Resp Flashcards
1
Q
Pneumonia: Criteria for hospitalization
A
CURB-65
- Confusion: abbrev MT 7mmol/L
- RR > 30
- BP < 90 systolic
Score 0-1 = home
Score 2 = hospital therapy
Score >2 = severe pneumonia and may require ICU.
2
Q
Community acquire pneumonia: organisms & empirical treatment
A
Organisms:
- Streptococcus pneum.
- Haemophilus Influenza
Treatment for mild:
- Oral amoxicillin 500mg/8hr OR
- Clarithromycin 500mg/12hrs
Treatment for moderate:
- IV amoxicillin + clarirthromycin at doses
above.
Treatment of severe case:
- Co-amoxiclav 1.2g/12hr IV or cefuroxime
- 5g/8hrs AND clarithromycin 500mg/12hr IV
- Add flucloxacillin if Staph suspected.
- Add vancomycin if MRSA suspected.
- Treat for 10 days.
3
Q
Hospital acquired pneumonia: Organisms and treatment
A
Organisms
- Gram negative bacillus
- Pneudomonas
- Anaerobes
Treatment:
- Aminoglycoside IV + pipericillin (anti-
pseudo) IV. OR - 3rd generation cephalosporin IV.
4
Q
Aspiration pneumonia: organisms + treatment
A
Organisms:
- Streptococcus
- Anaerobes
Treatment:
- Cefuroxime 1.5g/8hr IV + metronidazole 500mg/8h IV.
5
Q
Differential diagnosis of lung nodule on chest XRY
A
- Primary or secondary malignancy
- Abscess
- Granuloma
- Carcinoid tumour
- Pulmonary hamartoma
- AV fistula
- Cyst
- Foreign body
6
Q
Management of acute asthma attack: According to clinical oxford guidelines
A
- Assess the severity of attack
- ABC’s
- Can the patient talk/complete
sentences. - Level of consciousness
- Silent chest
- Immediate treatment
- Sit patient up
- High dose O2 in 100% non-
rebreathing bag. - Salbutamol 5mg + ipratropium
bromide 0.5mg nebulized with
oxygen. - Prednisalone 40-50mg IV or
hydrocortisone 100mg IV. - CXR to exclude pneumothorax
- Life threating features present
- Call for senior help
- Mg 1.2-2mg IV over 2 minutes.
- Salbutamol 5mg every 15 min => ECG
- Patient improving
- Decrease O2 to 40-60%
- Pred 40-50mg/24hrs PO for 5 days
- Neb salbutomol q4hr
- Monitor peak flow + O2 sats
- Patient not improving
- Continue 100% oxygen
- Salbutamol every 15 min
- Continue Ipratropium bromide 0.5mg
q4-6hrs.
- Still not improving
- Mg if not already given.
- Consider aminophylline: 5mg/kg IV
loading; 500ug/kg/hr - Adjust according to plasma levels.
- OR IV Salbutamol 3-20ug/min
- IPPV
- ITU
- Once patient has improved
- Wean off aminophylline over 24hrs
- Switch to inhaled B2 agonist
- Stop IV steroids; start oral
- Monitor PEF
- Look for cause.
7
Q
Signs of severe asthma attack
A
- Unable to complete sentences
- RR > 25
- Pulse > 110
- PEF < 50% of predicted
8
Q
Signs of life threatening attack
A
- Peak expiratory flow < 33% of predicted or best. - Silent chest. - Cyanosis - Decreased respiratory effort - Bradycardia or hypotension - Exhaustion, confusion, coma - ABG: PaCO2 > 4.6, PO2 < 8kPa/60mmHg
9
Q
Salbutamol:
- MOA
- SE
- Method of adminitration
- Dose used in asthma
A
- Relax bronchial smooth muscle within
minutes - short acting. - SE: tachyarrhythmias, decreased K+,
tremor, anxiety. - Aerosol, powder, nebulizer, PO or IV.
- Inhaled aerosol 100-200ug/6hrs
Inhaled powder 200-400ug/6hrs
Nebulized (supervised) 2.5-5mg/6hrs
10
Q
Salmeterol: Dose/puff and regimen
A
Inhaled aerosol
Dose/puff = 25ug
Recommended = 50-100ug/12hrs
11
Q
Corticosteroids in asthma
- MOA
- SE
- Doses used in acute vs. long term
A
1 Act over days to decrease bronchial
mucosal inflammation.
- Oral candidasis - rise mouth after use
SE from oral - cushingoid - Oral steroids
Acute: prednisolong 40mg/24hr po
Long term: 5-10mg/24hrs poInhaled beclometasone
Dose/puff = 50ug, 100ug or 250ug
Recommended = 100ug/12hrs up to
1000ug/12hrs
12
Q
Aminophylline
- MOA
- SE
- Indications
A
- Metabolized to theophylline
Inhibits phosphodiesterase = increases
cAMP = decreases bronchoconstriction - Arrhythmias, GI upset, seizures
- Used as an adjunct if inhaled therapy is
inadequate; given at night PO may
prevent morning dips; used IV in acute
severe asthma attacks.
13
Q
Ipratropium bromide
- MOA
- SE
- Indications
- Dose
A
- Anticholinergic - decreases muscle spasm
- Not recommended in guidelines for
asthma
Used in severe asthma attacks
More benefit in COPD
4. Aerosol : Dose/puff = 20ug
Regimen 20-40ug/6hr
Powder: Dose/puff = 40ug
Regimen 40-80ug/6hrs
Nebulized: Doss/puff = 250ug/mL
Regmen = 250-500ug/6hrs
14
Q
Define asthma
A
- Obstructive lung disease
- Characterized by
- Airway hypersensitivity,
- Reversible airflow obstruction
- Inflammation of bronchi
15
Q
Classification of asthma
A
- Intermittent
- Day time asthma symptoms occur
less than 2x per week. - < 2 nocturnal awakenings per month
- Use SABA < 2/week
- No interference with daily activity
- FEV1 > 80% of predicted normal
- Normal FEV1/FVC
- Day time asthma symptoms occur
- Mild persistent
- Symptoms more than twice per week.
