respiratory Flashcards
asthma:
- risk factors? 6
- three factors that contribute to airway narrowing?
- PMH atopic disease
- FH atopic disease
- exposure to tobacco smoke (or other lung irritants)
- social deprivation
- low birth weight
- obesity
1) bronchial muscle constriction (triggered by a variety of stimuli)
2) mucosal swelling/inflammation (dt mast cell + basophil degranulation)
3) increased mucus production
asthma:
- symptoms? 3
- common triggers? 8
- drugs which exacerbate? 2
- intermittent dyspnoea (diurnal variation)
- wheeze
- cough (often nocturnal) w sputum
- cold air
- exercise
- emotions
- allergens (dust mite, pollen, fur)
- infection
- smoking
- passive smoking
- pollution
- NSAIDs
- B blockers
asthma:
- clinical signs?
- conditions which often co-exist?
- clinical testing/diagnosis?
- symptomatic wheeze on auscultation
(- can get hyper inflated chest, but only if severe) - other atopic (hayfever, eczema)
- gastric reflux
- peak flow
spirometry
- FEV1/FVC ratio reduced (should be 90% in kids + 70% in adults)
- FEV1 improves with salbutamol
asthma:
- suggested lifestyle changes? 3
- pharmacological treatment ladder? (5 steps)
- stop smoking
- avoid precipitants
- weight loss (if overweight)
1) occasional SABA as required
(if used >1 a day or at night then go step 2)
2) add daily inhaled steroid (e.g. beclomethasone)
(before step 3, check inhaler technique, adherence + removal of triggers)
3) change to LABA/inhaled steroid dual inhaler (don’t take LABA alone)
- if no response, stop LABA + increase inhaled steroid dose
4) raise inhaled steroid dose or add other agents:
- oral theophylline
- oral B2-agonists
- LTRA
* refer to specialist at this point*
5) add daily steroid tablets
differential diagnosis for asthma:
- resp? 5
- cardiovascular? 3
resp:
- COPD
- bronchiectasis
- large airway obstruction
- pneumothorax
- obliterative bronchiectasis (suspect in elderly)
cardiac:
- pulmonary oedema (‘cardiac asthma’)
- PE
- SVC obstruction (e.g. by tumour)
acute severe asthma:
- presentation?
- signs of severe attack?
- signs of life-threatening attack?
- acute breathlessness + wheeze
severe:
- unable to complete sentences in one breath
- RR >25
- pulse >110
- PEF 33-50% of predicted (or best)
life threatening:
- PEF <33% of predicted or best
- silent chest, cyanosis, feeble respiratory effort
- arrhythmia or hypotension
- exhaustion, confusion, coma
- poor ABG results
acute severe asthma:
- management?
- what to monitor? 3
- stay calm!
- nebuliser salbutamol (keep going, can’t really overdose)
- oxygen
- oral prednisalone
- repeat salbutamol
- continue reassessing
- add ipratropium
GET HELP!!
- RR
- pulse
- O2 sats
differential diagnosis for acute asthma attack? 5
- acute infective exacerbation of COPD
- pulmonary oedema
- upper resp tract obstruction
- PE
- anaphylaxis
COPD:
- definition?
- definition of chronic bronchitis?
- factors which make COPD more likely than asthma? 5
- genetic risk factor?
progressive + prolonged airway obstruction
- FEV1 <80% predicted
- FEV1/FVC <0.7
- with little or no reversibility
- cough
- sputum production on most days for 3 months of 2 successive years
- symptoms improve if stop smoking
- age of onset >35years
- smoking (active or passive, or pollution related)
- chronic dyspnoea
- sputum production
- minimal diurnal or day-to-day FEV1 variation
- a1-antitrypsin deficiency
COPD:
- difference between a pink puffer and a blue bloater?
blue bloater
- mainly bronchitis
- earlier
- near normal PaO2
- cyanosed
- wheezing
- overweight
pink puffer
- mainly emphysema
- later
- low PaO2 and high CO2
- severe breathless
- quiet chest (hyper inflated lungs on x-ray)
- cachexic
COPD:
- symptoms? 4
- signs? 4
- cough
- sputum
- dyspnoea
- wheeze
- tachypnoea
- use of accessory muscles
- hyperinflation (barrel chest)
- wheeze
COPD:
- main investigation?
- signs on x-ray? 2
- spirometry
nb CXR may be normal if early/well-controlled
- hyperinflation
- flat hemidiaphragms
(- may see bullae)
COPD:
- non-pharm treatment? 3
- what is the general progression of inhalers? 3
- end-stage treatment?
