Respiratory Flashcards
what is COPD?
- chronic respiratory symptoms eg cough, SOB
- airflow obstruction
what is FEV1
forced expiratory volume in one second
what is FVC
forced vital capacity
what FEV1/FVC ratio show airflow obstruction
<0.7
what is bronchitis characterised by?
chronic cough
sputum production
(for at least 3 months in 2 consecutive years)
what are GOLD grades in COPD?
1 - mild - FEV1 >80%
2 - moderate - FEV1 50-80%
3 - severe - FEV1 30-50%
4 - very severe - FEV1 <30%
COPD risk factors
Smoking
Biomass fumes
Occupational exposures
Air pollution
Genetic factors
Aging population
symptoms of COPD
- SOB
- cough
- wheeze
- sputum
signs of COPD
- tachypnoea
- accessory muscle use
- hyperextended chest
- cyanosis
- cor pulmonal
- weight loss
differential diagnosis of COPD
Heart failure
Pulmonary embolus
Pneumonia
Lung cancer
Asthma
Bronchiectasis
what does xray show in COPD
hyperinflated lungs
what is MRC dyspnoea scale
1 SOB on vigorous exercise
2 SOB going up hills
3 Able to walk on flat at own pace
4 Exercise tolerance 100-200 meters on flat
5 Housebound/SOB on minor tasks or dressing
what is CAT assessment
asseses COPD severity
Qs like sleep, tight chest? etc..
prevention of COPD
- stopping smoking
- PPE
- air quality measures
management of COPD non pharmaceutical
- pulmonary rehab programme - exercise program
- smoking cessation/nicotine replacement therapy - most important factor
- vaccinations eg flu
- lung vol reduction surgery
medications for COPD
-Beta 2 agonists (SABA/LABA) (SABA - salbutamol)
- anticholinergics
- inhaled corticosteroids
what are inhaled corticosteroids not recommended?
- repeated pneumonia events
- blood eosiophils <100
- history of myobacterial infection
what is procalcitonin
inflammation marker
- more specific to bacterial infection that CRP
what is acute exacerbation of COPD
worening of symptoms beyond normal variation
- breathlessness, fever, sputum change
resp failure type 1 vs 2
1 - low paO2 normal/low Paco2
2 low paO2, HIGH paCo2
what causes a raised alveolar-arterial gradient
V/Q mismatch
diffusion limitation
Shunt
restrictive vs obstructive airflow
restrictive - low FVC, ratio normal - parenchyma/chest wall conditions
obstructive - FEV1 low, ratio <0.7 - airway conditions
causes of low/high TLCO
low - reduced lung vol
high - increased capillary blood flow - large lung vol - obesity/severe asthma - pulmonary haemorrhage
what is pneumothorax
collapse of the lung - air in pleural space - injury or hole in lung/pleura
common presentation of pneumothorax
tall, thin young man
sudden breathlessness and pleuritic chest pain
cause of pneumothorax
- spontaneous
- trauma
- iatrogenic - eg from biopsy
- infection
- asthma/copd
investigations for pheumothorax
erect chest xray - shows no lung markings
- measure by BTS guidelines
- ct thorax if too small to be seen on xray
management of high risk pneumothorax
chest drain
management options for lower risk pneumothorax
- conservative
- pleural vent ambulatory device
- needle aspiration, chest drain
where is a chest drain inserted
triangle of safety
- 5th intercostal space
- midaxillary line
- anterior axillary line
just above rib - avoids neurovascular bundle
complication of chest drain
air leaks around drain site
surgical emphysema (subacutaneous)
surgical options for pheumothorax
(if recurrent or chest drain fails)
- by Video-assisted thoracoscopic surgery (VATS)
abrasive or chemical pleurodesis
pleurectomy
what can tension pneumothorax lead to
cardiorespiratory arrest
signs of tension pneumothorax
Tracheal deviation away from the side of the pneumothorax
Reduced air entry on the affected side
Increased resonance to percussion on the affected side
Tachycardia
Hypotension
management of tension pneumothorax
Insert a large bore cannula into the second intercostal space in the midclavicular line - to relieve pressure
- follow with chest drain
what is ruptured in primary spontaneous pneumothorax
apical pleural bleb
symptoms of pneumothorax
breathlessness
pleuretic chest pain
cough
signs of pneumothorax
Tachyopnoea
Hypoxia
Unilateral chest wall expansion
Reduced breath sounds
Hyper-resonant percussion note
tension pneumothorax
valve-like mechanism
- +ve pleural pressure
- displaces mediastinum and cardiac compromise
what is pleural effusion
collection of fluid in pleural space
causes of transudate pleural effusion
- HF
- cirrhotic liver diease
- renal failure
- hypoalbuminemia
- myxoedema
- meig syndrome
causes of exudate pleural effusion
- pneumonia
- cancer
- TB
- autoimmune
- PE
- DRugs
exudate vs transudate
trans - pleural fluid protein <1/2 serum protein
ex - >1/2 serum protein
symptoms of pleural effusion
- asymptomatic
- breathlessness
- cough
- pain
- fever
signs of pleural effusion
Reduced chest wall
expansion
Quiet breath sounds
“Stony” Dull Percussion
Reduced tactile/ vocal
fremitus
Meditational shift away from affected side
chest xray pleural effusion
blunting of diaphragm
fluid in lung fissures
meniscus - larger effusion
tracheal/mediastinal deviation
lights criteria for exudative effusion
pleural fluid protein / serum protein greater than 0.5
Pleural fluid LDH / serum LDH greater than 0.6
Pleural fluid LDH greater than 2/3 of the normal upper limit of the serum LDH
triad for meigs syndrome
pleural effusion
benign ovarian tumour
ascites
pleural fluid analysis
protein count
LDH
pH
Glucose
microbiology
what is empyema
infected pleural effusion
- pus, low pH, low glucose, high LDH
- treated with chest drain and antibiotics
treatment of pleural effusion
conservative - small effusions resolve when treating underlying cause
- pleural aspiration - may recur
- chest drain
microbiology for TB
zeihl nelson stain - turn bright red against blue background
(resistant to acid staining) - acid-fast bacilli
disease course of TB
immediate clearance
primary activation
latent TB
secondary TB
extrapulmonary TB
areas other than lungs
eg lymph nodes, pleura, CNS, pericardium etc
abscess type in TB
COLD abscess in neck
- not red and painfull
BCG vaccine
- protects against M.tuberculosis - severe form and complicated but less against pulmonary TB
- Mantoux test prior
presenatation of TB
cough (haemoptysis)
lethargy
fever/night sweats
weight loss
lymphadenopathy
erythema nodosum (on shins)
spinal pain - potts disease
tests for immune response for TB
mantoux test (tuberculin intradermally shows bleb over 5mm)
interferon-gamma release assay
primary Tb on xray
patchy consolidation,
pleural effusions
hilar lymphadenopathy.
