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Medicine Block Year 3 > Respiratory > Flashcards

Respiratory Flashcards

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1
Q

What is spirometry?

A

FEV1 and FVC are measure
A ratio is determined from the two values.
Normal ratio with reduced FEV1 and FEV = restrictive
Reduced ratio with just reduced FEV1 = obstructive

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2
Q

What are the 4 main causes for hypoxia?

A

Hypoventilation
Diffusion impairment
R->L Shunt (Pulmonary embolus, congenital heart disease and pericardial tamponade can all cause this)
V/Q mismatch

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3
Q

What is the A-a gradient?

A

A= Alveolar
a= arterial

The gradient less than 2kPa in young healthy people or less than 4kPa in older people implies lung pathology

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4
Q

What is Anaphylaxis?

A

A serious allergic reaction.
A sensitised individual is exposed to a specific antigen, leading to an increase in IgE , causing mast cell release of histamine and an increase in basophils

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5
Q

What are the symptoms of Anaphylaxis?

A

Angioedema
Hoarseness
Stridor
Wheeze
Bronchospasm
Chest tightness
Pruritus

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6
Q

How do you treat anaphylaxis?

A

If medication/contrast reaction, stop administration of the offending substance
Give high flow O2 ( 15L/min with non-rebreathable mask )
Administer 0.5ml of IM adrenaline ( 1:1000)
Administer antihistamine (diphenhydramine (25-50mg IV)

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7
Q

What are the features of a Mild Asthma Exacerbation?

A

No features of severe asthma
PEFR > 75%

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8
Q

What are the features of a Moderate Asthma exacerbation?

A

No features of severe asthma
PEFR 50-75%

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9
Q

What are the features of a Severe Asthma exacerbation?

A

Any of the following:

PEFR 33-50%
Cannot complete sentences in one breath
Respiratory Rate >25/min
Heart Rate >110/min

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10
Q

What are the features of a Life Threatening Asthma exacerbation?

A

PEFR <33%
Sats <92%
ABG pO2< 8kPa
Cyanosis, Poor Respiratory Effort or near or full Silent Chest
Exhaustion, Confusion, Hypotension or Arrhythmias
Normal pCO2

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11
Q

What is the feature of a Near Fatal Asthma exacerbation?

A

Raised pCO2

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12
Q

What is the management for an acute asthma exacerbation?

A

ABCDE
Aim for SpO2 94-98% with O2 if needed ( controlled O2 )
ABG if sats <92%
2.5mg nebulised Salbutamol ( can repeat in 15mins)
40mg PO Prednisolone STAT ( if PO not possible give IV Hydrocortisone

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13
Q

What is the management for Anaphylaxis?

A

Remove trigger
Ensure airway stability + high flow O2 if needed
IM Adrenaline 0.5mg ( Repeat every 5mins )
If hypotensive lie flat and fluid recuss
Treat bronchospasm -> NEB Salbutamol

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14
Q

What is the management for severe asthma?

A

NEB Ipratropium Bromide 500mg
Back to back Salbutamol?

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15
Q

What is the management for life threatening or near fatal asthma?

A

Urgent ITU
Urgent portable CXR
IV Aminophylline
Consider IV Salbutamol if NEB ineffective

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16
Q

What implies an infective COPD exacerbation?

A

Change in sputum volume/ colour
Fever
Raised WCC +/- CRP

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17
Q

What is the management for a Non-Infective COPD exacerbation?

A

ABCDE
Aim for SaO2 of 94-98% but if any evidence of acute or previous Type 2 Respiratory Failure then target is 88-92%
Salbutamol and Ipratropium NEBS
Prednisolone 30 mg STAT and then for 7 days o.d

Consider IV Aminothylline if no improvement

Consider Non invasive ventilation if Type 2 Respiratory Failure and pH 7.25-7.35

If pH<7.25 consider ITU

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18
Q

What is the mangement for Pneumonia if Consolidation+/- purulent sputum+/- raised WCC and or CRP ?

A

ABCDE
If any septic features treat immediately with Sepsis 6 bundle
If not treat with antibiotics as per CURB-65 score and local guidelines

Mild- Amoxicillin
Moderate- Co-Amoxiclav
Severe= Co-amoxiclav

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19
Q

What does CURB-65 stand for?

A

C - Confusion
U - Urea > 7
R - Resp Rate > 30/min
B - Blood Pressure < 90mmHg or < 60mmHg
65 - Above 65

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20
Q

What is counts as Massive Haemoptysis?

A

> 240mls in 24 hours
100mls / day over consecutive days

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21
Q

What is the management for Massive Haemoptysis?

