Respiratory Flashcards
What is the treatment of stable COPD?
Initial empirical treatment, offer a short acting bronchodilator as required to relieve breathlessness and exercise Limitation
This can either be a SABA or SAMA
How would you manage acute exacerbation of COPD?
Management
The emergency management of Chronic Obstructive Pulmonary Disease centres around oxygen, bronchodilators and steroids.
Oxygen Therapy
Sit-up
24% O2 via Venturi mask: SpO2 88-92%,
Vary FiO2 and SpO2 target according to Arterial Blood Gas
Nebulised Bronchodilators (Air Driven)
Salbutamol 5mg/4h
Ipratropium 0.5mg/6h
Steroids
Hydrocortisone 200mg IV
Prednisolone 40mg PO for 7-14d
Antibiotics (if evidence of infection)
Further treatments if no response (considering pre-morbid status)
Repeat Nebulisers and consider aminophylline IV
Consider NIV (BiPAP) if pH <7.35 and/or RR >30
Consider invasive ventilation if pH<7.26
How would you manage aspiration pneumonia?
IV cephalosporin and IV metronidazole
What is the management of croup?
Can be remembered as ODA..
Oxygen (humidified)
Dexamethasone PO 0.15/kg or budenosideneb 2mg
Adrenaline nebulised 5ml (1:5000)
How do you treat lung abscess?
Conservative management:
Chest physiotherapy for postural drainage
Smoking cessation therapy if necessary
Medical management:
Supportive treatment: Oxygen; fluid Regime; analgesia
Antibiotic treatment: Intravenous therapy for 3 weeks followed by oral antibiotics for 1-2 months.
Surgical management:
CT-guided percutaneous drainage or pulmonary resection
What is the management of obstructive sleep apnoea?
Weight loss
Smoking cessation
Alcohol avoidance in the evening (sedative effect)
CPAP (Continuous positive airway pressure) maintains upper airway patency and is the gold standard
What is the management of pleural effusion?
The underlying cause should be treated and the patient should be managed in an ABCDE approach, including appropriate oxygen therapy and attempts to reduce respiratory distress medically (eg. diuretics for heart failure or antibiotics for chest infections). Ultrasound-guided pleural aspiration is indicated if this fails or the patient remains symptomatic from the pleural effusion.
Other management options to be considered include:
An intercostal drain: for large pleural effusions or empyemas (pus in the pleural space).
For recurrent or persistent pleural effusions: pleurodesis (obliteration of the pleural space) may be considered. Pleurodesis can be chemical (with use of a sclerosing agent e.g. tetracycline or bleomycin) or surgical (via thoracotomy or thoracoscopy).
How do you treat PCP?
Treatment is based on clinical or radiological evidence of infection or clinical indicators of general immune deficiency.
The first choice agent in the treatment of PCP, regardless of severity, is Co-trimoxazole
Alternative therapy can be used if Co-trimoxazole does not eliminate infection. This includes Clindamycin-primaquine, dapsone, IV pentamidine.
If the patient has p02 <9.3kPa and an arterial alveolar 02 gradient >4.7kPa, is it important to consider adjuvant corticosteroids. This has a proven reduction of mortality.
What is the treatment for community acquired pneumonia?
First choice oral abx if low severity (CUrB65 score 0 or 1)
Amoxicllin 500mg 3x a day
(Doxy/clarith/erythro- if pregnant)
First choice if moderate severity;
500mh 3x a day
W/ (if atypical pathogens suspected)
Clarithromycin- 500mg 2x for 5 days
First choice antibiotics if high severity;
Co‑amoxiclav:
500/125 mg three times a day orally or 1.2 g three times a day intravenously for 5 days
With
Clarithromycin:
500 mg twice a day orally or intravenously for 5 days
Or
Erythromycin (in pregnancy):
500 mg four times a day orally for 5 days
(Levofloxacin if pen allergic)
What is the abx for HAP
First choice oral antibiotics if non severe symptoms or signs and not at higher risk of resistance- co amoxiclav
Penicillin allergy- doxycycline
Severe sx/ signs
Piperacillin with tazobactam (4.5g 3x a day)
Or Ceftriaxone
What is the management of primary pneumothorax?
