Respiratory Flashcards

1
Q

What is the most significant cause of lung cancer?

A

Smoking

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2
Q

What is the most common type of lung cancer?

A

Non-small-cell lung cancer (80%):
Adenocarcinoma (40%)
Squamous cell carcinoma (20%)
Large-cell carcinoma (10%)
Other types (10%)

Small-cell lung cancer (SCLC) (20%)

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3
Q

What is mesothelioma?

A

Lung malignancy affecting mesothelial cells of pleura
Strongly linked to asbestos
Can take up to 45y to develop

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4
Q

What is the prognosis of mesothelioma?

A

Very poor
Chemo can improve survival, but is essentially palliative

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5
Q

Outline small-cell lung cancer

A

Contains neurosecretory granules that release neuroendocrine hormones
May be responsible for various paraneoplastic syndromes

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6
Q

Outline presentation of lung cancer

A

SOB
Cough
Haemoptysis
Finger clubbing
Recurrent pneumonia
Weight loss
Lymphadenopathy (often supraclavicular nodes 1st to be found)

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7
Q

List extrapulmonary manifestations of lung cancer

A

Recurrent laryngeal nerve palsy
Phrenic nerve palsy
SVC obstruction
Horner’s syndrome
Syndrome of inappropriate ADH (SIADH)
Cushing’s syndrome
Hypercalcaemia
Limbic encephalitis
Lambert-Eaton myasthenic syndrome

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8
Q

What is the association between lung cancer and recurrent laryngeal nerve palsy?

A

Presents with hoarse voice
Caused by tumour pressing on or affecting recurrent laryngeal nerve as passes through mediastinum

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9
Q

What is the association between lung cancer and phrenic nerve palsy?

A

Due to nerve compression
Causes diaphragm weakness and presents with SOB

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10
Q

What is the association between lung cancer and SVC obstruction?

A

Caused by direct tumour compression on SVC
Presents with facial swelling, difficulty breathing, distended neck and upper chest veins
Pemberton’s sign
MEDICAL EMERGENCY

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11
Q

What is Pemberton’s sign?

A

Raising hands over head causes facial congestion and cyanosis

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12
Q

What is the association between lung cancer and Horner’s syndrome?

A

Triad of partial ptosis, anhidrosis and miosis
Caused by Pancoast tumour (in pulmonary apex) pressing on sympathetic ganglion

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13
Q

What is the association between lung cancer and SIADH?

A

Caused by ectopic ADH secreted by SCLC
Presents with hyponatremia

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14
Q

What is the association between lung cancer and Cushing’s syndrome?

A

Caused by ectopic ACTH secretion by SCLC

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15
Q

What is the association between lung cancer and Hypercalcaemia?

A

Caused by ectopic PTH secreted by squamous cell carcinoma

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16
Q

What is the association between lung cancer and Limbic encephalitis?

A

Paraneoplastic syndrome
SCLC causes immune system to make antibodies to tissues in brain (limbic system), causing inflammation
Associated with anti-Hu antibodies

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17
Q

List the symptoms of limbic encephalitis

A

Short-term memory impairment
Hallucinations
Confusion
Seizures

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18
Q

What is the association between lung cancer and Lambert-Eaton Myasthenic Syndrome?

A

Caused by antibodies against SCLC
Antibodies target and damage voltage-gated calcium channels on presynaptic terminals in motor neurones

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19
Q

List the symptoms of Lambert-Eaton Myasthenic Syndrome

A

Weakness in proximal muscles
Affect intraocular muscles causing diplopia (double vision)
Levator muscles in eyelid, causing ptosis
Pharyngeal muscles, causing slurred speech and dysphagia (difficulty swallowing)
Dry mouth, blurred vision, impotence, dizziness due to autonomic dysfunction

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20
Q

Outline the referral criteria for lung cancer

A

Suspected cancer- Recommend chest xray within 2wks to patients over 40y with signs of:
Clubbing
Lymphadenopathy (supraclavicular/persistent abnormal cervical nodes)
Recurrent/persistent chest infections
Raised platelet count (thrombocytosis)
Chest signs of lung cancer

Offer chest xray to patients over 40y with:
2+ unexplained symptoms in patients that have never smoked
1+ unexplained symptoms in patients that have smoked/had asbestos exposure

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21
Q

What are unexplained lung cancer guidelines as NICE guidelines suggest

A

Cough
SOB
Chest pain
Fatigue
Weight loss
Loss of appetite

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22
Q

What are the 2 key examination findings that automatically indicate an urgent chest xray for lung cancer?

A

Finger clubbing
Supraclavicular lymphadenopathy

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23
Q

Outline investigations for lung cancer

A

Chest xray 1st line
Staging CT scan- Chest, abdomen, and pelvis- Should be contrast-enhanced
PET-CT- Inject radioactive tracer- Identify metastases by highlighting areas of increased metabolic activity
Bronchoscopy with endobronchial US (EBUS)- Detailed assessment of tumour and US-guided biopsy
Histological diagnosis (biopsy)

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24
Q

List some potential findings of lung cancer on xray

A

Hilar enlargement
Peripheral opacity (visible lesion in lung field)
Pleural effusion (usually unilateral in cancer)
Collapse

