Resp Flashcards
What is obstructive sleep apnoea?
Collapse of the pharyngeal airway during sleep resulting in apnoea episodes where the person will stop breathing periodically for up to a few minutes
What are the risk factors for developing OSA?
Middle aged, male, obese, alcohol, smoking
Symptoms of OSA?
Apnoea episodes, snoring, morning headache, waking up unrefreshed, daytime sleepiness, concentration problems, reduced SATs during sleep
Management of OSA
Refer to ENT specialist or specialist sleep clinic
Advise them to stop smoking, drinking and lose weight
Use CPAP
Surgical reconstruction of soft palate and jaw
What is a pneumothorax?
when air gets into the pleural space, separating the lung from the chest wall.
What can cause a pneumothorax? What are some risk factors?
- spontaneous (usually tall, thin males)
- trauma
- iatrogenic (lung biopsy, mechanical ventilation or central line insertion)
- lung pathologies such as infection, asthma or COPD
- Collagen disorders such as Marfan’s, Ehlers-Danlos
Epidemiology of a pneumothorax
annual incidence 9/100,000
20-40 yr olds
4 times more common in males
How does a pneumothorax present?
- asymptomatic if small
- signs of respiratory distress
- reduced expansion
- hyper-resonant
- reduced breath sounds
- tension pneumothorax would cause severe distress, tachycardia, hypotension, cyanosis, distended neck veins, tracheal deviation away
Investigations for a pneumothorax
- Chest x-ray will show a dark area of film with no vascular markings
- ABG to check for hypoxaemia
How to manage a pneumothorax
- If no shortness of breath and less than a 2cm rim of air on CXR then no treatment is required and follow up in 2-4 weeks
- If shortness of breath and/or more than a 2cm rim then aspiration followed by reassessment, if that fails twice then go for a chest drain
- Unstable, bilateral or secondary pneumothoraces require a chest drain
- Surgery if chest drain fails, persistent leak in drain or if pneumothorax is recurrent, abrasive or chemical pleurodesis or pleurectomy
- If tension then large bore cannula into second intercostal space at the midclavicular line, then do chest drain
What is the safe triangle for a chest drain?
5th intercostal space, midaxillary line (lateral edge of latissimus dorsi and anterior axillary line (lateral edge of pec major)
What are the different types of pneumonia?
- community acquired
- hospital acquired
- aspiration pneumonia
Triggers for asthma
- infection
- night time or early morning
- exercise
- animals
- cold/damp
- dust
- strong emotions
How would asthma present?
Acute: worsening SOB, use of accessory muscles, tachypnoea, symmetrical wheeze,
Chronic: episodic symptoms, diurnal variability, dry cough with wheeze and SOB, personal/family history of atopic conditions, bilateral wheeze
How is asthma investigated?
1st line = fractional exhaled nitric oxide and spirometry with bronchodilator
2nd line = peak flow variability, direct bronchial challenge test with histamine or methacholine
How is acute asthma graded?
- Moderate = PEFR 50-70% predicted
- Severe = PEFR 33-50% predicted, resp rate above 25, heart rate above 110, unable to complete sentences
- Life-threatening = PEFR below 33%, sats below 92%, tired, no wheeze, haemodynamic instability
How is acute asthma treated?
Moderate:
Nebulised beta-2 agonists (i.e. salbutamol 5mg repeated as often as required)
Nebulised ipratropium bromide
Steroids: Oral prednisolone or IV hydrocortisone. These are continued for 5 days
Antibiotics if there is convincing evidence of bacterial infection
Severe:
Oxygen if required to maintain sats 94-98%
Aminophylline infusion
Consider IV salbutamol
Life threatening:
IV magnesium sulphate infusion
Admission to HDU / ICU
Intubation in worst cases – however this decision should be made early because it is very difficult to intubate with severe bronchoconstriction
Side effects of salbutamol
- causes potassium to be absorbed into the cells
- causes tachycardia
Why is a normal pCO2 concerning during an asthma attack?
patients will have a respiratory alkalosis as tachypnoea causes a drop in CO2 so if the pCO2 is high then is suggests they’re fatiguing.
Long term management of asthma
- Short acting beta 2 adrenergic receptor agonists for short term relaxation of smooth muscle
- Inhaled corticosteroids (beclometasone) to reduce inflammation and reactivity, used as maintenance or preventer medications
- Long acting beta 2 agonists (salmeterol)
- Long acting muscarinic antagonists (tiotropium) which block acetylcholine receptors which prevents the PNS from causing contraction of bronchial smooth muscles
- Leukotriene receptor antagonists (montelukast) which stop leukotrienes from causing inflammation, bronchoconstriction and mucus secretion
- Theophylline relaxes smooth muscle and reduces inflammation. Only has a narrow therapeutic window and can be toxic in excess. So needs monitoring.
