Respiratory_Medicine Flashcards
Resp exam - do not forget what?
Pleural effusion, pneumothorax, lung collapse, lung fibrosis, consolidation on resp exam?
Hands/arms:
- CRT, clubbing (PF, lung cancer, CF, bronchiectasis, sarcoidosis/TB)
- Co2-retention flap (T2RF) - check pulse while doing
- RR (arm over chest while taking pulse)
Head/neck: JVP, tracheal assessment (3 fingers, palpate either side of trachea), cricosternal distance (<3 fingers = lung hyperinflation), cervical LNs
Chest:
- Apex beat
- Chest expansion (front/back)
- Percussion, auscultation, vocal resonance (front/back incl. supraclavicular + axillae)
- NOTE: make sure to auscultate in axilla
Other: peripheral oedema, DVT
PaO2 (Partial Pressure of Oxygen) normal range?
Normal: ≥10 on room air
On Oxygen: PaO2 (kPa) should be 10 less than FiO2 (level of oxygen they are on %)
Reading an ABG?
Respiratory failure:
- Low O2 = T1RF (PaO2 <8kPa)
- Low O2 + High CO2 = T2RF (PaO2 <8kPa, PaCO2 >6kPa)
Determining acid: base balance:
- Low pH + high CO2 = Respiratory acidosis (low CO2 = metabolic)
- High pH + low CO2 = Respiratory alkalosis (high CO2 = metabolic)
- NOTE: if bicarb is high in RA = chronic RA (compensation by bicarb is slow) –> this determines if should be on scale 1/2 O2 (scale 2 = 88-92%)
Causes of acid: base balance:
- RA causes: COPD, ILD, hypoventilation, asthma (normally resp alkalosis but can be acidotic if severe)
- MA causes: lactic acid, ketoacids (CO2 blown off to compensate –> Kussmaul breathing)
When to do ABG vs VBG?
ABG (radial artery) - acute breathing problem
VBG (venous) - check lactate, glucose, elctrolytes FAST
Oxygen therapy principles
Oxygen from wall = 100%
Peak inspiratory flow - the maximum rate of drawing in O2 normally is 20L/min (not normally measured unless ITU)
O2 therapy goal is increasing conc grad between alveoli and blood - done by increasing FiO2 (fraction of inspired O2)
Devices types: 1) variable (can’t guarantee FiO2, depends on PIF) - nasal cannula, hudson mask, non-rebreather mask 2) fixed - venturi mask (useful if COPD as need to know exactly how much O2 giving)
NOTE: If PIF increases (breathing harder) –> FiO2 decreases so more device O2 is required
High-flow nasal oxygen therapy - humidifies + warms O2 = well-tolerated –> very high flow rate can be achieved - finely controlled FiO2
CXR for Infective Exacerbation of COPD (IECOPD)
Emphysematous changes
Opacity
Flattened diaphragm + hyperexpanded chest
How does lactic acidosis appear on VBG? Lactate physiology/pathology?
Acute metabolic acidosis - low pH, low cHCO3/low BE, high lactate
Physiology:
- Glucose –> Pyruvate –O2–> mitochondria –> ATP
- Glucose –> Pyruvate –NO O2–> Lactate (+ small ATP) –> excreted by kidney or liver/muscle –gluconeogenesis –> glucose
Pathology:
- Hypoxia
- Reduced oxygen delivery - from reduced circulating volume (bleed), vascular compromise (clot)
- Reduced oxygen carriage - reduced gas exchange, anemia
- Mitochondrial toxicity - mitochondria can’t aerobically produce ATP
- Drugs - metformin, propofol, cyanide
- Inherited - MELAS
- Reduced metabolism (of lactate) - liver/renal impairment, muscle compromise
- Increased glycolysis (more pyruvate) - both paths increase
- Increased glucose uptake from adrenergic stimulation e.g. salbutamol use
- Increased energy demand of cells - exercise
O2 therapy vs ventilation
O2 therapy - increase FiO2 so bigger conc gradient between alveoli and bloodstream (of part of the lung that is working)
Ventilation - pressure increases SA of lungs available for gas exchange e.g. if part of the lung is blocked off (e.g. mucus, collapse)
SO COMBO IS NORMALLY USED
Types of Non-Invasive Ventilation
CPAP = fixed IPAP and EPAP
- Holds open/splints airways –> for T1RF –> increase O2
BiPAP = IPAP higher than EPAP
- Gradient allows exhalation more easily –> for T2RF –> excrete CO2
- (- If had high CO2 on ABG –> increase IPAP –> more excreted CO2)
What area of the lungs does aspiration pneumonia normally affect? Mx?
The right bronchus is more vertical and so aspiration normally affects the right lung base = coarse crackles
Mx: O2, suction, abx, NBM until SALT review
Asthma - def? Presentation? Ix? Severity? Short-term/long-term Mx incl. conservative? Mneumonic for conservative long-term Mx?
