Respiratory Flashcards
How is COPD diagnosed?
Bedside: spirometry, ECG, BMI
Bloods: full blood count
Imaging: PA chest x-ray
What features would you expect to find during an COPD examination?
Inspection - tar-stained fingers, asterixis, hyper inflated barrel chest, tripod position, cyanosis, tremor
Palpation - reduced chest-expansion
Percussion - hyper-resonance
Auscultation - coarse crackles, wheeze, prolonged expiration, tachypnoea
(NB fine crackles = pulmonary fibrosis)
What scale should be used to measure the effect of COPD on daily activities?
MRC dyspnoea scale
What types of smoking cessation are there?
Nicotine replacement - patches/inhaled therapy
Bupropion
Varenidine
What measures should be taken emergency situation of low 02 sats?
- Give 15L high flow oxygen
- Give 2L after a bit (if C02 retainer)
- Give nebulised salbutamol and ipatropium
- Give prednisolone, doxycycline
Consider CPAP, BIPAP
How should COPD be managed initially?
Conservative: education, smoking cessation, pulmonary rehabilitation
Medical: short-acting b2 agonists (salbutamol), vaccinations
How should COPD be managed long-term?
Conservative: sputum suction, chest physiotherapy, 02 therapy, regular reviews
Medical: montelukast, muscarinic antagonists (tiotropium bromide), nebulisers, antibiotics, steroids, theophylline, mucolytics, give home rescue packs
Surgical: lung transplant
What is the criteria for LTOT?
- p02 below 7.3
- p02 below 8, PLUS cor pulmonale
- stopped smoking, clinically stable
- FEV1 < 30% preducted
What does pink, frothy sputum mean?
Pulmonary oedema
What is the definition of COPD?
A chronic disorder characterised by airway obstruction (FEV1/FVC = 70%) for over several months. It includes emphysema and chronic bronchitis
What is the pathophysiology behind COPD?
- Loss of elastic recoil in lungs
- Hyperinflated lungs and flattened diaphragm
- Loss of alveolar attachments to bronchi (emphysema)
- Loss of pleural pressure and airway collapse
How is a smoking pack year calculated?
(years smoked x cigs per day)/20
What is a pink puffer?
Increased alveolar ventilation and nearly normal O2/C02 levels, breathless but not cyanosed
What is a blue bloater?
Decreased alveolar ventilation, low O2 and high CO2, cyanosed but not breathless, rely on hypoxic drive to breathe
What are the signs of respiratory failure, secondary to COPD?
- Decreased level of consciousness
- Cyanosis
- Flapping tremor (asterixis)
- Oedema (cor pulmonale)
- Tachypnoea/cardia
- Fine inspiratory crackles
How should an acute exacerbation of COPD be managed?
Prednisolone 30mg for 5 days
Nebulised bronchodilators
Oxygen (24-28% via venturi)
+ antibiotics if sputum appears bacterial
When is pulmonary capillary wedge pressure measured?
Suspected respiratory distress - <19mmHg is diagnostic
How is ARDS managed?
- Respiratory support - CPAP, mechanical ventilation
- Circulatory support - inotropes, vasodilators, blood transfusion
- Sepsis - antibiotics
- Nutritional support - enteral
What is the definition of Type 1 respiratory failure?
Hypoxia (paO2<8) with adequate paC02
What causes type 1 RF?
Ventilation/perfusion mismatch:
- Pneumonia
- Pulmonary oedema
- PE
- Asthma
- Emphysema
- Pulmonary fibrosis
- ARDS
What is the definition of Type 2 respiratory failure?
Hypoxia (pa02<8) with hypercapnia (paC02>6)
What causes type 2 RF?
Alveolar hypoventilation:
- Pulmonary disease - COPD, pneumonia, asthma
- Reduced respiratory drive - drugs, tumour, trauma
- Neuromuscular disease - GBS, myasthenia gravid
What are the signs of hypercapnia?
Headache, peripheral vasodilatation, tachycardia, bounding pulse, tremor, confusion, drowsiness
What is the definition of asthma?
