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Medicine Y6 > Respiratory > Flashcards

Respiratory Flashcards

1
Q

Non-invasive ventilation: indications

A

BTS guidelines -

  • acute respiratory failure eg COPD (if persisting after bronchodilators + controlled O2 therapy):
    • pH <7.35 pCO2 >6.5 RR >23
  • NM disease: any respiratory illness where
    • RR>20 and usual vital capacity <1L (even if pCO2<6.5)
    • pH<7.35 and pCO2>6.5
  • Obstructive sleep apnoea:
    • pH <7.35, pCO2>6.5, RR>23
    • Daytime pCO2>6.0 and somnolent

NOT INDICATED in asthma/pnuemonia. ITU if resp distress, pH<7.35 or pCO2>6.5

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2
Q

Non-invasive ventilation: absolute contraindications

A

BTS guidelines: severe facial deformity facial burns fixed upper airway obstruction

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3
Q

Non-invasive ventilation: relative contraindications

A

BTS guidelines:

  • pH<7.15
  • pH<7.25 + additional adverse feature
    • GCS<8
    • Confusion / agitation
    • Cognitive impairment (warranting enhanced observation)
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4
Q

Non-invasive ventilation: indications for ICU referral

A

BTS guidelines:

  • Acute hypoxaemic respiratory failure (impending resp arrest)
  • NIV failing to augment chest wall movement or reduce pCO2
  • Inability to maintain SaO2 85-88% on NIV
  • Need for IV sedation
  • Possible intubation difficulties
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5
Q

Non-invasive ventilation: initial settings

A

BTS guidelines

Initial pressure settings: EPAP = 3 (or higher if obstructive sleep apnoea expected). IPAP = 15 (if pH<7.25, IPAP = 20) then titrate up to 20-30 over 30 mins

IPAP should not exceed 30, or EPAP 8 without expert r/v

Backup rate: 16-20 I:E ratio 1:1 (in COPD 1:2 or 1:3)

Inspiratory time 1.2-1.5 (in COPD, 0.8-1.2)

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6
Q

Non-invasive ventilation: what O2 sats are you aiming for?

A

88-92% in all pts

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7
Q

Non-invasive ventilation: red flags

A

BTS guidelines: pH<7.25 on optimal NIV RR>25 persistently New onset confusion / distress

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8
Q

Community-acquired pneumonia: scoring system

A

CURB65 Confusion Y/N Urea >7 mmol/L RR >30 BP <90/60 mmHg (either) Age >=65 Score: 1=mild (outpt tx) 2=moderate (inpt tx) 3+=severe (consider ITU)

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9
Q

DVT/PE risk: scoring system

A

Well’s criteria

  • PMH: ‘A PIMP’
    • Active cancer
    • Previous VTE
    • IMmobilisation for past 3d or recent (<12w) surgery
    • Paralysis / paresis
  • O/E: ‘PPOSS’
    • localised Pain along the venous system
    • Prominent superficial veins
    • pitting Oedema
    • unilateral calf Swelling
    • whole leg Swelling
  • if alternative dx as probable then - 2

score of 2+ suggests DVT/PE likely (40%)

(BMJ)

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10
Q

URTI: criteria predicting streptococcal infection

A

Modified Centor Criteria Age 3-14 (+1), 45+ (-1) Exudate on tonsils Tender ant cervical LNs Fever >38 No cough Score: 3+ indicates antibiotics

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11
Q

Type 1 respiratory failure: 5 most common causes

A

Pneumonia PE Malignancy Pulmonary oedema Pulmonary fibrosis (this all lead to V/Q mismatch)

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12
Q

Type 2 respiratory failure: common causes

A

COPD Asphyxiation (any loss of airway) Opiate toxicity Neuromuscular (GBS, myasthenia gravis)

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13
Q

What are the indications for Long Term Oxygen Therapy (LTOT) in chronic respiratory disease?

