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Respiratory Flashcards

1
Q

What is pneumonia?

Name pneumonia treatments.

A

LRTI, bacterial, inflammation with consolidation leading to infection of bronchi

Abx- oral/IV amox
Painkiller- NSAIDS
Vaccines- early pneumococcal
O2 therapy
Cough assistance
Ventilation support

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2
Q

Name pneumonia investigation?

A

Acute- ABCDE
Bloods- FBC, U&E, CRP, LFT, lactate
Obs
ECG
CXR
Sputum/ blood cultures
CURB-65

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3
Q

What is bronchiectasis?

Name bronchiectasis investigations?

A

Permanent dilation of airways leading to sputum accumulation -> inflammation -> infections
Caused by other diseases- CF, obstruction, immune, A-1AT def

Bloods- FBC, U&E, CRP, LFT,
Obs
CXR
HRCT
Spirometry
Cystic fibrosis test
Aspergillus antigen test
Sputum/ blood cultures

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4
Q

Name bronchiectasis management?

A

-Physical training (inspiratory muscle training)
-postural drainage
-antibiotics for exacerbations + long-term rotating antibiotics in severe cases- amoxicillin or clarithromycin
-bronchodilators: short-acting beta-2 agonists
-immunisations: annual influenza
-surgery (FEV <30%, >65yrs, rapid disease progression)

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5
Q

Name respiratory failure investigations?

A

Acute= ABCDE
Bloods- FBC, U&E, CRP, LFT, TFT, CK
Obs
ABGs
Sputum cultures
ECG
Lung function- spirometry
CXR
HRCT

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6
Q

Name respiratory failure management?

A

Main goal to support oxygenation
Acute= ITU -> ABCDE
Assisted ventilation- intubation and mechanical ventilation-> invasive
Non-invasive ventilation- venturi/ non-rebreather

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7
Q

Medical management for CF? (12)

A

Medical:
-Dornase alpha (reduces mucus viscosity)
-Hypertonic saline nebs (help airway clearance)
-Abx prophylaxis (flucloxacillin to prevent S. aureus should be given from diagnosis until 3-6 years)
-Eradication therapy with Abx (Peudomonas- using a combination of inhaled and systemic antibiotics -oral ciprofloxacin and nebulised colomycin)
-New Burkholderia cepacia infection- IV Abx
-If Aspergillus then antifungal agents
-Oral azithromycin if declining lung function or frequent exacerbations
-Lumacaftor-ivacaftor (Orkambi) if homozygous for the delta F508 mutation
-Pancreatic enzyme replacement (Creon) for exocrine insufficiency and fat soluble vitamin supplementation (A, D, E and K)
-Insulin for DM
-Ursodeoxycholic acid for liver disease
-Nasal steroids for polyps or sinusitis.

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8
Q

Name cystic fibrosis investigation?

A

Sweat test- babies
Genetic testing
CXR
HRCT
Sputum cultures
Bloods

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9
Q

Name pulmonary embolism investigation?

A

Bloods- D-dimer, FBC, U&E, CRP, LFT, coag screen

CXR
CTPA
ABG
ECG

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10
Q

Name pulmonary hypertension investigations?

What is PH?

A

Bloods- D-dimer, FBC, U&E, CRP, LFT
CXR
ABG
ECG
ECHO
Spirometry
V/Q scan

Increased arterial pressure in lung vessels

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11
Q

Name pulmonary hypertension management?

A

Anticoagulant- warfarin
Diuretics
Digoxin
O2 therapy
Lung/ heart transplant
Balloon therapy angioplasty

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12
Q

Name lung cancer investigations?

A

2WW referral
Emergency admission
X-ray/ CT
Biopsy of lung
Lung function test
Determine pre-existing co-morbidities
MDT- patient reviewed by an MDT to ensure best outcome and correct diagnosis

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13
Q

Name lung cancer management?

A

Lobectomy- entire lung lobe removed

Wedge recession- tumour removal and a wedge of lung to ensure all cancer cells have been removed

Bi-lobectomy- 2 lobes of the right lung removed (Upper + Lower) or (Midder + Lower)

Pneumectomy- whole lung is removed (R or L)

Radiotherapy- stereotactic radiotherapy or stereotactic radiosurgery- high does to a specific region with minimal damage to surrounding tissue

Chemotherapy- cytotoxic drugs- severe side effects due to killing healthy cells

Tyrosine kinase inhibitors TKI’s- prevent cancer growth by blocking TK growth signals, only work on patients with certain genetic mutations and non-smokers

Immunotherapies- boost immune system, PDL-1 receptor blockers prevent cancers ability to hide from immune system

Pain medications

Holistic- yoga

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14
Q

Asthma investigations in adults??