A

ABCDE Approach
-Lie patient on side of suspected lesion
-O2 if needed
-Fluid recussitation ( bloods / I.V)
-Stop NSAIDs/ Aspirin/ Anticoagulants
-Reverse any anticoagulation ( I.V Vitamin K and Prothrombin Complex )
-Oral or IV Tranexamic Acid for 5 days
-Antibiotics if any evidence of infection
-CT aortogram to identify bleeding site

Investigations-
Bloods - FBC, U&Es, G+S, Crossmatch, Coagulation, LFTs

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22
Q

What are the symptoms of a tension pneumothorax?

A

Hypotension
Tachycardia
Tracheal deviation away from side of pnemothorax
Mediastinal shift away from side of pnemothorax

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23
Q

What is the management for a Tension Pneumothorax?

A

Large bore IV cannula into 2nd ICS MCL
Then chest drain into affected side

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24
Q

What are the symptoms of a PE?

A

Chest Pain
SOB
Haemoptysis

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25
What are examples of risk factors for a PE?
Recent travel ( long haul ) Recent surgery Lower limb fracture Late pregnancy Previous DVT / VTE
26
What is an unprovoked PE?
A PE without clear cause/ risk factors
27
What is the management for a PE?
ABCDE Oxygen if hypoxic Analgesia Subcutaneous LMWH whilst awaiting CTPA DOAC for 3 months if provoked PE DOAC for 6 months is unprovoked PE LMWH ( Dalteparin ) if poor renal function ( eGFR < 15 )
28
What is the management for a massive PE?
Thrombolysis with IV Alteplase
29
What is a CTPA?
CT Pulmonary Angiogram Tool used to detect blood clots in lungs using contrast
30
What determines if a PE is massive?
Hypotension/ Imminent cardiac arrest Signs of right heart strain on CT/ECHO
31
What are the absolute contraindications for Thrombolysis?
Stroke in last 6 months CNS neoplasia Recent trauma/surgery GI bleed in last month Bleeding disorder Aortic DIssesction
32
What are the only indications for high flow oxygen as apposed to controlled oxygen?
Cardiorespiratory Arrest Peri-Arrest Anaphylaxis Sats < 85% on air Carbon Monoxide poisoning
33
What is asthma?
Chronic inflammatory disease of the airways Reversible obstruction - sprirometry demonstrates
34
What are some symptoms of asthma?
Wheeze SOB Chest pain
35
What is the treatment for Acute Asthma Attack?
ABCDE -Controlled O2- aim for SpO2 94-98%, if <92% do an ABG to see if in Respiratory Failure -2.5mg NEB Salbutamol ( repeat after 15 mins ) -40mg PO Prednisolone STAT
36
What is the treatment for severe asthma attack?
ABCDE -Controlled O2- aim for SpO2 94-98%, if <92% do an ABG to see if in Respiratory Failure -2.5mg NEB Salbutamol ( consider back to back) -40mg Oral Prednisolone STAT -NEB Ipratropium Bromide 500mg !!!
37
What is the management for life-threatening asthma?
ABCDE -Controlled O2 , aim for SpO2 94-98%, if <92% do an ABG to see if in Respiratory Failure -Urgent ITU or anaesthetist assessment -Urgent portable CXR -40mg Prednisolone STAT -NEB Ipratropium Bromide 500mg -Back to back Salbutamol ( Consider I.V if ineffective) -IV Aminophylline ( should only be administered after consulting senior)
38
What do you give in an acute asthma attack if Prednisolone PO is not available?
IV Hydrocortisone
39
What is the safe asthma discharge criteria ?
PEFR > 75% Stop NEBs 24 hours prior to discharge Asthma nurse review of inhaler technique PEFR reading and written action plan GP follow up within 2 days Resp Clinic follow up within 4 weeks
40
What do eosinophilic presentations respond well to?
Steroids
41
What can Eosinophilia be caused by?
Asthma COPD Hayfever Parasites Eosinophilic Pneumonia Lymphoma SLE Multiple courses of antibiotics for infection Eosinophilic Granulomatosis with Polyangiitis Hypereosinophilic Syndrome
42
What are the causes of COPD?
Smoking a1-antitrypsin deficiency Industrial exposure
43
What is emphysema?
Alveolar wall destruction causing irreversible collapsing, stretching or overinflation of the alveolar air spaces. Can cause air to get trapped in lung parenchyma ( Obstructive )
44
What is the outpatient COPD management?
COPD Care Bundle ( Prednisolone and Amoxicillin) Smoking cessation Pulmonary Rehabilitation Bronchodilators Antimuscarinics Mucolytics
45
What is Long Term Oxygen Therapy and who is it indicated in?
