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Respiratory Flashcards

1
Q

What does this show?

A

Moderate Chronic Obstructive Pulmonary disease

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2
Q

Lifestyle management Strategies for COPD

(5)

A

SPRINT

Stop smoking

Pulmonary Rehab + usual exercise recommendations

Regular reviews (start of careplan and have an action plan)

Immunisations especially pneumococcal and influenza

Nutrition- balanced diet and healthy weight

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3
Q

What is the treatment (and prophylaxis) for pertussis? with dosing

A

Clarithromycin: (child 7.5 mg/kg up to) 500 mg orally 12 hourly for 7 days

OR

Erythromycin: (child 10 mg/kg up to) 250 mg orally, 6 hourly for 7 days

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4
Q

How do you diagnose Asthma?

A

there is no one test.

  1. Spirometry that shows reversible airflow of > 12% AND 200ml (anything > 400ml is strongly indicative)
  2. Peak flow measurements. Over 14 days. If there is a greater than 20% difference between the highest and lowest measurements.
  3. Clinical assessment alone can be enough.
  4. Clinical trial/treatment trial to assess improvement.
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5
Q

What increases the possibility of an Asthma Diagnosis?

A

More than one of:
1- wheeze
2- chest tightness
3 - SOB
4- cough

AND

1- worse at night
2- occurs during exercise
3- occurs after exposure to cold air or allergens
4- occurs after NSAID or B-Blocker use

Other factors that increase possibility

-History of atopy: personal or family
-Widespread wheeze on auscultation
-Improvement with therapy
-Unexplained eosinophilia on bloods

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6
Q

What FEV1 measurements delineate the severity of asthma?

A

FEV1 > 80% predicted = mild
FEV 1 60-80% = moderate
FEV1 < 60% = severe

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7
Q

What main co-morbidities are important in asthma management?

(5)

A

Obesity
Anxiety and Depression
Allergic rhinitis and sinus issues - rhinosinusitis
GORD
Inducible laryngeal obstruction

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8
Q

What triggers should be avoided/be mindful off in asthma?

(5)

A
  1. Always avoid cigarette smoke
  2. Allergens- dust, pollen
  3. Drugs like NSAIDs, Beta Blockers
  4. Environment: cold air, occupational irritants, pollution
  5. Dietary triggers if patient has a food intolerance
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9
Q

What are the diet and exercise recommendations for asthma

A

Diet:
Mediterranean diet
Refer to the Australian Dietary Guidelines

Exercise
Regular exercise at usual recommendations still recommended.

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10
Q

What education should you cover with a patient regarding asthma?

(6)

A

1 what is asthma
2 rationale for treatment
3 difference in relievers and preventers
4 education in inhaler technique
5 potential adverse outcomes of treatment
6 what to do if there is an exacerbation

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11
Q

What is step 1 pharmacotherapy in all asthma patients?

A

As needed Salbutamol 100microg/puff in a MDI

1-5 years 2-6 Puffs, through a spacer , when needed

Children aged 6+ and adults
2-12 puffs, through a spacer, as needed

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12
Q

What is step 2 therapy in different aged patients for asthma?

(not including the SABA in step 1)

A

1-5 years old:

Fluticasone propionate 50-100micrograms Inhaled with a MDI, through a spacer, 12 hourly
(or other ICS)

OR

Montelukast 4mg, orally, daily

6-12 years old:

Fluticasone 50-100micrograms, by DPI or pMDI with spacer, 12 hourly.
(or other ICS)

OR

Montelukast 5mg, orally, daily.

In adults:

Same fluticasone dosing Or other ICS

Or

Montelukast 10mg, orally, daily

ORRR

Symbicort combination (no SABA needed)
budesonide + formeterol 100+6 micrograms, via a DPI or pMDI with spacer. taken WHEN NEEDED in step 2.

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13
Q

Step 3 Therapy for different age groups in asthma?

(not including reliever therapy).

