Respiratory Flashcards
investigation of PE
wells score
>1 = CTPA and give LMWH
<1 = D-dimer
ECG: sinus tachycardia, S1,T3,Q3, RBBB, RAD
V/Q scan if cant have contrast (pregnancy/renal impairment)
definition and causes of transudative Pleural effusion
<30 g/L protein
HF, low albumin (malabsorption, liver disease, nephrotic syndrome, HF, fluid overload) hypothyroidism
definition and causes of exudative Pleural effusion
> 30g/L protein
infection, connective tissue disorders, neoplasia, pancreatitis, PE, dresslers
describe the score used to assess severity of pneumonia
Confusion Urea >7 Resp rate >30 BP <90 systolic/<60 diastolic 65 years old <
1= home, 2/3 = hospital, >3 = ICU
most typical organism in HAP
staph aureus
typical organisms causing CAP
strep pneumoniae
HIB in COPD, group B strep/RSV in children
list some atypical organisms causing pneumonia and their associations
legionella (low sodium, detected in urine - antigen)
klebsiella (alcoholics)
Pneumocystis jiroveci/PCP (HIV)
mycoplasma (erythema multiforme)
what is pulsus paradoxus and causes
drop >10mg/Hg on inspiration
asthma, COPD, tamponade
what wheeze do you get in asthma
expiratory
describe the types of respiratory failure and common conditions causing each
Type 1: hypoxia (<8), normal or low CO2 (<6)
failure of gas exchange - asthma, pneumonia, fibrosis
Type 2: hypoxia (<8) with hypercapnia (>6)
ventilation failure- COPD, myasthenia , GBS
describe the spirometry in asthma
obstructive
FVC:FEV1 <0.7
FVC <80%
FEV1 improves by 12% with SABA
describe spirometry in airway restriction
FEV1:FVC = 1
FEV1 <80%
what are the FEV1 ranges in mild, moderate and severe asthma
mild 65-80
moderate 50-65
severe <50
what questions to ask in assessing asthma severity
how many days a week do you get symptoms
how often does it wake you at night
does it interfere with ADLs
management of acute asthma
Oxygen (15L NRB mask aim for 94-98%)
Salbutamol nebuliser (2.5-5mg back to back/ every 15 mins)
Hydrocortisone IV (100mg) or oral prednisolone (40mg)
ipratropium bromide neb (4 hourly)
escalate/ get senior help
aminophylline, magnesium sulphate, ITU
management of chronic asthma ladder
SABA \+ ICS \+LTRA (if <5 refer to specialist) \+LABA increase ICS oral steroid
definition of COPD
cough most days lasting > 3 month period for 2 years
symptoms of hypercapnia
papilledema, confusion, tachycardia, vasodilation, pins and needles, asterixis
indications for spirometry - COPD
over 35
smoker/ex smoker
chronic cough
investigations for COPD
spirometry - obstructive (FEV1 <80%, FEV1:FVC <0.7) non reversible
CXR: flat hemi diaphragm, bullae, hyper expansion
sputum culture
FBC (polycythaemia)
chronic management of COPD
SABA/SAMA >50% FEV1 = LAMA/LABA <50% FEV1 = LAMA/LABA + ICS triple therapy: LABA, LAMA, ICS pulmonary rehab
indications for LTOT
cyanosis sats <92% polycythaemia FEV1 <30% peripheral oedema (= pulmonary HTN) raised JVP (= pulmonary HTN)
how do you assess how effective LTOT is in COPD
ABG’s 3 weeks apart
common causes of COPD exacerbation and management
strep pneumonia, HIB, RSV
increase SABA (?nebs)
oral prednisolone 7-14 days
sputum culture (doxycycline if positive)
most common type of lung Ca in smokers
squamous cell
small cell
most common lung Ca in non smokers
adenocarcinoma
associated features of squamous cell lung cancer
clubbing, hypercalcaemia due to high PTH, raised TSH
obstruction of central airways
paraneoplastic syndromes of small cell lung cancer
SIADHS
cushings (ectopic ACTH)
lambert eaton syndrome (MG)
paraneoplastic syndromes of large cell lung cancer
beta HCG secretion
carcinoid syndrome - serotonin = flushing
