Respiratory from Passmed Flashcards
types of fibrosis that typically affect the upper zones
CHARTS
- Coal worker’s pneumoconiosis
- Histocytosis/Hypersensitivity pneumonitis
- Ank spon
- Radiation
- Tuberculosis
- Sarcoid/Silicosis
fibrosis causes that predominantly affect the lower zones
idiopathic pulmonary fibrosis
most connective tissue disorders EXCEPT ank spon (so like SLE)
drug induced
asbestosis
drugs that cause fibrosis
amiodarone
bleomycin
methotrexate
nitrofurantoin (and other abx).
chemo drugs
three things you can prescribe as part of smoking cessation
NRT
Varenicline
Buproprion
they should not be prescribed in combination with each other
what poisoning is associated with resp alkylosis
salicylate
salicylate overdose leads to a mixed respiratory alkalosis and metabolic acidosis. Early stimulation of the respiratory centre leads to a respiratory alkalosis whilst later the direct acid effects of salicylates (combined with acute renal failure) may lead to an acidosis
key indications for NIV
- COPD with respiratory acidosis pH 7.25-7.35
- can be used if more acidotic but they need HDU and lower threshold for intubation
- type II resp failure secondary to chest wall deformity, neuromuscular disease or obstructive sleep apnoea
- cardiogenic pulmonary oedema unresponsive to CPAP
- weaning from tracheal intubation
what are the recommended initial settings for bi-level pressure support in COPD
- EPAP: 4-5cm H2O
- IPAP: 10-15cm H2O
- back up rate 15 breaths/min
- back up inspiration:expiration ratio: 1:3
hypercalcaemia + bilateral hilar lymphadenopathy = ?
sarcoidosis
most common organisms that cause infective exacerbations of COPD
Haemophilus influenzae (most common cause)
Streptococcus pneumoniae
Moraxella catarrhalis
treatment for infective exacerbation of COPD
- increase frequency of bronchodilator use and consider giving via a nebuliser
- give prednisolone 30 mg daily for 5 days
- oral antibiotics ‘if sputum is purulent or there are clinical signs of pneumonia’
- the BNF recommends one of the following oral antibiotics first-line: amoxicillin or clarithromycin or doxycycline.
what is varenicline
- nicotinic receptor partial agonist
- start 1 week before they stop smoking
- recommended course is 12 weeks
- nausea is most common adverse effect
- caution in pts with self-harm/depression history
- contraindicated in pregnancy and breastfeeding
what is bupropion
a norepinephrine and dopamine reuptake inhibitor and nicotinic agonist
- start 1-2 weeks before stop smoking date
- 1 in 1000 risk of seizures
- contraindicated in
- pregnancy
- epilepsy
- breast feeding
management of smoking in pregnancy
- All women are CO tested
- anyone with CO of 7ppm or more referred to NHS stop smoking
- first line
- CBT
- NRT
- note that varenicline and bupropion are contraindicated in pregnancy
COPD management flow diagram
criteria to determine whether a patient has asthmatic features of COPD
- any previous, secure diagnosis of asthma or of atopy
- a higher blood eosinophil count - note that NICE recommend a full blood count for all patients as part of the work-up
- substantial variation in FEV1 over time (at least 400 ml)
- substantial diurnal variation in peak expiratory flow (at least 20%)
when can you fly after a pneumothorax
one week after a CXR shows complete resolution of the pneumothorax
what is catamenial pneumothorax
Catamenial pneumothoraces are pneumothoraces that occurs in association with menses, secondary to thoracic endometriosis
management of primary pneumothorax
- patient not breathless AND rim <2cm from chest wall
- consider discharge
- OTHERWISE
- aspiration attempted
- if this fails
- defined as >2cm or pt still SOB
- insert chest drain
management of secondary pneumothorax
- if pt >50 and/or rim >2cm and/or they are short of breath
- chest drain
- otherwise if rim 1-2cm aspirate
- if aspiration fails then chest drain
- if rim <1cm then give oxygen and admit for observation
what are the 3 types of altitude related disorders
acute mountain sickness (AMS) which may progress to high altitude pulmonary edema (HAPE) or high altitude cerebral edema (HACE)
all caused by chronic hypobaric hypoxia which develops at high altitudes
management of HACE
high altitude cerebral oedema
descent and dexamethasone
management of HAPE
high altitude pulmonary oedema
descent
nifedipine, dexamethasone, acetaxolamide (all work by reducing systolic pulmonary artery pressure)
oxygen if available
multiple, round well-defined lung secondaries seen on CXR are often referred to as _____ and they are most commonly seen in which type of cancer
these are cannonball mets
they are most commonly seen in renal cell cancer but can also be secondary to choriocarcinoma and prostate cancer
what is the grading system for COPD
what is histoplasmosis and what are the typical CXR findings
fungal lung disease
CXR shows unilateral or bilateral interstitial or reticulonodular infiltrates
blood test that can help diagnose sarcoid
serum ACE is raised in approximately 60% of sarcoid patients at diagnosis
where would you insert the chest drain for a pleural effusion?
