Respiratory Flashcards
List some potential environmental factors which may predispose to asthma?
Allergens Microbial exposure Diet Vitamins Breastfeeding Tobacco smoke Air pollution Obesity
Describe the typical clinical features of a patient presenting with undiagnosed asthma
Recurrent episodes of symptoms which are worse at night and early in the morning, including:
- Wheeze
- Breathlessness
- Chest tightness
- Coughing
List the classic triggers of asthma
Exercise Cold weather Airborne allergens/pollution Viral upper respiratory tract infections Drugs - beta-blockers, NSAIDs, oral contraceptive pill, cholinergic agents, PGF2a
Describe the ‘classic case’ of aspirin-sensitive asthma
A middle aged female with asthma symptoms, rhino sinusitis and nasal polyps, who’s symptoms are worse after alcohol or food containing salicylate.
What would you typically find on examination of a patient with suspected asthma?
Normal, except for wheeze.
May see nasal polyps, eczema or a vascular rash.
What is the diagnostic criteria for asthma?
- Compatible clinical history
- FEV1 >12% (200ml) increase following bronchodilator therapy or glucocorticoid trial (reversibility test)
- > 20% diurnal variation on >2 days in a week for a 2 week PEF diary
- FEV >14% decrease after 6 minutes of exercise
What investigations would you consider doing in a patient with suspected asthma?
- PEF
- Spirometry
- Glucocorticoid trial
- FBC - eosinophilia
- Exercise testing
- Skin-prick testing/IgE levels
- CXR
- High-resolution CT
What advice would you give to a patient diagnosed with asthma?
- Explanation of condition, relationship between symptoms and inflammation
- Red flag symptoms for poor control e.g. nocturnal waking
- Explanation of PEF monitoring
- Avoidance of aggravating factors
- Smoking cessation
- Adequate warm up or pre-treatment before exercise
- Reviews of medication adherence and inhaler technique
Describe the management plan of a patient with diagnosed asthma
- Short-acting Beta-agonist as required (CONTINUED THROUGHOUT)
- ADD regular low dose inhaled corticosteroids
- ADD inhaled LABA (combination inhaler)
- No response to LABA - STOP LABA and INCREASE inhaled corticosteroid to medium dose
Inadequate response to LABA - CONTINUE LABA and INCREASE inhaled corticosteroid to medium dose OR CONTINUE LABA and inhaled corticosteroid AND consider trial of leukotriene receptor antagonist, sustained-release theophylline or long-acting muscarinic antagonist - Consider trials of INCREASE inhaled corticosteroid to high dose OR ADD leukotriene receptor antagonist, sustained-release theophylline or long-acting muscarinic antagonist or beta-agonist tablet AND refer to specialist care
- ADD daily steroid table and maintain high dose inhaled corticosteroid AND refer to specialist care
- Biologics - Omalizumab (atopic) or Mepolizumab (eosinophilic)
List the indications for addition of a regular preventer inhaler
- Exacerbation in the last 2 years
- Uses B-agonist >3x weekly
- Reports symptoms >3x weekly
- Awakened by asthma 1x weekly
Why would you not prescribe a LABA alone to an asthmatic?
Associated with increased risk of life-threatening attack and asthma death
Describe the management of a mild-moderate asthma exacerbation in secondary care
Short course of oral rescue prednisolone
Describe the management of a mild acute asthma attack in primary care
- Measure PEF
- Give usual inhaled bronchodilator and wait 60 mins
- Send home with advice - return immediately if worsens, GP appointment within 48 hours
OR
- Nebulised treatment
- Measure PEF
- Wait 30 mins
- Re-check PEF
- PEF >60% –> send home (after checking with senior medical professional) with 5 days of prednisolone and start/double inhaled corticosteroids
Describe the management of a moderate acute asthma attack in primary care
- Measure PEF
- Perform ABG
- Nebulised salbutamol 5mg or terbutaline 2.5mg
- High flow/60% oxygen
- Prednisolone 40mg PO
- Wait 30 mins
- PEF >60% –> home, PEF <60% –> follow protocol for severe asthma attack
Describe the management of a severe/life-threatening acute asthma attack in primary care
- Measure PEF (if patient able)
- Perform ABG
- Nebulised salbutamol 5mg or terbutaline 2.5mg 6-12x daily as required
- High flow/60% oxygen
- Prednisolone 40mg PO OR hydrocortisone 200mg IV
- Obtain IV access and get plasma theophylline level and plasma K+
- Order CXR
- Administer repeat salbutamol and ipratropium bromide by oxygen-driven nebuliser (consider continuous salbutamol nebuliser)
- Consider IV MgSO4 or amiophylline (cardiac monitoring required)
- Correct fluids and electrolytes
Record PEF every 15-30mins then every 4-6 hours
Continuous pulse oximetry and repeat ABGs
Describe the features of an acute severe asthma attack
Unable to complete sentences in 1 breath
PEF 33-50% predicted value
HR >110bpm
RR >25
Describe the features of a life-threatening asthma attack
Silent chest Cyanosis Feeble respiratory effort Bradycardia, arrhythmias Hypotension Exhaustion, delirium, coma PEF <33% predicted SpO2 <92% PaO2 <8kPa PaCO2 normal or raised
List the indications for a rescue course of glucocorticoids in an asthmatic
- Symptoms and PEF progressively worsening day to day, with fall of PEF <60% of patient’s personal best
- Onset or worsening of sleep disturbance by asthma
- Persistence of morning symptoms until midday
- Progressively diminishing response to an inhaled bronchodilator
- Symptoms that are sufficiently severe enough to require treatment with nebulised or injected bronchodilators
List the indications for assisted ventilation in an asthmatic
- Coma
- Respiratory arrest
- PaO2 <8kPa and falling
- PaCO2 >6kPa and rising
- pH low and falling
- Exhaustion, delirium, drowsiness
List the 2 criteria that asthmatic s need to meet before discharge after an asthma attack
- Patient should be stable on discharge medication, nebulised treatment discontinued for >24 hours
- PEF has reached >75% of predicted value or personal best
List some risk factors for COPD
Tobacco smoking Indoor air pollution Occupational exposure e.g. coal dust, silica, cadmium Low birth weight Childhood infection Maternal smoking during childhood Recurrent infection Low socioeconomic status Cannabis smoking Alpha-1-antitrypsin deficiency Airway hyper-reactivity
List some co-morbidities commonly associated with COPD
Cardiovascular disease Cerebrovascular disease Metabolic syndrome Osteoporosis Depression Lung cancer
Describe chronic bronchitis
Cough and sputum for at least 3 consecutive months in each of 2 consecutive years
Describe emphysema
Abnormal permanent enlargement of the airspaces distal to the terminal bronchioles, accompanied by destruction of their walls and without obvious fibrosis
Describe the typical clinical features of a patient with COPD
Age >40 Cough Sputum Breathlessness Haemoptysis (during exacerbations) Peripheral oedema Morning headaches Muscular weakness Weight loss Osteoporosis
What might you find on examination of a patient with COPD?
Quiet breath sounds Crackles Peripheral oedema Barrel chest Tar staining on fingers
List 6 differential diagnoses for COPD
Chronic asthma TB Bronchiectasis Congestive cardiac failure Alpha-1-antitrypsin deficiency Lung cancer
List the investigations you may consider doing in a patient with ?COPD?
1) Spirometry - required to diagnose COPD –> post-broncholdiator FEV1 <80% predicted OR FEV1/FVC <70%
2) CXR - rule out differentials, identify bull
3) FBC - anaemia, polycythaemia
4) Alpha-1-antitrypsin assy
5) Helium dilution lung volume measurement or body plethysmography
6) Exercise testing
7) HRCT
Describe the ‘classic case’ of alpha-1-antitrypsin deficiency
A patient under 45 of Caucasian descent with a family history and symptoms of COPD
Describe the non-medical management of COPD
- Smoking cessation
- Use of non-smoking cooking devices or alternative fuels
- Pulmonary rehabilitation
- Annual flu vaccine
- Pneumococcal vaccine
Describe the surgical management options for COPD, and their indications
Bullectomy - for large bull compressing surrounding normal lung tissue
Lung volume reduction surgery - patients with predominantly upper lobe emphysema
Lung transplantation - advanced COPD
Describe the medical management of COPD
1) Avoid risk factors
2) ADD SABA +/- anticholinergic as required (mild disease)
3) ADD regular tiotropium (and/or LABA) AND pulmonary rehabilitation (moderate disease)
4) ADD inhaled glucocorticoids if repeated exacerbations occur AND consider theophylline (severe disease)
5) Add LTOT AND consider surgical options (advanced disease)
Describe the medical management of a severe infective exacerbation of COPD
1) Controlled oxygen (24-28%)
2) Nebulised salbutamol AND ipratropium
3) Oral prednisolone
4) Antibiotics e.g. amoxicillin (in patients with increased sputum purulence, volume or breathlessness)
5) Non-invasive ventilation
6) Diuretics
Describe the medical management of a mild exacerbation of COPD
Managed at home
Increased bronchodilator therapy
Short course of oral glucocorticoids
(consider antibiotics)
Indications for COPD exacerbation should be managed in hospital
Cyanosis
Peripheral oedema
Alterations in consciousness
If a patient has more than ? COPD exacerbations per year, you should consider prescribing a LABA or combination inhaler
2
The prognosis of a COPD patient is inversely related to ?? and directly proportional to ???
