Respiratory Flashcards
PEFR 33-50%
Can’t complete sentences
RR >30
HR>110
What kind of asthma is it
Moderate
PEFR <33%
Oxygen sats < 92%
Silent chest, cyanosis or feeble respiratory effort
Bradycardia, dysrhythmia or hypotension
Exhaustion, confusion or coma
What kind of asthma is it
Severe
What if in an asthma attack ; the PCo2 is Normal
Life Threatening Asthma
What is the Mx of Asthma
SIMMAN
S- Salbutamol
I- Ipratropium
M- Magnesium
M- Metheylpred/ Steroids
A- Aminophylline
N- Need to call for ITU
O2 if Hypoxic
PEFR 50-75% best or predicted
Speech normal
RR < 25 / min
Pulse < 110 bpm
What is the Asthma
Moderate
What happens if in an asthma attack, the Pco2 Is raised
Near fatal Asthma
What group is Salbutamol
Short Acting Beta Agonist ( SABA)
What group is Ipratropium
Short Acting Muscarinic Antagonist
(SAMA)
What is the std initial NIV setting
15 ( IPAP) / 5 ( EPAP)
back up rate: 15 breaths/min
back up inspiration:expiration ratio: 1:3
Severe pulmonary oedema
Presents within 1 week of ;
infection: sepsis, pneumonia
massive blood transfusion
trauma
smoke inhalation
acute pancreatitis
Covid-19
cardio-pulmonary bypass
What is you Dx
ARDS
( Non cardiogenic oedema)
What are the key features of
Allergic Bronchopulmory Aspergillosis
> eosinophilia
positive radioallergosorbent (RAST) test to Aspergillus
positive IgG precipitins (not as positive as in aspergilloma)
raised IgE
Pt. may have BG of asthma / bronchiectasis
Mx:
Steroids - 1st
Itraconazole
What is the Genotype of someone who manifests disease in Alpha-1 Antitrypsin deficiency
PiZZ
Key features;
>lungs: panacinar emphysema, most marked in lower lobes
>liver: cirrhosis and hepatocellular carcinoma in adults, cholestasis in children
> Obstructive picture in spirometry
Investigations
A1AT concentrations
spirometry: obstructive picture
Note:
Usually presents in young, non smokers, early onset
What is the drug prophylaxis to prevent AMS
Acetazolamide
What is the Mx of HACE
Dexamethasone
Decent is main Mx
What is the mx of HAPE
Nifedipine- 1st
dexamethasone, acetazolamide, phosphodiesterase type V inhibitors*
Decent is main Mx
How do you administer Aminophylline
Loading dose : 5mg/ kg ( over 20mins IV)
Maintainance dose ;
1g of aminophylline is added to 1 litre of normal saline to give a solution of 1 mg/ml.
dose: 500-700mcg/kg/hour.
If elderly: 300mcg/kg/hour
Monitor Theophylline levles
Which lung fields are commonly affected in asbestosis
Lower lung zone fibrosis
How Is asbestosis different to mesothelioma
In mesothelioma, it is the malignancy of the pleura
in CXR- Looks for thickening of pleura
Which lung zones are most commonly affected in aspiration pneumonia
Right Mid to Lower zones
What is the new BTS guidelines for new Dx of Asthma as per 2024
Step 1
Start AIR ( anti- inf Reliever therapy)
a low-dose inhaled corticosteroid (ICS)/formoterol combination inhaler to be taken as needed
Step 2
Add on Low dose MART to step 1
MART describes using an inhaled corticosteroid (ICS)/formoterol combination inhaler for daily maintenance therapy
Step3
Switch Low Dose MART to Moderate dose MART
Step4
Check if Pt. has the following;
a) Eosinophilia
b) FeNO testing +ve ( raised)
if +ve. —> Refer to Asthma Care Specialist
if -ve;
Add either LTRA ( Montelukast) or SAMA ( Tiotropium) to step 3
Step 5
refer people to a specialist in asthma care when asthma is not controlled despite treatment with moderate-dose MART, and trials of an LTRA and a LAMA
What is the new BTS guideline 2024 to switch pt.’s already on old regimen of Asthma Tx to new regimen
What Advice do we give to Dx Occupational Asthma
Serial measurements of peak expiratory flow are recommended at work and away from work.