Def: chronic inflammatory airway disease characterized by reversible airway obstruction + airway hyperresponsiveness
Presentation
- Dry cough, polyphonic wheeze ( worse@night/morning)
- Triggers: cold air, pollen, pollution, exercise
- Atopic features - eczema, nasal polyps
Ix:
- Peak flow variability (in peak flow diary)
- Spirometry (shows reversibility after bronchodilator)
- FeNO (fractional exhaled nitric oxide - a marker of airway inflamme, in uncertain Dx)
- On exacerbation:
- ABG, peak flows (min x4/day), CXR
- Other:
- Allergy testing - total IgE, specific IgE (RAST), serum eosinophil count
Asthma severity:
-
Life-threatening: PEF <33% of baseline/SpO2 <92%/PaO2 <8/Normal or raised PaCO2 - should be low with resp alkalosis due to excess breathing only becomes acidotic when get tired
- CHEST: Cyanosis, Hypotension, Exhaustion, Silent chest, Tachycardia
- Acute severe: PEF <50% of baseline/RR >25/HR >110/can’t complete sentence without taking a breath
- Moderate: PEF <75% of baseline
Short-term Mx:
- A-E approach, seek senior support (call for help if life-threatening)
- O2 - 15L NRM (if hypoxaemic)
- Burst therapy:
- SABA (spacer up to 10 puffs every 20 mins –> nebs)
- Ipratropium Bromide (add to nebs if poor response/severe, every 4-6hrs)
- Corticosteroids (min 5-day course, give within 1 hour, give IV if can’t take orally)
- Other Tx options:
- IV Magnesium sulfate (STAT dose if poor response above/severe) - consult senior before use
- IV salbutamol (if on ventilation) - consult senior before use
- IV Aminophylline - consult senior before use, requires ITU setting
- If less distressed/more tired/shallow breaths/confused –> call critical care outreach team (CCOT) for ITU support
Long-term Mx (>16yrs):
-
Conservative: TAME
- Technique
- Avoid triggers
- Monitor peak flow
- Educate - formulate Personalised Asthma Action Plan (PAAP), Annual flu vaccine
-
Medical:
- SABA (reliever)
- SABA + ICS (preventer)
- SABA + ICS + LTRA (leukotrine receptor antagonist e.g. montelukast)
- SABA + ICS + LABA (+ LTRA stopped unless good response)
- SABA + MART (ICS + LABA COMBO) (+ LTRA)
- NOTE: maintenance & reliever therapy (MART) - used as preventer & maintenance inhaler
- Specialist input (e.g. for oral steroids)
COPD - definition? Signs & Sx? New Dx & exacerbation Ix/Mx? Prognosis factors?
Def: chronic bronchitis (damaged to cilia in bronchi - blue bloater) + emphysema (damage to alveoli - pink puffer)
Presentation:
- Cough (productive), SoB (starts on exercise)
- RF exposure - smoking/pollution
- Signs:
- Barrel chest
- Hyper-resonant (air trapping)
- Reduced breath sounds
- Widespread expiratory wheeze
- Coarse crackles if exacerbation (mucus in airways)
- Other - asterixis (CO2 retention flap), raised JVP (cor pulmonale)
- NOTE: COPD does not cause clubbing –> cancer/bronchiectasis
New Dx Mx:
- Ix:
- Bedside - mMRC dyspnoea scale, O2 sats, ECG (cor pulmonale)
- Spirometry - FEV1/FVC <0.7 (forced exp volume in 1s)
- Bloods - FBC, ABG, eosinophil count, alpha1-antitrypsin level
- Imaging - CXR, CT chest
- Other: serial peak flows if asthma DDx, sputum culture (in freq exacerbation), pul funct tests
- Mx:
- Conservative - stop smoking, influenza + pneumococcal vaccine, inhaler device training
- Persuade to stop smoking
- Pul rehab
- Prick them - influenza + pneumococcal vaccine
- Psych issues
- Medical - depends on severity - GOLD group –> solo/combo of:
- SABA e.g. salbutamol
- SAMA e.g. Ipratropium bromide
- LABA e.g. salmeterol
- LAMA e.g. tiotropium
- ± ICS e.g. beclomethasone
- Other: mucolytic e.g. acetylcysteine, O2 therapy, theophylline
- Medical pathway:
- 1 - SABA/SAMA
- 2a - Steroid-responsive (eosinophilia/atopy): LABA + ICS
- 2b - Not steroid-responsive: LABA + LAMA
- 3 - LABA + LAMA + ICS
- 4 - specialist input e.g. theophylline
- Surgical - lung reduction surgery (large bullae)
- Other: long-term O2 therapy
- Only if non-smoker (smoker –> burns)
- Only if <7.3 PaO2/<8 if also pul HTN
- Only if PaCO2 does not rise excessively on O2
- Conservative - stop smoking, influenza + pneumococcal vaccine, inhaler device training
Acute Exacerbation Mx:
- Ix: ABG, ECG, CXR
- Mx:
- 15L O2 NRM
- Nebs - salbutamol + IpB
- Steroids (PO pred/IV hydrocortisone)
- Abx if infective –> prophylactic abx if persistent infections - azithromycin
Prognosis factors:
- Body mass - worse if obese
- Obstruction - worse if reduced FEV1
- Dyspnoea
- Exercise capacity - how far can you walk in 6 minutes?
Pneumonia - def? Presentation? Types? Ix? Scoring? Mx?
