Resp Flashcards
1
Q
classical sx of pneumonia
A
- Fever, rigors, sweating
- Malaise
- Cough
- Sputum (yellow, green, rusty in S pneumoniae)
- Breathlessness
- Pleuritic chest pain
- Confusion (severe cases, elderly, legionella)
2
Q
atypical pneumonia presentation
A
headache, mnyalgia, diarrhea, abdominal pain
3
Q
signs of pneumonia
A
- Pyrexia
- Tachypnoea, tachycardia
- Hypotension
- Cyanosis
- Decreased chest expansion, dullness to percussion, increased vocal fremitus, bronchial breathing (inspiration phase length = expiration phase length), coarse crepitations on affected side
4
Q
Ix for suspected pneumonia
A
Bedside: flu swab, covid swab
Sputum culture
Consider urine culture– for pneumonoccus and legionella antigens
Bloods o FBC (abnormal WCC) o U&E (low Na+ esp with Legionella) o LFT o Blood culture o ABG (assess pulmonary function) o Blood film (RBC agglutination by mycoplasma caused by cold agglutinins)
CXR – lobar or patchy shadowing, pleural effusion, repeat 6-8 weeks later if abnormal, suspect underlying pathology e.g. lung cancer.
Atypical viral serology (increase antibody titers between acute and convalescent samples)
Bronchoscopy and broncheolaveolar lavage if pneumonia fails to resolve or clinically progresses
5
Q
What score do you use to assess for pneumonia and explain it
A
CURB 65
Confusion (AMTS <=8) Urea >7 Resp rate >30 BP <90/60 65 years old or older
6
Q
How do you manage pts based on CURB 65
A
Score of 1: Home abx
Score of 2: admission abx
Score >=3= ITU
7
Q
What antibiotics do you give as examples for pneumonia? (ALWAYS FOLLOW HOSPITAL GUIDELINES)
A
mild: amoxicillin
Severe: co-amoxiclav + clarythromycin
8
Q
What defines a HAP
A
Occurrence >48 hours from hospital admission
9
Q
How do you manage a HAP
A
Non-severe: Co-amox or doxy
Severe: Piptazobactam
ALWAYS FOLLOW LOCAL GUIDELINES
10
Q
what other management other than abx (long term) is important in pneumonia
A
Prevention is important in vulnerable groups (e.g. elderly, spenectomized) – give prophylactic pneumococcal or H influenzae type B vaccination.
11
Q
What is a pleural effusion
A
buildup of fluid in pleural space
12
Q
what are sx of a pleural effusion
A
dyspnoea
cough
pleuritic chest pain
13
Q
what are the two kinds of pleural effusion you can get
and what criteria do you use to assess
A
TRANSUDATE V EXHUDATE
LIGHT CRITERIA
14
Q
Explain the difference in protein in TRANSUDATE vs EXHUDATE
A
TRANSUDATE = low protein (<30g) EXHUDATE = high protein (>30g) (= EGG)
15
Q
What are causes of transudate in pleural effusion
A
Due to factorsa that alter hydrostatic preessure / pleural permeability / oncotic pressure
e.g. CCF, cirrhosis, nephrotic syndrome
16
Q
What are causes of exhudate in pleural effusion
A
Due to change in local facotrs that influence the formation and absorption of pleural fluid
e.g. Infection (pneumonia, lung empyema) PE Trauma Pancreatitis Malignancy
17
Q
What are ix for suspected pleural effusion
A
Exam, obs, urine dip for protein
Baseline bloods esp LFT, CRP, clotting, blood culture
CXR (shows costophrenic blunting) > then considercontrast CT (if exhudative cause) or echo (CCF)
USS guided pleural aspiration and chest draWin
18
Q
Why aree you doing a USS guided pleural aspiration
A
to get details on the sample
e.g. MC&S, cytology, pH, LDH, glucose, protein, TB, amylase, Hb
19
Q
What do you do if the aspirate from the pleural effusion is turbid, tests positive on MCS or has pH <7.2?
