Respiratory Flashcards
what are the two types of lung cancer?
non small cell (majority) - adenocarcinoma, squamous cell carcinoma, large cell carcinoma, other
small cell - contain neurosecretory granules that can release neuroendocrine hormones..paraneoplastic syndromes
what are the signs and sx of lung cancer?
Shortness of breath
Cough
Haemoptysis (coughing up blood)
Finger clubbing
Recurrent pneumonia
Weight loss
Lymphadenopathy – often supraclavicular nodes are the first to be found on examination
which investigations are required for lung cancer?
chest x ray - hilar enlargement, peripheral opacity (lesion), pleural effusion (usually unilateral), collapse
staging CT TAP with contrast
PET-CT for metastatic spread
bronchoscopy with endobronchial USS - detailed assessment of the tumour
histological diagnosis - types of cells in cancer
what are the tx options for lung cancer?
MDT
surgery for non small cell such as lobectomy, segmentectomy
radiotherapy for non small cell
chemo - adjuvant or palliative for non small cell
chemo + radio - small cell
endobronchial tx with stents or debulking - small cell
what are the extrapulmonary manifestations of lung cancer?
recurrent laryngeal nerve palsy - hoarse voice, compresses as passes through mediastinum
phrenic nerve palsy - diaphragm weakness - SOB
SVC obstruction - facial swelling, difficult breathing, distended veins..pemberton’s sign (raising the hands over head causes facial congestion and cyanosis)
horner’s syndrome - partial ptosis, anhydrosis, miosis caused by pancoast tumour pressing on sympathetic ganglion
SIADH - by ectopic ADH by small cell, hyponatraemia
Cushing’s - ectopic ACTH from small cell
hypercalcaemia - ectopic PTH from squamous cell
limbic encephalitis - small cell causes immune system to make antibdoies to tissues in brain, esp limbic sx…memory impairment, hallucinations, confusion, seizures…anti-Hu antibodies
Lambert-eaton myasthenic syndrome
define labert-eaton myasthenic syndrome
result of antibodies produced by the immune system against small cell lung cancer cells. These antibodies also target and damage voltage-gated calcium channels sited on the presynaptic terminals in motor neurones - weakness, in the proximal muscles also affect intraocular muscles causing diplopia (double vision), levator muscles in the eyelid causing ptosis and pharyngeal muscles causing slurred speech and dysphagia (difficulty swallowing). also experience dry mouth, blurred vision, impotence and dizziness due to autonomic dysfunction.
The tendon reflexes become temporarily normal for a short period following a period of strong muscle contraction. For example, the patient can maximally contract the quadriceps muscle for a period, then have their reflexes tested immediately afterwards, and display an improvement in the response. This is called post-tetanic potentiation.
In older smokers with symptoms of Lambert-Eaton syndrome consider small cell lung cancer.
define mesothelioma
lung malignancy affecting mesothelial cells of the pleura
linked to asbestos but latent period between exposure and sx (45 yrs)
prognosis poor, chemo can help
define pneumonia
inflammation of the lung tissue and sputum filling the airways and alveoli
how does pneumonia present?
Shortness of breath
Cough productive of sputum
Fever
Haemoptysis (coughing up blood)
Pleuritic chest pain (sharp chest pain worse on inspiration)
Delirium (acute confusion associated with infection)
Sepsis
what are the signs of pneumonia?
Tachypnoea (raised respiratory rate)
Tachycardia (raised heart rate)
Hypoxia (low oxygen)
Hypotension (shock)
Fever
Confusion
possibly septic
bronchial breath sounds - harsh breath sounds equally loud on inspiration and expiration
focal coarse crackles - like a straw blowing into a drink
dullness to percussion due to tissue collapse/consolidation
how is the severity of pneumonia measured?
in hospital - CURB 65
out of - no urea measured
C – Confusion (new disorientation in person, place or time)
U – Urea > 7
R – Respiratory rate ≥ 30
B – Blood pressure < 90 systolic or ≤ 60 diastolic.
65 – Age ≥ 65
Score 0/1: Consider treatment at home
Score ≥ 2: Consider hospital admission
Score ≥ 3: Consider intensive care assessment
what are the common causes of pneumonia?
step pneu
haemoph influe
what are the other causes of pneumonia and their associations?
Moraxella catarrhalis in immunocompromised patients or those with chronic pulmonary disease
Pseudomonas aeruginosa in patients with cystic fibrosis or bronchiectasis
Staphylococcus aureus in patients with cystic fibrosis
define atypical pneumonia and the possible causes
pneumonia caused by an organism that cannot be cultured in the normal way or detected using a gram stain. They don’t respond to penicillins and can be treated with macrolides (e.g. clarithomycin), fluoroquinolones (e.g. levofloxacin) or tetracyclines (e.g. doxycycline).
