Respiratory Flashcards
What antibiotic is used in P.Jirovecci
Co-trimoxazole
Legionella
Flu + Dry Cough
Bradychardia
Confusion
Hyponaetramia
What is the antibiotic of choice in Legionella Pneumonia
Macrolides
Azithromycin and Erythromicin
How is Legionella diagnosed
Urinary Antigen
What is offered to a COPD patient with recurrent infections?
Azithromycin prophylaxis
In a viral induced wheeze what is prescribed?
First Line - SABA
Second Line - ICS or Oral Montelukast
In a multiple trigger wheeze what is prescribed?
A trial of a ICS or Oral Montelukast for 4-6 weeks
In a secondary pneumothorax <1cm what is the management?
Admission and Oxygen
If you have an acute exacerbation in a COPD. What are the indications for using non invasive ventilation?
Despite receiving adequate treatment they have a Respiratory Acidosis of 7.25-7.35.
What non invasive ventilation is used first line in acidotic COPD patients?
Bi-PAP
What is Klebsiella linked to?
Development of an empyema
When can a COPD patient receive Long Term Oxygen Therapy?
Stopped Smoking
Over two separate occasions pO2 <7.3
Management of Acute Bronchitis
Guided by CRP
20-100 Delayed Amoxicillin or doxycycline prescription
>100 - Immediate Amoxicillin or Doxycycline prescription
Upper Zone Fibrosis
Coal Sarcoidosis Silicon Ankylosing Spondylitis TB
Lower Zone Fibrosis
Idiopathic Pulmonary Fibrosis
Connective Tissue Disorders
Drugs induced - bleomycin amiodarone
Asbestosis
If Emphysema is located mainly in the upper lungs what is the likely cause?
COPD
If emphysema is located mainly in the lower lobes what is the likely cause?
Alpha 1 Anti Trypsin deficiency
Treatment for Alpha 1 Anti trypsin Deficiency
Bronchodilator Physiotherapy IV A1AT protein Lung volume reduction surgery Transplant
If someones Wells PE score is over 4 what does this mean?
A PE is likely - CTPA should be done ASAP
If there is a delay with the CTPA a DOAC should be started.
If someones WELLs score comes back less than four what does this mean?
PE is unlikely - D-Dimer is indicated to rule it out completely.
WELLs score of less than 4 but D-Dimer is +ve
CTPA is indicated - if delay in getting DOAC should be started
What is indicated in all patients with a suspected PE?
Chest X-Ray to rule out other pathology
WELLs score of less than 4 and a -ve D-Dimer
PE is ruled out stop anticoagulation if started and look for alternative.
If someones WELLs score is over 4 but their CTPA shows no signs what is the next investigation to undertake?
Doppler for DVT
Criteria for Bi PAP use in COPD
Persistent Respiratory Acidosis 7.25-7.35 despite tailored oxygen therapy.
Gynaecomastia
Hypertrophic pulmonary osteoarthropathy
Adenocarcinoma
SIADH
Ectopic ACTH
Lamberton Eaton sydrome
Small Cell Carcinoma
Clubbing
Hypercalcaemia (pPTH)
Squamous Cell Carcinoma
If someone has had a PE which has a trigger i.e recent surgery. How long should they be anticoagulated ?
3 months DOAC
If someone has an unprovoked PE how long should they be anti coagulated for?
6 months DOAC
When is Heparin and warfarin used in a PE?
Contraidicated
Or eGFR <15 - LMWH is used to bridge warfarin cover
CAP - CURB65 = 0 - 2
Amoxicillin Oral
Pen allergy Doxycycline
5 days
CAP CURB65 = 3 - 5
IV Co Amoxiclav + Oral Doxycycline
Pen allergic - levofloxacin mono therapy
5 days
CAP - ICU or HDU
IV Co-Amoxiclav + Clarithromycin
Stepping down to Doxycycline
Pen allergy - Levofloxacin monotherapy
5 days
HAP - Non Severe
Amoxicillin 5 days
Pen allergy = doxycycline
HAP - Severe
IV Amoxicillin + Gentamicin
Pen allergy = Co trimoxazole + Gentamicin
Step Down therapy is Oral Co Trimoxazole
7 days
Aspiration Pneumonia - Non severe
Oral Amoxicillin + Metronidazole
Pen allergy - Doxycycline + metronidazole
5 days
Aspiration Pneumonia - Severe
IV Amoxicillin + Metronidazole + Gentamicin
Pen allergy - either doxycycline or clarithromycin
7 days
What are the indications for Antibiotic use in a COPD exacerbation?
Purulent Sputum
No purulent sputum but consolidation on X-Ray
Antibiotics in acute exacerbation of COPD
1st line Amoxicillin
2nd line Doxycycline
A dry cough +/- haemoptysis
Chest x ray shows a cresenteric lesion
past medical history of cavitating lesion
Aspergilloma
What can pre dispose you to an aspergilloma?
