Respiratory Medicine Flashcards
What are some causes of nodules on a CXR?
Infective Causes: Aspergilosis, Tuberculosis, Lung Abscess, Round pneumonia
Non-infective Causes: RA, Sarcoidosis, Wegener’s (GPA), lung tumour.
What are some risk factors for PE?
- recent surgery (especially abdominal, pelvic or hip/knee replacement)
- thrombophilia
- leg fracture
- prolonged bed rest/ reduced motility
- malignancy
- pregnancy/postpartum
- pill/HRT
- previous PE
Describe PE, it’s symptoms, relevant tests and management
Venous thrombi, usually from DVT, pass into pulmonary circulation and blocks blood flow to lungs.
Symptoms: acute dyspnoea, pleuritic chest pain, syncope, haemoptysis
Signs: hypotension, tachycardia, increased JVP, tachypnoea, cyanosis, AF
Tests:
- d dimer if wells score less than 3 to exclude PE
- FBC, U+E, ABG may show decreased PaO2 and PaCO2.
- ECG may show RBBB, right ventricular strain (inverted t wave in v1-v4) RAD
Imaging:
- CTPA 1st line for diagnosis
- if haemodynamically unstable Transthoracic echocardiogram looking for evidence of right ventricular dysfunction
Management:
- oxygen if hypoxic
- morphine and antiemetic if in pain
- if critically ill or unstable consider thrombolysis
- Anticoagulation with LMWH and start warfarin once confirmed . (Start LMWH before imaging if intermediate/high clinical risk)
- Stop heparin when INR > 2 and continue warfarin for 3 months (aim for INR 2-3)
- Testing for thrombophilia should be considered in patient afed under 50 with recurrent PE or those with strong family history of VTE.
- Investigations for occult cancer are indicated for unprovoked PE.
Prevention: thrombophylaxis and compression stockings
Describe Asthma, its symptoms and signs, tests, and non-emergency treatment
Asthma is characterised by recurrent episodes of dyspnoea, cough and wheeze caused by reversible airways obstruction. Three factors contribute to airway narrowing:
- Bronchial muscle contraction
- Mucosal inflammation
- Increased mucus production
Signs and symptoms: Intermittent dyspnoea, wheeze, cough (often nocturnal) and sputum. Tachypnoea, audible wheeze, hyperinflated chest, hyperresonant percusion notes, decreased air entry, widespread polyphonic wheeze.
Tests: decreased PEF, Spirometry shows obstructive defect (Decreased FEV1/FVC) with reversibility I.e. improvment in FEV1 following B2 agonists.
Treatment:
-Step 1: SABA
-Step 2: SABA + low-dose ICS (First step if symptoms 3/wk or night time waking)
-Step 3: SABA + Low-dose ICS + LTRA
-Step 4: SABA + low-dose ICS + LABA (Continue LRTA depending on patients response to LRTA)
-Step 5 SABA +/- LRTA and switch Low-dose ICS/LABA for a Maintenance and Reliever Therapy (MART), that includes a low-dose ICS.
-Step 6: SABA +/- LRTA + Medium-dose ICS MART. (May consider switching back to fixed dose of moderate-dose ICS and a separate LABA)
-Step 7: SABA +/- LRTA + High-dose ICS (Not in MART) OR a trial of additaional drug e.g. LAMA or theophylline OR seek advice from asthma specialist
-Omalizumab is used in severe asthma with Raised IgE, and Mepolizumab can be used in severe asthma with eosinophilia
(Low-dose ICS is less than 400micrograms, medium is 400-800 and High is over 800)
Describe COPD, its symptoms, signs, complications, tests and treatment.
A common progressive disorder characterised by airway obstruction (FEV1 less than 80%, FEV1/FVC les than 0.7) with little or no reversibility. It includes chronic bronchitis (cough and sputum for most days for 3 months of 2 successive years) and emphysema which is histologically enlarged air spaces. Pathologically there is mucous gland hypertrophy, goblet cell hyperplasia, and squamous metaplasia of respiratory epithelium.
