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
Pulmonary hypertension - complications (3)
cor pulmonale clots/PE arrhythmias
26
Pulmonary hypertension - Ix (5)
``` ECHO ECG CXR - right ventricle enlargement, evidence of other pulm pathology Spirometry V/Q scan ```
27
COPD - key features presentation (3 major, 3 minor)
chronic cough breathlessness/dyspnoea/SOBOE +/- increased sputum production feeling tired/fatigue increased freq or recurrent LRTI wheeze/chest tightness
28
COPD - RF (6)
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
29
COPD - dx, Ix modality and criteria
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
30
COPD severity criteria
based on % predicted FEV1: mild = 60-79%% mod = 40-59% severe <40%
31
COPD - Key features Mx (6)
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
32
clinical features of bacterial exac of COPD (3)
increased sputum volume increased sputum purulence or change in sputum colour fever
33
exac of COPD - tx (3)
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
Rx for COPD stepwise approach (4)
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
COPD - SAMA drug and dose (1)
ipratropium 21mcg MDI 2-4 puffs qid/prn
36
COPD - SABA drug and dose (2)
salbutamol 100mg 2-4 puffs qid/prn 4-8 puffs 1-4hrly/prn for acute exac terbutaline 500mcg 1-3 puffs qid/prn
37
COPD - LABA - drug and dose (3)
formoterol 12mcg bd salmeterol 50mcg bd indaceterol 150-300mcg od
38
COPD - LAMA - drug and dose (4)
``` 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
COPD - LAMA/LABA combo therapy - drugs and dose (3)
spiolto (tiotropium/olodaterol) 2.5/2.5mcg od anoro (vilanterol/umeclidinium) 25/62.5mcg od Ultibro (indaceterol/glycopyrronium) 110/50mcg od
40
COPD - ICS/LABA combo therapy - drugs and dose (3)
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
COPD - ICS/LABA/LAMA combo therapy - drug and dose (1)
trelegy (fluticasone/umeclidinium/vilanterol) 100/62.5/25mcg od
42
COPD- key features ex (7)
``` cyanosis reduced chest expansion increased AP diameter/barrel chest hyper resonant chest percussion reduced breath sounds early inspiratory crackles end expiratory wheeze ```
43
COPD ddx (8)
``` heart failure/CCF LRTI Pulmonary embolism Asthma Pleural effusion Arrhythmia Acute pulmonary oedema Pulmonary fibrosis ```
44
COPD - Mx goals "COPD-X"
``` Confirm dx and severity Optimise function Prevent deterioration Develop a care plan X-acerbation management ```
45
COPD - initial Ix
``` spirometry - confirm dx and severity r/o alternative ddx CXR - hyperinflated lungs, diaphragm flattening ECG ECHO FBC UEC ```
46
COPD - Non pharmacological Mx (7)
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
short and long acting muscarinic antagonist side effects (4)
dry mouth blurred vision urinary retention constipation
48
short and long acting beta2 agonist side effects (5)
``` tremor palpitations/tacchycardia headache insomnia hyperglycaemia - high doses (rare) ```
49
Latent Tuberculosis/reactivation - key features (6)
``` fever night sweats weight loss cough for 2-3/52 or more lethargy +/- haemoptysis ```
50
Pulmonary Tuberculosis - key features
pneumonia or pleural effusion SOS fever cough +/- haemoptysis
51
Pulmonary Tuberculosis - Ix (5)
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 2. 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
define chronic cough in adults
chronic cough = a cough lasting >8/52 | cough lasting 4-8/52 = protracted cough
53
chronic cough in adults - most common ddx (3)
GORD Asthma URTI (rhinosinusitis)
54
chronic cough in adults - serious causes not to miss (7)
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
chronic cough in adults - common causes (6)
``` ACE inhibitor side effect protracted bacterial bronchitis Pertussis Post-infectious cough Environmental exposures - tobacco, air pollutants OSA ```
56
define chronic cough in children
a cough lasting >4/52 | cough lasting 2-4/52 = protracted cough
57
chronic cough in children - most common ddx (2)
protracted bacterial bronchitis | asthma
58
chronic cough in children - serious causes not to miss (5)
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
Red flag SOS chronic cough in adults (10)
``` 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
Red flag SOS chronic cough in children (7)
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
chronic cough in adults - Ix (6)
``` CXR sputum mcs and pcr spirometry FBC CRP ``` If above all NAD then do HRCT chest
62
Tuberculosis - RF/high risk of exposure in past/present Hx (5)
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
Tuberculosis - RF for reactivation (6)
``` immunocompromised states old age chemotherapy malignancy HIV post transplant recipients ```
64
Persistent/chronic cough in adults - key features to ask about in Hx (12)
``` 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
Wells criteria for suspected PE (7)
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
Pulmonary embolism Ix for a - low risk/pretest probability ≤2 b - mod/indeterminate risk/pretest probability ≤4 c - high risk/pretest probability > 4
a - consider d-dimer b - d-dimer, if positive do CT pulmonary angiogram c - CT pulmonary angiogram and venous doppler ultrasound lower limbs
67
Pulmonary embolism Tx - drug, dosage, duration (3)
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
Pulmonary embolism - key features hx (4)
new or worsening SOB, sudden onset acute onset chest pain - pleuritic, retrosternal haemoptysis syncope
69
Pulmonary embolism - key features examination (6)
``` tachypnoea ≥20/min tachycardia >100bpm hypoxia/SaO2 <95% SBP <90mmHg crepitations on auscultation of lungs ```
70
Pulmonary embolism - RF (9)
``` 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
Pulmonary embolism - mx
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
Ix for suspected pulmonary embolism in pregnant women
dont do d-dimer (elevated from 2nd trimester on). | Use V/Q scan in lieu of CTPA for pregnant women
73
Specificity of a test
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
Sensitivity of a test
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
4 factors to ask about when assessing Asthma symptom control in adults?
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
Indications to commence preventer Rx for asthma in adults
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
Asthma ddx (5)
``` Resp tract infections - LRTI/URTI COPD inhaled FB CCF bronchiectasis ```
78
Asthma - key features ex
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
Criteria for poorly controlled asthma (4)
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
Difficult to treat asthma definition
Asthma that is not controlled despite high dose ICS/LABA, 800mg < budesonide or equivalent per day
81
Causes of poor asthma control (4)
poor medication compliance poor inhaler technique poor avoidance of modifiable RF and triggers severe asthma, thats difficult to treat