Resp Flashcards
PEFR in obstructive disease
reduced
PEFR in restrictive disease
normal
restrictive or obstructive: asthma
obstructive
restrictive or obstructive: pulmonary fibrosis
restrictive
restrictive or obstructive: asbestosis, sarcoidosis
restrictive
restrictive or obstructive: COPD
obstructive
restrictive or obstructive: bronchiectasis
obstructive
what is measured in peak flow
peak expiratory flow rate, with variation depending on age height and sex (FVC)
what is measured in spirometry
forced vital capacity
forced expiratory volume in 1 second (FEV1)
Forced expiratory ratio (FER) - FEV1/FVC
FEV1/FVC in restrictive disease
normal
FEV1/FVC in obstructive disease
reduced
how can you distinguish between COPD and asthma in spirometry
FVC is normal in asthma but decreased in COPD
or do bronchial challenge/reversibility
results of bronchial challenge in COPD and asthma
asthma > 15% increase
COPD < 15% increase
TCLO in asthma
normal/raised
TCLO in emphysema
reduced
TCLO in restrictive disease
reduced
TCLO in Wegeners/good pastures
raised
TCLO in polycythaemia
raised
FVC: significantly reduced
FEV1: decreased
FER: > 75% i.e. normal
TCLO: reduced
restrictive pattern
restrictive spirometry pattern:
FVC, FEV1, FER, TCLO
FVC: significantly reduced
FEV1: decreased
FER: > 75% i.e. normal
TCLO - reduced
FVC - decreased
FEV1 decreased
FER decreased
TCLO decreased
COPD
spirometry of COPD
FVC - decreased
FEV1 decreased
FER decreased
TCLO decreased
what disease FVC - decreased FEV1 decreased FER decreased TCLO decreased
COPD
spirometry of asthma
FVC - normal
FEV1 significantly decreased
FER decreased
TCLO normal/raised
FVC - normal
FEV1 significantly decreased
FER decreased
TCLO normal/raised
asthma
chronic asthma > 17 YOs
step 1
SABA
chronic asthma > 17 YOs
step 2
SABA + ICS
chronic asthma > 17 YOs
step 3
NICE - SABA + ICS + LTRA
SIGN - SABA + ICS + LABA
chronic asthma > 17 YOs
step 4
SABA + ICS + LABA
continue LTRA if there was good response
chronic asthma > 17 YOs
step 5
SABA +/- LTRA + low dose ICS/LABA mart
chronic asthma > 17 YOs
step 6
SABA +/- LTRA + med dose ICS/LABA mart
or
moderate fixed dose ICS and separate laba
chronic asthma > 17 YOs
step 7
SABA +/- LRTA
+ high dose ICS fixed (not mart)
or trial of 4th drug e.g. LAMA or theophylline
seek advice
what is considered low dose ICS
< 400mcg
what is considered medium dose ICS
400-800mcg
what is considered high dose ICS
> 800 mcg
SIGN guidelines
patient on SABA, ICS, LABA poorly controlled asthma
increase ICS or trial another drug - LTRA, theophylline, LAMA
what is a common side effect of LTRA
night mares
when are LTRAs e.g. montelukast particularly good
allergic phenotypes or exercise induced
what drug is good in asthma with SOB without allergy or inflammation
tiotropium
why are theophyllines generally considered last line
make people feel sick
dont work in smokers
asthma in kids 5-15 step 1
SABA
asthma in kids 5-15 step 2
SABA + paed low dose ICS
asthma in kids 5-15 step 3
SABA + paed low dose ICS + LTRA
asthma in kids 5-15 step 4
SABA + paed low dose ICS + LABA
stop the LTRA
asthma in kids 5-15 step 5
SABA + PLD ICS Mart
asthma in kids 5-15 step 6
SABA + PMD ICS mart
or fixed dose moderate ICS + separate LABA
asthma in kids 5-15 step 7
SABA + one of
- paediatric high dose fixed dose regime or MART
- trial of theophylline
asthma kids < 5 step 1
SABA
asthma kids < 5 step 2
SABA + 8 week trial of paediatric moderate dose ICS - after 8 weeks stop the ICS and monitor - if symptoms did not resolve during the trial period review diagnosis
