Respiratory Flashcards
resp failure
p02 < 8kPa
type 1 CO2 normal
type 2 pCO2 > 6.0 due to hypoventilaition
- acidotic
- careful ox therapy - NIV (bipap)
- may see headahce, tachy, tremor/flap, bouding pulse
asthma mgmt
1) saba
2) +steroid
3)+laba (continue if benefitial)
inc steroid to 800
consider other options (luek, theoph)
4) steroid to 2000
5) oral steroid
Inhalers
Symbicort - budesonide + formeterol
- turbohaler
Seretide - purple mdi
- fluticasone + salmeterol
Spiriva= tiotroprium
asthma attack
severe vs life threat
SEVERE
pulse >110
resp>25
pefr 33-50%
LIFE THREAT
silent chest, cyanosis, bradycard
pef<33%
confusion, exhaustion
asthma attack initial mgmt
100% O2 (15L nrb)
nebs: iprat (0.5mg) and salb (5mg)
steroids: iv hydro (100mg) +/- pred (40mg)
do cxr
asthma attack treat (early)
O SHIT ME
100% O2 (15L nrb)
Salbutamol 5mg neb (back to back)
Ipratroprium 0.5mg neb
Hydrocortisone 100mg IV +/- prednis 40mg po
do CXR (rule out pn.th)
life threat: IV mg sulfate 1.2g iv over 20mins
escalate ?ICU
Samters triad
Asthma
Aspirin sensitivity
Polyps
eosinophilic asthma
abpa
churg strauss
abpa
main type of ‘eosinophilic asthma’
type 1 and 3 (IgG) hypersens
early bronchoconst, recurrent pneumonia,
eventual bronchiectasis
upper lobe fibrosis
sputum, skin test
eosinophilia, IgE
T: prednisolone, bronchodilat
abpa
main type of ‘eosinophilic asthma’
type 1 and 3 (IgG) hypersens
early bronchoconst, recurrent pneumonia,
eventual bronchiectasis
upper lobe fibrosis
sputum, skin test
eosinophilia, IgE
T: prednisolone, bronchodilat
PE Wells Score
general risks:
- immob, surgery
- thrombophilia
- malig
- oestrogen - hrt, pil, preg
DVT suspicious 3
alt diag less likely 3
tachycardia 1.5
hx immob or sugery 1.5
previous 1.5
haemoptysis 1
malignancy 1
blood gas in PE
ecg in PE
resp alkalosis
tachy, rbbb/rad, s1,q3,t3 (rare)
PE Mx
over 4 points
CTPA
under 4 points d dimer then ctpa if positive
ecg S1,Q3,T3
tachy, RBBB
PE Mx
over 4 points
CTPA
under 4 points d dimer then ctpa if positive
ecg S1,Q3,T3
tachy, RBBB
COPD exacerbation
give prednis and abx
if consolidation present likely strep pne
if no conolidation haemoph inlf
if frequent then keep pred and abx at home
copd diagnosis
ratio under 0.7 post bronchodilator
fev1 determines severity mild >80 mod 50-80 sev 30-50 v sev <30
invest: CXR, FBC (polycyth)
copd: emphys vs chron bronch
chron bronch
- clinical diag
- prod cough 3m, 2y
emphy
- histolog def: enlarged airspaces, destruc of alveolar walls
copd comps
exacerbations - may be infective polychyth cor pulmonale pneumothorax risk carcinoma risk
COPD exacerbation
give prednis and abx
if consolidation present likely strep pne
if no conolidation haemoph inlf
if frequent then keep pred and abx at home
copd treat
stop smoking, vaccines
mild: ipratro/salb prn
mod: regualar tiotr/salm
?inhaled steroid
pulm rehab
LTOT (may inc survival)
copd comps
exacerbations - may be infective polychyth cor pulmonale pneumothorax risk carcinoma risk
restrictive spirometry
FEV1 low but FVC also low
so ratio is normal
causes of interstitial lung disease
occupational casues: coal, silic, abest
extrinsic allergic alveolitis
(upper zone appart from asbest)
drugs: methotrexate, amiodarone etc
(lower zone)
w/ systemic conds
- sle, ra, sarcoidosis, UC
(lower zone apart from sarc)
IDIOPATHIC PULM FIBROSIS
-most common
(lower zone)
idiopathic pulmonary fibrosis
commonest cause of interstitial lung disease
inflam infiltrate and fibrosis
drugs causing lung fibrosis
methotrexate
amiodarone
bleomycin
sulfasalazine
nitrofurantoin
busulfan
asbestosis
fibrotic industrial lung disease
LOWER ZONE
severity prop to exposure
risk ca
pleural plaques = benign
silicosis
fibrotic industrial lung disease
upper zone
risk tb
