Resp Flashcards
Rx of ABPA
Oral presnisolone tapering off over 12 months
inhaler technique
take off cap and shake
sit up straight with chin tilted up
press button and breathe in for at least 10 seconds.
Hold breath for 10 seconds before exhaling
if using a steroid inhaler, wash mouth afterwards due to oral candidiasis risk
using a spacer and advice
seal and then breathe in and out deeply
clean with detergent once a month and air dry. don’t wipe as can causes static which causes med to stick
COPD rx - non pharm and pharm
offer pneumococcal and influenza vaccines
stop smoking support
give SABA or SAMA
If not improving and asthmatic features or steroid responsiveness - give LABA and ICS.
If not improving and no asthmatic features or steroid responsiveness - give LABA and LAMA
offer all if not working after this
what is COPD
emphysema (dilated alveoli) and chronic bronchitis
MRC dyspnoea scale
1 breathlessness on strenuous exercise
2 breathlessness when walking up a hill
3 breathlessness when walking on a flat
4 breathlessness <100m
5 can’t leave the house
FEV1:FVC ratio in copd
<0.7 (70%)
what is an example of a LABA, LAMA and ICS combined inhaler
Trimbow
when is LTOT offered in COPD
how long do you have to use it
Offer LTOT to patients with a pO2 of < 7.3 kPa or to those with a pO2 of 7.3 - 8 kPa and one of the following:
secondary polycythaemia
peripheral oedema
pulmonary hypertension (cor pulmonale)
Only to pts who are NON SMOKERS and do not retain CO2
16hrs per day for survival benefit
rx of acute exacerbation of copd
a-e
o2 - 88-92
salbutamol and ipatropium nebs
oral pred 30mg
NIV if type 2 response failure
abx if ?infective
signs of IECOPD
change in sputum volume
change insputum colour
fever
what is the most common cause of cor pulmonale
copd
what is cor pulmonale
respiratory failures leading to right ventricular failure due to pulmonary htn
likely ABG on COPD exacerbation
type 2 rest failure with a respiratory acidosis
ix on acute exacerbation of copd and why
FBC - infective
ECG - arrythmias
CXR - infection
Sputum culture
Blood culture
o2 targets in copd
88-92 if a co2 retainer
if not retaining CO2, then 94-98
practical tips for stopping smoking
use e cigarettes or nicotine patches
nicotine gum
smoke free helpline
nhs website has a smoking support locator
differentials of a monophonic localised wheeze
foreign body, tumour o thick sticky mucus plug
asthma triggers
cold
exercise
infection
animals
allergies
what wheeze is heard in asthma
widespread polyphonic expiratory wheeze
drugs that can worsen asthma
beta blockers
NSAIDs
ix for Asthma
spirometry and reversibility testing
Fractional exhaled Nitric Oxide
if still not sure:
PEFR variation - more than 20%
BTS stepwise approach for Asthma in children
1 SABA
2 SABA and very low dose ICS
3 SABA and very low dose ICS and LTRA or LABA
4 increase to low dose ICS or add other of LTRA or LABA
5 specialist care required
additional rx of asthma
Individual written asthma self-management plan
Yearly flu jab
Yearly asthma review when stable inc inhaler technique
Regular exercise
Avoid smoking (including passive smoke)
Avoiding triggers where appropriate
signs of resp distress in a child
accessory muscles
cyanosis
tracheal tug and intercostal muscles
initial ABG on acute exacerbation of asthma
what would be concerning
respiratory alkalosis due to tachypnoea
a normal CO2 is a concerning sign as is respiratory acidosis
features of mild, moderate, severe, life threatening and near fatal asthma
Mild:
* No features of severe asthma
* PEFR >75%
Moderate:
* No features of severe asthma
* PEFR 50-75%
Severe (if any one of the following):
* PEFR 33 – 50% of best or predicted
* Cannot complete sentences in 1 breath
* Respiratory Rate > 25/min
* Heart Rate >110/min
Life threatening (if any one of the following):
* PEFR < 33% of best or predicted
* Sats <92% or ABG pO2 < 8kPa
* Cyanosis, poor respiratory effort, near or fully silent
chest
* Exhaustion, confusion, hypotension or arrhythmias
* Normal pCO2
Near Fatal:
* Raised pCO2
rx of acute asthma
NEB salbutamol 5mg
Oral prednisolone 40 mg stat
Neb ipatropium bromide 500 micrograms
Back to back salbutamol
If life threatening or near fatal:
IV aminophylline or IV salbutamol
ITU or anaesthetic assessment
Criteria for safe asthma discharge after exacerbation
PEFR >75%
inhaler technique review
Provide PEFR meter and written asthma action plan
* At least 5 days oral prednisolone
* GP follow up within 2 working days
