Resp Flashcards
(144 cards)
1
Q
classical sx of pneumonia
A
- Fever, rigors, sweating
- Malaise
- Cough
- Sputum (yellow, green, rusty in S pneumoniae)
- Breathlessness
- Pleuritic chest pain
- Confusion (severe cases, elderly, legionella)
2
Q
atypical pneumonia presentation
A
headache, mnyalgia, diarrhea, abdominal pain
3
Q
signs of pneumonia
A
- Pyrexia
- Tachypnoea, tachycardia
- Hypotension
- Cyanosis
- Decreased chest expansion, dullness to percussion, increased vocal fremitus, bronchial breathing (inspiration phase length = expiration phase length), coarse crepitations on affected side
4
Q
Ix for suspected pneumonia
A
Bedside: flu swab, covid swab
Sputum culture
Consider urine culture– for pneumonoccus and legionella antigens
Bloods o FBC (abnormal WCC) o U&E (low Na+ esp with Legionella) o LFT o Blood culture o ABG (assess pulmonary function) o Blood film (RBC agglutination by mycoplasma caused by cold agglutinins)
CXR – lobar or patchy shadowing, pleural effusion, repeat 6-8 weeks later if abnormal, suspect underlying pathology e.g. lung cancer.
Atypical viral serology (increase antibody titers between acute and convalescent samples)
Bronchoscopy and broncheolaveolar lavage if pneumonia fails to resolve or clinically progresses
5
Q
What score do you use to assess for pneumonia and explain it
A
CURB 65
Confusion (AMTS <=8) Urea >7 Resp rate >30 BP <90/60 65 years old or older
6
Q
How do you manage pts based on CURB 65
A
Score of 1: Home abx
Score of 2: admission abx
Score >=3= ITU
7
Q
What antibiotics do you give as examples for pneumonia? (ALWAYS FOLLOW HOSPITAL GUIDELINES)
A
mild: amoxicillin
Severe: co-amoxiclav + clarythromycin
8
Q
What defines a HAP
A
Occurrence >48 hours from hospital admission
9
Q
How do you manage a HAP
A
Non-severe: Co-amox or doxy
Severe: Piptazobactam
ALWAYS FOLLOW LOCAL GUIDELINES
10
Q
what other management other than abx (long term) is important in pneumonia
A
Prevention is important in vulnerable groups (e.g. elderly, spenectomized) – give prophylactic pneumococcal or H influenzae type B vaccination.
11
Q
What is a pleural effusion
A
buildup of fluid in pleural space
12
Q
what are sx of a pleural effusion
A
dyspnoea
cough
pleuritic chest pain
13
Q
what are the two kinds of pleural effusion you can get
and what criteria do you use to assess
A
TRANSUDATE V EXHUDATE
LIGHT CRITERIA
14
Q
Explain the difference in protein in TRANSUDATE vs EXHUDATE
A
TRANSUDATE = low protein (<30g) EXHUDATE = high protein (>30g) (= EGG)
15
Q
What are causes of transudate in pleural effusion
A
Due to factorsa that alter hydrostatic preessure / pleural permeability / oncotic pressure
e.g. CCF, cirrhosis, nephrotic syndrome
16
Q
What are causes of exhudate in pleural effusion
A
Due to change in local facotrs that influence the formation and absorption of pleural fluid
e.g. Infection (pneumonia, lung empyema) PE Trauma Pancreatitis Malignancy
17
Q
What are ix for suspected pleural effusion
A
Exam, obs, urine dip for protein
Baseline bloods esp LFT, CRP, clotting, blood culture
CXR (shows costophrenic blunting) > then considercontrast CT (if exhudative cause) or echo (CCF)
USS guided pleural aspiration and chest draWin
18
Q
Why aree you doing a USS guided pleural aspiration
A
to get details on the sample
e.g. MC&S, cytology, pH, LDH, glucose, protein, TB, amylase, Hb
19
Q
What do you do if the aspirate from the pleural effusion is turbid, tests positive on MCS or has pH <7.2?