A

Children 1-5 years
Increased ICS dose (fluticasone 125microg in pMDI with spacer, 12 hourly)
OR
normal ICS dose + montelukast 4mg, oral, daily
AND
refer

Children 6-12 years old
Increased ICS dose (e.g. fluticasone 125-250microgram in pMDI with spacer, 12 hourly)
OR
Normal ICS dose and 5mg Montelukast, oral, daily
Or
Normal ICS dose and low dose LABA (e.g. fluticasone + salmeterol 100+50micrograms inhaled using pMDI and spacer, 12 hourly)

Adults
First line: add a LABA to ICS
flucticasone +salmeterol 100+50micrograms inhaled via pMDI with spacer (or DPI) , 12 hourly

Second:
Higher dose ICS
Flucticasone 500micrograms inhaled via pMDI with spacer, 12 hourly
up to 1000micrograms

OR

Fluticasone normal dose (50-100 microg) + montelukast 10mg oral daily

OR

Symbicort option regular 100+6 (or 200+6) micrograms, via DPI, 12 hourly
+ PRN Symbicort
(patient needs to fail other therapy first)

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14
Q

what should asthma reviews ALWAYS consist of checking?

What 2 other things can you check?

(2) +(2)

A

Inhaler technique

Adherence

Check comorbidity management (e.g. rhinitis)

Check avoidance or presence of triggers

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15
Q

What is the follow up time frame for asthma?

A

4-6 weeks after initiating therapy
then 12 monthly if no exacerbations
or 6 monthly if 1 exacerbation in the last 12 months
or 3 monthly if poor perceiver, or frequent exacerbations.

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16
Q

What is poor control of asthma defined as in an adult? vs Child?

A

ADULTS
Three or more of the following

  1. > 2 days of daytime symptoms
  2. > 2days of SABA use
  3. any limitations of activities
  4. any symptoms at night or wakening

CHILDS
Either of
A. daytime symptoms on more than 2 days a week lasting for minutes to hours, recurring or only partially relieved by SABA
B. Three or more features of partial control !

Partial control for a child:
one or two of the below
(same as above for adults)

NB limitation of activities is wheeze or breathlessness during exercise, play or laughter

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17
Q

What are the symptoms and how do you diagnose COPD?

A

Breathlessness
Wheezing
Cough
Sputum production
Recurrent infection

FEV1/FVC < 0.7 (post bronchodilator)

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18
Q

What do you use to diagnose COPD on spirometry and what do you use, with cut offs to define Severity?

A

FEV1/FVC ratio of <0.7 post bronchodilator to diagnose COPD

USE FEV1 alone to judge severity

> 80% would be unlikely to happen
60-80% is mild
40-60% is moderated
<40% is severe

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19
Q

What is the first step in treatment (pharmacological) in treating COPD?

A

Start with a SABA or SAMA
SABAs are preferred.

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20
Q

For COPD what are long acting medications that can be added to SABAs and general measures?

A
  1. LAMA
    e.g. Tiotropium 13-18micrograms, DPI, daily
  2. LABA
    the LABA that is PBS approved for COPD is indaceterol
    150micrograms, DPI, daily
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21
Q

If the first/second step of COPD management, if a LAMA or LABA addition doesn’t control asthma, what is the next option?

When do you need an ICS

A
  1. BOTH a LAMA AND LABA
    e.g. tiotropium and olodaterol 5+5micrograms via mist inhaler daily
  2. ICS can be used if patient has had a recent exacerbation that required hospitilisation or 2 moderate exacerbations
    OR regular symptoms despite DUAL long acting therapy

Nb never use ICS as sole monotherapy in COPD. risk of LRTI

22
Q

What are the 2 requirements for home O2 in COPD?

A

Needs to have quit smoking (only 1 month is needed)
AND
Sats < 90%

23
Q

When should you consider referral for a COPD patient?

(5)

A
  1. When there’s diagnostic uncertainty
  2. Frequent exacerbations despite long acting therapy and non drug therapy
  3. unusual symptoms: haemoptysis
  4. Rapid FEV1 decline
  5. COPD in anyone < 40 (to investigate for A1AntiTrypsin)
24
Q

When should you consider Antibiotics in a COPD exacerbation?

what can you use?

