Respiratory Flashcards
Explain perfusion and ventilation. what is the percentage of oxygen drawn into the lungs. What ventilation depends on
-ventilation (V): drawing oxygen into lungs (21%)
-perfusion (Q): the blood that reaches the alveoli via the capillaries, carrying de-oxygenated blood to lungs via veins, and oxygenated away in arteries .
-ventilation: depends on tidal volume, respiratory rate, resistance of airways, extensibility of lungs
Which muscles involved in inspiration and forced expiration
-inspiration= external intercostals and diaphragm
-expiration= internal intercostals and abdominal muscles
how perio can lead to respiratory issues
Periodontal disease can track down oropharynx to lungs causing pneumonia or lung abscess. Not common in the general population – but if in serious accident, sepsis from the oropharynx can easily track down cause secondary pneumonia/lung abscess.
Give examples of diseases associated with the airways, lung tissue and lung vasculature
airways= asthma, COPD
tissue (parenchyma)= fibrosis, pneumonia, asbestosis, bronchitis, carcinoma
vasculature= pulmonary embolism (from DVT), pulmonary vasculitis
How sedation affects respiratory system
slows respiratory rate, raises CO levels, hypoxia, danger of respiratory arrest
What could be causing breathlessness (dyspnoea) at rest or when walking
[cardiac and respiratory causes]
-at rest: MI, heart failure, cardiac tamponade, bronchospasm, pulmonary embolism, pneumothorax, bronchitis, pneumonia, upper airway obstruction by aspiration or anaphylaxis.
-walking - asthma, obesity, COPD, angina
Difference between wheeze and stridor and RS causes
-Wheeze (expiratory noise) = indicator of asthma, COPD, bronchitis, anaphylaxis
-Stridor – inspiratory noise = indicator of severe respiratory disease/cancer/central airway disruption/ something has been inspired
RS causes of coughing up phlegm or blood
-Cough – if patient bringing up much sputum (phlegm) – sign of infection. cystic fibrosis. bronchitis. COPD. Asthma
-Haemoptysis – coughing up blood = early sign of tumour, infection, pulmonary embolism, pulmonary oedema, pulmonary vasculitis.
- (haematemesis - vomiting up blood, sign of serious issue, investigate further – see GMP)
Difference between pain from lungs and angina
-pleuritic pain – pain that is worse on breathing in. Also when coughing, changing positions can also make it worse [Inflammation of pleura or lining of chest wall]
-angina- dull pain, ache, tight feeling in your chest. can spread to your arms, neck, jaw or back. On exertion. releived by GTN
What is normal breathing rate.
12-20 per minute
what is the main clinical sign of reduced oxygen. normal blood oxygen level %
-cyanosis -reduced Hb and O2.
-blue discolouration of skin or mucous membranes, when patient is warm. Seen clearly on lips or tip of tongue.
-normal = 95-100%
-deeply cyanosed= < 85%
What tests can be done to diagnose respiratory diseases
-Peak flow: forced expired volume
-Oximetry: measures oxygen saturation of blood (<90% is concerning)
-Haematology, biochemistry
-Spirometry to test lung function
-Bronchoscopy- Biopsies, histology, cytology
-chest x-rayt, CT
-microbiology for infections
Explain pink puffer, and blue bloater. causes. what blue bloater leads to
seen in COPD
-“pink puffer” (oxygenated/ fast/short breathing) chest anchored to maximise respiration
- “blue bloater” = Slow breathing, so low oxygen levels (cyanosis). Causes rise in pulmonary artery vasoconstriction causing right heart failure and peripheral oedema. Ankle swelling
why lungs cancer is one of the most fatal cancers. what are the main causes. treatment
-Poor prognosis. Can grow silently without experiencing symptoms. Has already spread before symptoms occur
-smoking and passive smoking
-surgery (if has not spread), radio/chemo therapy, palliation (for those with limited life expectancy)
symptoms of lung cancer
- Cough
- Haemoptysis – coughing up blood
- Weight loss, Anorexia
- Pain
- Metastases – spread of cancer causing secondary malignant growth elsewhere. Eg. A stroke due to lung cancer spreading to brain
-Also perhaps: finger clubbing
-facial swellings due to veins blocked
-oedema in upper arms,
-jugular vein protruding out
-veins across chest due to SVC obstruction
-enlarged cervical lymph nodes
-Horner’s syndrome
-stridor
Causes of finger clubbing (not just RS)
-RS (most common) - carcinoma, fibrotic lung disease (asbestosis, cystic fibrosis), bronchiectasis,
-CVS (rare) - IE, cyanotic congenital
-GI (rare) - liver disease. Crohn’s, coeliac disease
-hyperthyroidism
What is Horner’s syndrome (4 signs) and how lung cancer can cause it
loss of sympathetic nerve supply to one side of the face. If loss to right side then:
* Right eyelid is drooped compared to left (ptosis)
* Constriction of right pupil (meiosis)
* Anhidrosis –absence of sweating at side of face
* Enophthalmos = eyes sinking deeper in eye socket
-cancers on sympathetic nerve at top of right lung, hitting nerve going up to eye.
