Respiratory Med Flashcards
What symptoms are indicative of pneumothorax?
Sudden onset
SOB
Decreased breath sounds
COPD as risk factor
What is pulmonary oedema?
Fluid overload in the lung secondary to underlying cause e.g. MI
What are the three sections under HPC?
Symptom characteristic
Associated symptoms
DDx and RFs
What associated symptoms are important to ask in a resp history?
Cough
Sputum
Haemoptysis
Weight loss
What questions should you ask when considering PE?
Immobile Previous surgery Recent travel FH of DVT Malignancy - PMH or FH
What conditions are associated with different onsets of SOB?
Onset - seconds/minutes/days-weeks
Seconds - foreign body, PE, pneumothorax
Minutes - asthma exacerbation (inflammation), acute heart failure (fluid), infection (pus)
Weeks - Plural effusion, anaemia, chronic heart failure
How do we treat pneumothorax?
Oxygen
Primary
<2cm - discharge, repeat CXR
> 2cm/SOB - aspiration, if unsuccessful chest drain
Secondary
<2cm - aspiration
>2cm - chest drain
What do we mean by primary vs. secondary pneumothorax?
Secondary is when there is underlying lung disease
Pt. with pneumothorax improves after chest drain insertion but 2 hours later has recurrent SOB, why?
re-expansion pulmonary oedema
fluffy shadowing seen on CXR
What makes it more likely to be a tension pneumothorax?
Tracheal deviation
Trauma
Unlikely to see CXR since its an emergency
What do you see on an ECG in AF?
no P-waves
Which leads would should an inferior MI on an ECG?
II, III, aVF
ST elevation
How can we determine the axis?
Look at I and II - are either of them overall more negative
Yes - axis deviation
Is aVL overall positive?
Yes - left axis deviation
No - right axis deviation
How do you know if there is a RBBB?
MarrowW
V1 - M
V6 -W
RBBB
How do you know if there is a LBBB?
WilliaM
V1 - W
V6 - M
Why might a patient presenting with SOB have RBBB?
Pulmonary hypertension
PE causing strain on the right side of the heart
What is a cause of LBBB?
Acute coronary syndrome
Ischaemia
What is the treatment for PE?
If haemodynamically stable:
Anti-coagulate with Apixaban or Rivaroxiban. LMWH if unsuitable.
What is vanishing lung syndrom?
Large bullae - do NOT put in a chest drain
if in doubt need a chest drain
On CXR what would you see in pulmonary oedema?
Air-space shadowing
On CXR what would you see in pulmonary fibrosis?
Reticular/nodular shadowing
What are some obstructive lung diseases?
COPD
Asthma
FEV1/FVC < 70%
What is asbestosis?
Pulmonary fibrosis
not
Asbestos plaques
Signs of COPD on CXR?
Hyperexpansion
Flat diaphragm
Raised clavicle
How do you present a chest xray?
This is PA/AP CXR of:
Name and DOB
Taken at time
Commenting on the quality of the film:
Rotation
Inspiration
Penetration (look at appearance of vertebrae)
Compare Left and Right
Look for shadowing
Look at the peripheral margins
How can you tell the difference between a large effusion and lung collapse?
Where the trachea is deviated to
What are the causes of pleural effusion?
Infection
Inflammation
Malignancy
What is reticulonodular shadowing indicative of?
Restrictive/Fibrotic disease
Why shouldn’t you use cardiomegaly, what term should you use instead?
Increased cardiac shadow
Do not know if it fluid around the heard or cardiomegaly
What is homogenous shadowing?
White
Pleural effusion
How can breathlessness be characterised?
Air hunger- gas exchange
Wheeze - obstruction, inflammation
What can be some triggers for breathlessness?
Exertion
Exercise
Laying flat
How far can you walk? MRC Breathlessness scale
Define tension pneumothorax
Life threatening condition defines as
- air trapped in the pleural cavity
- under a positive pressure
- causing cardiopulmonary compromise
What is the treatment for a tension pneumothorax?
Emergency needle decompression (2nd ICS at MCL)
High flow oxygen
Chest drain
How are pneumothoracies managed?
Determine whether it is primary or secondary
Categorise the size and if >2cm aspirate
If <2cm they can go home
But if secondary they need chest drain and admission
What is a pulmonary embolism?
Venous thrombi that pass into the pulmonary circulation causing occulsion
Normally arise from DVTs
How are PEs diagnosed?
Gold standard - CT Pulmonary Angiogram
Ventilation/Perfusion Scan - will demonstrate perfusion defects
Scoring tools
How are PEs managed?
ABCDE - haemodynamicaly stable?
