respiratory Flashcards
(129 cards)
1
Q
define asbestos related lung disease
A
industrial dust diseases
asbestosis:
- long term inflammation and scarring of lungs caused by asbestos fibre inhalation
mesothelioma:
- aggressive tumour usually occurring in pleural (sometimes peritoneum, pericardium, or testes)
2
Q
epidemiology of asbestos-related lung disease
A
mesothelioma is rare - more common in elderly
asbestos exposure documented in 90% of cases
latent period between exposure and mesotheliomas = up to 50 yrs
3
Q
aetiology of asbestosis
A
commonly used in building trade (always ask occupation)
degree of exposure related to degree of pulmonary fibrosis
inflammation gradually causes mesothelial plaques in pleura
causes increased risk of bronchial adenocarcinoma and mesothelioma
4
Q
presenting symptoms of asbestosis
A
progressive dyspnoea
5
Q
bloody sputum in asbestos related lung disease
A
mesothelioma
if tumour invades blood vessel
6
Q
physical examination findings of asbestos related lung disease
A
asbestosis:
- clubbing
- fine end-inspiratory crackles
mesothelioma:
- occasional palpable chest wall mass
- clubbing (underlying asbestosis and pulmonary fibrosis)
- recurrent pleural effusions
- metastatic signs (lymphadenopathy, hepatomegaly, bone tenderness)
- abdominal pain/obstruction
- pneumothorax (rare)
7
Q
investigations and findings for asbestosis
A
Hx and examination
CXR: reticular nodular shadowing +/- pleural plaques
8
Q
aetiology of mesothelioma
A
associated with occupational exposure to asbestos - complex relationship
malignant pleural mesothelioma rarely spreads to distant sites
most patients present with locally advanced disease
9
Q
presenting symptoms of mesothelioma
A
SoB chest pain (dull, diffuse, developing)
weight loss
fatigue
fever
night sweats
bone pain
abdominal pain
10
Q
investigations and findings for mesothelioma
A
- Ultrasound guided fluid aspiration
- staging CT
- Pleural biopsy (DIAGNOSTIC)
CXR/CT:
pleural thickening/effusion; pleural mass; rib destruction
* bloody pleural fluid
MRI + PET:
- ULTRASOUND GUIDED pleural fluid aspiration - send for cytological analysis
- pleural biopsy (DIAGNOSTIC)
11
Q
Diagnosis of mesothelioma
A
histology following thoracoscopy (pleural biopsy)
biopsy can be immunostained with calretinin reactive stain
12
Q
define lung cancer
A
primary malignant neoplasm of the lung
13
Q
aetiology/risk factors of lung cancer
A
smoking
asbestos exposure
occupational hazards
atmospheric pollution
14
Q
epidemiology of lung cancer
A
3x more common in males
scc = 20% nscc = 80%
15
Q
presenting symptoms of lung cancer
A
due to primary tumour:
- cough
- haemoptysis
- chest pain
- dyspnoea
- recurrent pneumonia
due to local invasion:
- shoulder/arm pain (brachial plexus invasion)
- hoarse voice and bovine cough (left recurrent laryngeal nerve invasion)
- dysphagia
- arrhythmias
- horner’s syndrome
due to metastatic disease/paraneoplastic phenomenon:
- weight loss
- fatigue
- bone pain
- fractures
16
Q
physical examination findings of lung cancer
A
may be no signs
fixed monophonic wheeze
signs of lobar collapse or PE
signs of metastases (lymphadenopathy, hepatomegaly, bone pain, etc.)
