Respiratory Flashcards

Question

Pulmonary fibrosis: history Qs

Answer 1

* HPC: dyspnoea, cough, sputum, wt loss * cause: arthritis, radiation, occupation, hobbies, DHx * Smoking status

Answer 2

Bloods * FBC: anaemia exacerbates dyspnoea * ABG: low PaO2, high PCO2 * IPF: high ESR, high CRP, ANA (30%), RF (10%), raised Ig * EAA: +ve serum precipitins * CTD: C3/4, CCP (RF, ANA), ScL-70, centromere * Sarcoid: serum ACE, Ca2+ Imaging: * CxR: reticulonodular shadowing, reduced lung volume * HRCT: fibrosis, honeycomb lung Spirometry: restrictive * low TLC, low RV, low FEV, low FVC * FEV: FVC \>0.8 * reduced transfer factor Echo: PHT BAL: disease activity: high lymphocyts\>PMNs=better prognosis Lung biopsy: usual intersitial pneumonia patterns

Answer 3

**MDT:** GP, pulmonologist, physio, psych, palliative, specialist nurse, pt fam **Rx cause:** * EAA: steroids * Sarcoidosis: steroids * CTD: steroids **Supportive:** * Stop smoking * pulmonary rehabilitation * LTOT * Symptomatic Rx: * anti-tussives e.g. codein phosphate * HF: diuretics, BB, ACEi **Surgery:** lung Tx offers only cure for IPF **Prognosis:** IPF: 50% 5 yr surival

Answer 4

* Systemic sclerosis is a condition of unknown aetiology characterised by hardened, sclerotic skin and other connective tissues.* * It is four times more common in females*

Answer 5

**Limited cutaneous systemic sclerosis** * Raynaud's (may be first sign) * scleroderma affects: _face and distal limbs_ * anti-centromere antibodies * a subtype of limited systemic sclerosis is **CREST** syndrome: * Calcinosis, Raynaud's phenomenon, oEsophageal dysmotility, Sclerodactyly, Telangiectasia **Diffuse cutaneous systemic sclerosis:** * scleroderma _affects trunk and proximal limbs_ * scl-70 antibodies * hypertension, lung fibrosis and renal involvement seen * poor prognosis **Scleroderma** (without internal organ involvement) * tightening and fibrosis of skin * may be manifest as plaques (morphoea) or linear

Answer 6

**Peripheral Inspection** * Paraphernalia * Inhalers * Peak flow meter * Nebuliser * General * Airflow obstruction * Pursed lip breathing * Splinting diaphragm * Cushingoid * Cyanosed * Cachetic * Specific * Hands * Tar staining * CO2 retention flap * Bounding pulse * Face * Plethora: ↑Hb * Central cyanosis **Chest** * Barrel-shaped * ↓ cricosternal distance * ↓ expansion bilaterally * PN: resonant * Auscultation * ↓ breath sounds * Expiratory wheeze * Prolonged expiratory phase * Evidence of Hyperexpansion * ↓ cricosternal distance * Loss of cardiac dullness * Palpable liver edge **Extra:**Cor Pulmonale * ↑ JVP * Left parasternal heave: RV hypertrophy * Loud P2 ± S3 * MDM of tricuspid regurg * Ascites and pulsatile hepatomegaly * Peripheral oedema **Significant Negatives** * CO2 retention * Cor pulmonale * Clubbing: could indicate Ca

Answer 7

1. Chronic asthma 2. Bronchiectasis

Answer 8

1. **Symptoms**: cough, sputum, dyspnoea 2. **Limitation**: exercise tolerance 3. **Cause**: smoking Hx, FHx 4. **Control**: exacerbations, admissions 5. **Therapy**: inhalers, vaccinations, home O2

Answer 9

**Chronic bronchitis:** Cough productive of sputum on most days for ≥3mo on ≥2 consecutive years **Emphysema:** Histological description of alveolar wall destruction c¯ airway collapse and air trapping

