Respiratory Flashcards
Features of life threatening asthma?
33 92 CHEST
- PEFR <33%
- Sats <92% on air
- Cyanosis
- Hypotension
- Exhaustion
- Silent chest
- Tachycardia
Features of near-fatal asthma?
PaCO2 >6
Requiring high pressure ventilation
Complications of acute asthma?
- Hypoxia
- Coma
- ICU admission
- Pneumothorax
- Tension pneumothorax
- Death
Causes of infective exacerbation of COPD?
BACTERIAL
S.pneumoniae, H.influenzae, Maroxella, S.Aureus, Pseudomonas
VIRAL
Rhinovirus, influenza, parainfluenza, adenovirus, RSV
Chronic disease pattern of ABG?
- Low PaO2
- High PaCO2
- Raised bicarb
When to refer to secondary care if exacerbation COPD?
- Unable to cope at home
- Poor level of activity/bed bound
- Severe SOB, cyanosis
- Worsening oedema
- Confusion
- Low GCS
- Rapid onset or significant co-morbidity/LTOT SaO2 <90%
Causes of tension pneumothorax?
- Ventilated patients
- Trauma patients
- CPR patients
- Acute exacerbation of asthma/COPD
- NIV patients
Features of tension pneumothorax?
- Hypotension
- Tracheal deviation away from affected side
- Distended neck veins
Management of tension pneumothorax?
Needle decompression with large bore cannula (14-16G), 2nd ICS MCL
Leave in place before insertion of chest drain
Consequences of hyperventilation?
- Oxygen saturations usually unaffected, but low CO2 and resp alkalosis.
- Can cause secondary hypocalcaemia.
Symptoms of bronchitis?
- Cough lasting 7-10 days, or up to 3 weeks
- With sputum production, breathlessness or wheeze, pleuritic chest pain
Management of acute bronchitis?
Usually self-limiting
- Abx of little benefit if no co-morbidities
- 7 day delayed Rx with advice (amox TDS)
- Immediate abx if hospitalisation in past year, oral steroids, diabetes or CCF
Contraindications to CTPA?
- Allergy to contrast media
- Renal impairment
- Risk from irradiation
- Pregnancy (due to irradiation of glandular breast tissue and increased Ca risk)
Wells score for PE - likely?
4 –> immediate CTPA + immediate anticoagulation
If negative –> proximal leg vein USS
PE management if eGFR < 30?
Unfractionated heparin
Subsequent management of unprovoked PE?
- Physical examination following thorough history to identify red flags
- CXR
- Urinalysis
- Bloods (FBC, Ca2+, LFTs)
- Consider CT abdo/pelvis and mammogram if >40 years with first presentation and initial investigations normal
Anticoagulation after PE?
Rivaroxaban 20mg for 3 months with provoked,
6 months if unprovoked
Causes of CAP?
BACTERIAL
- S.pneumonia (40%)
- S.Aureus (2%)
- H.influenzae (5%)
- Moraxella (2%)
ATYPICAL
- Mycoplasma pneumoniae (11%)
- Legionella (4%)
- Chlamydophilia pnuemoniae (13%)
RARE
- Chlamydophila psittachi (birds)
- Coxiella burnetti (farm animals –> Q fever)
Causes of HAP?
>48 hours post admission
- Gram -ve bacteria (pseudomonas/klebsiella)
- MRSA
Components of CURB-65?
- Confusion
- Urea >7
- RR >30
- BP <90
- >65 years
CURB-65 results and treatment?
1
- <3% death
- Oral abx (500mg amox TDS 7 days) in community
2
- 9% death
- Oral amox and clarithromycin (500mg BD) in hospital
- Send for sputum and blood cultures
- Consider checking for legionella and pneumococcal antigen
3-5
- 15-40% death
- Hopsital admission
- Supportive care – consider transfer to critical gave unit
- (Co-amoxiclav (1.2g) + Clarithromycin 500mg IV)
- Sputum, blood and urine culture: consider atypical and viral pathogen screen
Signs of COPD on CXR?
