Resp Flashcards
pres of asthma
wheezing, sob, chest tightness, cough (nocturnal)
diurnal variation
wheeze (polyphonic, expiratory)
FHx atopy/nasaly polyposis
triggers of asthma?
allergic?
non-allergic?
house dust mite, pet fur, grass pollen -> IgE
exercise, cold air, stress, emotion, viral infection, smoking
drugs CI in asthma?
Beta blockers -> B2 = airway obstruction
NSAIDs/aspiring -> block COX-1 -> decrease PGs + overprod of inflam leukotrienes
what happens in acute airway inflammation?
constriction
oedema
mucus hypersecretion
features of chronic airway inflammation?
airway remodelling
airway hyperresponsiveness
pathology of early phase asthma?
allergen -> mast cells release IgE
histamines, leukotrienes and TNFa -> increased vascular permeability and hypersecretion of mucus
AIRWAY OEDEMA
key cell in later phase asthma? what happens?
eosinophil mediated
increase goblet cells -> hyperresponsive
effect of acute vs chronic inflam?
acute inflam -> bronchoconstriction
chronic -> airway hyperresponsiveness
Qs to assess asthma control?
in the last 4 weeks how often have you:
i) been SoB?
ii) woken from sleep?
iii) used reliever?
iv) been stopped from doing normal activities?
v) how would you rate asthma control?
what should you always check in asthma?
inhaler technique
ix in asthma?
PEFR Reversibility testing [FEV1 improves by 15% on SABA] spirometry CXR FBC
mx of asthma?
- saba
- ics
- ltra
- ltra + laba
ix in acute exacerbation of asthma
PEF
SpO2
ABG
mx of acute asthma exacerbation?
if exhausted?
OSHIT O2 (94-98) Salbutamol (neb) Hydrocortisone/pred Ipratropium (neb) Theophyline (IV) MgSO4 (IV)
if exhausted -> intubate
features of life threatening asthma attack?
33,92,CHEST 33>PEFR 92>O2 sats Cyanosis Hypotension Exhaustion Silent chest Tachypniea
what is COPD
chronic obstruction, irreversible -> air trapping and hyperinflation
pathology of COPD
chronic inflam -> increased goblet cells, narrow airways + vascular changes -> pulm HTN
o/e of COPD
barrel chest
CO2 flap
hyperresonant
In actue exacerbation -> coarse crackles + wheeze
comps of COPD
cor pulmonale pneumonia depression polycythaemia resp failure
signs of cor pulmonale
raised JVP
distended neck veins
hepatomegaly
mx of cor pulmonale
LT O2
Loop diuretic
T1 vs T2 resp failure
T1 = V/Q mismatch [pink puffer]
T2 = alveolar hypoventilation [blue bloater]
spiro finding in COPD
obstructive: FEV1/FVC<0.7
non reversible
ix in COPD
Spirometry ABG CXR FBC sputum culture
CXR signs of COPD
flat diaphragm
increased intercostal spaces
hyperlucent lungs
increased AP diameter
severity of COPD - FEV1
mild > 80%
mod 50-80%
severe 30-50%
v severe <30%
non pharma mx of COPD
education
vaccinations
smoking cessation
obesity mx
pharma mx of COPD
SABA/SAMA
if FEV1>50% [LABA, LABA+ICS]
if FEV1<50% [LABA+ICS]
then: LABA+LAMA+ICS
common causes of COPD exacerbation
H. influenza
S. pneumoniae
M. catarrhalis
mx of acute exacerbation of COPD
SHONA Steroids Heparin O2 (88-92%) Neb bronchodilators Abx
Abx in COPD exacerbation?
CAP vs HAP?
CAP = amoxicillin / doxycycline
HAP = vancomycin / tazocin
when is pneumonia classified as HAP?
if LRTI >2d post admission
pneumonia risk score? + where to treat?
CURB 65
0-1 = low risk, o/p 2 = mod risk -> admit 3-5 = high risk -> ITU
cause of CAP in younger adults?
pres?
Mycoplasma pneumoniae
dry cough + atypical CXR + AI haemolytic anaemia + erythema multiforme
possible cause of HAP in immunocomp patient?
fungus; pneumocystis jirovecii = PCP
how does PCP pres?
