Respiratory Medicine 🫁✅ Flashcards
Primary pneumothorax <2cm Mx
Discharge
Primary pneumothorax with >2cm marking. Mx
Aspirations (then chest drain if unsuccessful)
Secondary pneumothorax in >50 year old, with >2 cm marking, and/or patient is short of breath… Mx
Chest drain
Secondary pneumothorax with 1-2cm marking Mx
Aspiration (drain if fails)
Secondary pneumothorax with <1cm marking Mx
Give o2 and admit for 24hours
Signs of mild airway obstruction
Patient is able to speak and answer the question, cough, and breathe
Symptoms of severe airway obstruction
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
How to manage a patient with mild airway obstruction
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.
Management of patients with severe airway obstruction and his conscious
Give five back blows, five abdominal thrusts and continue until successful
Management of severe airway obstruction and unconscious
Call an ambulance and start CPR. 30 chest compressions then 2 mouth-to-mouth
The presence of warm flushed skin and bounding pulses is a sign of which type of acute respiratory failure 
Type II, because the high CO2 causes an acidosis
Two main investigations to do for a patient with acute respiratory failure
ABG to confirm the diagnosis and chest x-ray
Indications for ventilation in acute resp failure
O2 therapy doesn’t increase PaO2 to 60. Ph less that 7.25, resp muscle fatigue, apnoea, RR > 30, hemodynamically unstable.
Management for acute respiratory failure. Consider when to give O2. Recall considerations for ventilation
Prompt hospitalisation. ABCDE. Aim for oxygen of more than 90% saturation.
Discharge advice to patients following a pneumothorax
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
Final option for patient if they have recurrent pneumothorax even after chest tube and drainage
Refer for video assisted thorascopic surgery to seal the pleura to the thorax
First thing to do in a patient with tension pneumothorax
Insert a large ball cannula in the second intercostal space in the mid clavicular line (do not wait for investigations)
Two features that score 3 on Wells criteria for PE
Signs of DVT and an alternative diagnosis being less likely and PE
Three features on the wells criteria that score 1.5
Heart rate above 100, previous DVT and immobilisation for more than three days or surgery in the past month
Two features that score one on Wells criteria
Hemoptysis and malignancy
Patient presents with PE like symptoms and scores more than four on Wells.
What is the initial investigation
CTPA, If there is a delay give therapeutic anticoagulation until performed
Following a patient with a Wells score above four and after a CTPA is done and is negative… what next?
Proximal leg ultrasound with Doppler to check for DVT
Patient presents with PE like symptoms with a wells score of four or less. First investigation
Do a D dimer test
If a patient had a Well’s score of four or less, and the d-dimers is positive what to do
Do a CTPA
If a patient has a renal impairment, do you do a CTPA or VQ
VQ To avoid contrast nephropathy
Most common finding on an ECG for PE
Sinus tachycardia, less commonly S1Q3T3
Role of x-ray in PE investigation
To exclude other pathology
First line management of PE
Direct oral anti-coagulant
Alternatives to DOAC in management of PE
Low molecular weight heparin and dabigatran or low molecular weight heparin and warfarin
If a patient’s DVT was provoked, how long should anticoagulation be done for
Three months
If the patient’s PE was unprovoked how long should anticoagulation be for
Six months
If a patient PE was due to malignancy How long should anticoagulation be for
Between six and three months
First line for massive PE or PE with circulatory failure
Thrombolysis
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
When is the fractional exhaled nitrogen oxide test done
It is a diagnostic test in adults only for asthma
When is the Metacholine: challenge test done for asthma
In adults only, if all of the tests were uncertain
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%
Step 1 in asthma treatment
Newly diagnosed and not bad asthma. SABA ONLY
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
3rd step in asthma management
SABA, ICS, LTRA
4 step in asthma management
SABA, low dose ICS, LABA (with or without the LTRA previously)
5th step in asthma management
SABA and MART (with or without LTRA)
6th step in asthma management
SABA, Medium dose MART (with or without LTRA)
7th step in asthma management
SABA, high dose ICS and trial of additional drug (theo or high dose ICS). With or without LTRA
Asthma Patient on SABA and ICS… not well controlled. Add what?
