Respiratory Flashcards
(222 cards)
1
Q
What is Emphysema?
A
- In emphysema, the alveolar air sacs become damaged or destroyed.
- The alveoli permanently enlarge and lose elasticity, and as a result, individuals typically have difficulty with exhaling, which depends heavily on the ability of lungs to recoil.
2
Q
What are the risk factors for Emphysema?
A
- Smoking
- Air pollution
3
Q
What are the signs of Emphysema
A
- Breathing with pursed lips (pink puffers)
- Barrel shaped chest
- Loss of cardiac dullness
- Downward displacement of the liver
- On imaging: increased anterior-posterior diameter, a flattened diaphragm, and increased lung field lucency
4
Q
What are the symptoms of Emphysema?
A
- Dyspnoea
- Cough: could be productive
- Weight loss: due to energy expenditure while breathing
- Signs of CO2retention
- Drowsy
- Asterixis
- Confusion
5
Q
What is the management for emphysema?
A
Examples include:
- Smoking cessation
- Supplemental oxygen
- Bronchodilators
- Inhaled steroids
- Antibiotics: for secondary infections
Full management is on CPOD flashcard.
6
Q
What are the complications of emphysema?
A
Examples include
- Pneumothorax
- Cor pulmonale
- RSHF
- Pulmonary hypertension
Full complications are on CPOD flashcard.
7
Q
What is chronic bronchitis?
A
- Bronchitis means inflammation of the bronchial tubes in the lung.
- It is said to be chronic when it causes a productive cough for at least 3 months each year for 2 or more years.
- Usually co-exists with emphysema, causing COPD.
8
Q
What are the risk factors for chronic bronchitis?
A
- Smoking
- Exposure to air pollutants e.g. sulfur and nitrogen dioxide
- Exposure to dust and silica
- Family history of chronic bronchitis
9
Q
What are the signs of chronic bronchitis?
A
- Wheeze: due to narrowing of the passageway available for air to move in and out
- Crackles or rales: caused by the popping open of small airways
- Cyanosis (blue bloaters): if there is build-up of CO2 in blood
10
Q
What are the symptoms of chronic bronchitis?
A
- Productive cough
- Dyspnoea
- Signs of CO2retention
- Drowsy
- Asterixis
- Confusion
11
Q
What is the management for chronic bronchitis?
A
Examples include:
- Smoking cessation
- Management of associated illnesses
- Antibiotics for infections
- Supplemental oxygen
- Bronchodilators
- Inhaled steroids
Refer to COPD for full management
12
Q
What are the complications of chronic bronchitis?
A
Examples include
- Cor pulmonale
- RSHF
- Pulmonary hypertension
- Lung infections
Refer to COPD for full lost of complications
13
Q
What is asthma?
A
Asthma is a chronic inflammatory airway disease characterised by intermittent airway obstruction and hyper-reactivity.
14
Q
What are the two causative types of Asthma?
A
- Allergic/ eosinophilic: allergens and atopy
- Non-allergic/ non-eosinophilic: e.g. exercise, cold air and stress
15
Q
What are the risk factors for asthma?
A
- History of atopy
- Family history
- Allergens
- Viral upper respiratory infections
- Other triggers: cold weather and exercise
- Occupational exposure
16
Q
What are the signs of asthma?
A
- Diurnal PEFR variation: worse at night and early morning
- Dyspnoea and expiratory wheeze
- Samter’s triad
- Nasal polyps
- Aspirin insensitivity
- Asthma
17
Q
What are the symptoms of asthma?
A
- Episodic shortness of breath: diurnal variation (worse at night and early morning)
- Dry cough
- Wheeze and ‘chest tightness’
- May be sputum
- History of exposure to a trigger
18
Q
What are the 4 types/severities of asthma?
A
- Intermittent
- Mild persistent
- Moderate persistent
- Severe persistent
19
Q
What are the investigations for asthma?
A
- FIRST LINE - Fractional exhaled nitric oxide (FeNO)
- FIRST LINE - Spirometry with bronchidilator reversibility
- Allergy testing
- Chest X-ray
- Airway hyperreactivity testing
- Peak flow rate (PEFR)
20
Q
What is the first line management for asthma?
A
Short-acting beta antagonist (SABA)
- e.g. Salbutamol
21
Q
What is the second line management for asthma?
A
- SABA (salbutamol)
+ Low dose inhaled corticosteroid (ICS)
22
Q
What is the third line treatment for asthma?
A
- SABA (salbutamol)
- Low dose ICS
- Check adherence and how they are taking the drugs if using properly then:
+ Leukotriene Receptor antagonist e.g. Montelukast
23
Q
What other treatment options are there for asthma?
A
- Short- and long-acting muscarinic antagonists (LAMA) e.g. ipratropium, tiotropium.
- Maintenance and reliever therapy (MART)
- Phosphodiesterase (PDE) inhibitors e.g. theophylline & aminophylline
24
Q
What is the fourth line management for asthma?
A
- SABA (salbutamol)
- Low dose ICS
- LTRA (montelukast)
+ Long-acting beta antagonist (LABA)
- e.g. Salmeterol
25
What are the complications of asthma?
- Asthma exacerbations: typically triggered by an upper respiratory tract infection, pneumonia, or exposure to a trigger, e.g. an allergen or occupational exposure
- Pneumothorax
- Oral thrush: due to steroid medication
26
What is cystic fibrosis?
- Cystic fibrosis (CF) is an inherited, autosomal recessive, multi-system disease affecting mucus glands.
- Respiratory problems most prominent, as well as pancreatic insufficiency.
27
What are the risk factors for cystic fibrosis?
- Family history of cystic fibrosis
- Known parental carriers: if both parents are known carriers, the child has a 1 in 4 chance of having cystic fibrosis
- Caucasian ethnicity
28
What are the signs of cystic fibrosis?
- Low weight or height on growth charts
- Nasal polyps
- Finger clubbing
- Crackles and wheezes on auscultation
- Abdominal distention
29
What are the symptoms of cystic fibrosis?
- Chronic cough
- Can be haemoptysis if inflammation erodes into a blood vessel
- Thick sputum production
- Recurrent respiratory tract infections
- Loose, greasy stools (steatorrhoea) due to a lack of fat digesting lipase enzymes
- Abdominal pain and bloating
- Parents may report the child tastes particularly salty when they kiss them, due to the concentrated salt in the sweat
- Poor weight and height gain (failure to thrive)
30
How would an antenatal patient present with cystic fibrosis?
Hyperechogenic bowel (appears brighter than usual) on ultrasound
31
How would a neonatal patient present with cystic fibrosis?
