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KFP > Respiratory > Flashcards

Respiratory Flashcards

1
Q

Bronchiectasis - key features hx

A 
chronic cough
sputum production
dyspnoea 
recurrent LRTI
\+/- haemoptysis
?smoker 
pmhx recurrent LRTI as child
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2
Q

Bronchiectasis - key features ex

A

bibasal crackles chest auscultation
+/- wheeze
digital clubbing
SaO2 N or low

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3
Q

Bronchiectasis - single most useful Ix to diagnose

A

HRCT chest - abnormally dilated airways, bronchoarterial ratio>1

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4
Q

Bronchiectasis - initial Ix to rule out secondary causes

A

Initial:
FBC
Sputum MCS x 1 routine resp pathogens
Sputum MCS x 3 morning samples for atypical pathogens
TB serology/PCR quantiferon gold
Total IgE
spirometry - normal in early disease, variable mixed pattern, restrictive or obstructive

+/- Immunoglobulins IgG, IgA, IgM
+/- HIV/HTLV serology
+/- Aspergillus serology
+/- Cystic fibrosis screening - sweat test and CF transmembrane conductor regulator gene mutation

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5
Q

Bronchiectasis - Mx

A

Immediate:
Referral to resp physician at dx
Physio pulm rehab exercise program
Airway clearance - breathing, cough, neb normal saline, mycolytics
Vaccination - Pneumococcal and influenza
Early treatment of acute exacerbations with appropriate antibiotics
Aug DF bd or doxycycline 100mg bd for 10-14 days
Long term:
prophylactic poabx if 3 or more acute exacerbations in 1yr
+/- palliative care referral
+/- transplant surgery

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6
Q

Bronchiectasis - key features of acute exacerbation

A 
2 or more of:
increase cough
increased SOB
increase volume or purulence of sputum 
reduction of FEV1 >10% in <2/52
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7
Q

Bronchiectasis - indications for referral to respiratory physician

A

rapid progression of symptoms
severe symptoms
frequent exacerbations and POABx
haemoptysis

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8
Q

Pertussis/whooping cough - key features

A

persistent cough for ≥ 2/52 plus:
paroxysms of coughing
inspiratory whoop
post tussive vomiting

mild coryzal symptoms between coughing paroxysms

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9
Q

Pertussis/whooping cough - Ix and timing

A

Nasopharyngeal swab for PCR - < 2/52 since onset of symptoms. will be neg if >21/7 since onset or 5/7 poabx
Nasopharyngeal swab for MCS - less sensitive, positive after 2-4/52 catarrhal phase.
Pertussis serology (IgA) detectable after 2/5 of symptom onset

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10
Q

Pertussis/whooping cough - Mx

A 
advise goal - prevent disease transmission, doesnt alter disease duration
Avoid contact with others until had 5/7 POABx
Contact Prophylaxis (same tx as index case) - kids <2yrs, pregnant women 3rd trimester
household contacts if < 6/12 baby in household
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11
Q

Pertussis/whooping cough - Tx

A

azithromycin (10mg/kg, then 5mg/kg) 500mg po stat, 250mg po od for 4/7
Bactrim DS 160/800mg po bd for 7/7
Clarithromycin 500mg po bd for 5/7

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12
Q

Interstitial lung disease - causes “schart rasco”

A 
Sarcoidosis
Coal miners pneumoconiosis
Histiocytosis
Ankylosing spondylitis + Allergic aspergillosis
Radiation
Tuberculosis
Rheumatoid arthritis
Asbestosis
Scleroderma
Cryptogenic fibrosing alveolitis
Other - drugs: amiodarone, MTX, nitrofurantoin, hydralazine, bleomycin
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13
Q

Interstitial lung disease- key features hx

A

Indolent and progressive
SOB/dyspnoea
dry cough

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14
Q

Interstitial lung disease- key features ex

A

fine inspiratory crackles
reduced SaO2
digital clubbing

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15
Q

Interstitial lung disease - key Ix

A
  • HRCT chest:
    honey combing
    ground glass and mosaicism opacity pattern
    spirometry - restrictive ventilatory defect
  • CXR:
    basal and peripheral reticulonodular opacities/interstitial opacities (network of lines that form nodules and ring shadows)
    +/- medistinal ipsilateral displacement
    Fibrocystic changes
  • Lung biopsy - gold standard for Dx cause of ILD
other to determine cause:
spirometry
ANA, Anti CCP, ANCA (autoimmune)
FBC (infection, eosinophilia)
LFT/UEC autoimmune, systemic vasculitis multiorgan involvement
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16
Q

