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1. Fellowship Written - SAQ > Respiratory > Flashcards

Respiratory Flashcards

1
Q

What are the biochemical features of exudate from effusion?

A

Purulent pleural fluid
* + gram stain / culture
* WCC > 50,000
* Pleural fluid glucose <3
* Pleural fluid pH <7.2
* Pleural fluid LDH >1000

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2
Q

What is the Lights criteria for exudate

A

Lights criteria (High protein and LDH = exudate), determines presence of exudate with protein and LDH levels
Pleural fluid protein to serum protein ratio >0.5
Pleural fluid LDH to serum LDH ratio >0.6
Pleural fluid level >2/3 of upper value for serum LDH

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3
Q

What are the US features of empyema?

A

Loculation
effusion
consolidation

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4
Q

What are the steps in management for empyema?

A
  • Supportive - Oxygen, analgesia, fluids
  • Medical - Iv abx eg tazocin or vanc if MRSA. 20fr chest drain
  • Surgical - fibrinolytics via chest drain, VATS (video assisted thorascopic surgery). open thoracotomy
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5
Q

list two pathological processes linked to the Gas and explain it

A

Severe acute Resp acidosis - Raised Pco2 with low PH

Chronic resp acidosis with metabolic compensation - HCO3 is raised at 44 more than would be expected for a
purely acute process (expect about HCO3 of 34) ie raise of 1
mmol/L for every raise in 10mmHg of CO2

Raised A/a gradient - A-a gradient = PAO2 – PaO2

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6
Q

What is the A-a gradient

A

A-a gradient is calculated as PAO2 – PaO2

Normal is 5-10mmHG

It is a measure of the difference in oxygen concentration between alveolar and the arteries

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7
Q

Someone is failing BIPAP for severe COPD. What are the next steps in ED?

A
  1. Intubate
  2. hyperventilate to decrease Co2
  3. reduce Fi02
  4. IV abs
  5. IV fluid
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8
Q

What are the abnormalities?

Diagnosis?

A
  • Left hilar mass - rounded opacity left hilum and patchy consolidation around this area
  • Confluent consolidation RUL with air bronchograms
  • Consolidation right middle lobe oscuring right hear border

Diagnosis
Multi lobe pneumonia with likely malignancy left hilum

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9
Q

multi lobe pneumonia with following obs
What are the treatment steps and end points?

A
  1. titrate o2 to over 92
  2. IV fluid boluses aiming for HR under 100 and systolic BP over 100
  3. IV cef and azi
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10
Q

abnormalities?

Differentials?

Investigations and justification

A
  • RUL opacification
  • cavitating lesion with air fluid level
  • RUL collapse with trachel deviation
  • small left effusion

Differentials
Neoplastic - Primary lung or secondary mets
Lung abscess - bacterial infection. TB
Vasculitis eg Wegners

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11
Q

chemo for melanoma
two positve and two negative findings

What are the possible infective causes?

non infective

A

Positive
* bilateral symmetrical infiltrates
* alveolar infiltrates with round lesions

Negative
* no effusions
* no pneumorax
* normal heart size

Infective causes:
Mycoplasma pneumonia
influenza/covid
Aspergillosis
TB

Non Infective
Pulmonary haemorrhage
ARDS
Pulmonary oedema

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12
Q

SOB
what are the significant findings?

What are the possible infective causes?
Non infective

A

Positive
left upper zone cavitating lesion with air fluid level
Air bronchograms

Negative
no effusion
no pneumothorax

Infective
S.pneumonae
S.aureus
Klebsiella

Non infective
malignancy
infarct
Vasculitis
pulmonary haemorrhage

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13
Q

What are the eight steps in inserting IJ line

A
  • *Aseptic preparation
  • Head down
  • Local anaesthetic to site
  • Use of USS guided technique where possible
  • Insert needle to IJV
  • Pass wire
  • Dilate vein
  • Insert central line
  • Flush all lumens
  • Secure to skin*
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14
Q

when assessing a patient with CP what features are important in the history?

A
  1. communication - how do they communicate and express pain
  2. Diet - PEG or oral feed
  3. any CP co-morbidities eg seizures
  4. previous ICU admissions
  5. Previous intubations
  6. advanced health care directive
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15
Q

What are the differences between aspiration pneumonia and aspiration pneumonitis?