LTRA (not LABA). This is step 2 to 3
Moderate asthma exacerbation is defined
X-X% of PEFR
RR< x
Pulse < x
50-75% of PEFR
RR< 25
Pulse < 110
Severe asthma exacerbation is defined
X-X% of PEFR
RR > x
Pulse > x
33-50% of PEFR
RR > 25
Pulse > 110
Life threatening asthma exacerbation is defined As?
PEFR < 33%, O2 < 92%, silent chest, hemodynamic changes, confusion (AMS) = overrules anything else
Investigation for acute asthma exacerbation
ABG, not X-ray unless suspect pneumothorax or life threatening asthma
Who should be admitted to hospital (regarding acute asthma exacerbation)
Life threatening cases or severe cases who don’t respond to treatment
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
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.
Discharge requirements for patients with acute asthma exacerbation
PEGR > 75%, inhaler technique check, stable on med for 12-24 hours
When could you give ipratropium bromide in acute asthma exacerbation
If patient didn’t respond to SABA
Best investigation for COPD
Spirometry
Stage 1 COPD
FEV1 > 80% predicted
Stage 2 COPD
FEV1 50-79% predicted
Stage 3 COPD
FEV1 30-49% predicted
Stage 4 COPD
FEV1 < 30% predicted
Advise and Vx for patients with COPD
Stop smoking, annual influenza, one off pneumococcal, rehab if QoL impaired.
First treatment for COPD
SABA or SAMA
If SABA or SAMA doesn’t work for a patient with COPD. Assess what?
Steroid responsiveness/asthmatic features
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%)
If a patient has COPD with asthmatic features and failed on SABA. Do what?
SABA or SAMA, and LABA and ICS
If patient is not steroid responsive, has COPD that failed with SABA. Do what
SABA, AND LABA AND LAMA
3rd step for COPD treatment (regardless of steroid responsiveness)
SABA. LABA, LAMA, ICS
When to give mucolytics in COPD
If patient has chronic productive cough
Patient had more than three COPD exacerbations. What should be given as prophylaxis?
Oral Azithromycin (azif my magic… no more exac)
Treatment for cor pulmonale
Loops and long term o2
2 things that improve COPD survival
Quit smoking and long term O2 therapy
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
Cause of severe exacerbation of COPD
Haemophilus I. (Main one).
Streptococcus and moraxella second
How to prevent COPD exacerbations?
Oral Azithromycin
COPD exacerbation investigation
ABG, pulse ox, ecg
COPD exacerbation management
Nebulised bronchodilator, oral prednisolone, and oral antibiotics (only if patient has signs of pneumonia !)
Investigations for suspected pneumonia
Chest X-ray, Blood cultures and sputum cultures (amongst other things)
CURB65 vs CRB65
CURB includes urea, and is done in hospital. CRB65 is fine in community to assess whether to be hospitalised
What does CRB65 stand for (pneumonia)
Confusion, resp rate > 30, BP < 90/60, over 65 years old
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)
What to do with a pneumonia patient with a CRB65 of 2 or more?
Hospital assessment
When to give O2 in a pneumonia patient
If sats <94%
Strep pneumonia treatment
Amoxicillin (oral) or benzylpenicillin (IV)
Treatment for mycoplasma pneumoniae or chlamydia pneumoniae
Clarithromycin
Investigations for Tb
Mantaux (), chest X-ray (if more acute?)
Mantoux less than 6mm
Negative. And can give BCG to this patient
Mantoux 6-15mm
Positive. Can be due to previous Tb or BCG. So no BCG Vx for this patient
Mantoux > 15
Strongly positive (suggests Tb infx)
Active tb patient management
Isolate patient. 2 months RIPE, 4 months RI
Latent TB management
3mo RI or 6mo I
If a Tb patient is homeless, a prisoner, or unlikely to comply… what should we do to ensure medicated
Directly observed therapy
Three criteria for ARDS diagnosis
Acute onset (in 1 week), bilateral opacities, PaO2 < 40kPa (Four letters in ARDS add a 0 on, equals 40)
Invx for ARDS?
