RESPIRATORY SYSTEM Flashcards
what is the prevalence of acute asthma in children and young adults?
a) 5%
b) 15%
c) 25%
d) 35%
b) 15%
is acute asthma more common in developed or developing countries?
developed
what is the name for chronic inflammation of the large airways?
bronchospasm
name one hypothesis for the development of asthma
hygeine
what antibody mediates an asthma allergic reaction?
IgE
name 5 cells which are recruited during an asthma attack
mast cells dendritic cells eosinophils lymphocytes T helpers
what epithelial and basement re-modelling occurs in asthma?
loss of cilia
increase of mucus cells
thickened basement membrane
what happens to smooth muscle in the airways in chronic asthma?
hyperplasia from chronic infection
What are the four main symptoms of worsening asthma?
SOB at night
Wheeze at night
Cough
Chest tightness
what would occur upon percussion of a patient with asthma?
hyper resonance
is the airway obstruction of asthma reversible or irreversible?
reversible
what 4 things cause bronchial inflammation in asthma?
infiltration of immune cells
muscle hypertrophy
mucus plugging
epithelial damage
What are the signs of acute asthma attack?
PEFR <35%-50% RR= >25 HR=> 110pbm Can't speak full sentance Cyanotic
What is the signs for fatal asthma attack?
PEFR <35%
Poor respiratory effort and silent chest sound
Pa02= <8
O2 sats= 92% on air
Unconsciousness and arrhythmia may be present
What is the atopic triad commonly seen in medical/family history of a patient with asthma?
The patient or within the family they are suffering from
Eczema
Asthma
Hay fever
give 4 examples of exacerbating factors for asthma
cold air exercise allergens pets existing atrophy acid reflux
what is the difference between intrinsic and extrinsic asthma?
intrinsic = no known cause (chemical/exercise induced) extrinsic = allergen
what two measurement test might you recommend for a patient with suspected asthma?
peak expiratory flow
spirometry
what type of drug is salbutamol and terbutaline and how are they administered and how often?
beta agonist
inhaled
short acting up to 4x daily
Give an example of an inhaled steroid for asthma or COPD
Corticosteriods such as beclometasone, fluticasone and budesonide
why are inhaled steroids given for asthma and how often are they administered?
prevention
two times daily
give 3 side effects of inhaled steroids
reduced bone mineral density
growth failure
adrenal suppression
oral candida
What is the treatment for acute asthma attack?
O SHIT ME
Oxygen 15L non rebreathable mask
Salbutamol 5mg Nebulizer ( change oxygen to 6L/8L) = every 15-20 minutes
Hydrocortisone 200mg Iv or prednisolone 40mg oral
Ipratropium bromide Iv 0.5mg 4-6 hours
Theophylline
Magnesium Sulphate 2g Iv
Extra help
how many people are affected by COPD in the UK?
a) 50
b) 50,000
c) 500,000
d) 1.5 million
d) 1.5 million
what 2 things is COPD a combination of?
emphysema (pink puffer) and chronic bronchitis (blue bloaters)
how does COPD lead to air collapse?
emphysema causes loss of elasticity and loss of alveoli
how can a patient with COPD get blocked airways?
increased goblet cells and mucus secretion
why does a COPD patient get lung hyperinflation and shortness of breath?
narrowing of small airways and trapping of air
what is the major cause of COPD?
smoking
give 2 minor causes of COPD
infections a1-antitrypsin deficiency Air pollution (motor vehicles) Occupational pollution ( dust, chemicals)
why does a1-antitrypsin deficiency cause COPD?
Occurs in emphysema and a1 antitrypsin protects lungs from elastase enzyme. when there is a deficiency, the lungs are destroyed by elastase. Lower lobes are more severely affected
is COPD reversible or irreversible?
irreversible
What are the general symptoms of COPD?
Recurrent infections SOB Fatigue Productive cough Fever
what chest abnormality might you see with a patient with COPD?
barrel chest
give 2 examples of behavioural abnormalities of a patient with COPD in an attempt to ease shortness of breath
pursed lip breathing
tripod positioning
use of accessory muscles
how long do symptoms have to be present for a diagnosis of COPD to be considered?
more than 3 months
What is the FEV1:FVC ratio in a patient with COPD?
