Resp Flashcards
Pancoast tumour
Ptosis
Miosis
Wasting of 1st webbed space
Clubbing
Interstitial lung disease
Malignancy (bronchogenic carcinoma AND mesothelioma)
Suppurative lung disease (bronchiectasis, abscess, empyema, CF)
Consolidation Examination features
Percussion: dull
Breath sounds: bronchial or reduced
Vocal resonance: hyper resonant
Mediastinal shift: none
Collapse (or lobectomy/pneumonectomy) Examination features
Percussion: dull
Breath sounds: reduced or absent
Vocal resonance: reduced or absent
Mediastinal shift: towards
Effusion (or raised hemidiaphragm due to phrenic nerve palsy) Examination features
Percussion: stony dull
Breath sounds: reduced or absent
Vocal resonance: reduced or absent
Mediastinal shift: away if big
Pneumothorax Examination features
Percussion: hyper resonant
Breath sounds: reduced or absent
Vocal resonance: reduced of absent
Mediastinal shift: away if tension
Hoover’s sign
intercostal indrawing = hyperinflation
Wheeze causes
Small airway obstruction = asthma or COPD
Obstruction from object or tumour ==> monophonic and probably collapse further down
Creps causes
Secretions (if normal get them to cough and should disappear, if not pneumonia)
Pus (cystic fibrosis, bronchiectasis)
Oedema
ILD
ILD
see extra notes
Idiopathic:
Extrinsic allergic alveolitis: bird fancier’s lung; farmer’s lung
Inhaled irritant: asbestosis; silicosis; coal worker’s pneumoconosis
Systemic disease: SLE; RA; sarcoid; systemic sclerosis
Iatrogenic: methotrexate, amiodarone, radiotherapy
Horner’s syndrome
Central lesion: stroke/tumour
T1 root lesion: neurofibroma
Brachial plexus lesion: pancoast tumour, cervical rib, trauma (at birth = Klumpke’s)
Neck lesion: tumour, carotid artery aneurysm
Fine creps causes
Pulmonary oedema
ILD
Coarse creps causes
Bonchiectasis
CF
Bibasal pneumonia
Pleural effusion classification
Transdate (<30g/L) = reduced oncotic pressure
E.g. LVF, volume overload, hypoalbuminaemia, Meig’s syndrome
Exudate (>30g/L) = infection (pneumonia, TB); infarction (PE); inflammation (RA, SLE); malignancy (bronchogenic, mesothelioma)
Pneumonia CURB-65
Confusion (< or equal 8) Urea >7mM RR >30 BP <90/60 > or equal 65
0-1 –> home Rx
2 –> hospital Rx
3 or > –> consider ITU
Pneumonia Empiric Rx
CAP:
Mild - amoxi 500mg TDS for 5 d OR clari 500mg BD 7 d
Moderate - amoxi AND clari 500mg BD for 7 d
Severe - clari 500mg BD IV AND co-amoxi 1.2g TDS IV / cefuroxime 1.5g TDS IV 7-10 d; (add fluclox if staph suspected)
Atypical typically treated with clari:
chlamydia - tetracycline (clari)
PCP - co-trimoxazole
Legionella - clarithromycin + rifampicin
HAP:
mild/<5days/aspiration: co-amoxi 625mg TDS PO for 7 days
Severe: tazocin +/- vanc +/- gent for 7 days
SIRS
> or equal 2 of: Temp >38 or <36 HR >90 RR >20 or PaCo2 <4.6 WCC >12 or <4
Klebsiella features
Cavating pneumonia esp upper lobes
Treated with cefotaxime
Mycoplasma features
Dry cough
reticular-nodular shadowing
Flu-like prodrome
Treated with clari
Legionella looks similar but bibasal consolidation and hyponatraemia / deranged LFTs. Also treated with clari and both can be investigated via serology
Chlam. pneum features
pharyngitis, otitis –> pneumonia
treated with clari and Ix serology
Chlam. psittaci features
dry cough horder's spots - rose spots splenomegaly epistaxis meningo-encephalitis treated with clari and Ix serology
PCP features
Dry cough Exertional dyspnoea Bilateral creps CXR: normal or bilateral perihilar interstitial shadowing
Ix: BAL, sputum and biopsy
Rx: high dose co-trimoxazole
Bronchiectasis causes
idiopathic (50%)
Congenital - CF, Kartagener’s (situs inversus), Young’s syndrome
Post-infectious - Measles, pertussis, pneumonia, TB
Immunodeficiency - Bruton’s, CVID
Yellow nail syndrome
Bronchiectasis signs
O/E: Clubbing, coarse creps and wheeze, purulent sputum
CXR - thickened bronchial walls (tramlines and rings)
Spirometry: obstructive pattern
Bronchiectasis Rx
chest physio
Abx for exacerbations - e.g. cipro for 7-10 days
bronchodilators (nebulised B agonists)
From CF - GI dysfunction give Creon to replace pancreatic enzymes, insulin and UDCA for bile stimulation
Lung cancer complications
Local Recurrent laryngeal N. palsy Phrenic N. palsy SVC obstruction Horner’s (Pancoast’s tumour) AF
Paraneoplastic
Endo
ADH → SIADH ( euvolaemic ↓Na+)
ACTH → Cushing’s syndrome
Serotonin → carcinoid (flushing, diarrhoea)
PTHrP → 1O HPT (↑Ca2+, bone pain) – SCC
Rheum
Dermatomyositis / polymyositis
Neuro
Purkinje Cells (CDR2) → cerebellar degeneration
Peripheral neuropathy
Derm
Acanthosis nigricans (hyperpigmented body folds)
Trousseau syndrome: thrombophlebitis migrans
DDx of pulmonary oedema
Tranusdates: ↑ capillary hydrostatic pressure CCF Iatrogenic fluid overload Renal failure Relative ↑ in negative pressure pulmonary oedema ↓ capillary oncotic pressure Liver failure Nephrotic syndrome Malnutrition, malabsorption, protein-losing enteropathy ↑ interstitial pressure ↓lymphatic drainage: e.g. Ca
Exudates
ARDS (admit to ITU for organ support and treat underlying cause)
Indications for ventilation in ARDS
PaO2<8KPa despite 60% FiO2
PaCO2>6KPa
Method
6ml/kg + PEEP (e.g. 10cm H2O)
Type 1 resp failure
PaO2 <8kPa and PaCO2 <6kPA; caused by V/Q mismatch which can be vascular (PE, pulmonary shunt); asthma; pneumothorax; atelectasis
as well as fluid and fibrosis
Type 2 resp failure
PaO2 <8kPa and PaCO2 >6kPA; caused by alveolar hypoventilation from obstructive (COPD, asthma, bronciectasis) or restrictive (GBS, fluid and fibrosis) causes
A-a gradient
PAO2= (95 x FiO2) – (PaCO2/0.8)
↑ (PAO2-PaO2) suggests lung pathology
O2 therapy
In pts. at risk of hypercapnic resp failure:
Start O2 therapy at 24% and do an ABG
– Blue Venturi @ 2-4L/min
O2 therapy mechanism
Nasal Prongs: 1-4L/min = 24-40% O2
Simple Face Mask
Non-rebreathing Mask
Reservoir bag allows delivery of high concentrations of O2.