LTOT can be used for up to 16 hours a day for survival benefit Offered if pO2 is consistently below 7.3kPa Patients must be non smokers and not retain high levels of CO2
46
What is Pulmonary Rehabilitation?
An MDT 6-12 week programme of supervised exercise , unsupervised home exercise, nutritional advice and disease education
47
What are the common organisms for community acquired pneumonia?
Streptococcus Pneumoniae Haemophilus Influenzae Moraxella Cartarrhalis
48
What are the atypical organisms for community acquired pneumonia?
Legionella Pneumophila Chlamydia Pneumoniae Mycoplasma Pneumoniae
49
What are the typical organisms for hospital acquired pneumonia?
E.Coli MRSA Pseudomonas Aeruginosa
50
What is the investigation for pneumonia?
CXR - will see consolidation
51
What is the management for pneumonia?
ABCDE Controlled O2 aim for 94-98% CURB-65 score to indicate mortality and need for admission If CURB-65 = 0-1 , can prescribe oral antibiotics and discharge If CURB-65 = 2 , hospital admission , I.V antibiotics, sputum sample, bloods If CURB-65 = 3-5 , consider ITU admission IV Antibiotics, IV Fluids, bloods and Atypical Pneumonia Screen ABG if low sats (<92%)
52
What is Legionnaire's Disease?
A form of Pneumonia caused by Legionella Pneumophila Associated with infected water ( showers/ hot tubs) and air conditioning Presents with hyponatraemia
53
How is Legionnaire's Disease detected?
Urinary Antigen Test
54
How does LD present on CXR
Bilateral mid-lower zone patchy consolidation
55
What is the Pneumonia follow up procedure?
HIV Test Immunoglobulins Pneumococcal IgG Serotypes Haemophilus Influenzae Type B IgG
56
What are the causes of a non-resolving Pneumonia? (CHAOS)
Complication - Empyema, Abscess Host- Immunocompromised Antibiotic - inadequate dose, poor oral absorption Organism - Resistant to empirical antibiotics Second Diagnosis- PE, cancer
57
What are the empirical antibiotics for Pneumonia?
Amoxicillin Amoxicillin + Doxycycline Co-Amoxiclav + Doxycycline
58
What is SARS-CoV-2
Severe Acute Respiratory Syndrome COVID (name of virus ) Can cause viral pneumonia Patients requiring hospital admission will have hypoxia , lymphopaenia, eosinopaenia, bilateral lower-zone changes on CXR
59
What is the management for severe COVID?
High flow O2 / CPAP / Invasive ventilation Dexamethasone Anticoagulation with subcut Heparin
60
What is the common symptoms of TB?
Night Sweats Weight Loss Malaise If Respiratory - Cough, Haemoptysis If Non Resp - Erythema Nodosum , Lymphadenopathy, CNS TB ( Meningitis )
61
What are the risk factors for TB?
Past history of TB Recent Positive Contact Born in a TB incidence country Recent Foreign Travel Immunosupression
62
What is the management for TB
ABCDE Admit to negative pressure side room Take 3x Sputum Samples for Acid-Fast Stain ( Ziehl-Neelsen Stain ) and TB Culture ( Takes 6-8 weeks ) Routine bloods - FBC , LFTS, U&Es Vit D Blood Test (causes hypocalcaemia) HIV Test CXR - if not typical do CT chest If high likelihood of TB do PCR then start RIPE Therapy
63
What are the principles of RIPE therapy?
All 4 medications for 2 months then first two for 4 more months Dose is weight dependent Check LFTs and visual acuity before commencing Directly Observed Therapy may be used to ensure compliance R- Rifampicin I - Isoniazid P - Pyrazinamide E - Ethambutol Must also give Pyridoxine supplementation with Isoniazid to prevent peripheral neuropathy
64
What are some side effects of each medication in RIPE?
R - Orange secretions, Hepatitis I - Peripheral Neuropathy, Hepatitis P - Arthralgia , Hepatitis E - Retrobulbar neuritis
65
What drug is given with Isoniazid and why?
Pyridoxine To prevent peripheral neuropathy
66
What is Bronchiectasis?
Chronic dilation of one or more bronchi, leading to a build-up of excess mucus that can make the lungs more vulnerable to infection and causes air to get trapped in lungs ( Obstructive) Poor mucus clearance Recurrent Bacterial Infection
67
What is the gold standard diagnostic tool for Bronchiectasis?
High Resolution CT Will see the Signet Ring Sign where the bronchi is larger than the accompanying blood vessel due to dilation Will also see tram-track opacities
68
What are the post infective causes of Bronchiectasis?
Pertussis , TB
69
What are the genetic causes of Bronchiectasis?
Kartegener Syndrome Cystic Fibrosis Young's Syndrome Primary CIliary Dyskinesia
70
What is Kartegener Syndrome?
