Respiratory Flashcards
Most common organism in bronchiectasis
H influenza - most common
Pseudomonas aeruginosa
Klebsiella
Strept pneumoniae
Main features of bronchiectasis
Chronic persistent cough
Copious excessive sputum
Recurrent respiratory tract infections
Clubbing - not specific, not always present
Tramlines , cysts/ring opacities on CXR
Bronchiectasis
*CXR can often be normal
How do you confirm dx
HRCT
= shows bronchial dilatation and wall thickening w/ ground glass opacities
Management of bronchiectasis
Bronchiectasis = permanent dilation of airways 2ry to infection/inflammation
-chest physio
-postural drainage
- ABx treatment in exacerbation / long term in severe cases
-bronchodilators - selected cases
Immunisation
Surgery - selected cases = e.g localised disease
Features of life threatening asthma (11)
Altered mental status w/ drowsiness Silent chest Poor resp effort Exhaustion Cyanosis Arrhythmia Hypotension PEF <33% predicted or best Spo2 < 92% PaO2 <8 Paco2 = normal = 4.6-6 kpa
Suspect mesothelioma or bronchial carcinoma when ….
(Malignant tumour of mesothelial cells)
How do you confirm dx?
Worker - builder , shipyard worker etc
Asbestos exposure
SOB + chest pain + weight loss
Clubbing, recurrent pleural effusion
Pleural BIOPSY (not cytology)
Asbestos exposure in ..
Firefighters
Construction workers
Power plant workers
Shipyard etc
Veterans
Who should deaths from mesothelioma be reported to and why?
It is an industrial disease - leads to unnatural death
Report/ consult coroner
Compensation often available
60 y/o builder, Smoker , Comes with SOB + chest pain
CT - irregular pleural thickening
CXR - mediastinal lymphadenopathy + rt sided pleural effusion
Dx, cause ?
Mesothelioma
Cause - asbestos
80% of mesotheliomas are due to it
If he dies - refer to coroner
When should you suspect atelectasis?
Dyspnoea Tachycardia \+/-Fever Hypoxemia Within 72 hrs post op
Management of atelectasis
Chest physio
Common cause of tension pneumothorax
Mechanical ventilation
- suspect if pt suddenly deteriorates and develops low O2 sat + hypotension
Management of pneumothorax
High O2 initially
Needle decompression - large bore 2nd ICS mid clavicular line
Chest drain
If pt stable - CXR
Features of cardiac tamponade
Becks triad = hypotension , muffled heart sounds, high JVP (distended neck veins)
CXR - large globular heart - pericardial effusion or tamponade
Dx + Tx of cardiac tamponade
Echo
Urgent pericardiocentesis
Primary spontaneous pneumothorax
Consider in …
Initial dx?
Tall thin males - dyspnoea + chest pain
No apparent reason, NO hx of lung disease
Dx = erect CXR if pt not severely distressed
Other wise proceed to needle decompression
Secondary spontaneous pneumothorax
Initial management
Occurs spontaneously
In presence of underlying lung disease - asthma, COPD
If pneumothorax = 2cm air rim (<= 50%) — aspirate/insert cannula
If >2 cm - insert chest drain
Haemothorax vs pneumothorax
No distended neck veins in haemothorax
Treatment of community acquired pneumonia
Mild
Amoxicillin
Treatment of community acquired pneumonia
Moderate
Amoxicillin + clarithromycin
Treatment of community acquired pneumonia
Severe
Co-amoxiclav +clarithromycin
Treatment of pneumocystitis jirovecii
P.Carinii
Co trimoxazole
(Trimethoprim + sulfamethoxazole)
AKA Bacterim
In case of
-severe allergy to penicillin
-pt is on statins
What antibiotics should be given in community acquired pneumonia
AVOID Cephalosporin - cefuroxime in severe allergy - 10% cross reactivity clarithromycin
AVOID clarithromycin - if on statins - risk of rhabdomyolysis
GIVE doxycycline
Features of sarcoidosis (5)
Bilateral hilar lymphadenopathy - most common CXR finding
Erythema nodosum - tender red nodules over shin
Polyarthralgia
Hypercalcemia
Fever
Consider DX if 2 or more features seen
What syndromes are associated with sarcoidosis
Lofgren’s syndrome
