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BPT > Summary Book Respiratory > Flashcards

Summary Book Respiratory Flashcards

1
Q

Example of inhaled corticosteroid preventer

A

Flixotide (given BD)

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2
Q

3 examples of inhaled corticosteroid and LABA combo

A

Symbicort (budesonide/formoterol, BD), Seretide (fluticasone/salmeterol, BD), Breo Ellipta (fluticasone, vilanterol, daily)

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3
Q

Example of LAMA (Long-acting muscarinic receptor antagonists)

A

Spiriva (tiotropium, given daily)

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4
Q

Example of LAMA/LABA combo

A

Spiolto daily or Ultibro daily

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5
Q

Clinical signs of pancoast tumour syndrome

A

Cachectic, clubbing, wasting of small hand muscles, reduced sensation of c8-t1, lymphadenopathy, horners, dullness to percussion.

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6
Q

Causes of pancoast tumour syndrome

A

lung ca, lymphoma, mets

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7
Q

Causes of trachea deviation - towards or away from lesion

A

Towards: collapse, lobectomy, pneumonectomy, pulmonary fibrosis . Away: large mass (goitre, mediastinal mass), pleural effusion, tension, pneumothorax

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8
Q

Causes of prolonged and reduced forced expiratory time

A

COPD and bronchiectasis - prolonged. Restrictive disease - reduced.

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8
Q

Clinical signs of pemberton’s sign (SVC obstruction)

A

oedema of face / arms with dilated veins, raised JVP, cervical lymphadenopathy

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8
Q

Causes of atypical unilateral and bilateral chest expansion.

A

Unilateral = effusion, collapse, pneumothorax, consolidation and fibrosis. Bilateral = COPD, ILD, asthma, myasthenia gravis, GBS

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8
Q

Causes of dullness to percussion

A

lobectomy, pneumonectomy, lung consolidation, pleural effusion, pleural thickening, raised hemidiaphragm

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9
Q

Causes of reduced breath sounds

A

Airway and bronchial obstruction, large bullae, lobectomy, pneumonectomy, lung consolidation, lung hyperinflation, obesity, pleural effusion, pleural thickening, pneumothorax, raised hemidiaphragm, shallow breathing

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10
Q

5 T’s of mediastinal mass

A

tumour, thyroid goitre, teratoma, thymoma, thromboembolism

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11
Q

Causes of wheeze - widespread with lower airway cause, widespread with central airway cause and unilateral

A

Widespread and lower = asthma, bronchitis, bronchiolitis, COPD, CCF, cystic fibrosis. Widespread and central = intra-luminal obstruction (foreign body, mucus plug, vocal cord dysfunction), luminal obstruction (laryngeal or tracheal stenosis, anaphylaxis), extra-luminal obstruction (retrosternal goitre, mediastinal malignancies). Unilateral = bronchiectasis, intra-luminal stenosis, luminal obstruction and extra luminal obstruction.

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12
Q

Causes of crepitations - fine vs coarse

A

Fine = specific interstitial lung disease subtypes (idiopathic pulmonary fibrosis, asbestosis, non-specific interstitial pneumonitis, connective tissue disease associated interstitial fibrosis), pneumonia (resolving), posture induced crackles. Coarse = bronchiectasis, COPD, CCF, pneumonia (acute).

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13
Q

Lights criteria for transudate

A

protein <0.5, LDH <2/3 ULN, LDH <0.6 ratio

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14
Q

Causes of transudate pleural effusion

A

cardiac failure, hypothyroidism, liver failure, nephrotic syndrome

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15
Q

Lights criteria for exudate

A

protein >0.5, LDH >2/3 ULN, LDH >0.6 ratio

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16
Q

Causes of exudate pleural effusion

A

Drugs: nitrofurantoin, beta blocker, lupus inducing drugs. Granulomatous disease: sarcoidosis. Infective: pneumonia, tuberculosis. Neoplastic: pleural malignancy (mesothelioma), primary lung carcinoma, metastatic carcinoma. Rheumatological: rheumatoid arthritis, systemic lupus erythematosus. Sub diaphragmatic: pancreatic. Vascular: pulmonary infarction.

