Respiratory Flashcards
define ARDS
An acute inflammatory process occurring in the lungs which leads to increased pulmonary vascular permeability and a build up of fluid in the alveoli reducing aerated lung tissue
causes impaired gas exchange and hypoxaemic respiratory failure
What are the causes of Ards (8)
Aspiration of gastric or bowel contents into lungs
Chemical inhalation
Lung transplant
Infections e.g. pneumonia from any cause
Severe trauma (i.e. bilateral lung confusion, fat embolism)
Septic shock
Burns
Massive transfusion
Drugs (overdose) and alcohol
Must exclude cardiac cause (not ARDS if caused by cardiac failure)
What are the causes of Ards (8)
Aspiration of gastric or bowel contents into lungs
Chemical inhalation
Lung transplant
Infections e.g. pneumonia from any cause
Severe trauma (i.e. bilateral lung confusion, fat embolism)
Septic shock
Burns
Massive transfusion
Drugs (overdose) and alcohol
Must exclude cardiac cause (not ARDS if caused by cardiac failure)
ARDS complication <7>
Secondary pulmonary fibrosis (may be irreversible)
Pneuomothorax due to lung stiffness and reduced compliance (Barotrauma from PEEP of ~ > 35mmH2O)
Abnormal lung function
obstruction / restriction / reduced diffusing capacity
Infection
Venous thromboembolism – Pulmonary embolism
Cognitive dysfunction / memory loss as a result of prolonged hypoxaemia and sedation related to ICU stay
Death
what are you most likely to die from with ARDS
usually older in age, multiple medical comorbidities, concomitant hepatic failure, history of alcoholism
define asthma
Chronic inflammatory disease of the airways associated with reversible airflow limitation and characterised clinically by recurrent respiratory symptoms of dyspnoea, wheezing, chest tightness and/or cough
Ddx asthma (10)
COPD Acute Bronchitis Bronchiectasis Inhaled foreign body Lung cancer/endobronchial tumour Vocal cord dysfunction (inspiratory stridor) Gastro-oesophageal reflux Left ventricular failure Pulmonary embolism Pulmonary eosinophilia
therapeutic investigation for asthma
Flexible Bronchoscopy – Washings for mucus plugging.
Gina guidelines
Variability
is a difference of >20% between morning and evening PEF with bronchodilator usage
Reversibility
is reflected by an increase in PEF >15% after inhalation of a fast-acting ß2-agonist
In patients without bronchodilator use, a variability of >10% meets the definition of asthma
obstructive pattern on spirometry
= FEV1/FVC < 70%
what is reversibility on spirometry
Reversibility = an FEV1 must increase by > 12%
or > 200 mls
Broncoprovaction test
The provocative concentration is the amount of inhaled agonist required to drop the FEV1 by 20% from the baseline
The amount of metacholine required to do this in asthma is usually < 8 mg/min
complication of asthma
Status asthmaticus Pneumothorax Respiratory failure Pneumomediastinum Subcutaneous emphysema Theophylline toxicity Hypoxic brain injury Complications 20 steroid therapy Mortality with life-threatening asthma
COPD definition
COPD is a preventable and treatable disease characterised by airflow obstruction that is not fully reversible
The airflow limitation is usually progressive and is associated with an enhanced inflammatory response of the lungs to noxious particles/gases, primarily tobacco smoke
Heterogenous disease
Chronic Bronchitis
Emphysema
Signs of CO2 retention
CO2 rentension
- dilated veins and warm periphery
- astarexis
- bounding pulse
- papilledema
- chemosis
- decrease LOC
- palmar erythemosis (weak finding)
Egg findings suggestive of Cor pulmonate
ECG (Suggestive of Cor pulmonale)
Tall P wave, RBBB, Right ventricular hypertrophy
in COPD what does the 6 minute walking test tell you
6 minute walk test
≤ 86% = indication for portable oxygen
when do you use NIV in acute exhasterbation of COPD
) if arterial pH < 7.35 and/or pCO2 > 6.5 kPa
fac
when is long term O2 therapy used
paO2 ≤ 7.3 kPa
paO2 < 8kPa with
- pulmonary hypertension (clinical signs of cor pulmonale/right heart failure) or
- echocardiogram showing a mean Pulmonary Artery Pressure (mPAP) > 20 mmHg
