Acute Respiratory Flashcards
1
Q
Investigations of asthma:
A
> = 17yo:
- obstructive spirometry with BDR (FEV1 improvement 12% and increased volume 200ml)
- FeNO test (>=40ppb positive)
5-16yo:
- obstructive spirometry with BDR (improvement FEV1 12%)
- FeNO (>=35 ppb positive) if normal spirometry or negative BDR
2
Q
Asthma management steps:
A
- SABA
- SABA + low dose ICS (not controlled or newly diagnosed with symptoms >=3/week or night time waking)
- SABA + ICS + leukotriene receptor antagonist
- SABA + ICS + LABA
- SABA +/- LTRA + MART (low dose ICS/LABA)
- SABA (+LTRA) with increased dose ICS or trial LAMA or theophylline
3
Q
What is MART?
A
- combined ICS and LABA for maintenance therapy and reliever
- LABA must have fast acting component e.g. formoterol
4
Q
Inhaler technique:
A
- hold breath 10 seconds after inhaling
- wait 30 seconds before 2nd dose
5
Q
Moderate asthma attack:
A
- PEFR 50-75% best or predicted
- speech normal
- RR <25/min
- pulse <110bpm
6
Q
Severe asthma attack:
A
- PEFR 33-50% b or p
- can’t complete sentences
- RR >25/min
- pulse >110bpm
7
Q
Life threatening asthma attack:
A
- PEFR <33% b or p
- O2 sats <92%
- silent chest, cyanosis, feeble effort
- bradycardia, dysrhythmia, hypotension
- exhausation, confusion, coma
8
Q
Acute asthma management:
A
- O2 if hypoxic - 15L non rebreather
- SABA increased dose - salbutamol, terbutalline
- corticosteroids - IV hydrocortisone (40-50mg oral prednisolone daily to recover)
- nebulised ipratropium bromide
- IV magnesium sulphate and aminophylline
- intubation and ventilation
9
Q
Risk factors for pneumothorax:
A
- pre-existing LD
- CTD
- ventilation
- catamenial pneumothorax (endometriosis)
10
Q
Symptoms of pneumothorax:
A
- diminished breath sounds on affected side
- hyperresonant percussion on affected side
- chest pain, dyspnoea, sweating, tachypnoea, tachycardia
11
Q
Management of primary pneumothorax:
A
- no underlying case
- rim of air <2cm, no SOB - discharge
- aspiration
- chest drain
- avoid smoking
12
Q
Management of secondary pneumothorax:
A
- underlying cause
- > 50yo + rim of air >2cm + SOB - chest drain
- aspiration
- <1cm - O2 and admit
- no scuba diving life long
13
Q
Where should the chest drain be placed in pneumothorax:
A
lateral lat for
lateral pec maj
level of nipple
14
Q
Management of tension pneumothorax:
A
- large bore 14-16 needle
- partially filled 0.9% saline
- 2nd ICS midclavicular on side of pneumothorax
15
Q
How is tension pneumothorax different?
A
- deviated trachea
- systemic features
- worsening dyspnoea
- hypotension
16
Q
Causes of pericarditis:
A
- viral infections (Coxsackie)
- TB
- uraemia (fibrinous pericarditis)
- trauma
- post MI, Dressler’s syndrome
- CTD
- hypothyroidism
- malignancy
- radiotherapy
17
Q
ECG changes in pericarditis:
A
- saddle shaped STE
- PR depression
- wide spread
18
Q
Management of pericarditis:
A
NSAIDs + colchicine
19
Q
Constrictive pericarditis signs:
A
- dyspnoea
- RSHF
- increased JVP with prominent x and y descent
- pericardial knock (S3)
- Kussmaul’s sign - paradoxical JVP increase on inspiration
- CXR - pericardial calcification
20
Q
Well’s score
A
clinical signs and symptoms of DVT - 3
alternative diagnosis less likely than PE - 3
heart rate >100bpm - 1.5
immobilisation more than 3 days or surgery in past 4 weeks - 1.5
previous DVT/PE - 1.5
haemoptysis - 1
malignancy - 1
21
Q
When would you use a V/Q over a CTPA:
A
- if normal CXR
- renal impairment (no contrast)
22
Q
What is the next step if the CTPA is negative?
A
proximal limb vein US for DVT
23
Q
ECG findings in PE:
A
- tachycardia
- S1Q3T3
24
Q
Management of PE:
A
- DOAC if stable
- haemodynamically unstable - thrombolysis (hypotension + massive PE): LMWH with dabigatran or edoxaban or vit K antagonist
- all patients at least 3 months of anticoagulant therapy
- provoke VTE - stop at 3, unprovoked continue up to 6
- active cancer 3-6 months
25
CO poisoning: (features, investigations, management)
- high affinity for Hb and myoglobin - left shift of dissociation curve and tissue hypoxia
- severe toxicity: pink skin and mucosa, hyperpyrexia, arrhythmias, extrapyramidal, coma, death
- pulse ox - false high similarity oxyHb and carboxyHb (so VBG or ABG)
- typical carboxyHb levels: <3% non-smokers or <10% smokers; >30% severe toxicity
- ECG - cardiac ischaemia
- 100% high flow O2 non-rebreathe, target sats 100% until symptoms resolve
- cerebral oedema - mannitol
- metabolic acidosis to correction of hypoxia
26
Which pneumonia is most common with smokers and generally?
