resp important Flashcards
COPD spirometry
FEV1/FVC ratio less than 70%, FEV1 less than 80%
treatment COPD
1- SABA/SAMA
2- no asthmatic features: add LABA + LAMA (if taking SAMA, switch it to SABA)
3- asthmatic features: add LABA + ICS, if patients remain breathless then add LAMA also
first line antibiotics for infectious exacerbation of COPD
amoxicillin or clarithromycin or doxycycline
Most frequent cause of COPD exacerbation
haemophilus influenzae
COPD symptoms in a young person may be a sign of
A1AT deficiency
how to tell severity of COPD
mild COPD- normal FEV1
moderate COPD- FEV1 50-70%
severe COPD- FEV1 30-49%
very severe FEV1<30%
clinical features Wegener’s granulomatosis
- saddle nose/sinus pain/epistaxis
- airway constriction- difficulty breathing, cough
- kidney problems- reduced urine production, increased blood pressure, haematuria/proteinuria
- skin purpura/nodules
tests for Wegener’s granulomatosis
- cANA- IgG antibody
- increased ESR + CRP
- CXR- fluffy infiltrates or nodules
treatment Wegener’s granulomatosis
- corticosteroids + cyclophosphamide (or rituximab) for disease remission
- Azathioprine and methotrexate for maintenace
- plasma exchange if severe renal disease & pulmonary haemorrhage
- Co-trimoxazole - prophylaxis against pneumocystis jirovecii and staph colonisation
small cell cancer features
Paraneoplastic syndrome- ACTH, ADH and also can create autoantibodies that destroy neurones, causing lambert-eaton syndrome
adenocarcinoma features
- can cause pancoast tumours in upper nerve
- can damage thoracic inlet, brachial plexus and cervical sympathetic nerve; Horner’s syndrome (constricted pupil, drooping upper eyelid and cant sweat on same side as nerve damage)
- Often see triad of clubbing, long bone swelling and arthritis
squamous cell carcinoma features
- Form square shaped cells that produce keratin pearls
- Centrally located
- Paraneoplastic syndrome possible- parathyroid hormone release, which decreases calcium in bones - leads to hypercalcaemia (more calcium in blood) and bones are more brittle
Bronchial carcinoid tumour features
- Develop from mature endocrine cells
- Can be located throughout the lungs
- Paraneoplastic syndrome- tumours release serotonin which causes increased peristalsis of gut, diarrhoea, and bronchoconstriction which causes asthma
lung cancer associated with gynaecomastia
adenocarcinoma
cancer with strongest associated with smoking
squamous cell carcinoma
stats for moderate asthma
PEFR 50-75% best of predicted
RR<25/min
pulse <110
stats for severe asthma
PEFR 33-50% best of predicted
cannot complete sentences
RR >25/min
Pulse >110
stats for life-threatening asthma
PEFR <33% best or predicted Oxygen sats <92% 'normal' pCO2 silent chest, cyanosis, feeble respiratory effect confusion or soma hypotension or bradycardia
acute asthma attack management
1- oxygen 2- salbutamol 3- ipratropium bromide nebuliser 4- IV hydrocortisone or oral Prednisolone 5- magnesium sulfate IV
investigations for asthma
- FEV1/FVC <70% (obstructive)
- peak flow- variability of more than 20% between am and pm measurements
- fractional exhaled nitric oxide + bronchodilator reversibility test if the spirometry comes back normal despite symptoms
asthma management in adults
1- SABA 2- SABA + ICS 3- SABA + ICS + LABAS 4-ABA + ICS + LTRA (e.g. montelukast) 5- SABA + LTRA + MART
types of hypersensitivity
ACID
1- Allergy (immediate)- IgE
2- Cytotoxic- antibody dependent- IgM/IgG e.g. Goodpasture’s
3- Immune complex- IgG + neutrophils e.g. SLE, pneuomonitis, Wegener’s
4- Delayed hypersensitivity- cell mediated by T cells- e.g. Tuberculosis =, nickel, poison IV
o Kidney biopsy: inflammation in the basement membrane- ‘crescent glomerulonephritis’
AND
CXR shows infiltrates due to pulmonary haemorrhage
Goodpasture’s syndrome (anti-glomerular basement membrane disease, a rare autoimmune disease in which antibodies attack the basement membrane in lungs and kidneys, leading to bleeding from the lungs and kidney failure.)
