Respiratory Flashcards
1
Q
Types of Pneumonia
A
Community acquired
Hospital acquired
aspiration
immunocompromised
2
Q
Community acquired pneumonia
A
primary or secondary to underlying cause
most common: streptococcus pneumoniae
Also: staphylococcus aureus, legionella, moraxella catarrhalis and chlamydia
viruses = 15%
may be complicated by MRSA
3
Q
Hospital acquired pneumonia
A
acquired after >48hrs in hospital
most commonly gram negative enterobacteria or staph. aureus
also psuedomonas, klebsiella, bacteriordes and clostridia
4
Q
aspiration pneumonia
A
stroke, myasthenia, bulbar palsies, decreased conciousness (e.g. post ictal/drunk) oesophageal disease (achalasia/reflux) or poor dental hygiene
5
Q
Immunocompromised patient
A
strep pneumoniae, h. influenzae, staph. aureus, Mycoplasma catarrhalis, mycoplasma pneumoniae, gram negative bacilli, pneumocystis jirovecii
fungi, viruses (CMV, HSV) and mycobacteria
6
Q
Symptoms of pneumonia
A
fever rigors malaise anorexia dyspnoea cough purulent sputum haemoptysis pleuritic pain
7
Q
Signs of pneumonia
A
pyrexia cyanosis confusion tachypnoea tachycardia hypotension signs of consolidation - diminished expansion, dull percussion, increased vocal fremitus/ resonance, bronchial breathing) pleural rub
8
Q
Pneumonia investigations
A
CXR - lobar infiltrates, cavitation or pleural effusion
SpO2- less than 92% = severe –> ABG
FBC, U&E, LFT, CRP, blood cultures
Sputum MC&S- PCR if possible atypical organism
Pleural fluid aspiration
Bronchoscopy
Bronchoalveolar lavage- immunocompromised or ITU
9
Q
Pneumonia Severity Score
A
CURB 65
- C = confusion
- U = urea >7
- R = resp rate >30/min
- B = BP <90 systolic
- 65 = age over 65
0-1 treat at home
2- hospital therapy
3- may need ITU
10
Q
Management of Pneumonia
A
Abx Oxygen IV fluids VTE prophylaxis Analgesia if pleurisy
11
Q
Complications of pneumonia
A
pleural effusion empyema lung abscess respiratory failure septicaemia brain abscess pericarditis myocarditis cholestatic jaundice
12
Q
Treatment of mild, community acquired pneumonia
Strep. pneumoniae
Haemophilus influenzae
A
Oral amoxicillin 500mg- 1g/ 8hr
clarithromycin 500mg/12hr
doxycycline 200mg loading dose then 100mg/day
13
Q
Treatment Moderate community acquired pneumonia
Strep pneumoniae
h. influenzae
mycoplasma pneumoniae
A
oral amoxicillin 500mg-1g/8hrs + clarithromycin 500mg/doxycycline 200mg loading then 100mg/day
14
Q
Treatment of severe community acquired pneumonia
Strep pneumoniae
h. influenzae
mycoplasma pneumoniae
A
co-amoxiclav 1.2g/8hr IV
or
cephalosporin (cefuroxime) IV + clarithromycin IV
add flucloxacillin ± rifampacin if staph suspected
vancomycin or teicoplanin if MRSA
15
Q
Treatment of Atypical community acquired pneumonia
legionella pneumophilia
chlamydia species
pneumocystis jiroveci
A
legionella -
fluroquinolone with clarithromycin or rifampicin if severe
chlamydia - tetracycline
pneumocystitis - high dose trimoxazole
16
Q
Treatment of hospital acquired pneumonia
Gram negative bacilli
psuedomonas
anaerobes
A
Aminoglycoside (gentamicin) IV + antipseudomonal penicillin (ticcarcillin)IV or 3rd gen cephalosporin IV (cefotaxim)
17
Q
Treatment of aspiration pneumonia
streptococcus pneumoniae
anaerobes
A
cephalosporin IV + metronidazole IV
18
Q
Treatment of pneumonia in neutropenic patients
- gram +ve cocci
- gram -ve bacilli
A
Aminoglycoside (Gentamicin) IV + antipseudomonal penicillin (ticarcillin) or 3rd gen cephalosporin (cefotaxime)
consider antifungals after 48hrs if not improving
19
Q
