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Respiratory Flashcards

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1
Q

What are the causes of Asthma? (3)

A

Caused by a Reversible airway obstruction
Cause unknown exactly- combination of:
Environmental factors
Genetic factors

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2
Q

What 3 factors contribute to airway narrowing in Asthma? (3)

A

Bronchial muscle contraction (triggered by variety of stimuli)
Mucosal swelling/inflammation (caused by mast cell and basophil degranulation resulting in the release of inflammatory mediators)
Increased mucus production

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3
Q

What are the risk factors for Asthma? (7)

A 
Gender (male more likely than female)
Family History 
Atopic allergies (eczema/hayfever)
Smoking 
Obesity 
Viral respiratory infections in infancy and childhood
Air pollution
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4
Q

What are the symptoms of Asthma? (4)

A

Intermittent dyspnoea
Wheeze
Cough (often nocturnal)
Sputum

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5
Q

What are the signs of Asthma on examination? (6)

A 
Tachypnoea
Audible wheeze
Hyperinflated chest
Hyper resonant percussion note
Decreased air entry
Polyphonic wheeze
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6
Q

What are the possible differential diagnoses of Asthma? (4)

A

COPD
Pulmonary oedema
Large airway obstruction
Superior Vena Cava obstruction

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7
Q

What investigations could be done to diagnose Asthma? (4)

A

Peak expiratory flow
Sputum culture
Blood tests (FBC, U&Es, CRP, cultures)
ABG (showing normal/slightly low PaO2 and low PaCO2 due to hyperventilation)

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8
Q

What drugs can be used to treat Asthma?

A
  • B2-adrenoreceptor agonists (relax bronchial smooth muscle by increasing cAMP, act in minutes, eg Salbutamol)
  • Corticosteroids (⬇️ bronchial mucosal inflammation, act over days, eg beclometasone)
  • Aminophylline (inhibits phosphodiesterase, thus ⬇️ bronchoconstriction by ⬆️ cAMP)
  • Anticholinergics (⬇️ muscle spasm synergistically with B2 agonists, eg ipratropium)
  • Leukotriene receptor antagonists (block the effects of cysteinyl leukotrienes in the airways by antagonising the CystLT1 receptor, eg montelukast)
  • Anti-IgE monoclonal antibody (used in persistent allergic asthma, eg omalizumab)
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9
Q

How common is COPD?

A

Affects 10-20% of >40s

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10
Q

What is COPD?

A

COPD is a common progressive disorder characterised by airway obstruction with little or no reversibility.

It includes chronic bronchitis and emphysema.

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11
Q

What is a “pink puffer” and a “blue bloater”?

A

PINK PUFFER: have increased alveolar ventilation, normal PaO2 and low/normal PaCO2. They are breathless but not cyanosed. They may progress to T1 Respiratory failure.

BLUE BLOATER: have decreased alveolar ventilation, low PaO2 and high PaCO2. They are cyanosed but not breathless. They may go on to develop cor pulmonale. Their respiratory centres are relatively insensitive to CO2. They rely on hypoxic drive to maintain respiratory effort. (Therefore O2 given with care).

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12
Q

What causes COPD?

A

Smoking

The lining of the lungs becoming inflamed which can lead to scarring. This can be caused by smoking and exposure to smoke and air pollution.

Alpha-1 antitrypsin deficiency can cause COPD as if there is a deficiency in A1AT then elastase breaks down elastin and in the lungs this leads to the destruction of alveolar walls and emphysematous change. Smoking can accelerate this very quickly.

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13
Q

What are the risk factors for COPD?

A

Smoking
Air pollution
Occupation (dusts, chemicals, vapours, irritants, fuels)
Frequent LRTIs in childhood

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14
Q

What are the symptoms of COPD? (4)

A

Cough
Sputum
Dyspnoea
Wheeze

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15
Q

What are the signs of COPD on examination? (10)

A

Tachypnoea
Use of accessory muscles during respiration
Hyperinflation
Decreased cricosternal distance (

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16
Q

What are the possible differential diagnoses of COPD? (6)

A 
Asthma
Bronchiectasis
CCF
Lung cancer
Obliterative bronchiolitis
Bronchopulmonary dysplasia
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17
Q

What investigations are necessary to diagnose COPD? (2)

A

Spirometry

  • Mild (stage 1) COPD is FEV1 at least 80% of predicted value
  • Moderate (stage 2) COPD is FEV1 between 50% and 79% of predicted value
  • Severe (stage 3) COPD is FEV1 between 30% and 49% of predicted value
  • Very severe (stage 4) COPD is FEV1 of less than 30% of predicted value

Chest X-Ray (necessary to exclude other diagnoses)

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18
Q

What are the possible treatments of COPD?

