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Year 3 > Chronic SOB > Flashcards

Chronic SOB Flashcards

asthma, COPD, ILD, HSP

1
Q

What is the definition of asthma?

A

A chronic inflammatory airway disease with intermittent airway obstruction and hyper-reactivity

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2
Q

What are the associations with asthma?

A 
Worse in the morning and night
Recurrent episodes
Hx atopy/eczema
FHx
Smoker
Pets
Occupation
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3
Q

What can be seen on examination of a Pt with asthma?

A

May be normal
Dyspnoea
Nasal polyposis
Polyphonic, high-pitched expiratory wheeze

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4
Q

What investigations would you do on a Pt with asthma?

A

Peak expiratory flow rate
Spirometry (FEV1:FVC ratio + reversibility with SABA)
FeNO test
Bloods

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5
Q

What does an FEV1:FVC ratio of <0.7 indicate?

A

An obstructive pulmonary disease

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6
Q

What are the types of obstructive pulmonary diseases?

A

Asthma

COPD

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7
Q

What is the order of treatment for asthma (in accordance to the BTS guidelines)?

A 
SABA
SABA + ICS
LABA + ICS
Trials (LTRA, LAMA, theophylline)
\+OCS
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8
Q

When should you consider moving up to the next step of treatment (in accordance to the BTS guidelines)?

A

If the Pt needs to use the SABA 3+ times in a week

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9
Q

What are the 4 categories of acute asthma?

A

Moderate
Acute-severe
Life threatening
Near fatal

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10
Q

How do you define moderate asthma?

A

If the PEF is 50-75%

no features of severe asthma

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11
Q

How do you define acute-severe asthma?

A

If the PEF is 33-50% of predicted
RR >25
HR >110
Inability to complete sentences in one breath

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12
Q

How do you define life threatening asthma?

A

If the PEF is <33% of predicted
SpO2 <92%
PaO2 <8kPa
normal PaCO2 (not low)

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13
Q

How do you define near fatal asthma?

A

If the pCO2 is raised

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14
Q

What investigations would you do on a Pt with acute asthma?

A 
Basic obs
PEF
O2 sat
ABG
Serum K+ and glucose
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15
Q

A patient has come in with an exacerbation of asthma. What is the first treatment you would administer?

A

Oxygen.

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16
Q

A patient has come in with a moderate exacerbation of asthma. Oxygen has been administered.

What is the next line of management?

A

Neb salbutamol 5mg
Oral prednisolone 40-50mg (5 days)
IV hydrocortisone 100mg

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17
Q

A patient has come in with an acute-severe/life-threatening exacerbation of asthma. Oxygen has been administered.

What is the next line of management?

A

Neb salbutamol 5mg
Oral prednisolone 40-50mg (5 days)
IV hydrocortisone 100mg

PLUS:
Neb ipratropium bromide 0.5mg

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18
Q

A patient has come in with an acute-severe exacerbation of asthma. Oxygen, salbutamol, prednisolone, hydrocortisone, and ipratropium bromide has been administered and the patient has not recovered. What is the next line of management?

A

IV magnesium sulphate AND call for senior help

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19
Q

A patient has come in with an acute-severe exacerbation of asthma. Oxygen, salbutamol, prednisolone, hydrocortisone, ipratropium bromide, and magnesium sulphate has been administered and the patient has not recovered. A senior has arrived to help. What is the next line of management?

A

IV aminophylline

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20
Q

A patient has come in with an acute-severe exacerbation of asthma. Oxygen, salbutamol, prednisolone, hydrocortisone, ipratropium bromide, magnesium sulphate, and IV aminophylline has been administered and the patient has not recovered. A senior has arrived to help. What is the next line of management?

A

ITU and intubate

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21
Q

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
A

E. Near fatal

Her pCO2 is raised, classifying this exacerbation as near fatal.

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22
Q

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 a blue inhaler. 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

A

D. Add an inhaled low-dose corticosteroid to her medications, taken OD

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23
Q

What is the definition of COPD?

