Respiratory Flashcards
Asthma Ix?
Lung function tests - peak flow, spirometry
Bronchial challenge test
Measure FENO and blood eosinophils
Blood tests: FBC, IgE
(can do skin prick test, Chest x-ray should be normal)
Asthma sx?
Wheeze, nocturnal cough, allergy to house dust mites, pets
Wheeze in asthma?
Polyphonic wheeze
Treatment for asthma?
SABA, ICS low-dose, low-dose ICS + LABA (bronchodilator) + LTRA or up ICS to medium-dose, refer to specialist care
Asthma treatment (hollistic)?
Inhalers + inhaler technique
Trigger avoidance
Annual review
Vaccination - flu, covid
Asthma action plan
Treatment for severe asthma?
Biologics, anti-IL-5
Ix for COPD?
Spirometry with reversibility
Asthma differentials for finals?
COPD, allergic bronchopulmonary aspergillosis (ABPA), bronchiectasis, bronchiolitis
ABPI symptoms?
Wheeze, recurrent chest infections, mucus plugs, haemoptysis
Ix for ABPI?
Must have evidence of hypersensitivity to aspergillus fumigatus
IgE and IgG raised to aspergillus
High eosinophils
Flitting changes on X-ray
Signs of bronchiectasis on High resolution CT scan
Treatment for ABPA?
Oral corticosteroids
Chest physio
Antifungals (itraconazole) may also be required
Cause of pneumonia in COPD?
Moraxella catarrhalis
What signs insidcate atypical pneumonia?
Headache, low grade fever, malaise
Treatment for Legionnaire’s disease?
Ciprofloxacin
COPD in <40 y/o: what could be the cause?
Alpha-1-antitrypsin deficiency
How is the obstructive picture in COPD shown in spirometry?
FEV1/FVC ratio <0.7
Severity of COPD obstruction?
> 80% = mild
50-79% = moderate
30-49% = severe
<30% = Very severe
COPD allergic features?
History of asthma/atopy
High eosinophils
COPD treatment?
Inhalers, smoking, vaccinations, pulmonary rehabilitation
Type 1 respiratory failure?
Low oxygen
Normal/low carbon dioxide
Type 2 respiratory failure?
Low oxygen
High carbon dioxide
Which spirometry pattern indicates restrictive lung disease?
FEV1/FVC > 0.7
Features of interstitial lung disease?
Inflammation and fibrosis
Progressive breathlessness and dry cough
Clubbing, find-end inspiratory crackles,
Causes of interstitial lung disease?
Idiopathic pulmonary fibrosis, asbestosis, methotrexate, RA, silicosis
Ix for interstitial lung disease?
History, high resolution CT thorax (honeycombing, ground glass appearance), lung biopsy, pulmonary function tests (reduced lung volume)
Treatment for interstitial lung disease?
Anti-fibrinotics (nintedanib)
Smoking cessation
vaccinate, exercise
Long term oxygen therapy
Transplant
Palliative care
TB treatment side effects?
Rifampicin = orange secretions, enzyme inducer
Isoniazid = peripheral neuropathy due to B6 deficiency
Pyrazinimde = Gout, arthralgia, liver toxicity
Ethambutol = Colour vision
Pneumonia chest x-ray guidelines?
Do a chest x-ray 6 weeks post pneumonia to ensure there’s nothing behind the consolidation on chest x-ray
Signs of lung cancer?
Cough, haemoptysis, chest pain, unresolving pneumonia
Hypertrophic pulmonary osteoarthropathy
Periosteal bone proliferation, clubbing, large joint inflammation
Diagnosis of bronchiectasis?
high resolution CT scan (signet ring)
Mx of bronchiectasis?
Chest physio, prophylactic antibiotics
Causes of secondary pneumothorax?
COPD, TB, malignancy
Ix for pneumothorax?
CXR, ABG
Diagnosing TB imaging?
CT thorax
Transudative pleural effusions?
Liver cirrhosis, congestive heart failure, hypoalbuminaemia, nephrotic syndrome
Exudative pleural effusion causes?
Malignancy, infection, PE
Prophylactic abx in copd?
azithromycin
Surgery in COPD?
Bullectomy
Lung reduction surgery (indication: heterogenous emphysema)
Endobronchial valve placement (valve placed in part of lung iatrogenic distal collapse)
Lung transplant
Medical mx of COPD?
1, PRN SAMA OR SABA:
* Short-acting muscarinic antagonist / SAMA e.g. ipratropium
* Short-acting beta-agonist / SABA e.g. salbutamol
2 LABA + LAMA (no asthmatic features) OR LABA + inhaled corticosteroid (asthmatic features):
* Long-acting muscarinic antagonist / LAMA e.g. tiotropium
* Long-acting beta-agonist / LABA e.g. salmeterol, formeterol
* Symbicort (LABA + ICS = Symbicort)
Asthmatic features:
* History of asthma or atopy Eosinophilia (FBC in workup)
* FEV1 variation over time (>400mL) Diurnal variation in PEFR (>20%)
3 LABA + LAMA + ICS
Asthma investigations in >17 year old?
FeNO test then spirometry
o Positive test thresholds asthma:
FEV1/FVC ratio <70% (obstructive)
FeNO ≥40 parts per billion
BDR (FEV1) ≥12% variability and >200mL increase in volume after SABA administration
Peak flow variability (PFV) >20% PEFR variability
Bronchial challenge (BC) PC20 ≤8mg/mL (with methacholine or histamine challenge)
Differentials for a Wheeze
Respiratory: asthma, COPD
Rheumatological: GPA (obliterative bronchiolitis), rheumatoid arthritis
Cardiac: heart failure
Asthma mangement long-term
SABA
SABA and ICS
SABA and ICS + LTRA
Increase ICS dose
Refer to specialist - trial LAMA or theophylline
Asthma A&E sent home: follow-up
Treated in A&E, better in 1 hour discharge, TAME T
T Technique, Avoidance (triggers), Monitor (PEFR), Educate
(1) Review in GP in 2 days
o Acute severe asthma?
PEFR 33-50%
Not completing full sentences
RR >25, HR >110, pO2 >92%
Oral corticosteroids following asthma exacerbation?
Prednisolone 40mg, OD, PO, 5 days; OR
When to admit asthma exacerbation?
Acute severe if no response and above
Dose of nebulised salbutamol asthma exacerbation?
5mg
Dose of nebulised ipatropium bromide asthma exacerbation?
0.5mg
Rusty sputum pneumonia bacteria?
Streptococcus pneumoniae
Red-currant jelly sputum, alcoholism, DM, elderly, haemoptysis, aspiration, cavitating upper lobes
K. pneumoniae
Air travel, air conditioner, water towers, hepatitis, hyponatraemia, urinary antigen
L. pneumophilia (Legionella)
CURB-65 cut-offs
Confusion (AMTS ≤8)
Urea ≥7mmol/L
RR ≥30
BP ≤90/60mmHg
Age ≥65yo
HAP causative organisms?
Early-onset (48 hours to 4 days) streptococcus pneumoniae
Late onset (>4 days) Enterobacteria (E. coli, K. pneumoniae) > S. aureus (MRSA) > Pseudomonas
o Klebsiella tx?
Cephalosporin (resistant to most penicillin)
Ix for TB?
Bedside exam, obs, TST, sputum (MC&S), sputum smear + ZH / auramine stain
Bloods baseline (FBC, U&Es), CRP, IGRA
Imaging CXR
Special tests EBUS (histology)
Treatment of PCP?
Mild-moderate: co-trimoxazole
Severe: IV pentamidine
Hypoxia: steroids
Chest-drain complications
Immediate failure, pain, haemorrhage, pneumothorax
Early infection, haematoma, long thoracic nerve damage ( winged scapula), blockage
Late scar formation
Ix for pleural effusion?
- Investigations:
o Bedside exam, obs, urine dip (protein)
o Bloods baseline bloods (FBC, U&Es), LFTs, CRP, clotting, blood culture
o Imaging CXR contrast-CT (esp. for exudative causes), echo (CCF)
o Special tests USS-guided pleural aspiration ± chest drain, BAL (cellularity), EBUS (sarcoid, TB)
USS + pleural tap (21G needle + 50mL syringe) – do even for massive effusions - chest drain
Exudate = >30g/L protein; transudate = <30g/L protein
Use Light’s criteria if 25-35g/L protein (helps differentiate causes) … an exudate is likely if…
* Pleural fluid protein / serum protein >0.5
* Pleural fluid LDH / serum LDH >0.6
* Pleural fluid LDH > 2/3rds ULN serum LDH
Other characteristic findings:
* Low glucose RhA, infection (TB)
* Raised amylase pancreatitis, oesophageal perforation
* Heavy blood staining mesothelioma, PE, TB, iatrogenic (pneumothorax)
Mx of pleural effusion?
(1) Pleural effusion with aspirate… * turbid/cloudy, tests +ve on MC&S, pH <7.2 - chest drain
N.B. can use an ABG to ascertain if the pH is acidic quickly
(2) Treat underlying cause (i.e. ABx for pneumonia, furosemide for AHF, etc.)
