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Senior medicine and surgery > Respiratory > Flashcards

Respiratory Flashcards

1
Q

Asthma

A
  • chronic inflammatory disease, with intermittent airway obstruction and hyper-reactivity -> bronchoconstriction and increased mucus production
  • dyspnoea, cough, expiratory wheeze
  • worst early morning
  • triggers eg cold, exercise, allergens, smoking
  • acid reflux, other atopic disease associated

Ix

  • FEV1/FVC ratio <0.7 (same lung capacity, just can’t get air out as quickly)
  • FEV1 <80% predicted
  • peak flow monitoring
  • CXR (hyperinflation)
  • allergy testing with skin prick
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2
Q

Asthma management

A

Step 1 - low dose ICS preventor (beclomethasone) and SABA (salbutamol)
Step 2 - add LABA (salmeterol/eformetasol/fluticasone)
Step 3 - add montelukast or increase dose ICS
Step 4 - refer to specialist care (oral prednisolone / immune modulator)

  • beware oral candidiasis, wash mouth after ICS
  • consider inhaler technique, + the environment! (dry powder if poss)
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3
Q

Chronic obstructive pulmonary disease

A

= emphysema + chronic bronchitis

  • older age at onset, smoking / pollution history, minimal diurnal variation
  • chronic bronchitis = cough + sputum for most days for 3mo of 2 years
  • emphysema = histologically enlarged air spaces distal to terminal bronchioles

Pink puffers - normal sats, breathless but not cyanosed, may -> type 1 resp failure
Blue bloaters - low sats and high CO2, cyanosed but not breathless, may -> cor pulmonale (RHF)

  • risk acute exacerbations and infections, + carcinoma, pneumothorax (bullae rupture), resp failure
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4
Q

Ix and Mx of COPD

A

Ix

  • FEV1/FVC ratio <0.7 (same lung capacity, just can’t get air out as quickly)
  • FEV1 <80% predicted
  • pulse oximetry low (88-92%)
  • ABG
  • CXR (hyperinflation)
  • bloods/sputum for infection
  • ECG - RVH

Mx
- chronic stable - SABA or SAMA, then + LABA/LAMA, then + ICS
+ smoking cessation!, vaccinations
- acute - nebulised SABA, controlled oxygen therapy, IV steroids, abx

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5
Q

Community acquired pneumonia

A 
Typically 
- strep pneumoniae
- haemophilus influenzae
- moraxella catarrhalis
\+ atypicals eg mycoplasma, staph aureus, legionella, chlamydia
- viral in 15%
  • fevers, rigors, malaise, anorexia, dyspnoea, cough, purulent sputum, haemoptysis, pleuritic chest pain
CURB-65
(confusion AMTS<8, urea>7, resps>30, BP<90 or 60, age>65)
- 0-1 - home abx
- 2 - hospital therapy
- 3 - high mortality, consider ITU

Ix

  • CXR
  • FBC, ABG, U+Es, glucose
  • urine (if ?atypicals)
  • sputum + MC+S (bronchoscopy culture more accurate)

Mx

  • abx - oral amoxicillin / doxycyline / clarithromycin, co-amoxiclav + clarithromycin if high severity
  • maintain O2, fluids, VTE prophylaxis

(Pneumocystitis pneumoniae = AIDS or immunosuppression)

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6
Q

Hospital acquired pneumonia

A 
>48hr after hospital admission
Typically
-  enterobacter (E coli, klebsiella, salmonella) 
- staph aureus
\+ atypical  pseudomonas
  • fevers, rigors, malaise, anorexia, dyspnoea, cough, purulent sputum, haemoptysis, pleuritic chest pain

Ix

  • CXR
  • FBC, ABG, U+Es, glucose
  • urine (if ?atypicals)
  • sputum + MC+S (bronchoscopy culture more accurate)

Mx

  • culture, broad spec abx, then narrow down
  • abx - co-amoxiclav, doxycycline, piperacillin or ceftriaxone if high severity
  • maintain O2, fluids, VTE prophylaxis
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7
Q

