Resp Flashcards
vital capacity
the max change possible
IRV + TV + ERV
functional residual capacity
the volume in the lungs after a normal expiration
RV + ERV
FVC
total volume expired from max inspiration to max expiration
FEV1
max volume that can be expired in 1 sec
normal FEV1/FVC
> 70%
obstructive picture on spirometry
FEV1 reduced
FVC normal
FEV1/FVC ratio reduced
restrictive picture on spirometry
FEV1 reduced
FVC reduced
FEV1/FVC ratio normal or increased
presentation of SEVERE asthma attack
inability to complete sentences in 1 breath
PEF 33-50% of normal
HR > 110
RR > 25/min
presentation of LIFE THREATENING asthma attack
silent chest altered conscious level exhaustion/poor resp effort cyanosis PEF < 33% of predicated normal PaCO2
presentation of NEAR FATAL asthma attack
raised PaCO2
Ix of asthma
spirometry and bronchodilator reversibility
why should NSAIDs be avoided in asthmatics
NSAIDs inhibit the COX pathway, which is involved in the production of prostaglandins
this induces overproduction by eosinophils, mast cells and macrophages - bronchospasm
Mx chronic asthma
- SABA
- SABA + ICS
- SABA + ICS + LTRA
- SABA + ICS + LABA +/- LTRA (stop if not working)
- SABA + MART(combo ICS + LABA)
- SABA + increase dose of MART
- SABA + increase dose of MART + refer
LTRA
montelukast
mnemonic for asthma attack Mx
OSHIT ME -
Oxygen
Salbutamol 5mg Neb
Hydrocortisone 100mg IV (or pred 40mg PO)
Ipratropium 500 mcg Neb
Theophylline (aminophylline infusion 1g in 1L saline (0.5ml/kg/h)
Magnesium sulphate 2g IV over 20min
Escalate care (intubate and ventilate)
how many nebs can be given /hr in asthma attack
can be given back to back - max 5-10mg/hr
how often can IV steroids be given in acute asthma attack
6hrly
where is theophylline usually given in asthma attack and why
ICU - needs to be monitored as it causes arrhythmias, seizures, GI upset
when is Mg sulphate given in asthma attack
before theophylline as a once off dose (theophylline can cause seizures)
chronic bronchitis
a cough productive of green sputum on most days for 3m of at least 2 successive years
emphysema
enlarged air spaces distal to terminal bronchioles with destruction of the alveolar wall. Causes loss of elastic recoil of the lungs and collapse on expiration.
Ix COPD
spirometry + bronchodilator reversibility
CXR to rule out lung ca
bloods (exclude secondary polycythaemia)
Mx COPD
- SABA or SAMA prn
- LABA + LAMA
- LABA + LAMA + ICS
should Abx always be given for exacerbation of COPD
no- only if increased sputum purulence
Abx for infective exacerbation COPD
- Amoxicillin 500mg tds for 5d
2. Doxycycline 200g on day 1 then 100mg OD for 5d
target sats for COPD
88-92%
CURB 65 score
Confusion Urea >7 Resp Rate >30 BP <90s, <60d age >65
1 point for each
0-1: home Tx poss
2: hop Tx
3 or more: consider ITU
pneumonia signs on examination
signs of consolidation
- reduced chest expansion
- dull percussion note
- increased tactile vocal fremitus
- bronchial breathing
- late inspiratory crackles
what pneumonia do u get after influenza infection
staphylococcal
Mx staphylococcal pneumonia
cefotaxime or imipenem
who gets klebsiella pneumonia
alcoholics
diabetics
Mx klebsiella pneumonia
meropenem
who gets pseudomonas pneumonia
CF patients
Mx pseudomonas pneumonia
Ciprofloxacin
pneumonia associated with erythema nodosum
mycoplasma
presentation mycoplasma pneumonia
insidious onset
dry cough
flu-like symptoms
Ix mycoplasma pneumonia
serology
- cold agglutinins, can cause haemolytic anaemia
Mx mycoplasma pneumonia
macrolide - clarithromycin, azithromycin
Mx chlamydia psittaci pneumonia
doxycycline
who gets pneumocystis jirovecii pneumonia
HIV/AIDs patients
Ix pneumocystis jirovecii pneumonia
bronchoalveolar with lavage
Mx pneumocystis jirovecii pneumonia
high dose co-trimoxazole
most common cause of CAP
strep pneumoniae
Empirical Mx mild/mod CAP (0-2)
Amoxicillin 1g tds for 5d
Empirical Mx severe CAP (3-5)
co-amoxiclav IV + doxycycline PO for 7d
Empirical Mx severe CAP if in ICU/HDU or NBM
co-amoxiclav IV + clarithromycin IV
most common cause of HAP
strep pneumoniae
Mx non-severe HAP
Amoxicillin
Mx severe HAP
IV Amox + Gent
if allergic: IV co-trim + gent
Most common cause of aspiration pneumonia
strep pneumoniae, anaerobes
Mx non severe aspiration pneumonia
PO amoxicillin + metronidazole
Mx severe aspiration pneumonia
amox + met + gent
Ix lung ca
- CXR
- CT chest/abdo
- Pathological confirmation - either bronchoscopy or transthoracic needle biopsy
- staging: MRI (brain mets), PET-CT
small cell lung ca paraneoplastic syndromes
ADH production - SIADH, hyponatraemic
ACTH production - cushings syndrome
Lambert Eaton syndrome - antibodies to voltage gated ca channels
squamous cell lung ca paraneoplastic syndromes
PTH-rp production - hypercalcaemia
Finger clubbing
Hypertrophic pulmonary osteoarthropathy
where do lung adenocarcinomas tend to be located
peripherally
where do large cell lung cancers tend to be located
centrally
adenocarcinoma paraneoplastic syndromes
gynaecomastia
hypertrophic pulmonary osteoarthropathy
causes of pneumothorax
spontaneous - primary or secondary
secondary to trauma
either can be complicated by tension
pathology of pneumothorax
communication develops between alveoli and pleural space, or the atmosphere and the pleural space.
