Respiratory Flashcards
what is coryza
acute viral infection of the nasal passages; highly infectious due to rhinoviruses, coronaviruses and
adenoviruses. Spread via droplets, facilitated by overcrowding and poor ventilation.
symptoms of coryza
watery nasal discharge mild pyrexia malaise sneezing tiredness sore nose and throat
complications of coryza
sinusitis
acute bronchitis
secondary infection
otitis media
treatments of coryza
bed rest
fluids
isolation
herbal extracts
what is sinusitis
bacterial/fungal infection of paranasal sinuses, usually preceded by coryza. Can occur with asthma.
symptoms of sinusitis
frontal headache, facial pain
purulent rhinorrhoea
fever
can be split into:
Acute: 1 week – 1 month
Subacute: 1-3 months
Chronic: >3 months
investigations for sinusitis
CT of paranasal sinuses, MRI to demonstrate bony landmarks
treatment of sinusitis
Nasal decongestants (xylometazoline)
Broad-spectrum antibiotics (co-amoxiclav)
Topical corticosteroid
(fluticasone propionate nasal spray)
FESS for ventilation and drainage
what is rhinitis
Sneezing attacks, nasal blockage/discharge occurring >1hr on most days.
can be split into seasonal and perennial
what is seasonal rhinitis
Limited period of the year; “hay-fever” but not restricted to grass pollen.
Intermittent rhinitis
symptoms of seasonal rhinits
Nasal irritation, rhinorrhoea, sneezing
Itchy eyes and ears
Irritated soft palate
Wheeze
what is perennial rhinitis
Throughout the whole year
Split into:
Allergic: caused by faeces of dust mites; cats; industrial dust and fumes.
Non-allergic: no identifiable stimulus, but eosinophilic granulocytes are present in secretions.
symptoms of perennial rhinitis
Nasal blockage, rhinorrhoea
Loss of smell and taste
treatment of general rhinits
Antihistamines (loratidine, cetirizine)
Topical corticosteroids (beclometasone, fluticasone propionate)
CysLT antagonist (montelukast)
Anti-inflammatory (sodium
cromoglicate)
what is pharyngitis
Endemic adenovirus infection, causing reddened oropharynx and soft palate and inflamed tonsils.
symptoms of pharyngitis
Sore throat
Tonsillar lymph nodes enlargement
Localised endemics of fever and
conjunctivitis
treatment of pharyngitis
phenoxymethylpenicillin or cefaclor if severe
what is acute laryngotracheobronchitis
Occasional complication of URTIs, particularly those caused by parainfluenza viruses and measles.
Most severe in children < 3yrs. Inflammatory oedema usually present which can spread to vocal cords.
symptoms of acute laryngotracheobronchitis
Hoarseness Barking cough (croup) Stridor Progressive airway obstruction
treatment of acute laryngotracheobronchitis
Nebulised adrenaline
Oral/IM corticosteroids (dexamethasone)
Oxygen and adequate fluids
Tracheostomy (rare!)
what is acute epiglottitis
Life-threatening airway obstruction in children aged 2-7yrs caused by H. influenzae.
symptoms of acute epiglottits
severe airflow obstruction
high fever
complications of acute epiglottitis
mostly of H. influenzae meningitis diptheria osteomyelitis septic arthritis
treatment of acute epiglottitis
Urgent endotracheal intubation
IV antibiotics (ceftazidime, ceftriaxone)
Prevention vaccine given to infants
Do NOT inspect epiglottis until airway is
patent
what is influenza
Influenza A (pandemics) and Influenza B (localised outbreaks) incubate within 3 days. Not a cold!
symptoms of influenza
Abrupt fever
Shivering and aching
Severe headache
Sore throat + dry cough
complications of influenza
Secondary bacterial infection/pneumonia
Encephalomyelitis (rare)
investigations for influenza
Increase in complement-fixing antibody (hemagglutinin) between onset and after 1-2 weeks
Nasal/throat secretion analysis
treatment of influenza
Bed rest, fluids
Paracetamol
Neuraminidase inhibitors within 48hrs
(zanamivir, oseltamivir)
what is acute bronchitis
acute infection of bronchi causing them to become inflamed
Usually arises from Strep. pneumoniae/H. influenzae infections, or in people with COPD.
