RESP Flashcards
Pneumonia (CAP
RF: older, immunosup, CLD.
Sx: fever, cough (prod).
OE: fever, creps, < 95%/HR > 100, dullness to percuss, poor AE, bronchial BS or creps not clearing without coughing.
Dx: Sx, CXR: new evidence pulmonary congestion. CLD/older may be more subtle. if early imaging, repeat in 24-48 hours.
Differentiate from bronchitis: has fever, creps, low sats, tachycardia. pleuritic pain/unwell. consolidation on XR. If protracted/not repsond abx consider atypical.
Ix: CXR, vitals.
MC+S/NATT low yield.
pneumo urinary antigen only used to confirm strep - not for diagnosis. legionella urinary/myco sero if suspicious.
Mx:
amoxyl 1g tds, 5 days if improved 2-3 days. 7 if not. consider adding doxy if not improved by 2 days.
allergy: cefuroxime 500mg BD/moxifloxacin if severe.
red flags: RR>22, HR>100, BP < 90, onfused, <92%, multilobar involvement, lactate > 2, social concern. immosup. curb/smartcop higher.
prevent:
- immunisation, smoking, exercise/mx obesity, medication review. reduce risk aspiration
atypical pneumo: legionella, mycoplasma, chlamydophillia.
RF: young adult/school aged. enviro/location. legionella often in aircon.
close community setting for mycloplasma.
rare in RACG.
Sx: persistent dry/bad coughfever. rash/headache. myalgia. >5 days Sx. , looks OK.
OE: creps B/L . not clearing w coughing like bronchitis
Dx: presumtive diagnosis. can do XR : bilateral lower zone infiltrates. suspcion, sero/urinary to confirm ,
Rx: monotherapy w doxy (100mg BD 5-7 days. ) +/- clarifthro.
(legionella: RF
; elderly, CLD, DM, CKD, immunocomp. doxy BD 10-14 days/azithro. )
pertussis
RF: community spread. < 6 month at risk.
Sx: persistent cough > 2 weeks. insp whoop, post tussive vomit, paroxysmal cough. ‘100 day cough’
Ix: NAAT PCR. sero less usefull.
Rx:
evidence of abx unclear in terms of altering cilnical course, do to reduce contagion. . . only Rx in first 3 weeks of Sx, after than unlikely infectious.
isolate until 5 days PO ABx.
prophylaxis same as Rx. for infants < 6 months, women in last month of pregnancy. infants who can transmit to others. contacts (1 m 1 hour).
azithro 500mg, then 250 od for 5 days.
TB
RF: epi RF + Immunocmop RF. travel. contact. HIV
Sx: undiagnosed febrile/wasting illness. persistent cough. haemoptysis. SOB. systemic Sx.
OE: look for meningitis/extrapulm sources also
Ix/Dx: CXR: upper lobe cavitating infection. AFB x3. mantoux/quant gold - specialist only.
Rx:
latent vs. active. can take years to be active.
kids less infectious.
pleural/miliary: less infectious.
long course abx for Rx either.
monitor LFT, BMI, colour vision throughout.
bronchiectasis
RF: pneumo as child, CF, copd, asthma. severe reps infections. think if recurrent or difficult to treat infections + psueo/h.influe on sputum culture. IBD.
airway inflammation and infection resulting in damage to airways. can be idiopathic.
Sx: chronic productive cough, recurrent infections. fatigue. SOB. pleuritic pain. can get haemoptysis in exacerbations.
OE: CLUBBING. coarse crackles w OK AE.
Ddx: aspergilosis, CF, cancer if haemotpysis/p[rogressive sob.
Ix; HRCT gold standard for Dx as CXR/PFT can be normal. . sputum mc=s for psuedo colonisation as changes abx choice
Rx: limit progression, optimise QOL
- pulm rehab. airway clearnce. action plan. imms, nutrition.
treat infections as per CAP but 10-14 days. rarely surgical removal of lung.
**no clubbing in CCF, COPD, asthma.**
bronchitis
self limiting LRTI. prod/non prod acute cough. can have URTI Sx also - 90% viral.
Sx: 2-3 week cough. 10% last up to 8 weeks as bronchial inflam. oingoing.
OE: well, sometimes w creps - clearing w coughing often. wheeze.
DDx: any cause of cough. inc cardiac. so if not better by 3 weeks then review / implement mx.
Dx: cough, prod/non prod, in presence of other signs LRTI: purulent sputum, sob, wheeze, chest discomfort, nasal cognestion, headche, fever.
CLD = usually diff.
Rx: antibiotics are not indicated as per cochrane review. day 7 only shorten by 12 hours even if WAS bact, and not viral - which 90% are.
asthma
Sx:suspect w wheeze/cough/sob/chest tightness
particularly if worse a night/early morning. occurs in response to allergen/cold/air/exercise. meds (aspirin/bblocker). recurrent.
OE: atopical exam : dark circles, nasal crease, mouth breathing, scattered wheeze. alelrgic rhinitis . hyperinflation.
Dx: reversible airway limitation; 10-15 mins after 2-4 SABA puffs.
