Resp Flashcards
1
Q
presentation of asthma
A
intermittemt dyspnoea SOB chets tightness wheeze cough (nocturnal) Diurnal variation
2
Q
signs o/e of asthma
A
- hyperinflation (reduced chest exp and reduced crico sternal distance)
- Hyperresonane on percussion
- decrease in tactile vocal frem
- polyphonic wheeze
3
Q
other conditions that are associated with asthma
A
allergic rhinitis and eczema
GORD
Churg-straus- (eosinophillic granulomatosis with polyangiitis)
4
Q
ix for ?asthma
A
spirometry- obstructive FEV1/FVC ratio <0.7 (FEV1 reduced more than FVC)
- bronchodilator reversal - improvement in FEV1 by 12% or more
- peak flow- varies >20%
- fractional exhaled nitric oxide (FeNO)- eosinophils emit NP (>40ppb)
- CXR- hyperinflation
- challenge with histamine or methacholine- FEV falls by 20%
- sputum culture
5
Q
what tests do you do for screening once asthma has been diagnosed
A
- skin prick
- serum total and specific IgE
- eosinophil count
- exercise challenge- severity
6
Q
Management of asthma
A
- avoid precipitants
- education
- reduce NSAID dose
pharmac
- SABA (salbutamol)
- SABA + ICS (beclo, pred)
- SABA + ICS +LTRA (montekukast) - SABA +ICS+ LABA (salmeterol/formeterol) +- LTRA
then ask for specialist help
7
Q
What specialist meds arethere for asthma
A
- oral pred
- LAMA- tiotropium/ipratropium
- Theophylline/aminophylline- phosphodiesterase inhibs
- omalizumab (anti- igE monocloncal Ab)
8
Q
tx of subacute worsening of asthma- what could u do med wise?
A
double/triple/x4 ICS dose for 1 week
9
Q
Types of asthma
A
Atopic
- type 1/igE mediated
- dust, pollens, food, animals
fhx and atopy triad present
Intrinsic/non-atopic/non-allergic
- stress, cold air, anxiety, smoke, infections, aspirin
- mechanism unknown
Eosinophillic
- assoc with allergy
- Th2 cells
- overproduction of mucus- lumen plugging
- ix autoimmune causesand vasculitis
- responds well to steroids
Neutrophillic
- not well understood
10
Q
things to cover in an asthmatic hx
A
- diurnal/seasonal variation
- cough at night
- atopy
- fam hx
occupation and relation to work - severity- how many events/admissions in last year/how many times do they use SABA
- inhaler technique
11
Q
Management of acute asthma exacerbation
A
ABCDE Airways Breathing - RR, Sp02 - auscultate- polyphonic wheeze, air entry - percuss- hyperres
OSHITME
O- 15L non rebreathe mask
S- Salbutamol- 2.5mg-5mg, neb in O2, repeat every 15min
H- hydrocortisone 100mg IV/pred 40mg PO
I- Ipratropium ** 0.5mg 4-6 hourly, neb in O2
T- Theophylline/aminophylline **1g in 1L saline at 0.5ml/kg/h
M- Mgsulphate 2g IV over **40min
E- escalate- anaesthetist, ICU, crash call
Circulation
- IV access 2x wide bore
- basic bloods, ABG
- fluid bolus 250-500ml nomrla saline over 15min
Disability
Exposure
- rashes
- temp
12
Q
ix for acute exacerbation of asthma
A
ABG-
T1/T2 resp failure
Pco2 may be decreased if hyperventilating
**Sputum and blood culture CXR- infection, PTX **ECG SPO2 PEFR if stable
13
Q
Grading severity of asthma
A
mod
- increase in asthma sx
- PEFR 50-70%
Severe
- PEFR 35-50%
- RR >25
- HR >110
- inability to complete sentences
Life- threatening
- PEFR <33%
- resp- <92%, silent chest, cyanosis, poor resp effort, bradycardia
- confusion, exhaustion, coma
near fatal
- hypercapnia, requires mechanical ventilation
14
Q
Types of lung cancers
A
Small cell
non small cell (sq, adeno, large cell)
15
Q
presentation of lung cancer
A
- cough, dyspnoea, wheeze, haemoptysis
- hoarseness
- pleurisy
- head/neck/arm pain (SVCO)
- horner’s syndrome (symp chain)
- brachial plexus- shoulder/arm pain
- Dysphagia
- effusions
- wt loss, fatigue, appetite
- *- clubbing
- *- lymphadenopthy
- paraneoplastic sx- excessive **PTH, ADH, ACTH
16
Q
where can lung cancers met to
A
- brain
- bone
- liver
17
Q
what is the 2ww criteria for ?lung cancer
A
- CXR suggestive of lung cancer
- > 40yo with unexplained haemoptysis
urgent 2-w CXR if
- > 40 and 2 of the following (or 1 in they’ve ever smoked)
- cough, wt loss, appeitie loss, dyspnoea, chest pain, fatigue
18
Q
ix for ?lung cancer
A
- CXR
- CT to confirm
- Bronchoscopu and biopsy
- bloods - LFT (bone,- ALP, liver), UE (SIADH- low Na), Ca
- Mets- CT head/abdo-pelvis
19
Q
staging of lung Ca
A
I- <4cm
II- >4cm, +- lymph nodes
III- contralteral lymph nodes/eroded local strcutures
IV- extra-thoracic mets
20
Q
management of lung Ca
A
- stop smoking
- lobectomy/pneumoectomy
- RT
- CT
21
Q
complications of lung Ca
A
- SVCO
- Horners
- Paraneoplastic syndromes (small cell)-
- ADH- SIADH
- PTH- hyperPT
- ACTH- cushings
- cauda equina
- alopecia, neutropenia, bone marrow insuff due to CT
- mucositis, pneumonitis, oesophagitis from RT
22
Q
What cell type is small cell lung ca
A
neuroendocrine
23
Q
whihc type of cancer has the worse prognosis
A
small cell
24
Q
which type of cancer is most common
A
non-small cell- adeno
25
sx of SIADH
```
vomiting
**headache
lethargy
**cramps
confusion
**seizures
```
