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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
Asthma Ix?
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%
26
Asthma spirometry?
1. Reduced FEV1, raised RV 2. FEV1/FVC < 0.7 3. >=15% improvement in FEV1 with b-agonist
27
Asthma Mx?
1. General = MDT, TAME patient | 2. Medical = 5-stage BTS guidelines
28
Ddx for acute severe asthma?
1. Pneumothorax 2. COPD acute exacerbation 3. Pulmonary oedema
29
Acute severe asthma admission criteria?
1. Life threatening attack 2. Severe attack persisting despite initial Rx 3. May discharge if PEFR > 75% 1hr after initial Rx
30
Acute severe asthma when to discharge?
1. Been stable on discharge meds for 24 hours | 2. PEFR > 75% with diurnal variability <20%
31
How to TAME an asthma pt?
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
32
Acute severe asthma discharge plan?
1. TAME pt 2. PO steroids for 5 days 3. GP appt w/in 1 week 4. Resp clinic w/in 1 month
33
Acute asthma Mx?
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
34
Life threatening asthma Mx?
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
35
Classification of causes of pulmonary fibrosis?
1. Upper | 2. Lower
36
Causes of upper pulmonary fibrosis?
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)
37
Causes of lower pulmonary fibrosis?
STAIR 1. Sarcoidosis 2. Toxins = BANS ME 3. Asbestosis 4. IPF 5. Rheum = RA, SLE, SS, Sjogrensm PM/DM
38
Toxins that cause lower pulmonary fibrosis?
BANS ME 1. Bleomycin 2. Amiodarone 3. Nitrofurantoin 4. Sulfasalazine 5. MEthotrexate
39
Pulmonary fibrosis Ix?
1. Bedside = PEFR, ECG (RVH) 2. Bloods 3. Imaging 4. Spirometry 5. Other = Echo (PHT), BAL, lung biopsy (UIP)
40
Pulmonary fibrosis bloods?
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
41
Pulmonary fibrosis imaging?
1. CXR = reticulonodular shadowing, low lung volume | 2. HRCT = fibrosis, honeycombing
42
Pulmonary fibrosis spirometry?
1. Reduced TLC, RV, FEV and FVC 2. FEV1/FVC > 0.8 3. Reduced transfer factor
43
Pulmonary fibrosis Mx?
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
44
Medical Mx of pulmonary fibrosis?
1. Cause = Steroids for EAA/Sarcoid/CTD | 2. Complications = Codeine phosphate (antitussive), HF (triple therapy)
45
IPF prognosis?
50% 5 year surviva
46
Classification of causes of bronchiectasis?
Congenital and acquired
47
Congenital causes of bronchiextasis?
1. CF 2. PCD/Kartageners 3. Young's syndrome (azoospermia + bronchiectasis) 4. Hypogammaglobulinaemia (XLA, CVID)
48
Acquired causes of bronchiectasis?
1. Idiopathic 2. Infection = Pertussis, TB, measles 3. Inflammation = RA, ABPA, IBD 4. Malignancy/foreign body --> obstruction
49
Bronchiectasis Ix?
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
50
Bronchiectasis CXR?
Tramlines and ring shadows (bunch of grapes)
51
Bronchiectasis HRCT?
1. Signet ring sign = thickened dilated bronchi and smaller adjacent vascular bundle 2. Pools of mucus in saccular dilatations
52
Bronchiectasis complications?
1. Recurrent infections 2. Pulmonary HTN 3. Massive haemoptysis 4. Cachexia 5. T2RF 6. Amyloidosis
53
Bronchiectasis Mx?
1. Conservative 2. Medical 3. Surgical = may be indicated in severe localised disease or obstruction
54
Conservative Bronchiectasis Mx?
1. MDT = GP, physician, physio, dietician, immunologist | 2. Physio = postural drainage, active cycle breathing, rehab
55
Medical Bronchiectasis Mx?
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
CF defn?
Autosomal recessive mutation in the CFTR gene on Chr 7, which leads to thick secretions that has deleterious effects on multiple organ systems
57
CF pathophysiology?