A
Insert Chest DRAIN
Then treat underlying cause
20
Q
What is percussion like in PLEURAL EFFUSIOON
A
STONY DULL
21
Q
What is vocal fremitus like in PLEURAL EFFUSION
A
Reduced
22
Q
What is lung ascultation like in PLEURAL EFFUSION
A
Reeduced
23
Q
why do you get RBBB in a PE
A
due to increased strain on the right side of the heart
24
Q
what else must you do in unprovoked PE patient while after starting on DOAC
A
try to find CAUSE
25
what is COPD
chronic bronchitis + emphysema
26
What are investiigations for COPD
Bedside: sputum sample (for infective exacerb), **SPIROMETRY** (gold standard)
Bloods: baseline bloods (incl FBC for secondary polycythaemia), CRP, ABG, BNP, U+E, blood culture IE)
Imaging: CXR, CT CHEST
consider ECG, echo (cor pulmonale)
consider alpha1 antitrypsin levels if young / non smoker
27
What is conservative general management of long-term COPD
* smoking cessation (offer nicotine replacement therapy, varenicline or bupropion)
* annual influenza vaccination
*one-off pneumococcal vaccination
28
2 treatments to consider in long-term COPD management
mucolytics (for chronic productive cough)
prophylactic azithromycin
29
when do you give prophylactic azithromycin in COPD
250mg TDS if
- non smoker
- optimised medical mx
- referred pulm rehab
- x4 infective exacerbations per year AND at least one hospitalisation per year
30
what is medical COPD mx
1. SAMA or SABA PRN
* Are there asthmatic features or features suggestive of steroid responsiveness?
2. YES --> SAMA or SABA PRN AND LABA + ICS
3. NO --> SABA PRN AND LABA + LAMA regularly
4. SABA PRN AND LABA + LAMA + ICS
5. senior input eg. oral theophylline
31
when would you give inhaled corticosteroids vs LAMA in COPD mx
corticosteroids if asthmatic featurres (e.g. oesinophilia, history of atopic conditions, which make them more lkely to be steroid responsive )
32
what are the two key components of asthma
airway hypersensitivity
| reversible airway obstruction
33
investigations of asthma
**spirometry and bronchodilator reversibility**
**FeNO** (marker of airway inflammation)
**Peak flow variability** (getting them to keep an peak flow diary)
34
long term asthma management
1. SABA
2. SABA + ICS
3. SABA + ICS + LTRA
4. SABA + ICS + LTRA + LABA
5. SABA + "ICS+LABA" + LTRA
35
WHat is ICS+LABA
MART THERAPY
both reliever and prophylactic
i.e. take in morning and evening every day, but also iif you get acutely out of breath
36
example of SABA
salbulamol
| Beta 2 agonist
37
example of SAMA
itratropium
| muscarinic antagonist
38
example of LAMA
tiotropium
39
example of LABA
salmeterol
40
what does atypical pneumonia mean
one that does not present with typical symptoms
41
how do you manage a typical CAP
Amoxicillin (mild)
Co-amoxiclv (severe)
often also add clarythromycin if atypical pneumonia cannot be excluded
42
what are the top thjree most common typical CAPS
S pneumonia
H influenza
M catarrhalis
43
How does S pneumonia typically present
rusty sputum
lobar pattern
reactivated HSV
44
how does H influenza present
pre-existing lung disease e.g. COPD
| bronchoalveolar pattern, affecting lower lobes mainly
45
how does Klebsiella pneumoniae present present
```
redcurrant jelly sputum
alcoholism
DM
elderly
haemoptysis
```
46
How do you treat an atypical pneumonia
clarythromycin
| or doxycycline
47
what are common pathogens that cause atypical pneumonia
```