hyponatraemia due to water retention
26
sx of cushings
- central obesity
moon face
thinning skin
striae
27
cell type of non small cell lung cancer
Adenocarcinoma- most common overall, and also most common in people who have never smoked
Sq- more linked with smoking than adenocarcinoma
Large cell
NSCLCs are all linked with hx of smoking, however, SCLCs are way more strongly linked with smoking, with the vast majority of the cases being in smokers
28
mutations NSCLC assoc with
Epidermal growth factor receptor
Anaplastic lymphoma kinase
Programmed ligand death 1
29
what type of lung Cancer is a pancoast cell usually
NSCLC- sq
30
presentaiton of pancoast tumour
Most Pancoast tumours are NSCLC- adeno, sq, large cell
* *- Horner's syndrome- miosis, anhidrosis, ptosis- ipsilaterally
* *- brachial plexus compression- pain in shoulder radiating to scapula, pain/weakness in arm, thoracic outlet syndrome (vasculature)
- recurrent laryngeal- hoarseness, bovine cough (non-explosive)
- SVCO- facial swelling, cyanosis, neck veins
- rib erosion (chest pain)
* *- 1/4 of cases have spinal involvement/compression at presentation- screen for weakness, neuropathic pain
31
histology of mesothelioma
epithelioid, on pleura
32
causes of mesothelioma
asbestos
33
progression of mesothelioma
1. pleural plaques
2. asbestos effusion and pleural thickening
3. asbesotsis (fibrosis)
4. Mesothelioma
34
presentation of mesothelioma
- recurrent pleural effusion
- dyspnoea, cough
- pleuritic pain
- B sx
35
ix for ?mesothelioma
Biopsy- GOLD STANDARD
CXR- white spots, plerual mass, rib destruction, pleural thickening, effusion
CT
Pleural aspiraton- straw coloured
36
management of mesothelioma
- palliative- CT, RT, debulking surgery
- indwelling intrapleural drain
- chemical, mechnical pleurodesis (fusion)
37
What is a pneumothorax
air in the pleural space
38
Causes of pneumothorax
spontaneous/idiopathic
Secondary- due to underlying disease
- emphysema
- COPD
- fibrosis etc
Trauma- broken rib, stab wound
Iatrogenic- pleural biopsy, hgih pressure vent
39
Why does PTX have effect on lung ventilation
loss of pressure gradient (pressure in lung is increased so less air is sucked in)
40
who do you usually see spontenous PTX in
young, slim male
41
RF for PTX
```
reps cond- asthma, COPD, LRTI
connective tissue disorder
**A1- antitrypsin deficiency
**CF
SMoking, smoking cannabis
```
42
presentaion of PTX
- acute onset dyspnoea
- pleuritis chest pain
- Sensation of not being able to take full breath
- beware of the pt who rapidly declines (BP, sats, tachycardia) after intubation- the ventilation is making the tension PTX worse
43
signs of PTX o/e
- diminished breath sounds/silent chest
- hyperresonance on percussion
- reduced tactile vocal fremitus (which is only raised in colsol, reduced in effusion)
44
Ix of PTX
- monitor obs
- ABG
- CXR on insp
- bloods- A1AT
45
Clasificaiton of PTX (size)
- small- <2cm between chest wall and lung border
| - Large- 2cm
46
Management of PTX
- high flow O2 15L non rebreath
- if small and not in resp distress- can discharge
- chest drain- 14-16G, no lower than 5th ICS mid-axillary line/2nd ICS mid-clavicular
always admit if secondary cause for observation (more serious presentations and outcomes)
pt education
- stop smoking
- advice on recurrence
- avoid flying until resolution
- avoid diving permanently
47
tx of recurrent PTX
pleurodesis
48
why is tension PTX an emergency
pleural cavity expands, compressing lung and other thoracic structures
- Resp distress
- Impaired venous return leading to less contractility
- Reduced CO
- -> lead to hypoxaemia and haemodynamic comprimise
49
causes of tension ptx
ventilated pts
trauma, CPR
acute presentations of asthma/COPD
blocked/displaced chest drains
50
presentation of tension PTX
SOB
Chest pain, pleurisy
profuse diaphoresis
51
signs of tension pTX
```
tachypnoea
tachycardia
cyanosis
mass effect
- tracheal deviation away from PTX
- displaced apex beat
- raised JVP
```
- beware of the pt who rapidly declines (BP, sats, tachycardia) after intubation- the ventilation is making the tension PTX worse
52
Causes of PE
- embolisation from DVT
- septic vegetation (endocard)
- parasitic
- fat
- air
- amniotic fluid
- neoplastic cells
53
presentation of PE
acute SOB
pleuritic chest pain
haempotysis
syncope
54
signs o/e of PE
```
cyanosis
tahcypnoea
tachycardia
hypotension
***raised JVP
**pleural rub (sounds like squeaky leather on ausc)
pleural effusion- stony dull percussion
```
55
What criteria is used for ?PE
Wells
56
What is the cut off thresholds for PE on the Well's score and tx
>4-- likely
- CTPA or V/Q scan
<=4- unlikely
- D- dimer
- if raised, do CTPA or V/Q sc
- if normal- observe, consider other dx
if pt is haemodyn unstable- do CTPA straight away, give anticoags w/o delay
tx-
- alteplase if haemodyn unstable
- DOAC (or LMWH followed by dabigatran; heparin if renally impaired)
57
ix for PE
