Respiratory Flashcards
Exam findings in Bronchiectasis
Coarse crackles
Clubbing
Features of Bronchiectasis (exam and history and clues)
- Clubbing
- Coarse crackles
- Pseudomonas or HIB colonisation
- Recurrent infections
- Minimal smoking history
- Pleuritic chest pain
- Haemoptysis
Features of ILD
- Similar clinically to CCF
- Fine inspiratory ‘velcro’ like crackles on exam - usually bibasally
- Clubbing (30-50%)
- Cor pulmonary in advanced disease
Spirometry pattern for ILD
Restrictive
Restrictive Spirometry possible causes
- ILD
- Obesity
- Kyphoscoliosis
- Neuromuscular disease
- Pleural disease
- Pneumonia
Causes of ILD
Connective tissue dx
Sarcoidosis
Drugs (nitrofurantoin)
occupational exposures (dust, mould, asbestos, bird, home brewing)
Idiopathic pulmonary fibrosis
Diagnosis for ILD or Bronchiectasis and findings
HRCT
Ground glass or honeycombing
reticular pattern
STEP wise approach to COPD puffers
- SABA or SAMA
Salbutamol or atrovent
Add
2. LAMA: “Spiriva” tiotropium
“seebri” Gylcopyrronium
LABA:
Indacterol
OR LAMA/LABA
“spiolto” tiotropium /olodaterol
“brimica” Aclidinium /formeterol
add
3. ICS /LAMA/ LABA (combo)
“Trelegy” Fluticasone, umeclidinium, vilanterol
LAMA/LABA common drugs
“spiolto”
tiotropium /olodaterol
“brimica”
Aclidinium /formeterol
LAMA
Tiotropium
“Spiriva”
Glycopyrronium
“seebri”
LABA
“Serevent”
Salmeterol
Formeterol
“oxis”
ICS/LABA
low med high doses
2 examples
“Symbicort”
budesonide/formeterol
Low= 200-400
Med= 500-800
High =>800
“Seretide”
Fluticasone/salmeterol
Low dose: 100-200
Med: 250-500
High 500+
ASTHMA STEPWISE
- SABA prn **almost no on one
- ICS/SABA
(OR BUDESONIDE/FORMETEROL PRN) - ICS/LABA
(plus prn or SABA prn) LOW dose - ICS/LABA
(plus prn or SABA prn) medium-high dose
ASTHMA STEPWISE
- SABA prn
almost no one - ICS/SABA
OR ICS/LABA Budesonide & formeterol (symbicort low dose) - ICS/LABA
(plus prn or SABA prn) LOW dose - ICS/LABA
(plus prn or SABA prn) medium-high dose
Vague story:
- Young
- Cough and dyspnoea
- Non- acute
- Likely occupational exposure (eg stonemason)
- Possibly other systemic signs (?rash)
DDX
- Interstitial lung disease from occupational exposure (silicosis)
- Hypersensitivity pneumonitis
- Work- associated asthma / occupational asthma
- Sarcoidosis
- Connective tissue disease (SLE, RA, systemic sclerosis)
- Emphysema
- Malignancy
Silicosis increases your risk of:
Lung cancer
TB
CRB-65
C: Confusion
R: Resp rate >30
B: BP systolic <90
65
1 point each
1-2 consider hospital
3+ - URGENT hospital
Epworth sleepiness scale cut off for concern
> 8
Gold standard OSA diagnosis
In-laboratory full Polysomnography
Questionnaires for OSA
STOP BANG
OSA50
OSA 50 score for testing
Obesity (3)
Snoring (3)
Apnoea (2)
Age >50 (2)
> 5
STOP BANG score for testing
Snoring
T: tired
O: observed apnoeas
P: Blood Pressure high
B: BMI >35
A: age> 50
N: Neck circ >40
G: Male gender
> 4
Hypersensitivity pneumonitis (common causes)
- Bird fancier’s lung
- Farmer’s lung
- Mushroom worker’s lung
- Humidifier’s lung
- Grain processing
Stages of TB
Primary TB (usually contained by immune system)
Post primary disease (Reactivation) - usually within 5 years of initial infection
Latent
- no signs or symptoms
- Granulomatous lesion
Cystic fibrosis differentials (chronic WET cough in child)
- Protracted bacterial bronchitis
- Primary cilliary dyskinesia
- Primary immunodeficiency
- Congenital cardiac disease
- Recurrent aspiration (eg TOF)
- A1antitrypsin deficiency
- Bronchiectasis
- Recurrent bronchiolitis
- TB
- FB aspiration
NOTE:
Not GORD or post viral cough = not productive
Pattern of inheritance CF
Autosomal recessive
Both parents must carry
If both then 1/4 chance
Manifestations of cystic fibrosis
GI
- Meconium ileus
- Steatorrhea
- Rectal prolapse
- Pancreatic exocrine insufficency
OTHER
- Failure to thrive, faltering growth
- Osteoporosis
- Hypochloraemic hyponatraemic alkalosis
Respiratory
- Bronchiectasis
- Sinusitis
- Nasal polyposis
- Chronic cough
Pertussis antibiotics
First line:
Azithromycin 10mg/kg day 1 (500mg), then 5mg/kg (250mg)for 4 more days
or clarithromycin 7.5mg/kg BD (500mg) for 7 days
Pertussis: who gets antibiotics
- Infants <6 months
- Parents / household members of infants <6 months
- If had symptoms for less than 21 days
- those in a household with someone in their last month of pregnancy
Good control of asthma….
