RESP Flashcards
What is tension pneumothorax?
Accumulation of air in the pleural space under positive pressure - this pressure causes the lung to collapse and a shift of the medistinum towards the contralateral side
Why can tension pneumothorax lead to a reduction in cardiac output?
There is impaired venous return to the heart - this causes a reduction in cardaic output and can cause cardiovascular collapse/arrest
-Left and right ventricular filling is impaired
How is the pressure created in the pleural space in a tension pneumothorax?
There is a one way valve that lets aiur in but not out, air is drawn in during inspirsation but can not escape
What are the signs of a tension pneumothorax?
-Tracheal deviation away from the side of pneumothorax
-Reduced air entry on the affected side (absent chest sounds)
-Increased resonance to percussion on affected side
-Tachycardia and hypotension
What can cause tension pneumothorax?
TRAUMA - penetrating or blunt chest trauma
IATROGENIC - thoracentesis, central venous catheter palacement, postive pressure ventilation
SPONTANEOUS - underlying disease such as COPD or cystic fibrosis
Lung blebs (blisters on lung surfaces) which can rupture and cause air to leak into pleural space
Management of tension pneumothorax?
-Insert large bore cannula into second ICS un midclavicular line on affected side - decompression of pleural space
-This is followed by placement of chest drain in safe triangle to allow continuous drainage of air
NOTE: DO NOT WAIT FOR INVESTIGATION
Even though clinically a large bore cannula is inserted into 2ICS midclavicular line what do the Advanced traumatic life support guidelines state?
-4th or 5th ICS anterior to midaxillary line
Pregnant women smoking cessation?
varenicline and bupropion are contraindicated
-Smoking clinic referall is first line but NRT can also be offered
Acute respiratory distress syndrome?
-Caused by increased permeability of alveolar capillaries (due to inflammatory process) which leads to accumulation of fluid in the alveoli
(noncardiogenic pulmoary oedema)
What are causes of acute respiratory distress syndrome?
-Infection: sepsis, pneumonia, COVID19
-Trauma
-Smoke inhalation
-Acute pancreatitis
-Massive blood tranfusion
-Cardio-pulmonary bypass
What are clinical features of ARDS?
-Dyspnoea
-Elevated RR
-Bilateral lung crackles
-Low oxygen saturation - despite oxygen therpay
Criteria for ARDS?
-Acute onset (within one week of known risk factor)
-Pulmonary odema - bnilateral infilrates on CXR
-non-cardiogenic
-pO2/FiO2 <40kPa
What is the management of ARDS?
-ITU
-Oxygenation/ventilation
-Organ support e.g. vasopressors
-Treat underlying cause
-Ventilation and proning
In ARDS lun g protectivce venitaltion is used what does this invole?
-Low tidal volume and pressure ventilation to reduce over inflating and trauma to remaining lung
-Positive end-expiratory pressure - this is to prevent lungs from collapsing further
CURB 65 score?
C-Confused?
U- Urea >7mmol/L
R- Respiratory rate >30?
B- Blood pressure <90 systolic <60 diastolic
65- over 65
CURB score intrepretation?
1 - Home treatment
2 - consider hospital admission
3 - Consider ITU
What are pleural plaques?
-Fibrosis/thickening - they are benign and do not undergo malignant change
-No follow-up is required
-Most common form of asbestosis related lung disease and occur after a latent period of 20-40 years
What else can asbestosis cause in the lung?
Pleural thickening
What is abestosis?
A type of pulmonary fibrosis (scarring of lung tissue) that occurs as a result of long-term asbestos exposure
Calcified plaques/ plueral plaques?
Abestosos exposure - no follow up - do not require CT scan
What is silicosis?
Fibrosing lung disease caused by inhalation of fine particles silica
What disease is silicosis a risk factor for?
TB silica is toxic to macrophages
What occupations are at risk of silicosis?
-Mining
-SLate works
-Foudnries
-Potteries
Features of silicosis on CXR?
-Upper fibrosing lung disease (increased lung markings)
-Egg shell calcifation of hilar lymphnodes
What does CT scan show silicosis?
-Upper zone prominent mass like scaring with calcification and volume loss
-Hilar calcifation
COPD management first line?
SABA or SAMA (bronchodilators)
After initial bronchodilator therapy what is used to decide next maanagement in COPD?
-Asthmatic features or features of steroid responsiveness?
Criteria for asthmatic features of features suggestive of steroid responsiveness?
