Respiratory Flashcards
What is spirometry?
FEV1 and FVC are measure
A ratio is determined from the two values.
Normal ratio with reduced FEV1 and FEV = restrictive
Reduced ratio with just reduced FEV1 = obstructive
What are the 4 main causes for hypoxia?
Hypoventilation
Diffusion impairment
R->L Shunt (Pulmonary embolus, congenital heart disease and pericardial tamponade can all cause this)
V/Q mismatch
What is the A-a gradient?
A= Alveolar
a= arterial
The gradient less than 2kPa in young healthy people or less than 4kPa in older people implies lung pathology
What is Anaphylaxis?
A serious allergic reaction.
A sensitised individual is exposed to a specific antigen, leading to an increase in IgE , causing mast cell release of histamine and an increase in basophils
What are the symptoms of Anaphylaxis?
Angioedema
Hoarseness
Stridor
Wheeze
Bronchospasm
Chest tightness
Pruritus
How do you treat anaphylaxis?
If medication/contrast reaction, stop administration of the offending substance
Give high flow O2 ( 15L/min with non-rebreathable mask )
Administer 0.5ml of IM adrenaline ( 1:1000)
Administer antihistamine (diphenhydramine (25-50mg IV)
What are the features of a Mild Asthma Exacerbation?
No features of severe asthma
PEFR > 75%
What are the features of a Moderate Asthma exacerbation?
No features of severe asthma
PEFR 50-75%
What are the features of a Severe Asthma exacerbation?
Any of the following:
PEFR 33-50%
Cannot complete sentences in one breath
Respiratory Rate >25/min
Heart Rate >110/min
What are the features of a Life Threatening Asthma exacerbation?
PEFR <33%
Sats <92%
ABG pO2< 8kPa
Cyanosis, Poor Respiratory Effort or near or full Silent Chest
Exhaustion, Confusion, Hypotension or Arrhythmias
Normal pCO2
What is the feature of a Near Fatal Asthma exacerbation?
Raised pCO2
What is the management for an acute asthma exacerbation?
ABCDE
Aim for SpO2 94-98% with O2 if needed ( controlled O2 )
ABG if sats <92%
2.5mg nebulised Salbutamol ( can repeat in 15mins)
40mg PO Prednisolone STAT ( if PO not possible give IV Hydrocortisone
What is the management for Anaphylaxis?
Remove trigger
Ensure airway stability + high flow O2 if needed
IM Adrenaline 0.5mg ( Repeat every 5mins )
If hypotensive lie flat and fluid recuss
Treat bronchospasm -> NEB Salbutamol
What is the management for severe asthma?
NEB Ipratropium Bromide 500mg
Back to back Salbutamol?
What is the management for life threatening or near fatal asthma?
Urgent ITU
Urgent portable CXR
IV Aminophylline
Consider IV Salbutamol if NEB ineffective
What implies an infective COPD exacerbation?
Change in sputum volume/ colour
Fever
Raised WCC +/- CRP
What is the management for a Non-Infective COPD exacerbation?
ABCDE
Aim for SaO2 of 94-98% but if any evidence of acute or previous Type 2 Respiratory Failure then target is 88-92%
Salbutamol and Ipratropium NEBS
Prednisolone 30 mg STAT and then for 7 days o.d
Consider IV Aminothylline if no improvement
Consider Non invasive ventilation if Type 2 Respiratory Failure and pH 7.25-7.35
If pH<7.25 consider ITU
What is the mangement for Pneumonia if Consolidation+/- purulent sputum+/- raised WCC and or CRP ?
ABCDE
If any septic features treat immediately with Sepsis 6 bundle
If not treat with antibiotics as per CURB-65 score and local guidelines
Mild- Amoxicillin
Moderate- Co-Amoxiclav
Severe= Co-amoxiclav
What does CURB-65 stand for?
C - Confusion
U - Urea > 7
R - Resp Rate > 30/min
B - Blood Pressure < 90mmHg or < 60mmHg
65 - Above 65
What is counts as Massive Haemoptysis?
> 240mls in 24 hours
100mls / day over consecutive days
What is the management for Massive Haemoptysis?
ABCDE Approach
-Lie patient on side of suspected lesion
-O2 if needed
-Fluid recussitation ( bloods / I.V)
-Stop NSAIDs/ Aspirin/ Anticoagulants
-Reverse any anticoagulation ( I.V Vitamin K and Prothrombin Complex )
-Oral or IV Tranexamic Acid for 5 days
-Antibiotics if any evidence of infection
-CT aortogram to identify bleeding site
Investigations-
Bloods - FBC, U&Es, G+S, Crossmatch, Coagulation, LFTs
What are the symptoms of a tension pneumothorax?
