Respiratory Flashcards
(151 cards)
1
Q
Venous thromboembolism (VTE)
A
an umbrella term used to describe deep vein thrombosis (DVT) with or without pulmonary embolism (PE)
2
Q
Risk factors for Venous thromboembolism (VTE)
A
↑ age obesity FH of VTE pregnancy immobility hospitalisation anaesthesia surgery acute medical illness prolonged travel smoking dehydration
3
Q
Underlying conditions predisposing to Venous thromboembolism (VTE)
A
malignancy thrombophilia HF antiphospholipid syndrome Behcets polycythaemia sickle cell nephrotic syndrome Homocystinuria
4
Q
Drugs predisposing to Venous thromboembolism (VTE)
A
COCP
HRT (risk higher in oestrogen + progesterone vs only oestrogen)
tamoxifen/raloxifene
antipsychotics e.g. olanzapine
5
Q
Prophylaxis for Venous thromboembolism (VTE)
A
mechanical:
- compression stocking
- intermittent pneumatic compression devices
medication:
-LMWH/UFH/fondaparinux (use UFH if CKD/↓ renal function)
presurgical intervention
-stop COPC/HRT 4 weeks before surgery
postsurgical interventions
- early mobilisation
- sufficent hydration
6
Q
Deep vein thrombosis (DVT)
A
the development of a blood clot in the major vein in the leg/thigh/pelvis/abdomen
7
Q
Pathological conditions leading to DVT
A
Virchows triad
- vascular endothelial damage
- venous stasis
- hypercoaguability
8
Q
Presentation of Deep vein thrombosis (DVT)
A
may be asymptomatic or present with PE
symptoms usually unilateral
-limb pain & tenderness, swelling of calf/thigh, pitting oedema, distension of superficial veins, ↑skin temp, erythema, heard/thickened palpable vein, discolouration (red/purple)
NB severe signs of DCT can mimic cellulitis
9
Q
Wells score for Deep vein thrombosis (DVT)
A
Clinical feature:
-Active cancer (treatment ongoing,
within 6 months, or palliative) 1
-Paralysis, paresis or recent
plaster immobilisation of the lower extremities 1
-Recently bedridden for 3 days or more or
major surgery within 12 weeks requiring
general or regional anaesthesia 1
-Localised tenderness along the distribution
of the deep venous system 1
-Entire leg swollen 1
-Calf swelling at least 3 cm larger than
asymptomatic side 1
-Pitting oedema confined to the symptomatic leg 1
-Collateral superficial veins (non-varicose) 1
-Previously documented DVT 1
-An alternative diagnosis is at least as likely as DVT -2
10
Q
Actions for wells score for Deep vein thrombosis (DVT)
A
IF wells score ≥2 points (DVT is likely)
- proximal leg USS within 4h
- if +ve = treat DVT
- if -ve do a d-dimer
- if USS can’t be done within 4h
- do d-dimer +interim therapeutic anticoagulation until USS (should be within 24h)
NB if D-dimer is +ve but scan is negative then the USS should be repeated after 6-8 days
IF wells score <1 point (DVT unlikely)
- d-dimer within 4h
- if -ve = DVT unlikely
- if +ve = arrange USS within 4h (if not possible then as above)
11
Q
Investigations for Deep vein thrombosis (DVT)
A
D-dimer (↑)
Doppler USS
12
Q
Wells score for DVT
A
≥2 points DVT is likely
<1 point DVT is unlikely
13
Q
Pulmonary embolism (PE)
A
caused by obstruction of the pulmonary arterial tree by an embolus (usually thrombus)
14
Q
Presentation of Pulmonary embolism (PE)
A
sudden onset, may have precipitating event that sets them off
dyspnoea, pleuritic*/retrosternal chest pain, haemoptysis, tachycardia, tachypnoea, low grade fever
dizziness, syncope, ↑JVP
obstructive shock (if massive PE)
signs of DVT (unilateral, swollen, erythematous leg/calf)
15
Q
Wells score for Pulmonary embolism (PE)
A
Similar to DVT score
≤4 points = PE unlikely
>4 points = PE likley
NB you can also use the PE rule out criteria (PERC)
a negative PERC reduces likelihood of PE to <2%
16
Q
Actions based on Wells score for Pulmonary embolism (PE)
A
Wells score >4 (PE likely)
- immediate CTPA
- if delay in CTPA = give interim anticoagulation
- if CTPA -ve consider USS doppler of leg if DVT symptoms
Wells score ≤4 (PE unlikely)
- arrange D-dimer
- if +ve = immediate CTPA / if delayed give interim anticoagulation
- if -ve = PE unlikely so consider alternative diagnosis
17
Q
Investigations for Pulmonary embolism (PE)
A
CTPA
-preferred for definitive diagnosis of PE
ECG
- sinus tachycardia
- S1Q3T3 (large S wave in lead I, large Q wave & inverted T wave in lead III)
D-Dimer (↑)
-very non specific but very sensitive
18
Q
Investigations for Pulmonary embolism (PE)
A
CTPA
-preferred for definitive diagnosis of PE
ECG
- sinus tachycardia
- S1Q3T3 (large S wave in lead I, large Q wave & inverted T wave in lead III)
D-Dimer (↑)
-very non specific but very sensitive
CXR
- usually normal
- recommended for all pts prior to CTPA*
V/Q scan
-preferred over CTPA in pts with renal impairment
Leg USS, ABG
19
Q
Management of Pulmonary embolism (PE)
A
If haemodynamically unstable = thrombolysis
If in cardiac arrest with suspected PE give thrombolysis and continue CPR for 60-90 min
