Respiratory Disease Flashcards
Symptoms that are typically associated with respiratory disease include:
- Dyspnoea: shortness of breath associated with a wide range of respiratory pathology including pneumonia, asthma and chronic obstructive pulmonary disease (COPD).
- Cough: can be productive (e.g. pneumonia, COPD, bronchiectasis) or dry (e.g. pulmonary fibrosis, side effect of ACE inhibitors).
- Haemoptysis: the coughing up of blood originating from the respiratory tract below the level of the larynx. Haemoptysis is typically associated with lung cancer but can be a rare clinical feature of pulmonary embolism.
- Wheeze: a continuous, coarse, whistling sound produced in the respiratory airways during breathing. It is commonly associated with conditions such as asthma, COPD and anaphylaxis.
- Chest pain: typically worsened by deep inspiration due to being pleuritic in nature (e.g. pulmonary embolism, pleurisy).
- Systemic symptoms: these can include fatigue (e.g. lung cancer, COPD), fever (e.g. pneumonia), and weight loss (e.g. end-stage COPD, lung cancer).
pneumonia
an infection that inflames the air sacs in one or both lungs. The air sacs may fill with fluid or pus (purulent material), causing cough with phlegm or pus, fever, chills, and difficulty breathing.
Respiratory risk factors
- Pre-existing respiratory disease (e.g. asthma, COPD)
- Family history of respiratory disease (e.g. cystic fibrosis, alpha-1 antitrypsin deficiency)
- Smoking
- Occupational exposure (e.g. coal mining, farming)
- Hobbies (e.g. bird keeping)
haemoptysis
the coughing up of blood.
Immunisation history:
Ask the patient if they have been vaccinated against respiratory diseases such as:
- Influenza
- Pneumococcus
- COVID-19
- Tuberculosis
Medical conditions relevant to respiratory disease include:
Asthma
COPD
Lung cancer
Bronchiectasis
Pulmonary fibrosis
Pulmonary embolism
Tuberculosis
Neuromuscular conditions (e.g. motor neurone disease)
Congestive heart failure
Cor pulmonale
Cystic fibrosis
Alpha-1 antitrypsin deficiency
COPD
Chronic obstructive pulmonary disease (COPD) is a lung disease characterised by persistent respiratory symptoms and airflow obstruction.
COPD is a triad of emphysema, chronic bronchitis and small airway fibrosis.
embolus/emboli
An “embolus” is a blood clot or a piece of plaque that acts like a clot. The word “emboli” means there is more than one clot or piece of plaque. When the clot travels from the site where it formed to another location in the body, it is called an embolism.
Bronchiectasis
Bronchiectasis is a chronic respiratory disease characterised by permanent bronchial dilation, due to irreversible damage to the bronchial wall.
Pulmonary fibrosis
it is a lung disease that occurs when lung tissue becomes damaged and scarred. This thickened, stiff tissue makes it more difficult for your lungs to work properly. As pulmonary fibrosis worsens, you become progressively more short of breath.
Pulmonary embolism
it is a potentially life-threatening medical emergency. It is a condition in which one or more emboli, usually arising from a blood clot formed in the veins, are lodged in and obstruct the pulmonary arterial system, causing severe respiratory dysfunction.
Tuberculosis
it is a granulomatous disease caused by the Mycobacterium tuberculosis complex. TB most commonly affects the lung, but it can affect almost any organ.
Congestive heart failure
it is a clinical syndrome involving reduced cardiac output because of impaired cardiac contraction. Typical clinical symptoms of CHF include shortness of breath, fatigue and ankle swelling.1
Cor pulmonale
it is a condition that causes the right side of the heart to fail.
Cystic fibrosis
it is an inherited condition that causes sticky mucus to build up in the lungs and digestive system. This causes lung infections and problems with digesting food.
Alpha-1 antitrypsin deficiency
an autosomal dominant condition which presents in younger patients (aged 20-40). Alpha-1 antitrypsin is a protease inhibitor with one of its actions being to prevent neutrophil elastase from breaking down alveolar structures. Therefore, a deficiency in alpha-1 antitrypsin leads to the increased destruction of alveolar structures, resulting in early-onset emphysema. Some cases of alpha-1 antitrypsin deficiency involve impaired secretion of alpha-1 antitrypsin by the liver, resulting in accumulation of it in the liver, and therefore cirrhosis.
Chronic granulomatous disease (CGD)
it is an inherited disorder that occurs when a type of white blood cell (phagocyte) that usually helps your body fight infections doesn’t work properly.
