Respiratory Flashcards
ABGs
Taken from radial or femoral artery
Indications
Unexpected deterioration
Acute exacerbation of chronic chest condition
Impaired consciousness or respiratory effort
CO2 retention
Cyanosis, confusion, hallucinations
To validate SpO2
Steps
1) Acid or Alkaline
2) CO2 high or low. If this fits with the pH then it is respiratory.
3) HCO3- high or low. If this fits with the pH then it is metabolic.
4) Is PO2 normal given fraction of inspired O2?
5) Is there compensation for pH?
6) Anion gap = (Na+K)-(Cl+HCO3). Should be 10-18mM
Chest findings
1) Expansion 2) Trachea 3) Percussion 4) Breath sounds 5) Vocal resonance
Pneumothorax: up, away, increased, decreased, decreased
Pneumonia: down, no change, decreased, bronchial, increased
Effusion: down, either, much decreased, decreased, decreased
Collapse: down, can be away, decrease, decreased, decreased
Full examination
WIPER
45 degrees, need full access to front and back
IPPA
Inspection
Around: Drugs: Inhalers - NB colour Steroids Devises: Sputum pot Peak Flow meter - measures FEV (NB ratio of this to FVC suggests whether obstructive (e.g.COPD, bronchiectasis) or restrictive (asbestos)) Nebuliser - slow release medication Ventilation machine - ventilatory issue e.g. NMSK or scoliosis PPV NIV CPAP - portable sleep apnoea like machine, for paroxysmal issues Oxygen Care with COPD - they already have a hypercapnic drive, too much oxygen too fast will lead to respiratory depression Drips: Chest drains - colour of the aspirate
Patient
Wellness
Difficulty breathing - tachy/bradypnoea
Use of assisted muscles e.g. abs, serratus anterior, scalenes
Scars - trach, lateral thorectomy, chest drain (5th intercostal and NB angles)
Signs of Horners - Ptosis, Myosis, Anhydrosis, Hypothenar wasting
Chest wall compliance compensation
Pectus Excavetum (pigeon)
Pectus Carinatum
Barrel chest
Radiotherapy tattoos
Examination
Hands
Clubbing (using Shammaroth’s Window or just feeling) - anything but COPD and asthma
Capiliary refill - prioritisation of central O2
Hypothenar wasting
Palmar creases
Tar staining
Wrists Pulse and respiratory rate (could switch hands) - also look for depth, time of inspiration vs. expiration and lip pursing Flapping test (Asterixis) - CO2 retention (obstructive), beta agonist (fine tremor)
Offer BP
Eye
Conjunctival palor
Horner’s
Blue sclera
Mouth
Perfussion under the tongue
Pursed lips
Neck
Lymph nodes - mentle, mand, preauricular, postauricular, medial SCM, around clav, lateral SCM
JVP - RAP, pulmonary hypertension, Cor Pulmonare
Trachea - middle finger, three fingers
Deviation - away (tension pneumo, massive pleural effusion), towards (pneumonectomy/lobectomy, lung collapse)
Cricosternal distance - hyperexpansion
Chest
NB expose and inspect if not done already - make sure to look carefully for scars
NB positions of the lungs, don’t go too far down anteriorly
Palpate
Apex of the heart (5th IC midline) - displacement (pulm. hypertension)
Heave on the R side of the sternum
Expansion - touching the fingers and thumbs together but just above the skin, on out. 3cm on inspiration. NB symmetry
Percuss - side to side direct comparison
Apex, 2 x anterior chest wall, mid axiliary, base
Notes:
Resonnant - normal
Hyperresonnant - hyperexpansion
Dull - consolidation (inflammation or infection), mallignancy, diaphragm pause
Stoney dull
Auscultation
Deep in and out, in the same way as above, through the mouth
Bell on the apex
Special tests
Tactile vocal frematous - side of hand 99s at the same time
Whispering pectoriloquy - 1,2,3 on contact of the stethescope (if resonnant - consolidation)
Vocal resonnance - 99s when you feel my stethescope
Ratio of insp:exp time
Sounds:
1. Vesicular
2. Bronchial (sound like listening over trachea - Darth Vader.) Transmission of bronchial sounds through a fluid filled area
3. Added
Crackle -
fine (fibrosis), coarse (e.g. pneumonia, HF oedema)
