CPC 1 (breathlessness) and basic resp Flashcards
Causes of clear grey mucoid sputum
Chronic bronchitis and COPD
Causes of white viscid mucoid sputum
Asthma
Causes of purulent yellow sputum
Acute bronchopulmonary infection. Asthma.
Causes of purulent green sputum
Longer standing infection; pneumonia, bronchiectasis, cystic fibrosis, lung abscess.
Rusty red sputum
Pneumococcal pneumonia.
Classes of causes of haemoptysis
Tumour, infection, vascular, vasculitis, trauma, cardiac, haematological.
Classes of causes of central chest pain
Tracheal, cardiac, oesophageal, great vessels.
Causes of chronic cough in a non-smoker with a normal X-ray.
GORD, chronic sinus disease or ACE inhibitors.
Causes of chronic wheezy cough
COPD and asthma.
Feeble non-explosive ‘bovine’ cough
lung cancer invading the left recurrent laryngeal nerve.
Harsh, barking, painful cough with stridor
laryngeal inflammation, infection or tumour.
Persistent moist cough in the morning.
Chronic bronchitis.
Dry, centrally painful, non-productive cough
tracheitis and pneumonia.
Chronic dry cough
interstitial lung disease
Inspiratory stridor
narrowing at the vocal cords
Biphasic stridor
tracheal obstruction
Expiratory stridor
tracheobronchial obstruction.
respiratory systems review
Shortness of breath Cough Wheeze Sputum production (colour, amount) Blood in sputum Chest pain
coarse crackles can be caused by…
pneumonia, exacerbation of COPD, bronchiectasis
Bilateral wheeze is caused by
Asthma, exacerbation of COPD, (LVF)
Bilateral fine crackles are caused by
LVF, (or exacerbation of COPD)
Focal reduced air entry
Pneumonia
Purulent phlegm
Pneumonia, exacerbation of COPD, (asthma).
Questions about cough
Onset,
Timing (on swallowing? Weekends?)
Questions about sputum
Colour
Amount
Taste or smell
Solid material
Questions about haemoptysis
Onset
Amount
Appearance
Haemoptysis for more than a week raises concern over…
Lung cancer.
Haemoptysis with purulent sputum suggests…
Infection
Coughing up large amounts of pure blood suggests…
Lung cancer, bronchiectasis, tuberculosis and lung abscess.
Causes of breathlessness while lying flat
LVF, resp muscle weakness, large pleural effusion or pressure on chest e.g. obesity, massive ascites
Causes of breathlessness lying on one side
Unilateral lung disease, dilated cardiomyopathy or tumour pressing on mediastinum.
Causes of breathlessness waking patient from sleep
Typical of asthma or LVF
Causes of breathlessness on walking or other exercise
COPD, may improve on coughing. Asthma, may continue to worsen for several minutes after stopping exercise.
Causes of tachypnoea due to increased ventilatory drive.
Fever, acute asthma and exacerbation of COPD.
Causes of tachypnoea due to reduced ventilatory capacity
Pneumonia, pulmonary oedema and interstitial lung disease.
Causes of bradypnoea
Opioid toxicity, hypercapnia, hypothyroidism, raised ICP and hypothalamic lesions.
What is one pack year
Smoking 1 pack of 20 cigarettes per day for a year equates to a single pack year.
Causes of bronchiectasis
Whooping cough or measles, especially if complicated by pneumonia.
Can be idiopathic.
Lung complications of connective tissue disorders and rheumatoid arthritis.
Pulmonary fibrosis, effusions, bronchiectasis.
Exposures causing pulmonary fibrosis
Asbestos, quartz, coal, beryllium (nuclear and aerospace industries)
Exposures other than smoking causing COPD
Coal, in coal mining.
Exposures causing malignancy
Asbestos and radon (in metal miners)
Exposures causing byssinosis
Cotton, flax or hemp.
Investigations for suggested asthma
Peak flow rate, eosinophil count (allergic asthma), allergen tests (specific IgE, skin prick).
