Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_2720_Библиотеки_им_академика_М_И_Перельмана
.pdf
264
https://t.me/med1917
264
CHAPTER10 Respiratorymedicine
Breathlessness
Dyspnoea Sensation of shortness of breath. Speed of onset helps diag-
nosis (Table 10.1). Try to quantify exercise tolerance (e.g. dressing, distance
walked, climbing stairs).
Acute breathlessness E p. 1068
Exertional dyspnoea Breathlessness with exercise. Causes are the same as
dyspnoea generally. The NewYork Heart Association classies the severity
of functional limitations in patients with heart failure:
• Class 1 Normal. No limitations
• Class 2 Slight limitation during ordinary activity
• Class 3 Marked limitation during less than ordinary activity, e.g. walking
short distances
• Class 4 Inability to do any activity. Symptoms present at rest
Orthopnoea Dyspnoea on lying at and relieved by sitting up. Associated
with left heart dysfunction, e.g. LVF.
Paroxysmal nocturnal dyspnoea Acute form of dyspnoea that causes the patient to awake from sleep. The patient is forced to sit upright or stand out
of bed for relief. Associated with pulmonary oedema.
Combined chest pain and dyspnoea Consider:
• MI
• Pericarditis
• Dissecting aneurysm
• Refer any patient with symptoms/ signs of superior vena cava obstruction (acute breathlessness, headache worse on stooping, swelling of the
face and/ or neck, with xed elevation of jugular venous pressure) for
immediate medical or oncology assessmentN.
Oer urgent CXR if ≥40y and ≥2 (or if smoker/ ex- smoker or history of asbestos exposure and ≥1) of the following unexplained symptoms:cough;
fatigue; shortness of breath; chest pain; weight d; appetite dN.
• PE
• Oesophageal pain
• Musculoskeletal pain
• Chest infection
• Pulmonary malignancy
Respiratory rate Normal values vary according to age:
• <1y:30– 40 breaths/ min
• 1– 2y:25– 35 breaths/ min
• 2– 5y:25– 30 breaths/ min
i respiratory rate Consider:
• Lung disease, e.g.
pneumonia, asthma
• Heart disease, e.g. LVF
d respiratory rate Consider:
• CNS disease, e.g. CVA • Drugs, e.g. opioids
• 5– 12y:20– 25 breaths/ min
• >12y:15– 20 breaths/ min
• Metabolic disease, e.g. ketoacidosis
• Drugs, e.g. salicylate overdose
• Psychiatric causes, e.g. hyperventilation
Pneumothorax E p. 1070
Hyperventilation May be fast (>20 breaths/ min) or deep (tidal
volumei). If inappropriate, results in palpitations, dizziness, faintness, tinnitus, chest pains, perioral and peripheral tingling (due to plasma Ca2+ d).
https://t.me/med1917
BREATHLESSNESS
Table10.1 Causes ofdyspnoea
Cause Acute Subacute Chronic
Cardiac
Acute LVF
disease
Arrhythmia
Acute MI
Aortic dissection
Tamponade
Lung
Acute asthma attack
disease
COPD exacerbation
Upper airway obstruction
Pneumonia
Acute pneumonitis, e.g.
due to inhaling toxic gas
Pulmonary embolus
Pneumothorax
Other Hyperventilation
Foreign body inhalation
Guillain– Barré syndrome
Altitude sickness
Ketoacidosis
Polio
Musculoskeletal pain
Oesophageal pain
Arrhythmia
Subacute bacterial
endocarditis
Pericarditis
Asthma
COPD exacerbation
Pneumonia
Pleural eusion
Lobar collapse
Aspirin poisoning
Myasthenia gravis
Thyrotoxicosis
Superior vena cava
obstruction
CCF
Valvular disease, e.g.
mitral stenosis
Congenital heart
disease
Asthma
COPD
Cystic brosis
Interstitial lung disease
Occupational lung
disease
Mesothelioma
Lung cancer
Kyphoscoliosis
Obesity
Anaemia
Neuromuscular
weakness, e.g. MND,
MS
Causes include:
• Anxiety (most common
cause)
• Early pulmonary oedema
• PE
• Hyperthyroidism
• Fever
• Lymphangitis
• Weakness of the
respiratory muscles
Kussmaul respiration Deep, sighing breathing that is principally seen in metabolic acidosis, e.g, diabetic ketoacidosis and uraemia.
