Respiratory Flashcards
Primary spontaneous pneumothorax conservative Rx
-Criteria
-Management
Criteria - haemodynamically stable (no hypotension/tachycardia/tachypnoea/hypoxaemia), no severe chest pain
Observe 4 hours
Discharge w/ safety net advice
Repeat CXR every 2 weeks until resolved
Refer to resp if still pressent after 8 weeks
?Type of lung cancer
-Central airways
-Smokers
-Rapid doubling time
Small cell lung cancer
Classification of severity levels of asthma (+features)
Mild/Moderate
-Can walk
-Speak whole sentences in 1 breath
-O2 Sats >94%
Severe
-Use of accessory muscles/tracheal tug
-Short phrases only
-Obvious resp distress
-Sats 90-94%
Life-threatening
-Redcued consciousness
-Cyanosis
-O2 Sats <90%
-Poor resp effort, absent breath sounds
LLN for FEV1 ratio
LLN for FEV1
LLN for FEV1 ratio >0.7
LLN for FEV1 >0.8
Ratio = the lower number
Updated change in most recent Asthma Handbook re: Adult/adolescent treatment?
Low-dose budesonide-formoterol as needed
(as alternative to maintenance low-dose ICS)
Bronchiectasis management principles (7)
Early recognition/treatment of infec exacs
Minimise exposure to resp infections
Airway clearance techniques - chest physio
Pulmonary rehab
Immunisation - pneumococcal/flu
Regu;ar exercise - maintain weight/muscle strength
Manage comorbidities
Pneumovax schedule for people >12mths (kids –> adults) diagnosed with at risk condition
1st dose Prevenar 13 at diagnosis
2nd dose Pneumovax 23 1 year later (or age 4, whichever later)
3rd dose Pneumovax 23 - 5 years later
Pneumovax schedule for people >12mths (kids –> adults) diagnosed with at risk condition
1st dose Prevenar 13 at diagnosis
2nd dose Pneumovax 23 1 year later (or age 4, whichever later)
3rd dose Pneumovax 23 - 5 years later
Pleural effusion DDx (transudate vs. exudate)
Transudate
-Heart failure (90%) of cases
-Nephrotic syndrome (hypoproteinaemia)
-Liver failure w/ ascites
-Constrictive pericarditis
-Hypothyroidism
-Ovarian tumour
Exudate
-Infection (bacerial penumonia, empyema, TB)
-Malignancy (bronchial Ca, mesothelioma)
-Lymphoma
-Sarcoidosis
-CTD (SLE,RA)
-Acute pancreatitis
Fitness to fly (based on Sats)
Resting sats <88% at sea level, long-term O2
Long-term O2 but sats correct w/ O2
Resting sats <92% or unable to walk 50m w/o stopping
Impaired exercise capacity (sats92-95%)
Good exercise capacity
Resting sats <88% at sea level, long-term O2 – should not fly
Long-term O2 but sats correct w/ O2 - high risk, needs to fly w/ O2 and increase flow rate by 1-2L/min
Resting sats <92% or unable to walk 50m w/o stopping - very likely torequire supplemental O2
Impaired exercise capacity (sats92-95%) - consider specialist referral for hypoxia challenge test
Good exercise capacity - safe to fly
PE Risk Factors (6)
- Surgery
- Acute/chronic medical illness (heart/lung disease, IBD etc.)
