Respiratory Flashcards
Definition of asthma
Recurrent episodes of dyspnea, cough and wheeze caused by reversible airway obstruction
Possible precipitants/causes of asthma
Cold Exercise Emotion LBW/not breast fed Quantity of exercise tolerance Sleep quality Acid reflux Atopic disease Dust/pets Aspirin Days off work/school
Asthma examination findings
Hyperinflated chest
Hyper resonant percussion
Diminished air entry
Widespread wheeze
Asthma differentials
Pulmonary oedema COPD SVC obstruction Pneumothorax/PE Bronchiectasis
investigations asthma
Bloods including ABG ( only if hypoxic) Peak flow Sputum culture CXR Spirometry
Non-pharmacological management of asthma
Smoking cessation Avoidance of precipitants Twice daily PEF Emergency action plan ?Home O2 Pulmonary rehabilitation
Pharmacological management of chronic asthma
Inhaled corticosteroid (fluticosone or beclometasone) and SABA PRN
ICS regularly and SABA PRN
LABA salmeterol and ICS low dose and SABA PRN
LABA and ICS high dose and SABA PRN
Leukotrine receptor antagonist (monteleukast)
Oral prednisone
Pharmacological management of acute asthma
Nebulised salbutamol
Oxygen
Hydrocortisone or prednisolone
Add ipratropium nebs and magnesium sulphate
Definition bronchiectasis
Permanent dilation of the walls of bronchi with associated destructive/inflammatory changes leading to chronic airway infection
List some causes of bronchiectasis
Cystic fibrosis Primary cilia dyskinesia Infections in childhood Rheumatoid arthritis COPD ILD Idiopathic (50%)
Complications of bronchiectasis
Pneumonia Pleurisy Empyema Lung abcess Cor pulmonale Amyloidosis
Differentials for bronchiectasis
Bronchitis
COPD
TB
investigations for bronchiectasis
CXR Sputum culture Test for cystic fibrosis Spirometry (for severity) High resolution CT \+- bronchoscopy
Non-pharmacological mangement bronchiectasis
twice daily postural drainage physiotherapy influenza/pneumococcal vaccines smoking cessation Home O2 with severe disease
Pharmacological management bronchiectasis
Antibiotics (based on culture)
bronchodilators
Surgery if localised disease/severe haemoptysis
Presentation of COPD
dyspnoea
chronic cough
chronic sputum production
history of risk factors (smoking, pollution, occupation chemicals and dust)
Most common genetic marker in COPD
alpha1-antitrypsin deficiency
Investigations for COPD
Spirometry (diagnosis)
CXR
ECG (RVH from cor pulmonale)
ABG
how do pathophysiologies of emphysema and chronic bronchitis differ
Emphysema:alveolar inflammation and decreased elastic tissue means hyperinflation. Hyperinflation leads to breathing at higher volumes. Lungs have less compliance at higher volumes, so in order to maintain positive airway pressure patient must purse lips (pink puffer)
Bronchitis: increasing mucus and airway narrowing leads to increased airway resistance. Expiration no longer passive, airways collapse on expiration. CO2 retention and relies on hypoxic drive (blue bloater)
Differentials for COPD
Asthma
Congestive Heart failure
Bronchiectasis
TB
Definition of “chronic bronchitis”
Cough and sputum production for at least three months in each of the last two consecutive years
Non pharmacological treatment of COPD
Smoking cessation
Oxygen therapy
Influenza vaccination
Ventilatory support
What is the difference between Bipap and Cpap
Bipap delivers different air pressures varying with inspiration or expiration. It is used in type 2 respiratory failure.
Cpap only delivers one strength of air pressure, it is not ventilation but splints the airway open. It is used in type 1 respiratory failure.
