Respiratory Flashcards
What are the symptoms of stable asthma?
Episodic symptoms with specific triggers and diurnal variation.
- Dry cough, worse at night
- Shortness of breath, chest tightness
- Wheeze
What signs would you find on examination in stable asthma?
Most likely none, unless having an attack.
May have: Audible wheeze and hyper inflated chest Tachypnoea Resonance to percussion Widespread polyphonic wheeze on auscultation
Which guidelines should you use to guide asthma management?
BTS guidelines
British Thoracic Society
What investigations should you do in suspected asthma?
Fractional exhaled nitric oxide testing Spirometry with bronchodilator reversibility testing Peak flow + PF diary Histamine challenge/allergy testing Trial with bronchodilators
What is the management algorithm for stable asthma?
- SABA- salbutamol
- ICS- beclometasone
- LABA- salmeterol
- Trial of inhaled ipratropium (SAMA) or tiotropium (LAMA)
- Trial oral montelukast (esp in children)
- Oral steroids
Lifestyle:
Annual review, smoking cessation, flu and pneumococcal vaccines.
What are the symptoms of acute asthma?
Shortness of breath, Chest tightness Audible wheeze / stridor Inability to complete full sentences Confusion / reduced GCS Use of accessory muscles to breathe Cyanosis
What are the features of a severe asthma attack?
Peak flow 33-50%
Inability to complete sentences
Resp rate >25
HR >110
What are the features of life-threatening asthma?
PEF <33% Silent chest Exhaustion and poor respiratory effort Normal PaCO2 or PaO2 <8 Reduced GCS SO2 <92%
What automatically makes an asthma attack have near-fatal classification?
Raised PaCO2
Requiring mechanical ventilation
What investigations should be done in somebody presenting with acute asthma?
A-E assessment PEF Pulse oximetry ABG CXR - if stable enough, purely for exclusion of alternative diagnoses.
How would you manage acute asthma?
High flow O2- 15L non-rebreathe Salbutamol news B2B Ipratropium nebs 4-6hrly Hydrocortisone IV or PO prednisolone if stable enough. -> Seek senior support, inform HDU/ICU -> IV magnesium sulphate -> Intubate and mechanically ventilate
? can try aminophylline infusion or IV salbutamol ? - seek advice
Post-recovery: 5 day course oral steroids
What would you expect on ABG in acute asthma?
- Respiratory alkalosis
- Hypoxia with normal CO2
- Respiratory acidosis (near fatal)
What are the symptoms of COPD?
Increasing breathlessness and reduced exercise tolerance
Chronic cough
Use of accessory muscles to aid breathing
Recurrent chest infections
What are the signs of COPD on examination?
Use of accessory muscles or pursed lip breathing Increased respiratory rate Hyper-inflated lungs Reduced chest expansion, hyper-resonance May have peripheral / central cyanosis Quiet breath sounds, bronchial breathing
What are the diagnostic criteria for COPD?
What are the different stages?
Symptom profile +
FEV1/FVC <0.7 with no bronchodilator reversibility
S1: FEV1 > 80% predicted
S2: FEV1 50-79% predicted
S3: FEV1 30-49% predicted
S4: FEV1 <30% predicted
How would you manage COPD?
Lifestyle: stop smoking = best prognostic indicator
Flu + pneumococcal vaccines
Medical:
1. SABA
2. If steroid responsible/atopic/high eosinophils: add ICS
Otherwise add LABA/LAMA / combination
3. LABA + LAMA + ICS
4. Oral steroids, home nebs, carbocysteine, LTOT, prophylactic abx
What are the indications for LTOT in COPD?
PaO2 < 7.3 despite optimal treatment
PaO2 7.3-8.0 with other complications
Contraindicated if still actively smoking due to flammability
What are the most common causative organisms in infective exacerbations of COPD?
- Haemophilus influenzae
2. Streptococcus pneumoniae
What investigations should you do in somebody presenting with infective exacerbation of COPD?
- A-E assessment
- O2 sats
- ABG- indicates severity and guides O2 therapy
- CXR
- Sputum culture
- Bloods + blood cultures
- ECG to rule out cardiac cause of presentation
How should you guide O2 therapy in COPD?
- If chronic retainers, aim sats 88-92%
- If not chronic retainers, aim sats >94%
- If acidotic on ABG -> NIV
How would you manage infective exacerbation of COPD?
