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Flashcards in Respiratory Deck (56)
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1
Q

what are the causes of a restrictive picture on FEV1/FVC?

A

fibrosis, obesity, sarcoidosis, pneumoconiosis, interstitial pneumonia, connective tissue disesase, massive pleural effusion, chest wall defects (kyphoscoliosis)

2
Q

what is the KCO?

A

the gas diffusion coefficient: represents the carbon monoxide diffusing capacity corrected for alveolar volume

3
Q

how is TLCO measured?

A

a single inspitation of CO held for 10s, then CO measured in the blood.

TLV is measured with a helium dilution test

4
Q

what are the causes of a high and low KCO?

A

high - alveolar haemorrhage

low - emphysema and interstitial lung disease

5
Q

what does this flow-volume loop represent?

A

there is a characteristic defect in the expiratory phase of the flow volume loop.

This is commonly seen in intra-thoracic chest disease.

examples include asthma and emphysema

6
Q

what does this abnormal flow-volume loop represent?

A

there is a characteristic pathological pattern during the inspiratory phase of this flow volume loop.

This typically represents an extra-throacic pathology.

An example would be tracheal obstruction, whereby during inspiration negative pressure the airway obstruction is sucked into the lumen reducing the flow of inspired air

7
Q

what is the role of USS in respiratory medicine?

A

USS is commonly used to guide pleural drain insertion and pleural aspiration, especially in the case of loculated effusion/empyema

8
Q

what is broncheoalveolar lavage? indications? complications?

A

BAL - performed during USS guided bronchoscopy. warmed 0.9% saline instilled into the distal airway and aspirated. fuild sent for lab testing.

  • *indications** -
    diagnostic: ?malignancy, ?pneumonia, ?bronchiectasis, ?TB, interstitial lung disease (sarcoid, pneumoconiosis, EAA)
    therapeutic: alveolar proteinosis

complications
transient shadow on CXR, transient hypoxia (give O2), transient fever
infection (rare)

9
Q

what are the methods for lung biopsy? when are they useful?

A
  • percutaneous needle biopsy* with USS guidance - peripheral tumours located on chest CT
  • transbronchial, performed during bronchoscopy* - interstitial lung disease (sarcoid, IPF)
10
Q

what is the indication of mediastinoscopy?

A

for visualisation, examination and biopsy of medisatinal lymph nodes/lesions

11
Q

who should be offered pneumococcal vaccine?

how frequently is the vaccine given?

A
  • adults >65 y/o
  • chronic heart, liver or renal failure patients
  • DM not controlled by diet alone
  • immunosupression: splenectomy, AIDS, chemo or pred >20 mg/OD

every 5 years

12
Q

what are the complications of pneumonia?

A

lung: respiratory failure (type I), parapneumonic effusion, empyema (pus in pleural space), lung abscess
systemic: hypotension, atrial fibrilation (elderly), sepsis, death, pericarditis/myocarditis, jaundice (co-amox and flucloxacillin)

13
Q

define bronchiectasis

A

chronic inflammation and insult to the airways leads to thinning and dilatation

14
Q

what are the causes of bronchiectasis?

A

congenital: CF, ciliary disorders (kartagner’s), PCD

post-infectious: measles, pertussis, recurrent bronchiolitis

15
Q

how do you manage bronchiectasis?

A

conservative: airway clearance, chest physio and pulmonary rehab

medical:
abx - treat the isolated organism. >3 exac per year, long-term nebs antibiotics

surgical:
lobectomy: maybe considered for localised disease or to control haemoptysis

consider: bronchodilators (co-existant obstructive pathology) or steroids & itraconazole (ABPA)

16
Q

what is the inheritance of CF?

A

most common autosomal recessive condition

affect 1:2000 live births, 1:25 carry a copy of the gene

17
Q

diagnosis of CF?

A

sweat sodium and chloride >60 mmol/L

(chloride > sodium usually)

18
Q

principles of managing CF?

A

lung

  • chest physio - frequently family/carers know best. usually in the morning, often >1 x per day
  • treat infections, prophylactic Abx, test for pseudomonas colonisation
  • mucolytics (DNase alpha or hypertonic saline)
  • bronchodilators
  • yearly CXR
  • extra: mutation-specific therapy ivacaftor and lumacaftor target the CFTR protein

GI

  • pancreatic enzyme replacement (CREON)
  • fat-soluble vitamin supplements (ADEK)
  • ursodeoxycolic acid for impaired liver function
  • cirrhosis = liver transplant

other

  • CF-related diabetes
  • osteoporosis
  • genetic councilling/fertility
19
Q

median age of survival in CF?