TB
Sarcoid
Bronchiectasis
Anklysoing spondylitis
What investigations should be undertaken in a query aspergilloma?
Chest Xray
High titre aspergillose precipitant
<6mm Mantoux test
Unlikely infection or vaccination.
Can administer BCG if required
6 - 15mm Mantoux test
Likely TB or BCG vaccination
> 15mm
Extremely likely TB infection
A1AT - obstructive or restrictive?
Obstructive present similarly to COPD
Pleural effusion - Protein >30g
Exudate - think malignancy infection PE etc
Pleural Effusion - Protein <30g
Transudate - HF, Cirrhosis Nephrotic syndrome
Other signs pleural effusion is due to an exudate.
Increased LDH - Pleural LDH is over 2/3 of normal plasma LDH
Pleural Protein / Serum protein = > 0.5
Pleural effusion in Rheumatoid Arthritis or TB
Low glucose
Pleural effusion in pancreatitis or oesophageal perforation
Raised amylase
Diagnosis of asthma.
<5 years - clinical diagnosis only
6-17 years - Spirometry and Bronchodilator reversibility test
>18 - Spirometry Bronchodilator reversibility test and FeNO
When is a bronchodilator reversibility test positive. Indicating asthma is likely?
If FEV1 increase by 12% or more
When might you use the FeNO test in someone aged 6-17?
If you have a strong clinical suspicion and reasoning but the other tests have come back negative.
Someone with a label of recent onset asthma has signs of eosinophilia and bronchiectasis what should be on your mind?
Allergic Bronchopulmonary Aspergillus - Increased IgE Aspergillus +ve
How is allergic bronchopulmonary aspergillosis managed?
Oral glucocorticoids -> Itraconazol
ABG in panic attack
Respiratory Alkalosis
Low CO2
Normal O2 and HCO3
Contraindication to surgical management of lung cancer
SVC obstruction
Vocal chord paralysis
FEV1 <1.5l
Malignant pleural effusion
What investigation is diagnostic of Sleep Apnoea
Polysomnography
Idiopathic Pulmonary Fibrosis - Diagnosis and Management
Spirometry -> reduced gas exchange transfer factor (TLCO) -> high resolution CT
Pulmonary rehab -> pirfenidone -> lung transplant
Management of pneumonia with a CURB65 of 0
Antibiotics at home
COPD management
- SABA or SAMA
- Asthmatic - ICS + LABA + SABA ( replaced SAMA)
Non Asthmatic - SABA (replaced SAMA) + LABA + LAMA - SABA + LABA + LAMA + ICS
If someone has developed HAP after day 5 in hospital what antibiotics are required?
Piperacillin and Tazobactam
or Ceftazadime
or Ciprofloxacin
Needs to cover pseudomonas
How long between each inhaler dose?
30 seconds
PEFR 50-75%
Normal speech
RR <25
Pulse<110
Moderate asthma
PEFR 33-50%
Cant complete a sentence
RR >25
>110bpm
Severe asthma attack
PEFR <33% <92% sats Silent chest Bradychardia Hypotension Confusion Normal pCO2
Life threatening
Increased pCO2
Mechanical ventilation required
Near fatal
When should an ABG be undertaken in acute asthma?
If oxygen sats <92%
Indications for a chest xray in asthma
Life threatening exacerbation
Pneumothorax
Failure to respond to management
Bordatella pertusis - diagnosis and management
Whooping cough + post coughing vomiting + subconjunctival haemorrhage
Nasal swab for diagnosis
Macrolides given + close house hold prophylaxis
Vaccine for 16-32 weeks pregnant
Admit if under 6 months
Start school 48hrs after antibiotics
Mesothelioma - diagnosis
X ray -> Pleural CT -> Pleural aspirate -> Thoracoscopy + histology
Acute - Dyspnoea Dry cough and fever
Chronic - Lethargy dyspnoea productive cough anorexia
Farmer, bird keeper, mushroom picker
Extrinsic Allergic Alveolitis
Type III hypersensitivity
Avoid allergy + oral glucocorticoids
Diagnosis of Extrinsic Allergic Alveolitis
Chest Xray -> upper and mid zone fibrosis
Bronchealveolar lavage -> lymphocytosis
Bloods - IgG and no eosinophils
How is latent TB managed?
Rifampicin + Isoniazide for 3 months
or
Isoniazide for 6 months
What medication is given to all people suffering with an acute exacerbation of COPD regardless of whether they qualify for antibiotics?