Hypotension
Tachycardia
Tracheal deviation away from side of pnemothorax
Mediastinal shift away from side of pnemothorax
What is the management for a Tension Pneumothorax?
Large bore IV cannula into 2nd ICS MCL
Then chest drain into affected side
What are the symptoms of a PE?
Chest Pain
SOB
Haemoptysis
What are examples of risk factors for a PE?
Recent travel ( long haul )
Recent surgery
Lower limb fracture
Late pregnancy
Previous DVT / VTE
What is an unprovoked PE?
A PE without clear cause/ risk factors
What is the management for a PE?
ABCDE
Oxygen if hypoxic
Analgesia
Subcutaneous LMWH whilst awaiting CTPA
DOAC for 3 months if provoked PE
DOAC for 6 months is unprovoked PE
LMWH ( Dalteparin ) if poor renal function ( eGFR < 15 )
What is the management for a massive PE?
Thrombolysis with IV Alteplase
What is a CTPA?
CT Pulmonary Angiogram
Tool used to detect blood clots in lungs using contrast
What determines if a PE is massive?
Hypotension/ Imminent cardiac arrest
Signs of right heart strain on CT/ECHO
What are the absolute contraindications for Thrombolysis?
Stroke in last 6 months
CNS neoplasia
Recent trauma/surgery
GI bleed in last month
Bleeding disorder
Aortic DIssesction
What are the only indications for high flow oxygen as apposed to controlled oxygen?
Cardiorespiratory Arrest
Peri-Arrest
Anaphylaxis
Sats < 85% on air
Carbon Monoxide poisoning
What is asthma?
Chronic inflammatory disease of the airways
Reversible obstruction - sprirometry demonstrates
What are some symptoms of asthma?
Wheeze
SOB
Chest pain
What is the treatment for Acute Asthma Attack?
ABCDE
-Controlled O2- aim for SpO2 94-98%, if <92% do an ABG to see if in Respiratory Failure
-2.5mg NEB Salbutamol ( repeat after 15 mins )
-40mg PO Prednisolone STAT
What is the treatment for severe asthma attack?
ABCDE
-Controlled O2- aim for SpO2 94-98%, if <92% do an ABG to see if in Respiratory Failure
-2.5mg NEB Salbutamol ( consider back to back)
-40mg Oral Prednisolone STAT
-NEB Ipratropium Bromide 500mg !!!
What is the management for life-threatening asthma?
ABCDE
-Controlled O2 , aim for SpO2 94-98%, if <92% do an ABG to see if in Respiratory Failure
-Urgent ITU or anaesthetist assessment
-Urgent portable CXR
-40mg Prednisolone STAT
-NEB Ipratropium Bromide 500mg
-Back to back Salbutamol ( Consider I.V if ineffective)
-IV Aminophylline ( should only be administered after consulting senior)
What do you give in an acute asthma attack if Prednisolone PO is not available?
IV Hydrocortisone
What is the safe asthma discharge criteria ?
PEFR > 75%
Stop NEBs 24 hours prior to discharge
Asthma nurse review of inhaler technique
PEFR reading and written action plan
GP follow up within 2 days
Resp Clinic follow up within 4 weeks
What do eosinophilic presentations respond well to?
Steroids
What can Eosinophilia be caused by?
Asthma
COPD
Hayfever
Parasites
Eosinophilic Pneumonia
Lymphoma
SLE
Multiple courses of antibiotics for infection
Eosinophilic Granulomatosis with Polyangiitis
Hypereosinophilic Syndrome
What are the causes of COPD?
Smoking
a1-antitrypsin deficiency
Industrial exposure
What is emphysema?
Alveolar wall destruction causing irreversible collapsing, stretching or overinflation of the alveolar air spaces. Can cause air to get trapped in lung parenchyma ( Obstructive )
What is the outpatient COPD management?
COPD Care Bundle ( Prednisolone and Amoxicillin)
Smoking cessation
Pulmonary Rehabilitation
Bronchodilators
Antimuscarinics
Mucolytics
What is Long Term Oxygen Therapy and who is it indicated in?
LTOT can be used for up to 16 hours a day for survival benefit
Offered if pO2 is consistently below 7.3kPa
Patients must be non smokers and not retain high levels of CO2
What is Pulmonary Rehabilitation?
An MDT 6-12 week programme of supervised exercise , unsupervised home exercise, nutritional advice and disease education
What are the common organisms for community acquired pneumonia?
