Resp Flashcards
What are the anatomical classifications of Pneumonia?
Bronchopneumonia (patchy consolidation of different lobes)
Lobar Pneumonia (Congestion, Red Hepatisation, Grey Hepatisation, Resolution)
What are the four aetiological classifications of Pneumonia?
Community Acquired, Hospital Acquired, Immunocopromised, Aspiration
Name three causative organisms of Community Acquired Pneumonia
Streptococcus Pneumoniae, Haemophilus Influenza, Moraxella Catarrhalis
Name three causative organisms of Hospital Acquired Pneumonia
Staphylococcus Aureus (inc MRSA), Klebsiella Pneumoniae, Pseudomonas Auerginosa
Name two causative organisms of Immunocompromised Pneumonia
Pneumocystis Jiroveccii (fungi) and TB
What type of organisms are responsible for aspiration pneumonia?
Anaerobes
What lung is more likely to be affected by aspiration pneumonia
Right
Name four symptoms of Pneumonia
Dyspnoea, Cough (Purulent), Fever, Pleuritic Chest Pain
Name four signs of Pneumonia
Tachycardia, Tachypnoea, Cyanosis, Confusion
What would you find OE of Pneumonia?
Decreased expansion, Dull percussion, Bronchial Breathing, Increased vocal resonance, Crackles
What are you looking for on a CXR of Pneumonia?
Infiltrates, Cavities, Effusion
When would you do an ABG in a pneumonia patient?
if pO2<92%
Apart from a CXR and ABG, name three investigations you could do for pneumonia, and what would you expect them to show?
Urine - Pneumococcal/Legionella antigens
Bloods - raised WCC, raised CRP, raised urea
Sputum - Microscopy, culture and staining
How is the severity of pneumonia scored?
CURB 65 - actually calculates the mortality but from this the severity can be inferred
Confusion, Urea>7mmol/l, Resp Rate>30, BP Systolic<90, Age>65
What is the management of mild CAP?
500mg Amoxicillin for 5 days
What is the management of moderate CAP?
500mg Amoxicillin AND 200mg Doxycycline for 5 days
What is the management of severe CAP?
IV Co-Amoxiclav and ORAL Clarithromycin
What is the management of HAP?
Mild/Moderate - Oral Co-Amoxiclav
Severe - IV Co-Amoxiclav (Or tazocin)
Fluids
Analgesia
Follow up CXR at 6/52
What is Pneumovax?
Vaccination against pneumococcal pneumonia
GIven to over 65s, immunosupressed, diabetics
Lasts for 6yrs
Name 5 complications of Pneumonia
Respiratory Failure, Hypotension, AF, Pleural Effusion, Empyema
What is Interstitial Lung Disease?
Umbrella term for disorders causing fibrosis of the lungs
What are the 5 classifications of ILD?
Idiopathic, Granulomatous, Occupational, Rheumatic, Iatrogenic
What are the causes of Idiopathic ILD?
Usual Interstitial Pneumonia, Acute Interstitial Pneumonia, Non Specific Interstitial Pneumonia
Name a granulomatous cause of ILD
Sarcoidosis - systemic inflammation characterised by non caseating granulomas
Name three drugs causing ILD
Bleomycin, Nitrofurantoin, Amioderone
What is Extrinsic Allergic Alveolitis?
Hypersensitivity reaction
Can be acute (more reversible) or chronic (less reversible)
Name three symptoms of ILD
Dry cough, Exertional Dyspnoea, Malaise
Name three signs of ILD (hint:3Cs)
Cyanosis, Clubbing, Crepitations (fine)
Name three investigations carried out for ILD, and what they would show
Bloods - ABG and looking for underlying cause
CXR- reduced lung volume, lower zone shadowing
Spirometry - Restrictive Pattern
What would a biopsy of UIP type ILD show?
Patchy and honeycombing
Name four managements of ILD
1) Remove offending cause
2) Stop smoking
3) Medication
4)Oxygen
In some cases can do lung transplant
Name the two possible pharmacological interventions for ILD
N - Acetyl Cystiene (anti-oxidant properties)
Pirfenidone (downregulates growth factors and reduces fibrosis, FVC between 50 and 80%)
Acute exacerbations - corticosteroids
Define Asthma
Chronic inflammatory disease of the airways causing intermittent and reversible airway obstruction
Name four pathological changes in asthma
Basement membrane thickening
TH2 mediated mast cell degranulation (Prostaglandins, Leukotrienes, Histamines)
Mucus Hypersecretion
Smooth Muscle hypertrophy and hyperplasia
Name three symptoms of Asthma
Dyspnoea, Intermittent cough, Wheeze
Name three signs of Asthma
Tachypnoea, Decreased air entry, Audible wheeze
Name the features of mild Asthma
No features of severe asthma
PEFR>75%
Name the features of moderate Asthma
No features of severe asthma
PEFR 50-75%
Can usually be managed at home
Name the features of severe Asthma
PEFR 33-50%
Incomplete sentences
RR>25
HR>110
Name the features of life threatening Asthma
PEFR<33%
pO2<92%
Cyanosis
Poor resp effort/silent chest
Any normal pCO2
Name the features of near fatal Asthma
raised pCO2
What is the management of acute asthma?
