Respiratory key points Flashcards
Questions to ask about breathlessness
MRC score, exercise tolerance, triggers, relieving factors, diurnal variation, Orthopnoea, PND
Questions to ask about chest pain
Site, severity, radiation, triggers, relieving factors, associated symptoms
Questions to ask about wheeze
Triggers, relieving factors, diurnal variation, associated cough
Questions to ask about cough
Dry or productive, triggers, relieving factors, diurnal variation, association with eating or dyspepsia, positional, nasal secretions, associated fever
Questions to ask about sputum
How much over 24 hours, colour, consistency
Questions to ask about haemoptysis
Quantity and frequency, fever/night sweats, appetite, weight loss
What appearance of CT scan suggests infection
Ground glass
How do you treat pseudomonas
Piperacillin
Principles of PE treatment
Look for cause, lifelong anticoagulants, check for cancer
Can you see pulmonary hypertension on CT scan
Yes
What drug can help bad ILD
Morphine
Features of bronchiectasis
Airway dilatation and mucous plugs
What can help people cough up mucous
Mucolytics e.g. NaCl nebulised and Carbocisteine, salbutamol helps as can dilate airways further to increase amount of mucous coughed up
Tips for resp exam
Don’t need to percuss in more than 3 areas, chest expansion important for thumbs to hover, with tracheal deviation check for empty space either side of trachea before localising centrally, ensure when auscultating back you are not listening over spine or scapula, check for clubbing by lowering down to height of nails, check RR tricking for pulse, remember lymph nodes
What usually causes COPD/ILD
COPD usually smoking, ILD more commonly occupational or allergy related
Examination in ILD
Fine crackles, especially at lung bases, inspiratory
Explanation of ILD appearance on spirometry
Restrictive pattern due to fibrosis as less air able to enter lungs
FEV1/FVC ratio normal as both are proportionately lower
Causes of delirium
M is also metabolic
target O2 sats
92%
Gold standard answer for giving oxygen
Controlled oxygen and assess patient response
How to present investigations
Start with bedside and do most invasive at the end
What 2 asthma drugs should not be given together in acute asthma attack
IV aminophylline and IV salbutamol
Why is hyperventilation a good sign in asthma
Shows good respiratory muscle function (CO2 is low), as time goes on the respiratory muscles begin to fatigue and the CO2 increases or becomes normal which is a worry as clearly the patient no longer has the physiological reserve to compensate
SOB and pleuritic chest pain key differentials
Pericarditis and pneumothorax, PE
What clinical finding defines a tension pneumothorax
Hypotension (haemodynamic instability). hemidiaphragm depressed
COPD exacerbation investigations
CXR and ABG (to check for high CO2 indicating type 2 respiratory failure especially if GCS not normal)
What do you call respiratory acidosis if not compensated
Acute rather than chronic
NIV is only for
T2 respiratory failure in context of respiratory acidosis and after you gave tried with medical therapy. CPAP is next step before intubation
Type 1 and 2 resp failure modes of oxygen as final step before intubation
T1 needs CPAP T2 needs BIPAP
Contraindications to NIV
Untreated pneumothorax, impaired conscious level, upper airway secretions, facial injury, life threatening hypoxia, vomiting, agitated
How does fibrosis show on CXR
Fine reticular Nodular shadowing
What should you check before you send someone for a CT scan
Us and Es for kidney function to check they can handle contrast
PE classification
PE can be provoked or unprovoked, haemodynamically stable or unstable
Treatment for different PE types
Thrombolysis for haemodynamically unstable, routine anticoagulation if stable
Treatment for asthma attack
Steroids 1st line
IV aminophylline/salbutamol
nebulised salbutamol/ipratropium bromide
Urgent ITU or anaesthetist assessment , admit patient, portable CXR
T1 and T2 resp failure O2 sats aim
T1 = above 94%
T2 = 88-92%
What is a safe asthma discharge bundle
PEFR > 75%, stopped regular nebs for over 24 hours, inhaler technique and adherance assessed, PEFR meter and asthma action plan
At least 5 days oral pred, GP follow up within 2 working days, resp clinic follow up within 4 weeks
Principle of asthma management
Step up and down treatment
Causes of COPD
Smoking, inherited alpha 1 antitrypsin deficinecy, industrial exposure such as sooty air pollution
What is COPD
Airflow obstruction which is progressive and not fully reversible. Encompasses emphysema and chronic bronchitis
ECG changes with electrolyte disturbance
What to check when prescribing furosemide
Us and Es for eGFR as can impact kidney function and K+ to check for hypokalaemia
Risk factors for heart failure
Previous MI, A fib, HTN
Raised Troponin in someone with Afib
Can be due to Afib, if not chest pain then not major concern, send for repeat perhaps
What are possible clinical signs when examining a patient with COPD
Tachypnoea, wheeze, pursed lip breathing, barrel chest, peripheral cyanosis, CO2 retention flap, oedema, accessory muscle use
COPD care bundle
Smoking cessation and pulmonary rehab
Bronchodilators, anti muscarinics, steroids and mucolytics
Diet
LTOT
What interventions alter prognosis for patients with COPD
