Resp Flashcards
Management of primary and secondary pneumothorax
(a) <2cm and no SOB - aspirate
(b) >50 years old and >2cm or SOB - chest drain
(c) <1cm - give oxygen, admit for 24hrs, likely discharge
Management of persistent/recurrent pneumothorax
Video-assisted thoracoscopic surgery (VATS) for mechanical/chemical pleurodesis +/- bullectomy
Discharge advice re: pneumothorax:
- Stop smoking
- Flying - absolute contraindication. CAA suggest can travel 2 weeks after successful drainage if no residual air. BTS state can travel 1-week post - CXR
- Avoid scuba diving unless bilateral surgical pleurectomy, normal lung function and CT chest
Causes of pleural effusion
(a) transudate
(b) exudate
(a) transudate - ALL THE FAILURES - heart failure, liver failure (cirrhosis), renal failure i.e. nephrotic syndrome, pulmonary embolism
(b) exudate - CANCER AND INFECTION - pneumonia, cancer, TB, viral infection, pulmonary embolism, autoimmune
Light’s crtieria for pleural effusion:
(a) pleural serum protein
(b) pleural serum LDH
(c) pleural fluid LDH
(a) pleural serum protein - exudate >0.5m transudate <0.5
(b) pleural serum LDH - exudate >0.6, transudate <0.6
(c) pleural fluid LDH - exudate >2/3 ULN, transudate <2/3 ULN
Lyme disease is caused by what pathogen
Borrelia burgdorferi
What rash is seen with Lyme disease
erythema migrans
What is the first-line test for Lyme disease?
ELISA antibodies to Borrelia burgdorferi
- if negative and Lyne disease is still suspected in people tested within 4 weeks from symptoms onset, repeat the ELISA 4-6 weeks after the first ELISA test
- if STILL suspected in people who have had symptoms for 12 weeks or more, or the ELISA test is positive, then an immunoblot test should be done
What is the management of Lyme disease
- Doxycycline
- amoxicillin if pregnant - Ceftriaxone if disseminated disease
What is Jarisch-Herxheimer reaction
Sometimes seen after initiating antibiotic therapy for Lyme disease: fever, rash, tachycardia after first dose of antibiotic (more commonly seen in syphilis, another spirochaetal disease)
COPD - still breathless despite using SABA/SAMA and asthma/steroid responsive features, what do you add next
Add both LABA and ICS
Treatment of Legionella
Erythromycin/clarithromycin
Drugs in syringe driver NaCl (not water for injection)
Grani(setron)
Ketamine
Ocreotide
Ketorolac
Ondansetron
Most common 3 bacterial pathogens causing COPD exacerbations
- Haemophilus influenzae - most common
- Strep pneumoniae
- Moraxella catarrhalis
NICE recommend giving antibiotics for COPD patients only if what
If sputum is purulent or there are clinical signs of pneumonia
NIV tends to be used for patients with COPD with T2RF. What pH is expected with them as they will have respiratory acidosis
pH 7.25-7.35
n.b. the more acidotic - likely will need HDU.
BiPAP settings initially for COPD
(a) Expiratory positive airway pressure - EPAP
(b) Inspiratory positive airway pressure - IPAP
(a) EPAP: 4-5cm H2O
(b) IPAP: 10-15 H2O
Smoking cessation 3 options are
Nicotine replacement therapy (NRT)
Vernicline
Bupropion
Varenicline is a nicotinic receptor partial agonist. It should be used in caution/ contraindicated in which patients
Depression/self-harm
Pregnancy
Breast feeding
Mechanism of action of bupropion for smoking cessation
Norepinephrine and DA reuptake inhibitor
Nicotinic antagonist
Bupropion is a norepinephrine and DA reuptake inhibitor and nicotinic antagonist. It is contraindicated in which patients?
