Show Menu
Cheatography
  1. Home >
  2. Home and Health >

Respiratory Conditions 1 Cheat Sheet (DRAFT) by

Respiratory Conditions: Presentation, DDx, investigations Pulmonary Embolism/Pneumonia/Pleurisy/Pleural Effusion/Pneumothorax

This is a draft cheat sheet. It is a work in progress and is not finished yet.

Pulmonary Embolism

-Disru­ption of the flow of blood in the pulmonary artery due to a thrombus
- Part of a thrombus in the leg (DVT) breaks off and travels to the lungs
- Other causes = air, fat, tumour cells

Causes

- Virchow's Triad: Hyperc­oag­ula­bility, venous stasis, endoth­elial injury
- Genetic
- Prolonged immobi­lis­ation: Bed rest >3 days, >4 hours travel, recent orthop­aedic surgery, malign­anct, venous catheter, obesity, pregnancy, smoking, oral contra­­ce­ptive pill
- F# of lower limb
- Hospit­ali­sation for heart failur­e/a­trial fibril­lat­ion­­/f­lutter within 3 months
- Hip/knee replac­­ement
- Major trauma
- Hx of previous DVT/PE
- Central venous lines
- Chemot­herapy
- Heart failur­e/r­esp­iratory failure
- Hormone replac­ement therapy
- Postpartum period
- Infection (UTI, pneumonia, HIV)
- Cancer ( Pancre­atic, haemto­log­ical, lung, gastric, brain highest risk)

Types

- Haemod­yna­mically unstable: PE that results in hypote­nsion (<9­0mmHg) or drop of systolic blood pressure of >40mmHg more likely to die from obstru­ctive shock (severe right ventri­cular failure)
- Haemod­yna­mically stable: Small can be sympto­mat­ic/­asy­mpt­omatic , mild hypote­nsion stablises with fluid therapy or right ventricle dysfun­ction

Pathology

- Can be multiple - lower lobes more affected
- Large ones obstruct pulmonary artery, smaller ones block peripheral arteries
- Impaired gas exchange occurs
- Mismatch in ventil­ation to perfusion ratio - dead space ventil­ation and hypoxemia
- Serotonin released - vasospasm and pulmonary flow further decreased
- Inflam­matory mediators - alteration of lung surfactant - hypocapnia and respir­atory alkalosis
- Right ventri­cular dilation and flatte­nin­g/b­owing of the interv­ent­ricular septum due to increased PVR
- RBB

Presen­tation

- Dyspnea
- Pleuritic chest pain (pleural irrita­tion)
- Cough
- Haemop­tysis
- Presyn­cop­e/s­yncope
- Arrhymias
- Haemod­ynamic collapse
- Assess risk factors with Virchows triad
- Tachypnea and Tachyc­ardia
- DVT signs (Calf swelli­ng/­red­nes­s/w­arm­ness), palpable cords, pedal oedema, rales, decreased breath sounds, pulmonary hypert­ension ( elevated neck veins, loud P2, right sided gallop, right ventri­cular parast­ernal lift)

Invest­iga­tions

- Arterial Blood Gas analysis - Widened alveol­ar-­art­erial gradient for oxygen, respir­atory alkalosis, hypocapnia
- Brain Natriu­retic Peptide (BNP) - RV pressure overload releases B-type natriu­retic peptide and N-terminal - proBNP (Blood test)
- Troponin - RV dysfun­ction
- D-Dimer (ELISA) - thrombotic process (high negative predictive value)
- ECG - usually nonspe­cific - tachyc­ardia, nonspe­cific ST and T-wave changes
- Chest X-ray - usually normal­/no­nsp­ecific, Hamptons hump, Wester­mark's sign
- Computed Tomogr­aphic Pulmonary Angiog­raphy (CTPA) -
-Lung Scinti­graphy
- Pulmonary Angiog­raphy
- MRA - low sensit­ivity, low availa­bility
- US for DVT

CXR

Left: Hampton's Hump: Dome/w­edged shaped opaque
Right: Wester­mark's sign lucency of the lung on x-ray due to lack of blood in the lung

CPR (Geneva)

- Previous PE/DVT - 3/1
- Heart Rate
- 75-94 BPM - 3/1
- >95 BPM - 5/2
- Surgery/f# within past month - 2/1
- Haemop­tysis - 2/1
- Active Cancer - 2/1
- Unilateral lower limb pulses - 3/1
- Pain on lower limb deep palpation and unilateral oedema - 4/1
- Age >65 years - 1/1
Three level score =
Low /0-3/0-1
Interm­edi­ate­/4-­10/2-4
High - >11­/>5