Aim for 94-98% O2
5mg Nebulised salbutamol (every 15 mins)
40mg Oral Prednisolone
What is the management of severe asthma?
500mcg Nebulised Ipratropium Bromide (Antimuscarinic)
Back to Back Salbutamol
What is the management of life threatening asthma?
ITU
CXR
IV Aminophylline (Adenosine Antagonist)
IV salbutamol
Name the 5 features of an asthma discharge plan
PEFR>75%
No nebulisers/o2 requirements in past 12-24h
Inhaler technique checked
Check that:
5 days oral prednisolone
GP follow up in 2 working days
Resp Clinic follow up in 4 weeks
Asthma Nurse referral
What is the definition of COPD?
Progressive airway obstruction with little or no reversibility.
Umbrella term for Chronic Bronchitis and Emphysema
Name 3 causes of COPD
Smoking
Alpha 1 Anti-Trypsin
Industrial Exposure (soot)
Name 3 pathological features of COPD
Mucous gland hyperplasia
Mucous gland hypersecretion
Ciliary Dysfunction
Name 5 signs of COPD
Tachypnoea, Hyperinflation, Decreased expansion, Hyper resonance, quiet breath sounds
What are 4 complications of COPD?
Exacerbations, Polycythaemia, Resp Failure, Cor Pulmonale
What would a CXR of COPD show?
Hyperinflation and flattened diaphragm
What would a CT of COPD show?
Bronchial wall thickening and air space enlargement
What would Spirometry of COPD show?
Obstructive pattern with poor reversibility
State the 5 features of the COPD care bundle
Smoking cessation
Pulmonary Rehab
COPD Information Booklet (breathe easy and british lung foundation)
Inhaler technique
Outpatient follow up
What are the requirements for giving LTOT to COPD patients?
Have to use it atleast 16/24 every day
Must be a non smoker
Must not retain CO2
If pO2 is constently less than 7.2kPa (or 8kPa with Cor Pulmonale)
What is the definition of Bronchiectasis?
Chronic dilation of one or more bronchi due to chronic inflammation leading to poor mucociliary clearance
Name the four main categories of Bronchiectasis causes
Post infective, Immune deficiency, Genetic Deficiency, Obstruction
Name two post infective causes of Bronchiectasis
Whooping Cough
TB
Name an immune deficiency causing Bronchiectasis
Hypogammaglobulinaemia
Name four genetic defects causing Bronchiectasis
Cystic Fibrosis, Primary Ciliary Dyskinesia, Youngs Syndrome (Bronchiectasis, SInusitis, Reduced Fertility), Kartageners Syndrome (Bronchiectasis, Sinusitis, Situs Inversus)
Name the four main infective organisms in Bronchiectasis
Haemophilus Influenza
Streptococcus Pneumoniae
Staphylococcus Aureus
Pseudomonas Auerginosa
State 3 symptoms of Bronchiectasis
Persistent cough, copious sputum production, intermittent haemoptysis
State 3 signs of Bronchiectasis
Clubbing, Coarse crepitations, Wheeze
What is the gold standard investigation for Bronchiectasis, and what does it show?
HRCT
Dilation of the bronchi to larger than the adjacent blood vessel (sygnet ring sign)
State 5 management options in Bronchiectasis
Airway Clearance (flutter valve,mucolytics,physio)
Antibiotics
Flu Vaccine
Steroids
Pulmonary Rehab
Name 2 mucolytics
Acetyl Cysteine
Bromhexine
Define Cystic Fibrosis
Autosomal recessive mutation on chromosome 7, leading to abnormalities of CFTR gene (reducing chlorine secreiton and hence mucous dilution)
How is Cystic Fibrosis diagnosed?
History of CF in Sibling/Positive Newborn Test
AND
Sweat Test/Genotyping/Nasal Potential Difference
Describe 3 ways CF can present
Meconium Ileus
Intestinal Absorption (reduced pancreatic enzymes)
Recurrent Chest Infections
Name 4 complications of CF
Respiratory Infections
Low Body Weight
Distal Intestinal Obstruction Syndrome (usually ileocaeca region, palpable RIF mass)
CF related diabetes
What lifestyle advice would you give CF patients?
