Respiratory guidelines Flashcards
Asthma investigation - what do all adults get - what do children get
FeNO and spirometry with reversibility children only get FeNO if spirometry inconclusive
Astham investigation - diagnostic cutoffs reversibility FEV1/FVC ratio FeNO
12% reversibility (AND 200ml in adults) ratio of <0.7 FeNO >40ppb (>35 in children)
Asthma treatment escalation ADULTS
SABA + low dose ICS + LABA + LRTA or moderate dose ICS (stop LABA if not working) specialist
Asthma treatment escalation CHILDREN
SABA + very low dose ICS Step 2 (>5) = LABA or LTRA Step 2 (<5) = LTRA Step 3 = increase to low dose ICS. Add LABA/LRTA and stop LABA if not helpful specialist
Acute asthma attack categories
Life threatening = PEFR<33, silent chest, <92%, normal CO2 Acute severe = >110bpm, cant complete sentences, PEFR33-50, RR>25 Moderate = 50-75% PEFR
Acute asthma management standard escalated
standard - oxygen driven nebs (salbutamol and ipratropium) give ipra 4-6hourly, salbutamol back to back oral pred/ IV hydrocortisone for at least 5d escalated - 1st: IV magnesium - 2nd: IV aminophylline 3rd: IV salbutamol (rarely used), intubation etc
COPD Ix - if you suspect COPD what 3 things do you get
CXR (?mass), FBC (2’ polycythaemia), spirometry/reversibility testing
Grading of COPD cutoffs
All based on FEV1 Mild= >80 WITH symptoms and FEV1/FVC <0.7 mod = 50-80 severe = 30-50 very severe = <30
COPD treatment escalation
1) SABA or SAMA 2) asthmatic features = LABA+ICS; no asthmatic features = LABA/LAMA 3) oral theophylline
Antibiotic prophylaxis in COPD?
Azithromycin
Asthmatic features for COPD step 2???
1) previous history of asthma or atopy 2) eosinophilia 3) diurnal variation of PEFR >20% 4) FEV1 variation >400ml
When do you assess someone for LTOT if has COPD
FEV1 <30% (i.e. very severe) cyanosis/polycthaemia oedema/raised JVP
How do you assess someone for LTOT?
ABGs on two separate occasions
Based on the ABGs, when do you offer LTOT for COPD
pO2 <7.3 pO2 7.3-8 + oedema, polycythaemia, pul HTN
COPD exacerbation Mx
Nebulised bronchodilators and prednisolone 7-14d Abx if sign of infection –> amox + clari
CURB65 score and meaning
Confusion <=8/10 AMTS urea >7 RR >=20 BP <=90/60 65+ 0-1 = home with amox 5d (depending on CRP test) 2-3 = hospital with amox+clari 7d 4-5 = ITU with coamox/tazocin 7d
CRP point of care test in GP for penumonia
Helps you decide if Abx are needed if they score CURB0 >100 = yes 20-100 = delayed <20 = no
Abx guideline: - CAP - atypical CAP - HAP
CAP = amox atypical CAP = clarithromycin HAP depends on when it has occurred after admission (remember HAP is defined as at least 48 hours after admission): - if within first 5d = coamox, cefurox - if after 5th day of admission = taz, cipro, ceftaz
2ww lung cancer referral for CXR
40+ and any of: - cough, fatigue, SOB, pain, weight loss, anorexia need 2 of them if never smoked
2ww lung cancer referral for clinic straight away
40+ and haemoptysis or abnormal CXR
best Ix for lung Ca
CT (hence why you do it if CXR negative and youre still suspicious)
Difference between SCLC and NSCLC
SCLC not usually amenable to surgery, need chemo NSCLC usually amenable to surgery, both have radio
Idiopathic lung fibrosis - gold standard Ix - TLCO and spirometry
gold standard- high res CT - ground glass appearance
+ spirometry
+ CXR
restrictive picture on spirometry:
- FEV1 reduced
- FVC reduced
- FEV1/FVC ratio normal
TLCO is low
- low uptake of O2 from lungs to blood
definitive Tx for idiopathic lung fibrosis
lung transplant
Sarcoidosis useful tests (no diagnostic one)
raised ACE and ESR restrictive spirometry non-caseating granuloma formation bilateral hilar lymphadenpatphy upper zone fibrosis
Management of sarcoid
Don’t treat asymptomatic lymphadenopathy If Sx –> prednisolone
Interpretation of Mantoux test
injection of tuberculin into skin - screening for TB
If <6mm = no reaction, immunise If 6-15mm = medium reaction, ?previous TB or previous vaccination, don’t immunise If >15mm = big reaction, active TB
when do you use interferon gamma quantiferon gold test?
