Respiratory Flashcards
Pneumonia symptoms (4 things) and signs (4 things)
Symptoms-
- Dyspnoea
- Fever
- Cough with purulent sputum
- PLEURITIC pain
Signs-
- Dull percussion
- Crackles and BRONCHIAL breathing on auscultation
- Rigors (septicaemia)
- Cyanosis and Tachypnoea (RESPIRATORY FAILURE)
Pneumonia investigations (4 things)
CXR- infiltrates
SPUTUM ANALYSIS to identify causative organisms
PNEUMOCOCCAL or LEGIONELLA antigens in urine
BLOODS- Raised WCC and raised CRP/ESR
Pneumonia assessment
CURB 65
Confusion Urea >7 Resp rate >30/min BP <90/60 >65 years old
Each is worth 1 point-
1= outpatient care
2= admission
3 or more= ICU admission
Pneumonia Treatment
BAPP
Breathing- maintain O2 levels
Antibiotics- treat underlying cause
Pain- analgesics
Pneumococcal vaccines (prioritised in D-I-65 (Diabetics, Immunosuppressant patients, patients over 65)
Pneumonia causative organisms (5 things)
Pneumococcal pneumoniae
Staph Pneu
Kleb Pneu
PSEUDONOMAS (like in BE/CF)
PNEUMOCYSTIS (seem more commonly in immunosuppressant patients)
Complications of pneumonia
Septic shock (if organism enters blood stream and releases cytokines)
Pleural effusion
Empyema
HYPOTENSION (due to sepsis or dehydration)
Respiratory failure
Bronchiectasis pathophysiology
infection of distal airways results in inflammation and release of inflammatory markers
impairs ciliary action- allows bacteria to proliferate
Bronchiectasis causative organisms (4 things)
Pseudonomas aeriginosa (common in patients with cystic fibrosis)
Strep pneumoniae
HAEMOPHILUS influenza
Staph aureus
Aspergillus
Causes of Bronchiectasis
TRICKY
Acquired-
- Tumor
- Rheumatoid arthritis
- INFLAMMATORY BOWEL DISEASE
Congenital-
- Cystic fibrosis
- Kartagener’s Syndrome (causes cilia to be immobile, removing the defensive mechanism of the respiratory tract)
- Young’s Syndrome (associated with AZOOSPERMIA)
Bronchiectasis symptoms (3 things) and signs (3 things)
Symptoms-
- PURULENT sputum
- persistent COUGH
- fever
Signs-
- Clubbing
- Crackles
- Inspiratory crepitations
Bronchiectasis investigations
CXR- tram track opacities
Sputum culture
Bloods- WCC/ CRP/ ESR/ TFTs/ LFTs
Bronchiectasis treatment
Antibiotics (ciprofloxacin for pseudonomas) Bronchodilators Corticosteroids (prednisolone) Postural Drainage Surgery
Cause of Cystic Fibrosis
CFTR gene mutation
Cystic Fibrosis pathophysiology
Defect in Cl- secretion and increased Na+ absorption
Cystic Fibrosis investigations
Sweat Test
Guthrie’s Test in neonatal period
CXR- hyperinflation/ bronchiectasis
Signs of Cystic Fibrosis
Cyanosis
Clubbing
Crackles (bilateral)
Cystic Fibrosis treatment (3 things)
Physiotherapy
Ciprofloxacin
Bronchodilators
Cystic Fibrosis associations (3 things)
Pancreatic insufficiency
Diabetes
Male infertility
Asthma Signs and Symptoms
Wheezing
Shortness of Breath
Coughing
Ask about history of ATOPY (tendency to develop allergies)
Asthma pathophysiology
Allergen affects Th2 cells
Th2 cells release IL 4
IL 4 stimulates B lymphocytes
B lymphocytes produce IgE
IgE cause mast cell degranulation
Mast cell degranulation releases histamine
Histamine causes bronchoconstriction
Asthma Investigations
