Respiratory Week 1 Flashcards
6 main symptoms of respiratory diseases
Cough Sputum Haemoptysis Chest pain Dyspnea Tachypnea
Why does cough syncope happen
Fainting after coughing too much happens because of the build up in intrathoracic pressure which reduces venous return to the heart
What conditions can cause creamy sputum?
COPD
What causes frothy white sputum?
Pulmonary edema
What is the definition of massive haemoptysis
Over 600ml in 24 hours of blood
Describe pleuritic pain
Sharp pain, stabbing, worse on inspiration
Clarification questions about dyspnea
When it came out, does it come at a particular time, pattern, weekday/weekend?
Exercise tolerance, relief and exacerbation
ADLs
What does PND indicate?
Heart failure
What is cheyne stokes breathing
Waxing an waning breaths, shallow intermittent breathing
What is stridor?
High pitched sound on inspiration due to large airway obstruction
Possible drugs that cause coughing
ACEI or methotrexate
What is finger clubbing associated with
Lung cancer, bronchiectasis, fibrosing alveolitis
What causes bronchial breath sounds?
Consolidation
2 variants of cough asthma?
Eosinophilic vs non-eosinophilic type
Acute management plan for someone coming in with SOB and low o2 sats, wheeze,
Give O2, neb SABA
Investigations of someone coming in with high RR, low sats, dyspnea and high BP
CXR, ABG,
Management of chronic asthma
Remove allergens SABA LABA Theophylline, montelukast Steroids
Difference between COPD and asthma
Asthma is reversible, COPD isn’t
What is Hoover’s sign in emphysema?
Flattened diaphragm due to over inflation.
How to differentiate obstructive VS restrictive lung disease?
FEV1/VC ratio if less than 70% is obstructive
What stage of copd is someone with
FEV1/VC = 57%
FEV 45% of predicted
Severe obstructive COPD
Differentiation between bronchial and vesicular breath sounds
Bronchial sounds heart on both inspiration and expiration
Whereas vesicular sounds are mostly heard during inspiration
What 3 patient identifier is required in writing a prescription
Patient name
Patient number
DOB
What information is required when prescribing PRN
Max 24 hour dose
Min Interval between dose
Indications for medication
Difference between type 1 and 2 respiratory failure
Type 1 RF is hypoxaemia but normal CO2
Type 2 RF is hypoxaemia and high CO2
What is measured in an ABG?
PO2 PCO2 PH HCO3 BE
How to tell if respiratory or metabolic acidosis/alkalosis
See if CO2 or HCO3 is abnormal.
4 steps to interprete ABG
Look at PH, acidosis/alkalosis or normal
Look at PCO2
Look at HCO3
Look at oxygenation
At what PO2 is patient in respiratory failure
<8
Pulmonary embolism will cause metabolic acidosis, true or false?
False
PE usually associated with respiratory alkalosis due to increased ventilation.
List these in order of doubling time
SCLC
Squamous cell carcinoma
Adenocarcinoma
SCLC
SCC
Adenocarcinoma
On a CXR, what can a raised diaphragm indicate?
Phrenic nerve palsy and muscle wasting of diaphragm
What would a SCC CXR feature
Necrosis and cavitation lesions shown as air and fluid.
Can be mistaken for an abscess
Classical presentations of lung cancer
Cough Dyspnea Chest pain Haemoptysis Weight loss Finger clubbing
What is a “sail sign” on a CXR?
Lower left lobe collapse dorsal to the heart, showing a straight line parallel to cardiac shadow
What causes hoarseness in lung cancer?
Recurrent laryngeal nerve compression
Symptoms and cause of horners syndrome in lung cancer
Ptosis, miosis and anhidrosis
Pancost tumor compressing sympathetic nerves at apex of lung
What can SVC obstruction present as
Swollen face, skin discoloration due to venous distension
What does a large globular heart on CXR indicate
Pericardial effusion
What does a spinal metastasis present with
Urinary changes, back pain, leg numbness
Why can lung cancer cause cushing’s syndrome
Paraneoplastic effects of cancer cells can cause ACTH overproduction.
How does SIADH present
Low plasma Na, low plasma osmolality, high urine Na, lethargy and anorexia. caused by too much ADH causing resorption of kidney filtrate
Difference between AP and PA view
AP view is taken with tube in front of patient and film plate at the back, this causes heart to be enlarged, scapular to be more visible and sometimes clavicles to be raised above lung apex.
What on a CXR indicates hyperinflation of lungs
Hyper lucent lung fields (decreased bronchial markings)
More than 10 posterior ribs visible or more than 6 anterior ribs visible at mid-clavicular lines
Flattened hemidiaphragms
What should the width of the cardiac shadow be in relation to the thorax
On PA film, half or less
What does a meniscus sign indicate on a CXR
Pleural effusion
How does a hydro-pneumothorax present
Straight line across the lung field separating gas and fluid
How does a pneuomthorax appear on a CXR
Increased lucency, visible lung field edges within thorax, possible deviated trachea
What does a collapsed lung do to the trachea
Pulls it towards the collapsed side
What does increased lung markings indicate?
Interstitial lung diseases/ fibrosis
What can cavitation in CXRs indicate
Lung cancer, TB, pneumonia, sarcoidosis, infection causing abscess (will have air-fluid level)
progression of clinical features in asthma attack
tachypnea
tachycardia
reduced PEF
low sats
cyanosis
silent chest
Risk factors for fatal asthma
Previous attacks, ITU admissions
Dhx - are they on 3 or more types of asthma meds
Repeated AnE attendance
High SABA use recently?
