Chronic Resp Flashcards
Presentation of asthma
Cough, wheeze, SOB Worse in morning and evening Atopy in hx and FHx Smoker *chronic inflammatory airway disease characterised by intermittent airway obstruction and hyperreactivity
Ix for asthma
Bloods
PEFR
- varies by/increases >20% for >3 days/weeks over several weeks
Spirometry
- FEV1:FVC<70%
- reversibility, 12% pre- and post- bronchodilator spirometry
Rx pathways for asthma
SABA => SABA + ICS =>
SABA + ICS + LTRA => LABA + ICS +/- LTRA =>
LABA + increase ICS +/- LTRA => trials => oral CS
SABA (short acting B agonist) - salbutamol
ICS (inhaled CS) - beclometasone, budesonide
LTRA (leukotriene rec antagonist) - montelukast
LABA (long-acting) + ICS - symbicort (budesonide/formoterol)
oral CS - prednisolone
How are acute asthma attacks classified?
Moderate - PEF 50-75% Acute-severe - PEF 33-50% Life-threatening - PEF <33% Near fatal - pCO2 raised *peak expiratory flow
Ix for acute asthma attacks
Basic obs PEF O2 sat and maintain SpO2 at 94-98% ABG (repeat if PaO2 <8kPa unless SpO2 <92% or PaCO2 normal/raised or pt deteriorates) serum K+ and glucose
Rx for acute asthma attack
Nebulised salbutamol 5mg Nebulised ipratropium bromide 0.5mg Oral prednisolone 40-50mg IV hydrocortisone 100mg => IV magnesium sulphate Call senior help => IV aminophylline => ITU + intubation
COPD presentation
SOB, productive cough, some wheeze Older age Heavy smoking status Barrel chest NO clubbing
How is COPD classified?
All have a FEV1/FVC < 0.7
FEV1 readings: Mild = >80% Moderate = 50-79% Severe = 30-49% Very severe = <30%
Ix for COPD
Spirometry (determine severity)
Bloods, ABG (check for alpha-1 antitrypsin)
ECG (assess cardiac status for cor pulmonale)
CXR (lung reduction associated with increased survival)
Serial peak flow measurements
Rx based on severity
Mild => SABA/SAMA (salbutamol, ipratropium bromide)
Moderate => SABA + LABA/SAMA + LAMA (tiotropium/salmeterol)
Severe => LABA + LAMA/LABA + ICS (symbicort)
Very severe => LAMA + LABA + ICS (tiotropim + symbicort)
Mx of COPD
General - smoking cessation - annual influenza vaccine - pneumococcal vaccine Improve survival - smoking cessation - long term O2 therapy (15hrs/day) - lung volume reduction surgery
When would a COPD pt start oxygen therapy?
1) pO2 < 7.3kPa
2) pO2 7.3-8kPa + one of the following:
- secondary polycythaemia
- nocturnal hypoxaemia
- peripheral oedema
- pulmonary HTN
Acute exacerbation of COPD rx
(Blue Venturi) 24% O2 => Nebulised salbutamol 5mg Nebulised ipratropium bromide 0.5mg Oral prednisolone 40-50mg IV hydrocortisone 200mg => IV amoxicillin => 500mg IV aminophylline => BiPaP (NIV) (type II resp. failure)
Name types of interstitial lung diseases
Idiopathic pulmonary fibrosis
Hypersensitivity Pneumonitis
Sarcoidosis
Pneumoconiosis
What may present in the hx of a pt with idiopathic pulmonary fibrosis?
SOBOE, dru cough, no wheeze Clubbing Animal/vegetable dusts Smoking status baad Occupational exposure to metal/wood Chronic microaspiration Drugs: bleomycin, methotrexate, amiodarone
Ix for idiopathic pulmonary fibrosis
Bloods, ABG, biopsy
CXR (ground-glass, reticulonodular, cor pulmonale, honeycombing)
High-res. CT (ground-glass)
Lung function tests (restrictive patterns)
How may hypersensitivity pneumonitis present?
Acute +/- chronic hx
Keeps pets
SOBOE, dru cough, fever
*Picks mushrooms, birdkeeper, farmer, plumber, maltworker
Ix for hypersensitivity pneumonitis
Bloods, ABG
CXR (ground-glass)
High res. CT (ground-glass)
Broncho-alveolar lavage (increased cellularity)
Lung function tests (restrictive pattern)
How may pneumoconiosis present?
