Respiratory Flashcards
List some precipitants of asthma
Cold Exercise Emotion, stress Allergens (house dust, fur, occupational) Infection Smoking
Which class of blood pressure drug can exacerbate/worsen asthma?
B-blocker
List some symptoms and signs of asthma
Dyspnoea Dry cough, typically worse at night Wheeze Chest tightness Hyperinflated/hyperresonant chest Reduced air entry
What are the clinical features of an acute severe asthma attack?
Unable to complete sentences
Pulse over 100 bpm
Resp rate over 25 breaths/min
PEFR under 50% of predicted
What are the clinical features of an acute life-threatening asthma attack?
Silent chest
Bradycardia
Confusion
PEFR under 33$ of predicted
How is asthma diagnosed using PEFR?
PEFR monitoring shows diurnal variation of greater than 20% on 3 or more days of the week for 2 weeks
How is asthma diagnosed on spirometry?
Obstructive pattern of spirometry with more than 15% reversibility with a bronchodilator
What investigations would you arrange during an acute asthma attack?
PEFR
Sputum culture
FBC, U+E, CRP, ABG
CXR
What lifestyle advice could you give to an asthmatic?
Stop smoking
Avoid allergens/wear protection at work
Write a trigger diary
What is the 1st step in therapy for asthma?
Inhaled SABA (salbutamol) PRN
When do you move to step 2 therapy in asthma?
If using bronchodilator excessively or having night symptoms
What is the 2nd step in therapy for asthma?
SABA
Add regular inhaled steroid (beclometasone)
What is the 3rd step in therapy for asthma?
SABA
Inhaled steroid
Increase dose of inhaled steroid or add in LABA (salmeterol)
What is the 4th step in therapy for asthma?
SABA
Inhaled steroid
Stop LABA if no effect/improvement and add theophylline/montelukast
What is the 5th step in therapy for asthma?
SABA
Inhaled steroid
4th line drug
Oral prednisolone
Outline treatment for acute asthma
Sit up Give high flow O2 Nebulised salbutamol + ipratropium IV hydrocortisone/oral prednisolone Get an anaesthetist; oral theophylline/IV magnesium sulphate
What is the clinical definition of bronchitis?
Cough with sputum production on most days for 3 months in a 2 year period
List some symptoms and signs of COPD
Productive cough
Wheeze
Dyspnoea
Infective exacerbations
Describe a “pink puffer”
Breathless
Not cyanosed
Cachectic
What is meant by hypoxic drive in a patient with COPD?
Respiratory centres are insensitive to CO2 (because it has remained very high for a long period), so they rely on low O2 to maintain respiratory effort
Therefore giving them too much O2 would be detrimental to their breathing
How would you differentiate COPD from asthma on investigation?
Typically little/no bronchodilator reversibility in COPD
Which genetic condition predisposes to emphysema?
Alpha-1-antitrypsin deficiency
What is the 1st step in therapy for COPD?
Inhaled SABA (salbutamol)/inhaled SAMA (ipratropium) PRN
What is the 2nd step in therapy for COPD?
Regular inhaled ipratropium/tiotropium
OR
Regular inhaled salmeterol-beclometasone combo inhaler
What is the 3rd step in therapy for COPD?
Inhaled salmeterol
Inhaled beclometasone
Inhaled ipratropium/tiotropium
Refer to specialist
When would a COPD patient be put on long-term O2 therapy?
If PaO2 less than 7.4 kPa
Outline treatment of acute exacerbation of COPD
24-28% O2 Nebulised salbutamol + ipratropium IV hydrocortisone Oral prednisolone Antibiotic if infection Consider theophylline and/or ventilation
What is pneumonia?
An acute lower respiratory tract infection that causes inflammation of the lungs
Which organisms typically cause community acquired pneumonia (CAP)?
