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Yr 4 - CCC > Corrections - Respiratory > Flashcards

Corrections - Respiratory Flashcards

1
Q

What is the new stepwise management for asthma under the 2017 NICE guidelines for adults?

A

1) SABA

2) SABA + low dose ICs

3) SABA + low dose ICS + leukotriene receptor antagonist (LTRA)

4) SABA + low dose ICE + LABA (+ review of LTRA, continue depending on patient’s response)

5) SABA +/- LTRA, switch ICS/LABA for maintenance and reliever therapy (MART) that includes a low dose ICS

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2
Q

RR in moderate vs severe acute asthma?

A

Moderate - <25/min

Severe - >25/min

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3
Q

Pulse in moderate vs severe acute asthma?

A

Moderate - <100 bpm
Severe - >100 bpm

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4
Q

PEFR in moderate, severe and life-threatening acute asthma?

A

Moderate - 50-75%

Severe - 33-50%

Life-threatening - <33%

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5
Q

Describe FEV1 in obstructive vs restrictive lung disease

A

Obstructive - significantly reduced

Restrictive - reduced

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6
Q

Describe FVC in obstructive vs restrictive lung disease

A

Obstructive - reduced or normal

Restrictive - significantly reduced

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6
Q

Describe FEV1% (FEV1/FVC) in obstructive vs restrictive lung disease

A

Obstructive - reduced

Restrictive - normal or increased

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7
Q

Give some important causes of haemoptysis

A

1) Lung cancer
2) Pulmonary oedema
3) Tuberculosis
4) Pulmonary embolism
5) LRTIs
6) Bronchiectasis
7) Mitral stenosis
8) Aspergilloma
9) Granulomatosis with polyangiitis
10) Goodpasture’s syndrome

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8
Q

What else should you look out for in haemoptysis if lung cancer is potential cause?

A
  • Smoking history
  • Symptoms of malignancy; weight loss, anorexia, fatigue
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9
Q

What else should you look out for in haemoptysis if pulmonary oedema is potential cause?

A
  • Dyspnoea
  • Bibasal crackles
  • S3 gallop on cardiac auscultation
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10
Q

What else should you look out for in haemoptysis if TB is potential cause?

A
  • Fever
  • Night sweats
  • Anorexia
  • Weight loss
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11
Q

What else should you look out for in haemoptysis if a PE is potential cause?

A
  • Pleuritic chest pain
  • Tachycardia
  • Tachypnoea
  • History of travel/surgery/immobilisation
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12
Q

What else should you look out for in haemoptysis if a LRTI is potential cause?

A

Usually acute history of purulent cough

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13
Q

What else should you look out for in haemoptysis if bronchiectasis is potential cause?

A

Usually long history of cough and daily purulent sputum production (i.e. PRODUCTIVE cough)

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14
Q

What else should you look out for in haemoptysis if mitral stenosis is potential cause?

A
  • Dyspnoea
  • Atrial fibrillation
  • Malar flush on cheeks
  • Mid diastolic murmur
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15
Q

What else should you look out for in haemoptysis if aspergilloma is potential cause?

A
  • Often past history of tuberculosis.
  • Haemoptysis may be severe
  • Chest x-ray shows rounded opacity
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16
Q

What is there often a history of in aspergilloma?

A

TB

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17
Q

What may CXR show in aspergilloma?

A

Rounded opacity

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18
Q

What else should you look out for in haemoptysis if granulomatosis with polyangiitis is potential cause?

A
  • Upper respiratory tract: epistaxis, sinusitis, nasal crusting
  • Lower respiratory tract: dyspnoea, haemoptysis
  • Glomerulonephritis
  • Saddle-shape nose deformity
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19
Q

What else should you look out for in haemoptysis if Goodpasture’s syndrome is potential cause?

A
  • Systemically unwell: fever & nausea
  • Glomerulonephritis
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20
Q

What are pleural plaques?

A

fibrous thickening on the pleura (the lining of the lungs)

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21
Q

What are pleural plaques often associated with?

A

Asbestos exposure (e.g. boiler engineer)

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22
Q

Are pleural plaques malignant?

A

No - don’t undergo malignant chance so NO follow up needed

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23
Q

What is the most common form of asbestos-related lung disease?

A

Pleural plaques

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24
Q

CXR findings in pleural plaques?