- assess legs for signs of DVT (>2cm increase in diameter, redness)
- FBC, UE, clotting, D-dimer
- CTPA
- V/Q
- ECG- RBBB. right axis deviation, inverted T waves, sinus tachy
58
Management of PE
ABCDE
- O2 15L non rebreathe
- Consider Alteplase IV if haemodyn unstable
anticoag
- DOAC- apixiban/rivaroxiban- 15mg BD for 21 days, then 20mg OD
- can offer LMWH (dalteparin)
- continue DOAC for at least 3m
- vena cava filter if anticoag CIed
- surgical thrombectomy/embolecomty if massive
59
what are the contraindications for a CTPA
renal impairement
contrast allergy
pregnant
60
thrombolysis contraindications
* *- recent surgery (3m)
* *- active malignancy
- active bleeding
- hx haemorrhagic stroke
* *- BP uncontrolled/>180 systolic
61
how are PEs prevented in anyone at at risk of them eg after surgery
- thromboprophylaxis- daily dalteparin SC
- compression stockings
- avoid dehydration
- stop meds like COCP
62
what is the prophylactic dose of dalteparin
2500U once every 24hours
63
what is tx dose dalteparin
7,500, 10,000, 12,500, 15,000, 18,000u depending on weight
64
Causes of interstitial lung disease
primary/idiopathic
secondary
- toxins- asbestosis, bird dander, silica, hot tubs
- medications- methotrexate, amiodarone, abx- nitrofurantoin, rituximab, *radiation
* - conditions- sjogrens, SLE, RA, Sarcoidosis, connective tissue disorders
* - infective- mycoplasma pneumonia, penumonocystis pneumonia (jiroveci)
65
what is intersitial lung disease
- inflammation and fibrosis of the lung intersitium
66
presentation of interstitial lung disease
- slowly progressive exertional dyspnoea
- dry cough
- malaise, fatigue
- sx of underlying condition
67
signs of intersitial lung disease
- fine end-respiratory crackles
- dullness to percussion
- finger clubbing
68
ix ffor ?intersitial lung disease
- sats
- spirometry (restrictive- FEV1/FVC >0.7 reduced FVC, normal FEV1)
- bloods- anaemia of chronic disease
- urine dip- haema/proeinturia= vasculitis
- antibodies- anti-ccp+ RF (RA, sjorgens), ANA (lupus, sjogren's), ANCA (vasculitis), dsDNA (biliary cirrhosis, mononucl., hepatitis, lupus) antiRo (lupus, sjogrens), anti-La (sjogrens, lupus)
- RAST- igE in blood
- CXR- fine opacities
- CT lung- honeycombing, reticular opacities, traction bronchiectasis
- bronchoscopy, bronchial lavage, biopsy
69
management of interstitial lung disease
- avoid cause- meds, toxins, smoking
- pulm rehab
- annual flu vacc
- tx cause- often w steroids
- IPF: pirfenidone (antifibrotics)
- LTOT (spO2 <88%, paO2 <7.3)
- lung transplant
70
complications of instersitial lung disease
- pulm HTN--> right HF, cor pulmonale
- resp failure
- anxiety, depression
71
what is idiopathic pulmonary fibrosis
- chronic, progressive intersitial lung disease
| - unknown origin
72
presentation of IPF (immune pulm fibrosis)
- SOB
- persistent cough (dry usually, hacking)
- fatigue
73
signs of ITP
BL fine insp crackles
| clubbing
74
ix for ?IPF
- lung function/spirometry (restrictive >0.7)
- CXR
- CT thorax
- bronchoalveolar lavage/biopsy if no dx can be made from above
75
managament of Idiopathic pulmonary fibrosis disease
- review 6m after diagnosis to assess deterioration
- smoking cessation
- pulm rehab
- LTOT
* ***- opioids/thalidomide for cough
* **- pirfenidone (antifibrotic)
- palliative care referral
median survival is 4 years
76
RF Idiopathic pulmonary fibrosis
- smoker
- GORD
* *- >70y/o
- fam hx
* *- viral infections
77
what is hypersensivity pneuomnitis
- extrinsic allergic alveolitis
| - allergic sensitisation, leading to inflammation and then fibrosis
78
causes of hypersensitivity pneuomonitis
**bacterial, fungal
animals
pollen
**insecticides, plastics
```
Occupational:
bird fanciers
farmers lung (mould spores in hay- micopolyspora)
**malt workers lung (aspergillus)
**bagassosis/sugar workers lung
**Coal workers pnemoconiosis
**silicosis
```
79
presentation of hypersensitivity pneumonitis
- progressive SOB
- worse after contact with allergen
- wheeze
- fevers, rigors, myalgia, headache, wt loss
can be acute (4-6hours after exposure, flu-like) or chronic (insidious dyspnoea)
80
signs of hypersensitivity pneumonitis
fine basal crackles
81
ix ?hypersensitivity pneumonitis
- CRP, ESR
- serum igG antibodies
- spirometry (restrictive)
- CXR- upper zone consoliation/fibrosis/honeycombing
- CT thorax
- Bronchoalveolar lavage/biopsy- lymphocytes, mast cells
82
tx of hypersensitivity pneumonitis
```
avoid allergen-preventative
chest physio, bronchodilators, cough suppressors
O2
pred LT
lung transplant
```
83
sx of asbestosis
- SOB
- persistent cough
- wheeze
- shoulder/chest pain
- extreme fatigue
- finger clubbing
84
high risk jobs for asbestos exposure
- heating, ventilation engineers
- demolition workers
- plumbers
- construction workers
- electricians
85
What is sarcoidosis
- autoimmune
- inflammation, granulomas
- affects lungs mainly, but also lymph nodes, skin and other organs