-Previosu asthma or atopy
-Increased eosinophuil count
-Substantial variation in FEV1 over time (400ml)
-Substantial variation in PEFR (20%)
If no asthmatic or steriod responsiveness in COPD patients what is next step?
-SABA required
-LAMA and LABA regualrly
If patient has features of asthma/steroid responsievness what is next step in management?
-SABA or SAMA as required
-LABA and ICS regularly
What is the third step in COPD patient if still symptoms still not controlled for all patients with COPD?
-SABA as required
-LAMA and LABA and ICS
BTS guidelines for ABG in asthma?
Acute asthma if oxygen stats <92%
Upper zone fibrosis causes?
-Hypersensitivity pneumonitis
-Coal workers pneumoconiosis
-Silicosis
-Sarcoidsosi
-AK (rare)
-Histocytosis
-TB
-Radiation induced PF (breast or lung cancer?
Lower lobe fibrosis?
-IPF
-Connective tissue disorders (excluding AK), SLE
-Drug induced
-Fibrosis
Bronchiectasis most common organsim?
Haemophilus influenzae
Differentials for cavitating lung lesions
-Abscess (staph aureus, klebsiella and pseudomonas)
-Squamous cell lung cancer
-TB
-Wegeners granulomatosis
-PE
-Rheumatoid arthritis
-Aspergillosis, histoplasmosiss, coccoidiomycosis
When to consider COPD as a diagnosis?
->35
-Smokers or ex smokers
-Exertional breathlessness
-Chronic cough
-Regular sputum production
Post bronchodilator spirometry to invetsigate COPD?
-Post-bronchodilator spirometry - demonstrates airflow obstruction FEV1/FVC ratio <70%
What CXR findings for COPD
-Hyperinflation
-Bullae
-Flat hemidiaphragm
ALSO important to rule out lung cancer
What investigation for suspected COPD?
-Post bronchodilator spirometry
-CXR
-FBC (exclude secondary polcythaemia)
-BMI
Why do you need to do a blood test in patients with suspected COPD?
-FBC to rule out secondary polycythemia which occurs due to chronic hypoxia
What are blood test findings for polycytheamia?
RBC increased in response to hypoxia
-Increased Hb and hematocrit
-Elevated EPO (secondary) - this is ordered is hemoglobin and hematocrit levels are high
What does spirometry measure?
-FVC - Forced vital capacity - this is the amount of air you can forcefully exhale after a deep breathe
-FEV1 - Forced expiratory volume in 1 second - amount of air can forcibly exhale in one second
-FVC/FEV1 ratio
What does FEV1/FVC ratio tell you?
Differentiate between obstructive and restrictive lung disease
-Obstructive - Reduced (70%)
-Restrictive - ratio is increased or normal
Stages of COPD and values
-FEV1/FVC <0.7
-STAGE 1 MILD - FEV1>80%
-Stage 2 MODERATE - FEV1 50-79%
-STAGE 3 SEVERE - FEV1 30-49%
-STAGE 4 VERY SEVERE- FEV1 <30%
Causes of COPD exacerbations
BACTERIA
-Haemophilus influenza most common
-Streptococcus penumonia
-Moraxella catarrhalis
VIRUSES
-30% of exacerbations
-Human rhinovirus
Features of exacerabtion of COPD
-Increase in dyspnoea, cough, wheeze
-Hypoxia and acute confusion
-Increase in sputum
NICE for acute exacerbation of COPD
-Increase bronchodilator and consider giving it via a nebuliser
-Prednisolone 30mg 5 days
-Antibiotics common practise - Especially if purulent sputum or clinical signs of pneuomonia
What antibiotics are recommended for acute exacerbation of COPD BNF?
-Amoxicillin, clarithromycin or doxycycline
Admission to hospital COPD exacerbation?
-Severe breathlessness
-Acute confusion
-Cyanosis
-O2<90%
-Social reason
-Significant comorbidity
Oxygen therapy COPD?
-Initial target 88-92% - prior to blood gas if patient is at risk of hypercapnia
-28% venturi mask at 4/L
-Adjust target rnage 94-98% if pCO2 is normally
Reasons for hypercapnia in patient with COPD
-Blunted hypoxic drive - in COPD body adpats to high levels of CO2, when oxygen is given brain sense improved oxygenation reducing drive leading to hypoventilation and more co2 retention
-Ventilation perfusion mismatch
-Haldane effect - With supplemental oxygen, hemoglobin releases CO₂ into the bloodstream, raising arterial CO₂ level
What bronchodilators are given?
