resp Flashcards
Investigations for asthma
TLCO- normal spirometry and PEF- >15% reversibility Fev1 and FEV1/FVC reduced FBC and Sputum- Eosinophils Skin prick tests CXR- excludes pneumothorax
conservative management for chronic asthma
Make a personalised action plan
avoid allergens
train to use inhaler
stop smoking
pharmacological reliever of asthma
SABA salbutamol PRN
Pharmacoloical prevention in uncontrolled asthma 1st line
ICS Beclometasone
Pharmacoloical prevention in uncontrolled asthma 2nd line
ICS + LTRA
Pharmacoloical prevention in uncontrolled asthma 3rd line
ICS + LABA- salmetreol
Pharmacoloical prevention in uncontrolled asthma 4th line
ICS + LAMA- theophyline
Asthma biologic agents
uncontrolled after everything else- Omalizumab
Acute Asthma: uncontrolled or moderate classification
PEFR > 50
RR<25
pulse<110
able to make sentences
Acute Asthma: severe classification
PEFR 33-50
RR>25
pulse>110
unable to make sentences
Acute Asthma: life threatening classification
PEFR <33
PaO2 low
Paco2 normal
Acute Asthma: near fatal classification
PACO2 high
Treatment of acute asthma
predniselone oral or IM O2 SABA or SAMA - Ipatropium Bromide CXR exclude pneumothorax ABGs PEFR Review within 48 hours
3 Pathophysiology of asthma
Inflamation of the Bronchi
Bronchial smooth muscle spasm
Mucus production
symptoms of Asthma
Diurnal varation and episodic Cough wheeze SOB/ Dyspnoea Sputum
Signs of Asthma
Tachypnoea
Hyperinflated chest
PEFR low
what are the conditions under the term COPD
chronic bronchitis
chronic asthma
emphysema
what is meant by Blue bloaters and what is the pathophysiology and symptoms
chronic bronchitis and excess mucus production,
productive cough, SOB
reduced O2 to enter and less CO2 to leave, Hypoxia and hypercapnia. this causes Cyanosis and type 2 resp failure (VQ mismatch) as well as vasoconstriction. progressing to COR pulmonar- pulmonary hypertension, RV hypertrophy and right Heart failure.
this leads to oedema, ascites and raised JVP
hypoxemia causes polycythemia and hypercapnia causes Acidosis
what is meant by pink puffers and what is the pathophysiology and symptoms
emphysema, also caused by smoking, inflamation causes destruction of alveolar wall and capillaries.
causes air trapping due to lack of recoil.
causes barrel chest. and pursing of lips of intercostals to allow breathing, heavy use of accessory muscles.
can eventually lead to cor pulmonar too
Matched VQ deficit due to hypoxia and reduced perfusion
TLC increased TLCO/DLCO decreased due reduced SA
hyperinflation
what is the pathophysiology behind emphysema
smoking causes increased work by alveolar macrophages and release of cytokine.
neutrophil recruitment and formation of neutrophil granulomas which secrete elastin
elastin destroys alveoli and inflammation destroys capillaries
what is the pathophysiology behind chronic bronchitis
smoking causes goblet cell hypertrophy= increased mucus
inflammation causes ulcers and fibrosis causing scarring that leads to narrowing
what are the cardinal features of COPD
Chronic cough, productive cough
dyspnoea
other: wheeze tightness
signs of COPD
raised JVP ascites oedema
barrel chest cynosis cor pulmonary tachypnoea weight loss hyperinflation intercostal drawing and pursed lip respiration
Investigations for COPD
Spirometery ABG=O2 low and CO2 high FBC= Polycythemia CT or CXR- barrelcesting and hyperinflation ECG= RV hypertrophy Echo=pulmonary valve incompetency
other than smoking what is a cause for emphysema
Alpha antitrypsin Deficiency- inhered disease lacking anti elastin proteins so causes destruction of alveoli.