86
presentation of sarcoidosis
- wheeze
- SOB
- persistent dry cough
- arthralgia
- red spots on skin
sign- hepatosplenomegaly
87
ix for sarcoidosis
- Kveim test- SC injection of sarcoid tissue- induced granulomas
- lung function tests
* **- serum ACE increase due to granulomas
- CXR/CT
- bronchoscopy, biopsy
88
management of sarcoidosis
- watch and wait
- corticosteroids (pred)plus bisphosphonates
- infliximab
- paracetemol/NSAIDs
89
What is Caplan's syndrome
RA patients with diffuse lung fibrosis (pneumoconiosis) with nodules on CXR
90
Tx of radiation pneumonitis
- long course corticosteroids
- NSAIDs
- O2
* *- bronchodilators
91
What type of vasculitis can affect the lungs
Small vessels:
Goodpastures
Granulomatosis with polyangiitis (wegners)
92
sx of good pastures with lung involvement
haematuria, proteinuriea, kidney failure
General discomfort, pain
anaemia
chets pain, SOB, cough, haempotysis
93
ix for ?goodpastures/anti glomerular basement membrane
- kidney biopsy- ***cresentic glomeruloneohritis
- CXR- infiltrates, lower zones
- anti glomerular membrane antibodies
* **- ANCA
* **- alpha 3 subunit of type 4 collegen (goodpastures antigen)
94
tx of goodpastures
corticosteroids, cyclophosphamides
| plasmapheresis/dialysis
95
what is granulomatosis with polyangiitis
(Wegners)
small vessels
ear, nose, sinuses, kidneys, lungs
96
sx of granulomatosis with polyangiitis
fatigue, pyrexia, wt loss
sinusitis, inflam of nose, epistaxis
scleritis, episcerlitis
renal disease, glomerulonephritis- haematuria
cough, haemoptysis, pleuritis
purpura, peripheral neuropathy, arthritis
97
Ix of ?granulomatosis with polyangiitis
```
cANCA
urinanalysis - proteinuria, haematuria
CXR- haemorrhage, nodules, infiltrates
CT
renal biopsy
```
98
tx granulomatosis with polyangiitis
- steroids
- with cyclophosphamide, rituximab
- LT may be given- rituximab, methotrexate, azathioprine, mycophenolate.
- plasmaphoresis, haemodyalysis
99
What mutation causes CF
autosomal recessive
cystic fibrosis transmembrane conductance regulator gene (CFTR)
on chromosome 7
100
What is the pathophysiological process that occurs in CF
- defective CFTR channel which transports CL- into/out of cells channel
- Less Cl- absorbed into cell
- therefore less Na+ absorbed, as Na+ follows Cl-
- More water moves into cell due to osmotic gradient
- mucus is dehydrated (more viscous)
- salty sweat
- Pancreatic ducts blocked (malabs)
- Lumen of bile duct plugged, local damage, bile deficiency
- Meconium ileus
- resp mucous plugging, infection, intersitial damage
- Male infertility- vas deferens absence
- female infertility- plugging of fallopian tubes, cervical mucous thickening
101
How common is CFTR mutation
1/25
102
Presentation of CF
```
productive cough
Wheeze
*finger clubbing
BL coarse crackles
Recurrent resp infections, *bronchiectasis
*PTX
```
weak infant with meconium ileus/rectal prolapse
```
Steatorrhea
*intestinal obstruction
*gallstones
*liver cirrhosis (jaundice)
*haemorrhage (vit K malabs)
Malnutrition/FTT
infertility
*OP, arthritis
```
103
Ix for ?CF
- newborn screening- heel prick test for immunoreactive trypsinogen
- genetic screening
- sweat test (Na+ and Cl- >60mmol/L. Cl- higher then Na+)
* **- FAECAL ELASTASE= decreased-- panc insuff
- bloods- deranged LFTs, deranged clotting (vit K malabs)
- sputum culture
- CXR- hyerpinfl, bronchiectasis
- spirometry- obstructive
- semen analysis- aspermia
104
Management of CF
resp
- Resp physio
- muclytics (boranse alfa, hypertnoic saline)
- infection prophylaxis
- regular sputum MC&S
- lung, liver transplant
GI/malabs
- Pancreatin (creon), insulin replacement
- vit supplements, Ca/vit D
- ursodeoxycholic acid to improve bile flow
- regular DEXA for OP, bisphosphonates
- high calorie intake (130%)
- psych support
- biannual f/u
105
What organism is common in CF penumonia
pseudomonas aeruginosa
106
What is primary ciliary dyskinesia
- autosomal recessive
| - cilia- ineffective movement of mucous
107
What is Kartagener's syndrome
- causes primary ciliary dyskinesia and situs inversus totalis (everything in body is other side)
108
presentation of primary ciliary dyskinesia
- CF but less severe
- chronic/recurrent resp infection
- infertility
* *- hearing loss, otitis media
109
ix for ?primary ciliary dyskinesia
Spirometry
| biopsy of bonchial airway cilia
110
Management of primary ciliary dyskinesia
- same as CF
- mucolytics
- mucous clearance physio
- infection prophylaxis
111
What is acute resp distress syndrome
- fluid build up in the lungs
| - causes reduced O2 exchange
112
Causes of acute resp distress syndrome
- pleural trauma
- inhalation of dense smoke or chemical fumes,
- pneumonia (esp aspiration)
- cerebral trauma
- hypovolaemic shock
Systemic inflammatory resposne-
- sepsis
- acute pancreatitis
- burns
- massive trauma (esp if shcok /mult transfusions neede)
- near drowning
113
sx of ARDS
- SEVERE SOB!
