resp Flashcards
4-month history of increasing breathlessness, fatigue and weight loss.
He is now retired but previously worked as a shipyard worker for 50 years
and he has a 40 pack-year smoking history.
cancer?
mesothelioma
Pneumothorax- what to avoid in lifestyle?
Pneumothorax -> life long ban on deep sea diving
Restrictive spirometry example?
FVC, FEV1, FEV1/FVC, TLCO?
pulmonary fibrosis, scoliosis, neuromuscular disorder, ARDS
FVC and FEV1 are reduced proportionately so the FEV1/FVC is normal/increased
FVC reduced <70% (significantly)
FEV1 reduced/normal
TLCO reduced (impaired gas exchange)
Obstructive spirometry example?
FVC, FEV1, FEV1/FVC, TLCO?
COPD, ASTHMA, CF, Bronchiatasis, alpha 1 antritrypsin
FEV1 AND FVC are reduced disproportionately FEV1/FVC reduced <70%
FVC normal or reduced
FEV1 reduced <80%
TLCO reduced (impaired gas exchange)
most common causes of bilateral hilar lymphadenopathy
sarcoidosis and tuberculosis.
All cases of pneumonia should have a …….. at 6 weeks after clinical resolution
All cases of pneumonia should have a repeat chest X-ray at 6 weeks after clinical resolution
admitted with acute severe asthma.
reatment is initiated with 100% oxygen, nebulised salbutamol and ipratropium bromide nebulisers and IV hydrocortisone.
no improvement. What is the next step in management?
IV MAG SULPHATE
A 23-year-old woman comes for review. Despite using beclometasone 200mcg bd she is regularly having to use her salbutamol inhaler. Her inhaler technique is good. next addition?
What is the main therapeutic benefit of inhaled corticosteroids in patients with COPD?
reduce frequency of exacerbations
diagnosed as having bilateral bronchiectasis following a high resolution CT scan. Which one of the following is most important in the long term control of his symptoms?
Symptom control in non-CF bronchiectasis - inspiratory muscle training + postural drainage
Most common organisms isolated from patients with bronchiectasis:
Haemophilus influenzae (most common)
Pseudomonas aeruginosa
Klebsiella spp.
Streptococcus pneumoniae
prescribed bupropion to help him quit smoking. What is the mechanism of action of bupropion?
Norepinephrine and dopamine reuptake inhibitor, and nicotinic antagonist
COPD- best type of oxygen device?
Bilevel Positive Airway Pressure (BIPAP)
first-line pharmacological treatment of COPD
SABA or SAMA (ipratropium)
LAMA(tiotropium)
target sats COPD
88% to 92%
CURB 65 score?
what score means treat at home?
Patients presenting to primary care who have pneumonia can usually be managed in the community with oral antibiotics if their CRB-65 score is 0
Confusion = 1
Respiratory rate ≥ 30 = 1
Blood pressure, SBP ≤ 90mmHg or DBP ≤ 60mmHg = 1
65 years and above = 1
(Urea is removed as this cannot be routinely tested in primary care).
distinguish pleural effusion
exudate vs transudate?
EXUDATE IF:
Effusion lactate dehydrogenase (LDH) level greater than 2/3 the upper limit of serum (blood) LDH
Pleural fluid LDH divided by serum LDH >0.6
Pleural fluid protein divided by serum protein >0.5
The commonest causes of an anterior mediastinum mass?
4 T’s:
teratoma
terrible lymphadenopathy
thymic mass
thyroid mass
anti-acetylcholine receptor antibodies in her blood.
dx?
Myasthenia gravis
The most common organism causing infective exacerbations of COPD is
Haemophilus influenzae
Pleural plaques indicate the patient has been exposed to asbestos 20-40 years prior.
This is seen on x ray findings, what todo next?
Pleural plaques are benign and do not undergo malignant change. They, therefore don’t require any follow-up.
Acute bronchitis management?
Management:
1. analgesia
2. good fluid intake
3. consider antibiotic therapy if patients:
are systemically very unwell
have pre-existing co-morbidities
have a CRP of 20-100mg/L (offer delayed prescription) or a CRP >100mg/L (offer antibiotics immediately)
NICE Clinical Knowledge Summaries/BNF currently recommend doxycycline first-line
doxycycline cannot be used in children or pregnant women
Acute bronchitis is a type of chest infection which is usually self-limiting in nature. It is a result of inflammation of the trachea and major bronchi and is therefore associated with oedematous large airways and the production of sputum.
Sarcoidosis presentation?