Commonly prescribed respiratory medications
Medications commonly prescribed to patients with respiratory disease include:
- Short-acting beta-2-agonist inhalers (e.g. salbutamol, terbutaline)
- Long-acting beta-2-agonist inhalers (e.g. salmeterol, formoterol)
- Inhaled corticosteroid inhalers (e.g. fluticasone, budesonide, beclometasone)
- Short-acting antimuscarinic inhalers (e.g. ipratropium)
- Long-acting antimuscarinic inhalers (e.g. tiotropium)
- Oral steroids (e.g. prednisolone)
- Theophylline
- Antibiotics (e.g. co-amoxiclav, doxycycline, azithromycin)
- Anticoagulants (e.g. warfarin, apixaban)
Some over the counter drugs which may impact the respiratory system include:
- Aspirin (may worsen haemoptysis if already present)
- St John’s Wort (an enzyme inducer which may reduce the effects of warfarin)
Medications with respiratory side effects include:
- Beta-blockers and NSAIDs (bronchoconstriction)
- ACE inhibitors (dry cough)
- Oestrogen-containing medication (increased risk of pulmonary embolism)
- Amiodarone and methotrexate (pleural effusions, interstitial lung disease)
Pulmonary Hypertension
is a pathophysiological disorder occurring when mean pulmonary artery pressure is >25mmHg at rest when assessed with right heart catheterisation.
Sarcoidosis
is a rare condition that causes small patches of swollen tissue, called granulomas, to develop in the organs of the body. It often affects the lungs and lymph nodes, and can also affect your skin.
Bronchiectasis
Bronchiectasis is a long-term condition where the airways of the lungs become widened, leading to a build-up of excess mucus that can make the lungs more vulnerable to infection.
Obstructive Sleep Apnoea
Obstructive sleep apnoea (OSA) is a sleep disorder that is characterised by recurrent episodes of upper airway obstruction during sleep, which results in apnoea (temporary cessation of breathing) or hypopnoea (temporary decreases in breathing).
Obstructive sleep apnoea is a condition where the upper airway frequently becomes obstructed during sleep, resulting in short periods of apnoea (not breathing).
Asthma
examples of obstructive diseases:
means px has trouble getting air OUT
- Asthma
- COPD
- Bronchiectasis
- Cystic fibrosis
examples of restrictive diseases:
means px has trouble getting air IN
- Pulmonary fibrosis, Pneumoconiosis, Pulmonary oedema, Lobectomy/pneumonectomy, Parenchymal lung tumours
- Kyphoscoliosis
- Neuromuscular diseases (e.g. motor
neuron disease, myasthenia gravis,
Guillan-Barre syndrome) - Obesity or pregnancy
Pneumoconiosis
Pneumoconiosis is one of a group of interstitial lung disease caused by breathing in certain kinds of dust particles that damage your lungs. Because you are likely to encounter these dusts only in the workplace, pneumoconiosis is called an occupational lung disease. Pneumoconiosis usually take years to develop
Pulmonary oedema
a condition caused by too much fluid in the lungs. This fluid collects in the many air sacs in the lungs, making it difficult to breathe.
Lobectomy/pneumonectomy
a surgical procedure to remove a lung. Removal of just one lobe of the lung is specifically referred to as a lobectomy
What determines if a disease is obstructive or restrictive?
It is DIAGNOSED BY SPIROMETRY.
Kyphoscoliosis
a deviation of the normal curvature of the spine in the sagittal and coronal planes and can include a rotation of the spinal axis.
interstitial lung disease
a group of about 100 chronic lung disorders characterized by inflammation and scarring that make it hard for the lungs to get enough oxygen. The scarring is called pulmonary fibrosis.
spirometry
a simple test used to help diagnose and monitor certain lung conditions by measuring how much air you can breathe out in one forced breath.
Chronic bronchitis
Long term inflammation of the airways
Hallmark of Chronic bronchitis
- Chronic productive cough: cough and sputum production for at least 3 months in each of 2 consecutive years.
- Mild dyspneoa initially
- Cyanotic
- Obese
- Crackles / wheeze possible
Emphysema
Damage to the alveoli (air sacs) within the lung
Hallmark of Emphysema
- Dyspnoea
- Minimal cough
- Pink skin, pursed lips
- Cachexic
- Accessory muscle use
- Barrell chested, Hyperinflation
- Decreased breath sounds
Cachexic
a wasting syndrome that leads to loss of skeletal muscle and fat
wasting syndrome
defined as a 10 percent loss in body weight accompanied by 30 days of fever and/or diarrhea.
signs of chronic bronchitis
- Cough.
