Respiratory Flashcards
3 key features of asthma?
- airflow limitation which is reversible
- airway hyper-responsiveness to a wide range of stimuli
- inflammation of the bronchi
symptoms of asthma
cough often worse at night
dyspnoea
wheeze
chest tightness
signs on spirometry of asthma
FEV1 significantly reduced
FVC normal
therefore FEV1/FVC <70%
shows bronchoconstriction
Mx of asthma
SABA e.g. salbutamol
SABA + ICS e.g. budenoside 400mcg OD or beclomethasone
SABA + ICS + LTRA (leukotriene receptor antagonist) e.g. Montelukast
SABA + ICS + LABA e.g. salmeterol (can continue LTRA)
SABA +/- LTRA + MART (maintenance and reliever therapy- contains low dose ICS and LABA)
Trial of long-acting muscarinic antagonist or theophylline
increase ICS
SEs of ICS?
oral candidiasis and stunted growth in children
when should children with asthma be given a paediatric ICS?
Not controlled with SABA
OR
Newly-diagnosed asthma with symptoms >= 3 / week or night-time waking
what are the steps after SABA + pICS for childhood asthma?
- add leukotriene receptor antagonist
- then stop LTRA and add LABA (different to adult guidance)
- SABA + MART
What is MART
a form of combined ICS and LABA
used for both daily maintenance therapy and the relief of symptoms as required
signs of life-threatening of acute asthma?
PEFR <33% O2 sats <92% Silent chest, cyanosis or feeble respiratory effort bradycardia, dysrhythmia, hypotension exhaustion, confusion, coma
signs of severe acute asthma?
PEFR 33-50%
Can’t complete sentences
RR >25/min
Pulse >110 bpm
mx of acute severe asthma?
salbutamol nebs prednisolone or IV hydrocortisone magnesium sulphate 1.2-2g IV over 20 mins IV aminophylline IV salbutamol
causes of COPD?
Smoking
alpha-1 antitrypsin deficiency
causes of IECOPD?
H.influenza
Strep pneumoniae
Moraxella catarrhalis
features of COPD?
Cough: often production
dyspnoea
wheeze
Right heart failure
Ix of COPD?
airflow obstruction- FEV1/FVC ratio <70%
CXR
FBC-exclude polycythaemia
FEV1 severity of COPD?
>80%= stage 1- mild 50-79%= stage 2- moderate 30-49%= stage 3- severe <30%= stage 4- very severe
general management of COPD?
stop smoking
annual influenza vaccination
one-off pneumococcal vaccine
pulmonary rehab
drug management of COPD
- SABA or SAMA is first line
- if not steroid responsiveness- LAMA (tiotropium)+ LABA
- if steroid responsiveness- LABA (salmeterol) + ICS (beclomethasone 200mcg BD)
- Consider adding theophylline
others- azithromycin (oral prophylactic antibiotic therapy), mucolytics
who shouldn’t you offer LTOT for COPD?
If people continue to smoke
who should get LTOT?
Long-term O2 therapy- >15 hours a day. Used in patients with pO2 <7.3kPa or 7.3-8kPa and one of:
- very severe airflow obstruction (FEV1 <30%)
- cyanosis
- polycythaemia
- peripheral oedema
- raised JVP
- O2 sats <92%
What is a well’s score?
Shows likelihood of DVT
Active cancer (treatment ongoing, within 6 months, or palliative)
- Paralysis, paresis or recent plaster immobilisation of the lower extremities
- Recently bedridden for 3 days or more or major surgery within 12 weeks requiring general or regional anaesthesia
- Localised tenderness along the distribution of the deep venous system
- Entire leg swollen
- Calf swelling at least 3 cm larger than asymptomatic side
- Pitting oedema confined to the symptomatic leg
- Collateral superficial veins (non-varicose)
- Previously documented DVT (-2)
> 2= DVT likely
1 or less= unlikely
An alternative diagnosis is at least as likely as DVT
what to do if DVT is likely?
proximal leg vein USS
if negative-> D-dimer
what to do if DVT unlikely?
