Resp Conditions Flashcards
1
Q
Aspergillus Lung Disease
- Definition
- Aetiology/Risk factors
- Epidemiology
- Presenting Syx
- Presenting Sx
- Investigations
A
- Lung disease associated with Aspergillus infection (Asp. fumigatus)
- Inhalation of spores produces:
- Aspergilloma (growth of A. fumigates mycetoma ball in pre-existing lung cavity), OR
- Allergic bronchopulmonary aspergillosis (ABPA)
- colonisation of airways by asp leads to IgE and G mediated IR,
- usually in asthmatics
- release of proteolytic enzymes, mycotoxins and Ab leads to airway damage and central bronchiectasis)
- Invasive aspergillosis: invasion of asp into lung tissue and fungal dissemination; occuring in immunosuppressed pts
- Uncommon, mainly in elderly and immunocompromised
- Aspergilloma = asyx and potentially massive haemoptysis; ABPA = difficult to control asthma, recurrent pneumonia with wheeza, cough, fever and malaise; invasive aspergillosis = dyspnoea, rapid deterioration and septic picture
- Tracheal deviation with large aspergilloma; dullness in affected lung; reduced breath sounds; wheeze in ABPA; cyanosis possible in invasive aspergillosis
- x
- Aspergilloma: CXR = round mass with crescent of air around it; CT/MRI if CXR unclear; sputum culture could be negative
- ABPA: immediate skin test reactivity to asp Ag, eosinophilia, raised total sIgE and specific sIgE and IgG to A. fumigatus; CXR = transient patchy shadows, collapse, distended mucous filled bronchi, complications = fibrosis in upper lobes and bronchiectasis; CT = lung infiltrates and central bronchiectasis; lung function tests = reversible airflow limitation and reduced lung volumes/gas transfer
- Invasive aspergillosis: cultures/histological exam; broncheoalveolar lavage fluid/sputum may be used diagnostically; Chest CT = nodules with halo sign,
2
Q
Asthma
- Definition
- Aetiology/Risk factors
- Epidemiology
- Presenting Syx
- Presenting Sx
- Investigations
- Management plan
- Complications
- Prognosis
A
- Chronic inflammatory airway disease characterised by variable reversible airway obstruction, airway hyper-responsiveness and bronchial inflammation
- Genetic:FHX, atopy; environment: house dust mites, pollen, pets, cigarette smoke, viral RTI, asp fumigatus spores, occupational allergens
- 10% of children, 5% of adults with prevalence increasing
- Episodic Hx, wheeze, SOB, cough (worse am and night), previous hospitalisations; precipitating factors: cold, viral infection, drugs, exercise, emotions; check for PMH of atopic disease
- Tachypnoea, use of accessory muscles, prolonged exp phase, polyphonic wheeze, hyperinflated chest
- SEVERE attack: PEFR < 50% predicted, pulse>110/min, RR >25/min, inability to complete sentences
- LIFE THREATENING attack: PEFR <33% predicted, silent chest, cyanosis, bradycardia, hypotension, confusion, coma
- Acute: peak flow, pulse oximetry, ABG, CXR, FBC (WCC raised if infective exacerbation), CRP, U&Es, blood and sputum cultures
- Chronic: peak flow monitoring (diurnal variation with dip in the morning), pulm function test, bloods: eosinophilia, IgE level, asp Ab titres, skin prick tests (ID allergens)
- Management:
- Acute: ABCDE, resuscitate, monitor O2 stats, ABG, PEFR, high flow O2, salbutamol nebulizer (5mg, initially continuously then 2-4hrly), ipatropium bromide (0.5mg QDS), steroid therapy (100-200mg IV hydrocortisone; followed by 40mg oral prednisolone for 5-7d and if not improved IV MgSO4), consider IV aminophylline infusion/salbultamol; treat underlying cause (Abx), monitor electrolytes (drop in K), invasive ventilation in severe attacks
- Discharge when: PEF >75% predicted, diurnal variaton <25%, inhaler technique checked, stable on discharge meds for 24h, pt owns PEF meter and has steroid and bronchodilator therapy -> arrange follow up