- FEV1 increase by > 200mL and 12 % from baseline.
- exp airflow limitation (FEV1/FVC less than lower limit of normal for age and < 80% predicted FEV1).
- Rx trial response dependt on age.
Rx:
1- SABA: salb 2-4 puffs PRN. 100mcg/dose.
2 low dose ICS - ICS: flixotide fluticasone proprionate 50-100mcg BD. mod. 125-250. vs montelukast.
3- ICS/LABA: seretide 100+50mcg BD
4- medium ICS/LABA.
10-15 mins after 2-4 SABA puffs.
vs symcibort (LABA/ICS up to 12 puffs 200+6) PRN.
reduce ICS dose 25% every 2=3 months.
step up in exac by x 4 dose.
acute: IV mag sulphat 10mmol IV; salb IV; aminophylline IV.
PF/ILD
think occupational lung disease/hypersensitivity/multisystemm (IBD, CTD, sarcoid)/eosinophillic
RF: > 65 for idiopathic PF. occ / bird/irritatant expsure. CTD/IBD. drugs. smoking.
Sx: SOBOE. dry cough.
OE: crackles. clubbing.
Ix: restrictive on PFTs. FVC reduced, normal/reduced FEV1 so ratio is INCREASED. HRCT helps diagnosis. CXR can be normal.
always do autoimmune bloods.
asbestosis: NSCLC + mesothelioma are sequalaie. chronic progressive dyspnoea
Rx: progressive often. avoidance. MDT. pulma rehab. lung trnasplant.
specialist referral.
imms
smoking cessation.
consider oxygen.
COPD
C-onfirm Dx
O-ptimise function
P-prevent deterioration
D- develop a plan
X- manage exac.
progressive. gradual decline. exacerbations.
consider in > 35, SOB/cough/sputum. and current/ex smoker. occupation hx important.
Dx:
1) FEV1< 80%
2) NON REVERSIBLE post bronchodilator (no response FEV1/FVC
3) reduced FVC
4) post bronchodilator FEV1/FVC < 0.7… can still have a >200mL change but < 12% change otherwise Rx as asthma (ICS sooner)
MIL 60-80% FEv1.
MOD 40-59%
SEV <40%
OE: hyperinflation lungs. reduced chest exp. hyperresonant PN. soft BS. R heart failure. barrel chest. accessory muscle use.
Rx
pulm rehab
action plan + self mx
immunisations: PCV/influenza/covid.
cease smoking
exercise 150min /122k
nutrition
comorbiditis: hyperchol, inc. BSL, HTN. atherosclerosis.
Rx:
PRN bronchodilator SABA or SAMA
then LABA (serevent acculhaler. (LAMA incruse ellipta = umicllindium.
then LABA/LAMA.
LABA/LAMA/ICS if > 2 exac in 12 months.
exac:
- 4-8 puffs MDI spacer SABA.
- oral pred 30-50mg for 5 days
abx: if increase purulence, increased vol/change in colour AND fever. amoxyl 500mg TDS or doxy 100mg 5 days.
bronchiolitis
RF < 6-12 months. otherwise not bronch. RSV.
Sx: urti. wheeze/incrased wob
worsen day 2-3, 7-10 day duration
OE: increased RR/wob/insp crackles widespread.
Ix: no specific, cxr if concerned pneumo ontop
Mx: reassure, educate
small frqeuent feeds
may need O2/ED for support. hosiptal w feeding if unable. CPAP if bad. no evidence for salbutamol.
croup
RF for bad: previous unexpected ED, < 6 months, preexisting airway problem. hx severe.
Sx: 6mo-6 year
hoarse, stridor, brassy barking cough. variable airway obstruction. can then get the post infectious cough for weeks. can just get spasmotic cough withou tother Sx
Ix: nil required. minimise handline
Rx:
minimise handlind. keep child w parent to reduce stress. keep child calm/position themselves.
mild: 1mg/kg pred stat. if not improved 30 mins = Rx as severe
severe: adrenaline 1mg/mL x 5mL neb, repeat 30 mins. pred/dex + repeat 24 hours.
kid: protracted bacterial bronchitis
Sx: chronic wet cough > 4 weeks. concurrent wheeze/rattly breathing.
Ix: bronchoscopy may assist. but unecessary. CXR usually no specific
Rx: 2=6 week ABx course: Aug DF 20mg/kg BD.
mostly Sx improve at 1-2 course.
asthma ICS spiel
○ Use every day to be effective.
○ Educate about inhaler technique.
○ Common for parents to care about the potential growth suppression caused by ICS.
○ Poorly controlled asthma is also associated with growth suppression, and benefit of good asthma control outweighs risk of growth suppression related to ICS
- ICS does have a small effect on growth velocity. dose dependent. Most pronounced during first year of Rx. (Cochrane = -0.48cm… / year), should return to normal within a few years or starting on ICS.
- Only 1 study found adult height was 1.2cm lower in patients using ICS compared w placebo.
Need more evidence to clearly recommend one ICS over another.