A

General

  • smoking cessation
  • encourage exercise
  • diet (treat poor nutrition or obesity)
  • influenza & pneumococcal vaccinatio
  • pulmonary rehabilitation
  • PRN short acting antimuscarinics (ipratropium) or B2 agonist (salmeterol)

Mild/moderate
- inhaled long-acting antimuscarinic (tiotropium) or B2 agonist

Severe
- Combination long-acting B2 agonist & corticosteroids

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19
Q

How common is Bronchial Carcinoma?

A

Approximately 95% of all primary lung tumours are bronchial carcinomas
Bronchial carcinomas account for approximately 19% of all cancers

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20
Q

Who does Bronchial carcinoma affect?

A

Mostly affects smokers

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21
Q

What are the risk factors for Bronchial Carcinoma? (6)

A

Smoking
Increased age
COPD
Past history of head and neck cancer
Industrial dust diseases, asbestos, chromium, arsenic, iron oxide, radiation
Epidermal growth factor receptor tyrosine kinase (EGFR-TK) mutation

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22
Q

What are the symptoms of Bronchial Carcinoma? (8)

A 
Cough
Haemoptysis
Dyspnoea
Chest pain
Recurrent/slowly resolving pneumonia
Lethargy
Anorexia
Weight loss
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23
Q

What are the signs of Bronchial Carcinoma on examination? (3)

A 
General signs:
Cachexia
Anaemia
Clubbing
Hypertrophic pulmonary osteoarthropathy (HPOA) 
Supraclavicular or axillary nodes

Chest signs: 
None
Consolidation
Collapse
Pleural effusion

Metastases:
Bone tenderness
Hepatomegaly
Confusion
Fits
Focal CNS signs
Cerebellar syndrome
Proximal myopathy
Peripheral neuropathy
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24
Q

What are the possible differential diagnoses of Bronchial Carcinoma? (10)