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17
Q

Causes of interstitial lung disease with known exposure

A

Drugs: amiodarone, chemotherapy (bleomycin, cyclophosphamide), methotrexate, nitrofurantoin. Environmental (hypersensitivity pneumonitis): bird, allergen. Occupational (pneumoconiosis): asbestos, silica, beryllium, coal dust. Radiation: intra-thoracic malignancy, radiation therapy.

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18
Q

Causes of interstitial lung disease without known exposure

A

Connective tissue disease: ankylosing spondylitis, eosinophilic polyangiitis, poly- /dermatomyositis, rheumatoid arthritis, systemic lupus erythematosus, systemic sclerosis. Granulomatous Disease: sarcoidosis. Idiopathic Interstitial Pneumonias: idiopathic pulmonary fibrosis and other subtypes (NSIP, COP, DIP, RBILP, AIP, LIP). Miscellaneous Disorders: pulmonary lymphangioleiomyomatosis, pulmonary langerhans cell histiocytosis.

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19
Q

Risk factors for interstitial lung disease

A

smoking, drugs, connective tissue disease, exposure, asthma

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20
Q

Define usual interstitial pneumonia

A

A histopathologic and radiologic pattern of interstitial lung disease and hallmark pattern of idiopathic pulmonary fibrosis

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21
Q

Management of interstitial lung disease

A
  1. Prevention with vaccines, smoking cessation and pulmonary rehabilitation. 2. For IPF/UIP = treatment is poor + don’t give steroids, Nintedanib (multi TKI - 60% get diarrhoea) and Pirfenidone (anti-tumour growth factor - rash/nausea/vomiting). 3. Treatment of non-specific interstitial pneumonia (systemic sclerosis) - cyclophosphamide/steroids. 4. Lung transplant.
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22
Q

Complications of interstitial lung disease

A

oxygen dependence, loss of function, pulmonary hypertension, death

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23
Q

Clinical findings for interstitial lung disease

A

clubbing, fine crepitations, systemic features of connective tissue disease or rheumatoid complications of steroid use

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24
Q

CXR findings of COPD

A

right sided cardiomegaly

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25
Q

Respiratory function testing findings of COPD

A

Obstructive spirometry, non-reversible, increased total lung capacity, increased residual capacity, decreased DLCO, obstructive flow-volume loop

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26
Q

ECG of COPD

A

right axis deviation with possible right ventricular hypertrophy

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27
Q

ECHO of COPD

A

pulmonary hypertension, possible right ventricular failure

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28
Q

Aetiology of COPD

A

cigarette smoking (80% - active/passive), indoor biomass fuel, chronic asthma, tuberculosis, alpha-1 antitrypsin deficiency, loeys-dietz syndrome (SMAD 3 gene)

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29
Q

Causes of apical crackles in restrictive lung disease

A

seronegative spondyloarthropathies, sarcoidosis, silicosis, ABPA, TB, pulmonary Langerhans histiocytosis X

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30
Q

Causes of basal crackles in restrictive lung disease

A

IPF, asbestosis, connective tissue disease, medications, chronic aspiration

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31
Q

CXR findings for restrictive lung disease

A

reduced volumes, reticular interstitial opacities

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32
Q

HRCT findings for restrictive lung disease (5 classic IPF changes)

A
  1. reticular fibrosis. 2. honeycombing +/- traction bronchiectasis. 3. basal and subpleural predominance. 4. absence of atypical features (ground glass, mosaic attenuation, consolidation). 5. temporal heterogeneity.
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33
Q

Respiratory function tests for restrictive lung disease

A

FEV1/FVC >70%. FVC <80%. reduced DLCO

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34
Q

Additional tests to consider for restrictive lung disease

A

VATS for lung biopsy, 6MWT + ABG on room air, TTE to exclude pulmonary hypertension, ABG to investigate hypoxia and T1RF

