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Respiratory > T- yr CPL > Flashcards

T- yr CPL Flashcards

1
Q

Definition of asthma

A

Chronic inflamm. disorder of the airways 2ndary to type 1 hypersensitivity

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2
Q

How do the Sx of asthma manifest?

A

Reversible bronchospasm –> progresses to airway obstruction

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3
Q

Criteria for moderate acute asthma

A
  • PEFR 50-75%
  • Norm. speech
  • RR< 25
  • HR< 110
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4
Q

Criteria for severe acute asthma

A
  • PEFR 33-50%
  • incomplete sentences
  • RR> 25
  • HR> 110
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5
Q

Criteria for life-threatening acute asthma

A

Dx if ONE feature is present

  • PEFR < 33%
  • O2 sats < 92%
  • Norm. pCO2
  • Silent chest, cyanosis, decrea. resp. efoort
  • Bradycardia, dysrrhythmia, hypotension
  • coma, confusion
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6
Q

What makes acute asthma life-threatening?

A

An increa. pCO2

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7
Q

What are the Sx of asthma?

A
  • Dyspnoea
  • Nocturnal cough
  • Wheeze
  • Chest tightness
  • increa. sputum
  • Diurnal variation- PF decrea. in AM
  • Acid reflux- 40% pt.
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8
Q

What are the signs of asthma on Px

A
  • expiratory polyphonic wheeze
  • tachypnoea
  • decrea. air entry
  • Hyperinflat.
  • decrea. peak expiratory flow rate (PEFR)
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9
Q

What are some conditions assoc. w/ asthma?

A
  • atopic dermatitis (eczema)
  • allergic rhinitis
  • aspirin sensitivity
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10
Q

What are the causes/ RF for asthma?

A
  • Hx/ FHx of atopy
  • antenatal factors: mat. smoking, RSV infect., decrea. birth weight
  • formula-fed
  • allergen exposure
  • air pollution
  • NSAIDs
  • Beta- blockers
  • Hygiene hypothesis- predom. Th2 immune response
  • occupational asthma: isocyanates, flour
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11
Q

Bed-side Ix for asthma + expected result in asthmatic pt.

A
  • Peak expiratory flow (PEF)
  • Result= variable
  • +ve test= > 20% variability (PEF x2/ day 2-4wks)
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12
Q

When would you consider a CXR when Dx asthma?

A
  • older pt.

- pt. w/ smoking Hx

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13
Q

What special tests are used to Dx asthma?

A
  • Spiromety: FEV1, FVC, FEV1%
  • Fractional exhaled nitric oxide (FeNO)
  • Bronchodilator reversibility test (BDR)
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14
Q

What are the expected spirometry results in an asthma pt.?

A
  • FEV1= signif. decrea.
  • FVC= norm.
  • FEV1% <70%
  • Shows obstructive lung disease
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15
Q

What are the expected FeNO results in an asthma pt.?

A
  • increa. iNOS- increa. eosinophil airway inflamm.
  • adult +ve test= > 40ppb
  • child +ve test= > 35 ppb
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16
Q

What are the expected BDR results in an asthma pt.?

A
  • Asthma= +ve result
  • adult +ve test= 12% increa. FEV1+ increa. vol. 200ml
  • child +ve test= 12% increa. FEV1
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17
Q

What is the criteria to dx asthma in a child <5yo?

A
  • Clinical judgment
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18
Q

What is the criteria to dx asthma in a child 5-16yo?

A
  • obstructive spirometry result
  • +ve BDR
  • (+ FeNO if BDR= -ve)
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19
Q

What is the criteria to dx asthma in an adult >17yo

A
  • ? occupational asthma
  • Obstrucive spirometry result
  • +ve BDR
  • +ve FeNO
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20
Q

What is the 1st line treat. for asthma w/ e.g.?

A
  • SABA

- salbutamol, terbutaline

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21
Q

What is the 2nd line treat. for asthma w/ e.g.?

