Respiratory Flashcards

Question

Summarise the epidemiology of bronchiectasis

Answer 1

Most often arises initially in childhood Incidence has decreased with use of ABx 1/1000 per year

Answer 2

Chronic lung inflammation --> fibrosis + permananet dilation of bronchi --> mucus pooling --> predisposes to further cycles of infection, damage, and fibrosis of bronchial walls Causes: Idiopathic (50%) Post-infections - eg pneumonia, whooping cough, TB Host-defence defects - eg Kartagener's syndrome, CF Obstruction of bronchi - eg foreign body, enlarged LNs GORD Inflammatory disorders - eg RA

Answer 3

Productive cough w purulent sputum or haemoptysis Breathlessness Chest pain Malaise Fever Weight loss Symptoms usually begin after acute respiratory illness

Answer 4

Clubbing Coarse crepitations (usually at lung bases) that shift with coughing Wheeze

Answer 5

Sputum: Culture and sensitivity ``` CXR: Dilated bronchi - tramline shadows (parallel lines from hilum to diaphragm) Fibrosis Atelectasis Pneumonic consolidations May be normal ``` High-res CT: Best diagnostic method Dilated bronchi w thickened walls

Answer 6

Conservative: Maintain hydration Flu vaccination Physiotherapy - enable sputum and mucus clearance Medical: Acute exacerbation - 2 IV ABx which cover Pseudomonas aeruginosa Prophylactic ABx w >3 exacerbations/yr ICS eg fluticasone - to reduce inflammation and sputum volume Bronchodilators Surgical: Bronchial artery embolisation - if life-threatening haemoptysis Localised resection Lung/heart-lung transplantation

Answer 7

``` Life-threatening haemoptysis Persistent infections Empyema Respiratory failure Cor pulmonale Multi-organ abscesses ```

Answer 8

Most patients continue to have symptoms after 10 years

Answer 9

``` Pseudomonas aeruginosa Haemophilus influenzae Staphylococcus aureus Streptococcus pneumoniae Klebsiella Mycobacteria ```

Answer 10

Interstitial inflammatory disease of the distal gas-exchanging parts of the lung AKA hypersensitivity pneumonitis

Answer 11

Uncommon 2% of occupational lung disease 50% of reported cases affect farm workers Geographical variation

Answer 12

Inhalation of antigenic dusts induce a hypersensitivity response in susceptible individuals Antigenic dusts include microbes and animal proteins Eg Farmer's Lung - mouldy hay containing thermophilic actinomycetes Pigeon Fancier's Lung - blood on bird feathers and excreta Maltworker's Lung - barley/maltings containing Aspergillus clavatus

Answer 13

Smoking Viral infection Exposure to avian protein/mould/bacterial antigen Exposure todiisocyanate Exposure to acid anhydride antigen Exposure to metal-working fluid Nitrofurantoin, methotrexate, roxithomycin, rituximab Herbal supplements with ayurvedic medicine

