Respiratory Flashcards
Bronchiectasis - key features hx
chronic cough sputum production dyspnoea recurrent LRTI \+/- haemoptysis ?smoker pmhx recurrent LRTI as child
Bronchiectasis - key features ex
bibasal crackles chest auscultation
+/- wheeze
digital clubbing
SaO2 N or low
Bronchiectasis - single most useful Ix to diagnose
HRCT chest - abnormally dilated airways, bronchoarterial ratio>1
Bronchiectasis - initial Ix to rule out secondary causes
Initial:
FBC
Sputum MCS x 1 routine resp pathogens
Sputum MCS x 3 morning samples for atypical pathogens
TB serology/PCR quantiferon gold
Total IgE
spirometry - normal in early disease, variable mixed pattern, restrictive or obstructive
+/- Immunoglobulins IgG, IgA, IgM
+/- HIV/HTLV serology
+/- Aspergillus serology
+/- Cystic fibrosis screening - sweat test and CF transmembrane conductor regulator gene mutation
Bronchiectasis - Mx
Immediate:
Referral to resp physician at dx
Physio pulm rehab exercise program
Airway clearance - breathing, cough, neb normal saline, mycolytics
Vaccination - Pneumococcal and influenza
Early treatment of acute exacerbations with appropriate antibiotics
Aug DF bd or doxycycline 100mg bd for 10-14 days
Long term:
prophylactic poabx if 3 or more acute exacerbations in 1yr
+/- palliative care referral
+/- transplant surgery
Bronchiectasis - key features of acute exacerbation
2 or more of: increase cough increased SOB increase volume or purulence of sputum reduction of FEV1 >10% in <2/52
Bronchiectasis - indications for referral to respiratory physician
rapid progression of symptoms
severe symptoms
frequent exacerbations and POABx
haemoptysis
Pertussis/whooping cough - key features
persistent cough for ≥ 2/52 plus:
paroxysms of coughing
inspiratory whoop
post tussive vomiting
mild coryzal symptoms between coughing paroxysms
Pertussis/whooping cough - Ix and timing
Nasopharyngeal swab for PCR - < 2/52 since onset of symptoms. will be neg if >21/7 since onset or 5/7 poabx
Nasopharyngeal swab for MCS - less sensitive, positive after 2-4/52 catarrhal phase.
Pertussis serology (IgA) detectable after 2/5 of symptom onset
Pertussis/whooping cough - Mx
advise goal - prevent disease transmission, doesnt alter disease duration Avoid contact with others until had 5/7 POABx Contact Prophylaxis (same tx as index case) - kids <2yrs, pregnant women 3rd trimester household contacts if < 6/12 baby in household
Pertussis/whooping cough - Tx
azithromycin (10mg/kg, then 5mg/kg) 500mg po stat, 250mg po od for 4/7
Bactrim DS 160/800mg po bd for 7/7
Clarithromycin 500mg po bd for 5/7
Interstitial lung disease - causes “schart rasco”
Sarcoidosis Coal miners pneumoconiosis Histiocytosis Ankylosing spondylitis + Allergic aspergillosis Radiation Tuberculosis
Rheumatoid arthritis Asbestosis Scleroderma Cryptogenic fibrosing alveolitis Other - drugs: amiodarone, MTX, nitrofurantoin, hydralazine, bleomycin
Interstitial lung disease- key features hx
Indolent and progressive
SOB/dyspnoea
dry cough
Interstitial lung disease- key features ex
fine inspiratory crackles
reduced SaO2
digital clubbing
Interstitial lung disease - key Ix
- HRCT chest:
honey combing
ground glass and mosaicism opacity pattern
spirometry - restrictive ventilatory defect - CXR:
basal and peripheral reticulonodular opacities/interstitial opacities (network of lines that form nodules and ring shadows)
+/- medistinal ipsilateral displacement
Fibrocystic changes - Lung biopsy - gold standard for Dx cause of ILD
