Medicine Finals > Respiratory > Flashcards

Respiratory Flashcards

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1
Q

Where are B1 adrenergic receptors?

A

the heart

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2
Q

What beta receptors are in the brochi?

A

B2

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3
Q

What receptors does the parasympathetic NS work on to cause bronchoconstriction?

A

muscarinic (M3) cholinergic receptors

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4
Q

Name the 2 types of acetylcholine receptors

A

Nicotinic
Muscarinic

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5
Q

What class of medications is Salbutamol?

A

SABA (short acting beta 2 agonist)

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6
Q

Name a LABA

A

Salmeterol

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7
Q

Name an ICS

A

Beclametasone

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8
Q

Name a LAMA (Long acting muscarinic antagonist)

A

Tiotropium

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9
Q

How does Tiotropium work?

A

Blocks ACh receptors. These are stimulated by the PNS and caise contraction of the bronchial smooth muscles. This dilates the bronchioles and reverses bronchoconstriction.

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10
Q

What are leukotrines?

A

They are produced by the immune system and cause inflammation, bronchoconstriction and mucus secretion in te airways.

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11
Q

What does AIR therapy include?

A

AIR = Anti-inflammatory reliever therapy

A dry powder inhaler containing an ICS (e.g. budesonide), plus a fast and long acting beta agonist (e.g. fomoterol)

Patients use as a reliever, but get a dose of ICS at same time

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12
Q

What is MART therapy?

A

MART = Maintenance and reliever therapy

A dry powder inhaler containing an ICS (e.g. budesonide), plus a fast and long acting beta agonist (e.g. fomoterol)

Used as a preventer and reliever

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13
Q

What is first line for management of asthma in those over 12?

A
  • AIR therapy (low-dose ICS / Formoterol combination inhaler)
  • Low dose MART
  • Moderate dose MART
  • Specialist referal if FeNO or eosinophils are raised at this stage
  • Add a LTRA or LAMA (8-12 week trial and switch if not helping)
  • Specialist referral
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14
Q

What does LTRA stand for? Give an example of one

A
  • Leukotrine receptor antagonist
  • Montelukast
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15
Q

Name some additional asthma management

A
  • Individual written asthma self-management plan
  • Yearly flu jab
  • Yearly asthma review when stable
  • Regular exercise
  • Avoid smoking (including passive smoke)
  • Avoiding triggers where appropriate
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16
Q

What would an asthma exacerbation be on ABG? (initial presentation)

Explain why

A

respiratory alkalosis

raised resp rate causes a drop in CO2

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17
Q

When would you be very worried reviewing someone’s ABG in an asthma exacerbation?

A

respiritory acidosis
normal or low pO2 (hypoxia), means they’re tiring, indicating life-threatening asthma

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18
Q

Life threatening exacerbation features:

A
  • Peak flow <33%
  • pO2 <92%
  • PaO2 <8kPa
  • Becoming tired
  • Confusion or agitation
  • No wheeze or silent chest
  • Haemodynamically unstable (shock)
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19
Q

Severe exacerbation features:

A
  • Peak flow 33-50%
  • RR above 25
  • Heart rate above 110
  • Unable to complete full sentences
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20
Q

How may you treat someone having a moderate (asthma) exacerbation?

A

Consider hospital admission
Beta-2 agonists (e.g., salbutamol) via a spacer or nebulised
Steroids (e.g., oral prednisolone 40-50mg or IV hydrocortisone)
Max dose MART or quadrupled ICS dose (up to 7 days)
Antibiotics only if there is convincing evidence of bacterial infection
Follow-up within 48 hours (if not admitted)

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21
Q

How would you manage a severe (asthma) exacerbation?

A
  • Hospital admission
  • O2 to maintain sats at 94-98%
  • Nebulised ipatropium bromide
  • IV magnesium sulphate
  • IV salbutamol
  • IV aminophylline
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22
Q

What electrolytes should be monitored when giving someone Salbutamol treatment?

A

Serum potassium
Salbutamol can cause cells to absorb K+ from the blood, so lowers serum K+, putting patients in hypokalaemia

Lactic acidosis
Can result from fast HR from salbutamol

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23
Q

Causes of lower zone fibrosis (acronym)

A

ACID

Asbestos
Connective tissue diseases
Idiopathic pulmonary fibrosis
Drugs (e.g. methotrexate, nitrofurantoin)

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24
Q

What does asbestos exposure lead to?

