Respiratory Flashcards
What is the definition of chronic obstructive pulmonary disorder?
A progressive respiratory disorder characterised by an obstructive pattern:
FEV1 = <80% predicted
FEV1/FVC <0.7
Little to no reversibility
What is COPD an umbrella term for?
Chronic Bronchitis - cough, sputum production on most days for 3 months of 2 successive years
Emphysema - histologically as enlarged air spaces distal to terminal bronchioles, with destruction of alveolar walls
What are the risk factors for developing COPD?
Non-modifiable = genetics (alpha 1 antitrypsin deficiency)
Modifiable = SMOKING, environmental exposure e.g. coal, pollution
What are the 3 main symptoms of COPD?
Wheeze
Dyspnoea
Cough + frothy white sputum production
What are the signs of an exacerbation of COPD?
Resp - tachypnoea, hand flap (CO2 retention), quiet breath sounds, hyperressonance
Use of accessory muscles, tripodding
Cyanosis
What is a pink puffer?
Breathless but not cyanosed
↑ alveolar ventilation but O2 cannot cross alveolar wall as efficiently due to thickening/fibrosis
T1RF
(emphysematous)
What is a blue bloater?
Cyanosed but not breathless
↓ alveolar ventilation due to inflammation and ↑ mucous
T2RF + have a hypoxic drive to breath due to chronic CO2 retention
What is the management of an acute exacerbation of COPD?
Neb salbutamol and ipratropium bromide
Titrated o2 - aim for 88-92%
Steroids
IV aminophylline if no response
Consider abx if infective symptoms
When would NIV be considered in a patient with an acute exacerbation of COPD?
Resp rate >30
pH <7.35 and worsening despite treatment
What is the long term pharmacological management of COPD?
1) SABA
2) FEV >50 = LABA or LAMA
FEV <50 = LAMA/LABA + ICS
3) all of it together
What is the non-pharmacological long term management of COPD?
Smoking Cessation!!! Diet advice!!
Influenza + Pneumococcal Vaccine!!!
Pulmonary Rehabilitation
Long Term Oxygen Therapy
Ceiling of care
?Surgery
When would long term oxygen therapy be considered for a patient with COPD?
if pO2 = <7.3 on >2 occassions >3 weeks apart
OR
7.3-8 + other conditions/symptoms e.g. cor pulmonale
What are the 3 most common causative organisms for CAP?
Strep Pneumoniae
H. Influenzae
Moraxella Catarrhalis
What are 3 atypical organisms for CAP?
Staph Aureus
Chlamydia
Mycoplasma Pneumoniae
What is the CURB 65 score?
Confusion
Urea = >7
Respiratory rate = >30
Blood pressure = <90 mmHg
> 65
How should the CURB 65 Score be interpreted?
0-1 = PO abx 2 = Hospital 3 = very bad
When can a hospital acquired pneumonia be diagnosed? What are the 3 most common causative organisms?
within 48hr of admission
Gram-negative enterobacteria
Staph. aureus
Klebsiella
Pseudomonas
Give 2 examples of causative organisms of pneumonia in an immunocompromised host
The normal CAP organisms
Pneumocystis Jiroveci
Aspergillus SPP
How does pneumonia present?
Productive cough (greenish sputum) +/- blood
Shortness of breath
Feeling generally unwell - fever, rigors, anorexia
Pleuritic chest pain
What signs could be elicited on a patient with pneumonia?
Consolidation - Coarse crackles, dull percussion, reduced chest expansion, bronchial breathing
Tachypnoea, tachycardia
cyanosis
What is the management of CAP?
CURB 65
Moderate = PO amoxicillin/doxycyline/clarithromycin
severe = admit for IV abx
What is the management of HAP?
Moderate = PO Co-Amox/ Doxycylcine/ Cefalexin
Severe = IV Piperacillin + Tazobactam, Meropenem, Ceftriaxone, Cefuroxime
How can immunocompromised be protected against their specific pneumonias?
pneumococcal vaccine
give to: >65 Chronic heart, liver, renal, lung conditions Diabetes on meds Immunocompromised
What is the definition of interstitial lung disease?
Fibrosis or chronic inflammation within the parenchyma
leading to a restrictive pattern of breathing on spirometry
What are the causes of upper lobe ILD?
APENT
Aspergillosis (malt worker) Pneumoconiosis (silica, coal) Extrinsic Allergic Alveolitis (pigeon) Seronegative (PAIR) TB
What are the causes of lower lobe ILD?
STAIR
Sarcoidosis Toxins Asbestosis Idiopathic pulmonary fibrosis Rheumatological conditions (RA, SLE, Scleroderma)
Give 6 toxins that may cause lower lobe ILD
Methotrexate Bleomycin Sulfalazine Azathoprine Amiodarone Nitrofurantoin
what are the signs and symptoms of ILD?