Answer 14

``` Dyspnoea Non-productive/productive cough Fever/chills Malaise Weight loss/anorexia ```

Answer 15

Acute: Rapid shallow breathing Pyrexia Inspiratory crepitations Chronic: Fine inspiratory crepitations Clubbing

Answer 16

1. Bloods FBC - neutrophilia, lymphopenia ABG - reduced PO2 + PCO2 2. Serology - IgG to fungal/avian antigens 3. CXR - often normal in acute episodes - fibrosis in chronic 4. High-rest CT thorax - patchy 'ground glass' shadowing and nodules 5. Lung function tests - restrictive defect (low FEV1, low FVC) - preserved or increased FEV1:FVC - reduced TLC 6. Bronchoalveolar lavage - increased cellularity - biopsy

Answer 17

Inflammatory condition of the lung resulting in fibrosis of the alveoli and interstitium

Answer 18

Rare 6/100,000 More common in males

Answer 19

Genetically predisposed host (e.g. surfactant protein mutations); recurrent alveolar damage results in cytokine release, activating fibroblasts, differentiating into myofibroblasts and increased collagen synthesis Drugs can produce similar illnesses (bleomycin, methotrexate, amiodarone)

Answer 20

Smoking Occupational exposure to metal or wood Chronic microaspiration Animal and vegetable dusts

Answer 21

Gradual-onset, progressive SOB on exertion Dry cough No wheeze Symptoms may be preceded by viral-type illness

Answer 22

Clubbing Bibasal fine late inspiratory crackles Signs of RHF in advanced disease

Answer 23

Bloods: ABG - normal early, PO2 decreases w exercise, normal PCO2, rises in late disease ANA/RF - 1/3 pts +ve CXR: Normal at presentation Early disease - ground glass shadowing Later disease - reticulonodular shadowing, signs of cor pulmonale, honeycombing High-res CT: More sensitive in early disease than CXR - ground- glass ``` Lung function tests: Restrictive features - reduced FEV1 and FVC, w preserved or increased FEV1:FVC Decreased lung volumes Decreased lung compliance Decreased TLC ``` Lung biopsy - gold standard for diagnosis

Answer 24

A disease characterised by recurrent prolapse of the pharyngeal airway and apnoea (cessation of airflow > 10s) during sleep, followed by arousal from sleep AKA Pickwickian Syndrome

Answer 25

Common 5-20% of men > 35 years 2-5% of women > 35 years Prevalence increases with age

Answer 26

Occurs due to narrowing of the upper airways because of the collapse of soft tissues of the pharynx Due to decreased tone of pharyngeal dilators during sleep

Answer 27

``` Weight gain Smoking Alcohol Sedative use Enlarged tonsils and adenoids in children Macroglossia Marfan's syndrome Craniofacial abnormalities ```

Answer 28

``` Excessive daytime sleepiness Unrefreshing or restless sleep Morning headaches Dry mouth Difficulty concentration Irritability and mood changes Partner reporting snoring, nocturnal apnoeic episodes or nocturnal choking ```

Answer 29

``` Large tongue Enlarged tonsils Long or thick uvula Retognathia (pulled back jaws) Neck circumference > 42 in males/40 in females Obesity Hypertension ```

Answer 30

Sleep study - monitor airflow, respiratory effort, pulse oximetry and HR Bloods - TFTs, ABG

Answer 31

Fibrosing interstitial lung disease

Answer 32

Occupational exposure to silica, coal, beryllium High cumulative dose of inhaled silica or coal Cigarette smoking Chronic beryllium disease: glutamic acid at position 69 of the HLA-DP1 beta chain

Answer 33

``` Insidious onset SOB Dyspnoea on exertion Dry cough Black sputum (melanoptysis) Pleuritic chest pain ```

Answer 34

Normal chest exam Silicosis: decreased breath sounds, signs of RHF Asbestosis: Bi-basal, inspiratory crepitations Clubbing Signs of pleural effusion or RHF (cor pulmonale)

Answer 35

1. CXR Simple: micronodular mottling Complicated: nodular opacities in upper zones, micronodular shadowing, eggshell calcification of hilar LNs (characteristic of silicosis), bilateral lower zone reticulonodular shadowing and pleural plaques (in asbestosis) 2. CT scan - fibrotic changes 3. Bronchoscopy 4. Lung function tests - restrictive pattern (reduced FEV1 and FVC)

Answer 36

A chronic gramulomatous disorder of unknown aetiology, commonly affecting the lungs, skin, and eyes. Characterised by accumulation of lymphocytes and macrophages and the formation of non-caseating granulomas in the lungs and other organs.

Answer 37

Age 20-40 years FHx sarcoidosis Scandinavian origin

Answer 38

``` Cough Dyspnoea Chronic fatigue Arthralgia Wheeze Rhonchi - bronchospasm Photophobia Red painful eye Blurred vision ```

Answer 39

Lymphadenopathy | Red eye

Answer 40

1. CXR Hilar and/or paratracheal adenopathy with upper lobe predominant, bilateral infiltrates; pleural effusions (rare) and egg shell calcifications (very rare) ``` 2. Bloods FBC: anaemia, leukopenia Serum urea: elevated Creatinine: elevated Liver enzymes: elevated Serum Ca: elevated ``` 3. Lung function tests Restrictive/obstructive/mixed pattern 4. ECG - conduction defects 5. Purified protein derivative of tuberculin (PPD) - negative