Peak expiratory flow rate (note diurnal variation)
Blood test- INCREASED IgE
CHECK FOR ONEUMOTHORAX and CONSOLIDATIONS in CXR
Treatment of ACUTE ASTHMA
Oxygen Salbutamol HYDROCORTISONE Ipratropium Theophylline
Side effects of SALBUTAMOL
Increased HR
Decreased potassium
Tremor
Anxiety
Side effects of THEOPHYLLINE
GI upsets
Fits
Arrhythmias
GENERAL treatment of Asthma
Salbutamol
Salbutamol + BECLOMETASONE
Salbutamol + salmeterol +
more BECLOMETASONE
Salbutamol + salmeterol + even more BECLOMETASONE
Consider Theophylline or Montelukast (leukotriene receptor antagonist)
COPD PATHOPHYSIOLOGY
CHRONIC BRONCHITIS-
- cough with sputum production for at least 3 months in 2 consecutive years
- Mucus gland HYPERPLASIA and smooth muscle HYPERTROPHY
EMPHYSEMA-
- permanent dilated airways distal to terminal bronchioles with alveolar destruction and bullae formation
- associated with ALPHA-1 ANTITRYPSIN DEFICIENCY and INCREASED ELASTASE ACTIVITY
Causes of COPD
GASES
Genetic Air pollutiion Smoking Exposure through occupation (COAL MINING) Second hand smoking
INVESTIGATIONS of COPD (5 things)
Spirometry- FEV1<80% of predicted value OR FEV1/FVC <0.7
BLOODS- Alpha-1 antitrypsin levels/ WCC/ ESR/ CRP
CXR- hyperinflation/ emphysema/ DIAPHRAGMATIC flattening
ECG- COR PULMONALE
SPUTUM CULTURE
Treatment of COPD
FEV1<50%-
- SABA/ SAMA
- LABA
- LABA + ICS
- LAMA + LABA/ICS
FEV1>50%-
- SABA/ SAMA
- LABA+ ICS
- LAMA + LABA/ICS
OR for both-
SABA/ SAMA
LAMA
LAMA + LABA/ICS
SABA- salbutamol
LAMA- salmeterol
SABA- iptratropium
LABA- tiotropium
Complications of COPD
CLIPPeR
Cor pulmonale (right sided heart failure due to pulmonary hypertension)
Lung cancer
Infections (MACROLIDE usually helps)
Pneumothorax
Polycythaemia
Respiratory Failure
Type 1 (Normal CO2) Respiratory Failure Causes
Pneumonia Pulmonary Embolism Pulmonary Oedema Emphysema Asthma
Type 2 (High CO2) Respiratory Failure Causes
COPD/ Asthma Cerebrovascular disease Opiate overdose Myasthenia gravis Motor neuron disease
Respiratory Failure symptoms
Agitation
Breathlessness
Confusion
Drowsiness/ Fatigue
Signs of Type 2 (High CO2) Respiratory Failure
A flapping tremor
Bounding pulse
Cyanosis
Pink Puffer
Type 1 Respiratory Failure
Blue Bloater
Type 2 Respiratory Failure
Complications of Respiratory Failure
Heart failure
Arrhythmia
Pericarditis
When to consider ABG (6 conditions)
Acute exacerbation of Chronic chest condition
Validate measurements from pulse oximetry
CO2 retention signs (bounding pulse/ flaps)
IMPAIRED CONSCIOUSNESS
Signs of LOW O2- CONFUSION/ CYANOSIS/ HALLUCINATIONS
Unexpected deterioration
Coal Worker Pneumoconiosis
Inhalation of coal dust particles
Dust particles accumulate in parenchyma and are engulfed by macrophages
They die releasing enzymes that result in TISSUE FIBROSIS
Asbestosis (5 things)
Inhalation of asbestos fibres
Fusiform rods are found in macrophages
Associated with MALIGNANT MESOTHELIOMA
PLEURAL PLAQUES in CXR
White asbestos- lowest fibrogenicity
Blue asbestos- highest fibrogenicity
Silicosis (7 things)
AKA Potter’s ROT
Inhalation of silica particles (they can’t be removed by respiratory defences)
Macrophages engulf these and release TNF and cytokines
