Resp Flashcards
Ix for asthma?
- Fractional exhaled nitric oxide
Spirometry with bronchodilator reversibility - If diagnostic uncertainity:
Peak flow variability
Direct bronchial challenge test with histamine or methacholine
General asthma guidelines:
Roughly
- SABA
- SABA + low-dose ICS
- SABA + low-dose ICS + LTRA (montelukast)
- SABA + low-dose ICS + LABA (salmeterol)
3/4 depends on guidelines
- Consider options:
- MART (maintenance and reliever therapy)
- Oral beta 2 agonist (oral salbutamol)
- Oral theophylline
- Inhaled LAMA (tiotropium) - Increase ICS dose
LTRA = leukotriene receptor antagonist
PEFR in moderate, severe and life-threatening acute asthma?
. PEFR % predicted
Moderate 50 - 75%
Severe 33 - 50%
Life-threatening <33%
Features of severe asthma attack?
PEFR 33-50% predicted
Resp rate >25
Heart rate >110
Unable to complete sentences
Features of life-threatening asthma attack?
PEFR <33%
Sats <92%
Becoming tired
No wheeze - airways so tight, no air entry at all
Haemodynamically unstable
Mx of acute asthma attack?
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
ABG in asthma attack
Initially - Resp alkalosis as drop in CO2 from tachypnoea
Late - Resp acidosis as high CO2 (can’t blow it off = bad)
What electrolyte to monitor with salbutamol?
Serum potassium (will increase)
Asthma spirometry findings?
PEFR reduced
Reduced FEV1
Normal FVC
FEV1/FVC ratio reduced
Restrictive spirometry findings?
PEFR normal
Reduced FEV1
Reduced FVC
FEV1 / FVC ratio normal
COPD spirometry findings?
PEFR reduced
Reduced FEV1
Reduced FVC
FEV1 / FVC ratio reduced (<0.7)
COPD Mx?
- SABA or SAMA
- Either:
No asthma -> Combined inhaler (LABA + LAMA) [Anoro ellipta]
Yes asthma -> Tripple therapy (LABA + LAMA + ICS) [Fostair, seretide]
What is type 1 respiratory failure?
Normal pCO2 with low pO2
What is type 2 respiratory failure?
Raised pCO2 with low pO2
What mask for oxygen in COPD?
Venturi mask
What O2 sats to aim for in COPD?
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%
Mx of COPD exacerbation in community?
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
Most common infective cause of COPD exacerbation?
Haemophillus influenza
Mx of COPD in hospital
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
When to use BiPAP oxygen therapy?
When there is type 2 resp failure and resp acidosis (pH<7.35, PACO2>6) despite adequate medical mx
Indications for CPAP?
Obstructive sleep apnoea
Congestive cardiac failure
Acute pulmonary oedema
Ix of interstitial lung disease
Ix - Restrictive spirometry, bilateral interstitial shadowing on CXR
Dx - high resolution CT showing “ground glass” appearance
Lung biopsy if diagnostic uncertainty
Key px of idiopathic pulmonary fibrosis?
Insidious onset SOB and dry cough over >3mo
Bi-basal fine inspiratory crackles
Finger clubbing
Drugs which can cause pulmonary fibrosis?
Amiodarone
Cyclophosphamide
Methotrexate
Nitrofurantoin
Conditions which can cause pulmonary fibrosis?
- Alpha-1 antitripsin deficiency
- Rheumatoid arthritis
- Systemic lupus erythematosus (SLE)
- Systemic sclerosis
What type of hypersensitivity reaction is extrinsic allergic alveolitis?
Type 3 hypersensitivity reaction
What does asbestosis inhalation cause? (4)
- Lung fibrosis
- Pleural thickening and pleural plaques
- Adenocarcinoma
- Mesothelioma
What is sarcoidosis?
Granulomatous inflammatory condition
Histology of sarcoidosis?
Non-caseating granulomas with epithelial cells
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
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
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
Amount of protein for exudative and transudative pleural effusion?
> 3g/dL = exudative
<3g/dL = transudative
Exudative pleural effusion causes?
Inflammation:
- Lung cancer
- Pneumonia
- RA
- TB
Transudative pleural effusion causes?
Fluid shifting:
- Congestive cardiac failure
- Hypalbuminaemia
- Hypothyroidism
- Meig’s syndrome
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.
What is empyema?
Empyema is an infected pleural space
Pleural effusion + new-onset fever
Pus on aspiration, acidic pH, low glucose and high LDH
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
CXR changes pulmonary hypertension?
