Resp Flashcards
Acute severe asthma symptoms?
PEF 33-50
resp 25
HR 110
Cannot complete sentences
Life threatening asthma features?
PEF <33%
spo2 <92%
Normal PaC02
Silent chest
cyanosis
arrhythmia
hypotension
poor effort
Near fatal Asthma features
Raised PaC02 and or mechanical ventilation needed
Differentials for asthma?
Foreign body
Anaphylaxis
Pneumothorax
Bronchiolitis in children
Treatment of acute ashtma attack?
Salbutamol 5 mg nebulised with O2 (repeat 15-20 minute intervals)
Ipratropium bromide 500 mcg nebulised with O2 (4-6 hourly)
Hydrocortisone 100 mg IV or prednisolone 40 mg orally
Magnesium sulphate 2 g IV over 20 minutes
CXR for pneumonia/pneumothorax
Acute exacerbation COPD treatment?
Similar to asthma:
Controlled 02 88-92%
Arterial blood gas (decreased PaO2, raised PaCO2 and raised bicarbonate if chronic disease)
Chest X-ray (to exclude pneumothorax/infection)
ECG (might show evidence of cor pulmonale)
Salbutamol 5 mg nebuliser
Ipratropium bromide 500 mcg nebuliser
Hydrocortisone 100 mg intravenously or prednisolone 30 mg orally (7 days)
Antibiotics if evidence of infection
Steroid doses for asthma and for copd and length?
COPD 30mg 7-14days
Asthma 40-50mg 5 days
Infective exacerbation of COPD?
Increased volume, colour sputum or cough, no x rays signs
Acute bronchitis ABX dose if unwell?
Amox 500mg TDs, or Doxy 200mg then 100mg 5 days for both
When to sent for urgent Chest Xray?
in people aged 40 and over if they have two or more of the following unexplained symptoms
Cough
Fatigue
Shortness of breath
Chest pain
Weight loss
Appetite loss
Cough lasting how long for CXR?
>3 weeks
Wells score >4 suspected PE what to do?
CTPA
Suspected PE wells score 4 or less what to do?
D-dimer and if +ve CTPA
Consider what in patients with unprovoked PE?
Offer investigations to assess the possibility of an undiagnosed cancer
Consider arranging hereditary thrombophilia testing or antiphospholipid
VTE in pregnancy or Cancer what to use?
LMWH- 6 months minimum or until end of cancer treatment
or end of preggers
What chadsvasc score would make you not consider anticoagulation ?
Score of 0 in men and of 1 in women
When would you consider treatment of AF which chadsvasc scores?
>2 start in all people and consider if 1 in men
What does CHA2DS2VASc mean ?
C- CCF
H- Hypertension
A2- Age >75
D- Diabetes-
S2- Stroke
V- Vascular
A- Age 64-75
S- Sex female
Risk of falls, should we anticoagulate?
Yes, no evidence that falls induce bleeds
What classifies someone as having a secondary pneumothorax?
Age >50 significant smoking history
Evidence of underlying lung disease on history, exam or CXR
You have diagnosed a secondary pneumothorax which is >2cm what is your management?
Admit and insert a chest drain
You have diagnosed a secondary pneumothorax which is between 1-2cm what do you do?
Initially aspirate and if it is <1cm admit for observation and high flow 02, if not insert a chest drain
All secondary pneumothoraces require….?
Admission to hospital for a least 24hrs and usually high flow 02
Bilateral pneumothoraces management assume any size?
Proceed to chest drain, also consider if haemodynamic instability
Diagnose a primary pneumothorax of 2.5cm what is your initial management?
Aspirate 16-18g cannula (<2.5l)
You aspirate a 2.5cm primary pneumothorax how is it considered succesful? What will you do if it is or is not?
Considered a succes if <2cm and breathing improvement you can consider discharge and OPD 2-4 weeks, if no or limited success admit for chest drain.
Primary pneumothorax of 1cm management?
Consider discharge and safety netting.
Where is size of pneumothorax measured?
Interpleural distance at level of the hilum
Which way does the trache deviate in a Tension pneumothorax?
