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Medicine (Year 5) > Respiratory (pneumonia, acute bronchitis, asthma) > Flashcards

Respiratory (pneumonia, acute bronchitis, asthma) Flashcards

1
Q

when to give oxygen

A

Always give oxygen to an acutely ill hypoxic patient, regardless of if they have COPD or not:

  • Any critically ill patient should initially have oxygen via a reservoir mask at 15L/min
  • Hypoxia is more dangerous than hypercapnic respiratory failure in acute scenarios
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2
Q

Oxygen saturation targets for acutely ill patients are

A

94-98%

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3
Q

Oxygen saturation targets for COPD

A

Patients with COPD and other risk factors for hypercapnia who develop critical illness should have the same initial target saturations as other critically ill patients pending the results of blood gas results after which these patients may need controlled oxygen therapy with target range 88–92% or supported ventilation if there is severe hypoxaemia and/or hypercapnia with respiratory acidosis.”

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4
Q

oxygen management in COPD

A

1st-line: prior to blood gas results: 28% Venturi mask at 4 L/min + aim for SpO2 88-92%

Once blood gas results are available:

  • If pH and PCO2 are normal on blood gas: aim for 94-98%
  • If pH is normal but pCO2 and bicarbonate raised: aim for 88-92%
    This is because if the pCO2 is raised, and so is the bicarbonate, it is likely that the patient has longstanding hypercapnia
  • If pH is 7.25-7.35 and pCO2 is raised: use non-invasive ventilation (NIV)
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5
Q

FEV1

A

The forced expiratory volume in one second (FEV1) is the volume of air exhaled in the first second of a forced expiration:

This is usually reduced in both obstructive and restrictive disease

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6
Q

FVC

A

The forced vital capacity (FVC) is the maximum amount of air forcibly exhaled after taking in the deepest breath possible:

This may be reduced in obstructive and restrictive disease

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7
Q

In obstructive disease, the FEV1/FVC ratio is generally

A

<0.7

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8
Q

In restrictive disease, the FEV1/FVC ratio may be

A

normal or raised (i.e. ≥0.7)

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9
Q

Example obstructive conditions may be:

A

Asthma
COPD
Bronchiectasis
Cystic fibrosis
Lung tumours

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10
Q

Example of restrictive conditions may be:

A

Pulmonary fibrosis
Asbestosis
Kyphosis/scoliosis
Neuromuscular disorders
Severe obesity

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11
Q

pneumonia classification

A
  • Community-acquired pneumonia (CAP): developed outside of hospital and most common
  • Hospital-acquired pneumonia (HAP): developed in hospital (>48 hours after hospital admission)
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12
Q

Community-Acquired Pneumonia

Typical bacteria:

A
  • Streptococcus pneumoniae – most common cause
  • Haemophilus influenzae
  • Staphylococcus aureus (following an influenza infection)
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13
Q

atypical bacteria

A
  • Mycoplasma pneumoniae
  • Legionella peumophila (air-conditionig, hotels, hyponatraemia)
  • Klebseilla pneumonia (alcoholics and diabetics, aspiration)
  • Chlamydia psottaci (parrots)

Fungal
* Pneumocystis jirovecii
* Usually clear chest and dry cough
* Desaturations with exertion may be seen

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14
Q

Hospital-Acquired Pneumonia
bacteria

A

Early-onset HAP (<5 days after hospital admission): Streptococcus pneumoniae

  • Late-onset HAP (>5 days after hospital admission): Methicillin-resistant Staphylococcus aureus or Pseudomonas aeruginosa
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15
Q

presentation of pneumonia

A
  • Cough with or without sputum
  • Dyspnoea
  • Chest pain which may be pleuritic
  • Fever
  • Tachycardia
  • Reduced oxygen saturations
  • Coarse crackles on auscultation
  • Reduced breath sounds on auscultation
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16
Q

presentation of atypical pneumonia : mycoplasma pneumoniae

A
  • Flu-like symptoms (fever/malaise/myalgia) precede a dry cough
  • There may be erythema multiforme or erythema nodosum
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17
Q

presentation of atypical pneumonia : legionella pneumoniae

A
  • Classically spread by air-conditioning systems and in-building water systems
  • Dry cough
  • Diarrhoea
  • Encephalopathy
  • Hyponatraemia
  • Reduced lymphocytes
  • Deranged LFTs
  • Elevated creatine kinase
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18
Q

presentation of atypical pneumonia : Klebsiella pneumoniae

A
  • More common in alcoholics and diabetics
  • May happen after aspiration
  • “Red-currant” sputum may be present
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19
Q

pneumoni assessment in primary care

A

CURB-65

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20
Q

CURB-65

A
  • Confusion
  • Urea
  • RR- >30
  • Blood pressure - systolic <90 mmHg, diastolic <60mmHg
  • Age - >65
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21
Q

