Respiratory Flashcards

Question

Presentation of aspiration pneumonia?

Answer 1

Cough (which may be productive of purulent sputum) Shortness of breath Chest pain Fevers Malaise

Answer 2

COPD PE Bronchitis

Answer 3

Sputum culture Blood tests; WCC, CRP CXR; consolidation

Answer 4

Initial antibiotic; co-amoxiclav Consider complications such as empyema if failure to resolve

Answer 5

Hyper-reactive airway disease characterised by intermittent recurrent symptoms of wheeze, cough, SOB and chest tightness caused by reversible bronchoconstriction, hyperreactivity and chronic inflammation

Answer 6

Cold air and exercise Pollution and cigarette smoke Allergens such as animal dander, dust mites and pollen Irritants such as perfumes, paints or air fresheners Medications such as NSAIDs or beta-blockers

Answer 7

Family history of asthma or atopy Personal history of atopy (eczema, allergic rhinitis, allergic conjunctivitis) Exposure to smoke, including maternal smoking in pregnancy Respiratory infections in infancy Prematurity and low birth weight Obesity Social deprivation Occupational exposures (e.g. flour dust, isocyanates from paint)

Answer 8

Wheeze Dyspnoea Cough Chest tightness Diurnal variation; symptoms worse at night/ early morning Signs; Tachypnoea Increased work of breathing Hyperinflated chest Expiratory polyphonic wheeze throughout the lung fields Decreased air entry (if severe)

Answer 9

Bronchiectasis Vocal cord dysfunction COPD GORD Eosinophillic granulomatosis with polyangiitis

Answer 10

FeNO; >50ppb FBC, eosinophil count Bronchodilator reversibility Spirometry Direct bronchial challenge test

Answer 11

Non pharmacological; Teach good inhaler technique and review this regularly Spacer devices can be used to optimise medication delivery Regular peak flow monitoring Smoking cessation Advice on avoiding triggers where possible (e.g., certain medications) Ensure vaccinations are up to date, including annual influenza vaccination Assess for occupational asthma by asking if symptoms are better when the patient is away from work and arrange specialist referral if this is suspected Pharamcological; LABA+ ICS combination inhaler MART; maintenance and reliver therapy inhaler LTRA LAMA

Answer 12

Uncertainty regarding diagnosis Suspected occupational asthma Severe or life-threatening asthma requiring admission to hospital Multiple exacerbations requiring oral steroid treatment per year

Answer 13

pneumococcal polysaccharide vaccine (PPV) protecting against 23 serotypes of pneumococcus pneumococcal polysaccharide conjugate vaccine (PCV) protecting against 13. (given in childhood imms)

Answer 14

Over 65 year olds Splenic dysfunction or asplenia (e.g. coeliac disease, sickle cell disease) Chronic respiratory disease (e.g. COPD) Chronic heart disease (e.g. heart failure) Chronic kidney disease (e.g. CKD stage 4 or 5) Chronic liver disease (e.g. cirrhosis) Patients with diabetes requiring anti-diabetic medication Immunosuppression (e.g. HIV, chemotherapy, long-term steroid usage) Cochlear implant Those at risk of cerebrospinal fluid leakage (e.g. skull fracture) Those exposed to metal fumes at work (e.g. welders)

Answer 15

Bilateral hilar lymphadenopathy refers to the enlargement of lymph nodes around both hila of the lungs due to inflammation, infection or malignancy.

Answer 16

Inflammatory: sarcoidosis Infective: tuberculosis, mycoplasma, histoplasmosis Malignancy: lymphoma (Hodgkin more common than non-Hodgkin), carcinoma Pneumoconioses (diseases due to inhalation of dusts/fibres): silicosis, berylliosis

Answer 17

Chronic lung disease where inflammation and obstruction causes damage to the bronchial walls leading to their permanent dilation May affect whole lobe or one lung

Answer 18

40% of patients have no identifiable cause Most common cause is severe LRTI (pneumonia, TB, influenza) Immunodeficiency (HIV, common variable immunodeficiency) Defective mucociliary clearance (cystic fibrosis, primary ciliary dyskinesia e.g. Kartagener syndrome) Allergic Bronchopulmonary Aspergillosis (ABPA) Autoimmune disease (rheumatoid arthritis, systemic lupus erythematosus, inflammatory bowel disease) Airway obstruction (inhaled foreign bodies, bronchial carcinoma, severe obstructive lung disease e.g. COPD/asthma) Chronic aspiration Congenital defects of the large airways (Marfan’s, tracheobronchomegaly)

Answer 19

Symptoms include: Productive cough lasting at least 8 weeks Copious production of purulent sputum Dyspnoea Haemoptysis Chest pain Fatigue Weight loss Examination; Coarse crackles on auscultation Wheeze Rhonchi (snoring sounds caused by secretions in the larger airways) Finger clubbing

Answer 20

Sputum culture Spirometry Bloods; WCC, CRP CXR High resolution CT Rheumatological serology Serum immunoglobulins HIV serology Test for cystic fibrosis Bronchoscopy

Answer 21

Conservative; Sputum clearance exercises Smoking cessation Pulmonary rehabilitation Influenza and pneumococcal vaccination Medical management; Treat with antibiotics Treat comorbidities Surgical; Lung resection Treat haemoptysis Consider lung transplantation

Answer 22

Chronic obstructive pulmonary disease (COPD) involves airway obstruction that is usually progressive. It encompasses both emphysema (where alveolar wall destruction leads to enlargement of the distal airspaces) and chronic bronchitis (persistent or recurrent productive cough usually due to mucus hypersecretion).