A

Chronic airway obstruction that is not fully reversible, encompassing emphysema and chronic bronchitis.

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24
Q

What signs on general inspection may indicate COPD?

A 
Tar staining
Cyanosis
Barrel chest
Tripod-ing
Signs of RHF
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25
Q

What signs on palpation and percussion may indicate COPD?

A

Reduced expansion

Hyper-resonance

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26
Q

What signs on auscultation may indicate COPD?

A

Reduced air movement
Wheezing
Coarse (hair-like) crackles

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27
Q

What FEV1 percentage indicates a mild COPD?

A

> 80%

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28
Q

What FEV1 percentage indicates a moderate COPD?

A

50-80%

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29
Q

What FEV1 percentage indicates a severe COPD?

A

30-50%

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30
Q

What FEV1 percentage indicates a very severe COPD?

A

<30%

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31
Q

What investigations would you do on a Pt with COPD?

A 
Spirometry (FEV1:FVC <0.7)
Bloods
ABG
CXR
Serum alpha-1 antitrypsin

OTHER: ECG if features of cor pulmonale, peak flow if suspect asthma, CT if CXR abnormality

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32
Q

What is the management for mild COPD?

A

SABA or SAMA

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33
Q

What is the management for moderate/severe COPD?

A

if asthmatic features: LABA +ICS

if no asthmatic features: LABA + LAMA

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34
Q

What is the management for very severe COPD?

A

LABA+LAMA+ICS

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35
Q

What other long-term management is available for COPD?

A
  • Smoking cessation
  • Annual influenza + pneumococcal vaccination
  • Long term 02 therapy (15hr/day)
  • Lung volume reduction surgery
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36
Q

When should you give long-term O2 therapy?

A

If the pO2 < 7.3 kPa

If the pO2 7.3-8.0 kPa AND they have:

  • secondary polycythaemia
  • nocturnal hypoxaemia
  • peripheral oedema
  • pulmonary hypertension
37
Q

What is the first line management of a Pt with IE-COPD?

A

24% O2 (via a blue Venturi mask)

NOTE: hypoxia kills quicker than hypercapnia (always give more O2 if you’re unsure / you have no ABG results)

38
Q

A patient with IE-COPD has been put on a blue Venturi mask. What is the next line of management?

A

Neb salbutamol 5mg
Neb ipratropium bromide 0.5mg

Oral prednisolone 40-50mg
IV hydrocortisone 200mg

IV amoxicillin / co-amoxiclav

39
Q

A patient with IE-COPD has been put on a blue Venturi mask. The patient has been given salbutamol, predmisolone, hydrocortisone, and ipratropium bromide. What is the next line of management?

A

IV amoxicillin

40
Q

What is the next line in the management of IE-COPD if the patient isn’t responding to nebulisers/steroids/Abx?

A

Call for senior support
500mg IV aminophylline
NIV (BiPAP)

41
Q

A patient with IE-COPD has been put on a blue Venturi mask. The patient has been given salbutamol, prednisolone, hydrocortisone, ipratropium bromide, amoxicillin and aminophylline. What is the next line of management?

A

BiPAP

42
Q

State the indications for CPAP and BiPAP

A

CPAP- T1RF eg. sleep apnoea

BiPAP- T2RF eg. COPD

43
Q

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 a SABA and 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

A. Replace the SABA with a LAMA

44
Q

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 abscess)
A

C. COPD

45
Q

What are the respiratory causes of clubbing?

A

Malignancy
Empyema/suppurative lung disease
Interstitial lung disease
Cystic fibrosis

46
Q

What is the definition of interstitial lung disease?

A

ILD is an umbrella term for a large group of disorders causing lung tissue fibrosis.

47
Q

Name some ILDs

A

Idiopathic pulmonary fibrosis
Hypersensitivity pneumonitis/extrinsic allergic alveolitis
Sarcoidosis
Pneumoconiosis

48
Q

What might a Pt with idiopathic pulmonary fibrosis present with?

