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
ix for bronchiectasis
CXR: sometimes normal
if severe: tram lines + ring shadows
GS = CT chest - bronchial dilation
what increase of FEV1 is indicative of asthma (after inhalation of SABA)
12%
what blood result might be seen in lung cancer
raised platelets
ix for lung cancer
CXR
CT IS GS
bronchoscopy for biopsy
pulmonary HTN presentation
Shortness of breath is the main presenting symptom. Others include:
Syncope (loss of consciousness)
Tachycardia
Raised jugular venous pressure (JVP)
Hepatomegaly
Peripheral oedema
ECG signs in pulmonary HTN
indicate R sided heart strain
P pulmonale (peaked P waves)
Right ventricular hypertrophy (tall R waves in V1 and V2 and deep S waves in V5 and V6)
Right axis deviation
Right bundle branch block
what cancer is most assoc w asbestos exposure
Mesothelioma - cancer of the mesothelial layer of the pleural cavity
there is a substantial latent period between exposure + dev
chemo can help, but is palliative
characteristic chest signs of pneuomonia
bronchial breath sounds - harsh inspiratory + expiratory breath sounds due to consolidation around the airways
focal course crackles due to air passing through sputum in the airways
dullness to percussion due to lung tissue filled w sputum or collapsed
sx of pneumonia
Cough
Sputum production
Shortness of breath
Fever
Feeling generally unwell
Haemoptysis
Pleuritic chest pain
Delirium )
what can indicate sepsis secondary to pneumonia
Tachypnoea (raised respiratory rate)
Tachycardia (raised heart rate)
Hypoxia (low oxygen)
Hypotension (shock)
Fever
Confusion
severity assessment for pneumonia + what it means
CURB-65
C – Confusion (new disorientation in person, place or time)
U – Urea > 7 mmol/L
R – Respiratory rate ≥ 30
B – Blood pressure < 90 systolic or ≤ 60 diastolic.]
65 – Age ≥ 65
The CURB-65 score predicts mortality. NICE state 0/1 is low risk (under 3%), 2 is intermediate risk (3-15%), and 3-5 is high risk (above 15%):
Score 0/1: Consider treatment at home
Score ≥ 2: Consider hospital admission
Score ≥ 3: Consider intensive care
most common causes of typical pneumonia
Streptococcus pneumoniae (most common)
Haemophilus influenzae
other causes of typical pneumonia
- Moraxella catarrhalis in immunocompromised patients or those with COPD
- Pseudomonas aeruginosa in patients with cystic fibrosis or bronchiectasis
- Staphylococcus aureus in patients with cystic fibrosis
- Methicillin-resistant Staphylococcus aureus (MRSA) in hospital-acquired infections
causes of Legionella pneumophila (Legionnaires’ disease)
inhaling infected water from infected water systems, such as air conditioning units
what can Legionnaires’ disease cause
syndrome of inappropriate ADH (SIADH), resulting in hyponatraemia
initial screening test for Legionnaires’ disease
urine antigen test
Mycoplasma pneumoniae presentation
causes a milder pneumonia
erythema multiforme - varying-sized ‘target lesions’ formed by pink rings w pale centres
can cause neuro sx in young px
how do you get chlamydia psittaci pneumonia
typically contracted from contact with infected birds.
how do you get Coxiella burnetii pneumonia
or Q fever
linked to exposure to the bodily fluids of animals. The typical exam patient is a farmer with a flu-like illness.
5 causes of atypical pneumonia (cannot be tx by penicillin)
Legions – Legionella pneumophila
Psittaci – Chlamydia psittaci
M – Mycoplasma pneumoniae
C – Chlamydophila pneumoniae
Qs – Q fever (coxiella burnetii)
what fungal pneumonia commonly occurs in immunocompromised px + how does it present
Pneumocystis jirovecii pneumonia (PCP)
px w poorly controlled HIV + low CD4 count - at risk
usually presents w dry cough
SOB on exertion
night sweats
PCP tx
Co-trimoxazole (trimethoprim/sulfamethoxazole)
brand name Septrin
px with a low CD4 count are prescribed prophylactic co-trimoxazole to protect against PCP. (under 200)
pneumonia tx
Mild community-acquired pneumonia is typically treated with 5 days of oral abx, eg:
Amoxicillin
Doxycycline
Clarithromycin
Moderate or severe pneumonia is usually treated initially with IV abx and stepped down to oral antibiotics as the condition improves.
