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1. Fellowship Written > Respiratory > Flashcards

Respiratory Flashcards

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1
Q

What are the biochemical features of exudate from effusion?

A

Purulent pleural fluid
* + gram stain / culture
* WCC > 50,000
* Pleural fluid glucose <3
* Pleural fluid pH <7.2
* Pleural fluid LDH >1000

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2
Q

What is the Lights criteria for exudate

A

Lights criteria (High protein and LDH = exudate), determines presence of exudate with protein and LDH levels
Pleural fluid protein to serum protein ratio >0.5
Pleural fluid LDH to serum LDH ratio >0.6
Pleural fluid level >2/3 of upper value for serum LDH

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3
Q

What are the US features of empyema?

A

Loculation
effusion
consolidation

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4
Q

What are the steps in management for empyema?

A
  • Supportive - Oxygen, analgesia, fluids
  • Medical - Iv abx eg tazocin or vanc if MRSA. 20fr chest drain
  • Surgical - fibrinolytics via chest drain, VATS (video assisted thorascopic surgery). open thoracotomy
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5
Q

Someone is failing BIPAP for severe COPD. What are the next steps in ED?

A
  1. Intubate
  2. hyperventilate to decrease Co2
  3. reduce Fi02
  4. IV abs
  5. IV fluid
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6
Q

What are the abnormalities?

Diagnosis?

A
  • Left hilar mass - rounded opacity left hilum and patchy consolidation around this area
  • Confluent consolidation RUL with air bronchograms
  • Consolidation right middle lobe oscuring right hear border

Diagnosis
Multi lobe pneumonia with likely malignancy left hilum

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7
Q

multi lobe pneumonia with following obs
What are the treatment steps and end points?

A
  1. titrate o2 to over 92
  2. IV fluid boluses aiming for HR under 100 and systolic BP over 100
  3. IV cef and azi
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8
Q

abnormalities?

Differentials?

Investigations and justification

A
  • RUL opacification
  • cavitating lesion with air fluid level
  • RUL collapse with trachel deviation
  • small left effusion

Differentials
Neoplastic - Primary lung or secondary mets
Lung abscess - bacterial infection. TB
Vasculitis eg Wegners

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9
Q

chemo for melanoma
two positve and two negative findings

What are the possible infective causes?

non infective

A

Positive
* bilateral symmetrical infiltrates
* alveolar infiltrates with round lesions

Negative
* no effusions
* no pneumorax
* normal heart size

Infective causes:
Mycoplasma pneumonia
influenza/covid
Aspergillosis
TB

Non Infective
Pulmonary haemorrhage
ARDS
Pulmonary oedema

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10
Q

SOB
what are the significant findings?

What are the possible infective causes?
Non infective

A

Positive
left upper zone cavitating lesion with air fluid level
Air bronchograms

Negative
no effusion
no pneumothorax

Infective
S.pneumonae
S.aureus
Klebsiella

Non infective
malignancy
infarct
Vasculitis
pulmonary haemorrhage

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11
Q

What are the eight steps in inserting IJ line

A
  • *Aseptic preparation
  • Head down
  • Local anaesthetic to site
  • Use of USS guided technique where possible
  • Insert needle to IJV
  • Pass wire
  • Dilate vein
  • Insert central line
  • Flush all lumens
  • Secure to skin*
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12
Q

when assessing a patient with CP what features are important in the history?

A
  1. communication - how do they communicate and express pain
  2. Diet - PEG or oral feed
  3. any CP co-morbidities eg seizures
  4. previous ICU admissions
  5. Previous intubations
  6. advanced health care directive
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13
Q

What are the differences between aspiration pneumonia and aspiration pneumonitis?

A
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14
Q

someone with CP and sats 88% with fi01 0.21 (normal air) - what methods are there for oxygenation

A

Non Invasive
Hudson - if for ward based therapies, non able to blow of Co2, less invasive

Invasive
high flow nsal probs. BIPAP/CPAP

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15
Q

what features of a history would suggest poor asthma control

A
  1. daytime symptoms twice a week
  2. reliever needed twice a week
  3. limitations on activities
  4. symptoms overnight
  5. 3 or more presentations in a month
  6. prior ICU admissions
  7. poor health/social literacy
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16
Q

what do you need to ensure to safely discharge asthma patient?

A
  1. ASTHMA PLAN
  2. scripts
  3. preventer
  4. GP FU
  5. understand when to return
  6. handout in appropriate language
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17
Q

What are the advantages and disadvantages on NIV in asthma

A

Advantages
* PEEP aids with WOB
* IPAP increases tidal volume
* prevents intubation
* shorter inspiratory times increase tidal volumes

Disadvantages
* may delay intubation
* wrong settings may increase WOB
* increased risk pneumothorax
* difficult to clear secretions

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18
Q

asthma

A
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19
Q

what are the contraindications for NIV in COPD

A
  1. decreased GCS
  2. patient refusal
  3. vomiting
  4. haemoptysis
  5. not intiating own breathing
  6. facial abnormalities
  7. lack of nursing staff to supervise
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20
Q

how may you alter NIV settings if no improvement after an hour and why?

