Respiratory Flashcards
(89 cards)
1
Q
What is Asthma?
A
- Chronic respiratory condition with airway inflammation and hyper-responsiveness
- Variable over time
- Eosinophilia
2
Q
What are the Royal College of Physicians 3 questions for Asthma?
A
No to all Q’s consistent with controlled asthma
- ‘Have you had difficulty sleeping because of your symptoms?’
- ‘Have you had your usual symptoms during the day?’
(cough, wheeze, chest tightness or breathlessness) - ‘Has your asthma interfered with your usual activities?’
Expanded Score with frequency of symptoms (0-3)
3
Q
What is the ACQ-5 for Asthma?
A
4
Q
H&E for Asthma
A
- Cough - worse at night
- Breathlessness
- Wheezing
- Recent upper respiratory tract infection
- Chest tightness
5
Q
RF for Asthma
A
- Other atopic features
- Eczema
- Hayfever
- Allergic rhinitis
- Family history
- Smoking
6
Q
Investigations for Asthma
A
- Spirometry with bronchodilator reversibility
- Reduced FEV1 - improvement by 12% or more
- Normal FVC
- FEV1/FVC < 70%
- FeNO for eosinophilic inflammation (not for <5yr)
- 40 ppb or more is positive in adults
- 35 ppb or more is positive in children
- Peak expiratory flow rate
- Chest X-ray
- FBC: Eosinophils: > 0.3
7
Q
Severity of acute Asthma exacerbation?
A
8
Q
Management for Asthma
A
- SABA
- Add ICS if regular exacerbations
- Add LABA
- Increase ICS if not responding well
- Add LTRA
EXTRA FLASHCARD FOR HOW EACH MED ACTS
9
Q
Management of Acute Asthma attack
A
- Hospital admission for life-threatening and unresponsive severe, or previous near-fatal attack, pregnancy, if using oral corticosteroid or presentation at night
- 15L oxygen via non-rebreathe mask, target 94-98%
- SABA - salbutamol, terbutaline
- Nebulised in life-threatening
- Corticosteroid
- 40-50mg oral prednisolone for 5 days or until patient recovers
- SAMA if not responding/severe or life-threatening - ipratropium bromide
- If still not responding and becoming acidotic, senior critical care support, intubation and ventilation
10
Q
Criteria for discharge for acute asthma attack
A
- Stable on discharge medication for 12-24 hours
- Inhaler technique checked and recorded
- PEF >75% of best or predicted
11
Q
What is Allergic Bronchopulmonary Aspergillosis (ABPA)
A
- Hypersensitivity reaction to bronchial colonisation by Aspergillus fumigatus mould
- Typically affects patients with asthma
- Presentation similar to asthma, with fever, malaise, mucus expectoration and haemoptysis
- Peripheral blood eosinophilia
12
Q
What is Asthma COPD overlap syndrome?
A
Diagnosed when you have symptoms of both asthma and COPD.
Not a separate disease
“Persistent airflow obstruction with features of asthma”
13
Q
H&E for A+COPD OS
A
People diagnosed with ACOS typically experience symptoms more frequently than people with asthma or COPD alone and have reduced lung function. Symptoms include:
- Difficulty breathing
- Frequent shortness of breath
- Excess mucus (more than usual)
- Wheezing
- Feeling tired
- Frequent coughing
14
Q
Investigations for A+COPD OS
A
Lung function tests - obstructive pattern
15
Q
What is Acute Bronchitis?
A
Self-limiting lower respiratory tract infection
16
Q
What is Acute Bronchitis usually caused by?
A
- Rhinovirus
- Parainfluenza
- Influenza A / B
- Respiratory Syncytial Virus
- Coronavirus
17
Q
H&E for Acute Bronchitis
A
- Cough, may be productive
- Dyspnoea and wheezing
- Mild fever
- Exclusion of other causes
18
Q
RF for Acute Bronchitis
A
- Infection exposure
- Smoking
19
Q
Investigations for Acute Bronchitis
A
Usually clinical diagnosis
BUT
Consider CXR if:
- suspected pneumonia
- elderly patient
- persistent cough > 6 weeks
- history of chronic illness
20
Q
Management for Acute Bronchitis
A
If otherwise healthy - paracetamol + ibuprofen
If cough > 2 weeks - inhaled corticosteroids
If patient has underlying lung pathology - Amoxicillin / Doxycycline
SABA + Antitussives if wheezy / disrupting sleep
21
Q
What is Pneumothorax?
