Respiratory (Quesmed) Flashcards
What is Acute Respiratory Distress Syndrome?
What are 2 examples of diseases that typically cause it?
It is defined as a Non-Cardiogenic Pulmonary Oedema and Diffuse Lung Inflammation- usually secondary to an underlying illness (like Pancreatitis/ Pneumonia)
The pathophysiology includes Diffuse Alveolar Damage
Alveoli are being accumulated with Fluid
What is the pathophysiology of Acute Respiratory Distress Syndrome?
How is it different from NEONATAL RESPIRATORY DISTRESS SYNDROME?
1) ARDS is a respiratory failure that occurs within a week of onset of Lung Injury
2) It involves BILATERAL ALVEOLAR INJURY due to inflammation mediated by Inflammatory Mediators like TNF-Alpha, IL1 and IL8
3) The resulting Endothelial Injury ACTIVATES NEUTROPHILS in Pulmonary Capillaries- this releases Reactive OXYGEN SPECIES and PROTEASES that damage the Alveolar Endothelium and Type 2 Alveolar Cells
4) So the Vascular Permeability increases and the Lung Surfactant is lost. This Fluid Accumulation in the Alveoli causes Pulmonary Oedema and Hypoxaemia as a result
5) This is NOT DUE TO Cardiogenic Pulmonary Oedema, Pleural Effusion or Atelectasis
6) ARDS is not the same as Neonatal Respiratory Distress Syndrome btw (which is due to Inadequate Surfactant Production due to Prematurity)
What are the causes of ARDS?
What is the most common cause? What are the 3 other important causes of ARDS?
Pneumonia (most common cause)
Sepsis
!!!!!!!!!!!SMOKE INHALATION
Aspiration
Pancreatitis
Trauma and Fractures
Transfusion Reactions
Fat Embolism
What are the signs of ARDS? What are the Four Defining Features of ARDS?
What can you measure if there is a doubt on whether the ARDS is cardiogenic or not?
What is the ONLY Heart Failure symptom seen in ARDS?
It presents as Acute Respiratory Failure which does NOT improve with Supplemental Oxygen
There are FOUR Defining features of ARDS
1) Acute Onset (<1 week of a known risk factor)
2) Pulmonary Oedema (Bilateral Infiltrates on CXR)
3) Non-Cardiogenic (Pulmonary Artery Wedge Pressure needed if there is a doubt)
4) PaO2/FiO2<40
Dyspnoea
Tachypnoea
Confusion
Presyncope
There will be Bibasal Crackles (but no other signs of Heart Failure)
What imaging investigations should be ordered in ARDS?
What is the defining feature of ARDS?
Chest Xray- Bilateral Alveolar Infiltrates- NO OTHER SIGNS OF HEART FAILURE like the Kerley B Lines or Cardiomegaly
CXR will ONLY show the Pulmonary Oedema- nothing else that suggest Heart Failure
CT Scan may help to characterise changes found on X ray
PaO2/FiO2<40 is a Defining Feature of ARDS
What is the management of ARDS?
Where should ARDS be managed?
!!!!!!!!!!!!!!!!!!Transfer them to ITU!!!!!!!!!!!!!!!!!!!!!!
1) Mechanical Ventilatory Support- A Low Tidal Volume is associated with better outcomes- Give them OXYGEN!
2) Haemodynamic Support to maintain Mean Arterial Pressure>60mmHg- VASOPRESSORS can be given
3) DVT Prophylaxis
4) Nutritional support through Enteral/ Parenteral if NEEDED
5) Regular Repositioning of Patients for Pressure Ulcer Prophylaxis
6) Antibiotics only needed if an infective cause is suspected (Pneumonia or Sepsis)
What is Asbestosis?
It is a LOWER ZONE interstitial lung fibrosis that manifests in patients with Pleural Plaque diseases 10 or more years after they have exposure to Asbestos
What are the signs and symptoms of Asbestosis?
History of Asbestos Exposure- usually 20 or more years prior
Symptoms- Dyspnoea and Cough
Signs- Crepitations on Auscultation (cos it is fibrosis) , Finger Clubbing, Cyanosis and Reduced Chest Expansion
What is seen on the Chest Xray for Asbestosis?
What must you remember about the Pleural Plaques?
How do you manage Atelectasis?