A
  • SABA + low- dose ICS
  • SABA: salbutamol, terbutaline
  • ICS: beclometasone
  • admin. if sx uncontrolled- increa. sx 3x/ wk OR night waking
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22
Q

What is the 3rd line treat. for asthma w/ e.g.?

A
  • SABA + low-dose ICS + LTRA
  • SABA: salbutamol, terbutaline
  • ICS: beclometasone
  • LTRA= leukotriene receptor antag.: montelukast
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23
Q

What is the 4th line treat. for asthma w/ e.g.?

A
  • SABA + low-dose ICS + LABA
  • Continue LTRA depending on pt. response
  • SABA: salbutamol, terbutaline
  • ICS: beclometasone
  • LABA: formeterol
  • LTRA= leukotriene receptor antag.: montelukast
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24
Q

What is the 5th line treat. for asthma w/ e.g.?

A
  • SABA +/- LTRA + MART (inclu. low-dose ICS)
  • SABA: salbutamol, terbutaline
  • LTRA= leukotriene receptor antag.: montelukast
  • MART= Maintenance reliever therapy= combo ICS + fast-acting LABA: Fostair
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25
Q

What is the 6th line treat. for asthma?

A
  • SABA +/- LTRA + med.-dose ICS MART
    OR
  • SABA +/- LTRA + mod. ICS + LABA
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26
Q

What is the 7th line treat. for asthma?

A
  • SABA +/- LTRA +:
  • High- dose ICS
    OR
  • trial LAMA- ipratropium
    OR
  • trial theophylline
    OR
  • refer for specialist input
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27
Q

How often should you step down asthma treat.?

A

Every 3 mths

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28
Q

What are the Sx of acute asthma?

A
  • increa. dyspnoea
  • wheeze + cough
  • Sx NOT responding to salbutamol
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29
Q

What Ix should you carry out in acute asthma?

A
  • ABG- O2< 92%

- CXR- life-threatning, ? pneumothorax, no response to treat.

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30
Q

When should you admit for acute asthma?

A
  • life-threat.
  • severe if no treat. response
  • prev. near- fatal episode
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31
Q

What is the management for acute asthma?

A
  • O2 if hypoxaemic- 15L non-rebreathe titrated down until maintain sats 94-98%
  • Bronchodilate w/ SABA- nebulised if life-threat.
  • Corticosteroid: 40-50mg prednis. PO daily for min 5 days (continue norm. ICS)
  • Ipratropium bromide- if no response to prev. treat.
  • IV MgSO4- severe + life-threat.
  • Last resort= intubat. + ECMO
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32
Q

When should you discharge a pt. after acute asthma?

A
  • Stable on discharge meds. 12- 24hrs
  • Inhaler technique checked
  • PEFR> 75%
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33
Q

What is the definition of COPD?

A
  • Progressive airway obstruct. disorder inclu. chronic bronchitis + emphysema
  • Sx NOT reversible
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34
Q

What is the definition of chronic bronchitis?

A
  • clin. definition

- cough + sputum on most days 3/12 of 2 success. yrs.

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35
Q

What is the definition of emphysema?

A
  • Histolog. definition

- permanent dilation of airways dist. to terminal bronchioles

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36
Q

What are the sx of COPD?

A
  • Chronic product. cough
  • dyspnoea
  • Wheeze
  • progressive dyspnoea
  • R- sided HF –> periph. oedeme
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37
Q

What is the definition of acute COPD exacerbation?

A

Sudden sustained worsening in pt. sx beyond norm. variation

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38
Q

What are the RF for COPD?

A
  • Smoking
  • Alpha- 1- antitrypsin def.
  • dust. inclu. coal dust
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39
Q

What are causes of COPD exacerbat.?

A
  • infect. of airways
  • pneumothorax
  • PE
  • LVF
  • lung carcinoma
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40
Q

What organisms cause infect. exacerbat. of COPD?

A
  • H. influenzae
  • S. pneumoniae
  • M. Catarrhalis
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41
Q

What bloods to Ix COPD?

A

FBC- exclu. 2ndary polycythaemia

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42
Q

What imaging to Dx COPD?

