Resp Flashcards
what is hospital acquired pneumonia
pneumonia that has occurred 48 hrs after hospital admission
common causes of community acquired pneumonia
streptococcus pneumoniae (!)
mycoplasma pneumoniae
haemophilus pneumoniae
atypical organisms that cause pneumonia
mycoplasma pneumoniae
legionella pneumophilia
chlamydia psittaci
chlamydia pneumoniae
common causes of hospital acquired pneumonia
staphylococcus aureus
pseudomonas aeruginosa
klebsiella
causes of aspiration pneumonia
anaerobes from gut flora
risk factors for pneumonia
smoking
recent travel
immunocompromised
faulty air conditioning (legionella)
pet birds (chlamydia psittaci)
pneumonia symptoms (typical)
fever
SOB
productive cough (yellow/green sputum)
pleuritic chest pain
pneumonia symptoms (atypical)
dry cough
headache
diarrhoea
myalgia
hepatitis
confusion (legionella)
pneumonia signs (typical)
resp distress
cyanosis
reduced chest expansion
dull percussion over areas of consolidation
basal coarse crepitus
bronchial breathing
increased vocal resonance
pneumonia signs (atypical)
mycoplasma pneumoniae
- transverse myelitis
- erythema multiforme
- associated with AIHA
legionella
- hyponatraemia
- abnormal LFTs
pneumonia investigations
sputum MCS
FBC (high WCC)
high CRP
ABG (type 1 resp failure)
pleural fluid MCS via thoracentesis
CXR (consolidation with fluid levels)
atypical:
blood film
urinary antigens
LFTs
what would cxr show for pneumonia
lobar pneumonia
- consolidation within one lobe
bronchopneumonia
- consolidation all over the lungs
how is pneumonia severity assessed
CURB-65
confusion
urea > 7mmol/L
resp rate > 30
BP <90
age >65
mx of pneumonia
depends on CURB-65 score
1 = GP + oral antibiotics
2 = A&E + IV antibiotics
3+ = hospital admission + IV antibiotics + consider ITU
community acquired pneumonia antibiotics
typical:
- amoxicillin
- co-amoxiclav if severe
atypical:
- clarithromycin
typically amoxicillin and clarithromycin are given together if causative organism not yet identified
hospital acquired pneumonia antibiotics
staph aureus:
- flucloxacillin
MRSA:
- vancomycin
pseudomonas:
- tazocin + gentamicin
anaerobes:
- metronidazole and amoxicillin
special considerations when prescribing for pneumonia
if pt has penicillin allergy give doxycycline
in HIV pts give co-trimoxazole
pneumonia differentials
bronchitis
bronchiectasis
lung cancer
complications of pneumonia
pleural effusion
sepsis
ARDS
acute bronchitis typical organisms
rhinovirus
parainfluenza
influenza A or B
respiratory syncytial virus
coronavirus
risk factors acute bronchitis
smoking
cystic fibrosis
COPD
acute bronchitis signs and symptoms
non-productive or minimally productive cough
dyspnoea
MILD fever
acute bronchitis investigations
diagnosis based on clinical presentation
maybe CXR
Mx in acute bronchitis
otherwise healthy pts:
- paracetamol and ibuprofen as required
- hydration
cough persisting > 2 wks:
- inhaled corticosteroids
- inhaled beta 2 agonist may be useful if wheeze
- antitussives if cough interfering with sleep
pts with underlying lung pathology:
- oral abx (7 days of amoxicillin or doxycycline)
acute bronchitis differentials
asthma
pneumonia
acute bronchitis complications
pneumonia
chronic bronchitis
sinusitis
pulmonary embolism risk factors
cancer, chemo, cardiac failure, COPD, factor c deficiency
trauma, thrombocytosis, travel
stasis, surgery, factor S deficiency
varicose veins, virchow’s triad, factor V Leiden
pill (OCP), pregnancy, previous VTE, polycythaemia, paraprotein deposition
signs and symptoms of PE
depends on severity
pleuritic chest pain
dyspnoea
collapse if severe
central crushing pain
haemoptysis
CXR can show Westermark’s sign
what would ecg show PE
S1Q3T3 pattern
right axis deviation
right bundle branch block
sinus tachycardia
PE ix
depends on wells score
wells score < 4:
low risk, d-dimer
wells score 4+:
high risk, CTPA (except if pregnant)
PE Mx
depends on whether pt is haemodynamically stable
stable:
(subacute/ chronic)
