Resp Flashcards
Obstructive lung disease:
Bronchiectasis
COPD
Asthma
Permanent dilation of bronchi due to destruction of bronchial wall, due to recurrent infection/underlying disease
Causes: CF
Kertagner’s syndrome (autosomal recessive ciliary disorder)
Post-infection (H. influenzae, childhood e.g. measles),
Allergic bronchopulmonary aspergillosis (hypersensitivity I+III to aspergillus fumigatus)
Sx: chronic cough, sputum production, (foul smelling), intermittent haemoptysis
Sx: finger clubbing, crackles, rhonchi (low-pitched wheeze - caused by obstruction in large airways), fever
Complications: secondary amyloidosis, pneumonia
Ix: CXR (ring shadows)
CT (gold standard) - thickened, dilated airways, bronchial cysts, signet ring sign (bronchioles larger than pulmonary artery)
FBC (neutrophilia - infection, esosinophilia - aspergillos)
Sputum culture
Alpha - 1 trypsin
Sweat chloride test (CF)
Tx: airway clearence therapy, salbutamol, long-term macrolides
Asthma
Chronic respiratory condition characterised by intermittent airway obstruction + hyper-reactivity.
Pathophysiology: Inflammation (T-helper cells, eosinophils, mast cells) causing bronchial hyper-responsiveness in large and small airways
Triggers: cold air, aspirin, Bblockers (bronchospasm), infections (mycoplasma, rhinovirus), hx atopic disease e.g. eczema (type I HS)
Sx: cough, wheeze, dyspnoea, chest tightness
Signs: wheeze, hyper-resonant percussion, hyperinflation chest
Ix: PEF (diurnal variation >20%) FEV/FVC: <70% (obstructive) Decreased FEV1, Increased RV Reversibility with bronchodilator (400ml/>18% FEV1) CXR: hyperinflation FBC (eosinophils) Histamine/methacholine challenge IgE level
Tx:
1. SABA (salbutamol)
2. + ICS
3. ICS + LABA or MART (maintenance and reliever therapy)
4. Medium dose-ICS + LTRA (Montelukast) or theophylline
5. Oral prednisolone
Omalizumab (Anti-IgE) (if known allergy)
COPD
Progressive airflow obstruction that is not fully reversible. Chronic bronchitis + emphysema
Chronic bronchitis: increased sputum production most days >3 months in 2 years
Increased thickness of mucus glands
“Blue bloaters” - Low O2, high CO2. Cyanosis, cor pulmonale. Not breathless. Rely on low O2 to maintain resp effort (as chronic high CO2)
Emphysema: abnormal enlargement of alveolar airpsaces distal to terminal bronchioles
Loss of elastic recoil and collapse of small airways causing air trapping
Centri-acinar (Destruction proximal to the respiratory bronchiole). Smoking. Upper lobes.
Pan-acinar (destruction of entire acinus, distal to respiratory bronchiole). Alpha-1 trypsin deficiency. Lower lobes.