Answer 23

Tobacco smoking and passive smoke exposure Marijuana smoking Occupational exposure to dusts and fumes Household air pollution from wood or coal burning Alpha-1 antitrypsin deficiency

Answer 24

Poor exercise tolerance Smoking Low body mass index Multi-morbidity and frailty Exacerbations requiring admission to hospital or frequent exacerbations Severe obstruction on spirometry (as measured by a lower FEV1) Chronic hypoxia Cor pulmonale

Answer 25

As a protective reaction to smoke or other pollutants, goblet cells hypersecrete mucus in the bronchi and bronchioles of the lungs. Cilia are not able to remove the excess mucus and so it obstructs the small airways. Ongoing inflammation causes remodelling and thickening of the airway walls that also contributes to obstruction.

Answer 26

Inflammation in the lungs is usually countered by antiproteases such as alpha-1 antitrypsin, however the activity of these is reduced by smoke and other pollutants. Without sufficient antiprotease activity, proteolytic enzymes produced by inflammatory cells break down the walls of the alveoli. This causes enlargement of the terminal airspaces and reduces the surface area available for gas exchange.

Answer 27

Grade 1; mild, post bronchodilator FEV1 >80% Grade 2; moderate, post bronchodilator FEV1 50-79% Grade 3; severe, post bronchodilator FEV1 30-49% Grade 4; very severe, post bronchodilator FEV1 <30%

Answer 28

Grade 0; I only get breathless with strenuous exercise. Grade 1; I get short of breath when hurrying on level ground or walking up a slight hill. Grade 2; On level ground, I walk slower than people of the same age because of breathlessness, or I have to stop for breath when walking at my own pace. Grade 3; I stop for breath after walking about 100 yards or after a few minutes on level ground. Grade 4; I am too breathless to leave the house, or I am breathless when dressing or undressing.

Answer 29

Symptoms; Shortness of breath that worsens with exertion Reduced exercise tolerance Chronic productive cough Recurrent lower respiratory tract infections Wheeze In more advanced cases, systemic symptoms such as weight loss and fatigue may be present Examination; Wheeze or crackles on auscultation Accessory muscle usage Pursed lip breathing (this creates a small amount of positive end expiratory pressure to prevent the alveoli from collapsing) Cyanosis Hyperinflation of the chest Cachexia Raised JVP and peripheral oedema (indicating cor pulmonale has developed)

Answer 30

Spirometry Bloods; polycythaemia/ anaemia, BNP, alpha-1 antitrypsin ECG CXR Sputum culture

Answer 31

Asthma Bronchiectasis Heart failure Interstitial lung disease Lung cancer TB

Answer 32

Patient education, smoking cessation Nutritional support Annual influenza, one off pneumococcal vaccination SABA/ SAMA ICS LABA LAMA Thyophyline Long term oxygen therapy if; Oxygen saturations <92% in air or cyanosis FEV1 <30% predicted (consider referring if <49%) Polycythaemia Peripheral oedema or raised jugular venous pressure (suggesting cor pulmonale)

Answer 33

Multisystem autosomal recessive condition that leads to bronchiectasis, pancreatic insufficiency and fertility problems

Answer 34

Most common genetic disease in white populations 1 in 25 people with European ancestry carrying a causative gene 1 in 2500 babies born in the UK have the condition

Answer 35

Mutations in the cystic fibrosis transmembrane conductance regulator gene on chromosome 7 Most common of these is called F508del which is a type of deletion mutation and results in the CTFR protein not being transported to the surface of cells CFTR protein is responsible for regulating chloride ion transport across the cell membrane. If this is defective, there is an increase in the viscosity of mucus produced and so secretions are thickened throughout the body. In the sweat glands however, chloride is transported the opposite way and so mutations cause excess chloride to be transported onto the skin, explaining why sweat testing in CF reveals raised sweat chloride

Answer 36

Respiratory features; Bronchiectasis (chronic productive cough, dyspnoea) Frequent lower respiratory tract infections Chronic sinusitis Nasal polyps Increased incidence of pneumothoraces GI features; Meconium ileus Distal intestinal obstruction syndrome Rectal prolapse Pancreatic insufficiency cirrhosis and portal hypertension Gall stones Failure to thrive in infancy Prolonged neonatal jaundice Reproductive features; Congenital absence of vas deferens Thickened cervical mucus MSK features; Finger clubbing Osteopenia or osteoporosis secondary to malnourishment Short stature Non-specific joint and muscular pains

Answer 37

Bronchiectasis Coeliac disease Primary ciliary dyskinesia

Answer 38

Neonates are screened by heel prick test Chloride sweat test; >60nmol/ L is diagnostic Genetic testing Other tests; Faecal elastase - to test for pancreatic insufficiency Glucose testing - to assess for diabetes secondary to pancreatic insufficiency Sputum microbiology Bloods CXR CT chest DEXA scan Liver USS

Answer 39

Review every 3-6 months Peer, social and psychological support Physiotherapy Dietician Dornase alpha; mucoactive agent Hypertonic saline nebuliser Antibiotic prophylaxis - flucloxacillin to prevent Staphylococcus aureus should be given from diagnosis until 3-6 years old. Lumacaftor-ivacaftor (Orkambi) is a treatment licensed for patients with two copies of the F508del mutation Creon Insulin Nasal steroids

Answer 40

Median survival is 46 for men and 41 for women

Answer 41

Lung cancer Carcinoid tumour Bronchitis Bronchiectasis Airway trauma Pneumonia Tuberculosis Lung abscess Granulomatosis with polyangiitis Goodpastures syndrome PE AV malformation Mitral stenosis Iatrogenic

Answer 42

Urinalysis Sputum culture of acid fast bacilli ECG Bloods; FBC, U+E, coagulation CXR CT chest Bronchoscopy

Answer 43

Hyposplenism Chronic diseases of the respiratory, cardiovascular, renal, liver, neurological systems Diabetes mellitus Immunosuppression Morbid obesity Pregnancy

