Respiratory Flashcards
Aetiology Bronchiectasis
Complications of Bronchiectasis
Cor Pulmonale
Pneumonia
Empyema
Lung abscess
AA Amyloidosis
Cerebral abscess
Investigations for Bronchiectasis
-HRCT -> Confirms diagnosis
-Sweat chloride / immotile cilia function in young adults
- Eosinophil level (ABPA)
- Immunoglobulin levels - Sptum MCS
- PFT (FEV 1 affected in severe disease)
- ABG
Management Bronchiectasis
- Treatment of infections
- Long term azithromycin
- Inhaled tobramycin
- Bronchodilators / ICS if bronchial reactivity
- Chest wall physio (postural drainage and PEEP)
- Vaccination
- Surgery for localised disease
- Transplant
MRC Breathlessness Scale
0 - Only with strenuous exercise
1- When hurrying or walking uphill
2- When walking at own pace
3- Walking ~100m
4- When undressing / too breathless to leave house
Radiographic Types of Emphysema
- Centrilobular (most common) involves proximal respiratory bronchioles in upper lobes
- Panlobular involves secondary bronchioles predominately lower lobes (seen in A1ATD)
- Paraseptal involves peripheral areas. Assoc with bullous emphysema / smoking
ECG findings COPD
1) Right ventricular hypertrophy ( Prominent R wave V1, TWI V1-2, RAD)
2) Multifocal atrial tachycardia
COPD and flying?
During flight equivalent Fi02 is ~15%
If patients Sats ate <95% supplemental oxygen will be needed.
If sats 88-95% then should have an altitude simulation test prior to flying.
Smoking Cessation
- Ask
- Assess motivation and nicotine dependance
- Advise to quit
- Assist with smoking cessation
-Ensure follow up
Treatments:
- Non-pharmacological using QUIT helpline, hypnotherapy, counselling
- Varenicicline (Champix) which acts as partial nicotine agonist.
S/E: mood changes and suicidal thoughts
- Nicotine replacement therapy
- Bupropion
S/E: seizures
COPD Criteria Lung transplant?
- FEV1 <25%
- PaCO2 >55
- Complications including cor pulmonate
- Age <65yoa
Sleep apnoea exam
-Pharyngeal crowding
-Raised BMI
-Signs of pulmonary hypertension (loud p2, parasternal heave)
-Signs of acromegaly / hypothyroidism
Benefits of CPAP in OSA
- Safe driving
- Reduced sleepiness
- Better QOL
- Better cognition
Methotrexate and lungs
- <5% of persons
- No correlation between dose and severity of condition
- Occur at any time during treatment
- Resolves with withdrawal
- May require steroids
Causes of idiopathic pulmonary hypertension
- Idiopathic
- Inherited (BMPR2)
- Assoc Connective tissues disease
- HIV
- Cirrhosis / portal hypertension related
- Chronic haemolytic anaemia
- Shchistosomiasis
Clinical signs of Pulmonary Hypertension
Loud P2
Palpable P2
Large A wave
Larve V wave (if Concurrent tricuspid regurgitation)
Parasternal impulse
Pulmonary Hypertension
CXR -> Large pulmonary arteries with pruning in periphery +/- Right ventricular hypertrophy
PFT -> Isolated low DLCO
ECG -> Right heart strain, P Pulmonale
Bood Gas ->
VQ -> Rule out CTEPH
HRCT -> Rule out IPD
TTE
Six minute walk test -> <330 metres confers poor prognosis
Clinical manifestations Sarcoid
- Asymptomatic hilar adenopathy
- Generalised symptoms: fever, lethargy, cough, dyspnoea
- Pulmonary fibrosis (upper zone predominant)
- Skin erythema nodosum
- Polyarthralgia
- Uveitis
- Hypopituitarism
- Cardiac conduction abnormalities (CHB and VT)
- Facial nerve palsy or Peripheral neuropathy
- Hypercalcaemia
Clinical signs Sarcoidosis
- Uveitis
- Parotitis
- Generalised lymphadenopathy
- Lupus pernio
- End inspiratory crackles
- Erythema nodosum
- Facial nerve palsy
- Hepato / Splenomegaly
Management of sarcoidosis
If evidence of detrimental end-organ involvement give prednisolone 1mg/Kg daily for 6 weeks then taper over 6 months.
Steroids sparing agents MTX, AZA
Physiotherapy treatment for Cystic Fibrosis
Postural drainage
Positive End Expiratory devices
Percussion
Deep breathing exercises
Pulmonary Rehabilitation
Clinical signs Cystic Fibrosis
Prolonged Forced Expiratory Time >6 seconds
Barrell chest
Clubbing
Wheeze, local crackles
Muscle wasting
Faecal loaded colon
Right heart failure secondary to pulmonary HTN
CF investigations
Sputum MCS
CXR
FBC -> May be anaemic
Fat soluble Vitamins (ADEK) due to concurrent pancreatic insufficiency
Spirometry: FEV1 <40% confers poor prognosis
Cystic Fibrosis management
- Ivacaftor / Tezacaftor
- Chest Physiotherapy **Very important
- Tune ups for IV antibiotics according to sputum MCS
- Azithromycin as anti-inflammatory
- Bronchodilators
- Home oxygen
- DNAse mucolytic
- Lung transplant
- ** Pancreatic enzyme replacement
- Regular aperients to avoid constipation
Tuberculosis Treatment
Active TB:
- 2 months RIPE
- 4 months RI
* Ensure smear negative at conclusion of treatment
Latent TB:
- Treat in high risk groups
> HIV
> Less than 35yo
> Contact with smear positive patient
> Health care worker
> About to receive immunosuppressive drugs
- Isoniazid 9 months
- 3 Months RI
- Rifampicin 4 months
Most common indications lung transplant
Pulmonary Hypertension
COPD
Eisenmengers
Cystic fibrosis
Indications and Contraindications for Lung Transplant
Bronchiolitis Obliterans
Chronic damage and obstruction of small airways seen in chronic rejection post transplant.
Manifest as gradual development of dyspnoea, fatigue and cough.
Accompanied slow decline in FEV1
Treat: agressive immunosuppresion steroids / ATG
Acute Lung Rejection
Fever, breathlessness, pulmonary infiltrates, declining FEV1
Diagnose on Bronchoscopy and transbronchial biopsy
Treatment: High dose steroids
Causes of Clubbing
Bronchiectasis
Cystic fibrosis
Bronchogenic Carcinoma
Interstitial lung disease
Cyanotic congenital heart disease
Infective endocarditis
Inflammatory bowel disease
Primary biliary Cirrhosis
Hypothyroidism
Causes of tracheal deviation
Upper lobe fibrosis (towards side deviation)
Mediastinal lesion (Retrosternal goitre)
Tension pneumothorax
Pneumonectomy (towards deviation)
Large Pleural effusion (away)
Stooped Posture
May indicate Ankylosing Spondylitis -> Upper lobe fibrosis
Bronchial breath sound
Harsh blowing quality, inspiration equal to expiration with pause between respiration.
Causes: lobar pneumonia, above pleural effusion, localised fibrosis.
Wheeze
Expiratory wheeze: Asthma or COPD
Fixed inspiratory wheeze: Bronchogenic carcinoma
Crackles
Late or Paninspiratory Crackles
Fine: Fibrosis
Medium: Pulmonary Oedema
Coarse: Bronchiectasis
Early inspiratory coarse crackles: COPD
Cavitating Lung lesion
TB
Carcinoma (Especially squamous cell)
Aspergilloma
Lung Abscess
