CSI 7 Flashcards
What are the 4 main causes of breathlessness?
- lung condition
- heart condition
- anxiety
- being unfit
If you get breathless everyday you may be diagnosed with one of these causes
In what ways can lung conditions lead to breathlessness?
- cause the airways to become inflamed and narrowed
- fill the airways with phlegm=harder for air to ove in and out of the lungs
- make lung stiff and less elastic so its harder for them to expand and fill with air
Which Lung conditions cause long term (chronic) breathlessness?
- Chronic obstructive Pulmonary disease(COPD)
- asthma
- interstitial lung disease (ILD), including pulmonary fibrosis
- bronchiectasis
- industrial or occupational lung diseases such as asbestosis, which is caused by being exposed to asbestos
- lung cancer
What lung conditions cause short term (Acute) breathlessness?
- a flare-up of asthma or COPD
- a pulmonary embolism or blood clot on the lung
- a lung infection such as pneumonia or tuberculosis
- a pneumothorax or collapsed lung
- a build-up of fluid in your lungs or the lining of your lungs – this might be because your heart is failing to pump efficiently or may be because of liver disease, cancer or infection
What can lead to heart failure?
problems in rhythm, valves, or cardiac muscles
Why would heart failure cause breathlessness?
- because the heart is not able to increase its pumping strength in response to exercise
- or because the lungs become congested and filled with fluid
When is breathlessness due to heart failure the worst?
at night or when asleep because lying down can make it worse
What heart conditions can cause acute breathlessness?
- heart attack
- abnormal heart rhythm(miss or beat or palpitations)
Why would anxiety lead to breathlessness?
-anxious due to stress=body prepares for action=breath faster and tense muscles
What are the reasons for anxiety?
-general stress
-PHYSICAL HEALTH IS POOR- you could get anxious if you fell like you’re not in control of your condition
-SYMPTOMS-of a condition might make you fell anxious
-
What symptoms are similar to anxiety?
- Breathlessness
- tightness in chest
- getting tired easily
What happens during a panic attack?
- body normal response is exaggerated and you get a rapid build up of physical responses
- As your body tries to take in more oxygen breathing quickens and body releases hormones so your heart beats faster and your muscles tense
What symptoms do you experience during a panic attack?
- have a pounding heart
- feel faint
- sweat
- feel sick
- have shaky limbs
- feel you’re not connected to your body
- feel like you cant breathe
Why would you experience breathlessness if you are unfit?
Muscles get weaker=need more oxygen to work=more breathless you feel
Why would being an unhealthy weight make you fell breathless?
UNDERWEIGHT- breathing muscles are weaker
OVERWEIGHT:
- more effort to breathe and move around
- more weight around the abdomen restricts how much your lungs can move
What is obesity hypoventilation syndrome?
- People who are severely overweight have it
- when poor breathing leads to lower oxygen levels and higher carbon dioxide levels in their blood
What are other causes of long term breathlessness?
- smoking
- conditions that affect how your muscles work, such as muscular dystrophy, myasthenia gravis or motor neurone disease
- postural conditions that alter the shape of your spine, and affect how your ribs and how your lungs expand. For example scoliosis and kyphosis
- anaemia, when a lack of iron in the body leads to few red blood cells
- kidney disease
- thyroid disease
Why can early diagnosis of breathlessness be beneficial?
-you may feel less anxious and therefore less breathless if you have a diagnosis
What will happen when you go see your doctor about your breathlessness?
They’ll show you an MRC (Medical Research Council) breathlessness scale to help describe how breathless you get
What is MRC breathlessness scale based on?
- Does not consider how you think or feel about getting out of breath
- It shows what your breathlessness stops you doing
Describe the Grades on the MRC breathlessness scale?
1-Not troubled by breathlessness except on strenuous exercise
2- Short of breath when hurrying on the level or walking up a slight hill
3- Walks slower than most people on the level, stops after a mile or so, or stops after 15 minutes walking at own pace
4- Stops for breath after walking about 100 yards or after a few minutes on level ground
5-Too breathless to leave the house, or breathless when undressing
What should you tell your doctor when going in for an appointment about breathlessness?