Triad - Bronchiectasis - Sinusitis - Situs Inversus
71
What is Young's Syndrome?
Triad - Bronchiectasis - Sinusitis - Reduced Fertility
72
What are some obstructive causes of Bronchiectasis?
Foreign Body Tumour
73
What are some secondary immune causes of Bronchiectasis?
HIV Malignancy RA
74
What are some other causes of Bronchiectasis?
Gastric aspiration Inhalation of toxic chemicals
75
What is the management of Bronchiectasis
Treat underlying cause Physiotherapy ( Mucus Clearance ) If infective exacerbation give 10-14 days of appropriate antibiotics
76
What antibiotic do you give for Haemophilus Influenzae infective exacerbation of Bronchiectasis?
Amoxicillin 10-14 days
77
What antibiotic do you give for Pseudomonas infective exacerbation of Bronchiectasis?
Ciprofloxacin
78
What is Allergic Bromnchopulmonary Aspergillosis?
Caused by exposure to Aspergillus fungus It is a combo of Type 1 and Type 3 hypersensitivity reactions leading to repeated damage
79
How is Allergic Bromnchopulmonary Aspergillosis confiremed ?
Bloods - Raised Aspergillus IgE and Raised Total IgE , Eosinophilia
80
How is Allergic Bromnchopulmonary Aspergillosis treated ?
Steroids
81
What kind of inheritance is Cystic Fibrosis?
Autosomal recessive
82
What is the mechanism behind Cystic Fibrosis pathology?
There are mutations in the gene that codes for the CTFR protein. Less chloride ions are secreted extracellularly, therefore more sodium ions are transported into cells to maintain electroneutrality. This means that more water is reabsorbed into cells as water follows sodium. This results in thicker secretions.
83
How do you diagnose CF?
One or more characteristic phenotypic features or : -History of CF in sibling -Positive Newborn Screening Test AND -Positive Sweat Test -or two mutations on genotyping -or abnormal nasal epithelial ion transport
84
What are the 4 classic presentations of CF?
1) Meconium Ileus ( no first excretion due to bowel blockage) 2) Intestinal Malabsorbtion ( Usually due to lack of pancreatic enzymes) 3) Recurrent Chest Infections 4) Newborn Screen
85
What are some symptoms/signs of CF?
Nasal Polyps High Salt content sweat Recurrent LRTI Pancreatic Insufficiency Portal Hypertension Steatorrhea Male Infertility
86
What are some complication of CF?
Respiratory Infections Low body Weight ( due to malabsorbtion ) Distal Intestinal Obstruction Syndrome (DIOS) Diabetes
87
What is DIOS and how is it treated ?
Due to thick, dehydrated faeces caused by pancreatic insufficiency. Treated with Gastrografin - draws water across bowel wall to rehydrate faeces
88
What is the lifestyle advice for CF Patients?
No smoking Avoid other CF Patients Avoid people with infections Avoid jacuzzis ( Pseudomonas ) Avoid stables and compost ( Aspergillus ) Annual flu vaccine Na/CL Replacement after exercise/ hot weather
89
What is the management for CF?
Airway Clearance Physiotherapy Mucolytics Pancreatic Hormone Replacement Vit ADEK Replacement Long term antibiotics ( can be NEBs ) Long term monitoring
90
What are the 6 types of pleural disease?
Pneumothorax ( air in cavity ) Empyema ( pus in cavity ) Pleural Effusion ( fluid in cavity ) Pleural Tumour ( benign or malignant ) Pleural Plaque ( fibrous area ) Pleural Thickening ( scarring/calcification -> thickening)
91
What are the types of Pneumothorax?
Spontaneous Traumatic Secondary Tension Iatrogenic ( central line / pacemaker usually )
92
What is the treatment for a Spontaneous Pneumothorax that is < 2cm ?
Discharge ( self resolving ) Follow up CXR in 2 weeks
93
What is the treatment for a Spontaneous Pneumothorax that is > 2cm ?
Aspiration with large bore needle (16G/18G)
94
What is the treatment for a Secondary Pneumothorax that is < 2cm ?
1-2cm - Aspiration with large bore needle to reduce to 1cm and admit and observe <1cm - High flow O2 and admit, observe for 24 hours
95
What is the treatment for a Secondary Pneumothorax that is > 2cm or patient is breathless ?
Chest drain insertion
96
What is the treatment for a Tension Pneumothorax ?
Immediate Needle Decompression then Chest Drain
97
What are the borders of the safety triangle for chest drain insertion?
Top - Base of axilla Lateral - Anterior Latimus Dorsi Medial - Lateral Pectoralis Major in the 5th ICS
98
What is the position for Emergency Needle Decompression?
