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Respiratory > Acute Respiratory > Flashcards

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

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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
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3
Q

What is MART?

A
  • combined ICS and LABA for maintenance therapy and reliever

- LABA must have fast acting component e.g. formoterol

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4
Q

Inhaler technique:

A
  • hold breath 10 seconds after inhaling

- wait 30 seconds before 2nd dose

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5
Q

Moderate asthma attack:

A
  • PEFR 50-75% best or predicted
  • speech normal
  • RR <25/min
  • pulse <110bpm
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6
Q

Severe asthma attack:

A
  • PEFR 33-50% b or p
  • can’t complete sentences
  • RR >25/min
  • pulse >110bpm
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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
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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
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9
Q

Risk factors for pneumothorax:

A
  • pre-existing LD
  • CTD
  • ventilation
  • catamenial pneumothorax (endometriosis)
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10
Q

Symptoms of pneumothorax:

A
  • diminished breath sounds on affected side
  • hyperresonant percussion on affected side
  • chest pain, dyspnoea, sweating, tachypnoea, tachycardia
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11
Q

Management of primary pneumothorax:

A
  • no underlying case
  • rim of air <2cm, no SOB - discharge
  • aspiration
  • chest drain
  • avoid smoking
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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
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13
Q

Where should the chest drain be placed in pneumothorax:

A

lateral lat for
lateral pec maj
level of nipple

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14
Q

Management of tension pneumothorax:

A
  • large bore 14-16 needle
  • partially filled 0.9% saline
  • 2nd ICS midclavicular on side of pneumothorax
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15
Q

How is tension pneumothorax different?

A
  • deviated trachea
  • systemic features
  • worsening dyspnoea
  • hypotension
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16
Q

Causes of pericarditis:

A
  • viral infections (Coxsackie)
  • TB
  • uraemia (fibrinous pericarditis)
  • trauma
  • post MI, Dressler’s syndrome
  • CTD
  • hypothyroidism
  • malignancy
  • radiotherapy
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17
Q

ECG changes in pericarditis:

A
  • saddle shaped STE
  • PR depression
  • wide spread
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18
Q

Management of pericarditis:

A

NSAIDs + colchicine

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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
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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

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21
Q

When would you use a V/Q over a CTPA:

A
  • if normal CXR

- renal impairment (no contrast)

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22
Q

What is the next step if the CTPA is negative?

A

proximal limb vein US for DVT

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23
Q

ECG findings in PE:

A
  • tachycardia

- S1Q3T3

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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
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25
Q

CO poisoning: (features, investigations, management)

A
  • 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
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26
Q

Which pneumonia is most common with smokers and generally?

A
  • streptococcus pneumoniae

- rapid onset, herpes labialise, high fever

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27
Q

Which pneumonia is most common in COPD patients?

A

haemophilus influenzae

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28
Q

Which pneumonia is most common following an influenza infection?

A

staphylococcus aureus

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29
Q

Which pneumonia most commonly presents with erythema multiforme?

A
  • mycoplasma pneumoniae
  • atypical chest signs/CXR
  • dry cough
  • autoimmnune haemolytic anaemia
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30
Q

Which pneumonia is associated with hyponatraemia:

A
  • legionella pneumophilia
  • lymphopenia
  • infected air conditioning units
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31
Q

Which pneumonia most commonly affects alcoholics or diabetics?

A
  • klebsiella pneumoniae
  • aspiration
  • upper lobes
  • red currant jelly
32
Q

Idiopathic Interstitial Pneumonia:

A
  • non-infective cause
  • e.g. cryptogenic organising pneumonia - bronchiolitis
  • complication of RA or amiodarone therapy
33
Q

CURB-65

A

Confusion (abbreviated mental test score <=8/10)
Urea >7mmol/L
RR >=30/min
Blood pressure: systolic <=90mmHg and /or diastolic <=60mmHg
65yo

34
Q

What is the pleural fluid protein like in pneumonia?

A

> 30g/L

35
Q

Antibiotics for pneumonia:

A
  • first line: amoxicillin

- allergy: macrolide or tetracycline

36
Q

Transudate

A

<30g/L protein

  • HF most common
  • hypoalbuminaemia: liver, nephrotic syndrome, malabsorption
  • hypothyroidism
  • Meig’s syndrome: ovarian tumour, ascites, pleural effusion
37
Q

Exudate

A

> 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
Q

Light’s criteria:

A

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
Q

Management of pleural infection:

A
  • purulent/turbid/cloudy fluid - chest tube for drainage

- clear but pH <7.2 + suspected pleural infection - chest tube

40
Q

Pleural aspiration:

A
  • 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
Q

Causes of tracheal deviation towards white:

A
  • pneumonectomy
  • complete lung collapse
  • pulmonary hypoplasia
42
Q

Causes of tracheal deviation away from white:

