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Respiratory Flashcards

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1
Q

Describe/draw the flow volume curves of normal, restrictive and obstructive lung disease

A
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2
Q

What is restrictive lung disease?

A

Pulmonary fibrosis that decreases lung volume and increases work of breathing with inadequate ventilation

  • Low FEV1
  • Low FVC
  • Normal FEV1/FVC ratio
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3
Q

Name some causes of restrictive lung disease

A
  • Pneumoconiosis
  • Pulmonary fibrosis
  • TB
  • Chest wall disease (kyphoscoliosis)
  • Weak respiratory muscles
  • Sarcoidosis
  • RA
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4
Q

What is obstructive lung disease?

A

Narrowing of airways due to excessive smooth muscle contraction

  • Normal FVC
  • Low FEV1
  • Low FEV1/FVC ratio (<0.7)
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5
Q

Name some causes of obstructive lung disease

A
  • Chronic bronchitis
  • COPD
  • Asthma
  • Bronchiectasis
  • CF
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6
Q

Describe/draw the spirometry curve of normal, obstructive and restrictive lung disease

A
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7
Q

What is respiratory failure?

A

When gas exchange in the lungs is inadequate which results in hypoxia. It is defined as pO2 < 8kPa. Divided into:

  • Type 1 - normal or low pCO2
  • Type 2 - high pCO2
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8
Q

Name some causes of Type 1 respiratory failure

A

Mainly ventilation perfusion mismatch

  • Pneumonia
  • Pulmonary oedema
  • PE
  • Asthma
  • Pneumothorax
  • Fibrosing alveolitis
  • ARDS
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9
Q

Name some causes of Type 2 respiratory failure

A

Alveolar hypoventilation

  • Pulmonary disease - COPD, fibrosis,
  • Reduced respiratory drive - Opiates, CNS tumour, trauma
  • Neuromuscular disease - Cervical cord lesion, diaphragmatic paralysis, myasthenia gravis
  • Thoracic wall disease - flail chest, kyphoscoliosis
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10
Q

Describe the effects of hypoxia (Type 1 and 2 respiratory failure)

A
  • Impaired CNS function
    • Confusion
    • Agitation
  • Dyspnoea
  • Restlessness
  • Central cyanosis
  • Pulmonary hypertension
  • Cardiac arrhythmia
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11
Q

Describe the effects of hypercapnia (Type 2 respiratory failure)

A
  • Headache
  • Peripheral vasodilation
  • Tachycardia
  • Bounding pulse
  • Tremor/flap
  • Papilloedema
  • Confusion
  • Drowsiness
  • Coma
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12
Q

How is respiratory failure investigated?

A
  • Bloods
    • FBC
    • U&E
    • CRP
    • ABG
  • CXR
  • Sputum culture (if febrile)
  • Spirometry
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13
Q

How is respiratory failure managed?

A
  • Treat underlying cause
  • Airway maintenance
  • Clearance of secretions
  • Oxygen by face mask
  • Assisted ventilation (CPAP/BIPAP) if pO2 < 8 kPa
  • Intubation
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14
Q

What is asthma?

A

A chronic inflammatory disorder characterised by increased responsiveness of the bronchi to various stimuli, causing reversible airway obstruction

  • Airway hyperresponsiveness
  • Increased mucosal inflammation
  • Hypersecretion of mucus
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15
Q

Describe the symptoms of asthma

A
  • Intermittent dyspnoea
  • Wheeze
  • Cough (often nocturnal)
  • Sputum production
  • Exercise intolerance
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16
Q

Name some asthma precipitants

A
  • Allergens (pollen, house dust mites, animals)
  • Smoke
  • Stress
  • Exercise
  • VIral infections
  • Drugs - NSAIDs, aspirin, beta blockers
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17
Q

Name the clinical signs of asthma

A
  • Tachypnoea
  • Audible polyphonic wheeze
  • Hyper-inflated chest
  • Hyper-resonant percussion
  • Diminished air entry
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18
Q

How is asthma investigated?

