Respiratory Flashcards
Stepwise long-term management of Asthma
(1) SABA
(2) SABA + ICS
(3) SABA + ICS + LTRA
(4) SABA + ICS + LABA
+/- Continue LTRA depending on their response to LTRA
(5) SABA + MART (w/ Low-dose ICS)
(6) SABA + MART (w/ Moderate-dose ICS)
(7) Specialist
- Muscarinic receptor antagonist
- Theophylline
- High dose ICS
- Oral prednisolone
Causes of upper lobe fibrosis
Tip: CHARTS
Coal workers pneumoconiosis
Hypersensitivity pneumonitis (= EAA)
Ank Spond + Aspergillosis (ABPA)
Radiation
TB
Sarcoidosis + Silicosis
Causes of lower lobe fibrosis
- Asbestosis
-
Connective tissue disorders (except Ank Spond –> Aprical)
- RA
- SLE
- Scleroderma
- Sjogren’s
- Polymyositis / Dermatomyositis
- Idiopathic pulmonary fibrosis
-
Drug-induced pulmonary fibrosis (BS NAME)
- Bleomycin, Busulfan
- Amiodarone
- Nitrofurantoin
- Sulfasalazine
- Methotrexate
Causes of drug related pulmonary fibrosis
Tip: BS NAME
- Bleomycin, Busulfan
- Amiodarone
- Nitrofurantoin
- Sulfasalazine
- Methotrexate
Causes of bilateral hilar lymphadenopathy
- TB
- Sarcoidosis
- Lymphoma
- Pneumoconiosis
- Fungi (Histoplasmosis, Coccidioidomycosis)
Classifying the different severities of Asthma
Define
- Inspiratory capacity
- Vital Capacity
- Total Lung Capacity
- Functional residual capacity
- Residual Volume
- Tidal Volume
- Inspiratory Reserve Volume
- Expiratory Reserve Volume
Borders of safe triangle
- Base of the Axilla
- Pectoralis major (lateral edge)
- 5th ICS
- Latissimus dorsi (anterior border)
Where to insert the chest drain
In safe triangle
ABOVE the rib
Obstructive pattern on spirometry is defined as
↓↓ FEV1 (<80% predicted)
↓ FVC (but decreases by a lesser extent)
FEV1:FVC < 70% (predicted) ==> Obstructive
Causes of obstructive lung disease
Asthma
COPD
Bronchiectasis
Bronchiolitis obliterans
Positive reversibility testing is defined as
↑ FEV1 which is > 200ml AND 12% of the pre-test value
Classification of severity of COPD
Name of classification?
Based on what factor?
GOLD Classification - based on FEV1
Mild COPD: FEV1 > 80% (predicted) - i.e. normalises after medication
Moderate COPD: FEV1 50-79% (predicted)
Severe COPD: FEV1 30-49% (predicted)
Very severe COPD: FEV1 < 30% (predicted)
Restrictive pattern on spirometry is defined as
↓ FEV1 (<80% predicted)
↓ FVC (<80% predicted)
FEV1:FVC ratio (>70%)
i.e. preserved ratio but absolute values for both FEV1 and FVC are both lower
Causes of restritive lung disease
- Pulmonary fibrosis
- Pneumoconiosis / Asbestosis
- Extrinsic allergic alveolitis
- Neuromuscular conditions
- Sarcoidosis
- Kyphoscoliosis / Ankylosing spondyltitis
- Neuromuscular conditions (affecting diaphragm)
Next investigation if
FEV1 < 80% predicted
reduced FVC
FEV1:FVC ratio < 0.7
Bronchodilator reversibility testing
Reversible –> Asthma (increase FEV1 by 200ml and 12%)
Irreversible –> COPD
TLCO is defined as
Total factor of the Lung for Carbon Monoxide
= rate at which a gas will diffuse from the alveoli into the blood
Carbon monoxide is used to test the rate of diffusion
Causes of increased and decreased TLCO
Varenicline
Indication?
MOA?
C/I
Varenicline
Indication: Smoking cessation
MOA: ACh receptor agonist –> reduced cravings of nicotine
C/I in Pregnancy, Breastfeeding
Caution: increased suicidal thoughts
Bupropion
Indication
MOA
C/I
Bupropion
Indication: Smoking cessation
MOA: NA and Dopamine re-uptake inhibitor (atypical antidepressant)
C/I in Pregnancy and Breastfeeding
S/E: Seizures
Pulsus paradoxus
Definition
Causes
Pulsus paradoxus = difference between sBP on inspiration and expiration > 20mmHg
Causes
- Severe asthma
- Cardiac tamponade
PERF variability
cut off?
indicates?