* Respiratory Clinic follow up within 4 weeks
Stop regular nebulisers for 24 hours prior to
discharge
Characteristic examination signs in pneumonia
dull percussion
coarse crackles
bronchial breath sounds
CURB 65 score and what total means
confusion
Urea >7
RR >30
BP <90
age >65
0/1 - treat at home
>2 - admit
>3 consider ITU
top 2 bacterial causes of pneumonia
+ others
strep pneumoniae
haemophilus influenzae
moraxella caterhalis in immunocompromised pts
MSRA
pseudomonas aureginosis in CF and bronchiectasis
patient has recently had a cheap hotel holiday and presents with pneumonia symptoms and hyponatraemia. What is dx and why are they hyponatraemia
legionaries disease
can cause SIADH
pneumonia with target lesions. What is the offending organism
mycoplasma pneumonia. Can cause erythema multiform
rx of atypical pneumonia
macrolides, fluroquinilones or tetracyclines
Pneumonia complications
lung abscess
emphysema
sepsis
ARDS
pleural effusion
death
exudative vs transudative causes of pleural effusions
exudative - pneumonia, tb, malignancy, rheumatoid
transudative - hf, liver cirrhosis, renal failure
Lights criteria and when is it used
If pleural fluid protein level between 25 and 35 g/L (i.e. borderline) use Light’s criteria
– exudate if one or more of the following:
– Pleural fluid/Serum protein >0.5
– Pleural fluid/Serum LDH >0.6
– Pleural fluidLDH>2/3 of the upper limit of normal
pleural effusion examination findings
dull percussion
Reduced breath sounds
Tracheal deviation away from the effusion in very large effusions
CXR pleural effusion
blunting of costaphrenic angles with a meniscus
may have fluid in the fissures
rx of pleural effusion
US guided pleural aspiration
Chest drain
When to suspect empyema
Pleural aspiration results
Rx
a pt with pneumonia gets better but then develops a new onset of fever.
Pleural aspiration shows pus, low pH, low glucose and high LDH. Empyema is treated with a chest drain and antibiotics.
Pulmonary oedema presentation
SOB
Pink frothy sputum
Tachypnoea
Raised JVP
Decreased O2 sats
Examination of pulmonary oedema
reduced breath sounds
coarse crackles
CXR pulmonary oedema
Bilateral peri-hilar shadowing - bat wing sign
Blunting of the costophrenic angles
Fluid in the fissures (e.g. right horizontal fissure)
Kerley B lines
rx of pulmonary oedema
A-E
IV furosemide
causes of bronchiectasis
pneumonia
TB
CF
Alpha 1 antitrypsin
Whooping cough
presentation of bronchiectasis
chronic productive cough and SOB
recurrent chest infections
signs of bronchiectasis on examination
Weight loss (cachexia)
Finger clubbing
Signs of cor pulmonale (e.g., raised JVP and peripheral oedema)
Scattered crackles throughout the chest that change or clear with coughing
Scattered wheezes and squeaks
Gold standard for bronchiectasis
high resolution CT - signet ring sign
CXR findings in bronchiectasis
tram track sign
ring shadows
general rx of bronchiectasis
Vaccines (e.g., pneumococcal and influenza)
Respiratory physiotherapy to help clear sputum
Pulmonary rehabilitation
Long-term antibiotics (e.g., azithromycin) for frequent exacerbations (e.g., 3 or more per year)
Inhaled colistin for Pseudomonas aeruginosa colonisation
Long-acting bronchodilators may be considered for breathlessness
Long-term oxygen therapy in patients with reduced oxygen saturation
Surgical lung resection may be considered for specific areas of disease
Lung transplant
rx of bronchiectasis exacerbations
sputum culture and abx - most often ciprofloxacin
abx for 7-14 days
key features to remember for bronchiectasis
The key features to remember with bronchiectasis are finger clubbing, diagnosis by HRCT, Pseudomonas colonisation and extended courses of 7-14 days of antibiotics for exacerbations.
rf for pneumothorax
young thin tall male
cannabis
COPD, asthma, pneumonia
Iatrogenic - lung biopsy, mechanical ventilation or central line insertion
RX of simple pneumothorax and landmarks
chest drain in the safety triangle (5th intercostal space mid axillary line and
Anterior axillary line)
insert above rib to avoid neuromuscular bundle
how to know if chest drain is successful in pneumothorax
swinging - water in drain rises and fall as pt breathes
repeat cxr shows reduction in size
2 key complications of chest drains
surgical emphysema
air leaks
rx of pneumothorax that is resistant to treatment
abrasive or chemical pleurodesis
rx of tension pneumothorax
Insert a large bore cannula into the second intercostal space in the midclavicular line.
