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Respiratory Flashcards

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1
Q

What is pleural effusion, what are the types and what effect does it have on the lungs?

A
  • collection of fluid in the pleural cavity
  • can be exudative (high protein) or transudative (low protein)
  • causes lung compression
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2
Q

What are exudative causes of pleural effusion?

A
  • changes to fluid formation and absorption
  • infection: pneumonia, TB, subphrenic abscess
  • autoimmune: RA, SLE
  • neoplasia: cancer, metastases
  • pancreatitis
  • PE
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3
Q

What are transudative causes of pleural effusion?

A
  • changes to hydrostatic/oncotic pressure, pleural permeability
  • heart, liver or renal failure
  • low blood albumin
  • nephrotic syndrome, dialysis
  • myxoedema
  • ascites
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4
Q

What are the symptoms of pleural effusion?

A
  • small/moderate: asymptomatic
  • breathlessness
  • non-productive cough
  • pleuritic chest pain
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5
Q

What symptoms can attribute the cause of pleural effusion to the following:
- cancer
- heart failure
- infection?

A
  • cancer: haemoptysis, weight loss
  • heart failure: orthopnoea, PND, oedema
  • infection: fever
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6
Q

What is seen on examination of pleural effusion?

A
  • stony dull to percussion
  • reduced breath sounds
  • reduced chest expansion
  • reduced tactile vocal fremitus
  • mediastinal shift away from affected side
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7
Q

What type of CXR is done for pleural effusion and what does it show?

A
  • posterioanterior CXR
  • blunting of costophrenic angle
  • fluid in lung fissures
  • meniscus and tracheal/mediastinal deviation
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8
Q

What is the difference between exudative and transudative pleural effusion on imaging?

A
  • exudative: unilateral
  • transudative: bilateral
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9
Q

What other secondary imaging may be done for pleural effusion?

A
  • USS: good for aspiration, sensitive to septations
  • echo: HF/RH strain
  • contrast CT: exudative causes
  • aspiration: septic or pneumotic illness
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10
Q

How is an exudative pleural effusion further investigated?

A
  • aspiration guided by USS
  • biochemistry: pH, protein, LDH, glucose, microbiology, cytology
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11
Q

What protein level distinguishes between exudative and transudative?

A
  • exudative: >30g/L
  • transudative: <30g/L
  • If 25-35, use Light’s criteria to distinguish
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12
Q

What is Light’s criteria for pleural effusion?

A
  • exudative if one of following is met:
  • pleural fluid protein/serum protein >0.5
  • pleural fluid LDH/serum LDH >0.6
  • pleural fluid LDH >2/3 upper limit of normal serum LDH
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13
Q

What does low complement in pleural fluid suggest?

A
  • low C3/C4: SLE
  • pleural effusions occur in 30-50% SLE patients
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14
Q

What does pleural fluid pH <7.3 suggest?

A
  • malignancy
  • RA
  • TB
  • oesophageal rupture
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15
Q

What are the criteria for pleural infection?

A
  • pH <7.2
  • glucose < 3.3 mmol/L
  • PF LDH > 1000IU/L
  • bacterial growth
  • macroscopic appearance of pus
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16
Q

When should a chest drain be placed in pleural infection following aspiration?

A
  • purulent/turbid fluid aspirated
  • clear fluid but pH <7.2 and suspected infection
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17
Q

How is pleural effusion managed?

A
  • smaller: observation + conservative
  • pleural aspiration
  • chest drain
  • treat underlying cause
  • surgical: video-assisted thoracic surgery (VATS)
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18
Q

How is recurrent pleural effusion managed?

A
  • recurrent aspiration
  • pleurodesis
  • indwelling pleural catheter
  • drug management for symptoms
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19
Q

What are complications of pleural effusion?

A
  • large: resp compromise
  • parapneumonic: empyema, sepsis
  • procedures: pneumothoraces
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20
Q

What is empyema?

A
  • infected pleural effusion
  • improving pneumonia but new/ongoing fever
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21
Q

How is empyema investigated, what is seen in the results and how is it treated?

A
  • aspiration: pus, acidic pH, low glucose, high LDH
  • chest drain to remove pus and antibiotics
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22
Q

What are the bacterial causes of empyema in the community and in hospital?

A
  • community: S. milleri, S. pneumoniae, S. aureus
  • Hospital: MRSA, enterococcus
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23
Q

What is sarcoidosis?

A
  • multisystem disorder
  • granulomatous inflammatory condition
  • granuolmas: nodules of inflammation full of macrophages
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24
Q

What is the epidemiology of sarcoidosis?

A
  • young adulthood or around age 60
  • more frequent in black patients
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25
What are the 4 stages of sarcoidosis on CXR?
0 = normal 1 = bilateral hilar lymphadenopathy 2 = BHL + interstitial infiltrates 3 = diffuse interstitial infiltrates only 4 = diffuse fibrosis
26
What are the pulmonary manifestations of sarcoidosis?
- bilateral hilar lymphadenopathy with pulmonary infiltrates and fibrosis - dry cough, progressive dyspnoea, chest pain
27
What are the extra pulmonary presentations of sarcoidosis?
- uveitis, conjunctivitis - lupus pernio (facial rash) - cirrhosis - erythema nodosum - fever, fatigue, weight loss
28
What are the differential diagnoses for sarcoidosis?
- TB - lymphoma - hypersensitivity pneumonitis - HIV
29
What is the treatment of sarcoidosis?
- no treatment if mild - oral steroids and bisphosphonates - 2nd line: methotrexate/azathioprine
30
What imaging investigations are done in sarcoidosis? Which enzyme and which electrolyte are raised in sarcoidosis?
- CXR and high res CT - raised serum ACE and IL-2 receptor - hypercalcaemia
31
What is the gold standard diagnosis of sarcoidosis?
- bronchoscopy w USS guided biopsy of mediastinal lymph nodes - histology from biopsy - non-caseating granulomas with epithelioid cells
32
Why is there hypercalcaemia in sarcoidosis?
- macrophages inside granulomas cause increased conversion of vit D to active form
33
What is Lofgren's syndrome?
- acute form of sarcoidosis - features: bilateral hilar lymphadenopathy, fever, erythema nodosum, polyarthralgia - excellent prognosis
34
What is Heerfordt's syndrome?
- uveoparotid fever - parotid enlargement - fever - uveitis - secondary to sarcoidosis
35
What is pneumothorax?
- accumulation of air in the pleural space - results in partial or complete collapse of affected lung
36
What is the pathophysiology of pneumothorax?
- alveolar and atmospheric pressure > intrapleural pressure - air moves down pressure gradient into space until space seals/gradient equilibrates
37
What are the types of pneumothorax?
- primary spontaneous - secondary spontaneous - traumatic - iatrogenic
38
What is primary spontaneous pneumothorax?
- no underlying lung disease - rupture of apical pleural bleb: air escaping into weakness in pleura
39
What are the risk factors for primary spontaneous pneumothorax?
- tall, thin, males - smokers - age 20-40
40
What are the causes of secondary spontaneous pneumothorax
- known lung disease, 60% due to COPD - infection - genetic predisposition - catamenial pneumothorax (endometriosis in thorax)
41
What is the epidemiology of secondary pneumothorax?
- over 50 - smoker
42
What are the causes of iatrogenic pneumothorax?
- complication of medical procedures - thoracentesis - central venous catheter placement - NIV or lung biopsy
43
What are the symptoms of pneumothorax?
- acute/sudden - dyspnoea - pleuritic chest pain - cough
44
What are the signs of a pneumothorax?
- hyperresonant percussion - reduced breath sounds and expansion - tachycardia and pnoea
45
What is seen on lung ultrasound in pneumothorax?
- used in supine trauma pts - absence of lung sliding between visceral and parietal pleura
46
What is the management of asymptomatic pneumothorax?
- conservative - primary: r/v every 2-4 days as outpatient - secondary: review as inpatient - outpatient CXR after 2-4 weeks
47
What are the high risk characteristics to assess if a pneumothorax is symptomatic?
- haemodynamic compromise (suggests tension pneumothorax) - significant hypoxia - bilateral pneumothorax - lung disease - ≥ 50y/o with significant smoking history - haemothorax
48
How does management differ for pneumothorax if high risk characteristics are present?
- high risk: chest drain - no high risk: conservative, ambulatory or needle aspiration - r/v all as outpatient after 2-4 weeks