▶︎what you used to be able to do that you can’t do any more
▶︎what people of your age around you do that you think you should be able to do
▶︎what your personal goals are for your day-to-day activity
If you have a phone or camera with you how could this help you at your doctors appointment?
record the sort of activities that make you out of breath so you can show your doctor what it looks/sounds like
What questions will the doctor ask?
▶︎How long have you been feeling breathless and how quickly did it come on?
▶︎Does it come and go or is it there all the time?
▶︎Is there any pattern to your breathlessness?
▶︎Does it start or get worse at any particular time of day?
▶︎Does it come on or get worse when you lie flat?
▶︎Does anything bring it on? For example, pollen, pets or medication?
▶︎Do you smoke?
▶︎Do you also have a cough, or bring up phlegm?
▶︎Do you get chest pain, palpitations or ankle swelling?
▶︎How active are you usually?
▶︎What’s your job or occupation?
▶︎Is your breathlessness related to certain times at work?
▶︎Do you have a history of heart, lung or thyroid disease or of anaemia?
▶︎Have you made any changes in your life because of your shortness of breath?
▶︎Do you feel worried or frightened, depressed or hopeless?
▶︎What have you done to help you cope with the way you’re feeling?
What tests will you doctor do to help diagnose whats causing your breathlessness?
- breathing and LUNG FUNCTION tests
- check BREATHS PER MIN, listen to your chest, and look and feel how your chest moves as you breathe
- heart rate and rhythm
- check if FLUID is building up in your ankles or lungs
- BLOOD PRESSURE and TEMPERATURE
- height, weight, waist and body mass index
- examine your head, neck and armpits to see if your LYMPH GLANDS SWOLLEN
- look at your eyes, nails, skin and joints
- check your BLOOD OXYGEN levels with a PULSE OXIMETER
- might ask you a short questionaire if they spot that you are anxious or depressed
For which tests will you be referred to a hospital for?
- CHEST x-ray
- SPIROMETRY TEST
- ECG(if breathlessness is intermittent you might be asked to wear a portable recorder for 24 hours or 7 days)
- ECHOCARDIOGRAM(non invasive ultrasound of the heart)
- blood tests to detect anaemia, allergies or any thyroid, liver, kidney or heart problems
How long will it take to get a diagnosis?
-time because all possible causes must be considered and you may need to repeat tests and try various treatment before the cause is identified
What investigations should be arranged when diagnosis for breathlessness cannot be established by clinical features alone?initi
◾Chest radiography - to look for signs of heart failure and pulmonary pathology (including pleural effusion).
◾Electrocardiography (ECG) - to look for signs of heart failure, arrhythmia, and pulmonary embolism.
◾Spirometry - to look for signs of obstructive airway disease or a restrictive pattern associated with interstitial lung disease (such as idiopathic pulmonary fibrosis, sarcoidosis, pneumoconiosis, or extrinsic allergic alveolitis).
◾Full blood count - to check for anaemia.
◾Urea and electrolytes, and random blood glucose level - to test for renal failure and diabetes as causes of metabolic acidosis and breathlessness.
◾Thyroid function tests - to detect thyroid disease as a cause of breathlessness.
◾B-type natriuretic peptide (BNP) or N-terminal pro-B-type natriuretic peptide (NTproBNP) - to assess for heart failure.
What should you do if the investigations you arranged do not identify any of the causes of breathlessness?
◾Reassess for risk factors and clinical features of pulmonary embolism. If this is suspected, arrange urgent referral for further investigations
What results would lead you to suspect asthma or COPD?
Airway obstruction is confirmed by a forced expiratory volume in 1 second (FEV1) less than 80% of the predicted value and FEV1/forced vital capacity (FVC) ratio less than 70%.
How would you distinguish between asthma and COPD?
◾Smoking history - almost always present in people with COPD.
◾Age - usually older than 35 years of age for COPD.
◾Chronic productive cough - common with COPD, uncommon with asthma.
◾Breathlessness - progressive with COPD, variable with asthma.
◾Variability of symptoms - common with asthma, uncommon with COPD.
◾Night time wakening with wheeze and breathlessness - common with asthma, uncommon with COPD.
