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Finals HH > Resp > Flashcards

Resp Flashcards

1
Q

Ix for asthma?

A
  1. Fractional exhaled nitric oxide
    Spirometry with bronchodilator reversibility
  2. If diagnostic uncertainity:
    Peak flow variability
    Direct bronchial challenge test with histamine or methacholine
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2
Q

General asthma guidelines:

A

Roughly

  1. SABA
  2. SABA + low-dose ICS
  3. SABA + low-dose ICS + LTRA (montelukast)
  4. SABA + low-dose ICS + LABA (salmeterol)

3/4 depends on guidelines

  1. Consider options:
    - MART (maintenance and reliever therapy)
    - Oral beta 2 agonist (oral salbutamol)
    - Oral theophylline
    - Inhaled LAMA (tiotropium)
  2. Increase ICS dose

LTRA = leukotriene receptor antagonist

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3
Q

PEFR in moderate, severe and life-threatening acute asthma?

A

. PEFR % predicted
Moderate 50 - 75%
Severe 33 - 50%
Life-threatening <33%

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4
Q

Features of severe asthma attack?

A

PEFR 33-50% predicted
Resp rate >25
Heart rate >110
Unable to complete sentences

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5
Q

Features of life-threatening asthma attack?

A

PEFR <33%
Sats <92%
Becoming tired
No wheeze - airways so tight, no air entry at all
Haemodynamically unstable

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6
Q

Mx of acute asthma attack?

A

OSHITSMA

O - Oxygen to maintain sats 94-98%
S - Nebulised Salbutamol
H - IV Hydrocortisone or oral prednisolone
I - Ipratropium bromide
T - Theophylline / aminophylline
S - Consider IV Salbutamol
M - IV Magnesium sulphate
A - Admit to HDU / ICU

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7
Q

ABG in asthma attack

A

Initially - Resp alkalosis as drop in CO2 from tachypnoea

Late - Resp acidosis as high CO2 (can’t blow it off = bad)

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8
Q

What electrolyte to monitor with salbutamol?

A

Serum potassium (will increase)

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9
Q

Asthma spirometry findings?

A

PEFR reduced
Reduced FEV1
Normal FVC
FEV1/FVC ratio reduced

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10
Q

Restrictive spirometry findings?

A

PEFR normal
Reduced FEV1
Reduced FVC
FEV1 / FVC ratio normal

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11
Q

COPD spirometry findings?

A

PEFR reduced
Reduced FEV1
Reduced FVC
FEV1 / FVC ratio reduced (<0.7)

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12
Q

COPD Mx?

A
  1. SABA or SAMA
  2. Either:
    No asthma -> Combined inhaler (LABA + LAMA) [Anoro ellipta]
    Yes asthma -> Tripple therapy (LABA + LAMA + ICS) [Fostair, seretide]
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13
Q

What is type 1 respiratory failure?

A

Normal pCO2 with low pO2

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14
Q

What is type 2 respiratory failure?

A

Raised pCO2 with low pO2

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15
Q

What mask for oxygen in COPD?

A

Venturi mask

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16
Q

What O2 sats to aim for in COPD?

A

If prior to ABG, 28% Venturi mask at 4 l/min and aim for an oxygen saturation of 88-92% and adjust target range to 94-98% if the pCO2 is normal

If not retaining CO2 and bicarbonate is normal -> aim for >94%
If retaining CO2 and bicarbonate abnormal -> aim for 88-92%

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17
Q

Mx of COPD exacerbation in community?

A

Antibiotics + prednisolone + consider nebuliser

Antibiotics if purulent sputum or pneumonia signs - amoxicillin or clarithromycin or doxycycline

Admit if:
- Severe breathlessness
- Acute confusion or impaired consciousness
- Cyanosis
- Oxygen saturation less than 90% on pulse oximetry.
- Social reasons e.g. inability to cope at home (or living alone)
- Significant comorbidity

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18
Q

Most common infective cause of COPD exacerbation?

