Master Respiratory Medicine
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Core Concepts
Respiratory medicine focuses on conditions affecting the airways, lungs, pleura, and respiratory muscles, crucial for gas exchange (O2 uptake, CO2 excretion). Key physiological principles include ventilation (airflow), perfusion (blood flow), and the ventilation-perfusion (V/Q) ratio; V/Q mismatch is central to many respiratory pathologies. Spirometry assesses lung function, distinguishing obstructive patterns (reduced FEV1/FVC, e.g., asthma, COPD) from restrictive patterns (reduced FVC with normal or increased FEV1/FVC, e.g., ILD, chest wall disease). Respiratory failure is broadly classified into Type I (hypoxaemic, normal CO2) and Type II (hypoxaemic and hypercapnic). Understanding basic lung anatomy (trachea, bronchi, bronchioles, alveoli, pulmonary vasculature, pleura, diaphragm) is fundamental.
Clinical Presentation
- Cough: Acute (<3 weeks), subacute (3-8 weeks), chronic (>8 weeks). Productive (sputum colour/consistency) vs. non-productive. Causes: infection, asthma, COPD, GORD, ACE inhibitors, malignancy.
- Dyspnoea: Shortness of breath. Onset (sudden vs. gradual), severity, associated features (wheeze, chest pain), orthopnoea (cardiac failure), paroxysmal nocturnal dyspnoea (PND).
- Chest Pain: Pleuritic (sharp, worse on inspiration/cough, localised) suggests pleural irritation (pneumonia, PE, pneumothorax). Non-pleuritic (angina, musculoskeletal, GORD, anxiety).
- Wheeze/Stridor: Wheeze (expiratory, musical) indicates lower airway narrowing (asthma, COPD, bronchiectasis). Stridor (inspiratory, harsh) indicates upper airway obstruction (epiglottitis, foreign body, laryngeal tumour).
- Haemoptysis: Coughing up blood (streaks vs. frank blood). Causes: infection (bronchiectasis, TB), malignancy, PE, vasculitis.
- Systemic Symptoms: Fever, night sweats, weight loss (infection, malignancy), fatigue.
- Signs: Cyanosis, clubbing, lymphadenopathy. Tachypnoea, accessory muscle use, tracheal deviation, percussion (dullness - effusion/consolidation, hyper-resonance - pneumothorax/emphysema). Auscultation (crackles - fibrosis/oedema/consolidation, wheeze, rhonchi, pleural rub, absent breath sounds).
Diagnosis (Gold Standard)
Initial assessment often includes chest X-ray (CXR) for gross pathology (pneumonia, effusion, pneumothorax, tumour). Computed Tomography (CT) Thorax provides detailed anatomical information for masses, interstitial lung disease (ILD), bronchiectasis, and pulmonary embolism (PE, via CTPA). Spirometry (with reversibility) is the gold standard for diagnosing and monitoring obstructive airway diseases (Asthma, COPD) and restrictive patterns. Arterial Blood Gas (ABG) assesses oxygenation, ventilation, and acid-base status, critical for respiratory failure. Bronchoscopy with bronchoalveolar lavage (BAL) or biopsy is used for specific infections, malignancies, or ILD. Sleep studies (polysomnography) diagnose sleep apnoea. Pleural fluid analysis (differentiating exudate vs. transudate via Light's criteria) guides management of effusions. Tuberculin skin test (Mantoux) or Interferon-gamma release assay (IGRA) for TB screening, with sputum smears (AFB) and culture for active disease. ECG and echocardiogram are crucial to rule out cardiac causes of respiratory symptoms.
