Revision Flashcards
What are some iatrogenic causes of a pnuemothorax?
1) Positive pressure ventilation
2) Central line insertion
3) Lung biopsy
How is a pneumothorax measured in size on a CXR?
Measured horizontally from lung edge to chest wall (at level of hilum)
Mx of a 1ary pneumothorax:
1) If rim of air is <2cm and patient is NOT short of breath –> discharge
2) If >2cm and/or SOB –> aspiration, then chest drain if aspiration fails
Mx of 2ary pneumothorax:
1) If patient is >50 y/o and rim of air is >2cm and/or patient is SOB –> chest drain
2) If rim of air is 1-2cm –> aspiration (then chest drain if aspiration fails)
3) If rim of air is <1cm –> O2 & admit for 24h
ALL patients should be admitted for at least 24 hours
What are the 3 classifications of pneumothorax?
1) Spontaneous (can be 1ary or 2ary)
2) Traumatic
3) Iatrogenic
What are the 2 types of spontaneous pneumothorax?
1ary & 2ary:
1ary –> no underlying lung pathology
2ary –> underlying lung pathology e.g. COPD
1ary vs 2ary pneumothorax?
A pneumothorax is termed primary if there is no underlying lung disease and secondary if there is.
Mx of a pneumothorax in a 52 y/o patient with COPD with 2.1cm rim of air on CXR?
Chest drain insertion (due to age, size & COPD status)
Mx of a pneumothorax in a 21 year old with no lung pathology that is 1.5cm and no SOB?
Discharge, reassess in 2-4w
Mx of a pneumothorax in a 21 year old with no lung pathology that is 2.1cm and is SOB?
Aspirate (then chest drain if that fails)
Where is a chest drain located in a pneumothorax?
Triangle of safety
Is the needle inserted above or below the rib when inserting a chest drain in a pneumothorax?
Just above - to avoid neurovascular bundle that runs just below the rib.
Once the chest drain has been inserted in a pneumothorax, what should you do?
Get a CXR to check position
A surgical/SC emphysema is a potential complication of a chest drain.
What is this?
Collection of air in the subcutaneous tissue.
What surgical method is used to correct a pneumothorax?
Video-assisted thoracoscopic surgery (VATS)
What are the 3 surgical options for pneumothorax?
1) Abrasive pleurodesis (direct irritation)
2) Chemical pleurodesis (chemical irritation)
3) Pleurectomy
Why is tension pneumothorax an emergency condition?
It creates pressure inside the thorax to push the mediastinum across, kink the big vessels in the mediastinum and cause cardiorespiratory arrest.
What type of bacteria is aspiration pneumonia associated with?
Anaerobic bacteria
What CRB-65 score indicates the need to consider hospital assessment?
More than 0
What organisms cause atypical pneumonia? (5)
1) Legionella
2) Mycoplasma pneumoniae
3) Chlamydia psittaci
4) Chlamydophila pneumoniae
5) Q fever
Which causative organism of pneumonia is particularly associated with high fever, rapid onset and herpes labialis?
Strep. pneumoniae
What 2 organisms typically cause pneumonia in CF patients?
1) Pseudomonas aeruginosa
2) S. aureus
What organism typically causes pneumonia in patients with cystic fibrosis or bronchiectasis?
Pseudomonas aeruginosa
Which type of pneumonia causes hyponatraemia? Why?
Legionella pneumophilia
Can cause SIADH
Initial screening test for Legionella pneumophila (Legionnaires’ disease)?
Urine antigen test
What type of severity of pneumonia does Mycoplasma pneumoniae cause?
Milder pneumonia
What type of pneumonia can cause neurological symptoms in young patients?
Mycoplasma
What type of pneumonia often present a dry cough and atypical chest signs/x-ray findings. Autoimmune haemolytic anaemia and erythema multiforme may be seen?
Mycoplasma
What type of pneumonia causes mild to moderate chronic pneumonia and wheezing in school-age children?
