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EXAM 2 > Resp 9.5 > Flashcards

Resp 9.5 Flashcards

1
Q

Indications for NIV in COPD?

A

if persisting after bronchodilators & controlled O2 therapy:
pH <7.35
pCO2 >6.5
RR>23

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2
Q

Indications for NIV in neuromuscular disease?

A

resp illness with RR>20 if usual VC <1litre even if pCO2 <6.5
OR
pH <7.35 and pCO2 >6.5

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3
Q

Indications for NIV in obesity?

A

pH <7.35 pCO2 >6.5 RR>23
OR
daytime pCO2 >6.0 and somnolent

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4
Q

Absolute C/I for NIV?

A
  • severe facial deformity
  • facial burns
  • fixed upper airway obstruction
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5
Q

Relative C/I for NIV?

A
  • pH <7.15
  • or pH<2.5 and additional adverse features
  • GCS<8
  • confusion/agitation
  • cognitive enhancement (warrants enhanced observation)
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6
Q

Latent TB Rx?

A

3 months R + I (with pyridoxine) - esp people <35yrs where hepatotoxicity is a concern
or 6 months Isoniazid (with pyridoxine) - esp if rifamycin interactions is a concern e.g. HIV/Tx

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7
Q

RFs for developing Active TB in someone with latent TB?

A 
silicosis
chronic renal failure
HIV +ve
solid organ Tx with immunosuppression
IVDU
haem malignancy
anti-TNF Rx
previous gastrectomy
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8
Q

Wegener’s granulomatosis with polyangitis = autoimmune necrotising vasculitis of upper & LRT and kidneys
features?
Ix?
Rx?

A
  • URT epistaxis, sinusitis, nasal crusting, saddle-shape nose deformity
  • LRT dyspnoea
  • rapidly progressive GN (pauci-immune 80%)
  • also vasculitic rash, eye involvement e.g. proptosis, CN lesions
  • cANCA >90% (pANCA 25%)
  • CXR: variety inc caveatting lesions
  • rneal Bx: epithelial crescents in Bowmans capsule

Rx = steroids, cyclophosphamide 90% response, plasma exchange

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9
Q

IPF = idiopathic progressive fibrosis of interstitium of lungs
Features?
Dx?
Rx?

A
  • progressive SOBOE, bibasal crackles, dry cough, clubbing
  • Dx: restrictive on spiro, impaired gas exchange -> reduced TLCO
  • BL interstitial shadowing, ground-glass, honeycombing high-res CT
  • ANA +ve 30% RF 10%
  • pulm rehab
  • Pirfenidone (antifibrotic agent) may be useful in selected pts
  • O2 then lung Tx
  • NINTEDANIB = small molecule TK inhibitor inc PDGFR & FGFR 1-3 & VEGFR 1-3; can be used when FVC 50-80%, discounted, Rx stopped if disease progresses in any 12month period
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10
Q 
Asthma Long-term Rx?
1. Newly-Dx
2. Not controlled or Newly dx with Sx 3+x/wk or night-time waking
3. 
4.
5.
6.
7.
A
  1. SABA
  2. SABA + ICS
  3. SABA + ICS + LTRA
  4. SABA + ICS + LABA
    - cont LTRA depending on pt’s response
  5. SABA +/- LTRA
    - switch ICS/LABA for a MART (maintenance & reliever Rx) that inc low-dose ICS
  6. SABA +/- LTRA + medium-dose ICS MART
    - or consider changing back to a fixed dose of a mod dose ICS & separate LABA
  7. SABA +/- LTRA + 1 of the following:
    - inc to high-dose ICS
    - trial additional drug e.g. LAMA/theophylline
    - expert advice

MART = fast-acting LABA/ICS combo

Low dose ICS <400 mcg budesonide
400-800 mod
>800 high

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11
Q

Inadequate controlled asthma + eosinophilia + elevated FENO

- what other Rx can be used?

A
  • anti-IL-5 therapies eg Mepolizumab for eosinophilic asthma

- IV/SC Mepolizumab shown to significantly reduce asthma exacerbations and esp useful in pts on long-term steroids

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12
Q

Several inflammatory phenotypes in asthma mostly: eosinophilic, neutrophilic, mixed, and paucigranulocytic.
The presence of eosinophilic inflammation can be demonstrated by what factors?

A

sputum eosinophils 3%+
FENO 50ppb+
eosinophil count 0.3+
prompt deterioration of asthma control after a 25% or less reduction in ICS

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13
Q

Mantoux & quantiferon testing in active/latent TB & BCG?

A

Mantoux +ve = active/latent TB or BCG

Quantiferon +e = active/latent TB

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14
Q

CAP Rx low-severity?

mod-high severity?

