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Respiratory Flashcards

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1
Q

Asthma aetiology and triggers

A

Type 1 hypersensitivity

Maternal smoking
Atopy
Hygiene hypothesis
Viral illness
Occupation - Flour

Triggers - CHIPEES

  • Cold
  • House dust mites
  • Infection
  • Pets/pollen
  • Exercise
  • Emotion
  • Stress
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2
Q

Asthma pathophysiology

A

ATOPIC

Irritant allergen binds to IgE

Mast cells stimulate an increase in…

  • Leukotrines
  • Histamine
  • TNF-a

This causes…

  • Increased smooth muscle contractility
  • Hypersecretion of mucus
  • Increased vascular permeability

6 hours later…

  • Airway remodelling
  • Airway hypersensitivity
  • Increased goblet cells
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3
Q

Asthma presentation and investigations

A

Diurnal variation

  • Cough
  • Wheeze
  • Dyspnoea
  • Harrison’s sulci
  • Hyperinflation

Investigations - Spirometry - LuFTs

  • FEV1 / FVC < 70% - Obstructive
  • PEF diurnal variation > 20%
  • FEV1 bronchodilator reversibility > 12%
  • FeNO > 40ppb
  • CXR - Hyperinflation
  • Occupational asthma - Weekday/weekend PEF diary
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4
Q

Asthma management - Chronic

A

Try each for 3 weeks before escalating…

  1. SABA - Salbutamol
  2. SABA + ICS (Betamethasone)
  3. SABA + ICS + LTRA (Montelukast)
  4. SABA + ICS + LABA (Salmeterol)
  5. SABA + LTRA + MART (LABA + low-dose ICS)
  6. SABA + LTRA + MART (LABA + moderate-dose ICS)
  7. SABA + LTRA + MART + Theophylline
  8. Refer…

CI medications - NSAIDs / BBs

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5
Q

Asthma housekeeping

  • Severity
  • Questionnaire
  • Response to treatment
A

Assessing severity

  1. How many steroid courses in the past year
  2. How many hospital admissions
  3. ICU admissions

RCP3 questions - AST

  1. ADLs affected?
  2. Symptoms during the day?
  3. Trouble sleeping?
Poor response to treatment - ABCDE
Adherence (compliance)
Bad disease
Choice of drug
Diagnosis
Environment
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6
Q

Asthma attack severity

A

Moderate

  • PEF > 50% predicted
  • SpO2 > 92%
  • Able to speak in full sentences

Severe

  • PEF 33-50%
  • SpO2 < 92%
  • Unable to speak in full sentences

Life-threatening

  • PEF < 33% predicted
  • SpO2 < 92%
  • Silent chest / Brady / Cyanosis / Altered consciousness

PaCO2 normal = Exhaustion = Life-threatening

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7
Q

Asthma management - Acute

A

O SHIT ME

O2
Salbutamol - Nebulised - Repeat up to 3x
Hydrocortisone IV or Prednisolone PO (if tolerated)
Ipatropium - Nebulised - Repeat up to 3x

Theophylline IV (not used much)

Magnesium IV

Escalate - Anaesthetists - Intubation

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8
Q

COPD aetiology and presentation

A 
Smoking
A1AT deficiency
Coal
Cement
Cotton
Grain

Presentation

  • Cough - Productive
  • Dyspnoea
  • Recurrent infections

On examination

  • Wheeze
  • RHF - Cor pulmonale
  • Barrel chest
  • CO2 retention flap
  • Hyper-resonant chest
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9
Q

COPD investigations

A

Spirometry - LuFTS

Severity - FEV1

  • Mild > 80
  • Moderate 50-80
  • Severe 30-50
  • Very severe < 30

FEV1 / FVC < 70% - Obstructive

SpO2
ABG - Hypoxia, hypercapnia, respiratory acidosis
CXR - Hyperinflation, bullae, flattened hemidiaphragms
FBC - Exclude secondary polycythaemia

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10
Q

COPD management

A 
Stop smoking
Vaccinations - Influenza / Pneumococcal
Pulmonary rehab
Prophylactic abx - Azithromycin (can cause long QT)
Mucolytics - Acetylcysteine
  1. SABA (Salbutamol) or SAM (Ipatropium)
  2. Switch SAMA to SABA
    Non-steroid responsive - LABA (Salmeterol) + LAMA (Tiotropium)
    Steroid responsive - LABA + ICS (Beclamethasone) ± LAMA
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11
Q

COPD steroid responsive features

A

FEV variation over time > 400ml
Diurnal PEF variation
Eosinophils ^
Atopy / Asthma