- resp support
- anticoagulation
> fondaparinux/heparin for 5 days
> warfarin for 3 months
unstable:
SBP <90
(massive PE)
- resp support
- 1st line: thrombolysis
- 2nd line: embolectomy
IV thrombolytics: alteplase, streptokinase, rt-PA
VTE prevention
everyone must be VTE assessed within 24 hrs of hospital admission
compression stockings (TED stockings)
LMWH (eg tinzaparin)
classifying pneumothorax
traumatic: damage to parietal pleura
spontaneous: damage to visceral pleura
primary: young and otherwise healthy pt
secondary: pre-existing lung pathology, elderly
risk factors pneumothorax
male
smoking
Marfan’s
pneumothorax Ix
CXR
- look for loss of lung markings
FBC, clotting screen
- correct clotting abnormalities before inserting chest drain
pneumothorax Mx
primary:
<2cm, no SOB: discharge and OPD review
>2cm or SOB: needle aspirate
- aspiration unsuccessful: chest drain
- aspiration successful: observe + O2
secondary:
<1cm, no SOB: observe + O2
1cm-2cm, no SOB: needle aspirate:
- aspiration unsuccessful: chest drain
- aspiration successful: observe + O2
>2cm or SOB: chest drain
Tension pneumothorax signs and symptoms
MEDICAL EMERGENCY
lung compression
- severe dyspnoea
- tracheal deviation away from lesion
- silent chest, hyperresonance, reduced expansion
mediastinal shift
- hypotension
- tachycardia
Mx of tension pneumothorax
insert large bore cannula (orange or grey) in 2nd ICS, MCL just above 3rd rib to avoid neurovascular bundle of the 2nd rib
What is ARDS (+Berlin’s criteria)
non-cardiogenic pulmonary oedema
Berlin’s criteria:
- no alternative cause for pulmonary oedema
- rapid onset < 1 week
- dyspnoea
- bilateral signs on CXR
Causes of ARDS
hypoxaemic acute lung injury:
- sepsis
- pneumonia
- ventilation
- severe burns
- acute pancreatitis
- transfusion reactions
- drug overdose
- COVID-19
body responds with profound inflammatory response
- vascular permeability increased
- alveolar collapse
ARDS Ix
bilateral diffuse opacities on chest x-ray
ABG (type 2 resp failure)
sputum culture
blood culture
ARDS Mx
refer to ICU
ventilator
intubation
draining effusions
consider proning to improve oxygenation
what receptor does SARS-CoV-2 bind to
ACE2
covid symptoms
dyspnoea
fever
altered smell and taste
headache
GI disturbances
covid Ix
RT-PCR: +ve for viral DNA
pulse oximetry: low o2 sats
bloods: ABG, FBX, TFTs, glucose, CRP, ESR, cardiac biomarkers, coagulation screen, u+e
CXR,CCT: ground glass opacity, consolidation
covid Mx
mild/moderate: bed rest, paracetamol, ibuprofen, hydration, monitor O2 sats
severe: hospital admission, O2 therapy, VTE prophylaxis, dexamethasone, remdesivir, IL-6 inhibitor, consider ICU for ventilation, JAK inhibitor, ECMO
asthma signs and symptoms
SOB, dry cough, chest tightmess
expiratory polyphonic wheeze
work of breathing
nasal polyps
asthma risk factors
fhx of asthma
fhx or personal history of atopy
GORD can make asthma worse
asthma investigations
basic obs (should be normal unless asthma attack)
FEV1 reduced
FEV1/FVC < 0.7 with BDR
peak flow diary (>20% variability over 2-4 wks)
FeNO 40+
asthma mx
learn this
COPD risk factors
childhood resp disease or infection
malnourishment or poor development
smoking
genetics
resp infections
susceptibility to inflammation
environmental exposures
a1-antitrypsin deficiency
copd signs and symptoms
dyspnoea, exercise induced, progressive
chronic cough, may be productive
weight loss, fatigue, anorexia can be seen in severe disease
ankle swelling secondary to cor pulmonale
tripod, flared nostrils, accessory muscles
hypercapnia
wheeze
barrel chest
hoovers sign
COPD risk factors
increasing age
childhood resp disease or infection
malnourishment
smoking
genetics
fhx susceptibility to inflammation, environmental exposures
a1-antitrypsin deficiency
COPD investigations
gold standard:
- spirometry post-bronchodilator FEV1/FVC < 0.7 with no BDR
basic obs: low sats
CXR: hyper-expansion, air trapping
FBC: exclude anaemia
COPD management
1) educate
