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Phase 4 > Respiratory > Flashcards

Respiratory Flashcards

1
Q

if you are aiming for sats of 88-92% what device is best used?

A

Venturi mask 28% at 5L/ min

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2
Q

What is the single best advice that can be given to help stop a pneumothorax reoccurring?

A

Stop smoking

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3
Q

If there is COPD symptoms in a young person, what should you think of?

A

Anti - Alpha 1 deficiency

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4
Q

What is the definition of a Hospital acquired Pneumonia and what are the most likely organisms?

A

> 48 hours after admission or <7 days after discharge.

Staph aureus
Pseudomonas
Klebsiella Bacteroides
Clostridia

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5
Q

Who are at risk of aspiration pneumonia?

A 
Stroke victims 
Myasthenia gravis bulbar palsies 
Low GCS 
Achalasia 
Poor dental hygiene patients
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6
Q

List some clinical signs you may expect on someone with pneumonia:

A 
Pyrexia 
Cyanosis 
Confusion 
Tachy/ pnoae/ cardia 
Signs of consolidation
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7
Q

What are some signs of consolidation?

A 
Reduced chest expansion 
Dull to percussion
Increased tactile fremitus 
Reduced breath sounds 
Bronchial breathing 
Pleural rub
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8
Q

What investigation should be carried out on suspected pneumonia?

A

Bloods

  • FBC
  • CRP
  • U&Es
  • ABG

Sputum cultures
+/- urine cultures (if history suggestive of legionella)

CXR

special tests:

  • pleural biopsy
  • Viral serology
  • Bronchoscopy
  • Bronchoalveolar lavage
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9
Q

What thing supercede the CURB 65 score when working out if a patient has severe pneumonia or not?

A

Respiratory Failure: Pa O2 <8

Spreading of the infection: Bilateral, multilobular

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10
Q

What types of pneumonia require serological antigen testing?

A

Chlamydophila Psittaci

Mycoplasma Pneumonia

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11
Q

If a young person develops pneumonia what is an important investigation to carry out and what is needed before doing it?

A

HIV test

Permission

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12
Q

Which pneumonia are alcoholics most likely to acquire?

A

Klebsiella Bacteroides

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13
Q

List some complications of pneumonia along with initial treatment:

A

Respiratory failure

  • 60% high flow
  • consider ITU if not improving of hypercapnia

AF
- treat

Hypotension
- give fluid challenge

Pleural effusion
- aspiration and Light’s criteria

Empyema
- drainage

Lung abscess
- drainage
- antibioitics for 4-6 weeks post drainage
+/- surgical intervetion

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14
Q

Which drug can trigger asthma?

A

Aspirin

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15
Q

What is the management of a P.E?

A

ABCDE

  • oxygen
  • Un-fractioned heparin - (5000 units medium, 10000 if large) - warfarin

If massive P.E/ clinical unstable:
- Alteplase 10mg IV followed by infusion

  • Warfarin and Enoxaparin together for first few days until INR >2. After which enoxaparin should be stopped
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16
Q

What test can be performed to establish if a person has had/ has TB? what kind of results are there and what may cause false negatives?

A

Mantoux test/ Tuberculin Skin testing
<6mm diameter - never been in contact
6-15mm - suggests previous exposure/ or vaccinated
>15mm - active infection

False Negatives include:

  • <6 months
  • HIV
  • miliary TB
  • Sarcoidosis
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17
Q

What vaccine can be given to patients with TB?

A

BCG vaccine
- live attenuated mycobacterium bovis

also provides some immunity against leprosy

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18
Q

What are some features of hypercapnia?

A
  • Headache
    • Peripheral dilation - facial flushing/ Malory rash
    • Tachycardia
    • Bounding pulse
    • CO2 retention flap
    • Confusion
    • Reduced GCS / Coma
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19
Q

What is considered severe hypoxia?

A

<6.7kPa

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20
Q

What investigations can be done into asthma? and what findings would suggests asthma?

A

PEEK Flow diary
- diurnal variation >20% on >3days/week over 2 weeks

Histamine provocation test
- >20% drop on FEV1 from baseline

Spirometry
- >15% reversibility on FEV1/FVC

Scratch Test

Sputum
- eosinophils

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21
Q

What are the differentials for asthma?