-beta adrenergic agonist - SABA, salmutamol
-Muscuranic antagonists - Ipratropium (SAMA)
Steroid therpay
-Oral prednisolone
-IV hydrocortisone
What is used if patient is not responding to nebulised bronchodilators
IV theophylline
COPD patient prone to develop T2RF ?
Non-invasive ventilation - if respiratory acidosis
Patients who are more acidotic <7.2 with COPD NIV?
-Can still be used
-Greater degree of monitoring and a lower threshold for intubation and ventilation
What NIV is used in COPD?
-BiPAP
-Expiratory and inspiratory
-EPAP: 4-5 cm H2O
-IPAP: 10 cm (RCP) or 12-15 cm (BTS)H20
Step down treatment for asthma ?
Can reduce dose of ICS by 25-30% at a time
Bronchitis requiring ABx?
if CRP>100
What is pneumothorax?
AIr in the pleural space which separates lung from chest wall
What are the causes of penumothorax?
-Spontaneous
-Trauma
-Iatrogenic (lung biposy, mechanical ventilation,)
-Lung pathology
Investigation for pneumothorax
-CXR (measure size of pneumothorax)
-CT - accurately mesaures size
Management of pneumothorax
Based on size and symptoms
If pneumothorax is <2cm and asymptomatic?
-Likely resolve spontaneously
-Follow up in 2-4 weeks
If pneumothorax 2>cm or symptomatic?
-Aspiration is required followed by re-assessment
-If aspiration fails twice - chest drain
NOTE: now more based on clinical picture no symptoms and oxygenating fine can follow up patient
When do you consider a chest drain as initial management in a patient with a pneumothorax?
-Unstable
-Bilateral
-Secondary pneumothroax
Hwo to measure size of pneumothorax CXR?
-Interpleural distance at hilum
-Measure lung edge to hilum
What is empyema?
Collection of infective fluid/pus in pleural cavity
Pleural fluid analysis in empyema?
-Low ph
-High LDH
-Low glucose
First line treatment for empyema?
Chest drain with Abx
Severe acute asthma classifications
MODERATE - 70-75%
SEVERE - 33-50%
LIFE THREATENING -<33%
Asthma diagnosis >17
-All patients Spirometry and bronchodilator reversibility test
-All patients FeNO test
-Ask if symptoms are better away from work - occupational asthma
Asthma diagnosis 5-16 years
-Spirometry and bronchodilator reversibility
-FeNO if normal spirometry or obstructive spirometry with a negative BDR test
Results of FeNO considered positive in asthma diagnosis?
Adults: =>40 ppb
Children:=>35ppb
When is spirometry considered obstrictive?
FEV1/FVC <70%
Reversibility testing values in asthma diagnosis
-Adults FEV1 improvement of 12% or more and increase volume in 200ml
-Children FEV1 improvement 12% or more
How can pleural effusions be classified?
TRANSUDATE: <30g/L protein
EXUDATE: >30g/L protein
Causes of transudate pleural effusion
-Heart failure (most common)
-Hypoalbuminamiea (liver disease, nephrotic syndrome, malabsorption)
-Meig’s syndrome
Causes of exudate pleural effusion
-Infection (penumonia most common)
-Connective tissue (RA, SLE)
-Neoplasia (lung cancer, metastases, mesothelimo)
-Pancreatitis
-PE
-Pulmonary embolism
-Dresslers
What characterises sarcoidosis?
-Non-caseating granulomas
pH to benfit from NIV?
ph 7.25-7.35
risk factor for aspiration pneumonia?
-Intubation
-Poor dental hygiene
-Swallowing difficulties
-Prolonged hospitalisation
-Impaired consciousness
-Impaired mucocilary clearance
Most common sites to be affected by aspiration pneumonia?
Right middle and lower lung lobes
Why is the right middle and lower lung lobes most commonly affected by aspiration pneumonia?
-Right bronchus is larger and more vertical
Sudden deterioration after patient ventilated?
Tensionpneumothorax
Upper lobe fibrosis
CHARTS
-Coal worker pneumoconisis
-Histiocytosis/hypersensitvity
-Ankylosing spondylitis
-Tuberculosis
-Siliosis/sarcoidosis
Churg-Strauss syndrome/Eosinophilic granulomatosis with polyangiitis
pANCA associated small-medium vessel vascultits
What are the features of eosinophilic granulomatosis with polyangiitis ?
-Asthma
-Blood eosinophila
-Paranasal sinusitis
-Mononeuritis multiplex (causes pain weakness and sensory loss)
-pANCA postiev 60%
three stages of eosinophilic polyaginiitis?
