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MSRA > Respiratory > Flashcards

Respiratory Flashcards

How can I breathe with no air

1
Q

What scale can be used to assess breathlessness?

A

The MRC (Medical Research Council) Dyspnoea Scale is a 5-point scale for assessing breathlessness:
🔹Grade 1: Breathless on strenuous exercise
🔹Grade 2: Breathless on walking uphill
🔹Grade 3: Breathlessness that slows walking on the flat
🔹Grade 4: Breathlessness stops them from walking more than 100 meters on the flat
🔹Grade 5: Unable to leave the house due to breathlessness

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2
Q

What spirometry result suggests COPD?

A

Obstructive picture with FEV1:FVC ratio < 70%
little or no response to reversibility testing with beta-2 agonists (e.g. salbutamol)

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3
Q

How can severity of COPD be graded?

A

The severity can be graded using the forced expiratory volume in 1 second (FEV1):

🔹Stage 1 (mild): FEV1 more than 80% of predicted
🔹Stage 2 (moderate): FEV1 50-79% of predicted
🔹Stage 3 (severe): FEV1 30-49% of predicted
🔹Stage 4 (very severe): FEV1 less than 30% of predicted

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4
Q

What is the management of COPD?

A

Non-pharm: smoking cessation, pneumococcal and flu vaxx, pulmonary rehab

Medical: SABA (salbutamol) or SAMA (ipratropium bromide)

2nd line: determine if asthmatic or steroid responsive features
if NO features => LABA/LAMA e.g. anoro ellipta
if YES => LABA/ICS e.g. fostair, symbicort, seretide

3rd line: LABA/LAMA/ICS e.g. timbow, trelegy ellipta

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5
Q

What monitoring is needed for patients on azithromycin?

A

ECG
LFT

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6
Q

What are the indications for LTOT in COPD?

A

🔹chronic hypoxia (sats <92%)
🔹polycythaemia
🔹cyanosis
🔹cor pulmonale

smoking is C/I - fire risk

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7
Q

What is cor pulmonale?

A

Right sided HF caused by resp disease
Pulm HTN limits RV in pumping into pulm arteries => bac pressure into RA, VC, and venous system

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8
Q

What are some causes of cor pulmonale?

A

🔹COPD (most common)
🔹PE
🔹ILD
🔹CF
🔹Pulm HTN

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9
Q

What are symptoms of cor pulmonale?

A

most are asymptomatic
🔹SOB
🔹peripheral oedema
🔹SOBOE
🔹syncope
🔹CP

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10
Q

What are signs of cor pulmonale?

A

🔹hypoxia
🔹cyanosis
🔹raised JVP
🔹peripheral oedema
🔹parasternal heave
🔹loud second HS
🔹murmurs
🔹hepatomegaly

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11
Q

What can be seen on an ABG in ECOPD?

A

resp acidosis - ROME:
🔹low pH
🔹low pO₂
🔹raised pCO₂
🔹raised HCO₃⁻

set sats target to 88-92%

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12
Q

What is the management of ECOPD?

A

1st line:
🔹reg salb and ipra nebs
🔹prednisolone 30mg OD for 5 days
🔹Abx if infective

resp physio

severe ECOPD:
🔹IV aminophylline
🔹NIV
🔹intubation and ventilation + ITU

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13
Q

What are the criteria for NIV? What are some contraindications?

A

🔹Persistent resp acidosis (pH < 7.35 + PaCO₂ > 6)
🔹Potential to recover
🔹Acceptable to the pt

Contraindications
🔹untreated pneumothorax
🔹structural abnormality or pathology affecting the face/airway/GI tract

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14
Q

How can OSA be assessed?

A

Epworth Sleepiness Scale
Sleep studies
- simple sleep study - sats monitor overnight
- resp polygraphy - machine monitor RR, flow rate, sats, HR
- complex sleep study at sleep centre with polysomnography may inc EEG EMG ECG

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15
Q

How long before a pneumonia is classified as a HAP?

A

after >48hrs in hospital

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16
Q

What are the typical bacterial causes of pneumonia?

A

STREP PNEUM (most common)
🔹Haem influenza

🔹morazella catarrhalis (immunocomp or chronic resp diseases)
🔹pseudomonas aeruginosa - CF/bronchiectasis
🔹staph aureus - CF
🔹MRSA - HAP

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17
Q

What is atypical pneumonia? What antibiotics are used?

A

Atypical pneumonia is caused by organisms that cannot be cultured in the normal way or detected using a gram stain. Treatment with penicillin is ineffective. They are treated with macrolides (e.g., clarithromycin), fluoroquinolones (e.g., levofloxacin) and tetracyclines (e.g., doxycycline).

