Resp Flashcards
what is acute bronchitis
usually viral infection causing inflammation of trachea and major bronchi
how does acute bronchitis present
cough - some sputum sore throat rhinorrhea wheeze low grade fever
how to differentiate between pneumonia and bronchitis
pneumonia - wheeze + other focal signs - crepitations, dull to percussion, bronchial breathing
pneumonia may also have some systemic symptoms such as fever malaise and myalgia
bronchitis - just wheeze
how is acute bronchitis managed
analgesia
fluids
if CRP 20-100 - offer delayed antibiotic prescription
if CRP >100 - immediate doxycycline
alternative for pregnancy/children - amoxicillin
what antibiotics in acute bronchitis
doxycycline
amoxicillin if preg/children
how would anaphylaxis present
- angioedema of face, tongue, lips
- hoarse voice
- stridor (swelling of larynx)
- wheeze
- dyspnoea
- hypotension
- tachycardia
- can also present with abdo pain
what skin changes in anaphylaxis
urticarial/erythematous rash
generalised itch
what dose of adrenaline for adult anaphylaxis
500mcg - 1 in 1000
how often can adrenaline IM injections be repeated and where is the best place to administer?
every 5 minutes
anterolateral aspect of middle third of thigh
what is refractory anaphylaxis
cardiorespiratory problems persist after 2 doses of IM adrenaline
how is refractory anaphylaxis treated
fluids if shocked
refer for ITU for IV adrenaline line
what treatment for anaphylaxis after patient has been stabilised?
- non-sedating antihistamines such as CETIRIZINE for rash
- serial tryptase measurements (tryptase can remain elevated for 12 hours, MEASURE WITHIN 6 HOURS)
- all patients should be referred to specialist allergy clinic
- provide patients with 2 adrenaline auto-injectors and training for how to use
what type of hypersensitivity is anaphylaxis
type 1
what is the pathophys of anaphylaxis
IgE stimulates mast cell degeneration causing release of histamine and other pro-inflammatory chemicals
what three treatments are given in anaphylaxis
IM adrenaline
Oral antihistamines
IV hydrocortisone
what conditions can be caused by asbestos exposure
- pleural plaques
- asbestosis
- pleural thickening
- mesothelioma
- lung cancer
describe pleural plaques
- benign, do not undergo malignant change, no follow up required
- 20-40 year latency period
what can cause pleural thickening
empyema
haemothorax
asbestos exposure
describe asbestosis and its treatment
asbestosis causes lower lobe fibrosis, severity related to length of exposure
conservative treatment
what are the symptoms of asbestosis
progressive shortness of breath
reduced exercise tolerance
what is mesothelioma
cancer of the pleura, commonly caused by asbestos exposure, severity not related to length of exposure
what are the presenting features of mesothelioma
progressive sob
chest pain
pleural effusion
how is mesothelioma treated
palliative chemo
some radio/surgery
how does asbestos exposure relate to lung cancer
increases risk of lung ca
synergistic effect with smoking
what are the RFs for sleep apnoea
obesity
macroglossia (acromegaly, hypothyroidism, amyloidosis)
large tonsils
marfan’s
how does sleep apnoea present
- excessive snoring
- periods of apnoea during sleep
- daytime somnolence, fatigue
- HTN
- compensated respiratory acidosis
what would ABG of sleep apnoea look like?
compensated respiratory acidosis
what scoring systems/assessments for sleep apnoea
epworth scale
multiple sleep latency tes - assess time taken to fall asleep in dark room
what investigations for sleep apnoea
sleep studies - polysomnography
what management for sleep apnoea
- weight loss, stop drinking + smoking
- CPAP
- intra-oral devices such as mandibular advancement
- inform DVLA if excessive daytime somnolence
explain the pathophys of sleep apnoea
collapse of pharyngeal airway
what are the complications of sleep apnoea
HTN
heart failure
can increase risk of MI and stroke
what is the mgmt of PE with renal impairment (severe)
LMWH
what is the mgmt of PE with anti phospholipid syndrome
LMWH
what are the complications of PE
sudden death cardiac arrest hypotension syncope pulmonary hypertension
what is bronchiectasis
permanent dilation of airways secondary to chronic inflammation/infection
what infections can lead to bronchiectasis
TB
measles
whooping cough
pneumonia
what medical conditions can lead to bronchiectasis
CF
ciliary dyskinesia - kartagener, Young’s
bronchial obstructions - foreign body, lung cancer
yellow nail syndrome
IgA deficiency, hypogammaglobulinaemia
allergic bronchopulmonary aspergillosis
how is bronchiectasis diagnosed
CXR
High resolution CT chest - tram-track and signet ring signs
how does bronchiectasis present?
cough, productive of large volumes of sputum sob chest pain clubbing recurrent chest infections
how is bronchiectasis managed
- physical training
- postural drainage
- antibiotics (long term rotating antibiotics if severe cases)
- bronchodilators
- immunisations
- surgery if localised disease
what are the most common organisms isolated in bronchiectasis
- Haemophilus influenzae
- Pseudomonas aeruginosa
- Klebsiella spp.
