Resp Flashcards
Define vital capacity
Volume of air expired from the lungs from a maximal inspiration using a slow/relaxed manoeuvre
Define forced vital capacity
Volume of air that can be forcible expelled from the lungs from a position of maximal inspiration
Define forced expiratory volume
volume of air forcibly expelled from the lungs in the first second - following maximal inspiration
Pathophysiology of anaphylaxis
Sensitised individual exposed to specific antigen
Immunological response:
– IgE → antigen → mast cell & basophils ‡ → histamine ↑ → body response
Features of anaphylaxis
Uritus, urticaria & angioedema, hoarseness, progressing to stridor & bronchial obstruction, wheeze & chest tightness from bronchospasm
Management of anaphylaxis
DO NOT DELAY! GET HELP
• Remove trigger, maintain airway, 100% O2
• IM adrenaline 0.5 mg
(Repeat every 5 mins as needed to support CVS)
• IV hydrocortisone 200mg
• IV chlorpheniramine 10 mg
• If hypotensive: lie flat and fluid resuscitate
• Treat bronchospasm: NEB salbutamol
• Laryngeal oedema: NEB adrenaline
monitor for secondary deterioration; advice about epipens and wearing medic alert braclet
arrange f/u in clinic
Severity of asthma exacerbations
Mild:
• No features of severe asthma
• PEFR >75%
Moderate:
• No features of severe asthma
• PEFR 50-75%
Severe (if any one of the following):
• PEFR 33 – 50% of best or predicted
• Cannot complete sentences in 1 breath (or unable to feed/talk in children)
• Respiratory Rate > 25/min (2y/o - >40; >5; >30)
• Heart Rate >110/min (2y/o - >140; >5; >125)
Life threatening (if any one of the following):
• PEFR < 33% of best or predicted
• Sats <92% or ABG pO2 < 8kPa
• Cyanosis, poor respiratory effort, near or fully silent
chest
• Exhaustion, confusion, hypotension or arrhythmias
• Normal pCO2
Near Fatal:
• Raised pCO2
Acute asthma attack management
ABCDE
Oxygen - aim 94-98%
Salbutamol 5mg NEB (repeat after 15 min) - 2.5-5 if <11y/o
Hydrocortisone 100mg IV (or prednisolone 40mg PO)
(>2 = 20mg)
Ipratropium bromide 500mcg (250mcg in children) NEB
Theophyilline (IV amionophylline)
Magnesium sulphate
Escalate care - ITU
Consider IV salbutamol
Life threatening - portable CXR
Features of an infective COPD exacerbation
Change in sputum volume / colour
Fever
Raised WCC +/- CRP
Management of COPD exacerbation
Oxygen - 24-28% fixed performance face mask. AIm sats 88-92% Antibiotics (if infective) Salbutamol NEB Ipratropium NEB Steroids - prednisolone 30mg STAT and 7d
Consider IV aminophyline
Consider NIV if pH <7.35
ITU if pH <7.25
CURB -65
C Confusion, MMT 2 or more points worse
U Urea > 7.0
R >30/min
B < 90 mm Hg systolic or < 60 mm Hg diastolic 65 Age above 65 years
Treatment of pneumonia
ABCDE
If any features of sepsis – immediately treat using sepsis pathway – NO DELAY in initiating IV antibiotics and fluids
-ABx as per CURB-65 score, local pneumonia guidelines and awareness of any patient drug allergies
- analgiea; PT
CURB SCORE - amoxicillin <1 - home rx; 2 - hospital
- Co-Amoxiclav IV 1.2g tds and Doxycycline PO –> rx; 3 - itu or HAP
Features of pneumonia
Consolidation on CXR with fever +/- purulent sputum +/ raised WCC and / or CRP
- May have malaise; dyspnoea; cough; pleuritic pain
Signs - tachypnoea; tachycardia; cyanosis; confusion; consolidation( reduced expansion; dull percussion; bronchial breathing; reduced air entry; crackles; pleural rub)
Classification of massive haemoptysis
> 240mls in 24 hours OR >100mls / day over consecutive days
Management of massive haemoptysis
• ABCDE
• Lie patient on side of suspected lesion (if known) • Oral Tranexamic Acid for 5 days or IV
• Stop NSAID’s / aspirin / anticoagulants
• Antibiotics if any evidence of respiratory tract
infection
• Consider Vitamin K
• CT aortogram – interventional radiologist may be able to undertake bronchial artery embolisation
Features of pneumothorax +/- tension
- sudden onset dyspnoea, pleuritic chest pain which reduced chest expansion and breath sounds and resonant percussion
TENSION
o hypotension
o tachycardia
o deviation of the trachea away from the side of
the pneumothorax
o Mediastinal shift away from pneumothorax
Management of tension pneumothorax
- ABCDE (no CXR)
- Large bore intravenous cannula into 2nd ICS MCL
- Chest drain into the affected side (0.9% saline-water seal)
Symptoms and signs of PE
Sx – Chest pain (pleuritic) – SOB – Syncope – Haemoptysis – Massive --> RHF - hypotension, raised JVP, loud P2, +/- cardiac arrest
Signs
- fever, cyanosis, tachycardia, tachypnoea, evidence of DVT
Risk factors for PE
Thrombopillia/ antiphospholipid syndrome Hx PE/VTE Recent travel Obstetric - pregnancy/ OCP Malignancy Break lower limb/ varicose veins Old age Surgery / smoking Immobility Sex (F)
Management of PE
A - sit up and 100% oxygen
B - CXR (exclude pleural effusion/ consolidation)
C - ECG, bloods (Trop, FBC, U+E, Clotting, D-Dimer), ABG
D -
E -
• Fluid resuscitation (if hypotensive), analgesia +/- anti-emetic
• Thrombolysis should be considered if a massive PE
is confirmed on Echo or CT scan ( IV Alteplase) –> senior!
