Respiratory Flashcards
What are the causes of a pleural transudate?
Heart failure Hypoalbuminaemia Hypothyroidism Meigs syndrome
What defines a transudate?
<30g/L protein
What defines an exudate?
>30g/L protein
What are the causes of a pleural exudate?
Infection (pneumonia, TB, abscess) Connective tissue disease Neoplasia Pancreatitis PE Dressler’s syndrome Yellow nail syndrome
What is acute bronchitis?
Inflammation of the bronchi
What causes bronchitis?
Viruses (influenze, RSV, rhinoviruses) Bacteria (pneumococcus, H.influenzae, staph aureus)
What are the symptoms of acute bronchitis? How long does it last?
Main= cough SOB, wheeze, sputum Cough lasts 7-10d but can be up to 3 weeks
What is the treatment for bronchitis?
Reassurance Analgesia/antipyretics DOES NOT NEED ANTIBIOTICS
What are the risk factors for bronchitis?
Smoking Damp
What family of viruses causes influenza?
Orthomyxoviridae
What are the 3 types of influenza and what are the differences between them?
Influenza A- most common, more virulent. Causes most local outbreaks. Influenza B- often co-circulates with A, less severe illness. Influenza C- mild/asymptomatic infection
What is the management of influenza in health individuals vs those who are “at risk”?
Healthy- rest, paracetmaol/ibuprofen, adequate fluids, stay off until worst sx resolved (~1 week) At risk- antivirals (oseltamivir or zanamivir) within 48hr of sx
Which groups are “at risk” of complications from influenza?
Chronic disease (lung/heart/kidney/neuro) Diabetics Obese Immunosuppressed >65 years <6 months Pregnant (or up to 2 weeks postpartum)
What are the complications of flu?
Bronchitis, sinusitis, otitis media, exacerbation of COPD/asthma, pneumonia
What is laryngotracheobronchitis?
Croup
What are the symptoms of croup?
Seal-like barking cough Stridor Hoarse voice Respiratory distress Worse at night Preceded by 12-48hr cough, fever, rhinorrhoea
What determines if croup is mild/mod/severe?
Mild- cough, no stridor or recession Moderate- cough with stridor or recession at rest, no agitation/lethargy Severe- cough, stridor, recession with agitation/lethargy
What are the signs of impending respiratory failure in croup?
Increasing airway obstruction Recession (can decrease as child tires!) Asynchronous chest/abdo movements Fatigue Pallor Cyanosis Decreased consciousness
What is the management of croup and where should patients be managed?
Single dose oral dexamethasone 0.15mg/kg Paracetamol/ibuprofen for pain Mild- home Moderate/severe- hospital admission
In which circumstances would you admit a child with mild croup?
<3 months Inadequate oral fluids Chronic lung disease Congenital heart disease NM disease Immunodeficient
How long does croup normally last?
48 hrs
What is the most common causative organism for croup?
Parainfluenza viruses
What is the most common causative agent of bronchiolitis?
RSV
What are the symptoms of bronchiolitis?
Coryzal prodrome 1-3d Persistent cough Tachypnoea/recession Wheeze/crackles Fever (<39 usually) Poor feeding Apnoea
How long does bronchiolitis usually last?
3-7d, cough 3 weeks
What is the management for bronchiolitis?
Self-care Paracetamol/ibuprofen if distressed by fever Oral fluids
What is the vaccination for bronchiolitis called and who receives it?
Palivizumab SCID/premature/chronic lung disease/congenital heart disease
What would prompt referral of a child with bronchiolitis to hospital?
O2 <92% RR >70 Cyanosis Apnoea Respiratory distress (grunting/severe recession)
What is the management of CAP?
CURB 0-1 amoxicillin 500mg TDS for 5d CURB1-2 consider adding clarithromycin 500mg BD 7-10d
What is the main cause of CAP?
Strep pneumoniae
What is required to diagnose pneumonia?
Cough + 1 of: sputum/wheeze/SOB/pleuritic pain + systemic feature (fever, myalgia, sweats) +/- temp >38
What is CURB65?
Scoring system for pneumonia C- new confusion U- urea >7 R- RR>30 B- BP <90 systolic or <60 diastolic 65- Over 65yrs of age
What follow up is needed after pneumonia?
Repeat CXR in 6/52
What are the complications of pneumonia?
Pleural effusion Empyema Lung abscess Sepsis Systemic infection
What is pneumoconiosis?
Restrictive lung disease Coal workers- 15-20yr lag
What would show a restrictive pattern on spirometry plus opacities on CXR?
Pneumoconiosis
What are the symptoms of pneumoconiosis?
Breathlessness on exertion Cough +/- Black sputum
What is the pathophysiology of pneumoconiosis?