- Chronic => Step match severity to pick start =
- inhaled SABA, if needed >1/d then onto step 2
- inhaled SABA and reg inhaled low dose steroids (400mcg/d)
- 2+inhaled LABA; if inadequate control with LABA then increase steroid to 800mcg/day (no control with LABA = stop LABA and up steroid)
- increased inhaled steroid (2000 mcg/d), 4th drug (leukotriene antagonist, slow release theophylline or b2 agonist)
- Regular oral steroids, maintain high-dose oral steroids, refer to specialist
- Advice = teach proper inhaler technique, explain importance of PEFR monitoring and avoid provoking factors
- Growth retardation, chest wall deformity (pigeon chest), recurrent infections, pneumothorax, resp failure and death
- Many children improve with age; adult onset is usually chronic
3
Q
Bronchiectasis
- Definition
- Aetiology/Risk factors
- Epidemiology
- Presenting Syx
- Presenting Sx
- Investigations
- Management plan
- Complications
- Prognosis
A
- Lung airway disease characterised by chronic bronchial dilation, impaired mucociliary clearance and frequent bacterial infections
- Chronic lung inflammation leads to fibrosis and permanent dilation of bronchi -> mucus pooling and further infections, damage and fibrosis of bronchial walls -> causes:
- idiopathic
- post-infection (pneumonia, tb)
- host-defence defects (cystic fibrosis)
- obstruction of bronchi
- GORD
- inflammatory disorders (rheumatoid arthritis)
- often initially in childhood; incidence decreased with Abx
- Productive cough with purulent sputum/haemoptysis; SOB; chest pain; malaise; fever; weight loss; syx begin after acute resp illness
- clubbing, coarse crepitaions (lung bases, shift with cough), wheeze
- Sputum for culture and sensitivity = P. aeruginosa, H influenzae, S aureus, strep pneumo, klebsiella, mycobacteria; CXR = dilated bronchi, fibrosis, atelectasis, pneumonic consolidations; High res CT shows bronchi dilated with thick walls; bronchography; sweat electrolytes for CF, serum Ig, mucociliary clearance study
- Acute exacerbations with 2 Abx IV, covering P. aeruginosa; prophhylactic Abx if frequent exacerbations; inhaled corticosteroids; bronchodilators; maintain hydration; flu vaccine; physio for mucus and sputum clearance; bronchial artery embolisation; surgical
- Life threatening haemoptysis, prsistent infections, empyema, resp failure, cor pulmonale, multi-organ abcesses
- Continue to have syx after 10yrs
4
Q
COPD
- Definition
- Aetiology/Risk factors
- Epidemiology
- Presenting Syx
- Presenting Sx
- Investigations
- Management plan
- Complications
- Prognosis
A
- Chronic progressive lung disorder characterised by airflow obstruction with the following -> chronic bronchitis (chronic cough and sputum production most days for at least 3m per year or over 2 consecutive years) and emphysema (pathological dx of permanent destructive enlargement of air spaces distal to terminal bronchioles)
- Broncheolar and alveolar damage caused by environmental toxins; rarely = alpha 1 antitrypsin deficiency; chronic bronchitis = narrowing of airways, bronchiolitis, bronchial mucosal oedema, mucous hypersecretion and squamous metaplasia; emphysema = destruction and enlargement of alveoli, leads to loss of elasticity, with larger spaces forming = bullae
- Very common (8%), middle age or later, more common in males (changing due to increase in female smokers)
- Chronic cough, sputum production, SOB, wheeze, reduced exercise tolerance
- Inspection = resp distress, accessory msucles, barrel chest, decreased cricosternal distance, cyanosis; Percussion = hyperresonant, loss of liver and cardiac dullness; auscultation = quiet breath sounds, prolonged exp, wheeze, rhonchi, crepitations; sx of CO2 retention = bounding pulse, warm peripheries, asterixis, late stage RHF (RV heave, raised JVP, anlkle oedema
