Respiratory Medicine
6 things to always ask in Respiratory History
1. Shortness of breath
2. Chest pain
3. Wheeze
4. Stridor
5. Fever
6. Cough
7. Occupational history and exposure (asbestos, silicois, pneumoconiosis)
Type 1 penumocytes: blood gas barrier
Type 2 pneumocytes: produce surfactant and cell division
Lung ultrasound:
• A lines: parallel to the ultrasound probe (horizontal on the screen)
• B lines: perpendicular to the ultrasound probe (vertical downwards on the screen)
o May be normal in individuals, but number and intensity of B lines is
directly proportional to degree of pulmonary, septal, or alveolar edema
(Radiological diagnosis of flail chest: 3 contiguous ribs with at least 2 breaks in each rib)
Anyone 50-60yo with subcutaneous emphysema and NO penetrating injuries needs to be
careful when inserting chest tube. MUST be CHECKED for lung adhesions prior with finger
sweeping!
Anyone with tracheastomy and bleeding, PLEASE CALL the CONSULTANT
Hamman sign: A crunching rasping sound synchronous with heartbeat, heard over
precordium in spontaneous mediastinal emphysema
Any patient with haemoptysis SHOULD BE ON ANTIBIOTICS!
Any lung collapse in a patient 50y and over is always an obstructing lesion until proven
otherwise. If there is tracheostomy or intubated or in children with asthma, think about
mucous plugging!
Bohr effect: dissociation of O2 from Hb (body parts)
• Increased dissocation;
o Decrease pH
o Increase CO2
o Increase Temperature
o Increase 2,3 DPG
o Increase exercise
Haldane effect: O2 binding effect on CO2 dissociation (Lungs)
• Decreased CO2 transport:
o Binding of O2 causes displacement of CO2 bound to Hb
o Binding of O2 render the O2 more acidic and hence cause release of H+ in
the blood. The equilibrium buffering system of the blood will then favour
towards CO2 and Water. Hence causing CO2 to be formed
Basic respiratory investigations:
• Bloods: FBE, UEC, LFT, ESR, CRP, ABG, VBG, CMP,
• Bedside: Sputum MCS, throat swaps, PEFR,
• Imaging: CXR, CTPA, VQ scan, CT chest
• Special: spirometry (lung function test)
CXR: If opacification in the right hemidiaphragm, will be the right lower lobe, if right heart
border may be right middle lobe, if left hemidiagphram obscured, will be left lower lobe. If left
heart border may be lingual.
, • Calcified nodules: varicella pneumonitis, Wegener, TB, histoplasmosis, chronic renal
failure
When using examination signs to think of differentials: Always use the following
• General inspection
• Tracheal deviation
• Chest expansion and chest wall movement
• Percussion tone
• Air entry
• Vesicular breathing sounds +/- bronchial breathing sounds +/- adventitious sounds
• Vocal resonance
Salbutamol puffer: 100-200mcg per puff, 2.5-5mg nebulised salbutamol
Ipratropium puffer: 21mcg per puff, 500mcg nebulised ipratropium
Complex 4 (AKA cytochrome C oxidase) found in mitochondria of cells: carbon monoxide,
cyanide and azide will bind to these particles and inhibit oxygen from binding to the active
sides in hemoglobin
CLUBBING: fibrosis, cancer in the lungs and any cause of PUS! NOT COPD!
