Respiratory Flashcards

1
Q

What are the symptoms of stable asthma?

A

Episodic symptoms with specific triggers and diurnal variation.

  • Dry cough, worse at night
  • Shortness of breath, chest tightness
  • Wheeze
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2
Q

What signs would you find on examination in stable asthma?

A

Most likely none, unless having an attack.

May have:
Audible wheeze and hyper inflated chest
Tachypnoea
Resonance to percussion
Widespread polyphonic wheeze on auscultation
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3
Q

Which guidelines should you use to guide asthma management?

A

BTS guidelines

British Thoracic Society

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4
Q

What investigations should you do in suspected asthma?

A
Fractional exhaled nitric oxide testing
Spirometry with bronchodilator reversibility testing
Peak flow + PF diary
Histamine challenge/allergy testing
Trial with bronchodilators
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5
Q

What is the management algorithm for stable asthma?

A
  1. SABA- salbutamol
    • ICS- beclometasone
    • LABA- salmeterol
  2. Trial of inhaled ipratropium (SAMA) or tiotropium (LAMA)
  3. Trial oral montelukast (esp in children)
  4. Oral steroids

Lifestyle:
Annual review, smoking cessation, flu and pneumococcal vaccines.

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6
Q

What are the symptoms of acute asthma?

A
Shortness of breath, Chest tightness
Audible wheeze / stridor
Inability to complete full sentences
Confusion / reduced GCS
Use of accessory muscles to breathe
Cyanosis
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7
Q

What are the features of a severe asthma attack?

A

Peak flow 33-50%
Inability to complete sentences
Resp rate >25
HR >110

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8
Q

What are the features of life-threatening asthma?

A
PEF <33%
Silent chest 
Exhaustion and poor respiratory effort
Normal PaCO2 or PaO2 <8
Reduced GCS
SO2 <92%
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9
Q

What automatically makes an asthma attack have near-fatal classification?

A

Raised PaCO2

Requiring mechanical ventilation

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10
Q

What investigations should be done in somebody presenting with acute asthma?

A
A-E assessment
PEF
Pulse oximetry
ABG
CXR - if stable enough, purely for exclusion of alternative diagnoses.
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11
Q

How would you manage acute asthma?

A
High flow O2- 15L non-rebreathe
Salbutamol news B2B
Ipratropium nebs 4-6hrly
Hydrocortisone IV or PO prednisolone if stable enough.
-> Seek senior support, inform HDU/ICU
-> IV magnesium sulphate
-> Intubate and mechanically ventilate

? can try aminophylline infusion or IV salbutamol ? - seek advice

Post-recovery: 5 day course oral steroids

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12
Q

What would you expect on ABG in acute asthma?

A
  1. Respiratory alkalosis
  2. Hypoxia with normal CO2
  3. Respiratory acidosis (near fatal)
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13
Q

What are the symptoms of COPD?

A

Increasing breathlessness and reduced exercise tolerance
Chronic cough
Use of accessory muscles to aid breathing
Recurrent chest infections

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14
Q

What are the signs of COPD on examination?

A
Use of accessory muscles or pursed lip breathing
Increased respiratory rate
Hyper-inflated lungs
Reduced chest expansion, hyper-resonance
May have peripheral / central cyanosis
Quiet breath sounds, bronchial breathing
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15
Q

What are the diagnostic criteria for COPD?

What are the different stages?

A

Symptom profile +
FEV1/FVC <0.7 with no bronchodilator reversibility

S1: FEV1 > 80% predicted
S2: FEV1 50-79% predicted
S3: FEV1 30-49% predicted
S4: FEV1 <30% predicted

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16
Q

How would you manage COPD?

A

Lifestyle: stop smoking = best prognostic indicator
Flu + pneumococcal vaccines

Medical:
1. SABA
2. If steroid responsible/atopic/high eosinophils: add ICS
Otherwise add LABA/LAMA / combination
3. LABA + LAMA + ICS
4. Oral steroids, home nebs, carbocysteine, LTOT, prophylactic abx

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17
Q

What are the indications for LTOT in COPD?

A

PaO2 < 7.3 despite optimal treatment
PaO2 7.3-8.0 with other complications

Contraindicated if still actively smoking due to flammability

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18
Q

What are the most common causative organisms in infective exacerbations of COPD?

A
  1. Haemophilus influenzae

2. Streptococcus pneumoniae

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19
Q

What investigations should you do in somebody presenting with infective exacerbation of COPD?

A
  1. A-E assessment
  2. O2 sats
  3. ABG- indicates severity and guides O2 therapy
  4. CXR
  5. Sputum culture
  6. Bloods + blood cultures
  7. ECG to rule out cardiac cause of presentation
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20
Q

How should you guide O2 therapy in COPD?