Signs and symptoms: Cough, sputum, dyspnoea, wheeze, tachypnoeic, use of accessory muscles of respiration, hyperinflation, decreased cricosternal distance (less than 3cm), hyper resonant percussion notes, cor pulmonale.
Complications: Acute exacerbations +/- infection, polycythaemia, respiratory failure, cor pulmonale (oedema, raised JVP), pneumothorax (ruptured bullae), lung carcinoma
Tests:
- FBC may show increased packed cell volume.
- CXR shows hyperinflation (more than 6 anterior ribs), flat hemidiaphragms.
- ECG may show right atrial and ventricular hypertrophy (cor pulmonale).
- ABG shows decreased PaO2 +/- hypercapnia
- Spirometry shows obstructive (FEV1/FVC less than 0.7) severity graded by FEV1, greater than 80% is stage 1 mild, 50-79% is stage 2 moderate, 30-49% is stage 3 severe, and less than 30% is stage 4 very severe
Treatment:
- Conservative: Smoking cessation advice, encourage exercise, Flu and pneumococcal vaccinations, pulmonary rehabilitation programme
- Pharmcological: Step 1 = PRN short acting anti-muscarinic or B2-agonist. Step 2 = inhaled long-acting anti-muscarinic or B2-agonist if FEV1 greater than 50% Step 3 = combination long-acting B2-agonist + corticosteroid Or long-acting anti-muscarinic. Step 4 = combination long-acting B2-agonist + corticosteroid, + long-acting anti-muscarinic.
- Roflumilast is an Long-acting PDE-4 Inhibitor used in severe COPD in those with FEV1 less than 50% and 2 or more exacerbation in a year despite triple therapy.
- If severe PaO2 less than 8kpa or pulmonary hypertension consider Long-Term Oxygen Therapy (LTOT) in non-smokers.’
Define Chronic Bronchitis
Chronic bronchitis is defined clinically as cough with sputum production on most days for 3 months of 2 successive years.
What are the stages of severity of COPD?
Stage 1 Mild = FEV1 >80% Pred
Stage 2 Moderate = FEV1 50-79% Pred
Stage 3 Severe = FEV1 30-49% Pred
Stage 4 Very Severe = FEV1 less than 30%
Describe Bronchiectasis, it’s causes, symptoms, and tests, and management
Chronic infection of the bronchi and bronchioles leading to permanent dilatation of these airways. Three main types cylindrical (Most common), Varicose and Cystic.
Causes:
- congenital e.g. CF, youngs syndrome, kartageners syndrome
- post infection e.g. Measles, pertussis, bronchiolitis, pneumonia, TB, HIV
- Other e.g. Bronchial obstruction, RA, UC, idiopathic
Symptoms: persistent cough, copious purulent sputum, intermittent haemoptysis, clubbing, coarse inspiratory crepitations, wheeze
Tests: Sputum culture (commonly Haem Influzenzae, strep p, staph a, pseudomonas), CXR shows thickened bronchial walls (Tramlines and ring shadows). HRCT assesses extent and distribution of disease. Spirometery shows obstructive picture.
Management:
- Postural drainage should be performed twice daily
- Antibiotics guided by culture, if more than 3 exacerbations consider long-term antibiotics.
- Bronchodilators in patients with underlying asthma, COPD, CF
- Surgery may be needed in localised disease or to control severe haemoptysis.
Describe Interstitial lung disease, its symptoms and classification
A term used to describe a number of conditions characterised by chronic inflamation and or/progressive interstitial fibrosis
Symptoms: dyspnoea on exertion, non-productive paroxysmal cough, abnormal breath sounds, abnormal CXR or HRCT (fibrosis) restrictive pulmonary spirometry.