A

Order of tests:
-Eosinophil count OR FeNO (diagnose if above ref range or >50ppb)

-BDR with spirometry (diagnose if FEV1 >12% or 200ml increase from pre-BDR or FEV1 increase is ≥ 10% of predicted normal FEV1)

-Peak flow with variability (daily for 2 weeks and result is >20%)

-Bronchial challenge test (diagnose if bronchial hyper-responsiveness present)

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15
Q

Name asthma management?

A

1st-line: SAB2A- salbutamol (rapid action, airway dilation)
2nd-line: Inhaled Corticosteroids (ICS)- hydrocortisone, beclometasone (reduce inflammation)
3rd-line: LABA + ICS- Symbicort, formoterol
4th-line- Leukotriene receptor antagonists (LTRAs)- alternative to LABA + ICS

Poorly controlled- biologic therapy (mabs)

Other:
Periodic assessment- step-up or step-down
Asthma education for patient
Smoking cessation/ healthy diet
Good inhaler technique
Avoiding triggers

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16
Q

Name COPD management?

A

First-line: mild= SABA and/or SAMA
Second-line if fails to improve= SAMA + LABA + ICS
Third-line: If LABA fails to improve then add LAMA -> (SABA + LABA +LAMA)

If patients don’t respond to this regime, a trial period of a SABA + LABA + LAMA + ICS can be offered for 3 months.

1st: SABA + SAMA
2nd: SABA + LABA + ICS
3rd: SABA +LABA + LAMA
4th: SABA +LABA + LAMA +ICS

MRC dyspnoea scale
Smoking cessation!!!
Pulmonary rehab- exercise/ breathing techniques
Personalised management plan
Weight management
Vaccinations
Rescue pack- antibiotics and steroids

Final step- lung transplant or bullectomy

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17
Q

Name COPD investigation? (10)

A

-Bloods- FBC, CRP, U&E, LFT, lactate
-Chest x-ray- hyperinflation, bullae, flat diaphragm, exclude lung Ca
-ECG- tachycardia
-BDR spirometry- obstructive pattern <70% or <0.7
-ABGs- reduced PaO2 and hypercapnia- unable to breath out CO2
-Spirometry- grade severity 1-4
-BMI
-FBC- polycythaemia
-Genetic testing- A1AT deficiency
-Grade SOB on MRC dyspnoea scale

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18
Q

Name pleural effusion investigation?

Name types of effusion.

A

Inspection
Palpation
Percussion
Auscultation
Chest X-ray/ CT
Ultrasound

Pleural effusion- fluid in pleural space
Pneumothorax- air in pleural space
Mesothelioma- pleural malignancy
Haemothorax- blood in pleural space (trauma, cancer, embolism)
Chylothorax- lymphatic fluid in pleural space
Empyema- pus in pleural space (secondary infection)

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19
Q

Name pleural effusion management?

A

Thoracentesis- fluid/ air removal from thoracic cavity.
Needle through 7-8th intercostal space below rib to avoid nerves.

Diagnostic/therapeutic- biopsy or fluid sample
Pleural fluid protein content analysis-
Transudate- low protein content = increased capillary hydrostatic P + decreased osmotic P = fluid leakage (heart failure, cirrhosis)
Exudate- high protein content = increased capillary permeability due to inflammation (pneumonia, TB, malignancy)

CT/ X-RAY- not pneumothorax

Treatment of Underlying Cause:
Infection: Antibiotics are prescribed for bacterial infections.

Heart Failure: Diuretics and medications to manage heart failure may be recommended.

Malignancies: Treatment options may include surgery, chemotherapy, or radiation therapy.

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20
Q

Name pneumothorax investigation?

A

Clinical examination
Inspection
Palpation
Percussion
Auscultation
Never CXR if tension

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21
Q

Name pneumothorax management?

A

Tension pneumothorax- medical emergency and refer straight to intensive care and perform thoracostomy needle decompression to relieve air and then chest drain (and not delay by X-ray/CT)

Other pneumothorax
History
Examination
Chest X-ray
Distinguish between PSP or SSP

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22
Q

Likely causes bilateral hilar adenopathy?