A
A collapsed lung - when air leaks into the space between your lung and the chest wall, the air pushes on the outside of the lung and makes it collapse
Can be a complete lung collapse or only a portion of the lung
22
Q
H&E of Pneumothorax
A
Sudden onset:
- Dyspnoea
- Pleuritic chest pain
- Sweating
- Tachypnoea
- Tachycardia
- Hyperresonance on percussion
- Absent breath sounds
- Decreased tactile vocal fremitus
23
Q
Investigations of Pneumothorax
A
Chest X-ray:
- Regions of dark around the edge of the lung (darker than lung)
24
Q
How can Pneumothorax be classified?
A
Primary - in absence of underlying lung disease
Secondary - in presence of underlying lung disease
25
RF of Pneumothorax
- pre-existing lung disease : COPD, asthma, cystic fibrosis, lung cancer, pneumocystis pneumonia
- connective tissue diseases : Marfan's, rheumatoid arthritis
- ventilation, including non-invasive ventilation
- catamenial pneumothorax - cause of 3-6% of spontaneous pneumothoraces occurring in menstruating women (thought to be caused by endometriosis within the thorax)
26
What is management of Pneumothorax dependent on?
Depends on type, size + clinical status of patient
27
Management of Primary Pneumothorax
- <2cm rim of air and no dyspnoea: discharge
- >2cm rim of air and/or dyspnoea: pleural aspiration
- If this fails (>2cm or dyspnoea), insert chest drain
28
Management of Secondary Pneumothorax
- If rim of air <1cm, give oxygen and admit for 24 hours
- Rim of air between 1-2cm: pleural aspiration
- If this fails, then insert chest drain
- Patient >50 and rim of air >2cm and/or dyspnoea: chest drain
- If chest drain fails → video-assisted thoracoscopic surgery (VATS)
29
Management of Tension Pneumothorax
- May occur following thoracic trauma when a lung parenchymal flap is created.
- This acts as a one way valve and allows pressure to rise.
- The trachea shifts and hyper-resonance is apparent on the affected side.
- Treatment is with emergency needle thoracocentesis and chest tube insertion.
30
What is Pneumonia?
It describes any inflammatory condition affecting the alveoli - in majority of patients this is secondary to a bacterial infection
31
Pathophysiology of Pneumonia
Once pathogen has entered the lower respiratory tract, an inflammatory cascade begins.
Neutrophils migrate to affect alveoli and release cytokines which activate immune response and induce fever.
Leads to accumulation of fluid and pus with the alveoli which impairs gaseous exchange, leading to hypoxic state, characteristic of pneumonia.
32
What can cause Community-Acquired Pneumonia?
Streptococcus pneumonia - 80%
Haemophilus influenza
Staphylococcus aureus: commonly after influenza
Atypical pneumonias
Viruses
33
What are the characteristic features of pneumococcal Pneumonia?
- Rapid onset
- High fever
- Pleuritic chest pain
- Herpes labialise (cold sores)
34
H&E of Pneumonia
- cough with purulent sputum (rust coloured/bloodstained)
- Dyspnoea
- Chest pain (may be pleuritic)
- Fever
- Malaise
- Signs of systemic infection
- pyrexia
- tachycardia
- hypotension
- confusion
- Tachypnoea
- Low O2 sats (below 95% or 88% in COPD)
- Reduced breath sounds, bronchial breathing, and crepitation/crackles, dullness of percussion (fluid)
If symptoms develop more than 48hrs after hospital admission it is hospital-acquired
35
Investigations for Pneumonia
- CXR
- consolidation in area of infection
- may show effusion
- REPEAT AT 6 WEEKS AFTER CLINICAL RESOLUTION
- Bloods
- FBC : Raised WCC
- U&Es : Urea for CURB65
- CRP : monitor to see response to treatment
- Blood cultures
- Sputum sample
- Legionella antibodies in immediate and high-risk patients
36
Investigations for Atypical Pneumonia
Same as Pneumonia but also:
- CT to detect abscesses/empyema formation with bronchoscopy in some cases
- Mycoplasma serology
- Positive cold agglutination test
37
What is CRB-65?
