repsiratory Flashcards
what is asthma?
chronic inflammatory disorder characterised by recurrent episodes of typical symptoms: wheee, chest tightness, breathlessness, cough + airflow obstruction, hyper responsiveness and airway inflammation
2 types of asthma
extrinsic/atopic childhood asthma: triggered by inhalational of allergens
intrinsic/ non-atopic adult onset: progressive and less responsive to therapy
what is an asthma attack?
worsened symptoms over a period of hours to days not responsive to patients normal asthma medications
requires either an increase in normal treatments or new more complex treatment
who gets asthma?
1 in 12 children
1 in 10 adults
males more than females in childhood then opposite in adults
causes of asthma
atopy
genetic
environment: allergen exposure, occupational factors, viral infections, drugs, maternal smoking, hygiene hypothesis
risk factors of asthma
personal or family history of atopy air pollution obesity prematurity and low birth weight viral infections in early childhood maternal smoking smoking early exposure to broad spec Abc beta blockers anti inflammatory drugs
pathophysiology of asthma
allergen induced airway inflammation = smooth muscle constriction, thickening of airway wall, basement membrane thickening and mucus and exudate in airway lumen
airway remodelling -
presentation of asthma
typical episodic symptoms: breathlessness, chest tightness, cough, wheeze
diurnal variation
reduction on holiday or at home (occupational)
sputum
triggered by cld air, URTI, exercise, pollution, allergen, occupation
signs on examination of asthma
tahcypnoea wheeze - polyphonic hyperinflated chest hyper reosnant to percussion decreased air entry
acute asthma signs
severe attack = inability to complete sentences, pulse>110, RR > 25, PEFR 33-55%
investigations for asthma
peak flow - diurnal variation
spirometry - does FEV1 improve with bronchodilator?
exercise tests
prednisolone trial
CXR to rule out other causes
skin prick, blood tests and allergen provocation tests to find triggers
treatment of asthma
step wise approach
salbutamol \+ low dose ICS \+ low dose ICS + LABA \+ medium dose ICS +LABA \+high dose ICS + LABA + omalizumab \+ high dose ICS + LABA + oral corticosteroid + omalizumab
acute asthma treatment
O SHIT ME
Oxygen 15L non rebreathe mask Salbutamol 5mg nebulizer every 15-30min Hydrocortisone 200mg IV or prednisolone 40mg oral Ipratropium bromide IV 0.5mg 4-6hts Theophylline Magnesium sulphate 2g IV Extra help
what is COPD
progressive lung disease characterised by airflow obstruction with little or no reversibility
chronic bronchitis + emphysema
who gets COPD
> 50 yo
insidious onset
more in men
smokers
risk factors for COPD
tobacco smoking
occupation exposure - dust, chemicals, noxious gas, particles
air pollution
genetics - homoxygous antitrypsin deficiency?
pathophysiology of COPD
damage to lung by 3 mechanisms
- inflammatory cell activation by cigarrete smoke
- oxidative stress
- impaired mucociliary clearance
presentation of COPD
progressive SOB
reduced exercise tolerance
persistent cough
chronic sputum production
wt loss, peripheral muscle weakness or wasting
frequent infective exacerbations occur giving purulent sputum
signs on examination of COPD
pink puffers - breathlessness is predominant problem, they’re not cyanosed
blue bloaters - hypoventilation, cyanosed, oedematous, CO2 retention
red flag = clubbing - lung cancer until proven otherwise
investigations for COPD
gold standard = spirometry
FEV1/FVC ratio <0.7 = presence of persistent airflow limitation
severity classified in terms of effect on lung function
pulse oximetry, CXR, FBC, sputum culture, A antitrypsin, ECG/ECHO
management of COPD
smoking cessation
bronchodilators - step wise approach, inhaled tiotropium bormide, short acting beta antagonist, long acting B2 agonist added
corticosteoids
prevention of infectiosn - vaccines
oxygen
complications of COPD
exacerbations
respiratory failure
cor pulmonale
lung cancer
what is bronchial carcinoma
95% of primary lung tumours
most common malignant tumour in western world
more in men 3:1
types of bronchial carcinoma
small cell 20-30% - in endocrine cells, repsonds to chemo, mets common, poor prognosis
non-small cell (squamous, large cell, adenocarcinoma) -
risk factors for bronchial carcinoma
smoking
urban areas
passive smoking
exposure to asbestos and possibly also contact with arsenic, chromium, ron oxides and products of coal combustion
presentation of bronchial carcinoma
local effects of tumour - cough, chest pain, haemoptysis, breathlessness
spread within chest - pain and bone fractures, pancoasts tumour - horners syndrome, spread to LRL nerve - coarseness and bovine cough,
metastatic disease - bone, brain are common
non metastatic manifestations, - finger clubbing, malaise, lethargy, weightloss, lymphadenopathy
investigations of bronchial carcinoma
confirm diagnosis y CXR
determine histology by biopsy via bronchoscopy or tranthoracic FNA
assess spread of tumour by PET CT
treatment of bronchial carcinoma
non-small cell lung cancer - surgeyr, neoadjuvant chemo, radiotherapy
