Respiratory Flashcards
ALLERGIC BRONCHOPULMONARY ASPERGILLOSIS (ABPA)
Symptoms/signs
Investigation
Management
Cough, wheezing, mucus plugs
Usually presents in people with asthma, CF (exacerbation)
History or atopy common
Skin test for aspergillus fumigatus sensitivity = positive wheal and flare reaction
Serum total IgE = elevated
FBC with peripheral blood eosinophil count = elevated
Chest X-ray = upper and middle lobe infiltrates
Oral corticosteroid (prednisolone) + manage underlying condition +azole antifungal
EXTRINSIC ALLERGIC ALVEOLITIS/HYPERSENSITIVITY PNEUMONITIS
Symptoms
Investigations
Management
Exposure to birds and cleaning cages may cause acute symptoms.
Exposure to mouldy air conditioners, humidifiers, or ventilation systems, or to organic products that are mouldy such as hay, grain, wood, wood dust, or sugar cane
Occupational exposure to chemicals - epoxy resins, polyurethane foam, plastic coatings, and spray paint for vehicles
Dyspneoa and Cough (productive or non-productive)
Typically presents in a farmer
CXR - infiltrates, fibrosis
avoidance of causative agents + prednisolone
Asthma symtoms and investigations
Dyspnea
Cough
Expiratory wheeze
Initial tests for suspected acute attack - ecg, peak flow, abg
First line = Spirometry with reversibility testing - FEV1/FVC ratio < 70% of predicted!!!
PEFR - demonstrating > 12%
improvement with bronchodilator use
Asthma management (basic + escalation)
Step 1 = SABA
Step 2 = SABA + ICS(fluticasone, budesonide) - give ICS if symptoms 3x or more in a week or night time waking
Step 3 = SABA + ICS + LTRA(montelukast)
Step 4 = SABA + ICS + LABA(salmeterol). May continue LTRA
Acute asthma/asthma emergency management
oxygen FIRST, nebulized SABA and ipratropium bromide, and prednisolone. If peak flows are still <50% of patients best, give IV magnesium sulphate. Also consider aminophylline in severe cases
Once resolved, give prednisolone as prophylaxis
Signs of severe asthma = <90% o2 sats. Peak flow <33% best
COPD Symptoms Investigations Management Complications
Emphysema+chronic bronchitis Progressive shortness of breath Wheeze (auscultation finding) Cough Sputum production
Spirometry - FEV1/FVC ratio <0.70
Stage 1 = SABA/SAMA(ipratroprium)
Stage 2 = LABA + LAMA BUT LABA + ICS if asthmatic features e.g atopy, high oesinophil count
Complications = cor pulmonale
Infective exacerbation = amoxicillin, doxycycline, or clarithromycin(avoid in congenital long QT) as 1st line!!!!!!!
Non infective exacerbation = prednisolone
Prophylaxis = azithromycin
Asbestosis Symptoms Risk factors Investigations and findings Key complication
Occupation - shipbuilding, roofing, plumbing, construction worker
Dyspnea on exertion, cough , uncommonly chest pain
CXR:
Affects LOWER LOBES
interstitial fibrosis in the lower zones and bilateral pleural thickening is highly specific.
Subdiaphragmatic and PLEURAL PLAQUES
Pleural effusions or rounded atelectasis may occur
Complication = mesothelioma
Mesothelioma
Symptoms
Like asbestosis, mesothelioma is also caused by asbestos exposure
Therefore Risk factors are the same
Mesothelioma however is malignant
A malignancy of pleura - unilateral BLOOD STAINED pleural effusion, pleural thickening, SOB and chest pain
Acute bronchitis
Symptoms
Management
a cough(<30days) that is worse at night or with exercise. Mucus production may occur
Clincal diagnosis after ruling out other causes of cough.
Paracetamol, symptom relief
Only offer antibiotics if CRP >100 or comorbidities!!! Oral doxycycline is 1st line in adults.
