Respiratory Flashcards
Restrictive lung disease
- FEV1, FVC and ratio
- examples
FEV1 and FVC reduced (<80%)
Ratio is normal or increased (>0.7)
Examples:
- Pulmonary disease e.g. pulmonary fibrosis, interstitial pneumonitis, sarcoid, pul oedema
- Connective tissue disorders
- Neuromuculsar diseorders
- Skeletal
- Obesity
Obstructive lung disease
- FEV1, FVC and ratio
- examples
FEV1 reduced more than FVC (<80%)
Ratio is reduced (<0.7)
Examples:
- Asthma
- COPD
- Bronchiectasis
- CF
Pneumonia
- Cause
- CURB-65
- Investigations
- Management
- HAP criteria
Cause - strep pneumoniae (most common), then haemophilia influenzae and then mycoplasma influenza
CURB-65
Confusion
Urea>7
RR >30
BP <90sys <60dias
>65 years
0-1: mild, consider home
2: inpatient
>3: high mortality so consider ITU
Point of care CRP:
- CRP < 20 mg/L - do not routinely offer antibiotic therapy
- CRP 20 - 100 mg/L - consider a delayed antibiotic prescription
- CRP > 100 mg/L - offer antibiotic therapy
Investigation:
ABG
CXR
Bloods
Sputum
Atypical screen for legionella
CT, chest CTPA
Broncheolar lavage if patient immunocomp/ITU
HIV test
Mx - O2, ABX, IV fluids, physio, follow up CXR @ 6 weeks
HAP: >48h after admission
Repeat chest XR 6 weeks after resolution
Bronchiectasis
- symptoms
- investigations
- Mx
Sx
Shortness of breath
Chronic productive cough
Recurrent chest infections
Weight loss
Investigations
- CXR
- bloods : Igs, aspergillum specific IgE
- sputum
- CXR
- high res CT: signet ring sign (see pic)
Mx:
- ABX
- prophylactic abx if >3 exacerbations
- mucolytics e.g. carbocysteine
- bronchodilators e.g. salbutamol
- corticosteroids
- chest physio
Cystic fibrosis
- prevalence
- gene defect
- clinical features
- diagnosis
- complication
1 in 2000 births
CFTR gene defect
Sx
resp - bronchiectasis, pneumonias, pneumothorax
GI - pancreatic insufficiency, distal intestinal obstruction, gallstones, focal biliary cirrhosis
other - male infertility, osteoporosis, nasal polyps, arthritis, vasculitis
Diagnosis
- sweat test >60mmol/L on 2 occasions
- CFTR gene mutation
- trypsinogen test for newborns
Long-term
- pancreatic enzymes e.g. CREON
- mycolytics
- CFTR potentiators e.g. ivacaftor
- lung transplant
Complication
- pneumothorax
Fungal respiratory lung infections
- risk factors
- investigations
- management
Risks - immunocomp, CF, existing lung cavities (previous TB), advanced lung disease
Investigations - FBC, blood cultures, sputum, serum assays (aspergillum antigen)
Mx - antifungals (e.g. voriconazole, amphotericin B, caspofungin) or surgical excision for solitary lesions
Lung cancer
- small cell lung cancer (NSCLC)
- non-small cell lung cancer (NSCLC)
- complications
SCLC: 20% of cancers
- associated with Cushings and Lambert-Eaton syndrome
- poor prog because of metastasis
- sensitive to chemo
NSCLC: 80%
- squamous cell - PTH secretion (hypercalcaemia)
- adenocarcinoma - common in non-smokers
- large cell - poor differentiation
- carcinoid - good prognosis
- Mx: radio, chemo and surgery
Local: SVC obstruction, bronchial obstruction, pleural effusion, recurrent laryngeal palsy, phrenic nerve palsy, Horner
- metastatic: cerebral, bone liver, adrenal
Asthma
- investigations
- management
Investigations
FeNO:
- >=40ppb in adults is +ve
- >= 35ppb in children is +ve
Spirometry: FEV1/FVC <70%
Reversibility:
- in adults, a positive test is indicated by an improvement in FEV1 of 12% or more and increase in volume of 200 ml or more
- in children, a positive test is indicated by an improvement in FEV1 of 12% or more
NICE management
Step 1: beta-2-agonist (salbutamol) for short-term
Step 2: inhaled steroid (beclometasone)
Step 3: add LTRA such as montelukast or a long-acting beta-2 agonist such as formoterol
Step 4: add inhaled corticosteroid dose and consider adding 4th drug such as theophylline or monoclonal antiBs
COPD
- CXR
- Mx
- Complication
CXR
- hyperinflation (>6 anterior ribs above diaphragm)
- flattened hemidiaphragms
- decreased peripheral vascular markings
- bullae
Management
Mild: inhaled long-acting antimuscurinic (tiotropium) or beta-2-agonist (salmeterol)
Moderate: add short-acting bronchodilator (e.g. salbutamol)
Severe: add inhaled corticosteroid (e.g. symbiocort
Complication
COPD can cause a retention of CO2 called HYPERCAPNIA this presents with signs such as reduced GCS, asterixis, palmar erythema and a bounding pulse.
