resp Flashcards
causes of pleural effusion
exudate (protein > 35g/dl): infection (pneumonia), inflammation (SLE, rheumatoid arthritis), malignancy (lung cancer, mets)
transudate (protein < 25g/dl): cardiac, liver, renal failure
causes of ILD
idiopathic pulmonary fibrosis
occupational / environmental: extrinsic allergic alveolitis / pneumoconiosis
drugs: methotrexate, amiodarone
inflammatory: SLE, RA, sarcoidosis, ank spond, systemic sclerosis
other: radiation
ILD investigations
bloods: FBC, CRP/ESR,
serology: RF, ANA, anti-CCP, anti-Jo
lung function tests (restrictive pattern)
CXR (initial)
high-res CT → honeycombing
bronchoscopy + biopsy (diagnostic)
definition of COPD
emphysema + chronic bronchitis
emphysema = enlargement of alveolar spaces
chronic bronchitis = chronic productive cough for at least 3mths/year for at least 2 years
signs of hyperexpansion
reduced cricosternal distances (normal = 3 fingers) tracheal tug barrel chest reduced chest expansion loss of cardiac dullness displaced liver edge
signs on examination for COPD
hyperexpansion hyperresonance reduced breath sounds + vocal resonance coarse crackles expiratory wheeze
causes type 1 resp failure
ventilation perfusion mismatch: pneumonia PE pulmonary oedema asthma ARDS
causes type 2 resp failure
resp disease: COPD, asthma, pneumonia, obstructive sleep apnoea
reduced resp drive: sedatives, CNS tumour / trauma
neuromuscular disease: guillain-barre, myasthenia gravis
thoracic wall disease: flail chest, kyphoscoliosis
pulmonary embolism ECG findings
S1Q3T3
deep S waves in lead I
deep Q waves in lead III
inverted T waves in lead III
management suspected pulmonary embolism
Well’s score:
4 or less = PE unlikely → D-dimer → immediate CTPA + admission if +ve
5 or more = PE likely → admission + immediate CTPA
management confirmed pulmonary embolism
- LMWH (tinzaparin 175units/kg once daily SC) / fondaparinux for > 5 days / until INR > 2 for > 24hrs
for 6mths for pts w active cancer - start warfarin within 24hrs
continue for at least 3mths and reassess whether should be continued
continue for >3mths if unprovoked PE - thrombolysis for massive PE w haemodynamic instability: tPa, streptokinase
management stable COPD
- short acting bronchodilator: SABA (salb) / SAMA (ipratropium)
- long acting bronchodilator: LABA (salmeterol), LAMA (tiotropium)
- inhaled corticosteroid (combined inhalers if poss)
long-term oxygen therapy
surg: lung volume reduction surg / transplant
- inhaled corticosteroid (combined inhalers if poss)
management acute COPD
ABCDE
- neb salb / ipratropium
- oxygen if sats < 90 (aim for 88-92%) via venturi
- oral steroids 5 days
- NIV (BiPAP) if respiratory insufficiency
- antibiotics if infective exacerbation
management acute asthma
ABCDE oxygen: high-flow 15L via non-rebreathe mask neb 5mg salb (oxygen-driven / via spacer) oral pred 40mg (5 days) neb ipratropium IV magnesium sulphate IV aminophylline intubation + ventilation
management stable asthma
- PRN inhaled SABA (salb)
- BD inhaled low-dose CS (beclamethasone)
- inhaled LABA (salmeterol)
if not effective consider: increased steroid dose, LTRA (montelukast), SR theophylline, oral beta-agonist
- inhaled LABA (salmeterol)
- daily oral steroids
indications for NIV (BiPAP)
COPD w respiratory acidosis 7.25-7.35
type 2 respiratory failure (neuromuscular disease or chest wall deformities)
failure of CPAP for pulmonary oedema
indications for CPAP
chronic severe obstructive sleep apnoea
type 1 respiratory failure e.g. acute pulmonary oedema
ILD management
cons: MDT approach, smoking cessation, pulmonary rehabilitation
med: anti-fibrotic drugs e.g. pirfenidone, nintedanib
steroids (exacerbation fo Sx)
LTOT
surgery: lung transplant (curative)
signs on examination ILD
clubbing
fine end-inspiratory crepitations
causes of upper lobe fibrosis
ROTAS: radiation occupational: EAA / pneumoconiosis TB ank spond sarcoidosis
causes of lower lobe fibrosis
DR CIA: drugs: methotrexate, amiodarone connective tissue disease e.g. RA, SLE idiopathic pulmonary fibrosis asbestos
indications for pneumonectomy
primary lung cancer pulmonary metastases traumatic lung injury bronchiectasis infection: TB, fungal
indications for lobectomy
primary lung cancer
lung volume reduction (COPD)
bronchiectasis
infection: TB (upper lobe), fungal
differentials for thoracotomy scar
pneumonectomy lobectomy lung transplant chest wall resection oesophagectomy
indications for lung transplant
