Resp Flashcards
Asthma Definition + Cause
recurrent episodes of dyspnoea, cough, wheeze due to reversible airway obstruction
stimuli triggers bronchial constriction, mucosal inflammation and swelling, increased mucous production
Asthma S+S
dyspnoea, cough (nocturnal), wheeze, sputum
hyperinflated chest, hyper-resonant percussion, dec air entry, widespread polyphonic wheeze
Severe Asthma S+S
Inability to complete sentences
HR >110bpm
RR >25/min
PEF 33-50% predicted
Life threatening asthma S+S
Silent chest Confusion Exhaustion Cyanosis: PaO2<8kPa, PaCo2 4.6-6.0, SpO2<92% Bradycardia PEF<33% predicted
If inc PaCO2 = near fatal
Increased probability of asthma
- wheeze, chest tightness, dyspnoea
- diurnal variation
- responds to triggers: exercise, cold air, allergens
- onset after aspirin or beta blockers
- history of atopy
- FH of atopy/asthma
- widespread wheeze heard on auscultation
- unexplained low FEV1/PEF
- unexplained peripheral blood eosinophilia
Asthma precipitants
Cold air, exercise, emotion, allergens, infection, smoking, pollution, NSAIDs, beta-blockers
Asthma Hx factors
precipitants, diurnal variation, exercise tolerance, difficulty sleeping, acid reflux, atopic disease, home: pets, carpet, feather pillows/duvets. occupation, days off
Asthma Ix - Adults
Low prob = Ix or treat other cause, consider referral, if no response to Rx, further Ix or referral
Medium prob = FEV1/FVC ><0.7
High prob = trial of asthma Rx, if successful continue minimum effective dose, if unsuccessful check compliance/technique, if no improvement, refer
Asthma Rx
Conservative = stop smoking, avoid precipitants, lose weight, check technique, monitor PEF 2x/day, self adjust rx, breathing techniques
Pharm =
- move up if uncontrolled, down if control for >3m
- rescue prednisolone
1. occasional short acting beta-2-agonist –> if use >1/day or nighttime
2. standard dose inhaled steroid: beclometasone
3. long acting beta-2-agonist
4. higher dose steroid, modified release oral theophylline, modified release oral b-2-agonist tablets, oral leukotriene receptor antagonist
5. regular oral prednisolone
Bronchiectasis About
= chronic inflammation of bronchi and bronchioles causing permanent dilatation and thinning
= mainly H influenzae, Strep pneumoniae, Staph aureus, Pseudomonas aeruginosa
Bronchiectasis Causes
Congenital: cystic fibrosis, Young’s syndrome, primary ciliary dyskinesia, Kartagener’s syndrome
Post-infection: measles, pertussis, bronchiolitis, pneumonia, TB, HIV
Other: bronchial obstruction (tumour, foreign body), allergic bronchopulmonary aspergillosis, hypogammaglobulinaemia, rheumatoid arthritis, ulcerative colitis, idiopathic
Bronchiectasis S+S
Persistent cough, copious purulent sputum, intermittent haemoptysis
Clubbing, coarse inspiratory crepitations, wheeze (asthma, ABPA)
Bronchiectasis Ix
Sputum culture
CXR: cystic shadows, thickened bronchial walls (tramline and ring shadows)
HRCT chest: assess extent and distribution of disease
Spirometry: obstructive pattern
Bronchoscopy: locate site of haemoptysis, exclude obstruction and obtain samples for culture
Serum immunoglobulins, CF sweat test, Aspergillus precipitins or skin-prick test RAST and total IgE
Chronic Asthma Ix
PEF monitoring
Diurnal variation of >20% on >3d a week for 2wks
Spirometry: obstructive defect = dec FEV1/FVC and inc RV
Usually 15% improvement in FEV1 after beta-2-agonists or steroids
CXR: hyperinflation
Skin prick test for allergens
Histamine or methacholine challenge
Aspergillus serology
Bronchiectasis Rx
Airway clearance techniques and mucolytics
○ Chest physiotherapy and flutter valve may aid sputum expectoration and mucus drainage
Antibiotics
- Pseudomonas requires oral ciprofloxacin or IV antibiotics
- If >3 exacerbations/yr consider long term antibiotics
Bronchodilators
- Nebulised salbutamol
- In those with asthma, COPD, CF, ABPA
Corticosteroids
- Prednisolone + itraconazole for ABPA
Surgery for localised disease or for severe haemoptysis
COPD
progressive obstructive airway with little/no reversibility
= chronic bronchitis and emphysema
- if >35yrs
- smoking/pollution related
- chronic dyspnoea
- sputum production
- minimal diurnal variation
Chronic bronchitis definition
cough and sputum production on most days for 3m of 2 successive years
Emphysema definition
enlarged alveoli and destruction of alveoli wall
Pink puffers
- Inc alveolar ventilation
- Near normal PaO2 and a normal or low PaCO2
- Breathless but not cyanosed
- May progress to type 1 respiratory failure
Blue bloaters
- Dec alveolar ventilation
- Low PaO2 and high PaCO2
- Cyanosed but not breathless
- May go on to develop cor pulmonale
- Respiratory centres are relatively insensitive to CO2 and they rely on hypoxic drive to maintain respiratory effort
COPD S+S
- Cough
- Sputum
- Dyspnoea
- Wheeze
- Tachypnoea, use of accessory muscles of respiration