Within 72 hrs post Op
Pt. is hypoxic, dyspnoeic
CXR shows Collapse
What is the Dx
Atelectasis
Mx:
Upright positioning
Chest Physio
> aerospace industry
manufacture of fluorescent light bulbs/golf-club heads
What is the common lung condition with these occupations
Berrylosis
Note;
Features
lung fibrosis
bilateral hilar lymphadenopathy
Where do you see Tram Track and Signet Ring Signs
Broncheictasis
What is the most common organism isolated in Broncheictasis
H. Influenza ( most common)
Other causes
Pseudomonas aeruginosa
Klebsiella spp.
Streptococcus pneumoniae
How do yo prevent re-expansion Pulm Oedema
drain tubing should be clamped regularly in the event of rapid fluid output i.e. drain output should not exceed 1L of fluid over a short period of time (less than 6 hours).
What are the causes of cavitating lung lesions
abscess (Staph aureus, Klebsiella and Pseudomonas)
aspergillosis,
histoplasmosis,
squamous cell lung cancer
tuberculosis
Wegener’s granulomatosis
pulmonary embolism
rheumatoid arthritis
coccidioidomycosis
What are the key features of lung collapse
> tracheal deviation towards the side of the collapse
mediastinal shift towards the side of the collapse
elevation of the hemidiaphragm
Note:
Sail sign - right lower lobe collapse
Veil Sign - Right Upper Collapse
Where do you most commonly see canon ball mets
RCC - most common
Note;
May also occur secondary to choriocarcinoma and prostate cancer.
What are some of the ; causes
Trachea pulled toward the white-out lung
Pneumonectomy
Complete lung collapse e.g. endobronchial intubation
Pulmonary hypoplasia
What is the classification of COPD
What is the criteria 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
Note:
If Pt. is current smoker, LTOT is contraindicated
What is the stepwise COPD mx
What is the mx of CF
> regular (at least twice daily) chest physiotherapy and postural drainage.
high calorie diet, including high fat intake*
patients with CF should try to minimise contact with each other to prevent cross infection with Burkholderia cepacia complex and Pseudomonas aeruginosa
vitamin supplementation
pancreatic enzyme supplements taken with meals
lung transplantion
> Lumacaftor/Ivacaftor (Orkambi) **
What is an absolute CI for Lung TX in CF
**chronic infection with Burkholderia cepacia
What are the Ix for Extrinsic Allergic Alveolitis ( Hypersensitivity Pneumonitis)
imaging: upper/mid-zone fibrosis
bronchoalveolar lavage: lymphocytosis
serologic assays for specific IgG antibodies
blood: NO eosinophilia
Mx:
Steroids
Remove precipitants
Examples
bird fanciers’ lung: avian proteins from bird droppings
farmers lung: spores of Saccharopolyspora rectivirgula from wet hay (formerly Micropolyspora faeni)
malt workers’ lung: Aspergillus clavatus
mushroom workers’ lung: thermophilic actinomycetes*
Mississippi and Ohio River valleys.
URTI symptoms
retrosternal pain
CXR: Cavitating lung lesion
Histoplasmosis
Mx:
Amphotericin or itraconazole
What drug can be used in idiopathic Pulm Fibrosis
pirfenidone
What is the CT finding in pulm fibrosis
Honey Combing
What are the key features of Kartageners syndrome
Features
dextrocardia or complete situs inversus
bronchiectasis
recurrent sinusitis
subfertility (secondary to diminished sperm motility and defective ciliary action in the fallopian tubes)
Hint ;
(e.g. ‘quiet heart sounds’, ‘small volume complexes in lateral leads’)
What is the common infection in alcoholics/ Diabetics
Klebsiella (Gram-negative rod)
acute form sarcoidosis characterised by bilateral hilar lymphadenopathy (BHL), erythema nodosum, fever and polyarthralgia.