2) reduce risk factors:
- smoking cessation
- pneumococcal and influenza vaccines
- develop personal COPD plan
3) if breathless with exercise limitation (CAT score):
- SABA or SAMA prn
4) if symptoms continues or has exacerbations:
- reduce risk factors or review adherence
5) asthmatic features (hx of asthma, eosinophils, peak flow variability > 20%):
- no: LABA + LAMA, if no success after 3 month review then add ICS. review after 3 months and if ICS doesn’t help then remove ICS
- yes: LABA + ICS, LABA + LAMA + ICS
when to consider long term oxygen therapy for COPD
if pt has:
PaO2 < 7.3 when stable
or
PaO2 between 7.3 and 8 kPa when stable with 1+ of:
- secondary polycythaemia
- peripheral oedema
- pulmonary hypertension
also non smoker
what is idiopathic pulmonary fibrosis
lung scarring of an unknown cause
risk factors for idiopathic pulmonary fibrosis
older (>65) males
smoking
Fhx
idiopathic pulmonary fibrosis signs and symptoms
progressive SOB
exertional dyspnoea
dry cough
may have weight loss, fatigue, malaise
slow insidious onset
clubbing (not common)
bi-basal fine end inspiratory crepitations
Ix for idiopathic pulmonary fibrosis
MDT approach
rule out common mimics:
- CXR
- spirometry and gas transfer: (restrictive FEV1:FVC > 0.7 with reduced gas transfer)
rule in pulmonary fibrosis with imaging:
- HRCT to show IPF pattern of fibrosis (bi-basal sub-pleural fibrosis)
rule out any other cause of pulmonary fibrosis:
- i.e other ILDs (exposure history, ANA panel, rheumatoid factor, anti CCP and myositis panel for collagen vascular disease)
bronchoalveolar lavage +/- lung biopsy if MDT aren’t sure
IPF management
monitoring and assess for treatment:
- baseline, 6mo, 12mo: spirometry and gas transfer, 6 min walking test, SO2, and QoL
specialist care:
- pulmonary rehab
- supportive care - ambulatory or long term o2
antifibrotics: pirfenidone or nintedanib if FVC is between 50-80% predicted
lung transplant
typical pt profile for sarcoidosis
black woman with cough and skin patch on her shin
what is sarcoidosis
systemic non-caseating granulomas deposited around the body causing disease. affects lungs and other organs
sarcoidosis risk factors
infection (eg TB)
FHx
Scandinavian
Afro-Caribbean (esp extrapulmonary)
woman 20-40 yrs
sarcoidosis signs and symptoms
chronic dry cough
progressive SOB with exertional dyspnoea
disproportionate chronic fatigue
joint pain
skin lesion (lupus pernio and erythema nodosum)
eye problems
wheeze
rhonci
serum biochem - high calcium and ACE
cardiac involvement most common cause of death
What is Lofgrens syndrome
self resolving pulmonary manifestation of sarcoidosis
bilateral hilar lymphadenopathy
erythema nodosum
arthralgia
fever
staging Lofgrens syndrome
stage 1: bilateral hilar lymphadenopathy
stage 2: bilateral hilar lymphadenopathy + pulmonary infiltrates
stage 3: pulmonary infiltrates alone
stage 4: extensive fibrosis with distortion
sarcoidosis investigations
CXR
HCRT
- ground glass (reversible)
- cystic (irreversible)
PFTs: obstructive or restrictive
BAL
lung biopsy
skin biopsy
ECG
urea and creatinine
AST high
high serum calcium and high ACE
sarcoidosis management
done by specialist
not all need treatment
currently revolves around corticosteroids and later immunosuppressants (azathioprine, methotrexate)
sleep apnoea pathology
complete or partial collapse of upper airway
sleep apnoea risk factors
things that make you more overweight or thicken airway soft tissue
-obesity
-Cushing’s
-acromegaly
-menopause
sleep apnoea presentation
assess risk using STOP-BANG score:
snoring
tired
observed apnoea
pressure (BP)
BMI>35
age>35
neck circumference>40cm
gender - male
scores > 3 should be referred for polysomnography
sleep apnoea Ix
night time in lab polysomnography
Apnoea Hypopnoea Index is the average number of obstructive events per hour
mild: AHI 5-14
moderate: AHI 15-30
severe: AHI > 30
sleep apnoea mx
all: address risk factors
mild asymptomatic: intra-oral mandibular advancement device
