Respiratory Flashcards
(36 cards)
Atelectasis is a common – complication in which basal alveolar collapse can lead to respiratory difficulty.
It is caused when airways become obstructed by b
Features
it should be suspected in the presentation of d—and – around – hours postoperatively
Management
x2
Atelectasis is a common postoperative complication in which basal alveolar collapse can lead to respiratory difficulty. It is caused when airways become obstructed by bronchial secretions.
Features
it should be suspected in the presentation of dyspnoea and hypoxaemia around 72 hours postoperatively
Management
positioning the patient upright
chest physiotherapy: breathing exercises
Consider granulomatosis with polyangiitis when a patient presents with –, – and – involvement
Consider granulomatosis with polyangiitis when a patient presents with ENT, respiratory and kidney involvement
The loss of the left heart border is a classic sign of left –. There is no left middle lobe!
The loss of the left heart border is a classic sign of left lingula consolidation. There is no left middle lobe!
If there is a ‘white-out’ of a hemithorax it is useful to assess the position of the trachea - is it central, pulled or pushed from the side of opacification.
Trachea pulled toward the white-out ?
Trachea central
Trachea pushed away from the white-out
If there is a ‘white-out’ of a hemithorax it is useful to assess the position of the trachea - is it central, pulled or pushed from the side of opacification.
Trachea pulled toward the white-out :
Pneumonectomy
Complete lung collapse e.g. endobronchial intubation
Pulmonary hypoplasia
Trachea central:
Consolidation
Pulmonary oedema (usually bilateral)
Mesothelioma
Trachea pushed away from the white-out:
Pleural effusion
Diaphragmatic hernia
Large thoracic mass
– are the treatment of choice for allergic bronchopulmonary aspergillosis
Oral glucocorticoids are the treatment of choice for allergic bronchopulmonary aspergillosis
– typically causes upper zone pulmonary fibrosis
Tuberculosis typically causes upper zone pulmonary fibrosis
A number of conditions predominantly cause fibrosis of the upper lobes. They can be summarised with the mnemonic
K CHARTS:
K- C- H - A - R - T - S -
A number of conditions predominantly cause fibrosis of the upper lobes. They can be summarised with the mnemonic CHARTS: K- Klebsiella C- Coal worker's pneumoconiosis H - Histiocytosis/ hypersensitivity pneumonitis A - Ankylosing spondylitis R - Radiation T - Tuberculosis S - Silicosis/sarcoidosis
Fibrosis predominately affecting the lower zones:
idiopathic—
most — disorders (except —) e.g. SLE
drug-induced: MAB
asbestosis
Fibrosis predominately affecting the lower zones
idiopathic pulmonary fibrosis
most connective tissue disorders (except ankylosing spondylitis) e.g. SLE
drug-induced: amiodarone, bleomycin, methotrexate
asbestosis
The most common organism causing infective exacerbations of COPD is —
The most common organism causing infective exacerbations of COPD is Haemophilus influenzae
NICE guidelines from 2010 recommend the following:
COPD Exacerbations
increase frequency of –use and consider giving via a –
give — 30 mg daily for 5 days
it is common practice for all patients with an exacerbation of COPD to receive –
NICE do not support this approach.
