Respiratory 🫁 Flashcards
describe type 1 resp failure
low p02 <8 kPa
normal pco2
Ventilation - perfusion mismatch
describe type 2 respiratory failure
low PaO2 < 8kPa
high PaCO2 > 6 kPa
alveolar hypoventilation - fail to effectively oxygenate and blow off co2
what is FEV1
forced expiratory volume in 1s
volume exhaled in first second after deep inspiration and forced expiration
what is FVC
total volume of air that the patient can forcibly exhale in 1 breath
what would spirometry tell us in an obstructive resp condition
FEV1 reduced - <80%
FVC also reduced slightly but not to same extent
so FEV1/FVC ratio is reduced - <0.7
what would spirometry tell us in a restrictive lung disease
FEV1 and FVC both reduced so normal ratio
examples of restrictive lung diseases
fibrosis
obesity
myasthenia gravis
lungs can’t take as much volume but airway is not narrowed so expiration is normal speed
examples of obstructive lung diseases
asthma
COPD
cystic fibrosis
airways narrowed so can’t get air out as quickly but lung tissue is still stretchy so can take in normal volume
presentation that would suggest asthma
episodic symptoms
cough worse at night
dyspnoea
expiratory wheeze
hx of other atopic conditions such as eczema
family hx
Ix and Dx of asthma
feNO testing + spirometry with bronchodilator reversibility testing => gold standard
feNO will be raised
mx of asthma
SABA - reliever
ICS (inhaled corticosteroids) - preventer
LTRA - oral med
LABA - long term reliever
MART - preventer and reliever
LAMA
mx of asthma ladder - NICE guidelines
SABA
SABA + low dose ICS
SABA + ICS + LTRA
SABA + ICS +LTRA + LABA
consider changing to MART
increase ICS to moderate dose
signs of moderate acute asthma
PEF >50-75%
SpO2 >92%
speech normal
RR<25
pulse <110
signs of acute severe asthma
PEF 35-50
SpO2 > 92
can’t complete sentences
RR|>25
pulse > 110
signs of life threatening asthma
PEFR <33
SpO2 <92
PaO2 <8kPa
normal C02
silent chest, cyanosis
arrhythmia or hypotension
exhaustion altered consciousness
treatment of acute moderate asthma
B2 bronchodilator
if no improvement
salbutamol via nebuliser
give prednisolone
treatment of acute severe asthma
oxygen
B2 bronchodilator
prednisolone or IV hydrocortisone
what is COPD
characterised by irreversible obstruction of airways
almost always caused by smoking
umbrella term for chronic bronchitis and emphysema
presentation of COPD
productive cough
chronic SOB
wheeze
recurrent resp infections
severe : cor pulmonale
Ix COPD
spirometry reduced fev1/fvc ratio <0.7
chest x ray : hyperinflation, bullae, flat hemidiaphragm
FBC: secondary polycythaemia
mx COPD
smoking cessation + pneumococcal and flu vaccine
bronchodilator therapy
Long term oxygen therapy - non smokers + severe COPD
acute exacerbation of COPD signs and symptoms
increased SOB
cough
wheeze
increased sputum
hypoxia
confusion
mx acute exacerbation COPD
OABC
Oxygen - high flow
Antibiotics - amoxicillin or clarithomycin
Bronchodilators
Corticosteroids - oral prednisolone or IV hydrocortisone
sx and signs of lung cancer
persistent cough, SOB, haemoptysis
weight loss
finger clubbing
lymphadenopathy
when to order urgent cxr for lung cancer suspected case
over 40 with 2 or more symptoms or 1 symptom and previous/current smoker
when to use 2WW suspected cancer pathway for lung cancer
patients aged over 40 with haemoptysis
x ray findings in keeping with lung cancer
what does paraneoplastic syndrome mean
when a range of symptoms in a patient is caused by a hormone secreted by cancer cells
cells that cause lung cancer as they are often functional i.e they can secrete hormones
important features of small cell lung carcinoma
can cause presentations of addison’s and cushing’s
spreads very early
poor prognosis
lambert-eaton syndrome
SIADH
features of lung squamous cell carcinoma
on CT jagged border seen
often causes hypercalcaemia
often associated with clubbing and hypertrophic pulmonary osteoarthropathy
with adenocarcinoma lung cancer what associated sx would you get
most common in non-smokers
gynaecomastia
HPOA
sx hypercalcaemia
groans
psychiatric moans
thrones
bones
stones
CURB65 score
Confusion - AMTS <8
Urea - >7 mmol
Resp rate - >= 30/min
BP - <= 90/60
65 - over 65?