Def: inflammation of lung caused by inf w/ visible radiographic changes
Presentation:
- Decreased chest expansion, dull on percussion, increased sound vocal resonance
- Coarse crackles
- Bronchial breathing – bronchial airflow instead of alveolar airflow (due to transmission of sounds through consolidation) – check by listening to sound at the throat
Ix: ABG, CXR, sputum culture (mod/high severity)
Scoring for CAP: CURB-65 (confusion, urea ≥7mmol/L, RR ≥30, BP <90/60, ≥65yrs)
- +1 = outpatient; +2 = outpatient/inpatient, +3 = inpatient ± ITU
- NOTE: urea is no longer used
Types & Mx –> local abx guidelines
-
CAP:
- Typical (S. pneumo, H. influenzae) –> Amox/Co-Amox
-
Atypical (Legionella, Mycoplasma, Chlamydia) –> Clari
- Dry cough (instead of productive), myalgia, confusion, diarrhoea
- NOTE: if not sure often given Co-Amox + Clari
- HAP - pneumonia arising >48hrs after admission to hospital (S. pneumo, S. aureus, P. aeruginosa) –> Taxocin (pseudomonal cover)
- Aspiration - RFs: swallowing dyfunct, reduced consciousness, reduced mental status –> elderly/frail
Goes into septic shock –> give IV fluid + senior help + check abx sensitivity (ring lab) –> ITU (intropic support - NA to increase PVR)
- Other aspects of septic-6
- NOTE: dobutamine is for cardiogenic shock to increase CO - this is not relevant here
PE - def? Sx? RFs? Scoring & Ix? Mx?
Def: occlusion of pulmonary vasculature characterized by sharp pleuritic chest pain
Sx: SYNCOPE, sudden SoB, pleuritic chest pain, haemoptysis
RFs: SICC - Surgery, Immobility, Cancer, COCP
Initial Tx:
- DOAC (e.g. Apixaban) or unfractionated heparin (if bleeding risk, can be reversed easily)
- Massive PE –> IV unfractionated heparin for hours before and after thrombolysis e.g. IV alteplase
Scoring & Ix: Well’s score
- ≤4 = D-Dimer –sign raised–> CTPA
- >4 = CTPA
- ECG useful - sinus tachycardia, right heart strain, S1Q3T3
- NOTE: Troponin = useful markers for PE severity (indicates right heart strain)
Ongoing anticoagulation - DOAC/Warfarin
- Provoked - 3 months (SICC)
- Unprovoked - >6 months + cancer & thrombophilia testing
- Ix for cancer –> any Sx?
- If yes - CT TAP
- If no - FBC, U&E, LFTs, clotting, physical exam –> if concern –> CT TAP
- Consider thrombophilia screen if no cancer for anti-phospholipid syndrome (anticardiolipin, lupus anticoagulant, anti-beta-2-glycoprotein)
- Ix for cancer –> any Sx?
Restrictive vs Obstructive lung conditions
Restrictive (belt around lungs) - reduced lung volume (restricted expansion) + FEV1/FVC ratio > 80% (normal/increased - from decrease in FVC)
- Poor breathing mechanics - Myasthenia gravis, scoliosis, obesity
- Interstitial lung disease - pulmonary fibrosis, sarcoidosis
Obstructive (hand choking airway) - increased lung volume (air trapped) + FEV1/FVC ratio < 80% (decreased - reduced expiratory volume)
- Airway obstruction (from inflammation of airways & problem exhaling) - Asthma, COPD (chronic bronchitis, emphysema), Bronchiectasis
What is FEV1 and FVC? WHat does FEV1/FVC ratio indicate
FEV1 - total air expired forcibly in 1s (spirometry reading)
FVC -total air expired in complete breath
FEV1/FVC ratio - decrease <80 indicates an obstructive condition
What spirometry measurement is used to Dx COPD? What figure needs to be reached? How is COPD further categorised by severity?
FEV1/FVC <0.7:
- Mild - FEV1 ≥ 80%
- Moderate - FEV1 ≥ 50%
- Severe - FEV1 ≥ 30%
- Very severe - FEV1 <30%
Chronic bronchitis vs emphysema?
Chr bronchitis - defined by clinical features (productive cough for ≥ 3 months/yr for ≥ 2 yrs - excess mucus & less mobile cilia) - airflow blocked by mucus –> decreased O2, increased CO2 –> cyanosis = BLUE BLOATER
Emphysema - defined by structural changes (enlarged air spaces –> reduced gas exchange) - breath slowly through pursed lips to increase airway pressure = prevent collapse –> PINK PUFFER
- Centriacinar - proximal alveoli affected, assoc w/ smoking, upper lobes
- Panacinar - entire alveoli affected, assoc w/ alpha1-antitrypsin def, lower lobes
- Paraseptal - distal alveoli affected, lung peripheries –> can rupture –> pneumothorax
NOTE: commonly co-exist
Both = COPD –> airway obstructed –> reduced FVC (air expired in complete breath) & very reduced FVC1 (air expired in 1s) –> low FVC1/FVC ratio (<0.7 for Dx)
- COPD –> vasoconstriction to redirect blood flow to well-oxygenated areas of the lungs –> if widespread –> pul HTN –> cor pulmonale
Bronchiectasis - definition? causes? presentation? Ix? Mx?
