respiratory Flashcards
How is a pneumothorax managed?
if no or minimal symptoms - conservative care regardless of pneumothorax (minimal symptoms is defined as no significant pain, breathlessness and no physiological compromise)
if they are symptomatic - assess for high risk characteristics
high risk characteristics:
haemodynamic compromise (suggesting a tension pneumothorax)
significant hypoxia
bilateral pneumothorax
underlying lung disease
≥ 50 years of age with significant smoking history
haemothorax
if not high risk characteristics are present - either conservative management, ambulatory device, needle aspiration
If high risk characteristics - chest drain
patients with a primary spontaneous pneumothorax that is managed conservatively should be reviewed every 2-4 days as an outpatient
patients with a secondary spontaneous pneumothorax that is managed conservatively should be monitored as an inpatient
if stable, follow-up in the outpatients department in 2-4 weeks
what is ambulatory care for pneumothorax ?
an example of an ambulatory device is the Rocketµ Pleural Vent„
it includes an 8FG catheter mounted on an 18G needle and a pigtail catheter to minimize the risk of occlusion
ambulatory devices typically have a one-way valve and vent to prevent air and fluid return to the pleural space while allowing for controlled escape of air and drainage of fluid
many devices also have an indication diaphragm that signals when the catheter tip enters the pleural space and continues to fluctuate with respiration, aiding in the assessment of pneumothorax resolution
when can you fly after a pneumothorax?
absolute contraindication, the CAA suggest patients may travel 2 weeks after successful drainage if there is no residual air. The British Thoracic Society used to recommend not travelling by air for a period of 6 weeks but this has now been changed to 1 week post check x-ray
when can you scuba dive post pneumothorax?
the BTS guidelines state: ‘Diving should be permanently avoided unless the patient has undergone bilateral surgical pleurectomy and has normal lung function and chest CT scan postoperatively.’
What is sarcoidosis?
a multisystem disorder of unknown aetiology characterised by non-caseasting granulomas.
what are the features of sarcoidosis?
acute: erythema nodosum, bilateral hilar lymphadenopathy, swinging fever, polyarthralgia
insidious: dyspnoea, non-productive cough, malaise, weight loss
ocular: uveitis
skin: lupus pernio
hypercalcaemia: macrophages inside the granulomas cause an increased conversion of vitamin D to its active form (1,25-dihydroxycholecalciferol)
how is sarcoidosis investigated?
ACE levels have a sensitivity of 60% and specificity of 70% and are therefore not reliable in the diagnosis of sarcoidosis although they may have a role in monitoring disease activity.
Routine bloods may show hypercalcaemia (seen in 10% if patients) and a raised ESR
A chest x-ray may show the following changes:
stage 0 = normal
stage 1 = bilateral hilar lymphadenopathy (BHL)
stage 2 = BHL + interstitial infiltrates
stage 3 = diffuse interstitial infiltrates only
stage 4 = diffuse fibrosis
spirometry - restrictive defect
tissue biopsy - non-caseating granulomas
how is sarcoidosis managed?
Indications for steroids
patients with chest x-ray stage 2 or 3 disease who are symptomatic. Patients with asymptomatic and stable stage 2 or 3 disease who have only mildly abnormal lung function do not require treatment
hypercalcaemia
eye, heart or neuro involvement
what factors in sarcoidosis are associated with poor prognosis?
insidious onset, symptoms > 6 months
absence of erythema nodosum
extrapulmonary manifestations: e.g. lupus pernio, splenomegaly
CXR: stage III-IV features
black African or African-Caribbean ethnicity
how are pleural effusions classified?
Pleural effusions may be classified as being either a transudate or exudate according to the protein concentration.
Transudate < 30g/L protein
Exudate >30g/L proetein
what are causes of transudate pleural effusions?
heart failure (most common transudate cause)
hypoalbuminaemia
liver disease
nephrotic syndrome
malabsorption
hypothyroidism
Meigs’ syndrome
what are causes of exudate pleural effusions?
Infection - pneumonia, TB, subphrenic abscess
Connective tissue disease - RA, SLE
Neoplasia - lung Ca, mesothelioma, mets
pancreatitis
PE
Dressler’s syndrome
yellow nail syndrome
when should LTOT be offered to patients?