if Mantoux equivocal or positive If Mantoux inaccurate (sarcoid, military TB, lymphoma HIV)
Drugs for TB and SEs
Active = 2m RIPE and 4m RI Latent = 3m RIP or 6m IP Meningeal = 12m RIPE + steroids rifampicin = red piss and hepatitis isoniazid = peripheral neuropathy and hepatitis pyranzinamide = gout and hepatits ethambutol = optic neuritis
Pneumothorax Mx
Primary <2cm = clinic in 6/52!! >2cm OR BREATHLESS = aspirate and observe Secondary 0-1 = admit O2 observe 1-2 = aspirate >2 = chest drain
Wells score PE
0-4 is unlikely to be PE - D-dimer wihin 4 hrs
if D-Dimer +ve -> immediate CTPA
if D-Dimer -ve -> consider other diagnosis
. 5+ = CTPA` immediately or interim therapeutic anticoag while awaiting CTPA
do V/Q scan instead if contrast allergy or renal failure
PE most likely = 3 DVT present = 3 Recent immobilisation = 1.5 Previous DVT/PE = 1.5 Tachycardia >100 = 1.5 Haemoptysis = 1 Malignancy = 1
Well score DVT just the cutoff Mx based on that
0-1 is unlikely –> D-dimer to exclude 2+ is likely ==> USS leg within 4 hours. if cant get one within 4 hours, treat with LMWH assuming its there
DVT Wells score:
cancer: 1
calf swelling >= 3cm (measured 10cm below tibial tuberosity): 1
collateral superficial veins: 1
pitting oedema (in symptomatic leg): 1
swelling of entire leg: 1
localised tenderness along deep venous system: 1
paralysis, paresis, or recent cast immobilisation of legs: 1
recently bedridden >= 3 days, or major surgery in last 12 wks: 1
previous DVT : 1
alternative diagnosis at least as likely as DVT: -2
Do you start LMWH before the CTPA is back
yes because it usually takes a number of hours to get done
Tx of PE
haemodynamically unstable = thrombolysis (alteplase)
stable = DOAC (apixaban or rivaroxaban) or warfarin
if not suitable then: LMWH (e.g. enoxaparin) for 5d or until INR>2 for 2days whichever is longer.
start warfarin or NOAC witin 24 hours. if warfarin crossover with LMWH, if NOAC just give it 2 hours before dose and don’t carryover.
continue for at least 3 months in primary PE
3-6 months for active cancer
ARDS - how do you exclude thatit is cardiac in origin if unsure
pulmonary artery wedge pressure.
obstructive sleep apnoea Best Ix and other Ix
Sleep studies is best test Epworth sleepiness scale and multiple sleep latency test also used
Mx of obstructive sleep apnoea
If sleepiness in daytime –> CPAP at night If no sleepiness or CPAP not tolerate –> mandibular advancement device
pleural effusions and lights criteria
protein >35 = exudate protein <25 = transudate 25-35 use lights criteria exudate if: - pleural protein is >50% the serum protein - pleural LDH >60% serum LDH - pleural LDH >2/3rds NORMAL serum LDH
if pleural fluid is exudate?
