respiratory Flashcards
asbestosis
what is the type of disease, what is its pattern, which area is most affected
ILD - lower lobe fibrosis
restrictive pattern
Pleura are most affected
CXR findings in asbestosis
bilateral lower lobe fibrosis
HRCT findings in asbestosis
pleural thickening
pleural plaques
symptoms of asbestosis
progressive exertion dyspnea
dyr cough –> productive cough
digital clubbing
FLWAS + haemoptysis
ABG findings in asbestosis
type 1 resp failure
management of asbestosis
no cure
oxygen therapy
immunisation: influenza, pneumococcal pneumonia
what is a mesothelioma
malignant tumour of the mesothelial cells of the lung pleura, complication of asbestosis
symptoms of mesothelioma
chronic dry cough
chest pain
SOB
weight loss
clubbing
CXR findings of mesothelioma
pleural thickening
pleural plaques
pleaural mass
pleural effusion
Ix for mesothelioma
pleural tap
thoracoscopy + histology
diagnostic Ix for mesothelioma
thoracoscopy + histology
average incubation days of covid
5 days
Ix for covid
RT-PCR from nasopharyngeal swab
pulse oximetry
CXR of suspect pneumonia
3 important parts of management for severe covid
VTE propylaxis (LMWH, compression stockings)
O2 therapy
mechanical ventilation
is acute bronchitis usually viral or bacterial
viral
which type of infection does acute bronchitis usually follow
it is a LRTI which follows a URTI
describe the cough in acute bronchitis
productive - CLEAR sputum
describe CXR in acute bronchitis
no radiological changes
describe change in pulmonary function test over time in acute bronchitis vs asthma
improves over time in acute bronchitis
dissent in asthma
Tx for acute bronchitis
if high CRP or pre existing conditions
- oral doxycycline
(or amoxicillin in pregnant women/children)
is influenza a URTI or LRTI
both
is tonsillitis a URTI or LRTI
URTI
which test can diagnose influenza
RT-PCR
which medication can be given if the influenza is more severe and requires more than just supportive therapy
neuraminidase inhibitors:
- oseltamivir (tamiflu)
- ranamivir
which medication can be given if the influenza progresses to become bacterial pneumonia
ceftriaxone (broad spectrum abx)
what type of hypersensitivity reaction causes extrinsic allergic alveolitis aka hypersensitivity pneumonitis
type 3 hypersensitivity
a pt develops a chronic dry cough, digital clubbing and worsening dysnpnea. they own a bird farm so have lots of exposure to bird droppings. what is the likely diagnosis
hypersensitivity pneumonitis
aka extrinsic allergic alveolitis
typical pt population for idiopathic pulmonary fibrosis
men
50-70 years
causes of ILD/pulmonary fibrosis causing UPPER zone fibrosis
CHARTS
Coal workers pneumonitis
histiocytosis / hypersensitivity pneumonitis
ankylosing spondylitis
radiation
TB
sarcoidosis / silicosis
causes of ILD/pulmonary fibrosis causing LOWER zone fibrosis
DIAL
Drugs (amiodarone, bleomycin, methotrexate, nitrafuratonin)
Idiopathic pulmonary fibrosis
asbestosis
lupus (most connective tissue disorders cause lower zone fibrosis except ankylosing spondylitis - upper zone fibrosis)
symptoms of ILD/Pulmonary fibrosis
chronic dry cough
progressively worsening dyspnea (exertion –> at rest)
digital clubbing
bilateral inspiratory crackles
what do you hear on auscultation in ILD/Pulmonary fibrosis
bilateral inspiratory crackles
disease pattern in ILD/Pulmonary fibrosis
restrictive (v reduced FVC, FEV1/FVC is increased, >0.7)
TLCO change in ILD/Pulmonary fibrosis
reduced
CT scan findings in ILD/Pulmonary fibrosis
honeycombing, ground glass appearance
CXR findings in IPF
Bilateral lower zone reticulonodular shadowing
which antifibrotic agent can be used to slow disease progression in IPF
pirfenidone
only definitive treatment for end stage ILD
lung transplant
which gene is mutated in cystic fibrosis and what does this cause
CTFR mutation
causes defective Cl- channels
this causes increased viscosity of mucus
how is Cystic fibrosis diagnosed
sweat test - will have high sweat chloride
Mx for Cystic fibrosis bronchiectasis
chest physiotherapy
what disease pattern is bronchiectasis
obstructive
what is the likely diagnosis if a person has chronic cough, recurrent chest infections, inspiratory coarse crackles, dextrocardia an recurrent sinusitis
Kartagener’s syndrome (primary ciliary dyskinesia) causing bronchiectasis
what is the likely diagnosis if a person has chronic cough, recurrent chest infections, inspiratory coarse crackles in response to contact with mould
allergic bronchopulmonary aspergillosis causing bronchiectasis
Tx for allergic bronchopulmonary aspergillosis causing bronchiectasis
oral prednisolone
likely diagnosis: chronic cough with large amounts of rusty/green sputum - made worse by lying flat
recurrent chest infections
clubbing
SOB on exertion
fever
weight loss, fatigue
wheezing
bronchiectasis
what is the FEV1/FVC ratio for OBSTRUCTIVE pattern
< 0.7
most common infective agent found in sputum MCS of a non-CF bronchiectasis pt and a CF bronchiectasis pt
non CF: haemophilus influenza
CF: pseudomonas aeruginosa
gold standard diagnostic test for bronchiectasis
HRCT
which medicine can be used to clear the airway in bronchiectasis
mucoactive agents: eg nebulised hypertonic saline
