Respiratory Flashcards
Causes of breathlessness
Lungs - cardiovascular issues Anxiety e.g hyperventilation poisoning - CO poisoning , cyanide Endocrine - Hyperthyroidism musculoskeletal - myasthenia gravis, Guillain barre syndrome (if you have respiratory breathing difficulties Hematology - anaemia
1;2 ration of inspiration to expiration.
what you may see in a respiratory exam
in obstruction condition - body breathes in fast to give body longer to breathe out to get rid of built up air in the lungs.
pursed lips breathing - tell you someone has got airway obstruction.
accesory muscle - if using other muscle e.g holding on to something - using more effort to breathe - abnormal .
Stridor - (outside chest - inspiration
wheeze - inside chest - expiration)
(but you may hear each of them in either inspiration or expiration)
(all caused by airway narrowing)
cor pulmonale
if they yawn & sigh a lot - if you have strong drive to breathe - feeling like they are not getting enough air in.
if you feel breathless - ASK patient when they get breathless.
onbstructive sleep apnoea
during slee- - gravity is waying on our airways & if the is a weight then the airways narrow.
as they stop ventilation - oxygen sat drops, when ventilation starts again - oxygen sats pick up.
peak flow - reduction with reduction in airway diameter
asthma etc - cause airway narrowing
spirometry - how much you have breathed out related to time ( 70 % in the 1 sec - normal )
on the spirometry page - if there is a restrictive picture - the graph will have the same shape , only the litres of air involved will be less.
(fev1/FVC - small
gas transfer measurement - residual volume. ## ventilation /perfusion ratio - dye defects back were blood is . if area of black is less - lack of perfusion (PE)
pulse oximerty around the block -
What is COPD ?
Chronic Obstructive pulmonary disease.
Group of lung conditions tat cause breathing difficulties including :
0 emphysema (damage to air sacs —–> loss of elasticity —–> means unable to maintain shape & become larger (unable to rebound) , smaller SA : V ratio (less efficient gas exchange)
0 Chronic bronchitis long term inflammation of bronchi ——> causes mucus build up——–> swelling + mucus make it hard for CO2 to get out (C02 retention)
(These are types of COPD)
CAUSES :
Exposure to irritants e.g. smoking
SIGNS/ SYMPTOMS - * (means most important )
- Cough (usually initial symptom) - usually productive (sputum)
- starts as a morning cough usually then becomes constant
- *SOB ( on exercise at first progresses to SOB on rest)
- Chronic Sputum production
- Barrel chest - (anterior - posterior diameter of the chest is increased - (appears like it is always inflated - Suggest hyperinflation and air trapping due to incomplete expiration)
- Recurrent lower tract infections
- Hyper resonance (louder ?) - indicates hyperinflation .
- Distant breath sounds
*WHEEZE - common in excaerbations
- expiratory wheeze
or
polyphonic wheeze (multiple pitches / notes starting & ending at the same time.
(sign of inflammation & resistance
COARSE CRACKLES - indicates airway inflammation & muscus over -secretion.
- pursed lip breathing ( action done by patient to prolong expiration to decrease air trapping)
- use of accessory muscles
RISK FACTORS
- Cigarette smoking
- advancing age
- genetic factors - Alpha - 1 - antitrypsin (smoking in this group can activate lung manifestations of this disease)
WEAKER
- exposure to air pollution , burning solid / biomass fuel , ocupational exposure to dust , chemicals , fumes & gases.
COMPLICATIONS OF CO2
(breathing difficulties ———————> drop in serum 02 levels ————-> body increase BP ———————————-> pulmonary hypertension ——————————> Right sided heart failure ————————————–> Cor pulmonale ( impairment of right side of heart bcc of respiratory disease)
SIGNS
0 Distended neck veins 0 cyanosis 0 Loud P2 0 hepatosplenomegaly 0 hepatojugular reflux ( manual pressure applied to liver - if neck veins , distend - positive) - ankle swelling (peripheral oedema) - systolic parasternal heave. -
DIagnosis of COPD ?
