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Respiratory Medicine > Respiratory Med > Flashcards

Respiratory Med Flashcards

1
Q

What symptoms are indicative of pneumothorax?

A

Sudden onset
SOB
Decreased breath sounds
COPD as risk factor

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2
Q

What is pulmonary oedema?

A

Fluid overload in the lung secondary to underlying cause e.g. MI

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3
Q

What are the three sections under HPC?

A

Symptom characteristic
Associated symptoms
DDx and RFs

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4
Q

What associated symptoms are important to ask in a resp history?

A

Cough
Sputum
Haemoptysis
Weight loss

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5
Q

What questions should you ask when considering PE?

A 
Immobile
Previous surgery
Recent travel
FH of DVT
Malignancy - PMH or FH
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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

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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

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8
Q

What do we mean by primary vs. secondary pneumothorax?

A

Secondary is when there is underlying lung disease

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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

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10
Q

What makes it more likely to be a tension pneumothorax?

A

Tracheal deviation
Trauma
Unlikely to see CXR since its an emergency

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11
Q

What do you see on an ECG in AF?

A

no P-waves

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12
Q

Which leads would should an inferior MI on an ECG?

A

II, III, aVF

ST elevation

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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

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14
Q

How do you know if there is a RBBB?

A

MarrowW

V1 - M
V6 -W

RBBB

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15
Q

How do you know if there is a LBBB?

A

WilliaM

V1 - W
V6 - M

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16
Q

Why might a patient presenting with SOB have RBBB?

A

Pulmonary hypertension

PE causing strain on the right side of the heart

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17
Q

What is a cause of LBBB?

A

Acute coronary syndrome

Ischaemia

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18
Q

What is the treatment for PE?

A

If haemodynamically stable:

Anti-coagulate with Apixaban or Rivaroxiban. LMWH if unsuitable.

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19
Q

What is vanishing lung syndrom?

A

Large bullae - do NOT put in a chest drain

if in doubt need a chest drain

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20
Q

On CXR what would you see in pulmonary oedema?

A

Air-space shadowing

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21
Q

On CXR what would you see in pulmonary fibrosis?

A

Reticular/nodular shadowing

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22
Q

What are some obstructive lung diseases?

A

COPD
Asthma

FEV1/FVC < 70%

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23
Q

What is asbestosis?

A

Pulmonary fibrosis
not
Asbestos plaques

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24
Q

Signs of COPD on CXR?

A

Hyperexpansion
Flat diaphragm
Raised clavicle

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25
Q

How do you present a chest xray?

A

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

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26
Q

How can you tell the difference between a large effusion and lung collapse?

A

Where the trachea is deviated to

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27
Q

What are the causes of pleural effusion?

A

Infection
Inflammation
Malignancy

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28
Q

What is reticulonodular shadowing indicative of?

A

Restrictive/Fibrotic disease

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29
Q

Why shouldn’t you use cardiomegaly, what term should you use instead?

A

Increased cardiac shadow

Do not know if it fluid around the heard or cardiomegaly

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30
Q

What is homogenous shadowing?

A

White

Pleural effusion

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31
Q

How can breathlessness be characterised?

A

Air hunger- gas exchange

Wheeze - obstruction, inflammation

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32
Q

What can be some triggers for breathlessness?

A

Exertion
Exercise
Laying flat

How far can you walk? MRC Breathlessness scale

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33
Q

Define tension pneumothorax

A

Life threatening condition defines as

  1. air trapped in the pleural cavity
  2. under a positive pressure
  3. causing cardiopulmonary compromise
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34
Q

What is the treatment for a tension pneumothorax?

A

Emergency needle decompression (2nd ICS at MCL)
High flow oxygen
Chest drain

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35
Q

How are pneumothoracies managed?

A

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

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36
Q

What is a pulmonary embolism?

A

Venous thrombi that pass into the pulmonary circulation causing occulsion

Normally arise from DVTs

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37
Q

How are PEs diagnosed?

A

Gold standard - CT Pulmonary Angiogram

Ventilation/Perfusion Scan - will demonstrate perfusion defects

Scoring tools

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38
Q

How are PEs managed?

A

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

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39
Q

What are signs of pulmonary oedema on CXR?