Coal dust inhaled, reaches terminal bronchioles and engulfed by alveolar and interstitial macrophages. The dust is removed from the body as mucus. With many years of exposure, system is overwhelmed and macrophages accumulate in alveoli causing immune response and damage to lung tissue.
What is the safe triangle for chest drain insertion?
The triangle is located in the mid axillary line of the 5th intercostal space. It is bordered by: Anterior edge latissimus dorsi, the lateral border of pectoralis major, a line superior to the horizontal level of the nipple, and the apex below the axilla.
Features of klebsiella pneumonia
Red-currant jelly sputum Cavitations Often affects upper lobes More common in alcoholics/diabetics May occur following aspiration
Features of lung Ca
Peristent cough Haemoptysis Dyspnoea Chest pain Weight loss Anorexia
Lung Ca exam findings
fixed monophonic wheeze Supraclavicular/cervical lymphadenopathy Clubbing
Spirometry for COPD
FEV1/FVC less than 0.7
MRC dyspnoea scale
Grade 1: breathless only on strenuous exertion Grade 2: SOB when hurrying on level ground/slight incline Grade 3: walks slower than contemporaries due to breathlessness or has to stop for breath at own pace Grade 4: stops for breath after 100m/few minutes of walking Grade 5: breathless on dressing/undressing, too breathless to leave house
COPD severity
1- mild, FEV1 >80% predicted 2- moderate, FEV1 50-79% predicted 3- severe, FEV1 30-49% predicted 4- very severe, FEV1 <30% predicted or <50% with respiratory failure
COPD symptoms
Exertional breathlessness Cough (chronic) Wheeze Regular sputum production Recurrent chest infections Others; weight loss, exercise intolerance, ankle swelling, fatigue
Signs on examination for COPD
Cyanosis Raised JVP Cachexia Pursed lip breathing Hyperinflated chest Use of accessory muscles Wheeze or quiet breath sounds Peripheral oedema
Features of cor pulmonale
Sx/signs are due to back up of blood:
Fatigue, SOB, fainting
Peripheral oedema
Raised JVP
Hepatomegaly
Systolic parasternal heave
Loud pulmonary second HS (over 2nd left intercostal space)
Widened descending pulmonary artery on CXR
Right ventricular hypertrophy on ECG
Investigations for COPD
Post bronchodilator spirometry CXR FBC (check for anaemia/secondary polycythaemia) +/- pulse oximetry, ECG, sputum culture
Fundamentals of COPD care
Stop smoking Pneumococcal and influenza vaccines Pulmonary rehab Optimise co-morbidities
Asthmatic features/features of steroid responsiveness
Previous asthma/atopy High eosinophil count Substantial FEV1 variation (at least 400ml) Diurnal variation in peak flow (at least 20%)
Indications for long-term oxygen therapy in COPD
Oxygen saturation 92% or less FEV1 less than 30% Cyanosis Secondary polycythaemia Peripheral oedema Raised JVP
Treatment for acute exacerbation of COPD
Oral prednisolone 30mg OD 7-14d Oral amoxicillin 500mg TDS 5d (or dox 200mg first day then 100mg for 4 more days)
Indications for admission in acute exacerbation of COPD
Severe breathlessness, rapid onset of symptoms, acute confusion, cyanosis, worsening peripheral oedema, impaired consciousness Unable to cope or lives alone Reduction in activities, confined to bed, or on long-term oxygen Significant comorbidity Oxygen saturation less than 90%
Definition of end-stage COPD
FEV1 less than 30% predicted/MRC dyspnoea scale grade 4/5 and unresponsive to medical treatment and life expectancy of less than 6-12 months
Drug treatment for breathlessness in end-stage COPD
Opioid first line (immediate release oral morphine) Benzodiazepines (diazepam, lorazepam or midazolam) Short burst oxygen therapy
Complications of COPD
Disability and impaired quality of life Depression and anxiety Cor pulmonale Frequent chest infections Secondary polycythaemia Type II respiratory failure Lung cancer
Chronic Bronchitis
Chronic cough with mucus for at least three months for two consecutive years Shortness of breath which can become worse with exercise
Emphysema
Dilation/destruction of lung parenchyma Mild cough, severe constant dyspnoea
Symptoms of asthma
Wheeze- widespread, bilateral, predominantly expiratory Breathlessness Chest tightness Cough Worse at night/early morning Associated with exercise/cold air/allergens/NSAIDs/beta blockers
Investigations for asthma
FeNO testing (those over 17yrs) Spirometry (all over 5yrs) - FEV1/FVC <0.7 Bronchodilator reversibility (all over 17, consider in ages 5-16)- FEV1 improvement of 12% or more + increase in volume of 200ml Peak flow- if diagnostic uncertainty
