Respiratory Medicine Flashcards
Define
Dyspnoea:
Exertional Dyspnoea:
Paroxysmal Nocturnal Dyspnoea:
Dyspnoea: Shortness of breath
Exertional Dyspnoea: Shortness of breath on exertion
Paroxysmal Nocturnal Dyspnoea: Acute shortness of breath awakening patient from sleep.
Define Orthopnoea?
What is it associated with
Dypsnoea on lying flat, relieved by sitting up.
Left heart dysfunction, pulmonary oedema, and cor pulmonare
Paroxysmal nocturnal dyspnoea is the acute shortness of breath awakening a patient from sleep. The patient would need to sit up or get out of bed for relief. What is this associated with?
pulmonary oedema and cor pulmonare
What is the normal RR for different ages?
<1yo - 30-40
1-5 - 25-35
5-12 - 20-25
12+ 12-20
Give 1 cause of increased RR from each of the following categories
Lung disease:
Heart disease:
Metabolic:
Drugs:
Psychological:
Then give 4 causes of reduced RR
Lung disease: Pneumonia, asthma
Heart disease: LVF
Metabolic: Ketoacidosis
Drugs: Salicylates
Psychological: Anxiety
Reduced RR:
CNS disease: Brainstem lesions, Guillain barre
Neuromuscular disease (myasthenia gravis)
Opioids
Kyphoscoliosis (limits chest expsnsion)
Give 20 ddx for Dyspnoea (good luck!)
Cardiac:
Acute: Arrhythmia (A.fib), MI, LVF, Aortic dissection, pericarditis, tamponade
Chronic: Congestive cardiac failure, valvular disease, Congenital heart disease
Resp:
Acute: Asthma exacerbation, COPD exacerbation, pneumonia, PE, pneumothorax, pleural effusion, upper airway obstruction
Chronic: Asthma, COPD, CF, Lung Ca, Mesothelioma
Other:
Acute: Ketoacidosis (Kussmaul breathing), MSK pain (costochondritis), oesophagitis/pain, salicylates, thyrotoxicosis
Chronic: Obesity, anemia, neuromuscular
Define Kussmaul breathing
Deep, sighing breathing due to metabolic acidosis commonly seen in diabetic ketoacidosis.
Define Cheyne-Stokes Respiration
What is it caused by?
Breathing gets progressively deeper and shallower +/- episodic apnoea
Caused by brainstem lesions/compression (stroke/TIA), pulmonary oedema
Neurogenic hyperventilation is one of the causes of dyspnoea. What are examples of this?
Stroke, tumour, CNS infection. This puts pressure on the brainstem => Cheyne-stokes respiration
Give 7 ddx for acute Dyspnoea + Chest pain
Cardiac: MI, Pericarditis, dissecting aneurysm
Resp: PE, pneumonia, pulmonary malignancy
Other: MSK pain/Costochondritis, oesophageal pain/spasm/itis
How can a pulmonary malignancy cause acute chest pain and SOB?
Superior vena cava obstruction
How does superior vena cava obstruction present
Remember the cause would be a pulmonary malignancy
=> Obstruction: Acute breathlessness + headache worse on stooping + Swelling of face and neck (increased ICP)
+
=> Malignancy: Haemoptysis, unexplained cough, reduced weight and appetite, fatigue
What timeframe would be considered an acute cough?
Acute cough <3 weeks => chronic is >3 weeks
Give 5 causes of acute and 5 causes of a chronic cough
Acute:
1) URTI
2) Croup
3) Bronchitis
4) Acute exacerbation of COPD/Asthma
5) Tumour
6) Pneumonia
Chronic:
1) Post-nasal drip
2) Post-viral
3) COPD/Asthma
4) Lung Ca
5) TB, Pertussis
6) Bronchiectasis
7) Cystic fibrosis
8) Pulmonary oedema
9) GORD!
10) ACEinhibitors
11) Smoking
You ask for a sputum sample from the patient with a cough. What does each of the following sputum samples indicate?
Clear:
Black specks:
Yellow-green:
Pink Froth:
Clear: Normal saliva, maybe test for Tb
Black specks: Smoking
Yellow-green: Bronchiectasis, cellular debris (infection)
Pink Froth: Pulmonary oedema => do CXR
Blood in sputum always requires investigation => requires urgent referral or emergency admission. Give 5 causes of Haemoptysis
1) Infection (bronchitis, abscess Tb)
2) Lung Ca/Bronchial adenoma
3) PE
4) Anticoagulation (iatrogenic)
5) Trauma (violent coughing)
6) Cardiac (acute LVF, Mitral stenosis)
7) Collagen vascular disease e.g. Wegner’s/polyangitis with granulomatosis
8) Good Pasture’s Syndrome
9) Bronchiectasis!