Pneumococcal pneumonia
A
commoner in the elderly, alcoholics, post-splenectomy, immunosuppressed and chronic heart failure or pre-existing lung failure
Treat- amoxicillin, benzylpenicillin or cephalosporins
20
Q
Staphylococcal pneumonia
A
complicate influenza infection
young/ elderly, IVDU or underlying disease
bilateral cavitating broncho-pneumonia
Treat- flucloxacillin ±rifampacin
MRSA - consider vancomycin
21
Q
Psuedomonas pneumonia
A
common in bronchiectasis and CF
causes HAP - ITU/ post-op
Treatment- anti-pseudomonal penicillin (ticarcillin/pipericillin).ceftazimide, meropenem or ciprofloxacin +aminoglycoside (gentaminc/ fluroquinolone)
22
Q
Klebsiella pneumonia
A
rare elderly, diabetics, alcoholics cavitating pneumonia of the upper lobes often drug resistance Tret - cefotaxime or imipenem
23
Q
Mycoplasma pneumonia
A
occurs in epidemics every 4ish years flu-like symptoms --> dry cough CXR- reticular nodular shadowing Diagnosis - Sputum PCR/ serology Complications - skin rash (erythema multiforme), steven-johnson syndrome, meningoencephalitis or myelitis, GBS
Treat- clarithromycin/doxycline/fluroquinolone
24
Q
Legionella pneumonia
- colonises water tanks kept <60C
A
flu like symptoms proceed dry cough and dyspnoea
extra-pulmonary - anorexia, D&V, hepatitis, renal failure, confusion and coma
CXR- bi-basal consolidation
Investigations- lymphopenia, hyponatraemia, deranged LFTS, haematuria
Dx- legionella antigen urine/ culture
Rx- fluroquinolone (2/3 weeks) or clarithromycin
25
Chlamydophila pneumoniae
commonest chlamydial infection
person-to-person spread with biphasic illness
- pharyngitis, hoarseness, otitis followed by pneumonia
Dx- chlamydophilia complement fixation fests, PCR invasive samples
Rx- doxycycline or clarithromycin
26
Chlamydiophila psittaci
causes psittacosis - ornthosis from infected birds (esp. parrots)
Sx- headache, fever, dry cough, lethargy, arthralgia, anorexia and D&V
CXR- patchy consolidation
Dx- chlamydophila serology
x- doxycyline or clarithromycin
27
Viral pneumonia
commonest cause- influenza, could also be measles, CMV or varicella zoster
28
Pneumocystis pneumonia
PCP
immunosuppressed
dry cough, exertional dyspnoea, low PaO2, fever, bilateral crepitations
CXR- normal or bilateral perihilar interstitial shadowing
Dx- visualisation - visualisation in sputum, broncho-alveolar lavage or lung biospy
Rx- high dose co-trimoxazole or pentamidine for 2-3 weeks
steroids if severe hypoxaemia
29
Complications of pneumonia
respiratory failure
Type 1 respiratory failure common
treat with high flow oxygen
check ABGs often
30
Complications of pneumonia
hypotension
combination of dehydration and vasodilatation due to sepsis
| IV fluid challenges 250ml boluses
31
Complications of pneumonia
atrial fibrillation
common - particularly in the elderly
usually resolves with treatment of pneumonia
B-blockers of digoxin may be required to slow ventricular response rate in the short term
32
Complications of pneumonia
pleural effusion
Inflammation of the pleura by adjacent pneymona may cause fluid exudation into pleural space
if it accumulates quicker than it gets reabsorbed --> pleural effusion
Drain if large
33
Complications of pneumonia
empyema
pus in the pleural space
suspect in pts with resolving pneumonia with recurrent fever
CXR- indicates pleural fusion
Pleural fluid aspirate is typically yellow and turbid with a low ph, low glucose and raised LDH
Rx- drain with a chest drain
34
Complications of pneumonia
Lung abscess
Causes
