resp Flashcards
How much salbutomol neb would you give in acute asthma
2.5mg
how much pred/ hydro would you give in asthma
pred - 30mg PO
Hydro - 100mg IV
what are you looking for in the metacholine histamine challenge for asthma
- 20% reduction in fev1; how much metacholine is required to do this
RF for asthma
- low birthweight
- atopy triad
- fhx atopy/ personal
- maternal viral infection esp RSV
- Maternal smoking
- not breastfed
- antenatal smoking
- high exposure to allergens
- air pollution
- hygiene hypothesis
sx of acute severe ashtma
- 33-50% PEFR
- UNABLE to compelte sentences
- pulse >110
- RR>25
SX of life threatening asthma
- hypotension
- silent chest
- confusion
- pao2<8 but paco2 normal
- exhaustion
- bradycardia
- PEFR<33%
- near fatal paco2 will be high
rx pathway for adults with ashtma
- SABA for all
- ICS
- ICS +LABA
- ICS +LABA + LTRA.
rx pathway for asthma in kids
- SBA for all
- ICS very low dose
- ICS + if <5 = LTRA. if >5 = LABA
- Add whatever was not given before
when do you refer a patient with acute asthma to ITU
- Decreased PEF
- Confused/ drowsy
- hypercapnic
- low PH/ high H+
- needs ventilatory support
- worsenign hypxia
acute asthma rx
- o2
- neb salb 2.5mg through 02 back to back
- pred/ hydro
- ipratropium bromide
- mg sulphate
- aminophylline
- ITU
what are the rx of copd before starting inhalers
- pulmonary rehab
- stop smoking
- vaccines
- self manage plan
- comorbidities optimisation of rx
COPD inhaler rx pathway
- SABA/SAMA
IF non asthma like
1. LABA +LAMA
2. LABA + LAMA + ICS
If asthma like
- ICS + LABA
- ICS + LABA/LAMA
+ mucolytic if sputum heavy
NEXT LEVVEL
- amino/theo
- LTOT
what exam findings should you assess for in copd when considering LTOT
- <30% FEV1
- Cyanosis
- polycythaemia
- high JVP
- peripheral oedema
- <92% o2 sats
ABGS twice at least 3 weeks apart with stable COPD and on optimal rx
Criteria for LTOT in COPD-
PO2<7.3KPA or p02 7.3 -8 +
- secondary polycythaemia
- peripheral oedema
- pulmonary HTN
Do not give if still smoking
in alpha 1 antitrypsin deficiency what is the rx
- replace with IV if <310 + abnormal lung function
secondary polycythaemia rx
- venesect
what advise should be given about air travel with COPD
- Need trial 15% o2 instead of room air 21%. if falls below 85% sats need supplementary o2
what ix to do in resp failure
- FBC, U and E, CRP, ABG, CXR, sputum culture if debrile
- spirometry if thinking of certain pathologies
complications of intubation and ventilation
- traumat to URTI
- Secondary pulm infection
- barotrauma; = surgical emphysema/ tension pneumo
- reduced CO - increase intrathoracic pressure and so impairs filling
- abdo distention due to inestinal ileus
- increased ADH and reduced ANP = salt and wter retention
which peripheral chemoreceptors detect ph, co2 and blood 02
- carotid body
aortic does not do ph
what does the pneumotaxic centre of the brain do
- inhivits apneustic centre of pons so reduces inspiration
why do you get pulmonary HTN in massive PE but not small PE-
- Small PE = blocking segmental pulmonary artery so still being ventilated but not perfused
- in massive PE = proximal Pulmonary artery blocked causing backflow of blood .
how do you treat pneumonia caused by staph
- fluclox and rifampicin
how does mycoplasma pneumonia present and rx
- dry cough and atypical chest signs/CXR. flu like sx then cough.
