Respiratory Flashcards
(34 cards)
Asthma:
- Definition
- Risk factors
- Triggers (10)
- Symptoms (5)
- Investigations
- Management
Asthma:
- Definition: chronic inflamm lung disease where episodic bronchoconstriction
- Risk factors: atopy, maternal smoking, lbw, air pollution, aspirin allergy, occupational (isocyanates sprays, platinum salts, flour)
- Triggers (10): smoking, cold, urti, dust, fur, exercise, stress, nigt time (inc psns), pollution
- Symptoms (5): dry cough, sob, wheeze, bilat expir wheeze
- Investigations: spirometry obstructive <70% w broncho dil reversibility (fev1 improves by 12%), pefr, feno >50 (>35 in children), clinical if <5 yrs
- Management:
1. low dose MART for symptom relief only
2. low dose MART (ics + LABA formoterol)
3. mod dose MART
4. Check feno + eosinophils and if raised refer to asthma specialist, if not consider LTRA or LAMA
if infection oral steroids + abx always
step down every 3 months by 25-50%, reduce ICS by 25-50%
Asthma exacerbation:
- DD for wheeze
- Signs (4)
- Severity
- Management
- Criteria for discharge (8)
- DD for wheeze: bronchitis, pul oedema, pe, gord, foreign body, allergy
- Signs (4): sob, resp muscles, wheeze bilat expir
- Severity
mild: pefr >75%
mod: pefr 50-75%
sev: pefr 33-50%, can’t complete sentences, rr>25, hr>110
life thr: pefr <33%, sats <92%, silent chest, cyanosis
fatal: inc pco2 - Management: 40mg pred 5 days, salbut (neb only if life threatening), 94-98% oxy if <92. if severe neb ipatropium 500 micrograms. if life threatening then uti, cxr, iv mg sulfate, amiophylline, intubation and ventilation
- Criteria for discharge (8): pefr >75, no nebs 24 hours, assess inhaler technique, asthma action plan, 5 days pred, follow up gp 2 days, resp follow up 4 weeks
Eosinophilia:
- DD
copd
hayfever
allergic bronchopul; aspergillosus
esosinophilic granulomatosis w polyangiitis
lymphoma
sle
Chronic obstructive pulmonary disease:
- Definition
- Pathophysiology
- Causes (3)
- Symptoms (3)
- Signs
- DD
- Investigations
- Management (10)
- Health professionals involved in management (7)
- Complications (5)
- definition: a progressive condition of increased resistance causing airflow obstruction - is either chronic bronchitis (mucus gland hyperplasia + loss cilia), empysema (alveolar wall destruction)
- causes: smoking, alpha 1 antitrypsin deficiency, industrial exposure
- symptoms: progressive dyspnoea, clear sputum, cough
- signs: barrel chest, purse lips breathing, hyperressonant percussion, wheeze
- dd: interstitial, lung cancer
- ix: fbc/crp/serum alpha antitrypsin, sputum culture, cxr (hyperinflated, flat hemidiaph), spirometry obstructive diagnostic <70
- mx: copd care bundle, smoking cessation, mucolytics, bronchodilators, antimusc, steroids, annual flu + pneum, ltot (to prevent renal/cardiac damage meaning po2<7.3/88% but at least 15 hours day + not smoke), pul rehab (if mrc >3, 6-12 week supervised/home/nutrition/education), azithromyycin prophylaxis
Start with saba or sama (ipatropium), if steroid responsive (atopy/high eosino/fev1 variation) then laba + ics + (lama), if not then laba + lama + saba - complications: cor pulmonale (loop diuretic only), 2ndary polycythaemia, hypercapnic resp failure, osteoporosis, bronchiectasis
Chronic obstructive pulmonary disease exacerbation:
- Definition
- Management
- def: acute worsening of symptoms either infective or not
- causative org: haem influ, strep pneum, moraxella
- mx:
1. oxy 94-98%, 88-92% via 28% 4l venturi mask if raised pco2 (acute), or previous type 2 resp failure (if chronic retainer look at their bicarb and if its inc then renal is compensating)
2. salbut + ipatropium nebs
3. steroids 30mg 5 days
4. abx amox/clarith if clinical signs, cxr, iv aminophylline
5. niv BIPAP if resp failure
Massive haemoptysis:
- Definition
- Management
- def: >240ml in 24 hours or >100mls/day over conseq days
- mx: a-e, lie on side, oral tranexamic acid 5 days, stop anticoags, abx, vit k, ct aortogram
Anaphylaxis and angioedema:
- Definition
- Causes
- Symptoms
- Complications (4)
