Respiratory Flashcards
define asthma ?
- chronic inflammatory airway disease leading to variable airway obstruction
- bronchoconstriction is reversible with bronchodilators
name 3 respiratory emergencies
anaphylaxis
pneumothorax
pulmonary embolism
define ventilation
movement of air into and out of lungs during a single breathing cycle
what is alveolar ventilation and how do you calculate it?
total volume of air that reaches the alveoli and contributes to gas exchange
alveolar ventilation = RR x (tidal volume - dead space volume)
why is the concept of physiological dead space important?
physiological dead space = volume of lung that doesn’t eliminate CO2
- important because if this space increases (e.g. pneumonia) then patient needs to increase minute ventilation to maintain adequate gas exchange
what is hypoxic pulmonary vasoconstriction?
physiological response to alveolar hypoxia
- if PA02 decreases, pulmonary arterioles vasoconstrict to limit blood flow to hypoxic alveoli
what is the V/Q ration if ventilation is 4L/min and perfusion is 5L/min ?
4/5 or 0.8
what happens to V/Q ration if you decrease ventilation or perfusion?
decreased ventilation? V/Q ration decreases
increased ventilation? V/Q ratio increases
NB both V&Q are greater at the lung bases than apices
spirometry: what is FEV1?
Forced expiratory volume in 1 second (FEV1) = air a person can forcefully exhale in 1 second.
Measures how easily air can flow out of the lungs.
Reduced with airflow obstruction.
spirometry: what is FVC?
forced vital capacity = total air a person can exhale after a full inhalation
Measures volume of air someone can take into their lungs
Reduced with restricted lung capacity
when can we diagnose obstructive lung disease on spirometry?
Diagnosed when the FEV1 is less than 70% of the FVC = FEV1:FVC ratio of less than 70%
someone may have good lung volume but air can only move slowly in or out of lungs
causes of obstructive lung disease?
- asthma
- COPD
- bronchiectasis
- A1AT
- CF
when can we diagnose restrictive lung disease on spirometry?
- FEV1 and FVC are equally reduced
- FEV1:FVC ratio greater than 70%
lungs have limited ability to expand and fill with air
causes of restrictive lung disease?
fibrosis
sarcoidosis
obesity
MND
asthma risk factors?
- atopy (or FHx of atopy)
name 5 common asthma triggers?
Infection
Nighttime or early morning
Exercise
Animals
Cold, damp or dusty air
Strong emotions
name two medication classes that can worsen asthma symptoms?
- Beta-blockers, particularly non-selective beta-blockers (e.g., propranolol)
- NSAIDs (e.g., ibuprofen or naproxen)
what type o wheeze do you hear in asthma?
widespread “polyphonic” expiratory wheeze
asthma Px?
- episodic sx
- diurnal variation - worse at night
- SOB
- chest tightness
- dry cough
- wheeze - widespread, polyphonic
- reduced PEFR
asthma Ix?
NICE recommend:
1. Fractional exhaled nitric oxide (FeNO)
2. Spirometry with bronchodilator reversibility
Others to add in:
3. peak flow diary
4. direct bronchial challenge - opposite of reversibility testing
what % increase of FEV1 on reversibility testing suggests asthma?
greater than 12% increase in FEV1
BTS asthma management?
- SABA - salbutamol
- Add ICS - low dose beclometasone
- Add LABA - salmeterol / maintenance and reliever therapy (MART)
- Increase ICS dose / add leukotriene receptor antagonist (LTRA) - montelukast
- Specialist mx - eg oral prednisolone
NICE asthma management?
- SABA - salbutamol
- Add ICS - low dose beclometasone
- Add LTRA - montelukast
- Add LABA - salmeterol
- Consider changing to MART
- Increase ICS dose
- Consider high dose ICS or additional drugs - LAMA / theophylline
- Specialist mx - eg oral prednisolone
what other things are involved with asthma management other than asthma medication?
- ?occupational - refer to resp
- yearly flu jab
- yearly asthma review
- consider stepping down tx every 3mo or so
- reducing ICS dose - only by 25-30% at a time
- regular exercise, avoid smoking, avoid triggers
what medications make up MART and Trimbow?
MART - Fostair - beclometasone (ICS) + formoterol (LABA)
Trimbow - beclometasone + formoterol + glycopyrronium
example of a SABA?
salbutamol, terbutaline
name a LABA?
salmeterol, formoterol
name a SAMA?
ipratropium
Name a LAMA?
tiotropium
name some ICS used in asthma ?
beclometasone / budesonide / fluticasone
what is an acute exacerbation of asthma?
- rapid deterioration in sx in asthma
- triggers as chronic, may be infection
how might acute asthma present?
- SOB
- Cough
- Accessory muscle use
- Tachypnoea
- Global wheeze
- Reduced air entry
acute asthma grading criteria: moderate versus severe?
Moderate
- PEF 50-75%
Acute severe
- PEF 33-50% best
- RR>25
- HR>110
- Unable to complete sentences
acute asthma severity: life threatening
- PEF <33%
- Sats <92%
- Silent chest, cyanosis
- Bradycardia, low BP
- Exhaustion, confusion, coma
near fatal = raised pCO2
acute asthma Ix?