Neurogenic hyperventilation Stroke, tumour, or CNS infection.
Hypoventilation Abnormally d pulmonary ventilation. Respiration may
be too slow or tidal volume d. Causes include:
• Respiratory depression, e.g. opioid analgesia, anoxia, trauma
• Neurological disease, e.g. Guillain– Barré disease; polio; motor neurone
disease; syringobulbia
• Lung disease, e.g. pneumonia, collapse, pneumothorax, pleural eusion
• Respiratory muscle disease, e.g. myasthenia gravis, dermatomyositis
• Limited chest movement, e.g. kyphoscoliosis
Cheyne– Stokes respiration Breathing becomes progressively deeper
and then shallower (± episodic apnoea) in cycles. Causes: brainstem lesions/
compression (stroke, i ICP); chronic pulmonary oedema; poor cardiac
output. It is enhanced by narcotics.
Further information
NICE (2015, updated 2017)Suspected cancer:recognition and referral.
Mwww.nice.org.uk/ guidance/ ng12
265
ALGRAWANY
266
https://t.me/med1917
266
CHAPTER10 Respiratorymedicine
Cough
A cough is a reaction to irritation anywhere from pharynx to lungs.
Acute cough (<3wk) Causes:
• URTI
• Croup
• Tracheitis
• Acute bronchitis
Reserve CXR for patients with marked focal chest signs or where inhalation
of foreign body or lung cancer is suspected.
Management Treat the cause where possible; steam inhalation often eases
symptoms temporarily; review if not clearing.
Reasons toprescribe antibiotics immediatelyN Investigate further and/ or give
antibiotics (e.g. amoxicillin 500mg tds/ clarithromycin 500mg bd/ doxycycline 100mg od) immediately if the patient:
• Is systemically very unwell or has symptoms/ signs suggestive of serious
illness and/ or complications, e.g. pneumonia
• Is at high risk of serious complications because of pre- existing co-
morbidity, e.g. signicant heart, lung, renal, liver, or neuromuscular
disease, immunosuppression, CF, and young children born prematurely
• Is aged >65y with acute cough and ≥2 or more of the following, or aged
>80y with acute cough and ≥1 of the following:
• Hospitalization in the previous year
• Type 1 or type 2 DM
• History of congestive heart failure
• Current use of oral glucocorticoids
Chronic cough (>3wk) Causes:
• Postnasal drip
• Post viral
• COPD/ asthma
• Lung cancer
• Pertussis
• TB
• Pneumonia— productive, loose cough
• Acute exacerbation of normally well- controlled
asthma
• Inhaled foreign body— especially in well children
• Bronchiectasis
• Pulmonary oedema
• Foreign body
• Vocal cord palsy
• GORD
• LVF
• Drug induced (e.g. ACE
inhibitors)
• Smoker’s cough
• Ear wax
• Psychogenic
• Idiopathic
H Red ags:Weight d, night sweats, fever, haemoptysis.
Management Oer an urgent CXR in those ≥40y if they have ≥2 (or if
smoker/ ex- smoker or exposed to asbestos and ≥1) of the following symptoms:cough; fatigue; shortness of breath; chest pain; weight d; appetite dN.
Treat the cause. If no cause is found, refer.
Sputum 0 Absolutely clear sputum is probably saliva.