- Prolonged jaundice
- Meconium ileus: first stool passed is thick and sticky and obstructs the bowel
32
How would a child present with cystic fibrosis?
- Recurrent chest infections (40%)
- Failure to thrive despite a voracious appetite
- Malabsorption: diarrhoea and steatorrhea (30%)
- Nasal polyps and chronic sinusitis
- Delayed puberty and short stature
- Other features: pancreatitis, rectal prolapse, portal hypertension (5-10%)
33
How would an adult patient present with cystic fibrosis?
- Recurrent chest infections
- Atypical asthma
- Diabetes mellitus
- Male infertility: absence of vas deferens
- Female subfertility
34
What are the primary investigations for cystic fibrosis?
- Sweat test - GOLD STANDARD
- Genetic testing for CFTR gene mutation
- Guthrie heel prick test
35
What are the other investigations for cystic fibrosis?
- Lung function test
- Sputum sample
- Faecal elastase
- Chest X-ray
36
What is the management for cystic fibrosis?
NOTE: Cystic fibrosis is managed by a specialist MDT
GI and Hepato-
- High calorie diet
- Liver transplant
- CREON tablets
- PPI
- Ursodeoxycholic acid
Respiratory
- Chest physiotherapy
- Antibiotics
- SABAs (salbutamol)
- Vaccinations
- Lung/ heart transplant
- Mucoactive agents
Other
- Fertility treatment
- Genetic counselling
37
What Mucoactive agents can be used in the management of cystic fibrosis?
- First-line: rhDNase e.g. dornase alfa / recombinant human deoxyribonuclease
- Second-line: hypertonic sodium chloride +/- mannitol dry powder (for inhalation) +/- rhDNase
- Third-line: Lumacaftor/Ivacaftor (Orkambi)
38
What is bronchiectasis?
Bronchiectasis is the permanent dilation of bronchi due to the destruction of the elastic and muscular components of the bronchial wall.
39
What are the clinical manifestations of bronchiectasis?
*Usually affects the lower lobes*
- Inspiratory crepitations
- Wheezing
- Productive coughing
- Large amounts of khaki coloured sputum (sometimes flecked with blood)
- Shortness of breath
- Foul smelling mucus
- Chest pain
- Digital clubbing: due to long term hypoxia
40
What are the investigations for bronchiectasis?
- HR-CT - GOLD STANDARD
- Sputum culture
- Pulmonary function testing
- Genetic testing
- CXR
- FBC
41
What is the management for bronchiectasis?
- Antibiotics: for recurrent infections
- Postural drainage: to remove excess mucus
- Chest physio
- Mucolytics
- Bronchodilators e.g. nebulised salbutamol: useful for asthma or COPD sufferers
- Anti-inflammatory agents e.g. long term azithromycin can reduce exacerbation frequency
- Surgery: to remove physical obstruction e.g. foreign object
42
What are the differential diagnoses for bronchiectasis?
- COPD
- Asthma
- Pneumonia
- Chronic sinusitis
43
What are the complications of bronchiectasis?
- Pulmonary hypertension
- LV hypertrophy
- Cor pulmonale
- Pneumonia
- Pneumothorax
- Haemoptysis
44
What is lung cancer?
- Lung cancer is the uncontrolled division of epithelial cells which line the respiratory tract.
- The majority of lung cancers are primary bronchial carcinomas. These are categorised into small-cell lung cancer (SCLC) and non-small cell lung cancer (NSCLC).
45
What are the risk factors for lung cancer?
- Increasing age
- Smoking
- Other environmental exposure
- Family history
46
What are the signs of lung cancer?
- Reduced breath sounds and a fixed monophonic wheeze may be present
- Stony dull percussion: suggests a malignant pleural effusion
- Supraclavicular or persistent cervical lymphadenopathy
- Extrapulmonary manifestations:
- Clubbing
- Facial plethora and swelling
- Hoarseness
47
What are the symptoms of lung cancer?
- Persistent cough +/- haemoptysis
- Dyspnoea
- Pleuritic chest pain
- Recurrent pneumonia
- Fever
- Weight loss and anorexia
- Night sweats
- Lethargy
48
What are the NICE guidelines in relation to lung cancer referral?
- If you suspect cancer offer a chest X-ray to be carried out within 2-weeks to patients over 40 with:
- Clubbing
- Lymphadenopathy (supraclavicular or persistent abnormal cervical nodes)
- Recurrent or persistent chest infections
- Raised platelet count (thrombocytosis)
- Chest signs of lung cancer
49
What are the primary investigations for lung cancer?
- Chest X-ray - FIRST LINE
- Chest CT with contrast GOLD STANDARD
- PET-CT if CT is suggestive of malignancy.
- Biopsy
- Mediastinoscopy for NSCLC
50
What are the other investigations for lung cancer?
- Mediastinoscopy
- Sputum cytology
- Lung function test
- Brain imaging for metastasis
- FBC
51
What staging is used for lung cancer?
TNM
52
What is the management for small cell lung cancer?
- Surgery is not usually offered due to the late presentation of disease.
- Limited disease - chemoradiotherapy with platinum-based agents, e.g. cisplatin
- Extensive disease - chemoradiotherapy with platinum-based agents, or palliative chemotherapy.
53
What general management is given to patients with lung cancer?
- Smoking cessation
- Pain management
- Endobronchial treatment with stents or debulking
54
What are the complications of lung cancer?
- Local obstruction
- Metastasis
- Paraneoplastic syndromes
- Nephrotic syndromes
- Hypercoagulability
- DIC
55
What is the management for non-small cell lung cancer?
- Non-metastatic disease (stage I-IIIa): surgery, usually with adjuvant chemotherapy
- Typically involves lobectomy or pneumonectomy. Segmentectomy or wedge resection (taking a segment or wedge of lung to remove the tumour) is also an option.
- Removal of lymph nodes, if affected
- Curative radical radiotherapy can be used as an alternative to surgery
- Metastatic disease (stage IIIb and above): palliative treatment with immunotherapy, chemotherapy, and radiotherapy
56
What is an upper respiratory tract infection?
- Defined as self-limited irritation and swelling of the upper airways.
- Any infection of the: paranasal sinuses, nasal cavity, pharynx, larynx.
57
What are the risk factors for upper respiratory tract infections?
- Close contact with children: both day-cares and schools
- people with asthma and allergic rhinitis
- smoking,
- Immunocompromised individuals
58
What are the clinical manifestations of an upper respiratory tract infection?
