Week 3: Respiratory medicine (2) (emergencies, X-ray, infections) Flashcards
anaphylaxis
- SERIOUS allergic reaction
- Sensitised individual exposed to specific antigen
- Commonly from insects bites/ stings, food, medications
- Immunological response: – IgE → antigen → mast cell & basophils ‡ → histamine ↑ → body response
signs and symptoms of anaphylaxis
- Occurs in minutes - Pruritus, urticaria & angioedema, hoarseness, progressing to stridor & bronchial obstruction, wheeze & chest tightness from bronchospasm
management of anaphylaxis
- DO NOT DELAY! GET HELP
- Remove trigger, maintain airway, 100% O2
- Intramuscular adrenaline 0.5 mg (Repeat every 5 mins as needed to support CVS)
- IV hydrocortisone 200mg
- IV chlorpheniramine 10 mg
- If hypotensive: lie flat and fluid resuscitate
- Treat bronchospasm: NEB salbutamol
- Laryngeal oedema: NEB adrenaline
COPD exacerbation
- Infective
- Change in sputum volume / colour o Fever
- Raised WCC +/- CRP
- Non-infective
symptoms and signs of COPD exacerbartion
- More coughing, wheezing, or shortness of breath than usual.
- Changes in the color, thickness, or amount of mucus.
- Feeling tired for more than one day.
- Swelling of the legs or ankles.
- More trouble sleeping than usual.
- Feeling the need to increase your oxygen if you are on oxygen
management of COPD exacerbation
classification of asthma
raised CO2 in asthma attack
Raised CO2 is near fatal because shows patient is getting tired and cannot blow off CO2 anymore -→ need anaesthetics and intubation
management of acute asthma
- ABCDE
- Aim for SpO2 94-98% with oxygen as needed, ABG if
- sats <92%
- 5mg nebulised Salbutamol (can repeat after 15 mins)
- 40mg oral Prednisolone STAT (IV Hydrocortisone if
- PO not possible)
severe asthma management
same as acute +
- Nebulised Ipratropium Bromide 500 micrograms
- Consider neb back to back Salbutamol
life threatening asthma
acute + severe +
- Urgent ITU or anaesthetist assessment
- Urgent portable CXR
- IV Aminophylline
- Consider IV Salbutamol if nebulised route ineffective
pneumonia
Consolidation on CXR with fever +/- purulent sputum +/ raised WCC and / or CRP
management of pneumonia
- ABCDE
- If any features of sepsis – immediately treat using sepsis pathway – NO DELAY in initiating IV antibiotics and fluids
- Otherwise treat with antibiotics as per CURB-65 score, local pneumonia guidelines and awareness of any patient drug allergies
first line Abx for pneumonia
PO amoxicillin
second line antibiotics for CAP
PO amoxicillin and doxycycline (dual)
third line antibiotics for CAP
IV CO-AMOXICLAV or meropenem + oral doxycycline
which pathogens cause typical CAP
- S.pneumoniae
- H. influenzae
- S. aureus
which pathogens cause atypical CAP
Mycoplasma pneumoniae, Chlamydia pneumoniae, and Legionella pneumophila
common HAPs
- MRSA
- SA
- Pseudomonas
masisve haemoptysis
- >240mls in 24 hours OR
- >100mls / day over consecutive days
Management of Massive Haemoptysis
• ABCDE
- Lie patient on side of suspected lesion (if known)
- Oral Tranexamic Acid for 5 days or IV
- Stop NSAID’s / aspirin / anticoagulants
- Antibiotics if any evidence of respiratory tract infection
- Consider Vitamin K/
- CT aortogram – interventional radiologist may be able to undertake bronchial artery embolisation
presentation of tension pneumo
- Hypotension
- Tachycardia
- deviation of the trachea away from the side of the pneumothorax
- mediastinal shift away from pneumothorax
Management of Tension Pneumothorax:
- Large bore intravenous cannula into 2nd ICS MCL
- Chest drain into the affected side
symptoms of PE
- Chest pain (pleuritic)
- SOB
- Haemoptysis
- Low cardiac output followed by collapse (if Massive PE)
unprovoked PE