Maintenance and reliever therapy which is a combination inhaler with low dose inhaled corticosteroid and a fast acting LABA. Acts as a preventer and reliever.
NICE:
- SABA
- ICS
- Leukotriene receptor antagonist
- LABA
- Maintenance and reliever therapy
- Increase ICS dose to moderate
- High dose ICS or oral theophylline or inhaled LAMA
- Specialist
What is sarcoidosis?
- multisystem granulomatous inflammatory condition
- nodules of inflammation full of macrophages
Who is affected by sarcoidosis?
- young adults and 60 year olds
- usually 20-40 year old black woman with a dry cough and SOB
How does sarcoidosis usually present?
- 50% are asymptomatic
- dry cough
- SOB
- erythema nodosum
- hilar lymphadenopathy
Which organs are affected by sarcoidosis?
- Lungs - hilar lymphadenopathy, pulmonary fibrosis, pulmonary nodules
- Systemic - fever, fatigue, weight loss
- Liver - liver nodules, cirrhosis, cholestasis
- Eyes - uveitis, conjunctivitis, optic neuritis
- Skin - erythema nodosum, lupus pernio, granulomas in scar tissue
- Heart - bundle branch block, heart block, myocardial muscle involvement
- Kidneys - stones, nephritis
- CNS - nodules, diabetes insipidus, encephalopathy
- PNS - facial nerve palsy, mononeuritis complex
- Bones - arthralgia, arthritis, myopathy
What is Lofgren’s syndrome?
specific presentation of sarcoidosis: erythema nodosum, bilateral hilar lymphadenopathy, polyarthralgia
How is sarcoidosis investigated?
- raised serum ACE
- raised serum calcium
- raised serum soluble interleukin-2 receptor
- raised CRP
- raised immunoglobulins
- CXR - hilar lymphadenopathy
- CT shows hilar lymphadenopathy and pulmonary nodules
- MRI shows CNS involvement
- PET scan shows active inflammation
- histology is gold standard for diagnosis (from bronchoscopy with US guided biopsy of mediastinal lymph nodes)
- shows non-caseating granulomas with epithelioid cells
How is sarcoidosis treated?
no treatment if no/mild symptoms as it usually resolves spontaneously within 6 months
oral steroids
bisphosphonates to protect against osteoporosis
methotrexate or azathioprine
lung transplant
Prognosis of sarcoidosis
resolves within 6 months in around 60% of patients
- pulmonary fibrosis or pulmonary hypertension in some patients which may require lung transplant
- death caused by arrhythmias or CNS issue
Presentation and signs of COPD
- long-term smoker
- SOB
- productive cough
- wheeze
- recurrent respiratory infections
- use of accessory muscles
- cyanosis
- barrel chest
- prolonged expiration
- signs of CO2 retention
MRC breathless scale
Grade 1 = on strenuous exercise Grade 2 = up a hill Grade 3 = on a flat Grade 4 = 100 metres on flat Grade 5 = can't leave home
Diagnosis of COPD
- clinical presentation and spirometry
- FEV/FVC < 0.7
- FEV >80% of predicted is stage 1
- FEV 50-79% of predicted is stage 2
- FEV 30-49% of predicted is stage 3
- FEV <30% of predicted is stage 4
How is COPD managed?
SABA + Short acting antimuscarinic (ipratropium bromide)
LABA + long acting antimuscarinic combination
LABA + ICS
ABG in acute setting
Prednisolone, antibiotics, inhaler
Risk factors for PE
- immobility
- recent surgery
- long haul flight
- COCP
- thrombophilia
- polycythaemia
- pregnancy
- malignancy
- SLE
What is VTE prophylaxis and what is given to patients?
- risk of VTE for patients in hospital
- increased risk means LMWH should be given (enoxaparin) unless on warfarin or DOAC
- anti-embolic stockings unless peripheral arterial disease
Contraindication to anti-embolic stocking
peripheral arterial disease
Contraindication to LMWH
active bleeding (thrombophilia) or warfarin or DOACs
How does PE present?
- SOB
- cough with or without haemoptysis
- pleuritic chest pain
- hypoxia
- tachycardia
- tachypnoea
- low grade fever
- hypotension
What is the Wells score?
risk of symptomatic patient actually having a PE
takes into account recent surgery, clinical findings and haemoptysis
Describe how a PE is diagnosed/investigated?
- History, exam and CXR to calculate Wells score
- Wells score >4 = CT pulmonary angiogram
- If Wells 4 or less then do a d-dimer, if that’s positive then do a CT pulmonary angiogram
What can cause a raised d-dimer?
very sensitive but not specific so good at ruling out VTE
venous thromboembolism, pneumonia, cancer, heart failure, recent surgery, pregnancy
On an ABG, patients with a PE often have ___________
respiratory alkalosis due to high RR blowing off CO2 and low O2 due to perfusion issue
How should a PE be managed?
