Respiratory Flashcards
What are the causes of pulmonary hypertension?
Group 1. Primary pulmonary HTN or SLE Group 2. LHF due to MI or system HTN Group 3. Chronic lung disease e.g. COPD Group 4. PE Group 5. Sarcoidosis, haematological disorders
What are the signs and symptoms of Pulmonary HTN?
SOB is main
Other: Syncope Loud S2 Tachycardia Raised A waves on JVP Hepatomegaly Peripheral odema
What are the investigations for pulmonary HTN?
ECG:
- R ventricular hypertrophy
- R axis deviation
- RBBB
CXR:
- dilated pulmonary arteries
- R ventricular hypertrophy
What is the management of pulmonary HTN?
Primary pulmonary HTN:
- IV prostanodids e.g. epoprostenol
- Endothelin receptor antagonist e.g. macitentan
- Phosphodiesterase-5 inhibitors e.g. sidenafil
What is the presentation of asthma?
Episodic symptoms Diurnal variation - worse at night Dry cough with wheeze and SOB Hx of other atopic conditions FHx Bilateral widespread polyphonic wheeze
Acute: respiratory alkalosis
What are the investigations for asthma?
First line:
- fractional exhaled NO
- spirometry with bronchodilator reversibility
Second line:
- peak flow variability
- direct bronchial challenge test
What is the management of asthma? (NICE)
- Salbutamol
- Add inhaled corticosteroid
- Add oral LTRA e.g montelukast
- Add LABA e.g. salmeterol
- Consider changing to MART regime
- Increase inhaled corticosteroid dose to moderate
- Increase inhaled corticosteroid to high dose or oral theophyline or tiotropium
- Refer to specialist
How is an asthma exacerbation graded?
Moderate:
- PEFR 50-75% predicted
Severe:
- PEFR 33-50% predicted
- RR > 25
- HR > 110
- Unable to complete full sentences
Life threatening:
- PEFR <33%
- Sats <92%
- Becoming tired
- Silent chest
- Haemodynamically unstable
What is the treatment for an asthma exacerbation?
Moderate: Neb salbutamol Neb ipratropium bromide Steroids Abs
Severe:
O2
Aminophyline infusion
Consider IV salbutamol
Life threatening:
IV magnesium sulfate infusion
Admission to ITU
Intubate
Give the presentation of COPD
Chronic SOB Cough Sputum production Wheeze Recurrent resp infections esp in winter
Describe the MRC Dyspnoea Scale
Grade 1. Breathless on strenuous exercise Grade 2. On walking up hill Grade 3. SOB that slows walking on flat Grade 4. Stop to catch breath after 100m Grade 5. Unable to leave house
What is the diagnosis of COPD?
Based on clinical presentation plus spirometry
FEV1/FVC <0.7
FEV1 <80% of predicted
What is the long term management of COPD?
Stop smoking
Pneumococcal and annual flu vaccine
- Salbutamol or Ipratropium bromide
- Combined LABA+LAMA (if no asthmatic or steroid responsive features)
- If steroid responsive/asthma features = Combined LABA+ICS
How do you distinguish the different types of respiratory failure?
Low PO2 indicates hypoxia and respiratory failure
Normal PCO2 with low PO2 = type 1
Raised PCO2 with low PO@ = type 2
Oxygen therapy in COPD
If retaining CO2 aim for 88-92% titrated by venturi mask
If not retaining CO2 and bicarb normal, then give oxygen aim >94%
Give the histology of lung cancers
Non-small cell lung cancer (80%)
- Adenocarcinoma (40%)
- Squamous cell carcinoma (20%) (cavitating)
- Large cell carcinoma (10%)
Small cell lung cancer (20%)
What are the signs and symptoms of lung cancer?
SOB Cough Haemoptysis Finger clubbing Recurrent pneumonia Weight loss Lymphadenopathy
What are the investigations for lung cancer?
CXR: first line
- hilar enlargement
- peripheral opacity
- pleural effusion
- collapse
Staging CT
PET CT
Bronchoscopy
Histological diagnosis
What are the treatment options for lung cancer?
Surgery = first line in non-small cell lung cancers
Radiotherapy - curative in NSCLC
Chemo
Tx for SCLC = radio and chemo
What are the extrapulmonary manifestations of lung cancers?