indications for lobectomy in brochiectasis
uncontrollable haemoptysis
localised disease
what is bronchiectasis
permanent and irreversible dilated of the bronchi
what is seen on CXR in bronchiectasis
thin walled ring shadows (cysts), some with fluid levels
tram lines (depicts the thickened bronchi)
tubular / ovoid opacities (depicts the thickened bronchi)
obscured hemidiaphragm
what is seen on HRCT in brocnhiectasis
cysts / tree in bud pattern
signet ring sign - bronchus is wider in diameter than pulmonary artery next to it
tram track sign
what changes are seen on a CXR in silicosis of stonesmen/pottery workers/ceramic workers
egg shell calcification of hilar lymph nodes
what does black sputum indicate
coal workers pneumoconiosis
which type of lung cancer causes clubbing
NSCLC esp squamous cell carcinoma –> secrets a PTHrP which cases hypercalcaemia, clubbing, cavitating lesions, hyperthyroidism
what are the types of lung cancer
NSCLC
- Adenocarcinoma
- squamous cell carcinoma
SCLC
Pancoast tumour
most common type of lung cancer
adenocarcinoma
which type of lung cancer is most common in non smokers
adenocarcinoma
which type of lung cancer is most common in smokers
squamous cell carninoma
SCLC
pancoast tumour
which paraneoplastic syndrome can adenocarcinoma of lung cause
gynaecomastia
which paraneoplastic syndrome can squamous cell carcinoma of lung cause
the tumour secrets a PTHrP
this causes hypercalcaemia, clubbing, cavitating lesions, hyperthyroidism
which paraneoplastic syndrome can SCLC cause
SIADH
Cushings
Lambert Eaton syndrome
SVCO
how does muscle weakness in Lambert Eaton syndrome compare to myasthenia gravis
it improves with exercise in Lambert Eaton syndrome
describe Lambert Eaton syndrome symptoms
waddling gait, difficulty walking, muscle tenderness, hyporeflexia
improves on exercise
which type of lung cancer causes hyponatraemia
SCLC
what does raised ALP indicate in lung cancer
bony mets
1st line Ix for lung cancer
CXR
Ix to look for mets and lymph node involvement in lung cancer
PET-CT
diagnostic Ix that’s also used for staging for lung cancer
bronchoscopy with biopsy
which conditions cause Horners syndrome
pancoast tumour
carotid artery dissection (causes partial horners syndrome - no anhidrosis)
stroke
main 3 symptoms of Horners syndrome
ipsilateral miosis
ptosis
anhidrosis
which lung cancer can cause hoarseness of voice and why
pancoast tumour
recurrent laryngeal nerve damage/paralysis
which lung cancer causes SVCO
tumour in right lung apex (SCLC or pancoast tumour)
symptoms/signs of SVCO
dyspnea
face/neck/arm swelling
raised JVP
headaches worse in morning
visual disturbances
which test shows SVCO
pembertons test
immediate treatment needed for SVCO
oral dexamethasone
does SCLC or NSCLC have worse prognosis
SCLC
NSCLC first line Tx
lobectomy
- can use curative radiotherapy for stages 1,2,3
Tx for advanced NSCLC
EGFR inhibitors
ALK tyrosine kinase inhibitors
Tx for SCLC
palliative chemo
what is a pneumothorax without underlying disease called
primary spontaneous
what is a pneumothorax as a complication of an underlying disease called
secondary spontaneous
how can tension pneumothorax cause hypotension
in a tension pneumothorax it is a one way valve - air can enter pleural space but can’t leave it
this causes tracheal shifts and presses on heart
this causes cardiac outflow obstruction - hypotension
what is sudden deterioration following intubation a sign of
tension pneumothorax
pneumothorax breath sounds
reduced
pneumothorax percussion resonance
hyper resonant
pneumothorax fremitus
decreased
fist line Ix for pneumothorax
CXR
- erect PA on inspiration
first line Ix for pneumothorax in to who can’t sit up
chest ultrasound
pneumothorax CXR findings
clear rim between lung margin and chest wall
no lung markings visible between lung margin and chest wall
area for aspiration in pneumothorax
2nd ICS
area for chest drain in pneumothorax
between anterior border of latissimus dorsi and lateral border of pec major
at 4/5th ICS at mid- or anterior- axillary line
Tx for tension pneumothorax
large bore cannula
into 2nd ICS at MCL
Tx for primary pneumothorax w/o SOB and <2cm
discharge and follow up in 2/4 weeks
Tx for primary pneumothorax w/o SOB and >2cm
aspirate, if doesn’t work chest drain
Tx for secondary pneumothorax w/o SOB and 1-2cm
aspirate
Tx for secondary pneumothorax w/o SOB and <1cm
oxygen therapy and admit
Tx for secondary pneumothorax w/o SOB and >2cm or secondary pneumothorax with SOB
chest drain
which condition is most lily to cause bilateral hilar lymphadenopathy on chest X-ray
sarcoidosis
most common site of lung cancer metastasis
brain
most common causes of inspiratory bibasal lung crackles
pneumonia
pulmonary oedema
bronchitis
pulmonary fibrosis
likely diagnosis in a pt with lung cancer and worsening headaches, double vision and ataxic gait
raised ICP due to brain metastases
best scan for brain mets
contrast enhanced CT of the brain
which conditions can contrast used in a contrast enhanced CT worsen
the contrast is nephrotoxic - don’t use in pts with kidney issues
which condition are voltage gated calcium channel (VGCC) antibodies present in
Lambert eaton myasthenic syndrome
