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Medicine and Surgery Mushkies > Respiratory Mushkies > Flashcards

Respiratory Mushkies Flashcards

1
Q

Resp exam around the bedside examination?

A
  1. Inhalers
  2. Peak flow meter
  3. Nebuliser
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2
Q

Resp exam general inspection?

A
  1. Airflow obstruction = pursed lip breathing, splinting diaphragm
  2. Cushingoid
  3. Cyanosed
  4. Cachectic
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3
Q

Resp hand features?

A
  1. Clubbing
  2. Tar staining
  3. CO2 retention flap
  4. Bounding pulse
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4
Q

Resp exam face?

A
  1. Plethora (raised Hb)

2. Central cyanosis

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5
Q

Signs of core pulmonale?

A
  1. Raised JVP
  2. Left parasternal heave
  3. Loud P2 +/- S3
  4. MDM of tricuspid regurg
  5. Ascites and pulsatile hepatomegaly
  6. Peripheral oedema
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6
Q

2 ddx for a COPD pt in PACES?

A
  1. Asthma

2. Bronchiectasis

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7
Q

Chronic bronchitis defn?

A

Cough productive of sputum on most days for >=3m on >2 consecutive years

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8
Q

Emphysema defn?

A

Alveolar wall destruction with airway collapse and air trapping

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9
Q

COPD Ix?

A
  1. Bedside = PEFR, BMI, Sputum MC+S, ECG (RVH)
  2. Bloods = FBC, ABG, CRP, Albumin, a1-At levels
  3. Imaging = CXR(acute = consolidation/pneumothorax, chronic), Echo (cor pulmonale)
  4. Spirometry
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10
Q

Why ix BMI for COPD?

A

BMI is an independent RF for mortality in COPD

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11
Q

Why Ix albumin in COPD?

A

Malnutrition

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12
Q

Chronic COPD CXR findings?

A
  1. Hyperinflation = >10 posterior ribs, flat hemidiaphragm
  2. PHTN = prominent pulmonary vessels
  3. Bullae
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13
Q

Spirometry CXR findings?

A

Obstructive picture

  1. Raised TLC and RV (residual volume)
  2. FEV1 < 80%
  3. FEV1/FVC < 0.7
  4. Reduced transfer factor
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14
Q

Mx of COPD?

A
  1. General
  2. Medical
  3. Surgical
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15
Q

General Mx of COPD?

A
  1. MDT = GP, dietician, physio, physician, specialist nurse
  2. Smoking cessation = support programme, NRT< varenicline
  3. Pulmonary Rehabilitation therapy
  4. Co-morbidities = dietary support, CV risk Mx, vaccination (pneumococcal and seasonal influenza)
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16
Q

Medical Mx of COPD?

A
  1. Inhaled = antimuscarinics, b-agonists, ICS
  2. Oral = theophylline
  3. Home emergency pack for acute exacerbations
  4. LTOT
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17
Q

LTOT indications for COPD?

A
  1. Stable non smokers with PaO2 < 7.3 or

2. PaO2 <8 + cor pulmonale/polycythaemia

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18
Q

Surgical Mx of COPD?

A
  1. Bullectomy

2. Lung reduction surgery

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19
Q

BODE index?

A

Tool to predict mortality in COPD

  1. BMI
  2. Obstruction = FEV1
  3. Dyspnoea = MRC score
  4. Exercise capacity = 6 minute walk
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20
Q

Mx of acute COPD exacerbation?

A
  1. Controlled O2 therapy = sit up, 24% O2 via Venturi mask SpO2 88-92%
  2. Nebulised bronchodilators = Salbutamol 5mg/4hrs, Ipratropium 0.5mg/6hrs
  3. Steroids = 200mg IV hydrocortisone, Prednisolone 40mg PO 7-14 days
  4. Abx
  5. NIV if no response = repeat nebs and consider aminophylline IV, BiPAP if pH <7/35 and/or RR>30
  6. Invasive ventilation if pH < 7.26
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21
Q

Inspection of asthma pt?

A
  1. Paraphernalia = inhalers, peak flow, nebulisers

2. General = Cushingoid, Oral thrush

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22
Q

Inspection of asthmatic chest?

A

Harrison sulcus

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23
Q

DDX for asthma in PACES?