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25
Outline management options in non-SCLC
Surgery 1st line if disease isolated to single area Radiotherapy Chemotherapy (adjuvant (to improve outcomes) or palliative)
26
Outline management of SCLC
Chemo and radiotherapy Prognosis generally worse for SCLC than non-SCLC
27
When is endobronchial treatment used in lung cancer?
Stents or debulking as part of palliative treatment to relieve bronchial obstruction
28
Outline surgical options for removing lung tumour
Segmentectomy or wedge resection Lobectomy (remove lung lobe)- Most commonly used Pneumonectomy (remove entire lung)
29
What are the types of surgery that can be used to remove a lung tumour?
Thoracotomy Video-assisted thoracoscopic surgery (VATS)- Minimally invasive 'keyhole' surgery Robotic surgery
30
What is pneumonia?
Infection of lung tissue, causing inflammation in alveolar space Seen as consolidation on chest xray LRTI
31
What is acute bronchitis?
Infection and inflammation in bronchi and bronchioles LRTI
32
Outline classification of pneumonia
Community-acquired pneumonia (CAP) Hospital-acquired pneumonia (HAP)- Develops after >48h in hospital Ventilator-acquired pneumonia (VAP)- Develops in intubated patients in ICU Aspiration pneumonia
33
Outline aspiration pneumonia
Infection due to aspiration of food or fluids Usually in patients with impaired swallowing (eg: Following a stroke or advanced dementia) Associated with anaerobic bacteria
34
Outline presentation of pneumonia
Cough Sputum production SOB Fever Feeling generally unwell Haemoptysis (coughing up blood) Pleuritic chest pain (sharp chest pain, worse on inspiration) Delirium (acute confusion)
35
What are the characteristic chest signs of pneumonia?
Bronchial breath sounds- Harsh inspiratory and expiratory breath sounds- Due to consolidation around the airway Focal coarse crackles- Caused by air passing through sputum in airways Dullness to percussion- Due to lung tissue filled with sputum/colapse
36
Outline indications of sepsis associated with pneumonia
Tachypnoea Tachycardia Hypoxia Hypotension Fever Confusion
37
Outline the severity assessment scale of pneumonia
C- Confusion U- Urea >7mmol/L R- RR >30 B- BP <90 systolic or <60 diastolic 65- Age >65y 0-1= Consider treatment at home >2= Consider hospital admission >3= Consider intensive care
38
What is the most common cause of typical bacterial pneumonia?
Streptococcus pneumoniae (most common) Haemophilus influenzae
39
When is Moraxella catarrhalis more likely to be a cause of pneumonia?
Immunocompromised patients Chronic pulmonary disease
40
When is Pseudomonas aeruginosa more likely to be a cause of pneumonia?
Patients with cystic fibrosis or bronchiectasis
41
When is Staphylococcus aureus more likely to be a cause of pneumonia?
Cystic fibrosis
42
When is Methicillin-resistant Staphylococcus aureus (MRSA) more likely to be a cause of pneumonia?
Hospital-acquired infections
43
What is atypical pneumonia?
Caused by organisms that can't be cultured in the normal way or detected using a gram stain
44
How is atypical pneumonia treated?
Penicillin is ineffective Treat with macrolides (eg: Clarithromycin), fluoroquinolones (eg: Levofloxacin) and tetracyclines (eg: Doxycycline)
45
When is Legionella pneumophilia more likely to be a cause of pneumonia?
Atypical pneumonia Caused by inhaling infected water from infected water systems, such as air conditioning Causes a syndrome of SIADH, resulting in hyponatremia Typical patient- Cheap hotel holiday, presents with pneumonia and hyponatremia Diagnosis- Urine antigen test
46
When is Mycoplasma pneumoniae more likely to be a cause of pneumonia?
Atypical pneumonia Milder pneumonia Rash- Erythema multiforme- Target lesions Neurological symptoms in young patients
47
When is Chlamydophilia pneumoniae more likely to be a cause of pneumonia?
Atypical pneumonia Mild to moderate chronic pneumonia and wheezing in school-age children
48
When is Coxiella burnetii more likely to be a cause of pneumonia?
Atypical pneumonia Q fever Linked to exposure to bodily fluids of animals Patient- Farmer with flu-like illness
49
When is Chlamydia psittaci more likely to be a cause of pneumonia?
Contracted from contact with infected birds Patient example- Parrot owner
50
Outline pneumocystis jirovecii pneumonia (PCP)
Fungal pneumonia Occurs in immunocompromised patients Poorly controlled HIV and low CD4 count at particular risk
51
How does PCP present?
Subtle Dry cough SOB on exertion Night sweats
52
Outline management of PCP
Co-trimoxazole (trimethoprim/sulfamethoxazole) Low CD4 count prescribed prophylactic co-trimoxazole to protect against PCP
53
List complications of pneumonia
Sepsis ARDS Pleural effusion Empyema Lung abscess Death
54
How is mild community-acquired pneumonia typically managed?
5 days oral ABs: Amoxicillin or doxycycline or clarithromycin
55
How is moderate/severe pneumonia managed?
IV ABs Respiratory support (eg: Oxygen/intubation/ventilation)
56
Outline investigations of pneumonia
Point-of-care test for CRP level Chest xray FBC- Raised WCC Renal profile- Urea level for CURB-65 and AKI CRP- Raised in inflammation and infection Sputum cultures Blood cultures Pneumococcal and Legionella urinary antigen tests
57
What is PaO2 a marker of on an ABG
Partial pressure of oxygen Amount of oxygen dissolved in blood Low PaO2- Indicates hypoxia and respiratory failure
58
What is FiO2 a marker of?
Fraction of inhaled oxygen Room air= FiO2 of 21% Venturi masks control FiO2
59
How can you distinguish the type of respiratory failure?
Normal PaCO2 with low PaO2- Type 1 respiratory failure (only one affected) Raised PaCO2 with low PaO2- Indicates Type 2 respiratory failure (2 affected)
60
Outline respiratory acidosis
CO2 makes blood acidotic by breaking down into carbonic acid (H2CO3) Low pH (acidosis) with raised PaCO2- Respiratory acidosis Suggests patient is retaining CO2
61
What is the role of bicarbonate in the body?
Kidneys produce bicarbonate Bicarbonate acts as buffer to neutralise acid in blood and maintain normal pH In acute resp acidosis- Bicarbonate not produced fast enough to compensate rising CO2
62
What does a raised bicarbonate suggest?
Patient chronically retains CO2 Kidneys respond to CO2 by producing additional bicarbonate Seen in COPD
63
Outline respiratory alkalosis