Two level score:
PE unlikely - 0-5/0-2
PE likely - >6/­>3

Management

- Send to A&E
- Antico­agu­lant: Heparin then oral antico­agulant therapy
- Prophy­laxis in severe cases

Pneumonia

- Acute inflam­mation of and around the alveolis and terminal bronch­ioles - neutro­phils
- Oedema and inflam­mation consol­idate the affected lobe
- Can be bacter­ial­/vi­ral­/fu­nga­l/p­ara­sitic

Pathogens

Viral:
Bacterial:
- Respir­atory Syncytial Virus (RSV)
- Strept­ococcus pneumoniae
- Rhinovirus
- Haemop­hilis influenzae
- Influenza A,B,C (A greatest cause of mortality)
- Staphy­loc­occus aureus
- Human Metapn­eum­ovirus (SARS)
- Group A strep
- Parain­fluenza 1,2,3,4
- Moraxella catarr­halis
- Human Bocavirus Corona­virus
- Anaerobes and aerobic gram negative bacteria
- Adenovirus
- Legionella
- Entero­viruses
- Mycoplasma pneumoniae
- Varice­lla­-Zoster virus
- Chlamydia pneumoniae
- Hantavirus
- Chlamydia psittaci
- Epstei­n-Barr (EBV)
- Human Herpes­virus 6 &7
- Herpes simplex virus
- Minimi virus Cytome­gal­ovirus (CMV)
- Measles
- MERS (Coron­avirus)
- Metapn­eum­ovirus

Causes

- Age (Young childr­en/­eld­erly)
- Pregnancy (usually viral)
- Immune compro­mised
- Chemot­her­apy­/Ra­diation
- Immuno­sup­presive medica­tions
- HIV/AIDS
- Inherited diseases :
- Trauma/ Severe burns
- Uncont­rolled diabetes
- Malnut­rition
- Poverty
- Enviro­nmental exposure
- Group living

Presen­tation

Viral:
Bacterial:
- Gradual
- Sudden
- No/lower temper­ature
- Purule­nt/­bloody sputum
- Hx of immuno­sup­pre­ssion
- Temper­ature (>38C) & increased RR (>18 breaths per minute)
- Hx of HIV
- Exposure to animals, crowds, water, air condit­ioning , aspiration
- Hx of solid organ/­hae­mto­poietic transp­lan­tation
- Tachyc­ard­ia/­Tac­hypnoea
- Hx of neoplasm
- Chills
- Flu/GI symptoms
- Myalgi­a/a­rth­ralgia
- Tachyc­ard­ia/­Tac­hypnea
- Fatigue
- Usually affects lungs bilate­rally
- Headache
 
- Atypical pneumonia presents with GI and altered mental state
 
- Pleuretic chest pain
Both: Dull on percus­sion, chest expansion reduced unilat­erally, crackles heard on auscul­tation (lung bases)
Sputum:
S.pneu­nomiae: Rust coloured
Pseudo­monas , haemop­hilius: Green
Kiebsella: Red currant jelly
Anaerobes: Foul smelling, bad tasting

Invest­iga­tions

Labora­tory:
- ELISA (viral)
- Blood cultures (not sensitive)
- CRP, ESR
- Urine testing
- Sputum culture
Chest X-ray - can differ­entiate between viral and bacterial pneumonia
- Chest CT - if normal chest x-ray and high suspicion of pneumonia (+ve parenc­hymal defects)

Chest X-ray

Bacterial:
Alveolar infilt­rates
Lobar consol­idation
Nodular densities
Pleural effusion
Viral:
Inters­titial infilt­rates - patchy and bilateral
X-ray usually unrema­rkable

Management

Viral:
Bacterial:
Influenza: Oselta­miv­ir/­pre­ami­vir­/za­namivir
Fluoro­qui­nol­one­/ma­crolide and beta-l­actam
RSV: Ribavirin
Stop smoking
Parain­flu­enza: Ribavirin
Hydration
HSV: Acyclovir
Chest physical therapy
Adenov­irus: Ribavirin
Upright position
Measles: Ribavirin
Nutrition
CMV: Gancic­lov­ir/­fos­carnet
Bronch­odi­lators
VZ: Acyclovir
Pulse oximetry monitoring

DDx

- Any other type of pneumonia
- Bronch­iti­s/B­ron­chi­ect­asi­s/b­ron­chi­olitis
- Sarcoi­dosis
- Amyloi­dosis
- Pulmonary oedema­/hy­per­ten­sio­n/e­mbo­lis­m/f­ibrosis
- Hyperr­eactive airway disease
- Aspiration of a foreign body
- Atelec­tasis
- Lung abscess
- Respir­atory failure
If in children consider: Asthma , Bronch­iol­itis, Croup, Respir­atory distress syndrome, Epiglo­ttitis as DDx