- legionella pneumophila - infected water supplies/air conditioning units -> hyponatraemia from SIADH
- mycoplasma pneumonia - erythema multiforme rash with pink rings and pale centres, neurological sx in young patients
- chlamydiophila pneumonia - school aged child, chronic pneumonia and wheeze
- coxiella burnetii - Q fever - linked to animals and bodily fluids like farmers
- chalmydia psittaci - infected birds like parrot owners
“Legions of psittaci MCQs”
M – mycoplasma pneumoniae
C – chlamydydophila pneumoniae
Qs – Q fever (coxiella burnetii)
what is fungal pneumonia, the risk factors and treatment?
immunocompromised
poorly controlled or new HIV with low CD4
dry cough, SOB on exertion and night sweats
tx with co-trimoxazole, prophylactic for HIV to protect against PCP
which investigations are required for pneumonia?
Chest xray
FBC (raised white cells)
U&Es (for urea)
CRP (raised in inflammation and infection) - can see abx working but VRP delayed and WCC is faster picture, if immunocompromised may not be raised at all
Patients with moderate or severe cases should also have:
Sputum cultures
Blood cultures
Legionella and pneumococcal urinary antigens (send a urine sample for antigen testing)
which abx are used to treat pneumonia?
Mild CAP: 5 day course of oral antibiotics (amoxicillin or macrolide)
Moderate to severe CAP: 7-10 day course of dual antibiotics (amoxicillin and macrolide)
—per local guidlines and resistance patterns
what are the complications of pneumonia?
Sepsis
Pleural effusion
Empyema
Lung abscess
Death
define FEV1 and how it is affected
forced expiratory volume in 1 second…reduced in obstruction
define FVC and how it is affected
forced vital capacity…reduced in restriction
what is the FEV1:FVC ratio in obstructive disease?
<75%
give 2 examples of obstructive disease and how these can be differentiated
asthma - reversible >12% with bronchodilator
COPD -> irreversible, <12%
what is the FEV1:FVC ratio in restrictive disease?
FEV1 and FVC are equally reduced, >75%
what are the causes of restrictive disease?
ILD
neurological - MND
scoliosis
obesity
how can the severity of an asthma exacerbation and how well the asthma is controlled be estimated?
peak flow meter - measured peak expiratory flow rate
- stand tall, takes deep breath in, make good seal around device, blow as fast and hard as possible
- take 3 attempts and record best one
- varies on size and age of patient - so recorded as percentage of predicted based on sex, height and age
how can the severity of an asthma exacerbation and how well the asthma is controlled be estimated?
peak flow meter - measured peak expiratory flow rate
- stand tall, takes deep breath in, make good seal around device, blow as fast and hard as possible
- take 3 attempts and record best one
- varies on size and age of patient - so recorded as percentage of predicted based on sex, height and age
define asthma
chronic inflammatory condition of the airways where bronchocontriction cocurs
what triggers asthma?
Infection
Night time or early morning
Exercise
Animals
Cold/damp
Dust
Strong emotions
what is the typical presentation of a patient who is likely to have asthma?
Episodic symptoms
Diurnal variability. Typically worse at night.
Dry cough with wheeze and shortness of breath
A history of other atopic conditions such as eczema, hayfever and food allergies
Family history
Bilateral widespread “polyphonic” wheeze
what kind of presentation indicated a diagnosis other than asthma?
Wheeze related to coughs and colds more suggestive of viral induced wheeze
Isolated or productive cough
Normal investigations
No response to treatment
Unilateral wheeze. This suggests a focal lesion or infection.
what are the NICE guidlines of the diagnosis of asthma?
not based on clinical diagnosis, requires testing
first line - Fractional exhaled nitric oxide
- Spirometry with bronchodilator reversibility
If there is diagnostic uncertainty after first line investigations these can be followed up with further testing:
Peak flow variability measured by keeping a diary of peak flow measurements several times per day for 2 to 4 weeks
Direct bronchial challenge test with histamine or methacholine
how is asthma managed long term?
SABA - salbutamol acts as reliever in exacerbation
ICS - beclometasone acts as preventer
LABA - salmeterol - longer action
LAMA - tiotropium
leukotriene receptor antag - montelukast
theophylline - relax smooth muscle (narrow therapeutic window and can be toxic in excess)
maintenance and reliever therapy - combination of ICS and LABA…preventor and reliever
what is the BTS/SIGN stepwise ladder?
