Respiratory Flashcards
if you are aiming for sats of 88-92% what device is best used?
Venturi mask 28% at 5L/ min
What is the single best advice that can be given to help stop a pneumothorax reoccurring?
Stop smoking
If there is COPD symptoms in a young person, what should you think of?
Anti - Alpha 1 deficiency
What is the definition of a Hospital acquired Pneumonia and what are the most likely organisms?
> 48 hours after admission or <7 days after discharge.
Staph aureus
Pseudomonas
Klebsiella Bacteroides
Clostridia
Who are at risk of aspiration pneumonia?
Stroke victims Myasthenia gravis bulbar palsies Low GCS Achalasia Poor dental hygiene patients
List some clinical signs you may expect on someone with pneumonia:
Pyrexia Cyanosis Confusion Tachy/ pnoae/ cardia Signs of consolidation
What are some signs of consolidation?
Reduced chest expansion Dull to percussion Increased tactile fremitus Reduced breath sounds Bronchial breathing Pleural rub
What investigation should be carried out on suspected pneumonia?
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
What thing supercede the CURB 65 score when working out if a patient has severe pneumonia or not?
Respiratory Failure: Pa O2 <8
Spreading of the infection: Bilateral, multilobular
What types of pneumonia require serological antigen testing?
Chlamydophila Psittaci
Mycoplasma Pneumonia
If a young person develops pneumonia what is an important investigation to carry out and what is needed before doing it?
HIV test
Permission
Which pneumonia are alcoholics most likely to acquire?
Klebsiella Bacteroides
List some complications of pneumonia along with initial treatment:
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
Which drug can trigger asthma?
Aspirin
What is the management of a P.E?
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
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?
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
What vaccine can be given to patients with TB?
BCG vaccine
- live attenuated mycobacterium bovis
also provides some immunity against leprosy
What are some features of hypercapnia?
- Headache
- Peripheral dilation - facial flushing/ Malory rash
- Tachycardia
- Bounding pulse
- CO2 retention flap
- Confusion
- Reduced GCS / Coma
What is considered severe hypoxia?
<6.7kPa
What investigations can be done into asthma? and what findings would suggests asthma?
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
What are the differentials for asthma?
COPD
Pulmonary Oedema (cardiac asthma) - polyphonic wheeze
SVC obstruction
Bronchiectasis
Contrast COPD and asthma:
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.
Outwith medicines, name some important factors in managing asthma:
Quit smoking
Avoid triggers
Weight loss
Good inhaler technique
Twice daily PEF recordings
Training and understanding regarding what to do in emergencies
What is the difference between obstructive sleep apnoea and obstructive sleep apnoea syndrome?
Obstructive sleep apnoea syndrome is the associated daytime symptoms as well
What is the criteria for obstructive sleep apnea?
A decrease in 4% sats over >10seconds (apneaic episode)
+
>15 episodes an hour
or
>5 episodes an hour with significant day time solmenace
When stepping down asthma treatment, when should medications etc be reviewed and what targets are recommended?
Review 3 monthly.
Step down aim for 25-50% reduction in ICS
What assessments and investigations should be done into sleep apnea?
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)
What does polysomnography all entail?
Oxygen saturation airflow through nose and mouth ECG EMG of chest muscles Abdominal wall movement Audio Video
What are the differentials for sleep Apnea?
Hypopnea
- reduced flow but does not meet criteria
What is the major complication of sleep apnoea?
Hypertension
What is the management of sleep Apnoea?
Weight reduction
Avoidance of alcohol before bed
Mandibular adjustment device
CPAP
Surgery
- to relieve pharyngeal obstruction
What mutations are commonly attributed to lung cancer?
p53
EML4 - ALK (non- small cell)
KRAS
PDL-1
What are some complications of lung cancer?
Recurrent Laryngeal nerve palsy
Superior vena cava obstruction
Horner’s syndrome
Pericarditis
Pleural effusion
Paraneoplastic syndromes
What are the paraneoplastic syndromes of lung cancer?
SIADH
- small cell
Cushing’s syndrome ectopic ACTH
- small cell
Hypercalcemia - PTHrP
- Squamous cell
Eaton Lambort Syndrome
What might you see on a CXR of lung cancer?
Consolidation
Hilar mass
Pleural effusion
Atelectasis - lung collapse
What investigations should be done into suspected lung cancer?
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
What are the different types of lung cancer in order of their prevalence and name the cell they derive from?
Squamous cell
- metaplastic squamous cells
Adenocarcinoma
- Goblet cells
Small cell
- neuroendocrine
Large cell
Anaplastic
- neuroendocrine
What things must be taken into consideration first before carrying out treatment for lung cancer?
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
What is the treatment for Small cell lung cancer?