symtptoms of acute bronchitis
Irritating dry cough; becomes productive
Wheeze
Breathlessness
Mild fever
treatment of acute bronchitis
NO antibiotics unless there is underlying chronic lung disease (amoxicillin)
what is pneumonia
Acute infection of the lungs causing inflammation. Community, Hospital and Immunocompromised
-acquired pneumonia. Main causes: Strep. pneumoniae, H. influenzae, Staph. aureus, Influenza A.
Atypical causes: Mycoplasma, Legionella, Chlamydophila pneumoniae/psittaci, coxiella burnetti.
HAP only diagnosed after 48hrs in hospital
symptoms of pneumonia
Fever and rigors Pleuritic chest pain Anorexia Breathlessness Cough – dry or productive
investigations for pneumonia
CXR consolidation, effusions,
collapse
FBC + U&Es, CRP
Sputum culture to detect organisms
CURB65 for CAP
treatment of pneumonia
CAP (see Antibiotic Man)
Mild/Moderate: (7 days) PO amoxycillin
If penicillin allergy PO doxycycline; if IV required IV clarithromycin
Severe: (10 days) IV co-amoxiclav + IV clarithromycin/PO doxycycline
If penicillin allergy IV levofloxacin
HAP
Severe: (7-10days) amoxicillin + metronidazole + gentamicin
Non-severe: (7 days) amoxicillin + metronidazole
Specific
Staph. aureus flucloxacillin/vancomycin if MRSA
Klebsiella cefotaxime
Pseudomonas ceftazidime/ciprofloxacin + aminoglycide
Mycoplasma clarithromycin/ciprofloxacin
Legionella levofloxacin/moxifloxacin/consider rifampicin
Chlamydophila doxycycline/clarithromycin
Pneumocystis jiroveci co-trimoxazole
Fungal amphoterecin
what is COPD
encompasses 2 main clinical syndromes: chronic bronchitis and emphysema
characterised by airflow obstruction that is most reversible with bronchodilators
symptoms of COPD
productive cough
wheeze
breathlessness
infective exacerbations
complications of COPD
Hypertension
Osteoporosis
Weight loss
Cor pulmonale
investigations for COPD
Smoking history/chronic history of
symptoms
Family history (α1-antitrypsin deficiency)
Lung function tests (↓FEV1/↓FVC,
↓PEFR)
CXR classically normal
ABGs de-saturate over time
treatment of COPD
Smoking cessation and lifestyle advice
SABA (salbutamol) mild COPD,
LABA (salmeterol) mod-sev COPD
SAMA (ipratropium) or
LAMA (tiotropium)
Inh. corticosteroid (beclometasone),
PO corticosteroid if severe
(prednisolone)
Seretide (salmeterol + beclometasone)
Xanthine (theophylline)
Anti-mucolytic (carbocysteine)
treatment of an acute exacerbation of COPD
ISOAP ipratropium (neb) salbutamol (neb) oxygen (24%) amocillin/doxyclycine is purulent sputum prednisolone (PO)
what is asthma
chronic inflammatory condition where reversible obstruction of the airways occurs.