- Management
Anaphylaxis and angioedema:
- Definition: type 1 hypersens where ige ab causes release of histamine from mast cells
- Causes: bites, food, drugs,
- Symptoms: urticaria/angiooede, bronchospasm, pruritis, d+v, wheeze, hypotension, tachycardia
- Complications (4): arrhythmias, cardiogenic shock, hypoxia
- Management: oxy, im adrenaline 0.5mg 1:1000 repeat every 5 mins if >12 (300 if 6-12, 150 if <6), iv hydrocort 200mg, iv chlorophenamine 10mg, neb salbut
If 2 doses adren and no response then is refractory and needs iv
Then measure serum trypase and follow up in allergy clinic. Can discharge after 2 hours of symptoms settling if immediate good response + trained how to use an epipen - or minimum 12 hours post if >2 doses
Pulmonary embolism:
- Definition
- Risk factors (6)
- Symptoms
- Signs
- Complications (3)
- Investigations
- Management
- Massive PE
Pulmonary embolism:
- Definition: blood clot in pul art
- Risk factors (6)
- Symptoms: pleuritic chest pain, sob, hemoptypsis, syncope, chest wall tenderness, unilat leg pain
- Signs: fever, dec breath sounds, hypot, accenuated s2, inc rr
- Complications (3): rv overload hence arrhythmia, resp failure, pul infarction
- Investigations: firstly do wells score. if over 4 then needs ct angiogram pul (if ckd then v/q mismatch) (if neg consider uss leg). if low then d dimer. can also do abg + ecg (s1q3t3)
- Management: oxy, doac, ivc filter is oesoph bleed
- Massive PE: if hypotension and right sided hf signs. needs iv altepase however can’t if stroke <6 months, gi bleed <6 months, blood disorder, cns neoplasm, aortic dissection
- Cardiac arres: 1mg iv adren, iv altepase and cpr 60-90 mins
LRTI: Pneumonia:
- Definition
- Causes
- Risk factors (4)
- Symptoms
- Signs (6)
- DD for consolidation on CXR (5)
- Investigations
- Management
- Follow up (5)
- Complications + Causes of non resolving pneumonia
LRTI: Pneumonia:
- Definition: infection of lung parenchyma
- Causes:
CAP: strep pneum (cold sores), haem influ, moraxella
HAP (>48 post admission): ecoli, mrsa, pseudomonas, staph aures (commonly after influenza)
Atypical: mycoplasma (dry cough, erythema multiforme, gradual onset, bilat infiltrates, mycoplasma serology, doxy or macrolide), legionella (lymphopenia, hyponat, derranged lfts, dry cough, bradycardia, lower zone consolidation, urinary ag, erythromycin), chlamydia psittaci (bird contact - also headache/organomeg/ resistance to penicillin abx so need deoxy), kleb (alcoholics)
- Risk factors (4): age, immunocompromised, smoking, copd, cf
- Symptoms: wet cough + green phlegm, pleuritic chest pain, sob, haemoptysis
- Signs (6): fever, low oxy sats, ausc (reduced breath sounds, bronchial breathing, coarse crackles), dull percussion
- DD for consolidation on CXR (5): pneum, tb, lung cancer, haemorrhage
- Investigations: curb65 (confusion, urea >7, rr >30, bp <90/60, 65 years - if 2 admit, if 3 itu), fbc/crp/u+es, sputum cultures, abg, cxr (consolidation, effusion)
- Management: abx if crp >100, amox 5-7 days - if severe coamox + macrolide 7-10 days, repeat cxr at 6 weeks
- Complications: lung abscess (aures, kleb, pseudo), pe, cancer, effusion, resistant abx
COVID:
- Definition
- when to admit
- Management
COVID:
- Definition: sars-cov-2
- When to admit: hypoxia, lymphopenia, bilat lower zone changes on cxr
- mx: oxy, cpap, dexameth
TB:
- Definition + Pathophysiology
- Risk factors
- Symptoms
- Latent tb ix
- Active tb ix
- Management
TB:
- Definition: mycobacterium tuberculosis infection. Primary infection can develop in lungs and a lesion called Ghon focus (tubercle laden mO) forms. This with hilar lymph nodes is called ghons complex where formation of caseous necrotic centre of granulomas (epitheloid histiocytes). This lesion can fibrose in normal people but can form miliary tb in immunocomp. If host becomes immunocomp then initial infection becomes reactivated in secondary tb (steroids/hiv/malnut). Can also affect cns, vertebral bodies (potts disease), renal, gi, pericardium
- Risk factors: country, exposure, immunocomp, hiv, apical fibrosis
