Resp Flashcards
Serious complications of sinusitis
Infection of meninges
Orbital cellulitis
Kartagener’s sx triad and pathophysiology
Bronchiectasis
Sinusitis
Situs inversus
Abnormal ciliary function: failure to clear mucus + bacteria
Most common association with nasopharyngeal carcinoma
EBV
Rare outside E/SE Asia - usually undetected until metastasises to lymph nodes
Decent prognosis with radiation therapy
Causes of acute laryngitis
Pathogens
Irritants (esp cigarette smoke)
Mechanical factors, eg endotracheal intubation
Overuse of voice
Sequelae of acute laryngitis
- Resolution
- Spread of infection: bronchitis, bronchopneumonia, lung abscess
3 Airway obstruction: laryngeal oedema (esp epiglottitis in children)
Causes of atelectasis
Obstruction: foreign object, mucus plugging
Compression: pneumothorax, oedema
Scarring:
Surfactant loss
Causes of bronchiectasis
Irreversible dilatation of bronchi
Congenital: CF, Kartagener’s etc.
Acquired: infection (esp measles + pertussis), obstruction (foreign object or tumour)
Signs of idiopathic pulmonary fibrosis
Dyspnoea
Cough
Finger clubbing
3 most common pneumoconioses
Coal worker’s
Silicosis (slate minining, quarrying, stone masonry)
Asbestosis
What are farmer’s lung/ pigeon-fanciers’ lung examples of?
Extrinsic allergic alveolitis
type III and type IV
Predisposing factors for pneumonia
INSPIRATION Immunosuppression Neurological impairment of the cough reflex Secretion retention Pulm oedema Impaired mucociliary clearance Resp tract infection Abx and cytotoxics Tracheal intubation Impaired alveolar macraphages Other Neoplasia
Pathogens causing CAP
Generally Gram +ve
Strep pneumoniae
Haemophilus influenzae
Pathogens causing HAP
Generally Gram -ve Klebsiella Pseudomonas MRSA E.coli
Who gets viral pneumonia?
Children, eg measles, varicella
Immunocompromised, eg CMV - esp common after bone marrow transplant
Pathogens causing fungal pneumonia
Candida and aspergillus
Can cause widespread areas of necrosis - mortality is high
PCP (Pneumocystis carinii pneumonia) - small fungal yeasts
How can TB spread from the Ghon complex?
If no resolution, e.g. in immunocompomise:
Bronchus: from lymph nodes erodes into bronchus > other bronchus > neighbouring lung
Blood vessel: causing miliary TB
Direct lymphatic spread: pleura, pericardium
What is secondary TB?
Reactivation of latent infection - occurs in ~5-10%
Apical Assmann focus
Primary TB has small granulomatous focus but large lymph node response
Secondary TB has large granulomatous disease but minimal lymph node involvement
Types of lung ca
Squamous (slow-growing, metastasises late)
AC (slow-growing, including from peripheries, metastasises early)
Large-cell anaplastic
Small-cell (neuroendocrine) - mets normally present at diagnosis
Common primary sites for lung mets
Breast Kidney Uterus Ovaries Testes Thyroid
usually via blood, ie bilateral deposits
Meds that can cause chronic pulmonary fibrosis
Some anticancer agents
CCBs
amiodarone
Causes of haemothorax
Trauma, esp rib #
Surgery
Pulmonary infarcts
Spontaneous rupture of diseased arteries, eg atheroma, dissecting aortic aneurysm
Causes of chylothorax
Leakage from thoracic duct, typically malignant infiltration, surgery, trauma
Where is the anatomical dead space?
Conducting part of tract ~150 mL
Where does aspirated material tend to go?
R bronchus
How many lung lobes?
2 on L: superior + inferior
3 on R: superior + middle + inferior
What is the normal V/Q
0.8
1 is ideal
Which conditions are obstructive? How would this be reflected by FEV1/FVC?
Asthma, COPD, bronchiectasis
<0.7
Asthma steps
- Inhaled SABA
- Add inhaled CS (400 mcg/day usual starting dose - up to 800)
- Add LABA (discontinue if poor response)
- Increase inhaled CS up to 2000 mcg/day, or add leukotriene receptor antagonist
- Oral steroids in addition to inhaled steroids
Possible cause of emphysema in younger patients
alpha-1-antitrypsin deficiency
Most common pathogen implicated in acute exacerbations of COPD
Haemophilus influenzae
MRC dyspnoea scale
Grade 1: only on exertion
Grade 2: SOB on walking up hill
Grade 3: slower than contemporaries
Grade 4: has to stop after few mins/ 100 m
Grade 5: too breathless to leave house/ on dressing
What is the BODE index
For prognosis in COPD BMI Obstruction Dysnoea (MRC scale) Exercise tolerance
COPD steps
- SABA or SAMA
- LABA or LAMA (+ICS if FEV <50%)
- Theophylline, mucolytics - oral CS not recommended
- LTOT
What may be seen on bronchiectasis CXR?