Unstable Oxygen, fluids Urgent thrombolysis - local or systemic OR Percutaneous embolectomy
Stable
Risk stratification
Low risk - LMWH (cancer), DOAC and Warfarin for 3 months
Moderate to high - admit
What are signs of pulmonary oedema on CXR?
Alveolar oedma - white dots at peripheries
Kerley B lines
Cardiomegaly
Dilated upper lobe vessels
What are signs symptoms of pulmonary oedema?
Pitting odema
Breathlessness
Raised JVP
What is pulmonary oedema?
Acute accumulation of fluid within the lung parenchyma
Results in impaired gas exchange
What are the causes of pulmonary oedema?
Cardiogenic - HF, Arrythmia, MI
Renal - Acute, severe kidney failure
ARDS - lung injury, infection e.g. covid
What is the management of acute cardiogenic pulmonary oedema?
Give O2 if hypoxic
High dose IV diuretics - Furosemide bolus
Treat cause e.g. beta blockers for arrhythmia
NO improvement - then
Nitrate infusion e.g GTN if BP is high enough >100mg systolic
Consider CPAP
What does CPAP do?
recruits alveoli
drives fluid out of alveolar spaces
What are signs of life threatening asthma?
CHEST
Cyanosis Hypotension Exhaustion Silent chest Tachy/Brady/Arrhythmias
What is conservative management for an asthma attack?
O2 aim for 98% sats
Bronchodilators
Steroids
If they improve:
Wean 02
Daily PEF
TAME (technique, avoid triggers,
What is CAP?
Acute lower resp tract infection associated with fever and chest signs
What will you find on auscultation in CAP?
Coarse crepitations
Dullness to percussion
Increased vocal fremitus
How do we assess severity of CAP?
CURB 65 Confusion Urea > 7 Resp rate > 30bpm B - SBP < 90mmHh 65 age
What is whooping cough a common cause of?
Bronchiectasis in adulthood after whooping cough in childhood is commone
What is bronchiectasis?
Permanent dilation of bronchi/bronchioles due to chronic inflammation
What are the causes of bronchiectasis?
Congenital - CF, Primary ciliary dyskinesia, young’s syndrome
Acquired - post infection, aspergillosis, inflammatory diseases e.g. RA or UC
How do we diagnose brochiectasis?
High res CT is gold standard
Bloods - Ig, HIV, FBC, autoimmune screen
Sputum - will commonly grow pseudomonas
Spirometry - obstructive pattern
How do we treat bronchiectasis?
Chest physio
Mucolytics, ABx, Inhaled steroids, bronchodilators
Surgery on indicated in severe disease with haemoptysis
What discharge advice should be give to people with small pneumothoraces?
Avoid smoking
No air travel for 2 weeks after successful drainage
Diving should be avoided unless bilateral surgical pleuroectomy has been performed
What some RFs for pneumothorax?
Pre-existing lung disease e.g. COPD, asthma, CF
Connective tissue disease e.g. Marfans, RA
Ventilation e.g. NIV
Tall and slender build
< 40 years old
What are the symptoms of pneumothorax?
dyspnoea chest pain: often pleuritic sweating tachypnoea tachycardia
How does a spontaneous pneumothorax from?
Bullae breaks
Bullae form from air leaks from alveoli
How does a traumatic pneumothorax form?
e.g. gunshot or stab wound
rips through parietal pleura
Air enters the pleural space
What are clinical signs of pneumothorax?
Reduced breath sounds
Hyper-resonant when percussed
What are some symptoms of PE?
chest pain typically pleuritic dyspnoea haemoptysis tachycardia tachypnoea
What criteria is used to investigate PE?
2-level PE Wells score
What features are present on a 2-level PE Wells score?
Clinical signs and symptoms of DVT (minimum of leg swelling and pain with palpation of the deep veins) - 3
An alternative diagnosis is less likely than PE - 3
Heart rate > 100 beats per minute - 1.5
Immobilisation for more than 3 days or surgery in the previous 4 weeks - 1.5
Previous DVT/PE - 1.5
Haemoptysis - 1
Malignancy (on treatment, treated in the last 6 months, or palliative) - 1
What is the threshold score for the 2-level PE Wells score?
PE likely - more than 4 points (arrange CTPA, interim anticoag if waiting)
PE unlikely - 4 points or less
(check D-dimer and if pos do CTPA)
What are the ECG changes seen in PE?
Large S wave in Lead I
Large Q wave in Lead III
Inverted T wave in Lead II
S1Q3T3
Only in 20% of patients
Why is a CXR done in suspected PE, what is seen?
To exclude other pathology
Typically normal
Wedge shape opacification
What is CTPA?
Computed tomography pulmonary angiogram
What are some DOACs?
