Respiratory

Question 1

different stages of acute asthma

Answer 1

moderate - PEFR 50-75% of predicted, RR<25, BPM <110

severe - PEFR 33-50%, cant complete sentences, RR>25, BPM >110

life-threatening - <33%, sats <92%, silent chest, cyanosis, bradycardia, dysrhythmia, hypotension, exhaustion, confusion, coma

normal PCO2 = exhaustion

Question 2

management of acute asthma

Answer 2

admit

oxygen if hypoxaemic - 15L if acutely unwell then downtitrate to flow rate which maintains 94-98%

SABA - inhaled, nebulised

corticosteroid - 40-50mg pred PO 5 day

ipratropium bromide (SAMA)

IV magnesium sulphate

IV aminophylline

ITU/HDU - intubation and ventilation, ECMO

Question 3

discharge critera for patients admitted with acute asthma

Answer 3

stable on discharge meds for 12-24h
inhaler technique checked and recorded
PEFR >75% best or predicted

Question 4

features of acute bronchitis

Answer 4

clinical diagnosis

sx - cough, sore throat, rhinorrhea, wheeze, low grade fever

no other focal chest signs other than wheeze, no real systemic features (whereas pneumonia has systemic features)

Question 5

overview of acute bronchitis

Answer 5

self limiting chest infection lasting 3w (viral) due to inflammation of trachea + major bronchi - assx with oedematous large airways and sputum production

Question 6

management of acute bronchitis

Answer 6

CRP testing may be used to guide whether abx therapy is needed

analgesia
good fluid intake
abx if - very unwell, pre-existing co-morbidities, CRP 20-100 (delayed script), CRP >100 (immediate abx)

doxycycline

amoxicillin in children/pregnant women

Question 7

infective causes of COPD exacerbations

Answer 7

bacteria - haemophilus influenza, streptococcus pneumoniae, moraxella catarrhalis

respiratory virus - 30% exacerbations - human rhinovirus

Question 8

features of COPD exacerbations

Answer 8

dyspnoea, cough, wheeze

increase in sputum suggestive of an infective cause

patients may be hypoxic and in some cases have acute confusion

Question 9

management of COPD exacerbations

Answer 9

frequent bronchodilator use + nebuliser
prednisolone 30mg 5 days

oral abx if purulent sputum or clinical signs of pneumonia (amoxicillin, clari, doxy)

admission if adverse criteria

Question 10

inpatient management of COPD exacerbations

Answer 10

oxygen - hypercapnia risk therefore target 88-92 with 28% venturi at 4l/min, adjust to 94-98 if pCO2 normal

nebulised bronchodilator - beta-adrenergic agonist (salbutamol), muscarinic antagonists (ipatroprium)

IV hydrocortisone if needed

IV theophylline - if pt not responding to nebulised bronchodilators

NIV - if resp acidosis

Question 11

overview of ARDS

Answer 11

due to increased permeability of alveolar capillaries causing fluid accumulation in alveoli - significant morbidity, 40% mortality

acute onset and severe
dyspnoea
elevated respiratory rate
bilateral lung crackles
low oxygen saturations

Question 12

causes of ARDS

Answer 12

infection: sepsis, pneumonia
massive blood transfusion
trauma
smoke inhalation
acute pancreatitis
Covid-19
cardio-pulmonary bypass

Question 13

criteria for ARDS

Answer 13

acute onset (<1w risk factor)
pulmonary edema - bilateral infiltrates on CXR
non cardiogenic
pO2 <40kPA

Question 14

management of ARDS

Answer 14

ITU mx

oxygenation for hypoxaemia
organ support e..g, vasopressors

tx underlying cause - abs for sepsis

prone position , muscle relaxation

Question 15

features of allergic bronchopulmonary aspergillosis

Answer 15

allergy to aspegillus spores

causes proximal bronchiectasis and bronchoconstriction (wheeze, cough, dyspnoea)

hx eosinophilia, bronchiectasis
may have previosu hs asthma

Question 16

CXR features of allergic bronchopulmonary aspergillosis

Answer 16

eosinophilia
flitting CXR changes - ring shadow, tram track opacities shows bronchiectasis
positive radioallergosorbent (RAST) test to Aspergillus
positive IgG precipitins (not as positive as in aspergilloma)
raised IgE

Question 17

management of allergic bronchopulmonary aspergillosis

Answer 17

oral glucocorticoids
itraconazole

Question 18

overview of alpha-1 antitrypsin deficiency

Answer 18

AR inherited condition Chr14
lack of protease inhibitor (A1AT) which is normally produced by the liver - this protects cells from enzymes such as neutrophil elastase

causes emphysema in young, non smokers

Question 19

features of alpha 1 antitrypsin deficiency

Answer 19

lower lobe panacinar emphysema

cirrhosis and HCC in adults, cholestasis in children

test A1AT concentration
obstructive spirometry

Question 20

management of alpha 1 antitrypsin deficiency

Answer 20

no smoking
bronchodilators
physiotherapy
IV A1AT protein concentrates
lung volume reduction surgery, lung transplantation

Question 21

risk factors for aspiration pneumonia

Answer 21

Poor dental hygiene
Swallowing difficulties
Prolonged hospitalization or surgical procedures
Impaired consciousness
Impaired mucociliary clearance

Question 22

features of aspiration pneumonia

Answer 22

affects right middle and lower lobes
can be aerobic or anaerobic bacteria

Question 23

main symptoms of asthma

Answer 23

cough - worse at night
dyspnoea
wheeze
chest tightness

expiratory wheeze
reduced PEFR

Question 24

asthma management guidelines

Answer 24

SABA
SABA + ICS (low dose - <400mcg budesonide or eq)
SABA + ICS + LRTA
SABA + ICS + LABA (+LRTA depending on pt response)
SABA + LTRA + MART (med-dose ICS 400-800 budesonide or eq)

SABA + LTRA + high dose ICS >800mg/additional drug e.g., theophylline

Question 24

drugs used in asthma management

Answer 24

SABA - salbutamol - relaxes smooth muscle of airways

ICS - beclomethasone

LABA - salmeterol

LRTA - montelukast

MART - ICS + LABA

Question 25

investigation findings in asthma

Answer 25

spirometry
reduced FEV1
normal FVC
FEV1 <70%

FeNO
nitric oxide levels correlate with level of inflammation

CXR

Question 26

stepping down asthma treatment

Answer 26

step down every 3m

reduce inhaled steroids by 25-50% at a time

Question 27

features of atelectasis

Answer 27

postop complication
basal alveolar collapse - can lead to respiratory difficulty

dyspnoea and hypoxaemia ~72h postop

position pt upright and do chest physio