Respiratory Flashcards
Lung malignancy associated with asbestos
Mesothelioma
Presentation of lung cancer
SOB
Cough
Haemoptysis
Finger clubbing
Lymphadenopathy
Weight loss
Recurrent pneumonia
Clubbing causes
Respiratory
- Pulmonary fibrosis
- Lung Cancer
- Bronchiectasis
- Tb
not COPD?
Cardio
- Heart failure
- Endocarditis
Gastro
-IBD
SIADH presentation
Syndrome of inappropriate ADH
Ectopic ADH secreted by small-cell lung cancer - presents with hyponatremia
Cushing’s syndrome small cell lung cancer
Ectopic ACTH secretion
Hypercalcaemia lung cancer
Ectopic parathyroid hormone secreted by squamous cell carcinoma
Lung cancer bloods don’t forget
Electrolytes
- Ca - PTH secretion
- Na - ADH secretion
Thrombocytosis causes - raised platelet count
Blood loss, cancer, infections, bone marrow damage, recent surgery, splenectomy
Thrombocytopenia causes
Bleeding, infections, immune thrombocytopenia, blood cancers.
Lung cancer syspected - investigation first?
CXR
CXR findings suggestive of cancer
Hilar enlargement, peripheral opacity, pleural effusion (unilateral), collapse
CXR suggests lung cancer - then what
Staging CT chest abdo & pelvis, PET CT
Bronchoscopy with endobronchial ultrasound
Biopsy - percutaneous or via bronchospy
Treatment lung cancer
Surgery, radiation, chemo.
Stents if obstruct
Pneumonia is
Infection of the lung tissue, causing inflammation of the alveolar space
Acute bronchitis is
Infection and inflammation in the bronchi & bronchioles
LRTI includes
Pneumonia & Acute bronchitis
LRTI vs URTI causative organism
The lower down in the respiratory tract the more likely to be bacterial
Pneumonia classifications
Community acquired
Hospital acquired
Ventilator acquired
Aspiration pneumonia
Aspiration pneumonia is associated with which bacteria
Anaerobic
Pneumonia symptoms
Cough
Sputum production
SOB
Fever
Malaise
Haemoptysis
Pleuritic chest pain
Delirium - acute confusion
Chest examination of pneumonia
Bronchial Breath sounds
Focal coase crackles
Dullness to percussion
CURB-65 predicts
Mortality with pneumonia - use to determine treatment at home, hospital, ICU
CURB-65 stands for
Confusion
Urea >7
Resp rate >30
Blood pressure <90 systolic, <60 diastolic
age 65
Top causes of typical bacterial pneumonia (2)
Streptococcus pneumoniae
Haemophilus influenzae
Cystic fibrosis or bronchiectasis pneumonia causative organism
Pseudomonas aeruginosa
Hospital acquired pneumonia organism
MRSA
Immunocompromised patients, chronic pulmonary disease - pneumonia causative organism
Moraxella catarrhalis
Atypical pneumonia caused by
organisms that cannot be culture in the nomal way, or detected using a gram stain.
Atypical pneumonia treatment with penicillin is
Ineffective - use macrolides - clarithromycin, tetracycline - doxycline
Causes atypical pneumonia
Legionella, Mycoplasma pneumoniae.
Pneumocystis jirovecii - fungal
Legionella
The typical exam patient has recently had a cheap hotel holiday and presents with pneumonia symptoms and hyponatraemia. A urine antigen test can be used as an initial screening test.
Patients with low CD4 in HIV are prescribed prophylacted co-trimoxazole to protect against
Pneumocytis jiovecii pneumonia - PCP - a fungal pneumonia
Pneumonia investigations
CRP
CBC
Renal profile - urea level for CURB-65 score, and AKI
CXR
For moderate or severe infection
-Sputum cultures
-Blood cultures
Pneumonia management
Typical - ABx amoxicillin, doxycycline
Moderate may need IV ABx first.
Respirator support - Oxygen, intubation and ventilation
Complications pneumonia
Sepsis, acute respiratory distress syndrome, pleural effusion, empyema, lung abscess, death
Empyema
Collection of pus in a cavity in the body
Infected pleural effusion
ABG normal value for pH
7.35-7.45
ABG normal value for HCO3
22-26
Type 1 respiratory failure
low o2, normal co2
Type 2 respiratory failure
low o2, high co2
Causes of respiratory alkalosis
hyperventilation - anxiety, PE
Causes of metabolic acidosis
DKA, diarrhoea, renal failure, hypoxia raised lactate
Metabolic alkalosis causes
Vomiting
Acute respiratory distress syndrome is
Severe inflammatory reaction of the lungs often secondary to pneumonia or trauma
Acute respiratory distress syndrome clnical findings
Atalectasis, pulmonary oedema, decreased lung compliance, fibrosis of lung tissue
Acute respiratory distress syndrome symptoms
Respiratory distress, hypoxia
PEEP
Positive end-expiratory pressure - keeps airway from collapsing
CPAP
Provides Peep
Obstructive disease diagnosis
FEV1/FVC < 70%
Obstructive lung disease examples
Asthma, COPD
Restrictive lung disease diagnosis
FEV1 and FVC equally reduced
FEV1 and FVC ratio greater than 70%
Restrictive lung disease examples
Interstitial lung disease
Sarcoidosis
Obesity
Peak flow reduced in
Obstructive lung disease, especially asthma
Asthma - other atopic conditions
Eczema, hay fever, allergies
Asthma presentation
Dyspnoea, chest tightness, dry cough, wheeze
Symptoms should improve with bronchodilators
Asthma examination
Normal when patient is well
Polyphonic expiratory wheeze
localised wheeze differentials
Inhaled foreign body, tumour, thick sticky mucus plug obstructing airway
CXR next step
Typical triggers of asthma
Infection, night time or early morning, exercise, animals, cold damp air, strong emotions.