49
What is ambulatory care for pneumothorax?
- catheter mounted on an 18G needle - one-way valve to prevent air and fluid return - r/v every 2-3d as outpatient and remove when resolved
50
What is the management for pneumothorax if needle aspiration is unsuccessful?
- small bore chest drain <14 French - daily inpatient review - remove when resolved
51
What would a bubbling chest drain in pnemothorax indicate?
- fluid bubbles initially - persistence for >48 hours can indicate an air leak - bronchopleural fistula
52
What is the guidance on air travel post pneumothorax?
- absolute contraindication - pts may travel 2 weeks after successful drainage if no residual air - do not travel until 1 week post check x-ray
53
What is the guidance regarding scuba diving and pneumothorax?
- permanently avoid - unless: bilateral surgical pleurectomy, normal lung function and chest CT postop
54
What is the management of recurrent pneumothoraces?
- VATS for assessment - open thoracotomy and pleurectomy: parietal pleura removed - Medical pleurodesis if unfit for surgery - tetracycline/talc obliterates the space between pleura
55
What is tension pneumothorax? How can it lead to cardiorespiratory arrest?
- ONE WAY valve like mechanism causes air to be drawn into chest cavity during inspiration and trapping air in expiration - displaces mediastinium causing dec cardiac output and can lead to cardioresp arrest
56
What are the symptoms of tension pneumothorax?
- acute dyspnoea - pleuritic chest pain - tachypnoea
57
What are the clinical signs of tension pneumothorax?
- hyper resonant percussion - hypoxia - unilateral chest wall expansion - reduced breath sounds + air entry - tracheal deviation away from affected side - distended neck veins - severe: shock
58
What is the management of tension pneumothorax?
- needle thoracostomy - insert large bore cannula into 5th intercostal space in mid axillary line - orange 14G or grey 16G - follow with chest drain to continue air drainage
59
What is haemothorax and how is it managed?
- blood in the pleural cavity with a haemtocrit ratio of > 50% - management: drainage
60
What is hydropneumothorax and what are the causes?
- air and fluid in the pleural space - cause: iatrogenic, gas forming organisms, thoracic trauma
61
What is bronchiectasis?
- obstructive lung disease - abnormal dilation of bronchi - caused by excessive, persistent inflammation - influx of inflammatory cells into airway wall
62
What is the presentation of bronchiectasis?
- chronic cough - excess sputum - dyspnoea - chest pain - haemoptysis
63
What are the investigations and management of bronchiectasis?
- sputum sample - obstructive spirometry: FEV1:FVC <0.7 - high res CT: signet ring sign dilated bronchi, cysts - mucolytics, β2 agonists
64
What is idiopathic pulmonary fibrosis?
- stiffening of interstitium due to chronic inflammation - excess fibrous connective tissue > permanent scarring, airway thickening - of unclear cause
65
What is the pathophysiology of ILD?
- fibroblasts secrete extracellular matrix - excess accumulates in interstitium > fibrosis - thicker interstitium > inc diffusion distance > dec gas exchange
66
What are the primary causes of ILD?
- IPF - acute interstitial pneumonia - desquamative interstitial pneumonia
67
What are the secondary causes of ILD?
- connective tissue disease: sarcoidosis, SLE, RA - infective - environmental: asbestos/silicosis - drugs: methotrexate, amiodarone
68
What is the epidemiology of IPF?
- ages 50-70 - 2x more common in men
69
What are the features of IPF?
- progressive exertional dyspnoea (presents over weeks/months) - dry cough - clubbing
70
What is heard on examination of IPF?
- bibasal fine end-inspiratory crepitations on auscultation
71
What is seen on investigation for IPF? (spirometry/bloods/TLCO)
- spirometry: restrictive - reduced TLCO - ANA +ve in 30%
72
How is IPF diagnosed using imaging?
- CXR: bilateral interstitial shadowing - ground glass > honeycombing - GOLD: high res CT
73
What is seen on high rest CT for IPF?
- honeycombing (clusters) - traction bronchiectasis (dilated airways) - reticular opacities (thickening of interstitium)
74
# CHARTS What are causes of upper zone fibrosis in ILD?
- coal worker pneumoconiosis - hystiocytosis-X - ankylosing spondylitis - radiation - tuberculosis - sarcoidosis and silicosis