A

COPD

Pulmonary Oedema (cardiac asthma) - polyphonic wheeze

SVC obstruction

Bronchiectasis

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22
Q

Contrast COPD and asthma:

A

COPD:

  • smokers
  • rare <35 years
  • Chronic cough is common
  • Persistent shortness of breath
  • Night symptoms are uncommon
  • variability in symptoms is minimal

Asthma is the opposite to all these.

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23
Q

Outwith medicines, name some important factors in managing asthma:

A

Quit smoking

Avoid triggers

Weight loss

Good inhaler technique

Twice daily PEF recordings

Training and understanding regarding what to do in emergencies

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24
Q

What is the difference between obstructive sleep apnoea and obstructive sleep apnoea syndrome?

A

Obstructive sleep apnoea syndrome is the associated daytime symptoms as well

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25
Q

What is the criteria for obstructive sleep apnea?

A

A decrease in 4% sats over >10seconds (apneaic episode)
+
>15 episodes an hour
or
>5 episodes an hour with significant day time solmenace

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26
Q

When stepping down asthma treatment, when should medications etc be reviewed and what targets are recommended?

A

Review 3 monthly.

Step down aim for 25-50% reduction in ICS

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27
Q

What assessments and investigations should be done into sleep apnea?

A

Referral to ENT:

History from partner

Mallampati score

Clinical examination - neck size, BMI, Craniofacial appearance

Investigations:
- polysomnography

  • Transcutaneous Oxygen saturations and Carbon Dioxide Assessment (TOSCA)
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28
Q

What does polysomnography all entail?

A 
Oxygen saturation 
airflow through nose and mouth 
ECG 
EMG of chest muscles 
Abdominal wall movement 
Audio 
Video
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29
Q

What are the differentials for sleep Apnea?

A

Hypopnea
- reduced flow but does not meet criteria

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30
Q

What is the major complication of sleep apnoea?

A

Hypertension

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31
Q

What is the management of sleep Apnoea?

A

Weight reduction

Avoidance of alcohol before bed

Mandibular adjustment device

CPAP

Surgery
- to relieve pharyngeal obstruction

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32
Q

What mutations are commonly attributed to lung cancer?

A

p53
EML4 - ALK (non- small cell)
KRAS
PDL-1

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33
Q

What are some complications of lung cancer?

A

Recurrent Laryngeal nerve palsy

Superior vena cava obstruction

Horner’s syndrome

Pericarditis

Pleural effusion

Paraneoplastic syndromes

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34
Q

What are the paraneoplastic syndromes of lung cancer?

A

SIADH
- small cell

Cushing’s syndrome ectopic ACTH
- small cell

Hypercalcemia - PTHrP
- Squamous cell

Eaton Lambort Syndrome

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35
Q

What might you see on a CXR of lung cancer?

A

Consolidation
Hilar mass
Pleural effusion
Atelectasis - lung collapse

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36
Q

What investigations should be done into suspected lung cancer?

A

CXR

  • lateral
  • PA

Bronchoscopy with endobronchial ultrasound

  • to assess the lesion
  • to take biopsy

Cytology

  • sputum
  • bronchial wash

PET -CT
- for metastasis spread

CT

  • thorax
  • abdomen
  • pelvis
  • assess for metastasis

Radionucleotide Bone scan

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37
Q

What are the different types of lung cancer in order of their prevalence and name the cell they derive from?

A

Squamous cell
- metaplastic squamous cells

Adenocarcinoma
- Goblet cells

Small cell
- neuroendocrine

Large cell

Anaplastic
- neuroendocrine

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38
Q

What things must be taken into consideration first before carrying out treatment for lung cancer?

A

Before carrying out treatment the functioning of:
- heart
- lungs (remaining lung)
need to be considered as there is a likely chance there is going to be a lobectomy

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39
Q

What is the treatment for Small cell lung cancer?

A

Chemotherapy + radiotherapy

Palliative radiotherapy for complications such as bone pain, obstruction
+
stenting of bronchi

Analgesics
Bronchodilators
cough linctus
antidepressants

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40
Q

What is the treatment for Non- small cell lung cancer?