TNF and cytokines induce fibroblasts- results in fibrosis and collagen deposition
EGGSHELL CALCIFICATION of HILAR LYMPH NODES i CXR
NODULAR lesions in UPPER LOBES
Associated with increased TB infection
Beryliosis
Caused by inhaling beryllium
Causes GRANULOMA formation made up of:
- Giant cells
- Macrophages
- Epithelioid cells
GRANULOMATOUS CONDITIONS (resp) (5 things)
Beryliosis TB Leprosy Sarcoidosis Cat-scratch disease
Siderosis
Inhaling IRON
Benign with NO APPARENT SYMPTOMS or ALTERED LUNG FUNCTIONS
If RESPIRATORY ACIDOSIS
Type 2 Respiratory Failure
If RESPIRATROY ALKALOSIS
Hyperventilation
If METABOLIC ACIDOSIS
Check ANION GAP-
High= increase in internally produced acids Normal= high ingested acids, or high excreted HCO3-
Lung cancer CENTRAL LOCATION (3 things about each)
SQUAMOUS CELL CARCINOMA-
- Associated with SMOKING
- Paraneoplastic PARATHYROID-like actions
- KERATIN PEARLS seen histologically
SMALL CELL CARCINOMA-
- Associated with LAMBERT-EATON SYNDROME
- ACTH and ADH are generated ectopically
- KULCHITSKY CELLS seen histologically
Lung cancer PERIPHERAL LOCATION (4 things about each)
ADENOCARCINOMA-
- Associated with HYPERTROPHIC OSTEOARTHROPATHY
- NOT associated with smoking
- More common in women
- MUCIN-POSITIVE STAINING seen histologically
LARGE CELL CARCINOMA-
- Larger anaplastic cells
- High cytoplasm to nucleus ratio
- Lack light microscopic features of other tumors
- Treated by SURGICAL EXCISION
Lung cancer located in APEX
PANCOAST’s TUMOR-
- Results in Homer’s Syndrome-
1) MIOSIS (pupil’s constricted heavily)
2) PTOSIS (drooping eyelid)
3) ANHIDROSIS (inability)
Lunch Cancer located in PLEURA
MESOTHELIOMA-
- Associated with ASBESTOSIS
- PSAMMOMA BODIES are seen histologically
Deep Vein Thrombosis PATHOPHYSIOLOGY
VIRCHOW’s TRIAD
HYPERCOAGULABILITY-
- Malignancy
- Clotting abnormalities
- Oral contraceptive pill
- Surgery
- Trauma
VENOUS STASIS-
- Heart failure
- Immobility (e.g. surgery)
- Pregnancy
TRAUMA-
- Inflammation
- Previous thrombosis
Signs and Symptoms of Deep Vein Thrombosis
AE POET
Asymptomatic
Engorgement of surface veins
Pain
Oedema
Erythema/ discoloration
Temperature increased in symptomatic leg
Differential diagnosis of DVT
A musculoskeletal injury
Baker’s cyst rupture
Cellulitis
Investigations in DVT
D- DIMER test
B-mode venous compression ultrasonography (for DVT above knee)
Investigations to uncover cause of DVT
TREATMENT for DVT
Anticoagulation therapy with unfractionated HEPARIN or LMWH (DALTEPARIN)
Secondary management with WARFARIN
Signs and Symptoms of PULMONARY EMBOLISM
Pleuritic chest pain Breathlessness Tachycardia/ Tachypnoea Cyanosis HAEMOPTYSIS
Pulmonary Embolism PATHOPHYSIOLOGY
THREE pathways-
1) Platelet factor release- SEROTONIN and THROMBOXAN A2 cause vasoconstriction
2) Decreased alveolar perfusion (underperfused lung leads to diminished gas exchange)
3) Decreased surfactant- leads to ventilation/ perfusion mismatch, hypoxaemia, dyspnoea
Causes of Pulmonary Embolism
DVT
Fat/ air emboli
AMNIOTIC FLUID EMBOLI
Foreign material introduced via IV drug use
Investigations of Pulmonary Embolism (6 things)
D Dimer
Thrombophilia screening if recurrent PE and under 50yo
CXR USUALLY NORMAL!
