Resp Flashcards
What causes upper lobe fibrosis?
Coal workers pneumonitis
Hypersensitivity
Ankylosing spondylitis
Radiation
Tuberculosis
Sarcoidosis
management of acute COPD exacerbation
- increase bronchodilator use; can give via nebs
- corticosteroid for 30 days
- oral antibiotics ‘if sputum is purulent or there are clinical signs of pneumonia’; clarithromycin, doxycycline or amoxicillin
most likely cause of pneumonia if recent influenza
staphlycoccus aureus
treatment for sinusitis
intranasal corticosteroids
Stepwise asthma treatment
SABA
ICS
LTRA
LABA and review LTRA
MART therapy
Increase to high dose ICS or try additional drug
Spirometry of COPD
Obstructive non reversible picture
GOLD stages COPD
I FEV1>80%
II 50-80%
III 30-50%
IV <30%
Criteria for assessment for oxygen therapy in COPD
FEV1 <30% predicted
Cyanosis
Polycythaemia
Peripheral oedema
Raise JVP
Oxygen sats <92 on air
Must not smoke
Offer LTOT to patients with…
PO2 <7.3kpa
Or PO2 7.3-8kpa and one of secondary polycythaemia, peripheral oedema, pulmonary hypertension
pharamcological COPD treatment
- SABA(salbutamol) or SAMA (ipratropium)
- no asthmatic features; add LABA or LAMA (stop SAMA if starting LAMA)
- with asthmatic features; add LABA and ICS.
if still breathless add LAMA - oral theophylline under specialist
- consider prophylactic azithromycin if lots of exacerbations
- can try mucolytics if lots of mucus e.g. carbocisteine
non-pharmacological COPD treatment
smoking cessation
annual flu vaccine
one off pneumococcal
pulmonary rehabilitation
What cause of pneumonia is associated with erythema multiforms
Mycoplasma pneumonia
active TB treatment
pyrazinamide + ethambutol for first 2 months
isoniazid + rifampicin for the whole 6 months
important side effects of TB drugs
rifampicin - orange bodily fluids, toxicity and interactions
isoniazid - neuropathy, hepatitis
pyrazinamide - hepatotoxicty, arthralgia, sideroblastic anaemia
ehtambutol - optic neuritis
where does lung cancer tend to metastasise to
Bones
Liver
Adrenals
Brain
treatment/prognosis of SCLC
treatment not curative
classified as limitied or extensive
worse prognosis than NSCLC
responsible for the paraneoplastic syndromes
treatment/prognosis of NSCLC
based on TNM staging
stage 1 operable
2 & 3 mixed
stage 4 chemo only
types of NSCLCs
adenocarcinoma (most common 40%)
sqamous carcinoma (20%)
large cell (10%)
others (10%)
Non metastatic manifestations of lung cancer
Lambert Eaton syndrome
Myasthenia graves
(Both related to Ach in the synapse)
SIADH
hypertrophic osteoarthropathy (more common is nsclc)
Cushing syndrome
What is pancoast syndrome
Malignant neoplasm in the thoracic inlet disrupting the brachial plexus and cervical sympathetic nerves
causes Horner’s syndrome; ptosis, anhidrosis and miosis
what is the treatment for small cell lung cancer
combination of chemotherapy and radiotherapy
treatment of Non Small Cell LCas
mainstay is surgery + radiotherapy
later chemotherapy can be added
characteristic chest signs of pneumonia
bronchial breath sounds
focal course crackles
dullness to percussion
CURB-65
Confusion
Urea >7
Resp rate 30+
Blood pressure <90 systolic or <60 diastolic
>65 years
hospital investigations pneumonia
CXR
FBC
U+Es
CRP
+/- sputum and blood cultures depending on severity
pneumonia complications
acutely; reps failure, hypotension, AF
empyema
pleural effusion
sepsis
lung abscess
kidney or liver failure
mild CAP treatment
5-7 days antibiotics
can usually be managed in the community
moderate to severe CAP treatment
7-10 days of dual antibiotics
will need admission
what key drugs can induce pulmonary fibrosis
methotrexate
nitrofurantoin
amiodarone
cyclophosphamide
classical signs idiopathic pulmonary fibrosis
bibasal fine end inspiratory crackles
finger clubbing
progressive symptoms
what conditions can cause secondary pulmonary fibrosis
SLE
rheumatoid arthritis
systemic sclerosis
a1-antitrypsin deficiency
what is sarcoidosis
epidemiology
a granulomatous inflammatory condition
two age spikes - 20s and 60s
more common in women
more common in black people
main symptoms and systems affected in sarcoidosis
chest symptoms but also has multiple extra-pulmonary manifestations such as erythema nodosum and lymphadenopathy
lungs; fibrosis, nodules, mediastinal lymphadenopathy
systemic; fever, fatigue, weight loss
liver; nodules, cirrhosis, cholestasis
eyes; uveitis, conjunctivitis, optic neuritis
skin; erythema nodosum, granulomas in scar tissue
each of heart, kidneys and nervous system can also be affected in about 1 in 20
sarcoidosis investigations
serum ACE; diagnostics and screening
calcium in often raised
CRP can be raised
raised serum IL-2 receptor
histology is gold standard for confirming diagnosis
sarcoidosis treatment
can often conservatively manage initially
when treatment required start oral steroids for 6 to 24 months
second line are azathioprine and methotrexate
what is pulmonary hypertension
increased resistance and pressure of blood in the pulmonary arteries which causes strain on the right side of the heart and eventually back pressure into the venous system
causes of pulmonary hypertension
primary pulmonary hypertension
CTDs such as lupus
chronic lung disease such as COPD
pulmonary vascular disease e.g. PE
others; haematological, sarcoidosis
action if PE Well’s score
- likely (4+)
- unlikely
likely; immediate CTPA and anticoagulant
unlikely; interim anticoagulate, D-dimer and if positive CTPA, if negative PE very unlikely
exudative pleural effusion
fluid has:
high protein
high LDH
high cholesterol
causes are related to inflammation; cancer, pneumonia, rheumatoid arthritis, TB
transudative pleural effusion
fluid has:
low protein
low LDH
low cholesterol
caused by fluid shifts e.g from heart failure, hypoalbuminaemia, hypothyroidism, Meig’s (R sided due to Ovarian Ca)
what is an empyema?