No smoking
Avoid other CF patients
Avoid Jacuzzis
NaCl tablets in hot weather
Flu Vaccine
Give 5 risk factors for PE
COCP/HRT
Recent surgery
Reduced mobility
Malignancy
Leg Fracture
PE may be asymptomatic, however give 4 ways in which they can present
Acute Dyspnoea
Pleuritic chest pain
Haemoptysis
Syncope
Give 4 signs of a PE
Pyrexia
Tachycardia
Tachypnoea
Raised JVP
What is a massive PE
A PE causing haemodynamic compromise, causing hypotension
What investigations would you do for a PE
ABG
D Dimers (only if WELLS score<4)
ECG (S1Q3T3)
CTPA
How would you manage a PE?
DOAC or warfarin
Long-term anticoagulation or IVC filter
Dabigatran and warfarin require bridging anticoagulation with heparin (until INR >2)
How would you manage a massive PE?
Thrombolysis with alteplase
What are the contraindications to thrombolysis?
Stroke less than 6 months ago
GI bleed less than 1 month ago
Bleeding disorder
Name four classifications of Pneumothorax
Spontaneous (Primary or Secondary)
Traumatic
Tension
Iatrogenic (post central line/pace maker)
Give 5 risk factors for a Pneumothorax
Pre-existing lung disease
Tall and thin
Smoking
Diving
Marfans
How would a pneumothorax present?
Asymptomatic
OR
Sudden onset dyspnoea, pleuritic chest pain, reduced expansion, diminished breath sounds
When do you NOT do a CXR in pneumothoraces?
If a tension pneumothorax is suspected
How do you manage a tension pneumothorax?
Large bore needle into 5th intercostal space mid axillary line
How do you manage a primary pneumothorax?
If lung markings are more than 2cm from chest wall then give O2 and insert a large bore needle into 4th intercostal space mid axillary line
If this is unsuccessful then try a chest drain
What are the two types of pleural effusion?
Transudative (pleural protein<30g/l)
Exudative (pleural protein>30g/l)
Give 3 causes of a transudative pleural effusion
Heart Failure, Cirrhosis, Hypoalbuminaemia
Give 3 causes of an exudative pleural effusion
Malignancy, Infection (eg parapneumonic effusion), Inflammatory (RA)
How would you diagnose a pleural effusion?
CXR
Ultrasound guided pleural aspiration (biochemistry,cytology,microbiology)
How might a patient with Pleural Effusion present? What would you find OE?
May be asymptomatic OR dyspnoea/pleuritic chest pain
OE: stony dull percussion,reduced expansion, diminished breath sounds
Name three different types of management for a pleural effusion
Always test sample first - for pH and protein content (can culture as well)
Drain (URGENT if empyema/pH<7.2)
Pleurodesis
Surgery (if increasing collections/pleural thickening)
What should you consider before draining a pleural effusion?
If you have reached the correct diagnosis
Define Obstructive Sleep Apnoea
Upper airway narrowing, provoked by sleep causing excessive daytime sleepiness
Give two broad causes of Obstuctive Sleep Apnoea
Small Pharyngeal Size (neck fat, large tonsils, craniofacial abnormalities)
Excess narrowing (Obesity, Neuromuscular Disease, Muscle relaxants)
Give 3 presentations of OSA
Snoring, Excessive daytime sleepiness, Nocturia
Give 3 diagnostic methods for OSA
Epworth Sleepiness Scale, Overnight Oximetry, Sleep Study EEG
Give a conservative and a surgical management for OSA
Conservative - Lose weight
Surgical - Pharyngeal surgery
Describe the two possible ventilation methods used in OSA
CPAP - upper airways splinted open with 10mmHg positive pressure, no ventilatory support
bipap - non invasive ventilation, bilevel postive pressure so does provide ventilatory support
Give 3 non respiratory presentations of lung cancer
SVC Obstruction (raised JVP, upper limb swelling)
Horner’s Syndrome (Miosis, Anhidrosis and Partial Ptosis)
Paraneoplastic (Cushings, Hypercalcaemia)
Describe the WHO Performance Status
0 - Fully active without restriction
1 - Restricted in strenuous activity but able to carry out light work
2 - Capable of self care but unable to carry out work activities, up and about more than 50% working day
3 - Limited self care, confined to bed/chair more than 50% waking hours
4 - Completely disabled
5 - Dead
Give four histological sub types of non small cell carcinoma
35% Squamous Cell
27% Adenocarcinoma
10% Large Cell
<1% Adenocarcinoma in situ
Why do small cell carcinomas often give rise to paraneoplastic syndromes?
