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CP3 Management > Respiratory > Flashcards

Respiratory Flashcards

1
Q

Tx acute exacerbation of asthma

A

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

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2
Q

what are features on an ABG that indicate a life threatening asthma attack

A

Normal PaCo2 - should be low due to hyperventilation

Severe Hypoxia

Low pH

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3
Q

post recovery Tx for acute asthma exacerbation

A

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

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4
Q

Tx for chronic asthma in primary care

A
  1. SABA + ICS
    Used to be one each but this changed to pretty much everyone getting preventer inhalers
  2. SABA + ICS + LABA
  3. Increased ICS dose OR add LTRA
    If there has been no response to the LABA consider stopping it
  4. 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

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5
Q

side effects of SABAs

A

tachycardia
cramps
tremor
hypokalaemia

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6
Q

Side effects of inhaled corticosteroids for asthma

A

oral candidiasis

pneumonia

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7
Q

side effects of LTRAs for chronic asthma

A

Thirst

GI disturbance

Churg-Strauss syndrome (eosinophilic granulomatosis with polyangiitis (EGPA))

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8
Q

side effects of theophyllines

A

Similar to caffeine

Tremor

Headache

Arrhythmia

Tachycardia

Nausea

Insomnia

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9
Q

Primary care tx for COPD

A

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

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10
Q

Specialist care tx for COPD

A

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%)
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11
Q

indictions for long term oxygen therapy in COPD

A

<92% SpO2

FEV1 <30%

Cyanosis

Secondary polycythaemia

Cor pulmonale

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12
Q

what are surgical options for COPD

A

Pleurectomy for recurrent pneumothoraxes

Bullectomy for isolated bullous disease

Lung volume reduction
Allows expansion of functioning lung

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13
Q

indications for hospital admission in an acute exacerbation of COPD

A

Severe breathlessness

Rapid symptom onset

Acute confusion

Peripheral oedema

Cyanosis

Low O2 sats

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14
Q

outpatient management of acute exacerbation of COPD

A

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

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15
Q

inpatient managment of an acute exacerbation of COPD

A

Oxygen titration

If unknown aim for 88-92%

28% venturi mask on 4L

Management as per outpatient regime with oxygen/nebs

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16
Q

Tx Bronchiectasis

A

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

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17
Q

what sign on chest CT is typical in bronchiectasis

A

signet ring sign

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18
Q

whats the most common organisms for infective exacerbations of COPD + bronchiectasis

A

1st = Hib

others: psuedomonas, klebsiella, strep pneumoniae

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19
Q

Tx Cystic fibrosis

A

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

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20
Q

Tx non-severe CAP

A

Oral amoxicillin as OPC

Doxycycline if pen allergic

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21
Q

Tx moderately severe CAP

A

Oral amoxicillin + clarithromycin IPC

Oral doxycycline if pen allergic

22
Q

Tx severe CAP

A

IV clarithromycin + co-amoxiclav in HDU

Pen allergic/MRSA suspected levofloxacin + vancomycin

Tx for at least 10 days

23
Q

Tx aspiration pneumonia

A

Treat based on CURB score and add metronidazole

24
Q

tx HAP

A 
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

25
Q

what is the post discharge management of a pneumonia

A

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

26
Q

complications of pneumonia

A

Parapneumonic infusion

Empyema

Post-infective bronchiectasis

Lung abscesses

Clubbing

Sepsis

27
Q

what is the mantoux test for and how do you interpret it

A

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

28
Q

before treating TB what should be screened for

A

HIV/HEPB/C screening should be offered before starting treatment

29
Q

Tx Tb

A

2 months of rimapicin, izoniazid(+pyridoxine), ethambutol, pyrazinamide then 4 months of rifampicin and izoniazid (+pyridoxine) for a total of 6 months

30
Q

how does CNS involvement of Tb change the treatment time

A

CNS involvement = 12 months of dual therapy

31
Q

what is the close contact protocol with a confirmed case of Tb

A

all household members should be tested

32
Q

side effects of RIPE drugs for Tb

A

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

33
Q

Tx tension pneumothorax

A

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

34
Q

Tx simple pneumothorax

A

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

35
Q

what advice should be given post pneumothorax

A

avoid flying for 6 weeks

avoid diving permanently

36
Q

management for small cell lung cancer

A

Nearly always disseminated at presentation, may respond to chemo/radio

Prophylactic cranial radiotherapy may be indicated

37
Q

management for non-small cell lung cancer

A

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

38
Q

what are the neuroendocrine complications of small cell lung carcinoma

A

eaton-lambert syndrome

SIADH

Cushings

39
Q

Tx of empyema

A

Requires IVABx and chest drain

40
Q

Tx interstitial lung disease

A

Many cases will be unresponsive

20% respond to long courses of prenisolone

Some patients are suitable for lung transplantation

41
Q

causes for upper zone fibrosis of the lung

A

CHARTS

C - Coal worker's pneumoconiosis
H - Histiocytosis/ hypersensitivity pneumonitis
A - Ankylosing spondylitis
R - Radiation
T - Tuberculosis
S - Silicosis/sarcoidosis
42
Q

causes for lower zone fibrosis of the lung

A

idiopathic pulmonary fibrosis

most connective tissue disorders (except ankylosing spondylitis) e.g. SLE, RA

drug-induced: amiodarone, bleomycin, methotrexate
asbestosis

43
Q

Treatment of acute extrinsic allergic alveolitis

A

Oxygen

Prednisolone

44
Q

Long term Tx of extrinsic allergic alveolitis

A

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

45
Q

causes of extrinsic allergic alveolitis

A

Farmers lung
Caused by micropolyspora

Bird fanciers lungs
Proteins in bird droppings

Malt workers lung
Aspergillus

46
Q

Tx OSA

A 
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

47
Q

complications of OSA

A

Pulmonary hypertension and cor pulmonale

Type 2 respiratory failure

Hypertension and increased cardiac risk

48
Q

Tx for T1RF

A

Treat underlying cause

High flow oxygen (60%)

Consider assisted ventilation if PaO2 remains <8kpa despite 60% O2

49
Q

Tx for T2RF

A

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

50
Q

Tx for sarcoidosis

A

Simple analgesia

NSAIDs

Corticosteroids (occasional - only if symptomatic)

51
Q

respiratory causes of clubbing

A

Intrathoracic neoplasm

Supparative lung disease (lung disease that leads to a cough)  
Lung abscess 
CF 
Bronchiectasis  
Fungal infection

Interstitial lung disease

CP3 Management (11 decks)

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