PEFR variability = (highest PEFR - lowest PEFR) / (average PEFR)
Uncontrolled asthma have ↑ variability in PEFR (worse in morning)
Values > 20% variability suggests asthma
Ix for diagnosis of (stable) Asthma
if High probability
if Intermidiate probability
High probability –> Trial treatment + Spirometry (FEV1 or serial PEFR)
Intermediate probability –> Spirometry + Bronchodilator reversibility
Obstructive pattern on spirometry
- ↓↓ FEV1 < 80% (predicted or best)
- ↓ FVC
- FEV1:FVC ratio < 70% (predicted or best)
+ve bronchodilator response
- ↑ FEV1 which is > 200ml AND 12% of the pre-test value
Ix to exclude Asthma if -ve Spirometry and -ve PEFR variability
Bronchial challenge test (using Histamine)
Negative test excludes Asthma
Asthma attack given nebulised salbutamol
ECG changes show?
Salbutamol
S/E: Hypokalaemia
ECG changse: TWI + U waves + long QU interval
Severe Asthma given IV MgSO4
S/E?
IV MgSO4
Hypotension
Severe asthma started on IV aminophylline
S/E?
Monitoring?
IV Aminophylline
cardiac arrhythmias
Requires cardiac monitor
Examples of asthma therapy
SABAs
LABAs
ICS
LTRA
SABAs
- Salbutamol
- Terbutaline
LABAs
- Salmeterol
- Formeterol
ICS
- Beclometasone dipropionate / Clenil
- Budesonide
LTRA
- Montelukast
Signs of well controlled asthma
Signs of well controlled asthma
- No daytime symptoms or waking at night
- No exacerbations
- No need for reliver inhaler
- Ideally, 1 SABA inhaler should last > 1 year
- No limitations on activity (including exercise)
- No asthma attacks
- Normal lung function (PEFR > 80% of predicted or best)
- Minimal S/E from medication
Kartagener’s syndrome triad
Kartagener’s syndrome
bronchiectasis
sinusitis
situs inversus
Causes of bronchiectasis
- Post-infection (Haemophilus influenzae - most common)
- Genetic
- Cystic fibrosis
- a1 antitrypsin
- Kartagener syndrome (ciliary dyskinetic syndrome)
- Yellow nail syndrome
CXR signs in bronchiectasis
CXR signs in bronchiectasis
- Dilated bronchi / Tramtrack opacities
- Caose, thickened bronchidal markings
- Ring shadows (mainly in upper lobes)
- Fibrosis
- Atelelactasis
Ix for bronchiectasis
HR-CT: [best diagnostic method for bronchiectasis]
- Dilated airways
- +/- thickened wall
- Mucus plugs
- Tram-track sign
- Signet ring sign
Management of bronchiectasis
Acute
- Antibiotics
- Bronchodilators
- Hypertonic 3% saline nebs
Long term
- Chest physiotherapy –> postural drainage
- +/- Prophlactic ABx (Azithromycin)
- +/- Surgical resection +/- Lung transplant
a1 anti-trypsin deficiency
Mode of inheritence
Clinical features
a1 anti-trypsin deficiency
Autosomal recessive (PIZZ homozygous)
Presents with COPD in yougng people + Liver cirrhosis
IECOPD - causes
IECOPD - causes
- Viral URTI (30%)
- Rhinovirus (most common viral cause)
- Bacterial infection
- Haemophilus influenzae (most common bacterial cause)
- Streptococcus pneumoniae
- Moraxella catarrhaslia
Diagnosis of COPD
Spirometry
Post-bronchodilator FEV1/FVC ratio < 0.70 on spirometry is diagnostic for COPD
Tx options which improve survival in COPD
ONLY smoking cessation + oxygen supplementation
have been shown to ↑ survival in COPD
Stepwise management of COPD
Stepwise management of COPD
- SABA / SAMA
2A. If Asthmatic features or steroid responsiveness –> LABA + ICS
2B. If no asthmatic features or steroid responsiveness –> LABA + LAMA
- LABA + LAMA + ICS
Cystic fibrosis
- mode of inheritance
Cystic fibrosis
Autosomal recessive
Mutation in CFTR
ΔF508 is the most common mutation in the UK
Most common organsisms in cystic fibrosis
cystic fibrosis
In Children –> S. aureus & H. influenzae
In Adults –> Pseudomonas aeruginosa (85%) + Burkholderia species
Ix for Cystic fibrosis
Ix for Cystic fibrosis
-
