Resp Flashcards
PE
Blood clot in the pulmonary arteries = obstruction of blood flow to lung tissue, strain on right heart
= pleuritic chest pain, SOB, haemoptysis, ^HR, clear chest or crackles, fever
Inv - ECG (sinus tachy, S1Q3T3 deep s/q, inverted T)
PE: Risk Factors
Immobility - long haul flights / surgery
Cancer
Oestrogen HRT
Pregnancy
Polycythemia
Thrombophilia
If patient has major RF for travel related thrombosis (FH or VTE themself) then can give TED stocking as prophylaxis
PE: Scoring
PERC - <2% if less than 1
Wells - >4 is likely
DVT signs (3), most likely diagnosis (3)
HR >100 (1.5), prev Hx (1.5), immobile (1.5)
Cancer (1), hemoptysis (1)
*CXR needed before CTPA and D dimer
Well’s for DVT: 2 points or more = likely
PE: Management
Wells >4 - CTPA, interim AC if delay, neg then prox leg US
Wells 4 or less - D-Dimer, pos then CTPA, neg consider alt.
VQ if renal impairment
-> 3m Xa inhibitor if provoked, 3-6m if cancer, 6m if unprovoked (LMWH if severe renal impairment), thrombolysis if v BP
Lung Cancer - Types
Non-small cell
- Adenocarcinoma: most common, peripheral, smokers (+ non), gynaecomastia
- Squamous cell: central cavitating lesions, PTHrp (^Ca), clubbing, HPOA
- Large cell: poor prognosis, b-HCG
- Alveolar cell: not related to smoking, ^^sputum
- Bronchial adenoma: carcinoid (bradykinin, serotonin = flushing, bronchoconstriction, diarrhoea, ACTH)
-> no surgery if FEV1 < 1.5L, malignant effusion, SVC obstruction, hilar involvement, vocal cord paralysis
Small cell (neuroendocrine, APUD cells)
15% of cases, worse prognosis.
= central, release ADH (vNa) / ACTH (Cushing), Lambert-Eaton
-> surgery if early, often mets at diagnosis
Lung Cancer: Features
= cough, blood, SOB, chest pain, weight loss, SVC syndrome, hoarse (RLN, Pancoast), supraclavicular/ cervical lymph, clubbing
fixed monophonic wheeze
Inv - ^PLT, CXR, bronchoscopy + biopsy, CT/ PET
COPD
Damage to lung tissue 2nd to smoking/ A1AT. Irreversible obstruction of air flow.
= cough, SOB, wheeze, right-sided HF, 2nd polycythemia. NO CLUBBING
Inv - post-bronchodilator spirometry (obstructive, FEV1/FVC <70%), CXR (hyperinflation, bullae, flat hemidiaphragm), BMI
Grading scale - 1) FEV1 (predicted) over 80%, 2) 50-80, 3) 30-50, 4) <30%
COPD: Management
General - stop smoking, annual flu vacc, one-off pnem, pulm rehab
-> SABA / SAMA
Asthma features -> LABA + ICS, then +LAMA
Not -> LABA + LAMA
Lastly, theophylline
*combined inhaler where poss
Steroid responsive (atopic/ asthma diagnosis, ^eosinophils, FEV1 400ml variation or 20% diurnal variation peak flow)
-> azithromycin as Abx prophylaxis
Long Term O2 Therapy
Offer if pO2 of < 7.3 kPa, or 7.3-8 + one of;
secondary polycythaemia
peripheral oedema
pulmonary hypertension
NOT if still smoking
COPD: Exacerbation
Cause - ^^Hib, strep pneum, ^human rhinovirus
-> BD inh, neb, with ipratropium, IV theophylline, 5 days of pred 30mg
-> 28% Venturi mask at 4 l/min (aim 88-92% in retainer), NIV if T2RF
-> Abx if purulent sputum/ pneumonia (doxy, clarithromycin, amoxicillin)
Bronchiectasis
Permanent airway dilatation 2nd to chronic inflammation, ^Hib/ pseudomonas
Causes - infection, cancer, CF, immune def (hypogammaglobulinemia), yellow nail syndrome, Kartagener’s, young’s syndrome
= SOB, ^sputum, cough, hemoptysis, clubbing, wheeze, crackles
Inv - high res CT (signet ring, tramtrack)
-> postural drainage, Abx, surgery if local
Pneumonia
Inflammation of alveoli, ^bacterial
HAP: 48hrs+ after admission (CAP <48hrs)
Inv - FBC, CRP, ABG, U&Es, CXR (consolidation)
CURB-65: confusion, RR 30+, BP <90/60, 65yr+ (home if 0, consider 1/2, hospital 3+)
Add urea >7 in hospital (ICU if 3+)
-> 5d amox (or 7-10d amox + macrolide), CXR at 6wk for resolution
Pneumonia: Organisms
Strep pneum - 80%, rapid onset, fever, herpes labialis
Hib - COPD/ bronchiectasis patients
Staph aureus - post-flu, cavitating
Klebsiella - alcoholics, cavitating
Mycoplasma - atypical, cold AIHA, erythema multiforme, immune neuro, RBC agglutination
Legionella - v Na (SIADH), v WCC, air con
Pneumocystis - HIV, dry cough, no chest signs, exercise desat
Coxiella Burnetti - Q fever, animals
Chlamydia psittaci - infected birds
Pneumothorax
Air gets into the pleural space
RF - lung disease, ventilation, CTD
= sudden onset
Pneumothorax: Management
Erect CXR to measure the size - from level of the hilum
Minimal symptoms -> conservative
Symptoms + low risk -> conservative, ambulatory or aspiration
Symptoms + high risk -> chest drain
? high risk = haem compromise, sig. hypoxia, underlying lung disease, bilateral, haemothorax, 50+ with sig smoking
Recurrent -> video-assisted thoracoscopic surgery (pleurodesis +/- bullectomy)
Tension -> needle decompression and chest drain
No scuba diving ever, no flying 2wk post-drain, stop smoking.
