RESP Flashcards
What are the three types of pneumonia?
HAP
CAP
Aspiration
What is the definition of a HAP?
> 48 hours after admission
Name 5 signs of septic shock secondary to pneumonia.
• Tachypnoea (raised respiratory rate) • Tachycardia (raised heart rate) • Hypoxia (low oxygen) • Hypotension (shock) • Fever ConfusioN
Name 3 chest signs of pneumonia.
- Bronchial breath sounds - consolidation of surrounding lung tissue (inspiration and expiration)
- Focal coarse crackles - air passing through sputum (like a straw through a drink)
Dullness to percussion - due to collapse or consolidation
Which bacteria most commonly cause CAP?
Streptococcus pneumoniae
Haemophilus influenzae
Which bacteria cause pneumonia in immunocompromised patients?
Moraxella catarrhalis
Which bacteria cause pneumonia in patients with cystic fibrosis?
Pseudomonas aeruginosa
Staphylococcus aureus
Which investigations should be ordered for pneumonia?
CXR
FBC (WCC)
U&Es (for urea)
CRP
When is a rise in CRP expected in pnuemonia?
Delayed response, 2-3 days after.
WCC is more accurate of current infection.
Patients who are immunocompromised may not see a rise in CRP.
What scoring system is used to assess the severity of pneumonia? What are each of the parameters?
• C – Confusion (new disorientation in person, place or time)
• U – Urea > 7
• R – Respiratory rate ≥ 30
• B – Blood pressure < 90 systolic or ≤ 60 diastolic.
65 – Age ≥ 65
How should you interpret the CURB65 score?
• Score 0/1: Consider treatment at home
• Score ≥ 2: Consider hospital admission
Score ≥ 3: Consider intensive care assessment
What are the complications of pneumonia?
Sepsis Pleural effusions Empyema Lung abscess Death
What is the definition of an atypical pneumonia?
Cannot be cultured in the normal way OR detected using a gram stain.
How can you remember the 5 causes of atypical pneumonia?
Legionella pneumophila Psittaci Mycoplasma pneumoniae Chlamydia pneumoniae Coxiella burnetii (Q fever)
What electrolyte imbalance is seen in legionnaires disease? How is it caused?
Hyponatraemia
SIADH
Which bacteria causes pneumonia and erythema multiforme?
Mycoplasma pneumoniae
Which bacteria is associated with farming/animals?
Coxiella burnetii (Q fever)
Which bacteria is associated with infected birds?
Chlamydia psittaci
Which organism causes fungal pneumonia? Which patients are most likely to be infected?
Pneumocystis jiroveci (causes PCP in patients with HIV)
What antibiotics can be used to treat atypical pneumonias?
macrolides (e.g. clarithromycin)
fluoroquinolones (e.g. levofloxacin)
tetracyclines (e.g. doxycycline)
Which antibiotic is used to treat PCP?
Septrin
Which organisms is more common in patients who have recently had influenza?
Staphylococcus aureus
What are the two types of lung disease that can be distinguished using lung function tests?
Obstructive
Restrictive
What is FEV1?
Forced expiratory volume in 1 second
What is FVC?
Forced vital capacity
What is a reversibility test?
Use a bronchodilator e.g. salbutamol and repeat the test.
Describe the pattern seen in obstructive disease? Name two causes.
FEV1:FVC ratio is <75%
FEV1 <80%.
Describe the pattern in restrictive disease? Name 4 causes.
FEV1:FVC ratio >75%
How can you distinguish between COPD and asthma on spirometry?
Asthma is reversible (FEV1 improves after bronchodilator).
What is peak flow? What is it used for?
Measure of the fastest expiratory flow (measures how much obstruction to air flow there is).
How should you counsel a patient on doing a peak flow test?
Stand up
Take a deep breath in
Form a tight seal around the mouth piece
Blow as fast and hard as possible into the device
Take three attempts and record the best result
How are the results of a peak flow interpreted?
Compared to predicted value (%) based on height, age, and sex.
What is the biggest risk factor for lung cancer?
Smoking - 80% preventable if non-smoker
What is the most common cancer in non-smokers?
Adenocarcinoma
Which type of cancer is most common in smokers?
Squamous cell carcinomas
What are the three main types of cancer?
NSCLC:
- Adenocarcinoma
- Squamous cell carcinoma
SCLC (neurosecretory)
Which type of lung cancer carries a worse prognosis?
Small cell lung cancer
How does lung cancer present? Name some red flag symptoms.
- Shortness of breath
- Cough
RED FLAGS • Haemoptysis (coughing up blood) • Finger clubbing • Recurrent pneumonia • Weight loss Lymphadenopathy – often supraclavicular nodes are the first to be found on examination
Which nodes are most commonly infiltrated by lung cancer?
Supraclavicular nodes
Name 6 paraneoplastic syndromes.
- Nerve palsies - phrenic & laryngeal
- SVC obstruction - Pemberton’s sign (medical emergency)
- Exogenous hormone secretion - SIADH, Cushing’s & hyperparathyroidism
- Limbic encephalitis
- LEMS
- Horner’s syndrome
Name two nerves that can be affected in paraneoplastic syndromes.