PE i.e. no obvious risk factor – in these cases consider underlying malignancy or thrombophilia
PE management
- ABCDE
- Oxygen if hypoxic
- Analgesia if pain
- Subcutaneous DOAC (or LMWH if contraindicated) whilst awaiting CTPA
- Should be fully anticoagulated once confirmed diagnosis on CTPA
massive PE management
- hypotension/ imminent cardiac arrest
- signs of right heart strain on CT / Echo
- Consider thrombolysis with IV alteplase (risk of intracerebral bleed approx. 4%)
Thrombolysis contraindications
how to report a chest x-ray
- intro
- quality of film
- ABCDE
- review areas
X-ray intro
- Name and age of patient
- Date CXR taken
- Type of CXR (e.g. PA or AP, erect or mobile)
- Quality of film
Quality of film
-
Rotation
- Medial aspect of each clavicle should equidistant from spinous processes
- Spinous processes should be vertically orientated against vertebral bodies
- Inspiration – 5-6 anterior ribs
- Projection (not AP or PA)
- Exposure- left hemidiaphragm should be visible to the spine and vertebrae should be visible behind the heart
airway
trachea central, carina, bronchi, hilar structures
breathing
lungs, pleura
cardiac
heart size and border
diaphragm
costophrenic angles - flattened?
everything else
soft tissue, bones, tubes, valves, pacemakers, review areas
review areas
- the lung apices
- the retrocardiac region
- behind the diaphragm
- the peripheral region of the lungs
- the hilar regions
how to present a potential diagnosis from an X-ray
e.g. “loss of right costophrenic angle which may be in keeping with a pleural effusion” as opposed to “a right pleural effusion”)
descriptive terms x-ray
- Refer to zones
- Right Upper, Middle and Lower,
- Left Upper, Middle and Lower
- Shadowing can be
- Complete (whiteout of whole lung field)
- Dense / opacification (affecting one or more zones),
- Diffuse
- Alveolar (cotton wool like appearance)
Cardio thoracic ratio
(The heart diameter is the shorter white arrow; the thoracic diameter is the longer black arrow. The Heart diameter is over 1⁄2 the thoracic diameter. The Cardio-thoracic ratio is therefore increased = Cardiomegaly.)
deviation towards pathology
atelectasis
deviation away from pathology
pleural effusion
pneumothorax
pleural effusion X-ray
pneumothorax
pneumonia
Lung cancer
Cant tell the difference between lung cancer and pneumonia on X-ray
which medications causes coughs
ACEi, ARB, B blockers, NSAIDS
pneumonia and its risk factors
Lung inflammation caused by bacterial or viral infection, in which the air sacs fill with pus and may become solid. Inflammation may affect both lungs ( double pneumonia ) or only one ( single pneumonia ).
Risk factors
Smoking, age>65, immuno-suppression, exposure to chemicals, and underlying lung disease
legionaires disease
s a form of pneumonia, usually caused by Legionella pneumophila. Association with infected water in showers or hot tubs – ask your patient if there is a history of recent travel or stay in a air conditioned hotel? Associated with higher CURB-65 scores.
CXR consolidation differntials
Pneumonia
TB (usually uopper lobe)
lung cancer
lobar collapse
haemorrhage
causes of non-resolving pneumonia
CHAOS
Pneumonia Follow Up
- HIV test
- Immunoglobulins
- Pneumococcal IgG serotypes
- Haemophilus influenzae b IgG
- Follow up in clinic in 6 weeks with a repeat CXR to ensure resolution
COVID-19
- Coronavirus disease (COVID-19) is an infectious disease caused by a newly discovered coronavirus Coronaviruses (CoV) are a large family of viruses that cause illness ranging from the common cold to more serious diseases such as Severe Acute Respiratory Syndrome (SARS-CoV)
- SARS-CoV-2 (severe acute respiratory syndrome-related coronavirus 2) is the name of the virus, not the disease that results from it.
