Resp Flashcards
More common type of lung cancer
- Non small cell lung cancer = 80%
- SCLC = 20%
types of non small cell lung cancer
- adenocarcinoma
- squamous cell carcinoma
- large cell carcinoma
S+S lung cacner
- Cough
- Haemoptysis
- SOB
- Weight loss
- Supraclavicular LN
Extrapulmonary manifestations
- Recurrent laryngeal nerve palsy = hoarse voice
- Phrenic nerve palsy = SOB
- SVC obstruction = face swell, distended neck and upper chest veins = pembertons sign
- Horners = ptosis, anhidrosis, miosis, pancoast
Paraneoplastic syndromes
- SIADH = SCLC
- Cushings = SCLC
- Hypercalcaemia = squamous cell
- Lambert eaton = SCLC = antibodies against SCLC cells and calcium channels
guidelines for lung cancer 2ww
> 40 with
- clubbing
- lymphadenopathy
- recurrent chest infections
- thrombocytosis (increased plt)
- chest signs
CXR for patients over 40 who have
- 2+ unexplained sx in pt who never smoked
- 1+ unexplained sx in pt that have ever smoked or had asbestos
UE - cough, sob, chest pain, fatigue, weight loss
CXR in lung cancer
- hilar enlargement
- peripheral opacity (visible lesion)
- pleural effusion (unilateral)
- collapse
lung ca ix
- CXR
- Staging CT (contrast)
- PET CT (for mets)
- Bronchoscopy with endobrachial USS
- histology = bronchoscopy
1st line tx NSCLC
surgery
- radiotherapy can also be curative
Tx SCLC
- chemo and radio
CURB65
- Confusion
- urea >7
- RR >30
- BP <90 s or <60 d
- > 65
Atypical pneumonia treatment
- Macrolides (clarithromycin)
- fluoroquinolones (levofloxacin)
- tetracyclines (doxy)
Legionella S+S
- can cause SIADH = hyponatraemia
- urine antigen test to screen
Mycoplasma pneumoniae
- rash = erythema multiforme
- target lesions
- neuro sx in young
PCP
- Fungal pneumonia
- Immunocompromised patients = steroids
- Dry cough, SOB, night sweats
- Prophylactic co-trimoxazole
Spirometry results for obstructive disease
- FEV1 <70%
- Obstruction is slowing air passage out the lungs
Sprirometry results for restrictive
- FEV1 and FVC are equally reduced
- FEV1:FVC ratio >70%
Asthma exam finding
- Polyphonic expiratory wheeze
drugs that can worsen asthma
- BB
- NSAIDs
Asthma Ix
- Spirometry
- Reversibility testing >12% increase on testing
- FeNO >40
- Peak flow variabulity >20%
Asthma Mx
1 = SABA
2 = Inhaled corticosteroid (beclametasone)
3 = Leukotrine receptor antagonist
4 = LABA (salmeterol)
5 = MART regime
6 = increase ICS dose
ABG in acute asthma
- initially = respiratory alkalosis as a raised RR caused drop in CO2
- Normal PCo2 or low O2 = SCARY = getting tired
moderate exacerbation features asthma
- peak flow 50-75%
severe exacerbation features asthma
- peak flow 33-50%
- RR >25
- HR >110
- Can’t complete sentences
life threatening features asthma
- Peak flow <33%
- sats <92%
- PaO2 <8
- tiredness
- confusion
- Silent chest
- shock
asthma exacerbation mx
OSHITME
- Oxygen
- Salbutamol 5mg nebs 20-30mins
- Hydrocortisone=pred 40-50mg oral or 100mg H IV
- Ipratropium = 500mcg nebs
- T
- Magnesium = IV 1.2-2g
MRC dyspnoea scale for COPD
1 = SOB on strenuous
2 = SOB uphill
3 = SOB on flat
4 = SOB <100m
5 = cant leave house
spirometry in COPD
- FEV1:FVC <70%
- no response to reversibility testing
FEV1 staging for COPD
1 (mild) = FEV1 >80% predicted
2 (moderate) 50-79%
3 (severe) 30-49%
4 (V severe) <30%
Initial COPD tx
- SABA = salbutamol
- SAMA = Ip bromide
COPD Mx if no asthma/steroid response
- LABA = formoterol and LAMA = tiotropium
COPD Mx if are asthma/steroid response
LABA and ICS
Chronic bronchitis COPD
- Mucus hypersecretion and airway obstruction
Blue bloaters - Alveolar and renal hypoxia
- Increased EPO secretion = polycythaemia
- Increased renin = fluid retention