Chemotherapy + radiotherapy
Palliative radiotherapy for complications such as bone pain, obstruction
+
stenting of bronchi
Analgesics
Bronchodilators
cough linctus
antidepressants
What is the treatment for Non- small cell lung cancer?
Lobectomy
- often performed using Video Assisted thoracoscopic Surgery (VATS) *leaves 3 small scars
Radiotherapy + chemotherapy for more advanced cancer
(usually platinum based)
List some causes of exudative pleural effusions:
Infection
Malignancy
Autoimmune
Pancreatitis
What investigations should be done into a pleural effusion?
Diagnostic tap:
- microscopy and culture
Cytology
pH (<7.2 indication for chest drain)
LDH
What is a serious cause of pleural effusion that can follow after excessive vomiting or endoscopy that can be fatal?
Boerhaave’s syndrome
What is the investigation of choice into idiopathic pulmonary fibrosis?
High resolution CT scan
What has been shown to improve survival in patients with COPD and when should it be offered?
Long term Oxygen therapy (LTOT)
When stopped smoking and oxygen <7.3 kPa
What does COPD have to include?
• 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
What is needed for the diagnosis of COPD?
FEV1 <80%
FEV1/ FVC ratio <0.7
with little no reversibility (<400ml or 15%)
Why are blue bloaters called blue bloaters?
Hypercapnia - inducing the blue tinge
Hypoxic pulmonary vasoconstriction induces cor pulmonale
Radiologically what types of pneumonia and can be seen and what are they most associated with?
Lobar pneumonia
- strep pneumonia
Bronchial Pneumonia
- H. Influenzae
- moraxella
- usually superimposed on COPD
Interstitial Pneumonia
- spreads throughout the interstitium
What are the differentials for pneumonia?
Acute Bronchitis
Heart failure
Lung cancer
Asthma/ COPD
Bronchiectasis
What drugs are not recommended for COPD?
Mucolytics
Which disease may cause a rash over the face called lupus perinco?
Sarcoidosis
What signs may be seen on xray in a pleural effusion?
Blunting of costa phrenic angles
Fluids in fissures
Meniscus sign
Tracheal deviation
- away from affected side
What are the key diagnostic tests for asthma?
Spirometry with beta reversibility
Fraction exhaled NO
Histamine provocation
PEAK flow diary
- 20% variation, >3 days for 2 weeks
What can be done to increase mucus production?
Chest Physiotherapy
Sodium Chloride
Carbocysteine
What is the screening test for sarcoidosis and what is the definitive test?
Blood ACE levels is screening
Biopsy is definitive
- non caseating granulomatous epithelioid cells
What is the common skin manifestations of sarcoidosis?
Lupus Pernio
Erythema nodosum
What is the treatment of sarcoidosis?
- majority spontaneously remissive
- steroids
More advance:
- methotrexate
- azathioprine
Lung transplant
Following severe COPD exacerbation - the patient has been given aminophylline and is not able to be intubated, what drug can be given?
Doxapram
- respiratory stimulator
What are the severities of COPD?
Based on FEV1
Mild >80
moderate 50-80
Severe 30-50
Very Severe <30 or <50 + respiratory failure
When is long term oxygen therapy given for COPD?
<7.3kPa
Which conditions tend to cause pulmonary fibrosis in the upper lobes?
CHARTS
- Coal miners
- hypersensitivity
- Ankylosing spondylitis
- Radiation
- TB
- Sarcoidosis
For exacerbations of COPD what is the most appropriate NIV to put patients on?
Bi PAP
What is the markers for light’s criteria?
Protein > 30g/L
Pleural protein: serum protein >0.5
Pleural LDH: serum LDH >0.6
What is the single most important intervention to increase survival in COPD?
Stop smoking
What investigations should be done into a pleural effusion sample?
Gross appearance
Cytology
Clinical biochemistry
- Lights criteria
Immunology
Which drugs should be withheld during C.Diff?
Anti-motility drugs
- opioids
- loperamide
- predispose to toxic megacolon
PPIs
At which blood pH should invasive intubation be considered?
<7.25
between 7.25- 7.35 are the optimal zone for non-invasive ventilation
List some devices used for NIV?
Nasal
Face mask
Bilevel positive airway pressure - BiPAP
What is the management for a recurrent pleural effusion?
pleurodesis
Indwelling pleural catheter
Drug management to control dyspnoea
In smoking terms what is a 1 pack year defined as?
20 Cigarettes daily for 1 year
What are the indications of life threatening asthma attack?
PEFR <33%
Sats <92%
Low GCS
Chest hyporesonance
Normal PaCO2
What are the signs of severe asthma attack?
Can’t complete sentences
33-55% PEFR
Tachy >110bpm
Tachypneic >25
What features would support a steroid response for COPD patients?
Atopy/ Asthmatic features
- raised eosinophils
- variation in Peak Flows - 20%
- variation of FEV1
Which pneumonia causes bilateral cavitating lesions on x-ray? and who is it most commonly seen in?
