Resp Flashcards
How do you manage a non-tension pneumothorax in a patient with no previous lung disease?
If >2cm or SOB do needle thoracentesis
If not discharge and review in OP in 2-4 weeks
How do you manage a non-tension pneumothorax in a patient with previous lung disease?
> 2cm or SOB do chest drain and admit
If 1-2cm do needle thoracentesis
If <1cm admit for observation and consider high flow oxygen
Describe the CURB-65 score?
Confusion (abbreviated mental state score =< 8/10)
Urea >7
RR >= 30
BP =< 90 systolic and/or =<60 diastolic
Age >= 65
Sx of a lung abscess?
Fever, chest pain, productive cough with foul smelling sputum, dyspnoea and clubbing
Ix and Mx of a lung abscess?
CXR = fluid filled space with an area of consolidation (+ air fluid level)
Mx = IV Abx, if it does not resolve use percutaneous drainage
Name the causes of mediastinal widening on CXR?
Pt. rotation, aneurysm, lymphoma, retrosternal goitre, teratoma and thymus tumours
What are the indications for steroid treatment in sarcoidosis?
PUNCH
Parenchymal lung disease
Uveitis
Neurological involvement
Cardiac involvement
Hypercalcaemia
How does sarcoidosis commonly present?
What is the gold standard for diagnosis?
In young (20-40s) black females
Chest Sx e.g. dry cough, erythema nodosum (shin lumps), lymphadenopathy and may have changes to the skin on the face
Biopsy of the granulomas - non-caseating granuloma with epithelioid cells
How should you deliver oxygen to critically ill patients?
High flow (15L/min) through a non-rebreath mask until target saturations are reached. Do this even if they are a known retainer
What are the possible consequences of asbestos exposure?
Pleural plaques (benign no Mx required)
Pleural thickening
Asbestosis - lower lobe fibrosis which requires conservative Mx
Mesothelioma - malignant and requires palliative chemo
Lung Cancer (non-mesothelioma cancers are the most common form of cancer associated with asbestos)
How do we differentiate between transudate and exudate fluid in a pleural effusion?
Exudate have a protein of >30g/L, transudates have a protein of <30g/L
If protein is between 25-35g/L consider the Light’s criteria (exudate if):
Pleural:Serum protein >0.5
Pleural:Serum LDH >0.6
Pleural fluid LDH is more than 2/3rd the upper limit of normal serum LDH
Name the most common cause of exudate and transudate pleural effusion?
Transudate = heart failure
Exudate = pneumonia
How do we diagnose asthma?
> = 17 years old = spirometry with Bronchodilator reversibility testing and FeNO test
5-16 years old = spirometry with Bronchodilator reversibility testing, if negative or normal do FeNO test
<5 years old - clinical judgement
What is the most common lung cancer in smokers vs non-smokers?
Non-Smokers = Adenocarcinoma
Smokers = SCLC
Where is the lung most commonly affected in aspiration pneumonia? Name 1 procedure that increases the risk?
Right middle and lower lobes
Recent intubation is a RF
What are the CXR findings seen in HF?
Alveolar oedema (bat wings)
Kerley B lines
Cardiomegaly
Dilated upper lobe vessels
Effusions
Mx of CAP vs HAP?
CAP = Amoxicillin
HAP (>= 48 hours after hospital admission) = Co-Amoxiclav
What is Left lingual consolidation?
loss of the L heart border on CXR
What is the diagnosis when a CXR shows a completely white lung with the trachea pulled towards it?
Lung collapse
When should you consider NIV in exacerbation of COPD?
When respiratory acidosis persists despite maximum standard medical treatment (nebs, steroids and theophylline)
Which are the standard antibiotics which you can use in COPD exacerbation?
Amoxicillin, Clarithromycin or Doxycycline
Avoid clari if there is congenital long QT syndrome
What is the criteria for diagnosing TB after Manteaux skin test?
> 5mm if immunocompromised
10mm if risk factors for infection (e.g. healthcare worker or travel to high risk area)
15mm if no risk factors
When should you give antibiotic treatment over supportive Mx for bronchitis? Which Abx should you give?
If systemically unwell or if there are co-morbidities or CRP>100
Give doxycycline or Amoxicillin if pregnant/a child
What should you suspect if a young person or non-smoker presents with COPD Sx?