Conservative?
Primary: review every 2-4 days as outpatient
Secondary: monitor as inpatient
Stable/ resolved: follow-up as outpatient in 2-4wks
Pleural effusion
Collection of fluid in the pleural cavity
Exudative (protein >30g/L)
- pneumonia, TB, cancer, SLE, RA, pancreatitis, PE
Transudative (<30)
- HF, v albumin, v thyroid, meig (right-sided linked to ovarian cancer)
= SOB, stony dull, reduced breath sounds and trachea pushed away if large.
Inv - PA CXR (lose costophrenic angles, tracheal deviation, fluid in fissure and meniscus), US, contrast CT (cause), pleural asp
Lights Criteria
If protein level between 25-35 g/L -» Light’s criteria
Exudate likely if one of;
- pleural / serum protein >0.5
- pleural / serum LDH >0.6
- pleural LDH >2/3rds upper limit of normal serum LDH
Other findings - v glucose in TB/ RA. ^amylase in panc/ oes perf. Blood in mesothelioma/ TB.
If purulent, turbid/cloudy, pH <7.2 then place a chest tube to allow drainage (infection)
Chronic Asthma
Chronic airway inflammation, reversible bronchoconstriction, hypersensitivity
RF - Hx atopy, v BW, maternal smoking, ^allergen exposure
Link - aspirin sensitivity, nasal polyps
= cough, chest tightness, wheeze
Asthma: Diagnosis
<5yrs = clinical judgement
5-17yrs = spirometry with BDR, FeNo if neg
17+ = spirometry with BDR + FeNo (40+).
Reversibility is positive if >12% increase in FEV1 (or 200ml in adults)
Asthma: Management
SABA -> +Low ICS -> +LTRA
-> SABA +low ICS +LABA (+/-LTRA)
-> swap low ICS/LABA to MART
-> swap for mod dose MART
-> swap MART for high ICS/ LABA or LAMA or theophylline or refer to expert
When reducing steroids reduce by 25-30%
Low dose <400, high dose >800mcg budesonide
Acute Asthma
Moderate - PEFR 50-75%, normal speech, RR <25, HR <110
Severe - PEFR 33-50%, can’t complete sentences, RR >25, HR >110
Life Threatening - <33%, sats <92%, v BP, v HR, silent chest, cyanosis, poor resp effort, exhaustion, normal pCO2
Near fatal - ^pCO2
Acute Asthma: Management
Inv - ABG, CXR if life threatening
Admit - severe and not responding, life threatening, prev near fatal, pregnancy, attack even if taken steroid dose
-> oxygen, 5d pred, inh/ neb SABA, neb ipratropium, IV MgSO4, IV aminophylline, senior support (ITU), I+V/ ECMO
Discharge - stable on discharge meds for 12-24hrs, check inhaler use, PEF >75% best
Sarcoidosis
Multisystem disorder of unknown cause, leads to non caseating granulomas
RF - young adults, African
= SOB, malaise, cough, weight loss, erythema nodosum, BHL, swinging fever, arthralgia, lupus pernio (raised purple lesions), ^Ca, uveitis, conjunctivitis
Inv - ^ACE, ^Ca, ^ESR, CXR , spirometry (restrictive), biopsy (nc granulomas, epithelioid)
CXR stages - 0 = normal. 1 = BHL. 2 = BHL + interstitial infiltrates. 3 = diffuse infiltrates only. 4 = diffuse fibrosis.
-> steroids if symptoms + stage 2/3, also if ^Ca or organ involvement (eye heart or neuro)
Sarcoid Syndromes
Logfrens - acute sarcoidm good prog, BHL + erythema nodosum + fever + polyarthralgia
Mikulicz - parotid + lacrimal gland enlargement
Heerfordts - rare acute, fever + uveitis + parotid enlargement