- allergy and asthma - inflammation of small vessels
- Eosinophilia
- Vascultis - kidney failure (petechial rash)
Pleural effusion investigationn?
-PA chest CXR
-Ultrasound is recommended - sussesful aspiration and sensitive for detecting pleural fluid septations
-CT with contrast - underlying cause and exudative effusions
Pleural aspiration management?
-Ultrasound - reduce complication
-21G needle and 50ml syringe
What is Light’s criteria?
Used to distinguish between transudates and exudates
-Transudates <30g/L
-Exudates >30g/L
If >30g/L then apply Lights criteria
Lights criteria - exudate is likely if one of following criteria is met
-Pleural fluid protein/serum >0.5
-Pleural LDH /serum LDH >0.6
-Pleural LDH is 2/3 upper limit of normal serum LDG
Pleural fluid findings?
-Protein
-pH
-LDH
-GLucose (low RA and TB)
-Amylase (pancreatitis and esophageal perforation)
-Heavy blood stainng (mesothelioma, PE, TB)
-Send for cytology and microbiology
Pleural infection?
- if associated with sepsis
-iffluid is purulent or turbid/cloudy a chest tube should be inserted
-FLuid clear <7.2 with suspected infection a chest tube should be inserted
Mesothelioma most diagostic test?
-Thoracosopy and histology
In an acute presentation of COPD oxygen?
-Always start 15L NRB
-Set down if patient gets worse
TB CXR findings?
Upper zone pulmonary fibrosis
Pulmonary fibrosis spirometry?
-FEV1/FVC ratio >70%
-TLCO reduced
Disease where there is an increase in ACE?
Sarcoidosis
How are ACE levels used in sarcoidosis?
Can be used to indicated sarcoidosis, but also with CXR findings and clinical picture
CXR findings and staging of sarcoidosis
Stage 0- Normal
Stage 1 - bilateral hilar lymphadenopathy (BHL)
Stage 2 - BHL and interistial infiltrates
Satge 3 - Diffuse interistial infilrates only
Stage 4 - Diffuse fibrosis
Other investigations for sarcoidosis?
Spirometry - may be restrictive
Tissue biposy - non-caseating granulomas
Criteria for treating sarcoidosis with steroids?
-Stage 2 or 3 on CXR with symptoms
-Hypercalcemia
-Eye, heart or neuro involvment
What characterises non-caseating granuloms?
-no necrosis
-immune dirven/sterile unlike caseating
What is sarcoidosis?
Multisystem disorder that is characterized by no-caseating granuloma
What is cor pulmonale?
-Right sided heart failure caused by respiratory disease
How does cor pulmonale occur?
-Increased pressure in pulmonary arteries (pulmonary hypertension)
-This limits right ventricle from pumping blood into the pulmonary arteries
-This in turn causes back pressure into right atrium, vena cava and systemic venous system
What are the causes of cor pulmonale?
-COPD (most common)
-PE
-Interstitial lung disease
-CF
-Primary pulmonary hypertension
Symptoms of cor pulmonale?
-In early stages asymptomatic
-SOB
-Breathless on exertion
-Syncope
-Chest pain
What are signs of cor pulmonale on exmaination?
-Hypoxia
-Cyanosis
-Raised JVP (backlog of blood in jugular vein)
-Perepheral heav e
-Loud 2nd heart sound
-Murmurs (PANSYSTOLIC and TRICUSPID)
-Hepatomegaly - this is due to back pressue of hepatic vein
What is the management of cor pulmonale?
-Loop diuretics for symptoms of odema
-Long term oxygen therapy to treat underlying cause - improves survival
When should Long term oxygen therapy be offered to patients with COPD?
-pO2 of <7.3
-Po2 of 7.3-8kPa
-Secondary polycythaemia
-Nocturnal hypoxaemia
-Peripheral odema
-Pulmonary hypertension
Lung cancer in non-smoker?
Adenocarincoma - non small cell lung cancer
How is lung cancer first classified?
-Small cell lung cancer (15%)
-Non small cell lung cancer (85%)
-Mesothelioma
Which type of lung cancer generally carries the worse prognosis?
Non small cell lung cancer
Divisions of non small cell lung cancer?
- Adenocarcinoma (40% total LC)
- Squamous cell carcinoma (20%) - cavitating lesions are more common than in other types of lung cancer
- Large cell carcinoma
Features of life-threatening asthma attack?
-Confusion
-Normal pCO2
-Silent chest
-Hypotension
-Exhaustion, confusions or coma
Lupus perino?