Classification:
- Occupational e.g. asbestosis, berylliosis, silicosis, cotton workers lung (byssinosis)
- drugs e.g. nitrofuratoin, bleomycin, amiodarone, sulfasalazine
- hypersensitivity reactions e.g. extrinsic allergic alveolitis
- infections - TB, fungi, viral
- GORD
- Those associated with systemic disorders e.g. sarcoidosis, RA, SLE, systemic sclerosis, sjrogren syndrome, UC, Renal tubular acidosis, autoimmune thyroid disease
- Idiopathic e.g. idiopathic pulmonary fibrosis, cryptogenic organising pneumonia, lymphocytic interstitial pneumonia
Describe pleural effusion, its causes, symptoms, signs, tests and management
A pleural effusion is fluid in the pleural space. They can be divded by their protein concentration into transudates (protein les than 25g/L) and exudates (protein greater than 35g/L). Blood in the pleural space is a haemothorax, pus in the pleural space is an empyema.
Causes of transudates:
- increased venous pressure (Cardiac failure, constrictive pericarditis, fluid overload)
- hypoproteinaemia (cirrhosis, nephrotic syndrome, malabsorption)
- hypothyroidism
Causes of exudates:
-leakiness of pleural capillaries due to infection (TB, pneumonia) inflammation (RA, SLE) or malignancy (Bronchogenic carcinoma, lung metastases, lymphoma, mesothelioma)
Symptoms: Asymptomatic or dyspnoea and pleuritic chest pain.
Signs: decreased expansion, stony dull percussion note, diminished breath sounds occur on affected side. vocal resonance is decreased. trachea deviation away from large effusion.
Tests: CXR show blunting of costophrenic angles abd water-dense shadows with meniscus.
Management:
- drainage and fluid analysis
- pleurodesis with tetracycline, bleomycin or talc may be helpful for recurrent effusions. Thorascopic talc pleurodesis is most effective for malignant effusions.
- Surgery may be needed for persistent collections and increasing pleural thickness.
Describe simple pneumothorax, its causes, features, and management.
Causes:
-Primary (especially in young thin men) due to rupture of a subpleural bulla
Secondary:
-chronic lung disease e.g. asthma, copd, lung fibrosis, sarcoidosis
-infection e.g. TB, pneumonia, lung abscess
-traumatic including iatrogenic
-carcinoma
-connective tissue disorders e.g. marfans or ehlers-danlos
Features: Pleuritic chest pain, SOB
Management:
Primary:
-less than 2cm, and patient not short of breath, discharge with follow up
-rim of air 2cm or more, or breathless it needs needle aspiration
-if needle aspiration fails (i.e. Still more 2cm air or symptomatic) then a chest drain should be inserted.
-those that are admitted for observation high flow oxygen increases the absorption of the pneumothorax
Secondary:
-all patients should be admitted for at least 24hours.
-If patient over 50 and rim of air over 2cm or breathless then chest drain
-aspiration if 1-2cm, if it fails (pneumothorax still greater than 1cm) a chest drain should be inserted
-those that are admitted for observation high flow oxygen increases the absorption of the pneumothorax if tolerated
Describe type 1 respiratory failure and its management
Defined as hypoxia (PaO2 less than 8kPa) with a normal or low PaCO2. It is caused primarily by ventilation/perfusion mismatch e.g. Pneumonia, pulmonary oedema, PE, asthma, emphysema, pulmonary fibrosis, ARDS.
Management:
- treat underlying cause
- Give oxygen to correct hypoxia
- Assisted ventilation if PaO2 less than 8kPa despite 60% oxygen.
Describe type 2 respiratory failure and its management
Defined as hypoxia (PaO2 less than 8kPa) with hypercapnia (PaCO2 greather than 6kPa). Caused by alveolar hypo ventilation causes include pulmonary disease such as asthma, COPD, pneumonia, end-stage pulmonary fibrosis, obstructive sleep apnoea, reduced respiratory drive e.g. Sedative drugs CNS tumour or trauma, neuromuscular disease or thoracic wall disease.
