Respiratory Flashcards
Treatment of acute exacerbation of COPD
A 5-day course of prednisolone is part of the treatment given for an acute exacerbation of COPD.
Precipitants for asthma attacks
D I P L O M A T s
Drugs - NSAIDs, Beta blockers Infections Pollutants Laughter Oesophageal reflux Mites Allergens Temp - COLD Some exercise
3 causes of airway narrowing in asthma
mucus production
brochoconstriction
mucousal inflammation
Signs of an asthma attack
tachycardia tachypnoea resontant chest on percussion hyperinflated decreased chest well movement
Severe asthma
RR BP Peak exp flow rate Blood gas CO2 / O2 General
>25 breaths per min >110 30-50% CO2 low / normal, hypoxic Anxious
Life threatening asthma
RR BP Peak exp flow rate Blood gas CO2 / O2 General
SHOCC
Silent chest Hypotension One third Cyanoised, CO2 increasing and acidotic Confused
NORMAL CO2 INDICATES LIFE THREATENING
Bed side tests for asthma exacerbation
Observations - RR, HR, Sat, BP
Peak flow
ECG
When to do an ABG in asthma exacerbation
<92% sats
Blood tests in asthma exacerbation
FBC U&Es CRP Infectious screen ABG
Longer term tests in asthma
Lung function
Skin prick
Important social aspects to an asthma hx
Occupation
Pets
Smoking
Allergens
HPC in asthma
Attacks per week
Exaserbations
Been to ITU?
Acute asthma attack - initial medication
Salbutamol inhaler - can give 3 doses 5mg back to back
then doses every 15mins
Severe / life threatening asthma attack - initial medication
Impratropium bromide + salbutamol inhaler
Medication to consider in severe / life threatening
Hydrocortisone / pred
MgSo4
Who should life threatening asthma be stepped up to?
ICU
Asthma long term treatment
Step 1
Step 2
Step 3
Step 4
Beta agonist inhaler
+ICS
+Leukotriene receptor antagoist
+ LABA +/- LRA
Orthopnoea =
SOB on lying flat
Sudden causes of SOB
PE
Inhaled foreign body
Pneumothorax
Acute causes of SOB
Asthma exacerbation
COPD exacerbation
Pneumonia
Chronic causes of SOB (resp)
Asthma
COPD
Pulmonary fibrosis
Cardiac causes of SOB
HF MI Angina Valve disease Arrhythmias
Sudden systemic causes of SOB
Anaphylaxis
Hyperventilation
Anxiety
Acute on Chronic cause of SOB
Metabolic acidosis Thyrotoxicosis Fever Anaemia Obesity Neurological disease
CURB65 score
Confusion Urea 0 >7 mmol/L RR >30 Systolic BP < 90 mmHg or Diastolic BP ≤ 60 mmHg Age ≥ 65
What cancers metastasie to the lung?
breast, kidney, testes and bladder
Signs on examination for lung cancer
Clubbing Cyanosis Consolidation Chest expansion asymmetry? Lymphadenopathy
White out on a chest xray may show?
pleural effusion
or lobular collapse
Hormone syndromes caused by lung cancers
Hypercalcaemia Inappropriate ADH (SCC) Ectopic ACTH (SCC)
Ddx for lung cancer
TB
Pneumonia
Secondary tumour?
Gold standard investigation for lung cancer ?
fiberoptic bronchoscopy
- can take samples and do procedures
Which types of lung carcinoma causes hypercalcaemia?
squamous cell carcinoma
Examples of obstructive defects
Important aspect
COPD
Asthma
Bronchiectasis
REVERSIBLE
Obstructive condition
FVC ?
FEV1/ FVC
FVC same
Ratio reduced
Examples of Restrictive defects
scoliosis fibrosis post trauma Asbestosis NM disorders
Restrictive condition
FVC
FEV1/FVC
FVC = reduced
increased or normal
What is Atelectasis?
Atelectasis is a common post operative complication in which basal alveolar collapse can lead to respiratory difficulty. It is caused when airways become obstructed by bronchial secretions.
Two causes of COPD
Smoking and alpha 1 antitrypsin deficiency
Basis of COPD exacerbation treatment
O SHIT
7-14 days of steroids - 30mg pred
antibiotics if due to infection
consider chest physio and BiPAP
Where is the alpha 1 antitrypsin enzyme found?
liver
Causes of pulmonary fibrosis
Occupational Idiopathic Medication - amiodarone and methotrexate Vasculitis CTD
Clinical features of pulmonary fibrosis
Cyanosis Inspiratory fine creps Cough and SOB Finger clubbing Weight loss Fatigue
Bloods in pulmonary fibrosis
FBC UandE LFT CRP ANCA ACE levels
treatment of idiopathic pulmonary fibrosis
steroids and azathioprine
treatment of extrinsic allergic alveolitis
steroids and remove from precipitant
Pleural plaques indicates what?
exposure to asbestos NOT pulmonary exposure
Special characteristics of pulmonary sarcoidosis?