+/- autoimmune haemolytic anaemia and erythema multiforme
- CXR; reticular nodular shadowing or patchy consoloidation often LOWER lobe
- rx clarithro/doxy
in legionella what happens to na and lymphocytes-
hyponatraemia nd lymphopenia
how do legionella pneumonia present
- flu like x then dry cough and SOB
- Anroexia, D and V, hepaitis, renal failure, confusion, coma
- Bibasal consolidation on CXR
rx - fluoroquinolone
who is klebsiella pneumonia more common in
- DM
- Elderly
- Alcoholics
rx klebsiella
- ceoftaxime
what happens to neutrophils in bacterial pneumonia
- neutrophilia
what bloods to do for pneumonia
- FBC
- U and E
- LFT
- CRP
if you do a point of care CRP test for pneumonia , when do you give abx
- CRP <20 = no abx
- 20-100 - delayed prescription
- > 100 = abx
when do you admit patietns with pneumonia
- CURB65 > or equal to 2
- if 1 then if sat s <92% admit
- if 1 and >92% then do cxr, if bilateral or multilobar then admit
common empirical abx for pneumonia
CAP
- Doxy/amoxi if mod
- clarithro and benpen if severe
HAP
- Benpen and gent
aspiration
- benpen, gent and metro
when should you discharge a patient who has had pneumonia
- if in last 24hrs
no temp, RR<24, HR <100, SBP >90, O2>90%, ABNORMAL AMTS, Cant eat without assistance
how long after pneumonia do you stop having a fever
1 week
how long after pneumonia does chest pain and sputum production go
- 4 weeks
how long after pneumonia does cough resolve
- 6 weeks
when does fatigue resolve after pneumonia
- 3/12
empyema; what is the ph, glucose and LDH
- LDH is high
- ph = low <7.2
- glucose is low
what wells score do we need to do USS for DVT
2+
WHAT DO you do if d dimer is high on a patient suspected of DVT but there USS is -ve
- repeat USS in 1 week
how long do you treat for after unprovoked DVT-
- 3/12
post thrombotic limb syndrome rx
- elevate, compress, weight manage etc
- vasc surgery if conservative not working
what type of smokers is pneumothorax more common in
- healthy smokers
ECG changes in pneumothorax
left sides:
- V2-V6 = reduced QRS amplitude
right sides:
- v5-v6 = increased amplitude
STE/D in pneumothorax
how do you treat pneumothorax due to traum or mechanical ventilation
- chest drain
where to insert chest drain for pneumothorax-
4th intercostal space in between ant and median axillary line
rx pneumothorax primary
- <2cm / asymptomatic - go home
- >2cm / breathless - aspirate then chest drain if need
rx pneumothorax secondary
<1cm - admit and observe 24hrs + 02
1-2cm = aspirate
2cm/ breathless= drain
indications for surgery in pneumothorax
- bilateral
- unresolving after 48hrs of chest draian
- persistent air leak
- 2 or more previous pneumothoraxes on same side
advise for flying post pneumothorax
- no flying for 1 - 4/52 after; check airlines
- also no scuba divign ever
where do you insert the needle for emergency decompression in pneumothorax-
2nd intercostal space mid clavicular line
Non small cell carcinoma pathology
- EGFR; TK mutation. can target with TKI; gefitinib and erlotinib
- inversion of chr short arm = EML4+ ALK gene fusion. = fusion TK. target with crizotinib
what is PDL1 and how is it related to lugn cancers
- PDL1 is produced by lugn cancer cells to attach to T cells to inhbiit their function
- can give PDL1 inhibitors to stop this = MABS = Pendormulizab
what side of Lung cancer often causes SVC obstruction
- right sided. often Smal cell
PTHRP , SIADH, ACTH, Lambeth eaton; is most common in which kind of lung cancer
- small cell
where on CXR would you see TB related problems
- Upper lope.
what is the difference between the IGRA test and mantoux test in TB
- Mantoux ; test immunity
- IGRA - tests latency
WHO gets DOT therapy in TB
- Homeless with active TB
- Prisoners with active or latent
- those with pooor concordance
what drugs should you not give rifampicin with
- OCP, Prednisolone
which Tb drug gives you peripheral polyneuropathy
- Isoniazid
which TB drug gives you gout
- pyrazinamide
what is lights criteria for pleural effusions
fluid is exudate if:
1. pleural fluid protein divided by serum protein >0.5
- pleural fluid LDH >
Divided by seurm LDH >0.6 - fluid LDH >2/3rds of ULMN of serum
if pleural fluid has low glucose - what is the cause of pleural effusion?
