Resp

Question 1

What is the management plan for acute Asthma attack? (in line with BTS)

Answer 1

• ABCDE approach ​Supplementory O2 (Venturi mask) + monitor resp vitals
  
  • ​Aim for 94-98% O2 sats
• 1st Line - SABA (salbutamol) - consider nebulisation
  
  • ​0.5mg every 15 minutes + oral prednisolone
• 2nd Line - add (SAMA) iprotropium bromide if severe
• 3rd Line - IV magnesium sulphate or aminophylline
  
  • ​only if PEFR <50%
• Treat underlying cause e.g. infection w/ ABx
• Monitor K+ as bronchodilators can cause hypokalaemia

Question 2

What is the management plan for Chronic Asthma?

Answer 2

• Stepwise approach to improve Sx and PEFR
  
  • ​Move up or down depending if Sx improve for >3 months
• Step 1 - SABA (salbutomol) alone for symptomatic relief
  
  • ​If necessary add LD inhaled corticosteroids (2x/day)
  • Review in 4-8 weeks
• Step 2 - add LTRA (Montelukast)
  
  • Consider upping dose of ICS
• Step 3 - Consider LABA (formoterol) or theophylline trial
• Step 4 - High dose ICS or trial of LAMA (tiotropium)
• Step 5 - Oral corticosteroids

Advice - teach proper inhaler technique and perform PEFR 2/day

Question 3

What is the management plan for Bronchiectasis?

Answer 3

• 1st Line = exercise + improved nutrition w/ pulmonary rehabilitation
  
  • ​Airway clearance therapy e.g. postural drainage/percussion/ or vibration
  • Essential, should be performed 2-3 times a day
• Consider SABA if asthma + COPD
• Consider inhaled hypertonic saline to reduce symptoms
• Acute exacerbation - amoxicillin oral 14 days
  
  • ​if severe or pseudomonas - IV ciprofloxacin
• Surgery = local resection/transplant if recurrent or refractory disease
  
  • Bronchial artery emobolisation if high risk of life threatening haemoptysis

Maintain good fluid intake and flu vaccinations

Question 4

What is the management plan for COPD?

Answer 4

​General - stop smoking, increase exercise + nutrition, Influenza/ pneumococcol vaccinations, pulmonary rehab, palliative care

• Step wise approach similar to asthma
• STEP 1 = SABA or SAMA (ipratropium)
• STEP 2 = if FEV1>50% w/out asthmatic features –> LABA (Salmeterol) + LAMA
  
  • ​STEP 2b = If FEV1<50% w/ asthmatic features –> LABA + ICS
• STEP 4 = LAMA + LABA + ICS (FEV<30%)
  
  • ​Offered if severe exacerbation/ 2 mod exacerbations/ affecting daily life
  • Review after 3 months
• Avoid regular inhaled corticosteroids (ICS) if possible
• Surgery considered if = recurrent pneumothoraces, issolated bollous disease, lung volume reduction surgery

If stopped smoking you can consider pulmonary rehabilitation oxygen therapy if:

• PaO2<7.3 kPa on air but clinically stable
• PaO2 7.3-8kPa w/ signs of polycythaemia, nocturnal hypoxaemia, Peripheral oedema, pulmonary HTN

Question 5

What is the management plan for Acute exacerbation of COPD?

Answer 5

note - Usually occurs in the winter due to viral or bacterial infection

• 1st Line = Controlled O2 (venturi mask) - aim for 88%-92% 02
  
  • ​+ SABA nebulised, consider SAMA if innefective
  • • Oral/IV hydrocortisone - 100mg/
      
      • ​Reduce down to oral prednisolone when possible 30mg/5 days
  • Consider oral amoxicillin if infectious cause
• 2nd Line = IV aminophylline
• 3rd Line = intubation and ventilation in ITU

Question 6

What is score to assess Pneumonia Severity?

Answer 6

CURB-65 score (1 mark for each)

• Confusion - AMTS <8
• Urea - >7mmol/L
• RR - >30
• BP - systolic <90, diastolic <60
• >65 yrs

0-1 = treat at home

2= hospital

>3 = consider ICU

Question 7

Describe the ABCDE management for Pneumonia?