Decreased luminal Cl secretion and increased Na reabsorption --> viscous secretions
58
Systems affected by CF?
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
CF Dx?
1. Immunoreactive trypsinogen (neonatal screening) 2. Sweat test: Na and Cl > 60mM 3. Faecal elastase = pancreatic exocrine function 4. Genetic screening
60
Cf Ix?
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
CF Mx?
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
Chest Mx of CF?
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
Prognosis of CF?
Mean survival 35 years but rising
64
Primary ciliary dyskinesia defn?
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
Kartagener's syndrome?
PCD accompanied by situs inversus, chronic sinusitis and bronchiectasis
66
What % of PCD pts have Kartageners?
50%
67
Young's syndrome?
1. Bronchiectasis 2. Rhinosinusitis 3. Azoospermia
68
Yellow nail syndrome?
AKA Primary lymphoedema associated with yellow nails and pleural effusion
69
ABPA defn?
A type I and III hypersensitivity reaction to Aspergillus fumigatus, with subsequent airway inflammation and bronchiectasis
70
ABPA Ix?
1. Raised IgE and eosinophilia | 2. Positive skin prick test or RAST
71
ABPA Mx?
Prednisolone and bronchodilators
72
3 Ddx of dull lung base?
1. Effusion 2. Consolidation 3. Collapse 4. Malignancy
73
Causes of pleural effusion classification?
Transudate and exudate
74
Transudate causes of pleural effusion?
1. CCF 2. Renal failure 3. Liver failure (hypoalbuminaemia) 4. Meigs' syndrome 5. Hypothyroidism
75
Exudate causes of pleural effusion?
1. Infection = Pneumonia, TB 2. Inflammation = RA, SLE 3. Malignancy = primary or secondary 4. Infarction = PE 5. Trauma
76
Transudate effusion pathophysiology?
Due to increased hydrostatic pressure or reduced plasma oncotic pressure
77
Exudate effusion pathophysiology?
Inflammation leads to increased capillary permeability
78
Transudate protein level?
<30g/L
79
Exudate protein level?
>30g/L
80
Light's criteria?
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
Pleural effusion diagnostic pleurocentesis, what will you send the fluid for?
1. Chemistry = protein, LDH, pH, glucose, amylase 2. Bacteriology = MCS, auramine stain, TB culture 3. Cytology 4. Immunology = RF, ANA, complement
82
Resp exam chest scars?
1. Lateral thoracotomy, anterior thoracotomy 2. Clamshell scar 3. Chest drain scar
83
Differential for thoracotomy in resp exam?
1. Lobectomy/wedge resection 2. Pneumonectomy 3. Abscess/empyema 4. Lung transplant
84
Indications for lobectomy/pneumonectomy?
1. 90% for bronchial carcinoma 2. Bronchiectasis 3. COPD (lung reduction surgery) 4. TB (historic, upper lobe)
85
Lobectomy operative mortality?
7%
86
Pneumonectomy operative mortality?
12%
87
Lung cancer types?
1. NSCLC | 2. SCLC
88
NSCLC subtypes?
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
SCLC?
20% of lung cancer, highly related to smoking, central location, 80% present with advanced disease
90
Complications of lung cancer classification?
1. Local 2. Metastatic 3. Paraneoplastic
91
Lung cancer local complications?
1. RLNP 2. Phrenic nerve palsy 3. SVCO 4. Horner's 5. AF
92
Lung cancer metastatic complications?
1. Pathological fracture 2. Hepatic failure 3. Confusion, fits, focal neuro 4. Addisons
93
Lung cancer paraneoplastic complications?
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
Lung cancer Ix?
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
Lung cancer staging Ix?
1. CT 2. PET 3. Radionuclide bone scan 4. Thoracoscopy, mediastinoscopy
96
Lung cancer Mx?
1. General = MDT, stop smoking, optimise nutrition and CV function 2. NSCLC 3. SCLC 4. Palliative care
97
NSCLC Mx?
