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Flashcards in Respiratory conditions Deck (69)
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1
Q

Primary vs Secondary vs Tension pneumothorax

A

primary- occurs in pt w/o a known resp disease
secondary- occurs in pt w/ pre existing resp disease
tension- severe pneumothorax involving displacement of mediastinal structures and haemodynamic compromise

2
Q

primary pneumothorax risk factors

A

smoking
tall and thin
male
young

3
Q

secondary pneumothorax risk factors

A

pre existing lung disease eg COPD, lung cancer, CF, pneumonia, connective tissue disorders - Marfan’s, trauma, iatrogenic (subclavian central line insertion)

4
Q

pneumothroax presentation

A

Sudden
Dyspnoea
Pleuritic chest pain - ipsilateral
cough
tachypnoea
tachycardia

5
Q

pneumothorax signs

A

hyperresonance on percussion
reduced breath sounds
reduced lung expansion
reduced vocal resonance

6
Q

tension pneumothorax additional findings

A

tracheal deviation away from it
cyanosis
raised JVP

7
Q

Management of primary pneumothorax

A

if rim of air is small (<2cm) and pt isn’t short of breath, then consider discharge and review
If rim of air is >2cm or pt is SoB, attempt aspiration in the 2nd ICS in the MCL. If this fails insert a chest drain in triangle of safety- 5th ICS, mid axillary line, anterior axillary line. Needle’s inserted just above the rib to avoid the NV bundle.

8
Q

Management of secondary pneumothorax

A

If pt is >50, and rim of air is >2cm and or pt is SoB, then a chest drain should be inserted.
Attempt aspiration if rim of air is bwt 1-2cm. If aspiration fails, a chest drain should be inserted.
If pneumothorax is less than 1cm, give oxygen and admit for 24 hrs.

9
Q

Management of Tension pneumothorax

A

emergency decompression- insert large bore cannula into 2nd ICS along the midclavicular line (same spot as usual aspiration)
chest drain insertion immediately after emergency decompression.

10
Q

PE symptoms

A

Sharp chest pain (typically peluritic)
Dyspnoea
Haemoptysis
Sudden onset

if v large- dizziness/syncope

11
Q

PE investigations

A

If suspect PE, do 2 levels PE Wells Score:
Clinical signs and symptoms of DVT (leg swelling + pain w/ palpation of deep veins)- 3 points
alternative diagnosis is less liekly than PE - 3 points
heart rate > 100bpm - 1.5 points
immobilisation for over 3 days or surgery in last 4 weeks - 1.5 points
previous DVT/PE- 1.5 points
Haemoptysis - 1 point
Malignancy - 1point
PE likely = more than 4 points

12
Q

If PE is likely what do you do

A

CTPA immediately- give DOAC in meantime. IV contaast reveals thrombi

13
Q

If PE is unlikely what do you do

A

D dimer test- if positive arrange immediate CTPA, if negative consider alternative diagnosis

14
Q

Contraindications for CTPA- ie to do V/Q scan

A

renal impairment, contrast allergy, pregnancy

15
Q

ECG changes in PE

A

S1Q3T3- large S waves in lead 1, large Q wave in lead III and an inverted T wave in lead III

16
Q

ABG findings in PE

A

Low PaO2 and normal/low PaCO2 a massive PE may also cause metabolic acidosis

17
Q

PE management

A

DOAC first line- apixaban or rivaroxaban
If not sutiable then LMWH follwoed by dabigatran or edoxaban or LMWH followed by VKA ie warfarin

If renal impairment is severe then LMWH, unfractionated heparin or LMWH followed by a VKA.
If pt has antiphospholipid syndrome (specifically triple positive in the guidance) then LMWH followed by a VKA should be used.

If VTE was provoked- stop treatment after 3 months.
If VTE was unrpvoked then continue for up to 3 further months

ORBIT Score to assess risk of bleeding

PE w/ haemodynamic instability- Thrombolysis.

