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Medicine block (Y3) > Week 3: Respiratory medicine (2) (emergencies, X-ray, infections) > Flashcards

Week 3: Respiratory medicine (2) (emergencies, X-ray, infections) Flashcards

1
Q

anaphylaxis

A
  • SERIOUS allergic reaction
  • Sensitised individual exposed to specific antigen
  • Commonly from insects bites/ stings, food, medications
  • Immunological response: – IgE → antigen → mast cell & basophils ‡ → histamine ↑ → body response
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2
Q

signs and symptoms of anaphylaxis

A
  • Occurs in minutes - Pruritus, urticaria & angioedema, hoarseness, progressing to stridor & bronchial obstruction, wheeze & chest tightness from bronchospasm
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3
Q

management of anaphylaxis

A
  • DO NOT DELAY! GET HELP
  • Remove trigger, maintain airway, 100% O2
  • Intramuscular adrenaline 0.5 mg (Repeat every 5 mins as needed to support CVS)
  • IV hydrocortisone 200mg
  • IV chlorpheniramine 10 mg
  • If hypotensive: lie flat and fluid resuscitate
  • Treat bronchospasm: NEB salbutamol
  • Laryngeal oedema: NEB adrenaline
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4
Q

COPD exacerbation

A
  • Infective
    • Change in sputum volume / colour o Fever
    • Raised WCC +/- CRP
  • Non-infective
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5
Q

symptoms and signs of COPD exacerbartion

A
  • More coughing, wheezing, or shortness of breath than usual.
  • Changes in the color, thickness, or amount of mucus.
  • Feeling tired for more than one day.
  • Swelling of the legs or ankles.
  • More trouble sleeping than usual.
  • Feeling the need to increase your oxygen if you are on oxygen
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6
Q

management of COPD exacerbation

A
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7
Q

classification of asthma

A
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8
Q

raised CO2 in asthma attack

A

Raised CO2 is near fatal because shows patient is getting tired and cannot blow off CO2 anymore -→ need anaesthetics and intubation

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9
Q

management of acute asthma

A
  • ABCDE
  • Aim for SpO2 94-98% with oxygen as needed, ABG if
  • sats <92%
  • 5mg nebulised Salbutamol (can repeat after 15 mins)
  • 40mg oral Prednisolone STAT (IV Hydrocortisone if
  • PO not possible)
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10
Q

severe asthma management

A

same as acute +

  • Nebulised Ipratropium Bromide 500 micrograms
  • Consider neb back to back Salbutamol
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11
Q

life threatening asthma

A

acute + severe +

  • Urgent ITU or anaesthetist assessment
  • Urgent portable CXR
  • IV Aminophylline
  • Consider IV Salbutamol if nebulised route ineffective
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12
Q

pneumonia

A

Consolidation on CXR with fever +/- purulent sputum +/ raised WCC and / or CRP

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13
Q

management of pneumonia

A
  • ABCDE
  • If any features of sepsis – immediately treat using sepsis pathway – NO DELAY in initiating IV antibiotics and fluids
  • Otherwise treat with antibiotics as per CURB-65 score, local pneumonia guidelines and awareness of any patient drug allergies
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14
Q

first line Abx for pneumonia

A

PO amoxicillin

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15
Q

second line antibiotics for CAP

A

PO amoxicillin and doxycycline (dual)

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16
Q

third line antibiotics for CAP

A

IV CO-AMOXICLAV or meropenem + oral doxycycline

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17
Q

which pathogens cause typical CAP

A
  • S.pneumoniae
  • H. influenzae
  • S. aureus
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18
Q

which pathogens cause atypical CAP

A

Mycoplasma pneumoniae, Chlamydia pneumoniae, and Legionella pneumophila

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19
Q

common HAPs

A
  • MRSA
  • SA
  • Pseudomonas
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20
Q

masisve haemoptysis

A
  • >240mls in 24 hours OR
  • >100mls / day over consecutive days
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21
Q

Management of Massive Haemoptysis

A

• ABCDE

  • Lie patient on side of suspected lesion (if known)
  • Oral Tranexamic Acid for 5 days or IV
  • Stop NSAID’s / aspirin / anticoagulants
  • Antibiotics if any evidence of respiratory tract infection
  • Consider Vitamin K/
  • CT aortogram – interventional radiologist may be able to undertake bronchial artery embolisation
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22
Q

presentation of tension pneumo

A
  • Hypotension
  • Tachycardia
  • deviation of the trachea away from the side of the pneumothorax
  • mediastinal shift away from pneumothorax
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23
Q

