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Respiratory Y3 > Resp - mx > Flashcards

Resp - mx Flashcards

1
Q

Anaphylaxis management

A
  1. Help
  2. Remove trigger
  3. Lie flat + raise legs
  4. IV adrenaline 0.5mg 1:1000
  5. ABC
  6. IV chlorphenamine (anti-histamine), IV hydrocortisone
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2
Q

Aspiration pneumonia - likely pathogen + treatment

A

Infection commonly due to anaerobes
Metronidazole + cefuroxime (broad sepctum)

(klebsiella, H influenzae)

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3
Q

SE of pyrazinamide + where is it used

A
  • Hepatitis
  • Gout
  • Arthralgia
  • Rashes
  • Pruritus
  • Photosensitivity
  • Nephrotoxic
  • Hepatotoxicty
  • Sideroblastic anaemia

Used in treatment of TB
Pro-drug that inhibits the growth of M. Tuberculosis
- Rifampicin + isonazid (+pyridoxine) for first 6 months
- Pyrazinamide + ethambutol for the first 2 months

2 months of isoniazid, rifampicin, pyrazinamide, ethambutol
Followed by
4 months of isoniazid + rifampicin

Pyidoxine is vitamin B6 + given with isonazid because the drug depletes it

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4
Q

Staph aureus pneumonia

Who is likely to get it
Features
How is it treated

A
  • Young, elderly
  • Underlying diseases (leukaemia, lymphoma, CF)
  • Existing lung disease
  • Influenza
  • IVDU
  • Central venous catheters

Staph - Flucloxacillin + gentamycin
if MRSA - vancomycin

very rare to cause pneumonia, usually causes abscesses

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5
Q

SE of rifampicin + where is it used

A
  • Liver enzyme inducer (CYP450)
  • Hepatotoxicity
  • Fever
  • GI disturbance
  • Rash
  • Red urine + body secretions
  • Can make OCP less effective [CYP450 inducer]

Used in treatment of TB

  • Rifampicin + isonazid (+pyridoxine) for first 6 months
  • Pyrazinamide + ethambutol for the first 2 months

2 months of isoniazid, rifampicin, pyrazinamide, ethambutol
Followed by
4 months of isoniazid + rifampicin

Pyridoxine is vitamin B6 + given with isonazid because the drug depletes it

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6
Q

Empyema management

A
  • Chest drain insertion under US guidance

- Abx

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7
Q

Mycoplasma pneumoniae

Who is likely to get it
How is it treated

A
  • Nosocomial
  • Bronchiectasis
  • CF
  • claritrhomycin

second most common after strep pneumoniae

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8
Q

PE management - haemodynamically stable [SBP >90]

A
  • Prevent VTE
    Mechanical - anti-embolic stocking
    Pharmacological - LMWH (Tinzaparin)

If Well’s >4 (incl. 4) and CTPA not immediately available, offer immediate interim parenteral anticoagulant therapy -> LMWH within 24h of dx

Haemodynamically stable
- O2
- Anticoagulation (INR 2-3)
Heparin for 5 days (UFH given IV, LMWH given SC)
Warfarin for 3 months
or
DOACs (dabigatran, edoxaban, rivaroxaban, apixaban)

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9
Q

PE management - haemodynamically unstable [SBP <90]

A

Haemodynamically unstable

  • O2
  • 1st line thrombolysis
  • 2nd line embolectomy/catheter-directed therapyIV thrombolytics: alteplase, streptokinase, rt-PA (tissue plasminogen activator)
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10
Q

PE management - ongoing

  • Confirmed
  • Recurrent PE, malignancy, pregnancy, hepatic impairement, coagulopathy
  • Increased risk of bleeding
  • Renal impairement
A
  • Confirmed - anticoagulation [DOACs, warfarin]
    Heparin for 5 days (bc warfarin causes a prothrombotic state) (LMWH)
    Warfarin for 3 months
  • Recurrent PE, malignancy, pregnancy, hepatic impairement, coagulopathy - LMWH
  • Increased risk of bleeding - UFH
  • Renal impairement - UFH, Warfarin
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11
Q