Positive FeNO level in steroid-naive adults
40 ppb
To dx asthma you need
Postive FeNO + bronchodilator reversibility or peak flow variability or bronchial hyperreactivity
Asthma management (according to NICE)
1) SABA alone 2) low dose ICS (if use SABA >3/week or sx 3/week or woken at night 1/week) 3) consider LTRA 4) Add LABA 5) MART (maintainer and reliever) regimen with low dose ICS 6) Increase dose of ICS
Asthma management for ages 5-16 according to NICE
1) SABA 2) low dose ICS 3) LTRA 4) stop LTRA, add LABA 5) MART 6) increase dose ICS
Salbutamol and terbutaline are…
SABAs
Salmeterol and formetorol are…
LABAs
Budesonide, beclometasone, ciclesonide, fluticasone and mometasone are
Inhaled corticosteroids
Montelukast and zafirlukast are…
LTRAs
Ipratropium bromide and tiotropium are
Muscarinic agents Ipratropium- SAMA Tiotropium- LAMA
Hx for near drowning
Mechanism and duration of submersion Type/temperature of water Time until CPR Time to first spontaneous breath Time to return of spontaneous cardiac output Vomiting Likelihood of associated trauma Other precipitants e.g. Arrythmia, MI, seizure, non-accidental
Examination in near drowning
Temp, O2 sats Cardiac rhythm Respiratory pattern Any evidence of pulmonary oedema Head/neck injuries Intra-abdominal/thoracic injuries (if fall from height) Neurological status
Investigations for near drowning
ECG- check for ischaemia, J waves= hypothermia Bloods- ABG, U&Es, glucose, osmolarity, alcohol level, FBC, LFTs, coag, cultures CXR +/- C-spine/CT head
Treatment of near drowning
Resuscitation + intubation if needed Oxygen Treat hypothermia, hypoglycaemia, seizures, hypovolaemia and hypotension if they occur NG tube +/- catheter May need CPAP, PEEP or ECMO If awake/alert, observe for at least 6hrs
Acute onset severe sore throat and fever
Muffled voice
Drooling
Stridor
Epiglottitis
Management of epiglottitis
Usually IV or oral antibiotics
Intubation may be needed
Tracheostomy if intubation not possible
Catarrhal phase- malaise, conjunctivitis, nasal discharge, sore throat, dry cough, mild fever for 1-2 weeks
At least 2 weeks of paroxysmal cough (dry, hacking) associated with whoops or post cough vomiting
Convalescent phase- may last additional 2 months, gradual improvement in sx
Whooping cough (pertussis)
If suspicious of whooping cough, you need to…
Send a notification form to PHE within 3 days
Management of whooping cough
Admit if unwell
Macrolide antibiotic e.g. clarithromycin, azithromycin, erythromycin
Rest, fluid intake, paracetamol/ibuprofen
Children/HC workers to stay off until 48hr abx
Close contacts may need prophylactic abx
Define empyema
Collection of pus in the pleural space
Causes of empyema
Pneumonia (not treated fully)
Bronchiectasis
Pulmonary infarct
Surgery/endoscopy
Chest injury
TB
Symptoms of empyema
Fever
Night sweats
Fatigue
Difficulty breathing
Weight loss
Chest pain
Cough, coughing up mucus
Management of empyema
Chest drain
Antibiotics
+/- fibrinolytics and DNase’s
Definition of OSA
A clinical condition in which there is intermittent and repeated upper airway collapse during sleep. This results in irregular breathing at night and excessive daytime sleepiness.
Symptoms suggestive of OSA
- Excessive daytime sleepiness.
- Impaired concentration.
- Snoring.
- Unrefreshing sleep.
- Choking episodes during sleep.
- Witnessed apnoeas.
- Restless sleep.
- Irritability/personality change.
- Nocturia.
- Decreased libido.
Assessment and management of OSA
Epworth scale- if >10 investigations recommended
Polysomnography to dx, >5 apnoeas is mild
Management:
Lifestyle- weight loss, smoking cessation, avoid evening alcohol, sleep on side. Assess CV risk and diabetes, regular monitoring of BP.
CPAP- need to wear for minimum 4hr/night. Maintains patency of upper airway.
intraoral devices
Cor pulmonale and its pathophysiology
Cor pulmonale is right sided heart dysfunction caused by lung dysfunction
Can lead to right heart failure
Pathophysiology:
Lung dysfunction leads to hypxoia, resulting in hypoxic vasoconstriction, which increases resistance and leads to pulmonary hypertension.
In chronic lung disease, this causes right ventricular hypertophy which results in less ventricular space and therefore diastolic failure. The thickened muscle increases oxygen demand which leads to ischaemia and systolic failure.
