Respiratory conditions Flashcards
Primary vs Secondary vs Tension pneumothorax
primary- occurs in pt w/o a known resp disease
secondary- occurs in pt w/ pre existing resp disease
tension- severe pneumothorax involving displacement of mediastinal structures and haemodynamic compromise
primary pneumothorax risk factors
smoking
tall and thin
male
young
secondary pneumothorax risk factors
pre existing lung disease eg COPD, lung cancer, CF, pneumonia, connective tissue disorders - Marfan’s, trauma, iatrogenic (subclavian central line insertion)
pneumothroax presentation
Sudden
Dyspnoea
Pleuritic chest pain - ipsilateral
cough
tachypnoea
tachycardia
pneumothorax signs
hyperresonance on percussion
reduced breath sounds
reduced lung expansion
reduced vocal resonance
tension pneumothorax additional findings
tracheal deviation away from it
cyanosis
raised JVP
Management of primary pneumothorax
if rim of air is small (<2cm) and pt isn’t short of breath, then consider discharge and review
If rim of air is >2cm or pt is SoB, attempt aspiration in the 2nd ICS in the MCL. If this fails insert a chest drain in triangle of safety- 5th ICS, mid axillary line, anterior axillary line. Needle’s inserted just above the rib to avoid the NV bundle.
Management of secondary pneumothorax
If pt is >50, and rim of air is >2cm and or pt is SoB, then a chest drain should be inserted.
Attempt aspiration if rim of air is bwt 1-2cm. If aspiration fails, a chest drain should be inserted.
If pneumothorax is less than 1cm, give oxygen and admit for 24 hrs.
Management of Tension pneumothorax
emergency decompression- insert large bore cannula into 2nd ICS along the midclavicular line (same spot as usual aspiration)
chest drain insertion immediately after emergency decompression.
PE symptoms
Sharp chest pain (typically peluritic)
Dyspnoea
Haemoptysis
Sudden onset
if v large- dizziness/syncope
PE investigations
If suspect PE, do 2 levels PE Wells Score:
Clinical signs and symptoms of DVT (leg swelling + pain w/ palpation of deep veins)- 3 points
alternative diagnosis is less liekly than PE - 3 points
heart rate > 100bpm - 1.5 points
immobilisation for over 3 days or surgery in last 4 weeks - 1.5 points
previous DVT/PE- 1.5 points
Haemoptysis - 1 point
Malignancy - 1point
PE likely = more than 4 points
If PE is likely what do you do
CTPA immediately- give DOAC in meantime. IV contaast reveals thrombi
If PE is unlikely what do you do
D dimer test- if positive arrange immediate CTPA, if negative consider alternative diagnosis
Contraindications for CTPA- ie to do V/Q scan
renal impairment, contrast allergy, pregnancy
ECG changes in PE
S1Q3T3- large S waves in lead 1, large Q wave in lead III and an inverted T wave in lead III
ABG findings in PE
Low PaO2 and normal/low PaCO2 a massive PE may also cause metabolic acidosis
PE management
DOAC first line- apixaban or rivaroxaban
If not sutiable then LMWH follwoed by dabigatran or edoxaban or LMWH followed by VKA ie warfarin
If renal impairment is severe then LMWH, unfractionated heparin or LMWH followed by a VKA.
If pt has antiphospholipid syndrome (specifically triple positive in the guidance) then LMWH followed by a VKA should be used.
If VTE was provoked- stop treatment after 3 months.
If VTE was unrpvoked then continue for up to 3 further months
ORBIT Score to assess risk of bleeding
PE w/ haemodynamic instability- Thrombolysis.
Asthma symptoms
Wheeze (bilateral expiratory widespread)
Cough
Breathlessness
Dry cough often nocturnal
Symptoms often worse at night bcos less cortisol (which is immunosuppressive) at night
Asthma signs on examination
Tachypnoea
Hyperinflated chest
Hyperresonance on percussion
decrease air entry (sign of severe illness: silent chest)
wheeze on auscultation
Asthma diagnosis in patients 5-16 year old
Spirometry w/ bronchodilator reversibility test: FEV1:FVC <70% is obstructive. Asthma if there’s obstruction and >12% improvement in FEV1 w/ bronchodilator. Request fractional exhaled nitric oxide if there’s normal spirometry or obstructive spirometry w/ a negative bronchodilator reversibility test. FeNO >= 35 ppb is considered positive in children.
Asthma diagnosis in over 17s
Ask if symptoms better away from work/holidays- refer for occupational asthma specialist if so.