ECG- Sinus tachycardia
ABG- Hypoxaemia
WELL’s Score
Treatment for Pulmonary Embolism
MASSIVE PE or HAEMODYNAMICALLY UNSTABLE= ALTEPLASE
HAEMODYNAMICALLY STABLE= LMWH or HEPARIN (if renal impairment)
Then give DOAC or WARFARIN
Pneumothorax Signs and Symptoms
CHAD TIPS
Cyanosis
Hypoxia
Auscultation (decreased on affected side)
Dyspnoea
Tachypnoea
Ipsilateral chest pain
Percussion- HYPER RESONANT or NORMAL
Shoulder tip pain
Pneumothorax Pathophysiology
Primary- idiopathic/ rupture of pleural bleb- TALL, YOUNG, SLIM MEN
Secondary- in patients with prior lung condition
Tension- Due to trauma- MEDIASTINAL SHIFT and lung collapse
Causes of Pneumothorax
RALTS CRIT
Rheumatoid arthritis Ankylosing Spondylitis Lung cancer Trauma (stab wound) Sarcoidosis
COPD
Ruptured pleural bleb
Idiopathic pulmonary fibrosis
TUBERCULOSIS
Investigations on Pneumothorax
CXR- follow the PLEURAL LINE, may show tracheal deviation away from lesion
CT scan
ABG- hypoxia
Pneumothorax Treatment
If <2cm- no treatment- advice against diving and flying
If >2cm- aspirate with or without intercostal drain
Tension pneumothorax- immediate decompression with a bore needle inserted into 2nd intercostal space mid-clavicular line
Complications of Pneumothorax (3 things)
Cardiac arrest
Risk of future pneumothorax
Cardiac arrest
Causes of TRANSUDATE Pleural Effusion (3 things)
Increased Venous Pressure-
- Cardiac Failure
- Constrictive Pericarditis
- Fluid Overload
Decreased Protein-
- CIRRHOSIS
- Nephrotic Syndrome
- Malabsorption
Decreased Thyroid
Causes of EXUDATE Pleural Effusion (3 things)
(Increased leakiness of pleural capillaries)
- Infection (pneumonia/ TB)
- Inflammation (SLE/ RA)
- Malignancy
Investigations of Pleural Effusion
CXR- Costophrenic angle blunted
- If there is a FLAT HORIZONTAL UPPER BORDER- there is also a pneumothorax
Pleural Fluid- High Neutrophils (2 things)/ High Lymphocytes (5 things)
HIGH NEUTROPHILS-
- Parapneumonic effusion
- Pulmonary Embolism
HIGH LYMPHOCYTES-
- Malignancy
- TB-
- RA
- SLE
- SARCOIDOSIS
Pleural Fluid- Low Glucose/ Low pH/ High LDH (5 things)
- Malignancy
- SLE
- RA
- TB
- EMPYEMA
Pleural Fluid- High Amylase (4 things)
PANCREATITIS
OESOPHAGEAL RUPTURE
Bacterial pneumonia
Carcinoma
Causes of Sarcoidosis
Fever
Polyarthralgia
Erythema Nodosum
Bilateral Hilar Lymphadenopathy
Causes of Bilateral Hilar Lymphadenopathy
OH SHIM-
Organic Dust Disease
Hypersensitivity Pneumonitis
Sarcoidosis
Histocytosis X
Infection- TB/ Mycoplasma
Malignancy
Non Pulmonary Signs of Sarcoidosis (7 things)
OG ABC
(Organs, glands, arrhythmia, bell’s palsy, calcium)
- Large Liver and Spleen
- Large Parotid and Lacrimal glands
- Arrhythmia/ BBB
- BELL’s PALSY
- HIGH CALCIUM
- HIGH ESR
- HIGH ACE
Sarcoidosis Treatment and Indications for corticosteroids in Sarcoidosis (4 things)
