Respiratory notes Flashcards
What are discharge medications for COPD?
What is the GOLD guidelines for usage of ICS?
Inhaled bronchodilator: b2 agonists (LABA), anticholinergics
Escalate treatment from use of LABA + LAMA to use of LABA +ICS (in severe exacerbation)
Gold guidelines for usage of ICS
* Hospitalizations for COPD exacerbation
* >2 moderate COPD exacerbation/year
* Eosinophil level >300
* History/concomitant asthma
Blood gases : pH : 7.37
PaO2 : 7 kPa (on 2L O2)
PaCO2 : 5.5 kPa
BE : + 2 mmol/L
Total bicarbonate: 26 mmol/L
Acute exacerbation of COPD
What is the dx and management?
Type 1 respiratory failure
Increase supplemental oxygen to 3L and monitor closely (to avoid further further spO2 drop due to oxygen dissociation curve)
How do you assess history of exertional dyspnoea in suspected COPD?
mMRC: modified medical research council
How to assess severity of respiratory distress in general examination?
General inspection: tripod sign, use of accessory respiratory muscles
Central cyanosis
GCS: drowsiness due to retained CO2 in the brain resulting in low respiratory rate (in T2 resp failure)
What is the mode of SABA admin for medium severity and severe asthmatic attack?
Metered dose inhaler for medium severity
Nebulization for severe condition (requires no respiratory effort)
If pleural effusion and do thoracocentesis reveals blood what should be done?
Let sample sit: if clots it means thae there is active clotting factors = active bleeding (requires embolization, resuscitation)
If no clotting after a while –> there is underlying pathology
How to classify pleural infection?
Simple, complicated, empyema
What is the management of loculated pleural effusion?
Chest drain/pig tail catheter 14Fr (preferred as studies show the efficacy is same as chest drain) may require 2nd or 3rd USG guided insertion if multiple locules. Or catheter thoracostomy.
Patients who fail antibiotic therapy and initial drainage should undergo fibrinolysis of septums
* Fibrinolytics: urokinase, streptokinase, tPA (most used)
* Intrapleural tPA with DNase
If these treatments have minimal/no response –> then VATS is typically indicated (video assisted thoracoscopic surgery)
If there is salmonella entericus empyema what must you test for?
Pleural empyema is a result of bacteremia from salmonella enteridis which is associated with underlying immunodeficiency, sickle cell anemiae and lung cancer. If there is any abnormal encapsulated bacterial infection think immunodeficiency (can be splenectomy).
Must do HIV PCR test
If there is salmonella entericus in septicemia, what other manifestations can there be?
- Meningitis
- Endocarditis
- Mycotic aneurysm (non typhoidal salmonellae): abd aorta is the most common (S. typhimurium is most common)
- Septic arthritis
- Pneumonia (due to bacteremia)
- Abscessation: spleen, ovary, heart, lungs
Complications during pregnancy
* Chorioamnionitis, transplacental infection, preterm labor and abortion
Compare NSIP vs UIP in respond to steroids and prognosis
In dermatomyositis/polymyositis what is affected?
NSIP (non specific interstitial pneumonia): good response to steroids and good prognosis
Deratomyositis/polymyositis causes NSIP
UIP (usual interstitial pneumonia): poor response to steroids
What is measured in a lung function test?
Spirometry
* FEV1/FVC
* Lung volumes
Diffusing capacity: DLCO
What is included in a basic PSG for sleep disorder?
- EEG: testing for sleeping and arousal (wakefulness)
- Oximetry: periods of desaturation
- Submental EMG: detect hypotonia in REM
- Leg EMG: periodic leg syndrome
- Abd and thoracic belt:
Obstructive OSA there is paradoxical movement (There is diaphragm contraction for inspiration which moves the abd up. However, due to obstruction there is no inflation of the lungs so the thorax does not move up. Normally both the thorax and abd will move upon inspiration.)
Central OSA: there is a lack of ventilatory drive so diaphragm not moving (no paradoxical movement as both thorax and abd dont move)
Both will have desaturation after event
Can asthma can present with spirometry results that are not reversible by bronchodilator?
- Yes, in chronic asthma there is airway remodelling which results in fibrotic airways. These fibrotic airways are not reversible to bronchodilator
What are the indications for usage of antifibrotic agent?
Slow progression of disease
* Idiopathic pulmonary fibrosis
* Progressive pulmonary fibrosis
Nintedanib
Any drug for asthma that is taken in tablet form?
What drugs can cause dizziness?
Leukotriene receptor antagonist (useful for excercise induced asthma and aspirin/NSAID exacerbated respiratory disease)
Salmeterol, leukotriene receptora ntagonist
How would you assess the severity of asthma?