airflow limitation -> airway hyerresonsivemess -> bronchial inflammation
investigations for asthma
Allergen skin prick test
Lung function tests (↓PEFR: mod<80%,
severe<50%, life-threatening<30%)
Bronchial challenge testing (histamine,
methacholine)
CO transfer (normal in asthma)
treatment for asthma
SABA (salbutamol)
LABA (salmeterol) \+ inhaled corticosteroid (beclometasone) \+ sodium cromoglicate \+ CysLT antagonist (montelukast) \+ oral corticosteroid (prednisolone)
treatment of acute asthma
O SHIT MAn oxygen salbutamol (neb) hydrocortisone (IV) ipratropium (neb) magnesium sulpahte (IV) prednisolone (PO)
characteristics of acute severe asthma
Unable to complete sentences
Respiratory rate >25 per minute
Pulse rate >110 beats per min
PEFR <50 % predicted
characteristics of life threatening asthma
PEFR <33% predicted
Bradycardia, hypotension, silent chest
Exhaustion, confusion, coma
ABG PaCO2 >5, PaO2 <8 or acidosis
what is OSA
airway becomes closed during sleep; muscles hypotonic during sleep and thus do not open airway. partial occlusion = snoring and complete occlusion = apnoea (cessation of breathing)
symptoms of OSA
Loud snoring Daytime sleepiness Unrefreshed/restless sleep Headache Large neck and tongue Small mandible
aetiology of OSA
Obesity
Narrow pharyngeal opening
Co-existent COPD
Respiratory depre
investigations of OSA
Epworth Sleepiness Scale
Overnight pulse oximetry
Diagnose if >10-15 apnoeas in any 1hr of
sleep
treatment of OSA
Nasal Continuous Positive Airway Pressure (via mask during sleep)
CNS stimulant (modafinil
what is bronchiectasis
Abnormal permanent dilatation of airways, resulting inflammation and thickening of walls.
Mucociliary transport mechanism is impaired and thus recurrent bacterial infections ensue.
Cystic fibrosis = most common cause.
symptoms of bronhiectasis
Productive cough (yellow-green sputum, can become haemoptysis) Halitosis (bad breath) Recurrent febrile episodes, malaise Clubbing Coarse crackles, pneumonic episodes
complications of bronchiectasis
Pneumonia, pneumothorax
Empyema
Metastatic cerebral abscesses
Life-threatening haemoptysis
investigations of bronchiectasis
CXR dilated + thickened bronchi
CT thickened bronchi, cysts
Sputum S. aureus, Pseudomonas, HiB
IgA deficiency
treatment of bronchiectasis
Postural drainage!
Antibiotics (mild: cefaclor/ciprofloxacin,
flucloxacillin if S. aureus;
persistent: ceftazidime)
Bronchodilators + anti-inflammatory
agents
what are lung abscesses
Localised suppuration assoc. with cavity formation on CXR/CT
aetiology of lung abscess
aspiration, TB, Stap/Klebs pneumonia, septic emboli, foreign body inhalation
symptoms of lung abscess
persisting pneumonia, foul sputum, malaise, weight loss, raised inf. markers
treatment of lung abscess
guided by culture results, surgical drainage
what is cystic fibrosis
autosomal recessive disorder in which there is a defect in the CFTR gene, a critical chloride channel.
Failed opening of Cl channel -> ↑cAMP, resulting in ↓Cl and ↑Na -> ↑viscosity of airway secretions.
symptoms of CF
Recurrent infections Sinusitis, nasal polyps Breathlessness Haemoptysis Steatorrhoea Meconium ileus (SI obstruction) Malabsorption Abnormal teenage milestones
investigations in CF
Family history Gene testing (sweat test)
treatment of CF
Lifestyle (smoking, vaccines)
Antibiotics (as per bronchiectasis)
SABAs, ICS for symptoms
Inh recombinant DNAse (dornase)
what is tuberculosis
Airborne infection spread by droplets by Mycobacterium species. Affects 1/3 of population.