Away from affected side as pressure builds and pushes it away
What si the curb 65 score? what do the results mean?
Confusion or <8/10 amts
Urea >7
Resp >30
BP <90sys or <60 dia
65 years or more
Score out of 5 0-1 low 2 intermediate 3-5 high
0-1 home care, 2 hospital care higher consider intensive interventions
ABX therapy for curb score of 2?
Consider dual therapy and IV 7-14 days
Amoxicillin plus a macrolide
Pneumonia in alcoholics and which other group? classic sign? What seen on CXR?
Klebsiella, Diabetics red currant jelly
Often causes abscess and empyema in upper lobes
Exercise inducte desaturation, bilateral interstitial infiltrates?
Treatment?
PCP
Co-Trimoxazole
Steroids if hypoxic
PCP symptoms?
Dry cough, dyspnoea, fever, few chest signs
Flu like symptos preceeding a dry cough, bilateral consolidation- thrombocytopenia and erythema multiforme?
Mycoplasma pneumoniae
Legionella pneumonia signs?
Hyponatraemia, dry cough, recent travel, possible lft problems
Pneumonia screen?
Urinary antigen for legionella and pneumococcus
Sputum culture
Patient had flu a few weeks ago and presents with pneumonia, ?organism
Staph aureus
COPD exacerbation organism?
Haemophillus
Organism which likes to grow and cause pneumonia in bronchiectasis?
Pseudomonas
Bronchiectasis causes?
post-infective: tuberculosis, measles, pertussis, pneumonia
cystic fibrosis
bronchial obstruction e.g. lung cancer/foreign body
Kartageners
Bronchiectasis CT sign?
Signet ring
CXR signs bronchiectasis?
Tramlines
Most common cause of pneumonia?
Strep pneumoniae
Characteristic symptoms of strep pneumoniae?
Rapid onset
High fever
herpes labialis
pleuritc chest pain
What to include in asthma history?
wheeze, cough or breathlessness, and any daily or seasonal variation in these symptoms
any triggers that make symptoms worse
a personal or family history of atopic disorders.
Occupational history
Fraction of expired FENO to diagnose asthma and improvement of what on use of peak flow after bronchdilator?
>40ppb and 12% or greater improvement and >200ml volume
% significant peak flow variability?
20%
What should you measure first if suspecting asthma?
FENO and spirometry with bronchodilator reversability
Initial and add on treatment for asthma?
SABA for everyone, but can start ICS immediately if symptoms >3 times a week at diagnosis.
Asthma not contolled on SABA and low dose ICS?
Add LTRA
SABA, ICS and LTRA not controlled?
Add in LABA and consider improvement that LTRA gave consider stopping
SABA and LABA and ICS +/- LTRA not controlled?
Low dose ICS plus MART
Initial COPD treatments?
Stop smoking, pneumococcal and influenza vaccines
Pulmonary rehab, optimise comorbidities
COPD with exercise limitation and conservative management implimented?
Offer SABA or SAMA
COPD takes SABA or SAMA still feeling breathless?
Asthmatic features- LABA+ICS
No asthmatic features- LABA + LAMA
COPD takes LABA+ICS still problematic?
Offer LAMA+LABA+ICS
What suggests steroid responsiveness or asthma features in COPD?
Substantial variation in FEV1 overtime or diurnal peak flows >20%
First investigation in pleural effusion?
WHat should be tested?
Aspiration guided by ultrasound.
Send for pH protein, LDH cytology and micro
When should lights criteria be used?
Protein 25-35g/l
Exudate is likely if pleural fluid protein/serum is >?
Pleural LDH/Serum LDH >?
Or Pleural fluid LDH more than what the upper limit of normal serum LDH?
>0.5
>0.6
>2/3 upper limits of serum LDH
Low gluocse <2.2 in pleural effusion?
Glucose < 2.2 mmol/L is associated with an emphysema, rheumatoid arthritis, tuberculosis or malignancy.
Low pH in pleural effusion seen with?
A pH < 7.3 is seen with emphysema, tuberculosis, malignancy, collagen vascular disease or oesophageal rupture.
Transudative causes of pleural effusion?
