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Internal Medicine > Respiratory > Flashcards

Respiratory Flashcards

1
Q

Assessment of asthma control*

A
  1. Daytime symptoms >2x/ week
  2. Night waking
  3. Reliever use >2x/week
  4. Activity limitation
  • Well controlled: none above
  • Partly controlled: 1-2
  • Poor controlled: 3-4
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2
Q

Step ladder for Asthma - GINA*

A

1 - symptoms <2/month
(Preferred: As needed low dose ICS-formoterol)
2 - symptoms >2/month, but less than daily
(Preferred: Daily low dose inhaled ICS/ As-needed low dose ICS-formoterol)
3 - symptoms most day/ waking with asthma >=1/week
(Preferred: Low dose ICS-LABA)
4 - symptoms most days/ waking with asthma >=1/week/ low lung function
(Preferred: Medium dose ICS-LABA)
5 - uncontrolled symptoms/ exacerbation
(Preferred: High dose ICS-LABA; Refer for specialist assessment of contributory factors +- add-on therapy eg: tiotropium, anti-IgE

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3
Q

Adjusting treatment for asthma*

A

> Step up
Assess the following before consider stepping up treatment:
i. Incorrect inhaler technique
ii. Poor adherence to medications
iii. Modifiable risk factors
iv. Symptoms due to co-morbid conditions

  • Sustained step up (at least 2 - 3 months)-> persistent symptoms and/or exacerbations despite 2-3 months of controller treatment
  • Short term step up (for 1 - 2 weeks) with written asthma action plan e.g. for during viral infection or allergen exposure
  • Day-to-day adjustment by patient for those with mild asthma and on low dose ICS-formoterol as maintenance and reliever

> Step down
Indication: good asthma control for 3 months
Step down: reduce dosage of ICS by 25-50% at 2-3 month interval but never stop ICS unless the diagnosis is in doubt

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4
Q

Assessing the severity of acute asthma attack*

A 
○ Severe attack
§ Unable to complete sentences in one breath
§ Respiratory rate >25/min
§ Pulse rate >110 beats/min
§ PEF 33-50%
○ Life-threatening attack
§ PEF <33%
§ Silent chest, cyanosis
§ Arrhythmia or hypotension
§ Exhaustion, confusion or coma
§ ABG:
Normal/high PaCO2 >4.6kPa
PaO2 <8Pa, or SaO2 <92%
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5
Q

Approach to acute exacerbation of Asthma

A
  1. Assess severity of attack
  2. Immediate treatment
    - Supplemental O2 to maintain 94-98%
    - Salbutamol 5mg nebulized with O2
    - If severe + ipratropium 0.5mg/6h to nebulizers
    - Hydrocortisone 100mg IV/ Prednisolone 40-50mg PO
  3. Reassess every 15min
    - If PEF <75% repeat Salbutamol nebulizer every 15-30min. Add ipratropium if not already given
    - Monitor ECG; watch for arrhythmias
  4. -> If not improving
    - Refer ICU +- IV salbutamol
    - > If improving
    - Continue nebulized salbutamol every 4-6 hours
    - Prednisolone 40-50mg PO OD for 5-7 days
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6
Q

What is FEV1, FVC and their normal value

A
  • FEV1: the volume exhaled in the first second after deep inspiration and forced expiration (Normal: >80% predicted)
  • FVC: the total volume of air that the patient can forcibly exhale in one breath (Normal: >80% predicted)
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7
Q

GOLD classification

A

COPD severity

  • 1: Mild (FEV1 >= 80%)
  • 2: Moderate (50-80)
  • 3: Severe (30-50)
  • 4: Very severe (<30)
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8
Q

MMRC Scale*

A

Grade of dyspnea

  • 0: No except on strenous exercise
  • 1: SOB hurrying on level/ walking up slight hill
  • 2: Walk slower than same age/ stop for breath when walking at own pace on the level
  • 3: Stop for breath after walking about 100m/ few minutes on the level
  • 4: Too breathless to leave the house/ dressing
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9
Q

How to diagnose COPD

A
  • Spirometry (FEV1/ FVC <70%, both pre and post bronchodilator)
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10
Q

X-ray sign for COPD**

A
  • Hyperinflation
  • Flat hemidiaphragm
  • Large central pulmonary artery
  • Decrease peripheral vascular marking
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11
Q

HRCT finding for COPD

A
  • Bronchial wall thickening
  • Scarring
  • Air space enlargement
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12
Q

Medication for acute COPD attack

A
  • Nebulized bronchodilator: Salbutamol 5mg/4h and ipratropium 500mcg/6h
  • Controlled oxygen therapy if SaO2 <88% or PaO2 <7 kPa
  • Steroids: IV hydrocortisone 200mg and oral prednisolone 30mg OD (continue for 7-14 days)
  • Antibiotics: if evidence of infection, eg: amoxicillin 500mg/8h PO
  • IV Aminophylline: if no response to nebulizer and steroids
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13
Q

Causes of Bronchiectasis***

A

> Congenital

  • cystic fibrosis
  • primary ciliary dyskinesia

> Acquired

  • TB
  • pneumonia
  • bronchial obstruction (tumor, foreign body)
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14
Q

Signs of bronchiectasis*

A
  • Clubbing
  • Coarse inspiratory crepitation
  • Wheeze
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15
Q

Investigation for bronchiectasis***

A

> Initial Ix

  • CXR (tram-line, cystic lesion)
  • Spirometry (variable, may show obstructive pattern)

> To diagnosed bronchiectasis
- HRCT (signet ring appearance)

> To find the cause

  • Mantoux test
  • Sweat test
  • FBC
  • Sputum culture
  • Bronchoscopy (locate site of hemoptysis, exclude obstruction)
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16
Q

Management for bronchiectasis***

A
  • Airway clearance technique and mucolytic
  • Antibiotics
  • Bronchodilators (eg: nebulized salbutamol)
  • Corticosteroid (eg: prednisolone)
  • Surgery (indicated in local disease or to control severe hemoptysis)
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17
Q

History directing to asthma diagnosis

A
  • Wheeze, SOB
  • Diurnal variation
  • Response to exercise, cold air, allergen
  • Symptoms after aspirin, B-blocker
  • History/ Family Hx of atopy/ asthma
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18
Q

Light’s criteria

A

> Transudate

  • Fluid/Serum protein <=0.5
  • Fluid/Serum LDH <=0.6

> Exudate

  • Fluid/Serum protein >0.5
  • Fluid/Serum LDH >0.6
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19
Q

Definition of bronchiectasis**

A
  • Irreversible abnormal dilatation of the bronchial tree
  • Divide macroscopically into: cylindrical, varicose, cystic
  • Main organism: H. influenzae, Strep. pneumoniae, Staph. aureus
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20
Q

Complications of bronchiectasis*

A
  • Recurrent pneumonia
  • Empyema
  • Lung abscess
  • Progressive respiratory failure
  • Cor pulmonale
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21
Q

Physical signs expected in COPD**

A

> General

  • Breathlessness
  • Cachexia
  • Malnourished
  • Evidence of respiratory distress

> Respiratory

  • Reduced chest expansion
  • Reduced breath sound
  • Loss of cardiac dullness, downward displacement of liver - hyperinflated lungs
  • Coarse crepitation - sign of pneumonia

> Cardiovascular

  • Raised JVP
  • Right displacement of apex beat
  • Parasternal heave
  • Peripheral edema, hepatomegaly
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22
Q

Examination finding for pneumothorax**

A

○ Inspection
- Respiratory distress

○ General examination

  • Raised JVP
  • Distended neck veins
  • Tracheal deviation away

○ Respiratory examination

  • Reduced chest expansion
  • Hyper-resonance
  • Absent breath sound
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23
Q

CXR features of pneumothorax**

A
  • Exaggerated radiolucency
  • Loss of vascular marking
  • Contralateral shift of the trachea and mediastinum
  • Flattening of the ipsilateral diaphragm
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24
Q

Definition of COPD - Keyword*

A
  • Persistent, progressive

- Airway and/or alveolar abnormalities

25
Q

Definition of chronic bronchitis*

A
  • Chronic productive cough

- Most day for 3 months in 2 successive years

26
Q

CXR features of COPD***

A 
□ Hyperinflated lung
- >6 anterior or 10 posterior ribs in the midclavicular line at diaphragm level
□ Flat hemidiaphragms
□ Large central pulmonary arteries
□ Decrease peripheral vascular marking
27
Q

Management of acute COPD***

A
  1. Nebulized bronchodilators (Salbutamol 5mg/4h and ipratropium 500mcg/6h)
    Ix: CXR, ABG
  2. Controlled O2 therapy if SaO2 <88% (start at 24-28%, aim sat 88-92%)
  3. Steroids: IV hydrocortisone 200mg and oral prednisolone 30mg OD (continue for 7-14 days)
  4. Antibiotics: if infection; amoxicillin 500mg/8h PO
  5. If no response to nebulizer and steroids -> IV aminophylline
  6. If no response -> consider non-invasive positive pressure ventilation
28
Q

Pharmacological therapy for COPD**

A

> Bronchodilators

  • Beta agonist: salbutamol (short) and salmeterol (long)
  • SE: fine tremor, sinus tachycardia
  • Antimuscarinic: ipratropium bromide (short), tiotropium (long)
  • SE: dry mouth, metallic taste

> Corticosteroid

  • eg: fluticasone, beclomethasone, budesonide
  • SE: oral candidiasis, hoarseness of voice

> Phosphodiesterase-4 inhibitors
- eg: Roflumilast

29
Q

Management for pneumothorax***

A

> Spontaneous

  • Aspirate using 16-18G needle
  • Insert chest drain and admit

> Tension
- Emergency needle thoracentesis (2ns ICS at midclavicular line, insert chest tube)

30
Q

Definition of emphysema

A
  • abnormal permanent enlargement of air spaces
  • distal to the terminal bronchioles,
  • accompanied by the destruction of alveolar walls
31
Q

Definition of bronchiectasis

A
  • Abnormal chronic dilatation of one or more bronchi

- Associated with building up of mucus making the person more vulnerable to infection

32
Q

Finding differentiating COPD from bronchiectasis*

A

> COPD

  • Reduced chest expansion bilaterally
  • Breath sound: prolonged expiratory phase
  • Wheezing

> Bronchiectasis

  • Normal chest expansion, breath sound
  • Coarse crackles
33
Q

Classification of pneumothorax

A

> Main

  • Traumatic
  • Atraumatic -> primary (without known eliciting event); secondary (subsequently due to an underlying pulmonary disease)

> Alternative

  • Simple
  • Tension
  • Open
34
Q

Complication of smoking

A
  • Cancer
  • Heart disease
  • Stroke
  • Lung disease
  • Diabetes
  • COPD (eg: emphysema, chronic bronchitis)
35
Q

Investigation for TB**

A

> Active

  • CXR
  • Sputum smear (culture still be required even if smear is negative -> possible of smear negative TB)
  • Sputum culture
  • Nucleic acid amplification test

> Latent
- Tuberculin skin testing (Mantoux test)

36
Q

Light’s criteria**

A
  • For pleural effusion
  • Transudative:
    Fluid/ Serum protein <= 0.5
    Fluid/ Serum LDH <=0.6
  • Exudative
    Fluid/ Serum protein > 0.5
    Fluid/ Serum LDH >0.6
37
Q

Management for TB**

A
  • 2 month intensive phase (Rifampicin, Isoniazid, Pyrazinamide, Ethambutol) + 4 month maintenance phase (Rifampicin, Isoniazid)
38
Q

Management of close contact of TB**

A

> Asymptomatic
□ Mantoux test
□ CXR if Mantoux test >=10mm

> Symptomatic
□ CXR
□ Sputum AFB
□ Mantoux test

39
Q

Side effect of TB medications**

A
  • Rifampicin (enzyme inducer: care with warfarin, temporary discoloration of urine, sweat)
  • Isoniazid (peripheral neuropathy)
  • Pyrazinamide (hepatitis)
  • Ethambutol (optic neuritis)
40
Q

What is miliary TB*

A
  • Massive dissemination of TB via hematogenous route to various organs, including lung itself
  • Chest radiograph
    □ Involve both lung predominantly lower lobes
    □ Evenly distributed diffuse 2-3mm nodules
41
Q

Physical signs for pleural effusion*

A
  • Decrease chest expansion
  • Stony dull percussion
  • Diminished breath sound
  • Decreased tactile vocal fremitus and vocal resonance
  • Tracheal deviation
42
Q

Investigation for pleural effusion*

A
  • CXR: blunt costophrenic angle, meniscus sign, tracheal deviation
  • Pleural fluid aspiration: biochemistry, Gram/ AFB stain, culture and sensitivity, cytology (WCC, malignant cells)
43
Q

Monitoring of treatment for TB

A

> At 2 month
□ Repeat sputum AFB direct smear
□ Sputum MTB C&S if smear positive
□ CXR