Treatment of persistent postinfectious cough (common in patients recovering from a viral pneumonia)

A
  • Antitussives - if underlying cause can’t be identified, provide symptomatic relief
    Depress brainstem cough centre - codeine, phlocodine (opioids), dextropmethorphan (non-opioid)
    Reduce peripheral receptor sensitivity - benzocaine (local anaesthetic)
    SE - constipation, dependence
  • Inhaled corticosteroids
  • Inhaled ipratropium brominde
    Anticholinergic
    Blocks efferent limb of cough reflex
    May also decrease the simulation of the cough receptors
    Benefit in patients with persistent cough after an URTI
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12
Q

TB management

A
  • Notifiable disease
  • Isonazid (+ pyridoxine ) + Rifampicin for first 6 months
  • Ethambutol + Pyrazinamide for first 2 months

2 months of isoniazid, rifampicin, pyrazinamide, ethambutol
Followed by
4 months of isoniazid + rifampicin

Streptomycin - used for patients previously treated with TB - more likely to have developed drug resistance
used in place of ethambutol or in combination with all 4 in resistant TB

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13
Q

SE of isonazid

A
  • Periphera neuropathy as it depletes vitamin B6 (pyridoxine)
  • CNS effects
  • Rash
  • Deranged liver function
  • Sideroblastic aneamia

Deranged liver function as drug is metabolised in the liver and converted to ammonia which can cause hepatitis

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14
Q

Function + SE of ethambutol

A

Function - inhibits formation of cell wall in M tuberculosis, bacteriostatic drug

  • Optic neuritis
  • Red-green colour blindness
  • Peripheral neuropathy
  • Vertical nystgmous
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15
Q

Management of bronchiectasis for all patients

A 
Conservative
- Exercise + improved nutrition 
- Airway clearance therapy
   Chest physiotherapy
   High frequency oscillation devices
   Inhaled hyperosmolar agents e.g. hypertonic saline/mannitol inhaled (nebulised hypertonic saline)

Pharmacological

  • Inhaled bronchodilator e.g. salbutmol
  • Long term oral macrolide e.g. azithromycin

IV abx acute - IV levofloxacin - if pseudomonas

Immunoglobulin replacement decreases the frequency of infectious episodes and prevents further destruction of the airways

• Surgical therapy (e.g. resection of bronchiectatic areas, lung transplantation)
Pt who continue to deteriorate despite optimal medical management

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16
Q

Management of bronchiectasis for patients at high risk or with known chronic/recurrent pseudomonas aeruginosa infection

A
  • Bronchodilators should be used prior to administration of inhaled abx
  • Inhaled abx e.g. tobramycin, colistimethate, gentamicin
  • Improves resp symptoms in pt with severe bronchiectasis
  • For patients who never had Pseudomonas in their sputum cultures, an appropriate initial choice would be an abx with coverage against Haemophilous influenzae or Staph aureus
17
Q

Acute asthma attack mx

Mild exacerbation

Moderate to severe exacerbation

Life-threatening exacerbation

with hypoxaemia

with normal oxygen

A

Mild exacerbation

  • Neb Salbutamol (5mg)
  • prednisolone PO (40-80mg)
Moderate to severe exacerbation
- O2
- Neb Salbutamol (5mg)
- prednisolone PO (40-80mg)
\+/-  neb ipratropium bromide (0.5 mg)
\+/- IV MgSO4
Life-threatening exacerbation 
- ICU + O2
- neb Salbutamol (5mg)  + neb ipratropium bromide (0.5mg)
 - IV hydrocortisone (100mg)
\+/- IV MgSO4
  • High flow oxygen
  • IV hydrocortisone or oral prednisolone (5 days) [depends on the state of the patient]
  • Salbutamol nebs
  • Ipratropium bromide nebs
  • IV MgSO4 if not improving
  • IV aminophylline
  • Inform ITU - can consider use IV salbutamol

