Respiratory Flashcards
What is Asthma?
- Chronic respiratory condition with airway inflammation and hyper-responsiveness
- Variable over time
- Eosinophilia
What are the Royal College of Physicians 3 questions for Asthma?
No to all Q’s consistent with controlled asthma
- ‘Have you had difficulty sleeping because of your symptoms?’
- ‘Have you had your usual symptoms during the day?’
(cough, wheeze, chest tightness or breathlessness) - ‘Has your asthma interfered with your usual activities?’
Expanded Score with frequency of symptoms (0-3)
What is the ACQ-5 for Asthma?
H&E for Asthma
- Cough - worse at night
- Breathlessness
- Wheezing
- Recent upper respiratory tract infection
- Chest tightness
RF for Asthma
- Other atopic features
- Eczema
- Hayfever
- Allergic rhinitis
- Family history
- Smoking
Investigations for Asthma
- Spirometry with bronchodilator reversibility
- Reduced FEV1 - improvement by 12% or more
- Normal FVC
- FEV1/FVC < 70%
- FeNO for eosinophilic inflammation (not for <5yr)
- 40 ppb or more is positive in adults
- 35 ppb or more is positive in children
- Peak expiratory flow rate
- Chest X-ray
- FBC: Eosinophils: > 0.3
Severity of acute Asthma exacerbation?
Management for Asthma
- SABA
- Add ICS if regular exacerbations
- Add LABA
- Increase ICS if not responding well
- Add LTRA
EXTRA FLASHCARD FOR HOW EACH MED ACTS
Management of Acute Asthma attack
- Hospital admission for life-threatening and unresponsive severe, or previous near-fatal attack, pregnancy, if using oral corticosteroid or presentation at night
- 15L oxygen via non-rebreathe mask, target 94-98%
- SABA - salbutamol, terbutaline
- Nebulised in life-threatening
- Corticosteroid
- 40-50mg oral prednisolone for 5 days or until patient recovers
- SAMA if not responding/severe or life-threatening - ipratropium bromide
- If still not responding and becoming acidotic, senior critical care support, intubation and ventilation
Criteria for discharge for acute asthma attack
- Stable on discharge medication for 12-24 hours
- Inhaler technique checked and recorded
- PEF >75% of best or predicted
What is Allergic Bronchopulmonary Aspergillosis (ABPA)
- Hypersensitivity reaction to bronchial colonisation by Aspergillus fumigatus mould
- Typically affects patients with asthma
- Presentation similar to asthma, with fever, malaise, mucus expectoration and haemoptysis
- Peripheral blood eosinophilia
What is Asthma COPD overlap syndrome?
Diagnosed when you have symptoms of both asthma and COPD.
Not a separate disease
“Persistent airflow obstruction with features of asthma”
H&E for A+COPD OS
People diagnosed with ACOS typically experience symptoms more frequently than people with asthma or COPD alone and have reduced lung function. Symptoms include:
- Difficulty breathing
- Frequent shortness of breath
- Excess mucus (more than usual)
- Wheezing
- Feeling tired
- Frequent coughing
Investigations for A+COPD OS
Lung function tests - obstructive pattern
What is Acute Bronchitis?
Self-limiting lower respiratory tract infection
What is Acute Bronchitis usually caused by?
- Rhinovirus
- Parainfluenza
- Influenza A / B
- Respiratory Syncytial Virus
- Coronavirus
H&E for Acute Bronchitis
- Cough, may be productive
- Dyspnoea and wheezing
- Mild fever
- Exclusion of other causes
RF for Acute Bronchitis
- Infection exposure
- Smoking
Investigations for Acute Bronchitis
Usually clinical diagnosis
BUT
Consider CXR if:
- suspected pneumonia
- elderly patient
- persistent cough > 6 weeks
- history of chronic illness
Management for Acute Bronchitis
If otherwise healthy - paracetamol + ibuprofen
If cough > 2 weeks - inhaled corticosteroids
If patient has underlying lung pathology - Amoxicillin / Doxycycline
SABA + Antitussives if wheezy / disrupting sleep
What is Pneumothorax?