A
  1. Normal
  2. COPD
  3. Pulm. oedema –> cardiac asthma
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24
Q

Asthma defn?

A

Episodic, reversible airway obstruction due to bronchial hyper-reactivity to a variety of stimuli

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25
Q

Asthma Ix?

A
  1. Bedside = PEFR, BMI, Sputum MC+S
  2. Bloods = FBC, IgE, ABG, CRP, Albumin, a1-At levels
  3. Imaging = CXR(hyperinflation)
  4. Spirometry
  5. Atopy = skin-prick testing, RAS
  6. Peak flow diary = diurnal variation > 20%
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26
Q

Asthma spirometry?

A
  1. Reduced FEV1, raised RV
  2. FEV1/FVC < 0.7
  3. > =15% improvement in FEV1 with b-agonist
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27
Q

Asthma Mx?

A
  1. General = MDT, TAME patient

2. Medical = 5-stage BTS guidelines

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28
Q

Ddx for acute severe asthma?

A
  1. Pneumothorax
  2. COPD acute exacerbation
  3. Pulmonary oedema
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29
Q

Acute severe asthma admission criteria?

A
  1. Life threatening attack
  2. Severe attack persisting despite initial Rx
  3. May discharge if PEFR > 75% 1hr after initial Rx
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30
Q

Acute severe asthma when to discharge?

A
  1. Been stable on discharge meds for 24 hours

2. PEFR > 75% with diurnal variability <20%

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31
Q

How to TAME an asthma pt?

A
  1. Technique for inhaler use
  2. Avoidance of allergens, smoke, dust
  3. Monitor w/ peak flow diary
  4. Educate = emergency action plan, specialist nurse, need for Rx compliance
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32
Q

Acute severe asthma discharge plan?

A
  1. TAME pt
  2. PO steroids for 5 days
  3. GP appt w/in 1 week
  4. Resp clinic w/in 1 month
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33
Q

Acute asthma Mx?

A
  1. Sit up
  2. 100% O2 via non-rebreathe mask aiming for 94-98%
  3. Salbutamol 5mg and Ipratropium 0.5mg
  4. Hydrocortisone 100mg IV and Prednisolone 40mg
  5. Write no sedation on drug chart
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34
Q

Life threatening asthma Mx?

A
  1. Call ITU
  2. MgSO4 2g IVI over 20 mins
  3. Neb salbutamol every 15 minutes (monitor ECG)
  4. Consider aminophylline
  5. Consider ITU transfer for invasive ventilation
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35
Q

Classification of causes of pulmonary fibrosis?

A
  1. Upper

2. Lower

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36
Q

Causes of upper pulmonary fibrosis?

A

A TEA SHOP

  1. ABPA
  2. TB
  3. EAA
  4. Anklyosing spondylitis
  5. Sarcoidosis
  6. Histiocytosis
  7. Occupational (Silicosis, berylliosis)
  8. Pneumoconiosis (e.g. Coal worker’s lung)
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37
Q

Causes of lower pulmonary fibrosis?

A

STAIR

  1. Sarcoidosis
  2. Toxins = BANS ME
  3. Asbestosis
  4. IPF
  5. Rheum = RA, SLE, SS, Sjogrensm PM/DM
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38
Q

Toxins that cause lower pulmonary fibrosis?

A

BANS ME

  1. Bleomycin
  2. Amiodarone
  3. Nitrofurantoin
  4. Sulfasalazine
  5. MEthotrexate
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39
Q

Pulmonary fibrosis Ix?

A
  1. Bedside = PEFR, ECG (RVH)
  2. Bloods
  3. Imaging
  4. Spirometry
  5. Other = Echo (PHT), BAL, lung biopsy (UIP)
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40
Q

Pulmonary fibrosis bloods?

A
  1. FBC = anaemia exacerbates dyspnoea
  2. ABG = low O2, high CO2
  3. IPF = ESR, CRP, ANA, RF
  4. EAA = positive precipitins
  5. CTD = C3/C4, RF, ANA, Scle70, centromere
  6. Sarcoid = ACE, Ca
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41
Q

Pulmonary fibrosis imaging?

A
  1. CXR = reticulonodular shadowing, low lung volume

2. HRCT = fibrosis, honeycombing

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42
Q

Pulmonary fibrosis spirometry?