75
# RASIO What are causes of lower zone fibrosis in ILD?
- RA - asbestosis - SLE, scleroderma, Sjrogen's - IPF - others (incl drugs)
76
What invasive investigations can be done for ILD?
- bronchoalveolar lavage: saline injected through bronchoscope, collected and analysed - trans-bronchial biopsy
77
How is IPF managed medically?
- pirfenidone/nintedanib (antifibrotic) - supplementary oxygen > lung transplant
78
What is the conservative management of ILD?
- pulmonary rehabilitation - smoking cessation - annual flu vaccine/one off pneumococcal
79
What are complications of ILD?
- respiratory failure - pulmonary hypertension
80
What are the most common form of asbestos related lung disease?
- pleural plaques - benign - occur after latent 20-40y period
81
Describe the presentation of asbestosis
- dyspnoea + dec exercise tolerance - bilateral end-inspiratory crackles - clubbing - restrictive spirometry and dec TLCO
82
Describe asbestosis
- severity related to length of exposure - latent period 15-30 years - causes lower lobe fibrosis
83
What is mesothelioma?
- malignant disease of mesothelial cells of pleura - linked to asbestos inhalation - latent period of up to 45 years
84
What are the features of mesothelioma?
- progressive shortness-of-breath - chest pain - pleural effusion
85
How does lung cancer relate to asbestos exposure?
- MC form of cancer associated with asbestos exposure - synergistic effect with smoking - smoking cessation important
86
What is the prognosis of mesothelioma?
- palliative chemotherapy - surgery and radiotherapy - poor prognosis: 8-14 months
87
What is hypersensitivity pneumonitis (extrinsic allergic alveolitis)?
- hypersensitivity induced lung damage via inhaled particles - type III reaction to environmental allergen - type IV in chronic phase of disease - causes parenchymal inflammation and destruction
88
What is the timeframe and acute presentation of EAA?
- 4-8hrs - dyspnoea - dry cough - fever
89
What is the timeframe and chronic presentation of EAA?
- after weeks-months - lethargy - dyspnoea - productive cough - anorexia and weight loss
90
How is hypersensitivity pneumonitis tested for?
- bronchoalveolar lavage: collecting cells from airways during bronchoscopy by washing with fluid - lymphocytosis and mast cells - no eosinophilia
91
What is seen on imaging for EAA?
- upper/mid zone fibrosis
92
How is hypersensitivity pneumonitis managed?
- remove allergen - give oxygen - oral glucocorticoids
93
What are some specific examples of types of hypersensitivity pneumonitis?
- Bird-fanciers lung: bird droppings - Farmers lung: mouldy spores in hay - Mushroom workers’ lung: mushroom antigens - Malt workers lung: mould on barley
94
What is acute bronchitis and when is it most prevalent?
- infection/inflammation of trachea and large bronchi - most cases occur in autumn/winter
95
What are causes of acute bronchitis?
- viral infection (leading) - bacteria - airway irritants e.g. smoke
96
What are viral causes of acute bronchitis?
- parainfluenza - RSV - rhinovirus
97
What are bacterial causes of acute bronchitis?
- S. pneumonia - Mycoplasma pneumoniae - H. influenzae
98
What are the symptoms of acute bronchitis?
- acute onset - cough (may be productive) - sore throat - rhinorrhoea - wheeze
99
What are symptoms of acute bronchitis on examination?
- low grade fever - bilateral wheeze and crackles
100
In what circumstances should you give antibiotics for acute bronchitis?
- systemically unwell - pre-existing co-morbidities - raised CRP
101
What CRP means you should give a delayed Abx prescription vs an immediate Abx prescription in acute bronchitis?
- delayed: CRP 20-100 - immediate: >100
102
Which antibiotic is used to treat acute bronchitis and in who is it contraindicated?
- 1st line: doxycycline - alternative: amoxicillin - CI: children and pregnant women
103
How may acute bronchitis differ from pneumonia in history?
- Sputum, wheeze, breathlessness absent in acute bronchitis - at least one tends to be present in pneumonia.
104
How can you differ acute bronchitis from pneumonia on examination?
- acute bronchitis: only wheeze - pneumonia: dull to percussion, creps, bronchial breathing - pneumonia: systemic signs