A

Haemophillus influenza

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19
Q

Mx of COPD in hospital

A

Nebulised bronchodilators - salbutatmol +/- ipratropium
Steroids
Oxygen
Antibiotics
Prednisolone or IV hydrocortisone

Severe:
- IV aminophylline
- Non-invasive ventilation (Bi-PAP)
- Intubation and ventilation
- Doxaprom - respiratory stimulant if NIV or intubation not appropriate

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20
Q

When to use BiPAP oxygen therapy?

A

When there is type 2 resp failure and resp acidosis (pH<7.35, PACO2>6) despite adequate medical mx

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21
Q

Indications for CPAP?

A

Obstructive sleep apnoea
Congestive cardiac failure
Acute pulmonary oedema

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22
Q

Ix of interstitial lung disease

A

Ix - Restrictive spirometry, bilateral interstitial shadowing on CXR

Dx - high resolution CT showing “ground glass” appearance

Lung biopsy if diagnostic uncertainty

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23
Q

Key px of idiopathic pulmonary fibrosis?

A

Insidious onset SOB and dry cough over >3mo
Bi-basal fine inspiratory crackles
Finger clubbing

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24
Q

Drugs which can cause pulmonary fibrosis?

A

Amiodarone
Cyclophosphamide
Methotrexate
Nitrofurantoin

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25
Q

Conditions which can cause pulmonary fibrosis?

A
  • Alpha-1 antitripsin deficiency
  • Rheumatoid arthritis
  • Systemic lupus erythematosus (SLE)
  • Systemic sclerosis
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26
Q

What type of hypersensitivity reaction is extrinsic allergic alveolitis?

A

Type 3 hypersensitivity reaction

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27
Q

What does asbestosis inhalation cause? (4)

A
  • Lung fibrosis
  • Pleural thickening and pleural plaques
  • Adenocarcinoma
  • Mesothelioma
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28
Q

What is sarcoidosis?

A

Granulomatous inflammatory condition

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29
Q

Histology of sarcoidosis?

A

Non-caseating granulomas with epithelial cells

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30
Q

Mx of sarcoidosis?

A

Mild -> no mx, spontaneously resolves within 6mo in 60% of patients
Moderate:
1. Oral steroids for 6-24mo
2. Methotrexate or azathioprine
3. Lung transplant

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31
Q

Ix of sarcoidosis?

A

CXR showing:
- Hilar lymphadenopathy
- Interstitial infiltrates
- Fibrosis

Bloods:
- Raised serum ACE
- Hypercalcaemia
- Raised CRP / ESR

Dx - Biopsy
- Usually bronchoscopy + US guided of mediastinal lymph nodes

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32
Q

Sarcoidosis Px?

A

Lung: SOB, non-productive cough, bilateral hilar lymphadenopathy

Skin: Erythema nodosum - tender, red nodules on shins

Systemic - swinging fever, fatigue, weight loss

Eyes: Uveitis, conjunctivitis, optic neuritis

Polyarthralgia & hypercalcaemia

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33
Q

Amount of protein for exudative and transudative pleural effusion?

A

> 3g/dL = exudative
<3g/dL = transudative

34
Q

Exudative pleural effusion causes?

A

Inflammation:
- Lung cancer
- Pneumonia
- RA
- TB

35
Q

Transudative pleural effusion causes?

A

Fluid shifting:
- Congestive cardiac failure
- Hypalbuminaemia
- Hypothyroidism
- Meig’s syndrome

36
Q

CXR change in pleural effusions?

A

Blunting of the costophrenic angle
Fluid in the lung fissures
Larger effusions will have a meniscus. This is a curving upwards where it meets the chest wall and mediastinum.
Tracheal and mediastinal deviation if it is a massive effusion.

37
Q

What is empyema?

A

Empyema is an infected pleural space

Pleural effusion + new-onset fever
Pus on aspiration, acidic pH, low glucose and high LDH

38
Q

ECG change in pulmonary hypertension?

