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Year 6 Medicine > Respiratory > Flashcards

Respiratory Flashcards

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1
Q

What is COPD

A

Chronic obstructive pulmonary disease (COPD) is a chronic inflammatory lung disease that causes obstructed airflow from the lungs

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2
Q

What are the investigations for COPD?

A

bedside: examination, obs, sputum sample (MC&S)
Bloods: baseline FBC (polycythaemia), CRP, ABG, BNP (cor pulmonale)
Imaging: CXR, HR-CT, echo (cor pulmonale)
Special tests: biopsy (PAS stain;A1AT), spirometry (gold standard)

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3
Q

What is the scale used for COPD assessment?

A

mMRC (modified medical research council scale`0
0 only breathless with strenuous exercise
1 SOB when hurrying or walking slightly uphill
2 slower than average person of same age, need to stop for breaks
3 stop for breath after walking 100 m or after a few minutes
4 too breathless to leave the house; breathless when dressing

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4
Q

What is the conservative management of COPD?

A 
Smoking cessation
mucolytics
Prophylactic azithromycin
Vaccines 
LTOT
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5
Q

Which patients with COPD should be given azithromycin?

A

non smoker
optimised medical management
referred for pulmonary rehabilitation
x4 IE/year with >=1 hospitalisation

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6
Q

What is the medical management of COPD?

A
  1. PRN SAMA or SABA
  2. asthmatic features -> LABA + inh steroid
    no asthmatic features -> LABA + LAMA
  3. LABA + LAMA + ICS
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7
Q

What are the asthmatic features in COPD to look out for?

A

History of asthma or atopy
FEV1 variation over time (>400mL)
Eosinophilia
Diurnal variation in PEFR (>20%)

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8
Q

What is the surgical management of COPD?

A

Remove diseased lung to allow non-diseased parts to become more ventilated:
- bullectomy
- lung reduction surgery (indication: heterogenous emphysema)
- endobronchial valve placement (valve placed in part of lung -> iatrogenic distal collapse)
Lung transplant

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9
Q

How is mild COPD categorised?

A

FEV1/FVC <0.7

FEV1 >80%

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10
Q

How is moderate COPD categorised?

A

FEV1/FVC <0.7

FEV1 50-79%

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11
Q

How is severe COPD categorised?

A

FEV1/FVC <0.7

FEV1 30-49%

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12
Q

How is severe COPD categorised?

A

FEV1/FVC <0.7

FEV1 <30%

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13
Q

Who is eligible for LTOT?

A

Non smoker AND…

  1. pO2 of <7.3 kPa (x2 measurements) OR
  2. pO2 of 7.3-8 kPa and of of…
    - secondary polycythaemia
    - peripheral oedema
    - pulmonary hypertension
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14
Q

what are the indications for NIV in COPD?

A

resp alkalosis pH 7.25-7.35
T2RF secondary to chest wall deformity, neuromuscular disease, OSA
cariogenic pulmonary oedema
weaning from tracheal intubation

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15
Q

what is the management of COPD exacerbation

A 
24% fiO2 venturi 
neb salbutamol 5mg
neb ipratropium bromide 0.5 mg 
IV hydrocortison 200 mg
PO pre 40-50 mg (5 days)
IV amox/co-amox

Senior support
IV aminophylline
BiPAP

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16
Q

What are the complications of COPD?

A

Local - pneumothorax, lobar collapse, bull formation, lung cancer
systemic - pulmonary hypertension +/-cor pulmonale, polycythaemia, medication/ steroid complications

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17
Q

What are some differentials for a wheeze?

A

Resp: asthma, COPD
Rheum: GPA (obliterative bronchiolitis), rheumatoid arthritis
Cardiac: HF

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18
Q

Which features are present in a life threatening asthma attack?

A

PEFR <33%
pO2 <92%
GCS down, exhaustion, low BP
Silent chest, confusion, arrhythmia

ADMIT

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19
Q

What is a moderate asthma attack?

A

PEFR
50-75%
No other features

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20
Q

What is a severe asthma attack?

A

PEFR 33-50%
Not completing full sentenes
RR >25, HR >110, pO2 >92%

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21
Q

What is a near fatal asthma attack?