A
  • Increase IPAP - increase TV and ventilation to remove CO2
  • increse Fio2 or PEEP increase oxygenation
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21
Q

abnormalities

A
  • Marked hyperinflation
  • Moderate/Large left sided pneumothorax
  • Mediastinal shift to the right – possible tension PTX
  • Bilateral widespread pulmonary infiltrates
  • Right midzone (basal segment of upper lobe) wedge shaped cavitating
    lesion/consolidation
  • Right apical focal consolidation
  • Interposed hepatic flexure under right hemidiaphragm (Chilaiditti
    syndrome)
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22
Q

what are the causes of massive haemoptysis?

A
  • bronchiectasis
  • tuberculosis
  • immune - good passtures
  • malignancy - lung/bronchial
  • AVM
  • lung abscess
  • necrotising bacterial infection
  • iatorgenic - post procedure
  • coagulopathy
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23
Q

what are the key interventions for massive haemoptysis?

A
  1. ABC
  2. fluid resus with fluid and blood
  3. massive transfusion protocol
  4. clear airway - may need intubation
  5. TXA
  6. reversal of anticoagulation
  7. urgent bronchoscopy
  8. NBM
  9. may need IR
  10. abx to cover infection
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24
Q
A
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25
26
main abnormality
solitary lesion left upper zone contains air/fluid **Cavitating lesion**
27
what are the top three causes of pneumomediastinum linked to vomiting
* oesophageal perforation * vasalva * asthma * chest trauma * ideopathic
28
what is the management of someone shocked with pneumomediastinum
* abx to cover GI source eg taz * fluid resus to 0.05ml/kg hr UO * cardiothoracic referral * analgesia
29
main pathology and why
large right pleural effusion Reasons: * homogenous opacification of right middle and lower lobe * loss of right hemidiaphragm * rim of opacity around rim consistent with fluid
30
what are the causes of large pleural effusions
* malignancy * parapneumonic effusion * PE * hydrothorax from massive PE
31
investigations and justification for large PE
32
what are the causes of a pleural exudate
infection eg pneumonia malignancy inflammatory eg RA PE asbestos related Pancreatitis
33
what are the indications for thoracocentesis of pleural effusion in ED?
1. respiratory compromise 2. haemodynamic instability 3. mediastinal shift 4. severe symptoms
34
what are the risk factors for re-expansion pulmonary oedema post thoracocentesis
under 30 pleursl effusion over 7 days over 3 litres aspirated suction used rapid drainage of over 1.5l/hr
35
6 radiological abnormalities
1. multiple opacities left lung 2. loss volume right hemithorax 3. right upper lobe consolidation 4. air bronchograms 5. pleural effusion right side 6. hilar mass
36
positive and negative findings
Positive right pneumothorax significant tension flattened right hemidiphragm small pleural effusion Negative trachea midline no lines no consolidation
37
what are the immediate management steps of tension pneumothorax
* immediate chest decompression via needle thoracostomy - finger thoracostomy * ensure improvement via clinical sgns * chest drain with underwater seal
38
complications of needle thoracostomy for pneumothorax
1. misplacement of ICC 2. solid organ injury 3. infection 4. haemorrhage 5. tube blockage/kinking
39
describe and interpret
left sided pneumothorax
40
what would point toward conservative management of pneumothrax
symptoms patient choice primary size
41
in pre hospital setting what are advantages and disadvantages of using US to diagnose pneumothorax
**Pros** * fast * no radiation * accurate with training **Cons** * need training * patient access may be difficult * subcut air may disrupt views
42
Write brief notes on the pros and cons of needle decompression vs finger thoracostomy
43
signs and symptoms of tension pneumothorax
hypotension tachycardia hypoxia tachypnoeia increased WOB SOB
44
what are the causes of a pneumthorax
* primary * secondary - asthma * trauma/rib fracture * inhalation/IVDU * collagen disease eg marfans
45
pneumothorax
46
for a cavitating lung lesion
47
what are the symptoms of pulmonary hypertension?
Dyspnoea Chest pain Syncope
48
what are the ED investigations for ?pulmonary hypertension
Echo - Dilated RV ECG - Right heart strain
49
1. **PAH** - idiopathic or drug use eg cocaine 2. **PVH **- systolic or diastolic dysfunction, MS, MR 3. **Chronic hypoxaemia -** COPD, ILD 4. **Thromboembolic **- PE 5.** Misc** - sarcoidosis, vasculitis, SLE
50
abnormalities
left midzone opacities right midzone opacificaiton kerly b lines small effusion
51
differentials and investigative finding
52
unwell post lung transplant key findings Differentials
