Learning objectives AH1 - Respiratory Flashcards
Learning objectives for respiratory medicine:
Use of PFTs?
Indications?
Contraindications?
Risks?
What is normal FEV1/FVC?
What does ratio indicated obstruction?
What is the ratio in restrictive lung disease?
What is your DDX for obstructive PFTs?
What is your DDx for restrictive PFTs?
What value do flow volume loops have?
What is it based on?
What are the findings on flow volume loop of an obstructive condition?
What is meant by Reversibility in PFTs with asthma? E.g what are the values that would indicated this when pt given salbutamol?
What is your differential diagnosis for restrictive lung disease? - think - interstial pleuram NM, chest wall disease.
What are the findings you would expect on PFTs+ Flow volume loop in restrictive lung conditions?
Outline a stepwise approach to interpreting PFTs:
Whats the importance of RV and TLC in obstructive?
How do you assess small airways?
Whats the importance of DlcO?
What is the Diffusion lung Carbon monoxide test (DLCO)
How is the test done? How long do they hold their breath? What is the normal range?
What conditions cause an decrease diffusion capacity? Which can be increased
What conditions have normal PFTS but decreased DLCO test?
What is Bronchectasis? What is the definition of it?
What are the eitologies? Congenital? Post-infectious? Obstruction?
Pathogens commonly involved in bronchiectasis?
Pathogenesis?
What are the clinical features associated with Bronchiectasis?
- Consititutional? Respiratory ?Signs of exacerbations(2/3) needed?
What examination findings would you expect?
Inspection, Vitals, Peripheries, JVP, Chest?
What are diagnostic investigations? (CT diagnostic)
What are CXR findings associated with Bronchiectasis? CT Findings? - 2 marks
What investigations should be done to determine underlying cause of bronchiectasis?
What are the general Management measures? Abx? Bronchodilators? Ongoing monitoring? Closing?
What role does palliative care have in Bronchiectasis? (what do they provide)
What is the definition of COPD? Overview read
Case examples for patients with COPD: BMJ
History and examination findings in COPD: Outline:
What are spirometry values needed for diagnosis of COPD?
What are the GOLD criteria for severity of COPD? (FEV1 score)
What are 4 key factors on history and 8 on examination which could be expected in COPD?
More factors on examination for COPD?
What are major risk factors for COPD? List 5
First line investigatons in COPD? (3 marks)
Investigations to consider? Ongoing
Differential diagnosis for COPD? (pt presenting with COPD like symptoms) List 6 (3 marks)
What do you need to continually address and monitor when managing a patient with COPD? (think symptoms, use of medications (puffers +steroid), no of exacerbation, vaccination, exposures etc)
What is the intial pharmacological interventions in COPD?
COPD management continued: Read - based on severity
What is COPD X? What does it stand for? Explain
What are risk factors for COPD?
C – confirm diagnosis (FEV/FVC <70%)
O – Optimised function:
- Pharmacological intervention
- Pulmonary rehabilitation
- Exercise and healthy eating
P – Prevent deterioration
- Smoking cessation
- Vaccines (influenza and pneumococcal)
- Long term low flow oxygen therapy
D - Develop supportive networks and self-management skills
- Written COPD action plans are an important component of comprehensive self-management.
X - Exacerbation management
C- COPD X - Confirm diagnosis -
How is a diagnosis of COPD made, what investigations will support this diagnosis?
Diagnosis made on combination of
History
Exam findings
- Spirometry
- FEV1/FVC <70%
- Irreversible with bronchodilator
- RV + TLC increased
- DLCO reduced
- COPD Assessment Score (CAT)
- Validated questionnaire
Others
- CXR - features, rule out LuCa
- COPD Assessment Score (CAT)
- ABG - CO2 retainers have chronically ↑PaCO2 with compensatory ↑HCO3 and normal pH
How do you differentiate COPD from Asthma? Hx? Examination findings? Clinical signs. (Outline assessment findings COPD vs asthma)
How do you determine the severity of COPD? (think symptoms, exacerbations, other comorbidites)
What self assessment scores can be used to determine severity?
Outline overall management of COPD:
Non-pharmacological? (smoking, vaccination, action plan, physio, excercise, pulmonary rehabiliatation)
Pharmacological management? Mild, moderate, severe-palliative
Ongoing monitoring?
Complications of COPD? + Comorbidities to consider
Important complications and comorbidities include:
- CVD:
- Cardio-selective ß-blockers are generally safe and well tolerated for patients with COPD
- Avoid ßB if significantly overlapping asthma.
- Anxiety and depression:
- Associated with worse prognosis and increased hospitalisations.
- Pulmonary rehab –> reduces symptoms of both anxiety and depression.
- Osteoporosis:
- BMD is 10% lower on average than controls.
- Manage as osteoporosis guidelines.
- Diabetes
- COPD –> increased risk of DM & increased risk of diabetic complications 2º to ICS
- Regularly monitor BSLs
- Limit short courses of PO corticosteroids +/- escalation of hypoglycaemic therapy during course.
- pHTN & Cor Pulmonale:
- mild-mod pHTN is common complications
- pVasculature remodelling 2º hypoxia, inflammation and loss of capillaries .
- Severe pHTN – rare; diagnosed if pulmonary artery pressure >35mmHg and is disproportionally high compared to current level of lung damage.
- Cor Pulmonale:
- Consider if – peripheral oedema, eJVP; systolic parasternal heaves; loud P2
- Assess need for long-term O2
- Consider diuretics if oedema.
- mild-mod pHTN is common complications
Other complications of COPD:
- Secondary Pneumothorax due to rupture of bullae
- Chronic respiratory failure
- Acute exacerbation of COPD
O -Optimise function: Where to start?
What non-pharm strategies are recommended?
- Assessment is the first step to optimising function
- a validated assessment tool is a convenient way to measure baseline functional status and to measure response to treatment
O - Optimise continued- Approach to prescribing pharmacological therapies: Key points.
O - Optimise continued- Approach to prescribing pharmacological therapies: Key points.
When should inhaler technique be reviewed?
When Should treatment of comorbidities be optimised?
Stepwise approach:
• For all patients, check:
Adherence with COPD management strategies involves patients’ knowledge of
their non-pharmacological and pharmacological treatment strategies, motivation,
skill and physical ability with inhaler technique, health literacy, cost of medicines, willingness to pay, use of multiple inhalers and treatment for comorbidities.
- adherence with non-pharmacological (e.g. smoking cessation, immunisation,
exercise and oxygen therapy) and pharmacological treatment strategies
regularly, preferably at each visit. SR ME - inhaler technique at each visit, especially in older, frail and cognitively impaired
patients. SR ME
• Consider a home medicines review by a consultant pharmacist.
When should referral to specialist be made with patients with COPD?
P- Prevent deterioration
Whats the importance of giving smoking cessation advice; What is the 5 ‘as strategy- Brief intervention?
How can exacerbations risk be reduced?
What immunizations are needed for patients with COPD?
Why give smoking cessation advice?
- Smoking cessation is the most important intervention to prevent worsening of COPD
- Smoking cessation reduces the rate of decline in lung function [I].
- Smoking cessation advice from health professionals can increase quit rates [II].
- The major effect is to help motivate a quit attempt. (Zwar 2014)
- Personalising smoking cessation advice based on lung age and the lung age
- calculator may increase cessation rates [III]. (Parkes 2008)
- Anxiety and depression are associated with high rates of smoking and reduce the likelihood of success of smoking cessation [III-2]. (Jimenez-Ruiz 2015)
- Counselling combined with nicotine replacement therapy, bupropion, varenicline is more effective than counselling alone [I-II]. (Tashkin 2011)
- In more nicotine dependent smokers, the combination of a nicotine patch with a rapid delivery form of nicotine replacement (e.g. gum) is more effective than one form alone [I]. (Stead 2012)
- Based on a small number of trials, varenicline is more effective than nicotine replacement monotherapy but equally effective as a nicotine replacement combination therapy.
• Flag current smokers for brief smoking cessation advice or referral to local programs.
• Refer to best practice for brief smoking cessation counselling which is summarised in the
5-A strategy:
- Ask and identify smokers at every visit.
- Assess nicotine dependence and motivation to quit.
- Advise about the risks of smoking and benefits of quitting.
- Assist cessation by offering behavioural counselling and pharmacotherapy.
- Arrange follow-up within a week of the quit date and one month after.
A combination of pharmacological interventions and non-pharmacological strategies such as counselling and exercise improve effect.
P-Prevent deterioration-
What immunizations are needed for patients with COPD? Why immunize against these?
When should be mucolytics be used?
Who benefits from long term oxygen in COPD
D - Develop a care plan:
What good chronic disease care?
How can health professionals improve quality of life and reduce disability? (what does this entail at GP level)
D - Develop a care plan:
What is self-management support and how can patients with COPD benefit? (e.g there action plan, self management education, excercise training, psychosocial support) read
What other services can a patient with COPD benefit?
When and how should end stage palliative care be considered?
End-Stage & Palliative Care
Prognosis:
- Each exacerbation requiring hospitalisation increases the subsequent mortality risk
- Consider end-of-life discussion and palliative care treatment when:
- FEV1 <25%
- O2 dependence
- Respiratory failure
- Heart failure or other comorbidities
- Weight loss or cachexia
- Decreased functional status
- Increased dependence on others
- Advanced age.
Discussions:
- Include resuscitation and intubation wishes
- Advanced care planning in outpatient setting.
- Medical EPOA appointment.
- Ensure patient and caregivers are aware of palliative care services
Treatment Offerings / Symptom Management:
- Physiotherapy +/- OT for chest clearance
- Low-dose opioids +/- anxiolytics (lorazepam)
- Palliative oxygen therapy – must not be smoking.
Create at home care plan, so many of the symptoms can be managed at home preventing hospitalisation
End-Stage & Palliative Care
Prognosis:
- Each exacerbation requiring hospitalisation increases the subsequent mortality risk
- Consider end-of-life discussion and palliative care treatment when:
- FEV1 <25%
- O2 dependence
- Respiratory failure
- Heart failure or other comorbidities
- Weight loss or cachexia
- Decreased functional status
- Increased dependence on others
- Advanced age.
Discussions:
- Include resuscitation and intubation wishes
- Advanced care planning in outpatient setting.
- Medical EPOA appointment.
- Ensure patient and caregivers are aware of palliative care services
Treatment Offerings / Symptom Management:
- Physiotherapy +/- OT for chest clearance
- Low-dose opioids +/- anxiolytics (lorazepam)
- Palliative oxygen therapy – must not be smoking.
Create at home care plan, so many of the symptoms can be managed at home preventing hospitalisation
X- Manage Exacerbations:
How is a COPD exacerbation defined?
What are the benefits of early diagnosis and treatment of exacerbations: What is the role of an COPD action plan?
How is a COPD exacerbation defined?
- A COPD exacerbation is characterised by a change in the patient’s baseline dyspnoea, cough and / or sputum that is beyond normal day-to-day variations, is acute in onset and may warrant a change in regular medicine or hospital admission.
- The greatest predictor of an exacerbation is a history of exacerbations as these events cluster in time and become more frequent as the severity of COPD worsens
- Exacerbations become more frequent in those with a history of prior exacerbations, more severe disease (based on FEV1) and other predictors (including history of heartburn, poorer quality of life and elevated white cell count)
- Triggers for exacerbations include viral or bacterial respiratory infection, left ventricular failure, psychosocial stressors and air pollution [III-2].
- Pulmonary embolism should be considered in patients who require hospitalisation for an acute exacerbation
X- Manage exacerbations:
When should a patient with COPD be hospitalised? (list 4-6 reason) 2-3 marks:
Can patients with an excerbation be treated at home?
X- Manage exacerbations:
Are inhaled bronchodilators effective for excerbations? When, how and what doses should be given?
What role does oral corticosteroids have for treating excerbations?
X- Manage Excerbations
When are antibiotics beneficial in treating a patient with an excerbation? (e.g clinical features of infection)?
Is oxygen beneficial in treating a patient with an excerbation? (e.g treat hypoxaemia!)
When is non-invasive ventilation effective? (think ABG)
Following an excerbation how soon can pulmoary rehabilitation be started?
X: Manage excerbations:
What is the best approach to post-hospital care after an excerbation? (discharge plan, intergrated care approach, self management etc)
What is the Modified medical research council dyspnoea scale? (what are the gradigs and what do they represent)
COPD STEPWISE MANAGEMENT OF STABLE COPD: (stepwise management model)
Mild, Moderate, Severe?
Confirm diagnosis:
Optimise function+Develop care plan
Non-Pharm interventions:
Pharmacological interventions:
Algorithm: Managing excerbation: COPD X:
Outline approach: What to do initially when patient is having increased symptoms (sputum, cough, sob all increasing)
What is the first option?
Second option (COPD action plan)?
When to send to hospital? (list 5) 2.5 marks
Managing a COPD Excerbation checklist: (COPD X)
what should be done in
1) Hospital (List 6)
2) Prior to leaving the hospital (List 8)
3) Ongoing care (1-4 weeks post discharge) (list 6)
Acute excerbations of COPD:
What are the major features to diganose or suspect this?
Eitology: Infective vs Non infective? What are three common bacteria? (H.influenzae, m,cattarhalis, S.pneumoniae)
Differential diagnosis?
What should you rule out??? (PE, LVHF)
Clinical features?
History?
Acute excerbations of COPD:
What are your examination findings? (3 marks)
What Investigations need to be completed? List 6-8 (3-4 marks) Explain what your looking for in each Investigation:
How is an infective excerbation diagnosed? How is a non-infective excerbation diagnosed?
When should a patient be admitted?
What is the acute management? Medical (Bronchodilators, systemic corticosteroids, antibiotics, nebulised mucolytics + chest physiotherapy) + Supportive management? (4 marks:
Pulmoary function tests:
Compare Obstrutive vs restrictive volume flow loops: What would you expect TLC to be in each?
What are 4 ddx for obstructive picture? (2 marks)
What are 4 DDx for restrictive lung picture?
Interpreting CXR:
Consolidation: Signs on CXR- What are common DDX (3 marks)
Reticular (interstial disease)- What are signs on CXR? What are 6 diseases that cause this picture? 3 Marks
Nodular- Cavitary vs non-cavitary - What is you DDx- Think ((Neoplasm/infectious/inflammatory (RA, sarcoid, GPA, IPF))
Airways
- Start at the top in the midline and review the airways.
- trace down the trachea to the carina
- is it straight and midline?
- is there any narrowing?
- trace down both main bronchi
- is the carina wide (more than 100 degrees)?
- is there bronchial narrowing or cut-off?
- is there any inhaled foreign body?
- Read more: chest x-ray assessment of the airways
Breathing
- Look for lung and pleural pathology.
- both lungs should be well expanded and similar in volume
- can you count 10 posterior ribs bilaterally?
- is one lung larger than the other?
- compare the apical, upper, middle and lower zones in turn
- are they symmetrical?
- are there areas of increased density?
- trace the lung vessels
- do they branch out progressively and uniformly?
- can you see the retrocardiac and retrodiaphragmatic lung vessels?
- are there extra lines in the periphery that aren’t vessels?
- trace the lateral margins of the lung to the costophrenic angles
- are the costophrenic angles crisp?
- trace the hemidiaphragms in to the vertebra
- can you see the whole of the hemidiaphragm?
- trace the cardiac borders
- can you clearly see the left and right heart border?
- can you see the descending aorta?
- Read more: chest x-ray assessment of lungs and pleural spaces
Circulation
- Look at the heart and vessels (systemic and pulmonary).
- check the cardiac position
- is 1/3 to the right and 2/3 to the left?
- assess cardiac size
- is the cardiothoracic ratio < 50%?
- check the position and size of the aortic arch and pulmonary trunk
- check the width of the upper mediastinum
- look at the hilar vessels
- can you see them clearly on both sides?
- are they at a similar height?
- can you see a preserved hilar point bilaterally?
- Read more: chest x-ray assessment of the cardiomediastinum
Disability
- Check for any bony pathology (fracture or metastasis).
- trace along each posterior (horizontal) rib on one side of the chest
- is there a fracture or abnormal area?
- repeat with the other side of the chest
- now trace lateral and anterior ribs on the first side
- repeat on the other side
- now, check the clavicles and shoulders
- can you trace around the cortex of the bones?
- finally the check the vertebral bodies
- are they all rectangular and of a similar height?
- can you see 2 pedicles per vertebral body?
- are there disc spaces?
Read more: chest x-ray assessment of the bony thorax
Everything else
- Review the upper abdomen, soft tissues and take a look at some final check areas.
- is there free gas under the diaphragms?
- is there subcutaneous emphysema?
- is the gastric bubble in the correct place?
- is there a hiatus hernia?
- is there an absent breast shadow?
- are there any surgical clips?
- check again…
- are the lung apices clear?
- is there any retrocardiac or retrodiaphragmatic pathology?
Arterial Blood gases: Outline step by step approach:
1) Ph
2) What is the metabolic disturbance? (metabolic vs respiratory)
3) Is there compensation?
4) If patient has metabolic acidosis- What is the anon gap and osmolar gap? (what does an abnormal osmolar gap indicate) ?
5) if Anion gap is increased, is the change in Bicarbonate the same as the change in anion gap? (if not consider a mixed metabolic picture
Differential diagnosis of Respiratory acidosis? (increase PaCo2 secondary to hypoventilation) - E.g Lung diseases (all, Drugs, trauma, stroke, COPD)
Differential diagnosis for Respiratory alkalosis? (decrease PaC02 secondary to hyperventilation)
Approach to hypoxaemia:
What is the A-a gradient? (decreased DLco) - What do you do (management) give 02!
When is DLCo decreased? Ddx? (think ILD, anaemia, emphysema)
DCLo increased? (think) (asthma, obesity, polycythemia)
PFTS- Obstructive vs restrictive:
How do you define restrictive conditons from PFTs?
What is alpha-1 antitrypsin deficency?
What is Asthma? - Define: How does it clinically present?
How is asthma defined? (atopic, non-atopic (intrinsic)
Eitology (Atopic disease)?
Risk factors for asthma?
Pahtogenesis of asthma:
Sensitization, Early phase response, Late phase response.
How does asthma result in a respiratory acidosis? (airway obstruction causes V/Q mismatch)
Gross pathology? (mucus plugs, inflammed bronchi)
DDx for Acute wheeze and dyspnoea (Asthma)
1) Children
2) Adults
What is the natural history of asthma attack?
What are triggers for asthma?
What are the clinical features of asthma? (list 6 atleast) what is the hallmark? - WHat are typical features of asthma?
What needs to be covered in a History in patient with asthma? (consider DDx when taking history)
SOCRATES, triggers, associated, DDX, Pmhx, medications, immunizations, allergies, social (big in this) family hx) - 6 marks
What are expected examination findings in Acute asthma attack?
Inspection (ABCEDEF), VS, Hands, face, neck, chest, auscultation: (5 marks)
What is Status asthmaticus? What is the cause?
How is a diagnosis of asthma made? think Hx, exam, Ruling out other casues, PFT, bronchial challenge test, PEFR (diurnal variation):
How is PEFR done? Whats its use? What are the expected results from day to night?
How is asthma severity determined? (mild, moderate, severe)
What is the emergency ACUTE management of acute asthma attack:
Risk factors for severe asthma? (1 mark)
What is the 4 by 4 approach for children? (2 marks)
What are red flags to go to ED (DANGER)? (list 4)
Outline Assessment of acute asthma attack: How do we assess? (think vitals, WOB, RR< O2, behaviour LOC)
Mild? Moderate? Severe asthma signs clincally?
List life threatening signs in Asthma?
What are investigations should be considered in acute asthma?
Asthma attack; First line therapy and management:
1) DRSABC
2) 1st line
3) 2nd line or things to consider
4) After 1 hour reassess
5) Post acute care and discharge after resolution: (think- non pharm 5 a’s ) Medictions? Closing?
Maintenance Management of Asthma in adults: THINK (symptom control, education and non pharmological, Medical (preventers, relievers, pred) Saftey net and follow up.
What are signs of poor asthma control? (DANGER) need to know !
What are the non-pharm/education 5 as of asthma management? (action plan, avoid triggers, annual vaccines, and educated )
What is an asthma action plan?
What needs to be included on it? Drs details, check up dates
When well? (regular medication)
When not well? (asthma intefering with usual activity)
If symptoms get worse? (plan for severe asthma- when to go to hospital)
Pharmacological management of Asthma:
What is the stepped approach to asthma management?
Step 1, Step 2, Step 3, Step 4, Step 5.
What is a common starting regimen for asthma?
What other very important things need to be taught and explinaed regarding use of MDI
How do you assess and manage poorly controlled asthma? What need to be assessed (think 5 as of asthma)
How do you manage excercise induced asthma?
Children under 6 with newly diagnosed reactive airways disease: Management prinicple: