Respiratory Flashcards
Lights criteria
Pleural:serum protein >0.5
Pleural:serum LDH >0.6
Pleural fluid LDH >2/3 serum LDH upper limit of normal
GLUCOSE NOT USED
Lung volumes -typical values
TV - 500ml M and 359ml F - vol inspired and expired at normal breathing at rest
IRV 2-3L - total vol inspired at end of normal tidal insp
ERV - 750ml - max vol of air expired at end of normal
Tidal resp
RV 1.2L - vol air remaining in lungs after max expiration - increases with age
VC - 4,500 M and 3,500 F - max vol air expired after max inspiration - decreases with age - = inspiratory capacity + ERV
TLC = viral capacity + residual Vol
Physiological dead space = TV* (PaCO2 - PeCO2/PaCO2)
Bilateral
Hilar LN
- Please Helen Lick My Popsicle Stick
-p-rimary TB H-istioplasmosis L-ymphoma M- Malignancy/Mets P- pneumocnoiosis S- Sarcoid
Fungi - histoplasmosis and coccidiodimycosis
COPD - LTOT
Assess if:
- FEV1 <30% (consider between 30-40)
- cyanosis
- polycythaemia
- peripheral oedema
- Raised JVP
- 02
Indications for chest tube insertion in pleural infection
- frankly purulent or turbid/cloudy fluid
- presence of organisms on Gstain or culture
- pleural fluid pH <7.2
Pleural effusion protein levels
<25 - transudateb
> 35 - exudate
Between 25–35 —> lights criteria
Smoking cessation
- NRT, vareniciline Or bupropion
NRT:
- s/e - N/V, headaches, flu like symptoms.
- prescribe 2 weeks
Vareniciline:
- nicotinic receptor PARTIAL agonist
- 3/4 weeks
- start 1 week before due to stop.
- nausea/headaches/ insomnia / vivid dreams
- DONT USE IF DEPRESSION
- DONT USE IF PREG OR BREASTFEEDING
Bupropion:
- norepinephrine and dopamine reuptake inhibtor.
- contraindicated in EPILEPSY/ PREG / BREASTFEED
Pregnant women:
- all should be tested for smoking with CO detector.
- if smoke or stopped smoking last 2/52 or CO >7 —> refer to stop smoking
Mx:
- 1st - CBT
- NRT I’d above fail -> patches to be removed prior to bed
Lung carcinoid
CHERRY RED LESION
40-50yrs
Smoking not RF
Slow growing
Carcinoid syndrome - rare
Mx:
Surgical
If no met —> good survivals
Cryptogenic organising pneumonia
Pneumonia type presentation that doesn’t respon to abx
Weeks history
ILD
Raised leukocytes, ESR and CRP
Cavitating lung lesions
Abscess
Squamous cell Ca
TB
WEgners
PE
RA
aspergillosis, histoplasmosis, coccididiomycosis
contraindications to surgical of lung Ca
FEV1 <1.5 lobectmy or FEV1 <2.0 if oneumonectomy.
Malignant pleural effusion
Vocal cord paralysis
SVCO
Tumour near hilum
Surfactant
secreted by type 2 pneumocytes
acitive ingredient - DPPC
Pousielles Law
R = 8nL/Pie*R^4
Ohms Law
airflow = Pressure gradient/airway resistance
Pulm perfusion
Low pressure system 15-30mmHg
Pulm vasc = 1/10th resistance of systemic
Get Hypoxic VC –> Shunt blood away from low ventilated areas.
Respiratory centre
Poorly definned nervous system in pons and medulla -
can eb OVERIDDEN by cortex
Chemoreceptors
Central:
- Ventral surface of medilla
- Responds to H+/inc PCO2
Peripheral:
- Carotid and aortic bodies
- Repsond to low PO2 and H+/CO2
In normal lung most improtant factor = CO2 howevr eif chronic CO2 retainer then relies on hypoxic drive.
Cheyne stokes breathing
Apnoea alt w/ tachypnoea
seen in:
- Brain damage
- Altitude
- HFx
Pulm Fn Tests
PEFR:
- Asthma
Spirometry:
- Obstructive - Asthma/COPD
- Restrictive: Pulm fibrosis, neuromusc, obesity, pleural disaease.
