Resp General Flashcards
Vital capacity/forced vital capacity
Volume that can be exhaledafter maximum inspiration
(ie. maximum inspiration to maximum expiration)
IRV + TV + ERV = VC
=4.5L
What does Spirometer measure
FCV,
FEV1
Flow vol loop
PEFR
What ratio is used to distinguish between obstructive and restrictive
- FEV1/FVC
< 0.7 = obstructive
If FEV1/FVC decrease what do you look at next
and what do conclude if that measure is
- Normal
- Low
FVC
Normal = Obstructive
Low = Mix
(usually reduced to a lesser extent in obstructive )
If FEV1/FVC in normal or High
you at the FVC again and if
- normal/ High
- Low
What does it indicate
FCV Low= restrictive
FCV normal high = normal lung mechanics
In obstructive disease and change of what in FEV1 pre & post bronchodilator is significant ?
12-15%
What does this indicate
Mild and severe obstruction
What can spirometry not measure and thus can give us TLC ?
Residual volumes
What does a pt have if they have a low TLC but normal/high FEV1/FVC?
Restrictive disease
If residual volume increased and TLC Increased
Obstructive
What does a pt have if they have a low TLC AND low FEV1/FVC?
mix restrictive & obstructive
Reduction of all lung volumes
restrictive disease
What test are needed to IX asthma in adults
- spirometry with a bronchodilator reversibility (BDR) test
- FeNO test
Decrease DLco (4)
- Decrease membrane surface area
(emphysema) - Increase membrane membrane thickness.
- PHTN
- Anemia
Increase in DLCO
- Exercise
- Asthma
- Pul. Hemorrhage
- Polycythemia
- Mile left HF
Describe moderate Asthma
PEFR
Speech
RR
Pulse
PEFR 50-75% best or predicted
Speech normal
RR < 25 / min
Pulse < 110 bpm
Describe Severe Asthma
PEFR
Speech
RR
Pulse
PEFR 33 - 50% best or predicted
Can’t complete sentences
RR > 25/min
Pulse > 110 bpm
Life-threatening Asthma
PEFR < 33% best or predicted
O2 < 92%
Silent chest, cyanosis or feeble respiratory effort
Bradycardia, dysrhythmia or hypotension
Exhaustion, confusion or coma
‘Normal’ pC02 (4.6-6.0 kPa)
Near-fatal asthma
raised pC02
and/or requiring mechanical ventilation with raised inflation pressure
What do SABA’s end in
- buterol
COPD - still breathless despite using SABA/SAMA and no asthma/steroid responsive features
add a LABA + LAMA
what is after SABA, low ICS Step 3
SABA (ending -ol)
+ low-dose ICS
+ leukotriene receptor antagonist (LTRA) (-kast)
Nb. Caution with LTRA in pregnancy
What medication are used in the Step 4 of asthma
SABA
+ low-dose ICS
+ long-acting beta agonist (LABA) (ending in -metrol)
Continue LTRA depending on patient’s response to LTRA
name some long-acting beta agonist
relax smooth muscle work on B2
Arformoterol.
Bambuterol.
Clenbuterol.
Formoterol.
Salmeterol.
Protokylol.
Name some LAMA’s & Moa
Inhibits binding of ACh to M3 muscarinic receptors; blocks the bronchoconstrictor effects of acetylcholine, leading to bronchodilation.
aclidinium (Genuair)
glycopyrronium (Breezhaler)
tiotropium (HandiHaler, Respimat)
umeclidinium (Ellipta)
COPD Indication for LTOT O2
- PaO2 < 7.3
**PaO2 < 8 **if also have:
- polycythemia,
-peripheral oedema
-nocturnal hypoxaemia or
- Pul HTN
1st step in rx of COPD without asthma
Saba
LABA + LAMA
1st step in rx of COPD with Asthma
SABA OR Sama
LABA + ICS
2nd step of Rx COPD
SABA
LABA + ICS +LAMA
Asthma rx step 5
SABA +/- LTRA
Switch ICS/LABA for a maintenance and reliever therapy (MART), that includes a low-dose ICS
Asthma rx step 6
SABA +/- LTRA + medium-dose ICS MART
OR consider changing back to a fixed-dose of a moderate-dose ICS and a separate LABA
Asthma rx step 6
SABA +/- LTRA + one of the following options:
- increase ICS to high-dose (only as part of a fixed-dose regime, not as a MART)
- a trial of an additional drug (for example, a long-acting muscarinic receptor antagonist or theophylline)
- seeking advice from a healthcare professional with expertise in asthma
What is Maintenance and reliever therapy (MART) ?
