Respiratory medicine Flashcards
BTS classification of acute asthma
Life-threatening: 33 92 CHEST
PEFR <33
Sats < 92%
Confusion/Cyanosis
Hypotension
Exhaustion
Silent chest
Transiently normal CO2
Diagnosis + Management
- If asymptomatic –> conservative regardless of size
–> 2-4days OPD clnic
–> secondary pneumothroax + stable –> 2-4 weeks OPD
Obstructive lung disease
FVC
FEV1/FVC
FVC
FEV1%
FEV1
Examples
FEV1 - REDUCED
FVC - reduced / normal
FEV1% - REDUCED
Examples: ABCC
* Asthma
* COPD
* Bronchiectasis
* Bronchioitis obliterans
Airflow obstruction is defined as a ratio of FEV1/FVC of less than 0.7.
Restrictive lung disease
FVC
FEV1%
FEV1
FEV1 - reduced
FVC - REDUCED
FEV1% - normal / increased
P- pulmonary fibrosis
I-
N- neuromuscular disorders
Examples: PINK ASS
Patient with acute exacerbation of COPD w/ respiratory acidosis –> next step in management?
NIV –> BiPAP
Why?
- prevents rebreathing of exhaled gases
- faciliating reduction of CO2 retention
**CPAP **
- maintains open airways and supports oxygenation through constant air pressure delivery
- does not assist in CO2 removal as effectively as BiPAP
- better for T1RF
PaCO2>6kPa, pH 7.25-7.35
Lung cancer: types summarised
Small cell (15%, worse), non-small cell (85%)
Non small cell
1. Adenocarcinoma: non-smokers
2. Squamous: cavitating lesions!
3. Large ell
4. Alveolar cell: not related to smoking, ++ sputum
5. Bronchial adenoma: mostly carcinoid
40 MALE
pc: 6/12 worsening productive cough.
pmh: pneumonia, IVDU
OE: conjunctival pallor & bilateral wheezing
CXR: proximal bronchiectasis and consolidations R upper lobe
Sputum microscopy: eosinophils and fungal hyphae
DIAGNOSIS AND Mx
Diagnosis: Allergic bronchopulmonary aspergillosis
Features: bronchoconstriction, proximal bronciectasis
Management:
1st line –> oral glucocorticoids
2nd line –> itraconazole
37 MALE
pc: persitent productive cough w/ purulent sputum, SOB 8/12.
pmh: recurrent resp infections tx w/ Abx.
oe: bilateral finger clubbing and coarse crackles bilaterally
diagnosis and management:
BRONCHIECTASIS= permanent dilatation of airways secondary to chronic infection / inflammation
Management:
1. Inspiratory muscle training (non-cystic bronchiectasis)
2. postural draiange
3. Abx for exacerbations , bronchodilators? immunisations
SIGNET RING SIGN SEEN
Common organisms isolated from patients with bronchiectasis
Haemophilus influenzae (most common)
Pseudomonas aeruginosa
Klebsiella spp.
Streptococcus pneumoniae
Acute exacerbation of COPD management
- Increase frequency of bronchodilator use
- Give prednisolone 30mg daily for 5 days
- ABx
–> amoxicillin OR clarithromycin OR doxycycline
Most common infective causes
- Haemophilus influenza
- Streptococcus pn
Severe exacerbation of asthma mx
- Oxygen therapy (88-92%)
–> venturi 28% mask at 4 L - Nebulised bronchodilator:
–> beta agonist e.g. Salbutamol
–> muscarinic antagonist e.g. ipratropium - Steroid (IV hydrocortisone»_space; pred)
- IV theophylline
- NIV –> BiPAP (pH < 7.25)
55 Female: 4/12 facial rash purple plaque indurated skin affecting tip of nose and right nostril.
What chronic condition is the patient most likely suffering:
Sarcoidosis –> Lupus pernoi
Features
Acute: erythema nodosum, bilateral hilar lymphadenopathy,
Interpret CXR
- large peripheral mass on left
- pleural plaques inferiorly over left lower lung field
MESOTHELIOMA
- malignant disease of pleura
Features
- progress
Smoking cessation is important!
Pleural effusion: transudative vs exudative & examples
Transudative (<30g/L)
–> HF
–> Hypoalbuminaemia (liver disease, nephrotic, malabsorption)
–> hypothyroidism
–> Meig’s syndrome (ovarian tumour)
Exudatve (>30g/L)
–> infection (pneumonia, TB)
–> connective tissue disease (RA, SLE)
–> Neoplasia (lung cancer, mesothelioma)
–> pancreatitis
–> PE
–> Dressler’s syndrome
–> Yellow nail syndrome
Lung fibrosis
Upper vs Lower zone affecting examples.
Investigation:
Management
Investigations
* CXR
* High res CT (ground glass, honey combing)
* Spirometry (restrictive?)
* Bloods: anti-nuclear antibody, RF, anti-centromere antibody
* Lung biopsy
Management
1. Corticosteroids
2. Antifibrotics: pirfenidone / nintedanib (IPF)
3. Smoking cessation
4. Pulmonary rehab
5. LTOT
6. Lung transplant
Pneumonia: investigation + management
Investigation:
* CXR
* Intermediate/high risk: blood, sputum, pneumococcal and legionella urinary antigen tests
* CRP: determine response to tx
Management of Low severity CAP
1. AMOXICILLIN 1st line - 5 days
–> macrolide / tetracycline (if pen allergic)
Management of moderate and high severity CAP
- dural abx recommended w/ amoxicillin + macrolide
- 7 to 10 day course
- beta-lactamase stable penicillin: co-amoxiclav, ceftriaxone or piperacillin w/ tazobactam AND macrolide
All patients should have repeat CXR at 6 weeks after clinical resolution
CURB 65
0 = tx at home
1-2 = intermediate risk
3-4 = high risk
The following indicate diagnosis of:
KARTAGENER’S SYNDROME (aka primary ciliary dyskinesia)
Pathogenesis
–> dynein arm defect results in immotile cilia
Features
–> dextrocardia or complete situs inversus
–> bronchiectasis
–> recurrent sinusitis
–> subfertility
COPD Management algorithm
In idiopathic pulmonary fibrosis - what is the investigation of choice:
CT is investigation of choice
average life expectancy is around 3-4 years
28 Male: flail chest several hours earlier, Intubated and ventilated.
Now: increasingly hypoxic, needing increased ventilation pressures.
Most common cause:
Tension pneumothorax
why?
- flail chest segment may lacerate the underlying lung and create a fla[ valve.
- tensoin pneumothorax created by intubation and ventilation
In a patient with COPD what investigations are indicated:
- Post-bronchodilator spirometry (FEV1/FVC ratio <70%)
- CXR
–> hyperinflation
–> bullae (may mimic pneumothorax)
–> flat hemidiaphragm - FBC: excldue polycythaemia
- BMI
CXR shows:
- bilateral diffuse upper lobe reticular shadowing
- superimposed w/ occasional scattered mass like opacities
- these features are keeping with silicosis and progressive massive fibrosis
Features
upper zone fibrosing lung disease
‘egg-shell’ calcification of the hilar lymph nodes