cavitating, suppurative infection within the lung
- inadequately treated pneumonia
- aspiration (alcohol/obstruction/bulbar palsy)
- bronchial obstruction (tumour/ FB)
- pulmonary infarction
- septic emboli (scepticaemia, R heart endocarditis, IVDU)
- subphrenic or hepatic abscess
35
Complications of pneumonia
Lung abscess
Clinical features
```
swinging fever
cough
purulent, foul-smelling sputum
pleuritic chest pain
haemoptysis
malaise
weight loss
```
--> finger clubbing, anaemia, crepitations, empyema
36
Complications of pneumonia
Lung abscess
Tests
Blood- FBC (anaemia, neutrophilia), EXR, CRP, blood culutres
Sputum microscopy, culture and cutology
CXR- walled cavity, often with a fluid level
37
Complications of pneumonia
Lung abscess
Treatment
Abx as indicated by sensitivities
Continue until healed (4-6 weeks)
Postural drainage
Repeated aspiration, antibiotic instillation or surgical excision may be necessary
38
Complications of pneumonia
Septicaemia
result of bacterial spread from the ung parenchyma into the blood streat
metastatic infection - e.g. infective endocarditis or meningitis
Rx- IV abx
39
Complications of pneumonia
Jaundice
usually cholestatic
| may be due to septic or secondary to antibiotic therapy (Esp flucloxacillin or co--amoxiclav)
40
Bronchiectasis
pathology
chronic infection of bronchi and bronchioles leading to permanent dilatation of these airways
Main organisms - h. influenzae, strep. pneumoniae, staph. aureus, pseudomonas aeruinosa
41
Causes of bronchiectasis
congenital - CF, Young's syndrome, primary ciliary dyskinesia, Kartagner's syndrome
Post infection - measles, pertussis, bronchiolitis, pneumonia, TB, HIV
Other - bronchial obstruction, allergic bronchopulmonary aspergillosis, hypogammaglobulinaemia, rheumatoid arthritis, UC, idiopathic
42
Clinical features of bronchiectasis
symptoms- persistent cough, copious purulent sputum, intermittent haemoptysis
Signs- finger clubbing, coarse inspiratory crepitations, wheeze
Complications - pneumonia, pleural effusions, pneumothorax, haemoptysis, cerebral abscess, amyloidosis
43
Tests for Bronchiectasis
Sputum culture
CXR- cystic shadows, thickened bronchialwalls (tramline and ring shadows)
Spirometry - obstructive pattern
Bronchoscopy
Others- serum immunoglobilines, CF sweat teast, aspergillus precipitins or skin prick tests
44
Management of bronchiectasis
Postual drainage 2x day- chest physio my aid sputum expectoration and mucous drainage
Antibiotics
Bronchodilators e.g. nebulised salbutamol
Cortio-steroids
Surgery in localised disease or to control severe haemoptysis
45
Pathology of CF
commonest life-threatening autosomal recessive condition
Cl- channel defect leads to a combination of defective chloride secretion and increased sodium absorption across airway epithelium
predisposes lung to chronic pulmonary infections and bronchiectasis
46
Neonate CF
Clinical features
failure to thrive
meconium ileus
rectal prolapse
47
Clinical features of CF
Children and young adults
Resp- cough, wheeze, recurrent infections, bronchiectasis, pneumothorax, haemoptysis, respiratory failure, cor pulmonale
GI- pancreatic insufficiency, distal intestinal obstruction syndrome, gallstones, cirrhosis
Other - male infertility, osteoporosis, arthritis, vasculitis, nasal polyps, sinusitis, hypertrophic pulmonary osteoarthroapthy
Signs - finger clubbing, bilateral coase crackles
48
Diagnosis of CF
Sweat test- sweat sodium and chloride levels >60mmol
Genetics
Fecal elastase
49
How does aspergillus affect the lungs?
