respiratory medicine Flashcards
fine crackles causes
pulmonary oedema
exudative vs transudative pulmonary effusions
transudative - high pressure eg. HF, LV, CKD, cirrhosis, Pulmonary embolism
exudative - high protein & LDH eg. infection, malignancy,
end expiratory BILATERAL wheeze
asthma
polyphonic inspiratory and expiratory (biphasic) wheeze
COPD
clubbing in COPD?
no clubbing in COPD
causes of stridor?
Croup
Epiglottitis
Post-extubation laryngeal edema
Foreign body aspiration
breathlessness score?
MRC dyspnoea scale
MRC grade 1 - SOB only on strenerous exercise
grade 2 - even when climbing slight hill
5 grades with different statements that patient says when they get breathless
causes of obstructive lung disease
Asthma, COPD, bronchiectasis
causes of restrictive lung disease
pulmonary fibrosis, asbestos, sacroidosis, obesity, neuromuscular disorders, kyphosis, obesity, acute respiratory distress syndrome
spirometry obstructive vs restrictive
obstructive: FEV1 significantly reduced & FVC normal or slightly reduced —-> FEV1:FVC reduced
restrictive: FEV1 slightly reduced & FVC is significantly reduced –> FEV1:FVC increased or normal
investigations for obstructive sleep apnoea
ABG: compensated respiratory acidosis
Hypertension
Epworth sleepiness scale questionnaire
Multiple sleep latency test (MSLT) - time to fall asleep in dark room using EEG criteria
sleep studies (polysomnography) with pulse oximetry, EEG, thoraco-abdominal wall movement
COPD patient, pneumothorax 1.5 cm
aspirate +/- chest drain
sit up
high flow oxygen but keep an eye on sats
monitor for 24hrs
COPD patient, pneumothorax 0.5cm
sit up
high flow high flow oxygen but keep an eye on sats
monitor for 24hrs
cut offs pneumothorax for do nothing vs aspiration vs chest drain
primary
- <2cm monitor and review
- > 2cm aspirate –> chest drain
secondary
<1cm do nothing
1-2cm aspirate –> chest drain
>2cm chest drain
criteria for LTOT in COPD?
measure ABG on 2 occasions, 3 weeks apart on optimum medication
two ABGs pO2 < 7.3kPa
ABG pO2 7.3-8kPa + pulmonary HTN or peripheral oedema or secondary polycythemia
COPD patient, pneumothorax 2.5cm
chest drain
which heart murmur can give you haemoptysis?
mitral stenosis
cardiac pulmonary oedema vs acute respiratory distress syndrome
pulmonary capillary wedge pressure is high then this is due to backlog into veins due to heart failure
ARDS can only be diagnosed in absence of heart failure
Venturi mask in COPD
24/28% blue Venturi masks
Sats of 88-92%
Steroid conc acute exacerbation of asthma or copd
In asthma, give 100mg IV hydrocortisone
In COPD, give 200mg IV hydrocortisone
Asthma reversibility cut off
FEV1 > 12% with SABA
site of aspiration in tension pneumothorax
2nd ICS mid clavicular line
6th ICS anterior axillary line in safe triangle
site of safe triangle
lateral border of pec major anterior border of lattisimus dorsi 6th ICS (nipple) directly ABOVE the rib
what way does the trachea/mediastinum deviate for different pathologies?
tension - away
lobal collapse - towards
pleural effusion - away
causes of pneumothorax
spontaneous
secondary to chronic lung issues: COPD, asthma, Marfans, mechanical ventilation
trauma - rib fractures, central line insertion
left lobe collapse on X ray
- sail sign/ triangle behind the heart + NB. lung field may actually seem normal
- aortic -knob sign – the aortic arch is very circular and prominent
- reduction of volume on left (can be subtle) + elevation of the left diaphgram!
normal ABG values
pH 7.35 - 7.45
pCO2 35-45 mmHg
HCO3- 22-26
pO2 80-100 mmHg
when do you do V/Q over CTPA for pulmonary embolism?
pregnancy
renal failure (can’t deal with contrast)
allergic to contrast
where is bifurcation of trachea?
T5 to 7 (behind sternum)
where is bifurcation of AORTA?