18
Q

Asthma symptoms

A

Wheeze (bilateral expiratory widespread)
Cough
Breathlessness
Dry cough often nocturnal
Symptoms often worse at night bcos less cortisol (which is immunosuppressive) at night

19
Q

Asthma signs on examination

A

Tachypnoea
Hyperinflated chest
Hyperresonance on percussion
decrease air entry (sign of severe illness: silent chest)
wheeze on auscultation

20
Q

Asthma diagnosis in patients 5-16 year old

A

Spirometry w/ bronchodilator reversibility test: FEV1:FVC <70% is obstructive. Asthma if there’s obstruction and >12% improvement in FEV1 w/ bronchodilator. Request fractional exhaled nitric oxide if there’s normal spirometry or obstructive spirometry w/ a negative bronchodilator reversibility test. FeNO >= 35 ppb is considered positive in children.

21
Q

Asthma diagnosis in over 17s

A

Ask if symptoms better away from work/holidays- refer for occupational asthma specialist if so.
All pts should have spirometry w/ bronchodilator reversibility test. Asthma if obstruction and >12% improvement in FEV1 and increase in volume of 200ml or more. All pts should have FeNO test- >40 ppb is positive in adults

22
Q

Asthma management

A
  1. SABA
  2. SABA and low dose ICS
  3. SABA + low dose ICS + LTRA
  4. SABA + low dose ICS + LABA (+LTRA)
  5. SABA + MART (combined ICS and LABA) (+LTRA)
  6. SABA + medium MART (+LTRA)
  7. SABA + high MART OR LAMA OR theophyline (+LTRA)
23
Q

Acute Asthma presentation

A

Worsening dyspnoea
Bilateral wheeze
Cough not responding to salbutamol
Possilbe chest tightness
maybe triggered by a resp tract infection
Use of accessory muscles

24
Q

moderate acute asthma features

A

PEFR 50-75% best or predicted
normal speech
RR <25/min
Pulse <110bpm

25
Q

Severe asthma features

A

one of these:
PEFR: 33-50% best or predicted
Can’t complete sentences
RR > 25/min
Pulse > 110bpm

26
Q

Life threatening asthma features

A

any of these:
PEFR <33% best or predicted
Oxygen sats <92%
normal pCO2 indicates exhaustion and should be classed as life threatening
Mnemonic CHEST:
C- cyanosis
H- hypotension
E- exhaustion, confusion or coma
S- silent chest (airways so tight there’s no air entry)
T- tachycardia (pulse >110)

27
Q

Acute Asthma management

A

O SHIT ME:
Oxygen- maintain sats 94-98%
S- Salbutamol
H- Hydrocortisone 100 mg IV or prednisolone 40mg daily which should be continued daily for at least 5 days from the attack
I- ipratropium bromide- SAMA
T- Theophylline. aminophylline infusion if deteriorating
M- Magnesium sulphate IV if severe/life threatening
E- escalate to ICU if severe/life threatening

28
Q

Pneumonia presentation

A

Fever
Dry/productive cough- pneumofococcal pneumonia is rust/red coloured
Dyspnoea
Pleuritic chest pain
Myalgia and arthralgia - esp in infections w/ legionella or mycoplasma

29
Q

Pneumonia signs

A

Reduced chest expansion
Dullness to percussion
Crepitations or bronchial breathing may be heard over the affected area
Focal coarse crackles
Increased vocal fremitus

30
Q

CXR protocol for pneumonia

A

Repeat at least weekly as an inpatient and then at 6 weeks follow up

31
Q

What determines pneumonia management?

A

CURB-65
Confusion- abbreviated mental test score <8/10
U- Urea > 7
R- resp rate >=30
B- BP:systolic <=90, diastolic <=60
A- age >65

0-1 points- treat as outpatient
2: secondary care/hospital admission
3: ICU

32
Q

Pneumonia treatment for 0-1 on CURB 65

A

Oral amoxicillin for 5 days. If allergy then use a tetracycline (eg doxycycline)/ macrolide (eg clarithromycin)- avoid this in congenital long QT syndrome

33
Q

Pneumonia treatment for 2 on CURB 65

A

Dual therapy for 7-10 days. Amoxicillin + macrolide (eg clarithromycin)

34
Q

Pneumonia treatment for 3-5 on CURB 65

A

Co-amoxiclav + macrolide for up to 21 days

35
Q

If pneumonia is severe and/or vomiting?

