RESP Flashcards
Define COPD
Chronic, progressive lung disorder characterised by airflow obstruction, with the following:
Chronic Bronchitis & Emphysema
chronic bronchitis: Chronic cough and sputum production on most days for at least 3 months per year over 2 consecutive years
emphysema: Pathological diagnosis of permanent destructive enlargement of air spaces distal to the terminal bronchioles
What is chronic bronchitis?
Narrowing of the airways resulting in bronchiole inflammation (bronchiolitis) Bronchial mucosal oedema Mucous hypersecretion Squamous metaplasia
COPD criteria:
Chronic cough and sputum production on most days for at least 3 months per year over 2 consecutive years
What is emphysema?
Destruction and enlargement of alveoli
Leads to loss of elasticity that keeps small airways open in expiration
Progressively larger spaces develop called bullae (diameter > 1 cm)
COPD criteria:
Pathological diagnosis of permanent destructive enlargement of air spaces distal to the terminal bronchioles
What are the PC of COPD?
Recognise the presenting symptoms of COPD Chronic cough Sputum production Breathlessness Wheeze Reduced exercise tolerance
Recognise the signs of COPD on physical examination on INSPECTION
Respiratory distress Use of accessory muscles Barrel-shaped over-inflated chest Decreased cricosternal distance Cyanosis
Recognise the signs of COPD on physical examination on PERCUSSION
Hyper-resonant chest
Loss of liver and cardiac dullness
Recognise the signs of COPD on physical examination on AUSCULTATION
Quiet breath sounds Prolonged expiration Wheeze Rhonchi Sometimes crepitations
rhonchi= rattling, continuous and low-pitched breath sounds that sounds a bit like snoring. They are often caused by secretions in larger airways or obstructions
Recognise the signs of Co2 retention of COPD on physical examination
Bounding pulse
Warm peripheries
Asterixis
LATE STAGES: signs of right heart failure (cor pulmonale)
Right ventricular heave
Raised JVP
Ankle oedema
What is cor pulmonale?
Abnormal enlargement of the right side of the heart as a result of disease of the lungs or the pulmonary blood vessels.
What are the results of spirometry and pulmonary function tests of a COPD pt?
Shows obstructive picture Reduced PEFR Reduced FEV1/FVC Increased lung volumes Decreased carbon monoxide gas transfer coefficient
What does a CXR of a COPD pt look like?
May appear NORMAL
Hyperinflation (> 6 anterior ribs, flattened diaphragm)
Reduced peripheral lung markings
Elongated cardiac silhouette
What would the FBC of a COPD pt show?
Increased Hb and haematocrit due to secondary polycythaemia
List the tests you would do for a COPD pt
Spirometry & Pulmonary Function Tests
FBC
CXR
ABG (may be hypoxic with raised paco2)
ECG and Echo (cor pulmonale)
Sputum and blood cultures (for infective exacerbations)
a1-antitrypsin deficiency if they are really young
Generate a management plan for COPD
STOP SMOKING
Bronchodilators
SABA(e.g. salbutamol)
Anticholinergics (e.g. ipratropium bromide)
LABA (if > 2 exacerbations per year)
Steroids
Inhaled beclamethasone - considered in all patients with FEV1 < 50% of predicted OR > 2 exacerbations per year Regular oral steroids should be avoided if possible
Pulmonary rehabilitation
OXYGEN THERAPY
Only for those who stop smoking
Indicated if: PaO2 < 7.3 kPa on air during a period of clinical stability
PaO2: 7.3-8 kPa and signs of secondary polycythaemia, nocturnal hypoxaemia, peripheral oedema or pulmonary hypertension
Prevention of infective exacerbations: pneumococcal and influenza vaccination
What is the mx of ACUTE COPD exacerbations?
24% O2 via Venturi mask *
Increase slowly if no hypercapnia and still hypoxic (do an ABG)
Corticosteroids
Start empirical antibiotic therapy if evidence of infection Respiratory physiotherapy to clear sputum
Non-invasive ventilation may be necessary in severe cases
Identify the possible complications of COPD
Acute respiratory failure Infections Pulmonary hypertension Right heart failure Pneumothorax (secondary to bullae rupture) Secondary polycythaemia
What is the normal FEV1/FVC?