investigations in Lung cancer
sputum culture and cytology CXR biopsy of lymph nodes CT, bronchoscopy and biopsy PET scan isotope bone scan / bone profile
local complications of lung cancer
recurrent laryngeal nv palsy
phrenic nv palsy
SVCO
horners syndrome (Pancoast tumour)
what is horner’s syndrome / pancoast tumour
apical lung tumours cause damage to sympathetic nerves of face when they exit the spinal cord causing:
1) miosis
2) partial ptosis
3) anhidrosis
immediate management of tension pneumothorax
14 gage cannula (orange) into 2nd ICS mid clavicular line
management of pneumothorax
if small discharge/ monitor O2
aspirate
chest drain
what is and what causes respiratory alkalosis
resp alkalosis is a pH >7.45 withlow arterial CO2 <4.5
due to hyperventilation ~ blowing CO2 off
neurological disorders, PE, pregnancy, pneumonia, asthma
what is and what causes respiratory acidosis
pH <3.5
normal/ high CO2 (44.5-6.5)
due to inadequate ventilation ~ retaining CO2
COPD, opiates, decompensated asthma, benzos
causes of pulmonary fibrosis
idiopathic
occupational : silicosis, asbestosis
sarcoidosis
infection: TB, pneumonia
EAA
connective tissue disease (SLE, RA, scleroderma, GPA, ankylosing spondylitis)
drugs: amioderone , methotrexate, nitrofurantoin
causes of bilateral hilar lymphadenopathy
sarcoid infection - TB, mycoplasma malignancy - lymphoma, carcinoma, mediastinal ca silicosis EAA
presentation of acute sarcoidosis
erythema nodosum and polyarthralgia cough and SOB hepato/splenomegaly eye signs (-itis's) lupus pernio cardiomegaly and arrhythmias hypercalcaemia
investigations in sarcoidosis
serum ACE , ESR, LFT’s, Calcium, Ig’s
24h urine test for calcium
CXR - honeycombing, bilateral hilar lymphadenopathy, bullae
tissue biopsy - granulomas non caseating
list some extrapulmonary manifestations of TB
pott’s disease (spine and skull)
meningitis
sterile dysuria/ pyuria (urinary)
lupus vulgaris (mucocutaneous - face)
investigations in TB
CXR (consolidation, cavitation, fibrosis, calcification)
3 sputum samples - one early morning
- ziehl nelson stain - acid fast bacilli
- lowenstein johnson culture
management of pulmonary TB (+side effects and monitoring)
2 months:
ethambutol - optic neuritis and decline in renal function. check colour vision with ischihara chart and do U&E’s
pyazidamide - anaemia. FBC (also U&E’s for renal function)
6 months:
Rifampicin - orange secretions and deranged LFT’s. stop if increased bilirubin.
Isoniazid - peripheral neuropathy. monitor LFT’s.
also contact tracing and public health notification
what is the prophylaxis of TB
3 months rifampicin and isoniazid
management of meningeal TB
1 year RIPE + prednisolone
side effects of steroids
Cataracts, cushingoid Ulcers Skin thinning, bruising, striae Hyperglycemia, hypertension, hirsutism Immunosuppression Necrosis (femoral head) Growth suppression, glaucoma Osteoporosis, obesity Illness - mental (psychosis, depression) Diabetes
Peripheral oedema and proximal myopathy
explain pathophysiology of cystic fibrosis
AR - chromosome 7
affects CFTR protein
Cl- not transported out of cells so secretions more viscous
affects pancreatic ducts, lungs and sex organs
often presents with meconium ileus
investigation for cystic fibrosis
Guthrie test - immunoreactive trypsinogen sweat test (high NaCl) fecal elastase reduced
what bug often infects cystic fibrosis patients
pseudomonas aureginosa
management of cystic fibrosis
dont smoke flu jab nutrition physio sputum thinners (recombinant DNAase) mucolytics and broncho dilators Abx if +ve sputum sample
what is sail sign indicative of in CXR
left lower lobe collapse
