Respiratory Flashcards
Asthma Management
Step 1
SABA + Low ICS
Step 2
(LABA + Low ICS) or trial of LTRA
Step 3
LABA + Mod ICS. or trial of LTRA
Step 4
High ICS + trial of LAMA , theophylline
LAMA - Tiotropium
ICS - Beclomethasone , fluticasone , budesonide
LTRA - Montelukast
LABA - salmeterol , formoterol
SABA - salbutamol
Bacteriostatic Antibiotics
Tetracyclines (Doxycycline) Macrolides, (Clarithromycin ) Clindamycin, Trimethoprim/sulfamethoxazole, Linezolid Chloramphenicol.
Pulmonary Embolism
Direct Acting Anti Coagulant (Warfarin) In pregnancy (LMWH )
Inv of choice - CT Pulmonary Angiogram / CXR (in practical ECG also)
Acute Asthma Exacerbation
OSHIM 💁♀️Oxygen (100%) 💁♀️Salbutamol (neb) 💁♀️Hydrocortisone (IV) if not available than, Oral Prednisolone 40mg ⚡⚡⚡ 💁♀️Ipratropium (neb) 💁♀️MgSO4 (IV)
IV Aminophylline and IV Salbutamol, to be administered by senior consultant
OSTH-PIMPO (mneumonic)
O2
Salbutamol or Terbutaline
IV Hydrocortisone or PO Prednisolone
Ipratropium
Mgso4
Prednisolone Oral for 5-7days
Mesothelioma
builder, chimney , veteran
Asbestos exposure
Latent period to develop up to 45yrs
Finger Clubbing (seen in <1% of patients)
Shortness of breath , Chest pain , Weight loss
CT/ CXR - pleural thickening or effusion
(lung cancer does not necessarily show pleural thickening)
Diagnosis - Thoracoscopy - PLEURAL BIOPSY - Histology
(Broncoscopy - Lung malignancy and Pneumocystis jiroveci )
if there is pleural effusion due to mesothelioma -> long term indwelling pleural drainage is the management for the pain relief
Exercise induced Asthma
SABA+ICS (not well controlled)
add Sodium CROMOglicate or LTRA or LABA or Theophylline
Antibiotics Pneumonics
Antibiotics Aminoglycosides Ampicillin, Gentamycin G-
Can Cephalosporins Ceft , Cepho G+ G-
Protect ….. Penicillin Amoxicillin ,Co-amoxi G+ G-
The ….. Tetracyclines Tetra, Doxy G+ G-
Queen ….. Quinolones
Men … Macrolides Clarithromycin
Servants. Sulphonamide
Guards .. Glycopepdies Vancomycin,
COPD Management
C Confusion GCS<8/10 U Blood Urea Nitrogen>7 mmol/L / > 19mg/dl R RR> 30 B BP S <90 D<60 65 Age >65
0 - Mange at home by oral antibiotics (Amoxicillin / pen-allergy - Clarithomycin/erythromycin/doxycycline)
1-2 - (Amoxi + Claritho) or Doxycycline
2- consider hospital admission
3- IV AB + hospital admission
The normal peak flow is
450-550 L /min in adult males
320-470 L/min in adult females
Asthma pt (doent know when to use bronchodilators)
Peak Flow Diary—- show diurnal variation (worse at night and early morning)
treatment monitoring and adjustment (after diagnosis)
spirometry (pulmonary function test)—– to establish diagnosis
Life threatening asthma VS Acute severe Asthma
LTA Chest silent (No Wheeze) Confusion Poor respiratory effort Exhaustion
ASA
Cannot complete a sentence in one BREATH
Use of Accessory muscles
Intercostal resection
Specific Pneumonias
Pneumonias: -
MYCOplasma: epidemic every 4 yr flu like symptoms, erythema MULTIforme , Steven Johnson S , Guillian Barre’ S, myelitis and meningocephalitis
CXR- Patchy Consolidation of Bilateral lobe
P. Jirovecii: CD4 count usually less than 200 cls/mm3, exertional dyspnoea, O2 desaturation -
Legionella: travel history (stay in hotel, visit to swimming pools, hot tubs etc), hyponatraemia , Lymophopenia
CXR- Bi-Basal-Consolidation
Dx- Urine antigen, culture
StAphylococcal : Pt with influenza, seen in elderlies, IV drug users or pts with underlying disease;(leukaemia, lymphoma , cystic fibrosis)
Xray-BILATERAL CAVATIONS -
Pneumococcal /Streptococcus: COMMONEST BACT, elderly, immunocompromised, alcoholic , preexisting lung dis
associated with herpes labialis -
Xray -LOBAR CONSULDATION
Klebsiella: Cavitating Pneumonia , common in the elderly, immunocopromised and alcoholics.