Less than 0.7
name 2 things you might see on a chest X-ray of a patient with COPD
hyperinflation
enlarged pulmonary vessels
name something which you might see on an ECG of a patient with COPD
right ventricular hypertrophy
in an ABG of a patient with COPD, the PaO2 would be ___ and the PaCO2 would be ____
PaO2 low
PaCO2 high
what treatment might you recommend for mild COPD?
ipratropium inhaler (antimuscarinic)
or
Salbutamol ( Short acting B2 agonist)
what 3 things might you recommend for moderate COPD?
ipratropium
long acting b2 agonist ( salmeterol and formoterol)
steroid (fluticasone and budesonide
what is seretide a combination of?
salmeterol (B2 agonist)
fluticasone (steroid)
what is symbicort a combination of?
formoterol (b2 agonist)
budesonide (steroid)
what is combivent a combination of?
salmeterol (b2 agonist)
ipratropium (antimuscarinic)
what 3 things would you recommend as combination therapy for severe COPD?
long acting beta 2 agonist (salmeterol)+
long acting antimuscarinics (tiotropium) +
Inhaled steroids
what drug might you prescribe to reduce inflammation and relax smooth muscle in severe COPD?
theophylline
how would you treat theophylline toxicity?
beta blockers
give 3 cardiac complications of COPD
right sided heart failure
oedema
hypertension
give an MSK complication of COPD
osteoporosis
give a metabolic complication of COPD
weight loss
what accounts for 95% of all primary lung tumours?
bronchial carcinoma
is bronchial carcinoma more likely in men or women?
men
what makes up 15-20% of bronchial carcinomas?
small cell calcer
SCC is a cancer of what cells?
Kulchitsky cells (endocrine)
what do kulchitsky cells do?
secrete polypeptide hormones
how do kulchitsky cells stimulate tumour growth?
secretion of polypeptide hormones
do SCCs metastasise early or late?
early
is the prognosis of SCCs good or bad?
bad - inoperable at presentation
what makes up 40% of NSCCs?
squamous/epidermoid= flat cells near the centre of the lungs presenting which cause bronchial blocking and infeciton
what makes up 42% of NSCCs?
adenocarcinomas= mucus gland cells in bronchial epithelium which invades lymph nodes and pleura
what makes up 10% of NSCCs?
large cell cancer
large cell carcinomas are _____ differentiated and metastasise _____
poorly
early
What are the common symptoms of bronchial carcinoma?
Chest pain* Haemoptysis* Cough* Dysponea and sob* Weight loss and fatigue * Malaise Slow resolving infection/pneumonia
what is the main risk factor for the development of bronchial cancer?
smoking
give 2 other risk factors for the development of bronchial cancer
urban areas
occupation
name 2 peripheral signs you might see relating to lung cancer
clubbing
weight loss
what medical imaging technique might you suggest for diagnosis of bronchial cancer?
CT (MRI not useful)
if during a bronchoscopy you noticed that there was a loss of the sharp angle of the carina, what might you suspect?
mediastinal lymph node involvement
why might you perform a full blood count in suspected bronchial cancer?
anaemia of malignancy
why might you perform LFTs in suspected bronchial cancer?
liver metastases
is prognosis better for NSSCs or SCCs?
NSSCs
give 4 examples of where bronchial cancer can directly spread
pleura ribs brachial plexus hilar region phrenic nerve oesophagus pericardium
give 3 common metastatic sites for bronchial cancer
bone
brain
liver
adrenal gland
give 4 examples for benign tumour that can exist in the lung
pulmonary harmatoma bronchial adenoma chondroma lipoma mesothelioma tracheal squamous papilloma
give 2 circulatory complications of bronchial cancer
superior vena cava obstruction
pericarditis
AF
which gender are more likely to get a pneumothorax?
males
Who commonly develops spontaneous pneumothorax?