Answer 41

Granulomatous disease caused by Mycobacterium tuberculosis

Answer 42

Annual mortality = 3 million (95% in developing countries) Annual UK incidence = 6000 Asian immigrants are highest risk group in UK

Answer 43

``` Primary TB: Mostly asymptomatic Fever Malaise Cough Wheeze Erythema nodosum Phlyctenular conjunctivitus ``` ``` Miliary TB: Fever Weight loss Meningitis Yellow caseous tubercles spread to other organs ``` Post-primary TB: Fever/night sweats Malaise

Answer 44

``` Exposure to infection Born in Asia, Latin America, Africa HIV infection Immunosuppressive medicines: systemic CS, TNF-alpha antagonists Silicosis 30x risk Apical fibrosis ```

Answer 45

Infection by Mycobacterium tuberculosis (IC organism) | Survives after being phagocytosed by macrophages

Answer 46

``` Mostly asymptomatic Fever Malaise Cough Wheeze Erythema nodosum Phlyctenular conjunctivitus ```

Answer 47

Fever Weight loss Meningitis Yellow caseous tubercles spread to other organs

Answer 48

1. CXR: abnormal typical for TB; abnormal atypical for TB; or normal 2. Sputum acid-fast bacilli smear: positive for acid-fast bacilli 3. Sputum culture: positive; no growth; or other mycobacteria 4. FBC: raised WBC, low Hb 5. Nucleic acid amplification tests: +ve for M tuberculosis

Answer 49

``` Fever Night sweats Malaise Weight loss Breathlessness Cough Sputum Haemoptysis Pleuritic chest pain Signs of pleural effusion Collapse Consolidation Fibrosis ```

Answer 50

Haematogenous dissemination of TB

Answer 51

Reinfection or reactivation of TB

Answer 52

Initial infection may be pulmonary or, more rarely, gastrointestinal

Answer 53

``` Subacute obstruction Change in bowel habit Weight loss Peritonitis Ascites ```

Answer 54

``` Subacute obstruction Change in bowel habit Weight loss Peritonitis Ascites ```

Answer 55

Infection of distal lung parenchyma

Answer 56

5-11/1000 | Community-acquired pneumonia is responsible for > 60,000 deaths per year in UK

Answer 57

``` Age Smoking Alcohol Pre-existing lung disease Immunodeficiency Contact with patients with pneumonia ```

Answer 58

``` Fever Rigors Sweating Malaise Cough Sputum Breathlessness Pleuritic chest pain Confusion ```

Answer 59

``` Pyrexia Respiratory distress Tachypnoea Tachycardia Hypotension Cyanosis Decreased chest expansion Dull to percuss over affected area Increased tactile vocal fremitus over affected area Bronchial breathing over affected area Coarse crepitations on affected side ```

Answer 60

``` 1. Bloods FBC - raised WCC U+Es LFTs Culture ABG - assess pulmonary function Film - Mycoplasma causes red cell agglutination ``` 2. CXR Lobar or patchy shadowing Pleural efusion Note: Klebsiella often affect upper lobes May detect complications, eg lung abscess 3. Sputum/pleural fluid - MC&S 4. Urine - Penumococcus and Legionella antigens 5. Atypical viral serology 6. Bronchoscopy and bronchoalveolar lavage - if Penumocystis carinii pneumonia suspected, or if pneumonia fails to resolve

Answer 61

1. Assess severity using BTS guidelines 2. Empirical ABx - oral amoxicillin (0 markers) - oral/IV amoxicillin + erythromycin (1 marker) - IV cefurozime/cefotaxime/co-amoxiclav + erythromycin (>1 marker) - add metronidazole if: aspiration, lung abscess, empyema - switch to appropriate antibiotic based on sensitivity 3. Supportive treatment - oxygen - IV fluids - CPAP, BiPAP, ITU care for resp failure - surgical drainage for abscess/empyema 4. Discharge planning If 2+ features of clinical instability present (high temp, tachycardia, tachypnoea, hypotension, low O2 sats) - high risk of readmission and mortality Consider other causes if pneumonia not resolving