cachexia
anaemia
clubbing
hypertrophic pulmonary osteoarthropathy
17
Q
investigations for lung cancer
A
for dx:
CXR
- peripheral nodule
- hilar enlargement
- consolidation
- lung collapse
- PE
- bony secondaries
sputum and pleural fluid cytology
bronchoscopy with brushings/biopsy (histology)
CT/US guided percutaneous biopsy
lymph node biopsy
for staging:
CT/MRI of head, chest, and abdomen
PET scan
radionuclide bone scan if suspected metastatic disease
lung function test (assess suitability of lobectomy)
bloods:
- FBC
- U&Es
- calcium (raised)
- ALP (raised with bone metastases)
- LFT
pre-operative ABG and pulmonary function test
18
Q
prognosis of lung cancer
A
scc - worse prognosis than nscc
19
Q
define obstructive sleep apnoea
A
recurrent prolapse of pharyngeal airway and apnoea during sleep followed by partial arousal
decreased tone of pharyngeal dilators during sleep
collapse of soft tissues of pharynx causes narrowing of upper airways
20
Q
epidemiology of obstructive sleep apnoea
A
common
prevalence increases with age
associated with:
- weight gain
- smoking and alcohol
- sedative use
- macroglossia
- marfan’s
- craniofacial abnormalities
21
Q
presenting symptoms of obstructive sleep apnoea
A
excessive daytime sleepiness
unrefreshing or restless sleep
morning headaches
dry mouth
difficulty concentrating
irritability and mood changes
decreased libido
snoring
nocturnal choking
22
Q
physical examination findings in obstructive sleep apnoea
A
large tongue
enlarged tonsils
long/thick uvula
retrognathia
increased neck circumference (M>42cm, F>40cm)
obesity
hypertension
23
Q
investigations for obstructive sleep apnoea
A
pulse oximetry
video recording
sleep study/polysomnography
- overnight monitoring
- airflow, respiratory effort, pulse oximetry, HR, snoring, and movement
* >15 episodes of apnoea/hypopnoea during 1hr of sleep = significant sleep apnoea
bloods:
- TFTs
- ABG
24
Q
investigations for obstructive sleep apnoea
A
pulse oximetry
video recording
sleep study/polysomnography
- overnight monitoring
- airflow, respiratory effort, pulse oximetry, HR, snoring, and movement
* >15 episodes of apnoea/hypopnoea during 1hr of sleep = significant sleep apnoea
bloods:
- TFTs
- ABG
25
define pneumothorax
air in pleural space
26
aetiology/risk factors of pneumothorax
spontaneous:
- patients have typically normal lungs
- tall thin males
- caused by rupture of sub pleural bulla
secondary:
- in patients with pre-existing lung disease
traumatic:
- penetrating injury to chest
- often iatrogenic
risk factors:
- collagen disorders
tension pneumothorax
27
presenting symptoms of pneumothorax
may be asymptomatic if small
* sudden onset SOB
* pleuritic chest pain
* distress with rapid shallow breathing in tension PTX
patients on ventilation may present with hypoxia/increase in ventilation pressures
28
physical examination findings of pneumothorax
may be no signs if small
* respiratory distress signs (low O2 sats)
* **reduced expansion** on affected side
* **hyper-resonance** on affected side
* **reduced breath sounds** on affected side
29
physical examination findings of tension pneumothorax
* severe respiratory distress (low O2 sats, cyanosis)
* **tachycardia**
* **hypotension**
* distended neck veins
* **tracheal deviation** away from side of PTX
* increased percussion note
* reduced breath sounds
30
investigations for pneumothorax
**_CXR:_**
- darker area with no vascular markings (increased air)
- fluid levels if bleeding
\* do not perform for suspected tension pneumothorax (can delay immediate necessary treatment)
ABG:
- check for hypoxaemia
31
management plan for tension pneumothorax
emergency
1. needle decompression
* large bore needle into 2nd ICS MCL on affected side just above 3rd rib
* \<2.5L of air can be aspirated
* \* stop if patient coughs/resistance felt
2. High flow oxygen (max O2)
3. chest drain
follow up CXR 2hrs and 2 wks later
32
management of primary pneumothorax
\<2cm rim of air on CXR:
- discharge
- repeat CXR
\>2cm +/- SoB:
- aspiration
- if unsuccessful =\> chest drain
33
management of secondary pneumothorax
\<2cm:
- aspiration
- 24hr admittance
\>2cm + SoB + \>50yrs:
- chest drain
34
when to perform chest drain with underwater seal in pneumothorax case
if:
- aspiration fails
- fluid in pleural cavity
- after tension PTX decompression
inserted in 4-6th ICS MAL avoiding long thoracic nerve and artery
35
advice after pneumothorax
avoid air travel until follow up CXR
avoid diving/ subadiving
36
complications of pneumothorax
recurrent pheumothoraces (manage with chemical pleurodesis- fusing of visceral and parietal pleura with tetracyline/calcium or surgical pleurectomy)
bronchopleural fistula
37
prognosis of pneumothorax
* after 1 PTX, ~20% will have another PTX
* frequency increases with repeated PTX
38
define pulmonary embolism
dislodged thrombi occluding pulmonary vasculature
R heart failure and cardiac arrest potential if not aggressively treated
thrombus formation occurs as a result of Virchow's triad
- stasis of blood flow
- trauma (blood vessel wall damage)
- hyper coagulability
39
key diagnostic factors of pulmonary embolism
* dyspnoea
* **PLEURITIC chest pain** (pain on inspiration)
* **SUDDEN onset SOB**
* haemoptysis -blockage of artery
* risk factors for PE (Hx - surgery, cancer, immobility-long flights, OCP, thrombophillia)
* leg pain/ swelling =\> signs of DVT
40
Risk factors for PE
* **Immobility**
* **Malignancy**
* **Surgery**
* Trauma/ thrombophillia (too many platelets=\> too much clotting)
* Virchows triad (hypercoagulability- factor V leiden, vessel wall damage, stasis)
* Pregnancy/ previous VTE/ **_OCP_**(DVT risks)
41
Examination signs of PE
- tachypnoea (fast breathing)
- hypertension
- tachycardia
- early (normal chest) =\> later (dullness to percussion from lobar collapse/ pleural effusion)
- normal/reduced breath sounds
- l**eg swelling** (DVT)
42
investigations for pulmonary embolism
Bedside:
* ECG- sinus tachycardia, RBBB (right heart strain)
* ***Calculate risk*** (WELLSCORE \>4, geneva score)
Bloods:
* D-dimer (low = PE unlikely \*due to clot breakdown)
* FBC
* U&Es
* coagulation studies
* LFT
Imaging:
* **_CTPA_ (CT pulmonary angiogram)-** detects an embolism **_DIAGNOSTIC_**
* **V/Q scan** (for people who can't have CTPA as radiation risk for pregnancy/ renal problems)
* echo
consider:
- ABG (respiratory alkalosis =\> due to hyperventilation)
- CXR- exclude pneumothorax, pneumonia
- lower limb compression venous US
- cardiac biomarker
-
43
management of acute PE when haemodynamically unstable (bp \<90 SBP)
1. A=\> E approach: respiratory support (oxygen, non-rebreather mask) + fluid resuscitation
2. Urgent **_thrombolysis_**/ percutaneous embolectomy (with unfractionated heparin infusion)
consider:
- vasoactive drug
- surgical embolectomy/percutaneous catheter-directed treatment
44
management of acute PE when haemodynamically stable (SBP \>90)
1. risk stratify (Hestia score/ pulmonary embolism severity index)
Low risk
1. high dose LMWH
2. next 3 months - warfarin / DOACs (not for pregnant women)
3. Outpatient follow up monitoring
Moderate/High risk
1. Admit to hospital
2. High dose LMWH
3. Oxygen only if hypoxic
45
management after PE
* continue long term anticoagulation
* increase dose or switch to heparin if necessary
* consider venous filter
46
definition of respiratory failure
acute impairment in gas exchange causing hypoxia with/without hypercapnia
PaO2 \< 8kPa (type 1) + PaCO2 \> 6.5kPa (type 2)
47
presentation of respiratory failure
SoB
anxiety
confusion
tachypnoea
cardiac dysfunction
cardiac arrest
48
key diagnostic factors of respiratory failure
risk factors
- smoking
- age
- pulmonary infection
direct trauma to thorax and neck
cyanosis
dyspnoea
accessory muscle use
retraction of intercostal spaces
stridor
inability to speak
confusion
49
investigations for respiratory failure
pulse oximetry
ABG
FBC - elevated WBC?
