Respiratory Flashcards
Outline respiratory failure and the 2 types of RF
Respiratory failure: inability to maintain adequate oxygen levels or remove carbon dioxide
Type 1:
Low O2
Low/normal CO2
Type 2:
Low O2
High CO2 (retaining)
List some common causes of type 1 and type 2 respiratory failure
Type 1 RF:
- V/Q mismatch (PE, COPD, pneumonia, RDS newborn, pulmonary oedema)
- Diffusion defect (lung fibrosis)
- Intra-lung shunt (ARDS)
- Low atmospheric oxygen (high altitude)
- Right-to-left shunt (congenital heart defect)
Type 2 RF:
- Hypoventilation (many, including chest wall disorders, NM junction disorders)
- Increased carbon dioxide production
Outline the difference between acute and chronic respiratory failure
Acute:
- Needs urgent treatment
- May need artificial ventilation
- Minimal compensation by kidneys (bicarbonate levels)
Chronic:
- Slow onset and progression, allows for compensation
- Better tolerated, treatment is less urgent
- Compensation by kidneys (bicarbonate levels)
Outline how someone with respiratory failure presents (acute and chronic)
Acute:
- Respiratory symptoms e.g. SOB, cough, fever
- Drowsiness / coma
- Confusion
- Warm hands
- Bounding pulse
- Headache
Chronic:
- Mild vasodilation (pink puffers)
- May have no presenting features
List some investigations for suspected respiratory failure
ABG - gold standard for respiratory failure!
(gives pH, PaO2, PaCO2 and HCO3-)
May also do:
- Imaging e.g. chest x-ray
- O2 sats probe
List common causes of acute and chronic respiratory failure
Acute:
- Opioid overdose
- Head injury
- Severe acute asthma
Chronic:
- Severe COPD (can get acute exacerbations due to LRTI)
Outline the management steps for acute and chronic respiratory failure
ABCDE approach!
- Correct hypoxaemia/hypoxia with O2
- Nasal cannula
- Non-rebreathing mask
- Venturi mask - Correct hypercapnia / acidosis
- Correct underlying cause of hypercapnia if known
- Ventilatory support (non-invasive ventilation or intubation)
List some common asthma triggers
- Pet fluff
- Dust / dust mites
- Cold weather
- Exercise
- Pollution
- Cigarette smoke
- Pollen
- Damp
Describe the correct inhaler technique
- Hold inhaler with thumb underneath and finger on top
- Breathe out
Put inhaler into mouth, teeth on the plastic but don’t bite down, form a seal with your lips - Breathe in and press down on top
- Keep inhaling until lungs are full
- Hold breath for 10 seconds
May use spacer if their inhaler technique is ineffective
Outline occupational lung disease, including occupations that are associated with lung diseases and specific types of occupational lung disease
Can occur when there is long term exposure to hazardous / toxic / irritating particles or gases
Occupations:
- Factory workers
- Coal workers
- Farmers
- Worked with asbestos
- Industrial cleaners
- Labourers
Type:
- Coal workers’ pneumoconiosis (Black Lung Disease)
- Asbestosis (presents 20-30 yrs post exposure)
- Silicosis
- Farmers’ lung (allergic alveolitis)
Asbestosis - state the following:
- Pathophysiology
- Those at risk
- Presentation
- Investigations
- Management
Pathophysiology:
- Disturbing asbestos can lead to release of fine asbestos particles
At risk:
- Construction worker in 1970-1990s
- Builders/labourers working with older houses
Presentation:
- SOB
- Wheeze
- Chest pain
- Cough
- Fatigue
- Clubbing
Investigations:
- Lung function tests
- Chest x-ray
- CT scan
Management:
- No treatment once damage has occured
Can help
- Pulmonary rehabilitation
- O2 therapy
- Inhalers
- Stop smoking / don’t start smoking
- Ensure vaccinations up to date
Asthma (non-acute) - state the following:
- Pathophysiology
- Presentation
- Investigations
- Management
Pathophysiology:
- Chronic hypersensitivity condition caused by bronchoconstriction and leads to reversible airway obstruction
- Inflammatory response due to eosinophils, mast cells and Th2 cells
- Reversible on bronchodilators
Presentation:
- Wheeze
- SOB
- Dry (nocturnal) cough
- Chest tightness
- Atopic triad (asthma, eczema and hay fever)
- Family history of asthma
- Raised eosinophils
Investigations:
- PEFR
- Spirometry with reversibility with bronchodilators
- Fractional inhaled NO
Management:
NEW GUIDELINES
1. Low dose Fometerol/ICS as needed
2. Low dose Fometerol/ICS preventer
3. Moderate dose Fometerol/ICS preventer
4. Check FeNO level + eosinophil count
- If either raised: refer to specialist
- If normal, add LRTA e.g. Montelukast or LAMA e.g. Tiotroprium
(OLD GUIDELINES)
1. Short acting beta 2 agonists (SABA) e.g. Salbutamol
2. Inhaled corticosteroids (ICS) e.g. Beclomethasone
3. Leukotriene antagonists e.g. Montelukast
4. Long acting beta 2 agonists (LABA) e.g. Salmeterol
5. Increase ICS dose
6. Long acting muscarinic antagonists (LAMA) or Theophylline or increase ICS further
7. Refer to specialist
- Trigger avoidance
- Vaccinations up to date
- Yearly asthma review
- Avoid / stop smoking
Outline the chronic management of asthma for > 12 years (adults)
Management:
NEW GUIDELINES
1. Low dose Fometerol/ICS as needed
2. Low dose Fometerol/ICS preventer
3. Moderate dose Fometerol/ICS preventer
4. Check FeNO level + eosinophil count
- If either raised: refer to specialist
- If normal, add LRTA e.g. Montelukast or LAMA e.g. Tiotroprium
(OLD GUIDELINES)
1. Short acting beta 2 agonists (SABA) e.g. Salbutamol
2. Inhaled corticosteroids (ICS) e.g. Beclomethasone
3. Leukotriene antagonists e.g. Montelukast
4. Long acting beta 2 agonists (LABA) e.g. Salmeterol
5. Increase ICS dose
6. Long acting muscarinic antagonists (LAMA) or Theophylline or increase ICS further
7. Refer to specialist
- Trigger avoidance
- Vaccinations up to date
- Yearly asthma review
- Avoid / stop smoking
Outline the chronic management of asthma for 5-11 years
Management:
NEW GUIDELINES
1. Low dose ICS + SABA e.g. Salbutamol
2. Assess ability to use MART
- Suitable = low dose MART (ICS/Fometerol), increase to moderate dose if needed
- Unsuitable = ICS/LRTA e.g. Montelukast for a trial, then consider ICS/Fometerol
Outline the chronic management of asthma for < under 5
Management:
NEW GUIDELINES
1. Low dose ICS + SABA e.g. Salbutamol for 8-12 weeks
- If resolving symptoms, consider stopping ICS and monitor symptoms for 3 months
- If unresolving symptoms, refer to specialist
If symptoms return after 3 month break, restart ICS + SABA and titrate ICS dose up to moderate
Then consider adding LTRA as well
State the different severities of acute asthma:
- Mild
- Moderate
- Severe
- Life threatening
- Near fatal
Mild:
- PEFR > 75%
Moderate:
- PEFR 50-75%
Severe:
- PEFR 33-50%
- Can’t complete full sentences
- RR >25
- HR > 110
Life threatening:
- PEFR < 33%
- Sats < 92%
- Low RR or HR
- Cyanosis
- Silent chest
- Acute type 1 respiratory failure (low O2, low/normal CO2)
- Exhaustion
Near fatal:
- Acute type 2 respiratory failure (low O2, high CO2)
Outline the management for acute asthma
- Non-severe
- Severe
- Life threatening/fatal
ABCDE approach!
Non-severe:
- O2 therapy
- Nebulised Salbutamol (5mg)
- Oral Prednisolone 40mg (can use IV hydrocortisone)
Severe:
- Nebulised Ipratropium Bromide (500microg)
- Consider Salbutamol back-to-back
Life threatening/fatal:
- Urgent ITU/anaesthetist assessment
- CXR (portable)
- IV Aminophylline
What needs to be done to ensure safe discharge of a patient after asthma exacerbation
- PEFR > 75%
- 5 days oral Prednisolone
- 24 hrs without the use of nebulisers
Follow ups:
- Ensure asthma plan and PEFR tube
- Assess inhaler technique
- GP fu after 2 days
- Respiratory clinic after 4 weeks
COPD - state the following:
- Pathophysiology
- Presentation
- Investigations
- Management
Pathophysiology:
- Chronic obstructive non-reversible disease
- Either chronic bronchitis, emphysema or mixed
- Non-reversible with bronchodilators
- Associated with noxious particles (mostly smoking)
Presentation:
- Productive cough
- Wheeze
- SOB
- Periods of infective exacerbations
Investigations:
- Spirometry which shows non-reversibility with bronchodilators
Management:
- SMOKING CESSATION
- Pulmonary rehabilitation
- Inhalers (beta agonists and ICS)
- Mucolytics
- O2 therapy
- Up to date vaccinations
Outline the management for COPD exacerbations
ABCDE approch!
