Brainscape's Knowledge GenomeTM

Browse over 1 million classes created by top students, professors, publishers, and experts.


See full index

MBBS - Year 2 > Respiratory - Pleural and Pulmonary Vascular Diseases > Flashcards

Respiratory - Pleural and Pulmonary Vascular Diseases Flashcards

1
Q

The structure of the pleura

A

The pleural space is bounded by the parietal and visceral membranes covered by a continuous layer of mesothelial cells

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

What can result in the accumulation of excess pleural fluid

A

Disturbances in either formation or absorption

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

When can we determine pleural fluid is an exudate - Light’s criteria

A

Pleural fluid proteins divided by serum proteins is >0.5
Pleural fluid LDH divided by serum LSD > 0.6
Pleural fluid LDH > 2/3 the upper limits of labs normal value for serum LDH

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

Determining transudates vs exudates

A

Hx
Examinations
Ix

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

Ix to help determine transudates vs exudates

A 
Radiology 
Bloods - clotting screen, FBC, LFTs etc 
Light's criteria 
CT, PET 
Bx
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

Most important examples of condns causing transudates

A

Usually caused by failures

HF
Liver cirrhosis
Nephrotic syndorme
Hypoalbuminaemic status

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

Other condns causing transudates

A

Mitral stenosis
Meigs syndrome
Constrictive pericarditis

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

Features of transudates

A

Slower time scale

Usually bilateral but R side may be larger - may find fluid in other areas e.g. ascites, pitting oedema

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

Treatment of transudates

A

Treat the case- if pt fails to respond will need to reconsider dx

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

Causes of pleural exudates

A 
Parapenumonic effusions and empyema 
Malignancy 
Pulmonary infarction 
TB 
Drugs 
RhA
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

Clinical assessment of pleural exudates

A

Risk factors (smoking, asbestos)
Red flag symptoms
A/c and subacute symtoms - timescale
Look for systemic signs (should be minimal) and effusion is often unilateral

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

Examination findings of pleural exudates

A

Reduced chest expansion
Percussion - stony dullness
Absent breath sounds

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

Use of ultrasound when determining between transudates and exudates

A

Fluid vs thickening - darker fluid. is usually transudate
Loculations
Guided thoracocentesis (Light’s criteria)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

What do we send pleural aspiration for

A 
Cytology 
Protein 
LDH 
pH/ glucose 
Gram stain 
Culture & sensitivity
Optional extras depending on likely cause
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

Thoracoscopy

A

Placing camera in pleural space under anaesthetic

Can also take fluid from parietal pleura during this procedure

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

Why should an ultrasound be done before a thoracospy

A

To guide needle placement

Should be above rib to avoid neurovasc bundle

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
17
Q

Ddx for complete white-out on CXR w/ trachea deviation

A

Complete lung collapse
Massive pleural effusion
Pneumonectomy

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
18
Q

Pleural plaques

A

Benign condn

Sign of asbestos exposure

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
19
Q

When might a pt develop diffuse pleural thickening

A 
Heavy exposure to asbestos **
Previous haemothorax 
TB 
Chest surgery 
Radiation 
Infection 
drugs
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
20
Q

What can diffuse pleural thickening lead to

A

SOB, restricted lung function - requires follow up

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
21
Q

What are the majority of pleural effusions. (90%) caused by

A

Infection - treat w/ abx, CXR in 6-8 weeks (exudate)
HF - treat cause, don’t drain (transudate)
Malignancy (exudate)
PE (exudate)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
22
Q

Clinical px of PTX pts

A

Hx - cigarette, cannabis smoking
PMH - lung disease
A/c onset symptoms - pleuritic chest pain, breathlessness

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
23
Q

Examination findings in PTX pts

A 
Trachea/ mediastinum - pushed 
Reduced/ absent expansion 
Percussion - hyper resonant 
Reduced/ absent breath sounds 
Hypoxamia esp if underlying lung disease
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
24
Q

Hypoxaemia

A

Low levels of oxygen in blood nOT tissues

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
25
Q

Causes of PTX

A

Primary spontaneous
Secondary spontaneous
Iatrogenic
Trauma

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
26
Q

Which group of people do we tend to see primary sponatanoues PTX in

A

Taller pts
Alveoli at the lung apex in tall individuals are subject to significantly greater distending pressure than those at the base of the lung

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
27
Q

What are apical pleural blebs associated with

A

High risk of PTX

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
28
Q

What should you ask spontaneous PTX pts about

A

Smoker - 12% risk of developing PTX

Lung disease

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
29
Q

Causes of secondary spontaneous PTX

A 
COPD 
PJP
CF
TB
Others - incl Marfan
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
30
Q

