Respiratory Flashcards
What is bronchiectasis?
A persistent or progressive chronic debilitating disease characterized by permanent dilation of the bronchi due to irreversible damage to the elastic and muscular components of the bronchial wall.
What causes bronchiectasis?
Inflammatory damage to the airways associated with a range of underlying diseases.
What is the prevalence of bronchiectasis in the UK?
Around 5 in every 1000 adults.
Is bronchiectasis more common in men or women?
More common in women.
What are common clinical features of bronchiectasis?
- Daily expectoration of large volumes of purulent sputum
- Cough
- Breathlessness
- Haemoptysis
- Chest pain (non-pleuritic)
- Coarse crackles during early inspiration
- Wheeze
- High pitched inspiratory squeaks
- Large airway rhonchi
- Palpable chest secretions on coughing
What symptom should raise suspicion of bronchiectasis in adults?
Persistent production of mucopurulent or purulent sputum.
What cough duration is concerning for bronchiectasis in adults?
A cough that persists for longer than 8 weeks.
What underlying condition is associated with bronchiectasis in rheumatoid arthritis patients?
Chronic productive cough or recurrent chest infections.
What indicates bronchiectasis in patients with COPD?
- Frequent exacerbations (two or more annually)
- Positive sputum culture for Pseudomonas aeruginosa whilst stable.
What are the signs of bronchiectasis in children?
- Chronic moist or productive cough unresponsive to 4 weeks of antibiotics
- Recurrent or persistent wet cough (over 6 weeks’ duration)
- Asthma unresponsive to treatment
- Severe pneumonia with unresolved symptoms
- Recurrent pneumonia
- Unexplained haemoptysis
- Exertional breathlessness
What investigations should be arranged if bronchiectasis is suspected?
- Sputum culture
- Chest X-ray
- Spirometry
- Oxygen saturation level
- Full blood count including differential white cell count
Who should suspected bronchiectasis patients be referred to?
A respiratory physician.
How can an infective exacerbation of bronchiectasis be managed?
In primary care, but hospital admission may be required in some cases.
What should guide antibiotic choice for bronchiectasis?
Previous microbiology cultures, when available.
What is the first-line antibiotic if previous microbiology cultures are not available?
Amoxicillin.
Fill in the blank: Bronchiectasis is characterized by _______.
permanent dilation of the bronchi.
True or False: Bronchiectasis can be caused by a single disease.
False.
what is the first line investigation for suspected asthma?
First line testing - measure eosinophil count OR FeNO test.
Diagnose asthma if the eosinophil count is above the laboratory reference range or the FeNO level is 50 parts per billion (ppb) or more.
what is the physiology of a FeNO test?
FeNO is produced by eosinophils in the airway epithelium. Elevated levels indicate eosinophilic inflammation, which is characteristic of asthma.
what is the second line investigations for asthma?
If asthma is not confirmed by eosinophil count or FeNO level, measure bronchodilator reversibility (BDR) with spirometry.
If spirometry not available -measure peak expiratory flow (PEF) twice daily for 2 weeks.
what spirometry result would confirm asthma?
Diagnose asthma if the FEV1 increase is 12% or more and 200 mL or more from the baseline pre-bronchodilator measurement (or if the FEV1 increase is 10% or more of the predicted normal FEV1).
how can asthma be diagnosed through peak flow readings?
The best of three measurements should be used each time.
Diagnose asthma if PEF variability (amplitude percentage mean) is 20% or more.
how to diagnose asthma in children aged 5-16 years?
FeNO test
whati s the diagnostic level in the FeNO test for asthma in 5-16 year old?
35ppb or more
what tests should be done next to diagnose asthma in 5-16 year old if the FeNO test is not conclusive?
measure bronchodilator reversibility (BDR) with spirometry
diagnose asthma if:
the FEV1 increase is ≥ 12% from the pre-bronchodilator measurement, or
the FEV1 increase is ≥ 10% of the predicted normal FEV1
if spirometry is not available or it is delayed, measure peak expiratory flow (PEF) twice daily for 2 weeks
diagnose asthma if:
PEF variability (expressed as amplitude percentage mean) is ≥ 20%
what is the step 1 management of asthma in > 12 years old?
low dose ICS + LABA - taken PRN as needed for symptom relief
example - Easyhaler® Beclometasone® 200 DPI 1 puff bd or
Clenil Modulite® 100 MDI +spacer 2 puffs bd or
Qvar® 50 MDI+spacer 2 puffs bd or
Qvar Easi-Breathe® 50 inhaler 2 puffs bd
what is step 2 asthma treatment in patients > 12 years old
MART - i.e.e using the ICS/formoterol combination inhaler for daily maintenance
what is step 3 treatment for asthma in > 12 year olds?
increase dose to a moderate dose MART
what is step 4 in the asthma management guidelines for >12 years old?
check FeNO level and blood eosinophil count - if raised refer to resp, if normal then: consider trial of either LTRA or LAMA in addition to the moderate dose MART for 8-12 weeks and r.v
If still uncontrolled at this time - refer to resp
what are the three categories of acute asthma?
moderate
severe
life threatening
what re the features of moderate asthma attack?
PEFR > 50% best or predicted
speech normal
RR < 25/min
Pulse < 110 bpm
what are the features of severe asthma attack?
PEFR 33-50% best of predicted
cant complete full sentences
RR > 25/min
pulse > 110bpm
what are the features of life threatening asthma attack?
PEFR < 33% best or predicted
oxygen sats < 92%
silent chest
cyanosis
feeble resp effort
bradycardia
dyshythmia or hypotension
exhuastion
confusion or coma
what is the management of moderate asthma?
beta 2 agonists such as salbutamol - nebulised or via spacer (repeated at intervals 10-20 mins)
if improved of PEFR to 50-70%, then prednisolone 40mg - 50mg, home and r.v
what is the management of severe asthma?
consider admission
oxygen to hypoxaemic patients to maintain sats 94-98%
beta 2 agonist via spacer or neb
prednisolone 40-50mg
if no response, then admit
management of life threatening asthma?
arrange immediate admission
oxygen
nebs + ipratropium bromide
pred 40-50mg
hydrocortisone 100mg via IV if available
what are the crtieria for severe asthma attack in children <12 yrs?
SpO2 < 92%
PEF 33-50%
too breathless to talk or feed
heart rate > 125 (> 5 years), > 140 (1-5 years)
RR > 30 breaths/min (5 yrs old)
> 40 (1-5 years)
use of accessory neck muscles
what are the categories for acute asthma attack for children?
severe
life threatening
signs of life threatening asthma attack in children?
SpO2 < 92%
PEF < 33% best or predicted
silent chest
poor resp effort
agitation
altered consciousness
cyanosis
management of mild to moderate asthma attack in children?
Bronchodilator therapy
give a beta-2 agonist via a spacer (for a child < 3 years use a close-fitting mask)
give 1 puff every 30-60 seconds up to a maximum of 10 puffs
if symptoms are not controlled repeat beta-2 agonist and refer to hospital
Steroid therapy
should be given to all children with an asthma exacerbation
treatment should be given for 3-5 days
what are the doses of steroids to give to chidren 2-5 years?
20mg OD
what is the dose of steroid to give to children > 5 years old?
30-40mg OD
what is the diagnostic criteria for COPD?
Post bronchodilator FEV1/FVC < 70% and symptoms suggestive of COPD
what are the investigations for suspected COPD?
spirometry - post bronchodilator FEV1/FVC ratio < 70%
CXR
FBC
what are the CXR findings of COPD?
hyperinflated lungs
bullae
flat hemidiaphragm
what are the stages of copd and how are they defined?
defined by FEVC/FVC post bronchodilator + FEV1 of predicted -
Mild FEV1/FVC <0.7 FEV1 > 80%
Moderate FEV1/FVC <0.7, FEV1 50-79%
Severe FEV1/FVC < 0.7 , FEV1 30-49%
Very severe FEV1/FVC <0.7, FEV1 < 30%
what are the causes of COPD?
smoking
alpha-1 antitrpsin deficiency
exposure to coal/cotton/cement/grain
what is the general lifestyle management of COPD?
> smoking cessation advice: including offering nicotine replacement therapy, varenicline or bupropion
annual influenza vaccination
one-off pneumococcal vaccination
pulmonary rehabilitation to all people who view themselves as functionally disabled by COPD (usually Medical Research Council [MRC] grade 3 and above)
what is step 1 management of COPD?
SABA or SAMA as required
what is step 2 copd management?
decide if has asthmatic features or features suggestive of steroid responsiveness -
if no - SABA PRN, LABA + LAMA
if yes - SABA or SAMA prn, LABA + ICS
what are features of copd that would be suggestive of asthmatic features or features suggestive of steroid responsiveness?
previous diagnosis of asthma or atopy
raised eosinophil count
variation of FEV1 over time
diurinal variation of PEF
what is step 3 treatment of COPD?
SABA PRN
LABA + LAMA + ICS
who should be offered rescue pack at home in COPD?
have had an exacerbation in the last year
understand how to take the medication - aware of risks vs benefits
know when to seek help + replace after completed
who should mucolytics be considered for in COPD?
patients with chronic productive cough and continued if symptoms improve
when are PDE-4 inhibitors recommended for the treatment of COPD?
the disease is severe - considered to be FEV1 post bronchodilator < 50%
more than 2 exacerbations in previous 12 months desptie triple therapy with a long acting muscarinic agonist , LABA and ICS
how do PDE-4 inhibtors work for copd?
inhibit breakdown of cyclic AMP leading to inflammation and improved lung function
what is an example of PDE-4 inhibitor?
Roflumilast
what is a complication of COPD?
right sided heart failure secondary to pulmonary hypertension, often resulting from COPD
what are the features of cor pulmonale?
exertional dyspnoea
fatigue
peripheral oedema
JVP raised
hepatomegaly
systolic parasternal heave
loud P2
how do you treat cor pulmonale?
ACE I
CCB
alpha blockers
LTOT if needed
critreia for LTOT?
Offer LTOT to patients with a pO2 of < 7.3 kPa or to those with a pO2 of 7.3 - 8 kPa and one of the following:
secondary polycythaemia
peripheral oedema
pulmonary hypertension
stopped smoking
what does the risk assessment include to assess if someone is safe for LTOT?
NICE suggest that a structured risk assessment is carried out before offering LTOT, including:
the risks of falls from tripping over the equipment
the risks of burns and fires, and the increased risk of these for people who live in homes where someone smokes (including e-cigarettes)
what criteria suggests admission for acute asthma exacerbation?
severe breathlessness
acute confusion or impaired consciousness
cyanosis
oxygen saturation less than 90% on pulse oximetry.
social reasons e.g. inability to cope at home (or living alone)
significant comorbidity (such as cardiac disease or insulin-dependent diabetes)
are antibiotics recommended with every acute exacerbation of COPD?
no - NICE recommends abx only if there is purulent sputum or there are clinical signs of pnuemonia
what are the first line abx for acute exacerbation of copd when indicated?
amoxicllin
clarithromycin
doxycycline
what is emphysema?
damage to the alveolar sacs, leading to loss of elastin and formation of enlarged air spaces and hyperinflation of the lungs
what are the symptoms of emphysema?
SOB
accessory muscle use
cough
barrell chest
pursing lips to stop airways from collapsing
causes of emphysema?
smoking - 90%
alpha 1 antitrypsin deficinecy - suspect in young patient, who does not smoke, and has liver changes/derranged LFT’s
what is alpha 1 antitrypsin deficiency?
genetic - autosomal recessive/codominant condition that leads to low alpha 1 antitrypsin - protein which is responsible for protecting liver/lungs from autoimmune destruction
what is the most common way in which alpha 1 antitrypsin deficiency is inherited?
PiZZ homozygous
Investigations for alpha 1 antitrypsin?
A1At concentrations
spirometry - obstructive
what is the treatment of alpha 1 antitrypsin?
stop smoking
inhlaers/bronchdilators same as COPD
IV alpha 1 antitrypsin concentrates
suregery if severe - lung volume reduction surgery / lung transplant
what is the pathophysiology of cystic fibrosis?
mutation in CFTR gene. the CFTR protein is a channel in cells which moves chloride ions into secretions. This leads to less chloride ions in the secretions. Water follows chloride, and so secretions are very thick.
which two organs does CF affect?
lungs
pancreas
which gene is affected in CF?
the CFTR gene
how is CF inherited?
autosomal recessive
how can CF present in newborns?
meconium ileus - first stool is extremely thick due to lack of chloride, which becomes obstructed in the intestine causing ileus - surgical emergency
how does CF affect the pancreas?
thick secretions obstruct the pancreatic ducts, preventing pancreatic enzymes from reaching the small intestine, leading to pancreatic insufficiency.
what is the effects of pancreatic insufficiency?
acute / chronic pancreatitis
poor weight gain
failure to thrive
steatorrhoea
endocrine function compromised - insulin dependent insulin
how does CF damage the lungs?
thick mucous production - which is unable to be cleared by the cillia, leading to colonization of bacteria such as pseudomonas and staph aureus, this leads to acute exacerbations and bronchiectasis over time.
what are some features of CF?
resp + pancreatic presentation
meconium ileus Other features of cystic fibrosis
short stature
diabetes mellitus
delayed puberty
rectal prolapse (due to bulky stools)
nasal polyps
male infertility, female subfertility
how is CF tested for?
newborn screening test - detects pancreatic enzyme IRT - released into blood when pancreas damaged
if postitive - sweat test - detects high levels of Cl- in sweat
both done to confirm diagnosis
what is the management of CF?
BD chest physio
high calorie/high fat diet
minimise contact with other people with CF to stop spread of pseudomonas
Creon/pancreatic supps
vitamins
personalised immune therapy
what is an example of personalised therapy for CF?
lumacaftor/ivacaftor - brings CFTR to membrane surface, to increase Cl transmission - life changing medication
what is the first step in pneumothorax management?
assess whether symptomatic - if asymptomatic with pneumothorax of any size -> can usually manage as OPD
what are higher risk factors of spontaneous pneumothroax which may indicate needs inpatient management?
if age > 50 years
significant smoking hx
evidence of underlying resp disease on CXR
haemodynamic compromise
dyspnoea / hypoxia
bilateral
haemothorax
what is some advice given to patient with pneumothroax after resolution regarding flying?
Fitness to fly
absolute contraindication, the CAA suggest patients may travel 2 weeks after successful drainage if there is no residual air. The British Thoracic Society used to recommend not travelling by air for a period of 6 weeks but this has now been changed to 1 week post check x-ray
what is the advice that should be given to a patient post pneumothorax resolution regarding scuba diving?
Scuba diving
the BTS guidelines state: ‘Diving should be permanently avoided unless the patient has undergone bilateral surgical pleurectomy and has normal lung function and chest CT scan postoperatively.
what is the advice that should be given to a patient following pneumothorax regarding smoking?
Smoking
patients should be advised to avoid smoking to reduce the risk of further episodes - the lifetime risk of developing a pneumothorax in healthy smoking men is around 10% compared with around 0.1% in non-smoking men
what is the management of tension pneumothorax?
Needle decompression -involves inserting a large-bore cannula into the pleural cavity through the 2nd intercostal space mid-clavicular line or 5th intercostal space mid-axillary line. A subsequent hiss of air confirms the diagnosis.
Following chest drain insertion, a CXR must be performed; any persisting pneumothorax or clinical instability warrants discussion with a thoracic surgeon
what is the CURB-65 score?
Confusion
Urea > 7
RR > 30
BP - systolic < 90, diastolic < 60
65 - age > 65
score 0 - low risk
1-2 - intermediate risk - consider hosp assessment
3-4 high risk - needs admission
what are risk factors to developing long covid?
older age
female
high BMI
asthma
what are the rules around driving with OSA and DVLA notification?
A person with suspected OSA syndrome must stop driving immediately if they have excessive sleepiness. They need only notify the DVLA if control of symptoms is not achieved within three months. If moderate or severe OSAS is diagnosed, the DVLA must be notified with review every three years as a minimum.
Group 2 - lorrys - annually
what abx are recommended for low severity CAP (CURB-65 1-2)?
amoxicillin
+ clari/erythromycin if needed
what abx are recommended for high severity CAP (3-4)?
co-amox AND clari/erythromycin
levofloxacin if pen allergic