- The triangle of safety actually has four sides
- The base of the axilla (superior boundary)
- Lateral edge of the pectoralis major (medial boundary)
- 5th intercostal space (inferior boundary)
- Anterior border of latissimus dorsi (lateral boundary).
what are the pleural plaques seen on CXR of pts with exposure to asbestos
- Pleural plaques are most common form of asbestos-related lung disease
- Are benign.
- Indicate the patient has been exposed to asbestos 20-40 years prior
- this could put them at a higher ris of mesothelioma but the plaques themselves are not premalignant and don’t require monitoring
what spirometry findings are there in asbestosis
FEV1 is reduced
FVC is SIGNIFICANTLY reduced
therefore it’s: FEV1 reduced, FEV1/FVC - normal or increased
what effect does ankylosing spondylisis have on pulmonary function tests
FEV1 and FVC are both reduced but the ratio remains normal or increased
- this is because of
- apical lung fibrosis
- thoracic kyphosis and reduced chest wall expansion
what is the treatment for allergic bronchopulmonary aspergillosis
oral glucocorticoids
which patients with COPD should be considered for prophylactic treatment with azithromycin?
criteria are as follows
- do not smoke
- have optimised all other therapies including inhaled, vaccinations, rehab
- continue to have one or more of the following
- frequent exacerbations (4 or more per year)
- prolonged exacerbations with sputum production
- exacerbations resulting in hospitalisation
why does FeNO testing work for asthma
Nitric oxide is produced by 3 types of nitric oxide synthases (NOS). One of the types is inducible (iNOS) and levels tend to rise in inflammatory cells, particularly eosinophils. Levels of NO therefore typically correlate with levels of inflammation.
what tests to diagnose asthma in an adult
Spirometry with reversibility
FeNO
what is the criteria of reversibility in a diagnosis of asthma
>12% increase in FEV1
this must also be an absolute increase in FEV1 of 200ml
where is alpha-1 antitrypsin made
in the liver - that’s why deficiency damages the liver as it accumulates there
what is allergic bronchopulmonary aspergillosis
- it is an allergy to aspergillus spores
- it often occurs with a history of bronchiectasis and eosinophilia
- features include
- bronchosonstriction
- possibly with previous label of asthma
- bronchiectasis
- bronchosonstriction
- management is with oral glucocorticoids
- triconozole is sometimes used as second line
what is dextrocardia
condition in which the heart is pointed toward the right side of the chest
it presents with quiet heart sounds and small volume complexes in the lateral leads
what is kartagener’s syndrome
- rare, autosomal recessive genetic ciliary disorder comprising the triad of:
- situs inversus or dextrocardia
- chronic sinusitis
- bronchiectasis
what is acute bronchitis
usually viral
occurs generally in autumn and winter
usually self limiting
inflammation of the trachea and major bronchi and is therefore associated with oedematous large airways and the production of sputum
differentiating acute bronchitis from pneumonia
History: Sputum, wheeze, breathlessness may be absent in acute bronchitis whereas at least one tends to be present in pneumonia.
Examination: No other focal chest signs (dullness to percussion, crepitations, bronchial breathing) in acute bronchitis other than wheeze. Moreover, systemic features (malaise, myalgia, and fever) may be absent in acute bronchitis, whereas they tend to be present in pneumonia.
when should you consider antibiotics in acute bronchitis
and what abx should you choose
- if patients are very unwell systemically
- have pre-existing co-morbidities
- have high CRP above 100
doxycycline is first line
what are the indications for steroids in sarcoidosis
and what steroids would you prescribe
- patients with chest x-ray stage 2 or 3 disease AND who are symptomatic.
