resp treatments

Question 1

asbestosis

Answer 1

symptom management

no treatment known to alter disease but corticosteroids are often prescribed

Question 2

acute bronchitis

Answer 2

over the counter painkillers

antibiotics are often given (amoxicillin)

Question 3

ARDS

Answer 3

admit to ITU, supportive care, treat underlying cause

Respiratory Support: Early ARDS - CPAP with 40-60% oxygen, later mechanical ventilation may be required

Question 4

asthma

Answer 4

Step 1: SABA (salbutamol) as required + low dose ICS (beclometasone)
Step 2: + LABA (salmeterol)
↑ICS
Step 3: + 4th Drug: LTRA (montelukast), Methylxanthines (theophylline), LAMA (tiotropium), Sodium Cromoglicate in children
Step 4: + oral steroid (prednisolone)
Step 5: Consider trials of anti-IgE (Omalizumab)/IL-5 (Mepolizumab)/IL-4 (Dupilumab)

Question 5

acute asthma

Answer 5

Acute O SHIT Man:
Oxygen
Salbutamol (neb)
Hydrocortisone IV / oral prednisolone
Ipratropium (neb) if PEF <75%
Theophylline
Magnesium Sulphate IV
Anaesthetist

Question 6

small cell carcinoma

Answer 6

chemotherapy and radiotherapy (SABR)

Question 7

non-small cell carcinoma

Answer 7

surgery – lobectomy or pneumonectomy, radical radiotherapy, palliative chemotherapy, adenocarcinoma – EGFR mutations

Question 8

bronchiectasis

Answer 8

Stop smoking, flu vaccine, pneumococcal vaccine
Airway clearance techniques and mucolytics

Antibiotics:
>3 exacerbations/year, preventative treatment:
low dose oral macrolides – clarithromycin 1x daily, azithromycin 3x a week

Persistent bacteria in bronchiectasis: 
oral macrolide (azithromycin), nebulised gentamycin, alternating oral Abs, pulsed IV Abs

Exacerbations
2 weeks of sensitive antibiotics

Bronchodilators
Corticosteroids
Surgery: for localised disease or to control severe haemoptysis

Question 9

COPD

Answer 9

LABA/LAMA + SABA

LABA/LAMA/ICS – for frequent exacerbator with high eosinophilic counts (>300 cells)

Question 10

acute COPD

Answer 10

iSOAP

Ipratropium (SAMA) – nebulised
Salbutamol (SABA) – nebulised
Oxygen 24-28%, keep SaO2 between 88-92% (if CO2 is normal target is 94-98%)
Amoxicillin if infection likely
(or doxycycline or clarithromycin)
Prednisolone – oral / hydrocortisone – IV
Aminophylline – IV (if no response)

Question 11

cor pulmonale

Answer 11

Treat underlying cause
Treat respiratory failure – 24% oxygen in PaO2 <8kPa, monitor and slowly increase
Treat cardiac failure –diuretics (eg. furosemide), monitoring U&E
Consider venesection if haematocrit >55%
Consider heart-lung transplantation in young patients

Question 12

cystic fibrosis

Answer 12

Physiotherapy (autogenic drainage, active cycle of breathing)
Antibiotics
Mucolytics
CREON (for absorbing energy due to exocrine failure)
Dietary input
Gastrograffin/Laxido for distal intestinal obstruction syndrome
Annual glucose monitoring
Out of hospital parenteral admission therapy
New gene therapies which target mutations
Lung Transplantation

Question 13

empyema

Answer 13

Chest drainage
Broad spectrum IV antibiotics: amoxicillin and metronidazole
Targeted oral antibiotics for 5 weeks

Question 14

epiglottis

Answer 14

Secure airway with ET tube and urgent IV antibiotics (vancomycin, clindamycin or ceftriaxone)

Question 15

Hypersensitivity Pneumonitis

Answer 15

Acute: remove allergen and give O2 (35-60%), prednisolone

Chronic: allergen avoidance, long-term steroids (prednisolone)

Question 16

idiopathic pulmonary fibrosis

Answer 16

Supportive Care: oxygen, pulmonary rehabilitation, opiates, palliative care input
Anti-fibrotic drugs (pirfenidone and nintedanib): slow disease progression
Oxygen if hypoxic
Pulmonary rehabilitation
Lung transplant (in young patients)