Surgery for COPD
Bullectomy
Lung Volume Reduction Surgery (LVRS)
Resection of the most severely affected areas of emphysematous lung
More beneficial in upper lobe emphysema
Lung transplantation
complication of COPD (11)
Acute exacerbations COPD
Hypoxia
Hypercapnia
Compensated Chronic Type II Hypercapnic Respiratory Failure
Acute acidotic hypercapnic respiratory failure
Pneumothorax 20 bullous rupture
Recurrent pneumonia
Cor pulmonale
Secondary Polycythaemia
Osteoporosis and diabetes 20 steroid therapy
Hearing impairment from azithromycin prophylaxis
Prognosis for COPD
uses the BODE score
- BMI
- Obstruction
- Dyspnea
- Exercise capacity
Approximate 4-year survival 0-2 points = 80% 3-4 points = 67% 5-6 points = 57% 7-10 points = 18%
DDX of cOPD
ABAC Asthma Bronchiectasis A1AT v CCF
TB
Obliterated bronchiolitis
Ddx for CF
Non-CF Bronchiectasis
Common Variable Immunodeficiency (CVID)
Primary Ciliary Dyskinesia (Kartagener’s Syndrome)
Right middle lobe syndrome
Swyer-James Syndrome
Shwachman-Diamond Syndrome
Acute management of CF
Antimicrobial therapy tailored to known pathogens and sensitivies
Nebulised bronchodilators
Chest physiotherapy
Mucolytics; DNase (dornase-alpha)
Nutritional support
treatment for p. aeruginosa
- CIPROFLOXACIN PO _ ist isolate
2. exacerbation - treatment with B-lactam and amino glycoside
Burkholderia Cepacia complex
1 . ceftazidime
2. pip/tazo
Treatment of Macronodular Cirrhosis in CF
Ursodeoxycholic acid, taurine, seek specialist advice
Severe cases may need liver transplant
How do you treat complication CF arthropathy
NSAIDs, prednisolone +/- rheumatologist
st
drugs targeted to specific mutation
Ataluren - class 1 mutation Lumacaftor - class 2 - delta508 ivacaftor - class 3 - GG51D mutation
how often do you follow up CF patients
3 months for spirometry and sputum for cultures/sensitivity
6 months for nutritional screen/OGTT
1 year evaluation including CXR
2 yearly liver ultrasound and DEXA scans
when does a CF patient need a lung transplant
FEV1 < 30% predicted is an indication for referral for possible lung transplant
death in CF
Respiratory Failure
Pneumonia
Pneumothorax
Haemoptysis
Bronchiectasis
A disorder characterised by abnormal bronchial wall thickening and luminal dilatation of the central and medium-sized bronchi
Due to a vicious cycle of transmural infection and inflammation with mediator release
Prevalence increases with age
More common in females
Chronic cough, mucopurulent sputum
Haemoptysis, pleuritic pain, recurrent fever, wheeze and dyspnoea less frequent
Causes of bronchiectasis
Idiopathic in 50% of adults and ~25% of children Primary Ciliary Dyskinesia Common Variable Immunodeficiency (CVID) Cystic Fibrosis Kartagener’s Syndrome Post-infective causes-measles, pertussis, adenovirus, influenza Mechanical obstruction Pulmonary fibrosis Right middle lobe syndrome Swyer-James Syndrome
Bronchiectasis si ass. w/ (II CD MAM)
Infertility Inflammatory Bowel Disease (IBD) Connective Tissue Disorders Diffuse panbronchiolitis Malignancy AATD Mercury poisoning
Radiological findings in bronchiectasis
Internal bronchial diameters 1.5 times greater than that of the adjacent pulmonary artery (signet ring sign)
Lack of bronchial tapering
Bronchial wall thickening, ‘tram lines’
upper lobe causes of fibrosis
Upper Lobe Predominant (SCHA-ARTS) Silicosis Coal worker’s lung Histiocytosis X Ankylosing Spondylitis ABPA Radiotherapy TB Sarcoidosis
Lower Lobe Predominant
(RRASCO) Rheumatoid Arthritis Radiotherapy Asbestosis Scleroderma Cryptogenic Fibrosing Alveolitis Other (Methotrexate, Amiodarone, Nitrofurantion, Bleomycin, Busulfan)
when do you take a lung Bx when a patient has ILD
Atypical progressive disease < 50yrs old Fever Weight loss Haemoptysis Vasculitis Unexplained pulmonary hypertension Cardiomegaly Rapid deterioration
Complication iLD
Pulmonary Hypertension
Right Ventricular Failure/Cor pulmonale
Respiratory Failure
Secondary infections while on steroid or immunosuppressive therapy
~ 5% patients with LIP (Lymphoid Interstitial Pneumonia) progress to Pulmonary Lymphoma
