Respiratory Flashcards
What is a common organism which causes pneumonia in bird owners?
chlamydia psittaci
cavitating pneumonia in the upper lobes, mainly in diabetics and alcoholics suggest what?
Klebsiella pneumoniae
Long term use of what can precipitate restrictive lung disease?
Nitrofurantoin
Which condition is immune deficiencies such as hypogammaglobulinemia associated with?
Bronchiectasis
What type of picture do you get on pulmonary function testing in asbestosis?
Restrictive - FEV1 goes down, FVC goes down A LOT therefore overall FEV1/FVC increases
What is the investigation of choice for occupational asthma?
Peak flows at work and home
What is the pathogen involved in Farmer’s lung?
Saccharopolyspora rectivirgula
Chlamydophila psittaci is associated with what?
Contact with birds
How should any critically ill patient be managed with oxygen?
15L high flow oxygen via non-rebreather as hypoxia kills before hypercapnia
What should you aim for in step down treatment of asthma?
reduction of 25-50% in the dose of inhaled corticosteroids
pulmonary fibrosis predominantly affecting the lower zones
Asbestosis
How would opiate overdose present on blood gas?
Respiratory acidosis
Redcurrant jelly sputum is found in what?
Klebsiella pneumonia
What is the COPD exacerbation treatment?
- Give O2 if <90%; Venturi 24% mask at 2-3l or nasal cannula flow rate 1-2l/min; Target oxygen sats 88-92%
- Nebulised bronochodilators: salbutamol (beta adrenergic agonist) or ipratropium (muscarinic antagonis)
- Steroid therapy: 30mg oral pred od for 5d or IV hydrocortisone
- Consider need for Abx: amoxicillin 500mg 3x d for 5d (or clarithromycin or doxy) or if at high risk of treatment failure then co-amoxiclav 500/125mg 3xd for 5d
- IV Theophylline if not responding to bronchodilators
- Non invasive ventilation e.g. BIPAP (if develop T2resp failure)
Why does hypotension occur in tension pneumothorax?
Cardiac outflow obstruction
Most common organism causing infective exacerbation of COPD?
H influenzae
30-40 year old with basal emphysema and abnormal LFTs
Alpha-1-antitrypsin deficiency
Fine end-inspiratory crepitations
pulmonary fibrosis
Investigation of choice for sleep apnoea?
Polysomnography
Coal workers’ pneumoconiosis causes what?
Upper zone fibrosis
What should be sent with diagnostic pleural taps?
- Biochemistry to determine protein
- Cytology
- Microbiology for gram staining and culture
What is important to remember about lung cancers?
Lesion can sometimes be too small to see on CXR
Paratracheal lymph nodes should raise alarm bells for?
Lung cancer
Sarcoidosis can cause what?
Hypercalcaemia
What is atelectasis?
A post op complication when the airways become blocked by bronchial secretions leading to respiratory collapse
- Managed with chest physio and positioning the patient upright
Normal/raised total gas transfer with raised transfer coefficient
Asthma
Lung collapse vs pleural effusion on CXR?
Lung collapse - trachea pulled towards the side of the white out
Pleural effusion - trachea pulled away from the side of the white out
Management of bronchiectasis?
Muscle training + postural drainage techniques
Patients who have frequent COPD exacerbations should have home supply of what?
Abx plus prednisolone
Investigation of choice for pulmonary fibrosis?
High res CT
Pack years formula
No of packs per day (1 pack is 20) x no of years smoking
Everyone over the age of 5 should have what to diagnose asthma?
Spirometry with bronchodilator reversibility testing
ENT, respiratory and kidney involvement
Think of Granulomatosis with polyangiitis
A negative result on spirometry does not what?
Exclude asthma -> FeNO testing needed
What pattern on lung function does bronchiectasis have?
Obstructive
When should Abx be given for COPD exacerbation?
- If purulent sputum or signs of pneumonia
Facial rash plus lymphadenopathy
Sarcoidosis
Cavitating lesions are associated with what?
Squamous cell carcinoma
increased FEV1/FVC ratio and reduced transfer factor
Pulmonary fibrosis
Which paraneoplastic syndrome is associated with squamous cell carcinoma?
Parathyroid hormone related protein secretion
Decrease in pO2/FiO2 in poorly patient with non-cardiorespiratory presentation
ARDS
Neuromuscular disorders present how on pulmonary function tests?
Restrictive pattern
How is asthma diagnosed on spirometry?
Improvement in FEV1 by > 15% following administration of bronchodilator
How does salbutamol work?
Stimulates ß2 receptors of respiratory tract, which increases sympathetic activity and relaxes bronchial smooth muscle.
What physiological measurement is used to determine the severity
of COPD?
FEV1
What must patients do to qualify for long term oxygen therapy?
Stop smoking
What are some examination signs of consolidation?
Reduced chest expansion, dull percussion note, increased tactile
vocal fremitus, increased vocal resonance, bronchial breathing.
Why should statins and macrolides not be given together?
Increased risk of myositis
What are some complications of pneumonia?
- Resp failure
- Sepsis
- Empyema
- Lung abscess
- Shock
How would pleural effusion present on examination?
- Reduced chest expansion
- Stony dull to percuss
- Reduced breath sounds
How would pneumothorax present on examination?
- Reduced chest expansion
- Hyper resonant on percussion
- Reduced breath sounds
What is an indication for surgery in bronchiectasis?
If the disease is localised to one lobe
Massive PE + hypotension
Thrombolysis
What is used to guide if patients need Abx with acute bronchitis?
CRP levels - if >100 -> offer Abx
multiple lip telangiectases
Think hereditary haemorrhagic telangiectasia -> strong association with epistaxis
Investigation of choice for suspected PE in someone with renal impairment?
V/Q scan
When should LTOT be started for COPD patients?
When 2 measurements of pO2 are < 7.3
pO2 of 7.3 - 8 AND polycythaemia/peripheral oedema/pulmonary HTN
Causes of upper zone fibrosis
C - coal workers pneumoconiosis
H - histiocytosis
A - ankylosing spondylitis
R - radiation
T - TB
S - Silicosis/Sarcoidosis
Causes of lower zone fibrosis
D - drugs
A - asbestosis
I - idiopathic
M - Most connective tissue disorders except AS
Non-obs based admission criteria for asthma?
- Previous near fatal attack
- Pregnancy
- Oral steroids not helping with symptoms
Bilateral parotid gland swelling can be indicative of what?
Sarcoidosis
What are some complications of bronchiectasis?
Pneumonia, sepsis, recurrent infections, resp failure
What is the mechanism of PE?
T1 Resp failure due to V/Q mismatch
Pemberton’s test
Test for SVC obstruction - raise arms above head and they go cyanosed
Non respiratory causes of pulmonary fibrosis
- Amiodarone, methotrexate
- RA
- SLE
- Sjogrens
- UC
ECG signs of cor pulmonale
- right axis deviation
- P pulmonale
Causes of bilateral hilar lymphadenopathy
Lymphoma, TB, Sarcoidosis, bronchial carcinoma
What are extra-pulmonary manifestations of sarcoidosis?
- Erythema nodosum
- Anterior uveitis
- Neuropathy
- Cardiomyopathy
- CN palsies
Where should pleural tap needle be inserted?
Above rib to avoid neurovascular bundle
What could an area of dull to percuss in someone with a pneumothorax suggest?
Haemothorax -> needs chest drain
Lung cancer can present as what?
SVC obstruction
What helps to reduce mortality in someone with ARDS?
Low tidal volume mechanical ventilation
Uncompensated type 2 resp failure with pH <7.35
Think about non invasive ventilation
Radiation exposure can cause what?
Lung cancer
What is the pathophysiology of ARDS?
Diffuse bilateral alveolar injury due to inflammation
Previous history of haemorrhagic stroke at any time is a C/I to what?
Thrombolysis
Excessive daytime sleepiness with visual hallucinations
Narcolepsy -> multiple sleep latency test needed
What is PERC criteria used for?
To rule out PE
What are indications for steroids in sarcoidosis?
PUNCH
Parencymal lung disease
Uveitis
Neuro involvement
Cardio involvement
Hypercalcaemia
Large round well circumscribed masses in the lungs?
Cannonball metastases -> renal cell carcinoma
Investigations for lung cancer?
- CXR
- CT with contrast
- Bronchoscopy
Raised platelets can be a sign of what?
Lung cancer
When are Abx used in acute bronchitis?
If there are existing co-morbidities
Preceding influenza predisposes you to what?
Staph aureus pneumonia
What is the treatment for latent TB?
3 months of isoniazid and rifampicin or 6 months of isoniazid
How should patients with acute asthma who do not respond to medical treatment and become acidotic be managed?
Intubation and Ventilation
Where should needle thoracostomy be placed?
cannula into the second intercostal space in the midclavicular line on the affected side
egg shell calcification of lymph nodes?
Silicosis
What are causes of resp alkalosis?
- Anxiety
- PE
- Stroke, sub arachnoid
- Altitude
What are causes of resp acidosis?
- COPD
- Neuromuscular disease
- Sedating drugs like benzos/opiates
Pneumothorax management
- Asymptomatic -> conservative care
- If symptoms and high risk -> chest drain
- If symptoms and not high risk -> can manage conservatively/needle aspiration
How should pneumothorax be followed up when managed conservatively?
- If primary -> review every 2-4 days as outpatient
- If secondary -> monitor as inpatient
- Everyone should be reviewed in outpatients in 2-4 weeks
CURB65 criteria
Confusion
Urea > 7
RR > 30
BP <90 systolic or <60 diastolic
Aged > 65
Community acquired pneumonia treatment
0 - treat at home - Amoxicillin/Clarithromycin
1-2 - consider hospital - Amoxicillin + Clarithromycin
3-4 - urgent hospital - Co-amoxiclav or
+ Clarithromycin
Hospital acquired pneumonia treatment
No severe signs: Co-amoxiclav
Sever signs: Piperacillin with Tazobactam
Exudate vs Transudate pleural effusion
Exudate - >30
Transudate - <30
What are exudative causes of pleural effusion?
- Pneumonia
- RA/SLE
- Neoplasia
What are transudative causes of pleural effusion?
- HF
- Liver disease
- Hypothyroidism
How to diagnose mesothelioma?
- CXR
- Pleural CT with biopsy
- Thoracoscopy can be used
Types of non small cell lung cancer?
- Large cell
- Squamous cell
- Adenocarcinoma
What paraneoplastic features do lung cancers have?
Small cell
- SIADH
- Cushings
- Lambert-Eaton
Squamous
- PTHrP
- Hypercalcaemia
- Hypertrophic pulmonary osteoarthropathy
Adenocarcinoma
- Gynaecomastia
How long should patients hold breath when taking inhaler?
10 seconds after pressing down on cannister
Wait 30 seconds before repeating next dose
What is Churg Strauss syndrome?
Eosinophilic granulomatosis with polyangiitis -> asthma features with pANCA positive
What is the triangle of safety?
- Located in the mid axillary line of the 5th intercostal space
- Bordered by anterior edge of latissimus dorsi, lateral border of pectoralis major, line superior to the horizontal level of the nipple
Where is aspiration pneumonia most common?
- Right middle and lower lobes
How is alpha 1 antitrypsin deficiency inherited?
Autosomal recessive
How can A1AD be managed?
- Obstructive picture on spirometry
- Supportive treatment with bronchodilators
- Lung volume reduction surgery can be done in severe cases
Moderate asthma features
PEFR 50-75% best or predicted
Speech normal
RR < 25
Pulse < 110
Acute severe asthma features
PEFR 33-50% best or predicted
Can’t complete sentences
RR > 25
Pulse > 110
Life threatening asthma features
PEFR < 33% best or predicted
Sats <92%
Normal PCO2
Silent chest, cyanosis or poor resp effort
Bradycardia/Hypotension
Exhaustion/Confusion/Coma
What are some blood tests for sarcoidosis?
- elevated ACE, ESR, calcium, immunoglobulins
- Deranged LFTs
ECG signs of PE
- Sinus tachycardia
- Right BBB
- S1 Q3 T3
Complications of recurrent or untreated PE?
- Pulmonary HTN
- Right sided heart failure
Surgical interventions for COPD?
- Bullectomy
- Lung reduction surgery
Extra-respiratory manifestations of cystic fibrosis
- Pancreatic insufficiency
- DM
- Cirrhosis
- Nasal polyps
- Sinusitis
- Male infertility
- Osteoporosis
Over rapid aspiration/drainage of pneumothorax can result in what?
Reexpansion pulmonary oedema
What test should be offered to all patients with TB?
HIV
What size of pneumothorax would be indicated to do a needle aspiration?
> 2cm
Bilateral, mid-to-lower zone patchy consolidation in an older patient
Legionella
Deranged LFTs, hyponatraemia, low lymphocytes?
Legionella
Mycoplasma pneumonia can cause what?
Immune mediated neurological diseases e.g Guillan Barre
Pneumonia + red cell agglutination?
Mycoplasma
Large bullae in COPD can mimic what?
Pneumothorax
Why should intranasal decongestants not be used for prolonged periods?
Risk of tachyphylaxis -> increasing doses are needed
What is the Abx of choice for acute bronchitis?
Doxycycline
When to use NIV vs IV?
NIV - 7.25 - 7.35
IV - <7.25
What is used to assess drug sensitivities in TB?
Sputum culture
Staph aureus pneumonia is associated with what?
Cavitating lesions
What is the gold standard test for TB?
Sputum culture
HIV decreases what?
Sensitivity to sputum smear for TB
Investigation to diagnose mesothelioma?
Thoracoscopy with histology
Pneumonia with cold sores?
Strep pneumoniae
Marked volume loss of the lung with thickening of the pleura?
Think mesothelioma
What is the management of empyema?
Chest drain insertion for drainage + IV Abx
What is the advice around air travel following pneumothorax?
No travel until full resolution on CXR
Acute asthma steps
- Oxygen
- Nebulised salbutamol
- Oral steroids
- Nebulised Ipratropium
- IV Mag Sulph
- IV Aminophylline -> discuss with seniors
- Intubation and Ventilation in HDU/ITU
What is criteria for discharge following asthma exacerbation?
- Stable on discharge meds for 12-24 hours
- Inhaler technique checked
- PEFR > 75%
Asthma stepwise management for adults
- SABA
- SABA + ICS
- SABA + ICS + LTRA
- SABA + ICS + LABA (+LTRA if helping)
- SABA + MART (ICS+LABA) (+LTRA if helping)
- SABA + medium dose MART (+LTRA if helping)
- Seek help from secondary care
Asthma stepwise management for children
- SABA
- SABA + ICS
- SABA + ICS + LTRA
- SABA + ICS + LABA
- SABA + MART
- SABA + medium dose MART
- Seek help from secondary care
COPD stepwise medical Mx
- SABA or SAMA
- SABA + LABA + LAMA if no asthma features OR SABA + LABA + ICS if asthma features
- SABA + LAMA + LABA + ICS (even if no asthma features)
- Seek help from secondary care
What would chronic bronchitis COPD show on V/Q?
Low V/Q due to decreased ventilation
What would emphysema COPD show on V/Q?
High V/Q due to loss of alveolar surface area causing more ventilation per available perfusion area
CXR signs for COPD
- Hyperinflated chest
- Bullae (if large may mimic pneumothorax)
- Decreased peripheral vascular markings
- Flattened diaphragm
Where will pancoast tumours be?
- Same side as the Horner’s signs
- At the lung apex
Heart sounds
1st - mitral/tricuspid
2nd - aortic/pulmonary
Split second heart sound with loud pulmonary component?
Cor pulmonale
TB Treatment
RIPE - 2 months
RI - 4 more months
Management of secondary pneumothorax which is not improving post chest-drain insertion?
Discuss with cardiothoracic
Diffuse alveolar damage with hyaline membrane formation
Acute respiratory distress syndrome
Pleural effusions due to rheumatoid arthritis have what?
Low glucose levels
massive haemoptysis
Think lung abscess
What does a pancoast tumour invade when it causes Horners?
Cervical sympathetic plexus
bilateral pulmonary infiltrates
Think ARDS
Patient with swallowing difficulties/previous stroke with resp pathology?
Think lung abscess
What is the initial management of hypercalcaemia?
IV Fluids
What pharmacological therapy can be used for idiopathic pulmonary fibrosis?
Pirfenidone / Nintedanib
What is a pneumothorax?
Air in the pleural cavity which is the potential space between the visceral and parietal pleura
Where do you measure for pneumothorax?
Chest wall to the outer edge of the lung at level of hilum
What are surgical options for recurrent pneumothorax?
Video assisted thorascopic surgery
Surgical pleurodesis
PE like symptoms following a percutaneous vertebroplasty?
Pulmonary cement embolism
diffuse bilateral opacities on x ray?
Think ARDS
Management of solitary pulmonary nodules?
CT guided needle aspiration biopsy if >8mm
Unilateral pleural effusion?
Rule out malignancy
Why can people with carbon monoxide poisoning have?
Normal O2 sats as monitors cannot differentiate between the 2
Investigation of choice for pnemocystitis jiroveci?
Bronchoalveolar lavage
Acute bronchitis?
LRTI which causes inflam in bronchial airways causing oedematous large airways and sputum production.
Normally resolves in 3w but 25% will have cough after
Mx for acute bronchitis?