Def: obstructive lung disease characterised by permanent dilation of bronchi from the destruction of elastic & muscular components of the bronchial wall
- Results from diseases causing chronic inflammation:
- Primary ciliary dyskinesia - cilia don’t move –> mucus trapped in airways –> recurrent pneumonia –> chr inflammation
- Cystic fibrosis - mucus thick & sticky –> recurrent pneumonia –> chr inflammation
- Airway obstruction - tumour inside/outside airway or inhaled foreign body –> mucus can’t clear –> recurrent pneumonia –> chr inflammation
- NOTE: worse with certain infections e.g. aspergillosis –> hypersensitivity response
- Chr inflammation - has immune cells that release cytokines –> damage ciliated epithelial cells + destroys elastin –> airways dilated + clogged with mucus –> fibroblasts deposit collagen –> stiff lungs + mucus plug –> obstructive lung disease
Presentation:
-
RFs: CF, PCD, congenital disorders of airway, host immunodef (incl. HIV), recurrent lung inf
- Less common - inhaled foreign body, connective tissue disease, IBD, alpha1-antitrypsin def
- Productive cough (large amounts of sputum) ± haemoptysis - worse lying flat/one side
- Dyspnoea (with increased severity)
- Fever (on exacerbation)
- Crackles, inspiratory squeaks & rhonchi, clubbing (from long-term hypoxia)
Ix: CXR (ring shadows, tramlines), high-res CT (signet ring sign), FBC + sputum culture & sensitivity (inf e.g. pseudomonas), pul function tests
- Genetic testing (for possible RF causes): serum alpha1-antitrypsin, serum Ig lvls (ID), specific IgE for Aspergillus, sweat Cl test (CF), rheumatoid factor (CTD), HIV test, nasal nitric oxide (PCD)
Mx:
-
Conservative:
- Persuade to stop smoking
- Pul rehab
- Prick them - influenza + pneumococcal vaccine
- Psych issues
-
Medical:
- Mucoactive agent (nebulised hypertonic saline)
- Inhaled bronchodilator (SABA/SAMA/LABA/LAMA) - ONLY If co-existing asthma/COPD
- Surgical: depending on primary cause e.g. IFB, tumour –> lobectomy/lung transplant
- Exacerbation: short-term abx (azithromycin)
Sarcoidosis - def? presentation? Ix? Mx?
Def: a chronic multisystem disease characterized by the formation of non-caseating granulomas across various tissues
- Physiologically granulomas are supposed to form around insulting body e.g. infection but in sarcoidosis form for no apparent reason
Presentation:
- Profile - Afro-Caribbean, female, 20-40yrs
- Lungs - SoB, dry cough
- Skin - erythema nodosum & lupus pernio
- Other - dry eyes (uveitis, conjunctivitis, optic neuritis), polyarthralgia, fever/fatigue/weight loss, cardiac (cardiomyopathy, conduction defects), neuro (cranial nerve palsies)
Ix:
- Bloods:
- Serum ACE (high), serum soluble IL-2 receptor, ESR
- Serum Ca (activated macrophages in sarcoidosis prod 1alpha-hydroxylase –> excess activated vitamin D)
- CXR (bilateral hilar lymphadenopathy)
- Gold-standard: transbronchial biopsy (non-caseating granulomas)
Mx:
- Asymptomatic - NSAIDs/no Tx
- Symptomatic:
- Long-term steroids + bisphosphonates (osteoporosis protection)
- Steroid-sparing agents - Methotrexate/Azathioprine
What is Lofgren’s syndrome?
Acute sarcoidosis triad of erythema nodosum + bilateral hilar lymphadenopathy + polyarthralgia (+ fever)
- 80% resolve over 2yrs (but if reticulonodular shadowing on CXR does not resolve –> chronic)
Pneumonectomy - signs & indications
Signs
- Thoracotomy scar
- Unilateral chest flattening
- Tracheal deviation towards
- Reduced expansion
- Dull percussion
- Reduced breath sounds
- Bronchial breathing in upper-zone due to deviated trachea
Indications
- Lung cancer
- Bronchiectasis
- Bullectomy in COPD
Note: lobectomy would have thoracotomy scar ONLY
Interstitial lung disease - causes? presentation? Ix? Mx? Prognosis?
Interstitial lung disease
- Refers to the tissue the gasses pass through e.g. surface of alveoli –> reducing gas exchange
Causes:
- Upper zone fibrosis: PATEN (more occupational causes)
- Pneumoconiosis (not asbestosis) - caused by inorganic dust (e.g. soot)
- Aspergillosis/ABPA
- TB
- Extrinsic allergic alveolitis - caused by organic dust e.g. animal shedding
- Negative seroarthropathies
- Lower zone fibrosis: STAIR
- Sarcoidosis
- Toxins: B-MANS (Bleomycin, Methotrexate, Amiodarone, Nitrofurantoin, Sulfasalazine)
- Asbestosis
- Idiopathic pulmonary fibrosis
- Rheum: SLE, RhA etc
Main Sx: progressive SOBOE, dry cough, fatigue, weight loss
Signs: find end-insp creps, clubbing
- Other: reduced chest expansion, normal/reduced percussion, normal vocal fremitus
Investigations: spirometry, high-res CT & lung biopsy
- Bedside: spirometry (low FEV1, low FVC, FEV1/FVC>0.8 = restrictive lung disease), ECG (right heart strain), drug review
- Bloods
- FBC, U&E, LFTs, CRP, ESR, ABG (T1RF)
- AI screen - Serology (CTD): ANA, RhF, anti-CCP
- Serum ACE for sarcoidosis
- TB testing
- Imaging
- CXR: reticulonodular shadowing (honeycombing) + rule out lung cancer
- High-res CT: more detailed view of alveolar structure –> ‘honeycombing’ + lung biopsy
- Echo (right heart strain/cor pulmonale)
- Invasive
- Bronchoscopy + lung biopsy (gold-standard)
Management:
- Conservative (4Ps):
- Persuade to stop smoking, reduce exposure (meds, EAA)
- Pul rehab
- Prick them - influenza + pneumococcal vaccine
- Psych issues
- Medical: anti-fibrotic e.g. pirfenidone +/- prednisolone ± O2 (if hypoxaemic)
- Surgical: lung transplant if severe deterioration/impairment/oxygen dependent
Prognosis: 3-4yrs post-Dx (no Mx increases survival)
Pleural effusion - signs? causes? Ix? Mx?