Tall thin white boys
what could cause a spontaneous pneumothorax?
rupture of subdural bulla
what is a major cause of pneumothorax?
chest trauma
give 3 rare, chronic respiratory causes of pneumothorax
asthma
COPD
CF
give 2 infective causes of pneumothorax
TB
pneumonia
give a systemic, connective tissue, inflammatory cause of pneumothorax
sarcoidosis= production of granulomas in the body in response to inflammation
give 2 inherited causes of pneumothorax
marfan’s
ehlers-danlos
give a rare, more serious cause of pneumothorax
cancer
CVP line, pleural aspiration and biopsy are all examples of _____ causes of pneumothorax
iatrogenic
why does pneumothorax occur?
negative pressure in lungs is lost and the lungs partially deflate - air is sucked into cavity through valve causing lung compression
pneumothorax can be described as ____ onset ____ pain
sudden onset
pleuritic pain
what would you hear on percussion and auscultation of the chest of a patient with a pneumothorax?
hyper-resonant and absent breath sounds
What is the presentation of tension pneumothorax?
Distended neck veins (raised JVP), deviated trachea and cardiac arrest
tension pneumothorax is a medical emergency, how would you treat it?
Needle thoracostomy ( 14/16g large bore needle into the 2nd intercostal space midclavicular line)
how would you treat a normal pneumothorax?
If symptoms are severe then do chest drain or needle aspiration
what is a unilateral pleural effusion?
fluid in pleural space
what is the difference between transudate and exudate?
transudate = low in protein exudate = high in protein
give 4 causes of transudate pleural effusion
increased venous pressure
hypoproteinaemia
hypothyroidism
meig’s syndrome
give 2 examples of what can cause increased venous pressure
heart failure
fluid overload
pericarditis
give 2 examples of what can cause hypoproteinaemia
malabsorption liver disease (reduced albumin production) nephrotic syndrome (albumin loss through leaky glomeruli)
what is Meig’s syndrome?
unilateral pleural effusion and ovarian fibroma
give 6 causes of exudative pleural effusion
increased capillary leakage infection (pneumonia, TB) malignancy rheumatoid arthritis SLE pulmonary infarction
what would you hear on percussion in a pleural effusion?
stony dullness
what other sign would be reduced during a respiratory examination on a patient with pleural effusion?
decreased vocal resonance/fremitus
what is light’s criteria used to distinguish?
whether an effusion is exudative or transudative
What is the Lights criteria of exudate pleural effusion?
Pleural fluid protein:serum protein is >0.5
Pleural fluid LDH: Serum LDH >0.6
Fluid fluid LDH > 2/3 of the upper limit of the serum LDH
what might you see on a chest x-ray of someone with a pleural effusion?
blunting of costophrenic angles
what is pleurodesis?
treatment of pleural effusion and recurrent pneumothorax
Adhesion of 2 pleural layers to remove pleural space
give 4 complications of pleural effusions
scarring
sepsis
empyema
pneumothorax
how common is pneumonia?a) 2/1000 a year
b) 10/1000 a year
c) 50/1000 a year
d) 100/1000 a year
a) 2/1000 a year
what is the mortality of pneumonia?
a) 1%
b) 5%
c) 10%
d) 20%
c) 10%
in what age group is pneumonia most dangerous?
elderly
what is pneumonia?
inflammation of lungs, consolidation fluid in alveoli
how can pneumonia be classified by area? Describe a) age of onset b) gender c) common causes d) spread e)
bronchial:, extreme of ages, common in both genders. Caused by strep/staph and h.influenz, spread around the brocnhial and not limited to one lobe. Bilateral in spread = secondary in sick
lobular= male 20-50, pneumococcus, entire lobe, uniltaeral = primary in healthy
how can pneumonia be classified by cause?
bacterial
fungal
viral
parasitic
how can pneumonia be classified by location of onset?
community acquired
hospital acquired
name a type of pneumonia that can have iatrogenic causes
aspiration
what is the 3 most common causative organism for community acquired bacterial pneumonia?