contrast CT and send off sample to lab
if pleural fluid is purulent or has pH <7.2
chest tube
NG tube safety
pH <5.5 is happy days Otherwise need to do a CXR
NIV indications in COPD
any respiratory acidosis despite maximal therapy
when is an aspirate exudate
<25 protein = transudate >35 protein = exudate in between use lights criteria. Exudate if pleural fluid: - protein >50% serum protein - LDH >60% serum LDH - LDH >2/3rds normal serum LDH
should CO2 be normal in ABG in asthma
no it should be low - need referral to ITU if normal or high on ABG
safety triangle for pleural tap - pleural fluid aspirate, thoracocentesis
not below 5th intercostal space top is base of axilla posterior border of pectorals major anterior border of latissimus dorsi go on superior border of rib to avoid NV bundle
layers that you go through to do a pleural tap
- skin 2. epidermis 3. intercostal muscles 4. endothoracic fascia 5. parietal pleura
65yr M
progressive SOB
unilateral pleural effusion
pleural aspirate - what type of pleural effusion?
transudate
- low protein
- low LDH
causes of transudate
HF
liver cirrhosis
renal - nephrotic syndrome
ovarian - Meigs syndrome
sarcoidosis
thyroid myxoedema
causes of exudate pleural effusion
malignancy
infection
trauma
pulmonary embolus/ infarct
78
3 wk hx
dry cough
weight loss
breathlessness at rest
unilateral pleural effusion - type?
exudative
most likely due to cancer
monitoring of chest drain
bubbling
- normal in pneumothorax
abnormal in effusion - check for air leaks
swinging
- should occur with inspiration and expiration - if its not- blockage?
58yr M
routine abdo paracentesis
tender abdo
jaundice
confusion
fever
polymorphic neucleocyte count: 0.3
SA-AG = 15
SBP - Spontaneous bacterial peritonitis
indications for ascitic tap
diagnosis of new onset ascites
suspected SBP
therapeutic ( usually drainage/ paracentesis)
surface anatomy of ascitic tap
15cm lateral to umbilicus - left or right lower quadrant
avoid enlarged liver/ spleen and epigastric arteries
ascitic tap analysis
PMNs/neurophil > 250 = diagnostic of SBP
presentation of TB
suspected in anyone with cough for >3 wks
especially if accompanied by:
- haemoptysis
- SOB
- loss of appetite
- weight loss
- fever and sweating, especially night sweats
- fatigue and tiredness
- swollen glands
indication for CXR or referral to specialist for idiopathic pulmonary fibrosis
>45yrs
persisent breathlessness on exertion
persistent cough
bilateral inspiratory crackles
clubbing of fingers
normal spirometry or restrictive pattern
investigations if TB suspected
for active:
CXR/ CT + deep cough sputum sample (for micro, culture and histology)
for latent TB:
- Mantoux test - for close contacts with TB patients
- if Mantoux positive –> interferon-gamma release assay (quantaferon gold)
- if +ve: assess for active TB
- if -ve: treat for latent TB
radiological features of TB
primary TB:
- less than half of patients show radiological abnormalities
- there may be hilar lymph node enlargement
post-primary TB:
- patchy solid lesions
- cavitated solid lesions
- streaky fibrosis
- flecks of calcification
- solitary tuberculoma presenting as a coin lesion
- hilar node enlargement
Miliary TB:
- millet-sized nodules present throughout the lung fields
diagnosis
miliary TB
cough
fatigue
recently moved from developing country
diagnosis?
primary TB
upper zone consolidation
+ ipsilateral hilar enlargement
what is this showing in TB
healed primary TB
Ghon focus - TB has gone!