A
  1. If chronic retainers, aim sats 88-92%
  2. If not chronic retainers, aim sats >94%
  3. If acidotic on ABG -> NIV
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21
Q

How would you manage infective exacerbation of COPD?

A
  1. Oxygen
  2. At home: regular inhalers, oral antibiotics, oral steroids, regular review
  3. In hospital: bronchodilator nebs, IV antibiotics and steroids, chest physio
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22
Q

What would you expect to see on ABG in type 1 and type 2 respiratory failure?

A

Type 1: Low O2 and normal CO2

Type 2: Low O2 and high CO2

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23
Q

What are the most common causative organisms of pneumonia?

A
  1. Streptococcus Pneumoniae

2. Haemophilus influenzae

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24
Q

What is the most common causative organism in somebody with pneumonia who has just been treated for flu?

A

Staphylococcus aureus

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25
What are the atypical pneumonias and their high-risk groups?
Legionella: stagnant water Klebsiella: Alcoholics and diabetics Mycoplasma: School aged children, alcoholics Pseudomonas: cystic fibrosis patients Pneumocystis jirovecii: HIV/immunosuppressed Coxiella Burnetti: exposure to animals + their fluids Chlamydia Psittaci: from bird contact
26
What are the signs on examination for pneumonia?
``` Fever, increased RR Coarse crepitations on auscultation Bronchial breathing Reduced chest expansion Dullness to percussion Increased tactile vocal fremitus ```
27
What is the severity classification system for pneumonia?
``` CURB - 65 Confusion Urea > 7 Respiratory rate >30 BP <90/60 65 age + ``` 0-1: treat @ home 2+: hosp admission 3+: consider ITU
28
What investigations should be done in somebody presenting with pneumonia?
``` A-E assessment ABG Bloods: FBC, U&E, CRP, cultures if septic CXR Urine: pneumococcal, legionella ```
29
What are the most common causes of hospital acquired pneumonia?
Enterobacteria: e-coli, klebsiella Staphylococcus aureus Pseudomonas Generally gram -ve organisms.
30
What are the symptoms of pneumothorax?
Sudden onset pleuritic chest pain Shortness of breath May present with syncope/haemodynamic instability in tension
31
What are the signs of pneumothorax on examination?
Increased RR and look breathless Reduced chest expansion Hyper-resonant to percussion Reduced/absent breath sounds In tension: Tachycardia, hypotension, tracheal deviation, quiet heart sounds.
32
How would you investigate somebody presenting with pneumothorax?
O2 saturations ABG CXR - D-dimer and Well's score to calculate risk of PE - ECG to rule out cardiac cause of pain
33
How would you manage each type of pneumothorax?
<2cm rim: supportive treatment, repeat CXR in 2-4 weeks >2cm rim: Admit + needle aspiration & if this fails after 2 attempts, chest drain. Confirm resolution with repeat CXR. Tension: Needle aspiration followed by chest drain
34
What are the anatomical locations to place needles for aspiration and chest drains?
Needle: 2nd ICS, Mid-clavicular line Chest drain: SAFETY TRIANGLE Boundaries: 5th ICS, anterior axillary line and mid-axillary line Always insert near the upper border of a rib so as to miss the neuromuscular bundle.
35
What are the risk factors for PE?
Virchow's triad: hypercoagulability, endothelial injury, haemostasis 1. Hypercoagulability: pregnancy, COCP, polycythaemia, thrombophilia, inflammatory conditions, malignancy 2. Endothelial injury: Recent surgery 3. Haemostasis: long haul flights, hospital admissions, surgery, AF, immobility
36
What are the symptoms of PE?
``` Sudden onset pleuritic chest pain Shortness of breath Cough, haemoptysis Symptoms of concomitant DVT Haemodynamic instability in massive PE ```
37
How would you investigate somebody with suspected PE?
1. A-E assessment 2. Calculate Well's score 3a. If low risk, D-dimer and only CTPA if D-dimer positive 3b. If high risk, CTPA straight away 4. CXR to rule out pneumothorax or other pathology 5. ECG to rule out cardiac cause or identify underlying AF If unstable, ABG should be performed following A-E
38
How would you manage somebody with PE?
If haemodynamically stable: LMWH or fondaparinux If unstable: thrombolysis with alteplase Duration of treatment: Clear, reversible cause/non-recurrent PE: 3 months Clear/irreversible cause/recurrent/ active cancer: 6 months
39
What are the causes of pulmonary hypertension?
