Respiratory
AsthmaBronchiectasisConsolidationCOPDCor Pulmonale and Pleural RubCystic FibrosisFibrosing AlveolitisLung CancerOld TBPickwickian SyndromePleural EffusionPneumothorax
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Asthma
Chronic asthma
WheezeCoughSOB
Diagnosis
PEFR >25% variablePEFR + FEV1 inc post nebDec FEV1Dec FEV1/ FVC ratio
(<70%)Gas trapping
Triggers
InfectionEmotionExerciseDrugs
Management of chronic asthma
Step 1. Occasional short actingStep 2. Short acting and steroidStep 3. Short acting + increase steroid or short
acting + add long acting beta2Step 4. Add other alternativesStep 5. Add oral steroid
Acute asthma
SevereH R >110A BG pO2 <8R R >25P EFR <50%
Life threateningPEFR <33%ExhaustionBradycardia/ hypotension
Wheeze differential
COPDLVFPANTumourEosinophilic lung disease
Extrinsic asthma (kids)
(Dermatophagoides pteronyssinus)
Intrinsic asthma (late onset)
Smoking related – more severe and continuous
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Bronchiectasis (= chronic necrotising infection)
Clubbing
Types (Reid’s classification)
1. Cylindrical2. Varicose3. Cystic/ saccular
Tests:CXR/ HRCT/ sputum cultureAetiology testing
Causes
Congenital Post-infective OtherCF TB/ HIV SarcoidKartagener’s Measles AspirationYoung’s Pertussis Hypogammaglob Pneumonia Idiopathic ABPA
Management
P hysioA ntibioticsB ronchodilatorS urgery – if restricted to a single lobe
Haemoptysis
Complications
SinusitisHaemoptysisBrain abscessAmyloidosisEffusionPneumothoraxPneumonia
Bilateral coarse and end insp crackles – coarse bronchiectasis. They clear with coughing
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Consolidation
Dec movement of affected sideBronchial BS (bronchial)Crackles ( )Dec PN – not stony dull (THUD)
Causes of pneumonia
Community Hospital
Typical AtypicalS. pneumo Chlamydia pneumoH. influenzae Mycoplasma pneumo Legionella pneumo Chlamydia psittacii
Poor prognosis signs
Confusion and comorbiditiesUrea >7RR >30BP Sys <90/ Dias <60Age >65
Causes of recurrent pneumonia
AspirationAntibioticsCancerChurg–Strauss
CNS/ PNS problems
DIC
Pericarditis/ myocarditis
HepatitisHaemolytic anaemia
Glomerulonephritis
Extrapulmonary manifestations of mycoplasma
Pulmonary eosinophilic disorders
Löffler’sABPAChronic pulmonary eosinophilia
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COPD (3 months cough/ year for 2+ years
– a combination of chronic bronchitis and emphysema)
Hyperresonant (and loss of cardiac dullness)Decreased cricothyroid distanceDecreased air entry
Classification
Mild FEV1 60–80%Mod FEV1 40–60%Sev FEV1 <40%
Treatment
Nebulisers/ inhalers/ O2/ antibiotics
Other treatments
Nutrition (diet high in n-3 fatty acids)Bullectomy: COPD with >1/3 of hemithorax
taken upLung transplantation: <60 yrs with no
underlying systemic probs or cancerLung volume reduction surgery
Cricosternal distance <3 finger breadths
Genetics in COPD
1. Alpha1 antitrypsin deficiency2. TNF-alpha3. Microsomal epoxide hydroxylase
BOOM
Long term O2 therapy
pO2 on air <7.3pO2 7.3–8 with portal hypertension/ peripheral
oedema/ nocturnal hypoxaemiaFEV1 <1.5 LNormal or increased pCO2
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Cor PulmonaleMortality 50% at 5 years
Causes
Both obstructive and restrictive respiratory disease
Pulmonary vascular disease
Treatment
Careful O2
FrusemideVenesect if HCT >55%
Causes
PEInfection
‘Like shoes in the snow’Doesn’t clear on coughingPainful
RUB
P2Click
HEAVE
Heave/ raised JVP/ pansystolic murmur/ loud P2Hepatomegaly and pedal oedema
Pleural Rub
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Cystic Fibrosis
Delta 508 mutation
Clubbing Bibasal creps Cyanosis
Treatment
PhysioAntibioticsBronchodilatorsHeart-lung transplantationHigh dose ibuprofenAerosolised human recombinant DNaseImprove hydration of secretions with
