Respiratory Flashcards
Asthma - Chronic
Pathophysiology
Presentation
Management
Pathophysiology
- Reversible airway obstruction: bronchoconstriction, mucosal inflammation, increased mucous production
- Associated w/ atopy, hypersensitivity
Presentation
- wheeze, cough, intermittent SOB, diurnal variaition.
- Triggers: cold, viral infection, exercise, emotion, allergens, NSAIDs, B-blockers
Investigations
>17yo:
- Spirometry w/ bronchodilator reversibility testing (+ve if improves by 12%) AND FeNO testing (released by eosinophils so correlates w/ inflammation - >40 = positive in adults, >35 in children)
5-16yo
- spirometry w/ BDR testing
- FeNO if normal spirometry OR obstructive spironmetry (FEV1/FVC <0.7) w/ -ve BDR test
<5yo
- clinical judgement
Management - adults
1. SABA (eg. salbutamol)
2. SABA + ICS (eg. budesonide, beclometasone) (if 1. uncontrolled OR if new diagnosis w/ symptoms >3x/week or night-time waking)
3. SABA + ICS + LTRA (eg. montelukast)
4. SABA + ICS + LABA (eg. salmeterol or formeterol) +/- LTRA (depending on response)
5. SABA + low dose MART (maintenance + reliever therapy containing low dose ICS + fast-acting LABA eg. symbicort) +/- LTRA
6. SABA + medium dose MART +/- LTRA
7. SABA +/- LTRA + specialist advice (? for high dose ICS or additional drug e.g. LAMA (eg. tiotropium) or theophylline (A receptor antagonist)
Steroid dosing
- <400mcg budesonide (or equivalent) = low
- 400-800mcg = moderate
- >800 mcg = high dose
Stepping down treatment
- Consider every 3/12. Take into account duration of treatment, side-effects + patient preferance
- If decreasing ICS dose do by 25-50% at a time
Asthma - acute
- Presentation
- Investigation
- Management
Presentation
- SOB, wheeze
*Moderate *
- PEF 50-75%
- Normal speech
- RR <35
- Pulse <110
*Severe *
-PEF 33-50%
- Unable to complete full sentences
- RR > 25
- HR > 110
Life-threatening
- PEF <33%
- O2 <92%
- Silent chest, cyanosis, feeble effort, confusion, coma
- normal pCO2
- bradycardia, hypotension, dysrrhythmia
Near-fatal
- Raised pCO2
- Requiring mechanical ventilation
Investigation
- PEF
- ABG (if sats <92%)
- CXR - only if life-threatening, suspected pneumothorax, failure to respond to Tx
Management
- Admit: severe that doesn’t respond to initial Tx, any life-threatening, pregnant, anyone already taking PO steroids, presentation at night
- O2
- Bronchodilation - SABA (inhaler or nebs (nebs definitiely if life-threatening)
- Steroids - 40-50mg PO OD for at least 5 days post-recovery
- Other - for severe/life-threatening:
- Ipratropium bromide (SAMA)
- IV Magnesium Sulfate
- IV aminophylline
- ITU/HDU - intubation/ventilation, ECMO
Discharge Criteria
- Stable on discharge meds for 12-24h
- Inhaler technique checked + recorded
- PEF > 75% of best/predicted
COPD - long-term management
- Pathophysiology
- Presentation
- Investigations
- Management
Pathophysiology
Combination of:
- Chronic bronchitis (clinical diagnosis) - airway inflammation/obstruction/remodelling: cough + sputum most days for 3/12 in 2 consecutive years
- Emphysema (histological diagnosis) - enlarged air spaces w/ alveolar wall destruction: wheeze, lung hyperinflation
- Causes: smoking, alpha-1-antitrypsin deficiency, cadmium (smelting), coal, cotton, cement, grain
Presentation - >35yo
- Progressive SOB, wheeze, sputum
- purse lip breathing, barrel chest, quiet breath sounds, resonant percussion
- Can develop cor pulmonale: peripheral oedema, raised JVP, parasternal heave, loud P2 (loop diuretic +/- LTOT but NOT classic HF Tx)
Investigation
- Spirometry -not reversible. FEV1/FVC <70%
FEV1 determines severity:
- >80% - stage 1 (mild)
- 50-79% - stage 2 (moderate)
- 30-49% - stage 3 (severe)
- <30% - stage 4 (v severe)
- CXR: hyperinflation, bullae
- FBC: exclude secondary polycythaemia
(PEF not helpful in COPD)
CAT used to assess impact on life (questions e.g. how much do u cough, is sleep affected etc). Gives score of 0-40 w/ high = more severe.