- Cough
- Sore throat
- Runny nose (underlying rhinitis)
- Nasal congestion
- Headache
- Fever
- Sneezing
- Malaise
- Myalgia
Rhinosinusitis - pain or pressure on face, change in voice
Pharyngitis - sore throat
Tonsillitis - pain or swelling, hard to swallow
Laryngitis - hoarse voice and dry cough
Epiglottitis - trouble breathing, tripods (leans forward to keep airway open)
- Epiglottitis is an emergency
59
What are the investigations for an upper respiratory tract infection?
- Clinical diagnosis
- Nasal swab to identify causative pathogen
60
What are the differential diagnoses for an upper respiratory tract infection?
- COVID-19
- Hay fever
- Chronic sinusitis
- Streptococcal tonsillopharyngitis
- Acute sinusitis
61
What is the management for an upper respiratory tract infection?
- Reassurance and supportive care
- Analgesic/Antipyretic
- Decongestant and/or antihistamine
- Antitussive
- Could give antibiotics for bacterial cause
62
What are the complications of upper respiratory tract infections?
- Otitis media
- Asthma acute exacerbation
- Acute sinusitis
- Bronchospasm
- Pneumonia
63
What is sinusitis?
- Sinusitis is inflammation of the paranasal sinuses.
- Acute sinusitis can last up to four weeks, subacute sinusitis lasts between 1 to 3 months, and chronic sinusitis lasts more than 3 months.
64
What are the clinical manifestations of sinusitis?
- Purulent rhinorrhoea
- Facial pain
- Headache
- Fever
- Voice changes
- Change in smell and taste
- Cough: due to mucus build-up
65
What are the investigations for sinusitis?
- Diagnosis is mainly based on clinical presentation
- Investigations to consider:
- Rhinoscopy: tube containing a camera is inserted into the nose; shows evidence of clogged up sinuses that may be filled with mucus or pus.
- Sinus culture
- CT/ X-ray/ MRI sinuses
66
What is the management for sinusitis?
- Sinusitis usually last 2-3 weeks and resolves without treatment
- High dose steroid nasal spray: if no improvement
- Antibiotics: if likely due to bacterial cause
- First line: penicillin V (phenoxymethylpenicillin) for a 5 day course
- Second line: co-amoxiclav
- If penicillin allergy: clarithromycin, erythromycin (pregnancy), doxycycline
- Sinus surgery: to allow drainage in cases of chronic or recurrent sinusitis
67
What is acute epiglottitis?
Epiglottitis refers to inflammation and localised oedema of the epiglottis, which can result in potentially life-threatening airway obstruction.
68
What are the risk factors for acute epiglottitis?
- Age: since the introduction of the HiB vaccination, its incidence has shifted from children to adults. The peak age of presentation is 6 to 12 years, although it can occur at any age.
- Male gender
- Unvaccinated
- Immunocompromised
69
What are the signs of acute epiglottitis?
- Stridor
- Muffled voice: voice box is located close to epiglottis
- Respiratory distress: intercostal and subcostal recession (ribs show when breathing), tracheal tug, nasal flaring, accessory muscle use
- Tripod position: a sign of respiratory distress
- The patient leans forward and supports their upper body on their knees
- Pyrexial: often a very high temperature ~40°C
- Looks very unwell or ‘toxic’
70
What are the symptoms of epiglottitis?
- Fever
- Sore throat
- Dysphagia
- Dysphonia (stridor)
- Drooling
- Distress
71
What are the investigations for acute epiglottitis?
- Laryngoscopy - GOLD STANDARD
- Lateral neck radiograph
- FBC
- Cultures of blood/supraglottic region
72
What is the management for acute epiglottitis?
- FIRST LINE - secure the airway
- FIRST LINE - IV antibiotics
- Nebulised adrenaline may be used in an emergency
- Oxygen supplementation
- Corticosteroids - Dexamethasone
73
What are the complications of acute epiglottitis?
- Airway obstruction: occurs secondary to significant upper airway inflammation and oedema
- Respiratory failure can lead to a respiratory acidosis
- Mediastinitis: infection can track along the retropharyngeal space and involve the mediastinum, which is associated with a poor prognosis
- Soft tissue involvement: cellulitis or abscess within the neck
74
What is pharyngitis?
Acute pharyngitis is characterised by the rapid onset of sore throat and pharyngeal inflammation.
75
What is tonsillitis?
Acute tonsillitis refers to inflammation of the parenchyma of the palatine tonsils.
76
What are the risk factors for Pharyngitis / Tonsillitis?
- Young age
- Infected contacts: school-age children are often in close contact with others and are frequently exposed to viruses or bacteria that can cause tonsillitis
77
What are the signs of Pharyngitis / Tonsillitis?
- Pyrexia
- Red, inflamed, and enlarged tonsils with(out) exudates
- Anterior cervical lymphadenopathy
- Evidence of dehydration
78
What are the symptoms of Pharyngitis / Tonsillitis?
- Sore throat: usually sudden onset
- Pain on swallowing
- Loss of appetite
- Fever
- Malaise
- Non-specific symptoms: headache, nausea, vomiting
79
What are the investigations for Pharyngitis / Tonsillitis?
- Acute tonsillitis is primarily a clinical diagnosis
- Throat culture - GOLD STANDARD
- Rapid group A streptococcal (GAS) antigen test
80
What are the differential diagnosis of pharyngitis / tonsillitis?
- Infectious mononucleosis (glandular fever; due to EBV)
- Epiglottitis
81
What is the management for pharyngitis / tonsillitis?
- Supportive care - FIRST LINE
- Analgesics and local anaesthetics
- Confirmed GAS - Antibiotic therapy
- Obstructive sleep disorder or recurrent disease - tonsillectomy
- Candida - Antifungal therapy
82
What are the complications of pharyngitis / tonsillitis?
- Chronic tonsillitis
- Acute otitis media
- Scarlet fever
- Acute rheumatic fever
- Glomerulonephritis
83
What is otitis media?
- Acute otitis media (AOM) is defined by NICE as "the presence of inflammation in the middle ear, associated with an effusion and accompanied by the rapid onset of symptoms and signs of an ear infection"
- It is a common complication of viral respiratory illnesses.
84
What are the risk factors for otitis media?
- Children: 6 to 24 months are most frequently affected
- Bottle feeding: the absence of breastfeeding is a well-recognised risk factor
- Family history
- Craniofacial abnormalities
- Gastroesophageal reflux disease
85
What are the signs of otitis media?