Answer 44

Influenza A - capable of causing pandemics and epidemics; found in humans, birds and pigs; multiple different sub-types; most common cause of seasonal flu infections Influenza B -capable of epidemics only; only found in humans; only one subtype Influenza C - mainly occurs in humans, but also found in dogs and pigs Influenza D - only found in cattle; not known to cause illness in humans

Answer 45

The incubation period is typically 1-4 days and patients can remain infectious for 7-21 days. Fever > 37.8°C Nonproductive cough Myalgia Headache Malaise Sore throat Rhinitis

Answer 46

Sepsis Meningitis Common cold Streptococcal pharyngitis LRTI Infectious mononucleosis

Answer 47

Pulmonary - viral pneumonia, secondary bacterial pneumonia (particularly S. aureus) , worsening of chronic conditions (eg. COPD and asthma) Cardiovascular - myocarditis, heart failure Neurological - encephalopathy Gastrointestinal - anorexia and vomiting are common

Answer 48

Large group of diseases that cause inflammation and ultimately fibrosis of the interstitium of the lung

Answer 49

Idiopathic pulmonary fibrosis; commonest cause Hypersensitivity pneumonitis Sarcoidosis Asbestosis Lung damage; pneumonia or TB Irritants; dust/ silica Connective tissue disease; RA, SLE, systemic sclerosis, sjogren's syndrome Medications; Amiodarone, Nitrofurantoin and Bleomycin Radiation

Answer 50

Upper zones predominant: Hypersensitivity pneumonitis Ankylosing spondylitis Radiotherapy Tuberculosis Sarcoidosis Lower zones predominant: Rheumatoid arthritis Asbestosis Idiopathic Drugs

Answer 51

Insidious and progressive onset of; Dry cough Shortness of breath Reduced exercise tolerance Fatigue Anorexia Weight loss Signs; Cyanosis Clubbing Cachexia Fine end-inspiratory crackles location depends on where in the lung is affected do not clear on coughing

Answer 52

Pulmonary oedema Lymphangitis carcinomatosis COPD Lung cancer

Answer 53

Bloods; FBC, U+E, LFT, bone profile, CRP, Autoimmune screen, serum ACE CXR High resolution CT Spirometry Bronchoscopy Lung biopsy

Answer 54

IPF; Pirfenidone- reduces fibroblast proliferation Nintedanib- tyrosine kinase inhibitor Smoking cessation Hypersensitivity pneumonitis; Potential for reversal if causative agent is removed Steroids Immunosuppression; cyclophosphamide, azathioprine

Answer 55

Tobacco smoking (e.g. cigarettes, pipes, cigars) Passive smoke exposure Occupational exposures (e.g. beryllium, cadmium, arsenic, asbestos, silica) Radon exposure Family history of lung cancer Radiation to the chest (e.g. in lymphoma treatment) Air pollution Immunosuppression (e.g. HIV, medications) Increasing age

Answer 56

Small cell lung cancer; neuroendocrine cells of lung Non small cell lung cancer has 2 types; Adenocarcinoma; arising from type 2 alveolar epithelial cells Large cell carcinoma

Answer 57

Symptoms; Persistent cough Haemoptysis Dyspnoea especially on exertion Chest pain Weight loss Recurrent chest infections, or infections resistant to treatment Anorexia Signs; Cachexia Finger clubbing Lung collapse from tumour Pleural effusion Paraneoplastic syndrome; small cell cancer Cushings syndrome SIADH Lambert- Eaton myasthenic syndrome Humoural hyperglycaemia

Answer 58

Lung metastases Mesothelioma Tuberculosis Bronchiectasis

Answer 59

In primary care, patients should be referred on a 2 week wait pathway in the following situations: Aged 40+ with unexplained haemoptysis Chest X-ray findings suspicious for lung cancer Urgent chest X-ray in patients who have smoked and are over 40 years with one of the following; Cough Fatigue Shortness of breath Chest pain Weight loss Anorexia Sputum cytology Diagnostic thoracocentesis Bloods; FBC, U+E, LFT, CRP CT chest with contrast Biopsy Spirometry CT TAP PET CT/ MRI

Answer 60

Smoking cessation Advanced care planning Chemotherapy Immunotherapy Radiotherapy Lobectomy Wedge resection Pneumonectomy Hilar node sample

Answer 61

Spread to lymph nodes, liver, brain, bones, adrenal glands, contralateral lung Horners syndrome SVC obstruction Malignant pleural effusion Hoarse voice Persistent LRTI Raised hemidiaphragm Brachial plexus injury

Answer 62

Average 5 year survival rate of 17% Small cell lung cancers are aggressive and are usually metastatic at the time of presentation, hence curative treatment is not possible

Answer 63

Rounded opacity in the lung that measures under 3cm in diameter (if over 3cm would be referred to as a mass). They are a common incidental finding on chest X-rays and CT scans and there are a wide variety of causes, as well as agreed criteria for follow up

Answer 64

Inflammatory causes; Granuloma Rheumatoid nodule Infective causes; Lung abscess Small focus of pneumonia Tuberculosis Fungal - e.g. aspergillosis, histoplasmosis Neoplastic; Primary lung cancer Metastasis Carcinoid tumour Lymphoma Benign neoplasia Congenital; Lung cyst AV malformation Pulmonary sequestration Bronchial atresia with mucous plugging

Answer 65

Artefact Nipple shadow Skin lesion Bone lesion Summation of markings

Answer 66

If the nodule is detected on X-ray, a CT chest may be done to better delineate it. Nodules considered to have a 10% or more risk of being malignant should be considered for biopsy, either excisional or image-guided.