D-dimer
if positive -> arrange USS asap
if can’t do USS in 4 hours -> LMWH
Mx of DVT?
LMWH or fondaparinux- continued until INR >2 for at least 24 hours
Give a vitamin K antagonist i.e. warfarin for 3 months
At 3 months clinicians should assess the risks and benefits of extending treatment.
If unprovoked DVT- full physical examination, CXR, bloods (FBC, serum calcium, LFTs) and urinalysis
what needs doing in patients over 40 with first unprovoked DVT/PE?
investigate for malignancy with abdo-pelvic CT scan
features of PE?
Chest pain (pleuritic) dyspnoea haemoptysis tachycardia tachypnoea
mx of PE?
Same as DVT
thrombolysis if massive PE where there is circulatory behaviour
IVC filters if repeat PE
causes of upper zone fibrosis
CHARTS Coal worker's pneumoconiosis Hypersensitivity pneumonitis Ankylosing spondylitis Radiation TB Silicosis/sarcoidosis
diagnosis of lung fibrosis
restrictive picture: FEV1 normal/decreased, FVC decreased, FEV1/FVC increased
CXR- ground-glass appearance, progresses to opacities
CT-diagnostic
what is coal-workers’ pneumoconiosis?
caused by long term exposure to coal dust particles, can be a long lead time 1st exposure and development of disease
caused by accumulation of macrophages in the alveoli which starts an immune response, causing damage to the lung tissue
what can coal-workers’ pneumoconiosis lead to?
Simple pneumoconiosis- opacities in lungs, can be asymptomatic
Progressive massive fibrosis- dust exposure causes patients to develop round fibrotic masses which can be several cms. Symptomatic with SOB, cough, black sputum
What are the effects of asbestos on the lung?
- pleural plaques
- pleural thickening
- asbestosis- lower lobe fibrosis
- mesothelioma- malignant disease of the pleura
- lung cancer
which type of lung cancer has the worst prognosis?
SCLC
What are the main types of non small cell LC?
squamous (35%)
adenocarcinoma (30%)
large cell (10%)
features of SCLC?
Arises from APUD cells
Associated with ectopic ADH, ACTH secretion
ADH-> hyponatraemia
ACTH -> cushing’s syndrome, bilateral adrenal hyperplasia
Lambert-Eaton syndrome: antibodies to voltage gated calcium channels causing myasthenic like syndrome
mx of SCLC?
usually mets at time of diagnosis
surgery
chemoradiotherapy
features of NSCLC?
SCC-
typically central, associated with PTHrP secretion -> hypercalcaemia + finger clubbing
HPOA- hypertrophic pulmonary osteoarthropathy
Adenocarcinoma-
typically peripheral
most common type in non-smokers, can cause HPOA and gynaecomastia
large cell- typically peripheral, poorly differentiated tumours with a poor prognosis, may secrete bHCG
mx of NSCLC?
Only 20% suitable for surgery
curative or palliative radiotherapy
2 week wait criteria for lung cancer
CXR features that suggest lung cancer over 40 with unexplained haemoptysis over 40 with 2 of the following: - cough - fatigue - SOB -chest pain - weight loss - appetite loss
Consider if over 40 and persistent chest infections, clubbing, supraclavicular lymphadenopathy, thrombocytosis
what is bronchiectasis?
a permanent dilatation of the airways secondary to chronic infection or inflammation
causes of bronchiectasis?
post-infective- TB, measles, pertussis, pneumonia
CF
Bronchial obstruction
Immune deficiency- selective IgA, hypogammaglobulinaemia
ABPA
What is a transudate and exudate?
transudate= <30g/L of protein exudate= >30g/L of protein
causes of transudate pleural effusion?
heart failure
hypoalbuminaemia (liver disease, nephrotic syndrome, malabsorption)
Meig’s syndrome
causes or exudate pleural effusion?
Infection e.g. pneumonia. TB subphrenic abscess connective tissue disease- RA, SLE neoplastic pancreatitis PE Dressler's syndrome yellow nail syndrome
features of pleural effusion?
dyspnoea
non-productive cough or chest pain