Strep pneumoniae H influenzae Mycoplasma Staph aureus Legionella Moraxella, Chlamydia, Coxiella, gram -ve (atypical)
Which organisms typically cause hospital acquired pneumonia (HAP)?
Staph aureus
Enterobacter
Pseudomonas
Klebsiella
List some causes of aspiration pneumonia
Stroke
Myasthenia gravis
Bulba palsy
Oesophageal disease
Which organism can cause pneumonia in immunocompromised people?
Pneumocystis jirovecii
List some symptoms and signs of pneumonia
Fever Rigors Malaise Anorexia Dyspnoea Cough with purulent sputum Pleuritic chest pain Cyanosis Confusion Chest consolidation - reduced percussion, reduced expansion, crackles
What specific investigation is done for Legionella pneumonia?
Urinary antigen
Define the CURB65 score for CAP
Confusion Urea over 7 Resp rate over 30 BP under 90/60 Age 65 or over Score of 3 = severe
What supportive treatment is advised for pneumonia?
IV fluids
O2
Analgesia
Which antibiotics are used for mild-moderate CAP?
Amoxicillin PO
Doxycycline PO if penicillin allergy
IV clarithromycin if NBM
Which antibiotics are used for severe CAP?
IV co-amoxiclav + PO doxycycline
IV levofloxacin if penicillin allergy
IV clarithromycin if NBM
Which antibiotic should be added if Legionella is suspected?
Rifampicin
Which antibiotic should be added if pneumocystis is suspected?
Co-trimoxazole
Which antibiotics are used for HAP?
Amoxicillin
Metronidazole
+/- gentamicin if severe
Which strain of H influenzae causes pandemics and which causes endemics?
A - pandemics
B - endemics
What investigations are done for influenza?
Nasopharyngeal swab PCR/culture
Serology
What is the treatment for influenza?
Bed rest, fluids, paracetamol
Oseltamivir (Tamiflu)
What is bronchiectasis?
Chronic dilation of airways due to longstanding infection or chronic disease
Which conditions predispose/cause bronchiectasis?
Cystic fibrosis
Ciliary dyskinesia
Kartagener’s syndrome
Post-infection (measles, mumps, HIV, pneumonia, pertussis)
Which organisms are associated with bronchiectasis?
H influenzae
Strep pneumoniae
Staph aureus
Pseudomonas
List some symptoms and signs of bronchiectasis
Persistent cough Purulent sputum Halitosis Clubbing Wheeze Coarse inspiratory crepitations
Outline treatment options for bronchiectasis
Postural drainage, chest physiotherapy
Antibiotics if infection
Bronchodilators, steroid
Surgery if localised
What inheritance pattern does cystic fibrosis follow? What is the genetic defect?
Autosomal recessive
Mutation in CFTR gene on c7, leading to defective Cl- secretion and increased Na absorption in airways
List some symptoms and signs of cystic fibrosis
Failure to thrive, meconium ileus in infants Cough Wheeze Recurrent infections Bronchiectasis GI upset (steatorrhoea) Male infertility Arthritis Nasal polyps Clubbing
What investigations are done for cystic fibrosis?
Sweat test
Genetic screen
Faecal elastase
Outline treatment options for cystic fibrosis
Symptom relief
Chest physiotherapy
Antibiotic if infection
What happens in obstructive sleep apnoea?
Intermittent closure/collapse of pharyngeal airway during sleep
List some causes of obstructive sleep apnoea
Obesity
Narrow anatomy
COPD
Resp depressants (opioids)
List some symptoms and signs of obstructive sleep apnoea
Loud snoring Daytime somnolence Poor sleep, unrefreshed feeling Morning headache Low libido Decreased cognitive performance Large neck and tongue, small mandible
What investigations can be done for sleep apnoea?
Pulse oximetry
Video recording/sleep studies/polysomnography
Epworth sleepiness scale
What is the clinical definition/diagnosis of obstructive sleep apnoea?
