Respiratory Flashcards
1
Q
What is the criteria for moderate asthma?
A
PEFR: 50-75% best or predicted
Normal Speech
Respiratory rate <25/min
Pulse <110bpm
2
Q
What is the criteria for severe asthma?
A
PEFR: 33-50% best or predicted
Can’t complete sentences
Respiratory rate >25/min
Pulse >110bpm
3
Q
How many of the life-threatening symptoms of asthma does a patient need to have to be classed as life-threatening?
A
One
4
Q
If a patient presents with asthma but has normal CO2 levels which classification (moderate, severe, life-threatening) is it?
A
Life-threatening as it indicates exhaustion
5
Q
If asthma is being considered in a patient >16 what diagnostic tests must be done?
A
- Spirometry
- Bronchodilator Reversibility
- FeNO
6
Q
When is a FeNO test done in children under 17 with suspected asthma (criteria)?
A
If the child has:
- Normal Spirometry
- Obstructive Spirometry and a negative BDR test
7
Q
What FeNO is considered positive in adults and children?
A
Adults >= 40 parts per billion (ppl)
Children >= 35 parts per billion
8
Q
What is the treatment order for management of newly diagnosed asthma in adults?
A
1st: SABA (short acting beta 2 agonist)
2nd: SABA + ICS (1st line if newly diagnosed and night waking/ >= 3 times. Week)
3rd: SABA + ICS + LTRA (Leukotriene receptor antagonist)
4th: SABA + low-dose ICS + long-acting beta agonist (LABA)
5th: SABA +- LTRA + MART (maintenance and reliever therapy)
9
Q
What symptoms does asthma present with?
A
Dyspnoea
Wheeze
Cough- dry or productive, worse in the night and morning
Chest tightness
10
Q
Describe the pathophysiology of asthma?
A
Chronic inflammatory condition caused by type 1 hypersensitivity of the airways resulting in:
1. Airway inflammation: release of cytokines, leukotrines, histamine and infiltration of immune cells into airway wall
2. Bronchoconstriction, mucus production and airway oedema
3. Hyperresponsiveness: excessive reaction
4. Airway damage and remodelling: excessive mucus production, smooth muscle hypertrophy
11
Q
What is an exacerbation of asthma?
A
Progressive worsening of symptoms over an acute or sub-acute time period
12
Q
What investigations are done for acute asthma exacerbation?
A
PEFR
Sp02
Arterial blood gases
Venous blood gas
13
Q
If a patient presents with near fatal or life threatening asthma exacerbation, what should be done?
A
Hospital admission and treatment started immediately
14
Q
If asthma exacerbation patient is hypoxaemic, how much oxygen should be given?
A
15L of oxygen via non-rebreather mask, Venturi or nasal cannulae. Adjust flow rates as necessary to maintain an oxygen saturation of 94–98%
15
Q
Describe the course of treatment in patients with acute asthma exacerbation awaiting hospital admission?
A
- Supplemental oxygen if patient is hypoxaemic
- SABA (salbutamol 5mg, terbutaline): via pressurised metered-dose inhaler (pMDI) in moderate and via oxygen driven nebuliser in life-threatening/ near fatal
- Severe/ life-threatening/ poor response in moderate give patient nebulized ipratropium bromide (500 micrograms for adults and 250 micrograms for children aged 2–12 years, do not repeat within 4 hours).
- Give a dose of a course of prednisolone (40–50 mg for adults, 30–40 mg for children over 5 years, 20 mg for children aged 2–5 years, and 10 mg for children aged under 2 years). Continue for 5 days
16
Q
What is the mechanism of action of ipratrobium bromide?
A
It is an anticholinergic and an antagonist of the muscarinic receptor (M3) resulting in smooth muscle dilation and subsequent opening of the airways as well as reduced mucus secretions
17
Q
What is the mechanism of action of salbutamol?
A
Salbutamol is a beta 2 agonist. Salbutamol relaxes the smooth muscles of all airways, from the trachea to the terminal bronchioles.
18
Q
What are the 2 classifications of COPD?
