Respiratory Medicine Flashcards
What are some causes of nodules on a CXR?
Infective Causes: Aspergilosis, Tuberculosis, Lung Abscess, Round pneumonia
Non-infective Causes: RA, Sarcoidosis, Wegener’s (GPA), lung tumour.
What are some risk factors for PE?
- recent surgery (especially abdominal, pelvic or hip/knee replacement)
- thrombophilia
- leg fracture
- prolonged bed rest/ reduced motility
- malignancy
- pregnancy/postpartum
- pill/HRT
- previous PE
Describe PE, it’s symptoms, relevant tests and management
Venous thrombi, usually from DVT, pass into pulmonary circulation and blocks blood flow to lungs.
Symptoms: acute dyspnoea, pleuritic chest pain, syncope, haemoptysis
Signs: hypotension, tachycardia, increased JVP, tachypnoea, cyanosis, AF
Tests:
- d dimer if wells score less than 3 to exclude PE
- FBC, U+E, ABG may show decreased PaO2 and PaCO2.
- ECG may show RBBB, right ventricular strain (inverted t wave in v1-v4) RAD
Imaging:
-CTPA 1st line for diagnosis
Management:
- oxygen if hypoxic
- morphine and antiemetic if in pain
- if critically ill or unstable consider thrombolysis
- Anticoagulation with LMWH and start warfarin.
- Stop heparin when INR > 2 and continue warfarin for 3 months (aim for INR 2-3)
Prevention: thrombophylaxis and compression stockings
Describe Asthma, its symptoms and signs, tests, and non-emergency treatment
Asthma is characterised by recurrent episodes of dyspnoea, cough and wheeze caused by reversible airways obstruction. Three factors contribute to airway narrowing:
- Bronchial muscle contraction
- Mucosal inflammation
- Increased mucus production
Signs and symptoms: Intermittent dyspnoea, wheeze, cough (often nocturnal) and sputum. Tachypnoea, audible wheeze, hyperinflated chest, hyperresonant percusion notes, decreased air entry, widespread polyphonic wheeze.
Tests: PEF diary
Spirometry shows obstructive defect (Decreased FEV1/FVC) with reversibility I.e. improvment in FEV1 following B2 agonists.
Challenge test
Eosinophil count, skin prick test, IgE
Treatment:
SABA PRN consider moving up if 3x a weeks
-Step 1: low dose ICS
-Step 2: add LABA
-Step 3:
No response, stop LABA and increase ICS
Response not enough,
A) continue LABA and increase ICS to medium dose
B) continue LABA and ICS and trial of other therapy - LTRA, SR theophylline, LAMA
-Step 4: consider trials of -
A) increasing ICS to high dose
B) add 4th drug - LTRA, SR theophylline, beta agonist tablets, LAMA
-Step 5: use daily steroid tablets in lowest dose, maintain high dose ICS, consider other Rx
Describe COPD, its symptoms, signs, complications, tests and treatment.
A common progressive disorder characterised by airway obstruction (FEV1 less than 80%, FEV1/FVC les than 0.7) with little or no reversibility. chronic bronchitis (cough and sputum for most days for 3 months of 2 successive years) emphysema: histologically enlarged air spaces.
Signs and symptoms: Cough, sputum, dyspnoea, wheeze, tachypnoeic, use of accessory muscles of respiration, hyperinflation, decreased cricosternal distance (less than 3cm), hyper resonant percussion notes, cor pulmonale.
Complications: Acute exacerbations +/- infection, polycythaemia, respiratory failure, cor pulmonale (oedema, raised JVP), pneumothorax (ruptured bullae), lung carcinoma
Tests:
- FBC may show increased packed cell volume.
- CXR shows hyperinflation (more than 6 anterior ribs), flat hemidiaphragms.
- ECG may show right atrial and ventricular hypertrophy (cor pulmonale).