Age
Post-bronchodilator therapy FEV1
List 2 poor prognostic indicators in a COPD patient
Weight loss
Pulmonary hypertension
Describe the scoring system used to assess prognosis in COPD patients
BODE score: B - BMI O - degree of airflow obstruction (FEV1) D - measurement of dyspnoea (MRC scale) E - exercise tolerance (distance walked in 6 mins)
Score from 0-3 given for each category. Score or 0-2 = mortality of 10%, score of 7-10 = mortality of 80%.
List the risk factors for a VTE
Age Obesity Varicose veins Previous DVT Family history Pregnancy Oestrogen-containing oral contraceptives HRT Immobility IVDU Surgery MI/Heart failure IBD Malignancy Nephrotic syndrome COPD Pneumonia Neurological conditions/spinal injury associated with immobility Coagulation disorders Lower limb fractures Major trauma Transfusions Chemotherapy EPO agents IVF Infection
List the 3 components of Virchow’s triad
1) Hypercoaguability
2) Endothelial damage
3) Venous stasis
Describe the clinical features of PE
Faintness/collapse Chest pain (central, crushing or pleuritic) Dyspnoea Haemoptysis Cough Sepsis symptoms Symptoms of pulmonary hypertension or right heart failure Apprehension
What signs might you see on examination of a patient with PE?
Acute massive PE:
- Tachycardia
- Hypotension
- Raised JVP
- Right ventricle gallop rhythm
- Loud S2
- Severe cyanosis
- Decreased urinary output
Acute small/medium PE:
- Tachycardia
- Pleural rub
- Raised hemidiaphragm
- Crackles
- Effusions (often blood stained)
- Low-grade fever
Chronic PE:
- RV heave
- Loud S2
- Signs of right heart failure
What signs may you see on a CXR of a patient with PE?
- Normal CXR
- Oligaemia
- Pleuropulmonary opacities
- Pleural effusions
- Linear shadows
- Raised hemi-diaphragm
- Enlarged pulmonary artery trunk
- Enlarged heart, prominent right ventricle
What signs may you see on the ECG of a patient with PE?
- S1Q3T3
- Anterior T wave inversion
- RBBB
- Sinus tachycardia
- Normal ECG
- RV hypertrophy
- Right heart strain pattern
What signs may you see on the ABG of a patient with PE?
- Normal
- Decreased PaO2
- Decreased PaCO2
- Metabolic acidosis
- Desaturation on exercise/exertion
What differentials would you consider in a patient presenting with suspected PE?
- MI
- Pericardial tamponade
- Aortic dissection
- Pneumonia
- Pneumothorax
- MSK chest pain
List some of the causes of bronchiectasis
TB Cystic fibrosis Primary ciliary dyskinesia Kartagener's syndrome Primary hypogammaglobulinaemia Severe infection in infancy e.g whooping cough, measles Inhaled foreign body Suppurative pneumonia Allergic bronchopulmonary aspergillosis complicating asthma Bronchial tumours
Describe the pathophysiology of bronchiectasis
Abnormal dilatation of the bronchi, resulting in chronic airway infection, sputum production, progressive scarring and lung damage.
Clinical features of bronchiectasis
Chronic, persistant cough Copious, continuously purulent sputum Pleuritic chest pain Haemoptysis Exertional breathlessness
Halitosis
Weight loss
Anorexia
Infective exacerbations are characterised by increased sputum production, fever, malaise and anorexia.
Describe the features you may see on examination of a patient with bronchiectasis
Physical examination may be normal (if no airway secretions and no lobar collapse).
May show unilateral/bilateral:
- Coarse crackles
- Locally diminished breath sounds
- Bronchial breathing
What investigations would you consider in a patient with suspected bronchiectasis?
