Respiratory Flashcards
1
Q
Features moderate asthma exacerbation
A
- PEFR 50-70% predicted
- Speech normal
- RR <25/min
- Pulse <110
2
Q
Features severe asthma exacerbation
A
- PEFR 33-50% best or predicted
- Can’t complete sentences
- RR >25
- Pulse >110
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
4
Q
Features near-fatal asthma attack
A
Raised pCO2
Requiring mechanical ventilation with raised inflation pressures
5
Q
When is CXR indicated in asthma
A
- Life threatening asthma
- Suspected pneumothorax
- Failure to respond to treatment
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
7
Q
First line management asthma attack
A
- Oxygen to maintain sats >94%
- Bronchodilation with SABA
- Corticosteroid
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
9
Q
Dose corticosteroid in asthma attack
A
40-50mg pred PO OD
10
Q
How long to continue steroid in asthma attack
A
At least 5 days, or until patient recovers from attack
11
Q
Further treatment options in asthma attack not responding to initial therapy
A
- Ipratropium bromide
- IV magnesium sulphate
- IM aminophylline
12
Q
Role of ipratropium bromide in asthma attack
A
- Severe or life threatening asthma
- Not responding to initial beta agonist and corticosteroid therapy
13
Q
ITU treatment options for asthma not responding to medical treatment
A
I&V
ECMO
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
15
Q
What is acute bronchitis
A
Inflammation of the trachea and major bronchi → oedematous large airway and sputum production
16
Q
Presentation acute bronchitis
A
- Cough (productive or non-productive)
- Sore throat
- Rhinorrhoea
- Wheeze
17
Q
Examination findings acute bronchitis
A
Majority have normal chest examination.
May have;
- Low grade fever
- Wheeze
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
19
Q
Management acute bronchitis
A
- Analgesia
- Fluid intake
- Consider antibiotics
20
Q
Investigations in acute bronchitis
A
Clinical diagnosis
CRP may be used to guide if antibiotic therapy needed
21
Q
Indications for antibiotics in acute bronchitis
A
- Systemically unwell
- Co-morbidities
- CRP of 20-100 (delayed prescription) or >100 (immediate)
22
Q
Antibiotics acute bronchitis
A
Doxycycline first line
Amoxicillin alternative (e.g. for children, pregnant women)
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)
24
Q
Features COPD exacerbation
A
Increase in dyspnoea, cough, wheeze
Increase in sputum productive (suggests infective cause)
Hypoxic
Acute confusion
25
Management COPD exacerbation
- Increase frequency of bronchodilator use, consider giving via neb
- Pred 30mg daily for 5 days
26
Indications for antibiotics in COPD exacerbation
Sputum purulent
Clinical signs of pneumonia
27
Antibiotic of choice COPD exacerbation
Amoxicillin, clarithromycin, or doxycycline
28
Criteria for admission COPD exacerbation
- 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
29
Management of severe COPD exacerbations requiring secondary care
- Oxygen
- Nebulised bronchodilator
- Steroid therapy
30
Sats target COPD exacerbation
Initial target 88-92%, adjust to 94-98% if pCO2 normal on gas
31
Initial oxygen therapy in COPD exacerbation
28% venturi mask at 4L and titrate
32
Nebulised bronchodilators used in severe COPD exacerbation
- Beta adrenergic agonist, e.g. salbutamol
- Muscarinic antagonists, e.g. ipratropium
33
Steroid therapy in severe COPD exacerbation
Consider IV hydrocort instead of PO pred
34
What drug considered if not responding to bronchodilators in severe COPD exacerbation
IV theophylline
35
Indications for NIV in COPD exacerbation
Respiratory acidosis 7.25-7.35
36
Management COPD patients with pH <7.25
NIV can be used with greater degree of monitoring (HDU) and lower threshold for I&V
37
Alpha 1 antitrypsin deficiency inheritance
Autosomal recessive / co-dominant
38
Presentation alpha 1 anti-trypsin deficiency
Panacinar emphysema, most marked in lower lobes
Liver cirrhosis and hepatocellular carcinoma in adults, cholestasis in children
39
Investigations alpha 1 anti-trypsin deficiency
A1AT concentrations
Spirometry
40
Spirometry findings alpah 1 anti-trypsin deficiency
Obstructive picture
41
Management alpha-1 antitrypsin deficiency
No smoking
Supportive - bronchodilators, physiotherapy
IV alpha1-antitrypsin protein concentrates
Surgery - lung volume reduction surgery, lung transplantation
42
Interpretation of pCO2 on blood gas
>6.0 - respiratory acidosis (or resp comp for metabolic alkalosis)
<4.7 - respiratory alkalosis (or resp comp for metabolic acidosis)
43
Interpretation of bicarbonate on blood gas
If bicarb <22, metabolic acidosis (or renal comp for resp alkalosis)
If bicarb >26, metabolic alkalosis (or renal comp for resp acidosis)
44
Asbestos related lung diseases
- Pleural plaques
- Pleural thickening
- Asbestosis
- Mesothelioma
- Lung cancer
45
Management pleural plaques
Don't need anything - benign, do not undergo malignant change
46
Relationship between asbestos exposure and asbestosis
Severity is related to length of exposure
47
Relationship between asbestos exposure and mesothelioma
Very limited exposure can cause disease
48
Latent period asbestosis
15-30 years
49
Presentation asbestosis
- Dyspnoea
- Clubbing
- Bilateral end-inspiratory crackles
50
Lung function tests asbestosis
Restrictive pattern, reduced gas transfer
51
Where does asbestosis typically cause fibrosis
Lower lobe
52
Treatment asbestosis
Conservative
53
Features mesothelioma
Progressive shortness of breath
Chest pain
Pleural effusion
54
Management mesothelioma
Palliative chemo
Limited role for surgery and radiotherapy
55
Most common form of cancer associated with asbestos exposure
Lung cancer
56
Step 1 management of ≥12 years old with newly diagnosed asthma
Low dose inhaled corticosteroid/formoterol combo inhaler to be taken as needed for symptom relief
57
Step 1 management of ≥12 years old with newly diagnosed asthma if presenting highly symptomatic or with severe exacerbation
Start treatment with low-dose MART (ICS/formoterol combo inhaler for daily maint + relief of symptoms when needed)
58
Step 2 management of ≥12 years old with newly diagnosed asthma
Low dose MART (ICS/formoterol combo inhaler for daily maint + relief of symptoms when needed)
59
Step 3 management of ≥12 years old with newly diagnosed asthma
Moderate dose MART
60
Step 4 management of ≥12 years old with newly diagnosed asthma
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)
61
Step 4.5 management of ≥12 years old with newly diagnosed asthma
If control not improved, stop the LTRA/LAMA and try the other one
62
Step 5 management of ≥12 years old with newly diagnosed asthma
Refer to specialist
63
Management of patients previously on SABA as required only
Switch to step 1 (low dose ICS/formoterol combo inhaler as needed)
64
Management of patients previous on SABA as required + low dose something else
Switch to low dose MART
65
Management of patients previously on SABA as required + moderate dose something else
Switch to moderate dose MART
66
Management of patients previously on regime containing high dose ICS
Refer to resp specialist
67
When to consider stepping down asthma treatment
Every 3 months
68
How to reduce dose of inhaled steroids in asthma
25-50% at a time
69
Most common causes of bilateral hilar lymphadenopathy
Sarcoidosis
Tuberculosis
70
Other causes bilateral hilar lymphadenopathy
Lymphoma/other malignancy
Pneumoconiosis, e.g. berylliosis
Fungi, e.g. histoplasmosis, coccidiomycosis
71
What is pneumoconiosis
Lung disease occurring when dust is inhaled and becomes trapped in the lungs
72
What is bronchiectasis
Permanent dilation of the airways secondary to chronic infection or inflammation
73
Management bronchiectasis
- Physical training, e.g. inspiratory muscle training
- Postural drainage
- Antibiotics
- Bronchodilators in some cases
- Imms
- Surgery
74
When is surgery suitable in bronchiectasis
Localised disease
75
Role of antibiotics in bronchiectasis
Treatment of exacerbations
Long-term rotating antibiotics in severe cases
76
Most common organisms isolated from patients with bronchiectasis
Haemophilus influenzae (most common)
Pseudomonas aeruginosa
Klebsiella
Streptococcus pneumoniae
77
Features of pulmonary oedema on CXR
- Interstitial oedema
- Bat wings appearance
- Upper lobe diversion
- Kerley B lines
- Pleural effusion
78
Causes of white out with trachea pulled towards it
Pneumonectomy
Complete lung collapse, e.g. endobronchial intubation
Pulmonary hypoplasia
79
Causes of white out with trachea central
Consolidation
Pulmonary oedema, usually bilateral
Mesothelioma
80
Cause of white out with trachea pushed away from the white out
Pleural effusion
Diaphragmatic hernia
Large thoracic mass
81
Causes of COPD
Smoking
Alpha 1 antitrypsin deficiency
Cadmium, coal, cotton, cement, grain
82
CXR findings COPD
- Hyperinflation
- Bullae
- Flat hemidiaphragm
83
FEV1/FVC in COPD
<0.7
84
FEV1 % in mild COPD
>80%
85
FEV1 % in moderate COPD
50-79%
86
FEV1 in severe COPD
30-49%
87
FEV1 in very severe COPD
<30%
88
General management COPD
Smoking cessation advice/medication
Annual influenza vaccination
One off pneumococcal vaccination
Pulmonary rehabilitation
89
Who is offered pulmonary rehabilitation in COPD
All people who view themselves as functionally disabled by COPD
90
First line therapy COPD
Bronchodilator - SABA or SAMA
91
How is second line therapy determined in COPD
If patient has asthmatic/steroid responsive features
92
Asthmatic/steroid responsive features in COPD
- 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%)
93
Second line management COPD if no asthmatic/features suggesting steroid responsiveness
Add LABA and LAMA (if already taking SAMA, stop and switch to SAMA)
94
Second line management COPD if asthmatic features/features suggesting steroid responsiveness
LABA + inhaled corticosteroid
95
Third line management COPD if asthmatic features/features suggesting steroid responsiveness
LAMA + LABA + IBS (if already take SAMA, switch to SABA)
96
When to offer oral theophylline in COPD
- If trials of short and long acting bronchodilators fail
- If cannot use inhaled therapy
97
Oral theophylline and antibiotics
Dose of oral theophylline needs to be reduced if macrolide or fluoroquinolone antibiotics are co-prescribed
98
Prophylactic antibiotic used in COPD
Azithromycin
99
When to offer prophylactic antibiotics in COPD
- Non smoker
- Optimised standard treatments
- Continuing to have exacerbations
100
Investigations needed prior to starting prophylactic azithromycin in COPD
- CT thorax (exclude bronchiectasis)
- Sputum culture (exclude atypical infections/TB)
- LFTs
- ECG (exclude QT prolongation)
101
When to offer standby medication in COPD
- 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
102
When should mucolytics be considered COPD
In patients with chronic productive cough
103
Phosphodiesterase-4 inhibitor e.g.
Roflumilast
104
Criteria for trying PDE-4 inhibitors COPD
- 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
Features cor pulmonale
- Peripheral oedema
- Raised JVP
- Systolic parasternal heave
- Loud P2
106
Management cor pulmonale
- Loop diuretic for oedema
- Consider LTOT
107
Factors that may improve survival in patients with stable COPD
- Smoking cessation
- LTOT
- Lung volume reduction therapy (select patients)
108
Churg-Strauss syndrome aka
Eosinophilic granulomatosis with polangiitis (EGPA)
109
Features eosinophilic granulomatosis with polangiitis
- Asthma
- Eosinophilia
- Paranasal sinusitis
- Mononeuritis multiplex
Renal involvement in 20%
110
Antibody in eosinophilic granulomatosis with polangiitis
pANCA (60%)
111
What might precipitate eosinophilic granulomatosis with polangiitis
Leukotriene receptor antagonists
112
Examination features pulmonary oedema
Bibasal crackles
S3
113
Features aspergilloma
Often past Hx TB
Haemoptysis may be severe
CXR shows rounded opacity
114
Features granulomatosis with polyangiitis
- Epistaxis, sinusitis, nasal crusting
- Dyspnoea, haemoptysis
- Glomerulonephritis
- Saddle shape nose deformity
115
Features Goodpasture's syndrome
Haemoptysis
Systemically unwell - fever, nausea
Glomerulonephritis
116
Features idiopathic pulmonary fibrosis
- Progressive exertional dyspnoea
- Bilateral fine end inspiratory creps
- Dry cough
- Clubbing
117
Lung function tests in IPF
Restrictive picture on spirometry - FEV1 normal/decrease, FVC decreased, FEV1/FVC increased
Impaired gas exchange - reduced transfer factor
118
Investigation of choice IPF
HRCT
119
CXR findings IPF
Bilateral interstitial shadowing (typically small, irregular, peripheral opacities - ground glass → honeycombing)
120
Antibodies in IPF
- ANA 30%
- RF 10%
121
Management IPF
- Pulmonary rehabilitation
- Some benefit of pirfenidone (antifibrotic agent) in select patients
- Oxygen
- Eventually lung transplant
122
Features Kartagener's syndrome
- Dextrocardia or complete situs invertus
- Bronchiectasis
- Recurrent sinusitis
- Subfertility
123
What type of bacteria is klebsiella
Gram negative
124
Risk factors klebsiella pneumonia
- Alcoholic
- Diabetic
- Aspiration
125
Features klebsiella pneumonia
Red current jelly sputum
Often affects upper lobes
126
Complications klebsiella pneumonia
Lung abscess formation
Empyema
127
Causes lung abscess
- 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
Risk factors lung abscess caused by aspiration pneumonia
- Poor dental hygiene
- Previous stroke
- Reduced consciousness
129
Bacteria causing lung abscess
Typically polymicrobial
Monomicrobial causes:
- Staphylococcus aureus
- Klebsiella pneumonia
- Pseudomonas aeruginosa
130
Presentation lung abscess
- 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
Signs lung asbcess
- Dull percussion
- Bronchial breathing
- Clubbing
132
CXR findings lung abscess
- Fluid filled air space within an area of consolidation
- Air-fluid level typically seen
133
Management lung abscess
IV antibiotics
If not resolving, percutaneous drainage
Very rare cases, surgical resection
134
Purpose of PET scanning lung cancer
Typically done in non-small cell lung cancer to establish eligibility for curative treatment
135
Paraneoplastic features of small cell lung cancer
- ADH → hyponatraemia
- ACTH → Cushing's syndrome
- Lambert-Eaton syndrome
136
Paraneoplastic features of squamous cell lung cancer
PTH → hypercalcaemia
Clubbing
Hypertrophic pulmonary osteoarthropathy
Hyperthyroidism due to ectopic TSH
137
Paraneoplastic features of adenocarcinoma
Gynaecomastia
Hypertrophic pulmonary osteoarthopathy
138
2WW referral lung cancer
- CXR findings suggestive of lung cancer
- Aged over 40 and over with unexplained haemoptysis
139
Criteria for CXR within 2 weeks ?lung cancer
Aged 40+ and 2 or more of;
- Previous smoker
- Cough
- Fatigue
- Shortness of breath
- Chest pain
- Weight loss
- Appetite loss
140
Criteria to consider CXR within 2 weeks
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
Risk factors lung cancer
- Smoking
- Asbestos
- Arsenic
- Radon
- Nickel
- Chromate
- Aromatic hydrocarbon
- Crytogenic fibrosing alveolitis
Not coal dust
142
Where in lungs is SCLC
Usually central
143
What is Lambert-Eaton syndrome
Antibodies to voltage gated calcium channels causing myasthenic like syndrome
144
Management SCLC
If very early stage disease, consider surgery
If limited disease, combo chemo and radiotherapy
If extensive, palliative chemo
145
Most common type of lung cancer
Adenocarcinoma
146
Distinguishing features squamous lung cancer
Cavitating lesions more common
147
Distinguishing features alveolar cell carcinoma
Not related to smoking
++ sputum
148
Features mesothelioma
- Dyspnoea
- Weight loss
- Chest wall pain
- Clubbing
30% present as painless pleural effusion
149
Latent period mesothelioma
30-40 years
150
Most common met locations mesothelioma
Lung and peritoneum
151
CXR findings mesothelioma
Pleural effusion or pleural thickening
152
First line investigation mesothelioma
- Pleural CT
- Pleural effusion testing - MC&S, biochem, cytology
153
When is thoracoscopy done in ?mesothelioma
If cytology negative exudative effusions
154
Further investigation if area of pleural nodularity seen on CT ?mesothelioma
Image guided pleural biopsy
155
Management mesothelioma
Symptomatic
Industrial compensation
Chemo, surgery if operable
156
Prognosis mesothelioma
Median survival 12 months
157
What is microscopic polyangiitis
Small-vessel ANCA vasculitis
158
Features microscopic polangiitis
- Renal impairment - raised Cr, haematuria, proteinuria
- Fever
- Other systemic symptoms - lethargy, myalgia, weight loss
- Rash - palpable purpura
- Cough, dyspnoea, haemoptysis
- Mononeuritis multiplex
159
Antibodies microscopic polyangiitis
pANCA in 50-75%
cANCA in 40%
160
Indications for non-invasive ventilation
- 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
Predisposing factors OSA
- Obesity
- Macroglossia (acromegaly, hypothyroidism, amyloidosis)
- Large tonsils
- Marfan's syndrome
162
Presentation OSA
- Excessive snoring, periods of apnoea
- Daytime somnolence
- Hypertension
163
Gas OSA
Compensated resp acidosis
164
Assessment of OSA
- Epworth sleepiness scale
- Multiple sleep latency test (MSLT)
- Polysomnography
165
What is multiple sleep latency test?
Measures time to fall asleep in a dark room using EEG criteria, measure of sleepiness
166
What is measured in polysomnography
- EEG
- Resp airflow
- Thoraco-abdominal movement
- Snoring
- Pulse ox
167
First line management OSA
- Weight loss
- CPAP
168
Use of intra-oral devices in OSA
Used if CPAP not tolerated, or patients with mild OSA where no daytime sleepiness
169
DVLA and OSA
DVLA should be informed if OSA causing excessive daytime sleepiness
170
Imaging in pleural effusion
- CXR
- Ultrasound - improves chance of aspiration and sensitive for detecting pleural fluid septations
- Contrast CT - investigate underlying cause, esp exudative
171
Testing of fluid in pleural effusion
- pH
- Protein
- LDH
- Cytology
- Microbiology
172
How to distinguish between exudate and transudate pleural effusion
Exudates protein level >30, transudates <30
If protein level 25-35, Lights criteria should be applied
173
What is Lights criteria
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
Low glucose in pleural fluid causes
- RA
- TB
175
Raised amylase in pleural fluid causes
- Pancreatitis
- Oesophageal perf
176
Heavy blood staining in pleural fluid causes
- Mesothelioma
- Pulmonary embolism
- TB
177
Management pleural effusion in association with sepsis/pneumonic illness
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
Management of recurrent pleural effusion
- Recurrent aspiration
- Pleurodesis
- Indwelling pleural catheter
- Drug management to alleviate symptoms, e.g. opioids for dyspnoea
179
Most common organism causing pneumonia
Streptococcus pneumoniae
180
Features of S. pneumoniae pneumonia
- High fever
- Rapid onset
- Herpes labialis
181
Organism commonly causing pneumonia in COPD patients
Haemophilus influenza
182
Organism commonly causing pneumonia after influenza infection
Staphylococcus aureus
183
Features mycoplasma pneumonia
- Dry cough
- Atypical chest signs +/- x-ray findings
- Autoimmune haemolytic anaemia and erythema multiforme may be seen
184
Common complications/weird features of legionella pneumophilia
Hyponatraemia
Lymphopenia
185
Classic source of legionella pneumonia
Infected air conditioning units
186
Organism causing pneumonia in alcoholics
Klebsiella
187
Presentation pneumocystis jiroveci pneumonia
Dry cough
Exercise induced desats
Absence of chest signs
188
What is idiopathic interstitial pneumonia
Group of non-infective causes of pneumonia
189
What is cryptogenic organising pneumonia
Type of idiopathic interstitial pneumonia
Form of bronchiolitis
190
Causes idiopathic interstitial pneumonia
Rheumatoid arthritis
Amiodarone
191
CRB-65 scoring
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
Interpretation CRB-65 in primary care
- If CRB65 0, home-based care
- If 1-2, consider hospital assessment
- If 3-4, urgent admission to hospital
193
Interpretation CRP in pneumonia
If CRP <20, no antibiotics
If CRP 20-100, consider delayed prescription
If CRP >100, antibiotics
194
Interpretation CURB-65 in secondary care
If 1-2, consider home based care
If 2+ (intermediate risk), hospital care
If 3+ (high risk), consider ITU
195
Investigation intermediate/high risk pneumonia
- Blood and sputum cultures
- Pneumococcal and legionella urinary antigen tests
196
Antibiotic low risk pneumonia
Amoxicillin 5 days
If pen allergic, macrolide or tetracycline
197
Antibiotic moderate/high risk pneumonia
Amoxicillin and macrolide 7-10 day course
Consider co-amox, cef, or taz + macrolide in high severity
198
Discharge criteria
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
How long should fever take to resolve pneumonia
1 week
200
How long for chest pain and sputum production to substantially reduce pneumonia
4 weeks
201
How long for cough and breathlessness to substantially reduce pneumonia
6 weeks
202
3 months post pneumonia
Most symptoms should have resolved, fatigue may still be present
203
6 months post pneumonia
Most people feel back to normal
204
Follow up pneumonia
CXR after 6 weeks - ensure consolidation resolved, and check for underlying secondary abnormalities, e.g. tumour
205
Management pneumothorax with no or minimal symptoms
Conservative care (regardless of pneumothorax size)
206
How to determine management of symptomatic pneumothorax
Assess for high risk characteristics
207
High risk characteristics pneumothorax
- Haemodynamic compromise
- Significant hypoxia
- Bilateral pneumothorax
- Underlying lung diesase
- ≥ 50 years old with significant smoking history
- Haemothorax
208
Options for symptomatic pneumothorax with no high risk features
- Conservative care
- Ambulatory device
- Needle aspiration (if safe to intervene)
209
Treatment symptomatic pneumothorax
Chest drain (if safe to intervene)
210
Criteria for safe to intervene in pneumothorax
- 2cm laterally or apically on CXR, or
- Any size on CT scan which can be safely accessed with radiological support
211
Conservative care primary pneumothorax
Review every 2-4 days as outpatient
If stable, f/u as OP in 2-4 weeks
212
Conservative care secondary pneumothorax
Monitor as IP
If stable, f/u as OP in 2-4 weeks
213
What is ambulatory device
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
What to do if needle aspiration of pneumothorax is unsuccessful
Chest drain insertion
215
What to do if needle aspiration of pneumothorax is successful
Discharge and f/u in OP in 2-4 weeks
216
Management of pneumothorax treated with chest drain
- Daily review as IP
- Remove drain when resolved - discharge and f/u in OP in 2-4 weeks
217
When is surgical intervention indicted in pneumothorax
- Persistent air leak
- Insufficient lung re-expansion
- Recurrent pneumothoraces
218
What surgical intervention used in pneumothorax
Video-assisted thoracoscopic surgery - allows for mechanical/chemical pleurodesis +/- bullectomy
219
Discharge advice pneumothorax
- 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
Lung function tests in obstructive lung disease
FEV1 significantly reduced
FVC reduced or normal
FEV1% (FEV1/FVC) reduced
221
Causes of obstructive lung disease
- Asthma
- COPD
- Bronchiectasis
- Bronchiolitis obliterans
222
Lung function tests in restrictive lung disease
FEV1 - reduced
FVC - significantly reduced
FEV1% (FEV1/FVC) - normal or increased
223
Causes of restrictive lung disease
- Pulmonary fibrosis
- Asbestosis
- Sarcoidosis
- ARDS/infant RDS
- Kyphoscoliosis, e.g. ankylosing spondylitis
- Neuromuscular disorders
- Severe obesity
224
Causes of respiratory alkalosis
- Anxiety → hyperventilation
- PE
- Salicylate poisoning
- CNS disorders - stroke, SAH, encephalitis
- Altitude
- Pregnancy
225
What is sarcoidosis
Multisystem disorder of unknown aetiology characterised by non-caseating granulomas
226
Demographic sarcoidosis
More common in young adults and people of African descent
227
Acute features sarcoidosis
- Erythema nodosum
- Bilateral hilar lymphadenopathy
- Swinging fever
- Polyarthralgia
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Insidious features sarcoidosis
- Dyspnoea
- Non-productive cough
- Malaise
- Weight loss
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Ocular features sarcoidosis
Uveitis
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Skin features sarcoidosis
Lupus pernio
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Metabolic features sarcoidosis
Hypercalcaemia
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Syndromes associated with sarcoidosis
- Lofgren's syndrome
- Mikilicz syndrome
- Heerfordt's syndrome
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What is Lofgren's syndrome
Acute form of sarcoidosis characterised by;
- Bilateral hilar lymphadenopathy
- Erythema nodosum
- Fever
- Polyarthraglia
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What is Mikulicz syndrome
Enlargement of the parotid and lacrimal glands due to sarcoidosis, tuberculosis, or lymphoma
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What is Heerfordt's syndrome
Parotid enlargement, fever, and uveitis secondary to sarcoidosis
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Features of shortness of breath seen in heart failure
- Orthoponea
- Paroxysmal noctural dyspnoea
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Examination findings in heart failure
- Bibasal crackles
- Third heart sound
- Peripheral oedema
- Raised JVP
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What is silicosis
Fibrosing lung disease caused by inhalation of fine particles of crystalline silicon dioxide
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Occupations at risk of silicosis
Mining
Slate works
Foundries
Potteries
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Condition associated with silicosis
TB (silica is toxic to macrophages)
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CXR silicosis
- Upper zone fibrosing lung disease
- Egg shell calcification of hilar lymph nodes
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Options medical management smoking cessation
- Nicotine replacement therapy
- Varenicline
- Bupropion
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How much medication to give smoking cessation
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
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Repeat prescription of medication after unsuccessful smoking cessation attempt
Do not offer repeat prescription within 6 months unless special circumstances have intervened
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Adverse effects nicotine replacement therapy
- Nausea and vomiting
- Headaches
- Flu like symptoms
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When and how to offer 2 forms of NRT in smoking cessation
Offer if high level of dependence, or found single forms inadequate in past
Combo of patches and another form (gum, inhalator, lozenge, nasal spray)
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When should varenicline be started
1 week before patient due to stop
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How long is course of varenicline treatment
12 weeks (but monitor regularly and continue treatment only if not smoking)
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Varenicline vs bupropion effectiveness
Varenicline more effective
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Adverse effects varenicline
- Nausea (most common)
- Headache
- Insomnia
- Abnormal dreams
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Cautions varenicline
History of depression or self-harm
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Contraindications varenicline
Pregnancy and breastfeeding
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When should bupropion be started
1-2 weeks before patient's target date to stop
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Contraindications bupropion
- Epilepsy (risk of seizures
- Pregnancy and breastfeeding
- Eating disorder (relative)
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Which pregnant women need referring to stop smoking services
- Women who smoke, or stopped smoking in past 2 weeks
- With a CO reading of 7+
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First line smoking cessation in pregnancy
CBT, motivational interviewing, or structured self help
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Second line smoking cessation in pregnancy
NRT - should remove patches before going to bed