- self-care: NSAIDs/paracetamol; honey; stop smoking; seek help if systemically unwell or don’t improve after 3-4w
- Abx if indicated but not routine (only shortens cough by half a day and S/Es & resistance)
When to offer Abx for acute bronchitis?
- Immediate= systemically unwell
- Consider= high risk of Cx eg. CF, immunosupression, comorbid condition; >65yrs with 2 or >80yrs with 1: DM, hospital admission <1yr, CHF, take corticosteroids
- Back-up prescription= if not needed but pick up if worse rapidly
- CRP levels
When to offer Abx for acute bronchitis based on CRP levels?
CRP <20= not routine
CRP 20-100= consider delayed
CRP >100= Abx
Abx for acute bronchitis if indicated?
Oral doxycycline 200mg 1st day then 100mg OD for 4d
pregnant or 12-17yrs = amoxi 500mg 3xd 5d
or clarithro
Cause of acute bronchitis?
uncertain but likely virus; 80% cases in autumn/winter
CP of acute bronchitis?
- cough: productive or not
- sore throat
- rhinorrhoea
- may have wheeze
- low grade fever
Differentiate acute bronchitis from pneumonia?
Hx= sputum, wheeze, breathlessness may be absent in AB but at least one present in P
Ex= no other focal chest signs (dullness to percussion, creps, bronchial breathing) in AB except wheeze. Systemic symptoms more likely in pneumonia (malaise, myalgia, fever)
Ix for acute bronchitis?
CLINICAL
- CRP can be used to guide if Abx therapy indicated
Who can not take doxycycline?
children or pregnant women, use amoxicillin instead
Allergic rhinitis?
inflam disorder of nose that occurs when nasal mucosa becomes exposed and sensitised to allergens, to produce typical symptoms of sneezing, nasal itching, rhinorrhoea and congestion
What type of inflam reaction is allergic rhinitis?
IgE mediated
Classification of allergic rhinitis?
Mild or moderate to severe or..
- seasonal eg. grass, pollen (hayfever), around same time every yr
- perennial (throughout yr) eg. dust mites, animals
- intermittent= <4d a w or <4 consecutive w
- persistent= >4d a w AND >4 consecutive w
- occupations (allergens in work environment)
When does allergic rhinitis usually begin?
childhood/adolescence
Cx of allergic rhinitis?
reduced QOL, impaired school/work performance, disturbed sleep, reduced conc, possible development of: asthma, sinusitis, nasal polyps
Features of allergic rhinitis?
- occurs after exposure to known causative allergen
- sneeze, nasal itch, rhinorrhoea, congestion, post-nasal drup
- associations: allergic conjunctivitis, asthma, eczema
Mx for allergic rhinitis?
- ?saline nasal irrigation
- allergen avoidance
- prn intranasal antihistamine or non-sedating oral
- regular intranasal corticosteroids during allergen exposure for moderate to severe or if inital Mx ineffective
- review 2-4w if persist
- refractory= intranasal antihis + corticosteroid spray
- ? add on eg. short course intranasal decongestant, intranasal anticholinergic or LTRA
- severe uncontrolled: short course oral corticosteroids
When to refer to allergy or ENT for allergic rhinitis?
- Red flags
- unresponsive to Mx
- allergy testing may be needed if think its house dust mite or animal
- uncertain
Why should nasal decongestants eg. oxymetazoline not be used for prolonged periods?
Increasing doses will be needed to achieve same effect (tachyphylaxis) and rebound hypertrophy of nasal mucosa (rhinitis medicamentosa) may occur upon withdrawl
Types of allergy tests?
- skin prick
- Radioallergosorbent test (RAST)
- skin patch
Skin prick allergy test?
- most common
- drops of diluted allergen placed on skin after which the skin in pierced with needle
- large no. allergens can be tested in 1 session
- Normally incl. histamine (+ve) and sterile water (-ve control)
- a wheal will typically develop if pt has allergy after 15minds
- good for food allergy and pollen
Radioallergosorbent test for allergy?
- determines amount of IgE that reacts with suspected or known allergens eg. IgE to egg protein
- results given in grades: 0 (-ve) to 6 (strongly +ve)
- good for food allergies, inhaled allergens (eg. pollen) and wasp/bee venom
- when skin prick not suitable eg. extensive eczema or pt taking antihistamines
Skin patch allergy testing?
- useful for contact dermatitis
- 30-40 allergens placed on back
- irritants may also be tested for
- patches are moved 48hrs later with results being read by derm after further 48hrs
Food allergy describes what?
adverse immune-mediated response which occurs when person is exposed to specific food allergen(s).
IgE mediated food allergy produces what?
immediate and consistently reproducible multi-organ symptoms
Common food allergies?
cow’s milk, eggs, peanuts and other legumes, tree nuts, shellfish, fish and wheat
RFs for development of food allergy?
pre-existing food allergy, atopic eczema, FHx food allergy and/or atopy
Possible Cx of food allergy?
- severe/life-threatening rections (incl. anaphylaxis)
- anxiety
- reduced QOL (restrictions, social interactions, peer pressure, stigma, embarrassment, social exclusion)
- restricted diet and malnutrition
When should diagnosis of IgE mediated food allergy be suspected?
classic symptoms develop within secs or mins to 1-2hrs after ingestion of trigger food:
- urticaria
- angioedema
- itching
- cough
- hoarseness
- wheeze
- SOB
- N & V
- diarrhoea
- abdo pain
consider if unexplained persistent symptoms of atopic eczema
Assessment of suspected IgE mediated food allergy?
- examine nutritional status and signs of clinical reaction/comorbid conditons + Hx
- arrange skin prick testing and/or serum-specific IgE allergy testing
Referral for pt with food allergy?
- A&E= systemic symptoms or ?anaphylaxis
- allergy specialist= multiple; uncertain; signif atopic eczema; Hx of systemic symptoms or increased risk anaphylaxis; persistent food allergy
- Dietician= nutritional concerns or already on restricted diet
Mx of food allergy?
- individualised written allergy Mx plan
- advise on prompt recognition and Mx of acute symptoms= immediate oral antihistamines (cetirizine or chlorphenamine if <2yrs) for non-severe symptoms or adrenaline auto-injector for suspected anaphylaxis
- review annually
Systemic symptoms of food allergy that suggest anaphylaxis?
resp distress; wheeze; hypotension; tachy or bradycradia; drowsiness; confusion; collapse; loss of consciousness
Differential diagnosis for IgE-mediated food allergy?
- acute spontaneous urticaria and angioedema (no allergic trigger, often following viral infection)
- carcinoid syndrome
- food intolerance (non-immune, non-specific reactions, delay in CP and prolonged symptoms)
- food poisoning and toxic reactions
- food aversion or refusal
- IBS/IBD
- urticaria
- asthma exacerbation
- atopic dermatitis
- coeliac
- GORD
- gastroenteritis
Mx of IgE mediated allergy vs non-IgE mediated?
IgE= skin prick or bloods specific for IgE antibodies
Non-IgE= eliminate suspected allergen for 2-6w then introduce; consult dietician about nutritional adequancies, timing and follow up
IgE-mediated food allergy vs Non-IgE mediated presentation?
IgE:
- anaphylaxis
- skin= pruritus, erythema, urticaria, angioedema
- GI= N, V, D, colicky abdo pain
- Resp= URT symptoms (nasal itching, sneezing, rhinorrhoea, congestion); LRT symptoms (cough, wheeze, chest tightness, SOB)
Non-IgE:
- skin= pruritus, erythema, atopic eczema
- GI= GORD; loose/frequent stool; blood/mucus in stool; abdo pain; infantile colic; food refusal or aversion; contipation; perianal redness; pallor/tired; faltering growth + other symptoms above
Sensitivity to latex may cause what problems?
- type I hypersensitivity (anaphylaxis)
- type IV hypersensitivity (allergic contact dermatitis)
- irritant contact dermatitis
Latex allergy is more common in who?
children with myelomeningocele spina bifida
Latex-fruit syndrome?
people who are allergic to latex are also allergic to fruits, particularly: banana, avocado, pineapple, kiwi, chestnut, mango, passion fruit, strawberry
Oral allergy syndrome?
aka pollen-food allergy
IgE mediated hypersensitivity reaction to specific raw, plant-based foods incl. fruits, vegetables, nuts and certain spices.
How does oral allergy syndrome (pollen-food allergy) typically present?
mild tingling or pruritus of lips, tongue and mouth
How is the hypersensitivity reaction in oral allergy syndrome initiated?
by cross-reaction with non-food allergen, most commonly birch pollen whereby the protein in food is similar but not identical in structure to original allergen (explains why OAS strongly linked with pollen allergies & why cooking culprit food prevents symptoms-denatures the protiens)
What is oral allergy syndrome (OAS) strongly linked with?
pollen allergies and seasonal variation
What can you do to prevent symptoms occurring in oral allergy syndrome?
cooking culprit food- denatures the proteins
OAS vs food allergy?