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12
Q

COPD indications for LTOT

A

2 ABG readings 3 weeks apart

PaO2 < 7.3

OR

PaO2 7.3-8.0 + One of the following…

  • Secondary polycythaemia
  • Nocturnal hypoxia
  • Pulmonary HTN
  • Peripheral oedema suggestive of CCF
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13
Q

COPD common infections / exacerbation management / complications

A

HiB - Most common
Moraxella catarrhalis
Strep pneumonia

Exacerbation management

  • Increase SABA dose
  • Short course of corticosteroids
  • Abx if indicated
  • In hospital - Give O2 and nebulisers

Complications

  • Recurrent infections / exacerbations
  • Depression
  • Type 2 RF
  • Secondary polycythaemia
  • Pulmonary HTN - Cor pulmonale
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14
Q

Bronchiectasis aetiology

A

Previous infection

  • Pneumonia
  • TB
  • Bordetella
  • Measles

RA
IBD
CF
Kartagener’s

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15
Q

Bronchiectasis presentation

A 
Productive cough
Clubbing
Crackles
Haemoptysis
Weight loss

Recurrent infections

  • HiB
  • Strep pneumonia
  • Klebsiella
  • Pseudomonas
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16
Q

Bronchiectasis investigations and management

A

FEV1 / FVC decreased - Obstructive
CT - Dilated bronchioles
Sputum culture
Bronchoscopy - Rule out malignancy

Management

  • Mucolytics - Carbocysteine
  • PT
  • Vaccinations - Influenza / Pneumococcal
  • Bronchodilators - Salbutamol
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17
Q

PE risk factors and presentation

A 
OCP
Pregnancy
Malignancy
Recent immobility - Surgery
Thrombotic disorder - Thrombophilia

Presentation

  • Sharp pleuritic chest pain - Worse on inspiration
  • Dyspnoea
  • Cough (+ Haemoptysis)
  • Tachycardia
  • Tachypnoea
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18
Q

PE investigations

A

Wells score > 4 - Request CTPA - Gold standard
(VQ scan is alternative)

Wells score < 4 - D-dimer
D-dimer positive - Request CTPA

CXR - Rule out differential
ECG - Rule out differential - Sinus tachycardia (S1Q3T3)

PERC score - Should all be NEGATIVE to rule out PE

  • Age > 50
  • HR > 100
  • SpO2 < 94%
  • Previous DVT/PE
  • Recent surgery or trauma < 4 weeks
  • Haemoptysis
  • Unilateral leg swelling
  • Oestrogen use
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19
Q

Wells score

A

PAD THAI

Previous VTE
Alternative diagnosis not likely
DVT signs/symptoms
Tachycardia > 100bpm
Haemoptysis
Active malignancy
Immobilisation for 3/7 or surgery in the last 4/52
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20
Q

PE management

A

DOAC - Do not wait if Wells > 4 and CTPA not immediately available
Renal impairment - LMWH

Alteplase - If haemodynamically unstable

Continue DOAC on discharge…

  • 3 months if PE provoked
  • 6 months if PE unprovoked
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21
Q

Pneumonia causative organisms

A

Typical

  • GBS
  • Listeria
  • HiB
  • Strep P
  • TB
  • Klebsiella - Alcoholics
  • Pneumocystitis pneumoniae

Atypical

  • Mycobacterium pneumoniae
  • Legionella
  • Chlamydia pneumonia
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22
Q

Pneumonia presentation and investigations

A

Cough - Productive
Dyspnoea
Systemic features - Fever, tachycardia, tachypnoea

Investigations - CURB-65

  • Confusion - AMT < 8/10
  • Urea > 7
  • RR > 30
  • BP < 90/60
  • Age > 65
Sputum sample - MC&S
CXR - Consolidation
Septic screen?
Urinary antigen for Legionella
Serum electrolytes - Hyponatraemia in Legionella
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23
Q

Pneumonia management

A

0-1 - Treat in community - PO Amox
2 - Consider admission - PO Amox + Clari
3-5 - ICU admission - IV Co-amox + Clari

Pen allergy - Doxy or Clari
Atypical - Clari

HAP - As per local policy

  • Co-amox
  • Taz
  • Cefuroxime
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24
Q

Pneumothorax aetiology

A

Primary

  • Male
  • Sport

Secondary

  • RA
  • IBD
  • COPD - Bullae
  • Cancer
  • Asthma
  • CF
  • Ventilation
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25
Pneumothorax presentation and investigations
Dyspnoea Chest pain - Pleuritic Cough Absent breath sounds Hyper-resonance Unequal chest expansion Tension pneumothorax - Deviated trachea - Respiratory distress Investigations - CXR - Radiolucency - ECG - Rule out differentials
26
Pneumothorax management and complications
Primary 0-2cm - OPD CXR > 2cm - Aspirate Failed - Chest drain Secondary 0-1cm - Monitor 24 hours - IP CXR 1-2cm - Aspirate > 2cm or failed - Chest drain Tension pneumothorax Immediate aspiration - 14G cannula Flail chest - Good knowledge but unsure why this is here - 3 or more ribs broken in 2 or more places OR - More than 5 adjacent rib fractures
27
Pulmonary fibrosis aetiology
Upper zone - SCRATcHES - Sarcoidosis - Coal-workers pneumoconiosis - Radiation - Anky spond - TB - c - Histiocytosis - Extrinsic allergic alveolitis - Silicosis Lower zone - RAID - RA - Asbestosis - Idiopathic pulmonary fibrosis - Drugs - Bleomycin, Amiodarone, Methotrexate
28
Pulmonary fibrosis presentation and investigations
DDDD - Dyspnoea - Dry cough - Diffuse inspiratory crackles - Digital clubbing Investigations -Investigate cause - high resolution CT - Ground glass appearance - FEV1/FVC > 80% - Restrictive - Reduced transfer factor - CXR - Shaggy heart border
29
Pulmonary fibrosis management and complications
Treat cause! - Pulmonary rehab - Vaccinations - Pirfenidone - LTOT - Transplant Complications - P.HTN - Type 2 RF - Cachexia - Depression
30
Sarcoidosis
Type IV hypersensitivity - Afro-Caribbean - 20-40 Presentation - Lungs - Fibrosis upper - Lymphadenopathy - Eyes - Anterior uveitis - MSK - Arthralgia - Skin - Lupus pernio and erythema nodosum - Other - Cardiomyopathy, Bells palsy, parotitis Investigations - CXR - Bilateral hilar lymphadenopathy, upper zone fibrosis - ACE ^ - Serum calcium ^ - Biopsy - Non-caseating granuloma Management - Asymptomatic - Bed rest - Moderate / Severe - Pred PO
31
TB aetiology / presentation
Mycobacterium Tuberculosis RF - Homelessness Presentation - Night sweats - Fever - Cough + Haemoptysis - Weight loss
32
TB investigations
CXR - Bilateral hilar lymphadenopathy and upper zone fibrosis Biopsy - Caseating granuloma Sputum sample - ZN stain for AFB Mantoux test < 6mm - Never exposed 6-15mm - Previous exposure > 15mm - Active TB PCR - NAAT Culture - Lowenstein Jensen LFTs + ^Ca Visual acuity
33
TB management and side-effects
RIPE Rifampicin - 6 months - Orange secretions - Flu-like symptoms - CP450 inducer - Hepatitis Isoniazid - 6 months - CP450 inhibitor - Hepatitis - Peripheral neuropathy Pyrazinamide - 4 months - Hepatitis - Arthralgia - Gout Ethambutol - 4 months - Optic neuritis
34
Lung cancer aetiology and presentation
Smoking! Cough + Haemoptysis Pleuritic chest pain Weight loss Clubbing Apical tumour - SVCO - T1 wasting - Hoarse voice - Horner's syndrome Metastases - Bone - Brain - Liver - Adrenals
35
Lung cancer types
Small-cell carcinoma - Lambert-Eaton syndrome (MG) - ADH - SiADH - Hyponatraemia - ACTH - Cushing's Squamous cell carcinoma - 35% - PTH - Hyperthyroid - HPOA Adenocarcinoma - Not related to smoking - Gynaecomastia - HPOA - Peripheral features Large-cell carcinoma - bHCG - Peripheral features*********
36
Lung cancer investigations and management
CXR CT + Biopsy PTH and calcium profile Sodium - LES in SC Dexamethasone suppression - ACTH Desmopressin test - SiADH Management - Non-SC - Surgial excision / Pneumonectomy - SC - Surgery only in T1 N0 M0
37
ARDS aetiology and presentation
Alveolar oedema due to increased vascular permeability ``` Pancreatitis Shock - Sepsis Trauma DIC Burns ``` Presentation - Dyspnoea - Tachypnoea - Persistent low SpO2 despite ventilation / oxygenation - Bibasal crackles
38
ARDS criteria and management
pANiC 1. pO2 < 40 2. Acute 3. Not attributed to cardiogenic cause 4. CXR - Pulmonary oedema Management - Treat cause - B1 agonist - Dobutamine - CPAP - Mechanical ventilation - ITU ventilation
39
Pleural effusion aetiology
Transudate - Protein < 30 - HF - Cirrhosis - Hypoalbuminaemia - Nephrotic - Hypothyroid - Meig's syndrome Exudate - Protein > 30 - Malignancy - TB - Connective tissue - RA - Pancreatitis - Pneumonia - PE
40
Pleural effusion criteria and presentation
Light's criteria - Protein 25-35 - More likely to be exudate if... - Pleural protein / Serum protein > 0.5 - Pleural LDH / Serum LDH > 0.6 - Pleural LDH > 2/3 upper limit ``` Pleuritic chest pain Dyspnoea Cough Dullness on percussion Decreased breath sounds ```
41
Pleural effusion investigations and management
CXR - Blunted costophrenic angles USS + Pleuritic tap - LDH - Protein - Cytology - Gram staining Investigate cause! Management - Treat cause + Observe - Pleural tap - Diagnostic and therapeutic - Chest tube - If purulent or pH < 7.2 - O2 if sats < 94% - Pleurodesis - Talc
42
Asbestos related disease presentation
``` Pleural plaques - 20-40 years latency Pleural thickening Asbestosis - Lower zone fibrosis - 15-30 years Mesothelioma Lung cancer ``` Fibrosis symptoms - DDDD - Dyspnoea - Dry cough - Diffuse end inspiratory crackles - Digital clubbing
43
Asbestos related disease investigations and management
CT - Fibrosis and pleural plaques Management - Pulmonary rehab - Vaccinations - Pirfenidone - LTOT - Transplant
44
Mesothelioma
Aetiology - Asbestos Presentation - Pleural effusions - Pleuritic chest pain - Dyspnoea - Cough + Haemoptysis - Weight loss Investigations - CXR - Effusion - CT + Biopsy Management - Palliative (+ Compensation) Prognosis - 8-14 months Notify the coroner!
45
Extrinsic allergic alveolitis aetiology and presentation
Type 3 hypersensitivity - Farmer's lung - Malt worker's lung - Bird fancier's lung - Mushroom worker's lung Presentation - The 4 Ds - Dyspnoea - Dry cough - Diffuse end inspiratory crackles - Digital clubbing
46
EAA / Coal worker's lung | Investigations and management
Restrictive picture - FEV1/FVC > 80% CXR/CT - Upper zone fibrosis - Ground glass with honeycombing Management - Remove allergen - O2 therapy if acute - Prednisolone - Advice - Eligible for compensation
47
Coal worker's lung aetiology and presentation
``` Coal dust particles ingested by macrophages Macrophages die and release enzymes Enzymes cause fibrosis May progress to massive pneumoconiosis - Round fibrotic masses - Black sputum ``` Presentation - The 4 Ds! - Dyspnoea - Dry cough - Diffuse end inspiratory crackles - Digital clubbing
48
Goodpasture's
Aetiology - Anti-GBM antibodies - Destroy type 4 collagen - Associated with HLA-DR2 Presentation - Blood - Haemoptysis - Haematuria Investigations - Anti-GBM - U&Es - Renal biopsy - CXR - Rule out other causes of haemoptysis Management - Steroids - Plasma exchange
49
Silicosis
Aetiology - Construction workers - Pottery workers - Miners Presentation - 4 D's Investigations - Egg shell calcification of hilar lymph nodes - CXR - Ground glass and honeycombing - Restrictive picture - FEV1/FVC > 80% Management - Pulmonary rehab - Vaccinations - Pirfenidone - LTOT - Transplant
50
Allergic bronchopulmonary aspergillosis
Aetiology - Allergic to aspergillus fumigatus - Associated with atopy and bronchiectasis Presentation - Cough - Dyspnoea - Wheeze Investigations - Eosinophils ^ - IgE ^ - RAST - Aspergillus - CXR - Tram track opacities Management - Itraconazole - Steroids
51
Pulmonary HTN
mPAP > 25 Aetiology - COPD - Fibrosis - CVD Presentation - Progressive SOBOE - Exertional syncope - Symptoms of RHF Examination - Raised JVP - Loud S2 - Right ventricular heave - Tricuspid regurgitation Investigations - Pulmonary arterial pressures Management - Vasodilator testing +ve - CCB -ve - Sildenafil / Prostacyclin analogue (Iloprost)
52
Oxygen delivery methods
Nasal cannulae - 24-30% - 1-4L - Non-acute or mildly hypoxic patients Venturi mask - 24-60% - Blue - 2-4L - 24% - White - 4-6L - 28% - Yellow - 8-10L - 35% - Red - 10-12L - 40% - Green - 12-15L - 60% Non-rebreather - 85-90% - 15L - Acutely unwell patients Intubation - GCS < 8
53
CPAP vs BiPAP
CPAP - Uses your own respiratory rate - Pneumonia - Type 1 RF - Obstructive sleep apnoea - Heart failure BiPAP - Patients too weak to breathe out - COPD - Atelectasis
54
Respiratory acidosis
Hypoventilation - Unable to blow off CO2 ``` COPD Asthma attack Opioids Obesity GBS MG ```
55
Respiratory alkalosis
Hyperventilation - Blowing off too much CO2 ``` Anxiety Hypoxia Acute pulmonary insult Pneumonia Asthma attack Pulmonary oedema ```
56
Metabolic acidosis
``` Increased anion gap = Acid added to body MUDPILES - Methanol - Uraemia - DKA - Propylene glycol - Iron / Isoniazid - Lactate - Ethylene glycol - Salicylates ``` Normal anion gap... - Retaining H+ - Renal tubular acidosis, Addisons - Losing HCO3- - Diarrhoea
57
Type 1 RF
1 gas abnormal O2 = LOW CO2 = NORMAL V/Q mismatch Low V/Q - Perfused but not ventilated - Airway obstruction - Mucus plug - Asthma - COPD - Airway collapse in emphysema High V/Q - Ventilated but not perfused - PE CO2 normal because venilated/perfused areas can blow off extra CO2 by increasing ventilation rate O2 is low as extra oxygen cannot be absorbed - Maximum amount is already absorbed under normal circumstances
58
Type 2 RF
2 gases abnormal O2 = LOW CO2 = HIGH Alveolar hypoventilation - O2 can't get in - CO2 can't get out ``` Obstructive lung disease - COPD Restrictive lung disease Decreased respiratory drive Neuromuscular disease Thoracic wall disease ```
59
Lactic acidosis
Product of anaerobic metabolism Type 1 - Hypoxic - Producing too much lactic acid - DKA - Starvation - CV / Resp depression Type 2 - Non-hypoxic - Cannot breakdown lactic acid - Secondary to metformin - Poisoning LDH - Increased in tissue breakdown/turnover - Muscle trauma - Stroke / MI - Haemolysis - Cancer - Acute pancreatitis - HIV - Meningitis / Encephalitis
60
Wegener's
Granulomatosis with polyangitis Autoimmune Necrotising granulomatous vasculitis Affects respiratory tract + Kidneys
61
Wegener's clinical features
URT - Epistaxis, sinusitis, nasal crusting LRT - Dyspnoea, haemoptysis Rapidly progressive glomerulonephritis - Haematuria Saddle-shaped nose deformity Fatigue / Malaise Fever / Night sweats Anorexia / Weight loss ``` Cutaneous - Vasculitic rash Ocular - Redness, pain, proptosis, diplopia, blurring MSK - Myalgia, arthralgia, swelling Neuro symptoms VTE ```
62
Wegener's investigations / management / prognosis
Urinalysis - Haematuria cANCA positive (90%) pANCA +ve (25%) CXR/CT - Cavitating lesions FBC - Anaemia Creatinine ^ ESR ^ Renal biopsy - Epithelial cells in Bowman's capsule Steroid - Pred Cyclophosphamide Plasma exchange Prognosis - 8-9 years
63
CF aetiology
AR Defect in CFTR gene Coding for cAMP-regulated chloride channel Delta-F508 on Chromosome 7 Sodium/Chloride pump affected Sodium reabsorption = Water retention = Increased viscosity of secretions
64
CF - Clinical features
Neonates - Meconium ileus (24 hours) - Prolonged jaundice Recurrent chest infections - Staph A - Pseudomonas aeruginosa - Burkholderia - Aspergillus Malabsorption - Steatorrhoea - FTT Liver disease ``` Short stature DM Delayed puberty Rectal prolapse - Bulky stools Nasal polyps Male infertility Female subfertility ```
65
CF diagnosis
Sweat test - Chloride > 60 mEg/L False positives... - Skin oedema - Hypoalbuminaemia - Pancreatic exocrine insufficiency - Malnutrition - Adrenal insufficiency - Glycogen stores disease - Nephrogenic DI - Hypothyroid - Hypoparathyroid - G6PD - Ectodermal dysplasia
66
CF management
Chest PT - Twice daily - Postural drainage - Deep breathing exercises Vaccines! Bronchodilator - Salbutamol Mucolytic - Dornase Alfa Diet - High calorie with high fat Minimise contact with other CF patients Vitamin supplements - Fat soluble - ADEK Pancreatic enzyme supplements - Pancreatin Lung transplant - not in burkholderia/ not isolating from CF patients

3B (23 decks)

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