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Respiratory Flashcards

1
Q

CAP (I)

A

CRB-65 (severity assessment [in community]):
- C: Confusion (AMT 8 or less) – 1 point
- R: Respiratory rate 30 or more – 1 point
- B: Blood pressure <90/60 (either systolic or diastolic) – 1 point
- 65: Age 65 or more – 1 point

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2
Q

CAP (II)

A

CRB Categories
- Score 0: low risk of death – consider home care
- Score 1-2: intermediate risk of death – consider hospital assessment
- Score 3-4: high risk of death – consider hospital assessment (admit)

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3
Q

CAP (III)

A

CRB-65 of 0: Amoxicillin 500mg TDS 5 days (Doxycycline/Clarithromycin/Erythromycin if Penicillin allergy)
CRB-65 of 1-2: Amoxicillin 500mg TDS 5 days and (if atypical pathogens suspected) Clarithromycin or Erythromycin
CRB-65 of 3-4: Options may include: Co-amoxiclav + Clarithromycin or Erythromycin
Higher severity
(hospital)

General self-care management: e.g. rest, fluids, analgesia, (don’t recommend cough syrups)

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4
Q

Asthma diagnosis

A

Asthma diagnosis based of probability:
- Variable symptoms in history?
- Personal/family history of atopy?
- FeNO (fractional exhaled nitric oxide): Positive if 40 ppb (steroid-naïve adults), Positive if 35 ppb (age 5-16)
- Tests suggesting airflow:
Spirometry (over age 5, look for FEV1/FVC ratio ,70%)
Bronchodilator reversibility (do B-agonists/corticosteroids improve FEV1 by 12%?)
Peak flow variability (look for 20% variability – measure at least BD over 2-4 weeks)
- Direct bronchial challenge test: with histamine or methacholine (Needs specialist referral for this)

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5
Q

Asthma Management (non-acute, 17 and over)

A

Asthma Management (non-acute, 17 and over
1. Reliever therapy: SABA inhaler as needed
2. Low-dose inhaled ICS (Beclomethasone/Budesonide/Fluticasone): e.g. if uncontrolled: Asthma symptoms/inhaler used 3x a week or more OR woken at night by symptoms once a week
3. LTRA (Montelukast): In addition to a low dose ICS
4. Add LABA (Salmeterol/Formoterol): In combination with low dose ICS ((Beclomethasone/Budesonide/Fluticasone) +/- LTRA (Montelukast)
5. Offer MART regime:
Maintenance and Reliever therapy together (MART)
Combination of low dose ICS and fast acting LABA (e.g. fomoterol) in one inhaler (Symbicort, Fostair)
6. Increase steroid dose to - Moderate-dose steroid: Either with MART, or back as individual inhalers
7. Other options or Refer:
- Increase steroid dose to - High-dose steroid
- Additional medications, e.g. LAMA, theophylline

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6
Q

Ashma Management (non-acute, 5-16)

A

Ashma Management (non-acute, 5-16)
1. Reliever therapy: SABA inhaler as needed
2. Low-dose inhaled ICS (Beclomethasone/Budesonide/Fluticasone): e.g. if uncontrolled: Asthma symptoms/inhaler used 3x a week or more OR woken at night by symptoms once a week
3. LTRA (Montelukast): In addition to a low dose ICS (Beclomethasone/Budesonide/Fluticasone)
4. Add LABA (Salmeterol/Formoterol): In combination with low dose ICS ((Beclomethasone/Budesonide/Fluticasone) STOP LTRA (Montelukast)
5. Offer MART regime:
Maintenance and Reliever therapy together (MART)
Combination of low dose ICS and fast acting LABA (e.g. fomoterol) in one inhaler (Symbicort, Fostair)
6. Increase steroid dose to - Moderate-dose steroid: Either with MART, or back as individual inhalers
7. Refer:
- Increase steroid dose to - High-dose steroid
- Additional medications, e.g. LAMA, theophylline

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7
Q

Asthma Management (non-acute, under 5s)

A
  1. Reliever therapy: SABA inhaler as needed
  2. Moderate-dose inhaled ICS trial:
    **8-week trial ** and review (as a test)
    Stop and monitor symptoms
    If symptoms recur in 4 weeks, commence maintenance low-dose ICS
    Consider LRTA ((Montelukast): In addition to low-dose ICS (Beclomethasone/Budesonide/Fluticasone)
    4. Refer
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8
Q

Acute asthma Assessment

A

Moderate: PEFR 50-75% predicted (for that age)
Severe: PEFR 33-50% predicted (for that age)
Life-threatening: PEFR: <33% predicted (for that age): Also, may have
- Sats <92%
- Silent chest
- Exhaustion
- Altered conscious level
- Cyanosis

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9
Q

Acute Asthma - Community Management

A

Admit if severe/life-threatening asthma or if in doubt, but if not:

  • Oxygen
  • B-agonist: either inhaled or nebulised salbutamol
  • Considered nebulised ipratropium 0.5mg (500mcg)
  • Steroids: Prednisolone 40-50mg OD 5 days or IM methylprednisolone 160mg (adult)
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10
Q

COPD investigations/dx

A

Post-bronchodilator spirometry:
- Carry out 15-20 minutes after taking a bronchodilator
- Airflow obstruction: FEV1/FVC ratio <0.7 (less than 0.7)
- Imaging: e.g. CXR (rule out other conditions), CT chest
- FBC: check for polycythaemia (high RBC or high haematocrit or high Hb or high platelets or high WBC or low EPO), anaemia
- Serial peak flow: if asthma considered
- Serum alpha-1 antitrypsin: deficiency especially if young or FH
- Sputum culture
- Cardiac investigations: e.g. ECG, BNP, echo
- NO CLUBBING in COPD. (Note clubbing in mesothelioma)

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11
Q

COPD grading

A

Stage 1 Mild FEV1 >80% predicted
Stage 2 Moderate FEV1 50-79% predicted
Stage 3 Severe FEV1 30-49% predicted
Stage 4 Very Severe FEV1 <30% predicted
Smoking, RSV, Flu, Covid jab, Pulmonary rehab

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12
Q

COPD Management

A

Step 1: Short-acting bronchodilators (SABA or SAMA) – SABA (salbutamol, terbutaline), SAMA (ipratropium)

Step 2:
YES asthma features: LABA (salmeterol) + ICS (Beclomethasone/Budesonide/Fluticasone)
NO asthma features: LABA (salmeterol) + LAMA (tiotropium)

Step 3: LABA (salmeterol) + LAMA (tiotropium) + ICS (Beclomethasone/Budesonide/Fluticasone)
Add on therapies may include (with respiratory input):
- Regular oral steroids
- Oral theophylline
- Oral mucolytics, e.g. Carbocisteine
- Prophylactic antibiotics, e.g. Azithromycin (usually 250mg 3 times a week)

*Remember ICS not to be used alone in COPD
Flu jab annually + PPV (ONE OFF)

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13
Q

Reccurent infective exacerbations (further info)

A

Azithromycin 250 mg three times a week can be used (off-label licence) as antibiotic prophylaxis for patients with chronic obstructive pulmonary disease who are prone to exacerbations (usually four or more in a year), or prolonged productive exacerbations or those resulting in hospitalisations.