- streptococcus pneumoniae
| - rapid onset, herpes labialise, high fever
27
Which pneumonia is most common in COPD patients?
haemophilus influenzae
28
Which pneumonia is most common following an influenza infection?
staphylococcus aureus
29
Which pneumonia most commonly presents with erythema multiforme?
- mycoplasma pneumoniae
- atypical chest signs/CXR
- dry cough
- autoimmnune haemolytic anaemia
30
Which pneumonia is associated with hyponatraemia:
- legionella pneumophilia
- lymphopenia
- infected air conditioning units
31
Which pneumonia most commonly affects alcoholics or diabetics?
- klebsiella pneumoniae
- aspiration
- upper lobes
- red currant jelly
32
Idiopathic Interstitial Pneumonia:
- non-infective cause
- e.g. cryptogenic organising pneumonia - bronchiolitis
- complication of RA or amiodarone therapy
33
CURB-65
Confusion (abbreviated mental test score <=8/10)
Urea >7mmol/L
RR >=30/min
Blood pressure: systolic <=90mmHg and /or diastolic <=60mmHg
65yo
34
What is the pleural fluid protein like in pneumonia?
>30g/L
35
Antibiotics for pneumonia:
- first line: amoxicillin
| - allergy: macrolide or tetracycline
36
Transudate
<30g/L protein
- HF most common
- hypoalbuminaemia: liver, nephrotic syndrome, malabsorption
- hypothyroidism
- Meig's syndrome: ovarian tumour, ascites, pleural effusion
37
Exudate
>30g/L protein
- infection: pneumonia, TB, subphrenic abscess
- CTD: RA, SLE
- neoplasia: lung cancer, mesothelioma, metastases
- pancreatitis
- PE
- Dressler's syndrome: type of pericarditis
- yellow nail syndrome
38
Light's criteria:
exudate
- >30g/L
- pleural fluid protein: serum protein >0.5
- pleural fluid LDH: serum LDH >0.6
- pleural fluid LDH more than 2/3 upper limit for normal serum LDH
39
Management of pleural infection:
- purulent/turbid/cloudy fluid - chest tube for drainage
| - clear but pH <7.2 + suspected pleural infection - chest tube
40
Pleural aspiration:
- US to reduce complications
- 21G needle and 50ml syringe
- fluid for pH, protein, LDH, cytology and microbiology
- low glucose: RA, TB
- increased amylase: pancreatitis, oesophageal perforation
- heavy blood staining: mesothelioma, PE, TB
41
Causes of tracheal deviation towards white:
- pneumonectomy
- complete lung collapse
- pulmonary hypoplasia
42
Causes of tracheal deviation away from white:
- pleural effusion
- diaphragmatic hernia
- large thoracic mass
43
Small Cell Lung Cancer:
- worse prognosis
- more likely smokers
- central, APUD cells
- ectopic ADH - hyponatraemia
- hyperglycaemia, hypertension
- ACTH secretion - Cushing's (no dexamethasone suppression)
- bilateral adrenal hyperplasia - increased cortisol, hypokalaemia alkalosis
- Lambert Eaton syndrome - myasthenic like syndrome
44
Management of small cell lung cancer:
- usually metastatic by diagnosis
- very early stage - surgery (no metastasis or nodes)
- chemotherapy and radiotherapy
45
Squamous cell lung cancer:
- central
- parathyroid hormone related protein PTHrP - hypercalcaemia
- strong association clubbing
- hypertrophic pulmonary osteoarthropathy HPOA
- hyperthyroidism (ectopic TSH)
46
Adenocarcinoma:
- peripheral
- most common type in non-smokers
- gynaecomastia
- HPOA
47
Large cell carcinoma
- peripheral
- anaplastic, poorly differentiated tumours, poor prognosis
- may secrete beta-hcg
48
NSCLC surgery contraindications:
- stage IIIb or IV (mets)
- FEV1 <1.5L
- malignant pleural effusions
- tumour near hilum
- vocal cord paralysis
- SVC obstruction
49
Lung cancer features:
- cough, haemoptysis, dyspnoea, chest pain, weight loss anorexia
- hoarseness (pan coast tumours on recurrent laryngeal nerve)
- superior vena cava syndrome - obstruction caused by malignant tumours in mediastinum
- fixed, monophonic wheeze
- supraclavicular lymphadenopathy or persistent cervical lymphadenopathy
- clubbing
- complications: hoarseness, stridor
50
What might indicate A1AD as the cause of COPD?
