Resp Flashcards
Acute bronchitis
Cause, Sx, ix, mx
The majority of cases are viral, with common causes including:
• Rhinovirus
• Coronavirus
• Adenovirus
• Respiratory syncytial virus (RSV)
• Influenza A and B
• Parainfluenza
Bacteria may be responsible in 1-10% of cases, including:
• Streptococcus pneumoniae
• Haemophilus influenzae
• Moraxella catarrhalis
• Mycoplasma pneumoniae
• Bordetella pertussis
Sx:
- dry or productive cough
- chest pain
- dyspnoea
- fatigue
- fever
- wheeze on forced expiration
- rhonchi that clear with coughing
Ix:
- mainly clinical
- swab or culture for cause
- normal CXR
Mx:
- supportive
- abx only in those with high risk of complications and 1st line is 5 days oral doxycycline
Asbestos related lung disease
Def, Sx, ix, mx
Chronic fibrotic lung disease that manifests 10-20 years following exposure to asbestos fibres
Sx:
- progressive dyspnoea
- dry cough
- weight loss
- fatigue
- bilateral fine end expiratory crepitations predominantly basal
- finger clubbing
- cyanosis
Ix:
- pulmonary function tests showing restrictive pattern (reduced FVC and TLC with normal FEV1/FVC ratio) with decreased diffusion capacity
- CXR showing bilateral shadowing at the bases, pleural plaques
- high res CT showing honeycombing, traction bronchiectasis and parenchymal bands in the lower zones (fibrosis signs)
Mx:
- supportive
- vaccination against influenza
Asthma
Sx, ix, mx, severity
Sx:
- wheeze
- dyspnoea
- couch
- tight chest
These are normally episodic and show diurnal variation
- tachypnoea
- increased WOB
- hyper inflated chest
- expiratory polyphonic wheeze throughout the lung fields
- decreased air entry
Ix:
- FeNO (> 50 ppb) or blood eosinophil as first line
- spirometry (FEV1/FVC <70%) with bronchodilator reversibility (>12% improvement)
- peak flow twice a day for 2 weeks (>20% variability)
- direct bronchial challenge test
Mx:
- chronic= 1.LABA (formoterol) and ICS (budesonide) 2.MART (ICS and fast acting LABA) 3. Increase ICS dose to moderate 4.check FeNO and blood eosinophil 5.if neither are raised then add LTRA (montelukast) or LAMA (tiotropium)
- acute= 02 therapy, nebulised salbutamol, nebulised ipratropium bromide, prednisolone 40-50 mg oral or IV hydrocortisone, IV magnesium sulfate if not responding to nebulisers
Bronchiectasis
Cause, Sx, ix, mx
Causes:
- 40% have no identifiable cause
- most common is previous severe LRTI eg. Pneumonia, TB or influenza
- immunodeficiency
- defective mucociliary clearance
- ABPA
- autoimmune disease
- airway obstruction
Sx:
• Productive cough lasting at least 8 weeks
• Copious production of purulent sputum
• Dyspnoea
• Haemoptysis
• Chest pain
• Fatigue
• Weight loss
• Coarse crackles on auscultation
• Wheeze
• Rhonchi (snoring sounds caused by secretions in the larger airways)
• Finger clubbing
Ix:
- sputum culture
- spirometry
- CXR showing increased lung markings, tram-track opacities and ring shadows
- high res CT is the diagnostic test and shows tapering of airways, increased ratio of bronchi to pulmonary arteries, bronchial wall thickening and impacted mucus
Mx:
- abx
- long term abx for more than 3 exacerbations in a year
- lung resection
- lung transplant
COPD
Def, rf, classification, Sx, ix, mx
Progressive airway obstruction that encompasses emphysema and chronic bronchitis
Rf:
- smoking
- dust and fume exposure
- air pollution
- alpha-1 antitrypsin deficiency
Sx:
- SOB worse on exertion
- reduced exercise tolerance
- chronic productive cough
- recurrent LRTI
- wheeze
- accessory muscle use
- pursed lip breathing
- cyanosis
- hyperinflation of the chest
- cahexia
- raised JVP and peripheral oedema (cor pulmonale)
Ix:
- spirometry is key diagnostic and indicates severity
- ECG showing right axis deviation, prominent P waves in inferior leads, inverted p waves in lateral leads, low voltage QRS, P pulmoale, RBBB
- CXR showing hyperinflation
- sputum culture during exacerbations
Mx:
- SABA (salbutamol) or SAMA (iprtropium)
- add LABA (formoterol) and ICS (beclomethasone) or LABA (tiotropium)
- then add 3rd inhaler
- long term oxygen therapy for patients who have O2 <92%, FEV1 <30% predicted, polycythaemia, peripheral oedema
Lung cancer
Rf, class, Sx, ix, mx
Rf:
- smoke
- occupational exposures
- fhx
- chest radiation
- air pollution
- immunosuppression
- age
Classification:
- Small cell cancers come from neuroendocrine cells of the lung.
