Respiratory Flashcards
Summarise lung cancer
Types:
Non-small cell (most common) e.g. adenocarcinoma, squamous, large cell
Small cell - neuroendocrine hormones
Mesothelioma: pleura affected, asbestos causes
Presentation:
SOB, cough, haemoptysis!, clubbing, recurrent infections, wt loss, lymphadenopathy
Recurrent laryngeal palsy: hoarse voice
SVCO: facial swelling, distended JVP, SOB
Pancoasts tumour: Horners - ptosis, anhidrosis, miosis -pressing on sympathetic ganglion
Small cell: SIADH; Cushings; limbic encephalitis, LEMS
Squamous: hypercalcaemia
Ix: CXR first line showing hilar enlargement, peripheral opacities, unilateral pleural effusion, collapse
CT chest, abdo and pelvis with contrast for staging
Bronchoscopy allows biopsy for histology
Mx: MDT - surgery first line for non-small cell; chemo/ radio for small cell
Endobrachial treatment with stents can be used in palliative treatments for bronchial obstruction
Summarise pneumonia
Types:
CAP; HAP (after 48h in hospital), aspiration
Causes: S. pneumoniae, h. influenzae, moraxella catarrhalis (COPD), pseudomonas/ s. aureus (bronchiectasis/ CF),
Atypical: legionella (can cause SIADH), mycoplasma pneumoniae (erythema multiforme), chlamydiophila pneumoniae (children), Q fever (animal exposure), chlamydia psittaci (bird exposure), PCP (fungal, HIV)
Presentation: SOB, pleuritic CP, cough, fever, haemoptysis, delirium, sepsis, bronchial breath sounds (consolidation), coarse crackles, dullness to percussion
Ix: CXR (focal consolidation); FBC, UE, CRP
Mx:
CURB65 >2 –> refer hospital; >3 —> ICU
Abx: amoxicillin/ macrolide
Atypical: macrolides (clarithromycin) or tetracyclines
Summarise chronic asthma (adult)
Pathophysiology: Chronic inflammatory condition that causes bronchoconstriction –> obstructed airways due to hypersensitivity
Presentation: Episodic; diurnal variability (worse at night(; dry cough; SOB; bilateral polyphonic wheeze; atopy; fhx
Ix: 1) fractional exhaled NO or spirometry showing bronchodilator reversibility
2) Peak flow variability, direct bronchial challenge test
Mx: NICE: 1. SABA 2. ICS low dose 3. LTRA (Montelukast) 4. LABA 5. MART (ICS + LABA) 6. ICS moderate dose 7. ICS high dose/ theophylline/ LAMA (tiotropium) 8. Specialist Also: flu jab, asthma r/v yearly, lifestyle advice
Summarise acute asthma
Presentation: progressive SOB, accessory muscle use, tachypnoea, wheeze, reduced air entry
Grading:
Moderate: PEF 50-75%
Severe: PEF 33-50%, RR >25, HR >110, can’t complete sentences
Life-threatening: PEF <33%, sats <92%, tired, silent chest, shock
Ix:
ABG - respiratory alkalosis as tachypnoeic –> normal pCO2/ hypoxia/ respiratory acidosis shows tiring and is worrying
Mx:
Salbutamol nebs 5mg repeated, oxygen, neb ipratropium bromide, steroids for 5 days, abx if evidence infection
–> senior –>
IV aminophylline and salbutamol –> IV Mg SO4, ICU
Summarise COPD
Presentation: smoker with SOB, productive cough, wheeze, recurrent infections. Does not usually cause haemoptysis, CP or clubbing
MRC dyspnoea scale:
1) strenuous exercise
2) uphill
3) slower
4) stop at 100m
5) can’t leave house
Ix:
spirometry shows obstruction (FEV1/ FVC <0.7), TLCO decreased, potentially: CXR, FBC, sputum culture
Mx:
Stop smoking, pneumococcal + flu vaccine
1. SABA/ SAMA
2. asthmatic features (LABA + steroid eg seretide) or no asthmatic features (LABA + LAMA eg anoro ellipta)
3. nebs, theophylline, mucolytic, prophylactic abx, LTOT
Exacerbation:
Ix: ABG to see if they are acidotic (if bicarb is raised indicates chronic retainer)
CXR, ECG, FBC, UE, cultures
Mx: in CO2 retainers use venturi to titrate; steroids, abx;
+ in hospital: SABA and ipratropium; PT –> IV aminophylline, NIV, intubate, doxapram if cannot NIV
summarise ILD
Definition: Umbrella term for conditions causing lung fibrosis (replacement of elastic tissue with scar)
Ix: Ground glass appearance on CT. Biopsy if unsure.
Types:
Idiopathic - insidious SOB, dry cough, bibasal fine insp crackles, clubbing. Mx with pirfenidone and nintedanib
Drug Induced - amiodarone, methotrexate, nitrofurantoin, cyclophosphamide
Secondary - RA, SLE, systemic sclerosis, alpha-1-antitrypsin can all cause
Hypersensitivity/ Extrinsic Allergic Alveolitis - Type 3 hypersensitivity, shows raised lymphocytes and mast cells on bronchoscopy. E.g. pigeon-fanciers, farmers lung
Asbestosis: oncogenic and fibrogenic
Mx for all: treat cause, LTOT, stop smoking, PT, vaccines, advance care planning, transplant
Summarise pleural effusion
Exudative: Inflammatory causes which lead to protein in the pleural space e.g. cancer, RA, infection
Transudative: Fluid shifts across pleural space e.g. HF, hypoalbuminaemia, hypothyroid, Meig’s
Empyema: infected effusion, suspect if pt has improving pneumonia but ongoing fever - on Ix will be acidic pH, low glucose and high LDH
Presentation: SOB, dullness to percussion, reduced breath sounds, tracheal deviation away if big enough
Ix: CXR (costophrenic blunting, fluid in lung fissures, meniscus if large enough, tracheal deviated)
Fluid sample to see protein count (>3g exudative), LDH, microbiology, pH, glucose
Mx: conservative if small, bigger aspirate/ chest drain.