COPD ILD cystic fibrosis alpha1-antitrypsin deficiency pulmonary HTN bronchiectasis
differentials for coarse crackles vs fine crackles
corase: bronchiectasis, COPD, pneumonia
fine: ILD, pulmonary oedema, pneumonia, atelectasis
differentials for wheeze
asthma / COPD
bronchiectasis
anaphylaxis
foreign body
signs on examination bronchiectasis
clubbing coarse crackles high-pitched inspiratory squeaks monophonic wheeze rhonchi (low-pitched rattling due to secretions in bronchial airways)
causes of bronchiectasis
idiopathic
post-infective: TB, measles, ABPA
genetic: a1antitrypsin, cystic fibrosis, Kartagener’s
bronchial obstruction: malignancy, foreign body, lymphadenopathy
connective tissue disease: RA, sjogren’s EDS, marfan
management bronchiectasis
cons: airway clearance therapy (postural drainage, percussion, vibration)
pulmonary rehabilitation
med: ABx for acute exacerbations
long-term macrolide if >2 / year
bronchodilators / theophylline if trial shows improvement
LTOT
surg: resection of bronchiectatic areas of lung
lung transplant
investigations bronchiectasis
bedside: sputum culture
bloods: FBC, U&Es
alpha1 antitrypsin
screen for immunodeficiency / connective tissue disease
aspergillus markers
cystic fibrosis testing
imaging:
CXR
high-res CT is diagnostic (ring shadows, tramlines)
other:
lung function testing (obstructive)
types of lung cancer
non-small cell:
squamous cell: PTHrP → Ca
adenocarcinoma: non-smokers
large cell
small cell:
ectopic hormone production (ADH, ACTH, PTH, GnRH)
presentation pancoasts tumour
apical lung tumour → compression of structures:
brachial plexus → hand muscle wasting
arteries → oedema of arms
sympathetic ganglion → Horner’s syn (ptosis, miosis, anhydrosis)
SVC → facial swelling / flushing, difficulty breathing
small cell tumours → ectopic hormone production (ACTH, ADH, PTH)
investigations lung cancer
bloods: FBC, U+Es, LFTs, bone profile CXR, contrast CT PET-CT → distant mets bronchoscopy + biopsy lung function testing (?fit for surg)
complications of old TB
aspergilloma in old TB cavity
bronchiectasis (lymph node causes obstruction)
risk of bronchial carcinoma
causes of consolidation
fluid: pulmonary oedema
pus: pneumonia
blood: pulmonary haemorrhage
cells: malignancy
pneumonia severity score + resulting action
confusion
urea > 7
resp rate > 30
BP < 90/60 (either systolic OR diastolic)
age > 65
1: community management
2: community management if sats > 90 + normal CXR
3: admit
4: consider ITU
5: manage in ITU (30% mortality at 30 days)
types of pneumothorax
spontaneous: no precipitating event
traumatic: penetrating / blunt chest injury
tension: one-way valve → air entry during inspiration (emergency)
management pneumothorax
primary: no underlying lung disease
< 2cm / no SOB: conservative, discharge w advice + follow-up CXR
> 2cm / SOB: aspiration 2nd ICS MCL w large-bore cannula
failure → chest drain: 5th ICS MAL
secondary: underlying lung disease e.g. asthma, COPD, cystic fibrosis admit for > 24hrs < 1cm: oxygen + analgesia + observation 1-2cm: aspiration >2cm / > 50years: chest drain
borders of safe triangle (for chest drain)
base of axilla
lat border pec major
ant border latissimus dorsi
5th ICS / line superior to horizontal level of nipple
signs on examination pneumothorax
reduced chest expansion
hyperressonance
absent / reduced breath sounds + TVF
tracheal deviation from affected side in tension pneumothorax
management recurrent pleural effusion
recurrent aspiration
pleurodesis: insertion of temporary chest drain + talc (sclerosing agent)
indwelling pleural catheter
opioids relieve dyspnoea
management pneumonia
ABCDE
oxygen, analgesia, fluids
ABx:
mild: 5 days oral amox (macrolide if allergic / atypical)
mod: 7-10 days oral / IV amox + macrolide
severe: IV co-amox + macrolide
repeat CXR in 6wks post-resolution
mechanism of BiPAP
iPAP > ePAP
iPAP: ventilates
ePAP: recruits collapsed / underventilated alveoli
causes of tracheal deviation
pulls towards: lobar / lung collapse, pneumonectomy, pulmonary hypoplasia
pushes away: tension pneumothorax, massive pleural effusion, large thoracic mass, diaphragmatic hernia
management of anaphylaxis (incl dose)
IM adrenaline 0.5mg 1:1000 IV hydrocortisone 200mg neb salb IV chlorphenamine 10mg \+ IV fluids if shock
management hospital acquired pneumonia
< 5 days: co-amox / cefuroxime
> 5 days: tazocin / ciprofloxacin
pseudomonas: tazocin
MRSA: vancomycin
causes of ARDS
pulmonary: trauma, pneumonia, inhalation of smoke / soot
extra-pulmonary: sepsis, DIC, pancreatitis