D-dimer - rule out acute PE
serum bicarbonate
ECG - arrhythmias, MI, ischaemia, heart disease
CXR
pulmonary function test
urine/serum toxicology
chest CT
CTPA
V/Q scan
capnometry
cardiothoracic US
50
management of respiratory failure with airway obstruction
airway clearance
+ supplemental O2 (lower target if COPD)
+ treat underlying causes
51
management of stable respiratory failure without airway obstruction when conscious
1. supplemental O2 (lower target if COPD)
treat underlying causes
2. +Ive pressure ventilation (NIV)
treat underlying causes
52
management of stable respiratory failure without airway obstruction when unconscious
1. supplemental O2 (lower target if COPD)
treat underlying causes
2. endotracheal intubation + mechanical ventilation
rapid sequence induction
treat underlying causes
53
management of unstable respiratory failure without airway obstruction
supplemental O2 (lower target if COPD)
endotracheal intubation + mechanical ventilation
rapid sequence induction
treat underlying causes
54
define sarcoidosis
* chronic granulomatous disorder commonly affecting lungs, skin, and eyes
* accumulation of lymphocytes and macrophages
* non-caseating granulomas in lungs and other organs
* unknown aetiology, heterogenous, and unpredictable
55
risk factors for sarcoidosis
age 20 - 40 yrs
FHx
female
non-smokers
56
symptoms and signs of sarcoidosis
* non-specific (weight loss, chronic fatigue)
* chest
* cough
* dyspnoea
* haemoptysis
* skin
* erythema nodosum
* lupus pernio
* MSK - arthritis, joint pain
* ocular - blurred vision, photophobia
57
investigations for sarcoidosis
* **CXR**
* stage 0 = normal
* stage 1 = **bilateral hilar lymphadenopathy**
* stage 2 = bilateral hilar lymphadenopathy + pulmonary infiltrates
* stage 3 = pulmonary infiltrates only
* stage 4 = extensive fibrosis with distortion
* **Spirometry** - restrictive
* FBC- anaemia
* serum urea and creatinine- renal injury
* LFTs
* serum calcium (high calcium)
* ECG- arrhymias
* PPD (purified protein derivative of tuberculin)
58
management of sarcoidosis and ongoing pulmonary disease
* observe
* oral/inhaled corticosteroid
* cytotoxics
* oxygen (ventilatory support if ARF)
* end stage = lung transplant
ocular/ CNS/PNS/ heart
1. tropical/oral corticosteroids
2. cytotoxics
cutaneous:
1. topical corticosteroids
2. hydroxychloroquine
59
define bronchiectasis
chronic inflammation of bronchi and bronchioles =\> **_permanent dilatation and thinning_**
60
main causative organisms of bronchiectasis
* **_H influenzae_**
* strep pneumoniae
* staph aureus
* pseudomonas aeruginosa
61
causes of bronchiectasis
congenital
* CF
* primary ciliary dyskinesia
* Young's/kartagener's syndrome- thick mucus prone to infection
aquired
* childhood post-infection: measles, pneumonia, TB, HIV, whooping cough
* allergic bronchopulmonary aspergillosis (ABPA) - allergic reation to mould
* inflammation: RA, ulcerative colitis
* bronchial obstruction
* idiopathic
62
symptoms of bronchiectasis
* persisent cough
* large amount of purulent sputum (yellow/green/brown)
* intermittent haemoptysis
* SOB +/- wheeze
* fatigue fever chills
63
signs of bronchiectasis
* clubbing
* coarse inspiratory crepitations
* wheeze
64
investigations for bronchiectasis
Bedside:
* suptum culture (check for pseudomonas, s. aureus, H. infleunzae)
Bloods:
* serum immunoglobulins
* FBC
* HIV
* autoimmune screen (chronic inflammation)
Imaging
* **_CT chest_** (dilated bronchioles) **GOLD STANDARD**
* CXR - cystic shadows, thickened bronchial walls
Other
* spirometry - obstructive pattern
* bronchoscopy
* CF sweat test
65
management of bronchiectasis
* **CHEST PHYSIO** (airway clearance techniques)
* mucolytics - flutter valve
* Antibiotics - pseudomonas = oral **ciprofloxacin**/suitable IV abx
* bronchodilators - if comorbid asthma, COPD, CF, ABPA
* corticosteroids - if ABPA
* surgery - if localised disease, or to control severe haemoptysis
66
complications of bronchiectasis
* pneumonia