Add short-acting beta 2 agonist inhaler (e.g. salbutamol) as required for infrequent wheezy episodes.
Add a regular low dose corticosteroid inhaler.
Add LABA inhaler (e.g. salmeterol). Continue the LABA only if the patient has a good response.
Consider a trial of an oral leukotriene receptor antagonist (i.e. montelukast), oral beta 2 agonist (i.e. oral salbutamol), oral theophylline or an inhaled LAMA (i.e. tiotropium).
Titrate inhaled corticosteroid up to “high dose”. Combine additional treatments from step 4. Refer to specialist.
Add oral steroids at the lowest dose possible to achieve good control.
what are the NICE guidlines stepwise ladder for asthma?
Add short-acting beta 2 agonist inhaler (e.g. salbutamol) as required for infrequent wheezy episodes.
Add a regular low dose inhaled corticosteroid.
Add an oral leukotriene receptor antagonist (i.e. montelukast).
Add LABA inhaler (e.g. salmeterol). Continue the LABA only if the patient has a good response.
Consider changing to a maintenance and reliever therapy (MART) regime.
Increase the inhaled corticosteroid to a “moderate dose”.
Consider increasing the inhaled corticosteroid dose to “high dose” or oral theophylline or an inhaled LAMA (e.g. tiotropium).
Refer to a specialist.
which additional management as well as inhalers are used for asthma?
Each patient should have an individual asthma self-management programme
Yearly flu jab
Yearly asthma review
Advise exercise and avoid smoking
how can an acute asthma exacerbation present?
Progressively worsening shortness of breath
Use of accessory muscles
Fast respiratory rate (tachypnoea)
Symmetrical expiratory wheeze on auscultation
The chest can sound “tight” on auscultation with reduced air entry
how is acute asthma graded?
Moderate - PEFR 50 – 75% predicted
Severe -
PEFR 33-50% predicted
Resp rate >25
Heart rate >110
Unable to complete sentences
Life-threatening -
PEFR <33%
Sats <92%
Becoming tired
No wheeze. This occurs when the airways are so tight that there is no air entry at all. This is ominously described as a “silent chest”.
Haemodynamic instability (i.e. shock)
how is acute asthma treated?
Moderate:
Nebulised beta-2 agonists
Nebulised ipratropium bromide
Steroids. Oral prednisolone or IV hydrocortisone. These are continued for 5 days
Abx if have infection
Severe:
Oxygen if required to maintain sats 94-98%
Aminophylline infusion
Consider IV salbutamol
Life threatening:
IV magnesium sulphate infusion
Admission to HDU / ICU
Intubation in worst cases – however this decision should be made early because it is very difficult to intubate with severe bronchoconstriction
what will the results of an ABG in asthma?
tachypnoea - drop in CO2 - respiratory alkalosis
if normal CO2 or hypoxia - life threatening
if high CO2 - very bad
what is the main side effects of salbutamol?
hypokalaemia
tachycardia
how must patients with asthma be admitted?
asthma action plan
rescue pack or steroids
how does COPD present?
long term smoker
chronic SOB, cough, sputum, recurrent resp tract infections, haemoptysis, chest pain, NOT CLUBBING
what are the grades used for assessing the impact of breathlessness?
MRC dysponea scale
Grade 1 – Breathless on strenuous exercise
Grade 2 – Breathless on walking up hill
Grade 3 – Breathless that slows walking on the flat
Grade 4 – Stop to catch their breath after walking 100 meters on the flat
Grade 5 – Unable to leave the house due to breathlessness
how is COPD diagnosed?
clinical presentation
spirometry - obstructive and not reversible
how can the severity of airway obstruction be measured?
FEV1 -
Stage 1: FEV1 >80% of predicted
Stage 2: FEV1 50-79% of predicted
Stage 3: FEV1 30-49% of predicted
Stage 4: FEV1 <30% of predicted
what other investigations are useful in diagnosing COPD?
chest x ray - lung cancer
FBC - polycythaemia, anaemia
BMI - weight loss - cancer, COPD and weight gain - steroids
sputum culture - pseudomonas
ECG and echo - heart
CT thorax - fibrosis, cancer, bronchiectasis
serum alpha 1 antitrypsin - early onset COPD
TLCO - decreased in COPD
what is the long term management of COPD?
smoking cessation
pneumococcal and flu vaccine
step 1 - SABA or SAMA
step 2 - combined LABA + LAMA if no asthma/steroid responsive features, if they do have those features - LABA + ICS such as symbicort and add in LAMA
if severe - nebulisers, oral theophylline, oral mucolytics, long term prophylactix abx, long term o2
when might 02 therapy be used?
if COPD is causing chronic hypoxia, polycythaemia, cyanosis, HF secondary to cor pulmonale
…not if smoke as risk of fire
how are exacerbations of COPD investigated?
