Respiratory Conditions A Flashcards
Chronic Brochitis - Description
progressive irreversible airway obstruction due to mucus hypersecretion, type of COPD
Chronic Brochitis - Risk Factors (6)
1) smoking
2) age
3) genetics
4) air pollution (e.g. S2, NO2)
5) work pollution (e.g. mining)
6) Caucasian
Chronic Brochitis - Pathophysiology (7)
1) exposure to irritants and chemicals
2) inflammation
3) hypertrophy and hyperplasia of mucus secreting goblet cells
4) mucus hypersecretion
5) airway obstruction
6) alveoli hypoxia
7) decreased gas exchange
Chronic Brochitis - Pathophysiology (Blue Bloater) (5)
1) alveoli hypoxia
2) renal hypoxia
3) increased EPO secretion —> polycythaemia
4) increased renin secretion —> fluid retention
5) cyanosed and bloated
Chronic Brochitis - Symptoms (3)
1) productive cough (more than emphysema)
2) wheeze
3) cachexia (wasting syndrome: anorexia, weight loss, muscle atrophy, fatigue)
Chronic Brochitis - Signs (4)
1) cyanosis
2) coarse rales (abnormal crackling lung sounds)
3) high JVP
4) peripheral oedema
Chronic Brochitis - Complications (5)
1) pulmonary hypertension —> cor pulmonale
2) type II respiratory failure
3) pneumonia
4) lung malignancy
5) polycythaemia
Chronic Brochitis - Investigations (5/2)
initial 1) spirometry (FEV1<0.8, FEV1/FVC<0.7) 2) pulse oximetry (low) 3) ABG (PaO2<8kPa ± PaCO2>6.7kPa) 4) FBC (high PCV) 5) ECG (RVH) consider 1) chest x-ray (exclusion) 2) chest CT (bronchial wall fibrosis)
Chronic Brochitis - Management (3/6/0)
conservative
1) smoking cessation
2) pulmonary rehabilitation (inc. exercise, education, breathing techniques)
3) vaccinations (annual influenza, pneumococcal)
medical
1) LAMA
2) SAβA (as required)
3) INH corticosteroid (severe)
4) long term domiciliary oxygen therapy (severe, non-smokers)
5) antimucolytic
6) diuretic (oedema)
Emphysema - Description
progressive irreversible airway obstruction due to acinar elastin breakdown, type of COPD
Emphysema - Risk Factors (6)
1) smoking
2) age
3) genetics (e.g. alpha-1-antitrypsin-deficiency)
4) air pollution (e.g. S2, NO2)
5) work pollution (e.g. mining)
6) Caucasian
Emphysema - Pathophysiology (8)
1) exposure to irritants and chemicals
2) inflammation
3) neutrophil elastase breaks down airway elastin
4) decreased airway elasticity
5) airway expansion on inhalation —> decreased gas exchange surface
6) airway collapse on exhalation —> airway obstruction
7) alveoli trapping
8) decreased gas exchange
Emphysema - Pathophysiology (Alpha-1-Antitrypsin-Deficiency) (3)
1) decreased hepatic production of alpha-antitrypsin
2) decreased inhibition of neutrophil elastase
3) emphysema
Emphysema - Pathophysiology (Pink Puffer) (5)
1) airway collapse on exhalation —> airway obstruction
2) exhale slowly through pursed lips
3) increased airway pressure
4) prevent airway collapse
5) flushing and puffing
Emphysema - Symptoms (3)
1) productive cough (less than chronic bronchitis)
2) dyspnoea
3) cachexia (wasting syndrome: anorexia, weight loss, muscle atrophy, fatigue)
Emphysema - Signs (4)
1) pursed lips
2) barrel chest
3) use of accessory respiratory muscles
4) tachypnoea
Emphysema - Complications (4)
1) pneumothorax
2) type II respiratory failure
3) pneumonia
4) lung malignancy
Emphysema - Investigations (5/2)
initial 1) spirometry (FEV1<0.8, FEV1/FVC<0.7) 2) pulse oximetry (low) 3) ABG (PaO2<8kPa ± PaCO2>6.7kPa) 4) FBC (normal) 5) ECG (normal) consider 1) chest x-ray (hyperinflation, bullae) 2) alpha-1-antitrypsin level
Emphysema - Management (3/5/0)
conservative
1) smoking cessation
2) pulmonary rehabilitation (exercise, education, breathing techniques)
3) vaccinations (annual influenza, pneumococcal)
medical
1) LAMA (+ LAβA in persistent dyspnoea)
2) SAβA (as required)
3) INH corticosteroid (severe)
4) long term domiciliary oxygen therapy (severe, non-smoker)
5) alpha-1-antitrypsin replacement (deficiency)
Asthma - Description
chronic airway inflammation characterised by airway obstruction and hyperresponsiveness
Asthma - Causes (7)
1) genetic (ADAMS-33)
2) atopy (eczema, atopic dermatitis, allergic rhinitis)
3) family history (inc. atopy)
4) clean childhood environment
5) smoking (inc. passive, e.g. maternal smoking)
6) obesity
7) gastro-oesophageal reflux disease
Asthma - Risk Factors (9)
1) allergen
2) pollution
3) dust
4) occupation (e.g. wood dust, bleaches, dyes, latex)
5) cold air
6) exercise
7) emotion
8) NSAID
9) βB
Asthma - Pathophysiology (Acute Exacerbation) (14)
1) inhalation of allergen
2) allergen activates dendritic cells
3) dendritic cells attract and activate t helper 2 cells
4) t helper 2 cells activate plasma cells
5) plasma cells produce IgE
6) IgE bind to mast cells
7) allergen binds to IgE/mast cell complex
8) mast cell releases histamine
9) histamine causes 1st wave bronchoconstriction and inflammation (after minutes)
10) t helper 2 cells activate eosinophils
11) eosinophils release major basic protein
12) major basic protein induces mast cell histamine release
13) histamine causes 2nd wave of bronchoconstriction and inflammation (after hours)
14) re-inhalation of allergen recurs process
Asthma - Pathophysiology (Chronic Remodelling) (4)
1) goblet cell metaplasia —> increased mucus
2) mast cell hyperplasia —> increased histamine
3) smooth muscle hypertrophy —> airway narrowing
4) basement membrane thickening —> airway narrowing
Asthma - Pathophysiology (Asthmatic Triad) (3)
1) airway obstruction
2) airway hyperresponsiveness
3) airway inflammation
Asthma - Symptoms (4)
1) dyspnoea
2) wheeze
3) dry irritating cough
4) cachexia (wasting syndrome: anorexia, weight loss, muscle atrophy, fatigue)
Asthma - Signs (4)
1) symptoms worse at night
2) use of accessory respiratory muscles
3) hyperinflated chest
4) hyperresonant percussion
Asthma - Signs (Severe Attack) (3)
1) tachypnoea
2) tachycardia
3) inability to complete sentences in one breath
Asthma - Signs (Life-Threatening Attack) (3)
1) cyanosis
2) bradycardia
3) silent chest (inability to generate enough airflow to wheeze due to fatigue/exhaustion)
Asthma - Complications (4)
1) respiratory tract infection
2) pneumonia
3) pneumothorax
4) type II respiratory failure
Asthma - Investigations (3/4)
initial 1) peak expiratory flow (low) —> bronchodilator test peak expiratory flow (>15% improvement) 2) spirometry (FEV1<0.8, FEV1/FVC<0.7) —> bronchodilator test spirometry (>15% improvement) 3) pulse oximetry (attack) consider 1) chest x-ray (exclusion) 2) specific IgE assay 3) skin prick test 4) ABG (attack)
Asthma - Management (3/6/0)
conservative 1) avoid allergen 2) inhaler technique 3) vaccinations (influenza) medical 1) SAβA (as required) 2) + LAβA 3) + INH corticosteroid (beclometasone) (increase dose as required) 4) PO corticosteroid (prednisolone) (severe) 5) montelukast (consider if severe) 6) theophylline (consider if severe)
Asthma - Management (Attack) (5)
1) NEB SAβA
2) PO corticosteroid (prednisolone)
3) oxygen therapy (severe)
4) anti-ACh (ipatropium) (severe)
5) magnesium (severe)
Small Cell Lung Carcinoma - Description
malignant proliferation of lung neuroendocrine cells
Small Cell Lung Carcinoma - Risk Factors (6)
1) 65-70 years old
2) family history
3) smoking (inc. passive)
4) chronic obstructive pulmonary disease
5) occupational (asbestos, coal)
6) radon gas