A

Sarcoidosis
Infections- TB, fungal
Malignancy

A multisystem disorder characterised by the formation of non-caseating granulomas and typically presents with adenopathy in the hilar region of the lungs, hence it is usually an incidental finding on chest x-ray.

Causes- hypercalcemia, infection, immune response -> inflammation -> granuloma formation, genetic predisposition, dust/chemicals,

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23
Q

How does alkolising spondylitis affect lung function?

A

Ankylosing spondylitis causes a restrictive defect on pulmonary function testing
FEV1 and FVC values are both reduced
Combination of apical lung fibrosis and thoracic kyphosis
Reduced chest wall expansion.

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24
Q

How do pleural plaques present on x-rays?

A

Fibrous wall thickening of the pleura
Related to asbestos exposure

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25
Most common organism that causes cavitating lesion in pneumonia?
Klebsiella pneumoniae most commonly causes cavitating pneumonia lesions in the upper lobes, mainly in diabetics and alcoholics
26
What are the FEV1/FVC classification readings for CODP?
MILD: FEV1 <80% MODERATE: FVE1 between 50%-70% SEVERE: FVE1 between 30%-49% VERY SEVERE: FEV1 48%-<30%
27
What could COPD symptoms in a young patient also possibly mean?
Alpha-1 antitrypsin deficiency This is commonly misdiagnosed as asthma or COPD.
28
Management of acute exacerbations of COPD?
1. Prednisolone 30mg for 5 days 2. Increase the frequency of bronchodilator use and consider giving via a nebulise 3. Oral antibiotics first-line: amoxicillin or clarithromycin or doxycycline.
29
What does a patient's ABG with DKA who has diabetes show?
Metabolic acidosis with increased anion gap
30
Name lung cancer types, location and associated conditions/ symptoms.
SCLC- central, Cushing's syndrome Adenocarcinoma- peripheral, women, non-smokers, asbestos, gynaecomastia Squamous cell- central, columnar -> squamous, hypercalcemia Large cell- peripheral Pancoast tumours Paraneoplastic syndrome- SC Bronchial carcinoid- throughout Mesothelioma- cancer of the pleura due to asbestos exposure
31
What is CODP? Causes?
Inflammation of bronchial tubes leading to persistent cough with mucus 2 Causes: Emphysema Chronic bronchitis Chronic bronchitis: Chronic, slowly progressive airflow limitation caused by an inflammatory response from poisonous substances. Non-reversible Chronic bronchitis= Irritation from substance -> inflammation bronchi -> increased mucus production -> mucus plugging-> productive cough Emphysema characteristics: Alveolar damage -> reduction in surface area for gas exchange Loss of elasticity -> reduced expansion Increased air trapping -> harder air to move in and out Emphysema causes: Acquired emphysema- alpha-1 antitrypsin inactivated due to smoking. Centriacinar and affects apical areas of lungs Genetic emphysema- alpha-1 antitrypsin absent due to inherited genetic deficiency. Panacinar and affects lower areas of lungs Smoking Occupational- asbestos
32
CODP causes?
Smoking A1AT- deficiency Occupational- asbestos Repeated resp infections Age- older
33
Features of asbestosis?
dyspnoea Reduced exercise tolerance clubbing bilateral end-inspiratory crackles restrictive pattern on lung function test
34
Treatment for asbestosis?
It is treated conservatively - no interventions offer a significant benefit.
35
Features of mesothelioma?
progressive shortness-of-breath chest pain pleural effusion
36
Management for mesothelioma?
Patients are usually offered palliative chemotherapy and there is also a limited role for surgery and radiotherapy. Unfortunately, the prognosis is very poor, with a median survival from diagnosis of 8-14 months.
37
What is more common in asbestos exposure, lung cancer or mesothelioma?
Lung cancer
38
Features of mesothelima?
Dyspnoea weight loss chest wall pain Clubbing 30% present as painless pleural effusion Only 20% have pre-existing asbestosis History of asbestos exposure
39
Investigations for mesothelioma?
1st line: CXR -> pleural thickening/ effusion 2: pleural CT 3: pleural effusion sent for MC&S, biochem and cytology 4: if pleural nodularity seen on CT-> image guided pleural biopsy