small cell - chemo and radiotherpay for limited disease, just chemo for extensive disease, very poor prognosis
causes of pneumothorax
tension penumothorax - pleural tear acts as one way valve for air. unilateral increase in intrapleural pressure
spontaneous - tall, young and thin men, rwuslt of rupture of a pleural bleb (congenital defect in connective tissue of alveolar wall)
secondary - pneumothorax associated with underlying lung disease (COPD)
presentation of Pnuemothorax
sudden onset of pleuritic chest pain and breathlessness
signs on examination of pneumothorax
reduced breath sounds
hyperessonant percussion
investigations of pneumothorax
standard PA chest XR to confirm diagnosis
CT differentiates emphysematous bullae from pneumothoracies and prevent potentially dangerous aspiration
CT detects small pneumothoracies
treatment of pneumothorax
if breathless
aspirate air
if failure to re-expand lung
intercostal tube drainage
if still no re expansion after 48hrs , then surgery pleurectomy or pleurodesis
causes of pleural effusion - unilateral
transudate - protein <30g/L
- caused by imbalance of hydrostatic forces
- heart failure, hypoalbuminaemia, constrictive pericarditis, hypothyroidism, ovarian fibroma
exudate >30mg protein
- infection, malignancy, PE with infarction, connective tissue disease,
presentation of pleural effusion
may be asymptomatic if small but breathless if large
reduced chest wall movements
stony dull to percussion
absent breath sounds
reduced vocal resonance`
investigations of pleural effusion
CXR - mensicus visible on erect
diagnostic pleural fluid aspiration - appearance noted and sent to cytology
contrast enahnced CT if diagnosis remains unclear
pleural biopsy - for tissue diagnosis
treatment of pleural effusion
exudates - drain
transudates - treat underlying causes
malignant effusions - treat by aspiration followed by installation of sclerosing agent into pleural space - talc, tetracycline, bleomycin
cuases of lobar pneumonia
inflammation of lungs caused by bacteria
classified anatomically - lobar, bronchopneumonia
TB also is cause
can be caused by aspiration of vomit and radiotherapy
risk factors of lobar pneumonia
underlying lung disease smoking alcohol abuse immunosuppression other chronic illness
presentation of lobar pneumonia
pyrexia, respiratory symptoms (cough, sputum, pleurisy, dyspnoea), signs of consolidation and pleural rub,
important history questions for pneumonia
contact with bird (psittacosis) farm animals recent stays in large hotels chronic alcohol abuse IV drug abuse contact with other patients with pneumonia
signs on examination of pneumonia
CURB 65
Confusion
Urea >7mmol/L
Respiratory rate >30/min
Blood pressure <90/<60
investigations for pneumonia
CXR - only this if outpatient sputum blood tests serology ABG urine
treatment of pneumonia
pleuritic pain = analgesia
hypoxaemia = oxygen
fluids
physiotherapy
HAP: coamoxiclav 3x daily or more severe cases use second generatio cephalosporin
metronidazole dded in those at risk of anaerobic infection
antibiotic treatment adjusted after MC+S results
causes of PE
most common = DVT in lower limb
other sources - tumours, fat, amniotic fluid, sepsis, foreign bodies, air
risk factors of PE
DVT prev DVT or PE active cancer recent surgery hospitalisation lower limb trauma immobilisation pregnancy
presentation of PE
dyspnoea
tachypnoea
pleuritic chest pain
features of DVT
signs on examination of PE
tahcycardia haemoptysis syncope hypotension crepitations cough or fever
investigations for PE
wells score
CXR, ABG, ECG
ddimer for exclusion
spiral CT with IV contrast
radionuclide lung scan (demonstrates areas of ventilated lung with perfusion defects)
treatment of PE
high flow oxygen if hypoxemic
thrombolysis for massive embolism
surgical embolectomy occasionally if thrombolysis contraindicated or ineffective
analgesia
prevention of further: LMWH, oral warfarin
who gets pulmonary fibrosis
late 60s
more common in males
what is pulmonary fibrosis
restrictive lung disease
patchy fibrosis of the interstitium and minimal or absent inflammation, acute fibroblastic proliferation and collagen deposition
risk factors of pulmonary fibrosis
cigarette smoking
viral infections
exposure to environmental pollutants, inc silica and hard metal dusts
bacteria and animal proteins and gases and fumes
use of certain meds
genetics
GORD
presentation of pulmonary fibrosis
progressive breathlessness and non-productive cough
eventually, resp failure, pul hypertension and cor pulmonale
finger clubbing in 2/3 and fine inspiratory basal crackles heard on auscultation
acute form = hamman-rich syndrome
investigations of pulmonary fibrosis
CXR appearances are initially of a ground glass appearance progressing to fibrosis and a honeycomb lung
changes mostly in lower lung zones
high res CT most sensitive imaging
blood tests: hypoxaemia with normal PacO2 autoantibodies such as antinuclear factor and rheumatoid factor in 1/3
histological confirmation is required in some patients
treatment of pulmonary fibrosis
large doses of prednisolone daily
azathioprine and cyclophosphamide can be tried
single lung transplantation now an established treatment in some patients