A

CXR

  • hyperinflation
  • bullae
  • flat hemidiaphragm
  • (exclude lung Ca)
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43
Q

What special test can Dx COPD + expected result for COPD pt.?

A

post- bronchodilator spirometry

  • Result: FEV1% <70%
  • shows airflow obstruct.
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44
Q

What is stage 1 COPD?

A
  • Sx must be present
  • FEV1%< 70%
  • FEV1> 80% (of predict.)
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45
Q

What is stage 2 COPD?

A
  • Moderate
  • FEV1%< 70%
  • FEV1= 50-79% (of predict.)
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46
Q

What is stage 3 COPD?

A
  • Severe
  • FEV1%< 70%
  • FEV1= 30-49% (of predict.)
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47
Q

What is stage 4 COPD?

A
  • v. severe
  • FEV1%< 70%
  • FEV1<30% (of predict.)
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48
Q

What is the general management of COPD?

A
  • Smoking cessat. + nicotine replacement
  • Annual flu vacc.
  • pneumococcal vacc.
  • pulm. rehab.
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49
Q

What is 1st line treat. for COPD?

A
  • SABA/ SAMA as requ.
50
Q

What is the prep. for 2nd line treat. of COPD?

A

? asthmatic fx/ steroid responsiveness fx

  • prev. dx asthma/ atopy
  • increa. serum eosinophil count
  • substant. FEV1 variation over time (>400ml)
  • Diruranl variation in peak flow (>20%)
51
Q

What is 2nd line treat. for COPD?

A

?Asthma fx YES:

  • SABA/ SAMA as requ.
  • LABA + ICS reg.

? Asthma fx NO:

  • SABA as requ.
  • LABA + LAMA reg.
52
Q

Whats is the 3rd line treat. for COPD?

A
  • SABA as requ.

- LABA, LAMA + ICS reg.

53
Q

What is the 4th line treat. for COPD?

A

oral theophylline

54
Q

How does cor pulmonale develop in COPD?

A
  • emphysema –> loss pulm. arterioles + capillaries
  • Chronic hypoxia –> pulm. art. constrict.
  • Chronic hypoxia –> increa. EPO –> increa. erythrocytosis –> increa. blood viscosity
55
Q

What are the main causes of death in COPD pt.?

A
  • bronchopenuomia
  • Resp. failure
  • Heart failure
56
Q

What is oral prophylactic ABX in COPD pt.

A

Azithromycin

pt. criteria:
- not smoke
- optimised on standard treat. –> still have exacerbat.
- CT thorax to exclu. bronchiectasis
- Sputum culture to exclude atyp. infect. + TB
- LFTs
- ECG exclude QT prolongation

57
Q

What is a SE of azithromycin?

A

QT prolongation

58
Q

When would you Rx mucolytics in COPD?

A

pt. w/ chronic product. cough- continue if sx improve

59
Q

Sx of cor pulmonale?

A
  • periph. oedema
  • increa. JVP
  • syst. parasternal heave
  • loud P2
60
Q

What is the treat. for cor pulmonale?

A
  • loop diruetic

- LTOT

61
Q

What is LTOT for COPD?

A

Breathe O2 15h/ day

62
Q

Criteria for COPD pt. to be asses. for LTOT?

A
  • v. severe airway obstruct.- FEV1< 30%
  • cyanosis
  • polycythaemia
  • periph. oedema
  • increa. JVP
  • O2 sats< 92% room air
63
Q

How to assess. pt. for LTOT?

A

2 ABG 3wks apart w/ stable COPD on optimal management

64
Q

When to offer LTOT for COPD pt.?

A 
pt. w/ pO2 <7.3
OR 
pO2 7.3- 8 +: 
- 2ndary polycythaemia 
- peipheral oedema 
- pulm. HTN

DO NOT offer if pt. still smokes

65
Q

What is the definition of respiratory failure?

A
  • Hypoxia

- PaO2< 8kPa

66
Q

Definition of type 1 resp. failure?

A
  • Hypoxia

- w/ norm OR decrea. PaCO2

67
Q

Definition of type 2 resp. failure?