Flow Vol loops:
- See note book
Gas Transfer:
- Measure using CO as completely diffusion dependant:
- Increased: Asthma, pulm haemorrhage, polycythaemia, L–> R shunt.
- Decreased: everything else
O2 dissoiation curve
x-axis = pO2 y-axis = % saturation
Right shift: raised H+/CO2/Temp/ 2-3 DPG - increas O2 offload
Left shift: opposite of abive + Foetal Hb + carboxyhaemoglobin
Altitude related disorders.
decrease pO” - approx 1/2 at 18,000ft
stimulates periph chemoreceptors
get metabolic alkalosis –> increase renal HCO3- secretion
Physiological changes: Increase Hb Increase 2,3-DPG increase renal exc of HCO3 hypoxic VC (as prev) --> can lead to increase pulm vasc R --> RV fhypetrophy
Pulm and cerebral oedema.
3 syndromes:
- acute mountain sickness
- HACE
- HAPE
acute moutnain sickness Mx
Prophylactic acetazolamide
- Descent
HACE
DEXAMETHASONE
descent
HAPE
descent, Dex, nifedipine, PDE-4 inhib, acetozolamide.
Astham - See revision notes
Remember in chronic mx - 3rst step now LTRA
Acute Mx: MgSO4- if not settled with steroid + NEbs –> ten theophylline
Referral to ITU:
- deterirating PEFR
- persistent or worsening hypoxia
- increas pCO2
- exhaustion
- GCS
- resp arrest
Discharge criteria: - settlef off neb for 24hr PEFR>75% of baseline diurnal variability <25% written astham plan f/u in 30 days
Astham pathiphysiology
NArroawing by:
- Mucosal oedema
- SM contraction
- Mucus plugging
chronic asthma:
- thicken BM
- Coblet cell hyperplasia
SM hypertrophy
inflamm cells
mast cells/ mac/ T cells/ neutrophils/ eosinophils
these cells release cytokines:
Histamine/bradykinin/ leukotriene/ PGs/ PAF
Astham diagnosis
FEV1 decrease FEV 1 increase post bronchodilator >400ml or PEFR post >15% FEV1:FVC <70% histamine provocation test <8mg/ml FENO >325 part per billion sputume eosinophillia >2%
if >17yrs:
FENO + PFTs with reversibility
alpha-1 antitrypsin deficiency
Pz of COPD type illness in young or no smoking history.
it is a protease inhibitor.
PIMM - 50% still active
PiZZ = 10%
piMZ = 35%
PIMM an PiMZ –> you dont need active treatment no LT
MX - SMOKIN CESSATUIB
- lung transplant
- counselling
NIV
initiall setings IPAP:EPAP
10:5
Invasive ventillation
Type 2 RF PAralysis Trauma --> Chest/cpine Mult orga dysfn low GCS
CAP
Causes:
Strep - most common
Staph post viral infection - IVDU –> ABSCESS
Mycoplasma - Atypical. Long prodrome.
Legionella - TRAVEL - urinary Ag. - Clarithromycin
CURB 65 - =>3 = severe
Curb 65 <3 = Po Amox + clari
=> IV Co-amox + macro
HAP
Causes:
- Staph A:
- G- - Klebsiella (EtOH), Pseudomonas, E.Col
- Anaerobes
- Funghi
Mx:
- Co-amox or Taz
- pen allergc –> Levoflox.
Aspiration
Get Abscess + Empyema
Mx: Metroniazole + 3rd gen ceph
Lung Abscess
suspect if non-improving infection +/- swinging fever
RF:
- imunnocomp
- bronchial ca
- dental procedure
- pneumonia
- septic emboli - Right I.E.
Causes:
- Staph
- Klebsiella
- legionella
- psuedomonas
- anaerobes
- Mycobacter
Empyema
- pleurla aspirate pH <7.2
Urgent drainage + IV Abx –> Fx (intraplueral tPA + DNAse) –> Fx –> Thoracotomy +/- decortication
Bronchiectasis
causes: SEE NOTES.