Spirometry - needed for confirmation of diagnosis
(FEV1/FVC ration below 0.7 )
- consider COPD in young PL with symptoms indicative of COPD even if FEV1 /FVC lower than 0.7 ( in under 40 yrs consider Alpha - 1 - antitryspin deficiency if FHX)
- for older people , if no typical symptoms of COPD & FEV1/FVC below 0.7 - consider alternative cause.
COPD can exist with other conditions.
0 FBC
0 CXR
CONSIDER
0 ECG & serum natriuretic peptides - if cardiac disease r pulmonary hypertension suspected.
0 echocardiogarm - if pulomary hypertension suspected .
0 CT thorax - if sysmptoms seem disproportionate to spirometry results - may indicate another condition e.g fibrosis , bronchiectasis.
0 Serum alpha - 1 - antitryspin.
if acute presentation & breathing difficulties :
- check 02 sat (Pulse oxim)
- ABG
0 SERIAL PEAK FLOW MEASUREMENT - to exclude asthma if in doubt.
0 Sputum culture -if frequent excaberations , sever airflow limitation , exacberations requirng mechanical ventilation (SPUTUM SHOULD BE SENT FOR CULTURE - IN THESE CASES. )
What are the criteria for stages of COPD ?
4 stages (GOLD - Global initiative for Chronic Obstructive Lung disease)
0 Gold 1- mild (FEV1 > 80 % )
0 Gold 2 - moderate - 50 % - 80 %
0 Gold 3 - Severe - below 50 %
0 Gold 4 - Very severe - below 30 % FEV1
FEV1 - forced expiratory volume (the amount of air you can force out in one second - COPD prevents breathing out (causing co2 uild up)
What is mMRC dyspnoea scale ?
Modified medical research council dyspnea scale
Determines the severity of dyspnoea in respiratory disease i.e. COPD.
0 - 4 Points
0 - dyspnoea on excretion
1- Dyspnoea when hurrying or walking up slight hill
2- walks slower than pl of same age bcc of dyspnoea or has to stop for breath when walking at own pace
3- Stop for breath after walking 91 m (100 YARDS ) or after a few mins.
4 - Too dyspneic to leave house or breathless when dressing.
This can be incorpated into the GOLD critera for COPD when trying to assess more breathless patients .
0 Group A: low risk (0-1 exacerbation per year, not requiring hospitalisation) and fewer symptoms (mMRC 0-1 or CAT <10)
0 Group B: low risk (0-1 exacerbation per year, not requiring hospitalisation) and more symptoms (mMRC≥ 2 or CAT≥ 10)
0 Group C: high risk (≥2 exacerbations per year, or one or more requiring hospitalisation) and fewer symptoms (mMRC 0-1 or CAT <10)
0 Group D: high risk (≥2 exacerbations per year, or one or more requiring hospitalisation) and more symptoms (mMRC≥ 2 or CAT≥ 10).
- CAT - means COPD Assessment test - questionaire used for people with COPD - assess impact of COPD on a person’ life , how this changes over time ( used to aid management. )
( assesses cough , phlegm , chest tightness , breathlessness , activities , confidence , sleep . energy)
Treatment of COPD ?
(if patient is breathless and has exercise limitation)
1ST LINE - short acting or long acting bronchodilator (short acting BETA -2 - AGONIST (SABA) , short acting muscarinic antagonist (SAMA)
0 short acting Beta - 2 - agonist (salbutamol )
or
0 short acting muscarinic antagonist (SAMA) - ipratropium
( these used to reduce breathlessness & increase excercise tolerance.
