Respiratory Flashcards
dx: Pink frothy sputum, swollen ankles
Acute pulmonary edema
LMNOP reverse
NYHA criteria (note beta-blocker only when fluid status is stabilized)
Daily weighs, salt and water restriction.
Device therapy if indicated
Precipitants of acute pulmonary edema
MAD HATTER 3P Myocardial infarction Anemia Drugs - NSAID, negative inotropes, compliance Hypertension Arrythmia Temperature (infection) Thyroid (hyper or hypothyroid) Endocarditis, eclampsia Renal failure, rupture of chordae 3P - peri-op, PE, pregnancy
70 yo M retired army officer, constant dyspnea 2 years at rest, productive cough, thick sputum
COPD
Spirometry to confirm diagnosis
Typical organisms for bronchiolitis
RSV (most common in children
12 month old M o increased work of breathing (link) o widespread expiratory wheeze and crepitations, expiration is also prolonged + hyperinflation o +/- fever o May have reduced oxygen saturation o signs of dehydration
Bronchioliitis
Diagnosis is clinical
Treatment is supportive - oxygenation, fluid, nutrition. Admit to hospital for signs of moderate-severe
CXR will show hyperinflation - flattened diaphragm on AP, barrel-chest on lateral
inspiratory stridor, increased work of breathing + absent cough with low pitched expiratory stridor (often snoring) and drooling. No swallowing. Prefers to sit upright.
Acute epiglottitis
Emergency, give IV abx and send to hospital
Typical organism for acute epiglotitis
H inluenzae type B
Chest tap - what are the anatomical landmarks
5th AAL
2nd MCL
Done immediately above costal margin
Recurrent attacks of slow onset SOB, uncoordinated breathing, palpitaitons, lightheadedness, fatigue, agitation O/E chest normal
Anxiety
Paper bag rebreathing
COPD - Outline main management for acute exacerbation
Bronchodilator - inhaled, dual if not responsive
Systemic steroid - pred po once daily, 7-14 days
Antibiotics - amoxicillin or doxycycline
Oxygen therapy - target O2 saturation levels of 88 – 92, and nasal prongs (2L/min) OR venturi mask (28% and 4L/min) .Take ABG, If ABG results show respiratory acidosis (pH 45 OR signs of CO2 retention – asterexis, confusion consider NIPPV (biPAP)
Diagnosis of bronchiectasis
high resolution CT scan
Most likely diagnosis of persistent morning cough
smoking
Yellow sputum in the absence of infection
Asthma (eoisnophilis)
Smoking
Copious quantities of yellow-green sputum
Pseudomonas
Bronchiectasis
Red flags of sick child with resp. illness
Behaviour - irritability, fatigue, drowsiness
Resp rate
Accessory muscle use
Poor feeding
22 yo migrant from east timor, 4 months of persistent cough, mucus production and flecks of blood, anorexia, tired, night sweats, weight loss, feverish and mild headache.
Probability diagnosis - TB
Must not miss - carcinoma of lung
Pitfalls - bronchiectasis, cystic fibrosis, sarcoidosis, wegeners, churg-straus, whooping cough
Common benign causes of persistent cough
URTI with post-viral cough chronic bronchitits post-nasal drip ASthma Smoker's cough
TB investigations and diagnosis
Quantiferon (does not distinguish latent vs active disease)
Ziel-Neelson stain of sputum (3x early morning)
PCR
CXR
TB management
Isolation and quarantine Reportable disease Medications 2x4, 4x2 - 2 months of 4 agents - rifampicin, isoniazid, pyrazinamide, ethambutol - 4 months of rifampicin and isoniazid
TB drug side effects
o Risk factors;
10% serious AE
Risk factors: age, female, pre existing liver disease/Hep B or C co infection)
o Ethambutanol: reversible optic neuritis/neuropathy (need to monitor color vision)
o Isoniziad: epilepsy, peripheral neuritis, hepatitis (pyridoxine can be prescribed if peripheral neuropathy)
o Rifampicin: orange body fluids, CYP450 drug inducer (warfarin, steroids), severe drug interactions with pill (need alternative contraceptive) , hepatotoxicity
o Pyrazinamide: hyperurecemia (gout), polyarthralgia, hepatotoxicity (monitor LFTs)
18 m.o female cough + vomit
Cough and coryza for one week (catarrhal phase), followed by a more pronounced cough in spells or paroxysms (paroxysmal phase). Paroxysms may be precipitated by feeding. Paroxysms cause redness of face.
Inspiratory whoop and vomiting often follows a coughing spasm.
Infants may develop apnoea and/or cyanosis with coughing spasms, instead of having inspiratory whoop.
?Sick contact
Other family members frequently have a cough (>70% of household contacts are also infected).
Whooping cough
Laboratory confirmation is not necessary for diagnosis, but may be helpful for infection control.
A nasopharyngeal aspirate/swab for PCR is the investigation of choice. The test is usually negative after 21 days, or 5-7 days after effective antibiotic therapy has been commenced.
