Respiratory Flashcards
Berlin Criteria
For ARDS
- Acute onset
- Respiratory failure not primarily due to hydrostatic oedema
- Bilateral opacities on lung radiograph
- paO2:FiO2 < 300
Management
- Prone nursing
- Low tidal volume ventilation @ 6ml/kg
Home NIV indications in MND
VC < 50%
SNIP < 30cm H20
Low max insp pressure (MIP) - diaphragm and inspiratory muscles
Low max exp pressure (MEP) - abdominal and expiratory muscles
Imp in QOL and survival if commenced before bulbar dysfunction but prophylactic NIV before above indications worsens prognosis
Predictors of NIV failure
Acidosis < 7.25
Marked onset new hyperaemia
Respiratory distress signs with RR > 25
Non-pulmonary organ failure
Samters Triad
Asthma
Aspirin intolerance
Nasal Polyps
Rx with Leukotriene antagonists
Allergic Bronchopulmonary Aspergillus
Found in the soil, dust, water, vegetation (like dead leaves or compost piles),
- Chronic asthma with brown mucus plugs
- Recurrent pulmonary infiltrates
- Very high total IgE > 1000
- Positive skin test to aspergillus antigens
Rx with steroids, Mepolizumab (anti-IL5) and anti-fungals (Itraconazole)
Eosinophilic granulomatosis with polyangitis (EGPA)
- Churgg Strauss Vasculitis with granulomas
- Tissue and skin eosinophilia
- Asthma
- Cardiac involvement common
- Renal involvement rare
- 40% pANCA positive
Asthma Diagnosis
FEV1/FVC < normal
Reversibility > 12% or 200ml
Anti-IgE Immunotherapy
Omalizumab
Step 1 Asthma Management
PRN low dose ICS + Formoterol
+/- PRN SABA every-time ICS is used
Step 2 Asthma Management
Commence controller if using reliever > 3 times/week;
Daily low dose ICS
Reliever;
PRN low dose ICS + formetarol +/- SABA
+/-
PRN LTRA when SABA taken
Step 3 Asthma Management
Controller;
Daily low dose ICS + LABA
or
Daily low dose ICS + LTRA
or
Daily medium dose ICS alone
Reliever;
PRN Low dose ICS + formetarol
+/-
PRN SABA
Step 4 Asthma Management
Controller;
Medium dose ICS + LABA
or
High dose ICS alone +/- Tiotropium
Reliever;
PRN Low dose ICS + formetarol
+/-
PRN SABA
Step 5 Asthma Management
Controller
High dose ICS + LABA
plus
Omalizumab
Reliever;
PRN Low dose ICS + formetarol
+/-
PRN SABA
PRN PO corticosteroids
Definition well-controlled Asthma
day symptoms < 2 x weekly
night symptoms < 2 x monthly
Over lasy 4 week period
Mepolizumab & Benralizumab MOA
Binds IL-5 receptor for treatment of eosinophilic asthma. Effective in those with eosinophil levels > 150 regardless of IgE Level
Dupilumab MOA
Binds IL4 & IL13 receptor for Asthma and severe eczema
Alpha-1 anti-trypsin
Basilar pan-acinar emphysema
Associated with;
- hepatic cirrhosis and HCC
- panniculitis of skin
- Bronchiectasis
- Check alpha-1 antitrypsin level if COPD < 45 yrs old, FHx or absence of RF
mMRC dyspnoea score
Dyspnea only with strenuous exercise = 0
Dyspnea when hurrying or walking up a slight hill = 1
Walks slower than people of the same age because of dyspnea or has to stop for breath when walking at own pace = 2
Stops for breath after walking 100 yards (91 m) or after a few minutes = 3
Too dyspneic to leave house or breathless when dressing = 4
GOLD classification
A - < 1 exac/year, mMRC 0-1, CAT < 10
B - < 1 exac/year, mMRC > 2 , CAT > 10
C - > 2 exac/year, mMRC 0-1, CAT < 10
D - > 2 exac/year including hospitilisation, mMRC > 2, CAT > 10
Youngs Syndrome
Bronchiectasis, chronic sinusitis and Azospermia due functional blockage of the sperm in the caput epididymis, which is usually enlarged and palpable in the scrotum. Can occur later in life
Pseudomonas strains with worse outcomes
AUST-01 in Melbourne
AUST- 02 in Brisbane
Smoking related ILD
- Respiratory bronchiolitis associated with ILD
- Desquamating interstitial pneumonia
- Pulmonary Langerhans cell histocytosis
Lymphangioleiomyomatosis
- Women 30-40
- Spontaneous PTX
- Chylous effusions
- CT showing cystic disease
Idiopathic interstitial pneumonias
- Idiopathic pulmonary fibrosis
- Non-specific interstitial pneumonia
- Acute interstitial pneumonia
- Crypotogenic organising pneumonia
Empyema diagnosis
pH < 7.2
Gram stain +
Glucose < 3.3
Rapid Score
For pleural effusion
- Renal - Urea > 8
- Age > 70
- Purulent
- Infection - HAP
- dietary factors - Albumin < 27
High risk for poor outcome with pleural effusion
LENT Score
Predicts survival with malignant pleural effusions;
LDH
ECOG
Neutrophil:Lymphocyte ration
Tumour type
Riociguat
Dual mode of action, directly stimulating soluble cyclic guanosine monophosphate (cGMP) independently of nitric oxide, and increasing the sensitivity of cGMP to nitric oxide.