Answer 67

If a nodule is under 5mm diameter or 80mm3 volume, or looks clearly benign (e.g. a hamartoma), or if the patient is unfit for any treatment it does not need any follow up. 5-6mm nodules should be followed up with a CT in 1 year. 6-8mm nodules should be followed up with a CT in 3 months. For nodules over 8mm, the Brock model is used to estimate the risk of lung cancer. Under 10% risk of lung cancer is classed as low risk and patients can continue surveillance. Patients with a risk of 10% or over should have a PET-CT to further risk assess, with higher risk nodules recommended to undergo biopsy or excision

Answer 68

Collection of pus in the lung parenchyma that causes a cavity to form. An air-fluid level is often seen on imaging due to necrotic debris within the cavity

Answer 69

Chronic aspiration Poor oral hygiene Immunosuppression Thoracic trauma Recent trauma

Answer 70

Aspiration Necrotising pneumonia Tuberculosis Bronchial obstruction Infective endocarditis Contagious spreaf

Answer 71

Fevers Productive cough Shortness of breath Lethargy Night sweats Weight loss Can cause haemoptysis Abscesses near the pleura can cause pleuritic chest pain Signs; Finger clubbing Localised dullness to percussion Reduced air entry over the abscess

Answer 72

Bronchiectasis Tuberculosis Lung cancer

Answer 73

Sputum MC&S Blood test; CRP, WCC, LFT, U+E CXR; round lesion with an air-fluid level; the right lower lobe is the most commonly affected area due to aspiration CT chest with contrast Bronchoscopy Pus MC&S

Answer 74

Antibiotic treatment: broad spectrum antibiotics (e.g. co-amoxiclav) should be initiated, via the intravenous route for the first 2-3 weeks then continue oral treatment for 4-8 weeks as guided by microbiology and local guidelines as well as clinical progress Supportive management Chest physio Surgical drainage

Answer 75

Empyema Bronchopleural fistula Pneumothorax Sepsis Abscesses elsewhere in the body due to haematogenous spread

Answer 76

Upper airway becomes completely or partially obstructed during sleep, causing apnoeas (where breathing temporarily stops) or hypopnoeic episodes (decreased airflow during breathing). These episodes cause oxygen desaturations which cause brief arousals from sleep which can be hundreds of times per night

Answer 77

85% remain undiagnosed Around half are overweight OSA is strongly linked with cardiovascular disease and the metabolic syndrome, and is a significant risk factor for coronary artery disease, type 2 diabetes and stroke

Answer 78

Obesity Male sex Older age Decreased muscle tone - e.g. alcohol excess, sedative medications, muscular dystrophy or other neuromuscular disorders Anatomical defects - e.g. retrognathia, macroglossia Large neck circumference Adenotonsillar hypertrophy (particularly in children) Sleeping supine Down’s syndrome

Answer 79

During sleep there is a normal loss of muscle tone in the oropharynx. In most people, there is still sufficient airway patency during sleep so that it does not become obstructed. Patients with OSA, however, require the muscle tone when awake to counteract additional pressures on their airway and so are unable to maintain patency when asleep.

Answer 80

Unrefreshing sleep, or frequent waking at night Daytime sleepiness Others may witness snoring, apnoeas, gasping or choking during sleep Nocturia Difficulty concentrating Morning headaches Behavioural problems and hyperactivity in children Signs; Obesity Large neck circumference Jaw abnormalities (retrognathia or micrognathia) Mouth breathing or nasal speech (due to nasopharyngeal obstruction, e.g. due to adenotonsillar enlargement)

Answer 81

Insomnia Sleep disturbance Restless leg syndrome Narcolepsy Hypothyroidism Depression Medications; SSRI, benzodiazepines GORD

Answer 82

STOP-Bang asks about snoring, sleepiness, apnoeas, hypertension, obesity, neck circumference, age and sex and gives a low, medium or high risk of OSA. The Epworth sleepiness scale focuses on daytime sleepiness and asks how likely the patient would be to fall asleep in a variety of situations (e.g. when watching TV). This gives a result of either normal daytime sleepiness or mild, moderate or severe excessive daytime sleepiness. Sleep study; apnoea hypoxia index Mild OSA: AHI 5-14 per hour Moderate OSA: AHI 15-30 per hour Severe OSA: AHI over 30 per hour

Answer 83

Patient education Sleep on side rather than supine Weight loss Reduction in alcohol intake Smoking cessation CPAP Tonsillectomy

Answer 84

If OSA is suspected or mild, advise patients not to drive until symptoms are controlled. If this is not achieved within 3 months, they should inform the DVLA. If OSA is moderate or severe, patients should inform the DVLA immediately and not drive; this will be reviewed by the DVLA and they may be allowed to drive once symptoms are controlled.

Answer 85

Road traffic collisions Accidents at work or home Deterioration in mental health, including irritability and depression CVD and metabolic complications; Stroke Coronary artery disease Hypertension that may be treatment resistant Congestive heart failure Type 2 diabetes

Answer 86

Collection of fluid in the pleural cavity

Answer 87

Examples of transudative causes include: Heart failure Nephrotic syndrome Cirrhosis Hypoalbuminaemia Examples of exudative causes include: Pneumonia (a “parapneumonic effusion”) Malignancy Tuberculosis Pulmonary embolism Rheumatoid arthritis Systemic lupus erythematosus Pancreatitis Trauma

Answer 88

Transudates are classified as pleural fluid with a protein level less than 25g/L (assuming a normal serum protein). Exudates are classified as pleural fluid with a protein level more than 35g/L. For intermediate effusions, Light’s criteria are used - if any of the following are true then the effusion is an exudate: The ratio of pleural to serum protein is greater than 0.5 The ratio of pleural to serum LDH is greater than 0.6 The pleural fluid LDH is greater than ⅔ of the upper limit of normal serum value

Answer 89

Symptoms; Shortness of breath Reduced exercise tolerance Dry cough Pleuritic chest pain Signs; Reduced chest expansion on the affected side Dullness to percussion over the effusion Reduced or absent breath sounds over the effusion Loss of vocal resonance over the effusion Large pleural effusions may cause tracheal deviation away from the effusion Respiratory distress (e.g. accessory muscle usage)