Linear Interstitial Fibrosis
Pleural Plaques (Pleural Plaques are BENIGN and do NOT undergo a malignant change)
Pleural Thickening
Atelectasis (partial collapse or incomplete inflation of a lung)
- Management- Position them upright and Chest Physiotherapy
What do pulmonary function tests show for Asbestosis?
Restrictive pattern (Small Lung)
- Low FVC
- Low TLC
- Normal FEV1/FVC ratio
Can also be Obstructive (Blocked Lung)
- Reduced FEV1
What is needed for the definitive diagnosis of Cancer in Asbestosis?
Open Lung Biopsy
What is the management of Asbestosis?
CONSERVATIVE, then O2 then Surgery
Smoking Cessation
Pulmonary Rehabilitation
Oxygen if SpO2 <90%
Lung Transplant
If death occurs due to Asbestosis, this must be reported to the coroner
Which conditions cause Aspiration Pneumonia?
Anything that may cause an Unsafe Swallow
Neurological Conditions plus Upper GI Conditions plus ALCOHOL and SEIZURE
- Stroke
- Myasthenia Gravis
- Bulbar Palsy
- Achalasia
- G.O.R.D.
- Alcoholics
- Post Ictal State
What microorganisms cause Aspiration Pneumonia?
Streptococcus Pneumoniae
Staphylococcus Aureus
Haemophilus Influenza
Pseudonomas
Enterbacteriaceae
Can Also be Gram Negative Bacteria
What is the treatment of Aspiration Pneumonia?
Cover for both Gram Positive and Negative
IV Ceftriaxone and IV Metronidazole
Aspiration= CEF-MET
When must food and water be stopped before a Hernia Surgery?
Food- 6 hours before
Only Water until 2 hours before
Which Lung Regions usually mean Aspiration Pneumonia?
If the RIGHT MIDDLE and LOWER Lung Lobes are consolidated
When is the Pneumococcal vaccination routinely offered?
2 Months
4 Months
12-13 Months
And Over 65 years
2-4-12-65
What groups are at risk of Pneumonia and need the vaccination every 5 years?
What suggests immunocompromisation?
Chronic Heart, Lung, Liver or Kidney Disease
Liver Cirrhosis
!!!!!!!!!!!!!Post-Transplant
Renal Failure
Nephrotic Syndrome
Immunosuppression)- AIDS, Chemotherapy, Splenectomy, SICKLE CELL DISEASE
Chronic Lung Conditions- CPD/ Bronchiectasis
What are the causes of Bilateral Hilar Lymphadenopathy?
Inflammatory- Sarcoidosis
Infective- Tuberculosis and Mycoplasma
Neoplastic- Bronchial Carcinoma and Lymphoma
Interstitial Lung Disease can also cause this. It can be Inorganic (Silicosis) or Organic (Extrinsic Allergic Alveolitis)
What is Bronchiectasis?
What is the most likely organism that causes it?
It is the PERMANENT Dilatation of the Bronchi and Bronchioles due to Chronic Infection/ Inflammation
This is usually caused by (These 4 are the ones associated with ASPIRATION PNEUMONIA AS WELL)
1) Haemophilus Influenzae
2) Pseudonomas Aeruginosa
3) Streptococcus Pneumoniae
4) Staphylococcus Aureus
What are the causes of Bronchiectasis?
What are the 5 main ones to remember?
Also remember YOUNG-KART
Post Infection- Tuberculosis, HIV, Measles, Pertussis, Pneumonia
Bronchial Pathology- Obstruction caused by Foreign Body or Tumour
Allergic Bronchopulmonary Aspergillosis (ABPA)
Congenital- Cystic Fibrosis, KARTAGENER’s SYNDROME, Primary Ciliary Dyskinesia, Young Syndrome
Hypogammaglobuminaemia (Low Antibodies)- IMMUNE DEFICIENCY causes Bronchiectasis
Rheumatoid ARTHRITIS
What is the presentation of Bronchiectasis?
Persistent (DAILY) Productive Cough (+/-Haemoptysis) in a YOUNG person with Resp Issues (that may be the cause of it)
PLUS the 2C’s-
1) Clubbing
2) Coarse Inspiratory Crackles
Dyspnoea
Wheeze
What investigations should be ordered in Bronchiectasis?
What is the best investigation to order?
What are the 2 signs that are seen?
Is Bronchiectasis OBSTRUCTIVE or RESTRICTIVE on Spirometry?