- emphysema lower lobes as opposed to upper
- commonly young patients with COPD symptoms but don't respond to treatment
- can be diagnosed pre-natally by amniocentesis
51
Features and diagnostic criteria of COPD:
- productive cough
- dyspnoea
- wheeze
- rare: RSHF, peripheral oedema
- NOT finger clubbing
- criteria: obstructive spirometry and symptoms of COPD
52
Investigations for COPD:
- post bronchodilator spirometry
- CXR: hyperinflation, bullae, flat hemidiaphragm, exclude cancer
- FBC: exclude secondary polycythaemia (increased haematocrit concentration)
- BMI
53
Stage I COPD
- mild
| - FEV1 >80%
54
Stage II COPD
- moderate
| - FEV1 50-79%
55
Stage III COPD
- severe
| - FEV1 30-49%
56
Stage IV COPD
- very severe
| - <30%
57
Stable management of COPD
- smoking cessation: nicotine replacement, bupropion, varenicline
- annual flu vaccine and pneumococcal vacc
- pulmonary rehabilitation as soon as SOB
- bronchodilator therapy
- oral theophylline (reduce dose if macrolide or fluoroquinolone)
- oral prophylactic Abx: azithromycin
- mucolytics
- loop diuretics and long term O2 therapy for cor pulmonale
58
CONTRA of smoking cessation therapies:
- bupropion (norepinephrine and dopamine reuptake inhibitor and nicotinic antagonist): epilepsy and pregnancy and breast feeding
- varenicline (nicotinic receptor partial agonist): pregnancy and breastfeeding
| - varenicline: pregnancy
59
Bronchodilator therapy in stable management of COPD:
- SABA or SAMA
- asthmatic/steroid responsive features (eosinophilia, variation FEV1 >400ml, diurnal variation peak expiatory flows >20%)
- NO - LABA + lAMA
- YES - LABA + ICS or LABA + LAMA + ICS
60
Acute exacerbation management of COPD:
- most commonly haemophilia influenzae, strep pneumonia, moraxella catarrhalis
- increase bronchodilator use and nebuliser
- prednioslone 30mg od 5 days
- antibiotics if sputum purulent and signs of pneumonia
- amoxicillin, clarithromycin or doxycycline
61
ARDS causes:
- infection
- massive blood transfusion
- trauma
- smoke inhalation
- acute pancreatitis
- cardio pulmonary bypass
- long bone fracture/multiple fractures (fat embolism)
- HI
62
Criteria of ARDS:
- acute onset (within 1 week of risk factor)
- pulmonary oedema: bilateral infiltrate on CXR
- non-cardiogenic (pulmonary artery wedge pressure if doubt)
- pO2/FiO2 <40kPa
63
What type of ventilation can be used for ARDS:
- mechanical ventilation
| - low tidal volumes
64
Allergic Bronchopulmonary Aspergillosis
- history of bronchiectasis and eosinophilia
- positive radioallergosorbent test
- positive IgG percipitins
- increased IgE
- manage with oral glucocorticoids or itraconazole
65
Psittacosis
- chlamydia psittaci
- cause of atypical pneumonia
- no response to penicillins
- 'sticky eyes'
- flu like symptoms and respiratory symptoms
- unilateral crepitations and vesicular breathing
- pleural effusion uncommon
- hepatomegaly and splenomegaly
- 1st line: tetracyclines (doxycycline)
- 2nd line: macrolide (erythromycin)
66
How do you investigate occupational asthma?
- serial measurements of peak expiratory flow at work and away from work
- referral to specialist for suspected occupational asthma
67
Asthma stepping down treatment:
- consider every 3 months
| - 25-50% reduction of inhaled steroids at a time
68
Most common organisms causing aspiration pneumonia:
aerobic:
- strep pneumoniae
- staph aureus
- haemophilus influenzae
- pseudomonas aeruginosa
69
Which lobes are most commonly affected in aspiration pneumonia?
- right middle and lower
| - large calibre and vertical orientation of right main bronchus
70
Asthma testing patients >=17 years
- investigate occupational asthma
- spirometry with bronchodilator reversibility test
- FeNO test
71
Asthma testing patients 5-16 years
- BDR test
| - FeNO if normal spirometry or obstructive spirometry with negative bronchodilator reversibility
72
Asthma testing patients <5 years
clinical judgement
73
How does asthma reversibility testing work?
- adults, positive indicated by improvement in FeV1 of 12% or more and increased in vol 200ml or more
- children, positive indicated by improvement of FEV1 of 12% or more
74
Referring using suspected cancer pathway:
- CXR findings
| - >40yo with unexplained haemoptysis
75
Urgent CXR for lung cancer criteria:
- >40yo with 2 symptoms or smoking and 1 or more symptoms
| - cough, fatigue, SOB, chest pain, weight loss, appetite loss
76
Consider urgent CXR for lung cancer if:
- persistent or recurrent chest infection
- clubbing
- supraclavicular lymphadenopathy or persistent cervical lymphadenopathy
- chest signs consistent with lung cancer
- thrombocytosis