15 or more episodes of apnoea during 1 hour of sleep
Outline treatment options for obstructive sleep apnoea
Weight loss Avoid tobacco and caffeine CPAP via nasal mask during sleep Modafinil Surgery to relieve pharyngeal obstruction
List some causes of acute respiratory distress syndrome
Pneumonia Aspiration Vasculitis Trauma Sepsis Haemorrhage Obstetric events Drugs (aspirin, heroin, paraquat)
List some symptoms and signs of acute respiratory distress syndrome
Cyanosis
Dyspnoea
Fine inspiratory crackles
Peripherally warm
What 4 features indicate severe ARDS?
Acute onset
CXR findings (infiltrates)
Pulmonary capillary wedge pressure under 19
Refractory hypoxaemia
Outline treatment of ARDS
Treat cause
Resp support - CPAP, ventilate, inhaled NO
Diuretics
Aerolised surfactant
Define type 1 respiratory failure
V/Q mismatch
Hypoxia (PaO2 under 8) with normal or low PaCO2
List some causes of type 1 respiratory failure
Pneumonia Pulmonary oedema PE Asthma Emphysema ARDS
List some symptoms and signs of type 1 respiratory failure
Signs of hypoxia: cyanosis, dyspnoea, confusion, agitation
Outline treatment of type 1 respiratory failure
Treat cause
15L O2 non-rebreather
Assisted ventilation if required
Define type 2 respiratory failure
Alveolar hypoventilation
Hypoxia with hypercapnia (PaCO2 over 6)
List some causes of type 2 respiratory failure
Asthma COPD Pulmonary fibrosis Obstructive sleep apnoea Reduced resp drive (opioids) Chest wall abnormality
What investigations are done in respiratory failure?
FBC, U+E, CRP, ABG
CXR
Microbiology if afebrile
Outline treatment of type 2 respiratory failure
O2 24%
Keep reassessing ABG’s
Resp stimulant
NIPPV
What is the maximum amount of O2 delivered by a nasal cannula?
1-4 L / min
O2 24-40%
What is the maximum amount of O2 delivered by a Venturi mask
Blue: 24% White: 8% Yellow: 5% Red: 40% Green: 60%
What is the maximum amount of O2 delivered by a non-rebreather mask?
10-15 L / min
O2 60-90%
What is Virchow’s triad with regards to thrombus formation?
Hypercoaguability of blood
Vessel damage
Abnormal flow of blood
List some causes of pulmonary embolism
Pregnancy Immobility Obesity Post-surgery Fracture Malignancy Contraception
List some symptoms and signs of pulmonary embolism
Sudden dyspnoea Pleuritic pain Haemoptysis Pleural rub Hypotension Cyanosis Raised JVP
What investigations are done for suspected pulmonary embolism?
D-dimers (exclusive of PE but not specific)
CTPA is gold-standard; V/Q if unable
ECG
Outline treatment of pulmonary embolism
LMW heparin
Oxygen
Commence warfarin
Thrombolyse if massive PE (alteplase)
How does cor pulmonale arise?
Emphysema leads to hypoxia which causes vasoconstriction and right heart failure
List some symptoms and signs of cor pulmonale
Dyspnoea Fatigue Syncope Cyanosis Raised JVP Tricuspid regurgitation
Outline treatment of cor pulmonale
Encourage exercise and treat causes
Oxygen therapy
Diuretic (furosemide)
Vaccinate against pneumococcus and influenza
What’s the difference between a transudative and exudative pleural effusion?
Transudate: protein content less than 25 g/L
Exudate: protein content more than 35 g/L
List some causes of a transudate pleural effusion
Heart failure Cirrhosis Nephrotic syndrome Malabsorptive diseases Hypothyroidism Meig's syndrome
List some causes of an exudate pleural effusion
Infection Inflammation Cancer Pancreatitis MI
List some symptoms and signs of pleural effusion
Dyspnoea Pleuritic pain Reduced chest expansion Stony dull percussion Reduced breath sounds Tracheal deviation Clubbing Lymphadenopathy
How is pleural effusion investigated?
