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 male with a history of hypertension and hyperlipidaemia presents with a 4-week history of progressive shortness of breath, dry cough, and fatigue. He denies fever or chest pain. On examination, he is tachypnoeic with bilateral fine end-inspiratory crackles heard throughout both lung fields. Clubbing is noted on his fingers. His oxygen saturation is 90% on room air. Chest X-ray shows bilateral reticular opacities predominantly in the lower zones. Pulmonary function tests reveal a restrictive pattern with reduced diffusing capacity. What is the most likely diagnosis?
A 68-year-old man presents to the emergency department with a 3-day history of increasing shortness of breath, productive cough with yellow sputum, and subjective fever. He has a past medical history of chronic obstructive pulmonary disease (COPD) and is a current smoker. On examination, he is tachypnoeic at 24 breaths/minute, has a temperature of 38.2°C, and oxygen saturation of 90% on air. Auscultation reveals widespread expiratory wheeze and scattered crepitations in the right lower zone. A chest X-ray shows consolidation in the right lower lobe. His blood tests show a white cell count of 14 x 10^9/L and C-reactive protein of 120 mg/L. According to national guidelines, which of the following scores would be most appropriate to assess the severity of his community-acquired pneumonia and guide management?
A 24-year-old female with a known history of moderate persistent asthma presents to the emergency department with acute shortness of breath, wheezing, and chest tightness. She is sitting forward, using accessory muscles of respiration. Her respiratory rate is 28 breaths/minute, heart rate 110 beats/minute, and oxygen saturation is 91% on room air. Her peak expiratory flow rate (PEFR) is 40% of her best.
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