1st line:
- DOACs e.g. apixaban/riveroxaban
- in renal impairment use UFH/LMWH
- in antiphospholipid syndrome use LMWH
Duration:
- 3 months minimum if provoked
- 6 months minimum if unprovoked
- 3-6 months if caused by cancer
NB for unprovoked PE consider investigating the patient for underlying cancer or follow up closely
20
Q
Asthma
A
a chronic inflammatory disease of the respiratory system characterised by bronchial hyperresponsiveness,
21
Q
Asthma
A
a chronic inflammatory disease of the respiratory system characterised by bronchial hyperresponsiveness, episodic acute exacerbation and reversible airway obstruction (i.e. intermittent bronchospasm)
affects ~10% of children & 5-10% of adults
22
Q
Risk factors for asthma
A
personal history of atopy (hay fever/eczema) Family history of asthma/atopy inner city environment socio-economic deprivation obesity prematurity maternal smoking low birth weight
23
Q
Presentation of asthma
A
wheeze, chest tightness, SOB, cough
- worse at night / early morning cough
- presents on exercise, exposure to cold, other triggers or irritants
expiratory wheeze on auscultation
24
Q
Investigations of asthma
A
FEV1/FVC ratio
- <80% of predicted
- FEV1 ↓ & FVC normal
- obstructive picture
PEFR ± reversibility testing with salbutamol
-PEFR ↓ but reversible with SABA
fractional exhaled nitrous oxide (FeNO) (↑)
CXR
-for smokers & older people
25
Management of asthma
All pts should have a personalised asthma action plan
All pts should have a SABA e.g. salbutamol for symptomatic relief
between each step ensure adequate inhaler technique and compliance
consider stepping down treatment every 3 months or so if asthma is well controlled
1: SABA + low dose ICS
2: SABA + low dose ICS + trial of LTRA
3: SABA + low dose ICS + LABA ± LTRA
4: SABA + MART (ICS + LABA) ± LTRA
5: SABA + medium dose ICS in MART ± LTRA
6: expert help
26
Step 1 for asthma management
SABA + low dose ICS
consider SABA only therapy if infrequent short lived wheeze & normal lung function after SABA
27
Step 3 for asthma management
SABA + low dose ICS + long acting beta agonist (LABA) ± leukotriene receptor antagonist (LTRA)
LTRA only used if pt shows response to it
examples of LABA include salmetarol
28
Step 4 for asthma management
SABA
Low dose ICS + LABA in a MART regime ± leukotriene receptor antagonist (LTRA)
MART = maintenance & deliver therapy i.e. 1 inhaler as preventer and reliever
29
Step 5 for asthma management
SABA + moderate dose ICS in MART ± leukotriene receptor antagonist (LTRA)
can also consider separate ICS & LABA inhalers
30
Step 6 for asthma management
Options include
- seek expert help
- try high dose ICS as a separate inhaler
- trial of long acting muscarinic receptor antagonist (LAMA)
- trial of theophylline
31
Acute asthma exacerbation
an acute/subacute episode of progressive worsening of symptoms of asthma
generally a clinical diagnosis
32
Risk factors for severe exacerbation of asthma
```
previous near fatal asthma
previous admission for asthma
need ≥3 medication for control
non compliance/denial of illness
obesity
smoking/second hand smoke
≥1 severe exacerbations in last 12 months
```
33
Presentation of Acute exacerbation of asthma
```
dyspnoea/wheeze/cough
-worsening
-no response to salbutamol
tachycardia, tachypnoea
accessory muscle use
hypoxia, altered mental status
silent chest
paradoxical breathing
exhaustion
```
34
Moderate acute asthma exacerbation
```
PEFR 50-75%
sats ≥92%
normal speech
RR <25
HR <110
```
35
severe acute asthma exacerbation
```
PEFR 33-50%
sats ≥92%
can't complete sentences
RR ≥25
HR ≥110
```
36
life threatening acute asthma exacerbation
```
PEFR <33%
sats <92%
silent chest/cyanosis/poor respiratory effort
bradycardia/dysrhythmia/hypotension
altered consciousness
```
37
near fatal acute asthma exacerbation
indicated by a ↑ PCO2 / normal PCO2 or need for mechanical ventilation
indicates exhaustion
38
Severity of acute asthma exacerbation
may be moderate, severe, life threatening or near fatal
depends on PEFR, RR, sats, HR, ability to complete sentences and PCO2
39
Management of acute asthma exacerbation
ABCDE assessment, ABG
O2 via non rebreather mask (target sats 94-98%)
SABA e.g. salbutamol
- via spacer or O2 driven nebuliser
- 5mg
- 4 puffs + 2 puffs every 2 min for up to 10 puffs
- nebs can be back to back, but monitor K+
Ipratropium bromide
- 500 micrograms via nebuliser
- can be given with salbutamol but not back to back
Steroids
- 100mg hydrocortisone IV
- 40-50mg prednisolone PO for minimum 5 days
IV Magnesium sulphate
IV amiophylline
ITU support for airway management
-make sure you call for help early
40
Discharge criteria post acute asthma exacerbation
stabile on discharge medications for 12-24h
no use of nebulisers for >24h
inhaler technique checked & recorded