- Otoscopy findings:
- A red or cloudy tympanic membrane
- Bulging of the tympanic membrane
- Middle ear effusion: air-fluid level behind the tympanic membrane
- Tympanic membrane perforation may be present
- Otorrhoea: discharge due to perforation of tympanic membrane
86
What are the symptoms of otitis media?
- Ear pain often associated with holding, tugging or rubbing of the ear in children
- Reduced hearing
- Recent upper respiratory tract infection
- Balance issues and vertigo: if infection affects the vestibular system
- Non-specific symptoms
- Fever
- Irritability and poor feeding
- Vomiting
- Sore throat
- Cough and coryza
87
What are the investigations for otitis media?
- Otitis media is a clinical diagnosis
- Examination: of ears and throat. Use otoscope to visualise the tympanic membrane - may appear bulging, red and inflamed. May be signs of discharge.
- Triad of: bulging tympanic membrane, impaired mobility, and redness or cloudiness of the tympanic membrane
- Imaging:
- CT to confirm diagnosis but not strictly necessary
88
What is the management for otitis media?
- Observation: many cases are self-resolving
- Analgesia: e.g. paracetamol or ibuprofen - FIRST LINE
- Antibiotics: if not self-resolving, systemically unwell or suspected complications
- First line: amoxicillin
- Second line: co-amoxiclav if no improvement on amoxicillin
- Penicillin allergy: macrolide, e.g. clarithromycin or erythromycin
- Tympanocentesis for relief of middle ear pressure
89
What are the complications of otitis media?
- Glue ear
- Tympanic membrane perforation
- Chronic or recurrent infection
- Hearing loss
90
What is pulmonary embolism?
Pulmonary embolism (PE) refers to obstruction of the pulmonary vasculature, secondary to an embolus.
91
What are the risk factors for a pulmonary embolism?
- Virchows triad.
- Right ventricular thrombus (post-MI)
- Septic emboli (right-sided endocarditis - bacterial vegetation)
- Fat embolism (due to long bone fracture)
- Air embolism
- Amniotic fluid embolism
- Neoplastic cells
- Parasites
- Foreign material during IV drug misuse
92
What are the signs of a pulmonary embolism?
- Hypoxia
- Cyanosis may be present
- Deep vein thrombosis: swollen, tender calf
- Pyrexia may be present
- Tachypnoea and tachycardia
- Crackles
- Hypotension: SBP <90 mmHg suggests a massive PE
- Elevated JVP: suggests cor pulmonale
- Right parasternal heave: suggests right ventricular strain
93
What are the symptoms of pulmonary embolism?
- Pleuritic chest pain
- Dyspnoea
- Cough +/- haemoptysis
- Fever
- Fatigue
- Syncope: a red flag symptom
94
What are the investigations for pulmonary embolism?
- CXR
- ECG
- CT pulmonary angiogram
- ABG
- V/Q scan
- D-Dimer
- Pulmonary angiography - GOLD STANDARD but more invasive and has higher complications
95
What is the prevention and supportive management for pulmonary embolism?
- Compression stockings
- Frequent calf exercises during long periods of sitting still
- Prophylactic treatment with low molecular weight heparin
- Admission to hospital
- Oxygen, as required
- Analgesia, if required
- Adequate monitoring for any deterioration
96
What is the management for massive and non-massive PE?
Massive
- Thrombolysis e.g. alteplase
Non-massive
- Anticoagulation:
- Provoked: consider stopping anticoagulation at 3 months
- Unprovoked: consider continuing anticoagulation beyond 3 months.
- Interim anticoagulation: if a PE is likely
Further management for both
- IVC filter
- Surgical embolectomy
97
What are the complications of PE?
- Cor pulmonale
- Pulmonary infarction
- Sudden death
- Respiratory alkalosis
- Embolic stroke
- Heparin-associated thrombocytopenia
98
What is pulmonary hypertension?
- Pulmonary hypertension is increased resistance and pressure of blood in the pulmonary arteries.
- A mean pulmonary arterial pressure that is greater than 25 mmHg.
99
What are the clinical manifestations of pulmonary hypertension?
- Shortness of breath
- If caused by left-sided heart failure, there can be orthopnea - the shortness of breath is worse while lying flat.
- Fatigue
- Chest pain
- Syncope
- Tachycardia
- Raised JVP
- Hepatomegaly
- Peripheral oedema
100
What are the investigations for pulmonary hypertension?
- ECG
- Right ventricular hypertrophy
- Right axis deviation
- RRRB
- CXR
- ECHO
- Raised NT-proBNP
101
What is the management for pulmonary hypertension?
- Supportive treatment
- Primary pulmonary hypertension can be treated with:
- IV prostanoids (e.g. epoprostenol)
- Endothelin receptor antagonists (e.g. macitentan)
- Phosphodiesterase-5 inhibitors (e.g. sildenafil)
- Secondary pulmonary hypertension is managed by treating the underlying cause such as pulmonary embolism or SLE.
102
What are the complications of pulmonary hypertension?
- Respiratory failure
- Heart failure
- Arrhythmias
103
What is a pneumothorax?
A pneumothorax is an abnormal accumulation of air within the pleural space, which is the space between the parietal and visceral pleura.
104
What are the risk factors for primary spontaneous pneumothorax?
- Tall, slender, young (aged 20-30)
- Smoking
- Marfan syndrome
- Rheumatoid arthritis
- Family history
- Homocystinuria (body can't process the amino acid methionine)
- Diving or flying
105
What are the risk factors for secondary spontaneous pneumothorax?
- Underlying lung disease e.g. COPD, asthma, lung cancer
- TB
- Pneumocystic jirovecii
106
What are the risk factors for a tension pneumothorax?
- Mechanical ventilation and NIV
- Trauma
- Iatrogenic: central line insertion, biopsy
107
What are the signs of a pneumothorax?
- Tachycardia and tachypnoea
- Cyanosis
- Hyperresonance ipsilaterally (resonance is higher when percussed)
- Reduced breath sounds ipsilaterally
- Hyper-expansion ipsilaterally
- Contralateral tracheal division
- Hypotension
108
What are the signs of a pneumothorax?
- Sudden-onset pleuritic chest pain
- Sudden-onset dyspnoea
- Sweating: may be present
109
What are the investigations for a pneumothorax?
- If tension pneumothorax is suspected, don't wait for investigations!
- Erect CXR - FIRST LINE
- CT chest - GOLD STANDARD
110
What is the management for spontaneous pneumothorax?
- Aspiration at the 2nd intercostal space
- Chest drain is inserted into the 5th intercostal site
- High flow oxygen
- Repeat CXR
111
What is the management for a tension pneumothorax?