A collapsed lung - when air leaks into the space between your lung and the chest wall, the air pushes on the outside of the lung and makes it collapse
Can be a complete lung collapse or only a portion of the lung
H&E of Pneumothorax
Sudden onset:
- Dyspnoea
- Pleuritic chest pain
- Sweating
- Tachypnoea
- Tachycardia
- Hyperresonance on percussion
- Absent breath sounds
- Decreased tactile vocal fremitus
Investigations of Pneumothorax
Chest X-ray:
- Regions of dark around the edge of the lung (darker than lung)
How can Pneumothorax be classified?
Primary - in absence of underlying lung disease
Secondary - in presence of underlying lung disease
RF of Pneumothorax
- pre-existing lung disease : COPD, asthma, cystic fibrosis, lung cancer, pneumocystis pneumonia
- connective tissue diseases : Marfan’s, rheumatoid arthritis
- ventilation, including non-invasive ventilation
- catamenial pneumothorax - cause of 3-6% of spontaneous pneumothoraces occurring in menstruating women (thought to be caused by endometriosis within the thorax)
What is management of Pneumothorax dependent on?
Depends on type, size + clinical status of patient
Management of Primary Pneumothorax
- <2cm rim of air and no dyspnoea: discharge
- > 2cm rim of air and/or dyspnoea: pleural aspiration
- If this fails (>2cm or dyspnoea), insert chest drain
Management of Secondary Pneumothorax
- If rim of air <1cm, give oxygen and admit for 24 hours
- Rim of air between 1-2cm: pleural aspiration
- If this fails, then insert chest drain
- Patient >50 and rim of air >2cm and/or dyspnoea: chest drain
- If chest drain fails → video-assisted thoracoscopic surgery (VATS)
Management of Tension Pneumothorax
- May occur following thoracic trauma when a lung parenchymal flap is created.
- This acts as a one way valve and allows pressure to rise.
- The trachea shifts and hyper-resonance is apparent on the affected side.
- Treatment is with emergency needle thoracocentesis and chest tube insertion.
What is Pneumonia?
It describes any inflammatory condition affecting the alveoli - in majority of patients this is secondary to a bacterial infection
Pathophysiology of Pneumonia
Once pathogen has entered the lower respiratory tract, an inflammatory cascade begins.
Neutrophils migrate to affect alveoli and release cytokines which activate immune response and induce fever.
Leads to accumulation of fluid and pus with the alveoli which impairs gaseous exchange, leading to hypoxic state, characteristic of pneumonia.
What can cause Community-Acquired Pneumonia?
Streptococcus pneumonia - 80%
Haemophilus influenza
Staphylococcus aureus: commonly after influenza
Atypical pneumonias
Viruses
What are the characteristic features of pneumococcal Pneumonia?
- Rapid onset
- High fever
- Pleuritic chest pain
- Herpes labialise (cold sores)
H&E of Pneumonia
- cough with purulent sputum (rust coloured/bloodstained)
- Dyspnoea
- Chest pain (may be pleuritic)
- Fever
- Malaise
- Signs of systemic infection
- pyrexia
- tachycardia
- hypotension
- confusion
- Tachypnoea
- Low O2 sats (below 95% or 88% in COPD)
- Reduced breath sounds, bronchial breathing, and crepitation/crackles, dullness of percussion (fluid)
If symptoms develop more than 48hrs after hospital admission it is hospital-acquired
Investigations for Pneumonia
- CXR
- consolidation in area of infection
- may show effusion
- REPEAT AT 6 WEEKS AFTER CLINICAL RESOLUTION
- Bloods
- FBC : Raised WCC
- U&Es : Urea for CURB65
- CRP : monitor to see response to treatment
- Blood cultures
- Sputum sample
- Legionella antibodies in immediate and high-risk patients
Investigations for Atypical Pneumonia
Same as Pneumonia but also:
- CT to detect abscesses/empyema formation with bronchoscopy in some cases
- Mycoplasma serology
- Positive cold agglutination test
What is CRB-65?
