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Respiratory Flashcards

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1
Q

What is the difference between Stridor and Stertor?

A
  • Stridor= harsh. Indicates partial obstruction of laryngeal/ tracheal airways
  • Stertor= snoring-like breathing. Obstruction of nasopharynx/ oropharynx
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2
Q

Management of airways obstruction

A
  1. Airway manoevers/suction/ adjuncts
  2. Intubation
  3. Cricothyroidotomy/ tracheostomy
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3
Q

Anaphylaxis presentation

A
  • Oedema- larynx, eyelids, lips, tongue
  • Wheeze/stridor
  • Itching
  • Capillary leak
  • Urticaria
  • D+V
  • Sweating
  • Erythema
  • Cyanosis
  • Shock- SBP<90 and evidence of end organ hypoperfusion
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4
Q

Acute management of anaphylaxis

A
  1. ABCDE!
  2. Secure airway. Raise feet
  3. Remove cause
  4. Adrenaline 0.5mg 1:1000 IM
  5. Secure IV access
  6. Chlorphenamin 10mg IV + hydrocortisone 200mg IV
  7. IVT stat
  8. ?wheeze –> salbutamol NEBS
  9. Still hypotensive –> ICU. ?IV adrenaline/aminophylline
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5
Q

Presentation of PE

A
  • Acute SOB
  • Pleuritic chest pain
  • Haemoptysis
  • Sudden collapse
  • Signs of DVT
  • High RR, HR. Low BP
  • Cyanosis
  • RV Heave
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6
Q

Well’s score for PE

A
  • Signs/ Sx of DVT (3)
  • PE most likely Dx (3)
  • HR >100 (1.5)
  • >3 days immobilisation/ surgery <4w (1.5)
  • Prev. DVT/ PE (1.5)
  • Haemoptysis (1)
  • Malignancy- current/ Tx <6m ago (1)
  • ==> 4 or less= low risk –> d-dimer –> ?CTPA
  • >4= High risk –> CTPA
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7
Q

PE Ix

A
  • Bedside- O2 sats, ECG (tachy, RBBB, inverted T waves, S1Q3T3)
  • Bloods- d-dimer, ABG
  • Imaging- CTPA, USS of leg, ?V/Q scan
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8
Q

PE Tx

A
  1. ABCDE + o2 + IVT
  2. Morphine + metoclopramide
  3. LMWH (tinzaparin)/ fondaparinux
  4. ?Alteplase/ embolectomy
  5. (Vena cava filter)
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9
Q

Presentation of Pneumothorax

A
  • Chest pain (unilat)
  • Worsening SOB
  • Tracheal deviation AWAY
  • Resp. distress
  • Cyanosis
  • O/E Reduced expansion, hyper-resonance, reduced breath sounds
  • Tension: Shocked, mediastinal shift, raised JVP
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10
Q

Investigations and management of pneumothorax

A
  • Ix: ABG, CXR (lung markings not to edges)
  • ABCDE + o2
  • Primary pneumothorax:
    • <2cm- discharge. r/v 2-4w
    • >2cm- 2x aspiration attempts –> chest drain
  • Secondary pneumothorax:
    • Always treat
    • 1-2cm: aspirate
    • >2cm/ SOB/ >50y: chest drain
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11
Q

Pleural effusion: Difference between transudate and exudate and causes

A
  • Transudate= Protein <25, LDH <0.6. FAILURE
    • Increased venous return- CHF, cirrhosis
    • Decreased proteins- Nephrotic syndrome, hypoalbuminaemia
  • Exudate= Protein >35, LDH >0.5. INFECTION/ INFLAMMATION/ MALIGNANCY
    • Malignancy
    • Pneumonia
    • TB
    • PE
    • Pancreatitis
    • Oesophageal rupture
    • AI
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12
Q

Presentation of Pleural Effusion

A
  • Sx: ASx, SOB, chest pain
  • Stony dull percussion
  • Reduced expansion
  • Reduced breath sounds
  • Reduced vocal resonance
  • Tracheal deviation (large)
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13
Q

