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Medicine > Respiratory > Flashcards

Respiratory Flashcards

1
Q

what is respiratory failure

A

syndrome of inadequate gas exchange due to dysfunction of 1 or more essential components of the respiratory system

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2
Q

what are the types of respiratory failure?

A

type 1 aka hypoxaemic respi failure = PaO2 <8kPa (or <60 mmHg) on RA
type 2 aka hypercapnoeic respi failure = PaCO2 >6 kPa (or >45 mmHg)

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3
Q

causes of respiratory failure

A

V/Q Mismatch

shunt —- V «&laquo_space;Q (perfusion)
(most common cause in acutely ill patients)
intrapulmonary: pneumonia, pulmonary oedema, atelectasis, collapse, pulmonary haemorrhage or contusion
intracardiac: right-to-left shunt — tetrallogy of fallot, eisenmenger’s syndrome, pulmonary HTN + patent foramen ovale

dead space —- Q &laquo_space;V
(the other cause of V/Q mismatch)
physiological dead space = anatomical dead space + alveolar/functional dead space
pulmonary: emphysema, PE
non-pulmonary: CVS shock, high PEEP (+ve end-expiratory P)
apparatus: increased dead space = NIV mask; decreased = ETT or tracheostomy

diffusion defect — interstitial deposition between alveoli & capillaries
fibrosis
pulmonary oedema
pneumonia
infarction

alveolar hypoventilation — type II respi failure
central: brainstem stroke, head injury, intracranial bleed, increased ICP, compression of respi centres, drugs (sedatives, opioids)
neuromuscular: MG myasthenia gravis, GBS guillain barre, polio
thoracic cage limitation: kyphoscoliosis, flail chest, rib fractures (acute)
restricted lung expansion: pneumothorax, haemothorax, pleural effusion, diaphragmatic paralysis
pulmonary causes: COPD, pneumonia, pulmonary fibrosis, pulmonary oedema, ARDS

low inspirated PaO2 – due to high altitude

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4
Q

Tx of respi failure

A

if type 1 respi failure
ABCDs
supplementary O2 — target SpO2 94-98%
nasal cannula –> venturi mask –> non-rebreather mask

reverse any cause
pneumonia = Abx
pulmonary oedema = diuretics

if 60% O2 but PaO2 <8 = consider assisted ventilation
non invasive: CPAP or BiPAP
CPAP = start at 4cm H2O
BiPAP = start at IPAP 20cm, EPAP 4cm

invasive: ventilator — ETT or tracheostomy

if type 2 respi failure
ABCDs
supplementary O2 — target SpO2 88-92

reverse any obv cause
if PaO2 <8 = BiPAP
if respi stimulant needed = doxapram

tune O2 down if and when possible

(essentially type 1 = CPAP, type 2 = BiPAP)

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5
Q

what is ARDS acute respiratory distress syndrome

A

acute diffuse inflammatory lung injury — causing non-cardiogenic pulmonary oedema

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6
Q

causes of ARDS acute respiratory distress syndrome

A

pulmonary
pneumonia
aspiration
inhalation injury
contusion (trauma)

systemic
shock
sepsis
haemorrhage
multiple transfusions
pancreatits

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7
Q

diagnostic criteria for ARDS acute respiratory distress syndrome

A

berlin criteria:
acute onset (within 1 wk or less)
BILATERAL infiltrates on CXR or CT
no evi of elevated LA P —- PCWP (pulmonary capillary wedge P) <18 mmHg
ie NON-CARDIOGENIC pulmonary oedema
PaO2/FiO2 <300 mmHg

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8
Q

severity of ARDS

A

acc to PaO2/FiO2
mild: 200-300
moderate: 100-200
severe: <100

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9
Q

Ix for ARDS

A

bloods
FBC
U&E
C&S
amylase & lipase
ABG

urine C&S
sputum C&S
CXR

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10
Q

what are the different types of pneumonia

A

community acquired pneumonia
hospital acquired pneumonia
aspiration pneumonia
ventilator-associated pneumonia

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11
Q

causal organisms of community acquired pneumonia — typical vs atypical

A

typical pneumonia
bacterial:
strep pneumoniae
haemophilus influenza
moraxella catarrhalis
klebsiella
pseudomonas
burkholderia

atypical pneumonia
bacterial:
mycoplasma
legionella
coxiella burnetti
chlamydia

viral:
coronavirus
adenovirus
paeds — RSV, parainfluenza

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12
Q

presentation of pneumonia — typical vs atypical

A

typical pneumonia:
fever, rigors, myalgia
anorexia
SOB
productive cough (purulent)
+/- haemoptysis
+/- pleuritic pain

atypical pneumonia
URTI
headache
arthralgia, myalgia
erythema multiforme/nodosum
haemolytic anaemia

