respiratory Flashcards
1
Q
questions to ask about shortness of breath
A
onset, progression, duration, wheeze, chest tightness, diurnal variation, cough, haemoptysis, sputum, chest pain, night sweats, weight loss, oedema, exacerbating factors, distance they can walk, severity, change in QoL
2
Q
potential exacerbating factors of breathlessness
A
cold, air, flour, dust, URTI, occupation, allergies, medications (ask how they avoid these)
3
Q
questions to ask about sputum
A
colour, consistency, amount, onset, timing, diurnal variation, odour
4
Q
what would these sputum results suggest: rust, frothy pink, blood, odours
A
rust = pneumococcal pneumonia
frothy pink = pulmonary oedema
blood = malignancy
odours = bronchiectasis, lung abscess
5
Q
questions to ask about haemoptysis
A
origin, colour, quantity, consistency, sputum, weight loss, fever, night sweats, trauma, other bleeding
6
Q
drugs to ask about in respiratory history
A
nsaids, aspirin, inhalers, steroids, antibiotics, ace-i, amiodarone, BBs, O2
7
Q
specific family history questions in respiratory
A
allergic rhinitis, hay fever, eczema, asthma, lung cancer, family infections, CF, alpha-1-antitrypsin deficiency
8
Q
social history in respiratory
A
occupation, smoking, pets, travel, living conditions, alcohol, exercise, ADLs, indepedence
9
Q
if not a respiratory illness, what are the DDx
A
cardiac, gastro, msk, neuro
10
Q
Ddx of respiratory illness
A
PE, asthma, pulmonary fibrosis, CF, bronchiectasis, COPD, TB, lung cancer, sarcoidosis, pneumonia
11
Q
hand findings in resp exam
A
clubbing, tar stain, wasting of intrinsic muscles, flapping astrexis, fine tremor, pulses paradoxes, bounding pulse
12
Q
eye findings in resp exam
A
Horner’s, chemosis
13
Q
face findings in resp exam
A
facial swelling, central cyanosis, dental caries
14
Q
what is chemosis
A
conjunctival oedema in hypercapnia due to copd
15
Q
cause of raised JVP in resp
A
raised = cor pulmonate
raised and non pulsatile = SVCI
16
Q
chest inspect findings in resp exams
A
barrel chest, severe kyphoscoliosis, severe pectus excavatum, pectus carinatum, hamson’s sulci , recession, symmetry, scares, muscle wasting, accessory muscle
17
Q
what does tracheal and apex deviation mean
A
towards pulmonary fibrosis and collapse, away from tension pneumothorax or massive effusion
18
Q
4 things to do in palpate for resp
A
tracheal dev, apex dev, chest expansion, tactile vocal resonance
19
Q
results of vocal resonance
A
increased in consolidation
reduced in effusion or pneumothorax, is suspect consolidation - do whispering pectoriloquy
20
Q
what you could hear on auscultation
A
bronchial breathing, wheeze, crackles, crepitations, fine inspiratory crackles, coarse crackles, pleural rub
21
Q
what to do to complete resp exam
A
SPOT X sputum peak flow O2 sats temperature xray
lymph nodes and oedema
22
Q
CXR findings in pneumonia
A
opacification in a zone (if atypical = reticulonodular opacities)
23
Q
acute management of pneumonia
A
ABCDE
if SIRS = sepsis 6
CURB-65 score to see if admission needed
antibiotics
24
Q
causative organisms of CAP
A
streptococcus pneumonia, mycoplasma, haemophillus, staphlococcus aureus
25
atypical pneumonia organisms
mycoplasma, legionella, chlamydia
26
causative organisms of HAP
e.coli, klebsiella, pseudomonas, MRSA
27
type of pneumonia in: COPD, IVDU, alcoholics, hotels, bird fancier
h.influenza
s.aureus
klebsiella
legionella
chlamydia
28
CURB 65
```
confusion
urea >7
rr >30
BP <90/60
age >65
```
29
results of curb 65
```
0-1 = home
2 = hospital
3+ = ITU
```
30
auscultation of pneumonia
areas of consolidation, increased vocal resonance/whispering pectoriloquy, reduced air entry, crackles
31
investigations for pneumonia
```
SPOT X
sputum - culture
peak flow
o2 sats
temperature
xray chest - opacification (consolidation)
```
urine antigens for atypical
BAL and immuno-flourence for PCP, bloods
32
antibiotics for pneumonia