Asthma investigations
Spirometry, reversibility testing (give bronchodilator & expect 12 % increase in FEV1)
SMART therapy
Formoterol + ?
Asthma management additional
Yearly flu jab, regular exercise, avoid smoking, avoid triggers, careful when sick change dose
Acute exacerbation of asthma grading
Proportion of peak flow compared to predicted or best
COPD is
Long-term, progressive condition involving airway obstruction, chronic bronchitis and emphysema.
Chronic bronchitis is the
long-term symptoms of a cough
Emphysema is
damage and dilation of the alveolar sacs and alveoli, decreasing the surface area for gas exchange.
COPD salbutamol
Minimally reversible
COPD
Shortness of breath, cough, sputum, wheeze, recurrent respiratory infections especially in winterr
COPD investigations
CXR especially to exclude other pathology.
FBC
Sputum culture
ECG, Echo
Serum alpha-1-antitrypsin deficiency
SAMA example
Ipratropium
COPD long term management
Annual flu vaccine
SMOKING Cessation
Cor pulmonale is
Right sided heart failure caused by respiratory disease (pulmonary hypertension).
COPD, PE, interstitial lung disease, cystic fibrosis.
Cor pulmonale signs on examination
Hypoxia, Raised JVP, Peripheral oedema
parasternal heave
Murmurs
Hepatomegaly
Acute exacerbation of COPD typically causes respiratory acidosis or alkalosis
Acidosis - CO2 retaining
IE COPD investigations
CXR, ECG, FBC, Us&Es to check electrolytes, Sputum culture, blood culture
O2 therapy in COPD
Tend to retain CO2 when treated with oxygen - target o2 sats of 88-92%
COPD management of acute exacerbation
Inhalers or nebulisers
steroids
antibiotics
Respiratory physiotherapy
Monitor - ABGs
Bronchiectasis is
Involves permanent dilation of the bronchi
Causes of bronchiectasis
Damage to airways
- idiopathic
- pneumonia
- whooping cough
- Tb
- Cystic fibrosis
- RA
Symptoms bronchiectasis
SOB
Chronic productive cough
Recurrent chest infections
Weight loss
Bronchiectasis clinical signs
Clubbing, Cor pulmonale, Scattered crackles that clear with coughing, scattered wheezes and squeaks.
Common infective organisms bronchiectasis
Haemophilus influenza, pseudomonas aeruginosa
Test of choice for bronchiectasis
high resolution CT
Management bronchiectasis
Vaccines
Respiratory physiotherapy
Long term antibiotics for frequent exacerbations
Long acting bronchodilators for breathlessness
Long term oxygen therapy
Lung transplant end stage
nfective exacerbations require:
Sputum culture (before antibiotics)
Extended courses of antibiotics, usually 7–14 days
Ciprofloxacin is the usual choice for exacerbations caused by Pseudomonas aeruginosa
Interstitial lung disease is
Inflammation and fibrosis of the lung parenchyma - fibrosis involves the replacement of elastic and functional lung tissue with non-functional scar tissue.
Symptoms of interstitial lung disease
Shortness of breath on exertion, dry cough, fatigue
Idiopathic pulmonary fibrosis findings on examination
Bibasal inspiratory crackles, finger clubbing, reduced chest expansion
Diagnosis of intersitial lung disease involves
Clinical features, high resolution CT, spirometry showing restrictive pattern
Management interstitial lung disease
Poor prognosis & limited options
- remove or treat underlying cause
- home oxygen
- stop smoking
- flu vaccine
- advanced care planning
Respiratory ask about
Asbestos
Home damp
Idiopathic pulmonary fibrosis
No apparent cause
2-5 year life expectancy from diagnosis
Pirfenidone reduces fibrosis and inflammation through various mechanisms
Nintedanib reduces fibrosis and inflammation by inhibiting tyrosine kinase
Secondary Pulmonary Fibrosis
Several drugs can cause pulmonary fibrosis:
Amiodarone (also causes grey/blue skin)
Cyclophosphamide
Methotrexate
Nitrofurantoin
Pulmonary fibrosis can occur secondary to other conditions:
Alpha-1 antitrypsin deficiency
Rheumatoid arthritis
Systemic lupus erythematosus (SLE)
Systemic sclerosis
Sarcoidosis
Hypersensitivity Pneumonitis
Allergic alveolitis - hypersensitivity to environmental allergen.
