Respiratory Flashcards
Tests for cause of pneumonia - 3
Bronchoalveolar lavage and legionella stain
IgG pneumonoccal and H influenzae B
Radiocontrast oesophogram for aspiration
Features of life threatening asthma
33, 92, CHEST PEFR <33% O2 <92% Cyanosis Hypotension Exhaustion Silent chest Tachy, brady, arrhythmias
Pathology of asthma
CGPIE
Cytokines amplify inflammatory response
Goblet cell and smooth muscle hypertrophy
Plugging of mucus
Inflammatory factors - Th2, eosinophils, mast cells
Endothelial damage and subendothelial fibrosis
When to do a CT for pneumothorax - 3
1) differentiate from bullae
2) surgical emphysema obstructing X-ray
3) concerned about aberrant drain placing
Causes of transudate pleural effusion
Cirrhosis, HF, low albumin, PE
Constrictive pericarditis
Meig’s syndrome - benign ovarian tumour, ascites and pleural effusion
Hypothyroid - myxoedema
Causes of exudate pleural effusion - 7
Malignancy, infection, inflammation (Dressler’s) Pancreatitis Connective tissue disease PE Asbestos
Differentiate exudate and transudate and diagnosing and when to insert drain
<30g/l = transudate Light’s criteria if 25-35g/l: >0.6 x protein in serum >0.6 x LDH in serum LDH >2/3 upper limit of normal
Drain if pus or pH<7.2 (empyema)
US guided aspirate for cytology, micro and biochem (LDH, protein)
Biopsy if recurrent effusion or thickening - image guided cuttin needle, or Abrams needle for TB
Thoracoscopy
Causes of eosinophilia - 6
Inflammation Parasites Vasculitis SLE Allergic bronchopulmonary aspergillosis Hay fever, allergies
Pneumonia after taking nitrofurantoin or phenytoin?
Acute idiopathic eosinophilic pneumonia:
Fever, unexplained resp failure, hypoxia, diffuse pulmonary shadowing on cxr
TB inv
3x early morning sputum samples for acid fast bacilli and culture Bronchoscope if no cough FBC, LFT, HIV, vit D CXR, CT MRI CNS if military
What is bronchiectasis, causes of bronchiectasis, risks and abx prophylaxis
Chronic dilation of more than 1 bronchi with mucus production and increased infection
Post infective - whooping cough, TB
AI - hypergammalobulinaemia in IBD
ABPA (aspergillosis), RA, HIV - secondary immunodeficiency
Toxic - chemicals, aspiration
Foreign body - tumour, lymph node
Mucociliary dysfunction in CF, Kartagener’s (sinusitis and situs inversus) and Young’s (infertility and sinusitis)
Risks of moraxella, H influenza, pseudomonas
Physio, flu vaccinations, bronchodilators
Give azithromycin prophylaxis 3x/w
When to take COPD rescue meds
Prednisolone if 2 of: SOB, cough, tight chest or phlegm for >24h despite inhaler use
ABx if phlegm is coloured
Causes of massive haemoptysis and management
> 240ml/24h or >100ml/d for 2d
TB, asperillosis
Malignancy, abscess
Bronchiectasis
Less common = PE, AV malformation
A-E, lie on side of lesion Tranexamic acid Abx if infection ?vit K CT aortogram for bronchial artery emboli
Features of assessment for sleep apnoea
Epworth sleepiness scale - 0 for wouldn’t dose and 3 for high chance of dosing, in a list of situations eg tv, traffic lights
STOPBANG Snore Tired Observed choking/stop breathing bP high BMI >35 Age >50yo Neck size large Gender male
When to discharge someone in hospital for asthma
If <1h, when PEFR >75% normal If admitted: - PEFR >75% normal - stable on normal med for 24h - appointment with GP in 2d and resp clinic <4w - assessed inhaler technique - ensure have PEFR measured and action plan - 5d prednisolone - psychosocial
Aspirin sensitive asthma?