Bronchial challenge test can exclude asthma
Causes of hyper-resonance
Pneumothorax
Causes of dullness on percussion
Consolidation, pulmonary collapse, severe fibrosis.
Causes of stony dullness
Pleural effusion, haemothorax.
Causes of early inspiratory crackles
Small airway disease e.g. bronchiolitis
Causes of middle to late inspiratory crackles
Pulmonary edema (middle and late), pulmonary fibrosis, COPD, pneumonia, abscess, TB (coarse).
Causes of biphasic coarse crackles
Bronchiectasis.
Causes of bronchial breathing
Common; pneumonia causing consolidation.
Whispering pectoriloquy
The whispering is not heard over normal lung, only over consolidation.
Common causes of chronic shortness of breath
Obesity, COPD, anaemia, congestive heart failure, asthma
Less common causes of chronic shortness of breath.
Bronchiectasis, many small PEs, malignancy, effusion, aortic stenosis, fibrosing alveolitis.
Define dyspnoea
Difficulty breathing
Define tachypnoea
Increased rate of breathing
Hyperpnoea
Increased level of ventilation as in metabolic acidosis.
Hyperventilation
Over breathing resulting in decreased alveolar and arterial pCO2.
Pulmonary causes of acute, sudden onset dyspnoea
Pneumothorax, inhaled foreign body, anaphylaxis
Cardiovascular causes of acute sudden onset dyspnoea
PE
Pulmonary causes of acute dyspnoea, onset over hours
Acute bronchitis, pneumonia, asthma
Cardiovascular causes of acute dyspnoea onset over hours
LVF, pericardial tamponade, high altitude.
Psychogenic causes of acute dyspnoea, onset over hours
Anxiety, panic attacks
Metabolic causes of acute dyspnoea onset over hours
Diabetic ketoacidosis, ureamia, poisons
Types of causes of acute dyspnoea
Pulmonary, cardiovascular, psychogenic, metabolic.
Types of causes of chronic dyspnoea
Respiratory, cardiovascular, neuromuscular, mechanical, endocrine.
Resp causes of chronic dyspnoea
Pleural effusion, tumour, interstitial lung disease, TB, emphysema, chronic bronchitis.
Cardiac causes of chronic breathlessness
CCF, recurrent PEs, pulmonary hypertension, anaemia.
Neuromuscular causes of chronic breathlessness
Myasthenia gravis, MND, myopathies.
Mechanical causes of chronic breathlessness
Chest wall deformities, obesity.
Endocrine causes of chronic breathlessness
Thyroid disease
Definition of asthma
Variable airflow obstruction that is reversible either spontaneously of with treatment
Diagnosis of acute severe asthma
One of the following; PEF 33-50% of best or predicted RR more than 25 per minute HR greater than 110 per minute Inability to complete sentence in one breath
Investigations for acute dyspnoea
CXR, thoracic CT,
resp function test,
Blood gas interpretation
Diagnosis of near fatal asthma
Raised PaCO2, and/or requiring mechanical ventilation.
Life-threatening asthma
1) PEF
2) SpO2
3) PaO2
4) PaCO2
5) on ausculatation
6) appearance
7) circulation
8) mental state.
1) PEF less than 33% best or predicted
2) SpO2 less than 92%
3) PaO2 less than 8
4) normal PaCO2 (4.6-6.0 kPa)
5) silent chest
6) cyanosis and feeble respiratory effort
7) bradycardia, arrhythmia, hypotension
8) exhaustion, confusion,
coma
Seasonal allergen variations (pollens and spores)
Grass in early summer
trees in spring
weeds across summer
mould in late summer.
IgE mediated responses to allergen challenge (timescale)
immediate phase = 20-40 mins
late phase = 6-12 h
Immediate response in asthma mediated by…
histamine
Effects of histamine in asthma
Increased local blood vessel permeability, bronchial smooth muscle contraction, stimulation of vagal receptors.
Asthma late response profile
Mast cells in secretory state (remodelling)
IL-4, IL-5, IL-13, TNFa
neutrophils, eosinophils, and Th2 cells
Proliferation of airway epithelial cells and smooth muscle cells.