CAP - amoxicillin or co-amoxiclav with clarithromycin
HAP - co-amoxiclav, tazocin, vancomycin, gentamycin
33
complications of pneumonia
sepsis, res failure, hypotension, AF, lung abscess
34
symptoms of bronchiectasis
persistent cough and sputum for > 1 year, recurrent chest infections, wheeze
35
pathophysiology of bronchiectasis
chronic infection of bronchi leads to permanent dilation and thickened vessel wall and retained mucus as failed clearance - causing airway damage
36
common organisms in brochiectasis
h.influenzae, pseudomonas, strep pneumonia, staph aureus
37
symptoms of acute exacerbation of bronchiectasis
increased sputum, change in sputum colour/appearence, haemoptysis, SOB
38
investigations
```
SPOTX
sputum, peak flow (obstructive), O2 sats, temp, X-ray chest (tramlines and signet ring)
CT CT CT dilated and thickened airways
CF sweat test
aspergillum skin test
```
39
management of bronchiectasis
chest physio, Abx, bronchodilators nebs
40
causes of bronchiectasis
CF, post infection, hypogammaglobulinaemia, tumour, ABPA, autoimmune
41
CXR in CF
bronchiectasis
| thick dilated airways, tramlines, mucus plugs/fluid lines, signet ring, patchy shadowing
42
neonate presentation of CF
FTT, meconium ileus, rectal prolapse, chronic cough, increased appetite
FIBROSIS
FTT, ileus meconium, buttocks wasting, recurrent infection, polyps nasal, steatorrhoea
43
symptoms of CF
```
nose - polyps, sinusitis
resp - cough, wheeze, bronchiectasis (recurrent infections)
pancreas - steatorrhoea, DM
GI - gallstones, intestinal obstruction
fertility - infertility in men
```
44
pathophysiology of CF
AR - CFTR gene mutation, delta 508, leading to abnormal chloride channels so thick airway secretions, malabsorption, poor growth, pancreatic enzyme deficiency
45
screening for CF
carrier testing
antenatal test = amniocentesis and chronic villi samping
5 day heel prick test
46
counselling patients with CF
osteoporosis, infertility, clubbing, vasculitis, cor pulmonale, Segregation of patients with CF, reduced lifespan (40 years)
47
managing a child with CF
FAUVISM
- fat soluble vitamins (ADEK)
- antibiotics
- urodeoxycholic acid for impaired hepatic function
- vaccines (pneumococcal and flu)
- insulin
- salbutamol bronchodilators
- MDT
- pancreatic enzyme supplements (exocrine), mucolytics (neb DNAse), chest physiology, high calorie diet
48
diagnosing CF
sweat test, genetics, faecal elastase, immunotrypsinogen reactive test heel prick
49
investigations for CF
```
CXR, CT
spirometry - obstructive
aspergillum skin prick test
sputum MC+S
bloods
abdo US - fatty liver, cirrhosis, pancreatitis
```
50
what the child can do to help in CF
regular exercise to shift the mucus, increased calories needed, avoid smoking and pollution, make sure everyone in the house washes hands, leaflets, support groups, websites
51
what is an autosomal recessive disease in CF
25% of having a disease if both parents are carriers, could be a carrier
52
respiratory complications of CF
increased chest infections, wheeze, bronchiectasis, cough
53
gastro complications of CF
fatty liver, cirrhosis, gallstones, intestinal obstruction
54
CXR on pleural effusion
blunted costophrenic angles, opacification, tracheal and mediastinal deviation away meniscal level, dense shadow, at the bottom
55
difference between transudate and exudate pleural effusion
transudate has protein <25g/l due to increased hydrostatic and reduced oncotic forces
exudate has protein >35g/L due to increased capillary permeability
56
causes of transudate pleural effusion
stuff not in the lungs
| CCF, renal failure, liver failure, reduced albumin, hypothyroidism, meigs
57
causes of exudate pleural effusion
stuff happening in the lung
| infection, neoplasm, inflammation (CTD, RA, SLE), infarction, TB, pneumonia, abscess, pancreatitis
58
what is light's criteria
used when protein 25-35, takes into account protein and LDH
59
what would you find on examination of pleural effusion
