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Respiratory Flashcards

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1
Q

Stepwise long-term management of Asthma

A

(1) SABA
(2) SABA + ICS
(3) SABA + ICS + LTRA
(4) SABA + ICS + LABA

+/- Continue LTRA depending on their response to LTRA

(5) SABA + MART (w/ Low-dose ICS)
(6) SABA + MART (w/ Moderate-dose ICS)
(7) Specialist
- Muscarinic receptor antagonist
- Theophylline
- High dose ICS
- Oral prednisolone

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2
Q

Causes of upper lobe fibrosis

A

Tip: CHARTS

Coal workers pneumoconiosis

Hypersensitivity pneumonitis (= EAA)

Ank Spond + Aspergillosis (ABPA)

Radiation

TB

Sarcoidosis + Silicosis

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3
Q

Causes of lower lobe fibrosis

A
  • Asbestosis
  • Connective tissue disorders (except Ank Spond –> Aprical)
    • RA
    • SLE
    • Scleroderma
    • Sjogren’s
    • Polymyositis / Dermatomyositis
  • Idiopathic pulmonary fibrosis
  • Drug-induced pulmonary fibrosis (BS NAME)
    • Bleomycin, Busulfan
    • Amiodarone
    • Nitrofurantoin
    • Sulfasalazine
    • Methotrexate
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4
Q

Causes of drug related pulmonary fibrosis

A

Tip: BS NAME

  • Bleomycin, Busulfan
  • Amiodarone
  • Nitrofurantoin
  • Sulfasalazine
  • Methotrexate
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5
Q

Causes of bilateral hilar lymphadenopathy

A
  • TB
  • Sarcoidosis
  • Lymphoma
  • Pneumoconiosis
  • Fungi (Histoplasmosis, Coccidioidomycosis)
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6
Q

Classifying the different severities of Asthma

A
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7
Q

Define

  • Inspiratory capacity
  • Vital Capacity
  • Total Lung Capacity
  • Functional residual capacity
  • Residual Volume
  • Tidal Volume
  • Inspiratory Reserve Volume
  • Expiratory Reserve Volume
A
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8
Q

Borders of safe triangle

A
  • Base of the Axilla
  • Pectoralis major (lateral edge)
  • 5th ICS
  • Latissimus dorsi (anterior border)
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9
Q

Where to insert the chest drain

A

In safe triangle

ABOVE the rib

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10
Q

Obstructive pattern on spirometry is defined as

A

↓↓ FEV1 (<80% predicted)

↓ FVC (but decreases by a lesser extent)

FEV1:FVC < 70% (predicted) ==> Obstructive

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11
Q

Causes of obstructive lung disease

A

Asthma

COPD

Bronchiectasis

Bronchiolitis obliterans

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12
Q

Positive reversibility testing is defined as

A

↑ FEV1 which is > 200ml AND 12% of the pre-test value

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13
Q

Classification of severity of COPD

Name of classification?

Based on what factor?

A

GOLD Classification - based on FEV1

Mild COPD: FEV1 > 80% (predicted) - i.e. normalises after medication

Moderate COPD: FEV1 50-79% (predicted)

Severe COPD: FEV1 30-49% (predicted)

Very severe COPD: FEV1 < 30% (predicted)

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14
Q

Restrictive pattern on spirometry is defined as

A

↓ FEV1 (<80% predicted)

↓ FVC (<80% predicted)

FEV1:FVC ratio (>70%)

i.e. preserved ratio but absolute values for both FEV1 and FVC are both lower

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15
Q

Causes of restritive lung disease

A
  • Pulmonary fibrosis
  • Pneumoconiosis / Asbestosis
  • Extrinsic allergic alveolitis
  • Neuromuscular conditions
  • Sarcoidosis
  • Kyphoscoliosis / Ankylosing spondyltitis
  • Neuromuscular conditions (affecting diaphragm)
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16
Q

Next investigation if

FEV1 < 80% predicted

reduced FVC

FEV1:FVC ratio < 0.7

A

Bronchodilator reversibility testing

Reversible –> Asthma (increase FEV1 by 200ml and 12%)

Irreversible –> COPD

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17
Q

TLCO is defined as

A

Total factor of the Lung for Carbon Monoxide

= rate at which a gas will diffuse from the alveoli into the blood

Carbon monoxide is used to test the rate of diffusion

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18
Q

Causes of increased and decreased TLCO

A
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19
Q

Varenicline

Indication?