L4 just above the junction of the left and right common iliac veins.
mx of massive PE
local guidelines
intra-arterial: urgent pulmonary angiography and perfusion of thrombolytic drugs into the pulmonary arteries to dissolve the thrombus
OR intravenous: thrombolysis can be done via peripheral IV if radiological expertise is not available or less severely comprised patients
surgical thrombectomy is done at cardiothoracic units
examples of thrombolytics
CI to thrombolytic agent use
egs. streptokinase, urocinase, recombinant tissue plasminogen activator
CIs: BLEEDING
- recent haemorrhage, trauma, surgery
- suspected/known aortic dissection
- suspected/known peptic ulcer disease
- previous allergy
- previous history of intracerebral haemorrhage event
- severe HTN
presenting CXR
Rotation - clavicles equidistant from spinous processes
Inspiration - 6 anterior ribs
Peneration - vertebrae (+ see anterior ribs, if over peneterated then will see mainly posterior ribs)
Exposure - can you see entire chest
presentation of any imaging/ investigations
what is it? orientation eg. PA/AP
patient details
date and time taken
previous images
was the patient symptomatic?
how does cystic fibrosis result in chronic renal failure
CF –> systemic amyloidosis
Hilar enlargement causes
Bilateral -
- infection: TB, HIV
- inflammation: sarcoidosis, pneumonoconiosis, silicosis,
- malignancy: (lymphoma, mets)
- vascular: pulmonary hypertension (COPD, recurrent mets)
Unilateral/asymmetrical - malignancy, TB, pulmonary artery aneurysm
TB diagnosis
- CXR
- sputum stain for acid fast bacilli
- sputum culture for TB - most specific and sensitive
- 3 samples, 8 hrs, at least one in the morning - NAAT (nucleic acid amplification test)
- can use sputum sample or sample from bronchoscopy with broncholavage
- quick diagnosis but not all centers have it - bloods - low Hb (chronic disease), raised WCC, pancytopenia (disseminated infection)
tuberculin skin test is not so helpful
what do you do if you have a patient with acid fast bacilli
TB until proven otherwise
- negative pressure side room (minimise transmission to other parts of hospital)
- tell hospital infection control team
- inform local Health Protection Consultant
cause of bronchial breath sounds
pneumonia
expiratory lasts longer than inspiratory
DDx multiple ill defined opacities in CXR
infection - septic emboli Inflammation - rheumatoid arthritis - granulomatosis with polyangitis malignancy - pulmonary mets vascular - pulmonary infarcts (following PE, death of lung tissue)
NB. miliary TB gives much smaller lesions a few mm in diameter
MX of mesothelioma
no effective treatments
installation of sclerosant substances (dehydrating the pleural cells) to prevent re-accumulation of pleural effusions resulting in breathlessness
typically mets to lungs, hilar, other pleura in the body
Miliary shadowing CXR
Miliary - few mm blotches everywhere
Tuberculosis!! Sarcoidosis Mets Extrinsic allergic alveolilitis Occupational lung disease
Mx of aspergilloma/ mycetoma
- IV antifungals
2. surgical resection
which lung malignancy causes a horner’s syndrome?
what can it result in?
superior sulcus/ apical lung carcinoma aka pancoast tumour
tumours can invade and compress surrounding structures resulting in Pancoast syndrome
invasion of sympathetic chain = Horners
invasion of brachial plexus = shoulder/arm pain
compession of spinal cord
recurrent laryngeal nerve invasion = hoarse voice
how does aspergillus species affect the lung?
- asthma (type 1 hypersensitivity)
- allergic bronchopulmonary aspergillosis (type 1 & 3 hypersensitivity) - recurrent asthma and bronchial damage and bronchiectasis
- extrinsic allergic alveolitis - reccurent dyspnoea and dry cough and ultimately fibrosis
- mycetoma (aspergilloma) - fungus bal forming in a pre-existing lung cavity
- invasive aspergillosis in the immunosuppressed with high mortality
DDx cavitating mass on chest radiograph
infection
- s.aureus
- klebsiella
- mycetoma (aspergillus)
- TB
wegener’s granulomatosis (granulomatosis with polyangitis)
carcinoma of the bronchus, SCC metastasis
pulmonary infarct
diagnosis of aspergillus disease
serum preciptins is best
aspergillus skin test is positive in 30% of cases
Mx of aspergilloma/ mycetoma
- IV antifungals
2. surgical resection
most common histological subtype of lung cancer
adenocarcinoma 40%
causes of superior vena cava syndrome
malignancy - bronchal ca, lymphoma in hilum
thrombosis secondary to pacing wirses or central venous catheters
mx of superior vena cava syndrome
- oxygen, head elevate
- steroids, diuretics to relieve laryngeal/ cerebral oedema
- surgical bypass or SVC stenting
ddx widespread opacity
pulmonary oedema (bat wing/ hilar) non-cardiogenic pulmonary oedema
aspiration
pulmonary haemorrhage
pneumocystis pneumonia (ground glass)