reduced air entry, stony dull percussion, reduced vocal resonance, reduced chest expansion, bronchial breathing
60
investigations of pleural effusion
```
CXR
find the cause
bloods
US guided tap for diagnosis
send for protein, LDH, pH, glucose, amylase, bacteria, cytology, immunology
```
61
treatment of pleural effusion
treat the cause, avoid drainage if transudate
62
complication of pleural effusion
parapneumonic effusion and bronchopleural fistula
63
CXR in pneumothorax
absent lung markings to the periphery of one side, mediastinal shift away, evidence of cause, flat diaphragm
64
management of pneumothorax
depends on size and severity
- observe (asymptomatic, <2cm, no underlying lung disease)
- needle aspiration (primary but >2cm or symptomatic OR secondary 1-2cm)
- chest drain (failure to resolve after aspiration, unstable, secondary >2cm)
- needle decompression with large bore cannula and chest drain (tension)
65
examination findings of pneumothorax
reduced air entry, resonant percussion, reduced chest expansion, reduced breath sounds
66
risk factors of pneumothorax
primary = young thin male smokers = spontaneous
secondary = COPD, CTD, pulmonary fibrosis, sarcoidosis
trauma
iatrogenic = CVP line insertion, post aspiration
67
symptoms in tension pneumothorax
respiratory distress, cardiac arrest, mediastinal shift away, increased JVP, increased HR, low BP
68
investigations of pneumothorax
CXR, ABG, US (shouldn't CXR tension as emergency)
69
borders of chest drain
2nd ICS mid axillary line
70
causes of coin shaped lesion on CXR
foreign body, abscess, malignancy, granuloma (TB), structural
71
risk factors of lung cancer
occupation , FHx, smoking, abscess, COPD, male
72
red flags for lung cancer
weight loss, haemoptysis, hoarseness, Horner's, enlarged virchows node, paraneoplastic syndromes (hypercalcaemia, bone pain, gynaecomastia, flushing, hyponatraemia, bushings)
73
types of lung cancer
```
non small cell
small cell
squamous
adenocarcinoma
carcinoid
mesothelioma
pancoast (apex of lung)
```
74
lung symptoms to ask in lung cancer history
cough, haemoptysis, chest pain, dyspnoea, orthoptera, exertion dyspnoea, hoarseness, pleuritic chest pain
75
systemic symptoms to ask in lung cancer history
weight loss, anorexia, fever, anaemia, clubbing, lymphadenopathy
76
CXR in lung cancer
coin shaped lesions, pleural effusion, collapse, consolidation
77
symptoms of mets in lung cancer
```
bone = bone pain and pathological fractures
liver = hepatomegaly
brain = confusion
```
78
paraneoplastic syndrome of each lung cancer
squamous = hyperparathryodism, hypercalcaemia, bone pain
adenocarcinoma = gynaecomastia
carcinoid = flushing, wheeze, diarrhoea
small cell = SIADH (hyponatraemia) and Cushing's and Lambert Eaton syndrome
pancoats = corners and shoulder tip pain and hand wasting due to branchial plexus and T1 nerve involvement, SVCO
79
investigations in lung cancer
```
bloods
CXR
CT/MRI
luft
sputum
radio nucleotide bone scan
biopsy
```
80
treatment of lung cancer
chemo, surgery, radio, analgesia, drains, dexamethasone, stents, smoking cessation
81
local symptoms to ask in lung cancer history
recurrent laryngeal nerve palsy, phrenic nerve palsy, SVCO, horners, AF
82
which lung cancer is caused by smoking
squamous
83
which asbestos fibre causes mesothelioma
blue (crocidolite)
84
what will investigations show in mesothelioma
pleural thickening, pleural plaques, pleural mass, mediastinal enlargement, diaphragmatic plaques
85
treatment of mesothelioma
chemo, palliative, surgery, compensation
86
causes of haemoptysis
trauma, coagulation defect, malignancy, lung abscess, PE, bronchiectasis, bronchitis, TB, pneumonia, aspergillioma
87
occupational lung diseases
coal workers lung
silicosis (quarrying and sandblasting)
asbestosis (demolition, ship building)
pneumoconiosis
88
lung diseases caused by animal exposure
Extrinsic allergic alveolitis - bird fanciers lung, farm workers, malt workers lung