- food allergy= direct sensitivity to a protein present in food. OAS= cross-sensitisation to a structurally similar allergen present in pollen
- food allergens can be caused by plant or non-plant foods but OAS is not caused by non-plant foods
- OAS normally limited to oropharynx but food allergies more likely to cause systemic symptoms (V&D)
Why do non-plant foods not cause OAS but food allergies can be caused by plant and non-plant foods?
OAS= no cross-reactive allergens in pollen which would be structurally similar to meat
Food allergy= allergens occur in response to substances that are more stable and able to survive stomach enzymes and acid processing and cooking
Why are food allergies more likely to cause systemic symptoms (eg. V&D) but OAS is limited to oropharynx?
Food allergy= allergens are not readily broken down
OAS= proteins that cause the symptoms are denatured by stomach enzymes
About 1/2 of pts with general pollen allergy and 3/4 pts with allergy to birch pollen (most common allergen in UK) report symptoms of what?
OAS
Associations with OAS?
- birch pollen allergy (most common)
- Rye grass pollen allergy
- Rubber latex allergy
Presentation of OAS?
- suspect in pts with Hx of seasonal allergy symptoms and present with symptoms mins after eating a specific raw food
- itching, tingling of lips, tongue and mouth
- mild swelling and redness of lips, tongue and throat may occur
- severe= N&V
- fully resolve within 1hr of contact
- anaphylaxis very rare
Ix for OAS?
- clinical but can use allergy testing to rule out food allergies if Hx unclear
Mx for OAS?
- avoid culprit foods
- can take oral antihistamine if get symptoms
- inform that once cooked it shouldn’t cause symptoms
Many pts who report an allergy to penicillin may be describing what?
intolerance/side efects eg. diarrhoea or a coinincidental rash eg. amoxicillin in pts with infectious mononucleosis
0.5-6.5% of pts who are allergic to penicillin are also allergic to what?
cephalosporins
Pts with Hx of immediate hypersensitivity to penicillin should not receive a what? What if it is essential because an alternative Abx is not available?
Cephalosporin.
If pt needs cephalosporin then can use: cefixime, cefotaxime, ceftazidime, ceftriaxone or cefuroxime with caution.
AVOID= cefaclor, cefadroxil, cefalexin, cefradine and ceftaroline fosamil
Types of penicillin? (to be aware of to avoid accidental prescription if pt has allergy)
- phenoxymethylpenicillin
- benzylpenicillin
- flucloxacillin
- amoxicillin
- ampicillin
- co-amoxiclave (Augmentin)
- co-fluampicil (Magnapen)
- piperacillin with tazobactam (Tazocin)
- ticarcillin with clavulanic acid (Timentin)
Allergic reactions to venom eg. after insect bite/sting may be considered as long or systemic, what does this mean?
- Local= redness, swelling, pain limited to skin and soft tissues directly related to the site of venom exposure but spreading >10cm from the site
- Systemic= cutaneous reactions that are relatively distant from the exposure site eg. widespread redness, itching, urticaria and/or angioedema (not affecting mouth or throat)
Anaphylaxis may occur with/without evidence of systemic cutaneous reaction & any reaction there is any airway compromise or signs of haemodynamic compromise should be managed as anaphylactic in nature
Mx of venom allergy eg. after insect bite or sting?
Supportive: remove stingers by scraping sideways with fingernail or card; cold compress; avoidance of scratching to prevent secondary infection.
Can use oral paracetamol/ibuprofen for pain, topical hydorcortisone and oral antihistamines eg. chlorphenamine to reduce itching.
When should referral to an allergy specialist be made for pt with venom allergy (insect bite or sting)?
if pt has had or suspected of having a systemic reaction
Testing for venom allergy is recommended in who?
pt with a history of systemic reaction causing airway compromise or haemodynamic instability
Mx for pt with history of previous reaction to insect bite/sting which presented with airway and/or haemodynamic compromise and raised levels of venom-specific IgE on skin prick or in vitro testing?
Venom immunotherapy (VIT)
Baseline tryptase level should be preformed to exclude indolent mastocytosis or monoclonal mast cell activation syndrome
What can asbestos cause in the lung?
- Pleural plaques
- Pleural thickening
- Asbestosis
- Mesothelioma
- Lung cancer
What are pleural plaques (can be caused by asbestos)?
benign and do NOT undergo malignant change
- don’t require follow uo
- most common form of asbestos related lung disease
- occur after a latent period of 20-40yrs
What is pleural thickening (can be caused by asbestos)?
asbestos exposure can cause diffuse pleural thickening in similar pattern seen following an empyema or haemothorax
What is asbestosis (can be caused by asbestos)?
- Typically causes lower love fibrosis
- severity linked to length of exposure (contrast to mesothelioma- limited exposure can cause disease)
- Patent period 15-30yrs
Features of asbestosis?
- SOB & reduced exercise tolerance
- clubbing
- bilateral end-inspiratory crackles
- restrictive pattern with reduced gas transfer on lung function tests
What do lung function tests show for asbestosis?
restrictive pattern with reduced gas transfer
Treatment for asbestosis?
conservative as no interventions offer signif benefit
What is mesothelioma?
Cancer of the mesothelial layer of the pleural cavity that is strongly associated with asbestos exposure (other m. layers may be affected eg. abdo in small no. of cases).
- Latent period= 30-40yrs
- Even very limited exposure to asbestos can cause it
Most dangerous form of mesothelioma?
Crocidolite (blue) asbestos
Possible features of mesothelioma?
- progressive SOB
- chest wall pain
- painless pleural effusion (30%)
- 20% have pre-existing asbestosis
- weight loss
- clubbing
- 85-90% have Hx of asbestos exposure
Mx for mesothelioma?
- palliative chemo, surgery if operable
- industrial compensation
- prognosis v. poor= median survival from diagnosis of 8-14m
Most common form of cancer associated with asbestos exposure?
LUNG cancer most common
Mesothelioma also associated but less common
What is important for pt to do if they smoke and have a history of asbestos exposure?
smoking cessation as the risk of lung ca in smokers who have history of asbestos exposure is very high
Overview of the malignancy in mesothelioma?
- malignancy of mesothelial cells of pleura
- mets to contralateral lung and peritoneum
- R lung affected more than L
Ix and diagnosis for mesothelioma?
- CXR shows pleural effusion or pleural thickening
- get pleural CT= if area of pleural nodularity seen then image-guided pleural biopsy
- pleural effusion present= send fluid for MC&S, biochemistry and cytology
- cytology -ve exudative effusion= local anaesthetic thoracoscopy
DIAGNOSIS= histology following thoracoscopy
Asthma?
chronic inflam condition of the airways: airways are hyper-responsive and constrict easily in response to wide range of stimuli. May result in coughing, wheezing, chest tifhtness and SOB.
Suspect asthma in who (CP)?
- wheeze, breathlessness, chest tightness, cough
- Diurnal= worse at night and early morning
- occur in response to exercise, allergen exposure, cold air; occur after taking NSAIDs, BB; occur in absence of URTI
- Hx of atopic disorder
- Widespread bilateral polyphonic expiratory wheeze
- may be triggered by emotion and laughing in children
Ix that help support asthma diagnosis (not one single diagnostic test)?
- Fractional exhaled nitric oxide (FeNO) testing (sometimes primary care but may require referal). (ALL)
- Spirometry (all symptomatic pts >5yrs) then do Spirometry with bronchodilator reseversibility (BDR). (ALL).
- Peak expiratory flow (can do in ALL or if uncertain)
- direct bronchial challenge testing with histamine or methocholine (specialist referal needed) (if uncertain/negative results)
FeNO test for asthma?
in steroid naive adults…
+ve if 40ppb or higher (adults) or 35 in children (only do in children in uncertain after spirometry)
Spirometry test for asthma?
all symptomatic pts >5yrs (FeV1/FVC <70% is +ve result and suggest airflow obstruction).
THEN DO:
- Spirometry with bronchodilator reversibility (BDR): adults= improvement of 12%+ with increased volume of 200mL+ in response to SABA or corticosteroids is positive for asthma. Improvement >400mL in FEV1 is strongly suggestive. Children= improvement of FEV1 of 12%+ is positive.
Peak expiratory flow test for asthma?
Value of >20% variability after monitoring at least twice daily for 2-4w if positive for asthma. PEF variability calculated: difference between highest and lowest readings expressed as a % of the average PEF. Upper limit of normal is approx 20% using at lest PEF reading per day but may be lower when using twice daily readings.
Direct bronchial challenge testing with histamine or methocholine (specialist referal needed) for asthma?
PC20 value of 8mg/ml or less is positive. Offer if normal spirometry and FeNO of 40 but no variability in PEF or FeNO <40 but with variablility in PEF
When to diagnose, suspect or consider alternative diagnosis/refer for specialist opinion in asthma?