A
  1. Reduced TLC, RV, FEV and FVC
  2. FEV1/FVC > 0.8
  3. Reduced transfer factor
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43
Q

Pulmonary fibrosis Mx?

A
  1. MDT = GP, physician, physio, specialist nurses, palliative
  2. Conservative = stop smoking, pulmonary rehab
  3. Medical = cause and complications
  4. Surgery = lung transplant offers only cure for IPF
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44
Q

Medical Mx of pulmonary fibrosis?

A
  1. Cause = Steroids for EAA/Sarcoid/CTD

2. Complications = Codeine phosphate (antitussive), HF (triple therapy)

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45
Q

IPF prognosis?

A

50% 5 year surviva

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46
Q

Classification of causes of bronchiectasis?

A

Congenital and acquired

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47
Q

Congenital causes of bronchiextasis?

A
  1. CF
  2. PCD/Kartageners
  3. Young’s syndrome (azoospermia + bronchiectasis)
  4. Hypogammaglobulinaemia (XLA, CVID)
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48
Q

Acquired causes of bronchiectasis?

A
  1. Idiopathic
  2. Infection = Pertussis, TB, measles
  3. Inflammation = RA, ABPA, IBD
  4. Malignancy/foreign body –> obstruction
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49
Q

Bronchiectasis Ix?

A
  1. Bedside = PEFR, urine dip (proteinuria e.g. amyloidosis)
  2. Bloods = FBC, Serum Ig, Aspergillus (RAST, precipitins, IgE), RA (anti-CCP, RF, ANA)
  3. Imaging = CXR, HRCT
  4. Spirometry = obstructive
  5. Other = bronchoscopy, CF sweat test, Aspergillus skin prick testing
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50
Q

Bronchiectasis CXR?

A

Tramlines and ring shadows (bunch of grapes)

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51
Q

Bronchiectasis HRCT?

A
  1. Signet ring sign = thickened dilated bronchi and smaller adjacent vascular bundle
  2. Pools of mucus in saccular dilatations
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52
Q

Bronchiectasis complications?

A
  1. Recurrent infections
  2. Pulmonary HTN
  3. Massive haemoptysis
  4. Cachexia
  5. T2RF
  6. Amyloidosis
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53
Q

Bronchiectasis Mx?

A
  1. Conservative
  2. Medical
  3. Surgical = may be indicated in severe localised disease or obstruction
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54
Q

Conservative Bronchiectasis Mx?

A
  1. MDT = GP, physician, physio, dietician, immunologist

2. Physio = postural drainage, active cycle breathing, rehab

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55
Q

Medical Bronchiectasis Mx?

A
  1. Abx for exacerbations or prophylactic azithromycin
  2. Bronchodilators
  3. Vaccination e.g. influenza, pneumococcus
  4. Underlying cause = Immune deficiency (IVIG), ABPA (steroids), CF (DNAase, Creon, ADEK vitamins)
56
Q

CF defn?

A

Autosomal recessive mutation in the CFTR gene on Chr 7, which leads to thick secretions that has deleterious effects on multiple organ systems

57
Q

CF pathophysiology?

A

Decreased luminal Cl secretion and increased Na reabsorption –> viscous secretions

58
Q

Systems affected by CF?

A
  1. Bronchioles –> bronchiectasis
  2. Pancreatic ducts –> DM, malabsorption
  3. GIT –> distal intestinal obstruction syndrome
  4. Liver –> gallstones, cirrhosis
  5. Fallopian tubes –> reduced female fertility
  6. CAVD = male infertility
59
Q

CF Dx?

A
  1. Immunoreactive trypsinogen (neonatal screening)
  2. Sweat test: Na and Cl > 60mM
  3. Faecal elastase = pancreatic exocrine function
  4. Genetic screening
60
Q

Cf Ix?

A
  1. Bedside = PEFR, Sputum MC&S
  2. Bloods = FBC, LFTs, clotting, ADEK levels, OGTT
  3. Imaging = CXR (diffuse tramlines and rings), abdo US (fatty liver, cirrhosis, pancreatitis), spirometry (obstructive)
61
Q

CF Mx?

A
  1. MDT = GP, physician, physio, dietician, specialist nurse
  2. Chest
  3. GI = Creon, ADEK, Insulin
  4. Other = Fertility and genetic counselling, DEXA
  5. Surgical = heart-lung transplant
62
Q

Chest Mx of CF?