- Oxygen
- At home: regular inhalers, oral antibiotics, oral steroids, regular review
- In hospital: bronchodilator nebs, IV antibiotics and steroids, chest physio
What would you expect to see on ABG in type 1 and type 2 respiratory failure?
Type 1: Low O2 and normal CO2
Type 2: Low O2 and high CO2
What are the most common causative organisms of pneumonia?
- Streptococcus Pneumoniae
2. Haemophilus influenzae
What is the most common causative organism in somebody with pneumonia who has just been treated for flu?
Staphylococcus aureus
What are the atypical pneumonias and their high-risk groups?
Legionella: stagnant water
Klebsiella: Alcoholics and diabetics
Mycoplasma: School aged children, alcoholics
Pseudomonas: cystic fibrosis patients
Pneumocystis jirovecii: HIV/immunosuppressed
Coxiella Burnetti: exposure to animals + their fluids
Chlamydia Psittaci: from bird contact
What are the signs on examination for pneumonia?
Fever, increased RR Coarse crepitations on auscultation Bronchial breathing Reduced chest expansion Dullness to percussion Increased tactile vocal fremitus
What is the severity classification system for pneumonia?
CURB - 65 Confusion Urea > 7 Respiratory rate >30 BP <90/60 65 age +
0-1: treat @ home
2+: hosp admission
3+: consider ITU
What investigations should be done in somebody presenting with pneumonia?
A-E assessment ABG Bloods: FBC, U&E, CRP, cultures if septic CXR Urine: pneumococcal, legionella
What are the most common causes of hospital acquired pneumonia?
Enterobacteria: e-coli, klebsiella
Staphylococcus aureus
Pseudomonas
Generally gram -ve organisms.
What are the symptoms of pneumothorax?
Sudden onset pleuritic chest pain
Shortness of breath
May present with syncope/haemodynamic instability in tension
What are the signs of pneumothorax on examination?
Increased RR and look breathless
Reduced chest expansion
Hyper-resonant to percussion
Reduced/absent breath sounds
In tension:
Tachycardia, hypotension, tracheal deviation, quiet heart sounds.
How would you investigate somebody presenting with pneumothorax?
O2 saturations
ABG
CXR
- D-dimer and Well’s score to calculate risk of PE
- ECG to rule out cardiac cause of pain
How would you manage each type of pneumothorax?
<2cm rim: supportive treatment, repeat CXR in 2-4 weeks
>2cm rim: Admit + needle aspiration & if this fails after 2 attempts, chest drain. Confirm resolution with repeat CXR.
Tension: Needle aspiration followed by chest drain
What are the anatomical locations to place needles for aspiration and chest drains?
Needle: 2nd ICS, Mid-clavicular line
Chest drain: SAFETY TRIANGLE
Boundaries: 5th ICS, anterior axillary line and mid-axillary line
Always insert near the upper border of a rib so as to miss the neuromuscular bundle.
What are the risk factors for PE?
Virchow’s triad: hypercoagulability, endothelial injury, haemostasis
- Hypercoagulability: pregnancy, COCP, polycythaemia, thrombophilia, inflammatory conditions, malignancy
- Endothelial injury: Recent surgery
- Haemostasis: long haul flights, hospital admissions, surgery, AF, immobility
What are the symptoms of PE?
Sudden onset pleuritic chest pain Shortness of breath Cough, haemoptysis Symptoms of concomitant DVT Haemodynamic instability in massive PE
How would you investigate somebody with suspected PE?
- A-E assessment
- Calculate Well’s score
3a. If low risk, D-dimer and only CTPA if D-dimer positive
3b. If high risk, CTPA straight away - CXR to rule out pneumothorax or other pathology
- ECG to rule out cardiac cause or identify underlying AF
If unstable, ABG should be performed following A-E
How would you manage somebody with PE?
If haemodynamically stable: LMWH or fondaparinux
If unstable: thrombolysis with alteplase
Duration of treatment:
Clear, reversible cause/non-recurrent PE: 3 months
Clear/irreversible cause/recurrent/ active cancer: 6 months
What are the causes of pulmonary hypertension?
- Primary PH / connective tissue disease
- Chronic lung disease e.g. COPD, emphysema
- Secondary to L heart failure and backlog in pulmonary vasculature
- Pulmonary vascular insult e.g. PE
- Sarcoid + other restrictive disease
What are the signs and symptoms of pulmonary hypertension?
