Resp II Flashcards
Which type of organisms are most likely to cause HAP? [1]
Which infective organisms are most likely to cause HAP? [4]
Gram negative organisms:
PEKA:
Pseudomonas aeruginosa,
Escherichia coli
Klebsiella pneumoniae
Acinetobacter species.
Which organisms are most likely to cause atypical pneumonias? [5]
TOM TIP: You can remember the 5 causes of atypical pneumonia with the mnemonic: “Legions of psittaci MCQs”:
Legions: Legionella pneumophila
Psittaci: Chlamydia psittaci
M – Mycoplasma pneumoniae
C – Chlamydophila pneumoniae
Qs – Q fever (coxiella burnetii)
State 4 clinical consequences of untreated Mycoplasma pneumonia [4]
Haemolytic anaemia
Erythema multiforme
Encephalitis
Peri / myocarditis
How do you treat Mycoplasma pneumonia? [2]
1st line:Erythromycin OR Clarithromycin
2nd line: Doxycycline or a macrolide (e.g. )
Because generally there is no diagnosis of the pathogen at the time of treatment, initiation of the treatment is usually empirical
BMJ BP
State and describe this complication of Mycoplasma pneuomia [2]
bullous myringitis: painful vesicles on the tympanic membrane
What clinical presentation may indicate COVID caused pneuomonia? [1]
Silent hypoxia: Patients may not feel particularly short of breath despite having low oxygen saturations
Alongside CURB65, describe which test is sometimes used to determine Abx therapy in the primary care setting [3]
NICE also mention point-of-care CRP test. This is currently not widely available but they make the following recommendation with reference to the use of antibiotic therapy:
CRP < 20 mg/L - do NOT routinely offer antibiotic therapy
CRP 20 - 100 mg/L - consider a DELAYED antibiotic prescription
CRP > 100 mg/L - OFFER antibiotic therapy
Describe the treatment algorithm for mild / low severity CAP? [2]
First line: 5 day course
- Amoxicillin
- If if penicillin allergic: clarithromycin (macrolide) OR doxycycline (tetracycline)
Second line:
- No respond to amoxicillin monotherapy, consider adding, or switching to, a macrolide (e.g., clarithromycin).
Describe the treatment algorithm for confirmed CAP on chest x-ray: presenting in hospital | moderate-severity (CURB-65 = 2)?
7-10 day course is recommended
1st line:
- ORAL amoxicillin plus a macrolide: clarithomycin
- For patients who are allergic to penicillin in whom oral antibiotics are contraindicated: second-generation cephalosporin (e.g., cefuroxime) or a third-generation cephalosporin (e.g., cefotaxime or ceftriaxone)
PLUS
clarithromycin, or intravenous levofloxacin monotherapy
2nd line:
- Change to doxycycline or a fluoroquinolone: ciprofloxacin AND pneumococcal cover: levofloxacin or moxifloxacin
Describe the treatment algorithm for confirmed CAP on chest x-ray: presenting in hospital | high-severity (CURB-65 = 3-5)?