Prognosis

Viral:
Bacterial:
- Depends on virulence of the virus - hantav­irus, SARS, MERS worse prognosis
- Age (>60 most at risk)
- Immuno­com­pro­mised patient - HIV worse prognosis
- Comorb­idities
- Comorb­idities (COPD, CHF, Diabetes, cancer, haemat­olo­gical dyscrasias increase risk of death and compli­cat­ions)
- Antibiotic resistance of bacteria
- Presen­ce/­absence of concom­itant bacterial infection
- Type of bacteria - pseudo­monas, staphy­loc­occus aureus highest mortality
- Time between diagnosis and treatment

Compli­cations

Viral:
Bacterial:
- Abscess
- Respir­atory failure
- Empyema
- Sepsis­/me­nin­gitis
- Pleural effusion
- Multiorgan failure
- Sepsis
- Coagul­opathy
- Acute respir­atory failure
- Exacer­bation of preexi­sting conditions
- Cardio­vas­cular collapse
- Lung fibrosis
- Multiorgan failure
- Destru­ction of lung parenchyma
 
- Necrot­ising pneumona
 
- Cavitation
 
- Empyema
 
- Lung abscess

Pleurisy

- Localised chest pain
- Inflam­mation of the pleura
- Can be primary or secondary

Pleural anatomy

Pleural anatomy

- Visceral Pleura:
- Parietal pleura
- Surrounds lung tissue
- Lines inner chest wall
- Single mesoth­elial cells
- Contains stomata which drains pleural fluid to lymphatic capill­aries in connective tissue
- No connective tissue
- Innervated by interc­ostal nerves (sensory) + phrenic nerve
- Supplied by vagus nerve
- Sensitive to pain
- Both are supplied by the bronchial arteries
- Function is to allow fricti­onless movement between the chest wall and chest, helps expand the lung outwards during inspir­ation and prevents infection into the lungs
- A space inbetween the visceral and parietal pleura is where the pleural fluid lies (pleural cavity)

Causes

- Hypera­cute:
- Pneumo­thorax
- Acute coronary syndrome
- Pulmonary emboli
- Acute perica­rditis
- Chest wall trauma
- Acute: Viral and bacterial pneumonia
- Subacu­te/­Chr­onic:
- RA
- Malignancy (Metas­tases, pleural lymphoma, fibrous tumour, angios­arcoma, pleuro­pul­monary blastoma, synovial sarcoma, mesoth­elioma)
- Tuberc­ulosis

Presen­tation

- Sharp and localised thorac­ic/­sho­ulder pain
- Exacer­bated by coughing, sneezing, chest wall/trunk movement
- Can be dull, achy, burning or "­cat­chi­ng"
- Travel hx, alcohol use, tobacc­o/e­-ci­g/drug use
- +ve Friction rub in inspir­ation on auscul­tation (peric­ardial friction rub heard on both inspir­ation and expira­tion)
- Dullness to percussion
- Diminished breath sounds
- Vocal/­tactile resonance

Invest­iga­tions

- If pleurisy left sided acute coronary syndrome should be ruled out
- ECG, serum troponin
- Rule out acute perica­rditis and aortic dissection
- Blood count, serum protein, albumin, lactate dehydr­oge­nase, serum lipase (if acute pancre­atitis suspected)
- Sample of pleural fluid if effusion present (pH, Glucose, cell count, lactate dehydr­oge­nase, bacterial gram stain and cultures)
- Chest x-ray/CT

Management

- Treat underlying cause
- Drainage of the fluid to relieve pressure on the lungs

DDx

- Acute coronary syndrome
- Aortic dissection
- Pneumo­thorax
- Perica­rdial effusi­on/­tam­ponade
- PE
- Intrat­horacic malign­ancies
- Infection in the lung
- Perica­rditis

Pleural Effusion

- Accumu­lation of fluid between parietal and visceral pleura (pleural cavity)
- Fluid maintained by oncotic and hydros­tatic pressure and lymph drainage
- Pleural fluid can build up if one or more of the processes above is disturbed

Causes

- Fluid can be transudate and exudate
- Exudate if:
- Fluid protei­n/serum protein ratio >0.5
- Lactate dehydr­oge­nas­e(L­DH)­/serum LDH ratio >0.6
- Serum LDH >2/3 of upper limits of normal
- Exudate causes: Pulmonary infect­ions, malign­ancy, inflam­matory disorders (pancr­eat­itis, lupus, RA, post-c­ardiac injury syndrome, chylot­horax, haemot­horax, benign asbestos pleural effusion) , PE, drug induced, post-r­adi­oth­erapy, oesphageal rupture, ovarian hypers­tim­ulation syndrome (increased hydros­tatic pressure)
- Transu­dates: Congestive left heart failure, nephrotic syndrome, liver cirrhoris, hypoal­bum­inemia (distu­rbance of hydros­tat­ic/­oncotic pressure)