Shortness of breath, fatigue Syncope, chest pain Tachycardia, tachypnoea Raised JVP, cyanosis Hepatomegaly and peripheral oedema once R heart affected by backlog
How to investigate pulmonary hypertension?
ECG: RVH, R axis deviation, RBBB
CXR: RV hypertrophy
BNP
Echo
FBC, U&E, CRP
How do you manage primary pulmonary hypertension?
IV prostanoids
Endothelin receptor antagonists
PDE5 inhibitors
What is the classic triad of symptoms in sarcoid?
Dry cough
Shortness of breath
Painful skin rash (erythema nodosum)
What is the screening test for sarcoid?
Serum ACE
What is the gold standard test for sarcoid?
Lymph node biopsy and histology
What would you expect to see on chest imaging in sarcoid?
Bilateral hilar lymphadenopathy
Pulmonary fibrosis
Pulmonary nodules
What is the management for sarcoid?
- If mild/no symptoms, no treatment
- Oral steroids 6-24m
2a. PPI + bisphosphonate protection - Methotrexate or Azathioprine
- Lung transplant in severe disease
What are the risk factors for obstructive sleep apnoea?
Male Middle age Obesity / Large neck circumference Increased alcohol consumption Smoking Neuromuscular disorders
What are the symptoms of obstructive sleep apnoea?
Loud snoring Apnoeic episodes in the night Daytime sleepiness, fatigue, waking up tired Morning headache Inability to concentrate
How do you investigate sleep apnoea?
Epworth sleepiness scale
STOP-BANG score
Sleep lab investigations- HR, BP, SO2 continuously through sleep
In OSA sats usually drop during the night
What is the treatment for OSA?
- Remove reversible causes: lose weight, reduce alcohol consumption, stop smoking
- CPAP during the night
- Surgical modifications to the palate and pharynx
What are the symptoms of idiopathic pulmonary fibrosis?
Shortness of breath
Dry cough
Malaise and weight loss
Arthralgia
What are the signs on examination of idiopathic pulmonary fibrosis?
Finger clubbing
Peripheral +/- central cyanosis
Reduced chest expansion
Fine end inspiratory crackles - sounds like walking on fresh snow
What investigations should be done in idiopathic pulmonary fibrosis?
ABG: hypoxia
Bloods: FBC, CRP, D-dimer, autoantibody tests, serum ACE, BNP
Spirometry: restrictive picture, FEV1/FVC normal/increased as both are reduced in proportion
CXR + high-resolution CT: ground-glass changes
Lung biopsy and histology
How do you manage idiopathic pulmonary fibrosis?
Manage risk factors: stop smoking, pneumococcal and flu vaccines
Pulmonary rehab
LTOT if chronically hypoxic
Pirfenidone + nintedanib medications can slow progression
Lung transplant in severe disease
Which drugs are most associated with pulmonary fibrosis?
A B C M N Amiodarone Bleomycin Cyclophosphamide Methotrexate Nitrofurantoin
Following a respiratory examination, what should you always examine?
Lymph nodes
What are the stages of TB infection?
Primary infection: mostly asymptomatic or very mild symptoms- associated with erythema nodosum
Latent TB: asymptomatic, unable to pass on to others, often found incidentally
Secondary infection: more severe symptoms, more dangerous
Miliary TB: widespread, advanced TB
What are the symptoms of active TB?
Chronic cough- may produce sputum or haemoptysis
Shortness of breath, chest pain
Fever, malaise, night sweats, weight loss
Painful lymphadenopathy
What are the signs of TB on examination?
Finger clubbing Lymphadenopathy Weight loss / cachexia in advanced disease Fever Erythema nodosum Cyanosis
How do you diagnose TB?
Bacterial sputum culture: Acid-fast bacilli on Ziehl-Neelson stain
Mantoux test: looks for previous TB (vaccination, active, latent), if >5mm then positive result
CXR: granulomatous, cavitating lesions often affecting the upper lobes
Bloods: FBC, CRP, U&E, LFT
How do you manage TB?
Supportive: O2 if needed, fluids
Antibiotic therapy:
- Latent TB= 3 months rifampicin + isoniazid OR 6months isoniazid
- Active TB: 6 months rifampicin + isoniazid and 2 months pyrazinamide + ethambutol
What are the side effects of rifampicin?
Turning body fluids orange
Altered liver function
CYP450 INDUCER- reduced effect of warfarin, COCP
What are the side effects of isoniazid?