Guthrie test: +ve = ↑ immunoreactive Trypsinogen (IRT) at birth
- Part of UK newborn heel prick test performed @ 5-8 days olD
-
If +ve Guthrie test
- Sweat test: Give Pilocarpine + measure [Cl-]
- Genetic testing: confirm patient’s genotype +/- family testing
Acute Tx for meconium ileus due to cystic fibrosis
(1) Gastrografin enemas + Lactulose
(2) Surgery +/- NG decompression
Long term management of CF
- Chest physiotherapy
- +/- Salbutamol +/- ICS +/- Mucolytic +/- Prophylactic ABx
- +/- CFTR modulator
- Ivacaftor (not effective for F508del)
- Orkambi (if F508del homozygous)
- +/- Lung traplant
- HIGH calorie + HIGH fat diet
- Pancreatic enzymes
- Fat-soluble Vitamin supplementation (ADEK)
Cystic fibrosis - presentation
Cystic fibrosis
- Newborns
- Meconium ileus (distal small bowel obstruction)
- Recurrent respiratory infections –> Bronchiectasis
- Prolonged neonatal jaundice
- Failure to thrive
- Steatorrhoea
- Young children
- Rectal prolapse
- Nasal polyps
- Teenagers
- Delayed puberty
- Diabetes mellitus
- Pancreatitis
- Distal intestinal obstructural syndrome (DIOS)
- Infertility
Obstructural sleep apnoea
Ix?
Tx?
Cx?
Obstructural sleep apnoea
Ix: Polysomnography [diagnostic]
Epworth Sleep Scale
Tx: Weight loss +/- CPAP +/- Oral appliance therapy
Complications: Respiratory acidosis
Ix for pulmonary fibrosis
High-resolution CT [diagnostic]
-
Reticular opacities
- Worse at the bases + sub-pleural
- (initially) Ground glass opacities
- (later) Honeycombing
- Traction bronchiectasis
EAA - definition
CXR
Tx?
Extrinsic allergic alveolitis
= Hypersensitivity pneumonitis
= Interstitial inflammatory disease of the alveoli due to inhalation of organic dusts
- Farmer’s lung = Mouldy hay
- Pigeon fancier’s lung = Bird droppings
- Mushroom worker’s lung = Compost (contains thermophilic actinomycetes)
- Humidifier lung = Water-containing bacteria & amoeba
- Maltworker’s lung
- Barley or maltings (contains Aspergillus clavatus)
CXR: reticulonodular opacities with ground glass appearance
Tx: Avoid allergn +/- Prednisolone
Tx and Cx of pulmonary fibrosis
Pulmonary fibrosis
Pulmonary rehabilitation
Anti-fibrotic therapy
-
Perfendione
- C/I: eGFR < 30
- Nintedanib
+/- Lung transplant
Complications: Pulmonary hypertension, Lung cancer
CXR Pleural plaques
Management?
None required as do NOT undergo malignant change
Do NOT require follow up
CXR shows egg shell calcification of hilar lymph nodes in upper lobes
Dx?
Silicosis
Tx for mesothelioma
Tx for mesothelioma
(1) Surgery
(2) Chemotherapy
Types of aspergillus lung disease
Aspergilloma
- pre-existing lung cavity
Allergic broncho-pulmonary aspergillosis (ABPA)
- Type I and III Hypersensitivity reaction to Aspergillus spores
Invasive aspergillosis
- invades lung tissue –> fungal dissemination
Definitive diagnosis of invasive aspergillosis
Galactomannan ELISA test
Definitive diagnosis of invasive aspergillosis
Tx for aspergilloma
Tx for ABPA
Tx for invasive aspergillosis
Tx for aspergilloma
- (1) Surgical resection
- (2) Radiological embolisation
Tx for ABPA
- Oral prednisolone
Tx for invasive aspergillosis
- Voriconazole
- Lipsomal Amphotericin B
Common organisms causing pneumonia
Productive, rusty coloured sputum
Cause
Streptococcus pneumoniae
COPD + Pneumonia
Cause
Haemophilus influenza
Alcoholic + Pneumonia
Klebsiella pneumoniae
Dry cough
Flu-like symptoms
Erythema multiforme
Young adult / Children
Ix? Dx?
Mycoplasma pneumoniae (atypical CAP)
Mycoplasma serology
Stagnant water systems
Dry cough
Flu-like symptoms
Confusion
Hyponatraemia
Diagnosis? Ix?
Legionella pneumophila
Ix: Urinary Legionella antigen
Dry cough
Flu like symptoms
Rose spots
Hepatosplenomegaly
Hepatitis
Dx? Risk factor?