- Hyperinflation, dec cricosternal distance (<3cm), dec expansion
- Resonant or hyperresonant percussion note
- Quiet breath sounds, wheeze
- Cyanosis
- Cor pulmonale
COPD Ix
- FBC: inc PCV
- CXR: hyperinflation, flat hemidiaphragms, large central pulmonary arteries, dec peripheral vascular markings, bullae
- CT: bronchial wall thickening, scaring, air space enlargement
- ECG: right atrial and ventricular hypertrophy (cor pulmonale)
- ABG: dec PaO2 +/- hypercapnia
- Spirometry: obstructive and air trapping
(FEV1<80% of predicted, FEV1:FVC ratio <70%, inc TLC, inc RV, dec DLCO in emphysema)
COPD Rx
- SABA/SAMA - FEV1><50%
- LABA or LAMA or LABA+ICS inhaler
- LAMA + LABA/ICS inhaler
- LTOT if PaO2<7.3kPa
- NIV if hypercapnic on LTOT
Smoking cessation advice
Encourage exercise and diet advice with supplements
Mucolytics: productive cough
Disabilities may cause serious depression: screen for this
Respiratory failure
Oedema: diuretics
Flu and pneumococcal vaccinations
BODE (BMI, airflow Obstruction, Dyspnoea, Exercise capacity) index helps predict outcome and number and severity of exacerbations
COPD Acute Rx
- nebulised bronchodilators: salbutamol + ipratropium
- O2 start 24-28%
- steroids: IV hydrocortisone 200mg + oral prednisolone 30mg OD
- Abx if evidence of infection: amoxicillin 500mg/8h PO
- physiotherapy to aid sputum expectoration
if no response to nebulisers and steroids: IV aminophylline
if no response,
- NIPPV if RR>30, acidotic, PaCO2 rising
- resp stimulating drug: doxapram 1.5-4mg/min IV in those who can’t have mechanical ventilation
if pH<7.26 = consider intubation
Causes of rib fractures
- Mostly blunt trauma to chest wall
- Common in polytrauma as chest injuries present in 25% of major trauma
- Spontaneous rib fractures rarely after coughing/sneezing
○ PMH of osteoporosis, steroid use, COPD - Pathological from cancer met
○ Prostate in M, Breast in F
Rib Fracture S+S
- Severe, sharp chest wall pain
○ Pain often more with deep breaths or coughing - Chest wall tenderness over site of fracture, bruising
- Crackles
- Reduced breath sounds
- Reduced ventilation, dropped O2 sats
- Pneumothorax: complication = reduced expansion, reduced breath sounds, hyper-resonant percussion
Flail Chest
- Multiple rib fractures occurring after trauma
- > 2 fractures along >3 consecutive ribs, usually anterior
- Flail segment moves paradoxically during respiration and impairs ventilation of lung on side of injury
- Segment can cause contusional injury to underlying lung
- Rx: invasive ventilation, surgical fixation
Rib Fracture Rx
- Most are conservatively managed with analgesia to ensure breathing not affected by pain
- Fixation can be considered to manage pain or if fractures failed to heal after 12wks conservative management
- Flail chest segments need urgent Rx
- Complications (pneumothorax, haemothorax) managed
ILD S+S
= conditions that affect lung parenchyma diffusely
- Dyspnoea on exertion
- Non-productive paroxysmal cough
- Abnormal breath sounds
- Abnormal CXR or high res CT
- Restrictive pulmonary spirometry with dec DLCO
ILD Causes
With known cause
- Occupational/environmental ex.) asbestosis, berylliosis, silicosis, cotton worker's lung (byssinosis) - Drugs ex.) nitrofurantoin, bleomycin, amiodarone, sulfasalazine, busulfan - Hypersensitivity reactions: hypersensitivity pneumonitis - Infections ex.) TB, fungi, viral - Gastro-oesophageal reflux
Associated with systemic disorders
- Sarcoidosis - Rheumatoid arthritis - SLE, systemic sclerosis, mixed connective tissue disease, Sjogren's syndrome - Ulcerative colitis, renal tubular acidosis, autoimmune thyroid disease
Idiopathic
- Idiopathic pulmonary fibrosis - Cryptogenic organising pneumonia - Non-specific interstitial pneumonitis
Extrinsic Allergic Alveolitis
= repetitive inhalation of allergens (fungal spores or avian proteins) provokes hypersensitivity reaction
Acute phase = alveoli infiltrated with acute inflammatory cells
Chronic exposure = granuloma formation, obliterative bronchiolitis occurs
EAA Cause
- Bird fancier’s and pigeon fancier’s lungs (proteins in bird droppings)
- Farmer’s and mushroom worker’s lung (Micropolyspora faeni, Thermoactinomyces vulgaris)
- Malt worker’s lung (Aspergillus clavatus)
- Bagassosis or sugar worker’s lung (Thermoactinomyces sacchari)
EAA S+S
4-6hr post-exposure
- Fever, rigors, myalgia, dry cough, dyspnoea, fine bibasal crackles
Chronic
- Finger clubbing, increasing dyspnoea, weight loss, exertional dyspnoea, type I resp failure, cor pulmonale
EAA Ix
Acute
- Blood: FBC - neutrophilia, inc ESR, ABGs, serum antibodies (may indicate exposure/previous sensitisation) - CXR: upper zone mottling/consolidation, hilar lymphadenopathy (rare) - Lung fn: reversible restrictive defect, reduced gas transfer during acute attacks
Chronic
- Bloods: serum antibodies - CXR: upper zone fibrosis, honeycomb lung - CT chest: nodules, ground glass appearance, extensive fibrosis - Lung fn: restrictive defect - Bronchoalveolar lavage: inc lymphocytes and inc mast cells
EAA Rx
Acute
- Remove allergen
- Give O2 (35-60%)
- PO prednisolone (40mg/24h PO) reduces course
Chronic
- Allergen avoidance
- Wear facemask or positive pressure helmet
- Long term steroids often achieve CXR and physiological improvement
- Compensation may be payable
Idiopathic Pulmonary Fibrosis
- A type of idiopathic interstitial pneumonia
- Inflammatory cell infiltrate and pulmonary fibrosis of unknown cause
- Commonest cause of ILD
IPF S+S
- Dry cough
- Exertional dyspnoea
- Malaise
- Dec weight
- Arthralgia
- Cyanosis
- Finger clubbing
- Fine end-inspiratory crepitations
IPF Ix
- Blood: ABG (dec PaO2, if severe inc PaCO2), inc CRP, inc immunoglobulins, ANA (30% +ve), rheumatoid factor (10% positive)
- Imaging: dec lung volume, bilateral lower zone reticulo-nodular shadows, honeycomb lung (advanced)
- CT: shows similar changes to CXR but is more sensitive and is an essential for diagnosis
- Spirometry: restrictive, dec transfer factor
- BAL: may indicate activity of alveolitis: inc lymphocytes (good response/prognosis) or inc neutrophils and inc eosinophils (poor response/prognosis
- TC-DTPA scan: disease activity
- Lung biopsy: may be needed for diagnosis, histological changes = usual interstitial pneumonia
IPF Rx
- Supportive care: O2, pulmonary rehabilitation, opiates, palliative care input
- All should be considered for clinical trials or transplantation
- Strongly recommended that high dose steroids are not used except where diagnosis is in doubt
CAP organisms
Streptococcus pneumoniae = commonest
- Haemophilus influenzae, Moraxella catarrhalis
Atypicals: Mycoplasma pneumoniae, Staphylococcus aureus, Legionella species, Chlamydia
Rare: gram negative bacilli, Coxiella burnetii, anaerobes
- Viruses 15% - Flu can be complicated by CAP MRSA
HAP organisms
- > 48hr after hospital admission
- Most common = gram negative enterobacteria or Staph aureus
- Pseudomonas, Klebsiella, Bacteroides, Clostridia
Aspiration pneumonia causes
bulbar palsy, stroke, myasthenia gravis, dec consciousness, oesophageal disease, poor dental hygeine
Immunocompromised pneumonia organisms
Strep pneumoniae, H influenzae, Staph aureus, M catarrhalis, M pneumoniae, Gram -ve bacilli, Pneumocystis jirovecii
- Other fungi, viruses (CMV, HSV), mycobacteria
Pneumonia S+S
Fever, rigors, malaise, anorexia, dyspnoea, cough, purulent sputum, haemoptysis, pleuritic pain
- Pyrexia, cyanosis, confusion, tachypnoea, tachycardia, hypotension, signs of consolidation (reduced expansion, dull percussion, inc tactile vocal fremitus/vocal resonance, bronchial breathing), pleural rub
Pneumonia Ix
- Assess oxygenation: O2 sat, ABGs if SaO2 <92% or severe pneumonia, BP
- Blood tests: FBC, U&E, LFT, CRP
- CXR: lobar or multilobar infiltrates, cavitation, pleural effusion
- Sputum MC&S
- Urine: Legionella/Pneumococcal urinary antigens
- Atypical organism/viral serology = PCR sputum/BAL, complement fixation tests acutely, paired serology
- Pleural fluid aspiration for culture
- Bronchoscopy and bronchoalveolar lavage if immunocompromised or on ITU
CURB-65
- Confusion (abbreviated mental test <8)
- Urea >7mmol/L
- Respiratory rate >30/min
- BP <90 systolic and/or 60mmHg diastolic
- Age>65
0-1 = PO antibiotic/home treatment
2 = hospital therapy
>3 = severe pneumonia indicates mortality 15-40%, consider ITU
Features inc risk of death: comorbidity, bilateral/multilobar, PaO2<8kPa
Pneumonia Rx
Local hospital antibiotic:
- Non severe and not vomiting = PO antibiotic
- Severe = IV
- O2: keep PaO2>8 and or saturation>94%
- IV fluids (anorexia, dehydration, shock) and VTE prophylaxis
- Analgesia if pleurisy
- Consider ITU if shock, hypercapnia, or remains hypoxic
Follow up: 6wks with CXR
Pneumonia complications
Pleural effusion, empyema, lung abscess, respiratory failure, hypotension, septicaemia, brain abscess, pericarditis, myocarditis, cholestatic jaundice
Pneumococcal Pneumonia
- Affects all ages, commoner in elderly, alcoholics, post-splenectomy, immunosuppressed, patients with chronic heart failure or pre-existing lung disease
- Fever, pleurisy, herpes labialis
- CXR: lobar consolidation
- If mod/severe check for urinary antigen
- Rx: amoxicillin, benzylpenicillin, cephalosporin
- Vaccine given to >65, DM, chronic organ condition, immunosuppression
Staphylococcal Pneumonia
- May complicate influenza infection or in young, elderly, IVDU, patients with underlying disease (leukaemia, lymphoma, cystic fibrosis)
- Bilateral cavitating bronchopneumonia
- Rx: flucloxacillin and rifampicin
- MRSA: consider vancomycin
Klebsiella Pneumonia
- Rare
- Occurs in elderly, diabetics, alcoholics
- Cavitating pneumonia, particularly of upper lobes, often drug resistant
- Rx: cefotaxime, imipenem
Pseudomonas Pneumonia