Heart failure- most common
Liver disease
Hypothyroidism
Ecudative causes of Effusion?
Infection most common
Lunc cancer
Pancreatitis
Rheumatoidćonnective tissue
Pleural effusion, aspirate is clear in presumed infection when to place tube?
If pH <7.2
Important to ask about this in asthma history if having acute exacerbation?
Previous ICU or hospital admissions how many exacerbations and triggers etc
Investigation of choice in fibrosis?
High res CT
Strongest association with smoking cancer?
Squamous cell carcinoma
SCC of lungs tyically where?
Centrally affecting main bronchi and obstructing
Most common cancer of lung in non smoker? Where does it often metastasise to?
Adenocarcinoma, often ends up in bones and brain
Lung cancers associated with ectopic ADH and ACTH ? Lambert eaton syndrome
Small cell cancers
ADH-SIADH
ACTH-cushings
Long term prevention of infection in bronciectasis?
Azithroymycin
29 year old, cough blurred vision and this xray?
Sarcoidosis
Hilar lymphadenopathy seen on CXR
What is this skin condition associated with sarcoidosis?
Erythema nodosum
Skin condition associated with sarcoidosis?
Lupus pernio
Treatment of sarcoidosis?
Corticosteroids, cytotoxics and lung transplant
What does the CT show?
Pulmonary fibrosis (honeycombing) and ground glass opacities
Treatment of Idiopathic pulmonary fibrosis?
Limited- pirfenidone, rehab and transplant supplementary 02
WHat is this person doing and why?
Pursed lip breathing splints airways keeps a PEEP
How to remember which drugs taken only for 2 months in TB?
PERI
Pyrazinimide and Ehtambutol initially with the others and then the other two continued
Ethambutol side effect?
Optic neuritis
Best test for cystic fibrosis?
Sweat test
Genetics of cystic fibrosis?
Autosomal recessive
Chance of two carriers passing on CF? and carrier plus affected?
25% and 50%
Respiratory causes of clubbing?
Lung cancer, CF, Idiopathic fibrosis, TB
What is a negative mantoux?
<6mm
Signs and symptoms of CF?
Failure to thrive, frequent infections, does not pass meconium, absent vas deferens, increased appetite, sinusitis, polyps
CF treatments?
Resp and GI?
Chest physiotherapy, Bronchodilators, Tobramycin, mucolytics, transplant etc
Creon, nutrition optimisation PPI
History of night sweats and weight loss?
TB
How many samples to diagnose pulmonary TB?
3 preferably one early morning
Which Tb drug can cause peripheral neuropathy? What can you give to help?
Isonizid give B6
Gout caused by which TB drug?
Pyrazinamide
Yellow orange fluids caused by what drug?
Rifamp
Latent TB treatment choices?
3 Months isoniazid and rifamp or 6 months of isoniazid (if rifamp contraindicated)
Risks for developing active TB ?
Anti TNF, renal failure, HIV, Transplant, malignancy of blood
TB vaccine not given to which age group?
>35 doesnt work
Contraindications to TB vaccine?
previous BCG vaccination
a past history of tuberculosis
HIV
pregnancy
positive tuberculin test (Heaf or Mantoux)
FEV1 below 30% indicates what type of COPD?
Very severe
Severe COPD FEV1 of?
30-49%
50-79% FEV1?
Moderate COPD
>80% FEV1 in obstructive pattern?
Mild COPD
What type of pattern does the spirometry show?
Normal result
What type of pattern does the spirometry show?
Obstructive
What type of pattern does the spirometry show?
Restrictive
What is trastuzumab?
Herceptin
Best test for obstrutive sleep apnoea?
Polysomnography >15 episodes per hour
>5 episodes on polysomnography and any of HTN, ischaemic cardiac disease, history of stroke, excessive daytime sleepiness, insomnia, mood disorder, or cognitive dysfunction.
Can say is sufficient to say it is OSA
Spirometry values in restrictive disease?
FEV1 low FVC low Ration >0.7
Spirometry values in obstructive pattern?
FEV1 reduced <80%
FVC reduced (not as much as FEV1)
FEV1/FVC ration <0.7