Klebsiella pneumonia
- alcoholics
- diabetic patients
Who should be informed when there is a diagnosis of obstructive sleep apnea?
DVLA
What is the management of IPF?
Pulmonary rehabilitation
Oxygen therapy
Pirfenidone - antifibrotic agent
Lung transplant
What are the type biopsy results of IPF? and what histological findings?
usual interstitial Pneumonia pattern
Temporal heterogeneity
Fibroblastic Foci
What is the management for atelectasis following surgery?
Respiratory physiotherapy
What are the common causes of hypersensitivity pneumonitis?
Bird Fanciers Lung - avian proteins
Malt workers lung - Aspergillus clavatus
Farmers lung - Saccharopolyspora Rectivirgula
When is NIV indicated in exacerbation of COPD?
When patient fails to respond to initial treatment
pH <7.35
paCO2 >6
usually need to be admitted to HDU
What is an important history to take from someone with as asthma attack that my influence your management of them?
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?
What is the management of a >50 year old patient with significant smoking history who present with a pneumothorax 1-2cm?
Aspiration.
if not resolved pleural drain
If resolved High Flow oxygen
What is the management of a young male with no underlying lung disease who presents with a pneumothorax <2cm?
Discharge and review 2-4 weeks so long as there is no adverse features.
Clinical findings of pneumothorax?
Increased resonance to percussion Reduced breath sounds Reduced chest expansion Reduced tactile fremitus \+/- tracheal deviation \+/- Diaphragmatic movement - up in non tension, down in tension
What are the signs and symptoms of a tension pneumothorax?
Hypotension Distended neck veins reduced chest expansion Tracheal deviation Hyperresonance to percussion
What are the landmarks for the “safe triangle” in placing a chest drain?
Posterior body of the pectoralis (anterior border)
Anterior of the Lat dorsi (posterior border)
line across from nipple (inferior border)
Axillar (superior border)
How is a tension pneumothorax managed?
100% oxygen
Large bore cannula into either:
- 2nd intercostal space midclavicular line
- safe triangle
*keep the cannula in
Insert chest drain
What investigations should be done into pneumonia?
Bloods:
- FBC
- U&Es
- CRP
- ABG
- Blood cultures if moderate to severe pneumonia
Orifices:
- Sputum samples
- Urine samples - legionella
X-ray:
- CXR
When can someone with pneumonia be discharged?
Off oxygen Oral antibiotics CRP falling Apyrexial RR <24 HR <100 BP>90mmHg
6 week CXR
Smoking advice
Which CURB score is admitted? and what is the antibiotic choice?
CURB 2
What is the general management of pneumonia?
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
Which pneumonia typically comes from birds?
Chlamydia Psittaci
- Flu symptoms before hand + D&V
- Dry cough
What is the antibiotic management for CURB 3?
Clarithromycin
+
Amoxicillin
or if in HDU/ ICU:
IV co- amoxiclav
If a person has a CURB score of > 3 and sepsis and is penicillin allergic what antibiotic should they receive?
Levofloxacin
If a person develops HAP and has no sepsis what is the best antibiotic to prescribe?
Doxycycline
If a person develops HAP and has sepsis what is the best antibiotic to prescribe?
i.e. CURB >3
Amoxicillin
+
Gentamicin
What is the antibiotics for aspiration pneumonia?
Metronidazole
+
Amoxicillin
In the emergency situation of stridor what should the initial management be?
Contact ICU
Contact anaesthetist
ABCDE
- High flow oxygen
- Dexamethasone
- Nebulised salbutamol
Options needed to be considered:
- tracheostomy
- nebulised adrenaline
What is the long term management of COPD?
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
What are some other measures to improve target SaO2?
Chest physiotherapy
Adequate Hb - treat anaemia
Improve cardiac output
What are some causes of ARDS?
Pneumonia
Sepsis
Pancreatitis
Trauma
How is ARDS diagnosed and what is the management?
Acute onset within 1 week of risk factor
Bilateral pulmonary oedema
Bilateral pulmonary infiltrates
ICU Ventilation General organ support Antibiotics Prone positioning
What should the PaO2 be in comparison to SiO2?
-10 of it.
therefore SiO2 of 30% you would expect PaO2 of 20
What are some complications of asthma?
Respiratory failure Lobar collapse Pneumothorax side effects from treatment - tachy - tremor - Hypokalemia Fatigue
What are the causes of bronchiectasis?
Congenital
- CF
- Ciliary dysfunction
Acquired:
- pneumonia
- TB
- Aspergillosis
How is Bronchiectasis investigated and what are the treatments?
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
How is Mycoplasma investigated?
Mycoplasma serology
Positive cold agglutinin test
When would you carry out a CXR on an exacerbation of asthma?
Suspicion of infectious causes
Life threatening
Unresponsive to treatment
