Resp Flashcards
Ix for Pe
Wells score >4
CXR
CTPA
If CTPA - consider doppler for leg
<4- D dimer if + arrange CTPA
Mx of PE
Wells- >4- CTPA
<4- D dimer
DOAC whilst waiting for scan if high clinical suspicion
DOAC 3m/6m if unprovoked if stable
Thrombolyse is hypotensive- unfractionated heparin if CI to thrombylysis
Tension pneumothorax Tx
14G cannula in pleural space
Sx of sarcoidosis
Affects face- lupus pernio
Hypercalcaemia- constipated, polyuria ect
Ix and diagnosis of asthma
FEV/FVC1- <70%
If negative but high suspicion - FeNO
Both for adult
Tx of COPD
SABA/SAMA then
LABA +LAMA with SABA PRN
Then add ICS
But if asthmatic features/steroid responsive i.e peanut allergy - eosinophilia, prev asthma LABA + ICS
O2 treatment of COPD
If retainer- high CO2
Aim for Sats- 88-92
24-28% venturi if exacerbation
If not retainer- high Flow
LTOT- non smoker- if PO2- <7.3 or between 7.3-8- high HB/oedema/pulHTN
NIV- resp acidosis- 7.25-7.35
Scoring for OSA
Epworth scale
Causes of ARDS
Trauma, infection-sepsis, pancreatitis
Sign of ARDS on CXR
Bilateral lung infiltrates
Sign of bronchiectasis on CXR and CT
Parallel, linear densities in the lower zones) is consistent with ‘tram-tracks’
Signet sign
Signs of each lung lobe consolidation
Right upper- pulled up lung
Middle- loss of horizontal fissure
Lower- loss of heart border
Left lingula- loss of heart border
Life threatening asthma signs
CHEST
Cyanosed
Hypotension
Exhausted, confused
Silent chest
Tachyarrhythmia
Normal CO2
When to admit asthma attack
Severe- if no response to treatment
Moderate- if previous life threatening
If pregnant with severe even if responding to initial treatement
Signs and symptoms of sarcoidosis
Usually black African Caribbean
Joint pain
Erythema nodosum
Respiratory
Lupus pernio
High calcium feature- high 1a hydroxylase
High ACE levels
Non caseating
Tension Pneumo cannula size
14G cannula
COPD chronic treatment
SABA/SAMA
If asthmatic features- change SAMA to SABA and LABA and ICS
No- LABA and LAMA
3- all 3
Asthma diagnosis
Spirometry
Reversibility 12% or 200ml of FEV1
FeNO- >40- do if adult
Diagnosis of OSA
Overnight pulse oximetry then
Polysomnography
Diagnosis of bronchiectasis
High resolution CT
Tran tacks
Fibrosis causes
Drugs- amiodarone, sulfalazine, methotrexate
Post TB- apical
Hypersensitivity pneumonitis
Systemic- lupus, RA
ABPA vs EAA
ABPA- lumen affected, typically have CF or asthma
High IgE
BE on CT or CXR
EAA- interstitium affected due to breathed in material, low grade fever, mould, occupational cause
Worse at end of day, sx after few hrs of exposure
No IgE
Cause of white out on CXR
Pleural effusion- meniscus, trachea away
Collapse- trachea towards
Sx of Kartageners syndrome
Dextrocardia
Bronchiectasis
Recurrent infections
What is TLCO and when is it raised or lower
TLCO- CO test to represent O2 uptake
Raised TLCO- raised CO in blood- increased perfusion – asthma
Reduced- damage to parenchyma – COPD, PE
Criteria for ARDS
Acute
Non cariogenic pulmonary oedema- no leg swelling, HF history, normal pulmonary capillary wedge pressure
PaO2/FiO2- <40kPa
Hyperinfalted lungs on CXR
> 10 posterior
6 anterior
Bacteria in empyema
Klebiella
CF testing
CFTR gene- Cl pumping
Sweat test- high Cl
Faecal elastase- pancreatic insufficiency
CXR
Tx of CF
MDT
Mucolytics, bronchodilators, antimicrobials
Asbestosis features
Worse symptoms if increased exposure
What can’t you do after pneumothorax
Scuba diving- indefinitely
Flying- 2-6 weeks
Bronchitiis Mx
If CRP 20-100- delayed Abx
>100 or if significant co morbidities- Abx
Doxyxycline
Criteria for discharge after asthma attack
PEF >75%
Inhaler technique checked
Stable on meds for at least 12-24 hours
Bronchiectasis pneumonia organism
Haemophillus Influenza
When should NIV be started in COPD
PaCO2 >6
pH <7.35
Inhalier technique
Shake
Breath out
Lips on
Press and breath in
Hold for 10
Repeat after 30 secs
Pleural effusion aspiration testing
If ratio to serum >0.5 or above 30
LDH >0.6
Exudate- PE, malignancy, infection
Trasudative- HF
Chest infection with HIV