A

Use IV abx for 7 days

36
Q

CAP commonest causes

A

Streptococcus pneumoniae- commonest cause
Klebsiella pneumoniae- classically in alcoholics and diabetics
Legionella pneumophilia- associated w/ AC systems
Influenza A and B
Fungal causes- Pneumocystis jirovecii - in immunocompromised pts

37
Q

HAP commonest causes

A

HAP occurs over course of 48 hrs after admission.
Enterobacteria
Staph Aureus
Pseudomina Aureginosa
Legionella Pneumophila

38
Q

HAP treatment

A

within 5 days of admission: coamoxiclav or cephalosporin
over 5 days after admission: Tazocin or cephalosporin or quinolone eg levofloxacin

39
Q

Pneumonia discharge criteria

A

don’t discharge if 2 or more of the following:
Temp higher than 37.5
RR >24
HR > 100
SBP <90
Oxygen sats < 90
abnormal mental status
inability to eat w/o assitance

40
Q

TB presentation

A

Dyspnoea
Cough w/ or w/o haemoptysis
Constitutional symptoms: eg fever+chills, night sweats, fatigue, loss of appetite, weight loss, lymphadenopathy

41
Q

TB investigations

A

Sputum culture- gold standard
CXR

42
Q

What does CXR show for TB

A

Apical fibrosis, cavitation, paratracheal hilar lymphadenopathy

43
Q

TB management and side effects

A

RIPE for 4 months
Rifampicin- anorexia
Isoniazid- constipation
Pyrazinamide- sideroblastic anaemia
Ethambutol- optic neuritis
Continuation phase- next 4 months is Rifampicin and Isoniazid

44
Q

Latent TB- screening

A

Mantoux test- if positive skin will be sensitive to PPD tuberculin and a small hard red bump will develop at site of infection.
BCG vaccination- given to hgih risk infants

45
Q

Pleural effusion causes

A

Transudative (low protein)- heart failure, cirrhosis, nephrotic syndrome, hypothyroidism

Exudative (high protein)- infection, pneumonia, inflammation, infiltration-cancer, pancreatitis, drugs, autoimmune disease

46
Q

pleural effusion symptoms

A

asymptomatic
Dyspnoea
Cough
Pleuritic chest pain

47
Q

pleural effusion CXR findings

A

massive pleural effusion- trachea pushed AWAY from white out
Costophrenic blunting
Unilateral effusion is typically exudative whereas bilateral effusions are typically transudative
Pneumonectomy- Trachea pulled TOWARDS white out

48
Q

What is COPD

A

airway obstruction FEV1:FVC <0.7, little or no reversibility

49
Q

COPD risk factors

A

> 35
smoking history
alpha 1 antitrypsin deficiency- breaks down elastase, if elastase isn’t being broken down can dmg the connective tissue in the lungs causing COPD and liver cirrhosis

50
Q

COPD presentation

A

Chronic cough w/ or w/o sputum
Dyspnoea
Wheeze
can have weight loss, reduced exercise tolerance, ankle swelling, fatigue

51
Q

COPD signs

A

Use of accessory muscle of respiration
Hyperinflation (barrel chest)
Decreased expansion
Resonant/Hyperresonant percussion note
Decreased breath sounds
Cyanosis
Cor pulmonale (right side HF) pitting oedema, raised JVP
nicotine stains
bilateral wheeze

52
Q

COPD investigations

A

Spirometry- FEV1:FVC- <70%, no reversibility after bronchodilator

53
Q

COPD severity scale

A

FEV1:FVC <0.7
FEV1 >=80% - Stage 1 Mild
FEV1 50-79%- Stage 2 Moderate
FEV1 30-49% Stage 3- Severe
FEV1 <30% Stage 4- V severe