A

Discreet areas of bilateral pleural thickening (look up)

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25
Q

When is Abx prophylaxis required in COPD patients?

A

For people with COPD who have had more than 3 exacerbations requiring steroid therapy and at least 1 exacerbation requiring hospital admission in the previous year.

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26
Q

What class of Abx is used for prophylaxis in COPD patients?

A

Macrolides (e.g. azithromycin)

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27
Q

Stepwise management for COPD?

A

1) SABA or SAMA

For patients who remain breathless or have exacerbations despite using SABAs, the next step is determined by whether the patient has ‘asthmatic features/features suggesting steroid responsiveness’:

2a) No asthmatic features/features suggesting steroid responsiveness –> add LABA + LAMA (if already taking a SAMA, discontinue and switch to SABA)

2b) Asthmatic features/features suggesting steroid responsiveness –> add LABA + ICS

If patients remain breathless or have exacerbations offer triple therapy i.e. LAMA + LABA + ICS

NICE recommend the use of combined inhalers where possible

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28
Q

When should mucolytics be considered in COPD?

A

In patients with a chronic productive cough and continued if symptoms improve

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29
Q

All adults suspected to have asthma should have what tests?

A

1) Spirometry with a bronchodilator reversibility test

AND

2) FeNO test

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30
Q

What pO2 level is indicator for long term oxugen therapy (LTOT)?

A

pO2 <7.3 kPa

OR pO2 7.3-8 kPa and one of the following:
1) 2ary polycythaemia
2) peripheral oedema
3) pulmonary HTN

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31
Q

In terms of smoking, what is the NICE advice for LTOT in COPD?

A

Do NOT offer LTOT to people who continue to smoke despite being offered smoking cessation advice and treatment, and referral to specialist stop smoking services.

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32
Q

What CXR findings would indicate the need for needle aspiration in a pneumothorax?

A

> 2cm rim of air between lung margin and chest wall

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33
Q

What is Light’s criteria?

A

An exudate is likely if at least ONE of the following criteria are met:

1) pleural fluid protein divided by serum protein >0.5

2) pleural fluid LDH divided by serum LDH >0.6

3) pleural fluid LDH more than two-thirds the upper limits of normal serum LDH

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34
Q

Pleural fluid findings of low glucose may indicate what?

A

1) Rheumatoid arthritis (exudate)
2) TB (exudate)

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35
Q

Pleural fluid findings of raised amylase may indicate what?

A

1) pancreatitis
2) oesophageal perforation

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36
Q

Pleural fluid findings that are bloody may indicate what?

A

1) Mesothelioma
2) pulmonary embolism
3) tuberculosis

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37
Q

What is the most common cause of occupational asthma?

A

Isocyanates e.g. factories producing spray painting, foam moulding using adhesives

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38
Q

What pCO2 indicates near-fatal asthma?

A

Raised >6.0 kPa

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39
Q

What electrolyte abnormality is seen in sarcoidosis?

A

Hypercalcaemia

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40
Q

What skin manifestation is seen in sarcoidosis?

A

Erythema nodosum

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41
Q

Mainstay of treatment in small cell lung cancer?

A

Chemotherapy

Adjuvant radiotherapy is also now given in patients with limited disease.

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42
Q

Describe the CURB 65 score

A

1 point per:

  • Confusion (AMTS </= 8)
  • Urea (if in hospital) (>/= 7 mmol/L)
  • Respiratory rate (>/= 30)
  • BP (diastolic </= 90 and/or diastolic </= 60)
43
Q

Where in the lungs does asbestosis cause fibrosis?

A

Lower zone lung fibrosis

44
Q

What bacteria accounts for 80% of pneumonia cases?

A

Streptococcus pneumoniae (pneumococcus)

45
Q

What is the most common infective organism of pneumonia in COPD patients?

A

Haemophilus influenzae

46
Q

What organism typically causes pneumonia in patients following influenza infection?

A

Staph. aureus

47
Q

How does mycoplasma pneumoniae present?

A

One of the atypical pneumonias:
- Dy cough
- Atypical chest signs/CXR findings
- Autoimmune haemolytic anaemia and erythema multiforme may be seen

48
Q

Which organism causing pneumonia is classically seen in alcoholics?

A

Klebsiella pneumoniae

49
Q

Which organism causing pneumonia is classically seen in patients with HIV?