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18
Q

What are some causative organisms of atypical pneumonia?

A

Legionella pneumophila (Legionnaire’s disease) - inhaling infected water from water system e.g. AC => can cause SIADH . test with legionella urinary antigen

Mycoplasma pneumoniae - can cause erythema multiforme (“target”)

Chlamydophila pneumoniae - mild-mod chronic pneumonia and wheezing in school-age children

Coxiella burnetti (Q fever) - exposure to bodily fluid of animals e.g. farmer with a flu-like illness

Chlamydia psittaci - infected birds

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19
Q

What is PCP?

A

Pneumocystis jirovecii pneumonia - fungal
immunocompromise, HIV, low CD4 count
dry cough + SOBOE + night sweats

Tx with co-trimoxazole

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20
Q

How is COVID-19 transmitted?

A

Primarily through respiratory droplets
Contact with contaminated surfaces
Aerosol transmission in certain settings

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21
Q

How does SARS-CoV-2 enter host cells?

A

The virus binds to the ACE2 receptor on host cells, facilitating entry and replication.

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22
Q

What are common clinical features of COVID-19?

A

Fever, cough, fatigue, loss of taste or smell, myalgia

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23
Q

What is the incubation period for COVID-19?

A

The incubation period is 2-14 days, with a median of 5 days.

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24
Q

What is the gold standard for diagnosing COVID-19?