-could also be caused by an inner ear infection or surgical procedure hitting a nerve
What pleural effusion, cancer and pneumothorax looks like on an x-ray
-pleural effusion (fluid around lung compresses it) = white as no air getting to it
-cancer = if obstructing a lung then white
-pneumothorax -collapsed lung (severe pain followed by breathlessness)
Systemic effects of chemotherapy. and oral symptoms
- Marrow suppression - Low Hb [anaemia] Decreased WCC [prone to infection ] Low platelets – [prone to haemorrhage]
- Alopecia
- Nausea, vomiting
- Infertility, ototoxicity, renal toxicity, neuropathy
- Oral ulceration, mucositis
- Gingival bleeding, mucosal petechiae (thrombocytopenia)
- Xerostomia, caries
- Oral infection, dental abscess
- Oral candidiasis
- Altered taste
- Herpes simplex
what is chronic bronchitis and main symptom
-comprises COPD
-chronic or recurrent excessive mucus secretion in the bronchial tree. Increased coughing off phlegm. It is a symptoms-based diagnosis
What is emphysema. causes. diagnosis
-one of the diseases that comprises COPD
-gradual destruction of bronchioles
- damaged alveoli: increased air spaces with destruction of their walls, and without obvious fibrosis
- can end up with low oxygen saturation as unable to take in enough oxygen.
-Histological diagnosis and also seen on CT scan
-smoking main cause. Also coal dust
Symptoms and signs of chronic obstructive pulmonary disease. what is cor pulmonnale
Airway and tissue damage and chronic inflammation due to smoking. A mixture of chronic bronchitis and emphysema.
-shortness of breath
-raised shoulders, hyper inflated chest= pink puffer
-frequent exacerbation = periods where cough, phlegm and SOB worsens, perhaps caused by infection, so need antibiotics or steroids
-Cor pulmonnale – issue in lungs causing chronic hypoxia, causing strain on the RHS of the heart, leads to swollen ankles
-cyanosis
-laboured breathing
-chronic productive cough
-abnormal BMI
-respiratory failure
Explain FVC and FEV1. what the normal values, and what FEV1/FVC is in COPD and asthma
FVC= forced vital capacity: 5l. total volume in lungs
FEV1= forced expired volume in 1s.
COPD and asthma= reduced FEV1. Normal FVC. FEV1/FVC <70%
[from big breath in]
Is COPD reversible. management options
no, they have chronically lower O2 stopping smoking will cause lung function (FEV) to decline at a slower rate
-smoking cessation
-vaccinations
-pulmonary rehab
-inhalers - LABA, LAMA, ICS
-anti-inflammtory or antibiotic therapy (common to be on erythromycin, 3 times a week. Can predispose to heart arrythmia)
-meds to cough up phlegm (carbocisteine)
-long-term oxygen therapy for select pts.
Functions of LABA, LAMA and ICS inhalers for COPD
-LABA = long acting beta agonist: bronchodilator, open up airway (salmeterol, formoterol and indacateroll)
-LAMA = long acting muscarinic antagonist: blocks ACh to muscarinic receptors. bronchodilator, open up airway (ipratopium)
-ICS = inhaled corticosteroid: cortisol to reduce inflammation
What is respiratory failure. What PaO2 value is below. Difference between type 1 and 2 failure.
-oxygen saturation insufficient to meet the patient’s needs
-PaO2 <8kP
-type 1= low O2, caused by intrinsic lung disease causing poor ventilation (COPD, asthma, fibrosis, pneumonia, PE etc.)
-type 2= low O2 and high CO2, caused by under ventilation. Causes acidemia. (COPD, severe asthma attack, muscle weakness CNS depression)
Consequences of respiratory failure
chronic or acute hypoxia
cor pulmonale (hypoxia, pulmonary hypertension, narrowed pulmonary arteries, strained RHS heart, myocardium becomes bigger and eventually begins to fail. Ankle swelling)
Which situations should long term oxygen therapy be used in COPD. [what PaO2 value]
Oxygen is a treatment for low oxygen levels
When PaO2 <7.3 kPa, or <8 when stable and one of:
- Secondary polycythaemia (high RBC)
- Nocturnal hypoxaemia (oxygen saturation < 90% for > 30% of time)
- Peripheral oedema
- Pulmonary hypertension
Aim to keep saturation 88-92% (amount of O2 bound to Hb)
But giving oxygen to COPD is risky as it causes baroreceptors to decrease their respiratory rate.