Small Cell Lung Carcinoma - Symptoms (6)
1) cough
2) chest pain
3) haemoptysis
4) dyspnoea
5) weight loss
6) fatigue
Small Cell Lung Carcinoma - Complications (7)
1) metastasis (adrenal gland, liver, brain, bone)
2) pneumonia
3) pleural effusion
4) paraneoplastic syndrome (10%)
5) recurrent laryngeal nerve palsy
6) phrenic nerve palsy
7) superior vena cava syndrome
Small Cell Lung Carcinoma - Complications (Paraneoplastic Syndrome) (4)
1) PTH —> hypercalcaemia
2) ADH —> SIADH
3) ACTH —> Cushing’s syndrome
4) VEGF —> hypertrophic pulmonary osteoarthropathy
Small Cell Lung Carcinoma - Investigations (3/2)
initial
1) chest x-ray (central mass, pleural effusion, hilar lymphadenopathy)
2) chest CT
3) sputum cytology (malignant cells) (high false negatives)
consider
1) bronchoscopy + biopsy
2) adrenal, liver, brain, bone CT (metastasis)
Small Cell Lung Carcinoma - Staging (TNM) (4/4/2)
tumour
T1) <3cm
T2) >3cm
T3) invades chest wall, pericardium, phrenic nerve
T4) invades mediastinum, heart, great vessels, trachea, oesophagus, vertebrae, carina, recurrent laryngeal nerve
node
N0) no nodes
N1) ipsilateral hilar nodes
N2) ipsilateral mediastinal nodes, subcarinal nodes
N3) contralateral hilar or mediastinal nodes, supraclavicular nodes
metastasis
M0) no metastasis
M1) distant metastasis
Small Cell Lung Carcinoma - Management (0/3/1)
medical 1) chemotherapy 2) radiotherapy 3) prophylactic cranial irradiation surgery 1) surgical excision (e.g. lobectomy) (rare due to late presentation)
Non-Small Cell Lung Carcinoma - Description
malignant proliferation of lung cells
Non-Small Cell Lung Carcinoma - Risk Factors (6)
1) 65-70 years old
2) family history
3) smoking (inc. passive)
4) chronic obstructive pulmonary disease
5) occupational (e.g. asbestos, coal)
6) radon gas
Non-Small Cell Lung Carcinoma - Symptoms (6)
1) cough
2) chest pain
3) haemoptysis
4) dyspnoea
5) weight loss
6) fatigue
Non-Small Cell Lung Carcinoma - Complications (7)
1) metastasis (adrenal gland, liver, brain, bone)
2) pneumonia
3) pleural effusion
4) paraneoplastic syndrome (10%)
5) recurrent laryngeal nerve palsy
6) phrenic nerve palsy
7) superior vena cava syndrome
Non-Small Cell Lung Carcinoma - Complications (Paraneoplastic Syndrome) (4)
1) PHT —> hypercalcaemia
2) ADH —> SIADH
3) ACTH —> Cushing’s syndrome
4) VEGF —> hypertrophic pulmonary osteoarthropathy
Non-Small Cell Lung Carcinoma - Investigations (3/2)
1) chest x-ray (central mass, pleural effusion, hilar lymphadenopathy)
2) chest CT
3) sputum cytology (malignant cells) (high false negatives)
consider
1) bronchoscopy + biopsy
2) liver, adrenal, brain, bone CT (metastasis)
Non-Small Cell Lung Carcinoma - Staging (TNM) (4/4/2)
tumour
T1) <3cm
T2) >3cm
T3) invades chest wall, pericardium, phrenic nerve
T4) invades mediastinum, heart, great vessels, trachea, oesophagus, vertebrae, carina, recurrent laryngeal nerve
node
N0) no nodes
N1) ipsilateral hilar nodes
N2) ipsilateral mediastinal nodes, subcarinal nodes
N3) contralateral hilar or mediastinal nodes, supraclavicular nodes
metastasis
M0) no metastasis
M1) distant metastasis
Non-Small Cell Lung Carcinoma - Management (0/2/1)
medical 1) chemotherapy 2) radiotherapy surgery 1) surgical excision (e.g. lobectomy)
Pulmonary Embolism - Description
embolus blocks pulmonary arterial circulation
Pulmonary Embolism - Cause (6)
1) deep vein thrombosis rare 2) right ventricular thrombosis (post MI) 3) septic emboli (right IE) 4) fat emboli (fracture) 5) air emboli 6) amniotic fluid emboli
Pulmonary Embolism - Risk Factors (Change in Blood Flow) (4)
1) surgery
2) leg fracture —> plaster of Paris
3) long haul flights
4) obesity