- Strep pneumoniae
what is a serious complication of bronchiectasis
massive haemoptysis - needs bronchial artery embolisation
what is bronchiolitis, who does it usually affect
infxn of bronchioles, usually with RSV, can be adenovirus,
babies <1year
what RFs for severe bronchiolitis
congenital heart failure
superimposed bacterial infection
bronchopulmonary dysplasia (premature)
CF
what symptoms of bronchiolitis
dry cough wheeze/fine inspiratory crackles SoB mild fever, coryzal symptoms feeding difficulties associated with increasing dyspnoea
when should babies be referred to A&E by ambulance in bronchiolitis
- under 3 months
- apnoea
- child looks seriously unwell to a healthcare professional
- severe resp distress:
- grunting
- marked chest recession
- RR>70
- use of accessory muscles
- tracheal tug
- cyanosis
- O2 sats <92%
consider referral if dehydration or tachypnoea (>60) or if inadequate oral fluid intake (50-70% of usual)
what management of bronchiolitis
- humidified oxygen if low sats
- ensure adequate food and fluid intake - NG tube if necessary
- suctioning for secretions
how is bronchiolitis diagnosed
clinical
immunofluorescence of nasal secretions may show RSB
what are babies with bronchiolitis at inc risk of in childhood
viral induced wheeze
explain pathophys of pneumothorax
air in the pleural space causing separation of lung from chest wall
list some causes of pneumothorax
trauma
idiopathic
iatrogenic - central line insertion
lung pathologies - asthma, COPD, infection
how is primary pneumothorax managed
if <2cm - discharge
if >2cm - aspiration
- failure of aspiration (still SOB, still >2cm) - chest drain
how is secondary pneumothorax managed
> 2cm/sob/>50y = chest drain
1-2 cm - aspirate
<1cm - admit for obs and ox
when can patients fly/diving after pneumothorax
fly after 1 week post xray check
no scuba diving unless bilateral pleurectomy
what are the borders of the triangle of safety for chest drain insertion
- mid-axillary line (lateral edge of latissimus dorsi)
- anterior axillary line (lateral edge of pectoralis major)
- 5th intercostal space (nipple line)
always insert chest drain ABOVE ribs to avoid neurovascular bundle
how to confirm correct chest drain insertion
swinging (rise of water seal on inspiration, fall on expiration)
spontaneous bubbling of water as air leaves pleural space
re-inflation of lung
what surgical options for pneumothorax
- Video assisted thoracoscopic surgery
- chemical pleurodesis (talc to irritate pleura)
- abrasive pleurodesis (physical irritation of pleura)
- pleurectomy
what is a tension pneumothorax
trauma to chest cavity creating one-way valve that allows air into but not OUT of the pleural space
this is dangerous as air builds up with inspiration and increases the pressure in the thorax
this pushes on the mediastinum and its vessels and can lead to cardiorespiratory arrest
what signs of tension pneumothorax
- tracheal deviation AWAY from the side of the pneumothorax
- reduced air entry
- hyperresonant to percussion on affected side
- TACHYCARDIA
- HYPOTENSION
what is the mgmt of tension pneumothorax
insert a large bore cannula into the second intercostal space, midclavicular line
once pressure is relieved with a cannula, chest drain can be inserted
if tension pneumothorax suspected, do not await investigations
what is the difference between transudative and exudative pleural effusion
transudative - <30g/L protein
exudative - >30g/L protein
what are the causes of transudative pleural effusions
- heart failure
- hypoalbuminaemia (liv disease, nephrotic syn, malabsorption)
- hypothyroidism
- meig’s syndrome (pleural effusion, ascites, ovarian Ca)
what are causes of exudative effusion
- pneumonia
- lung ca, mesothelioma, mets
- TB
- connective tissue disease - RA/SLE
- pancreatitis
- PE
- dressler’s syndrome
- yellow nail syndrome
what symptoms of pleural effusion
shortness of breath
non-productive cough
chest pain
what signs of pleural effusion
tracheal deviation if massive
stony dullness to percussion
reduced breath sounds and chest expansion
what imaging for pleural effusion
- Posteroanterior CXR
- USS chest
- Contrast CT CAP to find underlying cause of exudative
what other investigations aside from imaging for pleural effusion
pleural aspiration
send fluid for:
- microbiology
- cytology
- pH, protein, LDH analysis
if unsure if transudate/exudate, how do serum/fluid protein level differ in pleural effusion
pleural fluid protein / serum fluid protein > 0.5 = exudative
what would CXR show in pleural effusion
blunting of costophrenic angles
fluid in lung fissures
larger effusion - meniscus
tracheal + mediastinal deviation if massive effusion
how would oesophageal rupture affect pleural effusion fluid analysis
low pH
low glucose
raised amylase
how would empyema fluid analysis look
turbid, cloudy
low pH <7.2
low glucose
high LDH
how is recurrent pleural effusion managed
- recurrent aspiration
- pleurodesis
- indwelling pleural catheter
- drug management to alleviate symptoms - opiates for dyspnoea