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13
Q

Ix for pneumonia

A

bloods
FBC
lymphocytosis = viral
lymphopenia = covid-19
neutrophilia = bacterial
U&Es — hypoNa sec to SIADH or ca
ESR, CRP — baseline
C&S

sputum C&S
urinary Ag — pneumococcus & legionella
+/- paired serum Ab – if ?atypicals (mycoplasma, legionella, chlamydia)
+/- ABG — if SpO2 <95%

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14
Q

risk stratification for pneumonia

A

CURB65 score

criteria
C: confusion — AMT abbreviated mental test 10 — score <8
U: urea >7
R: RR >30
B: BP <90/60
65: Age >65

interpretation
0-1: home Tx
2: hospital Tx
3-5: admission to HDU or ICU

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15
Q

Tx for pneumonia

A

ABCDs
supplementary O2
IV fluids

conservative Tx
analgesia
chest physio

medical Tx
empirical broad spectrum Abx acc to local hospital guidelines
mild: amoxicillin — if pen allergic = clarithromycin
moderate: co-amoxiclav + clarithromycin
severe: co-amoxiclav + clarithromycin + cefuroxime +/- flucloxacillin (if ?superimposed HiB or staph)
if ?atypical = clarithromycin/rifampicin (legionella), co-trimoxazole (PCP), tetracycline (chlamydia)

consider penicillin R if: beta lactams in last 3 months, IC, alcoholism, >65 y/o

change to narrow spectrum once C&S results out

follow up: CXR after 6 wks — check for clearance + r/o cancer

prevention
quit smoking

vaccines:
pneumococcus every 5-6 years
indications: >65 y/o, DM, CCF, CKD, liver failure, IC
C/I: active infection

covid-19 vaccine
influenza vaccine — annual before every winter flu season

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16
Q

complications of pneumonia

A

respi failure — type 1 or 2
hypotension — sec to dehydration + septic vasodilation
afib
pleural effusion
empyema
sepsis

17
Q

definition of hospital-acquired pneumonia

A

pneumonia — onset >48 hrs after admission or within 2-4 wks of hospital discharge

18
Q

causal organism of HAP hospital-acquired pneumonia

A

gram -ve enterobacteria — klebsiella, pseudomonas, E.Coli
anaerobes
MRSA

19
Q

Tx of HAP Hospital-Acquired pneumonia

A

ABCDs
supplementary O2
IV fluids

conservative Tx
analgesia
chest physio

medical Tx
empirical broad spectrum Abx acc to local hospital guidelines
mild: co-amoxiclav
severe: tazocin + vancomycin +/- gentamicin

change to narrow spectrum once C&S results out

follow up: CXR after 6 wks — check for clearance + r/o cancer

prevention
quit smoking

vaccines:
pneumococcus every 5-6 years
indications: >65 y/o, DM, CCF, CKD, liver failure, IC
C/I: active infection

covid-19 vaccine
influenza vaccine — annual before every winter flu season

20
Q

what is ventilator associated pneumonia

A

pneumonia — onset >48 hrs after endotracheal intubation

21
Q

risk factors for aspiration pneumonia

A

neuro
stroke
bulbar palsy
reduced GCS

GI
GERD
achalasia

iatrogenic
recent intubation
misplaced NG tube

22
Q

causal organisms

A

strep pneumo
staph aureus
haemophilus influenza
anaerobes
pseudomonas

23
Q

site of aspiration pneumonia

A

right middle lobe or bilateral lower lobes

24
Q

empirical Abx of aspiration pneumonia

A

co-amoxiclav or tazocin

25
Q

what is asthma

A

chronic inflammatory disease of the airways — characterised by reversible airflow obstruction

26
Q

presentation of asthma

A

symptoms:
wheeze + chest tightness — diurnal variation
cough +/- sputum — worse at night
dyspnoea —- exacerbated by triggers
atopic triad: hay fever + eczema + rhinitis

signs
vitals – increased HR, RR
widespread polyphonic wheeze
harrison’s sulci/hyperinflated chest
reduced air entry
signs of steroid use

to assess asthma control:
no. exacerbations in the last year —- of which how many required hospital admission, vs ICU admission
no. steroid & Abx courses per year

27
Q

diagnostic criteria for asthma

A

acc to GINA 2022 guidelines

typical Hx of asthma
>1 type of respi symptom
variable over time & intensity
worse at night or on waking
triggered by exercise, laughter, allergens, cold air
worse w viral infections

confirmed variable expiratory airflow limitation
before vs after bronchodilator admin — >12% FEV1 or >200ml volume