• LMWH and Ted Stockings
Wells score
<4 –> if D-dimer -ve - exclude; if +ve –> CTPA
>4 –> CTPA
Ongoing - Graduated compression stockings for 2 years if sign of DVT; Start warfarin -3m if known cause; 6m if unknown
ECG –> T wave inversion, AF, RBBB, RAD –> ?S1Q3T3
Absolute thrombolysis contraindications
Haemorrhagic stroke or Ischaemic stroke < 6 months CNS neoplasia Recent trauma or surgery GI bleed < 1 month Bleeding disorder Aortic Dissection
Relative thrombolysis contraindications
Warfarin
Pregnancy
Advanced Liver Disease
Infective Endocarditis
Complications of thrombolysis
- Bleeding
- Hypotension
- Intracranial haemorrhage / stroke
- Reperfusion arrhythmias
- Systemic embolisation of thrombus
- Allergic reaction
Pathophysiology of asthma
Airway epithelial damage – shedding and subepithelial fibrosis, basement membrane thickening
• An inflammatory reaction characterised by eosinophils, T-lymphocytes (Th2) and mast cells. Inflammatory mediators released include histamine, leukotrienes, and prostaglandins
• Cytokines amplify inflammatory response
• Increased numbers of mucus secreting goblet cells
and smooth muscle hyperplasia and hypertrophy
• Mucus plugging in fatal and severe asthma
define asthma and features
- Asthma is a chronic inflammatory disease of the airways
- Airway obstruction that is reversible (but not completely so in some subjects), either spontaneously or with treatment
- Increased airway responsiveness (bronchoconstriction) to a variety of stimuli
Features
sx- cough, wheeze (high pitched polyphonic), dyspnoea, diurnal variation, chest tightener
signs - increased RR and HR, widespread polyphonic wheeze, hyperinflated chetst, ? reduced air entery, tracheal tug/recession, nasal flaring/ accessory muscle use
Differentials of a wheeze
> Acute Asthma Exacerbation • Bronchitis – viral or bacterial Other causes of wheeze less likely: • Pulmonary oedema • PE • Vocal cord dysfunction • Gastro-oesophageal reflux • Foreign body • Allergy • Hyperventilation / psychosocial • Cardiac disease • Vasculitides – Churg-Strauss syndrome, polyarteritis nodosa, Granulomatosis with Polyangiitis (Wegener’s granulomatosis) • Carcinoid syndrome with hepatic metastases – release of HIAA
Criteria for safe asthma discharge after exacerbation
• PEFR >75%
• Stop regular nebulisers for 24 hours prior to discharge
• Inpatient asthma nurse review to reassess inhaler
technique and adherence
• Provide PEFR meter and written asthma action plan
• At least 5 days oral prednisolone
• GP follow up within 2 working days
• Respiratory Clinic follow up within 4 weeks
• For severe or worse, consider psychosocial factors
Differentials of eosinophilia
- Airways inflammation (asthma or COPD)
- Hayfever / allergies
- Allergic Bronchopulmonary Aspergillosis
- Drugs
- Churg-Strauss / vasculitis
- Eosinophilic Pneumonia
- Parasites
- Lymphoma
- SLE
- Hypereosinophilic syndrome
Asthma trigger factors
• Smoking
• Upper respiratory tract infections – mainly viral
• Allergens – pollen, house dust mite, pets
• Exercise – also cold air
• Occupational irritants
• Pollution
• Drugs – aspirin, beta blockers (including eye drops)
• Food and drink – dairy produce, alcohol, orange
juice
• Stress
• Severe asthma – consider inhaled heroin, pre-menstrual, psychosocial aspects
NICE definition of COPD
COPD is characterised by airflow obstruction. The airflow obstruction is usually progressive, not fully reversible and does not change markedly over several months. The disease is predominantly caused by smoking.