A

Alveolar oedma - white dots at peripheries

Kerley B lines

Cardiomegaly

Dilated upper lobe vessels

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40
Q

What are signs symptoms of pulmonary oedema?

A

Pitting odema
Breathlessness
Raised JVP

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41
Q

What is pulmonary oedema?

A

Acute accumulation of fluid within the lung parenchyma

Results in impaired gas exchange

42
Q

What are the causes of pulmonary oedema?

A

Cardiogenic - HF, Arrythmia, MI
Renal - Acute, severe kidney failure
ARDS - lung injury, infection e.g. covid

43
Q

What is the management of acute cardiogenic pulmonary oedema?

A

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
Q

What does CPAP do?

A

recruits alveoli

drives fluid out of alveolar spaces

45
Q

What are signs of life threatening asthma?

A

CHEST

Cyanosis
Hypotension
Exhaustion
Silent chest
Tachy/Brady/Arrhythmias
46
Q

What is conservative management for an asthma attack?

A

O2 aim for 98% sats
Bronchodilators
Steroids

If they improve:
Wean 02
Daily PEF
TAME (technique, avoid triggers,

47
Q

What is CAP?

A

Acute lower resp tract infection associated with fever and chest signs

48
Q

What will you find on auscultation in CAP?

A

Coarse crepitations
Dullness to percussion
Increased vocal fremitus

49
Q

How do we assess severity of CAP?

A 
CURB 65
Confusion
Urea > 7
Resp rate > 30bpm
B - SBP < 90mmHh
65 age
50
Q

What is whooping cough a common cause of?

A

Bronchiectasis in adulthood after whooping cough in childhood is commone

51
Q

What is bronchiectasis?

A

Permanent dilation of bronchi/bronchioles due to chronic inflammation

52
Q

What are the causes of bronchiectasis?

A

Congenital - CF, Primary ciliary dyskinesia, young’s syndrome

Acquired - post infection, aspergillosis, inflammatory diseases e.g. RA or UC

53
Q

How do we diagnose brochiectasis?

A

High res CT is gold standard

Bloods - Ig, HIV, FBC, autoimmune screen

Sputum - will commonly grow pseudomonas

Spirometry - obstructive pattern

54
Q

How do we treat bronchiectasis?

A

Chest physio

Mucolytics, ABx, Inhaled steroids, bronchodilators

Surgery on indicated in severe disease with haemoptysis

55
Q

What discharge advice should be give to people with small pneumothoraces?

A

Avoid smoking
No air travel for 2 weeks after successful drainage
Diving should be avoided unless bilateral surgical pleuroectomy has been performed

56
Q

What some RFs for pneumothorax?

A

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
Q

What are the symptoms of pneumothorax?

A 
dyspnoea
chest pain: often pleuritic
sweating
tachypnoea
tachycardia
58
Q

How does a spontaneous pneumothorax from?

A

Bullae breaks

Bullae form from air leaks from alveoli

59
Q

How does a traumatic pneumothorax form?

A

e.g. gunshot or stab wound
rips through parietal pleura
Air enters the pleural space

60
Q

What are clinical signs of pneumothorax?

A

Reduced breath sounds

Hyper-resonant when percussed

61
Q

What are some symptoms of PE?

A 
chest pain
typically pleuritic
dyspnoea
haemoptysis
tachycardia
tachypnoea
62
Q

What criteria is used to investigate PE?

A

2-level PE Wells score

63
Q

What features are present on a 2-level PE Wells score?

A

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
Q

What is the threshold score for the 2-level PE Wells score?

A

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
Q

What are the ECG changes seen in PE?

A

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
Q

Why is a CXR done in suspected PE, what is seen?

A

To exclude other pathology
Typically normal
Wedge shape opacification

67
Q

What is CTPA?

A

Computed tomography pulmonary angiogram

68
Q

What are some DOACs?

A

Apixiban

Rivaroxiban

69
Q

What are used first-line in the treatment of PE?

A

DOACs

Anticoagulation for 3 months at least

70
Q

What is used if DOACs are not suitable in PE?

A

LMWH

71
Q

When might DOACs be unsuitable for the treatment of PE?