Pleural effusion: Ix and Tx

A
  • Ix:
    • CXR- blunted costophrenic angle, dense shadowing with fluid level
    • USS- Diagnosis and guiding drain
    • Pleural fluid aspirate
    • Pleural biopsy
  • Tx:
    • Pleural fluid drainage (?repeated)
    • Pleuradhesis- tetracycline, bleomycin, talc
    • Surgical
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14
Q

Features of acute severe asthma attack

A
  • PEFR 33-50%
  • RR >25
  • HR >110
  • Unable to speak in full sentences
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15
Q

Features of acute life-threatening asthma attack

A
  • PEFR <33%
  • Silent chest
  • Cyanosis
  • Hypotension
  • Arrhythmia
  • Exhaustion/ confusion/ coma
  • ABG: CO2 >4.6, pO2 <8kpa/92%
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16
Q

Investigations of chronic and acute asthma

A
  • Chronic: PEFR, spirometry, bloods, CXR, IgE skin prick, sputum culture
  • Acute: NEWS, PEFR, bloods, ABG, CXR
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17
Q

BTS guidlines of chronic asthma management

A

INH SABA PRN. ?Step up >3 times/w

  1. INH SABA PRN- salbutamol
  2. Low dose ICS- beclometasone
  3. INH LABA eg salmeterol. If ineffective, stop and increase dose of ICS
  4. High dose ICS (upto 2000 micrograms/d). Consider addition of B2 agonist PO, motelukast, SR theophylline
  5. Prednisolone PO/ continue high dose ICS. Specialist care
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18
Q

Management of acute asthma attack

A
  • ABCDE + 02
  • Salbutamol 5mg NEB. Repeat every 15-30 mins
  • Ipratropium bromide 0.5mg/6h NEBS
  • Magnesium sulfate 1.2-2g IV over 20 mins
  • Not improving –> ICU ?ventilation ?aminophylline ?IV salbutamol
  • Improving 15-30 mins –> Continue salbutamol NEBS 4-6h, PO prednisolone 5-7d
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19
Q

Presentation of COPD

A
  • SOB (++ exercise)
  • Wheeze
  • Nocturnal cough
  • Sputum (white)
  • Fatigue
  • Plethora
  • Cyanosis
  • Raised JVP
  • Tremor
  • Hyperresonance
  • ??Smoker
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20
Q

Spirometry: Obstructive vs Restrictive

A
  • Obstructive- Reduced FEV1 and FEV1:FVC
  • Restrictive- Reduced FVC (?raised FV1:FVC)
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21
Q

Staging of COPD

A

Gold Classification

  1. Mild- FEV1 80-100%
  2. Moderate- FEV1 50-80%
  3. Severe- FEV1 30-50%
  4. V severe- FEV1 <30%
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22
Q

Management of chronic COPD

A

Conservative- smoking cessation, good diet, pulmonary rehab, vaccinations

  1. SABA (salbutamol) or SAMA (ipratropium) PRN
  2. FEV >50%: LABA (salmeterol) or LAMA (tiotropium) + stop SAMA. FEV<50%: LABA + ICS or LAMA
  3. LAMA + LABA/ICS combined (symbicort/ seretide)
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23
Q

Acute management of COPD

A

ABCDE

  1. NEBS- salbutamol, ipratropium bromide
  2. Controlled o2 (88-92%)
  3. Steroids- prednisolone/ hydrocortisone
  4. ABx- amoxicillin/ clarithromicin/doxycycline
  5. Chest physio
  6. No response to NEBS –> IV aminophylline
  7. NIV
  8. Doxapram
  9. ??Intubation
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24
Q