- Common pathogen in bronchiectasis and CF
- Causes hospital acquired infections, particularly on ITU or after surgery
- Rx: anti-pseudomonal penicillin, ceftazidime, meropenem, ciprofloxacin + aminoglycoside
Dual therapy to minimise resistance
Mycoplasma Pneumonia
- In epidemics every 4yrs
- Insidious presentation with flu like symptoms: headache, myalgia, arthralgia, then dry cough
- CXR: reticular-nodular shadowing or patchy consolidation often of one lower lobe, worse than signs suggest
- Diagnosis: PCR sputum/serology, cold agglutinins may cause autoimmune haemolytic anaemia
- Complications: skin rash (erythema multiforme), Stevens-Johnson syndrome, meningoencephalitis or myelitis, G-B syndrome
- Rx: Clarithromycin or doxycycline, or fluoroquinolone (ciprofloxacin, norfloxacin)
Legionella Pneumonia
- Colonises water tanks - hotel air conditioning and hot water systems
- Flu like symptoms (fever, malaise, myalgia) precede dry cough and dyspnoea
- Extra-pulmonary features: anorexia, D&V, hepatitis, renal failure, confusion, coma
- CXR: bi-basal consolidation
- Blood tests: lymphopenia, hyponatraemia, deranged LFTs
- Urinalysis: haematuria
- Diagnosis: urine antigen/culture
- Rx: fluoroquinolone for 2-3wks or clarithromycin
Chlamydia Pneumonia
- Commonest chlamydia infection
- Person to person spread, biphasic illness: pharyngitis, hoarseness, otitis, followed by pneumonia
- Diagnosis: Chlamydophila complement fixation test, PCR invasive samples
- Rx: doxycycline, clarithromycin
Chlamydophila psittaci pneumonia
- Causes psittacosis = ornithosis acquired from infected birds (parrots)
- Symptoms: headache, fever, dry cough, lethargy, arthralgia, anorexia, D&V
- Extra-pulmonary: meningo-encephalitis, infective endocarditis, hepatitis, nephritis, rash, splenomegaly - all rare
- CXR: patchy consolidation
- Diagnosis: Chlamydophila serology
- Rx: doxycycline, clarithromycin
Pneumocystis pneumonia
- In immunosuppressed
- Dry cough, exertional dyspnoea, dec PaO2, bilateral crepitations
- CXR: normal or bilateral perihilar interstitial shadowing
- Diagnosis: visualisation of organism in sputum, bronchoalveolar lavage, lung biopsy specimen
- Rx: high dose co-trimoxazole or pentamidine by slow IVI for 2-3wks, steroids beneficial if severe hypoxaemia
- Prophylaxis indicated if CD4 count <200x106/L or after 1st attack
Viral pneumonia
- Influenza commonest but swine flu (H1N1) considered seasonal and covered by flu vaccine
Other: measles, CMV, VZV
Lung cancer RFs
- Cigarette smoking
- Passive smoking
- Asbestos
- Chromium
- Arsenic
- Iron oxides
- Radiation - radon gas
Lung cancer S+S
- Cough, haemoptysis, dyspnoea, chest pain, recurrent or slow resolving pneumonia, lethargy, anorexia, weight loss, cachexia, anaemia, clubbing, HPOA wrist pain
- Supraclavicular or axillary nodes
- Chest: consolidation, collapse, pleural effusion
- Mets: bone tenderness, hepatomegaly, confusion, fits, focal CNS signs, cerebellar syndrome, proximal myopathy, peripheral neuropathy
Paraneoplastic Syndrome
Endocrine = ectopic secretion of ACTH, ADH, PTH, HCG = Cushing’s, SIADH, hypercalcaemia, gynaecomastia
Neuro = cerebellar degeneration, myopathy, polyneuropathy, myaesthenic syndrome
Vascular = thrombophlebitis migrans, anaemia, DIC
Cutaneous = dermatomyositis, herpes zoster, acanthosis nigricans
Skeletal = clubbing, HPOA
Lung Cancer Complications
- Recurrent laryngeal nerve palsy
- Phrenic nerve palsy
- SVC obstruction
○ Impairs venous backflow into right atrium, causing congestion in head, neck and upper extremities
○ Headache, dyspnoea, oedema of upper extremities and face, worse in morning and leaning forward/lying down
○ Venous pattern on face, chest, upper extremities - Horner’s syndrome (Pancoast’s tumour)
- Rib erosion
- Pericarditis
- AF
Lung Cancer Ix
- CXR: peripheral nodules, hilar enlargement, consolidation, lung collapse, pleural effusion, bony secondaries
- Cytology: sputum and pleural fluid (20mL)
- FNA or biopsy (peripheral lesions/lymph nodes)
- CT to stage tumour and guide bronchoscopy
- Bronchoscopy: give histology and assess operability + Endobronchial US for assessment and biopsy
- F-deoxyglucose PET or PET/CT EBUS scan to help staging
- Radionuclide bone scan if suspect mets
- Lung function tests: assess suitability for lobectomy
NSCLC Rx
- Lobectomy (open or thorascopic)
○ If medically fit, curative intent
○ Parenchymal sparing op for patients with borderline fitness and smaller tumours (T1a-b, N0, M0) - Radical radiotherapy
○ I, II, III NSCLC - Chemotherapy and radiotherapy
○ More advanced disease
○ Regimens may be platinum based ex.) with monoclonal Abs targeting epidermal growth factor receptor = Cetuximab
SCLC Rx
- Surgery with limited stage disease
- Chemo and radio if well enough
- Palliation
○ Radiotherapy: bronchial obstruction, SVC obstruction, haemoptysis, bone pain, cerebral mets
○ SVC obstruction: stent and radiotherapy and dexamethasone