Acute management of asthma attack
O SHIT ME
oxygen
salbutamol hydrocortisone ipratropium theophylline magnesium sulphate
escalate care
Presentation and signs of Pulm embolism
Pleuritic chest pain
Cough and haemoptysis
Haemodynamic collapse
signs:
Tachycardia, hypoxia, tricuspid rigurg, DVT, raised JVP
DVT
Hypotension
How to diagnose PE
Wells score
CTPA is diagnostic
Acute management of PE
ABC
oxygen
Thrombolysis
Anticoag
Possible causes of massive haemoptysis
Bronchial tumor Bronchiecstasis CF Active TB Pneumonia Pulmonary thromboembolic disease Pulmonary vasculitis Warfarin
Acute management of massive haemoptysis
Airway support IV access group and save Fluids fix clotting abnormality
Neb adrenaline
Oral or IV tranexamic acid
Difference between primary and secondary pneumothorax
Primary occurs in apparently normal lungs
Secondary is due to underlying lung disease
Difference between tension pneumothorax and normal pneumothorax
In tension pneumothorax, thoracic cavity fills with air with every breath taken “one way valve”
This compresses the lung and can be fatal
Presentation of pneumothorax
Pleuritic chest pain
Dyspnea
O/E of pneumothorax
Deviated trachea
Reduced chest expansion
Hyper resonant percussion
Reduced breath sounds
Management of pneumothorax
If tension pneumothorax - aspiration + chest drain
If small simple pneumothorax - observation
If tension pneumothorax is suspected, a CXR should be done to confirm diagnosis - true or false
FALSE. Do not wait for CXR if tension pneumothorax is suspected
Insert large bore needle into 2nd intercostal space mid clavicular line to aspirate.
Common causative organisms of LRTI
Strep pneumonia
Haemophilus influenza
Staph aureus
Moraxella carrhalis
Symptoms of LRTI
Cough, productive, purulent Fever Sob Pleuritic chest pain Confusion Rigors, night sweats
How to investigate suspected pneumonia
CXR Sputum, blood, urine culture ABG Blood test - FBC, CRP, U+E, LFT ECG Antigen testing
CXR signs of pneumonia
patchy opacification, consistent with consolidation
3 requirements to diagnose pneumonia
1) signs and symptoms
2) xray with consistent findings
3) no better explanation
Describe CURB65 scoring
C - confusion yes or no
Urea - more than 7 mmol/L
R - RR of >30
B - BP <90 systolic or <60 diastolic
Over 65?
Management of pneumonia based on CURB65 score
0 to 5
0-1 can be treated at home with antibiotics (amoxicllin)
2 - hospital stay, oral abtx per guidelines for 7 days
> 3 - ITU, 2 IV atbx per guidelines e.g. IV co-amoxiclav + IV clarithromycin
Oxygen if required (low sats)
Fluids, analgesia, neb saline
What MDT involvement is suggested for pneumonia?
Chest physio
Specialist nurse
Who should be given follow up CXR ? When?
> 65 YO
Smoker
6 weeks later to see if consolidation has settled.
What history is important in diagnosis legionnaire’s disease
Travel history
Antibiotic management of legionnaire’s disease
14-21 days of atbc
Most common lobe affected in aspiration pneumonia
Lower right lobe
What is in a rescue pack for COPD patients
Antibiotics - amoxicillin
Steroids - prednisolone
Acute management of infective COPD exacerbation
ONAB
Oxygen
Nebulised salbutamol
Antibiotics - doxycycline
Prednisolone
MDT involvement
NIV
Classical presentation of TB
Haemoptysis
Weight loss
Fever
Night sweats
CXR presentation of TB
Round cavitation with consolidations
drug treatment of TB
Notifiable disease
2 months of rifampicin, isoniazide, ethambutol, pyrazinamide
4 months of rifampicin and isoniazide
What does rifampicin cause
Orange sweat, urine, tears
what kind of conditions are more likely to cause coarse crackles
airway disease such as bronchiectasis, usually caused by fluid
what kind of conditions are more likely to cause fine crackles
disease involving interstitial process like fibrosis, congestive heart failure, atelectasis
how long is the test for CO2 flap usually done for
1 min
what is d dimer and what is it indicative of
part of coagulation pathway
can be raised in blood clot
in someone with fibrotic lungs and pneumothorax, would u put a chest drain in?
no
would organism causes a rust coloured sputum in an LRTI
strep pneumoniae
CXR presentation of emphysema COPD exacerbation
hyperinflated with flattened diaphragm
what is bronchiectasis
chronic infection of airways leading to damage of bronchi causing permanent dilation of airways giving rise to colonisation by bacteria
presentation of someone with bronchiectasis
recurrent cough copious sputum \+/- haemoptysis dyspnea chest pain
signs of bronchiectasis
finger clubbing
coarse crackles
wheeze
what is the “bat wing” sign on a cxr
caused by pulmonary edema usually from heart failure
increased hilar opacities due to fluid secretion
What 2 types of fluid can you get from pleural effusion
Transudate and exudate
Whats the difference between transudate and exudate in terms of contents
Exudate has more protein, dead cells, neutrophils “pus”
Transudate has very little to no protein and is generally clear
What is the difference in origin of transudate and exudate in a pleural effusion
Transudates usually caused by hypoalbunimea which is caused by an organ failure e.g liver, kidney; or heart failure
Exudate is usually caused by inflammatory or infective causes e.g. pneumonia, TB, malignancy
investigations and reasons for suspected PE
CTPA is main diagnostic tool CXR to rule out others ECG - T wave inversion and sinus tachy VQ scan - more useful in ruling out PE ABG - O2 often low, CO2 normal or low Troponin - commonly raised in PE due to strain on heart Echo - look at RV function