A
Chronic bronchitis
Emphysema
19
Q
Which type of COPD most commonly causes hyperinflation?
A
Emphysema
20
Q
Describe how a patient with chronic bronchitis presents?
A
Typically:
- overweight
- smoker
- Dyspnoea
- cough
- sputum production
21
Q
Describe how a patient with emphysema may present?
A
- cachexic
- Dyspnoea
- hyperinflation (barrel chest)
22
Q
What are the causes/risk factors of COPD?
A
- smoking
- air pollution
- work place dust and organic material
- alpha 1 antitrypsin deficiency
23
Q
What is the most common cause of COPD?
A
Smoking - 85-90%
24
Q
How do you diagnosed COPD?
A
- post-bronchodilator spirometry to demonstrate airflow obstruction: FEV1/FVC ratio less than 70%
- Serum alpha-1-antitrypsin deficiency if the person is younger than 40 years of age or has a family history.
- chest x-ray: hyperinflation, bullae, flat hemidiaphragm. Also important to exclude lung cancer
- full blood count: exclude secondary polycythaemia and anaemia
25
How is severity of airway obstruction in suspected COPD classified?
Stage 1, mild — FEV1 80% of predicted value or higher.
Stage 2, moderate — FEV1 50–79% of predicted value.
Stage 3, severe — FEV1 30–49% of predicted value.
Stage 4, very severe — FEV1 less than 30% of predicted value or FEV1 less than 50% with respiratory failure.
26
What non pharmacological treatments are indicated for COPD?
- smoking cessation: nicotine replacement therapy
- offer influenza and pneumococcal vaccinations
- pulmonary rehabilitation.
27
What is the first line drug treatment for COPD? When is it indicated?
If patient if breathless and has exercise limitations. Offer following to be used when needed for relief.
- SABA
- SAMA
28
What are 2 examples of short acting muscarinic antagonists?
Ipratropium bromide
oxitropium bromide
29
In acute exacerbation of asthma in children between 5-12 years, what is the respiratory rate and pulse rate to class it as a severe asthma?
RR >= 30
Pulse>= 125
O2< 92%
30
What does chest x ray show in COPD diagnosis?
hyperinflation, bullae, flat hemidiaphragm
31
How do you determine whether a COPD patient has asthmatic/steroid responsive features?
- any previous, secure diagnosis of asthma or of atopy
- a higher blood eosinophil count - note that NICE recommend a full blood count for all patients as part of the work-up
- substantial variation in FEV1 over time (at least 400 ml)
- substantial diurnal variation in peak expiratory flow (at least 20%)
32
If a patient has copd with asthmatic feature what is second line treatment of SABA alone isn’t working?
LABA + ICS
Otherwise LABA+ LAMA
33
What are other possible treatments for COPD?
Oral theophylline- multiple drug interactions, monitor serum levels
Oral mucolytic therapy- should be 'considered' in patients with a chronic productive cough and continued if symptoms improve
Oral prophylactic antibiotic therapy- azithromycin prophylaxis is recommended in select patients
patients should not smoke, have optimised standard treatments and continue to have exacerbations
Phosphodiesterase-4 (PDE-4) inhibitors- roflumilast
34
In which cases would you give long term oxygen therapy in a copd patient?
very severe airflow obstruction (FEV1 below 30% predicted)
cyanosis (blue tint to skin)
polycythaemia
peripheral oedema (swelling)
a raised jugular venous pressure
oxygen saturations of 92% or less breathing air.
35
Which of the following is not an indication for long-term oxygen therapy (LTOT) in patients with stable chronic obstructive pulmonary disease (COPD)?
1. PaO2 = 7.3-8.0 kPa with secondary polycythaemia
2. PaO2 = 7.3-8.0 kPa with anaemia
3. PaO2 = 7.3-8.0 kPa with pulmonary hypertension
4. PaO2 < 7.3 kPa
5. PaO2 = 7.3-8.0 kPa with peripheral oedema
2. PaO2 = 7.3-8.0 kPa with anaemia
36
What is the target range for oxygen saturation in copd patients?
88-92%
37
How is a COPD exacerbation managed?