Primary pneumothorax is a type of spontaneous pneumothorax with no underlying lung pathology (secondary have underlying lung pathology)
It depends on the size and the symptoms
If the primary pneumothorax is <2cm and NOT SHORT OF BREATH then conservative management os sufficient, the pt can be discharged and reviewed in the OP department in 2-4 weeks
If the pt IS short of breath or pneumothorax is >2cm the pneumothorax should be aspirated with a 16-18G cannula under local anaesthetic. If this is successful the pt can be discharged, if this fails then an intercostal drain is necessary and pt must be admitted.
What is the management of secondary pneumothorax?
Secondary pneumothorax have underlying lung pathology- COPD, asthma TB, Pneumonia, CG, idiopathic pulmonary fibrosis and neoplastic disease, can also be caused by connective tissue disorders
If the pt is NOT short of breath and the pneumothorax is <1cm then they do not require further invasive intervention but should be admitted for observation for 24 hours and administered O2 as required
If the pt is NOT short of breath and pneumothorax is 1-2cm on the CXR, if this is successful the pt can be admitted for 24 hours of observation, if this is unsuccessful and intercostal drain is necessary
If the pt is Short of breath OR the pneumothorax is >2cm on the CXR then an intercostal drain is necessary and the pt should be admitted.
What is the treatment of PE?
The duration of anticoagulation treatment depends on the aetiology of the PE. A provoked PE (identifiable risk factors e.g. surgery, peri-partum) should be treated for 3 months. An unprovoked PE should be treated for 6 months. If there is an ongoing cause (e.g. a thrombophilia) the patient should be treated for life.
What are the causes of respiratory alkalosis?
↑pH
↓pCO2
↓HCO3- (if partially compensated or chronic)
Causes; CNS infection Subarachnoid haemorrhage Panick attack PE Aspirin overdose Anaemia Hypoxia
What are the causes of type 1 respiratory failure?
Asthma
Congestive Cardiac Failure
Pulmonary embolism
Pneumonia
Pneumothorax
Low V/Q: areas that have poor ventilation with oxygen but are well perfused by blood. E.g. bronchoconstriction (Asthma), airway collapse in emphysema, mucus plug, congestive cardiac failure
High V/Q: areas of the lung with adequate ventilation but are lacking blood perfusion Eg/ Pulmonary embolism.
What would the causes of type 2 respiratory failure be?
Obstructive lung diseases – Chronic obstructive pulmonary disease
Restrictive lung diseases - idiopathic pulmonary fibrosis
Depression of the respiratory center – opiates
Neuromuscular disease – Guillan-Barre syndrome, motor neuron disease
Thoracic wall disease – rib fracture
What is the management of TB?
Isoniazid, rifampicin, ethambutol, and pyrazinamide for 2 months, then Isoniazid and rifampicin for a further 6 months.
Extended duration in TB meningitis, pericarditis, and spinal TB.
What are the side effects of Isoniazid?
Peripheral neuropathy (pyridoxine is given to prevent this) Liver toxicity
What are the side effects of rifampicin?
Liver toxicity Hepatic enzyme (p450) inducer Turns bodily fluids red/orange color
What are the side effects of ethambutol?
Visual disturbance (color blindness, colour acuity) Avoid in CKD
What are the side effects of pyrazinamide?
Liver toxicity
When would you recommend LTOT for COPD?
very severe airflow obstruction (FEV1 < 30% predicted). Assessment should be ‘considered’ for patients with severe airflow obstruction (FEV1 30-49% predicted)
cyanosis
polycythaemia
peripheral oedema
raised jugular venous pressure
oxygen saturations less than or equal to 92% on room air
What is bronchiectasis?
What are the causes?
Permanent dilation of the airways due to chronic infection or inflammation
post infectious- TB, whooping cough, pertussis, pneumonia, measles
Immune deficiency- hypogammaglobulinaemia
What are the causes of pleural effusion?