Management (First Line)
Asthma: Short-acting beta-agonists (SABA) for relief. Inhaled corticosteroids (ICS) as first-line maintenance, stepped up with long-acting beta-agonists (LABA) and/or long-acting muscarinic antagonists (LAMA) if uncontrolled. Oral corticosteroids for exacerbations. COPD: SABA/SAMA for relief, LAMA/LABA as maintenance. Oxygen therapy for chronic hypoxaemia. Smoking cessation is paramount. Pneumonia: Empirical antibiotics (e.g., Amoxicillin, Macrolide, Doxycycline) guided by CURB-65 score and local resistance patterns, refined with culture results. Pulmonary Embolism (PE): Anticoagulation (LMWH then DOAC/Warfarin) for most. Thrombolysis or surgical embolectomy for massive PE. Pneumothorax: Small, asymptomatic managed conservatively. Large or symptomatic requires needle aspiration or chest drain insertion. Pleural Effusion: Treat underlying cause. Therapeutic aspiration for symptomatic relief. Interstitial Lung Disease (ILD): Management is specific to the subtype (e.g., antifibrotics like Pirfenidone/Nintedanib for IPF, immunosuppression for CTD-ILD). Tuberculosis (TB): Multi-drug regimen (e.g., RIPE: Rifampicin, Isoniazid, Pyrazinamide, Ethambutol) for at least 6 months. Obstructive Sleep Apnoea (OSA): Continuous Positive Airway Pressure (CPAP).
Exam Red Flags
- Acute Severe/Life-Threatening Asthma: PEF <50% best/predicted, silent chest, exhaustion, confusion, altered consciousness. Immediate oxygen, high-dose nebulised SABA, systemic corticosteroids.
- Tension Pneumothorax: Sudden onset severe dyspnoea, pleuritic chest pain, tracheal deviation away from affected side, hyper-resonance, absent breath sounds, hypotension. Immediate needle decompression, then chest drain.
- Massive Pulmonary Embolism: Sudden onset dyspnoea, syncope, hypotension (systolic BP <90mmHg), persistent hypoxaemia. Consider thrombolysis.
- Upper Airway Obstruction (Stridor): Foreign body, acute epiglottitis, laryngeal tumour. Urgent airway management.
- Severe Haemoptysis: Coughing >100ml blood/hour or total >600ml/24 hours. Risk of airway compromise. Urgent bronchoscopy, embolisation, or surgery.
- Acute Respiratory Distress Syndrome (ARDS): Severe hypoxaemia refractory to oxygen, bilateral pulmonary infiltrates on CXR, non-cardiogenic oedema. Requires ventilatory support.
- Persistent Unilateral Wheeze: Always raises concern for an endobronchial lesion (e.g., foreign body in children, tumour in adults).
- New onset Clubbing: In an adult, investigate thoroughly for malignancy (lung cancer), bronchiectasis, or IPF.
- Sudden Deterioration in known COPD: Consider pneumothorax, PE, or severe infective exacerbation.
Sample Practice Questions
A 68-year-old retired factory worker presents with a 6-month history of progressive breathlessness and a dry cough. He worked in shipbuilding for 30 years, fabricating insulation materials. On examination, there is finger clubbing and bilateral fine inspiratory crackles at the lung bases. Pulmonary function tests show a restrictive defect with reduced diffusion capacity. A chest X-ray reveals bilateral pleural plaques and diffuse reticulonodular shadowing, predominantly in the lower zones. Which of the following is the most likely diagnosis?
A 45-year-old non-smoker female presents with a 2-month history of worsening cough, occasional haemoptysis, and recurrent fever. She also reports migratory joint pains and a violaceous skin rash on her lower limbs. Physical examination reveals audible wheezing and tender subcutaneous nodules on her shins. Laboratory tests show elevated ESR and CRP. Chest X-ray demonstrates transient, migratory pulmonary infiltrates. Renal function tests are normal. Which of the following conditions is the most likely diagnosis?
A 28-year-old woman with a known history of asthma presents to the emergency department with acute shortness of breath, wheeze, and cough. She is struggling to speak in full sentences. Her respiratory rate is 28 breaths/min, heart rate 110 bpm, blood pressure 130/80 mmHg, and oxygen saturation is 92% on room air. Peak expiratory flow rate (PEFR) is measured at 40% of her best. On auscultation, widespread polyphonic wheeze is heard. What is the most appropriate IMMEDIATE initial management step?
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