A
  1. Physio = postural drainage, active cycle breathing
  2. Abx = acute infections and prophylaxis
  3. Mucolytics = DNAase
  4. Vaccination = flu, pneumococcus
  5. Segregate from other CF pts (risk of transmission of Pseudomonas and Burkholderia
63
Q

Prognosis of CF?

A

Mean survival 35 years but rising

64
Q

Primary ciliary dyskinesia defn?

A
  1. Autosomal recessive defect in ciliary motility, leading to poor mucociliary clearance, and subsequent chronic recurrent inflammation and bronchiectasis
  2. Reduced sperm motility in males –> infertility
65
Q

Kartagener’s syndrome?

A

PCD accompanied by situs inversus, chronic sinusitis and bronchiectasis

66
Q

What % of PCD pts have Kartageners?

67
Q

Young’s syndrome?

A
  1. Bronchiectasis
  2. Rhinosinusitis
  3. Azoospermia
68
Q

Yellow nail syndrome?

A

AKA Primary lymphoedema associated with yellow nails and pleural effusion

69
Q

ABPA defn?

A

A type I and III hypersensitivity reaction to Aspergillus fumigatus, with subsequent airway inflammation and bronchiectasis

70
Q

ABPA Ix?

A
  1. Raised IgE and eosinophilia

2. Positive skin prick test or RAST

71
Q

ABPA Mx?

A

Prednisolone and bronchodilators

72
Q

3 Ddx of dull lung base?

A
  1. Effusion
  2. Consolidation
  3. Collapse
  4. Malignancy
73
Q

Causes of pleural effusion classification?

A

Transudate and exudate

74
Q

Transudate causes of pleural effusion?

A
  1. CCF
  2. Renal failure
  3. Liver failure (hypoalbuminaemia)
  4. Meigs’ syndrome
  5. Hypothyroidism
75
Q

Exudate causes of pleural effusion?

A
  1. Infection = Pneumonia, TB
  2. Inflammation = RA, SLE
  3. Malignancy = primary or secondary
  4. Infarction = PE
  5. Trauma
76
Q

Transudate effusion pathophysiology?

A

Due to increased hydrostatic pressure or reduced plasma oncotic pressure

77
Q

Exudate effusion pathophysiology?

A

Inflammation leads to increased capillary permeability

78
Q

Transudate protein level?

79
Q

Exudate protein level?

80
Q

Light’s criteria?

A
  1. If the protein level is between 25-35 g/L, Light’s criteria should be applied. An exudate is likely if at least one of the following criteria are met:
    a. effusion:serum protein ratio >0.5
    b. effusion:serum LDH >0.6
    c. effusion LDH is >2/3rds upper limit of normal
81
Q

Pleural effusion diagnostic pleurocentesis, what will you send the fluid for?

A
  1. Chemistry = protein, LDH, pH, glucose, amylase
  2. Bacteriology = MCS, auramine stain, TB culture
  3. Cytology
  4. Immunology = RF, ANA, complement
82
Q

Resp exam chest scars?

A
  1. Lateral thoracotomy, anterior thoracotomy
  2. Clamshell scar
  3. Chest drain scar
83
Q

Differential for thoracotomy in resp exam?

A
  1. Lobectomy/wedge resection
  2. Pneumonectomy
  3. Abscess/empyema
  4. Lung transplant
84
Q

Indications for lobectomy/pneumonectomy?

A
  1. 90% for bronchial carcinoma
  2. Bronchiectasis
  3. COPD (lung reduction surgery)
  4. TB (historic, upper lobe)
85
Q

Lobectomy operative mortality?

86
Q

Pneumonectomy operative mortality?

87
Q

Lung cancer types?

A
  1. NSCLC

2. SCLC

88
Q

NSCLC subtypes?

A
  1. SCC = 35%, highly related to smoking, centrally located, PTHrP –> raised Ca
  2. Adenocarcinoma = 25%, female non-smokers, peripherally located, 80% present with extrathoracic mets
  3. Large cell = 10%
89
Q

SCLC?

A

20% of lung cancer, highly related to smoking, central location, 80% present with advanced disease

90
Q

Complications of lung cancer classification?

A
  1. Local
  2. Metastatic
  3. Paraneoplastic
91
Q

Lung cancer local complications?