Bronchiectasis is the permanent widening of the bronchioles due to chronic inflammation and infection. What is the typical presentation of a patient with bronchiectasis?
Include Examination findings
Mild: Asymptomatic with prolonged winter exacerbations (fever cough, purulent green sputum, pleuritic chest pain, dyspnoea)
Moderate/severe: Persistent or recurrent chest infection, haemoptysis, clubbing, inspiratory/exp. crackles + wheeze
What are the causes of bronchiectasis
1) Cilia => CF, PCD, Kartagener syndrome, smoking
2) Post-infection: TB, Pertussis, measles, pneumonia
3) Other: Bronchial obstruction, gastric aspiration, aspergillosis
What investigations would you perform on a patient presenting with recurrent chest infections on a background of CF? What is the gold standard for diagnosis?
Chest Xray
CT chest (gold standard)
What is involved in the management of bronchiectasis
Referral to resp physician
Chest physiotherapy
Antibiotics
Bronchodilators
Vaccination for influenza and pneumococcus.
Define Asthma
Asthma is a condition of paroxysmal, reversible airway obstruction characterized by
1) Reversible airflow limitation
2) Airway hyper-responsiveness to wide range of stimuli
3) Inflammation of the bronchi
What are the symptoms of Asthma along with characteristic features
These features allow for clinical suspicion of asthma. What are the diagnostic tests you would perform to complete the diagnosis?
1) Recurrent episodic asthma symptoms: Wheeze, breathlessness, chest tightness, cough
2) Diurnal variability
3) Audible expiratory wheeze
4) Variable airflow obstruction (PEFR)
Diagnosis:
1) Spirometry demonstrating reversibility
2) FBC showing raised eosinophils
3) CXR showing hyperinflation and bronchial thickening
How is spirometry conducted?
What findings would be consistent with the diagnosis of asthma?
Spirometry is conducted initially to achieve baseline. 400mcg of salbutamol (SABA) is then given via a spacer. Spirometry is then conducted again 20 minutes later.
200+ increase in PEFT suggests asthma
400+ is a strong indication
Alternatively this can be tested before and after a 6 week trial of BD beclomethasone.
What is the difference between spirometry and peak flow
Spirometry allows you to measure all the components of breathing (vital capacity, tidal flow…). Peak flow is not as comprehensive and only measures the maximum speed of airflow during expiration. It is useful in monitoring.
What is occupational asthma and how would you enquire about it in the history?
Occupational asthma is reversible airway obstruction due to the work environment such as in factories
Breathing better when on holidays or days away from work?
What is the diagnostic definition of airflow obstruction?
FEV1/FVC <0.7
Give 6 differentials for airway obstruction (FEV1/FVC <0.7)
Asthma
COPD
Foreign body
Lung Ca
GORD
HF/pulmonary oedema
Pulmonary fibrosis
Bronchiectasis
Sarcoidosis
Hyperventilation syndrome
How would you identify a severe asthma attack/exacerbation?
How would you correctly identify if it is life threatening?
Severe asthma:
PEFR 33-50%
O2 Sat >92%
Unable to complete sentences
Tachypnea/tachycardia
Life Threatening
PEFR <33%
O2 Sat <92%
Altered conciousness
Cyanosis
Hypotension
Exhaustion
Silent chest
Tachycardia
What questionnaire is used to objectively measure asthma control
RCP3 questionnaire
What advice would you give an asthmatic patient as part of your conservative management?
Allergen avoidance
Correct technique of spacer
Medication adherence
Weight loss (a/w improved sx)
Tailored action plan in case of exacerbation
Advice for vaccination for exacerbation prevention
An asthmatic patient presents to you for their annual checkup. What will you do during the review
Symptoms: RCP3
Smoking -> Cessation
Exacerbations: Asthma diary -> Update medications
Examination: Spirometry, PEFR
Education: Tailored to patient, Allergen avoidance, Weight loss, action plan
Medication: Use, aherence, inhaler technique, side effects.
