MedED chronic SOB Flashcards
What are the 3 categories of lung disease anatomically?
Airways
Alveolar
Parenchymal
What are symptoms of resp conditions that you should ask about? What specifically might you ask about?
Cough- wet/dry? SOB- exertional? Haemoptysis Fatigue Chest pain- pleuritic?
What cells mediate inflammation in asthma?
Mast cells
IgE
Eosinophil
What happens to the airway and parenchyma in asthma?
Airway= obstructed (reversibly) Parenchyma= in tact
What type of obstruction is present in asthma?
Reversible/ variable obstruction
How will someone with asthma classically present?
SOB Dry cough Chest tightness Waking up at night coughing Triggered when cold Wheeze
What triad of atopy might someone with asthma have?
Food allergy
Hayfever
Eczema
What are risk factors for asthma?
Family history
Allergies eg food, hayfever, pets, dust mites
GORD (it can make asthma worse)
What condition can make asthma worse?
GORD
What is used to assess the severity of someones asthma? How does it work
ACT= asthma control test
It works by:
Score over 20= controlled
Score under 19= uncontrolled
What does BDR stand for?
Bronchodilator reversible
What will FEV1/FVC be in obstructive disease?
<0.7
What will FEV1/FVC be in restrictive disease?
> 0.7
What is the first line investigation for asthma?
Spirometry
What happens to FEV1 in asthma?
Reduced
What happens to FVC in asthma?
It stays the same
What investigations might you do for asthma?
Spirometry
Fractional exhaled nitric oxide
What is fractional exhaled nitric oxide in asthma?
Over 40 ppm
What treatment addresses inflammation in asthma?
Inhaled corticosteroids
What dose of ICS is most effective in asthma?
Low dose
What are the asthma reliever medications? Why are they relievers?
They make the symptoms go away but do not address the inflammation
1) SABA- not effective in infections or exacerbations
2) LTRA
3) LABA
4) LAMA
What medications should you start for an adult with asthma?
First= start low dose ICS (inhalers) Second= start LTRA Third= add LABA (if doing this stop LTRA) Fourth= LABA as MART
Also give SABA alongside all of this
Review every 4-8 weeks and they have to be adherent
What is MART?
Combination inhaler of ICS with a LABA (LABA has long and short acting components)
What is important when reviewing medications in a patient with asthma? How might you do this
Adherence- they have to be adherent or it wont work
Ask them:
How many times a week would you forget you medications
Can you show me how you take your inhaler
Do you know what your medications do?
What is occupational asthma and what do you need to know about it?
Asthma due to inhaled particles at work
Symptoms resolve during the holidays/ time away from work and get worse when at work
To manage they should try to avoid their triggers eg use PPE, then also manage like normal asthma
What type of obstruction do you get in COPD?
Irreversible airway obstruction
What are the features of COPD?
Small airway obstruction
Emphysema
Excess mucus production
What is the main anti inflammatory molecule in the lung?
Alpha 1 antitrypsin
Deficiency of what causes inflammation of the lungs?
Alpha 1 antitrypsin
What are the biggest risk factors for COPD?
Increasing age
Smoking
How will someone with COPD classically present?
Dyspnoea- exertional, persistent
Cough- this may be productive (30% of patients have a cough)
Wheeze
What will you ask in a COPD hx?
Smoking?
Family hx of COPD/ alpha 1 antitrypsin
Have you had any exacerbations
Ask all malignancy symptoms- increased risk of cancer
RHF- ankle swelling
Associated symptoms- pink frothy sputum/heamoptysis/ hoarse voice etc
What heart problem is associated with COPD and why?
RHF- the heart is pumping through an obstructed lung system
What are some signs of COPD?
Barrel chest/ hyperexpansion Wheeze Cyanosis CO2 flap Tachypnoea Cor pulmonale= ankle swelling, raised JVP, RV heave Tar staining Flared nostrils Use of accessory muscles to breathe Look for clubbing because of increased risk of malignancy
How do you identify hyperexpansion?
Reduced cricosternal distance
What is the first line investigation for COPD?
Spirometry
What will you see on spirometry in COPD?
Obstruction with no bronchodilator reversibility
FEV1/FVC <0.7
What should you use to assess severity of COPD? What does it measure
MRC- it measures dyspnoea
What is the first line pharmacological treatment for COPD?
SABA or SAMA
If this doesnt help and there are asthma features (eosinophils, FEV1 variability, peak flow variability)= ICS and LABA, then ICS and LABA and LAMA
If no asthma features= LABA and LAMA, them LABA and LAMA and ICS
Why is ICS not given to COPD patients unless they have asthma features?
It reduces immunity and increases risks of flares which they are more likely to die of
How will someone with idiopathic pulmonary fibrosis present?