• Smoking is the leading cause of excess sputum production— look for
black specks of inhaled carbon
• Yellow- green sputum is due to cell debris (bronchial epithelium,
neutrophils, eosinophils) and is not always infected
• Bronchiectasis causes copious greenish sputum
• Blood- stained sputum (haemoptysis) always needs full investigation
• Pink froth suggests pulmonary oedema
https://t.me/med1917
COUGH
Haemoptysis Expectoration of blood/ blood- stained sputum. Causes:
• Infection— bronchitis, pneumonia,
lung abscess, TB
• Violent coughing
• Bronchiectasis
• Lung cancer
• PE (blood is not mixed with sputum)
• Inhaled foreign body
• Iatrogenic:anticoagulation,
endotracheal tube
• Trauma
0 Dierentiate from haematemesis or local bleeding from the nasopharynx or sinuses. Melaena may occur if enough blood is swallowed.
Management Always requires investigation to nd the cause.
• Admit as an acute medical emergency if the patient is compromised by
the bleeding (i.e. tachycardia, low BP, postural drop) or has symptoms/
signs of a cause requiring acute admission (e.g. PE, acute LVF)
• Refer for urgent chest physician assessment if aged ≥40y with
unexplained haemoptysis
0 In patients with lung cancer who have a massive haemoptysis as a terminal event, consider treating with IV morphine/ diamorphine and a sedative (e.g. midazolam or rectal diazepam) rather than admitting.
N
• Cardiac:acute LVF, mitral stenosis
• Blood dyscrasia/ bleeding diathesis
• Idiopathic pulmonary
haemosiderosis
• Bronchial adenoma
• Mycosis, e.g. aspergilloma
• Goodpasture’s syndrome
• Collagen vascular disease, e.g. PAN,
granulomatosis with polyangiitis
• Idiopathic
Bronchiectasis Consider in patients with persistent or recurrent chest
infections. Permanently dilated bronchi act as sumps for infected mucus.
Causes:
• Congenital CF, Kartagener syndrome
• Post- infection TB, pertussis, measles, pneumonia
• Other Bronchial obstruction, aspergillosis (E p. 299),
hypogammaglobulinaemia (E p. 658), gastric aspiration
Presentation
• Mild cases Usually asymptomatic with winter exacerbations consisting
of fever, cough, purulent sputum, pleuritic chest pain, dyspnoea
• More severe cases Persistent cough and sputum, haemoptysis, clubbing,
low- pitched inspiratory and expiratory crackles and wheeze
Investigations CXR; sputum— M,C&S; spirometry— reversible airways obstruction is common; high- resolution CT detects disease in 97% of cases.
Management Refer to a respiratory physician. Treatment includes physiotherapy, antibiotics, bronchodilators, vaccination (inuenza and pneumococcal) and (rarely) surgery.
Further information
NICE (2008) Respiratory tract infections:antibiotic prescribing. M www.
nice.org.uk/ guidance/ cg69
NICE (2015, updated 2017)Suspected cancer:recognition and referral. M
www.nice.org.uk/ guidance/ ng12
267
ALGRAWANY
268
https://t.me/med1917
268
CHAPTER10 Respiratorymedicine
Chestsigns
Signs associated withcommon chest pathology Table 10.2
Chestdeformity
• Barrel chest The anteroposterior diameter of the chest is high
compared to the lateral diameter, and expansion is d. Ribs move
in a pump handle, up- and- down motion. Associated with chronic
hyperination (e.g. asthma or COPD)
• Pigeon chest (pectus carinatum) Prominent sternum and at chest
associated with history of chronic childhood asthma or rickets
• Funnel chest (pectus excavatum) The lower end of sternum is
depressed. Often inherited or idiopathic and usually harmless
• Kyphosis i forward spinal convexity usually aecting thoracic spine:
• Postural (‘drooping shoulders’ or ‘roundback’):is common and
voluntarily correctable
• Structural:cannot correct voluntarily. Causes: osteoporosis, Paget’s
disease, ankylosing spondylitis, Scheuermann’s disease. May cause a
restrictive ventilatory defect and eventually respiratory failure
• Scoliosis E p. 453
• Harrison’s sulcus Groove deformity of the lower ribs at the diaphragm
attachment site. Suggests chronic childhood asthma or rickets
• Scars Are there any scars indicative of previous chest surgery?