Management:
- Treat underlying cause
- Controlled oxygen therapy beware hypoxic drive.
- Recheck ABG after 20 min if PaCO2 steady or lower continue monitoring if increasing consider NIPPV, contact ITU
- If this fails consider intubation and artificial ventilation
Respiratory drive may be driven by hypoxia aim for sats 88-92% and monitor blood gases. If oxygen therapy not improving and CO2 rising consider NIPPV and failing that intubation and ventilation.
Describe sarcoidosis, its symptoms, tests, prognostic factors, and management.
It is a multisystem granulomatous disorder of unknown cause. Usually affects adults aged 20-40yrs and is more common in women. Afro-carribeans are more frequently and severly affected.
Symptoms: dry cough, progressive dyspnoea, chest pain. Non-pulmonary signs include lymphadenopathy, hepatomegaly, splenomegaly, lupus pernio, erythema nodosum.
Tests: Raised ESR, lymphopenia, raised serum ACE. Hypercalcaemia. 90% have abnormal 24 urine collection shows hypercalcaemia. CXR may show the following changes:
- Stage 0: Normal
- Stage 1: Bilateral Hilar Lymphadenopathy
- Stage 2: BHL + interstitial infiltrates
- Stage 3: Diffuse interstitial infiltrates only
- Stage 4: diffuse fibrosis
Poor prognostic factors:
- Insidious onset, symptoms longer than 6 months
- Absence of erythema nodosum
- Extrapulmonary manifestations e.g. lupus pernio, splenomegaly
- CXR stage III-IV features
- Afro-carribean
Management:
- patients with Bilateral hilar lymphadenopathy do not need treatment, acute sarcoid requires bed rest and NSAIDs.
- indication for predinsolone (40mg/24h PO) are uveitis, parenchymal lung disease, hypercalcaemia or neurological or cardiac involvement.
- in severe disease immunosuppressants may be tried (methotrexate, hydroxychloroquine, ciclosporin, cyclophosphamide).
Describe Obstructive Sleep Apnoea, its symptoms, investigations, and management
Characterised by intermittent closure/collapse of the pharyngeal airway causing apnoeic episodes during sleep. These are terminated by partial arousal.
Symptoms: Obese, middle-aged man apnoeic episodes during sleep. loud snoring, daytime somnolence, poor sleep quality, morning headache, decreased libido, reduced cognitive performance
Complications: Pulmonary hypertension, type II respiratory failure, risk factor of hypertension
Investigations: Sleep studies (O2 sats, airflow at nose and mouth, ECG, EMG chest and abdominal wall movement during sleep) 15 or more epsiodes during 1h of sleep indicates significant sleep apnoea, TFTs (hypothyroidism is treatable cause)
Management:
- Weight reduction, avoidance of tobacco and alcohol
- mandibular advancement device if mild
- CPAP via nasal mask during sleep for moderate to severe
- surgery to relieve pharyngeal obstruction is occasionally needed refer to chest physician for assessment, bariatric surgery
Describe Costochondritis (Tietze’s syndrome), its symptoms, and managements
Symptoms:
Localised pain/tenderness at the costosternal junction, enhanced by motion, coughing, or sneezing. The 2nd rib is most often affected. The diagnostic key is localised tenderness which is marked (flinches on prodding).
Management:
- Reassure patient, it is benign, usually clears up after a few weeks
- Simple analgesia e.g. NSAIDs
- In lengthy illness local steroid injections may be used
What is pleurodesis?
A medical procedure in which the pleural space is artificially obliterated, it involve the adhesion of the two pleurae. It can be done chemically or surgically, it prevents recurrence or pneumothorax or pleural effusion. Chemicals such as bleomycin, tetracycline or talc can be introduced into the pleural space through a chest drain, it is painful procedure so patients are often premedicated with sedative and analgesics.
What is the sail sign?