Answer 10

**Bedside** * PEFR * BMI: independent mortality RF in COPD * Sputum: MC+S **Spirometry**: obstructive * ↑ TLC and residual volume (RV) * FEV1 \<80% * FEV1:FVC \<0.7 * ↓ *transfer factor* **Bloods** * FBC: polycythaemia, ↑ WCC in exacerbations * ABG: Type 2 resp failure * CRP: if infective exacerbation * Albumin: malnutrition * α1-AT levels: if young and FHx **Imaging** * CXR * Acute * Consolidation * Pneumothorax * Chronic * Hyperinflation: \>10 posterior ribs, flat diaphragm * PHT: prominent pulmonary As, peripheral oligaemia * Bullae * Echo * Cor pulmonale **Other** * 6 minute walk * ECG: RVH

Answer 11

GOLD Classification: Global Initiative for Obstructive Lung Disease *Multidimensional classification to tailor therapy to pt.* **Parameters** 1. mMRC dyspnoea score 2. Airflow limitation 3. No. of exacerbations per year * *mMRC Dyspnoea Score** 1. SOB only on ***vigorous*** exertion 2. SOB on ***hurrying or walking up stairs*** 3. ***Walks*** slowly or has to stop for breath 4. Stops for breath after ***\<100m / few min*** 5. Too breathless to l***eave house*** or SOB on ***dressing*** * *Airflow Limitation** 1. Mild: FEV1 ***\>80%*** (but FEV/FVC \<0.7 and symptomatic) 2. Mod: FEV1 ***50-79%*** 3. Severe: FEV1 ***30-49%*** 4. Very Severe: FEV1 ***\<30%***

Answer 12

**General** * *MDT* * GP, dietician, physio, resp physician, specialist nurses * Regular review 1-2x / yr * *Smoking Cessation*: single most important intervention * Specialist nurse and support programme * Nicotine replacement therapy * Varenicline: partial nicotinic agonist * *Pulmonary Rehabilitation Therapy* * Tailored exercise programme * Disease education * Psychosocial support * *Co-morbidities* * Nutritional assessment and dietary support * CV risk Mx * Vaccination: pneumococcal and seasonal influenza **Medical Mx** * Principal Therapies * Anti-muscarinics: short- or long-acting * β-agonists: short- or long-acting * Inhaled corticosteroids: in combination c¯ β-B * Other Therapies * Theophylline or Roflumilast: PDIs * Carbocisteine: mucolytic * Home emergency pack for acute exacerbations * LTOT * Aim: PaO2 ≥8 for ≥15h / day (↑ survival by 50%) * Indications * Sable non-smokers c¯ PaO2 \<7.3 * PaO2 \<8 + cor pulmonale or polycythaemia **Surgical Mx** * Recurrent pneumathoraces or large bullae * Bullectomy or lung reduction surgery

Answer 13

Ix 1. **PEFR** 2. **Bloods**: FBC, U+E, ABG, CRP, cultures 3. Sputum **culture** 4. **CXR**: infection, pneumothorax

Answer 14

15% in-hospital mortality

Answer 15

Discharge 1. Spirometry 2. Establish optimal maintenance therapy 3. GP and specialist f/up 4. Prevention using home oral steroids and Abx 5. Pneumococcal and Flu vaccine 6. Home assessment

Answer 16

**BODE Index (4)** *Multidimensional tool to predict mortality in COPD Uses multiple independent risk factors* 1. BMI 2. Obstruction: FEV1 3. Dyspnoea: MRC score 4. Exercise capacity: 6 min walk

Answer 17

**Peripheral Inspection** * Paraphernalia * Inhalers * Peak flow meter * Nebuliser * General * Cushingoid * Specific * Oral thrush **Chest** * Harrison sulcus * Auscultation * Usually normal * May be ↓ AE and mild wheeze **Significant Negatives** * CO2 retention * Cor pulmonale * Clubbing: could indicate Ca

Answer 18

1. Symptoms: cough, dyspnoea, wheeze, diurnal variation 2. Limitations: exercise, sleep, work 3. Cause: atopy, exercise, cold, smoking 4. Control: SABA use, attacks, admissions, ITU * Check peak flow diary 5. Therapy: oral steroid use, check inhaler technique 6. Assocs. * GORD: dyspepsia * Churg-Strauss: recent onset, rash, neuropathy