Legionella pneumophilia (air conditioners, hyponatraemia, urinary antigen)
Chlamydia pneumoniae (children)
Chlamydia psittaci (birds, haemolytic anaemia)
```
48
what are common HAPs and what timeline do they occur in
```
Strep pneumonia (48h-4 days)
Enterobacteria, S aureus, Pseudomonas (>4 days)
```
49
how do you treat HAP
mild: co-amox or doxy
severe: piptazobactam
50
What are TB tests you can do
IGRA (no cross reaction with BCG)
TST (cross reacts with BCG)
Sputum smear x3 > NAAT (also Ziehl Neelsen stain)
Sputum culture is gold standard
51
when is auramine staining used for TB
for screening
52
how do you manage TB
RIPE
Rifampicin + Isoniazid 6m
Pyrazinamide + Ethambutol 2 months
53
Side effect of rifampicin
orange secretions
| enzyme inducer
54
Side effect of isoniazid
peripheral neuropathy > GIVE WITH PYRIDOXINE
55
SE of pyrazinamide
liver injury
56
SE of ethambutol
visual disturbance
57
what is pulmonary fibrosis / interstitial lung disease
umbrella term for disorders of lung parenchuma
58
what are causes of pulmonary fibrosis
idiopathic
hypersensitivity pneumonitis (to organic dusts)
pneumonicosis (to inorganic dusts)
59
how does pulmonary fibrosis show up in HR CT
honeycombing
60
what are signs and symptoms of IPF
progressive exertional dyspnoea
dry cough
clubbing
bibasal fine end espiratory creps
61
key Ix for IPF
HR CT
spirometry (restrictive)
lung biopsuy
62
management for IPF
smoking cessation
pysiotherapy
pulm rehabilityation
Pirfenidone, immunospuuressants if AI
lung transplant
63
what is sarcoidosis
chronic disease characterised by formation of granulomas in various tissue (with no infective cause)
64
signs and symptoms of sarcoidosis
SOB, dry cough
fatigue, joint aches
dry eyes
erythema nodosum
65
invesitgations of sarcoidosis
Serum ACE (raised as ACTH producing)
Serum calcium (raised)
CXR (bihilar lymphadenopathy> pulmonary infiltrates > fiibrosis)
biopsy
66
what is a pancoast tumour and how does it present
lung tumour at apex of lung
- Horner's syndrome
- Wasting of T1 in hand
67
what is bronchiectasis
permanent dilation of airways secondary to chronic inflammation (irreversible)
68
what is bronchiectasis due to
Post infectious - TB, measles, pertussis, pneumonia
Obstruction (foreign body)
AI (selective gA, hypogammaglobulinaemia, ABPA, RA, SLE)
CF, Kartageners, Youngs, yellow nail syndrome
69
what pneumonia do you see in AIDS
PCP (pneumocisti jirovecii)
70
hhow do you manage PCP
co-trimoxazole
71
what is the genetic defect in CF
Defecting CFTR (CF transmembrane conoductance regulator) on Chr 7
72
Sx CF
Meconium ileus
recurring chest infectionos, wheezing, coughing, SOB
diarrheoa / consiptation
Male sterility
faltering growth
jaundice (due to cirrhosis, portal HTN)
DM
73
how do you ix CF
```
Immunoreactive trypsinogen (on Guthrie)
Sweat test (raised sodium)
CXR (hyperinflation, peribronchial shadowing)
```
74
how do you mx CF (broad outline)
ROUTINE REVIEWS with MDT APPROACH, involve specialist CF centre
- Resp
- Infection
- nutritional
- other
75
Resp mx CF
- chest physio x2 daily
| - mycolytics (dornase alpha, mannitol dry powder)
76
Infection mx CF
PROPHYLACTIC ORAL ABX (with fluclox, azithhromyciin)
77
what bacteriium are we worried aboout in CF pneumonia
Pseudomonaas aerogiinosa
78
Nutritional mx CF
hiigh calorie + high fat diet
fat soluble vitamin supplements
pancreatic enzyme replacement (CREON) with every meal
79
What is Mx of CF in adults?