- PLUS - Supportive care e.g smoking cessation, inhaler training , vaccinatio against influenza & streptococcus pneumoniae. )
if not working & supportice care (non -pharmological ) is optimal use & NO ASTHMATIC FEATURES use:
2ND LINE
LABA + LAMA
( long acting beta -2 agonist ( salmeterol , formoterol , vilanterol ) + long acting muscarinic anatgonist - aclidinium , glycopyrronium , umeclidium )
3RD LINE
(trail of LABA + LAMA + inhaled cortiocosteriod (ICS ) - for 3 months
(if improved keep combination - review anually )
4TH LINE - if no improvement - go back to LABA + LAMA
- If a person has asthmatic features or respond (improve ) when steriod use (steriod responsiveness - consider LABA + ICS.
- however if they still have day to day symptoms affecting life or 1 severe exacerbations (need hopitalalisation or 2 moderate ones with 1 year - offer LAMA + LABA + ICS
add on treatments
- Oral mucolytic therapy ( if person with stable COPD develops chronic productive cough)
(erdosteine , acetylcysteine , carbocisteine
(mucolytics - dissolve thick mucus)
(STEINES)
- oral theophylline - only considered if both short & long acting bronchiodilatoes used or ICS can’t be used.
Mechanism of action of different types of bronchiodilators ?
examples of bronchiodilators
0 Beta - 2 - agonist
( B2 receptors when activated cause smooth muscle dilation of airways )
( (salbutamol , Terbutaine-SABA - short acting ) , salmeterol , formoterol , vilanterol - LABA (rest of these are Long acting - TEROLS)
0 Anticholinergics / muscarinic anatgonists
(block actelycholine which is responsible for involuntary muscle movements )
(ipratropium - SABA, tiotropium , aclidinium , glycopyrronium, umeclidium - LABA - PIUM)
0 ADD ON TREATMENT Theophylline (Xanthines - relax muscles around airways so they open up more easily , also decrease lungs response to irritants
(
Oral theophylline - should only be considered after trail of short & long bronchiodilators have beem used & inhaled corticosteriods cannot be used) - hIGH RISK , NARROW THERAPEUTIC RATIO , FREQUENT DRUG-DRUG INTERACTIONS
- ADD ON TREATMENTS - oral Corticosteriods should not be started in primary acre - refferal needed.
Which groups should use Beta - 2 agonists with caution ?
Effects Potassium levels (so will affect cardiac system - be careful in cardiovascular disease)
Hyperthyroidism — beta-2 agonists may stimulate thyroid activity.
0 Diabetes mellitus — there is a rare risk of ketoacidosis (especially after intravenous beta-2 agonist administration). Additional blood glucose measurements are recommended when treatment with a beta-2 agonist is commenced.
0 Cardiovascular disease (including hypertension) — beta-2 agonists may cause an increased risk of arrhythmias and significant changes to blood pressure and heart rate.
Susceptibility to QT-interval prolongation.
- RISK OF ADVERSE EFFECTS IF PRE - DISPOSED TO ARRYTHMIAS OR PRE - EXOSTING CARDIOVASCULAR DISEASE OR HYPERTENSION)
0 Hypokalaemia — plasma potassium concentration may be reduced by beta-2 agonists (particularly high doses).
0 Convulsive disorders.
Side effects - heart - QT prolongatiion - palapitations - cardiac arrythmias - rare
(Neurological) Seizures Fine tremour headache anxiety
(Lungs )
- bronchospasm - rare
- Acute angle closure glaucoma - risk in patients using nebulised SABAs - advise to wear mouthpiece rather than mask to reduce exposure to eyes.
Differenitals of COPD ?
Asthma - usually happens early in life , - personal history of allergic rhinitis : 0 eczema 0 allergic rhinitis (atopy triad - together with asthma)
- Overt wheeze which rapidly responds to bronchiodilators.
- Cough variant of COPD mimics COPD.
Investiagtions - Spirometry & PFTs show reversibility with bronchiodilators.