- O2 support
- Nebulisers - Salbutamol and Ipratropium
- Steroids (Prednisolone)
- Antibiotics if infective cause
- Consider IV Aminophylline
- Consider non-invasive ventilation or ITU referral if Type 2 RF
Outline how recommended guidelines for long term inhaler management for COPD patients differs in the following situtations:
- COPD with asthmatic features
- COPD with NO asthmatic features
Both: offer Salbutamol reliever inhaler
COPD with asthmatic features
- LABA and ICS e.g. Trimbow
(Formeterol and Beclometasone)
COPD with NO asthmatic features
- LABA and LAMA
List the common bacteria for pneumonia in:
- Community (CAP)
- Hospital (HAP)
- Atypical bacteria
Community (CAP)
- Strep pneumonia
- Haemophilus influenzae
- Moraxella catarrhalis
Hospital (HAP)
- MRSA
- E Coli
- Pseudomonas
Atypical bacteria - can’t be cultured or gram stained and don’t respond to Penicillins
- Legionella
- Mycoplasma pneumoniae
- Chlamydia pneumoniae
Pneumonia - state the following:
- Pathophysiology
- Presentation
- Chest examination findings
- Investigations
- Management
Pathophysiology:
- Infection of the lung parenchyma
- Chest x-ray abnormalities with respiratory symptoms
Presentation:
Symptoms
- SOB
- Fever
- Productive cough (yellow/green)
- Haemoptysis
- Pleuritic chest pain
- Fatigue/lethargy
Signs
- Low O2 sats
- Tachycardia
- Tachypnoea
- Hypoxia
- Hypotension
Chest examination findings:
- Bronchial breathing
- Coarse crackles
- Dullness to percussion
- May have reduced chest expansion
Investigations:
- Routine bloods (FBC, U&Es, CRP)
- Calculate CURB-65 score
- Chest x-ray
- Sputum culture (moderate/severe)
- Blood culture (moderate/severe)
- Legionella and pneumococcal urinary antigens (moderate/severe)
Management:
Mild: 5 days oral Abx
Moderate-severe: 7-10 days oral Abx (Flucloxacillin)
Outline the UHL recommended antibiotics for the following scenarios
Community acquired pneumonia (CAP):
- Mild
- Moderate
- Severe
Hospital acquired pneumonia (HAP):
- Mild
- Moderate
- Severe
Community acquired pneumonia (CAP):
Mild = Oral Amoxicillin (5 days)
Moderate = Oral Amoxicillin (5 days)
Severe = IV Co-Amoxiclav (5 days)
(Doxycycline second line)
Hospital acquired pneumonia (HAP):
Mild = Oral Co-Amoxiclav (5 days)
Moderate = Oral Co-Amoxiclav (5 days)
Severe = IV Co-Amoxiclav (5 days)
(Doxycycline second line)
Outline the scoring system used for pneumonia severity
- What it’s an indicator of
- What it is used for
- What does CURB-65 stand for?