- Daytime symptoms =<2 days
- Need SABA =<2 days
- No limit to activity
- No nocturnal symptoms
Children asthma preventers
ICS (flixotide JNR)
Montelukast
(NO LABAS)
Adolescents asthma how to treat (child or adult)
adult
use labas
EG Symbicort is good
Respiratory history questions
- Smoking
- Travel
- Occupational exposure to possible irritants
- Vaccination history
- Sputum production
- Systemic symptoms eg fever
- Asthma history eg wheeze
- Medication history eg ACEi
- Exposure to birds
- Post tussive vomiting
Respiratory presentations (don’t forget)
- Pertussis (prolonged cough)
- TB (overseas, cough, weight loss)
- Pulmonary abscess (weight loss)
Pertussis investigations (time course)
PCR & culture <4 weeks of cough
Serology >4 weeks of cough
Pneumothorax rule of criteria for conservative management
TRAUMATIC!!! - if traumatic then not for conservative
- BP <90
- Tachycardia
- Tachypnoea
- Hypoxia
- Severe chest pain or breathlessness
What is conservative management for pneumothorax?
ED observation 4 hours
Then DC home with 2 weekly CXRs
Small cell lung cancer radiological features
Central lesion (perihilar mass)
Mediastinal LN enlargement
Optimising chronic lung disease
- Vaccination
- Pulmonary rehabilitation
- Early recognition and treatment of infective exacerbations with antibiotics
- Regular exercise to maintain weight, muscle mass and strength.
- Minimising exposure to respiratory infections
Signs of exacerbation of bronchiectasis
- Increased sputum purulence
- Increased suputum volume or viscocity
- Increased cough (may be associated with wheeze, breathlessness or haemoptysis)
Severe exacerbation of bronchiectasis - indications for hospitalisation
- Worsening hypoxaemia (from baseline)
- Resp distress
- Confusion
- Sepsis
Contact with birds- what two diagnoses to consider
- Hypersensitivity pneumonitis (bird fancier’s disease)
- Psittacosis (chlamydia psittaci)
Red flags indicating hospital admission for CAP
- RR >22
- HR >100
- SPB <90
- Confusion
- O2 <92
- Multi-lobar involvement
Types of occupational interstitial lung disease
Pneumoconiosis:
- Silicosis
- Coal worker’s pneumoconiosis,
- Asbestosis
Hypersensitivity pneumonitis
- Farmer’s lung, bird fancier’s lung
Other interstitial disorders
- Textile worker’s lung
Causes of pleural effusion
Transudate
- CCF
- Liver failure (ascites)
- Nephrotic syndrome
Exudative
- Infection: pneumonia, pleurisy, empyema
- Malignancy: bronchial carcinoma, mesothelioma, metastatis
-SLE/RA
- Pulmonary infarction
Legionella pneumonia treatment (cooling systems)
Azithromycin 500mg for 3-7 days
Oxygen levels safe for flying
> 95%
When do you need respiratory specialist clearance to fly (oxygen level)
<95%
Investigations for pulmonary TB
CXR
Sputum for acid fast bacilli
Sputum for Mycobacterium PCR
Interferon- gamma release assay (more for latent)
Severe croup management (doses)
Adrenalin 1:1000 5ml nebulised, repeat 30 mins
PLUS
2mg/kg pred (up to 50)
General measures for OSA management (PLUS devices)
- Weight loss 5-10%
- Smoking cessation
- EtOH cessation
- Intranasal corticosteroids
- Supine positional therapy (with predominately supine OSA)
Devices:
- CPAP (moderate to severe)
- Mandibular advancement splint
Causes of Haemoptysis
Common:
- URTI (24%)
- Bronchiectasis
- Chronic bronchitis
- PE
- Pneumonia
- TB
- Bronchogenic carcinoma
- Blood from nose or throat
Markers of severity of croup
- Tachypnoea or bradypnoea
- Marked increased WOB
- Decreased level of consciousness/agitation
- Stridor at rest
Spirometry:
1) Cut off for moderate and severe obstruction for predicted FEV1?
2) % for bronchodilator response & terminology for this
1) >40%-59%
<40% predicted
2) 12%
“reversible airflow limitation”
Indications for specialist review for COPD/Asthma
- Following a life threatening asthma admission
- Occupational asthma
- Frequent asthma needing repeat urgent GP visits
- Moderate obstructive airways disease
- Assessment for home O2
- Frequent chest infections
Indications for asthma preventer medication
(paediatrics)
- Nocturnal symptoms > twice /month
- Symptoms restricting activity
- Admission
- 2 or more ED presentations
- 2 or more rounds of oral pred
Flixotide junior dose for paeds
Fluticasone propionate 50microg 1-2 puffs BD via spacer
Two options for preventer in kids
Montelukast 5mg PO
Fluticasone propionate 50microg 1-2 puffs BD via spacer
Side effects of montelukast
- Suicidal ideation
- Sleep disturbance
- Agression
- Anxiety
Exercise induced asthma management (pharmacological)
Inhaled corticosteroid
Pertussis isolation period
After 5 days of anitbiotics
OR
after 21 days of coughing
COPD specific LABA
Indacaterol
Size (mm) cut off for parapneumonic effusion needing sampling (instead of just regular CAP treatment)
10mm deep
Adult OSA examination
- Retrognathia
- Mallampati score or tonsillar hypertrophy
- BMI
- Neck circumference
- Nasal patency
- ECG
- CVD exam
