Respiratory Flashcards
Describe the clinical features of pulmonary hypertension
Exertional dyspnoea
Lethargy
Fatigue
RVF – peripheral oedema & abdominal pain from hepatic congestion
Describe the management of pulmonary hypertension
Oxygen
Anticoagulation
Diuretics for oedema
Oral CCBs
Describe the management of type 1 respiratory failure
Treat underlying cause
Give oxygen
Assisted ventilation
Describe the management of type 2 respiratory failure
Treat underlying cause
Controlled oxygen therapy – should be given with care
Recheck ABG after 20 minutes, if PaCO2 steady or lower, increase O2 concentration to 28%
If this fails – consider intubation and ventilation if appropriate
Describe the different severities of asthma
Mild: no features of severe asthma, PEFR > 75%
Moderate: no feature of severe asthma, PEFR 50-75%
Severe (if any one of the following): PEFR 33-50% of best or predicted, cannot complete sentences in one breath, respiratory rate > 25, heart rate > 110/min
Life-threatening (if any one of the following): PEFR < 33% of best or predicted, sats < 92%/ABG pO2 < 8kPa, cyanosis, poor respiratory effort, near/fully silent chest, exhaustion, confusion, hypotension/arrhythmias, normal pCO2
Near fatal: raised pCO2
Describe acute asthma management
Acute asthma management: ABCDE, aim for spO2 94-98% with oxygen, ABG if sats <92%
5mg nebulised salbutamol
40mg oral prednisolone STAT
Severe: nebulised ipratropium bromide 500 micrograms, consider back to back salbutamol
Life threatening or near fatal: urgent ITU/anaesthetist assessment, urgent portable CXR, IV aminophylline & consider IV salbutamol if nebulised route ineffective
Describe differentials in eosinophilia
Asthma – some patients have eosinophilic inflammation which typically responds to steroids
Differentials: hayfever/allergies, lymphoma, SLE, eosinophilic pneumonia
Describe outpatient COPD management
COPD care bundle
Smoking cessation
Pulmonary rehabilitation
Bronchodilators
Antimuscarinics
Steroids
Mucolytics
Diet
Describe long term oxygen therapy in COPD
Extended periods of hypoxia cause renal & cardiac damage – can be prevented by LTOT (to be used at least 16 hours/day)
Offered if pO2 consistently below 7.3kPa or below 8kPa with cor pulmonale
Must be non-smokers and not retain high levels of CO2
Describe pulmonary rehabilitation in COPD
Many COPD patients with COPD avoid exercise & physical activity because breathlessness
-may lead to a vicious cycle of increasing social isolation and inactivity leading to worsening of symptoms
Pulmonary rehab – aims to break this cycle -> an MDT 6-12 week programme of supervised exercise, unsupervised home exercise, nutritional advice & disease education
Describe COPD exacerbation management
ABCDE
Oxygen – target SaO2 94-98% but if any evidence of acute/previous type 2 respiratory failure, then target SaO2 88-92%
Salbutamol and ipratropium
Steroids – prednisolone 30mg STAT and OD for 7 days
Abx if raised CRP/WCC or purulent sputum
CXR
Consider IV aminophylline
Consider NIV if type 2 resp failure & pH 7.25-7.35, pH < 7.25 consider ITU referral
Describe pneumonia management (emergency)
ABCDE
If any features of sepsis – immediately treat using sepsis pathway (NO DELAY in initiating IV abx and fluids)
If not, treat with abx as per CURB-65 score
List the CURB-65 score
C = confusion, MMT 2 or more points worse
U = urea > 7
R = > 30/min
B = < 90mmHg systolic or < 60mmHg diastolic
65 = age above 65 years
Describe the different organisms which cause pneumonia
Community acquired:
1) Common organisms – streptococcus pneumonia, haemophilus influenza, Moraxella catarrhalis
2) Atypical – legionella pneumophilia, chlamydia pneumoniae, mycoplasma pneumoniae
Hospital acquired – E.coli, MRSA, peudomonas
List the causes of a non-resolving pneumonia
CHAOS
Complication – empyema, lung abscess
Host – immunocompromised
Antibiotic – inadequate dose, poor oral absorption
Organism – resistant or unexpected organisms not covered by empirical abx
Second diagnosis – PE, cancer
Describe the hospital management of covid-19
Oxygen supplementation – CPAP or invasive ventilation
Dexamethasone (& consider tocilizumab +/- remdesivir)
Abx may be needed if suspected superadded bacterial infection
List investigations for a suspected pulmonary embolus
U&Es, FBC, baseline clotting
ECG
CXR
ABG
Serum d-dimer
CT pulmonary angiography
Describe the management of a pulmonary embolus
Acute: oxygen, morphine & anti-emetic