Erythema nodosum and bilateral hilar lymphadenopathy
Bronchiectasis =
chronic inflammation and infection of bronchial walls leadings to permanent dilations of the airways
Causes of bronchiectasis
Cystic fibrosis
Kartageners syndrome
TB
Acute causes of a cough
Inhaled foreign object
Goite / tumour pressing on the larynx
Post nasal drip
URTI
Causes of a productive cough
Mucus
Blood stained
1)
Pneumonia
Bronchiectasis
Exacerbation of COPD
TB
Cancer
Pink frothy - heart failure
PE
Causes of a non productive cough
Asthma Pulmonary fibrosis GORD Drugs - ACE inhib ANCA +ve
Respiratory system questions
SOB Cough Wheeze Chest pain Haemoptysis Weightloss / fever / nightsweats
Blood tests in a chronic cough
FBC CRP / ESR U&Es TFTs ANCA
Other investigations in a chronic cough
- Bedside
- Non bediside
Peak flow
Sputum sample and culture
Spirometry
CXR
Echo
Causes of central cyanosis
Congenital heart disease
PE
Chronic lung disease
Abnormal Hb
Peripheral causes of cyanosis
Causes of central
Reynauds
Slow circulation
Vascular occlusion
Key test in central cyanosis
ABG
What needs to be excluded in peripheral cyanosis
Vascular occlusion
Main diagnostic test in Legionella disease
urine antigen detection
Bilateral lung conditions which are mainly found in the apex of the lung
Cystic fibrosis
Ank Spond
Sarcoidosis
TB
Bilateral lung conditions which are mainly found in the lower lobe of the lung
bronchiectasis
asbestosis
interstitial pneumonia
Respiratory causes of haempoytsis
Infection - pneumonia, TB Trauma PE Malinancy Foreign body
Systemic causes of haempotysis
Granulomatus polyangitis
Goodpastures
HPC q. in haempotysis
How much blood?
What colour?
Mixed with sputum?
B SYMPTOMS
PMH q. in haempotysis
Kidney disease
Clotting disorders
Occupation
Smoking
Associated symptoms to ask about in haemoptysis
Chest pain SOB Cough B symptoms Nose bleed-
Blood tests in haempotysis
FBC U&Es CRP ANCA Clotting screen Anti glomerular BM Antibodies
Imaging in haempotysis
CRX
Echo
Fibre-optic bronchoscopy
CT
CTPA - PE
Bedside tests in haempotysis
ECG
Urine dip and culture, urinary antigens - atypmical pneumonia
Sputum sample
Differentials for hyperventilation
Resp
- Pneumonia
- Asthma exacerbation
- PE
- Pneumothorax
Cardiac
- Cardiac failure
- Anaemia
- Valve failure
- MI
Metabolic
- sepsis
- diabetic ketoacidosis
Anxiety
Conditions causing fibrosis in the upper zones
CHARTS
Coal workers pneumoconiosis Hypersensitivity pneumonitis Ank Spond Radiation TB Silicosis / Sarcoidosis
Conditions causing fibrosis in the lower zones
Idiopathic
CTD
Drug induced - amiodarone, methotrexate
Asbestosis
Pulmonary fibrosis presentation on CXR
bilateral interstitial shadowing (typically small, irregular, peripheral opacities - ‘ground-glass’ -
Differentials in bilateral hilar lymphadenopathy
sarcoidosis and TB
Cardiac causes of clubbing
cyanotic congenital heart disease (Fallot’s, TGA)
bacterial endocarditis
Respiratory cause of clubbing
Lung cancer CF Bronchiectasis TB Asbestosis
“Other” causes of clubbing
GI/ Endocrine
Crohn’s
Cirrhosis
Primary biliary cirrhosis
Graves disease
Transudate protein level
Exudate protein level
< 30 g/L
> 30g/L
If protein level on the boarderline in a pleural effusion what can you use ?
Lights criteria
Test to see if a pleural effusion is a chylothorax?
triglyceride > 1.1g/L
Symptoms of a pleural effusion
can be asymptomatic
dyspnoea
pleuritic chest pain
Signs on exam of a pleural effusion
Decreased chest expansion Stony dull to percussion decreased breath sounds decreased vocal frematus mediastinal shift away from a large effusion
Imaging needed in a pleural effusion
CXR 1st line
Test in pleural effusion
Aspirate - check protein, glucose, WBC, amylase, cytology, culture, lipids
Treatment of pleural effusion
Conservative - if small leave to resolve on own
surgical - drainage
Causes of primary pneumothorax
Trauma
Iatrogenic
Causes of secondary pneumothorax
COPD / Asthma
Carcinoma
CF
CTD
Signs on examination of pneumothorax
Decreased lung expansion Tracheal deviation away in tension Hyporesonant on percussion Absent vocal frematus Mediastinal shift in tension
What denontes a small pneumothorax on CXR?
