RESPIRATORY – PHASE 2A - PowerPoint Presentation

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RESPIRATORY – PHASE 2A

Molly B & Ruby S

*download this powerpoint, in the notes section (the bit you drag up under the powerpoint

slides) there are extra notes that explain things in more detail

Your Resp Syllabus

‘By the end of year 2 of the course you are expected to be able to:Describe the microbiology of respiratory infections

and explain how they are diagnosed and the principles of managementExplain the pathophysiology of reversible airways disease,

describe the clinical presentation and pharmacological treatmentList the causes and describe the pathophysiology, clinical presentation and principles of management of

chronic inflammatory lung diseaseExplain the classification, pathology and describe the clinical presentation and principles of management of

benign and malignant

tumours

of the lungs, pleura and mediastinumExplain the role and be able to interpret the basic investigations used in the diagnosis and management of lung disease (CXR, spirometry and blood gases)’

You should make sure that you understand the pathological basis, clinical manifestations, main differential diagnoses, common investigations and principles of management

of the following index conditions which are relevant to this block of study and covered or referred to in the lectures. However, the lectures will not be provide all you need and you are expected to add to your knowledge and understanding by further reading in personal study time.Chronic obstructive pulmonary disease

AsthmaHypersensitivity pneumonitis Occupational lung disordersBronchiectasisCystic fibrosisPleural effusionPneumothorax

Lung TumoursMesotheliomaWegner’s granulomatosis

Infection

What will be covered in today’s session:

Phase 1 Resp recap (relevant stuff)

Resp pharmacology Resp microbiology 😷😷Conditions:

How to interpret some investigations General exam tips

Stuff not covered: Wegners

granulomatosis

Resp

tract infections (self explanatory)

CONDITIONS Chronic obstructive pulmonary disease

Asthma

Hypersensitivity

pneumonitis

Occupational

lung disorders

Bronchiectasis Cystic fibrosis Pleural effusion Pneumothorax Lung Tumour’s Mesothelioma Resp tract infections

Phase 1 Recap

Happy to know – Resp

does not have a lot of phase 1 knowledge!  Pleura, Transudate and exudate (in relation to the pleural space) Apex of the lung comes up to just above the clavicle

Resp Microbiology

Pneumonia/influenza TB

GENERAL TIPS:

Send you flowcharts

ANTIBIOTICS!

Know the main conditions well, any could come up

Staining techniques and their results

Other tests for organisms

Pneumonia

Inflammation and fluid collection in the lungs due to infection

Causes 30% of deaths in ITU Causative Organisms

Bacteria:Strep pneumoniae (90% cases)Staph aureus

Legionella's (recently come back from SPAIN with chest infection)

Jirovecci

(HIV patients)

Virus:

H-influenza (flu)

PEOPLE AT RISK:

Infants and the elderly

COPD and other chronic lung conditions

Immunocompromised (HIV, AID’s)

Nursing Home residents

Impaired swallowing Diabetics and those with CV disease

Congestive heart diseaseAlcoholics and IV drug users

Signs and symptoms Signs: drop in BP, fever,

increased resp rate, SPUTUM

Symptoms: confusion, fatigue, pleuritic chest pain, SOB, headache,

cough with sputum

Investigations

Listen to the chest

Gold standard: CXR. Consolidation.

To determine the causative organism

…

Sputum sample and blood culture

Urinary antigen test

–

Legionellas Thoracentesis

Assess severity: CURB-65. Does anyone know what this stands for?

SYMPTOM

Points:

Confusion1

Blood

Urea Nitrogen (BUN) >7mmol/l

1

Resp Rate ≥30

1

Blood Pressure <90/

≤60

1

≥65 years old 1

SCORE 1:

TREAT AS AN OUTPATIENT

SCORE 2:

CONSIDER SHORT STAY IN HOSPITAL/MONITOR CLOSELY AS OUTPATIENT

SCORE 3+:

HOSPITALISATION, CONSIDERATION FOR ITU

CURB-65

TreatmentSupportive therapy and antibiotics ABCDE approach

: IV fluids, CPAP, etcAnalgesia (chest pain)

Antibiotics – first give them empirically immediately and then guided after MC and SThromboprophylaxis

– risk of VTE

Antibiotics CAP:

Mild: oral amoxicillin

Moderate: oral

amxoicillin

and clarithromycin Severe: IV co-amoxiclav and clarithromycin

Antibiotic

Legionellas

:

Fluoroquinolone + clarithromycin

TB

‘Mycobacterium Tuberculosis’ –

AEROBIC, non-motile rod shapedSpread: AIRBORNE DROPLETS

Apex (top) of the LUNGS

NOTIFIABLE DISEASE – report to public health England IMMEDIATELY

Signs and symptoms (active)

Signs: coughing up BLOOD, individual will look unwell

Symptoms:

Fever, night sweats, chills, fever, chest pain

Diagnosis:

Sputum test (3x),

Mantoux

skin test, CXR, CT scan

Ziehl

–Neelsen stainTreatment ‘RIPE’ *Exam: Recent travel to India (potentially drank milk) / contact with anyone who has recently been to India

R

P

-6 MONTHS 

 2 MONTHS 

Resp Pharmacology

‘List the commonly prescribed classes of drug

(with examples of individual generic drugs), their mechanisms of action, and common and severe adverse reactions and interactions used in the management of the following conditions: Respiratory: asthma, COPD, infection, cystic

fibrosis’Every drug we thought you need to be aware of (to do with

resp) in Phase 2A: Beta Agonists: COPD and Asthma (e.g. salbutamol, salmeterol)

Muscarinics

: COPD (e.g.