PJP

A

Pnemoctitis jiroveci pneumonia

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
31
Q

Tension PTX

A

Air trapped in between parietal and visceral pleura resulting in lung collapse, displacement of mediastinal structure and compromised cardiopulmonary function

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
32
Q

Medical emergency - Tension PTX

A

Low BP and low HR

Emergency needle decompression

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
33
Q

Anterior border of safe triangle for chest drain

A

Lateral border of Pec Major

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
34
Q

Superior border of safe triangle for chest drain

A

Base of axilla

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
35
Q

Inferior border of safe triangle for chest drain

A

Line of 5th ICS

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
36
Q

Lateral border of safe triangle for chest drain

A

Lateral edge of Lat Dor

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
37
Q

Complications of Chest Drain

A 
Infection/ pain 
Drain dislodgement 
Drain blockage 
Visceral injury 
Death
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
38
Q

Methods of chest drain insertion

A

Seldinger technique

Surgical blunt dissection approach

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
39
Q

Suction recommendations for chest drain

A

High volume low-pressure suction systems

Wall suction or digital suction system

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
40
Q

Conservative mx of PTX

A

Shouldn’t dive until definitive prevention strategy
Avoid air travel until 7/7 post PTX resolution
Smoking cessation
Organise follow up CXR to ,omit resolution
Manage comorbidities

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
41
Q

Definitive prevention strategy for ptx

A

Surgical pleurectomy

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
42
Q

Why do PTX pts need to stop smoking

A

Reoccurrence risk for smokers is 32%

8% in non-smokers

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
43
Q

When should a follow up CXR be organised for a PTX

A

2 - 4 weeks

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
44
Q

Risk factors for recurrence of SSP

A

Age
Pulmonary fibrosis
Emphysema

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
45
Q

Surgical intervention to prevent recurrence of PTX

A

Medical Chemical Pleurodesis (Talc)

Done for recurrent pneumothoraces and non-resolving PTX

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
46
Q

When is melatonin secreted

A

As a result of darkness, from the pineal gland

Retinal hyper thalamic pathway

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
47
Q

Stages of sleep

A

REM (dream sleep)

Non-REM - light sleep, slightly deeper, deep sleep

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
48
Q

When do we experience non-REM sleep

A

First half of sleep

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
49
Q

Which sleep refreshes cells

A

Deep sleep

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
50
Q

Breathing in NREM sleep

A

Normal

Regular muscle tone

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
51
Q

Breathing in REM sleep

A

Breathing is erratic

Muscles are atonic except diaphragm

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
52
Q

Which stage of sleep generally exacerbates sleep apnoea

A

REM sleep

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
53
Q

Sleep Disordered Breathing Classification

A

OSA
Central Sleep Apnoea
Mixed obstructive/ central apnoea
Obesity hypoventilation Syndrome

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
54
Q

Most common pattern seen in Sleep disordered breathing

A

OSA

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
55
Q

2nd most common pattern seen in sleep disordered breathing

A

Obesity Hypoventilation Syndrome

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
56
Q

Hx and clinical px of OSA pts

A 
Snoring 
Witnessed apnoea 
Excessive daytime sleepiness (EDS)
Nocturia 
Unrefreshed sleep 
Morning headaches
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
57
Q

Witnessed apnoea in OSA

A

Bed partner will note pt stopped breathing and then took a v loud breath on inspiration

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
58
Q

Nocturia

A

Urinating <4 a night

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
59
Q

Things to ask about in hx of OSA pts

A 
Occupation and riving 
Medications 
PMH 
Trisomy 21 
Past surgical hx
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
60
Q

What medication can be a ppts factor in OSA

A

Opiod analgesics

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
61
Q

What diseases should be screened for in PMH of OSA pts

A

Thyroid disease
DM
Systemic hTN
CDV and CBV disease

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
62
Q

Why do we ask about trisomy 21 in OSA pts

A

High risk for OSA (reduced muscle tone)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
63
Q

What is relevant in the past surgical hx of OSA pts

A

Tonsillectomy

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
64
Q

Measuring EDS

A

Epworth Sleepiness Scale

Scores of 11/24 = EDS

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
65
Q

Epworth Sleepiness Scale

A

Looks at high likely a pt is to fall asleep during following situations e.g sitting, watching TV, talking to someone, in a car
Rated from 0 (would never dose) - 3 (high chance)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
66
Q