BHL alone doesn’t need treatment
Acute Sarcoidosis- Bed rest and NSAIDs
In severe- IV methylprednisolone or immunosuppressants may be needed
INDICATIONS for CORTICOSTEROIDS-
- Parenchymal Lung Disease
- Hypercalcaemia
- Uveitis
- Neurological or Cardiac involvement
Causes of Upper (5), Mid (2) and Lower (2) Fibrotic Shadowing on CXR
Upper-
- TB
- Hypersensitivity Pneumonitis
- Ankylosing Spindylitis
- RADIOTHERAPY
- PROGRESSIVE MASSIVE FIBROSIS
Mid-
- Sarcoidosis
- Histoplasmosis
Lower-
- Idiopathic pulmonary fibrosis
- ASBESTOSIS
Symptoms (5) and Signs (3) of Idiopathic Pulmonary Fibrosis
Symptoms-
- Dry cough
- Dyspnoea
- Malaise
- Weigh LOSS
- Arthralgia
Signs-
- Clubbing
- Cyanosis
- Crackles
Investigations for Idiopathic Pulmonary Fibrosis
3 for bloods
4 for CXR
Bloods-
- low PaO2
- high CRP
- high Immunoglobulins
CXR-
- Low lung volume
- Bilateral lower zone
- Reticonodular shadows
- Honeycomb lungs
HIGH LYMPHOCYTES- good prognosis
HIGH NEUTROPHILS- bad prognosis
Management of Idiopathic Pulmonary Fibrosis
- O2
- Pulmonary rehabilitation
- Opiates
- NINTEDANIB and PIRFENIDONE are shown to help
- Don’t use high-dose steroids unless diagnosis of IPF is in doubt
Complications of Idiopathic Pulmonary Fibrosis (2 things)
Respiratory Failure
Increased risk of Lung Cancer
Phrenic Nerve innervates these three things
PERICARDIUM
CENTRAL DIAPHRAGM
MEDIASTINAL part of PARIETAL PLEURA
6 Respiratory Manifestations of Rheumatoid Arthritis
- Pulmonary Fibrosis
- Pleural Effusion
- Pleurisy
- Infection
- Pulmonary Nodules
- CAPLAN’s SYNDROME- massive fibrotic nodules with occupational coal dust exposure
What separates the thoracic and abdominal cavities and forms the central tendon of the diaphragm?
SEPTUM TRANSVERSUM
The two diaphragm hernias
Morgnani (anterior)
- minimal effect on lung development
- overall good
Bochdalek (posterior)
- pulmonary hyperplasia
- overall bad
Optimal PaO2 in ventilation
Needs to be 10kPa lower than % of O2 given (so 20kPa for someone on 30% O2)
Chemoceptor locations
Central- located in medulla-
- respond to DECREASED pH in brain interstitial fluid
- does NOT respond to low O2
Peripheral- located in BIFURCATION of carotid arteries and ARCH of AORTA-
- respond to low O2, low pH and increased CO2 in arterial blood
3 Respiratory Centres and 3 points for each of them
MEDULLARY RESPIRATORY CENTRE-
1) Inspiratory and Expiratory neurones
2) Has ventral group which controls FORCED EXPIRATION and has dorsal group which controls INSPIRATION
3) DEPRESSED BY OPIATES
APNEUSTIC CENTRE-
1) LOWER PONS
2) Stimulates INSPIRATION
3) Overridden by Pneumotaxic control to end inspiration
PNEUMOTAXIC CENTRE-
1) UPPER PONS
2) Inhibits INSPIRATION
3) FINE-TUNES RESP RATE
