Breathlessness- extra from lectures Flashcards
Flow volume loops
Plot of Inspiratory and Expiratory Flow (y-axis) against volume (x-axis)
Maximally forced inspiratory and expiratory manoeuvres
Useful for identifying the location of obstruction
Dynamic/variable extra-thoracic obstruction
Functional vocal cord paralysis
Extra-thoracic tracheomalacia
Polychondritis
Dynamic/Variable intra-thoracic obstruction
Tracheomalacia
Tracheal lesions
Fixed upper airway obstruction
Tracheal stenosis
Extra-thoracic compression (tumour/goitre)
Peripheral/lower airways obstruction
COPD
Asthma
Brochiolitis
Different measurements of lung volume
Tidal Volume = Volume of air in and out during normal breathing
Functional Residual Capacity = Volume of air in lungs at end of normal expiration
Total Lung Capacity = Volume of air in lungs after full inspiration
Residual Volume = Gas remaining in the lungs after full expiration
Vital Capacity = Volume of air expelled by a full expiration from position of full inspiration
Conditions causing increased and decreased lung volume
Increased lung volume- airflow obstruction (particularly raised residual volume), Emphysema
Decreased lung volume- Restrictive lung disease (lung parenchyma or extra-pulmonary)
TLCO and KCO
TLCO- Transfer factor for the Lung Carbon Monoxide. Measures the total ability of the lungs to transfer gas into the blood stream
KCO- transfer coefficient. Gas transfer per unit volume, reflects alveolar volume in the lung
What causes a reduced TLCO or KCO
Anything disrupting the alveolar membrane or reducing pulmonary capillary volume.
Conditions: Emphysema, Interstitial lung disease, Pulmonary hypertension, Pneumonia, Multiple PTE, Anaemia, Low cardiac output
What causes TLCO or KCO to be increased
By anything increasing the pulmonary capillary volume
- Asthma (decreased intrathoracic pressure)
- Alveolar haemorrhage (recent)
- Left to right shunts
- Polycythaemia
- Exercise
Conditions which cause the gas transfer (TLCO) to be reduced but the kco to not change
- Pneumonectomy
- Chest wall disease
TLCO and KCO: Airflow obstruction
Low TLCO : emphysema//bronchiolitis obliterans
Normal TLCO: COPD/bronchitis but no emphysema
Raised TLCO : Asthma
TLCO and KCO: Restriction (reduced FVC and reduced lung volume)
Low TLCO : ILD
Raised KCO: Extra pulmonary Restriction (obesity, pleural effusion, kyphoscoliosis, muscular weakness, pulmonary haemorrhage)
TLCO and KCO: Restriction (reduced FVC and reduced lung volume)
Low TLCO: ILD
Raised KCO: Extra pulmonary Restriction (obesity, pleural effusion, kyphoscoliosis, muscular weakness, pulmonary haemorrhage)
Isolated reduced TLCO with normal spirometry
- May suggest pulmonary vascular disease
- Anaemia
- CPFE
Raised TLCO and KCO
Polycythaemia, left to right shunt or pulmonary haemorrhage
Type 1 respiratory failure conditions
Pulmonary fibrosis
Pulmonary embolism
Pneumothorax
Acute severe asthma- only life threatening asthma is type 2
Difference between pneumonia and COPD on an x-ray
Pneumonia: consolidation on one side, wheeze
COPD: symmetrical, hyperinflated (bigger)
Heart failure- chest x-ray
In chronic heart failure you get pleural effusion
Pleural effusion has a meniscus
There may be an absent costophrenic angle due to fluid
How does the trachea move in a chest x-ray
Pleural effusion: Trachea shifts away
Lung collapse: Trachea shifts towards
Emphysema: chest x-ray
Hyperinflation
Narrow mediastinum
Hyperluency
Bullae
How many ribs cover the lungs
5th-7th rib hits the diaphragm
In emphysema it is more
Tension pneumothorax treatment
Air is let into the pleural space which causes a pressure imbalance
Put a needle into the 2nd intercostal midclavicular line to treat it
Then put the pleural drain int the 5th intercostal space midaxillary line
What investigation confirms the diagnosis of pulmonary embolism
CT pulmonary angiogram
Treatment for pulmonary embolism
Initial treatment: low molecular weight heparin and Rivaroxaban (Factor Xa inhibitor)
Long term: Warfarin (vitamin K antagonist)