- Emergency!
- Immediate needle decompression with the insertion of a cannula into the second intercostal space in the midclavicular line - FIRST LINE
- High-flow oxygen
- Chest drain after aspiration
- Repeat CXR
112
What is the management for an iatrogenic pneumothorax?
- Require monitoring
- Aspiration is preferred if treatment is required
- Ventilated patients and those with underlying lung disease (e.g. COPD) may require a chest drain
113
What are the surgical management options for a pneumothorax?
- Open thoracotomy and pleurectomy: removal of pleura
- Video-assisted thoracoscopic surgery (VATS) with pleurectomy and abrasion: causes adhesion between visceral and parietal pleura to prevent recurrence
- Surgical chemical pleurodesis: adheres lung to chest wall
114
What are the complications of a pneumothorax?
- Re-expansion pulmonary oedema
- Cardiorespiratory arrest
- Recurrence
115
What is pleural effusion?
- A pleural effusion results when fluid collects between the parietal and visceral pleural surfaces of the thorax.
- This can be exudative meaning there is a high protein count (>30g/L) or transudative meaning there is a relatively lower protein count (<30g/L).
116
What are the signs of pleural effusion?
- Reduced chest expansion and reduced breath sounds
- Decreased tactile or vocal fremitus
- Dullness to percussion over the effusion
- Pleural friction rub (raspy breathing sound) and bronchial breathing
- Tracheal deviation away from the effusion
117
What are the symptoms of pleural effusion?
- Shortness of breath
- Cough
- Pleuritic chest pain: usually associated with an exudate due to pleural irritation
- Symptoms of the underlying cause, for example:
- Peripheral oedema (heart failure)
- Ascites (liver cirrhosis)
- Productive cough and fever (pneumonia)
- Weight loss (malignancy)
118
What are the investigations for pleural effusion?
- Pleural ultrasound - GOLD STANDARD
- CXR
- Pleural aspiration and pleural fluid analysis (pH. glucose, protein level, LDH, microbiology, cytology)
- FBC and CRP
119
What is Light's criteria used for?
Light’s criteria is used to distinguish between transudate and exudate effusions
120
What is the management for pleural effusion?
- Light’s criteria is used to distinguish between transudate and exudate effusions will resolve with treatment of the underlying cause.
- Infective - Chest tube drainage is required.
- Non-malignant - Aspiration, thoracentesis, pleurodesis, pleural catheter
- Malignant - Observation, aspiration, talc pleurodesis, chest drainage
121
What are the complications of pleural effusion?
- Atelectasis/lobar collapse
- Empyema
- Trapped lung
- Re-expansion pulmonary oedema
- Pneumothorax
122
What is mesothelioma?
Malignant mesothelioma is an aggressive epithelial neoplasm arising from the lining of the lung, abdomen, pericardium, or tunica vaginalis.
123
What are the risk factors for mesothelioma?
- Increasing age: often presents in patients >60 years old due to a latent disease period
- Male gender
- Asbestos exposure:
- Other causes: radiotherapy, genetics, simian virus 40
124
What are the signs of mesothelioma?
- Finger clubbing
- Reduced breath sounds
- Stony dull percussion: suggests a pleural effusion
- Ascites: if peritoneal disease is present
- Signs of metastases: e.g. lymphadenopathy, hepatomegaly, bone pain/ tenderness, abdominal pain/obstruction
125
What are the symptoms of mesothelioma?
- Shortness of breath
- Cough
- Pleuritic chest pain or chest wall pain
- Bloody sputum: if blood vessels are affected
- Constitutional symptoms:
- Fatigue, fever, night sweats, weight loss
126
What are the investigations for mesothelioma?
- Video assisted thoracoscopic surgery - GOLD STANDARD
- CXR
- Contrast enhanced CT of the chest - after suspicious CXR
127
What is the management for operable mesothelioma?
- Surgery - FIRST LINE
- Extrapleural pneumonectomy
- Pleurectomy with decortication (removing the pleural lining + tumour masses)
- Rarely curative
- +/- Chemotherapy
- Cisplatin
- Pemetrexed
- +/- Radiotherapy
128
What is the management for inoperable mesothelioma?
- Chemotherapy
- Cisplatin
- Pemetrexed
- +/- Radiotherapy
129
What are the complications of mesothelioma?
- Pneumothorax
- Local invasion of structures
- Metastasis
- Complications of surgery/chemotherapy/radiotherapy
130
What is empyema?
Defined as the presence of pus in the pleural space
131
What are the risk factors of empyema?
- Gender → Male > Female.
- Age → More common in older people (60-70) and young children.
- Pneumonia
- Iatrogenic interventions of the pleural space
- Thoracic trauma
- Immunocompromised state
132
What are the clinical manifestations of empyema?
- Pyrexia
- Rigors
- Dullness to percussion
- Signs of sepsis - *pyrexia, tachypnoea, tachycardia, and hypotension*
- Productive cough
- Dyspnoea
- Pleuritic chest pain - *result of inflammation of parietal pleura*
133
What is the investigations of empyema?
- GOLD STANDARD - Ultrasound
- GOLD STANDARD - Thoracentesis
- Blood cultures
- CRP
- WBC count
- CXR
134
What are the differential diagnoses for empyema?
- Pneumonia
- Lung abscess
- Chylothorax
135
What is the management for empyema?
- FIRST LINE - IV antibiotics
- Ceftriaxone + Metronidazole
- One culture results are obtained, antibiotics can be tailored
- Chest tube drainage
- Supportive care
- Fluid resuscitation
136
What are the complications of empyema?
- Septic Shock
- Respiratory Failure
137
What is Croup?
Croup, also known as laryngotracheobronchitis, is a viral upper respiratory tract infection most commonly by the parainfluenza virus.
138
What are the causes of croup?
- Parainfluenza virus
- Adenovirus
- Influenza
- Respiratory syncytial virus (RSV)
- Bacterial croup e.g. laryngeal diphtheria, exists but is significantly less common than viral croup.
139
What are the risk factors for croup?
- Age: typical age of presentation is 6 months to 3 years, but can be seen up to 6 years of age
- Male gender
- Prematurity
- Underlying respiratory disease
140
What are the signs of Croup?
- Pyrexia
- Stridor
- Respiratory distress: intercostal and subcostal recession (ribs are visible on breathing), tracheal tug, nasal flaring, accessory muscle use
141
What are the symptoms of Croup?
- Barking cough: worse at night
- Difficulty in breathing
- Hoarse voice
- Fever
- Coryza
- Lethargy and agitation in severe disease
142
What are the investigations of Croup?
