Respi SAQ Flashcards
chronic smoker, months of SOB, 5 years of dry cough, 3 years of whitish + occasionally yellowish sputum + a few episodes of fever and sputum, says pneumonia; referred to SOPD clinic. PE: prolonged expiratory phase, LLZ coarse crackles, also raised JVP, bilateral ankle edema and central cyanosis. FEV1 1.3L FVC 2.4L FEV/FVC 54% CXR hyperinflated lung fields;
1. 2 most likely ddx
2. 1 Ix to differentiate the two
3. What complication from PE. Explain physiology of complication
4. Definition of reversibility on bronchodilator change
- COPD, bronchiectasis
- HRCT thorax
- Cor pulmonale due to pulmonary hypertension as a result of obliteration/occlusion of blood vessels. VQ mismatch hypoxia –> polycythemia –> hypervolemia causing increased cardiac output and causes pulmonary hypertension and increases RV workload –> resulting in congestion –> elevated JVP, peripheral edema
- Increased FEV1 >12% by bronchodilator/ >200ml increae in FEV
a) Respiratory acidosis as there is hyperventilation to compensate for the dead space. This is type 2 respiratory failure: wasted expenditure of energy.
b) Drugs: Short acting inhaled salbutamol +/- ipratropium bromide with spacer. Corticosteroids (hydrocortisone 100mg iv q6-8h or oral prednisolone 30-40mg daily). Steroids discontinued after the acute episode (e.g. 5-10 days)
Non drugs: supplemental oxygen (start with 1-2L/min by nasal prongs) to maintain spO2 88-92%. NIV to relieve dyspnea by decreasing work of breathing: consider when respiratory acidosis (pH<7.35), severe dyspnoea with signs of respiratory muscles fatigue, persistent hypoxemia despite supplemental O2 therapy)
c) cigarette smoking, occupational exposure to dust/fumes, indoor biomass combustion (wood, coal –> not in HK)
a) severe asthma, non responsive phenotype, poor inhaler technique, poor adherence, ongoing exposure to triggers, inadequately controlled comorbidities (rhinitis), misidagnosis
b) house dust, pollen, animal danders
c) Bronchodilator as reliever, increase to medium dosage ICS. Can add LABA if not well controlled (formoterol).
a) aspiration pneumonia due to impaired consiousness caused by stroke. Given IV because patient may be unable to swallow well.
b)
Ampicillins and cephalosporins (apart from 2nd gen cephalosporins) don’t cover anaerobes which is needed in aspiration pneumonia
aspiration pneumonia pathogens
Gram +ve: strept pneumoniae, staph aureus, alpha hemolytic streptococci
Gram -ve: haemophilus influenzae, pseudomonas aeruginosa, e.coli, klebsiella pneumoniae (DM+ elderly)
Anaerobic: bacteroides, peptostreptococus, fusobacterium
A 27/F found unconscious on the street. Respiratory rate 8 breaths per minute. Pinpoint pupils. The blood gas shows the following (pH 7.25, PaO2 low, PaCO2 high, HCO3 12, BE +2)
a. Interpret the blood gas findings
b. Most likely diagnosis
c. What drug treatment would you give for the diagnosis
d. Three alternative causes for the blood gas picture
a. Type 2 respiratory failure: hypoxia + hypercapnic due to hypoventilation (this is a ventilatory failure) + respiratory acidosis. There is no renal compensation as HCO3- is low (insufficient time to compensate).
b. Opioid intoxication (inability to dilate pupils)
c. Naloxone
d. GBS/ myasthenic crisis/ BDZ overdose
Bronchiectasis exacerbation with Gram-negative rod cultured
a. 2 typical features of bronchiectasis on CXR
b. Name one other confirmatory investigation
c. What is the Gram-negative bacteria cultured likely to be?
d. Three groups of antibiotics for the above bacteria
e. Name one evidenced based drug which has been proven to reduce the frequency and severity of exacerbations, 2 adverse effects to monitor associated with long-term use
a. tramline opacities, thickened and abnormally dilated bronchial walls, parallel linear densities
b. HRCT
c. Pseudomonas aeruginosa
d. Fluoroquinolones, aminoglycosides, at least 3rd gen cephalosporins, carbapenems, extended spectrum penicillins
e. immunomodulation by macrolide (azithromycin): takes at least 6 months for effect. AE: hepatotoxicity, ototixicity, QTc prolongation
Other immunomodulation
Inhaled antibiotics for PsA colonizer: inhaled gentamicin
Intermittent IV antibiotics
a. 2 types of cells affected by HIV
b. 3 groups of drugs in HAART
c. Pneumonia picture. Diffuse haziness on CXR. Give 2 ddx
d. CD4 140. AFB smear of sputum negative. What is most likely dx?
e. Name 1 Ix to confirm dx?
f. What drug treatment for dx?
a. macrophage, dendritic cell, helper T cell (CD4+)
b. NRTI, NNRTI, PI
c. PJP, miliary TB
d. PJP
e. BAL with methanamine silver stain
f. Septrin (cotrimoxazole). If G6PD+ve –> give pentamidine.
