Corrections - Respiratory Flashcards
What is the new stepwise management for asthma under the 2017 NICE guidelines for adults?
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
RR in moderate vs severe acute asthma?
Moderate - <25/min
Severe - >25/min
Pulse in moderate vs severe acute asthma?
Moderate - <100 bpm
Severe - >100 bpm
PEFR in moderate, severe and life-threatening acute asthma?
Moderate - 50-75%
Severe - 33-50%
Life-threatening - <33%
Describe FEV1 in obstructive vs restrictive lung disease
Obstructive - significantly reduced
Restrictive - reduced
Describe FVC in obstructive vs restrictive lung disease
Obstructive - reduced or normal
Restrictive - significantly reduced
Describe FEV1% (FEV1/FVC) in obstructive vs restrictive lung disease
Obstructive - reduced
Restrictive - normal or increased
Give some important causes of haemoptysis
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
What else should you look out for in haemoptysis if lung cancer is potential cause?
- Smoking history
- Symptoms of malignancy; weight loss, anorexia, fatigue
What else should you look out for in haemoptysis if pulmonary oedema is potential cause?
- Dyspnoea
- Bibasal crackles
- S3 gallop on cardiac auscultation
What else should you look out for in haemoptysis if TB is potential cause?
- Fever
- Night sweats
- Anorexia
- Weight loss
What else should you look out for in haemoptysis if a PE is potential cause?
- Pleuritic chest pain
- Tachycardia
- Tachypnoea
- History of travel/surgery/immobilisation
What else should you look out for in haemoptysis if a LRTI is potential cause?
Usually acute history of purulent cough
What else should you look out for in haemoptysis if bronchiectasis is potential cause?
Usually long history of cough and daily purulent sputum production (i.e. PRODUCTIVE cough)
What else should you look out for in haemoptysis if mitral stenosis is potential cause?
- Dyspnoea
- Atrial fibrillation
- Malar flush on cheeks
- Mid diastolic murmur
What else should you look out for in haemoptysis if aspergilloma is potential cause?
- Often past history of tuberculosis.
- Haemoptysis may be severe
- Chest x-ray shows rounded opacity
What is there often a history of in aspergilloma?
TB
What may CXR show in aspergilloma?
Rounded opacity
What else should you look out for in haemoptysis if granulomatosis with polyangiitis is potential cause?
- Upper respiratory tract: epistaxis, sinusitis, nasal crusting
- Lower respiratory tract: dyspnoea, haemoptysis
- Glomerulonephritis
- Saddle-shape nose deformity
What else should you look out for in haemoptysis if Goodpasture’s syndrome is potential cause?
- Systemically unwell: fever & nausea
- Glomerulonephritis
What are pleural plaques?
fibrous thickening on the pleura (the lining of the lungs)
What are pleural plaques often associated with?
Asbestos exposure (e.g. boiler engineer)
Are pleural plaques malignant?
No - don’t undergo malignant chance so NO follow up needed
What is the most common form of asbestos-related lung disease?
Pleural plaques
CXR findings in pleural plaques?
Discreet areas of bilateral pleural thickening (look up)
When is Abx prophylaxis required in COPD patients?
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.
What class of Abx is used for prophylaxis in COPD patients?
Macrolides (e.g. azithromycin)
Stepwise management for COPD?
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
When should mucolytics be considered in COPD?
In patients with a chronic productive cough and continued if symptoms improve
All adults suspected to have asthma should have what tests?
1) Spirometry with a bronchodilator reversibility test
AND
2) FeNO test
What pO2 level is indicator for long term oxugen therapy (LTOT)?
pO2 <7.3 kPa
OR pO2 7.3-8 kPa and one of the following:
1) 2ary polycythaemia
2) peripheral oedema
3) pulmonary HTN
In terms of smoking, what is the NICE advice for LTOT in COPD?
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.
What CXR findings would indicate the need for needle aspiration in a pneumothorax?