A

Right ventricular hypertrophy:
- Larger R waves in right sided chest leads V1-3
- S waves on left sided chest leads V4-5

Right axis deviation
Right bundle branch block

39
Q

CXR changes pulmonary hypertension?

A
  • Dilated pulmonary arteries
  • Right ventricular hypertrophy
40
Q

Primary pneumothorax mx?

A

if:
<2cm + no SOB -> discharge + follow-up in 2-4 weeks

Otherwisie:
1. Aspiration (attempt twice)
2. Chest drain

41
Q

Mx of secondary pneumothorax?

A

> 50y + >2cm and/or SOB -> chest drain

if 1-2cm:
1. Aspiration
2. Chest drain

If <1cm -> Give O2 and admit for 24h

42
Q

Mx of persitstant or reccurrent pneumothorax?

A

Video-assisted thoracoscopic surgery (VATS)

43
Q

Mx of tension pneumothorax?

A

Insert a large bore (14g) cannula into the second intercostal space in the midclavicular line

Once pressure relieved -> chest drain

44
Q

Where to insert a chest drain?

A

5th intercostal space, mid-axilary line

CXR after to check positioning

45
Q

PERC criteria?

(what should be absent to rule out pumonary embolism to <2%)

A
  • Age >50
  • Heart rate >100
  • O2 sats <94%
  • Previous DVT or P.E
  • Recent surgery or trauma (last 4weeks)
  • Haemoptysis
    -Unilateral leg swelling
  • Oestrogen use
46
Q

What score system for suspected P.E?

A

Wells score

47
Q

Wells score criteria?

A

Feature Points

Clinical signs and symptoms of DVT 3
An alternative diagnosis is less likely than PE 3
Heart rate > 100 beats per minute 1.5
Immobilisation >3 days or surgery (previous 4 weeks) 1.5
Previous DVT/PE 1.5
Haemoptysis 1
Malignancy (on mx, mx last 6 months, or palliative) 1

PE likely - more than 4 points
PE unlikely - 4 points or less

48
Q

What Mx if P.E likely in Wells score?

A

CTPA

If CTPA delay -> DOAC

49
Q

What Mx if P.E unlikely in Wells score?

A

D-dimer test

  • If +ve -> CTPA
  • if -ve -> stop DOAC
50
Q

What Ix for P.E if renal impairment?

A

V/Q scanning over CTPA

V/Q and CTPA both give definitive Dx

51
Q

ECG changes in p.e?

A

S1Q3T3

Large S wave in lead Large Q wave in lead III
Inverted T wave in lead III

RBBB and right axis deviation common

52
Q

ABG in p.e?

A

Respiratory alkalosis with low pO2 and low pCO2

53
Q

Mx of P.E?

A

Once a Dx is suspected:
1. DOAC - apixiban or rivaroxaban
2. LMWH
3. Dabigatran or edoxaban or LMWH followed by VitK aognist

If haemodynamically unstable (hypotension):
1. Thrombolyse

54
Q

When LMWH over DOAC in P.E?

A

Renal impairment
Anti-phospholipid syndrome
Pregnancy
Cancer

55
Q

How long to anticoagualte for after P.E?

A

All patients at last 3 months

Provoked P.E -> stop at 3mo
Unprovoked P.E -> continue for naother 3m0

Provoked = precipating factor such as surgery, immobilisation

56
Q

Diagnostic Ix of DVT?

A

Doppler ultrasound

57
Q

Mx of DVT?

A
  1. DOAC

Consider catheter-directed thrombolysis if symptoms last >14d

58
Q

Example of LMWH?

A

Enoxaparin
Dalteparin
Tinzaparin

59
Q

Obstructive sleep apnoea mx?

A
  1. Lifestyle - stop alcohol, smoking, lose weight
  2. CPAP

Severe -> surgery

60
Q

Characteristic breath sounds of pneumonia?