Used in primary care:
C - Confusion (abbreviated mental test score <= 8/10)
R - Respiratory rate >= 30/min
B - BP: systolic <= 90 and/or diastolic <=60
65 - Aged 65 or over
Score of 0 : low risk
Hospital assessment for all other patients
38
What is CURB-65?
Used in secondary care:
C - Confusion (abbreviated mental test score <= 8/10)
U - Urea > 7mmol/L
R - Respiratory rate >= 30/min
B - BP: systolic <= 90 and/or diastolic <=60
65 - Aged 65 or over
Score of:
0-1 : low risk, home-based care
2 : Intermediate risk, hospital care
3-5 : high risk, intensive care
39
Management of Pneumonia
Low severity CAP:
- amoxicillin is first-line
- if penicillin allergic then use clarithomycin or tetracycline
- 5 day course
Moderate-high CAP:
- dual antibiotic therapy with amoxicillin and clarithomycin
- 7-10 day course
- consider a beta-lactamase stable penicillin such as co-amoxiclav, ceftriaxone or piperacillin with tazobactam and a macrolide in high-severity CAP
Give Flucloxacillin if suspecting Staph.A e.g. after influenza
HAP:
- co-amoxiclav
- doxycycline if penicillin allergic
Atypical:
- Clarithromycin or doxycycline
40
Complications of Pneumonia
- Severe pneumonia can result in respiratory failure and / or septic shock
- Empyema is a complication of pneumonia and should be suspected if the patient is not responding as expected to antibiotics
- Atrial fibrillation can be triggered by pneumonia (both in known patients and as the first presentation)
- Bacterial pericarditis can arise because of local spread of bacteria
- Jaundice may arise from sepsis or antibiotic treatment.
41
What is Influenza?
- Acute respiratory tract infection caused by seasonal influenza A or B
- Aerosol transmission
- Single-stranded RNA genome
- H-antigen helps binding and entry into tracheobronchial epithelial cells
- N-antigen helps virus to escape
- Typical in winter season
42
H&E of Influenza
Key Diagnostic Features:
- Fever, malaise, myalgia
- Cough
- Sore throat
- Unvaccinated
- Winter
- Cervical lymphadenopathy
43
RF for Influenza
- Age over 65 or 1/2-5 years old
- CKD
- Chronic respiratory conditions
- Pregnancy
- Diabetes
- Immunocompromised
- Healthcare workers
44
Investigations for Influenza
- Clinical diagnosis
- Can do viral culture but takes a few days to be reported
45
Management of Influenza
- Bed rest, antipyretics and simple analgesia
- Consider antiviral therapy (e.g. oseltamivir) in high-risk groups, but only effective in first 48 hours from onset
- Provide antiviral therapy to hospitalised patients
46
What is Bronchiectasis?
Describes a permanent dilatation of the airways secondary to chronic infection or inflammation
47
Causes of Bronchiectasis
- Post-infective: TB, measles, pertussi, pneumonia
- Cystic fibrosis
- Bronchial obstruction e.g. lung cancer/foreign body
- Immune deficiency : selective IgA, hypogammaglobulinaemia
- Allergic bronchopulmonary aspergillosis
- Cilliary dyskinetic syndromes
- Yellow nail syndrome
48
H&E of Bronchiectasis
- Persistent productive cough
- Coarse crackles, high-pitched inspiratory squeaks and pops
- Wheeze
- Dyspnoea on exertion
- Haemoptysis
- Clubbing
49
RF for Bronchiectasis
- Cystic fibrosis
- Host immunodeficiency
- Previous infection
- Congenital disorder of bronchi
- Primary cilliary dyskinesia
50
Investigations of Bronchiectasis
First:
- High-resolution chest CT
- CXR : parallel line opacification, indicate dilated bronchi
- Bloods
- Sputum MC&S
- Test for RF
51
Management of Bronchiectasis
- Physical training
- Postural drainage
- Abx for exacerbations or long-term in severe cases
- Consider bronchodilators
- Immunisation
- Surgery for localised disease
52
What is Respiratory Failure?
Acute impairment in GasX between the lungs and blood causing hypoxia with or without hypercapnia (e.g. acute decompensation of chronic pulmonary disease)
53
What is Type 1 Respiratory Failure?
Hypoxic respiratory failure without hypercapnia w/ PaO2 < 8kPa
on room air at sea level
54
What is Type II Respiratory Failure?