1. Chemo = platinum based + biologics 2. Radio 3. Surgery = rx of choice of no metastatic spread --> wedge resection/lobectomy/pneumonectomy
98
SCLC Mx?
.Usually disseminated at presentation, some benefit with chemo
99
Lung cancer palliative Mx?
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
Lung cancer prognosis?
1. NSCLC = 50% 5 yrs w/o spread, 10% w/ spread | 2. SCLC = 1-1.5 years medial survival treated, 3m untreated
101
Pneumonia Ix?
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
Pneumonia Mx?
1. Conservative = Analgesia, Oxygen, Fluids, Chest Physio | 2. Medical = Abx
103
Complications of pneumonia?
1. Septic shock + MOF --> ITU 2. Parapneumonic effusion/empyema/abscess --> drainage 3. Resp failure --> ventilation
104
Pneumonia f/up?
CXR at 6 weeks to check for underlying Ca and resolution
105
Classification of pneumonia?
1. Anatomically | 2. Aetiologically
106
Anatomic classification of pneumonia?
1. Bronchopneumonia = patchy consolidation of different lobes 2. Lobar pneumonia = fibrosuppurtaive consolidation of a single lobe (congestion --> red --> grey --> resolution)
107
Aetiological classification of pneumonia?
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
Aspiration pneumonia RFs?
1. Stroke 2. Bulbar palsy 3. Reduced GCS 4. GORD/Achalasia
109
Aspiration pneumonia typical site?
Posterior segment of RLL
110
Aspiration pneumonia organisms?
Anaerobes
111
Aspiration pneumonia Mx?
Co-Amoxiclav
112
Immunocompromised pneumonia causes and mx?
1. PCP = Co-trimoxazole 2. TB = RIPE 3. Fungi = amphotericin 4. CMV/HSV = ganciclovir
113
Atypical pneumonia?
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
CURB-65 score?
Severity of pneumonia 1. Confusion: AMTS <=8 2. Urea >7mM 3. RR > 30 4. BP <90/60 5. >=65
115
CURB-65 score interpretation?
1. 0-1 = Home Rx 2. 2 = Hospital Rx 3. >=3 = Consider ITU
116
SIRS - MODS spectrum?
1. SIRS 2. Sepsis 3. Severe sepsis 4. Septic shock 5. MODS
117
SIRS defn?
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
Sepsis defn?
SIRS with a presumed or confirmed infectious process
119
Severe sepsis defn?
Sepsis with at least 1 organ dysfunction or hypoperfusion
120
Septic shock defn?
Severe sepsis with refractory hypotension
121
MODS defn?
Impairment of >=2 organ systems, such that homeostasis cannot be maintained without therapeutic intervention
122
Old management of TB?
It was believed that lower PaO2 would inhibit TB proliferation, and therefore inducing apical collapse was a treatment
123
3 complications of old TB?
1. Aspergilloma in old TB cavity 2. Bronchiectasis 3. Scarring predisposes to Bronchial Ca
124
TB subtypes and pathophysiology?
1. Primary 2. Primary Progressive 3. Latent 4. Secondary
125
Primary TB features?
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
Primary progressive TB features?
1. Resembles acute bacterial pneumonia 2. Mid and lower zone consolidation, effusions, hilar LNs 3. Lymphohaematogenous spread --> extrapulmonary and miliary TB
127
Latent TB features?
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
Secondary TB features?
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
Dx of Latent TB?
1. TST, if positive --> | 2. IGRA
130
Dx of Active TB?
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
When is PCR helpful for TB?
Can Dx rifampicin resistance
132
Tuberculin skin test defn?
Intradermal injection of purified protein derivative, with induration measured at 48-72 hours
133
TST False +ive causes?
1. BCG 2. Other mycobacteria 3. Previous exposure
134
TST False -ive causes?
1. HIV (infection) 2. Sarcoid (inflammation) 3. Lymphoma (malignancy)
135
IGRA defn?
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
IGRA example?
Quantiferon Gold

Medicine and Surgery Mushkies (52 decks)

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