CURB-65 score
- Predictor of mortality
- Used to help decide whether a patient needs to be admitted for their pneumonia
Confusion
Urea > 7
Respiratory rate > 30
Blood pressure systolic < 90mmHg OR diastolic < 60
and > 65 yrs
Mild score 0-1 = treat at home
Moderate score 2 = admit to hospital
Severe score 3-5 = intensive care
Outline the scoring results for CURB-65 and how it influences treatment
0-1 Mild = treat at home (oral abx)
2 Moderate = admit to hospital (oral abx)
3-5 Severe = admit to intensive care (IV abx)
CURB-65 score can be used to estimate 30 day mortality rate from pneumonia e.g. CURB-65 of 1 = 3% mortality but CURB-65 of 5 = 57% mortality
Pulmonary Embolism - state the following:
- Pathophysiology
- Risk factors
- Presentation
- Investigations
- Management
Pathophysiology:
- Embolus lodged within the pulmonary arteries
- Main source is usually thrombus dislodged from a DVT
Risk factors:
- Previous DVT/PE
- Prolonged immobilisation / long haul flights
- Recent surgery
- HRT/OC
- Pregnancy
- Malignancy
- Polycythaemia
Presentation:
- Pleuritic chest pain
- Haemoptysis
- Cough
- SOB
- Tachycardia
- Haemodynamic instability if large
Investigations:
1. Calculate Wells’ score
If > 4 (likely) = CTPA
If < 4 (unlikely) = d-dimer, if high then CTPA
Management:
- Immediate anticoagulation with LMWH e.g. Enoxaparin or Dalteparin
- If massive PE, may do thrombolysis e.g. Streptokinase or Alteplase
- Supportive: O2 or analgesia
- Long-term DOACs (3 months if temporary cause, indefinitely if malignancy or unknown) e.g. Apixaban
List some reasons why pneumonia may not be resolving (AEIOU)
Antibiotic issue - incorrect dose, poor absorption or abscess
Emphysema
Immunocompromised
Organism - resistant or atypical
Underlying/secondary diagnosis - e.g. PE
Outline the score used to assess the likelihood of a DVT/PE and how the outcome of the score differs based on whether it’s a DVT or PE
Wells’ score
DVT
Likely if 2 or more
Unlikely if less than 2
PE:
Likely if 4 or more
Unlikely if less than 4
List some other reasons for a high d-dimer (other than a PE)
- PE
- Recent surgery
- Pneumonia / infection
- Pregnancy
- Malignancy
- Heart failure
Tuberculosis - state the following:
- Pathophysiology
- Common extrapulmonary colonisation sites
- Presentation
- Investigations
- Management
Pathophysiology:
- Mycobacterium tuberculosis bacteria
- Inhaled through droplets of an actively infected individual
- Spreads through the lymphatics and blood
- TB can be active or latent
Common extrapulmonary colonisation sites:
- Lymph nodes
- Pleura
- Pericardium
- GI system
- Genitourinary system
- Subcutaneous
- CNS
- Bones and joints
Presentation:
- Weight loss
- Night sweats
- Cough +/- haemoptysis
- Lethargy
- Erythema nodosum
- Lymphadenopathy
- Spinal pain (if spinal TB)
Investigations:
- Mantoux test or QuantiFERON gamma
- Sputum cultures (if suspect active disease)
- Chest x-ray (if suspect active disease)
Management:
Acute pulmonary TB: RIPE
- Rifampicin
- Isoniazid (plus Pyridoxine)
- Pyrazinamide
- Ethambutol
Latent TB (at risk groups): 3 months of Rifampicin and Isoniazid OR 6 months of Isoniazid
Other:
- Test for other infectious disease e.g. HIV, Hepatitis
- Notify Public Health
- Contact tracing
- Isolation in -ve pressure rooms
Bronchiectasis - state the following:
- Pathophysiology
- Causes
- Presentation
- Investigations
- Management
Pathophysiology:
- Permanent dilation of the bronchi, with paradoxical narrowing due to decreased mucus clearance
- Caused by chronic damage
Causes:
- Post-infection e.g TB
- Recurrent childhood respiratory infections
- Immune deficiency e.g. hypogammaglobinaemia
- Genetic defects in mucus clearance e.g. cystic fibrosis
Presentation:
- Considerable productive cough (white)
- Haemoptysis
- Fatigue
- SOB
- History of risk factors/causes
Investigations:
- Sputum culture
- High resolution CT (gold standard) = signet ring sign
- Lung function tests
- Autoimmune screen / genetic testing
Management:
- Pulmonary rehabilitation
- Stop smoking
- Up to date vaccinations
- Long term O2 therapy
- Mucolytic agents
- Bronchodilators
- Long term abx
- Therapy for any underlying cause
Cystic fibrosis - state the following:
- Pathophysiology
- Presentation
- Investigations
- Management
Pathophysiology:
- Autosomal recessive disease affecting CFTR
- Impaired mucus clearance throughout body
Presentation:
- Meconium ileus at birth
- Intestinal malabsorption
- Recurrent respiratory infections
- Pancreatitis / gallstones
- Often found on newborn screening
Investigations:
- Newborn screening or family history
PLUS
- Positive sweat test or genotyping
Management:
- Newer therapies e.g. Kaftrio and Orkambi
- Pulmonary physiotherapy
- Mucolytics
- Pancreatic enzyme replacement therapy
- Up to date vaccinations
- Fat soluble vitamin replacement
List some complications of cystic fibrosis and how they are managed
- Recurrent respiratory infections
- Prophylactic antibiotics
- Physiotherapy - Low BMI
- Nutritional supplements
- Pancreatic enzyme supplementation
- May need NG / PEG feeding - Distal intestinal obstruction syndrome (DIOS)
- Oral Gastrografin (osmotic) - Diabetes
- Normal management
List some lifestyle advice given to patients with cystic fibrosis
- Avoid other CF individuals
- Avoid stables / hay (aspergillus)
- Avoid hot tubs (pseudomonas)
- Stay hydrated and have NaCl replacement in hot weather
- Don’t smoke
- Up to date vaccinations
Interstitial lung disease - state the following:
- Pathophysiology
- Presentation
- Investigations
- Management
Pathophysiology:
- Inflammation and fibrosis of the lung parenchyma
- Leads to thickening of the basement membrane and impaired gas exchange, particularly O2
Presentation:
- DRY cough
- SOB
- Fatigue/lethargy
- Finger clubbing
- Chest discomfort
- History of causes/risk factors
Investigations:
- Routine bloods
- High Resolution CT
- Lung function tests including Spirometry
Management:
- Limited treatment options (damage is irreversible)
- Manage any risk factors / underlying because
- Smoking cessation
- O2 therapy
- Physiotherapy and pulmonary rehabilitation
- Up to date vaccinations
- Advanced care planning if appropriate
- Perhaps lung transplant
Outline the different types of interstitial lung disease (causes)
Types/causes:
1) Idiopathic
- Progressive pulmonary fibrosis with no clear because
- Bibasal fine inspiratory crackles and finger clubbing
2) Drug-induced (MAN-C)
- Methotrexate
- Amiodarone
- Nitrofurantoin
- Cyclophosphamide
3) Secondary (R-ASS)
- Secondary to other conditions
- RA
- Alpha-1 antitrypsin deficiency
- SLE
- Systemic sclerosis
4) Hypersensitivity pneumonitis
Type 3 hypersensitivity reaction to an environmental allergen
4 main causes:
- Bird fancier’s lung (bird droppings)
- Farmer’s lung (mould in hay)
- Mushroom worker’s lung (specific mushrooms)
- Malt worker’s lung (mould on barley)
5) Cryptogenic organising pneumonia
- Local inflammation of the lung (almost any trigger)
- Similar presentation to pneumonia and on chest x-ray
- Definitive diagnosis with lung biopsy
6) Asbestosis
- From exposure to asbestos
- Often takes 30-40 yrs to develop
Outline the presentation of lung cancer
- Chronic cough > 3 weeks
- Haemoptysis
- SOB
- Finger clubbing
- Lymphadenopathy (supraclavicular)
- Recurrent chest infections
- Weight loss
- Lethargy
- Night sweats
BUT may have no symptoms
Outline the common causes of finger clubbing (mnemonic CLUBBING)
Cyanotic diseases
Lung abscess
Ulcerative colitis
Bronchiectasis
Brachial AV fistula
Interstitial lung disease / infective endocarditis
Neoplasia (incl. lung / fibroma / mesothelioma)
Graves’ disease
Pleural effusion - state the following:
- Pathophysiology
- Presentation
- On examination
- Investigations
- Management
Pathophysiology:
- Accumulation of fluid in the pleural cavity (between visceral and parietal pleura)
- Can be transudate or exudate
Presentation:
- SOB only
On examination:
- Dull percussion and reduced breath sounds on auscultation
- May have tracheal deviation if large
Investigations:
- Chest x-ray (blunted costophrenic angles, meniscus, tracheal deviation if large)
- Need to sample fluid with chest drain or aspiration, for analysis
Management:
Dependent on cause
- Small effusions = conservative management
- Pleural aspiration, but may reoccur
- Chest drain, prevents from recurring
Outline the main causes of pleural effusion (exudate and transudate and empyema)
Exudate (self-producing):
- Pneumonia
- TB
- Lung cancer
- RA
Transudate (due to pressure):
- Congestive heart failure
- Hypoalbuminemia
- Hypothyroidism
- Meig’s syndrome (ovarian malignancy)
Empyema:
- Infected pleural effusion
- Suspect if pneumonia is improving but new/unresolving fever
- Treat with chest drain and abx
Pleural infection - state the following:
- Pathophysiology
- Most common organisms
- Presentation
- Investigations
- Management
Pathophysiology:
- Infection of the pleural lining
Most common organisms:
- Strep pneumoniae
- Strep pyogenes
- Staph aureus
Presentation:
- Pleuritic chest pain (sharp and well localised)
- Pain worse on inspiration
- Fever
- SOB
- Cough with purulent sputum
Investigations:
- Chest x-ray which shows pleural effusions (from pneumonia) but with failure to improve
Management:
Variable!