- Symptoms: cough, hemoptysis, lethargic, fever, night sweats, weight loss, lymphadenopathy, erythema nodosum, spinal pain, clubbing
- Latent tb test + management: assymp + non infectious - + mantoux tuberculin skin test >5mm (not accurate if extreme age, fever, sarcoidosis, immunosupp) or + interferon gamma release assay (quantiferon), normal cxr. 3 months isoniazid + rifampicin if <35 + hepatotoxicity risk or 6 months isoniazid esp if hiv/transplant
- Active tb investigations: cxr (upper lobe cavitation, bilat hilar lymphad, pleural effusions), 3x sputum smears stained for acid fast bacilli (ziehl neelsen stain - bright red rods against blue), sputum culture x3 gold standard but takes 1-3 weeks, NAAT results within 24-48 hours
- Pericardial tb signs, complications, management: pericardial rub
- Meningeal tb symptoms, investigations, management: needs LP. Mx for 12 months
- Miliary tb investigations
- Management
rifampicin: orange urine, hepatotoxicity, flu - 6 months
isoniazid + pyridoxine: peripheral neuropathy, hepatotoxicity - 6
ethambutol: vision disturbances optic neuritis - 2
pyrazinamide: hyperuricaemia, hepatotoxicity - 2
Measure lfts + visual acuity before.
Also test for other infections, contacts, notify public health, isolate for at least 2 weeks of treatment
Can get paradoxical reaction where inc in inflamm as bacteria die so can give steroids
Pulmonary hypertension:
- Definition
- Causes (4)
- Signs
- Investigations
- Management
- Definition: inc resistance and pressure of pulmon arts which then causes right sided heart strain and peripheral oedema
- Causes (4): pe, mi/htn, copd, sle
- Signs: sob, inc jvp, peripheral oedema, hepatomegaly
- Investigations: ecg (rad, rbbb), cxr, probnp, echo
- Management: treat cause
Bronchiectasis:
- Definition
- Causes
- Causative organisms
- Symptoms
- Signs
- Investigations
- Management
- Bronchiectasis infective exacerbation guidelines
- Definition: chronic dilatation of bronchi due to chronic inflammation making it difficult to clear mucus
- Causes: tb, whooping cough, allergic bronchopulmonary aspergillosus, yellow nail syndrome, ibd, cf, hypogammaglobulinaemia, primary ciliary dyskinesia, ra
- Causative organisms: haem influ, pseudomonas aerug, klebsiella (more common in alcs/diabetes, jelly red sputum) , strep pneum
- Symptoms: cough with lots lots sputum, sob, hemoptysis, dec weight, fatigue, recurrent infections
- Signs: coarse crackles, wheeze, clubbing
- Investigations: sputum cultures, spirometry (obstructive), cf genotype, bloods, ig levels, hiv test, hrct gold standard (signet ring), cxr
- Management: treat cause, physio for mucus clearance, prophylactic abx, vaccines, bronchodilators, pul rehab, 10-14 days amox or cipro if exacerbation, surgery (uncontrolled haemoptysis, localised to one lobe)
- Bronchiectasis infective exacerbation guidelines: deterioration in 3 or more of these in 48 hours: cough, sputum purulence/consistency, sob, fatigue, hemoptysis
Allergic bronchopulmonary aspergillosis ABPA:
- Cause
- Associations
- Investigations
- Management
- Cause: aspergillus fumigatus exposure, following inhalation of fungal spores in type1/3 hypersens and then repeated exposure leads to bronchiectasis
- Associations: asthma, cf, bronch
- Investigations: clinical (dry cough, wheeze) + inc aspergillus ige level, total ige, high eosinophils
- Management: steroids
Cystic fibrosis:
- Definition
- What 3 systems does it affect
- common organisms colonising cf patients
- Presentations (4)
- Symptoms
- Investigations
- Lifestyle advice
- Management
- Complications
Cystic fibrosis:
- Definition: auto recessive mut in CFTR leading to abnormal cl transport inc viscosity of secretions
- What 3 systems does it affect: resp, pancreas, vas deferens, biliary
- common organisms: staph aures, pseudo
- Presentations (4): meconium ileus, recurrent chest infections, intestinal malabsorption, + newborn test, prolonged jaundice
- Symptoms: nasal polyps, chronic sinusitis, repeated lung infections, diabetes, infertility, gallstones, dios, steatorrhoea, finger clubbing, osteoporosis