Signs (if fluid > 300ml):
- Key:
- Stony dull in lung base
- If large: tracheal deviation away
- Reduced chest expansion
- Reduced breath sounds
- Reduced vocal fremitus
Causes:
-
Transudative (<30g/L protein)
- HEART FAILURE
- Hypoalbuminaemia: liver disease, nephrotic syndrome, malabsorption
- Hypothyroidism
- Meig’s syndrome (benign ovarian tumor + ascites + pleural effusion)
-
Exudative (>30g/L protein)
- Infection: PNEUMONIA, TB, subphrenic abscess
- Connective tissue disease; RA (also low glucose), SLE
- Neoplasia: lung cancer, mesothelioma, metastases
- Pancreatitis: high amylase in pleural fluid
- Pulmonary embolism
Ix:
- Bedside: obs, urinalysis for protein
- Bloods:
- ABG, BC
- FBC, U&E, LFTs, CRP
- Clotting (before needle aspiration), albumin (nephrotic syndrome)
- Mantoux/ELISPOT (TB)
- Imaging:
- CXR: meniscus sign, dense shadowing, pleural effusion if ≥300mL fluid
- CT chest - identify the cause
Management: US-guided pleural aspiration = thoracocentesis (21G needle, 50ml syringe) - above rib to avoid NV bundle
- LDH & protein in pleural fluid & serum + RBCs, WBCs, cytology, culture, pH & glucose of pleural fluid
- MC&S
-
Biochemistry: PPALS
- Protein (also serum)
- pH
- Amylase
- LDH (also serum)
- Sugar (glucose)
- Cytology
- Immunology - if indicated (RF, ANA, complement)
- Findings:
- Protein > 30g/L: exudate
- Protein < 30g/L: transudate
- Protein 25-35g/L: use Light’s criteria. An exudate is likely if at least 1 of:
- Pleural protein/serum protein > 0.5
- Pleural LDH/serum LDH > 0.6
- Pleural LDH > 2/3 upper limits of normal serum LDH
- Tx cause e.g. abx for infection, furosemide for HF
- Management of recurrent pleural effusion
- Recurrent aspiration (thoracocentesis)
- Pleurodesis
- Indwelling pleural catheter
Pleural fluid features
- Heavy blood staining - mesothelioma, TB, PE, trauma
- Purulent/turbid/cloudy - empyema secondary to bacterial pneumonia –> insert chest tube to allow drainage
- Milky - chylothorax via lymphatic obstruction secondary to malignancy
PE ECG findings?
Sinus tachycardia
S1Q3T3 (S in lead 1, Q in lead 3, inverted T in lead 3)
Pneumothorax - Def? RFs? Causes? Ix? Mx? How do you identify a Tension Pneumothorax?
Pneumothorax = accumulation of air in pleural space (subdivided into primary and secondary)
RFs: pre-existing lung disease, Marfan’s, RA, smoking
Causes: cystic pathology, parenchymal necrosis, iatrogenic, trauma
Ix: CXR
Mx:
- Primary (no pre-existing lung disease)
- <2cm (betw lung margin & chest wall), no SoB – observe 4-6hrs ± supplemental O2
-
SoB/≥2cm – needle aspiration (16-18G) –> observe 4-6hrs
- Do NOT repeat needle aspiration x2
-
Chest drain if above fails + ADMIT ± supplemental O2
- NOTE: correct clotting before inserting if possible
- Surgery
- Secondary (pre-existing lung disease) - ADMIT all secondary pneumothorax (for at least 24hrs observation)
- <1cm - high-flow O2 + ADMIT (24hrs observation)
- 1-2cm - needle aspiration (16-18G) –> high-flow O2 + ADMIT (24hrs observation)
- SoB/≥2cm/previous failed - chest drain + ADMIT ± supplemental O2
- Surgery
Tension pneumothorax = pushes away the trachea to the opposite side
- Non-traumatic:
- IMMEDIATE peri-arrest call (2222)
- Needle decompression = emergency Tx, 2nd ICS MCL (grey cannula) + high-flow O2
- Follow-up = ADMIT + chest drain
- Traumatic:
- Open thoracostomy
- Follow-up = ADMIT + chest drain
- Traumatic non-tension pneumothorax:
- High-flow O2 + ADMIT (24hrs observation)
- If open pneumothorax/penetrating chest wound –> occlusive dressing + observe
- Refer to thoracic surgeons - chest drain/thoracotomy
Location:
- Needle aspiration = 2nd ICS, MCL
- Chest drain = triangle of safety (axilla, pectoralis major, latissimus dorsi, 5th ICS) - 4th/5th ICS, MAL
Surgery:
- Open thoracotomy (or video-assisted thoracoscopic surgery = VATS)
- Follow-up surgery –> pleurodesis (mechanical abrasion/chemical irritation)
Causes of different ABGs? Resp/Met Acidosis/Alkalosis
Resp acidosis (not breathing out enough) - asthma, COPD, GBS
Resp alkalosis - pain, panic attack, PE, pneumothorax
Metabolic acidosis - DKA, lactic acidosis, diarrhoea, renal failure
Metabolic alkalosis - vom/diarrhoea, diuretics (loop/thiazide), Conn’s syndrome, liver cirrhosis, HF
T1RF vs T2RF causes?