- Spirometry and pulm function tests (reduced PEFR/FEV1/FVC, increased lung volumes and decreased CO gas transfer coefficient); CXR = normal, hyperinflation, reduced peripheral lung markings, elongated cardiac silhouette; bloods = FBC = increased Hb and Hct due to 2ry polycythaemia; ABG; ECG and echo; sputum and blood cultures (in acute infective exacerbations); alpha 1 antitrypsin levels
- Stop smoking; bronchodilators = SABA, LABA, anticholinergics; steroids = inhaled beclamethasone (FEV1 <50% or > 2 exacerbations per yr; pulm rehab; O2 therapy (stopped smoking and pO2 <7.3kpa); tx of acute exacerbations = 24% O2 with venturi mask, corticosteroids, abx therapy, resp physio for sputum
- Acute resp failure, infections, pulm hypertension; RHF; pneumothorax;2ry polycythaemia
- high morbidity, 3-years survival = 90% in FEV1 if under 60yrs old; FEV1 >50% predicted,
5
Q
Extrinsic allergic alveolitis
- Definition
- Aetiology/Risk factors
- Epidemiology
- Presenting Syx
- Presenting Sx
- Investigations
A
- interstitial inflammatory disease of distal gas-exchaning parts of lung caused by inhalation of organic dusts -> hypersensitivity pneumonitis
- Inhalation of antigenic dusts causes hypersensitivity response = farmer’s lung, pigeon fancier’s lung, maltworker’s lung
- Uncommon, 2% of occupational lung disease, 50% reported cases affect farm workers
- Acute = 4-12h after exposure, reversible episodes of = dry cough, dyspnoea, malaise, fever, myalgia (wheeze and productive cough may develop if repeat high level exposure); chronic = slowly increasing SOB, decreased exercise tolerance, weight loss, exposure usually chronic, low-level and may be no Hx of previous acute episodes
- Acute = rapid shallow breathing, pyrexia, inspiratory crepitations; chronic = fine inspiratory crep and clubbing (rare)
- Bloods = FBC (neutrophilia, lymphopoenia), ABG reduced PO2/CO2; serology = IgG to fungal/avian Ag; CXR = normal in acute episodes, fibrosis seen in chronic cases; high res CT-thorax; pulm function tests = restrictive defect (low FEV1, low FVC, preserved/increased FEV1/FVC, reduced total lung capacity); bronchoalveolar lavage = increased cellularity, lung biopsy can be performed
6
Q
Idiopathic pulmonary fibrosis
- Definition
- Aetiology/Risk factors
- Epidemiology
- Presenting Syx
- Presenting Sx
- Investigations
A
- Inflammatory condition of the lung resulting in fibrosis of the alveoli and interstitium, known as cryptogenic fibrosing alveolitis
- Genetically predisposed individuals, recurrent iinjury to alveolar epithelium = cytokine and growth factor secretion; leads to fibroblast activation, recruitment, proliferation, differentiatiions into myofibroblasts and increased collagen synthesis and deposition; interstitial pneumonia and RF = smoking, occupational exposure to metal/wood, chronic microaspiration, animal and veg dusts
- Rare, more common in males, 6/100000
- Gradual onset, progressive dyspnoea on exertion, dry irritating cough, no wheeze, may be preceded by viral type illness, fatigue and weight loss common
- clubbing (50%), bibasal fine late inspiratory crackles; signs of RHF in advanced stages of disease
- Bloods = ABG PCO2 rises in late stages of disease, ANA and RhF (1/3 positive); CXR = normal, ground glass shadowing, later stage reticulonodular shadowing, signs of cor pulmonale and honeycombing; high res CT; pulm function tests = restrictive features, decreased lung vols/compliance/lung capacity; bronchoalveolar lavage; lung biopsy - gold standard for dx; echo
7
Q
Obstructive sleep apnoea
- Definition
- Aetiology/Risk factors
- Epidemiology
- Presenting Syx
- Presenting Sx
- Investigations
A
- Disease characterised by recurrent prolapse of pharyngeal airway and apnoea (cessation of airflow for >10s) during sleep, followed by arousal for sleep