A
  • pleural effusion
  • diaphragmatic hernia
  • large thoracic mass
43
Q

Small Cell Lung Cancer:

A
  • 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
Q

Management of small cell lung cancer:

A
  • usually metastatic by diagnosis
  • very early stage - surgery (no metastasis or nodes)
  • chemotherapy and radiotherapy
45
Q

Squamous cell lung cancer:

A
  • central
  • parathyroid hormone related protein PTHrP - hypercalcaemia
  • strong association clubbing
  • hypertrophic pulmonary osteoarthropathy HPOA
  • hyperthyroidism (ectopic TSH)
46
Q

Adenocarcinoma:

A
  • peripheral
  • most common type in non-smokers
  • gynaecomastia
  • HPOA
47
Q

Large cell carcinoma

A
  • peripheral
  • anaplastic, poorly differentiated tumours, poor prognosis
  • may secrete beta-hcg
48
Q

NSCLC surgery contraindications:

A
  • stage IIIb or IV (mets)
  • FEV1 <1.5L
  • malignant pleural effusions
  • tumour near hilum
  • vocal cord paralysis
  • SVC obstruction
49
Q

Lung cancer features:

A
  • 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
Q

What might indicate A1AD as the cause of COPD?

A
  • 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
Q

Features and diagnostic criteria of COPD:

A
  • productive cough
  • dyspnoea
  • wheeze
  • rare: RSHF, peripheral oedema
  • NOT finger clubbing
  • criteria: obstructive spirometry and symptoms of COPD
52
Q

Investigations for COPD:

A
  • post bronchodilator spirometry
  • CXR: hyperinflation, bullae, flat hemidiaphragm, exclude cancer
  • FBC: exclude secondary polycythaemia (increased haematocrit concentration)
  • BMI
53
Q

Stage I COPD

A
  • mild

- FEV1 >80%

54
Q

Stage II COPD

A
  • moderate

- FEV1 50-79%

55
Q

Stage III COPD

A
  • severe

- FEV1 30-49%

56
Q

Stage IV COPD

A
  • very severe

- <30%

57
Q

Stable management of COPD

A
  • 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
Q

CONTRA of smoking cessation therapies:

A
  • 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
Q

Bronchodilator therapy in stable management of COPD:

A
  • 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
Q

Acute exacerbation management of COPD:

A
  • 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
Q

ARDS causes:

A
  • infection
  • massive blood transfusion
  • trauma
  • smoke inhalation
  • acute pancreatitis
  • cardio pulmonary bypass
  • long bone fracture/multiple fractures (fat embolism)
  • HI
62
Q

Criteria of ARDS:

A
  • 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
Q

What type of ventilation can be used for ARDS:

A
  • mechanical ventilation

- low tidal volumes

64
Q

Allergic Bronchopulmonary Aspergillosis

A
  • history of bronchiectasis and eosinophilia
  • positive radioallergosorbent test
  • positive IgG percipitins
  • increased IgE
  • manage with oral glucocorticoids or itraconazole
65
Q

Psittacosis

A
  • 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
Q

How do you investigate occupational asthma?

A
  • serial measurements of peak expiratory flow at work and away from work
  • referral to specialist for suspected occupational asthma
67
Q

Asthma stepping down treatment:

A
  • consider every 3 months

- 25-50% reduction of inhaled steroids at a time

68
Q

Most common organisms causing aspiration pneumonia:

A

aerobic:

  • strep pneumoniae
  • staph aureus
  • haemophilus influenzae
  • pseudomonas aeruginosa
69
Q

Which lobes are most commonly affected in aspiration pneumonia?

A
  • right middle and lower

- large calibre and vertical orientation of right main bronchus

70
Q

Asthma testing patients >=17 years

A
  • investigate occupational asthma
  • spirometry with bronchodilator reversibility test
  • FeNO test
71
Q

Asthma testing patients 5-16 years

A
  • BDR test

- FeNO if normal spirometry or obstructive spirometry with negative bronchodilator reversibility

72
Q

Asthma testing patients <5 years

A

clinical judgement

73
Q

How does asthma reversibility testing work?

A
  • 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
Q

Referring using suspected cancer pathway:

A
  • CXR findings

- >40yo with unexplained haemoptysis

75
Q

Urgent CXR for lung cancer criteria:

A
  • > 40yo with 2 symptoms or smoking and 1 or more symptoms

- cough, fatigue, SOB, chest pain, weight loss, appetite loss

76
Q

Consider urgent CXR for lung cancer if:

A
  • persistent or recurrent chest infection
  • clubbing
  • supraclavicular lymphadenopathy or persistent cervical lymphadenopathy
  • chest signs consistent with lung cancer
  • thrombocytosis

Respiratory (3 decks)

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