Occurs when patient has raised respiratory rate and 'blows off' too much CO2 Hyperventilation syndrome High pH and low PaCO2
64
Outline metabolic acidosis
Low pH, low bicarbonate
65
List causes of metabolic acidosis
Raised lactate- Lactate released during anaerobic respiration (indicating tissue hypoxia) Raised ketones- DKA Increased hydrogen ions- Due to renal failure, type 1 renal tubular acidosis or rhabdomyolysis Reduced bicarbonate- Due to diarrhoea, renal failure or type 2 renal tubular acidosis
66
Outline metabolic alkalosis
Raised pH, raised bicarbonate
67
What are the causes of metabolic alkalosis?
Results from loss of H+ ions: GI tract- Vomiting Kidneys- Due to increased activity of aldosterone- Increased H+ ion excretion
68
List causes of increased aldosterone activity
Conn's syndrome (primary hyperaldosteronism) Liver cirrhosis HF Loop diuretics Thiazide diuretics
69
List respiratory support options from least to most invasive
Oxygen therapy High flow nasal cannula Intubation and mechanical ventilation ECMO
70
What is Acute Respiratory Distress Syndrome (ARDS)?
Occurs due to severe inflammatory reaction in lungs Often secondary to sepsis or trauma
71
Outline features of ARDS
Collapse of alveoli and lung tissue (atelectasis) Pulmonary oedema (not related to HF or fluid overload) Decreased lung compliance (reduced lung inflation when ventilated) Fibrosis of lung tissue (typically after 10+ days
72
List the clinical signs of ARDS
Acute respiratory distress Hypoxia with inadequate response to oxygen therapy Bilateral infiltrates on chest xray
73
Outline management of ARDS
Respiratory support Prone position Careful fluid management to avoid excess fluid collecting on lungs PEEP
74
Why is PEEP used in ARDS?
In ARDS- Only small portion of total lung volume is aerated During mechanical ventilation, low volumes and pressures used to avoid over-inflating small functional portion of lung PEEP prevents lungs from collapsing further
75
List the benefits of prone positioning
Reduces compression of lungs by other organs Improving blood flow to lungs, especially well-ventilated areas Improves clearance of secretions Improves overall oxygenation Reduces required assistance from mechanical ventilation
76
Outline basic methods of oxygen therapy
FiO2 depends on oxygen flow rate Nasal cannula: 24-44% oxygen Simple face mask: 40-60% oxygen Venturi mask: 24-60% oxygen Face mask with reservoir (non-rebreather): 60-95% oxygen
77
What is the maximum oxygen flow rate of a nasal cannula?
4L/min
78
What is the function of a venturi mask?
Used to deliver exact conc. oxygen in COPD CO2 retainers Blue- 2L, 24% FiO2 White- 4L, 28% FiO2 Orange- 6L, 31% Yellow- 8L, 35% Red- 10L, 40% Green- 15L, 60%
79
What is end-expiratory pressure?
Pressure that remains in airways at end of exhalation
80
How can PEEP be delivered?
High-flow nasal cannula Non-invasive ventilation (NIV) Mechanical ventilation
81
What is PEEP?
Positive end-expiratory pressure Additional pressure in airways at end of exhalation that keeps them inflated Keeps airways from collapsing and improves ventilation Reduces atelectasis Decreases effort of breathing
82
Outline high-flow nasal cannulas
Allows controlled flow rates up to 60L/min of humidified and warmed oxygen High flow rate reduces amount of room air patient inhales alongside O2, increasing conc. inspired O2 Adds PEEP Provides dead space washout- Adds O2 to dead space
83
What is CPAP?
Continuous positive airway pressure Constant pressure added to lungs to keep airways expanded Used in OSA Not technically NIV as ventilation is still dependant on respiratory muscles
84
Outline non-invasive ventilation (NIV)
Full face mask, hood or tight fitting nasal mask to blow air forcefully into lungs BiPAP (Bilevel) Involves a cycle of high and low pressure to correspond with inspiration and expiration
85
Outline NIV IPAP and EPAP
High and low pressure to correspond to inspiration and expiration IPAP (inspiratory PAP)- Pressure during inspiration- Air forced into lungs EPAP (expiratory PAP)- Pressure during expiration- Stops airways collapsing
86
Outline mechanical ventilation
Used when other forms of respiratory support (NIV and oxygen) inadequate or CI Ventilator machine used to move air in and out of lungs Patients generally require sedation whilst on ventilator ETT or tracheostomy Delivers controlled pressures and volumes into lungs
87
Outline Extracorporeal Membrane Oxygenation (ECMO)
Blood removed from body and oxygenated, CO2 removed, then pumped back into body Only used short term in potentially reversible cause of respiratory failure
88
What is spirometry?
Establishes objective measures of lung function Involves different breathing exercises into machine and measures volume of air and flow rates
89
What is reversibility testing?
Give bronchodilator (eg: Salbutamol) before repeating spirometry
90
What is FEV1?
Air a person can forcefully exhale in 1s Measures how easily air moves out of lungs Reduced with airflow obstruction
91
What is FVC?
Total air a person can forcefully exhale in 1s Measures total volume of air a person can take into their lungs Reduced with restricted lung capacity
92
How is obstructive lung disease diagnosed?
FEV1:FVC ratio <70% Suggests obstruction is slowing air passage out of lungs
93
What is the difference between asthma and COPD?
Asthma- Obstruction is a narrowed airway due to bronchoconstriction COPD- Chronic airway and lung damage causing obstruction Test reversibility- Give bronchodilator- Typically reversible in asthma, less so in COPD
94
Outline restrictive lung disease
FEV1 and FVC equally reduced FEV1:FVC ratio >70% Limits ability of lungs to expand and sill with air Leads to inadequate ventilation of alveoli and insufficient blood oxygenation FEV1:FVC ratio normal/raised in restrictive without obstructive pathology affecting airflow- FVC reduced due to restriction of lung expansion and capacity
95
List conditions of restrictive lung disease
Interstitial lung disease- Idiopathic pulmonary fibrosis Sarcoidosis Obesity Motor neurone disease Scoliosis
96
What does a low FVC and normal FEV1:FVC ratio indicate?
Restrictive lung disease
97
What does a low FVC and low FEV1:FVC ratio indicate?
Combination of obstructive lung disease and restrictive lung disease
98
What does a low FEV1:FVC ratio indicate?