- dual abx - amoxicillin + a macrolide (clarithromycin) 7-10 days
Respiratory support (e.g., oxygen or intubation and ventilation) is also used.
V high severe
co-amoxiclav/tazocin + mactolide
what is exudate
a high protein content (more than 30g/L)
what is transudate
a lower protein content (less than 30g/L)
when would you start steroids in sarcoidosis
parenchymal lung disease
uveitis
hypercalcaemia
neurological or cardiac involvement
what ph does someone benefit most from NIV
7.25-7.35
what is a restrictive respiratory pattern
FVC and FEV1 are reduced proportionately so the FEV1/FVC ratio is normal
FVC < 70%
FEV1 reduced
usually has a reduced transferred factor for CO2 reflecting impaired gas exhange
examples of restrictive lung disease
where lung vol is reduced
pulmonary fibrosis
scoliosis
what is an obstructive resp pattern
FVC and FEV1 are reduced disproportionately so the FEV1/FVC ratio is reduced (<70%)
FVC normal or reduced
FEV1 reduced <80%
examples of obstructive lung disease
airways are obstructed due to diffuse airway narrowing of any cause
COPD
cystic fibrosis
asthma
bronchiectasis
airway obstruction due to lung tumours
CXR for PCP
bilateral interstitial pulmonary infiltrates
moderate asthma attack
PEFR 50-75% best or predicted
Speech normal
RR < 25 / min
Pulse < 110 bpm
severe asthma attack
PEFR 33 - 50% best or predicted
Can’t complete sentences
RR > 25/min
Pulse > 110 bpm
life-threatening asthma attack
PEFR < 33% best or predicted
Oxygen sats < 92%
‘Normal’ pC02 (4.6-6.0 kPa)
Silent chest, cyanosis or feeble respiratory effort
Bradycardia, dysrhythmia or hypotension
Exhaustion, confusion or coma
near-fatal asthma
raised pC02 and/or requiring mechanical ventilation with raised inflation pressures
first line treatment for Allergic bronchopulmonary aspergillosis (ABPA)
oral glucocorticoids - pred
Refer people using a suspected cancer pathway referral (for an appointment within 2 weeks) for lung cancer if they:
have chest x-ray findings that suggest lung cancer
are aged 40 and over with unexplained haemoptysis
OFFER an urgent chest x-ray (to be performed within 2 weeks) to assess for lung cancer if:
they are 40+ + have 2+ of the following unexplained sx, or if they have ever smoked and have 1+:
cough
fatigue
shortness of breath
chest pain
weight loss
appetite loss
CONSIDER an urgent chest x-ray (to be performed within 2 weeks) to assess for lung cancer in people:
aged 40 and over with any of the following:
persistent or recurrent chest infection
finger clubbing
supraclavicular lymphadenopathy or persistent cervical lymphadenopathy
chest signs consistent with lung cancer
thrombocytosis
lung abscess sx
sim features to pneumonia but more SUBACUTE - sx may dev over wks
may get systemic features such as night sweats and weight loss
fever
productive cough - often w foul smelling sputum
sometimes haemoptysis
chest pain
dypsnoea
lung abscess signs
bronchial breathing
dull percussion
maybe clubbing
hx aspiration pneumonia
lung abscess CXR
fluid filled space w area of consolidation
usually see an air-fluid level
lung abscess mx
intravenous antibiotics
if not resolving percutaneous drainage may be required and in very rare cases surgical resection
when might you get Legionnaire’s disease from Legionella pneumophilia
It typically colonizes water tanks and hence questions may hint at air-conditioning systems or foreign holidays (often SPAIN).