- DIAGNOSE= FeNO level 40ppb+ with either +ve BDR, +ve PEFV or bronchial hyperactivity. OR + BDR AND +ve PEFV irrespective of FeNO level.
- SUSPECT= obstructive spirometry with: -ve BDR, FeNO level 40+ or FeNO level 25-39 but with +ve PEFV
- alternative diagnosis/specialisgt if normal spirometry, FeNO and PEFV
What if suspect asthma in pt <5yrs?
use CP to determine likelihood and when reach 5 carry out the objective tests
Asthma Mx in adults (17yrs+)?
1) SABA
2) SABA + low dose ICS
3) SABA + ICS + LTRA
4) SABA + ICS + LABA (+ LTRA if good response to LTRA)
5) SABA + MART with lose dose ICS (+/- LTRA)
6) SABA + MART with moderate dose ICS
notion
7) SABA + MART with high dose ICS OR trial additional drug eg. LAMA
8) specialist referral
Asthma Mx in pts aged 5-16yrs?
1) SABA
2) SABA + lose dose ICS
3) SABA + ICS + LTRA
4) SABA + ICS + LABA
5) SABA + MART with lose dose ICS
6) SABA + MART with moderate dose ICS
7) specialist referral
Asthma Mx for children <5yrs?
1) SABA
2) SABA + 8w trial of moderate dose ICS
3) after 8w stop ICS and monitor symptoms.
- if didn’t resolve during trial= alternative diagnosis
- if resolved but then reoccured within 4w stopping ICS= restart ICS at lose dose
- if resolved but reoccured >4w after stopping ICS= repeated 8w trial of moderate dose ICS
4) SABA + low dose ICS + LTRA
5) stop LTRA and specialist referral
When to refer to resp for pt with asthma?
if symptoms not controlled after all Mx steps, lower threshold for children
Follow up for asthma?
annual
FeNO testing in asthma can be effected by what?
inhaled corticosteroids
approx 1 in 5 with -ve result will have asthma
approx 1 in 5 with +ve result won’t have asthma
Red flags that suggest an alternative diagnosis to asthma and prompt immediate resp referral?
Adults= systemic features (myalgia, fever, weight loss); non-variable SOB; unexpected clincial signs (crackles, clubbing, cyanosis, cardiac disease, monophonic wheeze, stridor); chronic sputum; CXR shadowing; unexplained restricted spirometry; blood eosinophilia
Children= FTT; focal signs, abdnorm voice/cry, dysphagia, inspiratory stridor; symptoms present from birth; XS vomiting/posseting; severe URTI; persistent wet productive cough; FHx unusual chest disease; nasal polyps
Obstructive vs restrictive spirometry?
Obstructive:
- eg. asthma, COPD, bronchitis
- FEV1 decreased
- FVC normal or decreased
- FEV1/FVC ratio= <70%
Restrictive:
- eg. sarcoidosis, pulmonary fibrosis, interstitial lung disease, (conditions affecting chest wall, muscles or pleura)
- FEV1 decreased
- FVC decreased
FEV1/FVC= >=70%
Spirometry: FEV1 vs FVC?
FEV1= forced expiratory volume in 1 sec
FVC= forced vital capacity
How is complete control of asthma defined?
- no daytime symptoms
- no night waking due to asthma
- no need for rescue meds (SABA)
- no asthma attacks
- no limitations on activity incl exercise
- normal lung function (PEF >80% predicted or best)
- minimal side effects from meds
Advice for pt with asthma?
- keep up to date with routine vaccinations incl. annual flu
- avoid triggers
- weight loss and smoking cessation
- assess for anxiety/depression
- ensure pt has own peak flow meter
- explain how to use inhaler incl if using a spacer (can use tidal breathing, washed and dry in air)
- SABA for reliever therapy and ICS for preventer
Asthma MX: lose dose ICS?
400ug (micrograms) budesonide
if =<16yrs= 200ug
Asthma Mx: moderate dose ICS?
400-800ug budesonide
=<16yrs= 200-400ug
Asthma Mx: high dose ICS?
> 800ug budesonide
=<16yrs= >400ug
Asthma Mx: MART?
Maintenance and reliever therapy.
Form of combined ICS and fasting-acting LABA in a single inhaler.
When could you consider decreasing maintenance therapy for pts asthma?
once it has been controlled with their current maintenance therapy for at least 3m.
decrease ICS dose slow: every 3m by 25-50%
Monitoring pts for asthma?
Annually
But review response to Mx after 4-8w
- spirometry or peak flow
- advice on inhaler technique
- no. of attacks, ICS use, time off school/work due to asthma; nocturnal symptoms; adherence; hospital admissions
- use of SABA (overuse= >12 per hr)
If on long term steroid (>3m) then monitor= BP; HbA1c; cholesterol; BMD; vision
3 questions to ask every pt with asthma?
Have you had difficulty sleeping because of your asthma symptoms (including cough)?
Have you had your usual asthma symptoms during the day (e.g. cough, wheeze, chest tightness, or breathlessness)?
Has your asthma interfered with your usual activities (e.g. housework, work, school)?
Asthma Mx: SABA?
Short-acting beta-2 agonists
eg. salbutmol
rapid onset (<5mins) and last up to 4hrs
up to 4x a day (not exceding 4hrly)
Asthma Mx: LABA?
Long-acting beta-2 agonists
eg. salmeterol
last 12hrs
What drugs should pts with asthma avoid?
NSAIDs
Beta-blockers
Adverse effects of beta-2 agonists (SABA & LABA)
- fine tremor: hands, worse in 1st few days of Mx
- palpitations
- headache
- seizure
- hypokalaemia
- anxiety
- cardiac arrhythmia and paradoxoical bronchospasm (rare)
- acute angle-closure glaucoma
Use beta-2 agonists eg. SABA & LABA with caution in who?
- hyperthyroidism (may stimulate T activity)
- DM (rare risk ketoacidosis)
- CVD & HTN
- QT-prolongation
- hypokalaemia
- convulsive disorders
Asthma Mx: LTRA?
leukotriene receptor antagonist
eg. montelukast 10mg OD in evening
5-16yrs= 5mg
<5yrs= 4mg
What pts need hospital admission for acute exacerbation of asthma?
- all life-threatening
- severe which persists after initial bronchodilator Mx
- moderate with worsening symptoms despite BD Mx and/or had previous near fatal attack in past. Or if: <18yrs; poor treatment adherence; live alone; recent hospital admission; previous severe attack
Mx for acute exacerbation of asthma whilst awaiting admission to hospital?
1) supp O2 if hypoxia to maintain sats 94-98%
AND
2) severe= NEBULISED SALBUTAMOL (5mg) oxygen driven (flow rate 6L/min) over 30-60mins.
2) moderate= pressurised metered-dose inhaler with large volume spacer; 4 piuffs then 2 puffs every 2mins up to 10 puffs; can repeat every 10-20mins. (children-puff every 30-60secs up to 10puffs)
AND if severe/poor response
3) NEBULISED IPRATROPIUM BROMIDE (500ug adults, 250ug children). Do not repeat within 4hrs.
AND
4) give 1st dose of PREDNISOLONE (40-50mg adults, 30-40mg >5yrs, 20mg <5) ; if can’t swallow then IV hydrocortisone 100mg
AND
5) monitor PEF and O2 sats to assess response to Mx
6) short course oral pred
Mx for acute exacerbation of asthma if pt does not need hospital admission?
1) SABA via large volume spacer
AND
2) Adults= short course oral prednisolone
Acute exacerbation of asthma follow up?
within 48hrs if not admitted to hospital; or within 48hrs of discharge
- PEF and review CP
- check inhaler technique
- consider stepping up Mx
- advice on recognising poor asthma control and early signs of exacerbation (sudden persistent worsening symptoms)
- give oral corticosteroids to take if have early signs of exacerbation
When to consider referral to resp for asthma after acute exacerbation?
2 asthma attacks within 12m
Summary of Mx for acute exacerbation of asthma if pt is admitted to hospital and attack is severe/life-threatening?
1) NEBULISED SALBUTAMOL (5mg) oxygen driven (flow rate 6L/min) over 30-60mins.
AND
2) NEBULISED IPRATROPIUM BROMIDE (500ug adults, 250ug children)
AND
3) 1st dose of PREDNISOLONE (40-50mg adults, 30-40mg >5yrs, 20mg <5) ; if can’t swallow then IV hydrocortisone 100mg
How long should pt take oral pred after acute exacerbation of asthma?
5d
Moderate attack of asthma in children 2-5yrs?
SpO2 > 92%
No clinical features of severe asthma
Severe attack of asthma in children 2-5yrs?
SpO2 < 92%
Too breathless to talk or feed
Heart rate > 140/min
Respiratory rate > 40/min
Use of accessory neck muscles
Life-threatening attack of asthma in children 2-5yrs?
SpO2 <92%
Silent chest
Poor respiratory effort
Agitation
Altered consciousness
Cyanosis
Moderate attack of asthma in children >5yrs?
SpO2 > 92%
PEF > 50% best or predicted
No clinical features of
severe asthma
Severe attack of asthma in children >5yrs?
SpO2 < 92%
PEF 33-50% best or predicted
Can’t complete sentences in one breath or too breathless to talk or feed
Heart rate > 125/min
Respiratory rate > 30/min
Use of accessory neck muscles
Life-threatening attack of asthma in children >5yrs?
SpO2 < 92%
PEF < 33% best or predicted
Silent chest
Poor respiratory effort
Altered consciousness
Cyanosis
Normal pCO2 in acute asthma attack?
indicates exhaustion and should be classified as life-threatening
Near-fatal asthma?
Raised pCO2 and/or requiring mechanical ventilation with raised inflation pressures
Mx for pts who fail to respond to any intervention for acute asthma attack?
admit ITU/HDU for intubation and ventilation
Criteria for discharge after acute asthma exacerbation?
- been stable on their discharge medication (i.e. no nebulisers or oxygen) for 12-24 hours
- inhaler technique checked and recorded
- PEF >75% of best or predicted
When diagnosing asthma, what tests should all pts have?
Adults:
- spirometry with BDR
- FeNO test
5-16yrs:
- spirometry with BDR
- FeNO if normal S or obstructive S with -ve BDR
<5yrs:
- clinical
Asthma-COPD overlap syndrome (ACOS)?
pts with airway disease who have features of both asthma and COPD
10-30% of asthma and COPD pts
Criteria for asthma-COPD overlap syndrome?
- > 40yrs
- resp symptoms (eg. exertional dyspnoea) persistent but variability in symptoms may be prominent
- persistent airflow obstruction
- Hx of asthma or evidence of partial BDR
- exposure to a RF eg. >=10 pack yr tabacco smoking or equivalent indoor/outdoor air pollution
Pathophysiology of asthma-COPD overlap syndrome?
- Asthma= eosinophilic inflam, reversible airway obstruction and airway hyperresponsiveness
- COPD= neutrophilic inflam, irreversible airway obstruction and progressive airflow limitation due to alveolar destruction (emphysema) and chronic bronchitis
- ACOS= combination of both so more complex disease process
Mx for ACOS?
- smoking cessation, immunisation, inhaler technique
- SABA for symptomatic control
+ ICS (low or moderate) - can + LABA or LAMA
need specialist input as more exacerbations, lower QOL and decline in lung function and mortality worse in ACOS than just asthma or COPD
Bronchiectasis?
Persistent or progressive chronic debilitating disease characterised by permanent dilation of the bronchi due to irreversible damage to elastic and muscular components of the bronchial wall
What is bronchiectasis caused by?
inflam damage to airways:
irreversible damage to elastic and muscular components of bronchial wall causing permanent dilation of the bronchi
Clinical features of bronchiectasis?
- daily expectoration of large volumes of purulent sputum
- cough
- SOB
- haemoptysis
- non-pleuritic chest pain between exacerbations
- coarse crackles during early inspiration
- wheeze
- high pitched inspir squeaks
- large airway rhonchi (low pitched sore like sound)
- palpable chest secretions on coughing
Suspect bronchiectasis in adults with what?
- cough >8w with sputum production or Hx of trigger
- RA + chronic productive cough or recurrent chest infections
- COPD with 2+ exacerbations annually and/or +ve sputum culture for Pseudomonas aeruginosa whilst stable
- IBD + chronic productive cough
Suspect bronchiectasis in children with what?
- chronic productive cough unresponsive to 4w Abx, between viral colds or with +ve sputum culture for = s. aureus, H. influenza, P.aeruginosa, non-TB mycobacteria or Burkholderia capacia complex
- wet wough >6w
- asthma unresponsive to Mx
- severe pneumonia where symptoms, signs or radiological changes don’t complete resolve
- recurrent pneumonia
- localised chronic bronchial obstruction
- exertional SOB
- unexplained haemoptysis
- persistent & unexplained signs or CXR abnormalities
Ix for bronchiectasis?
- sputum culture
- CXR
- spirometry
- O2 sats
- and FBC incl WCC
- refer to resp to confirm diagnosis
Mx for infective exacerbation of bronchiectasis? (most in primary care but sometimes hospital admission may be needed)
- previous microbio cultures should guide Abx therapy
- if not available then local protocols, if not available then amoxicillin or clarithromycin/erythromycin
Signs on examination in bronchiectasis?
- Coarse crackles, especially in the lower lung zones.
- Wheeze.
- High-pitched inspiratory squeaks.
- Large airway rhonchi (low pitched snore-like sounds).
- Palpable chest secretions on coughing or forced expiratory manoeuvre, persisting over time.
- Finger clubbing (uncommon).
Clinical symptoms of bronchiectasis?
- Daily expectoration of large volumes of purulent sputum
- Dyspnoea
- Fever
- Fatigue, reduced exercise tolerance.
- Haemoptysis that can be frank (up to 10 mL) or massive (more than 235 mL) (26–51.2%).
- Rhinosinusitis.
- Weight loss.
- Chest pain that is present between exacerbations and is usually non-pleuritic
- Sputum colonization with P. aeruginosa.
- Young age at presentation.
- History of symptoms over many years.
- Absence of smoking history.
Differential diagnosis of bronchiectasis?
- asthma
- COPD
- chronic sinusitis
- pneumonia
- lung ca
- interstitial lung disease (asbestosis, hypersensitivity pneumonitis, pulmonary fibrosis, sarcoidosis)
- TB
When to suspect an infective exacerbation in pt with bronchiectasis?
- change in 1+ symptoms: increased sputum vol or purulence, worse SOB, increased cough or fatigue/malaise
- new symptoms eg. fever, pleuritic pain or haemoptysis
Ix in secondary care for bronchiectasis?
- high-resolution computed tomography (HRCT)= most frequently used to diagnose
- test for CF
- screen for gross antibody def eg. IgG, IgA, IgM= for all pts with confirmed diagnosis
- serum total IgE and specific IgE/skin prick test to Aspergillus (exclude allergic bronchopulmonary aspergillosis)
- specific antibody levels against strep pneumonia
could do= RF, anti-CCP, ANA and ANCA; HIV serology; A1AT def
What pts with bronchiectasis to be followed up in secondary care?
all to diagnose then
either follow up in primary care or
follow up in secondary care if:
- 3+ exacerbations in 1 yr
- chronic p.aeruginosa, MRSA or non-TB mycobacteria colonisation
- deteriorating or advanced disease
- allergic pulmonary aspergillosis
- long term Abx therapy
- associated RA, immune def, IBD, or primary ciliary dyskinesia
- considering lung transplant
Follow up for bronchiectasis?
- Baseline severity score= Bronchiectasis Severity Index
- Offer pulmonary rehab
- BMI
- check exacerbation Hx (refer for ?long-term prophy Abx if 3+ in 1yrs)
- sputum sample and culture (refer if chronic colonisation for p.a, mycobacteria or MRSA)
- MEDICAL RESEARCH COUNCIL DYSPNOEA SCALE
- spirometry
- O2 sats
- sputum clearance exercises compliance (refer to physio if havent been taught)
- Immunisation against influenza and strep pneumonia
- tell pt how to recognise exacerbations and what to do if get one
Arrange hospital admission for pt with bronchiectasis and?
- so unwell that need IV Abx (eg. cardioresp failure or sepsis)= cyanosis, confusion, marked SOB, rapid resps or laboured, peripheral oedema, 38C+
Mx for infective exacerbation of bronchiectasis if don’t need hospital admission?
- sputum for C&S before starting Abx but don’t wait for results
- Empirical Abx 7-14d (if already taking then stop and prescribe from different class)
- airway clearance technique
- Review Abx response once C&S available
- Offer a LABA but NOT ICS
- consider prophylactic Abx
Empirical Abx for acute exacerbation of bronchiectasis?
- amoxicillin 500mg 3td for 7-14d
or clarithromycin 500mg 2tds 7-14d
Prophylactic Abx for bronchiectasis if needed?
1st= azithromycin 500mg 3 times a week
min 6m but can use up to 1yr
If current P.aeruginosa= inhaled colistin
What should be done before starting pt on oral macrolides eg. azithromycin prophylaxis for bronchiectasis exacerbation?
- ECG: assess QT interval
- baseline LFTs
- baseline exacerbation rate
- microbio testing of sputum before starting
What should you do after starting pt on oral macrolides?
- LFTs 1m and then every 6m after starting
- ECG 1m after starting: if new QT prolongation then stop
What can cause bronchiectasis?