* if sputum or blood shows eosinophillia (high levels of eosinphils )- sign of type of severe asthma - marked by high WBC - high levels of eosinophils cause swelling & inflammation of airway - rare)
0 Bronchiectasis ( long term condition where airways become widened & mucus builds up)
* some patients can develop bronchiectasis as a result of COPD)
(Bronchiectasis - is caused by lung infection , immunodieficency, aspiration (airway is senstive to gastric contents so can trigger inflammation, Cystic fibrosis - complication - as mucus is a good evironment for infection) , cillia abnormalities , connective tissue disorders (RA , Sjogren’s syndrome , crohn’s disease , UC)
* 1 IN 3 CASES ARE ASSOCIATED WITH SEVERE LUNG INFECTION IN CHILDHOOD ( TB , whooping cough , measles , severe pneumonia)
- history of recurrent lung infection in childhood (especially Hx of TB or whooping cough (pertussis)
- Large volume of prulent content present.
0 CHF -
usually :
history of Cardiovascular disease present , othropnoea & inspiratory crackles
(raised B -nauiretic protein X ray shows pulmonary vascular congestion & echo confirms this)
0 TB -
signs - Hx of fever , night sweats , weight loss , chronic productive cough
microbiological confirmation
- granuloma , fibrosis , inflitates seen on X RAY
- positive skin test for TB
0 ACE inhibitor induced cough - ACE inhibitors cause chronic cough - NOT USUALLY PRODUCTIVE. (cough improves when ACE stopped )
0 Chronic sinusitis / rhinitis - common cause of chronic cough
(Hx of sinus pressure , runny nose (rhinorrhoea , non -productive cough , headache)
rrhoea - flow / discharge
0 GORD - chronic cough can occur especially when supine - worsens at night
(accompained with GORD symptoms (dyspepsia , frequent bletching )
0 LUNG CANCER - COPD INCREASED RISK OF LUNG CANCER
(weight loss , neight sewats , haempytsis , chest , back pain.
0 Upper airway dysfunction
0 Bronchiolitis - inflammation of the bronchioles (post infectious , Hx of connective tissue disorders , fume exposure)
CXR - hyperinflation
What is a COPD excaebation ?
exacerbation of COPD - acute worsening of respiratory symptoms that results in additional therapy .
SIGNS /SYMPTOMS
- increased level of dyspnoea
(change from baseline can test with questionaires , scales - breathlessness can be described by patients as reduced excercise capacity e.g. can only walk 10 min instead of 15. ) - worsening of chronic cough (in frequency or severity )
- increase in volume , thickness , colour or purulence (pus) of sputum produced (change in purulence may indicate presence of bacteria .
0 The most frequently identified bacterial pathogens include : *Haemophilus influenzae, *Streptococcus pneumoniae, *Moraxella catarrhalis.- VIRAL INFECTIONS CAN HAPPEN ALONGSIDE BACTERIAL.
0 Wheeze
(beware of decreased breath sound - indicates impending respiratory failure.)
0 tachypnoea - could be respiratory failure
0 Cor pulmonale (could occur due to exacerbation - induced hypoxaemia ) - peripheral oedema elevated JVP - hepatojugular reflux systoluc parasternal heave - relative hypotension - loud pulmonary second heart sounds
Just for knowledge - practical tip to differentiate upper airway sound from wheeze?
Transmitted upper airway noise ‘wheeze’ is common both as a symptom and as a sign. Be aware that patients or relatives may describe ‘wheeze’, especially on exertion, that is actually upper airway transmitted noise and not wheeze. Consider this on auscultation. Likewise wheeze heard at the end of the bed is often from the upper airway rather than small airways and may not improve with usual COPD treatment.
- GORD - can trigger excaberations.
INVESTIGATIONS
- Arterial blood gas (in hospital )
(if moderate - severe excaberations)
( may see chronic hypercapnia , acute respiratpry acidosis) - COMPARE WITH PRIOR ABG to determine difference from baseline levels. - Pa02 < 8KPA
- <7.35 or PaCO2 > 6.5 KPA - Respiratory acidosis.