Answer 90

Haemothorax Chylothorax Empyema Mesothelioma

Answer 91

Pleural tap FBC, CRP, U+E, LFT, clotting, ANA, amylase CXR Pleural biopsy Echo Fibroscan

Answer 92

Supportive management, O2 Antibiotics if infectious cause Diuretics USS guided aspiration Pleural drain Pleurodesis can be chemical (where an irritant is injected into the pleural space, sealing it shut via a fibrotic reaction) or surgical via thoracotomy or thoracoscopy

Answer 93

Infection caused by the fungus Pneumocystis Jirovecii. Usually affects patients who are immunocompromised, for example patients with late-stage HIV or those on immunosuppressant medications after an organ transplant

Answer 94

Reducing due to improvement in HIV ARVT

Answer 95

PCP is caused by Pneumocystis Jirovecii, a fungus that causes pulmonary infections. Patients at risk of PCP are those who are immunocompromised (it is classed as an opportunistic infection, and an AIDS-defining illness in those with HIV).

Answer 96

HIV with a CD4 count below 200 Steroids or other immunosuppressive medications Previous organ transplant Congenital immunodeficiencies (e.g. hypogammaglobulinaemia) Severe malnutrition Comorbid lung disease Haematological malignancies

Answer 97

Fever Dry cough Exertional breathlessness Chest pain

Answer 98

Bacterial/ viral pneumonia TB PE

Answer 99

Oxygen saturations ABG Sputum sample FBC, CRP, HIV test and CD 4 count CXR CT Bronchoscopy with bronchoalveolar lavage

Answer 100

Supportive treatment with analgesia, oxygen if hypoxic, consider holding immunosuppressant treatment High dose co-trimoxazole Steroid in moderate/ severe disease with PaO2 < 11kPa, either oral prednisolone or IV hydrocortisone

Answer 101

inflammatory condition of the lung parenchyma caused by infection. Alveoli become filled with inflammatory cells and microorganisms, leading to consolidation of the lung tissue. This impairs gas exchange and can lead to hypoxia.

Answer 102

Community-acquired pneumonia has an incidence of 5-10 per 1000 adults in the UK per year. Approximately 22-42% of these cases require admission to hospital. Mortality estimates range from 5 to 14%, with half of these being in people aged over 84 years

Answer 103

Most common; streptococcus pneumonia Haemophilus influenzae Moraxella catarrhalis Atypicals; Mycoplasma pneumoniae, Legionella pneumophila and Chylmydophila psittaci HAP; >48 hours after hospital admission pseudomonas aeruginosa, staphylococcus aureus

Answer 104

Using CURB-65; Confusion Urea > 7mmol/L Respiratory rate > 30 breaths/min Blood pressure < 90 systolic and/or < 60mmHg diastolic 65 years or older 30 day mortality; CURB-65 0 - 0.7% CURB-65 1 - 3.2% CURB-65 2 - 13% CURB-65 3 - 17% CURB-65 4 - 41.5% CURB-65 5 - 57% A CURB-65 score of 0-1 requires home treatment, 2 should consider hospital admission, 3-5 admit to hospital and consider ITU referral.

Answer 105

Fever Malaise Rigors Cough Purulent sputum Pleuritic chest pain Haemoptysis Signs; Tachypnoea Tachycardia Hypotension Cyanosis Pyrexia Dullness to percussion over the consolidated area Increased vocal resonance/ tactile vocal fremitus over the consolidated area Bronchial breathing over the consolidated area Pleural rub may be heard due to inflammation of the adjacent pleura

Answer 106

Bronchiectasis Tuberculosis Lung cancer Bronchitis

Answer 107

Bedside; Sputum MC+S ABG Urinary legionella and pneumococcal antigens Bloods; FBC, CRP, U+E, LFT Mycoplasma serology CXR CT chest

Answer 108

Conservative; Oxygen if low saturations IV fluids if dehydrated Analgesia for myalgia or chest pain Escalate for respiratory support (e.g. continuous positive airway pressure or intubation and ventilation) if patients are severely unwell - consider escalation status and patient wishes Medical; Oral Abx; amoxicillin 500mg TDS for 5 days IV co-amoxiclav and clarithromycin for severe disease Patients with pneumonia should be followed up with a repeat chest X-ray after 6 to 8 weeks to screen for an underlying lung cancer

Answer 109

Parapneumonic effusion Empyema Lung abscess Sepsis

Answer 110

Collection of air in the pleural cavity which may cause collapse of the underlying lung parenchyma

Answer 111

Spontaneous Traumatic Primary; with no underlying lung disease Secondary Tension; defect in the pleura that has led to the pneumothorax creates a one-way valve effect whereby air can enter the pneumothorax but not leave it. - This causes the pneumothorax to progressively expand, putting pressure on the heart and great vessels and causing mediastinal shift

Answer 112

Sudden onset shortness of breath Pleuritic chest pain Dry cough Tachypnoea and increased work of breathing Signs; Unilateral reduced expansion Unilateral hyper-resonance to percussion Reduced or absent breath sounds Reduced vocal resonance or tactile vocal fremitus In tension pneumothorax; Tracheal deviation to the contralateral side Tachycardia Hypotension Distended neck veins

Answer 113

Erect PA chest Xray CT chest ABG

Answer 114

Tension pneumothorax; Decompress using large bore cannula in 2nd intercostal space in mid clavicular line If fails then open thoracotomy Chest drain after emergency decompression Pleural vent Review in 2-4 weeks Smoking cessation Advise patients not to fly until 7 days after chest imaging has confirmed resolution of the pneumothorax Advise patients they should not take part in underwater diving for life

Answer 115

One or more blood clots lodge in and obstruct the pulmonary arterial vasculature

Answer 116

Triad; Sudden-onset shortness of breath (the commonest symptom, present in around half of patients) Pleuritic chest pain Haemoptysis Cough Syncope Signs; Tachypnoea Crackles on auscultation Tachycardia Hypoxia Low-grade pyrexia in some In massive PE: - Hypotension - Cyanosis - Signs of right heart strain (e.g. a raised JVP, parasternal heave and loud P2)

Answer 117

Normal mean pulmonary arterial pressure is 11-20mmHg. Pulmonary hypertension is characterised by an increase in this to above 25mmHg at rest. There are a variety of causes, all of which involve an increase in pulmonary vascular resistance which ultimately leads to right heart failure due to increased backpressure on the right ventricle.