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14
Q

Acute COPD Exacerbation

A

Consider need for admission, e.g. how unwell, sats, past history etc.
Increase SABA – not beyond maximum recommended
Prednisolone: 30mg OD 5 days (? Osteoporosis prophylaxis) [lower dose pred than asthma]
(if multiple COPD exacerbations in the last year consider osteoporosis prophylaxis)
Antibiotics if purulent sputum (dependent on local guidance):
- Amoxicillin 500mg TDS for 5 days
- Doxycycline 200mg day 1, then 100mg OD for 5-day total course
- Clarithromycin 500mg BD for 5 days
In hospital may need nebs, O2, theophylline, NIV etc.
(Check steroid risk over over year)

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15
Q

LTOT in COPD

A

Consider LTOT in:

  • Chronic hypoxemia oxygen saturation of <92% (measured on two occasions at least 3 weeks apart and at least 5–6 weeks after an exacerbation)
  • Partial pressure of oxygen (PaO2) <7.3 kPa (8 kPa in patients with pulmonary hypertension, secondary polycythaemia, peripheral oedema from cor pulmonale)
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16
Q

Pulmonary Embolism (I)

A
  • Multiple risk factors:
    Previous history, age
    Smoking, obesity, COCP, long flights, immobility
    Acute infection, varicose veins, hospitalisation, pregnancy/postpartum, cancer, chemotherapy
  • Classic presentation:
    Dyspnoea, pleuritic chest pain, cough, haemoptysis
    Calf swelling/pain
  • Examination:
    Tachycardia, high RR, hypoxia
    Gallop rhythm, raised JVP, widely split 2nd heart sound
17
Q

Pulmonary Embolism Management (I)

A

Admit if pregnant (or having given birth within the past 6 weeks) and PE suspect (don’t use Well’s score if pregnant)

2-level PE Well’s score:
- PE likely if score of more than 4 points
- PE unlikely if score of 4 or less

18
Q

Well’s score

A
  • Clinical features of DVT (minimum of leg swelling and pain with palpation of the deep veins) - minus 3 points
  • An alternative diagnosis is less likely than PE - 3 points
  • Heart rate greater than 100 beats per minute - 1.5 points
  • Immobilization for more than 3 days or surgery in the previous 4 weeks - 1.5 points
  • Previous DVT or PE - 1.5 points
  • Haemoptysis - 1 point
  • Cancer (receiving treatment, treated in the last 6 months, or palliative) - 1 point
19
Q

Pulmonary Embolism Management (II)

A

If PE likely: Admit for CTPA (V/Q scan if contraindicated) immediately – if not possible, offer interim therapeutic anticoagulation

If PE unlikely: Check D dimer within result within 4 hours – if result not possible within 4 hours, offer therapeutic anticoagulation therapy while awaiting the result. If D dimer positive, admit to hospital for immediate CTPA

Other investigations (likely in secondary care), e.g. CXR, Bloods, ABG to rule out differentials

20
Q

Interim anticoagulation & treatment/mgt. for confirmed PE

A

If interim anticoagulation is needed: First-line – Apixaban or Rivaroxaban (LMWH if not suitable)
If confirmed PE, management may include:
- Medications, e.g. LMWH / fondaparinux / ongoing oral anticoagulants (e.g. apixaban) / streptokinase
- Interventions, e.g. IVC filters
- Will need ongoing anticoagulation at least 3 months if proven PE
- Unprovoked PE: screen for cancers, thrombophilia screen

21
Q

Pneumothorax

A

Different types:
- Simple vs tension
- Spontaneous (e.g. tall thin men) vs traumatic (e.g. biopsy/trauma)
Presentation:
- May be asymptomatic (particularly small ones)
- SOB, chest pain, deterioration of conditions, e.g. asthma/COPD
Examination:
- Tachycardia, high RR, pulsus paradoxus (pulse slows inspiration)
- Reduced air entry, reduced expansion, hyperresonance, trachea may be deviated away (typically if very large pneumothorax)

Pneumothorax Management
Non-tension:
- Conservative VS
- Active intervention (e.g. needle/chest drain/surgery) – depending

Tension (ATLS):
- Large-bore cannula
- Adult: 5th intercostal space, mid-axillary line of the affected side
- Child: 2nd intercostal space, mid-clavicular line of the affected side