Apixiban
Rivaroxiban
What are used first-line in the treatment of PE?
DOACs
Anticoagulation for 3 months at least
What is used if DOACs are not suitable in PE?
LMWH
When might DOACs be unsuitable for the treatment of PE?
Severe renal impairment <15mlmin
If pt has antiphospholipid syndrome
What is provoked vs. unprovoked VTE?
Provoked - result of precipitating event e.g. surgery
Unprovoked - absence of precipitating event
3 further months of anti-coag
What is the management of PE with haemodynamic instability?
thrombolysis - where there is circulatory failure (e.g. hypotension)
What do thrombolytic drugs do?
Activate plasminogen to form plasmin
Degrades fibrin and breaks up thrombin
What are some examples of thrombolytic drugs?
alteplase
tenecteplase
streptokinase
Why is DVT more common in pregnancy?
pregnancy is a hypercoagulable state
majority occur in last trimester
How do you manage DVT in pregnancy?
warfarin contraindicated
S/C low-molecular weight heparin preferred to IV heparin (less bleeding and thrombocytopenia)
How does pleural effusion usually present?
Breathlessness Cough Pleuritic chest pain Dullness to percussion Decreased tactile fremitus Quieter breath sounds
What do you see on a CXR in pleural effusion?
> 200ml of fluid
What can US or CT be used for in pleural effusion?
Whether fluid is free-lowing or loculated
What is the definitive treatment of pleural effusion?
Therapeutic thoracentesis
Define pleural effusion
Fluid collects between the parietal and visceral surfaces of the thorax
What are the RFs for pleural effusion?
Congestive HF
Pneumonia
Malignancy
Recent CABG
What investigations are used in pleural effusion?
PA CXR Pleural US LDH and protein in fluid and serum Cytology/Culture/Glucose/pH of fluid BNP
What is the significance of exudate and transudate?
Exudate = fluid/serum protein ratio >0.5
OR
protein < 30g/L
Caused by infection, malignancy
Transudate
Caused by factors altering hydrostatic pressure etc.
Protein > 30g/L
What are the typical findings of normal pleural fluid?
Appearance: clear pH: 7.60-7.64 Protein: < 2% (1-2 g/dL) White blood cells (WBC): < 1000/mm³ Glucose: similar to that of plasma LDH: <50% plasma concentration Amylase: 30-110 U/L Triglycerides: <2 mmol/l Cholesterol: 3.5–6.5 mmol/l
What are some causes of transudative pleural effusions?
Congestive heart failure
Liver cirrhosis
Severe hypoalbuminemia
Nephrotic syndrome
What are some causes of exudative pleural effusions?
Malignancy Infection (e.g. empyema due to bacterial pneumonia) Trauma Pulmonary infarction Pulmonary embolism
What is the criteria used to diagnose exudative pleural effusion?
The ratio of pleural fluid to serum protein is greater than 0.5
The ratio of pleural fluid to serum LDH is greater than 0.6
The pleural fluid LDH value is greater than two-thirds of the upper limit of the normal serum value
What is the management for pleural effusion in HF?
Diuretic
Physio
+/- therapeutic thoracentesis
Define asbestosis?
diffuse interstitial fibrosis of the lung as a consequence of exposure to asbestos fibres
What are presenting features of asbestosis?
Occupational exposure Smoking Dyspnoea on exertion Cough Crackles
What investigations are done for asbestosis?
PA CXR
Pulmonary function tests (mixed obstructive/restrictive changes)
What is the management of asbestosis?
Smoking cessation guidance
Supportive care e.g. ABs if signs of infection
Pulmonary rehab
Lung transplant
What is pleurisy?
Pain on breathing
What causes pain on inspiration?
Virus - flu most commonly
bacterial infections e.g. pneumonia or tuberculosis
PE
injury – if the ribs are bruised or fractured, the pleura can become inflamed
lung cancer
autoimmune conditions e.g. rheumatoid arthritis and lupus
What are some causes of cyanosis?
COPD Bronchiolitis Acute 'life-threatening' asthma Congenital heart disease Acute HF
What exposures are risks for occupational asthma?
Isocynates (spray paint)
Flour
Resins
Proteolytic enzymes
What is the management for occupational asthma?
Avoidance of irritant/sensitiser
Inhaled corticosteroids and brochodilators
What is fibrotic lung disease?
life-threatening disease that manifests over several years and is characterised by the formation of scar tissue within the lungs and progressive dyspnoea
What are presenting features of fibrotic lung disease?
Dypnoea Cough Crackles Male, Older, FH Smoking
What is the management for fibrotic lung disease?
Antifibrotic therapy
Smoking cessation
Pulmonary rehabilitation
PPI
OR
Lung transplant