- Dilated pulmonary arteries
- Right ventricular hypertrophy
Primary pneumothorax mx?
if:
<2cm + no SOB -> discharge + follow-up in 2-4 weeks
Otherwisie:
1. Aspiration (attempt twice)
2. Chest drain
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
Mx of persitstant or reccurrent pneumothorax?
Video-assisted thoracoscopic surgery (VATS)
Mx of tension pneumothorax?
Insert a large bore (14g) cannula into the second intercostal space in the midclavicular line
Once pressure relieved -> chest drain
Where to insert a chest drain?
5th intercostal space, mid-axilary line
CXR after to check positioning
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
What score system for suspected P.E?
Wells score
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
What Mx if P.E likely in Wells score?
CTPA
If CTPA delay -> DOAC
What Mx if P.E unlikely in Wells score?
D-dimer test
- If +ve -> CTPA
- if -ve -> stop DOAC
What Ix for P.E if renal impairment?
V/Q scanning over CTPA
V/Q and CTPA both give definitive Dx
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
ABG in p.e?
Respiratory alkalosis with low pO2 and low pCO2
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
When LMWH over DOAC in P.E?
Renal impairment
Anti-phospholipid syndrome
Pregnancy
Cancer
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
Diagnostic Ix of DVT?
Doppler ultrasound
Mx of DVT?
- DOAC
Consider catheter-directed thrombolysis if symptoms last >14d
Example of LMWH?
Enoxaparin
Dalteparin
Tinzaparin
Obstructive sleep apnoea mx?
- Lifestyle - stop alcohol, smoking, lose weight
- CPAP
Severe -> surgery
Characteristic breath sounds of pneumonia?
Bronchial breath sounds
Focal coarse crackles
Dullness to percussion
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
Causative organism of pneumonia in immunocompromised patient?
Moraxella catarrhalis
Causative organism of pneumonia in patient with CF or bronchiectasis?
Pseudomonas aeruginosa
Staphylococcus aureus
Low severity CAP mx?
- Amoxicillin
- Doxycycline
CRB65 score 0, CURB65 0 or 1
Moderate severity CAP mx?
- Amoxicillin + clarithromycin
- Doxycycline + clarithromycin
Erythromycin instead of clarithromycin if pregnant
Macrolides (clarithromycin) cover atypical pneumonia
CRB65 score 1 or 2, CURB65 2
High severity CAP
- Co-amoxiclav + clarithromycin
- Levofloxacin
CRB65 3 or 4, CURB65 3 to 5
Mx of Hospital acquired pneumonia?
- Co-amoxiclav
- Levofloxacin
Px of mycoplasma pneumoniae?
Pneumonia px
Erythema multiforme - “target lesions”
Neurological symptoms
Coxiella burnetii px?
Exposure to animals and their bodily fluids
“Farmer with flu-like illness”
Pneumocystis jiroveci (PCP) px?
Dry cough without sputum
SOB on exertion
Night sweats
History of low CD4 count (HIV +ve)
Mx - Co-trimoxazole
Ix of lung cancer?
- CXR
- Staging CT scan (contrast enhanced)
- Bronchoscopy + biopsy
PET if non-small cell to establish eligibility for curative mx
Types of lung cancer:
Non-small cell (80%):
- Adenocarcinoma (40%)
- Squamous cell carcinoma (20%)
- Large-cell carcinoma (10%)
Small cell lung cancer (20%)
Mx of non-small cell lung cancer?
- Surgery - Lobectomy
- Radio +/- chemo
Mx of small cell lung cancer/
- Chemotherapy + radiotherapy
Extrapulmonary manifestations of lung cancer?
Recurrent laryngeal nerve palsy
Phrenic nerve palsy
Superior vena cava obstruction
Horner’s syndrome
Paraneoplastic syndromes
Recurrent laryngeal nerve palsy px?
Hoarse voice
Superior vena cava obstruction px?
Facial swelling
Difficulty breathing
Distended veins in neck and upper chest
“Pemberton’s sign”
What is “Pemberton’s sign”
Occurs in SVC obstruction where raising hands over head -> facial congestion + cyanosis
Px of Horner’s syndrome?
Triad of:
- Partial ptosis
- Anhidrosis
- Miosis
Pancoast tumour pressing on sympathetic ganglion
Paraneoplastic features of small cell lung cancer?
ADH -> SIADH
ACTH -> Cushing’s syndrome
Lambert-eaton syndrome
Paraneoplastic features of squamous cell lung cancer?
PTH-related protein secretion -> hypercalcaemia
Clubbing
Hypertrophic pulmonary osteoarthropathy (HPOA)
Hyperthyroidism due to ectopic TSH
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