- cyanosed and bloated
Emphysema COPD
- Alveolar trapping
Pink puffers - Airway collapse on exhalation = obstruction
- Exhale slowly through pursed lips
- Increased airway pressure to prevent airway collapse
- Flushing and puffing
- Well perfused, barrel chest
final inhaler step for COPD
LABA, LAMA and ICS
when LTOT needed
- Chronic hypoxia <92%
- polycythaemia
- cyanosis
- cor pulmonale
what is cor pulmonale
- Right sided HF
- Pulmonary HTN limits RV pumping blood into pulmonary arteries
- Causes back pressure
S+S cor pulmonale
- SOB
- Oedema
- Syncope
- CHest pain
- Hypoxia and cyanosis
- Raised JVP
ABG in acute exacerbation COPD
Resp acidosis
- Low pH
- Hypoxia
- Hypercapnia
- Riased bicarb
COPD exacerbation mx
- inhalers and nebs
- steroids = pred 30mg for 5d
- abx if needed
- physio
Severe - IV aminophylline
- NIV
- ITU
when is NIV considered
- Persistent resp acidosis despite tx
- potential to recover
- acceptable to patient
what is bronchiectasis
- permanent dilation of the bronchi
- chronic cough
- continuous soutum production
- recurrent infections
Ix bronchiectasis
- culture = HI and Psued aeruginosa
- CXR - tram track opacities, ring shadows
Best ix for bronchiectasis
- High resolution CT
Mx bronchiectasis
- vaccines
- physio
- rehab
- long term abx
- colistin
- bronchodilatoers
- surgery
infective bronchiectasis mx
- cultures
- abx extended course
- ciprofloxaxin if pseud aer
S+S interstitial lung disease
- SOB
- Dry cough
- fatige
- bibasal fine end inspiratory crackles
- finger clubbing
Ix ILD
- clinical features
- HRCT = ground glass
- spirometry
spirometry for ILD
- restrictive
- FEV and FVC equally reduced
- FEV1:FVC ration >70% (normal/increased)
IDP signs and Mx
- SOB and cough >3 months
- > 50years old
- Pirfenidone reduces fibrosis and imflam
- Nintedanib inhibits tyrosine kinase
drugs that can cause pulmonary fibrosis
- amiodarone
- cyclophosphamide
- methotrexate
- nitrofurantoin
patho hypersensitivity pneumonitis
- also called extrinsic allergic alveolitis
- type 2 and 4 hypersensitivity reaction to an environmental allergen
Ix for Hypersensitivity Pneumonitis
- brobcheolar lavage = raised lymphocytes
causes of Hypersensitivity Pneumonitis
- bird fanciers lung
- farmers lung
- mushroom worker
- malt workers
Mx Hypersensitivity Pneumonitis
- remove allergen
- Oxygen
- Steroids
Asbestos causes
- fibrosis
- pleural thickening
- adenocarcinoma
- mesothelioma
exudative pleural effusion
- protein >30g/l
Transudative effusion
- protein <30g/l
Exudative causes
- inflamation
- cancer
- infeciton
- rheumatoid
transudative causes
- congestive cardiac failure
- hypoalbuminaemia
- hypothyroidism
- meigs syndrome
meigs syndrome
- benign ovarian tumour
- pleural effusion
- ascites
S+S effusion
- SOB
- dull percussion
- decreased breath sounds
- trachea away in large effusions
CXR effusion
- blunt CP angle
- fluid in fissures
- meniscus
- tracheal deviation away
Mx effusions
- Conservative
- pleural aspiration
- chest drain
empyema
- infected pleural effusion
- pus, low oh, low glucose, high ldh
- drain and abx
lights criteria for exudative
- Exudate = protein >30g/l if between 25-35 use lights criteria
- pleural fluid protein/serum protein >0.5
- pleural fluid LDH/serum LDH >0.6
- pleural fluid LDH >2/3 upper limits normal serum LDH
Mx pneumothorax
- No SOB and <2cm air rim = no tx, follow up
- SOB and >2cm = aspiration, if fails 2 then drain
where is drain in pneumothorax
- 5th IC space
- mid axillary line
- anterior axillary line
when surgery in pneumothorax
- chest drain fails to correct
- persistent air leak in drain
- recurrent pneumothorax
tension pneumothorax
- trauma