Hypoxia with hypercapnia w/ PaCO2 > 6.5kPa on room air at sea level
55
H&E of Respiratory Failure
- Trauma to chest +/- neck
- Dyspnoea
- Confusion
- Tachypnoea
- Accessory breathing
- Cyanosis
56
Investigations for Respiratory Failure
- Pulse oximetry
- ABG
57
Management of Respiratory Failure
- Clear any obstruction if present
- O2 therapy
- NIV for type II Respiratory Failure : BiPaP
- Endotracheal intubation and mechanical ventilation if unstable
58
What is Asbestosis?
- Asbestosis is a chronic lung disease caused by inhaling asbestos fibers, which can lead to scarring and stiffening of the lungs.
- Diffuse interstitial fibrosis
- It typically takes many years of exposure to asbestos before symptoms appear.
- Latent period is 15-30 years
- Asbestosis can increase the risk of lung cancer and mesothelioma.
- Crocidolite (blue) asbestos is most dangerous form leading to this
59
H&E of Asbestosis
- Patients may have Hx of exposure to asbestos e.g. mining, construction, or shipbuilding.
- Patients may present with dyspnea on exertion, dry cough, chest tightness or pain, and fatigue.
- Bibasilar end-inspiratory crackles
- Clubbing
60
Investigations for Asbestosis
- CXR may show bilateral interstitial fibrosis or pleural thickening
- High-resolution computed tomography (HRCT) of the chest is more sensitive and specific than X-ray, and can detect early stages of disease.
- Pleural plaques are benign, do not require any follow-up
- Pulmonary function tests (PFTs) may show restrictive lung disease with decreased lung volumes and impaired gas exchange.
- Bronchoscopy may be performed to rule out other causes of lung disease and to obtain a biopsy for histological examination.
61
Management of Asbestosis
- There is no cure for asbestosis, and treatment is mainly supportive.
- Smoking cessation is essential
- Patients should avoid further exposure to asbestos and other respiratory irritants.
- Oxygen therapy may be necessary if hypoxemia is present.
- Pulmonary rehabilitation, including exercise training and breathing techniques, may improve symptoms and quality of life.
- Vaccination against influenza and pneumococcus is recommended to reduce the risk of respiratory infections.
- Lung transplantation may be an option in severe cases, but eligibility criteria are strict and the procedure carries significant risks.
62
H&E of Anaphylaxis
Resus Council UK defined:
- Sudden onset and rapid progression of symptoms
ABC problems
- Airway problems : swelling of throat and tongue, hoarse voice and stridor
- Breathing problems : respiratory wheeze and dyspnoea
- Circulation problems : hypotension and tachycardia
80-90% have skin and mucosal changes :
- generalised pruritis
- widespread erythematous or urticarial rash
63
Investigations for Anaphylaxis
Serum Tryptase levels are sometimes taken as they remain elevated for up to 12 hours following an acute episode
64
What is Anaphylaxis?
Defined as a severe, life-threatening, generalised or systemic hypersensitivity reaction
65
Management of Anaphylaxis
IM adrenaline - most important drug
Repeated every 5 mins if necessary - best site is the anterolateral aspect of the middle third of the thigh
ALL patients with new diagnosis of anaphylaxis should be referred to specialist allergy clinic
66
Dose of adrenaline based on age
< 6 months : 100-150 mcg (0.1-0.15ml 1 in 1000)
6m - 6yo : 150 mcg (0.15ml 1 in 1000)
6-12yo : 300mcg (0.3ml 1in 1000)
Adult and Child > 12yo : 500mcg (0.5ml 1 in 1000)
67
What is Refractory Anaphylaxis?
Defined as respiratory +/ cardiovascular problems persisting despite 2 doses of IM adrenaline
IV fluids should be given for shock
Expert help should be sought for consideration of an IV adrenaline infusion
68
What is a Type I hypersensitivity reaction?
IgE antibodies to a specific allergen trigger mast cells and basophils to release histamines and other cytokines
Causes an immediate reaction.
69
What is a Type II hypersensitivity reaction?
IgG and IgM antibodies react to allergen and activate the complement system.
Leads to direct damage to the local cells.
e.g. haemolytic disease of newborn and transfusion reactions
70
What is a Type IV hypersensitivity reaction?