Answer 118

Pulmonary arterial hypertension - may be idiopathic, familial, associated with other diseases (e.g. HIV, connective tissue disorders or portal hypertension) or secondary to drugs or toxins (e.g. amphetamines, fenfluramine) Chronic pulmonary disease e.g. COPD, interstitial lung disease, bronchiectasis and obstructive sleep apnoea Chronic thromboembolic disease e.g. persistent or recurrent pulmonary emboli Chronic hypoventilation e.g. kyphosis or scoliosis, neuromuscular disorders Left heart disease e.g. chronic left heart failure or mitral stenosis Unclear or multifactorial mechanisms e.g. sarcoidosis, myelofibrosis, glycogen storage diseases

Answer 119

Group 1: pulmonary arterial hypertension Group 2: secondary to left heart diseases Group 3: secondary to chronic pulmonary diseases and/or hypoxia Group 4: due to chronic thrombotic or embolic disease Group 5: other causes including metabolic disorders, systemic disorders and haematological disease

Answer 120

Progressive shortness of breath Fatigue Syncope Fluid overload with ascites and peripheral oedema (late sign) Raised JVP Parasternal heave Loud P2 Presence of an S3 sound Pansystolic murmur indicative of tricuspid regurgitation (occurs due to the right ventricle becoming pressure and volume overloaded) End-diastolic murmur indicative of pulmonary regurgitation (due to high pulmonary pressures)

Answer 121

COPD Congestive heart failure Interstitial lung disease Mitral stenosis

Answer 122

ECG LFT, TFT, Autoimmune screen CXR High resolution CT CT/ MRI pulmonary angiography TTE Right heart catheterisation

Answer 123

Conservative; As with any chronic disease, patient counselling and education Early involvement of palliative care especially in deteriorating patients or those with troubling symptoms In women of childbearing age with pulmonary arterial hypertension, counselling regarding the risks of pregnancy and provide contraceptive advice Medical; Diuretics for fluid overload Medications that reduce pulmonary vascular resistance: Calcium channel blockers e.g. nifedipine PDE-5 inhibitors e.g. sildenafil Prostacyclin analogues e.g. iloprost Endothelin receptor antagonists e.g. bosentan, ambrisentan Soluble guanylate cyclase stimulators e.g. riociguat Surgical; Thrombo-arterectomy or pulmonary balloon angioplasty may be considered for chronic thromboembolic disease Atrial septostomy is a palliative treatment where a hole is made between the atria to reduce right sided pressures A heart-lung transplant may be considered in severe cases

Answer 124

Right heart failure Exertional syncope Alveolar haemorrhage Pulmonary artery dissection Pericardial effusions High risk of death during pregnancy

Answer 125

If right heart function is preserved at diagnosis, mean survival is approximately 3 years If right heart failure is present or pulmonary hypertension is severe, this decreases to 1 year The best prognosis is seen with pulmonary hypertension secondary to chronic thromboembolic disease, especially if this is amenable to surgical treatment to reduce clot burden

Answer 126

pathophysiological state characterised by a decrease in the partial pressure of carbon dioxide in the arterial blood (PaCO2), leading to a high blood pH. Normal PaCO2 is around 4-6kPa, and normal pH 7.35-7.45.

Answer 127

Pulmonary oedema Pneumonia Pulmonary embolism Pneumothorax Acute respiratory distress syndrome Anxiety/ panic attack Salicylate poisoning Meningitis/encephalitis Space occupying lesion Traumatic brain injury Hyperthermia Iatrogenic ventillation

Answer 128

Light-headedness Confusion Loss of consciousness Seizures Signs; Tachypnoea (the driver of the respiratory alkalosis) Hyperreflexia Tetany Decreased level of consciousness or confusion

Answer 129

High pH PaCO2; low HCO3- low/ normal

Answer 130

Type 1 respiratory failure (T1RF) is defined as hypoxaemia (PaO2<8kPa) with low or normal levels of carbon dioxide in the arterial blood

Answer 131

Type 2 respiratory failure (T2RF) is defined as hypoxaemia (PaO2<8kPa) with hypercapnia (PaCO2>6.5kPa)

Answer 132

Symptoms include: Dyspnoea Headache Light-headedness Confusion Drowsiness Agitation Symptoms related to underlying cause e.g. productive cough and fever in pneumonia Signs include: Tachypnoea (although respiratory rate may be low in some cases of T2RF e.g. opiate overdose) Cyanosis Accessory muscle usage Nasal flaring Signs of central nervous system dysfunction e.g. reduced GCS, irritability Signs related to underlying cause e.g. wheeze in a COPD exacerbation Signs related to hypercapnia (i.e. T2RF only): Flushed skin Bounding peripheral pulses Asterixis Tachycardia or arrhythmia Drowsiness

Answer 133

Important complications include: A decline in lung function after recovery from the acute illness Hypoxic ischaemic injury to other organs (e.g. the brain) Cor pulmonale Polycythaemia Death Other complications are associated with CPAP or NIV: Mask leak Pressure sores from tight-fitting masks Hypotension Aspiration (due to gastric inflation) Pneumothorax Epistaxis Complications of invasive ventilation include: Dental injury during intubation Barotrauma (pressure-induced trauma to the lungs) Ventilator-associated pneumonia Tracheomalacia Complications of immobility (e.g. venous thromboembolism, pressure ulcers)

Answer 134

Multi-system disease that is characterised by the formation of non-caseating granulomas around the body. This leads to inflammation and scarring in the organs affected, most commonly the lungs and skin. Other organs affected include the nerves, the brain, the heart, the liver and the eyes.