Lupus pernio - raised purple lesions covering nose, cheeks and lips - seen in sarcoidosis
Does a negative spirometry exclude asthma as a diagnosis?
No - FeNO testing must be carried out a postive result is >40ppm in adults and >35ppm in children
What is the criteria for discharge after an asthma attack?
-Stable on discharge medication for 12-24 hours
-PEF >75% of best or predicted
-Inhaler technique must be checked and recorded
Persistent / recurrent pneumothorax management?
Video-assisted thoracoscopic surgery (VATS)
-If recurrent pneumothoraces or persistent air leak/ lung re-expansion despite chest drain
What is extrinsic allergic alveolitis also known as?
Hypersensitivity pneumonitis
What is extrinsic allergic alveolitis?
Condition caused by hypersensitivity induced lung damage due to inhaled organic partciles?
Give examples of what can cause extrinsic extrinsic allergic alveolitis?
-Birds: protiens from bird droppping
-Farmers from wet hay
-Malt workers lung
-Mushroom worker lung
How does extrinsic allergic alveolitis present acutely?
(after 4-8 hours of exposure)
-Dyspnoea
-Dry cough
-Fever
how does chronic extrinsic allergic alveolitis present?
-Lethargy
-Dyspnoea
-Productive cough
-Anorexia and weight loss
What investigations for EAA?
-CXR: upper/mid zone fibrosis
-Bronchoalveolar lavage: lymphocytosis
-Seroloigcal assays for specific IgG AB
-Blood: no eosinophila - it is a type 3 and 4 hypersensitivity
What is the management of extrinsic allergic alveoltis?
-Avoid precipitating factors
-oral glucocorticoids
What is near fatal asthma?
Raised carbon dioxide - require mechanical ventilation
Paraneoplastic features of small cell lung cancer?
-ADH (SIADH)
-ACTH (cushing’s)
-Lambert-eaton
-Small cell lung cancer more likely to be paraneoplastic
What is a paraneoplastic syndrome?
Symptoms caused by immune responses or substances released by tumour
What are the paraneoplastic features caused by squamous cell (NSCLC)?
-Parathyroid hormone related protein (PTH-rp) secretion which causes hypercalcaemia
-Clubbing
-Hypertrophic pulmonary osteoarthropathy (clubbing joint pain and swelling)
-Hyperthyroidism due to TSH
What are the paraneoplastic features caused by adenocarcinoma (NSCLC)?
-Gynaecomastia
-Hypertrophic pulmonary osteoarthropathy
What is hypertrophic pulmonary osteoarthropathy?
-periostitis (inflammation of periosteum) which causes pain, swelling and bone deformity
-Typically involves long bones
Pulmonary fibrosis spirometry?
FEV1/FVC >70% with reduced TLCO
Relative contraindications for chest drain?
-INR >1.3
-Platelet count<75
-Pulmonary bullae n
-Pleural adhesions
Bronchitis presentation
-Cough - may or not be productive
-Sore throat
-Rhinorrhoea
-Wheeze
-low grade wheese
Bronchitis vs pneumonia
-Bronchitis may not have wheeze, breathlessness or sputum whereas present in penumonia
-Examination in bronchitis only a wheeze is present
What is used to guide antibiotic therapy in bronchitis?
CRP >100
What is first line ABx for bornchitis?
BNF - doxycycline
-if pregnant or children consider amoxicillin
LABA medication?
Salmeterol
LAMA medication?
tiotropium
LTRA medication?
Monetlukast
SABA medication?
Salbutamol
SAMA medication?
Ipratropium
How long should you wait when repeating inhaler dose?
30 seconds
Features of Klebsiella penumonia?
-Upper lobes
-Ref jelly sputum
-Can occur following aspiration
-More common with heavy alcohol use and peoples with diabetes
What is prognosis of klebsiella pneumonia?
-Causes lung abscess formation and empyema
-Mortality 30-50%
chest drain vs needle aspiration smoking and >50?
Chest drain
When do you keep a patient in hospital with pneumothorax even if it is small and no symtoms?
secondary spontaneous pneumothorax - monitor as inpatient
Contraindications to lung cancer surgery?
-SVC obstruction
-Malignant pleural effusion
-FEV<1.5 for lobetomy <2 for pneumonectomy
-Metastases present
-Tumour near hilum
-Vocal cord paralysis
silicosis ?
-mining
-upper zone fibrosis
-eggshell calcification hilar nodules
Canonball metastses?
-Multiple, round well-defind
-Associated with renal cell cancer -CT abdomen
Management of allergic bronchopulmonarty aspergillosis?