what sweat chloride level is diagnostic for CF
> 60 mmol/L
which lung cancers cause cavitating lesions
squamous cell carcinomas
what does central cavitation with air fluid level on CXR indicate
lung abcess
what does a target shaped lesion in the upper lobe on CXR indicate
aspergilloma
what is right sided heart failure in response to pulmonary HTN called
cor pulmonale
if you have a suspicion that a chest drain may be blocked what should you do
check the drain to see if the fluid is shining - ie moving up and down the tube on inspiration and expiration
what is a polyphonic wheeze on auscultation associated with
exacerbation asthma
what is bronchial breathing associated with
infection+ consolidation
- pneumonia
- bronchitis
what is stoney dull percussion at base associated with
pleural effusion
pt has pulmonary fibrosis and has recently had many UTIs. which drug has caused the fibrosis
nitrafurotonin - used to treat UTIs
causes of fibrosis in lung apices
ARTS
- Ankylosing spondylitis
- Radiation
- TB
- Sarcoidosis
classic cause of fine inspiratory crackles vs coarse inspiratory crackles
fine (basal) = fibrosis
coarse = consolidation / pneumonia
what does honeycombing on CT indicate
fibrosis
what do signet rings on CT indicate
bronchiectasis
what do diffuse ground glass opacities on CT indicate
PCP (pneumocytis penumonia)
what is the typical build of a person susceptible to a spontaneous pneumothorax
tall and slender body
in which conditions is a hyper inflated chest seen
asthma
copd
what does unilateral pitting oedema in calf suggest
DVT –> pulmonary embolism
likely diagnosis: foul smelling sputum, fever, history of stroke, finger clubbing
lung abscess
–> history of stroke: impaired swallowing
–> aspiration
what does hepatomegaly suggest in context of heart
right sided heart failure / cor pulmonale (due to blood congestion in liver)
what does reduced DLCO suggest
reduced diffusion across thinned fibrotic alveoli –> fibrosis
Tx for community acquired pneumonia with CURB score of 0/1
oral amoxicillin
Tx for exacerbation of COPD
salbutamol nebulised through air
initial Tx step for acute pulmonary oedema
IV furosemide
In what condition is a polyphonic wheeze heard
asthma
causes of bibasal crackles
fluid / mucus / infection in lungs
- pneumonia
- bronchitis
- pleural effusion
- heart failure (causes fluid to pool in lungs)
- pulmonary fibrosis
- bronchiectasis
main differentials for reduced FEV1/FVC ratio
asthma
copd
bronchiectasis
FEV1/FVC in restrictive lung disease
normal (as both FEV1 and FVC are reduced)
what is a pulmonary hamartoma
benign mass in lung
how does pneumothorax affect V/Q ratio
reduced V/Q
Tx for lung abscess
IV abx
FEV1/FVC in bronchiectasis
reduced, as its an obstructive disease pattern
what is a pyopneumothorax
a pleural collection of pus and air - has a visible fluid level on CXR
what is a pneumatocele
structure in lung which contains single or multiple air filled cysts
main cause of pneumatocele
complication of acute pneumonia caused by staph A
what is an empyema
pus collection - pleural empyema can be a complication of pneumonia
pleural empyema on cxr
lateral
makes an obtuse angle with the chest wall (so goes downwards along chest wall - not sideways into the lung)
does horners syndrome cause ipsilateral or contralateral ptosis / miosis
ipsilateral - the sympathetic chain on that side is being compressed by the tumour
a pt with lung cancer presents with abdominal pain and constipation. what type of lung cancer do they have
squamous cell carcinoma - the abdo pain and constipation is due to hypercalcaemia - PTHrP secretion)
diagnosis: pt has rheumatoid arthritis and productive cough of green sputum with red specks
bronchiectasis - rheumatoid arthritis can cause bronchiectasis
most likely diagnosis of fever, cough, pleuritic chest pain
lung abscess
in which pts is pseudomonas aeruginosa most likely to cause lung infections
cystic fibrosis pts
klebsiella pneumonia is highly associated with lung abscesses in which pts
alcoholic pts
what is the inheritance pattern of cystic fibrosis
autosomal recessive
for what is DNase given to CF pts
to break down mucus
for what is creon given to CF pts
for pancreatic exocrine insufficiency - causes steatorrhea
creon is aka pancrelipase
does copd present with clubbing
no
what does pleura rub sound indicate
pleurisy
which parts of the lungs are most affected in TB
upper lobes
TB medication
Rifampicin, Isoniazid, Pyrazinamide, Ethambutol (RIPE) for 2 months
followed by isoniazid + rifampicin (aka Rifinah 300) for 4 months
most common cause of bilateral hilarity lymphadenopathy
sarcoidosis
skin manifestation of sarcoidosis
erythema nodosum - raised painful red shin rash
management for pneumothorax > 2cm
chest drain
what does a monophonic wheeze indicate, in terms of obstruction
indicates that one airway is being obstructed rather than multiple
initial managment for pt with hypercalcaemia due to lung cancer
Iv NaCl fluids
then give IV bisphosphonate
which bacteria are most commonly associated with lung abscess
anaerobic bacteria
what is bronchiolitis obliterans
causes inflammation in the small airways causing them to become scarred, resulting in permanent narrowing.