Limitations of ESS

A

Pt may be worried to accurately report lapse in judgement e.g. driving
Timescale - values may may change by the time the pt is seen

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
67
Q

Possible sleep questionnaires

A

Pittsburgh sleep quality index index (PSQ1)
ESS
STOP BANG (pre-op screening)
4 variable screening tool used in Norfolk

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
68
Q

Examination for OSA

A

Obesity - BMI >30kg/m2, measure waist circumference
Upper airways -
Look for signs of acromegaly, hypothyroidism, Cushing’s syndrome
Look for cranial abnormalities

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
69
Q

What do you look for in upper airways when examining OSA pts

A

Enlarged tonsils esp in younger pts

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
70
Q

Which craniofacial abnormalities should you look for in OSA pts

A

Micrognathia (small jawline)
Retrognathia (receding jawline)

These can cause smaller airways

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
71
Q

Mallampati Score

A

Class I (Complete visualisation of soft palate) to Class IV (soft palate is covered)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
72
Q

Desaturation in apnoea

A

Cessation of breathing for 10s or more

Usually scored w/ >4% desaturation (SpO2)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
73
Q

Hypoapnoea

A

Reduction in the airflow (nasal flow) by 50% or more

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
74
Q

Does hypoapnoea always cause O2 desaturations

A

No - may not cause O2 desaturation

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
75
Q

Apnoea Hypoapnoea Index scores for OSA

A

2-15 - mild OSA
15 - 30 - moderate OSA
>30 severe OSA

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
76
Q

Desaturation index criteria fro OSA

A

> 4%

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
77
Q

OSAS

A

OSA syndrome

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
78
Q

OSA vs OSAS

A

Abnormal Sleep study and EDS - OSAS

Abnormal Sleep Study and no EDS - OSA

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
79
Q

Measurements in sleep disordered breathings

A 
Nocturnal oximetry 
Resp Polygraphy (Home Sleep Test)
Polysomnography - Gold standard
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
80
Q

Treatment of sleep disordered breathing

A

Lifestyle modifications - mild OSA/ OSAS
Wt reduction
Sleep Hygiene - excessive caffeine
Positional training

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
81
Q

Mandibular advancement devices

A

Used in mild OSA(S)

Boil and bite devices - pushes lower jaw forward creating more room at back of throat

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
82
Q

CPAP

A

Continuous Positive Airway Pressure

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
83
Q

When is CPAP given for OSAS

A

Definitive treatment - moderate/ severe disease
Given after attempting lifestyle modification and mandibular advancement devices
Relieves symptoms majorly

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
84
Q

Driving and sleep apnoea

A

Pts have to declare dx to DVLA
CPAP compliance > 4hrs/ night
HGV/ public transport drivers need to inform employers and occupational health - asked not to drive unless established in treatment

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
85
Q

Obesity Hyperventilation Syndrome

A

Morbid obesity BMI > 35kg/m2
Mean SpO2 < 90% in sleep study
Need to measure time spent <90% SpO3 - shallow breathing, reduced TV

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
86
Q

ABG of pts w/ obesity Hypoventilation Syndrome

A

Day time CO2 retention and/or elevated HCO3 (.27mmol/L)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
87
Q

Mx of Obesity Hypoventilation Syndrome

A

Wt loss

NIV (+ve pressure)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
88
Q

Co-existent lung disease in sleep disordered breathing

A

Asthma and OSA

COPD/ emphysema: overlap syndrome of OSA/COPD

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
89
Q

Consequences of SDB (sleep disordered breathing)

A

Systemic HTN
AF
MI, CVA
Pulmonary arterial hypertension

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
90
Q

Ventilation

A

Rate at which air enters or leaves the lungs

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
91
Q

Minute ventilation

A

Volume of air moving in and out per unit time

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
92
Q

Alveolar ventilation

A

Amount of air utilised for gas exchange (VT - dead space) x RR

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
93
Q

Perfusion (Q)

A

Movement of blood in to lungs through pulmonary capillaries

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
94
Q

V/Q ratio

A

Alveolar ventilation/ pulmonary blood flow

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
95
Q

When do we see hypoxaemia

A 
Reduction in altitude 
Hypoventilation 
Diffusion 
Shunts 
VQ mismatch
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
96
Q

When are V and Q matched

A

When pulmonary blood flow is proportionally matched to the pulmonary ventilation
Results in greatest efficiency for gas exchange