-Oral glucorticoids
-itraconazole
Prophylactic ABx for patients with chronic COPD?
Azithromycin 250mg three times a week
NICE guideliens for prophylatic ABx?
-Patient no longer smokes
-Optimised non-pharmacological and inhaled therpapies
-4 acute exacerbations (producing sputum), with one hospital admission
-Referred to pulmonary rehab
Most common cause of mediastinal widening on CXR?
Due to technical findings such a s patient rotation
Causes of acute mediastinal widening on CXR?
-Vascular: thoracic aortic aneurysm
-Lymphoma
-Retrosternal goitre
-Teratoma
-Thumour of thymus
When should NIV be considered in COPD patients?
paCO2 >6kpa and pH<7.35
In acute respiratory alkalosis what happens to bicarbonate?
Remains the same or is only slightly reduced this is because kindeysa have not had to do compensate
Information for patients in the resolution of penumonia symptoms ?
1 week - fever resolve
4 weeks - chest pain and sputum production
6 weeks - cough and breathlessness
3 months - most symptoms gone may feel fatigued
6 months - back to normal
When to repeat CXR after symptoms resolve?
6 weeks to ensure consolidation has resolved
Discharging patients with pneumonia ?
If patients have had 2 or more of the follwoing findings in the past 24 hours:
1. temp higher than 37.5
(this alone consider no discharging)
2. RR>24
3. HR >100
4. Systolic <90mmHg
5. Oxygen <90 RA
6. altered mental status
7. inability to eat
idiopathic pulmonary fibrosis sounds?
Bibasal fine end-inspiratory crepitations
What causes obstructive sleep apnoea?
-Collapse of pharyngeal airway
-Apenoa is an episode where patient stop breathing for a few minutes
Predisposing factors to OSA?
-Obesity
-Macroglossia (amyloidosis, hypothyroidism)
-Large tonsils
-Marfan’s syndrome
-Smoking
-Alcohol
-Most common in middle age
Presentation of OSA?
-Apnoea during sleep
-Snoring
-Morning headache
-Not refreshed from sleep
-Daytime sleepness - resulting in concentration issues
-Reduced oxygen saturation during sleep
WHat can severe cases of OSA cause?
-Hypertension
-Heart failure
What can can OSA increase the risk of?
-MI
-Stroke
OSA with daytime sleepiness?
Ask about occupation - patient may need amended work duties when waiting for assessment and treatment
What are used to assess sleepiness in OSA?
-Epworth sleepiness scale (questionnaire to be completed by patient assess symptoms )
-Multiple sleep latency test (MSLT)- measures time to fall asleep in a dark room
What are the diagnostic tests for OSA?
- Sleep studies (polysomnography)
What are the types of sleep studies?
- A simple sleep study - wearing oxygen monitor at home
- Respiratory polygraphy - measures RR, flow rate, o2 and HR - can be done at home
- Complex sleep studies - overnight stay with polysomnography - measure brain (EEG), muscle(EMG) and heart activity (ECG)
Management of OSA?
-Address reversible risk factors (weight loss, smoking, reduce alcohol)
-CPAP first line for moderate or severe
-If CPAP not tolerated intra-oral devices
-Surgery but this involves reconstruction of soft palate and jaw
What is alpha-1 antitrypsin deficiency?
-inherited conditions caused by lack of protease inhibitor and therefore a deficiency in alpha-1 antitrypsin
-located on chromosome 14
-autosommal recessive
What is the role of alpha-1 antitrypsin (A1AT)?
Protects cells from enzymes, if there is a deficiency it can cause emphysema (COPD) i patients who are young and non smokers
What are investigation for A1AT defieincy?
-A1AT concentrations
-Spirometry (obstructive picture)
What level of A1AT normal cause features of A1AT deficiency to manifest ?
-10% of nromal A1AT levels
Why does A1AT cause abnormal LFTs?
-Accumulation of abnormal A1At in liver cells can cause damage leading to deranged LFTs
What are the features of A1AT deficinecy?
Lungs: emphysema (COPD), lower lobes (decreased breath sounds/expiratory wheeze)
Liver: Cirrhosis and hepatocellular carcinoma
Management of A1AT?
-No smoking
-Supportive: bronchodilators, physio
-IV A1AT protein concentrates
-Surgery
Restrictive picture with spirometry but no impaired gas transfer?
Obesity
What does TLCO stand for and how is it carried out?