What should you consider if asthma and COPD cannot be distinguished between?
per day, for 14 days) is characteristic of asthma.
◾If FEV1 and the FEV1/FVC ratio return to normal with drug therapy, clinically significantly COPD is not present.
◾Significant diurnal or day-to-day variability of serial peak flow measurements suggest asthma.
◾If doubt still remains, refer the person for a specialist’s opinion.
What tests should be arranged for people with COPD?
- chest radiography to exclude other serious lung pathology (such as lung cancer)
- full blood count to identify anaemia or polycythaemia.
What tests should you arrange for people with suspected heart failure?
- Perform an ECG for all people with suspected heart failure.
- For people without a history of MI, check B-type natriuretic peptide (BNP) or N-terminal pro-B-type natriuretic peptide (NTproBNP) and refer to specialist assessment and echocardiography appropriately if raised above agreed levels for referral.
- For people with a history of MI, refer directly for urgent specialist assessment (to be seen within 2 weeks)
What tests should you arrange for people with suspected bronchiectasis?
- Arrange chest radiography to exclude other causes for the symptoms
- Refer to a respiratory specialist for confirmation of the diagnosis (by high resolution computed tomography scanning).
What tests should you arrange for people with suspected Pleural effusion?
Arrange chest radiography to confirm the diagnosis
What tests should you arrange for people with suspected lung/pleural cancer?
Arrange an urgent chest X-ray (to be performed within 2 weeks) in people aged 40 years and over with breathlessness if:
◾They have ever smoked; or
◾They have been exposed to asbestos; or
◾They have any of the following unexplained symptoms; cough, fatigue, chest pain, weight loss, appetite loss
An urgent chest X-ray (to be performed within 2 weeks) should also be considered in people aged 40 years and over if they have any of the following:
◾Persistent or recurrent chest infection.
◾Finger clubbing.
◾Supraclavicular lymphadenopathy or persistent cervical lymphadenopathy.
◾Chest signs consistent with lung cancer or pleural disease.
◾Thrombocytosis.
What tests should you arrange for people with suspected abdominal splinting secondary to ascites?
◦Arrange an abdominal ultrasound scan to confirm the presence of ascites and to exclude or confirm liver cirrhosis and peritoneal cancer. Arrange other investigations guided by clinical findings (for example liver function tests or erythrocyte sedimentation rate; for signs of cancer).
◦Awaiting results of investigations should not delay urgent referral if cancer is suspected.
What features of Mr Craven suggested he had COPD?
-Shortness of breaht
-Obstructive lung picture on his spirometry
-His chest x-ray showed enlarged hyperinflated lungs and flat hemidiaphragms
-
What are the respiratory diagnoses for shortness of breath?
-Asthma COPD -Pulmonary fibrosis Lung Cancer -Pulmonary embolism -Pneumothorax -Lower respiratory tract infection
What are the cardiovascular/systemic diagnosis for shortness of breath?
- Congenitive heart failure
- Pulmonary oedema
- Vascular defects
- Acute coronary syndrome
- Anaemia
- Renal or liver failure
- Deconditioning
What could prescence of blood when coughing indicate?
lung cancer
What could chest pain indicate?
on CARDIOVASCULAR SIDE-heart disease
on RESPIRATORY SIDE-pulmonary embolism and phneumothorax might cause lateral chest pain
What is a pulmonary embolism?
Blockage of artery in the lungs by a substance that has moved from eleswhere in the body
What is Phneumorthorax?
collapsed lung-occurs when air leaks into the space between your lung and chest wall. This air pushes on the outside of your lung and makes it collapse
What might waking up at night breathless be an indication of?
heart failure
What is swelling of the ankles a sign of if your breathless as well?
BILATERLAL swelling-right heart failure(pooling of the venous circulation) will go along with enlargement of the liver
UNILATERAL swelling-Deep vein thrombosis
What thing would you look at to help differentiate between the causes of breathlessness?
- History
1) When looking at the patient: - CYANOSIS-Blueish tinge tot he lips or mucous membranes(predispose to thinking of a respiratory problem)
- PANTING
- HYPERINFLATED CHEST-appears as rising of the shoulders. Measure chest expansion-this will be reduced
JUGUALR VENOUS PRESSURE-Pulsation of the internal jugular vein
What are the stages you take when doing a physical examination of the patient?