A

pCO2 RAISED

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22
Q

When should a patient be discharged after an asthma attack?

A

discharge when stable for 48 hours

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23
Q

When should a patient be reviewed after attending hospital for asthma

A

If discharged - review in GP in 2 days

If admitted - review in GP in 2 days, review in respiratory clinic in 4 weeks

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24
Q

What aspects of asthma need to be reviewed after admission to hospital?

A 
TAME
Technique
Avoidance of triggers
Monitor (PEFR)
Educate
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25
What drugs should a patient be discharged with after an asthma attack?
prednisolone 40 mg OD PO 5 days OR | quadruple inhaled ICS dose for 14 days if not admitted
26
How often can salbutamol and ipratropium be given in asthma attack
salbutamol can be given back to back PRN | ipratropium bromide can be given every 4 hours PRN
27
How is an asthma attack management
``` O2 100% Neb salb neb iptratropium PO pred 100mg IV hydrocort ``` **Senior** IV magnesium sulphate IV aminophylline ITU + intubate
28
What are the most common organisms that cause a CAP?
S.pneumoniae (30-50%) | H. Influenzae (15-35%)
29
Which antibiotic is used for a mild CAP
amoxicillin
30
Which antibiotic is used for a severe CAP/atypical
co-amoxiclav + clarithromycin
31
Which antibiotic is used for legionella?
Clarithromycin + rifampicin catheter - change with gentamicin cover
32
Which antibiotic is used for staphylococcus?
flucloxacillin
33
What is the most common atypical pneumonia organism?
mycoplasma pneumoniae
34
what is the antibiotic cover for atypical CAP?
Clarithromycin, doxycycline
35
What are the buzzwords for S.pneumonia?
rusty sputum, lobar pattern, reactivate HSV
36
What are the buzzwords for H.influenzae?
``` pre-existing lung disease (smoking/COPD) bronchoalveolar pattern (lower lobes). ```
37
What are the buzzwords for M.catarrhalis?
smoking
38
What are the typical organisms for CAP?
``` S.pneumoniae H.influenzae M.Catarrhalis S.aureus K.pneumoniae ```
39
What are the atypical organisms for CAP?
``` M2C3BL M.pneumoniae M.tuberculosis C.pneumoniae C.psittaci C.burnetii B.pertussis L.pneumophilia ```
40
What are the buzzwords for S.aureus?
recent viral infection +/- cavitation CXR
41
What are the buzzwords for K.pneumoniae?
redcurrant jelly sputum, alcoholism, dm, elderly, haemoptysis, caveatting upper lobes
42
Gram -ve typicals?
H.influenzae M.Catarrhalis K.pneumoniae
43
Gram +ve typicals?
S.pneumoniae | S.aureus
44
Gram -ve atypicals?
c.burnetii | B.pertussis
45
Gram +ve atypicals?
m.tuberculosis
46
Buzzwords for M.pneumoniae?
systemic, joint point, cold agglutinin test, erythema multiform, SJS, AIHA
47
Buzzwords for L.pneumophilia?
Air travel, air conditioner, water tower, hepatitis, hyponatraemia, urinary antigen
48
Buzzwords for C.psittaci?
birds | haemolytic anaemia
49
Buzzwords for C.pneumoniae?
child | adolescent
50
Buzzwords for B.pertussis?
whooping cough | unvaccinated
51
What is the curb 65 score
``` Confusion (AMTS <=8) Urea >=7 Resp rate >=30 BP <90/60 65 yo ```
52
What most commonly causes early onset (48h - 4d) HAP?
Strep pneumoniae
53
What most commonly causes later onset (>4 days) HAP?
Enterobacteria (E.coli, K.pneumoniae) > S.aureus (MRSA) > pseudomonas
54
Abx for non severe HAP?
Co-amox or doxy
55
Abx for severe HAP?
Piptazobactam or cef+gent
56
Abx for MRSA?
Vancomycin
57
Abx for Klebsiella?
cephalosporin
58
Abx for pseudomonas?
piptazobactam
59
Ix for TB?
Bedside; exam, obs, TST, sputum (MC&S), sputum smear +zh/auramine stain Bloods: FBC, U&E, CRP, IGRA Imaging: CXR Special: EBUS
60
Which test is the gold standard for tb?
BAL + SPUTUM culture (1-3 w)
61
Which TB test shows if the patient has been exposed
IGRA (Does not show if latent or active)
62
Which TB test shows latent TB?
TST/mantoux test | check size of bleb
