respiratory Flashcards
sarcoidosis presentation
20-40 year old black woman presenting with a dry cough and shortness of breath. They may have nodules on their shins suggesting erythema nodosum
lymphadenopathy
Lupus pernio (raised, purple skin lesions commonly on cheeks and nose)
eye + heart sx
what is sarcoidosis
granulomatous inflammatory condition.
Granulomas are nodules of inflammation full of macrophages.
what is lofgren’s syndrome
classical presentation of systemic sarcoidosis
classic triad of fever, erythema nodosum, and bilateral hilar lymphadenopathy
+polyarthralgia
Triad of Lofgren’s Syndrome
Erythema nodosum
Bilateral hilar lymphadenopathy
Polyarthralgia (joint pain in multiple joints)
blood tests for sarcoidosis
raised serum ACE
hypercalcaemia
Raised serum soluble interleukin-2 receptor
gold standard for sarcoidosis dx
histology from biopsy
= non-caseating granulomas with epithelioid cells.
tx for sarcoidosis
No treatment in px w no/mild sx - condition often resolves spontaneously.
Oral steroids 1st line where tx is req - for between 6 + 24 months
- bisphosphonates to protect against osteoporosis whilst on such long term steroids.
Second line options are methotrexate or azathioprine
Lung transplant is rarely required in severe pulmonary disease
COPD spirometry results
FEV1 according to stage
FEV1 <80% of predicted; FEV1/FVC <0.7
as OBSTRUCTIVE lung disease
Stage 1 Mild FEV1 ≥ 80% predicted
Stage 2 Moderate FEV1 50-79% of predicted
Stage 3 Severe FEV1 30-49% of predicted
Stage 4 Very Severe FEV1 <30% of predicted
CXR for COPD
Hyperinflated chest (>6 anterior ribs)
Bullae
Decreased peripheral vascular markings
Flattened hemidiaphragms
PE presentation
Sudden-onset shortness of breath
pleuritic chest pain
haemoptysis
signs of shock
PE ix
CT pulmonary angiogram
V/Q scan if renal impairment / preg/ contrast allergy
pneumothorax chest exam
- reduced chest expansion of the affected side.
- hyper-resonant percussion note on the affected side.
- reduced or absent breath sounds on the affected side, with no added sounds.
- vocal resonance (tactile vocal fremitus) is reduced on the affected side.
tension pneumothorax: signs of haemodynamic compromise (tachycardia and hypotension) and tracheal deviation to the contralateral side.
ix for pnuemothorax
urgent erect CXR (if no signs it is a tension pneumothorax)
CT thorax if too small to see on CXR
primary pneumothorax mx
No shortness of breath and less than a 2cm rim of air on the chest x-ray:
- No treatment is required as it will spontaneously resolve
Follow up in 2 – 4 weeks is recommended
Shortness of breath and/or more than a 2cm rim of air on the chest x-ray:
- Aspiration followed by reassessment
When aspiration fails twice, a chest drain is required
Emergency/earlier fails:
- Chest drain
what is the triangle of safety for insertion of a chest drain
- The 5th intercostal space (or the inferior nipple line)
- The midaxillary line (or the lateral edge of the latissimus dorsi)
- The anterior axillary line (or the lateral edge of the pectoralis major)
signs of tension pneumothorax
Tracheal deviation away from side of the pneumothorax
Reduced air entry on the affected side
Increased resonance to percussion on the affected side
Tachycardia
Hypotension
mx of tension pneumothorax
Do not wait for ix.
Insert a large bore cannula into the second intercostal space in the midclavicular line. (needle decompression)
abx prophylaxis for COPD
azithromycin
what are the ECG changes in a PE
large S wave in lead I, a large Q wave in lead III and an inverted T wave in lead III - ‘S1Q3T3’
but not always
may also see:
RBBB
right axis deviation
sinus tachycardia
CXR in PE
may be normal but cld show wedge shaped opacification
PE tx
Thrombolysis (alteplase)
thrombolysis is now recommended as the first-line treatment for MASSIVE PE where there is circulatory failure (e.g. hypotension)
If not + usually :
Apixaban as first line mx (DOAC)
if the patient has active cancer
- DOAC (prev guidelines said LMWH)
if renal impairment is severe (e.g. < 15/min) then LMWH, unfractionated heparin or LMWH followed by a VKA
if the patient has antiphospholipid syndrome then LMWH followed by a VKA should be used
anticoag for at least 3 months (6 months if unprovoked)
what is bronchiectasis?
permanent dilation of the airways secondary to chronic inflammation or infection
what are the causes of bronchiectasis
- post-infective: tuberculosis, measles, pertussis, pneumonia
- cystic fibrosis
- bronchial obstruction e.g. lung cancer/foreign body
- immune deficiency: selective IgA, hypogammaglobulinaemia
- allergic bronchopulmonary aspergillosis (ABPA)
- ciliary dyskinetic syndromes: Kartagener’s syndrome, Young’s syndrome
- yellow nail syndrome
s + sx bronchiectasis
sx
- persistent productive cough
- dyspnoea
- haemoptysis
s
- coarse crackles, wheeze
- clubbing