- Narrowing of upper airways because of the collapse of soft tissues of the pharynx, due to decreased tone of the pharyngeal dilators during sleep -> associated with = weight gain, smoking, alcohol, sedative use, enlarged tonsils/adenoids in children, macroglossia, marfan’s syndrome and craniofacial abnormalities
- Common, 5-20% men >35, 2-5% women >35 and prevalence increases with age
- Excessive daytime sleepiness, unrefreshing/restless sleep, morning headaches, dry mouth, difficulty concentrating, irritability and mood changes, partner reported choking/apnoeic episodes at night
- Large tongue, enlarged tonsils, long/thick uvula, retrognathia, neck circumference >42M, >40F; obesity, HTN
- Sleep study = monitor airflow, resp effort, pulse oximetry and HR; bloods = TFTs, ABG
8
Q
Pneumoconiosis
- Definition
- Aetiology/Risk factors
- Epidemiology
- Presenting Syx
- Presenting Sx
- Investigations
A
- Fibrosing interstitial lung disease caused by chronic inhalation of mineral dusts = types:
- Simple = coalworker’s pneumoconiosis (syx-free)
- Complicated = resulting in loss of lung function
- Asbestosis = pneumoconiosis which diffuse parenchymal lung fibrosis occurs as a result of long exposure to asbestos
- Caused by inhalation of particles of coal dust, silica and asbestos; RF = occupational exposure, risk is dependent on extent of exposure and size/shapes of particles, individual susceptibility is also important, co-factors such as smoking and TB also contribute
- increasing in developing countries; disability/mortality from asbestosis will increase for next 20-30yrs
- OCCUPATION, asyx picked up on routine CXR; Syx = insidious onset of shortness of breath, dry cough, black sputum (melanoptysis in coalworkers occasionally), pleuritic chest pain (asbestosis)
- Exam may be normal; coalworker’s pneumoconiosis and silicosis = decreased breath sounds; asbestosis = end inspiratory crepitations, clubbing; signs of pleural effusions or RHF
- CXR: simple = micronodular mottling, complicated = nodular opacities in upper lobes / micronodular shadowing / eggshell calcification of hilar lymph nodes / bilat lower zone retculonodular shadowing and pleural plaques; CT scan = fibrotic changes can be visualised early; bronchoscopy = visualisation and bronchoalveolar lavage; LFT = restrictive
9
Q
Pneumonia
- Definition
- Aetiology/Risk factors
- Epidemiology
- Presenting Syx
- Presenting Sx
- Investigations
- Management
- Complications
- Prognosis
A
- Infection of distal lung parenchyma, classified = Community-acquired, nosocomial, aspiration pneumo, pneumo in immunocompromised, typical and atypical (mycoplasma, chlamydia, legionella)
- CAP: Strep pneumo 70%, haemophilus influenzae, moraxella catarrhalis (COPD), chlamydia psittaci (psittacosis), legionella (air con), staph aureus, mycoplasma pneumonia, TB, coxiella burnetii (q fever); HAP: GNB (pseudomonas, klebsiella) and anaerobes; RF = age, smoking, alcohol, pre-existing lung disease, immunodeficiency, contact with patients with pneumonia
- CAP for >60,000 deaths per year in uk
- Fever, rigors, sweating, malaise, cough, sputum, SOB, pleuritic chest pain, confusion; atypical = headache, myalgia, darrhoea/abdo pain, DRY cough
- Pyrexia, resp distress, tachypnoea/cardia, hypotension, cyanosis, decreased chest expansion, chronic suppurative lung disease (clubbing), affected areas = dull to percuss , increased vocal fremitus, bronchial breathing and coarse crepitations
- Bloods = FBC (^WCC), U&Es, LFT, blood cultures, ABG, blood film (mycoplasma = agglutination of RBC); CXR = lobar/patchy shadowing, pleural effusion; sputum/pleural fluids; urine (pneumococcus and legionella Ag); atypical viral serology; bronchoscopy, bronchoalveolar lavage
- Assess severity with british thoracic society guidelines (markers).