- Hyperinflation (>6 ribs seen in mid clavicular line)
- Flat hemidiaphragms
- Large central pulmonary arteries
- Reduced peripheral vascular markings
- Bullae
COPD classification?
- Stage 1 = mild = 80%
- Stage 2 = moderate = 50-79%
- Stage 3 = severe = 30-49%
- Stage 4 = very severe = <30%
MRC dyspnoea scale?
- Not breathless unless vigorous exertion
- SoB when hurrying or on incline
- Walks slower than normal due to SoB or has to stop for breath when walking at own pace
- Stops for breath after 100 m or after a few minutes on the level
- Too breathless to leave home or breathless on dressing/undressing
BODE index?
Assesses prognosis in COPD
- BMI (Airflow)
- Obstruction (FEV1 %)
- Dyspnoea
- Exercise capacity index (6 minute walk)
COPD management if FEV1 >50%?
- SABA/SAMA
- LABA/LAMA
- (LABA + ICS) or (LAMA + LABA)
COPD management if FEV1 <50%?
- SABA or SAMA
- (LABA + ICS) or (LAMA + LABA)
- Triple therapy (LABA + ICS + LAMA)
COPD rescue pack?
7 days amoxicillin
7 days pred 30 mg
RFs for primary spontaneous pneumothorax?
- Male, tall, thin
- Marfan’s
- Recent central line
- Pleural aspiration or chest drain
RFs for secondary spontaneous pneumothorax?
In the presence of underlying lung disease/trauma
- COPD
- Asthma
- Infection
- Trauma
- Mechanical ventilation
- NIV
small and large pneumothorax?
Large
50% of lung volume lost – lung margin >2cm from chest margin on CXR
Small
Lung margin <2cm from chest wall on CXR
Management of primary pneumothorax?
Small
Discharge + safety netting + follow-up ·
Large/symptomatic
Aspiration with 16-18G cannula –> chest drain/discharge
Management of secondary pneumothorax?
Small
Aspiration with 16-18G cannula
Large
Chest drain (5th intercostal space midclavicular line)
Definition of transudate?
<30g/L or <3 g/100mL
A transudate results from abnormal accumulation of pleural fluid (excessive oncotic or not enough hydrostatic pressure)
Definition of exudate?
>30g/l or >3 g/100mL
An exudate results from an inflammatory and malignant processes which alter the permeability of the local capillary and pleural membrane or causes lymphatic blockage
Causes of transudative pleural effusion?
- Heart failure
- Liver failure
- Low albumin
- Peritoneal dialysis
Rare
Hypothyroidism, nephrotic syndrome, mitral stenosis, PE
Causes of exudative pleural effusion?
- Pneumonia
- Malignancy (lung in men, breast in women)
Less common
Pulmonary infarction (from PE), automimmune disease, asbestos exposure, pancreatitis, dressler’s syndrome, TB
Signs of pleural effusion?
- SOB, cachexia, accessory muscles of respiration, clubbing.
- Reduced chest expansion on side of the effusion
- Trachea away from the lesion
- Mediastinal shift
- Stony dullness on percussion
- Breath sounds diminished or absent over an effusion
Tests on pleural effusion?
Diagnostic aspiration (thoracentesis) –> to determine whether transudate or exudate
Lab testing for…
- Clinical chemistry (protein, glucose, LDH, amylase, pH)
- MC+S (TB)
- Cytology and immunology (RF, ANA)
Definitive management of pleural effusions?
- Drainage (use intercostal drain - 1-1.5L/24 hours)
- Pleurodesis with talc in recurrent effusions
- Thorascopic (VATS) for malignant effusion, epyemas: chest drain under USS/CT guidance.
Common-ness of NSCLC?
- Squamous (35%)
- Adenocarcinoma (27%)
- Large cell carcinoma (10%)
Pathology of small cell lung cancer?