-Transfer of carbon monoxide
-Patient inhales CO holds breath for 10 seconds and exhales
-concentration of CO inhaled vs exhaled is compared - gas exchange over alveolar capillary membrane
Near fatal asthma ?
pCO2 >6.0 kPa
Difference between high-resolution CT and CTPA?
-High resolution CT - imaging of parenchyma, insterstital lung disease and structure
-CTPA - pulmonary vasculature (PE)
Gold standard for OSA?
Nocturnal polysomnography
Hospital acquired pneumoina, hospital for 3-5 days abx?
co-amoxiclav
Kartagener’s syndrome causes and most reason occurs in examination finding?
-Also known are primary ciliary dyskinesia - cause by defect in structure and function of cilia
-Most frequently occurs in examinations due to associated with dextrocardia (quiet heart sounds)
What are the features of kartagener’s syndrome?
-Dextrocardia or complete situs inversus
-Bronchiectasis
-Recurrent sinusitis
-Subfertility (secondary to impaired sperm motility and defective ciliary action in fallopian tubes)
Klebsiella associated infection?
Pneumonia and UTI
What does klebsiella cause in lung?
Caviating lesions in upper lobes
Most common reason for lung abcess?
Secondary to aspiration pneumonia
What is atelectasis?
-Postoperative complication where there is basal alveolar collapse
-Airways become obstructed with bronchial secretions
Atelectasis features and when does it usually occur?
-Dyspnoea and hypoxaemia
-Occurs 72 hours postoperatively
What is the management of atelectasis?
-Position patient upright
-Chest physiotherapy: breathing exercises
Most common organism causing infective exacerbation of COPD?
Haemophilus influenzae
CXR findings COPD?
-Hyperinflation
-Flattended hemidiaphragms
-Hyperlucent lung fields
Prognosis of sarcoidosis?
Most patients will get better even without treatment (2/3)
What is bronchictasis?
-Permanent dilation and damage of bronchus
-Secondary to chronic inflammation or infection
What are presenting symptoms of bronchiectasis?
-SOB
-Chronic productive cough
-Recurrent chest infections
-Weight loss
-Haemopysis
Why does bronchiectasis occur?
Due to damage of the bronchi
What are the causes of bronchiectasis?
-Pneumonia
-TB
-A1AT deficiency
-Connective tissue
-Cystic fibrosis
-Yellow nail syndrome (yellow nails, bronchiectasis, lymphedema)
-Whopping cough
Signs that may be present with bronchiectasis?
-Sputum pot
-Finger clubbing
-May be signs of cor pulmonale
-Coarse crackles - chnage or clear with cough
-Scattered Wheeze
Investigations for bronchiectasis?
-Sputum culture - to identify haemophilus influenzae and pseudomonas aeruginosa (klebsiella and strep also)
-CXR
-High-resolution CT scan
CXR findings in bronchiectasis?
-Ring shadows
-Tram track opacities
What is gold standard for diagnosing bronchiectasis?
High resolution CT (HRCT)
General management of bronchiectasis? after treating causes
-Vaccines (pneumococcal and influenza)
-Respiratory physio to help clear sputum (non-CF)
-Pulmonary rehabilitation
-Postural drainage
-Bronchodilators
-Surgery if localised disease
-Long term antibiotics
-Inhaled colistin for pseudomonas
-ABx prophylaxis
What is the management for an infective exacerbation of bronchiectasis?
-Sputum culture before Abx
-Extended course of antibiotics (7-14 days)
-Ciprofloxacin for pseudomonas aeruginosa
What equipment is used for aspiration of pleural effusion?
21G needle and 50ml syringe
Test before macrolide such as azithromycin?
-ECG can cause QT interval prolongation - lead to cardiac arrhythmias
-Liver function test also needed
Referral for lung cancer (2WW)?
-CXR findings
->40 with haemoptysis
ARDS can only be diagnosed in absence of cardiac cause, how is this assessed?
-If increased pulmonary capillary wedge pressure
Asthma not responding to full medical treatment and are becoming acidotic?
Intubation and ventilation rather than CPAP or BiPAP
What is ARDS charcterised by?
bilateral pulmonary infiltrates and hypoxemia - no cardiac cause
Granulomatosis with polyangiitis vs Eosinophilic granulomatosis with polyangiitis ?
Both
-Sinusitis
-Vasculitis
-Dyspnoea
Granulomatosis with polyangiitis
-Renal failure
-Epistasis/haemoptysis
-cANCA
Eosinophilic granulomatosis with polyangiitis
-Asthma
-Eosinophila
-pANCA
Medications for smoking cessation?
