Resp Flashcards
TB drug side effects:
- Rifampicin?
- Isoniazid?
- Pyrazinamide?
- Ethambutol?
R: Orange tears/urine
I: neuropathy, agranulocytosis
P: gout, muscle pain
E: optic neuritis
All bar E can cause liver dysfunction
Most common cause of occupational asthma?
How is it diagnosed?
Management?
Iscyanates in paints, varnishes etc
Serial measurements of PEFR at work and away from work
Referral to resp specialist
inhaler technique?
Shake gently Exhale fully Put lips round mouthpiece Begin to breathe in slowly and deeply, press down canister as you do this Hold for 10 secs Wait 30 secs then repeat
Screening for TB?
Mantoux test
<6mm = no TB 6-15 = previous TB >15 = active TB
Dignosis of TB?
What reduces sensitivity of smears?
CXR - upper lobe cavitation and bilateral hilariously lymphadenopathy
Sputum smear - 3 specimens, ziehl-neelson stain (all mycobacterium test +ve so only 50-80% sensitivity)
Sputum culture - GOLD STANDARD - 1-3 weeks for results
NAAT - allows rapid diagnosis, more sensitive than smear but less than culture
(HIV reduces sensitivity of smears - should have culture/NAAT)
Asbestos:
- pleural pleural plaques?
- pleural thickening?
- asbestosis?
- mesothelioma?
Plaques: benign, do not undergo malignant change, don’t require follow up. Occur 20-40 years after exposure
Thickening: diffuse thickening similar to that seen in empyema or haemothorax
Asbestosis: lower lobe fibrosis (SOB, reduced exercise tolerance), 15-30 years after exposure - related to length of time exposed to it
Mesothelioma: malignant pleural disease caused by crocidolite (blue) asbestos. SOB, chest pain, pleural effusion. Palliative chemo, survival 1 year. Not related to length of exposure.
(can also cause lung cancer)
Asthma diagnostic tests 17+?
Asthma diagnosis 5-16?
17+ - FeNO and spirometry with bronchodilator reversibility
5-16 - spirometry with bronchodilator reversibility
Request FeNO if normal spirometry, or obstructive with no bronchodilators reversibility
For asthma, what is positive in:
- FeNO?
- spirometry?
- reversibility?
FeNO - in adults 40+ ppm is positive
In kids 35+ is positive
Spirometry - FEV1/FVC <70% is obstructive
Reversibility - 12% improvement
Diagnosis of asthma in someone <5?
Clinical judgement, consider if multiple bouts of ‘viral induced wheeze’
What is TLCO?
What is KCO?
TLCO - rate at which CO diffuses from alveoli into blood
KCO - TLCO corrected for lung volume
Causes of raised TLCO?
Asthma Wegener's, Goodpasture's Polycythaemia Male gender Exercise
Causes of lower TLCO?
Pulmonary fibrosis Pneumonia PE Pul oedema Emphysema Anaemia Low cardiac output
What causes a high KCO but a low TLCO?
Pneumonectomy
Scoliosis/kyphosis
Neuromuscular weakness
Ank spond
Diagnosis of IPF?
Spirometry - restrictive (FEV1 normal/decreased; FVC decreased; ratio normal/increased)
TLCO - decreased
HRCT - honeycombing/ground glass
Small cell lung cancer paraneoplastic?
ADH
ACTH - hypertension, hyperglycaemia, hypokalaemia, alkalosis, muscle weakness
Lambert Eaton
Squamous cell lung cancer paraneoplastic?
PTHrp
Clubbing
hypertrophic pulmonary osteoarthropathy
TSH
Adenocarcinoma paraneoplastic?
Gynaecomastia
hypertrophic pulmonary osteoarthropathy
Ix lung cancer?
imaging, biopsy, for mets, in bloods
CXR 1st line (10% are normal despite cancer)
CT - Ix of choice
Bronchoscopy - biopsy
PET - in non-small cell to establish if any mets for curative intent
Bloods - raised PLT
Urgent referral for lung cancer?
Urgent CXR to check for lung cancer?
CXR suggesting cancer
40+ and unexplained haemoptysis
40+ with standard lung cancer symptoms, or:
- persistent/recurrent chest infection
- finger clubbing
- supraclavicular lymph nodes
- persistent cervical lymph nodes
- chest signs consistent with lung cancer
- thrombocytosis
Examination findings in lung cancer?