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35
Q

9 management steps to consider for restrictive lung disease

A
  1. remove trigger. 2. smoking cessation. 3. influenzae and pneumococcal vaccination. 4. MDT for IPF medications. 5. management of GORD / rheumatological disease. 6. bronchodilators if reversibility. 7. IPF-specific anti-fibrotic (Nibtedanib and Pirfenidone). 8. Home oxygen (if PaO2 <55 or <60 with pulmonary hypertension). 9. Lung transplant.
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36
Q

Define bronchiectasis

A

Permanent bronchial dilation due to post-infectious fibrotic changes, resulting in airway obstruction, impaired mucus drainage and abnormal anti-microbial host resposnse

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37
Q

Upper lung zone causes of bronchiectasis

A

cystic fibrosis and congenital causes, TB, ABPA, autoimmune, connective tissue disorders, chronic hypersensitivity pneumonitis

38
Q

Middle lung zone causes of bronchiectasis

A

NTM (nontuberculous mycobacteria), MAC (Mycobacterium avium complex)

39
Q

Lower lung zone causes of bronchiectasis

A

chronic recurrent infections or aspiration, end-stage fibrotic lung disease

40
Q

Central lung zone causes of bronchiectasis

A

ABPA, congenital, cystic fibrosis

41
Q

CXR findings for bronchiectasis

A

coarse parallel tram-track, tubular or ring opacities of dilated bronchi. Also linear atelectasis.

42
Q

Organisms found in sputum for bronchiectasis

A

Hemophilus, pseudomonas, pneumococcus, mycobacterium

43
Q

HRCT findings for bronchiectasis

A

airways larger in diameter than the blood vessel they run with, distribution and pattern of bronchiectasis, presence of concomitant infections / effusions / mass lesions

44
Q

Pulmonary function tests for bronchiectasis

A

obstructive spirometry, possible gas trapping and hyperexpansion, decreased DLCO

45
Q

Tests for cystic fibrosis

A

chloride sweat test, exercise capacity, 6MWT

46
Q

10 Management steps to consider for bronchiectasis

A
  1. reduce inflammation with physiotherapy and postural drainage (twice daily). 2. control infections / vaccinations / smoking cessation. 3. low dose inhaled corticosteroids if reversibility. 4. azithromycin prophylaxis. 5. bronchodilators. 6. pulmonary rehabilitation. 7. bronchial artery embolization - massive haemoptysis. 8. home oxygen if FEV1 <40%. 9. Transplant. 10. IVIG - hypogammaglobulinemia
47
Q

Symptoms of bronchiectasis

A

haemoptysis, purulent sputum, fevers, dyspnoea, weight loss, possible right heart failure

48
Q

Risk factors for bronchiectasis

A

childhood respiratory disease, chronic lung infections (TB, influenza, adenovirus), COPD, cystic fibrosis, allergic bronchopulmonary aspergillosis, rheumatoid, sjogrens, immunodeficiency (hypogammaglobulinemia)

49
Q

Signs of bronchiectasis

A

respiratory distress, cachexia, signs of right heart failure, reduced breath sounds, wheeze, crepitations, sputum, dextrocardia (kartagener syndrome)

50
Q

Define reversibility

A

> 12% and 200ml in either FVC or FEV1

51
Q

Define DLCO and what decreases it, increases it or doesn’t change it

A

DLCO is indicative of gas exchange (alveolar-capillary interference) dysfunction. Decreases with COPD, ILD, pulmonary hypertension and anaemia. If DLCO is the only parameter to change then consider PE or ILD. DLCO increases with haemorrhage. Normal in asthma, neuromuscular disease, chest wall disorder and obesity.

52
Q

Signs of lung transplant.

A

Transplant scar - single (lateral thoracotomy) or bilateral (clamshell). If single then remaining lung may be IPF with abnormal expansion and auscultation. Also check for pulmonary hypertension, right heart failure and side effects of immunosuppression.