A

Offer LTOT to patients with

  • pO2 of < 7.3 kPa or
  • pO2 of 7.3 - 8 kPa + 1 of
    • secondary polycythaemia
    • nocturnal hypoxaemia
    • peripheral oedema
    • pulmonary hypertension

(Passmedicine)

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14
Q

Identify appropriate investigations for idiopathic pulmonary fibrosis

A
  • Spirometry: classically a restrictive picture (FEV1 normal/decreased, FVC decreased, FEV1/FVC increased)
  • Bloods: ANA (30% +ve), RF (10% +ve) + rule out other causes of sx (eg FBC, CRP, ESR)
  • Imaging:
    • CXR: bilateral interstitial shadowing (typically small, irregular, peripheral opacities - ‘ground-glass’ - later progressing to ‘honeycombing’)
    • HR CT: investigation of choice, required for dx

(passmedicine)

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15
Q

Generate a management plan for idiopathic pulmonary fibrosis

A
  • Acute exacerbation
    • Admit + high-dose steroids (prednisolone PO for at least 8w, tapering dose)
  • Long-term
    • Conservative: smoking cessation, pulmonary rehab
    • Medical
      • 1st line: antifibrotic (if mild/moderate disease)
        • PPI (as IPF associated with GORD)
        • LTOT if indicated
    • Surgical
      • 2nd line: lung transplantation (if medical management not stopping progression) (BMJ)
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16
Q

Recognise the presenting symptoms of idiopathic pulmonary fibrosis

A

progressive exertional dyspnoea

bibasal fine crackles on auscultation

dry cough

clubbing

(passmedicine)

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17
Q

Identify the possible complications of idiopathic pulmonary fibrosis

A

Short: pneumonia, pneumothorax, PE

Long: pulmonary HTN, lung ca, GORD

(BMJ)

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18
Q

Summarise the prognosis for patients with idiopathic pulmonary fibrosis

A

Morbidity: progressive functional decline + dyspnoea

Mortality: median survival 2-5y from diagnosis, most die from the disease

Good prognostic factors: atypical appearance on HR CT, stable FVC

Poor prognostic factors: old, male, severe FVC, desats on 6-min walk test, poor HR recovery from exercise, acute exacerbations

(BMJ)

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19
Q

Outline the severity criteria for COPD using FEV1

A

For all there must be

  • symptoms
  • Post-bronchodilator FEV1/FVC <0.7

then…

Stage 1 (mild): FEV1 >80% (of predicted)

Stage 2 (moderate): FEV1 50-80% (of predicted)

Stage 3 (severe): FEV1 30-49% (of predicted)

Stage 4 (v severe): FEV1 <30% (of predicted)

(passmedicine)

20
Q

Outline the new BTS guidelines for long-term asthma management

A

In terms of management, the BTS suggest the following approach:

  1. Start treatment at the level most appropriate to initial severity
  2. Achieve early control
  3. Maintain control by increasing treatment as necessary and decreasing treatment when control is good
    * (Passmedicine, British Thoracic Society)*
21
Q

Define chronic obstructive pulmonary disease (COPD)

A

Chronic inflammatory disease of the lungs involving airflow limitation, encompassing both emphysema and chronic bronchitis, which is primarily caused by cigarette smoking

(BMJ)

22
Q

Define chronic bronchitis

A

Chronic bronchitis is defined as a chronic productive cough for three months in each of two successive years in a patient in whom other causes of chronic cough (eg, bronchiectasis) have been excluded

(UpToDate)

23
Q

Define emphysema

A

Emphysema is a pathological term for structural changes in the lung involving abnormal and permanent enlargement of the airspaces distal to the terminal bronchioles that is accompanied by destruction of the airspace walls, without obvious fibrosis.