IPF
chronic progressive fibrotic disorder of lower part of the rest tract , age > 40
CXR IPF
Bibasilar
Reticulonodular
Infiltrates
Volume loss
Poorly defined pleural-
Parenchymal borders
HRCT Thorax:
IPF
Subpleural fibrosis
Volume loss
Traction bronchiectasis
HRCT Thorax:
NSIP
Ground-glass appearance
No significant volume loss
Treatment of IPF vs. NSIP
NSIP - steroids 1mg.kg .day
NO STEROIDS for IPF 1. Oxygen 2. pulm rehabilitation 3. vaccine Trial of sedenfil
COP - CXR finding
CXR: multiple ground-glass or consolidative opacities
PFTs: restrictive ventilatory defect with reduced DLCO
Bronchoalveolar lavage to rule out infection/haemorrhage/malignancy
+/- Transbronchial biopsy +/- lung biopsy
PULMONARY LYMPHANGIOLEIOMYOMATOSIS (LAM)
Rare Interstitial Lung disease
Young women of child-bearing age
Multiple cysts
Complications of pneumothorax and chylothorax
Affects 30% of women with Tuberous Sclerosis
No proven therapies; supportive treatment with bronchodilator therapy, oxygen and pulmonary rehabilitation
median survival for IPF and NSIP
IPF is 2 -3 years from diagnosis
NSIp - 5 years
what radiotherapy cancer’s make you increased risk of getting lung cancer
Radiotherapy for other malignancies
Breast cancer
Hodgkin’s Lymphoma
Paraneoplastic syndromes of lung cancer
Hypercalcaemia (SquamCCa)
Syndrome of Inappropriate ADH secretion (Small CLC)
Ectopic ACTH secretion (Small CLC)
Cerebellar Syndrome (Small CLC)
Lambert-Eaton Myasthenic Syndrome (Small CLC)
DDX of lung cancer
Pneumonia Exacerbation of COPD Parapneumonic effusion Tuberculosis Carcinoid Mesothelioma Metastatic lung disease Benign lung disease
T stages for lung cancer
tx - no assessed
t1 - <3cm - DOESN’t involve the main bronchus
T2 - 3-5cm + involves
- main bronchus
- visceral
- ass/ w/ atelectasis, obstructive penumonititis
T3 - 5- 7cm or has direct invasion with
1. chest wall
2. pleural Nerve
3. partial pericardium
4. tumour nodules
T4 - > 7 cm - or invades one of the following
- diaphragm , mediastinum
- heart, great vessels
- trachea , recurrent LN, esophagus
- vertebral body
- carina
- separate tumour nodules or ipsilateral lobe of primary
N staging for Lung cancer
N1 - ipsilateral peribronchial ± ipsilateral hilar LN Plus intrapulmonary nodules
N2 - ipsilateral mediastinum ± subcarnial LN
N3: contralateral mediastinum
Contralateral hilar
ipsilateral or contralateral scalene or supraclavicular LN
M staging for lung cancer
M - no distant mets
M1 - distant mets
M1a - separate tumour nodule in CL lobe
tumour with pleural or pericardial node
malignant pleural or pericardial effusion
M1b - extrathroacic mets in single organ
M1c - multiple extra thoracic mets in one or several organs
Limited staging vs. extensive staging
Limited - confined to ipsilateral hemithroax and regional LN
Extensive - distant mets contralateral SC and hilar LN , pericardial or pleural involvement
treatment for limited staging SCLC
CHEMO + thoracic RTX (platinum based chemo and etoposide)
Prophylactic cranial irradiation
treatment for extensive staging SCLC
- Palliative chemo
- increase survival 2-10 months
- whole brain RTX for brain mets
- palliative care
NSCLC treatment
T1,2,3
- SURGERY ( thoracotomy for lobectomyy and pneumonectomy OR VATS for wedge decision, lobectomy)
- CHEMO
- platinum doublet ± bevacizumab
- non squamous type - pemtrexed
- RTX / ST RTX
- TKI - ertotinib, Gefitinib (if EGFR oncogene)
- ALK TK inhibitors if ALk fusion oncogene +
- crizotinib
ECOG performance
Performance status is a scoring system used to identify a cancer patient’s general wellbeing and activities of daily living
PANCOAST TUMOUR/SUPERIOR SULCUS TUMOUR
Defines a tumour located at the apical pleuropulmonary groove, adjacent to the subclavian vessels
Pancoast Syndrome
Shoulder and arm pain (C8, T1, T2 dermatomes)
Horner’s Syndrome
Wasting and weakness of the small muscles of the hand
Lung cancer
Pleural effusion Post-obstructive Pneumonia Pulmonary Embolism Pericardial effusion Brain Metastases Bone Metastases Hypercalcaemia Superior Vena Cava Obstruction SIADH Ectopic ACTH production Pancoast Tumour Lambert-Eaton Myasthenic Syndrome Cerebellar Syndrome