- rheumatoid arthritis
- TB
IF pleural fluid has raised amyalse - what is the cause of pleural effusion
- pancreatitis
- oeseophageal perforation
if pleural fluid has lots of blood - what is the cause
- mesothelioma
- pulmonary embolism
- TB
Common cause of transudates of pleural effusions
- hypoalbuminaema
- CCF
- Constrictive pericarditis
- Meig’s syndrome (right pleural effusion, ovarian fibroma and ascites)
- HypoTH
common causes of exudate pleural effusions
- autoimmune disease
- oeseophageal rupture
- infection
- malingnacy
- pancreatitis
- post CABG
- PE
ix imaging for pleural effusion
- CXR
- USS
RX pleural effusions
- small: diagnostic tap
- moderate: therapeutic aspiration
- large: drain
never take more than 1.5l in one go = pulmonary oedema
If a pleural effusion is parapneumonic, what will the pH be
7.2 or less - chest drain if moderate+ size
ix for pleural effusions samples
- pH, biochem (LDH, Protein, glucose, adenosine deaminase)
- cytology
- microbiology = MCS
rx for pleural effusion due to pulmonary oedema
- diuretics
borders of the safe triangle for chest drain insertion
- lateral border of pec major
- anterior border lat dorsi
- superior border of 5th rib
- base of axilla
killer conditions in chest traums (ATOMFC)
- Airway obstruction
- Tension pneumothorax
- Open pneumothorax
- Massive haemothorax
- Flail chest
- Cardiac tamponade
what does crepitus with airway obstruction indicate
- Laryngeal fracture
what does surgical emphysema causing airway obstruction sound like
- bubble wrap
why are most haemothoraxs not detectable on scans
- need 500ml of blood to obliterate the costophrenic angle on erect CXR
- supine is not helpful
how big a drain should you use in adults with haemothorax
- 32F for adults to prevent clotting , if can get 36 the better
who gets a thoracotomy in haemothorax
- unstable
- large ; >1500ml
- ouput from drain not reducing (1-1.5l)
complications of haemothorax
- clotted residual haemothorax which doesnt drain - gets infected = empyema
- even uninfected = organissation and fibrosis = loss of lugn volume and reduce function
how do you know if someone with haemothorax now has empyema
- fever
- air fluid levels on CT
- leukocytosis
rx empyema post haemothorax
- surgery
traumatic pneumothorax rx
= - drain . only mechanically ventilate if need, after the drain
most common cause of haemothorax
- laceration of lung, intercostal vessel or internal mammary artery
what is becks triad for cardiac tamponade
- elevated venous pressure
- reduced arterial pressure,
- reduced heart sounds
what happens to pulse in cardiac tamponade
- pulsus paradoxus
how to treat pulmonary contusion
= lethal chest injury
- ABG and pulse ox
- early intubate within 1hr if significant hypoxcia
when do blunt cardiac injuries occur
- secodnary ot chest wall iniurt
in cardiac injury, what do ECGs look ike
- MI
cause of aortic disruption in trauma
- deceleration injuries
what do you see on XR in aortic disruption
- widened mediastinum
- cotnained haematoma
diaphgram disruption causes and which side is it more common on
- motor vehicle accidents and blutnt rauma cuasing large radial tears;
- left side
how to identify diaphragm disruption
- NG tube -> passes through to thoracic cavity
what inheritance pattern does Cystic fibrosis have
- autosomal recessive
which infection in cystic fibrosis is associated with accelerated disease and rapid death