Samter’s triad: asthma, aspirin/NSAIDs intolerance, nasal polyps
Features of COPD
- Emphysema
- Chronic inflammation with macrophages and neutrophils
- Ciliary dysfunction
- Mucous gland hyperplasia
Signs of atypical pneumonia and 4 causative organisms
Normal WCC, low sodium, liver and renal dysfunction
Chlamydia psitacci, mycoplasma, legionella, avians precipitans (hypersensitivity)
Causes of non resolving pneumonia
CHAOS Complication eg empyema Host immunocompromisd Antibiotic inadequate or not absorbed Organism atypical or resistant Secondary - PE, cancer
RF for pneumothorax, treatment
Primary: Iatrogenic - central line, biopsy Secondary: >50yo, lung damage, smoker RF: Diving CT disorder eg marfans CF - TB HIV - PCP
Primary and small = nothing
Primary and large (>2cm) = aspirate
Secondary and small = aspirate
Secondary and large = drain
Surgery if:
- persistent leak (>5d)
- bilateral and spontaneous or contralateral to previous
- occupation at risk eg pilot or diver
What is dressler’s syndrome
Pleuritic pain, fever and pericarditis after MI
- molecular mimicry = AI
Effect of methotrexate on lungs
Leucopoenia causing pneumonitis and fibrosis
Increased conc by penicillin
RF for OSA and inv and treat
Overweight Age Tonsils Craniofacial abnormality Myxoedema - submucosal tissue Neuromuscular disease Muscle relaxants
Oximetry alone
Limited sleep study with oximetry, hr, movements, snoring, oronasal flow
Polysomnography - EEG, EMG and limited study
Weight loss, reduce alcohol
Mandibular advancement device, consider pharyngeal surery as last resort
Significant: nasal CPAP and consider bypass/tracheostomy
Severe with CO2 retention: NIV the CPAP if acidotic
Where does lung cancer metastasise to
Liver Pleural Bone Adrenals CNS
Key paraneoplastic sx in lung cancer - 7
Anaemia Clubbing Hypercalcaemia SIADH Lambert-Eaton myasthenic syndrome Cushing’s Thromboembolic
Sx of TB
Fever, malaise, night sweats, weight loss
Resp - cough, purulent sputum, haemoptysis, effusion
Non-resp - lymphadenopathy, erythema nodosum, pericardial effusion, meningitis, abdo, GU, miliary
Treat TB and side effects
RIPE + steroids if meningitis - 1st 2 for 6m, 2nd 2 for 2m Rifampicin - orange secretions and fever Isoniazid - peripheral neuropathy, psychosis - give pyridoxine for neuropathy Pyrazinamide - vomiting and arthalgia Ethambutol - retrobulbar neuritis
RIP - rash and hepatitis
Assessments of breathlessness
MRC Dyspnoea scale: 1 - strenuous exercise 2 - hill or hurrying 3 - SOB on keeping pace with contemporaries on flat 4 - on walking 100m 5 - cannot leave house or dressing
WHO performance status: 0 - normal 1 - can do light work 2 - ambulatory and self care 3 - chair >50% time, limited self care 4 - bed bound
6 Qs for SOB hx
Sob Cough Sputum Haemoptysis Wheeze Chest pain
Sign of asbestosis on xray
Calcified pleural plaques
Mass in anterior mediastinum
Teratoma
Lymphoma
Thymoma
4 causes of type 2 resp failure
Drug induced - opiates, anaesthetics
C3-5 lesion = diaphragm paralysis
NMD - myasthenia gravis, Guillaum Barre
Chest wall problems
Sx of hypercapnaea
Headache Warm peripheries Increased hr, rr, bp Dizzy, drowsy, confusion Reduced reflexes, tremor
Feaures of severe asthma
PEFR 33-50%
Cannot complete sentences in 1 breath
Rr >25
Hr >110
Curb 65 and management
Confusion >2 less than normal on AMTS Urea >7 RR >=30 BP <90S or <60D >65yo
0-1 = home with PO amoxicillin 5d 2 = amoxicillin and doxycycline IV 3 = coamox and doxycline IV and send urine for legionella antigen
6 rf for pe
Surgery Obstetrics Lower limb fracture/varicose veins Malignancy (pelvic/abdo, or advanced) Previous VTE Immobile
6 absolute CI to thrombolysis and 4 relative
GI bleed <1m Stroke <6m Recent trauma/surgery CNS neoplasm Bleeding disorder Aortic dissection
Relative: Warfarin Pregnancy Advanced liver disease Infective endocarditis
Indications for long term o2 therapy in COPD
Non smoker
Not CO2 retainer
pO2 <7.3 or <8 with cor pulmonale
- 2 values on separate days
3 types of LRTI
Pneumonia
Bronchopneumonia - normally H infl cant be cleared due to smoke damage to bronchus = invade to bronchopneumonia
Pneumonitis - parenchyma inflammation from inf
Differentiate between COPD and asthma with one test
CO transfer factor - normal in asthma, reduced in COPD/malignancy
Safe triangle for chest drain?
Pec major - axilla - lat dorsi - 5th ICS
Repeat vomiting and bleed
Boerhaave’s syndrome - oesophageal tear, from alcohol and vomiting
Features and causes of lung fibrosis
Chronic inflammation with progressive fibrosis.