80%
<80% = obstructive picture >80% = restrictive picture
reversible in asthma but not in COPD
CURB 65
Criteria for each
And interpretation of scores
Clinical prediction rule for COMMUNITY ACQUIRED PNEUMONIA
C - Confusion U- Urea = >7 R - RR > 30 B - BP <90/60mmHg 65 - >65years old
Score:
0-1 = outpatient <5% mortality
2-3 = hospitalise for a bit then outpatient <10% mortality
3-5 = severe pneumonia and hospitalisation possible escalate to ICU 15-30% mortality
How does a classic pneumonia pt present?
Pyrexia
Productive cough with green sputum
Rigors Sweating Malaise Cough Sputum Breathlessness Pleuritic chest pain Confusion (in severe cases or in the elderly)
Define pneumonia and its 4 categories.
Infection of distal lung parenchyma.
It can be categorised in many ways: Community-acquired Hospital-acquired/nosocomial Aspiration pneumonia Pneumonia in the immunocompromised Typical Atypical
Which organisms cause atypical pneumonia?
Mycoplasma
Chlamydia
Legionella
What are common organisms for Community acquired pneumonia?
Streptococcus pneumoniae (70%) *
Haemophilus influenzae *
Moraxella catarrhalis (occurs in COPD patients) Chlamydia pneumonia
Chlamydia psittaci (causes psittacosis)
Mycoplasma pneumonia
Legionella (can occur anywhere with air conditioning) Staphylococcus aureus
Coxiella burnetii (causes Q fever)
TB
What are common organisms for Hospital acquired pneumonia?
Gram-negative enterobacteria (Pseudomonas, Klebsiella)
Anaerobes (due to aspiration pneumonia)
How does atypical pneumonia present?
Headache
Myalgia
Diarrhoea/abdominal pain
DRY cough
Recognise the signs of pneumonia on physical examination
Pyrexia Respiratory distress Tachypnoea (CURB RR>30) Tachycardia Hypotension (CURB <90/60mmHg) Cyanosis Decreased chest expansion Dull to percuss over affected area Increased tactile vocal fremitus over affected area Bronchial breathing over affected area Coarse crepitations on affected side* Chronic suppurative lung disease (empyema, abscess) --> clubbing
Identify appropriate investigations for pneumonia
Bloods FBC - raised WCC * U&Es LFT Blood cultures * ABG (assess pulmonary function) Blood film - Mycoplasma causes red cell agglutination *
CXR
Lobar or patchy shadowing
Pleural effusion
NOTE: Klebsiella often affects upper lobes
May detect complications (e.g. lung abscess)
Sputum/Pleural Fluid - MC&S
Urine - Pneumococcus and Legionella antigens **
Atypical Viral Serology
Bronchoscopy and Bronchoalveolar Lavage - if Pneumocystis carinii pneumonia is suspected, or if pneumonia fails to resolve
Generate a management plan for pneumonia
Assess severity using the British Thoracic Society CURB 65
Guidelines
Start empirical antibiotics
Oral Amoxicillin (0 markers)
Oral or IV Amoxicillin + Erythromycin (1 marker)
IV Cefuroxime/Cefotaxime/Co-amoxiclav + Erythromycin (> 1 marker)
Add metronidazole if:
Aspiration
Lung abscess
Empyema
Switch to appropriate antibiotic based on sensitivity
Supportive treatment:
Oxygen
IV fluids
CPAP, BiPAP or ITU care for respiratory failure
Surgical drainage may be needed for lung abscesses and empyema
What is the Discharge planning for pneumonia?
If TWO OR MORE features of clinical instability are present (e.g. high temperature, tachycardia, tachypnoea, hypotension, low oxygen sats) there is a high risk of re- admission and mortality
Consider other causes if pneumonia is not resolving
Identify the possible complications of pneumonia
Pleural effusion
Empyema
Localised suppuration (e.g. abscess)
Symptoms of abscesses:
Swinging fever *
Persistent pneumonia
Copious/foul-smelling sputum
Septic shock ARDS Acute renal failure Extra complications of Mycoplasma pneumonia Erythema multiforme Myocarditis Haemolytic anaemia Meningoencephalitis Transverse myelitis Guillain-Barre syndrome
What tests do you do for the atypical community acquired pneumonias?
Legionella - urinary antigen
Mycoplasma & Chlamydia - serology
Type 1 respiratory failure - how does it present on ABG?
Low PaO2
Normal/Low PaCO2
Type 1 respiratory failure - causes
Ventilation perfusion mismatch V/Q mismatch.
eg: Pneumonia Pulmonary Oedema Pulmonary Embolism Asthma Emphysema Fibrosing alveolitis ARDS
Type 2 respiratory failure - how does it present on ABG?