CXR as UPPER lobe cavitation
**In tuberculosis the CXR will usually show upper lobe infiltrates with cavitation.
Pancoast Tumor
Apical lung CA invades (structures of Thoracic inlet)
the sympathetic plexus in the neck (ipsilateral Horner’s’)
±brachial plexus(arm pain±weakness)
±recurrent laryngeal nerve(hoarseness of voice )
Horner’s Syndrome
Miosis
Enopthalmos
Ptosis
Diagnosis of COPD and Staging
Typical Clinical Features
(Breathlessness , Wheeze , Chronic Cough, regular sputum production)
Exposure to Toxins and Pollutants
(smoking , air pollution , occupational exposure to Chemicals )
**STAGING* is Supported by Spirometer
The predicted FEV1 is used to Stage the COPD patients
Stage 1 mild 80 or >
Stage 2 moderate 50 - 79
Stage 3 severe 30 - 49
Stage 4 very severe <30 or <50 with respiratory failure
Clinical and Xray diagnosis of COPD
Hyper inflated lung fields Flattened Diaphragm >7 ribs seen in X ray Bullae may be present Small heart
COPD: Chronic hypoxia > erythropoietin > polycythemia > increased hematocrit/PCV
Farmer / Pet shop / Hostel, Hotel , Hospital / Cavitation / Black Current Jelly / Patchy Conslidation on CXR / Lobar Consolidation on CXR
Farmer–> Extrinsic allergic alveolitis
CXR»_space; diffuse micro nodular interstitial shadowing
Pt works @ a pet shop –> [Ch]lamydiophilia psittaci
» Rx with [Cl]arithromycin
Pt was in anything that start’s with [H] like hospital, hostel, hotel, ect–
> Legionella / Clarithromycin
Hx of Cavitation in the lung (for any reason)–> Staph A
Black current jelly sputum, upper lobe cavitation on CXR –> (hard K sound) Klepsiella pneumonia which is
Rxed with C[K]ephalosporin or sometimes called kephlex !
Myalgia, bilat. patchy consolidation on CXR,
dry cough, target lesions on back of hands —> Mycoplasma pneu.
Rxed with Erythromycin
lobar consolidation on CXR—> strept. (G+ve cocci)
Sputum Rusty / Yellow and Green / Clear white / Clear frothy
RUSTY RED SPUTUM> PNEUMOCOCCAL PNEUMONIA
- YELLOW/GREEN(PURULENT) > LUNG ABCESS / BRONCHIETASIS/ CYSTIC FIBROSIS / PNEUMONIA
- CLEAR,GREY-WHITE(MUCOID) > ASTHMA / CHRONIC BRONCHITIS
- CLEAR,FROTHY PINK,WATERY> ACUTE PULMONARY EDEMA
Bronchiectasis
Bronchiectasis: obstructive-- Irreversible bronchial dilatation-- Chronic purulent copious sputum-- Coarse crackles & Rhonchi--- Recurrent infection-- CXR may be normal in early(ring opacities) -- HRCT Chest( tram tracks/signet ring sign
Main Features
Chronic Persistent Cough
Copious Excessive Sputum
Recurrent Respiratory Tract Infections
CXR Tramlines cysts / ring opacities
Clubbing Drumstick-shaped fingers (not always + not specific )
Dx - HRCT - Bronchial Dilatation and wall thickening with Ground Glass opacities
Obstructive pattern
Irreversible Dilatation of small and Medium sized bronchi
Wt loss/ fatigue
Managements
- Physical training
- Postural Drainage
- Antibiotics for exacerbation
- Immunizations
- Surgery(Tumor FB)
COPD/ Pneumoconiosis / Chronic Bronchitis / Bronchiectasis
COPD
progressive/ irreversible obstruction
shortness of breath during exertion, chronic cough with sputum.