A

1st Amoxicillin, Tetracycline/macrolide if pen allergic for 5/7

Mod-High: amoxicillin + macrolide 7-10/7, if high-severity then NICE suggest a beta-lactamase stable penicillin e.g. co-amox/ceftriaxone/pip-taz + macrolide

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15
Q

Asbestosis: latent peried 15-30yrs, severity related to length of exposure
- what does it cause?

A
  • lower zone fibrosis & interstitial pneumonitis
  • SOB & reduced ET
  • Rx conservatively
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16
Q

1ry pneumothorax Rx if:

  1. air <2cm and not SOB
  2. air >2cm or is SOB
  3. if persists
A
  1. discharge
  2. aspirate
  3. failed aspiration (if still 2.) then chest drain
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17
Q

2ry pneumothorax Rx if:

  1. > 50yrs and air >2cm &/or SOB
  2. air 1-2cm
  3. if persists
  4. if <1cm
A
  1. chest drain
  2. aspirate
  3. drain
  4. oxygen

Admit all 2ry pneumothoraces

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18
Q

Pleural aspirate: what to send the fluid for?

A 
pH
protein
LDH
cytology
microbiology
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19
Q

Light’s criteria for pleural effusions - used in borderline cases if protein 25-35
Exudate >30
Transudate <30

A

Exudate more likely if either:

  • pleural protein/serum protein >0.5
  • pleural LDH/serum LDH >0.6
  • pleural LDH is >2/3s ULN serum LDH
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20
Q

Pleural fluid findings:

  • low glucose?
  • raised amylase?
  • heavy blood-stain?
A
  • RA, TB
  • pancreatitis, oesophageal perforation
  • mesothelioma, PE, TB
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21
Q

All patients with a pleural effusion in ass with sepsis/pneumonic illness require Dx pleural fluid sampling
- when to consider chest drain?

A
  • if purulent/turbid/cloudy

- if pH <7.2 (empyema)

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22
Q

Rx of rec pleural effusions?

A

rec aspiration
pleurodesis
indwelling pleural catheter
Sx control

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23
Q

Indication for steroids in sarcoidosis?

A
  • CXR stage 2/3 disease AND mod-severe or progressive Sx
  • hypercalcaemia
  • eye, heart, neuro involvement
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24
Q

Silicosis = fibrosing lung disease caused by silica inhalation

  • it is a RF for developing what?
  • features?
A

TB - silica is toxic to macorphages

  • fibrosis
  • egg shell calcification of hilar LNs
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25
Q

NIV indications?

Recommended initial settings for BiPAP in COPD?

A
  • COPD with pH 7.25-7.35
  • T2RF 2ry to chest wall deformity, neuromuscular disease or OSA
  • cardiogenic pulm oedema unresponsive to CPAP
  • weaning from tracheal intubation
  • EPAP 4-5 IPAP 12-15
  • back up rate 15 breaths/min
  • back up insp:exp 1:3
  • increase in IPAP will help blow off CO2
  • EPAP increases oxygenation
  • haloperidol/morphine can help settle someone sufficiently to tolerate the mask
26
Q

Small cell lung ca

- paraneoplastic features?

A
  • ADH -> low Na
  • ACTH - but not typical features, HTN, high BM, low K, alkalosis, muscle weakness; can also cause BL adrenal hyperplasia
  • Lambert-Eaton syndrome: Ab to voltage gated calcium channels -> myasthenia like syndrome
27
Q

Paraneoplastic features of SCC lung?

A
  • PTHrp causing hypercalcaemia
  • clubbing
  • HPOA
  • ectopic TSH -> hyperthyroid
28
Q

Paraneoplastic features of adenocarcinoma lung?

A

gynaecomastia

HPOA

29
Q

Features & Rx of small cell lung ca?

A
  • usually central, arise from APUD cells (amine precursor uptake decarboxylase)
  • ADH, ACTH, Lambert-eaton

Usually metastatic at Dx

  • surgery if v early e.g. T1-2a N0 M0
  • most get chemoRT
  • palliative chemo if more extensive
30
Q

What should be done with nebulisers whilst having NIV (cold with T2RF)?

A

Take off NIV mask to give nebulisers

- higher proportion of the drug reaches the airways, necessary for bronchodilation

31
Q

Common causes of lobar collapse?

A

cancer
asthma - mucus plug
FB

32
Q

Lung cancer, progressive SOB, pleural effusion on CXR

  • aspirate withdraws BLOOD
  • Rx?
A

Surgical chest drain needed (not narrow seldinger)

33
Q 
ARDS: increased permeability of alveolar capillaries leading to fluid accumulation in alveoli i.e. non-cardiogenic pulmonary oedema
Causes?
Features?
Criteria?
Rx?
A
  • sepsis, pneumonia, massive blood transfusion, trauma, smoke inhalation, pancreatitis, cardio-pulmonary bypass
  • dyspnoea, inc RR, BL crackles, low sats
  • acute onset within 1wk of RF
  • pulm oedema on CXR otherwise unexplained
  • non-cardiogenic (do PAWP if doubt)
  • pO2/FiO2 <40kPa (200mmHg)
  • ITU, O2, ventilation, organ support, rx underlying cause, strategies e.g. muscle relaxation
34
Q

Causes of pulmonary eosinophilia?