- ABG shows decreased PaO2 +/- hypercapnia
- Spirometry shows obstructive (FEV1/FVC less than 0.7)
Treatment: -Conservative: Smoking cessation advice, encourage exercise, Flu and pneumococcal vaccinations, pulmonary rehabilitation programme -Pharmcological: 1: SABA or SAMA 2: FEV1 >50% - LABA or LAMA FEV1<50% - LABA + ICS or LAMA 3: switch to combination LABA + ICS Oral theophylline - only after trials of bronchodilator Mucolytics - if chronic production not improved LTOT -pO2 <7.3 or 7.3-8 and one of: - 2 polycythaemia - nocturnal hypoxaemia - peripheral oedema - pulmonary hypertension
Define Chronic Bronchitis
Chronic bronchitis is defined clinically as cough with sputum production on most days for 3 months of 2 successive years.
What are the stages of severity of COPD?
Stage 1 Mild = FEV1 >80% Pred
Stage 2 Moderate = FEV1 50-79% Pred
Stage 3 Severe = FEV1 30-49% Pred
Stage 4 Very Severe = FEV1 less than 30%
Describe Bronchiectasis, it’s causes, symptoms, and tests, and management
Chronic infection of the bronchi and bronchioles leading to permanent dilatation of these airways.
Causes:
- congenital e.g. CF, youngs syndrome, kartageners syndrome
- post infection e.g. Measles, pertussis, bronchiolitis, pneumonia, TB, HIV
- Other e.g. Bronchial obstruction, RA, UC, idiopathic
Symptoms: persistent cough, copious purulent sputum, intermittent haemoptysis, clubbing, coarse inspiratory crepitations, wheeze
Tests: Sputum culture (commonly Haem Influzenzae, strep p, staph a, pseudomonas), CXR shows thickened bronchial walls (Tramlines and ring shadows). HRCT assesses extent and distribution of disease. Spirometery shows obstructive picture.
Management:
- Postural drainage should be performed twice daily
- Antibiotics guided by culture, if more than 3 exacerbations consider long-term antibiotics.
- Bronchodilators in patients with underlying asthma, COPD, CF
- Surgery may be needed in localised disease or to control severe haemoptysis.
Describe Interstitial lung disease, its symptoms and classification
A term used to describe a number of conditions characterised by chronic inflamation and or/progressive interstitial fibrosis
Symptoms: dyspnoea on exertion, non-productive paroxysmal cough, abnormal breath sounds, abnormal CXR or HRCT (fibrosis) restrictive pulmonary spirometry.
Classification:
- Known cause
Occupational e.g. asbestosis, berylliosis, silicosis, cotton workers lung (byssinosis)
drugs (BANS ME)
hypersensitivity reactions e.g. eaa
infections - TB, fungi, viral
GORD
-associated with systemic disorders e.g. sarcoidosis, RA, SLE, systemic sclerosis, sjrogren syndrome, UC, Renal tubular acidosis, autoimmune thyroid disease
-Idiopathic e.g. idiopathic pulmonary fibrosis, cryptogenic organising pneumonia, lymphocytic interstitial pnemonia
Describe pleural effusion, its causes, symptoms, signs, tests and management
A pleural effusion is fluid in the pleural space. They can be divded by their protein concentration into transudates (protein les than 25g/L) and exudates (protein greater than 35g/L). Blood in the pleural space is a haemothorax, pus in the pleural space is an empyema.
Causes of transudates:
- increased venous pressure (Cardiac failure, constrictive pericarditis, fluid overload)
- hypoproteinaemia (cirrhosis, nephrotic syndrome, malabsorption)
- hypothyroidism
Causes of exudates:
-leakiness of pleural capillaries due to infection (TB, pneumonia) inflammation (RA, SLE) or malignancy (Bronchogenic carcinoma, lung metastases, lymphoma, mesothelioma)
Symptoms: Asymptomatic or dyspnoea and pleuritic chest pain.
Signs: decreased expansion, stony dull percussion note, diminished breath sounds occur on affected side. vocal resonance is decreased. trachea deviation away from large effusion.
Tests: CXR show blunting of costophrenic angles abd water-dense shadows with meniscus.