Keep in mind that although the corticosteroid therapy can cause adrenal suppression and reduce BMD, these effects are unlikely at the low dose used for ICS in children.
OSA
RF: obesity, neck circ, airway abnormality, increased age, T2Dm, alcohol/sedative use, HTN. male, FHx
Sx: unrefreshing sleep, tiredness, fatigue, poor concentration, low mood, daytime sleepiness, wtiness apnoea/snoring. morning headache.
OE: adenotsonailar hypertrophy. , BMI > 30, HTN, depression, jaw position, neck cric, tongue size, uvula palate.
Ix: STOPBANG/OSA50/ESS. sleeps study
Dx: AHI > 5
mod / severe > 15
Rx:
lifestyle, wt loss. less sedatives. smoking cessation.a void supine sleep. exercise regularly.
driving / occupational risk
CPAP
mandibular splint
positional therapy device
o/p surg.
SPIRO
repeat 10-15 mins after 4 salb doses via spacer.
record the best FEV1 and FVC obtained.
repeat the test until you obtain 3 reproducible and acceptable measures:
- FVE of 2 highest readigns dose not vary by more than 150mL
- manoeuvre performed with a good start
- forced exp has been maintained throughout the test
- patient did not cough during the first second of the test.
most people dont tol. more than 8 attempts.
PUFFER
TURBIHALER
(SYMBICORT)
1) lid off, hold vertical
2) check dose counter
3) twist base one way, then back the other until you hear it click
4) breath out away from turbihaler
5) mouth over top, still upright
deep breath in, lips seated.
hold breath 5 seconds.
6) breath out separately
7) rinse mouth pos dose.
PUFFER
ACCUHALER
(CIRCLE - SERVENT + SERETIDE)
1) open cover using thrumb clip
2) holding horizontal, slide level until it clicks
3) breath out separately
4) deep breath in w mouth over mouthpeice.
5) hold for 5-10 seconds
6) breathe out gently away.
7) close to click shut.
8) repeat same steps if needed.
9) rinse mouth. out + wipe mouth piece w dry tissue
PUFFER: RESPIMAT
(SPIRIVA) fancy preloaded stream one.
A) preload cannister (pharamcist does). make sure its primed.
b) hold upright
c) turn base in direction of red arrow until you hear it click
c) remove cap
d) hold vertically whole time.
e) breath out separately
f) lips over mouth piece - dont cover vents
g) start to breath in and press button.
h) cont to breath in slowly and deeply
i) hold 5-10 seconds
j) breath out separately
h) close cap. then repeat
PUFFER: HANDIHALER
looks like an egg w only 1 sided lever.
spiriva e.g.
1) open cover, then open mouth piece
2) remove capsule from foil
3) place capsule in mouth piece hold/hole
4) close mouth piece w a cick
5) holding up right - then pierce the capsule w a green button.
6) breathe out away from mouth piece
7) seal lips around mouth peice, breath in slowly and deeply,holding 5-10
8) breathe out separately.
9) repeat a second time to make sure its an empty capsule.
PUFFER: ELLIPTA
(the one you use).
e.g. trelegy.
1) open up until you hear click.
2) check counter.
3) keep vertical
4) breath out away
5) seal lips, breathe in, hold 5-10 seconds.
6) breath out gently away from device.
7) rinse mouth.
8) dry tissue to mouth piece to clean.
PUFFER: GENUAIR
(looks like a highlighter)
1) remove cap
2) upright + horizontal
3) press down button at the back + release (makes the front window go green, check dose counter aboev)
4) breathe out away, lips sealed - breath in strongly + deeply and will hear it click. cont breathing in. hold for 5-10seconds. braeth out away.
5) check its gone to red.
6) wipe mouth peice w tissue. + replace cap.
PUFFER: BREEZHALER
(bilateral buttons, tablet)
(e.g. ultibro)
1) take off cover, open mouth piece also
2) remove capsule from foil
3) place capsule in the compartment
4) close mouth piece.
5) tap gently on table to make sure it setles in the hole
6) press in buttons
7) breathe out separately
8) mouth seal, breath quickly + deeply, will hear a whirring sound, hold 5-10 seconsds
9) breath out gently away from mouthpeice.
10) do again to make suer capsule is empty.
11) take out capsule and discarg.
PUFFER: Raphihaler
(MDI)
can get symbicort.
still need to click in the top bit.
- best used w spacer
- cap off by pressing on both sides to remove cover.
- shake a few times.
- breath out separately
- mouth seal.
- as breathign in, press down the top. to breath in slowly and deeply. hold 5-10 seconds.
- breath out away from device.
PUFFER: Spiromax
fancy coloured cap.
(duoresp = can get symbicort)
- hold upright
- open mouth piece cover until hear a loud click
- breathe out away from device
- mouth seal
- deep breath in, hold 5-10 seconds.
- remove inhaler from mouth + breathe away seaprately
- close cover.
- always check counter.
PUFFER - autohaler
QVair
has the lever up top
- hold uprigh.
- shake
- level up.
- mouth on.
- deep breath + will hear click
- breath out separate.
