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General Medicine > Respiratory > Flashcards

Respiratory Flashcards

1
Q

Asthma | Clinical features & Investigations

A

Intermittent SOB, wheeze, nocturnal cough, chest tightness
Diurnal variation
Response to exercise, allergens, cold air, viral RTI
Disturbed sleep, PMH/FH atopy, occupational exposure
Days off/week from school/work
Adults triggered by NSAIDs, beta-blockers

Spirometry FEV1/FVC <70%
Variable PEF (worse in AM)
Bronchodilator reversibility
Eosinophilia
Serum IgE
FeNO
ABG in acute exacerbations
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2
Q

Asthma | Severity & Management
Acute
Follow up
Chronic

A

Moderate; PEFR 50-75% best/predicted, RR 25
Severe; PEFR 33-50%, RR >25, HR >110, inability to complete sentences in one breath, accessory muscle use, inability to feed, SpO2 >92%
Life-threatening; PEFR <33%, SpO2 <92%, silent chest, cyanosis, poor respiratory effort
Altered consciousness, confusion, exhaustion, coma
Arrhythmia, hypotension

[Acute]
15L oxygen via non-rebreathe mask, target sats 94-98%
Nebulised salbutamol 5mg with oxygen
PO prednisolone 40mg/IV hydrocortisone 100mg
Monitor PEFR, repeat nebs
(+ ipratropium)
Monitor ECG for arrhythmias; salb causing IC shift of K, hypokalaemia, TdP
(+ IV Mg sulfate)
(ICU for ventilatory support)

[Follow up]
Review by GP within 48hrs d/c
Review sx and PEFR
Check inhaler technique
Address triggers; exercise, smoking
Vaccinations
Safety net to recognise poor asthma control; worsening symptoms, PEF readings, increased SABA use
Personalised written management plan
Consider rescue pack steroids
Consider referral to specialist if 2x attacks within 1yr

[Chronic]

  1. Low-dose ICS (beclometasone)
    • LABA (combined)
  3. Medium-dose ICS/LABA + LTRA/LAMA/theophylline
  4. High-dose ICS/LABA + X + Y /(oral beta-agonist)
  5. High-dose ICS/LABA + oral prednisolone

Consider step up in therapy if using SABA inhaler 3x/week

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3
Q

COPD | Clinical features & Investigations

A

Cough, sputum, SOB, wheeze
Signs; accessory muscles, hyperinflation, reduced cricosternal distance (<3cm), reduced chest expansion, hyperresonant percussion, quiet breath sounds, polycythaemia, cor pulmonale

CXR; hyperinflation, flat hemidiaphragms, bullae
CT; bronchial wall thickening, scarring, air space enlargement
ECG; (RA enlargement) P pulmonale, (RVH) cor pulmonale, right axis deviation, PR/ST depression (atrial depolarisation), low voltage QRS complexes
ABG; low O2 (+ high CO2)
Spirometry
Alpha1-antitrypsin deficiency; age <40yrs, smoking hx <10pkyrs

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4
Q

COPD | Management

Long-term oxygen therapy (LTOT)

Complications

A
  1. SABA (continued throughout)

[FEV1 >50%]

    • LABA / + LAMA
  2. ICS/LABA
  3. ICS/LABA + LAMA

[FEV1 <50%]

    • ICS/LABA / + LAMA
  2. ICS/LABA + LAMA

Consider LTOT if SpO2 <92% on RA, non-smokers
NIV; T2RF BiPAP if no medical response in acute exacerbations

Secondary PTX from bullous disease, particularly during air travel

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5
Q

Pneumonia | Aetiology & Clinical features

A

CAP; Strep. pneumoniae (pneumococcus), H. influenzae
HAP; >48hrs after admission, Staph. aureus
Viral; influenza
Immunocompromised; PCP, Staph. aureus

Fever, SOB, cough, purulent sputum, haemoptysis, pleuritic pain, dull percussion, increased vocal resonance, bronchial breathing, pleural rub, confusion

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6
Q

Pneumonia | Diagnosis & Management

CAP
HAP

Complications

A

CURB-65
Score 0-1; PO abx, Tx at home
Score >2; IV abx, Tx in hospital

[CAP]
Amoxicillin 500mg-1g
Clarithromycin 500mg
Doxycycline 200mg

[HAP]
Co-amoxiclav
Levofloxacin

Resp failure, hypotension, AF, pleural effusion, empyema, lung abscess

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7
Q

Bronchiectasis | Clinical features, Investigations & Management

A

[Aetiology]
CF, bronchiolitis, TB, pneumonia, IBD, RA

Persistent cough, copious purulent sputum, intermittent haemoptysis, SOB, fatigue, recurrent LRTI, sinusitis, cough incontinence