A
  • Peak expiratory flow monitoring
  • Obstructive spirometry result
    • Improvement of FEV1 by 12% with beta agonist
  • CXR
  • Skin prick test - identify triggers
  • Fractionated exhlaed FeNO test (>40)
  • Bronchial provocation - inhalation of increase dose of histamine until FEV1 declines by 20%
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19
Q

Describe the guidelines to treating chronic asthma

A
  1. Short acting inhaled B2 agonist
  2. Add inhaled low dose steroid (beclometasone 100-400microg/12hrs)
  3. Add leukotriene receptor antagonist (montelukast)
  4. Add long acting B2 agonist (salmeterol 50microg/12hrs)
  5. Increase dose of steroids (up to 1000) / oral theophylline / oral B2 agonist / oral leukotriene receptor antagonist

Continue until no daytime symptoms, no limitations on activity, no exacerbations, no night-time awakening and normal lung function

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20
Q

Describe the emergency treatment of acute severe asthma

A
  • Oxygen via non-rebreathe bag (15L)
    • Aim for 94-98% sats
  • Salbutamol 5mg delivered with oxygen
  • Hydrocortisone 100mg IV or prednisolone 30mg PO
    • Continue for 5 days
  • Add ipatropium bromide 0.5mg nebuliser
  • CXR to exclude pneumothorax
  • If life-threatening: add magnesium sulphate 1.2-2mg IV over 20 min
  • Salbutamol nebulisers every 15 min
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21
Q

Name some ADRs of B2 agonists

A
  • Muscle tremor
  • Tachycardia
  • Palpitations
  • Arrhythmias
  • Hypokalaemia
  • Headache
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22
Q

What is chronic bronchitis?

A

Chronic mucosal inflammation, mucus gland hypertrophy and mucus hypersecretion

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23
Q

What is emphysema?

A

Progressive destruction of the alveolar septa and capillaries producing enlarged spaces (bullae) with decreased compliance and increased collapsibility

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24
Q

What is COPD?

A

An irreversible expiratory airflow obstruction. hyperinflation, mucus hypersecretion and increased work of breathing. Includes chronic bronchitis and emphysema.