Chest expansion Expansion should be symmetrical and equal. If not,
suspect chest pathology (e.g. consolidation, collapse, pneumothorax, eusion) on the side with d movement.
Vocal fremitus orresonance
• i transmission implies consolidation. Even whispered sounds are heard
clearly with a stethoscope (whispering pectoriloquy)
• d transmission implies something in the way blocking the transmission
of sound. Consider:air (e.g. pneumothorax), uid (e.g. eusion), pleural
thickening (e.g. mesothelioma)
Percussion Dene any areas of dullness to percussion by percussing
from a resonant to dull area. Interpretation:
• i resonance— emphysema or pneumothorax (E p. 1070)
• d resonance— consolidation, collapse, abscess, tumour, brosis
• Stony dullness— pleural eusion
Breath sounds Assess character of breath sounds and added sounds:
• Bronchial breathing Breath sounds are harsher than normal and there
is an audible gap between inspiration and expiration— often caused by
lung consolidation, e.g. due to pneumonia
• d breath sounds Consider:pleural eusion, pneumothorax,
emphysema, lung collapse
• Added sounds Pleural rub; wheeze; crepitations/ crackles
Wheeze Musical sound heard during expiration.
• Polyphonic Narrowing of many small airways; typical of asthma/ COPD
• Monophonic Indicates single large airway obstruction, e.g. due to foreign
body or tumour
https://t.me/med1917
CHESTSIGNS
Crackles inthe chest Produced by air ow moving secretions.
• Fine crackles Consider pulmonary oedema (early inspiratory— usually
best heard at the lung bases at the back); early pneumonia; brosing
alveolitis (late inspiratory)
• Coarse crackles Consider TB; resolving pneumonia; bronchiectasis; lung
abscess
Pleural rub Creaking sound produced by movement of visceral over
parietal pleura when both are inamed (e.g. pneumonia, infarction).
Pleural eusion Fluid in the pleural cavity. Simple eusions may be tran-
sudates (<30g/ L protein) or exudates (>30g/ L protein). Eusions may also
be blood, lymph, or pus (empyema). Causes of simple eusion:
• Malignancy, e.g. lung cancer,
mesothelioma, Meig’s syndrome
• Infection, e.g. pneumonia, TB
• Infarction (pulmonary embolus)
• Heart failure
• Constrictive pericarditis
• Inammation, e.g. SLE, RA,
pancreatitis, asbestos exposure
• Hypoproteinaemia
• Hypothyroidism
Presentation May be incidental nding on CXR. Symptoms:dyspnoea, pleur-
itic pain, symptoms of underlying cause. Signs:absent breath sounds, dullness to percussion, d tactile vocal fremitus, d vocal resonance. Above the
eusion there is usually a zone of bronchial breathing. Early on there may be
a pleural rub. Large eusions shift the mediastinum away from the aected
side and there may be d chest wall movement. Conrm with CXR. If cause
is not apparent, refer for diagnostic tap.
Management Treat the underlying cause. Refer for drainage if symptomatic.
Repeated drainage ± pleurodesis may be necessary.