- Apixaban or rivaroxaban (DOACs), LMWH (enoxaparin or dalteparin) as an alternative
- Warfarin, DOAC or LMWH in the long-term
Target an INR of 2-3
When switching to warfarin continue LMWH for 5 days or when INR is 2-3 for 24 hours
LMWH for cancer or pregnancy
DOACs (apixaban, dabigatran, rivaroxaban)
3 months if clear reversible cause
Over 3months if unclear cause or recurrent VTE or irreversible underlying cause
6 months in cancer
When should thrombolysis be given for a PE?
- haemodynamically unstable patients
- very high risk of bleeding
- used in massive PE
- streptokinase, alteplase, tenecteplase
How does pneumonia present?
- SOB
- productive cough
- fever
- haemoptysis
- pleuritic chest pain
- delirium
- sepsis
Signs of pneumonia
- possible sepsis
- tachypnoea
- tachycardia
- hypoxia
- hypotension
- fever
- confusion
- bronchial breath sounds (harsh sounds, equal on inspiration and expiration)
- coarse crackles (air passing through sputum)
- dullness to percussion due to lung tissue collapse and/or consolidation
Describe the CURB-65 scoring system
- Confusion
- Urea greater than 7
- RR 30 or more
- BP systolic below 90, diastolic 60 or less
- age 65 or above
0 or 1 = under 5% mortality
above 2 = consider hospital
above 3 = ICU assessment
What are the many causes of pneumonia?
Common: Streptococcus pneumoniae and Haemophilus influenzae
Other: Moraxella catarrhalis (immunocompromised or chronic pulmonary disease), Pseudomonas aeruginosa (CF or bronchiectasis) or Staphylococcus aureus (CF)
Atypical: Legionella pneumophila (infected water causing SIADH causing hyponatraemia), Mycoplasma pneumoniae (erythema multiforme), Chlamydia pneumoniae, Coxiella burnnetii (animal bodily fluids), Chlamydia psittaci (infected birds)
LEGIONS OF PSITACCI MCQs
Fungal: Pneumocystis jiroveci, treated with co-trimoxazole, SOB on exertion and night sweats
Investigations for pneumonia
CXR, FBC, U&Es, CRP
Sputum culture, blood culture, legionella ad pneumococcal urinary antigens
Treatment for pneumonia
- moderate to severe = 7 to 10 days of dual antibiotics (amoxicillin and macrolide)
- mild = 5 day course of amoxicillin or macrolide)
Complications of pneumonia
sepsis, pleural effusion, empyema, lung abscess, death
What are the 2 different types of pleural effusion and what causes them?
- Exudative (protein count greater than 3g/dl) related to inflammation causing protein to leak out into the pleural space, lung cancer, pneumonia, RA, TB
- Transudative (protein count lower than 3g/dl) related to fluid movement into pleural space, congestive heart failure, hypoalbuminaemia, hypothyroidism, Meig’s syndrome (right sided pleural effusion with ovarian malignancy)
Presentation of pleural effusion
SOB, dullness over effusion, reduced breath sounds, tracheal deviation
Investigations for pleural effusion
- CXR: blunting of costophrenic angle, fluid in lung fissures, meniscus in large pleural effusions, tracheal and mediastinal shift
- Pleural fluid analysis
Treatment for a pleural effusion
- Conservative management for small effusions
- Pleural aspiration
- Chest drain
What is empyema?
- infected pleural effusion
- suspect if improving pneumonia but new or ongoing fever
- aspiration shows pus
- acidic pH, low glucose, high LDH
- remove the pus using a chest drain and give antibiotics
What are the different causes of pulmonary hypertension?
Group 1: primary or connective tissue disorder
Group 2: left sided heart failure due to MI or systemic hypertension
Group 3: COPD
Group 4: pulmonary vascular disease
Group 5: miscellaneous (sarcoidosis, glycogen storage disease, haematological disorders)
Signs and symptoms of pulmonary hypertension
SOB, syncope, tachycardia, raised JVP, hepatomegaly, peripheral oedema
Investigations for pulmonary hypertension
ECG: will show larger R waves on V1-3 and larger S waves V4-6
Right axis deviation
CXR: dilated pulmonary arteries, right ventricular hypertrophy
Bloods: raised NT-proBNP in right ventricular failure
Echocardiogram
Management of pulmonary hypertension
Primary: IV prostanoids, endothelin receptor antagonist, phosphodiesterase-5 inhibitors
Secondary: treat underlying cause
How should pulmonary fibrosis be diagnosed?
- clinical features and high resolution CT
- lung biopsy if unclear
- Spirometry (FEV1:FVC >0.7, decreased FVC) and impaired gas exchange
How does pulmonary fibrosis present?
