obstructive disease Flashcards
Chronic bronchitis - what is it, dx, syx
Type of COPD, long term inflammation leading to hypertrophy and hyperplasia of mucus glands in the bronchi.
DX: Daily productive cough that lasts for 3 months of 2 successive years
Syx 'blue bloaters' pts tend to be 'overweight + chaotic' (1.) Productive cough (2.) fatigue (3.) sob (4.) chest discomfort (5.) wheezy (6.) peripheral oedema
Emphysema - what is it? cause? syx?
Type of COPD, destruction of alveolar walls/air spaces causes inefficient gas exchange and reduces elastic recoil of the lungs, results in airway collapse during exhalation
Causes: smoke, pollution, fumes, dust, alpha-1-antitrypsin deficiency
Syx: ‘pink puffers’
pts tend to be ‘older + thin’
(1.) severe dyspnoea
(2.) quiet chest
COPD syx + signs + ex
Syx
(1. ) Productive cough - colourless or green/yellow if LRTI
(2. ) Wheeze
(3. ) Progressive dyspnoea
(4. ) Reduced ET
(5. ) Fatigue
(6. ) Cachexia
Signs
- Tachypnoea
- Hyperinflation
- Reduced cisternal distance <3cm
- Reduced chest expansion
- Hyper-resonant percussion
- Decreased/quiet breath sounds
- Wheeze
- Cyanosis
- Cor pulmonale (RSHF): peripheral oedema, raised JVP
Ex
(1. ) COPD Assessment Test (CAT): Assess COPD on pt’s wellbeing and daily life
(2. ) MRC dyspnoea scale - quantify breathlessness
(3. ) Resp ex
COPD Ix + Dx
DX: Clinical features + spirometry
(1. ) Spirometry post bronchodilator FEV1 <80% + FEV1/FVC <0.7
- Used for staging + monitoring COPD
- FEV1 assess severity: Mild >80%, Moderate 50-80%, Severe 30-50%, Very Severe <30%
(2) . Bloods:
- FBC = raised PCV; polycythaemia, elevated Hb due to chronic hypoxia
- UE, LFT, CRP/ESR = if infection
- ABG = dec O2 +/- raised CO2 or T2RF
(3. ) Sputum Culture
(4. ) CXR: Hyperinflated chest (>6 anterior ribs), bullae
(5. ) Additional tests
- ECG: Cor Pulmonale = P-pulmonale (RAH), RVH, right axis deviation
- CT: scarring, bullae etc
COPD Mx: acute, conservative, pharmacological, indications for o2
Acute Mx ‘O SHI’
- Oxygen via 24-28% venturi + sats target 88-92%
- salbutamol neb
- hydrocortisone IV or PO prednisolone
- ipratropium neb
- abx if infection
- ITU + NIV if worsening, hypoxia/hypercapnia
Conservative
- Smoking cessation, improves prognosis
- Pulmonary rehabilitation,
- Pneumococcal + influenza vaccines
- Optimise comorbidities rx
Pharmacological (step approach)
(1.) SABA/SAMA + LABA
(2.) LABA + LAMA if no asthmatic features
OR LABA + ICS if asthmatic features (<50% FEV, atopy, diurnal syx, eosinophils)
(3.) Step 3: LAMA + LABA + ICS trial for 3months
(4.) Step 4: REFERRAL if still syx + affecting ADL
Oxygen therapy (LTOT) indicated:
- Clinically stable non-smoker with PaO2 <7.3kPa despite max tx
- Or PaO2 7.3-8kPa if nocturnal hypoxia, polycythemia, peripheral oedema, pulmonary HTN.
- Terminally ill pts
Asthma pathophysiology, types
Reversible airway obstruction that is chronic. Three factors contribute to airway narrowing:
- Bronchial hyperresponsiveness
- Mucosal swelling/ inflammation caused by mast cell and basophil degranulation
- Increased mucus production further narrows airways
This leads to recurrent episodes of wheezing, dyspnoea, cough. Episodes are often reversible either spontaneously or with treatment
Types
- Eosinophilic-Atopic asthma (or ‘allergic asthma’): IgE mediated reaction to allergens
- Eosinophilic-non-atopic asthma: no trigger but eosinophilic inflammation present.
- Non-eosinophilic asthma - not well understood, absence of eosinophilic airway inflammation
Asthma syx, ix, dx
Syx are reversible
(1. ) dyspnoea
(2. ) wheeze
(3. ) cough + diurnal variation (worse at night + morning)
(4. ) sputum
(5. ) o/e wheeze, hyper-inflated, reduced AE
Ix
(1. ). PEFR
(2. ) Spirometry
(3. ) CXR
(4. ) FBC
Dx
Spirometry
- Airway obstruction present (FEV1:FVC <70%)
- >12% FEV1 inc after bronchodilator i.e. reversibility
PEFR diary
- >20% variation on >3/7d for 2w
Others
- Increase responsiveness to challenge agents (mannitol, methacholine)
- FEV1 >15% decrease after 6mins of exercise
- Exhaled FeNO = marker of eosinophilic inflammation
Asthma (non-acute) Mx + name examples for inhaled rx
Stepwise approach: (1.) SABA (2.) + 200mg ICS (3.) + 800mg ICS + LTRA - or LABA - or MART (ICS + fast acting LABA) (4.) + 2000mg ICS +/- 4th drug Fourth drug: muscarinic receptor antagonist, SR theophylline or beta2agonist tablet (5.). Refer
LTRA = montelukast LABA = salmetrol ICS = beclomethasone
Acute Asthma: assess severity, mx
Classify severity: Life-threatening *33, 92, CHEST* - PEFR <33% - SpO2 <92% - Cyanosis, Hypotension, Exhaustion, Silent Chest, Tachycardiac
Severe
- PEFR 33-50
- SpO2 >92%
- RR >25
- HR >110
- Can’t complete sentences
Mild/Moderate
- PEFR 50-75%
- SpO2 >92%
- RR <25
- HR <110
- Normal speech + no features of severe asthma
Acute mx: O SHIT ME
(1. ) Oxygen
(2. ) Salbutamol NEB
(3. ) Hydrocortisone IV/ PO 30-40mg prednisolone if oral route possible
(4. ) Ipratropium NEB
Senior input:
(5. ) Theophylline
(6. ) Mg sulphate IV
(7. ) Escalate care: ICU
Monitor response to rx: PEFR, ABGs, Full assessment, Obs
What would you see on the spirometry for restrictive + obstructive pattern
Restrictive e.g. IPF
• FEV1 = <80%
• FVC = Reduced
• FEV1/FVC = >0.8
Obstructive e.g. COPD, asthma, bronchiectasis
• FEV1 = <80%
• FVC = close to normal
• FEV1/FVC = <0.7
Restrictive vs obstructive
• Both present with low FEV1
• H/e FVC in obstructive is close to normal, as they can fit a normal amount of air into lungs, the problem is expelling it out. This gives us a reduced FEV/FVC ratio.