Recurrent pleural effusion:
Recurrent aspiration
- Pleurodesis
Indwelling pleural catheter
Drug management (i.e. opioids for SOB)
Bronchiectasis Ix?
o Bedside exam, obs, sputum sample (MC&S), sweat testing
o Bloods baseline bloods (FBC, U&Es), CRP, immunoglobulins, CF genetic testing, aspergillus markers
o Imaging CXR, HR-CT
o Special tests spirometry
Diagnostic is high-res CT
Treatment of bronchiectasis?
o Prophylaxis:
Physiotherapy, pulmonary rehabilitation
Smoking cessation
Prophylactic rescue packs (ABx), education about when to use them
Bronchodilators
Immunisations
o Acute exacerbation:
ABx
Bronchodilators
Interstitial lung disease causes?
o Idiopathic pulmonary fibrosis (IPF)
o Hypersensitivity pneumonitis (formerly EAA): S/S: mild fever; ix: BAL cellularity
o Sarcoidosis
o Pneumoconiosis (simple = asymptomatic; complicated = symptomatic)
o Upper lobe fibrosis = TAPE:
T TB
A ABPA
P Pneumoconiosis (silica, coal)
E EAA (hypersensitivity pneumonitis) (mid-zone)
o Lower lobe fibrosis = STAIR:
S Sarcoid (mid-zone)
T Toxins (BANS Me)
* B Bleomycin, Busulfan
* A Amiodarone
* N Nitrofurantoin
* S Sulfasalazine
* Me Methotrexate
A Asbestosis
I Idiopathic pulmonary fibrosis (IPF; diagnosis of exclusion)
R Rheumatology (RhA, SLE, Sjogren’s, scleroderma / CREST)
HR-CT in ILD?
Honeycombing, ground glass appearance
S/S IPF?
o Progressive exertional dyspnoea
o Dry cough
o Clubbing (not often in EAA)
o Bibasal fine end-inspiratory crepitations on auscultation
Ix in ILD
o Bedside exam, obs
o Bloods baseline bloods (FBC, U&Es), SLE screen (complement, AI screen), serum IgE, ABG
o Imaging CXR, HR-CT, echo (pul. HTN)
o Special tests spirometry (restrictive), TLCO (low), BAL (cellularity in EAA), EBUS (sarcoid, TB)
Mx of sarcoidosis?
Steroids
restrictive spirometry picture?
o >70%, FEV1 reduced, FVC very reduced
Spirometry obstructive picture?
o <70% = obstructive, FVC very reduced/normal, FEV1 very reduced
- TLCO/DLCO in obstructive/restrictive?
Reduced
S/S of CF?
o Meconium ileus (surgery may be needed) Growth faltering (difficulty putting on weight)
o Recurring chest infections, wheezing, coughing, SoB Damage to the airways (bronchiectasis)
o ABPA, nasal polyps, sinusitis
Jaundice (cirrhosis, portal HTN)
o Diarrhoea or constipation
Diabetes mellitus
o Male sterility (absence of the vas deferens) CLUBBING FINGERS
Investigations for CF?
o Guthrie heel prick test for IRP / Immunoreactive Trypsinogen (if +ve, further tests are done):
Sweat test (abnormally high NaCl in sweat) – normal (10-40mmol/L), CF (60-115mmol/L)
Genetic tests (see below)
o CXR (hyperinflation, peri-bronchial shadowing, bronchial wall thickening, ring shadows)
Mx of CF?
Very routine reviews (specialist CF centres):
Physiotherapy twice a day → airway clearance manoeuvres and devices + encourage physical activity
Mucolytic therapy:
* 1st line: Dornase alfa
* 2nd line: rhDNase + hypertonic saline, mannitol dry powder (INH)
* Orkambi: Lumacaftor with Ivacaftor (potentiators and correctors) may be effective in treating (prolonging life) CF caused by the F508 mutation (78% of CF sufferers)
Prophylaxis oral antibiotics (flucloxacillin and azithromycin to reduce exacerbation chance)
Rescue packs (for prompt IV ABx with any symptoms or signs of infection)
Small cell lung cancer (SCLC) associations?
smokers, central, SIADH, ACTH, Lambert-Eaton Myasthenic Syndrome (LEMS)
Adenocarcinoma associations?
Non-smokers, peripheral, early metastasis, gynaecomastia, hypertrophic pulmonary osteoarthropathy HPOA
squamous cell carcinoma associations?
smokers, central, spread locally, late metastasis, PTHrP, ectopic TSH, HPOA
Which tumours metastasise most to bone?
Particular tumours love killing bone
Prostate, testicular, lung, kidney, breast
CXR 2ww guidelines
Age <40yo AND ≥2 symptoms OR current/past smoker and ≥1 symptom/s:
* Cough Fatigue SOB
* Chest pain WL Appetite loss
Age >40yo AND ≥1 symptom/s:
* Persistent/recurrent chest infection
* Clubbing
* Supraclavicular lymphadenopathy or persistent cervical lymphadenopathy
* Chest signs consistent with lung cancer
* Thrombocytosis
