Respiratory 1 Flashcards
Classification of asthma
PEFR
Speech
RR
Pulse
Moderate, severe, life threatening
PEFR 50-75%, 33-50%, <33%
Speech - normal, can’t complete sentences, silent chest
RR <25, >25, feeble respiratory effort
Pulse <110, >110, exhaustion
Life threatening signs (5)
sats <92%, normal CO2, bradycardia, dysrhythmia, hypotension
Mx acute asthma in secondary care
- SABA
- Ipratropium bromide
- IV magnesium sulphate
- IV aminophylline
Prednisolone 40-50mg
Criteria for discharge following asthma admission (3)
PEFR >75% of best or predicted
Off nebs for 12-24 hours
Inhaler technique
Bronchitis disease course
Sx 4
Don’t bother
3 weeks with cough for longer
Cough, sore throat, rhinorrea, wheeze
How to differentiate between pneumonia and bronchitis?
Symptoms
Signs
Sputum, wheeze, SOB in pneumonia
O/E: systemic features in pneum
Bronchitis Mx (3)
Analgesia
Fluid intake
Abx if CRP 20-100 - doxy
Acute exacerbation of COPD common bacteria (3)
H. influenza
Strep pneum
Moraxella catarrhalis
Mx COPD
(2)
Abx of choice (3)
Increase SABA
Pred 30mg OD 5/7
Abx - amoxi/ clarithro/ doxy
A1AT (alpha 1 antityrpsin deficiency) what is it?
Chromosome location
Emphysema/ COPD in young non smokers
Chrm 14
Features A1AT deficiency
(Impacts two organs)
Lungs - panacinar emphysema in lower lobes
Liver - cirrhosis and HCC in adults, cholestasis in children
A1AT - what do you see on spirometry?
Spirometry = obstructive
Prevention
Treatment of AMS (acute mountain sickness) (1)
Medication (1)
How much altitude can you gain per day (1)
Acetozolamide
Descent
500m per day
Gas findings with acute mountain sickness
Metabolic acidosis
Compensatory respiratory alkalosis
Increases RR and improves oxygenation
Acute mountain sickness can develop into? (2)
HAPE and HACE - high altitude pulmonary oedema and cerebral oedema
Mx HACE (2)
Descent
Dexamethasone
Mx HAPE (4)
Descent
Nifedipine, dex, acetazolamide, oxygen
Most common form of asbestos related lung disease
When do they form?
Pleural plaques
Latent period of 20-40 years
What is asbestosis?
When?
Don’t bother
Typically causes lower lobe fibrosis
15-30 years post exposure
Malignant disease from asbestos
Most dangerous form
Mesothelioma
Crocidolite blue
Mx mesothelioma
Prognosis
Palliative chemo
Poor prognosis 8-14 months
Mx mesothelioma
Prognosis
Palliative chemo
Poor prognosis 8-14 months
Diagnostic tests for asthma (3)
Hint: classified by age
<5yo
5-16yo
>16yo
< 5yo clinical judgement
5-16 - spirometry with bronchodilator reversibility test
>16 - spirometry with bronchodilator reversibility test + FeNO test
FeNO interpretation
adults = > 40 positive
children => 35 positive
Spirometry interpretation
FEV1/FVC ratio < 70% = obstructive
Reversibility test - if FEV1 has improved by ? in a volume of ?
Positive if FEV1 has improved by 12% or more in a volume of 200mls of more
Chronic asthma adults mx (7)
- SABA
- SABA + ICS
- SABA + ICS + leukotriene receptor antagonist (LTRA)
- SABA + ICS + LABA (if LTRA effective then to continue)
- SABA +/- LTRA + MART with low dose ICS
- SABA +/-LTRA + MART with medium dose ICS
- SABA +/-LTRA
AND
MART with high dose ICS
OR
LAMA
OR
Theophylline
What is a MART
ICS and LABA
Low medium and high dose ICS
What are the doses
<= 400mcg
400-800
>800
When to refer an asthmatic patient to secondary care? (3)
How many courses of steroids?
What step on the pathway
How many prescriptions in 1 year
> 2 courses of steroids in 12 months
On step 4 of tx pathway
12 SABA prescriptions in 1 year
Occupational asthma common cause
Isocyanates (spray paint and foam moulding)
How often should we consider stepping down treatment for asthma?
How much do you reduce steroids by?
Every 3 months
25-50% at a time
What is bronchiectasis?