A

Pneumocystis jiroveci

50
Q

Which organism causing pneumonia is classically seen 2ary to infected air conditioning units?

A

Legionella pneumophilia

51
Q

What does lung abscess most commonly form 2ary to?

A

Aspiration pneumonia

52
Q

Features of lung abscess?

A
  • Foul smelling sputum (and productive cough)
  • Systemic symptoms e.g. night sweats, weight loss
  • Fever
  • Chest pain
  • Dyspnoea
53
Q

Who is sarcoidosis more common in?

A

Young adults and in people of African descent

54
Q

Common causes of respiratory alkalosis?

A
  • Anxiety leading to hyperventilation
  • Altitude
  • PE
  • Salicylate poisoning
  • CNS disorders e.g. stroke, subarachnoid haemorrhage, encephalitis
  • Pregnancy
55
Q

What type of metabolic disurbance does salicylate poisoning cause?

A

Salicylate overdose leads to a MIXED respiratory alkalosis and metabolic acidosis.

Early stimulation of the respiratory centre leads to a respiratory alkalosis whilst later the direct acid effects of salicylates (combined with acute renal failure) may lead to an acidosis

56
Q

Which type of pneumonia is associated with herpes labialis?

A

Streptococcus pneumoniae

57
Q

In which type of pneumonia is there ‘red currant jelly’ sputum?

A

Klebsiella pneumoniae pneumonia

58
Q

Describe ph, CO2 and HCO3- in respiratory alkalosis

A

Increased pH
Decreased CO2
Normal HCO3-

59
Q

Does a PE cause respiratory acidosis or alkalosis?

A

Respiratory alkalosis

60
Q

3 most common causes of meningitis in >60 y/o?

A

1) Strep pneumoniae

2) Neisseria meningitidis

3) Listeria monocytogenes

61
Q

3 most common causes of meningitis in 0-3 month old patients?

A

1) Group B Streptococcus (most common)

2) E. coli

3) Listeria monocytogenes

62
Q

An elderly patient presents with watery diarrhoea after being treated for pneumonia. Blood tests show a new, marked neutrophilia.

What is most likely organism?

A

C. difficile

63
Q

Describe the FEV1 (of predicted) for the following COPD:

a) mild
b) moderate
c) severe
d) very severe

A

a) FEV1 >80% of predicted
b) 50-79%
c) 30-49%
d) <30%

64
Q

What are bullae?

A

Bullae are air spaces in the lung measuring >1cm in diameter when distended.

65
Q

Most common cayse of bullae?

A

1) smoking
2) emphysema

66
Q

What can large bullae in COPD frequently mimic?

A

Pneumothorax

67
Q

What is the investigation of choice in idiopathic pulmonary fibrosis?

A

High resolution CT

68
Q

With COPD symptoms in a YOUNG patient, what condition should you consider?

A

alpha-1 antitrypsin (A1AT) deficiency

69
Q

Symptoms of Psittacosis (i.e. infection by Chlamydia psittaci)?

A
  • Atypical pneumonia symptoms (most common) e.g. fever, headache, myalgia, dyspnoea, dry cough, chest pain
  • Severe headache
  • Hepatomegaly or splenomegaly (rare)
70
Q

What is silicosis?

A

Silicosis is a fibrosing lung disease caused by the inhalation of fine particles of crystalline silicon dioxide (silica)

71
Q

What is silicosis a risk factor for?

A

Developing TB

72
Q

What occupations are at risk of silicosis?

A

mining
slate works
foundries
potteries

73
Q

Features of silicosis?

A
  • Persistent cough
  • Exertional SOB
  • upper zone fibrosing lung disease
  • ‘egg-shell’ calcification of the hilar lymph nodes
74
Q

CXR findings in silicosis?

A
  • upper zone fibrosing lung disease (bilateral)
  • ‘egg-shell’ calcification of the hilar lymph nodes
75
Q

Features of Cushing’s syndrome?

A
  • Weight gain
  • Chubby face
  • Purple stretch marks (striae)
  • HTN
  • Proximal muscle weakness & muscle fatigue
  • Hyperglycaemia
  • Hypokalaemia
76
Q

How does Cushing’s affect glucose?

A

Hyperglycaemia

77
Q

How does Cushing’s affect BP?