Answer 62

``` Pleural effusion Epyema Localised suppuration, eg abscess - swinging fever, persistent pneumonia, copious/foul-smelling sputum Septic shock ARDS Acute renal failure ```

Answer 63

Most resolve with Tx within 1-3 weeks Severe pneumonia has high mortality

Answer 64

``` Community-acquired Hospital-acquired/nosocomial Aspiration Pneumonia in the immunocompromised Typical Atypical (Mycoplasma, Chlamydia, Legionella) ```

Answer 65

Headache Myalgia Diarrhoea/abdo pain Dry cough

Answer 66

Used to assess severity of pneumonia ``` Confusion < 8 AMTS Urea > 7 mmol/L Respiratory rate > 30/min Blood pressure: systolic < 90mmHg or diastolic < 60mmHg Age > 65 years ```

Answer 67

Pneumococcal vaccine Haemophilus influenzae type B vaccine Given to high risk groups, eg elderly, spenectomy

Answer 68

Pneumococcal vaccine Haemophilus influenzae type B vaccine Given to high risk groups, eg elderly, splenectomy

Answer 69

Air in the pleural space

Answer 70

Annual incidence: 9/100,000 20-40yos 4x more common in males

Answer 71

Spontaneous: - occurs in people w typically normal lungs - typically in tall, thin males - probably caused by rupture of subpleural bleb Secondary: - pre-existing lung disease, eg COPD, asthma, TB Traumatic: - penetrating injury to chest - often iatrogenic, eg during jugular venous cannulation, thoracocentesis

Answer 72

``` Smoking FHx Tall and slender <40yo Recent invasive medical procedure Chest trauma Acute severe asthma COPD TB AIDS-related Pneumocystis jirovecii infection CF Lymphangioleiomyomatosis Birt-Hogg-Dube syndrome Pulmonary Langerhans cell histiocytosis Erdheim-Chester disease ```

Answer 73

May be asymptomatic if small Sudden-onset breathlessness Pleuritic chest pain Distress w rapid shallow breathing in tension pneumothorax

Answer 74

``` No signs if small Signs of respiratory distress Reduced expansion Hyper-resonance to percussion Reduced breath sounds ``` ``` Tension pneumothorax: Severe resp distress Tachycardia Hypotension Cyanosis Distended neck veins Tracheal deviation away from side of pneumothorax ```

Answer 75

CXR: - dark area of film w no lung markings - fluid level may be seen if there is any bleeding ABG: check for hypoxaemia

Answer 76

Oxygen Chest-tube thoracostomy Immediate needle decompression (tension) Suction

Answer 77

Recurrent pneumothoraces | Bronchopleural fistula

Answer 78

20% have another pneumothorax | Frequency increases w repeated pneumothoraces

Answer 79

Occlusion of pulmonary vessels, most commonly by a thrombus that has travelled to the pulmonary vascular system from another site

Answer 80

``` Relatively common (especially in hospitalised patients) Occur in 10-20% of patients with confirmed proximal DVT ```

Answer 81

Thrombus 95% arise from DVT in lower limbs Rarely arises in right atrium (in AF patients) ``` Other causes of embolus: Amniotic fluid Air Fat Tumour Mycotic ```

Answer 82

``` Surgical patients Immobility Obesity OCP Heart failure Malignancy ```

Answer 83

Depends on site and size of embolus Small - may be asymptomatic Moderate - sudden onset SOB, cough, haemoptysis, pleuritic chest pain Large (or proximal) - as above + severe central pleuritic chest pain, shock, collapse, acute RHF, sudden death Multiple small recurrent - symptoms of pulmonary HTN

Answer 84

Small - often no clinical signs, may be some tachycardia and tachypnoea Moderate - tachypnoea, tachycardia, pleural rub, low O2 sats despite supplementation Massive - shock, cyanosis, signs of right heart strain (raised JVP, left parasternal heave, accentuated S2) Multiple recurrent PE - signs of pulmonary HTN, signs of RHF

Answer 85

Well's Score used to determine best investigation for PE Low probability (Wells 4 or less) - use D-dimer High probability (Wells>4) - requires imaging (CTPA) Also: Bloods - ABG, thrombophilia screen ECG - normal, tachycardia, right axis deviation or RBBB, S1Q3T3 pattern CXR - often normal but helps exclude other diagnoses VQ scan - shows areas of mismatch --> infarcted lung Doppler US of lower limb - VTE Echocardiography - may show right heart strain