- Cancer
- Hormone factors (pregnancy, OCP, HRT)
- Known thrombophilia
- BMI >30, varicose veins, immobilisation/travel
When to Apply WELLS/PERC
Clinical suspicion of PE/DVT –> Wells Score, score >4 needs imaging (clinical signs/symptoms of DVT, PE most likely dx. or any other RF)
If Wells low risk –> PERC rule –> D-dimer –> imaging
PE management/dosing
Rivaroxaban 15mg BD 3/52 –> 20mg daily
Apixaban 10mg BD for 1/52 –> 5mg BD
Meds used for altitude illness prevention
Ibuprofen (600mg TDS) - High altitude headache
Acetazolamide 125mg BD
Dexamethasone 2mg QID or 4mg BD (not longer than 10 days)
All as per eTG + AJGP Article
Contraindications to high altitude travel
○ Severe COPD
○ Unstable asthma
○ Severe IHD, CCF
○ Pulmonary hypertension
○ Complicated pregnancy
Interstitial lung disease clin. features
+findings on HRCT
+findings on spirometry
Clin. features: prgoressive SOB, dry cough, reduced ET. Fine creps on ausc. Oxygen desat during exercise
HRCT - nodules, cysts, ground glass changes, honeycomb change, traction bronchiectasis, septal thickening
Spirometry: Normal FEV1 ratio, low FVC, low FEV1, reduced lung volumes
COPD spirometry diagnosis
+what is a positive bronchodilator response?
FEV1/FVC ratio <0.7
FEV1<80% predicted
200ml increase AND 12% change in FEV1
COPD severity classifications (which spirometry measurement is used?)
FEV1
Mild = 60-80%
Moderate 40-60%
Severe <40%
COPD non-pharm optimisation (3)
- Stop smoking
- Pulmonary rehabilitation (for symptomatic pts
- Regular exercise - 150mins/week - walk until breathless - short rest - resume
COPD exacerbation management (3)
Salbutamol 4-8 puffs + spacer q3-4hourly (equiv to 2.5mg nebuliser)
Pred 30-50mg for 5/7 then stop
Abx - (if change in sputum volume/colour, fever) - Amoxicillin 500mg TDS OR 1g BD 5/7
OR Doxycycline 100mg daily 5/7
Oxygen - aim sats 88-92%
CXR, IV Abx and sputum MCS not usually needed in community pts
- Pulm rehab can be commenced immediately
Prevention strategies against inhaled foreign bodies - Paeds
Management step if suspected (1)
Avoid commonly aspirated foods in kids <15mths age (e.g popcorn, hard lollies, raw carrot)
Avoid nuts if <4 y.o
Referral to ENT on call or ED presentation
Findings that INCREASE probability of asthma in adults
> 1 of wheeze/SOB/cough/chest tightness
Recurrent/seasonal symptoms
Worse at night/early morning
Obvious triggers incl. exercise, cold air, meds (beta-blockers), viral infections, allergies, laughing
FHx of asthma/allergies
Hx of allergies (rhinitis, eczema)
Symptoms began in childhood
Widespread wheeze audible on ausc
FEV1/PEF lower than predicted
Eosinophilia/IgE rise w/o explanation
Rapid relief w/ SABA
Findings that DECREASE probability of asthma in adults
Dizziness, light-headedness
Isolated cough with NO other resp symptoms
Chronic sputum
No wheeze on ausc. when symptomatic
Change in voice
Symptoms only present during URTIs
Heavy smoker
Cardiovascular disease
Normal spirometry/PEF when symptomatic
Asthma DDx - Cough
Asthma DDx - wheeze
Asthma DDx - SOB
Cough
-Pertussis
-GORD
-Rhinosinusitis
-Medication side effect (e.g ACEi)
-Bronchiectasis
-COPD
-Idiopathic pulmonary fibrosis
-Inhaled freign body
-Habit -cough syndrome
Wheeze
-COPD
-Resp infections
-Upper airway dysfunction
SOB
-Poor fitness
-Hyperventilation
-Anxiety
-CCF
-Pulmonary HTN
-Lung Ca
Stepwise asthma management Adults/Adolescents (5)
- SABA Prn
- Regular low dose ICS + SABA Prn OR Symbicort Prn
- Regular daily low dose ICS-LABA (maintenance + reliever OR + Saba prn)
- Regular daily med-high dose ICS-LABA (maintenance + reliever OR +Saba PRN
- Specialist Rx
Criteria for good asthma control (4)