GINA assessment
* Daytime symptoms (>2 a week)
* Nocturnal symptoms (night awakening, nocturnal cough, sleep disturbance)
* Activity limitation
* Reliever use (>2 a week)
Hospitalization, away from work
If patient is admitted with acute exacerbation of asthma, how to assess patients severity?
GINA
* breathlessness, talkng, alertness
* RR, pulse, sO2, pO2, pCO2
* PE: wheezing, use of accessory muscles, pulsus paradoxus. Tripod position and use peak flow meter.
Use of peak flow meter in asthma?
- Check patients severity and obstructive pattern
- Can be used to demonstrate diurnal variation in obstruction
- Baseline for checking efficacy of treatment
What would you expect in PE of severe asthma?
What is wheeze?
At which phase?
More than that if really severe attack? What is it called?
- Use of accessory muscles, bilaterally reduced chest expansion, prolonged expiratory phase and wheeze on auscultation
- Wheeze: continous oscillation of opposing walls of an airway that is narrowed almost to the point of closure. High pitched and during expiration
- Expiratory phase
- Absence of breath sound
- Silent chest
Acute SOB ddx?
- Acute exacerberation of asthma
- pneumothorax
- COPD
If COPD in very young agent, what deficiency does this patient have?
Alpha 1 antitrypsin deficiency
In severe asthma cases, what treatment can be given other than bronchodilators and corticosteroids?
- Antimuscarinics: tiotropium
- LTRA: montelukast
- Biologics. Anti IgE antibody (omalizumab) for atopic asthma (IgE>30). anti IL5: mepolizumab. Anti IL5a: benralizumab
ddx of bronchiectiasis?
- Idiopathic: majority
- Congenital/primary: primary ciliary dyskinesia (kartagenners syndrome), cystic fibrosis (CFTR gene mutation), alpha 1 antitrypsin deficiency, hypogammaglobulinemia
- Acquired: infection (TB, severe pneumonia, EGPA), traction bronchiectasis (connective tissue disease)
- GERD
Workup for the dx of bronchiectasis?
- CBC (leukocytosis), sputum for smear and C/S
- Lung function test (obstructive pattern: FEV1/FVC <70%)
- Pulse oximetery (sO2), ABG
- CXR (bunch of grapes appearance, tramline shadows, irregular peripheral opacities representing mucopurulent plugs)
- HRCT (tramline shadows, signet ring sign, thickened bronchial wall, mucopurulent plugs
- Spirometry
- Sputum R/M, C/ST, gram stain, AFB smear
- Additional: Ig measurement, serum alpha 1 antitrypsin level, mutation analysis for cystic fibrosis
How to manage patient with massive haemoptysis?
100-200ml
ABCDE and resuscitation
Immediately placed into positon in which the presumed bleeding lung is in the dependent position (right bleeing lung –> right side down decubitus position
Establish a patent airway and give O2 (e.g. unilateral lung ventilation in the non bleeding lung)
Control the bleeding
* Bronchoscopy (balloon tamponade, topical adrenaline)
* Arteriographic embolization (urgent contrast CT and bronchial artery embolization by IR)
* Surgery (pneumectomy)
Organisms associated with bronchiectasis?
Tx?
- early or mild cases: H.influenzae (augmentin, macrolides: azithromycin)
- late or severe cases: P. aeruginosa
1st line is tazocin (piperacillin-tazobactam)
ceftazidine, meropenem
Causes of haemoptysis?
How will DLCO be affected?
- Pneumonia, bronchiectasis, CA lung, TB
- Small vessel vasculitis: wegeners (GPA), EGPA
- Rheumatic: Goodpasture syndrome (anti GBM antibody directed against an intrisic antigen to the GBM (NC1 domains of the alpha 3 chain of the type 4 collagen, which is found in GBM and alveoli), lupus pneumonitis, GPA, Behcet syndrome
- DLCO is increased
- Other causes of increased DLCO: polycythemia, left to right shunt, asthma due to increased pulmonary capillary blood volume
Typical findings of allergic bronchopulmonary aspergillosis (ABPA) on CT thorax and mechanism?
- ABPA is a cause of bronchiectasis
- Hypersensitivity reaction to aspergillus fumigatus that colonized airway, almost exclusively occurs in patients with asthma or cystic fibrosis
- Clinical picture = recurrent exacerbations of asthma
- Bronchial wall thickening, bronchiectasis, centrilobular nodules, mucoid impaction, mosaic perfusion, atelectasis and consolidation, tram lining
dx criteria for ABPA?
Predisposing conditions: asthma, cystic fibrosis
Obligatory criteria
* Aspergillus skin test +ve or detectable IgE levels against aspergillus fumigatus
* Elevated total serum IgE concentration
Other criteria:
* Precipitating serum antibodies to A. fumigatus (IgG, IgA)
* Radiographic pulmonary opacities consistent with APBA
* Eosinophilia