A
  • Pleural plaques
  • Asbestosis
  • Mesothelioma
  • Lung cancer
  • Lower zone fibrosis
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25
What long term effects can radiotherapy have on the lungs?
Upper zone fibrosis
26
Causes of upper zone fibrosis (acronym)
CHARTS - Coal worker's pneumoconiosis - Histocytosis / hypersensitivity pneumonitis - Ankylosing spondylitis - Radiation - TB - Silicosis / sarcoidosis
27
Name some drugs that can cause drug induced fibrosis (predominantly in the lower zones)
- Amioderone - Bleomycin - Methotrexate - Nitrofurantoin
28
29
When would someone with COPD be considered for long term prophylaxis and what would it be?
Prophylactic antibiotics (oral macrolides like azythromycin) Criteria: - people with COPD who have had more than 3 exacerbations requiring steroid therapy and at least 1 exacerbation requiring hospital admission in the previous year
30
When should someone be referred for long term oxygen therapy? (LTOT)
Patients with resting oxygen sats of <92% should be referred for ABG testing
31
When does someone qualify for LTOT?
Either: - x2 ABG results with pO2 <7.3 kPa - x1 ABG pO2 7.3-8kPa, plus one of: - secondary polycythemia - peripheral oedema - pulmonary hypertension
32
Who should not be offered LTOT?
Patients who smoke - even if in process of quitting
33
How does silicosis present on CXR?
- bilateral diffuse upper lobe reticular shadowing - eggshell calcification of the hilar nodes
34
Clubbing may be present in patients with _________
bronchiectasis
35
Is it okay to continue steroid management for asthma if pregnant?
Yes, it is safe to continue 30mg prednisolone and breastfeed
36
What is the most common type of lung cancer?
Adenocarcinoma
37
Who gets adenocarcinomas?
Anyone; - smokers - non-smokers / passive
38
Where do lesions appear in adenocarcinoma?
Peripherally within the lung
39
What is a mesothlioma?
lung malignancy affecting the mesothelial cells of the pleura
40
Mesothelioma formation is commonly associated with ___________________ (cause)
asbestos inhalation
41
Describe the progression of asbestosis from exposure
There is a substantial latent period between exposure to asbestos and the development of mesothlioma of up to 45 years.
42
How is asbestosis / asbestos mesothlioma managed?
Poor prognosis Chemotherapy can improve survival but it is essentially palliative
43
List some extra pulmonary manifestations of lung cancers
- Recurrent laryngeal nerve palsy - Phrenic nerve palsy - Superior vena cava obstruction - Horner's syndrome - SIADH - Cushing's syndrome - Hypercalcaemia - Limbic encephalitis - Lambert-Eaton myasthenic syndrome
44
What is Pemberton's sign?
Where raising the hands over the head causes facial congetsion and cyanosis - SVC obstruction (medical emergency)
45
What is pulmonary hypertension?
high blood pressure in the pulmonary circulation
46
What causes pulmonary hypertension?
- vasoconstriction of the pulmonary artery - left heart failure, backflow of blood - chronic lung diseases, hypoxia, pulmonary vasoconstriction - chronic PE, occluded pulmonary artery
47
What does MAP stand for?
mean arterial pressure
48
A MAP value of ___mmHg or higher, indicates pulmonary hypertension?
20mmHg
49
Pulmonary htn puts excessive pressure on the _______ side of the heart
right (ventricle specifically, pushing against high pulmondary artery pressures)
50
What can cause a high central venous pressure in pulmonary hypertension?
pulmonary htn, strain in right ventricles pushing blood into constricted pulmondary arteries, fatigued RV, blood backflows into vena cava
51
Signs of right heart faliure
- High JVP - Hepatomegaly (blood backs up into liver) --> liver cirrhosis / failure - Ascites - Peripheral oedema in legs - Exhertional dyspnoea - Syncope
52
Diagnosis of pulmonary hypertension
- ECG = right heart strain - CXR = dilated pulm arteries, RV hypertrophy - NT-proBNP (raised = RHF) - ECHO (estimate pressures and assess right heart failure) - Right heart catheterisation (inflate balloon and get MAP)
53
ECG findings in right sided heart strain
- P pulmonale (peaked p waves) - RV hypertrophy (tall R waves in V1 and V2, deep S waves in V5 and V6) - Right axis deviation - Right BBB
54
Prognosis of pulmonary htn if left untreated
2-3 years
55