1. Asthma
2. Allergic bronchopulmonary aspergillosis
3. Aspergilloma
4. Invasive aspergillosis
5. Extrinsic allergic alveolitis
50
Aspergillus asthma
type I hypersensitivity (atopic)reaction to fungal spores
51
Aspergillus allergic bronchopulmonary aspergillosis
type I and type III hypersensitivities
early - bronchoconstriction
late- inflammation persists -> permanent damage - bronchiectasis
Sx- wheeze, cough, sputum, dyspnoea and recurrent pneumonia
CXR- transient segmental collapse or consolidation, bronchiectasis
Rx- prednisolone acute- high dose, maintenance - low dose ± itraconazole ± bronchodilators
52
ASpergilloma (myectoma)
Fungal ball within a pre-existing cavity e.g. TB/ sarcoid
- asymptomatic may cause cough, haemoptysis, lethary ± weight loss
CXR- round opacity within a cavity, usually apical
surgical excision or local instillation of amphotericin
53
Extrinsic allergic alveolitis
sensitivity to aspergillus clavatus - malt workers lunf
54
Lung cancer
| risk factors
```
cigarette smoking
asbestos
chromium
arsenic
iron oxides
radiation
```
55
Histology of lung cancers
```
35% squamous
27% adenocarcinoma
20% small oat cell
10% large cll
alveolar cell carcinoma is very rare
```
clinically most important differentiation is small-cell or non-small cell
56
Symptoms of Lung cancer
```
Cough
haemoptysis
dyspnoea
chest pain
recurrent or slow resolving pneumonia
lethargy
anorexia
weigh loss
```
57
Signs of lung cancer
```
cachexia
anaemia
clubbing
hypertrophic pulmonary osteoarthropathy --> wrist pain
supraclavicular or axillary nodes
```
Metasteses- bone tenderness, hepatomegaly, confusion fits, focal CNS signs, cerebellar syndrome, proximal myopathy, peripheral neuropathy
58
Complications of lung cancer
local
```
recurrent laryngeal nerve palsy
phrenic nerve palsy
SVC obstruction
Horner's syndrome (Pancoast tumour)
rib erosion
pericarditis
AF
```
59
Complications of lung cancer
metastatic
```
brain
bone - pain, anaemia, high Ca2+
liver
adrenals- Addison's
Endocrine- ectopic hormone secretion (e.g. SIADH and ACTH (Cushings) (small cell tumours) or raised PTH (squamous cell tumours)
```
60
Complications of lung cancer
non-metastatic neurological
```
confusion
fits
cerebellar syndrome
proximal myopathy
neuropathy
polymyositis
Lambert-Eaton syndrome
```
61
Other complications of lung cancer
```
clubbing
hypertrophic pulmonary osteoarthropathy
dermatomyositis
acanthosis nigricans
thrombophlebitis migrans
```
62
Tests for lung cancer
```
Cytology - sputum and pleural fluid
CXR - perihilar nodule, hilar enlargement, consolidation, lung collapse, effusion, bony secondary
Fine needle aspiration or biopsy
Bronchoscopy
PET/CT
Radionuclide bone scan
Lung function tests
```
63
Treatment of non-small cell lung cancer tumours
1. Excision
2. curative radiotherapy
3. Chemoradiotherapy
immunological treatment options include cetuximab (monoclonal antibody that targets epidermal growth factor receptors)
64
Treatment of small cell lung cancer tumours
nearly always disseminated at presentation
may respond to chemotherapy but invariably relapse
- palliation
- radiation for bronchial obstruction, SVCO, haemoptysis, bone pain and cerebral mets
65
Clinical features of obstructive sleep apnoea
```
Obese, middle aged man presents because of snoring or daytime somnolence
partners often describe apnoeic episodes during sleep
- loud snoring
- daytime somnolence
- poor sleep quality
- morning headache
- decreased libido
- cognitive performance
```
66
Complications of OSA
pulmonary hypertension
type II respiratory failure
independent risk factor for hypertension
67
Investigations for OSA
pulse oximetry
polysomnography (O2 sats, airflow at nose and mouth, ECG, EMG chest and abdominal wall movement during sleep) is diagnostic
15+ episodes of apnoea during an hour = severe OSA
68
Management of OSA
weight reduction
avoid tobacco and alcohol