features of Legionnaire’s disease
flu-like symptoms including fever (present in > 95% of patients)
dry cough
relative bradycardia
confusion
lymphopaenia (low WBCs)
HYPONATRAEMIA
deranged liver function tests
pleural effusion: seen in around 30% of patients
dx of Legionnaire’s disease
urinary antigen
tx of Legionnaire’s disease
erythromycin/clarithromycin
what is bronchitis
self-limiting chest infection
result of inflammation of the trachea + major bronchi -> oedematous large airways and the production of sputum
bronchitis presentation
an initial dry cough over 3-4 days followed by a productive cough that usually resolves within 3 weeks
mild bilateral wheeze with no other findings
low grade fever
when to use abx in bronchitis and which one is used
CRP>100mg/L
doxycycline
what criteria does a px have to have to be discharged following asthma attack
stable on their discharge medication for at least 12 hours
PEFR >75% best or predicted
have a good inhaler technique
what are the causes of pleural effusion with transudate (< 30g/L protein)
related to fluid moving across or shifting into pleural space
mostly fails (heart, renal, liver)
HEART FAILURE (most common)
HYPOALBUMINAEMIA
liver disease
nephrotic syndrome
malabsorption
HYPOTHYROID
MEIGS’ syndrome
what are the causes of pleural effusion with exudate (> 30g/L protein)
related to inflammation -> protein leaking out of tissues into pleural space (EX = moving out)
or anything that causes cell death in the lungs
infection
- PNEUMONIA (most common),
- tuberculosis
- subphrenic abscess
connective tissue disease
- RA
- SLE
neoplasia
- lung CANCER
- mesothelioma
- metastases
pancreatitis
pulmonary embolism
Dressler’s syndrome
yellow nail syndrome
what is meigs syndrome
triad of
- benign ovarian tumour (usually a fibroma)
- pleural effusion
- ascites.
The pleural effusion and ascites resolve with the removal of the tumour.
pleural effusion sx
SOB
pleural effusion examination findings
dullness to percussion over effusion
reduced breath sounds
tracheal deviation away from effusion if v large
pleural effusion ix
CXR =
blunting of costophrenic angle
fluid in lung fissures
larger ones have meniscus
tracheal and mediastinal deviation away if large
US / CT if smaller
pleural fluid analysis (take sample by aspiration or chest drain)
pleural effusion tx
dx + tx underlying cause
conservative if small
pleural aspiration
chest drain
what is empyema
infected pleural effusion
Suspect an empyema in a patient with improving pneumonia but a new or ongoing fever.
pleural aspiration in empyema
pus
low pH
low glucose
high LDH
what is Kartagener’s syndrome (primary ciliary dyskinesia)
dextrocardia (heart on RHS)
bronchiectasis
recurrent sinusitis
subfertility
mx of asthma attack
oxygen
SABA - salbutamol (nebs)
Corticosteroid -Oral Prednisolone or Hydrocortisone IV
SAMA - ipratropium bromide (nebs)
IV magnesium sulphate
IV aminophylline
senior critical care support
- intubation + ventilation
how to dx adults w suspected asthma
Fractional exhaled nitric oxide (FeNO) test + spirometry w bronchodilator reversibility
if uncertain then test peak flow variability
if stilll uncertain then do direct bronchial challenge test with histamine or methacholine
px should be asked if their symptoms are better on days away from work/during holidays. If so, patients should be referred to a specialist as possible occupational asthma
what is acute respiratory distress syndrome (ARDS)
caused by the increased permeability of alveolar capillaries leading to fluid accumulation in the alveoli, i.e. non-cardiogenic pulmonary oedema.
Mortality of 40% + assoc with significant morbidity in those who survive
causes of acute respiratory distress syndrome (ARDS)
infection: sepsis, pneumonia
massive blood transfusion
trauma
smoke inhalation
acute PANCREATITIS
Covid-19
cardio-pulmonary bypass
features of acute respiratory distress syndrome (ARDS)
cute onset and severe:
dyspnoea
elevated respiratory rate
bilateral lung crackles
low oxygen saturations
ix acute respiratory distress syndrome (ARDS)
CXR - bilateral infiltrates
- non cardiogenic (pulmonary artery wedge pressure needed if doubt)
ABG - uncompensated resp acidosis
tx acute respiratory distress syndrome (ARDS)
ITU
what is the difference between primary + secondary pneumothorax
primary if there is no underlying lung disease and secondary if there is
secondary pneumothorax mx
> 50 >2cm/SOB = chest drain
1-2cm = aspiration attempt. if fails = chest drain. admit all px for at least 24 hrs
<1cm = give O2 + admit for 24 hrs
pneumothorax and flying
absolute CI
can travel 2 wks after successful drainage if there is no residual air
1 wk post check XR
pneumothorax + scuba diving
permanently avoided
unless the patient has undergone bilateral surgical pleurectomy and has normal lung function and chest CT scan postoperatively.