A

RT-PCR is the gold standard for detecting viral RNA

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25
What imaging findings are common in severe COVID-19?
Chest X-ray: Bilateral infiltrates CT Scan: Ground-glass opacities and consolidation
26
What are the main pharmacological treatment options for COVID-19?
Antivirals: Remdesivir for hospitalized patients Corticosteroids: Dexamethasone for severe respiratory distress Immunomodulators: Tocilizumab in cases of systemic inflammation
27
What causes Tuberculosis (TB)?
TB is caused by Mycobacterium tuberculosis, a slow-dividing, rod-shaped bacillus with high oxygen requirements.
28
Why is Mycobacterium tuberculosis referred to as an "acid-fast bacilli"? What staining is needed?
It has a waxy coating, making gram staining ineffective and resistant to acids in the staining process, requiring Ziehl-Neelsen staining.
29
What is the outcome of Ziehl-Neelsen staining for TB?
TB bacilli appear bright red against a blue background.
30
What are the possible outcomes after inhaling TB bacteria?
1. Immediate clearance 2. Primary active TB 3. Latent TB 4. Secondary TB (reactivation)
31
What is miliary tuberculosis?
It refers to disseminated and severe disease when TB spreads and the immune system cannot control the infection.
32
What are common sites for extrapulmonary TB?
Lymph nodes, pleura, CNS, pericardium, GI system, genitourinary system, bones and joints, skin (cutaneous TB).
33
What is a "cold abscess" in TB?
A firm, painless abscess, usually in the neck, without inflammation or redness typical of acute infection.
34
What investigations are used for diagnosing TB?
Mantoux test IGRA (Interferon-Gamma Release Assay) Chest x-ray Sputum cultures
35
What does a positive Mantoux test indicate?
Induration of 5mm or more at the injection site indicates a positive result, suggesting TB infection.
36
What are the typical chest x-ray findings for TB?
Primary TB: Patchy consolidation, pleural effusions, hilar lymphadenopathy Reactivated TB: Nodular consolidation with cavitation, typically in upper zones Miliary TB: Small nodules resembling "millet seeds" scattered throughout the lung fields.
37
What is the treatment regimen for latent tuberculosis?
Isoniazid and rifampicin for 3 months, or Isoniazid for 6 months
38
What does the RIPE mnemonic stand for in TB treatment?
R: Rifampicin (6 months) I: Isoniazid (6 months) P: Pyrazinamide (2 months) E: Ethambutol (2 months)
39
What are common side effects of TB treatment drugs?
Rifampicin: Red/orange secretions - “red-I’m-pissin’” Isoniazid: Peripheral neuropathy (prevented with pyridoxine or Vitamin B6) - “I’m-so-numb-azid” Pyrazinamide: Hyperuricaemia (gout) Ethambutol: Colour blindness and reduced visual acuity - “eye-thambutol”
40
What is the importance of nucleic acid amplification tests (NAAT) in TB?
NAAT detects TB DNA quickly and provides information about drug resistance.
41
What is a key examination finding in asthma?
A widespread "polyphonic" expiratory wheeze.
42
Which medications can worsen asthma symptoms?
Non-selective beta-blockers (e.g., propranolol) and non-steroidal anti-inflammatory drugs (e.g., ibuprofen or naproxen).
43
What test is used to measure lung function in asthma?
Spirometry
44
What is the significance of a FEV1 ratio of less than 70% in spirometry?
It suggests obstructive pathology, such as asthma or COPD.
45
How does reversibility testing support the diagnosis of asthma?
A greater than 12% increase in FEV1 after a bronchodilator supports a diagnosis of asthma.
46
What does a high FeNO (Fractional exhaled Nitric Oxide) level indicate in asthma diagnosis?
A FeNO level above 40 ppb supports a diagnosis of asthma due to airway inflammation.
47
What is the purpose of peak flow variability testing in asthma?
To measure fluctuations in airway obstruction, where a variability of more than 20% supports the diagnosis of asthma.
48
What are the signs of a life-threatening asthma exacerbation?
Peak flow less than 33%, oxygen saturations less than 92%, confusion or agitation, silent chest, and haemodynamic instability (shock).
49
Why is the "silent chest" a critical sign in asthma?
A silent chest indicates severe bronchoconstriction with no air entry, signifying life-threatening asthma.
50
What is the role of intravenous magnesium sulfate in severe asthma exacerbations?
IV magnesium sulfate helps to relax airway muscles and is used in severe exacerbations to relieve bronchoconstriction.
51
What are the peak flow measurements for moderate, severe, and life-threatening asthma exacerbations?
- Moderate: Peak flow > 50% predicted - Severe: Peak flow < 50% predicted - Life-threatening: Peak flow < 33% predicted
52
What are the heart rate and respiratory rate thresholds for severe asthma exacerbations in children aged 1-5 years and older than 5 years?
Heart rate: > 140 (1-5 years) or > 125 (>5 years) Respiratory rate: > 40 (1-5 years) or > 30 (>5 years)
53
How are bronchodilators stepped up in acute asthma management?
1. Inhaled or nebulised salbutamol 2. Inhaled or nebulised ipratropium bromide 3. IV magnesium sulfate 4. IV aminophylline
54
What is the stepwise approach to treating moderate to severe asthma exacerbations?
1. salbutamol inhalers via a spacer 2. nebulisers with salbutamol/ipratropium 3. oral prednisone 4. IV hydrocortisone 5. IV magnesium sulfate 6. IV salbutamol 7. IV aminophylline
55
What are common side effects of salbutamol in high doses?
Tachycardia (fast heart rate) and tremor.
56
When can a child with asthma exacerbation be considered for discharge?
When they are well on 6 puffs 4-hourly of salbutamol and can be prescribed a reducing salbutamol regime for home use.
57
What is the stepwise approach to managing asthma in children under 5 years?
1. SABA 2. low dose ICS or leukotriene antagonist 3. low ICS + leukotriene antagonist 4. Refer to a specialist if necessary.
58
What is the stepwise approach to managing asthma in children aged 5-12 years?
1. SABA 2. add a low-dose corticosteroid 3. add LABA 4. inc ICS dose 5. add ? leukotriene antagonists or theophylline.
59
What investigation is typically used to diagnose a simple pneumothorax?
An erect chest x-ray, which shows an area without lung markings and a clear line demarcating the lung edge.
60