- Sputum culture
- CXR –> bronchiectasis not apparent unless extensive. May see thickened airway walls, cystic bronchiectatic spaces and associated consolidation or collapse
- CT –> thickened, dilated airways
- Ciliary dysfunction test/Saccharin test –> abnormal if >20 mins
- Nasal biopsy
- Electron microscopy
Describe the management of a patient with bronchiectasis
- Inhaled bronchodilators
- Inhaled glucocorticoids
- Daily chest physiotherapy
- Antibiotics
- Surgical excision
Describe the pathophysiology of CF
A mutation in a gene on chromosome 7 which codes for a chloride channel - causing increased sodium and chloride content in sweat and increased resorption of sodium and water from the respiratory epithelium, causing airway dehydration.
The most common mutation is F508.
Clinical features of CF
Recurrent bronchiectasis Respiratory failure Spontaneous pneumothorax Haemoptysis Lobar collapse Pulmonary hypertension Nasal polyps Malabsorption and steatorrhoea Distal intestinal obstruction syndrome Biliary cirrhosis Portal hypertension, varices and splenomegaly Insatiable appetite Gallstones Diabetes Failure to thrive, delayed puberty Male infertility Stress incontinence Psychosocial problems Osteoporosis Arthorapthy Cutaneous vasculitis
What investigations would you do in a patient with suspected CF?
- Immuno-reactive trypsinogen test (newborn screening)
- Electrolyte sweat testing - positive = sweat chloride >60mmol/L
- Genotyping
- Sinus x-ray
- Deep throat swab
How would you manage a patient with CF?
- Daily chest physiotherapy
- Nebulised recombinant DNAse
- Nebulised tobramycin
- Regular azithromycin
- Nebulised hypertonic saline
- Oral/IV antibiotics during exacerbations
- Lung transplant
- Oral pancreatic enzymes
- Vitamin supplements
- Insulin
- Bisphosphonates
What pathogens would you expect to see in patients with CF?
Children
- S. Aureus
Adults
- Pseudomonas aeruginosa
- Strenotrophomonas maltophilia
- Other gram negative bacilli
Risk factors for CAP
Smoking Upper respiratory tract infection Recent influenza Pre-exisiting lung disease Alcohol intake Glucocorticoid therapy Extremes of age HIV Indoor pollution
What is the most common cause of CAP??
Strep. pneumoniae
Clinical features of pneumonia
Short, painful and dry cough --> becomes associated with mucopurulent sputum (or rust coloured sputum in Strep. pneumoniae) Haemoptysis Pleuritic chest pain Fevers/rigors/shivering Malaise Delirium Loss of appetite Headache
What features may you see on examination of a patient with pneumonia?
- Reduced chest expansion
- Dull percussion
- Increased breath sounds
- Bronchial breathing
- Increased vocal resonance
- Whispering pectoriloquy
- Coarse crackles
- Pleural rub
What investigations would you consider in a patient with suspected CAP?
- Bloods - FBC, U&Es, LFTs, CRP
- Blood cultures
- ABG
- Sputum culture
- Viral throat swab
- CXR
- Urinalysis
- Cold agglutinins
How would you manage a patient with mild CAP?
- Oxygen
- Fluids
- 5 days Amoxicillin PO
- Pleural pain relief
How would you manage a patient with moderate CAP?
- Oxygen
- Fluids
- 5 days Amoxicillin PO + Clarithromycin IV
- Pleural pain relief
How would you manage a patient with severe CAP?
- Oxygen
- Fluids
- 5 days Co-amoxiclav/cefuroxime/ceftriaxone + Clarithromycin
- Pleural pain relief
What follow up would you offer a patient with CAP?
Follow up appointment in 6 weeks time
Repeat CXR if still symptomatic
Complications of CAP
- Para-pneumnic effusion
- Empyema
- Lobar collapse
- DVT/PE
- Pneumothorax (S. Aureus)
- Suppurative pneumonia/lung abscess
- ARDs, renal failure, multi-organ failure
- Ectopic abscess formation (S. Aureus)
Hepatitis, myocarditis, pericarditis, meningoencephalitis, arrhythmias
What are the indications for ITU referral in a patient with CAP?
- CURB65 score 4-5, failing to respond rapidly to initial management
- Persisting hypoxia despite high flow oxygen
- Progressive hypercapnia
- Severe acidosis
- Circulatory shock
- Reduced consciousness