- Arise from endocrine cells (Kulchitsky) and secrete hormones
- Paraneoplastic syndromes: ACTH, cushing’s syndrome
What causes Horner’s syndrome? What does it entail?
Pancoast’s tumour
- Ptosis
- Anhydrosis
- Miosis (fixed)
What is sarcoidosis? Who gets it?
Multisystem granulomatous disorder of unknown cause.
- Highest prevalence in northern Europe
- Adults aged 20-40
- F>M
- Afro-carribean population more frequently and severely affected
Symptoms of Sarcoidosis?
Often incidental finding in 40% after routine CXR
ACUTE
- Fever
- Erythema nodosum
- Polyarthralgia
- Bilateral hilar lymphadenopathy (Lofgren syndrome)
PULMONARY
- Dry cough
- Progressive SOB
- Reduced Exercise tolerance
- Chest pain
- 20% have a deterioration in lung function.
Complications of Sarcoidosis?
Lung infection, cataracts, glaucoma, CKD
Investigations in sarcoidosis?
CXR
- Bilateral Hilar Lymphadenopathy
Tissue biopsy
- Non-caseating granulomata = DIAGNOSTIC
Bloods
- High ESR, low white cells, LFTs, high calcium 24 hr
Urine
- High calcium
Lung function tests
- Normal/reduced lung volumes (restrictive picture)
Bronchiolar lavage
- High lymphocytes in active disease
Differentials for bilateral hilar lymphadenopathy on CXR?
- Sarcoidosis
- TB
- Lymphoma
- Pneumoconiosis,
- Metastatic disease
Management of isolated/acute sarcoidosis?
ISOLATED
Do not need treatment, most resolve spontaneously
ACUTE
Bed rest, NSAIDS
Indications for steroids in sarcoidosis?
- Parenchymal lung disease
- Uveitis
- Hypercalcamia
- Neuro/cardiac involvement
40mg OD PO for 4-6 weeks then decrease dose gradually
Prognosis in sarcoidosis?
60% with thoracic disease resolve over 2 years.
Mutations in CF? Genetics?
CFTR (ch7) - dF 508
Autosomal recessive - 1 in 25 All screened at birth
Neonatal signs of CF?
- FTT
- Meconium ileus
- Rectal prolapse
Symptoms of CF> (children/young adult)
RESP
Cough, wheeze, recurrent infection, bronchiectasis, pneumothorax, haemoptysis, resp failure, cor pulmonale.
GI
Pancreatic insufficiency, obstruction, gallstones, cirrhosis
Other
Male infertility, osteoporosis, arthritis, vasculitis, sinusitis, nasal polyps, HPOA
Diagnosis of CF?
Sweat test (Na/Cl >60 mmol)
Which bronchus does stuff go down more often when you inhale a foreign bod?
Right
Investigations in CAP?
Bedside
- Sputum culture
- Nasopharyngeal swab for influenza
- Pneumococcal and legionella urinary antigen
Bloods
- FBC, U+E, CRP, LFTs, blood cultures
Imaging
- CXR (repeat 6 weeks after recovery)
What is the Light’s criteria?
Exudative pleural effusion has one or more of these criteria
- Pleural fluid protein / Serum protein >0.5.
- Pleural fluid LDH / Serum LDH >0.6.
- Pleural fluid LDH > 2/3 * Serum LDH Upper Limit of Normal
(/ = divided by)
Management of inhaled foreign body?
Effective cough?
- Encourage coughing
Ineffective cough?
- Conscious: 5 back blows, 5 abdominal thrusts
- Unconscious: Open airway, start CPR.
Difference between active and latent TB?
Active infection
- When containment by the immune system is inadequate
- Can result from primary infection, or reactivation of latent disease
- Patient is infectious
Latent TB
- Infection without disease due to adequate containment in granuloma
- Positive blood or skin testing with no symptoms and non-infectious
- 1/3 of world’s population thought to have latent TB
- Lifetime reactivation risk = 5-10%
Risk factors for reactivation of TB?