Pertussis serology (IgA) may be detectable 2 weeks after the onset of the illness but rarely affects clinical management.
CXR findings in TB
- primary: tuberculoma + ipsilateral hilar adenopathy
- latent TB: Ranke complex - subpleural calcified tuberculosis caseasting granuloma (tuberculoma) + calcified ipsilateral hilar node
- secondary TB: cavitary lesion in apical posterior segment of upper lobe, absence of lymphadenopathy
3yo, recurrent bouts of cough for 18 months, associated wheeze, thin pale, failure to thrive, large pale, bulky offensive stools, basal crackles on auscultation
Cystic fibrosis autosomal recessive CFTR gene mutation Heel prick test - population screening Confirmed with sweat test
Early and aggressive tx of respiratory infection - physio, early abx
High choloric diet
Replace enzymes + fat soluble vitamins supplementation
Dietary referral and weight monitoring
Male infertility
Delayed puberty
18 months, recent URTI, 3 hours, loud, harsh brassy cough, worse when starts to cry, worse at night, fever, hoarse voice
Inspiratory stridor due to submucosal edema in trachea
Signs of respiratory distress - suprasternal and sternal retraction
Expiratory component suggests tracheal and subglottic component
Croup - acute laryngotracheobronchitis
Virus - parainfluenza virus, transmitted by respiratory drops
Usually occurs 6 months to 6 years
ddx - laryngitis (isolated hoarse voice), rule out epiglottitis foreign body, bacterial tracheitis
Admit to hospital if stridor at rest or biphasic stridor, irritable, restless, anxious
** stridor being soft despite substantial respiratory effort suggests significant obstruction**
12 yo, 3 weeks after URTI, persistent dry cough, worse during night, nasal stuffiness, post nasal drip
Post-viral cough
? rhinosinusitis
smoker, 2 days irritating cough, then yellow-green sputum, chest tightness with wheezing, fever, occasional crackles on auscultation
ddx - bronchitis (usually afebrile), pneumonia (constitutional symptoms, systemically unwell, pleuritic chest pain)
Acute bronchitis - watchful waiting
58 yo, salesman, 3 month dry bovine cough, retrosternal tenderness, 1 week horseness, O.E no abnormalitity
ddx - bronchial carcinoma, GERD, recurrent laryngeal nerve palsy
diagnosis- GERD
36 yo F, 2 month dry cough, malaise, fever, tender rash on legs (erythema nodosum) for past 2 days. Bilateral hilar lymphadenopathy in CXR
Sarcoidosis
- confirm with ACE level
ddx lymphoma
Risk factors for severe croup
Risk Factors for severe croup
- pre-existing narrowing of upper airways
- subglottic stenosis (congenital or secondary to prolonged neonatal ventilation)
- Down Syndrome
- previous admissions with severe croup
- uncommon <3 months of age. Consider alternative diagnosis. Acute upper airway obstruction.
21 M, previously well, sudden onset dry cough, fever, headache, muscle ache and pains, NAD (apart from fever)
Likely and differential diagnosis?
Influenza : usually a higher fever, myalgia
Fever > 38 + one systemic symptom + one respiratory symptom = 60-70% chance of influenza
Must not miss: meningitis
4 month old, tachypnea, short-expiratory grunt, sick and restless, febrile, pallor (despite high fever)
pneumonia
3 pathophysiological components of asthma
Bronchial smooth muscle spasm
Airway inflammation and oedema
Mucus plugging
Triggers of asthma
Cigarette smoke,
Allergens,
Airborne/environmental,
Drugs (NSAIDS,aspirin, echinacea, betablockers), exercise,
URTI
Comorbid conditions - allergic rhinitis, rhinosinusitis, GERD, nasal polyposis
Diagnosing asthma
clinical diagnosis
History - wheeze, exposures/triggers, PMHX of bronchiolitis, family history or known atopy
Examination
Exclusion of other diagnoses
Documenting variable, reversible airflow:
Obstructive lung diseases
Asthma, COPD, bronchiectasis
Restrictive lung disease
o Diffuse lung diseases: extrinsic allergic alveolitis (Farmer’s lung, bird fancier’s lung), pneumoconioses (Coal worker’s pneumoconiosis, asbestosis), collagen vascular diseases (scleroderma, rheumatoid, polymyositis, Sjogren’s), sarcoidosis, cryptogenic fibrosing alveolitis, toxins, drug damage (amiodarone, methotrexate, bleomycin), radiotherapy
o Space-occupying lesions: hiatus hernia, cardiomegaly, pleural effusion
o Thoracic wall disorders: pleural disease, skeletal (AS, thoracoplasty), obesity, neuromuscular (MND, GBS, bilateral diaphragmatic paralysis, muscular dystrophy, myopathy), dermatological (scleroderma)
Lung function testing results in asthma
FEV1/FVC 20% decrease after exercise or > 10% diurnal variation
Side effects of salbutamol
Risk is greatest when more than 10 puffs a day
Tremors
Palpitations
Increased risk of asthma flare-ups requiring oral corticosteroids
Regular use of SABA leads to receptor tolerance (downregulation) to their bronchoprotective and bronchodilator effects
what is the classical clinical manifestation of allergic rhinitis?