what is curb65 score used for
severity of pneumonia
sx and signs of pneumonia
cough, pleuritic chest pain, haemoptysis
sweating, fevers, myalgia
O/E reduced breath sounds/crackles, bronchial breathing
the signet ring sign is pathognomonic for which respiratory condition
bronchiectasis
what is bronchiectasis
permanent dilation of bronchi and bronchioles due to chronic infection
sx of bronchiectasis
productive cough
large amounts of purulent sputum
haemoptysis
what drugs are most likely to cause drug-induced pulmonary fibrosis
amiodarone
nitrofurantoin
bleomycin
signs of pleural effusion
o/e of chest:
trachea is central or deviated
chest expansion is reduced on affected side
percussion note is stony dull on affected side
reduced/absent breath sounds over the effusion on auscultation
signs of near-fatal asthma
raised CO2
first line mx for pt reporting asthma sx 3 or more times per week or night time waking
SABA +Inhaled corticosteroid
name an inhaled corticosteroid
beclomethasone
for a patient to be discharged from hospital following an asthma attack they must be?
stable on their regular asthma regime for 24 hours
if a an asthmatic patient presents with white patches on her tongue what do you suspect
oral thrush caused by inhaled corticosteroid
what is the most common form of lung cancer in non-smokers
adenocarcinoma
first line ix suspected lung cancer
chest x ray
what findings on a chest x ray would suggest lung cancer
hilar enlargement
peripheral opacity
pleural effusion
collapse
what is horners syndrome and how is it related to lung cancer
triad of partial ptosis, anhidrosis and miosis
caused by a pancoast’s tumour (a tumour in pulmonary apex)
what is mesothelioma
rare form of lung cancer strongly linked to asbestos exposure
manifests in pleura
pleura thickens and some areas become plaque like
mx of hypercalcaemia
IV fluid replacement
mx of superior vena cava obstruction
IV dexamethasone
An 82-year-old man presents to the emergency department with a two-day history of worsening shortness of breath. He has a known history of squamous cell lung cancer.
On examination, the trachea has deviated to the left-hand side, percussion is dull and breath sounds are absent throughout the left side of the chest.
What is the most likely diagnosis?
left sided lung collapse
What is the most common organism associated with bronchiectasis?
Haemophilus influenzae
what level is the transpyloric plane
L1
What investigation confirms the diagnosis of bronchiectasis
high-resolution CT
Characteristic features include:
signet ring sign
tram-track sign
string of pearls/ cluster of grapes sign
how would pulmonary fibrosis present symptoms
dry cough
sob
fatigue
muscle pains
how would pulmonary fibrosis present on examination
clubbing
cyanosis
fine-end inspiratory crackles
on a CT what would you see for pulmonary fibrosis
honeycomb lung
how do you diganose cystic fibrosis
Neonatal heel prick day between day 5 and day 9
Sweat test: sweat sodium and chloride >60mmol/L
Faecal elastase: this can provide evidence for abnormal pancreatic exocrine function.