Answer 86

Primary prevention: Compression stockings Heparin prophylaxis for those at risk Good mobilisation and adequate hydration ``` If haemodynamically stable: O2 Anticoagulation w heparin or LMWH Switch over to oral warfarin for at least 3 months Maintain INR 2-3 Analgesia ``` If haemodynamically unstable (massive PE): Resuscitate O2 IV fluids Thrombolysis with tPA considered if cardiac arrest imminent Surgical/radiological: Embolectomy IVC filtres - sometimes used for recurrent PEs despite adequate anticoagulation/when CI

Answer 87

Death Pulmonary infarction Pulmonary hypertension Right heart failure

Answer 88

30% mortality in those left untreated 8% mortality with treatment Increased risk of future thromboembolic disease

Answer 89

Primary malignant neoplasm of the lung Small cell - 20% Non-small cell - 80%

Answer 90

Most common fatal cancer in the west 18% of cancer mortality worldwide 3x more common in males

Answer 91

Smoking Asbestos exposure Other occupational exposure: polycyclic hydrocarbons, nickel, radon Atmospheric pollution

Answer 92

May be asymptomatic Primary: Cough, haemoptysis, chest pain, recurrent pneumonia Local invasion: Brachial plexus invasion --> shoulder/arm pain Left recurrent laryngeal nerve invasion --> hoarse voice and bovine cough Dysphagia Arrhytmias Horner's syndrome ``` Metastatic disease/paraneoplastic phenomenon: Weight loss Fatigue Fractures Bone pain ```

Answer 93

May be asymptomatic Primary: Cough, haemoptysis, chest pain, recurrent pneumonia Local invasion: Brachial plexus invasion --> shoulder/arm pain Left recurrent laryngeal nerve invasion --> hoarse voice and bovine cough Dysphagia Arrhytmias Horner's syndrome ``` Metastatic disease/paraneoplastic phenomenon: Weight loss Fatigue Fractures Bone pain ```

Answer 94

May be NO SIGNS Fixed monophonic wheeze (single obstruction) Signs of lobar collapse or pleural effusion Signs of metastases - Virchow's node

Answer 95

Chronic, progressive lung disorder characterised by airflow obstruction that is not fully reversible, with the following: Chronic bronchitis - chronic cough and sputum production on most days for at least 3 months per year over 2 consecutive years Emphysema - pathological diagnosis of permanent destructive enlargement of air spaces distal to terminal bronchioles

Answer 96

Very common - 8% prevalence Presents in middle age or later More common in males Increasingly common in females

Answer 97

``` Chronic cough Sputum production SOB Some wheeze Reduced exercise tolerance ```

Answer 98

General inspection: Tar staining Cyanosis Barrel chest Palpation: Reduced expansion Percussion: Hyper-resonance Auscultation: Reduced air mvmt Wheezing Coarse crackles (hair-like) Other: Signs of RHF

Answer 99

Spirometry and lung function tests: Obstructive picture - reduced PEFR, FEV1:FVC, increased lung volumes, decreased CO gas transfer coefficient ``` CXR: May appear normal Hyperinflation (>6 anterior ribs, flattened diaphragm) Reduced peripheral lung markings Elongated cardiac silhouette ``` Bloods: FBC - increased Hb and hct due to secondary polycythaemia ABG: hypoxia, normal/raised PCO2 ECG and echocardiogram: check for cor pulmonale Sputum and blood cultures: useful in acute infective exacerbations A1 antitrypsin levels (deficiency)

Answer 100

``` Acute respiratory failure Infections Pulmonary hypertension Right heart failure Pneumothorax - secondary to bullae rupture Secondary polycythaemia ```

Answer 101

High morbidity 3-year surivial of 90% if < 60 years, FEV1 > 50% predicted 3-year survival of 75% if > 60 years, FEV1: 40-49% predicted

Answer 102

Diffuse interstitial fibrosis of the lung as a consequence of exposure to asbestos fibres