A

Severe renal impairment <15mlmin

If pt has antiphospholipid syndrome

72
Q

What is provoked vs. unprovoked VTE?

A

Provoked - result of precipitating event e.g. surgery

Unprovoked - absence of precipitating event
3 further months of anti-coag

73
Q

What is the management of PE with haemodynamic instability?

A

thrombolysis - where there is circulatory failure (e.g. hypotension)

74
Q

What do thrombolytic drugs do?

A

Activate plasminogen to form plasmin

Degrades fibrin and breaks up thrombin

75
Q

What are some examples of thrombolytic drugs?

A

alteplase
tenecteplase
streptokinase

76
Q

Why is DVT more common in pregnancy?

A

pregnancy is a hypercoagulable state

majority occur in last trimester

77
Q

How do you manage DVT in pregnancy?

A

warfarin contraindicated

S/C low-molecular weight heparin preferred to IV heparin (less bleeding and thrombocytopenia)

78
Q

How does pleural effusion usually present?

A 
Breathlessness
Cough
Pleuritic chest pain
Dullness to percussion
Decreased tactile fremitus
Quieter breath sounds
79
Q

What do you see on a CXR in pleural effusion?

A

> 200ml of fluid

80
Q

What can US or CT be used for in pleural effusion?

A

Whether fluid is free-lowing or loculated

81
Q

What is the definitive treatment of pleural effusion?

A

Therapeutic thoracentesis

82
Q

Define pleural effusion

A

Fluid collects between the parietal and visceral surfaces of the thorax

83
Q

What are the RFs for pleural effusion?

A

Congestive HF
Pneumonia
Malignancy
Recent CABG

84
Q

What investigations are used in pleural effusion?

A 
PA CXR
Pleural US
LDH and protein in fluid and serum 
Cytology/Culture/Glucose/pH of fluid
BNP
85
Q

What is the significance of exudate and transudate?

A

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
Q

What are the typical findings of normal pleural fluid?

A 
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
Q

What are some causes of transudative pleural effusions?

A

Congestive heart failure
Liver cirrhosis
Severe hypoalbuminemia
Nephrotic syndrome

88
Q

What are some causes of exudative pleural effusions?

A 
Malignancy
Infection (e.g. empyema due to bacterial pneumonia)
Trauma
Pulmonary infarction
Pulmonary embolism
89
Q

What is the criteria used to diagnose exudative pleural effusion?

A

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
Q

What is the management for pleural effusion in HF?

A

Diuretic
Physio
+/- therapeutic thoracentesis

91
Q

Define asbestosis?

A

diffuse interstitial fibrosis of the lung as a consequence of exposure to asbestos fibres

92
Q

What are presenting features of asbestosis?

A 
Occupational exposure
Smoking
Dyspnoea on exertion 
Cough 
Crackles
93
Q

What investigations are done for asbestosis?

A

PA CXR

Pulmonary function tests (mixed obstructive/restrictive changes)

94
Q

What is the management of asbestosis?

A

Smoking cessation guidance
Supportive care e.g. ABs if signs of infection
Pulmonary rehab
Lung transplant

95
Q

What is pleurisy?

A

Pain on breathing

96
Q

What causes pain on inspiration?

A

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
Q

What are some causes of cyanosis?

A 
COPD
Bronchiolitis
Acute 'life-threatening' asthma 
Congenital heart disease
Acute HF
98
Q

What exposures are risks for occupational asthma?

A

Isocynates (spray paint)
Flour
Resins
Proteolytic enzymes

99
Q

What is the management for occupational asthma?

A

Avoidance of irritant/sensitiser

Inhaled corticosteroids and brochodilators

100
Q

What is fibrotic lung disease?

A

life-threatening disease that manifests over several years and is characterised by the formation of scar tissue within the lungs and progressive dyspnoea

101
Q

What are presenting features of fibrotic lung disease?

A 
Dypnoea
Cough
Crackles
Male, Older, FH
Smoking
102
Q

What is the management for fibrotic lung disease?

A

Antifibrotic therapy
Smoking cessation
Pulmonary rehabilitation
PPI

OR

Lung transplant

Respiratory Medicine (12 decks)

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