Pulmonary Embolism - Risk Factors (Change in Blood Vessel) (2)
1) smoking
2) hypertension
Pulmonary Embolism - Risk Factors (Change in Blood Constituents) (6)
1) pregnancy
2) oral contraceptive
3) hormone replacement therapy
4) dehydration
5) polycythaemia
6) inherited thrombophilia
Pulmonary Embolism - Pathophysiology (3)
1) deep vein thrombosis (esp. pelvis, legs)
2) thromboembolus blocks pulmonary artery
3) v/q mismatch
Pulmonary Embolism - Symptoms (8)
1) asymptomatic (small)
2) chest pain (sudden severe)
3) dyspnoea
4) fatigue
5) presyncope—>syncope
6) fever
7) pleuritic chest pain (pulmonary infarction)
8) haemoptysis (pulmonary infarction)
Pulmonary Embolism - Signs (4)
1) tachypnoea (shock)
2) tachycardia (shock)
3) hypotension (shock)
4) high JVP (cor pulmonale)
Pulmonary Embolism - Complications (7)
1) cardiac arrest (pulmonary saddle)
2) cardiogenic shock
3) multiple pulmonary embolisms —> pulmonary hypertension —> cor pulmonale
4) pulmonary infarction
5) respiratory alkalosis
6) pleural effusion
7) heparin induced thrombocytopenia
Pulmonary Embolism - Investigations (4/0)
1) pulmonary CT angiogram*
2) D-dimer (negative excludes)
3) ventilation/perfusion scan
4) LFT (normal)
Pulmonary Embolism - Diagnosis (Well’s Score) (9)
≥5 PE likely, <2 PE unlikely
1) active cancer
2) differential calf swelling (>3cm)
3) swelling of entire leg
4) pitting oedema
5) prominent superficial veins
6) localised deep venous system pain
7) paralysis, paresis, recent cast immobility
8) recent bed rest >3 days or major surgery with 12 weeks
9) previous DVT
Pulmonary Embolism - Management (0/5/2)
medical
1) IV fluids
2) adrenaline
3) oxygen (high flow, 60-100%)
4) anticoagulant (LMW heparin + warfarin)
5) thrombolysis (IV alteplase)
surgery
1) pulmonary thrombectomy (thrombolysis contraindicated)
2) vena caval filter (thrombolysis contraindicated) (can be long term)
Community Acquired Pneumonia - Description
infection of lungs acquired in the community
Community Acquired Pneumonia - Causes (6)
typical 1) Streptococcus pneumoniae (30-35%) 2) Haemophilus influenzae 3) Morexalla catarrhalis atypical (22%) 4) Mycoplasma pneumoniae 5) Chlamydophila pneumoniae 6) Legionella pneumophilia
Community Acquired Pneumonia - Risk Factors (11)
1) >65 years old
2) <16 years old
3) healthcare residence
4) chronic obstructive pulmonary disease
5) chronic liver disease
6) chronic kidney disease
7) diabetes mellitus
8) smoking
9) alcohol
10) poor oral hygiene
11) acid-reducing drugs (e.g. PPI)
Community Acquired Pneumonia - Symptoms (4)
1) productive cough (rusty in Strep. pneumoniae)
2) dyspnoea
3) pleuritic pain
4) fever (inc. rigors)
Community Acquired Pneumonia - Symptoms (Atypical) (4)
1) dry cough
2) odynophagia
3) headache
4) diarrhoea
Community Acquired Pneumonia - Signs (6)
1) pyrexia
2) cyanosis
3) tachypnoea
4) tachycardia
5) hypotension
6) confusion (may be only sign in elderly)
Community Acquired Pneumonia - Signs (Consolidation) (5)
1) reduced expansion
2) bronchial breathing
3) dull percussion
4) coarse rales (abnormal crackling lung sounds)
5) increased tactile vocal fremitus (increased vibrations felt during low frequency vocalisation)
Community Acquired Pneumonia - Complications (9)
1) parapneumonic effusion (pleural effusion)
2) lung abscess
3) empyema
4) acute respiratory distress syndrome
5) type I respiratory failure
6) sepsis —> septic shock
7) pericarditis
8) myocarditis
9) atrial fibrillation (esp. elderly)
Community Acquired Pneumonia - Investigations (5/6)