Epilepsy
Pregnancy
Breast feeding
(+ eating disorder)
Mechanism of action of varenicline for smoking cessation
Nicotinic receptor partial agonist
Pregnant women who smoke - tested with carbon monoxide detectors, what is the level for referral
7ppm or above
Referral to NHS stop smoking
Management of smoking in pregnancy if CO reading >7ppm and referred to NHS stop smoking
- CBT
- Motivational interviewing
- Structured self-help
- Can consider NRT and remove patches before sleeping
VARENICLINE AND BUPROPION ARE CONTRAINDICATED
COPD patients receiving LTOT should breathe the extra oxygen for at least how many hours per day
15 HOURS
LTOT indications
Two readings of ABG pO2 of <7.3;
OR 7.3-8 and one of:
- secondary polycthaemia
- peripheral oedema
- pulmonary HTN
COPD management stepwise approach
- SABA/SAMA
- SABA + LABA + LAMA (if no asthma signs)
- Or SABA/SAMA + LABA + ICS (if asthma signs)
- SABA + LABA + LAMA + ICS
What are the vaccinations for COPD
Annual influenza vaccination
One-off pneumococcal vaccination
Who is pulmonary rehabilitation in COPD for
all people who view themselves as functionally disabled by COPD (usually Medical Research Council [MRC] grade 3 and above
Azithromycin can be used as prophylaxis in some COPD patients.
What tests need to be done for it
LFTs
ECG - can prolong QT interval
First line antibiotics for acute bronchitis (i.e. if systemically unwell, delayed Rx if CRP 20-100 or Rx now if CRP >100)
Doxycycline
(or amoxicillin for children and pregnant women)
Prednisolone dose for asthma vs COPD exacerbations
COPD = 30mg for 5 days
Asthma = 40mg for 5 days
Length of illness:
Acute otitis media
4 days
Length of illness:
Acute sore throat
1 week
Length of illness:
Common cold
1.5 weeks
Length of illness:
Acute rhinosinusitis
2.5 weeks
Length of illness:
Acute cough/bronchitis
3 weeks
What blood cell is raised in lung cancer
Raised platelets
What type of lung cancer is PET scan useful in
Non-small cell lung cancer
What type of lung condition has
FEV1/FVC <70%
Obstructive
e.g. COPD
CANNOT GET THE AIR OUT!
What type of lung condition has
FEV1/FVC >70%
Restrictive
e.g. GBS
CANNOT GET THE AIR IN
Obstructive lung disease i.e. COPD, asthma has FEV1/FVC <70%.
How much does this improve by at least (%) in reversibility asthma bronchodilator testing?
12% in FEV1
(and increase in 200ml or more volume)
Moderate asthma:
(a) PEFR
(b) Speech
(c) RR/sats
(d) HR
(a) PEFR >50% best
(b) Speech normal
(c) RR <25
(d) HR <110
this is treated with 10puffs salbutamol + prednisolone 40mg 5 days
Severe asthma:
(a) PEFR
(b) Speech
(c) RR/sats
(d) HR
(a) PEFR 33-50% best
(b) Speech - can’t complete sentences
(c) RR >25
(d) HR >110
Life-threatening asthma:
(a) PEFR
(b) Speech
(c) RR/sats
(d) HR
(a) PEFR <33% best
(b) Exhaustion - none
(c) Sats <92%, silent chest
(d) Bradycardia
Mid-diastolic murmur
What valve condition
Mitral stenosis
SOB
Atrial fibrillation
Malar flush
Granulomatosis with polyangiitis (Wegner’s) cANA +ve affects which organs
ENT
Renal - glomerulonephritis
+ saddle shaped nose deformity
Antibodies in Goodpastures disease
Anti-GBM
patients who have frequent exacerbations of COPD should be given a home supply of …?