PEFR >75% of best/predicted
if life threatening then GP follow up organised within 2 days of discharge
41
Chronic obstructive pulmonary disease (COPD)
a lung disease characterised by airway obstruction that is not fully reversible leading to persistent respiratory symptoms
the airflow limitation is usually progressive & is associated with an abnormal inflammatory response in the lungs
usually diagnosed in people in the 50s
42
Aetiology of Chronic obstructive pulmonary disease (COPD)
smoking*** (~90% of cases)
alpha-1 anitrypsin deficiency
air pollution
fine dust
43
Presentation of Chronic obstructive pulmonary disease (COPD)
```
chronic productive cough
dyspnoea (especially exertional)
wheeze
barrel chest
nail clubbing
peripheral oedema
hyperresonant lung
```
44
Investigations of Chronic obstructive pulmonary disease (COPD)
FEV1/FVC
- <70%
- no reversibility
CXR
- hyperinflation & bullae
- flat hemidiaphragm
- also to exclude lung cancer
FEV1 (↓)
FBC (
45
Investigations of Chronic obstructive pulmonary disease (COPD)
FEV1/FVC
- <70%
- no reversibility
CXR
- hyperinflation & bullae
- flat hemidiaphragm
- also to exclude lung cancer
FEV1 (↓)
FBC (↑ haematocrit, anaemia)
46
Severity of Chronic obstructive pulmonary disease (COPD)
Mild (Stage I)
- FEV1/FVC <70%
- FEV1 >80%
- symptoms must be present for diagnosis
Moderate (Stage II)
- FEV1/FVC <70%
- FEV1 50-79%
severe (Stage III)
- FEV1/FVC <70%
- FEV1 30-49%
very severe (Stage IV)
- FEV1/FVC <70%
- FEV1 <30%
47
Management of Chronic obstructive pulmonary disease (COPD)
Smoking cessation***
pulmonary rehabilitation
Step 1
- asthmatic features present = LABA + ICS + SABA
- no asthmatic features = LABA (e.g. salmeterol) + LAMA (e.g. tiotropium) + SABA
Step 2
- SABA (PRN)
- LABA + LAMA + ICS for everyone
Step 3:
-trial of theophylline
Oral prophylactic Abx
- azithromycin (1st line)
- do ECG to exclude QT prolongation & LFTs
- give to pts who don't smoke, have optimised treatment but have frequent exacerbations
Long term O2 therpay
-if pt fits criteria
48
Features suggesting steroid responsiveness in Chronic obstructive pulmonary disease (COPD)
I.e. asthmatic features
- previous history of asthma / atopy
- ↑ eosinophils
- substantial variation in FEV1 (≥400ml)
- substantial diurnal variation in PEFR (≥20%)
49
Most important intervention in Chronic obstructive pulmonary disease (COPD) management
smoking cessation
vital in any pt that still smokes
50
Acute exacerbation of Chronic obstructive pulmonary disease (COPD)
defined as an acute worsening of respiratory symptoms that results in addition therapy needs
one of the most common reasons for pts to present to the hospital
51
Aetiology of Acute exacerbation of Chronic obstructive pulmonary disease (COPD)
Most commonly viral
```
haemophilus influenzae (most common)
strep pneumonia (most common bacterial cause)
Others: mortadella catarrhalis, staph aureus
```
52
Presentation of Acute exacerbation of Chronic obstructive pulmonary disease (COPD)
```
↑ dyspnoea
↑ cough
↑ wheeze
↑ volume/purulence of sputum
fevers, chills, sore throat
↓ exercise tolerance
respiratory distress (dyspnoea, tachypnoea, confusion, cyanosis, peripheral oedema)
respiratory failure
```
53
Investigations for Acute exacerbation of Chronic obstructive pulmonary disease (COPD)
ABG
-↓PaO2, ↑PaCO2, pH <7.35
CXR
- hyperinflation, flattened diaphragm
- possible consolidation if infection
sats (↓)
sputum/blood cultures
ECG, FBC, U&Es
54
Management of Acute exacerbation of Chronic obstructive pulmonary disease (COPD)
↑ dose & frequency of SABA via inhalers with spacers
oral steroids:
- 30mg prednisolone for 7-14 days
- consider osteoporosis prophylaxis if requiring frequent courses
Abx (PO)
- if sputum purulent / clinical signs of pneumonia
- amoxicillin / clarithromycin / doxycycline (all 1st line on BNF)
O2 if below target sats
consider NIV
-for persistent hypercapnia respiratory failure
consider IV theophylline
-if poor response to bronchodilators
55
Small cell lung cancer (SCLC)
also known as oat cell carcinoma, is a malignant epithelial tumour arising from the cells lining the lower respiratory tract
~15% of all lung cancer
rapidly growing & highly malignant, spreading early (almost always inoperable at presentation)
seen generally in older adult smokers (both active & passive smoking is a risk factor)
56
Presentation of Small cell lung cancer (SCLC)
```
dyspnoea, cough, haemoptysis, chest pain
weight loss, fatigue
dysphagia, hoarseness, wheezing/stridor
recurrent pneumonias
superior vena cava syndrome
```
57
Investigations for Small cell lung cancer (SCLC)
CXR
- central mass
- hilar lymphadenopathy
- pleural effusion
CT chest/abdo/pelvis
-investigation of choice
bronchoscopy ± biopsy
PET scan
58
Management of Small cell lung cancer (SCLC)