Prevention: Influenza and pneumococcal vaccine
What does Symbicort contain? (include type of drug and name)
Contains both
Inhaled corticosteroid: Budenoside
LABA: Fomoterol
What does seretide contain? (include type of drug and name)
ICS: Fluticazone
LABA: Salmeterol
What is the role of leukotrienes in the management of asthma
Leukotriene !receptor antagonists! such as montelukast block the leukotriene pathway involved in bronchoconstriction, inflammation, and mucous production
It is used for mild-moderate asthma in those who prefer oral rather than inhaled medication
A patient on high dose seretide has presented complaining of excessive exacerbations. medication adherence and inhaler technique are correct. She is a non-smoker. What is your next course of action
Referral to specialist to prescribe them biologic therapy (Omalizumab tagetting IgE or Mepolizumab and others which all target IL-5
According to the GINA guidelines, what is the medical management of asthma?
According to the British thoracic society, do the same
Step 1: PRN Symbicort +/- PRN Salbutamol (SABA)
Step 2: OD Symbicort +/- PRN Salbutamol Alternatively Leukotriene receptor antagonist (montelukast)
Step 3: Low dose Seretide
Step 4: Medium dose Seretide
Step 5: High dose Seretide
Step 6: Referral - Biologic therapy (Omalizumab)
Step 1: PRN SABA
Step 2: Inhaled ICS OD + PRN SABA
Step 3: Symbicort/Seretide + PRN SABA
Step 4: Increase ICS dose or Add LTRA
Step 5: Refer to Specialist for biologic therapy (Omalizumab)
A patient presents with acute exacerbation of asthma. He is tachypnoeic and tachycardic. SPO2 is 95%. How will you manage this patient
ABCDE
Take salbutamol 10x
Take salbutamol 10x again 20 minutes later
Prednisolone OD 40mg for 1-2 weeks
What is COPD?
Give 4 causes
Slowly progressive disorder characterised by airflow obstruction. Caused by
1) Tobacco smoking (90%)
2) Occupational exposure to pollutants
3) Genetic: alpha-1 Antitrypsin deficiency
4) Poor lung growth due to low birth weight and infections
Go through the Dyspnoea scale in relation to physical activity
1 - Only on strenuous exercise
2 - When hurrying up or going up a slight hill
3 - Walks slower than others or has to stop for breath
4 - Stops for breath after 100m
5 - Too breathless to leave home/ on dressing clothes
What would you like to elicit in a patient with COPD?
1) Weight
2) Exertional dyspnoea/ Effort intolerance
3) Chronic productive cough
4) Audible wheeze
5) Paroxysmal nocturnal dyspnoea (Do you ever wake up at night gasping for breath)
6) Orthopnea
7) Ankle Oedema
8) !!Smoking history
Rule out cardiac cause e.g. chest pain
T or F: Lung hyperinflation is a feature of CXR that is present in BOTH asthma and COPD.
True
How would you assess for lung hyperinflation without an X-ray?
Poor chest rise which is measured via Cricosternal distance. Here it would be reduced.
What is a normal cricosternal distance
Normal = 3-4 fingers or 3-6cm. Reduced in COPD
You are asked to conduct an examination on a patient with Exertional dyspnoea, an audible wheeze, frequent chest infections and bronchitis. They have a 40 pack-year smoking hx.
Go through what you are looking for on examination
Inspection:
1) Hyperinflated chest with poor chest rise => Reduced cricosternal distance (<3cm)
2) Pursed Lip breathing on expiration
3) Tachypnoea
4) Use of accessory muscles
5) Cyanosis
6) Cachexia
Palpation:
1) Reduced Cricosternal distance
2) Raised JVP
3) Cachexia
Percussion: Hyper-resonant chest/reduced cardiac dullness
Auscultation: Wheeze/quiet breath sounds
How would you differentiate between COPD and asthma?
1) Age: <35 asthma, >35 COPD
2) Smoking: More a/w. COPD (90%)
3) Good response to inhaled therapy on spirometry for asthma, poor response in COPD although both will have FEV1/FVC <0.7
4) Breathlessness variable throughout the day in asthma but persistent and progressive in COPD
5) COPD commonly has a chronic productive cough
6) Asthma more commonly has paroxysmal nocturnal dyspnoea
You have conducted Hx and Exam on a patient and findings are suggestive of an obstructive lung disease. What investigations would you perform?
How would you diagnose COPD and how is it classified?
Labs: FBC, U&E..