Lung cancer

A
  • carcinoma of bronchus usually, 90% from smoking

Non small cell mostly - squamous cell, adenocarcinoma, large cell
Small cell - from endocrine cells and secrete paraneoplastic hormones eg ACTH - highly malignant and metastasised by time of diagnosis

  • cough, haemoptysis, dyspnoea, chest pain
  • weight loss, lethargy, anorexia
  • recurrent pneumonias
    + nerve palsies, SVC obstruction, Horner’s syndrome (Pancoast’s tumour), signs of mets

Ix

  • CXR (central mass, hilar lymphadenopathy, pleural effusion)
  • cytology of sputum and pleural fluid
  • FNA or biopsy
  • CT to stage
  • bronchoscopy for sample and assess operability
  • PET-CT

Mx

  • surgery
  • radiotherapy
  • chemotherapy
  • supportive
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8
Q

Mesothelioma

A
  • aggressive epithelial neoplasm in pleura, and sometimes peritoneum / other organs
  • occupational exposure to asbestos (maybe 45yrs ago), presents age 70-80s
  • chest pain, dyspnoea, weight loss, clubbing, recurrent pleural effusions
  • signs of mets - lymphadenopathy, hepatomegaly, bone pain

Ix

  • CXR / CT - unilateral pleural thickening/ calcified plaques, pleural effusion
  • bloody pleural fluid when tapped
  • thoracentesis, exudative (Light’s criteria)

Mx
- chemotherapy, but poor prognosis

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9
Q

Bronchiectasis

A

= dilation and destruction of the terminal bronchioles with chronic inflammation
+ infection - mainly H influenzae, strep pneumoniae, staph aureus, pseudomonas aeruginosa

Causes

  • congenital eg CF
  • post-infection - measles, pneumonia, TB, HIV (esp if recurrent or severe)
  • bronchial obstruction from tumour
  • persistent cough + LOTS purulent sputum, intermittent haemoptysis
  • clubbing, coarse expiratory creps, wheeze

Ix

  • sputum culture
  • CXR (cystic shadows, thickened bronchial walls)
  • high resolution CT
  • spirometry (obstructive)
  • bronchoscopy

Mx

  • exercise and chest physio
  • abx, long-term if >3 per year
  • nebulised salbutamol if co-morbidities
  • corticosteroids
  • surgery if localised disease or for severe haemoptysis
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10
Q

Interstitial lung disease

A
  • insult to lung -> abnormal healing -> fibrosis, so more difficult for alveoli to perform gas exchange (oxygen affected much more than CO2)

Causes

  • inhaled - inorganic (asbestos) or organic (hypersensitivity pneumonitis)
  • drug-induced (abx, antiarrhythmics)
  • connective tissue diseases
  • infection (TB, pneumocystic pneumonia)
  • idiopathic (MAIN CAUSE)
  • malignancy

Presentation

  • dyspnoea on exertion
  • non productive cough
  • abnormal CXR or CT
  • restrictive spirometry
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11
Q

Idiopathic pulmonary fibrosis

A
  • commonest type of idiopathic interstitial lung disease
  • rare, chronic, life-threatening disease, where scar tissue forms for unknown reason
  • dry cough, exertional dyspnoea, malaise, weight loss, arthralgia
  • cyanosis, clubbing, fine end-inspiratory creps

Ix

  • CXR - reduced lung volume, honeycomb lung
  • CT - needed for diagnosis
  • bloods + ABG, immunoglobulins raised, maybe ANA +ve
  • restrictive spirometry
  • bronchoalveolar lavage

Mx

  • supportive mostly (oxygen, opiates, pulmonary rehab)
  • perfenidone (immunosuppressant and antifibrotic) emerging use - all for clinical trials
  • 50% 5yr survival
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12
Q

Sarcoidosis

A
  • idiopathic cause of interstitial lung disease
  • chronic non-caseating granulomatous disorder affecting lungs, skin and eyes
  • dry cough, dyspnoea, fatigue, arthralgia, wheezing, lymphadenopathy, eye symptom
  • in 20s and 40s presents, fhx is RF

Ix

  • diagnosis of exclusion, only by biopsy
  • CXR, bloods (look at all organ systems)