How is the outer smooth muscle layer and inner epithelium in airways affected in asthma. how it causes narrowing (mention immune cells involved)
Smooth muscle abnormalities:
1-hyperesponsive to stimuli than normal, so more likely to constrict causing narrowing.
2-hypertrophic, so thicker and stronger response to any stimuli given to it
Epithelium:
-goblet cells produce too much mucous, leading to inflamed airways
=Allergen interacts with IgE causing release of inflammatory mediators. eosinophils, mast cell granulation, histamine release, lymphocytes cause scarring in airways, mucosal oedema (thicker and narrow airway), epithelial disruption, more inflammation, causing wheezing on exhalation
Diagnosis of asthma is with spirometer. What readings will show. what exacerbates asthma
FEV1 decreased
FVC usually stays normal (can get all air out just at slower rate)
FEV1/FVC <70%
-exercise, cold air, diurnal variation (day v night), allergens (dust, pollen, smoke, smells, pollution, solvents)
symptoms of asthma, and severe asthma
-wheeze on exhalation
-breathlessness. RR>25
-tachycardia
-chest tightness
-worse at night and in the morning
-cough
-sputum
Severe= bradycardia, drowsiness, exhaustion, arrhythmia, hypotension, cyanosis, silent chest, poor respiratory effort, <92% O2, <8kPaO2, raised PaCO2
Is asthma worse at night or in morning. And why
-Worse at night
-due to lower cortisol at night
-cortisol reduces inflammation
-[diurnal variation diminishing suggests asthma is improving]
What is the most common bronchodilator used in asthmatics. are they relievers or preventers. what coloured inhaler are they
-Beta adrenergic agonists – salbutamol (Ventolin)
-relievers, relaxing smooth muscle. Blue
What 3 types of anti-inflammatory medication is used in asthmatics. are they relievers or preventors.
i) Inhaled Corticosteroids - beclomethasone. brown
ii) Leukotriene antagonists – reduces amount of inflammation
iii) Anti IgE antibodies (monoclonal Ab therapy) – for severe cases (injections every 2 weeks, soaks up IgE and destroys it)
-preventors.
what is the parasympathetic and sympathetic nerve supply to the smooth lung muscle
-Parasympathetic = vagus nerve. constriction
-sympathetic = adrenaline. relaxation. B2 adrenergic receptors.
How anticholinergics help asthma. drug names. side effects
-blocks muscarinic AcH receptors so blocks parasympathetic, to prevent bronchoconstriction
-ipratropium and tiotropium.
- Dry mouth
- Glaucoma
- Urinary retention (only really in elderly men)
How B2 agonists help asthma. drug names for short acting and long acting inhalers
acts on the B2 adrenergic receptor causing dilation, via cAMP
-short acting= salbutamol (Ventolin), Terbutaline, Fenoterol. 1 min onset
-long acting= salmeterol, Formoterol. 12 hour duration
How theophylline helps asthma. side effects. what drug it interacts with
-tablet which blocks the breakdown of cAMP to AMP causing relaxation of the smooth muscle
-long-acting
-narrow therapeutic window so dangerous in overdose, so not often used
-tachyarrhythmias, convulsions, ventricular fibrillation
-interacts with erythromycin
How Mg injection helps asthma
interrupts with Ca levels outside the smooth muscle cells, displacing it and causing more bronchodilation
-IV in acute severe asthma in A&E setting
Side effects of beta adrenergic agonist inhalers
- tachycardia
- hypokalaemia
- hyperglycaemia
- tachyphylaxis – if a drug is used repeatedly, receptors are worn out and drug no longer has an effect
What corticosteroids used for asthma. side effects
-Inhaled: -Beclomethasone, Budesonide, Fluticasone
-Oral: prednisolone
-IV
- oropharyngeal candidiasis, dysphonia, bruising
- cataracts, osteoporosis, skin thinning, hypertension, adrenal suppression, diabetes (hyperglycaemia), etc
anti IgE antibodies drug name used for asthma
omalizumab
What are these combination inhalers made up of: seretide and Symbicort
long acting beta agonist + Inhaled corticosteroid
1. Seretide – Salmeterol & fluticasone
2. Symbicort – Formoterol & budesonide
why oral thrush is a side effect of inhalers and how to prevent this
when breathing in inhaler, most will just go to the back of the throat and only a little bit usually goes to the lungs. This causes localised immunosuppression for candida to thrive
-Recommend that people use spacer device
- hold breath in for a bit and then rinse their mouth out afterwards
4 devices used for administering asthma treatment
- Pressurised mitred-dose inhalers
- Spacer device
- Dry powder device
- Nebuliser
Pros and cons of pressurised mitred-dose inhaler
[regular inhalers used]
-convenient and cheap
-BUT require co-ordination, high inspiratory flow, oropharynx deposition
Pros of spacer device. what it looks like
Holding device attached to inhaler so easier to breath in
-decreases need for co-ordination, decreased oropharyngeal deposition, increased airway deposition
Dry powder devices pros and cons. what it involves
Unlike other inhalers which deliver a puff of medicine, these inhalers hold the medicine as a dry powder
-usually lower inspiratory flow rate, less co-ordination need, allows to get deeper into lungs, no propellant
Pros and cons of nebuliser.how it works. when it is used
-an electric machine that sprays a fine, liquid mist of medicine through a mouthpiece or mask
-can administer very high dose
-BUT inefficient, may delay hospital admission
-Salbutamol or ipratropium bromide delivered this way
-Only need to use if Pt is very unwell and can’t take inhaler themselves, can get 5mg (compared to 100 micrograms from a salbutamol inhaler)
what is the stepwise approach of medications given to asthmatics
-step 1: relieving inhaler (salbutamol)
-step 2: preventor inhaler
-step 3: add long acting B2 agonist
step 4:high dose corticosteroid and regular B agonist
step 5: steroid tablet, high dose ICS, steroid course
How to manage acute severe asthma (asthma attack)
-(assess severity, using peak flow measurements)
- sumon help
-sit them up and support
-2 puffs of reliever (salbutamol) ideally via spacer.