1) pneumococcal pneumonia. (+VE)
2) h. infleunza (-VE)
3) atypical bacteria e.g mycoplasma pneumoniae
4) Staphylococcal aureus,
5) mycobacterium tuberculosis,
6) viruses.
what are 3 most common causative bacteria for hospital acquired pneumonia? 48 hours after admission
Pseudomonas aeruginosa (-ve)
Staphylococcal aureus
Enterobacteriaceae (especially Klebsiella, E. coli and Enterobacter spp.
HAP related to ventilation assoiciated pneumonia
what type of pain is present in pneumonia?
pleuritic chest pain
what sign may be present in the sputum of someone with pneumonia?
It can be dry or productive of green grey phlegm
Severe cases cause haemoptysis
What are the common symptoms of pneumonia?
Chest pain worse by coughing Tachycardia Tachypnea Hypotension Dyspnea Lost of appetite Fever Rigors
what are the 4 stages of pneumonia progression?
congestion
consolidation
grey hepatisation
resolution
what 3 things occur in the congestion phase of pneumonia?
fluid accumulation
pulmonary oedema
neutrophil accumulation
what occurs in the consolidation phase of pneumonia and where?
exudate forms of neutrophils, fibrin and RBCs in the alveoli
what occurs in the grey hepatisation stage of pneumonia?
only neutrophils and fibrin persist in exudate - paler colour
give 2 examples of how the exudate is removed in the resolution stage of pneumonia
digested by macrophages
coughed up
what does CURB 65 stand for? (is a 5 point score)
confusion
urea >7
respiratory rate >30
blood pressure 65
On examination of the lungs what do you find in pneumonia?
Dull percussion
Basal Crackles on auscultation of the lung bases due to consolidation
Bronchial breathing
Increased tactile vocal fremitus
what would tactile vocal fremetus be like in a patient with pneumonia?
increased
what would happen to the blood markers WCC, CRP and ESR in a patient with pneumonia?
all increase
is there a vaccine available for pneumonia?
yes
a CURB score of 0 would recommend what antibiotic treatment for pneumonia?
oral amoxycillin OR clarithromycin
a CURB score of 1-2 would recommend what antibiotic treatment for pneumonia?
oral amoxycillin AND clarithromycin
a CURB score of >3 would recommend what antibiotic treatment for pneumonia?
co-amoxiclav &; clarithromycin IV
give 4 respiratory complications of pneumonia
respiratory failure
pulmonary effusion
empyema
lung abscess
give 4 cardiac complications of pneumonia
hypotension
AF
pericarditis
myocarditis
give a systemic complication of pneumonia
septicaemia
what percentage of pulmonary emboli are present undiagnosed in patients?
a) 10%
b) 30%
c) 60%
d) 80%
c) 60%
what percentage of PEs are fatal?
a) 1%
b) 10%
c) 50%
d) 100%
b) 10%
what is PE classically a complication of?
DVT
what is virchow’s triad?
blood constituents
blood flow
vessel properties
a change in virchow’s triad can cause what?
DVT or PE
how can bacterial endocarditis cause a pulmonary embolism?
septic emboli dislodges from RHS of heart and travels to lung
how can an MI lead to a pulmonary embolism?
right sided thrombus after MI
What are the symptoms of PE?
Sudden SOB and dysponea
Hypoxia
Sudden Pleuritic chest pain and also back pain
Coughing ( dry but can have mucus and blood)
Feeling light headness and dizzines
Fainting
Symptoms of DVT
when in a PE might you get haemoptysis?
if lung tissue is damaged
give 3 physiological risk factors for PE
age >60
obesity
pregnancy
give 3 pathological risk factors for PE
trauma
varicose veins
previous DVT/PE
give a blood-related risk factor for PE
hyper coagulability e.g. thrombophilia, factor V leiden, protein C/S deficiency, antithrombin def
give a lifestyle risk factor for PE
long air travel/immobility, diet and smoking
give 2 iatrogenic risk factors for PE
COCP
HRT
if a patient with a PE has an ABG showing low PaO2 and normal PaCO2 what does this show?
type 1 respiratory failure
what might an echo show of a heart of a patient with a PE?
dilated right ventricle and increased contraction of LV
what part of the lung is affected in a small or medium pulmonary embolism? what affect does this have?
terminal vessels
Causes coarse crackles, pleural rub and tachyponea.
what occurs to the lung in a massive PE?
sudden lung collapse due to pulmonary obstruction
what occurs systemically and peripherally in a massive PE?
shock
peripheral shutdown
What are the circulatory signs of massive PE?