- hypercalcaemia
- eye, heart or neuro involvement
prescribe oral prednisolone
X ray findings in heart failure
- ABCDE
- Alveolar oedema (bat wings)
- kerley B lines (interstitial oedema)
- Cardiomegaly
- Dilated prominent upper lobe vessels
- Effusion (pleural)
management of pleural effusion
- US guided aspiration
- 21G needle and 50ml syringe
- fluid sent for:
- pH
- protein
- lactate
- cytology
- microbiology
name two syndromes associatted with sarcoidosis
- lofgren’s syndrome
- acute form of disease
- bilateral hilar lymphadenopathy
- erythema nodosum
- fever polyarthralgia
- excellent prognosis
- heerfordt’s syndrome
- uveoparotid fever secondary to sarcoidosis
- parotid enlargement
- fever
- uveitis
features of sarcoidosis
acute: erythema nodosum, bilateral hilar lymphadenopathy, swinging fever, polyarthralgia
insidious: dyspnoea, non-productive cough, malaise, weight loss
skin: lupus pernio
hypercalcaemia: macrophages inside the granulomas cause an increased conversion of vitamin D to its active form (1,25-dihydroxycholecalciferol)
what organism often causes cavitating pneumonia in the upper lobes and is also commonly seen in patients with a history of alcohol abuse or diabetes
klebsiella pneumoniae
how do large emphesematous bullae appear on cxr and what might they be mistaken for
they appear as lucent areas without a visible wall
they are commonly mistaken for pneumothoraces
what are pneumatoceles
Pneumatoceles are intra-pulmonary air filled cystic spaces, usually caused as a result of ventilator induced lung injury. Pneumatoceles appear as a lucency with a thin wall on cxr.
lung cancer that produces lambert-eaton syndrome, cushings and hyponatraemia is likely what type of lung cancer
- small cell lung cancer has the following paraneoplastic features
- ectopic acth production –> cushings
- ectopic adh production –> dilutional hyponatraemia
lung cancer that produces hypercalcaemia is likely what type of lung cancer
squamous cell lung cancers produce parathyroid hormone related protein leading to hypercalcaemia
what are the steps for asthma management
7 steps
- Newly-diagnosed asthma
- Short-acting beta agonist (SABA)
- Not controlled on previous step OR new asthma with symptoms 3 times a week or night-time waking
- SABA + low-dose ICS
- SABA + low-dose ICS + leukotriene receptor antagonist (LTRA)
- SABA + low-dose ICS + long-acting beta agonist (LABA)
- Continue LTRA depending on patient’s response to LTRA
- SABA +/- LTRA
- MART that includes a low-dose ICS
- SABA +/- LTRA + medium-dose ICS MART
- OR consider changing back to a fixed-dose of a moderate-dose ICS and a separate LABA
- SABA +/- LTRA + one of the following options:
- increase ICS to high-dose (only as part of a fixed-dose regime, not as a MART)
- a trial of an additional drug (for example, a long-acting muscarinic receptor antagonist or theophylline)
- seeking advice from a healthcare professional with expertise in asthma
- SABA +/- LTRA + one of the following options:
What is MART
- Maintenance and reliever therapy
- combined ICS and LABA
- used as both maintenance and reliever as required
first line abx for infective exacerbation of COPD
doxycycline, clarithromycin or amoxicillin
think about pen allergy and local guidelines
how to escalate care in asthma 6 steps
- Oxygen
- Salbutamol nebulisers
- Ipratropium bromide nebulisers
- Hydrocortisone IV OR Oral Prednisolone
- Magnesium Sulfate IV
- Aminophylline/ IV salbutamol
what are centor criteria and what do they mean
- The Centor criteria* are as follows:
- presence of tonsillar exudate
- tender anterior cervical lymphadenopathy or lymphadenitis
- history of fever
- absence of cough
- *if 3 or more of the criteria are present there is a 40-60% chance the sore throat is caused by Group A beta-haemolytic Streptococcus
when should you assess patients with COPD for long term oxygen therapy
- Assess patients if any of the following:
- FEV1 < 30% predicted
- cyanosis
- polycythaemia
- peripheral oedema
- raised jugular venous pressure
- oxygen saturations less than or equal to 92% on room air
how should you assess COPD patients for long term oxygen therapy
- two abgs at least three weeks apart
- offer if:
- pO2 <7.3kPa
- pO2 7.3-8kpa and one of the following
- peripheral oedema
- secondary polycythaemia
- pulmonary hypertension
- also assess for risk of fall from equipment
in patients with exacerbations of COPD that is refractory to maximal medical treatment, which pH are they most likely to benefit from NIV
- patients with a pH of 7.25-7.35 achieve the most benefit from BiPAP
- if pH is less than 7.25 then they need invasive ventilation or BiPAP with HDU (more monitoring)
if there’s lung cancer picture with gynaecomastia and pulmonary osteoarthropathy what kind of lung cancer is it?