-If no rapid response give every 10 mins, up to 10 puffs
-100% oxygen 15l/min
-nebuliser if available
general signs and what to do if airway obstruction, if conscious and unconscious
-Ask if they can respond, speak, cough, breathe.
Encourage them to cough
-If unable to /wheezing/ stridor /silent coughs then…
-If conscious= 5 back blows, 5 abdominal thrusts
-if unconscious= CPR with sealed mouth and nose using mask
How CPR and abdominal thrusts differ in a baby <1 years old
CPR: use fingers. A finger sweep should not be performed (risk of pushing foreign body further back)- only in adult if can see
-for opening airway, do not tilt all the back
-Chest thrusts instead of abdominal thrusts as you might rupture their spleen
which lung is an inhaled foreign body likely to end up in and why
right as right bronchus is more vertical and slightly higher up than left. and it is shorter
what to if suspect an inhaled foreign body (doctors and dentists)
-must account for all objects so if lost something and suspect inhalation…
-identify what has disappeared, listen to chest, chest radiograph in 2 planes at 90 degrees, bronchoscopy, endoscope with grabbers to retrieve object. Rarely open surgery is required
when is a cricothyroidotomy used. where needle inserted. how long it usually lasts
-if no ventilation in an acute situation such as an inhaled object causing blockage
-needle inserted through cricothyroid membrane between cricoid and thyroid cartilage. Inserted 45 degrees downwards caudally to prevent damage to vocal cords. Needle replaced with catheter and high flow oxygen attached
-temporary, 30-45 mins, as CO starts to build up
Risks that can occur during a cricothyoidotomy
-inadequate ventilation can lead to hypoxia and death
-done for too long causes CO2 to build up so only done for 30-45 mins
-aspiration of blood bad, want to aspirate air as indicates the trachea
-oseophageal laceration
-laceration of back wall of trachea
-haematoma
-thyroid gland perforation
-subcutaneous or mediastinal perforation
When is a tracheostomy used. how it differs to cricothyroidotomy
This is an elective/semi-elective procedure which should be carried out in operating theatre
Must not be first line of treatment
Used if unable to breath normally due to injury, swelling, tumour
-lasts longer, bigger lumen of tube, air goes in and out much better
Difference between restrictive and obstructive lung disease. Give examples. How FEV1 and FVC will differ
-Restrictive= fibrosis, pneumonia, pulmonary oedema, parenchymal tumor, skeletal/ neuromuscular abnormalities, obesity. Reduced FEV1 and FVC but normal ratio (>0.7) You will never get all air out
-Obstructive= asthma, COPD. FVC reduced to a lesser extent than FEV1 so ratio decreased. Can still get all air out but at a slower rate.
Tension pneumothorax: what, management
pneomothorax (collapsed lung) occurs and get mediostinum shift
chest drain to balance pressure between out and in
or large bore canula as is a lot quicker
What is the most common type of lung cancer And the other types
-adenocarcinoma (40%)
-SCC (30%)
-large cell (15%)
-small cell (15%)
Definition of shock. And life threatening causes
-acute alteration of the circulation in which inadequate perfusion leads to cellular dysfunction, damage and failure of major organs
-caused by cardiac tamponade (fluid in cardiac sac), anaphylaxis, tension pneumothorax, MI, hypovolemia
-leads to hypoxia, anaerobic respiration, lactic acid build up, toward death