= acute form of sarcoidosis
- BHL, EN, fever, polyarthralgia
- excellent prognosis
Heerfordt’s
-uveoparotid fever
Parotid enlargement fever and uveitis 2ry to sarcoidosis
What is sarcoidosis
Multisystem disorder
Unknown aetiology
Characterised by non caseting Granulomatosis
Common young adults and people of African descent
Causes of oral thrush
Features
Inhaled corticosteroids
Immunosuppression
Smoking
Think white marks - can be rubbed out ***
Treatment of oral thrush
Oral fluconazole 50mg OD 7 days
Good inhaler techniques, spacer device, rinse mouth after use
Long term asthma management 4 steps
- SABA - salbutamol
I if not controlled i.e >3 doses/week - SABA + inhaled corticosteroids(ICS) (beclometasone)
- SABA + ICS + LTRA (leukotriene receptor antagonist)
- SABA + ICS + LABA +/-LTRA
LABA = salmeterol - SABA + ICS + LABA +/-LTRA + increased dose of ICS
If fails
SABA + LTRA + triall of new drug/further increase in dose
Difference b/w NICE and BTS guidelines for asthma management
Step 3
BTS - LABA (salmeterol)
NICE - LTRA (montelukast)
Side effects of beclometasone
Oral/ pharyngeal candidiasis
Sore throat
Dry mouth/throat
Excercise induced asthma management
SABA
- SABA +ICS
- SABA+ICS+ LTRA (preferred) or LABA or sodium cromoglicate
Drugs that aggravate asthma
Beta blockers
Aspirin
NSAIDs
Signs on examination - asthma
Expiration wheeze
Reduces PEFR (peak expiratory flow rate)
FEV1/FVC < 70% and improves with bronchodilators
Asthma vs COPD
FEV1/FEV <70% (<0.7) = asthma , improves with bronchodilator
COPD - remains < 0.7
Obstructive vs restrictive lung disease
Obstructive - FEV1/FVC < 70% or 0.7
Asthma, COPD, emphysema, bronchial it is
Restrictive > 70%
Interstitial lung disease, chest wall deformities, pulmonary fibrosis
Dx of asthma
Clinical
Or via spirometry
If however spitometry is Norma but patient has adopt or FHx of asthma or is clinically asthmatic
= peak flow diary
Use of peak flow diary
Helps determine appropriate time for use of bronchodilators
What is FEV1 and FVC
FEV1 - forced expiratory volume = volume exhaled @ end of forced expiration 1s
FVC - forced vital capacity - volume exhaled after maximal exhalation following full inspiration
Spirometry results asthma
FEV1- significantly reduced
FVC - normal
Ratio <0.7 and reversible with bronchodilators
Side effect of beta blockers
Bronchoconstriction
Atenolol, “lol”s
Side effect of beta agonist
Tachycardia
Salbutamol
Pneumonia that does not improve with ABx + night sweats or weight loss or new pleural effusion
Suspect??
What do you do?
Empyema,
pleural aspiration - sent for C&S
Chest drain = for treatment of confirmed empyema or compromising effusion
Causes of empyema
Complication of pneumonia - common
Penetrating chest trauma
Oesophageal rupture
Complication of lung surgery
SIADH is seen in
Small cell lung ca
SIADH = low serum Na, low serum osmolality, HIGH urine osmolality
-
SIADH
Cushing
SCC of the lung cause what metabolic imbalance
Hypercalcemia
SIADH vs diabetes inspidus
SIADH = low serum Na, low serum osmolality, high urine osmolality DI = hypERnatremia, high serum osmolality, low urine osmolality
*low urine osmolality in DI increases after vasopressin given
Histopathology of SCC
Large polygonal cells w/ keratin pearls & bridges
What is COPD
Most common cause
Chronic bronchitis + emphysema
Smoking
Features of COPD (6)
Smoking history Progressive dyspnoea FEV1/FVC <0.7 irreversible Hyper inflated chest on CXR, Productive cough Wheeze
What can develop in severe COPD
Right sided heart failure
- peripheral oedema
Spirometry of COPD
FEV1/FVC <0.7
FEV1 <80% predicted
Increased RV - due to air trapping
CXR of COPD
Hyperinflation
flat hemidiaphragm
>7 posterior ribs seen
What is chronic bronchitis
Most common cause
Form of COPD
= productive cough > 3 months
+ progressive dyspnoea, wheeze, low grade fever
Tobacco smoking
Management of COPD
Stop smoking !