- stop smoking
- exercise
- pneumococcal + flu vaccine
1) SABA or SAMA (short-acting muscarinic antagonist)
2) add LABA or LAMA
3) add inhaled steroid
- long term oxygen therapy (LTOT)
^contraindicated in smokers
nb can also consider surgery to remove bullae but rarely done
complications of COPD:
- exacerbations? 2
- other? 5
- infective
- non-infective
- polycythaemia (dt prolonged hypoxia)
- resp failure (1 or 2)
- cor pulmonale
- pneumothorax (ruptured bullae)
- lung cancer
bronchial carcinoma
- 4 types?
- risk factors?
small cell
- aka oat cell
- worse prognosis
- often have paraneoplastic syndromes (ACTH or ADH secretion)
non-small cell
- squamous
- adenocarcinoma (commonest in non-smokers + asbestos)
- large cell
- tobacco smoking (90%)
- passive smoking
- asbestos
- chromium
- arsenic
- iron oxides
- radiation
- pollution
bronchial carcinoma:
- local symptoms? 4
- systemic symptoms? 3
- signs? 3
- persistent cough (80%)
- haemoptysis (70%)
- dyspnoea (60%)
- chest pain (40%)
- lethargy
- anorexia
- weight loss
- cachexia
- anaemia
- clubbing
nb can get other signs if mets or paraneoplastic syndromes
- may auscultate an unresolved ‘pneumonia’ but not always
bronchial carcinoma:
- imaging?
- other tests?
CXR (nb if clear but smoker with haemoptysis send for CT as mediastinum may hide it) - peripheral nodule - hilar enlargement - (lung collapse or pleural effusion)
- fine needle aspiration or biopsy to identify + stage tumour
- can send sputum or pleural fluid as well
- bronchoscopy, to assess eligibility for surgery
- PET CT for staging/mets
bronchial carcinoma:
- ideal treatment?
- other treatments?
- lobectomy
- radical radiotherapy
- radiotherapy + chemo (for advanced)
very poor prognosis! (especially small cell)
differential diagnoses for nodules on the lung on a CXR:
- respiratory? 8
- other? 3
- primary lung cancer
- secondary lung cancer
- carcinoid (neuroendocrine) tumours
- abscess
- granuloma
- cyst
- pulmonary hamartoma
- encysted effusion (fluid, pus, blood)
- Arterovenous malformation
- foreign body
- skin tumour (e.g. seborrheic wart)
differential diagnosis for haemoptysis:
- commonest? 4
- others? 4
- bronchitis (26%)
- neoplastic (23%)
- pneumonia (10%)
- TB (8%)
- PE
- foreign body
- rare vasculitisis
- bronchiectasis
pneumothorax:
- commonest cause?
- other causes?
- spontaneous (in tall, young men)
chronic lung disease
- asthma
- COPD
- CF
- lung fibrosis
- sarcoidosis
infection
- TB
- pneumonia
- lung abscess
traumatic
- trauma (incl rib fracture)
- iatrogenic (e.g. lung biopsy, mechanical ventilation)
carcinoma
connective tissue disorder (e.g. marfans)
basically anything that affects the lung can cause a pneumothorax…
pneumothorax:
- symptoms? 2
- signs? 3
- signs of a tension pneumothorax? 3
- often asymptomatic in tall, young men
sudden onset
- dyspnoea
- pleuritic chest pain
(sudden deterioration in asthma/COPD patients)
on affected side:
- reduced expansion
- hyper resonant to percussion
- diminished breath sounds
tension:
- trachea deviation (away from pneumothorax)
- hypotension
- rapid deterioration/resp distress
pneumothorax:
- imaging? 1
- bloods? 1
CXR
- NOT in tension pneumothorax!!
- ABG (if hypoxic or chronic lung disease)
pneumothorax:
- management? 2
- future advice? 2
- treatment for recurrent? 1
- aspiration
- if unsuccessful (do CXR), or patient ill: intercostal chest drain
- no air travel for 6 weeks after normal CXR
- avoid diving permanently
- pleurodesis
pleural effusion:
- commonest causes of transudates? 2
- rare causes of transudates? 2
- causes of exudates? 3
- heart failure
- hypoalbuminaemia (liver failure)
(- hypothyroidism)
(- meig’s syndrome - ovarian fibroma)
infection
- pneumonia
- TB
inflammation
- RS
- SLE
malignancy
- bronchial carcinoma
- mets
- lymphoma
- mesothelioma
pleural effusion:
- symptoms? 2
- commonest signs? 3
- other signs? 3
asymptomatic if small
- dyspnoea
- pleuritic chest pain
on affected side:
- decreased expansion
- stony dull to percussion
- decreased breath sounds
- bronchial breathing (above effusion dt compression)
- tracheal deviation away from effusion, if large
- signs of underlying cause (liver disease, clubbing, SLE rash etc)
pleural effusion:
- imaging? 1
- other investigation? 1
- CXR (blunted costophrenic angles is first sign)
- USS guided pleural fluid aspiration (unless obvious it’s heart failure)
pleural effusion:
- treatment of transudates? 1
- treatment of exudates? 1
- treatment of recurrent pleural effusions? 1
- treat underlying cause in transudates
- drain in exudates (or if symptomatic) - nb also treat underlying cause!!