- New infection
- HIV
- Organ transplant
- Immunosuppression (inc. steroids)
- High risk setting
- Low socio-economic status
- Malnutrition
- Dialysis
Disease process of TB?
Initial infection in lung apices
- Body fights with white cells + macrophages
- Body cannot win so walls off infection with granulation tissue
- Ends up with bacteria and WCC death causing caseating core (necrotic)
- Ghon Complex as seen on chest X ray
What is this?
Gohn complex - calcified focus of infection and associated LN
How does TB cause symptoms?
Some TB bacteria remains active inside granuloma
- Results in body on alert = Systemic B sx (weight loss, night sweats)
- Breakdown of cells in lung paranchyma and haemoptysis
Cause and transmission of TB?
Caused by infection with Mycobacterium Tuberculosis.
Transmission of TB via inhalation of aerosol droplets – only pulmonary disease is infective
Signs of TB?
Systemic
- Clubbing (bronchiectasis), erythema nodosum
Pulmonary
- Pleural effusion
Spinal
- Bony destruction, vertebral collapse, soft tissue abscess (Pott’s vertebrae)
Symptoms of TB?
Systemic
- Fever, anorexia, weight loss, night sweats,
Pulmonary
- Cough, pleurisy, haemotypsis
Lymph
- Painless enlargement of cervical/supraclavicular nodes
- Firm to touch and not acutely inflamed. Needs FNA biopsy.
Gastro
- Colickly abdo pain,
- Obstruction due to wall thickening, stricture or adhesions.
Spinal
- Local pain and bony tenderness for weeks/months
Milliary
- Dissemination of granulomatous tissue
- Do LP, check for involvement (high protein, high neutrophils, normal glucose.
- Frontotemporal spread = personality change
Also
- CNS, Genitourinary, Cardiac, Skin
- Lupus vulgaris = progressive cutaneous TB
Investigations in TB?
Active TB
- CXR - may show gohn complex or active milliary TB
- Sputum smear - (3 specimens, early morning sample). Stained for presence of acid fast bacilli. If found, commence treatment and isolate patient
- NAAT - to detect rapidly in <8 hours. Good for drug resistance
Extrapulmonary
- Investigate if pulmonary disease co-exists
- Aspiration or biopsy for staining or NAAT (on any sterile body fluid)
HIV test for all - 12% concurrent infection.
Management of TB?
Isolate Patient!!
Medical
- RIPE
- Rifampicin (6M)
- Isoniazid (6M)
- Pyrazinamide (2m)
- Ethambutol (2m)
- Adherence v.important - directly observed therapy if doubts.
Screening of Contacts
- Mantoux test; house
- Active test: if with all day, very close contact
- Only treat if high risk exposure and any symptoms
Other
- Notifiable disease
Definition of sleep apnoea?
Intermittent closure/collapse of pharynx causing apnoeic episode during sleep, terminated by patient partially waking up.
Risk factors for sleep apnoea?
Overweight, older, male
Symptoms and complications of sleep apnoea?
Symptoms
- Loud snoring, day time tiredness, poor sleep quality, decreased libido, nocturia, morning headache, reduced cognitive impairment
Complications
- Pulonary hypertension, type II resp failure.
- Sleep apnoea = RF for hypertension
Management of sleep apnoea?
Investigations
- Pulse oximetry and video recordings.
- 15 or more episodes of apnoea in 1hr of sleep = significant disease
Management
- Weight reduction, avoidance of smoking and alcohol
- Mandibular advancement devise
- CPAP via nasal mask during sleep, recommended by NICE for mod-severe disease
- Surgery if pharangeal/nasal obstruction present.
Definition and causes of bronchiectasis?
Chronic inflammation of the bronchi and bronchioles leading to permanent dilatation and thinning of these airways.
