Table Of Contents
Normal
Hemoptysis
- Etiology:
- Important features on Hx:
- Risks:
- Physical Exam:
- DDX (BATTLE CAMP):
- DDX:
- Airway Disease
- -bronchitis
- -bronchiectasis
- -neoplasm
- -trauma
- -foreign body
- Parenchymal disease
- -TB
- -lung abscess
- -fungal infection
- -neoplasm
- Vascular
- -PE
- -AVM
- -vasculitis
- -pulm htn
- -Aortic aneurysm
- Hematologic
- -DIC
- -coagulopathy
- -thrombocytopenia
- Cardiac
- -congenital
- -valvular
- -endocarditis
- Infectious:
- other
- -cocaine
- -tracheal arterial fistula
- Airway Disease
- Work-Up:
- Intubation strategies for hemoptysis:
- Tracheo-innominate artery fistula:
Massive Hemoptysis
- Etiology:
- DDX:
- – cancer
- – vasculitis
- – pulmonary AVM
- – bronchiectasis
- – TB
- – mycetoma
- Rule out non-pulmonary sources of bleeding
- -mouth, nose, GI tract
- – cancer
- Diagnosis:
- -H&H
- -PT/INR
- -PTT
- -CBC &Diff
- -UA/ creatinine
- -CXR
- -CT: abnormal CXR findings OR persistent hemoptysis despite a normal CXR
- Management:
- Dependent positioning if side of bleeding can be identified
- Secure airway (intubation)
- low threshold for intubation
- bleeding side down
- can use a double lumen tube to ventilate one lung
- Stabilize cardiovascular function (IV fluids/transfusion)
- Stop bleeding
- Urgent surgical intervention
- -thoracotomy
Lungs Sounds
- Hyper-resonant percussion
- Vesicular breathing
- Bronchovesicular breathing
- Bronchial breathing
- Tracheal breathing
- Fine crackles
- Coarse crackles
- Wheezes
- Ronchi
- Stridor
- Pleural friction rub
- Muffled or absent breath sounds
- Bronchophony
- Egophony
- Whispered pectoriloquy
- Consolidation
Bronchiectasis
- Presentation:
- Diagnostic:
Tuberculosis
- Etiology:
- Reactivation TB Presentation:
- Diagnostic:
Aspergilloma
Atelectasis
- Presentation:
Bronchial Asthma
- Presentation:
- Main symptom: Paroxysmal attacks of dyspnoea and wheezing
- Movement of the chest wall: Symmetrical
- Tactile fremitus:
- Depends on the severity
- Normal or an overinflated (emphysematous) lung; occasionally pneumonia as well
- Percussion: Hyper-resonant
- Bronchophony:
- Depends on the severity
- Normal or an overinflated (emphysematous) lung; occasionally pneumonia as well
- Breath sounds: Wheeze, a prolonged expiratory phase with decreased breath sounds
Chronic Exertional Dyspnea
- Presentation:
COPD
- Etiology:
- Path:
- Chronic bronchitis
- Emphysema
- COPD Risk Factors:
- – tobacco
- – indoor and outdoor air pollution
- – occupational exposures
- – genetic
- – age and sex
- – lung growth and development
- – socioeconomic status
- – asthma and airway hyperreactivity
- – chronic bronchitis
- – infections (history of severe childhood respiratory infection OR recurrent lower respiratory tract infection)
- – tobacco
- Presentation:
- Diagnosis:
- Classification of COPD:
- Classification of Groups:
- Goals of therapy:
- Management:
- Group A:
- Group B:
- 1. LAMA or LABA
- – if persistent breathlessness on monotherapy, move to 2 bronchodilators
- 2. LAMA and LABA
- – if adding the second bronchodilator does not improve symptoms
- – May step down to monotherapy
- – likely to have co-morbidities that add to their symptoms
- – should be investigated and treated
- 1. LAMA or LABA
- Group C:
- Group D:
- 1. LAMA
- 2. LAMA and LABA (recommended) OR LABA and ICS
- – two agents better than single agents
- – LAMA/LABA better at preventing exacerbations and patient-reported outcomes
- – ICS — risk of developing pneumonia
- – LABA and ICS — first choice for asthma and COPD overlap
- 3. LAMA/LABA/ICS (recommended)
- – can add roflumilast if FEV <50%, chronic bronchitis and have 1 or more exacerbation
- – can add macrolide in former smokers
- Benefits of LABA and LAMA:
- – improve lung function, dyspnea, health status, exacerbation rates
- – LAMA have a greater effect on exacerbation reduction than LABA
- – combination of LABA and LAMA reduce symptoms more than monotherapy
- Tiotropium —> a LAMA can improve the effectiveness of pulmonary rehabilitation in increasing exercise performance
- Inhaled corticosteroids in COPD:
- Antibiotics in COPD:
- Theophylline in COPD:
- Non-pharmacological therapy:
- Education and self-management:
- Vaccination:
- Oxygen therapy:
- Long term oxygen therapy is indicated for stable patients who have:
- 1. PO2 less than 55mmHg and SaO2 at or below 88%, without hypercapnia confirmed twice over a three week period
- 2. PaO2 between 55-60mmHg or SaO2 88%
- – If there is evidence of pulmonary hypertension, peripheral edema
- – suggesting congestive cardiac failure or polycythemia
- Long term oxygen therapy is indicated for stable patients who have:
- Monitoring and follow up focus on:
COPD Exacerbation
- Etiology:
- MC Causes:
- Assessment:
- History:
- Presentation:
- Physical Examination:
- Goal of treatment for exacerbation:
- Classification of severity:
- No respiratory failure:
- Acute respiratory failure (not life-threatening):
- Acute respiratory failure (life-threatening):
- Oxygen therapy for exacerbation:
- Bronchodilator for exacerbation:
- Corticosteroids (systemic) for exacerbations:
- Theophylline for exacerbations:
- Antibiotics requirements for exacerbation:
- – controversy: viral infections is as common as bacterial infections and patients can be colonized with bacteria but not causing infections, overuse of antibiotics: results in the spread of resistant organisms
- – has to have 3 cardinal symptoms: worsening dyspnea, increased sputum purulence, increased sputum volume
—> can be just 2 cardinal symptoms with increased sputum purulence is one of them - – other indicators of infection: fever, increased WBC, change in chest X-ray
- Antibiotics options for exacerbation:
- Discharge criteria:
- – off the parental drug for 12-24 hours
- – inhaled bronchodilators no more than once every 4h
- – maintenance therapy with Long-acting bronchodilators should be initiated as soon as possible before hospital discharge
- – stable for 12-24 hours
- – able to walk short distances
- – understand the correct use of medication + inhaler technique
- – follow up appointments
- Intervention that can reduce the frequency of exacerbation:
Emphysema
Lung Fibrosis
- Presentation:
Paroxysmal Nocturnal Dyspnea
Pleural Effusion
Pneumothorax
- Risks:
- Recurrence
- Presentation:
- Types:
- Physical Exam:
- Diagnosis:
- Goals:
- Management:
Pneumonia
- Types:
- CAP:
- HAP:
- Aspiration Pneumonia:
- Presentation:
- Work-Up:
- Management:
Pulmonary Edema
Pulmonary Embolism
- Presentation: