Respiratory Medicine 🫁✅ Flashcards
1
Q
Primary pneumothorax <2cm Mx
A
Discharge
2
Q
Primary pneumothorax with >2cm marking. Mx
A
Aspirations (then chest drain if unsuccessful)
3
Q
Secondary pneumothorax in >50 year old, with >2 cm marking, and/or patient is short of breath… Mx
A
Chest drain
4
Q
Secondary pneumothorax with 1-2cm marking Mx
A
Aspiration (drain if fails)
5
Q
Secondary pneumothorax with <1cm marking Mx
A
Give o2 and admit for 24hours
6
Q
Signs of mild airway obstruction
A
Patient is able to speak and answer the question, cough, and breathe
7
Q
Symptoms of severe airway obstruction
A
Patient is unable to speak they will only respond to you by nodding, they may be wheezy, unable to breathe, and attempt to cough are silent
8
Q
How to manage a patient with mild airway obstruction
A
First ask if patient is choking, to know whether they can answer and that it is mild away obstruction. Then encourage patient to cough them self.
9
Q
Management of patients with severe airway obstruction and his conscious
A
Give five back blows, five abdominal thrusts and continue until successful
10
Q
Management of severe airway obstruction and unconscious
A
Call an ambulance and start CPR. 30 chest compressions then 2 mouth-to-mouth
11
Q
The presence of warm flushed skin and bounding pulses is a sign of which type of acute respiratory failure 
A
Type II, because the high CO2 causes an acidosis
12
Q
Two main investigations to do for a patient with acute respiratory failure
A
ABG to confirm the diagnosis and chest x-ray
13
Q
Indications for ventilation in acute resp failure
A
O2 therapy doesn’t increase PaO2 to 60. Ph less that 7.25, resp muscle fatigue, apnoea, RR > 30, hemodynamically unstable.
14
Q
Management for acute respiratory failure. Consider when to give O2. Recall considerations for ventilation
A
Prompt hospitalisation. ABCDE. Aim for oxygen of more than 90% saturation.
15
Q
Discharge advice to patients following a pneumothorax
A
All patients should stop smoking, do not fly until two weeks after successful drainage (given you have seen a good x-ray). And completely avoid scuba-diving unless the patient has had surgical pleurectomy
16
Q
Final option for patient if they have recurrent pneumothorax even after chest tube and drainage
A
Refer for video assisted thorascopic surgery to seal the pleura to the thorax
17
Q
First thing to do in a patient with tension pneumothorax
A
Insert a large ball cannula in the second intercostal space in the mid clavicular line (do not wait for investigations)
18
Q
Two features that score 3 on Wells criteria for PE
A
Signs of DVT and an alternative diagnosis being less likely and PE
19
Q
Three features on the wells criteria that score 1.5
A
Heart rate above 100, previous DVT and immobilisation for more than three days or surgery in the past month
20
Q
Two features that score one on Wells criteria
A
Hemoptysis and malignancy
21
Q
Patient presents with PE like symptoms and scores more than four on Wells.
What is the initial investigation
A
CTPA, If there is a delay give therapeutic anticoagulation until performed
22
Q
Following a patient with a Wells score above four and after a CTPA is done and is negative… what next?
A
Proximal leg ultrasound with Doppler to check for DVT
23
Q
Patient presents with PE like symptoms with a wells score of four or less. First investigation
A
Do a D dimer test
24
Q
If a patient had a Well’s score of four or less, and the d-dimers is positive what to do
A
Do a CTPA
25
If a patient has a renal impairment, do you do a CTPA or VQ
VQ To avoid contrast nephropathy
26
Most common finding on an ECG for PE
Sinus tachycardia, less commonly S1Q3T3
27
Role of x-ray in PE investigation
To exclude other pathology
28
First line management of PE
Direct oral anti-coagulant
29
Alternatives to DOAC in management of PE
Low molecular weight heparin and dabigatran or low molecular weight heparin and warfarin
30
If a patient’s DVT was provoked, how long should anticoagulation be done for
Three months
31
If the patient’s PE was unprovoked how long should anticoagulation be for
Six months
32
If a patient PE was due to malignancy How long should anticoagulation be for
Between six and three months
33
First line for massive PE or PE with circulatory failure
Thrombolysis
34
Main investigations for asthmatic suspicious patients. Children have two tests, adults can use another two also.
Spirometry and Bronco dilator reversibility test for both. FeNO and metacholine challenge can also be used
35
When is the fractional exhaled nitrogen oxide test done
It is a diagnostic test in adults only for asthma
36
When is the Metacholine: challenge test done for asthma
In adults only, if all of the tests were uncertain
37
What would be a significant value for bronchodilator reversibility test in an asthmatic
An increase in the FEV1 of more than or equal to 12%
38
Step 1 in asthma treatment
Newly diagnosed and not bad asthma. SABA ONLY
39
Step 2 in asthma treatment
For patients not managed on step 1, or with 3 or more symptoms a week, or night time waking. SABA and low dose ICS
40
3rd step in asthma management
SABA, ICS, LTRA
41
4 step in asthma management
SABA, low dose ICS, LABA (with or without the LTRA previously)
42
5th step in asthma management
SABA and MART (with or without LTRA)
43
6th step in asthma management
SABA, Medium dose MART (with or without LTRA)
44
7th step in asthma management
SABA, high dose ICS and trial of additional drug (theo or high dose ICS). With or without LTRA
45
Asthma Patient on SABA and ICS… not well controlled. Add what?
LTRA (not LABA). This is step 2 to 3
46
Moderate asthma exacerbation is defined
X-X% of PEFR
RR< x
Pulse < x
50-75% of PEFR
RR< 25
Pulse < 110
47
Severe asthma exacerbation is defined
X-X% of PEFR
RR > x
Pulse > x
33-50% of PEFR
RR > 25
Pulse > 110
48
Life threatening asthma exacerbation is defined As?
PEFR < 33%, O2 < 92%, silent chest, hemodynamic changes, confusion (AMS) = overrules anything else
49
Investigation for acute asthma exacerbation
ABG, not X-ray unless suspect pneumothorax or life threatening asthma
50
Who should be admitted to hospital (regarding acute asthma exacerbation)
Life threatening cases or severe cases who don’t respond to treatment
51
When to give oxygen in acute asthma exacerbation
If patient is hypoxemic, or if patient is acutely unwell. 15L of supplemental O2 via a non rebreathe mask
52
General treatment for all patients with acute asthma exacerbation.
High dose inhaler SABA (nebulise if life threatening exacerbation). Oral prednisolone (for at least 5 days). IV cortisone for patients unable to swallow.
53
Discharge requirements for patients with acute asthma exacerbation
PEGR > 75%, inhaler technique check, stable on med for 12-24 hours
54
When could you give ipratropium bromide in acute asthma exacerbation
If patient didn’t respond to SABA
55
Best investigation for COPD
Spirometry
56
Stage 1 COPD
FEV1 > 80% predicted
57
Stage 2 COPD
FEV1 50-79% predicted
58
Stage 3 COPD
FEV1 30-49% predicted
59
Stage 4 COPD
FEV1 < 30% predicted
60
Advise and Vx for patients with COPD
Stop smoking, annual influenza, one off pneumococcal, rehab if QoL impaired.
61
First treatment for COPD
SABA or SAMA
62
If SABA or SAMA doesn’t work for a patient with COPD. Assess what?
Steroid responsiveness/asthmatic features
63
What features suggest asthmatic features/steroid responsiveness in COPD.
History of asthma/atopy, raised eosinophils, diurnal variation in FEV1 and peak flow (more than 20%)
64
If a patient has COPD with asthmatic features and failed on SABA. Do what?
SABA or SAMA, and LABA and ICS
65
If patient is not steroid responsive, has COPD that failed with SABA. Do what
SABA, AND LABA AND LAMA
66
3rd step for COPD treatment (regardless of steroid responsiveness)
SABA. LABA, LAMA, ICS
67
When to give mucolytics in COPD
If patient has chronic productive cough
68
Patient had more than three COPD exacerbations. What should be given as prophylaxis?
Oral Azithromycin (azif my magic... no more exac)
69
Treatment for cor pulmonale
Loops and long term o2
70
2 things that improve COPD survival
Quit smoking and long term O2 therapy
71
Oxygen therapy in COPD. When do we give?
Give us O2 less then 7.3, or between 7.3-8 with polycythemia, edema, pulmonary hypertension
72
Cause of severe exacerbation of COPD
Haemophilus I. (Main one).
Streptococcus and moraxella second
73
How to prevent COPD exacerbations?
Oral Azithromycin
74
COPD exacerbation investigation
ABG, pulse ox, ecg
75
COPD exacerbation management
Nebulised bronchodilator, oral prednisolone, and oral antibiotics (only if patient has signs of pneumonia !)
76
Investigations for suspected pneumonia
Chest X-ray, Blood cultures and sputum cultures (amongst other things)
77
CURB65 vs CRB65
CURB includes urea, and is done in hospital. CRB65 is fine in community to assess whether to be hospitalised
78
What does CRB65 stand for (pneumonia)
Confusion, resp rate > 30, BP < 90/60, over 65 years old
79
How to treat a patient in the community with a pneumonia and CRB65 score of 0-1?
Oral amoxicillin (macrolide/tetra if allergic to penicillin)
80
What to do with a pneumonia patient with a CRB65 of 2 or more?
Hospital assessment
81
When to give O2 in a pneumonia patient
If sats <94%
82
Strep pneumonia treatment
Amoxicillin (oral) or benzylpenicillin (IV)
83
Treatment for mycoplasma pneumoniae or chlamydia pneumoniae
Clarithromycin
84
Investigations for Tb
Mantaux (), chest X-ray (if more acute?)
85
Mantoux less than 6mm
Negative. And can give BCG to this patient
86
Mantoux 6-15mm
Positive. Can be due to previous Tb or BCG. So no BCG Vx for this patient
87
Mantoux > 15
Strongly positive (suggests Tb infx)
88
Active tb patient management
Isolate patient. 2 months RIPE, 4 months RI
89
Latent TB management
3mo RI or 6mo I
90
If a Tb patient is homeless, a prisoner, or unlikely to comply… what should we do to ensure medicated
Directly observed therapy
91
Three criteria for ARDS diagnosis
Acute onset (in 1 week), bilateral opacities, PaO2 < 40kPa (Four letters in ARDS add a 0 on, equals 40)
92
Invx for ARDS?
Chest X-ray and ABG
93
Management ideas
for an ARDS patient
ITU often needed. Oxygenation/ventilation. Consider vasopressors. Treat cause. Prone positioning.
94
Cause of mediastinitis?
URI/recent dental infection. Thoracic surgery
95
Investigations for suspected mediastinitis . Complications of mediastinitis ?
Blood culture, Chest X-ray or CT. Can lead to severe sepsis, and even constricting mediastinitis (recquire stenting)
96
Management of mediastinitis
Antibiotics and drainage of fluid (if so)
97
Most common bacteria associated with Bronchiectasis
Hemphilus influenzae (followed by pseudomonas)
98
X-ray finding for Bronchiectasis
Tramlines (parallel lines)
99
Investigations for Bronchiectasis
CXR, CT and a sputum culture (Identify any colonisers)
100
Management ideas for Bronchiectasis
Physical therapy, antibiotics for exacerbations, antibiotics in severe cases, bronchodilators in some,
Surgery if localised m, immunisations,
101
Usual first investigation for a suspected lung cancer patient
Chest X-ray
102
Best investigation for lung cancer
CT
103
Role of PET scanning in lung cancer
Done for non small cell lung cancer To establish eligibility for curative treatment. Also gives good idea for cancer spread
104
When would you consider surgery in small cell lung cancer
Very early stages only (T1-2, N0, M0)
105
Limited small cell lung cancer (maybe a bit of spread). Mx?
Chemo and radio Tx
106
Patients with extensive small cell lung cancer. Mx?
Palliative chemoTx
107
Non small cell lung cancer… if do surgery, what should be done prior
Mediastinoscopy to see if there is mediastinal lymph node involvement (CT doesn’t always show)
108
Gimme some facts about non small cell lung cancer management?
Poor response to chemo, radiotherapy better. Surgery can be done in 20%
109
How to investigate and diagnose pulmonary hypertension
A dx of exclusion. Do CXR, ECG, and consider transthoracic Doppler echocardiography, and swan ganz.
110
What is the general supportive therapy for pulmonary hypertension?