- idiopathic
- post infectious - measles, TB, pneumo, pertussis
- congenital - marfans, williams.
- ABPA
- CF
- PCD, Kategeners, Youngs
- Alpha1 antitrypsin
px: chronic sputum prouction +/- haemoptsis.
assoc. conditions
w/L, fatiue, clubbing, malaise.
Inx : CT –> signet rings - can sometimes be sen on CXR#
PFT = obstructive pattern.
Test for underlying causes
Mx:
mosy important= PHYSIOTHERAPY - mucolytics nebs prophylactic abx: - =.>3 exac in 1 yr --> azithromycin surgery if sev localised.
CF
chromsome 7
transmembrane chlroide channel
poor sweat cl- reabs
poor airway Cl- secretion –> Na reabs.
Inx: CL- sweat test
Genetic analysis
Neonate –> Guthries.
Pulm dx
GI dx - Pancretic exocrine fn - Vit ADEK - Child - meconium ileus - adult - SBO - biliary obstruction gallstones - peptic ulcer - pajncreatitis.
Renal:
- Renal stones = oxalate
- Aminoglycloside –> Renal tubule dysfn.
Infertility
Mx: - MDT - Pseudomonas prophlaxis - Azithromycin mucolytics nebs. Pancreatic enzyme replace. NIPPV if type 2 RF --> Dbl lung transplantation.
Aspergillus - 4 Types
ABPA
- assoc. asth,a
- sensitivity rx - IgE IgG
- fleeting CXR signs
- Skin/RAST to Aspergillus
- serum IgE >1000
- EOSINOPHILLIA
Chronic pulm Aspergillus
- pt mildly immunocomp
- Culture + Aspergillus PCR
- radiograph –> Tree-in–bud apearance.
- Mx - PO Antifungal.
Invasive Aspergilliosis
- Rapdly spreading –> granulomas/necrosis/suppuratve
- pt is sig. immunocomp
- GALACTOMANNAN
- Sputum + BAL for fungal
- CT Thorax –> halo sign
Apergilloma
- Fungal ball - often in sited of old TB/CF/ sarcoid/ neoplasm
- typical cause = A. Fumigatabs
- can get massive heamoptysis –> Req bronchial A Embolisation.
- CXR diagnostic
Asbestosis
Q stem - Shipbuilder/deck worker/builder.
Pleural effusions
Pleural plaques:
- not premalignant
- Asx
Diffuse pleural thickening:
- Lung bases
- SOBOE
- PFTs = restrictibe
- reduced TLC
- KCO normal
Asbestosis
- Fibrotic changes at lower lobe
- Inx - HRCT
- KCO reduces
Mesothelioma
- malignancy
- Inx: CXR –> pleural effusion analysis or CT
- Cytology neg –> LA thoracoscopy
COMPENSATION
Coal workers pneumoconiosis
- Dust exposure
- UZ
- initially small nodules (<1cm) –> further exposure –> aggregate (>1cm)
- PFT = mixed obstructive and restrictive + Reduced KCO
Caplan syndrome - assoc with RA - NODULES IN PERIPHERY of lung
Silicosis
Quarry/miner
UZ –> silicotic nodules –> pofressive massive fibrosis
- EGG SHELL CALCIFICATION around enlarged hilar glands
- PFT as prev
ASSOC WITH TB
Berryliosis
Acute –> Acute alveolitis
Chronic – non-caseating granulomas
CXR - Bilat perihilar LN
Byssinosis
Cotton
Q stem - worse sx 1st day back after a break
Ft - FEV1 reduced –> more marked first day of the week/
Extrinsic allergic alveolitis
IgG relating
UZ
Extrinsic allergic alveolitis
IgG related
Initially type 3 hypersensitivity
UZ
CXR - generalised haze
PFT: restictive + low KCO
Histology: mononuclear cell infiltrates + non-caseating granulomas.
