Respiratory Flashcards
Acute Asthma
Moderate: Can speak sentences, 75-50% PEFR, <110bpm, <25 RR.
Severe: Can’t speak full sentences, 33-50% PEFR, >110bpm, >25 RR.
Life threatening: <33% PEFR, O2<92%, cyanosis, silent chest and bradycardia.
Management:
Severe and life threatening need hospital admission, moderate if irresponsive.
Give O2 if hypoxaemic.
SABA- through and inhaler, unless LF in which case nebulised
Steroid- Give prednisone 40-50mg daily for 5 days since the attack minimum or until pt recovers.
Ipratropium bromide in severe/life threatening, or that which has not yet responded to therapy.
Magnesium sulphate may be used
After this consider ITU for ventilation and O2.
Acute asthma discharge criteria:
Stable on discharge medication for 12-24hrs
Correct inhaler technique
PEFR>75%
Acute bronchitis
Sore throat, cough, rhinnorhoea or wheeze. May also present with low grade fever.
Inflammation of the trachea and main bronchi, usually due to viral infection. Self resolving within 3wks.
Pneumonia is different as have at least wheeze, dyspnoea or sputum and has focal chest signs, as well as systemic features. Not the case in acute bronchitis.
Manage with rest, lots of fluid intake and analgaesia. Only consider Abx if systemically unwell or have existing co-morbidities. Doxycycline first line, in pregnant/children five amoxicillin.
Acute COPD exacerbation
Infective exacerbation usually due to H. Influenza (most common). May also be due to strep.pneumonia.
Get increase dyspnoea, increase wheeze, increase in sputum or may present hypoxic.
Treat with increased bronchodilator, consider nebulised also. Give 30mg prednisolone for at least 5 days. Usually give Abx with the exacerbation, although not recommended by NICE.
Acute respiratory distress syndrome
Increased alveolar capillary permeability, therefore increased fluid in the alveoli- can lead to non-cardiogenic pulmonary oedema.
Need urgent ITU admission for treatment of hypoxia, general organ support and treatment of underlying condition (Abx)
Features include dyspnoea, increased RR, low O2 sat, bilateral lung crackles.
Allergic bronchopulmonary aspergillosis
Allergic reaction to aspergillos spores.
Bronchoconstriction; cough, wheeze, dyspnoea
Bronchiectasis
Eosinophilia
Treat with glucocorticoids and may need itraconazole as second line
Alpha 1 anti trypsin deficiency
Genetic
Lungs- emphysema
Liver- cirrhosis, adults can develop hepatocellular carcinoma
Treat with no smoking. Supportive; bronchodilators, physio, IV A1AT, lung volume reduction surgery
Asbestos in lungs
Can cause; Pleural plaques Pleural thickening Asbestosis- low lobe fibrosis- dyspnoea and reduced exercise tolerance. Mesothelioma- poor prognosis Lung cancer
Aspiration pneumonia
Inhalation of a foreign object, depending on its acidity can lead to chemical pneumonitis
Main causes; strep pneumonia, staph aureus, h.influenza
Commonly affected at the right middle and lower lobes.
Asthma RF Signs and symptoms Investigations Management (refer to drugs table) NB Step down review every 3 months
Chronic, reversible inflammation of the airways due to type 1 hypersensitivity reaction.
RF; FHx, maternal smoking/viral infection during pregnancy, not breastfed, exposed to smoking early on, occupation, LMBW, exposure to high levels of allergens (dust mites) etc
Signs + symptoms; wheeze, cough (worse at night), tight chest, dyspnoea. Also reduced FEV/FVC ratio, reduced PEFR. Atopy common
Investigations; fractions exhaled nitric oxide (used more as objective test), spirometry (including reversible spirometry), CXR.
Atelectasis
Alveolar collapse usually post op.
Should be considered if within 72hrs post op get dyspnoea/hypoxaemia.
Bilateral hilar lymphadenopathy
Common causes:
Sarcoidosis
TB
Bronchiectasis
Permanent dilation of the bronchi (larger than corresponding artery), due to infection/inflammation. (Pseudomonas, CF)
Gold standard diagnosis is CTPA.
Management: Physio training of sputum clearance Postural drainage Abx for exacerbation Immunisations
CXR
Cavitation; TB, abscess, RA, PE
Lobar lung collapse; lung cancer, asthma, inhaled foreign body. On CXR will see tracheal deviation and mediastinal shift towards collapse, hemidiaphragm elevation
Metastasis; renal (cannon ball mets), breast, colorectal, prostate and bladder.
‘White out lung’; consolidation, pleural effusion, pulmonary oedema, collapse or pneumonectomy. Look at tracheal deviation. Towards the white- pneumonectomy, lung collapse. Central- consolidation, oedema, mesothelioma. Away from the white- pleural effusion
Clubbing causes
Cardiac; congenital cyanotic conditions (Tetrology of fallout), bacterial endocarditis and atrial myxoma.
Respiratory; lung cancer, CF, TB.
Gastro; Crohns, coeliacs, liver cirrhosis.
COPD Causes Features Investigations Management
Chronic bronchitis or emphysema
Main causes are smoking!!! And also A1AT deficiency.
Features; cough (sputum usually), dyspnoea (especially on exertion), wheeze. May get RSHF in extreme cases.
Investigations: Spirometry post bronchodilator, CXR (barrel chest, bullae), FBC (exclude secondary polycythaemia), BMI.
Some pts may require long term oxygen therapy (15hrs/day). Consider if FEV1<30%, cyanosis, polcythaemia, O2 sats<92%. If a person is still smoking don’t offer LTOT.