Genetic screening: This can identify CF mutations
signs of bronchiectasis
finger clubbing
coarse inspiratory crepitations
dyspneoa
wheeze
treatment options for idiopathic pulmonary fibrosis
conservative : stop smoking, pulmonary rehab
medical : long term oxygen therapy, pirfenidone
surgical : lung transplant is the only cure
complications of idiopathic pulmonary fibrosis
type 2 resp failure
increased risk of lung cancer
Cor pulmonale
50% mortality in 5 years
what is pneumocystis pneumonia
infection with the fungus pneumocystis jiroveci
common with individuals with HIV who are non-compliant
clinical features of pneumocystis pneumonia
fever
non productive cough
exertional breathlessness associated with onset - specific sign for PCP
definitive diagnostic investigation for pneumocystis pneumonia
bronchoscopy with bronchoalveolar lavage
management of pneumocystis pneumonia
antibiotics such as co-trimoxazole
indications for long term oxygen therapy - COPD
have a PaO2 <7.3kPa on 2 readings more than 3 weeks
or have a Pa02 of 7.3-7.8kPa alongside one of the following: nocturnal hypoxia, polycythaemia (high RBC) , peripheral oedema and pulmonary hypertension
indications for surgery in COPD
upper lobe predominant emphysema
FEV1>20% predicted
paCO2 below 7.3kPa
TICO above 20% predicted
medical management for smoking cessation
nicotine replacement therapy - contra-indicated in severe cardiovascular disease
bupropion - contraindicated in epilepsy, eating disorders and bipolar disorders, CNS tumours, pregnancy and breastfeeding, current benzodiazepine or alcohol withdrawal
varenicline - contraindicated in pregnancy
are e-cigarettes and vaping used as smoking cessation techniques
not currently advocated as a first-line technique
only considered for those who have not been able to quit smoking through conventional techniques
what is pulmonary fibrosis
describes a group of diseases which lead to interstitial lung damage and ultimately fibrosis
causes of lung fibrosis
lung damage
irritants
diffuse parenchymal lung disease
connective tissue disease
meds
hypersensitivity pneumonitis
what is a pleural effusion
abnormal buildup of fluid in pleural cavity
can be exudative, meaning there is a high protein count or transudative, meaning there is a relatively lower protein count
exudative causes of pleural effusion (protein content >35g/L)
exudative causes are related to inflammation
inflammation results in protein leaking out of the tissues into the pleural space
think of the causes of inflammation:
lung cancer
pneumonia
rheumatoid arthritis
tuberculosis
transudative causes of pleural effusion (protein content <35 g/L)
relate to fluid moving across into the pleural space
think of causes of fluid shifting:
congestive cardiac failure
hypoalbuminaemia
hypothyroidism
meig’s syndrome
investigating pleural effusion
chest x-ray shows:
blunting of costophrenic angle
fluid in the lung fissures
larger effusions will have a meniscus
tracheal and mediastinal deviation
taking a sample of the pleural fluid by aspiration or chest drain is required to analyse it for protein count, cell count, pH glucose, LDH and microbiology testing
treatment of pleural effusion
small effusions - conservative management
larger effusions often need aspiration or drainage
what is an empyema
infected pleural effusion
suspect empyema in a patient who has improving pneumonia but a new or ongoing fever
what would a pleural aspiration show for an empyema
shows pus, acidic pH, low glucose and high LDH
hows an empyema treated
chest drain to remove pus
antibiotics
chronic management of COPD
STEP 1
step 1. SABA/SAMA
step 4. consider specialist referral
chronic management of COPD
STEP 2
pts with persistent exacerbations with no asthmatic features - add LABA and LAMA
WITH asthmatic features or evidence of steroid responsiveness - LABA + ICS
chronic management of COPD
STEP 2
3-month trial of LAMA+LABA+ICS
if this doesn’t work go back to LABA + LAMA
if any patient on step 2 is getting more than one severe or 2 moderate exacerbations in a year then LAMA +LABA + ICS should be started
chronic management of COPD step 4
consider specialist referral
what is a pulmonary embolism
when a blood clot in the pulmonary vasculature develops usually from an underlying DVT
presentation of a PE - classic triad
sudden-onset sob
pleuritic chest pain
haemoptysis
presentation of a PE signs
tachypnoea, tachycardia + hypoxia
initial management of PE
apixaban or rivaroxaban (DOACS) should be offered first line
if they are not suitable LMWH followed by dabigatran or edoxaban OR LMWH followed by vitamin K antagonist
management of PE if patient has active cancer
DOAC unless contraindicated
management of PE if renal impairment is severe
LMWH, unfractionated heparin or LMWH followed by VKA
mx of PE if the patient has antiphospholipid syndrome
LMWH followed by a VKA