Apnoea-Hypopnoea Scale
Number of apnoeas or hypopnea per hour
Normal < 5
Mild 5 - 14 (treat only if symptomatic)
Moderate 15-30 (treat regardless)
Severe 30 +
Kartegener Syndrome
- Associated with DNAI1, DNAH5
- Situs invertus
- Chronic sinusitis
- Bronchiectasis
- Infertility (male and female)
- Variable lung function and course - not diagnostic
CODEX score
Prediction of outcome 3-12 months after hospital admission for COPD
Comorbidities
Obstruction
Dyspnoea
Exacerbations [reviously
Lofgren syndrome
- Sarcoidosis
- Hilar adenopathy
- Migratory polyarthritis
- Erythema Nodosum
Associated with a good prognosis,with >90% of patients experiencing disease resolution within 2 years.
Treatments NSCLC
ANTI - PDL (Durvalumab), ANTI-PD1 (Pembrolizumab, Nivolumab), TYROSINE KINASE inhibit against EGFR, ALK, ROS1
Higher likelihood to TK inhibitors if Asian, female, never-smoker, adenocarcinoma
KCO
KCO = DLCO (diffusion capacity at one alveolar unit)/VA (accessible alveolar volume)
Low DLCO but high KCO
- Kyphoscoliosis
- Lobectomy
- Severe pleural disease
- diaphragmatic paralysis
Causes high DLCO
SAMPPLE
- Severe obesity
- Asthma
- Mild LVF
- Polycythaemia
- Pulmonary haemorrhage
- L to R) intracardiac shunting
- Exercise - associated with increased CO
REM Sleep disorders
Narcolepsy is the disruption of wakefulness into REM (HLA DQB1 0602)
REM behaviour disorder; disruption of REM into wakefulness -> male predominance
Staging NSCLC
Early - Stage 1-3a (surgical resection)
- Stage 1; < 3cm < 2 nodes
- Stage 2; < 5cm < 2 nodes
- Stage 3a; > 5cm < 1 node
Late - Stage 3b - 4
- Stage 3b; > 5cm > 2 nodes
- Stage 4 any contralateral node or dissemination
Aspergillus
Associated with bronchopulmonary allergic aspergillus
From compost, soil, dust decaying material
High IgE > 1000, eosinophilia
Positive skin test
Galactomannan (constituent of the aspergilus cell wall) used to Dx invasive aspergillus commonly on immunocompromised patients
Rx with steroids and anti-fungals
Small cell Lung Ca
- Strong association with smoking
- Common mets to brain requires prophylactic whole brain radiation
- Staging; Local - ipsilateral and single radiation site, Extensive - contralateral, metastatic or outside single radiation field
- Rx with platinum based CTX (cisplatin + etoposide), radiation plus prophylactic whole brain radiation
- Paraneoplastic syndromes
Cystic Fibrosis Gene Variants
Defects in gene on Chromosome 7 associated with CFTR ( Cystic fibrosis transmembrane conductance regulator)
- Delta 508 - most common - trafficking defect associated with pancreatic exocrine insufficiency and lung disease
- G551D - defective channel regulation, gate is produced but does not function
- G542X - Non-functional gate
- R117H
CFTR modulators
- Ivacaftor; opens channel
- Tezacaftor; moves channel to surface
- Elexacaftor
G551D - Ivacaftor
homozygous delta508 - Ivacaftor + Tevocaftor
heterozygous delta508 - Ivacaftor + Tevocaftor + Elexacaftor
Indications for lung transplant in CF
FEV1 < 35% predicted with rapid rate of decline
Increase frequency exacerbations
pO2 < 60mmHg
PCO2 > 50mmHg
Clinical organism resistance
Impaired QOL