Pneumoconiosis
interstitial lung ds d/t inhalation of certain fibres has caused pulmonary fibrosis.
asbestosis, coal miner’s lung and silicosis.
History/ occupational / 20-30 years after exposure.
Chronic Bronchitis
type of COPD
productive cough 3 consecutive months 2 sequential years.
cough, sputum, dyspnoea or wheeze.
Bronchiectasis
irreversible dilatation and destruction of the airway walls due to inflammation,infections.
chronic cough, purulent sputum,
haemoptysis, local crackles and wheezing.
Pneumothorax types
Based on Cause
P* - spontaneous
S* - COPD / Asthma / 50 yrs of smoking
Based on Nature
Closed - Lung collapses/ air shifts into Plural Cavity (no change in total air vol)
Opened - Communicates with atmosphere
Tension - (one way valve)Vol of air in Plural Cavity ↑ / Tracheal shift to opp side
Pneumocystis Jirovecii or Pneumocystis Carinii Pneumonia
HIV + Desaturation on ex + Dry cough = PCP
- Desaturation on exercise,
- HIV (esp when CD4<200),
- clear chest
Dx- Bronchoscopy with Bronchoalveolar lavage
Tx- Co-trimoxazole
(HIV + productive cough = TB )
63 yr old Advanced COPD on LTOT + relaxation therapy but still breathlessness
IN COPD WITH LTOT YOU SHOULD GIVE
PREDNISOLONE (1ST LINE) OR
NEBULISED NORMAL SALINE (2ND LINE) TP LOOSEN TENACIOUS SECRETIONS
CS 1390 Para pneumonic effusion
Effusion in pleural space adjacent to pneumonia
Well’s Score for PE (Rm1004/5) HR>100 , Immobi > 3 days
HHIP with a CAMera. H.....HR >100 - 1.5 H.....Hemoptysis - 1 I.......Immobilisation - 1.5 P......Previous hx of DVT- 1.5 C......Clinical signs and symptoms of DVT - 3 A.......Alternate diagnosis is less likely - 3 M.....Malignancy - 1
(3) + SnS of DVT(leg swelling/ pain/ palpation of DVs)
(3) Ddx is less likely than PE
(1. 5)HR>100bpm
(1. 5)Immobilisation> 3 days (or) surgery in prev 4 weeks
(1. 5)Previous DVT/PE
(1) Haemoptysis
(1) Malignancy (on Tx, Tx last 6mth, or palliative)
> 4 ****PE likely:
PE unlikely: 4 points or less (1st Ddimer then CTPA)
Dx- CTPA
Delay in CTAP - therapeutic anticoagulation
Allergic to contrast - V/Q scan
How Often to clean Spacers , (W)Every month , (R)Every Year
Wash with soapy water monthly -
Leave it to air dry -
Do NOT use clean cloth to dry -
Replace every 1 year
Child asthma Mgx
MART(maintenance(ICS:fluticasone/ beclomethasone) and reliever therapy(LABA: formoterol) )
- very low dose ICS or LTRA (<5 YRS)
- very low dose ICS + LABA (>5 YRS) or LTRA (<5 YRS)-
- inc V.LOW dose to LOW dose ICS + LTRA or LABA(stop LABA if no response)
- REFER
SIADH (peeing out salt when you dont have enough salt in your body)
due to ↑ADH (water absorption hormone)
In SCC of Lungs (Ectopic production of ADH and ACTH)
Complete opposite of Diabetes Insipidus
Low serum Na , Low serum Osmolality , High Urine Osmolality due to ↑Na+
Causes
CA - Small Cell Carcinoma of lungs
CNS - Meningitis , Tumor , Stoke
Chest Infections - TB , Pneumonia
Normovolaemic Hyponatremia
Dx - ADH level ↑
Treat the cause Restrict Fluids (0.5-1L/24hr)
Coal Miner/ Industrial worker/ Farmer
upper zone scarring,
calcification and opacity with radiating strands =progressive massive fibrosis =
coal miners pneumoconiosis
Industrial worker: asbestos»_space; Mesothelioma;
Farmer worker»_space; Allergic alveolites;
Coal mine worker»_space; Massive fibrosis (pneumoconiosis).