how long should the patient be on anticoagulation following a PE
ALL patients at least 3 months
provoked VTE - 3 months
unprovoked VTE - 6 months in total
when is thrombolysis used for PE patients
first-line treatment for massive PE where there is circulatory failure e.g hypotension
patients who have repeat pulmonary embolisms despite adequate anticoagulation what do you do
considered for inferior vena cava filter
what is obstructive sleep apnoea
caused by intermittent airway closure during sleep
presentation of obstructive sleep apnoea
symptoms can include:
not feeling refreshed on waking
fatigue
morning headache
decreased libido
decreased cognitive performance
nocturia
most common demographic for OSA?1
overweight middle-aged men
mx of OSA
weight loss
smoking cessation
alcohol avoidance in evening
CPAP - gold standard
how to calculate a WELLs score
3 points:
- clinical signs and symptoms of DVT
- if no alternative dx is more likely than a PE
1.5 points
- tachycardia
- immobile for more than 3 days or major surgery in last month
- previous PE or DVT
1 point
- haemoptysis
- active malignancy
what is sarcoidosis
a multi-system disease characterised by granuloma formation resulting in widespread inflammatory changes and complications
acute sarcoidosis features
fever
polyarthralgia
erythema nodosum
bilateral hilar lymphadenopathy
what cytokine is responsible for stimulating production of eosinophils
IL-5
most common organism that causes bronchiectasis
Haemophilus influenzae
most common organism that causes bronchiectasis
Haemophilus influenzae
what is bronchiectasis
describes a permanent dilation of the airways secondary to chronic infection or inflammation
scores of CURB65 and their relevant mortality rate
0-0.7%
1-3.2%
2-13%
3-17%
4-41.5%
5-57%
presentation of pleural effusion - just symptoms
general symptoms include:
- dyspnoea
- reduced exercise tolerance
- chest pain
presentation of pleural effusion - on examination
trachea may be deviated
reduced chest expansion
percussion note is stony dull
reduced breath sounds
reduced vocal resonance
A 45-year-old woman has presented to emergency department with shortness of breath and pleuritic chest pain. On examination of the chest, the right lower zone is stony dull to percussion, with reduced air entry and reduced vocal resonance.
what respiratory condition comes to mind
pleural effusion
what is meigs syndrome and how to spot it
an eponymous syndrome classified by a triad of :
- benign ovarian tumour
- pleural effusion
- ascites
acute sarcoidosis features
fever
polyarthralgia
erythema nodosum
bilateral hilar lymphadenopathy
A 30 year old female patient is referred to the respiratory clinic with a 3 month history of shortness of breath, dry cough, and fatigue. She also reports a red painful right eye with blurred vision.
Chest x-ray reveals bilateral hilar lymphadenopathy and pulmonary infiltrates.
what diagnosis is the correct one
sarcoidosis - symptoms and chest x ray findings support this diagnosis
also she likely has uveitis which also is a sign of sarcoidosis
chronic sarcoidosis features
Pulmonary (most common manifestation): dry cough, dyspnoea, reduced exercise tolerance. Examination may reveal crepitations.
Constitutional: fatigue, weight loss, arthralgia, and low-grade fever. General signs include lymphadenopathy and enlarged parotid glands.
Neurological: meningitis, peripheral neuropathy, bilateral Bell’s palsy.
Ocular: uveitis, keratoconjunctivitis sicca.
Cardiac: arrhythmias, restrictive cardiomyopathy.
Abdominal: hepatomegaly, splenomegaly, renal stones.
Dermatological: erythema nodosum, lupus pernio.
management of sarcoidosis
Bilateral hilar lymphadenopthy alone - usually self-limiting
Acute sarcoidosis - bed rest, NSAIDs
Steroid treatment: oral or IV, depending on severity of disease
Immunosuppressants: in severe disease
A 76 year old man is admitted to hospital due recurrent fever, productive cough with foul smelling sputum and dyspnoea. The hospital notes indicate the patient had a past history of a middle cerebral artery stroke.
On examination, he appears tachypneoic and there is a dull percussion note with bronchial breathing on auscultation of the lower right lung zone.
what is the most likely diagnosis
lung abscess :
- recurrent fever, productive cough with foul smelling sputum
- history of a middle cerebral artery stroke
signs of lung abscess
finger clubbing
localised dull percussion note
bronchial breathing
symptoms of lung abscess
fever
foul-smelling purulent mucus
dyspnoea
management of pneumonia - mild and moderate
amoxicillin
if penicillin is allergic - doxycycline/clarithromycin
management of severe pneumonia
co-amoxiclav + clarithromycin/erythromycin
if penicillin allergic - levofloxacin
diagnosis of tuberculosis
Mantoux test
interferon-gamma release assay
acid-fast staining with Ziehl-Neelsen stain
