Respiratory Flashcards
What is the main risk factor for COPD?
Smoking
What condition does alpha1-antitrypsin deficiency make you more susceptible for? And what is the usual age of onset?
COPD (lung disease) and Liver disease. Lung disease usually comes on at the age of 20-50.
What are the signs of emphysema? (PP or BB)
Pink Puffer = Barrel chest, pursed lips, muscle wasting
What is the pathology of emphysema?
Reduced elasting which causes reduced surface area –> collapsed alveoli. Due to reduced recoil this causes air trapping.
What would the blood gases look like for a patient with suspected emphysema?
Normal. Due to the effort they put in (pursed lips).
What are the signs of Chronic Bronchitis? (PP or BB)
BB = Productive cough, oedema and raised JVP. VQ mismatch and right heart failure. Fibrosis may be present and they may be hypoxic.
What is the pathology of Chronic bronchitis?
Hypersecretion and reduced cilia = airway obstruction
What are the 2 main investigations for COPD diagnosis - and what would they show?
Chest X-ray –> flat diaphragm and hyperinflated
Spirometry - reduced exhalation. FEV1:FVC = less than 70%
What is the 1st line treatment for COPD (in most patients - non-pharmalogical)?
SMOKING CESSATION
What are the pharmacological options for patients with COPD? (1st option –> if there are exacerbations –> oral –> aids –> surgery)
Inhaler = B2 agonist (salbutamol) or M3 antagonist
+ corticosteroid inhaler if there are exacerbations
Oral = Theophylline (dilation) or Macrolides - reduce exacerbations for ex-smokers
Aids = Oxygen - long term or ambulatory
Surgery = Lung transplant or resection (remove damaged area so the rest is more efficient)
What is the definition of asthma?
Reversible widespread bronchoconstriction which varies over time.
What are the symptoms of asthma? (is there a time pattern)
Breathlessness Chest tightness Cough Wheeze - diurnal variation
Non-specific triggers of asthma?
Exercise, cold air, fumes and smoke
Specific triggers of asthma?
Allergens
What are the 2 forms of asthma?
Atopic (allergic) or Intrinsic
Atopic asthma - When is the onset? What are other common co-morbidities? What antibody is produced and where? How do they respond to treatment?
Childhood onset
Eczema and rhinitis
IgE - systemically (skin prick test)
Good response to treatment
Intrinsic asthma - When is the onset? What are other common co-morbidities? What antibody is produced and where? How do they respond to treatment?
Late onset (adulthood)
Sinusitis and polyps
IgE - locally
Reduced response to treatment - increased response when steroids are used.
Which cells in the lamina propria are increased in asthma- and what are their roles (3)
Mast cells - histamine release Neutrophils - pro-inflammatory T2 helper cells - become unregulated - IL 13/4 = activate mast cells - IL 9 = Activate MC complex - IL 5 = increased eosinophils
What are the 2 stages of a asthma attack?
Early - rapid FEV1 drop - mast degranulation
Late (4-12 hours) - eosinophil recruitment - gradual FEV1 drop
What are the investigations for asthma (2)?
FeNO - 40ppb +
Spirometry - FEV1:FVC = less than 70%
- What is the reliever treatment for asthma? (when do you move to next treatment) ?
SHort acting B2 agonist (salbutamol)
Move up pathway if using 3+ times a week
- Initial preventer treatment for asthma?
Low dose inhaled corticosteroid - beclomethasone
- Add on preventer treatment for asthma?
Long acting B2 agonist (salmeterol)
- 2nd add on for asthma?
Anti-leukotrienes (Montelukast) - reduce constriction and anti-inflammatory.
Theophylline - Increase cAMP (bronchodilator)
Long acting muscarinic antagonist (ipratropium) - reduce constriction and mucus
- Last resort treatment for asthma (medication)?
Oral steroids (prednisolone)
What are the 3 things to give in a status asthmaticus?
Oxygen + B2 agonist nebuliser + Steroid (IV hydrocortisone/prednisolone)
If the first treatment for status asthmaticus doesn’t work (15-20 mins) what should be given next?
Ipratropium and Magnesium (reduces calcium levels)§
Multisystem disorder characterised by noncaseating granulomatous inflammation - What condition is this?
Sarcoidosis
A patient presents with sudden onset dyspnoea accompanied with some chest pain and a cough. They have a fever and have felt general malaise recently. They also state that they feel their clothes have been getting loser and they haven’t wanted food as much recently. O/E they have red bumps on their legs which are warm to the touch, hard and painful. They also have some anterior uveitis and mention some of their joints have been painful recently. What is the most likely diagnosis and how would you further investigate?
Acute sarcoidosis. Want to do bloods: - increase in inflammatory markers - Normal ACE, IgG, Calcium and ALP Pulmonary function tests Chest x-ray = hilar lymphadenopathy.
What is the treatment/management for acute sarcoidosis?
Majority will resolve spontaneously if more severe than can give bed rest and NSAIDs. Steroids and immunosuppressants if continuously severe.
What are the symptoms of chronic sarcoidosis? (A GRUELLING Disease)
ACE increase Granulomas Arthritis Uveitis Erythema nodosum Lymphadenopathy Lupus pernio Idiopathic Non-caseating Gammaglobulinemia Vitamin D increase (calcium increase)
A patient comes in with left hyper resonance, Right tracheal deviation and a raised JVP. What is the most likely diagnosis and which side?
Left sided tension pneumothorax
What is a pneumothorax?
Air in the pleural space causing partial or total lung collapse
When and in who are pneumothorax most likely to occur?
More likely in men
Peak at 20-30 years and at 60-70 years
What is the presentation of a pneumothorax and how may they differ between the old and young?
Young = chest pain (anterior radiating to the back)
Old = Dyspnoea
Non-productive cough
Tympanic resonance and decreased respiratory murmur over the affected side.
12% can be asymptomatic
What is the difference between type 1 closed pneumothorax and type 2 open pneumothorax?
Type 1/Closed = spontaneous. Usually due to a small visceral pleura laceration which can spontaneously close and the air is reabsorbed. No invasive treatment is required.
Type 2/Open = Most likely due to lung disease (emphysema). Due to a large laceration in the visceral or parietal pleura which is unable to close. There are repeated shifts of the mediastinum and needs to be treated immediately!
How would you deal with a small asymptomatic pneumothorax?
Bed rest - lie of affected side, anticoagulate and give oxygen. Can be discharged.
In what pneumothorax case would you aspirate with a 16-18g cannula? And what would you do after aspirating?
Aspirate in 2nd intercostal space mid clavicular
Large primary or small secondary pneumothorax. Symptomatic patient.
Put on high flow oxygen and observe.
If a patient with a pneumothorax has been aspirated and has not improved or they have a large secondary pneumothorax what would you do?
Put in a chest drain - until there is no leak of air and the lung has expanded and fluid is being removed.
Chest drain into 5th-6th intercostal space mix axillary.
What is a tension pneumothorax?
Ruptured tissue causes a valve to be made so on inspiration air enters the cavity and on expiration it doesn’t leave causing there to be a total lung collapse.
Causing there to be a big mediastinal shift.
What is and when does vena cava kinking occur?
Vena cava gets compressed in a tension pneumothorax causing there to be decreased venous return = reduced cardiac output. This can lead to a arrhythmia.
What is the treatment for a tension pneumothorax?
MEDICAL EMERGENCY!
Immediate aspiration - cannula 2nd intercostal space midclavicular. Then a chest drain to be placed in once the initial relief has occurred.
When would surgery be thought about in the case of pneumothoraces?
Recurrent episodes
First episode but a high risk patient
Prolonged air leak