Management
General:
- Smoking cessation, annual flu vaccine, one-off pneumococcal, pulm rehab
Bronchodilator:
- 1st line: SABA (eg. salbutamol) or SAMA (eg. ipratropium)
- 2nd line depends on whether ashtmatic features are present (PMHx of asthma/atropy, raised eosinophils, variation of FEV1 over time, diurnal variation of PEF (>20%))
- continue SABA or SAMA PRN plus:
- No asthmatic feature: LABA + LAMA
- Asthmatic features: LABA + ICS
-3rd: LAMA, LABA, ICS
- 4th: other: oral theophylline, oral prophylactic abx (azithromycin- needs to have stopped soking, have optimised meds + needs LFTs + ECG prior to starting (can -> long QT), mucolytics, lung volume reducing surgery, LTOT
(surgery, LTOT, stop smoking - can all improve prognosis; steroids reduces frequency of exacerbations)
COPD Exacerbation
- Pathophysiology
- Presentation
- Management
Pathophysiology
- Can be infective
Bacterial: H.Influenzae (most common), s.pneumonia, moraxella catarrhalis
Viral: rhinovirus mostly
- or Non-infective
Presentation
- Increase wheeze, SOB, cough, sputum
- Hypoxia, acute confusion
- Fever
Management
- O2 as needed
- Increase Salbutamol inhaler +/ salbutamol + ipratropium nebs
- Steroids - PO pred 30mg for 5 days
- Abx if evidence infection (clincal signs or purulent sputum) - amoxicillin, clarithromycin or doxycycline
- (if severe may need hosp admission, IV abx, nebs, NIV (optimal med management w/ no improvement in ABG)
Alpha-1-antitrypsin deficiency
- Pathophysiology
- Presentation
- Investigation
- Management
**Pathophysiology **
- Common inherted condition - lack of protease inhibitor (normally protects against neutrophil elastase) –> COPD in young non-smoking patients
- Autosomal recessive
Presentation
- Lungs: emphysema, mostly in lower lobes
- Liver: cirrhosis, hepatocellular carcinoma in adults, cholestasis in children
Investigations
- Alpha-1-antitrypsin concentrations
- Spirometery: obstructive
Management
- no smoking
- Supportive: bronchodilators, physio
- IV alpha-1-antitrypsin protein
- Surgery: lung vol reduction surgery, lung transplant
Smoking Cessation
- Management options + their mechanism of action
Nicotine replacement Therapy
Varenicline - nicotinic receptor partial agonist:
- start 1/52 prior to pt target stop smoking date
- 12 week course (but r/v regularly + only continue if not smoking)
- SEs: nausea, headache, insomnia, suicidual ideation (caution in those w/ depression).
- CI: pregnancy + breast feeding
Bupropion- norepinephrine + dopamine reuptake inhibitor, and nicotinic antagonist
- Start 1-2/52 prior to stop date
- SEs: as above + small risk of seizures
- CI: epilepsy, pregnancy, breast feeding
- Give as combination of patch plus gum/inhalator/lozenge/nsasal spray
- In pregnancy:
- all women have CO test - if >7ppm OR stopped smoking in last 2/52 OR current smoker - refer stop smoking services
- 1st line: CBT, motivational interviewing
Pulmonary Function Testing
- Give typical FEV1 + FVC findings in obstructive + restrictive lung disease
- Give example conditions for each
- Generally which type of NIV is used in Type 1 and Type 2 Respiratory Failure
Obstructive
Spirometry
- FEV1 - significantly reduced
- FVC - reduced/normal
- FEV1/FVC - <0.7
Conditions
- Asthma, COPD, bronchiectasis, bronchiolitis obliterans
Restrictive
Spirometry
- FEV1 - reduced
- FVC - significantly reduced
- FEV1/FVC - normal or raised (>0.7)
Conditions:
- Pulmonary fibrosis, asbestosis, sarcoidosis, ARDS, kyphoscoliosis, neuromuscular disorders, severe obesity
N.B. Pulmonary Fibrosis also has reduced TCLO (transfer factor for CO)
NIV
- Type 1: CPAP e.g. pulmonary oedema
- Type 2: BiPap e.g. COPD
Interstial Lung Disease
Pathophysiology
Presentation
Investigation
Management
Pathophysiology:
Known Cause:
- occupational e.g. asbestosis, beryllliosis, silicosis, coal worker’s pneumoconiosis (asymptomatic but can progress to progressive massive fibrosis)
Silicosis - mining, slate works, potteries - fibrosing lung disease w/ egg-shell calcification of hilar lymh nodes + upper zone fibrosis. Increases risk of TB (silica toxic to macrophages)
- Drugs e.g. bleomycin, nitrofurantoin, amiodarone
- Hypersensitivity e.g.
