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Medicine year 3 TCD > Respiratory conditions > Flashcards

Respiratory conditions Flashcards

1
Q

Primary vs Secondary vs Tension pneumothorax

A

primary- occurs in pt w/o a known resp disease
secondary- occurs in pt w/ pre existing resp disease
tension- severe pneumothorax involving displacement of mediastinal structures and haemodynamic compromise

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2
Q

primary pneumothorax risk factors

A

smoking
tall and thin
male
young

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3
Q

secondary pneumothorax risk factors

A

pre existing lung disease eg COPD, lung cancer, CF, pneumonia, connective tissue disorders - Marfan’s, trauma, iatrogenic (subclavian central line insertion)

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4
Q

pneumothroax presentation

A

Sudden
Dyspnoea
Pleuritic chest pain - ipsilateral
cough
tachypnoea
tachycardia

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5
Q

pneumothorax signs

A

hyperresonance on percussion
reduced breath sounds
reduced lung expansion
reduced vocal resonance

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6
Q

tension pneumothorax additional findings

A

tracheal deviation away from it
cyanosis
raised JVP

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7
Q

Management of primary pneumothorax

A

if rim of air is small (<2cm) and pt isn’t short of breath, then consider discharge and review
If rim of air is >2cm or pt is SoB, attempt aspiration in the 2nd ICS in the MCL. If this fails insert a chest drain in triangle of safety- 5th ICS, mid axillary line, anterior axillary line. Needle’s inserted just above the rib to avoid the NV bundle.

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8
Q

Management of secondary pneumothorax

A

If pt is >50, and rim of air is >2cm and or pt is SoB, then a chest drain should be inserted.
Attempt aspiration if rim of air is bwt 1-2cm. If aspiration fails, a chest drain should be inserted.
If pneumothorax is less than 1cm, give oxygen and admit for 24 hrs.

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9
Q

Management of Tension pneumothorax

A

emergency decompression- insert large bore cannula into 2nd ICS along the midclavicular line (same spot as usual aspiration)
chest drain insertion immediately after emergency decompression.

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10
Q

PE symptoms

A

Sharp chest pain (typically peluritic)
Dyspnoea
Haemoptysis
Sudden onset

if v large- dizziness/syncope

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11
Q

PE investigations

A

If suspect PE, do 2 levels PE Wells Score:
Clinical signs and symptoms of DVT (leg swelling + pain w/ palpation of deep veins)- 3 points
alternative diagnosis is less liekly than PE - 3 points
heart rate > 100bpm - 1.5 points
immobilisation for over 3 days or surgery in last 4 weeks - 1.5 points
previous DVT/PE- 1.5 points
Haemoptysis - 1 point
Malignancy - 1point
PE likely = more than 4 points

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12
Q

If PE is likely what do you do

A

CTPA immediately- give DOAC in meantime. IV contaast reveals thrombi

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13
Q

If PE is unlikely what do you do

A

D dimer test- if positive arrange immediate CTPA, if negative consider alternative diagnosis

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14
Q

Contraindications for CTPA- ie to do V/Q scan

A

renal impairment, contrast allergy, pregnancy

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15
Q

ECG changes in PE

A

S1Q3T3- large S waves in lead 1, large Q wave in lead III and an inverted T wave in lead III

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16
Q

ABG findings in PE

A

Low PaO2 and normal/low PaCO2 a massive PE may also cause metabolic acidosis

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17
Q

PE management

A

DOAC first line- apixaban or rivaroxaban
If not sutiable then LMWH follwoed by dabigatran or edoxaban or LMWH followed by VKA ie warfarin

If renal impairment is severe then LMWH, unfractionated heparin or LMWH followed by a VKA.
If pt has antiphospholipid syndrome (specifically triple positive in the guidance) then LMWH followed by a VKA should be used.

If VTE was provoked- stop treatment after 3 months.
If VTE was unrpvoked then continue for up to 3 further months

ORBIT Score to assess risk of bleeding

PE w/ haemodynamic instability- Thrombolysis.

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18
Q

Asthma symptoms

A

Wheeze (bilateral expiratory widespread)
Cough
Breathlessness
Dry cough often nocturnal
Symptoms often worse at night bcos less cortisol (which is immunosuppressive) at night

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19
Q

Asthma signs on examination

A

Tachypnoea
Hyperinflated chest
Hyperresonance on percussion
decrease air entry (sign of severe illness: silent chest)
wheeze on auscultation

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20
Q

Asthma diagnosis in patients 5-16 year old

A

Spirometry w/ bronchodilator reversibility test: FEV1:FVC <70% is obstructive. Asthma if there’s obstruction and >12% improvement in FEV1 w/ bronchodilator. Request fractional exhaled nitric oxide if there’s normal spirometry or obstructive spirometry w/ a negative bronchodilator reversibility test. FeNO >= 35 ppb is considered positive in children.