> At 4 month and 6 month
□ Repeat sputum AFB direct smear
□ CXR

44
Q

Type of respiratory failure***

A

> Type 1 (normocapnia)

  • VQ mismatch
  • Cause: right to left shunt, alveolar hypoventilation
  • Mx: correcting hypoxia -> supplementary O2

> Type 2 (hypercapnia)

  • CO2 retention
  • Cause: weakness in resp muscle, obstructive lung disease (asthma, COPD)
  • Mx: correcting ventilation -> non-invasive/ invasive mechanical ventilation
45
Q

Asthma vs COPD***

A

> Asthma

  • Age before 40
  • Episodic symptoms with interspersed symptoms free period
  • Trigger: laughter, exercise
  • History of atopy
  • Relieved by bronchodilator, ICS

> COPD

  • Age after 40
  • Chronic and progressive
  • History of smoking, noxious fume
  • Bronchodilator only provide limited relief
46
Q

Investigation for COPD*

A
  • FBC: leukocytosis, polycythemia
  • ABG: respiratory acidosis
  • ECG: right atrial and ventricular hypertrophy
  • Sputum C&S
  • CXR
  • Spirometry
47
Q

Discharge criteria for COPD

A
  • Inhaled SABA requirement not more frequent than 4 hours
  • Able to ambulate
  • Able to eat and sleep without frequent awakening by SOB
  • Clinically and ABG stable for 12-24 hours
48
Q

Triggering factor for asthma exacerbation*

A
  • Viral respiratory infection
  • Allergen exposure
  • Food allergy
  • Poor adherence with ICS
  • Exercise
  • Change in weather
  • Laughter
49
Q

What is Respimat, Seretide

A
  • Respimat: tiotropium

- Seretide: fluticasone + salmeterol

50
Q

Risk factor for COPD

A
  • Tobacco smoking
  • Occupational exposure to dust, fumes
  • Childhood respiratory infections
51
Q

Content of Seretide

A
  • Fluticasone (Steroid) + Salmeterol (LABA)

- Purple color, round inhaler

52
Q

What are classes of COPD

A

> No or 1 exacerbation not leading to hospitalization

  • A: mMRC 0-1
  • B: mMRC >=2

> > =2 exacerbation or >=1 exacerbation leading to hospitalization

  • C: mMRC 0-1
  • D: mMRC >=2
53
Q

Investigation for asthma

A 
> To diagnosed asthma
- Spirometry
□ FEV1/FVC <70%
□ Positive reversible test (FEV1 improve >200cc and 12% from baseline, after 10-15 minutes after 200-400mcg salbutamol)
- PEFR
□ Diurnal variation >10%

> During exacerbation
- Spirometry
□ If possible, recorded before treatment is initiates
- ABG
□ For patient with PEF or FEV1 <50% predicted, or do not respond to initial treatment
- CXR
□ Not responding to treatment and a pneumothorax is suspected

54
Q

Mechanism of O2 induced hypercapnia in COPD

A
  • The Haldane effect: rightward displacement of the CO2-hemoglobin dissociation curve in the presence of increased oxygen tension
  • Modest decrease in minute ventilation, which also reduces alveolar ventilation, due to decreased stimuli from peripheral chemoreceptor to the central respiratory center
55
Q

ECG changes of pulmonary embolism

A

> S1Q3T3 (McGinn-White sign)

  • Classic pattern of acute cor pulmonale
  • Large S wave in lead I, Q wave in lead III and inverted T wave in lead III
56
Q

Management of pulmonary embolism

A

> Hemodynamic unstable

  • Systemic thrombolysis: IV rtPA
  • Others: percutaneous catheter-directed thrombolysis, surgical embolectomy

> Stable

  • Anticoagulation: SC LMWH, fondaparinux
  • Rescue thrombolysis: if serum troponin +ve and RV dysfunction present

> Long-term
- Anticoagulation: min 3 months for all patient

57
Q

Important investigation for pulmonary embolism

A
  • ECG: S1 Q3 T3
  • CXR: oligemia of affected segment, dilated pulmonary artery, pleural effusion, wedge shape opacities
  • D dimer: +ve suggestive of PE
  • CTPA: look for filling defect in pulmonary artery due to embolus
58
Q

Classification of cough based on duration

A
  • Acute: <3 weeks
  • Subacute: 3-8 weeks
  • Chronic: >8 weeks

Internal Medicine (12 decks)

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