A
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16
Q

someone with CP and sats 88% with fi01 0.21 (normal air) - what methods are there for oxygenation

A

Non Invasive
Hudson - if for ward based therapies, non able to blow of Co2, less invasive

Invasive
high flow nsal probs. BIPAP/CPAP

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17
Q

what features of a history would suggest poor asthma control

A
  1. daytime symptoms twice a week
  2. reliever needed twice a week
  3. limitations on activities
  4. symptoms overnight
  5. 3 or more presentations in a month
  6. prior ICU admissions
  7. poor health/social literacy
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18
Q

what do you need to ensure to safely discharge asthma patient?

A
  1. ASTHMA PLAN
  2. scripts
  3. preventer
  4. GP FU
  5. understand when to return
  6. handout in appropriate language
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19
Q

What are the advantages and disadvantages on NIV in asthma

A

Advantages
* PEEP aids with WOB
* IPAP increases tidal volume
* prevents intubation
* shorter inspiratory times increase tidal volumes

Disadvantages
* may delay intubation
* wrong settings may increase WOB
* increased risk pneumothorax
* difficult to clear secretions

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20
Q

asthma

A
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21
Q

what are the contraindications for NIV in COPD

A
  1. decreased GCS
  2. patient refusal
  3. vomiting
  4. haemoptysis
  5. not intiating own breathing
  6. facial abnormalities
  7. lack of nursing staff to supervise
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22
Q

how may you alter NIV settings if no improvement after an hour and why?

A
  • Increase IPAP - increase TV and ventilation to remove CO2
  • increse Fio2 or PEEP increase oxygenation
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23
Q

abnormalities

A
  • Marked hyperinflation
  • Moderate/Large left sided pneumothorax
  • Mediastinal shift to the right – possible tension PTX
  • Bilateral widespread pulmonary infiltrates
  • Right midzone (basal segment of upper lobe) wedge shaped cavitating
    lesion/consolidation
  • Right apical focal consolidation
  • Interposed hepatic flexure under right hemidiaphragm (Chilaiditti
    syndrome)
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24
Q

what are the causes of massive haemoptysis?

A
  • bronchiectasis
  • tuberculosis
  • immune - good passtures
  • malignancy - lung/bronchial
  • AVM
  • lung abscess
  • necrotising bacterial infection
  • iatorgenic - post procedure
  • coagulopathy
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25
Q

what are the key interventions for massive haemoptysis?

A
  1. ABC
  2. fluid resus with fluid and blood
  3. massive transfusion protocol
  4. clear airway - may need intubation
  5. TXA
  6. reversal of anticoagulation
  7. urgent bronchoscopy
  8. NBM
  9. may need IR
  10. abx to cover infection
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26
Q
A
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27
Q
A
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28
Q

main abnormality

A

solitary lesion left upper zone
contains air/fluid
Cavitating lesion

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29
Q

what are the top three causes of pneumomediastinum linked to vomiting

A
  • oesophageal perforation
  • vasalva
  • asthma
  • chest trauma
  • ideopathic
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30
Q

what is the management of someone shocked with pneumomediastinum

A
  • abx to cover GI source eg taz
  • fluid resus to 0.05ml/kg hr UO
  • cardiothoracic referral
  • analgesia
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31
Q

main pathology and why

A

large right pleural effusion

Reasons:
* homogenous opacification of right middle and lower lobe
* loss of right hemidiaphragm
* rim of opacity around rim consistent with fluid

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32
Q

what are the causes of large pleural effusions

A
  • malignancy
  • parapneumonic effusion
  • PE
  • hydrothorax from massive PE
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33
Q

investigations and justification for large PE

A
34
Q

what are the causes of a pleural exudate

A

infection eg pneumonia
malignancy
inflammatory eg RA
PE
asbestos related
Pancreatitis

35
Q

what are the indications for thoracocentesis of pleural effusion in ED?

A
  1. respiratory compromise
  2. haemodynamic instability
  3. mediastinal shift
  4. severe symptoms
36
Q

what are the risk factors for re-expansion pulmonary oedema post thoracocentesis

A

under 30
pleursl effusion over 7 days
over 3 litres aspirated
suction used
rapid drainage of over 1.5l/hr

37
Q

6 radiological abnormalities

A
  1. multiple opacities left lung
  2. loss volume right hemithorax
  3. right upper lobe consolidation
  4. air bronchograms
  5. pleural effusion right side
  6. hilar mass
38
Q

positive and negative findings

A

Positive
right pneumothorax
significant tension
flattened right hemidiphragm
small pleural effusion