- ACIDAEMIA IMPLIES SEVERE EXCABERATION & 30 - DAY MORTALITY
(DO ABG wiithin 2 hours of starting acute NIV)
0 Pulse oximetry (community & hoospital )
0 ECG, Vitamin D ( can be done commmunity if possible & hospital )
REST CAN ONLY BE DONE IN HOSPITAL - FOR MODERATE TO SEVERE EXACERBATIONS) do :
- CXR - (or if pneumonia is suspected)
- FBC
- CRP (elevation - possible infection)
- Urea & electrolytes , creatinine
- Sputum microscopy , culture & gram stain.
- serum theophylline levels ( for anyone on theophylline)
Signs of respiratory failure ?
0 Change in mental status
- drowsiness
- confusion
- personality change
- irritability
0 Morning headaches
(sign of worsening hypercapnic ventilatory failure. )
0 accessory muscle use
& pursed lips breathing.
0 Paradoxial movement of the abdomen ( SEE SAW BREATHING)
Respiratory failure ( Pa02 below 8.0 KPA)
Types of breathing support / assistance ? - oxygen delivery devices ?
NIV - NON - INVASIVE VENTILATORY SUPPORT - delivery of O2 via a face mask - no need for endotracheal airway.
- Mask
0 Non -rebreathe (reservior )
0 Bag valve mask
0 Venturi mask
Treatment of excaberbation of COPD ?
1ST LINE
Oral corticosteriods - Prednisolone 5 days 30mg- FOR ALL THOSE ADMITTED TO HOSPITAL OR SIGNIFICANT INCREASE IN BREATHLESSNESS.
IF BACTERIAL INFECTION PRESENT
ORAL ANTIBIOTICS
- (amoxicillin, doxycycline , clathromyocin )
2ND LINE - if this does not work (pick another of those 3 )
if higher risk of treatment failure
(Co - amoxiclav , , Co - trimoxazole , IF THESE NOT POSSIBLE / WORKING levofloxacin)
3RD LINE
IV ANTIBIOTICS
- Amoxicillin
- Co - amoxiclav
- Clarithromycin
- Piperacillin with tacobactam
- if Oxygen needed use - NIV
- IF in hospital - can use :
- invasive ventilation
- intravenous theophylline (on if inadquate response to nebulised bronchodilators) - monitor levels of theo within 24 hrs of starting
- Pulmonary rehabilitation (supervised program including excercise training , health education , breathing techniques etc. )
- monitor pulse oximetry during recovery for non - hypercapnic / acidotic respiratory failure
- monitor with ABG for acidiotic respiratory failure
What is asthma ?
same guy that did tonsilitis .
Chronic respiratory condition associated with airway inflammation & hyper-responsiveness
(airway hyperresponsiveness - pre - disposition of airways to narrow excessively in response to stimuli) that would not really affect heathy pl. ————————-> leads to recurrent wheezing , breathlessness , chest tightness , coughing - resulting in variable airway obstruction that is reversible either spontaneously or with treatment.
SIGNS & SYMPTOMS
(MAINLY LOOK FOR
0 Cough , breathlessness , expiratory wheeze & daily or seasonal changes in symptoms
0 FHx or Hx of atopic disorders
0 Any triggers that make it worse. )
- Recent upper respiratory tarct infection
- dyspnoea , breathelessness
- Cough , expiratory wheeze (precipitated by allergen exposure , cold air , tobacco smoke , worse with emotions e.g laughing hard.