initial 1) chest x-ray* (consolidation) 2) FBC (leucocytosis) 3) high CRP + ESR 4) pulse oximetry (prognostic) 5) U+E (prognostic) consider 1) ABG (SaO2<92% or severe) 2) sputum MS+C (common) 3) blood MS+C (severe) 4) diagnostic thoracentesis + pleural fluid MS+C (pleural effusion) 5) bronchoscopy + brush sample MS+C (severe, refractory) 6) urinary Legionella antigen (Leg. pneumophilia)
Community Acquired Pneumonia - Score (CURB-65) (8)
C) confusion (abbr. mental test≥8)
U) urea>7mM
R) respiratory rate≥30/min
B) blood pressure SBP<90 and/or DBP<60
65) >65 years old
1) 0-1 —> home treatment + PO antibiotics
2) 2 —> hospital treatment + PO antibiotics
3) 3-5 —> hospital treatment + IV antibiotics
Community Acquired Pneumonia - Management (4/4/2)
conservative 1) smoking cessation 2) rest 3) fluids (IV if dehydrated or shock) 4) vaccination (influenzae, pneumococcal) medical 1) hospital guideline empirical antibiotics (e.g. amoxicillin, clarithromycin) 2) specific antibiotics (severe) 3) oxygen (aim for SaO2>94% or SaO2>88% in COPD) 4) analgesia (pleuritic pain) surgery 1) thoracentesis (pleural effusion) 2) surgical drainage (lung abscess)
Hospital Acquired Pneumonia - Description
infection of lungs acquired >48 hours after hospital admission
Hospital Acquired Pneumonia - Definition
new onset cough with purulent sputum along with x-ray showing consolidation in patients who were admitted to hospital more than 48 hours ago
Hospital Acquired Pneumonia - Causes (4)
1) Staphylococcus aureus (inc. MRSA) gram negative bacilli* 2) Pseudomonas aeruginosa 3) Escherichia coli 4) Klebsiella pneumoniae
Hospital Acquired Pneumonia - Risk Factors (4)
1) poor hand hygiene
2) poor oral hygiene
3) intubation (inc. prolonged sedation)
4) acid-reducing drugs (e.g. PPI)
Hospital Acquired Pneumonia - Symptoms (4)
1) productive cough
2) dyspnoea
3) pleuritic pain
4) fever (inc. rigors)
Hospital Acquired Pneumonia - Signs (6)
1) pyrexia
2) cyanosis
3) tachypnoea
4) tachycardia
5) hypotension
6) confusion (may be only sign in elderly)
Hospital Acquired Pneumonia - Signs (Consolidation) (5)
1) reduced expansion
2) bronchial breathing
3) dull percussion
4) coarse rales (abnormal crackling lung sounds)
5) increased tactile vocal fremitus (increased vibrations felt during low frequency vocalisation)
Hospital Acquired Pneumonia - Complications (9)
1) parapneumonic effusion (pleural effusion)
2) lung abscess
3) empyema
4) acute respiratory distress syndrome
5) type I respiratory failure
6) sepsis —> septic shock
7) pericarditis
8) myocarditis
9) atrial fibrillation (esp. elderly)
Hospital Acquired Pneumonia - Investigations (5/3)
initial 1) chest x-ray* (consolidation) 2) FBC (leucocytosis) 3) high CRP + ESR 4) pulse oximetry 5) bronchoscopy + brush border sample MS+C consider 1) ABG (SaO2<92% or severe) 2) diagnostic thoracentesis + pleural fluid MS+C (pleural effusion) 3) procalcitonin (antibiotic choice)
Hospital Acquired Pneumonia - Management (4/4/2)
conservative
1) smoking cessation
2) rest
3) fluids (IV if dehydrated or shock)
4) vaccinations (influenzae, pneumococcal)
medical
1) hospital guideline empirical antibiotics (e.g. amoxicillin, clarithromycin) (before culture results)
2) specific antibiotics (after culture results)
3) oxygen (aim for SaO2>94%, SaO2>88% in COPD)
4) analgesia (pleuritic pain)
surgery
1) thoracentesis (pleural effusion)
2) surgical drainage (lung abscess)
Immunocompromised Pneumonia - Description
infection of lungs in an immunocompromised patient
Immunocompromised Pneumonia - Causes (3)
1) Pneumocystic jirovecii
2) opportunistic pathogens
3) normal causes
Immunocompromised Pneumonia - Risk Factors (3)
1) immunocompromised (e.g. chronic steroids)
2) HIV (CD4+ count < 200 cells/μL)
3) genetics