- cough
- chest pain- esp with deep breathing
- confusion
- exhaustion
- dizziness
114
sings o/e of ARDS
- hypotension
- tachypnoea
- tachycardia
- fever
- cyanosis
- oedema (fluid is leaving blood into tissues)
- peripheral vasodilation
- BL fine end resp crackles
115
ix for ?ARDS
- FBC, UE, LFT
- amylase, CRP
- blood cultures
- ABG
- clotting
- CXR- BL alveolar shadowing
- CT (Trauma)
- echo if ?cardiac /HF cause instead
116
What criteria is used for ARDS
Berlin
- onset within 1 week of known clinical insult
or
- a pt recognising a worsening of resp sx
- presence of BL opacities on CXR/CT, not fully explained by effusion/lobar or lung collapse/nodules
- diagnosis of resp failure is not fully explained by cardiac failure or fluid overload
- presence of hypoxaemia
117
tx of ARDS
- ICU
- CPAP- 40-60% O2, intubation, ventilate prone
- arterial line- haemodynamic monitoring
- inotropes- dobutamine
- vasodilators
- antiplatelets- clopi
- fluids= with careful fluid balance, on some cases, negative fluid balance
- haemofiltration/blood transfusion
- enteral feeding
118
What is type 1 resp failure
Hypoxia, normo/hypocapnia
<8kPa (<60mmHg) O2
<=6KPa (<50mmHg) CO2
- assoc with damage to the lung tissue, preventign oxygenation but CO2 is still able to be excreted
119
causes of T1 resp failure
```
Lung tissue damage:
pulm oedema, HTN, ARDS
chronic pulm fibrosis
pneumonia, COVID 19
asthma
PTX, PE
```
120
What is type 2 resp failure
hypoxaemia with hypercapnia
<8kPa (<60mmHg)
>6kPa (>50mmhg)
- alveolar ventilation is insufficient to excrete CO2
121
causes of T2 resp failure
```
Ventilation issues:
COPD
Severe asthma
chest wall deformities
resp muscle weakness
CNS depression (reduced resp drive)- sedatives, strong opioids, MG
Hypothyroidism
```
122
sx of resp failure
- confusion, anxiety, restlessness, seizures, coma
| - reduced consciousness
123
signs of resp failure
tachycardia +- arrhythmias
cyanosis
polycythemia if chronic cause
cor pulmonale- pulmonary HTN induces RSHF-- hepatomegaly and peripheral oedema
124
ix ?resp failure
- ABG
- CXR
- FBC- anaemias, polycythemia
- UE LFT- Mg, K, PO4- may aggravate resp failure
- serum CK, trop- exclude recent MI/myositis
- TFT
- Spirometry
- Echo- cardiac causes suspected
- ECG- cardiac causes suspected
- sputum/blood culture
125
Management of resp failure
- immediate resus
- O2
- -->CPAP- expiratory positive pressure, keeps alveoli open during exp-- T1RF
- --> BiPAP- insp and exp pressure-- T2RF, as pressure on insp improves ventilation and solves CO2 issues
- Tx the cause
126
complications resp failure
PE
MI, Arrhythmias, pericarditis
polycythemia if chronic
AKI, abnormalities in electrolytes, Acid-base balance issues
gastric ileus, pneumoperitoneum, duodenal ulceration
127
What is the pathophysiology of bronchiectasis
Not fully understood
- initial insult (infection)
- leads to excessive mucus
- persistent colonisation in mucus
- chronic inflam leads to permanent damage of bronchial airways and dilation
- thickened walls
- vicious cycle of infeciton, inflamm, damage/dilation
128
causes of bronchiectasis
- post infectious
- pulm disease
- congenital
- connective tissue disease
- idiopathic (most cases)
129
what are some post infective causes of bronchiectasis
- recurrent childhood LTRI
- pulm TB
- allergic bronchopulmonary aspergillosis
130
What are some pulm diseases that causes bronchiectasis
asthma
| COPD
131
what are some congenital causes of bronchiectasis
CF
Primary ciliary dyskinesia
alhpha1 antitrypsin deficiency
132
what are some autoimmune conditions that may lead to bronchiectasis
RA
SLE
sarcoidosis
133
Presentation of bronchiectasis
daily cough
- productive (copious amounts, mucopurulent)
- haemoptysis in 50%
- extertional dyspnoea, may progress to at rest
- fatigue
- rhinosinusitis- nasal discharge, nasal obstruction, facial pressure
- onset over months/years
134
things to cover in hx of ?bronchiectasis
- no of exacerbations/hospitalisations
- exercise tolerance- recent change?- hx to
- sputum quantity and colour- recent change? blood?