2nd ICS , mid-clavicular line Should hear a hiss , leave device in whilst setting up chest drain
99
What are risk factors for a Spontaneous Pneumothroax?
Taller Smoking Cannabis Diving Trauma Marfan's Syndrome
100
How do you manage a suspected Pleural Effusion?
USS guided pleural aspiration -Biochemistry -Cytology -Microbiology Then only chest drain once diagnosis is well established following investigation
101
What is the only indication for an urgent chest drain for suspected effusion?
If there is an underlying empyema ( pH of pleural fluid will be <7.2 or visible pus on aspiration )
102
How do you know a fluid is transudate?
Pleural protein < 30g/L
103
What are the causes of a transudate effusion?
Heart Failure Cirrhosis Hypoalbuminaemia Hypothyroidism Mitral Stenosis Pulmonary Embolism Constrictive Pericarditis
104
What is Light's Criteria?
Used if fluid aspirate protein level is borderline ( i.e between 25g/L to 35g/L ) Pleural Fluid : Serum Protein < 0.5 Pleural Fluid : Serum LDH > 0.6
105
What are the causes of exudate effusions ?
Malignancy Infections Inflammatory ( RA, Dressler's, Pancreatitis ) Fungal Infections
106
What are the types of interstitial lung diseases?
Idiopathic Pulmonary Fibrosis Non-Specific Interstitial Pneumonia Extrinsic Allergic Alveolitis Sarcoidosis
107
What type of pneumoconiosis can dust cause?
Silicosis
108
What type of pneumoconiosis can asbestos cause?
Asbestosis
109
What can an occupational history of working with coal cause?
Pneumoconiosis ( Miner's Lung )
110
What investigations should be done for new ILDs?
ANA ( SLE / Autoimmune ) ENA ( SLE, Autoimmune ) Rheumatoid Factor ( RA) ANCA (granulomatosis with polyangiitis, eosinophilic granulomatosis with polyangiitis, microscopic polyangiitis) Anti-GBM ( Goodpasture's ) ACE ( Sarcoidosis ) IgG Hypersensitivity Pneumonitis HIV Test
111
What are the signs of Pulmonary Fibrosis ?
Clubbing Reduced Chest Expansion Fine Inspiratory Crackles
112
What is Extrinsic Allergic Alveolitis caused by?
Inhalation of antigen to which a person has been sensitised to Can be acute ( 4-8 hours after exposure ) Can be chronic ( months to years , less reversible )
113
What drugs commonly cause Extrinsic Allergic Alveolitis?
Amiodarone Bleomycin Methotrexate Nitrofurantoin Penicillamine
114
What is the histology of Sarcoidosis?
Non-caseating granulomas
115
What is the prognosis of Sarcoidosis?
50% - Remission 50% - Progressive Disease
116
What Investigations would you do for suspected Sarcoidosis?
Bloods - RFTs, ACE, Calcium, LFTS CXR Urinary Calcium CXR Cardio - ECG , ECHO , Cardiac MRI Transbronchial biposy of lung to confirm
117
What is a good indicator of Sarcoidosis on bloods?
ACE level
118
What is the management principles of ILD ?
Remove stimuli Stop smoking Anti-fibrotics ( Pirfenidone , Nintedanib ) slow progression Transplantation
119
What are the presentations of Lung Cancer?
Asymptomatic Resp Symptoms Horner's Syndrome Metastatic Disease Paraneoplastic symptoms
120
What are the risk factors for Lung Cancer?
Smoking Older Familyx Exposure to other carcinogens
121
What is the way to access a patient's fitness level?
WHO Scale 0- Normal 1- Restricted Strenuous Activity 2- Able to care for self but can't physically exert themselves , confined to bed or chair < 50% 3- Limited self care , confined to bed or chair > 50% 4- Completely disabled 5- Dead
122
What are the investigations to diagnose Lung Cancer?
Bloods ( FBC, U&E, Ca, LFTs, INR ) CXR Staging CT Some sort of biopsy PET scan ( can see metastases )
123
What are the classifications of Lung Cancers?
Small Cell Non Small Cell ( Large Cell, Sqaumous Cell, Adenocarcinoma, Bronchoalveolar Cancer )
124
What is the treatment for Stage 1 and 2 LC ?
Curative surgery
125
What is the treatment for Stage 3a LC ?
Surgery and adjuvant Chemotherapy
126
What is the treatment for Stage 3b/4 LC ?
Chemotherapy or Palliative
127
What should be used if patient is not suitable for Surgery/ Palliative ?
Radiotherapy
128
Why is SCLC not usually suitable to be treated with surgery?
Rapid growth rate Almost always too extensive to resect at time of presentation Chemotherapy is mainstay of treatment Even with treatment survival rate is still small
129
What is Obstructive Sleep Apnoea?
Upper Airway Restriction during sleep, leading to daytime sleepiness
130
What are the risk factors for OSA?
