Passmed: Resp Flashcards
Moderate asthma
PEFR 50-75
Speech normal
RR <25
Pulse < 110
Severe Asthma
PEFR 33-50
Can’t complete sentences
RR >25
Pulse >110
Life-threatening Asthma
PEFR < 33
O2 < 92
Normal pC02
Silent chest, cyanosis, low resp effort, bradycardia, dysrhythmia, hypotension
exhaustion, confusion or coma
near fatal = raised C02 or mechanical ventilation
ABG indication in acute asthma
O2 < 92
CXR indications in Asthma
life-threatening
Pneumothorax
failure to respond to treatment
Who should be admitted with acute asthma
Life threatening
severe - if not respond to intital treatment
previous near fatal
pregnancy
attack despite using oral CS that night
Acute asthma patients that need oxygen
Hypoxaemic
acutely unwell - 15L - 94/98
How should SABA be delivered in LT A asthma
neb
What is given post A asthma
40-50mg pred PO - 5 days
continue normal meds as well
Treatment options in ITU for A asthma and indications
failure to respond to treatments - give senior critical care support
intubation and ventilation + ECMO
Criteria for A asthma discharge
stable (no additional meds) - 12/24 hrs
inhaler technique checked
PEF > 75%
Signs of acute bronchitis
cough
sore throat
rhinorrhoea
wheeze - only chest sign
clinical diagnosis - CRP testing
Mx of Acute bronchitis
analgesia
fluid
AB if:
- systemic
- - pre-existing co morbidities
- CRP 20/100 delay - above 100 give AB
AB = doxycycline, give amoxicillin in children / pregnant women
Post A COPD treatment
increase BD use + neb
pred 30mg 5 days
purulent sputum / pneumonia - ABS
- amox / clari / doxy
A COPD admission criteria
breathlessness
confusion
cyanosis
90> sats
social reasons
comorbidity
Initial oxygen therapy COPD
28% venturi mask 4 litres - no history resp acidosis
if co2 normal adjust target range
T2Rf in A COPD
NIV
- 7.25-7.35
then use BiPaP
What is ARDS
increased permeability of alveoli = fluid accumulation
- non cardiogenic PO
Causes of ARDS
infection
blood transfusion
trauma
smoke
acute pancreatitis
covid-19
cardio-pulmonary bypass
Features of ARDS and Ix
dyspnoea
resp rate raised
bilateral lung crackles
low oxygen sats
Specific features of ARDS
acute onset - within 1 week of factor
PO
non cardiogenic -check wedge pressure
pO2/fio2 < 40 /300
Mx of ARDS
ITU
treat hypoxaemia
organ support e.g vasopressors
underlying cause
prone and muscle relaxation
Where is bronchiectasis in ABPA
proximal
Ix for ABPA
eosinophilia
CXR
+ve RAST test
raised IgE
glucocorticoids
How to interpret a blood gas
hypoxaemic
acidaemic or alklaemic
PaCO2
Metabolic component (base excess high or low)
Treatment of pleural plaques
benign and no malignant change
Features of asbestos exposure
pleural thickening
plaques
asbestosis - lower zone fibrosis, reduced exercise tolerance
Features of mesothelioma
progressive sob
chest pain
pleural effusion
palliative chemo
lung cancer more common with asbestos - smoking increase further
RF for aspiration pneumonia
poor dental hygiene
swallowing
prlonged hospitalisation
impaired consciousness
impaired mucociliary clearance
Most common site for aspiration pneumonia
right middle
right lower
larger and more vertical
Test for asthma over 17 and under
> 17 - ask about work for occupational, spirometry (less than 70) with BDR & FeNO
<17 - spirometry with BDR, FeNO only if normal (child 35 not 40)
BDR results
adults - FEV1 12% or 200ml
Child - 12% improvement
Occupational asthma causes and work up
Isocyanates - spray paint
serial measurements of peak expiratory flow - go to specialist
Asthma step down
every 3 months
25-50% of inhaled steroids
Atelectasis
basal alveolar collapse post operation
bronchial secretions leading to hypoxaemia and dyspnoea 72 hrs postoperatively
position upright and breathing exercises
Causes of Bilateral hilar lymphadenopathy
Sarcoid and TB
lymphoma
pneumoconiosis
fungi
Causes of bronchiectasis
permanent dilatation of airways in response to infection / inflammation
- post infective
- CF
- obstruction
- immune def
- ABPA
- Ciliary dyskinetic e.g kartageners
- yellow nail syndrome
tramlines and signet ring
Mx of Bronchiectasis
physio
postural drainage
ABs
bronchodilators
immunise
Contraindications for chest drain
INR > 1.3
platelet count < 75
Pulmonary bullae
pleural adhesions
Chest drain features
45 angle
5th intercostal space, MAL, lidocaine
seldinger technique - aspirate fluid, go up on inspiration
Complications of chest drain
failure to insert
bleeding
infection
penetration
re-expansion pulomonary oedema - clamp and urgent CXR ( avoid rapid fluid output)
Removal of chest drain
no output > 24 hrs
no longer bubbling
penetrating chest injury review by specialist
Causes of lobar collapse
lung cancer - adults
asthma
foreign body
trachea towards, media towards, elevation of hemidiaphragm
Cannonball mets from where
Renal cell carcinoma
Causes of mediastinal widening
patient rotation
acute: AAA, lymphoma, goitre, teratoma, thymus tumour
CXR pulmonary oedema
bat wing
upper lobe diversion
kerley b
pleural effusion
cardiomegaly - if cardiogenic
Causes of white lung lesions
Trachea toward - pneumonectomy, lung collapse, hypoplasia
Central - consolidation, PO, mesothelioma