- hx of childhood LRTI
- hx of asthma, COPD, TB. aspergillosis
- fam hx of RA, CF
- smoking hx, oets, mould in house
ddx exclusion
- COPD- smoking, o/e absence of high pitched sounds, CT normal
- Asthma- diurnal variation? hx of atopy, bronchodilator reversibility
- Pneumonia- acute presentation
- Chronic sinusitis- lack of productive cough
- lung cancer- wt loss, fatgue, haemoptysis
135
Sings o/e in bronchiectasis
- finger clubbing
- coarse creps- exp and insp
- rhonchi-- low pitched noises like snoring
- high pitched inspiratory squeaks and pops
136
Ix ?bronchiectasis
- CT- GOLD STANDARD
- sats
- sputum culture
- lung function tests- obstructive/normal
- echo- pulm HTN, vent function
- CXR- exclude other pathologies, tramline/ring shadows seen in severe disease
- FBC- neutrophilia, CRP
- autoimmune- Anti-ccp, ANA, ANCA, antiro/la, dsDNA
- CF/primary ciliary genetic testing
137
conservative tx bronchiectasis
- pulm rehab- physio
- smoking cessation
- annual flu and one off pneumococcal vacc
138
medical tx of bronchiectasis
- mucoactive- neb saline and carbocisteine
- prophylactic abx- azithromycin 3x a week >=3 exacerbations year
- bronchodilators- LABA (formoterol/salmeterol)
- LTOT
Acute exacerbation
- amoxicillin, clarithro, doxy oral
- coamx IV
139
surgical tx of bronchiectasis
- lung resection if localised
| - lung transplant if <65, with rapid deterioration despite above tx
140
The two 'presentations' of COPD
Blue bloater- Bronchitis
| Pink puffer- emphysema
141
What is th epathophysiology of bronchitis
- cough and sputum on most days for 3m in 2 consecutive years
hypersecretion of mucus
- hypertrophy of glands
- goblet cells hyperplasia
- epithelial cells become ulcerate, collumnar replace sq ep
142
Pathophysiology of emphysema
- large airspaces distal to terminal bronchioles due to destruciton of alveolar walls
- inflam and scarring decreased lumen size
143
sx of COPD
```
chronic cough- productive
dyspnoea- exertional SOB
- wheeze
- chest pain
- haemoptysis
```
144
signs of COPD
tachypnoea
cyanosis
hyerinflation (reduced cricosternal dist., chets expansion)
use of accessory muscles
coarse crackles, wheeze, quiet breath sounds
hyperesonant percussion
corpulmonale
145
Presentation of pink puffer
- SOB main sx
- anxious, jerky, short sentences
- prolonged exp time, breath with pursed lips to increased pressure in lungs for gas exchange
- cachectic
- decresase breath sounds
- orthopnoeic
- barrel chest
- RSHF
- hypoxic, normocapnic
146
presentation of blue bloater
chronic bronchitis
- Productive cough main sx
- cyanotic
- oedema
- exertional dyspnoea
- hypoxic and hypercapnic (t2RF)
- acidotic
147
How do you grade COPD
Medical research council breathlessness score
1- none, except on strenuous exercise
2- SOB when hurrying, walking up slight hill
3- walks slower than contempories on level ground due to breathlessness, or has to stop when walking at own pace
4- stops fro breath after walking ~100m/few mins level ground
5- cannot leave house due to SOB, SOB when dressing
148
COPD diagnosis, ix
none
>35
presence of RF (smoker, occupation exposure, air pollutions, A1AT deficiency)
typical sx
obstructive <0.7 on spirometry
```
ABG- hypoxia +- hypercapnia
sats
FBC- secondary polycythemia
- ECG, serum antriuretic peptide, echo (if cor pulmonale and pulm htn sx- oedema, cyanosis)
- sputum culture
- CXR- hyperinfl
- high rec CT
- PHQ-9, GAD-7
- serum A1AT- if early onset, no smoking, fam hx
```
149
tx of acute exacerbation of COPD
- cnsider admission
- increase dose/freq of SABA/SAMA-
- nebs SABA
- px oral corticosteroids (pred OD 1-2w)
- abx if purulent sputum/signs of pneumonia- amox, doxy, clarithro (oral or IV)
- f/u- review management, technique
- LTOT
NB- no acute IV steroids or inhaled steroids advised by NICE
150
Management of stable COPD
- smoking cessation, exercise, wt loss
- influenza, pneumococcal vacc
- cardiopulm rehab
- antimucolytics- carbocysteine
1. SABA (salbut)/SAMA (IpratropiuM- I(pratropium) need it now!)
2.
no asthma features/steroid responsiveness-- +LABA+LAMA (tiotropium)
asthma/steroid- +LABA (salmet)+ICS
3.LABA+LAMA+SABA+ICS
SABA continue throughout the steps
Specialist add-ons
- roflumilast
- theophylline
- prophylactic azithromycin
asthma features= high eosinophil, atopy hx, variation in FEV1, diurnal variation)
151
What baseline tests must you do before starting someone on prophylactic azithromycin, then how often do u monitor?