Anti-

mucanilitics: Cystic Fibrosis Steroids: COPD, Asthma (e.g. prednisolone) Antibitoics: Pneumonia *ACE inhibitors

Beta Agonistse.g. Salbutamol (SABA) and Salmeterol (LABA)

Used COPD, Asthma

Delivery Inhaler, nebuliser

Method of action

Bind to B2 receptors, cause smooth muscle relaxation

and

bronchodilation

Adverse Effects

Hypokalaemia (low Potasstium / K+)

Tremor

Palpatations

Muscle cramps

Corticosteroids

E.g. prednisolone, methylprednisolone, dexamethasone Suppress multiple inflammatory genes

Adverse effects: LOTS!

OSTEOPAROSIS and subsequent fractures. T

AKE BISPHOSPHONATES AND VITAMIN D ALONGSIDE

.

Increase infection risk (suppressed immune system)

Weight gain

ACE

Inhibtors

E.g.

rampipril

Used for

hypertension

Can

cause a

COUGH

(due to the build up of bradykinin).

COPD

What is it? Collection of lung diseases that cause

IRREVERSIBLE obstruction to airflow out of the lungs. Three diseases: Chronic bronchitis, emphysema and C.O.A.D Type 2 resp

failure (CO2 high, O2 low)Pathophysiology

---------------------

>

Causes

SMOKING (>90% cases!!!) Alpha 1 anti-trypsin deficiency

Signs and Symptoms Signs: Barrel shaped chest, ankle swelling (Resulting heart failure), sputum, chronic cough, use of accessory muscles to breathe, wheeze

Symptoms: tired and lack of energy, low mood, SOB

Investigations Spirometry: FEV1/FVC<70%CXR

DLCO

Treatment

Lifestyle: STOP SMOKING! Keep healthy (increased infection risk)

Iatrogenic: Oxygen therapy,

Drugs

------------------------------------>Surgical: Lung transplant

SABA

LABA

LABA + Corticosteroid

LABA + Corticosteroid

+ LAMA

Asthma

What is it?

REVERSIBLE chronic obstructive airway disease Hypersensitivity

TYPE 1 reaction Two types: Allergic (atopic) and non allergic (non-atopic)

Pathophysiology

Allergen is inhaled, remembered, next time inhaled causes inflammation and constriction of the airways.

Causes

Allergic: genetics, environmental stimuli, hygiene hypothesis

Non-allergic: intrinsic e.g. stress, cold air, infectionExacerbating Factors

Infection, trauma, allergens, pollution, smoking, stress, some medications

Signs and symptoms Symptoms: wheeze, SOB, dry cough – worse in MORNING

Investigations Spirometry FEV1/FVC<70% +

Reversibility testing Peak flow (keep a diary – diurnal variation

) Treatment

Lifestyle: stop smoking, avoid allergens and stress, keep healthy (increased infection risk)Drugs: (treatment ladder)

SABA

Corticosteroid

Corticosteroid + LABA

Higher dose corticosteroid +

consider biological therapy

+

Prednisolone

Pleura Double membrane, surrounds the lungs.

Two parts: Parietal: Chest Wall

Visceral: LungsFunctions

PROPER BREATHING: lungs move with the chest wallCushioning

Lubrication

Pleural Effusion

What is it?

Build up of FLUID in the pleural space Fluids: chyle, blood, serous, urine, pus.

Transudate vs Exudate

Transudate:

Excessive production of pleural fluid or resorption is reduced

. E.g. heart failure, cirrhosis, nephrotic syndrome

Exudate:

Result from damaged pleura. E.g. PE, bacterial pneumonia, cancer, viral infection, pancreatitis

Signs and symptomsSigns: decreased chest movement , reduced breath sounds, dull to percussion (all on affected side)Symptoms: SOB, cough, chest pain

Investigations

Is there a pleural effusion?  CXR: white (fluid), CT scan, ultrasound, Listen to the chest: dull to percussion (tap on chest), reduced breath sounds What caused the pleural effusion?

 Thoracocentesis

.

Treatment

Depends on the underlying cause.

Aspirate / chest drain

Pleurodesis

Appearance

Protein

content

Transudate

Clear

<25g/L

Exudate

Cloudy

>29g/L