Resp - Pneumothorax, Pleural Effusion, Pneumonia, Pulmonary HTN, Sarcoidosis, PE Flashcards
Pneumothorax - what is it?
Pneumothorax - is when air gets in the pleural space separating the lung from the chest wall
Pneumothorax - what are 4 causes?
- Spontaneous
- Trauma
- Iatrogenic e.g. lung biopsy
- Pathology - infection, COPD
Pneumothorax - what is the investigation of choice?
Erect chest x-ray
Pneumothorax - what would you see on a chest x-ray?
Area between lung tissue and chest wall with no lung markings
Line demarcating lung edge, where lung markings end and pneumothorax begins
Pneumothorax - what is the stepwise management for a primary pneumothorax and a secondary pneumothorax?
Primary:
- if the rim of air is < 2cm and the patient is not short of breath then discharge should be considered - DISCHARGE
- otherwise, aspiration should be attempted - ASPIRATE
- if this fails (defined as > 2 cm or still short of breath) then a chest drain should be inserted - CHEST DRAIN
Secondary:
- if the patient is > 50 years old and the rim of air is > 2cm and/or the patient is short of breath then a chest drain should be inserted - CHEST DRAIN
- otherwise aspiration should be attempted if the rim of air is between 1-2cm. If aspiration fails (i.e. pneumothorax is still greater then 1cm) a chest drain should be inserted. All patients should be admitted for at least 24 hours - 1 to 2cm, ASPIRATE, FAILS -> CHEST DRAIN
- if the pneumothorax is less the 1cm then the BTS guidelines suggest giving oxygen and admitting for 24 hours - ADMIT AND O2
Pneumothorax - what is a tension pneumothorax?
Tension pneumothorax caused by trauma to chest wall creating one way valve:
Air can get into pleural space during inspiration
Air can’t escape during expiration
So more air drawn into pleural space with each breath, can’t escape, pressure builds inside mediastinum, pushes mediastinum across (away from TP), kinks big vessels, can cause cardiorespiratory arrest
Pneumothorax - signs of tension pneumothorax on examination and obs?
Reduced air entry to affected side
Tachycardic
Hypotension
Pneumothorax - what would a tension pneumothorax show on XRAY?
Tracheal deviation away from pneumothorax side
Pneumothorax - management of tension pneumothorax?
Insert a large bore cannula into the second intercostal space in the midclavicular line
Once pressure is relieved with cannula, do chest drain fro definitive management
Pleural effusion - what is it?
Collection of fluid in pleural cavity
Pleural effusion - what are the two types of fluid it can be?
Exudative - high protein count >3g/dL
Transudative <3g/dL
Pleural effusion - what are exudative causes?
Exudative causes related to inflammation
Inflammation results with protein leaking out of tissues into pleural space
‘EX’udative - meaning moving out
Lung cancer
Pneumonia
Rheumatoid A
TB
Pleural effusion - what are transudative causes?
Transudative causes relate to fluid moving into the pleural space
‘TRANS’udative - meaning moving across
Congestive Cardiac Failure
Hypothyroidism
Hypoalbuminaemia - liver disease, less protein in blood so reduced oncotic pressure, so fluid moves out of blood vessels as oncotic pressure from albumin (protein), isn’t there to keep fluid in
Pleural effusion - what are the symptoms?
- SoB
- Pleuritic pain
- Non-productive cough
- Extra-pulmonary symptoms depending on underlying cause e.g. weight loss in malignancy
Pleural effusion - what are the signs?
Stony dull percussion over effusion
Reduced breath sounds
Tracheal deviation away from effusion if massive (>1000ml)
Reduced chest expansion
Pleural effusion - what imaging do you do and what do you see?
Chest X-Ray
Blunting of costophrenic angles
Meniscus if big effusion
Fluid in lung fissures
Tracheal deviation away from effusion
Pleural effusion - what other investigation can you do?
Pleural paracentesis and analysis
Analyse for protein count, pH, glucose, lactate dehydrogenase, microbiology testing
Pleural effusion - management
Should be directed towards underlying cause
- Small effusion - conservative management may be appropriate, as may resolve by fixing underlying cause
- Large effusion - pleural aspiration, effusion may recur, may need to repeat aspiration
- Chest drain - used to drain effusion and prevent it recurring
Pneumonia - what is it?