Triangular opacity over heart which indicates left lower lobe collapse commoner in asthmatics.
Describe Mesothelioma, its symptoms, investigations, types, and management.
A tumour of mesothelial cells that usually occurs in the pleura, and rarely in the peritoneum or other organs. It is associated with occupational exposure to asbestos. 90% report previous exposure to asbestos but only 20% of patients have pulmonary asbestosis. Compensation is available.
Symptoms: Chest pain, dyspnoea, weight loss, finger clubbing, recurrent pleural effusions, signs of metastases (lymphadenopathy, hepatomegaly, bone pain, abdominal pain/obstruction.
Investigations: CXR/CT show pleural thickening, diagnosis made on histology following thorascopy.
Types: there are three main histiological subtypes:
- Epitheliod - Most common, best prognosis, Characterised by high levels of calretinin
- Sarcomatous - less common, worst prognosis, Does not express high levels of calretinin
- Biphasic
Management:
- Pemetrexed + Cisplatin chemotherapy can improve survival.
- Pleurodesis may help recurrent effusions.
- Prognosis is poor, median survival 12 months
Describe Atelectasis, its symptoms, investigations, and management.
Collapse/closure of a lung. A common post-operative complication, also foreign body, tumour (usually squamous cell carcinoma), mucus plug.
Symptoms: SOB, chest pain, effusion, low O2 sats, cyanosis, tachycardia.
Investigations: CXR, CT, Bronchoscopy
Management:
- ABCDE
- CPAP
What are the different causes of tracheal deviation?
Pulled: Pneumonectomy, lung collapse, pulmonary hypoplasia
Pushed: Tension pneumothorax, Pleural effusion, diaphragmatic hernia, large thoracic mass.
What are the types of fibrosis predominately affecting upper zones?
BREAST: Berylliosis, silicosis, pneumoconiosis Radiation Extrinsic allergic alveolitis Ankylosing Spondylitis, Amiodarone Sarcoidosis TB
Which types of fibrosis typically affect the lower zones?
RAID: Rheumatoid Arthritis/SLE Asbestosis Idiopathic pulmonary fibrosis Drug induced e.g bleomycin, methotrexate
What is the Golden S sign on CXR?
Curves from lobar collapse then a counter curve caused by displacement by central mass. It’s significantly associated with bronchogenic carcinoma.
Describe Pulmonary Aspiration, its features, investigations, and management.
Aspiration of solid or liquid material into the upper and lower airways is likely when:
- decreased GCS
- decreased cough/gag reflexes
- tendency to regurgitate/vomit (Last meal?)
Features: large food particles may cause complete airway obstruction (choking, stridor, cyanosis, loss of concisouness) vomit leads to sudden onset of severe SOB, wheeze and cyanosis, the acidity causes severe damage to the alveolar-capillary membrane, with desaturation of pulmonary surfactant and increased pulmonary permeability with oedema and atelectasis.
Investigations:
- ABG shows hypoxemia initially with decreased CO2 due to hyperventilation until Pulmonary compliance and increased work of breathing lead to hypoventilation.
- CXR abnormalities may take hours to develop, Right lower lobe most commonly affected, diffuse bilateral infiltrates and pulmonary oedema similar to ARDS appearance.
Management:
- Prevention is key, in at risk patients pass an NG tube to empty the stomach
- correct hypoxia and give nebulised salbutamol. Although secondary infection is common use of antibiotics or steroids in initial management is not routinely indicated.
Describe Pulmonary contusion, its features, and management.
Caused by high energy transfer during blunt injury e.g. RTA or high falls. Suspect in all patients with flail segments, or multiple rib fractures.
Features: Causes ventilation-perfusion mismatch and so hypoxia and respiratory distress. CXR may show patchy opacification which tend to become more prominent over time.
Management:
-Mostly supportive, high flow oxygen and monitor ABG to help assess need for GA, tracheal intubation and IPPV.
In terms of Pleural Fluid Analysis what is lights criteria?