consider pts in early stages for surgery
generally chemo + radiotherapy = management of choice
if extensive disease = palliative chemo
59
Complications of Small cell lung cancer (SCLC)
Lambert-Eaton syndrome:
- myasthenia like syndrome
- antibody against presynaptic voltage-gated calcium channel
SIADH
-leading to hyponatraemia
ACTH secretion
-leads to bushings syndrome & adrenal hyperplasia
Superior vena cava syndrome
-dyspnoea, face & arm swelling, periorbital & conjunctival oedema, pulseless JVP distension
60
Referral criteria for suspected lung cancer
referral to specialist on 2 week wait
- if CXR findings are suggestive of cancer
- if ≥40 y/o + unexplained haemoptysis
Urgent CXR (within 2 weeks)
- if age ≥40yrs + ≥2 of the following unexplained symptoms
- if age ≥40yrs + ≥1 symptom if they ever smoked
- cough
- fatigue
- SOB
- chest pain
- weight loss
- loss of appetite
61
Non-Small cell lung cancer (NSCLC)
a group of malignant epithelia tumours representing ~85% of all lung cancers
most common risk factor is active & passive smoking
62
Types of Non-Small cell lung cancer (NSCLC)
Squamous (42& of NSCLC)
- often central presenting as obstructive lesion of bronchus leading to infection
- local spread common but metastasis occur relatively late
adenocarcinoma (39% of NSCLC)
- typically peripheral
- most common type of cancer in non-smokers
large cell lung carcinoma (8% of NSCLC)
- anaplastic, poorly differentiated tumours that metastasis early
- poor prognosis
carcinoid tumours (7% of NSCLC)
```
Bronchoalveolar tumour (4% of NSCLC)
-associated with ++ sputum
```
63
Presentation of Non-Small cell lung cancer (NSCLC)
```
persistent cough
haemoptysis
dyspnoea
chest pain
weight loss
fatigue
anorexia
hoarseness
recurrent pneumonias
superior vena cava syndrome
```
64
Investigations for Non-Small cell lung cancer (NSCLC)
CT chest/abdo/pelvis
-investigation of choice
CXR
- usually preliminary
- may show mass
bronchoscopy + biopsy
pet scanning
65
Management of Non-Small cell lung cancer (NSCLC)
surgery (indicated in ~20% of pts)
- lobar resection
- lobectomy
curative or palliative radio therpay
generally poor responsiveness to chemo
66
Respiratory failure
the acute or chronic inability of the reparatory system to maintain adequate gas exchange leading to hypoxia ± hypercapnia
67
Types of respiratory failure
Type I respiratory failure:
- hypoxic respiratory failure
- PaO2 <8kPa
- PaCO2 normal
Type II respiratory failure:
- hypercapnic respiratory failure
- PaO2 <8kPa
- PaCO2 >6kPa
68
Aetiology of type I respiratory failure
```
COPD
pneumonia
pulmonary oedema
pulmonary fibrosis
asthma
PE
cyanotic congenital heart disease
ARDS
bronchiectasis
obesity
kyphoscoliosis
```
69
Aetiology of type II respiratory failure
```
COPD
severe asthma (when pt is exhausted)
drug overdose/poisoning
muscular disorders
severe ARDS
```
70
Presentation of respiratory failure
```
tachypnoea
dyspnoea
cyanosis
tachycardia
confusion
↓GCS
arrhythmias
hypercapnia (hypoventilation, headache, coma, asterix)
```
NB clinical features of the underlying cause will be present
71
Investigations for respiratory failure
ABG***
CXR, FBC, TFTs, U&Es, LFTs, CK, troponin, ECG, CT-CTPA
72
Management of respiratory failure
resuscitation & ABCDE assessment
treat underlying cause
Hypoxia
- O2
- CPAP (↑ O2)
- mechanical ventilation
Hypercapnia
- NIV/BIPAP (↑O2, ↓CO2)
- mechnaical ventilation
73
BIPAP (NIV) vs CPAP
CPAP helps ↑ O2 but doesn't affect CO2
NIV/BIPAP helps ↑O2 & ↓CO2
74
Tuberculosis (TB)
an infectious disease caused by mycobacterium tuberculosis typically affecting the lungs
NB notifiable disease in the UK
spreads via inhalation of infected droplets
75
Types of Tuberculosis (TB)
Primary TB
latent TB/inactivated TB
secondary TB
-e.g. from reactivation of latent disease
miliary TB
-disseminated TB usually seen in immunocompromised pts
76
Risk factors for Tuberculosis (TB)
```
homelessness
institutionalisation e.g. prisons
alcohol/drug misuse
HIV +ve
immunocompromised
crowded lying
ethnic minority background
travel to/heritage from high prevalence areas
```
77
presentation of Tuberculosis (TB)
```
cough
fever
haemoptysis
night sweats
malaise
chest pain
dyspnoea
erythema nodosum
```
78
Investigations for Tuberculosis (TB)
CXR
- upper lobe opacities ± consolidation
- bilateral hilar lymphadenopathy
Sputum smear
- 3 samples needed
- uses Ziehl-Nielsen staining
Sputum culture
- gold standard
- helps asses drug sensitivity
- take a long time to get back
NAAT
-can help with rapid diagnosis
mantoux test
- to screen for latent TB
- alternative is inferno-gamma test (if mantoux test is inconclusive)
79
Management of Tuberculosis (TB)
Active TB:
- 2 months of rifampicin + isoniazid + pyrazinamide + ethambutol
- then 4 months of rifampicin + isoniazid
Latent TB:
- 3 months of rifampicin + isoniazid