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
97
Q

VQ ratio for single alveolus

A

Alveolar ventilation/ capillary blood flow

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
98
Q

How many zones are there for perfusion and ventilation in the lungs

A

3

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
99
Q

Pressures in zone I (apex) for perfusion and ventilation

A

PA > Pa > Pv

A - systemic arteries
a - alveoli
v - pulmonary vein

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
100
Q

Pressure in zone II for V & Q

A

Pa > PA > Pv

A - systemic arteries
a - alveoli
v - pulmonary vein

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
101
Q

Pressures in zone III

A

Pa > Pv > PA

A - systemic arteries
a - alveoli
v - pulmonary vein

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
102
Q

How does V/Q vary in diff zones of the lung

A

Highest in apex and lowest in base (but has higher O2 content)
Clinical rel - certain infections attack apex as less aerobic than base

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
103
Q

Shunt

A

Physiological phenomena where deoxygenated blood mixes w/ oxygenated blood
Occurs when there’s an intracardiac defect - doesn’t participate in gas exchange

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
104
Q

Pulmonary shunt

A

Mixing of blood without participating in the gas exchange at level of pulmonary capillaries

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
105
Q

When do we see a pulmonary shunt

A

Occurs when alveoli are perfused like normal but ventilation fails to supply perfused region - pathological condn (VQ = 0)

106
Q

Examples of intrapulmonary shunting

A

Fluid in alveoli e.g. pulmonary oedema & pneumonia

107
Q

Shunt fraction

A

% of blood pumped by heart that is not ventilated (oxygenated)

108
Q

When is the shunt fraction increased

A

Greater in pulm contusion or haemorrhage even at breathing 100% oxygen

109
Q

What can minimise shunt fraction

A

Vasoconstriction - compensatory mechanisms of hypoxaemia

110
Q

What can cause a VQ mismatch

A 
Dead space (physiological) - ventilation of poorly perfused alveoli (V > Q)
Shunts; perfusion of poorly ventilated alveoli (V < Q)
111
Q

Pathologies resulting in VQ mismatch - low VQ ratio

A 
Pneumonia 
Pulmonary oedema 
ILD/ pulm fibrosis 
Asthma 
Mucous plugging 
Airway obstruction
112
Q

Pathologies resulting in AQ mismatch - high VQ

A

PE

Emphysema

113
Q

What does a VQ mismatch respond to

A

100% oxygen

114
Q

Normal VQ in healthy lung

A

0.8

115
Q

Aa gradient

A

Alveolar to capillary oxygen gradient

116
Q

Mechanisms of hypoxaemia

A 
Shunt 
Diffusion impairment 
VQ mismatch 
Hypoventilation 
Low ambient oxygen
117
Q

Aetiology of primary pleural malignancy

A

Mesothelioma

118
Q

Aetiology of secondary pleural malignancies

A

Lung - 1st most common
Breast - 2nd most common
Lymphoma - 3rd most common

But almost any cancer can metastasise to the pleura

119
Q

What do pleural malignancies commonly cause

A

Malignant pleura effusions and/or pleural thickening

120
Q

Pathology of exudative effusion caused by pleural malignancy

A

Tumour dissemination
Angiogenesis - w/ vasc hyperpermeability
Tumour secreted vasoactive mediators (VEGF)

121
Q

Asbetsos-related resp disease

A 
Asbestosis 
Malignant pleural mesothelioma 
Pleural plaques 
Benign pleural thickening 
Benign pleural effusion
122
Q

Why is asbestos considered an ILD

A

Asbestos in lung tissue –> fibrosis and scarring

123
Q

When can pts get compensation for benign pleural thickening after asbestosis exposure

A

If disabled by SOB

124
Q

Epidemiology of pleural malignancy

A

Common - incidence about 30,000/ yr
Breast cancer commonest in women and lung cancer commonest cause in men
Increasing incidence w/ age (max at 80-85)

125
Q

Ddx of pleural effusion

A 
Transudative pleural effusion - cardiac, renal or hepatic failure 
Pleural infection 
PE 
CTD 
Benign asbestos pleural disease
126
Q

What should be asked in the hx of a pt w/ pleural malignancy

A 
Symptoms spp to effusion 
Constitutional symptoms 
Symptoms of other malignancy 
PMH - previous malignancies 
SH
127
Q