Recurrent episodes of dyspnoea, cough and wheeze caused by reversible airway obstruction
What would spirometry results of asthma look like?
- FEV1/FVC/PEFR reduced
- FEV1 >15% increase after beta agonist
What is bronchiectasis?
Permanent abnormal dilatation of the bronchi and bronchioli, caused by recurrent infections
What are the main organisms causing bronchiectasis?
H. influenzae
Strep. pneumoniae
Staph. aureus
Pseudomonas aeruginosa
What are the symptoms of bronchiectasis?
Cough, LOTS OF purulent sputum, intermittent haemopytsis
What are the signs of bronchiectasis?
Clubbing, coarse crackles, wheeze
What are some causes of bronchiectasis?
Congenital - CF, youngs syndrome, ciliary dyskinesia
Infection - measles, pneumonia, TB
Innate - allergic
How should bronchiectasis be managed?
Conservative - chest physio and mucus drainage
Medical - antibiotics, bronchodilators, steroids
Surgery - if severe haemoptysis
What are the symptoms of lung cancer?
Cough, dyspnea, chest pain, haemopytsis, weight loss, hoarseness, supraclavicular LN (pancoast), clubbing, recurrent chest infections
What is Horner’s syndrome?
Ptosis, meiosis, unilateral anhydrosis and small pupil.
–> these symptoms are associated with a pancoast tumour, found at the lung apex, and are caused by brachial plexus invasion
How is lung cancer classified?
Non-small cell -- squamous (35%), adenocarcinoma (27%) Small cell (20%)
Describe the characteristics of a squamous cell carcinoma
Located in proximal bronchi
Central, cavitating lesion
Slow-growing
Describe the characteristics of an adenocarcinoma in the lung
Located in peripheral lung
Spreads to lymph nodes and distant organs
Non-smokers
Slow-growing
Describe the characteristics of small cell lung cancer
Found all over the lung
Lymphadenopathy, highly metastatic
Fast-growing (median survival is 1 year if treated)
Usually presents as extensive (evident metastatic disease outside the ipsilateral hemithorax)
What is a mesothelioma?
A cancer affecting the lining of the organs (mesothelium), most commonly the lungs. It is associated with asbestos exposure and usually manifests as a unilateral pleural effusion.
How is non-small cell lung cancer managed?
Excision (if no spread), chemotherapy and radiotherapy (ceftuximab)
How is small cell lung cancer managed?
Attempt chemotherapy and radiotherapy but by presentation, care is usually palliative
What is a paraneoplastic syndrome?
A disorder triggered by an altered immune response to a neoplasm - these can sometimes present before the malignancy itself
Name some skeletal/cutaneous paraneoplastic syndromes, associated with lung cancer
Acanthosis nigricans (hyperpigmentation in body folds)
Clubbing
Dermatomyositis (inflammation of muscles and skin)
Osteoarthropathy (disease of bones and joints)
Name some endocrine paraneoplastic syndromes, associated with lung cancer
Cushings (SCLC)
Hypercalcemia (due to bone mets causing increased PTH)
SIADH (excessive secretion of ADH, associated with SCLC)
Tumour necrosis factor
Name some neurological paraneoplastic syndromes, associated with lung cancer
Lambort-Eaton syndrome (limb muscle weakness, associated with SCLC)
Neuropathies
Cerebellar degeneration
Confusion and fits
How is lung cancer staged?
TNM
T - primary tumour
N - regional nodes
M - distant metastasis
What could cause a pleural effusion with transudate?
Increased venous pressure (heart failure, fluid overload)
Hypoproteinaemia
Hypothyroidism
Meigs syndrome
What is a transudate?
Low protein content
Caused by pressure disturbance
What is an exudate?
High protein content
Caused by inflammation
What could cause a pleural effusion with exudate?
Increased leakiness of pleural capillaries secondary to infection, inflammation or malignancy (pneumonia, TB, SLE, carcinoma)
What is interstitial lung disease?