Allergic Extrinsic Alveolitis
inhalation of allergens -> acute (inflammatory infiltration of alveoli), chronic (granulomas + obliterative bronchiolitis)
*Bird fancier, farmer, malt/sugar workers’ lung
- Infection e.g. TB, fungal, viral
Associated w/ systemic disease
- Sarcoidosis, rheumatoid, SLE, Sjogren’s
- Idiopathic Pulmonary Fibrosis (most common)
Presentation
- SOBOE, non-productive cough, fine crackles
Allergic Extrinsic Alveolitis - acute (fever, rigor, myalgia, dry mouth, SOB, crackles). Chronic (SOB, weight loss, cor pulmonale), upper zone changes on CXR
Idiopathic Pulmonary Fibrosis - dry cough, SOBOE, malaise, weight loss, cyanosis, arthralgia, clubbing, CXR: lower zone, reticulo-nodular shaows, honeycomb lung.
Investigation
Abnormal CXR + CT
- upper zone - TB, extrinsic allergic alveolitis, anklylosing spondylitis, sarcoidosis, radiotherapy
- Mid zone: progressive massive fibrosis
- Lower: idiopathic pulmonary fibrosis, asbestosis
Restrictive spirometry
Management
Extrinsic Allergic Alveolitis - acute: remove allergen, O2, PO pred. Chronic: avoid allergen, long term steroids, compensation
Idiopathic pulmonary fibrosis - pulmonary rehab, O2, palliative care (?some poss drugs but limited effect)
N.B. Baker’s Lung is NOT ILD (it is form of occupational asthma)
Sarcoidosis
Pathophysiology
Presentation
Investigations
Management
Pathophysiology
- Multi-system non-caseating granulomatous disorder of unknown cause
- RF: female, age 20-40, black
Presentation
- Acute: erythema nodosum, B/L hilar lymphadenopathy, swinging fever, polyarthralgia
Other causes of B/L hilar lymphadenopathy: TB, other: lymphoma, pneumoconiosis, fungi eg. histoplasmosis
- Insidious: SOB, non-productive cough, malaise, weight loss
- Skin: lupus pernio (multiple vilaceous nodule on face/extremeties)
- Hypercalcaemia
plus more
Investigations
- Tissue biopsy is diagnostic (non caseating granuloma)
Management
- Acute: NSAIDs + bed rest (resolves spontaneously)
- Steroids for: lung disease, uveitis, hypercalcaemia, neuro or cardiac involvement
- Other: immunosupressants, anti-TNF alpha, lung transplant
Complications
- 60% resolves over 2yrs.
- In the rest prognosis is poor
Pneumothorax
- Pathophysiology
- Presentation
- Investigation
- Management
Pathophysiology
- Primary - in prev healthy lungs
- Secondary - w/ underlying lung disease
Presentation
- sudden onset SOB, pleuritic chest pain
- If tension - haemodynamic compromise or shifted mediastinum
Investigation
- CXR (unless tension)
Management
- Primary:
<2cm + asymptomatic - discharge
>2cm or <2cm and symptomatic - aspirate (if unsuccessful - chest drain
- Secondary
1-2cm + asymptomatic - aspirate (if fails then chest drain)
>2cm or symptomatic - chest drain
<1cm + asymptomatic - give O2 + admit for 24h - all secondary needs admission for at least 24h
- Iatrogenic
most resolve w/ observation +/- aspiration - Tension:
Emergency needle aspiration then chest drain
Ongoing Advice
- Stop smoking
- Permanent ban on scuba diving
- Flying = 1 week post clear check x-ray
Bronchiectasis
- Pathophysiology
- Presentation
- Investigation
- Management
Pathophysiology
- Abnormal widening of the bronchi -> increased infection, typically H.influenzae (most common), S.pneumoniae, pseudomonas, klebsiella
- Causes:
Congenital e.g. CF, PCD/kartageners
Post-infection - measles, pertussis, bronchiolitis, TB
Other: obstruction, idiopathic, allergic aspergillosis
Presentation
- Cough, daily mucopurulent sputum
- +/- SOB, pleuritic chest pain, wheeze, fever, weakness, weight loss (increased calorie req)
- Scattered wheeze, clubbing, crackles if exac
Investigations
- Sputum
- CXR - tram track sign (dilated airways in horizontal orientation) , ring opacities, tubular opacities (mucous filed bronchi)
- CT - signet ring (dilated airway next to pulm artery)
- Spirometry - obstructive
Management
- Physical training + postural drainage
- Immunisations
- Abx for exacerbations
- In some cases:
- Bronchodilators
- Surgery (e.g. localised disease)
- Long-term rotating abx (if severe)
Cystic Fibrosis
- Pathophysiology
- Presentation
- Investigations
- Management
Pathophysiology
- Autosomal recessive disorder -> increased viscosity of secretions due to defect in CF transmembrane conductance regulator gene
- Organisms that colonise in CF:
- Staph aureus, pseudomonas, burkholderia cepacia, aspergillus
Presentation
- Newborns - screening - if raised immunoreactive trypsinogen on heel prick -> blood screened for CF mutations –> sweat test
- Infancy:
- Meconium ileus, prolonged neonatal jaundice, recurrent chest infections, malabsorption + steatorrhoea
- Young children:
- bronchiectasis, rectal prolapse, nasal polyps, sinusitis
- Older children:
- DM, cirrhosis, distal intestinal obstruction, pneumothorax, sterility
- O/E - hyperinflated chest, coarse end inspiratory crackles, wheeze, finger clubbing
Management
- Resp:
- Monitoring (monitor symptoms in young children + spirometry in older children)
- physio, continuous prophylactic abx
- Other: nebulised DNAase/hypertonic saline (mucolytics), regular azithromycin, lung transplant
Nutritional:
- monitoring of weight/diet, pancreatic enzyme replacement, high calorie diet, fat soluble vitamin supplements
Teens/Adults- monitor for complications:
- DM
- Liver disease (ursodeoxycholic acid can improve bile flow)
- Distal intestinal obstruction syndrome (laxatives)
- Fertility (females normally ok)
Psych support, isolation, no contact w/ other CF patients.
