Respiratory guidelines

Question 1

Asthma investigation

• what do all adults get
• what do children get

Answer 1

FeNO and spirometry with reversibility

children only get FeNO if spirometry inconclusive

Question 2

Astham investigation
- diagnostic cutoffs
reversibility
FEV1/FVC ratio
FeNO

Answer 2

12% reversibility (AND 200ml in adults)
ratio of <0.7
FeNO >40ppb (>35 in children)

Question 3

Asthma treatment escalation ADULTS

Answer 3

SABA
\+ low dose ICS
\+ LABA
\+ LRTA or moderate dose ICS (stop LABA if not working)
specialist

Question 4

Asthma treatment escalation CHILDREN

Answer 4

SABA
\+ very low dose ICS
Step 2 (>5) = LABA or LTRA
Step 2 (<5) = LTRA
Step 3 = increase to low dose ICS. Add LABA/LRTA and stop LABA if not helpful
specialist

Question 5

Acute asthma attack categories

Answer 5

Life threatening = PEFR<33, silent chest, <92%, normal CO2
Acute severe = >110bpm, cant complete sentences, PEFR33-50, RR>25
Moderate = 50-75% PEFR

Question 6

Acute asthma management
standard
escalated

Answer 6

standard
- oxygen driven nebs (salbutamol and ipratropium)
give ipra 4-6hourly, salbutamol back to back
pred/hydrocortisone for at least 5d
escalated
- magnesium
- IV aminophylline
IV salbutamol, intubation etc

Question 7

COPD Ix

- if you suspect COPD what 3 things do you get

Answer 7

CXR (?mass), FBC (2’ polycythaemia), spirometry/reversibility testing

Question 8

Grading of COPD cutoffs

Answer 8

All based on FEV1
Mild=  >80 WITH symptoms and FEV1/FVC <0.7
mod = 50-80
severe = 30-50
very severe = <30

Question 9

COPD treatment escalation

Answer 9

1) SABA or SAMA
2) asthmatic features = LABA+ICS; no asthmatic features = LABA/LAMA
3) oral theophylline

Question 10

Antibiotic prophylaxis in COPD?

Answer 10

Azithromycin

Question 11

Asthmatic features for COPD step 2???

Answer 11

1) previous history of asthma or atopy
2) eosinophilia
3) diurnal variation of PEFR >20%
4) FEV1 variation >400ml

Question 12

When do you assess someone for LTOT if has COPD

Answer 12

FEV1 <30% (i.e. very severe)
cyanosis/polycthaemia
oedema/raised JVP

Question 13

How do you assess someone for LTOT?

Answer 13

ABGs on two separate occasions

Question 14

Based on the ABGs, when do you offer LTOT for COPD

Answer 14

pO2 <7.3

pO2 7.3-8 + oedema, polycythaemia, pul HTN

Question 15

COPD exacerbation Mx

Answer 15

Nebulised bronchodilators and prednisolone 7-14d

Abx if sign of infection –> amox + clari

Question 16

CURB65 score and meaning

Answer 16

Confusion <=8/10 AMTS
urea >7
RR >=20
BP <=90/60
65+

0-1 = home with amox 5d (depending on CRP test)
2-3 = hospital with amox+clari 7d
4-5 = ITU with coamox/tazocin 7d

Question 17

CRP point of care test in GP for penumonia

Answer 17

Helps you decide if Abx are needed if they score CURB0
>100 = yes
20-100 = delayed
<20 = no

Question 18

Abx guideline:

• CAP
• atypical CAP
• HAP

Answer 18

CAP = amox
atypical CAP = clarithromycin
HAP depends on when it has occurred after admission (remember HAP is defined as at least 48 hours after admission):
- if within first 5d = coamox, cefurox
- if after 5th day of admission = taz, cipro, ceftaz

Question 19

2ww lung cancer referral for CXR

Answer 19

40+ and any of:
- cough, fatigue, SOB, pain, weight loss, anorexia

need 2 of them if never smoked

Question 20

2ww lung cancer referral for clinic straight away

Answer 20

40+ and haemoptysis or abnormal CXR

Question 21

best Ix for lung Ca

Answer 21

CT (hence why you do it if CXR negative and youre still suspicious)