Haemodynamics in pulmonary hypertension
Where pulmonary wedge pressure = left atrial pressure
A-a gradient
Diffusion of air into alveolar = Age/4 + 4
Normal = hypoxia associated with hypoventilation, not lung disease
Abnormal = hypoxia associated with lung disease
Vital Capacity
Tidal volume + inspiratory reserve + expiratory reserve
Genes type 1 PAH
- BMPR2
- ALK1
Female predominance
Anti fibrotics
Pirfenidone; acts at TGF-beta to reduce fibroblast proliferation, SI of photosensitive rash ** improves survival but not dyspnoea scores **
Nintedanib; Inhibits multiple tyrosine kinases (PDGF, VEGF, FGF), SI of diarrhoea
For treatment patient must have VC > 50%, DLCO > 30%
R) shift O2 dissassociation curve
CADET shift right!
CO2
Acidosis
DPG (2,3)
Exercise
Temperature increase
Strains Pseudomonas with worse outcomes
AUST-01 in Melbourne
AUST- 02 in Brisbane
Rx with no evidence in Bronchiectasis
Tiotropium and Steroids
Indications for NIV in MND
- VC < 50%
- SNIP < 30cm H20
- Low max insp pressure (MIP) - diaphragm and inspiratory muscles
- Low max exp pressure (MEP) - abdominal and expiratory muscles
Imp in QOL if commenced before bulbar dysfunction but prophylactic NIV before above indications worsens prognosis
Metacholine test
Repeated measurements of FEV1
If falls < 20% - considered positive
Exhaled NO in Asthma
> 50ppb exhaled NO indicates steroid responsiveness in allergic asthma
Biologicals used in Asthma
Omalizumab - binds IgE for treatment of allergic asthma
Mepolizumab- binds IL-5; for treatment of eosinophilic asthma. Effective in those with eosinophil levels > 150 regardless of IgE Level
Benralizumab - IL-5 receptor
Dupilumab - Binds IL4 & IL13 receptor for Asthma and severe eczema
Eosinophilic granulomatosis polyangitis
- Small vessel vasculitis
- Asthma
- Tissue & blood eosinophilia
- Rhinosinusitis
- Granulomatous lung lesions
- Cardiac disease accounts for 50% of deaths
- Rarely renal involvement
MOA erythromycin
Bind the 50s/30s ribosomal complex on RNA to stop protein transcription in susceptible bacteria
Can increase risk of non-Tb mycobacterium
“radiating recall” pneumonitis
Exposure to etoposide, gemcitabine, paclitaxel and pemitrexed after radiation can cause delayed pnuemonitis
Crypotegenic organising pneumonia
Acute, migratory infiltrates preceded by a flu-like illness for 6-8 weeks. Non-responsive to antibiotics and treated with steroids.
Acute interstitial pneumonia
Mimics ARDS without the risk factors
Idiopathic pulmonary fibrosis
> 50 years
Radiological findings of usual interstitial pneumonia
Diagnosis of exclusion
Associated with Telomeropathy syndrome ; Short telomeres found in 20-25% of patients
Rx anti-fibrotics; slows progression but not mortality
Non-specific pulmonary fibrosis
- Young population
- Bilateral lower lobe reticular changes
- ground glass without Honeycombing
- Commonly associated with autoimmune disease
Types;
- Cellular
Worse prognosis and poor response to treatment
- Fibrotic
Better prognosis and response to treatment
Lights criteria
For exudative effusion
Fluid Protein: Serum protein > 0.5
Fluid LDH: Serum LDH > 0.6
Fluid LDH > 2/3 normal serum LDH
Types Pulmonary HTN