30mg Prednisolone for 5 days
Staging COPD
COPD is a FEV1/FVC ratio of <0.7
Stage 1 is mild = >80% predicted FEV1
Stage 2 is moderate = 50% - 79% predicted FEV1
Stage 3 is severe = 30% - 49% predicted FEV1
Stage 4 is V.Severe = <30% predicted FEV1
What are some characteristics that might point you more towards a Strep Pneumonia as a cause of pneumonia?
Reactivation of cold sores
Rust coloured sputum
What conditions affecting the lungs can cause an increased Transfer Coefficient ?
Scoliosis
Pneumonectomy
Neuromuscular weakness
Ankylosing spondylitis
What lung conditions increase the TLCO?
Asthma
Pulmonary Haemorrhage
Alongside Co Trimoxazole what should be used in Pneumocytis Jiroveci Pneumonia?
Steroids if hypoxic
Long term mechanical ventilation places you at risk of.
Tracheal Oesophageal Fistula -> aspiration pneumonia
Someone develops dyspnoea and hypoxemia 72 hours post surgery
Atelectasis - alveolar collapse -> shows opaque area
Sit upright and chest physio
What is the first thing you should do in anyone who is breathless?
Sit upright
When starting asthma management. What should be considered if they report a persistent night time cough keeping them up at night.
Start on SABA + ICS
Type 1 pneumothorax + <2cm rim and no symptom
Discharge
Type 1 pneumothorax + >2m rim and symptoms
Chest drain
Type 1 Pneumothorax + <2cm rim + symptoms
Aspirate
Secondary Pneumothorax + <1cm rim and no symptoms
Admit for 24 hours and oxygen
Secondary Pneumothorax + >2cm rim + SOB
Chest drain
Secondary Pneumothorax + 1-2cm + Symptoms
Aspirate
Advice post pneumothorax
NEVER scuba dive
Fly 1 week post Xray check
What are some indications for chest drain removal
Pneumothorax - if no longer spontaneously bubbles or coughing doesn’t cause bubbles
Pleural effusion - if drain has been dry for 24 hours
If someone develops worsening SOB and cough post chest drain insertion what might be happening?
Re expansion pulmonary oedema - clamp the drain and send for xray
Management of Non small cell lung cancer
1st line - curative lobectomy
Curative radiotherapy is offered for Stage I, II, III
Palliative Chemotherapy is offered for Stage III, IV
Management of Small Cell Lung cancer
Generally just palliative chemotherapy
Contraindications to curative lobectomy in lung cancer
FEV1 <1.5
Vocal chord paralysis
Metastatic disease
SVC obstruction
Management of pleural plaques
X ray
No further investigations required
Often asymptomatic and no malignant potential
Management of sarcoid
Generally just symptomatic - NSAIDs paracetamol etc
Steroids if - Neuro/cardio/renal/hepatic/splenic/ocular involvement
- worsening pulmonary function
-Hypercalcaemia
-Lupus pernio
Life Threatening Asthma
PEFR < 33% best or predicted Oxygen sats < 92% 'Normal' pC02 (4.6-6.0 kPa) Silent chest, cyanosis or feeble respiratory effort Bradycardia, dysrhythmia or hypotension Exhaustion, confusion or coma
Severe Asthma
PEFR 33 - 50% best or predicted
Can’t complete sentences
RR > 25/min
Pulse > 110 bpm
Moderate
PEFR 50-75% best or predicted
Speech normal
RR < 25 / min
Pulse < 110 bpm
Long term oxygen therapy in COPD
pO2 Kpa 7.3-7.8 \+ 1 off the following Polycythaemia Peripheral oedema Pulmonary hypertension
Allergic Bronchopulmary Aspergillosis management
Reducing prednisilone course
+/- Itraconazole
TB diagnosis
3 early morning sputum tests +ve for acid fast bacilli
+ history
Diagnostic of mycoplasma pneumonia
Urine Serology
Commonest cause of occupational asthma
Isocyonate
Latent TB management
6 months Isoniazide + pyroxidine
3 months Isoniazide + pyroxidine + rifampicin
Pyroxidine is Vitamin B6
A diurnal variation could indicate what in the context of COPD?
> 20% over the day is indicative of asthmatic features.
Include ICS in management.
What is a 1 pack year?
20 cigarettes a day for a year.
So 40 cigarettes is 2 pack years and 30 is 1.5 pack years
Causes of type II respiratory failure
COPD Brain lesion Bronchitis MND Deformity - scoliosis etc
Causes of type I respiratory failure
Ventilation perfusion mismatch Patent shunt Pneumonia ARDS PE
How does acute TB usually present on X ray
Patchy opacification across both upper zones
PE management at initial presentation
General history and examination
Chest Xray to exclude other causes
Calculate WELLs score
Indications for a thoracotomy
1.5L of blood removed initially
or
>200ml still draining an hour