- Nasal polyposis
(single or mutiple polyps in nasal cavity. )
RISK FACTORS
- Family history
- allergens
- atopic history
(atopic dermatitis , eczema , allergic rhinitis )
Investigations / Diagnosis of asthma ? - 17 & above (note children aged 5 - 16 are similar but slight differences )
Diagnose asthma :
- FeNO > 40 ppm + postive BDR or positive peak flow varibility / bronchial hyperreactivity
or
- FeN0 btw 25 & 39 + positive bronchial challenge
or Postive BDR + Positive peak flow varibility
Suspect asthma with :
- Negative BDR , FeN0 > 40 ppm or btw 25 & 39 with peak flow varibility
or
Positive BDR + FeN0 level btw 25 - 29 ppb with negative peak flow varibility .
(review diagnoses 6 -10 weeks after)
- NOTE IN CHILDREN - POSITIVE FeN0 = > 35ppb
Order of diagnosis
HIstory ————> Exam (respiratory - may be normal in people with asthma )———————> Objective testing - offer all 3 - (Spirometry , feNO , peak flow) ———————-> Bronchodilator reversibility test (BDR)( for aged over 17 with obstructive spirometry (FEV1 /FVC < 70 %) ——————–> Diagnostic uncertainity do : monitoring of peak flow variability for 2 to 4 weeks - 20 % variability - POSITIVE / ——> Bronchial challenge test (see requirements below) —————————->
Explanation of test
spirometry - aged over 5
FeNO - aged over 17
0 Spiromtery (FEV1/FVC 40 ppm + no variability in peak flow
or
0 FeN0 < 40 ppm + variability in peak flow)
(may be used if spirometry has been done but doctors not sure if you still have asthma.
(other names - airway provocation test - look to see if patient has sensitive airways - increasing doses of medicine that constrict / irritate the airways (e.g histamine , methacholine ) are breathed in. Pl with sensitive airways / asthma are affected by much lower doses. )
0 FeNO - fractional exhaled nitric oxide test ( test how much NO is in you breath - higher levels indicate asthma - MORE THAN 40 PPB (parts per billion)
* beware that smoking can lower levels.
0 Bronchodilator reversibility test (IMPROVEMENT OF FEV1 OF MORE THAN 12 % + increase in volume of 200 or more - POSITIVE )
OTHER TEST - NOT DIAGNOSTIC
- peripheral eosiophil count
- excercise challenge (17 & over)
FOLLOWING TEST ARE NOT DIAGNOSTIC - USED TO IDENTIFY ALLERGEN AFTER FORMAL DIAGNOSIS MADE (on if allergy is present ) :
- Skin prick allergy test
- immunoassay for allergen specific IgE
Treatment of asthma for ages 17 & over ?
Infrequent asmtha symptoms , short lived wheeze + normal function
1 ST LINE
reliever therapy
SABA - e.g salbutamol
2ND LINE
Low dose ICS
If maintence therapy needed e.g frequent asthma symptoms (3 or more times a weeks ) or waking at night.
1ST LINE
low dose ICS
2ND LINE
Lose dose ICS + LTRA (leukotriene receptor antagonist e.g . Montelukast , zafirlukast)
3RD LINE
Low dose ICS + LABA +/- LTRA
( discuss whether to continue LTRA)
4TH LINE
MART - maintence and reliever therapy combines ICS with LABA in single inhaler) - low dose ICS used +/= LTRA
5TH LINE
MART - medium dose of ICS
or fixed dose of ICS , LABA with a SABA
( + /- LTRA)
6TH LINE
- increase to High dose ICS
or trail of addition drug e.g. LMRA (muscarinic antagonist) or theophylline.
SELF MANAGEMENT - ADVICE ON AVOIDANCE OF EXPOSURE TO POLLUTANTS , ALLERGENS
- they have self management plan on how to deal with asthma if deteroriates e.g . Doctor prescribes a specific increased dose to take for 7 days etc.
CONSIDER REDUCING MAINTENCE THERAPY IF SYSMPTOMS CONTROLLED FOR 3 MONTHS .
(only consider stopping low ICS treatment if symptoms free)