prednisolone and antibiotics
Asthma inhaler stepwise guidelines
- SABA
- SABA + low dose ICS
- SABA + low dose ICS + LTRA
- SABA + low dose ICS + LABA
- SABA + LTRA + low dose MART
- SABA + LTRA + medium dose MART
- SABA + LTRA + high dose MART or theophylline /seek advice
Maintenance and reliever therapy (MART) is inhaler of which two inhalers combined
ICS and LABA combined
the median survival from the time of diagnosis of idiopathic pulmonary fibrosis
3-4 years
COPD - reason for using inhaled corticosteroids
reduced frequency of exacerbations
what medication can be used to prevent acute mountain sickness
Acetazolamide
causes primary metabolic acidosis, and compensatory respiratory alkalosis so increases resp rate + oxygenation!
high altitude cerebral oedema management
dexamethasone
high altitude pulmonary oedema management
nifedipine
dexamethasone
acetazolamide
phosphodiesterase type V inhibitors
+ oxygen
respiratory causes of clubbing
lung cancer
tuberculosis
asbestosis
mesothelioma
fibrosing alveolitis
pyogenic causes: CF, abscess, bronchiectasis, empyema
polycythaemia i.e. in COPD does what to the concentration of haemocrit
Increases
What marker is most useful for monitoring the progression of patients with chronic obstructive pulmonary disease?
FEV1
% will reduce with severity
what is the minimum number of salbutamol prescriptions in the past 12 months that should prompt an urgent review of a patient’s asthma control?
12
what ABG result is seen with those who have obstructive sleep apnoea
compensated respiratory acidosis
what is the most important management for long term symptom control in non-CF bronchiectasis
inspiratory muscle training + postural drainage
Most common 4 organisms isolated from patients with bronchiectasis
- Haemophilus influenzae (most common)
- Pseudomonas
- Klebsiella
- Strep pneumoniae
Following the 2014 National Review of Asthma Deaths, what number of courses of oral or intravenous steroids in the past 12 months should prompt referral to secondary care for optimisation of asthma treatment?
more than 2
recommended doses for adrenaline for anaphylaxis for:
< 6months
100 - 150 micrograms (0.1 - 0.15 ml 1 in 1,000)
recommended doses for adrenaline for anaphylaxis for:
6 months - 6 years
150 micrograms (0.15 ml 1 in 1,000)
recommended doses for adrenaline for anaphylaxis for:
6-12 years
300 micrograms (0.3ml 1 in 1,000)
recommended doses for adrenaline for anaphylaxis for:
Adult and child > 12 years
500 micrograms (0.5ml 1 in 1,000)
how often can adrenaline for anaphylaxis be repeated
every 5 mins if needed
best site for IM injection of adrenaline in anaphylaxis
anterolateral aspect of the middle third of the thigh
what blood test can be done to assess if true episode of anaphylaxis happened
serum tryptase
elevated for 12 hours after
patients with new diagnosis of anaphylaxis should be referred to a specialist allergy clinic. how many injectors should they be prescribed?
2 adrenaline auto-injectors
Anaphylaxis patients can be discharged after 2 hours of symptom resolution i.e. fast track discharge if …
- One dose of IM adrenaline
- Given adrenaline auto-injector and trained
- Supervision on discharge
Anaphylaxis patients can be discharged after 6 hours if …
- Two doses of IM adrenaline; OR
- Previous biphasic reaction
Anaphylaxis patients can only be discharged after 12 hours (i.e. not fast track 2 or 6 hour discharge) if…
- MORE than 2 doses of IM adrenaline
- Severe asthma
- Ongoing reaction e.g. slow-release meds
- Late at night/difficult to access A&E
Oral allergy syndrome, also known as pollen-food allergy is what type of hypersensitivity reaction
IgE mediated
The most common triggers for anaphylactic reactions in children is
food
What is the most suitable first-line test to investigate possible food and pollen allergy?
Skin prick test
cheaper than RAST IgE
People who’ve had a systemic reaction to an insect bite should be managed by…
refer to allergy specialist
Skin prick testing can be read after
15-20 mins
Skin patch testing can be read after
48 hours after patch removal
Patients with COPD may have some asthmatic/steroid responsive features. What are 4 of these features?