Palpate/CXR small effusions
USS guides diagnosis and therapeutic aspiration
Pleural aspirate cytochemistry
Where is the landmark for pleural effuson drainage?
Thoracocentesis 5th intercostal space, mid-clavicular line
List causes of pneumothorax
Spontaneous (young, thin male) Asthma COPD Trauma Infection CTD's (Marfan's, EDS) Iatrogenic
List some symptoms and signs of pneumothorax
Sudden pleuritic pain
Dyspnoea
Collapse
Reduced chest expansion and breath sounds
Hyperresonant percusion
Tracheal deviation (tension pneumothorax)
Where are the landmarks for treating pneumothorax?
Needle aspirate 2nd intercostal space mid-clavicular line
Chest drain 5th intercostal space mid-axillary line
What is the treatment for recurrent pneumothorax?
Pleurodesis
What is sarcoidosis?
Multi-system non-caseating granulomatous type IV hypersensitivity
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List some symptoms and signs of sarcoidosis
Erythema nodosum Polyarthralgia Fatigue Weight loss Uveitis Lymphadenopathy Dyspnoea
What is the classic appearance of sarcoidosis on CXR?
Bilateral hilar lymphadenopathy
Describe some typical blood results in sarcoidosis
Raised serum ACE, ESR, Ca
Deranged LFT’s
Outline treatment of sarcoidosis
Bed rest, NSAID
Steroid if symptomatic/organ involvement
IV steroid/immunosuppression if severe
What is extrinsic allergic alveolitis?
Inhalation of foreign antigen causes widespread hypersensitivity reaction with alveolar infiltration and inflammation
List symptoms and signs of extrinsic allergic alveolitis
4-6h post-exposure Fever Rigors Myalgia Dry cough Weight loss Type 1 resp failure Dyspnoea Coarse end inspiratory crackles
Describe CXR signs of extrinsic allergic alveolitis
Upper zone mottling, consolidation
Hilar lymphadenopathy
Honeycomb lung
Outline treatment of extrinsic allergic alveolitis
Allergen avoidance
Oxygen therapy
Oral prednisolone
What is the most common cause of interstitial lung disease?
Idiopathic pulmonary fibrosis
List aetiology/risk factors for lung cancer
Smoking
Asbestos exposure
Radiation
List clinical features of lung cancer
Cough Haemoptysis Dyspnoea Chest pain Weight loss, anorexia Cachexia Anaemia Clubbing Wrist pain (HPOA) Lymphadenopathy
List some complications of lung cancer mets
Bony tenderness Hepatomegaly Confusion, fits, focal CNS signs Recurrent laryngeal nerve palsy (hoarseness) Horner's syndrome (Pancoast tumour)
What investigations would you do for lung cancer?
CXR CT Bronchoscopy + biopsy PET scan Sputum + pleural fluid cytology
Which classification of lung cancer is most common?
Non-small cell lung cancer
In this group, squamous cell carcinoma is the most common
What endocrine hormones are secreted by small cell lung cancer?
ACTH
ADH
What endocrine hormones are secreted by non-small cell lung cancer?
Squamous: secretes PTH, TSH
Outline management of lung cancer
Chemotherapy or palliative radiotherapy for small cell
Surgery for small cell if T1-2 N0 M0
Surgery/curative radiotherapy for non-small-cell if stage I-II
Palliative radiotherapy +/- chemotherapy
When would surgery for lung cancer be contraindicated?
Tumour near hilum FEV1 less than 1.5L Metastasis Stage III/IV disease Vocal cord paralysis SVC obstruction
Which asbestos is more harmful - blue (crocidolite) or white (chrysotile)?
Blue asbestos is more fibrogenic and harmfuil