A

SOBOE
Dry cough
No wheeze

49
Q

What are some RF for IPF?

A

Smoking
Occupation (metal/wood exposure)
Exposure to animals/vegetable dust
Drugs (bleomycin, methotrexate, amiodarone)

50
Q

What would you look for on examination of a Pt with IPF?

A

Clubbing
Bi-basal, fine, inspiratory crackles
RHF (late stage ILD)

51
Q

What investigations would you do on a Pt with IPF?

A
  • Bloods + ABG
  • Biopsy- gold standard, not always necessary/feasable
  • CXR- late presentation
  • HRCT- early presentation (sensitive)
  • Spirometry- shows restrictive pattern (FEV1/FVC >0.8)
52
Q

What would you see in a CXR in IPF?

A

Ground-glass appearance
Reticulonodular appearance
Cor pulmonale
Honeycombing appearance

53
Q

What would you see in a HRCT in IPF?

A

Ground-glass appearance

54
Q

What might a Pt with hypersensitivity pneumonitis present with?

A

SOBOE
Dry cough
Fever

55
Q

Which occupations are RF for hypersensitivity pneumonitis? State the aetiological agent for each occupation

A

Inhalation of antigenic organic dusts

  • Farmer’s: mouldy hay w/ thermophilic actinomycetes
  • Bird fancier’s: feathers/bird droppings
  • Mushroom worker’s: compost w/ thermophilic actinomycetes
  • Malt worker’s: mouldy barley w/ aspergillus clavatus
  • Plumbers –> humidifier lung: water-containing bacteria
56
Q

What signs should you see in a Pt with Hypersensivity pneumonitis?

A

Clubbing (rare)
Mild pyrexia- MAY MIMIC ATYPICAL PNEUMONIA
Bi-basal fine inspiratory crackles

57
Q

What investigations would you do on a Pt with Hypersensitivity pneumonitis? What would they show

A

Bloods + ABG = T2RF
CXR = often normal unless late pres (same as IPF)
HRCT = ground glass
Lung function tests- spirometry = restrictive pattern (FEV1/FVC > 0.8)
Broncho-alveolar lavage = increased cellularity

58
Q

What causes pneumoconiosis?

A

Inhalation of coal/silica/asbestos dust

Nodules of collagen and dying macrophages form around the particles

59
Q

What is a typical pneumoconiosis patient?

A

ex. coal worker/builder- LONG LATENCY
May be asymptomatic for decades

SOB
Dry cough

60
Q

Compare the examination findings of pneumoconiosis caused by silicosis (coal worker) vs asbestosis (builder)

A

Both show signs of RHF

SILICOSIS- decreased breath sounds (upper lobe predominant) + no clubbing
ASBESTOSIS- clubbing, fine bi-basal inspiratory creps (lower lobe predominant)

61
Q

What investigations would you do on a Pt with pneumoconiosis?

A

CXR
HRCT
Lung function tests- restrictive pattern

62
Q

What would you see in a CXR of a Pt with pneumoconiosis?

A

Simple- micro-nodular mottling

Complicated- bilateral lower zone reticulonodular shadowing and pleural plaques

63
Q

What would you see in a CT of a Pt with pneumoconiosis?

A

Fibrotic changes

64
Q

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
A

D. Hypersensitivity pneumonitis

65
Q

What is the definition of sleep apnoea?

A

Recurrent collapse of pharyngeal airway and apnoea (cessation of airflow for >10s) during sleep; followed by arousal from sleep

66
Q

What may a Pt with sleep apnoea present with?

A

Chronic fatigue
Snoring
Unrefreshed sleep

67
Q

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
A

C. Marfan’s syndrome

68
Q

What are the criteria for a diagnosis of asthma?