reactivated TB on xray
patchy or nodular consolidation with cavitation
disseminated miliary (uncontrolled) TB on xray
millet seeds
cultures for TB
- sputum - induction with nebulised hypertonic saline or bronchoscopy and bronchoalveolar lavage if not enough
- mycobacterium blood culture
- lymph node aspiration or biospy
then NAAT
treatment of latent TB
isoniazid (6months) or 3months with rifampicin
treatment for active TB
R – Rifampicin for 6 months
I – Isoniazid for 6 months
P – Pyrazinamide for 2 months
E – Ethambutol for 2 months
what is given to prevent peripheral neuropathy by isoniazid
pyridoxine
or vit B6
side effects of TB drugs
Numbness or unusual sensations in their feet implicates isoniazide (“I’m-so-numb-azid”). Difficulty recognising colours implicates ethambutol (“eye-thambutol”). Urine or tears that are orange or red implicates rifampicin (“red-I’m-pissin’”).
what are interstitial lung diseases
broad spectrum of conditions affecting lung interstitium - space between alveolus and capilaries
most common type of ILD
idiopathic pulmonary fibrosis
pathology of ILD
- inflammation and fibrosis
- extracellular matrix secreted
- interstitium becomes thicker
- increased diffusion distance - gas exchange compramised
primary causes of ILD
- Idiopathic pulmonary fibrosis
- Acute interstitial pneumonia
- desquamative interstitial pneumonia
secondary causes of ILD
- RA, SLE
- Drugs - amiodarone
- infective - mycoplasma pneumonia
- environmental - asbestosis
risk factors for ILD
- male
- smoking
- occupational - dust exposure etc
symptoms of ILD
- Progressive exertional dyspnoea
- dry cough
- connective tissue symptoms eg arthralgia, dysphagia, dry eyes
- malaise fatigue
(signs of connective tissue diseases eg Raynaud’s)
ILD lung function tests
restrictive - FVC reduced, FEV1 reduced
- may be normal
ILD xray
reticular opacities (thickening of interstitium)- lower/upper zone
investigations for ILD
- HRCT
- chest xray
- cpr/esr
- FBC - may show anaemia
- antibodies for autoimmune conditions
- bronchalveolar lavage or lung biopsy may be needed
causes of upper zone fibrosis ILD
Coal-worker pneumoconiosis
Histiocytosis-X
Ankylosing spondylitis
Radiation (e.g. for breast cancer)
Tuberculosis
Sarcoidosis and silicosis
causes of lower zone fibrosis ILD
Rheumatoid arthritis
Asbestosis
SLE, scleroderma and Sjogren’s syndrome
Idiopathic pulmonary fibrosis
Others (including drugs)
management of ILD
- smoking cessation
- vaccines - flue & pneumococcal
- antifibrotics for idiopathic pulmonary fibrosis - pirfenidone/nintedanib
- corticosteroids for RA etc
complications of ILD
- resp failure
- pulmonary hypertension
- anxiety/depression
- cushings syndrome from corticosteroids
lung carcinoma risk factors
- smoking
- occupation eg asbestos
- air pollution
- ionising radiation
- genetics
- chronic lung diseases
progression of lung cancer
- atypical adenomatous hyperplasia
- carcinoma in-situ
- invasive carcinoma
presentation of lung cancer
- persistant cough
- haeoptysis
- SOB
- weight loss, fatigue
- complications eg pleural effusion, pneumothorax
- asymptomatic
2 broad types of lung carcinoma
small cell
non-small cell
subtypes of lung cancer
adenocarcinoma
squamous cell carcinoma - (non)keratinising
small cell carcinoma - neuroendo
diagnosis of lung cancer
- CT/CT-PET
- biopsy
what tumour receptor means better response for immune modulator therapy
PD-L1 - non-small cell
pleural malignancy
- risk factor = asbestos
- pleural thickening, persistent pleural effusion
- proliferation of mesothelial cells
FISH diagnosis of mesothelioma
p16 homozygous deletion - support diagnosis but doesn’t exclude
histology of ipf
usual interstitial pneumonia