- previous diagnosis of asthma or atopy
- high eosinophil count
- variation in FEV1 (at least 400ml)
- variation in diurnal PEFR (at least 20%)
cor pulmonale 4 features
peripheral oedema
raised JVP
systolic parasternal heave
loud P2
Cor pulmonale management
Loop diuretic for oedema
Consider LTOT
NICE does not recommend any ACE inhibitors, CCBs, a-blockers
What diagnostic testing should be done for asthma in patients >17 years
Spirometry with bronchodilator (BDR) test
FeNO test
Consider occupational asthma referral if at workplace
What diagnostic testing should be done for asthma in patients aged 5-16 years
Spirometry with BDR
FeNO test should then be requested if there is normal spirometry or obstructive spirometry with negative BDR test
What diagnostic testing should be done for asthma in patients aged <5 years
Base on clinical judgement
FEV1 is defined as..
expired volume of air in one second
as this is timed (in 1sec), it is lower than FVC! normally the ratio will be 80%
Severity of COPD is categorised using FEV1 (% of predicted) levels. What are the threshold levels?
> 80% - stage 1, mild
50-80% - stage 2, moderate
30-50% - stage 3, severe
<30% - stage 4, very severe
When should nicotine replacement patches be removed for pregnant women
at night-time before bed!
4 risk factors for obstructive sleep apnoea
- obesity
- macroglossia - acromegaly, hypothyroid, amyloidosis
- large tonsils
- Marfan’s syndrome
what two scores can be used for assessment of sleepiness symptoms in obstructive sleep apnoea
- epworth sleepiness scale
- Stop bang questionnaire
NOTE SLEEP STUDIES (POLYSOMNOGRAPHY) IS FOR DIAGNOSIS
what is a diagnostic test for obstructive sleep apnoea
sleep studies - polysomnography
management of obstructive sleep apnoea and who to inform
- weight loss
- CPAP
- intra-oral devices if CPAP not tolerated or mild OSA
- inform DVLA if excessive daytime sleepiness
inhaler technique
- put inhaler in mouth
- as you breathe in press down
- hold breath for 10secs
- for a second dose, wait approx 30secs before repeating
management of idiopathic pulmonary fibrosis
- pulmonary rehbailitation
- pirfenidone - antifibrotic agent
- LTOT
- lung transplant
what 2 treatments are not recommended in COPD patients if they continue to smoke
azithromycin
LTOT
CURB-65 score criteria
Confusion (AMTS <8/10)
Urea >7
RR >30
BP <90/60
Age >65
0 = treatment at home
1-2 = consider hospital
3-4 = urgent admission
As well as CURB-65 score, NICE also recommend CRP testing. What are the levels and recommendations?
CRP <20 - do not offer Abx
20-100 - delayed Abx prescription
>100 - prescribe Abx
First line for low-severity CAP
Amoxicillin
5 days
Management for moderate and high-severity CAP
Amoxicillin AND macrolide dual therapy
7-10 day course
all cases of pneumonia should have a repeat CXR when
6 weeks
for stepping down asthma treatment, BTS guidelines advise reducing dose of inhaled steroids by how much each time
25-50%
oxygen therapy for COPD patients in hospital - targets and what masks to use
initially target 88-92%
28% Venturi mask at 4L/min
adjust range to 94-98% if pCO2 normal
What can be offered as PRN use to patients with end-stage chronic obstructive pulmonary disease (COPD) that is unresponsive to other medical treatment?
Short acting oral morphine PRN
What is the most appropriate way to supply oxygen (LTOT) for COPD patients?
Oxygen concentrator supplied via Home Oxygen Order Form
cardiac causes of clubbing
- cyanotic congenital heart disease (Fallot’s, TGA)
- bacterial endocarditis
- atrial myxoma
What is an appropriate diagnostic investigation for occupational asthma?
Serial peak flow measurements at work and at home
Refer to respiratory occupational specialist
Parallel line shadows (often called tram-lines) on x-ray is typically seen in what disease
Bronchiectasis
Large amounts of purulent sputum