- Abx
- Thoracentesis
- Chest drain
Pneumothorax - state the following:
- Pathophysiology
- Categories of pneumothorax
- Presentation
- On examination
- Investigations
- Management
Pathophysiology:
- Collection of air within the pleural cavity, leading to disruption of the pleural seal
Categories:
- Simple vs tension
- Primary vs secondary
- Spontaneous vs iatrogenic
Presentation:
- Chest pain
- SOB
- Cough
- Evidence of original cause e.g. trauma
Investigations:
- Erect chest x-ray, which shows
1. Hyperlucency
2. Lung border
3. Loss of lung markings
CT thorax can be used if the pneumothorax is too small to be seen on chest x-ray
On examination:
- Hyperresonance
- Decreased breath sounds
- Reduced chest expansion
- Tracheal deviation if large tension
Management:
- Conversative (if small and no SOB) with f/u in 2-4 w
- Thoracentesis (if large OR SOB)
- Chest drain (if large or haemodynamically unstable OR the thoracocentesis fails twice)
List some causes of pneumothorax
Spontaneous:
- Subpleural blebs
Secondary / pre-existing conditions:
- COPD
- Asthma
- Bronchiectasis / cystic fibrosis
- Lung cancer
- Lung infections e.g. TB / pneumonia
- RA
- Marfan’s syndrome / Ehler’s Danlos syndrome
Traumatic:
- Stab wound
- Needle wound
- Fractured rib
Iatrogenic:
- Chest drain
- Central line
- Any other procedure near the lungs (including apices)
Outline the signs and management of tension pneumothorax
Signs:
- Tracheal deviation (to unaffected side)
- Reduced air entry on affected side
- Hyperresonance
- Haemodynamically unstable (hypotension and tachycardia)
Management:
1) Thoracocentesis (immediate management)
- Large bore cannula into 2nd intercostal space, midclavicular line
2) Chest drain (definitive management)
Outline the safety triangle for a chest drain and where needle should be inserted relative to ribs
- 5th intercostal space
- Mid-axially line
- Anterior axillary line
Insert needle above the ribs avoid the neurovascular bundle
Obstructive sleep apnoea (OSA) - state the following:
- Pathophysiology
- Risk factors
- Presentation
- Investigations
- Management
Pathophysiology:
- Collapse and obstruction of the pharyngeal airway during sleep
- Apnoea episodes where the patient stops breathing completely for up to a few minutes
- Leads individual to wake many times during the night (often reported by partner)
Risk factors:
- Obesity
- Smoking
- Alcohol
- Middle age
- Male
Presentation:
- Snoring reported by partner
- Reduced O2 sats at night
Problems with tiredness as a result of disrupted sleep
- Poor concentration
- Daytime tiredness / fatigue
- Morning headache
Investigations:
- Referral to ENT specialist or specialist sleep clinic for: Sleep studies
Management:
- Weight loss if appropriate
- Stop smoking / alcohol
- CPAP overnight
- If severe, surgery is UPPP (uvulopharyngoplasty to restructure soft palate and jaw)
*Consider occupation and whether it’s high risk e.g. HGV driver = require urgent referral
List causes of obstructive and restrictive lung diseases, as well as the FEV1:FVC ratios for both types of lung disease
Obstructive
Causes:
- COPD
- Asthma
FEV1:FVC ratio - < 0.75 (FEV1 reduced)
Restrictive
Causes:
- ILD e.g. pulmonary fibrosis
- Obesity
- Sarcoidosis
- Scoliosis
- Motor neurone disease
FEV1:FVC ratio - > 0.75 (FEV1 and FVC reduced)
Non-invasive ventilation - describe the difference between BiPAP vs CPAP and explain when you would use each
BiPAP (bilevel positive airway pressure)
- Positive pressure during inspiration to force air into lungs
- Less positive pressure during expiration to allow air to leave
Use: type 2 respiratory failure, with respiratory acidosis that doesn’t respond to treatment
CPAP (continuous positive airway pressure)