- alternatively 6 months of isoniazid
NB isoniazid is always given with pyridoxine to prevent peripheral neuropathy
80
Side effects of Tuberculosis (TB) drugs
Rifampicin:
- enzyme inducer
- orange secretions
- hepatitis
Isoniazid:
- enzyme inhibitor
- agranulocytosis
- hepatitis
Pyrazinamide:
- hyperuraemia (gout)
- arthralgia
- hepatitis
Ethambutol:
- optic neuritis
- monitor visual acuity
81
Pneumonia
inflammation of the lungs with consolidation & interstitial infiltration most commonly caused by bacteria
82
Types of pneumonia
Community acquired pneumonia (CAP):
-pneumonia acquired outside hospital/healthcare facilities
Hospital acquired pneumonia (HAP):
-pneumonia acquired >48h after admission to hospital
Atypical pneumonia
-caused buy atypical organisms e.g. legionella
83
Causes of pneumonia
CAP:
- strep pneumoniae (most common)
- H. Influenzae, staph aureus, mycoplasma pneumoniae
HAP:
- <5 days = strep pneumoniae
- >5 days = H.influenzae ± staph aureus (also pseudomonas or MRSA)
In alcoholics the usually cause is klebsiella pneumoniae
NB pneumonia post H.influenzae is often caused by staph aureus
84
Risk factors for pneumonia
```
infants/young children
elderly
smoking
alcohol misuse
asthma
COPD
malignancy
immunosuppression
IVDU
hospitalisation
```
85
Presentation of pneumonia
```
cough with purulent sputum
fever
malaise
dyspnoea
chest pain (pleuritic)
tachycardia
hypoxia
bronchial breathing & crackles on auscultation
dullness on percussion
```
86
Investigations for pneumonia
CXR
-new consolidation
FBC (↑ WCC)
CRP (↑)
U&Es
Blood cultures
87
Scoring system for pneumonia
```
CURB65 score
-C = Confusion
-U = Urea >7.0 mmol/L
-R = RR ≥30
-B = BP ≤90/60
=65 = age ≥65yrs
```
Score 0-1 = home based care
Score ≥2 = consider hospital care
Score ≥3 = intensive care assessment
NB in primary care the CRB65 score can be used, i.e. leaving out the urea
88
Management of Community acquired pneumonia (CAP)
low severity:
- 5 days of amoxicillin
- 5 days of clarithromycin/erythromycin if penicillin allergy)
moderate severity:
-7 days of amoxicillin + macrolide e.g. erythromycin
high severity:
-co-amoxiclav, ceftriaxone, tazocin
NB clarithromycin is contraindicated in pregnancy so if pregnant & allergic to penicillin then use erythromycin, otherwise clarithromycin tends to be favoured
89
Management of Hospital acquired pneumonia (HAP)
Consider broad spectrum IV Abx
then tailor treatment when sensitivities available
generally based on local guidelines & sensitivities
90
Aspiration pneumonia
results from the inhalation of oropharyngeal secretions or stomach contents into the lower airways leading to chemical pneumonitis, lung injury and resultant bacterial infection
most commonly seen in hospitals & care homes
91
Risk factors for Aspiration pneumonia
```
impaired consciousness
poor mobility
NBM
advanced age
swallowing disorders (e.g. oesophageal strictures, dysphagia)
neurological disorders (e.g. strokes, MS, Parkinsons)
poly pharmacy
poor dental hygiene
```
92
Aetiology of Aspiration pneumonia
Similar to normal pneumonia
strep pneumoniae, staph aureus, H. influenzae, pseudomonas aeruginosa
IN alcoholics its frequently Klebsiella pneumoniae
93
Presentation of Aspiration pneumonia
```
fever, headache, N&V, anorexia, myalgia
cough
dyspnoea
pleuritic chest pain
purulent sputum
tachycardia
↓ breath sounds on auscultation
crackles on auscultation
dullness on percussion
```
94
Investigations for Aspiration pneumonia
CXR
- new consolidation
- or atelectasis
FBC (↑WCC, neutrophilia)
sputum & blood cultures
95
Management of Aspiration pneumonia
- tracheal suction if aspiration is noticed early
- mechanical removal of object via bronchoscopy (e.g. in children)
- Abx treatment as per pneumonia
- NB if severe then IV/PO co-amoxiclav
NB remember to be mindful of pts swallow with PO meds even Abx
96
Sarcoidosis
a chronic granulomatous disorder of unknown aetiology characterised by non-caseating granulomas commonly affecting the lungs, skin and eyes, its a diagnosis of exclusion
NB lungs are affected in 90% of pts
97
Epidemiology of sarcoidosis
most commonly seen in young adults (20-40y/o)
| more common in people of african or northern european/scandinavian origin
98
Presentation of sarcoidosis
- erythema nodosum
- swinging fever
- polyarthralgia (common in acute attacks)
- dyspnoea, non productive cough
- weight loss, night sweats, fatigue
- lupus pernio (violaceous soft infiltration of skin of nose/cheeks)
- anterior & posterior uveitis
- lymphadenopathy
NB acute attacks are more common in white populations remitting after 2yrs
99
Investigations for Sarcoidosis
CXR
- bi-hilar lymphadenopathy
- bilateral infiltrations
FBC
- anaemia
- leukopenia
mantoux test
- negative
- to exclude TB
spirometry:
-restrictive pattern
Ca2+ (↑), ACE levels (↑)
U&Es, phosphate, LFTs
100
Pleural effusion
a collection of fluid between the pleural & visceral pleural surfaces in the thorax i.e. the pleural cavity
101
Aetiology of pleural effusion
Transudates (<30g/L of protein)
- HF (most common cause of transudates)
- cirrhosis, hypoalbuminaemia, hypothyroidism, nephrotic syndrome, meigs syndrome (bening ovarian tumour causing ascites + pleural effusion)
Exudates (>30g/L of protein)
- pneumonia (most common)
- malignancy (often cause large unilateral effusion)
- especially breast & lung cancer
- RA, SLE, PE, TB, pancreatitis, Dresslers syndorme
Haemothorax
- pleural effusion due to blood
- usually secondary to trauma
102
Presentation of Pleural effusion
small effusions <300ml are usually asymptomatic
```
dyspnoea, pleurite chest pain, dry non productive cough
dullness on percussion
↓ breath sounds
↓ chest expansion
↓ tactiel vocal remits
```
signs & symptoms of underlying cause will be present
103
Investigations for Pleural effusion
CXR
- blunting of costophrenic angles
- opacification of lung fields with fluid level
Pleural fluid analysis
- from USS guided aspiration
- pH, protein, LDH, cytology, microbiology
USS + aspiration
CT/MRI (helps find underlying cause)
NB use lights criteria if protein levels between 25-35g/L i.e. borderline of transudate & exudate
104
Management of Pleural effusion
treat underlying cause
therapeutic thoracentesis (avoid taking >1.5L as it can cause fluid shift leading to pulmonary oedema)
pleurodesis
chest drain / long term indwelling pleural drainage
105
Criteria for pleural effusion
Lights criteria
| -used if protein level 25-35g/L in pleural fluid to differentiate transudate & exudate
106
Criteria for pleural effusion
Lights criteria:
used if protein level 25-35g/L in pleural fluid to differentiate transudate & exudate
Exudate is likely if one of the following
- pleural fluid protein divided by serum protein >0.5
- pleural fluid LDH divided by serum LDH >0.6
- pleural fluid LDH >2/3 of upper limit of serum LDH
107
Pneumothorax
a collection of air in the pleural cavity leading to partial or complete collapse of the lung
108
Types of Pneumothorax
Primary spontaneous Pneumothorax (PSP)
-usually seen in health young people
Secondary spontaneous Pneumothorax (SSP)
- in pts with pre-exisitng lung disease
- e.g. rupture of bullae in COPD
Traumatic pneumothorax
-traumatic cause
Tension pneumothorax
- life threatening emergency
- usually post trauma
109
Presentation of Pneumothorax
```
dyspnoea
pleuritic chest pain with sudden onset
ipsilateral reduced breath sounts
ipsilateral hyper resonance on percussion
tachypnoea
hypoxia
tachycardia
```
110
Investigations for Pneumothorax
CXR
- visible rim on air between lung margin & chest wall
- absence of lung markings
consider CT or USS
-usually for complex cases
111
Management of Primary spontaneous Pneumothorax (PSP)
<2cm rim of air + pt not SOB
- consider discharge
- repeat CXR to check resolution
>2cm or symptomatic pt
-attempt simple aspiration
If aspiration failed i.e. >2cm rim of air or still SOB
-chest drain
112
Management of Secondary spontaneous Pneumothorax (SSP)
pt >50y/o / rim >2.0cm / pt SOB
-chest drain
Rim of air = 1-2cm
- trial of aspiration
- if it fails = chest drain
Rim of air <1cm
-admit for 24h of observation ± O2
113
Tension Pneumothorax
life threatening emergency usually seen post trauma
presents with respiratory distress (hypoxia, cyanosis, diaphoresis, dyspnoea, tachypnoea), haemodynamic instability (hypotension, tachycardia), trachea is deviated away from affected side
this is a clinical diagnosis and should be treated immediately (do not wait for imaging)
treatment includes emergency needle decompression & chest drain insertion
114
Obstructive sleep apnoea (OSA)
a clinical condition in which there is intermittent & repeated upper airway obstruction during sleep leading to poor sleep quality & frequent arousals
- apnoeas (≥10sec pauses in breathing)
- hypopnoea (≥10sec periods with breathing ↓50%)
pone of the most common causes of secondary hypertension
115
Risk factors for Obstructive sleep apnoea (OSA)
```
obesity***
male gender
smoking
excess alcohol consumption
macroglossia
acromegaly
hypothyroidism
```
adenotonsilar hyperplasia especially in children
116
Presentation of Obstructive sleep apnoea (OSA)
sleep partner complains of excessive snoring or describes apnoeas
```
daytime somnolence
snoring
waking headaches
unrefreshing sleep
sleep fragmentation
irritability
```
117
Investigations for Obstructive sleep apnoea (OSA)
Epworth sleepiness scale (asses for daytime sleepiness)
- score >10 suggests need for investigation
- score >18 / Road traffic accident or near miss = urgent referral
Polysomnography
-≥5 respiratory events e.g. apnoea/hypopnoea/arosals per hour associated with OSA symptoms
118