Answer 135

4,500 new diagnoses of sarcoidosis each year prevalence around 1 in 10,000 people highest rates seen in Northern Europe (e.g. Sweden, Finland and Denmark) Peak onset is in adults aged between 30 and 55 years old

Answer 136

Pulmonary manifestations Dry cough Dyspnoea Reduced exercise tolerance Chest pain Clubbing (rare, only if severe fibrosis) Fine crackles on auscultation Dermatological manifestations Erythema nodosum (inflammation of subcutaneous fat leading to tender nodules especially on the shins) Lupus pernio (red/purple plaques and nodules on the face) Hyper or hypopigmentation of the skin Neurological manifestations Meningitis Peripheral neuropathy Facial nerve palsy (may be bilateral) Headache Seizures/encephalopathy Ocular manifestations Uveitis Keratoconjunctivitis sicca Glaucoma Cardiac manifestations Arrhythmias Restrictive cardiomyopathy Syncope Abdominal manifestations Hepatomegaly Splenomegaly Renal stones Systemic manifestations Fatigue Weight loss Arthralgia Low-grade fevers Lymphadenopathy Enlarged parotid glands Lofgren's syndrome refers to the acute onset of: Fever Polyarthralgia Erythema nodosum Bilateral hilar lymphadenopathy (seen on chest X-ray) Heerfordt's syndrome refers to the combination of: Fever Uveitis Parotid swelling Facial nerve palsy

Answer 137

ECG Mantoux test Lung function test Ophthalmological examination FBC, LFT, U+E, bone profile, ESR, serum ACE Chest X-ray can be used to stage sarcoidosis as below: Stage 1 - Bilateral hilar lymphadenopathy (BHL) Stage 2 - BHL with peripheral infiltrates Stage 3 - Peripheral infiltrates alone Stage 4 - Pulmonary fibrosis High resolution CT chest PPET scan Echocardiogram Biopsy Bronchoalveolar lavage

Answer 138

Conservative; Patient education and support Smoking cessation No active treatment is needed in many cases of sarcoidosis Medical; Steroids e.g. oral prednisolone with a higher dose at induction which is then reduced to a lower maintenance dose Second line immunosuppressants (e.g. if steroids contraindicated or not effective) include methotrexate, mycophenolate or azathioprine Third line treatment is usually with biologics (e.g. infliximab) Surgical; Rarely in severe cases of pulmonary sarcoidosis a lung transplant may be considered In cases of pulmonary sarcoidosis complicated by aspergilloma, surgical management of haemoptysis is sometimes required

Answer 139

Pulmonary fibrosis (stage IV pulmonary sarcoidosis) Cor pulmonale Pulmonary hypertension Aspergillomas can form in cavities left by granulomatous pulmonary disease Arrhythmias and sudden death in cardiac sarcoidosis Low mood and anxiety Complications of long-term steroid use (e.g. osteoporosis, hyperglycaemia)

Answer 140

Cancer - smoking is the commonest cause of lung cancer, and contributes to the development of many other tumour types COPD Cardiovascular disease - including stroke, ischaemic heart disease and peripheral vascular disease Peptic ulcers Pregnancy complications (e.g. stillbirth, birth defects, low birth weight) Infertility Osteoporosis Dementia Dental disease

Answer 141

Mood changes (irritability, frustration, anger, anxiety, depression) Insomnia Poor concentration Increased appetite and weight gain Restlessness Cravings for cigarettes

Answer 142

inhibiting reuptake of dopamine and noradrenaline Tablet taken once a day for 6 days then twice a day for 7-9 weeks Should be started 7-14 days before the quit date

Answer 143

Epilepsy (decreases seizure threshold) Eating disorders Bipolar disorder Brain tumours Current benzodiazepine or alcohol withdrawal Pregnancy and breast-feeding

Answer 144

insomnia, hypersensitivity reactions and rarely seizures

Answer 145

partial nicotinic receptor agonist Start 7-14 days before the quit date, usually continued for 12 weeks

Answer 146

pregnancy and end-stage renal disease

Answer 147

Idiopathic pulmonary fibrosis Sarcoidosis Asbestosis Non-pulmonary causes include: Neuromuscular disorders such as motor neuron disease or myasthenia gravis Obesity Skeletal abnormalities e.g. kyphoscoliosis

Answer 148

Asthma COPD Bronchiectasis Cystic Fibrosis Extrathoracic causes include: Tracheal stenosis Malignancy obstructing the upper airways Foreign body

Answer 149

Any condition that reduces the lungs' ability to expand may lead to a restrictive defect on spirometry Both FEV1 and FVC are reduced (<80% of the predicted normal values), but the FEV1/FVC ratio is normal (>0.7)

Answer 150

Any narrowing or obstruction of the airways can cause an obstructive defect on spirometry FEV1 is reduced (<80% of the predicted normal value) and the FEV1/FVC ratio is also reduced (<0.7) FVC may be normal or reduced to a lesser extent than FEV1

Answer 151

Infection with the Mycobacterium tuberculosis bacterium

Answer 152

HIV Immunosuppression Close contact with infected individuals Being from a high-risk country - countries with high rates of TB include India, Pakistan, Romania, Somalia and Eritrea Homelessness Malnutrition Child Elderly

Answer 153

A quarter of the global population has been infected with TB Around 5-10% of these will develop active TB Worldwide, TB is the second commonest cause of death from infection (after COVID-19) More than 80% of TB deaths occur in low and middle-income countries In the UK there were 4411 cases of TB in 2021 The majority of cases are in people born outside the UK The highest rates are concentrated in urban areas (36% in London in 2021) Significant progress has been made in reducing the incidence of TB in the UK, with cases more than halving between 2011 and 2021