A number of conditions affecting the lung parenchyma in a diffuse way, causing chronic inflammation and fibrosis:
- Asbestosis
- Sarcoidosis
- Silicosis
- Drug related
- Hypersensitivity related
- Idiopathic
- Caplan’s syndrome
- Coal workers pneumoconiosis
What are the symptoms of ILD?
Dyspnoea on exertion, non-productive cough, abnormal breath sounds
What is Caplans syndrome?
Association between rheumatoid arthritis, pneumoconiosis and nodules
What is cor pulmonale?
Right heart failure caused by chronic pulmonary arterial hypertension (usually from chronic lung disease), causing dyspnoea, hepatomegaly and oedema
RESPIRATORY EMERGENCIES - What are the symptoms of a life-threatening asthma attack?
Unable to complete sentences, tachypnoea, tachycardia, silent chest, cyanosis
RESPIRATORY EMERGENCIES - How is an acute asthma attack managed?
DO PEFR then... Oxygen Steroids (prednisolone) Nebulised salbumatol IV magnesium sulphate
RESPIRATORY EMERGENCIES - What are the symptoms and signs of a PE?
Dyspnoea, sudden onset pleuritic chest pain, cough, haemoptysis, haemodynamic collapse, tachycardia, hypoxia, gallop pulse
RESPIRATORY EMERGENCIES - How is PE diagnosed?
CTPA scan D-dimer Well's scoring system, give 1 each for: - Previous PE/DVT (+1.5) - Heart rate >100bpm (+1.5) - Recent surgery or immobilization (+1.5) - Clinical signs of DVT (+3) - Hemoptysis (+ 1) - Cancer (+1) - Alternative diagnosis less likely than PE (+3)
RESPIRATORY EMERGENCIES - What are the risk factors for PE?
- Recent surgery
- Leg fracture
- Prolonged bed rest
- Pregnancy
- Malignancy
- Previous PE/DVT
- Combined oral contraceptive pill
RESPIRATORY EMERGENCIES - How should a PE be managed?
- Thrombolysis (alteplase)
- When stable, LMWH administration until INR >2, then start warfarin for at least 3 months
RESPIRATORY EMERGENCIES - What are the causes of massive haemoptysis?
Bronchial tumour, bronchiectasis, active TB, pneumonia, warfarin
RESPIRATORY EMERGENCIES - How is massive haemoptysis diagnosed?
100-600ml of blood loss in 24 hours
RESPIRATORY EMERGENCIES - How is massive haemoptysis managed?
- Airway protection and ventilation
- IV fluid resuscitation, cross match (CVS support)
- Nebulise adrenaline (stop bleeding)
- Oral/IV tranexamic acid (antifibrinolytic that stops bleeding)
RESPIRATORY EMERGENCIES - What is a pneumothorax?
Air in the pleural cavity
RESPIRATORY EMERGENCIES - What are the symptoms and signs of a pneumothorax?
CAN BE ASYMPTOMATIC IF YOUNG
Sudden onset pleuritic chest pain, dyspnoea, reduced chest expansion, hyper-resonant percussion, tracheal deviation
RESPIRATORY EMERGENCIES - What causes a pneumothorax?
- Spontaneous in young men due to bulla rupture
- Chronic lung disease
- Infection
- Trauma
- Carcinoma
- Connective tissue disorders (Marfans)
RESPIRATORY EMERGENCIES - What is a tension pneumothorax?
When air cannot escape the pleural cavity causing lung compression, inhibited venous return, hypotension and possible cardiac arrest (as heart has limited space)
RESPIRATORY EMERGENCIES - What are the signs of a tension pneumothorax?
- Raised JVP
- Hypotension
- Reduced air entry
- Tracheal deviation on CXR
- Cardiac arrest
RESPIRATORY EMERGNCIES - What is the difference in management of a pneumothorax and a tension pneumothorax?
Normal - chest drain, aspiration
Tension - ABC, oxygen, large cannula into second intercostal space at midclavicular line, NO CXR until stable, chest drain
What are the indications for pleural tap (aspiration)?
- Pneumothorax
- Pleural effusion
- Traumatic haemopneumothorax
- Post-op