diagnostic test for severity of Pneumonia + use of score
Confusion- 1 point Urea >7mmol/L - 1 point RR >30 - 1 point B: SBP<90 OR DBP <60- 1 65- age over 65
score of 0-1= home treatment, 2=admission/close outpatient management, 3-5= admission as severe
pneumonia antibiotics
Strep pneumoniae / H. influenzae / mycoplasma pneumoniae = amoxicillin,
clarithromycin or doxycycline
Legionella pneumophilia = fluroquinolone
Chlamoydophila species = tetracycline
Pneumocystis jiroveci = co-trimoxazole
Gram -ve bacilli / pseudomonas / anaerobes = aminoglycoside IV + antipseudomonal penicillin IV
Strep pneumoniae / anaerobes from aspiration = cephalosporin IV + metronidazole
most common organisms causing;
1- community acquired pneumonia
2- hospital acquired pneumonia
1- strep pneumoniae most common, but can also be caused by haemophilus influenzae or Moraxella
2- hospital acquired usually caused by staph aureus but may also be caused by pseudomonas, bacteriodes, clostridia
cell wall can hold onto dye despite being exposed to alcohol, which creates a bright red colour with a Ziehl-Neelson stain
mycobacterium tuberculosis
sarcoidosis signs/symptoms
- bilateral hilar lymphadenopathy
- fever
- erythema nodosum (swollen subcutaneous fat under ski, causing red bumps and patches)
- polyarthralgia
- uveitis- can cause vision changes
bilateral hilar lymphadenopathy
sarcoidosis
Facial rash plus lymphadenopathy
sarcoidosis
drugs which can cause pulmonary fibrosis
- Methotrexate
- Nitrofurantoin
- Amiodarone
- Sulphasalazine
- Bleoycin
features pleural effusion
dyspnoea, non-productive cough or chest pain are possible presenting symptoms
classic examination findings include dullness to percussion, reduced breath sounds and reduced chest expansion
Pleural effusion: causes
Pleural effusions may be classified as being either a transudate or exudate according to the protein concentration.
Transudate (< 30g/L protein)
heart failure (most common transudate cause)
hypoalbuminaemia (liver disease, nephrotic syndrome, malabsorption)
hypothyroidism
Meigs’ syndrome
Exudate (> 30g/L protein) infection: pneumonia (most common exudate cause), TB, subphrenic abscess connective tissue disease: RA, SLE neoplasia: lung cancer, mesothelioma, metastases pancreatitis pulmonary embolism Dressler's syndrome yellow nail syndrome
pleural effusion investigations
- PA CXR
- ultrasound- increases the likelihood of successful pleural aspiration and is sensitive for detecting pleural fluid septations; contrast CT is now also increasingly performed to investigate the underlying cause, particularly for exudative effusions
- PLEURAL ASPIRATION
management pleural effusion
Options for managing patients with recurrent pleural effusions include:
recurrent aspiration
pleurodesis
indwelling pleural catheter
drug management to alleviate symptoms e.g. opioids to relieve dyspnoea
pneumothorax features
dyspnoea chest pain: often pleuritic sweating tachypnoea tachycardia
management pneumothorax
- first line aspiration
- if aspiration fails, insert chest drain
PE management
- large clots and haemodynamically unstable= alteplase 10mg over 1 min then 90mg over 2 hours
- haemodynamically stable= LMWH
then start oral anticoagulant
pink puffers and blue bloaters
differentiation in COPD:
pink puffer= emphysema: high alveolar ventilation, near normal partial pressure of O2, normal or low partial pressure
of CO2, breathless but not cyanosed, can progress to type 1 respiratory failure
blue bloater= chronic bronchitis: have low alveolar ventilation, low partial pressure of O2, high partial pressure of CO2,
cyanosed but not breathless, may develop cor pulmonale, their respiratory centres are insensitive to CO2
and they require a hypoxic drive to maintain respiratory effort (be careful when giving supplementary
oxygen)
type I resp failure + causes
hypoxia (PaO2<8kPa) with normal or low pCO2
caused by ventilation /perfusion mismatch e.g. pneumonia, pulmonary oedema, PE, asthma, emphysema, pulmonary fibrosis, acute respiratory distress syndrome
type II resp failure + causes
hypoxia (PaO2<8kPa) with hypercapnia (PaCO2>6kPa)
caused by:
- pulmonary disease e.f. asthma, COPD, pneumonia, end stage pulmonary fibrosis, obstructive sleep apnoea
- reduced respiratory drive- sedative drugs, CNS tumour, trauma
- neuromuscular disease- cervical cord lesion, diaphragmatic paralysis, poliomyelitis, myasthenia gravis, guillan-barre syndrome
- thoracic wall disease- flail test, hyphoscoliosis