- Non-small cell cancers are split into adenocarcinomas (coming from alveolar type 2 epithelial cells), squamous cell carcinomas (coming from basal epithelial cells) and large cell carcinomas (which come from a variety of epithelial cells). There are also rarer subtypes of lung cancer such as sarcomatoid or salivary gland-type lung cancers which come under the NSCLC umbrella.
- TNM (tumour, node, metastasis) staging is used to describe how large the tumour is and where it has spread to. This can then be used to classify lung cancers into stage 1 to 4, where stage 1 is localised and small (under 4cm), stages 2 and 3 are locally advanced and stage 4 is metastatic.
Sx:
- cough
- haemoptysis
- dyspnoea
- chest pain
- weight loss
- chest infections
- cache is
- finger clubbing
- lymphadenopathy
- tracheal deviation if lung collapse
- Cushing syndrome
- SIADH
- LEMS
Ix:
- 2ww is >40 and unexplained heamoptysis or CXR suspicious
- CXR may indicate lung mass, consolidations, bulky hilum, lobar collapse, pleural effusion
- CT chest with contrast after CXR to characterise lesion and ix spread
- biopsy to confirm
- spirometry
Mx:
- chemo is first line in most cases with palliative intent
- lobectomy is standard curative therapy
- any surgery should have mediastinal and hilar lymph nodes sampled or resected
Obstructive sleep apnoea
Rf, Sx, ix, mx
Upper airway becomes completely or partially blocked during sleep causing breathing to temporarily stop
Rf:
- obesity
- male
- age
- low muscle tone
- large neck
- adenotonsillar hypertrophy
- sleeping supine
- Down’s syndrome
Sx:
- frequent waking
- snoring
- difficulty concentrating
- morning headaches
Ix:
- STOP-Bang asks about snoring, sleepiness, apnoeas, hypertension, obesity, neck circumference, age and sex and gives a low, medium or high risk of OSA.
- The Epworth sleepiness scale focuses on daytime sleepiness and asks how likely the patient would be to fall asleep in a variety of situations (e.g. when watching TV). This gives a result of either normal daytime sleepiness or mild, moderate or severe excessive daytime sleepiness.
- The definitive investigation is polysomnography (also called a sleep study) which would usually be arranged by a specialist clinic.
• Mild OSA: AHI 5-14 per hour
• Moderate OSA: AH| 15-30 per hour
• Severe OSA: AHI over 30 per hour
Mx:
- sleep on side
- weight loss, smoking cessation and reduce alcohol
- CPAP is first line
- intra0oral mandibular advancement device if CPAP not tolerated
- driving advice
Pleural effusion
Def, cause, sx, ix, mx
Collection of fluid in the pleural cavity meaning lungs cant expand properly
Causes:
Transudative (changes in pressure causes fluid leak from vasculature)
- HF
- nephrotic syndrome
- cirrhosis
- hypoalbuminaemia
Exudative (inflammation leads to increased vascular permeability and drainage of pleural fluid may be impaired)
- pneumonia
- malignancy
- TB
- PE
- rheumatoid arthritis
- SLE
- pancreatitis
- trauma
Classification:
- Transudates are classified as pleural fluid with a protein level less than 25g/L (assuming a normal serum protein).
- Exudates are classified as pleural fluid with a protein level more than 35g/L.
- For intermediate effusions, Light’s criteria are used - if any of the following are true then the effusion is an exudate:
- The ratio of pleural to serum protein is greater than 0.5
- The ratio of pleural to serum LDH is greater than 0.6
- The pleural fluid LDH is greater than ⅔ of the upper limit of normal serum value
Sx:
- Shortness of breath
- Reduced exercise tolerance
- Dry cough
- Pleuritic chest pain
- Reduced chest expansion on the affected side
- Dullness to percussion over the effusion
- Reduced or absent breath sounds over the effusion
- Loss of vocal resonance over the effusion
- Large pleural effusions may cause tracheal deviation away from the effusion
- Respiratory distress (e.g. accessory muscle usage)
Ix:
- pleural rap
- CBR is first line imaging showing blunting of costophrenic angle or white out of the lung if large
Mx:
- A to E
- Abx for infection
- diuretics if secondary to HF
- US guided pleural aspiration
- chest drain
- pleurodesis or tunnelled indwelling pleural drain if recurring
Pneumonia
Cause, classification, sx, ix, mx
Most common typical cause is strep pneumonia then haemophilus influnzae and moraxella catarrhalis. Most common atypical include Mycoplasma pneumoniae, Legionella pneumophila and Chylmydophila psittaci.
