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