mild/moderate/severe symptomatic: CPAP
occupational lung disease particulates
coal, silica, asbestos etc
asbestos related lung disease signs and symptoms
clubbing
reduced expansion
asbestos wart
bibasal crackles
RHF
types of asbestos related diseases
asbestos disease - presence of asbestosis with no symptoms or CXR findings
pleural plaques - thick calcified pleura on CXR, restrictive lung disease
asbestosis - lung fibrosis 5-10 yrs after heavy exposure, severe restrictive lung disease, reduced gas transfer, progressive dyspnoea
mesothelioma - pleural effusion, chest pain, SOB, 20-40 yrs after exposure
asbestos related lung cancer - usually 10+ yrs after first exposure
asbestos related lung disease investigations
hx of exposure and exclusion of other conditions
CXR
restrictive: low FEV1, low FVC, low residual vol
normal or high fev1/FVC
alveolar damage: reduced DLCO
ABG if acute may show hypoxia
HRCT:
- basal diffuse reticulonodular infiltrates
- shaggy heart border
- ground glass and diffuse interstitial fibrosis
lung biopsy
asbestos related lung disease Mx
no specific mx
compensation available if they apply within 3 yrs of diagnosis
corticosteroids
support groups
causes of cavitating lung lesions
CAVITY:
Cancer:
- lung cancer (ie squamous cell carcinoma)
- pulmonary metastasis
Autoimmune:
- granulomatosis with polyangiitis
- rheumatoid arthritis (rheumatoid nodules)
Vascular:
- bland and septic pulmonary emboli
Infection:
- abscess
- tuberculosis
Trauma:
- pneumatoceles
Youth:
- congenital pulmonary airway malformation
- pulmonary sequestration
- bronchogenic cyst
what is bronchiectasis
abnormal irreversible dilation of bronchi and bronchioles
causes of bronchiectasis
tuberculosis (worldwide)
cystic fibrosis (western world)
bronciectasis risk factors
post infection
chronic aspiration
immunodeficiency
chronic aspiration
chronic inflammation
chronic airway inflammation
congenital disease eg CF, Youngs, a1-antitrypsin deficiency, Kartagener’s, primary ciliary dyskinesia
underlying chronic lung condition
Kartagener’s syndrome/PCD triad
bronchiectasis
sinusitis
situs inversus
resp causes of clubbing
bronchiectasis
ILD
lung cancer
lung abscess
empyema
TB
CF
bronchiectasis signs and symptoms
chronic daily productive cough >8wks
-large amounts
-mucopurulent (pus) sputum
-foul smelling
-green/yellow if infection, white otherwise
haemoptysis
dyspnoea, SOB
weight loss
non pleuritic chest pain
recurrent resp infections
clubbing
course crackles in lower lung and maybe wheeze
bronchiectasis ix
basic obs
sputum MCS
FBC, u+e, high crp, lft, abg
x-ray (tram tracking)
HRCT gold standard imaging
tests for underlying cause
sweat test (CF)
genetic test
skin prick/serun IgE (ABPA)
serum immunoglobulin
classic bronchiectasis feature on imaging
signet ring sign
bronchiectasis mx
conservative
- exercise, diet
- vaccinations
- smoking cessation
- airway clearance (chest physio, nebulised hypertonic saline, high freq oscillation device)
pharm
- steroids, bronchodilators
- IV ABx in acute exacerbation
- oral ABx
- ciprofloxacin (pseudomonas)
surgery indicated in massive haemoptysis
complications of bronchiectasis
recurrent infections
cor pulmonale (RHF)
resp failure
organism causing TB
mycobacterium tuberculosis
latent TB vs active TB
latent TB:
- not transmissible
- TB contained in caseating granulomas
active TB:
- transmissible
- pt requires treatment
10% risk reactivation in immunocompromised or aging
TB risk factors
HIV
overcrowding
homeless
immunosuppressive meds
sub-sahara africa, india, bangladesh travel
signs and symptoms of TB
productive cough
dyspnoea/SOB
+haemoptysis (late)
pleural effusion
low grade fever
gradual weight loss
lymphadenopathy
erythema nodosum
extrapulmonary TB examples
TB can affect any organ
Meningitis
erythema nodosum
clubbing
Pott’s disease
addison’s disease
sterile pyuria
etc
active TB Ix
basic obs
sputum MCS (x3 samples, one in early morning)
- microscopy (AFB stain > Ziehl-Neelsen) !!!