Obstructive lung disease
99
Outline peak flow
Measures fastest point of expiratory flow of air Demonstrates how much obstruction to airflow is present in lungs
100
What is predicted peak flow based on?
Sex Height Age Result can be recorded as percentage of the predicted
101
What is asthma?
Chronic inflammatory airway disease leading to variable airway obstruction Smooth muscle in airways is hypersensitive and responds to stimuli by constricting and causing airflow obstruction Bronchoconstriction reversible with bronchodilators
102
List the atopic conditions
Asthma Eczema Hay fever Food allergies
103
Outline presentation of asthma
SOB Chest tightness Dry cough Wheeze Diurnal variability- Symptoms fluctuate at different times of day- Typically worse at night Widespread 'polyphonic' wheeze
104
What are the top differentials of a localised monophonic wheeze?
Inhaled foreign body Tumour Thick sticky mucus plug obstructing an airway Chest xray is next step
105
What are the typical triggers of asthma?
Infection Night time/early morning Exercise Animals Cold, damp, dusty air Strong emotions
106
What are the meds that can worsen asthma?
Non-selective BBs- Propanolol NSAIDs- Ibuprofen or naproxen
107
Outline investigations of asthma
Spirometry Reversibility testing- >12% increase in FEV1 supports diagnosis of asthma FeNO- Measures conc. NO exhaled- Marker of airway inflammation- >40ppb +ve test result- Smoking can lower FeNO making results unreliable Peak flow variability- >20% supports diagnosis Direct bronchial challenge
108
How is direct bronchial challenge testing done?
Tests for diagnosis of asthma Opposite of reversibility testing Inhaled histamine or metacholine stimulates bronchoconstriction, reducing FEV1 in patients with asthma
109
Outline beta-2 adrenergic receptor agonists
Bronchodilators (open airways) Adrenalin acts on smooth muscle of airways to cause relaxation Stimulating adrenalin receptors dilates bronchioles and reverses bronchoconstriction SABA (salbutamol)- Work quickly, effects last a few hrs- Rescue/reliever medication LABA (salmeterol)- Slower to act, last longer
110
Outline inhaled corticosteroids
Beclometasone Reduce inflammation and reactivity of airways Used as maintenance or preventer medications
111
Outline Long-acting muscarinic antagonists (LAMA)
Tiotropium Block acetylcholine receptors Acetylcholine receptors are stimulated by parasympathetic nervous system and cause contraction of bronchial smooth muscles Blocking acetylcholine receptors dilate bronchioles, reverse bronchoconstriction
112
Outline leukotriene receptor antagonists
Montelukast Block effects of leukotrienes Leukotrienes cause inflammation, bronchoconstriction and mucus secretion in airways
113
How does theophylline work?
Relaxes bronchial smooth muscle and reduces inflammation Has very narrow therapeutic window- Can be toxic in excess- Requires monitoring
114
Outline maintenance and reliever therapy (MART)
Combination inhaler containing ICS and fast and long-acting beta-agonist (eg: Formoterol) Replaces all other inhalers- Used as a preventer and a reliever
115
Outline long-term asthma management (NICE guidelines)
1. SABA (salbutamol) 2. ICS (low dose) 3. LRT (montelukast) 4. LABA (salmeterol) 5. Consider changing to MART 6. Increase ICS to moderate dose 7. High dose ICS or add LAMA or theophylline 8. Specialist management (eg: Oral corticosteroids)
116
Outline the additional management of asthma
Asthma self management plan Yrly flu jab Yrly asthma review Regular exercise Avoid smoking Avoid triggers where possible
117
List features of an acute exacerbation of asthma
Progressive SOB Use of accessory muscles Tachypnoea Symmetrical expiratory wheeze on auscultation Tight chest
118
What is seen on an ABG in a patient with an acute exacerbation of asthma?
Respiratory alkalosis Raised RR causes drop in CO2 Normal pCO2 or low O2 is concerning- Getting tired Respiratory acidosis due to high pCO2 is a very bad sign
119
List features of moderate exacerbation of asthma
Peak flow 50-75% best or predicted
120
List features of severe exacerbation of asthma
Peak flow 33-50% best or predicted RR >25 HR >110 Unable to complete sentences
121
List features of life-threatening exacerbation of asthma
Peak flow <33% O2 sats <92% PaO2 <8kPa Becoming tired Confusion or agitation No wheeze or silent chest Haemodynamic instability (shock)
122
Outline management of mild exacerbations of asthma
Inhaled salbutamol via spacer Quadrupled dose ICS (for up to 2wks) Oral steroids (prednisolone) if higher ICS is inadequate ABs if convincing evidence of bacterial infection Follow up within 48h
123
Outline management of moderate exacerbations of asthma
Consider hospital admission Nebulised beta-2 agonists Steroids (eg: Oral prednisolone or IV hydrocortisone)
124
Outline management of severe exacerbations of asthma
Hospital admission Oxygen to maintain sats 94-98% Nebulised ipratropium bromide IV magnesium sulphate IV salbutamol IV aminophylline
125
Outline management of life-threatening exacerbations
Admission to HDU or ICU Intubation and ventilation
126
What needs monitoring with salbutamol treatment?
Serum potassium Salbutamol causes potassium to be absorbed from blood into cells- Hypokalaemia Also causes tachycardia and lactic acidosis
127
Outline management of asthma after an acute attack
Consider rescue pack of oral steroids to start early in exacerbation Prednisolone (1 to 2mg/kg for 5d)
128
Outline obstructive sleep apnoea
Caused by collapse of pharyngeal airway Patient stops breathing for up to a few minutes
129
List risk factors for OSA
Middle age Male Obesity Alcohol Smoking
130
Outline presentation of OSA
Episodes of apnoea during sleep Snoring Morning headache Waking up unrefreshed from sleep Daytime sleepiness Conc. problems Reduced oxygen saturation during sleep Severe cases- HTN, HF- Increase risk of MI and stroke
131
Outline Epworth Sleepiness Scale
Used to assess symptoms of sleepiness associated with OSA
132
Outline investigations of OSA
Epworth sleepiness scale Sleep studies Respiratory polygraphy
133
Outline management of OSA
Reversible risk factors- Reduce alcohol, smoking cessation, weight loss CPAP Surgery- Involves significant surgical reconstruction of soft palate and jaw- Uvulopalatopharyngoplasty (UPPP)
134
What is sarcoidosis?