Infection of the lung tissue
Causes inflammation of lung tissue and sputum filling the airways and alveoli
Pneumonia - what are the three classifications of pneumonia?
COMMUNITY ACQUIRED PNEUMONIA - pneumonia developed outside of hospital
HOSPITAL ACQUIRED PNEUMONIA - develops >48 hours after hospital admission
ASPIRATION PNEUMONIA - develops as a result after inhaling foreign material
Pneumonia - what is the presentation?
SoB Productive cough Fever Haemoptysis Pleuritic chest pain Confusion
Pneumonia - what are the signs (obs)?
Tachypnoea Tachycardia Hypoxia Hypotension Fever Confusion
These obs can indicate sepsis secondary to pneumonia
Pneumonia - what are the signs on chest examination?
Bronchial breath sounds - heard on inspiration and expiration
Focal coarse crackles - this is the sound of air passing through the sputum
Dullness to percussion
Pneumonia - CRB65 and CURB65
CRB65 out of hospital
CURB65 in hospital
In CRB65, if score is anything other than 0, consider referral to hospital
Score predicts mortality, used to help guide whether to admit patient to hospital
Pneumonia - what are the parameters of CURB65?
C - confusion U - urea >7 R - resp rate >30 B - <90 systolic <60 diastolic 65 - age >65
Pneumonia - CURB65 scores
0/1 - consider home treatment
>2 consider hospital admission
>3 consider ICU assessment
Pneumonia - common causes
50% streptococcus pneumoniae
20% haemophilus influenzae
Pneumonia - what two headings can community acquired pneumonia be divided into, and what are the features of each?
Typical - classical symptoms
Atypical - insidious onset
- extrapulmonary symptoms
- caused by an organism that can’t be cultured in the
normal way or detected using gram stain
- don’t respond to penicillins
- treated with macrolides, tetracyclines
Pneumonia - investigations and diagnosis
Bedside: Obs Sputum sample Urinary sample ECG
Bloods: FBC U&Es CRP Blood cultures
Imaging:
Chest X-ray
Pneumonia - management of CAP
Always follow local area guidelines
CAP:
Mild - 5 day course oral amoxicillin or macrolide (if allergic to pencillin)
Moderate - 7 to 10 day course of dual antibiotics, amoxicillin and macrolide
(Doxycycline if allergic to penicillin)
Severe - IV co-amoxiclav and a macrolide, 7-10 days, may be extended to 14-21
Pneumonia - management of HAP
Follow local area guidelines
Mild - co-amoxiclav 625mg TDS
Severe - IV Tazocin 4.5g TDS
Pulmonary HTN - what is it?
It is increased resistance and pressure of blood in the pulmonary arteries, which causes strain on the right side of the heart trying to pump blood through lungs
Causes a back pressure of blood into systemic venous system
Pulmonary HTN - what are the causes?
COPD
SLE
PE
Sarcoidosis
Pulmonary HTN - what is main presenting symptom?
SoB
Pulmonary HTN - what are the signs?
Raised JVP
Hepatomegaly
Peripheral oedema
Tachycardia
Pulmonary HTN - Investigations
ECG
Chest X-Ray
Echo - used to estimate pulmonary artery pressure
Pulmonary HTN - what changes do you see on the ECG?
Right ventricular hypertrophy
Right axis deviation
Right bundle branch block
Pulmonary HTN - what changes do you see on Chest X-Ray?
Dilated pulmonary arteries
Right ventricular hypertrophy
Pulmonary HTN - management of primary pulmonary HTN
Treating underlying cause like SLE or PE
IV prostanoids - epoprostenol
Endothelin receptor antagonists (potent vasoconstrictor of vascular smooth muscle) - macitentan
Phosphodiesterase -5 inhibitors - sildenafil
Sarcoidosis - what is it?
It is a granulomatous inflammatory condition
Usually chest symptoms, but has multiple extra-pulmonary manifestations
Sarcoidosis - what are granulomas?
Granulomas are nodules of inflammation full of macrophages
Sarcoidosis - what is the cause of these granulomas?