* Bilateral areas of consolidation in RML, RLL & LLL * Multiple clips bilaterally consistent with double lung transplant * CTR within normal limits * (No Pneumothorax or pleural effusions) * (No free gas under diaphragm) Differentials Infection - Bacterial, viral or fungal acute rejection CCF PE
53
On physical examination he has multiple petechiae around his eyes, and an intermittent cough. He has mild indrawing of intercostal muscles and mild tracheal tug, but no stridor. Post FB inhalation -explain symptoms
* cough - trachobrochial irritaiton * petichae - raised venous pressure suggesting choking episode * tracheal tug - intrathoracic airway obstruction
54
post choking episode list significant findings Diagnosis
mediastinal shift to right on expiratory film increased lucency left lung on expiration hyper expansion left lung on exspiration Normal inspiratory film Diagnosis: Ingaled FB left main bronchus
55
management post choking episode and child becomes cyanosed and unresponsive
1. attempt bag valve ventilation with anaesthetic circuit 2. perform direct laryngoscopy with magills forceps to remove FB 3. Intubate if unable to remove - either ETT or LMA 4. needly cricothyroidotomy if unsuccessful and oxygen with occlusion of y connected 1 second on and 4 off
56
Good pastures - describe Xray
bilateral patchy infiltrates widespread Differentials Pulmonary haemorrhage CCF ARDS bilateral infection malignancy opportunistic infection eg PCP
57
Steps in intubation
* Fluid load – 0.9% saline 10ml/kg bolus, repeat to SBP >100mmHg * Augmented induction agent – ie ketamine IV at reduced dose ie 0.5-1mg/kg, rocuronium 1.2mg/kg * Co-administration of inotrope at induction – 1mcg/kg adrenaline with induction * Optimised pre-oxygenation with ongoing NRBM at 15lpm PLUS NP O2 at 15lpm * NP O2 at 15lpm throughout induction stage * Mitigate hypoxia/acidosis by bagging through induction with BVM O2 at 15lpm * Intubate at 30 degrees to minimise risk of hypoxia
58
59
what are the treatment options for asthma post burst and steroids?
* IV magnesium 2gm IV over 20 mins * Salbutamol IVI 250mcg bolus followed by an infusion 5 -10 mcg/kg/hour * BIPAP (IPAP 7 -15 cmH2O; EPAP 3 – 5 cm H2O) * Adrenaline 0.3mg IM or IV infusion * Aminophylline also acceptable if in discussion with ICU
60
how do you optimise asthma patient prior to intuabation
a) Keep upright until last moment b) Preoxygenate (BiPaP or 15L NRBM) c) High flow oxygen by nasal cannula (15L/min) d) Continuous salbutamol nebulisation 10 – 15 mg/hr e) Normal Saline 1L IV bolus
61
what are the steps for dealing with post intubation hypotension in asthmatic?
* Disconnect from ventilator & allow prolonged exhalation * IV fluid bolus 10 – 20 ml/kg * Rule out tension pneumothorax (clinical/ USS) or needle /finger thoracostomies * Vasopressors eg metaraminol 0.5-1mg bolus / adrenaline 10mcg IV bolus
62
treatment for severe asthma in kids
* Oxygen via mask to keep sats >92% * Salbutamol nebs 2.5 - 5mg continuous * Ipratropium 250mcg times 3 nebs in first hour * Steroid IV – methypred 1mg/kg or hydrocortisone 4mg/kg * Salbutamol IV – 5-10mcg/kg bolus then infusion * Also accept MgSO4 – 50mg/kg bolus then infusion * Also accept aminophylline – 10mg/kg loading dose
63
intubation drugs for asthma in kids
Ketamine 1-2mg/kg Sux 1-2mg/kg
64
what are the clinical manifestions of Wegners (granulomatosis with polyangitis)
* Renal failure * pulmonary haemorrhage * conjunctivits/episcleritis/scleritis * myalgia/arthralgia * pulmonary fibrosis, subglottic stenosis * myo/pericarditis
65
66
what is the bloods test for wegners
ANCA
67
what diseases can cause renal failure and pulmonary haemorrhage
wegeners malaria leptospirosis Influenza Dengue Hantavirus
68
What are some non infective causes of haemoptysis and haematuria
Goodpastures Churg strauss SLE HSP microscopic polyangitis IGA nephropathy Behcets
69
IV fluid bolus (N Saline 1-2L. Aim SBP 100 Central venous access and commence vasopressor if patient remains hypotensive (Noradrenaline infusion – Aim MAP 60-65) Organise bed side echo – look for elevated RV pressure and/or deviation of interventricular septum suggestion increased RV pressure Find further information of cerebral aneurysm – were there more thanone aneurysm/ what interventions done Discuss with cardiothoracic surgery regarding suitability for surgicalembolectomy (preferred treatment option) Discuss other treatment options with patient and family – thrombolysiswith tenecteplase (if RV pressure is high) / anticoagulation with heparin(if RV pressure normal) If patient arrests – thrombolysis
70
post PEA abnormalities
Sinus tachy RBBB RAD S1Q3T3 - RV strain St depression in V1 and V2 suggesting RV strain

1. Fellowship Written (30 decks)

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