They arise from Kulchitskey cells, which are endocrine cells
What is Lambert Eaton Syndrome?
Syndrome assoicated with Small Cell Carcinoma
Autoimmune attack against VGCCs causing impaired ACh release
Weak Muscles, Difficulty swallowing, Difficulty breathing
What is a Hamartoma?
Usually a benign cancer
Appears as a lobulated mass with flecks of calcification
What is a malignant mesothelioma? What is it strongly related to?
A cancer of the mesothelial cells occurring in the pleura of the lungs
Strong association with asbestos exposure
Poor prognosis
Define Acute Respiratory Distress Syndrome
A type of respiratory failure characterised by wide spread inflammation of the lungs
Give 5 causes of ARDS
Pneumonia, Vasculitis, Sepsis, Pancreatitis, Malaria
How would a patient in ARDS present?
Cyanotic, Tachypnoeic, Tachycardic, Peripheral vasodilation, Bilateral fine crackles
What is the diagnostic criteria for ARDS?
One of:
Acute Onset
Bilateral Infiltrates
Pulmonary Capillary Wedge Pressure <19mmHg
Refractory Hypoxaemia
Describe the management for ARDS
ITU admission
Resp Support - CPAP or mechanical ventilation (low tidal volume though to prevent pneumothorax)
Circulatory Support - Arterial line for haemodynamic monitoring, Inotropes, Vasodilators, Blood transfusions
Give 3 risk factors for Sarcoidosis
Age (20-40)
Afro-caribbean
HLA DRB1
What is Lofgren Syndrome
Acute form of Sarcoidosis
Characterised by Fever, Erythema Nodosum, Polyarthralgia, Bilateral Hilar Lymphadenopathy
How does Sarcoidosis Pulmonary Disease present?
Dry Cough, Progressive Dyspnoea, Chest Pain
Describe the stages of Pulmonary Sarcoidosis on a CXR
Stage 0 - Normal
Stage 1 - Bilateral Hilar Lymphadenopathy
Stage 2 - Bilateral Hilar Lymphadenopathy and Peripheral Pulmonary Infiltrates
Stage 3 - Peripheral Pulmonary Infltrates alone
Stage 4 - Progressive pulmonary fibrosis, Honeycombing, Bullae
How would you manage pulmonary sarcoidosis?
Mild/Moderate - 40mg Prednisolone OD then taper
Severe - IV methylpred, Anti TNF, Lung Transplant
What is Coal Workers Pneumoconiosis?
Workers inhale coal dust, which are ingested by macrophages which then die, release their enzymes and cause fibrosis
Can progress to Pulmonary Fibrosis
What would a CXR of Coal Workers Pneumoconiosis show?
Many round opacities (especially in upper zone)
What is Caplans Syndrome?
Pulmonary Fibrosis in coal workers who have rheumatoid arthritis
How would a patient with Caplans present?
Cough, SOB, Painful joints and morning stiffness
What three investigations would be indicated in Caplans and what would they show?
CXR - Well defined nodules (potentially cavitating like TB)
Spirometry - Mixed restrictive and obstructive
Bloods - RF, ANA
What is Silicosis?
Inhalation of silica particles which are fibrogenic. Associated with metal mining/stone quarrying/ceramic manufacture
How does Silicosis present?
Progressive Dyspnoea
Increased incidence of TB
What two investigations would be indicated in Silicosis?
CXR - Miliary Pattern in upper/mid zones
Spirometry - Restrictive
What is characteristic of Bronchiectasis on CXR?
Tram Tracks
How would you treat a COPD exacerbation?
No purulent sputum - supportive, likely viral
Purulent Sputum - Amoxicillin TDS 5d (or Doxycycline if Pen allergic)
+Prednisolone
+ supportive nebs if required
What antibiotics would you use for Aspiration Pneumonia?
Co-Amoxiclav
What antibiotics would you use for Pneumonia caused by an atypical pathogen?
Co-Amoxiclav + Doxycycline/Clarithromycin
What antibiotics would you use for Ventilator Assisted Pneumonia?
IV Piperacillin and Tazobactam
What is the difference between acute bronchitis and pneumonia?
May get similar symptoms
Less likely to get productivity in acute bronchitis
Significantly milder
Appears normal on a CXR
When would you refer a CAP?