Chronic granulomatous disorder Granulomas- Inflammatory nodules full of macrophages Usually associated with respiratory symptoms but has many extra-pulmonary manifestations
135
Outline epidemiology of sarcoidosis
20-39y or around 60y Women Black ethnic origin
136
20-40y black female with dry cough and SOB May have nodules on shins
Sarcoidosis (with erythema nodosum)
137
What are the skin features of sarcoidosis?
Erythema nodosum- Nodules of inflamed SC fat on shins- Raised, red, tender, painful, SC nodules on both shins Inflammation of fat = Panniculitis Lupus pernio- Specific to sarcoidosis- Raised purple skin lesions on cheeks and nose
138
How can sarcoidosis affect the lungs?
Mediastinal lymphadenopathy Pulmonary fibrosis Pulmonary nodules
139
List the systemic symptoms of sarcoidosis
Fever Fatigue Weight loss
140
How can sarcoidosis affect the liver?
Liver nodules Cirrhosis Cholestasis
141
How can sarcoidosis affect the eyes?
Uveitis Conjunctivitis Optic neuritis
142
How can sarcoidosis affect the heart?
Bundle branch block Heart block Myocardial muscle involvement
143
How can sarcoidosis affect the kidneys?
Kidney stones (hypercalcaemia) Nephrocalcinosis Interstitial nephritis
144
How can sarcoidosis affect the CNS?
Nodules Pituitary involvement (diabetes insipidus) Encephalopathy
145
How can sarcoidosis affect the PNS?
Facial nerve palsy Mononeuritis multiplex
146
How can sarcoidosis affect bones?
Arthralgia Arthritis Myopathy
147
What is Lofgren's syndrome?
Specific presentation of sarcoidosis Classic triad- Erythema nodosum, bilateral hilar lymphadenopathy, polyarthralgia
148
List differential diagnosis of sarcoidosis
TB Lymphoma Hypersensitivity pneumonitis HIV Toxoplasmosis Histoplasmosis
149
Which blood tests are used to investigate sarcoidosis?
Raised angiotensin-converting enzyme (ACE)- Used as a screening test Raised calcium (hypercalcaemia)
150
Outline imaging used in sarcoidosis
Chest xray- May show hilar lymphadenopathy High resolution CT- Hilar lymphadenopathy and pulmonary nodules MRI- CNS involvement PET scan- Active inflammation
151
Outline histology of sarcoidosis
Often bronchoscopy with US-guided biopsy of mediastinal lymph nodes Shows non-caseating granulomas with epithelioid cells
152
List other tests used to investigate sarcoidosis
U&Es- Kidney involvement Urine ACR- Look for proteinuria LFTs Ophthalmology ECG and ECHO US liver and kidney
153
Outline management of sarcoidosis
Conservative- If no/mild symptoms Oral steroids (for 6-24mths)- 1st line Bisphosphonates protect against osteoporosis if on long-term steroids Methotrexate- 2nd line Lung transplant- In severe pulmonary disease
154
What is the prognosis of sarcoidosis?
Spontaneously resolves in around half of patients, usually within 2yrs Sometimes progresses to pulmonary fibrosis and pulmonary HTN Overall mortality <10%
155
What is pulmonary HTN?
Increased resistance and pressure in pulmonary arteries Causes strain on R side of heart as tries to pump blood through lungs Back pressure through R side of heart and into systemic venous system Defined as mean pulmonary arterial pressure >20mmHg
156
List the causes of pulmonary HTN
Group 1- Idiopathic or connective tissue disease (eg: SLE) Group 2- Left HF, usually due to MI or systemic HTN Group 3- Chronic lung disease (eg: COPD or pulmonary fibrosis) Group 4- Pulmonary vascular disease (eg: Pulmonary embolism) Group 5- Miscellaneous- Sarcoidosis, glycogen storage disease, haematological disorders
157
What are the signs and symptoms of pulmonary HTN?
SOB Syncope (LOC) Tachycardia Raised JVP Hepatomegaly Peripheral oedema
158
Outline ECG changes 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 RBBB
159
Outline chest xray changes in pulmonary HTN
Dilated pulmonary arteries RV hypertrophy
160
Outline other investigations in pulmonary HTN
Raised NT-proBNP- Indicates RV failure ECHO- Can be used to estimate pulmonary artery pressure
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Outline management of idiopathic pulmonary HTN
CCBs IV prostaglandins (eg: Epoprostenol) Endothelin receptor antagonists (eg: Macitentan) Phosphodiesterase-5 inhibitors (eg: Sildenafil)
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How is secondary pulmonary HTN managed?
Treat underlying cause- Such as PE, COPD, SLE
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What are the supportive treatments of pulmonary HTN?
Oxygen and diuretics Used for complications- Respiratory failure, oedema, arrhythmias
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What is the prognosis of pulmonary HTN?
Poor Mean survival of 2-3yrs after diagnosis if untreated
165
What is a pulmonary embolism?
Thrombus in pulmonary arteries Embolus- Thrombus that has travelled in blood from a DVT Blocks lung tissue and strains R side of heart
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List risk factors for pulmonary embolism
Immobility Recent surgery Long-haul travel Pregnancy Hormone therapy with oestrogen Malignancy Polcythaemia (raised Hb) SLE Thrombophilia
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Outline VTE prophylaxis
LMWH- Enoxaparin Anti-embolic compression stockings
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What are the CIs of LMWH?
Active bleeding Existing anticoagulation (warfarin or DOAC)
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What are the CIs of anti-embolic compression stockings?
Peripheral arterial disease
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Outline presentation of PE
Can be asymptomatic SOB Cough Haemoptysis Pleuritic chest pain (sharp pain on inspiration) Hypoxia Tachycardia Raised RR Low-grade fever Haemodynamic instability causing hypotension Signs of DVT
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What is the PERC rule?
Pulmonary embolism rule-out criteria Clinician estimates <15% probability of PE to decide whether further investigations for PE are needed
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What is the Wells score?
Predicts probability of patient having PE
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Outline how PE is diagnosed
Chest xray- Usually normal in PE, but required to rule out other pathology Wells score- Outcome decides next step: - Likely- Perform CTPA - Unlikely- Perform d-dimer- If positive perform CTPA