- 3-4 nocturnal wakings per mo
- SABA use for more than 2x week
- Minor interference with activities
- FEV1/FVC normal
- > 2 exacerbations requiring steroids
per year.
- Moderate persistent
- Daily symptoms
- Nocturnal wakings > 1x week
- Need BA daily
- Limitation in normal daily activities
- FEV1 = 60-80%
- FEV1/FVC < normal
- Severe persistent
- Symptoms of asthma throughout day
- Nocturnal waking every night
- Use SABA several times a day
- Extreme limitations to daily activity
- FEV1 < 60% of predicted
- FEV1/FVC < normal
16
Q
Basic principals in managing asthma
A
- Lifestyle and triggers
- Education on proper technique
- Pharmcology
17
Q
Step wise approach to managing asthma
A
Step 1 - For intermittent asthma - SABA - If need SABA more than 2x / week = step up.
Step 2
- Mild persistent asthma
- SABA + low dose glucocorticoid
(<800mcg/day).
Step 3
- Moderate persistent
- SABA + inhaled corticosteroids
- Add long acting B2 agonist
- +/- leukotriene antagonist (montelukast)
- +/- aminophylline
Step 4&5 - Severe persistent - Inhaled glucocorticoids high dose (up to 2000mcg/day) + LABA - +/- leukotriene antagonist or aminophylline - +/- Anti-IgE therapy = omalizumab } consider for patients with allergies.
Step 6
- Below + oral steroids
18
Q
Investigations for asthma
A
- PFT: FEV1/FVC, PEFR
- Bronchial provocation testing with
histamine or metacholine. - Reversibility testing with B2 agonist }
FEV1 should increase by 12%. - Diurinal varability
- CXR for hyperinflation
- CBC = eosinophilia
- IgE = high
- RAST test
- Skin prick test
- O2 sats = aim > 92%
19
Q
Asthma: What indicates good control?
A
Well controlled - Less than 2 day time symptoms per week. - No night time symptoms - Normal PEF
Partially controlled
- > 2 symptoms per week
Uncontrolled
- All of the above
20
Q
Definition of COPD
A
- Characterized by irreversible airway obstruction. - Two subtypes: chronic bronchitis + emphysema. - Characterized by a gradual decline in FEV1 over years.
21
Q
Chronic bronchitis:
- Definition
- Pathophys
- Signs & symptoms
- Chest XRY findings
- PFT
A
Chronic bronchitis
1. Productive cough on most days for at
least 3 consecutive months in 2
successive years.
"Blue bloaters" - decrease alveolar
ventilation, hypoxic drive, low PaO2,
high PaCO2.
- Pathophys: obstruction due to narrowing of the airways lumen by mucosal thickening and excessive mucus production.
- Symptoms:
- Chronic productive cough
- Purulent sputum
- Hemoptysis
- Dyspnea
Signs: - Cyanotic due to hypoexemia and
hypercapnea. - RHF; cor pulmonale
- Crackles; wheeze
- Prolonged expiration
- Chest XRY: Normal AP diameter, increased bronchovascular markings, enlarged heart with cor pulmonale.
- PFT: Decrease FEV1/FVC, Normal TLC, normal Dco2.
22
Q
Emphsema
- Definition & Pathophys
- Signs
- Symptoms
- Chest XRY findings
- PFT
A
Emphysema
1. Definition & pathophy:
- Dilation and destruction of air spaces
distal to the terminal bronchioles
without obvious fibrosis.
- There is decreased elastic recoil =>
causing air trapping and alveolar
collapse.
- Pink puffers - increased alveolar
ventilation, normal PaO2, normal/low
PaCO2. Breathless but not
cyanosed.
- Symptoms
- Dyspnea
- Minimal cough
- Tachypnea
- Decreased exercise tolerance
- Signs
- Pink skin
- Accessory muscle use
- Cachetic appearance due to anorexia &
increased work of breathing. - Hyperinflation/barrel chest
- Hyperressonant percussion note
- Decreased breath sounds
- Decreased diaphargmatic excursion.
- Chest XRY
- Increased AP diameter
- Flat hemidiaphragm = 6 ribs anteriorly
- Decreased heart shadow
- Bullae
- Decreased vascular markings.
- PFTs
- Decrease FEB1/FVC
- Increase TLV = hyperinflation
- Increase RV = gas trapping
23
Q
Severity / Stages of COPD
A
FEV1 determines severity
- Stage I - Mild symptoms
- FEV1/FVC < 70%
- FEV1 > 80% - Stage II - Moderate COPD
- Symptoms on exertion
- FEV1/FVC < 70%
- FEV1 = 50-80% - Stage III - Severe COPD
- Symptoms on minimal
exertion
- FEV1/FVC < 70%
- FEV1 30-50% - Stage IV - Very severe COPD
- Symptoms at rest
- FEV1 < 30%
24
Q
Treatment of COPD based on severity
A
Stage I - Mild
- Stop smoking, influenza vaccine.
- Inhaled ipratropium bromide preferred prn
- Inhaled SABA prn
Stage II - Moderate
- As above
- Regular ipratropium bromide OR
- Long acting B2 agonist
Stage III - Severe
- As above + add in inhaled steroids.
Stage IV - Very severe
- Long term home oxygen.