Cardiovascular Respiratory GIT Misc
Cyanotic CHD Suppurative: IBD Thryotoxicosis
Infective endocarditis Empyema Celiac disease Secondary
Atrial myxoma Lung abscess Cirrhosis hyperparathyroidism
CF Axillary artery
Bronchiectasis aneurysm
Non suppurative:
NSCLC
Fibrosing alveolitis
Interstitial fibrosis
Asbestosis
Pleural mesothelioma
Causes of crackles
• Early and coarse: COPD
• Late
o Fine: fibrosis
o Medium: LV failure
o Coarse: bronchiectasis, retained secretions
Signs of CO2 retention:
• Warm peripheries
• Tachypnoea
• Tachycardia, bounding pulse (caused by reflex vasodilation to provide adequate
tissue perfusion, sign of acute CO2 retention)
• Asterixis +/- confusion
• Raised BP
• Reduced neural activity
• Papilloedema
Signs of hypoxia
• SOB
• Restlessness
• Central cynosis
• Tachycardia
• Pulmonary hypertension, cor pulmonale
Causes of atelectasis
• Luminal: mucus plug, blood, FB
, • Mural: carcinoma
• Extramural: LN, cancer, granulomata (TB, sarcoid)
Anatomical extent of respiratory tract:
• Upper: nasopharynx to larynx
• Lower: larynx and below
Red flags of signs of sick child with respiratory disease
• Hypoxia: drowsiness, irritability
• Increased RR, noisy breathing
• Cold extremities, delayed capillary refill (>2s)
Disease Organism
Bronchiolitis RSV and PAM (Parainfluenza, Adenovirus, mycoplasma)
Croup Parainfluenza virus 1
Common influenza Influenza A/B
Common cold Rhinovirus, adenovirus, parainfluenza, RSV, coronavirus
Whooping cough Bordetella pertussis
Epiglottitis Haemophilus influenzae type B
Avian influenza H5N1
Swine flu H1N1
SARS Coronavirus
Bornholm disease Coxsackie B: Epidemic pleurodynia/myalgia (fever, headache,
(Pleurodynia) severe chest pain or upper tummy pain with slightest chest wall
movement) flu like symptoms
Flu diagnosis
• 2 days of URTI symptom with at least 2 symptoms on at least 1 day and fever on at
least1 day
Epidemic:
• Fever >38 degrees
• At least 1 respiratory symptom (dry cough, sore throat, coryza)
• At least 1 systemic symptom (prostration/weakness, muscle aches, headache,
rigors/chill)
<6m 2y 21y
RR 45 30 15
HR 120-140 110 60-100
Obstruction VQ mismatch Increased breathing effort Ventilation failure
Wheeze Hypoxemia Tachypnoea Hypercarbia
Hyperinflation Central cyanosis Failure of speech Restlessness
Tachycardia Accessory muscle use Flushing
Arrhythmia SOB and distress Bounding pulse
Upright posture Exhaustion
Sweating Altered level of
Pulsus paradoxus consciousness
Coma and death
Red flags in examinations:
1. Inability to speak in sentences, phrases, words
2. “silent chest” implies poor air movement and imminent respiratory arrest in a sick
respiratory patient
3. Noted pursed lips (adults): PEEP to increase oxygenation
4. Grunting expiration and nasal flare in children
What are the accessory muscles
• Scalene: anterior, middle, posterior
• SCM
• Abdominal muscles
, Other muscles involved in breathing:
• Serratus anterior/posterior
• Pectoralis major/minor
• Trapezius
• Lattissimus dorsi
• Back muscles
• Subclavius
Tree in bud sign on chest CT:
• Bronchioles filled with pus or inflammatory exudate: TB, aspiration pneumonia
• Bronchiolitis thickening of bronchiolar walls and bronchovascular bundle: CMV,
obliterative bronchiolitis
• Bronchiectasis with mucus plugging: cystic fibrosis
• Tumour emboli to entriloubular arteries: breast cancer, stomach cancer
• Bronchoascular interstitial infiltration: sarcoidosis, lymphoma, leukemia
Approach to Tachypnoea
On the phone:
• Key informaito
• Patient (3x info)
• Bed card
• Reason for admissio
• What is nurses concerned with?
• Length of symptoms – sudden onset?
• Vital sign
• DDx: common causes, life-threatening causes
• Key red flags: cyanmosed (central or peripheral), haemoptysis (?large/small volume,
large is 100mL), chest pain, pre-syncope, low GCS
o Call MET call when MET call criteria is present
o PRIORITISE: Upper airway compromise, SOB, massive haemoptysis (can
get stuck in dead space and eventually lead to asphyxiation
• PMH: Smoer, COPD, Heart failure, asthma, CO2 retainer
• Medications: clexane, antibiotics, analgesia, sedatives
Other DDx:
• Upper airway obstruction (stridor)
• Metabolic acidosis (DKA, sepsis)
• NM weakness (GBS, myasthenia gravis, muscular dystrophy)
• Anaemia
• Hyperthyroidism
• Poisoning (aspirin, CO, mathaemoglobinamia: doesn't shift )
• Massive ascites
• Pregnancy (Physiological tachypnoea)
• Anxiety (diagnosis of exclusion ONLY)
For nurses:
• Oxygen targets
• ECG
• Sputum culture
• Blood culture
• ABG
• Trolley for IV
• Portable CXR
• Trial salbutamol, analgesia, SL GTN
• SOAP structure
6 things to always ask in Respiratory History
1. Shortness of breath
2. Chest pain
3. Wheeze
4. Stridor
5. Fever
6. Cough
7. Occupational history and exposure (asbestos, silicois, pneumoconiosis)
Type 1 penumocytes: blood gas barrier
Type 2 pneumocytes: produce surfactant and cell division
Lung ultrasound:
• A lines: parallel to the ultrasound probe (horizontal on the screen)
• B lines: perpendicular to the ultrasound probe (vertical downwards on the screen)
o May be normal in individuals, but number and intensity of B lines is
directly proportional to degree of pulmonary, septal, or alveolar edema
(Radiological diagnosis of flail chest: 3 contiguous ribs with at least 2 breaks in each rib)
Anyone 50-60yo with subcutaneous emphysema and NO penetrating injuries needs to be
careful when inserting chest tube. MUST be CHECKED for lung adhesions prior with finger
sweeping!