All pts should have spirometry w/ bronchodilator reversibility test. Asthma if obstruction and >12% improvement in FEV1 and increase in volume of 200ml or more. All pts should have FeNO test- >40 ppb is positive in adults
Asthma management
- SABA
- SABA and low dose ICS
- SABA + low dose ICS + LTRA
- SABA + low dose ICS + LABA (+LTRA)
- SABA + MART (combined ICS and LABA) (+LTRA)
- SABA + medium MART (+LTRA)
- SABA + high MART OR LAMA OR theophyline (+LTRA)
Acute Asthma presentation
Worsening dyspnoea
Bilateral wheeze
Cough not responding to salbutamol
Possilbe chest tightness
maybe triggered by a resp tract infection
Use of accessory muscles
moderate acute asthma features
PEFR 50-75% best or predicted
normal speech
RR <25/min
Pulse <110bpm
Severe asthma features
one of these:
PEFR: 33-50% best or predicted
Can’t complete sentences
RR > 25/min
Pulse > 110bpm
Life threatening asthma features
any of these:
PEFR <33% best or predicted
Oxygen sats <92%
normal pCO2 indicates exhaustion and should be classed as life threatening
Mnemonic CHEST:
C- cyanosis
H- hypotension
E- exhaustion, confusion or coma
S- silent chest (airways so tight there’s no air entry)
T- tachycardia (pulse >110)
Acute Asthma management
O SHIT ME:
Oxygen- maintain sats 94-98%
S- Salbutamol
H- Hydrocortisone 100 mg IV or prednisolone 40mg daily which should be continued daily for at least 5 days from the attack
I- ipratropium bromide- SAMA
T- Theophylline. aminophylline infusion if deteriorating
M- Magnesium sulphate IV if severe/life threatening
E- escalate to ICU if severe/life threatening
Pneumonia presentation
Fever
Dry/productive cough- pneumofococcal pneumonia is rust/red coloured
Dyspnoea
Pleuritic chest pain
Myalgia and arthralgia - esp in infections w/ legionella or mycoplasma
Pneumonia signs
Reduced chest expansion
Dullness to percussion
Crepitations or bronchial breathing may be heard over the affected area
Focal coarse crackles
Increased vocal fremitus
CXR protocol for pneumonia
Repeat at least weekly as an inpatient and then at 6 weeks follow up
What determines pneumonia management?
CURB-65
Confusion- abbreviated mental test score <8/10
U- Urea > 7
R- resp rate >=30
B- BP:systolic <=90, diastolic <=60
A- age >65
0-1 points- treat as outpatient
2: secondary care/hospital admission
3: ICU
Pneumonia treatment for 0-1 on CURB 65
Oral amoxicillin for 5 days. If allergy then use a tetracycline (eg doxycycline)/ macrolide (eg clarithromycin)- avoid this in congenital long QT syndrome
Pneumonia treatment for 2 on CURB 65
Dual therapy for 7-10 days. Amoxicillin + macrolide (eg clarithromycin)
Pneumonia treatment for 3-5 on CURB 65
Co-amoxiclav + macrolide for up to 21 days
If pneumonia is severe and/or vomiting?
Use IV abx for 7 days
CAP commonest causes
Streptococcus pneumoniae- commonest cause
Klebsiella pneumoniae- classically in alcoholics and diabetics
Legionella pneumophilia- associated w/ AC systems
Influenza A and B
Fungal causes- Pneumocystis jirovecii - in immunocompromised pts
HAP commonest causes
HAP occurs over course of 48 hrs after admission.
Enterobacteria
Staph Aureus
Pseudomina Aureginosa
Legionella Pneumophila
HAP treatment
within 5 days of admission: coamoxiclav or cephalosporin
over 5 days after admission: Tazocin or cephalosporin or quinolone eg levofloxacin
Pneumonia discharge criteria
don’t discharge if 2 or more of the following:
Temp higher than 37.5
RR >24
HR > 100
SBP <90
Oxygen sats < 90
abnormal mental status
inability to eat w/o assitance
TB presentation
Dyspnoea
Cough w/ or w/o haemoptysis
Constitutional symptoms: eg fever+chills, night sweats, fatigue, loss of appetite, weight loss, lymphadenopathy
TB investigations
Sputum culture- gold standard
CXR
What does CXR show for TB
Apical fibrosis, cavitation, paratracheal hilar lymphadenopathy
TB management and side effects
RIPE for 4 months
Rifampicin- anorexia
Isoniazid- constipation
Pyrazinamide- sideroblastic anaemia
Ethambutol- optic neuritis
Continuation phase- next 4 months is Rifampicin and Isoniazid
Latent TB- screening
Mantoux test- if positive skin will be sensitive to PPD tuberculin and a small hard red bump will develop at site of infection.