○ Endobronchial therapy: tracheal stenting, cryotherapy, laser, brachytherapy
○ Pleural drainage/pleurodesis for symptomatic pleural effusions
○ Drugs: steroids, antiemetics, cough linctus, bronchodilators, antidepressants
Mesothelioma S+S`
- Chest pain
- Dyspnoea
- Weight loss
- Finger clubbing
- Recurrent pleural effusion
- Signs of mets: lymphadenopathy, hepatomegaly, bone pain/tenderness, abdo pain/obstruction (peritoneal malignant mesothelioma)
Mesothelioma Ix
- CXR/CT
- Pleural thickening/effusion
- Bloody pleural fluid
- biopsy
- thorascopy
Mesothelioma Rx
- Pemetrexed and Cisplatin chemo can improve survival
- Surgery hard to evaluate
- Radiotherapy controversial
- Pleurodesis and indwelling intra-pleural drain may help
Pleural effusion transudate causes
- Inc venous pressure (cardiac failure, constrictive pericarditis, fluid overload)
- Hypoproteinaemia (cirrhosis, nephrotic syndrome, malabsorption)
- Hypothyroidism
- Meigs’ syndrome = R pleural effusion and ovarian fibroma
Pleural effusion exudate causes
- Inc leakiness of pleural capillaries secondary to infection, inflammation, malignancy
- pneumonia, TB
- pulmonary infarction
- rheumatoid arthritis, SLE
- bronchogenic carcinoma, malignant mets, lymphoma, mesothelioma, lymphangitis carcinomatosis
Pleural effusion S+S
- Asymptomatic
- Dyspnoea
- Chest pain
- Dec expansion
- Stony dull percussion note
- Diminished breath sounds on affected side
- Dec tactile vocal fremitus and vocal resonance
- Bronchial breathing above effusion where lung is compressed
- Tracheal deviation away, with large effusions
- Aspiration marks, signs of ass. disease:
○ malignancy, stigmata of chronic liver disease, cardiac failure, hypothyroidism, rheumatoid arthritis, butterfly rash of SLE
Pleural effusion Ix
- CXR: small effusions blunt costophrenic angles, larger ones are seen as water dense shadows with concave upper borders
○ Pneumothorax = flat horizontal upper border - US: identify presence of pleural fluid, guide diagnostic or therapeutic aspiration
- Diagnostic aspiration:
○ Percuss upper border of pleural effusion
○ 1/2 intercostal spaces below
○ Infiltrate down to pleura with lidocaine
○ Insert needle w. syringe just above upper border of appropriate rib
○ Draw pleural fluid, sent to lab: protein, glucose, pH, LDH, amylase, MCS, auramine stain, TB culture, cytology, immunology (rheumatoid factor, ANA, complement) - Pleural biopsy
○ If pleural fluid analysis inconclusive
○ Thoracoscopic or CT guided pleural biopsy inc diagnostic yield
Pleural effusion Rx
- underlying cause
- Drainage = if symptomatic, drain slowly - aspirated as diagnostic tap or using intercostal drain
- Pleurodesis = w/ talc for recurrent effusions
○ Thorascopic mechanical pleurodesis most effective for malignant effusions
○ Empyemas drained using chest drain, using US/CT - Intra-pleural alteplase and dornase alfa = empyema
- Surgery - persistent or inc pleural thickness
Haemothorax
- from laceration of lung, intercostal vessel or internal mammary artery
- if large enough to appear on CXR treat with large bore chest drain
- Surgical exploration if>1500ml blood drained immediately
Pneumothorax causes
- Spontaneous (esp young thin men) rupture of subpleural bulla
- Chronic lung disease: asthma, COPD, cystic fibrosis, lung fibrosis, sarcoidosis
- Infection: TB, pneumonia, lung abscess
- Traumatic: iatrogenic (CVP line insertion, pleural aspiration or biopsy, percutaneous liver biopsy, positive pressure ventilation)
- Carcinoma
- Connective tissue disorders: Marfan’s syndrome, Ehlers-Danos syndrome
Pneumothorax S+S
- Can be asymptomatic or sudden onset of dyspnoea and pleuritic chest pain
- Asthma/COPD patients = sudden deterioration
- Mechanically ventilated patients = develop hypoxia or inc in ventilation pressures
- Reduced expansion, hyper-resonance to percussion, diminished breath sounds on affected side
- Tension pneumothorax: trachea deviated away from affected side
Pneumothorax Ix
- no CXR if tension pneumothorax is suspected
- Expiratory film = areas devoid of lung markings, peripheral to edge of collapsed lung
- Ensure it is not large emphysematous bulla
- ABG in dyspnoeic, hypoxic, chronic lung disease
Pneumothorax Rx
- Depends on primary or secondary (underlying lung disease or smoker >50yrs), size, symptoms
1: SOB and/or rim of air >2cm on CXR pp
- if yes, aspirate then chest drain
- if no, review in 2-4wks
2: if SOB or rim of air >1cm then aspirate, if >2cm chest drain
- if no, admit for obs and O2 for 24h
- Size = measured from visible lung margin to chest wall at level of hilum
- Aspiration then chest drain
- Pneumothorax due to trauma or mechanical ventilation requires chest drain
○ Tubes removed 24hr after lung has re-expanded and air leak has stopped