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Outline d-dimer for use in diagnosing PE
Sensitive but not specific for VTE
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Which conditions can cause a raised d-dimer?
Pneumonia Malignancy HF Surgery Pregnancy
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List the 3 imaging options for diagnosing PE
CT pulmonary angiogram- With IV contrast Ventilation perfusion single photon emission computed tomography (V/Q SPECT) scan Planar ventilation-perfusion (VQ) scan
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What is a VQ scan?
Uses radioactive isotopes and gamma camera to compare ventilation with perfusion of lungs Used in patients with renal impairment/contrast allergy/risk from radiation, where CTPA unsuitable Isotopes inhaled to fill lungs, picture taken to demonstrate ventilation- Then contrast containing isotopes injected and demonstrates perfusion 2 images compared
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What is the result of a PE on a VQ scan?
Deficit in perfusion Lung tissue ventilated but not perfused
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What is the difference between Planar V/Q and V/Q SPECT scans?
Planar- 2D SPECT- 3D- More accurate
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What can an ABG show in PE?
Respiratory alkalosis Hypoxia causes raised RR Breathing fast- Blow off extra CO2 Low CO2- Blood becomes alkalotic
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How can you tell the difference between PE and hyperventilation on ABG?
PE- Low pO2 Hyperventilation- High pO2
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Outline supportive management of PE
Admission as required, oxygen as required, analgesia as required, monitor for deterioration
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Outline anticoagulation management in PE
1st line- Treatment-dose apixaban or rivaroxaban LMWH- An alternative
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How is a massive PE with haemodynamic compromise treated?
Continuous infusion of unfractionated heparin Consider thrombolysis
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What are the 2 ways of delivering thrombolysis?
IV using peripheral cannula Catheter-directed thrombolysis (directed into pulmonary arteries using central catheter)
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What is thrombolysis?
Inject fibrinolytic that rapidly dissolves clots Streptokinase, alteplase, tenecteplase
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What is the risk of thrombolysis?
Bleeding
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Outline long-term anticoagulation used in VTE
DOAC, warfarin or LMWH
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What are the CIs to DOACs?
Severe renal impairment (creatinine clearance <15ml/min) Antiphospholipid syndrome Pregnancy
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What is the target INR for warfarin when treating DVTs and PEs?
Between 2 and 3
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When is warfarin 1st line in patients with a DVT or PE?
In patients with antiphospholipid syndrome (who also require initial concurrent treatment with LMWH)
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When is LMWH the 1st line anticoagulant in DVT or PE?
Pregnancy
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How long is anticoagulation continued following PE or DVT?
3mths with reversible cause Beyond 3mths with unprovoked PE, recurrent VTE, or irreversible underlying cause (eg: Thrombophilia) 3-6mths in active cancer
194
What is a pneumothorax?
Air enters pleural space, separating lung from chest wall Can occur spontaneously or secondary to trauma/medical interventions/lung pathology
195
What are the risk factors for a spontaneous pneumothorax?
Tall, thin, young man presenting with sudden breathlessness and pleuritic chest pain, possibly whilst playing sports
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List causes of pneumothorax
Spontaneous Trauma Iatrogenic- Due to lung biopsy/mechanical ventilation/central line insertion Lung pathologies- Infection, asthma, COPD
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Outline investigations of pneumothorax
Erect chest xray- Simple pneumothorax- Shows area between lung tissue and chest wall with no lung markings- Will be a line demarcating edge of lung CT thorax- Detects pneumothorax too small to be seen on chest xray
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Outline management of pneumothorax
No SOB and <2cm rim of air on CXR- No treatment required as spontaneously resolves, follow up in 2-4wks SOB or >2cm rim of air on CXR- Aspiration and reassessment- If aspiration fails twice insert chest drain
199
When are chest drains required in pneumothorax?
If aspiration fails twice Unstable patients Bilateral or secondary pneumothoraces
200
Outline chest drains
Triangle of safety- 5th ICS, midaxillary line (lateral edge of latissimus dorsi), anterior axillary line (lateral edge of pec major) Needle inserted just above rib to avoid NV bundle Once inserted, CXR to assess positioning
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What are the key complications of chest drains?
Air leaks around the drain site (indicated by persistent bubbling of fluid, particularly on coughing) Surgical emphysema- Air collects in SC tissue
202
When may a pneumothorax require surgical management?
Chest drain fails to correct pneumothorax Persistent air leak in drain Pneumothorax reoccurs
203
Outline surgical management of pneumothorax
Video-assisted thoracoscopic surgery (VATS) Abrasive pleurodesis Chemical pleurodesis Pleurectomy
204
List signs of tension pneumothorax
Tracheal deviation away from side of pneumothorax Reduced air entry on affected side Increased resonance to percussion on affected side Tachycardia Hypotension
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What is a tension pneumothorax?
Caused by trauma to chest wall that creates 1 way valve that lets air in, but not out of pleural space Air is trapped in pleural space Creates pressure inside thorax to push mediastinum across, kink big vessels in mediastinum and cause cardiorespiratory arrest