DOUBLE CHECK
1st line:
- A broad-spectrum beta-lactamase-resistant penicillin: amoxicillin/clavulanate plus a macrolide: clarithromycin
- If allergic to penicillin: second-generation cephalosporin (e.g., cefuroxime) or a third-generation cephalosporin (e.g., cefotaxime or ceftriaxone) PLUS a macrolide (e.g., clarithromycin)
2nd line:
- Doxycycline OR
- Cefalexin OR
- Trimethoprim
3rd Line:
- levofloxacin
BMJ BP
In patients with suspected or confirmed Staphylococcus aureus MRSA infection, what are the two treatments? [2]
IV Vancomycin
OR
IV teicoplanin
with or without
Rifampicin (orally or intravenously)
State the treatments for these atypical pneumonias [5]
A: Clarithromycin (orally or intravenously)
B: Fluoroquinolone (ciprofloxacin) (orally or intravenously)
C: Amoxicillin (orally) or
D: benzylpenicillin
(intravenously)
E: Doxycycline (orally)
In patients with suspected or confirmed Staphylococcus aureus non-MRSA infection, what are the two treatments? [2]
Flucloxacillin (intravenously)
with or without
Rifampicin (orally or intravenously)
What is the treatment algorithm for mild to moderate symptoms/signs and not at higher risk of resistance for HAP? [2]
How long for? [1]
5 day prescription
ORAL:
- amoxicillin/clavulanate (aka Co-amoxiclax)
- If allergic: Doxycycline
Cefalexin (use caution in penicillin allergy)
Trimethoprim/sulfamethoxazole
NICE
What is the treatment algorithm for severe symptoms/signs and not at higher risk of resistance for HAP? [2]
How long for? [1]
1st line:
- piperacillin/tazobactam OR
- ceftazidime OR
- cefuroxime OR
- meropenem
2nd line:
- levofloxacin
Label the progress expected post-pneumonia from 1 week - 6 months
1 week:
- Fever should have resolved
4 weeks:
- Chest pain and sputum production should have substantially reduced
6 weeks:
- Cough and breathlessness should have substantially reduced
3 months
- Most symptoms should have resolved but fatigue may still be present
6 months:
- Most people will feel back to normal.
All patients with moderate-severe pneumonia should have what investigations? [3]
(NICE & BTS)
All in patients:
- CXR
- FBC (WCC raised; CRP raised)
- U&E
- LFTS
- Oxygen sats
Moderate-Severe:
- Blood and sputum culture
- Pneumococcal urinary antigen
- Legionella urinary antigen + sputum
All patients with severe + outbreaks of pneumonia should have what investigations? [3]
(NICE & BTS)
All in patients:
- CXR
- FBC (WCC raised; CRP raised)
- U&E
- LFTS
- Oxygen sats
Moderate-Severe:
- Blood and sputum culture
- Pneumococcal urinary antigen
- Legionella urinary antigen + sputum
Severe+:
- Mycoplasma PCR
- Chlamydophilia PCR
- Viral PCR
BTS guidelines:
What are the treatments for
S. aureus non-MRSA? [1]
S. aureus MRSA? [2]
S. aureus non-MRSA: flucloxacillin
S. aureus MRSA: vancomycin OR linezolid OR teicoplanin +/- rifampicin
State what is meant by Lofgren’s syndrome [1]
How does Lofgren’s syndrome usually present? [4]
Lofgren’s syndrome is an acute form of the disease characterised by:
- bilateral hilar lymphadenopathy (BHL)
- erythema nodosum
- fever
- polyarthralgia.
It usually carries an excellent prognosis
Explain what is meant by Heerford’ts syndrome [1]
What is the classical presentation? [3]
Heerfordt’s syndrome (uveoparotid fever) there is parotid enlargement, fever and uveitis secondary to sarcoidosis
Describe the clinical features of sarcoidosis if each of the following are effected:
- Skin [3]
- Lungs [3]
- Systemically [3]
Skin:
- Erythema nodosum - raised, red, tender painful subcut nodules across both shins. Over time they appear as bruises
- Papular sarcoidosis: multiple papules develop, generally on the head and neck or areas of trauma.
- Lupus pernio: specific to sarcoidosis and presents with raised purple skin lesions, often on the cheeks and nose.
What treatment might be given to for treating skin sarcoid? [1]
Hydroxychloroquine
a prolonged PR interval
Describe the classic triad of yellow nail syndrome [3]
- Yellow fingernails
- Bronchiectasis
- Lymphoedema
TOM TIP: Yellow nail syndrome is characterised by yellow fingernails, bronchiectasis and lymphoedema. Patients are stable and have good clinical signs, making it a good choice for OSCEs. As it is rare, examiners will score high marks if you can combine these features and name the diagnosis.