PRecipitants - measure SPECIFIC IgG response
if think pulm fibrosis –> HRCT
Types of EAA
Farmer lung - Saccharopolyspora rectivirgula
Bird fanciers - Avian proteins
MAlt workers lung - Aspergillus clavitus
Mushroom workers: Thermophilic actinomycetes
Lung Ca
Adenocarcinoma
- 30%
- peripheral lung
- assoc gynaecomastia
Sq cel Ca - 35%
- PTH like peptide
- best survival
- Ectopic TSH
SCC ca:
- Neuroendicrine
- SIADH
- ACTH
- LEMS - presynaptic MG like
- met at px –> CHEMO
- Cerebellar Syndrome
Pancoast tumour::
- pain in C8/T1 dermatome
- Wasting of small muscles of hand
- Horners.
- CT + CT guided biopsy
Sarcoid
Multisystem granulamatous disease = MAc + Lymphocytes + epithelioid cells –> aggregated –> Multinucleate giant cells
Affects : West indian + Asian
hyperCa –> Due to increased activation of Vit D
Q - Stem - YOung pt from above origine with BHL + ERYTHEMA NODOSUM
PFT - restrictive + low KCO
Heerfordt-waldenstrom:
- Parotid gland enlargement
- ant. uveitis
- Temp raised
- CN Palsy
LoffGRens - groaning from arthralgia whilst going into loft :
- Athralgia
- BHL + EN
- raised temp
Inx:
- Thoracic CT
- BIopsy
Sarcoid Mx
Ca restrict diet
if Ca restrict fx –> Steroids.
idiopathic pulm fibrosis
80% of ILD
Characterised by UIP:
- Honeycombing
- minimal celluar inflamm
- Fibroblastic foci
haziness –> peripheral + basal lung.
Px: fine END INSP crackles.
HRCT = gold standard to look for characteristic findings above.
Mx:
- NAC
- if FVC 50-80% - Perfenidone = reduces the fall in FVC
<65yrs –> Single lung transplant
Types of ILD
Steroid responsice:
- NSIP
- DIP
- RBILD
non-steroid responsive:
- AIP
LIP
Drug causes of pulm fibrosis:
A CAR carrying a BIKE, followed by a BUS and a TRUCK with a LOUD SPEAKER and a DRONE flying above
Carmustine
Cyclophosphamide
Buslphan
Methotraxate
Bleomycin
Amiodarone
Causes of UZ pulm fibrosis:
A TEA SHOP
ABPA
TN
EAA
Ank spond
Sarcoid
Histiocytosis
OCcupational
Pneumoconiosis
Granulomatosis w/ polyangitis
Wegners granulomatosis
cANCA
Small/med vasculitis
Glomerulonephritis
Eye + Joint
Vasculitic rash + Mono-neuritis
CXR: –> large rounded shadow can CAVITATE
Mx:
- Cyclophosphamide + Steroid
Eosinophillic granulamotosis with polyangitits
CHurg strauss
Asthm Blood eosinophillia paranasal sinusitis mono-neuritis multiplex pANCA
exac by LRTA
Pulmonary eosinophillia
EGwP (churg strauss)
Lofflers syndrome:
- assoc with parasitic infection - strongyloides/ascan’s lumbracoides
- lasta <2/52
- spont resolves or bendazole
Chronic eosinophilia pneumonia
- > 8/52
- CXR –> reverse batwing
- Mx - Steroids
Hyperesonophillic syndrome:
- V.high eosinophils
- can have hepatosplenomegaly & LN
- cardiac involvement –> arrythmia + Death
- VTE
Mx = I.S. + steroids.
Cryptogenic organising pneumonia
Diffuse ILD
Pneumoia picture with bilateral infiltates and NOT RESPONDING TO ABX
Cough, SOB, Malaise, fever
Watch and wait –> if v.sev high dose steroid
ABPA MAjor criteria
proximal bronchiectasis Clinical ft of asthma Blood eosinophillia Serum IgE >1000 immediate skin rection to aspergillus antigen
intubation criteria in COpd
pH <7.6 or pCO2 rising on NIV
Respiratory alkalosis causes
Anxiety PE Pregnancy CNS - Haemorrhage/encephalitis Salicylate poisoning Altitude
Middle easter respiratory syndrome
Patient returns from middle eastern country wth cough coryza and fever
Caused by MERS - CoV
Incubation 2-14 days
Contact with camels + Camel products
Treatments of flu
Tami flu - PO med:
- nueramidase inhibitor - stop viral particle release
- s.e = n/V and headaches
Zanamivir:
- Inhsaled med
- same mechanism of action
- Can cause bronchospasm in asthmatics.