- Production of mucus (sputum), which can be clear, white, yellowish-gray or green in color — rarely, it may be streaked with blood.
- Fatigue.
- Shortness of breath.
- Slight fever and chills.
- Chest discomfort.
- overweight
- cyanotic
- elevated haemoglobin
- peripheral oedema
- rhonchi and wheezing
Cyanosis
means there’s not enough oxygen in your blood, or you have poor blood circulation.
peripheral oedema
Peripheral edema happens when small blood vessels leak fluid into nearby tissues. The extra fluid build-up is what makes the tissue swell.
Rhonchi
are continuous gurgling or bubbling sounds (low-pitched noises, which sound like snoring) typically heard during both inhalation and exhalation. These sounds are caused by movement of fluid and secretions in larger airways (asthma, viral URI).
signs of emphysema
- older and thin (?)
- severe dyspnea
- quiet chest
- x-ray shows hyperinflation and flattened diaphragm.
risk factors for COPD
- Tobacco smoking
- Occupational exposure
- Air pollution
- Genetics – homozygous alpha -1-
antitrypsin deficiency. This accounts for
less than 1 % of COPD cases
symptoms of COPD
- Cough
- Productive, intermittent /persistent – smoker’s cough
- Breathlessness
- On exertion +/-wheeze
- Sputum
- Regular/daily clear
- Chest Infections
- More frequent with exacerbations
- Other non-specific symptoms
*Tiredness, weight loss, ankle swelling
signs of COPD
- Mild disease: wheeze
- Severe disease: tachypnoeic
- Prolonged expiration
- Accessory muscle use and intercostal recession
- Pursing of lips
- Poor chest expansion
- Hyper-inflated lungs
Tachypnoea
rapid breathing
intercostal recession/intercostal retraction
are due to reduced air pressure inside your chest. This can happen if the upper airway (trachea) or small airways of the lungs (bronchioles) become partially blocked. As a result, the intercostal muscles are sucked inward, between the ribs, when you breathe. This is a sign of a blocked airway
diagnosis of COPD
Suspect COPD in:
- Smokers/Ex-smokers >35 y/o (as opposed to Asthma) with:
- Exertional breathlessness or wheeze
- Chronic cough
- Regular sputum production (rare in Asthma)
- Frequent ‘winter bronchitis’
Diagnosis / Investigations of COPD
Disease characterised by airflow OBSTRUCTION
* Diagnosed by spirometry
* Airflow obstruction is defined as reduced FEV1/FVC ratio (< 0.7)
* Other causes should be considered in older people who have a FEV1/FVC ratio
below 0.7 but do not have typical symptoms of COPD.
* COPD should be considered in younger people with typical symptoms even if
FEV1/FVC ratio is above 0.7.
FEV1 = forced expiratory volume in 1 second
FVC = forced vital capacity
Medical Research Council (MRC)
Dyspnoea Scale
Grade 1 - Not troubled by breathlessness except during strenuous exercise
Grade 5 - Too breathless to leave the house, or breathless when dressing
COPD Classification of Severity
- Early/Mild (stage 1) - FEV1 >= 80% of predicted value
- Moderate (stage 2) - FEV1 50-79% of predicted value
- Severe (stage 3) - FEV1 30-49% of predicted value
- Very severe (stage 4) FEV1 < 30% of predicted value
COPD investigations
Post-bronchodilator spirometry: FEV1/FVC <0.7 confirms diagnosis
CXR – to exclude other diagnoses
FBC – for anaemia/polycythaemia
BMI (obesity/cachexia)
Consider:
Sputum Culture
Cardiac etiologies: BNP, ECHO
Fundamentals of COPD care (step 1)
- Offer treatment and support to stop smoking (smoking cessation)
- Offer pneumococcal and influenza vaccinations
- Offer pulmonary rehabilitation if indicated
- co-develop a personalised self-management plan
- optimise treatment for comorbidities
What does pulmonary rehabilitation involve?
focuses on tailored physical exercise and information that helps people to better understand and manage their condition/s and symptoms.
What are inhaled therapies
Inhalation therapy allows conveying of drugs directly into the airways. These therapies are needed to relieve breathlessness and exercise limitations. They are trained to use inhalers.
step 2 treatment/management of COPD (no asthmatic like symptoms)
- Offer Short-acting beta agonists (SABAs) / Short-acting muscarinic antagonist (SAMA)
- LABA + LAMA
- Consider offering ICS if symptoms worsen (for max 3 months, if no improvement stop)
What are asthmatic-like symptoms?
- Inspection: increased work of breathing, cyanosis, cough, audible wheeze
- Peripheries: fine tremor (salbutamol use), tachycardia, oral candidiasis (steroid inhaler use)
- Chest: polyphonic expiratory wheeze
- FEV1/FVC ratio <70% indicates airflow obstruction
-wheeze
-cough
-breathlessness
Risks of ICS
step 2 treatment/management of COPD (asthmatic like symptoms)
- Offer SABA or SAMA for breathlessness
- LABA + ICS
- LAMA + LABA + ICS
What is LAMA
- Glycopyrronium bromide / Tiotropium
bromide
What is LABA
- Salmeterol xinafoate / Formoterol
fumarate / Indacaterol maleate
What is ICS
beclomethasone, budesonide,
ciclesonide, flunisolide, fluticasone and
triamcinolone
What is SABA
salbutamol sulphate / Formoterol
fumarate
What is SAMA
Ipratropium bromide
acute exacerbations - Referred to hospital:
CXR
ABG
ECG
FBC, U&E
Sputum cultures
Blood cultures if fever
Follow up and Monitoring - At each review, measure:
- FEV1 and FVC (that means annual spirometry).
- BMI/nutritional status.
- MRC dyspnoea score.
- And in very severe disease (FEV1<30% predicted), measure oxygen saturations.
Follow up and Monitoring - At the review, discuss:
- Smoking status and motivation to quit.
- Symptom control (breathlessness, exercise tolerance, frequency of exacerbations).
- Review if home management plan (antibiotics/steroids) has been used in the past year. If more than 3 courses of oral steroids and/or oral antibiotics, review
why this might be. - Need for pulmonary rehab.
- Complications/need for specialist referral.
Acute exacerbation treatment - oral antibiotics/steroids
- amoxicillin
- doxycycline
- clarithromycin
sleep apnoea
- Intermittent and repeated upper airway collapse during sleep
- This leads to irregular breathing at night and excessive daytime sleepiness.
risk factors of sleep apnoea
Male sex
Obesity
Smoking
Hypothyroidism
signs of sleep apnoea
Excessive daytime sleepiness
Impaired concentration
Snoring
Unrefreshing sleep
Choking episodes during sleep
Witnessed apnoeas - a ten-second pause in breathing
Restless sleep
Sleep Apnoea diagnosis
- Polysomnography - is the gold standard investigation.
- Epworth Sleepiness scale.
Management of Sleep Apnoea
- Lifestyle advice/Behavioural interventions – weight loss, smoking cessation, reduction in alcohol consumption.
- CPAP – it is the gold standard treatment.
- Pharmacotherapy but its role is limited.
- Surgery
What is Polysomnography
a comprehensive test used to diagnose sleep disorders. Polysomnography records your brain waves, the oxygen level in your blood, heart rate and breathing, as well as eye and leg movements during the study.
what is CPAP?
continuous positive airway pressure therapy, is a a simple machine that blows air through a mask you wear at night. It’s designed to hold your airway open while you’re asleep.
What is Bronchiectasis
Chronic inflammation of the bronchi and bronchioles leading to permanent dilatation of these airways. It is an Obstructive disease.
causes of bronchiectasis
- half are idiopathic (unknown)
- Post-infection (TB, pertussis)
- Congenital (from birth)
- Immune deficiency or excessive immune response
- Connective tissue disease
- Cystic fibrosis (abnormal mucus clearance)
- Fibrosis (thickening or scarring of the tissue)
disclaimer: can occur with asthma and COPD
Symptoms of Bronchiectasis
- persistent cough
- copious purulent sputum (ggreen or yellow)
- intermittent haemoptyisis
- fever
intermittent haemoptysis
coughing up of blood or blood-stained mucus from the bronchi, larynx, trachea, or lungs (at intervals)
Signs of Bronchiectasis
- singer clubbing
- coarse inspiratory crepitations
- wheeze
- large airway ronchi
Bronchiectasis is frequently missed because:
It may be mistaken for asthma, COPD, rhinitis or reflux (all of which are more
common)
Spirometry may show co-existing airway obstruction, so symptoms are
attributed to COPD
Mild bronchiectasis may not show up on CXR
Investigations for Bronchiectasis:
- CXR – often non-specific and non-diagnostic
- CT – image modality of choice for diagnosis: Shows dilation of bronchi with or without airway thickening
- Sputum culture – when clinically stable to look for colonization/chronic infection
- FBC (WCC)
Management for Bronchiectasis:
Airway clearance
Pulmonary rehabilitation
Treat underlying cause
Immunisations: flu and pneumococcal
Treat exacerbations promptly
Surgery may be indicated in localised disease or to control severe haemoptysis
What causes cystic fibrosis?
defective chloride secretion and increased sodium absorption across airway epithelium.