- Start empirical Abx = oral amoxicillin (0), oral/IV amoxicillin and rythromycin (1), IV cefuroxime/cefotaxime/co-amoxiclav + erythromycin (>1), add metronidazole if aspiration, lung abcess or empyema, and switch based on sensitivity.
- Supportive treatment = O2, IV fluids, CPAP/BiPAP/ITU care for resp failure, surgical drainage for lung abcessess and empyema
- Discharge planning = 2 or more = high temp, tachycardia/pnoea, hypotension, low O2 sats, means high risk of readmission
- Prevention = pneumococcal vaccine, H. influenzae B vaccine
- Pleural effusion, empyema, localised suppuration (abcesses = swinging fever, persistent pneumonia, copious, foul smelling sputum), septic shock, ARDS, acute renal failure. Mycoplasma p = erythema multiforme, myocarditis, haemolytic anaemia, meningoencephalitis, transverse myelitis, guillan-barre syndrome
- Most resolve within 1-3wks, severe has high mortality. CURB-65 for severity = confusion <8AMTS, Urea >7mmol.L, RR >30/min, BP sys<90 or dias <60, age>65
10
Q
Pneumothorax
- Definition
- Aetiology/Risk factors
- Epidemiology
- Presenting Syx
- Presenting Sx
- Investigations
- Management
- Complications
- Prognosis
A
- Air in pleural space (haemo = blood, chylo = lymph)
- Spontaneous = normal lungs, tall/thin males, rupture of subdural bleb; 2ry = pts with pre-existing lung disease; traumatic = penetrating injury to the chest, iatrogenic (JV cannulation, thoracocentesis); RF = collagen disorders (marfan’s, ehlers-danlos)
- annual 9/100,000, mainly 20-40yr olds, 4x more common in M
- Asyx if small; sudden onset SOB, pleuritic chest pain, distress with rapid shallow breathing in tension pneumoT
- None if small, signs of resp distress, reduced expansion, hyper-resonance to percussion, reduced breath sounds; tension pneumoT = severe resp distress, tachycardia, hypotension, cyanosis, distended neck veins, tracheal deviation (AWAY)
- CXR -> dark film area with no vascular markings, fluid level may be seen if bleeding; ABG to check for hypoxaemia
- x
- Tension = EMERGENCY so max O2, insert large bore needle into 2nd ICS at MCL, aspirate up to 2.5L of air, stop if cough/resistance is felt; follow up CXR 2hr and 2wks later;
- Chest drain with underwater seal = performed if aspiration fails, fluid in pleural cavity or after decompression of tension, inserted in 4-6th ICS at mid axillary line;
- Recurrent = clhemical pleurodesis (fusing visceral+parietal pleura with tetracycline), surgical pleurectomy.
- Advice = avoid air travel until follow up CXR confirms it resolved, avoid diving
- Recurrent pneumothoraces, bronchopleura fistula
- after having 1, 20% or more have another, with freq increasing with recurrent
11
Q
Tuberculosis
- Definition
- Aetiology/Risk factors
- Epidemiology
- Presenting Syx and Presenting Sx
- Investigations
A
- Granulomatous disease caused by mycobacterium tuberculosis; 1ry = initial infection may be pulmonary or GI (rare), Miliary = haematogenous dissemination of TB, post-1ry TB caused by reinfection/reactivation
- M. TB is an intracellular organism, survives after being phogcytosed; RF = close contact with infected, immunocompromised = HIV, Substance abuse, Silicosis, DM, Severe kidney disease, Low body weight, Head and neck cancer, corticosteroids or organ transplant
- Annual mortality = 3 million, in UK 6000 incidence
- x
- 1ry = asyx, fever, malaise, cough, wheeze, erythema nodosum, phlyctenular conjunctivitis;
- miliary = fever, weight loss, meningitis, yellow caseous tubercles;
- post-1ry = fever/night sweats, malaise, weight loss, SOB, cough, sputum, haemoptysis, pleuritic chest pain, signs of pleural effusion, collapse, consolidation, fibrosis;
- LN has suppuration leading to abcesses,