if symptoms resolved and reoccurred within 4w of stopping then restart ICS at a low dose
if over 4 weeks and symptoms reoccurred repeat the trial
asthma kids < 5 step 3
SABA + PLD ICS + LTRA
asthma kids < 5 step 4
stop the LTRA and refer to paediatric asthma specialist
acute asthma treatment
- sit up and give high flow O2
- salbutamol neb
- prednisolone oral or hydrocortisone IV + normal ICS
- ipratropium bromide (SAMA) via neb
- IV theophylline
- IV mag sulf
how long should prednisolone be continued after an asthma attack
5 days
acute asthma acronym
O SHIT ME oxygen salbutamol hydrocortisone/prednisolone ipratropium theophylline mag sulf escalate
most important intervention in COPD
smoking cessation
vaccinations in COPD
annual flu
once of pneumococcal
who should be considered for LTOT
PO2 < 7.3, or 7.3-8 with one of the following:
• Secondary polycythaemia
• Peripheral oedema
• Pulmonary hypertension
COPD treatment ladder step 1
SABA or SAMA prn
COPD treatment ladder step 2 if patient has no asthma features
SABA + LABA + LAMA
if pt was taking SAMA as first therapy then switch to SABA
COPD treatment ladder step 2 if asthma features
SABA or SAMA + LABA + ICS
COPD treatment ladder step 3
SABA + triple therapy of LABA LAMA and ICS
COPD treatment ladder step 4
oral theophylline
what antibiotic prophylaxis is used in COPD in certain patients
azithromycin
acute exac of COPD acronym
iTOAPES - ipratropium - theophylline oxygen amoxicillin prednisolone escalate salbutamol
acute exac of COPD
- 0xygen
- nebulised salbutamol and ipratropium
- theophylline IV
- oral prednisolone (5 days)
- amoxicillin if infection suspected (doxy if pen al)
- NIV
what is the most common cause of acute exacerbations of COPD and bronchiectasis
H influenzae
what 3 paraneoplastic syndromes do Small cell lung cancers cause
Lambert eaton
SIADH
cushings
most common type of lung cancer
adenocarcinoma
two lung cancers found centrally and associated with smoking
small cell and squamous cell
where is adenocarcinoma typically found in lung
peripheries
what is a sign that can happen in adenocarcinoma
gynaecomastia
paraneoplastic syndrome caused by squamous cell carcinoma
PTHrp - hypercalcaemia
TSH - hyperthyroid
1st line IX in lung cancer
CXR
gold standard ix in suspected lung cancer
CT
what ix is needed for diagnosis of lung cancer
bronchoscopy and biopsy
most small cell tumours are _____sensitive
chemo
most non-small cell tumours are ____sensitive
radio
auscultation of idiopathic pulmonary fibrosis
bibasal fine end inspiratory crackles
CT mesothelioma
pleural thickenings
interstitial lung disease on XR
ground glass appearance
lower zone fibrosis cause
idiopathic pulmonary fibrosis
asbestosis
mid zone fibrosis cause
progressive massive fibrosis
idiopathic pulmonary fibrosis gold standard ix and findings
high resolution CT scan
honeycomb lung and thickened interstitium
idiopathic pulmonary fibrosis treatment
lung transplant
supportive
anti-fibrotic - perfenidone
granuloma in sarcoidosis
non-caseating
sarcoidosis treatment
oral or inhaled steroids +/- immunosuppression
extrinsic allergic alveolitis
- acute
- chronic
acute - tapered dose of oral steroids
chronic - allergen avoidance and long term steroids
egg shell calcification at hilar nodes
silicosis
treatment of pleural plaques from asbestos exposure
nothing - benign
croup cause
parainfluenza virus
croup presentation
stridor
barking cough worse at night
fever
coryza
croup xray
steeple sign