1. Primary PH / connective tissue disease 2. Chronic lung disease e.g. COPD, emphysema 3. Secondary to L heart failure and backlog in pulmonary vasculature 4. Pulmonary vascular insult e.g. PE 5. Sarcoid + other restrictive disease
40
What are the signs and symptoms of pulmonary hypertension?
``` Shortness of breath, fatigue Syncope, chest pain Tachycardia, tachypnoea Raised JVP, cyanosis Hepatomegaly and peripheral oedema once R heart affected by backlog ```
41
How to investigate pulmonary hypertension?
ECG: RVH, R axis deviation, RBBB CXR: RV hypertrophy BNP Echo FBC, U&E, CRP
42
How do you manage primary pulmonary hypertension?
IV prostanoids Endothelin receptor antagonists PDE5 inhibitors
43
What is the classic triad of symptoms in sarcoid?
Dry cough Shortness of breath Painful skin rash (erythema nodosum)
44
What is the screening test for sarcoid?
Serum ACE
45
What is the gold standard test for sarcoid?
Lymph node biopsy and histology
46
What would you expect to see on chest imaging in sarcoid?
Bilateral hilar lymphadenopathy Pulmonary fibrosis Pulmonary nodules
47
What is the management for sarcoid?
1. If mild/no symptoms, no treatment 2. Oral steroids 6-24m 2a. PPI + bisphosphonate protection 3. Methotrexate or Azathioprine 4. Lung transplant in severe disease
48
What are the risk factors for obstructive sleep apnoea?
``` Male Middle age Obesity / Large neck circumference Increased alcohol consumption Smoking Neuromuscular disorders ```
49
What are the symptoms of obstructive sleep apnoea?
``` Loud snoring Apnoeic episodes in the night Daytime sleepiness, fatigue, waking up tired Morning headache Inability to concentrate ```
50
How do you investigate sleep apnoea?
Epworth sleepiness scale STOP-BANG score Sleep lab investigations- HR, BP, SO2 continuously through sleep In OSA sats usually drop during the night
51
What is the treatment for OSA?
1. Remove reversible causes: lose weight, reduce alcohol consumption, stop smoking 2. CPAP during the night 3. Surgical modifications to the palate and pharynx
52
What are the symptoms of idiopathic pulmonary fibrosis?
Shortness of breath Dry cough Malaise and weight loss Arthralgia
53
What are the signs on examination of idiopathic pulmonary fibrosis?
Finger clubbing Peripheral +/- central cyanosis Reduced chest expansion Fine end inspiratory crackles - sounds like walking on fresh snow
54
What investigations should be done in idiopathic pulmonary fibrosis?
ABG: hypoxia Bloods: FBC, CRP, D-dimer, autoantibody tests, serum ACE, BNP Spirometry: restrictive picture, FEV1/FVC normal/increased as both are reduced in proportion CXR + high-resolution CT: ground-glass changes Lung biopsy and histology
55
How do you manage idiopathic pulmonary fibrosis?
Manage risk factors: stop smoking, pneumococcal and flu vaccines Pulmonary rehab LTOT if chronically hypoxic Pirfenidone + nintedanib medications can slow progression Lung transplant in severe disease
56
Which drugs are most associated with pulmonary fibrosis?
``` A B C M N Amiodarone Bleomycin Cyclophosphamide Methotrexate Nitrofurantoin ```
57
Following a respiratory examination, what should you always examine?
Lymph nodes
58
What are the stages of TB infection?
Primary infection: mostly asymptomatic or very mild symptoms- associated with erythema nodosum Latent TB: asymptomatic, unable to pass on to others, often found incidentally Secondary infection: more severe symptoms, more dangerous Miliary TB: widespread, advanced TB
59
What are the symptoms of active TB?
Chronic cough- may produce sputum or haemoptysis Shortness of breath, chest pain Fever, malaise, night sweats, weight loss Painful lymphadenopathy
60
What are the signs of TB on examination?
``` Finger clubbing Lymphadenopathy Weight loss / cachexia in advanced disease Fever Erythema nodosum Cyanosis ```
61
How do you diagnose TB?
Bacterial sputum culture: Acid-fast bacilli on Ziehl-Neelson stain Mantoux test: looks for previous TB (vaccination, active, latent), if >5mm then positive result CXR: granulomatous, cavitating lesions often affecting the upper lobes Bloods: FBC, CRP, U&E, LFT
62
How do you manage TB?
Supportive: O2 if needed, fluids Antibiotic therapy: 1. Latent TB= 3 months rifampicin + isoniazid OR 6months isoniazid 2. Active TB: 6 months rifampicin + isoniazid and 2 months pyrazinamide + ethambutol
63
What are the side effects of rifampicin?
Turning body fluids orange Altered liver function CYP450 INDUCER- reduced effect of warfarin, COCP