Answer 19

*Episodic, reversible airway obstruction due to bronchial hyper-reactivity to a variety of stimuli.*

Answer 20

* *Bedside**: PEFR * *Bloods** * FBC (eosinophila) * ↑IgE * Aspergillus serology * *CXR**: hyperinflation * *Spirometry**: obstructive * ↓ FEV1, ↑RV * FEV1:FVC \< 0.75 * ***≥15% improvement in FEV1 c¯ β-agonist*** **PEFR** monitoring / diary * Diurnal variation \>20% * Morning dipping **Atopy**: skin-prick testing, RAST

Answer 21

**General** * MDT: GP, specialist nurses, respiratory physician * Technique for inhaler use * Avoidance: allergens, smoke (ing), dust * Monitor: Peak flow diary (2-4x/d) * Educate * Liaise c¯ specialist nurse * Need for Rx compliance * Emergency action plan

Answer 22

1. No exacerbations 2. No reliever therapy: no PRN salbutamol 3. No night time waking 4. \<20% diurnal variation 5. Normal lung function

Answer 23

* Precipitant: infection, travel, exercise? * Usual and recent Rx? * Previous attacks and severity: ICU? * Best PEFR? AMPLE

Answer 24

* PEFR * ABG * PaO2 usually normal or slightly ↓ * PaCO2 ↓ * If PaCO2 ↑: send to ITU for ventilation * BloodS: FBC, U+E, CRP, blood cultures

Answer 25

1. PEFR \<50% 2. Can’t complete sentence in one breath 3. RR \>25 4. HR \>110

Answer 26

1. PEFR \<33% 2. SpO2 \<92%, PCO2 \>4.6kPa, PaO2 \<8kPa 3. **C**yanosis 4. **H**ypotension 5. **E**xhaustion, confusion 6. **S**ilent chest, poor respiratory effort 7. **T**achy-/brady-/arrhythmias

Answer 27

* pneumothorax * acute exacerbation of COPD * Pulmonary oedema

Answer 28

* Life-threatening attack * Feature of severe attack persisting despite initial Rx * May discharge if PEFR \> 75% 1h after initial Rx

Answer 29

**_When do dischage_** * Been stable on discharge meds for **24h** * **PEFR \>75%** c¯ **diurnal** variability **\<20%** **_Discharge Plan_** * TAME pt. * Technique for inhaler use * Avoidance: allergies, snoke, dust * Monitor: peak flow diary (2-4x/day) * Educate: * liase with specialist nurse * need for Rx compliance * emergency action pack * PO steroids for 5d * GP appointment w/i 1 wk. * Resp clinic appointment w/i 1mo

Answer 30

**Peripheral Inspection** * General * Cachexia * Hoarse voice or stridor * Hands * Clubbing ± HPOA (*Hypertrophic pulmonary osteoarthropathy)* * Tar staining * Claw hand c¯ wasting of interossei * Face * Anaemia * Horner’s * Plethora * Neck * LNs: check axilla too * Dilated veins **Chest** * Thoracotomy scar * Radiotherapy square burn + tattoo * Acanthosis nigricans 1.Collapse * Tracheal deviation towards lesion * ↓ expansion * PN: dull * Auscultation * ↓ or absent AE * ± crackles * ↑ VR 2. Effusion * Tracheal deviation away * ↓ expansion * PN: stony dull * Auscultation: ↓ AE * ↓ VR * *Extras:** *Hepatomegaly* or *spinal* tenderness * *Complications** 1. SVCO * Plethoric, oedematous face and upper limbs * Dilated neck and chest veins * Stridor 2. RLNP: hoarse voice c¯ bovine cough 3. Pancoast Tumour * Horner’s * Claw hand c¯ interossei wasting 4. Dermatomyositis