Surgical emphysema Air in the subcutaneous tissue. Can be caused
by spontaneous pneumothorax or trauma to the chest wall. Tissues appear
swollen and crackle on palpation
269
Table10.2 Chest signs associated withcommon chest pathology
Consolidation,
Mediastinum Not displaced Normal or
Expansion d d d d
Percussion Dull Stony dull Dull Hyper- resonant
Breath
sounds
Added
sounds
Other i vocal
e.g. pneumonia
Bronchial
breathing
Crackles ± rub Bronchial
resonance,
whispering
pectoriloquy
Pleural eusion Collapsed lung Pneumothorax
displaced away
from the eusion
d d d
breathing above
eusion
d vocal
resonance
Displaced
towards the
side of collapse
None None
Displaced away
from the side of
pneumothorax
d vocal
resonance
ALGRAWANY
270
https://t.me/med1917
270
CHAPTER10 Respiratorymedicine
Other signs ofrespiratorydisease
Thetrachea
• Palpate the trachea in the supraclavicular notch in the midline
• Deviation to the left or right suggests a shift of the upper mediastinum
to that side
• The distance between the suprasternal notch and cricoid cartilage in an
adult is 2– 3 nger breadths. If it is less than this, the lungs are probably
hyperinated
Weight loss Non- specic symptom or sign. Consider:
• GI causes Malabsorption, malnutrition, dieting
• Chronic disease Hyperthyroidism, DM, COPD, heart failure, renal disease,
degenerative neurological/ muscle disease, chronic infection (e.g. TB, HIV)
• Malignancy
• Psychiatric causes Depression, dementia, anorexia
• Oer an urgent CXRN to any patient aged ≥40y with unexplained
weight d if:
• Ever smoked or exposed to asbestos
• Never smoked but with any of the following:cough or fatigue or
shortness of breath or chest pain or appetite loss
Cachexia Severe generalized muscle wasting. Causes:neoplasia; malnu-
trition; chronic infection (e.g. TB); prolonged inactivity; dementia.
Night sweats Consider: TB; lymphoma; leukaemia; solid tumour (e.g.
renal carcinoma); menopause; anxiety states.
Erythema nodosum E p. 568
Peripheral oedema E p. 204
Horner’s syndrome Sympathetic nerve disruption to the iris causes:
• Small (meiotic) pupil with lack of pupil dilation in the dark
• Partial lid ptosis
• Anhidrosis of the forehead ±
• Enophthalmos
Causes
• Pancoast, cervical cord, or mediastinal tumour
• Aortic aneurysm
• Posterior inferior artery or basilar artery occlusion
• Hypothalamic lesion
• Syringomyelia
Pallor Check eyes/ mucous membranes for pallor suggesting anaemia.
Cyanosis Ep. 204
Persistent thrombocytosis E p. 636
Flapping tremor/ asterixis Bilateral motor disturbance. Ask the pa-
tient to hold his hands straight out in front of him and dorsiex his hands—
this provokes a apping, asynchronous tremor which is absent at rest. Due
to CO2 retention in severe COPD.
https://t.me/med1917
OTHER SIGNS OFRESPIRATORYDISEASE
Lymphadenopathy E p. 916
• Consider an urgent CXR in any patient ≥40y with supraclavicular
lymphadenopathy or persistent cervical lymphadenopathyN.
• Consider an urgent referral using a suspected cancer pathway if there
is an unexplained neck lump in a person ≥45y, or there is a persistent unexplained neck lump in a person <45yN.
Clubbing E p. 577
• Consider an urgent CXR to assess for lung cancer in people ≥40y with
nger clubbingN.
Yellow nails E p. 576
Hoarseness E p. 914
• Consider a suspected cancer pathway referral for laryngeal cancer in
people ≥45y with persistent unexplained hoarseness.
Stridor E p. 915
Jugular venous pressure E p. 205
Further information
NICE (2015, updated 2017)Suspected cancer:recognition and referral.
Mwww.nice.org.uk/ guidance/ ng12
271
ALGRAWANY
272
https://t.me/med1917
272
CHAPTER10 Respiratorymedicine
Respiratoryinvestigations
Indications forurgent CXR
• ≥2 (or if previously smoked or been exposed to asbestos ≥1) of the
following unexplained symptoms:cough; fatigue; shortness of breath;
chest pain; weight d; appetite d
• Any of the following Persistence of recurrent chest infection; nger
clubbing; supraclavicular or persistent cervical lymphadenopathy; chest
signs consistent with lung cancer or pleural disease; or thrombocytosis
Incidental ndings on CXR/ CT scan of emphysema/ signs of
chronic airways disease. Perform respiratory review and spirometry. Treat
according to results. If no symptoms + normal spirometry:
• If current smoker Oer smoking cessation advice (E p. 156); i risk of
COPD/ lung cancer; advise to return if new symptoms
• If non- smoker Ask about FH of lung/ liver disease— consider α1-
antitrypsin deciency (E p. 398); advise to return if new symptoms
Peak ow Simple and cheap test. Poor measure of airow limitation;
tends to overestimate lung function. Best used to monitor progress of
disease and eects of treatment for patients with asthma. Link with selfmanagement plan (E p. 281). Meters are available on NHS prescription—
EN 23747 (2007)/ EU standard peak ow meters are supplied. Charts are
available from NHS supplies (Form FP1010) and drug companies.