64
What are the side effects of isoniazid?
Peripheral neuropathy | Hepatitis
65
What are the side effects of pyrazinamide?
Increased uric acid levels and precipitation of gout | Hepatotoxicity
66
What are the side effects of ethambutol?
Reduced visual acuity, colour blindness, optic neuritis
67
Who should not be offered BCG vaccine?
Those with positive mantoux test | Immunocompromised (live attenuated vaccine)
68
What is the most common type of lung cancer?
Adenocarcinoma
69
What are the signs of lung cancer on examination?
``` Finger clubbing Horner's syndrome in Pancoast tumours Lymphadenopathy SVC compression- facial swelling, arm swelling, engorged neck veins Stridor Signs of pleural effusion ```
70
What is the diagnostic test for lung caner?
Bronchoscopy/EBUS, biopsy and histology
71
What are Pancoast tumours most commonly?
Squamous cell carcinomas
72
What symptoms do Pancoast tumours generally cause?
Horner's syndrome: compression of sympathetic chain | Arm pain and weakness: brachial plexus compression
73
Which types of lung cancer cause SVC compression?
Mediastinal tumours | Most commonly non-small cell cancers- esp squamous cell carcinomas
74
Where are adenocarcinomas usually found?
Peripherally in the lung field
75
Where are squamous cell and small cell cancers usually found?
Centrally in the lung
76
What are the extra pulmonary manifestations of small cell lung cancer?
1. SIADH - ectopic ADH 2. Cushing's syndrome- ectopic ACTH 3. Limbic encephalitis- antibody production against limbic brain tissue 4. Lamber-Eaton syndrome -> Ab against voltage gated calcium channels on pre-synaptic neurones. Central weakness. 5. Secondary hyperparathyroidism 6. Dermatomyositis and Myositis
77
What is the latency period for mesothelioma?
Up to 45 years
78
What are the signs of mesothelioma?
``` Finger clubbing Pleural effusion Lymphadenopathy Weight loss Hepatomegaly Bone pain ```
79
How is mesothelioma diagnosed?
1. CXR and chest CT to identify pleural thickening and plaques 2. Confirmed by thoracoscopy and biopsy / analysis of pleural fluid
80
How is mesothelioma managed?
1. Demetrexed + Cisplatin chemotherapy | 2. Surgery + radiotherapy adjuvants -> controversial benefit
81
What are the causes of pleural effusion?
1. Exudative: malignancy, TB, rheumatoid arthritis, pneumonia 2. Transudative: Heart failure, hypoalbuminaemia, nephrotic syndrome, cirrhosis, PE
82
What are the symptoms of pleural effusion?
Shortness of breath Pleuritic chest pain Unable to tolerate lying flat
83
What are the signs of pleural effusion on examination?
``` Shortness of breath Reduced chest expansion Stony dull to percussion Tracheal deviation away from massive effusion Reduced breath sounds Decreased vocal resonance ```
84
How should you diagnose pleural effusion?
CXR- meniscus, blunting of costo/cardiophrenic angles Chest drain/aspiration- check LDH, protein levels, culture, pH LIGHT'S CRITERIA- help determine whether transudate/exudate -> if effusion/serum protein >0.5 or LDH >0.6 then exudate
85
How to manage pleural effusion?
If clear cause, treat underlying cause Oxygen if sats low- CPAP if severe breathlessness and hypoxia on ABG Pleural drain/tap can relieve symptoms temporarily/permanently depending on cause Analgesia for pain
86
What are the characteristics of empyema vs. effusion?
Low pH (<7.2) Higher LDH Low glucose in fluid Symptoms of bacterial infection
87
Name the oxygen delivery devices in order of increasing O2 flow:
1. Nasal cannulae 2. Hudson mask 3. Venturi mask 4. Reservoir mask 5. CPAP 6. Bilevel ventilation (BiPAP) 7. Nasal high flow 8. Endotracheal tube.
88
When can an OP/guedel airway be used?
On the ward in patients not maintaining their airway properly- GCS <8 If higher GCS, stimulate gag reflex
89
When is a NP airway contraindicated?
Basal skull fracture
90
When are LMA/supraglottic airways most useful?
cardiac arrest situations to prevent the need to stop for breaths, can continuously ventilate
91
What is the mechanism of action of bupropion?
Inhibits dopamine and noradrenaline reuptake | Reduces nicotine craving and withdrawal due to reduced sensation of reward
92
What is the mechanism of action of varenicline?
Nicotine receptor partial agonist | Reduces reward, craving and withdrawal
93
Can you prescribe pharmacological therapies and nicotine replacement in smoking cessation?
No- you should not combine the two | You also should never coprescribe both pharmacological methods