Respiratory Flashcards
COPD general management?
- Smoking cessation = NRT, varenicline or bupropion-often in combo with behavioural support.
- Annual influenza vaccination
- One-off pneumococcal vaccination
- Pulmonary rehab for functionally disabled (MRC >=3)
COPD medication management?
- SABA/SAMA 1st line
- Next determine if asthmatic features/steroid responsiveness
Asthmatic/steroid responsive features?
- Any previous, confirmed Dx of asthma or atopy (eczema allergic rhinitis)
- Raised eosinophils
- Substantial FEV1 variation (>400ml): A significant improvement in Forced Expiratory Volume in 1 second (FEV1) following bronchodilator therapy (e.g., >400 mL increase) suggests reversible airway obstruction typical of asthma.
- Substantial diurnal variation in PEF (at least 20%)
(Don’t recommend formal reversibility testing): implies that current guidelines may discourage the routine use of formal bronchodilator reversibility testing in certain populations, as other clinical and diagnostic criteria (e.g., eosinophils, FEV1, PEF variability) may suffice to establish the diagnosis.
No asthmatic features/steroid responsiveness?
- LABA + ICS
- Triple therapy = LAMA + LABA + ICS
Oral theophylline mushkies?
- Only after trials of SA and LAs or to people who cannot use inhaled therapy
- Dose reduced if macrolide or fluoroquinolone Abx co-prescribed
COPD oral prophylactic antibiotic therapy mushkies?
- Azithromycin in select patients
- Not smoke, optimised Rx, continue to have exacerbations
- Need CT thorax to exclude bronchiectasis ad sputum culture to rule out atypicals + TB
- LFT and ECG as azithromycin can prolong QT interval
COPD and mucolytics?
Considered in pts with chronic productive cough and continued if symptoms improve
Cor pulmonale mushkies?
- Features = peripheral oedema, raised JVP, systolic parasternal heave, loud P2
- Use loop diuretic for oedema, consider LTOT
- ACEi, CCB and alpha blocker not recommended
Factors which improve survival in stable COPD?
- Smoking cessation
- LTOT if fit criteria
- Lung volume reduction surgery in some
Acute bronchitis definition?
Self-limiting chest infection as a result of inflammation of the trachea and major bronchi and is therefore associated with oedematous large airways and the production of sputum. The disease course usually resolves before 3 weeks, however, 25% of patients will still have a cough beyond this time. Although there is uncertainty in the literature regarding the exact proportion of pathogens giving rise to acute bronchitis, it is accepted that viral infection is the leading cause. Around 80% of episodes occur in autumn or winter.
Acute bronchitis presentation?
- Cough = productive/non-productive
- Sore throat
- Rhinorrhoea
- Wheeze
- Some = low grade fever
Differentiating acute bronchitis from pneumonia?
- Hx = sputum, wheeze and breathlessness may be absent in bronchitis but is usually present in pneumonia
- Ex = No focal chest signs in acute bronchitis other than wheeze
Acute bronchitis Dx?
Clinical (but CRP also helpful)
Acute bronchitis Rx?
- Usually conservative
- Abx if = systemically very unwell, pre-existing co-morbidities, CRP 20-100 (delayed prescription) or CRP >100
Acute bronchitis Abx?
Doxycycline 1st line (Amoxicillin 2nd line)
Smoking cessation general points?
- NRT or Varenicline or Bupropion
- Target stop date –> 2 more weeks of NRT, 3-4 more weeks of V/B prescription given –> further prescription only given to those who have demonstrated their quit attempt is continuing
- If unsuccessful do not offer repeat prescription within 6 months unless special circumstances
- Do not offer combination of them
NRT s/e?
- N&V
- Headaches
- Flu-like symptoms
NRT for high level of dependence/have found single forms of NRT inadequate in the past?
Combination of nicotine patch and another form of NRT
Varenicline MOA?
Nicotinic receptor partial agonist
Varenicline mushkies?
- Should be started 1 week before the patients target date to stop
- Recommended course of Rx is 12 weeks
- More effective than bupropion
- Nausea is most common s/e, others = headache, insomnia, abnormal dreams
- Caution in pts with Hx of depression or self harm
- C/I in pregnancy and breastfeeding
Bupropion MOA?
Norepinephrine and dopamine reuptake inhibitor, and nicotinic antagonist
Bupropion mushkies?
- Start 1-2 weeks before target date to stop
- 1/1000 risk of seizures
- C/I in epilepsy, pregnancy and breast feeding
- Having an eating disorder is a relative contraindication
Pregnant women referral for smoking cessation crieteria?
- All women who smoke
- Stopped smoking in last 2 weeks
- CO reading of 7ppm or above (all pregnant women should be tested using carbon monoxide detectors)
Pregnant women smoking cessation interventions?
- CBT, motivational interviewing, structured self help and support
- NRT can be used if above measures fail, should remove patches before bed
- Varenicline and Bupropion are contraindicated
RhA respiratory problems?
- Pulmonary fibrosis, pleural effusion
- Pulmonary nodules, bronchiolitis obliterans
- Complications of drug therapy
- Pleurisy
- Atypical infections
- Caplan’s syndrome = massive fibrotic nodules with occupational coal dust exposure
Most common COPD exacerbation causes?
- Haemophilus influenzae (most common)
- S. pneumoniae
- M. catarrhalis
Acute exacerbation of COPD Rx?
- Increase bronchodilator frequency and consider nebuliser
- Prednisolone 30mg 5 days
- Oral Abx if purulent sputum or clinical signs of pneumonia = Amoxicillin/Clarithromycin/Doxycycline
Acute asthma classification?
- Moderate
- Severe
- Life threatening
Moderate acute asthma?
- PEFR 50-75%
- RR < 25
- HR < 110
- Speech normal
Severe acute asthma?
- PEFR 33-50%
- RR > 25
- HR > 110
- Can’t complete sentences
Life-threatening acute asthma?
- PEFR < 33%
- SpO2 < 92%
- Normal pCO2
- Silent chest, cyanosis, or feeble respiratory effort
- Bradycardia, dysrhythmia or hypotension
- Exhaustion, confusion or coma
Near-fatal asthma?
Raised pCO2 and/or requiring mechanical ventilation with raised inflation pressures
Acute asthma when is ABG indicated?
SpO2 < 92%
Acute asthma who needs admission?
- All pts with life-threatening
- Severe if they fail to respond to initial treatment
- Others = previous near-fatal, pregnancy, attack occurring despite using oral corticosteroid and presentation at night
Acute asthma Rx?
- O2
- SABA e.g. salbutamol
- Prednisolone 40mg 5 days
- Ipratropium
- IV MgSO4
- IV Aminophylline
- ITU/HDU = I&V, ECMO
Asthma criteria for discharge?
- Been stable on their discharge medication (no nebulisers or oxygen) for 12-24 hours
- Inhaler technique checked and recorded
- PEF > 75% of best or predicted
Lung abscess pathophysiology?
- Most commonly secondary to aspiration pneumonia
- Others = haematogenous (IE), direct (empyema), bronchial obstruction (tumour)
- Typically polymicrobial
- Monomicrobial = S. aureus, K. penumonia, P. aeruginosa
Lung abscess features?
Subacute, fever, night sweats, weight loss, foul smelling sputum, possible clubbing
Lung abscess Ix?
- Sputum and blood cultures
- CXR = fluid-filled space within an area of consolidation, air-fluid level seen
Lung abscess Rx?
- IV Abx
- If not resolving percutaneous drainage may be required and in very rare cases surgical resection
Asthma management?
- SABA
- SABA + Low dose ICS
- SABA + Low dose ICS + LTRA
- SABA + Low dose ICS + LABA +/- LTRA
- SABA + Low dose ICS MART +/- LTRA
- SABA +/- Med dose ICS MART +/- LTRA
- SABA +/- LTRA + high dose ICS/theophylline/specialist
When to move straight to step 2 asthma management?
- Not controlled on previous step
- Newly diagnosed asthma with symptoms >=3/week or night-time waking
What is MART?
- Combines ICS + LABA used for both daily maintenance and relief of symptoms
- Only available for ICS and LABA combinations in which LABA has a fast-acting component
Inhaled corticosteroid doses?
- <=400 mcg budesonide = low dose
- 400-800 mcg budesonide = moderate dose
- > 800 mcg budesonide = high dose
Primary pneumothorax?
No underlying lung disease
Primary pneumothorax Rx?
- If <2cm and pt not SOB then consider discharge
- Otherwise, attempt aspiration
- If fails (>2cm or still SOB) then insert chest drain
Secondary pneumothorax Rx?
- > 50 y/o and >2cm and/or SOB then chest drain
- Otherwise attempt aspiration if 1-2cm, if fails (>1cm) then chest drain inserted. All admitted for at least 24 hours
- <1cm = give O2 and admit for 24 hours
Pneumothorax discharge advice?
- Stop smoking
- Flying = 1 week post CXR
- Lifelong scuba diving ban
Obstructive lung disease PFT?
- FEV1 = significantly reduced
- FVC = reduced or normal
- FEV1/FVC = reduced
Obstructive lung disease examples?
- Asthma
- COPD
- Bronchiectasis
- Bronchiolitis obliterans
Restrictive lung disease PFT?
- FEV1 = reduced
- FVC = significantly reduced
- FEV1/FVC = normal or increased
Restrictive lung disease?
- Pulmonary fibrosis, asbestosis, sarcoidosis
- ARDS, Infant RDS
- Neuromuscular disorders, kyphoscoliosis e.g. ankylosing spondylitis
- Obesity
CRB-65?
Used in primary care
- Confusion = AMTS < 8/10
- RR > 30
- BP <90 Systolic or <60 Diastolic
- Age >=65
0 = home
1-2 = consider hospital
3 = urgent hospital
Point of care CRP test for pneumonia?
- <20 = do not routinely offer Abx
- 20-100 = consider delayed Abx
- CRP > 100 = offer Abx
CURB-65?
Secondary care setting
Confusion < 8/10 AMTS
Urea > 7
RR > 30
BP <90 systolic or <60 diastolic
Age >= 65
0-1 = consider home
>=2 = consider hospital
>=3 = consider hospital
Pneumonia Ix?
- CXR
- Intermediate/high risk = blood cultures, sputum cultures, pneumococcal and legionella urinary antigen tests
- CRP monitoring to determine response to treatment
Low severity CAP Rx?
- Amoxicillin 5d 1st line
- If pen allergic then macrolide or tetracycline
Moderate/high severity CAP Rx?
- Amoxicillin + Macrolide 7-10d
Pneumonia discharge criteria?
Don’t d/c if in past 24h they have had 2 or more of the following
1. Temp > 37.5
2. RR > 24
3. HR > 100
4. SBP < 90
5. SpOt < 90%
6. Abnormal mental status
7. Inability to eat without assistance
Pneumonia resolution timeline?
- 1 week = fever resolved
- 4 weeks = chest pain and sputum production reduced
- 6 weeks = cough and breathlessness reduced
- 3m = most symptoms resolved but fatigue may still be present
- 6m = most back to normal
Pneumonia repeat CXR timing?
6 weeks
Causes of bi-hilar lymphadenopathy?
- Sarcoidosis
- TB
- Lymphoma/malignancy
- Pneumoconiosis e.g. berylliosis
- Fungi e.g. histoplasmosis, coccidioidomycosis
Mesothelioma definition?
Cancer of the mesothelial layer of the pleural cavity that is strongly associated with asbestos exposure. In a small percentage of cases, other mesothelial layers such as those in the abdomen may be affected.
Mesothelioma features?
- Clubbing
- Chest wall pain
- 30% present as painless pleural effusion
- Only 20% have pre-existing asbestosis
- History of asbestos exposure in 85-90%, latent period of 30-40 years
Mesothelioma which lung affected more often?
Right
Mesothelioma Ix?
- CXR = pleural effusion/pleural thickening
- CT
- Effusion = MC&S, biochem, cytology (cytology only helpful in 20-30% cases)
- Local anaesthetic thoracoscopy to Ix cytology negative exudative effusions as it has a high diagnostic yield (around 95%)
- If area of pleural nodularity seen on CT then image-guided pleural biopsy may be used
Mesothelioma Rx?
- Symptomatic
- Industrial compensation
- Chemo, surgery if operable
- Prognosis poor, median survival 12m
Predominant cough without lung function abnormalities?
Chronic cough syndromes and pertussis
Prominent dizziness, light headedness and peripheral tingling?
Dysfunctional breathing
Recurrent severe asthma attacks without objective confirmatory experience
Vocal cord dysfunction
Predominantly nasal symptoms without lung function abnormalities?
Rhinitis
Asthma diagnosis in children < 5 y/o?
Clinical
Asthma diagnosis 5-16 y/o?
- Spirometry with a bronchodilator reversibility (BDR) test
- FeNO test should be requested if there is normal spirometry or obstructive spirometry with a negative bronchodilator reversibility (BDR) test
Asthma diagnosis >=17 y/o?
- All should have FeNO test
- All should have spirometry with a bronchodilator reversibility (BDR) test
- Asked if their symptoms are better on days away from work/during holidays. If so, patients should be referred to a specialist as possible occupational asthma
FeNO positive levels?
> 40 in adults, >35 in children
Spirometry FEV1/FVC ratio in obstructive disease e.g. asthma?
<70%
Asthma reversibility testing?
- Adults = FEV1 improvement by 12% and increase in volume by 200ml
- Children = FEV1 improvement by 12%
When should COPD diagnosis be considered?
> 35 y/o smokers/ex-smokers with exertional SOB, chronic cough, or regular sputum production
Suspected COPD Ix?
- FBC = exclude secondary polycythaemia
- BMI calculation
- CXR = hyperinflation, bullae, flat hemidiaphragm, exclude lung cancer
- Post-bronchodilator spirometry to demonstrate airflow obstruction: FEV1/FVC ratio <70%
How is COPD severity categorised?
Using FEV1 % predicted
1. > 80% = Mild
2. 50-79% = Moderate
3. 30-49% = Severe
4. <30% = Very severe
Idiopathic pulmonary fibrosis epidemiology?
50-70 y/o, 2M:1F
IPF features?
- Progressive exertional dypsnoea
- Bibasal fine end-inspiratory crepitations on auscultation
- Dry cough
- Clubbing
IPF Dx?
- Spirometry = restrictive (FEV1 normal/decreased, FVC decreased, FEV1/FVC increased)
- Reduced TLCO = impaired gas exchange
- Imaging = ground glass on CXR, CT needed for diagnosis
- ANA +ve in 30%, RhF +ve in 10%
IPF Rx?
- Pulmonary rehabilitation
- Supplementary O2
- Lung transplant
- Pirfenidone (antifibrotic) may be useful in select patients
IPF Prognosis?
Life expectancy 3-4 years
ABG triad for chronic CO2 retention?
- Normal pH
- high pCO2
- High HCO3
OSA consequences?
- Daytime somnolescence
- Compensated respiratory acidosis
- HTN
Sleepiness assessment?
- Epworth Sleepiness Scale = questionnaire completed by patient +/- partner
- Multiple Sleep Latency Test (MSLT) = measures the time to fall asleep in a dark room (using EEG criteria)
OSA Dx?
Sleep studies (polysomnography) = ranging from monitoring of pulse oximetry at night to full polysomnography where a wide variety of physiological factors are measured including EEG, respiratory airflow, thoraco-abdominal movement, snoring and pulse oximetry
OSA Rx?
- Weight loss
- CPAP 1st line for moderate/severe
- Intra-oral devices e.g. mandibular advancement may be used if CPAP is not tolerated or for patients with mild OSAHS where there is no daytime sleepiness
- DVLA should be informed if OSAHS is causing excessive daytime sleepiness
COPD reason for using ICS?
Reduced exacerbations
Lung cancer risk factors?
- Smoking (x10)
- Asbestos (x5)
- Arsenic, radon, nickel, chromate
- Aromatic hydrocarbon
- IPF
When is BiPAP indicated for AECOPD?
Respiratory acidosis/rising PaCO2 resistant to best medical management
Pleural effusion Ix?
- Imaging
- Pleural aspiration
Pleural effusion imaging?
- PA CXR
- US
- Contrast CT
Pleural aspiration method?
- 21G needle and 50ml syringe
- Fluid sent for pH, protein, LDH, cytology, microbiology
Transudate protein level?
< 30 g/L
Exudate protein level?
> 30 g/l
When should Light’s criteria be used?
If protein level 25-35 g/L
Light’s criteria?
Exudate is likely if at least 1 of the following are present:
1. Pleural fluid protein divided by serum protein >0.5
2. Pleural fluid LDH divided by serum LDH >0.6
3. Pleural fluid LDH more than two-thirds the upper limits of normal serum LDH
Pleural fluid with low glucose?
TB, RhA
Pleural fluid with raised amylase?
Pancreatitis, oesophageal perforation
Pleural fluid with heavy blood staining?
Mesothelioma, PE, TB
Pleural infection mushkies?
- All patients with a pleural effusion in association with sepsis or a pneumonic illness require diagnostic pleural fluid sampling
- If the fluid is purulent or turbid/cloudy a chest tube should be placed to allow drainage
- If the fluid is clear but the pH is less than 7.2 in patients with suspected pleural infection a chest tube should be placed
Recurrent pleural effusion management?
- Recurrent aspiration
- Pleurodesis
- Indwelling pleural catheter
- Drug management to alleviate symptoms e.g. opioids to relieve dyspnoea
4 commonest causes of anterior mediastinum mass?
4 Ts
Teratoma
Thymic Mass
Thyroid Mass
Terrible lymphadenopathy
Cavitating pneumonia in upper lobes in diabetics and alcoholics?
Klebsiella
Klebsiella definition?
Klebsiella pneumoniae is a Gram-negative rod that is part of the normal gut flora. It can cause a number of infections in humans including pneumonia (typically following aspiration) and urinary tract infections.
Klebsiella pneumonia features?
- More common in alcoholics and diabetics
- May occur following aspiration
- Red-currant jelly sputum
- Often affects upper lobes
Klebsiella pneumonia prognosis?
- Commonly causes lung abscess formation and empyema
- Mortality is 30-50%
Bronchiectasis definition?
Permanent dilatation of the airways secondary to chronic infection or inflammation
Bronchiectasis Rx?
- Physical training
- Postural drainage
- Abx for exacerbations + long term Abx in severe cases
- Bronchodilators in selected cases
- Immunisations
- Surgery in selected cases e.g. localised disease
Most common organisms isolated from bronchiectasis?
- H. influenzae
- P. aeruginosa
- Klebsiella spp
- S. pneumoniae
Acute oxygen therapy management of COPD patients?
- Prior to availability of blood gases, use a 28% Venturi mask at 4 l/min and aim for an oxygen saturation of 88-92% for patients with risk factors for hypercapnia but no prior history of respiratory acidosis
- Adjust target range to 94-98% if the pCO2 is normal
NIV key indications?
- COPD with respiratory acidosis 7.25-7.35
- T2RG secondary to chest wall deformity, neuromuscular disease or OSA
- Cardiogenic pulmonary oedema unresponsive to CPAP
- Weaning from tracheal intubation
Recommended initial settings for bi-level pressure support in COPD?
- Expiratory Positive Airway Pressure (EPAP): 4-5 cm H2O
- Inspiratory Positive Airway Pressure (IPAP): RCP advocate 10 cm H20 whilst BTS suggest 12-15 cm H2O
- Back up rate: 15 breaths/min
- Back up inspiration:expiration ratio: 1:3
Pleural plaque mushkies?
Benign and do not undergo malignant change. They, therefore don’t require any follow-up. They are the most common form of asbestos-related lung disease and generally occur after a latent period of 20-40 years
Pleural thickening mushkies?
Asbestos exposure may cause diffuse pleural thickening in a similar pattern to that seen following an empyema or haemothorax. The underlying pathophysiology is not fully understood.
Asbestosis mushkies?
The severity of asbestosis is related to the length of exposure. This is in contrast to mesothelioma where even very limited exposure can cause disease. The latent period is typically 15-30 years. Asbestosis typically causes lower lobe fibrosis. As with other forms of lung fibrosis the most common symptoms are shortness-of-breath and reduced exercise tolerance. It is treated conservatively - no interventions offer a significant benefit
Goodpasture’s syndrome?
- Haemoptysis
- Glomerulonephritis
- Systemically unwell: fever, nausea
GPA?
- Upper respiratory = epistaxis, sinusitis, nasal crusting
- Lower respiratory = dyspnoea, haemoptysis
- Glomerulonephritis
- Saddle-shape nose deformity
Sarcoidosis definition?
Multisystem disorder of unknown aetiology characterised by non-caseating granulomas. It is more common in young adults and in people of African descent
Sarcoidosis features?
- Acute = erythema nodosum, bihilar lymphadenopathy, swinging fever, polyarthralgia
- Insidious = dyspnoea, non-productive cough, malaise, wight loss
- Skin = lupus pernio
- Hypercalcaemia = macrophages inside the granulomas cause an increased conversion of vitamin D to its active form (1,25-dihydroxycholecalciferol)
Syndromes associated with Sarcoidosis?
- Lofgren’s syndrome = an acute form of the disease characterised by bilateral hilar lymphadenopathy (BHL), erythema nodosum, fever and polyarthralgia. It usually carries an excellent prognosis
- Mikulicz syndrome = enlargement of the parotid and lacrimal glands due to sarcoidosis, tuberculosis or lymphoma
- Heerfordt’s syndrome = parotid enlargement, fever and uveitis secondary to sarcoidosis
SABA?
Salbutamol
SAMA?
Ipratropium
LABA?
Salmeterol
LAMA?
Tiotropium
Finger clubbing and > 40 y/o?
CXR
2ww lung cancer referral indications?
- CXR findings that suggest lung cancer
- > 40 with unexplained haemoptysis
A1AT deficiency spirometry picture?
Obstructive
A1AT deficiency definition?
A common inherited condition caused by a lack of a protease inhibitor (Pi) normally produced by the liver. The role of A1AT is to protect cells from enzymes such as neutrophil elastase. It classically causes emphysema (i.e. chronic obstructive pulmonary disease) in patients who are young and non-smokers.
A1AT genetics?
- Chromosome 14
- Autosomal recessive/co-dominant inheritance
A1AT deficiency features?
- Lungs = panacinar emphysema, most marked in lower lobes
- Liver = cirrhosis and HCC in adults, cholestasis in children
A1AT deficiency Ix?
- A1AT concentrations
- Spirometry = obstructive picture
A1AT deficiency Rx?
- No smoking
- Supportive = bronchodilators, physiotherapy
- IV A1AT protein concentrates
- Surgery = lung volume reduction surgery, lung transplantation
Which smoking cessation drug is C/I in epilepsy?
Bupropion as reduces seizure threshold
Tram lines on CXR?
Bronchiectasis
Large amounts of purulent sputum?
Bronchiectasis