Then chest drain
examination findings of ILD
fine inspiratory crackles
clubbing
most common type of ILD
idiopathic
drug causes of ILD
amiodarone
bleomycin
nitrofurantoin
penicillamine
methotrexate
spirometry result in ILD
restrictive - >0.7 (70%)
general rx of ILD
Remove or treat the underlying cause
Home oxygen where there is hypoxia
Stop smoking
Physiotherapy and pulmonary rehabilitation
Pneumococcal and flu vaccine
Advanced care planning and palliative care where appropriate
inflammatory causes of ILD
Alpha-1 antitrypsin deficiency
Rheumatoid arthritis
Systemic lupus erythematosus (SLE)
Systemic sclerosis
Sarcoidosis
presentation of TB
chronic cough, night sweats, haemoptysis
lymphadenopathy
erythema nodosum
RF for TB
Close contact with active tuberculosis (e.g., a household member)
Immigrants from areas with high tuberculosis prevalence
People with relatives or close contacts from countries with a high rate of TB
Immunocompromised (e.g., HIV or immunosuppressant medications)
Malnutrition, homelessness, drug users, smokers and alcoholics
TB CXR findings - primary, reactivated and disseminated military
Primary tuberculosis may show patchy consolidation, pleural effusions and hilar lymphadenopathy.
Reactivated tuberculosis may show patchy or nodular consolidation with cavitation (gas-filled spaces), typically in the upper zones.
Disseminated miliary tuberculosis gives an appearance of millet seeds uniformly distributed across the lung fields.
IX for TB
sputum cultures
blood cultures
CXR
Mantoux
Rx of TB
RIPE for 2 months then RI + pyridoxine for 4 months
Testing for other infectious diseases (e.g., HIV, hepatitis B and hepatitis C)
Testing contacts for tuberculosis
Notifying UK Health Security Agency (UKHSA) of suspected cases
Negative pressure side room, Isolating patients with active tuberculosis to prevent spread (usually for at least 2 weeks of treatment)
Side effects of TB drugs
Rifampicin - hepatitis, red/orange urine
Isoniazid - hepatitis, peripheral neuropathy
Pyrazinamide - hyperuricaemia (gout and kidney stones), hepatitis
Ethambutol - retrobulbular neuritis. Check visual acuity before treatment
ABG in Pe
resp alkalosis
PE rx if stable
apixaban or rivaroxaban
if CrCl <15 give LMWH
PE rx if unstable eg massive PE
Consultant decision
- continuous infusion of unfractionated heparin and systemic thrombolysis
first line long term anti coat option for pts with anti phospholipid syndrome who have had PE
warfarin
First line long term preventative anti coag in pregnant lady who has had a PE
LMWH
Causes of a raised D dimer
PE
pregnancy
HF
malignancy
surgery
Wells score
Clinical signs and symptoms of DVT (minimum of leg swelling and pain with palpation of the deep veins) 3
An alternative diagnosis is less likely than PE 3
Heart rate more than 100 beats per minute 1.5
Immobilisation for more than 3 days or surgery in previous 4 weeks 1.5
Previous DVT/PE 1.5
Haemoptysis 1
Malignancy (on treatment, treated in the last 6 months, or palliative)
diagnostic test for osa
polysomnography
complications of osa
htn
compensated resp acidosis
daytime somnolence
rx of osa
weight loss
CPAP
DVLA if execcisive daytime sleepiness
how does salbutamol work
stimulates B2 receptors in the lungs which causes relaxation of smooth muscle leading to bronchodilation
ddx of asthma in children (think chronic cough)
viral induced wheeze
bronchiolitis
foreign body
CF
airway abnormalities
insert chest drain above or below the rib?
above (5th intercostal space, mid axillary line)
presentation of sarcoidosis acronym
General - fever, malaise, lymphadenopathy
Respiratory - 90% have dry cough, dyspnoea, chest pain, reduced lung function
Arthralgia
Neurological - Bells palsy, meningitis, SOL
Urinary - increased calcium - renal stones
Low hormones - pituitary - amenorrhoea
Opthalmological - uveitis, sjrogens
Myocardial - restrictive cardiomyopathy secondary to granulomas, pericardial effusion
Abdominal - splenomegaly and hepatomegaly
ddx to consider for pneumothorax in a cold pt
large emphysematous bullae