Oral anticoagulant, diuretic, o2, digoxin
111
Some pulmonary hypertension treatments
Prostanoids, endothelin antagonists, PDE5 inhibitors
112
Epworth scale is for what?
A sleepiness scale. And be used to get a better idea of patients sleep
113
Best invx for a patient with potential sleep apnoea?
Polysomnography
114
Advice given to most peripheral sleep apnoea patients
Lose weight!
115
First line Mx for moderate-severe sleep apnoea
CPAP
116
Alternatives to CPAP for mild sleep apnoea (no daytime sleepiness), or patient unable to take CPAP.
Mandibular advancement (device or surgery)
117
If patients have excessive daytime sleepiness from sleep apnoea. You should do what??? (Like legal stuff)
Inform driver and vehicle licensing agency
118
Investigations for lung contusions (suspicion)
Chest X-ray 1st! ABG and pulse ox
119
If patient with lung contusion has severe hypoxia, what must we do?
Intubate within an hour
120
Little snapshot of lung contusion management
Most heals on it’s own, and with supportive care. Consider oxygen (esp if hypoxia), and closely monitor patient. May need fluids to ensure blood volume stable
121
Organisms colonising CF patients
Staph, pseudomonas, burkholderia, aspergillus.
122
CF invx (1st)
Sweat test: high chloride in sweat. (>60). Usually give pilocarpine to increase the sweat
123
What newborn screening is done for CF?
Immunoreactive trypsinogen test
124
Advise to give to patients with CF?
Avoid contact with each other (can spread bacteria between them). Have a high calorie and high fat intake. Do chest physiotherapist and postural drainage twice a day. Take vit supplements
125
What is Lumacaftor and Ivacaftor?
For CF patients (homozygous). Ivacfator increases conductance. Lumacaftor increases number of CFTRs send to cell surface.
126
Contraindication for lung transplant in CF?
Burkholderia colonisation
127
Role of Creon in CF
To replace pancreatic enzymes
128
How to investigate pulmonary fibrosis. Mention 1st and best.
1st: chest X-ray (bilateral interstitial shadowing, ground glass and later honeycombing)
Best: CT (need med for diagnosis)
Spirometery is good, and Sonia TLCO
129
Pulmonary fibrosis Mx ideas
Mainly rehab, and O2 if needed. Some need transplant. Pirfenidone (antifibrotic) for some.
130
What is Lofgren
An acute fulminant form of sarcoidosis. Has bilateral hilar LN, erythema nodosum, fever and polyarthralgia.
131
What is Heerfordts
Parotid enlargement, fever and uveitis 2° to sarcoidosis
132
Potential findings for Sarcoidosis, on a CBC
Hypercalcemia and high ESR
133
Some Invxs for sarcoidosis
Bloods, chest X-ray, spirometer, (biopsy is rare)
134
Stage 1 sarcoidosis
Bilateral hilar LN
135
Stage 2 sarcoidosis
BHL and interstitial infiltration
136
Stage 3 sarcoidosis
Diffuse interstitial infiltration
137
Stage 4 sarcoidosis
Diffuse fibrosis
138
When do we give steroids for sarcoidosis patients
Stage 2-3: who are symptomatic. Any patient with hypercalcemia or eye/heart/Neuro involvement. Any stage 4.
Not stage 1, or stable asymptomatic stage 2/3
139
Acute pulmonary edema Mx
CPAP, O2, morphine, nitrates, loops
140
Hypothyroidism pleural effusion is transudate or exudate?
Transudate
141
Aside from pleural aspiration, other investigations important in effusions?
ABG, CXR, CTs (helps to find cause, especially in exudative), US (helps to aspirate well)
142
First invx in pleural effusion to get to cause
Pleural aspiration
143
If a patient has a pleural effusion in association to sepsis or pneumonia… what do we do
Chance of empyema.
Do pleural fluid sampling. If cloudy/turbid = chest drain. If clear but acidic (<7.2) =chest drain.
144
If pleural fluid has protein more than 35, it meanssss??
Defo exudate
145
If pleural fluid has protein less than 25, it meanssss??
It is a transudate
146
What do you apply if the pleural fluid is between 25-35?