influenza vaccine indication (8)
age > 65 years Institutionalisation chronic cardiac diseases chronic pulmonary diseases unstable diabetes mellitus chronic renal diseases Immuno-compromised persons Women in the second or third trimester of pregnancy during the influenza season
Pneumococcal vaccine (9)
recommended for persons at risk for pneumococcal disease age > 65 years institutionalisation cerebrovascular disease, dementia, seizure disorders congestive heart failure chronic obstructive pulmonary disease history of prior pneumonia chronic liver disease diabetes mellitus chronic cerebrospinal fluid leakage
Acute complication of pneumonia
Pleural effusion Empyema Pulmonary haemorrhage Septicaemia, septic shock Type 1 or 2 respiratory failure Acute Respiratory Distress Syndrome (ARDS) Mortality
chronic complication of pneumonia
Bronchiectasis
Cavitation-classically staphylococcal and klebsiella pneumonia
systemic complication of pneumonia
SIADH
Deranged LFTs/biochemical hepatitis
Mycoplasma Stevens – Johnson syndrome Haemolytic anaemia Pericarditis , myocarditis headache
Legionella
- hypoNa
- GI . diarrhea, abdo pain
- ARF
high risk of asbestosis exposure
Asbestos miner Shipyard worker Textile mill worker Firefighter Insulators Construction workers Boiler repair workers
Ddx of mesothelioma
Pleural effusion from any other cause.
Benign asbestos related pleural thickening.
Primary bronchogenic carcinoma.
Pleural fibrosis from infection or inflammation (e.g. tuberculosis, actinomycetes).
Pleural metastases (pleural carcinomatosis).
Solitary fibrous tumour of pleura.
Signs of poor prognosis mesothelioma (8)
ABG. Possibility of needing supplemental O2
LDH (> 500 IU/L associated with poor prognosis)
FBC for platelet count. (> 400,000/microL = poor prognosis)
Non-epithelial histology.
Age >75
Poor ECOG
Chest pain present
Pleural involvement
Complication of mesothelioma
Symptomatic pleural effusion
Respiratory failure due to lung encasement or pleural thickening
Chest pain due to direct tissue / organ infiltration
Facial and swelling due to superior vena cava obstruction (SVC syndrome)
Dysphagia
Paraneoplastic disease (hypercalcaemia, DIC et cetera)
Death
Survival for mesothelioma
8-14 mon - pleural mediastinum
7 mon - peritoneal mediastinum
Define mesothelioma
Malignant neoplasm which arises from the mesothelial cells in the pleural cavity.
Less commonly can arise from peritoneal cavity or pericardium.
OSA definition
Reurrent collapse of the pharyngeal airway during sleep resulting in complete / near complete cessation of airflow despite normal breathing effort.
Leads to intermittent disturbance in gas exhange and fragmented sleep due to associated arousals.
OSA risk factors
Male gender Advancing age Obesity and increased neck circumference Cranio-facial and upper airway abnormalities Retrognathia Large tonsils obstructing upper airway Acromegaly Hypothyroidism Nasal congestion
Crowded airway
Narcolepsy Depression Hypothyroidism Seizures Periodic limb movement disorder / restless leg syndrome Drugs SSRIs, beta blockers, sedatives, alcohol Shift worker syndrome Sleep deprivation (quantity of sleep) Fragmented sleep (quality of sleep) Insomnia Primary snoring
OSA on polysomography
5 or more respiratory events per hour of sleep and associated symptoms or typical history: AHI > 5 per hour
Apnoea-Hypopnoea Index (AHI) greater than 15 per hour regardless of symptoms or comorbidities
OSA complications
Untreated OSA can lead to cardiovascular events such as stroke, arrhythmias and myocardial infarction
Potentiates pre-existing hypertension
Road traffic accidents due to sleepiness while driving
Reduced quality of life
Memory issues
Ddx of pleural effusion
Parapneumonic pleural effusion Malignant pleural effusion Empyema Lung mass Congestive Cardiac Failure Nephrotic Syndrome Cirrhosis Hypothyroidism Acute pancreatitis Sarcoid Meig’s Syndrome
how do you perform a pleural aspiration under US