Answer 7

• ABCDE on presentation
  
  • ​02 - If <94% or <88% if at risk of hypercapnia
  • IV fluid = assess patients for dehydration
    
    • ​follow by vasopressors to maintain MABP >65mmHg
  • VTE prophylaxis + nutritional support
  • Simple analgesia should be sufficient
  • ICU if necessary - avoid NIV
• Start empirical ABx
• Discharge - done if <2 features of clinical instability e.g. raised temp, HR, RR, or low BP
• Prevention - pneumococcal/ haemophilus/ Influenxa vaccine - usually given to at risk population

Question 8

What is the empirical Abx treatment for Pneumonia?

Answer 8

• Generally a 5 day treatment plan considered
• CURB 3-5 = IV Abx immediately after diagnossis
  
  • ​Penicillin + Macrolide e.g. Amoxicillin + Clarithryomycin
  • 2nd Line or legionella suspected = fluoroquinolone e.g. levofloxacin
  • If unresponsive switch to pathogen targeted ABx
• CURB 2 = Oral amoxicillin + clarithryomycin
  
  • ​if not responding or contraindicated –> IV ABx
• CURB 0-1 = Oral amoxicillin
  
  • ​If not responding add clarithryomycin
• If HAP = Gram -ve cover e.g. Cefuroxime/ ceftazidime
  
  • ​If MRSA suspected - + IV Vancomycin/gentamicin
• If aspiration pneumonia - IV cephalosporin + metronidazole

Question 9

Specific Pneumonia targeted treatments?

Answer 9

• Pneumococcal = amoxicillin +/- clarithromycin
• Staph non-MRSA = Flucloxacillin +/- rifampicin
• Staph MRSA = Vancomycin +/- rifampicin
• Mycoplasma = Clarithromycin (oral) or Doxycicline
• Chlamydia /coxiella = Doxycicline or Clarithromycin
• Legionella = Fluoroquinolone e.g. levofloxacin
• Haemophilus = Amoxicillin or Cefuroxime
• G-ve = Cefuroxime or Fluoroquinolone

Question 10

What is the management plan for a Tension pneumothorax?

Answer 10

• Medical Emergency
• Immediate needle decompression w/ 14 gauge IV catheter
  
  • ​at 2nd/3rd ICS MCL (just above rib)
• High O2 (>10L/min)
• Tube thoracostomy - after needle decompression to reduce reoccurance
• After management perform chest drain and admit

Question 11

What is the management for Pneumothorax?

Answer 11

• Primary Pneumothorax
  
  • ​<2cm on CXR = supplemental O2 + observation –> discharge
  • >2cm/SOB = Percutaneous aspiration + O2 therapy
    
    • ​2nd Line = repeat percutaneous aspiration
    • 3rd Line = chest drain (4th-6th ICS MAL)
• Secondary Pneumothorax
  
  • ​<1cm on CXR = Hospitalisation + O2 sats + observation
  • 1-2cm = Percutaneous aspiration
    
    • ​2nd Line = chest drain
  • >2cm/SOB = 1st Line = chest drain
• If reoccurance consider chemical pleurodesis (fusion of pleura)
  
  • ​or surgical pleurectomy
• Advice - against driving or flying until follow up CXR to confirm resolvement

Question 12

What is the management for Pulmonary Emboli?

Answer 12

• Primary Prevention - compression stockings, heparin prophylaxis for high risk, good mobilisation + hydration
• High/intermediate risk PE
• If massive RESUS - ABCDE
  
  • 1st Line - IV fluids, vasoactive agents + LMWH + Warfarin
  • For massive PE > Thrombolysis with alteplase
  • For Intermediate consider embolectomy or IVC filter (when recurrent or anti-coagulant is contraindicated)
• Low risk PE
  
  • 1st Line - Oxygen + Analgesia + LMWH/ NOAC
  • Consider IVC if recurrent or anti-coagulant is contraindicated
• Long-term Management
  
  • NOAC or warfarin for 6 months post event
  • If malignancy present use LMWH

Question 13

What is the management plan for TB?

Answer 13

RIPE

• Rifampicin, Isoniazid, Pyrazinamide, Ethambutol
  
  • First 2 for 6 months
  • Second 2 for 2 months
• Repeat cultures, until 2 consecutive all clears