A
  • Hypoxia

- Hypercapnia- PaCO2> 6 kPa

68
Q

Sx of resp. distress in resp. failure

A
  • tachypnoea
  • dyspnoea
  • access. musc. use
  • stridor
  • inabil. to speak
  • cyanosis
69
Q

Sx of hypoxia

A
  • dyspnoea
  • restelssness
  • anxiety + agitation
    confusion
  • cyanosis
  • headache
70
Q

Sx of hypercapnia

A
  • headache
  • periph. vasodilation
  • tachycardia
  • CO2 retention flat
  • papillodema
  • confusion + coma
  • severe: comfort. @ rest –> progress. hypoventilate –> coma
71
Q

Sx long standing hypoxia

A
  • polycythaemia
  • pulm. HTN
  • cor pulmonale
  • tachycardia + arrhythmias from hypoxaemia + acidosis
72
Q

What are modifiable RF for resp. failure?

A
  • cigarrettes
  • opiods + sedatives
  • toxic fumes + gases
73
Q

Non- modifiable RF for resp. failure

A
  • v. young

- v. old

74
Q

Pre-existing path. RF for resp. failure

A
  • pulm. infefct.
  • chronic lung disease
  • airway obstruct.
  • alveolar abnormal.
  • Perfusion abnormal.
  • cardiac failure
  • periph. nerve damage + musc. abnormal./ injury
75
Q

Causes of type 1 resp. failure

A
  • V/Q mistmach
  • hypoventilation
  • abnormal diffusion
  • cardiac shunts
76
Q

Causes of V/Q mismatch

A
  • pneumonia
  • pulm. oedema
  • PE
  • Asthma
  • Emphysema
  • ARDS
77
Q

Causes of type 2 resp. failure

A

Alveolar hypoventilation w/ OR w/o V/Q mismatch

  • pulm. disease: asthma, COPD, pneumonia
  • decrea. resp. drive
  • neuromusc. disease
  • thoracic wall disease/ injury
78
Q

Bedside Ix in resp. failure

A
  • pulse oximetry
  • FVC
  • ECG
79
Q

Blood Ix in resp. failure

A
  • FBC
  • U&Es
  • CRP
  • D-dimer
  • Toxicology
  • ABG
80
Q

ABG results in resp. failure

A

pH PaCO2 HCO3-
Metabolic acidosis Low Normal/ low Low
Resp. Acidosis Low High Normal/ high
Metabolic Alkalosis High Normal/ high High
Resp. Alkalosis High Low Normal/ low

Chronic hypercapnia- metabolic compensation has occurred: increa. PaCO2 + increa. HCO3- + slightly decrea./ norm. pH

81
Q

What special tests can be used to Ix resp. failure?

A
  • Microbiology: sputum, blood cultures
  • capnometry- used in intubat. pt. to measure expired CO2- reflect. arterial CO2
  • spirometry: PEFR + FEV- obstruct. + restrict. should NOT cause resp. failure
82
Q

General managment for resp. failure

A
  1. treat. underlying cause
  2. O2
  3. correction of acidosis/ alkalosis- may be achieved through ventilatory support
  4. NIPPV
  5. Endotrach. intubat. + ventilation
83
Q

Management of type 1 resp. failure

A
  1. treat underlying cause
  2. O2 24-60% non-RB facemask
  3. if pt. still hypoxic w/ 60% O2 –> NIPPV
84
Q

Management of airway obstruction

A
  1. airway clearance + O2

2. treat. underlying cause

85
Q

Management of Type 2 resp. failure

A 
Resp centre= CO2 insensitive 
1. Treat the cause 
2. controlled O2 via non-RB facemask- start @ 24% 
MAKE SURE HYPOXIA IS TREATED 
3. recheck ABG after 20 mins 
- PaCO2 decrea. --> increa. O2
- PaCO2 increa. --> NIPPV 
4. Endotrach. intubat. + ventilat.- CPAP + BIPAP
86
Q

Definition of pulmonary embolism

A

1+ emboli arising from venous thrombus in pelvis/ legs lodge in –> obstruct. art. pulm. circulation –> resp. dysfunct.

