Respiratory Flashcards
ARDS:
Features
Cyanosis
Tachypnoea
Peripheral vasodilation
Bilateral fine end respiratory crackles
ARDS:
Diagnostic criteria
= lung damage with (non cardiogenic) pulmonary edema +/- multi organ failure
Either from direct lung injury or from systemic illness
- acute onset
- CXR bilateral infiltrates
- low PCWP/no CHF
- refractory hypoxaemia
CURB65
Confusion
Urea >7
Respiratory rate >30
BP sys 65
CURB65:
Management
0-1 community ABx
2 admission
3-5 potential ICU admission
Hypercapnic drive:
At risk groups
- COPD
- CF
- Restrictive chest disorders (e.g muscular, neuromuscular)
- Morbid obesity >40
Hypercapnic drive:
Management
- Aim for 88-92% sats
- Decrease but don’t stop O2 2-4l
- Look for previous ABG for baseline
Pleural Effusion:
X Ray features
Blunt costophrenic angle Blunt cardio phrenic angle Fluid in fissures Meniscus Large one sided effusion --> mediastinal shift
Transudate vs Exudate
Transudate = low protein, low LDH, low specific gravity Exudate = high protein, high LDH, low specific gravity
Transudate - from increased hydrostatic pressure or decrease capillary oncotic pressure e.g HF, nephrotic syndrome, cirrhosis
Exudate - lung ca, PE, pneumonia, TB, mesothelioma
Consolidation:
Causes
Infection - pus
Haemorrhage - blood
Cancer - cells
Pulmonary edema - fluid
Consolidation:
X Ray features
Air bronchogram - homogenous opacity with dark lines running through
PE:
Risk factors
Cancer Fracture Immobility Thrombophilia Pregnancy/HRT
PE:
Sx
Tachycardia Tachypnoeic Raised JVP Breathlessness Pleuritic chest pain Haemoptysis Syncope/dizziness
PE:
Management
O2 100% Morphine 10mg+ anti emetic Critically ill --> thrombolysis alteplase /surgery Or LMWH Colloid infuse if hypotensive
ECG, CXR, ABG
D dimer
CTPA
Type I respiratory failure
Low O2 but normal CO2
From lung tissue damage; pneumonia, asthma, COPD, pneumothorax, PE, fibrosis, edema
Type II respiratory failure
Low O2 and high CO2
From poor ventilation eg: COPD, asthma, OD, MG, neuromuscular disorders, obesity
Bronchiectasis:
Definition/cause
Chronic infection of bronchi and bronchioles leading to permanent dilation of airways. From Hib, strep pneumoniae, staph A, pseudomonas
Bronchiectasis:
Symptoms
Persistent cough
Copious purulent sputum
Intermittent haemoptysis
Coarse inspiratory creps
Tram line CXR
Bronchiectasis:
Management
Postural drainage BD
Physio
ABX if needed
Surgery if severe haemoptysis
Pneumonia types:
Pneumococcal
Most common
Everyone
CXR: lobar consolidation
Amox/benpen/cephalosporin
Pneumonia types:
Klebsiella
Rare Elderly, diabetics and alcoholics Cavitating, upper lobes Drug resistant Tx: cefotaxime, imipemen
Pneumonia types:
Staphylococcal
From flu, young, elderly, IVDU, existing disease
Bilateral cavitating bronchopneumonia
Tx: fluclox
Pneumonia types:
Pseudomonas
Common in bronchiectasis
Cause HAF
Tx: anti pseudomonal penicillin
Pneumonia types:
Mycoplasma pneumoniae
Occurs in epidemics
Flu symptoms followed by dry cough
CXR: reticular shadowing, patchy consolidation worse than symptoms suggest
Can cause haemolytic anaemia, meningitis, guillain-barré
Tx: tetracycline, clarithromycin
Pneumonia types:
Legionella
Water tanks eg air con
D+v, hepatitis, anorexia, renal failure, confusion, haematuria
Tx: clarithromycin +-rifampicin
Types of pneumonia:
Chlamydophilia pneumoniae
Pharyngitis (hoarseness), otitis, then pneumonia
Tx: tetracycline or clarithromycin
Pneumonia types:
Pneumocystis pneumonia
HIV
Exertional cough and dyspnoea
CXR: bilateral creps and shadowing
Tx: high dose co-trimoxazole
Pleural effusion:
management
CXR to assess size Depends on how symptomatic it is Don't drain emergency patients Aspirate 1-2 spaces below top of effusion (from percussing) above rib Send off for lab trans vs exudate
Ix for ?PE with renal impairment?