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25
What signs differentiate COPD with asthma?
* Age of onset \> 35 * Smoking related * Chronic dyspnoea * Sputum production * No diurnal variation
26
What are pink puffers and blue bloaters?
Pink puffers: * Purse lipped breathing * Normal PO2 and normal/low CO2 * Barrel chest * Dyspnoea Blue bloater: * Dec alveolar ventilation * Low PO2 and high PCO2 * Cyanosed but not breathless * Rely on hypoxic drive
27
Name some symptoms of COPD
* Cough * Sputum production * Dyspnoea * wheeze
28
Name some signs of COPD
* Use of accessory muscles * Hyperinflation * Dec. expansion * Resonant on percussion * Cyanosis * Cor pulmonale
29
What are the risk factors for developing COPD?
* Male * Age \> 50 * Smoking * Asthma * Childhood chest infections * Low SES * A1 anti trypsin deficiency * Heavy metal exposure
30
Describe some investigations into COPD
* CXR * Hyperinflation (\>6 ant. ribs seen above diaphragm in mid-clavicular line) * Flat hemidiaphragm * Large pulmonary arteries * ECG - cor pulmonale (hypertrophy) * ABG - low PO2 +/- high PCO2 * Spirometry - irreversible airway obstruction (FEV1/FVC \< 0.7)
31
Name some complications of COPD
* Acute exacerbations * Infection * H influenzae most common in COPD * Polycythaemia * Cor pulmonale * Respiratory failure * Lung cancer * Pneumothorax
32
How is the severity of COPD assessed?
* Mild = FEV1 60-80% predicted * Moderate = FEV1 40-59% predicted * Severe = FEV1 \< 40% predicted
33
Describe the guidelines to treating chronic COPD
* Non pharmacological - smoking cessation, regular exercise, diet, flu vaccine * Pulmonary rehabilitation * Oxygen therapy * Long acting inhaled B2 agonists (salmeterol) * Inhaled steroid if FEV1 \< 50% * Inhaled ipatromium (LAMA) * Surgery * Lung volume reduction * Transplant
34
Name some side effects of steroids
CUSHINGOID * Cataracts * Ulcers * Skin: striae, bruising, thinning * Hypertension / hirsutism / hyperglycaemia * Infections * Necrosis (avascular necrosis of the femoral head) * Glycosuria * Osteoporosis / obesity * Immunosuppression * Diabetes
35
What is cor pulmonale?
Right heart failure caused by chronic pulmonary hypertension
36
How is pulmonary hypertension investigated?
* Bloods - Hb, ABG, LFTs, autoantibodies, HIV * CXR * Enlarged right atrium and ventricle * Prominent pulmonary artieries * Parenchymal disease? * ECG * RIght axis deviation * Right ventricular hypertrophy * Echo
37
What is sarcoidosis?
Multi system immune deposits characterised by non-caseating granulomas and an abnormal, antigen-triggered CD4 T cell response. Unknown aetiology.
38
Name some clinical features of sarcoidosis
* Acute = erythema nodosum, arthralgia, fever, bihilar lymphadenopathy * Constitutional = fatigue, malaise, weight loss * Resp = Non productive cough, dyspnoea, pain, decrease exercise tolerance * Eye = uveitis, conjunctivitis * Neuro = neuropathy, meningitis * Cardiac = arrhythmia, heart failure * Gastro = hepato/splenomegaly * Renal impairment
39
How is sarcoidosis diagnosed?
* CXR - bihilar lymphadenopathy, upper lobe fibrosis, pulmonary infiltrates * Tissue biopsy - non-caseating granuloma * Bloods - FBC, biochemistry, Ca, LFT, **SACE** * Lung function test - normal or restrictive * Mantoux - exclude TB * Slit lamp examination * Bronchoalveolar lavage - Inc lymphocytes
40
How is sarcoidosis managed?
* Acute - bed rest, NSAIDs * Steroids (4-6 weeks) if: * Parenchymal lung disease * Uveitis * Hypercalcaemia * Neuro or cardio involvement * Immunosuppression (methotrexate, azathioprine, cyclosporin) * Transplant
41
Name some differentials for granulomatous diseases
* TB * Sarcoidosis * Vasculitis (Wegeners) * Crohns * Extrinsic allergic alveolitis * Syphilis
42
How can PEs be prevented?
* Compression stockings * Heparin to all immobile patients * Stop HRT / OCP * Investigations for thrombophilia * Encourage mobilisation
43
What is interstital lung disease?
Inflammation and/or fibrosis of the pulmonary intersitium caused by inhalation of allergens which provokes a hypersensitivity reaction or is idiopathic. With chronic exposure, granulomas and obliterative bronchiolitis occur
44
How is interstital lung disease classified?
