Cough Flashcards
How does a lung abscess present
Subacute productive cough
Foul smelling sputum
Night sweats
Commonest cause of stridor in children
Laryngomalacia
What is taken everyday for the treatment of asthma regardless of whether the patient has symptoms
Inhaled corticosteroids eg beclometasone dipropionate
Features of moderate asthma
PEFR 50-75% of best or predicted
Speech normal
RR <25 / min
Pulse <110 bpm
Features of severe asthma
PEFR 33-50% of best or predicted
Can’t complete sentences
RR >25/min
Pulse >110
Features of life threatening asthma
PEFR <33% of best or predicted
O2 sats <92%
Silent chest, cyanosis or feeble respiratory effort
Bradycardia, dysrhythmia or hypotension
Exhaustion, confusion or coma
List conditions that lead to respiratory acidosis
Life threatening asthma (decompensated)
COPD
Opiate overdose
Benzodiazepines overdose
Neuromuscular disease
Obesity hypoventilation syndrome
List some conditions that cause respiratory alkalosis
Pulmonary embolism
Anxiety leading to hyperventilation
CNS disorders eg stroke, subarachnoid haemorrhage, encephalitis
Altitude
Pregnancy
Salicylate poisoning
Define asthma
Chronic inflammatory disorder of the airways secondary to T1 hypersensitivity
Symptoms are variable and recurring and manifest as reversible bronchospasm
CF of asthma
Wheezing
SOB
Worse during night or on exercise
Peak flow worse in morning
Chest tightness
Common asthma precipitants
Environmental allergens
Viral infections
Cold air
Emotion
Drugs: NSAID, B blockers
Atmospheric pollutants
Occupational pollutants
Features that suggest asthma diagnosis
Recurrent episodes
Variable symptoms
PH/FH of atopy
Recorded observation of wheeze
Variable PEF or FEV1
Absence of symptoms of an alternative diagnosis
2 phases of acute asthma
Early phase: bronchospasm due to spasmogen production - SM contraction narrows airway
Late phase due to chemotaxins attracting eosinophils and mononuclear cells
Features of acute severe asthma
RR>25
HR >110
PEF 33-50% of best
Can’t complete sentences in 1 breath
Features of life threatening acute asthma
PEF <33% of best
SpO2 <92%
Silent chest, cyanosis, or feeble resp effort
Bradycardia, hypotension or dysarhythmia
Exhaustion or confusion
Blood gas features that indicate a life threatening asthma attack
Normal PaCO2: should normally be low due to hyperventilation - raised = near fatal
Severe hypoxia
Acidosis
Management of acute severe asthma
Oxygen 15L/min by non rebreather
Salbutamol 5mg via oxygen derived nebuliser
Ipratropium bromide 0.5mg
Oral prednisolone or IV hydrocortisone
CXR required if suspecting pneumothorax
Management of acute life threatening asthma
Discuss with ICU team
Add IV magnesium sulphate
Give nebulised salbutamol
IV aminophylline
Management of chronic asthma
- SABA prn (less than 3x per week)
- Low dose ICS for all with confirmed asthma
- LABA eg salmeterol
If no response from LABA stop it and increase dose of ICS
If not enough continue LABA and increase ICS - Add leukotriene receptor antagonist if further needed
MOA of B agonists
Relax bronchial SM leading to bronchodilation
What causes side effects of B agonists
Action on other B adrenoceptors eg B1 in heart leads to tachycardia
B2 in skeletal muscle leads to tremor and cramps
How long do SABAs work for as oppose to LABAs
SABA - 4-6hrs
LABA - >12hrs
MOA of ICS
Reduce exacerbations due to anti inflammatory side effects
Side effects of ICS
Oral candidiasis
Pneumonia
MOA of LTRA
Block the effects of leukotrienes in the airways benefitting the actions of the ICS
Side effects of LTRA
Thirst
GI disturbance
Churg strauss syndrome
MOA of theophylline / aminophylline
Relax SM so dilate airways but also reduce exacerbations
Side effects of theophylline / aminophylline
Dose related
In high dose can get headache, insomnia, nausea, tachycardia and arrhythmias
Pathophysiology of COPD
Progressive airflow limitation that is not fully reversible associated with abnormal inflammatory response of the lungs to nitrous oxide particles or gases
Airflow limitation is due to decreased outflow pressure + increased airway resistance
What is emphysema
Dilation of any part of the respiratory acinus with destructive changes in alveolar walls
Absence of scarring
What is chronic bronchitis
Daily cough with sputum for at least 3mo per year for 2yrs
Abnormal amounts of mucus causes plugging of the airway lumen
Hypersecretion is due to hypertrophy and hyperplasia of bronchial mucus secreting glands
What is bronchiolitis
Cigarette smokers also develop inflammation of the airways <2mm in diameter eg the bronchioles with macrophage and lymphoid cell infiltration
COPD risk factors
Cigarette smoke exposure
Occupational exposure to dusts
A1-antitrypsin deficiency
Recurrent childhood chest infections
Low socioeconomic status
Asthma
How does cigarette exposure predispose COPD
Stimulates neutrophils to produce elastase - this can inactivate a-1-antitrypsin and directly cause mucus gland hypertrophy
CF of COPD
Productive morning cough
Increased amount of LRTIs
Slowly progressive dyspnoea and wheezing
Resp failure
Chronic right heart failure occurs late
Signs of COPD
Mild disease:
- widespread wheeze
Severe disease:
- tachypnoea, hypoxia
- hyperinflation
-poor chest expansion
- hyperresonant throughout chest
- decreased breath sounds
Complications of COPD
Acute exacerbations (infective or non)
Secondary polycythaemia
Cor pulmonale
Pneumothorax
Lung carcinoma
Investigations for suspected COPD
- post bronchodilator spirometry : FEV1/FVC ratio less than 70%
- CXR - hyperinflation, bullae, flat hemidiaphragm
FBC
BMI
How to calculate the severity of COPD
Use FEV1
> 80% of predicted = mild
50-79% of predicted = moderate
30-49% of predicted - severe
<30% = very severe
Medical management of long term COPD
SABA or SAMA
If no features of asthma or steroid responsiveness: LABA +LAMA
Add ICS if still symptomatic or ongoing exacerbations
If features of asthma / steroid responsiveness: add LABA +ICS + LAMA (exacerbations)
When is pulmonary rehabilitation considered
If a person is functionally disabled by COPD
Increases exercise capacity, decreases breathlessness and improves QOL
3 sessions per week for 6 weeks: physical, educational and behavioural
When to consider long term oxygen therapy for patients with COPD
Assess for LTOT if patients have SpO2 <92% on air, FEV1 <30% of predicted, cyanosis, secondary polycythaemia or cor pulmonale
Assess while at their best
Must not be smokers
Increases survival if used for >15hr / day
Management of pneumothorax
If <2cm and no SOB - consider discharge
If not aspiration attempted
If >2cm or SOB or patient is >50 - chest drain
Indications for placing a chest tube in pleural infection
- patients with frankly purulent or turbid / cloudy pleural fluid on sampling
- presence of organisms identified by gram stain and / or culture from a non purulent pleural fluid sample
- pleural fluid <7.2 pH
Management of acute bronchitis
Analgesia
Fluid intake
Doxycycline (not in children or pregnant women)
Amoxicillin
Investigation of choice for idiopathic pulmonary fibrosis
CT scan
When is BIPAP used vs CPAP
BIPAP is used in acute T2 respiratory failure and COPD
CPAP in T1 respiratory failure and pulmonary oedema
How to recognise lung collapse on X-ray
Trachea is pulled towards the opacity
What type of lung cancer presents with central weight gain, thinner and fragile skin
Small cell lung cancer as it secretes ACTH and can cause Cushing’s syndrome
What paraneoplastic syndrome is associated with squamous cell lung cancer
PTH related protein secretion
Management of a secondary pneumothorax <1cm
Admit and give oxygen for 24 hours and review
X ray findings in heart failure (ABCDE)
Alveolar oedema (bat’s wings)
Kelley B lines (interstitial oedema)
Cardio eagle
Dilated upper lobe vessels
Effusion (pleural)
What does normal PaCO2 on ABG in asthma attack indicate
Exhaustion
Suggests it is a life threatening attack
Panic attack results on ABG
Hyperventilation which causes respiratory alkalosis (high pH, low CO2)
PO2 will be normal as no issues with gas exchange
No metabolic compensation as attack resolves rapidly