Management:
- drainage and fluid analysis
- pleurodesis with tetracycline, bleomycin or talc may be helpful for recurrent effusions. Thorascopic talc pleurodesis is most effective for malignant effusions.
- Surgery may be needed for persistent collections and increasing pleural thickness.
What are some causes of pneumothorax?
- Spontaneous (especially in young thin men) due to rupture of a subpleural bulla
- chronic lung disease e.g. asthma, copd, lung fibrosis, sarcoidosis
- infection e.g. TB, pneumonia, lung abscess
- traumatic including iatrogenic
- carcinoma
- connective tissue disorders e.g. marfans or ehlers-danlos
Describe type 1 respiratory failure and its management
Defined as hypoxia (PaO2 less than 8kPa) with a normal or low PaCO2. It is caused primarily by ventilation/perfusion mismatch e.g. Pneumonia, pulmonary oedema, PE, asthma, emphysema, pulmonary fibrosis, ARDS.
Management:
- treat underlying cause
- Give oxygen to correct hypoxia
- Assisted ventilation if PaO2 less than 8kPa despite 60% oxygen.
Describe type 2 respiratory failure and its management
Defined as hypoxia (PaO2 less than 8kPa) with hypercapnia (PaCO2 greather than 6kPa). Caused by alveolar hypo ventilation causes include pulmonary disease such as asthma, COPD, pneumonia, end-stage pulmonary fibrosis, obstructive sleep apnoea, reduced respiratory drive e.g. Sedative drugs CNS tumour or trauma, neuromuscular disease or thoracic wall disease.
Management:
- Treat underlying cause
- Controlled oxygen therapy beware hypoxic drive.
- Recheck ABG after 20 min if PaCO2 steady or lower continue monitoring if increasing consider NIPPV, contact ITU
- If this fails consider intubation and artificial ventilation
Respiratory drive may be driven by hypoxia aim for sats 88-92% and monitor blood gases. If oxygen therapy not improving and CO2 rising consider NIPPV and failing that intubation and ventilation.
Describe sarcoidosis, its symptoms, tests, and management.
It is a multisystem granulomatous disorder of unknown cause. Usually affects adults aged 20-40yrs and is more common in women. Afro-carribeans are more frequently and severly affected.
Symptoms: dry cough, progressive dyspnoea, chest pain. Non-pulmonary signs include lymphadenopathy, hepatomegaly, splenomegaly, lupus pernio, erythema nodosum.
Tests: Raised ESR, lymphopenia, raised serum ACE. Hypercalcaemia. 90% have abnormal CXR with bilateral hilar lymphadenopathy +/- pulmonary infiltrates or fibrosis. 24 urine collection shows hypercalcaemia.
Management:
- patients with Bilateral hilar lymphadenopathy do not need treatment, acute sarcoid requires bed rest and NSAIDs.
- indication for predinsolone (40mg/24h PO) are uveitis, parenchymal lung disease, hypercalcaemia or neurological or cardiac involvement.
- in severe disease immunosuppressants may be tried (methotrexate, hydroxychloroquine, ciclosporin, cyclophosphamide).
Describe Obstructive Sleep Apnoea, its symptoms, investigations, and management
Characterised by intermittent closure/collapse of the pharyngeal airway causing apnoeic episodes during sleep. These are terminated by partial arousal.
Symptoms: The typical patient is an obese, middle-aged man who presents because of snoring or daytime somnolence. His partner often describes apnoeic episodes during sleep. loud snoring, daytime somnolence, poor sleep quality, morning headache, decreased libido, reduced cognitive performance
Complications: Pulmonary hypertension, type II respiratory failure, risk factor of hypertension
Investigations: Sleep studies (O2 sats, airflow at nose and mouth, ECG, EMG chest and abdominal wall movement during sleep) 15 or more epsiodes during 1h of sleep indicates significant sleep apnoea
Management:
- Weight reduction
- avoidance of tobacco and alcohol
- CPAP via nasal mask during sleep for those with moderate to severe disease
- surgery to relieve pharyngeal obstruction is occasionally needed refer to chest physician for assessment.