A

SPIROMETRY-

  • FEV:FVC <0.7 (obstructive pattern)
  • SABA reversibility >12% difference

FeNO TEST
- ≥35-40 parts / billion

PEFR
- varies by ≥20% , ≥3x/week over several weeks

69
Q

What is the order of treatment for asthma (in accordance to the NICE guidelines)?

A
  1. SABA
  2. SABA + ICS
  3. SABA + ICS + LTRA
  4. LABA + ICS + LTRA
  5. SABA + ↑ICS + LTRA
  6. Trials- theophylline, LAMA
  7. Oral corticosteroids
70
Q

Give 2 examples of ICS

A

beclometasone

budesonide

71
Q

Give an example of an LRTA

A

montelukast

72
Q

Give an example of a LABA + ICS combo inhaler

A

symbicort (budesonide + formoterol)

73
Q

Which oral CS would you prescribe in severe asthma?

A

prednisolone

74
Q

What are the clinical signs of life-threatening asthma?

A 
Altered consciousness level
Exhaustion (reduced respiratory effort)
Arrhythmia
Hypotension
Cyanosis
Silent chest
75
Q

Near fatal asthma is characterised by what?

A

Raised PaCO2 and/or requiring mechanical ventilation with raised inflation pressures

76
Q

Describe the progressive steps of management of asthma

A
  1. OXYGEN
  2. Neb salbutamol 5mg
  3. IV hydrocortisone 100mg + oral prednisolone 40-50mg
  4. Neb ipratropium bromide (if severe/unresponsive)
  5. IV MgSO4
  6. IV aminophylline
  7. ITU + intubation
77
Q

For each severity of asthma, state whether the patient would be admitted or not

A

moderate (PEF 50-75%) = no admission
acute-severe (PEF 33-50%) = admit if no response
life-threatening (PEF <33%) = admit
near fatal (PCO2 raised) = admit

if no admission, quadruple inhaled ICS instead of PO prednisolone

78
Q

State the dosing and frequency of salbutamol and ipratropium bromide in asthma exacerbation

A

salbutamol can be given back-to-back PRN

ipratropium bromide can be given every 4 hours PRN

79
Q

How does chronic COPD classically present?

A

SOB
Chronic productive cough
some wheeze

80
Q

CVS causes of clubbing

A 
Malignancy			
Infective (bacterial) Endocarditis		
Tetralogy of Fallot 
Congenital cyanotic heart disease	
Atrial myxoma
81
Q

Resp causes of clubbing

A

Malignancy
Interstitial lung disease
Empyema lung abscess
Cystic fibrosis

82
Q

GI causes of clubbing

A

Malignancy
Coeliac’s disease
IBD
Cirrhosis

83
Q

COPD DOESN’T CAUSE WHAT SIGN?

A

CLUBBING

84
Q

What is the other name for hypersensitivity pneumonitis?

A

Extrinsic allergic alveolitis

85
Q

What 3 mechanisms cause fibrosis in pneumconiosis?

A
  1. Direct cytotoxicity of particles
  2. Particle ingestion by macrophages => free radical production
  3. Pro-inflammatory cytokines from macrophages
86
Q

chronic asbestos exposure can lead to which 2 pathologies?

A
  1. Asbestosis (a pneumoconiosis)

2. Mesothelioma (most common cancer from asbestos exposure)

87
Q

compare CT appearance of asbestosis and silicosis

A

both show : bilateral lower zone reticulonodular shadowing + pleural plaques

asbestosis = fibrotic changes 
silicosis = eggshell calcification
88
Q

What is the classic patient suffering from sleep apnoea?

A 
OBESE
Smoker, alcohol
Truck driver
Macroglossia
Marfan's
89
Q

Investigations for sleep apnoea

A
  1. Sleep study - polysomnography (airflow monitoring; respiratory effort; pulse oximetry and HR)
  2. TFTs
  3. Glucose / IGF-1 if ? acromegaly (then random IGF-1, OGTT)

Year 3 (38 decks)

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