- ABG - resp alkalosis -> hypoxic -> normal pCO2
- bloods,
- CXR
when to admit with acute asthma?
- Life-threatening grade
- Acute severe grade + unresponsive to tx
- Previous near-fatal attack
- Pregnancy
- Occurring despite oral corticosteroid
- Px at night
acute asthma Mx?
Oxygen
Salbutamol - inhaler / nebs
Hydrocortisone - 100mg IV or prednisolone 40mg oral
Ipratropium - nebulised
Aminophylline - IV
Magnesium - IV
Escalate care
criteria for acute asthma discharge?
- Stable on discharge medication (no nebs / O2) for 12-24hrs
- Inhaler technique checked + recorded
- PEF >75%
why monitor serum potassium on salbutamol nebs?
salbutamol causes K+ to be absorbed from blood into cells leading to hypokalaemia
what is COPD?
- Chronic irreversible progressive condition involving airway obstruction, emphysema, chronic bronchitis
Related to:
- smoking
- A1AT deficiency
COPD: what is bronchitis and what is emphysema?
Bronchitis = long-term symptoms of a cough and sputum production due to inflammation in the bronchi
Emphysema = damage and dilatation of the alveolar sacs and alveoli, decreasing the surface area for gas exchange
how might COPD present?
long-term smoker with persistent symptoms of:
- Shortness of breath
- Cough
- Sputum production
- Wheeze
- Recurrent respiratory infections, particularly in winter
NB COPD does NOT cause clubbing!v
MRC SOB scale?
- SOB on marked exertion
- SOB on hills
- Slow or stop on flat
- Exercise tolerance 100-200 yards on flat
- Housebound / SOB on minor tasks
COPD versus asthma?
- Younger onset in asthma
- Smoking - in most with COPD
- Asthma - sx vary, less so in COPD
- Nocturnal sx in asthma
- Persistent productive cough - COPD
COPD Ix for diagnosis ?
- clinical
- spirometry - FEV1/FVC<70% with little/no response to reversibility testing
additional Ix you could do for COPD aside from spirometry?
- CXR - hyperinflation, flat hemidiaphragms, bullae
- FBC - anaemia/polycythaemia (raised Hb due to chronic hypoxia)
- ECG / ECHO - look for HF
- CT thorax - malignancy, bronchiectasis
- transfer factor for CO (TLCO)
- ?A1AT levels
how can we grade COPD severity - 4 stage scale
Using FEV1;
Stage 1 / mild - FEV1>80%
Stage 2 / moderate - FEV1 50-79%
Stage 3 / severe - FEV1 30-49%
Stage 4 - very severe - FEV1 <30%
COPD: conservative Mx?
- smoking cessation
- pneumococcal + flu jabs
- pulmonary rehab
COPD - describe stepwise medical Mx ?
1st step
- SABA / SAMA
2nd step:
if asthma/steroid responsive?
- LABA/ICS
Eg Fostair, Symbicort and Seretide =LABA and ICS combination inhalers
if not asthma/steroid responsive?
- LABA/LAMA
Eg Anoro Ellipta, Ultibro Breezhaler and DuaKlir Genuair = LABA and LAMA combination inhalers.
3rd Step:
- LABA / LAMA / ICS combination inhaler
Eg Trimbow, Trelegy Ellipta and Trixeo Aerospher
COPD: who is eligible for long term oxygen therapy?
severe COPD with chronic hypoxia (sats < 92%), polycythaemia, cyanosis or cor pulmonale.
what is cor pulmonale? why does it happen?
Right-sided heart failure caused by respiratory disease
- increased pressure and resistance in the pulmonary arteries (pulmonary hypertension) limits the right ventricle pumping blood into the pulmonary arteries. This causes back-pressure into the right atrium, vena cava and systemic venous system
causes of cor pulmonale?
COPD (the most common cause)
Pulmonary embolism
Interstitial lung disease
Cystic fibrosis
Primary pulmonary hypertension
what is an infective exacerbation of COPD?
- acute deterioration in sx in COPD pt
Causes - bacterial - H influenzae, strep pneumoniae, M catarrhalis
- Viral - human rhinovirus
IE-COPD Px?
- SOB, cough, wheeze
- increased sputum
- hypoxia, acute confusion
IE-COPD Ix?
- ABG
- Chest x-ray - pneumonia or other pathology
- ECG - arrhythmias or evidence of heart strain
- FBC to look for infection (raised white blood cells)
- U&E to check electrolytes, which can be affected by infections and medications
- Sputum culture
- Blood cultures in patients with signs of sepsis (e.g., fever
what would you see on ABG for someone with acute exacerbation of COPD?
- respiratory acidosis
Low pH indicates acidosis
Low pO2 indicates hypoxia and respiratory failure
Raised pCO2 indicates CO2 retention (hypercapnia)
Raised bicarbonate indicates chronic retention of CO2 - kidneys producing more bicarb to balance increased CO2 but cannot keep up with rate in exacerbation
IE-COPD Mx?