Immunocompromised Pneumonia - Symptoms (5)
1) oropharyngeal candiasis (oral thrush)
2) productive cough
3) dyspnoea
4) pleuritic pain
5) fever (inc. rigors)
Immunocompromised Pneumonia - Signs (7)
1) pyrexia
2) cyanosis
3) tachypnoea
4) tachycardia
5) hypotension
6) confusion (may be only sign in elderly)
7) long duration of symptoms (HIV)
Immunocompromised Pneumonia - Signs (Consolidation) (5)
1) reduced expansion
2) bronchial breathing
3) dull percussion
4) coarse rales (abnormal crackling lung sounds)
5) increased tactile vocal fremitus (increased vibrations felt during low frequency vocalisation)
Immunocompromised Pneumonia - Complications (9)
1) parapneumonic effusion (pleural effusion)
2) lung abscess
3) empyema
4) acute respiratory distress syndrome
5) type I respiratory failure
6) sepsis —> septic shock
7) pericarditis
8) myocarditis
9) atrial fibrillation (esp. elderly)
Immunocompromised Pneumonia - Investigations (5/3)
initial 1) chest x-ray* (consolidation) 2) FBC (leucocytosis) 3) high CRP + ESR + LDH 4) pulse oximetry 5) sputum MS+C consider 1) ABG (SaO2<92% or severe) 2) bronchoscopy + brush sample MS+C 3) diagnostic thoracentesis + pleural fluid MS+C (pleural effusion)
Immunocompromised Pneumonia - Management (4/4/2)
conservative
1) smoking cessation
2) rest
3) fluids (IV if dehydrated or shock)
4) vaccinations (influenzae, pneumococcal)
medical
1) hospital guideline empirical antibiotics (amoxicillin, clarithromycin) (before culture results)
2) specific antibiotics (after culture results)
3) oxygen (aim for SaO2>94%, SaO2>88% in COPD)
4) analgesia (pleuritic pain)
surgery
1) thoracocentesis (pleural effusion)
2) surgical drainage (lung abscess)
Aspiration Pneumonia - Description
infection of lungs due to inhalation or oropharyngeal contents
Aspiration Pneumonia - Risk Factors (7)
1) swallowing dysfunction (e.g. stroke, myasthenia gravis, bulbar palsy)
2) gastro-oesophageal reflux disease
3) achalasia
4) intubation
5) feeding tube
6) poor oral hygiene
7) acid-reducing drugs (e.g. PPI)
Aspiration Pneumonia - Symptoms (4)
1) productive cough
2) dyspnoea
3) pleuritic pain
4) fever (inc. rigors)
Aspiration Pneumonia - Signs (8)
1) purulent sputum
2) foul smelling breath
3) pyrexia
4) cyanosis
5) tachypnoea
6) tachycardia
7) hypotension
8) confusion (may be only sign in elderly)
Aspiration Pneumonia - Signs (Consolidation) (5)
1) reduced expansion
2) bronchial breathing
3) dull percussion
4) coarse rales (abnormal crackling lung sounds)
5) increased tactile vocal fremitus (increased vibrations felt during low frequency vocalisation)
Aspiration Pneumonia - Complications (9)
1) parapneumonic efffusion (pleural effusion)
2) lung abscess
3) empyema
4) acute respiratory distress syndrome
5) type I respiratory failure
6) sepsis —> septic shock
7) pericarditis
8) myocarditis
9) atrial fibrillation (esp. elderly)
Aspiration Pneumonia - Investigations (5/3)
initial 1) chest x-ray* (consolidation) 2) FBC (leucocytosis) 3) high CRP + ESR 4) pulse oximetry 5) sputum MS+C consider 1) ABG (if SaO2<92% or severe) 2) bronchoscopy + brush sample MS+C 3) diagnostic thoracentesis + pleural fluid MS+C (pleural effusion)
Aspiration Pneumonia - Management (4/4/2)
conservative
1) smoking cessation
2) rest
3) fluids (IV if dehydrated or shock)
4) vaccinations (influenzae, pneumococcal)
medical
1) hospital guideline empirical antibiotics (e.g. amoxicillin, clarithromycin) (before culture results)
2) specific antibiotics (after culture results)
3) oxygen (aim for SaO2>94%, SaO2>88% in COPD)
4) analgesia (pleuritic pain)
surgery
1) thoracentesis (pleural effusion)
2) surgical drainage (lung abscess)