22
Q

Pleural effusion

A

Different types:
- Transudate – lower levels of protein - (protein less than <30g/L), e.g. due CCF, nephrotic syndrome – usually a problem outside of the lung
- Exudate – higher level of protein - (protein more than >30g/L), e.g. due to infection, malignancy – usually a problem inside of the lung (except Meigs syndrome)
Examination:
- Classic: stony dull percussion
- Reduced breath sounds, Displaced trachea, Reduced fremitus, Reduced tactile vocal resonance
Investigations:
- Include CXR, USS, pleural tap, pleural biopsy
Management: Conservative management (is possible if small), may need drainage (sometimes repeatedly), Pleurodesis, Surgery

23
Q

Lung cancer referral

A

Appointment within 2 weeks (with lung cancer clinic):
- Have CXR findings that suggest lung cancer
- Over 40 with unexplained haemoptysis

24
Q

Urgent CXR with 2 weeks

A

Urgent CXR within 2 weeks if Over 40 if:

EITHER (symptoms)
Have 2 or more of below unexplained symptoms OR if ever smoked and 1 symptom:
- Cough
- Fatigue
- SOB
- Chest pain
- Weight loss
- Appetite loss

OR (signs):
- Persistent or recurrent chest infection
- Finger clubbing
- Supraclavicular LN
- Persistent cervical LN
- Chest signs consistent with lung cancer
- Thrombocytosis (high platelets)

25
Q

Pulmonary fibrosis

A

Many causes:
- Idiopathic
- Dust and chemical exposure, e.g. wood, asbestos, silica
- Allergen exposure e.g. birds, mould
- Certain medications, e.g. amiodarone, bleomycin, nitrofurantoin,
- Associated with connective tissue disease: e.g. RA, SLE, systemic sclerosis
Classic presentation:
- SOB, dry cough
- Fine inspiratory crackles o/e
- Clubbing
Investigation (may include):
- Spirometry – usually restrictive pattern
- Imaging: CXR, Gold standard is CT (honeycombing**, reticular pattern)
- Pleural biopsy
Multiple treatment options depending on cause:
- Oxygen, Physiotherapy
- Medications, e.g. **pirfenidone, **Immunosuppressants
- - Acute treatment, e.g. steroids
- Surgical, e.g. transplant

26
Q

Bronchiectasis

A

Permanent Bronchial wall thickening and dilation
- e.g. due to recurrent infection/inflammation (and then healing) or linked to connective tissue disease
Can be focal or diffuse
Many presentation features, e.g.
- Cough, Dyspnoea
- Purulent Sputum
- Haemoptysis
- Recurrent infections
Examination: (will be bilateral, where cancer will be bilateral)
- Coarse inspiratory crackles, rhonchi, wheeze
- Clubbing
Investigation:
-** HRCT gold standard for diagnosis – shows bronchial wall dilation**
- FBC, ESR, CRP, CXR, Spirometry, Sputum culture (looking to rule out pulmonary fibrosis, sarcoidosis, infections, asthma, COPD, etc.)
- Antibody levels, CF testing
- Bronchoscopy
Management (trying to get rid of the build of a lot of the fluid in the lungs):
- Physiotherapy and breathing techniques
- Bronchodilators
- Antibiotics, e.g.
Amoxicillin/clarithromycin 14 days (so increased length of treatment)
** Prophylaxis, e.g. long-term Azithromycin (for some patients - usually given 3 times weekly if patients have recurrent exacerbations)**
- Surgery, e.g. resection/lobectomy

27
Q

Management of acute flare of bronchiectasis (extra info)

A

When treating a patient with an acute exacerbation of bronchiectasis, amoxicillin (or doxycycline or clarithromycin) are reasonable choices.
If there is evidence of previous colonisation with pseudomonas aeruginosa, levofloxacin or co-amoxiclav should be used.