Spirometry- Bronchiectasis is OBSTRUCTIVE
Sputum Culture- To identify pathogens and guide management with Antibiotics
High Resolution CT- BEST DIAGNOSTIC INVESTIGATION for Bronchiectasis
Chest Xray- thickened Bronchial Walls and Cystic Appearance- TRAMLINE and SIGNET RING SHADOWS
Bronchoscopy- can locate areas of obstruction and haemoptysis or sample tissue for Culture
What Additional Investigations can be ordered to identify the cause of Bronchiectasis?
Serum Immunoglobulins- Hypogammaglobuminaemia
Cystic Fibrosis Sweat Test- Cystic Fibrosis
Aspergillus Precipitins or Skin Prick Test- ABPA
Rheumatoid Factor or ANA- Rheumatoid Arthritis
What is the management of Bronchiectasis?
Remember the 2 conservative managements and the ABC
Conservative
- Patient Education
- Support Group
- MOST IMPORTANT- _Chest Physiotherapy _ (Postural Drainage at least Twice Daily to help with Mucous Drainage)
- Smoking Cessation
Medical Management ABC
1) Antibiotics (long term if recurrent- PROPHYLACTIC if 3 or more exacerbations)
2) Bronchodilators (given if Dyspnoea and Wheeze (COPD, ABPA, Asthma))
3) Corticosteroid- Prednisolone if ABPA
- Carbocysteine- a Mucolytic Agent
Surgical Management
- Surgical Excision of Localised Area of Disease or Cessation of the Haemoptysis
- Lung transplant may be indicated
What is Primary Ciliary Dyskinesia (Kartagener’s)?
What is the inheritance?
What is weird about these Kartagener’s patients?
PCD is an Autosomal Recessive disorder of dysfunctional cilia.
Cilia are important as they determine the orientation/laterality of internal organs and line the inner walls of bronchi. Consequently, their dysfunction results in bronchiectasis and recurrent infections.
Percussion usually changes at the RIGHT lung base due to movement of the liver during inspiration and expiration. Patients may display this phenomena at their LEFT lung base, suggesting SITUS INVERTUS – a key features of PCD
CHEST XRAY shows DEXTROCARDIA
What are the Musculoskeletal signs of Cystic Fibrosis?
What is HPOA? What 3 conditions is it associated with?
Clubbing
Hypertrophic Pulmonary Osteoarthropathy
- Lung disease (CF, Lung cancer or Bronchiectasis) which causes Clubbing and Arthritis
Osteoporosis
Arthritis
What can be ordered for the diagnosis of Cystic Fibrosis?
When can the HEEL PRICK test be ordered?
1) Neonatal heel prick day between day 5 and day 9
2) Sweat test: sweat sodium and chloride >60mmol/L
3) Faecal elastase: this can provide evidence for abnormal pancreatic exocrine function.
4) Genetic screening: This can identify CF mutations
What kind of tests should be ordered in patients with KNOWN Cystic Fibrosis?
What is the Spirometry picture in Cystic Fibrosis?
~~~~~~~
Aspergillus Skin Prick
Spirometry- Obstructive
Abdominal Ultrasound- Distal Intestinal Obstruction, Liver Cirrhosis, Chronic Pancreatitis
Chest X Ray- Bronchiectasis, Hyperinflation
What is the management of Cystic Fibrosis?
(Read over but memorise the one in PAEDS)
~~~~~~
If INFECTIVE EXACERBATION
- Antibiotics
- Nebulised Mucolytics (Dornase Alfa)
- Bronchodilators (Inhaled Corticosteroids or B2 Agonists)
Pancreatic Insufficiency
- Insulin Replacement
- Creon
- Vitamin ADEK
If ABNORMAL LFTs
- URSODEOXYCHOLIC ACID
If Worsening Progressive Lung Disease
- Oxygen
- Non Invasive Ventilation
- Diuretics if Signs of Cor Pulmonale
Surgical Management
- If Cirrhosis- LIVER TRANSPLANT
- Lung Transplant may be needed
What suggests Cystic Fibrosis? (non-standard symptoms)
Recurrent Chest Infections
Short
Signs of Diabetes
DELAYED PUBERTY
What are the 4 types of differentials for Haemoptysis?
What is an Aspergilloma and when does it usually present?