gas then follows the pressure gradient into the pleural space.
tracheal deviation in tension penumothorax
AWAY from affected side
presentation spontaneous pneumothorax
sudden onset SOB ipsilateral chest pain ipsilateral hyperinflation reduced chest expansion diminished breath sounds hyper-resonance on percussion
Mx primary spontaneous pneumothorax
< 2cm + asymptomatic = discharge.
> 2cm + symptomatic = admit for aspiration.
If this fails = chest drain.
Mx secondary spontaneous pneumothorax
0-1cm + asymptomatic = oxygen & admit for 24h
1-2cm + asymptomatic = aspiration.
If this fails = chest drain.
> 2cm or symptomatic = chest drain.
chest drain insertion site
5th IC space mid axillary line in the ‘safe triangle’
borders of ‘the safe triangle’ for chest drain insertion
base of axilla
lateral edge of pectoralis major
lateral edge of lat dorsi
5th IC space
Mx tension pneumothorax
- large bore needle with syringe partially filled with saline into 2nd IC space, mid-clavicular line
- then CXR
- then chest drain
presentation PE
SOB pleuritic chest pain dizziness syncope haemoptysis
clinical assessment of PE - scoring systems
wells score
Geneva score
1st Ix if PE unlikely
D-dimers
if normal = exclude PE
if raised = CTPA
1st Ix if PE likely
CTPA
Ix if CTPA contraindicated
V/Q scan
ECG appearance in PE
sinus tachy (most common)
S1Q3T3 pattern (uncommon)
CXR appearance in PE
wedge-shaped opacities
Mx PE if haemodynamically unstable
thrombolysis (alteplase) - NOT if there is a bleeding risk tho!
Initial Mx PE
LMWH or Fondaparinux
then once Dx has been confirmed, put on Warfarin (or NOAC).
The heparin can be stopped when anticoagulation with the warfarin has been established (usually 6-10d) or INR >2.0
how long should warfarin (or NOAC) be continued in a provoked PE
3m
how long should warfarin (or NOAC) be continued in an unprovoked PE
6m
long term anticoagulation in malignant PE
LMWH for 6m
transudative pleural effusion protein content
<30g/L
causes of a transudative pleural effusion
SYSTEMIC FACTORS:
- increased venous pressure (HF, constrictive pericarditis, fluid overload)
- hypoalbuminaemia (cirrhosis, nephrotic synd)
- hypothyroidism
- meigs syndrome
exudative pleural effusion protein content
> 30gL
causes of an exudative pleural effusion
LOCAL FACTORS:
i. e. inflammation of the lung or pleura, causing capillary leakage into the pleural space
- pneumonia
- TB
- SLE
- malignant mets
when is light’s criteria applied to a pleural effusion
when protein content is between 25-35 g/L
light’s criteria
exudative is likely if:
- pleural fluid protein / serum protein > 0.5
- pleural fluid LDH / serum LDH > 0.6
- pleural fluid LDH >2/3 serum LDH upper limit of normal
presentation of pleural effusion
SOB non-productive cough pleuritic chest pain stony dull to percuss reduced breath sounds reduced chest expansion
stony dull to percuss
pleural effusion
Ix pleural effusion
- CXR - blunting of costophrenic angles
- pleural USS
- pleural aspiration
where is needle inserted for draining pleural effusion
on the upper border of the rub (so to miss nerves)
reason for doing pleural USS before aspiration
to increase likelihood of success (know the exact location)
pathology of primary TB
infection inhaled by droplets.