T1RF: low/normal CO2 –> pul oedema, ARDS, collapse
T2RF: high CO2 –> opiate OD, COPD, neuromusc disease
Respiratory causes of clubbing?
- Bronchogenic carcinoma
- CF
- Bronchiectasis
- Empyema
- Fibrosing alveolits
NOT COPD (but if COPD is smoker with clubbing –> lung cancer)
Pancoast tumour - what is it? what is the presentation?
Def: Apical lung tumours
Presentation - interferes with neurones & BVs at apex of lungs
- Horner’s syndrome - meiosis, ptosis, anhydrosis
- Shoulder pain/weakness –> scapula/elbow
- Voice hoarseness - recurrent laryngeal nerve impinged
General inspection findings and potential Dx? Resp station
Signs of conditions assoc with pulmonary fibrosis?
- MCP swelling - RA
- Malar rash - SLE
- Kyphosis - Ank Spond (apical fibrosis)
- Lupus pernio - sarcoidosis
- Thick skin/’bird beak’ nose - systemic sclerosis
- Aphthous ulcers, abdo scars - Crohn’s
- Grey skin - amiodarone
Causes of pul fibrosis
Drugs - amiodarone, nitrofurantoin, sulfasalazine
Hypersensitivity - extrinsic allergic alveolitis, silicosis, asbestosis
Associations - RA, Sarcoidosis, SLE, Ank Spond, Systemic sclerosis
Idiopathic pulmonary fibrosis
Causes of whiteout on CXR
Tracheal deviation:
- Towards whiteout = pneumonectomy
- Away from whiteout = massive pleural effusion
Chest asymmetry DDx?
What should you think if you see a scar (lobectomy/pneumonectomy)?
Lung cancer/TB
TB Tx?
Rifampicin & Isoniazid (6 months), Pyrazinamide & Ethambutol (2 months)
Resp station - Dx depending on observations
- No clubbing + tar staining = COPD
- Clubbing + RA = Pul fibrosis
- Wet cough + CF signs = Bronchiectasis
- Asymmetry + thoracotomy scar = Old TB/bronchial carcinoma
- Asymmetry + no scar = pleural effusion
WHat lung condition causes increased compliance of lung
Emphysema
Cor Pulmonale Def? Dx? Mx?
Def? RHF secondary to lung disease
Dx: (clinical Dx –> confirm with ECHO)
- Peripheral oedema
- Raised JVP
- Loud pul second HS
- Sytolic parasternal heave
Mx:
- Smoking cessation
- Optimise COPD meds
- If PaO2 <8 + features of Cor Pulmonale –> long-term O2 therapy (not if smoker)
- If not above –> Sx control = diuretics
Pul HTN def?
Pul artery pressure ≥20mmHg
P450 inhibitor + N&V + refractory hypokalaemia + patient on theophyline - what is going on?
Theophyline toxicity
In lung cancer can get hypercalcaemia - how is this classified & Mx?
Pathway also applicable to non-lung cancer high Ca
Small cell lung cancer (SCLC) + muscle strength improving on repetitive movement - Dx? Relevant abs?
Lambert-Eaton syndrome (opposite of MG)
- Anti-voltage gated calcium channels Abs (VGCC)
Breast Ca/SCLC, progressive muscle stiffness - Dx? Ab?
Dx: stiff man syndrome
Ab: anti-amphiphysin
SCLC, sensory neuropathy, cerebellar Sx - Ab?
Paraneoplastic syndrome
Anti-hu
Recurrent miscarriages, prolonged APTT, thrombocytopenia - Dx?
Anti-phospholipid syndrome
ECG - ST depression, T wave inversion V1-4, II, III, AvF - what does this show?
Right ventricular strain pattern
Skin necrosis after warfarin indicates what?
Protein C deficiency
Asthma, eosinophilia, pANCA - Dx?
Churg-Strauss syndrome (eosinophilic granulomatosis with polyangitis)
Obesity, T2RF, OSA (obstructive sleep apnoea) - Dx?
Obesity hypoventilation syndrome
Asthmatic, pCO2 ≥ 6 - what are we thinking?
Near-fatal acute asthma attack
When would you find air bronchograms in CXR? What are they? What do they look like?
Consolidation (e.g. pneumonia)
Air-filled bronchi (dark) being made visible by the opacification of surrounding alveoli (grey/white)
Key structures on CTPA? What does a saddle embolus look like?
Saddle embolus transverses right and left pulmonary arteries
Causes of lung consolidation? How do you know it is a consolidation?