Low PaO2
High PaCO2
Type 2 respiratory failure - causes
Alveolar hypoventilation with or without v/q mismatch
CAUSES:
Respiratory diseases: Pneumonia COPD Asthma Obstructive sleep apnoea
Reduced respiratory drive:
Sedative drugs
CNS tumour
Trauma
Neuromuscular disease: Cervical cord lesion Diaphragmatic paralysis Myasthenia gravis Guillain-Barre syndrome
Thoracic wall disease:
Flail chest
Kyphoscoliosis
54yo woman presents with weight loss, loss of apettite, SOB.
RR = 19, o2 sats = 93%
OE: reduced air entry and dullness to percussion on the lower to midzones of the right lung and reduced chest expansion on the right
What is this?
+ explanation
Pleural effusion
Explanation:
Stony dullness is classic for pleural effusion but no one can really distinguish so consider dullness as classic pleural effusion as well.
Dullness + reduced chest expansion = Pleural effusion
Its NOT cancer because = no cheeky history of smoking also she is quite young
Bronchial carcinoma would present with = BRONCHIAL breathing over affected are of lung (not reduced air entry and dullness)
How can pleural effusions be categorised into? And what are the criteria (and the name of the criteria) ?
Transudates & Exudates
LIGHTS CRITERIA
Transudates = protein content <30g/L low LDH
Exudates = High in protein >30g/L high LDH
What are common causes of TRANSUDATE pulmonary effusion?
TRANSUDATES
Increased venous pressure
eg: cardiac failure, restrictive pericarditis, fluid overload,
Hypoproteinaemia
eg: cirrhosis, nephrotic syndrome, malabsorbtion
Hypothyroidism
Meig’s shyndrome (right pleural effusion coupled with ovarian fibroma)
What are common causes of EXUDATE pulmonary effusion?
EXUDATES:
Increased capillary permeability secondary to infection
eg: pnemonia, TB
Inflammation
eg: pulmonary infarction, RhA, SLE
Malignancy
eg: bronhogenic carcinoma, seconary metastases, lymphoma, mesothelioma, lymphagitis carcinomatosis
45yo woman presents with weight loss, anorexia, SOB
OE: reduced air entry and dullness to percussion in the right lung
Pleural tap = protein content >30g/L
What is this?
Pleural effusion
Exudate pleural effusion because protein content is above 30
Adding this with a weight loss and anorexia history = bronchial carcinoma (malignancy is a cause for exudative pleural effusion)
What is the first line investigation for pulmonary embolism?
Ct-Pa (given wells is above 2 aka high risk)
It’s the most readily avaiable , sensitive and specific test for PE.
It can detect them down to the 5th order pulmonary arteries
It’s readily obtainable out of hospital hours
What are the steps of the british thoracic society approach to mx of chronic asthma
Step 1: SABA in mild intermittent asthma
Step 2: SABA + inhaled regular low dose corticosteroid (beclamethasone 400mcg/day) if pt uses SABA more than 3 times a week or has required oral CS the past 2 years then
Step 3: SABA + low dose inhaled CS + LABA
if the patient is still symptomatic
Step 4: SABA + HIGH dose inhaled CS + LABA + Leukotriene receptor antagonists
if there is still poor asthma control
Step 5: SABA + high dose inhaled CS + LABA + Leukotriene R antagonists + Oral CS
What would you expect to see on an ECG of a pulmonary embolism pt?
May be normal
May show tachycardia, right axis deviation or RBBB
May show S1Q3T3 pattern = which means: deep s waves in lead 1, deep q waves in lead 3 and inverted t waves in lead 3.
What would you expect the ABG of a COPD pt to look like?
low o2
high co2
normal pH
bicarbonate on the high side
AKA:
HYPOXIC
Respiratory acidosis = AKA type 2 respiratory failure
Normal Ph
COPD pts rely on hypoxic drive in order to drive respiration. The respiratory centre in the brain is relatively insensitive to co2 (this is also why o2 therapy must be used cautiously in COPD pts - giving too much o2 may cause a decrease in respiratory drive and hence pt deterioration)
ABG in COPD = type 2 resp failure caused by alveolar hyperventilation with or without v/q mismatch
Define bronchiectasis
Lung airway disease characterised by chronic bronchial dilation, impaired mucociliary clearance and frequent bacterial infections