A 
Secondary malignancy
Arteriovenous malformation
Pulmonary hamartoma
Bronchial adenoma
Abscesses
Granuloma
Encysted effusion 
Cyst
Foreign body
Skin tumour
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25
What investigations are necessary to diagnose Bronchial carcinoma? (5)
``` Cytology - sputum and pleural fluid Chest X-Ray: - peripheral nodule - hilar enlargement - consolidation - lung collapse - pleural effusion - bony secondaries ``` Bronchoscopy CT - to stage the tumour PET scan
26
What are the treatments for Bronchial Carcinoma? (4)
Non-small cell: - Excision - Curative radiotherapy - Chemotherapy +/- radiotherapy Small cell - almost always disseminated at presentation - may respond to chemo but will invariably relapse - palliative radiotherapy - analgesic drugs
27
What are the types of pneumothorax? (3)
Primary spontaneous pneumothorax - pneumothorax occurring in healthy people Secondary spontaneous pneumothorax - associated with underlying lung disease, worse consequences Tension pneumothorax - MEDICAL EMERGENCY!!
28
How common is a pneumothorax?
PSP - 24/100,000/year in males | - 9.9/100,000/year in females
29
Who does pneumothorax affect?
``` Young, tall, thin, males People with other lung diseases - Asthma - COPD - Cystic Fibrosis - Tuberculosis - Whooping cough ``` PSP occurs most often in the 20s and rarely over age of 40 SSP typically occurs between 60-65
30
What causes a pneumothorax?
Spontaneous due to rupture of sub-pleural bulla Lung diseases: - asthma - COPD - TB - pneumonia - CF - lung fibrosis - sarcoidosis Connective tissue disorders Trauma Iatrogenic
31
What are the risk factors for pneumothorax?
Tall, young, thin males Smoking Family history of pneumothorax Underlying lung conditions
32
What are the symptoms of a pneumothorax? (4)
Sudden onset dyspnoea Pleuritic chest pain Pts with asthma/COPD may present with sudden deterioration May be asymptomatic
33
What are the signs of a pneumothorax on examination? (4)
Reduce chest expansion unilaterally Hyper-resonance on percussion Reduced breath sounds unilaterally Deviated trachea
34
What are the possible differential diagnoses of a pneumothorax? (3)
Pleural effusion- tends to be slower onset and there is dullness on percussion Chest pain: a pleuritic pain may give sensation of breathlessness Pulmonary Embolism - may produce haemoptysis and more commonly affects lower lungs
35
What investigations are necessary to diagnose pneumothorax? (4)
Chest X-Ray Ultrasound CT ABG - show hypoxia
36
What are the treatments for a pneumothorax?
PSP - aspiration - observe SSP - supplementary O2 as relieves hypoxia and accelerates reabsorption of the pneumothorax compared to breathing air - most pts will need chest drain - If persistent air leak then pt needs referring to thoracic surgeons
37
What is a pleural effusion?
Fluid in the pleural space
38
How can you divide pleural effusions and what is the difference?
By their protein concentrations: - Transudates (35g/L) Examples: Haemothorax= blood in pleural space Empyema= pus in pleural space Chylothorax = lymph (with fat) in the pleural space Haemopneumothorax= blood and air in pleural space
39
What causes pleural effusion?
``` Transudates: May be due to ⬆️ venous pressure -cardiac failure -constrictive pericarditis -fluid overload Hypoproteinaemia -cirrhosis -nephrotic syndrome -malabsorption ``` Exudates: Mostly due to ⬆️ leakiness of pleural capillaries secondary to: -infection (pneumonia) -inflammation -malignancy (most commonly lung and breast cancer)
40
What are the symptoms of pleural effusion? (3)
Asymptomatic Dyspnoea Pleuritic chest pain
41
What are the signs of pleural effusion on examination? (6)
Decreased chest expansion Stony dull percussion note Reduced breath sounds on affected side Tactile vocal fremitus and vocal resonance are decreased. Bronchial breathing may be present above effusion where lung is compressed Tracheal deviation away from effusion in large pleural effusions
42
What are the possible differential diagnoses of pleural effusion?
``` Transudates: CCF Cirrhosis with hepatic hydrothorax Nephrotic syndrome Hypoproteinaemia Glomerulonephrotis SVC obstruction CSF leak to pleural space ``` ``` Exudates: Malignancy Pneumonia Tuberculosis PE Fungal infection ```
43
What tests are necessary to diagnose pleural effusion? (4)
Chest X-Ray - small effusions blunt costophrenic angles - large effusions seen as water dense shadows with concave upper borders Ultrasound Diagnostic aspiration Pleural biopsy
44
How do you treat/manage pleural effusion?
Drainage
45
What are the two classifications of pneumonia? (2)
Lobar pneumonia - form of pneumonia infection that only involves a single lobe of the lung - often due to streptococcus pneumoniae Bronchopneumonia
46
How common is CAP?
0.5-1% in UK every year
47
What causes lobar pneumonia?
Most often streptococcus pneumoniae Other causes: Haemophilus influemzae Moraxella catarrhalis Mycobacterium tuberculosis
48
What are the risk factors for lobar pneumonia?