A 
Churg-strauss
ABPA
Loffler's syndrome
acute eosinophilic pneumonia - highly responsive to steroids
hypereosinophilic syndrome
tropical pulm eosinophilia
nitrofurantoin, sulfonamides
(Wegener's less common)
  • cough, wheeze, pull infiltrates on CXR, raised IgE, eosinophilia
35
Q

Tropical pulm eosinophilia

  • ass with what infection?
  • Rx?
A
  • roundworms Wuchereria bancrofti spread via mosquitoes
  • can cause elephantiasis when they spread and settle in lymphatics & mature into adults & reproduce
  • paroxysmal nocturnal cough, wheeze, SOB
  • Diethylcarbamazine
36
Q

Loffler’s syndrome = transient CXR shadowing & blood eosinophilia
- cause, Sx

A
  • parasites eg Ascaris lumbricoides, strongyloides enter circulation via duodenal walls
  • chronic malabsorption
  • fever, cough, night sweats, <2weeks
  • Mebendazole can help
37
Q

Group 1 pull arterial Htn?

A

PAH

  • idiopathic (1ry)
  • familial
  • collagen vascular disease, congenital heart disease with systemic to pulmonary shunts, HIV, drugs & toxins, sickle cell disease
  • persistent pulm HTN of newborn
38
Q

Group 2 pulmonary HTN?

A

Pulm HTN with left heart disease
- left-sided atrial, ventricular o valvular disease e.g. LV systolic & diastolic dysfunction, mitral stenosis & MR

39
Q

Group 3 pulmonary HTN?

A

Pulm HTN 2ry to lung disease/hypoxia

  • COPD
  • ILD
  • sleep apnoea
  • high altitude
40
Q

Group 4 pulmonary HTN?

A

Pulm HTN due to thromboembolic disease

41
Q

Group 5 pulmonary HTN?

A

Miscellaneous conditions

  • lymphangiomatosis e.g. 2ry to carcinomatosis or sarcoid
  • Nb pulmonary HTN is a complication of TIPS: an increased cardiac preload by diverting blood past the cirrhotic liver, thereby significantly reducing peripheral resistance
42
Q 
ABPA: allergy to Aspergillus spores
- often hx of bronchiectasis &amp; eosinophilia
Features?
Ix?
Rx?
A
  • bronchoconstriction: wheeze, cough, dyspnoea, may have a prev label of asthma
  • proximal bronchiectasis
  • eosinophilia, flitting CXR changes
  • +ve RAST test to Aspergillus
  • +ve IgG precipitins (Not as +ve as in aspergilloma)
  • raised IgE
  • steroids
  • itraconazole 2nd line
43
Q

Immunosuppressed post-chemo pt gets fever, productive cough, haemoptysis despite Abx. Bloods show neutrophilia and caveatting lesion in RUZ which has a halo sign on CT. Hyphae seen on silver staining after BAL induced sputum
Dx?

A

invasive aspergillosis
- 1st line VORICONAZOLE IV
(oral takes 10 days to get to therapeutic levels)
- liposomal amphotericin if not tolerated

44
Q

NTM: non-tuberculous mycobacteria

  • Dx?
  • main types?
  • Rx?
A
  • hypersensitive like disease
  • cavitating disease
  • bronchiectasis with/out nodules

Dx: clinical, radiological, microbiological characteristics eg

  • cough, sputum, constitutional Sx, exclusion of alternative Dx
  • CXR/HRCT showing cavities, bronchiectasis &/or nodules
  • 2+ +ve sputum samples for an NTM taken on separate days (or 1+ +ve sample from BAL/tissue Bx)

MAC: mycobacterium avid complex Rx = Rifampicin, Clarithromycin, Ethambutol - continue until sputum negative for MAC for 12months

M. kansasii: Rifampicin, Isioniazid, Ethambutol - continue until sputum culture negative 12months

45
Q

1ry TB when non-immune host is exposed and can develop 1ry infection of lungs

  • Ghon focus develops composed of tubercle-laden macrophages
  • Ghon complex = Ghon focus + hilar LNs
  • how does it heal?
A
  • heals by fibrosis in immunocompetent

- but miliary/disseminated TB in immunocompromised

46
Q

2ry TB: if host becomes immunocompromised then initial infection may become reactivated
- causes?

