Mantoux test ``` 15 = active TB ```

Resp Flashcards by Joe McAuley

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

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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

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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

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Screening for TB?

Mantoux test

<6mm = no TB
6-15 = previous TB
>15 = active TB

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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)

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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)

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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

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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

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Diagnosis of asthma in someone <5?

Clinical judgement, consider if multiple bouts of ‘viral induced wheeze’

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What is TLCO?

What is KCO?

TLCO - rate at which CO diffuses from alveoli into blood

KCO - TLCO corrected for lung volume

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Causes of raised TLCO?

Asthma
Wegener's, Goodpasture's
Polycythaemia
Male gender
Exercise

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Causes of lower TLCO?

Pulmonary fibrosis
Pneumonia
PE
Pul oedema
Emphysema
Anaemia
Low cardiac output

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What causes a high KCO but a low TLCO?

Pneumonectomy
Scoliosis/kyphosis
Neuromuscular weakness
Ank spond

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Diagnosis of IPF?

Spirometry - restrictive (FEV1 normal/decreased; FVC decreased; ratio normal/increased)

TLCO - decreased

HRCT - honeycombing/ground glass

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Small cell lung cancer paraneoplastic?

ADH
ACTH - hypertension, hyperglycaemia, hypokalaemia, alkalosis, muscle weakness
Lambert Eaton

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Squamous cell lung cancer paraneoplastic?

PTHrp
Clubbing
hypertrophic pulmonary osteoarthropathy
TSH

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Adenocarcinoma paraneoplastic?

Gynaecomastia

hypertrophic pulmonary osteoarthropathy

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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)

1. SABA 2. SABA + ICS 3. SABA + ICS + LTRA 4. SABA + ICA + LABA 5. 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