Streptococcus Pneumoniae
Haemophilus Influenzae
Moraxella Cartarrhalis
What are the atypical organisms for community acquired pneumonia?
Legionella Pneumophila
Chlamydia Pneumoniae
Mycoplasma Pneumoniae
What are the typical organisms for hospital acquired pneumonia?
E.Coli
MRSA
Pseudomonas Aeruginosa
What is the investigation for pneumonia?
CXR - will see consolidation
What is the management for pneumonia?
ABCDE
Controlled O2 aim for 94-98%
CURB-65 score to indicate mortality and need for admission
If CURB-65 = 0-1 , can prescribe oral antibiotics and discharge
If CURB-65 = 2 , hospital admission , I.V antibiotics, sputum sample, bloods
If CURB-65 = 3-5 , consider ITU admission
IV Antibiotics, IV Fluids, bloods and Atypical Pneumonia Screen
ABG if low sats (<92%)
What is Legionnaire’s Disease?
A form of Pneumonia caused by Legionella Pneumophila
Associated with infected water ( showers/ hot tubs) and air conditioning
Presents with hyponatraemia
How is Legionnaire’s Disease detected?
Urinary Antigen Test
How does LD present on CXR
Bilateral mid-lower zone patchy consolidation
What is the Pneumonia follow up procedure?
HIV Test
Immunoglobulins
Pneumococcal IgG Serotypes
Haemophilus Influenzae Type B IgG
What are the causes of a non-resolving Pneumonia? (CHAOS)
Complication - Empyema, Abscess
Host- Immunocompromised
Antibiotic - inadequate dose, poor oral absorption
Organism - Resistant to empirical antibiotics
Second Diagnosis- PE, cancer
What are the empirical antibiotics for Pneumonia?
Amoxicillin
Amoxicillin + Doxycycline
Co-Amoxiclav + Doxycycline
What is SARS-CoV-2
Severe Acute Respiratory Syndrome COVID (name of virus )
Can cause viral pneumonia
Patients requiring hospital admission will have hypoxia , lymphopaenia, eosinopaenia, bilateral lower-zone changes on CXR
What is the management for severe COVID?
High flow O2 / CPAP / Invasive ventilation
Dexamethasone
Anticoagulation with subcut Heparin
What is the common symptoms of TB?
Night Sweats
Weight Loss
Malaise
If Respiratory - Cough, Haemoptysis
If Non Resp - Erythema Nodosum , Lymphadenopathy, CNS TB ( Meningitis )
What are the risk factors for TB?
Past history of TB
Recent Positive Contact
Born in a TB incidence country
Recent Foreign Travel
Immunosupression
What is the management for TB
ABCDE
Admit to negative pressure side room
Take 3x Sputum Samples for Acid-Fast Stain ( Ziehl-Neelsen Stain ) and TB Culture ( Takes 6-8 weeks )
Routine bloods - FBC , LFTS, U&Es
Vit D Blood Test (causes hypocalcaemia)
HIV Test
CXR - if not typical do CT chest
If high likelihood of TB do PCR then start RIPE Therapy
What are the principles of RIPE therapy?
All 4 medications for 2 months then first two for 4 more months
Dose is weight dependent
Check LFTs and visual acuity before commencing
Directly Observed Therapy may be used to ensure compliance
R- Rifampicin
I - Isoniazid
P - Pyrazinamide
E - Ethambutol
Must also give Pyridoxine supplementation with Isoniazid to prevent peripheral neuropathy
What are some side effects of each medication in RIPE?
R - Orange secretions, Hepatitis
I - Peripheral Neuropathy, Hepatitis
P - Arthralgia , Hepatitis
E - Retrobulbar neuritis
What drug is given with Isoniazid and why?
Pyridoxine
To prevent peripheral neuropathy
What is Bronchiectasis?
Chronic dilation of one or more bronchi, leading to a build-up of excess mucus that can make the lungs more vulnerable to infection and causes air to get trapped in lungs ( Obstructive)
Poor mucus clearance
Recurrent Bacterial Infection
What is the gold standard diagnostic tool for Bronchiectasis?
High Resolution CT
Will see the Signet Ring Sign where the bronchi is larger than the accompanying blood vessel due to dilation
Will also see tram-track opacities
What are the post infective causes of Bronchiectasis?
Pertussis , TB
What are the genetic causes of Bronchiectasis?
Kartegener Syndrome
Cystic Fibrosis
Young’s Syndrome
Primary CIliary Dyskinesia
What is Kartegener Syndrome?
Triad
- Bronchiectasis
- Sinusitis
- Situs Inversus
What is Young’s Syndrome?