LTOT should be offered to patients with a pO2 of < 7.3 kPa or to those with a pO2 of 7.3 - 8 kPa and one of the following:
secondary polycythaemia
nocturnal hypoxaemia
peripheral oedema
pulmonary hypertension
what is the general management of COPD?
> smoking cessation advice: including offering nicotine replacement therapy, varenicline or bupropion
annual influenza vaccination
one-off pneumococcal vaccination
pulmonary rehabilitation to all people who view themselves as functionally disabled by COPD
what is the medical management of COPD?
1st line - SABA or SAMA
if they remain breathless or have exacerbations the next step is to determine if the patient has asthmatic features suggesting steroid responsiveness
No asthmatic features
add a long-acting beta2-agonist (LABA) + long-acting muscarinic antagonist (LAMA)
if already taking a SAMA, discontinue and switch to a SABA
Asthmatic features
LABA + inhaled corticosteroid (ICS)
if patients remain breathless or have exacerbations offer triple therapy i.e. LAMA + LABA + ICS
if already taking a SAMA, discontinue and switch to a SABA
NICE recommend the use of combined inhalers where possible
what features suggest a patient with COPD has asthmatic/steroid responsive features?
any previous, secure diagnosis of asthma or of atopy
a higher blood eosinophil count - note that NICE recommend a full blood count for all patients as part of the work-up
substantial variation in FEV1 over time (at least 400 ml)
substantial diurnal variation in peak expiratory flow (at least 20%)
Interestingly NICE do not recommend formal reversibility testing as one of the criteria. In the guidelines they state that ‘routine spirometric reversibility testing is not necessary as part of the diagnostic process or to plan initial therapy with bronchodilators or corticosteroids
when is theophylline used in COPD?
NICE only recommends theophylline after trials of short and long-acting bronchodilators or to people who cannot used inhaled therapy
the dose should be reduced if macrolide or fluoroquinolone antibiotics are co-prescribed
when is prophylactic abx therapy indicated in COPD ?
azithromycin prophylaxis is recommended in select patients
patients should not smoke, have optimised standard treatments and continue to have exacerbations
other prerequisites include a CT thorax (to exclude bronchiectasis) and sputum culture (to exclude atypical infections and tuberculosis)
LFTs and an ECG to exclude QT prolongation should also be done as azithromycin can prolong the QT interval
when should a rescue pack for COPD be provided to patients?
have had an exacerbation within the last year
understand how to take the medication, and are aware of associated risks and benefits
know to when to seek help and when to ask for replacements once medication has been used
when are PDE-4 inhibitors recommended in COPD?
Phosphodiesterase-4 (PDE-4) inhibitors
oral PDE-4 inhibitors such as roflumilast reduce the risk of COPD exacerbations in patients with severe COPD and a history of frequent COPD exacerbations
NICE recommend if:
the disease is severe, defined as a forced expiratory volume in 1 second (FEV1) after a bronchodilator of less than 50% of predicted normal, and
the person has had 2 or more exacerbations in the previous 12 months despite triple inhaled therapy with a long-acting muscarinic antagonist, a long-acting beta-2 agonist and an inhaled corticosteroid
which type of lung cancer is not necessarily associated with smoking?
Adenocarcinoma
what are the features of squamous cell lung Ca?
Squamous cell lung cancers are strongly associated with smoking
They can cavitate and sometimes appear as cavitating lesions on chest x-ray. In addition, they are associated with hypercalcemia.
what are the features of small cell lung cancer?
Small cell carcinomas account for about 20% of lung cancers. They are the most aggressive type of lung cancer and have usually metastasized by the time of diagnosis
The are also associated with hyponatraemia.
what are risk factors for lung cancer?
Smoking
increases risk of lung ca by a factor of 10
Other factors
asbestos - increases risk of lung ca by a factor of 5
arsenic
radon
nickel
chromate
aromatic hydrocarbon
cryptogenic fibrosing alveoli’s
Smoking and asbestos are synergistic, i.e. a smoker with asbestos exposure has a 10 * 5 = 50 times increased risk