A

Lobectomy
- often performed using Video Assisted thoracoscopic Surgery (VATS) *leaves 3 small scars

Radiotherapy + chemotherapy for more advanced cancer
(usually platinum based)

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41
Q

List some causes of exudative pleural effusions:

A

Infection
Malignancy
Autoimmune
Pancreatitis

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42
Q

What investigations should be done into a pleural effusion?

A

Diagnostic tap:
- microscopy and culture

Cytology

pH (<7.2 indication for chest drain)

LDH

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43
Q

What is a serious cause of pleural effusion that can follow after excessive vomiting or endoscopy that can be fatal?

A

Boerhaave’s syndrome

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44
Q

What is the investigation of choice into idiopathic pulmonary fibrosis?

A

High resolution CT scan

45
Q

What has been shown to improve survival in patients with COPD and when should it be offered?

A

Long term Oxygen therapy (LTOT)

When stopped smoking and oxygen <7.3 kPa

46
Q

What does COPD have to include?

A

• Chronic Bronchitis
- Production of sputum on most days, for least 3 months in at least 2 years.
+
• Emphysema
Permanent enlargement of airspaces distal to bronchioles

47
Q

What is needed for the diagnosis of COPD?

A

FEV1 <80%
FEV1/ FVC ratio <0.7

with little no reversibility (<400ml or 15%)

48
Q

Why are blue bloaters called blue bloaters?

A

Hypercapnia - inducing the blue tinge

Hypoxic pulmonary vasoconstriction induces cor pulmonale

49
Q

Radiologically what types of pneumonia and can be seen and what are they most associated with?

A

Lobar pneumonia
- strep pneumonia

Bronchial Pneumonia

  • H. Influenzae
  • moraxella
  • usually superimposed on COPD

Interstitial Pneumonia
- spreads throughout the interstitium

50
Q

What are the differentials for pneumonia?

A

Acute Bronchitis

Heart failure

Lung cancer

Asthma/ COPD

Bronchiectasis

51
Q

What drugs are not recommended for COPD?

A

Mucolytics

52
Q

Which disease may cause a rash over the face called lupus perinco?

A

Sarcoidosis

53
Q

What signs may be seen on xray in a pleural effusion?

A

Blunting of costa phrenic angles

Fluids in fissures

Meniscus sign

Tracheal deviation
- away from affected side

54
Q

What are the key diagnostic tests for asthma?

A

Spirometry with beta reversibility

Fraction exhaled NO

Histamine provocation

PEAK flow diary
- 20% variation, >3 days for 2 weeks

55
Q

What can be done to increase mucus production?

A

Chest Physiotherapy

Sodium Chloride

Carbocysteine

56
Q

What is the screening test for sarcoidosis and what is the definitive test?

A

Blood ACE levels is screening

Biopsy is definitive
- non caseating granulomatous epithelioid cells

57
Q

What is the common skin manifestations of sarcoidosis?

A

Lupus Pernio

Erythema nodosum

58
Q

What is the treatment of sarcoidosis?

A
  • majority spontaneously remissive
  • steroids

More advance:

  • methotrexate
  • azathioprine

Lung transplant

59
Q

Following severe COPD exacerbation - the patient has been given aminophylline and is not able to be intubated, what drug can be given?

A

Doxapram

- respiratory stimulator

60
Q

What are the severities of COPD?

A

Based on FEV1

Mild >80
moderate 50-80
Severe 30-50
Very Severe <30 or <50 + respiratory failure

61
Q

When is long term oxygen therapy given for COPD?

A

<7.3kPa

62
Q

Which conditions tend to cause pulmonary fibrosis in the upper lobes?

A

CHARTS

  • Coal miners
  • hypersensitivity
  • Ankylosing spondylitis
  • Radiation
  • TB
  • Sarcoidosis
63
Q

For exacerbations of COPD what is the most appropriate NIV to put patients on?

A

Bi PAP

64
Q

What is the markers for light’s criteria?

A

Protein > 30g/L
Pleural protein: serum protein >0.5
Pleural LDH: serum LDH >0.6

65
Q

What is the single most important intervention to increase survival in COPD?