Tram-tracks/ fluid lines
HRCT is gold-standard
What are the GI/ endo features of CF?
DM, pancreatic insufficiency, liver disease, gallstones, osteoporosis, infertility in males (absent ductus deferens bilaterally), subfertility in females
First-line investigation in CF
Sweat test
What is the acute presentation of sarcoid?
Lofgren syndrome
Good prognosis: bedrest and NSAIDs
fever, erythema nodosum, bilat hilar lymphadenopathy, polyarthralgia
What is Caplan syndrome?
Coal workers’ pneumoconiosis associated with RA
What pathogen commonly causes pnemonia after influenza?
Staph aureus
Pathogen most likely to cause pneumonia in alcoholics?
Klebsiella
also most common in diabetics
What are the features seen on blood tests in Legionella pneumonia?
Deranged LFTs
Hyponatraemia
Erythema multiforme is associated with which pneumonia
Mycoplasma infections
CURB-65
Confusion (AMTS <8) Urea >7 RR >30 BP <90 or diastolic <60 65 years
0/1: treat at home
2: inpatient treatment
3: consider ITU
Causes of lung abscess
Primary: existing pneumonia or lung disease
Secondary: aspiration, septic emboli from R sided infective endocarditis
Clinical features of lung abscess
Swinging fevers, night sweats, productive cough (purulent sputum)
Extra-pulmonary manifestations of TB
arthritis, meningitis, Pott spine, erythema nodosum, clubbing
Why request LFTs in TB?
Meds tend to be hepatotoxic
Medications for TB
2 months RIPE
4 months RI
TB drug side-effects
Rifampicin (RED-fampicin): reddish/orange secretions, hepatitis
Isoniazid (Iso-NEURO-zid): peripheral neuropathy (supplement with vit B6 prophylaxis), agranulocytosis, hepatitis
Pyrazinamide (Pyr-OUCH-zinamide): hyperuricaemia causing gout, myalgia, hepatitis
Ethambutol (EYE-thambuto): optic neuritis, renal impairment
What is Meig syndrome?
Triad of ovarian cancer, ascites and R-sided pleural effusion
Causes transudate
Causes of pleural effusion transudates
Heart failure
Renal failure
PE
Meig syndrome
Causes of pleural effusion exudates
Pneumonia, TB
Lung ca
Symptoms of pleural effusion
Dyspnoea
Pleuritic chest pain
May be asymptomatic
Signs of pleural effusion
Dull to percuss
Reduced breath sounds
Trachea deviated to opp side (if large)
How may refractory pleural effusions be managed?
Pleurodesis
Site for chest drains
4-6th ICS MAL
Pneumothorax definition
Abnormal accumulatio of air in pleural space
Symptoms of pneumothorax
Sudden-onset dyspnoea or unilateral pleuritic chest pain
Sudden deterioration existing lung problem
Or asynptomatic - esp if small or they’re healthy
Signs of pneumothorax
Decreased chest expansion, reduced breath sounds, hyper-resonance on percussion
Treatment tension pneumothorax
Large bore cannula into 2nd ICS mid-clavicular line
Lambert-Eaton myaesthenic sx associated with which lung ca
Small cell
Which lung ca association with ectopic PTH
Squamous cell carcinoma
How to get cells for histopathology in lung ca
Fibre-optic bronchoscopy for central lesions, needl-guided bx (under CT or US) in peripheral lesion
Causes T1RF
Obstruction problem: alveoli are perfused but not ventilated
PaO2 < 8kPa
severe acute asthma
pneumonia
PE
pulmonary oedema
Causes T2RF
Ventilation problem
CO2 > 6.5 kPa
COPD asthma pneumonia pulmonary fibrosis obstructive sleep apnoea reduced resp drive: trauma, sedatives neuromuscular: cervical cord lesion, MG, GBS, diaphragm paralysis
Signs and symptoms of hypercapnia
headache, drowsiness, reduced GCS, bounding pulse, tremor in hands, peripheral vasodilatation, papilloedema
Options for non-invasive respiratory support
Humidified supplemental O2: for T1RF
CPAP: for T1RF
BiPAP: for T2RF
Why is invasive mechanical ventilation useful? When may it be used?
Set a desired pressure, desired tidal volume, desired RR
Severe resp failure/ increased work of breathing/ NIV not tolerated
Airway protection (eg GCS <8 or airway compromised by burns)
Control pO2 and pCO2 in acute neuro diease/ increased ICP
What are the options for invasive mechanical ventilation?