throughout, inspiration, expiration
early or late
Stridor - inspiration wheeze sound (URT blockage)
Wheeze - expiration (various inflammatory airway diseases e.g. asthma, COPD). NB whether polyphonic or monophonic (latter is for single airway obstruction)
Pleural rub sounds
DO ALL CHEST AGAIN ON THE BACK
NB to stay more in the midline to avoid the scapulae
Sacral oedema
Legs
Pitting oedema NB on both
To complete Sputum pot Peak Flow O2 sats Temp
X-ray chest
Peak Flow
Correlates well with FEV1
Used as an estimate for airway calibre in asthma
Effort dependent
Pneumonia
Def:
A LRTI with associated -
Fever
Symptoms and signs in the chest (cough, green sputum, chest pain, SOB)
With radiological features of unilateral consolidation
10/1000, 21% mortality in hospital
Classification: CAP - primary or secondary to underlying disease Typically: Strep. pneumoniae - affects all ages but most common in elderly, alcoholics, immuno-suppressed, post-splenectomy, HF, pre-existing lung disease Haem. influenza Atypically: Mycoplasma pneumoniae Staph. aureus Legionella Chlamydia
15% virus
HAP - >48h after admission Typically: Gram negative enterobacteria Staph. aureus Atypically: Pseudomonas - common in bronchiectasis Bacteriodes Clostridia
Aspiration - e.g. in those with stroke, myasthenia, decreased consciousness, oesophageal disease, poor dental hygiene
Immunocompromised - various of the above pathogens
Strep. pneumoniae
Haem. influenza
Staph. aureus
NB can also classified by acute or chronic (more likely to be fungal and TB, and potentially bilateral)
Symptoms: Fever Rigors Malaise SOB Productive cough
Signs: Pyrexia Cyanosis Confusion Tachypnoea Tachycardia Consolidation - reduced expansion, dull percussion, increased tactile vocal frematous/vocal resonnance, bronchial breathing
Tests Sats - if <92% then ABG Bloods - FBC, U&Es, LFT, CRP CXR - infiltrates, cavitation or effusion Sputum - culture Urine - Legionella/Pneumococcal antigens Atypical serology Pleural fluid aspirated for culture Bronchoscopy/bronchoalveolar lavage
Severity Point system, one for each C - onfusion U - rea >7mM R - espiratory rate >30 B - P <90/60mmHg 65 - age 0-1 PO Abx 2 Hospital therapy >3 severe pneumonia (15-40% mortality)
Management
CAP:
0-1 - Oral, 500mg/1g amoxicillin TD, clarithromycin 500mg BD, doxycycline 200mg loading then 100mg OD
2 - amoxicillin + clarithromycin or doxycycline, or IV amoxicillin + clarithromycin
>3 - Co-amociclav 1.2g TD IV, cephalosporin (1.5g TD IV) and clarithromycin (500mg BD IV).
Add flucloxacillin +/- if Staph suspected
Vancomycin if MRSA suspected
If PVL-SA, seek urgent help
Atypicals
Legionella - Fluoroquinolone + clarithromycin/rifampicin
Chlamydia - Tetracycline
Pneumocystis jirovecii - high dose co-trimoxazole
HAPS - Gram -ve bacilli, Pseudomonas, Anaerobes
Aminoglycosides IV + antipseudomonal penicillin IV/third gen cephalosporin IV
Aspiration - Strep pneumoniae, anaerobes
Cephalosporin IV + Metronidazole IV
Complications
Pleural effusion - inflammation of the adjacent pleura causes exudation. Requires draining if symptomatic or empyema
Empyema - pus in pleural space, think this is recurrent fever in resolving pneumonia. Fluid is yellow, acidic, low glucose, high LDH.
Lung abscesses - cavitating area of localised suppurative infection.
Resp. failure - T1 is common. Treat with 60% O2 aiming for 94-98% sats or PO2 >8kPa
Sepicaemia - can lead to hypotension, give 250ml IV crystalloid/15min.
Pericarditis
Myocarditis
Atrial fibrillation - common in elderly, usually resolves but may require digoxin or beta blockers
Resp history
Types of questions for each symptom
Presenting:
• Cough
- Duration
- Continuous or progressive
- Character
- In the night? (think asthma, ask about atopic conditions eczema and hay fever. Could also be reflux, NB bad taste)
- Exacerbating - exposure? anxiety? exercise?
- Alleviating - away from…? medication?