40
Acute asthma management? O SHIT ME
Oxygen Salbutamol Hydrocortisone/ prednisolone Ipratropium Theophylline Magnesium sulphate Escalation (intubations/ ventilation)
41
Moderate asthma classification?
PEFR 50-75 Normal speech RR <25 HR <110
42
Severe asthma classification?
PEFR 33-50% Cannot complete sentences RR >25 HR >110
43
Life-threatening asthma classification?
PEFR <33% O2 sats <92% Silent chest Cyanosis Reduced respiratory effort Bradycardia/ dysrhythmia Hypotension Exhaustion Confusion A normal pCO2 in an acute asthma attack indicates exhaustion and should, therefore, be classified as life-threatening.
44
Near fatal asthma classification?
Raised pCO2 -and/or requiring mechanical ventilation with raised inflation pressures.
45
Discharge criteria for asthma?
-been stable on their discharge medication (no nebulisers or oxygen) for 12-24 hours -inhaler technique checked and recorded -PEF >75% of best or predicted
46
Assessment in an asthma attack? Types of investigations
ABG for O2 sats <92% CXR not indicated unless -life-threatening asthma -suspected pneumothorax -failure to respond to treatment
47
Diagnosis of asthma in children 5-16?
Order of tests: -FeNO (diagnose if >35ppb) -BDR with spirometry (diagnose if FEV1 increase >12% or FEV1 >10% from predicted normal FEV1) PEF (daily for 2 weeks and diagnose if >20%) If asthma is not confirmed by FeNO, BDR or PEF variability but still suspected: skin-prick testing or IgE and eosinophil count If still doubt: paeds referral for bronchial challenge test
48
Causes of Bronchiectasis?
TB Measles Pertussis Pneumonia CF Lung Ca Foreign body Immune deficiency ABPA- allergic bronchopulmonary aspergillosis ciliary dyskinetic syndromes: Kartagener's syndrome, Young's syndrome yellow nail syndrome
49
Common organisms in bronchiectasis?
H. influenzae (most common) Pseudomonas aeruginosa Klebsiella spp. Streptococcus pneumoniae
50
Common organisms in CF?
Staphylococcus aureus- most common Pseudomonas aeruginosa Burkholderia cepacia* Aspergillus
51
Conservative management for CF?
Disease education Specialist rv every 3-6 months until 18 Peer support Psych support Social support Physiotherapy Dietician
52
Surgical management for CF?
End-stage disease: lung, hear transplant Liver transplant if liver failure Polypectomy for nasal polyps is a common procedure.
53
Most common organism for COPD exacerbations?
H. influenza
54
Management for COPD exacerbation in GP?
Increase bronchodilator use or give via nebs Prednisolone 30mg for 5 days Abx (amoxicillin, clarithromycin, doxycycline)
55
Management for severe COPD exacerbation in secondary care?
-O2 therapy (88-92%) -Nebulised bronchodilator (salbutamol or ipratropium) -IV hydrocortisone -IV theophylline (if not responding to nebs) -If type 2 resp failure (NIV via BiPAP)
56
FEV1 >80% of predicted in COPD classification?
Stage 1 mild disease
57
FEV1 30-49% of predicted in COPD classification?
Stage 3 severe disease
58
FEV1 <30% of predicted in COPD classification?
Stage 2 very severe disease
59
FEV1 50-79% of predicted in COPD classification?
Stage 2 moderate disease
60
Who should be assessed for LTOT in COPD?
very severe airflow obstruction (FEV1 < 30% predicted). Assessment should be 'considered' for patients with severe airflow obstruction (FEV1 30-49% predicted) cyanosis polycythaemia peripheral oedema raised JVP oxygen saturations less than or equal to 92% on room air
61
How is assessment for LTOT in COPD made?
ABG in 2 occasions 2 weeks apart
62
Who can have LTOT in COPD?
Offer LTOT if pO2 < 7.3 kPa or to those with a pO2 of 7.3 - 8 kPa and one of the following: -secondary polycythaemia -peripheral oedema -pulmonary hypertension
63
Drugs that can cause lung fibrosis?
amiodarone busulphan, bleomycin methotrexate, sulfasalazine nitrofurantoin
64
Features of IPF?
-progressive exertional dyspnoea bibasal fine end-inspiratory -crepitations on auscultation -dry cough -clubbing
65
Investigations for IPF?
HRCT- gold-standard Spirometry >0.7 ANA positive in 30% and rheumatoid factor positive in 10% reduced transfer factor (TLCO)
66
Causes of upper zone fibrosis? CHARTS