* PE
* pneumothorax
* haemoptysis
* cerebral abscess
* anyloidosis
67
define asthma
* chronic inflammatory airway disease with reversible airway obstruction and hyper-reactivity
inflammation causes increased bronchial hyper-responsiveness and recurrent episodes of wheezing, breathlessness, chest tightness, and cough
reversible spontaneously or with treatment
68
pathophysiology of asthma
1. Exposed to inhaled allergen (antigen) =\> presented to **_APC_** (dendritic cells in lungs)
2. Carried via MHC II to lymph nodes
3. Naive T cells differentiate to **_TH2 cells_** =\> Secrete TH2 cytokines
* IL-4: **_IgE_** production
* IL-5: **_eosinophill_** inflammation
* IL-13: mucus hypersecretion
4. On repeat exposure to allergen, IgE antibodies bind to mast cells =\> degranulate and release histamine/chemokines =\> allergic asthma
69
history and examination for dx of asthma
* recent URTI
* dyspnoea (painful breathing)
* cough
* expiratory wheezes
* risk factors
1. FHx
2. allergens
3. atopic Hx
4. nasal polyposis
70
investigations for dx of asthma
FEV1/FVC ratio
primary diagnostic test
\<80% of predicted
PEFR (peak expiratory flow rate)
- consider long term if moderate/severe persistent asthma, severe exacerbations, or worsening asthma
CXR
- normal or hyper inflated
- may show signs of infection in acute exacerbation
FBC
- normal/raised eosinophils
- neutrophilia
71
How to classify asthma
Non severe
* Peak expiratory flow 50-75% of normal
* no respiratory distress signs
Severe (CHEST)
* Peak expiratory flow 30-50% of normal
* Respiratory distress (RR \>25, hypotension, tachycardia \>110bpm)
* C- cyanosis
* H- hypotension
* E-exhaustion /can't speal full sentences in one breath
* S- silent chest (poor inspiratory effort, normal PCO2)
* T-tachy/brady arrythmias
72
Management for acute asthma exacerbation
severe asthma (EMERGENCY)
1. call for help =\> ITU (high flow oxygen/ ventillation)
2. Oxygen (\>98%)
3. Bronchodilators (salbutomol +/- ipatropium)
4. Steroids (oral prednisilone/ IV hydrocortisone)
5. RE-ASSESS
non-severe asthma
1. oxygen (\>98%)
2. bronchodilators- salbutamol +/- ipatromium +/- IV magnesium
3. steroids (prednisilone/ hydrocortisone)
4. Reassess and discharge if PEF \>75%
5. Long term ICS and TAME (technique inhaler, avoid triggers, monitor PEF, educate)
73
management of exercise induced bronchoconstriction in asthma (acute)
1. **_SABA_** (*salbutamol*) 5-20 mins before asthma
2. if uncontrolled =\> **_inhaled anticholinergics_**/ mast cell stabilising agents
regular ICS therapy significantly reduces severity of exercise induced bronchoconstriction
74
management plan for chronic asthma
newly diagnosed/infrequent symptoms = SABA
chronic:
1. low dose ICS (*fluticasone)*
2. low dose ICS + LTRA (*montelukast)*
3. add LABA (*salmeterol)* (if LTRA not effective stop it)
4. if uncontrolled, offer maintenance and reliever therapy (MART) combination therapy
= ICS + fast acting LABA
5. increase to moderate ICS dose
6. Specialist therapies
75
examples of asthma drugs + side effects
Acute (15-20mins)
* SABA- **salbutamol** *(palpitations, tachycardia, hypokalemia)*
* anticholinergics (SAMA- **ipatropium** bromide)
Chronic
* ICS- **fluticasone** *(sore throat, hoarse voice, mood swings)*
* LABA- **salmeterol**
* LAMA- tiotropium
* LTRA- **montelukast** *(nausea, fever, diarrhoea, headaches, mood swings)*
76
Define COPD
Chronic, progressive lung disorder characterised with irreversible airflow obstruction
* chronic bronchitis- chronic cough/ sputum production \>3 months
* emphysema
77
Causes of COPD
* smoking- shorter/less mobile cillia.
* environmental toxins (dust, NO)
* a-1 antitrypsin (protease inhibitor) deficiency -younger patients
78
Pathophysiology of COPD
* chronic bronchitis- due to irritants causing hyperplasia of bronchial mucous glands/ goblet cells =\> mucus hypersecretion (blocked airway)
* emphysema - enlarged air spaces distal to terminal bronchioles with destruction of alveolar walls.