Symptoms spp to effusion in pts w/ pleural malignancy

A

Breathlessness, cough, dull chest pain

Time course: months - weeks

128
Q

Constitutional symptoms seen in pts w/ pleural malignancy

A

Wt loss
Loss of appetite
Fatigue

129
Q

Symptoms of the malignancies that may be seen in pts w/ pleural malignancy

A

Dysphagia
Change in bowel habits
Lumps

130
Q

Relevant SH in pts w. pleural malignancy

A

Smoking
Asbestos exposure
Perfomance status

131
Q

ECOG performance status

A 
Looks at effects of malignancy on pts lifestyle 
From 0 (fully active, able to carry on pre-disease performance) to 4 (completely disabled, cannot cary on self-care)
132
Q

Why is ECOG performance status important for pleural malignancy

A

Helps determining what ix the pt is fit for e.g <2 fit for thoracoscopy
Helps determine mx, 4 is usually disseminated and not fit for treatment

133
Q

Examination of pts w/ pleural malignancy

A

Increased RR
Cachexic
not usually hypoxic
Decreased air entry, decreased lung expansion, dull percussion note, decreased vocal resonance
Other signs of malignancy e.g. breast lumps, testiuclar lumps, lymphadenopathy

134
Q

Main ix for pleural malignancy

A

Bloods - U&Es, FBC, CRP, clotting, PSA

CXR

135
Q

Addn ix for pleural malignancy

A

Thoracic ultrasound
CT
Pleural aspiration
Thoracoscopy

136
Q

What might you see in a thoracic ultrasound in pleural malignancy

A

Pleural effusion
Pleural thickening
Pleural modularity

137
Q

Difference in CT scan for men and women for suspected pleural malignancy

A

CT scans in men of chest and upper abdomen

For women also do pelvis

138
Q

What do you send pleural aspiration for in suspected pleural malignancy

A

Biochem: total protein, LDH (malignant effusions typical transudative)
MC&S - excl infection
Cytology - +ve in 90% MPE, only 20% in mesothelioma

139
Q

MPE

A

Malignant Pleural effusion

140
Q

Main procedures done in thoracoscopy

A

Fluid drainage and pleural biopsy

After procedure can perform pleurodesis (using sterile talc), IPC insertion

141
Q

IPC

A

indwelling pleural catheter

142
Q

Complication of thoracosocpy

A

Re explosion pulmonary oedema

143
Q

Making a dx of pleural malignancy - role of MDT

A

Team reviews hx and ix
Make a dx - radiological or definitive
Mx plan

144
Q

Possible mx plans for pleural malignancy

A

Further biopsies
Cancer treatment
Watch and wait
Palliative care

145
Q

Treatment for pleural malignancy

A 
Treat underlying malignancy - lymphoma, small cell lung cancer, breast cancer 
Therapeutic aspiration 
Chest drain and pleurodesis 
IPC insertion 
Pleurectomy
146
Q

Chest drain and pleurodesis for pleural malignancy

A

Inpt 2-5 days
Seldinger chest drain and underwater seal
~75% success rate

147
Q

Why is talc used in pleurodesis

A

4g talc creates infl causing pleura to fuse together

148
Q

What can pts be left w/ after chest drain and pleurodesis

A

Residual pleural thickening –> breathlessness

149
Q

IPC for pleural malignancy treatment

A

Day case
intermittent drainage at home using vacuum bags, 3x/ week initially
Definitive treatment
Can give talc to perform pleurodesis

150
Q

What IPC the treatment of choice for

A

Trapped lung

Failed pleurodesis

151
Q

Risk associated w/ IPC

A

Blockage

Infection

152
Q

Trapped lung

A

Thickened visceral pleura so unable to expand fully

153
Q

Pulmonary HTN

A

Pathophysiological disorder that may involve multiple clinical condns, where mPAP > 20 mmHg

154
Q

mPAP

A

Mean pulmonary artery pressure

155
Q

What can pulmonary HTN complicate

A

Majority of CDV and resp diseases

156
Q

What kind of symptoms are seen in pulm HTN

A

Non-spp

157
Q

What does pulmonary HTN dx and classification require

A

R heart catheterisation

158
Q

Calculating PVR

A

80(mPAP - PAWP)/ CO

159
Q

PAWP

A

Pulm artery wedge pressure

160
Q

Normal pulmonary artery pressure

A

14 mmHg +/- 3.3 mmHg at rest

161
Q

Criteria for Pulm HTN

A

Precapillary PH mPAP > 20mmHg, PVR > 3 WU and PAWP < 15mmHg

Combined pre and post capillary PH - mPAP > 20mmHg, PVR > 3 WU, PAWP > 15

162
Q

WU

A

Wood units

163
Q

Classification of pulm HTN

A 
Pulm arterial HTN (PAH)
Left heart disease - PAWP > 15
Lung disease 
CTEPH 
Unclear/ multifactorial
164
Q