63
Which test is used if not sputum culture for TB?
Sputum smear X3 -> NAAT auramine stain - screening Ziehl-neelson - diagnosis
64
What is the management of TB?
``` RIPE rifampicin (6m) Isoniazid (6m) Pyrazinamide (2m) Ethambutol (2m) ```
65
what are the side effects of rifampicin ?
orange secretions raised ALT/AST inducer
66
what are the side effects of isoniazid?
``` Drug induced liver injury (dili) peripheral neuropathy (give with pyridoxine) ```
67
what are the side effects of pyrazinamide?
DILI
68
what are the side effects of ethambutol?
visual disturbance
69
What is the most common opportunistic AIDS infection?
PCP
70
What are the S/S of PCP?
sob dry cough, fever, exercise induced low oxygen pneumothorax extra pulmonary:hepatosplenomegaly, lymphadenopathy, choroid lesions
71
Ix of PCP
CXR - bilat infiltrates but can be normal BAL > sputum (silver stain shows cysts) Exercise induced desaturation
72
Management for PCP?
Mild/mod: co-trimoxazole | severe: IV pentamidine
73
What are the complications of inserting a chest drain?
Immediate: failure, pain, haemorrhage, pneumothorax early: infection haematoma, long thoracic nerve damage (winged scapula), blockage late: scar formation
74
What is flail chest?
life threatening condition when >=3 consecutive ribs fracture in >=2 locations resulting in part of the chest wall moving independently of the rest
75
How does a flail segment move on inspiration?
moves inwards
76
How does a flail segment move on inspiration?
moves outwards
77
why is a flail segment dangerous?
increased WOB and pulmonary contusions | free rib may puncture -> tension pneumothorax
78
Ix for flail segment?
CXR: fracture, subcut emphysema, pneumothorax, mediatstinal shift
79
Mx for flail chest?
analgesia, chest physio (expansion and secretions), CPAP, surgical fixation
80
Causes of exudate pleural effusion?
``` >30 g protein Malignancy Infection (pneumonia, TB, abscess) PE Trauma pancreatitis CTD (RA, SLE) Dresslers ```
81
Causes of transudate pleural effusion?
``` <30 g protein CCF Cirrhosis Nephrotic syndrome Myxoedema Meig's (benign ovarian tumour, ascites, R sided pleural effusion) Hypothyroid Hypoalbuminaemia ```
82
Investigations for pleural effusion?
bedside: exam, obs, urine dip (protein) bloods: baseline, LFTs, CRP, clotting, culture imaging: CXR, echo (CCF), contact CT (exudative causes special: USS guided pleural aspiration and chest drain, EBUS (sarcoid, TB)
83
what features of a pleural tap would suggest an empyema?
pH <7.2 LDH high glucose low
84
When do you use lights criteria?
if tap shows 25-35g/L of protein to help differentiate cause
85
What is lights criteria?
an exudate is likely if: pleural fluid protein/serum protein >0.5 pleural fluid LDH/serum LDH >0.6 pleural fluid LDH>2/3 ULN serum LDH
86
What is the management of pleural effusion?
1. if aspirate turbid/cloudy, +ve MCS and pH <7.2 -> chest drain 2. Treat cause 3. recurrent: aspiration, pleurodesis, indwelling pleural catheter, drug management e.g opioids for SOB
87
What is the management of an acute exacerbation of COPD?
increase frequency of bronchodilator use and consider giving via a nebuliser give prednisolone 30 mg daily for 5 days it is common practice for all patients with an exacerbation of COPD to receive antibiotics. NICE do not support this approach. They recommend giving oral antibiotics 'if sputum is purulent or there are clinical signs of pneumonia' the BNF recommends one of the following oral antibiotics first-line: amoxicillin or clarithromycin or doxycycline.
88
What is the management of sarcoidosis
steroids
89
What are some indications for steroids in sarcoidosis?
- patients with chest x-ray stage 2 or 3 disease who are symptomatic. - Patients with asymptomatic and stable stage 2 or 3 disease who have only mildly abnormal lung function do not require treatment - hypercalcaemia - eye, heart or neuro involvement
90
what are 4 types of pulmonary fibrosis?