Answer 31

Consolidation collapse Effusion

Answer 32

* **Peripheral Inspection** * Clubbing * Cachexia * **Chest** * Scars * Lateral thoracotomy * Clamshell: double lung Tx * Chest drains * Chest wall asymmetry / deformity * Pneumonectomy Vs Lobectomy: * **Pneumonectomy** * Tracheal *+ apex* shift to abnormal side * Throughout normal sied: * reduced expansion * dull percussion * **no** breath sounds * **Lobectomy** * Teacheal shift * mainly upper lobectomy, therefore shift to abnormal side * Focal signs * reduced expansion * dull percussion * reduced breathsounds * **Completion** * ****history * CXR

Answer 33

* Lobectomy * Pneumonectomy * Scar but normal lung * Thoracotomy: * abscess * empyema * biopsy * wedge * Transplant: ? other lung normal

Answer 34

* 90% for non-disseminated _bronchial carcinoma_ * Other * _Bronchiectasis_ * _COPD_: lung-reduction surgery * _TB_: historic, upper lobe

Answer 35

Lobectomy: 7% Pneumonectomy: 12%

Answer 36

* ↑ ASA grade * Age \>70 * Poor resp function * FEV1:FVC \<55%

Answer 37

* 3rd commonest malignancy in men and women * Commonest cause of cancer death

Answer 38

* Non-Small Cell Lung Cancer * **SCC**: 35% * Highly related to smoking * Centrally located * PTHrP → ↑ Ca2+ * **Adenocarcinoma**: 25% * RF: female non-smokers * Peripherally located * 80% present c¯ extrathoracic mets * **Large-cell:** 10% * **Small Cell Lung Cancer:** 20% * Highly related to smoking * Central location * 80% present c¯ advanced disease * Ectopic hormone secretion

Answer 39

* Symptoms * Cough + haemoptysis * Dyspnoea * Chest pain * Anorexia and wt. loss * Smoking * Occupational expose

Answer 40

* **Local** * Recurrent laryngeal N. palsy * Phrenic N. palsy * SVCO * Horner’s (Pancoast’s tumour) * AF * **Paraneoplastic** * Endo * ADH → SIADH (euvolaemic ↓Na+) * ACTH → Cushing’s syndrome * Serotonin → carcinoid (flushing, diarrhoea) * PTHrP → 1 HPT (↑Ca2+, bone pain) – SCC * Rheum * Dermatomyositis / polymyositis * Neuro * Cerebellar degeneration * Peripheral neuropathy * Derm * Acanthosis nigricans * Trousseau syndrome: thrombophlebitis migrans * **Metastatic** * Pathological # * Hepatic failure * Confusion, fits, focal neuro * Addison’s

Answer 41

* *1. Bloods** - FBC: anaemia, ↑WCC if consolidation - U+E: ↓ Na (SIADH or Addison’s) - LFTs: deranged LFTs 2 to liver mets - Bone profile: ↑ Ca2+ (bone mets, ↑PTHrP) * *2.** **Dx of Mass** - CXR - Coin lesions - Effusion - Consolidation or collapse - Hilar LNs - Bony mets - Contrast-enhanced volumetric CT thorax * *3. Determine Cell Type** - Cytology - Induced sputum - US-guided pleurocentesis - Histology - Percutaneous FNA: adenocarcinoma - Endoscopic transbronchial biopsy: SCC * *4. Staging** - CT: neck, thorax, upper abdo ± brain - PET - Radionucleotide bone scan - Thoracoscopy, mediastinoscopy + LN sampling * *5. Pulmonary Function Tests** - Assess fitness for surgery - Pneumonectomy CI if FEV1 \<1.2L

Answer 42

General * MDT * Stop smoking * Optimise nutrition and CV function

Answer 43

* *Surgery** - Rx of choice if no metastatic spread (Stage 1/2:~25%) - Wedge resection, lobectomy, pneumonectomy * *Curative Radio:** if poor cardiorespiratory function * *Chemo:** platinum-based + biologics

Answer 44

* *Usually disseminated @ presentation* * *Some benefit c¯ chemo*

Answer 45

* *Analgesia**: opiates for pain and cough * *Radiotherapy**: haemoptysis, bone or CNS mets * *SVCO**: dex + radio or intravascular stent * *Persistent effusions:** chemical pleurodesis