Pleural effusion
- transudate examples
- exudate examples
- investigations
- mx
Transudates (protein <25g/L) - cardiac failure, fluid overload, hepatic failure, nephrotic syndrome, hypothyroidism
Exudates (protein >35g/L) - TB, malignancy, PE, pul infarction, RA, SLE, pancreatitis
(things that you catch!!!)
Investigations:
- Bloods & cultures
- USS for aspiration
- CT chest
- Pleural - aspirate pH low is exudative, high is transdative. glucose low in infection/malignancy and amylase can show oesophageal rupture.
Management:
- drainage
- broad spec ABX
- diuresis if HF
- pleurodesis for recurrent effusions.
Sarcoidosis
- clinical features
- investigations
Clinical features
- Pulmonary: chest pain, cough, dyspnea, bilateral hilar lymphadenopathy and fibrosis
- Extra-pulmonary: skin changes, arthralgia, eye involvement (uveitis, glaucoma), cranial nerve palsy, hepato/splenomegaly, hypercalcaemia, hypercacuria, renal calculi, arrhythmia and cardiomyopathy
Investigation:
- Bloods
- serum ACE (non-specific marker)
- urine for calciuria
- LFTs: restrictive
- CXR: bilateral hilar lymphadenopathy
- high res CT
- tissue biopsy is GOLD STANDARD*
Interstitial lung disease
- causes
- investigation
- Mx
Upper zone: CHARTS
* Coal workers’ pneumoconiosis
* Histiocytosis
* Ankylosing spondylitis/Allergic bronchopulmonary aspergillosis
* Radiation
* Tuberculosis
* Silicosis (progressive massive fibrosis), sarcoidosis
Investigation:
high res CT - honeycomb
- Spiro shows restrictive
- autoantibody
Mx: steroids (pred), chest physio, O2
Pneumoconiosis (abestos)
- malignancy associated
- CXR
- Mx
- sillicosis
mesothelioma associated
CXR:
- reticular shadowing
- pleural plaques/thickening
- pleural effusions
- presence of broncocarcinoma
Mx: smoking cessation, bronchodilators (salbutamol), oxygen
Silicosis typical Hx: mining occupation, upper zone fibrosis, egg-shell calcification of hilar nodes
OSA
- Mx
CPAP
Mesothelioma
- Sx
- Investigations
- Mx
Sx
Dyspnoea, weight loss, chest wall pain
Clubbing
30% present as painless pleural effusion
Only 20% have pre-existing asbestosis
Investigations
- Pleural CT
- Pleural biopsy
Management
Symptomatic
Industrial compensation
Chemotherapy, Surgery if operable
Prognosis poor, median survival 12 months
Asthma severity scale
Pleural effusion
Diagnosis:
- PA CXR performed in all patients
- USS recommended for pleural aspirate
Pleural aspirate:
- 21G needle & 50ml syringe
- fluid should be sent for pH, protein, lactate dehydrogenase (LDH), cytology and microbiology
Lights crtieria
- exudates protein >30g/L
- transudates protein <30g/L
- Exudate if pleural fluid protein/serum protein >0.5
- Exudate if pleural fluid LDH/serum LDH >0.6
- pleural fluid LDH more than two-thirds the upper limits of normal serum LDH
COPD severity