cough
HIV
diagnosis
TB
- post primary Tb (secondary or reactivation TB)
apical consolidation
hilar distortion
more common in immunocompromised (HIV)
Ix for pneumothorax
CXR for pneumothorax
tension pneumothorax should not be seen on CXR - clinical diagnosis (deviated trachea) and chest drain
clinical features of ARDS
stages:
respiratory distress - but with normal CXR
increasing cyanosis - CXR diffuse bilateral shadowing
hypoxaemia, respiratory acidosis
may be death from hypoxic cardiac arrest
Mx of ARDS
mechanical ventilation - using high inspired O2
blood gases checked regularly
fluids
Finer assessment using Swan Ganz catheter to measure pulmonary capillary wedge pressure (left atrial pressure)
mortality 50%
usually residual pulmonary disability due to developing pulmonary fibrosis
medical management of idiopathic lung fibrosis
pirfenidone - antifibrotic and anti-inflammatory
nintedanib - monoclonal antibody targeting tyrosine kinase
causes of pulmonary fibrosis (drug induced and secondary)
drug induced:
- amiodarone
- cyclophosphamide
- methotrexate
- nitrofurantoin
secondary:
- alpha-1 antitripsin deficiency
- RA
- SLE
- systemic sclerosis
what does asbestos cause
lung cancer - most common
Mesothelioma – rare but if you see it think asbestos
what type of hypersensitivity reaction is hypersensitivity pneumonitis (extrinsic allergic alveolitis)
type 3 hypersensitivity reaction
to environmental allergen that causes parenchymal inflammtation
can lead to pulmonary fibrosis in later stages
Ix for Hypersensitivity Pneumonitis
Bronchoalveolar lavage (during bronchoscopy)
- raised lymphocytes
- raised mast cells
Mx for Hypersensitivity Pneumonitis
remove allergen from patients environment
O2
steroids
4 causes of Hypersensitivity Pneumonitis
bird- fanciers lung - reaction to bird droppings
- avian proteins
farmers lung - reaction to mouldy spores in hay
- micropolyspora faeni
mushroom workers’ lung - reaction to specific mushroom antigens
malt workers lung - reaction to mould on barley
- aspergillus clavatus
cause of mesothelioma
asbestos
(especially blue asbestos)
can even get it from other peoples clothes
diagnostic test for mesothelioma
pleural biopsy: diagnostic test
CXR/CT shows pleural thickening and associated pleural effusion
Mx for mesothelioma
mostly symptomatic treatment
surgery may be possible for stage 1: extrapleural pneumonectomy
chemo - malignany pleural mesothelioma where surgical resection is inappropriate
70yr man
used to work on construction sites
diagnosis?
mesothelioma
- cancer of pleura
- due to asbestos
patient is woken by airway obstruction
- choking/ gasping during sleep
snoring
excessive daytime sleepiness
clinical presentation of bronchiectasis
bronchial wall thickening and dilatation
chronic cough
mucopurulent sputum production
recurrent infections
diagnostic test for bronchiectasis:
high resolution CT: diagnostic investigation
- if CXR is unhelpful
features:
- bronchial wall dilation (internal diameter of lumen bigger than accompanying bronchial artery - signet ring sign)
- lack of bronchial tapering
chronic productive cough
previous frequent infections
cystic fibrosis
diagnosis
bronchiectasis
on high res CT
signet ring sign - bronchi bigger than accompanying artery
Mx of bronchiectasis
physio - airway sputum clearance
abx - if infection
surgical resection if localised
aspergillosis Mx
caused by aspergillus mould - hypersensitivity reaction
Mx: oral steroids + oral antifungal
causes of pleuritic chest pain
pain on inspiration
- PE
- malignancy
- infection: TB, pneumonia
- injury: rib fracture
- autoimmune: RA and SLE
diagnosis
pulmonary fibrosis
‘honeycombing’
causes of upper zone pulmonary fibrosis
causes of lower zone pulmonary fibrosis
asbestosis
idiopathic pulmonary fibrosis
most connective tissue disorders (except ankylosing spondylitis)
drug induced (amiodarone, methotrexate)
pneumonia
high fever
rapid onset
herpes labialis
which bacteria?