- Post-infective= TB, measles, pertussis, pneumonia
- CF
- bronchial obstruction eg. lung ca, forign body
- immune def: selective IgA, hypogammaglobulinaemia
- allergic bronchopulmonary aspergillosis (ABPA)
- ciliary dyskinetic syndromes: Kartagener’s, Young’s
- yellow nail syndrome
Summary of 3 features and 3 signs of bronchiectasis?
Features:
- persistent productive cough, large vol of sputum may be expectorated
- dyspnoea
- haemoptysis
Signs:
- abnormal chest auscultation= coarse crackles; wheeze
- clubbing may be present
Most common organisms isolated from pts with bronchiectasis?
- Haemophilus influenzae (most common)
- Pseudomonas aeruginosa
- Klebsiella spp.
- Streptococcus pneumoniae
Bronchiolitis?
Acute bronchiolar inflammation. Most common cause of serious lower resp tract infection in <1yr olds (90% are 3-6m).
Pathogen that causes bronchiolitis in 75-80% of cases?
Respiratory syncytial virus (RSV)
What provides protection to newborns against RSV (causing bronchiolitis)?
maternal IgG
Higher incidence of bronchiolitis when?
winter
Causes of bronchiolitis?
- RSV (most)
- mycoplasa, adenoviruses
- may be secondary bacterial infection
What can cause bronchiolitis to be more severe?
if bronchopulmonary dysplasia (eg. premature), congenital heart disease or CF
Features of bronchiolitis?
- coryzal symptoms (eg. mild fever) precede:
- dry cough
- increasing SOB
- wheezing, fine inspiratory crackles (not always)
- feeding difficulties
Most often reason for hospital admission due to bronchiolitis?
feeding difficulties associated with increased dyspnoea
Immediate hospital admission (999 ambulance) in pts with bronchiolitis when?
any of…
- apnoea
- looks seriously unwell
- severe resp distress= GRUNTING, marked chest recession, resp rate >70
- central cyanosis
- peristent O2 sats <92% on air
Consider hospital admission in pt with bronchiolitis when?
any of…
- resp rate >60
- difficulty feeding or inadequate oral fluid intake (50-75% of usual volume)
- clinical dehydration
Ix for bronchiolitis?
immunofluorescence of nasopharyngeal secretions may show RSV
Mx for bronchiolitis?
Whilst awaiting hospital admission= supp O2 to all pts with O2 sats <92%
- Largely supportive
- humidified O2 via head box if O2 sats persistently <92%
- NG feeding if can’t take enough fluid/feed my mouth
- suction sometimes used for XS upper airway secretions
How to determine the severity of a child’s condition with bronchiolitis?
- degree of agitation and consciousness (can be sign of hypoxia)
- signs of exhaustion, cyanosis and invl. of accessory muscles of respiration at rest
- examine chest, RR, pulse and BP
- O2 sats on air (pulse oximetry)
- hydration status= cap refill time, skin tugor and dryness of mucous membranes, urine output
Impending resp failure in pt with bronchiolitis may be indicated by what?
listlessness or decreased resp effort, recurrent apnoea, and/or failure to maintain O2 sats despite O2 supp
Low threshold for hospital admission in pt with bronchiolitis?
- <3m
- chronic lung disease
- haemodynamically signif congenital heart disease
- immunodef
- born premature (esp. <32w)
- long distance to healthcare in case of deterioration
What type of illness is bronchiolitis and when do symptoms tend to peak?
self-limiting
peak between 3-5d of onset
Mx advice is pt with bronchiolitis does not need hospital admission?
- paracetamol/ibuprofen for fever and then for as long as child appears distressed
- do not undress to try and reduce fever
- regular fluids
- check child regularly, incl. through the night
- seek medical advice is child deteriorates
Sign of deterioration in child with broncholitis?
- RR increaases
- episodes of apnoea, cyanosis, increased effort of breathing (grunting, nasal flaring, marked chest recession)
- fluid intake reduced to 50-75% of normal or signs of dehyration eg. dry mouth or no wet nappy for 12hrs
- less responsive
- worsening of fever
COPD stands for what?
chronic obstructive pulmonary disease
COPD?
Common treatable (but not curable) and largely preventable lung condition.
Persistent resp symptoms and airflow obstruction which is usually progressive and not fully reversible.
Major RF for development of COPD?
tobacco smoking
Cx of COPD?
reduced QOL and increased morbidity & mortality
Diagnosis/Ix for COPD?
- Clinical +
- Spirometry with BDR +
- CXR (exclude other causes) +
- FBC (identify anaemia or polycythaemia)
Spirometry findings in COPD?
A post bronchodilator FEV1/FVC of <0.7 (70%) confirms persistent airflow obstruction.
Mx for COPD?
- info
- smoking cessation
- pnumococcal and influenza vaccine
- pulmonary rehab
- self-management plan
- medical therapy
What is the use of ICSs in COPD associated with?
increased risk of pneumonia
When to refer to resp specialist in COPD?
- lung ca, cor pulmonale or bronchiectasis suspected
- very severe/worsening
- <40yrs and/or FHx of A1AT def
- uncertain
- O2 therapy, long-term non-invasive ventilation therapy, long-tern oral corticosteroids or lung surgery being considered
Referral for pulmonary rehab in COPD is indicated when?
- is functionally disabled by COPD
- has had recent hospitalisation for acute exacerbation
Emergency admission for pt with acute exacerbation of COPD if?
- severe SOB
- inability to cope at home/living alone
- poor or deteriorating condition
- acute confusion/impaired consciousness
- cyanosis or reduced O2 sats
- worsening peripheral oedema
- new arrhythmia
Mx of acute exacerbation of COPD not requiring admission?
- increased dose of SABA
- consider oral corticosteroids and an Abx
- seek medical help if worsen rapidly or signif
All pts with COPD should be what?
- followed up, frequency depending on their severity
- end-of-life issues should be discussed and advance care planning offered when appropriate
Signs and symptoms of COPD?
- SOB (persistent, progressive over time, worse on exertion)
- chronic/recurrent cough
- regular sputum production
- frequent LRTI
- wheeze
- waking up at night with SOB
- reduced exercise tolerance
- cyanosis
- raised JVP, peripheral oedema (may indicate cor pulmonale)
- cachexia
- hyperinflation of the chest
- use of accessory muscles and/or pursed lip breathing
- wheeze and/or crackles on auscultation
COPD auscultation?
wheeze and/or crackles
What may indicate cor pulmonale in COPD?
- ankle swelling (peripheral oedema)
- raised JVP
- systolic parasternal heave
- loud pulmonary second heart sound (over 2nd L ICS)
- hepatomegaly
What symptoms are uncommon in COPD?
chest pain and haemoptysis uncommon- consider other causes
Cor pulmonale?
RHF secondary to lung disease. Caused by pulmonary HTN as a consequence of hypoxia.
Stages of severity of airflow obstruction (COPD) according to reduction in FEV1?
Post-BD FEV1/FVC= <0.7 (70%)
AND
Stage 1= mild- FEV1 80% of predicted or higher
2= moderate- 50-79%
3= severe- 30-49%
4= very severe- <30% or <50% with resp failure
Medical Research Council (MRC) dyspnoea scale?
Grade 1= not troubled by SOB except during strenuous exercise
2= SOB when hurrying or walking up slight hill
3= walks slower than others on the level because of SOB or has to stop for breath when walking at own pace
4= stops for breath after walking about 100m or after few mins on the level
5= too SOB to leave the house, or breathless when dressing/undressing
Differential diagnosis for COPD?
- Asthma (nocturnal/variable symptoms, Hx atopic disease, non-smoker, <35yrs)
- Bronchiectasis (copious sputum, freq chest infect, Hx of childhood pneumonia, coarse lung crepitations)
- HF (SOB when lying flat, Hx of IHD, fine lung crepitations)
- Lung ca (persistent cough, haemoptysis, weight loss or persistent hoarse voice)
- Interstitial lung disease (dry cough, fine lung crepitations)
- Anaemia (fatigue, SOB, palpitations)
- TB (persistent productive cough, SOB, haemoptysis)
- CF
- Upper airway obstruction eg. tracheal tumour
Coarse crackles (crepitations)?
- louder, low pitch, long lasting
- like bubbling or crackling
- during inspiration and expiration
- typically in conditions where secretions or fluid present in larger airways:
- pnuemonia
- chronic bronchitis
- late-stage pulmonary oedema
- bronchiectasis
- COPD exacerbation
Fine crackles (crepitations)?
- soft, high pitched, brief
- like velcro being pulled apart or hair rubbing near the ear)
- mostly during inspiration
- often in conditions affecting alveoli or small airways:
- pulmonary fibrosis (common)
- interstitial lung disease
- early HF (pulmonary oedema)
Lung sounds associated with COPD?