Alpha-1 Antitrypsin Deficiency
Who is Klebsiella pneumiae seen in? How does it present?
Seen in alcoholics and diabetics or secondary to aspiration pneumonia
Sputum is red-currant jelly like
It can commonly progress to an abscess
Should you do a CXR after CAP? If so when?
Yes if they are a smoker or >50
Do it 6 weeks after resolution of Sx
Above what % improvement of FEV1 with bronchodilators is asthma indicative?
> =12%
Sx of idiopathic pulmonary fibirosis?
Exertional dyspnoea, dry cough, weight loss, bibasal inspiratory crackles and finger clubbing
What scan should be offered to those with a known or suspected lung CA?
Contrast CT
When should you use BiPAP?
In those with a respiratory acidosis pH 7.25-7.35 and T2RF after medical management (nebulised salbutamol, ipratropium bromide and IV hydrocortisone) have failed
When should you use CPAP?
In those with T1RF for whom medical management has failed
Mx of COPD exacerbation?
Amoxicillin/Doxycycline/Clarithromycin and oral pred
What are the common causes of respiratory alkalosis
Panic attack, PE, Altitude, Pregnancy, Salicylate poisoning and CNS disorders e.g. stroke, encephalitis and SAH
What are the common causes of respiratory acidosis?
Life threatening asthma or pulmonary oedema, COPD, obesity hypoventilation syndrome, neuromuscular disease and sedative drugs e.g. benzos/opioids
When does the CURB-65 score indicate there is a need for hospital care?
> =2
If >= 3 consider intensive care
What are the paraneoplastic features of SCLC?
SIADH, Cushing’s syndrome, Lambert-Eaton syndrome (proximal muscle weakness similar to MG but weakness is worse in the legs)
What are the paraneoplastic features of squamous cell carcinoma (a Non-SCLC)?
Parathyroid Hormone Related Protein (leads to hypercalcaemia), clubbing, hyperthyroidism, Hypertrophic Pulmonary Osteoarthropathy (leads to pain in the long bones)
What are the paraneoplastic features of adenocarcinoma?
Gynaecomastia and Hypertrophic Pulmonary Osteoarthropathy (leads to pain in the long bones)
Which part of the lung is most commonly affected by aspiration pneuomonia?
R lower lobe
What are the distinguishing features of Klebsiella Pneumonia?
A cavitating pneumonia in the upper lobes with red currant jelly sputum, mainly seen in diabetics and alcoholics
Which conditions is bilateral hilar lymphadenopathy seen in?
TB or sarcoidosis
What causes cannon ball metastases of the lungs?
Renal cell carcinoma
Sx of bronchiectasis
Persistent productive cough +/- haemoptysis
Dyspnoea
Coarse crackles + wheeze
Clubbing
How do we stage COPD severity with FEV1 (as a % of predicted)
Stage 1 = mild = >80%
Stage 2 = moderate = 50-79%
Stage 3 = severe = 30-49%
Stage 4 = very severe = <30%
How does alpha 1 antitrypsin deficiency present?
Lungs = emphysema worse in the lower lobes (obstructive lung disease)
Liver = cirrhosis and hepatocellular carcinoma in adults, cholestasis in children
Where is the triangle of saftey for chest drain?
Base of the axilla, lateral edge of pectoralis major, 5th intercostal space and the anterior border or latissimus dorsi
Is a parapneumonic effusion exudate or transudate?
Exudate
What is the cause if there is exudate with a very low glucose?
Empyema
What will squamous cell carcinoma cause of CXR?
Cavitating lesions
Describe silicosis?
Seen in those with a history of mining or who work with slate/pottery, there is upper zone fibrosis and egg-shell calcification of the hilar nodes
What is the diagnosis if you have exudate which contains multinucleated giant cells?
Rheumatoid arthritis
What is Meig’s syndrome?
Transudate pleural effusion which occurs with ovarian fibromas and ascites
Describe Acute Respiratory Distress Syndrome?
Non cardiogenic pulmonary oedema
Characterised by dyspnoea, increased resp rate, bilateral lung crackles and decreased oxygen sats
Ix = pulmonary oedema, pO2/FiO2 <40kPa and a normal/reduced pulmonary capillary wedge pressure (<19.0)
Manage in ITU
Which lung cancer is SIADH associated with? How does it affect the serum sodium?