combined ICS and fast acting LABA treatment in one inhaler
This is used as both reliver and maintenance
Symbicort®(Budesonide/formoterol ),
DuoResp Spiromax® (Budesonide/formoterol )
What is Apha 1 Antitrypsin deficiency
protein is a protease inhibitor from the liver that is secreted to inactivate Neutrophils Elastase (which breaks down elastin of bacteria). However, when there is a deficiency Elastase continues to break down the wall of the alveolus = enlargement of the air spaces =
1. pan acinar emphysema
(Esp at the bases)
2. Chronic bronchitis
3. Bronchieltasis
4. Cirrhosis
Sx of Apha 1 Antitrypsin deficiency
COPD: pan acinar emphysema
(Esp at the bases), Chronic bronchitis,
Bronchieltasis
Cirrhosis - phtn, coagulation deficiency –> hepatocellular carcinoma
Apha 1 Antitrypsin deficiency: * heterozygous: PiMZ
o however, if non-smoker low risk of developing emphsema but may pass on A1AT gene to children
Apha 1 Antitrypsin deficiency:PiSS
50% normal A1AT levels
PiZZ:
10% normal A1AT levels
Rx Apha 1 Antitrypsin deficiency
- no smoking
- supportive: bronchodilators, physiotherapy
- intravenous alpha1-antitrypsin protein concentrates
- surgery: lung volume reduction surgery, lung transplantation
triangle of safety for chest drain
base of the axilla,
lateral edge pectoralis major,
5th intercostal space
anterior border of latissimus dorsi
common complication of plasma exchange
is hypocalcaemia
Indications for placing a chest tube in pleural infection:
- frankly purulent or turbid/cloudy pleural fluid on sampling
- organisms identified on G&S and/or culture from a non-purulent pleural fluid sample (indicates that pleural infection is established)
- Pleural fluid pH < 7.2
What causes exudative pleural effusions
exudative pleural effusions
-inflammation of the pulmonary capillaries which makes them much more leaky.
What causes transudative pleural effusions
transudative
when too much fluid starts to leave the capillaries either because of increased hydrostatic pressure or decreased oncotic pressure in the blood vessels.
Examples transudative pleural effusions (3)
Transudative
1LVF
2Cirrhosis
3Nephrotic syndrome
Other cause of hypoproteinemia
Uncommon: myoedema, sarcoid, peritoneal dialysis
Examples Exudative pleural effusions(6)
Exudative
1. Infections: TB
2. Malignancy
3. PE
4. Connective tissue disorders
5. Sub diaphragmatic: (pancreatitis, sub phrenic abscess )
6Trauma
Effusion with protein level < 25 g/L
Transudative
Effusion with protein level >35 g/L
Exudative
When do you need Lights criteria ?
When proteins levels are between 25-35 g/L
What is Lights criteria
Exudate is likely if one :
fluid/serum
- pleural fluid protein divided by serum protein >0.5
- pleural fluid LDH divided by serum LDH >0.6
- pleural fluid LDH more than 2/3 the upper limits of normal serum LDH
Characteristic pleural fluid findings:
low glucose:
RA & TB
Characteristic pleural fluid findings:
raised amylase:
pancreatitis, oesophageal perforation
Characteristic pleural fluid findings:
heavy blood staining:
mesothelioma, pulmonary embolism, tuberculosis
RX Primary pneumothorax
- Rim of air is < 2cm and pt NOT SOB = discharge
- Otherwise, aspiration should be attempted
- if this fails (defined as > 2 cm or still short of breath) then a chest drain should be inserted
Rx 2ndary pneumothorax (underlying lung ds)
All patients should be admitted for at least 24 hours
- pt is > 50 y.o & rim > 2cm &/or the pt is SOB = chest drain should be inserted.
- Otherwise aspiration should be attempted if rim is between 1-2cm.
-If aspiration fails (i.e. pneumothorax >1cm) a chest drain should be inserted.
if <1cm then the BTS guidelines suggest giving oxygen and admitting for 24 hours
Upper zone fibrosis
CHARTS
C - Coal worker’s pneumoconiosis
H - Histiocytosis/ hypersensitivity pneumonitis
A - Ankylosing spondylitis
R - Radiation
T - Tuberculosis
S - Silicosis/sarcoidos
Fibrosis predominately affecting the lower zones
- Idiopathic pulmonary fibrosis
- Most connective tissue disorders (except ankylosing spondylitis) e.g. SLE
- Drug-induced: amiodarone, bleomycin, methotrexate, asbestosis
Explain the flow volume loop
What is happening when the flow volume loop shift to the right
Restrictive
(Restrictive =right)
Respiratory alkalosis with decreased O2
PE
Oxygen dissociation curve shift left
Oxygen dissociation curve
shifts Left
- Lower oxygen delivery
- Lower acidity, temp, 2-3 DPG - also HbF,
carboxy/methaemoglobin
Oxygen dissociation curve what caused shift Right
shifts Right
- Raised oxygen delivery
- Raised acidity, temp, 2-3 DPG
Oxygen dissociation curve shift to the left means
decreased oxygen delivery to tissues
Oxygen dissociation curve shift to the Right means
enhanced oxygen delivery to tissues