CPAP via nasal mask during sleep
Surgery to relieve pharyngeal obstruction - tonsillectomy, uvulopalatopharyngoplasty or tracheostomy
69
What is cor pulmonale
right heart failure caused by chronic pulmonary arterial hypertension
- caused by: chronic lung disease, pulmonary vascular disorders, neuromuscular and skeletal diseases
70
Lung disease causes of cor pulmonale
```
COPD
Bronchiectasis
Pulmonary Fibrosis
Severe chronic asthma
lung resection
```
71
Pulmonary vascular causes of cor pulmonale
```
pulmonary emboli
pulmonary vasculitis
primary pulmonary hypertension
ARDS
sickle cell disease
parasite infection
```
72
Thoracic cage abnormalities causing cor pulmonale
kyphosis
scoliosis
thoracoplasty
73
Neuromuscular causes of cor pulmonale
myasthenia gravis
poliomyelitis
motor neurone disease
74
Hypoventilatory causes of cor pulmonale
sleep apnoea
| enlarged adenoids in children
75
Clinical features of cor pulmonale
Symptoms: fatigue, dyspnoea, syncope
Signs: cyanosis, tachycardia, raised JVP w/ prominent a and v waves, RV heave, loud P2, pansystolic murmur (tricuspid regurg) early diastolic Graham Steell murmur, hepatomegaly and oedema
76
Investigations in cor pulmonale
FBC - raised Hb and haematocrit (secondary polycythaemia)
ABG- hypoxia± hypercapnia
CXR- enlarged right atrium and ventricle, prominent pulmonary arteries
ECG- P pulmonale, right axis deviation, right ventricular hypertrophy/ strain
77
Management of cor pulmonale
```
treat underlying causes
treat respiratory failure
treat cardiac failure
consider venesection if haematocrit >55%
consider heart and lung transplant in young patients
```
78
Coal worker's pneumoconiosis
dust disease associated with underground mining
result of inhalation of coal dust over 15-20yrs
dust ingested by macrophages which die and release enzymes --> fibrosis
- asymptomatic but chronic bronchitis is common
- CXR shows many small round opacities in the upper zone
- management- avoid exposure, treat chronic bronchitis
79
Progressive massive fibrosis
due to progression of coal workers pneumoconiosis
progressive dyspnoea, fibrosis and cor pulmonale
CXR- upper zone fibrotic masses
80
Caplan's syndrome
association between rheumatoid arthritis, pneumoconiosis and pulmonary rheumatoid nodules
81
Silicosis
caused by inhalation of silica particles (very fibrogenic)
associated with metal mining, stone quarrying/ sand blasting/ pottery
progressive dyspnoea, increased incidence of TB, CXR- miliary or nodular pattern in upper and mid-zones, egg shell calcification of hilar nodes
82
Asbestosis
inhalation of asbestos fibres
progressive dyspnoea, clubbing, fine end crackles
also causes pleural plaques, increased risk of bronchial adenocarcinoma and mesothelioma
83
Malignant mesothelioma
tumour of mesothelial cells
usually occurs in the pleura, occasionally peritoneum
clinical features: chest pain, dyspnoea, weight loss, finger clubbing, recurrent pleural effusions
signs of mets- lymphadenoaphty, hepatomegaly, bone pain/tenderness, abdominal pain/obstruction )peritoneal malignant mesothelioma)
84
Idiopathic pulmonary fibrosis
what is it?
idiopathic interstitial pneumonia
inflammatory cells infiltrate and pulmonary fibrosis of unknown cause (AKA crytpogenic fibrosing alevolitis)
commonest cause of interstitial lung disease
85
Symptoms of idiopathic pulmonary fibrosis
```
dry cough
exertional dyspnoea
malaise
weight loss
arthralgia
```
86
Signs of idiopathic pulmonary fibrosis
cyanosis
finger clubbing
fine end-inspiratory crepitations
87
Complications of idiopathic pulmonary fibrosis
respiratory failure
| increased risk of lung cancer
88
Investigations in idiopathic pulmonary fibrosis
ABG- low PaO2, high PaCO2 if severe, raised CRP, immunoglobulines
ANA +ve/ rheumatoid factor positive
decreased lung volume, bilateral lower zone reticulonodular shadows, honeycomb lung
89
Management of idiopathic pulmonary fibrosis