Question 17

influenza

Answer 17

bed rest and paracetamol
Uncomplicated Influenza:
Symptomatic treatment
Antivirals for high risk patients

Complicated Influenza:
Antivirals Oseltamivir /Zanamivir

Antibiotics can also be given, as influenza can result in secondary bacterial infection

Question 18

lung abscess

Answer 18

IV antibiotics

Question 19

mesothelioma

Answer 19

Pemetrexed + cisplatin chemotherapy

Question 20

obstructive sleep apnoea

Answer 20

Weight loss, avoidance of tobacco and alcohol, mandibular advancement device/surgery, CPAP during sleep, surgery

Question 21

pertussis

Answer 21

clarithromycin

Question 22

pleural effusion

Answer 22

Drainage (slow) for symptomatic effusions
Pleural tap
Long term pleural catheters (malignancy)
Pleurodesis with talc for recurrent effusions
Surgery for persistent collections and increasing pleural thickness
Palliative care including chemotherapy (pemetrexed/cisplatin combo) and radiotherapy
INR> 1.3 is a contraindicator for chest drain insertion (high INR means blood takes longer to clot)

Chest drainage is required in patients with a pH <7.2 – raises suspicion of pleural infection

Question 23

pneumonia

Answer 23

Antibiotics
Community Acquired: amoxicillin / doxycycline
Hospital Acquired: amoxicillin + gentamycin
Aspiration: amoxicillin + metronidazole
Legionella: levofloxacin

Oxygen – SaO2 94-98% / 88-92%
Fluids
Bed Rest

Question 24

pneumothorax

Answer 24

Primary:
<2cm and not SOB: Discharge and outpatient review
>2cm and/or SOB: HF O2, aspirate (16-18G needle)
discharge and review

Secondary:
>2cm or SOB: Chest Drain
1-2cm: Aspirate (16-18G needle)
admit for 24hour observation and review

Question 25

tension pneumothorax

Answer 25

-needle decompression with a cannula through anterior second intercostal space in the mid-clavicular line on the side of the pneumothorax, then insert a chest drain and get a CXR

Question 26

pulmonary embolism

Answer 26

Thrombolyse (tenecteplase) for massive PE If haemolytically stable: LMWH (Fragmin) and warfarin – stop warfarin when INR is 2-3 Or DOAC (dabigatran) or factor X (rivaroxaban / apixaban) Consider placement of IVC filter for recurrent PE Prevention: heparin to all immobile patients vitamin k antagonist should be given within 24 hours of diagnosis

Question 27

respiratory distress syndrome

Answer 27

Keep warm, NCPAP to prevent atelectasis, intubation + ventilation to deliver artificial surfactant

Question 28

type 1 respiratory failure

Answer 28

``` Treat underlying cause Give oxygen (24-60% by facemask Assisted ventilation (NIPVV) if PaO2 <8kPa despite 60% O2 ```

Question 29

type 2 respiratory failure

Answer 29

Treat underlying cause Controlled oxygen therapy (start at 24% oxygen) If this fails, consider intubation and ventilation

Question 30

rhinitis

Answer 30

``` Glucocorticoids Anti-histamines Anti-cholinergic drugs Sodium Cromoglicate Cysteinyl Leukotriene Receptor Antagonists Vasoconstriction ```

Question 31

sarcoidosis

Answer 31

Acute Sarcoidosis: bed rest, NSAIDs, steroids if a vital organ is affected Indications for corticosteroids (prednisolone for 4-6 weeks): parenchymal lung disease, uveitis, hypercalcaemia and neurological or cardiac involvement

Question 32

sinusitis

Answer 32

Self-resolving but can require antibiotics Symptom relief: nasal decongestant vasoconstrictor (oxymetazoline), a nasal steroid or pseudo-ephedrine

Question 33

tuberculosis

Answer 33

Active TB Isoniazid & Rifampicin & Pyrazinamide & Ethambutol for 2 months + Isoniazid & Rifampicin for a further 4 months Latent TB Isoniazid & Rifampicin for 3 months