Triad
- Bronchiectasis
- Sinusitis
- Reduced Fertility
What are some obstructive causes of Bronchiectasis?
Foreign Body
Tumour
What are some secondary immune causes of Bronchiectasis?
HIV
Malignancy
RA
What are some other causes of Bronchiectasis?
Gastric aspiration
Inhalation of toxic chemicals
What is the management of Bronchiectasis
Treat underlying cause
Physiotherapy ( Mucus Clearance )
If infective exacerbation give 10-14 days of appropriate antibiotics
What antibiotic do you give for Haemophilus Influenzae infective exacerbation of Bronchiectasis?
Amoxicillin 10-14 days
What antibiotic do you give for Pseudomonas infective exacerbation of Bronchiectasis?
Ciprofloxacin
What is Allergic Bromnchopulmonary Aspergillosis?
Caused by exposure to Aspergillus fungus
It is a combo of Type 1 and Type 3 hypersensitivity reactions leading to repeated damage
How is Allergic Bromnchopulmonary Aspergillosis confiremed ?
Bloods - Raised Aspergillus IgE and Raised Total IgE , Eosinophilia
How is Allergic Bromnchopulmonary Aspergillosis treated ?
Steroids
What kind of inheritance is Cystic Fibrosis?
Autosomal recessive
What is the mechanism behind Cystic Fibrosis pathology?
There are mutations in the gene that codes for the CTFR protein.
Less chloride ions are secreted extracellularly, therefore more sodium ions are transported into cells to maintain electroneutrality. This means that more water is reabsorbed into cells as water follows sodium. This results in thicker secretions.
How do you diagnose CF?
One or more characteristic phenotypic features or :
-History of CF in sibling
-Positive Newborn Screening Test
AND
-Positive Sweat Test
-or two mutations on genotyping
-or abnormal nasal epithelial ion transport
What are the 4 classic presentations of CF?
1) Meconium Ileus ( no first excretion due to bowel blockage)
2) Intestinal Malabsorbtion ( Usually due to lack of pancreatic enzymes)
3) Recurrent Chest Infections
4) Newborn Screen
What are some symptoms/signs of CF?
Nasal Polyps
High Salt content sweat
Recurrent LRTI
Pancreatic Insufficiency
Portal Hypertension
Steatorrhea
Male Infertility
What are some complication of CF?
Respiratory Infections
Low body Weight ( due to malabsorbtion )
Distal Intestinal Obstruction Syndrome (DIOS)
Diabetes
What is DIOS and how is it treated ?
Due to thick, dehydrated faeces caused by pancreatic insufficiency.
Treated with Gastrografin - draws water across bowel wall to rehydrate faeces
What is the lifestyle advice for CF Patients?
No smoking
Avoid other CF Patients
Avoid people with infections
Avoid jacuzzis ( Pseudomonas )
Avoid stables and compost ( Aspergillus )
Annual flu vaccine
Na/CL Replacement after exercise/ hot weather
What is the management for CF?
Airway Clearance Physiotherapy
Mucolytics
Pancreatic Hormone Replacement
Vit ADEK Replacement
Long term antibiotics ( can be NEBs )
Long term monitoring
What are the 6 types of pleural disease?
Pneumothorax ( air in cavity )
Empyema ( pus in cavity )
Pleural Effusion ( fluid in cavity )
Pleural Tumour ( benign or malignant )
Pleural Plaque ( fibrous area )
Pleural Thickening ( scarring/calcification -> thickening)
What are the types of Pneumothorax?
Spontaneous
Traumatic
Secondary
Tension
Iatrogenic ( central line / pacemaker usually )
What is the treatment for a Spontaneous Pneumothorax that is < 2cm ?
Discharge ( self resolving )
Follow up CXR in 2 weeks
What is the treatment for a Spontaneous Pneumothorax that is > 2cm ?
Aspiration with large bore needle (16G/18G)
What is the treatment for a Secondary Pneumothorax that is < 2cm ?
1-2cm - Aspiration with large bore needle to reduce to 1cm and admit and observe
<1cm - High flow O2 and admit, observe for 24 hours
What is the treatment for a Secondary Pneumothorax that is > 2cm or patient is breathless ?
Chest drain insertion
What is the treatment for a Tension Pneumothorax ?
Immediate Needle Decompression
then Chest Drain
What are the borders of the safety triangle for chest drain insertion?
Top - Base of axilla
Lateral - Anterior Latimus Dorsi
Medial - Lateral Pectoralis Major
in the 5th ICS
What is the position for Emergency Needle Decompression?
