Flashcards in Respiratory Deck (47)
What is bronchiectaisis?
Abnormal permanently dilated airways with inflamed thickened bronchial walls.
On CT see signet ring sign and on CXR see tramline and ring shadows
What are the causes of bronchiectasis?
Congenital - impaired microcilary transport
Cystic fibrosis, Young's syndrome, primary ciliary dyskinesia, Kartagener's syndrome
Post infection: measles, pertusis, bronchiolitis, pneumonia, TB, HIV
Bronchial obstruction: foreign body, tumour
Allergic broncopulmonary aspergillosis,
What are the clinical features of bronchiectasis?
Persistent cough, copious purulent sputum, intermittent haemoptysis,
Clubbing, coarse inspiratory crackles, wheeze,
Complications - pneumonia, pleural effusion, pneumothorax, cerebral abscess, amyloidosis
Describe the illness cystic fibrosis:
Autosomal recessive condition
Mutation in 7q31.2 results in defect in cystic fibrosis transmembrane conduction regulator (Chlorine channel)
Failure of opening of the channel when cAMP increases in the cells, leads to a decrease in chlorine excretion into the airway lumen. This leads to an increase in the reabsorption of Na into the epithelial cells, which is followed by water, so there is less water excreted which increases the viscosity of the secretions.
The result of the increased viscosity of the secretions is an increase in respiratory infections leading to chronic lung disease, infections and bronchiectasis.
Patients also have pancreatic insufficiency leading to malnutrition and diabetes
What are the clinical features of cystic fibrosis at the different ages?
Neonate - Meconium ileus
Children and young adults -
Respiratory: cough, wheeze, chronic infections, etc Pts start with staph aureus and strep pneumonia infections and then develop chronic pseudomonas and burkholderia cepacia later on.
GI: energy needs increase by 130%, pancreatic insuffieceny requires enzymes, diabetes, GI obstruction more common
Other: infertility, osteoporosis, arthritis, vasculitis,
What result on the sweat test would diagnosis CF?
> 60mmol/l with chloride > Sodium
What are the three characteristics of asthma?
Airflow limitation - reversible
Bronchial inflammation : T and Mast cells, plasma exudation, oedema, muscle hypertrophy, matrix deposition, mucus plugging
There are three factors that contribute to the airway narrowing:
1. bronchial muscle contraction
2. mucosal swelling
3. increased mucus production
What are the steps in asthma management?
Step 1: inhaled short acting B2 agonist
Step 2: Add inhaled corticosteriod 200-800 ug/ day
Step 3: Add inhaled long acting B2 agonist
if good response from LABA cont
if response to LABA but inadequte control increase steroid to 800ug if not yet on
if no response to LABA stop it and increase steroid. if still inadequate consider adding leukotriene receptor agonist or SR theophylline
Step 4: increased steroid to 2000ug/day
think of adding a fourth drug (leukotriene receptor agonist, SR theophylline or B agonist tablet
Step 5: use daily steroid tablet - refer for specialist care
What are the different levels of acute asthma?
PEF >50 - 70% best or predicted
PEF 33-50% best or predicted
inability to complete full sentences
Life threatening asthma:
Poor respiratory effort
Exhaustion, altered LOC
How do you treat acute asthma?
Maintain stats between 94-98%
Use oxygen to drive nebuliser
2.5 - 5mg nebuliser - back to back if not helping
Can use IV but only in patients not responsive to nebs
0.5 mg neb 4-6hrly
100mg IV hydrocortisone or 30mg pred PO STAT
continue 40-50mg pred for 5 days post attack
IV 1.2-2g over 20mins (need to be on cardiac monitor)
When do you need to refer an asthmatic patient to ITU?
ANY ONE WHO HAS ACUTE OR LIFE THREATENING ASTHMA
need to refer early!!
What is a significant diurnial variation when diagnosing asthma?
>20% difference in peak flow on >3days a week for 2 weeks.
What are the three commonest causes of a chronic cough with a normal chest xray?
Sinusitis and post nasal drip
What are the differences between community acquired, hospital acquired and aspiration pneumonia?
CAP - pneumonia developed in the community
Strep pneumoniae is the most common, followed by haemeophilus influenzae
HAP - pneumonia developed >48hrs after hospital admission.
Gram -ve enterobacteria or staph aureus most common
Aspiration - results from aspiration of oropharyngeal organisms.