1. DM therapy
2. Liver therapy (ursodeoxycholic acid to improve flow; may require transplant)
3. Intestinal obstruction (oral laxatives)
4. Male sterility
80
what lung cancer is typical in smokers
Small cell lung cancer
81
what are associations of SCLC
smokers
central
SIADH
ACTH
LEMS
82
what is the most common yupe of lung cancer
non-SCLC
83
test criteria threshold for ASTHMA diagnosis
<70% FEV1/FVC
>40 FeNO
>12% variability FEV1 after SABA administration
>20% PEFR variability
84
2 key fts of Kartageners
situs invertus
| cilia immobiliity
85
2 key fts of yellow nail syndrome
lymphoedema
| pleural effusion
86
what is finding of bronchiectasis on CT
"signet ring" appearance of thickened bronchi
87
which iniherited condition can predispose to COPD
alph 1 antitrypsin deficiency
88
what is alpha 1 antitripsin deficinecy (mode of inheritance, pathophys)
autosomal co-dominant condition
alpha 1 antitrypsin usually inhibitss neutrophil elastase in lungs
so absence of it causes early COPD development
89
what does a CXR show in COPD
hyperinflated lungs
decreased peripheral markings
may show elongated cardiac silouhette (cor pulmonale)
90
what does spirometry show inn COPD
FEV1/FVC <70%
FEV1 reduced
| increased lung volume
91
what does an FBC show in COPD
secondary polycythaemia
92
criteria for long term oxygen therapy in COPD
NON SMOKER
AND:
- PaO2 <7.3 (x2 measurements)
OR
PaO2 of 7.3-8 + secondary polycythhaemia/ pulm oedema / pulm HTN
93
who is a pink puffer and who is a blue boater in COPD
pink puffer = emphysema dominant
| blue boater = bronchitis dominant
94
describe a pink puffer
Alveolar ventilation INCREASED
Build is THIN
Cx is T2RF
95
describe a blue boater
Alveolar ventilation DECREASED
Build is STOCKY
Cx is cor pulmonale
96
what is chronic bronchitis
chronic cough and sputum min 3 months min 2 consecutve years
97
what is emphysema
alveolar destruction > bullae formation
98
what is life expectancy for idiopathic pulmonary fibrosis
3 years
99
how do you manage idiopathic pulmonary fibrosis
Steroids (for 3 months) then reassess
100
what antibiotic do you give for Pseudomonas aeroginosa (so CF/ chemo / bronchiectasis pt)?
Tazocin, ciprofloxacin
101
How do you manage sarcoidosis
Steroids
NSAIDS
Steroid-sparing agent
102
what is hypersensittivity pneumonitis
hypersensitivity induced lung damage due to inhaled organic particles
103
examples of hypersensittivity pneumonitis
bird lung
farmers lung
malt workers lung
104
mx hypersensittivity pneumonitis
```
avoid causative agen t
oral glucocorticoids (second line)
```
105
what abx can you give for IE of COPD
amoxicillin
doxy
clarythromycin
106
what is SVCO caused by
mainly lung cancer (pancoast tumours)
| other causes include non-hodgkins lymphoma, sarcoid, aortic aneurysm
107
what is SVCO presentation
* facial and upper limb swelling
* headaches
* dyspnoea
* cough
* orthopnoea
* raised non-pulsatile JVP
* prominent vessels
108
when do patients admitted with pneumonia need a follow up CXR
ALL patients admtted need a follow upp CXR at 6-12 weeks
| This is to detect any underlying pathology and ensure resolution
109
what are causes of upper lobe pneumonicosis?
```
C- Coal worker's pneumoconiosis
H - Histiocytosis/ hypersensitivity pneumonitis
A - Ankylosing spondylitis
R - Radiation
T - Tuberculosis
S - Silicosis/sarcoidosis
```
110
features of moderate asthma
PEFR 50-75% best or predicted
Speech normal
RR < 25 / min
Pulse < 110 bpm
111
features of severe asthma
PEFR 33 - 50% best or predicted
Can't complete sentences
RR > 25/min
Pulse > 110 bpm
112
features of life threatening asthhma
```
CHEST:
Cyanosis
Hypotension, bradycardia
Exhaustion (PEFR < 33%, SpO2 < 92%)
Silent chest
Too confused or coma
```
113
when does the HR go above 110 in asthma
in SEVERE asthma
114
whenn does SpO2 go below 92 in asthma
in life threatening asthma
115
what is atelectasis , what is it caussed by
post-operative complication
= basal alveolar collapse which leads to respiratory difficulty
It is caused when airways become obstructed by bronchial secretions
116
how do you manage atelectasis
deep breathing exercises and chest physiotherapy.