Anyone with tracheastomy and bleeding, PLEASE CALL the CONSULTANT
Hamman sign: A crunching rasping sound synchronous with heartbeat, heard over
precordium in spontaneous mediastinal emphysema
Any patient with haemoptysis SHOULD BE ON ANTIBIOTICS!
Any lung collapse in a patient 50y and over is always an obstructing lesion until proven
otherwise. If there is tracheostomy or intubated or in children with asthma, think about
mucous plugging!
Bohr effect: dissociation of O2 from Hb (body parts)
• Increased dissocation;
o Decrease pH
o Increase CO2
o Increase Temperature
o Increase 2,3 DPG
o Increase exercise
Haldane effect: O2 binding effect on CO2 dissociation (Lungs)
• Decreased CO2 transport:
o Binding of O2 causes displacement of CO2 bound to Hb
o Binding of O2 render the O2 more acidic and hence cause release of H+ in
the blood. The equilibrium buffering system of the blood will then favour
towards CO2 and Water. Hence causing CO2 to be formed
Basic respiratory investigations:
• Bloods: FBE, UEC, LFT, ESR, CRP, ABG, VBG, CMP,
• Bedside: Sputum MCS, throat swaps, PEFR,
• Imaging: CXR, CTPA, VQ scan, CT chest
• Special: spirometry (lung function test)
CXR: If opacification in the right hemidiaphragm, will be the right lower lobe, if right heart
border may be right middle lobe, if left hemidiagphram obscured, will be left lower lobe. If left
heart border may be lingual.
, • Calcified nodules: varicella pneumonitis, Wegener, TB, histoplasmosis, chronic renal
failure
When using examination signs to think of differentials: Always use the following
• General inspection
• Tracheal deviation
• Chest expansion and chest wall movement
• Percussion tone
• Air entry
• Vesicular breathing sounds +/- bronchial breathing sounds +/- adventitious sounds
• Vocal resonance
Salbutamol puffer: 100-200mcg per puff, 2.5-5mg nebulised salbutamol
Ipratropium puffer: 21mcg per puff, 500mcg nebulised ipratropium
Complex 4 (AKA cytochrome C oxidase) found in mitochondria of cells: carbon monoxide,
cyanide and azide will bind to these particles and inhibit oxygen from binding to the active
sides in hemoglobin
CLUBBING: fibrosis, cancer in the lungs and any cause of PUS! NOT COPD!