Recurrent laryngeal nerve palsy - hoarse voice
Phrenic nerve - diaphragm weakness (SOB)
Which vessel might become obstructed by a lung tumour? How does this present?
SVC obstruction - facial swelling, distended veins in the neck and upper chest
What is Pemberton’s sign?
Raising the hands about the head causes facial swelling and cyanosis - medical emergency
Which two hormones can be exogenously excreted by SCLCs?
ADH –> SIADH
ATCH –> Cushing’s
Which hormone is exogenously excreted by squamous cell carcinomas of the lung?
Parathyroid hormone - secreted by squamous cell
What is limbic encephalitis?
Limbic encephalitis - SCLC causes immune system to make antibodies to the tissues in the brain.
Short-term memory loss
Hallucinations
Seizures
Anti-hu antibodies
What is LEMS?
Lambert-Eaton myasthenic syndrome (LEMS): antibodies again SCLC cells.
Also target voltage gated calcium channels on the pre-synaptic terminals of motor neurones.
What are the causes of post-operative pyrexia?
Post operative pyrexia (5 W's) Day 1 - wind: Atelectasis Day 3 - water: UTI Day 5 - Wound: site infection Day 7 - Walking: DVT/PE Anytime - Wonder drugs: Adverse drug reaction
What are the causes of upper zone fibrosis?
CHARTS
Coal workers’ pneumoconiosis
Histiocytosis
Ankylosing spondylitis/Allergic bronchopulmonary aspergillosis
Radiation
Tuberculosis
Silicosis (progressive massive fibrosis), sarcoidosis
Which bacteria commonly causes aspiration pneumonia?
Klebsiella pneumoniae
Which bacteria can cause red-current jelly sputum?
Klebsiella pneumoniae
Common in alcoholics and T2DM
What are the causes of a white out on CXR?
consolidation pleural effusion collapse pneumonectomy specific lesions e.g. tumours fluid e.g. pulmonary oedema
What are the symptoms of COPD?
Chronic cough –> sputum
SOBOE
Wheeze
Recurrent RTIs (esp in winter)
How is breathlessness graded?
MRC Dyspnoea Council:
Grade 1 = SOBOE (strenuous) Grade 2 = SOB walking uphill Grade 3 = SOB slows walking Grade 4 = must stop to catch breath after 100m Grade 5 = cannot leave the house
How is COPD diagnosed?
Clinical presentation
Spirometry
What investigations should be done in COPD?
- Spirometry (diagnose obstructive disease and assess severity)
- CXR. - RO Lung ca
- FBC - polycythaemia (secondary to chronic hypoxia)
- Sputum sample - RO pnuemonia
- Serum alpha-1 antitrypsin (esp if early onset)
- BMI baseline (weight loss = lung ca, weight gain = steroids)
- TLCO - reduced (raised in asthma)
How is the severity of COPD measured?
FEV1: Stage 1 = <80% Stage 2= 50-79% Stage 3= 30-49% Stage 4= <30%
What is the single most important factor in the management of COPD?
STOP SMOKING
What smoking cessation advice can be offered in COPD?
Nicotine therapy
Vareniciline
Bupropion
What is the first-line medical management of COPD?
SABA (salbutamol) or SAMA (ipratiotropium)
What are the steps in the medical management of COPD without asthmatic features?
- SABA or SAMA
- [SABA] + combined LABA & LAMA
- Oral theophylline (short courses)
- Oral azathioprine (prophylaxis in stable patients)
- Mucolytics
What are the steps in the medical management of COPD in a patient with asthmatic features/response to steroids?
- SABA or SAMA
- [SABA] + combined [LABA + ICS]
- [SABA] + combined [LABA + LAMA + ICS]
- Oral theophylline
- Oral azithromycin
- Mucolytics
What should be done before starting a patient on prophylactic azithromycin for COPD?
- CT thorax - RO bronchiectasis
- Sputum culture - RO TB or atypical pneumonia
- LFTs/ECG (azithromycin causes QT prolongation)
What can improve survival in COPD patients?
Smoking cessation
LTOT
Lung volume reduction surgery
Which vaccinations should COPD patients receive?
Annual influenza
One-off pneumococcal
Name a cardiac complication of COPD. How is it managed?
Cor pulmonale - ^JVP, peripheral oedema, parasternal heave, loud P2
Loop diuretics (oedema) LTOT
How should you manage an acute exacerbation of COPD?
O SHIT:
- O2
- Salbutamol 2.5-5mg NEB B2B
- Hydrocortisone 100mg IV
- Ipratropium 500mg NEB
- Theophylline: aminophylline infusion
+Antibiotics
+Chest physio
+NIV –> intubation
How do you assess a patient for LTOT therapy?
2xABG, 3 weeks apart:
pH <7.3 OR PaO2 7.3-8
+ polycythaemia, peripheral oedema, pulmonary hypertension
When can patients not be offered LTOT?
Continued smoking