Idiopathic (IPF) Hypersensitivity pneumonitis Sarcoidosis Pneumoconiosis
91
what are the symptoms of hypersensitivity pneumonitis
mild fever
92
Ix for hypersensitivity pneumonitis?
BAL - increased cellularity
93
what are the causes of upper lobe fibrosis?
``` TAPE TB ABPA Pneumoconiosis (silica, coal) EAA (hypersensitivity pneumonitis ```
94
what are the causes of lower lobe fibrosis?
STAIR Sarcoid (mid zone) Toxins (Bleomycine, amoidarone, nitrofurantoin, sulfasalazine, methotrexate) Asbestosis Idiopathic pulmonary fibrosis (diagnosis of exclusion) Rheumatology (RhA, SLE, Sjogrens, CREST/scleroderma)
95
What are the signs and symptoms of IPF?
Progressive exertion dyspnoea Dry cough Clubbing Bibasal fine end inspiratory crepe on auscultation
96
What are the investigations for pulmonary fibrosis?
Bedside: examination, obs Bloods: baseline, SLE screen, IgE, ABG Imaging: CXR, HR-CT, echo (pulmonary hypertension) Special tests: Spirometry (restrictive), TLCO (low), BAL (cellularity), EBUS (sarcoid)
97
what is the management of IPF?
Conservative: physio, pulmonary rehabilitation, smoking cessation Medical: LTOT, antitussives, pirfenidone/ninetadinib, immunosuppressants Surgical: lung transplant
98
What is the criteria for long term oxygen therapy (IPF)?
1. pO2 <7.3kPA (x2) OR 2. pO2 of 7.3-8kPA and one of... - secondary polycythaemia - nocturnal hypoxaemia - peripheral oedema - pulmonary hypertension
99
When should you give steroids in sarcoidosis?
``` HUNP Hypercalcaemia Uveitis Neurological/cardiac involvement Parenchymal lung disease ```
100
What is the prognosis for IPF?
Poor | life expectancy 3-4 y
101
What is bronchiectasis?
permanent dilatation of airways secondary to chronic inflammation
102
What are some causes of bronchiectasis?
Infection: haemophilia influenzae (most common), pseudomonas, klebsiella spp, strep pneumoniae obstruction (tumours or foreign body) idiopathic (majority) CF Kartageners Autoimmune: selective IgA, hypogammaglobulinaemia, ABPA, rheumatoid
103
What are some signs and symptoms of bronchiectasis?
Hx of cause | ABPA
104
What are the ix for bronchiectasis?
bedside: exam, obs, sputum (MCS), sweat test bloods: baseline, CRP, immunoglobulin, CF tests, aspergillus Imaging: CXR, HR-CT Special: spirometry
105
What is the management of bronchiectasis?
correct underlying cause ``` Prophylaxis: physio, pul rehab smoking cessation bronchodilators immunisations prophylactic rescue packs (abx) and education ``` Acute exacerbation: Abx bronchodilators
106
What are the complications of bronchiectasis?
local: haemorrhage, lobar collapse, T2RF systemic: pul HTN, cachexia
107
What is ABPA
Allergic response to aspergillum spores
108
What are the Ix of ABPA?
``` Eosinophils CXR +ve RAST Raised IgE +ve igG ```
109
What is the management of ABPA?
Oral glucocorticoids | itraconazole
110
What is cystic fibrosis ?
Defective CFTR chloride channel (chromosome 7)
111
What is the incidence and carrier rate of CF?
1 in 25000 live births | 1 in 25 carrier
112
What is the most common gene mutation in CF?
F508
113
What are the S/S of CF?
``` Meconium ileus Recurring chest infections ABPA, nasal polyps, sinusitis Diarrhoea or constipation Male sterility Faltering growth Jaundice Diabetes Clubbing ```
114
What are the investigations for CF?
Guthrie heel prick test for immunoreactive trypsinogen Sweat test for NaCl Genetic testing CXR
115
What signs of cystic fibrosis may be seen on CXR?
Hyperinflation peri-bronchial shadowing bronchial wall thickening ring shadows
116
What is the management of CF?
MDT - routine reviews ``` Resp: physio 2x a day encourage physical activity mucolytic: dornase alfa/rhDNase + saline lumacaftor with ivacaftor may be effective in prolonging life by F508 ``` Infection Abx prophylaxis (fluclox + azithromycin) Rescue packs Nutrition High calorie and fat diet Fat soluble vitamin supplements Creon (pancreatic enzyme replacement) with every meal ``` General: DM therapy Urso - for liver and bile problems intracytoplasmic sperm injection laxatives ```