- burkholderia cepacia
Presentation of CF
- Repeated childhood respiratory infection
- Sinusitis and nasal polyps
- pancreatic insufficiency; steatorrhoea
- gallstones of cholesterol
- cirrhosis
- peptic ulcers and GI malignancy high risk
- malnutirition due to malabsorption
- meconium ileus
- SOB and haemoptysis due to bronchiectasis
- delayed puberty and skeletal maturity
- male infertile due to lack of vas deferens and epidydmis
- females; secondary amenorrhoea with time
sx broncheictasis
- recurrent infections
- cough with yellow or green sputum
- persistent halitosis
- clubbing
- coarse crackles over bases
- haemoptysis if severe or even massive haemorrhage (bronchoscopy –> embolization)
rx bronchiectasis
- postural drainage
- treat infections
- bronchodilators
what is kartageners syndrome triad
- bronchiectasis
- situs inversus
- chronic sinusitis
what chromosome is affected in CF
7
CF signs in a neonate
- meconium ileus
- FTT
- rectal prolapse
CF signs in children
- resp
- cough, sputum
- wheeze
- recurrent chest infection
- haemoptysis
- bronchiectasis
- pneumothorax
- sinusitis
- cor pulmonale
- hyperinflation
- nasal polyps
CF sign in kids; Skin
- bruisinng due to vit K deficiency
- salty sweat
CF sign in kids - GI
- Steatorrhoea
- DM
- ADEK deficiency
- gallstones
- cirrhosis
what does bronchiectasis look like on CXR
- Tram track opacities seen in cylindrical pattern
is bronchiectasis obstructive or restrictive on spirometry
- obstructive
what tests should you regularly do for CF patients
- FBC
- U and E
- clotting
- Vit ADEK
- Annual glucose
- sputum mcs
- CXR
- Spirometry
what organism is common for infections in cf and what is the rx
- pseudomonas
- ciprofloxacin and nebulised tobramycin
what fev1 do you need to have lung transplant in CF
- <30%
What cranial nerve is affected in sarcoidosis
- CNVII palsy
what endocrine problem is common in sarcoidosis
- DIabetes insipidus
acute sarcoidosis presentation
- bilateral hular LNA
- anterior uveitis
- CNVII palsy
chronic sarcoidosis presentation
- permanent organ damag e - pulmonary fibrosis - lupus pernio - posterior uveitis
sarcoidosis stages
1 = Bilateral hilar lympadenopathy (BHL)
2 = BHL + Infiltrate
3 = Infiltrate without NHL
4 = Fibrosis
is sarcoidosis restrictive or obstructive
- restrictive
what does ecg show in sarcoidosis
- arrhytmias
- BBB
GS ix for sarcoidosis
- Biopsy
rx acute sarcoidosis
- bed rest
- NSAIDs
indications for steroids in sarcoidosis
- uveitis
- high ca
- neuro and ca involved
- parenchymal lung disease
what steroids to give for sarcoid
= pre 4-6 weeks then taper over a year
what conditions cause Upper lobe shadowing on CXR
- TB
- Ank spond
- RDT
- Fibrosis
what caonditions cause middle lobe shadowing on CXR
- Histoplasmosis
- sarcoidosis
what conditions cause lower zone shadowing on CXR
- Idiopathic fibrosis
- asbestos
extrinsic allergic alveolitis sx
- 4-6hrs post exposure
- fevers, rigors, Dry cough, SOB, fine bibasal crackles
- ltm = clubbing, weight loss, SOBOE, T1RF, Cor pulmonale
extrinsic allergic alvoeolitis rx
- steroids
is ANA +ve in Idiopathic fibrosis
- in 30%
describe appearance of IDPF on CXR and CT
- HONEYCOMB LUNG - in advanced
what happens to spirometry in IDPF
- Restrictive, lower transfer factor
what is caplans syndrome
- pulmonary rheumatoid nodules, pneumoconiosis, RA