Sputum and BAL findings in asthma
Curschmann’s spirals, creola bodies, charcot-Leyden crystals and eosinophils.
Bronchial asthma
severe end of disease, expiratory airway collapse
Gross pathology of asthma
Over-inflated lungs, collapsed tissue, mucus plugs.
Microscopic pathology of asthma (6)
1) eosinophilic sputum
2) changes to airways
3) mucus hypersecretion
4) oedema
5) smooth muscle hyperplasia
6) epithelial denudation.
Physiology behind mucus hypersecretion in asthma
Differentiation of epithelial and goblet cells, induced proteases, IL-13, IL-9, TNFa, increased mucin, MUC5AC and MUC5C .
Resp function test: decreased FEV1, normal FVC, FEV1/FVC below 70%
Obstruction
Sources of H+ in the blood
CO2 (oxidation of S containing aa, incomplete oxidation of energy substrates)
A normal pO2
11-15 kPa
A normal pCO2
4.5-6 kPa
normal pH
7.35 - 7.45
Causes of Type 1 resp failure
pulmonary oedema, pneumonia, cryptogenic fibrosing alveolitis and ideopathic pulmonary fibrosis.
Causes of Type 2 resp failure
COPD, chest wall deformation, respiration muscles weakness, opiate overdose.
Causes of of metabolic acidosis
Diabetic ketoacidosis, renal failure, lactic acidosis (circulatory failure or toxicity)
normal CRP
less than 10 mg/l
Raised CRP
Bacterial infections and inflammation.
Filling of alveoli in consolidation
Pus (= infection), blood (= alveolar haemorrhage), fluid (pulmonary oedema), tumour cells (lipidic adenocarcinoma, lymphoma), protein ( alveolar proteinosis).
Results of interstitial lung disease
Reduced elasticity resulting in a restrictive deficit on spirometry.
Increased diffusion distance resulting in impaired gas transfer.
Cause of interstitial fibrosis
After usual interstitial pneumonia or after non-specific interstitial pneumonia with a connective tissue disorder.
Types of interstitial lung disease.
Those with a known cause or association.
Idiopathic interstitial pneumonias
Granulomatous disorders (inc. sarcoidosis)
Cystic lung diseases.
Radiology of usual interstitial pneumonia
Subpleural distribution, honeycombing (heterogenous both temporally and spatially), increased risk of lung cancer.
Prognosis of usual interstitial pneumonia
Poor. Median survival is 3 years from diagnosis.
Epidemiology of interstitial pulmonary fibrosis. Age, sex and risk factors.
Males over 60. Risk factors include smoking, occupational hazards and family history.
Asbestos related diseases.
Asbestosis, mesothelioma, lung cancer, pleural fibrosis and fibrous pleural plaque formation.
Risk factors for PE
Smoking, DVT, contraceptive pill, immobility, malignancy, previous PE, being pregnant, obesity, HRT, increased abdominal pressure.
PE basic obs
Increased respiratory rate, decreased O2 stats, increased heart rate. (Occasionally febrile. Decreased BP if absolutely massive PE.)
PE on examination
Look for signs of DVT or varicosity. No other major signs on examination unless PE really massive, then cyanosis and signs of shock.
PE investigations
Baseline bloods, D-dimer for degrading clot, coag. screen, troponin to rule out MI.
Radiology: CSR (ruling out other), CT PA.
Special tests: V/Q scan for pregnant women.
PE treatment
Oxygen if hypoxic. Fluid bolus. Thrombolise Analgesia Anti-coagulants (low molecular weight heparin for 5 days to cover start of warfarin). Occasionally vena cava filter.
Causes of emphysema
Smoking (increased alveolar macrophages, effect on neutrophil elastase).
Alpha-1-antitrypsin deficiency.
Radiographic findings in emphysema
Hyper-transradiancy.
Changes in vascular pattern
Bulla
Hyperinflation.
Radiology. Reticular pattern in the lung resembles…
A net.
Radiological appearance of interstitial fibrosis
Interstitial thickening, architectural distortion, airway dilatation, honey-combing and ground glass.