egg shell hilar nodes
extrinsic allergic alveolitis
acutely: fever rigors myalgia dry cough crackles
chronically: granuloma formation, bronchiolitis
sob, t1rf, cor pulmonale
CXR: upper zone fibrosis
tx: O2, steroids
bird/pigeon fancier farmers lung - mycropolyspora faeni mushroom workers lung - thermoactinomyces vulgaris malt worker - aspergillus clavatus sugar worker - hermoactinomyces sacchari
haemoptysis
lung ca -wl, smoking pulm oed - sob, crackle tb - fever, night sweats, wl aspergil - prev tb, severe haemopt PE - pleauritic pain, tachy, sob bronchiect - chronic picture
goodpastures
-system unwell, kidney probs
wegeners
-kidneys, saddle nose
pleural effusion
exudate - high protein >35
- infec (pneumonia), inflamm, malig
transudate - low protein <25
- heart, renal, liver failures
between 25-35 use lights criteria
also test for ph (low in empyema)
cytology, culture
pneumothorax mgmt
primary >2cm sob
—–aspirate
secondary >50yrs >2cm sob
—-chest drain
secondary but <1cm
—-give oxygen and observe
lights criteria
pleural: serum protein 0.5
pleural: serum ldh 0.6
pleural ldh 2/3 more than upper normal
haemoptysis
lung ca -wl, smoking pulm oed - sob, crackle tb - fever, night sweats, wl aspergil - prev tb, severe haemopt PE - pleauritic pain, tachy, sob bronchiect - chronic picture
goodpastures
-system unwell, kidney probs
wegeners
-kidneys, saddle nose
CF
chro 7 delta f508
get infec w staph and pseudom
early: fail to thrive, meconium
infections, wheeze, cough. diarrhoea, pancreatitis.
later: bronchiectasis, diabetes, gallstones
other: infertile, osteoporo
∆ sweat test
pleural effusion
exudate - high protein >35
- infec (pneumonia), inflamm, malig
transudate - low protein <25
- heart, renal, liver failures
between 25-35 use lights criteria
also test for ph (low in empyema)
cytology, culture
lights criteria
pleural: serum protein 0.5
pleural: serum ldh 0.6
pleural ldh 2/3 more than upper normal
CF
chro 7 delta f508
get infec w staph and pseudom
early: fail to thrive, meconium
infections, wheeze, cough. diarrhoea, pancreatitis.
later: bronchiectasis, diabetes, gallstones
other: infertile, osteoporo
∆ sweat test
kartegeners
dextrocardia
bronchiectasis
sinusitis
subfertile
bronchiectasis
causes
- cf, post infection (severe), abpa (test aspergillus precipitans)
- youngs/kartageners (ciliary dyskinesia)
- hypogammaglob (test serum immonoglobs)
- RA, UC
persistent cough (haemop) sputum + clubbing
cxr - tramline and ring shadows - bronchia thickening
tx - physi/postural drain, abx, bronchodialtors
abpa - prednis
most common CAPs
strep - amox
- may see herpes
- rusty sputum
- classic lobar consolidation
haemoph influ - amox
- in copd w no consolidation
mycoplasma - clarith
- epidemics - often young, living close ie halls
- presents fluey then dry cough
- mild chest symtpoms but bad cxr (widespread consol)
- comps: heamolytic anaemia, erythema multiforme, SJS, GBS
conditions assoc w bronchiectasis
cystic fibrosis
alpha1 antitrypsin defic
RA
Marfans
- aortic dissection, valve regurg (esp aortic), lens dislocation, joint hypermobile
kartegeners
- situs inversus
youngs syndrome
- viscous mucus - infert, rhinosnus, bronchiect
kartegeners
dextrocardia
bronchiectasis
sinusitis
subfertile
abpa
type 1 and 3 (IgG) hypersens
early bronchoconst, recurrent pneumonia,
eventual bronchiectasis
upper lobe fibrosis
sputum, skin test
eosinophilia, IgE
T: prednisolone, bronchodilat
most common CAPs
strep - amox
- may see herpes
- rusty sputum
- classic lobar consolidation
haemoph influ - amox
- in copd w no consolidation
mycoplasma - clarith
- epidemics - often young, living close ie halls
- presents fluey then dry cough
- mild chest symtpoms but bad cxr (widespread consol)
