Resp Diseases Flashcards
types of pneumothorax?
Spontaneous- primary (no lung disease) and secondary (lung disease)-e.g. bronchiectasis, CF, emphysema, asthma
Traumatic
TENSION
Iatrogenic e.g. post central line or pacemaker insertion
RFs for pneumothorax?
smoking/cannabis diving pre-existing lung disease trauma/chest procedure height assoc. with other conditions e.g. Marfan syndrome- autosomal dominant condition assoc. with a mutation in the fibrillin-1 gene causing an increase in the protein transforming growth factor beta (TGF-beta) which causes CT problems- cardioresp include spontaneous pneumothorax, aortic dissection and aortic regurgitation.
Pneumothorax management as per BTS guidelines?
spontaneous primary- if symptomatic and rim of air more than 2cm on CXR (between lung margin and chest wall)=large pneumothorax, give O2 and needle aspirate. if unsuccessful, consider re-aspiration or intercostal drain (small bore). remove drain after full re-expansion/cessation of air leak. if small (so rim 2cm or less) and not significantly breathless, just OBSERVE. if no breathlessness, consider for discharge and early OP r.v, and advise to return if worsening breathlessness.
secondary- as above, but lower threshold for IC drain- if air rim more than 2cm and pt well, do IC drain as 1st line. should receive supplemental oxygen. if unfit for chest drain, consider medical pleurodesis or ambulatory management with a heimlich valve.
TENSION: emergency needle decompression with large bore cannula e.g. grey 16G into corresponding 2nd IC space anter. MCL before proceeding to chest drain.
if persistent air leak more than 5 days (bronchopleural fistula) refer to thoracic surgeons. may do open thoracotomy and pleurectomy if difficult or recurrent pneumothoraces.
emphasis on smoking cessation to minimise risk of recurrence
discharge advice- no flying or diving until resolved. diving should be permanently avoided.
if querying PE, what RFs should be identified in the history that may suggest risk of predisposing DVT/high risk of PE?
previous proven DVT/PE obese OCP malignancy lower limb fracture, varicose veins recent long haul flight, economy class-recent immobility immobilisation clotting disorder e.g. thrombophilia e.g. antiphospholipid syndrome* post-partum, C section
if the protein fluid of a pleural effusion is borderline, what criteria can be used to determine if the effusion is an exudate (pleural protein more than 30g/L)?
Light’s criteria: exudate if 1 or more of the following:
pleural fluid protein/serum protein more than 0.5
pleural fluid LDH/serum LDH more than 0.6
pleural fluid LDH more than 2/3 of the upper limit of normal serum lab value.
absolute contraindications to thrombolysis in PE patient?
haemorrhagic stroke or ischaemic stroke less than 6mnths ago CNS neoplasia recent trauma or surgery GI bleed less than 1 mnth ago bleeding disorder aortic dissection
relative contraindications to thrombolysis?
warfarin
pregnancy
advanced liver disease
infective endocarditis
complications of thrombolysis?
bleeding hypotension intracranial haemorrhage/stroke reperfusion arrhythmias systemic embolisation of thrombus allergic reaction
wells’ criteria for DVT, used to calculate DVT risk?
active cancer, treatment or palliation within 6 mnths
calf swelling more than 3cm compared to other leg
entire leg swollen
previous documented DVT
paralysis, paresis or recent plaster immobilisation of lower extremity
bedridden recently for 3 or more days, or major surgery within last 12 wks
pitting oedema confined to symtpmatic leg
localised tenderness along deep venous system
collateral (nonvaricose) superficial veins present, measured 10cm below tibial tuberosity
alternative diagnosis at least as likely
all score 1 point, apart from last which scores -2
implication of wells’ DVT risk score of 3 or more?
DVT likely, pt should receive diagnostic USS, pretest prob. 17-53%
implication of wells’ DVT risk score 1-2?
moderate risk, pretest prob. of 17%
should proceed to high sensitivity d-dimer testing
implication of wells’ DVT risk score of 0 or less?
DVT unlikely, prevalence 5%
proceed to d-dimer testing, where negative high or moderate sensitivity requires no further imaging, and positive d-dimer should proceed to USS.
wells’ criteria for PE?
previous VTE = 1.5
immobilisation or major surgery in previous 4wks = 1.5
cancer = 1
haemoptysis = 1
signs of DVT = 3
HR more than 100 = 1.5
alternative diagnosis less likely than PE = 3
max score=12.5
low risk= 0-1
moderate risk= 2-6
high risk= 7 or more
if pt deemed high risk of PE with wells’ criteria, how should management proceed?
consider CT pulmonary angiogram
d-dimer testing NOT recommended
if low risk, consider d-dimer testing.
causes of PE other than DVT?
RV thrombus post-MI septic emboli (R sided endocarditis) fat, air or amniotic fluid embolism thrombus formation after central venous access neoplastic cells parasites
define thrombophilia
an inherited or acquired coagulopathy predisposing to thrombosis, usually VTE.
conditions which increase thrombosis risk?
arterial=HTN, hyperlipidaemia, DM
venous= malignancy, thrombophilia, HF, IBD, nephrotic syndrome-lose proteins responsible for inhibiting clotting factors e.g. protein C-inactivates clotting factors Va and VIIIa, and antithrombin III-inactivates thrombin (II) and Xa, and paroxysmal nocturnal haemoglobinuria.
causes of inherited thrombophilia?
activated protein C (APC) resistance/factor V Leiden
Protein C and protein S deficiency
Antithrombin deficiency
Prothrombin gene mutation
what is antiphospholipid syndrome?
acquired coagulopathy. usually occurs as a primary disease, but be associated with SLE. antiphospholipid antibodies (anti-cardiolipin and lupus anticoagulant) cause CLOTS:
coagulation defect
livedo reticularis-pink-blue mottling caused by capillary dilatation and stasis in skin venules
obstetric (recurrent miscarriage)
thrombocytopenia
treament= low dose aspirin, or warfarin if recurrent thromboses
PE symptoms?
acute breathlessness
sudden onset pleuritic chest pain- sharp an worse with inspiration
sudden breathlessness and pleuritic chest pain most common
haemoptysis
low CO followed by collapse if massive PE-haemodynamic compromise and R heart strain, dizziness, syncope
PE signs?
pyrexia tachycardia tachypnoea cyanosis hypotension raised JVP pleural rub pleural effusion signs of a cause e.g. DVT- swollen calf, leg pitting oedema, tenderness, entire leg swollen
what might ABG show in PE?
type 1 RF:
PaO2 less than 8kPa
PaCO2 reduced as ventilation/perfusion mismatch with inadequate oxygen available in well perfused alveoli for Hb binding, so pt may hyperventilate.
therefore, may cause a respiratory alkalosis
what might a CXR in presence of PE show?
wedge shaped opacities or cavitation small pleural effusion- homogeneous white opacification, meniscus sign linear atelectasis* dilated PA oligaemia of affected segment*
what might an ECG show in PE?
normal
sinus tachycardia
RBBB, RAD
RV strain (inverted T in V1 to V4 and dominant R wave V1-V2, RAD, may be similar changes in II, III AND aVF, and may be deep S waves in I, path Q waves in III, and inverted T waves in III)