Tuberculosis - Description
infectious disease caused by Mycobacterium tuberculosis
Tuberculosis - Risk Factors (8)
1) origin from endemic region (India, China, Sub-Saharan Africa)
2) immunocompromised (e.g. HIV)
3) immunosuppressed (e.g chronic steroids)
4) extremes of age
5) diabetes mellitus
6) IV drug abuse
7) alcohol
8) smoking
Tuberculosis - Pathophysiology (Primary) (5)
1) airborne exposure to Mycobacterium tuberculosis via respiratory droplets
2) alveolar macrophages ingest M. tuberculosis
3) M. tuberculosis survive and proliferate within alveolar macrophages
4) alveolar macrophages die and release M. tuberculosis
5) asymptomatic —> flu-like symptoms
Tuberculosis - Pathophysiology (Latent) (6)
1) type IV cell mediated delayed hypersensitivity reaction to M. tuberculosis
2) subpleural caseating granuloma forms due to tissue necrosis (Ghon focus - initial granuloma)
3) M. tuberculosis spreads to hilar lymph nodes
4) lymph node caseating granuloma forms (Ghon complex - subpleural and associated lymph nodal granulomas)
5) granulomas fibrose and calcify (Ranke complex - calcified Ghon complex)
6) M. tuberculosis lies dormant
Tuberculosis - Pathophysiology (Reactivated) (5)
1) M. tuberculosis reactive due to compromised immune system (e.g. ageing, severe infection)
2) M. tuberculosis spreads throughout lungs (esp. upper lobes, more oxygenation)
3) memory immune response to M. tuberculosis
4) caseous necrosis forms lung cavities
5) M. tuberculosis disseminates throughout lungs
Tuberculosis - Pathophysiology (Miliary) (2)
1) M. tuberculosis disseminates to vasculature
2) M. tuberculosis disseminates systemically
Tuberculosis - Symptoms (9)
1) cough (dry then productive) (>3 weeks)
2) dyspnoea
3) haemoptysis (occasional)
4) pleuritic pain (if pleural involvement)
systemic
1) weight loss*
2) night sweats*
3) fever (low grade)
4) anorexia
5) malaise
Tuberculosis - Complications (5)
1) pleural effusion
2) bronchiectasis
3) pneumothorax
4) acute respiratory distress syndrome
5) extensive lung destruction
Tuberculosis - Investigations (Active) (2/3)
initial
1) chest x-ray (fibronodular shadows, calcification, cavitation —> esp. in upper lobes)
2) FBC (anaemia, leucocytosis)
consider
1) sputum nucleic acid amplification test
2) sputum acid-fast bacilli smear
3) sputum culture*
Tuberculosis - Investigations (Latent) (2/0)
initial
1) tuberculin skin test (>5mm induration if risk factors, >15mm if no risk factors)
2) interferon gamma release assay
Tuberculosis - Management (5/4/0)
conservative 1) neonatal BCG vaccine 2) notify Public Health England 3) ensure medical compliance 4) contact tracking 5) screening patient contacts medical 1) rifampicin (2 months intensive, 4 months continuation) 2) isoniazid (2 months intensive, 4 months continuation) 3) pyrazinamide (2 months intensive) 4) ethambutol (2 months intensive)
Type I Respiratory Failure - Description
impaired gas exchange leading to hypoxia generally due to a perfusion failure
Type I Respiratory Failure - Causes (12)
1) pulmonary embolism*
2) pneumonia
3) bronchiectasis
4) cystic fibrosis
5) obstructive sleep apnoea
6) asthma
7) emphysema
8) pulmonary fibrosis
9) pulmonary oedema
10) pleural effusion
11) pneumothorax
12) acute respiratory distress syndrome
Type I Respiratory Failure - Symptoms (6)
1) dyspnoea (more in type I)
2) confusion (more in type II)
3) headache
4) anxiety (inc. restlessness, agitation)
5) seizure
6) coma (severe)
Type I Respiratory Failure - Signs (4)
1) cyanosis
2) intercostal space retraction (intercostal muscles pull ribs in)
3) accessory breathing muscle use
4) tachypnoea
Type I Respiratory Failure - Complications (5)