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21
Q

Asthma diagnosis in over 17s

A

Ask if symptoms better away from work/holidays- refer for occupational asthma specialist if so.
All pts should have spirometry w/ bronchodilator reversibility test. Asthma if obstruction and >12% improvement in FEV1 and increase in volume of 200ml or more. All pts should have FeNO test- >40 ppb is positive in adults

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22
Q

Asthma management

A
  1. SABA
  2. SABA and low dose ICS
  3. SABA + low dose ICS + LTRA
  4. SABA + low dose ICS + LABA (+LTRA)
  5. SABA + MART (combined ICS and LABA) (+LTRA)
  6. SABA + medium MART (+LTRA)
  7. SABA + high MART OR LAMA OR theophyline (+LTRA)
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23
Q

Acute Asthma presentation

A

Worsening dyspnoea
Bilateral wheeze
Cough not responding to salbutamol
Possilbe chest tightness
maybe triggered by a resp tract infection
Use of accessory muscles

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24
Q

moderate acute asthma features

A

PEFR 50-75% best or predicted
normal speech
RR <25/min
Pulse <110bpm

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25
Severe asthma features
one of these: PEFR: 33-50% best or predicted Can't complete sentences RR > 25/min Pulse > 110bpm
26
Life threatening asthma features
any of these: PEFR <33% best or predicted Oxygen sats <92% normal pCO2 indicates exhaustion and should be classed as life threatening Mnemonic CHEST: C- cyanosis H- hypotension E- exhaustion, confusion or coma S- silent chest (airways so tight there's no air entry) T- tachycardia (pulse >110)
27
Acute Asthma management
O SHIT ME: Oxygen- maintain sats 94-98% S- Salbutamol H- Hydrocortisone 100 mg IV or prednisolone 40mg daily which should be continued daily for at least 5 days from the attack I- ipratropium bromide- SAMA T- Theophylline. aminophylline infusion if deteriorating M- Magnesium sulphate IV if severe/life threatening E- escalate to ICU if severe/life threatening
28
Pneumonia presentation
Fever Dry/productive cough- pneumofococcal pneumonia is rust/red coloured Dyspnoea Pleuritic chest pain Myalgia and arthralgia - esp in infections w/ legionella or mycoplasma
29
Pneumonia signs
Reduced chest expansion Dullness to percussion Crepitations or bronchial breathing may be heard over the affected area Focal coarse crackles Increased vocal fremitus
30
CXR protocol for pneumonia
Repeat at least weekly as an inpatient and then at 6 weeks follow up
31
What determines pneumonia management?
CURB-65 Confusion- abbreviated mental test score <8/10 U- Urea > 7 R- resp rate >=30 B- BP:systolic <=90, diastolic <=60 A- age >65 0-1 points- treat as outpatient 2: secondary care/hospital admission 3: ICU
32
Pneumonia treatment for 0-1 on CURB 65
Oral amoxicillin for 5 days. If allergy then use a tetracycline (eg doxycycline)/ macrolide (eg clarithromycin)- avoid this in congenital long QT syndrome
33
Pneumonia treatment for 2 on CURB 65
Dual therapy for 7-10 days. Amoxicillin + macrolide (eg clarithromycin)
34
Pneumonia treatment for 3-5 on CURB 65
Co-amoxiclav + macrolide for up to 21 days
35
If pneumonia is severe and/or vomiting?
Use IV abx for 7 days
36
CAP commonest causes
Streptococcus pneumoniae- commonest cause Klebsiella pneumoniae- classically in alcoholics and diabetics Legionella pneumophilia- associated w/ AC systems Influenza A and B Fungal causes- Pneumocystis jirovecii - in immunocompromised pts
37
HAP commonest causes
HAP occurs over course of 48 hrs after admission. Enterobacteria Staph Aureus Pseudomina Aureginosa Legionella Pneumophila
38
HAP treatment
within 5 days of admission: coamoxiclav or cephalosporin over 5 days after admission: Tazocin or cephalosporin or quinolone eg levofloxacin
39
Pneumonia discharge criteria
don't discharge if 2 or more of the following: Temp higher than 37.5 RR >24 HR > 100 SBP <90 Oxygen sats < 90 abnormal mental status inability to eat w/o assitance
40
TB presentation
Dyspnoea Cough w/ or w/o haemoptysis Constitutional symptoms: eg fever+chills, night sweats, fatigue, loss of appetite, weight loss, lymphadenopathy
41
TB investigations
Sputum culture- gold standard CXR
42
What does CXR show for TB
Apical fibrosis, cavitation, paratracheal hilar lymphadenopathy
43
TB management and side effects
RIPE for 4 months Rifampicin- anorexia Isoniazid- constipation Pyrazinamide- sideroblastic anaemia Ethambutol- optic neuritis Continuation phase- next 4 months is Rifampicin and Isoniazid
44
Latent TB- screening
Mantoux test- if positive skin will be sensitive to PPD tuberculin and a small hard red bump will develop at site of infection. BCG vaccination- given to hgih risk infants
45
Pleural effusion causes
