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1
Q

Management of haemodynamically stable PE

A

apixaban/rivaroxaban immediately if Well’s >4

Stable: DOAC for 3m/6m based on unprovoked/provoked
PESI score +/- Echo for Right Heart Strain

Consider IVC filter if CI to thrombolysis

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2
Q

Management of unstable PE

A

no CI to thrombolysis: unfractionated heparin
then hold heparin while administering alteplase
then heparin

CI to thrombolysis: heparin then surgery

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3
Q

Management of primary pneumothorax

A

<2cm: review in 2-4w

>2cm or SOB: aspirate

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4
Q

Management of secondary pneumothorax

A

<1cm: admit for 24h and O2
1-2cm: aspirate
>2cm: chest drain

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5
Q

Tension pneumothorax management

A

14-16G needle 5th ICS MAL

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6
Q

Management acute COPD

A

aim sats 88-92% (ABG again within 1h starting O2)

Start 28% O2 (or 24% if available)
Neb salbutamol 5mg b2b
Ipratropium 0.5mg every 4h
Pred PO 30mg
Co-amoxiclav/amox/clari/doxy

Consider aminophylline, ITU, NIV

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7
Q

Indications for BIPAP

A

COPD with resp acidosis 7.25-7.35
T2RF secondary to MND, deformity or OSA
Cardiogenic pulmonary oedema unresponsive to CPAP

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8
Q

Management of chronic COPD

A

Conservative: vaccines, smoking cessation, pulmonary rehab

Inhalers based on symptoms and risk (mMRC and GOLD system)
mucolytics
rescue packs
?Long term oxygen therapy if pO2 <7.2 or <8 and signs of decompensation (secondary polycythaemia, peripheral oedema, pulmonary HTN)

consider surgery: lung volume reduction, bullectomy, transplant

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9
Q

COPD inhaler management

A

1) SABA OR SAMA for breathlessness
2a) If NO asthmatic features: LABA + LAMA
2b) if ASTHMATIC features: LABA + ICS
3) LABA + LAMA + ICS

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10
Q

What is SABA/SAMA/LAMA/LABA/Symbicort/LTRA

A 
SABA: salbutamol
SAMA: ipratropium
LABA: salmeterol
LAMA: tiotropium
symbicort: LABA + ICS
LTRA: montelukast
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11
Q

Chronic Asthma management

A

Conservative: Review technique, avoid triggers, monitor peak flow, asthma action plan, flu vaccine

1) SABA + ICS
2) add LABA
3) Add LTRA or increase ICS
discard LABA if not working
4) Refer to specialist

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12
Q

FEV1 actual vs predicted COPD categories

A 
>80% = mild
50-79% = moderate
30-49 = severe
<30% = very severe
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13
Q

Acute Asthma management

A

High flow O2
Nebuliser (5mg salbutamol b2b + ipratropium every 4h)
pred PO OR hydrocort if can’t tolerate

Magnesium sulfate IV + senior support
Further support: aminophylline, ITU, intubation

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14
Q

Acute asthma PEF categories

A

50-75%: moderate
33-50%: acute severe
<33%: life threatening
normal/raised pCO2 = near-fatal

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15
Q

management for allergic bronchopulmonary aspergillosis

A

oral prednisolone
itraconazole 2nd line
consider antibiotics
salbutamol

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16
Q

3 forms of bronchiectasis

A

cylindrical
cystic
varicose

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17
Q

Management of bronchiectasis

A

Conservative: airway clearance techniques, flutter device
medical: mucolytics, prophylactic Abx, consider itraconazole
LABA/ICS

Surgery for severe disease/localised disease

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18
Q

Management of CF

A

conservative: physio, airway clearance techniques
pancreatic replacement therapy
high calorie diet

Medical: nebulised mucolytics, SABA/LABA, long term antibiotics (fluclox) with additional rescue antibiotics
nebulised hypertonic saline
laxatives
USDA

Surgical: Lung/liver transplant

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19
Q

Management of fibrosis

A

stop fibrosis drug
rehab
support groups

pirfenidone
LTOT if pO2 <7.3 OR 7.3-8 AND (polycythaemia, hypoxaemia, peripheral oedema or pul HTN)
steroids (poor evidence)

Treat any post nasal drip with steroids
Treat any GORD
transplant

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20
Q

management of sarcoid

A

NSAIDs

high dose steroids if parenchymal lung disease, uveitis, hypercalcaemia, neuro/cardio

consider other immunosuppression (methotrexate, ciclosporin)

