Resp Flashcards
PE
Blood clot in the pulmonary arteries = obstruction of blood flow to lung tissue, strain on right heart
= pleuritic chest pain, SOB, haemoptysis, ^HR, clear chest or crackles, fever
Inv - ECG (sinus tachy, S1Q3T3 deep s/q, inverted T)
PE: Risk Factors
Immobility - long haul flights / surgery
Cancer
Oestrogen HRT
Pregnancy
Polycythemia
Thrombophilia
If patient has major RF for travel related thrombosis (FH or VTE themself) then can give TED stocking as prophylaxis
PE: Scoring
PERC - <2% if less than 1
Wells - >4 is likely
DVT signs (3), most likely diagnosis (3)
HR >100 (1.5), prev Hx (1.5), immobile (1.5)
Cancer (1), hemoptysis (1)
*CXR needed before CTPA and D dimer
Well’s for DVT: 2 points or more = likely
PE: Management
Wells >4 - CTPA, interim AC if delay, neg then prox leg US
Wells 4 or less - D-Dimer, pos then CTPA, neg consider alt.
VQ if renal impairment
-> 3m Xa inhibitor if provoked, 3-6m if cancer, 6m if unprovoked (LMWH if severe renal impairment), thrombolysis if v BP
Lung Cancer - Types
Non-small cell
- Adenocarcinoma: most common, peripheral, smokers (+ non), gynaecomastia
- Squamous cell: central cavitating lesions, PTHrp (^Ca), clubbing, HPOA
- Large cell: poor prognosis, b-HCG
- Alveolar cell: not related to smoking, ^^sputum
- Bronchial adenoma: carcinoid (bradykinin, serotonin = flushing, bronchoconstriction, diarrhoea, ACTH)
-> no surgery if FEV1 < 1.5L, malignant effusion, SVC obstruction, hilar involvement, vocal cord paralysis
Small cell (neuroendocrine, APUD cells)
15% of cases, worse prognosis.
= central, release ADH (vNa) / ACTH (Cushing), Lambert-Eaton
-> surgery if early, often mets at diagnosis
Lung Cancer: Features
= cough, blood, SOB, chest pain, weight loss, SVC syndrome, hoarse (RLN, Pancoast), supraclavicular/ cervical lymph, clubbing
fixed monophonic wheeze
Inv - ^PLT, CXR, bronchoscopy + biopsy, CT/ PET
COPD
Damage to lung tissue 2nd to smoking/ A1AT. Irreversible obstruction of air flow.
= cough, SOB, wheeze, right-sided HF, 2nd polycythemia. NO CLUBBING
Inv - post-bronchodilator spirometry (obstructive, FEV1/FVC <70%), CXR (hyperinflation, bullae, flat hemidiaphragm), BMI
Grading scale - 1) FEV1 (predicted) over 80%, 2) 50-80, 3) 30-50, 4) <30%
COPD: Management
General - stop smoking, annual flu vacc, one-off pnem, pulm rehab
-> SABA / SAMA
Asthma features -> LABA + ICS, then +LAMA
Not -> LABA + LAMA
Lastly, theophylline
*combined inhaler where poss
Steroid responsive (atopic/ asthma diagnosis, ^eosinophils, FEV1 400ml variation or 20% diurnal variation peak flow)
-> azithromycin as Abx prophylaxis
Long Term O2 Therapy
Offer if pO2 of < 7.3 kPa, or 7.3-8 + one of;
secondary polycythaemia
peripheral oedema
pulmonary hypertension
NOT if still smoking
COPD: Exacerbation
Cause - ^^Hib, strep pneum, ^human rhinovirus
-> BD inh, neb, with ipratropium, IV theophylline, 5 days of pred 30mg
-> 28% Venturi mask at 4 l/min (aim 88-92% in retainer), NIV if T2RF
-> Abx if purulent sputum/ pneumonia (doxy, clarithromycin, amoxicillin)
Bronchiectasis
Permanent airway dilatation 2nd to chronic inflammation, ^Hib/ pseudomonas
Causes - infection, cancer, CF, immune def (hypogammaglobulinemia), yellow nail syndrome, Kartagener’s, young’s syndrome
= SOB, ^sputum, cough, hemoptysis, clubbing, wheeze, crackles
Inv - high res CT (signet ring, tramtrack)
-> postural drainage, Abx, surgery if local
Pneumonia
Inflammation of alveoli, ^bacterial
HAP: 48hrs+ after admission (CAP <48hrs)
Inv - FBC, CRP, ABG, U&Es, CXR (consolidation)
CURB-65: confusion, RR 30+, BP <90/60, 65yr+ (home if 0, consider 1/2, hospital 3+)
Add urea >7 in hospital (ICU if 3+)
-> 5d amox (or 7-10d amox + macrolide), CXR at 6wk for resolution
Pneumonia: Organisms
Strep pneum - 80%, rapid onset, fever, herpes labialis