MOA?

C/I

A

Varenicline

Indication: Smoking cessation

MOA: ACh receptor agonist –> reduced cravings of nicotine

C/I in Pregnancy, Breastfeeding

Caution: increased suicidal thoughts

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20
Q

Bupropion

Indication

MOA

C/I

A

Bupropion

Indication: Smoking cessation

MOA: NA and Dopamine re-uptake inhibitor (atypical antidepressant)

C/I in Pregnancy and Breastfeeding

S/E: Seizures

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21
Q

Pulsus paradoxus

Definition

Causes

A

Pulsus paradoxus = difference between sBP on inspiration and expiration > 20mmHg

Causes

  • Severe asthma
  • Cardiac tamponade
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22
Q

PERF variability

cut off?

indicates?

A

PEFR variability = (highest PEFR - lowest PEFR) / (average PEFR)

Uncontrolled asthma have ↑ variability in PEFR (worse in morning)

Values > 20% variability suggests asthma

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23
Q

Ix for diagnosis of (stable) Asthma

if High probability

if Intermidiate probability

A

High probability –> Trial treatment + Spirometry (FEV1 or serial PEFR)

Intermediate probability –> Spirometry + Bronchodilator reversibility

Obstructive pattern on spirometry

  • ↓↓ FEV1 < 80% (predicted or best)
  • ↓ FVC
  • FEV1:FVC ratio < 70% (predicted or best)

+ve bronchodilator response

  • ↑ FEV1 which is > 200ml AND 12% of the pre-test value
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24
Q

Ix to exclude Asthma if -ve Spirometry and -ve PEFR variability

A

Bronchial challenge test (using Histamine)