Age - young children and elderly Lifestyle - smoking and alcohol Preceding viral infections - eg influenza predisposing to streptococcus pneumoniae infection Immunosuppression IV drug abuse - associated with staph aureus infection Hospitalisation - often with Gram -ve organisms Underlying predisposing disease - DM, cardiovascular disease
49
What are the symptoms of lobar pneumonia?
``` Fever Rigor Malaise Anorexia Dyspnoea Cough Purulent sputum Haemoptysis Pleuritic pain ```
50
What are the signs of lobar pneumonia on examination?
``` Pyrexia Cyanosis Confusion Tachypnoea Tachycardia Hypotension Signs of lung consolidation: - diminished chest expansion - dull percussion note - increased tactile vocal fremitus/resonance - bronchial breathing Pleural rub ```
51
What are the possible differential diagnoses of lobar pneumonia?
``` Pulmonary oedema Pleural effusion Pneumothorax PE Asthma COPD Bronchiectasis Fibrosing alveolitis Neoplasm Sarcoidosis ```
52
What investigations would you do to diagnose lobar pneumonia?
Chest X-Ray SpO2 ABG BP Blood tests- FBC, U&Es, CRP, LFT, blood cultures Sputum microscopy and culture Aim to identify pathogen and assess severity CURB 65 scoring system
53
What is the CURB 65 scoring system for pneumonia?
C - confusion U- urea >7mmol/L R - respiratory rate >/= 30 breaths/min B - Blood pressure (65 years
54
How do you manage a pt with lobar pneumonia?
Antibiotics (mild-mod= amoxicillin OR clarythromycin severe= co-amoxiclav OR Cephalosporin e.g. Cefuroxime ) - Oxygen - keep PaO2 >8 and SpO2 >94% - IV fluids and VTE prophylaxis - Analgesia for pleuritic pain
55
How common is a PE?
1/1000 people/year have a DVT If untreated about 1/10 people with a DVT will develop a PE
56
What causes PE?
Results from obstruction within pulmonary arterial tree Emboli can be caused by: - thrombosis (DVT - causes most PEs) - fat - amniotic fluid - air
57
What are the risk factors for a PE?
``` Surgery Obstetrics Lower limb problems Malignancy Reduced mobility Previous venous thromboembolism ```
58
What are the symptoms of a PE?
Dyspnoea Pleuritic chest pain (sharp stabbing pain when breathing in) Retrosternal chest pain Cough Haemoptysis Any chest symptoms in a pt with symptoms suggesting a DVT
59
What are the signs of PE on examination?
Tachypnoea Tachycardia Hypoxia - leading to anxiety, restlessness, agitation and impaired consciousness Pyrexia Elevated JVP Galloping heart rhythm, widely split heart sounds, tricuspid regurg murmur Pleural rub Systemic hypertension and cardiogenic shock
60
What are the possible differential diagnoses of PE?
Other causes of collapse, chest pain or dyspnoea: ``` Acute coronary syndromes Aortic dissection Cardiac tamponade Pneumonia Pneumothorax Sepsis ```
61
What investigations are necessary to diagnose a PE?
Baseline obs: O2 sats, FBC, biochem, clotting screen ECG Chest X-Ray ABG - may show reduced PaO2 and PaCO2 due to hyperventilation Echocardiogram Cardiac troponins D-dimers- fibrin D-dimer is a degradation product of cross-linked fibrin, conc increases in patients with acute VTE and provides a very sensitive test to exclude acute DVT or PE ``` Specific investigations for VTE: Coronary angiography Leg ultrasound Isotope lung scanning CPTA ```
62
What are the treatments of PE?
Anticoagulation therapy: Starts as soon as PE is suspected Medications or tablets Low molecular weight heparins In pregnant women regular heparin instead or warfarin
63
What are the causes of pulmonary fibrosis?
Replacement fibrosis secondary to lung damage Extrinsic allergic alveolitis (bird fanciers lung) Granulomatous diseases eg sarcoidosis Radiation exposure
64
What are the risk factors of pulmonary fibrosis?
``` Drugs and environmental causes Smoking GORD Infectious agents Genetic factors ```
65
What are the symptoms of pulmonary fibrosis?
Gradual onset of SOB Chronic non productive cough Wheezing Haemoptysis Chest pain Non-specific fever, myalgia Finger clubbing
66
What is the treatment for pulmonary fibrosis?
``` Smoking cessation Avoidance of other cause Influenza and pneumococcal vaccination O2 therapy for significant hyperaemia Immunosuppressive therapy ```
67
How common is Asthma? (3)
Affects 5-8% of population 3rd most common Hospital Admission in children 5-10% of adults have severe asthma
68
Define type 1 respiratory failure
PaO2 ⬇️ | PaCO2 normal
69
Define type 2 respiratory failure
PaO2 ⬇️ | PaCO2 ⬆️
70
What organism causes cavitating pneumonia ?
Klebsiella
71
Local complications of bronchial carcinoma ?
- recurrent laryngeal nerve palsy - phrenic nerve palsy - SVC obstruction - horners syndrome (pancoasts tumour) - rib erosion - pericarditis
72
Causes of type 1 respiratory failure
V/Q mismatch: - pneumonia - pul oedema - PE - asthma - emphysema - pulmonary fibrosis
73
Causes of type 2 respiratory failure ?
Alveolar hypoventilation with or without v/q mismatch - pul disea: COPD, obstructive sleep apnoea, asthma - reduced respiratory drive: sedatives, CNS tumour - neuro muscular disease: myasthenia gravis, G-B - thoracic wall disease: flail chest, kyphoscoliosis
74
When to consider ABG ?
- any unexpected deterioration in ill patient - acute exacerbations of chronic chest conditions - impaired consciousness or impaired resp effort - signs if co2 retention - cyanosis, confusion
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