Flashcards in Respiratory Deck (141)
Causes of clubbing?
Malignant causes = Squamous cell carcinoma
Fibrosis = Pulmonary, Cystic, TB
Suppuration = Bronchiectasis, empyema, lung abscess
Pneumonia anatomical classification?
Bronchopneumonia = Patchy consolidation of different lobes
Lobar = Fibrosupparative consolidation of a single lobe
Pneumonia etiological classification?
CAP = S. Pneumonia, S. Aureus, mycoplasma
HAP = Pseudomonas, E. coli, S. Aureus
Aspiration = during anaesthesia, stroke, bulbar palsy
Strep pneumonia features?
80% of cases
High fever, rapid onset, herpes labialis
Which pneumonia in COPD patients?
Which pneumonia follows influenza infection?
Features of mycoplasma pneumonia?
Younger, prodromal flu then a dry cough
Serology is diagnostic
Hyponatraemia, deranged LFT's and lympopaenia
Also see diarrhoea and confusion
30% have pleural effusions
Diagnosis by urinary antigen
Alcoholics and diabetics
Cavitating upper lobe pneumonia
Redcurrant jelly sputum
Dry cough and exercise induced saturations
Often need BAL to diagnose
What is the CURB65 score and when do you treat?
Urea > 7
RR > 30
Score > 2 = hospital, >3 consider ITU
Management of community acquired pneumonia?
low severity = 5 days amoxicillin 1g TDS
Moderate = 10 days of amoxicillin and clarithromycin
Severe = 10 days of co-amoxiclav and clarithromycin
Management of hospital acquired pneumonia?
Mild (<5 days) = co-amoxiclav 625mg TDS
Severe (>5 days) = Tazobactam / piperacillin 4g IV QDS
How do you manage legionella and mycoplasma pneumonias?
How should you follow up pneumonias?
Chest x-ray at 6 weeks
3 complications of pneumonias?
What is an empyema and features?
Pus in the pleural cavity
Pyrexia rigors and dullness to percussion
Investigations and management of empyema?
Thoracentesis = fluid will be purulent, putrid and pH <7.2.
Total protein > 30
CAE = Amoxicillin and metronidazole
HAE = Vancomycin and tazocin
What is a lung abscess and its features?
Collection of pus in the lungs that leads to cavity formation
Fever + cough and putrid expectorations
Investigations and management of lung abscess?
FBC, CXR = cavitation with clear fluid level, sputum culture and stain.
chest physio and postural drainage
Clindamycin and ceftriaxone IV
Surgical drainage via video assisted thoracoscopy
What is SIRS?
Temperature >38 or <36
RR>20 or PaCO2 <32mmHg
WBC >12000 or <4000
What is sepsis, severe sepsis and septic shock?
sepsis = SIRS with a source of infection
Severe sepsis = Sepsis with end organ dysfunction
Septic shock = Severe sepsis with hypotension despite adequate fluid resuscitation
What is high risk criteria for sepsis?
New altered mental state
Oliguric for 18 hours or <0.5ml/kg for 1 hour
Management of sepsis?
Immediate senior review if high risk, and regular half hourly observations
What is bronchiectasis?
Permanent dilation of the bronchi due to destruction of elastic and muscular components of the bronchial wall
Causes due to recurrent severe infections secondary to an underlying disorder
Causes of bronchiectasis?
Post infective e.g. TB, pneumonia (most common is H. Influenza)
Genetic e.g. cystic fibrosis
Ciliary dyskinetic disorders e.g. Kartageners syndrome
Features of bronchiectasis?
Persistent cough with purulent sputum / haemoptysis
Coarse crackles and monophonic wheeze
Investigations for bronchiectasis?
CXR = non-specific dilated thickened airways
Volume-CT = signet ring sign where bronchi are larger than adjacent pulmonary arteries, dilated thickened airways and tram lines. = GOLD STANDARD
Test for other causes e.g. chloride sweat test (>60mmol/L)
Management of bronchiectasis?
Conservative = Exercise and improved nutrition. Pulmonary physio and clearance. STOP SMOKING
Medical = Salbutamol 200ug 2 puffs BD
Antibiotics for exacerbations
Whats is Kartageners syndrome and its features?