Mx

  • depends on severity - ICS, oral steroids, cytotoxics immunosuppression (methotrexate/azathioprine), lung transplant
  • topical steroids for skin/eye
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13
Q

Tuberculosis

A
  • caused by Mycobacterium tuberculosis
  • affects lungs + other systems (pleura, lymph, CNS, liver, bones, GI tract)
  • notifiable disease
  • inhalation -> caseous granuloma from Th1 and macrophages, so becomes not infectious, reactivation when immunocompromised

Presentation
- asymptomatic but with bacterial/radiological evidence
- cough (dry -> productive ± haemoptysis)
- low grade fever + night sweats
- weight loss
- malaise / fatigue
+ pleuritic chest pain, enlarged lymph nodes, bone pain, urinary symptoms

Ix and Mx

  • CXR (fibro-nodular opacities or miliary spread)
  • sputum +ve for acid fast bacilli, Ziehl-Neelson stain + culture
  • tuberculin skin testing
  • rifampicin in latent infection
  • isoniazid and pyridoxine in active TB
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14
Q

Acute asthma attack severity grading

A

Moderate - increase in symptoms, PEF 50-75% predicted, no other features as below

Severe - PEF 33-50% predicted, RR>25, HR>110, inability to complete sentences

Life-threatening - PEF<33% predicted, SaO2<92%, reduced consciousness, cyanosis

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15
Q

Management of acute asthma attack

A
  • usually viral (only give abx if see consolidation on CXR or purulent sputum)
  • or triggered by environmental allergen / irritant
  • Th2 IgE response triggering inflammation, bronchospasm and airway occlusion

Mx

  • A-E
  • measure peak flow, ECG, bloods (only ABG if life-threatening), CXR
  • oxygen (to target sats)
  • salbutamol (nebulised, beware hyperkalaemia, tremor, palpitations, lactic acidosis)
  • hydrocortisone PO or IV if life-threatening (or prednisolone)

+ magnesium sulfate if life-threatening / non-responsive
+ theophylline PO or aminophylline IV last line
±heliox

D/C with 5d oral steroids
? step up, assess inhaler technique
GP follow up after 2d
Can’t go home until stable on meds for 24hrs

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16
Q

Exacerbation of COPD

A
  • worsening of symptoms, including dyspnoea, cough, wheeze, change in sputum colour / volume, tachypnoea
  • tends to be worse in winter months
  • commonly infectious (H influenzae, Strep pneumoniae, moraxella catarrhalis)
  • or smoke/pollutant exposure

GOLD classification

  • mild FEV1>80% predicted
  • moderate 50-80%
  • severe 30-50%
  • very <30%
  • CXR (hyperinflation, flat diaphragm)
  • ECG
  • ABG (respiratory acidosis) + bloods
  • sputum MC+S

Mx

  • SABA ± abx
  • oral steroids + airway clearance
  • oxygen ± BiPAP
  • broad spec abx -> narrow after MC+S
17
Q

Pneumothorax

A

= air in pleural space

  • SMOKING, tall and slender
  • primary spontaneous = young with no prior resp disease
  • secondary spontaneous
  • traumatic
  • sudden sharp pleuritic chest pain
  • dyspnoea
  • hyperexpansion, absent breath sounds, hyper-resonant

Mx

  • primary:
    • <2cm - discharge
    • > 2cm - aspirate
    • if fails, chest drain + admit
  • secondary:
    • <2cm - aspirate
    • > 2cm chest drain + admit
18
Q

Pulmonary embolism

A
  • from VTE in legs or pelvis (via right side of heart)
  • pleuritic chest pain, dyspnoea, tachypnoea, cough ±haemoptysis, tachycardia, fever, signs of DVT
RFs:
Travel
Hypercoagulable
Recreational drugs
Old
Malignancy
Birth control pill
Obesity/obstetrics
Surgery/smoking
Immobilisation
Sickness

Ix

  • bloods, ABG, D-dimer (after Wells score if <4)
  • ECG
  • CXR normal
  • CTPA if Wells>4 or D -dimer +ve