Chronic SOB Progressive exertional dyspnoea Dry cough Clubbing Bibasal inspiratory creps Weight loss, fatigue, malaise
What crackles do you get with fibrosis?
Bi basal fine end inspiratory crackles
What are risk factors for pulmonary fibrosis?
Increasing age
Smoking
What is the gold standard investigation for IPF? What will the results be?
Spirometry and gas transfer- Spirometry= FEV1/FVC >0.7, reduced gas transfer
What is DLCO and what does it tell you?
Diffusing capacity for carbon monoxide- it tells you how quick carbon monoxide is moving across the alveoli and will therefore tell you if there is an alveolar pathology
What are causes of pulmonary fibrosis?
Exposure to toxins
Rheumatoid arthritis- check rheumatoid factor, anti ccp, ana panel etc
How is IPF managed?
Specialist care:
Pulmonary rehab
Ambulatory or long term o2
Antifibrotics (pirfenidone or nintedanib if FVC is between 50-80% predicted)
What is the prognosis of IPF?
2/3 years
It will stay until you die
Decline might be slow or extremely fast
What are extrapulmonary symptoms of sarcoidosis?
Joint pain
Lupus pernio or erythema nodosum
Eye problems- photophobia, red painful eye, blurry vision
What is sarcoidosis?
Non caseating granulomas deposited around the body causing disease
Can affect all organs but most commonly lungs
What are risk factors for sarcoidosis?
Infection with TB
Women aged 20-40
Family hx
Afro caribbean
How will someone with sarcoidosis classically present?
Chronic dry cough
Fatigue
Progressive SOB (exertional)
Skin lesions- erythema nodosum or lupus pernio
Eye problems - photophobia, painful red eye, blurry vision due to posterior and anterior uveitis
Facial nerve palsy
Cardiomyopathy
What is a non caseating granuloma?
A collection of macrophages around a core
Is there necrosis in sarcoidosis?
No
What are some signs of sarcoidosis when you examine someone?
Wheeze
Ronchi
Erythema nodosum
What are pulmonary manifestations of sarcoidosis?
Bilateral hilar lymphadenopathy
What electrolyte is high in sarcoidosis?
Calcium
What is there a lack of in stage 4 sarcoidosis?
Hilar lymphadenopathy
What investigations are done for sarcoidosis?
Investigate all organs Lungs: CXR High resolution CT ECG UEs LFTs
What is high in sarcoidosis?
Calcium
Serum ACE
How is sarcoidosis managed?
Mainly corticosteroids
Immunosupressants if this doesnt work eg azothioprine, methotrexate
What is OSA?
Complete or partial collapse of the upper airway causing obstructive apnoea or hypopnoea
What are risk factors for OSA?
Obesity
Cushings
Acromegaly
Menopause
How will OSA present?
Loud snoring, then silence then snoring again
Daytime sleepiness
Restless sleep
What will someone with sleep apnoea tell you when they present?
They will tell you they are tired and have bad sleep
They may not be aware they are waking at night because they can wake up hundreds of times without knowing it
What scoring system is used for OSA? What does it stand for? What score is needed
STOP BANG: snoring, tired, observed apnoea, pressure (BP), BMI over 35, age over 35, neck cirum over 40 and male gender
Score over 3= refer to polysomnography
What is the gold standard investigation for OSA? What does it calculate
Night time in lab polysomnography
It calculates apnoea hypopnoea index which is average no of obstrucitve events per hour
What is treatment for OSA when someone is asymptomatic vs symptomatic
Everyone= weight loss, smoking and alcohol stop, sleep on side if poss Asymp= intra oral mandibular advancement device Symp= CPAP
What occupational lung disease is caused by coal?
Simple pnuemocosis
Progressive massive fibrosis
What is simple pneumoconosis?
Coal in the lungs
What are symptoms of simple pneunomocosis?
None, usually asymptomatic
How will someone with progressive massive fibrosis present?
History of working in a coal mine
Exertional dyspnoea
Cough with or without black sputum
Fibrotic masses on CXR
What is important to remember in occupational lung disease?
The patients may be entitled to compensation if they apply within 3 years of being diagnosed
What professions increase risk of silicosis?
Arty stuff like stonemasonry, pottery, ceramics
How will someone with silicosis present?
Cough and SOB
Upper lobe fibrotic masses
What 3 main particles cause interstitial lung disease?
Coal
Asbestos
Silica
What professions increase risk of asbestosis?
Working with asbestos: shipyard workers, mining, aerospace
Working near asbestos: electricians, painters and masons
Background workers
How will someone with asbestosis present?
Chronic progressive exertional dyspnoea
Dry cough
May have malignancy symptoms- FLAWS and haemoptysis
What are signs of asbestosis?
Clubbing Reduced expansion Asbestos warts Bibasal crackles RHF
What type of CT is done for ILD?
High resolution