Hib - COPD/ bronchiectasis patients
Staph aureus - post-flu, cavitating
Klebsiella - alcoholics, cavitating
Mycoplasma - atypical, cold AIHA, erythema multiforme, immune neuro, RBC agglutination
Legionella - v Na (SIADH), v WCC, air con
Pneumocystis - HIV, dry cough, no chest signs, exercise desat
Coxiella Burnetti - Q fever, animals
Chlamydia psittaci - infected birds
Pneumothorax
Air gets into the pleural space
RF - lung disease, ventilation, CTD
= sudden onset
Pneumothorax: Management
Erect CXR to measure the size - from level of the hilum
Minimal symptoms -> conservative
Symptoms + low risk -> conservative, ambulatory or aspiration
Symptoms + high risk -> chest drain
? high risk = haem compromise, sig. hypoxia, underlying lung disease, bilateral, haemothorax, 50+ with sig smoking
Recurrent -> video-assisted thoracoscopic surgery (pleurodesis +/- bullectomy)
Tension -> needle decompression and chest drain
No scuba diving ever, no flying 2wk post-drain, stop smoking.
Conservative?
Primary: review every 2-4 days as outpatient
Secondary: monitor as inpatient
Stable/ resolved: follow-up as outpatient in 2-4wks
Pleural effusion
Collection of fluid in the pleural cavity
Exudative (protein >30g/L)
- pneumonia, TB, cancer, SLE, RA, pancreatitis, PE
Transudative (<30)
- HF, v albumin, v thyroid, meig (right-sided linked to ovarian cancer)
= SOB, stony dull, reduced breath sounds and trachea pushed away if large.
Inv - PA CXR (lose costophrenic angles, tracheal deviation, fluid in fissure and meniscus), US, contrast CT (cause), pleural asp
Lights Criteria
If protein level between 25-35 g/L -» Light’s criteria
Exudate likely if one of;
- pleural / serum protein >0.5
- pleural / serum LDH >0.6
- pleural LDH >2/3rds upper limit of normal serum LDH
Other findings - v glucose in TB/ RA. ^amylase in panc/ oes perf. Blood in mesothelioma/ TB.
If purulent, turbid/cloudy, pH <7.2 then place a chest tube to allow drainage (infection)
Chronic Asthma
Chronic airway inflammation, reversible bronchoconstriction, hypersensitivity
RF - Hx atopy, v BW, maternal smoking, ^allergen exposure
Link - aspirin sensitivity, nasal polyps
= cough, chest tightness, wheeze
Asthma: Diagnosis
<5yrs = clinical judgement
5-17yrs = spirometry with BDR, FeNo if neg
17+ = spirometry with BDR + FeNo (40+).
Reversibility is positive if >12% increase in FEV1 (or 200ml in adults)
Asthma: Management
SABA -> +Low ICS -> +LTRA
-> SABA +low ICS +LABA (+/-LTRA)
-> swap low ICS/LABA to MART
-> swap for mod dose MART
-> swap MART for high ICS/ LABA or LAMA or theophylline or refer to expert
When reducing steroids reduce by 25-30%
Low dose <400, high dose >800mcg budesonide
Acute Asthma
Moderate - PEFR 50-75%, normal speech, RR <25, HR <110
Severe - PEFR 33-50%, can’t complete sentences, RR >25, HR >110
Life Threatening - <33%, sats <92%, v BP, v HR, silent chest, cyanosis, poor resp effort, exhaustion, normal pCO2
Near fatal - ^pCO2
Acute Asthma: Management
Inv - ABG, CXR if life threatening
Admit - severe and not responding, life threatening, prev near fatal, pregnancy, attack even if taken steroid dose
-> oxygen, 5d pred, inh/ neb SABA, neb ipratropium, IV MgSO4, IV aminophylline, senior support (ITU), I+V/ ECMO
Discharge - stable on discharge meds for 12-24hrs, check inhaler use, PEF >75% best
Sarcoidosis
Multisystem disorder of unknown cause, leads to non caseating granulomas
RF - young adults, African
= SOB, malaise, cough, weight loss, erythema nodosum, BHL, swinging fever, arthralgia, lupus pernio (raised purple lesions), ^Ca, uveitis, conjunctivitis
Inv - ^ACE, ^Ca, ^ESR, CXR , spirometry (restrictive), biopsy (nc granulomas, epithelioid)
CXR stages - 0 = normal. 1 = BHL. 2 = BHL + interstitial infiltrates. 3 = diffuse infiltrates only. 4 = diffuse fibrosis.