Painful shin rash- erythema nodosum,
cough
also affect the kidneys, giving hypercalcaemia- macrophages inside the granulomas cause an increased conversion of vitamin D to its active form (1,25-dihydroxycholecalciferol)
the lymphatic system, giving lymphadenopathy, and other organs/systems.
more common in people of Scandinavian or African descent.
Syndromes associated with sarcoidosis
Lofgren’s syndrome is an acute form of the disease characterised by bilateral hilar lymphadenopathy (BHL), erythema nodosum, fever and polyarthralgia. It usually carries an excellent prognosis
In Mikulicz syndrome* there is enlargement of the parotid and lacrimal glands due to sarcoidosis, tuberculosis or lymphoma
Heerfordt’s syndrome (uveoparotid fever) there is parotid enlargement, fever and uveitis secondary to sarcoidosis
Lung abscess presentation?
Subacute productive cough, foul-smelling sputum, bronchial breath sounds, night sweats → ?lung abscess
ABG triad for chronic CO2 retention:
Normal pH
High pCO2
High HCO3
normal ph- 7.35 to 7.45
normal po2- 10 to14
normal co2- 4.5 to 6.0
bicarb 22-26
Pneumothorax tx?
primary?
secondary?
iatrogenic?
Discharge advice:
Smoking
patients should be advised to avoid smoking to reduce the risk of further episodes - the lifetime risk of developing a pneumothorax in healthy smoking men is around 10% compared with around 0.1% in non-smoking men
Fitness to fly
absolute contraindication, the CAA suggest patients may travel 2 weeks after successful drainage if there is no residual air. The British Thoracic Society used to recommend not travelling by air for a period of 6 weeks but this has now been changed to 1 week post check x-ray
Scuba diving
the BTS guidelines state: ‘Diving should be permanently avoided unless the patient has undergone bilateral surgical pleurectomy and has normal lung function and chest CT scan postoperatively.’
A 54-year-old HIV positive man who has just successfully completed treatment for pneumocystis jirovecii pneumonia comes to your clinic reporting haemoptysis and increasing shortness of breath. A chest x-ray reveals an apical mass in the right lung lobe. He is treated successfully with itraconazole and steroids.
Which bug?
Aspergilloma is a fungal growth affecting immunocompromised patients or those with underlying cavitating lung disease such as tuberculosis or emphysema.
COPD patient- has asthma features, currently on salbutamol, next addition?
using flow diagram
salmeterol and beclomethasone bronchodilator
LAMA= tiotropium
critically ill patient- sudden deterioration… oxygen therapy?
In patients who are critically ill (anaphylaxis, shock etc) oxygen should initially be given via a reservoir mask at 15 l/min. Hypoxia kills.
low-dose ICS name?
budesonide
difference in presentation with moderate vs severe vs life threatening asthma?
moderate: speech normal
severe: cant complete sentences
life threatening: silent chest, cyanosis, exhaustion, confusion
Non-invasive ventilation - key indications?
COPD with respiratory acidosis pH 7.25-7.35
(NIV can be used in patients who are more acidotic (i.e. pH < 7.25) but that a greater degree of monitoring is required (e.g. HDU) and a lower threshold for intubation and ventilation should be used)
type II respiratory failure secondary to chest wall deformity, neuromuscular disease or obstructive sleep apnoea
cardiogenic pulmonary oedema unresponsive to CPAP
weaning from tracheal intubation
most commonly causes a cavitating pneumonia in the upper lobes, mainly in diabetics and alcoholics
Klebsiella pneumoniae
Varenicline to stop smoking.
moa?
s/e?
nicotinic receptor partial agonist
nausea
CURB 65 secondary care- how much for U?
> 7
C Confusion (abbreviated mental test score <= 8/10)
U urea > 7 mmol/L
R Respiration rate >= 30/min
B Blood pressure: systolic <= 90 mmHg and/or diastolic <= 60 mmHg
65 Aged >= 65 years
pulmonary haemorrhage (haemoptysis), renal impairment (rapidly progressive glomerulonephritis) and flat or saddle nose (due to a collapse of the nasal septum) is characteristic of
granulomatosis with polyangiitis
what patients meet criteria for COPD prohylaxsis due to exacerbations?
what is the treatment?
patient with pleural effusion, pleural guided aspiration done. What factor determines if chest drain is needed?
what does negative base excess mean?
metabolic cause
partially compensated metabolic acidosis
Bupropion should not be used in a patient with ….
epilepsy as it reduces seizure threshold
bupropion- smoking cessation, norepinephrine and dopamine reuptake inhibitor, and nicotinic antagonist
pneumothorax- where to do needle decompression?