- Croup is a clinical diagnosis and does not usually require any further investigations.
- Clinical diagnosis
- Neck X-ray: not routinely carried out in clinical practice, but the classical finding is the steeple sign (tracheal narrowing).
143
What is the Westley score?
The Westley score is a classification system used to assess the severity of croup.
144
What is the management for Croup?
- FIRST LINE - Corticosteroids e.g. dexamethasone.
- If presenting with Stridor at rest + Nebulised Adrenaline
- Supplemental adrenaline
145
What are the complications of Croup?
- Airway obstruction
- Superinfection croup
- Bacterial tracheitis
- Pneumonia
146
What is Whooping Cough?
- An upper respiratory tract infection caused by Bordetella pertussis
- A gram negative bacteria
- It is called “whooping cough”, because the coughing fits are so severe that the child is unable to take in any air between coughs and subsequently makes a loud whooping sound as they forcefully suck in air after the coughing finishes.
- Pertussis is a notifiable disease → Public health needs to be notified
147
What are the risk factors for whooping cough?
- Age < 6 months
- No or incomplete immunisation
- School teacher or Healthcare workers
- Close contact with infected persons
148
What are the clinical manifestations of whooping cough?
- Pertussis typically starts with mild *coryzal* symptoms, a low grade fever and possibly a mild dry cough
- Cough
- Inspiratory whooping
- Rhinorrhoea - runny nose, thin, mostly clear nasal discharge
- Post-tussive vomiting - after coughing vomiting
- Absent/low grade fever
- Decreased appetite
149
What are the investigations for whooping cough?
- FBC
- Culture of nasopharyngeal aspirate
- OR swab from the posterior nasopharynx
- Anti-pertussis toxin IgG - if cough present for more than 2 weeks.
150
What are the differential diagnoses of whooping cough?
- Upper Respiratory Tract Infection
- Community Acquired Pneumonia
151
What is the management for whooping cough?
- Infants - FIRST LINE - Macrolide antibiotics e.g. Azithromycin or Clarithromycin
- Infants and Children - FIRST LINE is the same
- Infants and Children - SECOND LINE Trimethoprim
- Pregnant women - FIRST LINE - Erythromycin for 7 days
152
What are the complications of whooping cough?
- Pneumonia
- Seizures
- Rib fractures
- Encephalopathy
- Bronchiectasis
153
What is tuberculosis?
Tuberculosis (TB) is a granulomatous disease caused by Mycobacterium tuberculosis.
154
What are the risk factors for TB?
- Contact with a person with active TB
- Endemic regions: South Asia or sub-Saharan Africa
- Homelessness
- Alcohol or drug abuse
- Immunocompromised: e.g. secondary to HIV, steroid use, malnutrition, immunosuppression medication
- Silicosis: impairs macrophage function
- Haematological malignancy
155
What are the signs of TB?
Latent disease is asymptomatic
- Auscultation: often normal; crackles may be present
- Clubbing: if long-standing
156
What are the symptoms of TB?
Latent disease is asymptomatic
- Cough +/- haemoptysis
- Dyspnoea
- May be chest pain present
- Systemic symptoms:
- Fever
- Lethargy
- Weight loss
- Night sweats
- Lymphadenopathy
157
What some examples of extra-pulmonary manifestations of TB?
- Central nervous system: TB meningitis
- Heart: pericardial TB
- Bone: pain and swelling of joints
- Vertebral bodies: Pott’s disease (infectious disease of the spine)
- Adrenals: Addison's disease
- Lymph nodes: scrofuloderma (secondary cutaneous tuberculosis), swelling, discharge
- Liver: hepatitis
- Gastrointestinal tract: ascites, malabsorption
- Genitourinary: tuberculous epididymitis, dysuria, haematuria, frequency
158
What are the investigations for latent TB?
- Mantoux screening
- Interferon-gamma release assay (IGRA)
159
What are the investigations for active TB disease?
- CXR
- Microbiology: Ziehl-Neelsen stain (will turn red) and Mycobacterium culture
- Nucleic-Acid Amplification Test (NAAT)
- HIV and hepatitis status
160
What is the management for latent TB infection?
Isoniazid and rifampicin for 3 months.
OR
- Isoniazid only for 6 months: if interactions with rifampicin are a concern
- Pyridoxine (vitamin B6): usually co-prescribed with isoniazid prophylactically to help prevent peripheral neuropathy
161
What is the management for active TB infection?
- Notification: all cases of active TB need to be notified within three working days
- Contact tracing
- Isolate patients
- Initial phase: rifampicin, isoniazid, pyrazinamide and ethambutol (RIPE) for two months
- Continuation phase: rifampicin and isoniazid for a further four months
- Multi-drug resistant (MDR) TB: treatment will be extended for 1-24 months, with at least six drugs
- Pyridoxine (vitamin B6): usually co-prescribed with isoniazid prophylactically to help prevent peripheral neuropathy
162
What are the complications of TB?
- Empyema
- Aspergilloma
- Bronchiectasis
- Pneumothorax: TB is a cause of secondary spontaneous pneumothorax
- Miliary TB: massive lymphohaematogenous spread causing multi-organ involvement
- Extra-pulmonary disease: CNS (TB meningitis), vertebral bodies (Pott’s disease), adrenals (Addison's disease), cervical lymph nodes (scrofuloderma), renal and GI tract
- Drug-related side effects
163
What is pneumocystis pneumonia?
Pneumocystis pneumonia (PCP) is an opportunistic respiratory infection caused by the fungus, Pneumocystis jirovecii.
164
What are the risk factors for pneumocystis pneumonia?
- HIV/AIDS: PCP is associated with a CD4 count < 200/mm^3
- Primary immunodeficiency conditions
- Secondary immunodeficiency: e.g. steroids
- Other causes of immunosuppression: e.g. haematological malignancies
165
What are the signs of pneumocystis pneumonia?
- Chest examination is often normal
- Extrapulmonary manifestations (rare):
- Lymphadenopathy
- Hepatosplenomegaly
- Choroid lesions: benign naevi at the back of the eye
- Pyrexia
166
What are the symptoms of pneumocystis pneumonia?
- Dyspnoea: characteristically exertional
- Dry cough
- Fever
- Night sweats
- History of immunosuppression
167
What are the primary investigations for pneumocystis pneumonia?
- Oxygen saturation: patients with PCP characteristically desaturate on exertion
- Arterial blood gas
- Chest X-ray: may reveal bilateral interstitial infiltrates but can be normal
- Serum LDH levels
168
What are other investigations to consider for pneumocystis pneumonia?