Diagnosis of COPD
FEV1:FVC <0.7 + Symptoms
NSAIDS exac of Asthma MOA
Inhibits cox –> inhibits THromboxan + PG
therefore arachidonic acid goes dow lipoxygenase pathway –> pro inflamm LKTR !!
Pulonary arterial hypertension
> 25 mmHg
Vasodilator test –> + –> CCB
VD test –> neg :
- Prostacyclin analogu - iloptost, treprostinil
- Endothelin receptor anatag - bonsentan, ambrisentan
- PDEI - Sildenafil
Re-expansion pulmonary oedema
complciation of over rapid re-expansion fo lung after tx for effusion or pneumothorax
RF:
- Longer duration of lung collapse
- larger vol of lung collapse
- rapid drainage
- applicaton of suction
- Younger pt
COPD who to offer LTOT
Need 2 ABGs at least 3/52 apart
pO2 <7.3
or
pO2 7.3-8.0
- polycythaemia
- perpheral oedema
- pulm HTN
Indications for Steroid therapy in sarcooidosis
- Parenchymal lung involvement
- Cardiac involvement
- Neurosarcoid
- hypercalcaemia
- Uveitis.
Legionella indicators in Q stem
Flu - like prodrome
Foreign travel
Effusions
Hyponatraemia
tx:
- Erythomycin/clarithromycin
Mycoplasma pneumonia
Raised LDH
Cold agglutinins
Drycough, fever, malaise
can present with AUTOIMMUNE HAEMOLYTIC ANEAMIA
Mx:
- Macrolides
Rheumatoid pleural effusion
LDH high
Pleural glucose <1.6
PH <7.2
High cholesterol
High rheumatoid factor
PCP management - when to use steroids.
Evidence of sev. hypoxia - Steroids
Lung mets that calcify
Chondrosarcomas and osteosarcomas
Mycoplasma
Cold agglutinin +ve
Flu like illness
Erythema nodosum
Ezithromycin/claarithromycin
Primary pneumothorax
Rim of air <2cm (30%) and no sx –> discharge
Sx or >2cm –> Aspirate –> Fx –> chest drain
Following aspiration if air <2cm –> discharge with outpatient review.
Post - No fly 2 weeks.
Stop smoking (RR of recurrence 10% vs 0.1%)
Secondary pneumothorax
50 + >2cm +/or SOB –> Chest drain
Otherwais if >1cm –> aspirate –> chest drain (>1cm)
All should be admitted for 24 hrs.
<1cm –> Admit and observe + O2 for 24 hrs
AVOID SCUBA
Iatrogenic pneumothorax
less likely recurrence
seen in ventilated patients
oserve
Altitiude sickness
Prevention:
- Slow ascent
= Carbonic anhydrase inhibitor - Acetazolamide
HAPE: - O2 Descent PDE Type V inhib Acetazolamide Nifedipine Dex
HACE:
- Descent
- Dex
What factors iprove COPD survival
Smoking cessation - most important
LTOT
Lung vol reduction surgery
Churg strauss
Eosinophillic granulomatosis with polyangitis
small-medium vessel vasculitis
pANCA +ve
Px:
- Asthma
- Eosinophilia
- Paranasal sinusitis
- mononeuritis multiplex
LTRA –> precipitate disease
Staph pneumonia
Follows Flu like illness.
CAVITATING
Sen in:
- IVDU
- Pt wth central line
- Leukaemia/lmphoma
- CF
most important antigen presenting cells in sensitisation
Dendritic cells.
What is alpha-1 anitrypsin
Elastase inhibitor (helos prevent emphysema)
Most common respiratory complication of SLE?
Pleural effusions
EAA Investigation
IgG !!
despite its name its not allergic therefore dont commony get eosinophillia
COPD management despite inhalers
FEV1 >50%:
- LABA or LAMA
FEV1 <50%
- LABA + ICS or LAMA