Epidemiology of pulmonary HTN

A

Global PH incidence data is poor
In the UK, prevalence of 97/1,000,000
F:M ratio of 1.8
L heart disease believed to be most common cause

165
Q

How is clinical presentation of Pulm HTN classed

A 
By functional class 
From Class I (nob symptoms w/ exercise or rest) to Class IV (symptomatic at rest, syncope and fatigue)
166
Q

Determinants of prognosis in pulmonary HTN

A

Clinical signs of R heart failure
Progression of symptoms
Syncope
WHO functional class
Cardiopulmonary exercise testing
NT-proBNP plasma levels - higher is worse
Imaging - increased RA area, pericardial effusion

167
Q

General mx of pulmonary HTN

A 
Avoid pregnancy 
Influenza and pneumococcal vaccinations 
Psychosocial support 
Pulm/ cardiac rehab 
Diuresis if evidence of volume overload 
LTOT if pO2 consistently less than 8kPa
Correct anaemia
168
Q

Spp mx for pulm HTN

A

Group I - depends on functional class, assess severity
Group 2 - targeted therapy not currently licensed
Group 3 - no targeted therapy
Group 5 - v difficult to mx

169
Q

CTEPH

A

C/c thromboembolic pulmonary HTN

170
Q

What is CTEPH

A

Fibrotic transformation of a pulmonary arterial thrombosis, causing fixed mechanical obstruction of pulmonary arteries
Microvascular remodelling causing a progressive increase in PVR

171
Q

What % of CTEPH pts lack a hx of a/c PE

A

~25%

172
Q

Treatment for CTEPH

A

PEA (pulmonary endarterectomy) surgery - removing central obstructing lesions
BPA (Balloon pulmonary angioplasty)

173
Q

CTEPH prognosis

A

In operable pts, treated w/ drugs, 3 yrs survival varies from 41-805
3-yr survival of 89% in operated PEA pts and 70% in non operated pts

174
Q

Drugs given for CTEPH

A

IV prostacyclin analogues or oral PAH targeted drugs

175
Q

What does BPA in non-operable CTEPH pts show significant improvement in

A 
Functional status 
QoL
Pulm pressure 
Exercise capacity 
PVR
176
Q

Causes of cardiac chest pain

A

MI/ infarction
Pericarditis
Aortic dissection (pleurite chest pain)

177
Q

Resp causes of chest pain

A

PE
PTX
Pneumonia
Pleural infl (pain happens even at rest)

178
Q

GI causes of chest pain

A

Oesophageal spasm
Dysmotility/ reflux
Oesophageal rupture (Boerhavve’s)

179
Q

MSK causes of chest pain

A

Rib frature/ metastasis
Muscle spasm/ strain
Costochondritis (localised pain - can be elicited)

180
Q

Psychological states causing chest pain

A

Panic attack

Hyperventilation

181
Q

Ix for differentiating between causes of chest pain

A

Bloods - FBC, CRP/ESR, LFT, D-dimer etc
ECG - cardiac causes, arrhythmia
CXR +/- further imaging

182
Q

What is a PE

A

Occlusion of a segment of pulmonary arterial circulation through embolism from a distant source - lower limbs

183
Q

Embolic material that can cause a PE

A

Commonly blood clots
May be fat embolism - following major trauma
Air embolism following invasive procedures e.g. central line insertion

184
Q

Causes of a PE

A

Virchow’s triad

Hypercoagulable stae
Stasis (local/ systemic) - VV, immobilisation
Endothelial damage - c/c infl

185
Q

What can cause a hyper coagulable state –> PE

A

Factor V Leiden, Protein S/C deficiency
Malignancy
Loss of proteins incl clotting factors - myeloma

186
Q

Major risk factors for a PE

A 
Recent immobility 
Major surgery incl obstetric 
Leg fracture 
Previous DVT/ PE 
Thrombotic disorder 
Metastatic cancer
187
Q

Minor risk factors for PE

A 
Oestrogen 
Travel 
Known thrombophilia 
Obesity 
Minor surgery
188
Q

Presentation of a PE

A 
SOB 
Pleuritic chest pain 
Cough 
Leg swelling/ pain 
Haemoptysis
189
Q

Well’s score for PE - criteria

A 
Previous VTE 
Tachycardia 
Recent surgery/ immobilisation 
Clinical signs of DVT - 3 point 
Haemoptysis 
Cancer
190
Q