Negative test excludes Asthma

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25
Asthma attack given nebulised salbutamol ECG changes show?
Salbutamol **S**/E: **Hypokalaemia** ECG changse: **TWI + U waves + long QU interval**
26
Severe Asthma given IV MgSO4 S/E?
IV MgSO4 ## Footnote **Hypotension**
27
Severe asthma started on IV aminophylline S/E? Monitoring?
**IV Aminophylline** cardiac arrhythmias Requires cardiac monitor
28
Examples of asthma therapy SABAs LABAs ICS LTRA
SABAs * Salbutamol * Terbutaline LABAs * Salmeterol * Formeterol ICS * Beclometasone dipropionate / Clenil * Budesonide LTRA * Montelukast
29
Signs of well controlled asthma
Signs of well controlled asthma * **No daytime symptoms or waking at night** * **No exacerbations** * No need for reliver inhaler * Ideally, 1 SABA inhaler should last \> 1 year * **No limitations on activity** (including exercise) * **No asthma attacks** * Normal lung function (**PEFR \> 80%** of predicted or best) * **Minimal S/E from medication**
30
Kartagener's syndrome triad
**Kartagener's syndrome** bronchiectasis sinusitis situs inversus
31
Causes of bronchiectasis
* **Post-infection** (**Haemophilus influenzae** - most common) * Genetic * **Cystic fibrosis** * **a1 antitrypsin** * **Kartagener syndrome** (ciliary dyskinetic syndrome) * **Yellow nail syndrome**
32
CXR signs in bronchiectasis
CXR signs in bronchiectasis * Dilated bronchi / **Tramtrack opacities** * **Caose, thickened bronchidal markings** * **Ring shadows** (mainly in upper lobes) * **Fibrosis** * **Atelelactasis**
33
Ix for bronchiectasis
**HR-CT**: [best diagnostic method for bronchiectasis] * **Dilated airways** * +/- thickened wall * **Mucus plugs** * Tram-track sign * Signet ring sign
34
Management of bronchiectasis
Acute * Antibiotics * Bronchodilators * Hypertonic 3% saline nebs Long term * **Chest physiotherapy** --\> postural drainage * +/- Prophlactic ABx (**Azithromycin**) * +/- Surgical resection +/- Lung transplant
35
**a1 anti-trypsin deficiency** Mode of inheritence Clinical features
**a1 anti-trypsin deficiency** Autosomal recessive (**PIZZ** homozygous) Presents with **COPD** in yougng people + **Liver cirrhosis**
36
IECOPD - causes
IECOPD - causes * Viral URTI (30%) * **Rhinovirus** (most common viral cause) * Bacterial infection * **Haemophilus influenzae** (most common bacterial cause) * **Streptococcus pneumoniae** * **Moraxella catarrhaslia**
37
Diagnosis of COPD
Spirometry ## Footnote **_Post-bronchodilator_ FEV1/FVC ratio \< 0.70** on spirometry is **diagnostic for COPD**
38
Tx options which improve survival in COPD
ONLY **smoking cessation + oxygen supplementation** have been shown to ↑ survival in COPD
39
Stepwise management of COPD
Stepwise management of COPD 1. **SABA / SAMA** 2A. If Asthmatic features or steroid responsiveness --\> **LABA + ICS** 2B. If no asthmatic features or steroid responsiveness --\> **LABA + LAMA** 3. **LABA + LAMA + ICS**
40
**Cystic fibrosis** - mode of inheritance
_Cystic fibrosis_ **Autosomal recessive** Mutation in **CFTR** **ΔF508** is the most common mutation in the UK
41
Most common organsisms in cystic fibrosis
_cystic fibrosis_ ## Footnote In Children --\> **S. aureus** & H. influenzae In Adults --\> **Pseudomonas aeruginosa** (85%) + **Burkholderia species**
42
Ix for Cystic fibrosis
Ix for Cystic fibrosis * **Guthrie test**: +ve = ↑ immunoreactive Trypsinogen (IRT) at birth * Part of UK newborn heel prick test performed @ 5-8 days olD * *_If +ve Guthrie test_* * **Sweat test**: Give Pilocarpine + measure [Cl-] * *_Genetic testing_*: confirm patient's genotype +/- family testing
43
Acute Tx for meconium ileus due to cystic fibrosis
(1) Gastrografin enemas + Lactulose (2) Surgery +/- NG decompression