2nd ICS , mid-clavicular line
Should hear a hiss , leave device in whilst setting up chest drain
What are risk factors for a Spontaneous Pneumothroax?
Taller
Smoking
Cannabis
Diving
Trauma
Marfan’s Syndrome
How do you manage a suspected Pleural Effusion?
USS guided pleural aspiration
-Biochemistry
-Cytology
-Microbiology
Then only chest drain once diagnosis is well established following investigation
What is the only indication for an urgent chest drain for suspected effusion?
If there is an underlying empyema ( pH of pleural fluid will be <7.2 or visible pus on aspiration )
How do you know a fluid is transudate?
Pleural protein < 30g/L
What are the causes of a transudate effusion?
Heart Failure
Cirrhosis
Hypoalbuminaemia
Hypothyroidism
Mitral Stenosis
Pulmonary Embolism
Constrictive Pericarditis
What is Light’s Criteria?
Used if fluid aspirate protein level is borderline ( i.e between 25g/L to 35g/L )
Pleural Fluid : Serum Protein < 0.5
Pleural Fluid : Serum LDH > 0.6
What are the causes of exudate effusions ?
Malignancy
Infections
Inflammatory ( RA, Dressler’s, Pancreatitis )
Fungal Infections
What are the types of interstitial lung diseases?
Idiopathic Pulmonary Fibrosis
Non-Specific Interstitial Pneumonia
Extrinsic Allergic Alveolitis
Sarcoidosis
What type of pneumoconiosis can dust cause?
Silicosis
What type of pneumoconiosis can asbestos cause?
Asbestosis
What can an occupational history of working with coal cause?
Pneumoconiosis ( Miner’s Lung )
What investigations should be done for new ILDs?
ANA ( SLE / Autoimmune )
ENA ( SLE, Autoimmune )
Rheumatoid Factor ( RA)
ANCA (granulomatosis with polyangiitis, eosinophilic granulomatosis with polyangiitis, microscopic polyangiitis)
Anti-GBM ( Goodpasture’s )
ACE ( Sarcoidosis )
IgG
Hypersensitivity Pneumonitis
HIV Test
What are the signs of Pulmonary Fibrosis ?
Clubbing
Reduced Chest Expansion
Fine Inspiratory Crackles
What is Extrinsic Allergic Alveolitis caused by?
Inhalation of antigen to which a person has been sensitised to
Can be acute ( 4-8 hours after exposure )
Can be chronic ( months to years , less reversible )
What drugs commonly cause Extrinsic Allergic Alveolitis?
Amiodarone
Bleomycin
Methotrexate
Nitrofurantoin
Penicillamine
What is the histology of Sarcoidosis?
Non-caseating granulomas
What is the prognosis of Sarcoidosis?
50% - Remission
50% - Progressive Disease
What Investigations would you do for suspected Sarcoidosis?
Bloods - RFTs, ACE, Calcium, LFTS
CXR
Urinary Calcium
CXR
Cardio - ECG , ECHO , Cardiac MRI
Transbronchial biposy of lung to confirm
What is a good indicator of Sarcoidosis on bloods?
ACE level
What is the management principles of ILD ?
Remove stimuli
Stop smoking
Anti-fibrotics ( Pirfenidone , Nintedanib ) slow progression
Transplantation
What are the presentations of Lung Cancer?
Asymptomatic
Resp Symptoms
Horner’s Syndrome
Metastatic Disease
Paraneoplastic symptoms
What are the risk factors for Lung Cancer?
Smoking
Older
Familyx
Exposure to other carcinogens
What is the way to access a patient’s fitness level?
WHO Scale
0- Normal
1- Restricted Strenuous Activity
2- Able to care for self but can’t physically exert themselves , confined to bed or chair < 50%
3- Limited self care , confined to bed or chair > 50%
4- Completely disabled
5- Dead
What are the investigations to diagnose Lung Cancer?
Bloods ( FBC, U&E, Ca, LFTs, INR )
CXR
Staging CT
Some sort of biopsy
PET scan ( can see metastases )
What are the classifications of Lung Cancers?
Small Cell
Non Small Cell ( Large Cell, Sqaumous Cell, Adenocarcinoma, Bronchoalveolar Cancer )
What is the treatment for Stage 1 and 2 LC ?
Curative surgery
What is the treatment for Stage 3a LC ?
Surgery and adjuvant Chemotherapy
What is the treatment for Stage 3b/4 LC ?
Chemotherapy or Palliative
What should be used if patient is not suitable for Surgery/ Palliative ?
Radiotherapy
Why is SCLC not usually suitable to be treated with surgery?