C - Coal worker's pneumoconiosis H - Histiocytosis/ hypersensitivity pneumonitis A - Ankylosing spondylitis R - Radiation- breast or lung Ca T - Tuberculosis S - Silicosis/sarcoidosis
67
Causes of lower zone lung fibrosis?
-idiopathic pulmonary fibrosis -most connective tissue disorders (except ankylosing spondylitis) e.g. SLE -drug-induced: amiodarone, bleomycin, methotrexate -asbestosis
68
Antibiotic therapy for acute bronchitis?
consider antibiotic therapy if patients: -systemically very unwell -have pre-existing co-morbidities -CRP of 20-100mg/L (offer delayed prescription) CRP >100mg/L (offer antibiotics immediately) doxycycline first-line or amoxicillin as alternative
69
Small cell lung cancer paraneoplastic features?
ADH Ectopic ACTH production-> Cushing's (weight gain, HTN, striae, PMW) SIADH (hyponatraemia) Lambert-Eaton myasthenic syndrome (proximal muscles weakness, dry mouth, ED)
70
Squamous cell carcinoma lung cancer paraneoplastic features?
Hypercalcaemia-> bone pain, constipation, thirst confusion PTHrP
71
Adenocarcinomas lung cancer paraneoplastic features?
Hypertrophic pulmonary osteoarthropathy (HPOA)-> clubbing, arthritis of wrists and ankles Gynaecomastia
72
Investigations for occupational asthma?
Serial measurements of peak expiratory flow at work and away from work.
73
How to step down asthma treatment?
Aim for a reduction of 25-50% in the dose of inhaled corticosteroids
74
Which lung cancer releases ACTH?
Small cell bronchial carcinoma
75
How should patients with a secondary spontaneous pneumothorax be managed if asymptomatic?
Conservative management with inpatient monitoring
76
How should patients with a secondary spontaneous pneumothorax be managed if symptomatic?
Chest drain as first-line
77
Explain the different types of shock and their causes? Cardiogenic Distributive Hypovolaemic Obstructive
Cardiogenic: -heart unable to pump blood -ACS, HF, cardiac arrest Distributive: -pathological vasodilation that compromises blood distribution within the circulatory system -sepsis, anaphylaxis, neurogenic (spinal cord injury above T6 level) Hypovolaemic: -not enough/ fluid in the body -haemorrhage, dehydration Obstructive: -physically blocks the heart's ability to pump blood -pneumothorax, cardiac tamponade, PE
78
What vaccinations should COPD patients receive?
Annual influenza + one-off pneumococcal
79
Side effects of Rifampicin?
potent liver enzyme inducer hepatitis, orange secretions flu-like symptoms
80
Side effects of Isoniazid?
peripheral neuropathy: prevent with pyridoxine (Vitamin B6) hepatitis, agranulocytosis liver enzyme inhibitor
81
Side effects of Pyrazinamide?
hyperuricaemia causing gout arthralgia, myalgia hepatitis
82
Side effects of Ethambutol?
optic neuritis: check visual acuity before and during treatment dose needs adjusting in patients with renal impairment
83
Treatment regimen for latent TB?
NICE now give two choices for treating latent tuberculosis: -3 months of isoniazid (with pyridoxine) and rifampicin, or -6 months of isoniazid (with pyridoxine)
84
Name the extra-pulmonary infection sites in TB?
central nervous system (tuberculous meningitis - the most serious complication) vertebral bodies (Pott's disease) cervical lymph nodes (scrofuloderma) renal gastrointestinal tract
85
Causes of type 1 resp failure?
Pneumonia PE Asthma Pulmonary oedema ARDS
86
Causes of type 2 resp failure?
COPD Decompensation due to life-threatening asthma, pulmonary oedema ILD Neuromuscular disease- MND, Sedative drugs- benzos, opiates
87
What drug helps to reduce the risk of peripheral neuropathy in TB following isoniazid treatment?
Pyridoxine
88
What determines whether a chest tube is placed in pleural infection?
pH of pleural fluid (if <7.2)
89
Common causes of stridor?
Acute epiglottitis Croup Foreign body aspiration Anaphylaxis Laryngomalacia Vocal cord paralysis
90
Common causes of wheeze?
Asthma COPD Anaphylaxis Acute bronchitis Bronchiectasis
91
Common causes of haemoptysis?
TB- Fever, night sweats, anorexia, weight loss PE- pleuritic chest pain, raised HR + RR Lung cancer- smoking + weight loss Pulmonary oedema- Dyspnoea bi-basal crackles and S3 LRTI- purulent cough Bronchiectasis- long history of cough and daily purulent sputum production

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