which crackles are heard on auscultation in bronchiectasis
coarse
likely diagnosis: wheezing/SOB (asthma), diarrhoea, facial flushing
carcinoid syndrome
first line investigation for carcinoid syndrome
urinary 5-HIAA excretion
how can having breast cancer in the past increase the risk of developing lung cancer
the radiotherapy used to treat breast cancer increases the risk for further lung cancer
where is aspiration done for pneumothorax
5th intercostal space mid-axillary line
what are the target groups for pneumococcal vaccine
over 65s
pts with chronic lung conditions eg COPD
initial step total if pt is asymptomatic but has reduced air entry and is hyper resonant on one side
urgent chest xray
contrast the inflammation in sarcoidosis vs tb
sarcoidosis = non caseating granulomas
TB = caseating granulomas / cavitating lesions
in which pt population is sarcoidosis most prevalent
African American women
skin manifestations of sarcoidosis
lupus pernio
maculopapular rash
erythema nodosum
sarcoidosis symptoms/signs
wheeze
dry cough
SOB
arthralgia
anterior uveitis
lupus pernio
maculopapular rash
erythema nodosum
MSK manifestation of sarcoidosis
arthralgia
first line Ix for sarcoidosis and what does it show
CXR
bi-hilar lymphadenopathy
gold standard diagnostic Ix for sarcoidosis
bronchoscopy + biopsy
non caseating granulomas
stages 1-4 on CXR for sarcoidosis
1 - bi-hilar lymphadenopathy
2 - bi-hilar lymphadenopathy + pulmonary infiltrates
3 - only pulmonary infiltrates
4 - pulmonary fibrosis with distortion
what does spirometer show for sarcoidosis
restrictive
2 significant lab findings in sarcoidosis
high CD4/CD8 ratio in bronchoalveolar lavage
high ACE levels in serum
1st line Tx for sarcoidosis
corticosteroids : prednisolone, hydrocortisone
what are chloroquine, hydroxychloroquine
anti malarial drugs
what to give for sarcoidosis symptomatic relief
NSAIDs
severe disease last resort Tx for sarcoidosis
lung transplant
if a sarcoidosis pt can’t have corticosteroids what do you give
immunosuppression - methotrexate, azathioprine
in which pt population is TB most prevalent
immunosuppressed
born in india / Bangladesh / sub-saharan africa
previous TB exposure
silicosis
what would a biopsy for TB show
caseating granulomas
langhans giant cells
epithelioid macrophages
acid fast mycobacterium tuberculosis
which part of the lungs does TB usually affect
upper lobes
contrast primary and secondary TB
primary: when a non-immune pt is exposed to TB - normal non-immunocompromised ppl would usually recover
usually asymptomatic
secondary: if the pt becomes immmunocompromised, the initial infection can become reactivated
TB symptoms
productive cough - doesn’t heal w abx
haemoptysis
weight loss
fever
night sweats
malaise
SOB
anorexia
pleuritic chest pain
cervical and hilar lymphadenopathy
describe a TB cough
productive
haemoptysis
doesn’t heal w abx
contrast TB and sarcoidosis cough
TB - productive, haemoptysis
sarcoidosis - non productive, chronic dry cough
MSK manifestation of TB
Potts disease - spread of TB to the bones
first line Ix for TB and what does it show
CXR
bi-hilar lymphadenopathy
caseating granulomas / cavitating lesions esp in the upper lobes
gold Standard diagnotsic Ix for TB
sputum culture - Ziehl Nielsen test: positive for acid fast bacillus (AFB)
screening test for latent TB given to contacts of an infected person
Mantoux test
latent TB Tx
Rifampicin and Isoniazid
active TB Tx
RIPE
Rifampicin + Isoniazid + pyrazinamide + ethambutol
for 2 months
then
Rifampicin + Isoniazid
for 4 months
Rifampicin side effects
red/orange secretions
Isoniazid side effects
drug induced lupus
peripheral neuropathy - give vit B6 (pyridoxine) to prevent
Pyrazinamide side effects
gout (hyperuriceamia)
ethambutol side effects
optic neuritis
avoid in CKD
what is virchows triad
vessel wall damage
venous stasis
hypercoagluation
signs and symptoms of PE
tachypnoea - MOST COMMON SIGN
sudden onset one sided pleuritic chest pain
dyspnoea
tachycardia
DVT - unilateral leg swelling
cough / hameptysis / fever
which criteria is used to determine investigations for PE
wells criteria
Ix if wells criteria > 4
CTPA (CT pulmonary angiography)
if positive - confirms diagnosis
if negative - look further down for leg swelling / DVT
Ix if wells criteria <= 4
D-dimer
if positive - do CTPA
if negative - look for other diagnoses
what scan do to instead of CTPA for PE if pt is haemodynamically unstable
echocardiography
what scan do to instead of CTPA for PE if pt is renal impaired / contrast allergy / pregnant
V/Q scan
what does an ECG show in PE
sinus tachycardia
right heart strain
S1Q3T3 (S waves in lead 1, q waves in lead 3, inverted t waves in lead 3)
Tx for haemodynamically stable PE pts
DOAC (apixaban or rivaroxaban)
- unprovoked (idiopathic) PE: for 6 months
- provoked PE: for 3 months
if can’t take DOAC, give heparin
Tx for haemodynamically unstable PE pts (systolic <90)
thrombolysis - alteplase
what counts as pulmonary hypertension
mean pulmonary arterial pressure >= 25 mmHg
between 20 and 25 is still considered abnormal, but 25 is definitely pulmonary htn
what is cor pulmonale
right sided heart failure secondary to long standing pulmonary disease resulting in pulmonary arterial hypertension
signs and symptoms (including heart sounds/murmurs) for pulmonary hypertension
dyspnoea
RHF signs: raised JVP, peripheral oedema, hepatomegaly
parasternal heave: RVH
loud P2
pan systolic murmur (tricuspid regurgitation) ad early diastolic murmur (pulmonary regurgitation)
first line Ix for pulmonary HTN
transthoracic echocardiogram
gold standard diagnostic Ix for pulmonary HTN
right heart catheterisation - shows => 25 mmHg
between 20 and 25 is still considered abnormal, but 25 is definitely pulmonary htn
ECG finings in pulmonary HTN
RVH - tall S waves in V1
right axis deviation
p pulmonale - peaked p waves in lead 2