A

HTN

78
Q

How does Cushing’s affect potassium?

A

Hypokalaemia

79
Q

How does Cushing’s affect muscles?

A

Proximal muscle weakness

80
Q

What respiratory condition can lead to Cushing’s?

A

SCLC - ectopic ACTH secretion

81
Q

Prior to discharge, following an acute asthma attack, how long should a patient have been stable on their discharge medication (i.e. no nebulisers or oxygen)?

A

12-24 hours

82
Q

In patients with COPD, once the pCO2 is known to be normal, what should the target oxygen saturations be?

A

94-98%

83
Q

What triad is seen in Kartagener syndrome?

A

Primary ciliary dyskinesia

1) situs inversus totalis (including dextrocardia)
2) chronic sinusitis
3) bronchiectasis

84
Q

What Abx prophylactic is recommended in COPD patients who meet certain criteria and who continue to have exacerbations?

A

Macrolide e.g. azithromycin

85
Q

Gold standard investigation to diagnose mesothelioma?

A

Thoracoscopic biopsy –> histology performed

86
Q

FEV1 (of predicted) indicates the severity of COPD.

Describe FEV1 for COPD stage 1, 2, 3 and 4

A

1: >80%
2: 50-79%
3: 30-49%
4: <30%

87
Q

Does COPD cause clubbing?

A

No

88
Q

How long should oral prednisolone be given for in children with asthma attack?

A

3 days

89
Q

What is an aspergilloma?

A

a fungal mass that is found in pre-formed body cavities

90
Q

What is an aspergilloma normally 2ary to?

A

TB

91
Q

30-40 year old with basal emphysema and abnormal LFTs –> what is condition?

A

Alpha 1 antitrypsin deficiency

92
Q

Where is emphysema in A1AT most prominent?

What about in COPD?

A

A1AT –> lower lobes

COPD –> upper lobes

93
Q

What is the commonest cause of stridor in children?

A

Laryngomalacia

94
Q

Main iatrogenic cause of aspiration pneumonia?

A

Intubation

95
Q

How can intubation lead to aspiration pneumonia?

A

1) Use of neuromuscular agents may lead to an impaired swallow

2) Intubation itself can cause regurgitation

3) Intubation may cause damage to the trachea/airway that can inadvertently increase the risk of gastric contents aspirating into the lung

96
Q

1st line Abx in infective exacerbation of COPD?

A

Amoxicillin or doxycycline or clarithromycin

97
Q

How can clarithromycin affect QT interval?

A

Can prolong it –> clarithromycin should be avoided in patients with congenital long QT syndrome

98
Q

Which type of pneumonia is more common in alcoholics and diabetics?

A

Klebiella

99
Q

Presentation of Klebsiella pneumonia on CXR?

A

causes a cavitating pneumonia in the upper lobes

100
Q

The British Thoracic Society (BTS) published updated guidelines for the management of spontaneous pneumothorax in 2023.

What do the new guidelines put emphasis on for the guidance of management?

A

The updated guidelines put less emphasis on the size of the pneumothorax and more emphasis on whether the patient is symptomatic and the presence of high-risk characteristics.

101
Q

Decision algorithm for management of pneumothorax

A

1) Is the patient symptomatic?

2) If no –> conservative care, regardless of pneumothorax size

3) If yes, are there any high-risk characteristics?

4) If no then there is a choice of intervention:
- conservative care
- ambulatory device
- needle aspiration

5) If yes –> and it is safe to intervene → chest drain

102
Q

What are high-risk characteristics in a pneumothorax?

A

1) haemodynamic compromise (suggesting a tension pneumothorax)

2) significant hypoxia

3) bilateral pneumothorax

4) underlying lung disease

5) >/= 50 years of age with significant smoking history

6) haemothorax

103
Q

How is safety of intervention determined in a pneumothoax?

A

Before a needle aspiration/chest drain insertion, the safety of intervention should be assessed.

This depends on the clinical context, but is usually:
1) at least 2cm on CXR, or
2) any size on CT scan which can be safely accessed with radiological support

104
Q

How often should you consider ‘stepping down’ asthma treatment?

A

Every 3 months or so

105
Q

What should you aim for in the step down treatment of asthma?

A

Aim for a reduction of 25-50% in the dose of inhaled corticosteroids

106
Q
A

Yr 4 - CCC (54 decks)

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