Caseating granulomatous inflammation (necrotic centre; surrounded by epitheloid cells and Langhan’s
giant cells; formation of Ghon focus/complex). Primary=first infection. Latent=asymptomatic, smear –
ve
symptoms of TB
Persistent productive cough (>3weeks) +
occasional haemoptysis
Weight loss, night sweats, fever, fatigue
Hoarseness, pleuritic pain
investigations for TB
CXR consolidation +/- cavitation, fibrosis, calcification, pleural effusion, widening of
mediastinum
Latent: tuberculin skin test/Mantoux test (possible false –ve if previous BCG). If +ve do IFʎ test
Active: obtain tissue/fluid (induced sputum, bronchoalveolar lavage if unproductive cough,
aspiration of pleural fluid/biopsy, pus, ascites, urine, bone marrow, CSF)
Culture > PCR > ZN stain (but culture takes weeks, PCR is rapid so it is 1st line)
treatment of TB
2 months RIPE, 4 months RI
Rifampicin SE discolouration of
urine/tears, hepatitis, flu-like illness
Isoniazide SE neuropathy,
agranulocytosis, allergic reaction
Pyrazinamide SE hepatic toxicity (rare),
reduced renal excretion of urate, gout
Ethambutol SE colour blindness
developing into blindness
what is sarcoidosis
Multisystem non-caseating granulomatous Type IV hypersensitivity disorder of unknown aetiology
symptoms of sarcoidosis
Erythema nodosum
Fatigue, weight loss
Uveitis
Peripheral lymphadenopathy
investigations for sarcoidosis
CXR multiple abnormalities, BHL
Restrictive lung pattern
Hypercalcaemia, raised ACE level
Transbronchial biopsy
treatment for sarcoidosis
corticosteroids (PO prednisolone)
what is wegners granulomatosis
Granulomatous disease predominantly affecting small arteries. Lesions in URT, lungs, kidney
symptoms of wegners granulomatosis
Severe rhinorrhoea ->nasal mucosa ulcer
Cough, haemoptysis, pleuritic pain
Occasionally involves skin and nervous
system.
investigations of wegners granulomatosis
CXR nodular masses/pneumonia infiltrates with cavitation
Renal biopsy reveals necrotising microvascular glomerulonephritis
treatment of wegners granulomatosis
esponds well to cyclophosphamide or rituximab
what is churg-strauss syndrome
Eosinophilic infiltration with high blood eosinophil count, vasculitis of small arteries and veins.
Predominately affects 40 year old males
symptoms of churg-strauss syndrome
Rhinitis and asthma, breathlessness Systemic vasculitis (fever, sweats, fatigue, weight loss, rash) Cough Difficulty passing urine Cold peripheries
investigations for churg-strauss syndrome
CXR pneumonic shadows (bilateral)
ANCA +ve
treatment of churg-strauss syndrome
responds well to corticosteroids
what is systemic lupus erythematosis
Chronic type III hypersensitivity disease that causes inflammation in various parts of body
symptoms of systemic lupus erythematosis
Joint pain, fatigue Skin rash Pleurisy with or w/o effusion Effusions (usually small/bilateral) Basal pneumonitis (restricted chest movement due to pleural pain)
what is idiopathic pulomary fibrosis
Patchy scarring of lung with collagen deposition and honeycombing. Late onset. Commoner in males.
symptoms of idiopathic pulomary fibrosis
Progressive breathlessness Dry cough Cyanosis Fine bilateral end-inspiratory crackles Clubbing Assoc. with autoimmune diseases
investigations for idiopathic pulomary fibrosis
CXR initially ground-glass -> honeycomb CT bilateral changes, thick-walled cysts Restrictive lung pattern, ↓CO transfer Anti-nuclear antibodies
treatment of idiopathic pulomary fibrosis
Corticosteroids (oral prednisolone)
Anti-fibrotic (pirfenidone)
what is extrinsic allergic alveolitis
Widespread diffuse inflammatory reaction in small airways and alveoli due to inhalation of foreign
antigens, usually from animals. Cigarette smokers actually have decreased risk. Type III
hypersensitivity
symptoms of extrinsic allergic alveolitis
Fever, malaise
Cough, breathlessness, wheeze
Coarse end-inspiratory crackles
Weight loss and IPF features (chronic)
investigations for extrinsic allergic alveolitis
CXR fluffy upper zone nodular shadows
CT ground glass opacity
Restrictive lung pattern, ↓CO transfer
Raised leucocytes + T cells
treatment of extrinsic allergic alveolitis
Prevent exposure
Oral prednisolone in early stages
what is coal workers pneumoconiosis
Dust particles typically 2-5 micrometres in diameter are retained in small airways and alveoli
split into
simple pneumoconosis
progressive massive pneumoconiosis
what is simple pneumoconiosis and symptoms
More common form; refers to deposition of coal dust in lung.