Collection of fluid in the pleural cavity. This can be exudative >3g/l or transudative <3g/l
Exudative-
- Lung cancer
- Pneumonia
- RA
- TB
Transudative-
- Heart failure
- Liver failure
- Hypothyroidism
- Megs
What are the symptoms/signs of pleural effusion?
Symptoms= SOB
Signs= dullness to percussion, reduced breath sounds, tracheal deviation away from the effusion if massive
What Ix would you do for pleural effusion?
CXR
Blunting of the costophrenic angles or if larger then you get a meniscus
What is the treatment of pleural effusion?
Aspiration then chest drain
What would an empyema show on aspiration?
Low pH
low glucose
high LDH
What is interstitial lung disease?
How do you diagnose it?
This is an umbrella term to describe conditions that affect the lung parenchyma causing lung inflammation and fibrosis
Fibrosis involves the normal and elastic lung tissue with replacement with scar tissue that is thick and does not function effectively
Diagnosis is with high resolution CT which shows ground glass appearances
When diagnosis is unsure then biopsies can be taken
What is the management of interstitial lung disease?
Supportive Remove or treat underlying disease Home oxygen if hypoxic at rest Stop smoking Physiotherapy and pulmonary rehabilitation Pneumococcal and flu vaccine Advanced care planning and palliative care where appropriate Lung transplant
What is idiopathic pulmonary fibrosis? How does it present?
Fibrosis with no clear underlying cause
presents with bibasal fine inspiratory crackles and finger clubbing
What are the drugs that can induce pulmonary fibrosis?
Amiodarone
Cyclophosphamide
Methotrexate
Nitrofurantoin
What can secondary pulmonary fibrosis be caused by?
Rheumatoid arthritis
SLE
Systemic sclerosis
Alpha 1 antitrypsin deficiency
What are the risk factors for PE?
Immobility Cancer Pregnancy Long haul flights surgery Polycythaemia SLE Thrombophilia Hormone therapy with oestrogen
What are the CIs of LMWH?
Active bleeding
Existing coagulation
What is the main contraindications of TED stockings?
Peripheral arterial disease
What is the presentation of PE?
SOB Haemoptysis Pleuritic chest pain Hypoxia Raised RR Tachycardia Low grade fever haemodynamic instability causing hypotension
What is the management of PE?
Apixaban or another NOAC treatment dose
What is sarcoidosis?
Granulomatous inflammatory condition
What is TB?
Infectious disease which is caused by the bacteria- mycobacterium tuberculosis
It has a waxy coating which means it does not show up on gram staining- it requires a special type of stain called Zeihl Neelsen stain, which turns the TB bacteria bright red against a blue background
Acid fast bacilli
How is TB spread?
Inhaling droplets of saliva
It then spreads through the lymphatics and blood
Granulomas form around the bacteria
The immune system may encapsulate sites of infection and stop the progression of the disease- this is latent
When latent TB reactivates this is called secondary TB
When the immune system is unable to control the disease- this is disseminated TB and referred to as miliary TB
The main site for TB is the lungs, when it is miliary it means it has spread to other places, what can these places be?
CNS Genito urinary system Gastrointestinal system Bones and joints Lymph nodes
What are the risk factors for TB?
Immunosuppression
Homeless
Known contact
What is the presentation of TB?
Fever Haemoptysis Night sweats Weight loss Lymphadenopathy Erythema nodosum Spinal pain TB (POTTS)
What Ix are used for TB?
Mantoux test- will be positive in latent, active and previously vaccinated
Interferon gamma release assay (involves taking blood and mixing it with antigens from TB, if previously exposed then the antigens will release interferon gamma and the result will be positive (interferon gamma release assay is positive in LATENT TB)
Sputum samples (at least 3)
CXR- hilar lymph nodes, pleural effusion, consolidation
nucleic acid amplification tests (only in immunosuppressed)
How do you treat TB?
If latent;
Isoniazid and rifampicin for 3 months
Isoniazid for 6 months
If active; Rifampicin for 6 months Isoniazid for 6 months Pyrazinamide for 2 months Ethambutol for 2 months