- Pressure that is continuous to keep airways open, for airways that are prone to collapse
Use: obstructive sleep apnoea, congestive heart failure and acute pulmonary oedema
Influenza - state the following:
- Pathophysiology
- Presentation
- Investigations
- Management
Pathophysiology:
- Viral infection classified by haemagglutinin (H) and neuraminidase (N) surface antigens
- Spread through direct contact or via respiratory droplets
Presentation:
- Fever and chills
- Headache
- Rhinorrhoea
- Cough
- SOB
- Myalgia
- Arthralgia
- Fatigue / malaise
Investigations:
- Only test for influenza if it will change outcomes or if patients are at high risk of complications from influenza
- PCR tests
Management:
- Manage pt in a side room
- Usually supportive e.g. analgesia, fluids, O2 if required
- Oseltamivir if required
COVID-19 - state the following:
- Pathophysiology
- Presentation
- Investigations
- Management
Pathophysiology:
- Viral coronavirus infection
- Spread through direct contact or via respiratory droplets
Presentation:
- Fever and chills
- Continuous cough
- Loss / change sense of smell or taste
- SOB
- Sore throat
- Rhinorrhoea
- Myalgia
- Arthralgia
- Fatigue / malaise
- Headache
- Diarrhoea
Investigations:
- Rapid antibody test
- PCR test
Management:
- Manage pt in a side room
- Usually supportive e.g. analgesia, fluids, O2 if required
- Dexamethasone / corticosteroids
- Monoclonal antibody treatment (Casirivimab/Imdevimab)
Pulmonary hypertension - state the following:
- Pathophysiology
- Presentation
- Common causes
- Management
Pathophysiology:
- Increased pressures in the pulmonary vasculature
- Can be either primary or secondary to pulmonary disease
- Often leads to cor pulmonale
Presentation:
May be asymptomatic
- SOB
- Syncope
- Chest pain
Signs
- Raised JVP
- Peripheral oedema
- Reduced O2 sats / cyanosis
- Hepatomegaly
Common causes:
- Primary pulmonary hypertension
- Large PE
- Interstitial lung disease e.g. pulmonary fibrosis
- COPD
- Cystic fibrosis
Management:
- Treat the underlying cause
- Long-term O2
Cor pulmonale - state the following:
- Pathophysiology
- Presentation
- Common causes
- Management
Pathophysiology:
- Right-sided heart failure, secondary to respiratory disease (leading to pulmonary hypertension)
Presentation:
Symptoms
- May be asymptomatic
- SOB
- Syncope
- Chest pain
Signs
- Raised JVP
- Peripheral oedema
- Reduced O2 sats / cyanosis
- Hepatomegaly
Common causes:
- Large PE
- Primary pulmonary hypertension
- Interstitial lung disease e.g. pulmonary fibrosis
- COPD
- Cystic fibrosis
Management:
- Treat the underlying cause
- Long-term O2
Outline the 5 broad causes of pulmonary hypertension
1) Primary pulmonary hypertension or connective tissue disease (e.g. SLE)
2) Left-sided cardiac failure or systemic hypertension
3) Chronic lung conditions e.g. COPD
4) Vasculature issues e.g. PE
5) Miscellaneous e.g. sarcoidosis, haematological disorders
Outline the purpose of the MRC dyspnoea scale
and outline the 5 grades
Grade 1: breathless only on strenuous exertion
Grade 2: breathless when hurrying on the flat / walking up a slight hill
Grade 3: breathless after 15 minutes walking / walk slower than most people
Grade 4: breathless after a few minutes on the flat / breathless after walking 90m
Grade 5: breathless after undressing / too breathless to leave the house
List the 3 interventions that alter prognosis/mortality for patients with COPD
- SMOKING CESSATION
- Long term O2 therapy (used for > 15 hrs per day)
- Lung volume reduction surgery
List 3 common drug classes that can cause a cough (directly or indirectly)
- ACEi
- CCB
- DMARDs
Sarcoidosis - state the following:
- Pathophysiology
- Who commonly develops it?