Rapid growth rate
Almost always too extensive to resect at time of presentation
Chemotherapy is mainstay of treatment
Even with treatment survival rate is still small
What is Obstructive Sleep Apnoea?
Upper Airway Restriction during sleep, leading to daytime sleepiness
What are the risk factors for OSA?
Male
Obese
Muscle Relaxants ( Alcohol , Sedatives )
Neuromuscular Disease
What are the possible causes of small Phayngeal outlet ?
Fatty Infiltration or increased pressure from neck fat
Large tonsils
Undersized mandible
How is sleepiness measured ?
Epworth Sleepiness Scale
Likelihood of falling asleep during certain activities
>9 indicates high clinical suspicion of OSA
How is OSA diagnosed?
Sleep Study
Overnight oximetry
Limited Sleep Study ( oximetry, body movement, HR, oronasal flow )
Full polysomnography ( LSS + EEG and EMG )
What is the management for OSA?
Weight Loss
Reduce Alcohol
Nasal CPAP
Inform DVLA
If severe CO2 retention may require NIV prior to CPAP
What is CPAP?
Supplies constant positive pressure during inspiration and expiration , not ventilation aid
Aids oxygenation
What is BiPAP ( NIV )
A form of ventilation
Provides pressure at two levels to aid both inspiration and expiration
What do you give for an acute severe asthma attack if the person is not responding to initial treatment?
Give IV Aminophylline ( if already on oral don’t give loading dose ) OR
IV Salbutamol OR
IV Magnesium Sulphate
Why is a low CO2 a VERY bad clinical sign in an acute asthma attack?
CO2 should be high due to hyperventilation. After a while the respiratory muscles fail , it means the body can no longer compensate and the CO2 drops. This is NEAR FATAL asthma
How do you distinguish between a Massive Pneumothorax and a Tension Pneumothorax ?
A tension pneumothorax will have haemodynamic instability
Tension has tracheal shift
What is the management for an infective COPD exacerbation ( -> Sepsis ) ?
Controlled O2 ( nasal cannula up to 15L ) -> give CPAP ( only if in Type 1 Respiratory Failure) -> then give BiPAP ( Type 2 Respiratory Failure) -> intubation
NEBS Salbutamol and Ipratropium Bromide
Prednisolone 40mg
Empirical Antibiotics ( Amoxicillin )
Then no improvement give IV Aminophylline
What is Lambert-Eaton Syndrome?
Happens most often in people with small cell lung cancer. Person’s immune system attacks the connections between nerves and muscles. More commonly causes weakness in proximal limbs, usually proximal legs.
What is the progression of treatment in COPD?
SABA e.g Albuterol
SABA + ICS e.g Beclometasone
SABA + Fostair ( ICS + LABA e.g Salmeterol)
SABA + Trimbow ( ICS + LABA + LAMA e.g Tiotropium Bromide )
What is an example for each COPD/ Asthma drug type?
SABA - Salbutamol
ICS - Beclomethasone
LABA - Salmeterol
LAMA - Tiotropium Bromide
What are the requirements for COPD patients to start Long Term Oxygen Therapy?
Patients must have quit smoking
Had two consecutive ABGs of O2 < 7.3kPa
What must patients who have had a pneumothorax avoid?
Deep sea diving
How can nasogastric tube placement be confirmed as correct on aspirate?
A pH of < 5.5
When testing asthma on spirometry, what percentage increase after salbutamol use indicates the patient has asthma?
12% or more
How does Amiodarone affect the lungs ?
Lower zone fibrosis
Patchy ground glass opacities
What should be done if a needle aspiration of a pneumothorax fails?
Chest drain insertion
What are indications of something being small cell lung carcinoma?
Persistent cough
Night sweats
Haemoptysis
Dyspnoea
Chest pain
Weight gain ( Cushing’s)
Smoking Hx
Weight loss ( systemic cancer )
Arises from endocrine cells, so these tumours secrete many polypeptides, mainly adenocorticotrophic hormone (ACTH) Cushing syndrome
Spread very early – almost always inoperable at presentation
What type of NIV do you use in Type 1 Resp Failure?
CPAP
What type of NIV do you use in Type 2 Resp Failure?
BiPAP
Why does hypotension happen in Tension Pneumothorax?
Cardiac outflow obstruction
What would prompt you to admit a patient with a moderate acute asthma?
The presence of a previous near-fatal attack
How does Alpha-1 Antitrypin deficiency cause liver problems?
The accumulation of misfolded AAT protein within the liver can cause hepatocyte damage and death, leading to an increase in serum ALT levels as this enzyme leaks out from damaged cells.