- wheezing (due to airway narrowing)
- rhonchi (low pitch related to mucus in larger airways
- diminished breath sounds in later stages (air trapping and hyperinflation)
- coarse crackles during exacerbation
Crackles (crep) in pulmonary oedema?
fine crackles that may progress to coarse as fluid accumulates
- often associated with HF
Crackles (crep) in pulmonary fibrosis?
fine, late inspiratory crackles
“velcro crackles”
Crackles (crep) in bronchiectasis?
coarse crackles due to mucus build up in dilated airways
Crackles (crep) in pneumonia?
coarse crackles usually localised to area of lung infection
Early inspiratory crackles?
heard early during inspiration
often associated with chronic bronchitis or emphysema
Late inspiratory crackles?
heard later in inspiration
common in pulmonary fibrosis, HF and atelectasis
Examples of interstitial lung diseases?
asbestosis, pneumoconiosis, fibrosing alveolitis, sarcoidosis
Acute exacerbation of COPD definition?
sustained worsening of a pts symptoms from their usual stable state (beyond normal day to day variations)
Triggers of acute exacerbation of COPD?
- resp tract infections eg. rhinovirus, h.influenzae, s.pneumoniae, moraxella catarrhalis
- smoking
- envrionmental pollutants
Common trigger of COPD exacerbation?
H.influenzae (most common)
rhinovirus
many exacerbations won’t respond to Abx as not caused by bacterial infections
CP of COPD exacerbation?
increased…
- SOB
- cough
- sputum production & change in sputum colour
- wheeze and chest tightness
- URTI symptoms eg. cold, sore throat
- reduced exercise tolerange
- ankle swelling
- increased fatigue
- acute confusion
Differential diagnosis of COPD exacerbation?
- pneumonia
- PE
- pneumothorax
- acute HF
- cardiac ischaemia or arrhythmia
- lung ca
- upper airway obstruction
You should you not refer for pulmonary rehab if they have COPD?
- unable to walk
- unstable angina/recent MI
Oxygen is the treatment for what?
hypoxaemia not SOB
Inappropriate O2 therapy in pts with COPD may cause what?
resp depression
When to offer LTOT (long term O2 therapy) to pt with COPD?
Only after specialist assessment. Can improve survival in stable COPD and chronic hypoxia.
Refer for LTOT if…
- O2 sats 92% or less
- very severe or severe airflow obstruction
- cyanosis
- polycythaemia
- peripheral oedema
- raised JVP
Prophylactic Abx for COPD (initiated in secondary care)?
if have had 3+ exacerbating needing steroid therapy and at least 1 requiring hospital admission in previous yr= consider referral for Abx prophy
Azithromycin 500mg 3x per week for min 6-12m; assess benefit after 6m and 12m
Adverse effects of macrolides?
GI upset, hearing and balance disturbance, cardiac effects (prolongation of QTi) and microbio resistance
Follow up for COPD?
At least once per yr.
Very severe airway obstruction= twice per yr.
- MRC D scale to assess severity
- exacerbation freq and severity
- meds incl. inhaler technqiue
- smoking status and BMI
- annual flu vaccine and once-only pneumococcal
- Cx or cormorbities
- Spiraometry
- very severe= + pulse oximetry
What indicates rapidly progressing disease in COPD?
loss of 500ml or more over 5yr on spirometry
Target O2 sats for pt with COPD?
88-92% as risk of hypercapnia; adjust to 94-98% if pCO2 normal
SAMA?
short-acting muscarinic antagonist
eg. Ipratropium
slow onset: 30-60min and lasts 3-6hrs
LAMA?
long-acting muscarinic antagonists
eg. tiotropium
have prolonged binding to muscarinic receptors which lengthens duration of bronchodilator effect
SAMA for COPD?
ipratropium aerosol inhalation 1-2puffs (20-40ug) 3-4x daily
LAMA for COPD?
tiotropium (for maintenance)
Spiriva Respimat® 5 micrograms once daily by inhalation of aerosol (2 puffs is equivalent to 5 micrograms of tiotropium)
Causes of COPD?
- smoking!
- A1AT def
- cadmium (used in smelting)
- coal
- cotton
- cement
- grain
Why is the use of peak flow limited in COPD?
can underestimate the degree of airflow obstruction
Offer LTOT to who in COPD?
pO2 of <7.3kPa or those with pO2 of 7.2-8kpa and one of:
- secondary polycythaemia
- peripheral oedema
- pulmonary HTN
assessment done by ABG on 2 occasions at least 3w apart in pts with COPD stable
When to not offer LTOT to pt with COPD?
if continue to smoke despite being offered smoking cessation advice
Risk assessment for LTOT?
- smoking status
- risks of falls from tripping over equipment
- risk of burns and fires and increased risk of those who live in homes where someone smokes (incl. e-cigs)
Pts on LTOT for COPD should breathe the supp O2 for how long?
at least 15hrs a day
Things to do before starting azithromycin prophylaxis in pts with COPD who are indicated to have it?
- LFTS and ECG to exclude QT prolongation
- CT thorax to exclude bronchiectasis
- Sputum culture to exclude atypical infections and TB
What can reduce risk of COPD exacerbations in pts with severe COPD and Hx of freq exacerbations?
Phosophodiesterase-4 (PDE-4) inhibitors eg. roflumilast
If pt has COPD and is said to have ‘asthma features’ (which affects COPD mx) what are these?
- diagnosis of asthma or atopy
- raised esosinophil count
- substantial variation in FEV1 over time (at least 400ml)
- substantial dinural variation in PEFlow (at least 20%)
Cystic fibrosis?
autosomal recessive disorder causing increased viscosity of secretions (eg. lungs and pancreas).
What causes CF?
defect in the cystic fibrosis transmembrane conductance regulator gene (CFTR) which codes a cAMP-regulated chloride channel
What does CFTR gene code for?
a cAMP-regulated chloride channel
Most cases of CF are due to what?
delta F508 on long arm of chromosome 7 causing defect in CFTR gene
CF affects how many births?
1 per 2500
Carrier rate or CF?
1 in 25
Organisms which may colonise CF pts?
- Staph. aureus
- P. aeruginosa
- Aspergillus
- Burkholderia cepacia (p. cepacia)
Diagnosis of CF?
- +ve test result on infant screening (blood spot immunoreactive trypsin test) followed by sweat and gene tests to confirm
or
- CP + sweat test (children & young adults) or gene test (adults)
Assess for CF (sweat test or gene test) in people with what?
- FHx
- congenital intestinal atresia
- meconium ileus
- distal intestinal obstruction syndrome
- faltering growth
- undernutrition
- recurrent and chronic pulmonary disease
- chronic sinus disease
- obstructive azzoospermia
- acute/chronic pancreatitis
- malabsorption
- rectal prolapse in children
- pseudo-Barreter syndrome
Sweat test for CF?
- abnormally high sweat chloride if have CF
CF= >60mEq/l
normal= <40mEq/l
Causes of false positive sweat test (when testing for CF)?
- malnutrition
- adrenal insufficiency
- glycogen storage diseases
- nephrogenic diabetes insipidus
- hypothyroidism, hypoparathyroidism
- G6PD
- ectodermal dysplasia
Common reasons for false negative sweat test (when testing for CF)?
skin oedema, often due to hypoalbuminaemia/hypoproteinaemia secondary to pancreatic exocrine insuff
Features of CF?
- neonatal (20%)= meconium ileus, less common: prolonged jaundice
- recurrent chest infections (40%)
- malabsorption (30%)= steatorrhoea, failure to thrive
- other features (10%)= liver disease
- short stature
- DM
- delayed puberty
- rectal prolapse (due to bulky stools)
- nasal polyps
- male infertitlity, female subfertility
When are pts diagnosed with CF?
most on newborn screening or early childhood; 5% >18yrs
Meconium ileus in neonatal period can be sign of what?
CF
Recurrent chest infections, steatorrhoea, short stature, delayed puberty and male infertility?
CF
Symptoms/signs of malabsoption?
steatorrhoea, failure to thrive
Mx for CF? (7)
MDT approach
1) regular (2+ per d) chest physio and postural drainage (pts taught to do this); also deep breathing exercises
2) high calorie, high fat diet
3) minimal contact with other CF pts
4) vitamin supplements
5) pancreatic enzyme supplements taken with meals (Creon)
6) lung transplant
7) Lumacaftor/Ivacaftor (Orkambi)
Why should CF pts try to minimise contact with eachother?
to prevent cross infection with Burkholderia cepacia complex and Pseudomonas aeruginosa
What is an important CF specific contraindication to lung transplantation?
chronic infection with Burkholderia cepacia
Lumacaftor/Ivacaftor (Orkambi) for CF Mx?
used for CF pts who are homozygous for the delta F508 mutation