How is the size of a pneumothorax measured on a chest x-ray?
By measuring horizontally from the lung edge to the inside of the chest wall at the level of the hilum, according to BTS guidelines.
61
How is a pneumothorax managed if the patient has a <2 cm pneumothorax?
Conservative management with regular outpatient reviews, with no active treatment required.
62
What options are available for managing a pneumothorax larger than 2 cm in lower-risk patients?
Options include conservative management, pleural vent ambulatory devices, needle aspiration, or chest drains based on the patient's priority for procedure avoidance or rapid symptom relief.
63
What is a pleural vent ambulatory device, and when is it used?
A catheter inserted into the pleural space with a device allowing air to exit but not return, used in outpatient management of pneumothorax for rapid symptom relief.
64
Where is a chest drain inserted for treating pneumothorax?
In the "triangle of safety" formed by the 5th intercostal space, midaxillary line, and anterior axillary line, just above the rib to avoid the neurovascular bundle.
65
What are signs that a chest drain is functioning correctly?
Air bubbling through the drain, swinging of water during respiration, and lung re-inflation on a repeat chest x-ray.
66
What are two common complications of chest drains?
Air leaks around the drain site (persistent bubbling) and surgical emphysema (air collecting in the subcutaneous tissue).
67
When is surgical intervention required in the management of pneumothorax?
When a chest drain fails, there is a persistent air leak, or for recurrent pneumothorax.
68
What are the surgical options for treating recurrent pneumothorax?
Video-assisted thoracoscopic surgery (VATS) with options like pleurodesis (abrasive or chemical) or pleurectomy.
69
What causes a tension pneumothorax, and why is it dangerous?
A one-way valve lets air into the pleural space but not out, causing pressure to build, potentially shifting the mediastinum and leading to cardiorespiratory arrest.
70
What are key signs of a tension pneumothorax?
Tracheal deviation away from the pneumothorax, reduced air entry, increased resonance on percussion, tachycardia, and hypotension.
71
How is a tension pneumothorax managed in an emergency?
Insert a large-bore cannula into the second intercostal space in the midclavicular line or the 4th/5th intercostal space anterior to the midaxillary line.
72
What are the normal values for pH, PaO2, PaCO2, HCO3, and lactate in ABGs?
pH: 7.35 – 7.45 PaO2: 10.7 – 13.3 kPa PaCO2: 4.7 – 6.0 kPa HCO3: 22 – 26 mmol/L Lactate: 0.5 – 1 mmol/L
73
What is the main difference between type 1 and type 2 respiratory failure?
Type 1: Low PaO2 with normal PaCO2. Type 2: Low PaO2 with elevated PaCO2.
74
How can you distinguish between respiratory and metabolic causes of acid-base imbalance?
Respiratory cause: Changes in PaCO2 (high CO2 for acidosis, low CO2 for alkalosis). Metabolic cause: Changes in bicarbonate (HCO3) (low in acidosis, high in alkalosis).
75
How does the kidney respond to chronic CO2 retention?
The kidneys produce more bicarbonate (HCO3) to buffer the acidic CO2, helping maintain a normal pH, which is seen in chronic conditions like COPD.
76
What are some common causes of metabolic acidosis?
*Raised lactate*: Due to tissue hypoxia (e.g., shock). *Raised ketones:* In diabetic ketoacidosis. *Increased hydrogen ions:* Renal failure or rhabdomyolysis. *Reduced bicarbonate:* Diarrhea or renal tubular acidosis.
77
What are the common causes of metabolic alkalosis?
Loss of hydrogen ions from vomiting, or increased aldosterone activity (e.g., Conn's syndrome, heart failure, cirrhosis).
78
How do loop and thiazide diuretics contribute to metabolic alkalosis?
They increase aldosterone activity, leading to increased excretion of hydrogen ions in the kidneys.
79
What ABG findings are typical in a patient with diabetic ketoacidosis?
Metabolic acidosis with low pH, low bicarbonate, and raised ketones.
80
What ABG findings are expected in a patient with anxiety-induced hyperventilation?
Respiratory alkalosis with high pH, low PaCO2, and typically normal or high PaO2.
81
What are the escalating options for supporting a patient’s respiratory system?
1. Oxygen therapy 2. High-flow nasal cannula 3. Non-invasive ventilation (NIV) 4. Intubation and mechanical ventilation 5. Extracorporeal membrane oxygenation (ECMO)
82
What is the primary goal of respiratory support?
Respiratory support buys time to manage the underlying problem, but it does not fix the root cause.
83
What are the key features of Acute Respiratory Distress Syndrome (ARDS)?
Alveolar collapse (atelectasis) Pulmonary oedema (non-cardiogenic) Decreased lung compliance Lung fibrosis (after ~10 days)
84
What are the clinical signs of ARDS?
Acute respiratory distress Hypoxia unresponsive to oxygen therapy Bilateral infiltrates on a chest x-ray
85
How is ARDS managed?
Respiratory support Prone positioning Careful fluid management
86
What are the oxygen delivery methods and corresponding FiO2?
Nasal cannula: 24 – 44% Simple face mask: 40 – 60% Venturi masks: 24 – 60% Non-rebreather mask: 60 – 95%
87
What is Positive End-Expiratory Pressure (PEEP), and why is it important?
PEEP is the pressure applied at the end of exhalation to keep the airways inflated, reducing atelectasis and improving gas exchange.
88
What is Continuous Positive Airway Pressure (CPAP) used for?
CPAP provides constant pressure to keep airways open, commonly used in obstructive sleep apnoea and conditions prone to airway collapse.
89
What is the difference between CPAP and non-invasive ventilation (NIV)?
CPAP provides constant pressure without ventilating, while NIV uses varying pressures to assist both inhalation and exhalation, supporting ventilation.
90
What does BiPAP stand for, and how does it work?
BiPAP (Bilevel Positive Airway Pressure) delivers two pressures: IPAP for inhalation and EPAP for exhalation, preventing airway collapse and supporting breathing.
91
What is Extracorporeal Membrane Oxygenation (ECMO), and when is it used?
ECMO provides respiratory support by oxygenating blood outside the body. It is used in severe, reversible respiratory failure when mechanical ventilation is insufficient.

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