Sputum culture
CXR
HRCT* diagnostic
Spirometry (obstructive)
(Bronchoscopy)
(CF sweat test)
[Management]
Chest physiotherapy
Abx
Mucolytics
Nebulised saline
Pulmonary rehabilitation; physical exercise programme for people with lung conditions
Vaccinations
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8
Q

Lung Cancer | Clinical features, Investigations & Classification

Poor prognosis; 5yr survival for lung and mesothelioma <10%

RFs
Complications
Management

A

Cough, SOB, haemoptysis, chest pain, weight loss, loss of appetite, fatigue
Signs; clubbing, lymphadenopathy (cervical/supraclavicular),
DVT, effusion
Persistent/recurrent chest infection
Mets to bone/brain

CXR
CT thorax
Biopsy via bronchoscopy
(Sputum cytology)

RFs; smoking, asbestos, chemicals

Bronchial carcinoma, 95%
Malignant mesothelioma, asbestos-related pleural cancer

[NSCLC]
Squamous cell, 40%
Adenocarcinoma (non-smokers), 30%
Large cell, 10%

[SCLC] 20-30%
Often secrete hormones, resulting in paraneoplastic syndromes (ACTH, Cushing’s, SIADH)

[Complications]
Horner's syndrome
RLN palsy
SVC obstruction
Lambert-Eaton syndrome

[Management]
NSCLC; lobectomy, chemotherapy, radiotherapy
SCLC; chemotherapy, radiotherapy, ?surgery
Pleural drainage/pleurodesis

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9
Q

Pneumothorax | Aetiology & Clinical features

A

Spontaneous; (young, tall, slim men) rupture of sub pleural bulla
Secondary; asthma, COPD, trauma, pneumonia, lung abscess, IPF, CF, CTD, sarcoidosis

Symptoms; collapse, sudden-onset pleuritic pain, SOB

Signs; reduced chest wall movement/expansion, reduced breath sounds, reduced vocal fremitus, hyperresonance
Tension; tracheal deviation away, shock

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10
Q

Pneumothorax | Management

Primary
Secondary

Advice

A

[Primary]
1. SOB &/ air >2cm CXR
2. Yes; aspirate in 2nd ICS MCL above rib, up to 2L
3. If improvement, chest drain 5th ICS MAL above rib
4. If no; review in 2-4/52
Small will spontaneously resolve

[Secondary]

  1. SOB / air >2cm CXR
  2. Yes; chest drain
  3. If no; 1-2cm, aspirate if >1cm then chest drain if no improvement
  4. If <1cm; admit for 24hr observation + oxygen
  5. If no; admit for 24hr observation + high flow oxygen

[Advice]
Avoid flying for 6/52
Unable to go diving

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11
Q

PE | Clinical features, Investigations & Management

RFs
Long-term

A

Symptoms; acute onset SOB, pleuritic pain, cough, haemoptysis
Severe; dizziness, syncope
Signs; hypoxia, tachypnoea, crackles, tachycardia, DVT signs

RFs; immobilisation, surgery, active cancer, obesity, prolonged travel, previous DVT, DVT sx, FH

Wells score <4, D-dimer
D-dimer +ve, CTPA/Tx LMWH

Wells score >4, CTPA/Tx LMWH

[Long-term]
LMWH until target INR 2.5
Unprovoked; oral anticoagulation 3/12, warfarin/rivaroxaban
Provoked; oral anticoagulation >3/12

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12
Q

COPD | Acute Exacerbation

Clinical features
Investigations
Management
Follow-up

A

Acute confusion, reduced ET/ADLs, increased SOB, use of accessory muscles, hypoxia/cyanosis, peripheral oedema
IE; cough, mucopurulent sputum, fever

FBC, CRP, ABG, sputum culture, blood cultures
CXR; to r/o CAP

[Management]
Oxygen 24-28% Venturi mask 4L/min, titrate as needed to target sats (T2RF 88-92%)
SABA/SAMA back-to-back nebs
Oral prednisolone
Oral abx; amox/doxy/clari for 5/7
NIV; BiPAP