1st line - SABA or SAMA (muscarinic antagonist)
2nd line - add LABA +LAMA
If asthmatic features present
LABA +ICS
If still breathless
LAMA + LABA + ICS
Long term O2 therapy in COPD - when? (5)
LTOT = supplementary O2 for at least 15hrs/day
Severe airflow obstruction pneumonia FEV1 <30% predicted (Consider assessment if 30-49%) Sats < 02 on RA Polycythemia Cyanosis Peripheral oedema , raised JVP
When should oral theophylline be used in COPD
NICE : after trials of SA/LA bronchodilators or to people that can’t use inhaled therapy
If COPD patient is already on LTOT but is still breathless
What should be done?
Start on prednisolone or nebuliser normal saline to loosen secretions
Management of COPD exacerbation
20-28% O2 via Venturi mask
Maintains sats b/w 88-92%
Nebs - salbutamol w/ ipratropium
IV hydrocortisone 100mg or 30 mg pred stat
-(continue as 30mg OD for 7-14 day)
If no response - IV aminophylline
Give antibiotic if purulent sputum, fever, high CRP
If after all this there’s dyspnea to evidence of acidosis = NIV
Failed NIV —- intubate
Management of acute asthma exacerbation paediatric
O2
Salbutamol nebs
Ipratropium nebs
Corticosteroids - oral pred / iv hydrocortisone
If still excacerbated -
IV salbutamol IV aminophylline IV MgSo4
Management of acute asthma exacerbation - adults
O2 > salbutamol nebs 5mg or terbutaline nebs +O2
Corticosteroids - 100 mg IV hydrocortisone or 40-50 mg pred oral
Severe/not improving/ life threatening
- back2back salbutamol nebs every 15 mins + ipratropium 0.5 mg to the nebs
Single dose MgSo4 1.2-2g over 20mins
If improving salbutamol nebs q4hr + pred 40-50 mg PO OD 5 days
Asthma exacerbation
Adults vs children treatment
O2 > salbutamol nebs
3 step A- corticosteroids C- ipratropium
Uses of MgSo4
Eclampsia
Torsasdes des pointes
Refractory asthma excacerbation - after no response to salbutamol, hydrocortisone,ipratropium bromide
SCC vs lung adenocarcinoma
SCC - smokers
Adeno - non smokers
Differentiating pneumonia
- Herpes labialis
- Erythema multiforme (target lesions)
- Atypical - young adult, dry cough, bilateral consolidation
- HIV w/ CD4 <200 + desat on excercise
- After flu
- StreptococcaL/pneumococcal
- mycoplasma
- mycoplasma
- Pneumocystis jirovecii ( carinii)
- Staph aureus
Pneumonia after exposure to water
Staying in hotel
Low Na low lymphocyte
Tx?
Legionella
Macrolides - clarithromycin, azithromycin
Or tetracycline
CURB 65 to determine outpatient or admission treatment
C - confusion AMT score <=8/10 U- Uremia (urea > 7 mmol/l) R- RR >=30/ min B- SBP <=90 or DBP <= 60 65 - age >=65
Home treatment - score 0-1 low risk, <3% mortality risk
Hospital care - score 2 or more, 3-15% mortality risk
ICU - score 3 or more - high mortality risk >15%
Prophylaxis antibiotics in HIV
CD4 < 200
CD4 < 50
< 200 - cotrimoxazole (against jirovecii)
<50 - azithromycin (mycobacterium avium)
Initial investigation in suspicion of lung ca
How do you confirm dx?