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Outline management of tension pneumothorax
Insert a large bore cannula into 2nd intercostal space in midclavicular line Chest drain required for definitive management once pressure relieved
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What are the 2 categorisations of pleural effusion?
Exudative- High protein content (>30g/L) Transudative- Lower protein content (<30g/L)
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What is Light's criteria?
Establishes exudative effusion Uses protein or lactate dehydrogenase (LDH) Pleural fluid protein/serum protein >0.5 Pleural fluid LDH/serum LDH >0.6 Pleural fluid LDH >2/3 of normal upper limit serum LDH
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What are the exudative causes of pleural effusion?
Related to inflammation Cancer (lung or mesothelioma) Infection (pneumonia or TB) RA
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What are the transudative causes of pleural effusion?
Related to fluid moving across or shifting into pleural space Congestive HF Hypoalbuminaemia Hypothyroidism Meigs syndrome
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What is Meigs syndrome?
Triad of: Benign ovarian tumour Pleural effusion Ascites
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Outline presentation of pleural effusion
SOB Dullness to percussion over effusion Reduced breath sounds Tracheal deviation away from effusion in large effusions
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Outline CXR findings in pleural effusion
Blunting of costophrenic angle Fluid in lung fissures Larger effusions have meniscus (curving upwards where it meets chest wall and mediastinum) Tracheal and mediastinal deviation away from effusion in very large effusions
214
List investigations of pleural effusions
CXR US and CT- Detect smaller effusions Pleural fluid analysis- Requires sample taken by aspiration or chest drain
215
Outline treatment of pleural effusions
Conservative- If small Pleural aspiration- Needle in chest wall and aspirate fluid, may recur Chest drain- Prevents reoccurring
216
What is empyema?
Infected pleural effusion Pleural aspiration- Pus, low pH, low glucose, high LDH Treat- Chest drain and ABs
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What is interstitial lung disease?
Includes conditions that cause inflammation and fibrosis (scarring) of lung parenchyma
218
List types of ILD
Idiopathic pulmonary fibrosis Secondary pulmonary fibrosis Hypersensitivity pneumonitis Cryptogenic organising pneumonia Asbestosis
219
Outline presentation of ILD
SOB on exertion Dry cough Fatigue
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What are the typical findings of idiopathic pulmonary fibrosis on examination?
Bibasal fine end-inspiratory crackles Finger clubbing
221
Outline diagnosis of ILD
Clinical features High-resolution CT scan of thorax- Ground glass Spirometry- FEV1 and FVC equally reduced , FEV1:FVC ration >70%- Restrictive pattern Lung biopsy Bronchoalveolar lavage
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Outline general management of ILD
Remove/treat underlying cause Home oxygen if hypoxia Stop smoking Physiotherapy and pulmonary rehab Pneumococcal and flu vaccine Advanced care planning and palliative care if appropriate Lung transplant
223
What is idiopathic pulmonary fibrosis?
Progressive pulmonary fibrosis with no apparent cause
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Outline presentation of idiopathic pulmonary fibrosis
Insidious onset SOB and dry cough >3mths Usually affects adults >50y
225
What is the prognosis of idiopathic pulmonary fibrosis?
Poor 2-5y life expectancy from diagnosis
226
Which medications can slow progression of idiopathic pulmonary fibrosis?
Pirfenidone- Reduces fibrosis and inflammation Nintedanib- Reduces fibrosis and inflammation by inhibiting tyrosine kinase
227
Which drugs can cause secondary pulmonary fibrosis?
Amiodarine (also causes grey/blue skin) Cyclophosphamide Methotrexate Nitrofurantoin
228
Which conditions can cause secondary pulmonary fibrosis?
Alpha-1 antitrypsin deficiency RA SLE Systemic sclerosis Sarcoidosis
229
What is hypersensitivity pneumonitis?
Extrinsic allergic alveolitis Involves type III and type IV hypersensitivity reaction to environmental allergen Inhalation of allergens patient sensitised to causes immune response- Inflammation and damage to lung tissue
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Outline diagnosis of hypersensitivity pneumonitis
Bronchoalveolar lavage performed during bronchoscopy Airways washed with sterile saline to gather cells- Fluid collected and analysed Raised lymphocytes
231
List specific examples of causes of hypersensitivity pneumonitis
Bird-fancier's lung- Reaction to bird droppings Farmer's lung- Reaction to mouldy spores in hay Mushroom worker's lung- Reaction to specific mushroom antigens Malt worker's lung- Reaction to mould on barley
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What is cryptogenic organising pneumonia?
Focal area of inflammation of lung tissue Can be idiopathic or triggered by infection/inflammatory disorders/meds/radiation/environmental toxins/allergens
233
Outline presentation of cryptogenic organising pneumonia
SOB Cough Fever Lethargy Inspiratory crackles on auscultation
234
Outline management of cryptogenic organising pneumonia
CXR- Focal consolidation Lung biopsy- Definitive
235
How is cryptogenic organising pneumonia treated?
Systemic corticosteroids
236
What is asbestosis?
Lung fibrosis related to asbestos exposure Oncogenic- Causes cancer
237
What can asbestos inhalation cause?
Lung fibrosis Pleural thickening and pleural plaques Adenocarcinoma Mesothelioma
238
What is bronchiectasis?
Permanent dilation of bronchi Sputum collects and grows- Chronic cough, continuous sputum production and recurrent infections
239
What causes bronchiectasis?
Results from damage to airways Idiopathic Pneumonia Whooping cough (pertussis) TB Alpha-1-antitrypsin deficiency CT disorder (RA) CF Yellow nail syndrome
240
What is yellow nail syndrome?
Yellow fingernails Bronchiectasis Lymphoedema
241
What are the symptoms of bronchiectasis?
SOB Chronic productive cough Recurrent chest infections Weight loss
242
What are the signs of bronchiectasis?