79
Presenting symptoms of COPD
* chronic cough
* sputum production
* breathlessness
* wheeze
* reduced exercise tolerance
* SHx: smoker
80
Examination signs of COPD
inspection
* peripheral cyanosis
* asterixis/ bounding pulse (CO2 retention)
* pursed lip breathing
* barrel chest
palpation
* bilateral reduced chest expansion
percussion
* hyper-resonant chest
* loss of liver/cardiac dullness
auscultation
* quiet breath sounds
* wheeze
* crepitations
* prolonged expiration
* rhonchi- rattling continuous low breath sounds (like SNORING)
81
Investigations for COPD
* Bloods (FBC- increased Hb-secondary polycythemia)
* **ABG**- show hypoxia/hypercapnia)
* **CXR**- hyperinflation, elongated cardiac silhouette
* **Spirometry**- reduced FEV1:FVC, increased lung volume
* ECG + echo - check for cor pulmonale
* Sputum + blood cultures (exclude infective causes)
* Legionella/ pneumococci - urinalysis output
* a1 antitrypsin levels
82
FEV1:FVC ratio in COPD
Obstruction = partially blocked airway (reduced FEV1: FVC ratio \<70%)
FEV1- how much air you breathe out in 1s FVC- breathe out as much as possible (minus residual lung volume) FEV1:FVC ratio
83
Late signs of COPD
* right sided HF (cor pulmonale)
* raised JVP
* ankle oedema
* right ventricular heave
84
How to classify COPD
* GOLD grading
85
Management of acute COPD exacerbation
* Oxygen - venturi mask (88-92% O2)
* Steroids- reduce inflammation
* Nebulisers- bronchodilator
=\> WORSE= ventilator
86
Management of chronic COPD
1. SABA/ SAMA
2. if FEV1 \>50% =\> LABA/ LAMA
3. if FEV1 \<50% =\> LABA + inhaled corticosteroids
Lifestyle
* stop smoking
* exercise
* vaccines (flu, pneumococcal)
* pulmonary rehabilitation
* inhaler therapy
* oxygen therapy
Stopped smoking =\> home oxygen
87
Complications of COPD
* cor pulmonale
* respiratory failure
* pulmonary hypertension
* secondary polycythaemia
* pneumothorax (bullae rupture)
* infections
88
What are pink puffers and blue bloaters?
pink puffers = body not used to high CO2 - heavy pursed lip breathing- high energy expenditure *low BMI*
blue bloaters BRONCHITIS= mucus hypersecretion =\> obstruction =\> high CO2 retention *cyanosis* =\> can't do vigorous exercise =\> high BMI
89
Why should you not over oxygenate COPD patients?
V/q matching
1. Giving high Oxygen =\> accumulates in lungs even in useless dead space where there is more CO2
2. Hb prefers CO2 \> oxygen
3. So still hypoxic =\> resp acidosis + type 2 resp failure
90
define pneumonia
Upper respiratory tract infection with fever and productive cough
* Community acquired (CAP) or hospital acquired
1. bronchopneumonia - AIRWAY transmission
2. lobar pneumonia- blood transmission
91
common causative organisms of pneumonia
* Strep. pneumoniae (MOST COMMON)- gram+ve cocci
* Haemophilius influenzae- gram -ve
* Moraxella Cattarharlis
Less common:
* Mycoplasma
* Legionella
92
Presenting symptoms of pneumonia
* productive cough
* yellow/green sputum production
* fever + chills
* breathlessness
* aches (mylagia)
* dyspnoea
* pleuritic chest pain
* risk factors
93
Risk factors for pneumonia (ask in Hx)
HPC:
* older age
PMHx
* chronic lung conditions (COPD, asthma, bronchitis)
* diabetes
* CHD
SHx
* smoker
* XS alcohol
* home/work life - contact with young children
* home life- In a nursing home
94
Examination signs of pneumonia
* Percussion- dull sounds, increased vocal fremitus
* Auscultation- coarse crackles, wheeze
95
Investigations for pneumonia
Bedside:
* s*putum culture*
**Bloods:**
* FBC- raised WCC
* U&Es - raised urea \>7mmol/L
* CRP- \>100mg/L
* ABG- hypoxia
* LFTs- abnormal in legionella infection
* *blood culture*
**Imaging**
* **_CXR_** (DIAGNOSTIC)
96
How to assess severity of pneumonia?