Pus (infection)
Fluid (pul. oedema)
Cancer
Blood (pulm haemorrhage)
Protein (alveolar proteinosis = rare)
Consolidation has lung bronchograms
Pneumothorax appearance on CXR
- Visible lack of lung markings on the left with a visible lung edge
- Mediastinal shift to the right-hand side
- Flattened left hemidiaphragm (right side is normal domed shape)
Intraperitoneal free gas on AXR
Funny shaped gases (triangles)
Rigler’s sign (see both sides of the bowel wall)
Allergic bronchopulmonary aspergillosis (ABPA) - def? presentation? Ix? Mx?
Def: results from T1 hypersensitivity reaction to Aspergillus spores (in exam often Hx of bronchiectasis + eosinophilia)
Presentation:
- SoB, wheeze (bronchoconstriction), productive cough, recurrent chest infections
- Coarse crepitations (if bronchiectasis)
- RFs: asthma, CF, atopy
Ix:
- Bedside - allergic skin-prick, spirometry, oxygen sats
- Bloods - eosinophilia, raised total IgE (>1000), Aspergillus +ve IgE & G
- Imaging - CXR, CT-chest (bronchiectasis, mucus plugging)
Mx:
- Conservative - chest physio (if features of bronchiectasis)
- Medical:
- Oral glucocorticoids (low-medium dose tapered over 3-12 months)
- 2nd line - Itraconazole
Cystic fibrosis - def? presentation? Ix? Mx? Prognosis?
Def: hereditary AR disorder caused by a mutation in CFTR gene characterised by the production of thick sticky mucus
Presentation:
- Commonly presents in infancy (Muconium ileus, genetic testing)
- Multi-systemic:
- Resp - recurrent chest inf
- GI - weight loss, malnutrition
- Endo - infertility, T1DM
- MSK - poor muscle mass
Ix:
- Bedside:
- Immunoreactive trypsinogen test (IRT) - newborn screening, not diagnostic
- Faecal elastase - abn pancreatic function
- Sweat test (+ve if Cl >60mmol/L; -ve <30)
- Sputum culture (pseudomonas)
- Pul funct tests (obstructive pattern)
- Lab:
- Genetic testing - CFTR gene mutations, ciliary genetic defects after (kartagener’s)
- Bloods - FBC, Ig, Aspergillus precipitins, nutrition status (vit, protein, Fe)
- Imaging:
- CXR/CT-chest - hyperinflation, bronchiectasis
- Abdo USS - fatty liver
Mx: MDT approach
- Conservative - airway clearance techniques (chest physio), GI nutritional support
- Medical:
- Nebs mucolytics (Dornase alfa, hypertonic saline)
- Bronchodilator therapy (SABA/LABA)
- Long-term abx (azithromycin)
- Surgical: lung transplant (if FEV1<30% predicted, refractory haemoptysis, failure of medical therapy)
Prognosis:
- No cure, mean survival = 40yrs (determinant of age is severity of lung disease)
- Death from chronic resp failure, cor pulmonale (from pul HTN), resp complications (pneumothorax, pneumonia)
Hypersensitivity pneumonitis aka extrinsic allergic alveolitis - Def? Ix? Mx & specific Mx of psittacosis?
Def: immune-mediated ILD precipitated by hypersensitivity to inhalation of micro-organisms
- Examples: Mushroom worker’s lung (thermactinomyces vulgaris), Malt-worker’s lung (Aspergillus clavatus)
- DDx: pulmonary fibrosis, pneumoconiosis
Ix:
- Bedside - O2 sats, inflammatory markers
- Imaging: CXR (90% have consolidation), CT chest (apical lung fibrosis)
- Confirmation with serology (as part of atypical pneumonia screen)
Mx:
- Conservative - avoidance
- Acute - pred tapered for 6 weeks
- Chronic - long-term low-dose pred
- Psittacosis: Tetracycline e.g. Doxy (2nd line - Macrolide e.g. erythromycin)
Lung cancer - epi? presentation? types? Ix? Mx?
Epi: Second most common cancer in UK
Presentation: chronic cough, haemoptysis, FLAWS
- Monophonic wheeze, pleural effusion signs (dull on percussion, reduced BS), cachexia, SVCO (face swelling & engorged veins in venal-caval distribution), hypertrophic pulmonary osteoarthropathy (HPOA)
- RFs: smoking, asbestos exposure, FHx
Types:
- Non-small cell lung cancer (MOST)
-
Adenocarcinoma (MOST COMMON LC)
- Non-smoking women (40% cases)
-
Squamous cell carcinoma (SCC)
- Affects large airways of lungs (central)
- Classically assoc w/ paraneoplastic hypercalcaemia, as tumour may release PTHrP
- 2nd most common in non-smokers
- Most common cause of Pancoast tumour
- Keratinization (keratin pearls)
- Large cell carcinomas (Dx of exclusion)
- Alveolar cell carcinoma = ++sputum
- Bronchial adenoma = mostly carcinoid
- Carcinoid syndrome - flushing, diarrhoea, episodes of dyspnoea
- Urinary 5-Hydroxyindoleacetic Acid (5-IAA) levels may be used to screen for carcinoid syndrome
-
Adenocarcinoma (MOST COMMON LC)
- Small cell lung cancer (15%)
- Almost exclusively smokers
- Can be assoc w/ neuroendocrine syndrome (SIADH, Cushing’s)
- Early mets BUT chemo sensitive
Ix:
- Bloods - FBC, haematinics, Ca
- Imaging - CXR, CT chest (2WW referral), CT PET scan (staging, mets)
- Interventional if suspicious CXR:
- Endobronchial US-guided biopsy (EBUS) & biopsy
- Video-assisted Tracheostomy & Biopsy (VATS - BIOPSY) of accessible nodes
Mx:
- Conservative: lung cancer MDT
- Smoking cessation
- Psych support (McMillan Nurses, specialist lung cancer nurse involvement)
- Palliative care (if terminal, Sx control & planning)
- Medical:
- Systemic chemo - esp. for small cell lung cancer (chemosensitive)
- Adjuvant/radical radiotherapy
- Surgical - if NSCLC
- VATS-lobectomy
- Open lobectomy/Pneumonectomy
Mneumonic for life-threatening asthma signs?