Negative
trachea midline
no lines
no consolidation

39
Q

what are the immediate management steps of tension pneumothorax

A
  • immediate chest decompression via needle thoracostomy - finger thoracostomy
  • ensure improvement via clinical sgns
  • chest drain with underwater seal
40
Q

complications of needle thoracostomy for pneumothorax

A
  1. misplacement of ICC
  2. solid organ injury
  3. infection
  4. haemorrhage
  5. tube blockage/kinking
41
Q

describe and interpret

A

left sided pneumothorax

42
Q

what would point toward conservative management of pneumothrax

A

symptoms
patient choice
primary
size

43
Q

in pre hospital setting what are advantages and disadvantages of using US to diagnose pneumothorax

A

Pros
* fast
* no radiation
* accurate with training

Cons
* need training
* patient access may be difficult
* subcut air may disrupt views

44
Q

Write brief notes on the pros and cons of needle decompression vs finger
thoracostomy

A
45
Q

signs and symptoms of tension pneumothorax

A

hypotension
tachycardia
hypoxia
tachypnoeia
increased WOB
SOB

46
Q

what are the causes of a pneumthorax

A
  • primary
  • secondary - asthma
  • trauma/rib fracture
  • inhalation/IVDU
  • collagen disease eg marfans
47
Q

pneumothorax

A
48
Q

why is this lung US a tension pneumothorax:

A

IVC is like lead pipe and not changing

49
Q

what is happening here on lung US

A

IVC collapsing on inhalation so low intrathoracic pressure

50
Q

pneumothorax on m mode

A
51
Q

for a cavitating lung lesion

A
52
Q

what are the symptoms of pulmonary hypertension?

A

Dyspnoea
Chest pain
Syncope

53
Q

what are the ED investigations for ?pulmonary hypertension

A

Echo - Dilated RV
ECG - Right heart strain

54
Q
A
  1. PAH - idiopathic or drug use eg cocaine
  2. **PVH **- systolic or diastolic dysfunction, MS, MR
  3. Chronic hypoxaemia - COPD, ILD
  4. Thromboembolic - PE
    5.     Misc     - sarcoidosis, vasculitis, SLE
55
Q

abnormalities

A

left midzone opacities
right midzone opacificaiton
kerly b lines
small effusion

56
Q

differentials and investigative finding

A
57
Q

major acid base disturbance and evidence

A
  • Respiratory acidosis – raised CO2 61, low pH
  • High anion gap metabolic acidosis - Low HCO3, raised AG 17, low pH
58
Q

Anion Gap
Delta Gap
A-A gradient

Formula/ Interpretation and clinical implication

A
59
Q

COPD
two conclusions from this gas

A

Conclusion 1: There is acute on chronic respiratory failure with elevated CO2 and low pH, however
shift is less than predicted if all acute, and HCO3 elevated suggesting chronic compensation.

Conclusion 2: She has a large A-a gradient with PAlv O2 of 266 and gradient of approx. 170
(elevated) – indicative of shunt.

60
Q

unwell post lung transplant
key findings

Differentials

A
  • Bilateral areas of consolidation in RML, RLL & LLL
  • Multiple clips bilaterally consistent with double lung transplant
  • CTR within normal limits
  • (No Pneumothorax or pleural effusions)
  • (No free gas under diaphragm)

Differentials
Infection - Bacterial, viral or fungal
acute rejection
CCF
PE

61
Q

On physical examination he has multiple petechiae around his eyes, and an intermittent
cough. He has mild indrawing of intercostal muscles and mild tracheal tug, but no stridor.

Post FB inhalation -explain symptoms

A
  • cough - trachobrochial irritaiton
  • petichae - raised venous pressure suggesting choking episode
  • tracheal tug - intrathoracic airway obstruction
62
Q

post choking episode
list significant findings

Diagnosis

A

mediastinal shift to right on expiratory film
increased lucency left lung on expiration
hyper expansion left lung on exspiration

Normal inspiratory film

Diagnosis:
Ingaled FB left main bronchus

63
Q

management post choking episode and child becomes cyanosed and unresponsive

A
  1. attempt bag valve ventilation with anaesthetic circuit
  2. perform direct laryngoscopy with magills forceps to remove FB
  3. Intubate if unable to remove - either ETT or LMA
  4. needly cricothyroidotomy if unsuccessful and oxygen with occlusion of y connected 1 second on and 4 off
64
Q

Good pastures - describe Xray

A

bilateral patchy infiltrates
widespread

Differentials
Pulmonary haemorrhage
CCF
ARDS
bilateral infection
malignancy
opportunistic infection eg PCP

65
Q

Steps in intubation

A
  • Fluid load – 0.9% saline 10ml/kg bolus, repeat to SBP >100mmHg
  • Augmented induction agent – ie ketamine IV at reduced dose ie 0.5-1mg/kg, rocuronium 1.2mg/kg
  • Co-administration of inotrope at induction – 1mcg/kg adrenaline with induction
  • Optimised pre-oxygenation with ongoing NRBM at 15lpm PLUS NP O2 at 15lpm
  • NP O2 at 15lpm throughout induction stage
  • Mitigate hypoxia/acidosis by bagging through induction with BVM O2 at 15lpm
  • Intubate at 30 degrees to minimise risk of hypoxia
66
Q
A
67
Q

what are the treatment options for asthma post burst and steroids?

A
  • IV magnesium 2gm IV over 20 mins
  • Salbutamol IVI 250mcg bolus followed by an infusion 5 -10 mcg/kg/hour
  • BIPAP (IPAP 7 -15 cmH2O; EPAP 3 – 5 cm H2O)
  • Adrenaline 0.3mg IM or IV infusion
  • Aminophylline also acceptable if in discussion with ICU
68
Q

how do you optimise asthma patient prior to intuabation

A

a) Keep upright until last moment
b) Preoxygenate (BiPaP or 15L NRBM)
c) High flow oxygen by nasal cannula (15L/min)
d) Continuous salbutamol nebulisation 10 – 15 mg/hr
e) Normal Saline 1L IV bolus

69
Q

what are the steps for dealing with post intubation hypotension in asthmatic?

A
  • Disconnect from ventilator & allow prolonged exhalation
  • IV fluid bolus 10 – 20 ml/kg
  • Rule out tension pneumothorax (clinical/ USS) or needle /finger thoracostomies
  • Vasopressors eg metaraminol 0.5-1mg bolus / adrenaline 10mcg IV bolus
70
Q

treatment for severe asthma in kids

A
  • Oxygen via mask to keep sats >92%
  • Salbutamol nebs 2.5 - 5mg continuous
  • Ipratropium 250mcg times 3 nebs in first hour
  • Steroid IV – methypred 1mg/kg or hydrocortisone 4mg/kg
  • Salbutamol IV – 5-10mcg/kg bolus then infusion
  • Also accept MgSO4 – 50mg/kg bolus then infusion
  • Also accept aminophylline – 10mg/kg loading dose
71
Q

intubation drugs for asthma in kids

A

Ketamine 1-2mg/kg
Sux 1-2mg/kg

72
Q

what are the clinical manifestions of Wegners (granulomatosis with polyangitis)

A
  • Renal failure
  • pulmonary haemorrhage
  • conjunctivits/episcleritis/scleritis
  • myalgia/arthralgia
  • pulmonary fibrosis, subglottic stenosis
  • myo/pericarditis
73
Q
A
74
Q

what is the bloods test for wegners

A

ANCA

75
Q

what diseases can cause renal failure and pulmonary haemorrhage

A

wegeners
malaria
leptospirosis
Influenza
Dengue
Hantavirus

76
Q

What are some non infective causes of haemoptysis and haematuria

A

Goodpastures
Churg strauss
SLE
HSP
microscopic polyangitis
IGA nephropathy
Behcets

77
Q
A

IV fluid bolus (N Saline 1-2L. Aim SBP 100

Central venous access and commence vasopressor if patient remains hypotensive (Noradrenaline infusion – Aim MAP 60-65)

Organise bed side echo – look for elevated RV pressure and/or deviation of interventricular septum suggestion increased RV pressure

Find further information of cerebral aneurysm – were there more thanone aneurysm/ what interventions done

Discuss with cardiothoracic surgery regarding suitability for surgicalembolectomy (preferred treatment option)

Discuss other treatment options with patient and family – thrombolysiswith tenecteplase (if RV pressure is high) / anticoagulation with heparin(if RV pressure normal)

If patient arrests – thrombolysis

78
Q

post PEA
abnormalities

A

Sinus tachy
RBBB
RAD
S1Q3T3 - RV strain
St depression in V1 and V2 suggesting RV strain

79
Q

What ECG changes may you get in P.E

A

Sinus tachy
RBBB
RAD
S1Q3T3 - RV strain
St depression in V1 and V2 suggesting RV strain

80
Q

what may you fine on bedside US for PE

A

Dilated RV
Dilated IVC
Poorly contractile RV
Hyperdynamic LV

1. Fellowship Written - SAQ (27 decks)

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