Recurrent laryngeal nerve palsy Phrenic nerve palsy Superior vena cava obstruction Horners syndrome SIADH - SCLC Cushing's syndrome - SCLC Hypercalcaemia - Squamous cell carcinoma Lambert eatorn myasthenic syndrome
What is the lambert-eaton myasthenic syndrome?
A result of antibodies produced by the immune system against SCLC cells.
antibodies damage the voltage gated calcium channels on the presynaptic terminal in motor neurones leading to proximal muscle weakness, diplopia, ptosis.
Patients have reduced tendon reflexes
What is a mesothelioma?
Lung malignancy affecting mesothelial cells fo the pleura. Strongly linked to asbestos inhalation.
May have lag of up to 45 years between exposure and diagnosis
Difference between exudative and transudative pleural effusion
Exudative means high protein count >3g/dl
Transudative means low protein count <3g/dl
What are the exudative causes of pleural effusion?
Related to inflammation. Inflammation results in protein leaking out of tissues.
Lung cancer
Pneumonia
Rheumatoid arthritis
Tb
What are the transudative causes of pleural effusion?
Relate to fluid moving across into the pleural space.
Congestive heart failure
Hypoalbuminaemia
Hypothyroidism
Meig’s syndrome
What are the investigations and findings on pleural effusion
CXR:
- blunting of the costophrenic angle
- Fluid in the lung fissures
- larger effusions will have a meniscus
What is the treatment for pleural effusion?
Conservative management
Pleural aspiration
Chest drain
What is empyema?
Where there is infected pleural effusion Improving pneumonia but new or ongoing fever Pleural aspiration shows pus Acidic pH Low glucose, high LDH
Treat with chest drain and abs
What are the causes of pneumothorax?
Spontaneous
Trauma
Iatrogenic
Lung pathology
What is the management of pneumothorax?
If no SOB and <2cm rim of air on CXR = no treatment and follow up in 2-4 weeks
If SOB and/or >2cm rim of air on CXR then require aspiration and assessment
If aspiration fails twice it will require chest drain
Unstable patients or bilateral or secondary pneumothoraces require chest drain
What is the management of tension pneumothorax?
Insert a large bore canula into the second intercostal space in the midclavicular line
Definitive management = chest drain in the triangle of safety in the mid-axillary line
What is the presentation of pneumonia?
SOB Cough productive of sputum Fever Haemoptysis Pleuritic chest pain Delirium Sepsis
What are the characteristic signs of pneumonia?
Bronchial breathing
Focal coarse crackles
dullness to percussion
What tool is used to assess severity of pneumonia?
CURB-65
Confusion Urea >7 RR > 30 Blood pressure <90 systolic or <60 diastolic Age >65
What is fungal pneumonia and the treatment?
Pneumocystis jiroveci (PCP) occurs in patients that are immunocompromised. Particularly important in patients with poorly controlled or new HIV.
Treatments with co-trimoxazole
What are the risk factors for pulmonary embolism?
immobility recent surgery long haul flights pregnancy hormone therapy with oestrogen
What is VTE prophylaxis?
Given to all patients that are at risk of a VTE in hospital.
LMWH such as enoxaparin given unless active bleeding or existing anti coagulation
Anti-embolic compression stockings unless significant peripheral arterial disease
What is the presentation of PE
SOB Cough ± haemoptysis Pleuritic chest pain Hypoxia Tachycardia Raised RR Low grade fever
What are the investigations and their findings for PE
- Wells score
If likely: CTPA
Unlikely: D-Dimer and if positive = CTPA
Definitive diagnosis = CTPA
ABG = respiratory alkalosis
How long do you anticoagulate following a PE?
If there is an obvious reversible cause: 3 months
If the cause unclear, recurrent or irreversible: 6 months
In active cancer: 6 months
What is obstructive sleep apnoea?
Caused by collapse of the pharyngeal airway during sleep.
Characterised by apneoa episodes during sleep where the person will periodically stop breathing for a few minutes
What are the risk factors for obstructive sleep apnoea
Middle age Male Obesity Alchohol Smoking
What are the features of obstructive sleep apnoea?
Apnoea episodes during sleep (reported by partner) Snoring Morning headache Waking up tired Daytime sleepiness Concentration problems Reduced O2 sats during sleep
What tool is used to assess obstructive sleep apnoea?
Epworth sleepiness scale
What is the management for obstructive sleep apnoea?
Referral to ENT or specialist sleep clinic
Correct reversible risk factors
CPAP
Surgery
What is the typical exam question for sarcoidosis?
