Respiratory - SOB Flashcards
A 59 year old female with a 30 pack year history presents with progressive SOB and a productive cough. O/E you hear an audible wheeze.
a) Pulmonary oedema
b) Asthma
c) Pneumonia
d) Idiopathic pulmonary fibrosis
e) COPD
e) COPD
- older (less likely to be asthma)
- long history of smoking (biggest RF)
- progressive SOB, productive cough & audible wheeze - all classical features
A 27 year old female of Afrocaribbean origin presents with SOB that has come on over the last few months. She says it is increasingly difficult to complete her morning runs. O/E you notice tender, erythematous nodules on both her shins.
a) Sarcoidosis
b) Asthma
c) Pneumonia
d) Idiopathic pulmonary fibrosis
e) Pulmonary embolism
a) Sarcoidosis
- female
- aged 20-40
- Afro-Caribbean > Caucasian
- Progressive SOB
- erythema nodosum
(reduced exercise tolerance could be asthma or IPF but other features fit sarcoidosis)
A gentleman presents with acute breathlessness.
O/E his respiratory rate is 25bpm with good air entry in all fields. His ECG shows right axis deviation.
a) Pneumothorax
b) Pulmonary oedema
c) Pneumonia
d) Pleural effusion
e) Pulmonary embolism
e) Pulmonary embolism
- ACUTE onset SOB
- Tachypnoea
- ECG: RAD - classic
A 62 year old male presents with an 8 month history of exertional dyspnoea and a non-productive cough.
a) Sarcoidosis
b) Bronchogenic carcinoma
c) Pulmonary oedema
d) Idiopathic pulmonary fibrosis
e) COPD
d) Idiopathic pulmonary fibrosis
- > 60yo, M>F
- Progressive SOB (8/12)
- Dry cough
5) A 70 year old woman presents with fevers, SOB and right sided pleuritic chest pain. O/E the right side of her chest shows reduced expansion and dull percussion.
a) Pneumothorax
b) Bronchogenic carcinoma
c) Pneumonia
d) Pleural effusion
e) Pulmonary oedema
c) Pneumonia
- SOB, fever, CP
- reduced expansion
- dull percussion
Definition of COPD + its components
A progressive disorder of the lower respiratory tract characterized by airway obstruction with little or no reversibility
Chronic bronchitis + emphysema
Clinical diagnosis of chronic bronchitis?
Cough & sputum production on most days for 3 months of 2 successive years
Features of emphysema?
Enlarged air spaces distal to terminal bronchioles
Destruction of alveolar walls
(+ histological features)
Reversibility in COPD and asthma?
COPD is non-reversible
Asthma is reversible
How is severity of COPD MEASURED?
Measured by post-bronchodilator FEV1 and then classified as % of predicted
How is severity of COPD CLASSIFIED?
Classified as % of predicted FEV1 (in healthy individual):
Mild >79%
Moderate 50-79%
Severe 30-49%
Very severe <30%
What is FEV1?
FEV1 is the volume of air that can forcibly be blown out in one second, after full inspiration
What do average values (in healthy people) of FEV1 depend on?
Age, sex, height, (mass, ethinicity)
Aetiology of COPD?
Smoking (90% of cases) Occupational exposure (indoor air pollution, dusts, chemicals) Alpha-1 antitripsin deficiency
Patophysiology of chronic bronchitis?
Inflammation of bronchi -> scarring and thickening of bronchial walls + increased mucus -> small airway narrowing
Patophysiology of emphysema?
Proteases breakdown connective tissue of alveolar walls and septae -> loss of lung recoil -> limited expiratory flow + air trapping
What is Alpha-1 antitripsin deficiency?
Autosomal recessive disorder
a1at inhibits neutrophil elastase (a protease). If you have a deficiency of it then lungs become damaged by neutrophil elastase. You can also have GI symptoms:
cirrhosis, cholestatic jaundice
COPD: What are the causes and consequences of air trapping?
Cause: emphysema (causing loss of lung recoil)
Consequences: increased TLC -> hyperinflation and breathlessness
(also breakdown of alveoli in emphysema leads to decreased capacity of gas transfer)
Symptoms of COPD?
3 main ones
- Productive cough
- Wheeze
- Breathlessness
(also HTN, osteoporosis, depression, cachexia)
Worsening SOB, increased sputum/ change in sputum colour?
Acute/ Infectious exacerbation of COPD
Clinical signs of COPD?
Polyphonic wheeze (O/A loud, musical and continuous)
If severe:
tachypnoeic
prolonged expiratory phase (O/A)
accessory muscle use
pursing lips on expiration (increase in PEEP)
hyperinflation & hyper-resonance
signs of hypercapnia (vasodilation, bounding pulse, CO2 tremor)
Sarcoidosis definition?
Multisystem granulomatous disorder of unknown cause
Epidemiology of sarcoidosis?
Afro-Caribbean > Caucasian (with exception of Northern European)
Females > Males
Mostly adults aged 20-40
CXR features of sarcoidosis?
Bilateral hilar lymphadenopathy (BHL)
+/- pulmonary inflitrates or fibrosis
Clinical features of sarcoidosis?
Systemic: fever, fatigue, anorexia
Pulmonary (50%): dry cough, progressive SOB, reduced exercise tolerance
Extra-pulmonary (e.g. dermatological): erythema nodosum (tender, erythomatous nodules or lumps on both shins), lupus pernio ( hardened, purplish lesions and plaques on face)
May be incidental finding on CXR
Sarcoidosis investigations?