- Triggers
- Bringing up sputum
- Blood
• Haemoptysis
- Consider TB (recent travel, origin) and malignancy (cachexia) carefully
- Mixed with sputum? - not in PE, trauma or bleeding into lung cavity
- Melaena - if coughed up blood is swallowed
• SOB
- Duration, onset (circumstances)
- Exercise exacerbation
- NYHA class
- Diurnal variation (morning and night, think asthma)
- Wheeze vs stridor
- Fevers/Rigors
- Chest pain
- SOCRATES
- Think pleuritic
Medications • Methotrexate - fibrosis • Steroids - NB immunocompromise - why, how long, route • Opiates - respiratory depression • ACEi - dry cough, switch to losartan (A2RB) • Non-specific beta blocker • Amioderone - pneumonitis
Social • Socio-economic status, prisoners - TB • Smoking Pack-years - current or ex - how many - start and stop - relevance after 20 • Occupational exposures - can you talk me through the jobs you've had - hobbies • Pets, in particular birds
Fhx • Cancer • COPD • Asthma • alpha 1 antitrypsin • autoimmune
Systems review Rule out • heart burn • cardiac • renal vasculitis • Reynauld's or scleroderma - connective tissue • Other autoimmune - RA
Obstructive or restrictive
Obstructive
FEV1/FVC < 70%
TLC and RV increase
Restrictive
FEV1/FVC > 70%
TLC and RV reduce
Obstructive: Asthma, COPD, Bronchiectasis,CF
Restrictive: Fibrosis, Sarcoidosis, Pneumoconiosis, Interstitial pneumonias, Connective tissue disease, Pleural effusion, Obesity, Kyphoscoliosis, Neuromuscular
Sputum
NB changed every day
Blood specks (haemoptysis) - pneumonia, TB, malignancy, trauma Excessive clear - COPD Green/yellow - suggests infection Black - smoking, carbon particles Pink and frothy - pulmonary oedema
Types of inhaler
Reliever
BLUE (Bronchodilator)
Salbutamol 100-200mcg/6h
Most commonly via a Metered Dose inhaler e.g. Ventolin, Airomir
Preventer
BROWN (Corticosteroid)
Beclometasone (Clenil Modulite) - 200mcg/12h, then 400, then 1000
Fluticasone (Flixotide) - 100-250mcg/12h
Combination
PINK, PURPLE or RED (LABA and corticosteroid)
Fostair (beclometasone dipropionate and formoterol fumarate dihydrate) - 100/6 mcg/puff
Seretide (fluticasone and salmeterol) - 125/25mcg
Symbicort (budesonide and formoterol fumarate dihydrate) - 200/6 micrograms/inhalation.
Technique: Out gently and shake inhaler Place inhaler in mouth as breathing in and deliver a puff Continue to breathe in Hold breath for 10s Breathe out slowly
A spacer may be added to improve the delivery. Shake, attach to the spacer Out gently then put in mouth Puff Breathe in slowly (whistle if too fast)
Breath-actuated don’t require coordination of breathing (i.e. they automatically release on starting to breathe in)
Respiratory failure
Inadequate gas exchange, with a PaO2 <8kPa
Type I Def: Hypoxia and normal or low CO2 Eitiology: V/Q mismatch, hypoventilation, abnormal diffusion, R to L cardiac shunt Conditions: Pneumonia Pulmonary oedema PE Asthma Emphysema Pulmonary fibrosis
Type II
Def:
Hypoxia with hypercapnia (>6kPa)
Eitiology:
Alveolar hypoventilation, with or without V/Q mismatch
Conditions:
Pulmonary disease - asthma, COPD, pneumonia, end stage fibrosis, OSA
Reduced respiratory drive - Sedative drugs, CNS trauma or tumour
NMD - Cervical cord lesion, diaphragmatic paralysis, poliomyelitis, Myasthenia Gravis, Guillain Barre
Thoracic wall defects - Flail chest, kyphoscoliosis
Features Hypoxia: SOB Restless Confusion Central cyanosis. If longstanding - polycythaemia, pulmonary HTN, cor pulmonale
Hypercapnia: Headache Peripheral vasodilation Tachycardia Bounding pulse Asterixis Papilloedema
Investigations Bloods - FBC, U&Es, CRP, ABG Radio - CXR Microbiology - sputum and blood Spirometry
Management
Always attempt to treat underlying cause
TI
O2 - 24-60% via mask
Assist ventilation if necessary
TII
CAREFUL O2 therapy - increase gardually from 24%
Recheck ABG to see if CO2 is lower or steady before increasing O2
May req intubation or ventilation
Interstitial lung disease
Def: umbrella term to describe conditions with chronic inflammation and progressive interstitial fibrosis.