Male Obese Muscle Relaxants ( Alcohol , Sedatives ) Neuromuscular Disease
131
What are the possible causes of small Phayngeal outlet ?
Fatty Infiltration or increased pressure from neck fat Large tonsils Undersized mandible
132
How is sleepiness measured ?
Epworth Sleepiness Scale Likelihood of falling asleep during certain activities >9 indicates high clinical suspicion of OSA
133
How is OSA diagnosed?
Sleep Study Overnight oximetry Limited Sleep Study ( oximetry, body movement, HR, oronasal flow ) Full polysomnography ( LSS + EEG and EMG )
134
What is the management for OSA?
Weight Loss Reduce Alcohol Nasal CPAP Inform DVLA If severe CO2 retention may require NIV prior to CPAP
135
What is CPAP?
Supplies constant positive pressure during inspiration and expiration , not ventilation aid Aids oxygenation
136
What is BiPAP ( NIV )
A form of ventilation Provides pressure at two levels to aid both inspiration and expiration
137
What do you give for an acute severe asthma attack if the person is not responding to initial treatment?
Give IV Aminophylline ( if already on oral don’t give loading dose ) OR IV Salbutamol OR IV Magnesium Sulphate
138
Why is a low CO2 a VERY bad clinical sign in an acute asthma attack?
CO2 should be high due to hyperventilation. After a while the respiratory muscles fail , it means the body can no longer compensate and the CO2 drops. This is NEAR FATAL asthma
139
How do you distinguish between a Massive Pneumothorax and a Tension Pneumothorax ?
A tension pneumothorax will have haemodynamic instability Tension has tracheal shift
140
What is the management for an infective COPD exacerbation ( -> Sepsis ) ?
Controlled O2 ( nasal cannula up to 15L ) -> give CPAP ( only if in Type 1 Respiratory Failure) -> then give BiPAP ( Type 2 Respiratory Failure) -> intubation NEBS Salbutamol and Ipratropium Bromide Prednisolone 40mg Empirical Antibiotics ( Amoxicillin ) Then no improvement give IV Aminophylline
141
What is Lambert-Eaton Syndrome?
Happens most often in people with small cell lung cancer. Person’s immune system attacks the connections between nerves and muscles. More commonly causes weakness in proximal limbs, usually proximal legs.
142
What is the progression of treatment in COPD?
SABA e.g Albuterol SABA + ICS e.g Beclometasone SABA + Fostair ( ICS + LABA e.g Salmeterol) SABA + Trimbow ( ICS + LABA + LAMA e.g Tiotropium Bromide )
143
What is an example for each COPD/ Asthma drug type?
SABA - Salbutamol ICS - Beclomethasone LABA - Salmeterol LAMA - Tiotropium Bromide
144
What are the requirements for COPD patients to start Long Term Oxygen Therapy?
Patients must have quit smoking Had two consecutive ABGs of O2 < 7.3kPa
145
What must patients who have had a pneumothorax avoid?
Deep sea diving
146
How can nasogastric tube placement be confirmed as correct on aspirate?
A pH of < 5.5
147
When testing asthma on spirometry, what percentage increase after salbutamol use indicates the patient has asthma?
12% or more
148
How does Amiodarone affect the lungs ?
Lower zone fibrosis Patchy ground glass opacities
149
What should be done if a needle aspiration of a pneumothorax fails?
Chest drain insertion
150
What are indications of something being small cell lung carcinoma?
Persistent cough Night sweats Haemoptysis Dyspnoea Chest pain Weight gain ( Cushing's) Smoking Hx Weight loss ( systemic cancer ) Arises from endocrine cells, so these tumours secrete many polypeptides, mainly adenocorticotrophic hormone (ACTH) Cushing syndrome Spread very early – almost always inoperable at presentation
151
What type of NIV do you use in Type 1 Resp Failure?
CPAP
152
What type of NIV do you use in Type 2 Resp Failure?
BiPAP
153
Why does hypotension happen in Tension Pneumothorax?
Cardiac outflow obstruction
154
What would prompt you to admit a patient with a moderate acute asthma?
The presence of a previous near-fatal attack
155
How does Alpha-1 Antitrypin deficiency cause liver problems?
The accumulation of misfolded AAT protein within the liver can cause hepatocyte damage and death, leading to an increase in serum ALT levels as this enzyme leaks out from damaged cells. Also causes raised Gamma GT
156
What follow up should all cases of pneumonia have following discharge?
CXR 6 weeks after resolution
157
Which organism is associated with Pneumonia in alcoholics?
Klebsiella Pneumoniae
158