A
  • generally occurs in apex of lungs or may spread locally/to more distant sites
  • immunosuppressants eg steroids, HIV, malnutrition
  • lungs commonest site
  • CNS/meningitis
  • vertebral bodies/Pott’s disease
  • cervical LNs scrofuloderma
  • renal
  • GI tract
47
Q

causes of upper zone fibrosis?

A 
EAA/hypersensitivity pneumonitis
coal worker's pneumoconiosis
silicosis
Ank spond
sarcoidosis
histiocytosis
TB
48
Q

causes of lower zone fibrosis?

A

IPF
most CT disorders except AS
asbestosis
drugs: amiodarone, bleomycin, MTX

49
Q 
EAA = hypersensitivity pneumonitis 
- type III reaction although type IV can play a role esp in chronic phase
examples?
presentation?
Ix?
A
  • bird fanciers lung: avian protein
  • farmers lung: spores of saccharopolyspora rectivirgula
  • malt workers Aspergillus clavatus
  • muchroom lung thermophilic actinomycetes
  • acute 4-8h after exposure: SOB, dry cough, fever
  • chronic

Ix: upper/midzone fibrosis, BAL: lymphocytosis, NO eosinophilia

50
Q

Causes of exudative effusions?

A

Increased leakiness of pleural capillaries

- infection, inflammation, malignancy

51
Q

causes of transudate effusions?

A

Increased venous pressure

  • heart, kidney, liver failure
  • fluid overload, hypothyroidism, Meig’s syndrome
52
Q

Features of histoplasmosis?

Rx?

A
  • due to fungus Histoplasma capsulatum
  • URTI Sx with retrosternal pain, alias, fever, weight loss
  • hepatosplenomegaly, erythematous cutaneous lesions
  • Dx: serology, microscopy, culture

rx = Amphotericin/Itraconazole

53
Q 
COPD Stable Rx
conservative
1.
-> do they have asthmatic/steroid responsive features?
2. Yes
3. No

When is oral theophylline recommended?
mucolytics?
.

A
  • stop smoking, flu vaccine, one-off pneumococcal vaccine, pull rehab if functionally disabled
    1. SABA/SAMA
  • > previous Dx of asthma/atopy, higher eosinophil count, variation in FEV1 at least 400ml, diurnal peak flow variation at least 20% -> = Yes
  1. Yes then:
    - LABA + ICS, then LABA + ICS + LAMA if remain SOB/exacerbations
  2. No then:
    - add LABA + LAMA

Oral theophylline - after trials of short & long acting bronchodilators or people who cannot used inhaled therapy
- REDUCE the dose if macrolide/fluoroquinolones prescribed

  • consider mucolytics in pts with chronic productive cough - continue if Sx improve
54
Q

Cor pulmonale in COPD

  • features
  • Rx
A
  • peripheral oedema, raised JVP, systolic parasternal heave, loud P2
  • loop diuretic for oedema, consider LTOT
55
Q

Microscopic Polyangitis = small vessel ANCA vasculitis

  • features?
  • Ix?
A
  • systemic: fever, lethargy, myalgia, weight loss
  • chest: cough, SOB, haemoptysis
  • renal: raised Cr, haematuria, proteinuria
  • rash: palpable purpura
  • other: MONOneuritis multiplex
  • p-ANCA +ve
  • MPO Ab
  • crescenteric GN & focal necrosis but without granuloma formation in kidneys
  • no upper/lower airway involvement usually
56
Q

How to confirm Dx of TB?

A

Culture M. tb from rest specimen

  • bronchoscopy produces best specimen for acid-fast staining & mycobacterial culture
  • need multiple samples
57
Q

Pt with HIV & CD4 <200 has contact with TB and a negative Mantoux test
Next step?

A

IGN-gamma test

- Mantoux unreliable (false negatives)

58
Q

What is Lofgrens syndrome?

A

Acute sarcoid with BHL, erythema nudism, fever 7 polyarthralgia

  • good prognosis
  • give steroids if stage 2 sarcoid
59
Q

NSCLC Rx?

C/I to surgery?

A
  • 20% surgery suitable
  • mediastinoscopy performed prior to surgery as CT doesn’t always show mediastinal LN involvement
  • curative/palliative RT
    (chemo poor response)

Surgery C/I:

  • poor performance status
  • stage IIIb/IV (mets)
  • FEV1 <1.5L
  • malignant pleural effusion
  • tumour near hilum
  • vocal cord paralysis
  • SVC obstruction
60
Q

What is omalizumab?

A

Anti-IgE monoclonal Ab for pts with severe allergic asthma refractory to other Rx inc multiple courses of oral steroids/year
- manufacturer recommends only if +ve skin test to a recognised rest allergen

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