Indications for NIV in acute COPD

A
  • RR >30
  • pH <7.35
  • PaCO2 >6.5 and rising despite Tx
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25
Contraindications of NIV
* Unable to maintain airway- impaired swallow/cough, low GCS * Facial trauma/ burns * Pneumothorax * Cardio/pulmonary arrest * Relative- extreme anxiety, dementia, morbid obesity, multiple organ failure
26
COPD CXR
* Hyperinflation: \>6 ribs visible above diaphragm * Flattened hemidiaphragms * Large central pulmonary arteries * Reduced vascular markings * Bullae
27
Presentation of Pneumonia
* Productive cough * SOB * Pleuritic chest pain * Haemoptysis * Fever +/- rigors * Confusion (esp elderly) * Reduced chest expansion * Dull percussion * Crackles * Bronchial breathing * ??SEPSIS
28
Severity scoring of CAP
CURB-65 * Confusion * Urea \>7mmol/L * RR \>30 * BP \<90/60 * Age \>65 years 1-2= Mild. 2= Moderate, hospital. 3= Severe ?ICU
29
Common pathogens causing pneumonia
* Strep. pneumoniae * H. Influenzae * Moraxella catarrhalis * Klebsiella
30
Management of CAP
* Mild: 5d course of amoxicillin (or clarithromycin or doxycycline) * Mod: 7-10d course of amoxicillin + clarithromycin * Severe: 7-10d Tazocin/Co-amox + clarithromycin
31
Management of HAP
* Tx within 4 hours * 5-10d coure of tazocin/ co-amoxiclav IV
32
Different types of lung cancer and their key features
* Small cell lung cancer (20%)- AGGRESSIVE. Central/ hilar. Met early. Neuroendocrine cells --\> paraneoplastic syndromes * Non-small cell cancer * Squamous (35%)- \*\*SMOKERS\*\*. Proximal bronchi. Local spread. Met late. Hypercalcaemia * Adenocarcinoma (27%)- Peripheral. Glandular cells. ++mets: pleura, LN, brain, bone, adrenal glands * Large cell (10%) * Alveolar cell carcinoma (\<1%)
33
Presentation of Lung Cancer
* Chest pain * Persistent cough * Haemoptysis * Weight loss and anorexia * Lethargy * Chest signs- Consolidation, collapse, pleural effusion * ?Tar staining * Clubbing * Signs of complications
34
2 week wait criteria for Lung Cancer
* X-Ray finding * \>40y + unexplained haemoptysis * Urgent CXR if \>40y and 2 of following Sx (or smoker +1): Cough, fatigue, SOB, chest pain, weight loss, anorexia * ?Urgent CXR if \>40y with any of: Persistent chest infection, clubbing, lymphadenopathy, chest signs, thrombocytosis
35
Complications of Lung Cancer
* Local- SVCO, pleural effusion, pericarditis, phrenic n palsy, hoarse voice, Horner's (ptosis, myosis, anhydrosis), pain, rib erosion * Mets: LNs (supraclavicular, axillary, mediastinal), skin, adrenals, bone (fracture), brain (ICP) * Endocrine: SIADH (low Na+, high ADH), hyperparathyroidism --\> hypercalcaemia \*\*squamous\*\*, Cushing's (ACTH) \*\*SCLC\*\* * Neurological: Fits, cerebellar syndrome, neuropathy, proximal myopathy, polymyositis, Lambert-Eaton syndrome
36
Lung cancer investigations
* Bedside- Lung function, sputum cytology * Bloods- FBC, U+Es, LFTs, Ca2+, LDH (tumour lysis) * Imaging- CXR, CT, ?PET, ?bronchoscopy * CXR- Nodules, hilar enlargement, consolidation, collapse, pleural effusion, bony mets * Special- FNA/ Biopsy/ Pleural fluid analysis
37
What are the pulmonary signs and symptoms of TB?
* ASx * Cough * Sputum * Malaise * Weight loss * Night sweats * Pleurisy * Haemoptysis * Pleural effusion
38
What are the extrapleural signs and symptoms of TB?
* Miliary= Disseminated haematogenous spread * GU= Dysuria, frequency, loin/back pain, haematuria * Bone= Vertebral collapse * Skin= Jelly like nodules * Cardiac= Chronic pericardial effusion/ pericarditis * TB meningitis
39
Diagnosis of TB