(UpToDate)

24
Q

Give risk factors for COPD

A

RFs:

  • strong: smoking, age, anti1ntitrypsin deficiency (panacinar emphysema, young onset)
  • weak: white, male, air pollution / occuptional exposure, low socioeconomic status, developmentally abnormal lung

(BMJ)

25
Q

Recognise the presenting symptoms of chronic obstructive pulmonary disease (COPD)

A

A diagnosis of COPD should be considered in patients over the age of 35 who have a risk factor (generally smoking) and who present with one or more of the following symptoms:

  • exertional breathlessness
  • chronic cough
  • regular sputum production
  • frequent winter ‘bronchitis’
  • wheeze

(NICE)

26
Q

Outline the MRC dyspnoea scale

A
  • Stage 1: SOB on strenuous exercise
  • Stage 2: SOB when hurrying or walking up a slight hill
  • Stage 3: Walks slower than contemporaries on level ground because SOB, or has to stop for breath when walking at own pace
  • Stage 4: SOB after ~100m or after a few minutes on level ground
  • Stage 5: Too breathless to leave the house, or SOB when dressing or undressing

(NICE)

27
Q

Identify appropriate investigations for chronic obstructive pulmonary disease (COPD)

A
  • Confirm diagnosis
    • Post-bronchodilator spirometry: FEV1/FVC <0.7 diagnostic
  • Exclude other pathologies
    • BMI
    • CXR: bullae, hyperexpansion, flat hemidiaphragm (+check for malignancy)
  • Assess complications:
    • Bloods: FBC (look for secondary polycythaemia, anaemia)
    • Infective exacerbation: O2 sats, sputum cultures
    • Cor pulmonale: ECG, echo, O2 sats

(NICE)

28
Q

Identify the possible complications of chronic obstructive pulmonary disease (COPD)

A

Early: polycythaemia, anaemia, pneumothorax, infective exacerbation –> acute respiratory failure

Late: Cor pulmonale (–> peripheral oedema, raised JVP, parasternal heave, loud P2)

(BMJ)

29
Q

What drugs can cause pulmonary fibrosis?

A

NITRO, AM I ME BRO?

  • nitrofurantoin
  • amiodarone
  • methotrexate
  • bromocriptine
30
Q

Generate a management plan for an infective exacerbation of COPD

A

IECOPD

  • Medical (ABCDE): SOSSI
    • Sit up
    • Oxygen 24%: venturi mask, aim for 88-92%
    • SABA (salbutamol 5mg, every 20 mins for 2h)
    • Steroid (prednisolone PO)
    • IV antibiotics (broad spectrum eg tazocin or vancomycin)
  • Consult senior about escalation:
    • NIV: if pH <7.35, pCO2 >6.5, RR >23
    • Intubation: severe hypoxia, irregular breathing, massive aspiration, arrest

(BMJ)

31
Q

Outline the classification of acute asthma severity

A

(BTS)

32
Q

Define asthma

A

A chronic inflammatory process involving generalised narrowing of the airways which causes episodic, reversible intrathoracic airway obstruction. Reversibility may be spontaneous or as a result of therapy. Can only be diagnosed from age of about 4.

33
Q

Explain the aetiology / risk factors of asthma

A

Atopy

RFs: FHx, atopy hx (eczema, hayfever), environmental triggers (infections, allergens, irritants)

34
Q

Identify appropriate investigations for asthma

A
  • Confirm diagnosis (4 ways)
    • Home peak flow monitoring – demonstrating variability with time
    • Assessing the response to inhaled bronchodilators – 15% change + >200mls increase in FEV1
    • Assessing response to trial inhaled/oral steroids (30mg/day 2 weeks) – 20% increase peak flow, or 15% increase + >200mls increase in FEV1
    • Positive exercise test – 6 mins free running. Record peak flow (or FEV1) pre-exercise, then at 2 min intervals for 20 mins after. Have bronchodilators available.
  • Any fall abnormal, 15% fall is diagnostic
  • Monitor - PEFR
  • In exacerbation: Obs + PEFR to assess severity

(Y5 notes)

35
Q

Generate a management plan for acute severe asthma

A

Acute severe exacerbation:

  • Medical (ABCDE) (SOSS+)
    • Sit Up
    • Oxygen 60% high flow
    • SABA (salbutamol 5mg) +/- ipratropium (nebulised, consider continuous)
    • Steroids (prednisolone 40mg PO)
      • Magnesium sulphate (1.2-2mg)
      • call ITU for aminophylline / ventilatory support

(Meeran)

36
Q

Identify the possible complications of asthma

A

Early: exacerbation, steroid-associated oral candidiasis

Late: airway remodeling (persistent inflammation –> chronic airway narrowing)