CXR
Dx - bronchospy
Biopsy to obtain histological/cytological specimens
Post op prophylaxis for DVT / pulmonary embolism
Enoxaparin (LMWH) - ideal
Treatment of VTE/PE/DVT
If not pregnant
DOACS - apixaban , rivaroxaban 1st line
If pregnant - LMWH
Warfarin and DOACS contraindicated in pregnancy
RF for pulmonary embolism (6)
COCP Surgery Obesity Pregnancy Malignancy Previous VTE
Investigation of choice for pulmonary embolism
CTPA
Main causes of travellers diarrhoea
Campylobacter jejuni- gram neg
Salmonella “”
Self limiting, treat in elderly/immunocompromised
Sam - cipro
Camp - erythromycin/clarithromycin ; 2- cipro
Most common organism causing pneumonia
Treatment
Strept pneumoniae
Gram +
Associated w/ herpes labialis
Mild - amoxicillin
Mod - amoxicillin + clarithromycin
Sev - co amoxiclav + clarithromycin
Allergic — doxycycline
Most common organism causing UTI
Treatment
E. coli
Acute pyelonephritis- culture then start antibiotics
Upper UTI - cipro / co amoxiclav
Lower - trimethoprim or nitrofurantoin
Horners syndrome
Ptosis, mitosis, anhidrosis
Due to compression of sympathetic chain
Pan coast tumour
Pan coast tumour
Tumour of apex of lung
Spreads to nearby tissue- ribs, vertebrae
Unilateral compression of sympathetic chain - horners syndrome
Most pancoast = non small cell lung ca
Acid base imbalance seen in pulmonary embolism
Repiratory alkalosis
Acid base imbalance seen in asthma & COPD
Resp acidosis
Panic attack vs pulmonary embolism - acid base
Both resp alkalosis
PaO2 normal in panic attack , low in PE
Drugs that cause metabolic acidosis
MAIIAD Metformin Aspirin (later on) Iron Isoniazid Alcohol Digoxin Paracetamol - less common
Causes of metabolic acidosis
Drugs - MAIIAD
Diarrhoea
Renal insufficiency
Addison’s disease
Drugs that cause metabolic alkalosis
ACEi NSAIDs diuretics (ADD)
Causes of metabolic alkalosis
Drugs - ADD
Vomiting - loss of gastric acid
Hypovolemia, hypokalemia
2ry hypoparathyroidism
Respiratory acidosis causes -
Drugs - benzo, organophosphate
COPD asthma
Pneumothorax haemothorax
Ascites
Respiratory alkalosis causes
Any cause of hyperventilation Pulmonary embolism Panic attack Salicylate Aspirin (early)
Features of pulmonary fibrosis
Progressive excertional dyspnoea
Bi-basilar fine crepes - end inspiratory
Dry cough
Clubbing
*coal mines
Anticipatory meds
- Pain & breathlessness
- Nausea & vomiting
- Anxiety delirium agitation
- Noisy resp secretions
- SC morphine
- SC haloperidol
- SC midazolam
- SC hyoscine butylbromide
Hypersensitivity pneumonitis/ extrinsic allergic alveolitis Causing organism Birds Farmer Malt Mushroom,
Bird fancier - avian protein
Farmer** - saccharopolyspora rectivirgula / micropolyspora faeni
Malt worker - aspergillosis clavatus
Mushroom worker - thermophilic acctinomycetes
EAA/ hypersensitivity pneumo
Presentation
Investigation
SOB, dry cough fever - 4-8 hrs after exposure (acute)
Chronic
I - CXR upper/mid zone fibrosis = diffuse micronodular interstitial shadowing
Bronchoalveolar lavage - lymphocytes is
No eosinophilia in blood
Paraneoplastic syndrome : lung ca Small cell (3)
SIADH
ACTH - atypical, hyperglycaemia hypoK, HTN , alkalosis, muscle weakness
Lambert-Eaton = presents like myasthenia but reflexes absent, elicited after excercise
Increas in strength + power after repeated tests
Paraneoplastic syndrome : lung ca
SCC (5)
Hypercalcemia PTH-rp secretion Clubbing Hypertrophic pulmonary osteoarthropathy Hyperthyroidism- due to ectopic TSH
Resp alkalosis
Pulmonary embolism vs panic attack
Panic attack - PaO2 normal , pco2 low
PE - both low
Aspirin toxicity
Acid base disturbance
Early - resp alkalosis
Late - metabolic acidosis
Side effects SABA
Tachycardia
Palpitations
Tremors
Shaky hands
Where is mixed acidosis seen?