- Investigations: cf sibling or + newborn result and inc sweat chloride test >60 (this might be false + if malnut/adrenal insuff/hypothy/g6pd or false - if skin oedema)
- Lifestyle advice: avoid jacuzzis, avoid other cf, clean nebs, avoid ill, avoid rotting veg, annual influ, nacl tablets in hot weather
- Management: physio, mucolytics, creon, fat sol vit adek, insulin if diabetes, ivacaftor
- Complications: infections, low bmi, dios (ileocaecum obstruction - po gastrograffin), diabetes
Interstitial lung disease:
- Definition
- Symptoms (2)
- Causes (5)
- Investigations for new diagnoses
- Management
Usual interstitial pneumonia:
- Symptoms
- Signs
Extrinsic allergic alveolitis:
- Definition
- Common drug causes (6)
Interstitial lung disease:
- Definition: conditions causing inflammation and fibrosis of lung parenchyma
- Risk factors: male, age, smoking, fx
- Symptoms (2): dry cough, sob, fatigue
- Causes (5): usual interstitial pneumonia, non specific interstitial pneumonia, extrinsic allergic alveolitis, sarcoidosis
- Investigations for new diagnoses: ana/rhf/anca/antigbm/hiv, hrct (ground glass) diagnostic, lung biopsy if unclear, spirometry shows restrictive, reduced TLCO
- Management: remove occupational/environmental exposures, smoking stop, pirfenidone slows progression, physio, pul rehab, vaccines, oxy, lung transplant, 3-4 year life expectancy
Usual interstitial pneumonia:
- Symptoms: dry cough, sob, fatigue
- Signs: clubbing, reduced chest expansion, fine inspir bibasal crackles, pul htn features
Extrinsic allergic alveolitis:
- Definition: (hypersens pneumonitis). is acute if 4-8 hours but settles within 3 days (fever cough sob). is chronic for months e.g. farmers (dec weight, sob, dec ex)
- ix: cxr (upper/mid zone fibrosis), lymphocytosis on bronchoalveolar lavage, igG ab, no eosinophilia
- mx: avoid, steroids
- Common drug causes (6): amiodarone, bleomycin, methotrexate, nitrofuratoin, penicillamine, cyclophosphamide
Lung cancer:
- Risk factors (5)
- Causes (4)
- Symptoms
- Signs
- Investigations
- Management
- referral
- surgery contraind
Lung cancer:
- Risk factors (5): smoking (packs day/20 x years), asbestos, age, fx
- Causes (4):
1. sclc: siadh, cushings
2. nsclc squamous: smokers, hypercalc
3. nsclc adenocarc: most common, non smokers, hynaecomastia
4. nsclc large cell
- Symptoms: cough, sob, hemoptysis, b symptoms
- Signs: cachexia, wheeze, dull percussion, lymphadenopathy, clubbing, svco, horners, hoarse voice, lambert eaton
- Investigations: fbc (sometimes raised platelets)/u+es/bone/lfts, cxr first line (effusion, hilar enlargement), ct, histology via ct guided for peripheral, bronchoscopy for central or ebus for lymph nodes
- Management: if stage 1/2 curative surgery + chemo, if not chemo/radio
- Referral: 2ww if suggestive cxr, >40 w unexplained hemoptysis. cxr within 2 weeks if >40 w 2: cough, fatigue, sob, chest pain, weight, clubbing, persistent infection
- Surgery contraind: poor health, mets, fev1<1.5, malig pleural effusion, vc paralysis, svco
Pneumothorax:
- Definition
- Risk factors (6)
- Types (4)
- Symptoms
- Signs
- Investigations
- Management
Pneumothorax:
- Definition: air in pleural cavity
- Risk factors (6): height, trauma, smoking, pre existing lung condition, marfans
- Types (4): spont (prim, second), traumatic, tension, iatrogenic
- Symptoms: sudden onset pleuritic chest pain, sob
- Signs: hyperressonant percussion, reduced breath sounds on side, reduced lung expansion, resp distress/hypotension if tension
- Investigations: cxr (in tension displacement of mediastinum and trachea deviates AWAY FROM THE SIDE)
- Management:
1. cons and review outpt (or inpt if 2ndary characteristics) in 2-4 days if no symptoms or no high risk characteristics (haemod unstable, hypoxia, underlying lung disease, bilat, >50 w smoking, haemothorax)
2. if symptoms but not high risk then oxy + aspirate (chest drain if unsuccessful) or just leave or ambulatory device. outpt in 2-4 weeks.