Tachycardia
Tachypnea
Hypotension
Raised JVP
where might you feel a heave in a patient with a massive or multiple recurrent PE?
right ventricle
what might occur to the second heart sound in a patient with a massive or multiple recurrent PE?
split
What are the symptoms of multiple recurrent PE?
Increased shortness of breath over a few weeks
Syncope, weakness and angina
Pulmonary hypertension and RV overload signs
RV heaves and loud 2nd heart sound
what 3 immediate suppurative treatments would you give to a patient with a PE?
high flow oxygen
IV fluids
analgesia
give an example of a thrombolytic that you could give in a pulmonary embolism
streptokinase IV for 30 mins
give 2 methods you would use to prevent a further pulmonary embolism occurring in the future?
LMWH ( tinzaparin) initially and then warfarin following on or rivaroxaban
What are the symptoms of pulmonary fibrosis?
SOB on exertion Lose of apeptite Rapid Weight loss Fatigue and tired Clubbing Chest discomfort Chronic dry hacking cough
What therapy treatment can you have at home for pulmonary fibrosis?
Oxygen therapy
Pulmonary rehabilitation
What are the life style advice for a patient with pulmonary fibrosis?
Stop smoking
Exercise
Healthy diet
what is pulmonary fibrosis?
scarring of the lungs
pulmonary fibrosis is excess accumulation of what?
fibrous connective tissue
pulmonary fibrosis results in ____ of alveolar walls and ____ gaseous exchange
thickening
reduced
give an example of a cause of idiopathic pulmonary fibrosis
genetic mutation of a surfactant protein
FHx
GORD
Smocking
give 3 examples of diseases for which pulmonary fibrosis can be a secondary effect
TB
bacterial lung infection
viral lung infection
autoimmune diseases (e.g. sarcoidosis, granulomatosis)
give a lifestyle cause of pulmonary fibrosis
smoking
give a immune mediated cause of pulmonary fibrosis
hypersensitivity
give examples of 4 drugs which can cause pulmonary fibrosis
amoidarone
methotrexate
nitrofurantoin
apomorphine
which of these would NOT be reduced in a spirometry reading for pulmonary fibrosis
a) FEV1
b) FEV2
c) FVC
b) FEV2
is the scarring of pulmonary fibrosis permanent or temporary?
permenant
give 2 types of drugs that pulmonary fibrosis may respond to
steroids
immunosuppressents
give an example of an anti-fibrinic drug that can be used in treatment of pulmonary fibrosis
pirfenidone
nintedanib
what is end stage treatment of pulmonary fibrosis?
lung transplant
give 3 complications of pulmonary fibrosis
Hypoxia leading to pulmonary hypertension then heart failure
Pulmonary embolism
Chest infection
What is chronic bronchitis?
It is inflammation of the bronchioles causing production of mucus. Causing the patient to be cyanosed but not breathless
What is emphysema?
It is destruction, dilation and distention of the alveolar sacs. Which leads to being breathless but not cyanosed
What is the affect of
a) chronic bronchitis
b) emphysema
on alveolar ventilation?
a) decreased
b) increased
What can COPD be exacerbated by?
Infection
Exercise
Bad weather
Pollution
What heart condition can chronic bronchitis cause?
Cor pulmonale
What is cor pulmonale?
It’s right heart failure secondary to lung disease
Caused by pulmonary hypertension consequence of hypoxia
What is the treatment for exacerbation of COPD?
Abx and Steroids (prednisolone) for 7 days
What are pre medical treatment for COPD?
Stop smoking, nutrition and exercise
For acute asthma attack what is the 2 drugs plus oxygen you give immediately?
