritant/sensitiser
| Inhaled corticosteroids and brochodilators
100
What is fibrotic lung disease?
life-threatening disease that manifests over several years and is characterised by the formation of scar tissue within the lungs and progressive dyspnoea
101
What are presenting features of fibrotic lung disease?
```
Dypnoea
Cough
Crackles
Male, Older, FH
Smoking
```
102
What is the management for fibrotic lung disease?
Antifibrotic therapy
Smoking cessation
Pulmonary rehabilitation
PPI
OR
Lung transplant