first line Tx for pulmonary htn that is idiopathic or no signs of RHF
CCB’s (act as pulmonary vasodilators)
2 main cardiac complications of pulmonary htn
cor pulmonale
SVT
define type 1 resp failure
hypoxaemia
PaO2 < 8kpa
define type 2 resp failure
hypercapnia
PaCO2 > 6kpa
what type of resp is due to neurological condition causing respiratory muscle weakness
type 2
what type of resp failure is due to copd exacerbation
type 2
type 1 resp failure symptoms
tachypnoea
dyspnea
cyanosis
pleuritic chest pain
type 2 resp failure symptoms
hypoventilation
headache
anxiety
papilloedema
asterixis
drowsiness
confusion
unusual jerking or shaking
first line in management of resp failure
check for airway obstruction and clear it (head tilt, chin lift, jaw thrust)
which mechanical ventilation is used for type 1 resp failure
CPAP
which mechanical ventilation is used for type 2 resp failure
BiPAP
when is invasive mechanical ventilation used (endotracheal intubation)
pt is unconscious and supplemental o2 didnt work
which type of ventilation is useful in pulmonary oedema due to heart failure
CPAP
types of ventilation
non mechanical : o2 support, nasal cannula or face mask (doesn’t correct hypercapnia)
mechanical: invasive = endotracheal intubation
non invasive = CPAP, BiPAP
describe the inflammation in asthma
IgE mediated type 1 hypersensitivity –> mast cell degranulation, release of histamine –> bronchial hyper responsiveness, bronchial inflammation, endobrocnhial obstruction
clinical features of asthma including O/E on resp exam
persistent dry cough - worse at night, exercise, exposure to irritants
dynspoea
chest tightness
end expiratory wheeze
hyper resonance on percussion
prolonged expiratory phase on auscultation
how do NSAIDs affect asthma symptoms
worsen
Asthma: moderate vs severe vs life threatening acute attack
Moderate ⇒ peak flow 50-75%, normal speech, RR <25, pulse <110
Severe ⇒ peak flow 33-50%, can’t complete sentences, RR >25, pulse >110
Life Threatening ⇒ peak flow <33%, oxygen <92%, normal CO2, confusion, bradycardia
Near Fatal Asthma ⇒ raised CO2
primary diagnostic test for asthma and results
spirometry (FEV1/FVC < 0.7) - FEV1 is significantly reduced but FVC is same or slightly reduced
BUT THERE IS BRONCHODILATOR REVERSIBILITY: upon inhalation of SABA (salbutamol), FEV1 increases by 12% or more
–> OBSTRUCTIVE SPIROMETRY WITH BRONCHODILATOR REVERSIBILITY
what can you measure in asthma to show degree of eosinophilic inflammation
FeNO
what is measured in asthma to track progression
peak expiratory flow rate
CXR in asthma
hyper inflated lungs
inhaler advice
Remove cap and shake
Breathe out gently
Put mouthpiece in mouth and as you begin to breathe in, which should be slow and deep, press canister down and continue to inhale steadily and deeply
Hold breath for 10 seconds, or as long as is comfortable
For a second dose wait for approximately 30 seconds before repeating steps 1-4.
NICE lines of treatment for asthma
- SABA (Salbutamol)
- SABA + ICS (Beclomethasone or Budesonide) ⇒ if patient reports symptoms 3 or more times per week, or night-time waking either at initial diagnosis or review
- SABA + ICS + LTRA (Montelukast)
- SABA + ICS + LABA (Salmeterol)
- SABA + MART (ICS/LABA switched out for a MART, which includes a low dose ICS)
BTS guidlines do LABA then LTRA
what is a blue inhaler, when is it taken and what is that main side effect
salbutamol
reliever
take when needed
causes tremors
what is a brown inhaler, when is it taken and what is that main side effect
Beclomethasone
maintainer
taken in morning and night regardless of symptoms
causes oral candidiasis
acute asthma attack Tx
Oxygen (target sats 94-98%)
Salbutamol Nebulisers(+ipatropium bromdie)
Oral Prednisolone
(or IV Hydrocortisone if severe/if patient unable to swallow)- CONTINUE ICS ALONGSIDE THIS TX
consider
IV Magnesium Sulfate (only in asthma exacerbation, not COPD)
IF LIFE THRETENING AND DONT RESPOND TO STEROIDS, START VENTILATION - INTUBATION
NIV shouldn’t be used in acute asthma exacerbations. If needed, mechanical ventilation should be used.
define chronic bronchitis
chronic narrowing of the airways defined clinically as a productive cough on most days for at least 3 months per year for 2 consecutive years
define emphysema
defined histologically as permanent destructive enlargement of air spaces distal to the terminal bronchioles
what is asthma
reversible airflow obstruction
what is COPD
airflow obstruction with little or no reversibility
what is the usual cause of COPD in a young non smoker
alpha 1 antitrypsin deficiency
clinical features of COPD including O/E in resp exam
chronic productive cough - clear sputum
tachypnoea and dyspnea
pursed lips breathing
end expiratory wheeze
hyper resonance on percussion
reduced breath sounds
coarse crackles
Barrel Chest → anteroposterior diameter of chest is increased, suggests hyperinflation
what does it mean if sputum changes colour in COPD
exacerbation / infection
CXR findings in COPD
hyperinflated lungs (>6 anterior ribs seen above diaphragm),
bullae (lucency without a visible wall),
flat hemidiaphragm
spirometry findings in COPD
FEV1/FVC <0.7 (no bronchodilator reversibility, unlike asthma)
Significantly reduced FEV1, slightly reduced/normal FVC
COPD Severity (Based on FEV1)
○ Stage 1 (Mild) ⇒ >80%
○ Stage 2 (Moderate) ⇒ 50-79%
○ Stage 3 (Severe) ⇒ 30-49%
○ Stage 4 (Very Severe) ⇒ <30%
All = FEV1/FVC <0.7
first step of COPD management (non pharmacological)
smoking cessation
vaccinations - pneumococcal and influenza
pulmonary rehab
first line pharmacological management for COPD
bronchodilators: SABA (salbutamol) or SAMA (ipratropium bromide)
what is the most common organism which causes acute exacerbations of COPD
haemophilus influenza
what is the criteria for LTOT (long term oxygen therapy ) for COPD
pO2 <7.3kPa or 7.3-8.0kPa + secondary polycythaemia/peripheral oedema/pulmonary hypertension.