What system pathologies are associated with OSA?
Cardiac complications
159
What is the cause of pulmonary oedema in Heart Failure?
LV dysfunction leads to blood backing up into the left atrium, the pulmonary vein and the capilleries in the lungs. This causes increased hydrostatic pressure in the capilleries, which is higher than the opposing oncotic pressure, so fluid moves out of the capillary into the interstitium
160
Which type of lung cancer is more likely if there is a lack of smoking history?
Adenocarcinoma
161
What is the initial recommended anticoagulation recommended in a PE?
DOAC ( Rivaroxaban, Apixaban , Dabigatran ) In an in patient/ emergency situation then LMWH as it is quicker acting If they have renal impairment then LMWH A provoked PE (identifiable risk factors, such as surgery or peripartum) should be treated for 3 months An unprovoked PE should be treated for 6 months
162
What is the treatment of a Massive PE ( Causing severe haemodynamic instability )
Thrombolysis (an IV bolus of Alteplase®) Embolectomy – may be considered in patients with a massive PE when thrombolysis is contraindicated
163
What is the cause of consolidation on CXR seen in pneumonia?
Inflammatory reaction Consolidation refers to lung tissue that has filled with liquid. This would occur due to an inflammatory response, which has been triggered by the presence of bacteria or viruses, which could have caused damage to the alveoli or other lung tissue
164
What is the treatment for Pleural Effusion?
Appropriate oxygen therapy Attempts to reduce respiratory distress medically (eg. diuretics for heart failure or antibiotics for chest infections) If still symptomatic after medical management then: Thoracocentesis and therapeutic aspiration of the effusion
165
What is the advice given with a COPD rescue pack?
Prednisolone - take if breathlessness is not relived by inhaler Antibiotics - take if sputum changes colour or increases in volume
166
What are the causes of ARDS?
Pneumonia Sepsis Aspiration Pancreatitis Transfusion reactions Trauma and fractures Fat embolism
167
What is ARDS?
ARDS is an acute form of respiratory failure occurring within 7 days of the onset of a lung injury. It involves a diffuse bilateral alveolar injury, as a result of inflammation
168
What are the rules about oxygen for critically unwell COPD patients?
Should initially aim for 94-98% with high flow O2 ( 15L/min via a Non-Rebreather mask) Do ABG , if they are a CO2 retainer ( T2RF) then should switch to controlled oxygen a 4L/min via Venturi mask, target oxygen saturations 88-92% Hypoxia kills quicker than respiratory depression
169
What are the rules regarding discharge of anacute asthma exacerbation
For a patient to be discharged from hospital following an asthma attack they must be stable on their regular asthma regime for 24 hours
170
What is a useful mnemonic for remembering which conditions cause fibrosis in the upper and lower zones?
"CHART" (Upper Lobe) + "RAIDS" (Lower Lobe) Coal worker's pneumoconiosis Histiocytosis Ankylosing Spondylitis / Allergic Extrinsic Alveolitis Radiation Tuberculosis Sarcoidosis Rheumatoid Arthritis Aspiration, alpha-1 antitrypsin deficiency, asbestosis Idiopathic Pulmonary Fibrosis Drugs (e.g. busulfan, bleomycin lung toxicity, nitrofurantoin, hydralazine, methotrexate, amiodarone)
171
Which type of lung cancer is associated with ectopic production of parathyroid hormone related protein (PTHrP) which causes hypercalcaemia?
Squamous Cell Carcinoma
172
What is the treatment for a non massive PE?
DOAC ( If renal function intact) In the inpatient/emergency setting, low molecular weight heparin is usually started instead as it is shorter acting
173
What is Light's Criteria?
An effusion is an exudate if: The pleural fluid to serum protein ratio is >0.5 The pleural fluid to serum LDH ratio is >0.6; or The pleural fluid LDH is >2/3 the upper reference limit for serum LDH
174
When would you consider prophylactic antibiotics for
Guidelines from the British Thoracic Society (BTS) suggest that if a patient is experiencing 3 or more exacerbations per year and they are already on optimal medical management (including mucolytic treatment, in the form of saline nebulisers here) then they are a candidate for long term prophylactic antibiotics
175
What is the escalation of long term asthma drugs?