best supportive care
- oxygen
- pulmonary rehabilitation
- opiates
- palliative care input
* *avoid steroids**
90
Interstitial lung disease
clinical features
```
dyspnoea on exertion
non-productive paroxysmal cough
abnormal breath sounds
abnormal CXR/ high resolution CT
restrictive pulmonary spirometry with reduced DLCO (diffusion capacity of lungs for carbon monoxide)
```
91
Pathological features of interstitial lung diseases
fibrosis and remodelling of the interstitium
chronic inflammation
hyperplasia of type II epithelial cells of type II pneumocytes
92
idiopathic causes of interstitial lung diseases
idiopathic pulmonary fibrosis
cryptogenic organising pneumonia
lymphocytic interstitial pneumonia
93
systemic disease causes of interstitial lung disease
sarcoidosis
rheumatoid arthritis
SLE, systemic sclerosis, mixed connective tissue diseases, Sjögren's syndrome
UC, renal tubular acidosis, autoimmune thyroid disease
94
Known causes of interstitial lung disease
```
occupational/ environmental
drugs- nitrofurantoin, bleomycin, amiodarone, sulfasalazine, busulfan
hypersensitivity reactions
infections - TB, funghi, viral
GORD
```
95
Extrinsic allergic alveolitis
inhalation of allergens (fungal spores or avian proteins)
provokes hypersensitivity reaction
acute phase- alveoli are infiltrated with acute inflammatory cells
chronic - granuloma formation and obliterative bronchiolitis occur
96
Causes of extrinsic allergic alveolitis
bird-fancier's lung and pigeon's fancier lung
farmer's and mushroom worker's lung
malt worker's lungn
Bagassosis or sugar worker's lung
97
Clinical features of extrinsic allergic alveolitis
4-6 hours post exposure - fevers, rigors, myalgia, dry cough, dyspnoea, crackles (no wheeze)
Chronic - increasing dyspnoea, weight loss, exertional dyspnoea, type I respiratory failure, cor pulmonale
98
Tests for extrinsic allergic alveolitis
Acute
FBC - neutrophilia, raised ESR
ABG- positive serum precipitins
CXR- upper zone mottling consolidation, hilar lymphadenopathy
Lung function tests - reversible restrictive defect, reduced gas transfer during acute attacks
99
Tests for extrinsic allergic alveolitis
Chronic
Blood tests- positive serum precipitins
CXR- upper zone fibrosis, honey comb lung
Lung function tests- persistent changes, BAL shows raised lymphocytes and mast cells
100
Management of extrinsic allergic alveolitis
remove allergen and give O2. Oral prednisolone 40mg/24hrs then reducing dose
avoid exposure and long term steroids
101
What is sarcoidosis?
systemic granulomatous disorder of unknown causes
usually affects adults aged 20-40, more common in women
African-Caribeans more frequently and severely esp. extra-thoracic disease
associated with HLA-DRB1 and DQB1
102
Clinical features of sarcoidosis
pulmonary
erythema nodosum ± polyarthralgia
CXR with bilateral hilar lymphadenopathy ± pulmonary infiltrate or fibrosis
dry cough, progressive dyspnoea, decreased exercise tolerance, chest pain
103
Non-pulmonary features of sarcoidosis
```
lymphadenopathy
hepatomegaly
splenomegaly
uveitis
conjunctivitis,
keratoconjunctivitis sicca
glaucoma
terminal phalageal bone cyst
enlargement of lacrimal glands
Bell's palsy
meningitis
brain stem and spinal syndromes
SOL
erythema nodusum
lupus pernio
subcutaneous nodules
cardiomyopathy
arrhythmias
hypercalaemia/hypercalciuria
renal stones
pituitary dysfunction
```
104
Management of Sarcoidosis
acute- bed rest and NSAIDs
bilateral hilar lymphadenopathy -alone- no treatment
Indications for corticosteroids- parenchymal lung disease, uveitis, hypercalcaemia, neurological or cardiac involvement - Prednisolone 40mg/24 4-6/52 and gradually reduce over 1yr
105
Causes of bilateral hilar lymphadenopathy
Sarcoidosis
infection - TB, mycoplasma
Malignancy e.g. lymphoma, carcinoma, mediastinal tumours
organic dust disease e.g. silicosis or berylliosis