Primary ciliary dyskinesia. Dynein arm defect resulting in immotile cilia
Dextrocardia or complete situs inversus
Right testicle hangs lower than the left
What is cystic fibrosis?
Severely life shortening genetic disease, due to abnormalities in the cystic fibrosis transmembrane conductor.
causes reduced lumina secretion of chloride and increased Na absorption = viscous secretions
Clinical features of CF?
Newborn = failure to pass meconium, FTT, rectal prolapse
Adults = Nasal polyps / sinusitis
Infections and bronchiectasis
GI = Pancreatic insufficiency - DM, steatorrhoea
Investigations and management of CF?
Guthrie heel prick test
Sweat test >60mmol/L is likely
Resp = chest physio
Inhaled bronchodilators = salbutamol 100-200ug prior to clearance
Inhaled mucloytic = Dornase alfa 2.5mg nebulised + hypertonic saline
Antibiotics for acute infetions
GI = high calorie diet, high fat intake
Creon - give with ranitidine to create an alkali environment = better absorption
Fat soluble vitamins ADEK
What is pulmonary aspergillus infection?
Fungal infection predominantly affecting immunocompromised
What conditions come under the term aspergillosis?
Allergic bronchopulmoary aspergillosis
Extrinsic allergic alveolitis
Invasive pulmonary aspergillosis
What is allergic bronchopulmonary aspergillosis, features investigations and management?
Hypersensitivity reaction, often in long standing asthma / CF
SOB, cough and wheeze
Ix = CXR = bronchiectasis, sputum stain = black on silver stain
Mx = long term steroids and itraconazole + high dose steroids for acute attack
What is extrinsic allergic alveoli's and clinical features?
Hypersensitivity induced lung damage. Malt workers lung = aspergillus clavatus
4-8 hours post exposure, SOB, dry cough and fever
Upper - mid zone fibrosis
What is invasive pulmonary aspergillosis, PC, investigations and management?
Inhalation of spores resulting in sinus and pulmonary involvement.
Pleuritic chest pain and pleural rub.
Nasal ulcers, rash, headache
Aspergillus stain black on silver
CXR = consolidation
Mx = Voriconazole
What causes chronic aspergillosis, PC, investigations and management?
Caused by aspergillus fumigatus, seen in patients with chronic lung disease
>3 months of fatigue, cough and weight loss. HAemoptysis and SOB
CXR = caveatting / scarring fibrosis
What is aspergilloma, PC, investigations and management?
Occurs in pre-existing lung cavities, commonly secondary to TB
Usually occurs due to chronic aspergillosis secondary to A. Fumigatus
Cough, haemoptysis, Hx of TB
CXR = Round apical opacity
High titre of aspergillus precipitans
Mx = surgical removal
How can we classify lung cancer?
Non-small cell = 80%
- Squamous cell
- Large cell carcinoma
Small cell = 20%
Others are rare e.g. mesothelioma
Where is SCC located vs adenocarcinoma + large cell?
SCC = central
Adeno + large cell = peripheral
What hormones may each non-small cell cancer secrete?
SCC = PTHrP = hypercalcaemia
- can also get hyperthyroid due to ectopic TSH
Large cell = B-HCG
Which non-small cell cancer is associated with smoking?
SCC is strongly associated in smoking
Adenocarcinoma is the most common in non-smokers, however the majority are still smokers
Which non-small cell is strongly associated with finger clubbing?
Which non-small cell commonly has extra-thoracic metastases?
Where is small cell carcinoma located?
What ectopic hormones are produced in small cell?
ADH = hyponatraemia
ACTH = Cushings syndrome and bilateral adrenal hyperplasia.
- High cortisol levels can also cause hypokalaemic acidosis
Which lung cancer causes LEMS and what is it
Lambert-eaton myasthenia syndrome
Antibodies to voltage gated calcium channels = myasthenia like
Difficulty walking and muscle tenderness
What is the 2 week referral for lung cancer criteria?
CXR suggests cancer or if over 40 with unexplained haemoptysis
Differential for coin lesion on CXR?