Main organisms: H. influenzae; Strep. pneumoniae; Staph. aureus; Pseudomonas aeruginosa
Symptoms, signs and complications of bronchiectasis?
Symptoms
Persistent cough; copious purulent sputum; intermittent haemoptysis.
Signs
Finger clubbing; coarse inspiratory crepitations; wheeze (asthma, COPD, ABPA).
Complications
Pneumonia, pleural effusion; pneumothorax; haemoptysis; cerebral abscess; amyloidosis
Presentation and management of carbon monoxide poisoning?
Headache, vomiting, high pulse, tachypnoea, and, if COHb >50%, fits, coma, and cardiac arrest.
Remove the source and treat with 100% O2 until COHb <10%
Something to remember about carbon monoxide poisoning?
- Despite hypoxaemia skin is pink (or pale), not blue, as carboxyhaemoglobin (COHb) displaces O2 from Hb binding sites.
- For the same reasons SpO2 from a pulse oximeter may be normal.
Check ABG in a co-oximeter which will show low SaO2 and high COHb (normal <5%)
Presentation and complications of IPF?
Symptoms
- Dry cough, exertional SOB, malaise, weight loss, arthralgia
Signs
- Cyanosis, clubbing, fine end inspiratory crepitations
Complications
- Resp. failure, increase risk of lung Ca.
Definition/principles of mesothelioma?
Occurs in the pleura, related to occupational exposure to asbestos, although only 20% have pulmonary asbestosis.
Latent period until development of tumour may be up to 45 years
Presentation of mesothelioma?
Chest pain, SOB, weightloss, clubbing, recurrent pleural effusions.
Metastatic:
- Lymphadenopathy, hepatomegaly, bone pain/tenderness, abdo pain or obstruction (peritoneal mesothelioma)
Characteristically bloody pleural fluid if aspirated.
What is asbestosis?
Pulmonary fibrosis caused by inhalation of asbestos fibres
Asbestos was commonly used in the building trade for fireproofing, pipe lagging, electrical wire insulation, and roofing felt
Features and management of asbestosis?
Similar to other fibrotic lung diseases with progressive dyspnoea, clubbing, and fi ne end-inspiratory crackles. Also causes pleural plaques, risk of bronchial adenocarcinoma and mesothelioma
Management
- Symptomatic. Patients are often eligible for compensation through the UK Industrial Injuries Act
What is coalworker’s pneumoconiosis?
- A common dust disease in countries that have or have had underground coal-mines.
- It results from inhalation of coal dust particles (1–3μm in diameter) over 15–20yrs.
- These are ingested by macrophages which die, releasing their enzymes and causing fibrosis
Features and management of coalworker’s pneumoconiosis?
- Asymptomatic, but coexisting chronic bronchitis is common.
- CXR: many round opacities (1–10mm), especially in upper zone.
Management
Avoid exposure to coal dust; treat co-existing chronic bronchitis; claim compensation (in the UK, via the Industrial Injuries Act).
What is a lung asbcess? Causes?
A cavitating area of localised, suppurative infection within the lung
- Inadequately treated pneumonia
- Aspiration (eg alcoholism, oesophageal obstruction, bulbar palsy)
- Bronchial obstruction (tumour, foreign body)
- Pulmonary infarction
- Septic emboli (septicaemia, right heart endocarditis, IV drug use)
- Subphrenic or hepatic abscess
Presentation of lung abscess?
Symptoms
- Swinging fever; cough; purulent, foul-smelling sputum; pleuritic chest pain; haemoptysis; malaise; weight loss
Signs
- Finger clubbing; anaemia; crepitations
Empyema develops in 20-30%
What is an empyema? Presentation?
Pus in the pleural space. It should be suspected if a patient with a resolving pneumonia develops a recurrent fever.
CXR indicates a pleural effusion. The aspirated pleural fluid is typically yellow and turbid with an acidic pH (<7.2)
- May need VATS procedure if loculated and not easily drainable.
Side effects of TB drugs?