Asides from imaging investigations, describe what else you would investigate for bronchiestasis [7]
Sputum culture
- Most commonly Haemophilus influenzae and Pseudomonas aeruginosa
FBC:
- may reveal high eosinophil count in bronchopulmonary aspergillosis
specific IgE or skin prick test to Aspergillus fumigatus
serum alpha-1 antitrypsin phenotype and level
serum immunoglobulins
- to identify individual immunoglobulin deficiencies as underlying aetiology
Rheumatoid factor
Serum HIV antibody
Describe the treament algorithm for bronchiestasis for the initial presentation? [5]
initial presentation
1ST LINE: exercise and improved nutrition.
- Including vitamin D supplementation
- Higher BMI has beneficial outcomes
- Excercise is considered form of airway clearance
PLUS –
airway clearance therapy (ACT):
- maintenance of oral hydration; percussion, breathing, or coughing strategies
- positioning and postural drainage; positive expiratory pressure devices; and oscillatory devices
- recommended for 15 to 30 minutes, 2 or 3 times daily
PLUS –
self-management plan
CONSIDER –
inhaled bronchodilator:
- salbutamol inhaled
CONSIDER –
mucoactive agent
- hypertonic saline
BMJ BP
acute exacerbation: mild to moderate underlying disease if is first or new presentation of Pseudomonas aeruginsoa
1ST LINE –
short-term oral antibiotic:
- For adults, prescribe amoxicillin 500 mg three times a day for 7–14 days
PLUS –
increased airway clearance
PLUS –
continued maintenance therapy:
- Healthy diet & exercise
- Higher BMI
- Nebulised bronchodilators
- Nebulised hyperosmolar agents, such as hypertonic saline,
Describe how treatment for bronchiectasis would be escalated in a stepwise manner if they were suffering ≥ 3 exacerbations in one year despite following the initial management?
3 or more exacerbations per year despite maintenance therapy
1ST LINE –
reassess physiotherapy ± mucoactive treatment
PLUS –
continued maintenance therapy
- Azithromycin 500 mg three times a week, or
- Azithromycin 250 mg daily, or
- Offer a minimum of 6 months treatment, but up to 1 year may be required.
CONSIDER –
long-term antibiotic
CONSIDER –
surgery:
- Surgical resection is considered in patients with localised disease whose symptoms are not controlled by optimal medical treatment
- Complete resection of the bronchiectatic area is associated with the best results
CONSIDER –
treatment of respiratory failure
A patient is diagnosed with bronchiestasis. Subsequent sputum sampling diagnoses them the infective agent as Streptococcus pneumoniae. What is the approriate first line treatment
- Co-amoxiclav 625 mg three times daily
- Amoxicillin 500 mg three times daily
- Flucloxacillin 500 mg four times daily
- Doxycycline 100 mg twice daily PLUS rifampicin (for adults)
- Ciprofloxacin 500 or 750 mg twice daily
Amoxicillin 500 mg three times daily
A patient is diagnosed with bronchiestasis. Subsequent sputum sampling diagnoses them the infective agent as Haemophilus influenzaebeta lactam negative. What is the approriate first line treatment
- Co-amoxiclav 625 mg three times daily
- Amoxicillin 500 mg three times daily
- Flucloxacillin 500 mg four times daily
- Doxycycline 100 mg twice daily PLUS rifampicin (for adults)
- Ciprofloxacin 500 or 750 mg twice daily
A patient is diagnosed with bronchiestasis. Subsequent sputum sampling diagnoses them the infective agent as Haemophilus influenzae. What is the approriate first line treatment
- Co-amoxiclav 625 mg three times daily
Amoxicillin 500 mg three times daily
- Flucloxacillin 500 mg four times daily
- Doxycycline 100 mg twice daily PLUS rifampicin (for adults)
- Ciprofloxacin 500 or 750 mg twice daily
A patient is diagnosed with bronchiestasis. Subsequent sputum sampling diagnoses them the infective agent as Haemophilus influenzae (beta-lactamase positive). What is the approriate first line treatment