87
Q

How does a small PE often present?

A

asx

88
Q

Sx of PE

A
  • acute tachypnoea
  • pleuritic chest pain
  • haemoptysis
  • dizziness
  • syncope
  • dyspnoea
89
Q

Signs of a PE

A
  • pyrexia
  • cyanosis
  • tachypnoea
  • tachycardia
  • hypotension
  • increa. JVP
  • chest usually clear BUT can hear crackles
  • pleural rub
  • pleural effusion
  • AF
  • loud P2
  • RV parasternal heave
90
Q

Sx of massive PE (embolus in R outflow tract)

A

Haemodynamic collapse

91
Q

Considerations in pt. presenting w/ PE

A
  • ? RFs
  • ? PMH/ FHx thromboembolism
  • ? signs of cause e.g. DVT
92
Q

RF in PE

A

increa. coagulability
- recent surgery- decrea. risk if prophylaxis used
- thrombophilia
- leg #
- decrea. motility
- malignancy
- preg. COCP, (HRT)
- Prev. PE
- myeloproliferative disorder
- acitve inflamm.

93
Q

How to prevent PE

A
  • heparin in all immobile pt.

- stop HRT + COCP pre-op

94
Q

ECG signs for PE

A
  • norm.= norm./ sinus tachy
  • common: RV strain, V1- V3, RAD, AF, RBBB
  • classical BUT rare= S1Q3T3
95
Q

Bedside Ix for PE

A
  • O2 sats
  • RR
  • HR
  • Temp.
  • ECG
96
Q

Bloods for PE

A
  • FBC
  • U&Es
  • baseline clotting
  • ABG- hyperventilation + decrea. gas exchange –> decrea. PaO2, decrea. PaCO2, increa. pH
  • D- dimer
97
Q

Significance of D-dimer test in Ix for PE

A
  • -ve result excludes PE

- low specificity t/f only test pt. w/ low probabil. of PE

98
Q

Imaging Ix in PE

A
  • CXR

- USS of pelvic/ femoral vein clots

99
Q

PE findings on CXR

A
  • decrea. vasc. markings
  • small pleural effusions
  • edge shaped infarctions
  • atelectasis
100
Q

What is the Gold standard Ix for PE?

A

CTPA

101
Q

What are the special Ix to dx PE?

A
  • CTPA

- V/Q scan- aid dx BUT often equivocal results (preferred if renal impairment; COPD would show matched defects)

102
Q

When to Dx PE?

A
  • always suspect. in sudden collapse 1-2wks post- surg.
  • CTPA= test of choice in high- risk pt./ low risk pt. w/ +ve d-dimer
  • Wells Criteria: score > 4; score < 4 + d-dimer +ve
103
Q

Management process of PE

A
  1. Pulm. embolism rule out criteria (PERC)
  2. Calculate modified Wells Score
    3a. >4= immed. CTPA/ treat. w/ DOAC
    4a1. CTPA +ve= Dx PE
    4a2. CTPA -ve= prox. leg vein USS for DVT
    3b. <4- d-dimer
    4b1. d-dimer +ve= immed. CTPA/ DOAC
    4b2. d-dimer -ve= alternative dx + stop anticoag.
104
Q

What DOACs are used in management of PE?

A

Apixaban + rivaroxaban

- if unsuitable: LMWH + dabigatran/edoxaban OR LMWH + warfarin

105
Q

What is the Pulm. embolism rule-out criteria (PERC)

A 
used to exclude PE in pt. known to have low-pretest probabil. (<15%) of PE- if probail. >15% then skip --> Wells criteria 
- age >50
- HR> 100
- O2 sats <94% 
- prev. DVT/ PE 
- recent surge./ trauma in last 4 wks 
- haemoptysis 
- unilat. leg. swelling 
- oestrogen use 
If all above absent then probability of PE< 2%
106
Q