89
causes of lower lobe pulmonary fibrosis
```
STAIR
sarcoidosis
toxins - BANS ME = bleomycin, amiodarone, nitrofurotoin, sulfasalazine, methotrexate
asbestosis
interstitial pulmonary fibrosis
rheumatological
```
90
causes of upper lobe pulmonary fibrosis
```
A TEA SHOP
ABPA
TB
EAA
sarcoidosis
histiocytosis
occupational
pneumonitis
```
91
investigations in pulmonar fibrosis
HRCT = honeycombing, septal thinking
CXR - ground glass
lung biopsy = fibroblastic foci and interstitial fibrosis
LuFT - restrictive (reduced FEV, normal FEV1/FVC, reduced FVC, reduced total lung capacity)
reduced transfer factor
92
examination in pulmonary fibrosis
fine inspiratory crackles
93
treatment of pulmonary fibrosis
stop smoking, pulmonary rehab, O2 therapy, palliation,
in exacerbation, steroids and immunosuppression
monitor symptoms and lung function
lung transplant
94
describe FVC and FEV1
```
FVC = forced vital capacity
FEV1 = forced expiratory volume in 1 second
```
95
causes of restrictive lung disease
pulmonary fibrosis, asbestosis, sarcoidosis, ARDS, RDS, anky spon, obese, neuromuscular disorders
96
what is sarcoidosis
a multisystem non caseating granuloma disorder
97
symptoms of sarcoidosis
lungs - dyspnoea, cough
skin - erythema nodosum, lupus pernio
eyes - uveitis, photophobia, keratoconjunctivitis, sick/sjogrens
systemic - non tender lymph nodes, fatigue, weight loss, joint pain, hepatosplenomegaly, pituitary dysfunction, polyneuropathy, parotitis
98
CXR in sarcoidosis
bilateral hilar lymphadenopathy
99
tissue biopsy histopathological finding in sarcoidosis
non caseating granulomas
100
what to monitor in sarcoidosis
ophthalmology
bloods - ESR, serum ACE, Ig, LFTS, calcium
luft
CT/MRI
101
treatment of sarcoidosis
acute - NSAIDs, rest
| chronic - steroids (with PPI and bisphosphonates), immunosuppression
102
differentials of bilateral hilariously lymphadenopathy
```
TIMES
TB
idiopathic pulmonary fibrosis
malignancy
EAA
sarcoidosis
```
103
granuloma DDx
TB, leprosy, syphilis, PBC, GCA, PAN, wegeners, takaysus, chrons, sarcoidosis, EAA, silicosis
104
CXR pulmonary oedema
bat wing opacification
105
what is pulmonary oedema
accumulation of fluid in alveolar and parenchyma
106
cariogenic causes of pulmonary oedema
MI, arrhythmia, fluid overload (renal causes, fluid challenge)
107
non cardiogenic causes of pulmonary oedema
ARDS (sepsis, post op, trauma, pancreatitis), upper airway obstruction, head injury
108
symptoms of pulmonary oedema
orthopnoea, dyspnoea, pink frothy sputum
109
management of pulmonary oedema
```
ABCDE - o2, IV, ecg, bloods
diamorphine
metaclopramide
furosemide
GTN
investigate
dobutamine (inotrope) if shock
cpap
```
110
investigations in pulmonary oedema
bloods = FBC, U+E, troponin, BNP, ABG
CXR
ECG
ECHO
111
treatment of collapsed lung
ABCDE
| find and treat the cause (malignancy, mucus plugging)
112
life threatening chest injuries
```
ATOM FC
aortic/airway disruption
tension pneumothorax
open pneumothorax
massive haemothorax
flail chest
cardiac tamponade
```
113
extra pulmonary features associated with mycoplasma pneumonia
haemolytic anaemia, dry cough and erythema multiforme
114
symptoms of TB
cough >2 weeks, night sweats, fever, weight loss, haemoptysis, recent travel, enlarged lymph node, sputum, pleuritic chest pain
115
would MG be type 1 or 2 res failure
type 2
116
CXR of TB
upper lobe round caveating lesion
may also have consolidation, aviation, fibrosis, calcification
117
extrapulmonary symptoms of TB
LUTS, ascites, vertebral collapse, Potts vertebra, lupus vulgaris, peritoneal, Addison's, meningitis
118
extrapulmonary symptoms of TB
LUTS, ascites, vertebral collapse, Potts vertebra, lupus vulgaris, peritoneal, Addison's, meningitis, constrictive pericarditis
119
investigations of active TB
sputum sample x3 with one in the morning to look for acid fast bacilli with ziehl nelson stain on low stein jensen media