CURB-65 (for Hospital acquired)
* confusion AMST \<8
* Urea
* resp rate \>30
* Blood pressure SBP\<90
* \>65
CRB-65 (for community acquired)
97
Management of pneumonia
0 CURB-65 (in community)
* oral empirical antibiotics (**amoxicillin**/ clarithromycin if allergic)
1-2 CURB-65 (community/hospital referral)
* oral antibiotics
* oxygen (\>98%)
* Check for **_SEPSIS_**
*
3-4 CURB-65 (hospital)
* urgent hospital referral
* immediate IV antibiotics (amoxicllin)
* Check for SEPSIS
98
prognosis + complications of pneumonia
* 5-15% mortality rate
* 12% recurrence
Complications
* Sepsis
* ARDS
* pleural effusion
* Heart failure
99
define TB
* it's an infection caused by mycobacterium tuberculosis bacteria
* spread by droplet transmission (coughing/sneezing)
* NOTIFIABLE disease
1. active TB (symptomatic)
2. latent TB (asymptomatic + carrier)
3. extrapulmonary TB (brain, heart, bones, joints, abdo, genitourinary, lymphatic)
100
pathophysiology of TB
* bacteria reside in macrophages and travel to regional lymph nodes/ lungs
* form a granuloma
101
risk factors for TB
* **foreign endemic countries** (India, pakistan, bangladesh, somalia)
* co-morbid conditions (**HIV**, DM, CKD)
* i**mmunosuppressive drugs** (corticosteroids, infliximab, chemotherapy)
* **close contact**
* **previous TB**
* \<5 age
* at risk groups (homeless, **_prisons,_** hostels, poorer people)
* smokers, alcoholics, drug users
102
presenting symptoms of TB (respiratory)
* **productive cough**
* **breathlessness**
* **haemoptysis**
* FLAWS (fever, malaise, weight loss, anorexia, night sweats)
103
symptoms of extrapulmonary TB
* lymphadenopathy ( lymphatic TB)
* bone/joint pain (joint/spinal TB)
* headache, irritability, vomiting, cranial nerve abnormalities (TB meningitis)
* breathlessness, chest pain, ankle swelling (pericarditis TB)
* sterile pyuria (renal TB)
* abdo pain, constipation, bowel obstruction (gastric TB)
* skin lesions, erythema nodosum (cutaneous TB)
104
investigations for TB
Asymptomatic (latent TB)
1. Tuberculin skin test
2. Interferon gamma assay
\*if tests are positve =\> CXR
Symptomatic (active TB)
* x3 sputum samples MC&S- **acid-fast bacilli smear** (Ziel-Nielson stain)
* Bloods: FBC (high WCC, anaemia), CRP, ABG, HIV
* **CXR** (nodular opacities, pleural effusion, bihilar lymphadenopathy)
105
management for TB (RIPE)
* Rifampicin (*red secretions*)
* Isoniazid (*peripheral neuropathy*)
* Pyrazinamide (*gout*)
* Ethambutol (*eye-red-green colour blindness*)
if multi-drug resistant consider surgery (wedge/lobar resection)
NOTIFIABLE DISEASE
* identify and check on close contacts
106
define Influenza
winter flu associated with upper and lower respiratory tract infection symptoms
* Influenza A/B
* usually self resolving (1/2 weeks- anti-virals speed up recovery by 2 days)
* annual flu vaccine (preventatitve)
107
presenting symptoms of influenza
* fever
* cough
* runny nose (rhinorrhoea)
* chills
* headaches
* mylagia (muscle ache)
* risk factors
* Hx- vaccinated ?