A

A. only if ALL three are met

  1. Increased sputum purulence
  2. Change in sputum colour or change in volume
  3. Fever

B. Amoxicillin 1g 12 hourly, 5 days or 500mg 8 hourly 5 days
OR
Doxycycline 100mg, orally, daily for 5 days

25
Most common causes for Community Acquired Pneumonia?
Streptococcus Pneumoniae Or Mycoplasma, chlamydia, Legionella
26
What initial investigations are appropriate for work up of CAP?
1. CXR 2. Sputum for MCS 3. oxygen saturation (not really an investigation) 4. Severity assessment - see emergency medicine 5. Urinary antigens (pneumonoccocal or legionella) - consider for hospitalised patients 6. CRP - more for the sake of tracking
27
What is first line therapy for a low severity CAP?
Amoxicillin 1gram, orally, 8 hourly If atypical organism or hypersensitive to penicillin then use Doxycycline 100mg, orally, 12 hourly Review in 48-72 hours: If improvement then 5 days if slow improvement then 7 days if not better review, if still CAP considered then step up therapy
28
What is the escalation therapy if monotherapy for CAP hasn't worked after review at 48-72 hours? what if hypersensitive or not tolerated?
Amoxicillin 1gram, orally, 8 hourly PLUS Doxycycline 100mg, orally, 12 hourly Can substitute amoxicillin for CEFUROXIME 500mg, orally, 12 hourly Can substitute doxycycline (if not tolerated or contraindicated) to CLARITHROMYCIN 500mg, Orally, 12 hourly Again follow up in 48-72 hours.
29
What are red flags for a CAP presentation? (8)
RR> 22 HR > 100 BP < 90 systolic Acute onset confusion O2 92% RA (or lower than baseline in comorbid respiratory disease) Multilobar involvement on CXR Blood lactate > 2 BUN >7
30
What is the definition of bronchiectasis?
Abnormal, irreversible bronchial dilatation or a fixed increase in airway diameter.
31
How do you diagnose bronchiectasis?
high resolution CT of the Chest, when the patient is well. When unwell there is a degree of dilation in everyone.
32
When do you suspect a diagnosis of bronchiectasis? (4)
Anyone with cystic fibrosis Men with primary infertility- especially immobility or azoospermia Other immune deficiencies or chronic cough and chronic sputum production
33
What features make a diagnosis of Bronchiectasis more likely? (5)
Digital clubbing (rare in COPD) Lack of significant smoking (less than 20day for 10 years) Recurrent pneumonia including TB Unusual organisms in sputum: Aspergillus, pseudomonas, klebsiella, e.coli, Childhood with environmental and social disadvantage.- including being aboriginal and TSI
34
What spirometry pattern would you see in bronchiectasis?
all really Airflow obstruction is the most common ventilatory pattern seen in bronchiectasis, though mixed obstructive/restrictive, restrictive or normal patterns can also be seen. can still use spirometry to aid severity assessment but not useful for diagnosis. same cut off as for COPD
35
4 basic investigations other that a HRCT for bronchiectasis that GPs can initiate?
Full Blood Count Immunoglobulin IgG, IgM and IgA, as well as IgG subclasses Sputum culture including mycobacterium Serological tests for aspergillus and total IgE levels in adults- if history of asthma and wheeze is present
36
What are key aspects of management of bronchiectasis? (5)
exercise and pulmonary rehabilitation: important to maintain muscle mass airway clearance: chest physio and mucolytic agents general measures- similar to asthma- (eg developing action plans, smoking cessation, immunisation, nutrition, managing causes and comorbidities, spirometry testing) treating infective exacerbations managing haemoptysis→ hospital transfer
37
What is the role of bronchodilators in bronchiectasis?
Bronchodilators and corticosteroids have a limited role in the treatment of bronchiectasis. Can be used for concomitant asthma or COPD, which obviously will improve their respiratory function, but not as a therapy for bronchiectasis
38
How can you manage a bronchiectasis exacerbation?
1. Monitor for deterioration from baseline 2. Note about sputum: Those with bronchiectasis usually have sputum, so in itself sputum is not an indication for antibiotics Common colonizing organisms: Haemophilus influenzae, Streptococcus pneumoniae, Moraxella catarrhalis, Pseudomonas aeruginosa and Staphylococcus aureus 3. Consider a CXR for LRTI 4. Amoxicillin 1g, orally, 8 hourly usually 14 days. If improvement then can shorten to 10 days.