44
Long term management of CF
* Chest physiotherapy * +/- Salbutamol +/- ICS +/- Mucolytic +/- Prophylactic ABx * +/- CFTR modulator * **Ivacaftor** (not effective for F508del) * **Orkambi** (if **F508del homozygous**) * +/- Lung traplant * HIGH calorie + HIGH fat diet * Pancreatic enzymes * Fat-soluble Vitamin supplementation (ADEK)
45
Cystic fibrosis - presentation
Cystic fibrosis * Newborns * **Meconium ileus** (distal small bowel obstruction) * **Recurrent respiratory infections** --\> Bronchiectasis * Prolonged neonatal jaundice * Failure to thrive * **Steatorrhoea** * Young children * **Rectal prolapse** * Nasal polyps * Teenagers * Delayed puberty * **Diabetes mellitus** * **Pancreatitis** * Distal intestinal obstructural syndrome (DIOS) * **Infertility**
46
Obstructural sleep apnoea Ix? Tx? Cx?
**_Obstructural sleep apnoea_** Ix: **Polysomnography** [diagnostic] Epworth Sleep Scale Tx: **Weight loss** +/- **CPAP +/- Oral appliance therapy** Complications: **Respiratory acidosis**
47
Ix for pulmonary fibrosis
**High-resolution CT** [diagnostic] * **Reticular opacities** * Worse at the bases + sub-pleural * (initially) **Ground glass opacities** * (later) **Honeycombing** * **Traction bronchiectasis**
48
**EAA** - definition CXR Tx?
**Extrinsic allergic alveolitis** = **Hypersensitivity pneumonitis** = Interstitial inflammatory disease of the alveoli due to **inhalation of organic dusts** * Farmer’s lung = Mouldy hay * Pigeon fancier’s lung = Bird droppings * Mushroom worker’s lung = Compost (contains thermophilic actinomycetes) * Humidifier lung = Water-containing bacteria & amoeba * Maltworker’s lung * Barley or maltings (contains Aspergillus clavatus) CXR: reticulonodular opacities with ground glass appearance Tx: Avoid allergn +/- Prednisolone
49
Tx and Cx of pulmonary fibrosis
_Pulmonary fibrosis_ **Pulmonary rehabilitation** **Anti-fibrotic therapy** * **Perfendione** * **​**C/I: eGFR \< 30 * **Nintedanib** **+/- Lung transplant** Complications: **Pulmonary hypertension,** Lung cancer
50
**CXR Pleural plaques** Management?
None required as do NOT undergo malignant change ## Footnote **Do NOT require follow up**
51
CXR shows egg shell calcification of hilar lymph nodes in upper lobes Dx?
Silicosis
52
Tx for mesothelioma
_Tx for mesothelioma_ (1) **Surgery** (2) Chemotherapy
53
Types of aspergillus lung disease
**Aspergilloma** * pre-existing lung cavity **Allergic broncho-pulmonary aspergillosis (ABPA)** * Type I and III Hypersensitivity reaction to Aspergillus spores **Invasive aspergillosis** * invades lung tissue --\> fungal dissemination
54
Definitive diagnosis of invasive aspergillosis
**Galactomannan ELISA test** Definitive diagnosis of invasive aspergillosis
55
Tx for aspergilloma Tx for ABPA Tx for invasive aspergillosis
Tx for aspergilloma * (1) **Surgical resection** * (2) Radiological embolisation Tx for ABPA * **Oral prednisolone** Tx for invasive aspergillosis * **Voriconazole** * **Lipsomal Amphotericin B**
56
Common organisms causing pneumonia
57
Productive, **rusty coloured sputum** Cause
Streptococcus pneumoniae
58
COPD + Pneumonia Cause
Haemophilus influenza
59
60
Alcoholic + Pneumonia
Klebsiella pneumoniae
61
**Dry cough** **Flu-like symptoms** **Erythema multiforme** **Young adult / Children** Ix? Dx?
**Mycoplasma pneumoniae** (atypical CAP) Mycoplasma serology
62
**Stagnant water systems** **Dry cough** **Flu-like symptoms** **Confusion** **Hyponatraemia** Diagnosis? Ix?
**Legionella pneumophila** Ix: Urinary Legionella antigen
63
**Dry cough** **Flu like symptoms** **Rose spots** **Hepatosplenomegaly** **Hepatitis** Dx? Risk factor?
**Chlamydia psittaci** Birds
64
ABx for atypical pneumonia