Symptoms usually COPD-related. CXR fine micro-nodular shadowing.
what is progressive massive pneumoconiosis
Round fibrotic masses several cm in diameter develop in upper lobes -> apical destruction of lung.
Necrotic central cavities.
symptoms of coal workers pneumoconiosis
Considerable effort dyspnoea
Cough + black sputum
investigations for coal workers pneumoconiosis
Rheumatoid factor and ANAs +ve; restrictive/obstructive pattern, ↓lung volume, ↓CO transfer
what is asbestosis
Fibrosis causes by asbestos dust exposure
symptoms of asbestosis
Progressive breathlessness, clubbing
Bilateral basal end-inspiratory crackles
treatment of asbestosis
No treatment alters progression, but corticosteroids can help symptoms
what is pneumothorax
Air in the pleural space. May be spontaneous (tall, thin males) or the result of trauma to the chest
symptoms of pneuothorax
Sudden onset pleuritic pain Increasing breathlessness Pallor, tachycardia Mediastinal shift (tension pneumothorax)
treatment of pneumothorax
Needle aspiration (2nd IC space, midclavicular line)
Chest drain if recurs using large bore
what is empyema
Pus in the pleural space. Usually complication of pneumonia. Exudate of pH< 7.2 very suggestive.
symptoms of empyema
Ongoing fever
Persistent pneumonic symptoms
treatment of empyema
surgical drainage
what are pleural effusions
Excessive fluid in the pleural space.
can be split into
Transudate
protein < 30g/l LDH < 200
Heart failure, nephrotic syndrome, pericarditis
Exudate
protein > 30g/l LDH > 200
Pneumonia, cancer, TB, autoimmunity, MI, pancreatitis
symptoms of pleural effusion
breathlessness, sometimes chest pain but rarely
investigations of pleural effusion
Clinically detect when >500ml present
CXR detects when >300ml present, obliterated costophrenic angle, raised hemidiaphragm
Lights’ criteria (differentiates between transudate and exudate between 25-35g/l
treatment of pleural effusions
treat underlying cause but drain if empyema (purulent fluid).
Thoracocentesis 5th intercostal space, mid-axillary line
what is respiratory failure
Occurs when gas exchange is inadequate, resulting in hypoxia. It is defined as PaO2 <8kPa, subdivided
according to PaCO2 level
what is type I respiratory failure
hypoxia (PaO2 < 8kPa) with normal or low PaCO2
aetiology of type I respiratory failure
o Pneumonia
Pulmonary oedema
PE, fibrosing alveolitis
Asthma, emphysema, ARDS
treatment of type I respiratory failure
Treat underlying cause
Oxygen (15L) non-rebreather (hypoxia)
Assisted ventilation if PaO2 < 8kPa
despite 60% O2
what is type II respiratory failure
hypoxia (PaO2 < 8kPa) + hypercapnia (PaCO2 > 6.0 kPa)
aetiology of type II respiratory failure
Pulmonary disease (asthma, COPD, pneumonia, fibrosis, obstructive sleep apnoea)
Reduced respiratory drive (sedation drugs, CNS tumour/trauma)
Neuromuscular disease (cervical cord lesion, diaphragmatic paralysis, poliomyelitis, MG, Guillain-Barre Syndrome)
Thoracic wall disease (flail chest, kyphoscoliosis)
treatment of type II respiratory failure
Oxygen (24%), recheck ABGs after 20min
If PaCO2 is steady/lower, increase O2 concentration to 28%
If PaCO2 rises > 1.5kPa and patient is still hypoxic, consider a respiratory stimulant (doxapram)
or assisted ventilation (NIPPV)
what is ARDS
Respiratory distress due to stiff lungs (reduce pulmonary compliance) and gas exchange impairment.