Lofgren’s syndrome
Note:
Loefflers syndorme is a parasitic infection ( raised esinophils)
Ascaris lumbricoides
What are the paraneoplastic features of Lung Ca
Common organism causing pneumonia
How does CURB-65 help with mx of pneumonia
Note- If in GP setting , use CRB-65
What are the causes of Pulm Fibrosis
Fibrosis predominately affecting the upper zones
CHARTS
C - Coal worker’s pneumoconiosis
H - Histiocytosis/ hypersensitivity pneumonitis
A - Ankylosing spondylitis
R - Radiation
T - Tuberculosis
S - Silicosis/sarcoidosis
Fibrosis predominately affecting the lower zones
idiopathic pulmonary fibrosis
most connective tissue disorders (except ankylosing spondylitis) e.g. SLE
drug-induced: amiodarone, bleomycin, methotrexate
asbestosis
What are the surgical contra-indications for NSCLC
Surgery contraindications
assess general health
stage IIIb or IV (i.e. metastases present)
FEV1 < 1.5 litres is considered a general cut-off point*
malignant pleural effusion
tumour near hilum
vocal cord paralysis
SVC obstruction
- However if FEV1 < 1.5 for lobectomy or < 2.0 for pneumonectomy then some authorities advocate further lung function tests as operations may still go ahead based on the results
What is the Ix for Mesothelioma
1st- CXR
2nd- CT
3rd- Pleural Biopsy ( to confirm)
Contact with camels (including camel products such as milk)
Flu like Symptoms
LRTI
MERS CoV
(Middle East respiratory syndrome)
Most Common non-tuberculous mycobacteria
M. avium complex (MAC) organisms.
what is the difference between obesity hypoventilation syndrome and Obstructive sleep apnoea
OHS = daytime hypercapnia + obesity + hypoventilation
OSA = intermittent airway obstruction + normal daytime PaCO₂
OHS often coexists with OSA but requires BiPAP instead of CPAP due to chronic hypercapnia 🚀
How do you Mx Pneumothorax as per new BTS guideline (2023)
Pneumothorax Management (BTS 2023) – Key Points
Step 1: Assess Symptoms
Minimal/no symptoms → Conservative care (regardless of size)
Symptomatic → Assess for high-risk characteristics
Step 2: Assess High-Risk Characteristics
✅ High-risk factors:
Haemodynamic compromise (suggests tension pneumothorax)
Significant hypoxia
Bilateral pneumothorax
Underlying lung disease
≥ 50 years + significant smoking history
Haemothorax
✅ Management:
No high-risk factors → Choose between:
Conservative care
Ambulatory device
Needle aspiration
High-risk present → Chest drain (if safe to intervene)
Step 3: Determine Safety for Intervention
Needle aspiration or chest drain:
Safe if ≥ 2 cm on CXR (laterally/apically)
Any size on CT scan (if radiologically accessible)
Management Options
1️⃣ Conservative Care
Primary pneumothorax: Review every 2-4 days (outpatient)
Secondary pneumothorax: Monitor inpatient → outpatient follow-up in 2-4 weeks
2️⃣ Ambulatory Care
Example: Rocket™ Pleural Vent (8FG catheter + pigtail)
One-way valve prevents air/fluid return, allows controlled escape
Indicator helps assess resolution
3️⃣ Needle Aspiration
If successful → Discharge + follow-up in 2-4 weeks
If unsuccessful → Chest drain
4️⃣ Chest Drain
Daily inpatient review
Remove when resolved → Discharge + follow-up in 2-4 weeks
📌 Key takeaway: Prioritise symptoms + high-risk factors over size! 🚀
Obstructive vs. Restrictive Lung Disease – Key Differences
✅ Obstructive (↓ Airflow)
FEV1 ↓↓↓, FVC ↓/normal, FEV1/FVC ↓
Examples: Asthma, COPD, Bronchiectasis, Bronchiolitis obliterans
✅ Restrictive (↓ Lung Volume)
FEV1 ↓, FVC ↓↓↓, FEV1/FVC normal/↑
Examples: Pulmonary fibrosis, Asbestosis, Sarcoidosis, ARDS, IRDS, Kyphoscoliosis, Neuromuscular disorders, Severe obesity
What are the resp manifestations of rheumatoid arthritis
pulmonary fibrosis - lower zone
pleural effusion
pulmonary nodules
bronchiolitis obliterans (progressive dyspnoea ;obstructive pattern on spirometry)
centrilobular nodules, bronchial wall thickening is seen on CT