VP
Step 1 Asthma BTS guidelines
SABA
Step 2 Asthma BTS guidelines
Steroid inhaled 200-800mcg
Step 3 Asthma BTS guidelines
LABA (assess respond and up steroid up to 800mcg)
Step 4 Asthma BTS guidelines
Increase steroid to 2000mcg
Add theophylline or LRA eg montelukast
Step 5 Asthma BTS guidelines
Oral steroid tablet
Pneumothorax:
Findings
⬇️ expansion
⬇️ air entry affected side
Hyper resonant percussion
⬇️ vocal resonance
COPD:
Findings
Hyper inflated chest ⬇️ expansion ⬇️ air angry bilateral Hyper resonant percussion Wheeze, exploratory/polyphonic ⬇️ vocal resonance
Pulmonary fibrosis:
Findings
⬇️ expansion ⬇️ air entry bilaterally Resonant to percussion Mid/end inspiratory fine crackles don't clear on coughing Resonance normal/⬇️
Bronchiectasis:
Findings
⬇️expansion
⬇️ air entry
Fine expiration you crackles that change on coughing
Normal/⬇️ resonance
Asthma:
Findings
⬇️ expansion
⬇️ air entry
Hyper resonant
Expiratory polyphonic wheeze
Pneumonia:
Findings
⬇️ everything on affected side
Increased vocal resonance
Pulmonary edema:
Findings
Stony dull to percussion
Mid-late coarse crackles don’t clear on coughing
Pleural effusion:
Findings
⬇️ everything inc vocal resonance
Stony dull to percussion
Spirometery:
Obstructive defect
FEV1⬆️ more reduced than FVC
FEV1/FVC ratio is
Spirometery:
Restrictive
FVC⬇️
FEV/FVC ratio normal/⬆️ I.e >75%
E.g sarcoidosis, pneumoconiosis, pleural effusion, obesity, neuromuscular
Spirometery:
KCO/DLCO
KCO is CO diffusing capacity. DLCO is adjusted for volume.
⬇️ in emphysema, interstitial lung disease
⬆️ alveolar haemorrhage
Emphysema
Needs histological diagnosis
Enlarged distal air spaces, with destruction of alveolar walls
Pulmonary fibrosis:
Signs, symptoms
Symptoms:
Dry cough, externational dyspnoea, malaise, weight⬇️, arthralgia
Signs: cyanosis, clubbing, fine end inspiratory velcro creps
Respiratory failure (type 1), ⬆️ risk of lung cancer
Pulmonary fibrosis:
Investigations + findings
ABG: ⬇️O2 ⬆️CO2
Bloods: CRP⬆️, immunoglobulins⬆️, ANA, rheumatoid factor
CXR: ⬇️ lung volume, bilateral lower zone reticulo-nodular shadowing, honeycomb
CT essential
Spirometry: restrictive
Lung biopsy
Pulmonary fibrosis:
Management
O2 therapy Pulmonary rehab Opiates Palliative care Clinical trial/lung transplant
Spontaneous primary pneumothorax
OPD discharge and r/v
Spontaneous primary pneumothorax >2cm +/ SOB:
Management
Aspirate 2nd ICS midclavicular large bore needle
Spontaneous secondary pneumothorax
Aspirate 2nd ICS midclavicular
Success - admit high flow O2
Fail - chest drain
Spontaneous pneumothorax bilateral/unstable
Chest drain 4-6th ICS mid axillary, above rib, clamp when bubbling finished+CXR shows re inflation 24h
NEVER CLAMP BUBBLING TUBE
Tension pneumothorax:
Management
Needle Aspirate first 2nd ICS midclavicular - don’t delay with CXR
Then when aspirated, CXR, then chest drain 4-6th mid axillary
Acute Asthma management
OSHITME O2 Salbutamol Hydrocortisone 100mg IV (/40mg oral pred) Ipratropium 0.5mg Theophylline Mag sulphate 1.2-2g IV Escalate care
Cor pulmonale
Right heart failure caused by chronic pulmonary HTN
From chronic lung disease, pulmonary vascular disorders etc
Cor pulmonale:
Signs
Dyspnoefatigue Syncope Cyanosis Tachycardia Raised JVP (a and v waves) Pan systolic tricuspid regurg murmur/ graham steell murmur
Cor pulmonale:
Ix
⬆️ hb and haematocrit
Hypoxia
CXR: enlarged right heart w/ prominent pulmonary arteries
PE ECG
S1Q3T3
Large S wave lead 1
Q wave in lead 2
Inverted t wave lead 3
Acute severe asthma signs
Unable to complete sentences
RR>25
HR >110
PF
Life threatening asthma features
33-92-chest
Less than
Indications for home oxygen
PaO2
Indications for NIV
COPD + respiratory acidosis 7.25-35
Neuromuscular, sleep apnoea, chest deformity
Cardiogenic pulmonary edema unresponsive to CPAP
Weaning from tracheal intubation
Fibrosis affecting upper zones
Sarcoidosis
Coal workers
TB
Fibrosis affecting lower zones
Idiopathic pulmonary fibrosis
Drug induced
Asbestos
RA
Extrinsic Allergic Alveolitis
Farmers, bird, malt workers
Upper-mid zone fibrosis
Most common organism infective exacerbation COPD
Hib