Management of Tension Pneumothorax:

A
  • Large bore intravenous cannula into 2nd ICS MCL
  • Chest drain into the affected side
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24
Q

symptoms of PE

A
  • Chest pain (pleuritic)
  • SOB
  • Haemoptysis
  • Low cardiac output followed by collapse (if Massive PE)
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25
Q

unprovoked PE

A

PE i.e. no obvious risk factor – in these cases consider underlying malignancy or thrombophilia

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26
Q

PE management

A
  • ABCDE
  • Oxygen if hypoxic
  • Analgesia if pain
  • Subcutaneous DOAC (or LMWH if contraindicated) whilst awaiting CTPA
  • Should be fully anticoagulated once confirmed diagnosis on CTPA
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27
Q

massive PE management

A
  • hypotension/ imminent cardiac arrest
  • signs of right heart strain on CT / Echo
  • Consider thrombolysis with IV alteplase (risk of intracerebral bleed approx. 4%)
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28
Q

Thrombolysis contraindications

A
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29
Q

how to report a chest x-ray

A
  • intro
  • quality of film
  • ABCDE
    • review areas
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30
Q

X-ray intro

A
  • Name and age of patient
  • Date CXR taken
  • Type of CXR (e.g. PA or AP, erect or mobile)
  • Quality of film
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31
Q

Quality of film

A
  • Rotation
    • Medial aspect of each clavicle should equidistant from spinous processes
    • Spinous processes should be vertically orientated against vertebral bodies
  • Inspiration – 5-6 anterior ribs
  • Projection (not AP or PA)
  • Exposure- left hemidiaphragm should be visible to the spine and vertebrae should be visible behind the heart
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32
Q

airway

A

trachea central, carina, bronchi, hilar structures

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33
Q

breathing

A

lungs, pleura

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34
Q

cardiac

A

heart size and border

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35
Q

diaphragm

A

costophrenic angles - flattened?

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36
Q

everything else

A

soft tissue, bones, tubes, valves, pacemakers, review areas

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37
Q

review areas

A
  • the lung apices
  • the retrocardiac region
  • behind the diaphragm
  • the peripheral region of the lungs
  • the hilar regions
38
Q

how to present a potential diagnosis from an X-ray

A

e.g. “loss of right costophrenic angle which may be in keeping with a pleural effusion” as opposed to “a right pleural effusion”)

39
Q

descriptive terms x-ray

A
  • Refer to zones
    • Right Upper, Middle and Lower,
    • Left Upper, Middle and Lower
  • Shadowing can be
    • Complete (whiteout of whole lung field)
    • Dense / opacification (affecting one or more zones),
    • Diffuse
    • Alveolar (cotton wool like appearance)
40
Q

Cardio thoracic ratio

A

(The heart diameter is the shorter white arrow; the thoracic diameter is the longer black arrow. The Heart diameter is over 1⁄2 the thoracic diameter. The Cardio-thoracic ratio is therefore increased = Cardiomegaly.)

41
Q

deviation towards pathology

A

atelectasis

42
Q

deviation away from pathology

A

pleural effusion

pneumothorax

43
Q

pleural effusion X-ray

A
44
Q

pneumothorax

A
45
Q

pneumonia

A
46
Q

Lung cancer

A

Cant tell the difference between lung cancer and pneumonia on X-ray

47
Q

which medications causes coughs

A

ACEi, ARB, B blockers, NSAIDS

48
Q

pneumonia and its risk factors

A

Lung inflammation caused by bacterial or viral infection, in which the air sacs fill with pus and may become solid. Inflammation may affect both lungs ( double pneumonia ) or only one ( single pneumonia ).

Risk factors

Smoking, age>65, immuno-suppression, exposure to chemicals, and underlying lung disease

49
Q

legionaires disease

A

s a form of pneumonia, usually caused by Legionella pneumophila. Association with infected water in showers or hot tubs – ask your patient if there is a history of recent travel or stay in a air conditioned hotel? Associated with higher CURB-65 scores.