< 2cm
Large pneumothorax management
Aspiration -> chest drain
Klebsiella pneumonia associated with which two patient groups?
Diabetes
Alcoholics
Inspiratory stridor suggests….
Laryngeal obstruction
Expiratory stridor suggests
tracheobronchial obstruction
Bisphasic stridor suggests
subglottic or glottic anomaly
Stertor definition
low pitched snoring sound due to stenosis between nasopharynx and supraglottic region
Wheeze defintion
polyphonic expiratory airway sound caused by lower airway narrowing
Acute management of stridor
Stabalise the patient - high flow O2 Involve a senior Suction secretions / clear foreign body Adrenaline + steroids - IV or inhaled Bloods including an ABG May need a surgical ariway
Where in the lungs is emphysema prominant
1) due to ATAT1 deficiency
2) COPD
Lower lobes
Upper lobes
Caplan syndrome
lung nodules in the context of rheumatoid arthritis (RA).
Alpha-1 antitrypsin (A1AT) deficiency is?
lack of protease inhibitor enzyme produced by the liver
role of protease inhibitor
protect cells from enzymes e.g. neurtrophil elastase
management of Alpha-1 antitrypsin (A1AT) deficiency ?
Management
no smoking
supportive: bronchodilators, physiotherapy
intravenous alpha1-antitrypsin protein concentrates
surgery: volume reduction surgery, lung transplantation
presentation of Alpha-1 antitrypsin (A1AT) deficiency ?
Emphysema in the lower lungs
young age
liver derangement
Question in PC for asthma / COPD exacerbation
Severity - SOCRATES prevision admissions Inhaler compliance Rescue packs Home nebs?
Treating asthma attack
O
S H I T M E
Oxygen - used to drive nebs
Salbutamol 2.5-5mg
Hydrocortisone 100mg IV (or Pred 40mg PO)
Ipratropium 500microg
(Theophylline )
Magensium sulphate
Escalate care
How often should treatment be considered stepping down in asthma?
every 3 m
how should ICS be reduced when stepping down?
by no more than 50%
patients with asthma not controlled with salbutamol inhaler and ICS should have what added?
Following NICE 2017, patients with asthma who are not controlled with a SABA + ICS should first have a LTRA added, not a LABA
Step up of management in COPD
After a short-acting beta-2 agonist (SABA) (or short acting muscarinic antagonist (SAMA)):
If FEV1 is >50% predicted offer either a long-acting antimuscarinic bronchodilator (LAMA) or a long-acting beta-2 agonist (LABA)
If FEV1 is <50% predicted offer either a long-acting antimuscarinic bronchodilator (LAMA) or a combination inhaler containing long-acting beta-2 agonist (LABA) and corticosteroid
Any patient that remains breathless or continues to have exacerbations should be offered triple therapy with a combination inhaler containing LABA and corticosteroid plus a LAMA (e.g. tiotropium)
COPD LTOT
Offer LTOT to patients with a pO2 of < 7.3 kPa or to those with a pO2 of 7.3 - 8 kPa and one of the following:
secondary polycythaemia
nocturnal hypoxaemia
peripheral oedema
pulmonary hypertension
Assess patient for LTOT
Assess patients if any of the following:
very severe airflow obstruction (FEV1 < 30% predicted).
Assessment should be ‘considered’ for patients with
severe airflow obstruction (FEV1 30-49% predicted)
cyanosis
polycythaemia
peripheral oedema
raised jugular venous pressure
oxygen saturations less than or equal to 92% on room air
Most common lung cancer in non smokers
adenocarcinoma
How does mycoplasma pneumonia present?
Dry cough
Head ache
Haemolytic anaemia
What specific blood test result is found in mycoplasma pneumonia?
Cold agglutins on blood test
Common cause of pneumonia in dehabilitated and IV drug users
Staph aureus
Cause of pneumonia from parrots?
Chlamydia psittaci
double right heart border on c x-ray indicates?
advanced mitral stenosis causing left atrial enlargement
Pleural mass with lobulated margin on CXR = ?
Mesothelioma
Fever, cough, shortness of breath hours
after exposure to antigen (usually farmer
after hay exposure) likely to be?
Extrinsic allergic alveolitis