Acute asthma with hypoxaemia
First line – O2 to maintain SpO2 94-98%
Second line – SABA e.g. salbutamol

Acute asthma attack with normal oxygen levels
First line – neb SABA e.g. salbutamol
Might also need neb SAMA (ipratropium bromide), oral prednisolone or IV hydrocortisone

18
Q

Pneumonia mx

CAP
HAP
Aspiration
Atypical

A

GENERALLY - Amoxicillin (for strep pneumoniae) + clarithromycin (for potential atypical infection)
[atyipical - mycoplasma pneumonia, chlamydia psittaci, chlamyda pneumoniae, legionella pneumophilia]

CAP - amoxicillin + clarithromycin
HAP
Staph - flucloxacillin + gentamycin (aminoglycoside)
MRSA - vancomycin (glycopeptide)
Tazocin – tanzobactam + piperacillin
Aspiration - metronidazole (nitroimidazole) + cefuroxime (broad spectrum abx)
Atypical - clarithromycin (macrolide)

Generally give amoxicillin + clarithomycin to cover for any atypical organisms
Consider co-amoxiclav instead of amoxicillin if pneumonia is severe
If pt allergic to amoxicillin give clarithromyin or doxycycline

19
Q

Asthma mx

A

Maintenance therapy // Symptom relief
1. - // SABA

  1. Low dose ICS // SABA
  2. Low dose ICS + LTRA // SABA
  3. Low dose ICS + LABA +/- LTRA // SABA
  4. Moderate dose ICS + LABA +/- LTRA // SABA
  5. High dose ICS + LABA +/- LTRA // SABA
    Or
    Moderate dose ICS + LAMA/theophylline // SABA
  6. Oral CS

NICE guidelines
https://d3j7puhwqgd8ts.cloudfront.net/Pictures/2000x2000fit/0/7/1/5071_pharmacologicaltreatmentofchronicasthmainadultsaged17andover_102147.png

20
Q

Give examples of

SABA 
SAMA
ICS 
LTRA 
LABA 
LAMA

MART (maintenance + reliever therapy)

Oral CS

A 
SABA = salbutamol
SAMA = ipratropium bromide
ICS = budesonide, beclometasone
LTRA = montelukast, zafirlukast 
LABA = Formoterol, salmeterol
LAMA = tiotropium

LABA + ICS usually given within a MART (maintenance + reliever therapy) = Symbicort (Formoterol/budesonide)
Oral CS = prednisilone

21
Q

COPD mx

A
  1. SABA/SAMA+
2. LABA + LAMA (no asthmatic features)
or
LABA + ICS (asthmatic features)
3. LABA + LAMA + ICS
4. If no improvement, revert to LABA + LAMA
SABA = salbutamol
SAMA = ipratropium bromide
LABA = formoterol, salmeterol
LAMA = tiotropium 
ICS = budesonide, beclometasone
Smoking cesssation
Annual influenza vaccination
Pneumococcal vaccination
Long term oxygen therapy (15hrs/day) if
   PaO2 <7.3 kPa
   PaO2 7.3-8 kPa and one of the following
   FEV1 <1.5L
- Secondary polycythaemia
- Nocturnal hypoxaemia
- Pulmonary HTN
- Peripheral oedema (2y to CCF)
Lung volume reduction surgery
asthmatic features
PMHx of asthma or atopy
Higher blood eosinophil count
>400ml variation in FEV1 over time
>20% diurnal variation in PEFR
22
Q

infective exacerbation of COPD mx

IECOPD

A

• Nebulisers
o SABA – 5mg neb salbutamol - provides acute relief of symptoms
o SAMA – 0.5mg neb ipratropium bromide