28
Q
A
29
Q

Obstructive Sleep Apnoea Syndrome

A

Intermittent airway collapse/obstruction whilst asleep – various symptoms
Risk factors:
- Obesity, neck circumference >43cm
- Smoking, alcohol
- Family history of OSA
Presentation includes:
- Snoring
- Daytime sleepiness
- Fatigue, unrefreshed
- Witness apnoeas when asleep (collateral history important)
- Impaired concentration
- Unexplained morning headaches
Screening questionnaires (both suggested):
- Epworth sleepiness score
- STOP-Bang questionnaire
Can have routine or urgent referral to sleep clinic
Urgent referral to sleep clinic if:
- Sleepy when driving/machinery/hazardous job
- Other condition e.g. COPD, heart failure, angina
- Pregnant
- Undergoing pre-op for major surgery
- Non-arteritic anterior ischaemic optic neuropathy
Routine referral:
- Moderate or severe OSAS
- Mild OSAS that impacts on QOL
Primary care options:
- Discuss weight loss, exercise, alcohol, smoking
- Monitor BP, CVD risk, diabetes
Secondary care investigations:
- Sleep studies e.g. Oximetry, Respiratory polygraphy, Polysomnography (most detailed including brain activity, eye movements, muscle tone etc.)
Management options:
- CPAP
- Mandibular advancement splints. (oral device over teeth increases space back of mouth)
- Surgery e.g. tonsillectomy, oropharyngeal surgery

30
Q

Sarcoidosis

A

Multisystemic chronic inflammatory condition
- Leads to non-caseating granulomata in various parts of the body – commonly lungs & skin
Presentation:
- General symptoms, e.g. fever/fatigue
- Lung symptoms, e.g. persistent dry cough/dyspnoea
- Other features, e.g. tender skin swellings/lymphadenopathy etc.
Investigation:
- ESR raised
- CXR: classic finding of bilateral hilar lymphadenopathy
- CT chest
- Lung biopsy
Management:
- Supportive – can settle itself
- Oral steroids
- DMARDs e.g. methotrexate/azathioprine

31
Q

Long term oxygen (LTOT)

A

Treatment for hypoxaemia, not breathlessness
Consider referral to respiratory:
- PaO2 less than 7.3 (8 in some circumstances)
- Consider referral: Resting Sats 92% or less
Usage:
- Usually life-long
- Usually at least 15-16 hours a day
Multiple uses e.g.:
- COPD, Severe chronic asthma
- Bronchiectasis, Interstitial lung disease, Cystic fibrosis
- Pulmonary vascular disease, Primary pulmonary hypertension, Pulmonary malignancy
- Chronic heart failure
- Palliative care

32
Q

Smoking cessation

A

Many possible withdrawal symptoms when stop smoking e.g.
- Nicotine craving
- Increased appetite
- Poor concentration
- Restlessness
- Irritability
Offer referral to local stop-smoking clinics
3 methods (never used in combination)
- NRT
- Varenicline (Champix) – reduces nicotine cravings. Is not currently available
- Bupropion

33
Q

Nicotine replacement therapy

A

Nicotine replacement therapy
- Low levels of nicotine, without tar, carbon monoxide etc
- Multiple formats e.g. gum, transdermal patch, lozenge, spray (nasal or oral), inhalator, sublingual tablet (can be used in combination)
- Usual duration is 8-12 weeks, before gradual withdrawal
- Common side effects include nausea, dizziness, headache

34
Q

Bupropion (Zyban)

A

Bupropion (Zyban)
- Originally used for depression, found to help with smoking
- Plan stop date and start 1-2 weeks before this
- Usual course 7-9 weeks, no tapering usually after
- Contraindicated in under 18s, seizure disorder, Bipolar, eating disorders

35
Q

Varenicline (Champix)

A

Varenicline (Champix)
- Currently unavailable…
- Plan stop date and start 1-2 weeks before this
- Usual course 12 weeks, no tapering usually needed after
- Contraindicated in under 18s. severe renal disease
- Caution in psychiatric, cardiovascular illness

36
Q
A

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