strep pneumoniae
small cell lung cancer paraneoplastic features
ADH –> hyponatraemia
squamous cell lung cancer paraneoplastic features
parathyroid hormone-related protein (PTH-rp) secretion causing hypercalcaemia
adenocarcinoma paraneoplastic features
gynaecomastia
hypertrophic pulmonary osteoarthropathy (shown in pic)
vital capacity
vital capacity = inspiratory capacity + expriatory reserve volume
opiate overdose ABG
respiratory acidosis
PE ABG
respiratory alkalosis
life threatening asthma O2 sats
<92%
pneumonia with a PMH of COPD
which bacteria
H. influenza
new diagnosis of COPD
Mx
add SABA or SAMA
anxiety leading to hyperventilation ABG
respiratory alkalosis
tiring asthma attack abg
respiratory acidosis
as tiring they start retaining CO2
if CO2 normal or high - WORRY -> severe asthma attack
negative result on spirometry for asthma but symptoms of asthma
next step
refer for fractional exhaled nitric oxide (FeNO) testing
negative spirometry does not exclude asthma - further investigated
most common cause of SVC obstruction
lung cancer
due to extrinsic pressure
lung cancer can cause superior vena cava syndrome:
- visibly distended veins chest and neck
increased breathlessness particulary on exertion
SOB and bibasal atelectasis 72hrs postoperatively
Mx
Atelectasis: alveolar collapse
Mx: positioning patient upright
chest physiotherapy: breathing exercises
cough
fever
left lingula consolidation
- leads to loss of left heart border
diagnostic investigation for mesothelioma
thoracoscopic biopsy - histology
which tyoe of lung cancer is not related to smoking
alveolar cell carcinoma
increased sputum production
respiratory acidosis, agitated, low O2, high bicarb
after pneumonia patient put on O2 15L
most likely diagnosis
over administration of O2 in COPD patient
background of chronic respiratory acidosis with compensatory metabolic acidosis
retain CO and therefore hypoventilate –> respiratory arrest
if the bicarb was normal it would be acute respiratory acidosis 2ndry to pneumonia
facial rash + lymphadenopathy
sarcoidosis
features:
- erythema nodosum
- bilateral hilar lymphadenopathy
- skin: lupus pernio = sarcoidosis
- hypercalcaemia
most likely lung cancer in non-smokers
lung adenocarcinoma:
- most common in non-smokers
- peripheral lesion (not seen on bronchoscopy)
what can false negatives of mantoux test be caused by
miliary TB
sarcoidosis
HIV
lymphoma
very young age (e.g. < 6 months)
chest drain swinging
rises in inspiration, falls in expiration
test for suspected carbon monoxide poisoning
ABG
shows hypoxia
mx carbon monoxide poisoning
100% high flow O2 through non-rebeath
target O2 sats 100%
normal/ raised total gas transfer with raised transfer coefficient
asthma
pulmonary haemorrhage (Wegener’s, Goodpasture’s)
what test should be offered to all patients with TB
HIV test
trachea pulled toward white-out on cxr
pneumonectomy
complete lung collapse
pulmonary hypoplasia
trachea central with white out
consolidation
pulmonary oedema (usually bilateral)
mesothelioma
trachea pushed away from white out
pleural effusion
diaphragmatic hernia
large thoracic mass
O2 for critically ill COPD patient
given 15L/min O2 through non-rebreath then titrated down (hypoxia kills)
aim to raise sats to 94% and over
titrate down:
prior to availability of blood gases, use a 28% Venturi mask at 4 l/min and aim for an oxygen saturation of 88-92% for patients with risk factors for hypercapnia but no prior history of respiratory acidosis
adjust target range to 94-98% if the pCO2 is normal
paraneoplastic features of small cell lung cancer
ADH - hyponatraemia
ACTH - cushings syndrome
lambert-eaton syndrome (weakness of proximal arms and legs - normally worse in legs, slightly better with muscle use)
paraneoplastic features of squamous cell lung cancer
PTH - secretion causing hypercalcaemia
clubbing
hypertrophic pulmonary osteoarthropathy
hyperthyroidism due to ectopic TSH
paraneoplastic features of adenocarcinoma lung cancer
gynaecomastia
hypertrophic pulmonary osteoarthropathy
acute asthma levels by PEFR
75-50% of best: moderate
50-33% of best: severe
<33%: life threatening
COPD symptoms in young person