A

41 years in the UK, though baby born today would expect to live longer

20
Q

what lymph nodes are affected in bronchial carcinoma?

A

mediastinal (cannot palpate), supraclavicular and axillary

21
Q

differential diagnosis of nodule on CXR?

A
  • malignancy (1ary or 2ary)
  • abscess
  • granuloma (TB or sarcoid, look for lymphadenopathy)
  • carcinoid tumour, other benign neoplams (hamartoma)
22
Q

what must be done in the work-up for curative lung tumour resection before surgery?

A

PET-CT for staging

  • N0 no nodes
  • N1 peribronchial or ipsilateral hilum
  • N2 ipsilateral medistinum or subcarinal
  • N3 contralateral mediastinum or hilum, scalene or subcarinal
23
Q

what is the prognosis for patients with bronchial carcinoma?

A

NSCLC - 50% 2 year survival without spread, 10% with spread

SCLC - 3 months if untreated, 1-1.5 yrs if treated

24
Q

what are the 5 ways aspergillus can affect the lung?

A
  • asthma (present in 1-5% of asthmatics)
  • allergic bronchopulmonary aspergillosis
  • aspergilloma
  • invasive aspergillosis
  • extrinsic allergic alveolitis
25
Q

what are some systemic disease that can present with asthma?

(not atopy)

A

GORD/reflux, vasculitides (polyarteritis nodosa, eGPA Churg-Strauss), ABPA

26
Q

what are some complications of COPD?

A

lung

  • infectious exacerbations
  • fibrosis
  • type II respiratory failure
  • pneumothorax
  • lung CA

systemic

  • secondary polycythaemia
  • cor pulmonale
27
Q

beyond medical therapy, what is helpful in managing COPD?

A

smoking cessation

diet + supplements (often underweight)

pulmonary rehabilitation/exercise encouragement

LTOT - if resting hypoxaemia and successfully stopped smoking

diuretics (co-morbid heart failure)

vaccinations - influenza (all) and pneumococcus (>65 y/o)

28
Q

what are the common signs of PE on ECG?

A
  • sinus tachycardia
  • right ventricular strain (inverted T waves in V1-4)
  • right bundle branch block

don’t say S1 Q3 T3 first!

29
Q

causes of transudative and exudative pleural effusions

A

transudate - cardiac failure, hypoalbuminaemia (liver and renal failure)

exudate - malignancy and pneumonia

30
Q

where do you send samples of pleural fluid?

A

biochemistry

microbiology

cytology

need a paired sample of serum for protein and LDH

31
Q

Light’s criteria and differentiating pleural effusions

A

transudate protein <25 g/L

exudate protein >35 g/L

25-35 g/L - pleural fluid protein/serum protein >0.5 = exudate

pleural fluid LDH/serum LDH >0.6 = exudate

32
Q

what are some causes of cor pulmonale?

A

Lung parenchyma

  • COPD
  • bronchiectasis
  • pulmonary fibrosis

pulmonary vasculature

  • pulmonary embolism
  • primary pulmonary hypertension

other - thoracic cage and neuromuscular abnormalities

33
Q

what are the signs of cor pulmonale on chest examination?

A
  • prominent P2
  • right parasternal heave (RVH)
  • right heart failure: raised JVP, pulsatile hepatomegaly, oedema

+/- pulmonary regurg = Graham Steel murmur (early diastolic)

+/- tricuspid regurg = pansystolic murmur

34
Q

what are the indications for steroid treatment in sarcoidosis ?

A

parenchymal lung disease

uveitis

hypercalcaemia

neurologic or cardiac involvement

35
Q

what are some causes of bihilar lymphadenopathy?

A

benign

  • sarcoidosis
  • tuberculosis
  • hypersensitivity pneumonitis
  • pneumoconioses (silica, beryllium)

malignant

  • bronchial CA (stage N2-3)
  • lymphoma/CLL
  • histiocytosis x (langerhan’s cell histicocytosis)
36
Q

what happens to the TLCO/KCO in IPF?

A

decreased

37
Q

what are the treatment options for IPF?

A

supportive care: oxygen, pulmonary rehab, opiates and palliation

consideration of lung transplant and current clinical trial involvement

new: anti-fibrotic drugs nintedanib and pirfenidone starting to show promise

38
Q

what is the correct term for a patient with a large thoracic volume on inspection when you are examining them?