what might be the cause of pneumonia in an alcoholic
Klebsiella pneumoniae
2 broad types of lung cancer
Small-cell lung cancer (SCLC) (around 20%)
Non-small-cell lung cancer (around 80%)
types of non-small-cell lung cancer
Adenocarcinoma (around 40% of total lung cancers)
Squamous cell carcinoma (around 20% of total lung cancers)
Large-cell carcinoma (around 10% of total lung cancers)
Other types (around 10% of total lung cancers)
presentation of lung cancer
Shortness of breath
Cough
Haemoptysis (coughing up blood)
Finger clubbing
Recurrent pneumonia
Weight loss
Lymphadenopathy – often supraclavicular nodes are the first to be found on examination
what can SCLC cause
various paraneoplastic syndromes as the cells contain neurosecretory granules that release neuroendocrine hormones
presentation of recurrent laryngeal nerve palsy
hoarse voice
caused by tumour pressing on recurrent laryngeal nerve as it passes through mediastinum
presentation phrenic nerve palsy
due to nerve compression
causes diaphragm weakness -> SOB
what innervates diaphragm
The phrenic nerve - originates from C3 - C5 nerve roots
presentation superior vena cava obstruction + why can you get it
can be a comp of lung cancer
med emergency
presents w facial swelling, difficulty breathing, distended neck + upper chest veins
pemberton’s sign = raising the hands over the head causes facial congestion + cyanosis
horners syndrome triad
ptosis
anhidrosis
miosis
what can cause horner’s syndrome
pancoast tumour (tumour in pulmoary apex) pressing on sympathetic ganglion
ectopic cause of SIADH
SCLC
ectopic ADH secretion
ectopic cause cushing’s syndrome
SCLC
ectopic ACTH
what hormone can squamous cell carcinoma release
ectopic parathyroid hormone
-> hypercalcaemia
what is limbic encephalitis
paraneoplastic syndrome where SCLC causes the immune system to make antibodies to tissues in the brain (mostly limbic system) -> inflam in these areas
-> short term memory impairment, hallucinations, confusion, seizures
what arethe antibodies in limbic encephalitis
anti-Hu antibodies
what is lambert-Eaton myasthenic syndrome
caused by antibodies against SCLC cells
they also target + damage VG Ca channels on the presynaptic terminals in motor neurones
-> proximal muscle weakness
CXR findings suggesting cancer
hilar enlargement
peripheral opacity (a visible lesion in the lung field)
pleural effusion (usually unilateral in cancer)
collapse
first line tx in non-small cell lung cancer
surgery - in all px w disease isolated to a single area
types of lung tumour removal
Segmentectomy or wedge resection involves removing a segment or wedge of lung (a portion of one lobe)
Lobectomy involves removing the entire lung lobe containing the tumour (the most common method)
Pneumonectomy involves removing an entire lung
typical examination findings with idiopathic pulmonary fibrosis
Bibasal fine end-inspiratory crackles
Finger clubbing
what is interstitial lung disease
incs conditions that cause inflam + fibrosis of lung parenchyma
types of interstitial lung disease
Idiopathic pulmonary fibrosis (the most important to remember)
Secondary pulmonary fibrosis
Hypersensitivity pneumonitis
Cryptogenic organising pneumonia
Asbestosis
key presenting features of interstitial lung disease
Shortness of breath on exertion
Dry cough
Fatigue
dx interstitial lung disease
clinical features
spirometry
= restrictive pattern
FEV1 and FVC are equally reduced
FEV1:FVC ratio greater than 70%
HIGH RES CT SCAN OF THORAX
= GROUND GLASS appearance
- ix of choice to confirm dx
general mx of interstitial lung disease
Remove or treat the underlying cause
Home oxygen where there is hypoxia
Stop smoking
Physiotherapy and pulmonary rehabilitation
Pneumococcal and flu vaccine
Advanced care planning and palliative care where appropriate
Lung transplant is an option, but the risks and benefits need careful consideration
what is idiopathic pulmonary fibrosis + how does it present
progressive pulmonary fibrosis w no apparent cause
insidious onset SOB + dry cough over >3 months
adults > 50
poor prog 2-5 yrs LE from dx
medications which can slow progression of idiopathic pulmonary fibrosis
PIRFENIDONE reduces fibrosis and inflammation through various mechanisms
NINTEDANIB reduces fibrosis and inflammation by inhibiting tyrosine kinase
what drugs can cause 2ndary pulmonary fibrosis
amiodarone (also causes grey/blue skin)
cyclophosphamide
methotrexate
nitrofurantoin
pulmonary fibrosis can occur secondary to which conditions
alpha-1 antitrypsin deficiency
RA
SLE
systemic sclerosis
sarcoidosis