(Assessment is done by measuring arterial blood gases on 2 occasions at least 3 weeks apart).
what is the correlation between FeV1 and risk of COPD exacerbation
significant correlation between increased FEV1 and lower risk of COPD exacerbation
what is the risk with supplemental o2 given to COPD pts
reduces respiratory drive causing hypoventilation, leading to more CO2 retention
acute exacerbation of COPD: management
STEP 1: GIVE O2 IF THEY’RE HYPOXAEMIC
24% Oxygen (blue venturi mask)
STEP 2: GIVE BRONCHODILATORS
Nebulised Bronchodilators (salbutamol + ipratropium bromide nebulisers)
STEP 3: GIVE CORTICOSTEROIDS
Corticosteroids (oral prednisolone for 5 days or IV hydrocortisone)
STEP 4: GIEV ANTIBIOTICS
Antibiotics (only if evidence of infection such as green sputum - amoxicillin/doxycycline/clarithromycin)
NIV (BiPAP) If high CO2 and resp acidosis despite medical treatment
(IV Theophyllines may be given in conjungtion with meds)
what is given to COPD pts if they meet the criteria for recurrent exacerbations
prophylactic azithromycin (monitor QT interval)
contrast COPD and asthma
asthma
- dry cough
- end expiratory wheeze
- hyperinflated lungs
- reversible airflow obstruction
- FEV1 increases after salbutamol inhalation
- eosinophilic inflammation
- variability in obstruction eg at night, exercise, irritant exposure
COPD
- productive cough
- end expiratory wheeze
- hyperinflated lungs - but also bullae, flattened hemidiaphragm
- irreversible airflow obstruction
- FEV1 unchanged after salbutamol inhalation
- no eosinophilic inflammation
- no variability in obstruction
what criteria counts for COPD overlap syndrome
(asthmatic features / steroid responsiveness)
hx of asthma or atopy
eosinophilia
FEV1 variability (min. 400ml)
diurnal variation in peak flow (min. 20%)
lines of treatment for COPD without asthmatic features
SABA/SAMA
SABA + LABA + LAMA
SABA/SAMA + LABA + LAMA + ICS
lines of treatment for COPD with asthmatic features
SABA/SAMA
SABA/SAMA + LABA + ICS
SABA/SAMA + LABA + LAMA + ICS
what is salmeterol
LABA
what is tiotropium
LAMA
what is beclamethasone
ICS
what is salbutamol
SABA
what is ipratropium bromide
SAMA
3 features which distinguish COPD and ACOS (asthma copd overlap syndrome)
more of a response to bronchodilators
increased reversibility of airflow
eosinophilic inflammation
what is the likely diagnosis: acute resp failure, non cardiogenic pulmonary oedema, bilateral opacities/infiltrates on X-ray
ARDS (acute respiratory distress syndrome)
best form of management for ARDS
low tidal volume mechanical ventilation
what is a normal AMTS score
8 and above
what is coryza
Rhinitis, also known as coryza, is irritation and inflammation of the mucous membrane inside the nose. Common symptoms are a stuffy nose, runny nose, sneezing, and post-nasal drip.
what is KCO and whats is it used to measure
Carbon monoxide transfer coefficient
assesses the efficiency of alveolar transfer of carbon monoxide by measuring the pulmonary gas exchange across the alveolar–capillary membrane
is residual volume increased or decreased in COPD
increased
(Pts have hyperinflated lungs)
how is DLCO affected by emphysema
reduced
as there is less SA for diffusion due to the destruction the alveolar walls
pt has COPD and atopic dermatitis. what is next step in management after salbutamol
LABA
+ ICS
what is itraconazole
anti fungal - used for fungal pneumonia
likely diagnosis: pneumonia with a recurrent fever despite abx, with pleural fluid aspirate pH <7.2
empyema
empyema management
chest drain
and antibiotics
what does widespread bilateral crepitations with hypoxaemia indicate
ARDS (resp failure and pleural effusion)
can CPAP or BiPAP be used in ARDS
CPAP
what does consolidation on X-ray suggest
infection
what is the severity of an asthma attack if the pts CO2 is high
“Near Fatal” asthma attack
immediately take to ITU, endotracheal intubation
pt has COPD exacerbation nd low O2. After being given this their sats adjust but their ventilation work reduces, and CO2 goes up. what should you do
reduce the O2 being given to a fraction of the amount
deliver through a Venturi mask
first line PREVENTER therapy in asthma
ICS
what infections does E coli usually cause
UTIs
gram positive causative organism of aspiration pneumonia
strep pneumoniae
gram negative causative organism of aspiration pneumonia
bacteroides
klebsiella pneumoniae
which GCS indicates coma
8 or below
most likely diagnosis: pt has HIV and is desaturating (oxygen wise) with minimal exertion
PCP (pneumocystis pneumonia)
PCP diagnostic test
silver stain
which antibiotics can be given for infective exacerbation of COPD
amoxicillin
clarithromycin
doxycycline
which medication do you give to someone who is allergic to penicillin and is experiencing an infective exacerbation of their COPD
doxycycline
what investigation do you do if a pt comes in with what seems like a COPD exacerbation
ABG
ARDS diagnostic criteria
A: Acute respiratory failure, within 1 week of trigger (e.g. pneumonia)
- R: Really bad chest x-ray (bilateral opacities)
- D: Decreased PaO2
- S: Should not be CHF or fluid overload
list some symptoms of respiratory alkalosis
SOB
light headed
numbness
- resp alkalosis means low CO2 so they’re hypoventilating - need more oxygen therefore OSB, dizzy etc
if COPD pt has a high level of CO2 and low oxygen bt has a normal pH what method of oxygen delivery do you use
thus shows that they are chronic retainers of CO2 and that their ‘normal’ O2 level is lower.