Features: SOB on exertion Non-productive paroxysmal cough Abnormal breath sounds Abnormal radiology Restrictive spirometry with decrease in DLCO
Pathology:
Fibrosis and remodelling of the interestitium
Chronic inflammation
Hyperplasia of TII epithelial and pneumocytes
Known causes:
Occupational - asbestosis, berylliosis, silicosis, byssinosis
Drug induced - nitrofurantoin, bleomycin, amiodarone
Hypersensitivity
Infection - TB, fungi, viral
GORD
Associated with systemic disorders: Sarcoidosis RA SLE Connective tissue disease Sjogren's Ulcerative colitis Autoimmune thyroid disease
Idiopathic:
IPF - most common
Crytogenic organising pneumonia
Non-specific interstitial pneumonitis
IPF
Def: idiopathic pulmonary fibrosis, with inflammatory cell infiltrate.
Symptoms: Dry cough SOB on exertion Malaise Decrease in weight Arthalgia
Signs:
Cyanosis
Clubbing
Fine, end-inspiratory creps
Complications:
Respiratory failure
Increased risk of lung cancer
Tests:
Bloods - ABG (decrease PO2 and increased PCO2), increase in CRP and Igs, may be ANA or Rhuematoid Factor positive
Imaging - decrease in volume, bilateral lower zone reticulo-nodular shadowing, honey-combing
Spirometry - restrictive
Bronchio-alveolar lavage - increase lymphocytes (good), increase neutrophils or eosinophils (poor)
Biopsy - UIP changes
Management:
Supportive - oxygen, rehab, opiates
Consider clinical trials
Nintedanib and pirfenidone for mild to moderate disease
NB prognosis - 2-3 year median survival
Various different ‘paths’, no way of predicting which
Specific pneumonias
Pneumococcal:
Commonest
NB - elderly, alcoholics, post-splenectomy, immunosuppressed, HF, with lung disease
Features - fever, pleurisy, herpes labialis, CXR with lobar consolidation
Treatment - amoxicillin, benzlypenicillin, cephalosporin
Staph:
Complicated Influeza infection
NB - age extremes, IVDU, those with underlying disease
Leads to bilateral cavitating bronchopneumonia
Treatment - flucloxacillin +/- rifampicin
Klebsiella: RARE NB - elderly, alcoholic, diabetics Cavitating pneumonia in the upper lobes Often drug resistant Treatment - cefotaxime
Pseudomonas:
Common in bronchiectasis, CF and HAP (e.g. post ITU or surgery)
Treatment - anti-pseudomonal penicillin, ciprofloxacin + aminoglycoside
Mycoplasma:
Occurs in epidemics
Flu-like symptoms and dry cough
CXR - reticulo-nodular shadowing and patchy consolidation in one of the lower lung zones
Complications - skin rash, Steven-Johnson syndrome, meningoencephalitis, Guillain-Barre
Treatment - Clarithromycin, doxycycline, fluroquinolone
Legionella:
NB water tanks e.g. air-con
Leads to flu-like symptoms, fever, SOB, diarrhoea & vommiting, hepatitis, renal failure, confusion and coma
CXR - bibasal consolidation
Test - lymphopenia, hyponaturaemia, derranged LFTs
Urine - culture and antigens
Treatment - fluroquinolones
Chlamydophila pneumoniae: Person-to-person spread Pharyngitis, hoarseness, otitis Diagnosis - complement fixation Treatment - Doxycycline, clarithromycin
Chlamydophila psittaci:
Causes psittacosis (NB pet birds)
Headache, fever, dry cough, lethargy, arthralgia, anorexia, D&V
Treatment - Doxycycline and clarithromycin
Viral:
Influenza, H1N1
Pneumocystis:
NB in the immunosuppressed e.g. HIV
Caused by Pneumocystis jirovecii,
Dry cough, SOB exertion, decreased PO2, fever, bilateral creps
CXR - bilateral perihilar interstitial shadowing
Diagnosis - visualisation from sputum or BAL
Treatment - High dose co-trimoxazole
Auscultation
Vesicular - normal
Bronchial
• Harsh, Darth Vader-like
• Increase vocal resonance and whispering pectoriloquy
• Pathology
- Consolidation
- Localised fibrosis
- Area above pleural/pericardial effusion
Diminished sounds • Difficult to hear • Pathology - Pleural effusion - Pleural thickening - Pneumothorax - Bronchial obstruction - Asthma or COPD
Silent chest
• Cause - dead space is being ventilated
• Pathology
- Life-threatening asthma
Wheeze (expiratory)
• Cause - narrow airway
• Monophonic
- partial obstruction of one airway e.g. tumour of aspiration