> 2cm rim of air between lung margin and chest wall
What is Light’s criteria?
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
Pleural fluid findings of low glucose may indicate what?
1) Rheumatoid arthritis (exudate)
2) TB (exudate)
Pleural fluid findings of raised amylase may indicate what?
1) pancreatitis
2) oesophageal perforation
Pleural fluid findings that are bloody may indicate what?
1) Mesothelioma
2) pulmonary embolism
3) tuberculosis
What is the most common cause of occupational asthma?
Isocyanates e.g. factories producing spray painting, foam moulding using adhesives
What pCO2 indicates near-fatal asthma?
Raised >6.0 kPa
What electrolyte abnormality is seen in sarcoidosis?
Hypercalcaemia
What skin manifestation is seen in sarcoidosis?
Erythema nodosum
Mainstay of treatment in small cell lung cancer?
Chemotherapy
Adjuvant radiotherapy is also now given in patients with limited disease.
Describe the CURB 65 score
1 point per:
- Confusion (AMTS </= 8)
- Urea (if in hospital) (>/= 7 mmol/L)
- Respiratory rate (>/= 30)
- BP (diastolic </= 90 and/or diastolic </= 60)
Where in the lungs does asbestosis cause fibrosis?
Lower zone lung fibrosis
What bacteria accounts for 80% of pneumonia cases?
Streptococcus pneumoniae (pneumococcus)
What is the most common infective organism of pneumonia in COPD patients?
Haemophilus influenzae
What organism typically causes pneumonia in patients following influenza infection?
Staph. aureus
How does mycoplasma pneumoniae present?
One of the atypical pneumonias:
- Dy cough
- Atypical chest signs/CXR findings
- Autoimmune haemolytic anaemia and erythema multiforme may be seen
Which organism causing pneumonia is classically seen in alcoholics?
Klebsiella pneumoniae
Which organism causing pneumonia is classically seen in patients with HIV?
Pneumocystis jiroveci
Which organism causing pneumonia is classically seen 2ary to infected air conditioning units?
Legionella pneumophilia
What does lung abscess most commonly form 2ary to?
Aspiration pneumonia
Features of lung abscess?
- Foul smelling sputum (and productive cough)
- Systemic symptoms e.g. night sweats, weight loss
- Fever
- Chest pain
- Dyspnoea
Who is sarcoidosis more common in?
Young adults and in people of African descent
Common causes of respiratory alkalosis?
- Anxiety leading to hyperventilation
- Altitude
- PE
- Salicylate poisoning
- CNS disorders e.g. stroke, subarachnoid haemorrhage, encephalitis
- Pregnancy
What type of metabolic disurbance does salicylate poisoning cause?
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
Which type of pneumonia is associated with herpes labialis?
Streptococcus pneumoniae
In which type of pneumonia is there ‘red currant jelly’ sputum?
Klebsiella pneumoniae pneumonia
Describe ph, CO2 and HCO3- in respiratory alkalosis
Increased pH
Decreased CO2
Normal HCO3-
Does a PE cause respiratory acidosis or alkalosis?
Respiratory alkalosis
3 most common causes of meningitis in >60 y/o?
1) Strep pneumoniae
2) Neisseria meningitidis
3) Listeria monocytogenes
3 most common causes of meningitis in 0-3 month old patients?
1) Group B Streptococcus (most common)
2) E. coli
3) Listeria monocytogenes
An elderly patient presents with watery diarrhoea after being treated for pneumonia. Blood tests show a new, marked neutrophilia.
What is most likely organism?
C. difficile
Describe the FEV1 (of predicted) for the following COPD:
a) mild
b) moderate
c) severe
d) very severe
a) FEV1 >80% of predicted
b) 50-79%
c) 30-49%
d) <30%
What are bullae?
Bullae are air spaces in the lung measuring >1cm in diameter when distended.
Most common cayse of bullae?