A
  1. RLNP
  2. Phrenic nerve palsy
  3. SVCO
  4. Horner’s
  5. AF
92
Q

Lung cancer metastatic complications?

A
  1. Pathological fracture
  2. Hepatic failure
  3. Confusion, fits, focal neuro
  4. Addisons
93
Q

Lung cancer paraneoplastic complications?

A
  1. Endo = SIADH, ACTH (Cushings), Serotonin (Carcinoid), PTHrP (Primary HPT)
  2. Rheum = poly/dermatomyositis
  3. Neuro = cerebellar degeneration, peripheral neuropathy
  4. Derm = acanthosis nigricans, thrombophlebitis migrans
94
Q

Lung cancer Ix?

A
  1. Bedside = ECG, PEFR
  2. Bloods = FBC, U&E, LFTs, bone profile
  3. CXR
  4. Cell type = percutaneous FNA/endoscopic transbronchial biopsy
  5. Pulmonary function tests = fitness for surgery
95
Q

Lung cancer staging Ix?

A
  1. CT
  2. PET
  3. Radionuclide bone scan
  4. Thoracoscopy, mediastinoscopy
96
Q

Lung cancer Mx?

A
  1. General = MDT, stop smoking, optimise nutrition and CV function
  2. NSCLC
  3. SCLC
  4. Palliative care
97
Q

NSCLC Mx?

A
  1. Chemo = platinum based + biologics
  2. Radio
  3. Surgery = rx of choice of no metastatic spread –> wedge resection/lobectomy/pneumonectomy
98
Q

SCLC Mx?

A

.Usually disseminated at presentation, some benefit with chemo

99
Q

Lung cancer palliative Mx?

A
  1. Analgesia = opiates for pain and cough
  2. Radiotherapy = haemoptysis, bone or CNS mets
  3. SVCO = dexamethasone + radiotherapy or intravascular stent
  4. Chemical pleurodesis for persistent effusions
100
Q

Lung cancer prognosis?

A
  1. NSCLC = 50% 5 yrs w/o spread, 10% w/ spread

2. SCLC = 1-1.5 years medial survival treated, 3m untreated

101
Q

Pneumonia Ix?

A
  1. Bedside = Sputum MC+S. urine (Pnemococcal Ag, cold aggultinins)
  2. Bloods = FBC, U&E, CRP, LFT, Culture, ABG
  3. Imaging = CXR
  4. Special = Pleurocentesis, BAL
102
Q

Pneumonia Mx?

A
  1. Conservative = Analgesia, Oxygen, Fluids, Chest Physio

2. Medical = Abx

103
Q

Complications of pneumonia?

A
  1. Septic shock + MOF –> ITU
  2. Parapneumonic effusion/empyema/abscess –> drainage
  3. Resp failure –> ventilation
104
Q

Pneumonia f/up?

A

CXR at 6 weeks to check for underlying Ca and resolution

105
Q

Classification of pneumonia?

A
  1. Anatomically

2. Aetiologically

106
Q

Anatomic classification of pneumonia?

A
  1. Bronchopneumonia = patchy consolidation of different lobes
  2. Lobar pneumonia = fibrosuppurtaive consolidation of a single lobe (congestion –> red –> grey –> resolution)
107
Q

Aetiological classification of pneumonia?

A
  1. Community acquired = SP, SA, HI, MC, Atypicals, viruses
  2. Hospital acquired = >48hrs, Pseudomonas/MRSA/gm -ive enterobacteriacaeae
  3. Aspiration
  4. Immunocompromised
  5. Atypical
108
Q

Aspiration pneumonia RFs?

A
  1. Stroke
  2. Bulbar palsy
  3. Reduced GCS
  4. GORD/Achalasia
109
Q

Aspiration pneumonia typical site?

A

Posterior segment of RLL

110
Q

Aspiration pneumonia organisms?

111
Q

Aspiration pneumonia Mx?

A

Co-Amoxiclav

112
Q

Immunocompromised pneumonia causes and mx?

A
  1. PCP = Co-trimoxazole
  2. TB = RIPE
  3. Fungi = amphotericin
  4. CMV/HSV = ganciclovir
113
Q

Atypical pneumonia?