Chlamydophila pneumoniae
Be cautious, as this presentation is common without chlamydophila pneumoniae infection.
What type of pneumonia is linked to exposure to the bodily fluids of animals?
Coxiella / Q fever
The typical exam patient is a farmer with a flu-like illness.
What type of pneumonia is typically contracted from contact with infected birds?
Chlamydia psittaci
The typical exam patient is a parrot owner.
What type of pneumonia is classically seen in alcoholics or diabetes?
Klebsiella
What is Pneumocystis jirovecii pneumonia (PCP)?
A fungal pneumonia
What is the treatment for Pneumocystis jirovecii pneumonia?
Co-trimoxazole
Management of COVID-19 pneumonia?
Respiratory support (e.g., oxygen), dexamethasone and monoclonal antibodies.
What is idiopathic interstitial pneumonia?
A group of non-infective causes of pneumonia
FBC in bacterial pneumonia?
Neutrophilia (raised WCC)
WCC and CRP are raised roughly in proportion to the severity of the infection.
When does CRP peak?
After 24-48h
1st line Abx in the management of low-severity CAP?
Typical –> amoxicillin
Atypical –> macrolide e.g. clarithromycin
5 day course
Management of moderate and high-severity CAP?
Dual abx –> amoxicillin + macrolide e.g. co-amoxiclav + clarithromycin
7-10 day course, typically IV
When should all cases of pneumonia have a repeat CXR?
6 weeks after clinical resolution
After how many days of starting Abx should inflammatory markers be repeated in pneumonia?
3 days
Which lung is more affected in aspiration pneumonia? Why?
R lung as R bronchus is wider and more vertical
What is the pulmonary embolism rule out criteria (PERC)?
Recommended for use when a clinician estimates a LESS THAN 15% probability of a PE.
Used to decide whether further investigations for a PE are needed.
If all criteria are met –> no further investigations.
When is PERC used?
If clinician estimates probability of a PE is <15%.
What Wells score indicates that a PE is likely?
> 4
What Wells score indicates that a PE is NOT likely?
≤4
What does a Wells score of 4 indicate about a PE?
PE is not likely
What conditions can cause a raised d-dimer?
- PE/DVT
- Malignancy
- Pneumonia
- Pregnancy
- HF
If d-dimer is negative in suspcted PE, what is next step?
Consider alternative diagnosis and stop anticoagulation
When would a VQ scan be indicated over a CTPA in a PE?
1) Renal impairment
2) Contrast allergy
3) Risk from radiation e.g. pregnancy
ABG results in PE?
respiratory alkalosis
If patient has active cancer, what is 1st line anticoagulation in PE?
DOAC
When is anticoagultion stopped after an provoked vs unprovoked VTE?
Provoked - 3 months (except active cancer)
Unprovoked - 6 months in total
1st line anticoagulant in PE in pregnancy?
LMWH
Mechanism of warfarin?
Vitamin K antagonist
1st line anticoagulation in patients with antiphospholipid syndrome?
Warfarin (also require initial concurrent treatment with LMWH)
What makes up the Wells score for PE?
Clinical signs & symptoms of DVT (minimum of leg swelling and pain with palpation of deep veins) –> 3
Alternative diagnosis is less likely –> 3
HR >100bpm –> 1.5
Immobilisation for more than 3 days or surgery in previous 4 weeks –> 1.5
Previous DVT/PE –> 1.5
Haemoptysis –> 1
Malignancy (on treatment, treatment in last 6m, or palliative) –> 1
What score can be used to help identify patients with a PE that can be managed as outpatients
Pulmonary Embolism Severity Index (PESI)
If there is a strong suspicion of a PE but a delay in scans, what should be done?
Offer treatment dose of DOAC in the meantime
What is the target INR in patients who suffer from recurrent PEs?
3.5
What is the most common organism cause an acute exacerbation of bronchiectasis?
H. influenzae
Where does Klebsiella typically cause pneumonia?
Upper lobes
What type of lesions does Klebsiella pneumonia cause?
Cavitating