BCG vaccination- given to hgih risk infants
Pleural effusion causes
Transudative (low protein)- heart failure, cirrhosis, nephrotic syndrome, hypothyroidism
Exudative (high protein)- infection, pneumonia, inflammation, infiltration-cancer, pancreatitis, drugs, autoimmune disease
pleural effusion symptoms
asymptomatic
Dyspnoea
Cough
Pleuritic chest pain
pleural effusion CXR findings
massive pleural effusion- trachea pushed AWAY from white out
Costophrenic blunting
Unilateral effusion is typically exudative whereas bilateral effusions are typically transudative
Pneumonectomy- Trachea pulled TOWARDS white out
What is COPD
airway obstruction FEV1:FVC <0.7, little or no reversibility
COPD risk factors
> 35
smoking history
alpha 1 antitrypsin deficiency- breaks down elastase, if elastase isn’t being broken down can dmg the connective tissue in the lungs causing COPD and liver cirrhosis
COPD presentation
Chronic cough w/ or w/o sputum
Dyspnoea
Wheeze
can have weight loss, reduced exercise tolerance, ankle swelling, fatigue
COPD signs
Use of accessory muscle of respiration
Hyperinflation (barrel chest)
Decreased expansion
Resonant/Hyperresonant percussion note
Decreased breath sounds
Cyanosis
Cor pulmonale (right side HF) pitting oedema, raised JVP
nicotine stains
bilateral wheeze
COPD investigations
Spirometry- FEV1:FVC- <70%, no reversibility after bronchodilator
COPD severity scale
FEV1:FVC <0.7
FEV1 >=80% - Stage 1 Mild
FEV1 50-79%- Stage 2 Moderate
FEV1 30-49% Stage 3- Severe
FEV1 <30% Stage 4- V severe
COPD management
Smoking cessation- offer NRT< varenicicline or buporpoion as appropriate.
Vaccinations- influenza and pneumococcal
Physiotherapy/pulmonary rehab if indicated.
Treat comorbidities
- SABA or SAMA as required
2 a) No asthma- SABA as required + LABA +LAMA
b) Asthma- SABA/SAMA as required + LABA + ICS - SABA as required + LABA + LAMA + ICS
COPD Exarcebation symptoms
Preceding corzyal symptoms (cold)
Increased breathlessness, cough, sputum. Most common infective cause is haemophilus influenzae
Worsening ankle swelling
COPD exacerbation management
Oxygen to give SaO2 not over 92%
Prednisolone 40 mg/day 7 days
Abx if sputum is purulent or patient has severe illness.
If after 1 hrs still have T2 RF w/ resp acidosis and initial treatment doesn’t correct- urgent ICU opinion. Non invasive ventilation
Many COPD pts have T2 resp failure and therefore admin of too much O2 may be detrimental
Interstitial lung disease causes
Idiopathic pulmonary fibrosis, sarcoidosis, occupational- asbestos, environemtnal eg pigeons, immune- connective tissue disease. Drugs: Any! eg Methotrexate, Amiodarone, Bleomycin, Nitrofurantoin
Interstital lung disease symptoms
Chronic Dyspnoea
Dyspnoea on exertion
Non productive paroxysmal cough
joint swelling/stiffness
smoker
Interstitial lung disease on examination
Fine bi basal crepitations, end inspiratory
Clubbing
interstitial lung disease investigations
CXR- usually at bottom lungs, subpleural, basal and at the end of the lung
High res CT scan- ground glass appearance- basal fibrosis and honeycombing
Lung function tests- in restrictive lung disease like fibrosis- the lungs shrink- so FVC goes down and FEV1 geos down too, but in proportion, so ratio is above 70% in restrictive lung disease
Interstitial lung disease management
antifibrotics if idiopathic pulmonary fibrosis eg pirfenidone. pulmonary rehab to help symptoms.
if connective tissue disease is the cause- immunosuppression- steorids eg prednisolone
sarcoidosis demographics
Afro Caribbeans
20-40 year olds
sarcoidosis presentation
Fever
Erythema nodosum
Polyarthralgia
Bilateral hilar lymphadenopathy
Dry cough
Progressive dyspnoea- decreased exercise tolerance
Chest pain
Enlarged salivary glands
sarcoidosis investigations
FBC- leukopenia/lymphopenia
raised inflammatory markers
ACE levels can be elevated
Lung function tests can be obstructive or restrictive
CXR- bilateral hilar lymphadenopaty
Gold standard- histology from a biopsy
Sarcoidosis management
Treat w/ steroids if PUNCH:
P- parenchymal lung disease
Uveitis
Neurological involvement
Cardiac involvement
Hypercalcaemia (can cause renal dysfunction)
Treat w/ 0.5 mg per kg Prednisolone 2-4 weeks
Most pts get better even w/o treatment
Bronchiectasis- symptoms
persistent cough
lots of purulent sputum
intermittent haemoptysis
Dyspnoea
Wheeze
Bronchiectasis- signs
clubbing
coarse inspiratory crepitations
crackles and low pitch wheezing
Bronchiectasis investigations
High res CT- Signet scan
Bronchiectasis treatment
physiotherapy and airway clearance techniques
Smoking cessation
Pneumococcal and annual influenza vaccinations
treatment w/ short courses of Abx for exacerbations or chest infections