Peripheral neuropathy
Hepatitis
What are the side effects of pyrazinamide?
Increased uric acid levels and precipitation of gout
Hepatotoxicity
What are the side effects of ethambutol?
Reduced visual acuity, colour blindness, optic neuritis
Who should not be offered BCG vaccine?
Those with positive mantoux test
Immunocompromised (live attenuated vaccine)
What is the most common type of lung cancer?
Adenocarcinoma
What are the signs of lung cancer on examination?
Finger clubbing Horner's syndrome in Pancoast tumours Lymphadenopathy SVC compression- facial swelling, arm swelling, engorged neck veins Stridor Signs of pleural effusion
What is the diagnostic test for lung caner?
Bronchoscopy/EBUS, biopsy and histology
What are Pancoast tumours most commonly?
Squamous cell carcinomas
What symptoms do Pancoast tumours generally cause?
Horner’s syndrome: compression of sympathetic chain
Arm pain and weakness: brachial plexus compression
Which types of lung cancer cause SVC compression?
Mediastinal tumours
Most commonly non-small cell cancers- esp squamous cell carcinomas
Where are adenocarcinomas usually found?
Peripherally in the lung field
Where are squamous cell and small cell cancers usually found?
Centrally in the lung
What are the extra pulmonary manifestations of small cell lung cancer?
- SIADH - ectopic ADH
- Cushing’s syndrome- ectopic ACTH
- Limbic encephalitis- antibody production against limbic brain tissue
- Lamber-Eaton syndrome -> Ab against voltage gated calcium channels on pre-synaptic neurones. Central weakness.
- Secondary hyperparathyroidism
- Dermatomyositis and Myositis
What is the latency period for mesothelioma?
Up to 45 years
What are the signs of mesothelioma?
Finger clubbing Pleural effusion Lymphadenopathy Weight loss Hepatomegaly Bone pain
How is mesothelioma diagnosed?
- CXR and chest CT to identify pleural thickening and plaques
- Confirmed by thoracoscopy and biopsy / analysis of pleural fluid
How is mesothelioma managed?
- Demetrexed + Cisplatin chemotherapy
2. Surgery + radiotherapy adjuvants -> controversial benefit
What are the causes of pleural effusion?
- Exudative: malignancy, TB, rheumatoid arthritis, pneumonia
- Transudative: Heart failure, hypoalbuminaemia, nephrotic syndrome, cirrhosis, PE
What are the symptoms of pleural effusion?
Shortness of breath
Pleuritic chest pain
Unable to tolerate lying flat
What are the signs of pleural effusion on examination?
Shortness of breath Reduced chest expansion Stony dull to percussion Tracheal deviation away from massive effusion Reduced breath sounds Decreased vocal resonance
How should you diagnose pleural effusion?
CXR- meniscus, blunting of costo/cardiophrenic angles
Chest drain/aspiration- check LDH, protein levels, culture, pH
LIGHT’S CRITERIA- help determine whether transudate/exudate
-> if effusion/serum protein >0.5 or LDH >0.6 then exudate
How to manage pleural effusion?
If clear cause, treat underlying cause
Oxygen if sats low- CPAP if severe breathlessness and hypoxia on ABG
Pleural drain/tap can relieve symptoms temporarily/permanently depending on cause
Analgesia for pain
What are the characteristics of empyema vs. effusion?
Low pH (<7.2)
Higher LDH
Low glucose in fluid
Symptoms of bacterial infection
Name the oxygen delivery devices in order of increasing O2 flow:
- Nasal cannulae
- Hudson mask
- Venturi mask
- Reservoir mask
- CPAP
- Bilevel ventilation (BiPAP)
- Nasal high flow
- Endotracheal tube.
When can an OP/guedel airway be used?
On the ward in patients not maintaining their airway properly- GCS <8
If higher GCS, stimulate gag reflex
When is a NP airway contraindicated?
Basal skull fracture
When are LMA/supraglottic airways most useful?
cardiac arrest situations to prevent the need to stop for breaths, can continuously ventilate
What is the mechanism of action of bupropion?
Inhibits dopamine and noradrenaline reuptake
Reduces nicotine craving and withdrawal due to reduced sensation of reward
What is the mechanism of action of varenicline?
Nicotine receptor partial agonist
Reduces reward, craving and withdrawal
Can you prescribe pharmacological therapies and nicotine replacement in smoking cessation?
No- you should not combine the two
You also should never coprescribe both pharmacological methods