FBC( high wcc, anaemia)
high CRP
ABG
HIV
Chest x-ray (bi-hilar lymphadenopathy)
lymph node biopsy (caseating granuloma)
latent TB ix
Tuberculin skin test (Mantoux test)
interferon gamma release assay
if either test positive order CXR
what would you see on TB CXR
consolidation
bi-hilar lymphadenopathy
upper lobe scarring
cavitating lesions
pleural effusions
miliary TB: (nodular shadowing)
TB management
RIPE
Rifampicin
Isoniazid
Pyrazinamide
Ethambutol
R+I = 6mo
P+E = 2mo
side effects of TB drugs
all cause hepatotoxicity
red/orange secretions
peripheral neuropathy + vit B6 deficiency > give pyridoxine
hyperuricaemia (gout)
optic neuritis (reversible red-green colour blindness)
where does lung cancer metastasise to
bone
brain
liver
lung cancer signs and symptoms
cough (dry or productive)
haemoptysis
SOB
FLAWS
bone (bone pain, fractures)
brain (headaches, blurry vision)
liver (hepatomegaly)
lymphadenopathy
clubbing
tar staining
dull percussion
crepitations
increased vocal resonance
lung cancer risk factors
smoking
asbestos exposure (esp SqCC)
lung cancer sub-types
small cell lung cancer (15%)
non-small cell lung cancer (85%)
- adenocarcinoma
- squamous cell carcinoma
- large cell carcinoma
small cell lung cancer cell type and associations
Kulchitsky endocrine cells
SIADH, ectopic ACTH, Lambert-Eaton syndrome
central lung
adenocarcinoma cell type and associations
goblet cells
peripheral lung
periostitis
clubbing
arthropathy of large joints
squamous cell carcinoma cell type and associations
squamous epithelial cells
PTHrp
central lung
cavitating
large cell carcinoma cell type and associations
epithelial cells
peripheral + central lung
Pancoast syndrome signs and symptoms
Horner’s syndrome
sympathetic trunk (miosis, partial ptosis, anhidrosis)
branchial plexus (shoulder/arm pain, paraesthesia)
recurrent laryngeal nerve (hoarse voice +/- bovine cough)
can cause SVC syndrome if tumour in right lung apex
SVC syndrome signs and symptoms
+ve Pemberton sign
pooling of blood
oedema
facial flushing
lung cancer Ix
basic obs
sputum cytology
FBC
calcium (possibly high)
ALP (possibly high)
LFTs (possibly deranged)
CXR
CT chest, abdo, pelvis
PET (staging)
biopsy (TNM staging)
Lung cancer CXR findings
primary lung cancer:
- consolidations
- bi-hilar lymphadenopathy
- pleural effusion
- cavitating lesion
secondary lung cancer:
- coin shaped lesions (cannonball mets)
RF for mesothelioma
asbestos exposure (20-50 yrs latency)
mesothelioma signs and symptoms
dry cough
clubbing
FLAWS
pleural friction rub on auscultation
definitive way to diagnose mesothelioma
thoracoscopy and histology
mesothelioma Ix
sputum cytology
pleural fluid cytology via thoracentesis
FBC
calcium
ALP
LFT
CXR
CT chest abdo pelvis
PET scan
pleural lining biopsy