First check history
1) Look at the patient
2) feel with hands
3) Listen with stethoscope
What should you listen out for when listening to patient through a stethoscope?
CRACKLES-indicative of BRONCHITIS
WHEEZES- bronchoconstriction
added valvular sounds(3rd or 4th heart sounds murmurs)
What is FEV1, FVC and FEV1:FVC ratio?
FEV1-volume of air breathed out in 1 second
FVC-volume of air breathed out after taking the deepest breath you can
FEV1:FVC ratio-
What are the normal values for FEV1 and FEV1:FVC ratio?
FEV1:FVC ratio- 0.70-0.85
FEV1-depends on age and height (middle aged varies from 2.5-4.5L)
What are the 4 main causes for Obstructive lung diseases and what causes them?
1) Chronic obstructive pulmonary disease
2) asthma
3) Bronchiectasis
4) Cystic Fibrosis
Due to:
- swelling
- inflammation
- thick mucus
- Damage to the walls of the air sacs
- Narrowing of the airways (airflow obstruction)
What are the 2 main types of COPD?
- emphysema
- broinchitis
What are the causes of restrictive lung disease?
1-INTERSTITIAL LUNG DISEASE-idiopathic pumonary fibrosis
2-SARCOIDOSIS-an autoimmune disease
3-OBESITY(including obesity hypoventilation syndrome)
4-SCOLIOSIS
5-NEUROMUSCULAR disease-e.g. muscle dystrophy or amyotrophic lateral sclerosis
What is the FEV1:FVC ratio for adults with restrictive and obstructive lung disorders?
Restrictive-both forced expiratory volume in one second (FEV1) and forced vital capacity (FVC) are reduced, however, the decline in FVC is more than that of FEV1, resulting in a higher than 80% FEV1/FVC ratio(increased ratio)
Obstructive-less than 70%(Decreased ratio) becuase the FVC is almost the same but the FEV1 decreases
In obstructive diseases why is the FVC the same?
because the same amount of air can be breathed out but due to the obstruction it will just take longer
How do you get the FEV1 and FVC from a spirometry graph?
FEV1-go to time =1s and up to the line and read of the volume on the y-axis
FVC-where the line plateus
What is obstructive lung disease?
Obstructive lung disease is a type of lung disease that occurs due to blockages or obstructions in the airways.
What is restrictive lung disease?
restrict lung expansion, resulting in a decreased lung volume,
What are the symptoms for restrictive and obstructive lung disease?
similar and include: chronic cough shortness of breath dizziness exhaustion weight loss coughing up blood or white sputum chest pain
Describe the pathophysiology of Chronic bronchitis?
- Thick sticky mucus blocks up the airways rather than clears it(Hyperplasia and goblet cells)
- Inflammation and swelling further narrows airways(remodelling)
- g
Describe the pathophysicology of emphysema?
-Air become trapped in the alveoli and therefore gas exchange becomes difficult
What is the main difference between emphysema and chronic bronchitis?
- chronic bronchitis produces a frequent cough with mucus.
- The main symptom of emphysema is shortness of breath
What are the signs of hyperinflation of the lungs
- More than 7 anterior ribs visible at the mid-clavicular line(although this is not particularly sensitive)
- Flattening of the diaphragm(a more sensitive sign)
- Heart may appear small and narrow, sometimes with air visible below the inferior border(floating hear sign)
What is hyperinflation?
Occur when air gets trapped in the lungs and causes them to overinflate. Hyperinflated lungs are often seen in people with chronic obstructive pulmonary disease (COPD) likeemphysema
What are bullae?
Air-filled spaces with thin walls, bordered only by remnants of alveolar septae or pleura
-often caused by emphysema
How would emphysema present on a chest x-ray?
- bullae-look for areas of black=lots of air, and see if these area are outline=bubbles=bullae)
- hyperinflation of the lungs
What 8 actions can be take to help COPD?