What is the Wells Criteria

A
  • Clinical signs + Sx DVT 3
  • HR> 100 1.5
  • Recently bed-ridden (>3/7)/ maj. surgery (<4/52) 1.5
  • prev. DVT/ PE 1.5
  • Haemoptysis 1
  • Ca receiving active treat., treat. last 6/12, palliat. 1
  • Alternative Dx < likely than PE 3
    <4= PE unlikely
    > 4= PE unlikely
107
Q

Lenght of treat. for PE

A
  • Provoked= 3/12 –> reasses whether RF persists + risk/ benefit
  • Unprovoked= > 3/12
  • Malig.= continue w/ DOAC 6/12 until Ca cured
  • Preg.= LMWH heparin continued until delivery/ end of preg.
108
Q

Options for long term anticoagulation

A
  • DOACs= rapid onset + no need for LMWH overlap
  • Warfarin (Vit. K agonist)- stop heparin when INR= 2-3 d/t initial prothrombotic effect warfarin
  • Vena caval filter if anticoag.= CI
109
Q

Immediate treat. of PE

A
  1. O2 if hypoxic- 10-15L/ min
  2. IV morphine 5-10mg + anti-emetic
  3. IV access –> DOAC/ LMWH/ vit. K agonist
  4. if hypotensive 500ml IV fluid bolus- ICU input
  5. ?haemodynamically unstable
    6a. NO: persist. low BP –> vasopressors- aim for syst. BP> 90
    - Dobutamine IV
    - NA IV
    6b. YES: thrombolysis- alteplase 10mg IV bolus –> IVI 90mg/ 2h
  6. long- term anti-coag.
110
Q

Definition of primary pneumothorax

A

no underlying lung disease

111
Q

Definition of secondary pneumothorax

A

underlying lung disease

112
Q

Definition of large pneumothorax

A

visible rim > 2cm

113
Q

Definition of small pneumothorax

A

visible rim < 2cm

114
Q

Sx of pneumothorax

A

Sudden onset

  • dyspnoea
  • pleuritic chest pain
  • sweating
  • increa. HR
  • increa. HR
  • decrea. ipsilat. breath sounds + chest expansion
115
Q

Sx of tension pneumothorax

A
  • tracheal shift
  • hyper-resonant on affected side
  • cardiopulm. deterioration
116
Q

RF for a pneumothorax

A
  • pre- existing lung disease: COPD, asthma, CF, lung Ca, pneumocystis pneumoniae
  • connect tissue disease: Marfans; RA
  • Ventilation inclu. non- invasive
  • Catamenial pneumothorax- endometriosis in thorax
  • thoracic trauma where lung parenchymal flap formed
117
Q

Bloods to Ix pneumothorax

A
  • FBC
  • clotting screen- correct abnromal before chest drain
  • ABG- O2< 92% on room air
118
Q

What imaging is done to dx pneumothorax?

A
  • CXR (PA)

- Chest CT if Dx uncertainty/ trauma pt.

119
Q

What is the treatment of a tension pneumothorax?

A
  1. needle aspiration w/ wide bore cannula (grey), 2nd ICS midclav.
  2. O2 + admit
120
Q

What is the treat. of a primary pneumothorax?

A

Air< 2cm + no SOB
1. O2 + obs –> discharge

Air> 2cm

  1. aspiration <2.5L w/ wide bore cannula (if successful discharge)
  2. chest drain 5th ICS mid- axillary –> admit
121
Q

What is the treat. of a secondary pneumothorax?

A

pt. > 50yo + air> 2cm +/or SOB
1. Chest drain

air 1-2cm- admit all pt. 24h

  1. aspiration w/ wide bore cannula 2nd ICS midclav.
  2. chest drain 5th ICS midaxill.

air < 1cm
1. O2 + obs –> admit 24h

122
Q

Treatment for iatrogenic pneumothorax

A

most resolve on their own

  1. aspiration w/ wide bore cannula 2nd ICS midclav.
  2. Chest drain 5th ICS midaxill.- more likely in COPD + ventilat. pt.

Respiratory (1 decks)

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