Mx

  • oxygen if low sats
  • morphine
  • LMWH/fondaparinux
  • fluid bolus if low BP
  • thrombolysis if haemodynamically unstable
  • -> long term anticoagulation on DOAC (or IVC filter if contra-indicated)
19
Q

Pleural effusion

A

Transudates = protein conc <25
- due to raised venous pressure (HF, fluid overload, constrictive pericarditis)

Exudates = protein conc >35
- increased leakiness of capillaries due to infection, inflammation or malignancy

  • asymptomatic or dyspnoea / pleuritic chest pain
  • stony dull percussion, decreased expansion, diminished breath sounds
  • blunting of costophrenic angles on CXR
  • USS
  • pleural biopsy
20
Q

Acute respiratory distress syndorome

A
  • direct lung injury, or secondary to sever systemic illness
  • mortality >50%

Pulmonary
- pneumonia, gastric aspiration, inhalation, injury
Other
- shock, septicaemia (usually), haemorrhage, DIC, acute liver failure, pancreatitis, head injury, drugs/toxins

Need all four criteria:

  1. acute onset <7d
  2. bilateral infiltrates on CXR
  3. non-clinical heart failure (check BNP)
  4. refractory hypoxaemia with PaO2:FiO2<200 (arterial:inspired oxygen ratio)
  • cyanosis, tachypnoea, tachycardia, peripheral vasodilation, bilateral fine inspiratory crackles

Mx - ITU

  • resp support on CPAP
  • circulatory support to maintain CO
  • treat underlying cause (sepsis 6)
21
Q

Obstructive sleep apnoea

A
  • episodes of complete or partial upper airway obstruction during sleep
  • obesity
  • maxillomandibular anomalies
  • sleep partner notices episodic cessation of breathing, then loud snore/gasping

Ix

  • polysomnography - overnight test to calculate apnoea-hypopnoea index (if >15/hr then diagnostic)
  • nasoendoscopy

Mx

  • weight loss
  • mandibular repositioning /tongue retaining device
  • CPAP
  • surgery
22
Q

Hypersensitivity pneumonitis

A
  • non-IgE mediated immunological inflammation, caused by repeated inhalation of non-human protein (eg bird droppings, mushroom workers, mould)
  • type III or IV hypersensitivity reaction
  • dyspnoea and cough
    + fever, malaise, anorexia, clubbing

Ix

  • FBC (WCC)
  • CXR - upper zone mottling/consolidation
  • pulmonary function tests, restrictive pattern

Mx

  • remove allergen
  • oxygen
  • PO prednisolone
23
Q

Beta 2 receptor agonists

A
  • bronchodilators, for asthma and COPD
  • short acting eg salbutamol, for acute relief, takes 20 mins to work and can last 6 hours
  • LABA eg salmeterol, eformeterol, preventors
  • B2 agonism -> increased activation of cAMP, so inhibition of MLCK and activation of MLCP -> relaxation

SEs - tremor, headache, dizziness, tachycardia

24
Q

Muscarinic 3 receptor antagonists

A
  • bronchodilators, for asthma and COPD
  • SAMA eg ipratropium bromide, in severe asthma attack
  • LAMA eg tiotropium bromide, glycopyronium bromide, for preventor of COPD
  • inhibits bronchoconstriction

SEs - dry mouth, cough, rarely urinary retention

25
Q

Inhaled corticosteroids

A

eg beclomethasone, budesonide, fluticasone
- anti-inflammatory, preventors for asthma

SEs - none systemic as inhaled, but candidiasis of mouth unless washed after

26
Q

Mucolytics

A

eg carbocisteine

  • to reduce viscosity of sputum, making it easier to bring up
  • in COPD and bronchiectasis

SEs - nausea, vomiting
- CI if on anti-tussive

27
Q

Anti-histamines

A

eg cetririzine, selective H1 antagonist
- for allergy

To antagonise this:
- when allergen meets mast cells, binds to surface IgE antibodies and activates them, causing degranulation of mast cells, then release of histamine -> inflammation

SEs - drowsiness, headache

Senior medicine and surgery (9 decks)

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