General Medicine: Respiratory Flashcards
How can you determine asthma severity (mod, severe, life by…
Speech
PEFR
02
Moderate // Severe // Life-threatening
Normal // Incomplete sentences // Reduced consciousness
50-75% // <50% // <33%
NA // >92% // <92%
What RR indicate severe asthma in
>12yrs
5-12yrs
2-5yrs
>=25/min
>=30/min
>=40/min
What is the initial management of acute asthma in adults?
Oxygen 15L/min
Salbutamol 5mg 6ml/min NEB
IV hydrocortisone 200mg OR PO prednisilone 40mg
What is the initial management of acute asthma in children?
Oxygen
Salbutamol 1-2 puffs via spacer (up to 10 puffs)
Oral steroids
If a patient does not improve on initial acute asthma treatment, what add on treatment can you give (adult and children)
Nebulised ipratroprium
Following senior input, what further line treatments in asthma are there?
IV salbutamol
Aminophylline use
IV MgSO4
What is the discharge criteria for an adult following acute asthma attack?
Stable off nebs for 12-24 hours
PEFR >75% of expected
What is the discharge criteria for acute asthma in children?
Stable on 3-4 hourly nebs for continuation at home
FEV1 >75% of best
Sats >94%
Apart from wheeze, nocturnal cough and personal history of atopy, what other features suggest asthma?
Nothing really
Productive cough, systemic symptoms, persistent cough tend to be caused by other things
What investigations are performed and what are the thresholds for chronic asthma in
Adults
Children
Adults: Spirometry with reversibility + FeNO
Children: Spirometry with reversibility +/- FeNO if spirometry not asthmatic in nature
Spirometry: FEV1/FVC <70% + bronchodilator reversibility >=12% in both groups
FeNO: >=40ppb adults, >=35ppb children
What is the treatment ladder for asthma in adults (>=17yrs)
- Low dose steroid
- LABA
- Increase steroid to medium dose OR + LTRA (remove LABA if no effect)
- Refer for specialist
What is the management of chronic asthma management of children (<17yrs)
- V. low dose steroid
- LABA <5yrs < LTRA/LABA
- Increase to low dose steroid OR +LTRA/LABA if >5yrs
- Specialist management
For management of asthma, what are the conditions for
Stepping up treatment
Stepping down treatment
Up: >=3 doses SABA uses/week
Down: Every 3 months if stable
What is the spirometry for COPD
FEV1 reduced
FVC normal
–> FEV/FVC low
What is the management of COPD
- SABA/SAMA PRN
2.
a) Reversibility/IgE: LABA + ICS
b) No reversibility: LAMA* + LABA
3) 1 severe/ 2 mod exacerbations: LABA + LAMA + ICS
4) Specialist input
*Stop SAMA IF GOING ON LAMA*
How do you manage an acute exacerbation of COPD
ISOAP
Oxygen
Salbutamol 2.5mg
Ipratroprium bromide 0.5g
Prednisilone 30mg oral
How do ABGs and GCS affect managemnt in COPD?
Normal ABGs: O2 + nebs
Worsening hypoxaemia: Increase O2, repeat in 30 mins
Reduced GCS: Get senior help
Patient with a unilateral swollen leg develops SOB, chest pain and low grade fever, what is the main differential?
PE
How do you determine whether to perform a CTPA in a PE patient?
Well’s Score: >4 is positive
-ve Score but +ve D-dimer: CTPA
When is CTPA not suitable and what do you use instead?
Pregnancy or renal impairment
V/Q scanning
What would allow for a PE to be managed at home?
Low PESI score (essentially no comorbities, home support and haem stability)
What should you do if getting a CTPA is going to take a while?
Commence anticoagulation anyway
What is the 1st line treatment for PE in most cases?
What circumstances differ from this and what do you give?
DOAC (inc active cancer)
Renal impairment: LMWH/UFH or LMWH + VKA
Antiphospholipid syndrome: LMWH + VKA
Massive PE: Thrombolysis
How long is VTE treatment for?
3 months initially +/-3 months if unprovoked (ie spontaneous, not provoked by surgery)
Who gets long term oxygen therapy for COPD?
NON SMOKER
pO2 <7.3kpa
OR 7.3-8.0 AND one of:
- 2ary polycythaemia
- peripheral oedema
- pulmonary hypertension
What are the investigations for acute pneumonia?
1st: Blood culture for sputum
GS: CXR within 3-5 days
What makes up the CRB65/CURB65 score
Confusion
Urea >7mmol/L
Resp rate >=30
Blood pressure <90/60
65 years or over
What are the 3 most common causes of community acquired pneumonia?
S. pneumoniae
H. Influenzae
S. Aureus
What are the 3 most common atypical causes of pneumonia?
C. Pneumoniae
Mycoplasma
Legionella
What form of lung cancer is most
common?
Associated with paraneoplastic syndrome?
Adenocarcinoma
Small cell
What CXR features suggest lung cancer?
Hilar enlargement
Lesions
Unilateral effusion
Collapse
What is the order of investigations for lung cancer?