Cause of granulomas developing is unknown
Sarcoidosis - what is the typical incidence?
Young adulthood
Again aged round 60
Sarcoidosis - what is the classic ‘exam’ patient
20-40 year old black woman presenting with dry cough and SoB, may have nodules on shins
Sarcoidosis - what organs are affected?
Can affect almost any organ in the body:
Lungs (90%) Heart Eyes Skin Kidneys Bones CNS/PNS
Sarcoidosis - how are lungs affected?
- Mediastinal lymphadenopathy
- Pulmonary fibrosis
- Pulmonary nodules
Sarcoidosis - how is liver affected?
Liver nodules
Cirrhosis
Cholestasis
Sarcoidosis - how are the eyes affected?
- Uveitis
- Conjunctivitis
- Optic neuritis
Sarcoidosis - how is the skin affected?
- Erythema Nodosum - red nodules on shins caused by inflammation of subcut fat
- Lupus pernio - raised purple lesions commonly on cheek and nose
Sarcoidosis - how is the heart affected?
- Bundle branch block
- Heart block
- Myocardial muscle involvement
Sarcoidosis - how are the kidneys affected?
- Kidney stones - due to hypercalcaemia
- Nephrocalcinosis
- Interstitial nephritis
Sarcoidosis - how is the CNS affected?
- Encephalopathy
2. Nodules
Sarcoidosis - how is the PNS affected?
- Facial nerve palsy
2. Mononeuritis multiplex
Sarcoidosis - how are the bones affected?
- Arthralgia
2. Arthritis
Sarcoidosis - What is Lofgren’s syndrome?
Specific presentation of sarcoidosis, triad of:
- Erythema nodosum
- Bilateral hilar lymphadenopathy
- Polyarthralgia
Sarcoidosis - what investigations do you do?
Blood tests
Chest XRAY
Histology from biopsy - gold standard
Sarcoidosis - what blood tests do you do and what findings do you get from them?
Serum ACE - raised
Hypercalcaemia - key finding
Serum soluble interleukin-2 recepetor - raised
CRP - raised
Sarcoidosis - what do you see on chest Xray?
Shows hilar lymphadenopathy
Sarcoidosis - what characteristic finding do you get with histology?
Biopsy made from mediastinal lymph nodes
Non-caseating granulomas with epitheloid cells
Sarcoidosis - what is the treatment?
Mild/no symptoms - no treatment, should resolve spontaneously
When treatment is required - 1st line oral steroids, 6-24 months, also give bisphosphonates to protect bones
2nd line - methotrexate, azathioprine
Sarcoidosis - mnemonic off passmed that encompasses main points of condition
‘A Bug’s Life (with Sarcoid)’
A - Arthopathy B - Bell's Palsy U - Uveitis G - Granulomas, non-caseating S - Serum calcium/ ACE elevated L - Lupus Pernio I - Interstitial fibrosis F - Fever, swinging E - Erythema Nodosum
Pulmonary Embolism (PE) - what is it?
Condition where a blood clot forms in the pulmonary arteries
Usually as a result of a DVT from the pelvis or leg and travelled to pulmonary arteries
PE - what happens when thrombus is in pulmonary arteries?
Blocks blood flow to lung tissue, creates strain on right side of heart
PE - what are the symptoms?
Dyspnoea Pleuritic chest pain Cough with or without blood Unilateral, painful, swollen leg Dizziness Syncope
PE - what are the signs? (obs)
Tachycardia (>100bpm)
Low grade fever
Low O2 sats <94%
Hypotension <90mmHg
PE - what are the steps in diagnosis?
- Perform a wells score
- If score>4 PE likely, straight for CTPA
- If score<4 PE unlikely, d-dimer within 4 hours, then if positive, then do CTPA
PE - what other investigations can you do?
ECG, echo, troponin - markers to assess right ventricular strain/failure
ABG - pO2 low
pCO2 low - high resp rate, blow off extra CO2, low blood CO2, causes respiratory alkalosis
PE - initial management
Anticoagulation:
Apixaban or Rivaroxaban
LMWH (dalteparin) when NOACs aren’t suitable