117
what does lupus pernio occur with
with sarcoidosiss
118
what does lupus pernio look like
raised purple plaque of indurated skin that affects the tip of her nose and the skin around the right nostril
119
what is ABPA
Allergic Broncopulmonary Aspergillosis
= allergic response in asthmatics, causing bronchiectasis
120
how do you managge ABPA
PREDNISOLONE
121
when can you start corticosteroid tx for sarcoid
parenchymal lung disease, uveitis, hypercalcaemia and neurological or cardiac involvement
122
which drugs can precipitate an astthma atttack / must you avoid in asthmatics?
beta blockers
| NSAIDS
123
how does bronchiectasis present
history of cause (e.g. infection as a child)
recurrent chest infections, refractory to abx
chronic productive cough
lots of phlegm
124
O/E bronchiectasis
coarse crepitations, wheeze
125
ix bronchiectasis
sputum sample MCS (Pseudomonas), sweat test (exclude CF()
Baseline bloods, CRP, Ig, CF genetic test, aspergillus markers
CXR, HR CT (signet ring, tram lining)
Spirometry (obstructive)
126
Mx bronchiectasis
Correct underlying cause if possible
Conservative:
- physiotherapy, pulmonary rehab
- smoking cessation
Medical:
- mucolytic (carbocystine)
- antibiotics
- bronchodilators
127
Obstructive lung disease pulmonary function test
**FEV1 - significantly reduced**
FVC - reduced or normal
**FEV1% (FEV1/FVC) - reduced**
128
Restrictive lung disease pulmonary function test
FEV1 - reduced
**FVC - significantly reduced**
**FEV1% (FEV1/FVC) - normal or increased**
129
tension pneumothorax treatment
* *Do NOT do CXR to delay treatment *
* Ask someone to put out a peri-arrest call on 2222
* Oxygen: 15L via non-rebreather
* If conscious: sit them upright to help oxygenation
* Immediate **needle decompression**: insert** large bore (14-16G) IV catheter** into **2nd ICS MCL** on affected side, *just above 3rd rib *to avoid neurovascular bundle below rib
* Up to 2.5L air can be aspirated
* Stop if patient coughs or resistance felt
* Then: **chest drain** (definitive treatment)
130
how to follow up tension pneumothorax
Follow-up CXR 2 hours and then 2 weeks later
131
primary pneumothorax management
* < 2cm rim of air on CXR and NO SOB
* Monitor -> discharge, repeat CXR in 6hrs and outpatient review in 2-4 weeks
* > 2cm rim +/- SOB
* admit, high flow oxygen, simple needle aspiration inserted into 2nd ICS MCL
* 2nd line: repeat aspiration
* 3rd line: chest drain
132
secondary pneumothoax management
* < 1 cm and asymptomatic
* Admit for 24 hours
* Give oxygen
* 1- 2cm, patiently minimally breathless and aged <50
* Admit
* High flow oxygen
* Aspiration with a 16-18G cannula (up to 2.5L)
* Keep admitted for 24 hours
* > 2cm +/- SOB + age > 50
* Chest drain
* Admit until 24 hours after full re-expansion of the lung and cessation of any air leakage
133
Advice to patients after pneumothorax
stop smoking, avoid flying for 1 week (2 weeks if tension), avoid diving for life
134
pneumothorax symptoms
sudden onset SOB
pleuritic chest pain
135
pneumothorax signs
* Reduced expansion on affected side
* Hyper-resonance to percussion on affected side
* Reduced/absent breath sounds on affected side
136
tension pneumothorax signs
* tachycardia, hypotension, rapid shallow breathing,
* cyanosis
* raised JVP
* trachea deviated away
137
who is lung adenocarcinoma most common in
women and non smokers
138
where is lung adenocarcinoma usually found
in the lung periphery
139
what is the most common type of primary lung cancer
Lung adenocarcinoma
140
histology features of lung adenocarcinoma
o Glandular tumour
o Mucin-producing cells
141
lung adenocarcinoma associated mutations
EGFR, ALK, KRAS
142
symptoms of primary lung cancer
New-onset cough or change in cough
Haemoptysis
Chest pain
Dyspnoea
Wheeze
Recurrent pneumonia
FLAWS
143
signs of lung cancer
* pleural effusion
* cachexia
* clubbing
* anaemia
144
management of lung cancer
* Smoking cessation
* Limited disease: chemotherapy (cisplastin, etoposide) +