1) smoking
2) emphysema
What can large bullae in COPD frequently mimic?
Pneumothorax
What is the investigation of choice in idiopathic pulmonary fibrosis?
High resolution CT
With COPD symptoms in a YOUNG patient, what condition should you consider?
alpha-1 antitrypsin (A1AT) deficiency
Symptoms of Psittacosis (i.e. infection by Chlamydia psittaci)?
- Atypical pneumonia symptoms (most common) e.g. fever, headache, myalgia, dyspnoea, dry cough, chest pain
- Severe headache
- Hepatomegaly or splenomegaly (rare)
What is silicosis?
Silicosis is a fibrosing lung disease caused by the inhalation of fine particles of crystalline silicon dioxide (silica)
What is silicosis a risk factor for?
Developing TB
What occupations are at risk of silicosis?
mining
slate works
foundries
potteries
Features of silicosis?
- Persistent cough
- Exertional SOB
- upper zone fibrosing lung disease
- ‘egg-shell’ calcification of the hilar lymph nodes
CXR findings in silicosis?
- upper zone fibrosing lung disease (bilateral)
- ‘egg-shell’ calcification of the hilar lymph nodes
Features of Cushing’s syndrome?
- Weight gain
- Chubby face
- Purple stretch marks (striae)
- HTN
- Proximal muscle weakness & muscle fatigue
- Hyperglycaemia
- Hypokalaemia
How does Cushing’s affect glucose?
Hyperglycaemia
How does Cushing’s affect BP?
HTN
How does Cushing’s affect potassium?
Hypokalaemia
How does Cushing’s affect muscles?
Proximal muscle weakness
What respiratory condition can lead to Cushing’s?
SCLC - ectopic ACTH secretion
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)?
12-24 hours
In patients with COPD, once the pCO2 is known to be normal, what should the target oxygen saturations be?
94-98%
What triad is seen in Kartagener syndrome?
Primary ciliary dyskinesia
1) situs inversus totalis (including dextrocardia)
2) chronic sinusitis
3) bronchiectasis
What Abx prophylactic is recommended in COPD patients who meet certain criteria and who continue to have exacerbations?
Macrolide e.g. azithromycin
Gold standard investigation to diagnose mesothelioma?
Thoracoscopic biopsy –> histology performed
FEV1 (of predicted) indicates the severity of COPD.
Describe FEV1 for COPD stage 1, 2, 3 and 4
1: >80%
2: 50-79%
3: 30-49%
4: <30%
Does COPD cause clubbing?
No
How long should oral prednisolone be given for in children with asthma attack?
3 days
What is an aspergilloma?
a fungal mass that is found in pre-formed body cavities
What is an aspergilloma normally 2ary to?
TB
30-40 year old with basal emphysema and abnormal LFTs –> what is condition?
Alpha 1 antitrypsin deficiency
Where is emphysema in A1AT most prominent?
What about in COPD?
A1AT –> lower lobes
COPD –> upper lobes
What is the commonest cause of stridor in children?
Laryngomalacia
Main iatrogenic cause of aspiration pneumonia?
Intubation
How can intubation lead to aspiration pneumonia?
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
1st line Abx in infective exacerbation of COPD?
Amoxicillin or doxycycline or clarithromycin
How can clarithromycin affect QT interval?
Can prolong it –> clarithromycin should be avoided in patients with congenital long QT syndrome
Which type of pneumonia is more common in alcoholics and diabetics?
Klebiella
Presentation of Klebsiella pneumonia on CXR?
causes a cavitating pneumonia in the upper lobes
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?
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.
Decision algorithm for management of pneumothorax
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
What are high-risk characteristics in a pneumothorax?
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
How is safety of intervention determined in a pneumothoax?
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
How often should you consider ‘stepping down’ asthma treatment?
Every 3 months or so
What should you aim for in the step down treatment of asthma?
Aim for a reduction of 25-50% in the dose of inhaled corticosteroids