• Blue venturi 24% O2 - if patient is hypoxaemic AFTER giving SABA

• Steroids
o Prednisolone PO (40-50mg) (daily for 7-14 days)
o Hydrocortisone IV (200mg)

• Abx
o Amoxicillin IV

• 500mg IV aminophylline if poor response to bronchodilators

  • BIPAP (NIV)
  • Prophylactic LMWH
23
Q

Pneumothorax mx

A 
•	Tension
o	Immediate needle decompression (14G at 2nd ICS MCL)
o	O2 therapy - high flow O2
o	Analgesia
o	Chest drain

• Primary pneumothorax + pt >50
o Small (<2cm)
 O2 + observation at home
 Repeat CXR

o Large/SOB (>2cm)
 O2
 Needle decompression/aspiration
 Chest drain (if ND doesn’t work)

• Secondary spontaneous pneumothorax or pt >50
o Small + no SOB (<1cm)
 O2 + Observation at hospital
 Repeat CXR

o Moderate + no SOB (1-2cm)
 O2
 Needle decompression
 Chest drain (if ND doesn’t work)

o Large or SOB (>2cm)
 O2
 Chest drain

  • i.e. if there is shortness of breath you treat even if pneumthorax is small
  • if needle decompression doesn’t work, second line is chest drain
24
Q

A 60 year old man with severe COPD is admitted with an acute exacerbation. What is the most appropriate initial ix?

A

ABG + note the inspired oxygen concentration

  • so that controlled oxygen therapy can be tailored
  • these measurements should be repeated regularly, according to the response to treatment
25
Q

Streptomycin SE

A

Ototoxic
Nephrotoxic

used for patients previously treated with TB - more likely to have developed drug resistance
used in place of ethambutol or in combination with all 4 in resistant TB

26
Q

Pneumonia - pt allergic to penicillin alternatives

A

clarithromyin

doxycycline

27
Q

A 68-year-old woman has presented with acute onset shortness of breath 24 hours after a long haul flight. Her blood results show a raised D-dimer level and the arterial blood gas shows a PO2 of 8.3 kPa and PCO2 of 5.4 kPa. Your consultant suspects a pulmonary embolism and the patient needs to be started on treatment while a CT-PA is awaited. From the list below, please select the most appropriate treatment regime.

A. Commence loading with warfarin and aim for an international normalized ratio (INR) between 2 and 3
B. Thromboembolic deterrent stockings
C. Aspirin 75 mg daily
D. Prophylactic dose subcutaneous low molecular weight heparin + loading with warfarin and aim for INR between 2 and 3
E. Treatment dose subcutaneous low molecular weight heparin + loading with warfarin and aim for INR between 2 and 3

A

E. Treatment dose SC LMWH + loading with warfarin and aim for INR between 2 and 3

28
Q

Drugs that can cause pulmonary fibrosis with long term use

A 
Amiodarone
Methotrexate
Sulfalazine
Nitrofurantoin
Bleomycin
Bulsulfan
29
Q

COPD oxygen options

Long term oxygen
Ambulatory portable) oxygen
Short-burst oxygen
Non-invasive ventilation (NIV)

A 
•	Long term oxygen therapy (15hrs/day) if
   PaO2 <7.3 kPa
   PaO2 7.3-8 kPa and one of the following
   FEV1 <1.5L
- Secondary polycythaemia
- Nocturnal hypoxaemia
- Pulmonary HTN
- Peripheral oedema (2y to CCF)
  • Ambulatory (portable) oxygen - to patients who desaturate when they walk
  • Short-burst oxygen - Symptom relief
  • Non-invasive ventilation (NIV) - when T2RF persists during exacerbations despite medical therapy
30
Q

Immediate mx of PE

A

High flow oxygen
SC LMWH (e.g. enoxaparin)
Calcuate a Well’s score

31
Q

Mycoplasma pneumoniae pneumonia mx

A

doxycycline or a macrolide (e.g. erythromycin/clarithromycin)

Respiratory Y3 (4 decks)

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