Answer 46

* NSCLC: 50% 5ys w/o spread; 10% c¯ spread * SCLC: 1-1.5yrs median survival treated; 3mo untreated

Answer 47

Inspection * Asymmetry: absent ribs * Scars * Thoracoplasty * Supraclavicular fossa: phrenic nerve crush Palpation * Tracheal deviation towards apical fibrosis * ↓ expansion PN: dull * Auscultation * ± bronchial breathing * ↓ AE * Crackles * ↑VR

Answer 48

*It was believed that lower **PAO2** would inhibit TB proliferation. THEREFORE -\> inducing apical collapse was a treatment* Techniques 1. Plombage: insertion of polystyrene balls into thoracic cavity 2. Phrenic nerve crush: diaphragm paralysis 3. Thoracoplasty: rib removal to collapse lung 4. Apical lobectomy

Answer 49

* Aspergilloma in old TB cavity * Bronchiectasis * LN compression of large airways * Traction from fibrosis * Scarring predisposed to bronchial Ca

Answer 50

Initial Phase (RHZE): **2mos** 1. RMP: hepatitis, orange urine, enzyme induction 2. INH: peripheral sensory neuropathy, ↓PMN 3. PZA: hepatitis, arthralgia (CI: gout, porphyria) 4. EMB: optic neuritis → loss of colour vision first Continuation Phase (RH): **4mos** RMP INH

Answer 51

* Childhood or naïve TB infection * Organism multiplies @ pleural surface → Ghon Focus * Macros take TB to LNs * Nodes + lung lesion = Ghon complex * Mostly asympto: may → fever and effusion * Cell mediated immunity / DTH controls infection in 95% * Fibrosis of Ghon complex → calcified nodule (Ranke complex) * Rarely may → 1O progressive TB (immunocomp)

Answer 52

* Resembles acute bacterial pneumonia * Mid and lower zone consolidation, effusions, hilar LNs * Lymphohaematogenous spread → extra-pulmonary and milliary TB

Answer 53

**Latent TB** * Infected but no clinical or x-ray signs of active TB * Non-infectious * May persist for years * Weakened host resistance → reactivation **Secondary TB** * Usually reactivation of latent TB due to ↓ host immunity * May be due to reinfection * Typically develops in the upper lobes * Hypersensitivity → tissue destruction → cavitation and formation of caseating granulomas.

Answer 54

**Latent TB** * Tuberculin Skin Test * If +ve → IGRA **Active TB** * CXR * Mainly upper lobes. * Consolidation, cavitation, fibrosis, calcification * If suggestive CXR take ≥3 sputum samples (one AM) * May use BAL if can’t induce sputum * Microscopy for AFB: Ziehl-Neelsen stain * Culture: Lowenstein-Jensen media (Gold stand)

Answer 55

* Can Dx rifampicin resistance * May be used for sterile specimens

Answer 56

* Intradermal injection of purified protein derivative * Induration measured @ 48-72h * False +ve: BCG, other mycobacteria, prev exposure * False –ve: HIV, sarcoid, lymphoma

Answer 57

* Pt. lymphocytes incubated c¯ M. tb specific antigens → IFN-γ production if previous exposure. * Will not be positive if just BCG (uses M. bovis) E.g. Quantiferon Gold and T-spot-TB

Answer 58

**Peripheral Inspection** * Ill looking * Febrile * ↑RR, ↑HR, AF * Cough * Rusty sputum **Chest: Consolidation** * ↓ expansion * PN: dull * Auscultation * Bronchial breathing * ↓ AE * Focal coarse crackles * Pleural rub * ↑VR **Extras** * Para-pneumonic effusion * Erythema multiforme: mycoplasma

Answer 59

Collapse effusion

Answer 60

1. Symptoms * Fever, rigors, anorexia, malaise * Cough + sputum ± haemoptysis * Pleurisy 2. Smoking 3. Travel and contacts 4. Immunosuppression: HIV, steroids