if sputum sample in suggestive, do CXR
120
investigations in latent TB
mantoux tuberculin test and IFN gamma release assay
121
what can give false positive on mantoux tuberculin test
previous immunisation, sarcoidosis, hodgkins lymphoma
122
treatment of TB
```
rifampicin
isonzaid
pyrazidamide
ethambutol
treat w/o culture if clinical picture looks like it
NOTIFY PUBLIC HEALTH
```
123
side effects of rifampicin
orange secretions and hepatotoxicity
124
side effects of isonzaid
peripheral neuropathy and hepatotoxicity
125
side effects of pyrazidamie
muscle weakness and arthralgia and hepatotoxicity
126
side effects of ethambutol
optic neuritis and hepatotoxicity
127
what should be monitored during TB treatment
FBC, LFTs, visual acuity, urate
128
prophylaxis of TB
rifampicin and isoniazid
129
how does rifampicin work
inhibits RNA polymerase abd DNA transcriptase
130
how does isonzid work
inhibits cell wall synths
131
how does pyrazmdamide work
disrupts fatty acid synthesis
132
organism in TB
mycobacterium tuberculosis
133
pathophysiology of TB
organism multiplys at pleural surface to create ghon focus macrophages take TB infection to lymph nodes to form Ghon complex, fibrosis of the complex leads to calcified nodule
134
explain asthma
airflow limitation due to a hyperresposiveness to stimuli which causing airway narrowing and hyper secretion in the airway lumen and inflammation of the bronchi, smooth muscle hypertrophy and thickened walls
135
difference of acute and chronic asthma
acute - igE antibodies cause mast cells to release histamine and cause bronchoconstriction, muscus plugs and mucosal swelling
chronic - Th2 cells release IL3/4/5 to cause inflammatory cell recruitment and airway remodelling
136
symptoms of asthma
wheeze, SOB, chest tightness, cough, diurnal (worse at night and early morning), exacerbates, atopy, reduced air entry, hyper inflated chest
137
precipitators of asthma
cold, exercise, stress, emotion, smoking, pollution, factories, URTI, dust mites, pollen, food, animals, fungus, occupation
138
investigations in asthma
SPOTX
sputum, peak flow, O2 sats, temp, X-ray chest (hyperinflation)
Bloods - eosinophilia, increased IgE, aspergillosis serology
LuFT - obstructive
peak flow - diurnal variation >20%, morning dip
atopy skin prick
histology
139
what does histology show in asthma
smooth muscle hypertrophy
increased mucosal goblet cells
airway remodelling
140
general day to day management of asthma
```
TAME
technique for inhaler - spacer
avoid precipitants
monitor with peak flow
educate
```
141
risk factor of childhood asthma
maternal smoking, viral infections during pregnancy, low birth weight, not breast fed, air pollution
142
how to use salbutamol depending on age in children
<3yrs - close fit mask
| >3yrs - inhaler and spacer
143
side effects of salbutamol
fine tremor, hypokalaemia, VF/VT
144
example of a low dose inhaled corticosteroid
beclomethosone
145
side effect of beclamethasone
oral candidiasis
146
example of a LTRA
montelukast
147
example of LABA
salmetrol
148
side effect of montelukast
headache and Gi disturbance, churg strauss
149
when to increase asthma treatment
having to use inhaler >3 times a week, symptomatic, worsening QoL, needing >6 puffs in one go
150
what should you always check in asthma management
are they being compliant with treatment
151
what medications should be avoided in asthma
Nsaids and BBs because they decrease prostaglandin and cause overproduction of pro-inflammatories
152
how does salbutamol work
leads to bronchial smooth muscle relaxation and bronchodilator
153
what should be monitored in salbutamol
potassium
154
when is montelukast used
a LRTA, for asthma (preventer), allergic rhinitis and aspirin induced asthma
155
montelukast interactions
increases anticoagulant effect of warfarin
156
questions in acute severe asthma attack
precipitants, usual treatment, compliance, previous attacks, ICU, best PEFR
