Respiratory Flashcards
Tx acute exacerbation of asthma
Oxygen 15L via non rebreathe mask
Salbutamol 5mg via oxygen driven nebuliser
Ipratropium bromide 0.5mg via nebuliser
Oral prednisolone 50mg or IV hydrocortisone 100mg (both if very ill)
IV magnesium sulphate (Senior decision)
aminophylline/theophylline (Senior decision)
No sedatives
CXR if suspecting pneumothorax/consolidation or if patient is very likely to require intermittent positive pressure ventilation
what are features on an ABG that indicate a life threatening asthma attack
Normal PaCo2 - should be low due to hyperventilation
Severe Hypoxia
Low pH
post recovery Tx for acute asthma exacerbation
Oral prednisolone for 5 days
Nebulised salbutamol/ipatropium until discharge
Chart PEF before and after nebs, at least 4 times daily whilst In hospital
Prior to discharge check inhaler technique, agree on a written asthma action plan and ensure GP follow up within 2 working days
Tx for chronic asthma in primary care
- SABA + ICS
Used to be one each but this changed to pretty much everyone getting preventer inhalers - SABA + ICS + LABA
- Increased ICS dose OR add LTRA
If there has been no response to the LABA consider stopping it - Refer for specialist care
(anti IgE drugs, oral corticosteroids or B2 agonists)
Before specialist care you could increase ICS to high dose and add a theophylline or LAMA
Use of SABA >3 times a week indicates poor control and the care should be escalated
side effects of SABAs
tachycardia
cramps
tremor
hypokalaemia
Side effects of inhaled corticosteroids for asthma
oral candidiasis
pneumonia
side effects of LTRAs for chronic asthma
Thirst
GI disturbance
Churg-Strauss syndrome (eosinophilic granulomatosis with polyangiitis (EGPA))
side effects of theophyllines
Similar to caffeine
Tremor
Headache
Arrhythmia
Tachycardia
Nausea
Insomnia
Primary care tx for COPD
Patient education on recognizing an exacerbation early
Action plan/rescue medications for frequent exacerbators - Steroids/antibiotics
Lifestyle advice
Diet
Exercise
Smoking cessation
Medication
Level of inhaled medication depends on severity
SABA/SAMA should be given to everyone with a diagnosis to use when required
FEV1 >50% expected
SABA + LABA
If this is insufficient try SABA + LABA + ICS
If that still insufficient try LAMA + LABA + ICS
OR
LAMA (remove SABA)
If insufficient try LAMA + LABA + ICS
FEV1 <50%
LABA + ICS or
LAMA
For both if insufficient go to LABA + ICS + LAMA
Specialist care tx for COPD
Pulmonary rehab
3 sessions a week for 6 weeks
Consider if there is functional disability from COPD
Increases exercise capacity, decreases breathlessness and increases QOL
Aminophylline/theophylline
Consider if triple therapy unsuccessful
Mucolytics
Nutritional supplements
If low BMI
Long term oxygen therapy Increases survival (3 year survival increases by >50%)
indictions for long term oxygen therapy in COPD
<92% SpO2
FEV1 <30%
Cyanosis
Secondary polycythaemia
Cor pulmonale
what are surgical options for COPD
Pleurectomy for recurrent pneumothoraxes
Bullectomy for isolated bullous disease
Lung volume reduction
Allows expansion of functioning lung
indications for hospital admission in an acute exacerbation of COPD
Severe breathlessness
Rapid symptom onset
Acute confusion
Peripheral oedema
Cyanosis
Low O2 sats
outpatient management of acute exacerbation of COPD
Increase dose/frequency of the SABA
30mg prednisolone for 7-14 days
Ensure osteoporosis prophylaxis for patients on >3 treatments per year
Abx if there is clinical signs of an infection
‘Safety net’ the patients afterwards by reviewing 6 weeks later to optimise medication
inpatient managment of an acute exacerbation of COPD
Oxygen titration
If unknown aim for 88-92%
28% venturi mask on 4L
Management as per outpatient regime with oxygen/nebs
Tx Bronchiectasis
Assess for rare but treatable causes (immune deficiencies)
Stop smoking
Physiotherapy
Inspiratory muscle training
Effective for non CF-related disease
Postural drainage
Twice daily
A way to drain mucus out the lungs by changing positions
Antibiotics for exacerbations
Immunisations
Bronchodilators in most cases
Surgery is rarely indicated as the disease is rarely confined to one lobe
Lobectomies used to be common – seen in OSCE patients a lot
what sign on chest CT is typical in bronchiectasis
signet ring sign
whats the most common organisms for infective exacerbations of COPD + bronchiectasis
1st = Hib
others: psuedomonas, klebsiella, strep pneumoniae
Tx Cystic fibrosis
Chest
As per bronchiectasis
2 IVAbx used for exacerbations to decrease resistance
One often has pseudomonal cover
There may be azithrymycin prophylaxis
Mucolytics - DNAase nebulisers
Airway clearance devices - Acapella device
Lung transplant - If respiratory failure develops
GI
Pancreatic enzyme replacement - Creon
Fat soluble vitamin supplementation - ADEK
Liver transplant if there is advanced cirrhosis
Other
Diabetes treatment
Fertility treatment
Genetic counselling
Tx non-severe CAP
Oral amoxicillin as OPC
Doxycycline if pen allergic
Tx moderately severe CAP
Oral amoxicillin + clarithromycin IPC
Oral doxycycline if pen allergic
Tx severe CAP
IV clarithromycin + co-amoxiclav in HDU
Pen allergic/MRSA suspected levofloxacin + vancomycin
Tx for at least 10 days
Tx aspiration pneumonia