SOB, dry cough, fatigue, weight loss, clubbing
How should pulmonary fibrosis be managed?
- treat underlying cause, O2, stop smoking, pulmonary rehab, flu vaccine, lung transplant
What drugs can cause pulmonary fibrosis?
amiodarone, cyclophosphamide, methotrexate, nitrofurantoin
What can cause secondary pulmonary fibrosis?
alpha-1 antitrypsin deficiency
RA
SLE
Systemic sclerosis
How should primary pulmonary fibrosis be treated?
pirfenidone (antifibrotic, anti-inflammatory)
nintedanib (monoclonal antibody)
Give some examples of hypersensitivity pneumonitis
bird fanciers lung
farmers lung
mushroom workers
malt workers
What is acute bronchitis?
inflammation of the trachea and major bronchi
associated with oedematous large airways and sputum production
How does acute bronchitis present?
cough (may or may not be productive)
sore throat
rhinorrhoea
wheeze
How can you distinguish acute bronchitis with pneumonia?
History, wheeze, breathlessness may be absent in acute bronchitis whereas at least one of those is present in pneumonia
no focal chest signs in acute bronchitis other than possible wheeze
systemic features tend to be absent in acute bronchitis
How is acute bronchitis managed?
analgesia
good fluid intake
consider Abx if systemically unwell, comorbidities, or high CRP
doxycycline first-line but not in pregnant women
can also use amoxicillin
What respiratory issues can asbestos cause?
- pleural plaques which are benign (so not a big issue)
- pleural thickening
- asbestosis (lower lobe fibrosis)
- mesothelioma (malignant disease of the pleura, SOB, chest pain, pleural effusion)
- lung cancer
What stain is needed for TB?
Zeihl-Neelsen
Red against a blue background
Presentation of TB
chronic, worsening symptoms
lethargy, fever or night sweats, weight loss, cough with or without sputum, lymphadenopathy, erythema nodosum, spinal pain
Investigations for TB
Mantoux test and interferon gramma release assay
Positive mantoux test = over 5mm
Sensitised WBCs will release interferon gamma (blood sample mixed with TB proteins)
CXR: consolidation, pleural effusion, hilar lymphadenopathy
How should TB be managed?
Latent TB = left alone or if at risk: Isoniazid (6 months) or Isoniazid + Rifampicin (3 months)
Active TB: RIPE Rifampicin for 6 months Isoniazid for 6 months Pyrazinamide for 2 months Ethambutol for 2 months
Give pyridoxine too to prevent peripheral neuropathy
Side effects of RIPE drugs
Rifampicin causes red/orange urine, tears
Isoniazid causes peripheral neuropathy so give pyridoxine
Pyrazinamide causes hyperuricaemia
Ethambutol causes colour blindness and reduced visual acuity
What is bronchiectasis and what are some causes?
- permanent dilatation of the airways secondary to a chronic infection or inflammation
- post-infective: TB, measles, pertussis, pneumonia
- CF
- bronchial obstruction
- immune deficiency
- allergic bronchopulmonary aspergillosis
- ciliary dyskinetic syndromes
- yellow nail syndrome
Management of bronchiectasis
- assess for treatable cause
- physical training
- postural drainage
- antibiotics for exacerbations
- bronchodilators in selected cases
What are the different types of influenza?
A,B and C
A and B are more common
A has H and N subtypes
H1N1 = swine flu
H5N1 = avian flu
Who is at higher risk of developing the flu?
aged 65 or above young children pregnant women asthma, COPD, HF, diabetes healthcare workers and carers
How does flu present?
fever coryzal symptoms lethargy and fatigue anorexia muscle and joint aches headache dry cough sore throat
How is the flu diagnosed?
history, risk factors and presentation
Viral nasal or throat swabs for PCR analysis
How is the flu treated?
Only patients at risk of complications need treatment
- Oral oseltamivir 75mg twice daily for 5 days
- Inhaled zanamivir 10mg twice daily for 5 days
Start treatment within 48 hours of onset of symptoms
Complications of the flu
otitis media, sinusitis and bronchitis
viral pneumonia
secondary bacterial pneumonia
worsening of chronic conditions
encephalitis
What are the different types of respiratory failure?
Low PaO2 indicates hypoxia and respiratory failure
Normal pCO2 with low PaO2 indicates type 1 respiratory failure (only one is affected)
Raised pCO2 with low PaO2 indicates type 2 respiratory failure (two are affected)
Which cancers commonly spread to the lungs?
Bladder, breast, colon, kidney, neuroblastoma, prostate, sarcoma, Wilm’s tumour
Where does lung cancer commonly spread?
other lung, adrenals, lymph nodes, bones, brain, liver
Lung metastases symptoms
persistent cough, haemoptysis, chest pain, SOB, wheezing, weakness, sudden weight loss