They recommend giving oral — ‘if sputum is purulent or there are clinical signs of —’
the BNF recommends one of the following oral antibiotics first-line: –or clarithromycin or doxycyclin
NICE guidelines from 2010 recommend the following:
increase frequency of bronchodilator use and consider giving via a nebuliser
give prednisolone 30 mg daily for 5 days
it is common practice for all patients with an exacerbation of COPD to receive antibiotics. NICE do not support this approach. They recommend giving oral antibiotics ‘if sputum is purulent or there are clinical signs of pneumonia’
the BNF recommends one of the following oral antibiotics first-line: amoxicillin or clarithromycin or doxycyclin
Common causes of lobar collapse include:
– (the most common cause in older adults)
— (due to mucous plugging)
foreign –
The general signs of lobar collapse on a chest x-ray are as follows:
tracheal deviation — side of the collapse
mediastinal shift — side of the collapse
– of the hemidiaphragm
Common causes of lobar collapse include:
lung cancer (the most common cause in older adults)
asthma (due to mucous plugging)
foreign body
The general signs of lobar collapse on a chest x-ray are as follows:
tracheal deviation towards the side of the collapse
mediastinal shift towards the side of the collapse
elevation of the hemidiaphragm
Pulmonary fibrosis causes restrictive spirometry picture (FEV1:FVC –70%, — FVC)
and – gas exchange (—TLCO)
Pulmonary fibrosis causes restrictive spirometry picture (FEV1:FVC >70%, decreased FVC) and impaired gas exchange (reduced TLCO)
Acute asthma: management Moderate PEFR --% best or predicted Speech -- RR < -- / min Pulse < --- bpm
severe PEFR --% best or predicted Speech -- RR < -- / min Pulse < --- bpm
Life threatening PEFR < --% best or predicted Oxygen sats < --% 'Normal' pC02 (4.6-6.0 kPa) -- chest, cyanosis or feeble re-- Exhaustion, confusion or coma
Moderate PEFR 50-75% best or predicted Speech normal RR < 25 / min Pulse < 110 bpm
severe PEFR 33 - 50% best or predicted Can't complete sentences RR > 25/min Pulse > 110 bpm
life threatening: PEFR < 33% best or predicted Oxygen sats < 92% 'Normal' pC02 (4.6-6.0 kPa) Silent chest, cyanosis or feeble respiratory effort Bradycardia, dysrhythmia or hypotension Exhaustion, confusion or coma
Acute asthma: management
Further assessment
the BTS guidelines recommend – for patients with oxygen sats < 92%
a –is not routinely recommended, unless:
life-threatening asthma
suspected pneumothorax
failure to respond to treatment
Management
1.oxygen
if patients are hypoxaemic, it is important to start them on supplemental oxygen therapy
if patients are acutely unwell they should be started on –L of supplemental via a non-rebreathe mask, which can then be titrated down to a flow rate where they are able to maintain a SpO₂ –%.
- bronchodilation with
- corticosteroid
all patients should be given 40-50mg of – orally (PO) daily, which should be continued for at least five days or until the patient recovers from the attack
during this time, patients should continue their normal medication routine including inhaled corticosteroids. - – bromide: in patients with severe or life-threatening asthma, or in patients who have not responded to beta₂-agonist and corticosteroid treatment, nebulised ipratropium bromide, a short-acting muscarinic antagonist
- IV —
the BTS notes that the evidence base is mixed for this treatment that is now commonly given for severe/life-threatening asthma - IV – may be considered following consultation with senior medical staff
patients who fail to respond require senior critical care support and should be treated in an appropriate ITU/HDU setting.
Treatment options include:
intubation and ventilation
extracorporeal membrane oxygenation (ECMO)
Criteria for discharge
been stable on their discharge medication (i.e. no nebulisers or oxygen) for – hours
inhaler technique checked and recorded
PEF >–% of best or predicted
Further assessment
the BTS guidelines recommend – for patients with oxygen sats < 92%
a chest x-ray is not routinely recommended, unless:
life-threatening asthma
suspected pneumothorax
failure to respond to treatment
Management
admission
all patients with life-threatening should be admitted in hospital
patients with features of severe acute asthma should also be admitted if they fail to respond to initial treatment.
other admission criteria include a previous near-fatal asthma attack, pregnancy, an attack occurring despite already using oral corticosteroid and presentation at night
oxygen
if patients are hypoxaemic, it is important to start them on supplemental oxygen therapy
if patients are acutely unwell they should be started on 15L of supplemental via a non-rebreathe mask, which can then be titrated down to a flow rate where they are able to maintain a SpO₂ 94-98%.