Pneumocystic Jirovecii
Bilateral infiltrates
Reduced exercise tolerance
PCP Ix and Tx
CXR- bilateral infiltrates
Exercise desaturation
Co-trimoxazole
If PE is suspected and Wells </=4 and D dimer -ve what do you do
Stop anti coagulation
Consider alternate diagnosis
When to perform an ABG in asthma
When sats <92
Most common Organism causing infective exacerbations in COPD
H influenza
Tx of sarcoidosis
Monitoring
If high Ca, lung disease, neuro or cardio involvement
CS
If COPD exacerbation with low sats what Tx
High flow O2 first since hypoxia kills
Then titrate down
Ix of TB
Sputum culture
Mantoux test results
> 15mm- positive
10- IVDU
5- HIV
Surgery for bronchiectasis
Localised to one lobe
Types of disease pattern for asbestosis
Restrictive
FEV1- reduced
FEV1/FVC- increased
Tx of ABPA
Oral GC
Prednisilone
Itraconazole 2nd
Features of cluster headaches
Last 15 min-2 hours
Clusters- 4-12 weeks
Lacrimation, redness
Nasal stuffiness
Severe asthma feartures
PEF 33-50
Cant complete sentences
RR >25
Pulse >110
Severity of COPD
FEV1
Mild- normal, but FEV/FVC <0.87
Mod- 50-70
Severe 30-50
V severe <30
Things that cause upper lobe fibrosis
CHARTS
Coal worker- pneumoconiosis
Hypersensititve pneumonitis
AS
Radiation
TB
Sarcoid
Young person with liver failure and lung problems
a1 anti trypsin
Mx of A1AT
Bronchodilators, physio
Lung reduction surgery
Causes of caveatting lung lesion
Abscess
Staph, klebsiella
TB
Squamous lung cancer
Pleural effusion tx
After CXR
Pleural aspiration with USS
If cloudy or pH <7.20 chest tube
If cytology neg- CT- guided biopsy
When to use surgery/chemo/radio in lung cancer
If in situ- surgery
If spread to nodes- chemo and radio
First line drug for IE of COPD
Amoxicillin, clarithromycin and doxycycline
Causes of clubbing in resp
Cancer
Chronic infection- BE, CF
Fibrosis
Respiratory cause of raised JVP
Cor pulmonale
Different scars and what procedure it means was done
Mid sternotomy- CABG, lung transplant
Thoracotomy- lobectomy, pneumonectomy, transplant
Side- effusion, PTX
VATS scar- biopsy, effusion, pleurodesis
Heart signs on palpation for resp exam
Displaced or heave
RVH
Secondary to Pul HTN, COPD, ILD
Breath sound findings
Quiet breaths- pleural effusion
Bronchial- pneumonia
Coarse crackles- pneumonia, BE
Fine end- fibrosis, oedema
Effusion vs pneumonia OE
Stony dull
Quiet breath sounds
Decreased vocal remits
Dull
Bronchial/coarse
Increase vocal remits
Types of pneumonia and they signs
Aspiration- right more likely
Staph- elderly, IVDU, after influenza
Klebsiella- red curran, alcholic
Mycoplasma- arthlagia, myalgia, erythema multiforme
Legionella- hyponatraemia
FLAWS symptoms, increase urine, constiapted
Squamous cell
Producing PTH
HPOA- clubbing and periostitis
How to treat paroxysmal AF
Flecanide one off
Sotalol
Tx of severe sleep apnea
CPAP
When is Mantoux test used
Vaccinated patients in close contact with those. with TB
Tx of aspirational pneumonia
Broad spectrum- e.g co-amox
What can Small cell lung cancer cause
SIADH
Cushing
LEMS
Cerebellar degeneration
Mx of PE if end stage renal failure
Unfractionated heparin
Threshold for invasive ventilation in COPD
<7.25
if 7.25-35- NIV
Near fatal Asthma classification
Raised CO2
If frequent exacerbations of COPD what should you do
Home stash of ABx
>3 in a year
Only take ABx when sputum is purulent
Exacerbation of COPD tx
Neb salbutamol and ipratroprium
PO prednisolone and IV HC
IV co amor
Then IV aminophylline
Then NIV
Ix of occupational asthma
PEF in and out of work
Renal transplant patient with cough
CMV pneumonitis
How to know if chest drain is in pleural cavity
Water seal will sing
Will go up in inspiration and down in expiration
Complication of draining pleural effuison
Re expansion pulmonary oedema
CXR finding of PE
Wedge shaped opacification on CXR
How to tell if carcinoma
Nuclear enlargement
Pleomorphism
Hyperchromasia
Analgesia in post op gastric surgery with COPD
Epidural
To avoid opioid
Lung cancer with caveatting lesion
Squamous cell
Aspergilloma features