Interstitial lung disease - Mx

A

prompt referral to respiratory physician
general measures:
stop smoking
identify and tx associated comorbidities:
GORD
pulm HTN
depression/anxiety
Patient education - poor prognosis, planned EOLC discussion
Referral to palliative care
Irretractable dyspnoea - opioids

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17
Q

Interstitial lung disease - Tx for symptom control

A

dyspnoea - opioids
GORD - PPI
hypoxaemia at rest - O2
acute flare - oral prednisolone 0.5mg/kg/day for 1/12, then maintenance dose 10-15mg od for 2yrs

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18
Q

Pleural effusion - causes

A

exudative (local disease):

transudative (systemic disease):

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19
Q

Pleural effusion - key features hx

A

dyspnoea
pleuritic chest pain
cough

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20
Q

Pleural effusion - key features CXR

A 
meniscal edge (concave) of effusion
homogenous shadowing/opacity
\+/- contralateral mediastinal shift/tracheal displacement
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21
Q

Pleural effusion - key features Ex

A

tacchypnoea
SaO2 reduced
reduced chest expansion - ipsi or bilaterally
percussion dullness
reduced or absent breath sounds over fluid
reduced vocal resonance
+/- bronchial BS at upper border of effusion
+/- pleural friction rub above level of effusion

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22
Q

Pulmonary hypertension - causes

A 
Cardiac:
LV failure
Left sided valvular HD (CCF)
Intracardiac shunts(congenital VSD/ASD)
Liver cirrhosis
Respiratory:
COPD
Chronic PE
Idiopathic pulm arterial HTN from connective tissue disorders
Interstitial lung disease
OSA
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23
Q

Pulmonary hypertension - RF

A 
Fhx
Obesity
Asbestis exposure
High altitude living
cocaine + amphetamine use
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24
Q

Pulmonary hypertension - key features Hx

A 
SOB
fatigue
dizziness
syncope
chest pressure/pain
ankle swelling/ascites
cyanosis - lips and skin
heart palpitations
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25
Q

Pulmonary hypertension - complications (3)

A

cor pulmonale
clots/PE
arrhythmias

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26
Q

Pulmonary hypertension - Ix (5)

A 
ECHO
ECG
CXR - right ventricle enlargement, evidence of other pulm pathology
Spirometry
V/Q scan
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27
Q

COPD - key features presentation (3 major, 3 minor)

A

chronic cough
breathlessness/dyspnoea/SOBOE
+/- increased sputum production

feeling tired/fatigue
increased freq or recurrent LRTI
wheeze/chest tightness

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28
Q

COPD - RF (6)

A

smoking
genetic - fhx alpha 1 antitrypsin deficiency
long term environmental exposure - dust, fumes, smoke, noxious gases, air pollution
age >40yrs
male gender
PMHx Pulm TB

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29
Q

COPD - dx, Ix modality and criteria

A

Spirometry :obstructive ventilatory defect, that is not fully reversible
pre- bronchodilator
1. FEV1/FVC <0.7
2. FEV1 <80% predicted

post-bronchodilator
1. FEV1 not increased by ≥ 12%
AND
2. FEV1 not increased by ≥ 200ml

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30
Q

COPD severity criteria

A

based on % predicted FEV1:
mild = 60-79%%
mod = 40-59%
severe <40%

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31
Q

COPD - Key features Mx (6)

A

1 confirm dx and severity - FEV1, symptoms
2. optimise function - annual functional assessment and impact of COPD on QOL
encourage regular exercise
refer to pulmonary rehab program
psychosocial support/CBT for depression/anxiety
inhalers/Rx using stepwise approach
3. prevent deterioration -
quit smoking
avoid exposure to air pollution and tobacco smoke
vaccinations - pneumococcal 13+23, influenza
promote and educate on self management early recognition of acute exacerbation
4. develop a care plan - Written action/care plan for maintenance and for exacerbations
Advanced care directive, nominate enduring POA/POG
5. manage exacerbations - po abx + steroids

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32
Q

clinical features of bacterial exac of COPD (3)

A

increased sputum volume
increased sputum purulence or change in sputum colour
fever

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33
Q

exac of COPD - tx (3)

A

SABA 4-8puffs 3hrly prn

prednisolone 30-50mg po od 5/7- 14/7

+/- POABx if infectious symptoms:
amoxicillin 500mg po tds 5/7
OR
doxycycline 100mg po bd 5/7

34
Q

Rx for COPD stepwise approach (4)

A
  1. SABA or SAMA monotherapy
  2. Add LABA or LAMA monotherapy
  3. Use LABA/LAMA combo therapy
  4. Add ICS if ≥ 2 exac in 12/12 or FEV1 <50%
    ICS+LABA or ICS/LABA + LAMA
35
Q

COPD - SAMA drug and dose (1)

A

ipratropium 21mcg MDI 2-4 puffs qid/prn

36
Q

COPD - SABA drug and dose (2)

A

salbutamol 100mg 2-4 puffs qid/prn
4-8 puffs 1-4hrly/prn for acute exac

terbutaline 500mcg 1-3 puffs qid/prn

37
Q

COPD - LABA - drug and dose (3)

A

formoterol 12mcg bd
salmeterol 50mcg bd
indaceterol 150-300mcg od

38
Q

COPD - LAMA - drug and dose (4)

A 
spiriva (tiotropium) 10mcg od 
***Note, both Braltus® (13 micrograms) and Spiriva® (18 micrograms) inhalers deliver the same tiotropium dose (10 micrograms per capsule).
seebri (glycopyrronium) 50mcg od
Incruse (umeclidinium) 62.5mcg od
Bretaris (aclidinium) 322mcg bd
39
Q

COPD - LAMA/LABA combo therapy - drugs and dose (3)

A

spiolto (tiotropium/olodaterol) 2.5/2.5mcg od
anoro (vilanterol/umeclidinium) 25/62.5mcg od
Ultibro (indaceterol/glycopyrronium) 110/50mcg od

40
Q

COPD - ICS/LABA combo therapy - drugs and dose (3)

A

symbicort (budesonide/formoterol) 200/6mcg bd
seretide (fluticasone/salmeterol) 125/25mcg - 250/25mcg bd
250/50mcg - 500/50mcg bd
breo ellipta (fluticasone/vilanterol) 100/25mcg od

41
Q

COPD - ICS/LABA/LAMA combo therapy - drug and dose (1)

A

trelegy (fluticasone/umeclidinium/vilanterol) 100/62.5/25mcg od

42
Q

COPD- key features ex (7)

A 
cyanosis
reduced chest expansion
increased AP diameter/barrel chest 
hyper resonant chest percussion 
reduced breath sounds
early inspiratory crackles
end expiratory wheeze
43
Q

COPD ddx (8)

A 
heart failure/CCF
LRTI
Pulmonary embolism
Asthma 
Pleural effusion
Arrhythmia
Acute pulmonary oedema
Pulmonary fibrosis
44
Q

COPD - Mx goals “COPD-X”

A 
Confirm dx and severity
Optimise function
Prevent deterioration
Develop a care plan
X-acerbation management
45
Q

COPD - initial Ix

A 
spirometry - confirm dx and severity
r/o alternative ddx 
CXR - hyperinflated lungs, diaphragm flattening
ECG 
ECHO
FBC
UEC
46
Q

COPD - Non pharmacological Mx (7)

A

smoking cessation
regular physical exercise
pulmonary rehab
education and promotion of self management for early recognition of acute exacerbation
psychosocial support
CBT for depression/anxiety
Advanced care directive and enduring POA, POG

47
Q

short and long acting muscarinic antagonist side effects (4)

A

dry mouth
blurred vision
urinary retention
constipation

48
Q

short and long acting beta2 agonist side effects (5)

A 
tremor 
palpitations/tacchycardia
headache
insomnia
hyperglycaemia - high doses (rare)
49
Q

Latent Tuberculosis/reactivation - key features (6)

A 
fever
night sweats
weight loss
cough for 2-3/52 or more 
lethargy 
\+/- haemoptysis
50
Q

Pulmonary Tuberculosis - key features

A

pneumonia or pleural effusion SOS
fever
cough
+/- haemoptysis

51
Q

Pulmonary Tuberculosis - Ix (5)

A

CXR:
airspace consolidation - patchy areas of consolidation
ipsilateral hilar lymphadenopathy
cavitation (10-30% of cases) - well defined thick walled cavitatory lesion
fibrous contraction in 1 or both upper lobes (apical) or superior parts of the lower lobes (localised caseating/cannonball lesion)
+/- pleural effusion (40% adult 1 pulm TB)

Microbiological testing:
1.sputum x 3 morning samples for mcs - acid-fast, Ziehl Neelsen staining, detects 50% of cases

  1. TB molecular assays and PCR - high sensitivity, simultaneously detects rifampicin resistance

Suspected Latent TB:
Mantoux skin test - positive 4-6/52 post infection,
false positives after vaccination with BCG (Bacillus Calmette–Guérin)
or exp to environmental mycobacterium species

Quantiferon gold test - detects TB antigens, +ve 6/52 post infection, no false positive results secondary to BCG vaccination

52
Q

define chronic cough in adults

A

chronic cough = a cough lasting >8/52

cough lasting 4-8/52 = protracted cough

53
Q

chronic cough in adults - most common ddx (3)

A

GORD
Asthma
URTI (rhinosinusitis)

54
Q

chronic cough in adults - serious causes not to miss (7)

A

Cancer - lung, bronchus, larynx
Parenchymal lung diseases -
COPD
Interstitial lung disease
Bronchiectasis
Infections - pneumonia, atypical pneumonia, Pulmonary tuberculosis,
CVD - congestive cardiac failure, aortic aneurysm

55
Q

chronic cough in adults - common causes (6)

A 
ACE inhibitor side effect
protracted bacterial bronchitis
Pertussis
Post-infectious cough 
Environmental exposures - tobacco, air pollutants
OSA
56
Q

define chronic cough in children

A

a cough lasting >4/52

cough lasting 2-4/52 = protracted cough

57
Q

chronic cough in children - most common ddx (2)

A

protracted bacterial bronchitis

asthma

58
Q

chronic cough in children - serious causes not to miss (5)

A

Congenital airway abnormality
Foreign body inhalation
Parenchymal lung diseases -
cystic fibrosis, pulmonary fibrosis, bronchiectasis
Infection - pulmonary TB, pertussis, pneumonia
motor tic/habitual cough/psychogenic cough

59
Q

Red flag SOS chronic cough in adults (10)

A 
haemoptysis
smoker >20yr pack hx
smoker >45yrs old with new/altered cough
dyspnoea, esp at night or at rest
increased sputum production
vocal hoarseness  
systemic features- fever, weight loss, night sweats
GORD a/w weight loss, early satiety
dysphagia, anaemia and/or GIT bleeding
choking/vomiting/feeding difficulties
abnormal resp examination findings
60
Q

Red flag SOS chronic cough in children (7)

A

dyspnoea, esp at night or rest
recurrent episodes of productive or wet cough
systemic features - fever, weightloss, failure to thrive
feeding difficulties
recurrent pneumonia
stridor + other respiratory noises
abnormal respiratory examination findings

61
Q

chronic cough in adults - Ix (6)

A 
CXR
sputum mcs and pcr
spirometry
FBC
CRP

If above all NAD then do
HRCT chest

62
Q

Tuberculosis - RF/high risk of exposure in past/present Hx (5)

A

elderly
post war european+vietnam migrants/refugees
ATSI
Migrants/refugees from TB- burdened countries - Africa, China, Asia, Papua New Guinea, India, East Europe, Italy
HCW from high TB burden countries

63
Q

Tuberculosis - RF for reactivation (6)

A 
immunocompromised states
old age
chemotherapy
malignancy
HIV
post transplant recipients
64
Q

Persistent/chronic cough in adults - key features to ask about in Hx (12)

A 
Hx of possible exposure to infectious causes, 
Hx of possible exposure to other air pollutants/environmental exposures 
Hx of contact with unwell people
Immunisation Hx
weight loss/night sweats/fever
haemoptysis
sputum production?
smoking hx 
recent travel hx
any enlarged lymphnodes
any SOB or wheeze or chest pain 
any dysphagia/choking
65
Q

Wells criteria for suspected PE (7)

A

clinical signs of DVT (unilat lower limb pain or oedema)
PE is most likely dx
HR>100
Immobile ≥ 3 days or surgery in last 4/52
PMHx PE or DVT
Haemoptysis
Malignancy within past 6/12