-> steroids if symptoms + stage 2/3, also if ^Ca or organ involvement (eye heart or neuro)
Sarcoid Syndromes
Logfrens - acute sarcoidm good prog, BHL + erythema nodosum + fever + polyarthralgia
Mikulicz - parotid + lacrimal gland enlargement
Heerfordts - rare acute, fever + uveitis + parotid enlargement
Management of TB
-> 2 months RI(p)PE, 4m RI(p)
Latent -> RI(p) 3m
Meningeal -> 12m + steroids
TB Drugs
Rifampicin - hepatitis, orange secretions
Isoniazid - PN (give B6 - pyridoxine), hepatitis, agranulocytosis
Pyrazinamide - hepatitis, gout, myalgia
Ethambutol - optic neuritis
Chest Drains
Tube into pleural cavity, one way valve (out), 5th ICS mid-axillary line
Use - pleural effusion, pneum/hemothorax, empyema
Relative contra - INR >1.3, platelets <75, bullae or adhesions
Complications:
failure
Bleeding
Infection
Penetration of lung
Re-expansion Pulmonary oedema - need to clamp drain and urgent CXR. Happens because drained too quickly. Should not be more than 1L in 6hr.
Triangle of safety = base of Axilla, lateral pec major, 5th ICS, anterior lat dorsi
Acute Bronchitis
Inflammation of trachea and major bronchi, become oedematous, ^viral
= cough, sore throat, snotty, wheeze, low fever
Inv - clinical, CRP to guide Abx
-> Doxy if systemically unwell, co-morbid, CRP>100 (delayed prescription 20-100)
Prog - 3wks to resolve, 1/4 cont cough
COPD drugs
LABA - formeterol/ salmeterol
SAMA - ipratropium
LAMA - tiotropium
Empyema
Infected pleural effusion
= improving pneumonia but new fever
Inv - pH <7.2, v glucose, ^LDH
Lingula Consolidation
Loss of left heart border
Lingula is bottom projection of left upper lobe
Inhaler Technique
Metered dose inhalers
= Breathe out before use, slow deep inhalation whilst pressing down, hold breath for 10 seconds or as long as comfortable
Wait at least 30 seconds before next dose
Mesothelioma
Cancer of the mesothelial layer of the pleural cavity
RF - asbestos exposure (30yr latency), 20% also have asbestosis
= SOB, weight loss, chest wall pain, clubbing, 30% present as painless pleural effusion
Inv - CXR (pleural thickening, effusion), pleural CT, +
video-assisted thoracoscopic (VATS) biopsy, fluid culture
-> Industrial compensation, chemotherapy, surgery
Met to other lung and peritoneum
Pulmonary Function Tests
FEV1 - volume of air expired in the first second of forced expiration
FVC - max volume of air a person can exhale after full inspiration.
TLCO - overall measure of gas transfer in the lungs and reflects how much oxygen is being taken up into red cells.
KCO - TLCO / alveolar volume - therefore shows how efficient gas exchange is in relation to the alveolar capillary surface to volume ratio.
Kyphosis
Restrictive chest wall disease
- air can leave very quickly (^FEV1) but cannot enter quickly (v chest expansion, v FVC)
Normal/ low TLCO - alveoli cannot expand fully and so have less gas too exchange
High KCO - small alveolar vol so in proportion to this, pulm blood flow is high (^SA: vol)
Normal TLCO, High KCO
Pneumonectomy / lobectomy
Chest wall disease
NM weakness
Ankylosing spondylitis
Raised TLCO
Asthma
Pulm haemorrhage
Left to right shunt
Polycytheamia
Male gender and exercise
Reduced TLCO
Pulm fibrosis
Pneumonia
PE
Oedema
Emphysema
Low cardiac output and anaemia
Sarcoid: Prognosis
60% resolve in 6 months
Poor:
Insidious
>6m
Black
Extra pulm features
No erythema nodosum
CXR stage 3/4
Breath Sounds in Pneumonia
Bronchial Breath Sounds - harsh and equal on inspiration and expiration.
