Repiratory Flashcards
Signs and symptoms of pneumonia
Cough Sputum Wheeze Systemic signs - fever Rigors
Signs - cyanosis Crackles on auscultation Increased RE and HR Dull percussion Confusion
Common infection in COPD
Haemophilus influenza
Common lung infection in diabetics and alcoholics and its antibiotic
Klebsiella
Cefotaxime
Water associated pneumonia pathogen and its antibiotic
Legionella
Hyponatraemia common
Fluoroquinolone (ciprofloxacin) or clarithromyin
Mycoplasma infection findings and antibiotics
Dry cough, atypical CXR findings
Clarithromycin
Scoring system in pneumonia
CURB-65
Confusion Urea - > 7 RR > 30 BP <90 systolic, < 60 diastolic Age > 65
Empirical treatment for pneumonia
Amoxicillin
If curb > 2 = amoxicillin and clarithromycin
If curb > 3 = co-amoxiclav
First step in asthma management
Inhaled SABA as required
Someone’s asthma isn’t controlled on SABA
Add an inhaled corricosteroid (low dose)
Someomes asthma isn’t controlled on a SABA and ICS
Add a LeuKotriene reception antagonist
Montelukast
Someones asthma isn’t controlled on SABA, ICS and LTRA
Add a long acting B2 agonist (LABA)
Someone asthma isn’t controlled with SABA, ICS, LTRA, LABA
Increase doe of ICS or try another drug - theophylline
Signs of a severe asthma attack
Pefr 33-50 % of best
Cant complete ful sentences
RR > 25/MIN
Signs of a life-threarenjg asthma attack
PEFR < 33%
Oxygen sats < 92%
Silent chest
Cyanosis
Tests in COPD
Diagnosis based on clinical findings + spirometry
Spirometry will show obstructive pattern
ECG + echo for heart function
Peak flow
FBC - FBC - polycythaemia and anaemia
Alpha 1 antitrypsin - deficiency causes more severe disease
CXR - bronchial wall thickening, air space enlargement and rule out differentials
ABG - decreased oxygen with/out hypercapnia
Spirometry - obstructive pattern
Sputum cultures
Example of a SAMA
Ipratropium bromide
Example of SABA
Salbutamol,
Terbutaline
Step one in COPD management
SABA or SAMA
Someone’s COPD is not controlled by SABA, they do not have asthma and no response to steroids. What is next step?
LABA+LAMA (+SABA) as required
Someone’s COPD is not controlled by SABA, they do have asthma and show response to steroids. What is next step?
LABA+ICS (+SABA)
Someones COPD is not controlled by SABA, LAMA and LABA. Next step?
LAMA+LABA+ICS (+SABA)
Indications for long term oxygen therapy in COPD
Patients with paO2 < 7.3 kPa
Or those who have 7.3-8 and one of
- secondary polycythaemia
- peripheral oedema
- pulmonary HTN
Risk factors for PEs
Long haul flight Immobility Cancer Surgery Thrombophilia - antiphospholipid syndrome Leg fracture Previous PE COCP Pregnancy
Investigations for PE
Obs
ECG - sinus tachycardia
Bloods - FBC, U+E, ABG - decreased O2 and CO2
Wells score
D-DIMER
CT pulmonary angiogram
Definitive diagnosis of a pulmonary embolism
Wells score
<4 = D dimer, if positive then do CT pulmonary angio
If >4 = treat or CT pulmonary angio
Alternative = ventilation, perfusion scan - will be ventilated but not perfused
Management of PE
Oxygen if hypoxic Morphine and anti-emetic IV access Fluid if drop in BP Consider ITU
Haemodynamically unstable - thrombolysis
If not - apixaban or rivaroxiban, LMWH as an alternative
Long term coagulation - 3 months if provoked, 6 months if unprovoked, lifelong if active cancer
Someone treated for a PE with LMWH is being put onto long term warfarin how should this be done?
Continue warfarin for 5 days or until INR 2-3 for 24 hours (whichever is longer)
Causes of exudate pleural effusions and what does exudate mean
Protein concentration >35g/L
Think inflammation
- pneumonia
- cancer
- RA
- TB
Causes of transudate pleural effusions and what this means
Protein concentration <25 g/L
Think fluid movement
- heart failure
- hypoalbuminaemia- liver disease
- hypothyroidism
- meigs syndrome
Signs of pleural effusions
Dull percussion note Reduced breath sounds Bronchial breathing above effusion Reduced chest expansion Large - tracheal deviation away
CXR signs of pleural effusions
Reduced lung field
Meniscus
Fluid in lung fissures
Management of pleural effusion
Conservative - small and treatment of cause
Aspiration
Chest drainage
Pleurodesis
Does the trachea deviate away or towards a tension pneumothorax
Away
Management of a pneumothorax
Spontaneous, asymptomatic and <2cm of air = Conservative, will follow up CXR
Spontaneous SOB or >2cm of air = aspirate, if not successful then chest drain
Secondary
- SOB and/or rim of air >2cm - chest drain
- 1-2 cm - aspirate
- otherwise admit for 24 hours obs
Young Black woman with dry cough and SOB and nodules on shins, exclude what?
Sarcoidosis
Features of sarcoidosis
SOB, dry cough Extra pulmonary involvement - erythema nordosum , uveitis, mediastinal lymphadenopathy, arthralgia, arthritis HYPERCALCAEMIA Fever Weight loss Fatigue
Hypercalaemia associated with which lung condition?
Sarcoidosis
CXR of sarcoidosis will show what?
Bilhilar lymphadenopathy
Investigation for Sarcoidosis
Bloods - hypercalcaemia, Raised ACE, CRP, test for other organ involvement
CXR - bihilar lymphadenopathy
Histology - bronchoscopy
Treatment of sarcoidosis
No treatment if asymptomatic or mild symptoms
Steroids for at least 6 months
Second line - methotrexate, azathioprine
Lung transplant
Theophylline moA
Competitively inhibits phosphodiesterase
The enzyme responsible for breaking down cyclic AMP, in smooth muscle cells
Results in bronchodilation
When should someone be referred for lung cancer pathway
Over 40 with unexplained haemoptysis
Epistaxis, sinusitis, nasal crusting, dyspnoea, haemostasis
CXR - multiple cavitation lesions
Diagnosis?
Investigation?
Granulomatosis with polyangiitis
ANCA antibodies
Management of exacerbation of COPD
Home - prednisolone for 7-14 days
Regulat inhalers or home nebs
Abx if infection
Hospital - nebulised bronchodilators - salbutamol and ipratropium
Steroids - hydrocortisone
Abx if infection
Physiotherapy
Severe - IV aminophylline
Non-invasive ventilation
CXR findings of HF
Kerly B lines Cardiomegaly Pleural effusions Alveolar oedema - bats wings Dilated prominent upper lobe vessels
What would be an indication that a severe asthma attack may need intubation?
pH <7.35 - hypercapnia in a tired patient
Dyspnoea and hypoxaemia in a patient that underwent surgery less than 72 hours ago should indicate what?
Atelectasis
Criteria for discharge post-asthma attack
Been stable on their discharge medication (I.e. no nebuliser or oxygen) for 12-24 hours
Inhaler technique checked and recorded
PEF > 75% of best or predicted
Cavorting lung lesion differentials
Abscess Squamous lung cancer TB Wegrners glomerulomatosis PE RA
Shipbuilding may expose someone to what?
Asbestosis
Oxygen target sats in COPD
No blood gases or CO2 raised - 88-92%
If CO2 normal on ABG - 94-98%
Features of acute respiratory distress syndrome
Acute onset tachypnoea, tachycardia On a background of cause - e.g. pneumonia Hypoxia Bilateral pulmonary oedema - crsckles Cyanosis
Managrment of acute respiratory distress syndrome
ITU Supportive therapy, treat cause CPAP Invasive haemodynamic monitoring Fluids Oxygen and ventilation General organ support
Asbestosis will lead to what finding on spirometry
Restrictive
Think fibrosis
Causes of obstructive lung disease
Asthma
COPD
Bronchiectasis
Causes of restrictive lung disease
IPF Asbestosis Sacroidosis Acute respiratory distress syndrome Kyphoscoliosis Neuromuscular disorders Severe obesity
What scale is used for obstructive sleep apnoes
Epworth sleepiness scale
Managemeng of obstructive sleep apnoea
Refer to ENT or sleep clinic They can monitor obs during sleep First-step - correct lifestyle factors - weight, smoking, alcohol etc. Second step - CPAP Surgery
Macrolides (clarithromycin, azithromycin) what investigation should be done prior to starting?
ECG - they prolong QT
ABG - high pCO2, acidotic bicarb 44, indicates what?
Acute on chronic respiratory distress
- high CO2 indicates respiratory acidosis
- metabolic correction takes time so a very high bicarb. Suggests chronic respiratory acidosis
Indications for steroids in sarcoidosis
Parenchyma lung disease
Uveitis
Hypercalcaemia
Neurological or cardiac involvement
Formoterol is what type of medication?
LABA
What medication is usually combined with ICS in an inhaler?
LABA
Tiotropium is an example of what medication?
LAMA
What abx is used in COPD prophylaxis
Azithromycin
Cannonball mets are associated with what cancer?
Renal cell most commonly
Also prostate
Do CT abdomen
Causes of white lung lesions on CXR
Consolidation Pleural effusions Collapse Pneumonectomy Tumpurs Fluid - pulmonary oedema
White out of a hemithorax differentials
Penumonectomy
Complete lung collapse
Large pleural effusions
Trachea pulled towards a total white out of a lung
Pneumonectomy
Complete lung collapse
- trachea moves towards to side of least pressure
Trachea pushed away from a white-out
Pleural effusions
Diaphragmatic hernia
Large mass
- deviates towards lower pressure
Raised CO2, raised O2, severely acidotic, raised bicarb
Cause
Shows acidotic picture
Overadministration of O2 in a COPD patient
Raised bicarb, indicates chronic resp acidosis
Patient has lost hypoxic drive therefore retain CO2
And subsequently hypoventilate leading to respiratory arrest
If bicarb was normal - acute respiratory acidosis
Raised platelets may be seen in what?
Lung cancer
Extra-pulmonary manifestations of lung cancer
siADH Hypercalcaemia - hyperparathyroidism Lambert eaton Cushings syndrome Horners syndrome Recurrent laryngeal nerve palsy
Lambert Eaton vs myasthenia gravis
Lambert Eaton improves with exercise, myasthenia gets worse