108
risk factors for influenza
* \<5 or \>65
* pregnant women
* healthcare workers
* immunocompromised (HIV)
* Diabetics
* CKD
* unvaccinated
* winter season
109
investigations for influenza
* usually clinical diagnosis
can consider viral culture/serology, reverse transcriptase PCR, CXR- exclude pneumonia
110
management for influenza
Conservative:
* rest
* warm drinks
* anti-pyretics/ analgesia- symptom relief
,Medical:
* if complicated/severe disease =\> anti-viral
* if bacterial infection/ ear infection =\> broadspectrum antibiotics (amoxicillin)
Post-disease
* Vaccine
111
complications of influenza
* **_bacterial pneumonia_**
* viral pneumonia
* otitis media
* meningitis/ encephalitis
112
define pulmonary hypertension
increase in pulmonary vascular resistance in the pulmonary arteries leading to right ventricular failure and death
113
presenting symptoms of pulmonary hypertension
* exertional dyspnoea
* fatigue
* peripheral oedema
* cyanosis
* Risk factors: family Hx, female
114
signs of pulmonary hypertension
* pan-systolic murmur (tricuspid regurgitation)
* loud pulmonary component of S2
115
Investigations for pulmonary hypertension
Bloods: (check for cause)
* FBC- haemoglobinopathy
* LFTs - portal hypertension/liver disease
* BNP (right ventricular dysfunction)
Imaging:
* CXR
* Transthoracic echocardiogram
*
116
define pulmonary fibrosis
thickening and scarring of lung tissue =\> stiff lungs so they don't work properly and get more pregoressive SOB
117
causes of pulmonary fibrosis
* toxins - asbestos, silica, coal, grain, metal
* radiation
* medical conditions - dermatomyositosis, SLE, RA, polymyositosis
* medication- chemo, amiodarone, antibiotics
118
risk factors for pulmonary fibross
* smoking
* mining,farming,construction WORK
* cancer treatment
* family Hx
119
presenting symptoms + signs of pulmonary fibrosis
symptoms:
* shortness of breath/ dyspnoea on exertion
* dry cough
* fatigue
* weight loss
* muscle + joint aches
signs:
* finger clubbing
* bibasal crackles
120
investigations for pulmonary fibrosis
* Pulse ox
* **exercise stress test**
* lung function tests/ **spirometry**
* ABG - check for resp failure
Imaging:
* CXR
* CT thorax- shows lung scarring
* Echo
121
management for pulmonary fibrosis
* Usually conservative
* Pulmonary rehabillitation
* oxygen
* symptomatic relief - benzo's/ opioids
122
complications of pulmonary fibrosis
* respiratory failure
* pulmonary hypertension =\> cor pulmonale
* lung cancer
* PE/PTX/ collapsed lung
123
define lower respiratory tract infection
124
define COVID-19
* variant of SARS-COV-2 virus
* type of betacoronavirus
125
high risk groups for COVID-19
High
* cancer patients (leukaemia)
* undergoing chemo
* surgery
* on immunosuppressant drugs (corticosteroids)
* chronic lung conditons (CF)
* HIV/ sickle cell
Medium
* diabetics
* asthma, COPD, bronchitis
* heart failure
* CKD
* liver failure
* pregnancy
126
symptoms of COVID-19
* range from asymptomatic =\> mild resp. infection =\> pneumonia
common symptoms
* fever
* new coninuous dry cough
* loss of smell/taste
* SOB
* fatigue
* loss of appeitie
* other - rashes, headches, muscle pains, runny nose
delta variant common symptoms
* runny nose
* headache
* sore throat
127
investigations for COVID-19
* symptomatic / contact with positive person =\> PCR test (antibody test)
* asymptomatic =\> lateral flow tests
128
management for COVID-19
* self-isolate for 10 days
* admit to hospital if
1. pneumonia
2. influenza like illness (\>37.8 temp + SOB/nasal dishcarge, hoarseness)
3. acute respiratory distress syndrome
129
complications of COVID-19
* Long-covid -fever, fatigue, pain, SOB, chest pain, palpitations, cough, nausea, diarrhoea, muscle pain, tinitus,dizziness, delerium, depression
Investigate for severe complications
* FBC
* LFTs, U&Es
* CRP
* HbA1c
* BNP
Management
* urgent referral - hypoxemia, severe lung disease, cardiac chest pain, inflammatory syndrome, suicidal thoughts
* social prescribing
* manage symptoms