Cardiovascular Respiratory GIT Misc
Cyanotic CHD Suppurative: IBD Thryotoxicosis
Infective endocarditis Empyema Celiac disease Secondary
Atrial myxoma Lung abscess Cirrhosis hyperparathyroidism
CF Axillary artery
Bronchiectasis aneurysm
Non suppurative:
NSCLC
Fibrosing alveolitis
Interstitial fibrosis
Asbestosis
Pleural mesothelioma
Causes of crackles
• Early and coarse: COPD
• Late
o Fine: fibrosis
o Medium: LV failure
o Coarse: bronchiectasis, retained secretions
Signs of CO2 retention:
• Warm peripheries
• Tachypnoea
• Tachycardia, bounding pulse (caused by reflex vasodilation to provide adequate
tissue perfusion, sign of acute CO2 retention)
• Asterixis +/- confusion
• Raised BP
• Reduced neural activity
• Papilloedema
Signs of hypoxia
• SOB
• Restlessness
• Central cynosis
• Tachycardia
• Pulmonary hypertension, cor pulmonale
Causes of atelectasis
• Luminal: mucus plug, blood, FB
, • Mural: carcinoma
• Extramural: LN, cancer, granulomata (TB, sarcoid)
Anatomical extent of respiratory tract:
• Upper: nasopharynx to larynx
• Lower: larynx and below
Red flags of signs of sick child with respiratory disease
• Hypoxia: drowsiness, irritability
• Increased RR, noisy breathing
• Cold extremities, delayed capillary refill (>2s)
Disease Organism
Bronchiolitis RSV and PAM (Parainfluenza, Adenovirus, mycoplasma)
Croup Parainfluenza virus 1
Common influenza Influenza A/B
Common cold Rhinovirus, adenovirus, parainfluenza, RSV, coronavirus
Whooping cough Bordetella pertussis
Epiglottitis Haemophilus influenzae type B
Avian influenza H5N1
Swine flu H1N1
SARS Coronavirus
Bornholm disease Coxsackie B: Epidemic pleurodynia/myalgia (fever, headache,
(Pleurodynia) severe chest pain or upper tummy pain with slightest chest wall
movement) flu like symptoms
Flu diagnosis
• 2 days of URTI symptom with at least 2 symptoms on at least 1 day and fever on at
least1 day
Epidemic:
• Fever >38 degrees
• At least 1 respiratory symptom (dry cough, sore throat, coryza)
• At least 1 systemic symptom (prostration/weakness, muscle aches, headache,
rigors/chill)
<6m 2y 21y
RR 45 30 15
HR 120-140 110 60-100
Obstruction VQ mismatch Increased breathing effort Ventilation failure
Wheeze Hypoxemia Tachypnoea Hypercarbia
Hyperinflation Central cyanosis Failure of speech Restlessness
Tachycardia Accessory muscle use Flushing
Arrhythmia SOB and distress Bounding pulse
Upright posture Exhaustion
Sweating Altered level of
Pulsus paradoxus consciousness
Coma and death
Red flags in examinations:
1. Inability to speak in sentences, phrases, words
2. “silent chest” implies poor air movement and imminent respiratory arrest in a sick
respiratory patient
3. Noted pursed lips (adults): PEEP to increase oxygenation
4. Grunting expiration and nasal flare in children
What are the accessory muscles
• Scalene: anterior, middle, posterior
• SCM
• Abdominal muscles
, Other muscles involved in breathing:
• Serratus anterior/posterior
• Pectoralis major/minor
• Trapezius
• Lattissimus dorsi
• Back muscles
• Subclavius
Tree in bud sign on chest CT:
• Bronchioles filled with pus or inflammatory exudate: TB, aspiration pneumonia
• Bronchiolitis thickening of bronchiolar walls and bronchovascular bundle: CMV,
obliterative bronchiolitis
• Bronchiectasis with mucus plugging: cystic fibrosis
• Tumour emboli to entriloubular arteries: breast cancer, stomach cancer
• Bronchoascular interstitial infiltration: sarcoidosis, lymphoma, leukemia
Approach to Tachypnoea
On the phone:
• Key informaito
• Patient (3x info)
• Bed card
• Reason for admissio
• What is nurses concerned with?
• Length of symptoms – sudden onset?
• Vital sign
• DDx: common causes, life-threatening causes
• Key red flags: cyanmosed (central or peripheral), haemoptysis (?large/small volume,
large is 100mL), chest pain, pre-syncope, low GCS
o Call MET call when MET call criteria is present
o PRIORITISE: Upper airway compromise, SOB, massive haemoptysis (can
get stuck in dead space and eventually lead to asphyxiation
• PMH: Smoer, COPD, Heart failure, asthma, CO2 retainer
• Medications: clexane, antibiotics, analgesia, sedatives
Other DDx:
• Upper airway obstruction (stridor)
• Metabolic acidosis (DKA, sepsis)
• NM weakness (GBS, myasthenia gravis, muscular dystrophy)
• Anaemia
• Hyperthyroidism
• Poisoning (aspirin, CO, mathaemoglobinamia: doesn't shift )
• Massive ascites
• Pregnancy (Physiological tachypnoea)
• Anxiety (diagnosis of exclusion ONLY)
For nurses:
• Oxygen targets
• ECG
• Sputum culture
• Blood culture
• ABG
• Trolley for IV
• Portable CXR
• Trial salbutamol, analgesia, SL GTN
• SOAP structure