Severe systemic symptoms
Unresponsive to Abx
Unable to take oral abx
Cosndier if CURB 1-2
Admit if CURB 3
How should pneumonia respond to abx?
After 1 week - no fever
After 1 month - chest pain and sputum production reduced
After 6 weeks - cough resolved
After 3 months - only fatigue present
After 6 months - resolved
Give three primary care considerations for patients after CAP
6 week CXR (if non resolving or risk of malig)
Pneumococcal vaccine?
Smokng Cessation
Name a non respiratory drug that can be prescribed in ILD and supports lung function
PPI
What is FeNO testing for asthma?
Typically only in >17y
Not used in patients taking oral steroids
Breathe out into machine like spirometry which detects nitric oxide concentration
> 40ppb in airways indicates allergic inflammation and asthma
What bronchodilator reversibility suggests asthma?
An improvement in FEV1 of 12% or more 15-20 minutes after bronchodilator
Describe complete management of asthma
No daytime symptoms
No night waking
No need for rescue medication
No asthma attacks
No limitations on activity or exercise
Name two assessment tools for asthma
Asthma control questionnaire
Asthma control test
Describe the non-acute step up management for asthma
1) SABA
2) SABA + ICS (BD)
3) SABA + ICS +LTRA (oral)
4) SABA + ICS + LABA
5) MART
Consider stepping down after three months of good control
When should you start ICS in asthma?
If using SABA inhaler >3 times a week
Woken at night weekly
Name two types of asthma delivery devices
DPI (Dry Powdered Inhalers)
pMDI (Pressured Metred Dose Inhalers)
Name two MART inhalers and describe their administration
Symbicort (Budesonide and Formoterol
Fostair (Beclometasone and Formeterol)
1 puff in morning, 1 puff in evening, puffs for relief (max 6 per day)
State 5 things to monitor at an asthma review
Number of asthma attacks
Nocturnal symptoms
Adherence
Asthma management plan
Smoke exposure
What are the royal college of physicians’ three questions for controlled asthma?
1) Have you had trouble sleeping at night due to your asthma symptoms?
2) Have you had your usual asthma symptoms during the daytime?
3) Is this affecting your ADLs?
How often should asthma patients be followed up?
Annual review
After any medication change (4-8 weeks)
How should you manage asthma exacerbations in the community whilst awaiting admission?
Nebulised salbutamol if available
If not MDI - 4 puffs initially, followed by 2 puffs every 2 mins
If severe or life threatening consider giving nebulised ipratropium bromide
In diagnosis of COPD, the MRC dyspnoea score can be used. What is it?
Measures the severity of breathlessness from 1-5
When should COPD patients be referred for pulmonary rehab?
If MRC dyspnoea score >3 or recent hospitalisation
Not if unstable angina or unable to walk
Name two inhaler managements for COPD
SABA and SAMA
How should COPD exacerbations be managed in the community?
5d oral prednisolone +/- abx
When should you suspect bronchiectasis in children?
Recurrent chest infections
Chest infections failing to respond to abx
Asthma medication failing
Other than HRCT, how can bronchiectasis be investigated?
Chest X-Ray
Sputum sample
Spirometry
What should be considered in bronchiectasis end of year review?
How symptoms are affecting ADLs
BMI (<20 needs nutritional support)
Frequency of exacerbations
How should exacerbations of bronchiectasis be managed?
Take sputum sample
7-14d antibiotics (eg Amoxicillin)
When should you immediately admit people for PE?
If signs of haemodynamic instability
If pregnant/given birth 6 weeks ago
State 4 items on the WELLs score
Previous VTE
Haemoptysis
Tachycardia
Immoblisiation for >3d
How would you manage patients with WELLs>4 ?
CTPA (if not available within 4 hours then start interim apixaban)
How would you manage a WELLs score <4?
1) D-Dimer
2) If D-Dimer positive then CTPA (interim anticoag if more than 4 hours)
How long should anticoagulation be continued for in PE?
First episode provoked - 3 months
First episode unprovoked - 6 months
How is asthma diagnosed?
> 17y - Spirometry with reversibility AND FeNO
5-16 - Spirometry with reversibility and FeNO if unequivocal
<5 - clinical diagnosis only
Describe the step up management of adult asthma
1) SABA
2) SABA + ICS
3) SABA + ICS LTRA
4) SABA + ICS + LABA
5) MART
What should you always ask in acute exacerbation of asthma?
About previous exacerbations - any ITU admissions?
Describe the step up management of asthma exacerbation
1) Nebulised salbutamol
2) + Prednisolone 40mg
3) Nebulised ipratropium bromide
4) MgSO4
5) ITU opinion for aminophylline/intubation