- regular inhalers (salbutamol / ipratropium)
- oxygen (+/- chest physio)
- 30mg prednisolone for 5d
- antibiotics
if severe …
5. IV aminophylline
6. NIV
7. Intubation and ventilation
what is asthma-COPD overlap syndrome?
clinical syndrome consisting of persistent airflow limitation (COPD) in someone >40 with a Hx of asthma/bronchodilator reversible airway disease
Mx = inhaled steroid + LABA
pneumonia - definition
- infection of lung tissue causing inflammation in alveolar space
NB inflammation + pus - impairs gas exchange
types of pneumonia?
CAP - community
HAP - >48hrs in hospital
VAP - intubated
Aspiration - fromm aspiration of foods/fluids
typical bacterial causes of pneumonia?
Most common:
- Strep pneumoniae (most common)
- H influenzae (COPD)
others:
- Moraxella catarrhalis – COPD / immunocompromised
- Pseudomonas aeruginosa – CF / bronchiectasis
- S aureus – CF
- MRSA – HAP
- Klebsiella – alcoholics
atypical causes of pneumonia?
Atypical - cannot be cultured or gram stained in normal way
Legions – Legionella pneumophila = air con units
Psittaci – Chlamydia psittaci = contact with birds
M – Mycoplasma pneumoniae = erythema multiforme
C – Chlamydophila pneumonia = mild in children
Qs – Q fever (coxiella burnetii) = animal bodily fluid
Other
- Pneumocystis jirovecii pneumonia (PCP) – immunocompromised, eg HIV with low CD4 – dry cough, SOBOE, night sweats, co-trimoxazole to tx
- COVID-19
pneumonia symptoms?
Cough
Sputum production
Shortness of breath
Fever
Feeling generally unwell
Haemoptysis (coughing up blood)
Pleuritic chest pain (sharp chest pain, worse on inspiration)
Delirium (acute confusion)
signs of pneumonia on chest examination?
- bronchial breathing
- focussed coarse crackles
- dull to percuss (lung filled with sputum)
CURB-65 scoring system?
C – confusion
U – urea >7mmol/L
R – resp rate >30
B – BP<90 systolic / 60 diastolic
65 – age >65yo
- Score 0-1 – mild, consider home tx
- Score 2– moderate, hospital admission
- Score 3-5 – severe, admit, monitor, consider ITU
pneumonia Ix?
- Chest x-ray - look for focal consolidation
- Bloods (FBC, U&E, CRP)
- sputum cultures
- blood culture
- pneumococcal / legionella urinary antigen tests
pneumonia Mx?
Mild:
usually 5 days of amoxicillin / doxy / clari
Moderate / Severe?
- IV Abx
- respiratory support
acute bronchitis - Px, Ix and Mx?
self limiting URTI involving inflammation of bronchi
- usually viral
Px
- cough +/- sputum
- sore throat
- rhinorrhoea
- wheeze
- fever
DDx from pneumonia
- may have no sputum/wheeze/SOB
- no focal chest signs
Ix - clinical dx
Mx
1. smoking cessation
2. simple analgesia
3. ABx e..g doxy or amoxicillin
lung cancer RFs?
- smoking, occupational (asbestos, coal, tar etc), radiation, pulm fibrosis, COPD
2 histological types of lung cancer?
Small cell lung cancer (SCLC) - 20%
- NE hormones released -> paraneoplastic
Non-small cell lung cancer (NSCLC) - 80%
- adenocarcinoma - 40% - often seen in non-smokers
- squamous cell - 20% - cavitating lesions
- large cell - 10%
- other - 10%
lung cancer Px?
Shortness of breath
Cough
Haemoptysis (coughing up blood)
Finger clubbing
Recurrent pneumonia
Weight loss
Lymphadenopathy – often supraclavicular nodes are the first to be found on examination
extra pulmonary manifestations of lung cancer: name 2 possible associated nerve palsies?
Recurrent laryngeal nerve palsy = hoarse voice. Caused by a tumour pressing on or affecting the recurrent laryngeal nerve as it passes through the mediastinum.
Phrenic nerve palsy, due to nerve compression, causes diaphragm weakness and SOB
what triad makes up Horner’s syndrome and what tumour can cause it?
- partial ptosis, anhidrosis and miosis
- Pancoast tumour - pressing on sympathetic ganglion
extra pulmonary manifestation caused by ectopic ADH secretion by SCLC? ectopic ACTH by SCLC?
- SIADH - ectopic ADH from SCLC - Px with hyponatraemia
- Cushing’s syndrome - ectopic ACTH from SCLC - HTN, hyperglycaemia, hypokalaemia, alkalosis
why could lung cancer manifest with hypercalcaemia?
Hypercalcaemia can be caused by ectopic parathyroid hormone secreted by squamous cell carcinoma.
lung cancer patient with proximal weakness, diplopia and ptosis - what might have happened?
Lambert-Eaton myasthenic syndrome
- ABs against SCLC also target Ca channels in presynaptic motor neurons