Respiratory Flashcards
how would COPD present?
in a long term smoker usually with progressive shortening of breath, sputum, wheeze, recurrent RTIs and fatigue
name some DDx for COPD?
HF, fibrosis, cancer
how is COPD diagnosed?
clinical and spirometry
FEV1 reduces but FVC is normal therefore FEV1/FVC<0.7
CXR, FBC, BMI, ECG, sputum sample, echo, CT thorax, serum A1AT, TLCO (reduced)
how is COPD managed?
stop smoking, annual flu and the pneumococcal vaccines, SABA or SAMA, if there is asthmatic properties then use LABA and ICS or if not then LAMA and LABA
if severe - nebs, oral theophylline, oral mucolytics, LT prophylactic ABx, LTOT
why is LTOT needed?
chronic CO2 retention reduces the respiratory drive - therefore need to maintain O2 sats but also regular monitoring and ABGs to ensure not over saturated
what is the management of a COPD exacerbation?
usually infection with respiratory acidosis - pred 30mg OD for 7-14 days, inhalers or nebs, ABx, physio, IV aminophylline, NIV or doxapram if NIV not appropriate
what is the MRC dyspnoea scale?
measure of breathlessness
grade 1 - breathless with strenuous exercise
II - walking up a hill
III - on the flat
IV - 100m on the flat
V - at rest
what is pneumonia and how does it present?
it is inflammation of the lung tissue and sputum filling the alveoli
it presents with shortness of breath, sputum, fever, haemoptysis, pleuritic chest pain, delirium, sepsis, tachycardia, tachypnoea, hypoxia, hypotension, confusion, bronchial breathing, dull to percuss and coarse crackles
what are some investigations for pneumonia?
CRP, CXR, FBC, U+Es, cultures if moderate or severe, legionella urinary antigens
what are some complications of pneumonia?
sepsis, lung abscess, empyema, pleural effusion, death
what is the management of pneumonia?
use CURB65 to determine severity - if mild oral ABx for 5 days - amoxicillin or macrolide, moderate or severe ABx 7-10 days dual parenteral if needed
what is the most common lung cancer?
non small cell
what is the presentation of lung cancer?
shortness of breath, cough, haemoptysis, clubbing, pneumonia, weight loss, night sweats, lymphadenopathy
what are some extrapulmonary manifestations of lung cancer?
recurrent laryngeal and phrenic nerve palsy, SVCO, Horner’s, SIADH, Cushing’s, hypercalcaemia, limbic encephalitis, Lambert Eaton Myasthenic Syndrome
what investigations are done for lung cancer?
CXR (hilar enlargement, peripheral opacity, pleural effusion, collapse), staging CT, PET-CT, bronchoscopy with endobronchial USS, histology
what is the management for NSC and SCLC?
NSCLC - lobectomy, segmentectomy, wedge resection, radio and chemo
SCLC - chemo and radio, endobronchial treatment with stents and debulking - palliative
what is asthma?
it is episodic exacerbations of bronchoconstriction with reduced diameter and caused by hypersensitivity- reversible with bronchodilators
what is the presentation of asthma?
episodic, diurnal variation, dry cough, bilateral widespread polyphonic wheeze in absence of illness, atopic conditions, FHx, SOB
how is asthma investigated?
fractional exhaled nitric oxide, spirometry with bronchodilator reversibility
if uncertainty - peak flow variability, direct bronchial challenge test with histamine and metacholine
what is the management of asthma?
non pharmacological - asthma programme and yearly review, annual flu jab, avoid smoking and advise exercise
pharmacological - SABA, ICS, LRA, LABA, MART, increase ICS, oral theophylline or inhaled LAMA, specialist input
what will obstructive and restrictive disease show on lung function tests?
obstruction - FEV1/FVC<0.75
restrictive - FEV1/FVC>0.75
what is ILD?
affects the lung parenchyma with inflammation and fibrosis
how is ILD diagnosed?
high resolution CT showing ground glass appearance or if unclear use biopsy
what drugs can induce ILD?
amiodarone, cyclophosphamide, nitrofurantoin, methotrexate
what is the presentation and management of idiopathic ILD?
SOB and dry cough with no obvious cause occurring over a period of 3 months, there will be bibasal fine inspiratory crackles and finger clubbing - give antifibrotics and inflammatories such as pirfenidone, nintedanib
what is the non-pharmacological management of ILD?
stop smoking, remove and treat underlying cause, O2, physio and pulmonary rehabilitation, pnuemococcal and annual flu vaccine, ACP, lung transplant
what is the definition of acute asthma?
it is a rapid deterioration in symptoms with worsening SOB, accessory muscle use, tachypnoea, wheeze and reduced asthma
What is the treatment of acute asthma?
oxygen, salbutamol nebs 5mg, hydrocortisone 100mg IV, prednisolone 40mg PO, ipratropium bromide neb, IV theophylline, IV mag sulph, escalate, intubation, ABx if infective
what will an ABG show in acute asthma
initially respiratory alkalosis due to tachypnoea
if pCO2 normal then worry
if respiratory acidosis - near fatal
what needs to be monitored when using salbutamol?