- ## one way valve that lets air in and not out
signs tension pneumothorax
- deviation away
- reduced ae
- increased resonance
- tachy
- hypo
mx tension pneumothorax
- large bore cannula into 2nd IC in MC line
definition of pulmonary htn
mean pulmonary arterial pressure >20 mmHg
5 causes pulmonary htn
1 = idiopathic
2 = left heart failure
3 = chronic lung disease
4 = pulmonary vascular disease
5 = miscellaneous
ECG in pul htn
- p pulmonale = peaked p waves
- RV hypertrophy
- right axis devation
- RBBB
CXR in PHTN
- dilated pulmonary arteries
- rv hypertrophy
mx idiopathic PHTN
- CCB
- IV prostaglandins
- Endothelin receptor antagonists
- phosphodiesterae 5 inhibitors
epi of sarcoidosis
- 20-39 or 60
- women
- black
skin features sarcoidosis
- erythema nodosum on shins
- lupus pernio = purple lesions on cheeks and nose
lungs in sarcoidosis
- mediastinal lymphadenopathy
- pulmonary fibrosis
- pulmonary nodules
other s+s sarcoidosis
- fever, wl, fatigue
- liver nodules, cirrhosis, cholestasis
- uveitis, conjuncitivitis
- optic neuritis
- BBB
- Kidney stones, neprhitis
- DI
- nerve palsy
- arthralgia
lofgrens syndrome
- erythema nodosum
- bilateral hilar lymphadenopathy
- polyarthralgia
blood tests in sarcoidosis
- raised ACE
- hypercalcaemia
sarcoidosis histology
non caseating granulomas with epithelioid cells
mx sarcoidosis
- conservative
- oral steroids
- bisphosphonates
- methotrexate 2nd line
TB micro cause
- Mycobacterium tuberculosis
- Bacillus
- acid fast bacilli
staining for TB
Zeihl Neelsen stain
- turns them bright red against blue background
testing pre TB vacciantion
- mantoux test
- only given vaccine if negative
S+S TB
- cough
- haemoptysis
- lethargy
- night sweats
- weight loss
- erythema nodosum
TB Ix
- mantoux test
- interferon gamma release assay
- CSR
- cultures
what is mantoux
- inject tuberculin into intradermal space on forearm
- after 72 hrs, induration 5mm or more = +ve
TB CXR
- Primary = patchy consolidation, pleural effusion, hilar lymphadenopathy
- reactivated = patchy/nodular consolidation with cavitation
- Disseminated = millet seeds
when is NAAT used
- diagnosing TB in HIV or <16
- RF for multi drug resistance
Latent TB Tx
- Isoniazid and rifampicin for 3 months
- Or isoniazid for 5 m
RIPE
- Rifampicin 6m
- Isonizaid 6m
- Pyrazinamide 2m
- Ethambutol 2m
RIPE and SE
- R = red tears and urine, reduced COCP
- I = peripheral neuropathy
- P = hyperuricaemia = gout and stones
- E = colour blindness and reduced acuity
mx if wells score likely
- CTPA
mx if wells unlikely
- d dimer
- if +ve then CTPA
ABG in PE
- resp alkalosis
= blow off CO2 therefore alkalotic blood
mx PE
- 1st line = rivaroxaban
- 2nd = LMWH = enoxaparin
how long to anticoagulate for in PE
- 3m if reversible cause
- over 3m if unprovoked or irreversible cause
- 3-6m active cancer
T1RD
- normal CO2
- low O2
T2RF
- high CO2
- Low O2
does co2 make blood acidic or alkalotic
acidic = breaks down into carbonic acid
what causes obstructive sleep apnoea
- collapse of pharyngeal airway
S+S apnoea
- apnoea during sleep
- snoring
- morning headache
- unrefreshed
- daytime sleepiness
- concentration problems
- reduced oxygen sats
asthma diagnostic testing >17 years
- all pt should have spirometry with bronchodialtor reversibility
- all should have FeNO
asthma testing 5-16 yrs
- spirometry with BDR
- FeNo if normal spirometry or obstructive spirometry with negative BDR
what is polysomnography
sleep studies
common causes resp alkalosis
- anxiety
- PE
- CNS disorders
- altitude
- pregnancy
how does SABA work
- stimulates b2 receptors of resp tract
- increases sympathetic activity
relaxes bronchial smooth muscle