Permanent dilatation of the airways secondary to chronic infection or inflammation
Mx bronchiectasis (3)
Physio
Postural drainage
Immunisations
Bronchiectasis common causes (4)
H. influenza
Psuedomonas aeruginosa
Klebsiella
Strep pneum
Suspected COPD Ix (3) and expected results of each
- post bronchodilator spirometry: FEV1/FVC <70%
- CXR hyperinflation, bullae, flat hemidiaphragm
- FBC - to r/o polycythaemia
Severity of COPD (stages)
Post-bronchodilator FEV1/FVC
FEV1 (of predicted)
FEV1 of predicted
Stage 1 Mild >80
Stage 2 Moderate 50-79
Stage 3 Severe 30-49
Stage 4 Very severe <30
Post bronchodilater ratio
FEV1/FVC < 0.7 for all
LTOT criteria (5)
FEV1 ?
Consider at FEV1 of
FEV1<30% predicted
Consider if 30-49%
Cyanosis
Polycythaemia
Peripheral oedema
Raised JVP
Sats <92%
What pO2 to offer LTOT?
pO2 of ?
Or p O2 of with (3)
How many ABGs are needed and how far apart? Whilst on what?
pO2 <7.3
7.3-8 with either:
secondary polycythaemia
peripheral oedema
pulmonary hypertension
x2 ABG need to have been done three weeks apart whilst on optimum COPD treatment
Smoking and LTOT
Do not offer LTOT to people who continue to smoke following:
1. Being offered smoking cessation advice rx
2. Referral to specialist stop smoking services
LTOT risk assessment (2)
- Risk of falls from tripping over equipment
- Risk of burns and fires for those that live with someone who smokes
COPD general mx (4)
Smoking cessation advice
Influenza vaccine annual
One off pneumococcal vaccination
Pulmonary rehabilitation
Mx COPD (4)
2nd step is determined by?
- SABA OR SAMA
2nd step is determined by whether the patient has asthmatic features/ features suggesting steroid responsiveness
NO asthmatic features:
2. add LABA + LAMA
Asthmatic features
2. LABA+ICS
All patients
3. LABA+ICS+LAMA
4. PO theophylline
When should a theophylline dose be reduced? (2) (which two types of abx)
If on macrolides or fluoroquinolone abx
Prophylactic abx of choice in COPD
Azithromycin
Churg Strauss correct name
What is it?
Eosinophillic granulomatosis with polyangitis
Small to medium vessel vasculitis
Eosinophillic granulomatosis with polyangitis
Features (4)
ANCA type
Asthma
Eosinophillia
Paranasal sinusitis
Mononeuritis multiplex
pANCA
Way to remember - Patrick –> cat, breathes funny –> asthma, wet nose –> sinusitis –> Patrick there P-ANCA
Wegener’s correct name
Granulomatosis with polyangitis
Granulomatosis with polyangitis
What is it?
Impacts which organs? (2)
ANCA
Vasculitis
Lung and kidney
c-ANCA
Granulomatosis with polyangitis/ Wegeners
Features (5)
Epistaxis
Nasal crusting
Haemoptysis
Glomerulonephritis
Saddle shaped nose
Way to remember
Wegeners - Nazi
Nazi - begins with N - nasal crusting, Nose saddle shaped, Nose + cough bleeds, reNal issues - Not Patrick therefore C-ANCA
What can precipitate Churg Strauss?
LTRA
CXR of Granulomatosis with polyangitis (1)
Renal biopsy findings: (1)
Cavitating lesions
Epithelial crescents in Bowman’s capsules
Mx Wegener’s (3)
Steroids
Cyclophosphamide
Plasma exchange
Bird fancier’s lung (avian proteins)
Farmers lung
Malt workers lung
Mushroom worker’s lung
Can cause which disease?
Extrinsic allergic alveolitis
Extrinsic allergic alveolitis
XR findings (1)
Bronchoalveolar lavage (1)
Blood (1) (eosinophils - high or low)
Mx (1)
Upper/mid zone fibrosis
Lymphocytosis
No eosinophillia
Mx steroids
Haemoptysis
Systemically unwell
Fever
Nausea
Glomerulonephritis
= which condition?
Goodpastures
SOB, AF, malar flush, mid-diastolic murmur
= which condition?
Mitral stenosis
Long hx of cough and daily purulent sputum production = which condition?
Bronchiectasis
PMH TB, haemoptysis, CXR rounded opacity = which condition?
Aspergilloma