- Co-amoxiclav 625 mg three times daily
- Amoxicillin 500 mg three times daily
- Flucloxacillin 500 mg four times daily
- Doxycycline 100 mg twice daily PLUS rifampicin (for adults)
- Ciprofloxacin 500 or 750 mg twice daily
Co-amoxiclav 625 mg three times daily
A patient is diagnosed with bronchiestasis. Subsequent sputum sampling diagnoses them the infective agent as Pseudomonas aeruginosa. What is the approriate first line treatment
- Co-amoxiclav 625 mg three times daily
- Amoxicillin 500 mg three times daily
- Flucloxacillin 500 mg four times daily
- Doxycycline 100 mg twice daily PLUS rifampicin (for adults)
- Ciprofloxacin 500 or 750 mg twice daily
A patient is diagnosed with bronchiestasis. Subsequent sputum sampling diagnoses them the infective agent as Pseudomonas aeruginosa. What is the approriate first line treatment
- Co-amoxiclav 625 mg three times daily
- Amoxicillin 500 mg three times daily
- Flucloxacillin 500 mg four times daily
- Doxycycline 100 mg twice daily PLUS rifampicin (for adults)
- Ciprofloxacin 500 or 750 mg twice daily
A patient is diagnosed with bronchiestasis. Subsequent sputum sampling diagnoses them the infective agent as Klebsiella. What is the approriate first line treatment
- Co-amoxiclav 625 mg three times daily
- Amoxicillin 500 mg three times daily
- Flucloxacillin 500 mg four times daily
- Doxycycline 100 mg twice daily PLUS rifampicin (for adults)
- Ciprofloxacin 500 or 750 mg twice daily
A patient is diagnosed with bronchiestasis. Subsequent sputum sampling diagnoses them the infective agent as Klebsiella. What is the approriate first line treatment
- Co-amoxiclav 625 mg three times daily
- Amoxicillin 500 mg three times daily
- Flucloxacillin 500 mg four times daily
- Doxycycline 100 mg twice daily PLUS rifampicin (for adults)
- Ciprofloxacin 500 or 750 mg twice daily
[] is the usual choice for infective exacerbations caused by Pseudomonas aeruginosa
Ciprofloxacin is the usual choice for exacerbations caused by Pseudomonas aeruginosa
State 5 common causes of T1RF [6] (and the cause of hypoxia)
Diffusion abnormality:
- Pulmonary fibrosis
- Emphysema in COPD
V/Q mismatch: reduced V
- Pneumonia
- Pulmonary oedema
- Pneumothorax
V/Q mismatch: reduced Q
- Pulmonary embolism
Low inspired oxygen
Hypxoxia = increased V
More CO2 exhaled
Hypoxia but not hypercapnic
What are common causes of chronic T2FR? [5]
Obstruction to airways:
* COPD
* Severe asthma
Hyperexpanded lungs:
- COPD
Thoracic cage problems:
- Kyphoscoliois
- Obesity
Weakness of resp. muscles
* Chronic neurological disorders (e.g. motor neuron disease)
* Chronic neuromuscular disorders (e.g. myopathies)
Which of the following would this CXR cause hypoxaemia?
V/Q mismatch
Shunt
Diffusion limitation
Hypoventilation
Increased dead space
Lobar pneumonia causing V/Q mismatch
Out of which of the following would this CXR cause hypoxaemia?
V/Q mismatch
Shunt
Diffusion limitation
Hypoventilation
Increased dead space
Diffusion abnormality: patient has sarcoidosis
Out of which of the following would this CXR cause hypoxaemia?
V/Q mismatch
Shunt
Diffusion limitation
Hypoventilation
Increased dead space
Hypoventilation: patient has TB
Out of which of the following would this CXR cause hypoxaemia?
V/Q mismatch
Shunt
Diffusion limitation
Hypoventilation
Increased dead space
Hypoventilation: lobar collapse
Out of which of the following would this CXR cause hypoxaemia?
V/Q mismatch
Shunt
Diffusion limitation
Hypoventilation
Increased dead space
Diffusion limitation:
Pulmonary fibrosis
Out of which of the following would this CXR cause hypoxaemia?
V/Q mismatch
Shunt
Diffusion limitation
Hypoventilation
Increased dead space
Hypoventilation: COPD
Can be T1 or T2RF
Out of which of the following would this cause hypoxaemia?