SOB, unproductive paroxysmal cough, abn breath sounds
Abn cxr and CT. Restrictive spirometry and reduced transfer factor
- Known cause - hypersensitivity, occupations, drug (nitrofurantoin, bleomycin, amiodarone), infection (TB, fungi, viral)
- Systemic disease - sarcoidosis, RA, SLE, scleroderma
- Idiopathic - idiopathic pulmonary fibrosis/cryptogenic fibrosing alveolitis
Apical: (inhalants) BREAST CLAP
- Berrylliosis
- Radiation
- Extrisnsic allergic alveolitis
- ABPA
- Sarcoidosis
- TB
- Coal Workers pneumococomiosus
- Langerhands cells histtocytosis
- Ank spond
- Psoriasis
Basal: (rheumatoid) DR CIA
- Drugs
- RA
- Ct disease
- Idiopathic
- Asbestosis
Lung disease in coal workers
Coal workers pneumonoconiosis and silicosis - apical interstitial lung disease
- progressive massive fibrosis from mass wth radiating strands
CT = opacification and air bronchograms
MRI T2 = dark (cancer = light = differentiate)
Immunological markers to look for in ILD diagnosis
ANA, ENA
RhF
ANCA, anti-GBM
IgG for avians precipitins
3 main types of interstitial lung disease
Cryptogenic fibrosing alveolitis = Usual Interstitial Pneumonitis: reduced chest expansion and clubbing, fine basal insp crackles, pulm htn on CVS exam. ANA or RhF often positive, immunoglobulins raised
Extrinsic allergic alveolitis - hypersensitivity to a stimulus. - Bird fancier’s lung
Acute = 4-8h onset, 1-3d offset. = inflammatory cells.
Chronic exposure = long onset, less reversible. = granuloma and obliterative bronchiolitis
Sarcoidosis - noncaseating granulomas can affect anywhere in body, immune effect
- acute = polyarthragia and erythema nodosum
- PFT = obstructive until fibrosis, then restrictive
- renal function, CXR, urinary calcium, echo and 24h ECG, MRI head, lymph/splen/hepatomegaly, conjunctivitis/glaucoma
- CXR - bilateral hilar lymphadenopathy and pulmonary infiltrates/fibrosis
Treatment for ILD
Stop smoking Remove occupational exposure or allergen or drug Transplant Treat infections Oxygen MDT Pirfenidone - antifibrotic
Treatment lung cancer
SCLC - nearly always too extensive for surgery
- chemo and palliative radiotherapy
NSCLC
- stage 1-2 = surgery
- stage 3 = surgery and adjuvant chemo
- stage 3-4 = chemo, radiotherapy - curative or palliative
Lung cancer effects in lung - 4
In thorax - 4
Abscess
Ulceration - haemoptysis
Necrosis - cavitation
Bronchial obstruction - lobar collapse, consolidation
Left RLN palsy - hoarse
Phrenic nerve palsy/diaphragm - SOB
Mediastinum - SVCO, dysphagia
Pleural/pericardial effusion
Lung cancer and now leg weakness and difficulty talking
Lambert-Eaton Myasthenic Syndrome:
Autoantibodies against voltage gated calcium channels, preventing depolarisation. Assoc with cancer (SCLC or lymphoproliferative) or other AI disease
Sx:
- prox leg weakness
- reduced/absent reflexes
- fatigue
- SOB, dysarthria, dysphagia
- dry mouth, orthostatic hypotension - autonomic dysfunction
Diagnosis - nerve conduction studies, chest CT for cancer and test anti-AChR to rule out myasthenia gravis
Treat: intubate and ventilate, support, plasma exchange or IvIg, treat cause
2 causes of OSA
Small pharyngeal size - fatty infiltrates, tonsils, craniofacial abnormalities, myxoedema
Excessive narrowing of airway - NMD, muscle relaxants (sedative, alcohol), age, obesity encourages dilator relaxation
3 types of lung diffusion impairment
Thickened exchange surface - fibrotic lung disease
Reduced exchange surface - emphysema
Fluid in interstitial space increasing diffusion distance - oedema
Causes of type 1 respiratory failure
Poor perfusion - PE
Poor ventilation - pneumonia, early asthma, pulmonary oedema, fibrosis
VQ ratios
V = ventilation
Q = perfusion
Ideal V/Q is 1, apex = 3.3, base = 0.6
Consequences of chronic T2 resp failure
Cannot compensate for increase in CO2 retention
Choroid plexus resets central chemoreceptors to higher CO2 baseline
- resp drive decreases, driven by hypoxia via peripheral chemoreceptors (<8kpa)
- pulm arterioles constrict in hypoxia = pulm htn, RHF and cor pulmonale
Blood increases o2 binding capacity, increases hb (polycythaemia) and increases 2,3-BPG production
SE and CI of antimuscarinics
SE - dry mouth, constipation, cough, headache