ETT (requires anaesthesia, sedation) initially
Long-term: tracheostomy (little/ no sedation, improved comfort, improved nursing/ oral care)
Risks of ETT
Volutrauma
Barotrauma
Tension pneumothorax
Types of pulmonary embolus
Thrombosis
Fat (fractures)
Amniotic fluid
Air (neck vein: cannulation or bronchial trauma)
Symptoms PE
Dyspnoea, chest pain (pleuritic or retrosternal), cough, haemoptysis
Severe: RHF –> dizziness, syncope, arrest
Sign of PE
Tachypnoea, tachycardia, hypotension
hypoxia, pyrexia
pleuritic rub
increased JVP, gallop rhythm
Investigations for PE
FBC, U&Es, baseline clotting, troponin, consider BNP
Well Score: D-dimer if less likely
ABG
ECG: S1, Q3, T3 - tachy, RBB, RAD
CXR
Echo: may show thrombus and if location haemodynamically important
CTPA + leg USS (if Wells Score high)
If under 40, consider looking for cancer: hx, CXR, mammogram, CT AP, antiphospholipid antibodies, thrombophilia screen)
When would V/Q scan be offered?
Cannot have contrast/ renal impairment
Thrombolysis regimen in arrest/ pre-arrest
Suggested regime is Alteplase 10 mg iv bolus and 90 mg iv over two hours (total
dose 100 mg).
The total dose should not exceed 1.5 mg/kg in patients with a body weight below 65 kg.
If cardiac arrest is imminent and there is a high suspicion of massive PE thrombolysis
accelerated dosing is recommended even if the diagnosis has not been confirmed with
imaging. Alteplase 50 mg iv bolus, followed by IV UFH
Continue anticoagulation with heparin after thrombolysis.
The risks of bleeding should be explained to the patient and documented (BTS quoted 20%
bleeding risk with lysis).
Mx low to medium risk PE
General Oxygen 35-50% (higher if shocked) Adequate analgesia for pleuritic pain Allow right atrial pressure (i.e. JVP) to remain high if elevated AVOID diuretics
Specific
Low molecular weight heparin (LMWH) for at least 5 days despite therapeutic INR.
Once diagnosis confirmed initiate Warfarin, (until INR >2 for two consecutive days), or direct
oral anticoagulant (DOAC).
Offer Class II stockings ideally full length, (patients may choose below knee) to be worn for
at least two years (unless contraindications)
Continue 6 months: cancer/ unprovoked
3 months: provoked
May need surgical embolectomy/ IVC filter
Causes of ARDS
Pulmonary: trauma, infection, smoke inhalation, gastric contents aspiration, mechanical ventilation, near-drowning
Non-pulmonary: Gram-negative sepsis, pancreatitis, burns, CABG, perforated viscus, DIC, O2 toxicity, drug OD
Mx ARDS
Identify cause + support
-ve fluid balance as in HF
PEEP: prevent alveolar walls from collapsing during expansion
also vasodilators, steroids in late stages….
30-45% mortality
Causes of pneumothorax
Primary/ spontaneous: rupture of pleural pleb (congenital weakness), tall/ slim males - often apical
Secondary: COPD (emphysematous bullae), COPD, TB, pneumonia, bronchial ca, sarcoidosis, CF, trauma
Ix for OSA
Polysomnography gold standard (electrodes on eyes/ chin)
Mx OSA
Lifestyle, avoid supine sleeping
CPAP is gold standard
Modafinil for sleepiness maybe, maybe surgery
What happens in central sleep apnoea
Airway patent but no respiratory effort –> hypercapnia –> arouses pt
Causes pulmonary hypertension
Idiopathic is rare: associated with CREST/ autoimmune
Secondary to COPD, interstitial lung disease, congenital cardiac disease, others
How is pulmonary HTN confirmed?