Chest X-ray and ABG
Management ideas
for an ARDS patient
ITU often needed. Oxygenation/ventilation. Consider vasopressors. Treat cause. Prone positioning.
Cause of mediastinitis?
URI/recent dental infection. Thoracic surgery
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)
Management of mediastinitis
Antibiotics and drainage of fluid (if so)
Most common bacteria associated with Bronchiectasis
Hemphilus influenzae (followed by pseudomonas)
X-ray finding for Bronchiectasis
Tramlines (parallel lines)
Investigations for Bronchiectasis
CXR, CT and a sputum culture (Identify any colonisers)
Management ideas for Bronchiectasis
Physical therapy, antibiotics for exacerbations, antibiotics in severe cases, bronchodilators in some,
Surgery if localised m, immunisations,
Usual first investigation for a suspected lung cancer patient
Chest X-ray
Best investigation for lung cancer
CT
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
When would you consider surgery in small cell lung cancer
Very early stages only (T1-2, N0, M0)
Limited small cell lung cancer (maybe a bit of spread). Mx?
Chemo and radio Tx
Patients with extensive small cell lung cancer. Mx?
Palliative chemoTx
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)
Gimme some facts about non small cell lung cancer management?
Poor response to chemo, radiotherapy better. Surgery can be done in 20%
How to investigate and diagnose pulmonary hypertension
A dx of exclusion. Do CXR, ECG, and consider transthoracic Doppler echocardiography, and swan ganz.
What is the general supportive therapy for pulmonary hypertension?
Oral anticoagulant, diuretic, o2, digoxin
Some pulmonary hypertension treatments
Prostanoids, endothelin antagonists, PDE5 inhibitors
Epworth scale is for what?
A sleepiness scale. And be used to get a better idea of patients sleep
Best invx for a patient with potential sleep apnoea?
Polysomnography
Advice given to most peripheral sleep apnoea patients
Lose weight!
First line Mx for moderate-severe sleep apnoea
CPAP
Alternatives to CPAP for mild sleep apnoea (no daytime sleepiness), or patient unable to take CPAP.
Mandibular advancement (device or surgery)
If patients have excessive daytime sleepiness from sleep apnoea. You should do what??? (Like legal stuff)
Inform driver and vehicle licensing agency
Investigations for lung contusions (suspicion)
Chest X-ray 1st! ABG and pulse ox
If patient with lung contusion has severe hypoxia, what must we do?
Intubate within an hour
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
Organisms colonising CF patients
Staph, pseudomonas, burkholderia, aspergillus.
CF invx (1st)
Sweat test: high chloride in sweat. (>60). Usually give pilocarpine to increase the sweat
What newborn screening is done for CF?
Immunoreactive trypsinogen test
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
What is Lumacaftor and Ivacaftor?
For CF patients (homozygous). Ivacfator increases conductance. Lumacaftor increases number of CFTRs send to cell surface.
Contraindication for lung transplant in CF?
Burkholderia colonisation
Role of Creon in CF
To replace pancreatic enzymes
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
Pulmonary fibrosis Mx ideas
Mainly rehab, and O2 if needed. Some need transplant. Pirfenidone (antifibrotic) for some.
What is Lofgren
An acute fulminant form of sarcoidosis. Has bilateral hilar LN, erythema nodosum, fever and polyarthralgia.
What is Heerfordts
Parotid enlargement, fever and uveitis 2° to sarcoidosis
Potential findings for Sarcoidosis, on a CBC
Hypercalcemia and high ESR
Some Invxs for sarcoidosis
Bloods, chest X-ray, spirometer, (biopsy is rare)
Stage 1 sarcoidosis
Bilateral hilar LN
Stage 2 sarcoidosis
BHL and interstitial infiltration
Stage 3 sarcoidosis
Diffuse interstitial infiltration
Stage 4 sarcoidosis
Diffuse fibrosis
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
Acute pulmonary edema Mx
CPAP, O2, morphine, nitrates, loops
Hypothyroidism pleural effusion is transudate or exudate?