- Can cause a viral pneumonia
which COVID-19 pts require hospitlisation
- hypoxia (below 92%)
- lymphopaenia
- bilateral, lower zone changes on CXR
management of hospitalised COVID-19 patients
- Unwell patients require oxygen supplementation, some going on to CPAP or invasive ventilation
- Evidence Base e.g. Dexamethasone (and consider Tocilizumab +/- Remdesivir)
- Antibiotics may be needed if suspected superadded bacterial infection
prevention of covid 19
vaccination
novel therapies for covid-19
given to ‘at risk’ people who have tested positive of COVID-10
Casirivimab/imdevimab, sold under the brand name REGEN-COV among others, is a medicine developed by the American biotechnology company Regeneron Pharmaceuticals. It is an artificial “antibody cocktail” designed to produce resistance against the SARS-CoV-2 coronavirus responsible for the COVID-19 pandemic
covid chest x-ray
TB
A bacterial infection spread through inhaling tiny droplets from the coughs or sneezes of an infected person.
- Mycobacterium tuberculosis.
- Acid-fast bacilli
risk factors of TB
clinical features of TB
- Often fever and nocturnal sweats (typically drenching)
- Weight loss (weeks – months)
- Malaise
- Respiratory TB: cough ± purulent sputum/ haemoptysis, may also present with pleural effusion
- Non-Respiratory TB: Skin (erythema nodosum); Lymphadenopathy; Bone/joint; Abdominal; CNS (meningitis); Genitourinary; Miliary (disseminated); Cardiac (pericardial effusion)
DD of haemoptysis
investigations for TB
Admit to a side room& start infection control measures (e.g. masks & negative pressure room)
- If productive cough: x3 sputum samples for AAFB (acid-alcohol fast bacilli – acid-fast stain also called Ziehl-Neelsen stain) &TB culture (If no productive cough & pulmonary TB suspected consider bronchoscopy)
- Routine bloods (especially LFTs) & include HIV test and vitamin D levels
- Consider CT chest if pulmonary TB suspected but clinical features/ CXR not typical
If diagnosis between pneumonia and TB not clear
start antibiotics for pneumonia (as per CURB-65) whilst investigating possibility of TB.
If patient critically unwell and high likelihood of TB (no time to wait for sputum results)
then start anti-TB therapy AFTER sputum samples sent.
why is TB treatment started before TB culture
- TB culture can take 6-8 weeks. So, treatment is often started before a culture confirmed diagnosis can be made. A novel PCR test (Gene Xpert) is available in some centres which can give immediate information regarding drug sensitivities or resistance
Anti-TB therapy (ATT)
- Ripe (rifampicin, isoniazid, pyrazinamide, ethambutol for 2 moths follow by R and I for 4 months
- Minimum of 6 moths total
- Patients weight important – dose dependent
- Check baseline LFTs and monitor
- Check visual acuity before giving ethambutol
- Compliance is crucial and directly observed therapy sometimes used for patients
- Pyridoxine also given (while on isoniazid) as prophylaxis against peripheral neuropathy
major side effects of TB treatment rifampicin
hepatitis, orange/red secretions, many drug interactions inc warfarin
major side effects of TB treatment isoniazid
hepatitis
peripheral neuropathy
major side effects of TB treatment pyrazinamide
hepatitis, vomiting
major side effects of TB treatment ethambutol
optic neuritis
(must do a baseline visual acuity test and LFTs must be monitored closely)
bronchiectasis
- Chronic dilatation of one or more bronchi. The bronchi exhibit poor mucus clearance and there is predisposition to recurrent or chronic bacterial infection
- Gold standard diagnostic test = High Resolution CT
- Chronic dilatation of one or more bronchi. The bronchi exhibit poor mucus clearance and there is predisposition to recurrent or chronic bacterial infection
- Gold standard diagnostic test = High Resolution CT
Bronchiectasis Causes
*
- Post infective – whooping cough, TB