Classification:
CURB65
- Confusion
- Urea > 7mmol/L
- Respiratory rate > 30 breaths/min
- Blood pressure < 90 systolic and/or < 60mmHg diastolic
- 65 years or older
Sx:
- Fever
- Malaise
- Rigors
- Cough
- Purulent sputum
- Pleuritic chest pain
- Haemoptysis
- Tachypnoea
- Tachycardia
- Hypotension
- Cyanosis
- Pyrexia
- Dullness to percussion over the consolidated area
- Increased vocal resonance/ tactile vocal fremitus over the consolidated area
- Bronchial breathing over the consolidated area
- Pleural rub may be heard due to inflammation of the adjacent pleura
Ix:
- sputum
- ABG if hypoxaemic
- HIV testing for recurrent
- CXR may show lobar consolidation or bilateral consolidation in atypical infections, parapneumonic effusions
Mx:
- 0-1Oral antibiotics for patients managed in the community (e.g. amoxicillin 500mg three times a day for 5 days)
- 2-5 IV antibiotics for those admitted with more severe pneumonia (e.g. co-amoxiclav and clarithromycin)
Pneumothorax
Types, sx, ix, mx
Types:
- Spontaneous pneumothoraces can be divided into primary pneumothoraces (no underlying lung disease) and secondary (underlying lung diseases such as COPD or asthma).
- A tension pneumothorax occurs when the defect in the pleura that has led to the pneumothorax creates a one-way valve effect whereby air can enter the pneumothorax but not leave it. This causes the pneumothorax to progressively expand, putting pressure on the heart and great vessels and causing mediastinal shift
Sx:
- sudden SOB
- pleuritic chest pain
- dry cough
- tachypnoea and increased WOB
- Unilateral reduced expansion
- Unilateral hyper-resonance to percussion
- Reduced or absent breath sounds
- Reduced vocal resonance or tactile vocal fremitus
Tension:
- Tracheal deviation to the contralateral side
- Tachycardia
- Hypotension
- Distended neck veins
Ix:
- dx and mx with needle decompression for tension
- erect PA CXR for others
Mx:
- tension= large bore cannula into second intercostal space midclavicular line or fifth intercostal space mid axillary line if trauma suspected. If this fails then thoracostomy. Chest drain after emergency decompression
- spontaneous= chest drain for high risk, pleural vents under local anaesthetics and then follow up as outpatient
- no scuba diving ever and no flying for a week
Respiratory failure
Types, causes, sx, ix, mx
Types:
- Type 1 respiratory failure (T1RF) is defined as hypoxaemia (PaO2<8kPa) with low or normal levels of carbon dioxide in the arterial blood.
- Type 2 respiratory failure (T2RF) is defined as hypoxaemia (PaO2<8kPa) with hypercapnia (PaCO2>6.5kPa).
Causes:
Type 1:
- V/Q mismatch (most common cause of type 1, imbalance in ventilation versus perfusion) eg. PE
- diffusion limitation (impaired gas exchange) eg. Emphysema
- shunting (blood that passes through lungs and dont get oxygen) eg. AV malformations
Type 2:
- increase in dead space eg. Emphysema
- reduced minute ventilation (total amount of air entering lungs = resp rate x tidal vol) eg. Opiates
Sx:
- Dyspnoea
- Headache
- Light-headedness
- Confusion
- Drowsiness
- Agitation
- Tachypnoea (although respiratory rate may be low in some cases of T2RF e.g. opiate overdose)
- Cyanosis
- Accessory muscle usage
- Nasal flaring
Signs related to hypercapnia (i.e. T2RF only):
- Flushed skin
- Bounding peripheral pulses
- Asterixis
Ix:
- ABG (in chronic T2RF, a longstanding respiratory acidosis is compensated for by an increase in bicarbonate above the normal range of 22-26 mmol/L)
Mx:
- O2
- CPAP in severe T1RF but contraindicated by confusion and vomiting
- BIPAP for severe T2RF but contraindicated by confusion and vomiting
- intubation and ventilation for those not responding to other mx
Sarcoidosis
Def, sx, ix, mx
Sarcoidosis is an inflammatory disease characterised by non-caseating granuloma formation in various organs, with the most commonly affected being the lungs.