Cell mediated reactions caused by T cell lymphocytes
T cells are inappropriately activated, causing inflammation and damage to local tissues.
e.g. organ transplant reaction and contact dermatitis
71
Investigations for Allergy
- Skin prick testing
- RAST testing : blood tests for total and specific IgE
These test sensitisation but not allergy - can be misleading
- Food challenge testing : gold standard but needs a lot of time and resources
72
Management of Allergy
- Identifying allergen
- Avoiding allergen + triggers
- Regular cleaning of house to remove dust
- Avoid pollen
- Prophylactic antihistamines
- Keep rescue adrenaline
- Immunotherapy by slowly exposing self to allergen over time
73
Management of Allergy post-exposure
- Antihistamines (e.g. cetirizine)
- Steroids e.g. prednisolone, hydrocortisone
Work by dampening immune response to allergens
- IM adrenaline
74
What is a Type III hypersensitivity reaction?
Immune complexes accumulate and cause damage to local tissue.
e.g. SLE, RA, Henoch-Schonlein Purpura
75
Causes of upper zone fibrosis
CHARTS
C - coal worker’s pneumoconiosis
H - histiocytosis/ hypersensitivity pneumonitis
A - Ankylosing spondylitis
R - Radiation
T - Tuberculosis
S - silicosis/ sarcoidosis
76
Causes of predominantly lower zone fibrosis
- Idiopathic pulmonary fibrosis
- CT disorders e.g. SLE
- Drug-induced : nitrofurantoin, amiodarone, bleomycin, methotrexate
- Asbestosis
77
H&E of Fibrotic Lung Disease
- Progressive exertional dyspnoea
- Bibasal fine end-inspiratory crepitations
- Dry cough
- Clubbing
78
Investigations for Fibrotic Lung Disease
- Spirometry : restrictive picture (FEV1 normal or decreased, FVC decreased, FEV1/FVC increased)
- CXR
- High-resolution CT : bilateral interstitial shadowing, ‘ground glass’ to ‘honeycombing’
- Impaired GasX : reduced Transfer Factor (TLCO)
79
Management of Fibrotic Lung Disease
- Pulmonary rehabilitation
- Supplementary O2
- Lung transplant
- Pirifenidone may be useful
80
What is Cystic Fibrosis?
Autosomal recessive disorder causing increased viscosity of secretions (e.g. lungs and pancreas)
Due to defect in CF transmembrane conductance regulator gene (CFTR), which codes cAMP-regulated chloride channel
81
Presenting features of Cystic Fibrosis
- Neonatal period (around 20%) : meconium ileus, less commonly prolonged jaundice
- Recurrent chest infections (40%)
- Malabsorption (30%) : steatorrhea and failure to thrive
- Other features (10%) : liver disease
82
Other features of Cystic Fibrosis
- Short stature
- DM
- Delayed puberty
- Rectal prolapse (due to bulky stool)
- Nasal polyps
- Male infertility, female subfertility
83
Diagnosis of Cystic Fibrosis
Many picked up during childhood but 5% of patients diagnosed after 18
Sweat test :
- patient’s with CF have abnormally high sweat chloride
- normal value <40 mEq/L, CF indicated by > 60
84
Management of Cystic Fibrosis
- Regular chest PT and postural drainage, deep breathing exercises normal
- High calorie diet, including high fat diet
- Patients with CF, try to minimise contact with each other to prevent cross infection with Pseudomonas aeruginosa and Burkholderia capacia complex
- vitamin supplements
- pancreatic enzymes
- lung transplant
Lumacaftor/Ivacaftor (Orkambi)
- used to treat CF who are homozygous for delta F508 mutation
85
Examples of Self-limiting URTI
Rhinovirus, coronavirus, parainfluenza, RSV, influenza, adenovirus, Coxsackie Virus
86
H&E of URTI
Nasal symptoms : congestion, clear/purulent discharge, sneezing, erythema, swelling
Sore throat
Non-productive cough
Low grade fever
87
Investigations for URTI
Clinical diagnosis
88
Management of URTI
Conservative:
- Topical saline/ Nasal suction
- Fluids
- Rest
Medical:
- Decongestant
- Antihistamines
- Antipyretics/analgesia
- Dextromethorphan for cough
89
Complications for URTI
Secondary bacterial infection
- Otitis media
- Sinusitis
- Pneumonia
Asthma exacerbation