Alpha 1 antitrypsin
Pulse oximetry
CXR/CT to exclude other ddx
ECG/ECHO/BNP to exclude cardiac causes
BMI
Spirometry to diagnose COPD and exclude asthma
Diagnosis via Spirometery by calculating FEV1/FVC ratio (obstruction at <0.7)
Classification is based on PEFR
Stage 1 - >80% => Cough
Stage 2 - 50-79% => + dyspnoea + Wheeze => known to GP
Stage 3 - 30-49% => + Signs on exam + marked sx => known to specialist
Stage 4 - <30% => Severely restricted daily living
What is the conservative management of COPD?
1) Smoking cessation
2) Vaccination (influenza + pneumo)
3) Pulmonary/Chest physiotherapy
4) Weight loss
5) CBT, screen for depression
What is tiotropium?
Long acting Muscarinic/Anticholinergic (same thing) agonist used in steps 2 and 3 of the management of COPD
What guideline is used to manage a patient with COPD? Explain
What is the full management of COPD based on Oxford?
GOLD Guidelines. Based on
1) Risk: by number of moderate exacerbations/yr - 0,1 vs 2+ - (+ whether leading to hospital admission)
2) Disease impact based on CAT (COPD assessment test) or mMRC (modified medical research council dyspnoea questionnaire.
Group A: Low risk, Low Sx - SABA/SAMA
Group B: Low risk, High Sx - LABA/LAMA
Group C: High risk, Low Sx - LAMA
Group D: High risk, High Sx - LAMA or LAMA + LABA or ICS + LABA
Step 1: SABA/SAMA
Step 2: If asthma-like + LABA, otherwise +LABA+LAMA
Step 3: LABA + LAMA + ICS
+/- Mucolytics
+/- Antibiotics
Or Theophylline +/- Roflunilast (PDE4 inhibitor)
Give an example of a SAMA
Ipratropium
Give an example of a LABA
Formetorol (in Symbicort)
Give an example of a LAMA
Tiotropium
With a chronic productive cough in a COPD patient who is finding it hard to get rid of it, what will you prescribe? Give the name of the drug
Oral mucolytic therapy - Carbocisteine (Exputex)
What prophylactic Antibiotic would you give to patients with severe COPD?
Azithromycin
What is the role of Theophylline?
It is a bronchodilator, anti-inflammatory agent (both like montelukast), and CNS-stimulant used in refractory asthma AND COPD. Requires monitoring for serum drug levels
What is the medical management of COPD
Based on GOLD Guidelines
1) Bronchodilation
Group A: Low risk, Low Sx - SABA/SAMA (Salbutamol/Ipratropium)
Group B: Low risk, High Sx - LABA/LAMA (Formetorol/Tiotropium)
Group C: High risk, Low Sx - LAMA (Tiotropium)
Group D: High risk, High Sx - LAMA + LABA or ICS + LABA: Formetorol + Tiotropium or Seretide
2) Adjuvant: For more severe cases
a) Oral mucolytic therapy - Carbocisteine
b) Oral prophylactic antibiotics - Azithromycin
c) Roflunilast - PDE4 inhibitor to reduce exacerbations (only as an adjuvant as it does not bronchodilate)
4) Oxygen therapy (very very severe)
3) Theophylline for refractory Asthma or COPD
4) Oxygen therapy
The RF for asthma as well as COPD exacerbation are the same except with regards to physical activity. State 4 RF
1) Physical activity: Exacerbates asthma. The lack of exercise is a RF for COPD exacerbation
2) Smoking
3) Viral infection
4) Pollution
5) Seasonal variation
How are COPD exacerbations managed?
The same way you would manage acute asthma + antibiotics
=> Patients should have an individualised escalation/action plan to manage exacerbations.
=> Corticosteroids prednisolone 30-40mg OD
+ Send sputum culture!!! then give antibiotics (amoxicillin 500mg TDS)
If deterioration => send to hospital
Lung cancer is the 3rd most common cancer but the leading cause of cancer death. What are the different types?
Small Cell - 20%
Non-Small Cell Ca - 80% - Adeno or Squamous
A patient has lung Ca disseminated at diagnosis. What type is this likely to be?
Small Cell Lung Ca
What is a Pancoast Tumour?
What are it’s unique features?
Pancoast tumour is an apical lung cancer
It causes the loss of sympathetic stimulation from C8-T2 leading to Ipsilateral Horner’s Syndrome => Ptosis, Miosis, and Anhydrosis.
Also, Shoulder pain and hoarse voice due to phrenic nerve irritation and recurrent laryngeal nerve palsy
What are the 2 most important preventative measures for Lung Ca?