1. SABA - inhaler or nebuliser (If a person with COPD is hypercapnic or acidotic the nebuliser should be driven by compressed air rather than oxygen (to avoid worsening hypercapnia)
2. Oral corticosteroids- Offer 30 mg oral prednisolone daily for 5 days
3. Patients with persistent hypercapnia and respiratory acidosis despite optimal medical management need to be started on NIV
38
In what situations is theophylline contra indicated and why?
Patients with comorbidities such as heart failure, hepatic impairment and viral infections. It is metabolised in the liver, the toxic dose is very close to the therapeutic dose and in these conditions the plasma concentration is increased.
39
Which line of treatment for COPD is theophylline? When is it indicated?
Third line
If patient has tried both long and short acting bronchodilators and is unable to tolerate inhaled therapy
40
When would a pde-4 (phosphodiesterase) inhibitor be given for COPD?
the disease is severe, defined as a forced expiratory volume in 1 second (FEV1) after a bronchodilator of less than 50% of predicted normal
the person has had 2 or more exacerbations in the previous 12 months despite triple inhaled therapy with a long-acting muscarinic antagonist, a long-acting beta-2 agonist and an inhaled corticosteroid
41
What are the 3 types of pneumothorax?
Spontaneous
Traumatic
Iatrogenic
42
What are the 2 types of spontaneous pneumothorax?
Primary: no underlying lung pathology
Secondary: underlying lung pathology such as asthma, COPD, cystic fibrosis, lung cancer
43
What are the risk factors for a primary spontaneous pneumothorax?
Tall
Thin
Male
20-40 years
Smoker
Marfan syndrome
44
What are the possible causes of iatrogenic pneumothorax?
Lung biopsy
Mechanical ventilation
Insertion of central line
Thoracicentesis
45
Describe the typical presentation of a pneumothorax?
Sudden onset:
Pleuritic chest pain
Dyspnoea
46
How is a pneumothorax diagnosed?
Examination: diminished breath sounds, hyper resonance on percussion, decreased chest wall expansion
Chest X- ray: erect with lungs inflated, loss of lung markings
47
How is a primary pneumothorax treat?
No SOB/ <2cm : discharge with 2 week follow up
SOB present and/or >2cm: aspirate then reassess
If aspiration fails a chest drain must be inserted
48
How long after a pneumothorax must you wait before taking a flight?
2 weeks
49
How do you treat a secondary pneumothorax?
Age>50, size>2cm: chest drain
1-2cm: aspirate
If after aspiration it is <1cm admit to hospital, O2 and 24 hour monitoring
If after aspiration it is >1cm then insert chest drain
50
What is a tension pneumothorax?
One way valve, air enters the pleural space but can not leave
51
What are the symptoms of a tension pneumothorax?
Tracheal deviation
Raised JVP
Mediastinal shift
Respiratory distress
Haemodynamic instability: tachycardia and hypotension
52
How is a tension pneumothorax treated?
Insert a large bore cannula into the 2nd intercostal space, mid- clavicular line
Once patient has stabilised insert chest drain (4th intercostal space)
IMMEDIATELY- DONT WAIT
53
Once a chest drain is inserted, what must be done? Why?
Chest x ray to check the positioning
54
Is it normal for chest drain to swing and bubble? Why?
Yes
Due to inspiration and expiration
55
When should non invasive ventilation be given in COPD exacerbation?
NIV is indicated if the following features are present 60 minutes after optimal supplemental oxygen and bronchodilation have been given
- Acidosis - pH < 7.35
- Hypercapnia - pCO2 > 6.5
- Respiratory rate > 23
56
How does FEV/FVC present in COPdD and asthma?
Reduced FEV1 and reduced or normal FVC
FEV/FVC reduced
57
What are the major symptoms of CoPD?
Dyspnoea
Sputum production
Increased sputum purulence
58
Wha are the 4 most common causes of bronchiectasis?
Idiopathic
Post infection
Immunodeficiency
COPD
59
What respiratory infections are commonly associated with Bronchiectasis?
Tuberculosis
Whooping cough
Measles
Pneumonia
60
What are the main symptoms of Bronchiectasis?
Chronic productive cough
Daily sputum production
Haemoptysis
Recurrent chest infections
61
What are other symptoms of Bronchiectasis?
Rhinosinusitis symptoms: nasal discharge, reduced sense of smell, blocked nose
Dyspnoea
Chest pain
62
What comorbidities are often associated with Bronchiectasis development?
Rheumatoid arthritis
GORD
Inflammatory bowel disease
Asthma
COPD
Cystic fibrosis
63
What investigations are done for suspected Bronchiectasis?
Sputum culture
CxR: rule out TB and malignancy
Post bronchodilator spiromitry: obstructive or mixed
Oxygen sats
HRCT
64
If Bronchiectasis is confirmed what tests should be done?
serum total IgE and assessment of sensitisation to Aspergillus fumigatus - to investigate for Allergic Broncho Pulmonary Aspergillosis (ABPA)
Screening for gross antibody deficiency- Serum immunoglobulin G (IgG), immunoglobulin A (IgA) and immunoglobulin M (IgM) - to investigate for immunodeficiency
Specific antibody levels against capsular polysaccharides of Streptococcus pneumoniae
Cystic fibrosis screening: sweat chloride or gene
Alpha- 1- antitrypsin deficiency
Bronchoscope: aspiration
PCD
65
If Bronchiectasis is confirmed what tests should be done?
serum total IgE and assessment of sensitisation to Aspergillus fumigatus - to investigate for Allergic Broncho Pulmonary Aspergillosis (ABPA)
Screening for gross antibody deficiency- Serum immunoglobulin G (IgG), immunoglobulin A (IgA) and immunoglobulin M (IgM) - to investigate for immunodeficiency
Specific antibody levels against capsular polysaccharides of Streptococcus pneumoniae
Cystic fibrosis screening: sweat chloride or gene
Alpha- 1- antitrypsin deficiency
Bronchoscope: aspiration
PCD
66
How is Bronchiectasis managed?
Primary care:
ACS: airway clearance techniques - review in exacerbations
Infuenza vaccine
Pneumococcal vaccine
Antibiotics: prescribe for 7-14 days
SABA
67
When should a patient with Bronchiectasis be referred for secondary care to a respiratory specialist? What will be done?
If they have 3 or more exacerbations in a year despite treatment and management
Prophylactic antibiotic treatment
Mucolytics
68
Which antibiotic is given for prophylaxis in Bronchiectasis patients? What is the procedure?
Azithromycin: 500mg 3 times a week or 250mg daily
Possible side effects: diarrhoea, hearing loss, or tinnitus
Check liver function tests after 1 month and every 6 months thereafter.
Perform an ECG 1 month after starting treatment to check for new QTc prolongation. If present, stop macrolide treatment.
69
What is the first and second line treatment for streptococcus pneumoniae?
Amoxicillin - 500mg 3 times daily
Doxicycline - 100mg 2 times daily
70
Which organisms most commonly cause Bronchiectasis?
Pseudomonas aeruginosa
Haemophillus influenzae
71
What is the criteria for lung transplant in Bronchiectasis?
Aged 65 years or less and:
- FEV is <30% predicted with significant clinical instability or
- Rapid progressive deterioration despite optimal medical management
Localised disease: lung resection
72
What is the criteria for discharge in a patient with an acute exacerbation of asthma?
- been stable on their discharge medication (i.e. no nebulisers or oxygen) for 12–24 hours
- inhaler technique checked and recorded
- PEF >75% of best or predicted
73
What is pneumonia?
Inflammation of the alveoli due to infection
74
What are the causes of pneumonia?
Bacterial: Steptococcus pneumoniae, staphylococcus aureus
Viral: haemophilus influenzae
Fungi: pneumocystis is jiroveci
Klebsiella pneumoniae: alcohol use
75
What is the CRB-65 score and what is it used for?
Used to asses mortality risk for pneumonia in a primary care setting
C- confusion
R- respiratory rate >= 30
B- blood pressure, diastolic <= 60 or systolic < 90
Age greater than 65
76
What do the the different CRB-65 scores mean?
0: low risk (less than 1% mortality risk)
1 or 2: intermediate risk (1 to 10% mortality risk)
3 or 4: high risk (more than 10% mortality risk).
77
What are the symptoms of pneumonia?
Cough
Sputum
Chest pain: may be pleuritic
Dyspnoea
Fever
78
What tests should be done for suspected pneumonia?
Chest x-ray
Full blood count
Urea and electrolytes
CRP
ABGs
79
What type of pathogen causing pneumonia is commonly found in COPD patients?
Haemophilus influenzae
Pseudomonas aeruginosa
80
Which type of pathogen causing pneumonia is commonly found in alcoholics?
Klebsiella pneumoniae
Streptococcus pneumoniae
81
In alpha-1-antitrypsin deficiency, why is ALT and GgT raised?
buildup of the abnormal alpha-1 antitrypsin protein in the liver also can lead to permanent liver damage (cirrhosis) and even liver cancer
82
What is the first line antibiotic for hospital acquired pneumonia and what is the dosage?
Co-amoxiclav
500/125 mg 3 times a day for 5 days
83
What does examination show in pneumonia?
Course crackles
Dullness on percussion
Bronchial or reduced breathing sounds
Wheeze
84
What are the 2 classifications of pleural effusion?
Transudate
Exudate
85
Which vessels drain pleura fluid from the lymphatic space?
Lymphatic vessels
86
What are the symptoms of a pleural effusion?
Dyspnoea
Cough
Chest pain
87
What will examination show in a suspected pleural effusion?
Dullness on percussion
Reduced breathing sounds
Reduced chest expansion
88
What investigations are done to confirm pleural effusion?
Chest x ray: blunting of costophrenic angles, meniscal sign
Diagnostic aspiration: using 24 gauge needle to remove 10-30ml of pleural fluid to send for testing
Ultrasound: guide thoracocentesis
Full blood count
CRP
LFT
U&Es
Serum BNP
89
What is the lights criteria and when is its use indicated?
The lights criteria is used to determine whether a pleural effusion is exudate or transudate. It is indicated if the protein content in the pleural fluid is between 25-35g/L
90
Which of exudate and transudate typically cause bilateral pleural effusion?
Transudate
91
What is the requirements of the light criteria?
Pleural fluid protein to serum protein ratio > 0.5
Pleural fluid LDH to serum LDH > 0.6
Pleural fluid LDH greater than 2/3rd the upper limits of normal serum LDH
92
What are the possible exudative causes of pleural effusion?
Infections: Pneumonia, TB
Connective tissue disorders: rheumatoid arthritis
PE
Malignancy: lung cancer, mesothelioma, lymphoma
Gastrointestinal: pancreatitis, oesophageal perforation
SLE, yellow nail syndrome, MI
Abscess
Atelectasis
93
What levels of triglycerides and cholesterol in pleural fluid suggest Chylothorax and pseudochylothorax?
Chylothorax:
- tri > 1.24mmol/l
- cholesterol <5.18mmol/l
Pseudochylothorax
Tri- <0.56mmol/l
Cholesterol- >5.18mmol/l
94
What could purulent pleural fluid suggest?
Empyema
95
What are possible causes of a Chylothorax?
Thoracic duct trauma or surgery
Malignancy
Chronic inflammation
96
What are the symptoms of lung cancer?
Persistent cough
Haemoptysis
Chest pain
Weight loss
Appetite loss
Tiredness
Hoarseness
Dyspnoea
97
What are the 2 classifications of lung cancer? Which is more common?
Non-small cell lung cancer- more common
Small cell lung cancer
98
Describe the 3 subtypes of non small cell lung cancer?
Adenocarcinoma: non smokers, Asian females, metastasises early
Squamous cell carcinoma: common in smokers, produces parathyroid hormone, metastasises late
Large cell carcinoma: smokers; metastasises early
99
What paraneoplastic features are typically seen in small cell carcinoma?
ADH secretion: SIADH: hyponatremia
ACTH secretion: Cushing syndrome (hypertension, hyperglycaemia, hypokalaemia)
Lambert Eaton syndrome: disruption of neuromuscular junction
100
What investigations are done for lung cancer?
Chest x ray
CT
Bronchoscope + Biopsy
PET scan
Lfts
U&Es
Serum calcium
FBC: raised platelets
101
What are the nice guidelines on referral for suspected lung cancer?
Refer (2 week) for suspected cancer if:
- patient >= 40 with Haemoptysis
- CxR suggests lung cancer
102
What is the treatment for non small cell lung cancer?
Stages 1-3:
- lobectomy/ pneumonectomy
- pre operative chemotherapy
- post operative chemoradiotherpy
- Sabr: patients who are too frail
Stage 4:
- targeted therapy
- Immunotherapy
- chemotherapy
103
When should an urgent chest x ray be offered in suspected lung cancer?
If patient aged >= 40 and has two of the following or one if they are a smoker:
- weight loss
- cough
- fatigue
- appetite loss
- shortness of breath
104
What is the most common presenting symptom for lung cancer?
Cough
105
What is the most common cause of mesotheliomas?
Asbestos exposure
106
What are other types of lung cancers?
Mesotheliomas
Carcinoid
107
What is a Pancoast tumour? What are the symptoms?
Tumour of the apex of the lung
Symptoms:
- horners syndrome: facial flushing, reduced sweating, ptosis, pupil constriction
- shoulder pain
- weakness of arm/ hand on affected side
108
When is dual antibiotic therapy given for pneumonia? How long?
If the patient has a moderate or severe mortality risk - scores 2-5/
Patient is given antibiotic for 7-10 days
109
What is the requirement for discharge of a patient admitted with pneumonia?
Patient can’t be discharged if they have had 2 or more of the following in the last 24 hours:
- temperature > 37.5
- RR >= 24
- heart rate > 100
- blood pressure <=90 systolic
- oxygen below 90%
- inability to eat without assistance
- abnormal mental status
-
110
Which lung is commonly affected by aspiration pneumonia and why?
Right lung: right main bronchus is more vertically orientated and wider
111
What are the most common causes of aspiration pneumonia?
Stroke
Multiple sclerosis
Intoxication
Intubation
112
What is the most common type of interstitial lunge disease?
Idiopathic pulmonary fibrosis
113
Who is idiopathic pulmonary fibrosis more common in?
Ages 50-70
Men
Smokers
114
What are the symptoms of idiopathic pulmonary fibrosis?
Progressive exertional dyspnoea
Dry cough
Weight loss
115
What are the signs of IPF?
Clubbing
Bibasal fine end inspiratory crepitations
Clubbing
Cyanosis
116
What does the ct show in pulmonary fibrosis?
Honeycombing
Traction broncheiectasis
Lower zone reticular shadowing
117
What investigations are done for suspected idiopathic pulmonary fibrosis?
CxR
HRCT
Spirometer
Gas transfer
Antinuclear antibody and rheumatoid factor
Lung biopsy
118
How is idiopathic pulmonary fibrosis treated?
Pulmonary rehabilitation
Oxygen
Pirfenidone
Nintedanib
Lung transplant
119
What is the requirement for giving patients with IPF Pirfenidone and nintedanib?
Must have FVC between 50-80% of predicted
120
When do you perform an ABG in a patient with asthma exacerbation?
If oxygen salts are below 92%
121
What is sarcoidosis?
Multisystem autoimmune disorder which causes the formation of multiple Granulomas in different parts of the body
122
What is the epidemiology of sarcoidosis?
- typically found in 20-40 year olds
- more common in women
- more common in those of African and Caribbean descent
123
What are the symptoms of sarcoidosis?
-dry cough
- exertions dyspnoea
-chest pain
- fever
- weight loss
- fatigue
-jaundice
- malaise
- seizures
- erythema nodosum
- lupus pernio
124
What sis Löfgren syndrome? What is the triad of symptoms?
It is an acute presentation of sarcoidosis, which resolves within 6 months to a year. It presents with the following symptoms:
- erythema nodosum
- BHL
- polyarthralgia
125
What is the staging for sarcoidosis?
Staging is based on x ray presentation:
0: normal
1: BHL
2: BHL and interstitial changes
3: interstitial changes
4: pulmonary fibrosis
126
What investigations regarding bloods are done for sarcoidosis?
-LFTs
-U&Es
- CRP
-serum ACE
-ESR
-Calcium
-immunoglobulins
127
Aside from bloods what other investigations are done for sarcoidosis?
Urinalysis: Calcium, Protein
CxR
MRI
CT
ECG
Lung function
Tissue biopsy
Ultrasound
128
What is the gold standard investigation to confirm sarcoidosis? What will it show?
Tissue biopsy: non-caseating granulomata
129
How is sarcoidosis treated?
1st line: no treatment
Steroids: 6-24 months, must be given bisphosphonate
Immunosuppressants: methotrexate, azathioprine, infliximab
130
What are the indications for steroid treatment in sarcoidosis?
Parenchyma lung disease
Uveitis
Hypercalcaemia
Cardiac involvement
Neurological involvement
131
What conditions cause upper zone fibrosis?
Coal workers pneumoconiosis
Hypersensitivity pneumonitis
Ankylosing spondylitis
Radiation
Tuberculosis
Sarcoidosis/ silicosis
132
What is ARDS?
Acute respiratory distress syndrome is acute respiratory failure due to non carcinogenic pulmonary oedema secondary to alveoli damage
133
What are the causes of ARDS?
Primary: pneumonia, trauma, aspiration pneumonia, inhalation (smoke), drowning
Secondary: acute pancreatitis, fat emboli -long bone fractures, aspirin, burns, sepsis
134
What investigations are done for ARDS?
FBC
U&E
Urinalysis
LFT
Blood culture
Sputum culture
ABGs
Chest x ray
135
What is Berlin criteria?
Berlin criteria is used to determine a diagnosis of ARDS.
1. Acute onset of < 1 week after initial insult
2. Abnormal CxR showing bilateral infiltrates
2. Non carcinogenic cause - pwcp< 19mmHg
4. Decreased p/f ratio <=300mmhg
136
How is ARDS treated?
- patient admitted to ITU
- ventilation: nippv (Cpap 40%-60%)
- mechanical ventilation
- haemodynamic monitoring - swanz-ganz catheter (cardiac output, pwcp)
- treat underlying cause
- fluids
- vasopressors
- nutrition
137
What is eosinophilia granumolatosis with polyangitis?
This is a rare disorder which causes small-medium Vasculitis with symptoms of asthma and eosinophilia and multi organ involvement
138
What are the 3 main features of egpa?
Asthma
Sinusitis
Nasal polyps
139
How is EGPA diagnosed?
Urinalysis
X- ray/CT
ANCA
CRP
ESR
Tissue biopsy
140
What are the features of kartageners syndrome?
dextrocardia or complete situs inversus
bronchiectasis
recurrent sinusitis
subfertility (secondary to diminished sperm motility and defective ciliary action in the fallopian tubes)
141
What are the contraindications for surgery for treatment on non small cell lung cancer?
assess general health
stage IIIb or IV (i.e. metastases present)
FEV1 < 1.5 litres is considered a general cut-off point*
malignant pleural effusion
tumour near hilum
vocal cord paralysis
SVC obstruction
142
What are the new guidelines on treating a pneumothorax?
Treatment is based on whether patient is symptomatic or not, not on the size of the pneumothorax.
If the patient is symptomatic and has any of the following high risk characteristics then a chest drain must be inserted:
- over 50 and smoker
- underlying lung pathology
- hypoxia
- haemodynamic compromise
- haemotborax
143
If a patient has no high risk factors with a pneumothorax but is symptomatic, how should it be treated?
This is based on patient priority. They can have either:
- conservative management- regular outpatient review (2-4 days)
- rapid symptomatic relief: pleural vent ambulatory device
- rapid symptomatic relief with short term drainage: needle aspiration
-
144
What should all patients with secondary spontaneous pneumothorax have?
They should be admitted for inpatient monitoring regardless if treatment is conservative or not.