Bloods for a PE

A

ABG
D-dimer
FBC/ clotting profile

191
Q

ECG for PE

A

Sinus tachycardia
Fast AF
S1Q3T3

May also be normal

192
Q

Ix for PE

A 
Bloods 
ECG 
CXR - doesn't excl/ confirm dx
CTPA
V/Q
193
Q

D-dimer for PE

A

Highly sensitive
High -ve predictive value
Used in combo w/ probability score

194
Q

What is D-dimer commonly elevated in

A

Pts w/ infl states, infection, ACS, malignancy recent surgery

195
Q

What might you see on a CXR for for PE

A

Pulmonary infarct

Pleural effusion

196
Q

CTPA

A

CT pulmonary angio
Gold standard for PE
Involves higher dose of ionising radiation and risk of nephrotoxicity w/ contrast
Embolus is dark grey - found in white area

197
Q

VQ scan for a PE

A

Compares radioactive material uptake in lungs via inhalation and iV injection
Reported as probability risk

198
Q

Pulmonary angio for PE

A

Invasive
Superseded in a/c setting by CTPA
Relevat in dx CTEPH

199
Q

Echo for PE

A

Looks for evidence of R heart dilatation/ strain
Relevant in a/c setting/ peri-arrest situation
To screen for 2’ pulmonary HTN

200
Q

Treatment of a/c PE

A

Heparin - LMWH, unfractionated heparin (IV)
Warfarin

Anticoagulants for 3/12

201
Q

Massive PE

A

PE w/ evidence of systemic compromise - central/ proximal/ multiple clots
Hypotension, R heart strain

202
Q

Thrombolysis of a massive PE

A

Dissolution of a clot
Improvement of physiological parameter
Reduce risk of death

203
Q

Follow up for PE

A

Echo
Consider VTE risk factors and their modification
Consider lifelong anticoagulants

204
Q

Who gets lifelong treatment after a PE

A

Idiopathic PE - cause unknown
First episode and ongoing risk factors
2 or more VTE events - IVC filter

205
Q

Canonball metastases on CXR

A

Discrete lesion, multiple opacities

206
Q

Mx of tension PTX

A

Urgent needle decompression

Chest drain and admission

207
Q

Ddx of whole lung field white out

A

Collapse
Large pleural effusion
Pneumonectomy
Consolidation

208
Q

Pneumonectomy

A

Surgical removal of lung or part of lung

209
Q

What direction does the trachea move in lung collapse

A

Pulls trachea towards it

210
Q

What direction does a large pleural effusion push the mediastinum

A

Away

211
Q

Why might you see a white out on a CXR following a pneumonectomy

A

Fluid fills up space where lung has been taken out

212
Q

What direction does a pneumonectomy move the mediastinum

A

Moves in or may be normal

213
Q

When do you see a meniscus sign on a CXR

A

Pleural effusion

214
Q

What do we see in hydro PTX on CXR

A

Fluid line

215
Q

What side do you normally see surgical emphysema in

A

The side of the chest drain

216
Q

Pancoasts tumour

A

Apical lung tumour

May cause denervation

217
Q

Signs in Horner’s syndrome

A

Anhydrosis
Ptosis
Miosis

218
Q

What does it mean if the cricothyroid distance is <3 fingers

A

Hyperinflation of the chest

219
Q

What types of crackles do we hear

A

Coarse (infection and bronchiectasis) and fine end inspiratory (pulm fibrosis)

220
Q

Features of vesicular breathing

A

Normal breathing
Longer inspiratory phase (2:1)
Gentle sound

221
Q

Features of bronchial breathing

A

Seen in infections
Longer espiratrxy phase (1:3)
Break in between inspiratory and expiratory phases
Louder sound

222
Q

Features of rhonci

A

Sounds similar to snoring
Can be cleared by coughing
Combination of wheeze and crackles - low pitched