• Restrictive = can’t fit as much air into the lungs so the FVC is significantly reduced, low fvc and FEV1 gives use a bigger ratio.
OSA: RF, Syx, Ix + Dx, Mx
RF = 50-60y, obese, macroglossia (acromegaly, hypothyroidism, amyloidosis), large tonsil, marfans
nasopharyngeal obstruction, neuromuscular disorders.
Syx
(1. ) Apnoeic episodes noticed by partner
(2. ) Loud snoring
(3. ) Morning headache
(4. ) Unrefreshed sleep
(5. ). Daytime sleepiness
(6. ) Reduced concentration
(7. ) Dec libido
Ix
(1. ) Epworth sleepiness scale
(2. ) Multiple sleep latency test measures time to fall asleep in a dark room
(3. ) **Polysomnography ** for dx. Looks at: REM, sats, electrical acitivty of brain.
- DX requires at least 5 episodes of apnoea/hypopnoea/both lasting >10s/hr of sleep.
Mx
(1. ) Wt loss, smoking cessation, reduce alcohol
(2. ) Inform DVLA, must stop driving
(3. ) Refer:
- ENT/sleep clinic if: impacting job or moderate-severe
- Pead ENT if: nasopharyngeal obstruction + snoring at night
(4. ) CPAP
- initiated by specialists for moderate-severe
- poor adherence due to ill-fitting mask, pressure intolerance, nasal dryness or bleeding, throat irritation.
(5.) Surgery: uvulopalatopharyngoplasty (UPPP), tonsillectomy, polypectomy
Cystic fibrosis: patho, syx, dx, mx
Autosomal recessive genetic condition affecting mucus glands due to CFTR gene mutation.
Key consequences include:
- Thick pancreatic and biliary secretions that cause blockage of ducts, resulting in a lack of digestive enzymes
- Thick airway secretions that reduce airway clearance, resulting in bacterial colonisation and susceptibility to airway infections
- Congenital bilateral absence of vas deferens in males.
Syx
(1. ) Chronic cough
(2. ) Thick sputum production
(3. ) Recurrent RTI
(4. ) Other syx:
- Meconium ileus (baby’s first stool not passed in first 24hrs, abdo distention, vomiting)
- Failure to thrive
- Pancreatitis
- Steatorrhea
- Abdo pain + bloatind
O/e
- Low weight or height on growth charts
- Nasal polyps
- Finger clubbing
- Crackles and wheeze on auscultation
- Abdo distention
Dx
(1. ) Newborn blood spot testing
(2. ) The sweat test (GOLD for DX)***
(3. ) Genetic testing for CFTR gene
Mx
(1. ) FU w/specialist every 6m.
(2. ) Monitor sputum, screen for DM, osteoporosis, vitamin D deficiency, liver failure.
(3. ) Chest physiotherapy
(4. ) Exercise
(5. ) High calorie diet
(6. ) CREON to digest fats if pancreatic insufficiency
(7. ) Prophylactic flucloxacillin
(8. ) Bronchodilators
(9. ) Neb hypertonic saline
(10. ) Vaccinations: pneumococcal, influenza, varicella
Bronchiectasis: what is it? causes? syx? Ix? mx?
- Permanent airway dilation due to chronic inflammation
- Common organisms that infect pt: H.influenza (most common), P.auruginosa, Klebsiella spp
- RF: >70y, female, smoking, FH of cystic fibrosis
Causes
- Post infection: TB, HIV, measle, pertussis, pneumonia
- Bronchial pathology: obstruction by foreign body or tumour.
- Allergy
- Congenital: cystic fibrosis, primary ciliary dyskinesia
- Idiopathic
Syx
(1. ) Productive cough - copious amount of sputum, haemoptysis
(2. ) SOB
(3. ) Rhinosinusitis syx
(4. ) O/E: Clubbing, coarse crept, rhonic (low pitched noises sound like snoring)
Ix
(1. ) Sputum culture
(2. ) PFT - obstructive or normal
(3. ) Bloods: FBC, CRP
(4. ) Imaging:
- CXR
- High resolution CT (GOLD) shows bronchodilation
- Bronchoscopy
Mx
(1. ) Pulmonary rehab, Smoking cessation, flu + pneumococcal vaccine
(2. ) Mucoactive agents/neb saline aids sputum clearance
(3. ) Long term Abx
(4. ) Bronchodilators
(5. ) Surgery if rx fails, affects one lung. Lung resection or transplant if <65y