for these people, hypoxia causes a respiratory drive, not hypercapnia.
so you need to be careful not to give them too much oxygen so you dont dampen the respiratory drive.
the Venturi mask is the best way to administer this as it allows you to change the amount
diagnostic test for COPD
spirometry - check for obstructive pattern and for reversibility - should be irreversible
which pneumonia causes a ring shaped rash (erythema multiform)
mycoplasma pneumoniae
what is GOLD criteria for COPD severity
GOLD A
0-1exacerbations per year + fewer symptoms
GOLD B
0-1 exacerbations per year + more symptoms
GOLD C
2 or more exacerbations per year + fewer symptoms
GOLD D
2 or more exacerbations per year + more symptoms
which GOLD criteria classifies for COPD pulmonary rehab
GOLD B or higher
what is the aim of pulmonary rehab for COPD
dealing with emotional aspect of diagnosis
improve quality of life
pt has asthma and is on SABA and ICS, what is next line of treatment according to BTS (British thoracic society)
LABA
mortality risk for pneumonia pt from score 0-5 in CURB 65
0 – 0.7%
1 – 3.2%
2 - 13%
3 - 17%
4 - 41.5%
5 - 57%
how should you obtain your reading for your peak flow diary (asthma)
take 3 readings and note down the highest of the 3
what position should the pt be in to take a peak flow reading
standing up, sitting upright
NOT lying down
what is seen on CXR for ARDS
bilateral pulmonary infiltrates
how does hyperventilation change pH
causes respiratory alkalosis
(hyperventilation –> hypocapnia –> resp alkalosis)
does pneumonia cause resp acidosis or alkalosis
respiratory acidosis
(causes CO2 retention due to impaired exchange of o2 and co2)
does COPD cause resp acidosis or alkalosis
respiratory acidosis
(causes CO2 retention)
COPD indications for lung reduction surgery
Patients with severe COPD who remain breathless despite maximal medical therapy should be considered for lung volume reduction surgery if:
they have upper lobe-predominant emphysema
FEV1 >20% predicted
paCO2 <7.3 kPa
TLCO >20% predicted
likely diagnosis for immunocompromised pt (eg with HIV, or just had transplant and taking immunosuppressants) and presents with fever, non productive cough and SOB on exertion
PCP
definitive diagnostic investigation for PCP
bronchoscopy with bronchoalveolar lavage
what investigation should be done 6 weeks after clinical resolution in pneumonia
chest xray
if a pt doesn’t fast before surgery what are they at risk of
aspiration pneumonia
how long before surgery must a pt fast from clear fluids, and from non clear fluids + food
clear fluids (fruit juice w/o pop, coffee, tea, milk, water
—> 2 hr before op
non clear liquids and foods
–> 6 hr before op
what should you do to the O2 when a pt is in type 2 resp failure
decrease O2
what ecg change can COPD cause
prominent P waves in inferior lead (lead 2)
–> (COPD causes pulmonary hTN which causes cor pulomonale which causes p pulmonate)
what is a chylothroax
fluid from your lymphatic system (chyle) leaks into the space around your lungs
type of pleural effusion
pneumonia pt begins to deteriorate with spiking temperatures for the last 24 hrs, what is most likely cause if deterioration and what is the DEFINITIVE investigation to reveal the cause
empyema
pleural aspirate
are LAMAs (eg tiotropium) used for copd or asthma
copd
what is tiotropium
LAMA
what is the likely cause of slightly higher O2 and lower CO2
hyperventilation - anxiety / panic attack
what is a blue boater
another word for chronic bronchitis copd pt
cyanosed
decreased ventilation so V/Q ratio is reduced
what is a pink puffer
another word for emphysema copd pt
short quick breaths
pink in the face
what is samter’s triad
3 conditions which commonly cluster together:
asthma
nasal polyps
aspirin sensitivity
which 2 allergic conditions do asthma pts usually have
allergic rhinitis (hay fever)
atopic dermatitis (eczema)
lung abscess symptoms vs empyema symptoms
lung abscess
- swinging fever
- cough
- foul purulent sputum
- haemoptysis
- pleuritic chest pain
empyema
- swinging fever
- pleuritic chest pain
- large pleural effusion on chest xray
pt reports breathlessness when exercising and is disturbing his sleep
his spirometry shows reversibility airway obstruction
what medication should he be started on
SABA + ICS
(if to reports symptoms 3 or more times per week or disturbs sleep give ICS)
pt has CAP with CURB65 score of 4
what is next steps of action
1) administer amoxicillin (or cefotaxime/ceftriaxone) + clarithromycin
2) discuss moving to ITU
pt has acute asthma exacerbation and is relieved by salbutamol in A&E. what should you give them as a prescription
prednisolone 40-50mg for 5+ days to reduce risk of relapse of the exacerbation
contrast coarse crackles and crepitations
crepitations aka fine crackles =short, high pitched
coarse crackles = longer, lower pitched
what is FiO2
an estimate of the oxygen content a person inhales
ARDS PO2 /FiO2 ratio
< 40
nasal congestion, adult onset asthma, peripheral neuropathy, glomerulonephritis
likely diagnosis?