CD4 < 200
cough
sats drop on exertion
mx of PCP?
co-trimoxazole
pres of CAP?
cough with sputum + expectoration
fever (high in pneumococcal)
dyspnoea
pleuritic pain
o/e of pneumonia
crackles
reduced air entry (u/l)
pleural rub
vocal fremitus
ix for pneumonia
FBC, CRP ABG sputum - MC+S CXR blood cultures \+/- urinary antigen -> for legionella and pneumococcus
CXR of pneumonia?
air bronchograms
consolidation
atelectasis
CURB 65 score = which abx?
0-1 -> amoxicillin/clarithromycin 5d PO
2 -> amoxicililn + clarithromycin 7-10d PO
3 -> co-amoxiclav + clarithromycin (IV) 7-10d
if high risk pneumonia and penicillin allergic; what abx?
cefotaxime
mx of HAP?
IV cefotaxime + gentamicin
mx of legionella
clarithromycin + fluoroquinolone
mx of chalmydia pneumonia
doxycycline
comps of pneumonia
septic shock
ARDS
pleural effusion + empyema
RFs for TB
birth endemic immunocomp poor nutrition over crowding IVDU
screen for TB
tuberculin skin test
what type of infection is active TB
granulomatous
ix in TB
CXR
3x sputum acid fast bascilli smear
sputum culture
FBC
NAAT
?HIV
stain for TB
Ziehl-Neelsen turns pink
seen on CXR of TB:
primary?
healed primary?
post primary?
- consolidation + ipsilat hilar lymphadenopathy
- Ghon focus = large round calcified lesion near hilum
- upper zone opacities with cavitation + calcification + consolidation of hilum
Mx of TB
what to check before?
RIPE DOTS Rifampicin (6m) Isoniazid (6m) Pyrazinamide (2m) Ethambutol (2m)
directly observed therapy 3x/week
TB drugs + SEs?
Rifampicin -> liver toxicity, orange wee
Isoniazid -> liver tox, peripheral neuropathy
Pryazinamid -> liver tox, hepatitis
Ethambutol -> visual disturbance, optic neuritis
pres of extra-pulmonary TB
pleural effusions LN - scrofula GU - frequency, dysuria, haematuria Bone - osteomyelitis; Pott's disease Brain - meningitis Abdo - ascites
CT of disseminated TB
millet seed appearance
liver/spleen/lung
RFs for DVT
cancer, trauma, major surgery, hospitalisation, immobilisation, COCP, obesity
genetics -> factor V leiden, antiphospholipid
Virchow’s triad in DVT
venous stasis
vessel injury
activation of clotting system
DVT score
Wells >2
Ix in wells 0-1?
D-dimer
ix in wells >=2
PVUSS
comps of PE
RHF -> cardiac arrest
types of emboli in PE
thrombus amniotic fluid embolus fat embolus air embolus tumour
o/e PE
pleural rub tachyc, tachyp elevated JVP hypoxia shock
ddx of PE
ACS
aortic dissection
pneumothorax
ix in PE
Wells CXR ECG CXR ABG D-dimer
CTPA (if Wells>4 or D-dimer +ve)
mx of PE?
stable?
unstable?
100% O2, IV fluids, morphine
Stable -> LMWH
Unstable -> heparin +/- thrombolysis
long term mx of PE
warfarin for 3m
mx symptomatic DVT
dalteparin
Prevention of VTE
early mobilisation
stockings
avoid COCP
spiro of pulm fibrosis
restrictive
FVC reduced
FEV1/FVC normal
pres of Pulm fibrosis
4Ds Dry cough Dyspnoea Diffuse inspiratory crackles Digital clubbing
causes of pulm fibrosis
connective tissue disease
occupational
iatrogenic [amiodarone, bleomycin, MTX]
irritants [hypersensitiviy, pneumonitis]
radiation
RFs for idiopathic pulm fibrosis
smoking
dust exposure
chronic aspiration
Q in IPF?
occupation
main comp of IPF
pulm HTN -> cor pulmonale
ix in IPF
CXR CT spiro -> restrictive ANA (?SLE) Biospy
XR findings in IPF
reticular shadowing
shaggy heart border
high res CT of IPF?
ground glass
honeycomb
reticular
general mx of IPF
O2 physio exercise / wt loss vaccine smoking cessation
pharma mx of IPF
anti-fibrotic
pirfenidone
(inhibits collagen synthesis)
DDx for upper lung fibrosis
Upper - ESCHART (granulomatous) Extrinsic allergic alveolitis Sarcoid/silicosis Coal worker's pneumoconiosis Histiocytosis X Ank spond Radiotherapy TB
DDx for lower lung fibrosis
Lower - RASCO (systemic) RA Asbestosis Systemic sclerosis/SLE Cryptogenic fibrosing alveolitis Other (drugs)
upper vs lower lung fibrosis?
upper = granulomatous
lower = systemic
Caplans syndrome?
pulm fibrosis in coal workers with RA
EAA - RFs
hx of exposure to organic dust / birds / agricultural / mould
Pathophys of EAA
Non-IgE mediated inflam of alveoli and distal bronchioles
ix in EAA
WCC, CRP
CXR -> diffuse interstitial shadowing (upper zone)
CT -> reticulo-nodular shadowing, ground glass
Spiro -> restrictive
Bronchoalveolar lavage = CD8
Mx of EAA?
allergen avoidance
O2 + pred
Pneumoconioses?
Cause?
Latent period?
curable?
chronic lung disease from exposure to mineral dust or metal
coal, silicosis, asbestosis
coal - 10y
asbestos - 15-60y
incurable
NOTIFIABLE ? compensation
Coal worker with RA = ?
caplans syndrome
conditions causing black sputum?
coal workers pneumoconiosis
silicosis
ix in asbestosis
CXR -> ground glass
asbestosis can cause what cancer?
pleural mesothelioma
sx of pleural mesothelioma
dry cough, dyspnoea, clubbing, pleuritic chest pain
+/- pleural effusion
+/- wt loss, fatigue, fever, night sweats
ix in pleural mesothelioma
CXR -> irreg thickening
CT
thoracentesis -> exudate
pleural biopsy
mx of pleural mesothelioma
operable at stage 1 + chemo
if > 1 -> chemoradio
+ COMPENSATION
pleural effusion?
fluid in potential space between visceral and parietal pleura
types of effusion?
causes?
how to tell the difference?
Transudate (protein<30g/L) -> HF, cirrhosis, hypoalbuminaemia, nephrotic
Exudate (protein>30g/L) -> pneumonia, malignancy, TB, AI disease
o/e pleural effusion
u/l reduced chest expansion
stony dull to percussion
decreased breath sounds
CXR in small pleural effusion
blunted costophrenic angle
bilateral effusion, transudate or exudate?
likely to be transudate
mx pleural effusion?
transudate?
exudate?
trans - do not tap!!
ex - symptomatic -> pleural tap
mx of malignant cause of effusion
pleurodesis to prevent recurrence
causes of bilat hilar lymphadenopathy
TIMES TB Inorganic dust [silicosis] Malignancy [lymphoma, carcinoma, mediastinal] EAA Sarcoidosis
pneumothorax?
air in the pleural space
RFs for pneumothorax
primary spontaneous -> tall thin males, smoking, marfans, FH
secondary spontaneous -> lung disease; COPD, CF, TB, PCP
Trauma
tension pneumothorax?
intrapleural pressure > atmospheric pressure
valve mechanism lets air in but not out
-> lung deflates and mediastinum shits contralaterally compressing great veins and reducing venous return to heart
pres of pneumothorax
pain on breathing in
o/e of pneumothorax
hyperresonant
reduced expansion
decreased breath sounds
pres + o/e tension pneumothorax
resp distress
distended neck veins
tracheal deviation away
hyperexpanded hemithorax
CXR of pneumothorax
visceral pleural line
no lung markings
mx pneumothorax?
if initially unsuccessful?
high flow O2
aspirate 16-18G cannula in 2nd IC space, mid-clav line
if this doesnt work -> chest drain + admit
where to put chest drain?
mid-axillary line
IC 4-6
DDx of pleuritic chest pain?
ACS aortic dissection pneumothorax PE pneumonia malignancy
bronchiectasis?
permanent dilatation and thickening of airways due to recurrent infection and inflammation
causes of bronchiectasis?
post-infection
immunocomp
genetic [CF, ciliary dyskinesia, A1AD]
Connective tissue diseas
IBD
Bugs often seen in bronchiectasis
aspergillus fumigatus
S.aureus, H. influenza, S.pneumonia, Pseudomonas aeruginosa
pres on infective bronchiectasis
cough + sputum (+/- blood)
dyspnoea + wheeze
wt loss + fatigue
o/e bronchiectasis
inspiratory coarse crackles (shift on cough)
inspiratory squeaks
ix in bronchiectasis
CXR - dilate bronchi with thick walls
TRAM-TRACK SIGN
CT is gold standard
sputum -MC+S
Bronchiectasis bugs:
gram +ve?
gram -ve?
