Respiratory Flashcards
Bronchiectasis
What is it, and cause?
Main symptoms?
What are 3 syndromes it is most commonly associated with?
What - Chronic inflammation of the bronchi/oles that leads to permanent dilation and thinning of the airways
Main symptoms - Chronic cough, lots of sputum (yellow, green), intermittent hemoptysis
Causes - Basically get an inflammatory process after an inflammation alongside another contributing process such as airway obstruction, decreased lung defense mechanisms or impaired drainage. Get an chronic infection and result in irreversible damage and dilation of the bronchi
Associated diseases - CF,
Asthma - Symptoms and signs
Symptoms
-Cough, wheeze, dyspnea, chest tightness
Signs - wheezing,prolonged expiratory phase, hyper inflated or hyper resonant chest
-severe - signs of severe dyspnea - accessory muscle use and absence of lung sounds
How to initially diagnose someone?
Hospital - skip diagnosis and treat
Outpaint
- PFTs = FEV1/FVC reduced (FVC same and FEV1 reduced)
- If PFTs normal –> methyl choline (to induce bronchospasm) - if negative then no astham, if positive - asthma
- If PFTs decreased –> give albetelol - if positive - then asthma is reversible, if negative then not asthma
How to assess severity of disease and how to treat
Table
-learn !!!
Acute exacerbation
Diagram learn
Types of SABA, LABA, ICS, oral steroids used for asthma
SABA - salbutamol, terbutaline
ICS - Beclometasone diproprionate, Budesonide, fluticasone proprionate
LTA - oral montelukast (age 2-4)
LABA - formoterol, salmeterol, eformoterol
PO - oral prednisone
SAMA - Ipratropium
Differential diagnosis ASthma
Pulmonary oedema
- COPD
- Large airway obstruction (foreign body/ tumour)
- Pneumothroax
- Bronchiectasis
Acute attack COPD exhaserbation -pulmonary oedema -URI -pulmonary embolus -anaphylaxis
DVT - main symptoms , how are they diagnosed
-Odema in leg,
-typically in popliteal or femoral veins (no valves in deep veins - can travel)
-Difference >2cm between legs, and below 2cm of tuberosity
Diagnosed - Ultrasound
Treatment - anticoagulation
Physiology behind PE
- DVT occurs in leg travel to lung
- wedges in lung –> causes ischaemia, necrosis (haemoptysis, pleuritic chest pain)
- Get increased pressures - pulmonary hypertension –> can lead to right heart strain (S1,Q3,T3)
- Get platelet mediated vasodilation, fluid leaks into avleolar space -makes oxygen diffusion decreased (harder to flow through)
- Then to increase DL02 = hbg x sp02 x CO (hr x sv)
- will increased CO - get tachycardia and tachypnoea
- this will also cause a hypocapnia (co2 is perfusion limited and have increased perfusion so get more blown off)
- get a hypoxaemic respiratory alkalosis
Presentation PE
shortness of breath, tachypnea, tachycardia, a pleuritic chest pain, and a Clear Chest X-ray.
- can get right sided heart strain - ECG - S1Q3T3
- can also get haemoptysis
- look for one leg larger than the other
signs - pyrexia, cyanosis, tachypnoea, tachycardia, hypotension, raised JVP, plerual rub, plueral effsuion, DVT
Diagnosis PE
First complete a wells score
- if Low - D Dimer - rule out
- if more than 4 and kidneys are normal - CTA
- If more than 4 and abnormal kidneys - do a V/Q scan - MUST HAVE A NORMAL XRAY
-if leg is swollen do a leg US first - least invasive
pulmonary angiogram - is gold standard, however normally is not the answer because it is invasive (only in setting of massive PE producing hypotension) –> for tpa admission
-or if pre-test probability is extremly high and ct does not show PE
-chest xray, ecg - to rule out other things
xray - can show ateletaxis
Treatment PE
-heparin - 5 days
or LMWH - enoxaparin,
-bridge to warfarin
-or NOAC - dabigatran, rivaroxaban or apixiban
-tpa - only if massive PE - hypotension, heart signs, trop, bnp, strain on echo/ecg (Streptokinase, alteplase)
- DONT DO A IVC filter
- Thrombectomy - ONLY IF chronic MASSIVE PE AND pul hypertension
What does warfarin inhibit
What to do if INR gets large
factors 2,7,9,10 protein C
measure INR - 2-3
INR <5 - Hold a dose