A

Bronchial breath sounds
Focal coarse crackles
Dullness to percussion

61
Q

CURB65 criteria?

A

C - Confusion?
U - Urea >7
R - RR >30
B - BP (<90/60)
65 - are they >65?

Score:
0 = home Mx
1 or 2 = consider hospital
3 or 4 = urgent admission

62
Q

Causative organism of pneumonia in immunocompromised patient?

A

Moraxella catarrhalis

63
Q

Causative organism of pneumonia in patient with CF or bronchiectasis?

A

Pseudomonas aeruginosa
Staphylococcus aureus

64
Q

Low severity CAP mx?

A
  1. Amoxicillin
  2. Doxycycline

CRB65 score 0, CURB65 0 or 1

65
Q

Moderate severity CAP mx?

A
  1. Amoxicillin + clarithromycin
  2. Doxycycline + clarithromycin

Erythromycin instead of clarithromycin if pregnant
Macrolides (clarithromycin) cover atypical pneumonia

CRB65 score 1 or 2, CURB65 2

66
Q

High severity CAP

A
  1. Co-amoxiclav + clarithromycin
  2. Levofloxacin

CRB65 3 or 4, CURB65 3 to 5

67
Q

Mx of Hospital acquired pneumonia?

A
  1. Co-amoxiclav
  2. Levofloxacin
68
Q

Px of mycoplasma pneumoniae?

A

Pneumonia px
Erythema multiforme - “target lesions”
Neurological symptoms

69
Q

Coxiella burnetii px?

A

Exposure to animals and their bodily fluids
“Farmer with flu-like illness”

70
Q

Pneumocystis jiroveci (PCP) px?

A

Dry cough without sputum
SOB on exertion
Night sweats
History of low CD4 count (HIV +ve)

Mx - Co-trimoxazole

71
Q

Ix of lung cancer?

A
  1. CXR
  2. Staging CT scan (contrast enhanced)
  3. Bronchoscopy + biopsy

PET if non-small cell to establish eligibility for curative mx

72
Q

Types of lung cancer:

A

Non-small cell (80%):
- Adenocarcinoma (40%)
- Squamous cell carcinoma (20%)
- Large-cell carcinoma (10%)

Small cell lung cancer (20%)

73
Q

Mx of non-small cell lung cancer?

A
  1. Surgery - Lobectomy
  2. Radio +/- chemo
74
Q

Mx of small cell lung cancer/

A
  1. Chemotherapy + radiotherapy
75
Q

Extrapulmonary manifestations of lung cancer?

A

Recurrent laryngeal nerve palsy
Phrenic nerve palsy
Superior vena cava obstruction
Horner’s syndrome
Paraneoplastic syndromes

76
Q

Recurrent laryngeal nerve palsy px?

A

Hoarse voice

77
Q

Superior vena cava obstruction px?

A

Facial swelling
Difficulty breathing
Distended veins in neck and upper chest
“Pemberton’s sign”

78
Q

What is “Pemberton’s sign”

A

Occurs in SVC obstruction where raising hands over head -> facial congestion + cyanosis

79
Q

Px of Horner’s syndrome?

A

Triad of:
- Partial ptosis
- Anhidrosis
- Miosis

Pancoast tumour pressing on sympathetic ganglion

80
Q

Paraneoplastic features of small cell lung cancer?

A

ADH -> SIADH

ACTH -> Cushing’s syndrome

Lambert-eaton syndrome

81
Q

Paraneoplastic features of squamous cell lung cancer?

A

PTH-related protein secretion -> hypercalcaemia
Clubbing
Hypertrophic pulmonary osteoarthropathy (HPOA)
Hyperthyroidism due to ectopic TSH

82
Q

What is lambert-eaton myasthenic syndrome?

A

Result of antibodies produced by the immune system against small cell lung cancer cells

Antibodies attack calcium channels pre-synaptically

Finals HH (21 decks)

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