Management of Obstructive sleep apnoea (OSA)
weight loss
smoking cessation avoid alcohol/sedative
CPAP (gold standard)
- 1st line in moderate/severe OSA
- acts as pneumatic splint maintaining airway patency
- min 4h per night
BiPAP
-considered if hypoventilation or COPD
Mandibular advancement splints
-alternative to CPAP if mild/moderate OSA or intolerant to CPAP
119
Driving and Obstructive sleep apnoea (OSA)
must inform DVLA & stop driving until adequate control is achieve i.e. ↓daytime sleepiness
120
Pulmonary hypertension
a rise in mean pulmonary arterial pressure (mPAP) which can be due to a variety of use
defined as ↑ mean PAP ≥25 mmHg at rest
121
Idiopathic Pulmonary hypertension (PAH)
a rare disorder defined by ↑ pulmonary arterial pressure & ↑ pulmonary vascular resistance with normal pulmonary artery wedge pressure in the absence of a known cause
often severe and rapidly progressing
treated with high dose calcium channel blockers
122
Aetiology of Pulmonary hypertension
Group 1:
-idiopathic
Group 2:
-secondary to left heart disease, Valvular heart disease or restrictive cardiomyopathy
Group 3;
-secondary to chronic lung disease or environmental hypoxaemia
Group 4:
-due to chronic thrombotic disorders, embolic disease or both
Group 5:
-metabolic disorders, haematological disease & systemic illness
NB generally the most common causes are severe respiratory or cardiac disease
123
Presentation of Pulmonary hypertension
```
progressive dyspnoea
weakness
fatigue
exertional dizziness/syncope
loud S2 (often split)
↑ JVP
symptoms of right HF
```
124
Investigations for Pulmonary hypertension
Right heart catheterisation
-↑ PAP ≥25 mmHg at rest
CXR
-prominent R heart border
ECG, Echo, CT/MRI thorax
125
Management of Pulmonary hypertension
treat underlying cause
pulmonary vasodilators if acute deterioratio
if idiopathic PH (PAH) give high dose calcium channel blockers
126
Cor Pulmonale (Pulmonary heart disease)
altered structure (hypertrophy/dilation) or impaired function of the right ventricle due to pulmonary hypertension
diagnosed via echo
prominent signs of right sided HF will be present
127
Cystic fibrosis (CF)
autosomal recessive disorder causing ↑ viscosity of secretion due to defect in the cystic fibrosis transmembrane conductance regulatory gene (CFTR) which codes cAMP-regulated chloride channels
80% of cases in UK are due to delta F508 (DF508)
most common inherited condition in white populations
128
Presentation of Cystic fibrosis (CF)
- meconium ileus in neonates (very indicative fo CF)
- failure to thrive
- recurrent chest infections (causes include staph aureus, pseudomonas, Burkholida cepacia, aspergillus)
- malabsorption, steatorrhoea, pancreatitis
- CF related diabetes
- nasal polyps
- clubbing
- cholestasis, cholecystolithiasis
- subfertility/infertility
129
Investigations for Cystic fibrosis (CF)
Newborn screening
- +ve on newborn blood spot test
- day 5-7 post birth
Sweat test
- +ve
- >60mmol/L of sweat chloride
genetic testing
-for CFTR gene
lung function tests
sinus X-ray/CT
130
Genetics of Cystic Fibrosis (CF)
autosomal recessive disorder of cystic fibrosis transmembrane conductance regulatory gene (CFTR)
80% of cases in UK are due to delta F508 (DF508) gene
131
Management of Cystic fibrosis (CF)
regular chest physio & postural drainage
- twice a day minimum
- should be taught from young age
high calorie diet
-with high fat intake
minimise contact with other CF pts
-to prevent spread of burkholdia cepacia
Vitamin supplementation & pancreatic enzyme supplementation
if DF508 +ve
-trial lumacaftor or Ivacaftor
132
Bronchiectasis
an abnormal, irreversible dilation in the bronchial tree caused by cycles of bronchial inflammation leading to mucous plugging & progressive airway destruction
~70% of cases are in older women
133
Aetiology of Bronchiectasis
post-infective (most common cause)
-TB, measles, pertussis, pneumonia
cystic fibrosis, primary ciliary dyskinesia/Kartengers syndrome, immunodeficiency & HIV, bronchial obstruction e.g. malignancy, allergic brochopulmonary aspergillosis, COPD
134
Presentation of Bronchiectasis
chronic productive cough with copious mucopurulent sputum (may be blood stained)
dyspnoea
chest pain
clubbing
On auscultation
- coarse early inspiratory crackles
- rhonchi (low pitch snore like noises)
- wheeze
135
Investigations for Bronchiectasis
CXR
- baseline CXR for all pts
- ~90% of pts have abnormal CXR
- tram lines, fluid levels, ring shadows
high resolution CT chest (HRCT)
- gold standard
- bronchial wall dilation
- bronchial wall thickening
Sputum MC&S
-H.influenzae is the most commonly isolated
routine bloods, serum immunoglobulins, serum electrophoresis, antibody screening, ciliary function tests, lung function tests
136
Management of Bronchiectasis
Influenza & pneumococcal vaccines
chest physio & postural drainage
