Respiratory guidelines Flashcards
Asthma investigation
- what do all adults get
- what do children get
FeNO and spirometry with reversibility
children only get FeNO if spirometry inconclusive
Astham investigation - diagnostic cutoffs reversibility FEV1/FVC ratio FeNO
12% reversibility (AND 200ml in adults)
ratio of <0.7
FeNO >40ppb (>35 in children)
Asthma treatment escalation ADULTS
SABA \+ low dose ICS \+ LABA \+ LRTA or moderate dose ICS (stop LABA if not working) specialist
Asthma treatment escalation CHILDREN
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
Acute asthma attack categories
Life threatening = PEFR<33, silent chest, <92%, normal CO2
Acute severe = >110bpm, cant complete sentences, PEFR33-50, RR>25
Moderate = 50-75% PEFR
Acute asthma management
standard
escalated
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
COPD Ix
- if you suspect COPD what 3 things do you get
CXR (?mass), FBC (2’ polycythaemia), spirometry/reversibility testing
Grading of COPD cutoffs
All based on FEV1 Mild= >80 WITH symptoms and FEV1/FVC <0.7 mod = 50-80 severe = 30-50 very severe = <30
COPD treatment escalation
1) SABA or SAMA
2) asthmatic features = LABA+ICS; no asthmatic features = LABA/LAMA
3) oral theophylline
Antibiotic prophylaxis in COPD?
Azithromycin
Asthmatic features for COPD step 2???
1) previous history of asthma or atopy
2) eosinophilia
3) diurnal variation of PEFR >20%
4) FEV1 variation >400ml
When do you assess someone for LTOT if has COPD
FEV1 <30% (i.e. very severe)
cyanosis/polycthaemia
oedema/raised JVP
How do you assess someone for LTOT?
ABGs on two separate occasions
Based on the ABGs, when do you offer LTOT for COPD
pO2 <7.3
pO2 7.3-8 + oedema, polycythaemia, pul HTN
COPD exacerbation Mx
Nebulised bronchodilators and prednisolone 7-14d
Abx if sign of infection –> amox + clari
CURB65 score and meaning
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
CRP point of care test in GP for penumonia
Helps you decide if Abx are needed if they score CURB0
>100 = yes
20-100 = delayed
<20 = no
Abx guideline:
- CAP
- atypical CAP
- HAP
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
2ww lung cancer referral for CXR
40+ and any of:
- cough, fatigue, SOB, pain, weight loss, anorexia
need 2 of them if never smoked
2ww lung cancer referral for clinic straight away
40+ and haemoptysis or abnormal CXR
best Ix for lung Ca
CT (hence why you do it if CXR negative and youre still suspicious)
Difference between SCLC and NSCLC
SCLC not usually amenable to surgery, need chemo
NSCLC usually amenable to surgery,
both have radio
Idiopathic lung fibrosis
- gold standard Ix
- TLCO and spirometry
- high res CT
restrictive picture on spirometry
TLCO is low
definitive Tx for idiopathic lung fibrosis
lung transplant
Sarcoidosis useful tests (no diagnostic one)
raised ACE and ESR restrictive spirometry non-caseating granuloma formation bilateral hilar lymphadenpatphy upper zone fibrosis
Management of sarcoid
Don’t treat asymptomatic lymphadenopathy
If Sx –> prednisolone
Interpretation of Mantoux test
If <6mm = no reaction, immunise
If 6-15mm = medium reaction, ?previous TB or previous vaccination, don’t immunise
If >15mm = big reaction, active TB
when do you use interferon gamma quantiferon gold test?
if Mantoux equivocal or positive
If Mantoux inaccurate (sarcoid, military TB, lymphoma HIV)
Drugs for TB and SEs
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
Pneumothorax Mx
Primary
<2cm = clinic in 6/52!!
>2cm OR BREATHLESS = aspirate and observe
Secondary
0-1 = admit O2 observe
1-2 = aspirate
>2 = chest drain
Wells score PE
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
Well score DVT just the cutoff
Mx based on that
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
Do you start LMWH before the CTPA is back
yes because it usually takes a number of hours to get done
Tx of PE
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.
ARDS - how do you exclude thatit is cardiac in origin if unsure
pulmonary artery wedge pressure.
obstructive sleep apnoea Best Ix and other Ix
Sleep studies is best test
Epworth sleepiness scale and multiple sleep latency test also used
Mx of obstructive sleep apnoea
If sleepiness in daytime –> CPAP at night
If no sleepiness or CPAP not tolerate –> mandibular advancement device
pleural effusions and lights
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
if pleural fluid is exudate?
contrast CT and send off sample to lab
if pleural fluid is purulent or has pH <7.2
chest tube
NG tube safety
pH <5.5 is happy days
Otherwise need to do a CXR
NIV indications in COPD
any respiratory acidosis despite maximal therapy
when is an aspirate exudate
<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