1) pneumonia
2) pneumothorax
3) heart failure
4) arrythmia
5) pericarditis
Type I Respiratory Failure - Investigations (2/7)
initial 1) pulse oximetry (SaO2<80%) 2) ABG (PaO2<8kPa) consider find underlying cause 1) FBC 2) U&E 3) CRP 4) ECG 5) chest x-ray 6) spirometry 7) sputum/blood MS&C (fever)
Type I Respiratory Failure - Management (0/4/0)
medical
1) treat underlying cause
2) face mask oxygen (24-60%)
3) assisted ventilation oxygen (>60%) (e.g. CPAP)
4) endotracheal intubation + mechanical ventilation oxygen (unconscious)
Type II Respiratory Failure - Description
impaired gas exchange leading to hypoxia and hypercapnia generally due to a ventilation failure
Type II Respiratory Failure - Causes (9)
1) hypoventilation
2) chronic bronchitis
3) emphysema
4) asthma
5) pulmonary hypertension
6) extreme obesity
7) chest wall deformities (e.g. kyphoscoliosis)
8) muscle weakness (e.g. Guillain-Barre syndrome, motor neurone disease)
9) central respiratory centre depression (e.g. heroin)
Type II Respiratory Failure - Symptoms (6)
1) dyspnoea (more in type I)
2) confusion (more in type II)
3) headache
4) anxiety (inc. restlessness, agitation)
5) seizure
6) coma (severe)
Type II Respiratory Failure - Signs (10)
1) cyanosis
2) intercostal space retraction (intercostal muscles pull ribs in)
3) accessory breathing muscle use
4) tachypnoea –> bradypnoea (severe)
5) tachycardia
6) somnolence (strong desire to sleep)
7) bounding pulse
8) stridor
9) inability to speak
10) asterixis
Type II Respiratory Failure - Complications (5)
1) pneumonia
2) pneumothorax
3) heart failure
4) arrythmia
5) pericarditis
Type II Respiratory Failure - Investigations (2/7)
initial 1) pulse oximetry (SaO2<80%) 2) ABG (PaO2<8kPa, PaCO2>6.7kPa) consider find underlying cause 1) FBC 2) U&E 3) CRP 4) ECG 5) chest x-ray 6) spirometry 7) sputum/blood MS&C (fever)
Type II Respiratory Failure - Management (0/4/0)
medical
1) treat underlying cause
2) face mask oxygen (24-60%)
3) assisted ventilation oxygen (>60%) (e.g. CPAP)
4) endotracheal intubation + mechanical ventilation oxygen (unconscious)
Acute Respiratory Distress Syndrome - Description
respiratory failure characterised by rapid onset widespread lung inflammation
Acute Respiratory Distress Syndrome - Causes (9)
1) pneumonia (inc. aspiration)
2) sepsis
3) acute pancreatitis
4) acute liver failure
5) lung transplant
6) blood transfusion
7) haemorrhage
8) trauma
9) burns
Acute Respiratory Distress Syndrome - Symptoms (2)
1) dyspnoea
2) symptoms of underlying cause (esp. fever, cough, pleuritic pain)
Acute Respiratory Distress Syndrome - Signs (5)
1) tachypnoea
2) tachycardia
3) cyanosis
4) crepitus (fine end inspiratory rales)
5) low tidal volume
Acute Respiratory Distress Syndrome - Complications (5)
1) type I respiratory failure (acute)
2) pneumothorax
3) multiple organ failure
4) pulmonary fibrosis
5) pulmonary oedema (non-cardiogenic)
Acute Respiratory Distress Syndrome - Investigations (2/2)
initial
1) chest x-ray (bilateral opacities)
2) ABG (hypoxia)
consider
find underlying cause
1) blood/sputum MS&C (underlying infection)
2) amylase + lipase (>3x upper limit, acute pancreatitis)
Acute Respiratory Distress Syndrome - Diagnosis (4)
1) acute onset within 1 week
2) bilateral opacities on chest x-ray
3) refractory hypoxaemia PaO2:FiO2 ≤ 200
4) no congestive heart failure
Acute Respiratory Distress Syndrome - Management (2/4/0)
conservative 1) prone positioning 2) nutritional support medical 1) oxygen + ventilation (maintain 88-95%) 2) IV fluids (maintain fluid balance) 3) maintain cardiac output (e.g. inotropes, vasodilators) 4) antibiotic (sepsis)