A
  1. Refers to organisms which cause atypical generalised symptoms and bronchopneumonia
  2. Often presents with fever, headaches, myalgia
  3. Poor correlation between clinical and X-ray findings
  4. Often intracellular
  5. e.g. Mycoplasma, Chlamydia, Legionella
114
Q

CURB-65 score?

A

Severity of pneumonia

  1. Confusion: AMTS <=8
  2. Urea >7mM
  3. RR > 30
  4. BP <90/60
  5. > =65
115
Q

CURB-65 score interpretation?

A
  1. 0-1 = Home Rx
  2. 2 = Hospital Rx
  3. > =3 = Consider ITU
116
Q

SIRS - MODS spectrum?

A
  1. SIRS
  2. Sepsis
  3. Severe sepsis
  4. Septic shock
  5. MODS
117
Q

SIRS defn?

A

An inflammatory response to a variety of insults manifest by >=2 of:

  1. Temp >38 or <36
  2. HR > 90
  3. RR >20 or <4.6kPa
  4. WCC > 12 or <4 or >10% bands
118
Q

Sepsis defn?

A

SIRS with a presumed or confirmed infectious process

119
Q

Severe sepsis defn?

A

Sepsis with at least 1 organ dysfunction or hypoperfusion

120
Q

Septic shock defn?

A

Severe sepsis with refractory hypotension

121
Q

MODS defn?

A

Impairment of >=2 organ systems, such that homeostasis cannot be maintained without therapeutic intervention

122
Q

Old management of TB?

A

It was believed that lower PaO2 would inhibit TB proliferation, and therefore inducing apical collapse was a treatment

123
Q

3 complications of old TB?

A
  1. Aspergilloma in old TB cavity
  2. Bronchiectasis
  3. Scarring predisposes to Bronchial Ca
124
Q

TB subtypes and pathophysiology?

A
  1. Primary
  2. Primary Progressive
  3. Latent
  4. Secondary
125
Q

Primary TB features?

A
  1. A non-immune host who is exposed to M. tuberculosis may develop primary infection of the lungs (childhood/naive)
  2. Organism multiplies at pleural surface –> Ghon focus
  3. Macrophages take TB to LNs –> nodes + lung lesion = Ghon complex
  4. In 95%, cell mediated immunity and delayed hypersensitivity controls infection
  5. Fibrosis of Ghon complex –> calcified nodule (Ranke complex)
  6. Rarely may lead to primary progressive TB
126
Q

Primary progressive TB features?

A
  1. Resembles acute bacterial pneumonia
  2. Mid and lower zone consolidation, effusions, hilar LNs
  3. Lymphohaematogenous spread –> extrapulmonary and miliary TB
127
Q

Latent TB features?

A
  1. Infected but no clinical or CXr signs of active TB
  2. Non-infectious
  3. May persist for years
  4. If weakened host resistance –> reactivation
128
Q

Secondary TB features?

A
  1. Usually reactivation of latent TB due to reduced host immunity
  2. May be due to reinfection
  3. Typically develops in the upper lobes
  4. Hypersensitivity –> tissue destruction –> cavitatation and formation of caseating granulomas
129
Q

Dx of Latent TB?

A
  1. TST, if positive –>

2. IGRA

130
Q

Dx of Active TB?

A
  1. CXR = mainly upper lobes –> consolidation, cavitation, fibrosis, calcification. if suggestive CXR –>
  2. Take >=3 sputum samples (one AM), may use BAL if cant induce sputum –> microscopy for AFB (ZN stain), culture on Lowenstein-Jensen media (Gold standard)
131
Q

When is PCR helpful for TB?

A

Can Dx rifampicin resistance

132
Q

Tuberculin skin test defn?

A

Intradermal injection of purified protein derivative, with induration measured at 48-72 hours

133
Q

TST False +ive causes?

A
  1. BCG
  2. Other mycobacteria
  3. Previous exposure
134
Q

TST False -ive causes?

A
  1. HIV (infection)
  2. Sarcoid (inflammation)
  3. Lymphoma (malignancy)
135
Q

IGRA defn?

A

Pt lymphocytes are incubated with M.TB specific antigens –> IFNy production if previous exposure, will not be positive if just uses BCG (as BCG uses M.bovis)

136
Q

IGRA example?

A

Quantiferon Gold

Medicine and Surgery Mushkies (52 decks)

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