Infection = TB, klebsiella
Benign = Wegeners
Investigations for lung cancer?
Contrast enhanced volume CT of lower neck/thorax/upper abdo if known / suspected malignancy
Biopsy for staging
Lung cancer staging - tumour?
Tx = can't be assessed
T0 = no signs
T1 = <3cm, within lung
T2 = 3-5cm and involves main bronchus but 2cm from carina, pleural involvement, lung collapse
T3 = 5-7cm
Lung cancer staging nodes?
Nx = can't be assessed
N0 = don't contain cancer cells
N1 = Cancer in LN's within lung and hilum
N2 = in mediastinum on same side as the tumour
N3 = in mediastinum opposite side of tumour
Small cell lung cancer management?
Usually present very late
Combo of radiotherapy and chemotherapy
Extensive = palliative
Management of NSCLC?
Generally poor response to chemo
Stage 1/2 = surgical.
If sufficient pulmonary reserve = lobectomy, if not = wedge resection
± adjuvant chemotherapy
If can't have surgery = radiotherapy
Later stages = radiotherapy with platinum based chemotherapy regime
What is ARDS and its criteria?
Increased permeability of alveolar capillaries leading to fluid accumulation in alveoli = non-cariogenic pulmonary oedema
Onset within one week, on background of RF ew.g. pneumonia
Bilateral opacities on CXR
PaO2: FiO2 <200 on PEEP, or CPAP >5cm
Clinical features of ARDS?
Dyspnoea, RR raised, bilateral lung crackles, low sats
Causes of ARDS?
Infection e.g. sepsis or pneumonia
Trauma / burns / inhalation injury
Management of ARDS?
Ventilation = PEEP 5-10cm H2O, low tidal volume ventilation at 6ml/kg
GOAL = inspiratory plateau <30cm water
Maintain CO and oxygen with inotropes e.g. Noradrenaline / dobutamine
treat underlying cause
What is respiratory failure and the two types?
Acute impairment of gas exchange between the lungs and blood causing hypoxia ± hypercapnia
Type 1 = oxygen <8Kpa. Due to V/Q mismatch and diffusion failure
Type 2 = Oxygen <8Kpa, and PaCo2 >6Kpa
Due to Alveolar hypoventilation
Causes of type 1 respiratory failure?
V/Q mismatch and diffusion failure
Fluid - pulmonary oedema
Pus - pneumonia
Blood - pulmonary haemorrhage
Vascular e.g. PE, P-HTN
Causes of type 2 respiratory failure?
Obstruction e.g. Asthma/COPD, bronchiectasis
Restrictive e.g. Sedation, GBS, flail chest
Spirometry restrictive vs obstructive?
Obstructive = very low FEV1, FVC reduced / normal
FEV1:FVC is reduced
Restrictive = FEV1 reduced, but FVC significantly reduced
FEV1:FVC is normal / raised
Management of respiratory failure?
Type 1 = Oxygen to keep sats at 94-98
Assisted ventilation if PaO2 <8 despite 60% oxygen
Type 2 = controlled oxygen therapy at 24% aiming for saturations 88-92 and PaO2 >8
ABG after 20 minutes
What does each Venturi colour deliver?
Yellow = 5
White = 8
Blue = 24
Red = 40
Green = 60
What is asthma?
Chronic inflammatory airway disease characterised by intermittent airway obstruction and hyper-reactivity
Causes of asthma?
Atopy = T1 hypersensitivity to and allergen, pollen etc
Stresses = cold air, exercise and emotion
Toxins = Smoking, pollution, BB's and NSAIDs
Clinical features of asthma?
Cough ± sputum, often worse at night
Wheeze and chest tightness
Diurnal variation, worse AM
Expiratory wheeze, and reduced air entry
FEV1:FVC obstructive pattern = decreased = <70%
With bronchodilator reversibility. +ve if FEV1 improves by 12% or volume increase >200ml
Exhaled nitric oxide: In adults >40 parts/billion = positive
Management of chronic asthma - conservative?
Technique for inhaler use
Monitor peak flow with diary
Educate = Specialist nurse, need for compliance and written action plan in case of emergency
Management of chronic asthma - medical?