Lights criteria determines presence of exudates with protein and LDH levels, there are 3 main criterion:
1) Pleural fluid protein to serum protein ratio is greater than 0.5
2) Pleural fluid LDH to serum LDH ratio is greater than 0.6
3) Pleural fluid LDH is over 2/3 of upper value
4) Serum Albumin - Pleural Fluid albumin is less than 1.2g/dL
Describe Pulmonary Hypertension, its causes, features, investigations, and management.
An increase in mean pulmonary arterial pressure of greater than 25mmHg at rest or 30 mmHg after exercise. (Normally 8-20mmHg).
Causes:
Pulmonary Arterial Hypertension Group 1: Idiopathic, inherited (autosomal dominant mutation in BMPR2 gene), drug-induced (cocaine, SSRIs, Interferon), congenital heart disease, HIV, connective tissue disease, portal hypertension (Normal PCWP)
Group 2: Left heart disease e.g. Left ventricular systolic dysfunction, left ventricular diastolic dysfunction, valvular heart disease, cardiomyopathy (Raised PCWP)
Group 3 secondary to lung disease: COPD, ILD, Sleep apnoea, Chronic high altitude
Group 4 thromboembolic: Blood clots in pulmonary arterial system
Group 5 unclear or multifactorial: e.g. Myeloproliferative disorders, systemic disorders e.g. Vasculitis, metabolic disorders e.g. Thyroid disease
Features: Progressive SOB, Odema, Ascites, left parasternal heave, Loud P2, pulmonary regurgitation, triscupid regurgitation, raised JVP,
Investigations: LFTs, TFTs, Autoimmune screen, CXR, echo,
Management:
- Treat underlying condition.
- acute vasodilator testing aims to decide which patients show a significant fall in pulmonary arterial pressure following the administration of vasodilator such as IV epoprostenol or inhaled nitric oxide
- For those with a positive response to acute vasodilator testing oral Ca-Channel blockers,
- For those with a negative response to acute vasodilator testing, Prostacyclin analogues e.g. treprostinil, iloprost, Or Endothelin receptor antagonists e.g. bosentan. Or phosphodiesterase inhibitors e.g. sildenafil.
Describe Acute Respiratory Distress Syndrome, its causes, features, and management
An acute condition characterised by bilateral pulmonary infiltrates and severe hypoxaemia (PaO2/FiO2 ratio under 200) in the absence of evidence for cardiogenic pulmonary oedema (clinically or pulmonary capillary wedge pressure (CVP) less than 18mmHg
Causes: Sepsis, aspiration, trauma, acute pancreatitis, fat embolism, head injury (sympathetic stimulation leads to acute pulmonary HTN)
Features: Acute dyspnoea and hypoxaemia, hours/days after event. Multi-organ failure, rising ventilatory pressures.
Management:
- treat underlying cause
- antibiotics if signs of sepsis/aspiration
- negative fluid balance (diuretics)
- recruitment manoeuvres such as prone ventilation, use of positive end expiratory pressure
- mechanical ventilation with LOW tidal pressures (conventional tidal pressures may cause lung injury)
Describe Hereditary Angioedema, its features, and management.
Aka C1 esterase inhibitor deficiency. C1 esterase inhibitor is a member of the serum protease inhibitors and acts to inhibit the classical pathway of complement cascade. In the absence of C1 esterase inhibitor activation of complement leads to increased levels of vasoactive peptides that increase capillary permeability, most notably, bradykinin. This patients taking ACE-i leads to further increase of bradykinin. This is mast-cell independent so there is no itching or erythema.
Features: Facial oedema, laryngeal oedema, with subsequent airway obstruction. No Urticaria. Episodes may be provoked by traum to mucosal membranes e.g. sexual intercourse or dental work.
Management:
- patients may not respond to adrenaline and ultimately need C1 esterase inhibitor concentrate.
- intubate and involve ITU for supportive treatment