60-90% at 10-15L
Venturi Mask Provide precise O2 concentration at high flow rates Yellow: 5% White: 8% Blue: 24% Red: 40% Green: 60%
mMRC dyspnoea score (COPD)
- Dyspnoea only on vigorous exertion
- SOB on hurrying or walking up stairs
- Walks slowly or has to stop for breath
- Stops for breath after <100m / few min
- Too breathless to leave house or SOB on dressing
COPD Severity
Spirometry should show FEV1:FVC <0.7 for COPD and usually FEV1 <80%
Assess Severity Mild: FEV1 >80% (but FEV/FVC <0.7 and symptomatic) Mod: FEV1 50-79% Severe: FEV1 30-49% Very Severe: FEV1 < 30%
PE score system
For PE assess probability from Well’s score
If low probability perform D-dimer (if negative excludes PE, if positive do CTPA)
If high probability perform CTPA
NB. -ve D-dimer has 95% NPV for PE
NB review management of PE
Pleural effusion classification
Effusion protein < 25g/L = transudate
Effusion protein >35g/L = exudate
Between 25-35g/L: apply Light’s Criteria
Light’s Criteria An exudate has one of: Effusion : serum protein ratio >0.5 Effusion : serum LDH ratio >0.6 Effusion LDH is 0.6 x ULN
Pleural effusion Ix
Diagnostic Tap
Percuss upper boarder and go 1-2 spaces below
Infiltrate down to pleura with lignocaine.
Aspirate with 21G needle
Send for:
Chemistry: protein, LDH, pH, glucose, amylase
Bacteriology: MCS, auramine stain, TB culture
Cytology
Immunology: SF, ANA, complement
Sarcoidosis features
GRANULOMA General (FLAWS) Respiratory - dry cough SOB, chest pain Arthralgia Neurological (Bell's palsy) Urine (renal stones from hypercalcaemia) Low hormones (amenorrhoea) Ophthalmological (uveitis, Sjogren's) Myocardial (restrictive cardiomyopathy) Abdominal (hepatosplenomegaly + cholestatic LFT) Skin (erythema nodosum/lupus pernio)
Stages of sarcoid
Stage 1: BHL
Stage 2: BHL + peripheral infiltrates
Stage 3: Peripheral infiltrates alone
Stage 4: Progressive mid-zone fibrosis with bullae
Granulomatous Disease Differential
Infections: TB, leprosy, syphilis, crypto, schisto
AI: PBC
Vasculitis: GCA, PAN, Wegener’s, Takayasu’s
Idiopathic: Crohns, Sarcoid
Interstitial lung: EAA, silicosis
Sarcoidosis Rx
Acute sarcoidosis
Usually resolves spontaneously
Bed rest and NSAIDs
Chronic sarcoidosis
Steroids: pred 40mg/d for 4-6wks
Additional immunosuppression: methotrexate,
ciclosporin, cyclophosphamide
ILD causes by location
Upper Zone: A PENT Aspergillosis : ABPA Pneumoconiosis: Coal, Silica Extrinsic allergic alveolitis Negative, sero-arthropathy TB
Lower Zone: STAIR
Sarcoidosis (mid zone)
Toxins: BANS ME (bleomycin, amiodarone, nitrofurantoin, sulfasalazine, methotrextrate)
Asbestosis
Idiopathic pulmonary fibrosis
Rheum: RA, SLE, Scleroderma, Sjogren’s, PM/DM
Quitting smoking advice
Referral to NHS stop smoking service
Nicotine gum/patches
Varenicline (C/I depression)
Bupropion (C/I epilepsy)
Obstructive sleep apnoea
Daytime Features:
morning headache, somnolence, reduced memory, irritability, depression
Polysomnography is diagnostic Rx: weight loss, avoid smoking and EtOH CPAP during sleep surgery to relieve obstruction (tonsillectomy or uvulopalatpharyngoplasty)
COPD X-ray
Hyperinflation (>6 ant ribs) Decreased cricosternal distnace Flat hemidiaphragms Large central pulmonary arteries Decreased peripheral markings Bullae