• Polyphonic
- widespread narrowing e.g. asthma, cardiac wheeze (LVF)
Crepitations • Cause - reopening of small airways on inspiration • Fine and late inspiratory - pulmonary oedema • Coarse mid-inspiratory - bronchiectasis • Early inspiratory - small airway disease • Late/pan inspiratory - alveolar disease
Pleural rub
• Cause - roughened visceral and parietal pleura contact (e.g. due to exudate)
- pneumonia
- pulmonary infarction
Bronchiectasis
Def: Chronic inflammation of the conducting airways, leading to dilation and thinning
Typical organisms: Haem. influenza Strep. pneumoniae Staph. aureus Pseudomonas aeruginosa
Causes: Congenital - CF - Young's - Primary ciliary dyskinesia - Kartagener's Post-infection - Measles - Pertussis - bronchiolitis - pneumonia - TB - HIV Other - bronchial obstruction - allergic bronchiopulmonary aspergillosis (ABPA) - RA - ulcerative colitis
Symptoms:
• Persistent cough
• Copious, purulent sputum
• intermittent haemoptysis
Signs
• Clubbing
• Coarse inspiratory creps
• Wheeze
Complications • Pneumonia • Pleural effusion • Pneumothorax • Haemoptysis • Cerebral abscess • Amyloidosis
Tests • Sputum culture • CXR/CT - cystic shadows - thickened bronchial walls (tramlines and signet ring) • Spirometry - obstructive • Bronchoscopy - locate site of haemoptysis - exclude obstruction - obtain culture sample • Others - serum Igs - CF sweat test - Aspergillus precipitins
Management • Airway clearance techniques and mucolytics • Abx - ciprofloxacin if pseudomonas • Bronchodilators (if also asthma, COPD) • Corticosteroids - for ABPA • Surgery - to control haemoptysis
Pleural effusion
Def: fluid in the pleural space
Characterised by protein content
<25g/L = transudate
>35g/L = exudate
Can be
• Haemothorax
• Empyema
• Chylo
Causes:
Transudate • Increase venous pressure - HF - Constrictive pericarditis - Fluid overload • Hypoproteinaemia - cirrhosis - nephrotic syndrome - malabsorption • Hypothyroidism • Meig's - right pleural effusion following ovarian fibroma
Exudate • Increased leakiness of pleural capillaries - infection - inflammation - malignancy
Symptoms: • Can be asymptomatic • SOB • Non-productive cough • Pleuritic chest pain
Examination: • Stony dull percussion • Decreased breath sounds - may be bronchial breathing above • Decreased expansion • May be tracheal deviation if large
Look for other associated signs of disease which may point to the underlying cause
Investigations CXR • blunt costophrenic angle • meniscus USS • ID fluid • guides aspiration
Aspiration
• percuss upper border and goes 1 or 2 intercostals below
• take off fluid to analyse
Chemistry
- protein (classification)
- glucose (<3.3mM -> empyema, malignancy, TB, RA, SLE)
- pH (<7.2 -> above)
- LDH (pleural:serum >0.6 -> above)
- amylase (pancreatitis, carcinoma, bacterial pneumonia, oesophageal rupture)
Bacteriology
- cultures
Cytology
Immunology (Rheumatoid factor, ANA, decrease in complement)
Biopsy if inconclusive
Manage:
• Repeated aspiration
• Pleurodesis - talc for recurrent infection
• indwelling catheter
• intra-pleural alteplase and dornase alfa
• Surgery
• Opioids
Oxygen delivery
Types: • nasal cannula (not high flow or precise) • non-rebreathe (up to 15l) • venturee mask (Nb for COPD control) • humidified • NIV (CPAP and BIPAP).
Ventilation and tests
Causes for changes to ventilation: Lungs - restrictive and obstructive, infection Pneumonia - hospital, community, aspirated, ventilated Pathogens - typical and atypical Empyema Cancer - small and non small (squamous, adenoma), mesenchyme Vascular - PE Neurology MND Guillame Barre Opiates MSK Obesity Kyphosis Diaphragm failure
COPD
COPD
Emphysema- histopath of alveolar wall distraction
Chronic bronchitis - productive cough >3months in two consecutive years
NB smoking history
Alpha anti trypsin 1 def
Severity - MRC breathlessness scale, spirometer gold scale, bode index
Investigate - spirometer, peak flow, sputum, blood gases, sO2
Bloods - EPO response (secondary)
