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1
Q

Rx of ABPA

A

Oral presnisolone tapering off over 12 months

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2
Q

inhaler technique

A

take off cap and shake
sit up straight with chin tilted up
press button and breathe in for at least 10 seconds.
Hold breath for 10 seconds before exhaling

if using a steroid inhaler, wash mouth afterwards due to oral candidiasis risk

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3
Q

using a spacer and advice

A

seal and then breathe in and out deeply
clean with detergent once a month and air dry. don’t wipe as can causes static which causes med to stick

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4
Q

COPD rx - non pharm and pharm

A

offer pneumococcal and influenza vaccines
stop smoking support
give SABA or SAMA

If not improving and asthmatic features or steroid responsiveness - give LABA and ICS.

If not improving and no asthmatic features or steroid responsiveness - give LABA and LAMA

offer all if not working after this

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5
Q

what is COPD

A

emphysema (dilated alveoli) and chronic bronchitis

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6
Q

MRC dyspnoea scale

A

1 breathlessness on strenuous exercise
2 breathlessness when walking up a hill
3 breathlessness when walking on a flat
4 breathlessness <100m
5 can’t leave the house

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7
Q

FEV1:FVC ratio in copd

A

<0.7 (70%)

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8
Q

what is an example of a LABA, LAMA and ICS combined inhaler

A

Trimbow

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9
Q

when is LTOT offered in COPD

how long do you have to use it

A

Offer LTOT to patients with a pO2 of < 7.3 kPa or to those with a pO2 of 7.3 - 8 kPa and one of the following:
secondary polycythaemia
peripheral oedema
pulmonary hypertension (cor pulmonale)

Only to pts who are NON SMOKERS and do not retain CO2

16hrs per day for survival benefit

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10
Q

rx of acute exacerbation of copd

A

a-e
o2 - 88-92
salbutamol and ipatropium nebs
oral pred 30mg
NIV if type 2 response failure
abx if ?infective

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11
Q

signs of IECOPD

A

change in sputum volume
change insputum colour
fever

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12
Q

what is the most common cause of cor pulmonale

A

copd

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13
Q

what is cor pulmonale

A

respiratory failures leading to right ventricular failure due to pulmonary htn

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14
Q

likely ABG on COPD exacerbation

A

type 2 rest failure with a respiratory acidosis

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15
Q

ix on acute exacerbation of copd and why

A

FBC - infective
ECG - arrythmias
CXR - infection
Sputum culture
Blood culture

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16
Q

o2 targets in copd

A

88-92 if a co2 retainer
if not retaining CO2, then 94-98

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17
Q

practical tips for stopping smoking

A

use e cigarettes or nicotine patches
nicotine gum

smoke free helpline
nhs website has a smoking support locator

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18
Q

differentials of a monophonic localised wheeze

A

foreign body, tumour o thick sticky mucus plug

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19
Q

asthma triggers

A

cold
exercise
infection
animals
allergies

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20
Q

what wheeze is heard in asthma

A

widespread polyphonic expiratory wheeze

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21
Q

drugs that can worsen asthma

A

beta blockers
NSAIDs

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22
Q

ix for Asthma

A

spirometry and reversibility testing
Fractional exhaled Nitric Oxide

if still not sure:
PEFR variation - more than 20%

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23
Q

BTS stepwise approach for Asthma in children

A

1 SABA
2 SABA and very low dose ICS
3 SABA and very low dose ICS and LTRA or LABA
4 increase to low dose ICS or add other of LTRA or LABA
5 specialist care required

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24
Q

additional rx of asthma

A

Individual written asthma self-management plan
Yearly flu jab
Yearly asthma review when stable inc inhaler technique
Regular exercise
Avoid smoking (including passive smoke)
Avoiding triggers where appropriate