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21
Q

Squamous Cell Carcinoma endo link

A

high calcium due to PTHrP

TSH hyperthyroidism

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22
Q

Small Cell carcinoma endo link

A

Lambert-Eaton
insulinoma
ACTH
ADH

23
Q

Investigations for lung cancer

A

CXR
CT
PET for mets

EBUS or VATS biopsy

24
Q

Pneumonia management

A

mild - amoxicillin
severe - co-amox + clarithromycin

legionella = clarithromycin and rifampicin

staph - fluclox

25
CURB 65
``` Confusion Urea >7 Resp rate >30 Blood pressure <90/60 65yo ``` 2 points consider inpatient 3 points admit
26
PCP management
mild-moderate: co-trimoxazole severe: IV pentamidine Steroids if hypoxic
27
Management of pleural effusion
aspirate for MC&S, cytology, pH, protein chest drain treat underlying cause
28
Restrictive spiro result
FEV1:FVC ratio >70% | FVC very reduced
29
Obstructive spiro result
FEV1:FVC ratio <70% | FEV1 very reduced
30
Well's Score for PE
``` sign of DVT +3 PE most likely +3 HR>100 +1.5 immobilisation+1.5 Previous PE/DVT +1.5 haemoptysis malignancy <6m ```
31
Obstructive spiro causes
COPD Asthma Bronchiectasis CF
32
Restrictive spiro result
Fibrosis parenchymal tumours Pulmonary oedema Lobectomy
33
Hypersensitivity pneumonitis management
Avoid exposure | Steroids
34
Pneumoconiosis management
Improve working conditions
35
What can asbestos cause
``` Pleural plaque Mesothelioma Asbestosis (fibrosis) BAPE benign asbestos pleural effusion Diffuse pleural effusion ```
36
Indications for CPAP
Overall to recruit/splint open alveoli in T1RF CHF OSA Severe pneumonia
37
apical lung fibrosis causes
``` CF Sarcoid/TB Pneumoconioses ABPA Ank Spond ```
38
basal lung fibrosis causes
Rheumatoid asbestosis Scleroderma
39
Investigations for TB
Tuberculin skin test Sputum MC&S - Ziehl Nielsen stain and Lowenstein Jensen culture CRP, IGRA CXR EBUS
40
management of TB
RI 6m PE 2m ID input if resistant or extremely resistant TB
41
RIPE drug side effects
Rifampicin: orange secretions Isoniazid: hepatotoxic, give with pyroxidine to prevent peripheral neuropathy Pyrazinamide: hepatotoxic Ethambutol: Visual disturbance
42
``` Pneumonia buzzwords Rusty Smoking/COPD Cavitation Recent viral infection Red-current jelly Alcoholic Cavitating upper lobes Cold agglutinin Erythema Multiforme Air conditioner/water + hyponatraemia Birds Paeds Farm animals ```
``` Rusty: Pneumoniae Smoking/COPD: H influenzae + Catarrhalis Cavitation: Aureus Recent viral infection: aureus Red current: Klebsiella Alcoholic: Klebsiella Cavitating upper lobes: Klebsiella Cold agglutinin: mycoplasma pneumoniae Erythema multiforme: Mycoplasma Air conditioner/water and hyponatraemia: Legionella Birds: psattici Paeds: chlamydia pneumo Farm Animals: Burnetti ```
43
Investigations for PCP
CXR Exercise induced desaturation Broncho-alveolar lavage and silver stain
44
Define flail chest
3 consecutive rib fractures in >2 locations so chest wall moves in in inspiration and out in expiration
45
Mx of flail chest
analgesia Chest physio consider: CPAP and surgical fixation
46
Causes of upper lobe fibrosis
``` TAAPE TB ABPA Ank Spond Pneumoconiosis EAA ```
47
Causes of lower lobe fibrosis
``` TAIR Toxins Asbestosis IPF RhA ```
48
``` Extra-pulmonary manifestations of sarcoid Bloods Skin Histology Infiltrative ```
Bloods: ACE and calcium Skin: EN and Lupus Pernio Histology: Non-caseating granulomas, hilar lymphadenopathy Infiltrative: Restrictive cardiomyopathy, uveitis
49
Sarcoid management
Bed rest NSAIDs Oral high dose steroids Immunosuppression in severe and refractory disease
50
Gold standard for bronchiectasis
HRCT
51
Lobe collapse signs
Right Upper lobe: S sign Left Upper lobe: Veil sign Lower lobe: Sail or raised hemidiaphragm
52
Investigation mesothelioma
CXR HRCT Thoracoscopy and pleural biopsy
53
Management of mesothelioma
instillation of sclerosants into the pleural space can prevent or reduce re-accumulation of pleural effusions and accompanying breathlessness.

PACES Management (11 decks)

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