Treat based on CURB score and add metronidazole
tx HAP
Assess MRSA risk factors Known colonisation Previous infection Long term line/catheter Admitted from nursing home with skin breaks
Mild
Oral doxycycline
Severe
Oral co-trimoxazole
These patients should be discussed with microbiology
what is the post discharge management of a pneumonia
ALL patients should have a follow up CXR in 6 weeks to see resolution of consolidation and to assess for any permanent damage
Non-resolution raises the possibility of bronchial blockage due to carcinoma
complications of pneumonia
Parapneumonic infusion
Empyema
Post-infective bronchiectasis
Lung abscesses
Clubbing
Sepsis
what is the mantoux test for and how do you interpret it
latent TB
>5mm - Positive in Immunosuppressed individuals Those with prior TB Recent contacts
> 10mm
Positive in
Those at risk of TB
> 15mm
Positive in any individual
before treating TB what should be screened for
HIV/HEPB/C screening should be offered before starting treatment
Tx Tb
2 months of rimapicin, izoniazid(+pyridoxine), ethambutol, pyrazinamide then 4 months of rifampicin and izoniazid (+pyridoxine) for a total of 6 months
how does CNS involvement of Tb change the treatment time
CNS involvement = 12 months of dual therapy
what is the close contact protocol with a confirmed case of Tb
all household members should be tested
side effects of RIPE drugs for Tb
Rifampicin
Abnormal LFTs
Pink urine
Isoniazid
Peripheral neuropathy
Encephalopathy
Both rare when prophylactic pyridoxine co-prescribed
Pyrazinamide
Hepatotoxic
Rare but severe
Ethambutol
Optic neuritis
Assess with colour vision testing
Tx tension pneumothorax
100% oxygen
Large bore cannula into the 2nd intercostal space, mid-clavicular line
Attach to a 3 way tap and 50ml syringe and aspirate until there is resistance or the patient coughs excessively
Check with CXR
May discharge if successful with follow up XRs 24 hours and 7 days after to assess resolution
CXR
Chest drain
Tx simple pneumothorax
Rim of air <2cm and patient is not SOB
Discharge
Avoid strenuous exercise
Interval CXR every 2 weeks until resolution
Advise to quit smoking as this affects recurrence
Primary/spontaneous + Rim of air >2cm, or patient SOB
Attempt aspiration (2nd intercostal space method
Failure/recurrence = chest drain
CXR to confirm location
Drain should be attached via tubing to the underwater seal which must be below the level of the patient
Check drain is swinging with respiration, bubbling and CXR to make sure position is ok
Recurrent (>2)/secondary, lack of resolution in 5 days
First chest drain
Then if that does not work a pleurectomy may be indicated
Talc pleuridesis if not
what advice should be given post pneumothorax
avoid flying for 6 weeks
avoid diving permanently
management for small cell lung cancer
Nearly always disseminated at presentation, may respond to chemo/radio
Prophylactic cranial radiotherapy may be indicated
management for non-small cell lung cancer
If >2cm from carina – surgical excision
Also has to be peripheral enough with no lymph/metastatic spread
Adjuvant chemo also done
Curative radiotherapy done if there is poor respiratory reserve
Chemo-radiotherapy for more advanced disease
what are the neuroendocrine complications of small cell lung carcinoma
eaton-lambert syndrome
SIADH
Cushings
Tx of empyema
Requires IVABx and chest drain
Tx interstitial lung disease
Many cases will be unresponsive
20% respond to long courses of prenisolone
Some patients are suitable for lung transplantation
causes for upper zone fibrosis of the lung
CHARTS
C - Coal worker's pneumoconiosis H - Histiocytosis/ hypersensitivity pneumonitis A - Ankylosing spondylitis R - Radiation T - Tuberculosis S - Silicosis/sarcoidosis
causes for lower zone fibrosis of the lung
idiopathic pulmonary fibrosis
most connective tissue disorders (except ankylosing spondylitis) e.g. SLE, RA
drug-induced: amiodarone, bleomycin, methotrexate
asbestosis
Treatment of acute extrinsic allergic alveolitis
Oxygen
Prednisolone
Long term Tx of extrinsic allergic alveolitis
Aim for prevention
Face masks
No exposure
Long term prednisolone may give physiological improvement
Established fibrosis not amenable to treatment
Farmers lung is compensatable in the UK
causes of extrinsic allergic alveolitis
Farmers lung
Caused by micropolyspora
Bird fanciers lungs
Proteins in bird droppings
Malt workers lung
Aspergillus
Tx OSA
Behavioural changes Let partner sleep first Sleep on side Weight reduction Avoid alcohol/tobacco
CPAP via mask
50% will not tolerate CPAP therefore:
Intra-oral devices
Daytime stimulants - Modafinol
Upper airways surgery
complications of OSA
Pulmonary hypertension and cor pulmonale
Type 2 respiratory failure
Hypertension and increased cardiac risk
Tx for T1RF
Treat underlying cause
High flow oxygen (60%)
Consider assisted ventilation if PaO2 remains <8kpa despite 60% O2
Tx for T2RF
Respiratory centre may be reliant on hypoxic drive so oxygen therapy should be given with care starting at 24% O2 and checking the ABG after 20 mins
Tx for sarcoidosis
Simple analgesia
NSAIDs
Corticosteroids (occasional - only if symptomatic)
respiratory causes of clubbing
Intrathoracic neoplasm
Supparative lung disease (lung disease that leads to a cough) Lung abscess CF Bronchiectasis Fungal infection
Interstitial lung disease