Measuring peak expiratory ow rate (PEFR) Normal values— Table10.4, (E
p. 274). Ask the patient to stand up (if possible) and hold the meter horizontally. Check the indicator is at 0 and the track is clear:
• Ask the patient to take a deep breath and blow out forcefully into the
peak ow meter ensuring lips are sealed rmly around the mouthpiece
• Read the PEFR o the meter. The best of 3 attempts is recorded
• Consider using a low- range meter if predicted/ best PEFR is <250L/ min
Spirometry Measures the volume of air the patient (adult or child >5y)
is able to expel from the lungs after a maximal inspiration.
• FEV1 Volume of air the patient is able to exhale in the rst second of
forced expiration
• FVC Total volume of air the patient can forcibly exhale in 1 breath
• FEV1/ FVC Ratio of FEV1 to FVC expressed as a %
Measuring FEV
Table 10.5, E p. 275. Sit the patient comfortably and ask the patient to
take a deep breath in:
• Ask the patient to blow the whole breath out as hard as possible until
there is no breath left to expel and ensuring lips are sealed rmly around
the mouthpiece. Encourage the patient to keep breathing out
• Repeat the procedure × 2 (i.e. 3 attempts in all); ≥2 readings should be
within 100mL or 5% of each other
Flow volume measurement Figure 10.1
0 In England, sta providing/ interpreting spirometry require certication
by March 2021. Competencies will be assessed every 3y.
and FVC Interpreting results— Table 10.3; normal values—
1
N
If ≥40y and:
https://t.me/med1917
RESPIRATORYINVESTIGATIONS
RCP 3 questions Useful tool to identify patients with poor asthma
control in general practice and monitor eect of changes of treatment.
Morbidity categories correlate with lung function.
In thelastmonth
• Have you had any diculty sleeping because of your asthma symptoms
(including cough)?
• Have you had your usual asthma symptoms during the day (cough,
wheeze, chest tightness, or breathlessness)?
• Has your asthma interfered with your usual activities, e.g. housework,
work/ school, etc.?
NO to all questions=low morbidity
1× YES answer=medium morbidity
2 or 3× YES answer=high morbidity
0 Alternatives include the Asthma Control Questionnaire (ACQ) and
Asthma Control Test (ACT)/ Children’s Asthma Control Test. These questionnaires are not designed for use during an acute attack.
Figure10.1 Flow– volume curves for patients with restrictive and obstructive lung disease
Reproduced from p.15 of the British Thoracic Society Guidelines Spirometry in Practice, with permission from the British Thoracic Society. www.brit- thoracic.org.uk
273
Table10.3 Interpretation ofspirometry results
Restrictive lung disease, e.g.
FEV1 (%of predicted normal) d (<80%) d (<80%)
FVC (%of predicted normal) d (<80%) Normal or d
FEV1/ FVC Normal (>70%) d (<70%)
Further information
interstitial lung disease
Obstructive lung
disease, e.g. COPD
ARTP/ BTS Certicate in spirometry. M www.artp.org.uk
British Thoracic Society (BTS) (2013) A guide to performing quality as-
sured diagnostic spirometry. M https:// www.brit- thoracic.org.uk/ media/
70454/ spirometry_ e- guide_ 2013.pdf
NICE (2015, updated 2017)Suspected cancer:recognition and referral. M
www.nice.org.uk/ guidance/ ng12
ALGRAWANY
Соседние файлы в папке Библиотека им академика М.И. Перельмана