Fixed, monophonic wheeze
Supraclavicular lymphadenopathy
Persistent cervical lymphadenopathy
Clubbing
Main symptoms of acute bronchitis? (5)
Ix?
Rx?
Cough (+/- sputum) Sore throat Rhinorrhoea Wheeze Low-grade fever
Ix: clinical diagnosis
Rx: good fluid intake, paracetamol Antibiotics if: 1. systemically unwell 2. pre-existing co-morbidities 3. CRP >100 (if CRP 20-100, give delayed prescription)
Features that suggest tiring/life threatening asthma?
PEFR <33% O2 sats <92% Normal pCO2 Silent chest, cyanosis Feeble resp effort Bradycardia Hypotension Confusion
Commonest causes of COPD exacerbation?
Management?
H influenzae (most common)
Strep pneumoniae
Moraxella catarrhalis
Viruses (30%)
Rx:
- increase bronchodilator use, consider giving neb
- Pred 30mg 5 days
- Antibiotics if purulent sputum or signs of pneumonia
Where is fluid in ARDS? Exam findings? Key Ix? How to tell it's non-cariogenic? Rx?
in alveoli (non-cariogenic pulmonary oedema)
Dyspnoea, bi-basal crackles, low sats
Ix: CXR and ABG
Pulmonary artery wedge pressure
Rx:
- ITU
- oxygenate
- support (e.g. vasopressors, abx if needed)
- proning
Criteria for classifying COPD:
- mild?
- mod?
- severe?
- very severe?
ALL post-bronchodilator FEV1/FVC <0.7
Mild: FEV1 >80%
Mod: FEV1 50-79%
Sev: FEV1 30-49%
V sev: FEV1 <30%
What test should be offered to all pts with TB?
HIV test
Primary and secondary TB?
Primary - Ghon focus
Small lesion of tubercle-laden macrophages found alongside hilarious lymphadenopathy
In immune competent - this heals by fibrosis, in immunocompetent, it becomes miliary
Secondary - reactivation due to host immunocompromised. Assman focus at apex. Can be due to immunosuppressive drugs (e.g. steroids), HIV, malnutrition.
Secondary may spread elsewhere causing meningitis, vertebral osteomyelitis (pott’s), renal, GI, or cervical lymph node infection
What can form in the cavity caused by secondary TB, causing haemoptysis and round opacity within the cavity on CXR?
Aspergilloma
Treating pneumonia - patient getting better but CRP is still slightly higher than it was at admission, why?
CRP lags behind
Initial therapy for asthma?
If symptoms return?
Following 3 steps of ladder?
SABA
Pred 5 days + Beclomethasone
Add LTRA
Add LABA, continue LTRA if effective, stop if not
Then switch LABA/ICS for MART
Kids asthma ladder? (first 5 steps)
- SABA
- SABA + ICS
- SABA + ICS + LTRA
- SABA + ICA + LABA
- SABA + MART
Moderate asthma attack? (4 criteria)
PEFR 50-75%
Speech normal
RR <25
Pulse <110
Severe asthma attack? (4 criteria)
PEFR 33-50%
Can’t complete sentences
RR >25
Pulse >110
Life-threatening asthma? (6 criteria)
PEFR <33% SpO2 <92% Silent chest Normal CO2 on ABG Bradycardia/hypotension Confusion
Pneumonia with dry cough, erythema multiforme and haemolytic (normocytic) anaemia?
Mycoplasma pneumoniea
Pneumonia with dry cough, lymphopaenia, deranged LFT’s and hyponatraemia?
Legionella pneumophila
Commonest cause of bronchiectasis exacerbations?
H influenzae
Pneumonia that can cause outbreaks in schools?
Mycoplasma pneumoniae
How does miliary TB spread through the lungs?
Pulmonary venous system
Gold standard Ix for mesothelioma?
Thoracoscopy and biopsy
But tumour cells may be seen on MC&S if pleural effusion is aspirated
Diagnosis of mycoplasma pneumoniae?
Serology
Diagnosis of legionella?
Urinary antigen
4 indications for non-invasive ventilation?
- COPD pH 7.25-7.35 with increasing PaCO2
- Type 2 resp failure due to neuromuscular disease, chest wall deformity or sleep apnoea
- Cardiogenic pulmonary oedema not responsive to CPAP
- Weaning from tracheal intubation
Criteria for azithromycin in COPD?
Optimised all therapies, no longer smokes
At least 4 acute exacerbations in the past year, requiring hospital admission at least once
Azithromycin 3 times per week