A
Insert Chest DRAIN
Then treat underlying cause
20
Q
What is percussion like in PLEURAL EFFUSIOON
A
STONY DULL
21
Q
What is vocal fremitus like in PLEURAL EFFUSION
A
Reduced
22
Q
What is lung ascultation like in PLEURAL EFFUSION
A
Reeduced
23
Q
why do you get RBBB in a PE
A
due to increased strain on the right side of the heart
24
Q
what else must you do in unprovoked PE patient while after starting on DOAC
A
try to find CAUSE
25
what is COPD
chronic bronchitis + emphysema
26
What are investiigations for COPD
Bedside: sputum sample (for iinfective exacerb), SPIROMETRY (gold standard)
Bloods: baseline bloods (incl FBC for secondary polycythaemia), CRP, ABG, BNP
Imaging: CXR, HR-CT
consider ECG, echo (cor pulmonale)
consider alpha1 antitrypsin levels if young / non smoker
27
What is conservative management of long-term COPD
smoking cessation
mucolytics
vaccines
consider prophylactic azithromycin
28
when do you give prophylactic azithromycin in COPD
250mg TDS if
- non smoker
- optimised medical mx
- referred pulm rehab
- x4 infective exacerbations per year AND at least one hospitalisation per year
29
what is medical COPD mx
1, SAMA or SABA, PRN
2. LABA + (LAMA or inhaled corticosteroids (if asthmatic features))
3. LABA + LAMA + ICS
4. senior input e3.g. theophylline
30
when would you give inhaled corticosteroids vs LAMA in COPD mx
corticosteroids if asthmatic featurres (e.g. oesinophilia, history of atopic conditions, which make them more lkely to be steroid responsive )
31
what are the two key components of asthma
airway hypersensitivity
| reversible airway obstruction
32
investigations of asthma
```
spirometry
FeNO (marker of airway inflammation)
Peak flow variability (getting them to keep an peak flow diary)
```
33
long term asthm management
1. SABA
2. SABA + ICS
3. SABA + ICS + LTRA
4. SABA + ICS + LTRA + LABA
5. SABA + "ICS+LABA" + LTRA
34
WHat is ICS+LABA
MART THERAPY
both reliever and prophylactic
i.e. take in morning and evening every day, but also iif you get acutely out of breath
35
example of SABA
salbulamol
| Beta 2 agonist
36
example of SAMA
itratropium
| muscarinic antagonist
37
example of LAMA
tiotropium
38
example of LABA
salmeterol
39
what does atypical pneumonia mean
one that does not present with typical symptoms
40
how do you manage a typical CAP
Amoxicillin (mild)
Co-amoxiclv (severe)
often also add clarythromycin if atypical pneumonia cannot be excluded
41
what are the top thjree most common typical CAPS
S pneumonia
H influenza
M catarrhalis
42
How does S pneumonia typically present
rusty sputum
lobar pattern
reactivated HSV
43
how does H influenza present
pre-existing lung disease e.g. COPD
| bronchoalveolar pattern, affecting lower lobes mainly
44
how does Klebsiella pneumoniae present present
```
redcurrant jelly sputum
alcoholism
DM
elderly
haemoptysis
```
45
How do you treat an atypical pneumonia
clarythromycin
| or doxycycline
46
what are common pathogens that cause atypical pneumonia
```
Legionella pneumophilia (air conditioners, hyponatraemia, urinary antigen)
Chlamydia pneumoniae (children)
Chlamydia psittaci (birds, haemolytic anaemia)
```
47
what are common HAPs and what timeline do they occur in
```
Strep pneumonia (48h-4 days)
Enterobacteria, S aureus, Pseudomonas (>4 days)
```
48
how do you treat HAP
mild: co-amox or doxy
severe: piptazobactam
49
What are TB tests you can do
IGRA (no cross reaction with BCG)
TST (cross reacts with BCG)
Sputum smear x3 > NAAT (also Ziehl Neelsen stain)
Sputum culture is gold standard
50
when is auramine staining used for TB
for screening
51
how do you manage TB
RIPE
Rifampicin + Isoniazid 6m
Pyrazinamide + Ethambutol 2 months
52
Side effect of rifampicin
orange secretions
| enzyme inducer
53
Side effect of isoniazid
peripheral neuropathy > GIVE WITH PYRIDOXINE
54
SE of pyrazinamide
liver injury
55
SE of ethambutol
visual disturbance
56
what is pulmonary fibrosis / interstitial lung disease
umbrella term for disorders of lung parenchuma
57
what are causes of pulmonary fibrosis
idiopathic
hypersensitivity pneumonitis (to organic dusts)
pneumonicosis (to inorganic dusts)
58
how does pulmonary fibrosis show up in HR CT
honeycombing
59
what are signs and symptoms of IPF
progressive exertional dyspnoea
dry cough
clubbing