Dyspnoea on exertion
Non-productive, paroxysmal cough
Clubbing, cyanosis, fine end-inspiratory crackles, ? weight loss
Define extrinsic allergic alveolitis
Repeated inhalation of an allergen
leads to a type III hypersensitivity reaction in the acute phase.
prolonged and more chronic = type IV hypersensitivity reaction occurs leading to the formation of granulomas.
Define idiopathic pulmonary fibrosis
Infiltration of inflammatory cells and fibrosis of the parenchyma.
Unknown cause but common.
For supportive and palliative care.
What is the gold standard imaging to diagnose ILD?
High resolution computed tomography (HRCT chest)
What is the FEV1/FVC seen in obstructive disease?
<70% or <0.7
What is the FEV1/FVC seen in restrictive disease?
Normal to increased
so >70%
What is a pneumothorax and what is the difference between a primary and a secondary pneumothorax?
Air within the pleural cavity
Primary = no underlying lung condition Secondary = the patient has a pre-existing lung disease
What are the risk factors for pneumothorax?
Non-modifiable:
- Tall and slim
- Underlying lung disease e.g. Asthma or COPD
Modifiable:
- Trauma
- Invasive ventilation/ NIV
- Smoking
Give 4 symptoms of pneumothorax
Shortness of breath
Pleuritic chest pain
Reduced lung expansion
Tracheal deviation if tension
Give 3 signs of pneumothorax
Severe tachypnoea
Mediasteinal shift
hypotension
How can a large pneumothorax be differentiated from a small on CXR?
large = >2cm visible rim between lung margin and chest wall at the level of the hilum
How would a primary pneumothorax be managed in a patient <50?
Asymptomatic + small = o2, monitor and follow up CXR
Symptomatic or large = Aspirate. IF this fails then insert a chest drain
How would a secondary pneumothorax and/or a patient >50 be managed?
Small/asymptomatic = monitor + o2
Large/symptomatic = aspirate then chest drain if fails
What is the location of the chest drain to manage a pneumothorax?
Mid-clavicular line
2nd/3rd intercostal space
What is the management of a tension pneumothorax?
Emergency needle decompression!
Get a cardiothoracic surgeons opinion
Give a complication of pneumothorax
Surgical emphysema
occurs when air/gas is located in the subcutaneous tissues (the layer under the skin).
Which lung cancer is most associated with smoking and hypercalcaemia?
Squamous cell
What are the 4 medications used in TB treatment? Give one side effect for them
RIPE
Rifampicin - red/orange wee + hepatotoxic
Isonazid - peripheral neuropathy
Pyrazinamide - hyperuricaemia (gout)
Ethambutol - blurred vision/reduced visual acuity
Define bronchiectasis
Permanent dilation of the bronchi and bronchioles due to chronic infection
What are the 5 main causes of bronchiectasis?
Post-Infection: Tuberculosis; HIV; Measles; Pertussis; Pneumonia
Bronchial Pathology: Obstruction by foreign body or tumour
Allergic Bronchopulmonary aspergillosis (ABPA)
Congenital: Cystic fibrosis; Kartagener’s syndrome; Primary ciliary dyskinesia; Young syndrome
Hypogammaglobulinaemia
What are the features of an acute moderate asthma attack?
Increasing symptoms but no signs of a severe attack
PEFR 50-75%
What are the features of an acute severe asthma attack?
PEFR 33-50%
RR >25
HR >110
Can’t speak in full sentences
What are the features of an acute life threatening asthma attack?
PEFR <33% PaO2 <8 NORMAL PACO2 poor respiratory effort cyanosis exhaustion/unable to speak/change in conscious levels arrhythmia
What are the features of an acute near fatal asthma attack?
The same as life threatening but they begin to retain CO2 so PaCO2 increases
Describe the features of a safe asthma discharge bundle
Meds - Been on discharge medication for 12-24 hours, check inhaler technique, on PO and I corticosteroids
- PEF >75% of best or predicted
- Own PEF meter and written asthma action plan
- Follow up in 2 days with GP, and in 4 weeks at respiratory clinic
define COPD
progressive obstructive disorder of the airway
Get an obstructive pattern of breathing = (fev1 <80% predicted; fev1/fvc <0.7
little or no reversibility
It includes chronic bronchitis and emphysema.
What does the COPD care bundle comprise of? (5)
1) assess inhaler technique
2) Rescue pack and mx plan
3) Smoking cessation advice and referral
4) Pulmonary rehab referral
5) Follow up within 72 hours