Caution in closed angle glaucoma (dilation = increase intraocular pressure) and BPH (sphincter contraction = more urine retention)
ADR and SE of aminophylline
Positive chronotropic and inotropic action = serious arrhythamias
Seizures, nv, hypotension
Reflux, dizzy, GI upset
Sx and inv of extrinsic allergic alveolitis
4-6h post-exposure: fever, rigors, myalgia, dry cough, crackles, SOB
Chronic: increasing SOB, weight loss, exertional dyspnoea, T1 resp failure, cor pulmonale
FBC, ESR, serum precipitins (shows exposure)
CXR - upper zone consolidation, chronic = honeycomb and fibrosis
PFT: reversible restrictive deficit. Reduced gas transfer factor during attacks
Broncho-alveolar lavage = lymphocytes and mast cells
Manage: remove allergen and controlled O2, then oral pred
Long term - avoid allergen, ?long term steroids
When to offer steroids in sarcoidosis - 4
- Parenchymal lung disease
- Uveitis
- Cardiac or CNS involvement
- Hypercalcaemia
Tend to resolve in 2y
Differentials for bilateral hilar lymphadenopathy
Sarcoidosis Infection - TB, mycoplasma Malignancy - lymphoma, mets Silicosis Extrinsic allergic alveolitis
Risk of asbestosis
Increased risk of bronchial adenocarcinoma and mesothelioma
Sx of cor pulmonale and inv findings and treatment
Fatigue, dyspnoea, syncope
Raised JVP, loud S2, pansystolic murmur (tricuspid regurg) RV parasternal heave
Hepatomegaly and oedema
Hb and haematocrit raised - secondary polycythaemia
ABG - hypoxia +- hypercapnia
ECG: p pulmonale, RV strain, right axis deviation
X-ray: enlarged RV and RA, prominent pulmonary arteries
O2, LTOT
HF treatment - furosemide
Heart-lung transplant
Causes of cor pulmonale
Resp - COPD, fibrosis, asthma, bronchiectasis, lung resection
Vascular - PE, vasculitis, primary pulmonary htn, ARDS
Skeletal - kyphosis, scoliosis
NMD - MND, myasthenia gravis
Hypoventilation - OSA, large adenoids in kids
CVS disease
Indications for pneumococcal vaccine and CI
> 65yo
Diabetes
Immunocompromised incl splenectomy or steroids
Chronic heart, lung, liver or kidney disease
CI: pregnant, lactating, raised temperature
Antibiotics for pneumonia
Mild - strep pn, H infl - amoxicillin or clarithromycin Mod - + mycoplasma - amoxicillin and clarithromycin Severe - co-amox and clarithromycin IV ? Staph = fluclox ? MRSA = vancomycin ? Legionella = rifampicin ? Chlamydia = tetracycline ? PCP = co-trimoxazole
HAQ or immunocompromised - gr-, pseudomonas, anaerobes - aminoglycoside, and antipseudomonal penicillin IV or 3rd generation cephalosporin
Aspiration - strep pn, anaerobes - cefuroxime and metronidazole
Causes of pleurisy
Infection - viral or pneumonia PE Lung cancer AI - SLE, RA Pancreatitis
Causes of pulmonary hypertension and how to measure
Right heart catheterisation, mean arterial pressure
Idiopathic, genetic Drugs and toxins (bleomycin) CREST Left heart disease Lung disease Congenital heart disease CKD, sarcoidosis, vasculitis
What is granulomatosis with polyangitis, inv and treatment
Small and medium vessel vasculitis characterised by necrotising granuloma formation. Affects kidneys, URT and lungs
Kidneys - glomerulonephritis with crescent formation, haem/proteinuria
URT - sinusitis, epistaxis, nasal obstruction, saddle-nose
Lungs - cough, haemoptysis, pleuritis
Skin nodules, peripheral neuropathy, arthritis, keratitis/conjunctivitis/uveitis
c-ANCA, urinalysis, ?renal biopsy
CXR, sputum cytology = atypical cells
Treat: steroids and cyclophosphamide if severe
Co-trimoxazole for PCP and staph prophylaxis
? Plasma exchange
? Azathioprine and methotrexate maintenance
What is goodpasture’s, inv and treatment
Anti-GBM = crescentic glomerulonephritis and haemoptysis/pulmonary haemorrhage
CXR = infiltrates due to pulm haemorrhage, mostly lower zones
Treat: shock, then immunosuppression and plasmapheresis
Mesothelioma - what is it and inv
Tumour of mesothelium cells in pleura. Assoc with asbestos exposure
Sx: chest pain, weight loss, SOB, finger clubbing, recurrent pleural effusions
Mets = bone pain, abdo pain/obstruction, lymphadenopathy, hepatomegaly
Inv:
CXR/CT = pleural thickening and effusion.
Pleural biopsy with Abrams needle (bloody)
Thoracoscopy
Treat: chemotherapy can improve survival but poor prognosis