what is hypersensitivity pneumonitis (/extrinsic allergic alveolitis)
involves type III + type IV hypersensitivity reaction to an environmental allergen
inhalation of allergens in px sensitised -> immune res -> inflam + damage to lung tissue
what is bronchoalveolar lavage
performed in bronchoscopy
airways are washed w sterile saline to gather cells + the fluid is collects + analysed
Bronchoalveolar lavage result in hypersensitivity pneumonitis
raised lymphocytes
mx hypersensitivity pneumonitis
remove allergen
oxygen
steroids
Bird-fancier’s lung
Hypersensitivity Pneumonitis reaction to bird droppings
Farmer’s lung
Hypersensitivity Pneumonitis reaction to mouldy spores in hay
mushroom worker’s lung
Hypersensitivity Pneumonitis reaction to specific mushroom antigens
malt worker’s lung
Hypersensitivity Pneumonitis reaction to mould on barley
what is asbestosis
lung fibrosis related to asbestos exposure
what problems does asbestos inhalation cause
lung fibrosis
pleural thickening + pleural plaques
adenocarcinoma
mesothelioma
what is asthma
chronic inflammatory airway disease -> variable airway obstruction
smooth muscle in the airways is hypersensitive + responds to stimuli by constricting + causing airflow obstruction
auscultation finding w asthma
widespread “polyphonic” expiratory wheeze
differentials for a localised wheeze
inhaled foreign body
tumour
thick sticky mucus plug obstructing an airway
typical asthma triggers
Infection
Nighttime or early morning
Exercise
Animals
Cold, damp or dusty air
Strong emotions
what Fractional exhaled nitric oxide (FeNO) is a positive result supporting asthma dx
above 40 ppb
(smoking can lower it making results unreliable)
what level of peak flow variability is a positive result supporting asthma dx
more than 20%
what is Maintenance and reliever therapy (MART)
a combination inhaler containing an inhaled corticosteroid and a fast and long-acting beta-agonist (e.g., formoterol).
replaces all other inhalers
general asthma mx for adults NICE guidelines
- Short-acting beta-2 agonist SABA - salbutamol as reliever (as req)
- Inhaled corticosteroid (low dose) as maintenance
- Leukotriene receptor antagonist LRTA - montelukast take reg
- Long-acting beta-2 agonists LABA - salmeterol take reg
- Consider changing to MART
- Increase steroid dose to moderate
- Increase steroid dose to high (or + LAMA / + theophylline)
- Specicalist mx
additional asthma mx
Individual written asthma self-management plan
Yearly flu jab
Yearly asthma review when stable
Regular exercise
Avoid smoking (including passive smoke)
Avoiding triggers where appropriate
ABG in acute asthma attack
respiratory alkalosis initially
(increased RR blows of CO2)
Hypoxia is concerning sign
Resp acidosis is v bad sign
- means px is getting tired
what is COPD
a long-term, progressive condition involving airway obstruction, chronic bronchitis and emphysema.
result of smoking
COPD presentation
a long-term smoker with persistent symptoms of:
Shortness of breath
Cough
Sputum production
Wheeze
Recurrent respiratory infections, particularly in winter
MRC Dyspnoea Scale
Grade 1: Breathless on strenuous exercise
Grade 2: Breathless on walking uphill
Grade 3: Breathlessness that slows walking on the flat
Grade 4: Breathlessness stops them from walking more than 100 meters on the flat
Grade 5: Unable to leave the house due to breathlessness
vaccines in COPD
pneumococcal and annual flu vaccine
first line tx COPD
Short-acting beta-2 agonists SABA (e.g., salbutamol)
OR
Short-acting muscarinic antagonists SAMA (e.g., ipratropium bromide)
how to know if a px w COPD has asthmatic/steroid responsive features
any previous, secure diagnosis of asthma or of atopy
a higher blood EOSINOPHIL count - note that NICE recommend a FBC for all patients as part of the work-up
substantial variation in FEV1 over time (at least 400 ml)
substantial diurnal variation in peak expiratory flow (at least 20%)
next tx in COPD when there is no asthma features
combo of Long-acting beta agonist (LABA) + Long-acting muscarinic antagonist (LAMA)
if already taking SAMA, stop + switch to SABA
next tx in COPD when there is asthma features
combo of Long-acting beta agonist (LABA) +
Inhaled corticosteroid (ICS)
if already taking SAMA, stop + switch to SABA
final step tx COPD
triple therapy: LABA, LAMA and ICS
what do px taking azithromycin need
ECG and liver function monitoring before and during treatment
when to use long-term oxygen therapy in COPD
used for severe COPD with chronic hypoxia (sats < 92%), polycythaemia, cyanosis or cor pulmonale.