Focal coarse - air passing through the sputum
Triggers of Asthma
Infection
Night time / early morning
Exercise
Animals
Cold / damp
Dust
Emotions
BiPAP
Use - T2RF, resp acidosis despite adequate treatment
Contra - pneumothorax
Cycle of high and low pressure to match patients inspiration and expiration
CPAP
Use - acute pulm oedema, OSA, HF
Continuous air blown into lungs to keep airways expanded
Tension Pneumothorax
Cause - trauma to chest wall creates one way valve, air in but not out of pleural space, ^pressure
Kinking vessels = cardiac arrest
Trachea AWAY from affected side
Pulmonary HTN
Increased resistance and pressure of the blood in the pulmonary arteries, strain right side of the heart, back pressure of blood into venous system.
Causes - SLE, Left HF, CLD, PE
Inv - ECG (large R waves in V1-3 and S waves in V4-6)
Primary -> give PP5i , IV Prostanoids and endothelin antagonists
Secondary -> treat cause
OSA
Collapse of the pharyngeal airway during sleep, stop breathing
RF - obese man, alcohol, smoking
Link - acromegaly, hypothyroid, Marfan’s, large tonsils
= morning headache, daytime somnolence, unrefreshing sleep, HTN (due v O2/ ^CO2)
Inv - Epworth scale, ENT for study (polysomn)
-> weight loss, CPAP, oral devices
Lung Fibrosis
UPPER
Coal worker’s pneumoconiosis (progressive massive fibrosis)
HS pneumonitis (extrinsic allergic alveolitis), histiocytosis
Ankylosing spondylitis
Radiation (6-12m post-radiotherapy)
TB
Silicosis/ sarcoidosis
LOWER
Rheumatoid arthritis
Asbestosis
Idiopathic pulmonary fibrosis
Drugs: amiodarone, bleomycin, methotrexate, cyclophosphamide, nitrofurantoin
SLE/ scleroderma
Lung Fibrosis - Types
Coals Worker Pneumoconiosis
- 20yrs after exposure to coal dust, mixed picture
- Simple pneumoconiosis -> Progressive Massive Fibrosis
HS Pneumonitis (EAA)
- bird fanciers (protein in droppings), farmers (hay spores), malt (Aspergillus), mushroom (actinomycetes)
- T3HS reaction
= 4-8hrs fever and cough, chronic fatigue and SOB
-> Avoid triggers first, give steroids
Silicosis
- mining and foundries, RF for getting TB
- ‘egg-shell’ calcification of hilar lymph nodes
Asbestosis
- severity related to the length of exposure
IPF
- 50-70 years men, poor prognosis, restrictive picture
= progressive SOB, clubbing, bibasal fine insp crackles
Inv. - CXR (ground class -> honeycomb), high res CT
-> pulm rehab, pirfenidone
Cryptogenic Organising Pneumonia
- inflammation of bronchioles and alveoli caused by chronic RA, dermatomyositis, amiodarone
-> steroids
Kartagener’s syndrome
Primary ciliary dyskinesia
Dynein arm defect results in immotile cilia
= bronchiectasis, recurrent sinusitis, subfertility, associated dextrocardia/ situs inversus (quiet heart sounds, small volume complexes in lateral leads)
Psittacosis
Infection with Chlamydia psittaci, ^young adults
= fever, Hx of bird contact, pneumonia, severe headache, organomegaly, no response to penicillins
Inv. - inflam, CXR (consolidation), atypical pneumonia serology
-> tetracyclines e.g. doxycycline
Allergic Bronchopulmonary Aspergillosis
Allergy to Aspergillus spores, prev. label of asthma
= proximal bronchiectasis + eosinophilia, wheeze, cough, SOB, brownish mucus plugs
Inv - ^eosinophils, radioallergosorbent (RAST) test to Aspergillus, IgG precipitins, ^IgE, CXR (upper lobe infiltrates)
-> oral steroids, itraconazole 2nd