inspiratory muscle training
Abx for acute exacerbation
-1st line : amoxicillin/clarithromycin/doxycyline
Long term Abx
-if ≥3 expectations per year requiring Abx or exacerbations causing significant morbidity
Bronchodilators
-after assessing reversibility of airflow obstructions
surgery
-if localised disease
137
Asbestosis
a type of pneumoconiosis
138
Asbestosis
a type of pneumoconiosis caused by inhalation of asbestos fibres occurring primarily as a result of occupational exposure
severity is related to length of exposure, with a 20-30 year latent period
presents with gradual onset dyspnoea/SOB, ↓ exercise tolerance ± wheezing/productive cough, with fine bilateral inspiratory crackles, clubbing, cor pulmonale
Investigated with CXR (lower zone linear interstitial fibrosis & pleural thickening), pulmonary function tests (restrictive patterns), HRCT
no specific management available
139
Causes of upper zone lung fibrosis
Acronym for causes of upper zone fibrosis:
```
CHARTS
C - Coal worker's pneumoconiosis
H - Histiocytosis/ hypersensitivity pneumonitis
A - Ankylosing spondylitis
R - Radiation
T - Tuberculosis
S - Silicosis/sarcoidosis
```
140
Mesothelioma
an aggressive neoplasm arising from mesothelial cells lining the pleural cavity associated with asbestos exposure, more commonly seen in men aged >75yrs
often locally advanced but rarely metastasises
presents with dyspnoea, chest wall pain, weight loss, clubbing, painless pleural effusion
investigated with CXR (unilateral pleural effusion, irregular pleural thickening), CT, thoracoscopy
management includes radiotherapy, chemo and surgery
prognosis is poor, with median survival <12 months
141
Occupational asthma
pts with asthma may preset with concerns that chemical at their work are worsening their symptoms
OR
on history taking symptoms appear better at weekends / on holidays /away from work
142
Occupational asthma
pts with asthma may preset with concerns that chemical at their work are worsening their symptoms
OR
on history taking symptoms appear better at weekends / on holidays /away from work
most commonly associated with isocyanates
investigated with serial PEFR at work & away from work
treated by respiratory specialist
143
Silicosis
common occupational lung disease caused by inhalation of crystalline silica dusts commonly seen in mining, slate works, foundries and potteries
presents with chronic cough, sputum, exertional dyspnoea, fatigue, weight loss
investigated with CXR (egg-shell calcification of hilar lymph nodes, bilateral diffuse ground glass opacities), spirometry (restrictive pattern)
no definitive treatment
NB
Caplan syndrome - pneumoconiosis + RA
144
Coal workers pneumoconiosis (Black lung disease)
occupational lung disease caused by long term exposure to coal dust particles, severity linked to extent of exposure
may present with simple pneumoconiosis (often asymptomatic, often incidentally found)
may progress to progressive massive fibrosis (PMF) which presents as SOB on exertion & cough + black sputum
Investigated with CXR (upper zone fibrosis), spirometry (mixed obstructive / restrictive picture)
managed with irritant avoidance & supportive care
145
Interstitial lung disease (ILD)
a heterogenous group of disorders characterised by inflammation & progressive scarring (fibrosis) of the lung
146
Aetiology of Interstitial lung disease (ILD)
Idiopathic pulmonary fibrosis (IPF)
```
hypersensitivity pneumonitis (extrinsic allergic alveolitis)
-Pigeon breeders lung, farmers lung, bird fanciers lung
```
pneumoconiosis
-asbestosis, coal workers lung, silicosis
radiation pneumonitis
Medication
- amiodarone, bleomycin, methotrexate
- nitrofurantoin, sulfalazine, cabergoline
```
cocaine
sarcoidosis
vasculitis
sarcoidosis
TB
```
147
Medications causing Interstitial lung disease (ILD)
- amiodarone
- bleomycin
- methotrexate
- nitrofurantoin
- sulfalazine
- cabergoline
- bromocriptine
148
Presentation of Interstitial lung disease (ILD)
```
progressive dyspnoea
-exertional dyspnoea → dyspnoea at rest
persistent non productive cough
fatigue
clubbing
bibasal inspiratory crackles/rales
cyanosis
```
149
Investigations for Interstitial lung disease (ILD)
CXR
- reticular opacities
- ground glass opacities
CT/HRCT
- honey combing
- traction bronchiectasis
Spirometry
- Restrictive pattern i.e. ↓FEV1 & ↓FVC
- normal/↑ FEV1/FVC
bronchoalveolar lavage & biopsy
150
Management of Interstitial lung disease (ILD)
smoking cessation
supportive therapy
- O2
- pulmonary rehab
- vaccination e.g. influenza/pneumococcal
lung transplant
-end stage ILD
For Idiopathic pulmonary fibrosis (IPF)
-antifibrotic agents e.g. pirfenidone
151
Idiopathic pulmonary fibrosis (IPF)
no underlying cause found
usually seen in men aged 50-75yrs
consider treating with antifibrotic agents e.g. pirfenidone