39
What is interstitial lung disease vs restrictive lung disease?
ILD is not the same is restrictive lung disease Restrictive lung disease encompasses ILD and refers to the pattern on spirometry. All types of ILD are restrictive. Restrictive lung disease that is not ILD mainly consists of alveolar proteinosis and Anti-GBM. This is not particularly important to a GP but is worth noting that ILD is not an interchangeable term for restrictive lung disease.
40
Most common cause of ILD?
Idiopathic pulmonary fibrosis (most common) Idiopathic nonspecific interstitial pneumonia Genetic causes: Multisystem disorders: connective tissue disease, sarcoidosis, IBD Environment or lifestyle: smoking, occupation, radiation
41
Features of history that increase suspicion of ILD? (7)
Older age (median age: 66 years) Exertional dyspnoea (present in 90% of patients) Non-productive cough (present in >70% of patients) Decreased exercise tolerance Weight loss Features suggestive of an underlying cause of ILD, including clinical features of connective tissue disease, occupational and recreational causes and medication-related ILD Risk factors including family history and smoking history
42
Examination findings that are consistent with ILD? (2)
Finger clubbing (present in 30–50% of patients)[69] Bibasilar crackles (typically late inspiratory velcro-like fine crackles)
43
What investigations to order if you wanted to work up ILD?
chest x-ray, spirometry, bloods (FBC, EUC, ANA, RF, ENA, dsDNA, serum calcium) High resolution CT Chest is the best way to diagnose this if you’re suspecting it.
44
What are the 7 types of ILD?
Idiopathic pulmonary fibrosis Sarcoidosis Connective tissue disease Pneumoconioses (asbestos, silica, coal) Hypersensitivity pneumonitis (bird dander, fungal spores) Idiopathic interstitial pnuemonias Drug induced ILD (amiodarone, MTX)
45
General approach to management of ILD?
Given the majority of this would be managed by a specialist here’s a generalised approach Pulmonary rehabilitation Smoking cessation- extremely important Treat other associated diseases that can exacerbate: GORD, pulmonary HTN, depression and anxiety
46
What are the risks of asbestos exposure?
asbestosis (pulmonary fibrosis), but also benign pleural plaques (most commonly found with exposure, increase risk of effusions, mostly asymptomatic and its presence doesn’t mean increased risk of mesothelioma), primary bronchogenic carcinoma and malignant mesothelioma (of the pleura).
47
Asbestosis occurs about ___(a)___ to ___(b)___ years after exposure. Cigarette smoking + asbestos exposure together increases the risk of primary bronchogenic carcinoma (lung cancer) by __(c)___ times!!
1. 10 to 2. 20 years c. 60 times!
48
Idiopathic pulmonary fibrosis is the most common ILD in__(a)__ adults. Its peak age of onset is in the __(b)__ years age group and it has a poor prognosis with a median survival of only 3–5 years. New anti-fibrotics can be trailed in mild to moderate disease. An early referral to a lung transplant specialist is needed. Sarcoidosis is a ___(c)___ granulomatous disease which often involves the lungs. It occurs in a younger age group (peak incidence 20–50 years) and generally has a good prognosis.
a. older b. 50-60 years c multisystem
49
what are some environmental risk factors for lung cancer? (3)
Smoking: passive or active Air pollution Workplace: asbestos, wood dust, silica
50
When would you consider a Chest XRAY or CT chest for investigating lung cancer?
CT chest when there is persistent or unexplained haemoptysis, signs of superior vena cava obstruction or high clinical suspicion. Otherwise for potential symptoms lasting 3 weeks or more, get a XRAY first, if if persistent for >6 weeks then proceed to a CT CHEST.
51
Treatment (antibiotic) for CAP in a child > 2 months first and second line
amoxicillin 25 mg/kg up to 1 g orally, 8-hourly for 3 days. For children 2 months or older with immediate nonsevere or delayed nonsevere hypersensitivity to penicillins, use: cefuroxime (child 3 months or older) 15 mg/kg up to 500 mg orally, 12-hourly for 3 days if severe reaction azithromycin 10 mg/kg up to 500 mg orally, daily for 3 days

KFP study (31 decks)

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