117
what are some common organisms for CF infection?
S.aureus, P. Aeruginosa, Burkholderia cepacia complex
118
Types and incidence of Lung cancer?
``` Small cell lung cancer (15%) Non small cell lung cancer (85%) - adenocarcinoma (30%) - SCC (30%) - Large cell carcinoma (20%) - alveolar cell carcinoma - bronchial adenoma ```
119
What are the features of SCLC?
``` Smokers central SIADH ACTH LEMS ```
120
What are the features of adenocarcinoma?
``` non smokers peripheral early mets gynaecomastia HPOA (hypertrophy pulmonary osteoarthropathy) ```
121
What are the features of SCC?
``` Smokers central spread locally late mets PTHrp, ectopic TSH, HPOA ```
122
What are the features of large cell carcinoma?
peripheral, poor prognosis, beta HCG, anaplastic poor differentiation
123
Where do lung cancers commonly metastasise to?
``` prostate testicular bones kidney breast ```
124
What are some signs and symptoms of Lung Ca?
``` Cough WL Haemoptysis Anorexia SOB Hoarseness (pan coast) Chest pain SVCO ```
125
What paraneoplastic syndromes may SCLC cause?
SIADH - hyponatraemia ACTH - cushings LEMS (anti VGCC) - MG like but improves with activity
126
What paraneoplastic syndromes may SCC cause?
PTHrp - hypercalcaemia, HPOA Ectopic TSH - hyperthyroid Clubbing
127
What paraneoplastic syndromes may adenocarcinoma cause?
gynaecomastia, HPOA
128
What is HPOA?
Proliferative periostitis involving the long bones - often painful
129
What are the local and systemic complications of lung ca?
local: lung collapse, pleural effusion, haemorrhage, phrenic/recurrent laryngeal nerve palsy, horners, SVCO systemic: ectopic hormone production --> SIADH, ACTH, LEMS, PTH gynaecomastia dermatomyositis
130
Management of NSCLC?
1. surgery 2. curative/palliative radiotherapy 3. nivolumab is approved to treat NSCLC
131
When is surgery contraindicated for NSCLC?
- Poor health - Mets - FEV1 <1.5 - Malignant effusion - Hilum tumour - Vocal cord paralysis - SVCO
132
What is the management of SCLC?
- Early stages (T1-2a,N0,M0) -> surgery - non early stages/limited disease -> combination chemo - non early stages/extensive disease -> palliative chemo
133
what is sarcoidosis?
multisystem disorder involving non caveatting granulomas
134
What are the features of sarcoid?
polyarthralgia erythema nodosum bilateral hilar lymphadenopathy
135
What may cause widening of mediastinum on CXR
Goitre lymphoma thoracic aneurysm thymus tumour
136
When should someone be assessed for LTOT?
Assess patients if any of the following: - very severe airflow obstruction (FEV1 < 30% predicted). - - Assessment should be 'considered' for patients with severe airflow obstruction (FEV1 30-49% predicted) - cyanosis - polycythaemia - peripheral oedema - raised jugular venous pressure - oxygen saturations less than or equal to 92% on room air
137
What needs to be done before offering LTOT?
do not offer LTOT to people who continue to smoke despite being offered smoking cessation advice and treatment, and referral to specialist stop smoking services. NICE suggest that a structured risk assessment is carried out before offering LTOT, including: the risks of falls from tripping over the equipment the risks of burns and fires, and the increased risk of these for people who live in homes where someone smokes (including e‑cigarettes)
138
What is the most appropriate test prior to starting azithromycin for COPD?
ecg to rule out prolonged Qt interval | LFTs also advised
139
When should you keep someone in hospital for pneumonia?
``` NICE recommend that patients are not routinely discharged if in the past 24 hours they have had 2 or more of the following findings: temperature higher than 37.5°C respiratory rate 24 breaths per minute or more heart rate over 100 beats per minute systolic blood pressure 90 mmHg or less oxygen saturation under 90% on room air abnormal mental status inability to eat without assistance. ``` They also recommend delaying discharge if the temperature is higher than 37.5°C.