Sx:
- Dry cough
- Dyspnoea
- Reduced exercise tolerance
- Chest pain
- Clubbing
- Fine crackles on auscultation
- derm, neuro, ocular, cardiac, abdo and systemic sx
- Lofgren’s syndrome refers to the acute onset of: Fever, Polyarthralgia, Erythema nodosum, Bilateral hilar lymphadenopathy (seen on chest X-ray)
- Heerfordt’s syndrome refers to the combination of: Fever, Uveitis, Parotid swelling, Facial nerve palsy
Ix:
- mantoux to rule out TB
- lung function testing
- hypercalcaemia on bone profile
- raised serum ACE
- Chest X-ray can be used to stage sarcoidosis as below:
Stage 1 - Bilateral hilar lymphadenopathy (BHL)
Stage 2 - BHL with peripheral infiltrates
Stage 3 - Peripheral infiltrates alone
Stage 4 - Pulmonary fibrosis
- high res CT chest
- biopsy
Mx:
- no active mx in many cases
- prednisolone
- methotrexate if steroids contraindicated
- infliximab third line
- rarely a lung transplant
TB
Cause, sx, ix, mx
Caused my mycobacterium tuberculosis which is aerobic slow growing bacteria, it is acid fast bacilli
Sx:
- Chronic productive cough
- Haemoptysis
- Shortness of breath
- Collapse or pleural effusion leading to dullness on percussion and reduced breath sounds over the affected area
- systemic sx
- neuro, GU, MSK, GI, cardiac, cutaneous and adrenal sx
Ix:
- screening: mantoux and IGRA
- active: sputum (stained with ziehl-neelson), urine, ECG, bloods (HIV testing), CXR showing cavitation, pleural effusion, mediastinal or hilar lymphadenopathy, parenchyma infiltrates (especially upper lobes), military TB
Mx:
- BCG vaccine for prevention
- latent = Three months of isoniazid, pyridoxine and rifampicin OR Six months of isoniazid and pyridoxine
- active: 2 months of isoniazid (with pyradoxine), rifampicin, ethambutol and pyrazinamide, followed by isoniazid (with pyradoxine) and rifampicin alone for a further 4 months. Second-line antibiotics include amikacin, macrolides, quinolones and capreomycin. Lung resection if extensively drug resistant
Pulmonary embolism
Sx, ix, mx
Sx:
- Sudden-onset shortness of breath (the commonest symptom, present in around half of patients)
- Pleuritic chest pain
- Haemoptysis
- Symptoms of a DVT such as leg pain or swelling may be present
- Tachypnoea
- Crackles on auscultation
- Tachycardia
- Hypoxia
- Low-grade pyrexia in some
- In massive PE: - Hypotension - Cyanosis - Signs of right heart strain (e.g. a raised JVP, parasternal heave and loud P2)
Ix:
- wells score <4 then do d-dimer, >4 then do CTPA or V/Q scan
- ECG may show evidence of right heart strain
- ABG may show T1RF
- d-dimmer helpful to rule out
- CXR typically normal
- CTPA is main dx
- V/Q for those with severe renal impairment
- US Doppler
- TTE to ix right heart strain
Mx:
- LMWH or DOAC for 3 months if provoked or >3-6 months if unprovoked
- thrombosis is for massive PE (hypotension >15 mins) or embolectomy
Pulmonary hypertension
Def, cause, sx, ix, mx
an elevated mean pulmonary arterial pressure over 25mmHg at rest (normal is 11-20mmHg)
Causes:
- Pulmonary arterial hypertension - may be idiopathic, familial, associated with other diseases (e.g. HIV, connective tissue disorders or portal hypertension) or secondary to drugs or toxins (e.g. amphetamines, fenfluramine)
- Chronic pulmonary disease e.g. COPD, interstitial lung disease, bronchiectasis and obstructive sleep apnoea
- Chronic thromboembolic disease e.g. persistent or recurrent pulmonary emboli
- Chronic hypoventilation e.g. kyphosis or scoliosis, neuromuscular disorders
- Left heart disease e.g. chronic left heart failure or mitral stenosis
- Unclear or multifactorial mechanisms e.g. sarcoidosis, myelofibrosis, glycogen storage diseases
Classification:
- Group 1: pulmonary arterial hypertension
- Group 2: secondary to left heart diseases
- Group 3: secondary to chronic pulmonary diseases and/or hypoxia
- Group 4: due to chronic thrombotic or embolic disease