Bronchiectasis Symptoms/signs risk factors Investigations Management
Chronic DAILY cough with PURULENT sputum
- RECURRENT infections
- DYSPNEA
- CLUBBING! (Not seen in COPD)
Hemoptysis may occur
Risk factors:
Kartagener syndrome - cilia dysfunction - chronic sinusitis, bronchiectasis, male infertility, situs inversus
Cystic fibrosis
ABPA
1st line = high resolution CT -> shows dilation of bronchi with or without airway thickening. And *SIGNET ring sign
X-ray
Sputum culture
Management:
Chest physio
Treat with ciprofloxacin if pseudomonas identified
Idiopathic pulmonary fibrosis
Symptoms
Investigation
Management
Progressive dyspnea on exertion
Cough - NON-PRODUCTIVE
End-inspiratory crepitations(auscultation finding)
High resolution CT - honeycombing appearance(subpleural and basilar areas predominantly)
Antifibrotic therapy - pirfenidone, nintedanib
Corticosteroid for exacerbations - prednisolone
Pneumothorax
Symptoms/signs
Investigations
Management
Dyspnea and chest pain(typically pleuritic and localised)
Decrease in tactile vocal fremitus, hyperresonance, diminished breath sounds, uneven chest expansion
Cough - “trapped lung”
Young male smoker slender
- differentiate history from P.E. using P.E. risk factors
CXR
Primary <2cm = discharge
Primary >2cm/SOB = aspiration
Secondary <2cm = aspiration
Secondary > 2cm = chest drain
*** tension pneumothorax = MEDICAL emergency -> insert wide bore cannula into 2nd intercostal space
Pulmonary embolism Symptoms Investigations Management Complications
Risk factors from virchows triad
ACUTE onset dyspnea
Pleuritic chest pain - normally localised to one side
CTPA = 1st line. If chest x-ray is clear do V-Q scan
D-dimer = elevated
Coagulation and fbc - important before starting anticoagulation
ECG- Sinus tachycardia, right bundle branch block(due to right heart strain) and right axis deviation are the most common findings). S1Q3T3 pattern may also be observed.
Consider ABG to look at V/Q mismatch - hypoxia and hypocapnia
LMWH or anticoagulant like Apixaban
THROMBOLYSIS if hemodynamically unstable (hypotension) - with IV Alteplase
Complication = right heart failure
Pulmonary hypertension
Symptoms/signs
Investigations
Management
= pulmonary arteries pressure > or equal to 25 mm Hg
Causes severe respiratory distress -> cyanosis and RVH -> death from decompensated cor pulmonale
Dyspnea, fatigue
Accentuated P2 to the second heart sound (delayed closure of pulmonic valve)
Tricuspid regurgitation murmur, prominent Jugular v wave
Right heart catheterisation - 1ST line estimates pressure in the right side of heart and pulmonary arteries.
Anticoagulants(warfarin), diuretics(HF-furosemide),
Distinguish between type 1 and 2 respiratory failure.
Give conditions that cause each
Hypoxic/Type 1 respiratory failure = PaO₂ is <8 kPa (<60 mmHg).
Hypercapnic/type 2 respiratory failure(failure of lungs to eliminate CO2) = hypoxia (PaO₂ is <8 kPa [<60 mmHg]) associated with a PaCO₂ that is >6.7 kPa (>50 mmHg)
Type 1
Pneumonia, PE, pneumothorax, aspiration, pulmonary fibrosis
Type 2
COPD, neuromusclar disease, upper airway obstruction, flail chest
ARDS Symptoms/signs Key risk factors Investigations Management
Acute respiratory failure
Low oxygen despite supplementation
RFs: SEPSIS, aspiration, PNEUMONIA, trauma, pancreatitis
Abnormal CXR = bilateral infiltrates
Respiratory failure within 1 week of avelore insult
Symptoms of resp failure not due to HF/fluid overload
Low tidal MECHANICAL VENTILATION!!
Sarcoidosis
Symptoms/signs
Investigation
Management
Cough - dry Dyspnea Arthralgia - knees, ankles, wrists Chronic fatigue Wheezing Lymphadenopathy - usually cervical and submandibular. Non-tender Uveitis symptoms - photophobia, red painful eye, blurred vision Uncommonly: Erythema nodosum(also seen in streptococcal infections e.g post strep reactive arthritis), facial palsy - good prognosis predictor Conjunctival nodules Lupus pernio - poor prognosis predictor Hypercalcemia
It is a diagnosis of exclusion of granulomatous lung diseases, including tuberculosis and histoplasmosis.
CXR = bilateral hilar lymphadenopathy +/- pulmonary infiltrates and egg shell calcifications
Bronchoscopy + biopsy is diagnostic -> non-caseating granulomas
*raised serum ACE in 50% patients
topical corticosteroids for mild local cutaneous disease. Otherwise, Oral prednisolone
TB
Symptoms/signs
Investigations
Management
Cough - initially dry then productive. Can cause hemoptisis in late stage Fever WEIGHT LOSS NIGHT SWEATS (Can cause erythema nodosum)
CXR = 1st line = Typically presents as fibronodular opacities UPPER LOBES
Can also cause hilar lymphadenopathy
AFB stain (Ziehl Nielson) (not Gram stain) to confirm
Sputum acid-fast bacilli smear and culture = +ve
Negative pressure isolation room
1st line active infection = Isoniazid + pyridoxine + rifampicin + pyrazinamide + ethambutol. Add sreptomycin + ciprofloxacin for recurrent, drug resistant
1st line latent infection = isoniazid + pyridoxine
Key symptoms of pneumoconioses
dyspnea on exertion, cough, normal chest examination