140
What should all patients have 6 weeks after pneumonia?
CXR
141
Which autoantibodies may be seen in IPF?
ANA positive in 30%, rheumatoid factor positive in 10%
142
What is seen on CXR of IPF?
sub-pleural reticular opacities that increase from the apex to the bases of the lungs
143
What are the investigation findings in pneumoconiosis?
Chest x-ray: upper zone fibrosis | Spirometry: restrictive lung function tests - a normal or slightly reduced FEV1 and a reduced FVC
144
What is the management of pneumoconiosis?
Avoid exposure to coal dust and other respiratory irritants (e.g. Smoking). Manage symptoms of chronic bronchitis Patients may be eligible for compensation via the Industrial Injuries Act.
145
What can cause a metabolic acidosis with normal anion gap?
``` = hyperchloraemic metabolic acidosis) Gastrointestinal bicarbonate loss: diarrhoea, ureterosigmoidostomy, fistula Renal tubular acidosis Drugs: e.g. acetazolamide Ammonium chloride injection Addison's disease ```
146
What can cause a metabolic acidosis with raised anion gap?
Lactate: shock, hypoxia Ketones: diabetic ketoacidosis, alcohol Urate: renal failure Acid poisoning: salicylates, methanol
147
How can metabolic acidosis with a raised lactate be categorised?
Metabolic acidosis secondary to high lactate levels may be subdivided into two types: Lactic acidosis type A: (Perfusion disorders e.g.shock, hypoxia, burns) Lactic acidosis type B: (Metabolic e.g. metformin toxicity)
148
Causes of metabolic alkalosis?
``` Vomiting / aspiration (e.g. Peptic ulcer leading to pyloric stenosis, nasogastric suction) Diuretics Liquorice, carbenoxolone Hypokalaemia Primary hyperaldosteronism Cushing's syndrome Bartter's syndrome Congenital adrenal hyperplasia ```
149
Causes of respiratory acidosis?
COPD Decompensation in other respiratory conditions e.g. Life-threatening asthma / pulmonary oedema Sedative drugs: benzodiazepines, opiate overdose
150
Causes of respiratory alkalosis?
Psychogenic: anxiety leading to hyperventilation Hypoxia causing a subsequent hyperventilation: pulmonary embolism, high altitude Early salicylate poisoning* CNS stimulation: stroke, subarachnoid haemorrhage, encephalitis Pregnancy *Salicylate overdose leads to a mixed respiratory alkalosis and metabolic acidosis. Early stimulation of the respiratory centre leads to a respiratory alkalosis whilst later the direct acid effects of salicylates (combined with acute renal failure) may lead to an acidosis
151
what is the most common cause of occupational asthma
isocyanates | example occupations include spray painting and foam moulding using adhesives
152
What should pleural tap fluid be sent for?
pH, protein, lactate dehydrogenase (LDH), cytology and microbiology
153
When should a chest drain be placed in pleural effusion?
- if the fluid is purulent or turbid/cloudy a chest tube should be placed to allow drainage - if the fluid is clear but the pH is less than 7.2 in patients with suspected pleural infection a chest tube should be placed
154
what is alpha 1 anti trypsin deficiency?
Alpha-1 antitrypsin (A1AT) deficiency is a common inherited condition caused by a lack of a protease inhibitor (Pi) normally produced by the liver causes emphysema in young non smokers
155
Features of A1AT?
patients who manifest disease usually have PiZZ genotype lungs: panacinar emphysema, most marked in lower lobes liver: cirrhosis and hepatocellular carcinoma in adults, cholestasis in children
156
Ix A1AT?
A1AT concentrations | spirometry: obstructive picture
157
mX A1At?
no smoking supportive: bronchodilators, physiotherapy intravenous alpha1-antitrypsin protein concentrates surgery: lung volume reduction surgery, lung transplantation

Year 6 Medicine (18 decks)

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