suspect if family history of emphysema or young non smoker
what is the spirometery and LFTs of COPD show
FEV1<0.8 FVC/FEV1<70% TLCO reduced TLC increased RV increased
what is used to asses severity of COPD
GOLD classification
Global obstructive lung disease classification
GOLD Classification mild
FEV1>0.8 FVC/FEV1<0.7 no or mild breathlessness
GOLD Classification moderate
FVC/FEV1<0.7 FEV1= 0.5-0.8 SOB on exertion
GOLD Classification severe
FVC/FEV1<0.7 FEV1=0.3-0.5 SOB on minimal exertion like getting dressed
GOLD Classification very severe
FVC/FEV1<0.7 FEV1<0.3 SOB at rest
questionnaire used in COPD management
CAT questionnaire
Conservative management of COPD
stop smoking, exercise, improve diet, stay up to date on vaccinations- influenza and pneumococcal
relief of COPD symptoms
SAMA- ipatropium bromide or SABA - salbutamol
Management of COPD if uncontrolled after SAMA or SABA/ Mild to moderate COPD
add LAMA titropium or thyophiline or add LABA salmeterol. if adding LAMA avoid SAMA. SABA can still be continued
Management of sever COPD/ after LAMA LABA
ICS + LABAorLAMA
management if absolutely nothing else works
LTOT- long term oxygen therapy
what are the requirements for prescribing LTOT
palliative
medication isnt working (PaO2<7.2 after treatment)and they are have quite smoking
they have developed signs of cor Pulmonary( fluid overoad, RV hypertention, pulmonary hypertension )
other treatmnet options in COPD
mucolytics
antidepressants
Diuretics if cor Pulmonary
antibiotics if exacerbation
what is the difference between COPD and Athma
COPD the symptoms are not variable diurnally and are always present + there is less than 15% reversibility in COPD
main inflammatory cell is CD8+ in COPD
athma = CD4+
risk factors for COPD
Smoking, polutants working with harmful chemicals genetics-susceptibility or Alpha antitrypin deficiency infection
treating COPD exacerbation
antibiotics + steriods
if deveoped resp failure then give oxygen via venturi mask
what is bronchiactasis
abnormally dilated bronchi, occurred due to reoccurring infections and inflammation. is irreversible
causes of bronchiactasis
mostly idiopathic. cystic fibrosis congenital abnormality post infection, TB penumonia immune suppressed- HIV chemo autoimmune
what is the pathogens associated with infection in bronchiactasis
H influenza, Stap aures, strep pneumonia
symptoms of bronchiactasis
main: Persistent cough that brings up a large amount of sputum can be clear but also green if infection
SOB
haemoptysis
pleuritic chest pain
fever
halitosis
Hint to remember- there is chronic infection so symptom is trying to clear that by cough and sputum
signs of bronchiactaisis
finger clubbing (uncommon) crackles inspiratory crepitus Wheeze pyrexia
investigations of bronchoiactasis
golf standard
High resolution CT scan shows dilation and bronchial wall thickining
other investigations of bronchiactatsis
CXR- shows broncial dilation sputum sample spirometry- obstructive disease TLCO unaffected broncoscopy
Treatment of Bronchiactasis
conservative
Postural drainage, to remove mucus
stop smoking exercise diet and vaccinations
Treatment of Bronchiactasis
pharmacological
Bronchodilators - SABA for a flare up
ICS- reduce inflammation
Antibiotics - amoxicillin or clarithromycin
Treatment of Bronchiactasis
surgical
Treat localised Haemoptysis or option for transplant
Prevalence of cytic fibrosis
type of inheritance
prevalence
pathophysiology and location of mutation
commonest life treatening autosomal ressecive disease
1 in 2000 births
mutation in chromosome 7 causing dysfucntional CFTR Cystic fibrosis trasmembrane concirdance regulator causing Cl to be retained Na to be retained and causing secretions like mucus to be more viscous
clinical features of CF
SOB productive cough, very thick mucus reoccuring infections CF developes into bronchiactasis or resp failure and cor pulmonary due to obstruction
sterratohorrea
can develop DM
weightloss
meconium Ileus + failure to thrive
no development of vas deferns or empdysimus infertility
investigations and diagnostics in CF
Sweat Test= increased CL and NA in sweat
family history
genetic test
radiology check for bronchiectasis by HRCT
Managment of CF
postural drainage stop smoking+ diet+ vaccines Replacement pancreatic enzyme ADEK vitamins Bronchodilators - ICS+ SABA mucolytics + antibiotics
checking for complications of CF
Glucose-DM FBC, U&E Clotting CXR- Bronchiactasis Spirometery- Obstructive DEXA Scan?