Squamous cell / Small cell Ca happens smokngSentral leasions
Adenocarcinoma Peripheral leasionasbestos*Peripheral leasion
(S Sound)Central :
Squamous cell carcinoma : Keratin, intercellular bridges (if you see Keratin pick Squamous)
Small cell : Oat cell, neuroendocrine
Peripheral :
Large cell carcinoma:
Adenocarcinoma : Glandular, mucin producing large cell : anaplastic, undifferentiated sheets/nests of polygonal/multinuclear cells
Sq. Cell carcinoma + small cell caner»_space; centrally located»_space;»bronchoscopy for biopsy
Adenocarcinoma»_space;>peripherally located»_space;> trans-thoracic needle under CT guidance for biopsy
Mesothelioma»_space;> thoracoscopy for biopsy
Child / Adult / Asthma Mgx
Asthma excerbation Children: O-SIP-SAM 1.02 100% 2.Salbutamol neb 3.Ipratropium neb 4.Prednisolone oral or Iv hydrocortisone 5.IV salbutamol 6.Iv aminophylline 7.IV Mgso4
ADULTS: OSHIM
- O2 100%
- Salbutamol neb
- Hydrocortisone 100mg or oral prednisolone
- Ipratropium neb+Salbutamol neb every 15min
- IV Mgso4
COPD excerbation SNOwIN 1.antiniotic if sputum purulent 2.Steroid >>prednisolone 30mg 7-14d 3.O2 24-28% 2-4L/min by venturi mask target spo2:88-92% 4.IV aminophylline 5.NIPPV:acidosis,falling pao2, hypercapnia, altered mental state 6.Doxapram if rr<20
Child / Adult / Asthma Mgx COPD mgx
Asthma excerbation Children: O-SIP-SAM 1.02 100% 2.Salbutamol neb 3.Ipratropium neb 4.Prednisolone oral or Iv hydrocortisone 5.IV salbutamol 6.Iv aminophylline 7.IV Mgso4
ADULTS: OSHIM
- O2 100%
- Salbutamol neb
- Hydrocortisone 100mg or oral prednisolone
- Ipratropium neb+Salbutamol neb every 15min
- IV Mgso4
COPD excerbation SNOwIN 1.antiniotic if sputum purulent 2.Steroid >>prednisolone 30mg 7-14d 3.O2 24-28% 2-4L/min by venturi mask target spo2:88-92% 4.IV aminophylline 5.NIPPV:acidosis,falling pao2, hypercapnia, altered mental state 6.Doxapram if rr<20
Sarcoidosis ( Macrophages disorder / they produce Ca2* / asymp in 50%) 90% of symptoms are Lung(Bilat Hilar Lymph)
Unknown cause / early 20-40
Histology biopsy of skin nodules , lymph nodes - NON-Caseating Granuloma
LOFGREN SYNDROME
@BAE-
B/L HILAR LYMPHADENOPTAHY
ARTHRITIS (Poly)
ERYTHEMA NODUM
Heerfordt-Waldenstrom syndrome
@PUFF- PAROTID ENLARGEMENT UVEITIS FACIAL PALSY FEVER
56 yr old Lung CA with urinary retension , diminished reflexes , postural hypo , sluggish pupil reaction
Para Neoplastic Syndrome in Lung Cancer (esp in SCC )
Ca cell producing hormones and enzymes causing Effect IN different parts of the Body
Eg. ADH secreting … causing SIADH (Euvolemic Hypo-osomolar Hyponatremia with ↑Na in Concentrated Urine )
Stabbed form the back Tension Pneumo and Cardiac Tamponade and haemothorax
CT1216
Tension Pneumothorax (trachea deviation not always present )
In haemothorax(no distension of neck veins )
Beck’s Triad (Cardiac Tamponade )
Raised JVP
Hypovolemic
Muffled heart sound
Diagnosis of Asthma RM 3941
The initial test for 5 to 16 years is spirometry.