A

barrel chest

cannot say ‘hyperexpanded’ becuase you have to measure the chest with a tape measure and compare this to a nomogram for that to be accurate

39
Q

what are the most important findings when presenting intersitial lung disease?

A
  • supplimental oxygen
  • clubbing and cyanosis
  • fine crackles (+/- apex or base)
40
Q

what are the most important findings when presenting consolidation?

A
  • bronchial breathing (+/- coarse crackles)
  • dull to percussion
  • increased vocal fremitus
41
Q

what are the most important findings when presenting bronchiectasis?

A
  • clubbing
  • sputum
  • coarse crackles
42
Q

what are the most important findings when presenting pleural effusion?

A
  • decreased breath sounds
  • stoney dull to percussion
  • decreased vocal fremitus
43
Q

how do you describe the breathing pattern of somebody with COPD?

A

dyspnoeic, audible wheeze from the end of the bed

purse-lip breathing

prolonged expiratory phase

44
Q

COPD does not cause clubbing.

what should be suspected in a patient with COPD and clubbing?

A

smoking can also cause cancer, which can cause clubbing

investigate for small cell lung CA

45
Q

what is the pathophysiology of COPD?

A

smoking

  1. direct oxidative stress causes necrosis and apoptosis of the lung parenchyma
  2. activates resident macrophages and neutrophils of the airways to release elastases. proteolytic enzymes > anti-protease enzymes leads to destruction of compliant lung & airway tissue and obstruction
46
Q

what are the causes of COPD and how does this relate to their histological distribution?

A

smoking - mixed centri-/panancinar

alpha1 anti-trypsin - panacinar

coal dust - centriacinar

47
Q

what are the bugs of acute exacerbation of COPD?

A
  • haemophilus influenzae*
  • strep pneumo*
  • moraxella catarrhalis*
48
Q

what are the conditions for LTOT in COPD?

A

MUST

  • stopped smoking - carboxyhaemoglobin < 3%

AND

  • PaO2 < 7.3 kPa

OR

  • PaO2 7.3-8.0 kPa with
    • secondary polycythaemia
    • pulmonary hypertension
    • cor pulmonale
    • nocturnal deoxygenation
49
Q

what are the causes of bronchiectasis?

A

childhood infection

  • tuberculosis
  • pertussis
  • measles

muco-ciliary dysfunction

  • cystic fibrosis
  • kartagner’s
  • primary ciliary dyskinesia

bronchial obstruction

  • endobronchial tumour
  • foreign body aspiration

fibrosis

  • idiopathic pulmonary fibrosis (long-standing)
  • infection complicated by fibrosis

idiopathic

50
Q

what is the gold standard diagnostic test for bronchiectasis?

A

high-resolution chest CT

51
Q

what does the ‘signet ring sign’ represent? (CT)

A

signet ring sign = bronchiectasis

damaged and enlarged bronchus has a larger diameter than the adjacent blood vessel

52
Q

what are the LRTI bugs for bronchiectasis?

A
  • staphylococcus aureus*
  • haemophilus influenzae*
  • pseudomonas aeruginosa*
53
Q

which antibiotic is suitable for treating legionella pneumonia?

A

clarithromycin

… macrolide > quinolone

54
Q

which lung CA is associated with PHTrP?

which lung CA is associated with ectopic ACTH and ADH?

A

PTHrP = squamous cell carcinoma

ADH/ACTH/LEMS = small cell carcinoma

55
Q

what is the rule for calculating the blood gas expected PaO2 from the FiO2?

A

[FiO2 (%) - 10] = expected PiO2 (kPa)

can also be done using the arterial-alveolar (A-a) oxygen gradient, but usually works out to just FiO2 - 10

56
Q

what are the causes of intersitial lung disease/pulmonary fibrosis?

A

lung diseases

  • IPF
  • TB/sarcoid
  • EAA
  • COPD
  • pneumoconioses
    • beryllium
    • coal
    • silica
    • asbestos

rheumatological disease

  • SLE
  • rheumatoid arthritis
  • MCTD
  • systemic sclerosis

drugs

  • amiodarone
  • methotrexate
  • bleomycin
  • gold
  • nitrofurantoin

vasculitis

  • wegener’s
  • polyarteritis nodosa
  • goodpasture’s
  • churg-strauss