53
Q

Side effects of immunosuppression

A

tremor with tacrolimus, hirsutism with cyclosporin, diabetes, cushingoid, osteoporosis (scoliosis / thoracic kyphosis), skin cancers and gout (polyarthritis or tophi)

54
Q

5 aspects to monitor in transplantation

A

rejection, infection, immunosuppressant side effects, primary disease recurrence and for lung - bronchiolitis obliterans (secondary to chronic infections causing small airway obstruction)

55
Q

What to check for in rejection in lung transplant

A

check FEV1, transbronchial biopsy, ?requires pulse of steroids

56
Q

What to check for with infections in lung transplant

A

most common cause of death, needs 3 months of prophylactic agents. Organisms = CMV, adenovirus, influenzae and fungal.

57
Q

What to check for with immunosuppressant side effects in lung transplant

A

AKI, hypertension, hyperlipidaemia, osteoporosis, neuropathy, cancer

58
Q

What to check for with recurrence in lung transplant

A

sarcoid and ILD

59
Q

Prophylactic measures in lung transplant

A

vaccines, DEXA 5 yearly, skin check, mammogram 2 yearly between 50 and 74, FOBT + PSA 2 yearly between 50 and 74, cervical screening 5 yearly (25 to 74)

60
Q

5 indications for lung transplant

A
  1. severe COPD - FEV1 <25%, pCO2 >55mmHg. 2. cystic fibrosis with bronchiectasis - FEV1 <30%. 3. ILD with progressive symptoms and DLCO <60%. 4. Pulmonary hypertension with new york heart association 3 or 4. 5. Eisenmenger syndrome.
61
Q

What is triple drug maintenance?

A
  1. Calcineurin inhibitor (cyclosporin or tacrolimus). 2. Anti-proliferates (azathioprine or mycophenolate). 3. Corticosteroid (prednisolone).
62
Q

Side effects of corticosteroids

A

myopathy, infection, cataracts, hypertension, diabetes, osteoporosis, gastritis, mood

63
Q

Side effects of tacrolimus

A

CNS, hypertension, renal impairment, infection, skin cancer, alopecia, lipids, TMA (thrombotic microangiopathy), tremor, diabetes, CMV, BK

64
Q

Side effects of everolimus

A

hypertension, upset GIT, marrow suppression, pulmonary fibrosis, lipids, albuminuria, poor healing, effusions (cardio and resp)

65
Q

Side effects of cyclosporin A

A

hypertension, gout, gum hypertrophy, hirsutism, high cholesterol, renal impairment, neurotoxicity

66
Q

Side effects of mycophenolate

A

diarrhoea, marrow suppression

67
Q

Side effects of azathioprine

A

hepato and marrow toxicity, pancreatitis

68
Q

Presentation of cystic fibrosis

A

failure to thrive, recurrent respiratory tract infections - age of diagnosis 4 to 6 weeks. Also cough, sputum, haemoptysis, wheeze, dyspnoea, sinusitis, steatorrhea, diabetes, infertility, biliary cirrhosis.

69
Q

Risk factor for cystic fibrosis

A

Family history (autosomal recessive)

70
Q

Investigations for cystic fibrosis

A

Diagnosis - sweat test, CXR - progressive increase lung markings / acute consolidation, sputum culture - H. influenzae, pseudomonas, staph, blood - anaemia, vitamin malabsorption, LFT. Spirometry.

71
Q

Management of cystic fibrosis

A

Respiratory - postural drainage, prophylactic antibiotics (azithromycin, nebulised aminoglycosides), DNA mucolytic, vaccinations, lung transplant work up. Gut - insulin, creon, vit ADEK, PPI. Infertility specialist. Ivacaftor = increases activity of CFTR protein. Lumacaftor = improves protein folding of CFTR protein. Both Ivacaftor and Lumacaftor for F508 del type.

72
Q

Complications associated with cystic fibrosis

A

Recurrent LRTI, pancreatic insufficiency, pneumothorax, pulmonary hypertension, infertility, biliary cirrhosis. Salt crisis due to exercise or dehydration. Poor prognosis if low FEV1 / recurrent admissions / haemoptysis. Social support issues.