Chlamydia psittaci
Birds
ABx for atypical pneumonia
Usually –> (1) Macrolide
- Azithromycin
- Clarithromycin
- Erythromycin
Chlamydia psittaci or Coxiella burnetii (Q fever) –> (1) Tetracycline (Doxycycline)
Dx of TB
Sputum MC&S for TB –> Smear microscopy + staining for AFB
- Ziehl-Neelson stain (operator dependent)
- Auramine-Rhodamine stain (look for fluorescent AFBs, better sensitivity)
or
Bronchoscopy + Biopsy + Histology
- Caseating granuloma (hallmark of TB)
Paradoxical transient worsening of TB symptoms and lesions following anti-TB therapy
- Fever
- Worsening of CXR
- Lymphadenopathy
- Pleural effusions
Diagnosis?
Immune reconstitution inflammatory syndrome (IRIS)
Tx: Continue anti-TB therapy and anti-retrovirals, consider steroids
S/E of TB medications
Sputum culture grows Mycobacterium malmoense
Next Ix?
Repeat sputum culture
At least 2 samples if from a non-sterile source (as may be contamination)
High Altitude > 2500 m
Headache
Nausea
Fatigue
Dx? Tx? Prevention?
Acute mountain sickness (AMS)
Tx: Descent
Prevention: Acetazolamide
Altitude > 4000 m
Signs of pulmonary oedema
- SOB
- Productive cough
- Pink, frothy sputum
- Bibasal crackles
Dx? Tx?
High altitude pulmonary oedema
Descent +/- Oxygen
Altitude > 4000 m
Headache
Ataxia
Papilloedema
Dx? Tx?
High altitude cerebral oedema (HACE)
Tx: Descent + Dexamethasone
Progressive SOBOE
Fatigue
Loud P2
Dx?
Ix for screening? Ix for diagnosis? Ix for management?
Pulmonary hypertension
Screening Ix –> TTE
Diagnostic Ix –> R heart catherisation (pulmonary arterial pressure > 25mmHg)
Management Ix –> Vasodilator testing (Epoprostenol)
- +ve response –> CCBs (Nifedipine)
- -ve response
- PDE-5 inhibitor (Sildenafil)
- Endothelin receptor antagonist (Ambrisentan)
- Prostacyclin analogue (Epoprostenol, Iloprost)
- Guanylate cyclse stimulator (Riociguat)
Complications: VTE (Tx: + Warfarin), RVH, R heart failure
Progressive SOBOE
Fatigue
Loud P2
Dx?
Ix for screening? Ix for diagnosis? Ix for management?
Pulmonary hypertension
Screening Ix –> TTE
Diagnostic Ix –> R heart catherisation (pulmonary arterial pressure > 25mmHg)
Management Ix –> Vasodilator testing (Epoprostenol)
- +ve response –> CCBs (Nifedipine)
- -ve response
- PDE-5 inhibitor (Sildenafil)
- Endothelin receptor antagonist (Ambrisentan)
- Prostacyclin analogue (Epoprostenol, Iloprost)
- Guanylate cyclse stimulator (Riociguat)
Complications: VTE (Tx: + Warfarin), RVH, R heart failure
Classification of pleural effusion
Causes of pleural effusion
Diagnosis of pleural effusion
Pleural USS + Pleurocentesis
(diagnostic for pleural effusion)
Tx of pleural effusion
Transudative
- Furosemide
- If symptomatic –> USS-guided Thoracentesis
Exudative
- +/- Antibiotics
- If symptomatic –> USS-guided Thoracentesis
- If empyema –> Chest drain
If recurrent
- Pleurodesis
- Pleural catheter drainage
Thoracentesis: Turbid effusion with pH < 7.2, ↓ glucose and ↑ LDH
Diagnosis?
Tx?
Empyema
Chest drain + IV Antibiotics
Tx for stable pneumothorax
Primary pneumothorax in < 50 years old
-
< 2cm AND asymptomatic
- (1) Observation +/- Oxygen + OP CXR
-
> 2cm or symptomatic
- (1) Aspiration +/- repeat aspiration
- (2) Chest drain
-
> 2cm or symptomatic
Secondary pneumothorax or > 50 years old
-
< 1cm AND asymptomatic
- (1) Observation +/- Oxygen + OP CXR
-
1-2cm AND asymptomatic
- (1) Aspiration
- (2) Chest drain
-
1-2cm AND asymptomatic
-
> 2cm or symptomatic
- (1) Chest drain
-
> 2cm or symptomatic