* Latent= Mantoux test --\> ?Quantiferon gold * Active * CXR- Consolidation, cavitation, fibrosis, calcification * Sputum- C+S with Ziehl-Neelson stain ?acid fast bacilli * Histology- Caseating granulomata * ??HIV
40
TB Treatment and SE
* Rifampicin- orange fluids, less effective OCP * Isoniazid- Peripheral neuropathy * Pyrazinamide- Gout, photosensitivity, hepatitis * Ethambutol- Optic neuritis, reduced acuity, loss of colour vision * 4 drugs for 2 months, 2 drugs (R + I) for 4 months
41
What is Bronchiectasis?
* Bronchiectasis is chronic infection of bronchi and bronchioles --\> permenant dilatation. Underlying causes. * Common organisms- S. pneumonia, H. Influenzae, pseudomonas
42
What are the main causes of Bronchiectasis?
* Congenital- CF * Post-infective: Measles, pertussis, bronchiolitis, pneumonia, TB, HIV * Other- Idiopathic, RA, UC, bronchial obstruction eg tumour
43
What are the signs and symptoms of Bronchiectasis?
* Persisent cough * ++ purulent sputum * Intermittent haemoptysis * Clubbing * Coarse inspiratory crepitations * Advanced --\> cyanosis, RHF
44
What investigations would you do for Bronchiectasis?
* Bedside- sputum sample, CF breath test, spirometry * Bloods- immunoglobulins, FBC, CRP * Imaging- * CXR- Tramline and ring shadows. Cystic shadows, dilated airways, thickened bronchial walls * HRCT- Extent and distribution (CF upper lobe, all rest lower) * Special- ?Biopsy
45
Treatment of Bronchiectasis
* Conservative- Chest physio and postural drainage * Medical- ABx, ?bronchodilators, ?steroids * Surgical- Localised, haemoptysis
46
Types of respiratory failure and their causes
1. PaO2 \<8kPa = V/Q mismatch. PE, pulm. oedema, asthma 2. PaO2 \<8kPa + PaCO2 \>6kPa. Hypoventilation- COPD, pneumonia, MND, opiates, chest wall damage
47
Patients at risk of hypoventilation
* Chest wall deformity * COPD * Obstructive sleep apnoea * Muscle disease eg DMD * Spinal injury * Diaphragm paralysis
48
Hypoventilation investigations
* Bedside- NEWS, transcutaneous CO2 * Bloods- ABG= Respiratory acidosis (hypoxia, hypercapnia) * Imaging- CXR * Special- Pulmonary function tests (spirometry, resp muscle strength
49
What is obstructive sleep apnoea and how does it present?
* OSA= Intermitted collapse of pharyngeal airway --\> apnoeic eps. Terminated by rousal. * Typical patient= middle aged obese male. * Sx: Loud snoring, nocturia, daytime somnolence, poor cognitive performance, morning headache.
50
Investigations and treatment of obstructive sleep apnoea
* Ix: Pulse oximetry (desats), Epworth sleep scale, chest wall movement, flow, snoring. ??EEG. (Somnography) * Tx: Weight loss, CPAP, ?surgery to remove obstruction
51
What is interstitial lung disease? What are it's symptoms and Ix?
* Umbrella term for conditions primarily affecting the parenchyma diffusely. Chronic inflammation/ fibrosis * Sx: Dry cough, exertional dyspnoea, abnormal breath sounds. * Ix: Abnormal CXR/ **HRCT,** spirometry= restrictive, ABG= type 1 respiratory failure.
52
Categorise the causes of interstitial lung disease
* Known cause: * Occupational/ environmental eg asbestosis, silicosis * Drugs- nitrofurantoin, bleomycin, amiodarone * Hypersensitivity pneumonitis * Infections- TB, viral, fungi. * Secondary to systemic disorder- RA, SLE, Sarcoidosis * Idiopathic pulmonary fibrosis
53
Presentation of idiopathic pulmonary fibrosis (IPF)
* Dry cough * SOB (worse on exercise) * Malaise * Weight loss * CLUBBIN (2/3) * Cyanosis * Reduced expansion
54
Investigations and management of idiopathic pulmonary fibrosis
* Ix: NEWS, CRP, immunoglobulins, HRCT (reticular nodular shadowing/ honeycomb), restrictive spirometry, ?biopsy * Tx: O2, pulm rehab, palliation, antifibrotics (eg perfenidone), ??transplant
55
What is hypersensitivity pnuemonitis?