INR 5-9 - hold dose, vit K
INR > 9 - hold dose, Vit K, lower dose
Bleeding - Fresh frozen plasma, vit k
oncotic vs hydrostatic pressure
Hydrostatic - capillary pressure - pushes things out
Oncotic - solutes outside capilaries - can draw fluid out of vessels
Defining pleural effusions
transudate vs exudate
Transudate - (fluid from vessels)
- CHF (hydrostatic)
- Cirrhosis, gastrosis, nephrosis (oncotic pressure)
Exudate - (fluid + other stuff from inflammation)
- Malignancy
- Pneumonia
- TB
Signs/ Symptoms pleural effusion
- SOB, orthpnoea
- Pleurtic chest pain
- Dullness to percussion
Diagnosis
Chest Xray
- blunted costophrenic angle
- When it gets bigger - then get both above and horizontal meniscus (fluid in chest)
- dont know if haemothroax, chyothorax or plueral effusion (blood, chyme, fluid) —-> Throencitesis to figure out what it is
How to diagnose
Look at diagram
Image - lateral decubus xray, US, CT (pick xray)
- Is it loculated or not (simple or need surgeon)
- less than 1cm - to small, watch and wait
- if get sepitations lobes - pockets of fluid, then it is loculated –> throacostomy (chest tube +/- tpa)
- if this fails –> need to do a throcotomy
- if it is not loculated - DO not tap
- if they have CHF - most likely to be this, so just diurese - if this does not work, then can do thorosentesis
- then want to determine if it is exudate or transudate
How to determine if exudate or transudate
Do not tap if too small, loculated or CHF - on xray.
Thorsentesis Lights criteria -LDH >2/3 -LDH/Serum ULN >0.6 -TPfluid/TPserum LDH >0.5 (lactate dehydrogenase)
(fluid comes first) - if you have lots of stuff in the pleural space, then get ratios closer to 1 (exudate) (transudate - will be low ratios)
need all criteria negative for transudate
-Need one criteria to be exudate
Test these tubes -Tube 1 - Cell count w Diff Pneumonia - leukocytosis w polys) TB/Malignancy - white cells with - lymphocytes Haemothroax/cancer - rbcs
-Tube 2 - cytology = cancer - then is stage 4 (metastatic disease)
-Tube 3 - glucose, pH
adenosine deaminase - tb, Triglycerides - chylothroax
Tube 4 - Blood culture –> gram stain and culture - look for bacteria, fungi and tb -
What is COPD
-how to make diagnosis
Emphysema (pink puffer)
-pursed lips (proloned exhalation), barell chest, increased co2 retention, no change in 02
Bronchitis (blue blower)
- Decrease o2 - cyanosis (due to inflammatory damage)
- vasoconstriction - pulmonary hypertension –> right sided heart failure , oedema
Diagnosis - PFTs
-FEV1/FVC - (both are decreased and ratio is also decreased)
(can do chest xray, abg, ecg to rule out other things)
Treatment - stable
SABA LAMA LABA ICS PDe4 (phosphdiesteraid 4 inhibitors) Steroids
COPDER
C - corticosteroids (ICS, PO, IV - depending on severity)
O - oxygen SP02 <88% (want it between 88-92% because dont want to lose hypoxic drive) or give if Pa02 <55
P - Prevention - vaccines, flu and streptococcal, and stop smoking
D - Dilators - SABA, LAMA, LABA
R - rehab - exercise tolerance
COPD exacerbation - signs and symptoms
- cough, wheeze, sputum production
- do a chest xray, ecg, abg to cancel other differentials
Management COPD exacerbation
and how do we tell how bad?
Antibiotics - Amoxyicillin or doxycyclin
Bronchodilators - salbutamol, ipratropium
Steroids - Prednisone PO or IV methyprednisolone
Look at their response to therapy
- get better –> go home (PO steroids, mederdose inhalors)
- okay –> need more time –> wards (PO and nebulised - bronchodilators)
- Get worse - confusion, absent wheeze or lung sounds, co2 increase –> ICU - IV steroids, ipap or pt tube
Groups of COPD classification
FEV1/FVC <70%, and FEV1 post bronchodilator Group A - FEV1 60-80% MILD Group B - FEV1 40-60% MOD Group C - FEV1 <40% Severe Group D - acute exacerbation
Group A + B - saba, lama, laba
Group C - ICS
Group D - exhaserbation, consider home oxygen if <90% on more than 1 occasion
Types of SABA, LAMA, LABA
ICS
SABA - salbutamol, terbutaline SAMA - ipratrpoum
LAMA - umeclidinium, tiotroium, glycopyrronium
LABA - salmeterol, formeterol, indacaterol
ICS -