28
Q

Tx of asthma

A

(for acute exacerbation = see VIVA section)

conservative Tx
awareness/avoidance of triggers
smoking education
inhaler technique — hold breath for 10s + wait 30s before 2nd puff
adherence

GINA 2022 guidelines
2 separate tracks

preferred track: reliever = PRN low dose ICS-formoterol
step 1-2: PRN low dose ICS-formoterol
step 3: maintenance low dose ICS-formoterol
step 4: maintenance medium dose ICS-formoterol
step 5:
add on LAMA
refer for assessment of phenotype
consider high dose ICS-formoterol
+/- immunologics

alternative track: reliever = SABA PRN
step 1: take ICS whenever SABA taken
step 2: low dose maintenance ICS
step 3-5 same as above

regularly reassess — step down if possible, step up where necessary

29
Q

what is the GINA assessment for asthma control

A

asthma symptom control + risk factors for poor asthma outcomes

asthma symptom control
criteria — in the last 4 wks, how many times
day time asthma symptoms
night waking due to asthma
SABA reliever for symptoms
activity limitation due to asthma
interpretation
well controlled = none
partly controlled = 1-2
poorly controlled = 3-4

risk factors for poor asthma outcomes

meds: high SABA use, inadequate ICS, poor adeherence, incorrect inhaler technique
other co-morbidities: obesity, chronic rhinosinusitis, GERD
exposures
context: major psychological or socioeconomic problems
lung function: low FEV1 (<60% predicted), high BD responsiveness
type 2 inflammatory markers
other independent risk factors: ever intubated or in ICU for asthma, 1 or more severe exacerbation in last 12 months

30
Q

what is COPD

A

post-bronchodilator airflow obstruction (FEV1/FVC <0.7) + not fully reversible

31
Q

types of COPD pictures

A

chronic bronchitis — typical blue bloaters
productive cough on most days
inflammation –> increased mucus production –> constricted + obstructed airway

emphysema — typical pink puffers
permanently enlarged air spaces distal to terminal bronchioles + destruction of alveolar walls w/o obv fibrosis

32
Q

presentation of COPD

A

symptoms:
cough
SOB
wheeze
+/- sputum (chronic bronchitis)
+/- weight loss (emphysema)
reduced exercise tolerance

signs:

general inspection
inhalers
O2 supply
nicotine, cigarettes
sputum pot

respi exam
increased RR
prolonged expiration
hyperinflation – reduced cricosternal distance, hoover’s sign
wheeze +/- early inspiratory crackles
cor pulmonale — increased JVP, oedema, loud P2

peripheral exam
cyanosis – bronchitis
tar staining
tripod position
anaemia
cushingoid features
palmar erythema
high vol pulse
tremor

33
Q

Ix for COPD

A

bedside
BMI
ECG — ? RA or RV hypertrophy
ABG

bloods
FBC — polycythaemia, anaemia
U&E
CRP
alpha 1 antitrypsin

imaging

CXR — findings
hyperinflation — >6 anterior ribs
prominent pulmonary A
peripheral oligaemia
bullae

ECHO — pulmonary HTN

34
Q

Tx of COPD

A

conservative Tx
smoking cessation
pulmonary rehab — grp B & E only
education + physio + behavioural intent for 6-8 wks
physio
vaccinations: influenza, pneumococcal, covid-19, pertussis, shingles

acute Tx (see that section)

initial pharmco Tx
acc to the GOLD 2023 guidelines — ABE assessment
split into 3 groups according to mMRC & CAT scpre + no. exacerbations in the last year

grp A = bronchodilator
grp B = LABA + LAMA
grp E = LABA + LAMA
if blood eosinophils >300 = consider + ICS

if response to Tx not appropriate
check adherence + inhaler technique + possible interfering comorbidities
consider predominant treatable trait to target — dyspnoea or exacerbations

dyspnoea:
LABA or LAMA <–> LABA + LAMA <–> (a few possibilities)
consider switching inhaler device or molecules
implement or escalate non-pharmco Tx
Ix & Tx other causes of dyspnoea

exacerbations
LABA or LAMA <–> LABA + LAMA <–> LABA + LAMA + ICS <–> (either or)
roflumilast — FEV1 <50% + chronic bronchitis
azithromycin — preferentially in former smokers

supplementary O2 at home

surgical Tx
VATS video assisted thoracoscopic surgery
lung vol reduction in bronchoscopy

Medicine (18 decks)

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