Answer 61

* **Bedside** * Sputum MC+S, cytology * Urine * Pneumococcal Ag * Hb: cold agglutinins → haemolysis * **Bloods** * FBC: ↑ WCC * U+E: dehydration, ↓Na * CRP: trend * LFT: ↑LFTs in mycoplasma, Legionella * Culture: 25% positive * Paired Sera: Mycoplasma, Chlamydia, Legionella * ABG * **CXR** * Consolidation c¯ air bronchogram * Effusion * Cavities: esp. S. aureus * **Other** * Pleurocentesis * BAL

Answer 62

*Assess severity and Mx accordingly* 1. Specific - Abx - Analgesia 2. Supportive - Oxygen - Fluids - Chest physio

Answer 63

1. Septic *shock* + *MOF* (multiple organ failure) : ITU 2. Para-pneumonic *effusion* or *empyema*: drainage 3. Respiratory *failure*: ventilation 4. *Abscess*: drainage

Answer 64

* *CXR @ 6 wks:** Check for underlying Ca and resolution * *Smoking cessation** * *Pneumovax** (23 valent) Re-vaccinate every **6yrs** * ≥65yrs * Chronic HLRP failure or conditions * Immunosupp: DM, hyposplenism, chemo, HIV

Answer 65

* *Incidence**: 1/100 * *Mortality**: 10% in hospital, 30% in ITU

Answer 66

* *Bronchopneumonia** - Patchy consolidation of different lobes * *Lobar Pneumonia** - Fibrosuppurative consolidation of a single lobe - Congestion → red → grey → resolution

Answer 67

**Community Acquired Pneumonia** * Commonest organisms * Pneumococcus: 50% * Mycoplasma: 6% * Haemophilus: esp. if COPD * Chlamydia pneumonia * Viruses: 15% * Other organisms * S. aureus * Moraxella * Legionella * Rx: amoxicillin + clarithromycin **Hospital Acquired Pneumonia** \>48hrs after hospital admission * Common organisms * Pseudomonas * MRSA * Gm-ve enterobacteria * Rx: co-amoxiclav or tazocin ± vanc **Aspiration** ↑ Risk: stroke, bulbar palsy, ↓GCS, GORD, achalasia * Typically posterior segment of RLL * Orgnaisms: anaerobes * Rx: co-amoxiclav **Immunocompromised** * PCP: co-trimoxazole * TB: RIPE * Fungi: amphotercin * CMV/HSV: ganciclovir

Answer 68

* Refers to organisms which cause *_atypical generalised symptoms and bronchopneumonia_* * Fever, headaches, myalgia * Poor correlation between clinical and x-ray findings * Often intracellular: *mycoplasma*, *Chlamydia, Legionella*

Answer 69

**CURB-65** (only if x-ray changes) * Confusion (AMT ≤8) * Urea \>7mM * Resp. rate \>30/min * BP \<90/60 * ≥65 Score * 0-1 → home Rx * 2 → hospital Rx * ≥ 3 → consider ITU

Answer 70

1. WCC: \<4 or \>12 2. Temp: \>38 or \<32 3. PaO2: \<8KPa 4. AF 5. Multiple lobar involvement

Answer 71

1. Septic shock and MOF 2. Para-pneumonic effusion / empyema 3. Abscess: S. aureus, Klebsiella, anaerobes 4. Respiratory failure

Answer 72

**Inflam response to a variety of insults manifest by ≥ 2 of:** * Temperature: \>38°C or \<36°C * Heart rate: \>90 * Respiratory rate: \>20 or PaCO2 \<4.6 KPa * WCC: \>12x109/L or \<4 x109/L or \>10% bands * *Sepsis:** SIRS caused by infection * *Severe Sepsis:** Sepsis c¯ at least 1 organ dysfunction or hypoperfusion * *Septic Shock:** Severe sepsis with refractory hypotension

Answer 73

*Impairment of ≥2 organ systems Homeostasis cannot be maintained without therapeutic intervention.*

Respiratory Flashcards

(98 cards)