Respiratory for long case Flashcards
Lung disease severity measures - history
- Exercise tolerance, up flights stairs
- Ability to be comfortable, speaking in sentences
- Frequency of exacerbations
- Frequency of hospital admissions
- Frequency of respiratory infections
- Frequency of intubations
Lung disease severity measures - exam
- Respiratory rate
- Acute irritability
- Low sats and oxygen requirements
- cyanosis
Lung disease severity measures - investigations
- FEV1 and FVC
- DLCO
- Oxygen saturation and concentration on arterial blood gas
- Degree of hypercapnoea and compensation for respiratory acidosis
- Pulmonary pressure on TTE
- VO2 max on exercise testing
Adherence measures/history - cardiorespiratory
- Regular use of inhalers with correct use of spacer and medications
- Smoking cessation
- Peak expiratory flow measures on regular basis
- Use of action plan
- Regular GP and specialist appointments
- Yearly influenza vaccinations, completed pneumococcal vaccinations
- Avoidance of potential triggers
- Involvement in rehabilitation and exercise program
- Involvement of loved ones, community support in care
Bronchiectasis risk factors
recurrent childhood infections
immunodeficiency
abnormal mucociliary drainage – CF, kartager’s syndrome
complications of bronchiectasis
o Frequency of pneumonia, courses of antibiotics
o Abscess, empyema and thoracic decortication surgery (time of surgery, management, complications)
o Recurrent pleurisy – severity of symptoms, impact on life, management
o Colonisation with resistant organisms – recent cultures, eradication with Abx
o Pulmonary hypertension and right heart failure
o Bronchial haemorrhage requiring bronchoscopy and cautery
o Amyloidosis
o Other systemic infections (infective endocarditis)
Diagnosis of CF
CT
sweat testing
ciliary function testing
bronchoscopy
immunoglobulins
eosinophilia (allergic bronchopulmonary aspergillosis)
Treatment of bronchiectasis
o Sputum clearance
o Antibiotics
o Bronchodilators
o Inhaled steroids
o Oral steroids
o Twice daily postural drainage
o Vaccination
o Treatment of HF
o IV immunoglobulin
o Bronchoscopy of haemoptysis
o Lobectomies, wedge resections for localised drainage
Lung carcinoma - local symptoms
o Reduced exercise tolerance
o Pleural and thoracic chest pain (pleural and thoracic wall involvement)
o Dysphagia, hoarseness, stridor (tracheal and oesophageal obstruction)
o Headache and dizziness (superior vena caval obstruction)
o Bony pain, abdominal pain (metastasis)
lung carcinoma - systemic symptoms
o Loss of weight, appetite, night sweats
o New paraesthesia, weakness unsteadiness (LEMS, peripheral neuropathy, cerebellar degeneration, polymyositis and dermatomyositis, acute transverse myelitis)
o Limb pain, purpura (DVT, DIC)
o Polyuria (hypercalcaemia)
o Acanthosis nigricans, scleroderma
Lung carcinoma - investigations
o CT scans, biopsy -bronchoscopy or CT guided, VATS pleural, pleural tap
o Staging -CTCAP, PET scan
o PFTs for fitness for surgery FEV1 >1.5L
Lung carcinoma - treatment
o Chemotherapy – weekly/fortnightly course number of courses
Antiemetic therapy, chemotherapy nursing support
In hospital, clinic, home
o Radiotherapy
Brain – prophylactic
Chest –
Complications of lung carcinoma - disease
o Progression of local disease, metastasis – liver, abdominal, bony involvement
Cord compression ascites biliary sepsis obstructive pneumonia DVT/PE
Complications of prednisolone treatment
Myopathy
Opportunistic infections
Mania/psychosis
Osteoporotic fractures
Dysmorphic cushingoid features
BSL derangements, refractory hypertension
Chemotherapy SEs lung cancer
Nausea vomiting
Mucositis
Typhlitis, neutropaenic sepsis
Peripheral neuropathy and pain
Ototoxicity
Complications lung Ca - cancer pain
Degree of opioid requirement
- Number of rotations
- Overdoses
Local nerve blocks
Functional loss due to pain
Degree of sleep loss
Degree of emotional distress
Measures of response - lung cancer
Surveillance scans and PET post treatment course
Blood counts, BMT myeloid/lymphoid malignant cell counts
Blood tests – CA199, PSA
Degree of functionality – walking, daily activities, ability to walk, moods Level of pain
COPD precipitants
o Upper and lower respiratory tract infections
o Omission of medications
o Heart failure
o Sleep apnoea
o Pneumothorax
o GORD
o aspiration
COPD diagnosis
o Initial symptoms, spirometry – bronchodilator responsiveness, CT, arterial blood gases, FVC, FEV1
Complications of COPD
o Number of hospital admissions
o Number of exacerbations
o Number intubations
o Current exercise tolerance, flights of stairs, things unable to do
o FEV1, 6 minute walk test
o Oxygen concentration on arterial blood gas
o Current weight and degree of weight loss
o Pulmonary hypertension and right heart failure
o Lung cancer (separate issue)
o Depression (separate issue)
ECOG
0 Acute without restriction of performance
1 Ambulatory and able to attend light work activity, unable to carry out strenuous activity
2 Can manage self-care but unable to attend any form of work activity, ambulatory for more than 50% of the time while awake
3 Can manage one limited self care, bed bound for more than 50% of the time
4 Disabled, completely bed bound
Smoking - history
Amount smoked
Evidence of nicotine dependence –
smokes >10/day
30mins between smokes
smoking from waking
Smoking - high risk groups
- Pregnancy
- Parents of young children
- Aboriginal and torres strait islanders
- Mental illness
- Other substance abuse
- Lung disease
- CVD risk factors and diabetes
- Low socio-economic status
Smoking - Initial management
brief advice, motivational interviewing, quit date Follow up - Relapses occur in first few weeks of quitting and require follow up • Associated with weight gain, stress, and withdrawal symptoms
Smoking - pharmacological therapy
NRT increases quit rates by 60% from placebo, combination therapy oral and patch more effective than one alone CI – pregnancy, arrhthymias, lactation, CVD, angina, stroke
Varenicline – most effective, doubling abstinence rates, nausea; CI neuropsychiatric disease; however no increase in SI
Bupropion – effective with social support
- CI in seizures, CNS disease, PD MAOI treatment;
caution in DM, CKD, other drugs that may reduce seizure threshold
Current COPD treatment
o Bronchodilators and spacer
o Domociliary oxygen – ABG, desaturation on 6MWT
o Annual influenza vaccinations o BiPAP
o Number of prednisolone courses
o Pulmonary rehabilitation attendance, number of times, usefulness o Lung valves, lobectomies
o Transplantation work up (separate issue)
o Antiprotease therapy for alpha1 antitrypsin
o Frusemide for RHF
