Respiratory Flashcards
What does ARDS involved
Acute onset
bilateral pulmonary oedema
Hypoxaemia regardless of level of positive end expiratory pressure
No clinical evidence for increased left atrial pressure (i.e no HF, pulmonary cap wedge pressure <18)
dyspnoea, cough, cyanosis, tacypnoea, tachycardia, respiratory distress, widespread inspiratory crepitations
Give FiO2 50-60%, intubate and ventilate (sedate, analgesia, neuromuscular blockade only when required), use low tidal volumes to avoid complications (pneumothorax, subcut emphysema)
what are the 3 types of aspegillus lung disease
1) Aspergillioma - ball in a prexisting lung cavity (e.g old TB), asymptomatic or haemoptysis, can deviate tracheas, seen on CXR in upper lobes (round w/ crescent of air around it), can surgically resect ± itraconazole
2) Allergic bronchopulmonary asperigilliosis (usually asthmatics) - pneumonia, wheeze, cough, asthma exacerbation, dullness and decreased breath sounds in affected lung, eiosinophillia and raised IgE, skin test to aspergillus, mucuous filled bronchi show “gloved finger” appearance on CXR, Rx = steroids and itraconazole for 3-6m
3) Invasvice aspergillosis - 2º to immumnosupression, dyspnoea, sepsis, rapid deterioration, cyanosis, detect on culture or histology, nodules surrounded by ground glass appearance (halo sign) on CT, Rx = decrease immunosuppression, IV voriconazol or liposomal amphotericin B ± capsofungin if voriconazol isn’t tolerated
Acute Rx of asthma
Resus, O2 sats, ABG and PEFR
High flow O2
Nebulised salbutamol 5mg ± ipatropium
Steroid therapy - 100-200mg IV hydrocortisone, then oral prod 40mg for 5-7d
Iv mag sulphate or IV amiphophylline or Iv salbutamol if no improvement
Can discharge when PEFR >75% patients predicted best, diurnal variation <25%, inhaler technique checked and stable on discharge medicine for 24h
Severe asthma attack vs life threatening asthma attack
Severe - PEFR <50% predicted, pulse >110, RR >25, inability to complete sentences
Life threatening - PEFR <33%, silent chest, cyanosis, bradycardia, hypotension, confusion, coma
Pneumocystis jirovecii pneumonia
Usually HIV positive
Usually clear chest, and insidious onset - dry cough, dyspnoea, tachypnoea, resp distress
reticular, bilateral pulmonary interstitial infiltrates on CXR and CT - ground glass appearance
BAL + staining will be positive for PCP
Rx = trimethroprim/sulfamethoxazole (co-trimoxazole) or pentamidine w/ steroids as an adjunct §
Legionaire’s disease
legionella infection working with water, or using aircon pneumonia - productive cough, dyspnoea, haemoptysis Abdo signs - N+V, pain Confusion, cognitive defects Low sodium CXR - lower lobe consolidation gram negative rods Rx = levofloxacin/ciprofloxacin or clarithromycin (or if severe , both) for 7-14d doxycycline is 2nd line
Klebsiella Pneumonia
Usually older men, alcoholics etc
Currant jelly sputum
Cough, fever, chest pain, short of breath
upper lobe caveatting lesion (often right upper lobe)
gram negative
Can cause lung abscesses - swinging fever, persistent pneumonia, copious amounts of foul smelling sputum
Rx = antibiotics (cephlasporin)
Curb 65
Confusion Urea > 7 RR >30 BP - SBP <90, DBP <60 Age >65
if more than 1, manage in hospital
if 0 - oral amoxicillin
if 1 - oral/IV amoxicillin + macrolide
if >1 - IV cefuroxime/cefotaxime/co-amoxiclav + macrolide
Add metrondiazole if aspiration, lung abscess or empyema
Common causes of CAP
S pneumoniae H influenzae Moraxella catarrhalis Chlamydia pneumonia Chlamydia psitaci Mycoplasma pneumonia - can cause erythema multiform, myocarditis, haemolytic anaemia, menigioencephalitis, transverse mellitus, Gillian barre Legionella S. Aureus (IVDA) Coxiella Burnetti Tb
N.B decreased chest expansion, dullness to percussion, increased vocal remits, bronchial breathing, coarse creps
Common causes of HAP
Gram negative - pseudomonas, klebisiella
Anaerobes - aspiration pneumonia
Bronchiectasis
Chronic bronchial dilation, impaired mucocilliary clearance and frequent bacterial infection eventually leading to fibrosis
Productive cough w/ sputum or haemoptysis
Breathless
Finger clubbing
Basal coarse creps
Wheeze
CXR = dilated bronchi from hilum to diaphragm = tramline shadowing
Rx = 2 IV Abx if get infection, prophylactic course of Abs if >3 infections per year, inhaled corticosteroids (fluticasone) and bronchodilators physio (postural drainage)
COPD
Chronic bronchitis (chronic productive cough lasting most days for 3m per year over 2 consecutive years) \+emphysema (destructive enlargement of air spaces distal to terminal bronchi)
resp distress, accessory muscles
Hyperinflated chest which is hyper resonant
decreased circosternal distress
Co2 retention - bounding pulse, warm peripheries, flapping tremor, RHF
Obstructive picture
Rx= bronchodilators, anticholinergics (ipatropium0, steroids if FEV <50 or >2 exacerbations
home o2 if Pao2 <7.3 when stable or Pa7.3-8 and 2º polycythaemia, nocturnal hypoxaemia, peripheral oedema or pulmonary HTN
Sweat test is used for
Cystic fibrosis
low Cl- in sweat
Causing of extrinsic allergic alveolitis
Farmer's lung - mouldy hay Pigeon fanciers lung - bird feather bloom + excreta Mushroom worker lung Humidifier lkung Maltworker lung - aspergillus
Drug cough, dyspnoea, fever, malaise, inspiratory creps, tachypnoea –> slowly increasing breathlessness and decreased exercise tolerance if chronic w/ fine inspiratory crackles
Patchy ground glass appearance on CT or CXR
On CXR - nodular opacities in middle and lower zone, fibrosis in upper zone
Rx = avoid, corticosteroids
Idiopathic fibrosing alveoli’s
Bleomycin, methotrexate, amiodarone all cause something similar
Occupation exposure - metal, wood, animal and veg dust
Smoking
Gradual onset progressive dyspnoea on exertion
Dry cough
Bibasal fine later inspiratory crackles
Finger clubbing
CXR - ground glass, then reticulondoular shadowing (esp bases), cor Pulmonale (large Right ventricle), honeycombing
CT - lower zone honeycombing
Rx - no curative, can use azathioprine, steroids and acetylcysteine for 3-6m to see if there is improvement
Home O2, psychosocial support
can transplant