Used in primary care:
C - Confusion (abbreviated mental test score <= 8/10)
R - Respiratory rate >= 30/min
B - BP: systolic <= 90 and/or diastolic <=60
65 - Aged 65 or over
Score of 0 : low risk
Hospital assessment for all other patients
What is CURB-65?
Used in secondary care:
C - Confusion (abbreviated mental test score <= 8/10)
U - Urea > 7mmol/L
R - Respiratory rate >= 30/min
B - BP: systolic <= 90 and/or diastolic <=60
65 - Aged 65 or over
Score of:
0-1 : low risk, home-based care
2 : Intermediate risk, hospital care
3-5 : high risk, intensive care
Management of Pneumonia
Low severity CAP:
- amoxicillin is first-line
- if penicillin allergic then use clarithomycin or tetracycline
- 5 day course
Moderate-high CAP:
- dual antibiotic therapy with amoxicillin and clarithomycin
- 7-10 day course
- consider a beta-lactamase stable penicillin such as co-amoxiclav, ceftriaxone or piperacillin with tazobactam and a macrolide in high-severity CAP
Give Flucloxacillin if suspecting Staph.A e.g. after influenza
HAP:
- co-amoxiclav
- doxycycline if penicillin allergic
Atypical:
- Clarithromycin or doxycycline
Complications of Pneumonia
- Severe pneumonia can result in respiratory failure and / or septic shock
- Empyema is a complication of pneumonia and should be suspected if the patient is not responding as expected to antibiotics
- Atrial fibrillation can be triggered by pneumonia (both in known patients and as the first presentation)
- Bacterial pericarditis can arise because of local spread of bacteria
- Jaundice may arise from sepsis or antibiotic treatment.
What is Influenza?
- Acute respiratory tract infection caused by seasonal influenza A or B
- Aerosol transmission
- Single-stranded RNA genome
- H-antigen helps binding and entry into tracheobronchial epithelial cells
- N-antigen helps virus to escape
- Typical in winter season
H&E of Influenza
Key Diagnostic Features:
- Fever, malaise, myalgia
- Cough
- Sore throat
- Unvaccinated
- Winter
- Cervical lymphadenopathy
RF for Influenza
- Age over 65 or 1/2-5 years old
- CKD
- Chronic respiratory conditions
- Pregnancy
- Diabetes
- Immunocompromised
- Healthcare workers
Investigations for Influenza
- Clinical diagnosis
- Can do viral culture but takes a few days to be reported
Management of Influenza
- Bed rest, antipyretics and simple analgesia
- Consider antiviral therapy (e.g. oseltamivir) in high-risk groups, but only effective in first 48 hours from onset
- Provide antiviral therapy to hospitalised patients
What is Bronchiectasis?
Describes a permanent dilatation of the airways secondary to chronic infection or inflammation
Causes of Bronchiectasis
- Post-infective: TB, measles, pertussi, pneumonia
- Cystic fibrosis
- Bronchial obstruction e.g. lung cancer/foreign body
- Immune deficiency : selective IgA, hypogammaglobulinaemia
- Allergic bronchopulmonary aspergillosis
- Cilliary dyskinetic syndromes
- Yellow nail syndrome
H&E of Bronchiectasis
- Persistent productive cough
- Coarse crackles, high-pitched inspiratory squeaks and pops
- Wheeze
- Dyspnoea on exertion
- Haemoptysis
- Clubbing
RF for Bronchiectasis
- Cystic fibrosis
- Host immunodeficiency
- Previous infection
- Congenital disorder of bronchi
- Primary cilliary dyskinesia
Investigations of Bronchiectasis
First:
- High-resolution chest CT
- CXR : parallel line opacification, indicate dilated bronchi
- Bloods
- Sputum MC&S
- Test for RF
Management of Bronchiectasis
- Physical training
- Postural drainage
- Abx for exacerbations or long-term in severe cases
- Consider bronchodilators
- Immunisation
- Surgery for localised disease