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25
signs of resp distress in a child
accessory muscles cyanosis tracheal tug and intercostal muscles
26
initial ABG on acute exacerbation of asthma what would be concerning
respiratory alkalosis due to tachypnoea a normal CO2 is a concerning sign as is respiratory acidosis
27
features of mild, moderate, severe, life threatening and near fatal asthma
Mild: * No features of severe asthma * PEFR >75% Moderate: * No features of severe asthma * PEFR 50-75% Severe (if any one of the following): * PEFR 33 – 50% of best or predicted * Cannot complete sentences in 1 breath * Respiratory Rate > 25/min * Heart Rate >110/min Life threatening (if any one of the following): * PEFR < 33% of best or predicted * Sats <92% or ABG pO2 < 8kPa * Cyanosis, poor respiratory effort, near or fully silent chest * Exhaustion, confusion, hypotension or arrhythmias * Normal pCO2 Near Fatal: * Raised pCO2
28
rx of acute asthma
NEB salbutamol 5mg Oral prednisolone 40 mg stat Neb ipatropium bromide 500 micrograms Back to back salbutamol If life threatening or near fatal: IV aminophylline or IV salbutamol ITU or anaesthetic assessment
29
Criteria for safe asthma discharge after exacerbation
PEFR >75% inhaler technique review Provide PEFR meter and written asthma action plan * At least 5 days oral prednisolone * GP follow up within 2 working days * Respiratory Clinic follow up within 4 weeks Stop regular nebulisers for 24 hours prior to discharge
30
Characteristic examination signs in pneumonia
dull percussion coarse crackles bronchial breath sounds
31
CURB 65 score and what total means
confusion Urea >7 RR >30 BP <90 age >65 0/1 - treat at home >2 - admit >3 consider ITU
32
top 2 bacterial causes of pneumonia + others
strep pneumoniae haemophilus influenzae moraxella caterhalis in immunocompromised pts MSRA pseudomonas aureginosis in CF and bronchiectasis
33
patient has recently had a cheap hotel holiday and presents with pneumonia symptoms and hyponatraemia. What is dx and why are they hyponatraemia
legionaries disease can cause SIADH
34
pneumonia with target lesions. What is the offending organism
mycoplasma pneumonia. Can cause erythema multiform
35
rx of atypical pneumonia
macrolides, fluroquinilones or tetracyclines
36
Pneumonia complications
lung abscess emphysema sepsis ARDS pleural effusion death
37
exudative vs transudative causes of pleural effusions
exudative - pneumonia, tb, malignancy, rheumatoid transudative - hf, liver cirrhosis, renal failure
38
Lights criteria and when is it used
If pleural fluid protein level between 25 and 35 g/L (i.e. borderline) use Light’s criteria – exudate if one or more of the following: – Pleural fluid/Serum protein >0.5 – Pleural fluid/Serum LDH >0.6 – Pleural fluidLDH>2/3 of the upper limit of normal
39
pleural effusion examination findings
dull percussion Reduced breath sounds Tracheal deviation away from the effusion in very large effusions
40
CXR pleural effusion
blunting of costaphrenic angles with a meniscus may have fluid in the fissures
41
rx of pleural effusion
US guided pleural aspiration Chest drain
42
When to suspect empyema Pleural aspiration results Rx
a pt with pneumonia gets better but then develops a new onset of fever. Pleural aspiration shows pus, low pH, low glucose and high LDH. Empyema is treated with a chest drain and antibiotics.
43
Pulmonary oedema presentation
SOB Pink frothy sputum Tachypnoea Raised JVP Decreased O2 sats
44
Examination of pulmonary oedema
reduced breath sounds coarse crackles
45
CXR pulmonary oedema
Bilateral peri-hilar shadowing - bat wing sign Blunting of the costophrenic angles Fluid in the fissures (e.g. right horizontal fissure) Kerley B lines
46
rx of pulmonary oedema
A-E IV furosemide
47
causes of bronchiectasis
pneumonia TB CF Alpha 1 antitrypsin Whooping cough
48
presentation of bronchiectasis
chronic productive cough and SOB recurrent chest infections
49
signs of bronchiectasis on examination
Weight loss (cachexia) Finger clubbing Signs of cor pulmonale (e.g., raised JVP and peripheral oedema) Scattered crackles throughout the chest that change or clear with coughing Scattered wheezes and squeaks
50
Gold standard for bronchiectasis
high resolution CT - signet ring sign
51
CXR findings in bronchiectasis
tram track sign ring shadows
52
general rx of bronchiectasis
Vaccines (e.g., pneumococcal and influenza) Respiratory physiotherapy to help clear sputum Pulmonary rehabilitation Long-term antibiotics (e.g., azithromycin) for frequent exacerbations (e.g., 3 or more per year) Inhaled colistin for Pseudomonas aeruginosa colonisation Long-acting bronchodilators may be considered for breathlessness Long-term oxygen therapy in patients with reduced oxygen saturation Surgical lung resection may be considered for specific areas of disease Lung transplant
53
rx of bronchiectasis exacerbations
sputum culture and abx - most often ciprofloxacin abx for 7-14 days
54
key features to remember for bronchiectasis