Also causes raised Gamma GT
What follow up should all cases of pneumonia have following discharge?
CXR 6 weeks after resolution
Which organism is associated with Pneumonia in alcoholics?
Klebsiella Pneumoniae
What system pathologies are associated with OSA?
Cardiac complications
What is the cause of pulmonary oedema in Heart Failure?
LV dysfunction leads to blood backing up into the left atrium, the pulmonary vein and the capilleries in the lungs. This causes increased hydrostatic pressure in the capilleries, which is higher than the opposing oncotic pressure, so fluid moves out of the capillary into the interstitium
Which type of lung cancer is more likely if there is a lack of smoking history?
Adenocarcinoma
What is the initial recommended anticoagulation recommended in a PE?
DOAC ( Rivaroxaban, Apixaban , Dabigatran )
In an in patient/ emergency situation then LMWH as it is quicker acting
If they have renal impairment then LMWH
A provoked PE (identifiable risk factors, such as surgery or peripartum) should be treated for 3 months
An unprovoked PE should be treated for 6 months
What is the treatment of a Massive PE ( Causing severe haemodynamic instability )
Thrombolysis (an IV bolus of Alteplase®)
Embolectomy – may be considered in patients with a massive PE when thrombolysis is contraindicated
What is the cause of consolidation on CXR seen in pneumonia?
Inflammatory reaction
Consolidation refers to lung tissue that has filled with liquid. This would occur due to an inflammatory response, which has been triggered by the presence of bacteria or viruses, which could have caused damage to the alveoli or other lung tissue
What is the treatment for Pleural Effusion?
Appropriate oxygen therapy
Attempts to reduce respiratory distress medically (eg. diuretics for heart failure or antibiotics for chest infections)
If still symptomatic after medical management then:
Thoracocentesis and therapeutic aspiration of the effusion
What is the advice given with a COPD rescue pack?
Prednisolone - take if breathlessness is not relived by inhaler
Antibiotics - take if sputum changes colour or increases in volume
What are the causes of ARDS?
Pneumonia
Sepsis
Aspiration
Pancreatitis
Transfusion reactions
Trauma and fractures
Fat embolism
What is ARDS?
ARDS is an acute form of respiratory failure occurring within 7 days of the onset of a lung injury. It involves a diffuse bilateral alveolar injury, as a result of inflammation
What are the rules about oxygen for critically unwell COPD patients?
Should initially aim for 94-98% with high flow O2 ( 15L/min via a Non-Rebreather mask)
Do ABG , if they are a CO2 retainer ( T2RF) then should switch to controlled oxygen a 4L/min via Venturi mask, target oxygen saturations 88-92%
Hypoxia kills quicker than respiratory depression
What are the rules regarding discharge of anacute asthma exacerbation
For a patient to be discharged from hospital following an asthma attack they must be stable on their regular asthma regime for 24 hours
What is a useful mnemonic for remembering which conditions cause fibrosis in the upper and lower zones?
“CHART” (Upper Lobe) + “RAIDS” (Lower Lobe)
Coal worker’s pneumoconiosis
Histiocytosis
Ankylosing Spondylitis / Allergic Extrinsic Alveolitis
Radiation
Tuberculosis
Sarcoidosis
Rheumatoid Arthritis
Aspiration, alpha-1 antitrypsin deficiency, asbestosis
Idiopathic Pulmonary Fibrosis
Drugs (e.g. busulfan, bleomycin lung toxicity, nitrofurantoin, hydralazine, methotrexate, amiodarone)
Which type of lung cancer is associated with ectopic production of parathyroid hormone related protein (PTHrP) which causes hypercalcaemia?
Squamous Cell Carcinoma
What is the treatment for a non massive PE?
DOAC ( If renal function intact)
In the inpatient/emergency setting, low molecular weight heparin is usually started instead as it is shorter acting
What is Light’s Criteria?
An effusion is an exudate if:
The pleural fluid to serum protein ratio is >0.5
The pleural fluid to serum LDH ratio is >0.6; or
The pleural fluid LDH is >2/3 the upper reference limit for serum LDH
When would you consider prophylactic antibiotics for
Guidelines from the British Thoracic Society (BTS) suggest that if a patient is experiencing 3 or more exacerbations per year and they are already on optimal medical management (including mucolytic treatment, in the form of saline nebulisers here) then they are a candidate for long term prophylactic antibiotics
What is the escalation of long term asthma drugs?