SOB, cough
Asymptomatic generally
Long latency
Coal worker, builder (silicosis, asbestosis)
Ix for pneumoconiosis
CT (fibrotic changes)
CXR (micronodular mottling => bilateral lower zone reticulonodular shadowing + pleural plaques
Lung function tests (restrictive patterns)
How may CXR differentiate between silicosis and asbestosis?
Asbestosis
- fibrotic changes, not just plaques
Silicosis
- eggshell calcification, micronodular shadowing
Presentations of sleep apnoea
Chronic fatigue Truck driver Unrefreshed sleep Snoring Obesity, smoker, alcohol Enlarged tonsils, macroglossia, Marfan's syndrome
Ix and Rx for sleep apnoea
Ix
- TFTs
- sleep study: airflow monitoring, HR, pulse ox., resp. effort
Rx
- lose weight
- CPAP if real bad (damn)
What is sleep apnoea?
Recurrent collapse of pharyngeal airway and apnoea (cessation of airflow for 10s) during sleep, followed by arousal from sleep
A 17 year-old girl presents to the local A&E complaining of worsening shortness of breath, despite use of what she describes as her ‘blue inhaler’. On examination her oxygen saturations are 95%, she is afebrile and has a BP of 101/67. The attending physician takes an ABG and the results are shown below. Grade the severity of this patient’s asthma attack.
pH 7.25
pCO2 7.4 kPa (4.5-6.0)
pO2 10.4 kPa (>10.5)
HCO3 23 mmol/l
a) I cannot tell from the information available
b) Moderate
c) Acute severe
d) Life threatening
e) Near fatal
e) Near fatal
A 26-year-old bus driver presents to the GP complaining of a worsening shortness of breath. On examination, the patient is afebrile, has a BP of 110/85 and has a marked wheeze on auscultation. The only medications the patient is on is Salbutamol, PRN. What is the next most appropriate treatment step as per the treatment guidelines for this condition?
a) Replace the blue inhaler with a brown, low-dose inhaled corticosteroid
b) Replace the blue inhaler with a long-acting beta-agonist medication
c) Replace the blue inhaler with a long-acting muscarinic agonist medication
d) Add an inhaled low-dose corticosteroid to her medications, taken OD
e) Add oral corticosteroid tablets to her medications, taken OD
d) Add an inhaled low-dose corticosteroid to her medications, taken OD
A 72-year-old man attends the GP complaining of increased shortness of breath and a cough productive of clear sputum. The GP notes the gentleman has a history of diagnosed COPD and decides to review his medications. The man hands the GP two inhalers, one a SABA and the other a LABA. After conducting spirometry, the GP calculates an FEV1 of 40% expected. What is the next most appropriate treatment step?
a) Replace the SABA with a LAMA
b) Replace the LABA with an LAMA
c) Add a LAMA
d) Add an ICS
e) I need to conduct more tests to determine what medications to review
a) Replace the SABA with a LAMA
Which of the following is NOT a respiratory cause of clubbing?
a) Squamous cell lung cancer
b) Interstitial lung disease
c) COPD
d) Cystic fibrosis
e) An empyema (lung abcess)
c) COPD
A 65-year-old man with a medical background of benign prostatic hyperplasia, presents to the GP with a 1 week history of worsening shortness of breath on exertion. He has a temperature of 38.5C, reports no weight loss but does mention some mild fatigue from his ‘pet pigeons keeping him up all night’ recently. On auscultation, the GP can determine fine, bi-basal inspiratory crackles. What is the most likely diagnosis?
a) COPD
b) Lung cancer
c) Bronchiectasis
d) Hypersensitivity pneumonitis
e) Idiopathic pulmonary fibrosis
d) Hypersensitivity pneumonitis
A tall 26-year-old woman comes into the GP complaining of chronic fatigue. Upon further questioning she reports that she ‘can never get a good night’s sleep’ and that she tends to fall asleep a lot at her workplace as a call centre customer service representative. She also mentions that she thinks it may have something to do with a condition her mother had. The only significant finding upon examination is patches of stretchy skin, especially around the neck area. What is the most likely underlying condition leading to disrupted sleep?
a) Obesity
b) Bad sleeping position
c) Marfan’s syndrome
d) Down’s syndrome
e) Chronic fatigue syndrome
c) Marfan’s syndrome
* leading to sleep apnoea