“Pink Puffers”: Normal O2, normal CO2. Dyspnoea, prolong expiration+pursed lips (so can maintain O2, not cyanotic), weight loss, barrel chest (increased AP diameter of chest)
Sx: Sputum, cough, dyspnoea, wheeze
Signs: hyper-resonance percussion (air trapping), quiet breathe sounds, coarse crackles, use of accessory muscles inspiration
Complications: cor pulmonale, acute exacerbations, respiratory failure
Ix:
FEV/FVC <70%, increased RV, TLC, decreased DLCO (decreased in emphysema)
ABG
FBC (polycythemia)
CXR (hyperinflation, flattened hemi-diaphragm, bullae)
CT: air space enlargement, bronchial wall thickening
Tx:
Chronic
SABA (salbutmol) or SAMA (ipatropium brmoide)
If no asthmatic features, steroid responsive (esoinophilia, FEV1 variation)
- LABA + LAMA
- LABA + LAMA + ICS
Asthmatic features, steroid responsive (esoinophilia, FEV1 variation)
- LABA + ICS
- LABA + LAMA + ICS
Smoking cessation, pneumococcal + influenze vaccination, pulmonary rehab
Acute respiratory failure
Impaired gas exchange between lungs and blood causing hypoxia +/- hypercapnia
Type 1: Low O2 (<8), normal CO2
Type 2: Low O2 + low CO2
Respiratory causes:
Asthma, COPD, pneumonia
Non-respiratory causes:
Hypovolaemia, shock, drug overdose - opioids
Traumatic:
Haemorrhage, head injury, thoracic injury
Sx: SOB, dyspnoea, confusion
Signs: use of accessory muscles to breathe, stridor (upper airway obstruction), cyanosis
Ix: Sats ABG FBC D-dimer (PE) ECG CXR
Tx: A-E Treat underlying cause O2 CPAP or BIPAP
Acute asthma
Moderate asthma: PEF: 50-75% SpO2 >92% Speech normal RR <25 Pulse <110
Severe: PEF: 33-50% Cant complete sentences SpO2 <92% Pulse >110 ABG: normal CO2, O2 <8, low pH
Life threatening PEF: <33% SpO2 <92% Silent chest, cyanosis Hypotension Exhaustion, altered conciousness ABG: High CO2 Requires mechanical ventilation
Tx: Immediate: Maintain O2 94-98% Salbutamol + ipatropium nebs Prednisolone CXR if pneumothorax or consolidation
If life threatening features:
ABG
IV Mg
ICU
Other tx:
IV salbutamol
IV aminophylline
Mechanical ventilation
Finger clubbing in resp
Abscess Bronchiectasis Cancer Don't say COPD Empyema Fibrosis
Respiratory breathe sounds
Wheeze (narrowing of airways due to bronchospasm or secretions)
Monophonic (narrowing of larger airway)
Polyphonic wheeze (widespread narrowing of smaller airways) - severe asthma, COPD
Crepitations (when obstructed airways (fluid, inflammation) suddenly open) Fine crepitations (heard best at lung bases) - Pulmonary fibrosis, CHF, pneumonia
Coarse crepitations - Chronic bronchitis, Bronchiectasis, pulmonary oedema
Stridor - upper airway obstruction
- Epiglottitis, croup
Lung Ca
Small cell Central Aggressive Chemo+radiotherapy sIADH, ACTH (Cushing's) Neuro sx: Lambert-Eaton syndrome Histology: spindle shaped cells, canty cytoplasm, nuclear moudling
Non small cell:
Adenocarcinoma
Peripheral
Female, non-smokers
Trosseau’s sign - thrombophlebitis (blood clot in vein causing inflammation)
Histology: Glandular, solid, produces mucin
Squamous cell
Central (from major central bronchi)
PTHrP (hypercalcaemia)
Histology: Keratinization, Intercellular bridges
Large cell
Diagnosis of exclusion
Other: Carcinoid - secretes 5-HT (flushing, diarrhoea)
Sx: cough, haemoptysis, dyspnoea, weight loss
Signs: clubbing, pleural effusion, anaemia, cachexia, supraclavilar/axillary lymph nodes
Complications: Recurrent laryngeal nerve palsy, phrenic nerve palsy (diaphragmatic paralysis), SVC obstruction, Horner’s syndrome
Metastatic: hepatomegaly, bone pain, confusion
Bone, kidneys, breast, prostate
Multiple well rounded - cannonball mets (usually renal)
Ix: CXR (central/peripheral mass, pleural effusion) CT contrast (staging) Bronchoscopy+/-biopsy CT guided fine needle biopsy PET-CT Bone scan
Tx: Small cell: Chemo+radiotherapy Palliative radiotherapy Endobronchial stent
NSCLC:
Surgery+chemo+radiotherapy
EGFR - Cetuximab
Interstitial and fibrotic lung disease
Encompasses group of lung disorders which affects the lung parenchyma in a diffuse manner
Sx: dyspnoea on exertion, non-productive parosxmal cough
Ix:
Spirometry: FEV1/FVC >70%, decreased TLC, RV, DLCO
CXR
HR-CT
Classification: Known cause: Asbetosis Drugs: nitrofurantoin, amiodarone, sulfasalazine Infections Hypersensitivity pneumonitis
Assoc with systemic disorders:
Sarcoidosis, RA, SLE
Idiopathic:
Idiopathic pulmonary fibrosis
IPF (idiopathic pulmonary fibrosis)
Fibrotic lung disease with no known cause
Commonest case of interstitial lung disease
Risk fx: organic/inorganic dust, GORD, infections
Sx: dry cough, exertional dyspnoea, weight loss, arthalgia
Signs: clubbing, fine crepitations
Complications: resp failure, increased risk of lung Ca.