other to determine cause: spirometry ANA, Anti CCP, ANCA (autoimmune) FBC (infection, eosinophilia) LFT/UEC autoimmune, systemic vasculitis multiorgan involvement
Interstitial lung disease - Mx
prompt referral to respiratory physician
general measures:
stop smoking
identify and tx associated comorbidities:
GORD
pulm HTN
depression/anxiety
Patient education - poor prognosis, planned EOLC discussion
Referral to palliative care
Irretractable dyspnoea - opioids
Interstitial lung disease - Tx for symptom control
dyspnoea - opioids
GORD - PPI
hypoxaemia at rest - O2
acute flare - oral prednisolone 0.5mg/kg/day for 1/12, then maintenance dose 10-15mg od for 2yrs
Pleural effusion - causes
exudative (local disease):
transudative (systemic disease):
Pleural effusion - key features hx
dyspnoea
pleuritic chest pain
cough
Pleural effusion - key features CXR
meniscal edge (concave) of effusion homogenous shadowing/opacity \+/- contralateral mediastinal shift/tracheal displacement
Pleural effusion - key features Ex
tacchypnoea
SaO2 reduced
reduced chest expansion - ipsi or bilaterally
percussion dullness
reduced or absent breath sounds over fluid
reduced vocal resonance
+/- bronchial BS at upper border of effusion
+/- pleural friction rub above level of effusion
Pulmonary hypertension - causes
Cardiac: LV failure Left sided valvular HD (CCF) Intracardiac shunts(congenital VSD/ASD) Liver cirrhosis
Respiratory: COPD Chronic PE Idiopathic pulm arterial HTN from connective tissue disorders Interstitial lung disease OSA
Pulmonary hypertension - RF
Fhx Obesity Asbestis exposure High altitude living cocaine + amphetamine use
Pulmonary hypertension - key features Hx
SOB fatigue dizziness syncope chest pressure/pain ankle swelling/ascites cyanosis - lips and skin heart palpitations
Pulmonary hypertension - complications (3)
cor pulmonale
clots/PE
arrhythmias
Pulmonary hypertension - Ix (5)
ECHO ECG CXR - right ventricle enlargement, evidence of other pulm pathology Spirometry V/Q scan
COPD - key features presentation (3 major, 3 minor)
chronic cough
breathlessness/dyspnoea/SOBOE
+/- increased sputum production
feeling tired/fatigue
increased freq or recurrent LRTI
wheeze/chest tightness
COPD - RF (6)
smoking
genetic - fhx alpha 1 antitrypsin deficiency
long term environmental exposure - dust, fumes, smoke, noxious gases, air pollution
age >40yrs
male gender
PMHx Pulm TB
COPD - dx, Ix modality and criteria
Spirometry :obstructive ventilatory defect, that is not fully reversible
pre- bronchodilator
1. FEV1/FVC <0.7
2. FEV1 <80% predicted
post-bronchodilator
1. FEV1 not increased by ≥ 12%
AND
2. FEV1 not increased by ≥ 200ml
COPD severity criteria
based on % predicted FEV1:
mild = 60-79%%
mod = 40-59%
severe <40%
COPD - Key features Mx (6)
1 confirm dx and severity - FEV1, symptoms
2. optimise function - annual functional assessment and impact of COPD on QOL
encourage regular exercise
refer to pulmonary rehab program
psychosocial support/CBT for depression/anxiety
inhalers/Rx using stepwise approach
3. prevent deterioration -
quit smoking
avoid exposure to air pollution and tobacco smoke
vaccinations - pneumococcal 13+23, influenza
promote and educate on self management early recognition of acute exacerbation
4. develop a care plan - Written action/care plan for maintenance and for exacerbations
Advanced care directive, nominate enduring POA/POG
5. manage exacerbations - po abx + steroids
clinical features of bacterial exac of COPD (3)
increased sputum volume
increased sputum purulence or change in sputum colour
fever
exac of COPD - tx (3)
SABA 4-8puffs 3hrly prn
prednisolone 30-50mg po od 5/7- 14/7
+/- POABx if infectious symptoms:
amoxicillin 500mg po tds 5/7
OR
doxycycline 100mg po bd 5/7
Rx for COPD stepwise approach (4)
- SABA or SAMA monotherapy
- Add LABA or LAMA monotherapy
- Use LABA/LAMA combo therapy
- Add ICS if ≥ 2 exac in 12/12 or FEV1 <50%
ICS+LABA or ICS/LABA + LAMA
COPD - SAMA drug and dose (1)
ipratropium 21mcg MDI 2-4 puffs qid/prn
COPD - SABA drug and dose (2)
salbutamol 100mg 2-4 puffs qid/prn
4-8 puffs 1-4hrly/prn for acute exac
terbutaline 500mcg 1-3 puffs qid/prn
COPD - LABA - drug and dose (3)
formoterol 12mcg bd
salmeterol 50mcg bd
indaceterol 150-300mcg od
COPD - LAMA - drug and dose (4)
spiriva (tiotropium) 10mcg od ***Note, both Braltus® (13 micrograms) and Spiriva® (18 micrograms) inhalers deliver the same tiotropium dose (10 micrograms per capsule). seebri (glycopyrronium) 50mcg od Incruse (umeclidinium) 62.5mcg od Bretaris (aclidinium) 322mcg bd
COPD - LAMA/LABA combo therapy - drugs and dose (3)
spiolto (tiotropium/olodaterol) 2.5/2.5mcg od
anoro (vilanterol/umeclidinium) 25/62.5mcg od
Ultibro (indaceterol/glycopyrronium) 110/50mcg od
COPD - ICS/LABA combo therapy - drugs and dose (3)
symbicort (budesonide/formoterol) 200/6mcg bd
seretide (fluticasone/salmeterol) 125/25mcg - 250/25mcg bd
250/50mcg - 500/50mcg bd
breo ellipta (fluticasone/vilanterol) 100/25mcg od
COPD - ICS/LABA/LAMA combo therapy - drug and dose (1)
trelegy (fluticasone/umeclidinium/vilanterol) 100/62.5/25mcg od
COPD- key features ex (7)
cyanosis reduced chest expansion increased AP diameter/barrel chest hyper resonant chest percussion reduced breath sounds early inspiratory crackles end expiratory wheeze
COPD ddx (8)
heart failure/CCF LRTI Pulmonary embolism Asthma Pleural effusion Arrhythmia Acute pulmonary oedema Pulmonary fibrosis
COPD - Mx goals “COPD-X”
Confirm dx and severity Optimise function Prevent deterioration Develop a care plan X-acerbation management
COPD - initial Ix
spirometry - confirm dx and severity r/o alternative ddx CXR - hyperinflated lungs, diaphragm flattening ECG ECHO FBC UEC
COPD - Non pharmacological Mx (7)
smoking cessation
regular physical exercise
pulmonary rehab
education and promotion of self management for early recognition of acute exacerbation
psychosocial support
CBT for depression/anxiety
Advanced care directive and enduring POA, POG
short and long acting muscarinic antagonist side effects (4)
dry mouth
blurred vision
urinary retention
constipation
short and long acting beta2 agonist side effects (5)
tremor palpitations/tacchycardia headache insomnia hyperglycaemia - high doses (rare)
Latent Tuberculosis/reactivation - key features (6)
fever night sweats weight loss cough for 2-3/52 or more lethargy \+/- haemoptysis
Pulmonary Tuberculosis - key features
pneumonia or pleural effusion SOS
fever
cough
+/- haemoptysis
Pulmonary Tuberculosis - Ix (5)
CXR:
airspace consolidation - patchy areas of consolidation
ipsilateral hilar lymphadenopathy
cavitation (10-30% of cases) - well defined thick walled cavitatory lesion
fibrous contraction in 1 or both upper lobes (apical) or superior parts of the lower lobes (localised caseating/cannonball lesion)
+/- pleural effusion (40% adult 1 pulm TB)
Microbiological testing:
1.sputum x 3 morning samples for mcs - acid-fast, Ziehl Neelsen staining, detects 50% of cases
- TB molecular assays and PCR - high sensitivity, simultaneously detects rifampicin resistance
Suspected Latent TB:
Mantoux skin test - positive 4-6/52 post infection,
false positives after vaccination with BCG (Bacillus Calmette–Guérin)
or exp to environmental mycobacterium species
Quantiferon gold test - detects TB antigens, +ve 6/52 post infection, no false positive results secondary to BCG vaccination
define chronic cough in adults
chronic cough = a cough lasting >8/52
cough lasting 4-8/52 = protracted cough
chronic cough in adults - most common ddx (3)
GORD
Asthma
URTI (rhinosinusitis)
chronic cough in adults - serious causes not to miss (7)
Cancer - lung, bronchus, larynx
Parenchymal lung diseases -
COPD
Interstitial lung disease
Bronchiectasis
Infections - pneumonia, atypical pneumonia, Pulmonary tuberculosis,
CVD - congestive cardiac failure, aortic aneurysm
chronic cough in adults - common causes (6)
ACE inhibitor side effect protracted bacterial bronchitis Pertussis Post-infectious cough Environmental exposures - tobacco, air pollutants OSA
define chronic cough in children
a cough lasting >4/52
cough lasting 2-4/52 = protracted cough
chronic cough in children - most common ddx (2)
protracted bacterial bronchitis
asthma
chronic cough in children - serious causes not to miss (5)
Congenital airway abnormality
Foreign body inhalation
Parenchymal lung diseases -
cystic fibrosis, pulmonary fibrosis, bronchiectasis
Infection - pulmonary TB, pertussis, pneumonia
motor tic/habitual cough/psychogenic cough
Red flag SOS chronic cough in adults (10)
haemoptysis smoker >20yr pack hx smoker >45yrs old with new/altered cough dyspnoea, esp at night or at rest increased sputum production vocal hoarseness systemic features- fever, weight loss, night sweats GORD a/w weight loss, early satiety dysphagia, anaemia and/or GIT bleeding choking/vomiting/feeding difficulties abnormal resp examination findings
Red flag SOS chronic cough in children (7)
dyspnoea, esp at night or rest
recurrent episodes of productive or wet cough
systemic features - fever, weightloss, failure to thrive
feeding difficulties
recurrent pneumonia
stridor + other respiratory noises
abnormal respiratory examination findings
chronic cough in adults - Ix (6)
CXR sputum mcs and pcr spirometry FBC CRP
If above all NAD then do
HRCT chest
Tuberculosis - RF/high risk of exposure in past/present Hx (5)
elderly
post war european+vietnam migrants/refugees
ATSI
Migrants/refugees from TB- burdened countries - Africa, China, Asia, Papua New Guinea, India, East Europe, Italy
HCW from high TB burden countries
Tuberculosis - RF for reactivation (6)
immunocompromised states old age chemotherapy malignancy HIV post transplant recipients
Persistent/chronic cough in adults - key features to ask about in Hx (12)
Hx of possible exposure to infectious causes, Hx of possible exposure to other air pollutants/environmental exposures Hx of contact with unwell people Immunisation Hx weight loss/night sweats/fever haemoptysis sputum production? smoking hx recent travel hx any enlarged lymphnodes any SOB or wheeze or chest pain any dysphagia/choking
Wells criteria for suspected PE (7)
clinical signs of DVT (unilat lower limb pain or oedema)
PE is most likely dx
HR>100
Immobile ≥ 3 days or surgery in last 4/52
PMHx PE or DVT
Haemoptysis
Malignancy within past 6/12
Pulmonary embolism Ix for
a - low risk/pretest probability ≤2
b - mod/indeterminate risk/pretest probability ≤4
c - high risk/pretest probability > 4
a - consider d-dimer
b - d-dimer, if positive do CT pulmonary angiogram
c - CT pulmonary angiogram and venous doppler ultrasound lower limbs
Pulmonary embolism Tx - drug, dosage, duration (3)
LMWH - enoxaparin 1.5 mg/kg daily or 1 mg/kg twice daily.
Warfarin, target INR 2-3,
Apixaban 10mg bd for 1/52, then 5mg bd for 3/12
Rivaroxiban 15mg bd for 3/52, then 20mg od for 3/12
Pulmonary embolism - key features hx (4)
new or worsening SOB, sudden onset
acute onset chest pain - pleuritic, retrosternal
haemoptysis
syncope
Pulmonary embolism - key features examination (6)
tachypnoea ≥20/min tachycardia >100bpm hypoxia/SaO2 <95% SBP <90mmHg crepitations on auscultation of lungs
Pulmonary embolism - RF (9)
age> 65 years immobilisation/bed rest >3 days major surgery (TKR, THR) major trauma (hip or leg #) malignancy, CTX hypercoagulability - thrombophilia, antiphospholipid syndrome, factor 5 leiden excess oestrogen - HRT, COCP, pregnancy PMHx of VTE PMHX CVA
Pulmonary embolism - mx
call ambulance for urgent t/f to nearest ED
DRABCDE
IV thrombolysis - heparin infusion or alteplase in hospital - if haemodynamically unstable, SBP<90, or bradycardia <40/min, hypoxia
Ix for suspected pulmonary embolism in pregnant women
dont do d-dimer (elevated from 2nd trimester on).
Use V/Q scan in lieu of CTPA for pregnant women
Specificity of a test
The greater the specificity of a test, the better it is at ruling the condition in (a positive result is likely to be a true positive);
Sensitivity of a test
the greater the sensitivity, the better the test is at ruling the disease out (a negative result is likely to be a true negative).
4 factors to ask about when assessing Asthma symptom control in adults?
In the last month,
how many days did you experience daytime asthma symptoms?
how many days did you need to use your reliever medication?
did you experience any limitation of your usual activity due to your asthma symptoms?
did you experience any asthma symptoms overnight night or upon waking?
Indications to commence preventer Rx for asthma in adults
asthma symptoms ≥ 2 days in the past month
needed systemic steroids for asthma flare up, or required ED presentation for asthma in the last 12/12
needed HDU/ICU admission for severe asthma symptoms
Waking due to asthma symptoms in last 1/12
Asthma ddx (5)
Resp tract infections - LRTI/URTI COPD inhaled FB CCF bronchiectasis
Asthma - key features ex
widespread expiratory wheeze on chest auscultation
no creps or crackles
no stridor or rhonchi
RR, WOB, SaO2 - may be NAD, doesnt exclude asthma
Temperature - exclude alternative dx
Criteria for poorly controlled asthma (4)
- Poor symptom control in the last month
1 ≤ in the last 1/12:
- daytime asthma symptoms ≥2 days in a week
- any night time asthma symptoms
- reliever needed ≥ 2 days in a week
- any activity limitation due to asthma - frequent severe exacerbations needing prednisolone 2≤ in last 12months
- airflow limitation FEV1 <80% predicted (6hrs≤ since last bronchodilator)
- serious exacerbations needing hospital admission, ICU or ventilation in last 12months
Difficult to treat asthma definition
Asthma that is not controlled despite high dose ICS/LABA, 800mg < budesonide or equivalent per day
Causes of poor asthma control (4)
poor medication compliance
poor inhaler technique
poor avoidance of modifiable RF and triggers
severe asthma, thats difficult to treat