- CXR
- CT +/- PET scan
- Bronchoscopy
How does cancer subtype direct treatment for lung cancer?
Small cell: Chemo + radio
Non-small cell: Surgery +/- radiotherapy and adjuvant chemo
The following signs indicate what extrapulmonary manifestation of lung cancer?
Hoarse voice
Shortness of breath
Facial swelling, SOB and upper body vein distention
Hoarse voice –> recurrent laryngeal nerve palsy
Shortness of breath –> Phrenic nerve palsy
Facial swelling, SOB and upper body vein distention –> SVC obstruction
Name the following paraneoplastic syndromes
Eye droop, pupil dilation and lack of sweating
Cushingoid features
Hypercalcaemia
Short term memory difficulties, hallucinations, confusion
Proximal limb weakness, double vision, ptosis, slurred speech
Eye droop, pupil dilation and lack of sweating –> Horner’s syndrome
Cushingoid features –> ACTH from small cell
Hypercalcaemia –> ectopic PTH from squamous cell
Short term memory difficulties, hallucinations, confusion –> small cell limbic encephalitis
Proximal limb weakness, double vision, ptosis, slurred speech –> Lambert Eaton Myasthenic syndrome. Can improve reflexes with sustained muscle contraction
Differentiate TB and sarcoidosis based on
Cough
Systemic symptoms
CXR findings
Pathogen
Histology
TB // Sarcoidosis
Productive, haemoptysis // dry
Night sweats, +/- spinal pain // facial rash, lymphadenopathy
consolidation, cavitation. Ghon focus // bilateral hilar lymphadenopathy
Acid fast bacillus (M. tuberculosis) // autoimmune
caseating // non-caseating granuloma
How do you investigate for tuberculosis?
Active:
- CXR: Upper lobe cavitation
GS: Sputum culture for ZN stain
Latent
Mantoux >15 (6-15 may suggest previous TB or BCG)
What is the role of NAAT and sputum smear in TB?
Rapid testing for TB but less sensitive than culture
What is the treatment for diagnosed tuberculosis?
Primary
RIPE 6 months then 2 months RI
Reactivation
RI 3 months OR I 6 months
What are the side effects of the RIPE drugs?
Rifampicin –> red pee, reduced P450
Isoniazid –> Peripheral neuropathy
Pyrazinamide –> Gout
Ethambutol –> Colour blindness, visual acuity
How can you reduce the side effect of pyrazinamide?
Co-presribe B6
What additional screening test should be done in tuberculosis?
HIV test
What are the inveestigations for sarcoidosis?
- CXR shows bilateral hilar lymphadenopathy (as does TB, lymphoma)
Bloods show
Raised ACE and calcium (macrophage activity)
What is the management for sarcoidosis?
If mild, none
- Oral steroids 6-24 months
- Methotrexate, azathioprine
What symptoms are suggestive of pneumothorax?
acute breathlessness +/- pleuritic chest pain and hyperresonance
What is the treatment of simple pnemothorax?
Simple primary
SOB <2cm: No treatment, FU in 2-4 weeks
SOB >2cm: Aspirate
2x failed aspirations: Chest drain
Tension
- Large bore cannula 2IC space, mid clavicular
- Chest drain 5th IC
What is the treatment of the following pneumothoraces
Secondary
Iatrogenic
Secondary
>50 yrs + >2cm: Chest drain
Otherwise aspirate (if <1cm then give oxygen and admit for 24hrs)
Iatrogenic
Mostly spontaenous but aspirate if needed
What advice should be given to pneumothorax patients regarding
Smoking
Flying
Scuba diving
Stop
1 week post CXR check
Permanent avoidance unless pleurectomy with clear lung function and CT chest
Give the name of a
SABA
SAMA
LAMA
LABA
Salbutamol
Ipratrioprium
Tiotropium (lasts for Time-otropium)
-meterols
What conditions cause upper zone fibrosis?
CHARTS
Coal worker’s pneumoconiosis
Hypersensitivity pneumonitis
Ank spond (rare)
Radiation
TB
Silicosis and sarcodosis
How can you differentiate white out lung lesions?
See if trachea is central, pulled in or away from the white out
What conditions pull the trachea towards the white out?
Things reducing pressure on that side
Pneumonectomy
Complete lung collapse
Endobronchial intubation
Pulmonary hypoplasia
What white outs push the trachea away from the white out?
Things increasing pressure on that side
Pleural effusion
Diaphragmatic hernia
Large thoracic mass
What white out lesions keep a central trachea?
Consolidation
Pulmonary oedema
Mesothelioma
How do exudate and transudate differ in disease process?
Transudate: Increased fluid pressure (HF, liver disease, Meig’s)
Exudate: Increased capillary permeability (Infection, inflammation, cancer)
Dull percussion, reduced breath sounds and reduced chest expansion are indicative of what lung pathology?
Pleural effusion
How do you determine if an effusion is transudate or exudate?