bronchodilation with short-acting beta₂-agonists (SABA)
high-dose inhaled SABA e.g. salbutamol, terbutaline
in patients without features of life-threatening or near-fatal asthma, this can be given by a standard pressurised metered-dose inhaler (pMDI) or by an oxygen-driven nebulizer
in patients with features of a life-threatening exacerbation of asthma, nebulised SABA is recommended
corticosteroid
all patients should be given 40-50mg of prednisolone orally (PO) daily, which should be continued for at least five days or until the patient recovers from the attack
during this time, patients should continue their normal medication routine including inhaled corticosteroids.
ipratropium bromide: in patients with severe or life-threatening asthma, or in patients who have not responded to beta₂-agonist and corticosteroid treatment, nebulised ipratropium bromide, a short-acting muscarinic antagonist
IV magnesium sulphate
the BTS notes that the evidence base is mixed for this treatment that is now commonly given for severe/life-threatening asthma
IV aminophylline may be considered following consultation with senior medical staff
patients who fail to respond require senior critical care support and should be treated in an appropriate ITU/HDU setting. Treatment options include:
intubation and ventilation
extracorporeal membrane oxygenation (ECMO)
Criteria for discharge
been stable on their discharge medication (i.e. no nebulisers or oxygen) for 12–24 hours
inhaler technique checked and recorded
PEF >75% of best or predicted
Acute respiratory distress syndrome can only be diagnosed in the absence of a — for pulmonary oedema (i.e. the pulmonary capillary wedge pressure must not be –)
Acute respiratory distress syndrome can only be diagnosed in the absence of a cardiac cause for pulmonary oedema (i.e. the pulmonary capillary wedge pressure must not be raised)
Pleural infection
All patients with a pleural effusion in association with – or a — require diagnostic pleural fluid sampling
if the fluid is purulent or turbid/cloudy a — should be placed to allow drainage
if the fluid is clear but the pH is less than 7.2 in patients with suspected pleural infection a — should be placed
Pleural infection
All patients with a pleural effusion in association with sepsis or a pneumonic illness require diagnostic pleural fluid sampling
if the fluid is purulent or turbid/cloudy a chest tube should be placed to allow drainage
if the fluid is clear but the pH is less than 7.2 in patients with suspected pleural infection a chest tube should be placed
Pleural aspiration
as above, —is recommended to reduce the complication rate
a –G needle and 50ml syringe should be used
fluid should be sent for pH, protein, lactate dehydrogenase (LDH), cytology and microbiology
Light’s criteria was developed in 1972 to help distinguish between a transudate and an exudate.
The BTS recommend using the criteria for borderline cases:
— have a protein level of >30 g/L, — have a protein level of <30 g/L
if the protein level is between 25-35 g/L, Light’s criteria should be applied.
An exudate is likely if at least one of the following criteria are met: pleural fluid or serum
– fluid protein divided by – protein >0.5
– LDH divided by – LDH >0.6
pleural fluid LDH more than two-thirds the upper limits of normal serum LDH
Other characteristic pleural fluid findings:
low glucose: rheumatoid arthritis, tuberculosis
raised amylase: pancreatitis, oesophageal perforation
heavy blood staining: mesothelioma, pulmonary embolism, tuberculosis
Pleural aspiration
as above, ultrasound is recommended to reduce the complication rate
a 21G needle and 50ml syringe should be used
fluid should be sent for pH, protein, lactate dehydrogenase (LDH), cytology and microbiology
Light’s criteria was developed in 1972 to help distinguish between a transudate and an exudate. The BTS recommend using the criteria for borderline cases:
exudates have a protein level of >30 g/L, transudates have a protein level of <30 g/L
if the protein level is between 25-35 g/L, Light’s criteria should be applied. An exudate is likely if at least one of the following criteria are met:
pleural fluid protein divided by serum protein >0.5
pleural fluid LDH divided by serum LDH >0.6
pleural fluid LDH more than two-thirds the upper limits of normal serum LDH
Other characteristic pleural fluid findings:
low glucose: rheumatoid arthritis, tuberculosis
raised amylase: pancreatitis, oesophageal perforation
heavy blood staining: mesothelioma, pulmonary embolism, tuberculosis
Pleural effusions may be classified as being either a transudate or exudate according to the protein concentration.