54
Q

COPD management

A

Smoking cessation- offer NRT< varenicicline or buporpoion as appropriate.
Vaccinations- influenza and pneumococcal
Physiotherapy/pulmonary rehab if indicated.
Treat comorbidities

  1. SABA or SAMA as required
    2 a) No asthma- SABA as required + LABA +LAMA
    b) Asthma- SABA/SAMA as required + LABA + ICS
  2. SABA as required + LABA + LAMA + ICS
55
Q

COPD Exarcebation symptoms

A

Preceding corzyal symptoms (cold)
Increased breathlessness, cough, sputum. Most common infective cause is haemophilus influenzae
Worsening ankle swelling

56
Q

COPD exacerbation management

A

Oxygen to give SaO2 not over 92%
Prednisolone 40 mg/day 7 days
Abx if sputum is purulent or patient has severe illness.
If after 1 hrs still have T2 RF w/ resp acidosis and initial treatment doesn’t correct- urgent ICU opinion. Non invasive ventilation
Many COPD pts have T2 resp failure and therefore admin of too much O2 may be detrimental

57
Q

Interstitial lung disease causes

A

Idiopathic pulmonary fibrosis, sarcoidosis, occupational- asbestos, environemtnal eg pigeons, immune- connective tissue disease. Drugs: Any! eg Methotrexate, Amiodarone, Bleomycin, Nitrofurantoin

58
Q

Interstital lung disease symptoms

A

Chronic Dyspnoea
Dyspnoea on exertion
Non productive paroxysmal cough
joint swelling/stiffness
smoker

59
Q

Interstitial lung disease on examination

A

Fine bi basal crepitations, end inspiratory
Clubbing

60
Q

interstitial lung disease investigations

A

CXR- usually at bottom lungs, subpleural, basal and at the end of the lung
High res CT scan- ground glass appearance- basal fibrosis and honeycombing
Lung function tests- in restrictive lung disease like fibrosis- the lungs shrink- so FVC goes down and FEV1 geos down too, but in proportion, so ratio is above 70% in restrictive lung disease

61
Q

Interstitial lung disease management

A

antifibrotics if idiopathic pulmonary fibrosis eg pirfenidone. pulmonary rehab to help symptoms.
if connective tissue disease is the cause- immunosuppression- steorids eg prednisolone

62
Q

sarcoidosis demographics

A

Afro Caribbeans
20-40 year olds

63
Q

sarcoidosis presentation

A

Fever
Erythema nodosum
Polyarthralgia
Bilateral hilar lymphadenopathy
Dry cough
Progressive dyspnoea- decreased exercise tolerance
Chest pain
Enlarged salivary glands

64
Q

sarcoidosis investigations

A

FBC- leukopenia/lymphopenia
raised inflammatory markers
ACE levels can be elevated
Lung function tests can be obstructive or restrictive
CXR- bilateral hilar lymphadenopaty
Gold standard- histology from a biopsy

65
Q

Sarcoidosis management

A

Treat w/ steroids if PUNCH:
P- parenchymal lung disease
Uveitis
Neurological involvement
Cardiac involvement
Hypercalcaemia (can cause renal dysfunction)
Treat w/ 0.5 mg per kg Prednisolone 2-4 weeks
Most pts get better even w/o treatment

66
Q

Bronchiectasis- symptoms

A

persistent cough
lots of purulent sputum
intermittent haemoptysis
Dyspnoea
Wheeze

67
Q

Bronchiectasis- signs

A

clubbing
coarse inspiratory crepitations
crackles and low pitch wheezing

68
Q

Bronchiectasis investigations

A

High res CT- Signet scan

69
Q

Bronchiectasis treatment

A

physiotherapy and airway clearance techniques
Smoking cessation
Pneumococcal and annual influenza vaccinations
treatment w/ short courses of Abx for exacerbations or chest infections