1st line = SABA salbutamol 200ug 2 puffs BD as a reliever
2nd line = low dose ICS + SABA if not controlled by SABA alone or at presentation waking at night / symptoms >3 times a week
3rd line = Add in leukotriene receptor antagonist = monteleukast 10mg PO OD
SABA + low dose ICS + LABA = Salmeterol 50ug 1 puff BD.
Continue LTRA if it worked
5th line = continue SABA ± LRTA.
Also use low dose ICS with a MART (maintenance and reliever therapy) e.g. symbicort = Budesonide and formoterol
6th line = Continue SABA ± LRTA
Increase ICS to moderate dose
Continue MART or switch to LABA
7th line: one of.....
Increase ICS to high dose
Trial additional drug e.g. theophylline
What are the steroid doses for asthma?
Budesonide or equivalent:
Low = <400ug
Moderate = 400-800
High > 800
Signs of life threatening severe asthma?
Exhaustion and confusion
Tachycardia / arrhythmias
Admission criteria for acute asthma attack?
Any feature of life threatening
Moderate severity but had previously near fatal attack
If have any severe feature, refractory to treatment
Management of acute asthma attack
5mg Salbutamol driven via oxygen. Every 20 minutes for 3 doses.
Followed by every 1-4 hours when required
Ipratropium bromide 0.5mg neb
Steroids 100mg IV hydrocortisone
40mg prednisolone (continue for 5 days)
Refractory = discuss with senior clinician
Ipratropium neb with each salbutamol dose
If refractory still = Magnesium sulphate 1-2g IV over 20 minutes
Next IV salbutamol 5ug/minute IV
Life threatening = ITU, Aminophylline 100mg slow infusion
Monitoring in acute asthma attack?
PEFR before treatment and before and after each salbutamol
Monitor bloods after 1 hour
Discharge when PEF >75% expected
Discharge on steroids for 5 days, and book appointment with respiratory clinic in 4 weeks. GP in 2 days time.
What is COPD?
Progressive disease characterised by airflow limitation, that is not fully reversible
What is emphysema?
Enlarged air spaces distal to the terminal bronchioles = destruction of the alveolar walls
Prominent in upper lobes In COPD
Lower lobes in A1AT deficiency
What is chronic bronchitis?
Cough and sputum production on most days for 3 months of two successive years
Pathophysiology of COPD?
Chronic inflammation = airway narrowing and remodelling
Increased goblet cells
Enlargement of mucin secreting glands
Signs of hyper inflated chest?
Reduced cricosternal distance (normal 3 fingers)
Loss of cardiac dullness
Displaced liver edge
Clinical features of COPD?
RF's e.g. smoking
cough, frequently in the morning
wheezing and crackles on auscultation
Prolonged expiratory phase + pursed lips
What are pink puffers bs blue bloaters?
Pink puffers = emphysema
Increased alveolar ventilation = breathless but not cyanosed
nearly normal oxygen and CO2
Progresses to type 1 respiratory failure
Blue bloaters in chronic bronchitis = cyanosed but not breathless
Low oxygen and high CO2 = progress to type 2 failure
Complications of COPD?
Cor pulmonale if long standing = peripheral oedema, raised JVP
Recurrent pneumonia (H. Influenza)
Investigations for COPD?
Spirometry = fixed obstructive = FEV1:FVC = low
CXR = hyperinflated
GOLD criteria for post-bronchodilator FEV1 in COPD?
GOLD 1 = mild = >80%
2 = moderate = 50-79%
3 = severe = 30-49%
4 = very severe = <30%
COPD conservative management?
Influenza annual vaccine and pneumococcal one off
medical management of cOPD
SABA salbutamol 200ug 2 puffs BD
Remains breathless next step based on FEV1
>50% = LABA e.g. salmeterol and LAMA e.g. tiotropium
<50% = LABA + ICS, or LAMA
IF START LAMA STOP SAMA
If taking LABA alone add in ICS
Otherwise give LAMA+LABA+ICS
Still refractory = theophylline
When should you give long term oxygen therapy in COPD?
Do ABG on two occasions three weeks apart.