Arises where TB once was
Target shaped lesion with air crescent sign
Tx of legionella
Clarithromycin
What do you find on observations with OSA
Hypertension
Additional Ix for COPD
Spirometry
FBC- polycyth
ABG
CXR
ECG- RAD, p pulmonale
Treatment response in COPD
Most useful is symptomatic- reduced breathless, increased exercise and sleep
Causes of lobe collapse
Bronchial carcinoma
Extrinsic compression
Mucus plug
Foreing body
Cause of BE
Idiopathic
Post infectious
Immunodeficiency
ABPA
Adenocarcinoma sx
Gynaecomastia
HPOA- clubbing and periostitis
X ray after pneumonia
6 weeks after
BE sx
Clubbing
Purulent sputum- large amount in sputum pot
Haemoptysis
Coarse Creps
Wheeze
Tx of BE
AB in exacerbations
Physical training
Bronchodilators
Surgery
Tx of ARDS
Low tidal volume mechanical ventilation
Lung cancer ix order
CXR
CT scan
Biopsy
Sx of lung abscess
Recurrent fever
Foul smelling sputum
Clubbing
Aspiration RF §
Tx of staph aureus pneumonia
Flucloxacillin
Mycoplasma pneumonia sx
Erythema multiforme- multiple erythematous papule with deeply erythematous borders
Cold AIHA- blue fingers and toes when go outside
Ix of ABPA
Clinical
Aspergillus IgE and IgG
Asthma history
High eosinophils
May have BE- CT
Ix for IPF
CXR
Oximetry
Spirometry
Bloods
CT
Fibrosis on CT
Ground glass
Fibrosis sx
Clubbing
Dry cough
On medication/ inflammatory
Fine late crackles
Sx of lung transplant
Thoracotomy scar
Clubbing- CF, IPF
Cushings- side effects of suppressants
Mesothelioma gold standard
Thoracoscopic biopsy
PE can cause what change on ECG
RBBB
AS spirometry results
Restrictive picture due to apical fibrosis
FVC low, FEV1 low, Ratio normal
Sx of emphysematous bullae
Similar to PTX
Smoker
Lucent on CXR with thin wall
Bronchitis symptoms
Clear sputum, clear CXR, less systemic features, high CRP, low grade fever, cough
Pathogen for infection in CF
Psuedomonas
What is the step down of asthma
If good asthma control test
Step down by 25-50%
Prophylaxis for flights fro DVT
Anti embolic stockings
RF for aspergillosis
HIV
TNFa inhibitor
Leukaemia
Broad spec ABx
O2 target if CO2 not raised
94-98
If getting oral candiasis with steroid inhaler what should you switch to
Spacer
If massive PE and CI to thrombolysis tx
IV unfractionated heparin
Features of asthma in COPD
Diurnal or >20% variability
Large response to bronchodilators
Where should chest drains be places in ICS
Just above rib at bottom of space you want
So for chest drain- just above 6th rib
Where should chest drains be places in ICS
Just above rib at bottom of space you want
So for chest drain- just above 6th rib
SOB, hyponatraemia and clear CXR mx
Urgent referral to chest clinic
If suspicion of PE but CTPA neg but signs of DVT what do you do
USS leg
Dx of mycoplasma
Serology
DVT pathway mx
Well 1- D dimer within 4 hours - if + scan, if - alternate
>2 - doppler
If scan - but dimer + stop AC and repeat US in 6-8d
If delay in test give DOAC
When should you refer down lung cancer 2ww referral
Lung cancer on CXR
or haemoptysis >40
Pneumonia causing HSV reactivation
S pneumonia
Which lung cancer is found near the large airways
Small cell
DOAC time with DVT/PE with active cancer ?
3-6 months
High suspicion of PE but CTPA delayed
Give apixiban
Why nephrotic syndrome causes PE
Due to antithrombin deficiency
When to step up asthma to ICS
> 3 times per week symptoms
Or night waking
Prognosis score of COPD
BODE
BMI
Output FEV1
Dyspnoea
Exercise
Cause of BE
Idiopathic
Infection
CF, Kartangers
RhA
Suspected PE but has CKD investigation
V/Q scan
Cancers causing raised Plt
LEGO C
Lung
Endo
Gastric
Oesophageal
Colorectal
If pneumothorax persists despite appropriate treatment mx
Persistent air leak or recurrent episodes → consider referral for VATS to allow for mechanical/chemical pleurodesis +/- bullectomy
Tx of EAA
Avoid triggers
CS
Silicosis X ray
upper zone fibrosing lung disease
‘egg-shell’ calcification of the hilar lymph nodes§
Ix of lesion in chest
CXR
Contrast CT- due to high vascular
AB for COPD prophylaxis
Azithromycin
4 in last year
No smoking