Pharmacological treatment of COPD
Mild: SABA or SA anticholinergic
Moderate: LABA (salmeterol) or LA anticholinergic (tiotropium) incruse ellipta
Severe: ICS and LABA (Symbicort) or LA anticholinergic or LAMA and LABA (anora ellipta)
Very severe: ICS (Flixotide) and LABA and LA anticholinergic
Treatment of acute exacerbation of COPD
Oxygen SABA nebulisers +/- short-acting anticholinergics Systemic corticosteroids Antibiotics if evidence of infection Aminophylline if not responding Magnesium sulphate
Known causes of interstitial lung disease
Asbestosis, silicosis, bird poo, coal Methotrexate, amiodarone Hypersensitivity (extrinsic allergic alveolitis) TB, fungal Also associated with systemic disorders
Investigations for interstitial lung disease
CXR CT Spirometry Bloods Bronchoalveolar lavage Biopsy
Treatment interstitial lung disease
Cannot reverse established fibrosis
Steroids
Transplantation
Types of lung cancer
Non-small cell (85%): adenocarcinoma (most common) squamous cell cancer large cell alveolar cell Small cell (15%) - smokers Mesothelioma
Complications of lung cancer
Recurrent laryngeal palsy Horner's syndrome SVC obstruction SIADH ACTH by small cell tumours Lambert Eaton myasthenic syndrome (small cell) Dermatomyositis
Differential diagnosis of lung nodule on xray
Malignancy Abcesses Granuloma Carcinoid tumour-flushing/diarhoea due to serotonin Pulmonary hamartoma AV malformation Cyst Foreign body Skin tumour
Investigations for lung cancer
Cytology CXR Bronchoscopy Bloods CT/PET Lung function tests
Management of lung cancer
Non small cell: Exision if localised and no mets
radiotherapy
Chemo and radiotherapy if severe
Small cell: chemotherapy with platinum based drugs
Prophylactic cranial irradiation in patients with complete responses
Palliation (1-1.5 year survival)
Conditions which increase risk of obstructive sleep apnoea
pregnancy heart disease renal disease lung disease PCOS
Investigations for OSA
Pulse oximetry and video recordings at home
Sleep study/polysomnography
TFTs (hypothyroidism)
ECG
Definitive diagnosis is >5 apnoeic episodes per hour over several hours lasting >10 seconds each
Treatment OSA
Weight loss
Avoid sedatives
Reverse underlying cause
CPAP if moderate to severe
What are some signs of sarcoidosis?
Bilateral hilar lymphadenopathy Pulomary infiltrates Erythema nodosum Lupus pernio Polyarthralgia Cardiomyopathy Uveitis
Investigations sarcoidosis
Bloods (raised ESR, raised serum ACE) Urine (raised Ca) CXR Pulmonary Function tests Biopsy (non-caseating granulomata)
Treatment sarcoidosis
Mild: bed rest NSAIDS
Otherwise steroids (prednisone)
60% resolves after 2 years
What is the difference between pulmonary and miliary TB?
Pulmonary: cough, sputum, malaise, pleural effusion
Milliary: Haematogenous spread, non specific signs, no effusion but clinically unwell
What is the difference between diagnosing active and latent TB?
Latent TB use Mantoux or quantiferon gold
Active use CXR and PCR
Treatment TB
Start therapy without clinical results Rifampicin 600mg Isoniazid 300mg Pyrazinamide 2g Ethambutol 15mg/kg For 8 weeks then 16 weeks on just rifampicin and isoniazid
How does cystic fibrosis present in neonates vs children?
Neonates: failure to thrive, meconium ileus
Children: cough, wheeze, recurrent illness, bronchiectasis, pancreatic insufficiency
Diagnosis of cystic fibrosis
Sweat test
genetic testing
faecal elastase (pancreatic insufficiency)
Treatment cystic fibrosis
Pulmonary: physiotherapy, antibiotics, mucolytics
Gastro: pancreatic enzyme replacement, vitamin supplements
Treat diabetes
Most common causes of community acquired pneumonia
Step pneumonia
Haemophilus influenzae
Investigations for pneumonia
CXR Bloods Sputum culture \+-ABG Urine (pneumococcal/legionella antigen) \+- Pleural fluid for culture
Describe the CURB score
Confusion Urea >7mmol/L Respiratory rate >30 BP <90 systolic Age >65
Treatment pneumonia
Antibiotics-preferably oral Oxygen prn IV fluids Analgesia Repeat CXR
MRC dyspnoea scale
1 Breathless with hard exertion 2 Breathless when walking up slight hill 3 Slow walker on level ground 4 Stop for breath after walking 100 metres 5 Breathless getting dressed
Indications for home oxygen with COPD
PaO2< 55mmHg
SaO2 <88%
Therapy for an acute coronary syndrome
Antiplatelets ACE inhibitors Atorvastatin Beta blocker Bedside monitoring (telemetry) Bloods (both on admission and for monitoring) Clexane Cath lab Cardiac rehab
How is severity of COPD determined?
GOLD criteria based of FEV1
Mild FEV1 >80
Moderate 50
Contraindications for spirometry
Vomiting/haemoptysis pneumothorax recent thoracic surgery MI Thoracic aneurysms
How do we determine if a pleural fluid is exudate or transudate?
Light’s criteria
Pleural fluid protein/serum protein ratio = >0.5
Pleural fluid/serum LDH >0.6
Pleural fluid LDH> 2/3 upper limit for serum