Summarise pneumothorax
Pathophysiology: Air gets into the pleural space causing lung to separate from, chest wall.
Causes:
Spontaneous (Tall, thin, young man)
Trauma
Iatrogenic from biopsy/ central line/ ventilation
Pathology e.g. infection/ asthma, COPD
Tension - trauma which creates a one way valve
Presentation: acute SOB and pleuritic CP
Ix: Erect CXR shows an area between lung tissue and chest wall with no lung markings
Mx: no SOB + <2cm = no treatment
SOB/ >2cm = aspirate
Unstable/ bilateral/ secondary = chest drain
TENSION
Presentation: Tracheal deviation away from pneumothorax, reduced air entry, resonant to percussion, tachycardia, hypotension.
Mx: insert large bore cannula in second intercostal space mid clavicular line immediately, then chest drain definitive
summarise PE
RF: Immobility Recent surgery Long haul flights Pregnancy Hormone therapy with oestrogen Malignancy Polycythaemia Systemic lupus erythematosus Thrombophilia
Presentation: pleuritic CP, SOB, haemoptysis, hypoxia, tachycardia, tachpnoea, DVT sx
Ix: Well’s score –> high, do CTPA, low do d-dimer. Definitive testing with CTPA/ VQ scan, ABG shows resiratory alkolosis
Mx: DOAC, thrombolysis if big, continue anti-coagulation for 3m if reversible cause, 6m if not
Summarise Sarcoidosis
Pathophysiology: Granulomatous condition causing most commonly chest sx and erythema nodosum
Presentation: Commonly young black woman. Resp (mediastinal lymphadenopathy, fibrosis, nodules); Systemic (fever, wt loss, fatigue); Liver (nodules, cirrhosis, cholestasis); eyes (uveitis, conjunctivitis, optic neuritis); Skin (erythema nodosum, lupus pernio); Heart (BBB, heart block); Kidneys (stones, nephritis).
Ix:
Bloods- Raised: serum ACE, hypercalcaemia, interleukin-2 receptor, CRP, Ig.
CXR/ CT- hilar lymphadenopathy
Histology - gold standard –> bronchoscopy shows non-caseating granulomas with epithelioid cells
Mx:
1) PO steroids 6-24m is sx affecting pt
2) methotrexate/ azathioprine
Prognosis: Resolves in 6m in 60%, others get pulmonary fibrosis and htn
Summarise bronchiolitis
Pathophysiology: Inflammation in the bronchioles due to respiratory syncytial virus (RSV)
Presentation: <1 yr, winter, corzyal sx, dyspnoea, tachypnoea, poor feeding, mild fever, apnoea, wheeze and crackles O/E. Resp distress (accessory muscle use, intercostal/ subcostal recessions, nasal flaring, head bobbing, tracheal tug, cyanosis)
Ix: If concerned can CBG for monitoring resp distress
Mx:
Supportive - fluids/ NGT, nasal suctioning, oxygen, ventilation.
Admit if <3m/ vulnerable, intake milk 50-75% less than normal, dehyrated, obs abnormal, resp distress
Palivizumab - monoclonal Ab which acts as preventative to RSV in vulnerable children - given as part of vaccination
Summarise Asthma (Children)
Same except medical therapy is different:
<5 yrs:
- SABA
- Low dose ICS
- LTRA (montelukast)
- Specialist
5-12 yrs
- SABA
- Low dose ICS
- LABA (only continue if good resonse)
- Medium dose ICS
- LTRA/ theophylline
- High dose ICS
- Specialist - may use PO steroids
Summarise Croup
Pathophysiology: URTI which causes oedema in the larynx.
Causes: PARAINFLUENZA!, flu, adenovirus, RSV.
Presentation: WOB increased, barking cough, hoarse voice, stridor, low grade fever
Mx:
Supportive
PO dexamethasone
In hospital can try neb steroids, oxygen, adrenalin, intubation
Summarise Epiglottis
Pathophysiology: Swelling of epilogttis from haemophilus influenza B. Airway can be obstructed so if an emergency.
Presentation: Acute! Unvaccinated, sore throat, stridor, drooling, tripod position, high fever, muffled voice, septic
Ix: Lateral XR of neck to show thumbs sign. Also good to exclude foreign body.
Mx:
Do NOT examine - could distress child and close airway, call senior paediatrician, anaesthatist. Secure airway, IV abx and steroids.
Summarise Laryngomalacia
Pathophysiology: The aryepiglottic folds are shortened, epiglottis changes to an omega shape. Tissue surrounding supraglottic larynx is soft and floppy.
Presentation: Inspiratory stridor, may present with airway obstruction/ difficulty feeding.
Mx: often goes away by itself, rarely needs tracheo