- pleurodesis
pneumonia:
- definition?
an acute LRTI associated with fever, symptoms + signs in the chest AND abnormalities on the CXR
pneumonia:
- commonest organism in CAP?
- other typical CAP organisms?
- atypical CAP organisms?
strep pneumoniae (commonest)
typical
- Haemophilus influenzae (common w COPD)
- moraxella catarrhalis
atypical
- mycoplasma pneumoniae
- staph aureus (IVDU)
- legionella (water borne)
- chlamydia
nb 15% are caused by viruses
hospital acquired pneumonia:
- definition?
- 2 most common causative organisms?
- 4 rarer ones?
> 48hours after hospital admission
+ gram negative enterobacteria
+ staph aureus
- pseudomonas
- kleibsiella
- bacteroides
- clostridia
pneumonia:
- resp symptoms? 4
- other symptoms? 4
- productive cough (w green sputum)
- dyspnoea
- pleuritic pain
- haemoptysis
- fever
- rigors
- anorexia
- malaise
pneumonia:
- sign most commonly seen in elderly?
- score used to assess severity?
confusion (can be only sign in elderly)
CURB-65
C - confusion U - urea (in blood) R - RR B - BP 65 - over the age of 65
score 1 for each! determines whether treatment as outpatient or admitted
pneumonia:
- imaging?
- bloods? 4
- other bedside tests? 2
CXR
- FBC (raised WBCs)
- U+E (look for urea)
- LFTs (just cos)
- CRP (severity)
- O2 sats
- BP (see if getting septic)
pneumonia Abx treatment:
- first line if CAP with low CURB?
- first line if CAP with high CURB?
- first line if CAP with penicillin allergy?
- if caused by MRSA?
low CURB
- amoxicillin (initially 5 days)
high CURB
- co-amoxiclav (initially 7 days)
(- add clarithromycin if not clearing!)
penicillin allergy
- clarithromycin
nb always consult trust guidelines
nb above are for typical organisms - atypicals use other things (check guidelines)
- vancomycin
if hospital acquired, culture + treat organism
Pneumonia:
- non-Abx medication? 3
- follow up required?
- analgesia
- fluids
- oxygen (to keep up sats)
^all depend on severity
also physio to help cough
CXR in 6 weeks
pneumonia:
- main resp DDx? 3
- PE
- pulmonary oedema
- bronchial carcinoma
PE:
- commonest cause?
- rare causes? 4
emboli from DVT in legs or pelvis
- RV thrombus (post-MI)
- septic emboli (R infective endocarditis)
- fat, air or amniotic fluid emboli
- neoplastic cells
PE:
- risk factors which increase hypercoaguability? 5
- risk factors which increase stasis? 2
- risk factors which damage blood vessels? 2
hypercoaguable
- pregnancy (+ 6 wks postpartum)
- COCP (HRT, but less so)
- cancer
- thrombophilia (e.g. antiphospholipid syndrome)
- previous PE
stasis
- prolonged bed rest/reduced mobility (incl air travel)
- recent surgery (esp pelvic, hip or knee)
damaged blood vessels
- obesity
- over 60
also FH
PE:
- symptoms? 5
- signs? 6
nb small emboli may be asymptomatic
- acute breathlessness
- pleuritic chest pain
- haemoptysis
- dizziness
- syncope
- tachypnoea
- tachycardia (see on ECG)
- hypotension
- raised JVP
- pleural rub
- SIGNS OF DVT
PE:
- score used to work out likelihood of PE?
- investigation if this is low?
- investigation if this is high?
- other investigations? (incl bloods) 3
WELLS score
- uses clinical signs as well as risk factors
low WELLS score
= do D-Dimer
- if negative, consider alternative diagnosis
- if positive, do CTPA (or empirical LMWH treatment if delay)
high WELLS score
= do CTPA or treat empirically with LMWH if delay
- bloods, incl clotting
- ECG (rule out ACS)
- CXR (rule out other DDx)
PE:
- treatment if haemodynamically unstable?
- treatment if haemodynamically stable?
- investigations needed if unprovoked PE (i.e. no real risk factors)?
unstable
- thrombolyse (alteplase)
stable
- LMWH (unfractioned if renal probs) then introduce NOACs or warfarin (target INR = 2-3)
investigate for possible underlying malignancy
- full Hx + exam
- CXR, Ca2+, LFTs
if over 40, consider abdominal-pelvic CT + mammography for women
consider antiphospholipid + thrombophilia testing if FH positive