1. Idiopathic Interstital Pneumonias * Usual Interstital Pneumonias / Idiopathic Pulmonary Fibrosis = minimal inflammation with fibrosis * Non-Usual Interstital Pneumonias = more diffuse pulmonary involvement with less fibrosis 2. Non-idopathic causes * Drug-induced = nitrofurantoin, bleomycin, amiodarone * Hypersensitivity (extrinsic allergic alveolitis) * Connective Tissue Disease = RA/vasculitis * Occupational lung disease = pneumoconiosis/asbestosis 3. Granulomatosis (sarcoidosis) 4. Other causes * Infiltrative (amyloidosis) * Malignant * Post-infective (HIV)
45
What are the clinical features of ILD?
* Dyspnoea * Dry cough * Weight loss * Type 1 respiratory failure * Clubbing * RHF and hypoxaemia if advanced
46
How is ILD diagnosed?
* History - drugs, occupation, CTD, sarcoidosis * Bloods - rheumatoid factor, Inc ESR, neutrophilia * Serology - positive precipitans * Pulmonary function tests - Restrictive deficit with dec TLC, dec FRC and dec RV * CXR - mid-zone mottling/consolidation, hilar lymphadenopathy, upper-zone fibrosis, honeycomb lung * Decreased gas transfer * Broncholaveolar Lavage - inc lymphocytes and mast cells * Biopsy (non-IUP)
47
How is ILD treated?
* Oxygen therapy * Pulmonary rehab * Smoking cessation * Avoid allergens * Pharmacological * Steroids (non-IUP) * Immunosuppressants (azathioprine / methotrexate) * Lung transplant NB: non-IUP = low dose prednisolone, azathioprine, N-acetylcysteine
48
Name some causes of hypersensitivity pneumonitis / EAA
* Mouldy hay (thermophilic actinomycetes) - Farmers Lung * Compost - Mushroom Workers Lung * Feathers / excreta - Pigeon Fanciers Lung * Contaminated water (klebseilla) - Humidifiers Fever
49
Describe Coal Worker's Pneumoconiosis
Inflammatory reaction to the presence of coal dust in the lungs * Weakens bronchiolar walls to cause emphysema * Irreversible airflow limitation * Dec TLC * Dec compliance * Dec gas transfer * Limited treatment
50
Describe asbestosis
Fibrosing lung disease caused by inhalation of asbestos particles * Presents with progressive dyspnoea, inspiratory basal crackles and clubbing * Restrictive deficit with dec gas transfer * Predisposes to mesothelioma * No treatment available
51
Describe the x-ray appearance of asbestosis
* Diffuse streaky shadows * Thickened visceral pleura * Honeycombing in lower lobes
52
Descrbe the x-ray appearance of extrinsic allergic alveolitis / hypersensitivity pneumonitis
* Fluffy nodular shadowing * Ground glass opacity * Honeycomb lung
53
Name some indications for mechanical ventilation
Prevent type 2 respiratory failure: * Surgery * Respiratory centre depression (PCO2 \> 7-9kPa) * Head injury * Opiate overdose * Raised intracranial pressure * Lung disease * Pneumonia * ARDS * Severe asthma * Exacerbation of COPD * Cervical cord damage above C4 * Neuromuscular disorders * Chest wall disorders * Cardiac arrest
54
Describe the different types of mechanical ventilation
* Intermittent Positive Pressure Ventilation = air is driven into lungs by raising airway pressure via a tracheostomy tube * Expiration = pressure falls to 0 * Positive End-Expiratory Pressure = IPPV but positive airway pressure is maintained during expiration * Continuous Positive Airway Pressure = standing pressure applied to a facemask during spontaneous breathing * Biphasic Positive Airway Pressure = maintains pressure during inspiration and expiration * Non-Invasive Intermittent Positive Pressure Ventilation - IPPV delivered by face/nasal mask
55
Name some complications of using mechanical ventilation
* During intubation * Aspiration of gastric contents * Laryngospasm * Of intubation * Intubation of oeseophagus / bronchus * Laryngeal / tracheal damage or stenosis * Sedation * Cardiac depression * Respiratory depression * Mechanical ventilation * Barotrauma * Pneumothorax
56
Name some indications for the use of oxygen therapy
* Cardiac / respiratory arrest * Hypoxia (pO2 \< 8kPa) * Hypotension (systolic BP \< 100mmHg) * Low cardiac output * Metabolic acidosis (bicarp \< 18mmol/L) * Respiratory distress (RR \> 24)
57
What blood concentration of oxygen is aimed for?
* Normal patients = SaO2 of 94-98% * Risk of type 2 respiratory failure = SaO2 of 88-92% * COPD * If increased, risk of CO2 retention, dec ventilation and acidosis
58
Describe the different delivery methods of oxygen and which groups of patients they are appropriate for