What is GOODPASTUREs?
1) Vascular Causes
- Pulmonary Embolism
2) Infective Causes
- Pneumonia (dyspnoea)
- Tuberculosis (systemic symptoms- weight loss, night sweats)
- Aspergilloma- Ball of fungus in a cavity- usually secondary to TB or Sarcoidosis- No other symptoms
- Bronchiectasis
3) Immunological Causes
- Goodpasture’s Disease- Pulmonary-renal disease with features of GLOMERULONEPHRITIS- (Haematuria, Proteinuria and Hypertension)- This is due to Autoantibodies against Type 4 Collagen
-Granulomatosis with Polyangiitis- Vasculitis causing Necrotising Granulomatous Inflammation of Small and Medium Blood Vessels- NASAL Obstruction, Saddle Nose, Haemoptysis, Glomerulonephritis (if NOSE is affected)
4) Malignant Causes
- Lung Cancer- Squamous Cell Carcinoma is the most common type of Lung Cancer. Look for Signs of ANAEMIA and Lymphadenopathy
- Malignant Pleural Effusion
- Also LUNG ABSCESS if there are Air-Fluid Levels
What are the Xray findings and the main sign of a Lung Abscess?
They are causes of MASSIVE HAEMOPTYSIS (Large amounts of Blood)
Central Cavitation with an Air-Fluid Level
FOUL SMELLING Sputum
What are the risk factors for Lung Cancer?
What are the 3 UNUSUAL RISK factors?
Smoking
Occupational Exposure (Silica, Asbestosis, Welding Fumes, Coal)
H._O._B.
HIV
Organ Transplantation
Radiation Exposure (Xray, Gamma Rays)
Beta Carotene supplements in Smokers
What are the signs of Lung Cancer?
What are the Paraneoplastic Syndromes?
What type of cancer is associated with Lambert-Eaton and with Hyperparathyroidism?
1) Haemoptysis
2) Dyspnoea and Chest Pain
3) NAUSEA and VOMITING
4) Weight Loss and Anorexia
5) Clubbing
6) Hypertrophic Pulmonary Osteoarthropathy
7) Anaemia
8) Horner’s Syndrome (if the tumour is located Apically)
9) PARANEOPLASTIC SYNDROMES (4)- Cushing’s Syndrome, SIADH, Lambert-Eaton (which suggests a Small Cell Carcinoma), Hyperparathyroidism (which suggests Squamous Cell Carcinoma)
What is seen on Examination in Lung Cancer?
4 signs
Which lymph nodes are enlarged in Lung Cancer?
1) Consolidation (Pneumonia)
2) Collapse (Absent Breath Sounds, Ipsilateral Tracheal Deviation)
3) Pleural Effusion (Stony dull percussion, Decreased vocal resonance and breath sounds)
4) Supraclavicular and Axillary Lymph Nodes are enlarged
What is Superior Vena Cava Obstruction?
Cancer may invade into Surrounding Tissues which compresses the Superior Vena Cava
This leads to Dyspnoea and FACIAL PLETHORA
What are the features of Squamous Cell Carcinoma?
It s typically CENTRAL
How is Squamous on Xray?
How is Squamous with cavitation?
What are the 2 HYPERS of Squamous?
1) Usually presents as Obstructive Lesions of the Bronchus leading to Infection
2) It is the lung cancer that MOST COMMONLY CAVITATES
3) On Xray it is not possible to tell whether it is an Abscess or Cancer (as the border’s definition can not be seen). However, the JAGGED BORDER of cancer can be seen on CT
4) Metastasis is late
5) It often causes HYPERCALCAEMIA- bone destruction or production of PTH-LIKE PEPTIDES
6) Also associated with Clubbing and Hypertrophic Pulmonary Osteoarthropathy
What are the features of Adenocarcinoma?
Peripheral
What does it most commonly cause compared to the other lung cancers?
Which lymph nodes are usually affected? Where does it spread to?
What are the Paraneoplastic Syndromes?
1) This is the most common type of Lung Cancer in the UK
2) It arises from Mucous Cells in the Bronchial Epithelium
3) It commonly invades Mediastinal Lymph Nodes and the Pleura- it spreads to BRAINS and BONEs
4) It usually does NOT Cavitate (unlike Squamous)
5) It is the LEAST Likely to be linked to Smoking and is the MOST COMMON in NON-Smokers
6) It is also the MOST LIKELY to cause Pleural Effusions
7) Paraneoplastic Syndromes- Gynaecomastia and HPOA
What are the features of Small Cell Carcinoma?