A

Stop smoking

66
Q

What investigations should be done into a pleural effusion sample?

A

Gross appearance

Cytology

Clinical biochemistry
- Lights criteria

Immunology

67
Q

Which drugs should be withheld during C.Diff?

A

Anti-motility drugs

  • opioids
  • loperamide
  • predispose to toxic megacolon

PPIs

68
Q

At which blood pH should invasive intubation be considered?

A

<7.25

between 7.25- 7.35 are the optimal zone for non-invasive ventilation

69
Q

List some devices used for NIV?

A

Nasal

Face mask

Bilevel positive airway pressure - BiPAP

70
Q

What is the management for a recurrent pleural effusion?

A

pleurodesis

Indwelling pleural catheter

Drug management to control dyspnoea

71
Q

In smoking terms what is a 1 pack year defined as?

A

20 Cigarettes daily for 1 year

72
Q

What are the indications of life threatening asthma attack?

A

PEFR <33%
Sats <92%
Low GCS
Chest hyporesonance

Normal PaCO2

73
Q

What are the signs of severe asthma attack?

A

Can’t complete sentences
33-55% PEFR
Tachy >110bpm
Tachypneic >25

74
Q

What features would support a steroid response for COPD patients?

A

Atopy/ Asthmatic features

  • raised eosinophils
  • variation in Peak Flows - 20%
  • variation of FEV1
75
Q

Which pneumonia causes bilateral cavitating lesions on x-ray? and who is it most commonly seen in?

A

Klebsiella pneumonia

  • alcoholics
  • diabetic patients
76
Q

Who should be informed when there is a diagnosis of obstructive sleep apnea?

A

DVLA

77
Q

What is the management of IPF?

A

Pulmonary rehabilitation
Oxygen therapy
Pirfenidone - antifibrotic agent
Lung transplant

78
Q

What are the type biopsy results of IPF? and what histological findings?

A

usual interstitial Pneumonia pattern

Temporal heterogeneity
Fibroblastic Foci

79
Q

What is the management for atelectasis following surgery?

A

Respiratory physiotherapy

80
Q

What are the common causes of hypersensitivity pneumonitis?

A

Bird Fanciers Lung - avian proteins

Malt workers lung - Aspergillus clavatus

Farmers lung - Saccharopolyspora Rectivirgula

81
Q

When is NIV indicated in exacerbation of COPD?

A

When patient fails to respond to initial treatment

pH <7.35
paCO2 >6

usually need to be admitted to HDU

82
Q

What is an important history to take from someone with as asthma attack that my influence your management of them?

A

If they have been previously admitted due to an asthma attack and if it was severe. did they end up in ICU

What their normal PEF is

Do they have allergies - penicillin?

What are their usual meds and how well controlled?

Recent illness? - underlying cause?

Prior chest pain - pneumothorax?

83
Q

What is the management of a >50 year old patient with significant smoking history who present with a pneumothorax 1-2cm?

A

Aspiration.
if not resolved pleural drain

If resolved High Flow oxygen

84
Q

What is the management of a young male with no underlying lung disease who presents with a pneumothorax <2cm?

A

Discharge and review 2-4 weeks so long as there is no adverse features.

85
Q

Clinical findings of pneumothorax?

A 
Increased resonance to percussion 
Reduced breath sounds 
Reduced chest expansion 
Reduced tactile fremitus
\+/- 
tracheal deviation 
\+/- 
Diaphragmatic movement - up in non tension, down in tension
86
Q

What are the signs and symptoms of a tension pneumothorax?

A 
Hypotension 
Distended neck veins 
reduced chest expansion 
Tracheal deviation 
Hyperresonance to percussion
87
Q

What are the landmarks for the “safe triangle” in placing a chest drain?

A

Posterior body of the pectoralis (anterior border)
Anterior of the Lat dorsi (posterior border)
line across from nipple (inferior border)
Axillar (superior border)

88
Q

How is a tension pneumothorax managed?

A

100% oxygen

Large bore cannula into either:

  • 2nd intercostal space midclavicular line
  • safe triangle

*keep the cannula in

Insert chest drain

89
Q

What investigations should be done into pneumonia?