○ Done during expiration or Valsalva manoeuvre - Surgical: if bilateral pneumothoraces, lung fails to expand within 48h of drain insertion, persistent air leak, 2 or more previous pneumothorax on same side, history of pneumothorax on opposite side
Tension pneumothorax
- Air drawn into pleural space with each inspiration has no route of escape
- Mediastinum pushed over into CL hemithorax, kinking, compressing great veins
- Cardiorespiratory arrest can occur
Tension pneumothorax S+S
- Respiratory distress tachycardia, hypotension, distended neck veins, trachea deviated from side of pneumothorax
- Increased percussion note, reduced air entry/breath sounds on affected side
Tension pneumothorax Rx
- Insert large bore needle with syringe, partially filled with saline into 2nd intercostal space in midclavicular line
- Remove plunger to allow trapped air to bubble through syringe until chest tube can be placed
- Or large bore Venflon in same location
- BEFORE CXR
- Then insert chest drain
Cor pulmonale
= right heart failure from chronic pulmonary arterial hypertension
Cor pulmonale causes
Chronic lung disease
- COPD, bronchiectasis, pulmonary fibrosis, chronic severe asthma, lung resection
Pulmonary vascular disorders
- PE, vasculitis, primary pulmonary hypertension, ARDS, sickle cell, parasite
Neuromuscular and skeletal diseases
- kyphosis, scoliosis, thoracoplasty, myaesthenia gravis, poliomyelitis, MND
Hypoventilation
- sleep apnoea
- enlarged adenoids in children
Cerebrovascular disease
Cor pulmonale S+S
- Dyspnoea
- Fatigue
- Syncope
- Cyanosis
- Tachycardia
- Raised JVP with prominent a and v waves
- RV heave
- Loud P2
- Pansystolic murmur (tricuspid regurgitation)
- Early diastolic Graham Steell murmur
- Hepatomegaly
- Oedema
Cor pulmonale Ix
- FBC: Inc Hb and haematocrit (secondary polycythaemia)
- ABG: hypoxia, +/- hypercapnia
- CXR: enlarged RA and RV, prominent pulmonary arteries
- ECG: P pulmonale, RAD, RVH/strain
Cor pulmonale Rx
- Treat cause
- Treat respiratory failure: start acutely 24% O2 if PaO2<8kPa, inc O2 conc if PaCO2 stable
○ In COPD, LTOT increases survival - Treat cardiac failure: furosemide 40-160mg/24h PO
○ Monitor U&E
○ Amiloride or K supplements
○ Alternative: spironolactone - Consider venesection if haematocrit >55%
- Consider heart lung transplantation in young patients
Shunt Perfusion V/Q
= alveoli perfused but not ventilated, low V/Q
= pneumonia, pulmonary oedema, tissue trauma, atelectasis, mucus plugging, pulmonary AV fistulas
Deadspace Ventilation
= alveoli ventilated but perfused, high V/Q
= cardiovascular shock, emphysema, PE
Type 1 respiratory failure
= PaO2 <8kPa, normal or low PaCO2
= V/Q mismatch § Pneumonia § Pulmonary oedema § PE § Asthma § Emphysema § Pulmonary fibrosis § ARDS ○ Hypoventilation ○ Abnormal diffusion ○ R to L cardiac shunts
Type 2 respiratory failure
= PaO2 <8kPa, PaCO2>6kPa
=
○ Alveolar hypoventilation, +/- VQ mismatch
○ Pulmonary disease = asthma, COPD, pneumonia, end stage pulmonary fibrosis, obstructive sleep apnoea
○ Reduced respiratory drive = sedative drugs, CNS tumour or trauma
○ Neuromuscular disease = cervical cord lesion, diaphragmatic paralysis, poliomyelitis, myasthenia gravis, G-B syndrome
○ Thoracic wall disease = flail chest, kyphoscoliosis
Respiratory failure S+S
Hypoxia
- Dyspnoea, restlessness, agitation, confusion, central cyanosis
- Long-standing; polycythaemia, pulmonary hypertension, cor pulmonale
Hypercapnia
- Headache, papilloedema, confusion, drowsiness, coma
- Peripheral vasodilation, tachycardia, bounding pulse, tremor/flap
Respiratory failure Rx
Type 1
- Underlying cause - O2 (24-60%) facemask - Assisted ventilation if PaO2<8kPa despite 60% O2
Type 2
- May be insensitive to CO2 and respiration could be driven by hypoxia - Underlying cause - Controlled O2 24%, given with care - Recheck ABG after 20min, if PaCO2 steady or lower, increase O2 conc to 28%, if PaCO2 has risen >1.5kPa and still hypoxic, consider assisted ventilation: NIPPV - If fail, consider intubation and ventilation
Sarcoidosis
= multisystem granulomatous disorder
- Unknown cause
- 20-40yrs
- More in F, African-Caribbeans esp. extra-thoracic disease
- Associated with HLA-DRB1 and DQB1 alleles
Sarcoidosis Ix
- Bloods: inc ESR, lymphopenia, inc LFT, inc serum ACE, inc Ca, inc immunoglobulins
- 24h urine: inc Ca
- CXR
- ECG: arrhythmias, BBB
- Lung fn: normal or reduced lung volumes, impaired gas transfer, restrictive ventilatory defect
- Transbronchial biopsy: diagnostic = non-caseating granulomata
- Bronchoalveolar lavage: inc lymphocytes in active disease, in neutrophils with pulmonary fibrosis
- US: nephrocalcinosis, hepatosplenomegaly
- Bone x-ray: punched out lesions in terminal phalanges
- CT/MRI: assess severity of pulmonary disease or diagnosing neurosarcoidsosis
- Ophthalmology assessment
Sarcoidosis CXR Staging
○ 0 - normal
○ 1 - BHL
○ 2 - BHL + peripheral pulmonary infiltrates
○ 3 - peripheral pulmonary infiltrates alone
