Resp Flashcards by denise lin

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

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Management of persistent/recurrent pneumothorax

Video-assisted thoracoscopic surgery (VATS) for mechanical/chemical pleurodesis +/- bullectomy

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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

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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

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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

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Lyme disease is caused by what pathogen

Borrelia burgdorferi

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What rash is seen with Lyme disease

erythema migrans

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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

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What is the management of Lyme disease

Doxycycline
- amoxicillin if pregnant
Ceftriaxone if disseminated disease

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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)

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COPD - still breathless despite using SABA/SAMA and asthma/steroid responsive features, what do you add next

Add both LABA and ICS

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Treatment of Legionella

Erythromycin/clarithromycin

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Drugs in syringe driver NaCl (not water for injection)

Grani(setron)
Ketamine
Ocreotide
Ketorolac
Ondansetron

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Most common 3 bacterial pathogens causing COPD exacerbations

Haemophilus influenzae - most common
Strep pneumoniae
Moraxella catarrhalis

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NICE recommend giving antibiotics for COPD patients only if what

If sputum is purulent or there are clinical signs of pneumonia

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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.

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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

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Smoking cessation 3 options are

Nicotine replacement therapy (NRT)
Vernicline
Bupropion

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Varenicline is a nicotinic receptor partial agonist. It should be used in caution/ contraindicated in which patients

Depression/self-harm
Pregnancy
Breast feeding

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Mechanism of action of bupropion for smoking cessation

Norepinephrine and DA reuptake inhibitor
Nicotinic antagonist

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Bupropion is a norepinephrine and DA reuptake inhibitor and nicotinic antagonist. It is contraindicated in which patients?

Epilepsy
Pregnancy
Breast feeding

(+ eating disorder)

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Mechanism of action of varenicline for smoking cessation

Nicotinic receptor partial agonist

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Pregnant women who smoke - tested with carbon monoxide detectors, what is the level for referral

7ppm or above

Referral to NHS stop smoking

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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

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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

1. SABA/SAMA 2. SABA + LABA + LAMA (if no asthma signs) 3. Or SABA/SAMA + LABA + ICS (if asthma signs) 4. 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

1. SABA 2. SABA + low dose ICS 3. SABA + low dose ICS + LTRA 4. SABA + low dose ICS + LABA 5. SABA + LTRA + low dose MART 6. SABA + LTRA + medium dose MART 7. 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?

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

1. Haemophilus influenzae (most common) 2. Pseudomonas 3. Klebsiella 4. 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

1. obesity 2. macroglossia - acromegaly, hypothyroid, amyloidosis 3. large tonsils 4. Marfan's syndrome

what two scores can be used for assessment of sleepiness symptoms in obstructive sleep apnoea

1. epworth sleepiness scale 2. 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

1. weight loss 2. CPAP 3. intra-oral devices if CPAP not tolerated or mild OSA 4. inform DVLA if excessive daytime sleepiness

inhaler technique

1. put inhaler in mouth 2. as you breathe in press down 3. hold breath for 10secs 4. for a second dose, wait approx 30secs before repeating

management of idiopathic pulmonary fibrosis

1. pulmonary rehbailitation 2. pirfenidone - antifibrotic agent 3. LTOT 4. 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