Respiratory Flashcards
Community Acquired Pneumonia - bacterial causes
Streptococcus pneumoniae (80%)
Haemophilus influenzae
Staphylococcus aureus: commonly after the ‘flu
Atypical pneumonias (Mycoplasma pneumonia)
Alcoholics get Klebsiella
Characteristic features: rapid onset high fever pleuritic chest pain herpes labialis
Streptococcus pneumoniae
CURB-65
Confusion - AMT 7
RR > 30
BP 65 years
Severe if 3 or more.
Permanent dilatation of the airways due to chronic infection or inflammation
Tramlines on CXR, and signet rings on CT.
Bronchiectasis
Causes:
Post-infective: TB, CF, measles, pertussis
Bronchial obstruction
Immune deficiency: selective IgA, hypogammaglobulinaemia
Allergic bronchopulmonary aspergillosis (ABPA)
Ciliary dyskinetic syndromes: Kartagener’s syndrome, Young’s syndrome
White out on CXR:
Trachea central
Consolidation
Pulmonary oedema (usually bilateral)
Mesothelioma
White out on CXR:
Trachea deviated towards white out
volume loss
Pneumonectomy
Complete lung collapse e.g. endobronchial intubation
Pulmonary hypoplasia
White out on CXR:
Trachea deviated away
volume gain
Pleural effusion
Diaphragmatic hernia
Large thoracic mass
Bilateral hilar lymphadenopathy
Sarcoidosis TB Lymphoma/malignancy Pneumoconiosis Fungi
Oral amoxicillin or clarithromycin or doxycycline
Mild CAP (S.pneumo or Hib)
Oral amoxicillin AND clarithromycin or doxycycline
Moderate CAP (S.pneumo, Hib or mycoplasma)
IV co-amoxiclav or IV cefuroxime AND IV clarithromycin
Severe CAP (S.pneumo, Hib or mycoplasma)
Fluoroquinolone with clarithromycin, or rifampicin, if severe.
Atypical species e.g. Legionella, Clamydophila or PCP
IV aminoglycoside + antipseudomonal penicillin or 3rd gen cephalosporin IV
HAP (Gram neg bacilli (e.g. enterococcus), Pseudomonas or anaerobes)
IV cephalosporin and IV metronidazole
Aspiration pneumonia (S.pneumo, anaerobes)
Bacteria commonly associated with bronchiectasis and CF
Also causes HAI, particularly on ITU or after surgery
Pseudomonas aeruginosa
Gram-negative rod
Multi-drug resistant
Swinging fever
cough with purulent, foul smelling sputum
pleuritic chest pain and haemoptysis
malaise, weight loss
CXR: walled cavity, often with fluid level
Lung abscess
Can be a complication of pneumonia, aspiration, bronchial obstruction, subphrenic/hepatic abscess.
Tx = antibiotics according to sensitivities, continued for 4-6 weeks, postural drainage
Jaundice as a complication of pneumonia
Cholestatic
May be secondary to sepsis or antibiotic therapy (esp. flucloxacillin and co-amoxiclav)
Mx of Bronchiectasis
Postural drainage BD Chest physio ABX according to sensitivities (cipro if pseudo) ?Long term ABX if >3 exacerbations pa. Bronchodilators and steroids
Autosomal recessive: CFTR gene mutation on chrom 7
Defective chloride secretion and increased sodium absorption across endothelium
Dx by sweat test, genetic tests and faecal elastase
Babies: FTT, meconium ileus
Children/YA:
Resp - cough, wheeze, recurrent bilateral infections
GI - pancreatic insufficiency (DM, steatorrhoea), gallstones, cirrhosis, obstruction
other - male infertility, osteoporosis, nasal polyps
CF ON CXR
Hyperinflation
Bronchiectasis: tramlines from thickened bronchial walls, cystic shadows
Apical lung lesions
TB Sarcoidosis Aspergillosis Radiotherapy changes Extrinsic allergic alveolitis
Coarse crackles
CF
Bronchiectasis
CF on Abdo USS
Fatty liver
Cirrhosis
Chronic pancreatitis
Obstructive disease on spirometry
FEV1 reduced more than FVC
FEV1/FVC >75%
COPD
Asthma
CF
Restrictive disease on spirometry
FVC is reduced; FEV1/FVC may be normal
Fibrosis Sarcoidosis Interstitial pneumonia Pleural effusion Connective Tissue Disease Neuromuscular Disorder
Aspergillus
Causes 5 different disease patterns
- Asthma
- Allergic Bronchopulmonary Aspergillosis (ABPA)
- Aspergilloma
- Invasive aspergillosis
- Extrinsic allergic alveolitis
Proportions of lung tumours:
Squamous Adenocarcinoma Small cell Large cell Alveolar cell
Squamous - 35% Adenocarcinoma - 27% Small cell - 20% Large cell - 10% Alveolar cell - rare
Treatment of NSCLC
Excision of early tumours
Curative radio for those with poor respiratory reserve
Chemo +/- radio for late presenters
Treatment of SCLC
Almost always disseminated at presentation
May respond to chemo but relapse rate is high
Palliative radio
Often associated with paraneoplastic syndromes e.g SIADH, Cushing’s.
DDX of lung nodule on CXR
Malignancy Abscess Granuloma Carcinoid tumour AV malformation Cyst Foreign body
Lung cancer prognosis
NSCLC:
SCLC:
NSCLC = 50% 2 year survival if no spread; 10% with spread
SCLC = 3 months if untreated; 12-18 months if treated.
Recurrent episodic dyspnoea, cough and wheeze caused by reversible airway obstruction:
- Bronchial muscle contraction
- Mucosal swelling/inflammation
- Increased mucous production
Asthma
Things to ask in Asthma
Precipitants Diurnal variation Exercise tolerance Disturbed sleep Acid-reflux Atopy School/job
Non-cardiogenic pulmonary oedema
Pulmonary hypertension: hypoxic vasoconstriction redirects blood to areas of greater oxygenation
ARDS
Tachypnoea, dyspepsia, cyanosis, peripheral vasodilation and fine inspiration crackles
Pulmonary causes of ARDS
Trauma/shock Infection eg pneumonia Gas inhalation Aspiration of gastric contents Near drowning Mechanical ventilation
Extra pulmonary causes of ARDS
Gram negative septicaemia Pancreatitis Burns Cardiopulmonary bypass Perforated viscus DIC OD (opiates)
Bilateral diffuse shadowing in CXR
Tachypnoeic, cyanosis patient
Bilateral fine inspiratory crackles
ADRS
Do an ABG
Mx: PEEP and steroids
Causes of type 1 respiratory failure
PaO2
Severe acute asthma
Pneumonia
Pulmonary embolism
Pulmonary oedema
V/Q mismatch
Causes of type 2 respiratory failure
PaO2 6.5
COPD exacerbation Asthma Sedatives Fibrosis NMD
Management of T1RF
High flow oxygen via NRM
Consider assisted ventilation (CPAP) if PaO2 remains below 8 despite 60% oxygen
Management of T2RF
Titrate oxygen up from 24%
Recheck PaCO2 on ABG after 20 mins
If CO2 stable, increase oxygen
If CO2 is rising, consider NIV e.g. BiPAP