223
Q

Cause of rhonci

A

Build up of secretions

224
Q

Features of a wheeze

A

Heard in expiratory
High pitched
Whistling/ musical tone

225
Q

When do we hear a pleural rub

A

Pleurisy

226
Q

Added breath sounds

A 
Crackles 
Bronchial breathing 
Wheeze 
Stridor 
Rhonci 
Pleural rub
227
Q

Signs of anaphylaxis

A

V quick onset
Stridor (inspiratory wheeze)
Angiodema
Urticarial rash

Crash call should be put out

228
Q

Where do we aspirate PTXs from

A

2nd IC space, mid clavicular

229
Q

Where do we insert a chest drain for PTX

A

5th IC space mid axillary

230
Q

How do we measure a PTX

A

From edge of lung to hilum

231
Q

Mx of PSP

A

If >2cm and/or breathless - aspirate

If no success, insert chest drain and admit

232
Q

Mx of SSP

A

Insert chest drain if >2cm and/or breathless

Aspirate if 1-2cm

233
Q

Which hilum is higher

A

L

234
Q

What can a cavitating mass be caused by

A

Carcinoma of bronchus
SCC metastasis
Pulm infarct
Bacterial abscess

235
Q

Definition of apnoea

A

Cessation of breathing for 10 seconds, causing 4% destauration

236
Q

Ideal V/Q ratio

A

1 for maximally efficient pulmonary function

237
Q

Usual VQ ratio

A

0.84 overall

Diff ratios for diff areas due to where area lies in relation to heart

238
Q

How does VQ ratio change at the apex and base of lung

A

When standing up straight, ratio is 3.3 in apex and only 0.63 in base
V > Q in apex
V < Q in base

239
Q

Examples of diseases causing Class I PHTN

A

Idiopathic/ heritable PAH - pts usually px quite young

PAH 2’ to drugs of CTD

240
Q

Examples of diseases causing Class II PHTN

A

LV systolic/ diastolic dysfunction

Valvular disease e.g. MS, MR

241
Q

Examples of diseases causing Class III PHTN

A

COPD

ILD

242
Q

Examples of disease causing Class V PHTN

A

Sarcoidosis

Sickle cell anaemia

243
Q

What mutation causes familial PAH

A

BMPR2

244
Q

PAH

A

Pulm arterial HTN

245
Q

Symptoms of Pulm HTN

A 
(Non-spp) 
Progressive exertion dyspnoea
Syncope
Fatigue 
Limb swelling 
Chest pain 
Haemoptysis
246
Q

Examination findings for pulm HTN

A

Looking for associations w/ CTD e.g. Raynaud’s, calcinosis, telangiectasia, sclerodactyly

247
Q

Main ix for pulm HTN

A

R heart catheterisation
Echo
ECG
Bloods - NTproBNP, FBC (anaemic pts have worse prognoses)
Cardiac MRI
6 in walking test (stamina and desaturations)

248
Q

Why do we measure glucose in pleural aspirate

A

To rule out Rh effusion when glucose is low

249
Q

What is the pleural effusion most likely to be if the pH of the aspirate is below 7.2

A

Acidotic fluid implies parapneumonic effusion or empyema

Chest drain must be inserted ASAP (5th IC space)

250
Q

What can be done for a PTX pt if a chest drain has not worked

A

Insert large bore cannula
Surgery
Talc pleurodesis

251
Q

Key mechanism of hypoxaemia in pE

A

Physiological dead space - no gas supply to alveoli

252
Q

Key mechanism of hypoxaemia in pleural effusion

A

Physiological shunting

253
Q

What must HGV and public transport drivers do after a dx of OSA is made

A

Declare to DVLA and stop driving ASAP

Once established on treatment for 2-3/52, and assessed, they can resume

254
Q

Indications for CPAP

A

ESS 11/24 and moderat/severe apnoea

Mild apnoea but CDV risk factors

255
Q

Which CTD is most likely to cause heart failure

A

SScl

Specifically R heart

256
Q

h

A
257
Q

Example of a drug that may cause PAH

A

Fenfluramine - anti-epileptic

258
Q

Drug therapy for PAH

A

Sildenafil
Bosentan
Both venodilators

259
Q

Absolute contraindications for thrombolysis in PE

A 
Haemorrhage stroke 
Ischaemic stroke within 3/12
Recent head injury 
Recent surgery 
Current active bleeding 
Bleeding disorder
260
Q

Mechanism of tension PTX

A

The opening in the pleura creates a flap that acts as a one-way valve
This allows air to enter the cavity during inspiration but stops it from leaving during expiration

261
Q

Mechanism of a spontaneous PTX

A

Small bleb/ weakness ruptures - more common in tall pts
Air in pleural space can results in pain - variable in intensity
Feeling breathless - dependent on air leak
Air in pleural space may result in the lung collapsing

262
Q

Key landmark for insertion of a needle in a tension PTX

A

2nd IC space in the mid-clavicular line (urgent needle decompression)

MBBS - Year 2 (20 decks)

Brainscape helps you reach your goals faster, through stronger study habits.
© 2024 Bold Learning Solutions. Terms and Conditions