66
Q

Pulmonary embolism Ix for
a - low risk/pretest probability ≤2
b - mod/indeterminate risk/pretest probability ≤4
c - high risk/pretest probability > 4

A

a - consider d-dimer
b - d-dimer, if positive do CT pulmonary angiogram
c - CT pulmonary angiogram and venous doppler ultrasound lower limbs

67
Q

Pulmonary embolism Tx - drug, dosage, duration (3)

A

LMWH - enoxaparin 1.5 mg/kg daily or 1 mg/kg twice daily.
Warfarin, target INR 2-3,
Apixaban 10mg bd for 1/52, then 5mg bd for 3/12
Rivaroxiban 15mg bd for 3/52, then 20mg od for 3/12

68
Q

Pulmonary embolism - key features hx (4)

A

new or worsening SOB, sudden onset
acute onset chest pain - pleuritic, retrosternal
haemoptysis
syncope

69
Q

Pulmonary embolism - key features examination (6)

A 
tachypnoea ≥20/min
tachycardia >100bpm
hypoxia/SaO2 <95%
SBP <90mmHg
crepitations on auscultation of lungs
70
Q

Pulmonary embolism - RF (9)

A 
age> 65 years
immobilisation/bed rest >3 days
major surgery (TKR, THR)
major trauma (hip or leg #)
malignancy, CTX
hypercoagulability - thrombophilia, antiphospholipid syndrome, factor 5 leiden
excess oestrogen - HRT, COCP, pregnancy
PMHx of VTE
PMHX CVA
71
Q

Pulmonary embolism - mx

A

call ambulance for urgent t/f to nearest ED
DRABCDE
IV thrombolysis - heparin infusion or alteplase in hospital - if haemodynamically unstable, SBP<90, or bradycardia <40/min, hypoxia

72
Q

Ix for suspected pulmonary embolism in pregnant women

A

dont do d-dimer (elevated from 2nd trimester on).

Use V/Q scan in lieu of CTPA for pregnant women

73
Q

Specificity of a test

A

The greater the specificity of a test, the better it is at ruling the condition in (a positive result is likely to be a true positive);

74
Q

Sensitivity of a test

A

the greater the sensitivity, the better the test is at ruling the disease out (a negative result is likely to be a true negative).

75
Q

4 factors to ask about when assessing Asthma symptom control in adults?

A

In the last month,
how many days did you experience daytime asthma symptoms?
how many days did you need to use your reliever medication?
did you experience any limitation of your usual activity due to your asthma symptoms?
did you experience any asthma symptoms overnight night or upon waking?

76
Q

Indications to commence preventer Rx for asthma in adults

A

asthma symptoms ≥ 2 days in the past month
needed systemic steroids for asthma flare up, or required ED presentation for asthma in the last 12/12
needed HDU/ICU admission for severe asthma symptoms
Waking due to asthma symptoms in last 1/12

77
Q

Asthma ddx (5)

A 
Resp tract infections - LRTI/URTI
COPD
inhaled FB
CCF
bronchiectasis
78
Q

Asthma - key features ex

A

widespread expiratory wheeze on chest auscultation
no creps or crackles
no stridor or rhonchi
RR, WOB, SaO2 - may be NAD, doesnt exclude asthma
Temperature - exclude alternative dx

79
Q

Criteria for poorly controlled asthma (4)

A
  1. Poor symptom control in the last month
    1 ≤ in the last 1/12:
    - daytime asthma symptoms ≥2 days in a week
    - any night time asthma symptoms
    - reliever needed ≥ 2 days in a week
    - any activity limitation due to asthma
  2. frequent severe exacerbations needing prednisolone 2≤ in last 12months
  3. airflow limitation FEV1 <80% predicted (6hrs≤ since last bronchodilator)
  4. serious exacerbations needing hospital admission, ICU or ventilation in last 12months
80
Q

Difficult to treat asthma definition

A

Asthma that is not controlled despite high dose ICS/LABA, 800mg < budesonide or equivalent per day

81
Q

Causes of poor asthma control (4)

A

poor medication compliance
poor inhaler technique
poor avoidance of modifiable RF and triggers
severe asthma, thats difficult to treat

KFP (14 decks)

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