Management
Cardiac arrest
Low pH, high PaCO2 , low HCO3
- accumulation of CO2 , kidneys not over fused due to low cardiac output
Increase ventilation to washout CO2
First step of stable asthma management
SABA + low dose corticosteroids
How to clean spacers for inhalers
Monthly
Soak in detergent/warm water 15 mins
Air dry (not in sun)
Replace spacer every 12 months
Bronchopleural fistula is complication of
Lung cancer surgery - most common pulmonary resection, pneumonectomy > lobectomy
More common in rt sided lung surgery
Can also develop after chemo, radio, or infection
Dx of broncho-pleural fistula
Treatment
CT chest
Xray may show it
Tx - repair the fistula = endoscopy, bronchoscopy, open chest surgery
Managing PE in pregnancy
LMWH - throughout pregnancy and at least 3 months after treatment has been given
Types of respiratory failure
Type 1 - hypoxia w/o hypercapnia
= pneumonia , low o2 in air
-low po2 / pco2 low/normal
Type 2 Hypoxia + hypercapnia Reduced breathing effort Asthma COPD
Low po2 + high pco2
Methotrexate pneumonitis
Features
Imaging
Management
Dry cough SOB fever
Starts w/in 1st year of methrotrexate initiation
CXR - hazy opacity , prominent reticulation
HRCT chest
Mgmt - methotrexate needs to be stopped
Common organisms causing cellulitis
Common site
Strept pyogenes
Staph aureus
Cellulitis- inflammation of skin and subcutaneous tissue
Shins
Management of cellulitis
1 . Flucloxacillin
2. Clindamycin or clarithromycin (if penicillin allergic)
Oral clindamycin if fails to respond to flucloxacillin e.g. MRSA
Severe cellulitis - IV benzyl penicillin + flucloxacillin
MRSA - Vancomycin
What is lichen planus
4P + F - pruritic, purple , papular, polygonal rash on flexor surfaces
LP - white lacy pattern on buccal mucosa
Management of lichen planus
Topical steroids - mainstay
Benzydamine mouthwash or spray - recommended
Extensive lichen planus - oral steroids / immunosuppression
Suspicion of malignant melanoma
Asymmetry - 2 halves look different in shape
B - irregular border / edges
C- diffeernt shades of black, brown , pink
Diameter- >6 mm
Evolves/enlarges - grows upwards /downwards/ outwards as flat lesion
Benign mole - doesn’t bleed
Patient wants it removed
What do you do ?
