Resp Flashcards
Management of haemodynamically stable PE
apixaban/rivaroxaban immediately if Well’s >4
Stable: DOAC for 3m/6m based on unprovoked/provoked
PESI score +/- Echo for Right Heart Strain
Consider IVC filter if CI to thrombolysis
Management of unstable PE
no CI to thrombolysis: unfractionated heparin
then hold heparin while administering alteplase
then heparin
CI to thrombolysis: heparin then surgery
Management of primary pneumothorax
<2cm: review in 2-4w
>2cm or SOB: aspirate
Management of secondary pneumothorax
<1cm: admit for 24h and O2
1-2cm: aspirate
>2cm: chest drain
Tension pneumothorax management
14-16G needle 5th ICS MAL
Management acute COPD
aim sats 88-92% (ABG again within 1h starting O2)
Start 28% O2 (or 24% if available) Neb salbutamol 5mg b2b Ipratropium 0.5mg every 4h Pred PO 30mg Co-amoxiclav/amox/clari/doxy
Consider aminophylline, ITU, NIV
Indications for BIPAP
COPD with resp acidosis 7.25-7.35
T2RF secondary to MND, deformity or OSA
Cardiogenic pulmonary oedema unresponsive to CPAP
Management of chronic COPD
Conservative: vaccines, smoking cessation, pulmonary rehab
Inhalers based on symptoms and risk (mMRC and GOLD system)
mucolytics
rescue packs
?Long term oxygen therapy if pO2 <7.2 or <8 and signs of decompensation (secondary polycythaemia, peripheral oedema, pulmonary HTN)
consider surgery: lung volume reduction, bullectomy, transplant
COPD inhaler management
1) SABA OR SAMA for breathlessness
2a) If NO asthmatic features: LABA + LAMA
2b) if ASTHMATIC features: LABA + ICS
3) LABA + LAMA + ICS
What is SABA/SAMA/LAMA/LABA/Symbicort/LTRA
SABA: salbutamol SAMA: ipratropium LABA: salmeterol LAMA: tiotropium symbicort: LABA + ICS LTRA: montelukast
Chronic Asthma management
Conservative: Review technique, avoid triggers, monitor peak flow, asthma action plan, flu vaccine
1) SABA + ICS
2) add LABA
3) Add LTRA or increase ICS
discard LABA if not working
4) Refer to specialist
FEV1 actual vs predicted COPD categories
>80% = mild 50-79% = moderate 30-49 = severe <30% = very severe
Acute Asthma management
High flow O2
Nebuliser (5mg salbutamol b2b + ipratropium every 4h)
pred PO OR hydrocort if can’t tolerate
Magnesium sulfate IV + senior support
Further support: aminophylline, ITU, intubation
Acute asthma PEF categories
50-75%: moderate
33-50%: acute severe
<33%: life threatening
normal/raised pCO2 = near-fatal
management for allergic bronchopulmonary aspergillosis
oral prednisolone
itraconazole 2nd line
consider antibiotics
salbutamol
3 forms of bronchiectasis
cylindrical
cystic
varicose
Management of bronchiectasis
Conservative: airway clearance techniques, flutter device
medical: mucolytics, prophylactic Abx, consider itraconazole
LABA/ICS
Surgery for severe disease/localised disease
Management of CF
conservative: physio, airway clearance techniques
pancreatic replacement therapy
high calorie diet
Medical: nebulised mucolytics, SABA/LABA, long term antibiotics (fluclox) with additional rescue antibiotics
nebulised hypertonic saline
laxatives
USDA
Surgical: Lung/liver transplant
Management of fibrosis
stop fibrosis drug
rehab
support groups
pirfenidone
LTOT if pO2 <7.3 OR 7.3-8 AND (polycythaemia, hypoxaemia, peripheral oedema or pul HTN)
steroids (poor evidence)
Treat any post nasal drip with steroids
Treat any GORD
transplant
management of sarcoid
NSAIDs
high dose steroids if parenchymal lung disease, uveitis, hypercalcaemia, neuro/cardio
consider other immunosuppression (methotrexate, ciclosporin)
Squamous Cell Carcinoma endo link
high calcium due to PTHrP
TSH hyperthyroidism
Small Cell carcinoma endo link