complications of drug therapy e.g. methotrexate pneumonitis
pleurisy
Caplan’s syndrome
(massive fibrotic nodules with occupational coal dust exposure
infection (possibly atypical) secondary to immunosuppression)
What Is the skin manifeston of Sarcoid called as
Lupus Perinio
Syndromes associated with sarcoidosis
Lofgren’s syndrome is an acute form of the disease characterised by bilateral hilar lymphadenopathy (BHL), erythema nodosum, fever and polyarthralgia. It usually carries an excellent prognosis
In Mikulicz syndrome* there is enlargement of the parotid and lacrimal glands due to sarcoidosis, tuberculosis or lymphoma
Heerfordt’s syndrome (uveoparotid fever) there is parotid enlargement, fever and uveitis secondary to sarcoidosis
What are the CXR stages of Sarcoid
stage 0 = normal
stage 1 = bilateral hilar lymphadenopathy (BHL)
stage 2 = BHL + interstitial infiltrates
stage 3 = diffuse interstitial infiltrates only
stage 4 = diffuse fibrosis
What are Indications for steroids in Sarcoidosis
-patients with chest x-ray stage 2 or 3 disease who are symptomatic. -
-hypercalcaemia
-eye, heart or neuro involvement
mining
slate works
foundries
potteries
What are they at risk of
Silicosis
Features
Upper zone fibrosis
Egg shell calcifications of Hilar L.N
Smoking Cessation – Key Points
Smoking Cessation – Key Points
✅ First-line options: NRT, varenicline, or bupropion (no preference among them).
✅ Target stop date:
Start medication before quitting (1 week for varenicline, 1–2 weeks for bupropion).
Prescribe only until 2 weeks after stop date.
No repeat prescriptions within 6 months if unsuccessful.
✅ Medications:
🔹 NRT (Nicotine Replacement Therapy) – Use patches + another form (gum, lozenges, etc.) for heavy smokers. Side effects: nausea, headaches.
🔹 Varenicline (Partial Nicotinic Agonist) – More effective than bupropion. Side effects: nausea, abnormal dreams, insomnia. Avoid in depression, pregnancy.
🔹 Bupropion (Norepinephrine-Dopamine Reuptake Inhibitor) – Risk of seizures (1 in 1,000). Contraindicated in epilepsy, pregnancy, and eating disorders.
✅ Pregnant Women:
Screen for smoking with CO detectors.
First-line: behavioral therapy (CBT, motivational interviewing).
NRT can be used but remove patches at night.
Varenicline & bupropion are contraindicated.
What is the BTS guidelines for Solitary Lung nodule F/u
Nodule <5mm, or clear benign features, or unsuitable for treatment: can be discharged
Nodule =>8mm and high risk*: then CT-PET, and if CT-PET shows high uptake then biopsy
Nodule 5-6mm, or =>8mm and low-risk*: then CT surveillance
CT surveillance: if 5-6mm then at 1 year, if =>6 then in three months
What are the key features of theophylline toxicity
Features
acidosis, hypokalaemia
vomiting
tachycardia, arrhythmias
seizures
Management
consider gastric lavage if <1 hour prior to ingestion
activated charcoal
whole-bowel irrigation can be performed if theophylline is sustained release form
charcoal haemoperfusion is preferable to haemodialysis
Transfer Factor (TLCO & KCO) – Key Points
✅ Definition: Measures gas diffusion from alveoli to blood using carbon monoxide.
TLCO = Total gas transfer.
KCO = Transfer coefficient (TLCO corrected for lung volume).
✅ Causes of ↑ TLCO:
Increased blood flow: Asthma, polycythaemia, hyperkinetic states, left-to-right shunts.
Alveolar-capillary leak: Pulmonary haemorrhage (e.g., GPA, Goodpasture’s).
Others: Male gender, exercise.
✅ Causes of ↓ TLCO:
Lung pathology: Pulmonary fibrosis, pneumonia, emphysema.
Vascular issues: Pulmonary emboli, pulmonary oedema, low cardiac output.
Others: Anaemia.
✅ KCO increases with age. Conditions causing ↑ KCO with normal/↓ TLCO:
Reduced lung volume: Pneumonectomy, lobectomy.
Chest wall restriction: Scoliosis, kyphosis, ankylosing spondylitis.
Neuromuscular weakness.