Transudate (< –g/L protein):
– failure (most common transudate cause)
hypo— (liver disease, nephrotic syndrome, malabsorption)
hypo–
–syndrome
Exudate (> 30g/L protein) infection: --- (most common exudate cause), TB, subphrenic abscess connective tissue disease: --- neoplasia: -- cancer, --thelioma, metastases pancreatitis pulmonary --- --- syndrome --nail syndrome
Features dyspnoea, non-productive cough or chest pain are possible presenting symptoms classic examination findings include -- to percussion, -- breath sounds and --- chest expansion
Pleural effusions may be classified as being either a transudate or exudate according to the protein concentration.
Transudate (< 30g/L protein)
heart failure (most common transudate cause)
hypoalbuminaemia (liver disease, nephrotic syndrome, malabsorption)
hypothyroidism
Meigs’ syndrome
Exudate (> 30g/L protein) infection: pneumonia (most common exudate cause), TB, subphrenic abscess connective tissue disease: RA, SLE neoplasia: lung cancer, mesothelioma, metastases pancreatitis pulmonary embolism Dressler's syndrome yellow nail syndrome
Features
dyspnoea, non-productive cough or chest pain are possible presenting symptoms
classic examination findings include dullness to percussion, reduced breath sounds and reduced chest expansion
Normal/raised total gas transfer with raised transfer coefficient: – or–
Normal/raised total gas transfer with raised transfer coefficient: Asthma or pulmonary haemorrhage
Large – in COPD can mimic a pneumothorax
Large bullae in COPD can mimic a pneumothorax
Respiratory causes of clubbing:
--- cancer pyogenic conditions: x4 t a, m- fibrosing -
Respiratory causes lung cancer pyogenic conditions: cystic fibrosis, bronchiectasis, abscess, empyema tuberculosis asbestosis, mesothelioma fibrosing alveolitis
Sarcoidosis: management
Sarcoidosis is a multisystem disorder of unknown aetiology characterised by non-caseating –.
It is more common in young adults and in people of – descent.
Indications for steroids
patients with chest x-ray stage 2 or 3 disease who are symptomatic.
Patients with asymptomatic and stable stage 2 or 3 disease who have only mildly abnormal lung function do not require treatment
hyper–
e–, h– or n–involvement
Sarcoidosis: management
Sarcoidosis is a multisystem disorder of unknown aetiology characterised by non-caseating granulomas. It is more common in young adults and in people of African descent.
Indications for steroids
patients with chest x-ray stage 2 or 3 disease who are symptomatic. Patients with asymptomatic and stable stage 2 or 3 disease who have only mildly abnormal lung function do not require treatment
hypercalcaemia
eye, heart or neuro involvement
Klebsiella most commonly causes a cavitating pneumonia in the –lobes, mainly in —and –
Klebsiella most commonly causes a cavitating pneumonia in the upper lobes, mainly in diabetics and alcoholics
Syndromes associated with sarcoidosis
–syndrome is an acute form of the disease characterised by bilateral hilar lymphadenopathy (BHL), erythema nodosum, fever and polyarthralgia. It usually carries an excellent prognosis
In — syndrome* there is enlargement of the parotid and lacrimal glands due to sarcoidosis, tuberculosis or lymphoma
—syndrome (uveoparotid fever) there is parotid enlargement, fever and uveitis secondary to sarcoidosis
*this term is now considered outdated and unhelpful by many as there is a confusing overlap with Sjogren’s syndrome
Syndromes associated with sarcoidosis
Lofgren’s syndrome is an acute form of the disease characterised by bilateral hilar lymphadenopathy (BHL), erythema nodosum, fever and polyarthralgia. It usually carries an excellent prognosis
In Mikulicz syndrome* there is enlargement of the parotid and lacrimal glands due to sarcoidosis, tuberculosis or lymphoma
Heerfordt’s syndrome (uveoparotid fever) there is parotid enlargement, fever and uveitis secondary to sarcoidosis
*this term is now considered outdated and unhelpful by many as there is a confusing overlap with Sjogren’s syndrome