- Daytime symptoms ≤2 days per week
- SABA reliever use ≤days per week
- No limitation of activities
- No symptoms during night/on waking
Budesonide ICS low/medium/high dose
1. Adults
2. Kids
- Adults
-Low 200-400
-Medium 500-800
-High >800 - Kids
-Low 200-400
-High >400 (max 800)
Fluticasone propionate (Flixotide) ICS low/medium/high dose
1. Adults
2. Kids
- Adults
-Low 100-200
-Medium 250-500
-high >500 - Kids
-Low 100-200
-high >200 (max 500)
Indications for preventer treatment in kids 1-5 y.o
Any moderate or higher severity flare-ups (ED/oral steroids)
OR mild flare-ups (community) + symptoms at least once per week
Consider if symptoms every 4-6 weeks
Indications for preventer treatment in kids 6-11 y.o
Mod-severe flare-ups (>2 in last year needing ED/oral steroids) if flare-ups more than every 6 weeks
OR mild flare-ups (community) + persistant asthma
Stepwise asthma management kids 1-5 y.o (4)
- SABA prn
- Low dose ICS OR montelukast
- Low dose ICS + montelukast OR high dose ICS
- Specialist
Stepwise asthma management kids 6-11 y.o (4)
- SABA prn
- ICS low dose OR montelukast
- ICS low dose + monetlukast OR ICS-LABA low dose OR ICS high dose
- Specialist
Pred dose & duration for asthma exacs
1. Adults
2. Kids
- Pred 37.5-50mg daily for 5-10 days
- Pred 1mg/kg (max 50mg) for 3-5 days
DDx restictive lung patterns LFTs
-ILD (asbestosis, sarcoidosis/hypersensitivity pneumonitis, IPF)
-Pleural effusion (or pleural thickening/disease)
-Chest wall disease (NMD, diaphragm palsy, obesity, kyphoscoliosis)
Recommended bronchodilator withholding times prior to spirometry
○ SABA
○ SAMA (e.g atrovent)
○ LABA w/ BD dosing (e.g formoterol, salmeterol
○ LABA w/ daily dosing OR LAMA
○ SABA - 4 hours
○ SAMA (e.g atrovent) - 12 hours
○ LABA w/ BD dosing (e.g formoterol, salmeterol) - 24 hours
○ LABA w/ daily dosing OR LAMAs - 36 hours
Define narcolepsy
Define cataplexy
Diagnostic narcolepsy test
Narcolepsy - chronic sleep disorder characterized by overwhelming daytime drowsiness and sudden attacks of sleep
Cataplexy - sudden loss of muscle tone in response to intense emotion
Multiple sleep latency test/sleep study
OSA Examination features (5 categories)
- BMI
- Craniofacial structure, jaw position (retrognathia/micrognathia), neck circumference
- Oral cavity/tonsils/Mallampati score
- Nasal airways, congestion, sepal deviations/polyps
- CVS exam (CCF, HTN)
Risk factors for life-threatening asthma attack (9)
○ Poor lung function
○ Recurrent ED presentations
○ Hx of food allergy
○ Previous ICU admission
○ Recent hospital admission
○ Frequent reliever use
○ Need for steroid Rx
○ Need for multiple classes of asthma meds
○ Rural location/poor access to tertiary care
OSA children - other management options (2)
-Intranasal steroid spray trial 6/52
-Leukotreine receptor antagonist (montelukast)
-Chronic isolated wet cough >4 weeks w/o better explanation
-Often preceded by viral LRTIs
-O/E “rattly” airway secretions
?Diagnosis
?Treatment
Protacted bacterial bronchitis
2/52 min Aug DF (+ another 2/52 if no improvement)
Bronchiectasis exac criteria (3)
Abx Rx (1)
MUST have all 3 for Abx to be indicated
-Increase in sputum production/viscosity
-Increase in sputum purulence
-Increase in cough (w/ wheeze, SOB, haemoptysis)
Amoxicillin 1g TDS or Doxycycline 100mg BD, for 10-14 days
Indications for specialist referral for asthma/COPD (7)
-Following life-threatening exac needing hospitalisation
-Frequent asthma ED/GP presentations
-Suspected occupational asthma
-Diagnostic doubt
-Pts w/ poor self-management skills
-Assessment for home O2 therapy
-Assessment for lung transplant