Acute Bronchitis
Pathophysiology
Presentation
Management
Pathophysiology
- Usually self-limiting chest infection, due to inflammation of trachea/major bronchi
- Mostly viral w/ 80% of cases in autumn/winter
Presentation
- Cough (+/- sputum)
- sore throat
- Rhinorrhoea
- Wheeze
- To differentiate from pneumonia: no focal change on chest exam (can have generalised wheeze) + tend not to have systemtic features
Management
- Analgesia + fluids
- Consider Abx. Generally for acute cough (that sounds viral):
- No abx or delayed prescribing
- BUT in the following should have immediate abx due to risk of complications:
- Systemically v unwell
- Sx suggesting serious illness (pneumonia)
- High risk of serious complications due to pre-existing co-morbidity
- > 65 w/ acute cough + 2 of following OR >80 w/ one of the following:
- Hospitalisation in previous year
- T1 or T2DM
- Congestive Heart Failure
- Current use of PO steroids
Influenza
Pathophysiology
Presentation
Management
Indication for Vaccination
Pathophysiology
- caused by orthomyxovirus Influenza A &B
- Droplet or direct nasal/eye contact spread
Presentation
- Normally self-limiting BUT high mortality in those w/ chronic chest/CVS disease
- Rapid onset: anorexia/malaise, headache, fever, myalgia, non-productive cough, sore throat
Management
- General: rest, fluids, paracetamol, avoid aspirin in children <16 (risk of Reye’s syndrome)
- Pharm - antivirals (osteltamivir + zanamivir) in:
- At risk adults + children (children only osteltamivir)
- Post-exposure prophylaxis in at-risk >13yo + not protected by vaccine: ideally start within 48h of exposure
Indication for Vaccination
- CI: egg protein allergy
- anyone >65yo
- those >6/12 w/
- chronic resp disease
- chronic heart disease
- chronic kidney disease
- Diabetes (if on treatment)
- Immunosupression
- Asplenia/splenic dysfunction
- Or at risk individuals: health/social care staff, long-stay residential home, carers of elderly/disabled, those working w/ poultry
Pneumonia - CAP and HAP
Pathophysiology
Presentation
Investigation
Management
Pathophysiology
- CAP: Strep Pneumoniae (can -> rusty sputum)
- HAP = 48h after admission
- within 4d causative organisms same as CAp
- >4d: pseudomonas aerginosa, MSRA staph aureus, non-pseudomonal gram -ve organisms
Presentation
- Cough, sputum, SOB, pleuritic chest pain, fever, tachy, low O2
- Reduced breath sounds, bronchial breathing, increased vocal resonance
Investigation
- CXR, bloods, ABG
- CURB65 (or CRB65 in primary care)
- Confusion, urea >7, RR >30, BP <90 or <60, >65yo
CRB65:
-0 - low risk - home
- 1-2 - med risk - ?hosp
- 3-4 - high risk - urgent hosp
CURB65
- 0-1- low risk - home
- 2 - med risk - ?hosp
- 3 or more - hosp, ?ITU
Management
- Low risk CAP: Amoxicillin 5 day course
(tetracycline or macrolide if pen allergic)
- Mod risk CAP:
Dual abx: amoxicillin and macrolide (eg. clarithromycin) for 7-10d - High risk CAP:
Dual abx: IV amox/co-amox + macrolide
(? taxocin if bad) - If suspecting atypical infection: Clarithromycin
- Low risk HAP: Doxycycline
- Severe: IV amoxicillin (or teic if pen allergic)+ gentamicin
Repeat CXR at 6 weeks after clinical resolution
Discharge criteria
-Not if 2 or more of the following in last 24h (temp >37.5, RR >24, HR >100, BP <90, O2 <90, confusion, inability to eat without assistance)