Transudate
Aside from pleural aspiration, other investigations important in effusions?
ABG, CXR, CTs (helps to find cause, especially in exudative), US (helps to aspirate well)
First invx in pleural effusion to get to cause
Pleural aspiration
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.
If pleural fluid has protein more than 35, it meanssss??
Defo exudate
If pleural fluid has protein less than 25, it meanssss??
It is a transudate
What do you apply if the pleural fluid is between 25-35?
Lights criteria
Lights criteria for exudate
Pleural: serum protein >0.5
Pleural: serum LDH >0.6
(Only need one)
A pleural fluid is turbid, low pH, low glucose, high LDH… what you thinking?
Empyema
Management ideas for pleural effusion
Recurrent aspiration with US. Indwelling pleural catheter if needed. Pleurodesis if needed. Opioids to relieve dyspnoea.
Big empyema causing bacteria
Klebsiella (and lung abscesses)
Patient who has pneumonia, now has fever and rigours… consider?
Empyema
Management for Empyema
Thoracentesis, chest drain and prolonged course of Abx
First invx for suspected mesothelioma
Order Chest X-ray
Weight loss, chest wall pain, progressive dyspnoea, worked in shipyard 25 years ago. Thoughts?
Asbestos induced mesothelioma
Chest X-ray signs of mesothelioma
Pleural effusions and pleural thickenings. Do test fluid if effusion present
If suspect mesothelioma, and effusion fluid tested, yet cytology comes back negative. Can do what?
Local anaesthetic thoroscopy (high diagnostic yield).
At what O2, does respiratory failure occur
Below 60mmHg or 8kPa
Spare space
You’re doing great
Young patient who is wheezy, and has obstructive spirometry, should be sent for what invx?
Bronchodilator reversibility testing. (Improve more than 12% = asthma)
How to diagnose/invx a potential occupational asthma case
Take peak flow measurements at home and at work
COPD exacerbation given all medical therapy, and ABG does not improve. What next?
BiPAP
Indications for non invasive ventilation?
COPD and acidosis. Any type II resp failure. Pulmonary edema (when CPAP doesn’t work). Weaning of intubation
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)
How to determine if an asthma is specifically an allergic asthma
Allergy skin prick test
Signs of aspirin exacerbated asthma
Severe persistent asthma, aspirin sensitivity, eosinophilia sinusitis, nasal polyps
Main treatment for aspirin exacerbated asthma
Leukotriene antagonist, stop NSAID
Testing for allergic bronchopulmonary aspergillosis
Skin test for aspergillus antigen, high IgE to aspergillus, peripheral eosinophilia, bronchiectasis
Aside from usual COPD management, what is the indication for lung volume reduction therapy
Upper lobe predominant COPD, to remove emphysematous lung
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
When to give omalizumab in asthma
Uncontrolled symptoms, evidence of allergy, IGE elevated
When to give mepolizumab in asthma
When eosinophils are greater than 150. Nothing to do with IGE
COPD patient with weight loss… Xray normal, FBC normal etc… cause?
The COPD!
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%
CIs for DOACS
renal impairment, cirrhosis, pregnancy, mechanical heart valves
Abx for atypical pneumonias
azithromycin (macrolides)
Main Invx for mediastinitis
blood culture… rule out sepsis! But also do XRAY/CT
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
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
Main Tx for ABPA
oral steroids
Mild hospital acquired pneumoia abx
Intravenous (IV) ceftriaxone or IV levofloxacin
svere hospital acquired pneumonia abx
IV piperacillin-tazobactam or IV cefepime.
Chronic bronchitis Dx
Cough/productive for three months in each year and total of two consecutive years