Treatment for cor pulmonale
LTOT/NOT if sats <88%
Diuretics e.g. furosemide for oedema
PE risk factors
DVT
Previous DVT/PE
Active cancer
Recent surgery
Lower limb trauma
Recent immobilsation
Pregnancy/6 weeks postpartum
COCP/HRT
Thrombophilia
Long distance travel
Obesity
Increasing age
Clinical features/signs of PE
Symptoms:
- Dyspneoa
- Chest pain
- Cough
- Haemoptysis
- DVT (lef pain and swelling)
- Lower abdo pain
- Redness
- Increased temperature
- Dizziness
- Syncope
Tachycardia
Hypoxia
Pyrexia
Raised JVP
Gallop rhythm
Pleural rub
Hypotension
Shock
Investigations for PE
2 level Wells score:
- <4 = PE unlikely. Do D-dimer. If raised do CTPA.
- 4+ = PE likely. Do CTPA. If delay give LMWH or fondaparinux.
If unprovoked, need investigations for possible malignancy incl:
- Hx/examination
- CXR
- Bloods incl. FBC, Calcium, LFTs
- Urinalysis
- Consider referral for further investigationswith CT if >40 and above normal
- Consider antiphospholipid testing
- Consider thrombophilia testing if 1st degree relative has had PE/DVT
Management of PE
Initial resuscitation: O2, IV access, analgesia if required, assess circulation
Anticoagulation with LMWH/fondaparinux for at least 5d or until INR is 2 or more for at least 24hr
(or unfractionated heparin if increased bleeding risk/CKD)
Thrombolysis e.g. rt-PA if massive PE
Mechanical intervention e.g. IVC filters (if cannot have anticoagulation or recurrent PE despite anticoag)
Long Term:
3 months anticoagulation for unprovoked (with warfarin/NOAC)
6 months if provoked
ECG signs in PE
sinus tachycardia
non-specific ST-segment and T-wave abnormalities
right axis deviation
incomplete or complete RBBB
T-wave inversion in leads V1–V3
P pulmonale
classical S1, Q3, T3 (S wave in lead 1, Q wave in lead 3, and T-wave inversion in lead 3).
CXR signs in PE
atelectasis, pleural effusion, or elevation of a hemidiaphragm
Light criteria for pleural effusion- differentiates transudates and exudates if pleural fluid proteinis 25-35g/L
Measure LDH and protein in pleural fluid and serum
Fluid is considered exudative if one of the following criteria is present:
Pleural fluid-to-serum protein ratio >0.5; or
Pleural fluid-to-serum LDH ratio >0.6; or
Pleural fluid LDH >2/3rds upper limit of normal for serum LDH
Symptoms of pleural effusion
SOB
Cough
Pleuritic chest pain
Features of malignancy
Investigations for pleural effusion
CXR 1st line
US (more sensitive, detects small effusions)
CT/MRI
Pleural fluid analysis (if exudative need to do this)
Pleural fluid analysis
- Transudate vs exudate
- Bloody?- causes are malignancy, PE with infarct, trauma, asbestos
- If bloody measure haematocrit ?haemothorax
- pH. low= infection, rheumatoid, SLE, TB, malignancy, oesophageal rupture
- Cytology
- Cholesterol/triglycerides- chylothorax triglyceride >1.24, cholesterol <5.18
- Glucose- low glucose in empyema, rheumatoid, SLE, TB, malignancy, oesophageal rupture
- Differential WCC- lymphocytosis in malignancy and TB
Management of plueral effusion
Treat underlying cause
Pleural tap/chest drain
Pleurodesis if malignant effusion
Definition of pneumothorax
collection of air in the pleural cavity (between the lung and the chest wall) resulting in collapse of the lung on the affected side
Types of pneumothorax
Primary (spontaneous)
Secondary- associated with underlying lung disease
Traumatic
Tension- emergency
Iatrogenic
Treatment for tension pneumothorax
Large bore needle/cannula into pleural space through 2nd intercostal space in the mid-clavicular line
Oxygen
Symptoms and signs of pneumothorax
Symptoms — collapse, sudden-onset pleuritic pain, breathlessness.
Signs — reduced chest wall movements, reduced breath sounds, reduced vocal fremitus, and increased resonance of the percussion note on the affected side.
Tension pneumothorax can result in a rapid development of severe symptoms associated with tracheal deviation away from the pneumothorax, tachycardia, and hypotension.
Investigations and management of pneumothorax
Investigations:
- CXR
- CT if uncertain/complex case
- ABG (if O2 sats <92%)
Management:
Secondary pneumothorax- admit, observe, O2
Primary- if asymptomatic and small, discharge. If breathless- needle aspiration (14-16G), or chest drain if large
Pleurodesis if recurrent