Smoking cessation
Diet (increased vegetable and fruit consumption a/w reduced incidence)
Give 6 sx of Lung Ca
1) B symptoms: Fever, night sweats, weight loss/anorexia
2) Chest/shoulder pain (phrenic nerve)
3) Hemoptysis
4) Dyspnoea
5) Finger clubbing
6) Hoarseness of voice (Recurrent laryngeal nerve)
7) Malaise
How would you manage a patient presenting with chronic hemoptysis, chest pain, unintentional weight loss.
Once the diagnosis is confirmed, Liase with MDT and refer to specialist oncologist
Active Tx will include radiotherapy, chemotherapy, and surgery
The role of the GP is to have regular followups with the patient
A lung Ca presenting with what 2 features would be red flags indicating emergency admission
Stridor
Evidence of superior vena cava obstruction (Swelling of face and neck, headache, fixed raised JVP
Common Cold typically lasts 7 days (adult) or 14 days (children), cough lasting up to 3 weeks.
What are the most common pathogens?
What complications would we be worried about?
How is it managed?
Rhinovirus > Coronavirus > Influenza viruses causing URTI
Complications:
Acute exacerbation of asthma and COPD
Superinfection w bacterial (5%)
Management: Rest + symptomatic management with paracetamol/ibuprofen.
Bronchitis typically resolves within 3 weeks.
Define Bronchitis
What are the sx of bronchitis?
How is it managed?
Inflammation of the major bronchi often following an URTI
Sx: Cough (+/- productive), breathlessness, wheeze, fever, sweats
Management:
Self-limiting illness => Rest + symptomatic management with paracetamol/ibuprofen.
Bronchodilators if wheeze heard
When would you prescribe antibiotics in an individual presenting with acute bronchitis?
Antibiotics are only given if systemically unwell or evidence of pneumonia or past hx of hospitalisation
Influenza causes annual epidemics due to constant minor shifts in surface proteins. Influenza presents, as with all these viral infections with fever, cough, sore throat, !myalgia, nausea, vomiting, headache…
What complications can influenza cause?
Give 5 RF of severe disease in influenza. What is the significance of these RF
Complications include superinfection with bacteria causing otitis media, pneumonia, and bronchitis
RF: The significance is whether to prescribe antivirals for the tx of influenza
1) Age >65 or long-care facilities
2) DM
3) Immunosuppression/Asplenic or household contact to immunosuppressed
4) Pregnant women or <2 weeks post-partum
5) BMI >40
6) Healthcare and social care workers
7) Chronic Resp, heart, renal, liver, neuro disease
8) Hajj and umrah pilgrims
How would you manage influenza
Management includes Rest, fluids, analgesia, sx control, treatment of exacerbation and superinfection (e.g. pneumonia)
+
Antivirals Oseltamivir and Zanamivir only if
“at risk”,
national surveillace scheme indicates circulating virus,
and can begin medication within 48 hours of onset of symptoms
What are symptoms of LRTI?
productive cough, pleuritic chest pain, wheeze
Define Pneumonia including sx
Acute infection of the lung parenchyma characterised by:
1) Sx of LRTI (cough, purulent sputum, pleuritic pain, wheeze)
2) New focal chest signs (consolidation, reduced air entry, coarse crackles, pleural rub)
3) Systemic features including sweating, fevers, chills, shivers, and myalgia
If you say this GG
The incidence of pneumonia increases with age and peaks in winter. What organisms most commonly cause pneumonia?
Strep pneumoniae
H. Influenzae
Staph Aureus
Tb
A patient presents with a productive cough, tachypnoea, and fever. What are your differentials?
Pneumonia (communit acquired)
Pneumonitis
Malignancy
Pulmonary oedema
PE
Asthma/COPD exacerbation
TB
A patient presents with a productive cough, tachypnoea, and fever. How would you assess whether they would need to be referred to hospital?
CURB-65 (Urea often not done => go for CRB65)
C - Confusion
U - Urea BUN>7
R - RR 30+
B - BP <90/60
65 - Age
0-1 - GP care with antibiotics
2+ Send to A&E
How would you manage pneumonia as a GP
If mild or moderate with low risk (e.g. young),
1) Smoking cessation
2) Supportive care: Analgesia, fluids, paracetamol/clarithromycin
3) Antibiotics: Amoxicillin/Clarithromycin (500mg TDS for 5/7)
If moderate/severe => Admission to A&E
What are the complications of pneumonia
Pleural effusion/empyema
Lung abscess
Septicemia
Resp failure