Sputum pot by bedside Oxygen therapy Weight loss Finger clubbing Signs of cor pulmonale (eg: Raised JVP and peripheral oedema) Scattered crackles throughout chest that change/clear with coughing Scattered wheezes and squeaks
243
Outline investigations of bronchiectasis
Sputum culture- Haemophilus influenza, Pseudomonas aeruginosa
244
What can be seen on CXR of bronchiectasis?
Tram-track opacities (parallel markings of side-view of dilated airway) Ring shadows (dilated airways seen end-on) High resolution CT (HRCT)- Test of choice for establishing diagnosis
245
Outline general management of bronchiectasis
Vaccines (pneumococcal and influenza) Respiratory physiotherapy- Clear sputum Pulmonary rehab Long-term ABs (azithromycin) for frequent exacerbations Inhaled colistin for Pseudomonas aeruginosa colonisation Long-acting bronchodilators- For breathlessness Long-term oxygen therapy- In hypoxia Surgical lung resection Lung transplant
246
Outline management of infective exacerbations in bronchiectasis
Sputum culture Extended course of antibiotics- 7-14d Ciprofloxacin- For exacerbations caused by Pseudomonas aeruginosa
247
What is COPD?
Long-term, progressive condition involving airway obstruction, chronic bronchitis and emphysema Damage to lung tissue obstructs flow of air
248
What is chronic bronchitis?
Long-term symptoms of cough and sputum production due to inflammation in bronchi
249
What is emphysema?
Involves damage and dilatation of alveolar sacs and alveoli, decreasing surface area for gas exchange
250
Outline presentation of COPD
SOB Cough Sputum production Wheeze Recurrent respiratory infections Does NOT cause clubbing/haemoptysis/chest pain
251
Outline diagnosis of COPD
Based on clinical presentation and spirometry Spirometry- Shows obstructive picture- FEV1:FVC ratio <70%- Little or no response to reversibility testing with beta-2 agonists TLCO- Tests diffusion of inhaled gas into blood (reduced in COPD)
252
What is the initial medical treatment of COPD?
Short-acting beta-2 agonists (salbutamol) Short-acting muscarinic antagonists (ipratropium bromide)
253
How is extra management of COPD determined?
If symptoms and exacerbations still a problem, measured by: Previous diagnosis of asthma or atopy Variation in FEV1 >400mls Diurnal variability in peak flow >20% Raised blood eosinophil count
254
Which vaccines should patients with COPD receive?
Pneumococcal and annual flu
255
If there are no asthmatic or steroid-responsive features, what is the treatment of COPD?
LABA LAMA
256
If there are asthmatic or steroid-responsive features, what is the treatment of COPD?
LABA ICS
257
What is the final inhaler step for COPD management?
LABA LAMA ICS
258
What are the specialist management options of COPD?
Nebulisers- Salbutamol or ipratropium Oral theophylline Oral mucolytic therapy to break down sputum (eg: Carbocisteine) Prophylactic ABs (azithromycin) Oral corticosteroids (prednisolone) Oral phosphodiesterase-4 inhibitors (roflumilast) Long-term oxygen therapy at home Lung volume reduction surgery Palliative care
259
What monitoring is required when taking azithromycin?
ECG and liver function before and during treatment
260
When is long-term oxygen therapy an option in COPD?
Chronic hypoxia Polycythaemia Cyanosis Cor pulmonale Smoking is a CI
261
What is cor pulmonale?
Right sided HF caused by respiratory disease Increased pressure and resistance in pulmonary arteries limits RV pumping blood into pulmonary arteries Causes back pressure into RA, VC, and systemic venous system
262
What are the causes of cor pulmonale?
COPD PE ILD CF Primary pulmonary HTN
263
What are the symptoms of Cor pulmonale?
Can be asymptomatic SOB Peripheral oedema Breathlessness of exertion Syncope Chest pain
264
What are the signs of cor pulmonale on examination?
Hypoxia Cyanosis Raised JVP Peripheral oedema Parasternal heave Loud 2nd HS Murmurs (eg: Pansystolic in tricuspid regurg) Hepatomegaly (pulsatile in tricuspid regurg)
265
Outline management of cor pulmonale
Treat symptoms and underlying cause LTOT Prognosis is poor
266
Outline acute exacerbation of COPD
Rapidly worsening symptoms Cough/SOB/Sputum production/wheezing
267
Outline an ABG of COPD acute exacerbation
Respiratory acidosis Low pH- Acidosis Low pO2- Hypoxia and respiratory failure Raised CO2- CO2 retention (hypercapnia) Raised bicarbonate- Chronic retention of CO2
268
Outline diagnosis of a patient with COPD as a CO2 retainer
CO2 makes blood acidotic Low pH with raised pCO2 suggests acutely retaining CO2- Respiratory acidosis Raised bicarbonate suggests chronically retaining CO2- Maintain normal pH- In acute exacerbation kidneys can't keep up with rising CO2- Blood acidotic despite raised bicarbonate
269
List investigations used in COPD acute exacerbations
ABG Chest xray- Look for pneumonia ECG- Look for arrhythmias FBC- Infection U&E Sputum culture Blood cultures- In signs of sepsis
270
Outline oxygen therapy in COPD
CO2 retainers- When treated with oxygen can cause oxygen-induced hypercapnia- Ventilation-perfusion mismatch- Hb binding less well to CO2 when also bound to O2 Target 88-92% if risk of CO2 retention Target 94-98% if no retention CO2 Venturi masks
271
Outline use of venturi masks
Deliver a specific % conc. oxygen Allow some oxygen to leak out side of mask and normal air to be inhaled alongside O2 Environmental air contains 21% O2 24% (blue), 28% (white), 31% (orange), 35% (yellow), 40% (red), 60% (green)
272
Outline management of an acute exacerbation of COPD
1st line: Regular inhalers or nebulisers (eg: Salbutamol and ipratropium) Steroids (eg: Prednisolone 30mg once daily 5d) ABs (if evidence of infection) Respiratory physio can help clear sputum Additional: IV aminophylline NIV Intubation and ventilation with admission to intensive care Doxapram- Used as respiratory stimulant if NIV/intubation not appropriate
273
What are the inclusion criteria for NIV?
Persistent respiratory acidosis (pH <7.35 and PaCO2 >6) despite max. medical treatment Potential to recover Acceptable to patient
274
What are the main CIs to NIV?
Untreated pneumothorax Any structural abnormality or pathology affecting face/airway/GI tract All patients have CXR before NIV to exclude pneumothorax
275
What needs monitoring whilst on NIV?
ABGs (1h after every change, then 4h until stable) IPAP increased by 2-5cm increments until acidosis resolves