Lights criteria
147
Lights criteria for exudate
Pleural: serum protein >0.5
Pleural: serum LDH >0.6
(Only need one)
148
A pleural fluid is turbid, low pH, low glucose, high LDH… what you thinking?
Empyema
149
Management ideas for pleural effusion
Recurrent aspiration with US. Indwelling pleural catheter if needed. Pleurodesis if needed. Opioids to relieve dyspnoea.
150
Big empyema causing bacteria
Klebsiella (and lung abscesses)
151
Patient who has pneumonia, now has fever and rigours… consider?
Empyema
152
Management for Empyema
Thoracentesis, chest drain and prolonged course of Abx
153
First invx for suspected mesothelioma
Order Chest X-ray
154
Weight loss, chest wall pain, progressive dyspnoea, worked in shipyard 25 years ago. Thoughts?
Asbestos induced mesothelioma
155
Chest X-ray signs of mesothelioma
Pleural effusions and pleural thickenings. Do test fluid if effusion present
156
If suspect mesothelioma, and effusion fluid tested, yet cytology comes back negative. Can do what?
Local anaesthetic thoroscopy (high diagnostic yield).
157
At what O2, does respiratory failure occur
Below 60mmHg or 8kPa
158
Spare space
You’re doing great
159
Young patient who is wheezy, and has obstructive spirometry, should be sent for what invx?
Bronchodilator reversibility testing. (Improve more than 12% = asthma)
160
How to diagnose/invx a potential occupational asthma case
Take peak flow measurements at home and at work
161
COPD exacerbation given all medical therapy, and ABG does not improve. What next?
BiPAP
162
Indications for non invasive ventilation?
COPD and acidosis. Any type II resp failure. Pulmonary edema (when CPAP doesn’t work). Weaning of intubation
163
Patient with acute asthma exacerbation. It is severe and it is not responding to nebulisers. Should we admit!?
Admit patient (severe asthma exacerbation not improving with nebuliser)
164
How to determine if an asthma is specifically an allergic asthma
Allergy skin prick test
165
Signs of aspirin exacerbated asthma
Severe persistent asthma, aspirin sensitivity, eosinophilia sinusitis, nasal polyps
166
Main treatment for aspirin exacerbated asthma
Leukotriene antagonist, stop NSAID
167
Testing for allergic bronchopulmonary aspergillosis
Skin test for aspergillus antigen, high IgE to aspergillus, peripheral eosinophilia, bronchiectasis
168
Aside from usual COPD management, what is the indication for lung volume reduction therapy
Upper lobe predominant COPD, to remove emphysematous lung
169
Indication for lung transplant in COPD
Less than 65 years old, severe disability despite treatment, no co-mob, risk of dying in less than two years
170
When to give omalizumab in asthma
Uncontrolled symptoms, evidence of allergy, IGE elevated
171
When to give mepolizumab in asthma
When eosinophils are greater than 150. Nothing to do with IGE
172
COPD patient with weight loss... Xray normal, FBC normal etc... cause?
The COPD!
173
Details of O2 therapy for COPD exacs patients?
Patients with COPD should initially be given oxygen via a Venturi 28% mask at a flow rate of 4 l/min or a Venturi 24% mask at a flow rate of 2 l/min. The target oxygen saturation should be 88–92%
174
CIs for DOACS
renal impairment, cirrhosis, pregnancy, mechanical heart valves
175
Abx for atypical pneumonias
azithromycin (macrolides)
176
Main Invx for mediastinitis
blood culture... rule out sepsis! But also do XRAY/CT
177
A patient who is >= 40 years old presenting with unexplained hemoptysis/other signs should be referred using what?
the suspected cancer pathway (within 2 weeks) to exclude lung cancer
178
Patient with severe chest pain, low o2. decreased breath sounds and crackles over the left lung field. The patient's chest X-ray shows patchy opacities and consolidation in the left lung. PaO2 low. following car crash
lung contusion
179
Main Tx for ABPA
oral steroids
180
Mild hospital acquired pneumoia abx
Intravenous (IV) ceftriaxone or IV levofloxacin
181
svere hospital acquired pneumonia abx
IV piperacillin-tazobactam or IV cefepime.
182
Chronic bronchitis Dx
Cough/productive for three months in each year and total of two consecutive years