○ 4 - progressive pulmonary fibrosis, bulla formation (honeycombing), pleural involvement
Sarcoidosis Rx
- Patients with BHL alone don’t need Rx
- Acute sarcoidosis: bed rest, NSAIDs
- Indications for corticosteroids
○ Parenchymal lung disease: symptomatic, static or progressive
○ Uveitis
○ Hypercalcaemia
○ Neurological or cardiac involvement - Prednisolone (40mg/24h) PO for 4-6wks
- Severe: IV methylprednisolone or immunosuppressants (methotrexate, hydroxychloroquine, ciclosporin, cyclophosphamide)
- Anti-TFN-alpha therapy in refractory cases or lung transplant
Acute sarcoidosis S+S
○ Fever
○ Erythema nodosum
○ Polyarthralgia
○ Bilateral hilar lymphadenopathy (Lofgren syndrome) resolves spontaneously
Sarcoidosis pulmonary S+S
○ Abnormal CXR with BHL, pulmonary infiltrates or fibrosis ○ Dry cough ○ Progressive dyspnoea ○ Dec exercise tolerance ○ Chest pain
Causes of BHL
Sarcoidosis
Infection: TB, mycoplasma
Malignancy: lymphoma, carcinoma, mediastinal tumours
Organic dust disease: silicosis, berylliosis
Hypersensitivity pneumonitis
Histocytosis X
Obstructive sleep apnoea syndrome
= intermittent closure/collapse of pharyngeal airway causing apnoeic episodes during sleep, terminated by partial arousal
Obstructive sleep apnoea S+S
- Obese, middle aged man, presents with snoring or daytime somnolence
- (partner describes apnoeic episodes during sleep)
- Loud snoring
- Daytime somnolence
- Poor sleep quality
- Morning headache
- Decreased libido
- Nocturia
- Dec cognitive performance
Complications
- Pulmonary hypertension, type II resp failure - Sleep apnoea is independent risk factor for hypertension
Obstructive sleep apnoea Ix
- Pulse oximetry, video recordings
- Polysomnography = monitors O2 saturation, airflow at nose and mouth, ECG, EMG chest, abdominal wall movement during sleep = diagnostic
- Occurrence of >15 episodes of apnoea or hypopnoea during 1h of sleep indicates significant
Obstructive sleep apnoea Rx
- Weight reduction
- Avoiding tobacco and alcohol
- Mandibular advancement device
- CPAP via nasal mask for mod to severe
- Surgery = tonsillectomy, polypectomy
RF for TB reactivation
new infection (<2yr), HIV, organ transplantation, immunosuppression (corticosteroids), silicosis, drugs, malnutrition, high risk settings (homeless shelter, prison), low socio-economic status, haemodialysis
Primary TB
- Ghon focus = small lung lesion = tubercle-laden macrophages
- Ghon complex = ghon focus and hilar lymph nodes
- Immunocompetent people –> lesion heals by fibrosis
- Immunocompromised –> may have disseminated disease (miliary tuberculosis)
Secondary TB
- Initial infection reactivated
- Generally in apex of lungs, may spread locally or to most distant sites
- Immunocompromised: steroids, HIV, malnutrition
RF for active TB
- Silicosis
- Chronic renal failure
- HIV +ve
- Solid organ transplantation with immunosuppressants
- IV drug use
- Haematological malignancy
- Anti-TNF treatment
- Previous gastrectomy
TB Systemic S+S
- Low grade fever
- Anorexia
- Weight loss
- Malaise
- Night sweats
- Clubbing (bronchiectasis)
- Erythema nodosum
TB Pulmonary S+S
- Cough (>2-3 wks, dry then productive)
- Pleurisy
- Haemoptysis (uncommon, seen with bronchiectasis)
- Pleural effusion
- Aspergilloma/mycetoma may form in cavities
- Presentation varies, may be silent or atypical, especially with immunosuppression
Latent TB Ix
testing of close contacts of those with pulmonary/laryngeal TB, with immune dysfunction, healthcare workers, high risk populations
- Tuberculin skin testing (TST) <6, 6-15, >15
- Interferon-gamma release assays (IGRAS)
Active TB Ix
- CXR = Fibronodular/linear opacities in upper lobe (typical), middle or lower lobes (atypical), cavitation, calcification, miliary disease, effusion, lymphadenopathy
- Sputum smear
○ 2 specimens needed inc. early morning sample
○ Ziehl-Neelsen stain
○ Stained for presence of acid-fast bacili
○ If AFB seen, treatment commenced and patient isolated - Sputum culture
○ More sensitive than smear
○ Takes 1-3 wks (liquid media) or 4-8 wks (solid media)
○ Can assess drug sensitivity - Nucleic acid amplification test (NAAT)
○ Direct detection of M. tuberculosis in sputum by DNA or RNA amplification
○ Rapid diagnosis <8hrs
○ Can also detect drug resistance
HIV test for all
Latent TB Rx
- Balance risk of active disease with side effects of treatment
- Consider treatment in all at inc. risk of active disease
- Offer HIV, hepatitis B and C testing prior to treatment
= 3 months of isoniazid w/ pyridoxine and rifampicin OR 6 months isoniazid w/ pyridoxine
Active TB Rx
= Rifampicin, Isoniazid, Pyrazinamide, Ethambutol
○ Active CNS disease inc. spinal cord –> continuation phase of treatment extended from 4-10 months
- CNS and pericardial disease –> use adjunctive high dose steroids
Drug resistant TB Rx
- NAAT for drug resistance
- single agent/multi drug/ extensively drug resistant
