Introduction to respiratory.pptx

INTRODUCTION TO RESPIRATORY MEDICINE C Heffernan September 2022  OBJECTIVES  Describe the anatomy location terms  Describe the respiratory system  Brief recall of respiratory physiology  Recall common symptoms and signs  Describe common respiratory investigations  Discu...

INTRODUCTION TO RESPIRATORY MEDICINE C Heffernan September 2022  OBJECTIVES  Describe the anatomy location terms  Describe the respiratory system  Brief recall of respiratory physiology  Recall common symptoms and signs  Describe common respiratory investigations  Discuss common respiratory condition TERMINOLOGY  Pneumo: Air  Thorax: chest  -itis: inflammation  Mortality: Death  Morbidity: illness RESPIRATORY DISEASE IN THE UK  1 in 5 people effected  3rd biggest cause of death  Lung cancer  Chronic obstructive pulmonary disease (COPD)  Big increase over winter  Asthma: £ 3 Billion  COPD: £1.9 billion  All: £11 billion to the NHS  Mortality rates higher in disadvantaged groups  Higher incidence of smoking, air pollution, poor housing, occupational hazards  ANATOMY  In addition, where is the:  -Horizontal fissure  Notch for the heart  Cricoid cartilage  GAS Structure of the EXCHANGE alveoli COMMON SYMPTOMS & SIGNS  COMMON SYMPTOMS & SIGNS  Breathlessness  Cyanosis  (Cyan: blue = deoxygenated blood)  Cough  Productive  Crackles  Dry  Wet vs dry  Coarse  Wheeze  Inspiratory (Stridor)  Bronchial breathing  Expiratory  Hollow sound  Runny nose  Wheeze  Sore throat  Blocked nose  WHAT DOES THIS MEAN?  Groups of symptoms and signs help you diagnosis  Can you group any together?  Stridor: Obstruction  Wheeze: Asthma or COPD  Sore throat: Upper respiratory tract infection (URLI)  Dry cough: fibrosis  Productive cough: Pneumonia/Lower respiratory tract infection  More than one thing can be going on  Co-morbidies  RESPIRATORY SOUNDS  https://www.youtube.com/watch?v=2NvBk61ngDY INVESTIGATIONS (A SELECTION)  Bloods  Look for infection  Eosinophilia (Asthma/allergy)  Chest X-Ray (CXR)  Infection, fibrosis, cancer, collapse  CT scans  PE, cancer, fibrosis, complex infections  Peak flow  Asthma  Spirometry  COPD, asthma, fibrosis  Sleep studies  Obstructive sleep apnoea SOME COMMON RESPIRATORY CONDITIONS Summary slides ASTHMA  Common  Chronic inflammation of the airways  Hyper-responsive and reversible  Inflammatory cells infiltrate the airways  Smooth muscle hypertrophy  Hyper = big  Thickening of the airway  Trigger by pollution, occupational exposure, allergy, bacteria and virues ASTHMA HISTORY  Risk  Key history points  Smoking  Wheeze  Family history  Nocturnal cough  Childhood infections  Worse at night  Pollution  Worse at work/better on holiday  Prematurity  Atopy  Occupation (chemicals, dusts,  Eczema spores)  Hayfever  Illness  Risks of exacerbations  Viral/Bacteria  Poor inhaler technique  Continued triggers  Smoking (active vs passive) ASTHMA SIGNS & INVESTIGATIONS  Wheeze  Peak flow  BD (Twice a day)  Dry cough  Know their best  Unless infected  Breathless  Bloods  IgE, eosinophils  Usually acutely  Progressive while unwell  Spirometry  Responsive to treatment (usually)  Obstructive  Not speaking in full sentences  CXR (acute)  Sputum sample  Hypoxia and cyanosis in life threating exacerbations ASTHMA MANAGEMENT (NOT ACUTE)  Peak flow diary  Inhalers  See control  B2 agonist [salbutamol]: Relief (BLUE) (SABA)  Stop smoking/vaping  Steroid: preventer (BROWN) (ICS)  Avoid/limit triggers  Long acting B2 agonist (LABA)  Combo  Vaccinations  Fostair  Flu  Symbicort  Covid  Thinking inhaler: think technique  Annual review  Consider spacer  Tablets if poor control  Leukotriene antagonists, phyllines COPD  Emphysema & Chronic bronchitis  3 months productive cough for 2 years  2nd commonest admission cause to hospital  Over a million GP appointments a year  Irreversible airways disease  Smoking: > 80% cause COPD HISTORY  Breathless  Associated features  Progressive  Temperatures  MRC scale  Headaches  1-on exercise  Drowsy  5-house bound  Recurrent admissions  Try to quantify  Chronic cough  Ask about change volume and colour COPD: SIGNS AND INVESTIGATIONS  Breathless  CXR  Wheezy  Spirometry  FEV1/FVC 7  R = Respiratory rate >30  B = Blood pressure < 90 systolic  65 = aged 65 or above  1- mild: consider home  2- may need hospital admission  3- severe needs hospital admission  4/5 – need escalation plan and may need ITU CXR EXAMPLES  TOP  Right middle lobe pneumonia  BOTTOM  Left sided pleural effision BRONCHIECTASIS  Chronic disease due to irreversible bronchial dilation  Chronic productive cough  Colonised by bacteria  Recurrent infections  Causes  Idiopathic (unknown)  Post infection (recurrent childhood infections)  Respiratory disease (poorly controlled asthma) BRONCHIECTASIS HISTORY  Productive cough  Ask about haemopysis (blood in sputum)  MRC scale breathlessness  Childhood illness  Family history  Smoking history BRONCHIECTASIS: SIGNS AND INVESTIGATIONS  Wheeze  Sputum culture  Look