adenocarcenoma
what is hypertrophic pulmonary osteoarthritis
- syndrome characterised by triad of
- periostitis
- digital clubbijg
- painful arthropathy of the large joints
- can be caused by lung cancer
what is the diagnostic test for obstructive sleep apnoea
polysomnography
how do you classify asthma attack severity
how do you escalate treatment in asthma attacks
- Oxygen
- Salbutamol nebulisers
- Ipratropium bromide nebulisers
- Hydrocortisone IV OR Oral Prednisolone
- Magnesium Sulfate IV
- Aminophylline/ IV salbutamol
differentials for early post-operative SOB
atelectasis, pneumonia and pulmonary embolism
atelectasis is the most common and is treated with physio and deep breathing exercises
what are some things that cause anterior mediastinum masses
The commonest causes of an anterior mediastinum mass can be remembered by the 4 T’s: teratoma, terrible lymphadenopathy, thymic mass and thyroid mass
how do you manage small cell lung cancer
- usually metastatic disease by time of diagnosis
- patients with very early stage disease (T1-2a, N0, M0) are now considered for surgery. NICE support this approach in their 2011 guidelines
- however, most patients with limited disease receive a combination of chemotherapy and radiotherapy
- patients with more extensive disease are offered palliative chemotherapy
5 steps in inhaler technique
- Remove cap and shake
- Breathe out gently
- Put mouthpiece in mouth and as you begin to breathe in, which should be slow and deep, press canister down and continue to inhale steadily and deeply
- Hold breath for 10 seconds, or as long as is comfortable
- For a second dose wait for approximately 30 seconds before repeating steps 1-4.
All patients with a pleural effusion in association with sepsis or a pneumonic illness require diagnostic pleural fluid sampling - when should this be done with a chest tube?
- if the fluid is purulent or turbid/cloudy a chest tube should be placed to allow drainage
- if the fluid is clear but the pH is less than 7.2 in patients with suspected pleural infection a chest tube should be placed
what is acute respiratory distress syndrome?
Acute respiratory distress syndrome (ARDS) is caused by the increased permeability of alveolar capillaries leading to fluid accumulation in the alveoli, i.e. non-cardiogenic pulmonary oedema. It is a serious condition that has a mortality of around 40% and is associated with significant morbidity in those who survive.
6 causes of ARDS
- infection: sepsis, pneumonia
- massive blood transfusion
- trauma
- smoke inhalation
- acute pancreatitis
- cardio-pulmonary bypass
diagnostic criteria of ARDS
- acute onset (within 1 week of a known risk factor)
- pulmonary oedema: bilateral infiltrates on chest x-ray (‘not fully explained by effusions, lobar/lung collapse or nodules)
- non-cardiogenic
- pO2/FiO2 < 40kPa (200 mmHg)
management of ARDS
- due to the severity of the condition patients are generally managed in ITU
- oxygenation/ventilation to treat the hypoxaemia
- general organ support e.g. vasopressors as needed
- treatment of the underlying cause e.g. antibiotics for sepsis
- certain strategies such as prone positioning and muscle relaxation have been shown to improve outcome in ARDS
What are 4 situations in which oxygen therapy is not indicated unless there is evidence of hypoxia
- myocardial infarction and acute coronary syndromes
- stroke
- obstetric emergencies
- anxiety-related hyperventilation
advice for patients on how long URTIs will take to resolve
- acute otitis media: 4 days
- acute sore throat/acute pharyngitis/acute tonsillitis: 1 week
- common cold: 1 1/2 weeks
- acute rhinosinusitis: 2 1/2 weeks
- acute cough/acute bronchitis: 3 weeks
when would you take an immediate antibiotic prescribing approach with
- children younger than 2 years with bilateral acute otitis media
- children with otorrhoea who have acute otitis media
- patients with acute sore throat/acute pharyngitis/acute tonsillitis when 3 or more Centor criteria are present
what is the target oxygen saturation in acute asthma
94-98%
what is meig’s syndrome
Benign ovarian tumour, ascites, and pleural effusion.