* High dose (\>60%) by non-rebreathe, resvoir mask at 10-15 L/min * Cardiac arrest * Shock * Sepsis * CO poisoning * Moderate dose (40-60%) by nasal cannulae at 2-6 L/min * Pneumonia * Low dose (24-28%) by Venturi mask * CO2 retention * COPD * Neuromuscular disease * Cystic fibrosis
59
What are the risks of using oxygen therapy?
* CO2 retention * COPD patients * Rebound hypoxaemia (if suddenly withdrawn) * Absorption collapse / atelectasis * Toxicity * ARDS * Coronary / cerebro vasospasm * Burns (in smokers) * Cerebral vasoconstriction and epileptic fits (Paul-Bert effect)
60
What are the classifications of pneumonia?
* Community acquired - within 48 hours of hospital admission in patients that had not been hospitalised for 14 days * Hospital acquired - \> 2 days after admission * Aspiration (stroke, myasthenia gravis, dec. consciousness, oesophageal disease) * Opportunistic - immunosuppressed patients * Recurrent - CF, bronchiectasis
61
Name some risk factors for contracting pneumonia
* Age \> 65 * Chronic disease * Diabetes * COPD * Immunosuppression/compromised * Steroids * Alcohol dependency * Malnutrition * Mechanical ventilation * Post-operative * IVDU
62
Name the commin causative agents of CAP
* Strep pneumoniae * Haemophilus influenza * Klebsiella pneumoniae * Influenza * Mycoplasma * Aspergillus
63
What are the clinical features of pneumonia?
* General - fever, malaise, rigors, myalgia * Chest - dyspnoea, pleurisy, cough, haemoptysis * Cyanosis * Tachypnoea * Tachycardia * Confusion * Auscultation - focal dullness, crepitations, bronchial breathing, pleuritic rub * Hypotension
64
What investigations are needed for pneumia?
* Bloods - FBC, CRP, LFTs, ABG, U&Es, cultures * CXR - lobar infiltrates, cavitations, pleural effusion * O2 sats * Other cultures - sputum, pleural fluid, bronchoalveolar lavage * Serology (virus/atypical organism)
65
How is the severity of pneumonia assessed?
CURB 65 score * Confusion (mental test \< 8) * Urea \> 7 mmol/L * RR \> 30/min * Systolic BP \<90 or diastolic BP \< 60 * Age \> 65 Score \> 1 indicates severe pneumonia
66
What is the general management of pneumonia?
* Antibiotics * Oxygen (keep pO2 \> 8kPa and sats \> 92%) * IV fluids * Paracetemol if pleurisy * Sputum clearance * Ventilatory support (CPAP) * ITU if severe or failure to imrpove, shock or hypercapnic
67
Describe the antibiotic treatment regimes for the different types of pneumonia
* CAP - amoxicllin 500mg/8hr or erythromycin 500mg/6hr * Severe - IV Co-amoxiclav or cephalosporin AND erythromycin * Legionella - clarithromycin 500mg/12hr * Chlamydia - tetracycline * Gram negative - IV aminoglycoside
68
Name some complications of pneumonia
* Respiratory failure * Hypotension due to dehydration / septic vasodilation * Atrial fibrillation * Pleural effusion * Empyema * Lung abscess (cavitating area of infection) * Sepsis * Pericarditis
69
What are the risks of developing hospital acquired pneumonia?
Oropharyngeal colonisation with enteric gram negative bacteria due to: * Immobilisation * Impaired consciousness * Instrumentation * Poor hygiene * Inhibition of gastric acid (aspiration)
70
Name some common organisms for HAP
* Staph aureus * CAP organisms * MRSA * Gram negative bacilli
71
Name some causes of pneumothorax
* Primary (idiopathic) mainly in young men * Secondary * COPD * Asthma * TB * Pneumonia * HCTD * Carcinoma * Fibrosis * Traumatic
72
What are the clinical features of pneumothorax?
* Sudden breathlessness * Sharp pleuritic pain * Reduced air entry * Hyperresonant percussion * Cyanosis * Tachycardia * Respiratory failure * Hypertension
73
How is pneumothorax investigated?
* CXR (if tension not suspected) = area devoid of lung markings * ABG = respiratory failure
74
How is pneumothorax managed?
* Oxygen * Analgesia * If \>2cm and/or breathless = aspirate in 2nd intercostal space mid-clavicular with 16-28G cannula * If unsuccessful - chest drain in 5th intercostal space in axilla
75
Describe the pathogenesis of TB
* Primary = inital infection by inhaling acid-fast bacill (mycobacterium tuberculosis) affecting the upper lobes * Granuloma (Ghon focus) and enlarged hilar lymph nodes = Ghon complex * Post-primary = if Ghon focus fails to heal due to poor defences or following immunocompromised reactivation (HIV, malignancy, diabetes, steroids) * Lung lesions fibrose * Local dissemination * Bloodborne spread
76
What are the clinical features of pulmonary TB?