- Broncho-alveolar lavage (BAL): performed if sputum is normal
- High-resolution CT chest
- HIV serology and CD4 count
169
What is the management for pneumocystis pneumonia?
- FIRST LINE - Trimethoprim/sulfamethoxazole (co-trimoxazole)
- Prednisolone: indicated if hypoxic with pO2 < 9.3 kPa, to reduce the risk of respiratory failure (< 50% risk) and death
- IV/ nebulised pentamidine: this is reserved for severe cases where co-trimoxazole is contraindicated or has failed
170
What are the complications of pneumocystis pneumonia?
- Pneumothorax
- Respiratory failure
- Immune reconstitution inflammatory syndrome (IRIS)
171
What is pneumonia?
Pneumonia is an acute inflammation of the terminal bronchioles and the area surrounding the alveoli.
172
What are the risk factors for pneumonia?
- Extremes of age: young children and the elderly are particularly at risk
- Preceding viral infection
- Immunosuppressed: e.g. due to steroid use
- Intravenous drug abuse: Staphylococcus aureus
- Respiratory conditions: asthma, COPD, malignancy, cystic fibrosis
173
What are the signs of pneumonia?
- Reduced breath sounds
- Bronchial breathing: harsh breath sounds equally loud on inspiration and expiration
- Coarse crepitations
- Dullness to percussion due to lung tissue collapse and/or consolidation.
- Hypoxia
- Tachycardia
- Tachypnoea
- Pyrexia
174
What are the symptoms of pneumonia?
- Productive cough +/- haemoptysis
- Pleuritic chest pain
- Dyspnoea
- Fever
- Night sweats
- Fatigue
- Delirium: acute confusion associated with infection
- Atypical pneumonia: dry cough, mild dyspnoea, flu-like symptoms, and mild or no fever.
175
What are the primary investigations for pneumonia?
- CXR
- FBC
- U&Es
- CRP
- ABG
- Sputum culture
- Blood culture
- Urinary antigen testing
- Serology
176
What is the management for pneumonia?
- O2, if needed
- Analgesia
- Antibiotics: will vary by trust
177
What is the management for community acquired pneumonia?
- Low severity (CURB ≤ 1): oral amoxicillin OR doxycycline/clarithromycin if penicillin-allergic or an atypical pathogen is suspected; usually a 5 day course
- Moderate severity (CURB 2): amoxicillin; add clarithromycin if an atypical pathogen is suspected; usually a 5 day course
- High severity (CURB ≥ 3): IV co-amoxiclav and clarithromycin are often used
178
What is the management for hospital acquired pneumonia?
- Severity is determined clinically
- Low severity: oral co-amoxiclav
- High severity: a broad-spectrum antibiotic, such as IV tazocin or ceftriaxone
- Suspected or confirmed MRSA: add vancomycin
179
What is CURB-65 used for?
A criteria for the severity for pneumonia.
C - Confusion (1)
U - Urea - >7mmol/L (1)
R - Respiratory rate - >3/min (1)
B - Blood pressure - SBP/DBP = <90/<60 (1)
65 - >65 years old (1)
- Consider community-based care for patients if CURB-65 is 0 or 1 (low severity)
- Consider hospital-based care for patients if CURB-65 is 2 (moderate severity)
- Consider intensive care assessment if CURB-65 is ≥ 3 (high severity)
180
What are the complications of pneumonia?
- ARDS
- Sepsis
- Lung abscess
- Pleural effusion
181
What is respiratory failure?
- Results from acute or chronic impairment of gas exchange between the lungs and blood causing hypoxia with or without hypercapnia.
- Acute respiratory failure is often associated with pulmonary infections.
182
What is type 1 respiratory failure?
- Hypoxemic respiratory failure
- Characterised by low arterial oxygen tension (PaO2) <60mmHg with normal or low arterial carbon dioxide tension (PaCO2).
- Associated with virtually all acute disease of the lungs.
- Generally involves fluid filling or collapse of alveolar units.
183
What is type 2 respiratory failure?
- Hypercapnic respiratory failure.
- Characterised by a PaCO2 higher than 50mmHg.
- Hypoxemia is common in patients with type 2 respiratory failure who are breathing room air.
- The pH depends on level of bicarbonate, which depends on the duration of hypercapnia.
184
What are the clinical manifestations of respiratory failure?
- Dyspnoea
- Confusion
- Tachypnoea
- Stridor
- Cyanosis
- Lose consciousness
185
What are the investigations for respiratory failure?
- FIRST LINE - pulse oximetry
- GOLD STANDARD - ABG
186
What is the management for respiratory failure?
- Correct hypoxemia - controlled supplemental oxygen.
- Correct hypercapnia and respiratory acidosis - endotracheal intubation and mechanical ventilation.
- Physiotherapy.
187
What is the differential diagnosis of respiratory failure?
- Sleep apnoea
- Obesity
188
What is sarcoidosis?
Sarcoidosis is a granulomatous inflammatory multi-systemic disease in which any organ can be affected, although the lungs are the predominantly affected organ.
189
What are the risk factors for sarcoidosis?
- Afro-Caribbean and Scandinavian ethnicity
- Young adults: commonly presents at 20-40 years of age
- Female gender
- Family history
190
What are the signs of sarcoidosis?
- Cervical and submandibular lymphadenopathy
- Lupus pernio: a lupus-type rash
- Erythema nodosum: dusky coloured nodules on the shins
191
What are the symptoms of sarcoidosis?
- Cough: non-productive
- Dyspnoea: gradual onset
- Polyarthralgia
- Uveitis:
- Red-eye
- Photophobia
- Constitutional symptoms: swinging fever, fatigue, weight loss
192
What are the associated syndromes with sarcoidosis?
- Lofgren’s syndrome
- Heerfordt’s syndrome
- Mikulicz's disease
193
In terms of clinical manifestations what is the difference between acute and insidious sarcoidosis?
Acute sarcoidosis usually presents with features such as a swinging fever, polyarthralgia and erythema nodosum. In contrast, insidious sarcoidosis is commonly associated with a non-productive cough, dyspnoea and fatigue.
194
What are the investigations for sarcoidosis?
- GOLD STANDARD - Tissue biopsy
- CXR - FIRST LINE for imaging
- Angiotensin-converting enzyme levels
- FBC
- Serum urea
- Creatinine
- Calcium
- Liver enzymes
- ECG
*Mainly a clinical diagnosis*
195
What are the differential diagnosis for sarcoidosis?