SCLC
It causes low serum sodium
Describe Hypertrophic Pulmonary Osteoarthropathy?
Seen in squamous cell carcinoma and adenocarcinoma. It can affect the wrists, ankles and knees to cause new periosteal bone formation. Presents with swelling, pain, stiffness and reduced ROM
Describe correct inhaler technique?
1) Remove cap and shake
2) Breath out gently
3) Put in mouth and breath in slowly and deeply whilst pressing the canister
4) Hold breath for 10 secs
5) Wait 30 secs before 2nd dose
How can you differentiate between the sarcoidosis rash and the SLE rash?
Sarcoidosis is purple and includes the nose
SLE rash is red and spares the nose/nasolabial folds
Which metabolic abnormality is sarcoidosis associated with?
Hypercalcaemia
True or false, sarcoidosis is a cause of clubbing?
False!
What should you do before inserting any drain?
Check the INR!
INR >1.3 is a relative contraindication
What can happen if you drain pleural effusions too quickly?
Re-expansion pulmonary oedema
What are the steps in COPD management?
1st line = SABA or SAMA PRN
2nd line:
If asthmatic Sx or steroid responsiveness = LABA + ICS
If not = LABA + LAMA
3rd line = LABA + LAMA + ICS
Describe the Sx and Mx of acute bronchitis?
Sx = Dry cough which 3-4 days later may become productive. Also sore throat, pyrexia and rhinorrhoea/wheeze
Mx = supportive unless CRP >100 then give doxycycline
How can we help pregnant women stop smoking?
NRT
Varenicline and Bupropion are contraindicated in pregnancy
What has happened if one portion of the lung appears white but the rest appears blacker than you would expect?
Part of the lung has collapsed and the rest of the lung has hyperexpanded to compensate
How do we usually manage small cell lung cancers?
Chemo and radiotherapy (not surgery)
Which results from FeNO testing, post bronchodilator volume improvement and PEFR variability imply asthma?
FeNO shows asthma if >= 40 billion parts
Volume improvement with bronchodilators of >= 200
PEFR variability of >= 20%
If you drain an empyema what will you find?
A turbid effusion with pH <7.2, low glucose and high LDH
What on CXR would imply bronchiectasis? What is the most common cause of exacerbation?
Dilated bronchi and thickened walls.
Tram track sign will be seen
Most exacerbations are caused by H.influenzae
What is the maximum amount of air you should aspirate in pneumothorax? What should you do after this?
Maximum 2.5L
After this insert a chest drain
What is allergic bronchopulmonary aspergilliosis?
A fungal infection associated with eosinophilia.
Mx = oral prednisolone
True or false, adenocarcinoma of the lungs can cause gynaecomastia?
TRUE
How can platelets be affected in lung cancer?
They are raised
What is Kartagener’s syndrome?
Dextrocardia (the heart is on the right side of the chest - leads to quiet heart sounds), bronchiectasis, recurrent sinusitis and infertility
Who should you never give bupropion to?
Pregnant women and epileptics (it lowers the seizure threshold)
Where is the emphysema most prominent in alpha 1 antitrypsin deficiency and COPD respectively
Alpha 1 antitrypsin deficiency = lower lobes
COPD = upper lobes
Is bilateral hilar lymphadenopathy an indication for steroids in sarcoidosis?
NO! It is not parenchymal lung disease
Mx of end stage COPD or Alpha 1 antitrypsin deficiency?
Lung volume reduction surgery or transplant
What is Chlamydia Psittaci?
A type of pneumonia seen in bird keepers
What is the centor criteria for a sore throat?
Exudate seen on the tonsils
Anterior cervical lymphadenopathy/lymphadenitis
Hx of fever
Absence of cough
When should you prescribe Abx in COPD exacerbation?
If there is purulent sputum or symptoms of pneumonia
What is seen in restrictive lung disease?
Normal/slightly reduced FEV1 and a reduced FVC
FEV1:FVC normal or increased
How do you distinguish between Idiopathic Pulmonary Fibrosis and Pneumoconiosis as the cause of restrictive lung disease?
IPF = ground glass appearance on CXR
Pneumoconiosis = opacities on CXR, it is characteristically seen in coal miners
True or false, acute pancreatitis can cause ARDS?
TRUE
How should you give steroids in an acute asthma exacerbation?
As oral prednisolone, unless vomiting then give IV hydrocortisone