Answer 154

Systemic: Night sweats Fevers Weight loss Malaise Lymphadenopathy lymph nodes are typically enlarged and non-tender may form sinus tracts if chronic cervical and supraclavicular nodes are most commonly affected Respiratory: Chronic productive cough Haemoptysis Shortness of breath Collapse or pleural effusion leading to dullness on percussion and reduced breath sounds over the affected area Neurological: Meningitis causing headaches and meningism Focal neurological signs (classically cranial nerve lesions due to involvement of the basal meninges) Decreased consciousness Genitourinary: Renal TB may present with haematuria and flank pain Epididymo-orchitis may present with pain and swelling Salpingitis (TB of the fallopian tube) may cause pain and vaginal bleeding Musculoskeletal: Pott's syndrome (spinal TB) causes back pain, spinal deformities and neurological deficits Arthritis causes joint pain and swelling Osteomyelitis may lead to a painful 'cold abscess' with localised swelling and erythema, sometimes wiht a draining abscess Psoas abscesses may present with a classic triad of fever, limp and back pain Gastrointestinal: Ileocaecal TB can cause bowel obstruction with abdominal pain and constipation Ascites may result from perotineal TB Intestinal TB may mimic IBD with abdominal pain and bloody diarrhoea Pericardial: Pericardial effusions may cause a raised JVP and pulsus parodoxus Constrictive pericarditis also causes a raised JVP and may present with signs of right-sided heart failure such as peripheral oedema and hepatic congestion Cutaneous: Erythema nodosum (tender nodules, usually on the shins) Lupus vulgaris refers to painful nodular skin lesions caused by TB, usually around the face Miliary TB may spread to the skin causing a widespread rash Scrolfuloderma is direct invasion of the skin from a TB-infected lymph node or bone, forming ulcerating and fistulating tracts from subcutaneous nodules usually around the neck area Adrenal: TB is the leading cause of adrenal insufficiency worldwide Symptoms include fatigue, lightheadedness, nausea and abdominal pain Signs include hypotension and skin hyperpigmentation

Answer 155

Malignancy Sarcoidosis Lymphoma

Answer 156

Mantoux test Sputum MC+S Ziehl- Neelsen microscopy FBC, CRP, U+E, mycobacterial MCS, HIV testing CXR; Cavitation Pleural effusion Mediastinal or hilar lymphadenopathy Parenchymal infiltrates, especially in the upper lobes Miliary TB (tiny nodules throughout the lung fields) Joint or spinal X-rays if suspected skeletal involvement CT head for suspected CNS TB Ultrasound of lymphadenopathy, the genitourinary system or the abdomen Echocardiogram for suspected pericardial disease Biopsy or needle aspiration

Answer 157

Latent TB; Three months of isoniazid, pyridoxine and rifampicin OR Six months of isoniazid and pyridoxine ACTIVE; Medical treatment includes: The standard regimen for active pulmonary TB, which is 2 months of isoniazid (with pyradoxine), rifampicin, ethambutol and pyrazinamide, followed by isoniazid (with pyradoxine) and rifampicin alone for a further 4 months Longer courses of antibiotics in TB meningitis, pericardial and spinal TB Steroids may be added in the initial weeks of antibiotic treatment for CNS and pericardial TB Multidrug-resistant TB often requires 18-24 months of treatment with at least six drugs These second-line antibiotics include amikacin, macrolides, quinolones and capreomycin Surgical treatment involves: In selected cases of multidrug or extensively drug-resistant TB a lung resection may be considered This is either unilateral or of both lung apices Patients need adequate lung function to be eligible Some types of extra-pulmonary TB may warrant surgical treatment e.g. drainage of renal abscesses

Answer 158

Bronchiectasis Antibiotic resistance Transmission of TB Psychosocial distress Aspergilloma Pulmonary fibrosis Death

Answer 159

With treatment, 90% of patients worldwide with TB are cured Untreated TB has around 70% mortality at 10 years for smear-positive cases, verus 20% for smear-negative cases Poor prognostic factors include older age, HIV co-infection and more extensive disease Multidrug and extensively drug-resistant TB also confer a poorer prognosis, with only 48% of patients cured with treatment

Answer 160

Red/orange discolouration of bodily fluids CYP450 induction (i.e. reduces effectiveness of other medications such as the combined oral contraceptive pill) Hepatotoxicity

Answer 161

Peripheral neuropathy (prevented by co-administration of pyridoxine) Hepatotoxicity CYP450 inhibition

Answer 162

Arthralgia Hyperuricaemia (may cause gout) Hepatotoxicity

Answer 163

Retrobulbar neuritis

Answer 164

Coronaviruses Adenoviruses Enteroviruses Respiratory syncytial virus Metapneumovirus Influenza viruses

Answer 165

Coryza (which may manifest as rhinorrhoea, nasal congestion and loss of smell) Sneezing Cough Sore throat (may be erythematous on examination) Low-grade fever Malaise Headache Hoarse voice Conjunctival injection

Answer 166

Allergic rhinitis Influenza Whooping cough Infectious mononucleosis Nasal foreign body

Answer 167

Adequate fluid intake Rest Vapour rubs (e.g. Vicks) Inhaling steam or using nasal saline drops to help with nasal congestion Lozenges or analgesic sprays for sore throat Simple analgesia (paracetamol/ibuprofen) for fevers or pain Intranasal congestants should be used in the short term only as these can cause rebound symptoms if used chronically Prevent spread with good hand-hygeine, avoid sharing towels etc. Safety net people to seek medical advice if symptoms continue to worsen or are not improving beyond 10 days

Answer 168

Acute otitis media Sinusitis COPD exacerbation Pneumonia

Respiratory Flashcards

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