- CNS = meningitis, tuberculoma; skin = lupus vulgaris;
- heart = pericardial effusion, constrictive pericarditis;
- GI = subacute obstruction, change in bowel habit, weight loss, peritonitis, ascites;
- genitourinary = UTI syx, renal failure, epididymitis, endometrial/tubal involvement, infertility;
- adrenal insufficiency;
- osteomyelitis, arthritis, vertebral collapse, spinal cord compression
- Sputum/pleural fluid/bronchial washing, tuberculin tests, mantoux test, heaf test; INF-g test, HIV testing, CT, LN, pleural biopsy, sampling of other affected systems, CXR=
- 1ry = peripheral consolidation, hilar lymphadenopathy
- Miliary = fine shadowing
- Post-1ry = upper lobe shadowing, streaky fibrosis and cavitation, callcification, pleural effusion, hilar lymphadenopathy
12
Q
Pulmonary embolism
- Definition
- Aetiology/RF
- Epidemiology
- Presenting Syx
- Presenting Sx
- Investigations
- Management
- Complications
- Prognosis
A
- Occlusion of pulmonary vessels, commonly by thrombus that travelled to pulm vascular system from another site
- Thombus = 95% from DVT in lower limbs, rarely arising in right atrium in AF pts; other embolus causes = Amniotic fluid, air, fat, tumour, mycotic. RF =
- Surgical pts
- Immobility
- Obesity
- OCP
- HF
- Malignancy
- Relatively common, esp in hospitalised pts; occurs in 10-20% of pts with confirmed proximal DVT
- Small may be asyx; moderate = sudden onset SOB, cough, haemoptysis, pleuritic chest pain; large (or proximal) = as mod and severe central pleuritic chest pain, shock, collapse, acute RHF, sudden death; multiple and recurrent ones = syx of pulm hypertension
- Small often has no clinical signs or some tachycardia/pnoea; moderate = tachypneoa/cardia, pleural rub, low O2 sats; massive = shock, cyanosis, signs of RH strain: raised JVP, left parasternal heave, accentuated S2; multiple recurrent = sx of pulm hypertension and RHF
- Well’s score used to determine the best investigations = low probability with Wells <4 = d-dimer; high probability with Wells >4 = imaging (CTPA). Others:
- bloods = ABG, thrombophilia screen
- ECG = normal/tachy, right acis deviation or RBBB/ S1Q3T3 pattern
- CXR = normal but helps exclude other dx.
- Spiral CT pulm angiogram = 1st line investigation; poor sensitivity for small emboli, very for med-large emboli
- VQ scan = indicates area of infarcted lung
- Pulm angiography = invasive, rarely necessary
- Doppler US of lowe limb
- Echo
- x
- 1ry prevention: compression stocking, heparin prophylaxis and good mobilisation and adequate hydration
- If haemodynamically stable = O2, anticoag with heparin/LMWH, switch to oral warfarin for at least 3months (INR at 2-3), analgesia
- If haemodynamically unstable = Resuscitate, O2, IV fluids, thrombolysis with tPA if cardiac arrest imminent
- Surgical/Radiological = embolectomy, IVC filters (sometimes for recurrent PEs despite adequate anticoag/anticoag contraindicated
- Death, pulm infarction, pulm HTN, RHF
- 30% mortality if untreated, 8% mortality with treatment; increased risk of future thromboembolic disease
13
Q
Define
Aspergillus lung disease
A
- Lung disease associated with Aspergillus infection (Asp. fumigatus)
- Aspergilloma (growth of A. fumigates mycetoma ball in pre-existing lung cavity), OR
- Allergic bronchopulmonary aspergillosis (ABPA)
- colonisation of airways by asp leads to IgE and G mediated IR,
- usually in asthmatics
- release of proteolytic enzymes, mycotoxins and Ab leads to airway damage and central bronchiectasis)
- Invasive aspergillosis: invasion of asp into lung tissue and fungal dissemination; occuring in immunosuppressed pts
14
Q
S+S
Aspergillus lung disease
A
- Aspergilloma = asyx and potentially massive haemoptysis;
- ABPA = difficult to control asthma, recurrent pneumonia with wheeza, cough, fever and malaise;