amiloride, triphosphate nucleotideImmunisation
Treatment of steatorrhoea
Low fat dietPancreatic supplementH2 receptor antagonist
Chest infection bacteria
S. aureusH. influenzaeBurkholderia cepaciaePseudomonas aeruginosa
RIP aged 30 from respiratory complications as predicted by FEV1 <30% – gives 2 year survival
7
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Fibrosing Alveolitis
Types
UIP usualDIP desquamativeNSIP non-specificLIP lymphoidGIP giant-cell
Causes
RA/ SLE/ UC/ CAH/ SS/ dermatomyositisEAAChronic pulmonary oedemaOccupational lung disease
Features
Finger clubbingCyanosisBilateral fine late
inspiratory creps (‘velcro’)
Investigations
CXR/ ABG/ PFT/ HRCTInc ESR/ Inc Ig/ Inc ANA/
RFBAL: Lymphocytic = good
prognosis
Treatment
6/52 steroidsCyclophosphamide for
steroid non-respondersLung transplantation – has
a 60% 1 year survival
Prognostic factors
Young FemalePredominantly ground glass changesLittle fibrosisPredom lymphocytosis
LymphocytosisLittle fibrosis
Clubbing and creps differential
Bronchogenic CaBronchiectasisAsbestosisFibrosing alveolitis
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Lung Cancer
Inoperable disease
FEV1 <1.5 LCurrent IHDMalignant pleural effusionMediastinal LNCarinal involvement
Extrapulmonary
GynaecomastiaTSH raisedPTH raised
Extrapulmonary
SiADHCarcinoidACTHEaton–Lambert
Lung cancer types
Squamous (SQ) and small cell (SM) – central
Adenocarcinoma (AD) – peripheral
Treatment
Small cell – chemotxNon-small cell – surgery/radiotx
General extrapulmonary manifestations of lung cancers
CVS Endocrine Skeletal Cutaneous Neuro VascAF As above Clubbing Herpes zoster Eaton–Lambert DICPericarditis HPOA Dermatomyositis Neuropathies Marantic Horner’s endocarditis Cerebellar degeneration
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Old TB
Features
Trachea pulled overMay have obvious scarCreps upper zone
Pulmonary TB diagnosis
If sputum positive AFB: isolation for 2 weeks – can self isolate at home
Investigate contacts by enquiry re BCG/ do CXR/ Heaf testGive chemoprophylaxis if Heaf positive but CXR negativeEarly TB diagnosis done by PCR
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Pickwickian Syndrome
Features
Sleepy
Cyanosed
Short of breath
Micrognathia possibly
Obese
Right heart failure
Treatment
CPAPTonsillectomyCorrection of GH/ TSH/ OtherWeight lossMandibular surgeryTracheostomy
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Pleural Effusion
Investigations
C ytology: white cells >50 000 – parapneumonia; Lymph – Ca/ TB/ sarcoid/ collagen P rotein/ pH: If pH <7.2 suggests empyema G L ucose: glu/ LDH – TB/ Ca/ RA/ SLE; glu or LDH – in Ca poor prognosis Chol E sterol: <60 g/dL in transudates U R F: RF and ANA increased in SLE A lbumin/ ANA/ amylase: Boerhaave’s/ bact pneumonia / adenoCa/ pan L DH
Pleural effusion types
Exudate
(Serum albumin: pleural gradient >1.2 g/dL = exudate)
Lung Ca/ mesotheliomaSecondaries (breast/ lung/ ovary/ panc)Pneumonia/ TBRA/ SLE
Transudate
CCFLiver failureHypothyroidNephrotic
Empyema
Chylous
Haemothorax
Decreased movementTracheal deviation to opposite sideStony dullDecreased vocal resonance and
breath sounds (sounds travel badly through water)
Causes of dullness at the lung base
Pleural effusionPleural thickeningRaised right hemidiaphragmConsolidation and collapse
Use of USS
To differentiate thickening from effusionFor drain placementFor loculation
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Pneumothorax
Causes
SpontaneousTraumaAsthmaCOPDCa lungCFTBVentilationMarfan’sEhlers–Danlos
BTS grading
Small (<2 cm rim on CXR)MediumCompleteTension
Dec movement affected side
Inc PNDeviated tracheaDec breath soundsIf hypotensive/
tachycardic = tension
Thoracotomy if ...
a. More than three episodes of spontaneous pneumothorax
b. Bilateral pneumothoracesc. Failure of lung to expand after thoracostomy
for first episode