bibasal fine end espiratory creps
60
key Ix for IPF
HR CT
spirometry (restrictive)
lung biopsuy
61
management for IPF
smoking cessation
pysiotherapy
pulm rehabilityation
Pirfenidone, immunospuuressants if AI
lung transplant
62
what is sarcoidosis
chronic disease characterised by formation of granulomas in various tissue (with no infective cause)
63
signs and symptoms of sarcoidosis
SOB, dry cough
fatigue, joint aches
dry eyes
erythema nodosum
64
invesitgations of sarcoidosis
Serum ACE (raised as ACTH producing)
Serum calcium (raised)
CXR (bihilar lymphadenopathy> pulmonary infiltrates > fiibrosis)
biopsy
65
what is a pancoast tumour and how does it present
lung tumour at apex of lung
- Horner's syndrome
- Wasting of T1 in hand
66
what is bronchiectasis
permanent dilation of airways secondary to chronic inflammation (irreversible)
67
what is bronchiectasis due to
Post infectious - TB, measles, pertussis, pneumonia
Obstruction (foreign body)
AI (selective gA, hypogammaglobulinaemia, ABPA, RA, SLE)
CF, Kartageners, Youngs, yellow nail syndrome
68
what pneumonia do you see in AIDS
PCP (pneumocisti jirovecii)
69
hhow do you manage PCP
co-trimoxazole
70
what is the genetic defect in CF
Defecting CFTR (CF transmembrane conoductance regulator) on Chr 7
71
Sx CF
Meconium ileus
recurring chest infectionos, wheezing, coughing, SOB
diarrheoa / consiptation
Male sterility
faltering growth
jaundice (due to cirrhosis, portal HTN)
DM
72
how do you ix CF
```
Immunoreactive trypsinogen (on Guthrie)
Sweat test (raised sodium)
CXR (hyperinflation, peribronchial shadowing)
```
73
how do you mx CF (broad outline)
ROUTINE REVIEWS with MDT APPROACH, involve specialist CF centre
- Resp
- Infection
- nutritional
- other
74
Resp mx CF
- chest physio x2 daily
| - mycolytics (dornase alpha, mannitol dry powder)
75
Infection mx CF
PROPHYLACTIC ORAL ABX (with fluclox, azithhromyciin)
76
what bacteriium are we worried aboout in CF pneumonia
Pseudomonaas aerogiinosa
77
Nutritional mx CF
hiigh calorie + high fat diet
fat soluble vitamin supplements
pancreatic enzyme replacement (CREON) with every meal
78
What is Mx of CF in adults?
1. DM therapy
2. Liver therapy (ursodeoxycholic acid to improve flow; may require transplant)
3. Intestinal obstruction (oral laxatives)
4. Male sterility
79
what lung cancer is typical in smokers
Small cell lung cancer
80
what are associations of SCLC
smokers
central
SIADH
ACTH
LEMS
81
what is the most common yupe of lung cancer
non-SCLC
82
test criteria threshold for ASTHMA diagnosis
<70% FEV1/FVC
>40 FeNO
>12% variability FEV1 after SABA administration
>20% PEFR variability
83
2 key fts of Kartageners
situs invertus
| cilia immobiliity
84
2 key fts of yellow nail syndrome
lymphoedema
| pleural effusion
85
what is finding of bronchiectasis on CT
"signet ring" appearance of thickened bronchi
86
which iniherited condition can predispose to COPD
alph 1 antitrypsin deficiency
87
what is alpha 1 antitripsin deficinecy (mode of inheritance, pathophys)
autosomal co-dominant condition
alpha 1 antitrypsin usually inhibitss neutrophil elastase in lungs
so absence of it causes early COPD development
88
what does a CXR show in COPD
hyperinflated lungs
decreased peripheral markings
may show elongated cardiac silouhette (cor pulmonale)
89
what does spirometry show inn COPD
FEV1/FVC <70%
| increased lung volume
90
what does an FBC show in COPD
secondary polycythaemia
91
criteria for long term oxygen therapy in COPD
NON SMOKER
AND:
- PaO2 <7.3 (x2 measurements)
OR
PaO2 of 7.3-8 + secondary polycythhaemia/ pulm oedema / pulm HTN
92
who is a pink puffer and who is a blue boater in COPD
pink puffer = emphysema dominant
| blue boater = bronchitis dominant
93
describe a pink puffer
Alveolar ventilation INCREASED
Build is THIN
Cx is T2RF
94
describe a blue boater
Alveolar ventilation DECREASED
Build is STOCKY
Cx is cor pulmonale
95
what is chronic bronchitis
chronic cough and sputum min 3 months min 2 consecutve years
96
what is emphysema
alveolar destruction > bullae formation
97
what is life expectancy for idiopathic pulmonary fibrosis
3 years
98
how do you manage idiopathic pulmonary fibrosis
Steroids (for 3 months) then reassess
99
what antibiotic do you give for Pseudomonas aeroginosa (so CF/ chemo / bronchiectasis pt)?