What is a mesothelioma and its causes
Cancer of the mesothelium, cells lining organs like Pericardium, pleura or peritoneum
commonest cause is asbestos exposure
commonest type is pleural mesothelioma
Presentation for pleural mesothelioma
Fatigue unexplained weight loss Pyrexia SOB chest pain, persistent cough clubbing reduced expansion dull percussion
diagnoses of mesthelioma and its treatment
CXR+CT + Biopsy = diagnostic
treat by chemo+radiotherapy
if small enough use surgery
Prognosis of mesothelioma
50% mortality in 1 year
what is the commonest lung tumour and its main attributed cause
Bronchial carcinoma of non small cells, squamous
Smoking
Symptoms of Bronchial carcinoma
Cough chest pain Haemoptyis SOB \+ Weightloss and fatigue
Signs of Bronchial carcinoma
Anaemia, Clubbing
supraclavicular lymph node enlargement
slowly resolving infection or pneumonia
2 types of carcinoma
small cell carcinoma- usually of small cell endocrine cell- worst prognosis
non small cell- squamous cell or adenocarcinoma better prognosis
What is direct spread of Bronchial carcinoma
Presses on Phrenic-hemidiaphram paralysis recurrent laryngeal- horsness of voice or bracial plexus-parasthesia SVC - early morning headache Oesophagus- Dysphagia
common metastatic spread of Bronchial Carcinoma
Bone, Brain
Investigations and diagnosis of bronchial carcinoma
CXR- diagnostic, can show nodules, pleural effusion or lung collapse
CT and CT guided biopsy and PET= Staging of tumour
Treatment of Bronchial carcinoma
If stage 1 or 2 then surgically remove
if 3 or 4 then requires Chemo plus radiotherapy + palliative care
what is the infective agent in TB
Mycobacterium Tuberculosis
what tests can be done to detect Mycobacterium Tuberculosis in a lab
M TB is fast acid bacilli which means it doesn’t respond to gram test. would respond to ziehl neelson test +ve
how is TB transmitted
Transmitted via aersol dropplets
what are the signs of latent TB and how does it become active TB
CXR clear or may show rankes complex calcification
non infective
test +ve for Montoux test or Interferon gamma release assay
becomes activated when the immune system becomes suppressed
what are the signs of primary TB
many asymptomatic but can have symptoms of flu, lethargy malaise pyrexia
CXR is clear or may show small pleural effusion
what are the outcomes and complications of active TB
Locally- bronchial pneumonia, pleural effusion, bronchiactasis spread vascular becomes milliary TB: Renal Injury Potts Spine TB meningitis Hepatitis lymph adenoma
Presentation of active TB
cough starts dry then becomes productive
persisting cough
drenching night sweats
SOB
pleuritic chest pain
haemoptysis
infection: pyrexia, malaise, fatigue, weightloss
Investigations of TB
CXR shows cavitation + Pleural effusion
Sputum sample or bronchoalveolar lavage - Shows Mycobacterum TB - use Nucleic acid amplification test
Skin tests: TB test (mantoux test, tuberculin skin test) test +VE for primary active latent or Bovine (vaccination) TB Interferon Gamma Release Assay- more specific- doesnt pick up BCG
Treatment of Active TB
4 antibiotics for 6 months+ containment (-VE pressure room) until no longer infectious + Direct observation therapy to encourage taking medication
Isoniazid - Also prescribe this in Drug resistant TB 20 months
Rifampican
Pyrazinamide
Ethambutol
Treatment of latent TB
Isonizide + Vit B
Prevention of TB
BCG- Mycobacterium bovis
works 70% of the time and prevents milliary TB
What are the causes of plural effusion
Transudate causes (Increased venous pressure): fluid overload. Heart failure. Cor Pulmonary. pericarditis Hypoprotienemia
Exudate causes (increased leakyness and inflamation): Pneumonia, carcinoma, TB, rheumatoid and SLE
What are the types of fluid present in pleural effusion