nasal itching, rhinorrhea, nasal congestion and sneezing
other associated symptoms:
- post nasal drip
- cough
- irritability
- fatigue
- allergic conjunctivitis - bilateral itching, tearing, gritty sensation of the eyes
what are some clinical manifestation of chronic allergic rhinitis?
allergic shiners - blue gray/purple discoloration under the eye
transverse nose crease
edematous and pale nasal mucosa
allergic facies
investigations and diagnosis of allergic rhinitis
clinical diagnosis based on classical symptoms + suggestive fhx and phmx + supportive finding on exam
neither peripheral blood eosinophil, nor total serum IgE are sensitive enough to help diagnose allergic rhinitis
other tests available (but not required) are:
- skin prick testing
- blood testing
treatment of allergic rhinitis (separate into intermittent vs persistent)
intermittent (mild): oral or intranasal antihistamine
intermittent (moderate - severe): oral or intranasal antihistamine OR montelukast OR intranasal corticosteroid + r/v after 2 - 4 weeks
persistent (mild): oral or intranasal antihistamine AND/OR intranasal corticosteroid OR montelukast + r/v in 2 - 4 weeks
persistent (moderate - severe): intranasal corticosteroid AND EITHER oral intranasal antihistamine or montelukast + r/v in 2 - 4 weeks
if tx works, continue for 1 month
when is a specialist referral required
refractory to treatment
concomittant allergic rhinitis and asthma
recurrent episodes of sinusitis and otitis media
what are the features of rhinitis medicamentosa?
on examination showing swollen red nasal mucosal membrane
history of use of nasal decongestants of more than 3 consecutive days
what are the clinical features of a cold?
incubation period of around 24 - 72 hours, symptom duration of 3 - 10 days rhinitis/coryza sore throat cough malaise fever \+/- conjunctivitis \+/- nasal discharge
how do you ddx these from a cold?
- influenzae
- allergic rhinitis
- bacterial pharyngitis/tonsillitis
- pertussis (whooping cough)
influenza has presence of high fever, myalgia, headache
allergic rhinitis - absence of sore throat, cough and prominent nasal itching
bacterial pharyngitis/tonsillitis - no nasal stuffiness, prominent rhinorrhea
pertussis (whooping cough) - usually persistent coughing for more than 2 weeks
What are the features of croup?
usually worse at night around 2 - 3 times
harsh brassy cough that sounds barking
inspiratory stridor
associated widespread wheeze
increased work of breathing (respiratory muscles recruited)
will not have signs of toxicity but may be febrile
what is the treatment of croup?
acute mx:
- minimal handling, do not change the patient’s posture
if the patient only has a cough, does not require treatment
mild to moderate croup: prednisolone 1mg/kg AND 2nd dose for next evening
severe croup; nebulized adrenaline and 0.6mg/kg IM/IV dexamethasone
what is the pathogen that causes croup?
parainfluenza
what are the features of bronchiolitis
fever wide spread wheeze and crepitations coughing cyanosis cough especially if child, may be accompanied by otitits media
what are the features you look for when classifying the severity of bronchiolitis?
irritability RR, tracheal tug, nasal flaring accessory muscle use ability to feed oxygen saturations apneic episodes
what is the management of bronchiolitis?
mild - managed at home, supportive,
moderate - admission, o2 administration, supplemental fluid and monitoring
severe - monitoring, supplemental o2 and fluid support, consider cPAP or ventilation
clinical features of influenza
incubation period of 1 - 3D high fever systemic sx (myalgia, malaise, fever) cough \+/- sore throat usually absence of rhinorrhea, sneezing
clinical manifestations of whooping cough
catarrhal stage (1 - 2 weeks): URTI sx w/ mild cough and nasal drip
paroxysmal stage (2 - 8 weeks): coughing spells increased severity, paroxysmal coughing becomes distinctive (long series of cough w/ no respiratory effort).
child may become cyanotic/apneic post vomiting
convalescent stage: cough subsides over weeks to months
investigations and diagnosis of whooping cough
can be diagnosed clinically based on classical clinical hx of:
catarrhal stage that worsens to cough in spells or paroxysms
vomitting after a fit or developing apnea/cyanosis between fits
investigations that can be done are:
nasopharyngeal PCR
treatment of whooping cough
ind for abx: catarrheal phase, cough for less than 14 days, admittance to hospital, has existing complications of: pneumonia, cyanosis, apnea
children: azithromycin 10mg/kg oral first then 5 mg/kg oral for next 4 days
preventive:
- exclude from sch until 5 days of therapy or coughing for more than 21 days
- notify all cases to communicable diseases
- vaccination continue
- prophylaxis for;
ppl who were in close contact while case was infectious
children