50
Q

CXR consolidation differntials

A

Pneumonia

TB (usually uopper lobe)

lung cancer

lobar collapse

haemorrhage

51
Q

causes of non-resolving pneumonia

A

CHAOS

52
Q

Pneumonia Follow Up

A
  • HIV test
  • Immunoglobulins
  • Pneumococcal IgG serotypes
  • Haemophilus influenzae b IgG
  • Follow up in clinic in 6 weeks with a repeat CXR to ensure resolution
53
Q

COVID-19

A
  • Coronavirus disease (COVID-19) is an infectious disease caused by a newly discovered coronavirus Coronaviruses (CoV) are a large family of viruses that cause illness ranging from the common cold to more serious diseases such as Severe Acute Respiratory Syndrome (SARS-CoV)
  • SARS-CoV-2 (severe acute respiratory syndrome-related coronavirus 2) is the name of the virus, not the disease that results from it.
  • Can cause a viral pneumonia
54
Q

which COVID-19 pts require hospitlisation

A
  • hypoxia (below 92%)
  • lymphopaenia
  • bilateral, lower zone changes on CXR
55
Q

management of hospitalised COVID-19 patients

A
  • Unwell patients require oxygen supplementation, some going on to CPAP or invasive ventilation
  • Evidence Base e.g. Dexamethasone (and consider Tocilizumab +/- Remdesivir)
  • Antibiotics may be needed if suspected superadded bacterial infection
56
Q

prevention of covid 19

A

vaccination

57
Q

novel therapies for covid-19

A

given to ‘at risk’ people who have tested positive of COVID-10

Casirivimab/imdevimab, sold under the brand name REGEN-COV among others, is a medicine developed by the American biotechnology company Regeneron Pharmaceuticals. It is an artificial “antibody cocktail” designed to produce resistance against the SARS-CoV-2 coronavirus responsible for the COVID-19 pandemic

58
Q

covid chest x-ray

A
59
Q

TB

A

A bacterial infection spread through inhaling tiny droplets from the coughs or sneezes of an infected person.

  • Mycobacterium tuberculosis.
  • Acid-fast bacilli
60
Q

risk factors of TB

A
61
Q

clinical features of TB

A
  • Often fever and nocturnal sweats (typically drenching)
  • Weight loss (weeks – months)
  • Malaise
  • Respiratory TB: cough ± purulent sputum/ haemoptysis, may also present with pleural effusion
  • Non-Respiratory TB: Skin (erythema nodosum); Lymphadenopathy; Bone/joint; Abdominal; CNS (meningitis); Genitourinary; Miliary (disseminated); Cardiac (pericardial effusion)
62
Q

DD of haemoptysis

A
63
Q

investigations for TB

A

Admit to a side room& start infection control measures (e.g. masks & negative pressure room)

  • If productive cough: x3 sputum samples for AAFB (acid-alcohol fast bacilli – acid-fast stain also called Ziehl-Neelsen stain) &TB culture (If no productive cough & pulmonary TB suspected consider bronchoscopy)
  • Routine bloods (especially LFTs) & include HIV test and vitamin D levels
  • Consider CT chest if pulmonary TB suspected but clinical features/ CXR not typical
64
Q

If diagnosis between pneumonia and TB not clear

A

start antibiotics for pneumonia (as per CURB-65) whilst investigating possibility of TB.

65
Q

If patient critically unwell and high likelihood of TB (no time to wait for sputum results)

A

then start anti-TB therapy AFTER sputum samples sent.

66
Q

why is TB treatment started before TB culture

A
  • TB culture can take 6-8 weeks. So, treatment is often started before a culture confirmed diagnosis can be made. A novel PCR test (Gene Xpert) is available in some centres which can give immediate information regarding drug sensitivities or resistance
67
Q

Anti-TB therapy (ATT)

A
  • Ripe (rifampicin, isoniazid, pyrazinamide, ethambutol for 2 moths follow by R and I for 4 months
  • Minimum of 6 moths total
  • Patients weight important – dose dependent
  • Check baseline LFTs and monitor
  • Check visual acuity before giving ethambutol
  • Compliance is crucial and directly observed therapy sometimes used for patients
  • Pyridoxine also given (while on isoniazid) as prophylaxis against peripheral neuropathy
68
Q

major side effects of TB treatment rifampicin

A

hepatitis, orange/red secretions, many drug interactions inc warfarin

69
Q

major side effects of TB treatment isoniazid

A

hepatitis

peripheral neuropathy

70
Q

major side effects of TB treatment pyrazinamide

A

hepatitis, vomiting

71
Q

major side effects of TB treatment ethambutol

A

optic neuritis

(must do a baseline visual acuity test and LFTs must be monitored closely)

