Resp IV Flashcards
Which inherited diseases can cause bronchiectasis? [4]
- (Alpha-1-antitrypsin deficiency)
- Connective tissue disorders (e.g., rheumatoid arthritis)
- Cystic fibrosis
- Yellow nail syndrome
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.
Describe the classical signs of bronchiectasis [5]
- Scattered crackles throughout the chest that change or clear with coughing
- Scattered wheezes and squeaks
- Sputum pot by the bedside
- Oxygen therapy (if needed)
- Weight loss (cachexia)
- Finger clubbing
- Signs of cor pulmonale (e.g., raised JVP and peripheral oedema)
When taking a history and examining the patient, it is also important to consider other systems of the body too, as these may reveal co-morbid conditions associated with the development of bronchiectasis
.
Which do these include? [4]
Joints:
- RA
GI:
- IBD
- Cystic fibrosis
- GORD
Sputum culture is used to identify colonising and infective organisms. The most common infective organisms are? [2]
Haemophilus influenza
Pseudomonas aeruginosa
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
TOM TIP: The key features to remember with bronchiectasis are [4]
TOM TIP: The key features to remember with bronchiectasis are finger clubbing, diagnosis by HRCT, Pseudomonas colonisation and extended courses of 7-14 days of antibiotics for exacerbations.
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
When giving long term antibiotic therapy to those with bronchiestasis, if people have concurrent Pseudomonas aeruginosa infection, first-line therapy is []
inhaled colistin.
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
Which vaccines are recommonded for bronchiestasis? [2]
Vaccines (e.g., pneumococcal and influenza)
[] is the usual choice for infective exacerbations caused by Pseudomonas aeruginosa
Ciprofloxacin is the usual choice for exacerbations caused by Pseudomonas aeruginosa
How long are the extended course of Abx for infective exacerbations? [1]
Extended courses of antibiotics, usually 7–14 days
Cardiac tamponade
This CXR causes hypoxia due to which underlying mechanism
V/Q mismatch
Shunt
Diffusion limitation
Hypoventilation
Increased dead space
This CXR causes hypoxia due to which underlying mechanism
V/Q mismatch
This CXR causes hypoxia due to which underlying mechanism
V/Q mismatch
Shunt
Diffusion limitation
Hypoventilation
Increased dead space
Pneumothorax causing V/Q mismatch
Describe what is meant by low and high V/Q mismatch in hypoxia [2]
State what could cause each [2]
Hypoxaemia usually caused by:
Low V/Q:
- alveoli with poor ventilation compared to perfusion
- Caused by: airway disease or interstitial lung disease where ventilation is reduced
- Therefore, hypxoxia induced v/c occurs and redirects blood to better ventilated areas
High V/Q:
- Poor perfusion c.f ventilation
- Caused by: PE
State 4 conditions that cause pulmonary shunts [4]
pneumonia
ARDS
pulmonary oedema
alveolar collapse
What is meant by diffusion limitation (causing hypoxia?)
Describe two pathophysiological causes of diffusion limitation [2]
Diffusion limitation refers to the impairment of gaseous exchange across the alveolocapillary membrane.
Causes:
Reduced surface area:
- reduced surface area of alveoli due to pathological destruction limits the amount of lung tissue available for gaseous exchange.
Alveolocapillary membrane changes:
- inflammation and fibrosis of the alveolocapillary membrane impairs diffusion across it.
Describe what is meant by increased dead space causing hypoxaemia [1]
Areas of the lung that are ventilated but not perfused and therefore do not contribute to gaseous exchange.
(It can be thought of as an extreme V/Q mismatch and the opposite of a shunt)
Name two pathologies that cause increased dead space [2]
emphysema (COPD) and interstitial lung disease destroying pulmonary capillaries
What is the most common cause of T1RF? [1]
V/Q mismatch
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
T2RF is seen in conditions that cause what changes to alveoli? [1]
T2RF is seen in conditions that result in alveolar hypoventilation.
What are common causes of acute T2FR? [5]
Exacerbations of obstructive lung disease:
* COPD (most common)
* Severe asthma
* Cystic fibrosis
* Bronchiectasis
Respiratory depressants (e.g. opiate overdose)
Acute T2RF: failure of ventilation
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)
What type of hypoxia does scoliosis cause? [1]
Hypoventilation (get smaller diaphragm working)
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
Hypoventilaton:
State pathologies that cause
Obstruction to airways [2]
Hyper-expanded lungs [1]
Thoracic cage problems [2]
Weakness of respiratory muscles [2]
Obstruction to airways
- COPD
- Asthma
Hyper-expanded lungs:
- COPD
Thoracic cage problems
- Kyphoscoliosis
- Thoracoplasty
- Obesity
Weakness of respiratory muscles
- MND
- MD
V/Q mismatch:
State causes for:
- Area of lung perfused but not ventilating (airspaces filled with fluid [2]; lung collapsed [2] )
- Area of lung ventilated, but not perfused (2)
Area of lung perfused but not ventilating:
- airspaces filled with fluid: pneumonia; pulmonary oedema
- lung collapsed: pneumothorax; lung collaspe
Area of lung ventilated, but not perfused: PE; shock
Explain why diffusion abnormalities cause hypoxia but not hypercapnia [2]
In diffusiin abnormalities: ventilation is normal, but a barrier to the transer of oxygen from alveoli to blood stream
- Hypoxia leads to increased ventilation
- More CO2 is exhaled
- Creates hypoxia but not hypercapnia
Which of the following causes hypercapnia
V/Q mismatch
Shunt
Diffusion limitation
Hypoventilation
Increased dead space
Which of the following causes hypercapnia
V/Q mismatch
Shunt
Diffusion limitation
Hypoventilation
Increased dead space
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?