K+ - hypokalaemia
describe the two types of NIV?
BiPAP = IPAP and EPAP - keeps the airways open with pressure during inhalation - use if pH<7.35, type 2RF or PaCO2>6
CPAP - continuous pressure
what is the prophylaxis for PE?
LMWH e.g. enoxaparin - unless bleeding, using a DOAC or warfarin
can also use anti-embolic compression stockings
what is the management of a PE?
O2, analgesia, monitoring
initial - apixaban or rivaroxaban first line or LMWH if anti-phospholipid syndrome
long term anticoagulation - warfarin, DOAC or LMWH for 3months if provoked, 3-6m if active cancer or longer if unprovoked
when is thrombolysis indicated in PE?
massive PE with haemodynamic compromise
how is PE diagnosed?
Wells score - if likely then do CTPA and if unlikely then D Dimer. It D Dimer positive then CTPA and if not then find alternative diagnosis
can also do VQ scan and ABG
what are some causes of pneumothorax?
Iatrogenic, lung pathology e.g. COPD, spontaneous, trauma
what investigations for suspected pneumothorax?
CXR, CT thorax
what is a tension pneumothorax?
when there is a one way valve created - cardiorespiratory arrest - tracheal deviation, reduced air entry, increased resonance, increased heart rate, hypotension
treat with large bore cannula on in 2nd ICS MCL and then chest drain
what is the management of a pneumothorax?
less than 2 cm and asymptomatic - self resolving - follow up in 2-4 weeks
if SOB and over 2cm - aspiration and reassess
if 2 aspirations fail then chest drain
unstable - chest drain
where is a chest drain inserted?
triangle of safety - 5th ICS, MAL, AAL, just above rib to avoid NVB and do CXR to check position
what is the difference between exudative and transudative pleural effusion?
exudative is a protein count of >3g/dL - it is due to inflammation such as cancer or TB
transudative is a protein count of <3g/dL and is due to fluid shift such as in CCF
what is empyema?
it is an infected pleural effusion - often presents with fever, pus, ph<7.2 reduced glucose and high LDH on aspiration
what is the presentation of pleural effusion?
SOB, dull to percussion, decreased breath sounds, tracheal deviation away
how is pleural effusion investigated?
CXR with blunt costophrenic angles, fluid in lung fissures and a meniscus and mediastinal deviation, aspiration for protein, cell count, pH, glucose, LDH and microbiology
how is pleural effusion managed?
conservative if small
aspiration and drain if large
chest drain to prevent recurrence
what is pulmonary hypertension?
it is increased resistance and pressure of blood in the pulmonary arteries resulting in right heart strain and back pressure into the systemic venous system
what are the causes of pulmonary hypertension?
group 1 - primary e.g. SLE
2 - LHF due to MI etc
3 - CLF e.g. COPD
4 - primary vascular e.g. PE
5 - other e.g. haem disorders
how is pulmonary HTN investigated?
ECG - RVH (large R waves in V1-3 and S waves V4-6, RAD and RBBB), CXR (dilated PA and RVH), NTproBNP increased and echo (PA pressure)
how does pulmonary HTN present?
SOB, syncope, increased JVP, hepatomegaly, peripheral oedema
what is the management for pulmonary HTN?
primary - IV prostanoids, endothelin receptor antagonists, phosphodiesterase 5 inhibitors
secondary - manage underlying cause
supportive for complications (heart failure, arrhythmias, respiratory failure)
what is sarcoidosis?
it is granulomatous inflammation - nodules full of macrophages
how does sarcoidosis present?
typically a young black female with a cough
mediastinal lymphadenopathy, pulmonary fibrosis and nodules, weight loss, fever, fatigue, liver nodules, cirrhosis, cholestasis, uveitis, conjunctivitis, erythema nodosum, granulomas, bones, CNS, PNS
what is the DDx for sarcoidosis?
TB, lymphoma, HIV, hypersensitivity pneumonitis, toxo or histoplasmosis
how is sarcoidosis investigated?
bloods - serum ACE, Ca, CRP and Igs increase
CXR - hilar lymphadenopathy
CT - hilar lymphadenopathy and pulmonary nodules
MRI - CNS involvement
PET - inflammation
histology - non-caseating granulomas with epithelial cells
how is sarcoidosis treated?
monitor, oral steroids and bisphosphonates, methotrexate, azathioprine, lung transplant
what is the pathophysiology of OSA?
pharyngeal muscle collapse during sleep resulting in apnoea episodes for a few minutes
what are some associations with OSA?
risk factors - middle age, male, obesity, alcohol, smoking
can cause - HF, MI, stroke
what is the presentation of OSA?
apnoeas, snoring, morning headache, unrefreshed, day time sleepiness (use Epworth sleepiness scale), concentration problems and reduced O2 sats at night
what is the management of OSA?
refer to ENT, monitor sleeping sats, HR, RR, correct RFs
CPAP and surgery - uvulopalatopharyngoplasty