LTOT for 16 hours a day, smoking cessation, pulmonary rehab, vaccination
Why may uncontrolled oxygen be potentially dangerous in someone with COPD
Could cause hypercapnia due to loss of hypoxic pulmonary vasoconstriction and respiratory drive (T2 resp failure)
What is the role of pulmonary rehabilitation in COPD
To increase social activities and exercise to help symptoms. MDT 6-12 week programme of supervised exercise, unsupervised home exercise, nutritional advice and disease education
Common causes of cough
Pneumonia, asthma, COPD, bronchitis, acid reflux, bronchiectasis
What drugs can cause cough
ACEi, sitagliptin, CCB, fentanyl, latanoprost, methotrexate, phenytoin, mycophenolate mofetil, omeprazole
LRTI CXR changes
None
Investigations for cough
Lung function tests if chronic
Sputum sample, CXR, (pneumonia), FBC, CRP
CAP pathogens
Strep pn, H Influenzae, Moraxella Catarrhalis
Atypical pneumonia organisms
Legionella, pneumophila, chlamydia, mycoplasma
Considered when not common on sputum sample or normal antibiotics not helping, high CURB65
What features help differentiate CAP from TB
TB
Fever and nocturnal sweats in TB, weight loss over months, malaise, purulent sputum. May have skin/joint/Miliary TB, known TB contact or country
Longer history and upper zones on CXr affected
HAP pathogens
E. coli, MRSA, pseudomonas, staph/strep/acinobacter
Hap and cap antibiotics
HAP Coamox if non severe (broad spectrum), Piperacillin or levofloxacin if severe
CAP amox or azithro
What follow up arrangements should be made for a patient with pneumonia
HIV test, immunoglobulins, pneumococcal IgG serotypes, Haemophilus influenzae, 6 week CXR to check for resolution/cancer
What 3 clinical features do patients requiring hospital admission for COVID have
Hypoxia, bilateral lower zone changes on CXR, lymphopaenia (eosinopaenia)
COVID treatment
Oxygen, dexamethasone if on O2, tocilizumab/remdesivir, antibiotics, anticoagulation with heparin, CPAP
Co morbid conditions with lung cancer
TB scars, ILD, CAD, COPD
Clinical findings in lung cancer
Finger clubbing, dullness to percussion, cervical lymphadenopathy, wheeze, pallor, cachexia
What sites do lung cancer commonly metastasise to
Brain bones liver adrenals other lung
Nearby lymph nodes
Paraneoplastic syndromes associated with lung cancer
Clubbing - increased blood flow to finger area leading to accumulation of fluid, xs growth factors encourage growth of blood vessels
Hypercalcaemia - increased bone resorption as PTHrP has a similar action to PTH
Anaemia - impaired EPO stimulation and production
SIADH - cancer cells can produce ADH
Cushing’s - Small cell lung cancer due to XS production of cortisol
Lambert Eaton myasthenia syndrome - small cell lung cancer (development of autoantibodies due to antigens expressed by lung tumour, which cross react with channels at the neuromuscular junction)
CXR abnormalities in lung cancer
Single or multiple opacities, pleural effusion, lung collapse
How do you stage lung cancer
Staging CT
NSCLC is better than SC
Why is lung cancer prognosis generally poor
Present with advanced or metastatic disease as symptoms can be masked by COPD etc
Opacification due to pleural effusion in lung cancer
Bad sign as suggests pleural involvement
Further imaging to diagnose pleural effusion
USS
Clinical signs in pleural effusion
Reduced chest expansion, tracheal deviation away, reduced vocal resonance, stony dull percussion, breath sounds reduced
Nicotine staining, clubbing, RA joint deformity, fluid overload due to HF
How much is pleural fluid aspiration
50ml
How do you distinguish pleural fluid
Lights criteria
Exudate if pleural fluid protein divided by serum protein is greater than 0.5
Symptoms in ILD
Progressive SOBOE, dry cough, connective tissue disease symptoms (arthralgia, dysphagia, dry eyes), general fatigue and malaise
Clinical signs in ILD
Bilateral fine end inspiratory crackles, dullness to percussion, finger clubbing, reynauds, arthritis causing crepitus
Common types of ILD
Usual interstitial pneumonia: idiopathic pulmonary fibrosis
Non specific interstitial pneumonia: hypersensitivity pneumonitis
Sarcoidosis
Recognised drugs causing ILD
Amiodarone, bleomycin, methotrexate, nitrofurantoin
ILD CXR appearance
Like a web- diffuse alveolar shadowing, reticular opacities, fibrosis
Which test confirms bronchiectasis
High resolution CT thorax
Common causes of bronchiectasis
Post infecting (whooping cough, TB), pulmonary disease (COPD/asthma), congenital CF, connective tissue disease, ABPA,
Common pathogens in bronchiectasis sputum
Haemophilus inf., pseudomonas Aeruginosa, moraxella catarrhalis, strep pn
Key principles of managing bronchiectasis
Treat underlying cause, physio for mucous clearance, sputum for routine culture as well as non TB bacteria
10 - 14 days antibiotics according to sputum culture
Pathology of CF
Autosomal recessive disease leading to mutations in CFTR gene (chromosome 7). Leads to multisystem disease (mostly resp and GI), caused by thickened secretions
Common multi systemic complications of CF
Respiratory infections, low body weight due to pancreatic insufficiency, distal intestinal obstruction syndrome due to thick dehydrated faeces/insufficient pancreatic enzymes, CF related diabetes, male infertility
Name an ICS, SABA and LABA
ICS beclomethasone
SABA salbutamol
LABA salmeterol