at past results  Crepitations: coarse  Clubbing  CXR and CT Chest CLUBBING  Other causes  Lung cancer  Fibrosis  Yellow nail syndrome BRONCHIECTASIS MANAGEMENT  Stop smoking  Vaccination  Pulmonary rehab  Long term antibiotics  Chest physiotherapy  Inhalers  Carbocisteine (Breaks down mucus)  Long term oxygen  Surgical: resections/transplant PNEUMOTHORAX  Collapsed lung  Air between the visceral and parietal (chest wall) pleura  Primary  Normal lung  Second  Underlying lung disease like COPD  Spontaneous  Just happed  Traumatic  Provoked  Underlying connective tissue disease, tall statue PNEUMOTHORAX: HISTORY  Sudden breathless  Pleuritic pain  Worse when breathing in  Often well unless tension PNEUMOTHORAX SIGNS AND INVESTIGATIONS  Breathless  CXR  Hypoxic  If tension suspected: very  Reduced breath sounds on breathless, low BP  TREAT with needle in second affected side intercostal space, mid-clavicle  Hyperresonance on affected side  Do not delay for CXR  TENSION: deviated trachea AWAY from affected side PNEUMOTHORAX MANAGEMENT  Primary  Under 2cm: observe, repeat CXR in week  Oxygen  Larger: aspirate x 2 and repeat CXR  Chest drain  Secondary  Chest drain  Tension  Decompress  Chest drain PNEUMOTHORAX ADVICE  No diving  Avoid flying for 6 weeks  SOS advice FIBROSIS  Scarring of the lung  Idiopathic pulmonary fibrosis commonest type  Secondary types: RA (rheumatoid arthritis), SLE (lupus), Drugs (metrotrexate)  Restrictive lung disease  Reduces capacity of the lung: increased diffusion distance  Less oxygen available = more breathless FIBROSIS: HISTORY  Progressive breathlessness over time  Dry cough  Occupational history: ship yards, baker, miner, farmer, plumbers  Smoking FIBROSIS: SIGNS AND INVESTIGATIONS  Clubbing  CXR (looks hazy all over)  Fine crepitations like velco  High resolution CT (HRCT)  Sounds ‘dry’  Looks like honeycomb  Connective disease  ABG if hypoxic  Arthritis  Erythema nodosum  See later in course  Cyanosis  Hypoxia FIBROSIS MANAGEMENT  Stop smoking  Pulmonary rehab  Vaccination  Treatment depends on type  Secondary: steroids, stop drugs, avoid triggers  Primary: some antifibrotics: doesn’t always work  Complications  PE  Steroid induced complications (thin skin, bruises, osteoporosis, diabetes, Cushing's syndrome LUNG CANCER  Commonest cancer in the UK  Poor prognosis  Often diagnosed late  Smoking a major risk factor  Cancer grouped into:  Non-small cell (adenocarcinoma/squamous)  Small cell LUNG CANCER HISTORY  Smoking pack year  Occupation  Weight lost (unintentional)  Haemoptysis  Persistent cough  Bone pain  Night back pain LUNG CANCER: SIGNS AND INVESTIGATIONS  Clubbing  CXR/ CT chest  Cachexia  Bloods  Look for calcium  Pleural effusions  Liver function (metastases to liver) LUNG CANCER MANAGEMENT  If in community  Refer on 2 week wait  In hospital  CT chest (if abnormal CXR) and refer to respiratory (can be 2ww)  Once suspected: discussion at MDT  Biopsy  Oncology: chemo =/- surgery  Oncology lecture later in course PULMONARY EMBOLI (PE)  Clots in the pulmonary artery system  Unprovoked vs provoked  Surgery, immobility, cancer, medications (pill), pregnancy,  Often treated in SDEC (same day emergency care)  Can be life threatening  Variable presentation  Common cause of cardiac arrests  Presents with pleuritic chest pain  Multiple differentials PE HISTORY  Any surgery  Any immobility  3 days in bed  Long haul flights  > 4 hours  Past medical history  Previous clots, clotting disorder PE SIGNS AND INVESTIGATIONS  Breathless on exertion  ECG  Sinus tachycardia (common)  Hypoxic (low oxygen)  T-wave in V1-3  May on be on exertion  S1Q3T3 (rare)  Hypotenison (low BP)  If large  CXR  Alternative cause like infection/cancer  Can occur together)  ABG  Alkalotic/hypoxic  VQ or CTPA  Look for clot WELLS SCORE  D.dimer is a negative predictive test  If negative: not clot, look elsewhere  If positive, doesn’t mean anything as lot of things can raise it  Useful if under 14 days  Age adjusted in some places  IF above 4, DON’T do D.dimer CAN THEY GO HOME?  Class 1 or 2 can be managed as outpatients  Consider troponin if high volume or right heart strain PE MANAGEMENT  If unstable: thrombolysis  Anticoagulation (thin the blood)  Heparin injection  Warfarin (rare)  DOAC (direct oral anticoagulants)  3 months  Remove trigger  If removed stopped  If unprovoked, consider life long or if 2nd episode, life long  Look for cancer if unprovoked  CXR, breast exam/PSA, if malignant symptoms, CT Abdo, lupus anticoagulant DIFFERENTIALS DIAGNOSIS  Go back and look  Lots of common symptoms  Start with working and consider alternative  Use investigations to prove or disprove your working diagnosis and adjust  Remember, more than one thing can be going on  Multi-comorbidies: what changed?, what driving it? Don’t over complicate  For resp, some cardio (next week) causes: pul oedema, MI, pericarditis  Each week you will add more  Remember the golden rule  Common things are common