Question 22

Difference between SCLC and NSCLC

Answer 22

SCLC not usually amenable to surgery, need chemo
NSCLC usually amenable to surgery,
both have radio

Question 23

Idiopathic lung fibrosis

• gold standard Ix
• TLCO and spirometry

Answer 23

• high res CT
  restrictive picture on spirometry
  TLCO is low

Question 24

definitive Tx for idiopathic lung fibrosis

Answer 24

lung transplant

Question 25

Sarcoidosis useful tests (no diagnostic one)

Answer 25

``` raised ACE and ESR restrictive spirometry non-caseating granuloma formation bilateral hilar lymphadenpatphy upper zone fibrosis ```

Question 26

Management of sarcoid

Answer 26

Don't treat asymptomatic lymphadenopathy | If Sx --> prednisolone

Question 27

Interpretation of Mantoux test

Answer 27

If <6mm = no reaction, immunise If 6-15mm = medium reaction, ?previous TB or previous vaccination, don't immunise If >15mm = big reaction, active TB

Question 28

when do you use interferon gamma quantiferon gold test?

Answer 28

if Mantoux equivocal or positive | If Mantoux inaccurate (sarcoid, military TB, lymphoma HIV)

Question 29

Drugs for TB and SEs

Answer 29

``` Active = 2m RIPE and 4m RI Latent = 3m RIP or 6m IP Meningeal = 12m RIPE + steroids ``` ``` rifampicin = red piss and hepatitis isoniazid = peripheral neuropathy and hepatitis pyranzinamide = gout and hepatits ethambutol = optic neuritis ```

Question 30

Pneumothorax Mx

Answer 30

Primary <2cm = clinic in 6/52!! >2cm OR BREATHLESS = aspirate and observe Secondary 0-1 = admit O2 observe 1-2 = aspirate >2 = chest drain

Question 31

Wells score PE

Answer 31

0-4 is unlikely to be PE. 5+ = CTPA` PE most likely = 3 DVT present = 3 Recent immobilisation = 1.5 Previous DVT/PE = 1.5 Tachycardia >100 = 1.5 ``` Haemoptysis = 1 Malignancy = 1 ```

Question 32

Well score DVT just the cutoff Mx based on that

Answer 32

0-1 is unlikely --> D-dimer to exclude | 2+ is likely ==> USS leg within 4 hours. if cant get one within 4 hours, treat with LMWH assuming its there

Question 33

Do you start LMWH before the CTPA is back

Answer 33

yes because it usually takes a number of hours to get done

Question 34

Tx of PE

Answer 34

haemodynamically unstable = thrombolysis stable = LMWH for 5d or until INR>2 for 2days whichever is longer. start warfarin or NOAC witin 24 hours. if warfarin crossover with LMWH, if NOAC just give it 2 hours before dose and don't carryover.

Question 35

ARDS - how do you exclude thatit is cardiac in origin if unsure

Answer 35

pulmonary artery wedge pressure.

Question 36

obstructive sleep apnoea Best Ix and other Ix

Answer 36

Sleep studies is best test | Epworth sleepiness scale and multiple sleep latency test also used

Question 37

Mx of obstructive sleep apnoea

Answer 37

If sleepiness in daytime --> CPAP at night | If no sleepiness or CPAP not tolerate --> mandibular advancement device

Question 38

pleural effusions and lights

Answer 38

protein >35 = exudate protein <25 = transudate ``` 25-35 use lights criteria exudate if: - pleural protein is >50% the serum protein - pleural LDH >60% plasma LDH - pleural LDH >2/3rds NORMAL LDH ```

Question 39

if pleural fluid is exudate?

Answer 39

contrast CT and send off sample to lab

Question 40

if pleural fluid is purulent or has pH <7.2

Answer 40

chest tube

Question 41

NG tube safety

Answer 41

pH <5.5 is happy days | Otherwise need to do a CXR

Question 42

NIV indications in COPD

Answer 42

any respiratory acidosis despite maximal therapy

Question 43

when is an aspirate exudate

Answer 43

<25 protein = transudate >35 protein = exudate in between use lights criteria. Exudate if pleural fluid: - protein >50% serum protein - LDH >60% serum LDH - LDH >2/3rds normal serum LDH