157
when should you admit in asthma attack
life threatening symptoms, features of severe despite treatment
158
symptoms of moderate asthma attack
worsening symptoms, PEFR 50-75%
159
symptoms of severe asthma
PEFR <50%
RR >25
HR >110
can't complete sentences in single breath
160
symptoms of life threatening asthma
```
PEFR <33%, spo2 <92%, pao2 <8, pco2 >4.6
CHEST
cyanosis
hypotension
exhaustion
silent chest/poor respiratory effort
tachy/brady/arrythmias
```
161
treatment of asthma attack
```
sit up, 100% o2, 15L non rebreathe
salbutamol nebuliser every 15 minutes and monitor potassium with ECG
hydrocortisone
ipratropium bromide neb
theophylline IV
MgSo4 IV
salbuatmol IV
ITU for invasive ventilation
```
162
when can you discharge asthma attack
PEFR >75% within 1hr of Tx
| been stable on discharge meds for 24hrs
163
discharge plan for asthma attack
TAME - technique of inhaler, avoid precipitants, monitor PEFR, educate
steroids (5 days of prednisone)
GP appointment
resp clinic in 1 month
164
causes of wheeze in child
anaphylaxis, viral induced wheeze, broncholitis, asthma, inhaled foreign body, heart failure, GORD
165
additional diseases associated with asthma
cows milk protein intolerance, eczema, hay fever, allergies
166
what age can you use a peak flow meter
4-5years
167
what is a peak flow test
how quickly you can blow air out your lungs
168
how should you record peak flow
do it 3 times and record the highest and do morning and evening
169
how does the hygiene hypothesis relate to asthma
early exposure to micro organisms protects against allergic diseases by contributing to the immune system
170
how long can a spacer be used for
replace every 6-12 months
171
how to wash a spacer
wash once a week with warm water and leave to dry naturally without a cloth
172
advantages of using a spacer
helps get the inhaler medication to reach deep into the lungs without the complexity of getting the technique right
173
pathophysiology of copd
a combination of chronic bronchitis (productive cough on most days for 3 months a year over 2 successive years) and emphysema (enlargment of air spaces in the terminal bronchioles leading to inefficient gas exchange ratios and poor air outflow)
174
symptoms of COPD
cough, sputum, weight loss, early inspiratory crackles, cor pulmonate, oedema, barrel chest, hyper-resonant, co2 flap, dyspnoea
175
risk factors of COPD
smoking, age, family history, pollution, A1ATD
176
spirometry in copd
obstructive
FEV1/FVC <70%
FEV1 <80%
increased TLC
177
what is the bode classification
the copd survival prediction
stands for BMI, airflow obstruction, dyspnoea and exercise capacity
178
investigations in copd
```
SPOTX
sputum
peak flow/spirometry
o2 sats
temperature
xray
bloods
ECG
ECHO
mMRC dyspnoea score
bode classification
```
179
what will bloods show in copd
polycythaemia
abg
A1ATD
180
what will CXR show in COPD
he fucking breathes
hyperinflation
flat diaphragm
bullae
exclude lung cancer
181
what will ECHO show in copd
primary hypertension
182
lifestyle treatment in copd
smoking cessation, vaccines, copd nurse, depression screen, control BMI, educate, pulmonary rehab, treat comorbidities , mucolytics
183
how do you define an acute exacerbation of copd
worsening symptoms usually caused by an infection
184
treatment of acute exacerbation of copd
COAL BINS
chest physio
o2 (aim 88-92%)
Abx
LMWH
bronchodilators (SABA and SAMA)
invasive ventilation
NIV (BiPAP)
steroids (hydrocortisone IV and prednisone PO)
185
treatment of copd FEV >50%
```
SABA/SAMA
then LABA/LAMA
then LABA+LAMA+ICS
then LTOT
then surgery
```
186
treatment of copd FEV<50%
```
SABA/SAMA
then LABA/LAMA +ICS
then LABA+LAMA+ICS
then LTOT
then surgery
```
187
pros of LTOT
increases survival
188
indications of LTOT in copd
if clinically stable, non smoker, paO2 <7.3 or have pulmonary HTN, cor pulmonale, polycythaemia, nocturnal hypoxaemia, terminally ill
189
discharge for COPD
SHEDS vaccines