Refer to private dermatologist
No cosmetic services - NHS
Breslow thickness - single most prognostic variable in malignant melanoma
< 1 mm - 95-100% 5 year survival
1-2 mm 80-95%
2.1 - 4 mm - 60 -75%
> 4 mm - 37 -50%
Cardiac & renal manifestations of SLE
Pericarditis
Proteinuria
Glomerulonephritis - diffuse proliferative
Anti-histone is seen is
Drug induced lupus
Due to isoniazid or hydralazine or procainamide ( TB , HF)
Initial screening test for SLE / most sensitive
ANA
Confirmatory test for SLE
Anti dsDNA
Highly specific
Drug induced lupus vs SLE
DIL:
Renal and nervous system involvement rare in drug induced
Usually resolves after stopping
It is ANA positive+ dsDNA NEGATIVE + anti histone antibodies
Most common drugs that cause drug induced lupus
Procainamide - antiarrythmic
Hydralazine - vasodilator
Less common - isoniazid (anti-TB),minocycline, phenytoin
Acute vs chronic urticaria
Acute - <6 weeks
Chronic - >6 weeks
Drugs that can cause urticaria
Aspirin
Opiates
They release histamine from mast cells
Management of urticaria
Treat aggravating cause
- stop aspirin, opiates, overheating, stress, alcohol, caffeine
Antihistamine (non sedating) = cetirizine, loratidine
If pregnant - sedating antihistamine - chlorphreniramine
Key features psoriasis
Itchy elevated plaques w/ overlying white silver scales Elbows knees scalp Not contagious Extensor surfaces! Strong genetic basis/ family history Auspitz sign Kobners reaction
Auspitz sign
Seen in psoriasis
Pin point bleeding after scraping
Kobner’s reaction
New lesions at sites of skin injury
Treatment of psoriasis
Topical corticosteroids
Vitamin D analogues
Tar preparations
Key features of eczema
Itchy red rash
Skin creases - flexures - wrist , elbow folds, behind knees
Environmental triggers / URTI
FHX of atopic disease
Typically appears before age 6 mo , clears by 5 yrs in 50%, 75% by age 10
Treatment eczema
Mild
Emollients - 1st line
Topical steroids
= mild - hydrocortisone acetate .5/1/2.5% (mild case , new eczema no response to emollients)
Sebhorreic dermatitis - key features
Scaling rash
Affects sebaceous glands
Face scalp chest - inflamed greasy areas + scaling / dandruff on scalp
Inflammatory reaction to yeast
Treatment sebhorreic dermatitis
Regular anti fungal
Intermittent topical steroid
Oral thrush vs leukoplakia
OT can be rubbed out ( thick white marks +/- inflamed mouth and tongue
Leukoplakia - sharp well defined edges , cannot be rubbed out
Treatment oral thrush
Oral fluconaxole 50 mg OD 7 days
Or
Fluconazole oral suspension
Leukoplakia treatment
Stop smoking
Take biopsy as they are premalignant
Eczema
- infants
- younger children
Older children
Infants - face + trunk > extremities
YC - extensor surfaces
OC - flexor surfaces , creases face+ neck
Treatment eczema
Moderate
Betamethasone valerate .025%
Clobetasone butyrate .05%
= wide area of drynesss , crackling , redness
Eczema - severe
Treatment
Potent strength
Beclomethasone valerate .1%
Mometasone .1%
Hydrocortisone butyrate
Eczema that causes bleeding/ prevents sleep due to itching / no response to emollients and hydrocortisone
Very potent = clobetasol propionate
How should emollients be used with steroids
Apply emollient first - wait 30 mins
Apply topical steroid
Antifungal for
Athletes foot
Fungal groin infection
Fungal nappy rash
Clotrimazole
Itching w/o sign and symptoms of anaphylaxis give ___
If reaction is severe __
Oral anti histamine
Severe - IM adrenaline
Basal cell carcinoma / rodent ulcers
Features
Most common type
Slow growth ,Local invasion
Mets extremely rare,Most common type of ca in western world
Sun exposed sites - head neck majority
Nodular BCC
Initially Peary /flesh coloured w/ telangestasia > ulceration leaving central crater
Pearly white umbilicated ulcer w/ central depression
BCC
BCC management
Surgical removal/ cryotherapy
Topicals - imiquimod, fluorouracil
Radiotherapy
Molluscum contagiosum
Features
Treatment
Pox virus White/pink Pap ulcers w/ umbilicated/depressed central puncture Anywhere on skin Cheesy/white material when squeezed Children + immunocompromised commonly
Tx - resolve spontaneously w/in 6-24 months
Organism that causes impetigo
Staph aureus / strept pyogenes
Impetigo = superficial bacterial skin infection
Impetigo
1ry / 2ry complication of existing condition ; eczema, scabies, insect bite
Children commonly ; in warm weather
Face + flexures , limbs not covered
Contagious - spreads by direct discharge / indirect spread
Impetigo features
Appearance
Incubation
Incubation - 4-10 days
Golden crusted skin lesion - honey coloured crust
Very contagious