ABG - low pH with raised CO2 - acutely retaining - resp acidosis
if raised HCO3 they chronically retain CO2
distinguish type of resp failure
Chest xray to look for pneumonia or other pathology
ECG to look for arrhythmia or evidence of heart strain (heart failure)
FBC to look for infection (raised white cells)
U&E to check electrolytes which can be affected by infection and medications
Sputum culture if significant infection is present
Blood cultures if septic
why might you be cautious of oxygen therapy in COPD?
Too much oxygen in someone that is prone to retaining CO2 can depress their respiratory drive. This slows down their breathing rate and effort and leads to them retaining more CO2. Therefore in someone who retains CO2 the amount of oxygen that is given needs to be carefully balanced to optimise their pO2 whilst not increasing their pCO2. This is guided by oxygen saturations and repeat ABGs.
-venturi mask are used - so some ox leaks out and normal air to be inhaled along with o2 so percentage of inahled o2 can be carefully controlled
what are the target oxygen saturations in COPD?
If retaining CO2 aim for oxygen saturations of 88-92% titrated by venturi mask
If not retaining CO2 and their bicarbonate is normal (meaning they do not normally retain CO2) then give oxygen to aim for oxygen saturations > 94%
what is the medical tx of an exacerbation of COPD?
Typical treatment if they are well enough to remain at home:
Prednisolone
Regular inhalers or home nebulisers
Antibiotics if there is evidence of infection
In hospital:
Nebulised bronchodilators (e.g. salbutamol 5mg/4h and ipratropium 500mcg/6h)
Steroids (e.g. 200mg hydrocortisone or 30-40mg oral prednisolone)
Antibiotics if evidence of infection
Physiotherapy can help clear sputum
Options in severe cases not responding to first line treatment:
IV aminophylline
Non-invasive ventilation (NIV)
Intubation and ventilation with admission to intensive care
Doxapram can be used as a respiratory stimulant where NIV or intubation is not appropriate
define non invasive ventilation and when it is used
an alternative to full intubation and ventilation to support the lungs in respiratory failure due to obstructive lung disease
using full face mask or tight fitting nasal mask
either by BiPAP or CPAP
define BiPAP and when it is used
bilevel positive airway pressure
- cycle of low and high pressure to correspond to patients inspiration (IPAP) and expiration (EPAP)
used in type 2 resp failure when resp acidosis <7.35 and co2 >6 despite medical tx
monitor with ABG
what are the main contraindications of BiPAP?
untreated pneumothorax or any structural abnormality affecting face, airway or GI tract
define CPAP and its indications
continuous positive airway pressure - continuous air so keeps airways expanded
- obstructive sleep apnoea
- congestive HF
- acute pulmonary oedema
define ILD
inflammation and fibrosis of lung parenchyma
replacement of normal elastric and functioning lung tissue with scar tissue
how is ILD diagnosed?
high resolution CT of thorax - ground glass appearance
lung biopsy if required
how is ILD managed?
Remove or treat the underlying cause
Home oxygen where they are hypoxic at rest
Stop smoking
Physiotherapy and pulmonary rehabilitation
Pneumococcal and flu vaccine
Advanced care planning and palliative care where appropriate
Lung transplant
define idiopathic pulmonary fibrosis
progressive pulmonary fibrosis with no clear cause
SOB, dry cough >3 mths
>50 yr olds
bibasal fine inspiratory crackle and finger clubbing
poor prognosis
how is idiopathic pulmonary fibrosis medically treated?
only slows progression of disease-
Pirfenidone is an antifibrotic and anti-inflammatory
Nintedanib is a monoclonal antibody targeting tyrosine kinase
which drugs are responsible for causing pulmonary fibrosis?
‘drug induced’
Amiodarone
Cyclophosphamide
Methotrexate
Nitrofurantoin
which conditions cause pulmonary fibrosis?
secondary to
Alpha-1 antitripsin deficiency
Rheumatoid arthritis
Systemic lupus erythematosus (SLE)
Systemic sclerosis
define hypersensitivity pneumonitis
aka extrinsic allergic alveolitis
type 3 - parenchymal inflammation and destruction due to allergen