Ix: ABG CXR (reticular opacities) HR-CT (honeycombing ANA, RF/Anti-CCP Spirometry Biopsy (histological changes referred as usual interstitial pneumonia - interstitial fibrosis, lymphocytes, plasma cells, intra-alveolar macrophages)
Tx:
Pirfenidone or Nintendanib
Smoking cessation, pulm rehab, O2
Lung transplant
Hypersensitivity pneumonitis (extrinsic allergic alveolitis) Sensitised individuals have a reaction to allergens (fungal, bacteria, animal protein) causing hypersensitivity reaction
Obstructive sleep apnoea
Episodes of upper airway obstruction during sleep
Risk fx: obesity, male, madibular abnormalities, GORD, CVD
Sx: chronic snoring, insomnia, daytime sleepiness, reduced libido
Signs: macroglossia, retro/micrognathia, loud neck circumference
Complications: pulmonary HTN, respiratory failiure
Ix:
Polysomnograph (apnoea-hypopnoea sleep index >15 episodes/hr) - diagnostic. Measures O2 sats, airflow at nose/mouth, ECG, EMG, chest/abdo movement
Portable sleep test (resp event index >15 episodes/hr)
Tx: weight loss CPAP (sends air into upper airways preventing it from collapsing) mandibular devices modafinil (daytime sleepiness) upper airway surgery
Cor pulmonale
Right sided HF due to pulmonary arterial hypertensin
Causes:
Lung: COPD, severe asthma, bronchiectasis, interstitial lung disease
PE
Myasthenia Gravis, MND
Sx: dyspnoea, fatigue, syncope
Signs: raised JVP, RV heave, loud S2, pulmonary oedema
Ix: FBC (high HB) ABG (hypoxic) CXR: enlarged R. atrium,ventricle ECG: Right axis deviation, RBBB, Right heart strain (ST depression in V1-V4, T wave inversion), p pulmonale (peaked p wave in II, III, avF)
Treat: O2, LTO2 - COPD
Cardiac failure: diuretics
Venesection (high haematocrit)
Lung+heart transplant
Sarcoidosis
Multi-system granuloma disorder, unknown cause
Commonest in Northern Europe
Female 20-40 yrs
Sx: asymptomatic, incidental on CXR
Signs: clubbing, erythema nodosum, bilateral hilar lymphadenopathy
Pulmonary: progressive dyspnoea, dry cough, decreased exercise tolerance
Non pulm: splenomegaly, hepatomegay
Ix: Serum ACE CXR: 0: normal 1. BHL 2. BHL + peripheral pulmonary infiltrates 3. Peripheral pulmonary infiltrates 4. Pulmonary fibrosis Biopsy: non-caseating granuloma BAL: lymphocytes, neutrophils
Tx:
Bed rest, NSAIDs
Corticosteroids if: uveitis, high Ca2+, neuro/cardio involvement
DDx granulomatous disease: TB, Crohn’s, PBC
DDx BAL: TB, lymphoma, hypersensitivity pneumonitis
CXR fibrosis
Upper:
TB
Hypersensitivity pneumonitis
Alk spondolytis
Middle:
Sarcoidosis
Lower:
IPF
Asbestosis
Lobar collapse
Causes:
Lung Ca
Asthma
Foreign Body
CXR:
trachea towards side of collapse
mediastinal shift towards collapse
hemi-diaphram rises