Transudate <30gL< Exudate
If between >25-35g/L, its exudate if one of these is true:
- Pleural/serum protein >0.5
- Pleural LDH/serum LDH >0.6
- Pleural LDH = normal range x 1.66
What do the following features of an effusion suggest?
Heavy blood staining
Low glucose
Raised amylase
Mesothelioma, PE, TB
RA, TB (?inflammation using it up)
Pnacreatitis, oesophageal perforation
How is a pleural effusion investigated and treated?
Investigations
- CXR
GS: Pleural aspirate with US guidance. Use a 21G needle with 50ml syringe
Management
Treat cause
Repeat drainage/pleurodesis/drugs if recurrent
When should a chest tube be placed in pleural effusion?
Cloudy
Clear but pH <7.2
Regarding asbestos exposure…
are pleural plaques pre-malignant?
What is the most dangerous form of asbestos?
What is the treatment of mesothelioma?
No, plerual plaques are benign
Blue (crocodilite)
Palliative chemotherapy
How do you grade COPD and what are stages 1-4
Post-bronchodilator FEV/FVC <0.7 AND FEV1 of
>80%: Mild (I)
50-79%: Moderate (II)
30-49%: Severe (III)
<30%: Very severe (IV)
What does a Hx of bronchiectasis and allergy/raised eosinophils suggest and how is it treated?
Aspergillosis
- Oral glucocorticoids
- Itraconazole
Which COPD patients are eligible for daily oral azithromycin therapy?
Those who have
- Stopped smoking + have optimal medical management but keep having exacerbations
- Exclusion of the following
> Bronchiectasis (CT thorax) and atypical, TB (sputum culture)
> QT prolongation via LFTs and ECG
Whats wrong with this CXR?
NG tube in right lower lobe of lung
Should be sub-diaphramatic
What are the 4 common causes of an anterior mediastinal mass?
Thyroid mass
Thymic mass
Terrible lymphadenopathy
Teratoma
How can small cell cancer and cushing’s disease be diferentiated?
High dose dexamethasone will suppress cushing’s disease (due to -ve feedback)
Since SCLC is ectopic, it is unaffected by the normal ACTH system .’. no suppression
What should a pneumonia patient with COPD be presribed in addition to antibiotics?
Prednisilone
Regarding smoking cessation…
What 3 agents are available?
How long should presription last for?
How long should you wait before a repeat prescription if the cessation was unsuccessful?
NRT, varenicicline (nicotinic partial agonist), buproprion (NA + DA agonist, nicotinic antagonist)
Until 2 weeks post target quit date
Wait 6 months
Which smoking cessation drugs cause…
Nausea + headache
insomnia, weird dreams
seizzure risk
NRT + varencicline
varencicline
buproprion
What smoking cessation agents are contraindicated in…
Epilepsy
Pregnancy
Breastfeeding
Depression
Eating disorders
Bupriprion as increased seizure risk
Buproprion, varencicline in pregnancy and breastfeeding
varencicline as partial psych effects
buproprion in eating disorders
Which pregnant women get smoking cessation
What is the management plan
Current smokers, quit <2 weeks ago, CO >7ppm
- Behaviorual intervention
- Nicotine replacement therapy
What 3 pathogens are the most common exacerbants of COPD?
H. Influenzae
S. Pneumoniae
M. Catarrhalis
Can asthmatics taking prednisilone breastfeed?
Yes
Muscle tenderness in a suspected lung cancer patient is indicative of what?
LEMS
Autoimmunity against Ca2+ channels instead of the cancer
What drug should be avoided in pneumonia patients with long QT?
Clarithromycin
What features suggest acute bronchitis?
What lab finding indicates treatment and what is it?
Cough +/- white or discoloured sputum. CXR rules out pneumonia
If CRP >100, give doxycycline (Amox in children or pregnants)
How would you confirm occupational asthma?
Serial peak flow measurements in and out of work
How can you differentiate facial rashes in sarcoidosis and SLE?
Lupus: Photosensitive, ‘butterfly’ rash
Sarcoidosis: non-painful, indurated, affects nose, cheeks, ears and lips
How does restrictive lung disease present in terms of
FEV1
FVC
FEV1/FVC
FEV1: Reduced
FVC: Very reduced
FEV/FVC: Normal or increased
What does this CXR show?
Right upper lobe consolidation
Opacity abutting the horizontal fissure
What conditions cause finger clubbing?
CLUBBING
Cyanotic, cystic defects
Lung abscess
Ulcerative colitis
Bronchiectasis
Benign mesothelioma
Iinfective endocarditis
NOT COPD
GI stuff
If COPD symptoms present in a young person, what should you suspect?
a1-antitrypsin deficiency
red jelly sputum indicates what?
Klebsiella pneumoniae
When do you initiate management for sarcoidosis?
Evidence of worsening CXR or spirometry
Involvement of systems outside resp or joints
hypercalcaemia
Lupus pernio
What blood gas result is worrying in an asthma attack?
normal pCO2, shows no longer blowing off CO2 via hyperventilation because theyre tiring