* Primary * Fever * Erythema nodosum * Small pleural effusions * Lymphadenopathy * Wheeze * Post-primary * Malaise * Weight loss * Night sweats * Productive cough * Dyspnoea * Chest pain * Haemoptysis * Pneumonia
77
How is TB diagnosed?
* Sputum sample for MC+S (acid fast bacillus / Ziehl-Neilson stain) * Other relevant samples for culture - pleural fluid, urine, pus, ascites etc * Histology - caseating granuloma * CXR - consolidation, cavitation, fibrosis, calcification * Immunological tests * Mantoux (\>10mm) * Tuberculin skin test - cell-mediated response to intradermal TB antigen * Heaf (screening) * Bloods - anaemia, dec Na+, inc Ca2+
78
How is TB managed?
* Isolation * Notify communicable diseases practitioner * Inital antiobiotics (RIPE) for 2 months * Rifampicin * Isoniazid (+ pyridoxine / vit B6) * Pyrazinamide * Ethambutol * Continuation antibiotics (4 months) * Rifampicin * Isoniazid (+ pyridoxine / vit B6)
79
Name some side effects of the antibiotics treatment of TB. How are these monitored?
* Rifampicin - hepatitis, orange discolouration of urine and tears (contact lens staining), inactivation of OCP * LFTs * Isoniazid - hepatitis, neuropathy, vit B6 deficiency * Ethambutol - optic neuritis * Ishihara (colour) chart * Pyrazinamide - hepatitis, arthralgia
80
Name some complications of TB
* Reactivation when immunocompromised * Bronchiectasis * Lung cavities * Cranial nerve lesions * Renal tract obstruction * Multi-drug resistance
81
How do you present a chest x-ray?
DRSABCDE 1. Details - Patient details, type of film (AP) date and time 2. RIE (image quality) - rotation, inspiration (5-6 ant. ribs) exposure 3. Soft tissues and bones 4. Airway 5. Breathing 6. Circulation 7. Diaphragm 8. Extras
82
What is looked for in 'soft tissue and bones' of CXR?
* Ribs, sternum, spine, clavicles – symmetry, fractures, dislocations, lytic lesions, density * Soft tissues – looking for symmetry, swelling, loss of tissue planes, subcutaneous air, masses * Breast shadows * Calcification – great vessels, carotids
83
What is looked for in 'airway' of CXR?
* Trachea – central? * Carina & RMB/LMB * Mediastinal width \<8cm on PA film * Aortic knob * Hilum – T6-7 IV disc level, left hilum is usually higher (2cm) and squarer than the V-shaped right hilum. * Check vessels, calcification.
84
What is looked for in 'breathing' of CXR?
Lung fields: * Vascularity – to ~2cm of pleural surface (~3cm in apices), vessels in bases \> apices * Pneumothorax – don’t forget apices * Lung field outlines – abnormal opacity/lucency, atelectasis, collapse, consolidation, bullae * Pulmonary infiltrates – interstitial vs alveolar pattern * Coin lesions * Cavitary lesions Pleura * Pleural reflections * Pleural thickening
85
What is looked for in 'circulation' of CXR?
* Heart position –⅔ to left, ⅓ to right * Heart size – measure cardiothoracic ratio on PA film (normal \<0.5) * Heart borders – R) border is R) atrium, L) border is L) ventricle & atrium * Heart shape * Aortic stripe
86
Describe this x-ray
* Visible pleural edge * Lung markings not visible beyond this point * Rib fracture Diagnosis = left pneumothorax due secondary to rib fracture Tracheal and mediastinal structures are not deviated so no 'tension'
87
Describe this x-ray
* The left lower zone is uniformly white * At the top of this white area there is a concave surface - meniscus sign * The left heart border, costophrenic angle and hemidiaphragm are obscured * Slight blunting of the right costophrenic angle indicates a small pleural effusion on that side Diagnosis - large left pleural effusion
88
Describe this x-ray
* The right heart border (right atrial edge) is obscured * Consolidation (asterisk) is limited above by a crisp line, formed by the horizontal fissure * The pathology must therefore involve the right middle lobe * More extensive shadowing also involves the right and left peri-hilar regions Diagnosis = pneumonia involving the right middle lobe
89
Describe the x-ray
* The horizontal fissure (white line) has been displaced upwards from its original position (red line) * Dense opacification (asterisk) of the medial part of the right upper zone * Enlarged right hilum Diagnosis = right upper lobe collapse
90
Describe the x-ray
* Large, round, thick-walled lung cavity * The cavity is in the left middle zone, close to the hilum Diagnosis = Left lower lobe lung cavity, possible due to a squamous cell carcinoma