```
spirometry
home assessment
establish maintenance therapy
doctors appointment
steroids for prevention
```
190
abg in acute exacerbation of copd
respiratory acidosis due to inappropriate high flow o2 or respiratory depression
191
why does smoking cause copd
leads to increased neutrophils and oxidative stress causing elastin breakdown and inactivation of A!AT
192
most common organism in copd
h.influenza
193
complications of copd
```
cor pulmonale
pulmonary HTN
polycythaemia
respiratory failure
pneumothorax (ruptured bullae)
lung cancer
infections/exacerbations
```
194
causes of type 1 resp failure
PE, pulmonary HTN, pulmonary shunt (R to L), asthma, pneumothorax, pulmonary oedema, pneumonia, infarction, fibrosis
195
causes of type 2 resp failure
any cause of type 1 if severe enough
copd, asthma, lung fibrosis, sedatives, CNS tumours, trauma, neuromuscular disease (MG, GBS), flail chest
196
symptoms of acute hypoxia
dyspnoea, agitation, confusion, cyanosis
197
symptoms of chronic hypoxia
polycythaemia, pulmonary HTN, cor pulmonale
198
symptoms of hypercapnia
headache, flushing, bounding pulse, flap, coma
199
explain co2 retention in copd
in copd they optimise gas exchange with hypoxic vasoconstriction so when there is an increased o2, respiratory drive is lowered and hypercapnia respiratory failure occurs due to altered V/Q ratio
200
o2 sat aims in resp failure
hypoxic = 94-98
hypercapnia 88-92
try and do abg first
201
how does bipap work
adds pressure during inspiration and expiration to increase tidal volume and co2 clearance
202
how does cpap work
maintains minimum airway pressure to keep alveoli inflated
203
risks of bipap
non tolerance, gastric distension, aspiration, failure
204
types of invasive ventilation
tracheostomy
| ET tube
205
indications of invasive ventilation
emergency surgery, history of sev reflux, protect airway, GCS <8 or rapidly decreasing
206
risks of invasive ventilation
trauma, pneumothorax, lung injury, alveolar rupture, abdominal distension, water retention, emphysema, muscle relaxant
207
methods to give O2
nasal cannula, simple face mask, resovoir/non rebreathe, venturi mask, non invasive ventilation, invasive ventilation
208
what is ARDS
pulmonary oedema
209
criteria of ARDS
<1 week, CXR change, PaO2:FiO2 <200, no evidence of congestive HF
210
causes of ARDS
sepsis, trauma and pancreatitis or direct pulmonary injury lead to increased inflammatory mediators, increased capillary permeability, and non cariogenic pulmonary oedema
211
CXR in ARDS
bilateral opacity and perihilar infiltrates
212
treatment of ARDS
```
ABCDE - o2, IV, ecg, bloods
diamorphine
metaclopramide
furosemide
GTN
ITU, ventilation, supportive, Abx, nutritional support, invasive BP monitors
```
213
what is obstructive sleep apnoea
intermittent closure/collapse of airway leading to apnoea episodes during sleep
214
risk factors of obstructive sleep apnoea
obese, male, smoker, alcohol, IPF, structural pathology, MND
215
investigations in OSA
polysomonography for diagnosis
SpO2
epworth sleepiness scale
216
symptoms of OSA
snoring, choking, gasping, morning headache, reduced memory and attention, irritable
217
treatment of OSA
weight loss, avoid alcohol and smoking, CPAP mask at night, surgery
218
complications of OSA
pulmonary HTN, type 2 res failure, cor pulmonate, depression, DM, HTN
219
definition of pulmonary HTN
pulmonary artery pressure >25mmHG and capillary wedge pressure <15mmHg
220
symptoms of pulmonary HTN
leads to RVH and RHF so cor pulmonale, increased JVP, pulsatile HSM, murmurs, left parasternal heave, ascites, peripheral oedema
221
investigations in pulmonary HTN
ECG = p pulmonale, RVH, RAD
ECHO = R side hypertrophy and dysfunction and tricuspid regurgitation
right heart catheterisation for MPAP. PVR, CO, vasoreactivity test
222
treatment of pulmonary HTN
treat the cause and reduce pulmonary vascular resistance
anticoag, transplant
223