LMWH/fondaparinux
Long-term anticoagulation: either DOAC or warfarin
Treat underlying cause
List investigations for suspected TB
Culture
If productive cough – x3 sputum samples for acid-alcohol fast bacilli
Routine bloods (especially LFTs) & HIV test and vit D levels
Describe the management of TB
4 antibiotics for first two months – rifampicin, isoniazid, pyrazinamide, ethambutol
2 antibiotics for 4 months – rifampicin & isoniazid
Dose of anti-TB abx is weight dependent
List the major side effects of TB treatment
Rifampicin – hepatitis, rashes, orange/red secretions
Isoniazid – hepatitis, rashes, psychosis
Pyrazinamide – hepatitis, rashes, vomiting, arthralgia
Ethambutol – retrobulbar neuritis
List investigations for suspected bronchiectasis
High resolution CT
Blood tests – immunoglobulin, cystic fibrosis genotype, HIV test, RF
Sputum culture
Describe management of bronchiectasis
Treat underlying cause
Physiotherapy
10-14 abx according to sputum cultures
1) Haemophilus influenza: amoxicillin
2) Pseudomonas aeruginosa: ciprofloxacin
IV abx for severe infections
Long-term prophylactic abx for patients with recurrent infective exacerbations
List investigations for suspected cystic fibrosis
One or more of:
1) History of CF in sibling
2) Positive newborn screening result
AND:
1) Increased chloride concentration in sweat test
2) Identification of two CF mutations
3) Demonstration of abnormal nasal epithelial ion transport
Describe the management of cystic fibrosis
Physiotherapy, exercise
Mucolytics
Pancreatic enzyme replacement therapy for patients with pancreatic insufficiency
Fat soluble vitamins ADEK
Nutritional supplementation for underweight
List investigations for suspected interstitial lung disease
Pulmonary function tests – restrictive pattern
Bloods – ANA, ENA, Rh F, ANCA, anti-GBM, ACE, IgG
Describe the management for interstitial lung disease
Depends on underlying pathology
Remove occupational exposure/environmental exposure
Avoid drugs associated
Stop smoking
MDT approach
Treatment of infective exacerbations
List the investigations for suspected lung cancer
Bloods – FBC, U&E, calcium, LFTs, INR
CXR
Staging CT
Histology – bronchoscopy
PET scan – MDT decision if patient is a surgical candidate & initial CT suggestive of low stage
Describe the management of lung cancer
Curative surgery for stages I & II
Chemotherapy
Radiotherapy
Palliative care
List investigations for suspected pleural effusion
Ultrasound guided pleural aspiration – biochemistry, cytology, microbiology
Consider thoracoscopy or CT pleural biopsy
CXR
Describe the management of pleural effusion
Conservative management – small effusions will resolve treatment of the underlying cause
Pleural aspiration – sticking a needle in & aspirating the fluid -> temporarily relieve the pressure
Chest drain – drain the effusion & prevent it recurring
List exudative and transudative causes of pleural effusion
Exudative – lung cancer, pneumonia, rheumatoid arthritis, TB
Transudative – CCF, hypoalbuminaemia, hypothyroidism, Meig’s syndrome (right sided effusion with ovarian malignancy)
Describe the management of pneumothorax
Primary – if symptomatic and rim of air >2cm on CXR, give O2 and aspirate; if unsuccessful consider re-aspiration/intercoastal drain
Secondary – as above but lower threshold for ICD
Persistent air leak > 5 days – refer to thoracic surgeons
List investigations done for obstructive sleep apnoea
Sleep study
1) Overnight oximetry
2) Limited sleep study (inc. oximetry, snoring, body movement, heart rate = study of choice
3) Full polysomnography
Describe the management for obstructive sleep apnoea
Weight loss, sleep upright, avoid/reduce evening alcohol intake
Snorers & mild OSA – mandibular advancement devices, consider pharyngeal surgery as last resort
Significant OSA – nasal CPAP, consider gastroplasty/bypass & rarely tracheostomy
Severe OSA & CO2 retention – period of NIV prior to CPAP if acidotic, but compensated CO” may reverse with CPAP alone
Describe cor pulmonale
Right sided heart failure caused by respiratory disease
Right ventricle being unable to effectively pump blood out of the ventricle & into the pulmonary arteries -> back pressure of blood in the right atrium, vena cava & systemic venous system
Describe the management of cor pulmonale
Treating the symptoms and underlying cause
Long term oxygen therapy
(NB: prognosis is poor unless reversible underlying cause)