33 92 CHEST: ≤33 (PEF) ≤92 (O2 sats)
- Cyanosis
- Hypotension
- Exhaustion
- Silent chest
- Tachycardia
Where to percuss/auscultate/vocal fremitus on front & back in the respiratory station?
Atelectasis - def? Mx?
Def: collapse of small airway(s) of lung(s) - often because of mucus clogging small airways
- Common if had operation and been under GA - likely had high O2 + less mobile – lungs not expanding as much as normal
CXR: opacification with air bronchograms
Mx: chest physio
Bloody cough, CT chest shows mass in left lower lobe, needle biopsy shows nuclei that are enlarged, hyperchromatic and pleomorphic - what type of cancer?
Carcinoma (relevant to all body sites)
What should be measured in someone rescued from house fire with dull headache?
Carboxyhaemoglobin - carbon monoxide inhalation
4Ps of respiratory conservative Mx?
Persuade to stop smoking
Pul rehab
Prick them - influenza + pneumococcal vaccine
Psych issues
Fine crackles vs coarse crackles causes?
Fine: Fibrosis (fine, late), Fluid - pul oedema (middle, medium, reduced on cough)
Coarse: COPD (late), Pneumonia (late), Bronchiectasis (biphasic)
Early post-op fever + reduced O2 sat - Dx?
Bibasal atelectasis
What does multiple nodules on CXR most likely indicate?
Mets
Long Hx asthma with worsening breathlessness, productive cough w/ copious mucopurulent sputum, bloods high IgE - Dx? Ix? Tx?
ABPA - lungs colonised by Aspergillus
- Asthma-like Sx, raised IgE, proximal bronchiectasis
- Ix: RAST (for Aspergillus), +ve IgG precipitins
- Tx: 6 weeks with antifungals
What is KCO? When is it reduced & increased?
Part of spirometry - measures CO diffusion from alveolar to capillary blood
- Marker of gas exchange across alveolar membrane - alveolar pathology
- Reduced in anaemia, COPD, pul fibrosis/HTN
-
Increased by blood in alveolar space (increases gas diffusion):
- Lung haemorrhage - Wegener’s (GPA), Goodpasture’s (anti-GBM)
- Polycythaemia (high RBCs)
Resp scars?
- Median sternotomy scar: located in the midline of the thorax. This surgical approach is used for cardiac valve replacement and coronary artery bypass grafts (CABG).
- Axillary thoracotomy scar: located between the posterior border of the pectoralis major and anterior border of latissimus dorsi muscles, through the 4th or 5th intercostal space. This surgical approach is used for the insertion of chest drains.
- Posterolateral thoracotomy scar: located between the scapula and mid-spinal line, extending laterally to the anterior axillary line. This surgical approach is used for lobectomy, pneumonectomy and oesophageal surgery.
- Infraclavicular scar: located in the infraclavicular region (on either side). This surgical approach is used for pacemaker insertion.
- Radiotherapy-associated skin changes: may be present in patients who have been treated for lung cancer. Clinical features can include xerosis (dry skin), scale, hyperkeratosis (thickened skin), depigmentation and telangiectasia
Lobectomy ddx?
Pneumonectomy ddx?
Lobectomy:
- Cancer usually NSCLC or secondary,
- Infection e.g. localised bronchiectasis/CF with recurrent infection or haemoptysis, lung abscess, aspergilloma, TB,
- Infarction
- Trauma
- Inflammatory: sarcoidosis
- Bleeding,
- Pulmonary nodule
Pneumonectomy:
- Cancer involving more than 1 lobe/diaphragm/pleura/pericardium
- Infection e.g. bronchiectasis, multiple abscesses) NB: dull percussion note and reduced/absent breath sounds over the entire affected hemithorax
Fine vs coarse creps?
Vesicular vs bronchial breathing?
FINE (inspiratory) – pulmonary oedema (HF), interstitial lung disease (pul fibrosis)
- Best heard at base of lungs
COARSE (insp & exp) – bronchiectasis, COPD (chronic bronchitis), pneumonia
- No specific area of lungs louder
Vesicular - inspiratory > expiratory
Bronchial - inspiratory = expiratory
Paradoxical breathing - def? causes?
When your diaphragm moves in the opposite direction than it should when you’re inhaling and exhaling –> “seesaw” movement of chest vs abdo
Causes:
- Surgical = flail segment
- Medical = diaphragm paralysis (e.g. post-surgery) –> correct by lifting up the patient’s head (instead of lying flat)