It is a CENTRAL Cancer
What cells does it arise from?
What are the paraneoplastic conditions associated with it?
How quick or late doe they metastasise?
1) Arise from Endocrine Cells (Kulchitsky Cells). These are APUD cells- so they will secrete many Polypeptides such as ACTH
- APUD= (Amine - high amine content. Precursor Uptake - high uptake of amine precursors. Decarboxylase - high content of the enzyme decarboxylase)
2) These can cause various presentations- Addison’s and Cushing’s and Lambert Eaton Myasthenic Syndrome_(Limb weakness- due to VGCC antibodies)
3) Small cell carcinomas spread EARLY- metastatise early
4) These tumours respond to CHEMOTHERAPY
5) In addition to ACTH, these release ADH- which causes HYPONATRAEMIA
6) It causes Central Hilar Lymphadenopathy
7) Paraneoplastic SCLC (Sodium, Cushings, LEMS)
- ACTH- Cushings
- ADH- Hyponatraemia
- Lambert Eaton Myasthenic Syndrome
What are the Paraneoplastic Syndromes in Lung Cancer?
- Small cell (The A_H’s and LAMBERT EATON)
1) ADH- Hyponatraemia
2) ACTH - not typical, hypertension, hyperglycaemia, hypokalaemia, alkalosis and muscle weakness are more common than buffalo hump etc- look for the METABOLIC SIGNS of CUSHINGs- not the physical ones
3) Lambert-Eaton syndrome - Squamous cell (The 2 HYPERS and Clubbing)
1) parathyroid hormone-related protein (PTH-rp) secretion causing Hypercalcaemia
2) Clubbing
3) Hypertrophic pulmonary osteoarthropathy (HPOA)
hyperthyroidism due to ectopic TSH - Adenocarcinoma
1) Gynaecomastia
2) Hypertrophic pulmonary osteoarthropathy (HPOA)
What investigations should be ordered in Lung Cancer?
Which is the investigation of choice and which is first line?
Which blood test is an indicator for lung cancer?
How are biopsies obtained?
1) Sputum cytology
2) FIRST LINE- Chest X-ray: abnormalities that may be seen include nodules, lung collapse, pleural effusion, consolidation, and bony metastases.
3) INVESTIGATION of CHOICE= Contrast-enhanced CT scan: this is used to further confirm the diagnosis and stage (TNM classification) the disease. The CT scan should also include both the adrenals and liver to look for sites of metastases.
4) Bronchoscopy: used to obtain a BIOPSY for histology
5) Endobronchial ultrasound transbronchial needle aspiration (EBUS-TBNA): allows biopsy of lymph nodes, paratracheal and bronchial lung lesions for histology
6) Cardiovascular review and lung function tests should also be performed to assess patient’s suitability for treatment options.
7) RAISED PLATELETS is an indicator for LUNG CANCER
What is the management of Non-small Cell Lung Cancer?
At what stages are radiotherapy and chemotherapy offered?
First Line- LOBECTOMY
Curative Radiotherapy can be offered to Stage 1, 2 and 3 Non-Small Cell Carcinomas
Chemotherapy should be offered if Stage 3 or 4
What is the management of Small Cell Lung Cancer?
Chemotherapy and Palliative Care
What is the management of Hypercalcaemia?
IV Fluid Replacement first
with NORMAL SALINE
What is the management of Superior Vena Cava Obstruction?
Immediate Oral Dexamethasone
What 3 conditions increase the likelihood of a Lung Abscess?
1) Lung Malignancy
2) Pneumonia
3) Aspiration of Oropharyngeal Secretions- breathing in stuff that is secreted from mouth/nose
What are the signs of a Lung Abscess?
What most commonly causes a lung abscess and what pathogens?
1) Typically following ASPIRATION PNEUMONIA or a STROKE
2) They are typically POLYMICROBIAL
Fever
DENTAL EROSIONS- cos poor dental hygiene increases the risk
SMELLY Productive Cough
Dyspnoea
Lethargy
SYSTEMIC SYMPTOMS-
1) Night Sweats
2) Weight Loss/ Cachexia
CLUBBING
Bronchial Breathing