- Immune deficiency – Hypogammaglobulinaemia
- Genetic / Mucociliary clearance defects – Cystic fibrosis, primary ciliary dyskinesia, Young’s syndrome (triad of bronchiectasis, sinusitis, and reduced fertility), Kartagener syndrome (triad of bronchiectasis, sinusitits, and situs inversus)
- Obstruction – foreign body, tumour, extrinsic lymph node
- Toxic insult – gastric aspiration (particularly post lung transplant), inhalation of toxic chemicals/gases
- Allergic bronchopulmonary aspergillosis
- Secondary immune deficiency – HIV, malignancy
- Rheumatoid arthritis
- Associations – inflammatory bowel disease; yellow nail syndrome
Blood Tests to try and identify cause in newly diagnosed Bronchiectasis:
- Immunoglobulin levels
- Cystic Fibrosis Genotype
- Aspergillus IgE / IgG and Total IgE
- HIV test
- Rheumatoid Factor
- Auto Antibodies
- Alpha-1-antitrypsin level
Bronchiectasis Common Organisms
- Haemophilus influenzae
- Pseudomonas aeruginosa
- Moraxella catarrhalis
- Stenotrophomonas maltophilia
- Fungi – aspergillus, candida
- Non-tuberculous mycobacteria
- Less common - Staphylococcus aureus (think about CF)
Bronchiectasis Management
- Treat underlying cause
- Physiotherapy – mucus / airways clearance
- Sputum for routine culture as well as nontuberculous mycobacteria
- 10-14 days antibiotics according to sputum cultures / sensitivities for acute exacerbations (infections): Common 1st line Oral Antibiotics:
- IV antibiotics for severe infections
rare side effect of ciprofloxacin
achilles tendonitis
Long term bronchiectasis treatment
- Long-term (prophylactic) antibiotics for patients with recurrent infective exacerbations
- Supportive – flu / covid vaccines, bronchodilators if required
- Pulmonary Rehab – MRC Dyspnoea Score >3
- Long-term (prophylactic) antibiotics for patients with recurrent infective exacerbations
- Supportive – flu / covid vaccines, bronchodilators if required
- Pulmonary Rehab – MRC Dyspnoea Score >3
- Long-term (prophylactic) antibiotics for patients with recurrent infective exacerbations
- Supportive – flu / covid vaccines, bronchodilators if required
- Pulmonary Rehab – MRC Dyspnoea Score >3
Bronchiectasis Infective Exacerbations
- Sometimes patients and clinicians find it difficult to distinguish an acute infection (exacerbation) in patients with bronchiectasis versus their baseline chronic symptoms. Here is a useful definition:
- A person with bronchiectasis with a deterioration in 3 or more key symptoms for at least 48 hours:
- Cough
- Sputum volume and / or consistency
- Sputum purulence
- Breathlessness and / or exercise tolerance
- Fatigue
- Haemoptysis
signs of bronchiectasis on CT
Signet ring sign
with the dilated bronchus representing the “ring” and the adjacent smaller artery representing the “jewel” on the ring.
Allergic bronchopulmonary aspergillosis (ABPA)
- Caused by aspergillus fumigatus exposure
- Aspergillus is a common fungus found indoors and outdoors
- ABPA is a combination of types 1 and 3 hypersensitivity reactions following inhalation of fungal spores i.e. it is not a fungal infection
- Repeated damage from these immunological reactions leads to bronchiectasis (often upper lobe)
- ABPA is seen more in patients with Asthma, Bronchiectasis and Cystic Fibrosis
- Diagnosis is made by a combination of symptoms (often dry cough and wheeze) along with positive blood tests (raised Aspergillus IgE level as well as a high Total IgE – these are often accompanied by a high eosinophil level too)
- Treatment (steroids) may be required if ongoing symptoms and high Total IgE level
CF Definition
CF is an autosomal recessive disease leading to mutations in the Cystic Fibrosis Transmembrane Conductance Regulator (CFTR). This can lead to a multisystem disease (most commonly affecting the respiratory and gastrointestinal systems but can affect any part of the body with CFTR) characterised by thickened secretions.