Clinical features of Cystic Fibrosis
Neonate
- Failure to thrive, meconium ileus, rectal prolapse
Children and young adults
- Respiratory: cough, wheeze, recurrent infections, bronchiectasis,
pneumothorax, haemoptysis, respiratory failure, cor pulmonale
- Gastrointestinal: pancreatic insufficiency, distal intestinal obstruction syndrome, gall stones, cirrhosis
- Other: male infertility, osteoporosis, arthritis, vasculitis, nasal polyps, sinusitis, hypertrophic pulmonary osteoarthropathy
Cystic Fibrosis- Diagnosis
- Newborn: blood spot
- Sweat test: Sweat sodium and chloride >60mmol/L ; chloride usually >sodium
- Genetics: screening for known common CF mutations should be considered
- Faecal elastase is a simple and useful screening test for exocrine pancreatic
dysfunction
Pulmonary Fibrosis
a condition in which there is diffuse fibrosis of lung parenchyma with a resultant impairment of gas transfer and ventilation-perfusion mismatching. It is a Restrictive disease.
Risk factors for Pulmonary Fibrosis
- family history,
- cigarette
- smoking,
- advanced age,
- male sex
Clinical Features of Pulmonary Fibrosis
- Dyspnoea
- Cyanosis
- Clubbing
- Slightly reduced chest expansion
- Bronchial breathing
- On auscultation there may be late-inspiratory and pan-inspiratory crackles heard over the affected lung
what is Cyanosis
bluish discolouration of the skin due to poor circulation or inadequate oxygenation of the blood
Diagnosis of pulmonary fibrosis
- CXR – shows typical scarring pattern in the lungs, suggestive of the disease.
Typical basilar, peripheral, bilateral, asymmetrical, reticular opacities - CT scan of the lungs and/or a lung biopsy are usually needed to confirm
diagnosis. - CRP and ESR mildly elevated
Management of Pulmonary Fibrosis
- Pulmonary rehabilitation
- Corticosteroid therapy
- Other immunosuppressive therapy - drugs such as cyclophosphamide and
azathioprine have been used as a steroid sparing agents - Lung transplantation
- Antifibrotic agents - pirfenidone is an immunosuppressant that is thought to
have anti-inflammatory and antifibrotic effects. - Oxygen - to palliate symptoms of breathlessness
Sarcoidosis
It is a multisystem chronic inflammatory
condition characterised by non-
caseating epithelioid granulomata.
Affects lungs, skin, lymph nodes and
eyes most commonly. Accumulation of
lymphocytes and macrophages and the
formation of non-caseating granulomas.
Signs and symptoms of Sarcoidosis
- Constitutional symptoms – fever, night
sweats, weight loss - Lung – dry cough, dyspnoea
- Skin – erythema nodosum (tender,
painful, bilateral) - Eye – anterior uveitis
Investigations for Sarcoidosis
- CXR – bilateral hilar lymphadenopathy
- CT
- Blood tests
Pulmonary Hypertension
- Progressive increase in pulmonary vascular resistance (PVR) and, ultimately, right ventricular failure
and death. - Increase in mean pulmonary arterial pressure ≥25 mm Hg at rest as assessed by right heart
catheterisation.
Symptoms of Pulmonary Hypertension
- chest pain,
- exertional dyspnoea,
- fatigue,
- syncope.
Signs of Pulmonary Hypertension
- small volume pulse,
- peripheral cyanosis,
- a raised jugular venous pulse (JVP),
- a parasternal - right ventricular – heave, peripheral oedema
Investigations of Pulmonary Hypertension
- Right heart catheterisation is needed to confirm the diagnosis
- ECG - right ventricular hypertrophy
- Echocardiography - demonstrates a dilated right ventricle with impaired function
- Right heart catheterisation
Echocardiography
a scan used to look at the heart and nearby blood vessels. It’s a type of ultrasound scan