Varenicline - nicotinic receptor partial agonist
Bupropion - norepinephrine-dopamine reuptake inhibitor and nicotinic antagonist
Assessment of long term oxygen therapy with COPD?
2 ABG 3 weeks apart
What patients with COPD do you offer LTOT to?
-pO2 <7.3
-pO2 7.3-8 and one of the following:
-Secondary polycythaemia
-Pulmonary hypertension
-Peripheral oedema
Pattern of spirometry of neuromuscular disorder?
Restrictive pattern
FEV1/FVC >0.7 and FVC reduced
What is superior vena cava syndrome?
Increased venous pressure due to obstruction or compression of SVC
why does superior vena cava syndrome ?
-Due to reduced venous outflow there is increase in pressures in head and neck
-This can be due to malignancy such as lung cancer
Signs of superior vena cava syndrome?
-Engorged veins chest wall and neck
-Cyanosis/plethora of face
-Facial and limb swelling
iatrogenic pneumothorax causes?
-Central venous catheter
-Ventilation
-Non-invasive ventilation
-Lung biopsy
Prednisolone and breastfeeding?
-Safe in pregnancy
-only 0.1% reach the infant
-benefits outweigh the risk to infant
Empyema aspirate results?
-pH <7.2, low glucose, high LDH
-turbid
Severe asthma resp rate?
> 25
What is the most common bacteria in bronchiectasis?
Haemophilus influenza
what is a pneumoectomy?
A complete lung collapse
Trachea with pneumonectomy?
Trachea pulled towards white out
Trachea in pulmonary oedema, consolidation, mesothelioma?
Trachea central
Trachea in pleural effusion or large thoracic mass?
Trachea pushed away from white out
Cannon ball metastases what cancer most commonly cause?
renal cell carcinoma
What is the most common cause of exudative pleural effusion?
Pneumonia
How can you confirm that the chest drain is located in the pleural cavity?
It responds to thoracic pressures Rises in inspiration and falls in expiration - this is called chest drain “swinging”
Triangle of safety?
Base of axilla, lateral edge of pectoralis major, 5th ICS and anterior border of latissimus dorsi
When are phosphodiesterase-4 (PDE-4) inhibitors useful?
They used to reduce the risk of COPD exacerbation in patients with severe COPD and frequent exacerbations of COPD
When do NICE recommend PDE-4 inhibitors?
-Severe disease with FEV1 <50% of predicted after bronchodilator
- 2 or more exacerabtion in previous 12 months despite triple therapy (LAMA, LABA and ICS)
Severe asthma
-PEFR 33-50%
-Cant complete sentences
-RR>25
-Pulse >110bpm
neuromuscular disorder causing dyspnoea? spirometry pattern?
Restrictive pattern and muscle weakness
Squamous cell paraneoplastic features?
-PTH-rp secretion - high calcium
-Clubbing
-Hypertrophic pulmonary osteoarthropathy
-Hyperthyroidism
What is a hemithroax?
-One side of the thoracic cavity
-chest is divded into left and right hemithorax
Causes of white out of a hemithorax trachea toward the white out?
-Pneumonectomy
-Complete lung collapse
-Pulmonary hypoplasia
Causes of white out of hemithorax trachea pushed away from white out?
-Pleural effusion
-Diaphragmatic hernia
-Large thoracic mass
white out of a hemithorax central trachea?
-Consolidation
-pulmonary oedema (usually bilatera|l)
-Mesothelioma
Allergic bronchopulmonary asperigillosis?
Allergy to aspergillus spores
Features of allergic bronchopulmonary aspergillosis?
-Wheeze, cough, dyspnoea (previous label of asthma)
-Bronchiectasis (proximal)
Investigation of allergic bronchopulmonary aspergillosis?
-Eosinophila
-Postive RAST test aspergillus
-Positve IgG preciptins
-Raised IgE
What is the management of allergic bronchopulmonary aspergillosis?
-Oral glucocorticoids
-Itraconazole is sometimes introduced as a 2nd line agent
Amiodarone causing lower zone pulmonary fibrosis?
-Doses exceed 400mg after 2 or more months of therapy
-1-5% immunoloigcal reaction
What PE do to TLCO?
-Reduced TLCO
-Recurrent PE cna cause areas of the lung to be poorly perfused and ventilated - ventilation perfusion mismatch
Clinical fetaures of ARDS?
-Dyspnoea
-Elevated respiratory rate
-Bilateral lung crackles
-Low oxygen sats
What are the key investigations in ARDS?
-Acute onset
-Pulmonary oedema (bilater