Black woman aged 20-40 with dry cough and SOB. May also have nodules on their shins suggesting erythema nodosum.
Which organs are affected in sarcoidosis?
Lungs (90%)
- mediastinal lymphadenopathy
- pulmonary fibrosis
- pulmonary nodules
Liver (20%)
- Liver nodules
- Cirrhosis
- Cholestasis
Eyes (20%)
- uveitis
- conjuctivitis
- optic neuritis
Others
What is lofgren’s syndrome?
A specific presentation of sarcoidosis. Triad of:
- erythema nodosum
- bilateral hilar lymphadenopathy
- polyarthralgia
What do the blood tests show in sarcoidosis?
Raised serum ACE (screening tool) Hypercalcaemia Raised IL-2 receptor Raised CRP Raised immunoglobulin
Findings on imaging in sarcoidosis?
CXR - hilar lymphadenopathy
High resolution CT: hilar lymphadenopathy and pullmonary nodulles
MRI: CNS involvement
What is the gold standard test for sarcoidosis?
Non-caseating granulomas with epithellioid cells on histology
What is the treatment for sarcoidosis?
- no treatment
- steroids (+ bisphosphonates)
- methotrexate or axathioprine
4, lung transplant
What is interstitial lung disease?
An umbrella term to describe conditions that affect the lung parenchyma causing inflammation and fibrosis.
What is the diagnosis of interstitial lung disease?
Combination of clinical features on high resolution CT scan of the thorax: shows ground glass appearance.
What is the management for interstitial lung disease?
Mostly supportive to not make things worse.
- remove or treat underlying cause
- home oxygen
- stop smoking
- physiotherapy
What is idiopathic pulmonary fibrosis?
Condition where there is progressive pulmonary fibrosis with no clear cause
How does idiopathic pulmonary fibrosis present?
Insidious onset of SOB and dry cough for over 3 months
Usually affects over 50yr olds
What is seen on examination for idiopathic pulmonary fibrosis?
Bibasal fine inspiratory crackles and finger clubbing
What is the management of idiopathic pulmonary fibrosis?
pirfenidone
nintedanib
Which drugs can cause pulmonary fibrosis?
Amiodarone
Cyclophosphamide
Methotrexate
Nitrofurantoin
What causes secondary pulmonary fibrosis
Alpha 1 antitripsin deficiency
Rheumatoid arthritis
SLE
Systemic sclerosis
What is hypersensitivity pneumonitis?
type 3 hypersensitivity reaction to an environmental allergen.
e.g. farmers lung, bird fanciers lung, mushroom workers lung
Tx: oxygen, remove allergen and steroid
What is bronchiectasis?
Describes a permanent dilation of the airways secondary to chronic infection or inflammation
What are the causes of bronchiectasis?
Post-infective
CF
Bronchial obstruction e.g. lung ca/foreign body
Immune deficiency
What is the management of bronchiectasis?
Physical training Postural drainage Antibiotics for exacerbation Bronchodilators Immunisations Surgery
What is the most common causative organism of bronchiectasis?
Haemophilus influenzae
What are the features of carbon monoxide toxicity?
Headache N+V Vertigo Confusion Subjective weakness
What are the investigations and results for carbon monoxide poisoning
O2 sats: falsy high
ABG
ECG
What is the management of patients with CO poisoning?
100% high flow oxygen via a non-rebreather mask
Hyperbaric oxygen
What is seen on CXR in asbestosis?
Honey combing of lung with parenchymal bands and pleural plaques
Investigation of choice for unprovoked DVT?
CT abdo and pelvis
Which tube provides protection for lungs from regurgitated stomach contents?
Tracheal tube
What is the most common post COVID complication?
PE
Which the most common causative organism of COPD exacerbation?
Haemophilus influenza
Preceding influenza predisposes to which causative organism in pneumonia?
Staph aureus
Which normal acute procedure is contraindicated in haemoptysis?
Non invasive ventilation due to aspiration risk
What is the presentation of legionella penumonia?
Flu-like symptoms Dry cough Relative bradycardia Confusion Hyponatraemia
What is recommended for COPD patients with 4 or more exacerbations despite optimised control?
Azithromycin prophylaxis
What is the measurement of exudative and transudative pleural effusion in terms of protein ratio?
Pleural effusion protein/ serum protein ration >0.5 = exudative
What is an alternative presentation of lower lobe pneumonia?
Upper quadrant abdominal pain