More common in patients with stroke, myasthenia, low consciousness, oesophageal disease
What is the CURB 65 score?
A scoring system to help guide if hospital management of pneumonia is needed.
Confusion (AMTS 7 = 1 point)
Respiratory rate (>30 = 1 point)
BP (systolic 3 indicates severe disease inform ITU
Which pneumonia is most commonly complicated by influenza?
Causes bilateral cavitating bronchopneumonia
Where does Klebsiella pneumonia usually affect?
The upper lobes
Which pathogens cause atypical pneumonia, and what is atypical about them?
occurs in epidemics every 4 years
has insidious onset with flu like symptoms followed by dry cough
CXR usually looks worse than the symptoms suggest Autoimmune haemolytic anaemia may occur as a result of cold agglutinins
Associated with skin rashes
Colonizes water tanks and air conditioning units
Flu like symptoms preceed a dry cough and SOB.
Extra pulmonary features - anorexia, D+V, hepatitis, renal failure, confusion
CXR - bibasal consolidation
Urine - haematuria,
Biphasic illness: pharyngitis followed by pneumonia
Acquired from parrot
Headache, fever, ,dry cough, lethargy, arthralgia,
Extra pulmonary - menigoencephalitis, infective endocarditis, hepatitis, nephritis, rash, splenomegaly
Who gets PCP?
Patients are are immunocompromised
Now called pneumocystis jiroveci
Dry cough, exertional dyspnoea, fever. bilateral creps
What are the causes of PE?
Clot breaking off from a pre-existing venous thrombosis
Right ventricular thrombus (post MI)
Septic emboli (right sided endocarditis)
Fat, air or amniotic fluid embolism
What risk factors increase the chance of developing a PE?
Recent surgery - espc abdominal/ pelvic or ortho
Prolonged bed rest
Pregnancy, the pill, HRT
What are the symptoms, signs and results seen in PE?
Acute breathlessness and chest pain
Dizziness and syncope
Pyrexia, cyanosis, tachypnoea, tachycardia, hypotension, raised JVP, pleural rub
Signs of a DVT
Low PaO2 and PaCO2
ECG - sinus tachy with signs of right heart strain or SI, QIII TIII
-ve d-dimer rules out, a +ve one does NOT rule it in
How do you treat a PE
LMWH + warfarin until INR is stable for 3months if provoked
If unprovoked then longer than 3 months depending on risks
If cardiovascularly unstable may need to thrombolyse
What is the scoring system used to classify patients risk of developing a VTE?
Clinical signs of DVT
Is PE the most likely diagnosis
Immbolisation for >3days or surgery in previous 4 weeks
Paralysis or casting of leg
Bed ridden for 3 days or surgery in previous 4 weeks
Swelling of entire leg
Calf swelling >3cm compared to other leg
Greater pitting odeama in symptomatic leg
Collateral non varicose veins
Other diagnosis more likely (-2 points)
What is sarcoidosis and what are the features of it?
Multisystem granulomatous disorder of unknown cause.
Associated with HLA DRB1 and DQB1 alleles
Bilateral hilar lymphadenopathy, cough, dyspnoea, chest pain
Lymphadenopathy, hepatomegaly, splenomegaly
Uveitis, conjunctivits, keratoconjuctivitis sicca, gluacoma
Terminal phalangeal bone cysts
Enlargment of lacrimal and parotid glands
Lupus pernio - chronic plaques on the nose, ears, lips and cheeks
What are the stages of sarcodosis?
Stage 0 = normal
Stage 1 = bilateral hilar lymphadenopathy
Stage 2 = BHL + peripheral pulmonary infiltrates
Stage 3 = pulmonary infiltrates alond
Stage 4 = progressive pulmonary fibrosis, bulla formation, pleural involvement
What are the indications for giving steriods in sarcoidosis?
Parenchymal lung disease
Neurological or cardiac involvement
What are the common causes for pneumothorax?
Primary = Spontaneous - due to rupture of a sub pleural bulla.
Secondary = Asthma, COPD, TB, pneumonia, lung abscess, carcinoma, C, lung fibrosis, sarcoidosis, connective tissue disorders, trauma, iatrogenic - CVP insertion, pacemaker,)
What is the safe triangle to insert a chest drain?
4th-6th intercostal space (above the nipple)
Anterior to mid axillary line, posterior to pec major.