Respiratory Flashcards
Asthma - Sy, Ix, Mx kids, Mx adults.
Sy - precipitants (cold, exercise, emotion, allergens, infection, smoking), diurnal variation, disturbed sleep (severe), acid reflux, atopy, days off work/school.
Ix - FeNO >40ppb, FEV1/FVC <70%, increase >200mls/12% FEV1 post salbutamol, peak flow variability ?20% for 2 wks.
Mx kids - SABA, +ICS (8wk trial if <5y), +LRTA, stop LRTA +LABA, MART.
Mx adult - SABA, + ICS, +LTRA (monteleukast), +LABA (R/V LTRA), MART regimen, increase ICS.
Acute asthma - severe, life-threatening, Mx.
Severe - cant complete sentences, RR >25, pulse >110, P flow 33-50%.
LT - Pflow <33%, silent chest, poor resp effort, ABG low O2.
Mx - Salbutamol nebs in O2, Ipatropium bromide, Mg sulphate IV, IV hydrocortisone, IV salbutamol/aminophylline, intubate.
COPD - Ix, pink puffer, blue bloaters, Mx, acute Mx.
Ix - FEV1 <80%, FEV1/FVC <0.7. Similar to asthma but older, smoker, sputum, min diurnal variation. Response to bronchodilators <400mls.
PP - increased alveolar vent, breathless not cyanosed. Emphysema predominates. T1RF.
BB - low vent, bronchitis predominated. Danger of T2RF.
Mx - Smoking cessation (offer NRT/varenicline/bupropion). Offer all a SABA or SAMA (ipatropium). If still sy do FEV1 - if >50 add LABA or LAMA (tiotropium) if <50% LABA and ICS. If still sy ICS + LAMA + LABA. Start on long term O2 if P02 on ABG (two occasions on best Mx) <7.3 or <8 and polycythaemia, oedema, pul HTN or nocte hypoxia.
Acute Mx - hospital if not able to cope, severe SOB, cyanosed, rapid onset, SaO2 <90%. If not give 1-2wks 30mg pred and Abx if purulent sputum.
Pneumonia - def, classification and cause, scoring, Mx, comp
D - LRTI with abnormalities on CXR. CAP <48hrs in hospital or >48hrs post-D/C.
CAP - strep pneumoniae most common, H influenzae and M pneumoniae. HAP - Gram neg (kleb or E. coli) or staph aureus. Aspiration - strep or anerobes. Immunocomp - same plus M catarrhalis, pneumocystis jiroveci.
CURB 65 - 0-1 home, 2 hospital, 3+ severe ?ICU.
- Confusion - AMT <8
- Urea >7
- RR - >30
- BP <90
- >65yo
MAY UNDERSCORE YOUNG PEOPLE!
Mx - Amox and clarithromycin, SEPSIS 6. Follow up CXR at 6wks.
Comp - Resp failure, hypotension, AF (short term bBlocker), plural effusion (inflammation of pleura causes exudate, may need drain), empyema - pus in the pleural space, suspect if resolving and develops fevers. Abscess - SWINGING FEVER, foul-smelling sputum.
Specific pneumonias - most common, cavitating, CF, air conditioning, viral, AIDS defining, IECOPD
Common - pneumococcal - rust coloured sputum
Cavitating - klebisella, red current, alcholics
Psudomonas - bronchiectasis and CF, HAP
AC - Legionella, bibasal, hepatitis, Ix urine culture, fluroquinolone. Flu like sy, low Na.
Parrots - Chlamydiophila psittaci.
Viral - influenza. N.B. SARS - caused by SARS-Co virus, dry cough, persistent fever, leads to ARDS supportive Mx.
AIDs defining - pneumocystis co-trimoxazole. Desaturate on exertion.
IECOPS - Haemophilus influenzae.
Lung Ca - path, RF, Sy, comp, Ix, Mx
Path - Adeno (cavitating peripheral, can be in non-smokers), SCC (cavitating central), small cell (central).
RF - Smoking, asbestos, chromium, arsenic.
Sy - cough, haemoptysis, SOB, chest pain, recurrent/slowly resolving pneumonia.
Comp - Mets, pancoast (Horners, RL nerve palsy), SIADH, and ACTH (addisons) by small cell, PTH by squamous cell.
Ix - cytology sputum and pleural fluid, CXR, CT to stage tumour +- PET.
Mx - Non-small cell - excision if no spread, excision +chemo for more advanced. Small cell are usually disseminated at presentation, chemo but usually relapse.
Bronchiectasis - path, cause, sy, Ix, Mx
Path - chronic infection of bronchioles causes permanent dilation (h influenzae, strep pneumoniae).
Cause - CF, ciliary dyskinesia, Kartagener’s syndrome (dextrocardia and 1’CD), post-infection, obstruction.
Sy - persistent cough, copious purulent sputum, course creps.
Ix - Sputum culture, CXR (tramline and ring shadows), HRCT chest.
Mx - Postural drainage BD and chest physio, long term Abx if regular infections, salbutamol.
Idiopathic pulmonary fibrosis - def, Sy, Ix, Mx
Most common interstitial lung disease inflammatory pneumonia.
Sy - dry cough, SOB, malaise, weight loss, FINE END-INSP CREPS.
Ix - CT. Bloods (CRP, IG, ANA, RheumF), CXR (shadowing, honeycombe lung), biopsy.