treatment croup
dexamethasone
acute epiglottitis cause
haemophilus influenza B
acute epiglottitis presentation
rapid onset drooling fever stridor tripod position
acute epiglottitis CXR
thumb sign
acute epiglottitis tx
ceftriaxone IV
bronchiolitis cause
RSV
tx acute bronchitis
doxycycline or amoxicillin
cause of whooping cough
bordetella pertusis
key signs of whooping cough
inspiratory whoop
coughing bouts often ending in vomiting/cyanosis
diagnosis whooping cough
nasal swab culture
school exclusion of whooping cough
notifiable disease and school exclusion for 48 hours from starting abx or 21 days from cough onset
tx whooping cough
erythromycin
infective exac of COPD treatment
amoxicillin
prenisolone for 5 days
increase bronchodilator frequency
most common cause of CAP and HAP
strep pneumonia
1st line for all children with pneumonia
amoxicillin
pneumonia associated with cold sores
strep pneumonia
pneumonia common in COPD
H influenza
pneumonia secondary to viral influenza
S. Aureus
pneumonia associated with painful vesicles on tympanic membrane
mycoplasma
tx mycoplasma
doxycycline or clarithromycin
ix mycoplasma
serology
positive cold agglutination test
pneumonia seen in patients with pet birds
chlamydia psittaci
tx chlamydia psittaci
doxycycline
erythromycin
pneumonia from sheep
coxiella burnetti
treatment of coxiella
clarithromycin
treatment of legionella
levofloxacin or clarithromycin + rifampicin
legionella ix
urine antigen
deranged LFT
hyponatraemia
red current jelly sputum
klebsiella
when is PCP seen
immunocompromised/HIV
when CD4 < 200
ix of PCP
bronchoalveolar lavage
tx of PCP
co-trim
can be given as prophylaxis
when is pseudomonas pneumonia seen
CF / bronchiectasis
what is the treatment of pseudomonas
ciprofloxacin
CURB65 criteria
Confusion (>8/10 abbreviated mental test score), urea > 7, RR > 30, BP < 90 systolic, diastolic < 60, over 65
tx mild/moderate CAP
amoxicillin
tx mild/moderate CAP pen all
doxycycline
tx mild/moderate CAP if NBM
IV clarithromycin
tx severe CAP
co-amox IV + doxy
tx severe CAP if pen all
levofloxacin
tx severe CAP if in ITU
co amox + clarithromycin
or
levofloxacin + clarithromycin
tx severe HAP
IV amox and met and gent
tx severe HAP step down
co trim and met
tx non-severe amox
oral amox and met
tx pneumonia assocaited with influenza
co-amoxiclav
granuloma in TB
caseating
main test for latent TB
mantoux skin test
gold standard for TB
sputum culture
treatment of active TB
2 months RIPE
4 months RI
latent TB treatment
3 months R + I (with pyridoxine) or 6 months of I (with pyridoxine)
treatment meningeal tuberculosis
12 months RIPE + steroids
effusion of < 30g protein is a
transudate
effusion of > 30g protein or protein/serum ratio is > 0.5
exudate
most common cause of transudate
heart failure
1st line IX of effusion
PA CXR
D sign on X ray
empyema
CF inheritance
AR
CF ix
sweat test chloride > 60mmol
tx CF
supportive etc
orkambi
ix sleep apnoea diagnostic
polysomnography
tx sleep apnoea
CPAP
treatment pneumothorax
primary with < 2cm air and no SOB
discharge
treatment pneumothorax primary with > 2cm ring / SOB
aspiration
then chest drain if needed
treatment pneumothorax secondary
patient > 50 and >2cm air or SOB
chest drain
treatment pneumothorax
secondary
1-2cm air
aspirate
treatment pneumothorax secondary < 1cm air
admit and give o2 for 24 hours
how is aspiration done
Insert 16g cannula into mid clavicular line of 2nd intercostal space
tension pneumothorax treatment
1st aspirate (MCL, 2ICS) then chest drain (5ICS MAL)