Respiratory Flashcards
Asthma aetiology and triggers
Type 1 hypersensitivity
Maternal smoking Atopy Hygiene hypothesis Viral illness Occupation - Flour
Triggers - CHIPEES
- Cold
- House dust mites
- Infection
- Pets/pollen
- Exercise
- Emotion
- Stress
Asthma pathophysiology
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
Asthma presentation and investigations
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
Asthma management - Chronic
Try each for 3 weeks before escalating…
- SABA - Salbutamol
- SABA + ICS (Betamethasone)
- SABA + ICS + LTRA (Montelukast)
- SABA + ICS + LABA (Salmeterol)
- SABA + LTRA + MART (LABA + low-dose ICS)
- SABA + LTRA + MART (LABA + moderate-dose ICS)
- SABA + LTRA + MART + Theophylline
- Refer…
CI medications - NSAIDs / BBs
Asthma housekeeping
- Severity
- Questionnaire
- Response to treatment
Assessing severity
- How many steroid courses in the past year
- How many hospital admissions
- ICU admissions
RCP3 questions - AST
- ADLs affected?
- Symptoms during the day?
- Trouble sleeping?
Poor response to treatment - ABCDE Adherence (compliance) Bad disease Choice of drug Diagnosis Environment
Asthma attack severity
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
Asthma management - Acute
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
COPD aetiology and presentation
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
COPD investigations
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
COPD management
Stop smoking Vaccinations - Influenza / Pneumococcal Pulmonary rehab Prophylactic abx - Azithromycin (can cause long QT) Mucolytics - Acetylcysteine
- SABA (Salbutamol) or SAM (Ipatropium)
- Switch SAMA to SABA
Non-steroid responsive - LABA (Salmeterol) + LAMA (Tiotropium)
Steroid responsive - LABA + ICS (Beclamethasone) ± LAMA
COPD steroid responsive features
FEV variation over time > 400ml
Diurnal PEF variation
Eosinophils ^
Atopy / Asthma
COPD indications for LTOT
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
COPD common infections / exacerbation management / complications
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
Bronchiectasis aetiology
Previous infection
- Pneumonia
- TB
- Bordetella
- Measles
RA
IBD
CF
Kartagener’s
Bronchiectasis presentation
Productive cough Clubbing Crackles Haemoptysis Weight loss
Recurrent infections
- HiB
- Strep pneumonia
- Klebsiella
- Pseudomonas
Bronchiectasis investigations and management
FEV1 / FVC decreased - Obstructive
CT - Dilated bronchioles
Sputum culture
Bronchoscopy - Rule out malignancy
Management
- Mucolytics - Carbocysteine
- PT
- Vaccinations - Influenza / Pneumococcal
- Bronchodilators - Salbutamol
PE risk factors and presentation
OCP Pregnancy Malignancy Recent immobility - Surgery Thrombotic disorder - Thrombophilia
Presentation
- Sharp pleuritic chest pain - Worse on inspiration
- Dyspnoea
- Cough (+ Haemoptysis)
- Tachycardia
- Tachypnoea
PE investigations
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
Wells score
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
PE management
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
Pneumonia causative organisms
Typical
- GBS
- Listeria
- HiB
- Strep P
- TB
- Klebsiella - Alcoholics
- Pneumocystitis pneumoniae
Atypical
- Mycobacterium pneumoniae
- Legionella
- Chlamydia pneumonia
Pneumonia presentation and investigations
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
Pneumonia management
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
Pneumothorax aetiology
Primary
- Male
- Sport
Secondary
- RA
- IBD
- COPD - Bullae
- Cancer
- Asthma
- CF
- Ventilation
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
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
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
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
Pulmonary fibrosis management and complications
Treat cause!
- Pulmonary rehab
- Vaccinations
- Pirfenidone
- LTOT
- Transplant
Complications
- P.HTN
- Type 2 RF
- Cachexia
- Depression
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
TB aetiology / presentation
Mycobacterium Tuberculosis
RF - Homelessness
Presentation
- Night sweats
- Fever
- Cough + Haemoptysis
- Weight loss
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
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
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
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*******
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
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
ARDS criteria and management
pANiC
- pO2 < 40
- Acute
- Not attributed to cardiogenic cause
- CXR - Pulmonary oedema
Management - Treat cause
- B1 agonist - Dobutamine
- CPAP - Mechanical ventilation
- ITU ventilation
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
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
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
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
Asbestos related disease investigations and management
CT - Fibrosis and pleural plaques
Management
- Pulmonary rehab
- Vaccinations
- Pirfenidone
- LTOT
- Transplant
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!
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
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
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
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
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
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
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)
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
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
Respiratory acidosis
Hypoventilation - Unable to blow off CO2
COPD Asthma attack Opioids Obesity GBS MG
Respiratory alkalosis
Hyperventilation - Blowing off too much CO2
Anxiety Hypoxia Acute pulmonary insult Pneumonia Asthma attack Pulmonary oedema
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
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
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
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
Wegener’s
Granulomatosis with polyangitis
Autoimmune
Necrotising granulomatous vasculitis
Affects respiratory tract + Kidneys
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
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
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
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
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
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