A bronchodilator reversibility (BDR) test should be considered if spirometry shows an obstruction.
if diagnostic uncertainty remains after spirometry and BDR, consider a FeNO test.
If diagnostic uncertainty remains after FeNO, monitor peak flow variability for 2 to 4 weeks.
The initial tests for >17 years and over are FeNO followed by spirometry.
A BDR test should be carried out if spirometry shows an obstruction.
If diagnostic uncertainty remains after FeNO, spirometry and BDR,
monitor peak flow variability for 2 to 4 weeks.
If diagnostic uncertainty remains after measuring peak flow variability,
refer for a histamine or methacholine direct bronchial challenge test.
Respiratory Failures RM1011
Type 1 (1 abnormal ) ↓PaO
Respiratory Alkalosis
Hypoxic failure
Type 2(2 abnormal ) ↓PaO ↑PaCO Respiratory Acidosis Hypercapnic failure
Legionella L5 Hotel and L5 Menu for taste
Legionella Hotel Low Na Low Albumin Lymphocytopenia Liver enzymes Elevated****
L5 Menu For Taste
Macrolide (Clarithromycin )
Fluoroquinolones
Tetracycline
Note to self
4C OF PULMONARY FIBROSIS
Coal worker
Cough(dry)
Clubbing Creps (bibasal fine inspiratory)
CLUBBING
- Bronchiectasis
- Bronchogenic Ca/mesothelioma
- Pulmonary fibrosis
- Extrinsic allergic alveolitis(chronic)
Bibasal fine inspiratory creps
- Pulmonary fibrosis
- Extrinsic allergic alveolitis
Coarse inspiratory creps
Bronchiectasis
EN3030 , COPD patient with oral thrush despite washing his mouth regularly
Most appropriate next step
As he wash his mouth regularly (dont need Nystatin )
Check Spacer technique with his inhaled corticosteroid
RM3290 Coughing up for 18 months but only cough a tablespoon(very less)/ Chronic smoker and dyspnea sometime steak of blood . Initial appropriate Inv
Chest X ray (to rule out Lung CA , Bronchiectasis )
if ruled out (COPD) then sent to resp nurse for Spirometry and blood test for polycythemia
Coal Miner / Farmer
Farmer EAA (acute 4-8 hours) no erosinophilia CXR- Diffuse Micronodular Interstitial Shadowing
Coal Miner (clubbing) Auscultation- Bi Basal fine end inspiratory crepitation
Broncho pleural fistula
- Seen in lung cancer more likely in pneumonectomy rather than lobectomy.
- More common in right side.
- Coughing of copious amount of brown fluid is pathognomonic for BPF.
- Diagnosis is confirmed by CT chest.
- Two X-ray needed with classic finding of drop in the air fluid level.
- Treatment is by endoscopy, bronchoscopy or open chest surgery.
RM 4052
85yr , COPD , increasing breathlessness , even on walking , BUT STILL SMOKES , most appropriate tx
NICE GUIDELINES
No long term oxygen for smoking pt
Ans: smoking cessation programme