Transudates= low serum protein<30 g/l
Exudates = high serum protein > 30g/l
Emphyma- pus containing fluid- often due to pneumonia
symptoms of Pleural effusion
Asymptomatic, SOB, Pleuritic chest pain
Signs of pleural effusion
Friction pleural rub
dull percussion sounds
reduced chest inflation
tracheal deviation if effusion is severe
Investigation and diagnosis of Pleural effusion
Diagnostic- pleural effusion aspirate - analysis cause and type of fluid
other:
CXR - shows effusion
broncoscopy guided biopsy
managment of pleural effusion
only drain if emphyma, malignant effusion or if there is excess and severity
treat underlying condition
What is pneumothorax
air in the pleural space
causes of pneumothorax
mostly idiopathic, can be iatrogenic
if over 40, possibly not idiopathic- COPD Asthma TB pneumonia (anything that can cause pleural effusion)
risk factors for pneumothorax
male
tall
skinny
smoker
symptoms of pneumothorax
sudden onset of unilateral Pleuritic chest pain, SOB
signs of pneumothorax
tachypnoea tachycardia
no movement in chest wall on affected side
hyper resonance
pallor
tracheal deviation- sign of tension pneumothorax
what causes spontaneous pneumothorax
Bursting of pleural bullae- small collection of air between lung and visceral pleura- usually on upper lobes
Diagnosis and investigation of pneumothorax
CXR is diagnostic
management of peunmothorax
if small do nothing avoid exercise
if medium large or tension- insert chest drain + aspirate air
if reoccurring pneumothorax consider pleurictomy
Risk factors for pneumonia
immune deficiency , HIV, chemo, elderly and children
usually occurs post viral infection that lowers immune system
Altered lung physiology- Interstitial lung disease CF Asthma COPD
dysphagia
causing pathogen of Community acquired pneumonia
Strep. pneumoni - main agent
staph aures, including MRSA
H. Influenza
symptoms of pneumonia
Cough, productive SOB pleuritic chest pain haemoptysis symptoms of infection: malaise fatigue, rigor sweating
signs of pneumonia
confusion- may be only sign in elderly tachypnoea tachycardia pyrexia dull percussion reduced chest expansion pleural rub low BP
Investigation and diagnosis of pneumonia
CXR- shows effusion, air bronchiogram or normal sputum sample- Strep pneumonia blood sample exclude sepsis Other LFT U&E GFR- asses severity FBC= Increased WCC CRP ESR
management of pneumonia
start oral antibiotic or if severe , cannot wait for results start immediate IV antibiotics
IV Co-amoxiclav ( amoxicillan + Clavalic acid)
then continue on oral co- amoxiclav and clarythromycin
if hypoxia- O2
Hypotensive/shock - IV saline
pleuritic pain- analgesia + anti emetic
Complications of pneumonia
Pleural effusion- emphyma Sepsis lung absess Resp failure- Type 1 pericarditis
Assessing severity of of pneumonia
CURB65 confusion Urea>7mmole/L Resp rate>30 BP<90/60 Over 65 YO 0-1 mild outpatient 2 moderate - possible hospital 3-5 severe admit to hospital and consider ITU
prevention of pneumonia and who gets it
Pneumococcal vaccine
over 65, any lung disease that can be exacerbated
CF COPD Bronchiactasis asthma
renal or heart failure
Sepsis pathophysiology
increased pro inflammatory cytokines= vasodilation
Hypotension and impaired cardiac contractility
reduced perfusion to organs
tissue hypoxemia causes increased resp rate due to increased demand for O2 and renal impairment which increases urea>7mmol/L
Causative agent in Hosputal aquired pneumonia
Enterobacteria - E.Coli
S aures MRSA
Causative agents of pneumonia in immunocompromised
Step pneumonia
Staph aures
H.Influenza same as CAP
Causative agents in atypical pneumonia and presentation
legionella pneumophilia- found in colonised water tanks presnets with infection symptoms plus dry cough and SOB