+ve = S.aureus, S.pneumonia
-ve = pseudomonas aeruginosa (high risk in CF)
mx bronchiectasis
exercise, nutrition, airway clearance (postural drainage)
+ mucolytics
+inhaled bronchodilator
+inhaled hypertonic saline
mx recurrent pseudomosas
neb gentamicin
mx severe exacerbation of bronchiectasis?
IV ciprofloxacin
Gene in CF?
CFTR
Cl- channel
organs affected by CF
lungs bowel pancreas sweat reproductive organs
–> thick sticky secretions
screening for CF?
immunoreactive trypsinogen on heel prick (Guthrie test)
pres of CF
neonates -> failure to pass meconium, FTT, cough
resp -> recurrent infections, cough, wheeze, mucus
GI -> gallstones, decreased motility
Panc _> DM, steatorrhoea
Reprod -> male infertility
+/- clubbing
ix for CF
serum immunoreactive trypsiogen
sweat test
genetic test
faecal elastase (pancreatic assessment)
mx for CF
chest physio
inhaled bronchodilator
inhaled mucolytic (dornoase alfa + hypertonic saline)
vaccinations
prophylactic abx [fluclox]
pancreatic enzymes (DEAK)
pressure for pulm HTN
> 25mmHg at rest
mx pulm HTN
CCB / sildenafil
anticoag
furosemide
+/- O2
types of lung Ca?
NSCLC (85%) - adenocarcinoma, squamous cell carcinoma large cell carcinoma
SCLC (25%)
2ww for lung ca?
>40 + 2 of: cough fatigue sob chest pain wt loss anorexia smoker
paraneoplastic features of SCLC
LEMS [anti-VGCaC]
SIADH
ACTH [HTN, hyperglycaemia, hypoK, alkalosis]
paraneoplastic features of squamous cell Ca
PTH-rP -> hypercalcaemia + bone pain
TSH -> hyperthyroidism
paraneoplastic feature of adenocarcinoma
gynaecomastia
where are lung adenocarcinomas
peripheral lung
where are lung squamous cell carcinomas?
usual pres?
central airway
-> obstruction
pancoast tumour invades? (3)
brachial plexus -> weakness, paraesthesia, pain
sympathetic chain -> horners
recurrent laryngeal nerve -> hoarse
where is pancoast tumour found?
superior sulcus
signs of lung Ca
monophonic wheeze
pleural effusion
SVCO
clubbing
ix for lung ca
CXR CT/MRI brain spirometry FBC LFT bone scan biopsy
common mets of lung Ca
liver, bones, brain, adrenals
mx SCLC
not surgery!
chemo + radio
+ prophylactic cranial irradiation
palliative care sx+mx in lung Ca
SoB -> opiate Obstruction -> radio Pleural effusion -> aspiration Cough -> opiate Hoarse ->ENT SVCO -> chemo+radio Bone pain -> radio SCC -> dexamethasone
Good pastures?
anti-GBM
collagen type IV
pres of goodpastures
kidney -> oedema, reduced UO, haematuria
lung -> haemoptysis, cough, SoB
ix in goodpastures
urinalysis
U+Es
Renal biopsy -> crescentic glomerulonephritis
CXR
Anti-GBM
ANA (normal, r/o lupus nephrtitis)
Anti-steptolysin O -> r/o post strep glomerulonephritis
mx goodpastures
oral corticosteroid
+plasmapheresis
+cyclophosphamide
O2+ blood products for severe pulmonary haemorrhage
ABG in resp failure?
Type 1?
Type 2?
T1; O2<8kPa
T2; O2<8kPA + CO2>6kPa
mx resp failure
admit + resus
aim for sats>90%
what is ARDS?
non-cardiogenic pulm oedema and diffuse lung inflammation
causes of ARDS?
sepsis
pancreatitis
ix ARDS
low tidal volume ventilation CXR ABG blood cultures sputum culture urine culture
mx ARDS
supportive care - resus
Abx + treat cause