Answer 103

Inhalation of asbestos fibres A fibrous silicate, a naturally occurring mineral The more asbestos inhaled, the greater the risk of developing asbestosis

Answer 104

Cumulative dose of inhaled asbestos | Smoking (reduces ability of lung to clear asbestos fibres)

Answer 105

SOB on exertion | Dry, non-productive cough

Answer 106

Dyspnoea Crackles - initially at bases Clubbing in advanced disease

Answer 107

1. CXR: PA and lateral Lower zone linear interstitial fibrosis; progressively involves entire lung; pleural thickening 2. Lung function tests Restrictive changes May have obstructive picture - esp if Hx of asbestos exposure and smoking

Answer 108

An aggressive epithelial neoplasm arising from the lining of the lung, abdomen, pericardium, or tunica vaginalis

Answer 109

More common in men and white people Typically occurs in 60-90yos In UK, incidence increasing rapidly since 60s Country-to-country variation due to disparities in asbestos use and regulation

Answer 110

Asbestos exposure Dose-response relationship Latency period between exposure and development of malignancy = 20-40 years Also: Radiotherapy Genetic - BAP1 mutation, SV-40

Answer 111

Asbestos exposure 60-85 yo due to latency period (20-40 years) Male FHx

Answer 112

Increasing SOB Chest pain Dry, non-productive cough Constitutional: fever, fatigue, sweats, weight loss

Answer 113

Laboured breathing Diminished breath sounds (due to effusion, trapped lung, bronchial obstruction) Dullness to percussion (effusion)

Answer 114

1. CXR - unilateral pleural effusion - irregular pleural thickening - reduced lung volumes - parenchymal changes, eg lower zone linear interstitial fibrosis 2. Chest CT - pleural thickening and/or discrete pleural plaques - pleural and/or pericardial effusions - enlarged hilar and/or mediastinal LNs - chest wall invasion and/or spread along needle tracts 3. Thoracentesis - exudate - malignant cells in pleural fluid

Answer 115

1. SABA - salbutamol 2. SABA + ICS - salbutamol + beclomethasone 3. LABA + ICS - salmeterol + beclomethasone 4. Trials - theophylline, oral beta-agonists, oral leukotriene receptor agonists (Montelukast) 5. Oral CS

Answer 116

PEF Moderate = 50-75% Acute-severe = 33-50 Life-threatening = <33 Near fatal = raised pCO2

Answer 117

1. Basic obs - HR, SpO2 2. Measure and record PEF 3. O2 saturation and maintain SpO2 at 94-98% 4. ABG 5. Serum K and glucose Repeat ABG if PaO2 <8kPa, unless SpO2 >92%; or initial PaCO2 is normal or raised; or if patient deteriorates

Answer 118

1. SABA or SAMA - salbutamol or ipratroprium bromide - MILD 2. Add LABA or LAMA - salmeterol or tiotropium - MODERATE 3. LAMA + LABA or LABA + ICS - symbicort (budesonide (ICS) and formoterol (LABA)) - SEVERE 4. LAMA + LABA + ICS - VERY SEVERE ``` Also: Smoking cessation Annual flu vaccine Pneumoccocal vaccine Long term O2 therapy Lung volume reduction surgery ```

Answer 119

pO2 < 7.3kPa and one of the following: - secondary polycythaemia - nocturnal hypoxaemia - peripheral oedema - pulmonary HTN

Answer 120

1. O2 2. Neb salbutamol 5mg/Neb ipratropium bromide 0.5mg 3. Oral prednisolone 40-50mg + IV hydrocortisone 100mg 4. IV magnesium sulphate + SENIOR HELP 5. IV aminophylline 6. ITU + intubation

Answer 121

1. (Blue Venturi) 24% O2 2. Neb salbutamol 5mg, neb ipratropium bromide 0.5mg 3. Oral prednisolone 40-50mg, IV hydrocortisone 200mg 4. IV amoxicillin 5. 500mg IV aminophylline 6. BiPAP (NIV)

Answer 122

``` FEV1 % > 80% - mild 50-79% - moderate 30-49% - severe < 30% very severe ```

Answer 123

Malignancy Empyema lung abscess ILD CF

Respiratory Flashcards

(148 cards)