Usually --\> (1) **Macrolide** * **Azithromycin** * **Clarithromycin** * **Erythromycin** **Chlamydia psittaci** *_or_* **Coxiella burnetii** (Q fever) --\> (1) Tetracycline (**Doxycycline**)
65
Dx of TB
**Sputum MC&S for TB** --\> Smear microscopy + **staining for AFB** * Ziehl-Neelson stain (operator dependent) * Auramine-Rhodamine stain (look for fluorescent AFBs, better sensitivity) or **Bronchoscopy + Biopsy + Histology** * **Caseating granuloma** (hallmark of TB)
66
Paradoxical transient worsening of TB symptoms and lesions following anti-TB therapy * Fever * Worsening of CXR * Lymphadenopathy * Pleural effusions Diagnosis?
**Immune reconstitution inflammatory syndrome** (IRIS) Tx: Continue anti-TB therapy and anti-retrovirals, consider steroids
67
S/E of TB medications
68
Sputum culture grows Mycobacterium malmoense Next Ix?
**Repeat sputum culture** At least 2 samples if from a non-sterile source (as may be contamination)
69
High Altitude \> 2500 m **Headache** **Nausea** **Fatigue** Dx? Tx? Prevention?
**Acute mountain sickness (AMS)** Tx: **Descent** Prevention: Acetazolamide
70
Altitude \> 4000 m Signs of pulmonary oedema * SOB * Productive cough * Pink, frothy sputum * Bibasal crackles Dx? Tx?
**High altitude pulmonary oedema** Descent +/- Oxygen
71
**Altitude \> 4000 m** **Headache** **Ataxia** **Papilloedema** Dx? Tx?
**High altitude cerebral oedema (HACE)** Tx: Descent + Dexamethasone
72
**Progressive SOBOE** **Fatigue** **Loud P2** Dx? Ix for screening? Ix for diagnosis? Ix for management?
**Pulmonary hypertension** Screening Ix --\> **TTE** Diagnostic Ix --\> **R heart catherisation** (pulmonary arterial pressure \> 25mmHg) Management Ix --\> **Vasodilator testing** (Epoprostenol) * +ve response --\> **CCBs** (Nifedipine) * -ve response * **PDE-5 inhibitor** (Sildenafil) * **Endothelin receptor antagonist** (Ambrisentan) * **Prostacyclin analogue** (Epoprostenol, Iloprost) * **Guanylate cyclse stimulator** (Riociguat) *_Complications_*: VTE (Tx: **+ Warfarin**), RVH, R heart failure
73
**Progressive SOBOE** **Fatigue** **Loud P2** Dx? Ix for screening? Ix for diagnosis? Ix for management?
**Pulmonary hypertension** Screening Ix --\> **TTE** Diagnostic Ix --\> **R heart catherisation** (pulmonary arterial pressure \> 25mmHg) Management Ix --\> **Vasodilator testing** (Epoprostenol) * +ve response --\> **CCBs** (Nifedipine) * -ve response * **PDE-5 inhibitor** (Sildenafil) * **Endothelin receptor antagonist** (Ambrisentan) * **Prostacyclin analogue** (Epoprostenol, Iloprost) * **Guanylate cyclse stimulator** (Riociguat) *_Complications_*: VTE (Tx: **+ Warfarin**), RVH, R heart failure
74
Classification of pleural effusion
75
Causes of pleural effusion
76
Diagnosis of pleural effusion
**Pleural USS + Pleurocentesis** | (diagnostic for pleural effusion)
77
Tx of pleural effusion
Transudative * **Furosemide** * If symptomatic --\> **USS-guided Thoracentesis** Exudative * +/- Antibiotics * If symptomatic --\> **USS-guided Thoracentesis** * If empyema **--\> Chest drain** If recurrent * Pleurodesis * Pleural catheter drainage
78
Thoracentesis: Turbid effusion with pH \< 7.2, ↓ glucose and ↑ LDH Diagnosis? Tx?
**Empyema** Chest drain + IV Antibiotics
79
Tx for stable pneumothorax
_Primary pneumothorax in \< 50 years old_ * **\< 2cm** _AND_ **asymptomatic** * (1) **Observation** +/- Oxygen + OP CXR * * **\> 2cm** _or_ **symptomatic** * (1) **Aspiration +/- repeat aspiration** * (2) **Chest drain** _Secondary pneumothorax_ or _\> 50 years old_ * **\< 1cm** _AND_ **asymptomatic** * (1) **Observation** +/- Oxygen + OP CXR * * **1-2cm** _AND_ **asymptomatic** * **​**(1) **Aspiration** * (2) **Chest drain** * * **\> 2cm** _or_ **symptomatic** * (1) **Chest drain**
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