Offer it if PO2 < 7.3kPa or PO2 7.3-8 and one of following:
If on it need at least 15 hours a day
Acute exacerbation of COPD causes and management?
Viral URTI (30%) = human rhinovirus
Bacterial = H. Influenza
Controlled oxygen therapy via a blue 24% Venturi mask. aim for 88-92 sats
Aim for oxygen >8, PCO2 less than 1.5
Bronchodilators = nebulised salbutamol 5mg/4 hours and ipratropium 0.5mg neb / 6 hours
Steroids = IV hydrocortisone 200mg and prednisolone 30mg PO
Ongoing = increase bronchodilator dose and continue prednisone for 1 weeks
What are the Wells criteria for a PE?
3 points for:
Clinical signs of DVT
PE #1 diagnosis
Immobile <3 days ago, surgery <4 weeks ago
1 point for:
Malignancy w/treatment in last 6 months
Investigations for PE?
CXR = peripheral wedge, enlarged pulmonary artery
PE likely = Wells score > 4 = immediate CTPA
PE unlikely = Wells score <4 = D-Dimer, if +ve = CTPA
If have renal impairment do a V/Q scan to avoid contrast
Management of PE?
Acute = Oxygen, analgesia
Alteplase 50mg bolus stat
LMWH enoxaparin 1mg/kg/dose SC BD
If systolic >90 start warfarin 5mg PO OD until INR 2-3
Ongoing = TEDs, long term graduated compression stockings
Continue warfarin for 3 months if provoked
If unprovoked = > 3 months
What is a pneumothorax?
When air gains access to and accumulates in the pleural space
How can we classify pneumothoracies?
Closed = intact chest wall, air leaking from lung
Open = defect in chest wall, communication between pleural cavity and exterior
Tension = Air enters pleural cavity via one way valve, cannot escape
Causes of pneumothorax?
Spontaneous primary = smokers, young thin men
Management of tension pneumothorax?
Large bore cannula into the 2nd ICS midclavicular line
Chest tube following decompression to prevent immediate recurrence
Management of primary pneumothorax?
Rim >2cm and not SOB = consider discharge or percutaneous aspiration
If rim> 2cm, SOB or aspiration failed = chest drain.
Management of secondary pneumothorax?
All should be admitted
> 50 + rim >2cm / SOB = chest drain
If rim 1-2cm = aspiration. If it fails = chest drain
<1cm = oxygen for 24 hours
What is a pleural effusion?
Fluid collection between the parietal and visceral surfaces of the thorax
thin layer of fluid is always there but normal flow / production is disrupted
Classification of pleural effusion?
Transudate < 25
Lights criteria 25-35:
What is lights criteria?
Pleural protein : serum protein > 0.5
Pleural LDH : Serum LDH >0.6
Pleural LDH > 2.3rds the upper limit of normal
Causes of exudates?
Increased capillary permeability;
Infection = Pneumonia / TB
Inflammation e.g. SLE
What causes transudate?
Increased capillary hydrostatic pressure or reduced oncotic pressure:
Reduced albumin e.g. Nephrosis, liver failure and malabsorption
Investigations for pleural effusion
LDH, protein levels in pleural fluid and serum
Management of pleural effusion?
Symptomatic = Thoracocentesis
Suspect infection =Antibiotics
If malignant = Thoracocentesis and pleurodesis e.g. Talc, bleomycin. These cause inflammation and fusion of viscera
Indications for chest drain in pleural effusion?
Fluid is cloudy / purulent
pH < 7.2
What is sarcoidosis?
Multisystem disorder, of unknown aetiology characterised by non-caveating granulomas
Lungs and LNs involved in 90%
Clinical features of sarcoidosis?
General = Swinging fever, anorexia, fatigue, LN's
Resp = Otitis and sinusitis. Dry cough and SOB
Neuro = Peripheral / cranial neuropathy, SOL
Urine = raised calcium and macrophages in granulomas can convert vitamin D to active form = RENAL STONES
Low hormones = pituitary dysfunction
Opthalmological = uveitis
Myocardial = restrictive cardiomyopathy, pericardial effusion
Abdo = hepatosplenomegaly
Skin = erythema nodosum
Investigations for sarcoidosis?