Extrinsic allergic alveolitis
Histocytosis X
106
Pleural effusion
definition
fluid in the pleural space
Transudates --> <25g/L of protein
Exudates --> >35g/L of protein
107
Causes of transudates
increased venous pressure (cardiac failure, constrictive pericarditis, fluid overload)
hypoproteinaemia (cirrhosis, nephrotic syndrome, malabsorption)
108
Causes of exudates
increased leakiness of pleural capillaries secondary to infection, inflammation or malignancy
pneumonia, TB, pulmonary infarction, rheumatoid arthritis, SLE, bronchogenic carcinoma, malignant metastases, lymphoma, mesothelioma, lymphangitis carcionmatosis
109
Symptoms of pleural effusions
asymptomatic
dyspnoea
pleuritic chest pain
110
Signs of pleural effusions
decreased expansion
stony dull percussion note
diminished breath sounds
may be bronchial breathing or tracheal deviation
111
Management of pleural effusions
drainage
pleurodesis for recurrent effusions (tetracycline, bleomycin or talc)
intra-pleural streptokinase - no benefit
surgery- persistent collections and increasing pleural thickness on US requires surgery
112
Causes of pneumothorax
often spontaneous in young thin men due to rupture of sub-pleural bulla
other causes - asthma, COPD, TB, pneumonia, lung abscess, carcinoma, CF, lung fibrosis, sarcoidosis, connective tissue disorders, trauma, iatrogenic
113
Symptoms of pneumothorax
asymptomatic
sudden onset dyspnoea ± pleuritic chest pain
sudden deterioration (asthma/COPD)
hypoxia/ increased ventilation pressures
114
Signs of pneumothorax
reduced expansion
hyper-resonance to percussion
diminished breath sounds
tension pneumothorax- tracheal deviation from the addected side
115
Management of pneumothorax
place a chest drain
116
Causes of PE
```
venous thrombosis in pelvis or legs
rare causes:
right ventricular thrombus (post MI)
septic emboli (right sided endocarditis)
fat, air or amniotic fluid embolism
neoplastic cells
parasites
```
117
Risk factors of PE
```
recent surgery esp. abdo/pelvic/hip/knee
thrombophilia
leg fracture
prolonged bed rest/reduced mobility
malignancy
pregnancy/post partum; Pill/HRT
Previous PE
```
118
Clinical features of PE
```
acute breathlessness
pleuritic chest pain
haemoptysis
dizziness
syncope
pyrexia, cyanosis, tachypnoea, tachycardia, hypotension, raised JVP, pleural rub, pleural effusion
```
119
Tests for PE
FBC, U&E, baseline clotting, D-dimers
ABG- low PaO2 and low PaCO2
CXR- normal, oligaemia, dilated pulmonary artery, linear atelectasis, small pleural effusion
ECG- tachycardia, RBBB, R ventricular strain
120
Treatment of PE
Anticoagulate with LMWH
warfarin minimum of 3 months
thrombolysis for massive PE (alteplase)
Vena caval filter
121
Prevention of PE
give heparin to all immobile patients
prescribe compression stockings
encourage early mobilisation
stop HRT & the Pill pre-op
122
Causes of type I respiratory failure
hypoxia with normal PaCO2
ventilation/perfusion (V/Q) mismatch
- pneumonia
- pulmonary oedema
- PE
- asthma
- emphysema
- pulmonary fibrosis
- ARDS
123
Causes of type II respiratory failure
hypoxia with hypercapnia
caused by alveolar hypoventilation ± V/Q mismatch
pulmonary disease- asthma, COPD, pneumonia, end-stage pulmonary fibrosis, obstructive sleep apnoea
Reduced respiratory drive- sedative drugs, CNS tumour or trauma
Neuromuscular disease- cervical cord lesion, diaphragmatic paralysis, poliomyelitis, myasthenia gravis, Guilllan-Barré syndrome
Thoracic wall disease - flail chest, kyphoscoliosis
124
Clinical features of respiratory failure
hypoxia - dyspnoea, restlessness, agitation, confusion, central cyanosis (long standing - polycytheamia, pulmonary htn, cor pulmonale)
Hypercapnia - headache, peripheral vasodilatation, tachycardia, bounding pulse, tremor/flap, papilloedema, confusion, drowsiness, coma
125
Investigating resp failure
bloods- FBC, U&E, CRP, ABG
CXR
microbiology- sputum and blood cultures
spirometry
126
Management of type I resp failure
treat underlying cause
give oxygen
assisted ventilation
127
Management of type II resp failure
may have CO2 insensitivity- SpO2 88-94%
- treat underlying cause
- controlled oxygen therapy - repeat ABG after 20mins
- if this fails consider intubation and ventilation
128
Causes of ARDS (acute respiratory distress syndrome)
pulmonary - pneumonia, gastric aspiration, inhalation, injury, vasculitis, confusion
other- confusion, haemmorrhage, multiple transfusions, pancreatitis, acute liver failure, trauma, head injury, malaria, fat embolism, obstetric events, drugs/toxins
129
clinical features of ARDS
```
cyanosis
tachypnoea
tachycardia
peripheral vasodilatation
bilateral fine inspiratory crackles
```
130
Investigations of ARDS
FBC, U&E, amylase, clotting, CRP, blood cultures, ABG
| CXR shows bilateral pulmonary infiltrates
131
Diagnostic criteria of ARDS
1. Acute Onset
2. CXR- bilateral infiltrates
3. pulmonary capillary wedge pressure <19mmHg/ lack of clinical congestive heart failure
4. refractory hypoxaemia
132
Management of ARDS
1. Admit to IT, supportive therapy, treat underlying causes
- resp support - CPAP (risk for pneumothorax)
- circulatory support - arterial line
- sepsis
- nutritional support
133
Symptoms of COPD
cough
spututm
dyspnoea
wheeze
134
Signs of COPD
```
tachypnoea
use of accessory muscles of respiration
hyperinflation
decreased cricosternal distance
decreased expansion
resonant or hyperresonant percussion note
quiet breath sounds
wheeze
cyanosis
cor pulmonale
```
135
Complications of COPD
```
Acute exacerbations ± infection
polycythaemia
respiratory failure
cor pulmonale (oedema, raised JVP)
pneumothorax (ruptured bullae)
lung carcinoma
```
136
tests in COPD
FBC- PCV raised,
CXR- hyperinflation, flat hemi-diaphragms, large central pulmonary vessels, decreased peripheral vascular markings, bullae
ECG- right atrial and ventricular hypertrophy
ABG- low PaO2 ± hypercapnia
Lung function tests- obstructive + air trapping FEV1 <80%
137
Treatment of COPD
Chronic stable - general
```
stop smoking
encourage exercise
treat poor nutrition or obesity
influenza and pneumococcal vaccines
pulmonary rehabilitation
palliative care
Non-invasive positive presssure ventilation
PRN short-acting antimuscarinic (ipratropium) or B2 agonist
```
138
Treatment of COPD
Mild/moderate disease
inhaled long-acting antimuscarinic (tiotropium) or B2 agonist (salmeterol)
139
Treatment of severe COPD
combination of long acting B2 agonist (salmeterol)+ cortiocosteroids
e.g. Symbicort (budenoside + formoterol) or tiotropium
140
Characteristics of asthma
recurrent episodes of dyspnoea, cough and wheeze caused by reversible airway obstruction
- bronchial muscle contraction
- mucosal swelling/ inflammation caused by mast cell and basophils
- increased mucus production
141
Symptoms of asthma
intermittent dyspnoea
wheeze
cough (often nocturnal)
sputum
142
What to ask about in asthma?
```
precipitants- cold air, exercise, allergens, infection, smoking/ passive smoking
diurnal variation- marked moring dipping
exercise
disturbed sleep
acid reflux
other atopic disease
the home
job
days off/ week due to chest
```
143
Signs of asthma
```
tachypnoea
audible wheeze
hyperinflated chest
hyperresonant to percussion
reduced air entry
widespread polyphonic wheeze
```
144
Signs of severe asthma attach
inability to complete sentences
pulse>110 bmp
resp rate >25
PEF 33-50% of predicted
145
signs of life threatening asthma attack
```
silent chest
confusion
exhaustion
cyanosis
bradycardia
REF <33% predicted
```
146
Differential diagnosis of asthma
```
pulmonary oedema- cardiac asthma
COP
large airway obstruction- foreign body, tumour
SVC obstruction
pneumothorax
PE
bronchiectasis
obliterative bronchiolitis
```
147
Diseases associated with asthma
Acid-reflux
polyarteritis nodosa
Churg-Strauss