105
What is allergic rhinitis?
- inflammatory disorder - nose becomes sensitised to allergens - house dust mites, grass, tree and weed pollens
106
What are the 3 categories of allergic rhinitis?
- seasonal - perennial: year round - occupational
107
What are the features of allergic rhinitis?
- sneezing - bilateral nasal obstruction - clear nasal discharge - post-nasal drip - nasal pruritus
108
What is the management of allergic rhinitis?
- mild-moderate: oral/intranasal antihistamine - moderate-severe: intranasal corticosteroids - oral corticosteroids - topical decongestants
109
Describe a moderate attack of acute asthma: PEFR, speech, RR, HR
- PEFR 50-75% best or predicted - Speech normal - RR < 25 / min - HR < 110 bpm
110
Describe a severe attack of acute asthma: PEFR, sentences, RR, HR
- PEFR 33 - 50% best or predicted - Can't complete sentences - RR > 25/min - HR > 110 bpm
111
Describe a life-threatening attack of acute asthma: PEFR, sats, chest, obs, pco2
- PEFR < 33% best or predicted - Sats < 92% - Silent chest, cyanosis or feeble respiratory effort - Bradycardia, dysrhythmia or hypotension - Exhaustion, confusion or coma - normal PCO2 (indicates exhaustion)
112
What are the criteria for ABG/CXR in acute asthma?
- ABG: sats <92% - CXR: life-threatening, suspected pneumothorax, failure to respond to treatment
113
When should a patient with acute asthma be admitted to hospital?
- life-threatening - severe attack not responding to treatment - previous near-fatal attack - pregnancy - attack despite oral steroid
114
What are the stages of medication management of an acute asthma attack?
1. oxygen 2. SABA 3. corticosteroid 4. ipratropium bromide 5. IV magnesium sulphate 6. IV aminophylline 7. ITU: intubation
115
When should acute asthma attack patients be started on oxygen and what are target sats?
- hypoxaemic - acutely unwell, start on 15L non-rebreathe aiming for O2 sats 94%-98%
116
What is the route of SABA in acute asthma attack?
- pressurised meter dose inhaler - oxygen driven nebuliser - life-threatening: nebulised SABA
117
What is the dose of corticosteroid in acute asthma?
- 40-50mg prednisolone PO daily - continue for >5d or until pt recovers - in addition to ICS
118
What are the criteria for discharge following an acute asthma attack?
- stable on their discharge medication (i.e. no nebs or O2) for 12-24 hrs - inhaler technique checked and recorded - PEF >75% of best or predicted
119
What is the first line investigation for chronic asthma?
- eosinophil count: if above reference range - FeNO: ≥50ppb
120
What is the management pathway of asthma in adults?
1. low dose ICS/formoterol (AIR - anti-inflammatory reliever therapy) 2. low-dose MART 3. moderate dose MART 4. Check FeNO and blood eosinophil
121
What should be done in step 4 of asthma management if neither FeNO or eosinophils are raised?
- consider trial of LTRA or LAMA in addition to MART - trial the other one if the first doesn't work - refer to specialist if not already
122
What are the features of pulmonary embolism?
- pleuritic chest pain - dyspnoea - tachycardia and pnoea - haemoptysis
123
What is heard in respiratory exam in pulmonary embolism?
- clear chest
124
What is PERC and when is it used?
- pulmonary embolism rule out criteria - use if low probability of PE - all criteria absent to have negative PERC result
125
If a PE is likely on Wells score, what should be the next steps? if this imaging is delayed, positive or negative, what should be done?
- CTPA - if delayed: interim anticoag: DOAC - +ve: PE - -ve: consider proximal leg USS if DVT suspected
126
If a PE is unlikely on Wells score, what should be the next step? What are the next steps if this result is positive or negative?
- arrange D-dimer - if +ve: CTPA - if -ve: stop anticoag and consider alternative diagnosis
127
What investigation should be done for PE in renal impairment (why not CTPA)?
- V/Q scanning - contrast in CTPA is bad for renal impairment
128
What are ECG findings in PE?
- sinus tachycardia - S1Q3T3: large S wave in lead I, large Q wave in lead III, inverted T wave in lead III - RBBB and R axis deviation
129
How is occupational asthma investigated?
- serial PEF at work and away from work
130