Mx - Supportive, lung transplant.
N.B - causes lower zone fibrosis with CT disorders and drugs. Others cause upper - TB, hypersensitivity, silicosis, sarcoidosis.
Pulmonary sarcoidosis - Sy, Ix, Mx
Sy - asy (found on CXR - bilat hilar lymphadenopathy), erythema nodosum (red shins) and polyarthralgia. Pulmonary - dry cough, SOB, chest pain. Non-pul - lymphadenopathy, HSmegaly, conjunctivitis, glaucoma, bells palsy.
Ix - Tissue biopsy. CXR (bilat hilar lymphadenopathy, fibrosis), increased Ca and ACE, punched out lesions in phalanges Xray.
Mx - bed rest and NSAIDs, prednisolone 40mg for 6wks followed by dose reducing regime.
Mesothelioma - path, Sy, Ix, Mx. Coal workers pneumoconiosis, Silicosis.
P - tumour of mesothelial cells of pleura due to asbestos exposure many years previously.
Sy - chest pain, SOB, weight loss, clubbing, recurrent effusions.
Ix - CXR/CT pleural thickening and effusion. Will have plaques due to asbestosis.
Mx - Pleurodesis and permanent drain, can try chemo. Prognosis poor.
Can be split into Extrinsic allergic alveolitis (organic reaction type 3) or pneumoconiosis (exposure to metals/elements type 4).
Coal workers pneumoconiosis - macrophages ingest coal and cause inflammation causing round opacities in upper zone. Progresses to progressive massive fibrosis - SOB, fibrosis, cor pulmonale.
Silicosis (metal/stone mining, ceramics) - progressive SOB.
TB - stages, Ix, Mx
Stages - primary infection - macrophage ingests bacillus and forms ghon focus (apex, lymph nodes or similar), if immunocompromised will become primary progressive causing pneumonia and haem spread (miliary TB). If immune competent will become latent and reactivate later.
Sy - cough, sputum, malaise, weight loss, night sweats, pleurisy, haemoptysis, effusions.
Ix - Latent - Tuberculin skin test (positive means TB or previous BCG, neg if immunosupressed) or IGRA (more specific). Active - CXR, multiple sputum samples MC&S with Zeihl-Neilsen (acid fast bacilli).
Mx - Check U&Es. 8 weeks of 4 drugs e.g. rifampacin, isoniazid, pyrazinamide, ethambutol. then 16wks on 2 drugs. Steroids if meningeal or pericardial.
Pulmonary embolism - Causes, RF, Sy, Ix, Mx, Mx massive PE.
C - VTE in the pelvis/leg rarely post MI, septic emboli, fat/air/amniotic fluid.
RF - recent surg, increased clotting, reduced mobility, malignancy, pregnancy/postpartum/pill/HRT, previous PE.
Sy - SOB, pleuritic chest pain, haemoptysis, syncope. Low grade fever, cyanosis, raised JVP, hypotension, pleural rub, pleural effusion.
Ix - CTPA. ECG may show RBBB/strain, S1Q3T3 pattern rare - deep S in 1, path Q waves in 3, inverted T waves in 3. Wells score - if >4 do CTPA, if <4 do D-Dimer.
Mx - LMW heparin (dalteparin) treatment dose for 5 days or until INR >2 for 24hrs. Start warfarin for 3 months or 6m if unprovoked. In cancer and pregnancy use LMWH not warfarin (6wks post-natal/Ca cure or 6m).
MxM - Can do local thrombolysis and vena cava filter if continue despite anticoagulation.
Pneumothorax - Cause, Sy, Mx
C - Spontaneous (young male smokers) due to rupture of bulla, asthma, COPD, infection, CT dissorders.
Sy - May be asy, SOB, pleuritic chest pain, deterioration in asthma/COPD. Reduced expansion, hyperesonance to percuss and reduced breath sounds. IN TENSION THE TRACHEA IS DEVIATED.
Ix - CXR. NB none if tension is suspected.
Mx - Primary - if >2cm on CXR attempt to aspirate, if unsuccessful insert chest drain 4-6th intercostal MA line. Secondary - if >50 and >2cm insert drain, if 1-2cm aspirate, if <1cm give O2 and observe. Tension - 2nd intercostal MC line large bore needle with saline or venflon.
Acute respiratory distress syndrome ARDS - Def, Causes, Sy, Ix, criteria, Mx
Def - resp failure caused by widespread inflammation causing pul oedema.
Causes - Pulmonary (infection, aspiration, inhalation, contusion), non-pulmonary - schock, DIC, pancreatitis, liver failure, head injury, malaria.
Sy - Cyanosis, SOB, Tachy, bilateral fine crackles.
Ix - full bloods, pulmonary artery catheter.
Criteria - must be acute onset, CXR bilat infiltrates, PA pressure <14mmHg, refractory hypoxaemia.
Mx - ITU. Resp support, CPAP or intubate. Mort high.
Obstructive sleep apnoea - Sy, comp, Ix, Mx
Sy - Often obese middle aged men. Load snoring, daytime somnolence, poor sleep, morning headache, decreased libido.
C - pul HTN, T2RF.
Ix - Polysomnography (measure sats, ECG, EMG in sleep) diagnostic. Can just use video and sats.
Mx - weight reduction, avoid alcohol and tobacco, CPAP during sleep, surgery for pharyngeal obstruction.