- Group 5: other causes including metabolic disorders, systemic disorders and haematological disease
Sx:
- Progressive shortness of breath
- Fatigue
- Syncope
- Fluid overload with ascites and peripheral oedema (late sign)
- Raised JVP
- Parasternal heave
- Loud P2
- Presence of an S3 sound
- Pansystolic murmur indicative of tricuspid regurgitation (occurs due to the right ventricle becoming pressure and volume overloaded)
- End-diastolic murmur indicative of pulmonary regurgitation (due to high pulmonary pressures)
Ix:
- ECG may show right heart strain
- CXR may show enlarged right heart and pulmonary arteries
- high res CT
- CTPA
- TTE
- right heart catheterisation is gold standard
Mx:
- supportive
- diuretics
- CCB (nifedipine)
- PDE-5 inhibitors (sildenafil)
- Prostacyclin analogues (iloprost)
- Endothelin receptor antagonists (bosentan, ambrisentan)
- Soluble guanylate cyclase stimulators (riociguat)
- thrombo-arterectomy or pulmonary balloon angioplasty for chronic
- atrial septostomy for palliative
- heart-lung transplant for severe
Respiratory alkalosis
Def, cause, sx, ix, mx
Respiratory alkalosis is a pathophysiological state characterised by a decrease in the partial pressure of carbon dioxide in the arterial blood (PaCO2)
Causes:
- Pulmonary oedema
- Panic attack (hyperventilation)
- Pneumonia
- Pulmonary embolism
- Pneumothorax
- Chronic obstructive pulmonary disease
- Fibrosing alveolitis
- Acute pulmonary distress syndrome
- Acute anxiety/hyperventilation
- Compensation for metabolic acidosis
- Salicylate poisoning
- Hyperthyroidism
- Meningitis/encephalitis
- Space occupying lesion
Sx:
- light-headed
- confusion
- loss of consciousness
- seizures
- tachypnoea
- hyperreflexia
Ix:
- ABG showing high pH, low PaCO2, low/normal HCO3. Respiratory alkalosis can be compensated for by conserving hydrogen ions and increased excretion of HCO3- via the kidneys
Mx:
- treat underlying cause
Respiratory acidosis
Def, cause, sx, ix, mx
Respiratory acidosis is defined by an accumulation of carbon dioxide in the blood due to alveolar hypoventilation. Compensatory respiratory acidosis occurs in cases where there is a metabolic alkalosis (e.g. due to excessive prolonged vomiting), leading to hypoventilation as a way to correct the raised pH.
Cause:
- increase in dead space eg. Emphysema, COPD, pneumonia
- reduced minute ventilation eg. Alcohol, opiates, MND or chest wall deformities
Sx:
- Dyspnoea
- Headache
- Light-headedness
- Confusion
- Drowsiness
- Agitation
- Symptoms related to underlying cause e.g. cough in a COPD exacerbation
- flushed skin
- bounding peripheral pulse
- asterixis
Ix:
- ABG showing low pH, high PaCO2 and high/normal HCO3. Raised bicarbonate indicates metabolic compensation
Mx:
- non-invasive ventilation for severe (BIPAP)
Interstitial lung disease
Cause, sx, ix, mx
large group of diseases that cause inflammation and ultimately fibrosis of the interstitium of the lung. The most common forms are idiopathic pulmonary fibrosis and hypersensitivity pneumonitis.
Causes:
Upper zones predominant:
- Hypersensitivity pneumonitis
- Ankylosing spondylitis
- Radiotherapy
- Tuberculosis
- Sarcoidosis
Lower zones predominant:
- Rheumatoid arthritis
- Asbestosis
- Idiopathic
- Drugs eg. Nitrofuratoin, amiodarone and bleomycin
Sx:
- dry cough
- SOB
- reduced exercise intolerance
- cyanosis
- clubbing
- fine end inspiration crackles
Ix:
- FBC may show eosinophilia in hypersensitivity pneumonitis
- CRP raised
- autoimmune screen
- CXR shows reticular and nodular shadowing
- high res CT is gold standard showing honeycombing
- spirometry showing restrictive pattern
- bronchoscope
- lung biopsy
Mx:
- Idiopathic= pirfenidone (which reduces fibroblast proliferation) and nintedanib (a tyrosine kinase inhibitor)
- hypersensitivity= steroids then cyclophosphamide and azathioprine if dont work