most people clear the infection, or it sits dormant as latent TB.
in some, they develop a primary infection of the lung.
ghon focus
tubercle-laden macrophages in primary TB,
the lung lesion is walled off by macrophages and the cells inside die (caseating necrosis)
ghon complex
ghon focus + hilar lymph nodes
where does secondary TB occur in the lung
apex
TB in the vertebral bodies
pott’s disease
presentation TB
cough haemoptysis night sweats wt loss malaise pleural effusion clubbing erythema nodosum
latent TB
pt has no symptoms
Ix for latent TB
screening tests
- tuberculin skin test
- interferon-gamma test
if either are +ve, do CXR
Ix for active TB
CXR
sputum sample for NAAT and ziehl-neelson staining
Ix for active TB if pt unable to provide sputum samples
bronchoalveolar with lavage
ziel-neelson staining in TB
acid fast bacilli
Mx TB
“4 for 2 and 2 for 4”
- 4 drugs for 8w, then 2 drugs for 16w
- Rifampicin
- Isoniazid
- Pyrazinamde
- Ethambutol
(Rifampicin and Isoniazid for 16w)
Mx latent TB
3m - Isoniazid (with pyroxidine) and Rifampicin
or
6m - Isoniazid (with pyroxidine)
s/e of Rifampicin
orange discolouration of urine and tears
raised LFTs
reduced platelets
inactivation of the pill
s/e of Isoniazid
raised LFTs
reduced WCC
neuropathy (stop and give pyroxidine)
s/e of Pyrazinamide
hepatitis
arthralgia - gout
s/e of Ethambutol
optic neuritis
what are ILD characterised by
fibrosis of the lung, causing a restrictive pattern on spirometry
presentation of the interstitial lung diseases
dry cough
SOB on exertion
finger clubbing
bi-basal inspiratory crackles
farmer’s lung
hypersensitivity pneumonitis
caused by an allergic reaction to spores in mouldy hay
bird fancier’s lung
hypersensitivity pneumonitis
caused by reaction to avian proteins in dry droppings
occupations causing asbestosis
asbestos
ship building
power stations
what type of asbestos is the most and least dangerous
most - blue
least - white
industry causing berylliosis
aerospace industry
industries causing silicosis
stonemasons
pottery workers
egg shell calcification of hilar nodes
silcicosis
miners lung a.ka. ?
coal workers pneumoconiosis
presentation of CWP on CXR
small round opacities in the upper zones
what can CWP lead to
Progressive Massive Fibrosis
- large round opacities
- emphysema
- black sputum
leading to pulmonary HTN and cor pulmonale
systemic causes of ILD
RA sarcoidosis SLE systemic sclerosis ank spond psoriasis
drug causes of ILD
nitrofurantoin
amiodarone
sulfasalazine
idiopathic pulmonary fibrosis - area of lung usually affected
lower zones
CXR appearance IPF
ground glass / honeycomb appearance
Caplan’s syndrome
RA
Pneumoconiosis
Pulmonary rheumatoid nodules
Mx ILD
remove causative factor
steroids +/- immunosuppression
presentation of sarcoidosis
very non-specific
acute: erythema nodosum, bilateral hilar lymphadenopathy, swinging fever, polyarthralgia
insidious: SOB, non-productive cough, malaise, wt loss
skin: lupus pernio
hypercalcaemia
Mx sarcoidosis
Asymptomatic + stable stage 2 or 3: no Tx
Stage 2 0r 3 with symptoms: oral steroids
CXR stages of sarcoidosis
0 = normal 1 = BHL 2 = BHL + interstitial infiltrates 3 = diffuse interstitial infiltrates 4 = fibrosis
causes of bronchiectasis
GENETIC:
CF
alpha-1-antitrypsin deficiency
POST-INFECTION:
childhood viral infections (haemophilus most common)
CTD:
RA, sjogren’s
presentation bronchiectasis
persistent cough copious sputum finger clubbing course crackles wheeze
Ix bronchiectasis
CT - signet ring bronchi
Mx bronchiectasis
inspiratory muscle training postural drainage Abx for exacerbations bronchodilators surgery - focal disease
inheritance of CF
autosomal recessive
Ix CF
sweat test - positive if > 60mmol/L
(normal <30)
if in between - do genetic testing
most common bacteria to colonise CF pts
pseudomonas
Mx CF
2x daily postural drainage and chest physio
high calorie diet, high fat intake
minimise contact with other CF pts
vit supplements, pancreatic enzymes