* AKA Extrinsic allergic alveolitis * In sensitised individuals, inhalation of allergens provokes hypersensitivity reaction. * Eg Farmer's lung, pigeon fancier's lung etc
56
Presentation of hypersensitivity pneumonitis
* Acute: flu-like. Fever, myalgia, drug cough, squeak/squark * Chronic: SOB, weight loss, type 1 resp failure, cor pulmonale
57
Investigations and managment of hypersensitivity pneumonitis
* Ix: NEWS, ABG, CXR (honeycomb, upper lobe consolidation), **HRCT**, spirometry (restrictive). * Tx: Remove allergen, O2, PO Pred
58
What is sarcoidosis and how does it present?
* Sarcoidosis= multisystem granulomatous disorder of unknown cause. Predominantly affects the lung * Lung Sx- Hilar lymphadenopathy, SOB, dry cough, chest pain, poor lung function * Non-pulmonary Sx- Erythema nodosum, neuropathy, polyarthralgia, lupus pernio, arrhythmias, glaucoma, uveitis/ conjunctivitis, hypercalcaemia, hepatosplenomegaly
59
What is Lofgren's syndrome?
Sarcoidosis associated with arthralgia and hilar lymphadenopathy --\> NSAIDs
60
How would you investigate sarcoidosis?
* Bedside- 24h urine, ECG * Bloods- FBC, ESR, serum ACE (increased in 60%), immunoglobulins * Imaging- CXR (bilateral hilar lymphadenopathy + pulmonary infiltrates), CT/MRI, USS of liver/ spleen * Special- biopsy (non-caseating granuloma), restrictive spirometry, BAL
61
Sarcoidosis treatment
* Acute- bed rest, NSAID * PO prednisolone * Severe- IV methylprednisolone, immunosuppression (methtrexate, hydroxychloraquin, ciclosporin).
62
Differentials of hilar/ mediastinal lymphadenopathy
1. Sarcoidosis (usually young and healthy) 2. Lymphoma (fever and night sweats) 3. Carcinoma (smoker and haemoptysis\_ 4. TB
63
What is pneumoconiosis and what might cause it?
* Lung disease caused by inhalation of mineral dust. Fibrosis --\> restrictive lung disease. * Might be caused by coal/silica/asbestos * Silicon- Fibrosis. Diffuse nodules --\> large lumpy areas in upper zone. Sparkley birefringent pattern on biopsy * Coal- deposition around terminal bronchioles. * Asbestosis= fibrosis. Plaques (holly leaf). * Asbestost can also cause malignant mesothelioma (pleura) 40-50y after exposure.
64
Causes of Respiratory Acidosis
* = Hypoventilation * Opiates * Neuromuscular- Guillain-Barre, MND, DMD * Asthma * COPD * Iatrogenic (ventilator)
65
Causes of Respiratory Alkalosis
* = Hyperventilation * Anxiety * Pain * Hypoxia * PE * Pneumothorax * Iatrogenic
66
Causes of Metabolic Acidosis
* Determined by Anion Gap= Na+ - (Cl- + HCO3-) * High anion gap= increased acid production- DKA, lactic acidosis, aspirin OD * Low anion gap= decreased acid excretion or loss of HCO3-: Diarrhoea, ileostomy, Addison's, renal tubular acidosis
67
Causes of Metabolic Alkalosis
* GI loss of H+ (D+V) * Renal loss of H+: loop/thiazide diuretics, HF, nephrotic syndrome, cirrhosis, Conn's * Iatrogenic- Addition of alkali
68
Management of smoking cessation
* NB Hx to ask Pt about smoking and best way to support them. * Advise best way to quit, provide details of where to get help. * Refer to specialist smoking cessation service * Medical: * Nicotine replacement- gum, patches * Varencline- partial nicotine receptor agonist. Reccommended by NICE. Start whilst still smoking --\> high rates of abstinence * Alt= bupropion
69
What is the DECAF score?
= Predicts in hospital mortality in acute exacerbation of COPD. * Dyspnoea - MRCD 5a/b (1-2) * Eosinopenia - \<0.05x109/L (1) * Consolidation (1) * Acidaemia- pH \<7.3 (1) * Fibrillation (AF) (1) Score **\>3** = high risk!
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Finals!!! (19 decks)

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