Tazocin, ciprofloxacin
100
How do you manage sarcoidosis
Steroids
NSAIDS
Steroid-sparing agent
101
what is hypersensittivity pneumonitis
hypersensitivity induced lung damage due to inhaled organic particles
102
examples of hypersensittivity pneumonitis
bird lung
farmers lung
malt workers lung
103
mx hypersensittivity pneumonitis
```
avoid causative agen t
oral glucocorticoids (second line)
```
104
what abx can you give for IE of COPD
amoxicillin
doxy
clarythromycin
105
what is SVCO caused by
mainly lung cancer
| other causes include sarcoid, lymphoma, aortic aneurysm
106
what is SVCO presentation
facial and upper limb swelling
107
when do patients admitted with pneumonia need a follow up CXR
ALL patients admtted need a follow upp CXR at 6-12 weeks
| This is to detect any underlying pathology and ensure resolution
108
what are causes of upper lobe pneumonicosis?
```
C- Coal worker's pneumoconiosis
H - Histiocytosis/ hypersensitivity pneumonitis
A - Ankylosing spondylitis
R - Radiation
T - Tuberculosis
S - Silicosis/sarcoidosis
```
109
features of moderate asthma
PEFR 50-75% best or predicted
Speech normal
RR < 25 / min
Pulse < 110 bpm
110
features of severe asthma
PEFR 33 - 50% best or predicted
Can't complete sentences
RR > 25/min
Pulse > 110 bpm
111
features of life threatening asthhma
```
CHEST:
Cyanosis
Hypotension, bradycardia
Exhaustion (PEFR < 33%, SpO2 < 92%)
Silent chest
Too confused or coma
```
112
when does the HR go above 110 in asthma
in SEVERE asthma
113
whenn does SpO2 go below 92 in asthma
in life threatening asthma
114
what is atelectasis , what is it caussed by
post-operative complication
= basal alveolar collapse which leads to respiratory difficulty
It is caused when airways become obstructed by bronchial secretions
115
how do you manage atelectasis
deep breathing exercises and chest physiotherapy.
116
what does lupus pernio occur with
with sarcoidosiss
117
what does lupus pernio look like
raised purple plaque of indurated skin that affects the tip of her nose and the skin around the right nostril
118
what is ABPA
Allergic Broncopulmonary Aspergillosis
= allergic response in asthmatics, causing bronchiectasis
119
how do you managge ABPA
PREDNISOLONE
120
when can you start corticosteroid tx for sarcoid
parenchymal lung disease, uveitis, hypercalcaemia and neurological or cardiac involvement
121
which drugs can precipitate an astthma atttack / must you avoid in asthmatics?
beta blockers
| NSAIDS
122
how does bronchiectasis present
history of cause (e.g. infection as a child)
recurrent chest infections, refractory to abx
chronic productive cough
lots of phlegm
123
O/E bronchiectasis
coarse crepitations, wheeze
124
ix bronchiectasis
sputum sample MCS (Pseudomonas), sweat test (exclude CF()
Baseline bloods, CRP, Ig, CF genetic test, aspergillus markers
CXR, HR CT (signet ring, tram lining)
Spirometry (obstructive)
125
Mx bronchiectasis
Correct underlying cause if possible
Conservative:
- physiotherapy, pulmonary rehab
- smoking cessation
Medical:
- mucolytic (carbocystine)
- antibiotics
- bronchodilators