[Follow up]
Review in 6/52

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13
Q

Pleural Effusion | Aetiology, Clinical features & Management

A

Transudate; HF, fluid overload, hypoalbuminaemia (cirrhosis, nephrotic syndrome)
Exudate; infection (pneumonia, TB, empyema), inflammation (RA, SLE), malignancy

Signs; decreased expansion, stony dull percussion, diminished breath sounds, reduced vocal resonance/fremitus
Severe; tracheal deviation away

[Investigations]
?USS
CXR; blunting of costophrenic angles, dense opacity with meniscus fluid level
Diagnostic pleural tap
Pleural fluid analysis; Light’s criteria (protein, glucose, pH, lactate, M&C, cytology, immunology)

[Management]
Pleural tap/thoracentesis
Chest drain; fluid best removed slowly 0.5-1.5L/24hrs, empyema
Pleurodesis; for recurrent effusions

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14
Q

Cor pulmonale | Aetiology, Clinical features, Investigations & Management

A

RHF caused by chronic pulmonary HTN secondary to chronic lung disease (most commonly)

Symptoms; SOB, syncope, fatigue
Signs; cyanosis, tachycardia, raised JVP with prominent a/v waves, RV heave, TR (pansystolic murmur), hepatomegaly, systemic oedema

[Investigations]
FBC; raised Hb/Hct polycythaemia
ABG; hypoxia +/- hypercapnia
ECG; P pulmonale, R axis deviation, RV hypertrophy/strain
CXR; enlarged RA/RV, prominent pulmonary arteries

[Management]
Tx underlying cause; COPD, LRTI
Tx RF; oxygen 24% Venturi mask if hypoxic
Tx HF; diuretics, monitor U&Es

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15
Q

Fungal | Aspergillosis

A
  1. Asthma; hypersensitivity, bronchoconstrictionreaction to fungal spores
  2. Allergic bronchopulmonary aspergillosis; recurrent bronchoconstriction then causes bronchiectasis
  3. Aspergilloma; fungus ball within a pre-existing cavity (TB/sarcoid), nodular apical opacity with cavitation
  4. Invasive aspergillosis; RF immunocompromised
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16
Q

Respiratory Failure | Aetiology & Management

CO2 retention

A

[T1RF] Low PaO2 <8kPa
Caused by ventilation/perfusion mismatch, hypoventilation
Eg. Pneumonia, pulmonary oedema, PE, asthma, IPF, ARDS
Tx; Oxygen 24-60%, CPAP

[T2RF] Low PaO2, high PaCO2 >6kPa
Caused by alveolar hypoventilation
Eg. COPD, asthma, pneumonia, OSA, CNS depression of respiratory drive, neuromuscular disease (GBS), kyphoscoliosis
Tx; Controlled oxygen 24%, BiPAP

Signs of CO2 retention; bounding pulse, flapping tremor, drowsy, headache

17
Q

Oxygen | Therapy

A

Nasal cannula; low flow rate 24-40% 1-4L, can maintain SpO2 in when nebs on RA in COPD

Venturi mask; high flow rate, controlled % (24, 28, 35, 40, 60), aim 24-28% in COPD
Non-rebreathe mask; high flow rate 60-90% 10-15L, emergencies

18
Q

ILD | Sarcoidosis

A

Granulomatous disorder commonly affecting skin, lung, eyes
Pulmonary infiltrates/fibrosis

Non-pulmonary features; fever, erythema nodosum, uveitis, polyarthraliga, lymphadenopathy (bilateral hilar, H&N)

Inv; CXR, FBC

[Management]
Corticosteroids; PO pred/IV methylpred
Immunosuppressants; MTX, HCQ, CYP

19
Q

Idiopathic Pulmonary Fibrosis | Clinical features, Investigations & Management

A

Symptoms; dry cough, SOBOE, weight loss, arthralgia, malaise
Signs; cyanosis, clubbing, fine end-inspiratory crackles ‘velcro’

Diagnostic HRCT; honeycombing late, increased reticulation (ground-glass, early)
CXR; reticulo-nodular shadows
Spirometry; restrictive
ABG, ANA, RF

[Management]
Supportive, palliative care
Lung transplantation

20
Q

Atelectasis |

A

Can be a post-op complication

[Management]
Chest physiotherapy and deep breathing exercises

General Medicine (7 decks)

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