Lung injury, severe sepsis and pneumonia result in fibrous exudate lining alveolar walls, impairing gas
exchange and destroying alveoli.
symptoms of ARDS
Breathlessness
Tachypnoea
Increasing hypoxaemia, central cyanosis
Fine bilateral crackles
treatment of ARDS
Treat underlying condition (sepsis,
pneumonia), position patient prone
Diuretics
Inhaled nitric oxide (vasodilator
improves V/Q)
Aerosolized surfactant
PEEP
Inspired oxygen
what is pulmonary hypertension/cor pulmonare
Defined as mean pulmonary artery pressure of ≥25mmHg at rest.
Cor pulmonale = right heart failure due to pulmonary hypertension. Can occur in advanced COPD:
alveolar collapse (emphysema) results in hypoxia which causes vasoconstriction, increasing pressure in
the right side of the heart.
symptoms of pulmonary hypertension/cor pulmonare
Progressive breathlessness Ankle oedema Parasternal heave, tricuspid regurgitation Pulmonary hypertension RV hypertrophy Elevated JVP, ascites
investigations of pulmonary hypertension/cor pulmonare
CXR enlargement of pul. arteries,
atrial/ventricular enlargement
ECG pattern of RVH
treatment of pulmonary hypertension/cor pulmonare
Encourage exercise, avoid overexertion Oxygen (2l) during plane travel Vaccination for influenza + pneumococcal pneumonia Oral anticoagulants Diuretics
what is PE
Thrombus, usually from systemic veins, lodges in pulmonary arteries.
Virchow’s triad: endothelial damage, abnormal blood flow or hypercoagulable blood -> clot formation.
symptoms of PE
Sudden breathlessness
Sudden chest pain + haemoptysis
Tachypnoea
Fever, pleural rub, raised JVP
investigations of PE
CXR usually normal, possible blunting of costophrenic angle
D-dimer – if undetected, exclude diagnosis of PE
V/Q scan shows underperfused areas
Geneva score to predict PE likelihood
treatment of PE
Oxygen (60-100%) unless chronic lung disease
Anticoagulant (IM LMWH, IV heparin + warfarin)
IV fluids in massive embolus
Fibrinolytic (streptokinase
what is pulmonary oedema
accumulation of fluid in the pleural space
symptoms of pulmonary oedema
Breathlessness, orthopnoea
Cough + haemoptysis
Leg/abdominal swelling
Pale skin
treatment of pulmonary oedema
oxygen
diureticss
symptoms of lung cancer
Cough (3 week cough merits a CXR)
Breathlessness(central tumours occlude large airways)
Haemoptysis (tumour bleeding into airway)
Chest pain (peripheral tumour invade the chest wall/pleuritic pain
Wheeze (monophonic when due to partial obstruction of airway by tumour)
Hoarseness (compression of the recurrent laryngeal nerve)
Dysphagia (invasion of phrenic nerve/oesophagus)
describe small cell carcinoma
Arise from APUD cells; secrete ACTH
Often centrally located
Rapid metastasis
describe adenocarcinoma
Common in non-smokers; smoking can cause it
Arises from mucus-secreting glandular cells
Metastasises widely
describe squamous cell caricinoma
Most common. Arise from epithelial cells
Occasionally cavitates; central necrosis
Local, slow metastasis. Hypercalcaemia, PTH
describe large cell carcinoma
Poorly differentiated
Metastasises early on
investigations for lung cancer
CXR may be initially normal due to small lesion/confined to central structures
Common presentations: mass lesions, pleural effusion (large, unilateral), mediastinal widening or
hilar adenopathy, slow resolving consolidation, collapse, reticular shadowing
CT indicates extent of disease. Includes liver, adrenal glands. TNM staging can be done
PET characterises extent of mediastinal nodal involvement or distant metastases (2nd line to CT)
PET + CT for best correlation
Assess fitness for surgery
treatment of lung cancer
Surgery: early stage NSCLC surgery can be curative
If Stage III, treat with chemotherapy to downstage then surgical resection
Contraindicated if:
- Tumour is near hilum
- Evidence of metastasis
- FEV1 > 1.5 L
- Vocal cord paralysis
Radical radiotherapy: for patients with early stage NSCLC but adequate lung function, this is
ideal if surgery is not possible due to co-morbidities
Chemotherapy: effective against SCLC only