Raised lymphocytes
Two types of pleural effusion
Exudative (high protein)
Transudative (low protein)
Exudative causes of pleural effusion (3)
Related to inflammation
- lung cancer
- infection - pneumonia or TB
- RA
Transudative causes of pleural effusion (3)
Heart failure, hypoalbuminaemia, hypothyroid
Pleural effusion symptoms
Shortness of breath
Examination findings pleural effusion
-Dullness to percussion over the effusion
-Reduced breath sounds
- tracheal deviation away from the effusion in very large effusions
Pleural effusions investigations
CXR - blunting of costophrenic angle
- fluid in the lung fissures
- larger effusions will a meniscus - a curving upwards where it meets the chest wall and mediastinum
- tracheal deviation away from effusion
Pleural effusion small
Ultrasound and CT
Treatment pleural effusion
-Conservative management
- Pleural aspiration - drain
- Chest drain - drain and prevent recur
Pneumothorax is
Air enters the pleural space - separating the lung from the chest wall
Pneumothorax causes
Spontaneous, trauma, iatrogenic e.g. lung biopsy
Lung pathologies such as infection, asthma or COPD
Pneumothorax investigation
CXR
Pneumothorax management
No SOB - spontaneously resolve
SOB - Aspiration, or chest drain
Chest drain insertion point
Triangle of Safety
- 5th ICS
- Mid-axillary line
- Anterior axillary line (pec major edge)
Chest drain complications
Subcutaneous emphysema
Tension pneumothorax
Trauma - creates one way valve air in but not out of pleural space - pressure on mediastinum cardiorespiratory arrest
Management of tension pneumothorax
pressure relieved with cannula
then chest drain
Signs of tension pneumothorax
Tracheal deviation away, reduced air entry, increased resonance to percussion, tachycardia, hypotension
PE risks
Immobility, recent surgery, pregnancy, hormone therapy with oestrogen, malignancy, thrombophilia, long haul flights.
VTE prophylaxis
Enoxaparin
TEDS (unless PAD)
Presentation PE
SOB
Cough
Haemoptysis
Pleuritis chest pain
Hypoxia
Tachycardia
Raised resp rate
Low grade fever
+ may be signs DVT
PE tools online
PERC - pulmonary embolism rule out criteria
Wells score - predicts probability of patient having a PE
Diagnosis PE
CXR - usually normal, rule out other pathology
Wells score
D-dimer
CTPA
Conditions raised D-dimer
Pneumonia, malignancy, HF, surgery, pregnancy
PE management
Hospital admission, oxygen, analgesia, monitoring for deterioration
Anticoagulation
Thrombolysis (risk of bleeding)
PE long term anticoagulation
3 months if a reversible cause otherwise longer
Pulmonary hypertension refers to
Increased resistance and pressure in pulmonary arteries - causes strain on the right side of the heart
Causes of pulmonary hypertension
Left heart failure
Chronic lung disease - COPD or pulmonary fibrosis
PE
Signs and symptoms Pulmonary hypertension
SOB mainly
Also raised JVP, peripheral oedema
Investigations pulmonary htn
ECG - right axis deviation, R bundle branch block
CXR - R ventricular hypertrophy
proBNP
Echo
Pulmonary HTN management
CCB
Treat underlying cause
Supportive treatments - oxygen and diuretics
Sarcoidosis
Chronic granulomatous disorder
Sarcoidosis skin features
Erythema nodosum - appear kind of like bruises
Sarcoidosis imaging & bloods
Raised ACE - screening test, hypercalcaemia
- CXR - hilar lymphadenopathy
- CT
+ histology
Sarcoidosis management
Conservative if mild, oral steroids
Sarcoidosis spontaneously resolves 1/2 time, otherwise progress to pulmonary fibrosis
OSA risk factors
Middle age, male, obesity, alcohol, smoking
Presentation OSA
Snoring, morning headache, waking up unrefreshed, daytime sleepiness and concentration problems
Severe can cause HTN & HF
OSA investigations
STOP BANG
Epworth sleepiness scale
Then sleep study
Management
CPAP machine, reduce risk factors
Signs and symptoms of pleural effusion
Signs - reduced chest expansion, reduced breath sounds, reduced vocal resonance, tracheal deviation away, stony dull to percussion
Symptoms - dry cough, dyspnoea, orthopnoea, chest pain
HFrEF which of will not reduce mortality
Aldosterone agonist, ACEi, loop diuretic or B blocker
Loop diuretic
Large QRS complexes
LV hypertrophy