What chemicals are associated with occupational asthma?
- isocyanates - platinum salts
131
How often should asthma treatment be stepped down? What % reduction of steroids should be made?
- step down every 3mo - reduce steroids 25-50%
132
What is pulmonary hypertension?
- mean PA pressure is >25mmHg at rest
133
What are the 2 main pathophysiological causes of pulmonary hypertension?
- PA narrowed, thickened or damaged causing inc pressure - L heart disease reduces flow from R side of heart > inc pressure
134
What are features of pulmonary hypertension?
- symptoms worse on exertion - SOB - weakness and fatigue - chest pain - syncope
135
What ECG signs indicate R heart strain?
- P pulmonale (peaked P waves) - RV hypertrophy (tall R waves in V1-V2, deep S waves in V5-6) - right axis deviation - RBBB
136
What is seen on CXR in pulmonary hypertension?
- dilated pulmonary arteries - RV hypertrophy
137
What is atelectasis?
- postop complication - basal alveolar collapse - airways obstructed by bronchial secretion
138
What are the features of atelectasis?
- dyspnoea - hypoxaemia - occurs around 72h post op
139
What is the management of atelectasis?
- positioning the patient upright - chest physio, breathing exercises
140
What is the cause of acute respiratory distress syndrome?
- ARDS - increased permeability of alveolar capillaries - leads to fluid accumulation in alveoli - non-cardiogenic pulmonary oedema
141
What are causes of ARDS?
- infection - massive blood transfusion - acute pancreatitis - trauma - smoke inhalation
142
What are the features of ARDS?
- acute onset, severe - dyspnoea - elevated RR - bilateral crackles - low O2 sats
143
What investigations are done for ARDS?
- ABG - CXR
144
What are the criteria for ARDS? - onset - imaging - ratio
- onset within 1 week - bilateral opacities on CXR/CT - PaO2/FiO2 ratio of ≤40kPa (<300mmHg) - resp failure not attributed to heart failure/fluid overload
145
What are risk factors for ARDS?
- critical illness - smoking - chronic alcohol - long-term exposure to air pollutants
146
How is ARDS managed?
- oxygenation - treat underlying cause - prone positioning - fluids slightly negative/neutral
147
Where does reactivation begin in secondary tuberculosis and where does it spread to?
- begins in apex - spreads to: - CNS - cervical lymph nodes - kidneys - GI tract
148
What are risk factors for TB?
- living in Asia, Latin America, Eastern Europe or Africa - exposure to infectious TB - HIV - immunocompromised - silicosis - apical fibrosis
149
How can latent TB be diagnosed? 2 methods
- positive tuberculin skin test - IGRA + normal CXR
150
What are the 2 choices for treating latent TB?
- 3mo of isoniazid, pyroxidine and rifampicin - or 6 months of isoniazid and pyroxidine
151
When should 3mo of isoniazid, pyroxidine and rifampicin be used as a latent TB treatment?
- age <35 - concerns of hepatotoxicity
152
When should 6 months of isoniazid and pyroxidine be used as a latent TB treatment?
- interactions with rifampicin - e.g. HIV or transplant pts
153
What results of a Mantoux test may be positive or negative?
- <5mm: negative - ≥5mm positive
154
Where is cavitation seen on CXR in TB? How does bilateral vs unilateral hilar lymphadenopathy distinguish TB types?
- upper lobe cavitation - bilateral: reactivated - unilateral: primary
155
What is the sputum smear test that can be done for TB?
- Ziehl-Neelsen stain - stained for acid fast bacilli - stains positive
156
What is the gold standard for diagnosing active TB?
- sputum culture -
157
What is the drug management of tuberculosis? Initial and continuation phase
Initial: 2 months - rifampicin - isoniazid - pyrazinamide - ethambutol Continuation: 4 mo - rifampicin - isoniazid
158
What are the adverse effects of rifampicin?
- hepatitis, orange secretions - flu-like symptoms
159
What are the adverse effects of isoniazid?
- peripheral neuropathy: prevented by pyridoxine (Vitamin B6) - hepatitis, agranulocytosis - liver enzyme inhibitor
160
What are the adverse effects of pyrazinamide?
- hyperuricaemia causing gout - arthralgia, myalgia - hepatitis
161
What are the adverse effects of ethambutol?
- optic neuritis - check visual acuity before and during treatment
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