Salbutamol 5g Nebulizer
Hydrocortisone/Prednisolone
Why do you do a ECG when administrating continuous doses of salbutamol for acute asthma attack?
To identify any arrhythmias
What additional treatment do you give if acute asthma become severe?
Increase frequency of salbutamol
Ipratropium 0.5mg nebulizer
Magnesium sulphate over 15-20 minutes
Differential diagnosis of asthma for adults?
Chronic obstructive pulmonary disease Bronchiectasis Inhaled foreign body Lung cancer Sarcoidosis
Differential diagnosis of asthma for children?
Inhaled foreign body. Viral-associated wheeze of infancy, bronchiolitis, pneumonia, croup, bronchitis, pertussis. Sinusitis. Post-nasal drip. Bronchiectasis.
What are the usual clinical presentation of primary spontaneous pneumothorax?
Pleuritic chest pain with mild or moderate dyspnea
What are the usual clinical presentation of secondary spontaneous pneumothorax?
Pleuritic chest pain often absent but laboured dyspnea
What is the pathology of tension pneumothorax?
A tear in the lung causing a one way valve that leads air into the pleural space.
Causing collapse of the lungs and positive mass effect (shifting )of the mediastinum and heart.
How does tension pneumothorax cause cardiac arrest and potentially death?
Impaired venous return leads to reduced preload that leads to tachycardia
Over time this leads to reduced diastole period that means lead blood to the heart
Over time causes death of the heart
What is the treatment if you get recurrent pneumothorax?
Pleurodesis
Differential diagnosis of pneumothorax?
Pleural effusion
Pulmonary embolism
What is a life style risk factor for pneumothorax?
smocking
What lung conditions can occur in a patient with bronchial carcinoma?
Collapse
Pleural effusion
Slow resolving pneumonia
What are the 5 common causes of bone mets?
Lungs Prostate Kidney Thyroid Breast
What system is used to assess the staging of bronchial carcinoma?
TNM system
In what age group do you get confusion with pneumonia?
Elderly
What type of pneumonia is CURB 65 used for?
CAP
What is the treatment for HAP?
Gentamicin and ticarcillin
What types of surgery increase the likelihood of PE?
Surgery of the abdomen and pelvic area
Knee and hip replacement
What scan would you do if their was a positive D dimer test for PE?
CTPA
Is D Dimer test definitive for DVT and PE?
If -ve then yes
However if +ve then need to do other test to confirm
What would a ECG show of a PE?
Tachycardia and RV strain
What is the triad of symptom for PE?
Sudden onset of
Hypoxia
SOB
Pleuritic chest pain
What criteria is used for the development of potential PE?
WELLs score
What is the wells score for PE?
No other possible diagnosis HR= >100 Previous DVT or PE Active malignancy Haemoptysis DVT symptoms and signs Immobilisation for 3 days or surgery in past 4 weeks
Score of 4 or more =likely it is PE
What scan do you do if it is not possible to do a CTPA for a patient with potential PE?
VQ scan
What are differential diagnosis of PE?
Pneumonia Pneumothorax ACS GORD MSK pain
What are the signs and symptoms of pleural effusion?
Usually asymptomatic However Dyspnea and pleuritic chest pain can be present Reduced chest expansion and chest sound Stony Dull percussion Reduce vocal resonance and fremitus Bronchial breathing over the effusion
What is empyema?
It is collection of pus in the pleural space and a complication of pneumonia and pleural effusion
What does dull percussion indicate?
Consolidation, tumour or lung collapse
What would a increase in vocal resonance and dull percussion indicate ?
Consolidation, tumour or lung collapse
When is the criteria for a patient to be prescribed prophylaxis steroid inhaler for asthma?
If they are using their reliever inhaler more than 3 times a week or
Asthma is disturbing their sleep at least once a week or
They have had a asthma attack in the last 2 years that needed systemic steroids
What are the 7 most common primary tumours to cause mets in the lung?
kidney, prostate, breast, bone, gastrointestinal tract, cervix and ovary.
Which bronchial carcinoma is most commonly linked to asbestos and occurs in non smokers?
Adenocarcinoma