- > 6 agents that are sensitive
BCG Vaccine
- Live attenuated Mycobacterium bovis
- First have tuberculin skin test ○ Except children <6yrs who have had no contact - Given intradermally, normally lateral L upper arm - Limited protection against TB - CI - Previous BCG vaccination - Past history of TB - HIV - Pregnancy - Positive tuberculin test - Not given to anyone >35
Who gets BCG
- UK: given to high risk infants
○ All infants (0-12 months) living in high annual incidence areas
○ All infants with parent or grandparents who was born in country where annual incidence is high
(same with older children but if >6y/o they need tuberculin skin test first) - Previously unvaccinated tuberculin-negative contacts of cases of respiratory TB
- Unvaccinated, tuberculin negative <16yrs who were born in or who have lived for prolonged period (>3m) in country with high annual incidence
- Healthcare workers
- Prison staff
- Care home staff
- Work with homeless people
Cystic fibrosis
= autosomal recessive condition caused by mutations in CF transmembrane conductance regulator (CFTR) gene on Ch7 (Cl channel)
- defective Cl secretion and inc Na absorption across airway epithelium
- changes composition of airway surface liquid –> predispose lung to chronic pulmonary infections and bronchiectasis
- 1:25 carry copy of faulty gene
- Caucasians
- Babies in UK screened at birth
Cystic fibrosis S+S
Neonate = failure to thrive, meconium ileus, rectal prolapse
- Cough, wheeze, recurrent infections, bronchiectasis, pneumothorax, haemoptysis, respiratory failure, cor pulmonale
- Pancreatic insufficiency (DM, steatorrhoea), distal intestinal obstruction syndrome, gallstones, cirrhosis
- Male infertility
- Osteoporosis, arthritis
- Vasculitis
- Nasal polyps, sinusitis
- Hypertrophic pulmonary osteoarthropathy
- Cyanosis, finger clubbing, BL coarse crackles
Cystic fibrosis Ix
- Sweat test = sweat Na and Cl >60mmol/L (Cl > Na)
- Genetic screening
- Faecal elastase = screen for exocrine pancreatic dysfunction
- Blood: FBC, U&E, LFT, clotting, vitamin A, D, E, annual OGTT
- Bacteriology: cough swab, sputum culture
- CXR: hyperinflation, bronchiectasis
- Abdo US: fatty liver, cirrhosis, chronic pancreatitis
- Spirometry: obstructive defect
- Aspergillus serology/skin test (ABPA)
- Faecal fat analysis
Cystic fibrosis Rx
- Physician, GP, physiotherapist, specialist nurse, dietician
- Chest physiotherapy (postural drainage, airway clearance techniques)
- Abx for acute infective exacerbations and prophylactically
- Chronic pseudomonas infection is important predictor of survival
- Mucolytics can be useful (Dnas [Dornase alfa] 2.5mg daily nebulised or nebulised hypertonic saline)
- Bronchodilators
- Annual CXR monitoring
- Oxygen, diuretics (cor pulmonale), NIV, lung or heart/lung transplant
GI
- Rx malabsorption, GORD, distal obstruction syndrome
- Pancreatic enzyme replacement
- Fat soluble vitamin supplements (A, D, E, K)
- Ursodeoxycholic acid for impaired liver function
- Cirrhosis may require liver transplantation
- Treatment of CF-related diabetes (screen annually with OGTT from 12yrs)
- Screen/Rx of osteoporosis (DEXA), arthritis, sinusitis, vasculitis
- Fertility and genetic counselling
ARDS
= acute lung injury, either by direct lung injury or secondary to severe systemic illness
- Release of inflammatory mediators cause inc capillary permeability and non-cardiogenic pulmonary oedema
- Often with multi-organ failure
ARDS Causes
- Pneumonia
- Gastric aspiration
- Inhalation
- Injury
- Vasculitis
- Contusion
- Other: shock, septicaemia, haemorrhage, multiple transfusions, DIC, pancreatitis, acute liver failure, trauma, head injury, malaria, fat embolism, burns, eclampsia, drugs/toxins (aspirin, heroin, paraquat)
ARDS S+S
- Cyanosis
- Tachypnoea
- Tachycardia
- Peripheral vasodilation
- BL fine inspiratory crackles
ARDS Diagnosis
- Acute onset
- CXR: BL infiltrates
- PCWP <19mmHg or lack of clinical congestive heart failure
- Refractory hypoxaemia with PaO2: FiO2<200
- Also total thoracic compliance <30mL/cmH2O
ARDS Supportive Measures
- Early ARDS: CPAP with 40-60% O2
- Most patients need mechanical ventilation
- Indications for ventilation
○ PaO2<8.3kPa despite 60% O2
○ PaCO2 >6kPa
○ Large TV (10-15mL/kg) produced by conventional ventilation plus reduced lung compliance in ARDS may lead to high peak airway pressures and pneumothorax
○ Low TV, pressure-limited approach: low or moderate high positive end-expiratory pressure (PEEP) - Invasive haemodynamic monitoring with arterial line and Swan-Ganz catheter (PCWP and cardiac output)
- Conservative fluid management
- Maintain CO and O2 delivery with inotropes (dobutamine 2.5-10mcg/kg/min IVI), vasodilators, blood transfusion
- Consider treating pulmonary hypertension with low dose nitric oxide
- Haemofiltration may be needed in renal failure and to achieve negative fluid balance