Transudative (low protein)- heart failure, cirrhosis, nephrotic syndrome, hypothyroidism Exudative (high protein)- infection, pneumonia, inflammation, infiltration-cancer, pancreatitis, drugs, autoimmune disease
46
pleural effusion symptoms
asymptomatic Dyspnoea Cough Pleuritic chest pain
47
pleural effusion CXR findings
massive pleural effusion- trachea pushed AWAY from white out Costophrenic blunting Unilateral effusion is typically exudative whereas bilateral effusions are typically transudative Pneumonectomy- Trachea pulled TOWARDS white out
48
What is COPD
airway obstruction FEV1:FVC <0.7, little or no reversibility
49
COPD risk factors
>35 smoking history alpha 1 antitrypsin deficiency- breaks down elastase, if elastase isn't being broken down can dmg the connective tissue in the lungs causing COPD and liver cirrhosis
50
COPD presentation
Chronic cough w/ or w/o sputum Dyspnoea Wheeze can have weight loss, reduced exercise tolerance, ankle swelling, fatigue
51
COPD signs
Use of accessory muscle of respiration Hyperinflation (barrel chest) Decreased expansion Resonant/Hyperresonant percussion note Decreased breath sounds Cyanosis Cor pulmonale (right side HF) pitting oedema, raised JVP nicotine stains bilateral wheeze
52
COPD investigations
Spirometry- FEV1:FVC- <70%, no reversibility after bronchodilator
53
COPD severity scale
FEV1:FVC <0.7 FEV1 >=80% - Stage 1 Mild FEV1 50-79%- Stage 2 Moderate FEV1 30-49% Stage 3- Severe FEV1 <30% Stage 4- V severe
54
COPD management
Smoking cessation- offer NRT< varenicicline or buporpoion as appropriate. Vaccinations- influenza and pneumococcal Physiotherapy/pulmonary rehab if indicated. Treat comorbidities 1. SABA or SAMA as required 2 a) No asthma- SABA as required + LABA +LAMA b) Asthma- SABA/SAMA as required + LABA + ICS 3. SABA as required + LABA + LAMA + ICS
55
COPD Exarcebation symptoms
Preceding corzyal symptoms (cold) Increased breathlessness, cough, sputum. Most common infective cause is haemophilus influenzae Worsening ankle swelling
56
COPD exacerbation management
Oxygen to give SaO2 not over 92% Prednisolone 40 mg/day 7 days Abx if sputum is purulent or patient has severe illness. If after 1 hrs still have T2 RF w/ resp acidosis and initial treatment doesn't correct- urgent ICU opinion. Non invasive ventilation Many COPD pts have T2 resp failure and therefore admin of too much O2 may be detrimental
57
Interstitial lung disease causes
Idiopathic pulmonary fibrosis, sarcoidosis, occupational- asbestos, environemtnal eg pigeons, immune- connective tissue disease. Drugs: Any! eg Methotrexate, Amiodarone, Bleomycin, Nitrofurantoin
58
Interstital lung disease symptoms
Chronic Dyspnoea Dyspnoea on exertion Non productive paroxysmal cough joint swelling/stiffness smoker
59
Interstitial lung disease on examination
Fine bi basal crepitations, end inspiratory Clubbing
60
interstitial lung disease investigations
CXR- usually at bottom lungs, subpleural, basal and at the end of the lung High res CT scan- ground glass appearance- basal fibrosis and honeycombing Lung function tests- in restrictive lung disease like fibrosis- the lungs shrink- so FVC goes down and FEV1 geos down too, but in proportion, so ratio is above 70% in restrictive lung disease
61
Interstitial lung disease management
antifibrotics if idiopathic pulmonary fibrosis eg pirfenidone. pulmonary rehab to help symptoms. if connective tissue disease is the cause- immunosuppression- steorids eg prednisolone
62
sarcoidosis demographics
Afro Caribbeans 20-40 year olds
63
sarcoidosis presentation
Fever Erythema nodosum Polyarthralgia Bilateral hilar lymphadenopathy Dry cough Progressive dyspnoea- decreased exercise tolerance Chest pain Enlarged salivary glands
64
sarcoidosis investigations
FBC- leukopenia/lymphopenia raised inflammatory markers ACE levels can be elevated Lung function tests can be obstructive or restrictive CXR- bilateral hilar lymphadenopaty Gold standard- histology from a biopsy
65
Sarcoidosis management
Treat w/ steroids if PUNCH: P- parenchymal lung disease Uveitis Neurological involvement Cardiac involvement Hypercalcaemia (can cause renal dysfunction) Treat w/ 0.5 mg per kg Prednisolone 2-4 weeks Most pts get better even w/o treatment
66
Bronchiectasis- symptoms
persistent cough lots of purulent sputum intermittent haemoptysis Dyspnoea Wheeze
67
Bronchiectasis- signs
clubbing coarse inspiratory crepitations crackles and low pitch wheezing
68
Bronchiectasis investigations
High res CT- Signet scan
69
Bronchiectasis treatment
physiotherapy and airway clearance techniques Smoking cessation Pneumococcal and annual influenza vaccinations treatment w/ short courses of Abx for exacerbations or chest infections

Medicine year 3 TCD (10 decks)

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