SABA ( Salbutamol ) prn Add lose dose ICS ( Beclomethasone or Budesonide) Add Leukotriene Receptor Antagonist ( Montelukast ) ,LABA ( Salmeterol ) or Leukotriene Receptor Antagonist ( Montelukast ) or PO Theophylline Increase dose of ICS Add daily steroid tablet ( PO Prednisolone ) + referral to specialist
176
What is the definitive for diagnosis of Sarcoidosis?
Bronchoscopy with a transbronchial lung biopsy - you will see non-caseating granulomas ACE is raised in about 50% of patients
177
What type of hypersensitivity reaction in Asthma?
Type 1 hypersensitivity - mediated by IgE antibodies
178
How do you differentiate between Sarcoidosis and TB on CXR?
Sarcoidosis - bilateral hilar lymphadenopathy TB - unilateral hilar lymohanedopathy
179
What is the first line treatment for Bronchiectasis?
Chest physiotherapy, inhaled bronchodilators, and antibiotics as indicated Mucolytics
180
What is the safe discharge criteria for asthma? LEARN
Stopped regular nebulisers for 24 hours prior to discharge PEFR > 75% Inpatient Asthma Nurse review Assessment of Inhaler technique + adherence Medication Assessment Written Asthma action plan for how to manage care and future attacks
181
When do you prescribe ICS for COPD?
2nd line if there as asthma features present ( Eosinophilia, Diurnal variation
182
Are the Pneumococcal or Influenza vaccine live?
No - safe for use with DMARDs
183
What is the first line investigation for Lung Cancer?
CXR within 2 weeks
184
What colour sputum does a Streptococcus Pneumoniae infection present with typically?
Rusty-coloured
185
What treatment reduces mortality rate in ARDS?
low tidal volume mechanical ventilation
186
What happens to the CO2 levels in asthma?
Initially low due to hyperventilation, as patient tires they become normocapnic ( Life-threatening) and then hypercapnic ( Near-fatal)
187
What would be obscured by consolidation in an Upper, Middle and Lower lobe Right sided pneumonia on CXR?
Upper - Apex Middle - Cardiac border Lower - Costophrenic angle
188
Where does lung cancer tend to metastasise to?
Brain Breast Adrenals Bone
189
What may be heard on auscultation with bronchiectasis?
Coarse inspiratory crackles
190
What drugs can worsen Asthma?
B-Blockers NSAIDs Aspirin
191
What is the stages of giving drugs in COPD?
1st line - SABA or SAMA 2nd line - asthmatic features ( LABA + ICS ), if not LABA and LAMA 3rd line - LABA, LAMA and ICS
192
What is Extrinsic Allergic Alveolitis?
Inflammation of the alveoli, it is an early sign of interstitial lung disease Types -Idiopathic Pulmonary Fibrosis -Infections ( V/B Pneumonia) -Fungal infections ( aspergillosis, histiocytosis) -Environmental exposure ( Coal Worker's Lung, Silicosis, Asbestosis ) -Autoimmune (RA, SLE, Sarcoidosis) -Connective tissue ( Scleroderma )
193
What should be given first in an acute asthma attack NEBS or steroids?
NEBS
194
What should be given if a patient is unable to take Prednisolone ( severe - can't complete full sentences etc )
I.V Hydrocortisone
195
What are the associations of the lung cancers?
Small Cell Lung Cancer - Paraneoplastic syndromes (Lambert-Eaton, Ectopic ACTH , Addison's Disease, SIADH) Squamous Cell Carcinoma - PTHrP secretion Large Cell Carcinoma - b-HCG secretion Adenocarcinoma - Non-smokers
196
What may be heard on auscultation of Idiopathic Pulmonary Fibrosis?
Fine end-inspiratory crackles
197
What are the components of COPD?
Chronic Bronchitis ( increased mucus production Emphysema ( damage to alveoli leading to dilation, difficult exhalation as air gets trapped)
198
What are the indications for surgery in COPD? This is lung reduction surgery , indicated after LTOT fails
FEV1<50% predicted PaCO2 <7 Transfer capacity of the lung for carbon monoxide (TlCO) >20%
199
What are some signs of Mycoplasma Pneumoniae pneumonia?
Preceding flu-like illness Dry cough Erythema multiforme (target-shaped lesions) Anaemia
200
What is a positve FeNO test ( Asthma )
>40ppb
201
What type of bacteria are known to cause lung abcess?
Anaerobic
202
What are the stages of COPD?
Stage 1 (Mild) as his FEV1 is >80% of what is expected. Stage 2 (Moderate) is an FEV1 which is 50-79% of the predicted value. Stage 3 (Severe) is an FEV1 which is 30-49% of the predicted value. Stage 4 (Very severe) is an FEV1 <30% of the predicted value.

Medicine Block Year 3 (12 decks)

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