CF Diagnosis
One or more of the characteristic phenotypic features -
- Or a history of CF in a sibling
- Or a positive newborn screening test result
And
- An increased sweat chloride concentration (> 60 mmol/l) – SWEAT TEST
- Or identification of two CF mutations – genotyping
- Or demonstration of abnormal nasal epithelial ion transport (nasal potential difference)
CF Presentations
- Meconium ileus
- In 15-20% of newborn CF infants the bowel is blocked by the sticky secretions. There are signs of intestinal obstruction soon after birth with bilious vomiting, abdominal distension and delay in passing meconium.
- Intestinal malabsorption
- Over 90% of CF individuals have intestinal malabsorption. In most this is evident in infancy. The main cause is a severe deficiency of pancreatic enzymes.
- Recurrent Chest infections
- Newborn screening
CF complications: resp
-
Respiratory Infections
- Needs aggressive therapy with physio and antibiotics
- Antibiotic prophylaxis
CF complications: constitutional
-
Low Body Weight
- needs careful monitoring
- may be consequence of pancreatic insufficiency (lack of pancreatic enzymes), therefore in those patients give pancreatic enzyme replacement therapy
- high calorie intake and often extra supplements - may need NG or PEG feeding
CF complications: GI
-
Distal Intestinal Obstruction Syndrome (DIOS)
- DIOS vs. constipation – faecal obstruction in ileocaecum versus whole bowel
- Due to intestinal contents in the distal ileum and proximal colon (thick, dehydrated faeces)
- Due to insuffiencet prescription of pancreatic enzymes or non compliance, also salt deficiency/ hot weather
- Palable right iliac fossa mass (faecal)
- Diagnosis:right palabale mass in iliac fossa, AXR demonstratingfaecal loading at junction of small and large bowel
- Treatment: PO Gastrografin–this works by drawing water across the bowel wall by osmosis into the bowel lumen, aiming to rehydrate the dehydrated faecal mass and allow it to pass
CF can also be related to
diabetes
the thick, sticky mucus causes scarring of the pancreas. This scarring prevents the pancreas from producing normal amounts of insulin. So, like people with type 1 diabetes, they become insulin deficient.
CF Lifestyle Advice
- No smoking
- Avoid other CF patients
- Avoid friends / relatives with colds / infections
- Avoid jacuzzis (pseudomonas)
- Clean and dry nebulisers thoroughly
- Avoid stables, compost or rotting vegetation – risk of aspergillus fumigatus inhalation
- Annual influenza immunisation
- Sodium chloride tablets in hot weather / vigorous exercise
CF Management
- As per bronchiectasis – physio for airways clearance
- Exercise
- Mucolytic treatment options also include nebulised DNase (pulmozyme)
- Pancreatic Enzyme Replacement Therapy (e.g. Creon) for patients who are Pancreatic Insufficient
- Nutritional supplementation if under weight
- Fat soluble vitamin (A,D,E,K) replacement
- Long-term antibiotics (sometimes inhaled or nebulised)
- Optimisation of CF related diabetes – this occurs in approximately 1 in 3 adults with CF and if present requires insulin therapy
- Novel CFTR modulators / potentiators (e.g. Kaftrio) – these have shown excellent efficacy with improvements in FEV1, weight, quality of life and a reduction in frequency of infective exacerbations
- Long-term monitoring for CF related diabetes, CF related liver disease and osteoporosis