72
Q

bronchiectasis

A
  • Chronic dilatation of one or more bronchi. The bronchi exhibit poor mucus clearance and there is predisposition to recurrent or chronic bacterial infection
  • Gold standard diagnostic test = High Resolution CT
  • Chronic dilatation of one or more bronchi. The bronchi exhibit poor mucus clearance and there is predisposition to recurrent or chronic bacterial infection
  • Gold standard diagnostic test = High Resolution CT
73
Q

Bronchiectasis Causes

*

A
  • Post infective – whooping cough, TB
  • Immune deficiency – Hypogammaglobulinaemia
  • Genetic / Mucociliary clearance defects – Cystic fibrosis, primary ciliary dyskinesia, Young’s syndrome (triad of bronchiectasis, sinusitis, and reduced fertility), Kartagener syndrome (triad of bronchiectasis, sinusitits, and situs inversus)
  • Obstruction – foreign body, tumour, extrinsic lymph node
  • Toxic insult – gastric aspiration (particularly post lung transplant), inhalation of toxic chemicals/gases
  • Allergic bronchopulmonary aspergillosis
  • Secondary immune deficiency – HIV, malignancy
  • Rheumatoid arthritis
  • Associations – inflammatory bowel disease; yellow nail syndrome
74
Q

Blood Tests to try and identify cause in newly diagnosed Bronchiectasis:

A
  • Immunoglobulin levels
  • Cystic Fibrosis Genotype
  • Aspergillus IgE / IgG and Total IgE
  • HIV test
  • Rheumatoid Factor
  • Auto Antibodies
  • Alpha-1-antitrypsin level
75
Q

Bronchiectasis Common Organisms

A
  • Haemophilus influenzae
  • Pseudomonas aeruginosa
  • Moraxella catarrhalis
  • Stenotrophomonas maltophilia
  • Fungi – aspergillus, candida
  • Non-tuberculous mycobacteria
  • Less common - Staphylococcus aureus (think about CF)
76
Q

Bronchiectasis Management

A
  1. Treat underlying cause
  2. Physiotherapy – mucus / airways clearance
  3. Sputum for routine culture as well as nontuberculous mycobacteria
  4. 10-14 days antibiotics according to sputum cultures / sensitivities for acute exacerbations (infections): Common 1st line Oral Antibiotics:
  5. IV antibiotics for severe infections
77
Q

rare side effect of ciprofloxacin

A

achilles tendonitis

78
Q

Long term bronchiectasis treatment

A
  • Long-term (prophylactic) antibiotics for patients with recurrent infective exacerbations
  • Supportive – flu / covid vaccines, bronchodilators if required
  • Pulmonary Rehab – MRC Dyspnoea Score >3
  • Long-term (prophylactic) antibiotics for patients with recurrent infective exacerbations
  • Supportive – flu / covid vaccines, bronchodilators if required
  • Pulmonary Rehab – MRC Dyspnoea Score >3
  • Long-term (prophylactic) antibiotics for patients with recurrent infective exacerbations
  • Supportive – flu / covid vaccines, bronchodilators if required
  • Pulmonary Rehab – MRC Dyspnoea Score >3
79
Q

Bronchiectasis Infective Exacerbations

A
  • Sometimes patients and clinicians find it difficult to distinguish an acute infection (exacerbation) in patients with bronchiectasis versus their baseline chronic symptoms. Here is a useful definition:
  • A person with bronchiectasis with a deterioration in 3 or more key symptoms for at least 48 hours:
  • Cough
  • Sputum volume and / or consistency
  • Sputum purulence
  • Breathlessness and / or exercise tolerance
  • Fatigue
  • Haemoptysis
80
Q

signs of bronchiectasis on CT

A

Signet ring sign

with the dilated bronchus representing the “ring” and the adjacent smaller artery representing the “jewel” on the ring.

