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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
Conditions which can cause pulmonary fibrosis?
- Alpha-1 antitripsin deficiency - Rheumatoid arthritis - Systemic lupus erythematosus (SLE) - Systemic sclerosis
26
What type of hypersensitivity reaction is extrinsic allergic alveolitis?
Type 3 hypersensitivity reaction
27
What does asbestosis inhalation cause? (4)
- Lung fibrosis - Pleural thickening and pleural plaques - Adenocarcinoma - Mesothelioma
28
What is sarcoidosis?
Granulomatous inflammatory condition
29
Histology of sarcoidosis?
Non-caseating granulomas with epithelial cells
30
Mx of sarcoidosis?
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
31
Ix of sarcoidosis?
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
32
Sarcoidosis Px?
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
33
Amount of protein for exudative and transudative pleural effusion?
>3g/dL = exudative <3g/dL = transudative
34
Exudative pleural effusion causes?
Inflammation: - Lung cancer - Pneumonia - RA - TB
35
Transudative pleural effusion causes?
Fluid shifting: - Congestive cardiac failure - Hypalbuminaemia - Hypothyroidism - Meig's syndrome
36
CXR change in pleural effusions?
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
What is empyema?
Empyema is an infected pleural space Pleural effusion + new-onset fever Pus on aspiration, acidic pH, low glucose and high LDH
38
ECG change in pulmonary hypertension?
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
CXR changes pulmonary hypertension?
- Dilated pulmonary arteries - Right ventricular hypertrophy
40
Primary pneumothorax mx?
if: <2cm + no SOB -> discharge + follow-up in 2-4 weeks Otherwisie: 1. Aspiration (attempt twice) 2. Chest drain
41
Mx of secondary pneumothorax?
>50y + >2cm and/or SOB -> chest drain if 1-2cm: 1. Aspiration 2. Chest drain If <1cm -> Give O2 and admit for 24h
42
Mx of persitstant or reccurrent pneumothorax?
Video-assisted thoracoscopic surgery (VATS)
43
Mx of tension pneumothorax?
Insert a large bore (14g) cannula into the second intercostal space in the midclavicular line Once pressure relieved -> chest drain
44
Where to insert a chest drain?
5th intercostal space, mid-axilary line CXR after to check positioning
45
PERC criteria? (what should be absent to rule out pumonary embolism to <2%)
- 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
What score system for suspected P.E?
Wells score
47
Wells score criteria?
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
What Mx if P.E likely in Wells score?
CTPA If CTPA delay -> DOAC
49
What Mx if P.E unlikely in Wells score?
D-dimer test - If +ve -> CTPA - if -ve -> stop DOAC
50
What Ix for P.E if renal impairment?
V/Q scanning over CTPA V/Q and CTPA both give definitive Dx
51
ECG changes in p.e?
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
ABG in p.e?
Respiratory alkalosis with low pO2 and low pCO2
53
Mx of P.E?
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
When LMWH over DOAC in P.E?
Renal impairment Anti-phospholipid syndrome Pregnancy Cancer
55
How long to anticoagualte for after P.E?
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
Diagnostic Ix of DVT?
Doppler ultrasound
57
Mx of DVT?
1. DOAC Consider catheter-directed thrombolysis if symptoms last >14d
58
Example of LMWH?
Enoxaparin Dalteparin Tinzaparin
59
Obstructive sleep apnoea mx?
1. Lifestyle - stop alcohol, smoking, lose weight 2. CPAP Severe -> surgery
60
Characteristic breath sounds of pneumonia?
Bronchial breath sounds Focal coarse crackles Dullness to percussion
61
CURB65 criteria?
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
Causative organism of pneumonia in immunocompromised patient?
Moraxella catarrhalis
63
Causative organism of pneumonia in patient with CF or bronchiectasis?
Pseudomonas aeruginosa Staphylococcus aureus
64
Low severity CAP mx?
1. Amoxicillin 2. Doxycycline CRB65 score 0, CURB65 0 or 1
65
Moderate severity CAP mx?
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
High severity CAP
1. Co-amoxiclav + clarithromycin 2. Levofloxacin CRB65 3 or 4, CURB65 3 to 5
67
Mx of Hospital acquired pneumonia?
1. Co-amoxiclav 2. Levofloxacin
68
Px of mycoplasma pneumoniae?
Pneumonia px Erythema multiforme - "target lesions" Neurological symptoms
69
Coxiella burnetii px?
Exposure to animals and their bodily fluids "Farmer with flu-like illness"
70
Pneumocystis jiroveci (PCP) px?
Dry cough without sputum SOB on exertion Night sweats History of low CD4 count (HIV +ve) Mx - Co-trimoxazole
71
Ix of lung cancer?
1. CXR 2. Staging CT scan (contrast enhanced) 3. Bronchoscopy + biopsy PET if non-small cell to establish eligibility for curative mx
72
Types of lung cancer:
Non-small cell (80%): - Adenocarcinoma (40%) - Squamous cell carcinoma (20%) - Large-cell carcinoma (10%) Small cell lung cancer (20%)
73
Mx of non-small cell lung cancer?
1. Surgery - Lobectomy 2. Radio +/- chemo
74
Mx of small cell lung cancer/
1. Chemotherapy + radiotherapy
75
Extrapulmonary manifestations of lung cancer?
Recurrent laryngeal nerve palsy Phrenic nerve palsy Superior vena cava obstruction Horner's syndrome Paraneoplastic syndromes
76
Recurrent laryngeal nerve palsy px?
Hoarse voice
77
Superior vena cava obstruction px?
Facial swelling Difficulty breathing Distended veins in neck and upper chest "Pemberton's sign"
78
What is "Pemberton's sign"
Occurs in SVC obstruction where raising hands over head -> facial congestion + cyanosis
79
Px of Horner's syndrome?
Triad of: - Partial ptosis - Anhidrosis - Miosis Pancoast tumour pressing on sympathetic ganglion
80
Paraneoplastic features of small cell lung cancer?
ADH -> SIADH ACTH -> Cushing's syndrome Lambert-eaton syndrome
81
Paraneoplastic features of squamous cell lung cancer?
PTH-related protein secretion -> hypercalcaemia Clubbing Hypertrophic pulmonary osteoarthropathy (HPOA) Hyperthyroidism due to ectopic TSH
82
What is lambert-eaton myasthenic syndrome?
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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