- comps: heamolytic anaemia, erythema multiforme, SJS, GBS
legionella pneumonia
- dodgy water
- presents fluey, dry cough
- extrapulmonary: anorexia, d+v, liver/renal, confu
- blood: lymphopenia, hyponatraemia, deranged lft
other CAP bugs
staph - fluclox
- post flu, iv user
- bilat pathcy consol
- cavitating/abscess
klebsiella
- alcoholics, aspiration
- big abscess
- gram -ve rod
- faeculent sputum or red current
pseudomonas
- CF and bronchiectasis
- often returns
legionella
- water supply, abroad
- fluey pres - conf, diarrh, hyponatraemia
chlamydia psittaci
- parrots
TB
- apical abscess, cavitate
- may devel aspergilloma
- zn(afb) and auramine stain
Q fever
- sheep
- coxiella burnetti
rarer pneumonias
pneumocystis pneumoia / pneumocystis jiroveci
- HIV/immunocom
- septrin - cotrimoxazole
chlamdydia pneumonia
chlamydia psittacosis (rarer) - from parrots
viral - influenza
viral pneumonia/pneumonitis
h1n1, h5n1, sars
cmv
- post transplant
herpez zoster pneumonitis
- widespread microcalcification
CURB 65 and treat for CAP
CURB 65
0/1: amoxi (500tds)
2 hospital, amox + clarith (500bd)
3 severe: augmentin (625tds) + clarith
lung abscess
causes
- pneumoia (staph, kleb, tb), septic emboli, aspiration
- swinging fever, purulent sputum, pain
pulmonary hypertension
causes and signs
primary - idiopath/familial
2ndr to lungs - obstr or restric
2ndr to heart - LH fail, mitral (see orthop/pnd)
2ndr to thrombo embo - PE
sob, syncope, cp, tachy
congestion - asc, ankle, hepat
parasternal heave, murmur
lung cancer
mets, staging and treat
METS: brain, bone, liver, kidney
TNM
t1 3cm and 2cm from carina or pleural inv
t3 adjacent structures, closer to carina
t4 at mediastinal structures/carina, effusion
n2 ipsi mediastinum/subcarinal
n3 contralat
nsclc: surgery if poss
sclc: often disseminated, so chemo/rx
pleural effusions
transudate 35% leaky capills
- infection, inflam, malig
management of pleural effusions
transudate - treat cause
if exudate
- chest drain
- pleurdesis if malignant/recurrent
- ct chest abdo if ?malignant
- consider thoracoscopy and pleural biopsy
KCO: corrected for volume
DLCO: gas transfer
decreased in things affecting
- ventilation (extrathoracic, obstructive, restictive, infection, collapse, pneumonectomy)
- diffusion (ILD)
- perfusion (PE, pulm htn)
nb if DLCO red but KCO normal
–> think extrathoracic _ something limiting volume of expansion - NMJ prob, kyphoscoliosis
increased in alveolar haemorrhage
acute respiratory distress syndrome
following injury or systemic illness
bilateral infiltrates on cxr
resp and circ support
reen for sepsis
50-75% mortality
coal workers pneumoconiosis
fibrotic industrial lung disease
upper zone
assoc w/ chronic bronchitis
may progress to PMF (progressive massive fibrosis)
obstructive sleep apnoea
mornign headache, libido low, daytime somnolecence
comp: pulm htn, t2rf
tx: lose wt, avoid smoking alc
cpap, ? surgery
cpap and bipap
cpap
- most work of breathing still done by patient
- keeps collapsing lung units open
- used in
- pulmonary oedema
- sleep apnoea
bipap (niv)
- bilevel
- higher level drives inspiration, lower level keeps airway open in expiration
- used in acute respiratory failure
- eg infective exac of copd with sats not improving
meigs syndrome
unilateral pleural effusion
ovarian tumour
ascites
abg derangements
respiratory alkalosis
- hyperventilation
- PE
respiratory acidosis
- t2rf
- may be compensated if chronic - copd
metabolic acidosis
- dka
- ketoacidosis from alcohol
- lactic acidosis
- renal failure (uraemia)
- renal tubular acidosis (normal anion)
- toxin: salicylate, methanol
metabolic alkalosis
- vomiting ++
aspirin poisoning
- initially alkalosis (?resp) but then progressive metabolic acidosis w anion gap