Pathophysiology of COPD
COPD is an umbrella term which encompasses emphysema and chronic bronchitis:
• Mucous gland hyperplasia
• Loss of cilial function
• Emphysema – alveolar wall destruction causing
irreversible enlargement of air spaces distal to the
terminal bronchiole
• Chronic inflammation (macrophages and
neutrophils) and fibrosis of small airways
Causes of COPD
> Smoking
• Inherited α-1-antitrypsin deficiency
• Industrial exposure, e.g. soot
Members involved in MDT management of COPD
- Physicians
- G.P.’s
- Specialist nurses
- Physiotherapists
- Pharmacists
- Occupational therapists
- Dieticians
Outpatient COPD management
- ‘COPD Care Bundle’
- SMOKING CESSATION
- Pulmonary Rehabilitation
- Bronchodilators
- Antimuscarinics
- Steroids
- Mucolytics
- Diet
- LTOT if appropriate
- LUNG VOLUME REDUCTION if appropriate
Criteria for long term oxygen therapy in COPD
> pO2 consistently below 7.3 kPa, or below 8 kPa with cor pulmonale
• Patients must be non-smokers and not retain high levels of CO2
Reason for pulmonary rehabilitation in COPD
Many COPD patients with COPD avoid exercise and physical activity because of breathlessness
• This may lead to a vicious cycle of increasing social isolation and inactivity leading to worsening of symptoms
• Pulmonary Rehabilitation aims to break this cycle – an MDT 6-12 week programme of supervised exercise, unsupervised home exercise, nutritional advice, and disease education
CXR consolidation differentials
Pneumonia TB (usually upper lobe) Lung cancer Lobar collapse (blockage of bronchi) Haemorrhage
Investigations for pneumonia
CXR FBC, UE, CRP Sputum culture - MC+S Blood culture (if febrile) Serology and urine legionella test (if high CURB65) ABG
Pneumonia follow up
• HIV test • Immunoglobulins • Pneumococcal IgG serotypes • Haemophilus influenzae b IgG F/u in clinic in 6 weeks with a repeat CXR to ensure resolution
Causes of non-resolving pneumonia and other complications
CHAOS
• Complication – empyema, lung abscess
• Host – immunocompromised
• Antibiotic – inadequate dose, poor oral absorption
• Organism – resistant or unexpected organism not
covered by empirical antibiotics
• Second diagnosis – PE, cancer, organising
pneumonia
Complications - respiratory failure; hypotension; AF; pleural effusion (exudate); sepsis; pericarditis; jaundice (sepsis/drugs)
Clinical features of TB
- fever
- nocturnal sweats
- Weight loss (weeks – months)
- Malaise
- Respiratory TB: cough ± purulent sputum/ haemoptysis, (+/-pleural effusion)
Non-Respiratory TB: Skin (erythema nodosum); Lymphadenopathy; Bone/joint; Abdominal; CNS (meningitis); Genitourinary; Miliary (disseminated); Cardiac (pericardial effusion)
Differentials of Haemoptysis
Infection: • Pneumonia • Tuberculosis • Bronchiectasis / CF • Cavitating lung lesion (often fungal) Malignancy: • Lung cancer • Metastases Haemorrhage: • Bronchial artery erosion • Vasculitis • Coagulopathy Others: • PE
Risk factors for TB
Past history of TB
Known history of TB contact
Born in a country with high TB incidence
Foreign travel to country with high incidence of TB
Evidence of immunosuppression–e.g. IVDU, HIV, solid organ transplant recipients, renal failure/ dialysis, malnutrition/ low BMI, DM, alcoholism
Management for respiratory TB
ABCDE
CXR
Admit to side room and start infection control
3 x early morning sputum samples (AAFB and TB culture)
FBC,LFT, UE, vit D levles
HIV test
CT chest if CXR not clear
MRI/Spine if milary
Abx for pneumonia if diagnosis not clear
If highly likley TB - start anti-TB therapy (after cultures)
Notify TB nurse specialist (initiate contact tracing - Mantoux test to those at risk; IFN gamma if had bcg); notify public health etc)
TB culture can take 6-8 weeks
Anti-TB therapy
4 antibiotics for 2 months
(Rifampicin, Isoniazid, Pyrazinamide, Ethambutol) followed by 4 months on two antibiotics (Rifampicin, Isoniazid)
+ Pyridoxine as prophylaxis against peripheral neuropathy
- Dose is weight dependent
- check baseline LFT’s and monitor closely
- Check visual acuity
Compliance is crucial and Directly Observed Therapy (DOT) sometimes used for patients
Provide leaflets on treatment & ensure patient is aware of common and serious SE
Corticosteroids sometimes used, mainly seen in those with TB meningitis
Side effects of TB treatment
Rifampicin – Hepatitis, rashes, febrile reaction, orange/red secretions (N.B. contact lenses), many drug interactions including warfarin and OCP
Isoniazid – Hepatitis, rashes, peripheral neuropathy, psychosis
Pyrazinamide – Hepatitis, rashes, vomiting, arthralgia
Ethambutol – Retrobulbar neuritis
Definition of bronchiectasis
Chronic dilatation of one or more bronchi. The bronchi exhibit poor mucus clearance and there is predisposition to recurrent or chronic bacterial infection