infected plural effusion
suspect in improving pneumonia but new or ongoing fever.
Pleural aspiration shows pus, acidic pH (pH < 7.2), low glucose and high LDH
types of non-invasive ventilation
BiPAP - used in type 2 RF
CPAP - used in obstructive sleep apnoea, congestive cardiac failure, acute pulmonary oedema
what is the diagnostic investigation in obstructive sleep apnoea
Polysomnography
features of obstructive sleep apnoea
daytime sleepiness
compensated respiratory acidosis
hypertension
assessment of sleepiness
Epworth Sleepiness Scale - completed by pt +/- partner
Multiple Sleep Latency Test (MSLT) - measures time to fall asleep using EEG
management obstructive sleep apnoea
weight loss
CPAP
DVLA informed if excessive sleepiness
most common cause of COPD exacerbation pneumonia
Haemophilus influenzae.
Other bacterial causes include Streptococcus pneumoniae and Moraxella catarrhalis.
Respiratory viruses account for around 30% of exacerbations
most common pneumonia seen in alcoholics
Klebsiella pneumoniae
COPD exacerbation management
increased freq bronchodilator use and consider nebulisers
5 days oral prednisolone 30mg
antibiotics is sputum purulent or clinical signs of pneumonia - amoxicillin, clarithromycin or doxycycline
what antibiotic is used for prophylaxis in COPD patients who meet the criteria
azithromycin 250mg 3 times a week
> 3 exacerbations requiring steroid therapy and at least one exacerbation requiring hospital admission in the previous year
non smoker
trial for minimum of 6-12 months
what type of fibrosis tends to affect the lower zones
idiopathic pulmonary fibrosis
CTDs
drug induced
asbestosis
indications for surgery in bronchiectasis
uncontrolled haemoptysis
localised disease
management of atelectasis
chest physiotherapy with mobilisation and breathing exercises
Acute Respiratory Distress Syndrome
1) acute onset dyspnoea, increased RR, bilateral lung crackles, desaturating
2) signs of non-cardiogenic pulmonary oedema
3) reduced PaO2/FiO2 of <300 mmHg (or <40 kPa)
mortality around 40%
are pleural plaques malignant
no benign and do not undergo malignant change
life threatening asthma features
PEFR <33%
sats <92%
normocapnic
exhaustion
severe asthma features
PEFR 33-50%
HR >110 bpm
RR >25
can’t complete sentences
discharge criteria asthma exacerbation
stable on discharge medication for 12-24 hrs
PEF>75% best or predicted
inhaler technique checked and recorded
trachea pulled toward a whiteout CXR
pneumonectomy
complete lung collapse
pulmonary hypoplasia
trachea central complete white out CXR
consolidation
pulmonary oedema
mesothelioma
trachea pushed away from whiteout CXR
pleural effusion
large thoracic mass
diaphragmatic hernia
features of allergic bronchopulmonary aspergillosis
management
bronchiectasis + symptoms of bronchoconstriction
eosinophilia
managed with oral steroids sometimes with itraconazole
smoking cessation help in pregnancy women
nicotine replacement therapy
bupropion and varenicline are contraindicated!
what do lung abscesses usually occur secondary to
management
aspiration pneumonia
are typically polymicrobial due to this
needs IV antibiotics
what paraneoplastic syndromes squamous cell lung ca
hypercalcemia secondary to PTH
clubbing
hypertrophic pulmonary osteoarthropathy
hyperthyroidism
what paraneoplastic syndromes small cell lung cancer
hyponatramia secondary to SIADH
ACTH –> cushings
Lambert Eaton
what drug class is montelukast an example of
Leukotrine Receptor Antagonists
what blood gas abnormality does a neuromuscular disease usually cause
a respiratory acidosis
primary pneumothorax management
if <2cm and no SoB discharge and follow up
if >2cm or SoB needle aspiration
chest drain if not resolved
secondary pneumothorax management
if >50 yrs old or rim >2cm then chest drain should be inserted
if 1-2cm aspirate
all patients even if <1cm should be admitted with oxygen for 24 hrs
pleural plaques
large plaques seen on X-ray
appear 2-40 yrs after asbestos exposure benign and do not undergo malignant transformation
asbestosis
related to length of exposure
causes lower lobe fibrosis with symptoms of dyspnoea and reduced exercise tolerance, clubbing, end inspiratory crackles, restrictive lung function tests
mesothelioma
malignancy of the pleura presenting with progressive SoB, chest pain and pleural effusion
poor prognosis