(BMJ)

37
Q

Give causes of a transudative (protein <30g/L) pleural effusion

A
  • Increased venous pressure:
    • cardiac failure
    • restrictive pericarditis
    • fluid overload
  • Hypoproteinaemia:
    • cirrhosis
    • nephrotic syndrome
    • malabsorption
  • Meig’s syndrome (ovarian fibroma + R-sided pleural effusion)

(500 SBAs)

38
Q

Give causes of an exudative (protein >30 g/L) pleural effusion

A
  • Malignancy (primary lung, secondary, lymphoma, mesothelioma)
  • Infection
    • Pneumonia
    • TB
  • Inflammation
    • SLE
    • RA
    • Bronchiectasis

(500 SBAs)

39
Q

Define bronchiectasis

A

Permanent dilatation of the bronchi and bronchioles due to chronic infection

(500 SBAs)

40
Q

Explain the aetiology of bronchiectasis

A
  • Congenital: ‘CKY’
    • Cystic fibrosis
    • Kartagner’s syndrome = primary ciliary dyskinesia (AutoR)
    • Young’s syndrome = bronchiectasis + rhinosinusitis + reduced fertility
  • Acquired
    • Infection: pneumonia, TB, bronchiolitis, aspergillus, measles
    • Bronchial obstructive: tumour

(500 SBAs)

41
Q

What is the triad in Young’s Syndrome? Cause?

A

Bronchiectastis + rhinosinusitis + reduced male fertility

Due to viscous mucus production, thought to be genetic

(500 SBAs)

42
Q

Identify the possible complications of bronchiectasis

A

Early: pneumonia, pneumothorax, pleural effusion

Late: massive haemoptysis, chronic respiratory failure, cor pulmonale

(rare: cerebral abscess, amyloidosis)
* (OHCM, BMJ)*

43
Q

Identify appropriate investigations for bronchiectasis

Completed?

A
  • Confirm diagnosis: CXR, HRCT, pulmonary function tests (reduced FEV1)
  • Assess cause / complications
    • Pneumonia: FBC, cultures (blood, sputum), CRP
    • CF: sweat test, CFTR test
    • Primary ciliary diskinesia: nasal nitric oxide

(BMJ)

44
Q

Generate a management plan for bronchiectasis

A
  • Conservative
    • pulmonary rehab, exercise (clears mucus), airway clearance therapy, vaccinations (flu, pneumococcal)
  • Medical (long-term)
    • SABA (salbultamol MDI)
    • nebulised hypertonic saline
    • Azithromycin (PO, long-term)
  • In exacerbation
      • additional antibiotic (eg amoxicillin in CAP, cipro in Psuedo)
      • supplemental O2
      • consider NIV
  • Surgery:
    • Resection of bronchiectatic areas: severe haemoptysis, severe TB / aspergillus
    • Lung transplant: severe disease (eg FEV1 <30%, ITU stay, recurrent pneumothorax)

(BMJ, OHCM)

45
Q

Outline causes of cor pulmonale

A

Cor pulmonale = right sided HF due to chronic pulmonary HTN

  • Lung disease: COPD, asthma, pulmonary fibrosis, bronchiectasis
  • Pulmonary vascular disease: PE, vasculitides
  • Neuromuscular: myasthenia gravis, MND
  • Thoracokyphoses

(500 SBAs)

46
Q

What are the 5 ways aspergillus can affect the lung?

A
  • Type 1 HR –> asthma
  • Allergic bronchopulmonary aspergillosis (ABPA) –> bronchiectasis
  • Aspergilloma (often in TB / sarcoid cavity)
  • Invassive aspergillosis (in HIV, immunocompromise)
  • Hypersensitive pneumonitis (Farmer’s lung, Malt worker’s lung)

Note - each different way is associated with a common accompanying disease

47
Q

Give risk factors for lung cancer

A

RFs:

  • Smoking: x10 risk
  • asbestos: x5 risk
  • chemical exposure: arsenic, radon, nickel, chromate, aromatic hydrocarbon
  • Idiopathic pulmonary fibrosis

(passmedicine)

Medicine Y6 (14 decks)

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