Respiratory station Flashcards
What conditions is COPD
Chronic bronchitis (cough with sputum for most days for 3 months of 2 years) and emphysema (permanent dilation with destruction of alveolar walls distal to terminal bronchioles)
COPD signs
Common on initial inspection = tar staining, sternocleidomastoid hypertrophy, pursed lip breathing. NO CLUBBING. Hyperexpanded chest, and reduced breath sounds
COPD causes
SMOKING!, industrial duct exposure, alpha 1 antitrypsin deficiency
Investigations COPD
= spirometry = FEV1/FVC <0.7 and FEV1 = <80% of predicted
COPD management
Conservative = smoking cessation and exercise, influenza and pneumococcal vaccines, Long term oxygen therapy
Medical = 1st = SABA or SAMA PRN, 2nd if asthmatic features = LABA + ICS
2nd if no asthma = LABA + LAMA
3rd if severe or 2 hosp = LABA + LAMA + ICS
Surgical = lung reduction
COPD presentation
Today I examined this gentleman’s respiratory system. The patient was alert sitting in bed and showed signs of pursed lip breathing, sternocleidomastoid hypertrophy and tar staining. He was not clubbed and there was no asterixis. His chest was hyperexpanded with resonant percussion and reduced breath sounds bilaterally with no other added sounds. His JVP was non elevated. These signs are consistent with a diagnosis of chronic obstructive pulmonary disease likely due to cigarette smoke. I would like to perform spirometry and take a history to determine symptom severity and frequency of exacerbations.
long term oxygen therapy indications COPD
Non smoker
P02 < 7.3 on room air
Evidence of pulmonary hypertension + PO2 <8kPa
PCO2 does not rise significantly on oxygen
lung cancer types
NSCLC
- SCC = smoking
- Adenocarcinoma = most common NSCLC, most common lung cancer in non smokers
SCLC
- Fast growing + Presents with paraneoplastic syndromes
Lung ca investigations
CXR +ve
CT thorax
Biopsy
PET CT for staging
Pulmonary fibrosis signs
clubbing, reduced expansion, basal and mid zone crackles, JVP non raised, dry cough
pulmonary fibrosis signs from causes
MCP swelling (Rheumatoid), Facial rash (SLE), thick skin + bird nose (systemic sclerosis), oral ulcers (Crohn’s), grey skin (amiodarone), kyphosis (ankylosing spondylitis)
Pulmonary fibrosis causes
- Idiopathic Pulmonary Fibrosis.
- Rheumatoid, SLE, sarcoid, tuberculosis
Apical fibrosis
TB, sarcoidosis, ankylosing spond, extrinsic allergic alveolitis
Basal fibrosis
IPF, asbestosis, aspiration
Pulmonary fibrosis investigations
CXR = opacification in zones as above, honeycombing, groundglass appearance
Management of Pulmonary fibrosis
Conservative = stop smoking
Medical = trial of steroids or azathioprine, pirfenidone or nintedanib (anti-fibrotic drugs)
Surgical = single or double lung transplant
Respiratory clubbing causes
CF
fibrosis
malignancy
bronchiectasis
Horners triad
Ptosis (drooping), Miosis, anhydrosis
obstructive respiratory signs
Barrel chest, decreased expansion, hyperresonant, wheeze
signs of pleural effusion
tachypnoea, tar staining, dullness to percuss, reduced expansion, reduced vocal fremitus, reduced air entry
Lights criteria
Exudate = protein 25-35g/L or effusion/plasma albumin >0.5, or effusion/plasma LDH >0.6 or effusion LDH > 2x ULN
exudate examples
malignancy, PE, infection
Transudate examples
cirrhosis, heart failure, renal failure
signs of old TB
scars for lobectomy or pneumectomy, apical fibrosis with tracheal traction, crackles and bronchial breathing, dullness on percussion, reduced expansion, no clubbing or asterixis
TB management
rifampicin, isoniazid, pyrazinamide, ethambutol
TB management side effects
Rifampicin = orange secretions,
isoniazid = peripheral neuropathy (give pyridoxine),
pyrazinamide = hepatitis,
ethambutol = visual disturbances
Old tb presentation
Today I examined this gentlemen’s respiratory system. He was alert and comfortable at rest. He was not short of breath, not clubbed and there was no asterixis. He had a right sided thoracotomy scar with the underlying rib removed. This was associated with reduced lung expansion on that side, with reduced breath sounds and dullness to percussion. Auscultation of the remainder of the chest was normal. These signs are consistent with right upper lobectomy which would point to a diagnosis of previous tuberculosis or bronchial carcinoma. I would like to take a full history and perform spirometry.
CF signs
clubbing, pseudomonas prophylaxis inhaler, creon, gastrotomy, port-a-cath for IV access, wet cough
CF complications
infection, diabetes, infertility, digestive issues
CF management
Conservative = postural drainage, active cycle breathing, nutrition
Medical = creon, immunisations, RhDnase, prophylactic Abx
Surgical = lung transplant
CF presentation
I examined this gentleman’s respiratory system. On inspection he had a gastrostomy port and there was Creon by the bedside. He was clubbed, but comfortable at rest, and had a slightly wet cough. There was a Portacath in his right axilla. He had equal air entry bilaterally with no additional sounds and the chest was resonant throughout. These signs are consistent with a diagnosis of cystic fibrosis. I would like to take a full history and perform spirometry.
normal respiratory exam presentation
Today I performed a respiratory examination of X year old Y.
On general inspection the patient was comfortable at rest and did not have monitoring attached.
On closer inspection of the hands and arms, the patient did not exhibit any stigmata of respiratory disease such as cyanosis or clubbing.
There were no asterixis or fine tremor noted.
Pulse was regular at Z bpm, and RR was W bpm.
On closer inspection of face and chest, no anaemia, central cyanosis or Horner’s were identified.
JVP was non raised, trachea was not deviated and apex beat was non displaced.
On both the anterior and posterior chest wall, expansion was equal bilaterally and percussion was resonant. Vesicular sounds were audible and vocal resonance was normal throughout.
There was no cervical lymphadenopathy and no pitting oedema. Calves were soft non tender.
In conclusion this was a normal respiratory examination. To complete my examination, I would like to take full history and perform a cardiovascular examination.
I would like to take a full set of observations, take bloods, including FBC, U&Es and LFTs for baseline and request a peak flow reading, as well as a chest x ray if indicated.
Apical fibrosis (BREASTS CLAP)
Berylliosis
Radiation
Extrinsic allergic alveolitis
Allergic bronchopulmonary aspergillosis
Sarcoidosis
TB
Silicosis
Coal workers pneumoconiosis
Langerhans cell histiocytosis
Ankylosing spondylitis
Psoriasis (very rare)
Basal Fibrosis
Idiopathic pulmonary fibrosis
Rheumatological disease (not ank)
connective tissue disease e.g. SLE
Drugs (methotrexate)
Asbestosis
Aspiration
complications of interstitial lung disease?
- Respiratory failure
- Chest infection
- Pulmonary hypertension
- Cor pulmonale
- Carcinoma of the lung
most common pathogens in acute infective exacerbations of COPD?
- Streptococcus pneumoniae
- Haemophilus influenzae
- Moraxella catarrhalis
what is bronchiectasis?
Abnormal bronchial wall dilatation, destruction, and transmural inflammation.