Churg strauss syndrome aka eosinophilic granulomatosis with polyangiitis (EGPA).
antibodies found in churg Strauss syndrome
MPO-ANCA
P-ANCA
coughing, asthma, low fever, weight loss, splenomegaly, travel to Africa / Asia / South America
likely diagnosis?
filarial infection causing pulmonary eosinophilia
what is Reid index
ratio of gland layer to wall ratio of bronchus
which condition has reed index > 50%
chronic bronchitis
which condition has curschmann spirals on histology
asthma
which condition has psammoma bodies
Papillary thyroid cancer
which condition has intra alveolar exudate
lobar pneumonia
what is a likely cause of exertional desaturation in a HIV pt or IVDU
PCP
which medication can be used as a last line option in acute COPD exacerbation if the pt is not suitable for mechanical ventilation
Doxapram
which pneumonia comply affects the right middle and lower lobes
aspiration pneumonia
PCP xray
often normal
what is the criteria for discharge from hospital after acute asthma attack
stable on salbutamol INHALER for 24hrs
management of a symptomatic pleural effusion
thoracocentesis and therapeutic aspirations of the effusion
which condition is associated with lupus vulgaris (painless facial red/brown nodules)
TB
which condition is associated with lupus pernio (indurated purple facial lesions)
sarcoidosis
treatment for obstructive sleep apnoea
CPAP
treatment for obstructive sleep apnoea with coexisting rest failure
BiPAP
most likely cause barking cough in babies / young children
croup (usually caused by a parainfleunza virus)
management for mild croup - ie without resp distress (using external voluntary muscles to breathe)
reassure
give single dose of dexamethasone
send home
management for severe croup - with resp distress
oxygen
nebulised budesonide
what is elevated in pleural effusions caused by TB
pleural fluid adenosine deaminase (ADA)
which pleural effusions have LDH < 0.5 relative to serum LDH
transudative pleural effusions
which pleural effusions have low protein level
transudative pleural effusions
what are the glucose levels in pleural effusions due to rheumatoid arthritis
low
which syndrome links benign ovarian tumour, pleural effusion and ascites
Meigs syndrome
which lung is more affected in Meigs syndrome
right
how does pleural effusion affect vocal fremitus
causes reduced vocal fremitus
which scoring system is used to categorise daytime somnolence in relation to OSA
Epworth sleepiness scale
likely diagnosis: productive cough, pyrexia, reduced breath sounds, bronchial breathing, blunting of costophrenic angle
parapneumonic effusion
what is an exudative pleural effusion according to lights criteria
protein content > 35 g/L
ratio of plural fluid LDH to serum LDH >0.6
describe the pleural effusion’s caused by SLE
exudative
raised ANA
low complement
what are the most common causes of exudative pleural effusions
infection
malignancy
gold standard investigation for diagnosis of OSA
polysomnography
what is the investigation for pulmonary embolism for a pregnant woman
V/Q scan regardless of the wells score
- can have CTPA or D Dimer
what is the most likely ecg finding in a pulmonary embolism
sinus tachycardia
(S1Q3T3 is rare)
for which pts can conservative managment for sarcoidosis be considered instead of corticosteroids
stage 0 - normal xcr
stage 1 - bilateral hilar lymphadenopathy with no extra pulmonary features
initial treatment of pleural effusion due to heart failure
treat the cause –> give furosemide
what does a negative gran stain indicate
no bacteria found
contra indications to thrombolysis for pE
pts with orevious bleeding in CNS
recent trama / sirgery
bleeding disorder
which condition is swan neck deformity pathognomonic of
rheumatoid arthiritis
what is lofgrens syndrome and which condition does it relate to
triad of fever, erythema nodosum and bilateral hilarity lymphadenopathy
relates to sarcoidosis
pt presents with reduced breath sounds bilaterally, raised JVP, dullness to percussion, history of ischaemic heart disease
which investigation do you do
transthoracic echo
(usually for pleural effusion you do a pleural aspiration UNLESS there is clear evidence that the cause is HF, then you do echo)
what is the cause of a pleural effusion with multinucleate giant cells
rheumatoid arthiritis
gold standard investigation for sleep apnoea
polysomnography (a limited sleep study)
the diagnosis of OSA requires at least five episodes of apnoea or hypopnoea lasting a minimum of 10 seconds per hour of sleep
can do overnight pulse oximetry first, then polysomnography as the gold standard diagnostic test
likely diagnosis: recently resolved pneumonia new fever and a pleural effusion
empyema
first line quick investigation to do to confirm an empyema
pH
pH < 7.2 suggests empyema
empyema treatment/management
urgent drainage
IV abx
paroxysmal nocturnal dyspnoea vs OSA
paroxysmal nocturnal dyspnoea: patient wakes up gasping for air because lying supine worsens pulmonary oedema - would have background / other features consistent with HF
OSA: middle aged, overweight men, upper airway obstruction, morning headaches and daytime sleepiness
why does anti phospholipid syndrome increase risk of PE
it increases risk of venous thromboembolism
what is an absolute contraindication for thrombolysis for PE
history of a hemorrhagic stroke at any time
are antiplatelets such as aspirin contraindicated thrombolysis
no
what does auramine O test for
acid fast bacilli - like ziehl neelsen stain
what type of pleural effusion can hypothyroidism cause
transudate pleural effusion
how long can patients with active cancer take DOAC for PE
6 + months as its an ongoing risk faction
what medication can you give immediately for a post operative pt with PE
LMWH, then give DOAC or warfarin for 3 months
what to make sure you look for in a Ix question for PE
DO THEY HAVE KINDEY IMPAIRMENT or ARE THEY PREGNANT
–> Wells >4 : V/Q scan for both
–> Wells =<4: V/Q for pregnant, D dimer for renal impairment - check that???
what should you rule out in unilateral pleural effusion
malignancy
best medication for smoking cessation in a patient with psychiatric illness
NRT