Bloods: High Ca, ALP and ACE
Spirometry: restrictive lung disease (80-85% FEV1/FVC)
CXR
Reduced CO diffusion capacity test
Bronchoscopy + endobronchial biopsy: non-caseating granulomas (bacteria -ve) - DIAGNOSTIC
(high Ca due to ectopic hydroxylation of vit D)
Sarcoidosis management?
Depends on stage
BHL may recover sponatneously
NSAIDs for flare up
Corticosteroids (20% respond) in severe/extra-pulmonary disease, or immunosuppressants
(60% of those with thoracic sarocid resolve over 2 years)
Definition of PE?
Sudden occlusion in pulmonary artery or one of its branches
Aetiology of PE?
Thrombi originating in deep venous system (usually lower extremities - DVT)
Symptoms of PE?
Acute onset!
Pleuritic chest pain
SOB
+/- haemoptysis or haemodynamic compromise
Signs of PE?
Tachypnoea tachycardia fever lower limb swelling/ oedema cyanosis
O/A: Accentuated S2, S3/S4 gallop
What score is used to diagnose probability of PE and what are its features?
The Wells score/criteria:
- Clinically suspected DVT +3 points
- PE is no.1 Dx +3 points
- Heart rate > 100 +1.5 points
- Immobilization +1.5 points
- Recent surgery (4 weeks) +1.5 points
- History of DVT or PE +1.5 points
- Hemoptysis +1 points
- Malignancy (with treatment within six months) or palliative +1 points
> 4 points is high probability of PE
Patient comes in with suspected PE and has a Wells score of above 4. What investigations would you perform?
If Wells score >4 ->
Admit + immediate CT Pulmonary Angiogram
(if immediate CTPA not possible -> LMWH/fondaparinux)
Patient comes in with a suspected PE (Wells score is 4). What investigations would you perform?
If Wells score 4 or less ->
D-dimer -> if positive admit + immediate CTPA
(if immediate CTPA not possible -> LMWH/fondaparinux)
A 66 year old man with a history of DVT had a CTPA performed which showed a PE in his pulmonary artery. His BP is 120/90. How would you manage this patient?
Pt Haemodynamically stable -> anticoagulate (LMWH for 5 days until INR >2 for >24h)
A 66 year old man with a history of DVT had a CTPA performed which showed a PE in his pulmonary artery.
His BP is 90/60. How would you manage this patient?
Pt haemodynamically unstable -> thrombolytic therapy or embolectomy
A gentleman presents with acute breathlessness.
O/E his respiratory rate is 25bpm with good air entry in all fields. He has a history of DVT. What could you find on this man’s ECG?
(most common first:) Sinus tachycatrdia RAD T wave inversion in leads V1-3 (R ventricular strain) Complete or incomplete RBBB S1 Q3 T3!
Definition of Idiopathic Pulmonary Fibrosis
A chronic, progressive fibrosing interstitial lung disease of unknown cause
(Rapid medicine: inflammatory condition of the lung resulting in fibrosis of alveoli and interstitium)
Epidemiology of IPF?
Mean onset in late 60s
M>F
What type of lung disease is IPF? What would the FEV1/FVC ratio be like?
Restrictive lung disease
FEV1/FVC = 80-85% (normal/high)
Symptoms of IPF?
Dry cough
Progressive exertional SOB
Weight loss
Arthralgia (joint pain)
You perform an respiratory examination on a 66 year old man with IPF. What signs are you most likely to find?
Cyanosis
Digital clubbing
Fine end inspiratory crepitations
How can you describe the sound of fine end inspiratory crepitations on auscultation?
Like walking on snow/ Velcro
You suspect IPF in a patient. What investigation would you perform to confirm this diagnosis? 8 things
- Lung function tests (spiro) = restrictive
- 6 minute walk test = exertional SOB
- Bloods = CRP & ESR high, ANA may be high
- ABG = hypoxic
- CXR - reticulonodular shadowing
- HRCT - honeycomb lung
- Bronchioalveolar lavage
- Bronchoscopy + biopsy = DIAGNOSTIC
(ESR = erythrocyte sedimentation rate, ANA = Antinuclear Antibody Panel, HRCT = High Resolution CT)
IPF treatment
Supportive - O2, pulmonary rehab, palliation Prednisolone/ immunosppressants Antibiotics Tyrosine kinase inhibitors Lung transplant
(50% 5 year survival rate nevertheless)
WTF is a honeycomb lung?
Honeycombing - CT manifestation of diffuse pulmonary fiborsis. Features:
clustered cystic air spaces with well-defined and often thick walls
What are the symptoms of pneumonia?
Productive cough, SOB, Fever, Chest Pain, generally unwell
(in elderly - confusion, although non-specific)
What signs could you find during a resp exam on a patient with pneumonia?
Tachypnoea
Tachycardia
Expansion: reduced (on affected side)
Percussion: dull (on affected side, consolidation)
Auscultation: coarse crackles, bronchial breath sounds
A 65year old man presents with SOB and cough productive of pink frothy sputum. On examination he is cold, clammy, tachycardic and has bibasal end-inspiratory crackles. His JVP is elevated. What do you suspect the cause of his SOB is?
Pulmonary oedema - HF could be the underlying cause.
Pink frothy sputum is a classic sign of PO
A 65year old man presents with SOB and cough productive of pink frothy sputum. On examination he is cold, clammy, tachycardic and has bibasal end-inspiratory crackles. His JVP is elevated.
What else could you ask him about to confirm your diagnosis?
Orthopnoea?
Paroxysmal nocturnal dyspnoea (waking up gasping for air)?
Peripheral oedema?