Mechanism of salbutamol
Beta 2 adrenoreceptor agonist
What measurement is used for grading the severity of airflow obstruction in COPD
Forced expiratory volume (FEV1)
When should you/ should not offer oxygen therapy
Do not offer long term oxygen therapy to current smokers
Offer oxygen therapy to patients with pulmonary hypertension and an FEV1 of less than 30% predicted
Spirometry contraindications
MI, pneumothorax, haemoptysis, stroke, unstable angina, uncontrolled hypertension
What is found in a heart failure examination
Displaced apex beat
Heart murmurs
Crackles in the base of lungs
Oedema
What is found in a COPD exam
Reduced crico-sternal distance
Barrel chest
Hyper-resonant lungs
Focal crackles (if exacerbated)
Reduced breath sounds
Chest x-ray COPD
Hyper-lucency (darker)
Flattened diaphragm- lung will appear between the heart and the diaphragm
Hyper-inflation
Reduced cardio-thoracic ratio
Bullae (no lung markings)
Chest x-ray heart failure
Increased cardio-thoracic ratio (bigger heart)
Kerley B lines
Lots of white at the bottom
Bats wing appearance
Fluid in the fissure
Blood test for heart failure
Pro-BNP
Will be raised in heart failure
Released from cardiac myocytes due to stress
COPD non-medical management
Smoking cessation
Pulmonary rehab
Vaccination
Medication and diet
Management for anxiety (CBT)
When do you not give ICS in COPD
If there is infection risk
How to differentiate infection from PE
Infection: fever, unilateral consolidation, green sputum, more history
PE: pleuritic chest pain, breathlessness with no sputum, acute
PE risk factors
Immobility, cancer, pregnancy, oestrogen, COPD, HRT, previous PE or DVT, obesity, trauma, operation, family history
Ground glass opacification
Opacification but you can see the lung architecture
Treatment for mild pneumonia
Amoxicillin 500mg 3 times a day
Red flags for lung cancer
Persistent cough or change in cough for 3 weeks
Unexplained weight loss, loss of appetite, fatigue
Haemoptysis
Chest and shoulder tip pain which cant be explained by anything
Chest infection which isnt getting better
Hoarse voice for more than 3 weeks
Investigations for lung cancer
Endo-bronchial ultrasound- take a biopsy
CT guided biopsy
CT scan- in the lung as well as looking for metastasis
Ischaemic heart disease
A reduction in blood supply to the heart, can cause heart failure or MI
Major causes: atherosclerosis, coronary artery spasma
Treatment for ischaemic heart disease
Medicine: Nitrates, aspirin, beta blockers, statins, calcium channel blockers
Surgery: Percutaneous coronary angioplasty (inserting a small balloon), coronary artery biopsy
Co-morbidities which increase the risk of ischaemic heart disease
Diabetes
Hypertension
Chronic kidney disease
Inflammatory conditions i.e. rheumatoid arthritis
Atypical antipsychotic medications
Secondary prevention for cardiovascular disease
4 A’s
A – Aspirin (plus a second antiplatelet such as clopidogrel for 12 months)
A – Atorvastatin 80mg
A – Atenolol (or other beta-blocker – commonly bisoprolol) titrated to maximum tolerated dose
A – ACE inhibitor (commonly ramipril) titrated to maximum tolerated dose
Notable side effects of statins
Myopathy- check for creatine kinase in patients with muscle pain or weakness
Type 2 diabetes
Haemorrhagic stroke
Management of PE
Initial: LMWH either apixaban or rivaroxaban
Switch to long term anticoagulation: warfarin, NOAC or LMWH. Continue for 3 months if there is an obvious reversible cause. Or 6 months if the cause is unclear or there is active cancer
Thrombolyse if there is a massive PE with haemodynamic compromise
Wells score: PE
Outcome:
Likely: perform a CT pulmonary angiogram
Unlikely: perform a d-dimer and if positive perform a CTPA
Takes into account recent surgery, tachycardia and haemoptysis
Investigations PE
CT pulmonary angiogram
Ventilation-perfusion (VQ) scan- perfusion will be reduced
VTE prophylaxis
Prophylaxis: LMWH i.e. enoxaparin
Unless contraindicated with active bleeding or using warfarin or NOAC