145
If a patient has no symptoms or minimal symptoms with a pneumothorax how should they be treated?
Conservative management, review in outpatient every 2-4 days. Once stable review in 2-4 weeks
146
What does CT show in Bronchiectasis?
Bronchoarterial ratio > 1 : signet sign
Lack of tapering: bronchi should taper distally
Bronchus visible within 1cm of pleural surface
147
What are the risk factors for PE?
Immobility
Recent surgery
Long haul travel
Oestrogen hormone therapy
Malignancy
148
What symptoms are seen in PE?
Pleuritic chest pain
Breathlessness
Haemoptysis
Dizziness
Syncope
Unilateral leg swelling
Raised JVP
Tachypnoea
149
When do you do the PERC score for PE?
If PE is unlikely, less than 15% probability
150
When is the wells score done for PE?
When PE is suspected.
151
What is included in the wells score?
Clinical signs (leg swelling, leg pain on deep palpation)
Alternative diagnoses
Heart rate > 100
Immobilisation/ surgery in last 3 weeks
Previous DVT or PE
Haemoptysis
Malignancy
152
If a CTPA cannot be carried out immediately or a d-dimer within 4 hours, what must the patient be given?
Interim therapeutic anticoagulation
153
If a patient has antiphospholipid syndrome, what anticoagulant is given initially and long-term?
Initially: LMWH + Warfarin for 5 days
Long term: Warfarin
154
If renal impairment is severe (<15L/ min), which anticoagulant is given long term?
LMWH
155
What tests need to be carried out for anticoagulation treatment?
Renal function, U&Es
Lfts
APTT
PT
156
What investigations are done for suspected PE?
ABGs
CxR
ECG
D-dimer
CTPA
V/Q
157
What investigations are done for suspected copd exacerbation?
ABGs
FBC
U&E
CxR
ECG
Theoph
158
When should you admit a patient with copd exacerbation to hospital?
pO2 <90%
Confusion
Severe breathlessness
Peripheral oedema
FEV1<30%
Polycythaemia
Raised JVP
159
Describe the glucose levels that can be found in pleural effusions?
<3.4mmol/L : empyema, malignancy, TB, oesophageal rupture
<1.6mmol/L: empyema
160
How is low risk CAP treated?
5 day course on antibiotics
- amoxicillin: 500mg, three times daily
allergy:
- docycycline: 200mg day 1, 100mg OD next 4 days
- clarithromycin: 500mg TD
- erythromycin: 500mg QDS (pregnancy)
161
How is high risk CaP treated?
5 day course
First line:
- co-amoxiclav (500/125mg three times daily orally/ 1.2mg three times daily IV) + clarithromycin/ erythromycin (oral/IV)
PA allergy: levofloxacin (500mg TD oral/IV)
162
What is the discharge criteria for pneumonia?
Patient must not be discharged if they have had 2 or more of the following:
Temp greater than 37.5
Systolic BP below 90
Oxygen below 90%
Inability to eat without assistance
RR greater than 24
HR greater than 100
163
How long does it take chest pain and sputum production in pneumonia to resolve?
4 weeks
164
What causes obstructive sleep apnoea?
This occurs when the pharyngeal airway collapses during patients sleep. This results in periods of apnoea ( patient not breathing) for a few minutes
165
What are the risk factors for obstructive sleep apnea?
Obesity
Male
Middle aged
Smoking
Alcohol
Marfan syndrome
166
What symptoms are seen in obstructive sleep apnea?
Snoring
Daytime somnolence
Morning headache
Apnea during sleep
Concentration problems
Feeling tired
167
How is obstructive sleep apnea diagnosed?
Epsworth sleepiness scale: patient questionnaire
Sleep studies
168
How is obstructive sleep apnea treated?
Lifestyle: weight loss, smoking cessation, alcohol cessation
CPAP
Surgery: UPPP
169
Describe the time periods for which the symptoms of pneumonia may resolve?
1 week: fever
4 weeks: chest pain and sputum
6 weeks: cough and breathlessness
3 months: fatigue
6 months: back to normal