- CT thorax
- baseline ECG (can cause QT prolongation)
- LFTs
- review after 1st 3m
- then 6 monthly
152
Mciroorganisms that commonly cause pharyngitis
```
rhinovirus
influenza
adenovirus
coronavirus
parainfluenza
```
153
sx of pharyngitis
```
sore throat
hoarseness
mild cough
fever, headache, nausea, tiredness
dysphagia
```
154
signs of pharyngitis
lymphadenopathy in neck
| may see pus on tonsil
155
tx of pharyngitis
- usually goes within 1 week
- can last longer (10%)
- keep fluid intake up
- NSAIDs, paracetemol
- lozenges
- gargling warm salt water
- humidifier
- feverPAIN- pheoxymethylpenicillin (erythro/clarithro if allergic)
156
Causes of laryngitis
viral
- adenovirus, rsv , influenza, parainfluenza, herpes, HIV, coxsackievirus
bacterial
- H. influenza type B
- strep pneumonia
- S aureus
- group A beta haemolytic strep
- moraxella catarrhalis
- kelbsiealla
- candidiasis
Trauma
- voice misuse
157
Management of laryngitis
- should be self limiting
- vocal hygeine- resting, avoid smokig, humidifcation, hydration
- crhonic- voice therapy, tx underlying cond eg GORD
158
causes of pneumonia
cancer
viral
- influenza
- RSV
- SARS-CoV-2
bacterial
- strep pneumonia
- H influenza
- legionella, mycoplasma, chlamydia pneumoniae
Fungi
- histoplasmosis
cryptococcus
pneumocystis jiroveci (HIV)
Mycobacterial- tuberculosis
Aspiration
159
what organisms tend to cause HAP vs CAP
CAP- strep pnuemoniae
HAP- occurs >=48hours after hosp admission
- pseudomonas
- S.arueus- methicillin resistant and susceptible
- klebsiella
- E.coli
160
What features of a pneumonia suggest strep. pneumonia is the causative agent
- lobar
| - rust coloured sputum
161
Sx of pneumonia
```
Dyspnoea, SOB
Weakness, pale, fatigue
fever
productive cough- pus/blood/rust
chest pain
back pain
```
162
signs of pneumonia o/e
dullness on percussion (consolidation)
increase tactile vocal fremitus
**bronchial breath sounds
late insp crackles-- rales (crackles, larger airways, on insp, pneumonia/CHF), rhonchi (low pitched snore, larger airways, on exp, pnuemonia/COPD)
163
How do you calculate mortality risk of someone with pneumonia
CURB65
- Confusion
- Urea (blood urea nitrogen >7mmol/L)
- raised RR (>=30pm)
- BP <90 S or 60 D (one of the two)
- Age >=65
0- low risk
1-2= intermediate (1-10%)
3-4- high risk (>10%)
164
ix of ?pneumonia)
```
CXR
procalcitonin (high in bacterial)
sputum culture
bronchoalveolar lavage
blood culture
```
165
tx of pneumonia
CAP
low/mod severity:
amoxicillin 500mg TDS 5 days
doxy, clarithro, erythro if allergic/pregnant /atypical pathogen suspected
High severity:- oral or IV
coamox with ***clarithro 7-10d
oral erythro if allergic
HAP
co-amox 500/125mg TDS 5 days
severe- IV- Tazocin
if MRSA- add vancomycin
pain meds
CPAP, non invasive vent
166
what is a pleural effusion
- collection of fluid in pleural space
| reduces decrease lung expansion
167
causes of pleural effusion
Transudative (fluid leaving capillaries due to increase hydrostatic pressure/decrease in oncotic pressure)
- HF with pulmonary oedema
- liver cirrhosis (less proteins made)
- nephrotic syndrome (increase exc. of proteins causing hypoalbuminaemia)
Exudative- inflammation, caps leaky
* *- trauma
- malignancy
* *- inflammatory conditions/autoimmune (lupus)
- infection eg pneumonia
* *- PE
* **lymphatic/cyclothorax
- thoracic duct occlusion
- damage during surgery
* - mesothelioma (recurrent effusions)
168
sx of pleural effusion
- chest pain (pleurisy)
SOB
dyspnoea
orthopnea
169
signs of pleural effusion
- decreased breath sounds
- dull percussion
- decreased tactile vocal fremitus- only increased in inflammed or denser lung TISSUE! (pneumonia)- decreased with air or fluid in lungs/pleura (eg asthma, COPD, effusions)
- tracheal deviation away from effusion
- blurring of costophrenic angle on CXR when standing
170
Ix for ?pleural effusion
CXR
thoracenesis
- transudative- translucent (less protein)
- Exudative- Cloudy (immune cells, protein)
- lymphatic- milky (fats)
171
What criteria do you use for analysing aspirated fluid following thoracentesis
Light criteria
NB-
- EXudative means proteins EXit the capillaries into pleural space (leaky)-- fluid/serum protein >=0.5= exudative (increased proteins in fluid)
- TRANSudative is just increase pressure/decrease oncotic, so things that already wouldve gone across TRANSfer across-- fluid/serum protein <0.5-- transudative (less proteins in fluid)
Fluid Lact dehydrogenase/serum LD (protein)
- >=0.6= exudative
- <0.6- transudative
LDH
- >2/3 of upper limit of normal serum LDH- exudative
- <2/3 of upper limit of normal serum LDH- transudative
172
tx of pleural effusion
HF (transudative)- loop diuretics, Na restriction
Pneumonia/TB (exudative)- removal by surgery as fluid can thicken and form empyema
large effusion- thoracentesis drainage
173
Causes of pulm HTN
Grade 1 -idiopathic
Grade 2- LH disease
- valvular heart disease
- restrictive cardiopmyopathy
- HF
Grade 3- lung disease/environmental hypoxemia
- COPD
- interstitial
- sarcoidosis
- vasculitis
- pulm venous occlusive disease
Grade 4- chronic thrombotic disease/embolic
- PE
Grade 5- metabolic disorders/systemic disorder/haem/other misc disorders
- thyroid disease
- chronic renal failure