- Presentation
- Investigations
- Management
Pathophysiology:
- Multi-system disease characterised by granuloma formation (nodules of inflammation full of macrophages)
- Cause is unknown
- Usually associated with chest symptoms, but can also have multiple extra-pulmonary manifestations e.g. erythema nodosum and lymphadenopathy
Who commonly develops it?
- Young adulthood and aged 60
- Women
- Black ethnicity
Presentation:
- Dry cough
- SOB
- Lymphadenopathy
- Arthralgia
(young black woman, presenting with dry cough and SOB)
Investigations:
- Serum ace
- Chest x-ray (hilar lymphadenopathy)
- HRCT (pulmonary nodules)
- PET scan (active areas of inflammation)
- Histology = gold standard (skin biopsy or bronchoscopy) shows non-caseating granulomas
Management:
May spontaneously resolve in 6 months in 60% of patients
- No treatment needed if no/mild symptoms (often resolves spontaneously)
- Oral corticosteroids (6-24 months)
- Methotrexate or Azathioprine if above doesn’t work
Outline the complications of sarcoidosis (how it presents)
Lungs (mainly):
- Pulmonary fibrosis
- Nodules
- Mediastinal lymphadenopathy
Systemic:
- Fever
- Weight loss
- Fatigue
Liver:
- Nodules
- Cirrhosis
- Cholestasis
Eyes:
- Uveitis
- Conjunctivitis
- Optic neuritis
Skin:
- Erythema nodosum
- Lupus pernio
Heart:
- Heart block
- Heart failure
Kidneys:
- Kidney stones (hypercalcaemia)
- Calcium deposits
- Interstitial nephritis
CNS:
- Nodules e.g. in brain
- Pituitary involvement e.g. diabetes insipidus
- Encephalopathy
PNS:
- Bell’s palsy
Which lung cancer is most associated with non-smokers
Lung adenocarcinoma
Which lung cancer is almost always inoperable on presentation
Small cell carcinoma
List some causes of acute respiratory distress syndrome (ARDS)
- Pneumonia
- Aspiration pneumonia
- Sepsis
- Major trauma
- Pancreatitis
ARDS - state the following:
- Pathophysiology
- Presentation
- Investigations
- Management
Pathophysiology:
- Non-cardiogenic pulmonary oedema developing acutely within 1 week
- Usually occuring after an injury or illness affecting the lungs
Presentation:
- Tachypnoea
- SOB / severe dyspnoea
- Chest pain
- Cyanosis / low O2% / confusion
- Bilateral crackles
- Dullness to percussion over affected areas
- Sudden onset respiratory failure
Investigations:
- Bedside = sputum culutre, ABG, viral swabs e.g. covid-19
- Bloods = infection screen, BNP (?cardiac cause), blood cultures
- Imaging = chest x-ray (bilateral opacities)
- Procedures = brocheolar
Management:
Aim to resolve underlying cause
- Ventilatory support (low flow to prevent damage)
- Nutritional support e.g. NG tube
- DVT prophylaxis whilst immobile
State which bacterial pneumonia organism causes the following coloured sputum:
1. Red-current jelly sputum
2. Rust coloured sputum
- Klebsiella pneumoniae
- Streptococcus pneumoniae
List some potential complications of pneumonia
- Sepsis
- ARDS (acute respiratory distress syndrome)
- Empyema / lung abscess
- Parapneumonic effusion
- Death
List some potential causes of bilateral hilar lymphadenopathy
- Malignancy (lymphoma)
- Infective (TB)
- Inflammatory (sarcoidosis)
- Pneumoconiosis (e.g. silicosis from fibre inhalation)
List some lung conditions which would show a restrictive pattern on spirometry
- Pulmonary fibrosis / asbestosis / sarcoidosis
- Chest wall abnormalities / kyphosis
- Myasthenia gravis / MND
- Obesity
List some lung conditions which would show an obstructive pattern on spirometry
- COPD
- Asthma (with reversibility)
- Cystic fibrosis / bronchiectasis
- Foreign body / malignancy of the airway