alpha -1 antitrypsin (A1AT) deficiency
features of heart failure on cxr
ABCDE
A - alveolar oedema (bat’s wings)
B - Kerley B lines
C- Cardiomegaly
D- dilated prominent upper lobe vessels
E- effusion (pleural)
intervention most likely to increase survival in patients with COPD
smoking cessation
in hypoxic patients - long term O2 therapy
what type of O2 do you give to COPD patient with respiratory acidosis
COPD with respiratory acidosis 7.25-7.35: NIV
main treatment for small cell lung cancer
chemotherapy
adjuvant radiotherapy is also given in patients with limited disease
surgery can be used for T1, N0,M0
respiratory complication of methotrexate
methotrexate pneumonitis - bilateral interstitial shadowing on CXR
diagnosis
cannon ball mets - from renal cell carcinoma
less common primaries:
choriocarcinoma
endometrial carcinoma
benign ovarian tumour + ascites + pleural effusion
Meig’s syndrome
Alpha 1 anti-trypsin deficiency features
alpha1 -antitrypsin made in liver
lungs: panacinar emphysema - lower lobes
can also cause liver disease: cirrhosis and hepatocellular carcinoma
spirometry: obstructive picture
can be diagnosed prenataly
commonly 20-50yrs
chromosome 14
latent TB cxr
calcified Ghon focus may be seen (lateral calcified nodule)
+ bilateral lymphadenopathy
= Ghon complex
latent TB mx
either:
- 3 months isoniazid (with pyridoxine) + rifampicin
or - 6 months isoniazid (with pyridoxine)
when should asthma attacks be admitted to hospital
life threatening asthma should be admitted
severe asthma attack should be admitted if fail to respond to treatment
any level asthma attack should be admitted when theyve had a previous near-fatal attack
side effect of bupropion - for smoking cessation
small risk of seizures - contraindicated in epilepsy
also CI in pregnancy and breast feeing
bronchiectasis + dextrocardia
Kartagener’s syndrome (primary ciliary dyskinesia)
features of kartagener’s syndrome
primary ciliary dyskinesia - immotile cilia
features:
- dextrocardia
- bronchiectasis
- infertility (low sperm motility and defective ciliary action in fallopian tubes)
- recurrent sinusitis
what is 1 pack yr
20 cigarettes per day for 1 yr
varenicline - smoking cessation
nicotinic receptor partial agonist
risk of suicidal behaviour
contraindicated with pregnancy and breast feeding
most common causes of anterior mediastinum mass
4 T’s:
- teratoma
- terrible lymphadenopathy
- thymic mass
- thyroid mass
what should you look for in the chest with myasthenia gravis
thymoma
do CT scan
pharmaological treatment of choice for smoking cessation in pregnancy
nicotine replacement patch
first line: CBT, motivational interviewing
mx for obstructive sleep apnoea
weight loss
CPAP = first line for mod/severe OSA
ABG picture for opiod toxicity
metabolic acidosis
type 2 respiratory failure (O2 low, CO2 high)
klebsiella pneumonia
commonly due to aspiration
- e.g. recent stoke causing dysphagia
also common in history of alcoholics and diabetes
red-current jelly sputum
coal workers pneumoconiosis
coal worker + restrictive picture on spirometry + apical lung fibrosis
indications for steroid treatment in sarcoidosis
- cxr stage 2 or 3 + symptoms (parenchymal lung disease)
- hypercalcaemia
- eye (uveitis) , heart or neuro involvement
what should be done to this NG tube
nothing, it is in the correct position
what stage is confusion in an asthma attack
life-threatening (even if dont have other features)
mx pneumonia (CAP)
first line for low severity (CURB65 0-1): amoxicillin 5days
moderate and high severity (2 or more): dual abx therapy: amoxicillin + macrolide (e.g erithyromycin, clarithromycin) 7-10 days
what should be offered to COPD to start early on as soon as patients start feeling SOB with regular activity
pulmonary rehabilitation - to all people who view themselves as functionally disabled by COPD
rusty coloured sputum
strep pneumoniae
respiratory disease and their bacteria/ virus cause
legionella pneumophila pneumonia features
flu-like symptoms
dry cough
relative bradycardia
confusion
hyponatraemia
pleural effusion
diagnosis: urinary antigen
mx: eryth/clarith
legionella pneumonia vs mycoplasma pneumonia