91
Describe this x-ray
* Both costophrenic angles are blunt due to lung hyper-expansion * The hemidiaphragms are flattened indicating hyperexpansion * The lung markings are distorted bilaterally Diagnosis = COPD
92
Describe this x-ray
* The lungs are normal * The diaphragm is crisply defined on both sides (arrowheads) * Air under the diaphragm (asterisks) is seen as crescents of relatively low density (black) * Black air can be seen on both sides of the bowel wall (blue line) – this is known as the double-wall sign or Rigler's sign (usually only seen on abdominal X-rays) Diagnosis = perforated duodenal ulcer (pneumoperitoneum)
93
Describe this x-ray
* Cardiomegaly CTR = 18/30 (\>50%) * Upper zone vessel enlargement (1) – a sign of pulmonary venous hypertension * Septal (Kerley B) lines (2) – a sign of interstitial oedema – see next picture * Airspace shadowing (3) – due to alveolar oedema – acutely in a peri-hilar (bat's wing) distribution * Blunt costophrenic angles (4) – due to pleural effusions Diagnosis = left ventricular failure with pulmonary oedema
94
Describe this x-ray
* Dense airspace shadowing is due to alveolar oedema caused by fluid filling the alveoli and small airways * In the acute setting this airspace shadowing radiates from the hilar regions in a 'bat's wing' distribution and then becomes more generalised Diagnosis = alveolar pulmonary oedema
95
Describe this x-ray
* Sternal wires and aortic valve prosthesis (arrowhead) * Massive aortic knuckle (red line) * Displaced trachea (arrow) * Widened, tortuous descending aorta (blue lines) Diagnosis = chronic thoracic aortic aneurysm (treated with surgical repair of the aortic root)
96
Describe this x-ray
* No patient rotation - the spinous processes (red line) are central between the medial clavicles (blue lines) * Trachea (asterisk) shifted to the left of the midline * Soft tissue mass mainly to the right of the trachea
97
What is Acute Respiratory Distress Syndrome?
An acute, diffuse inflammatory lung injury in response to a variety of direct (inhaled) or indirect (bloodborne) insults.
98
Name some causes of ARDS
Direct: * Infection * Trauma * Near-drowning * Gas inhalation Indirect: * Sepsis * Burns * Haemorrhage * Post-arrest
99
What are the clinical features of ARDS?
* Dyspnoea and tachypnoea * Central cyanosis * Hypoxic confusion * Bilateral fine inspiratory crepitations * Peripheral vasodilations *
100
What is the diagnostic criteria for ARDS?
1. Acute onset 2. Bilateral infiltrates on CXR 3. Pulmonary capillary wedge pressure (PCWP) \< 19mmHg 4. Hypoxaemia
101
How is ARDS managed?
* Treat underlying cause * Respiratory support * CPAP / PEEP with 40-60% O2 * Circulatory support * Inotropes * Vasodilators * Blood transfusion * Sepsis - empirical broad spectrum * Nutritional support
102
What is bronchiectasis?
Chronic infection (staph aureus, h influenzae, strep pneumoniae, pseudomonas aeruginosa) of the bronchi and bronchioles leading to permenant dilation of these airways
103
Name some causes of bronchiectasis
* Congenital - cystic fibrosis * Post-infection - measles, pertussis, pneumonia, TB, HIV * Bronchial obstruction - tumour, foreign body * RA * UC * Idiopathic
104
What are the clinical features of bronchiectasis?
* Persistent cough * Copious purulent sputum * Intermittent haemoptysis * Clubbing * Coarse inspiratory crepitations * Wheeze
105
How is bronchiectasis investigated?
* Sputum culture * CXR * Cystic shadows * Thickened bronchial walls * High-resolution CT * SPirometry - obstructive
106
How is bronchiectasis managed?
* Postural drainage twice a day * Chest physiotherapy * Antibiotics * Bronchodilators (nebulised salbutamol) * Surgery
107
Name the different types of lung tumour
* Non-small cell * Squamous * Adenocarcinoma * Large cell (poorly differentiated) * Small cell - neuroendocrine tumour with poorer prognosis * Mesothelioma
108
Name the guidelines for urgent CXR guidelines in suspected lung cancer
Aged over 40 if 2 or more OR ever smoked with 1: * Cough * Fatigue * Shortness of breath * Chest pain * Weight loss * Appetite loss
109
Describe the guidelines for prescribing LTOT in a COPD patient
* pO2 \< 7.3 kPa * pO2 7.3-8.0 kPa if: * Secondary polycythaemia * Nocturnal hypoxaemia * Peripheral oedema * Pulmonary hypertension
IPE
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