CI to long-term oxygen therapy
smoking as fire risk
Cor Pulmonale
right-sided heart failure caused by respiratory disease. The increased pressure and resistance in the pulmonary arteries (pulmonary hypertension) limits the right ventricle pumping blood into the pulmonary arteries. This causes back-pressure into the right atrium, vena cava and systemic venous system.
causes of Cor Pulmonale
COPD (the most common cause)
Pulmonary embolism
Interstitial lung disease
Cystic fibrosis
Primary pulmonary hypertension
Signs of cor pulmonale on examination
Hypoxia
Cyanosis
Raised JVP (due to a back-log of blood in the jugular veins)
Peripheral oedema
Parasternal heave
Loud second heart sound
Murmurs (e.g., pan-systolic in tricuspid regurgitation)
Hepatomegaly due to back pressure in the hepatic vein (pulsatile in tricuspid regurgitation)
ABG in acute exacerbation COPD
typically causes a respiratory acidosis involving:
Low pH indicates acidosis
Low pO2 indicates hypoxia and respiratory failure
Raised pCO2 indicates acute CO2 retention (hypercapnia)
Raised bicarbonate indicates chronic retention of CO2
target sats in COPD px who are chronic CO2 retainers
88-92
reasons for CO2 retention in COPD when tx w O2
ventilation-perfusion mismatch
haemoglobin binding less well to CO2 when also bound to oxygen = Haldane effect
which masks to use that deliver a specific % conc O2
Venturi masks
mx of COPD acute exacerbation
Regular inhalers or nebulisers (e.g., salbutamol and ipratropium)
Steroids (e.g., prednisolone 30 mg once daily for 5 days)
Antibiotics if there is evidence of infection
If severe:
IV aminophylline
Non-invasive ventilation (NIV) - usually BiPAP
Intubation and ventilation with admission to intensive care
when to consider NIV in COPD
Persistent respiratory acidosis (pH < 7.35 and PaCO2 > 6) despite maximal medical treatment
Potential to recover
Acceptable to the patient
decision made by reg or above
CI = untx pneumothorax / stuctural abnormality
what is obstructive sleep apnoea caused by
collapse of the pharyngeal airway
RFs obstructive sleep apnoea
Middle age
Male
Obesity
Alcohol
Smoking
presentation obstructive sleep apnoea
Episodes of apnoea during sleep (reported by a partner)
Snoring
Morning headache
Waking up unrefreshed from sleep
Daytime sleepiness
Concentration problems
Reduced oxygen saturation during sleep
what is important to ask about in obstructive sleep apnoea + why
daytime sleepiness and occupation
px that need to be fully alert for work, such as heavy goods vehicle operators, require an urgent referral and may need amended work duties while awaiting assessment and treatment.
what is used to assess sx assoc w obstructive sleep apnoea
Epworth Sleepiness Scale
dx obstructive sleep apnoea
sleep studies
e.g. simple sleep study wearing an oxygen saturation monitor overnight at home.
or respiratory polygraphy
or complex sleep study staying at a centre overnight w polysomnography
mx obstructive sleep apnoea
Reversible risk factors
Continuous positive airway pressure (CPAP) machines
Surgical reconstruction of the soft palate and jaw - usually uvulopalatopharyngoplasty (UPPP).
when to repeat a CXR after clinical resolution of pneumonia
6 weeks
most common cause of HAP
aerobic gram -ve bacilli
- Pseudomonas aeruginosa
- Klebsiella pneumoniae
most common cause of COPD exacerbation
Haemophilus influenzae
which type of lung cancer causes hoarseness in voice + why
Pancoast tumours pressing on the recurrent laryngeal nerve
high-risk characteristics in pneumothorax + what do you do
haemodynamic compromise (suggesting a tension pneumothorax)
significant hypoxia
bilateral pneumothorax
underlying lung disease
≥ 50 years of age with significant smoking history
haemothorax
-> chest drain
GS for mesothelioma ix
thoracoscopy and biopsy
tx massive PE + hypotension
thrombolysis w alteplase
tx haemothorax
wide bore chest drain