- Tuberculosis
- Lymphoma
- Hypersensitivity pneumonitis
- HIV
- Toxoplasmosis
- Histoplasmosis
196
What is the management for pulmonary disease in sarcoidosis?
- Asymptomatic non-progressive disease: observation
- Symptomatic or progressive disease:
- First-line: corticosteroids, e.g. inhaled budesonide or oral prednisolone
- Second-line: immunosuppressants, e.g. methotrexate or azathioprine
- End-stage: consider lung transplantation
- Acute respiratory failure: oral or IV corticosteroid and ventilatory support
197
What is the management for extra-pulmonary disease in sarcoidosis?
- First line: corticosteroids (consider topical for cutaneous or ocular disease)
- Second-line: immunosuppressants, e.g. methotrexate or azathioprine
198
What is pulmonary fibrosis?
Pulmonary fibrosis describes interstitial fibrosis of the lung parenchyma and has a number of causes.
199
What are the risk factors for idiopathic pulmonary fibrosis?
- Advanced age: the mean age at diagnosis is 60-70 years of age
- Male gender: twice as common in men
- Smoking
- Family history
- Dust exposure: raising birds, metal, wood
200
What are the signs of idiopathic pulmonary fibrosis?
- Bibasal fine end-inspiratory crackles, predominantly in lower zones
- Clubbing
- Cyanosis
201
What are the symptoms for idiopathic pulmonary fibrosis?
- Progressive dyspnoea
- Non-productive cough
- Malaise
202
What are the investigations for idiopathic pulmonary fibrosis?
- CXR
- High resolution CT
- Spirometry
- Bronchioalveolar lavage - when CT and Lung FT are inconclusive
- ABG
- Anti-nuclear antibodies and rheumatoid factor
203
What is the management for idiopathic pulmonary fibrosis?
- Supportive care
- Pulmonary rehabilitation
- Vaccines
- Oxygen therapy
- Anti-fibrotic agents: Pirfenidone or nintedanib are indicated if FVC is 50% - 80%
204
What are the complications of idiopathic pulmonary fibrosis?
- Lung cancer: there is an increased risk of bronchogenic carcinoma
- Pulmonary hypertension and Cor pulmonale
205
What is hypersensitivity pneumonitis?
Hypersensitivity pneumonitis (HP), also known as extrinsic allergic alveolitis, is the result of non-IgE mediated immunological inflammation of the lungs.
206
What are the risk factors for hypersensitivity pneumonitis?
- Pre-existing lung disease
- Specific occupations e.g. farmers, cattle workers, ventilation system workers, vets and those jobs that involve working with chemicals
- Bird keeping
- Regular use of hot tubs
207
What are the clinical manifestations of acute hypersensitivity pneumonitis?
- Fever
- Rigors
- Headache
- Myalgia
- Shortness of breath
- Cough
- Chest tightness
208
What are the clinical manifestations of chronic hypersensitivity pneumonitis?
- Sustained shortness of breath
- Cyanosis and clubbing may develop
- Respiratory failure
A more gradual onset compared to acute form.
209
What are the investigations for hypersensitivity pneumonitis?
- CXR
- Lung function test
- ESR
- Bronchoalveolar lavage
- Lung biopsy
- Identify trigger - inhalation challenge
- Serum IgG
210
What is the management for hypersensitivity pneumonitis?
- FIRST LINE - avoidance of trigger / antigen
- For acute or sub-acute symptoms → Corticosteroids e.g. Prednisolone
- For chronic symptoms → long term low dose corticosteroid therapy
- Lifestyle changes e.g. smoking
211
What is interstitial lung disease?
Interstitial lung disease is an umbrella term to describe conditions that affect the lung parenchyma (the lung tissue) causing inflammation and fibrosis.
212
What are the investigations for interstitial lung disease?
- Requires combination of clinical features and high resolution CT scan.
- HRCT shows ‘ground glass’ appearance.
- Lung biopsy.
213
What is the management for interstitial lung disease?
NOTE: Generally there is a poor prognosis and limited management options in interstitial lung disease as the damage is irreversible.
- Treatment is designed to prevent further progression of the disease.
- Remove or treat the underlying cause.
- Home oxygen if 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 is an option but the risks and benefits need careful consideration.
214
What is the management for drug induced pulmonary fibrosis?
- Amiodarone
- Cyclophosphamide
- Methotrexate
- Nitrofurantoin
215
What is the management for cryptogenic organising pneumonia?
Treatment is with systemic corticosteroids.
216
What lung conditions can asbestos cause?
- Lung fibrosis
- Pleural thickening and pleural plaques
- Adenocarcinoma
- Mesothelioma
217
What is an asthma exacerbation?
An asthma exacerbation is an acute or subacute episode of progressive worsening of symptoms of asthma, including shortness of breath, wheezing, cough, and chest tightness.
218
What is COPD?
- Chronic obstructive pulmonary disease (COPD) describes progressive and irreversible obstructive airway disease.
- It is a combination of emphysema and chronic bronchitis.
219
What are the risk factors for COPD?
- Age: usually diagnosed after the age of 45
- Tobacco smoking: the single greatest risk factor for COPD
- Air pollution
- Occupational exposure: such as dust, cadmium (in smelting), coal, cotton, cement and grain
- Alpha-1 antitrypsin deficiency: younger patients present with features of COPD
220
What are the signs of COPD?
- Tachypnoea
- Barrel chest
- Hyperresonance on percussion
- Quiet breath sounds and wheeze
- Pursing of lips during expiration: helps to prolong expiration to breathe out as much air as possible.
- Cyanosis
- Loss of cardiac dullness: due to hyper-expansion of lungs from emphysema
- Downward displacement of liver: due to hyperexpansion of lungs from emphysema
- Evidence of an exacerbation:
- Significant dyspnoea, wheeze and cough
- Coarse crepitations
- Pyrexia
- Evidence of Cor Pulmonale: e.g. peripheral oedema
221
What are the symptoms of COPD?
- Dyspnoea
- Productive cough
- Wheeze
- Chest tightness
- Weight loss: due to energy expenditure while breathing
- Signs of CO2 retention
- Drowsy
- Asterixis
- Confusion
222
What is the GOLD classification?
A way of measuring/categorising the severity of COPD:
Mild - <0.7 FEV1/FVC and >80% of expected FEV1
Moderate - <0.7 FEV1/FVC and 50-79% of expected FEV1
Severe - <0.7 FEV1/FVC and 30-49% of expected FEV1
Very Severe - <0.7 FEV1/FVC and <30% of expected FEV1