The key features to remember with bronchiectasis are finger clubbing, diagnosis by HRCT, Pseudomonas colonisation and extended courses of 7-14 days of antibiotics for exacerbations.
55
rf for pneumothorax
young thin tall male cannabis COPD, asthma, pneumonia Iatrogenic - lung biopsy, mechanical ventilation or central line insertion
56
RX of simple pneumothorax and landmarks
chest drain in the safety triangle (5th intercostal space mid axillary line and Anterior axillary line) insert above rib to avoid neuromuscular bundle
57
how to know if chest drain is successful in pneumothorax
swinging - water in drain rises and fall as pt breathes repeat cxr shows reduction in size
58
2 key complications of chest drains
surgical emphysema air leaks
59
rx of pneumothorax that is resistant to treatment
abrasive or chemical pleurodesis
60
rx of tension pneumothorax
Insert a large bore cannula into the second intercostal space in the midclavicular line. Then chest drain
61
examination findings of ILD
fine inspiratory crackles clubbing
62
most common type of ILD
idiopathic
63
drug causes of ILD
amiodarone bleomycin nitrofurantoin penicillamine methotrexate
64
spirometry result in ILD
restrictive - >0.7 (70%)
65
general rx of ILD
Remove or treat the underlying cause Home oxygen where there is hypoxia Stop smoking Physiotherapy and pulmonary rehabilitation Pneumococcal and flu vaccine Advanced care planning and palliative care where appropriate
66
inflammatory causes of ILD
Alpha-1 antitrypsin deficiency Rheumatoid arthritis Systemic lupus erythematosus (SLE) Systemic sclerosis Sarcoidosis
67
presentation of TB
chronic cough, night sweats, haemoptysis lymphadenopathy erythema nodosum
68
RF for TB
Close contact with active tuberculosis (e.g., a household member) Immigrants from areas with high tuberculosis prevalence People with relatives or close contacts from countries with a high rate of TB Immunocompromised (e.g., HIV or immunosuppressant medications) Malnutrition, homelessness, drug users, smokers and alcoholics
69
TB CXR findings - primary, reactivated and disseminated military
Primary tuberculosis may show patchy consolidation, pleural effusions and hilar lymphadenopathy. Reactivated tuberculosis may show patchy or nodular consolidation with cavitation (gas-filled spaces), typically in the upper zones. Disseminated miliary tuberculosis gives an appearance of millet seeds uniformly distributed across the lung fields.
70
IX for TB
sputum cultures blood cultures CXR Mantoux
71
Rx of TB
RIPE for 2 months then RI + pyridoxine for 4 months Testing for other infectious diseases (e.g., HIV, hepatitis B and hepatitis C) Testing contacts for tuberculosis Notifying UK Health Security Agency (UKHSA) of suspected cases Negative pressure side room, Isolating patients with active tuberculosis to prevent spread (usually for at least 2 weeks of treatment)
72
Side effects of TB drugs
Rifampicin - hepatitis, red/orange urine Isoniazid - hepatitis, peripheral neuropathy Pyrazinamide - hyperuricaemia (gout and kidney stones), hepatitis Ethambutol - retrobulbular neuritis. Check visual acuity before treatment
73
ABG in Pe
resp alkalosis
74
PE rx if stable
apixaban or rivaroxaban if CrCl <15 give LMWH
75
PE rx if unstable eg massive PE
Consultant decision - continuous infusion of unfractionated heparin and systemic thrombolysis
76
first line long term anti coat option for pts with anti phospholipid syndrome who have had PE
warfarin
77
First line long term preventative anti coag in pregnant lady who has had a PE
LMWH
78
Causes of a raised D dimer
PE pregnancy HF malignancy surgery
79
Wells score
Clinical signs and symptoms of DVT (minimum of leg swelling and pain with palpation of the deep veins) 3 An alternative diagnosis is less likely than PE 3 Heart rate more than 100 beats per minute 1.5 Immobilisation for more than 3 days or surgery in previous 4 weeks 1.5 Previous DVT/PE 1.5 Haemoptysis 1 Malignancy (on treatment, treated in the last 6 months, or palliative)
80
81
diagnostic test for osa
polysomnography
82
complications of osa
htn compensated resp acidosis daytime somnolence
83
rx of osa
weight loss CPAP DVLA if execcisive daytime sleepiness
84
how does salbutamol work
stimulates B2 receptors in the lungs which causes relaxation of smooth muscle leading to bronchodilation
85
ddx of asthma in children (think chronic cough)
viral induced wheeze bronchiolitis foreign body CF airway abnormalities
86
insert chest drain above or below the rib?
above (5th intercostal space, mid axillary line)
87
presentation of sarcoidosis acronym
General - fever, malaise, lymphadenopathy Respiratory - 90% have dry cough, dyspnoea, chest pain, reduced lung function Arthralgia Neurological - Bells palsy, meningitis, SOL Urinary - increased calcium - renal stones Low hormones - pituitary - amenorrhoea Opthalmological - uveitis, sjrogens Myocardial - restrictive cardiomyopathy secondary to granulomas, pericardial effusion Abdominal - splenomegaly and hepatomegaly
88
ddx to consider for pneumothorax in a cold pt
large emphysematous bullae
89

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