3. if tension or high risk needs emergency needle decompression 5th ics axillary line then chest drain definitive, then removed when resolved and review in 2-4 weeks
Other info: no smoking, no air travel until 1 week post check up xray, no diving
- contraind: inr>1.3, platelets <75, pleural adhesions
Pleural effusion:
- Definition
- Symptoms
- Signs
- Investigations
- Types
- Lights criteria
- Management
Pleural effusion:
- Definition: excess fluid in pleural cavity
- Symptoms: sob worse lying down, dry cough, pleuritic chest pain
- Signs: stony dull percussion, decreased breath sounds, increased vocal resonance, reduced chest expansion
- Investigations: ecg, sputum cultures, fbc/crp/u+es/bone profile/ldh/d dimer, cxr (meniscus, loss costophrenic angle), aspirate for cytology/microbiology/biochem + uss guidedd
- Types:
1. exudative (pleural protein >30): malig, infection, inflammatory ra/pancreatitis/dresslers, pe
2. transudative: (more due to hydrostatic pressure): chf, liver cirrohosis, hypoalb, hypothyroidism, meigs
- Lights criteria: if protein level between 25-35 use this. Is exudative if: fluid: serum protein >0.5, fluid: ldh >0.6, fluid ldh>2/3 upper normal limit
- Management: if small conservative, if large aspirate, if recurring or ph<7.2/sepsis signs then chest drain or pleurodesis
Safe triangle borders
Obstructive sleep apnoea:
- Definition
- Risk factors (5)
- Pathophysiology
- Symptoms
- Investigations
- Management
Obstructive sleep apnoea:
- Definition: intermittent airway obstructive requiring arousal
- Risk factors (5): obese, male, middle aged, smoking, alc
- Pathophysiology: can either be due to excessive narrowing (alc, neuromusc disease, obese) or small pharngeal size (craniofacial, fat, large tonsils)
- Symptoms: snoring v loud and arousal, stops breathing during sleep, excessive sleepiness epworth >9, inc bp,
- Investigations: overnight oximetry, polysomnography (eeg, snoring, pulse oxim, resp airflow, thoraco abdo movements), resp acidosis
- Management: weight loss, cpap first line if mod/sev, mandibular devices if can’t tolerate cpap or if mild w no dayytime sleepiness, notify dvla if excessive daytime sleepiness
- CPAP: description, uses
- Non invasive ventilation (NIV) (BIPAP): description
- cpap
- niv: used in type 2 resp failure, copd w resp acidosis 7.25-7.35
Respiratory pattern generator:
- Peripheral chemoreceptors: what do they respond to
- Central chemoreceptors: what do they respond to
- po2, co2, ph via aortic + carotid bodies
- co2, ph. Responds first. located on brain side of BBB - has low perm to ions so co2 diffuses in and choroid plexus increases active transport of h/hco3- into csf as metabolic compensation. but if co2 remains elevated such as in copd a higher level of co2 is now needed to cause acidosis
Respiratory failure:
- Definition
- Type 1: definition
- Type 2: definition
- Impairment of gas exchange causing hypoxaemia / hypercapnia
- low pao2 <8Kpa / 90% sats
- low pao2, high pco2 >6.5kpa