- stop smoking
- eat well and keep a healthy weight
- Keep well in the cold
- medications-e.g. inhaler
- Control your breathing-e.g find a good position that helps when your breathless
- keep active
- look after your mental health
- Find out about PR(pulmonary rehabilitation)-programme of exercise and education for people with aims to help people cope with breathlessness
What are the types of inhaled bronchodialators that can help with COPD?
RESCUE THERAPY:
- short acting BETA AGONISTS(SABA)
- short acting muscarinic antagonists (SAMA)
MAINTENANCE THERAPY:
- long acting BETA AGONISTS(LABA). Formoterol, Salmeterol
- long acting MUSCARINIC ANTAGONISTS(LAMA)
What are the types of inhaled corticosteroids(ICS) for COPD?
TAKEN ALONE-not licensed in COPD(beclometasone, Fluticasone)
TAKEN IN COMBINATION-e.g with LABA(Fluticasome+vilaterol=Revlar)
What are the drug combinations that can exist within a single inhaler?
SABA+SAMA
LABA+LAMA
LABA+ICS
LABA+LAMA+ICS
Give examples of SABA, SAMA, LABA and LAMA?
SABA-salbutamol(ventolin)
SAMA-Ipratropium bromide(Atrovent)
LABA-Formoterol, Salmeterol(serevent)
LAMA-Tiotropium(spririva), Glycopyrronium
What do beta-2 agonists do ?
act on beta-2- receptors(sympathetic) and cause bronchial dialation.
SABA acts a lot faster but effects only last for a few hours whereas LABA take longer to act but effects last upto 24hours
What do Muscarinic antagonists do?
block ACh from triggering the bronconstriction by binding to muscarinic receptors (parasympathetic) and also have long and short acting forms
What are non drug treatments for smoking?
-They should also be advised that stopping in one step (‘abrupt quitting’) offers the best chance of lasting success
- a combination of drug treatment and behavioural support is likely to be the most effective approach
-referred to their local NHS Stop Smoking Services, where they will be provided with advice, drug treatment, and behavioural support options such as individual counselling or group meetings
-
What are drug treatment options to stop smoking?
- Nicotine replacement therapy (NRT),
- varenicline-
- bupropion hydrochloride
most effective is VARENICLINE or a combination of long-acting NRT (transdermal patch) and short-acting NRT (lozenges, gum, sublingual tablets, inhalator, nasal spray and oral spray)
-If this is not apporpriate try Bupropion hydrochloride or single therapy NRT
The use of NRT combined with varenicline or bupropion hydrochloride is not recommended
How long are nicotine patches applied for?
16 hours remove overnight OT use a stronger patch for 24 hours
In what forms can you get Nicotine replacement therapy(NRT)?
- Skin patches(release nictine slowly)
- Chewing gum
- Inhalators(look like plastic cigarettes)
- tablets, oral strips and lozenges
- Nasal and mouth spray
(everything apart form patches releases nicotine quicker =may be better for cravings so maybe combine a patch with a faster acting form)
What are the possible side effects of NRT?
- skin irritation when using patches
- irritation of the nose, throat or eyes when using nasal spray
- difficulty sleeping
- upset stomach
- dizziness
- headaches
may need to change dosage depending on effects
How does Varenicline work?
Varenicline (brand name Champix) is a medicine that works in 2 ways. It reduces cravings for nicotine like NRT, but it also blocks the rewarding and reinforcing effects of smoking.
It’s taken as 1 to 2 tablets a day. You should start taking it a week or 2 before you try to quit. Is usually taken for 12 weeks but can go longer
Who cant take Varenicline?
- children under 18 years of age
- women who are pregnant or breastfeeding
- people with severe kidney problems
What are the possible side effects of Varenicline?
- feeling and being sick
- difficulty sleeping (insomnia), sometimes with vivid dreams
- dry mouth
- constipation or diarrhoea
- headaches
- drowsiness
- dizziness
How does Bupropion work?
Bupropion (brand name Zyban) is a medicine originally used to treat depression, but it has since been found to help people quit smoking.
It’s not clear exactly how it works, but it’s thought to have an effect on the parts of the brain involved in addictive behaviour.
It’s taken as 1 to 2 tablets a day. You should start taking it a week or 2 before you try to quit.