R heart catheterisation
PAH by exclusion
Mx pulmonary HTN
Warfarin to minimise risk of thrombosis
CCBs to reduce pressure in pulmonary vasculature
HF should be treated aggressively
Prevalence of asthma
5% adults, 20% children
Extrinsic vs intrinsic asthma
Extrinsic: atopic childhood asthma - remits in teens
Intrinsic: usually adult, progressive, less responsive to treatment
Precipitating factors to asthma attacks
viral infections, beta-blockers, NSAIDs
Management of acute asthma
O2
5 mg salbutamol nebs (oxygen-driven) every 15-30 minutes (continuous if life-threatening)
100 mg IV hydrocortisone
0.5 mg ipratropium nebs (every 4-6 h)
then need senior for IV magnesium, IV aminophylline
Mx of COPD in addition to medication
Yearly influenza jab, 5-yearly pneumococcus Pulmonary rehab (6-12 weeks) to work on exercise tolerance
Mx acute exacerbation of COPD
O2 venturi
Nebulised SABAs (salbutamol, ipratropium)
Oral steroids (30 mg pred) - for 7-14 days (may need reducing regimen)
Abx if infected
BiPAP if resp failure/ acidotic
Ix IECOPD
ABG ECG Sputum microscopy/ culture if purulent FBC/ U&Es Blood cultures if pyrexial Theophylline levels if on theophylline BODE Index
Common complications of influenza
Secondary bacterial pneumonia (Staph aureus)
Otitis media
Sinusitis
Encephalitis
Complications of pneumonia
Empyems/ lung abscess
AF
What are the HIV-related lung diseases?
TB in 40% (more likely to have atypical symptoms, CXR often atypical, higher risk multidrug-resistant) PCP CMV Aspergillus pulmonary Kaposi's sarcoma
Mx Pneumocysis jiroveci
High-dose co-trimoxazole
Check with senior as toxic - are alternatives
How does Goodpasture’s affect the resp sx?
Pulmonary haemorrhage
Pts present with haemoptysis, haematuria and anaemia
How does Wegener’s affect the resp sx?
affects small vessels of midline structures: nose, lungs, kidneys
rhinorrhea, cough, haemoptysis, dyspnoea
rare, necrotising vasculitis
How does Churg-Strauss affect the resp sx?
late-onset asthma
(also eosinophilia and vasospasm: MI, PE, DVT)
small vessel vasculitis
How does RA affect lungs?
10-15% have lung involvement diffuse pulmonary fibrosis pleural fibrosis pleural effusions rheumatoid nodules on lung (rare) other stuff...
How does SLE affect lungs?
Usually pleurisy, with or without effusions
How does systemic sclerosis affect lungs?
Pulmonary fibrosis > rapidly-progressive pulmonary HTN
How does ankylosis spondylitis affect lungs?
apical lung fibrosis
Complications of lung ca
Ulceration of bronchus Bronchial obstruction Central necrosis (causing abscess) Pancoast tumours causing Horner's Paraneoplastic syndromes hypertrophic pulmonary osteoarthropathy
Why may Hb be increased or decreased as a result of respiratory disease?
Secondary polycythaemia due to longstanding hypoxia
Decreased (normocytic) in anaemia of chronic disease
What may cause a reduced eosinophil count in respiratory disease?
Steroid therapy
Which respiratory disease may cause increased monocytes?
TB
What does an ASO titre confirm?
Recent strep infection
Causes of hypercalcaemia in respiratory disease?
malignancy
sarcoid
squamous cell carcinoma of lung
What can cause an increase in ACE?
sarcoid
When doing pleural tap how may fluid appear?
Transudates clear
Exudates cloudy
Empyema
Haemothorax
Causes of respiratory acidosis?
Impaired ventilation
asthma, COPD, pneumonia, sleep apnoea, acute PE, severe obesity, neuro musc problems, scoliosis, sedative OD, arrest
Causes of respiratory alkalosis?
Hyperventilation
heart attack, pain, asthma, anxiety, fever, COPD, infection, PE, pregnancy
Side-effects of SAMA/ LAMA
muscarinic sx
Side effects of SABA/ LABA
Fight or flight symptoms: anxiety, tremor, palpitations
Differentials for haemotysis
acute bronchitis, PE, lung malignancy, lung abscess, pneumonia, TB, bronchiectasis
1st web space wasting
T1 lesion, eg Pancoast
Hand signs of hypercapnia
Dilated veins
Palmer erythema
Asterexis
Resp causes of clubbing
Ca
ILD
suppurative lung disease
When may JVP be raised?
RHF
PE
SVC obstruction
Cause of crackles on resp exam
Early: small airway disease, eg bronchiolitis
Mid-inspiration: pulm oedema
Late inspiration: ILD, COPD, pneumonia
throughout: bronchiectasis
Mx anaphylaxis
Adrenaline
ABCDE
Fluids 500 mL - 1000 mL, keep repeating
10 mg chlorphenamine, IM or slow IV
Consider corticosteroids
Consider salbutamol
Measure tryptase levels within 4 h
Observe for 6-12 h
Blood vessels on a rib
VAN
so trains go above the rib
What is a saddle embolus?
straddles pulmonary artery in lumens of both R and L pulmonary artery
Mendelson’s syndrome
Chemical pneumonitis secondary to aspiration
Which lobes commonly involved in aspiration pneumonia?
Supine: RUL
Sitting: RLL