Away - effusion, diaphragmatic hernia, thoracic mass
Features of pneumoconiosis
coal dust
immune response
simple - asymp, some opacities, normal lung marking and no lung markings
progressive massive fibrosis - mixed lung picture
upper zone fibrosis, avoid coal, chronic bronchitis treatment and get compensation
Features of COPD
CXR - hyperinflation, bullae, flat hemidiaphragm
Bloods - secondary poly
staging - 80, 50-79, 30-49, 30 (very severe) - FEV1
Asthmatic features of COPD
LABA + LAMA + ICS on triple
exclude lama if first time
swap sama to saba
theophylline if cannot inhale, reduce if macrolide co-prescribe
What should be done before prescribing azithromycin
ecg - qt prolongation
PDE-4 and COPD
reduce exacerbations e.g roflumilast
severe - less than 50%
2 or more exacerbations in previous 12 months despite triple therapy of LAMA< LABA and ICS
Churg strauss syndrome
asthma
blood eosinophilia
paranasal sinusitis
mononeuritis
pANCA
Gran with P - renal failure + epistaxis + cANCA - steroids
Aspergilloma and haemoptysis
past history of TB
Inhaler technique
remove cap and shake
breathe out gently
put in mouthpiece as breath in slow and depp, inhale steadiliy
hold breath for 10 seconds
second dose wait 30 seconds - repeat
only use number of doses on label
Features of kartageners
primary ciliary dyskinesia
dextrocardia
bronchiectasis
recurrent sinusitis
subfertility
Klebsiella
gram neg
following aspiration and uti
alcoholic and diabetics
red current jelly
upper lobe
lung abcess and empyema
Features of lung abscess
aspiration pneumonia
staph / kleb
subacute -slow symptoms and systemic features
CXR - fluid filled space
IV ABs then percutaneous drainage
Features of each lung cancer
small cell - adh, acth, lambert eaton (weak on use)
scc - parathyroid, clubbing, hypertrophic pulmonary osteoarthropathy, hypert ectopic tsh
adeno - gynaecomastia, hpoa
Ix for lung cancer
CXR - then ct
bronchoscopy for histology
raised platelets on blood
Referral criteria for lung cancer
cxr of LC
aged 40 unexplained lung cancer - 2ww
urgent cxr in 2 weeks over 40 and 2 / smoked / 1 - cough, fatigue, etc
consider if 40 over with - recurrent chest infection, clubbing, chest signs, thrombocytosis
Lung fibrosis zones
upper - hypersen pneumonitis, coal, silicosis, sarcoid, anklyosing, tbf, radiation induced
lower - ipf, connective tissue e.g. sle, drugs, asbestosis
cytology negative exudative effusions
local anaesthetic thoracoscopy
chemo for meso
Cons of OSA
daytime somnolence
resp acidosis
hypertension
Oxygen therapy indications
critically ill - anaphylais, shock - 15litre
no for MI, stroke, obstetirc, anxiety
Pleural effusion causes
trans - failures, heart most common
exudate (high protein above 30) - infection e.g. pneumonia, connecitve tissue, neoplasia, pancreaitis, pe, dressler
Ix and Mx of Pleural Effusion
PA CXR
USS on aspiration
21G and 50ml syndrine
lights: exudate likely if one - pleural fluid protein > 0.5, LDH pleural / serum ldh > 0.6, pleural ldh 2/3 upper limit of normal serum ldh
characterisitc pleural fluid
low glucose - RA and TB
raised amylase - pancreatitis and oesophageal perforation
heavy blood staining - mesothelioma, pe, tb
No symptoms with pneumothorax
conservative care regardless of size
high risk characteristics of pneumothorax
haemodynamic compromise (suggesting a tension pneumothorax)
significant hypoxia
bilateral pneumothorax
underlying lung disease
≥ 50 years of age with significant smoking history
haemothorax
always chest drain, Video (VATS) - persisent for pleurodesis
Pneumothorax discharge advice
smoking - avoid
flying - 2 weeks after if no air
no scube diving - unless bilateral surgical pleurectomy and normal lung function and CT scane
Causes of restrictive lung disease
PF
Asbestosis
sarcoidosis
ards
kyphoscoliosis
neuromuscular
severe obesity
Causes of resp acidosis
copd
asthma
neuromuscular
obesity
sedative - benzo / opiate overdose
Causes of resp alkalosis
anxiety
pe
salicylate poisoning
cns disorder: stroke
altitude
pregnancy
Resp tract infection features
centor: exudate, lymphadeno, fever, absence of cough
Sarcoidosis features
non-caseating
erythema nodosum, lupus pernio, uveitis
Indications for steroids: CXR staging (2 or 3 - BHL + interstitial infilitrates), hypercalcaemia, eye, heart or neuro involvement
fibrosis
Poor prognosis with Sarcoid
insidious > 6 months
no erythema nodosum
extrapulmonary features - lupus pernio, spelnomegaly,
stage III or more on CXR
black african
Silicosis
mining, slate,
silica inhalation - develop to TB
upper zone fibrosing lung disease, egg shell calcification
Smoking cessation
nicotine replacement therapy - 2 weeks to stop date
not offer re prescription in next 6 months
varenicline - nicotinic rec partial agonist - 1 week before stop date - 12 weeks , no for depresion and pregancy / breast feeding
bupropion - nor and dop reuptake inhibitor - 1 before stop, seizures and epilepsy + breast
Transfer factor
rate at which gas diffuse into blood
raised - asthma, pulmonary haemorrhage, polycythamia, hyperkinetic, male gender, exercise
lwoer - pf, pneumonia, pe, po, emphysema, anaemia, low cardiac output
