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1 - MSRA > Respiratory > Flashcards

Respiratory Flashcards

1
Q

Features moderate asthma exacerbation

A
  • PEFR 50-70% predicted
  • Speech normal
  • RR <25/min
  • Pulse <110
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2
Q

Features severe asthma exacerbation

A
  • PEFR 33-50% best or predicted
  • Can’t complete sentences
  • RR >25
  • Pulse >110
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3
Q

Features life threatening asthma exacerbation

A

PEFT <33% best or predicted
Sats <92%
Silent chest, cyanosis, or feeble resp effort
Bradycardia, dysrhythmia, or hypotension
Exhaustion, confusion, coma

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4
Q

Features near-fatal asthma attack

A

Raised pCO2
Requiring mechanical ventilation with raised inflation pressures

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5
Q

When is CXR indicated in asthma

A
  • Life threatening asthma
  • Suspected pneumothorax
  • Failure to respond to treatment
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6
Q

Criteria admission for asthma attack

A
  • Life threatening attack
  • Severe attach if fail to respond to initial treatment
  • Previous near-fatal attack
  • Pregnancy
  • Attack occurring despite already using oral corticosteroid
  • Presentation at night
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7
Q

First line management asthma attack

A
  • Oxygen to maintain sats >94%
  • Bronchodilation with SABA
  • Corticosteroid
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8
Q

Mode of administration SABA in acute asthma attack

A

In patients without life-threatening features, pMDI or oxygen-driven neb
If life-threatening, nebulised

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9
Q

Dose corticosteroid in asthma attack

A

40-50mg pred PO OD

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10
Q

How long to continue steroid in asthma attack

A

At least 5 days, or until patient recovers from attack

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11
Q

Further treatment options in asthma attack not responding to initial therapy

A
  • Ipratropium bromide
  • IV magnesium sulphate
  • IM aminophylline
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12
Q

Role of ipratropium bromide in asthma attack

A
  • Severe or life threatening asthma
  • Not responding to initial beta agonist and corticosteroid therapy
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13
Q

ITU treatment options for asthma not responding to medical treatment

A

I&V
ECMO

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14
Q

Criteria for discharge asthma attack

A
  • Stable on discharge medication for 12-24 hours
  • Inhaler technique checked and recorded
  • PEF >75% of best or predicted
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15
Q

What is acute bronchitis

A

Inflammation of the trachea and major bronchi → oedematous large airway and sputum production

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16
Q

Presentation acute bronchitis

A
  • Cough (productive or non-productive)
  • Sore throat
  • Rhinorrhoea
  • Wheeze
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17
Q

Examination findings acute bronchitis

A

Majority have normal chest examination.
May have;
- Low grade fever
- Wheeze

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18
Q

Acute bronchitis vs pneumonia

A

Sputum, wheeze, breathlessness may be absent in acute bronchitis, at least one tends to be present in pneumonia
No focal chest signs in acute bronchitis, tend to have no systemic features

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19
Q

Management acute bronchitis

A
  • Analgesia
  • Fluid intake
  • Consider antibiotics
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20
Q

Investigations in acute bronchitis

A

Clinical diagnosis
CRP may be used to guide if antibiotic therapy needed

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21
Q

Indications for antibiotics in acute bronchitis

A
  • Systemically unwell
  • Co-morbidities
  • CRP of 20-100 (delayed prescription) or >100 (immediate)
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22
Q

Antibiotics acute bronchitis

A

Doxycycline first line

Amoxicillin alternative (e.g. for children, pregnant women)

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23
Q

Most common infective causes of COPD exacerbations

A

Haemophilus influenzae (most common)
Streptococcus pneumoniae
Moraxella catarrhalis
Respiratory viruses (30% of cases, rhinovirus most important)

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24
Q

Features COPD exacerbation

A

Increase in dyspnoea, cough, wheeze
Increase in sputum productive (suggests infective cause)
Hypoxic
Acute confusion

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25
Q

Management COPD exacerbation

A
  • Increase frequency of bronchodilator use, consider giving via neb
  • Pred 30mg daily for 5 days
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26
Q

Indications for antibiotics in COPD exacerbation

A

Sputum purulent
Clinical signs of pneumonia

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27
Q

Antibiotic of choice COPD exacerbation

A

Amoxicillin, clarithromycin, or doxycycline

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28
Q

Criteria for admission COPD exacerbation

A
  • Severe breathlessness
  • Acute confusion or impaired consciousness
  • Cyanosis
  • Oxygen saturations less than 90% on pulse oximetry
  • Social reasons, e.g. inability to cope at home
  • Significant co-morbidity
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29
Q

Management of severe COPD exacerbations requiring secondary care

A
  • Oxygen
  • Nebulised bronchodilator
  • Steroid therapy
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30
Q

Sats target COPD exacerbation

A

Initial target 88-92%, adjust to 94-98% if pCO2 normal on gas

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31
Q

Initial oxygen therapy in COPD exacerbation

A

28% venturi mask at 4L and titrate

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32
Q

Nebulised bronchodilators used in severe COPD exacerbation

A
  • Beta adrenergic agonist, e.g. salbutamol
  • Muscarinic antagonists, e.g. ipratropium
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33
Q

Steroid therapy in severe COPD exacerbation

A

Consider IV hydrocort instead of PO pred

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34
Q

What drug considered if not responding to bronchodilators in severe COPD exacerbation

A

IV theophylline

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35
Q

Indications for NIV in COPD exacerbation

A

Respiratory acidosis 7.25-7.35

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36
Q

Management COPD patients with pH <7.25

A

NIV can be used with greater degree of monitoring (HDU) and lower threshold for I&V

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37
Q

Alpha 1 antitrypsin deficiency inheritance

A

Autosomal recessive / co-dominant

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38
Q

Presentation alpha 1 anti-trypsin deficiency

A

Panacinar emphysema, most marked in lower lobes
Liver cirrhosis and hepatocellular carcinoma in adults, cholestasis in children

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39
Q

Investigations alpha 1 anti-trypsin deficiency

A

A1AT concentrations
Spirometry

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40
Q

Spirometry findings alpah 1 anti-trypsin deficiency

A

Obstructive picture

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41
Q

Management alpha-1 antitrypsin deficiency

A

No smoking
Supportive - bronchodilators, physiotherapy
IV alpha1-antitrypsin protein concentrates
Surgery - lung volume reduction surgery, lung transplantation

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42
Q

Interpretation of pCO2 on blood gas

A

> 6.0 - respiratory acidosis (or resp comp for metabolic alkalosis)
<4.7 - respiratory alkalosis (or resp comp for metabolic acidosis)

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43
Q

Interpretation of bicarbonate on blood gas

A

If bicarb <22, metabolic acidosis (or renal comp for resp alkalosis)
If bicarb >26, metabolic alkalosis (or renal comp for resp acidosis)

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44
Q

Asbestos related lung diseases

A
  • Pleural plaques
  • Pleural thickening
  • Asbestosis
  • Mesothelioma
  • Lung cancer
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45
Q

Management pleural plaques

A

Don’t need anything - benign, do not undergo malignant change

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46
Q

Relationship between asbestos exposure and asbestosis

A

Severity is related to length of exposure

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47
Q

Relationship between asbestos exposure and mesothelioma

A

Very limited exposure can cause disease

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48
Q

Latent period asbestosis

A

15-30 years

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49
Q

Presentation asbestosis

A
  • Dyspnoea
  • Clubbing
  • Bilateral end-inspiratory crackles
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50
Q

Lung function tests asbestosis

A

Restrictive pattern, reduced gas transfer

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51
Q

Where does asbestosis typically cause fibrosis

A

Lower lobe

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52
Q

Treatment asbestosis

A

Conservative

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53
Q

Features mesothelioma

A

Progressive shortness of breath
Chest pain
Pleural effusion

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54
Q

Management mesothelioma

A

Palliative chemo
Limited role for surgery and radiotherapy

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55
Q

Most common form of cancer associated with asbestos exposure

A

Lung cancer

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56
Q

Step 1 management of ≥12 years old with newly diagnosed asthma

A

Low dose inhaled corticosteroid/formoterol combo inhaler to be taken as needed for symptom relief

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57
Q

Step 1 management of ≥12 years old with newly diagnosed asthma if presenting highly symptomatic or with severe exacerbation

A

Start treatment with low-dose MART (ICS/formoterol combo inhaler for daily maint + relief of symptoms when needed)

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58
Q

Step 2 management of ≥12 years old with newly diagnosed asthma

A

Low dose MART (ICS/formoterol combo inhaler for daily maint + relief of symptoms when needed)

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59
Q

Step 3 management of ≥12 years old with newly diagnosed asthma

A

Moderate dose MART

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60
Q

Step 4 management of ≥12 years old with newly diagnosed asthma

A

Check FeNO and blood eosinophil count
If either raised, refer to specialist in asthma care
If neither raised, trial of either leukotriene receptor antagonist (LTRA) or long acting muscarinic receptor antagonist (LAMA)

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61
Q

Step 4.5 management of ≥12 years old with newly diagnosed asthma

A

If control not improved, stop the LTRA/LAMA and try the other one

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62
Q

Step 5 management of ≥12 years old with newly diagnosed asthma

A

Refer to specialist

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63
Q

Management of patients previously on SABA as required only

A

Switch to step 1 (low dose ICS/formoterol combo inhaler as needed)

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64
Q

Management of patients previous on SABA as required + low dose something else

A

Switch to low dose MART

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65
Q

Management of patients previously on SABA as required + moderate dose something else

A

Switch to moderate dose MART

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66
Q

Management of patients previously on regime containing high dose ICS

A

Refer to resp specialist

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67
Q

When to consider stepping down asthma treatment

A

Every 3 months

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68
Q

How to reduce dose of inhaled steroids in asthma

A

25-50% at a time

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69
Q

Most common causes of bilateral hilar lymphadenopathy

A

Sarcoidosis
Tuberculosis

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70
Q

Other causes bilateral hilar lymphadenopathy

A

Lymphoma/other malignancy
Pneumoconiosis, e.g. berylliosis
Fungi, e.g. histoplasmosis, coccidiomycosis

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71
Q

What is pneumoconiosis

A

Lung disease occurring when dust is inhaled and becomes trapped in the lungs

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72
Q

What is bronchiectasis

A

Permanent dilation of the airways secondary to chronic infection or inflammation

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73
Q

Management bronchiectasis

A
  • Physical training, e.g. inspiratory muscle training
  • Postural drainage
  • Antibiotics
  • Bronchodilators in some cases
  • Imms
  • Surgery
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74
Q

When is surgery suitable in bronchiectasis

A

Localised disease

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75
Q

Role of antibiotics in bronchiectasis

A

Treatment of exacerbations
Long-term rotating antibiotics in severe cases

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76
Q

Most common organisms isolated from patients with bronchiectasis

A

Haemophilus influenzae (most common)
Pseudomonas aeruginosa
Klebsiella
Streptococcus pneumoniae

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77
Q

Features of pulmonary oedema on CXR

A
  • Interstitial oedema
  • Bat wings appearance
  • Upper lobe diversion
  • Kerley B lines
  • Pleural effusion
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78
Q

Causes of white out with trachea pulled towards it

A

Pneumonectomy
Complete lung collapse, e.g. endobronchial intubation
Pulmonary hypoplasia

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79
Q

Causes of white out with trachea central

A

Consolidation
Pulmonary oedema, usually bilateral
Mesothelioma

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80
Q

Cause of white out with trachea pushed away from the white out

A

Pleural effusion
Diaphragmatic hernia
Large thoracic mass

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81
Q

Causes of COPD

A

Smoking
Alpha 1 antitrypsin deficiency
Cadmium, coal, cotton, cement, grain

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82
Q

CXR findings COPD

A
  • Hyperinflation
  • Bullae
  • Flat hemidiaphragm
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83
Q

FEV1/FVC in COPD

A

<0.7

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84
Q

FEV1 % in mild COPD

A

> 80%

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85
Q

FEV1 % in moderate COPD

A

50-79%

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86
Q

FEV1 in severe COPD

A

30-49%

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87
Q

FEV1 in very severe COPD

A

<30%

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88
Q

General management COPD

A

Smoking cessation advice/medication
Annual influenza vaccination
One off pneumococcal vaccination
Pulmonary rehabilitation

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89
Q

Who is offered pulmonary rehabilitation in COPD

A

All people who view themselves as functionally disabled by COPD

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90
Q

First line therapy COPD

A

Bronchodilator - SABA or SAMA

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91
Q

How is second line therapy determined in COPD

A

If patient has asthmatic/steroid responsive features

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92
Q

Asthmatic/steroid responsive features in COPD

A
  • Any previous, secure diagnosis of asthma or atopy
  • Higher blood eosinophil count
  • Substantial variation in FEV1 over time (at least 400ml)
  • Substantial diurnal variation in PEF (at least 20%)
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93
Q

Second line management COPD if no asthmatic/features suggesting steroid responsiveness

A

Add LABA and LAMA (if already taking SAMA, stop and switch to SAMA)

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94
Q

Second line management COPD if asthmatic features/features suggesting steroid responsiveness

A

LABA + inhaled corticosteroid

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95
Q

Third line management COPD if asthmatic features/features suggesting steroid responsiveness

A

LAMA + LABA + IBS (if already take SAMA, switch to SABA)

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96
Q

When to offer oral theophylline in COPD

A
  • If trials of short and long acting bronchodilators fail
  • If cannot use inhaled therapy
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97
Q

Oral theophylline and antibiotics

A

Dose of oral theophylline needs to be reduced if macrolide or fluoroquinolone antibiotics are co-prescribed

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98
Q

Prophylactic antibiotic used in COPD

A

Azithromycin

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99
Q

When to offer prophylactic antibiotics in COPD

A
  • Non smoker
  • Optimised standard treatments
  • Continuing to have exacerbations
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100
Q

Investigations needed prior to starting prophylactic azithromycin in COPD

A
  • CT thorax (exclude bronchiectasis)
  • Sputum culture (exclude atypical infections/TB)
  • LFTs
  • ECG (exclude QT prolongation)
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101
Q

When to offer standby medication in COPD

A
  • Had exacerbation in last year
  • Understand how to take the medication, and aware of associated risks and benefits
  • Know when to seek help and when to ask for replacements once medication has been used
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102
Q

When should mucolytics be considered COPD

A

In patients with chronic productive cough

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103
Q

Phosphodiesterase-4 inhibitor e.g.

A

Roflumilast

104
Q

Criteria for trying PDE-4 inhibitors COPD

A
  • Severe disease (FEV1 after bronchodilator less than 50%), and
  • 2 or more exacerbations in past 12 months despite triple inhaled therapy with LAMA, LABA, and ICS
105
Q

Features cor pulmonale

A
  • Peripheral oedema
  • Raised JVP
  • Systolic parasternal heave
  • Loud P2
106
Q

Management cor pulmonale

A
  • Loop diuretic for oedema
  • Consider LTOT
107
Q

Factors that may improve survival in patients with stable COPD

A
  • Smoking cessation
  • LTOT
  • Lung volume reduction therapy (select patients)
108
Q

Churg-Strauss syndrome aka

A

Eosinophilic granulomatosis with polangiitis (EGPA)

109
Q

Features eosinophilic granulomatosis with polangiitis

A
  • Asthma
  • Eosinophilia
  • Paranasal sinusitis
  • Mononeuritis multiplex

Renal involvement in 20%

110
Q

Antibody in eosinophilic granulomatosis with polangiitis

A

pANCA (60%)

111
Q

What might precipitate eosinophilic granulomatosis with polangiitis

A

Leukotriene receptor antagonists

112
Q

Examination features pulmonary oedema

A

Bibasal crackles
S3

113
Q

Features aspergilloma

A

Often past Hx TB
Haemoptysis may be severe
CXR shows rounded opacity

114
Q

Features granulomatosis with polyangiitis

A
  • Epistaxis, sinusitis, nasal crusting
  • Dyspnoea, haemoptysis
  • Glomerulonephritis
  • Saddle shape nose deformity
115
Q

Features Goodpasture’s syndrome

A

Haemoptysis
Systemically unwell - fever, nausea
Glomerulonephritis

116
Q

Features idiopathic pulmonary fibrosis

A
  • Progressive exertional dyspnoea
  • Bilateral fine end inspiratory creps
  • Dry cough
  • Clubbing
117
Q

Lung function tests in IPF

A

Restrictive picture on spirometry - FEV1 normal/decrease, FVC decreased, FEV1/FVC increased
Impaired gas exchange - reduced transfer factor

118
Q

Investigation of choice IPF

119
Q

CXR findings IPF

A

Bilateral interstitial shadowing (typically small, irregular, peripheral opacities - ground glass → honeycombing)

120
Q

Antibodies in IPF

A
  • ANA 30%
  • RF 10%
121
Q

Management IPF

A
  • Pulmonary rehabilitation
  • Some benefit of pirfenidone (antifibrotic agent) in select patients
  • Oxygen
  • Eventually lung transplant
122
Q

Features Kartagener’s syndrome

A
  • Dextrocardia or complete situs invertus
  • Bronchiectasis
  • Recurrent sinusitis
  • Subfertility
123
Q

What type of bacteria is klebsiella

A

Gram negative

124
Q

Risk factors klebsiella pneumonia

A
  • Alcoholic
  • Diabetic
  • Aspiration
125
Q

Features klebsiella pneumonia

A

Red current jelly sputum
Often affects upper lobes

126
Q

Complications klebsiella pneumonia

A

Lung abscess formation
Empyema

127
Q

Causes lung abscess

A
  • Aspiration pneumonia (most common)
  • Haematogenous spread, e.g. from infective endocarditis
  • Direct extension, e.g. from empyema
  • Bronchial obstruction, e.g. secondary from lung tumour
128
Q

Risk factors lung abscess caused by aspiration pneumonia

A
  • Poor dental hygiene
  • Previous stroke
  • Reduced consciousness
129
Q

Bacteria causing lung abscess

A

Typically polymicrobial

Monomicrobial causes:
- Staphylococcus aureus
- Klebsiella pneumonia
- Pseudomonas aeruginosa

130
Q

Presentation lung abscess

A
  • Similar features to pneumonia but more subacute - symptoms may develop over weeks, systemic features e.g. night sweats, weight loss
  • Fever
  • Productive cough - often foul smelling sputum, haemoptysis in minority
  • Chest pain
  • Dyspnoea
131
Q

Signs lung asbcess

A
  • Dull percussion
  • Bronchial breathing
  • Clubbing
132
Q

CXR findings lung abscess

A
  • Fluid filled air space within an area of consolidation
  • Air-fluid level typically seen
133
Q

Management lung abscess

A

IV antibiotics
If not resolving, percutaneous drainage
Very rare cases, surgical resection

134
Q

Purpose of PET scanning lung cancer

A

Typically done in non-small cell lung cancer to establish eligibility for curative treatment

135
Q

Paraneoplastic features of small cell lung cancer

A
  • ADH → hyponatraemia
  • ACTH → Cushing’s syndrome
  • Lambert-Eaton syndrome
136
Q

Paraneoplastic features of squamous cell lung cancer

A

PTH → hypercalcaemia
Clubbing
Hypertrophic pulmonary osteoarthropathy
Hyperthyroidism due to ectopic TSH

137
Q

Paraneoplastic features of adenocarcinoma

A

Gynaecomastia
Hypertrophic pulmonary osteoarthopathy

138
Q

2WW referral lung cancer

A
  • CXR findings suggestive of lung cancer
  • Aged over 40 and over with unexplained haemoptysis
139
Q

Criteria for CXR within 2 weeks ?lung cancer

A

Aged 40+ and 2 or more of;
- Previous smoker
- Cough
- Fatigue
- Shortness of breath
- Chest pain
- Weight loss
- Appetite loss

140
Q

Criteria to consider CXR within 2 weeks

A

Over 40 with any of;
- Persistent or recurent chest infection
- Finger clubbing
- Supraclavicular lymphadenopathy or persistent cervical lymphadenopathy
- Chest signs consistent with lung cancer
- Thrombocytosis

141
Q

Risk factors lung cancer

A
  • Smoking
  • Asbestos
  • Arsenic
  • Radon
  • Nickel
  • Chromate
  • Aromatic hydrocarbon
  • Crytogenic fibrosing alveolitis

Not coal dust

142
Q

Where in lungs is SCLC

A

Usually central

143
Q

What is Lambert-Eaton syndrome

A

Antibodies to voltage gated calcium channels causing myasthenic like syndrome

144
Q

Management SCLC

A

If very early stage disease, consider surgery
If limited disease, combo chemo and radiotherapy
If extensive, palliative chemo

145
Q

Most common type of lung cancer

A

Adenocarcinoma

146
Q

Distinguishing features squamous lung cancer

A

Cavitating lesions more common

147
Q

Distinguishing features alveolar cell carcinoma

A

Not related to smoking
++ sputum

148
Q

Features mesothelioma

A
  • Dyspnoea
  • Weight loss
  • Chest wall pain
  • Clubbing

30% present as painless pleural effusion

149
Q

Latent period mesothelioma

A

30-40 years

150
Q

Most common met locations mesothelioma

A

Lung and peritoneum

151
Q

CXR findings mesothelioma

A

Pleural effusion or pleural thickening

152
Q

First line investigation mesothelioma

A
  • Pleural CT
  • Pleural effusion testing - MC&S, biochem, cytology
153
Q

When is thoracoscopy done in ?mesothelioma

A

If cytology negative exudative effusions

154
Q

Further investigation if area of pleural nodularity seen on CT ?mesothelioma

A

Image guided pleural biopsy

155
Q

Management mesothelioma

A

Symptomatic
Industrial compensation
Chemo, surgery if operable

156
Q

Prognosis mesothelioma

A

Median survival 12 months

157
Q

What is microscopic polyangiitis

A

Small-vessel ANCA vasculitis

158
Q

Features microscopic polangiitis

A
  • Renal impairment - raised Cr, haematuria, proteinuria
  • Fever
  • Other systemic symptoms - lethargy, myalgia, weight loss
  • Rash - palpable purpura
  • Cough, dyspnoea, haemoptysis
  • Mononeuritis multiplex
159
Q

Antibodies microscopic polyangiitis

A

pANCA in 50-75%
cANCA in 40%

160
Q

Indications for non-invasive ventilation

A
  • COPD with pH 7.25-7.35
  • Type 2 resp failure secondary to chest wall deformity, neuromuscular disease, OSA
  • Cardiogenic pulmonary oedema unresponsive to CPAP
  • Weaning from tracheal intubation
161
Q

Predisposing factors OSA

A
  • Obesity
  • Macroglossia (acromegaly, hypothyroidism, amyloidosis)
  • Large tonsils
  • Marfan’s syndrome
162
Q

Presentation OSA

A
  • Excessive snoring, periods of apnoea
  • Daytime somnolence
  • Hypertension
163
Q

Gas OSA

A

Compensated resp acidosis

164
Q

Assessment of OSA

A
  • Epworth sleepiness scale
  • Multiple sleep latency test (MSLT)
  • Polysomnography
165
Q

What is multiple sleep latency test?

A

Measures time to fall asleep in a dark room using EEG criteria, measure of sleepiness

166
Q

What is measured in polysomnography

A
  • EEG
  • Resp airflow
  • Thoraco-abdominal movement
  • Snoring
  • Pulse ox
167
Q

First line management OSA

A
  • Weight loss
  • CPAP
168
Q

Use of intra-oral devices in OSA

A

Used if CPAP not tolerated, or patients with mild OSA where no daytime sleepiness

169
Q

DVLA and OSA

A

DVLA should be informed if OSA causing excessive daytime sleepiness

170
Q

Imaging in pleural effusion

A
  • CXR
  • Ultrasound - improves chance of aspiration and sensitive for detecting pleural fluid septations
  • Contrast CT - investigate underlying cause, esp exudative
171
Q

Testing of fluid in pleural effusion

A
  • pH
  • Protein
  • LDH
  • Cytology
  • Microbiology
172
Q

How to distinguish between exudate and transudate pleural effusion

A

Exudates protein level >30, transudates <30
If protein level 25-35, Lights criteria should be applied

173
Q

What is Lights criteria

A

Exudate likely if at least one of following criteria is met:
- Pleural fluid protein divided by serum protein >0.5
- Pleural fluid LDH divided by serum LDH >0.6
- Pleural fluid LDH more than 2/3 upper limits of normal serum LDH

174
Q

Low glucose in pleural fluid causes

175
Q

Raised amylase in pleural fluid causes

A
  • Pancreatitis
  • Oesophageal perf
176
Q

Heavy blood staining in pleural fluid causes

A
  • Mesothelioma
  • Pulmonary embolism
  • TB
177
Q

Management pleural effusion in association with sepsis/pneumonic illness

A

Diagnostic pleural fluid sampling:
- If purulent or turbid/cloudy - chest tube
- If fluid clear but pH less than 7.2 with suspected pleural infection, chest tube

178
Q

Management of recurrent pleural effusion

A
  • Recurrent aspiration
  • Pleurodesis
  • Indwelling pleural catheter
  • Drug management to alleviate symptoms, e.g. opioids for dyspnoea
179
Q

Most common organism causing pneumonia

A

Streptococcus pneumoniae

180
Q

Features of S. pneumoniae pneumonia

A
  • High fever
  • Rapid onset
  • Herpes labialis
181
Q

Organism commonly causing pneumonia in COPD patients

A

Haemophilus influenza

182
Q

Organism commonly causing pneumonia after influenza infection

A

Staphylococcus aureus

183
Q

Features mycoplasma pneumonia

A
  • Dry cough
  • Atypical chest signs +/- x-ray findings
  • Autoimmune haemolytic anaemia and erythema multiforme may be seen
184
Q

Common complications/weird features of legionella pneumophilia

A

Hyponatraemia
Lymphopenia

185
Q

Classic source of legionella pneumonia

A

Infected air conditioning units

186
Q

Organism causing pneumonia in alcoholics

A

Klebsiella

187
Q

Presentation pneumocystis jiroveci pneumonia

A

Dry cough
Exercise induced desats
Absence of chest signs

188
Q

What is idiopathic interstitial pneumonia

A

Group of non-infective causes of pneumonia

189
Q

What is cryptogenic organising pneumonia

A

Type of idiopathic interstitial pneumonia
Form of bronchiolitis

190
Q

Causes idiopathic interstitial pneumonia

A

Rheumatoid arthritis
Amiodarone

191
Q

CRB-65 scoring

A

C = confusion
R = respiratory rate ≥30
B = BP systolic ≤90 and/or diastolic ≤60
65 = aged ≥65

CURB 65 used in hospital, U = urea >7

192
Q

Interpretation CRB-65 in primary care

A
  • If CRB65 0, home-based care
  • If 1-2, consider hospital assessment
  • If 3-4, urgent admission to hospital
193
Q

Interpretation CRP in pneumonia

A

If CRP <20, no antibiotics
If CRP 20-100, consider delayed prescription
If CRP >100, antibiotics

194
Q

Interpretation CURB-65 in secondary care

A

If 1-2, consider home based care
If 2+ (intermediate risk), hospital care
If 3+ (high risk), consider ITU

195
Q

Investigation intermediate/high risk pneumonia

A
  • Blood and sputum cultures
  • Pneumococcal and legionella urinary antigen tests
196
Q

Antibiotic low risk pneumonia

A

Amoxicillin 5 days

If pen allergic, macrolide or tetracycline

197
Q

Antibiotic moderate/high risk pneumonia

A

Amoxicillin and macrolide 7-10 day course

Consider co-amox, cef, or taz + macrolide in high severity

198
Q

Discharge criteria

A

Should not discharge if in the past 24 hours they have had 2+ of:
- Temp higher than 37.5 (this alone = don’t discharge)
- RR ≥24
- HR >100
- Systolic BP ≤90
- Sats <90
- Abnormal mental status
- Inability to eat without assistance

199
Q

How long should fever take to resolve pneumonia

200
Q

How long for chest pain and sputum production to substantially reduce pneumonia

201
Q

How long for cough and breathlessness to substantially reduce pneumonia

202
Q

3 months post pneumonia

A

Most symptoms should have resolved, fatigue may still be present

203
Q

6 months post pneumonia

A

Most people feel back to normal

204
Q

Follow up pneumonia

A

CXR after 6 weeks - ensure consolidation resolved, and check for underlying secondary abnormalities, e.g. tumour

205
Q

Management pneumothorax with no or minimal symptoms

A

Conservative care (regardless of pneumothorax size)

206
Q

How to determine management of symptomatic pneumothorax

A

Assess for high risk characteristics

207
Q

High risk characteristics pneumothorax

A
  • Haemodynamic compromise
  • Significant hypoxia
  • Bilateral pneumothorax
  • Underlying lung diesase
  • ≥ 50 years old with significant smoking history
  • Haemothorax
208
Q

Options for symptomatic pneumothorax with no high risk features

A
  • Conservative care
  • Ambulatory device
  • Needle aspiration (if safe to intervene)
209
Q

Treatment symptomatic pneumothorax

A

Chest drain (if safe to intervene)

210
Q

Criteria for safe to intervene in pneumothorax

A
  • 2cm laterally or apically on CXR, or
  • Any size on CT scan which can be safely accessed with radiological support
211
Q

Conservative care primary pneumothorax

A

Review every 2-4 days as outpatient
If stable, f/u as OP in 2-4 weeks

212
Q

Conservative care secondary pneumothorax

A

Monitor as IP
If stable, f/u as OP in 2-4 weeks

213
Q

What is ambulatory device

A

Needle device with one way valve and vent to prevent air and fluid return to pleural space, while allowing for controlled escape of air and drainage of fluid

214
Q

What to do if needle aspiration of pneumothorax is unsuccessful

A

Chest drain insertion

215
Q

What to do if needle aspiration of pneumothorax is successful

A

Discharge and f/u in OP in 2-4 weeks

216
Q

Management of pneumothorax treated with chest drain

A
  • Daily review as IP
  • Remove drain when resolved - discharge and f/u in OP in 2-4 weeks
217
Q

When is surgical intervention indicted in pneumothorax

A
  • Persistent air leak
  • Insufficient lung re-expansion
  • Recurrent pneumothoraces
218
Q

What surgical intervention used in pneumothorax

A

Video-assisted thoracoscopic surgery - allows for mechanical/chemical pleurodesis +/- bullectomy

219
Q

Discharge advice pneumothorax

A
  • Avoid smoking
  • Can travel 1 week post-check up x-ray
  • Never go scuba diving unless undergone bilateral surgical pleurectomy and normal lung function and chest CT post-op
220
Q

Lung function tests in obstructive lung disease

A

FEV1 significantly reduced
FVC reduced or normal
FEV1% (FEV1/FVC) reduced

221
Q

Causes of obstructive lung disease

A
  • Asthma
  • COPD
  • Bronchiectasis
  • Bronchiolitis obliterans
222
Q

Lung function tests in restrictive lung disease

A

FEV1 - reduced
FVC - significantly reduced
FEV1% (FEV1/FVC) - normal or increased

223
Q

Causes of restrictive lung disease

A
  • Pulmonary fibrosis
  • Asbestosis
  • Sarcoidosis
  • ARDS/infant RDS
  • Kyphoscoliosis, e.g. ankylosing spondylitis
  • Neuromuscular disorders
  • Severe obesity
224
Q

Causes of respiratory alkalosis

A
  • Anxiety → hyperventilation
  • PE
  • Salicylate poisoning
  • CNS disorders - stroke, SAH, encephalitis
  • Altitude
  • Pregnancy
225
Q

What is sarcoidosis

A

Multisystem disorder of unknown aetiology characterised by non-caseating granulomas

226
Q

Demographic sarcoidosis

A

More common in young adults and people of African descent

227
Q

Acute features sarcoidosis

A
  • Erythema nodosum
  • Bilateral hilar lymphadenopathy
  • Swinging fever
  • Polyarthralgia
228
Q

Insidious features sarcoidosis

A
  • Dyspnoea
  • Non-productive cough
  • Malaise
  • Weight loss
229
Q

Ocular features sarcoidosis

230
Q

Skin features sarcoidosis

A

Lupus pernio

231
Q

Metabolic features sarcoidosis

A

Hypercalcaemia

232
Q

Syndromes associated with sarcoidosis

A
  • Lofgren’s syndrome
  • Mikilicz syndrome
  • Heerfordt’s syndrome
233
Q

What is Lofgren’s syndrome

A

Acute form of sarcoidosis characterised by;
- Bilateral hilar lymphadenopathy
- Erythema nodosum
- Fever
- Polyarthraglia

234
Q

What is Mikulicz syndrome

A

Enlargement of the parotid and lacrimal glands due to sarcoidosis, tuberculosis, or lymphoma

235
Q

What is Heerfordt’s syndrome

A

Parotid enlargement, fever, and uveitis secondary to sarcoidosis

236
Q

Features of shortness of breath seen in heart failure

A
  • Orthoponea
  • Paroxysmal noctural dyspnoea
237
Q

Examination findings in heart failure

A
  • Bibasal crackles
  • Third heart sound
  • Peripheral oedema
  • Raised JVP
238
Q

What is silicosis

A

Fibrosing lung disease caused by inhalation of fine particles of crystalline silicon dioxide

239
Q

Occupations at risk of silicosis

A

Mining
Slate works
Foundries
Potteries

240
Q

Condition associated with silicosis

A

TB (silica is toxic to macrophages)

241
Q

CXR silicosis

A
  • Upper zone fibrosing lung disease
  • Egg shell calcification of hilar lymph nodes
242
Q

Options medical management smoking cessation

A
  • Nicotine replacement therapy
  • Varenicline
  • Bupropion
243
Q

How much medication to give smoking cessation

A

Only enough to last until 2 weeks after the target stop dates. Further prescriptions only given to people who have demonstrated their quit attempt is continuing

244
Q

Repeat prescription of medication after unsuccessful smoking cessation attempt

A

Do not offer repeat prescription within 6 months unless special circumstances have intervened

245
Q

Adverse effects nicotine replacement therapy

A
  • Nausea and vomiting
  • Headaches
  • Flu like symptoms
246
Q

When and how to offer 2 forms of NRT in smoking cessation

A

Offer if high level of dependence, or found single forms inadequate in past

Combo of patches and another form (gum, inhalator, lozenge, nasal spray)

247
Q

When should varenicline be started

A

1 week before patient due to stop

248
Q

How long is course of varenicline treatment

A

12 weeks (but monitor regularly and continue treatment only if not smoking)

249
Q

Varenicline vs bupropion effectiveness

A

Varenicline more effective

250
Q

Adverse effects varenicline

A
  • Nausea (most common)
  • Headache
  • Insomnia
  • Abnormal dreams
251
Q

Cautions varenicline

A

History of depression or self-harm

252
Q

Contraindications varenicline

A

Pregnancy and breastfeeding

253
Q

When should bupropion be started

A

1-2 weeks before patient’s target date to stop

254
Q

Contraindications bupropion

A
  • Epilepsy (risk of seizures
  • Pregnancy and breastfeeding
  • Eating disorder (relative)
255
Q

Which pregnant women need referring to stop smoking services

A
  • Women who smoke, or stopped smoking in past 2 weeks
  • With a CO reading of 7+
256
Q

First line smoking cessation in pregnancy

A

CBT, motivational interviewing, or structured self help

257
Q

Second line smoking cessation in pregnancy

A

NRT - should remove patches before going to bed

1 - MSRA (23 decks)

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