Resp Flashcards
Stepwise management of inhalers in adults
- low dose ICS
- Add LABA to low dose ICS
- Consider increasing ICS to medium dose or adding LTRA (if no response to LABA - consider stopping)
- refer for specialist care
Stepwise management of inhalers in children
- very low dose ICS (or LRTA if < 5 yrs)
- very low dose ICS plus
a. LABA or LRTA if > 5 yrs old
b. LRTA if < 5 - Increase ICS to low dose or in children > 5 add LRTA or LABA (if no response to LABA, consider stopping)
- refer for speclialist care
Features of life threatning asthma
Hypoxaemia (<92%)
PEFR <33% of predicted
Exhaustion
Bradycardia or arrythmia
Hypotension
Silent chest
Altered consciousness
Poor resp effort
Cyanosis
Normal or raised PCO2
What is Bronchiolitis Obliterans
The term used to describe the fibrous scarring of the small airways, seen in the following;
- inhalation of toxic fumes
- exposure to mineral dust
- viral infections
- mycoplasma infections
- legionella
- bone marrow, heart or lung transplant
- RA or SLE
- Penicillamine treatment
Presentation of bronchiolotiis obliterans
Dry cough
Dyspnoea
Signs of bronchiolitis obliterans
Unremarkable
Expiratory wheeze may be audible
CXR findings of bronchiolitis obliterans
Can vary
Normal
Reticular pattern
Reticulonodular pattern
Diagnosis of bronchiolitis obliterans
Lung biopsy
Prognosis of bronchiolitis obliterans
Poor
Rarely respond to steriods
Investigation specific to allergic bronchopulmonary aspergillosis
Early positive skin prick test for aspergillus fumigatus (antigen-specific IgE)
What does FEF reflect
Status of the small airways
What is sent away when a pleural aspiration is carried out
Cytology
Protein
LDH
pH
Gram stain
Culture
Sensitivity
Stepwise Tx of COPD
1 SABA or SAMA
2. Combined therapy
- a) no asthmatic or steriod responsive features; LABA + LAMA
- b) asthmatic or steriod responsive featutres; LABA + ICS
3. 3x therapy; add ICS to 2a or LAMA to 2b
What epworth sleepiness score is suggestive of OSA
11 or more
(can be up to 24)
What is an azygous lobe
Normal variant
Seen as reverse comma sign behind the medial end of the right clavicle
right upper zone
What is the only treatment proven to improve long term prognosis in patients with chronic hypoxaemia in COPD
Long term domicillary oxygen therapy
Presentation of histoplasmosis
Acute URTI
Substernal pain
Xray changes in histoplasmosis
Patchy pulmonary infiltrates
Mediastinal widening
10% arthralgia
5% have pleural effusions
Diagnosis of histoplasmosis
Culture of histoplasma capsultatum from urine, blood and bone marrow and sputum
Treatment of histoplasmosis
Amphotericin B - not required unless patients show signs of respiratory insufficiency
Causes of upper lobe fibrosis on CXR
Ankylosing spondylitis (apices)
TB
Sarcoidosis
Extrinsic allergic alveolitis
Silicosis
ABPA
Post Radiotherapy
Causes of lower lobe fibrosis
RA
Scleroderma
SLE
IPF
Criteria of allergic bronchopulmonary aspergillosis
Clinical deterioration in asthma symptoms
Raised IgE levels
Positive aspergillosis serology
Pulmonary infiltrates on CXR
Treatment of ABPA
Corticosteriods
Itraconazole
WHat genotype is most commonly assosiated with early onset a1at
PIZZ
Diagnosis of sarcoid
Skin biopsy - non ceasating granulomas
Which lung cancer can progress rapidly in under 3 months
small cell lung carcinoma
Xray findings of radiation pneumonitiis
Hazy consolidation demarcated by a sharp margin that corresponds to the limits of the irridation field
Treatment of idiopathic pulmonary fibrosis
Nintedanib (tyrosine protein kinase inhibitor)
Common features of sarcoidosis
Erythema nodosum
Bilateral hilar lymphadenopathy on CXR
Uveitis
Hypercalcaemia
What lung condition develops in people with a1at defieicny
Empysema
transfer factor in stable astham
unafffected
Which lung cancer is related to hyponatraemia and how
small cell lung cancer
syndrome of innapropriately secreated anti diuretic hormone (SIADH)
Which is the most aggressive lung cancer
Small cell lung cancer
Which lung cancer is most assosiated with smoking
squamous cell carcinma
Which lung cancer is often peripheral
adenocarcinoma
What is the most important thing to consider in the mangement of pneumothoraxes
Degree of clinical compromise, not the pneumothorax
Management of a patient < 50 with a primary spontaneous pneumothorax with no clinical distress which is < 2cm
No specific therapy
Supplemental o2 as required
F/u CXR to ensure lung expansion
Management of patient with primary spontaenus pneumothorax < 50 yrs old who is breathless or a large pneumothorax (>2cm)
Supplemental oxygen
Percutaneous needle aspiration (midclavicular line 2nd/3rd IC space)
If aspiration fails - insert a chest tube or a small bore catheter
Management of a secondary pneumothorax or patient > 50 yrs old if it is a small (<1cm) penumothorax and no SOB
Supplemental O2
Observe in hospital
Management of a secondary pneumothorax or a patient > 50 if it is moderate (1-2cm) pneumothorax and no SOB
Supplemental 02
Observe in hospital
Percutaneus needle aspiration
Chest drain
Suction
Hyponatraemia in small cell lung cancers
SiADH secretion
Dilutional
Low serum osmolality
High urine osmolality
Tx of hyponatraemia in small cell lung cancers
Fluid restriction
anti-GBM antibody is assosiated with what
Goodpastures syndrome
What antibody is assosiated with eosinophilic granulomatsosi with polyangitis
anti-myeloperoxidase antibody
Investigation of choice for eosinophilic granulomatosis with polyangitis
Skin biopsy
- small vessel ateriopathy
- granuloma formation
Treatment of eosinophilic granulomatosis with polyangitis
High dose methylpred
+/- cyclophosphamide
Example of a condition where the antibody anticardiolipin is found
antiphopsholipid syndrome
SLE
Examples of anaerobic pleuropulmonary infections
Aspiration pneumonia
Necrotising pneumonitis
Lung abscess
Empyema
Infection secondary to bronchiectasis and bronchial carcinoma
Example of pneumonia secondary to gram positive areobes
Strep
Staph
Example of presentation of allergic bronchopulmonary aspergillosis
Deteriorating asthma sx
Haemoptysis
General malaise
Headache
Investigations for ABPA
Peropheral blood eosinophilia
Increased serum IgE
Bilateral infiltrates on CXR
Increased aspergillus specific IgE or IgG
What is the main driver for LTOT prescription
02
Criteria for LTOT prescription
PO2 < 7.3
P02 > 7.3 but < 8 when stable, who also have
- Secondary polycythaemia
- peripheral oedema
- noctural hypoxaemia
- pulmonary HTN
What is indicated in the treatment of asthma when symptoms are still not controlled despite inhaled corticosteriods, LABA and LTRAs
Theophylline
Assosiations of OSA
Stroke
HTN
T2DM
Over 98% of men with cystic fibrosis have what
Bilateral Abscence of vas deferens
What sweat chloride value is diagnostic for CF?
> 60
If a sweat chloride test is 30 - 60, what should be done next
CFTR gene analysis
WHat is an auscultation finding of consolidation
Whisphering pectoriloquy
What picture do you get with silicosis
Mixed obstructive / restrictive picture
Investigation of legionella
Urinary antigen test
Presentation of legionella
Cough
SOB
Wheeze
Pleurtic pain
Fevers
Neurological / confusion
GI Sx / diarrhea / deranged LFTs
AKI
Hyponatraemia
What is GPA assosiated with
Midline sinusitis
Pulmonary haemorrhage
Retinal vasculitis
What is the syndrome called when you aspirate stomach contents and what pathology does this cause
Mendelson syndrome
bronchospasm
WHat bacteria commonly causes LRTIs in people with herbes libialis
strep pneumonia
An obstructive spirometry with raised lung volumes may indicate what
asthma
COPD
Transfer factor in asthma
normal
Beside test to assess lung function in a patient with GBS
forced vital capacity (FVC)
Indications for draingage of pleural effusion
Infected fluid
ph < 7.2
gram stain showing the prescence of organisms
fluid is frankly purulent
clinical improvement slow despite antibiotic therapy
WHat does oeosinophilia in a pleural cavity suggest and what does it make the diagnosis LEAST likely
suggests air in the pleural cavity
malignancy and TB less likely
Causes of low gluocse levels in pleural aspirate
RA
TB
Empyema
Malignancy
What do high levels of salivary amylase indicate
Oesophageal rupture
The prescence of anti-nuclear factor in a pleural aspirate is virtually diagnostic of what?
SLE