Bloods = raised calcium
CXR = lymphadenopathy
Stage 1 = bilateral hilar LN
2= + pulmonary Infiltrates
3 = infiltrates, no BHL
4 = extensive fibrosis
Management of sarcoidosis?
Acutely = steroids
Ongoing = prednisone 40mg PO OD for 3 months then taper
If cannot tolerate steroids. = methotrexate
Indications for steroid use in sarcoidosis?
Stage 2-4 on CXR
Parenchymal lung disease
Neuro / cardio involvement
What is interstitial lung disease?
Large group of disorders affecting the interstitium, which is the lace like network of tissue that extends throughout both lungs supporting the alveoli
Diseases cause thickening and scarring of interstitium
What is extrinsic allergic alveolitis?
Non-IgE mediated alveolitis due to repeated inhalation of non human protein
Types of extrinsic allergic alveolitis?
Avian proteins = bird fanciers lung
Saccharopolyspora = Farmers lung
Aspergillus cravats = malt workers lung
Thermophillic actinomyces = mushroom workers lung
Clinical features of extrinsic allergic alveolitis?
Acute = 4-6 hours post-exposure
Fevers, rigors and malaise
Dry cough and dyspnoea
Chronic = worsening dyspnoea
T1 resp failure
Investigations of EAA?
CXR = patchy nodular Infiltrates and fibrosis
Management of EAA?
Prednisolone 40mg PO OD
Long term low dose
Types of industrial lung disease?
Coal workers pneumoconiosis
What is coal workers pneumoconiosis, PC and CXR findings?
Progressive massive fibrosis
PC = dyspnoea and chronic bronchitis
CXR = upper one fibrotic mass
what is silicosis caused by and CXR findings?
Quarrying and sand blasting
Upper zone reticular shadowing and egg shell calcification of hilar nodes
What causes asbestosis, PC and CXR findings?
Demolition and ship building
Chest pain, weight loss, clubbing and effusions
CXR = Pleural plaques, pleural effusions. LOWER LOBE fibrosis
What is idiopathic pulmonary fibrosis?
Chronic lung condition characterised by progressive fibrosis of interstitum
Typically seen in males, 50-70
Clinical features of idiopathic pulmonary fibrosis?
Progressive SOB and cough
Investigations of idiopathic pulmonary fibrosis?
CXR = bilateral interstitial ground glass shadowing
Spirometry = restrictive = FEV1;FVC high as FVC low
Reduced transfer factor
Management of idiopathic pulmonary fibrosis?
Supportive = stop smoking, pulmonary rehab and oxygen.
Lung transplant is the only cure
What is the definition of pulmonary hypertension?
Mean pulmonary artery pressure > 25mmHg at rest, >30mmHg with exercise
Causes of pulmonary HTN?
Left heart disease = MR / MS, LVF and L to R shunt
Lung disease = COPD, severe chronic asthma and interstitial lung disease
Vascular e.g. PE, sickle cell
Hypoventilation e.g. Obesity and kyphoscoliosis
Clinical features of pulmonary HTN?
SOB, fatigue, chest pain
Cyanoiss and peripheral oedema
40% have tricuspid regurgitation
Investigations for pulmonary HTN?
CXR = enlarged right heart
ECG = P pulmonale and RVH
Management of pulmonary HTN?
Treat underlying cause
Long term oxygen therapy
What is cor pulmonale?
RHF due to pulmonary HTN
what is obstructive sleep apnoea?
Episodes of complete or partial upper airway obstruction
RF's for obstructive sleep apnoea?
idiopathic pulmonary fibrosis
Clinical features of obstructive sleep apnoea?
Excessive daytime sleepiness = Epworth sleepiness scale
Episodes of apnoea / gasping
Investigations of obstructive sleep apnoea?
Sleep studies and oxygen saturations
Management of obstructive sleep apnoea?
Weight loss, stop smoking and drinking
CPAP first line if moderate to severe
Surgery = tonsillectomy etc
Smoking cessation 3 methods?
NRT = pregnancy
How does varenicline work?
Nicotinic receptor partial agonist
Start 1 week before target to stop date, course is 12 weeks
Caution if depression