Management of pulmonary hypertension
- Calcium channel blockers - IV prostoglandins (e.g. epoprestonol) - Endothelin receptor antagonists (e.g. macitentan) - Phosphodiesterase-5-inhibitors (e.g. sildenefal) (secondary pulm htn --> treat underlying cause; COPD, SLE...)
56
Name some supportive treatments given to thise with pulmonary hypertension
- Oxygen - Diuretics (used for complications such as respiratory failure, oedema and arrhythmias)
57
What is sarcoidosis?
a chronic granulomatous disorder (systemic but usually has resp involvement)
58
What are granulomas?
Granulomas are inflammatory nodules full of macrophages
59
Who gets sarcoidosis?
- aged 20-39 - aged 60 - women - black ethnic origin
60
What are the skin features of sarcoidosis?
Erythema nodosum (inflammed subcut fat of the shins) Presents as raised red, tender, apinful nodules on both shins, overtime they may appear more like bruises
61
What is the name for inflammation of fat?
Panniculitis
62
What is lupus pernio?
raised purple skin lesions, often on the cheeks and nose that can be present in sarcoidosis
63
Respiratory features of sarcoidosis
- mediastinal lymphadenopathy - pulmonary fibrosis - pulmonary nodules --> granulomas
64
Liver presentation of sarcoidosis
- liver nodules - cirrhosis - cholestasis
65
Opthalmic presentation of sarcoidosis
- uveitis - conjunctivitis - optic neuritis
66
Cardiac features of sarcoidosis
- BBB - heart block - myocardial muscle involvement
67
Kidney involvement of sarcoidosis
- kidney stones (due to hypercalcaemia) - nephrocalcinosis - interstitial nephritis
68
CNS involvement of sarcoidosis
- nodules - pituitary involvement (diabetes insipidue) - encephalopathy
69
PNS involvement of sarcoidosis
- facial nerve paly - mononeuritis multiplex
70
Bone involvement of sarcoidosis
- arthralgia - arthritis - myopathy
71
What is Lofgren's syndrome?
Lofgren’s syndrome refers to a specific presentation of sarcoidosis with a classic triad of symptoms: - Erythema nodosum - Bilateral hilar lymphadenopathy - Polyarthralgia (joint pain in multiple joints)
72
What bloods would you request to confirm a dx of sarcoidosis?
- ACE - Calcium (both raised)
73
What findings could be found on different imaging investigations of a patient with sarcoidosis?
- Hilar lymphadenopathy - High-resolution CT scanning may show hilar lymphadenopathy and pulmonary nodules - MRI can show central nervous system involvement - PET scan can show active inflammation in affected areas
74
Histological findings in sarcoidosis
"Non-caseating granulomas with epithelioid cells" often uses a biopsy from US guided bronchoscopy of mediastinal lymph nodes
75
Management of sarcoidosis
- Conservative management - Oral steroids (+ bone protection if used long term) - Methotrexate - Lung transplant in severe pulmonary disease
76
Define pneumonia
an infection of the lung tissue, causing inflammtion in the alveolar space
77
Pneumonia on CXR
Lower lobe consolidation
78
What type of organism typically causes upper respiratory infections?
viruses
79
What are the 4 types of pneumonia?
- CAP (community aquired) - HAP (hospital aquired) - VAP (ventilator aquired - intubated patients in ITU) - Aspiration (infection from aspiration)
80
Aspiration pneumonia is associated with _________ bacteria
anaerobic
81
Presenting symptoms of pneumonia
- Cough - Sputum production - SOB - Fever - Generally unwell - Haemoptysis - Pleuritic chest pain - Delerium
82
Characteristic signs of pneumonia
- Bronchial breath sounds - Focal coarse crackles - Dullness to percussion
83
Severity assessment for pneumonia
CURB-65: - Confusion (new) - Urea (>7mmol/L) - RR (>30) - BP (<90 diastolic or <60 diastolic) - 65+ (age)
84
CURB-65 score interpretation
0-1 low risk = consider at home treatment >2 intermediate risk = consider hospital admisssion >3 high risk = consider intensive care
85
Most common pathogens causing pneumonia
- Strep pneumoniae - Haemophillus influenzae - Staph aureus (in CF patients) - MRSA in hospital aquired
86
Types of pneumonia and their respective pathogens
CAP = S.pneumoniae HAP = Pseudomonas aeruginosa
87
How long does someone have had to have been admitted to hospital for their pneumomia to count as HAP?
>48 hours
88
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