V/Q mismatch
Shunt
Diffusion limitation
Hypoventilation
Increased dead space
Hypoventilition: motor neuron disease - can’t use muscles / diaphragm to breathe
Out of which of the following would this CXR cause hypoxaemia?
V/Q mismatch
Shunt
Diffusion limitation
Hypoventilation
Increased dead space
VQ mismatch: pneumothroax
Out of which of the following would this cause hypoxaemia?
V/Q mismatch
Shunt
Diffusion limitation
Hypoventilation
Increased dead space
Morbid obesity: hypoventilation
Out of which of the following would this CXR cause hypoxaemia?
V/Q mismatch
Shunt
Diffusion limitation
Hypoventilation
Increased dead space
Shunt: eisenmenger syndrome
How do you manage acute T2RF? [4]
Controlled oxygen:
- 0.5 - 2l/min via nasal cannulae
- 24 to 28% masks using venturi valves
Regular ABG to monitor CO2 levels
Consider non-invasive ventilation (BIPAP) if pH and CO2 dont improve
Go over BIPAP - is this correct?
Which inherited disorders increase the risk of PE? [5]
Factor V Leiden mutation:
- Normally used for blood clotting: helps enzyme reaction to form fibrin in blood clot
- Once the coagulation process is turned on in people with factor V Leiden, it turns off more slowly than in people with normal factor V
Antithrombin deficiency
- Normally anti-thrombin acts as the inhibitory component to thrombin formation
Prothrombin deficiency
Protein C & S deficiencies
Antiphospholiipid syndrome
Describe the treatment algorithm for patients who have PE confirmed and are haemodynamically unstable [4]
First line:
- heparin: 10,000 units intravenously as a loading dose initially, followed by 18 units/kg/hour intravenous infusion
PLUS: thrombolysis: (involves injecting a fibrinolytic (breaks down fibrin) medication that rapidly dissolves clot)
- Alteplase or
- Streptokinase or
- Urokinase
PLUS:
- anticoagulation with unfractionated heparin (UFH) for several hours after the end of thrombolysis before: switching to apixaban or rivaroxaban; low molecular weight heparin (LMWH) is an alternative if these are unsuitable - this is preferable
CONSIDER: vasoactive drug if SBP < 90 mmHG after thrombolysis
- noradrenaline or
- dobutamine
-
Describe the treatment algorithm for patients who have PE confirmed and are haemodynamically stable [4]
Stable, no renal impairment or co-morbidities: offer apixaban/rivaroxaban. If not-suitable, LWMH for 5 days then offer edoxaban/warfarin*
First line: anticoagulation:
- apixaban or
- rivaroxaban
OR
- UFH / LMWH / Fondaparinux lead AND warfarin
- Target INR 2-3 then stop heparin
Describe three subacute complications of PE
Infarction and lung necrosis
- PE can cause ischemic injury to the lung parenchyma, leading to pulmonary infarction, haemorrhage, or lung necrosis.
Pleural effusion:
- Inflammatory processes triggered by PE may cause pleural effusion, which may be exudative or hemorrhagic.
Pneumothorax:
- Rarely, PE-induced lung infarction may lead to pneumothorax due to the rupture of a bulla or necrotic lung tissue
PE would cause change to axis deviation? [1]
Right axis deviation
Which of the following is used to treat chronic PEs unresolved after 3 months
- Embolectomy
- Mechanical fragmentation with R heart angiography
- Pulmonary thombro-endarterectomy
- IVC filter
Pulmonary thombro-endarterectomy (PTE)
Describe the different bridging times for LMWH if using:
- Warfarin
- Dabigatran or edoxaban
- Rivaroxaban or apixaban
Warfarin:
- Start LMWH and initiate warfarin at same time then after 5-10 days change to just warfarin
Dabigatran or edoxaban
- 5 days of LMWH with both then switch to doac same day
Rivaroxaban or apixaban
- No bridge - only use them
Describe the diagnostic pathway for PEs