how to reduce pulmonary vascular resistance
LTOT, CCB, sildenafil, prostaglandins
224
what is virchows triad
venous stasis, vessel damage and hypercoaguloable state
225
risk factors of PE
```
SPASMODIC
sex = female
pregnancy
age increase
surgery
malignancy
oestrogen (COCP/HRT)
DVT/PE
immobility
colossal size
antiphospholipid antibodies
lupus anticoagulant
```
chemo, trauma, thrombophillia
226
symptoms of PE
dyspnoea, pleuritic chest pain, haemoptysis, syncope, fever, cyanosis, tachypnoea, RHF
227
symptoms of DVT
```
limb tenderness/pain
unilateral swelling of calf
increased skin temperature
skin discolouration
distended superficial veins
pitting oedema
```
228
PE wells score
```
clinical signs of DVT = 3
PE most likely = 3
HR >100bpm = 1.5
recent PE/DVT = 1.5
recent surgery/immbolisation = 1.5
haemoptysis = 1
malignancy = 1
```
4 or more = PE
229
DVT wells score
```
active cancer = 1
bedridden >3days or major surgery in past 4 weeks = 1
calf swelling >3cm = 1
collateral superficial veins present = 1
entire leg swollen = 1
localised tenderness = 1
pitting oedema = 1
paralysis/recent immobile leg = 1
previous DVT = 1
```
2 or more is DVT
230
what is PESI
pulmonary emboli severity index = prognosis of PE in 30 days
231
PERC rule
risk of PE if no risk factors present <50 years (HADCLOTS)
232
DVT management
if suspected do wells, if 2 or more do PVUSS in 4 hrs, >4hrs, anticoagulate then PVUSS
if wells <2 - do d-dimer
233
PE management
do wells, if 4 or more do CTPA, if delayed do anticoagulant then CTPA
234
Pe management in renal disease
do V/Q scan instead of CTPA
235
investigations in PE
bloods = FBC, U+E, clotting, dimer, troponin
ABG = low O2, increased lactate
CXR = exclude pneumothorax, wedge shaped infarct, pleural effusion, vascular dilation
ECG = exclude MI, tachycardia, S1Q3T3, RBBB, RVs strain and deviation, AF
d dimer
VQ scan
thrombophilia/cancer screen
236
prophylaxis of PE/DVT
graduated compression stockings for 2 years, early mobility, hydration, LMWH, avoid RF, TED stockings in hospital
237
DD of PE
MI, pneumothorax, pericarditis, MSK, pneumonia, malignancy
238
ECG in PE
```
rule out MI
tachycardia/AF
S1Q3T3 = s wave in lead one, q wave in lead 3 and t wave invasion lead 3
RBBB
RV strain
RV deviation
```
239
issue with d dimer
high sensitivity, low specificity
240
acute management of PE
ABCDE
metaclopramide and morphine
anticoagulant
if BP <90 give fluids and dobutamine (an inotrope)
241
methods of anticoagulation in PE
LMWH (dalteparin) or fondaparinux (Xa inhibitor) until INR 2-3 or 5 days then give warfarin for 6 months if unprovoked or 3 month if first
242
what would an unprovoked PE suggest
cancer
243
what to do in VTE while on anticoagulants
could be a thrombophilia (Factor V Leiden, Protein c and S deficiency, antiphopsholipd syndrome, antithrombin deficiency), so increase INR to 3-4 and do clotting screen
244
anticoagulant of PE in anticoagulant CI or recurrent
IVC filter to prevent clots from moving to lung
245
when should you use unfractioned heparin in PE
if unstable, severe renal impairment or increased bleed risk
246
NOAC mechanism
apixaban = xa inhibitor
247
pros and cons of NOAC
```
pro = don't need measuring, faster onset and offset
cons = bleed and bruise, heparin induced thrombocytopenia
```
248
precautions in NOAC use
pregnancy, alert card, monitoring, side effects, lifestyle impact
249
what to monitor during LMWH use
FBC (platelets), APTT, U+Em LFTs, weight
250
4 types of hypersensitivity
ACID
1 = allergy IgE = due to mast cells releasing histamine e.g. anaphylaxis, hay fever, asthma
2= cytotoxic antibody dependent e.g autoimmune and transfusions
3 = immune activation of complement e.g. SLE, post strep GN
4 = delayed T cell mediated e.g. TB, contact dermatitis
251
methods to assess respiratory pre op
METS, ECG, ECHO, CXR, functional capacity assessment, BMI, Bloods
252
vasculitis and resp
wegener cANCA
| charge strauss pANCA