Lambert-Eaton
insulinoma
ACTH
ADH
Investigations for lung cancer
CXR
CT
PET for mets
EBUS or VATS biopsy
Pneumonia management
mild - amoxicillin
severe - co-amox + clarithromycin
legionella = clarithromycin and rifampicin
staph - fluclox
CURB 65
Confusion Urea >7 Resp rate >30 Blood pressure <90/60 65yo
2 points consider inpatient
3 points admit
PCP management
mild-moderate: co-trimoxazole
severe: IV pentamidine
Steroids if hypoxic
Management of pleural effusion
aspirate for MC&S, cytology, pH, protein
chest drain
treat underlying cause
Restrictive spiro result
FEV1:FVC ratio >70%
FVC very reduced
Obstructive spiro result
FEV1:FVC ratio <70%
FEV1 very reduced
Well’s Score for PE
sign of DVT +3 PE most likely +3 HR>100 +1.5 immobilisation+1.5 Previous PE/DVT +1.5 haemoptysis malignancy <6m
Obstructive spiro causes
COPD
Asthma
Bronchiectasis
CF
Restrictive spiro result
Fibrosis
parenchymal tumours
Pulmonary oedema
Lobectomy
Hypersensitivity pneumonitis management
Avoid exposure
Steroids
Pneumoconiosis management
Improve working conditions
What can asbestos cause
Pleural plaque Mesothelioma Asbestosis (fibrosis) BAPE benign asbestos pleural effusion Diffuse pleural effusion
Indications for CPAP
Overall to recruit/splint open alveoli in T1RF
CHF
OSA
Severe pneumonia
apical lung fibrosis causes
CF Sarcoid/TB Pneumoconioses ABPA Ank Spond
basal lung fibrosis causes
Rheumatoid
asbestosis
Scleroderma
Investigations for TB
Tuberculin skin test
Sputum MC&S - Ziehl Nielsen stain and Lowenstein Jensen culture
CRP, IGRA
CXR
EBUS
management of TB
RI 6m
PE 2m
ID input if resistant or extremely resistant TB
RIPE drug side effects
Rifampicin: orange secretions
Isoniazid: hepatotoxic, give with pyroxidine to prevent peripheral neuropathy
Pyrazinamide: hepatotoxic
Ethambutol: Visual disturbance
Pneumonia buzzwords Rusty Smoking/COPD Cavitation Recent viral infection Red-current jelly Alcoholic Cavitating upper lobes Cold agglutinin Erythema Multiforme Air conditioner/water + hyponatraemia Birds Paeds Farm animals
Rusty: Pneumoniae Smoking/COPD: H influenzae + Catarrhalis Cavitation: Aureus Recent viral infection: aureus Red current: Klebsiella Alcoholic: Klebsiella Cavitating upper lobes: Klebsiella Cold agglutinin: mycoplasma pneumoniae Erythema multiforme: Mycoplasma Air conditioner/water and hyponatraemia: Legionella Birds: psattici Paeds: chlamydia pneumo Farm Animals: Burnetti
Investigations for PCP
CXR
Exercise induced desaturation
Broncho-alveolar lavage and silver stain
Define flail chest
3 consecutive rib fractures in >2 locations so chest wall moves in in inspiration and out in expiration
Mx of flail chest
analgesia
Chest physio
consider: CPAP and surgical fixation
Causes of upper lobe fibrosis
TAAPE TB ABPA Ank Spond Pneumoconiosis EAA
Causes of lower lobe fibrosis
TAIR Toxins Asbestosis IPF RhA
Extra-pulmonary manifestations of sarcoid Bloods Skin Histology Infiltrative
Bloods: ACE and calcium
Skin: EN and Lupus Pernio
Histology: Non-caseating granulomas, hilar lymphadenopathy
Infiltrative: Restrictive cardiomyopathy, uveitis
Sarcoid management
Bed rest
NSAIDs
Oral high dose steroids
Immunosuppression in severe and refractory disease
Gold standard for bronchiectasis
HRCT
Lobe collapse signs
Right Upper lobe: S sign
Left Upper lobe: Veil sign
Lower lobe: Sail or raised hemidiaphragm
Investigation mesothelioma
CXR
HRCT
Thoracoscopy and pleural biopsy
Management of mesothelioma
instillation of sclerosants into the pleural space can prevent or reduce re-accumulation of pleural effusions and accompanying breathlessness.