Management of COPD: SMOKING CESSATION PULMONARY REHAB Annual influenza vaccine One off strep vaccine
Give SABA
If they have features of asthma/responsive to steroids (eosinophilia, previous asthma, atopy etc)- give ICS+LABA.
If not then LABA+LAMA
If still breathless then ICS+LAMA+LABA
Churg-Strauss syndrome
Eosinophillic granulomatosis with polyangitis
Asthma Eosinophilia Dyspnoea Sinusitis pANCA (small vessel vasculitis)
Wegeners syndrome
Granulomatosis with polyangitis
cANCA
Affecting URT- epistaxis, sinusitis, LRT- dyspnoea, haemoptysis and the kidneys- GN.
Also may have saddle nose deformity
Treat with steroids, cyclophosphamide, plasma exchange
Extrinsic allergic alveolitis
Inhalation of an allergen causing a type III hypersensitivity reaction.
Bird fanciers lungs (avian protein from bird dropping)
Farmers lungs
Malt workers lungs
Acute:
Dyspnoea
Cough (dry)
Fever
Chronic: Lethargy Weight loss Dyspnoea Productive cough
Treat by avoiding precipitating factors and glucocorticoids.
NB no eosinophilia. Fibrosis in mid/upper lobes of the lungs.
Idiopathic lung fibrosis
Lung fibrosis due to an unknown cause.
Dyspnoea, dry cough, clubbing.
Treat with pulmonary rehab, meds not effective, poor prognosis.
Lung cancer
Types
Management
Types: Non-small cell: Adenocarcinoma- gynaecomastia Squamous cell- PTHrP (hyperCa), clubbing Large cell
Small cell:
ACTH- Cushing’s syndrome, ADH- hypoNa, Lambert-Eaton syndrome- destruction of NMJ therefore MS like symptoms.
Non small cell management:
Usually can treat with surgery, unless metastatic, poor general health of vocal chord paralysis. Can also do palliative radiotherapy, poor response to chemo.
Small cell management:
Usually present at metastatic state therefore radio/chemotherapy. Unless early diagnosis then consider surgery.
Lung cancer
Features
Investigations
Referral
Features; dyspnoea, haemoptysis, persistent cough, weight loss, chest pain, hoarseness of voice.
Investigate with CXR first. Diagnostic by CT.
Referral via 2ww if >40yrs with unexplained persistent haemoptysis or if CXR suggestive of lung cancer.
Lung fibrosis
Upper lobe:
Extrinsic allergic alveolitis
Sarcoidosis
TB
Lower lobe:
Idiopathic LF
SLE
Drugs
Obstructive sleep apnoea
RF: obesity, HF, large tonsils, Marfans syndrome, large tongue-acromegaly, hypoT,
Leads to- HTN, daytime sleepiness, compensated resp acidosis.
Assess usually with questionnaire, also monitoring sleep with pulse oximetry.
Treat with weight loss, CPAP (continuous positive airway pressure), meds not effective.
Dissociation curves
Shifts to right if increased O2 delivery.
In the cases of raised CO2, raised H+, raised 2,3 BPG, raised temperature.
Opposite for shifting to the left
Oxygen saturation
Aim for 94-98%
COPD- 88-92% (Venturi mask)
COVID- 92-94%
Pleural effusion
Dyspnoea +/- dry cough, chest pain. Dull percussion, reduced BS
Transudate: <30g/L protein HF (common) Hypoalbuminameia HypoT
Exudate: >30g/L protein Infection Connective tissue disorder PE Neoplasia
Investigate with aspiration to determine if transudate or exudate.
Treat the cause, if recurrent then may need pleurodesis, recurrent aspiration or indwelling pleural catheter.
Pneumonia:
Features
CURB65
Inflammation of the alveoli usually secondary to a bacterial infection. Causing dyspnoea, chest pain, productive cough, fever, reduced O2 sats.
Commonly s.pneumonia, h.influenza in COPD, staph.aureus, can also be pneumocystis jiroveci in HIV.
CURB65 Confusion (8/10) Urea>7mM Resp rate>30 BP<90/<60 >65yrs
In community use CRB65. If >2 then hospital admission
Pneumonia
Investigations
Management
CXR- shows consolidation, FBC shows neutrophilia in bacterial infection, urea high and CRP increased, sputum cultures may be collected.
Give O2 if <92%
Mild CAP- 5 day amoxicillin (macrolide if allergy)
Moderate/severe CAP- 7-10 day amoxicillin +macrolide
Pneumothorax
Sudden onset chest pain, dyspnoea, tachycardia and tachypnoea.
RF include lung condition, connective tissue disorder, ventilation.
Management: Primary- if <2cm and asymptomatic then discharge. If <2cm but symptomatic then aspirate. If >2cm then chest drain. Avoid smoking to decrease recurrence.
Secondary- if >50yrs old >2cm +/- symptoms chest drain.
If <2cm then aspirate
Iatrogenic pneumothorax are less likely to recur and will usually resolve with observation.
RA manifestations in the lungs
Pleural effusion
Pulmonary fibrosis
Pleurisy
Infections (immunosuppressed)
Sarcoidosis
Multisystem disorder of unknown aetiology causing caseous granulomas.
Presents with erythema nodusum, bilateral hilar lymphadenopathy, dyspnoea, non-productive cough, malaise, weight loss, hyperCa
Spirometry may show restrictive pattern
Manage with steroids
Silicosis
Inhalation of silicone dioxide, can predispose to developing TB.
NRT- nicotine replacement therapy
Offer to those who are wanting to reduce smoking. Offered supply upto two weeks after their target date.
Don’t offer repeat if not committed.
Side effects: headaches, nausea, flu like symptoms.
Pregnant women should be tested to see if they smoke. First line CBT, motivational interview and self help. Can offer NRT but some contraindicated.