- hepatitis--> portal HTN
- drugs, toxins
- congenital
- haem: HIV, myeloproliferative, splenectomy
- tumour obstruction in venous/arterial system
174
what is pulm hypertension
- HTN in ateries in the lungs and right side of heart
175
sx of pulm HTN
- 0SOB- orthopnea, PND in venous HTN
- oedema
- cyanosis
* *chest pain , palpitations, fainting, lightheadedness
- poor appetite, fatigue
* *- R abdo pain
- haemoptysis
176
signs of Pulm HTN
tachycardia
cyanosis
peripheral oedema
3rd heart sounds- inflow of large volume of blood into LV in early diastole, best heard at apex and when pt leans to L
parastenal heaves due to R atrial hypertrophy
RSHF
- jugular venous distension
- ascites
- hepatojugular reflux
RS valve dysfunctions due to large volume of blood in pulmonary arteries:
tricuspid regurg (RA->RV)
- high pitched
- holosytolic (all of sytsole)
- L lower sternal border (5th ICS)
- intensity increases on inspiration
pulmonic regurg (RV-> pulm arts)
- early diastolic murmur
- high pitched
- decrescendo
- L upper sternal border
- louder pt holds breath at end- exp and sits upright
177
Ix for ?pulm HTN
Echo
- pulm/tricuspid regurg
- RA hypertorphy
- RSHF
* **CT
- enlarged pulmonary trunk
- calcification pulm arteries
- CXR
- ABG
- pulm function
* *- RH catheterisation
178
tx of pulm HTN
tx underlying cause
- pulm endarterectomy- remove clots
- replace, repair RSH valves
- Anticoags- warfarin, NOACs, heparin, if caused by clot
- O2 if due to hypoxia/lung disease
```
Meds
- diuretics
- digoxin for tachycardia, inotrop
Vasodilation:
- CCBs- eg amlodipine
- Prostaglandins (prostacyclin, iloprost nebs)- also prevent platelets aggregation
- Endothelin
- sildenafil
```
- angioplasty
- atrial septostomy- hole made to reduce pressure in RSH
- lung/heart transplant
179
what is pulm oedema
fluid build up in lung interstium
| - decreased gaseous exchange--> hypoxia
180
Causes of pulmonary oedema
Cardiogenic
- LSHF
- severe systemic HTN
```
Non-cardiogenic-
Reduced oncotic pressure (less proteins):
- malnutrition
- liver failure
- nephrotic syndrome
ARDS: damage to pulmonary caps or alveoli- inflammation- cap permeability
- pulm infection
- inhalation of toxic substances
- chest trauma
- sepsis
```
181
sx pulm oedema
- Severe SOB
| * ******- orthopnea due to LSHF (increased congestion when lying down)
182
ix for ?pulm oedema
CXR
| CT- fluid in interstitial space
183
tx pulm oedema
- O2
* *- cardiogenic- antiHTN, betablockers, ivadradine, digoxin
* *- antiinflams: diclofenac, high dose aspirin
- loop diuretics if LVHF (furosemide)
- tx liver failure, nephrotic syndrome, malnutrition
184
What species of mycobacterium are there
Tuberculosis
africanum
bovis
microti
185
where has high prevalence of TB
South asia- india, pakistan, indonesia, bangladesh
Sub saharan africa
Russia
China
South america
186
stages of TB infection
primary
- mild flu like sx/asymptomatic
- granuloma and caseous necrosis- gohn focus
- spread to hilar lymph nodes
- bacteria may be eliminated
Secondary
- fever, night sweats, malaise, wt loss, haempotysis, chest pain, SOB
- gohn focus activated
- upper lobe spread
- cavities form
- bronchopneumonia
- solid necrosis
- systemic TB
187
Systemic TB locations
- kidneys (sterile pyuria), loin pain, dysuria
Meninges
Lumbar vertebrae
Adrenals- Addisons (low cortisol, aldosterone- fatigue, wt loss, low mood, loss of appetite, increased thirst)
Liver- heaptitis, RUQ pain, jaundice
Cervical lymph nodes-neck
- skin- erythema nodosum- red, lumpy rash
188
Ix ?TB
- Montoux./uberculin skin test
- INterferon gama release assay (blood)
- CXR
- Sputum/bronchoalveolar lavage samples- Zhiel Neelson, PCR, culture
189
tx TB
Latent
- isoniazid 9m
- rifampicin and isoniazid for 3m
```
Active
Rifamicin- 6m
Isonizaid- 6m
Pyrazinamide- 1st 2 months
Ethambutol- 1st 2m
```
will be infective 2-3w into course
CNS involved- Rid and ison for 10m instead of 6m
TB in brain/pericardium - give pred to reduce swelling
190
SE of TB meds
Rifampicin- red/orange excretions
Isoniazid- Peripheral neuropathy
Pyrazinamide- hepatitis
Ethambutol- optic neuritis (diplopia, hemianopia)
191
what drug do you give for prophylaxis for close contacts of TB
isoniazid
192
causative organism in pt with bronchial breath sounds and productive cough who suffered from flu recently
S.aureus causes pneumonia following influenza
193
most likley causative organism of pneumonia in COPD pt
HiB
194
sx legionnaire's disease
flu like
dry cought
confusion
195
signs of legionnaires
lymphopenia
hyponatraemia
deranged LFTs
pleural effusion
196
transmission of legionella
warm stagnant water- water tanks
197
diagnosis of legionnaire's disease
urinary antigen
198
tx of legionnaire's
erythro/clarithro
199
sx and signs mycoplasma pneumonia
similar to legionnella:
- flu like
- dry cough
* **- deranged LFTs
```
But also has:
peri/myocarditis- chets pain
**haemolysis- jaundice
**ITP- bruising/bleeding
**erythema multiforme- targetoid lesions/rash
```
200
diagnosis of mycoplasma pneumonia
```
serology/culture/PCR of:
polymerase chain reaction of
- nasopharyngeal swab
- aspirate (lavage)
- sputum
```
201
tx mycoplasma pneumonia
macrolide- erythro
202
atypical pneumonia typically seen in alcoholics
klebsiella