Presen­tation

- Usually asympt­omatic
- Exertional breath­les­sness
- Fullness of interc­ostal spaces
- Dullness on percussion
- Decreased breath sounds on auscul­tation
- Decreased tactile and vocal fremitus
- Pleural rub
- Look for underlying causes
- Medias­tinal shift (deviated trachea and apex beat)

Invest­iga­tions

- Chest X-ray : Meniscus sign (fluid located in costop­hrenic angle) + medias­tinal shift towards contra­lateral chest cavity, displa­cement of trachea ipsila­terally
- CT if malignancy
- Ultrasound of chest more sensitive
- Fluid analysis (pH, protein, albumin, LDH, glucose, cell count, gram stain, culture, cytology)
- Adenosine Deaminase (ADA) - Tuberc­ulosis

Management

- Addressing underlying cause
- Tube drainage + antibi­otics

DDx

- Congestive Heart Failure
- Diaphragm injury­/pa­ralysis
- Malignant mesoth­elioma
- Pneumonia
- Atelec­tasis

Prognosis

- Depends on the cause
- Malignant causes have very poor prognosis (deceased within 12-24 months)
- Recurrent effusions should be drained
- Large effusions should not be drained too quickly due to the risk of re-exp­ansion pulmonary oedema

Pneumo­thorax

- Air accumu­lates between parietal and visceral pleura
- Can apply pressure onto the lung and cause a collapse

Causes­/Risk factors

- Can be sudden­/tr­aumatic (blunt­/pe­net­rating)
Primary sponta­neous causes­/Risk factors:
- Smoking
- Tall, thin, young men
- Pregnancy
- Marfan syndrome
- Familial
Secondary sponta­neous:
- COPD
- Asthma
- HIV + pneumo­cystis pneumonia
- Necrot­ising pneumonia
- Tuberc­ulosis
- Sarcoi­dosis
- Cystic fibrosis
- Bronch­ogenic carcinoma
- Idiopathic pulmonary fibrosis
- Severe ARDs
- Langerhans cell histio­cytosis
- Lympha­ngi­ole­iom­yom­atosis
- Collagen vascular disease
- Cocain­e/m­ari­juana
- Thoracic endome­triosis
Iatrog­enic:
- Pleura­l/t­ran­sth­oracic lung biopsy
- Central venous catheter insertion
- Trache­ostomy
- Interc­ostal nerve block
- Positive pressure ventil­ation
Traumatic:
- Penetr­ati­ng/­blunt trauma
- Positive pressure ventil­ation (barot­rauma)
- Percut­aneous Trache­ostomy
- Sponta­neous pneumo­thorax
- Open pneumo­thorax

Pathology

- Pressure in the pleural space is negative compared to atmosp­heric pressure
- Pressure in the thorax changes with pneumo­thorax
- Surface tension between parietal and visceral pleurae causes the lung to expand outwards when chest wall expands
- Lung usually collapses during elastic recoil
- Air fills the space between the pleurae changing the pressure gradient

Presen­tation

- Can be asympt­omatic or minimal symptoms
- Chest pain (pleur­itic, sharp, severe, radiating to the ipsila­teral shoulder)
- SOB (more severe in sponta­neous secondary)
- Can recur on the contra­lateral side
- Increased respir­atory rate
- Asymme­trical lung expansion
- Decreased tactile fremitus
- Hyperr­esonant on percussion
- Decrea­sed­/absent breath sounds
- Tension pneumo­thorax: Tachyc­ardia >134 BPM
- Hypote­nsion
- Jugular venous distension
- Cyanosis
- Respir­atory failure
- Cardiac arrest

DDx

- Aspira­tio­n/b­act­eri­al/­viral pneumonia
- Aortic dissection
- Myocardial infarction
- Pulmonary embolism
- Acute perica­rditis
- Oesoph­ageal spasm/­rupture
- Rib fracture
- Diaphragm injuries

Invest­iga­tions

Chest X-ray/­US/CT
Red arrows = radiol­ucent areas of pneumo­thorax
Yellow arrows = Displaced lung parenchyma

Management

- Refer to GP if primary sponta­neous
- Tension pneumo­thorax is considered a medical emergency send to A&E

Prognosis

- Usually resolves on its own
- Can reoccur
- Sponte­neous secondary can be more deadly
- COPD and HIV higher mortality
- Tension pneumo­thorax mortality is high