73
Q

Signs of cystic fibrosis

A

Malnourished, loose cough, nail clubbing, resp. sounds, right heart failure / pulmonary hypertension, organomegaly.

74
Q

Causes of lung lesions by radiologic appearance - reticular, cavitating, calcified, coin lesion.

A

Reticular - ILD / IPF. cavitating - abscess / cancer / TB / aspergillus. calcified - TB / pneumoconiosis. coin lesion - cancer / TB / rheumatoid nodules / hydatid cyst / haematoma / AV fistula.

75
Q

Differential for causes of fatigue

A

lack of sleep, medications, narcolepsy, depression, restless legs syndrome, anaemia, low thyroid

76
Q

Presentation and risk factors for OSA

A

Presentation - daytime fatigue, apnoea, tonsillar surgery, history of CCF / COPD. Risk factors - obesity , hypertension, alcohol, sedating medications, large tonsils.

77
Q

Investigations and examination tools for OSA

A

Sleep study, thyroid function, ECHO (pulmonary hypertension), STOP BANG, Epworth

78
Q

Management of OSA

A

CPAP and surgery

79
Q

Complications of OSA

A

IHD, CVA, MVA, hypertension, pulmonary hypertension, lethargy

80
Q

Presentation and risk factors of lung cancer

A

Haemoptysis, weight loss, pleural effusion, ECOG. Risk factors = smoking, radiation, occupational exposure, TB/ILD/scleroderma.

81
Q

Investigations for lung cancer

A

CT / PET - peripheral = adenocarcinoma or large cell, central = squamous or SCLC. Biopsy. Type and staging - TNM for NSCLC, limited or extensive for SCLC.

82
Q

Associations for lung adenocarcinoma

A

non-smoker, female, do EGFR mutation test

83
Q

Associations for squamous lung cancer

A

smoker, intrathoracic spread

84
Q

Associations for SCLC

A

strongest assoc. with smoking, neuroendocrine, paraneoplastic, distant metastasis

85
Q

Management for lung cancer

A

Surgery for stage 1 to 3a (plus chemo rad) - need to climb 3 stairs or FEV1 >1.5L. Chemotherapy (etoposide + cisplatin) +/- immunotherapy +/- radiotherapy. Average 5 year survival is 15%.

86
Q

Examination findings for lung cancer

A

clubbing, fixed expiratory wheeze, Pancoast tumour, recurrent laryngeal palsy, lymphadenopathy

87
Q

Tests and management of IgE asthma

A

Omalizumab (anti-IgE). Test - IgE, skin prick test, atopic features.

88
Q

Tests and management of eosinophil asthma

A

Mepolizumab (anti-IL5). Test - eosinophils / FENO.

89
Q

Escalating bronchodilators for COPD

A
  1. SABA PRN. 2. LAMA +/- LABA. 3. LAMA / LABA or LABA/ICS if also asthma. 4. Triple therapy
90
Q

Examination findings for COPD

A

respiratory distress, hypoxia, cachexia, decreased air entry, wheeze, crepitation, sputum, right heart failure

91
Q

Complications of COPD

A

hospital/ICU admissions, LRTI, ventilator support, steroid use, functional decline

92
Q

Severity of FEV1 by percentages

A

FEV1. >80% mild, >50% moderate, >30% severe, <30% very severe.

93
Q

Presentation and risk factors of COPD

A

cough, sputum, dyspnoea, wheeze, weight loss. Risk factors = smoking, occupational exposure, exacerbating factors.

94
Q

Investigations for COPD

A

spirometry with FEV1/FVC <0.7 + imaging

95
Q

Acute management of exac of COPD

A

assess severity with 6MWT and ABG, bronchodilators, steroids, IV Abx, BiPAP, septic screen, assess for right heart strain (TWI in 2,3,V1-4) and right axis deviation

96
Q

Preventative measures for COPD

A

stop smoking, management plan, preventative inhalers (asses technique), pulmonary rehab, vaccinations, antibiotics for infections, home oxygen (sat <88%, pO2 <55%), lung volume reduction surgery

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