Respiratory Flashcards
Types of respiratory disease and examples
Obstructive e.g. COPD, asthma, bronchiectasis
Restrictive e.g. sarcoidosis, pulmonary fibrosis
Malignant e.g. small and non small cell carcinomas
Infective e.g. pneumonias, tuberculosis
Difference between obstructive and restrictive lung pathologies
- Obstructive = FEV1 <80% of the predicted value,
FVC reduced but to a lesser extent than FEV1 and
FEV1/FVC ratio < 0.7, mainly disease of breathing tubes. - Restrictive = FEV1 <80% of the predicted value and FVC proprtioanlly reduced too, FEV1/FVC ratio normal (>0.7), mainly disease of lung paranchyma.
Differentials for chest pain
Resp = Costochondritis Tietze syndrome PE Pneumonia Pneumothorax Pleural effusion Non resp = MI, angina, GORD, musculoskeletal, pericarditis.
Differentials for shortness of breathe
Resp = COPD Asthma PE Pneumothorax Pneumonia Interstitial lung disease e.g pulmonary fibrosis Bronchiectasis Non resp = severe anaemia, CHF, ACS, shock
Differentials for cough
Resp = TB Pneumonia Cystic fibrosis Pulmonary fibrosis Asthma COPD Malignancy URTI Non resp = CHF, GORD, ACE inhibitors
Haemoptysis differentials
Lung cancer Tuberculosis PE Bronchiectasis Mitral stenosis Aspergilloma Granulomatosis with polyangiitis Goodpasture's sydrome
Differentials for wheeze
Asthma Inhalation of foreign body COPD Anaphylaxis Bronchiolitis (paeds)
Differentials for stridor
Croup
Epiglottitis
Inhalation of foreign body
Carcinoma of the larynx
Common causes of CAP
Streptococcus pneumoniae
Mycoplasma pneumoniae
Haemophilus influenza
Common causes of HAP
Develops 48 hours or more after hospital admission and that was not incubating at hospital admission.
Pseudomona aeruginosa,
E.coli (gram -ve),
Kledsiella pneumoniae
Risk factor for HAP
Intubation and ventilation machinery used.
Risk factors for CAP
Over 65yrs COPD Resides in care home Cigarette smoking Alcohol use Immunocompromised
Risk stratification for pneumonia
CURB 65 C - confusion U - urea >7mmol/L R - Resp rate >30/min B - SBP <90mmHg or DBP <60mmHg 65 - aged over 65yrs
Score of 0 = low risk. Outpatient care.
Score of 1 or 2 = intermediate risk. Inpatient care.
Score of 3 or 4 = high risk. HDU/ITU care.
Use of CRB65 is increasingly being used as no need to wait for laboratory tests to assess patient’s risk.
History and examination of pneumonia
Hx: Fever Productive cough SOB Malaise and fatigue Pleuritic chest pain Confusion Presence of risk factors
O/E:
High temp, tachycardiac, tachypnoea, hypotensive.
Reduced chest expansion.
Dull to percuss
Increased tactile vocal resonance.
Crackles and reduced air entry on auscultation.
Pleural friction rub
Atypical pneumonia - Mycoplasma pneumoniae and COMPLICATIONS.
Common cause in young adults.
S+S= Dry cough, haemolytic anaemia, lower grade fever, hoarse voice, headache, pharyngitis.
Complications = Steven-Johnson syndrome, Guillian-Barre syndrome, erythema multiforme.
Rx = clarithromycin or doxycycline. (no cell wall so beta-lactams e.g. penicillin are not effective)
Atypical pneumonia - Chlamydia pneumoniae
Biphasic illness.
Lower grade fever, headache, hoarse voice, pharyngitis.
Less sudden onset.
Rx = clarithromycin or doxycycline.
Atypical pneumonia - Chlamydia psitacci
Bird fanciers!
Fever, headache, dry cough, d&v.
Rx = doxycycline.
Atypical causes of pneumonia in immunocompromised
PCP = pneumocystis jirovecii (fungal) S+S = fever, dry cough, exertion dyspnoae, desaaturations on exertion, bilateral creps. Ix = fine peri-hilar infiltrations on CXR, usually spares the apicies and lower lobes, not as focal as typical pneumonia. Rx = co-trimoxazole.
Investigating a patient for pneumonia
ABG - oxygen saturation, are they in respiratory failure.
CXR - consolidation
Sputum culture - mc&s for appropriate antibiotic use.
Blood culture - sepsis screen.
FBC, CRP - WCC and CRP raised.
CXR for patients with suspected CAP who are over 60 years of age and smoke to rule out Ca.
CXR for atypical pneumonia
Diffuse reticular or reticulonodular opacities affecting interstitium.
Complications of pneumonia
Sepsis/Septic shock pleural effusion lung abscess respiratory failure pericardities Jaundice
First line treatment for CAP
Low-medium severity: Amoxicillin 500mg TDS for 5 days.
If penicillin allergic use Doxycyline 200mg on day 1 then 100mg OD for further4 days.
If high severity (based on CRB65):
Co-amoxiclav + clarithromycin or for penicillin allergic Levofloxacin.
First line treatment for HAP
- Non-severe symptoms and signs: Co-amoxiclav If penicillin allergic or high risk of resistance use Doxycycline. - Severe S+S and needing IV: Piperacillin + tazobactam. - Suspected MRSA: Vancomycin
Types of interstitial lung disease and pathophysiology.
Disease of lung interstitium -space between alveolar epithelium and capillary endothelial.
Type of RESTRICTIVE lung disease.
- Idiopathic pulmonary fibrosis.
- Pulmonary fibrosis due to lung disease.
-Pneumoconioses/occupational lung disease.
- Extrinsic allergic alveolitis.
Diseases which cause pulmonary fibrosis
- Connective tissue disease = rheumatoid arthritis, SLE, Sjogren’s syndrome, sarcoidosis.
- Occupational = asbestos, dust, coal, silica.
Irritant inhalation = birds, mould. - Radiation.
- Drugs e.g bleomycin, methotrexate.
Over-riding features of ILD
Dry cough. Digital clubbing Dyspnoea Diffuse fine inspiratory crackles. CXR shadows.
Spirometry result of ILD
FVC proportionally lower than FEV1
Ratio of FEV1/FVC is >80%
Peak incidence of idiopathic pulmonary fibrosis
45-65yrs
S+S of idiopathic pulmonary fibrosis
Weight loss Fatigue Progressive dyspnoea Dry cough Digital clubbing Diffuse fine inspiratory crackles Reduced chest expansion
Complications of idiopathic pulmonary fibrosis
Pulmonary HTN
Cor pulmonale
Cyanosis
Respiratory failure
RFx for idiopathic pulmonary fibrosis
Male Smoker Family history Chronic aspiration e.g. GORD Dust exposure ASK ABOUT OCCUPATION!
Investigations for idiopathic pulmonary fibrosis
CXR/CT-bilateral reticular nodular shaowing, honeycomb lung if severe.
Spirometry - restrictive pattern.
ABG - PaO2 low.
FBC - raised ESR.
Bronchoalveolar lavage - high neutrophils.
Lung biopsy.
Rheumatoid factor, antinuclear factor.
Management of idiopathic pulmonary fibrosis
Oxygen
Pulmonary rehabilitation
Smoking cessation and exercise support
Lung transplant
Caplan’s syndrome
Coal worker pneumoconiosis + rheumatoid arthritis.
Coal workers pneumoconiosis
S+S: Dry cough, dysnpoea, black sputum, exertional dyspnoea.
OCCUPATIOAL Hx!
Ix: restricitive pattern on spiromtry, CXR shoes large nodular fibrotic masses in UPPER lobes.
Rx: financial compensation, avoid exposure, smoking cessation.
Above is similar for Silicosis.
Types of occupational lung disease
Coal workers pneumoconiosis
Asbestosis
Silicosis/ Potter’s rot
Pleural mesothelioma
Asbestosis
5-10yrs from exposure.
S+S: dry cough, digital clubbing, dysnpoea, diffuse inspiratory crackles (velcro).
Blue asbesto fibres are the worst :(
Ix: restrictive pattern on spirometry. CXR shows ground-glass opacification, asbestos bodies (small nodular opacities), sputum microscopy shows asbestos bodies/fibres.
Mx: avoid exposure, smoking cessation, financial compensation.
RF for mesothelioma.
Extrinsic allergic alveolitis
- Hypersensitivity pneumonitis
- Type 3 hypersensitivity reaction, non IgE mediated.
- Sensitised patients inhale allergenand cause inflammation of alveoli and distal bronchioles.
-S+S: acute fever, rigors, SOB, cough, malaise. Chronic weight loss, exertional dyspnoea, type 1 resp failure.
-Ix: raised inflammatory markers, CXR/CT shows diffuse interstitial shadowing, ground-glass, BAL, spirtomtry shows restrictive pattern.
Mx: remove allergen exposure, oxygen, prednisolone, financial compensation, smoking cessation.
Allergens for EAA
Bird fanciers: bird poo Farmers: mushroom spores, mouldy hay Sugar cane fibres Cotton fibres Malt worker exposure Cheese-maker expsoure
FEV1 and FVC definition
FEV1 = the volume exhaled in the first second after deep inspiration and forced expiration. FVC = the total volume of air that the patient can forcibly exhale in one breath after maximum inhalation
Origin of thrombi in PE
Deep veins of calf or pelvis. Dislodge and travel to to pulmonary arterial tree where they come lodged in narrowing vessels.
Risk factors for PE
Immobilisation (long flight, bed rest, post-op)
COCP
Malignancy
Pregnancy and other Hypercoagulable states.
Genetic factors = factor V Leiden, antiphospholipid syndrome, protein C or S deficiency.
Clot formation triad
Virchow’s triad:
Blood stasis
Endothelial damage
Hypercoagulablity / Clotting system activation
Types of embolus
Thrombus Amniotic fluid Fat Air Tumour
Presentation of PE
Sudden onset chest pain Dyspnoea Tachycardia Tachypnoea Cough Syncope Hypotension Fever Increased JVP Signs of shock Unilateral calf swelling Haemoptysis
Investigations in suspected PE
- ECG - S1Q3T3, sinus tachycardia, RBBB.
- ABG - low PaO2 and PaCO2.
- D-Dimer - elevated but not SPECIFIC.
- CT pulmonary angiogram - assess clot size, location, number.
- CXR - exclude other causes, oligaemia of effected area.
FBC, U&E, Clotting screen
Scoring for DVT and PE
Well’s Score
Cause of high d-dimer
PE, sepsis, malignancy, pregnancy, post-operative, DIC, VTE.
Management of suspected PE
- A-E assessment and intervene when needed e.g. IV access, oxygen support.
- Oxygen and analgesia (morphine).
- Anticoagulate - LMWH e.g dalteparin subcut. Commence oral anticoagulant e.g warfarin.
- Thrombolysis if haemodynamically unstable e.g. hypotension. IV streptokinase or alteplase.
Anticoagulation post PE
3 months of warfarin aiming for INR 2.5-3.
Types of pneumothorax
Primary pneumothorax = spontaneous.
Secondary pneumothorax = as a complication of an underlying pulmonary disease.
Traumatic pneumothorax = penetrating or blunt injury to chest e.g. rib fracture, stabbing, poor central venous catheter placement.
Tension pneumothorax = intrapleural pressure > atmospheric pressure. Can occur after any of the above pneumothoraces and is an emergency!
Those at risk of spontaneous pneumothorax
Young, slim tall males with +ve family history.
Those at risk of secondary pneumothorax
COPD Sever asthma Recent invasive medical procedure TB HIV related pneumocystis jirovecii. Marfan's syndrome
S+S of pneumothorax
Sudden onset unilateral pleuritic chest pain.
Extreme and worsening dyspnoea.
Hyper-resonant area on percussion.
Reduced chest expansion.
Absent/diminished breath sounds.
In tension pneumothorax will have trachea deviation and mediastinum shift AWAY from affected side. Hemidiaphragm depression.
Investigations for pneumothorax
ABG
CXR - area of increased opacity, mediastinal shift in tension,
ECG
Management of pneumothorax (NOT TENSION)
If v small and not symptomatic can leave.
If needs intervention: supplementary O2. try and aspirate, if unsuccessful –> percutaneous aspiration/chest drain.
Management of tension pneumothorax
DO NOT CXR - start RX!!!
Immediate needle compression with cannula.
Oxygen therapy.
Chest drain with tube thoracostomy.
Prophylaxis for recurrent pneumothorax
Pleurodesis
Pleuritic chest pain differentials
ACS Aortic dissection Pneumothorax PE Pneumonia Malignancy
Differentials for bilateral hillar lymphadenopathy on X-ray
TIME Mnemonic TB Inorganic dust e.g. silicosis Malignancy (lymphoma, carcinoma) EAA (bird fancier's lung) Sarcoidosis