Sterile dressing pack Sterile gloves Antiseptic solution 1% lignocaine 50ml syringe 3 x 20 ml universal containers ABG needle Sterile dressing
Lights criteria
Pleural fluid protein: Serum protein > 0.5
Pleural fluid LDH: Serum LDH > 0.6
Pleural fluid LDH> 2/3 upper limit normal blood LDH
Criteria to put in a drain
Complicated para-pneumonic pleural effusion
Empyema; frankly purulent pleural fluid or pleural fluid pH < 7.2
Malignant pleural effusion +/- combined with talc pleurodesis
Symptomatic relief of large pleural effusion
Traumatic haemopneumothorax
complication of pleural effusions
REC FT
Empyema Recurrence of pleural effusion Fibrothorax Trapped Lung Complications secondary to drain insertion Infection Bleeding Haemopneumothorax Subcutaneous emphysema
causes of pleural effusion
CANCER:
Bronchogenic carcinoma
Mesothelioma
Metastatic disease (lung, breast, lymphoma, ovary, pancreas)
INFECTIOn:
Pneumonia (parapneumonic)
TB
Empyema
OTHER:
Pulmonary infarct (post PE)
Asbestosis
RA
SLE
Dressler’s syndrome
Yellow-nail syndrome (VERY RARE)
Conditions that have an elevated D-dimer
PULMONARY EMBOLISM
Heart failure
Pneumonia
95% of patients with recent surgery or malignancy
Consider iv unfractionated heparin when there is
Persistent hypotension SBP < 90mmHg in a massive PE ( may need to proceed to thrombolysis)
Increased risk of bleeding
Concern about subcutaneous malabsorption (morbid obesity)
Indication for thrombolysis in PE
Indications for Thrombolysis in PE massive PE cardiogenic shock hemodynamic instability Transit thrombus seen on ECHO in right ventricle
indication for IVC filter in acute TE
An absolute contraindication to therapeutic anticoagulation
Failure of anticoagulant therapy when there is acute proximal venous thrombosis
when do you do an embolectomy in pt with PE
Considered when a patient’s presentation is severe enough to warrant thrombolysis, but thrombolytic therapy either fails or is contraindicated.
Risk of embolectomy for PE
Requires cardiopulmonary bypass - carries high risk in mortality
Much better to have IR do the embolectomy but not always offered in hospital
complication pulm embolism
Pulmonary infarction (May resemble pneumonia on CXR)
Arrhythmias
Pleural effusion
Pulmonary Hypertension (Chronic Thromboembolic Pulmonary Hypertension = CTEPH)
Right ventricular failure
Bleeding complications 20 anticoagulation
Thrombocytopaenia 20 anticoagulation
Cardiorespiratory arrest and sudden death
what is prophylactic dosage of tinazeparin and enozaparin for PE in surgical patients
Tinazeparin 300 IU od sc
Enoxaparin 90mg od sc
what study looks at the efficiency of CTPA for PE
PIOPED study
prophylactic dose of PE
Tinzaparin 3500 iu od subcutaneously (4500 iu od dosing in patients with malignancy)
Prophylactic Enoxaparin 40 mg od subcutaneously
Sarcoidosis
A multisystem granulomatous disorder of unknown aetiology characterised by the development of non-caseating granulomas within an organ
lupus pernio
raised indurated hardened lesion of skin often in purple colour
Ddx sarcoidosis
Tuberculosis Lymphoma Granulomatosis with polyangiitis (formerly Wegener’s Granulomatosis) Churn-Strauss syndrome CVID Fungal infections; e.g. histoplasmosis Brucellosis, Chlamydia Chronic Beryllium Disease
Lofgren’s Syndrome
Erythema nodosum, bilateral hilar lymphadenopathy, arthralgia and fever
Usually resolves spontaneously
Mikulicz’s Syndrome
Parotid and salivary gland enlargement in conjuction with lacrimal gland involvement
Indications for systemic treatment
Progressive dyspnoea
Worsening pulmonary infiltrates
Fall in FVC and/or DLCO
Anterior or posterior uveitis unresponsive to topical therapy
Active cardiac involvement
Hypercalcaemia
CNS involvement (Facial Nerve / CN VII in 50%)
Complication of Sarcoidosis
Pulmonary fibrosis
Pulmonary hypertension
Respiratory failure
Lung transplantation
Cardiac arrhythmia, sudden cardiac death 20 to ventricular fibrillation
Hypercalcaemia
Chronic renal failure 20 to Renal sarcoid
Glaucoma and visual loss
Obstructive hydrocephalus 20 to Neurosarcoid
what test do you do to follow up patient with sarcoidosis
- PFT
- ACE
- CXR