A

Bloods:

  • FBC
  • U&Es
  • CRP
  • ABG
  • Blood cultures if moderate to severe pneumonia

Orifices:

  • Sputum samples
  • Urine samples - legionella

X-ray:
- CXR

90
Q

When can someone with pneumonia be discharged?

A 
Off oxygen 
Oral antibiotics 
CRP falling 
Apyrexial 
RR <24 
HR <100 
BP>90mmHg

6 week CXR

Smoking advice

91
Q

Which CURB score is admitted? and what is the antibiotic choice?

A

CURB 2

92
Q

What is the general management of pneumonia?

A

CURB 1: PO antibiotics

CURB >2:

  • IV antibiotics
  • Oxygen
  • Fluids
  • VTE prophylaxis
  • Analgesia is pleuritic chest pain
  • Chest physiotherapy
  • Anti- mucolytics

CURB 3:
- consider ICU admission especially if hypercapnia or hypoxia remains

93
Q

Which pneumonia typically comes from birds?

A

Chlamydia Psittaci

  • Flu symptoms before hand + D&V
  • Dry cough
94
Q

What is the antibiotic management for CURB 3?

A

Clarithromycin
+
Amoxicillin

or if in HDU/ ICU:

IV co- amoxiclav

95
Q

If a person has a CURB score of > 3 and sepsis and is penicillin allergic what antibiotic should they receive?

A

Levofloxacin

96
Q

If a person develops HAP and has no sepsis what is the best antibiotic to prescribe?

A

Doxycycline

97
Q

If a person develops HAP and has sepsis what is the best antibiotic to prescribe?
i.e. CURB >3

A

Amoxicillin
+
Gentamicin

98
Q

What is the antibiotics for aspiration pneumonia?

A

Metronidazole
+
Amoxicillin

99
Q

In the emergency situation of stridor what should the initial management be?

A

Contact ICU
Contact anaesthetist

ABCDE

  • High flow oxygen
  • Dexamethasone
  • Nebulised salbutamol

Options needed to be considered:

  • tracheostomy
  • nebulised adrenaline
100
Q

What is the long term management of COPD?

A

1st line: SABA or SAMA

Establish if asthma symptoms: 
2nd 
LABA+ LAMA 
or 
LABA + ICS + LAMA

3rd
Oral theophylline
+/-
Macrolides

Long term O2 therapy

  • <7.3kPa
  • Pulmonary hypertension
  • terminally ill
  • yearly flu vaccine
  • smoking
  • chest physio
101
Q

What are some other measures to improve target SaO2?

A

Chest physiotherapy

Adequate Hb - treat anaemia

Improve cardiac output

102
Q

What are some causes of ARDS?

A

Pneumonia
Sepsis
Pancreatitis
Trauma

103
Q

How is ARDS diagnosed and what is the management?

A

Acute onset within 1 week of risk factor
Bilateral pulmonary oedema
Bilateral pulmonary infiltrates

ICU 
Ventilation 
General organ support 
Antibiotics 
Prone positioning
104
Q

What should the PaO2 be in comparison to SiO2?

A

-10 of it.

therefore SiO2 of 30% you would expect PaO2 of 20

105
Q

What are some complications of asthma?

A 
Respiratory failure 
Lobar collapse 
Pneumothorax
side effects from treatment 
- tachy 
- tremor 
- Hypokalemia
Fatigue
106
Q

What are the causes of bronchiectasis?

A

Congenital

  • CF
  • Ciliary dysfunction

Acquired:

  • pneumonia
  • TB
  • Aspergillosis
107
Q

How is Bronchiectasis investigated and what are the treatments?

A

High resolution CT scan
Spirometry
Sputum sample

Analysis for primary congenital disease
- primary ciliary dysmotility

Management:

  • prevent complications - antibiotics, vaccines
  • Bronchodilators
  • ICS
  • Chest physiotherapy
  • breathing exercises - autogenic drainage

surgical procedures
- resection

108
Q

How is Mycoplasma investigated?

A

Mycoplasma serology

Positive cold agglutinin test

109
Q

When would you carry out a CXR on an exacerbation of asthma?

A

Suspicion of infectious causes

Life threatening

Unresponsive to treatment

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