A course of treatment usually lasts around 7 to 9 weeks.
Who cant use Bupropion
- children under 18 years of age
- women who are pregnant or breastfeeding
- people with epilepsy, bipolar disorder or eating disorders
What are the possible side effects of Bupropion?
- dry mouth
- difficulty sleeping (insomnia)
- headaches
- feeling and being sick
- constipation
- difficulty concentrating
- dizziness
What is the benefit of an e-cigarette?
delivers nicotine in a vapour. This allows you to inhale nicotine without most of the harmful effects of smoking, as the vapour contains no tar or carbon monoxide.
How do you use a pMDI inhaler?
First test if it hasnt been used in a few days:
- Take the cap of
- shake the inhaler well
- pointing the mouthpiece away from you press the canister to release a puff into the air(amount of test sprays you do depends on the inhaler so check)
Now ready for use:
- Some pMDI inhalers have a dose counter if yours has one check it isnt empty
- take the cap of and make sure there is nothing inside the mouthpiece
- shake the inhaler well
- sit or stand straight and slightly tilt your chin up as it helps the medicine reach your lungs
- breath out gently and slowly away from the inhaler and then seal your lips around the inhaler. Breathe SLOWLY and at the same time press the canister on the inhaler
- when your lungs feel full take the inhaler out of your mouth with your lips closed and hold your breath for 10 seconds and breathe out gently
- repeat if prescribed a second puff
What should you do if you’ve used a inhaler that contains steroids?
rinse your mouth with water and spit it out to reduce the chance of side effects
How do you use a Respimat(SMI) inhaler?
If the inhaler is new you will need to prime it for the first time:
- hold your inhaler upright with the cap closed and twist the base in the direction of the arrows until it clicks
- Push up the catch on the side of the inhaler and open the cap
- point the inhaler toward the floor away from you and press the big grey button
- If you do not see a white cloud repeat the sequence until you do and then close the cap
Now ready to use:
- check the dose count to make sure the inhaler is not empty
- hold the inhaler upright with the cap closed
- twist the base in the direction of the arrows until it clicks
- open cap
- hold inhaler horizontally and check there is nothing in the mouth piece
- sit or stand up straight and tilt chin up to help medicine reach the lungs
- cover 2 holes with mouth and inhale whilst pressing the big grey button once
- take inhaler out of mouth and hold breaht for 10 seconds before breathing out
If you have not used the SMI inhaler for 3 weeks or more than 3 weeks what should you do?
under 3 weeks-repeat the priming sequence once
More than 3 weeks-repeat the priming sequence 3 times
How do you use a DPI(Dry powder device)/ Turbohaler?
Get it ready:
- Twist of the cover and hold upright with the coloured base at the bottom
- turn coloured base as far as it goes in one direction and then all the way back again . you should hear a click and then repeat this
When ready:
- dont have to repeat any of the getting ready steps
- check the dose counter isnt empty
- Hold inhaler upright and twist coloured but to the left as far as it will go then back to the right until you hear a click
- hold inhaler horizontally but not upside down as the powder may tip out
- then breath in like with the other inhalers
What does a red strip mean on a DPI?
If at the top-There are only 20 doses left
If at the bottom-no doses left
How do you use a spacer with your inhaler?
Use tidal breathing technique(multiple breath technique):
- First, hold your inhaler upright and take the cap off. Check there’s nothing inside the mouthpiece.
- Shake the inhaler well. If your spacer has a valve, make sure the valve is facing upwards.
- Put your inhaler into the hole at the back of the spacer. If your spacer has a cap, take it off. Sit or stand up straight and slightly tilt your chin up as this helps the medicine reach your lungs.
- Put your lips around the mouthpiece of the spacer to make a tight seal and begin breathing in and out. Press the canister on the inhaler once, and breathe in and out steadily into the spacer five times. Remove the inhaler and spacer from your mouth.
- If you’ve been prescribed a second puff, with the spacer away from your mouth wait 30 seconds to a minute and shake the inhaler again. Then repeat the steps
Why use a spacer with your inhaler?
get more medicine into your lungs
What sound to some small inhalers make?
- some make whistling sound if your breathing to fast
- clicking sound as you breath in and out