- invasive aspergillosis = dyspnoea, rapid deterioration and septic picture
- Tracheal deviation with large aspergilloma;
- dullness in affected lung;
- reduced breath sounds;
- wheeze in ABPA;
- cyanosis possible in invasive aspergillosis
15
Q
Investigations
Aspergillus lung disease
A
- Aspergilloma:
- CXR = round mass with crescent of air around it;
- CT/MRI if CXR unclear; sputum culture could be negative
- ABPA:
- immediate skin test reactivity to asp Ag, eosinophilia, raised total sIgE and specific sIgE and IgG to A. fumigatus;
- CXR = transient patchy shadows, collapse, distended mucous filled bronchi,
- complications = fibrosis in upper lobes and bronchiectasis;
- CT = lung infiltrates and central bronchiectasis;
- lung function tests = reversible airflow limitation and reduced lung volumes/gas transfer
- Invasive aspergillosis:
- cultures/histological exam;
- broncheoalveolar lavage fluid/sputum may be used diagnostically;
- Chest CT = nodules with halo sign,
16
Q
Define
Asthma
A
Chronic inflammatory airway disease characterised by variable reversible airway obstruction, airway hyper-responsiveness and bronchial inflammation
17
Q
S+S
Asthma
A
- Episodic Hx, wheeze, SOB, cough (worse am and night), previous hospitalisations;
- precipitating factors: cold, viral infection, drugs, exercise, emotions;
- check for PMH of atopic disease
- Tachypnoea, use of accessory muscles, prolonged exp phase, polyphonic wheeze, hyperinflated chest
- SEVERE attack: PEFR < 50% predicted, pulse>110/min, RR >25/min, inability to complete sentences
- LIFE THREATENING attack: PEFR <33% predicted, silent chest, cyanosis, bradycardia, hypotension, confusion, coma
18
Q
Investigations
Asthma
A
- Acute: peak flow, pulse oximetry, ABG, CXR, FBC (WCC raised if infective exacerbation), CRP, U&Es, blood and sputum cultures
- Chronic: peak flow monitoring (diurnal variation with dip in the morning), pulm function test, bloods: eosinophilia, IgE level, asp Ab titres, skin prick tests (ID allergens)
19
Q
Management
asthma
A
- Acute:
- ABCDE, resuscitate, monitor O2 stats, ABG, PEFR,
- high flow O2, salbutamol nebulizer (5mg, initially continuously then 2-4hrly), ipatropium bromide (0.5mg QDS), steroid therapy (100-200mg IV hydrocortisone;
- followed by 40mg oral prednisolone for 5-7d and if not improved IV MgSO4),
- consider IV aminophylline infusion/salbultamol;
- treat underlying cause (Abx),
- monitor electrolytes (drop in K),
- invasive ventilation in severe attacks
- Discharge when: PEF >75% predicted, diurnal variaton <25%, inhaler technique checked, stable on discharge meds for 24h, pt owns PEF meter and has steroid and bronchodilator therapy -> arrange follow up
- Chronic =>
- Step match severity to pick start =
- inhaled SABA, if needed >1/d then onto step 2
- inhaled SABA and reg inhaled low dose steroids (400mcg/d)
- 2+inhaled LABA; if inadequate control with LABA then increase steroid to 800mcg/day (no control with LABA = stop LABA and up steroid)
- increased inhaled steroid (2000 mcg/d), 4th drug (leukotriene antagonist, slow release theophylline or b2 agonist)
- Regular oral steroids, maintain high-dose oral steroids, refer to specialist
- Advice = teach proper inhaler technique, explain importance of PEFR monitoring and avoid provoking factors
20
Q
define
Bronchiectasis
A
Lung airway disease characterised by chronic bronchial dilation, impaired mucociliary clearance and frequent bacterial infections
21
Q
S+S
Bronchiectasis
A
- Productive cough with purulent sputum/haemoptysis;
- SOB;
- chest pain;
- malaise;
- fever;
- weight loss;
- syx begin after acute resp illness
- clubbing,
- coarse crepitaions (lung bases, shift with cough),
- wheeze