SABA ( Salbutamol ) prn
Add lose dose ICS ( Beclomethasone or Budesonide)
Add Leukotriene Receptor Antagonist ( Montelukast ) ,LABA ( Salmeterol ) or Leukotriene Receptor Antagonist ( Montelukast ) or PO Theophylline
Increase dose of ICS
Add daily steroid tablet ( PO Prednisolone ) + referral to specialist
What is the definitive for diagnosis of Sarcoidosis?
Bronchoscopy with a transbronchial lung biopsy - you will see non-caseating granulomas
ACE is raised in about 50% of patients
What type of hypersensitivity reaction in Asthma?
Type 1 hypersensitivity - mediated by IgE antibodies
How do you differentiate between Sarcoidosis and TB on CXR?
Sarcoidosis - bilateral hilar lymphadenopathy
TB - unilateral hilar lymohanedopathy
What is the first line treatment for Bronchiectasis?
Chest physiotherapy, inhaled bronchodilators, and antibiotics as indicated
Mucolytics
What is the safe discharge criteria for asthma?
LEARN
Stopped regular nebulisers for 24 hours prior to discharge
PEFR > 75%
Inpatient Asthma Nurse review
Assessment of Inhaler technique + adherence
Medication Assessment
Written Asthma action plan for how to manage care and future attacks
When do you prescribe ICS for COPD?
2nd line if there as asthma features present ( Eosinophilia, Diurnal variation
Are the Pneumococcal or Influenza vaccine live?
No - safe for use with DMARDs
What is the first line investigation for Lung Cancer?
CXR within 2 weeks
What colour sputum does a Streptococcus Pneumoniae infection present with typically?
Rusty-coloured
What treatment reduces mortality rate in ARDS?
low tidal volume mechanical ventilation
What happens to the CO2 levels in asthma?
Initially low due to hyperventilation, as patient tires they become normocapnic ( Life-threatening) and then hypercapnic ( Near-fatal)
What would be obscured by consolidation in an Upper, Middle and Lower lobe Right sided pneumonia on CXR?
Upper - Apex
Middle - Cardiac border
Lower - Costophrenic angle
Where does lung cancer tend to metastasise to?
Brain
Breast
Adrenals
Bone
What may be heard on auscultation with bronchiectasis?
Coarse inspiratory crackles
What drugs can worsen Asthma?
B-Blockers
NSAIDs
Aspirin
What is the stages of giving drugs in COPD?
1st line - SABA or SAMA
2nd line - asthmatic features ( LABA + ICS ), if not LABA and LAMA
3rd line - LABA, LAMA and ICS
What is Extrinsic Allergic Alveolitis?
Inflammation of the alveoli, it is an early sign of interstitial lung disease
Types
-Idiopathic Pulmonary Fibrosis
-Infections ( V/B Pneumonia)
-Fungal infections ( aspergillosis, histiocytosis)
-Environmental exposure ( Coal Worker’s Lung, Silicosis, Asbestosis )
-Autoimmune (RA, SLE, Sarcoidosis)
-Connective tissue ( Scleroderma )
What should be given first in an acute asthma attack NEBS or steroids?
NEBS
What should be given if a patient is unable to take Prednisolone ( severe - can’t complete full sentences etc )
I.V Hydrocortisone
What are the associations of the lung cancers?
Small Cell Lung Cancer - Paraneoplastic syndromes (Lambert-Eaton, Ectopic ACTH , Addison’s Disease, SIADH)
Squamous Cell Carcinoma - PTHrP secretion
Large Cell Carcinoma - b-HCG secretion
Adenocarcinoma - Non-smokers
What may be heard on auscultation of Idiopathic Pulmonary Fibrosis?
Fine end-inspiratory crackles
What are the components of COPD?
Chronic Bronchitis ( increased mucus production
Emphysema ( damage to alveoli leading to dilation, difficult exhalation as air gets trapped)
What are the indications for surgery in COPD?
This is lung reduction surgery , indicated after LTOT fails
FEV1<50% predicted
PaCO2 <7
Transfer capacity of the lung for carbon monoxide (TlCO) >20%
What are some signs of Mycoplasma Pneumoniae pneumonia?
Preceding flu-like illness
Dry cough
Erythema multiforme (target-shaped lesions)
Anaemia
What is a positve FeNO test ( Asthma )
> 40ppb
What type of bacteria are known to cause lung abcess?
Anaerobic
What are the stages of COPD?
Stage 1 (Mild) as his FEV1 is >80% of what is expected.
Stage 2 (Moderate) is an FEV1 which is 50-79% of the predicted value.
Stage 3 (Severe) is an FEV1 which is 30-49% of the predicted value.
Stage 4 (Very severe) is an FEV1 <30% of the predicted value.