81
Q

Allergic bronchopulmonary aspergillosis (ABPA)

A
  • Caused by aspergillus fumigatus exposure
  • Aspergillus is a common fungus found indoors and outdoors
  • ABPA is a combination of types 1 and 3 hypersensitivity reactions following inhalation of fungal spores i.e. it is not a fungal infection
  • Repeated damage from these immunological reactions leads to bronchiectasis (often upper lobe)
  • ABPA is seen more in patients with Asthma, Bronchiectasis and Cystic Fibrosis
  • Diagnosis is made by a combination of symptoms (often dry cough and wheeze) along with positive blood tests (raised Aspergillus IgE level as well as a high Total IgE – these are often accompanied by a high eosinophil level too)
  • Treatment (steroids) may be required if ongoing symptoms and high Total IgE level
82
Q

CF Definition

A

CF is an autosomal recessive disease leading to mutations in the Cystic Fibrosis Transmembrane Conductance Regulator (CFTR). This can lead to a multisystem disease (most commonly affecting the respiratory and gastrointestinal systems but can affect any part of the body with CFTR) characterised by thickened secretions.

83
Q

CF Diagnosis

A

One or more of the characteristic phenotypic features -

  • Or a history of CF in a sibling
  • Or a positive newborn screening test result

And

  • An increased sweat chloride concentration (> 60 mmol/l) – SWEAT TEST
  • Or identification of two CF mutations – genotyping
  • Or demonstration of abnormal nasal epithelial ion transport (nasal potential difference)
84
Q

CF Presentations

A
  • Meconium ileus
    • In 15-20% of newborn CF infants the bowel is blocked by the sticky secretions. There are signs of intestinal obstruction soon after birth with bilious vomiting, abdominal distension and delay in passing meconium.
  • Intestinal malabsorption
    • Over 90% of CF individuals have intestinal malabsorption. In most this is evident in infancy. The main cause is a severe deficiency of pancreatic enzymes.
  • Recurrent Chest infections
  • Newborn screening
85
Q

CF complications: resp

A
  • Respiratory Infections
    • Needs aggressive therapy with physio and antibiotics
    • Antibiotic prophylaxis
86
Q

CF complications: constitutional

A
  • Low Body Weight
    • needs careful monitoring
    • may be consequence of pancreatic insufficiency (lack of pancreatic enzymes), therefore in those patients give pancreatic enzyme replacement therapy
    • high calorie intake and often extra supplements - may need NG or PEG feeding
87
Q

CF complications: GI

A
  • Distal Intestinal Obstruction Syndrome (DIOS)
    • DIOS vs. constipation – faecal obstruction in ileocaecum versus whole bowel
    • Due to intestinal contents in the distal ileum and proximal colon (thick, dehydrated faeces)
    • Due to insuffiencet prescription of pancreatic enzymes or non compliance, also salt deficiency/ hot weather
    • Palable right iliac fossa mass (faecal)
    • Diagnosis:right palabale mass in iliac fossa, AXR demonstratingfaecal loading at junction of small and large bowel
    • Treatment: PO Gastrografin–this works by drawing water across the bowel wall by osmosis into the bowel lumen, aiming to rehydrate the dehydrated faecal mass and allow it to pass
88
Q

CF can also be related to

A

diabetes

the thick, sticky mucus causes scarring of the pancreas. This scarring prevents the pancreas from producing normal amounts of insulin. So, like people with type 1 diabetes, they become insulin deficient.

89
Q

CF Lifestyle Advice

A
  • No smoking
  • Avoid other CF patients
  • Avoid friends / relatives with colds / infections
  • Avoid jacuzzis (pseudomonas)
  • Clean and dry nebulisers thoroughly
  • Avoid stables, compost or rotting vegetation – risk of aspergillus fumigatus inhalation
  • Annual influenza immunisation
  • Sodium chloride tablets in hot weather / vigorous exercise
90
Q

CF Management

A
  • As per bronchiectasis – physio for airways clearance
  • Exercise
  • Mucolytic treatment options also include nebulised DNase (pulmozyme)
  • Pancreatic Enzyme Replacement Therapy (e.g. Creon) for patients who are Pancreatic Insufficient
  • Nutritional supplementation if under weight
  • Fat soluble vitamin (A,D,E,K) replacement
  • Long-term antibiotics (sometimes inhaled or nebulised)
  • Optimisation of CF related diabetes – this occurs in approximately 1 in 3 adults with CF and if present requires insulin therapy
  • Novel CFTR modulators / potentiators (e.g. Kaftrio) – these have shown excellent efficacy with improvements in FEV1, weight, quality of life and a reduction in frequency of infective exacerbations
  • Long-term monitoring for CF related diabetes, CF related liver disease and osteoporosis

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