Radiology. Key point of fibrotic reticular pattern.
Peripheral distribution.
Causes of fibrotic reticular pattern on an X-ray.
Idiopathic pulmonary fibrosis, asbestosis, drug related fibrosis, collagen vascular disease, non-specific interstitial pneumonia and hypersensitivity pneumonitis.
Causes of paroxysmal nocturnal dyspnoea
Left-sided heart failure
Sudden onset dyspnoea
Obstruction, anaphylaxis, pneumothorax, PE, asthma
Dyspnoea onset over hours
Asthma, pneumonia, pulmonary oedema, extrinsic allergic alveolitis, cardiac tamponade.
Dyspnoea onset over days
Asthma, COPD, diffuse parenchymal lung disease, heart failure, pleural effusion, cancer, anaemia.
PEFR
Peak expiratory flow rate; useful in detecting airway limitation and in monitoring response to treatment in asthma.
FEV1:FVC > 75%
Restrictive lung disease.
Increased total lung capacity (TLC) and residual volume (RV) suggests…
Obstructive lung disease
Reduced total lung capacity (TLC) and residual volume (RV) suggests…
Restrictive lung disease such as fibrosis.
Investigations for asthma
Demonstration of variable airflow limitation by PEFR.
If not FEV1
Features of acute severe asthma
Unable to complete sentence in one breath.
RR > 25 breaths/min
HR > 110 bpm
PEFR 33-50% of predicted or best
Features of near fatal asthma
Silent chest, cyanosis or feeble resp effort
Exhaustion
Bradycardia/hypotension
PEFR
Which pneumonia can cause lymphopenia?
Legionella
Marked red cell agglutinationn of blood film is sometimes raised in which pneumonia?
Mycoplasma
Which pneumonias cause a sagging horizontal fissure sign?
Strep and Klebsiella
Differential diagnoses for increased ankle swelling and shortness of breath at night.
1) Congestive cardiac failure secondary to ischaemic heart disease
2) Congestive cardiac failure secondary to valvular heart disease
3) Right ventricular failure secondary to pulmonary disease
4) Deep venous thrombosis with recurrent pulmonary emboli. More commonly unilateral
Classic dyspnoea associated with cardiac disease
Orthopnoea (worse on lying down), requiring several pillows to sleep at night.
Paroxysmal nocturnal dyspnoea.
Dyspnoea associated with pulmonary emboli
Acute onset, often associated with pleuritic chest pain.
How can asthma and COPD cause RVF?
RVF can be secondary to pulmonary hypertension. Generally exacerbated by lying flat.
Timescale of asthma symptoms
Worse in the night (cough) and morning (breathlessness), getting better throughout the day.
General examination findings suggestive of cardiac cause of breathlessness.
Sinus tachycardia, elevated JVP, displaced cardiac apex, a third heart sound, bibasal crepitations (and possibly pleural effusions) and pedal +/- sacral oedema.
Examination findings suggestive of mitral valve cardiac cause of breathlessness.
Atrial fibrillation, elevated JVP, displaced and heaving cardiac apex, a third heart sound, a pansystolic murmur heard loudest at the apex and radiating into the axilla, bibasal crepitations (and possibly pleural effusions) and pedal +/- sacral oedema.
What are the NYHA grades of heart failure?
I No limitation No symptoms during usual activity
II Mild limitation Comfortable at rest or with mild exertion
III Moderate limitation Comfortable only at rest. Dyspnoea with mild exertion
IV Severe limitation Dyspnoea at rest
What conditions can cause cardiac decompensation in the setting of previously adequate cardiac function, leading to breathlessness and pitting oedema?
Anaemia, hyperthyroidism and renal failure.
What should you check on a pleural tap?
Check protein, glucose, lactate dehydrogenase.
More importantly cytology to check for malignant mesothelial cells.
Microscopy, culture and sensitivity in case of a parapneumonic effusion.
Acid fast bacilli culture and sensitivity in TB.
Key cytokines in asthma.
IL-4, IL-13 and IL-9
Obstructive lung diseases
Asthma, COPD, bronchiectasis