CURB-65 intepretation

A
  • 0 (low risk, mortality <1%): consider treating the patient at home - amoxicillin or doxycyline (clarithromycin)
  • 1-2 (moderate risk, mortality 1-10%): consider hospital referral for assessment and treatment - amoxicillin + doxycycline (clarithromycin)
  • ≥3 (high risk, mortality >10%): admit to hospital immediately - co-amoxiclav or meropenem
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22
Q

pneumonia investigations

A
  • Chest x-ray
  • FBC- WCC
  • CRP
  • Blood cultures
  • sputum cultures and gram stain
  • Legionella urinary antigen
  • Pneumococcal urinary antigen
  • PCR
23
Q

follow up after pneumonia

A

CXR after 6 weeks

24
Q

complications of pneumonia

A

Complications

  • Pleural effusion
  • Sepsis
  • Empyema
  • Lung abscess
  • Pneumothorax
  • Acute kidney injury
  • Post-infective bronchiectasis
25
Q

Acute bronchitis

A

Acute bronchitis describes the inflammation of the bronchi, usually caused by a viral or bacterial infection.

26
Q

causes of acute bronchitis

A

Viral
* Rhinovirus
* Enterovirus
* Influenza
* Parainfluenza
* Adenovirus
* Respiratory syncytial virus

Bacterial
* Streptococcus pneumoniae
* Haemophilus influenzae
* Moraxella catarrhalis

27
Q

Acute bronchitis vs pneumonia.

A
  • May or may not have sputum/wheeze/breathlessness
  • Substernal/chest wall pain may be present during coughing
  • Patients generally appear mildly ill
  • A wheeze is often present
  • Crackles are unlikely but may be present and improve with coughing
  • There is often no shortness of breath
  • Although not routinely performed for bronchitis, chest X-rays are normal
28
Q

management of acute bronchitis

A

If stable: self-care advice + simple analgesia (paracetamol +/- NSAIDs)

Offer antibiotics immediately if:
* The patient is systemically very unwell
* They have comorbidities such as heart/lung/kidney/liver/neuromuscular disease, immunosuppression, or cystic fibrosis
* CRP >100mg/L (offer delayed prescription if 20-100mg/L)

29
Q

antibiotics for acute bronchitis

A

1st-line: doxycycline (vs amoxicillin in pneumonia) – contraindicated in children/pregnancy

Consider amoxicillin or if penicillin-allergic, clarithromycin or erythromycin if pregnant

30
Q

asthma risk factors

A
  • Family history
  • Family and/or personal history of atopy e.g. eczema/food allergy/hayfever
  • Male sex – for pre-pubertal asthma
  • Female sex – for the persistence of asthma from childhood to adulthood
  • Respiratory infections in infancy
  • Prematurity
  • Obesity
  • Occupational triggers (e.g. isocyanates)
31
Q

asthma presentation

A
  • Wheeze
  • Cough – usually dry
  • Shortness of breath
  • Chest tightness

The pattern of these symptoms can help make a diagnosis of asthma more likely compared to other conditions such as chronic obstructive pulmonary disease (COPD). Features suggesting asthma are:

  • Episodic symptoms – they are usually diurnal (worse at night/early morning)
  • Symptoms may be triggered by exercise/chest infections/cold air exposure/allergens e.g. pollen, animal dander
  • Symptoms may worsen with aspirin and beta-blockers.
  • Beta-blockers are contraindicated in asthma
  • An expiratory polyphonic (multiple pitches and tones) wheeze is heard throughout the chest on auscultation
  • There may be a family or personal history of other atopic conditions
32
Q

investigations for asthma : >17

A
  • spirometry with bronchodilator
  • FeNO
33
Q

spirometry for asthma

A
  • Reduced FEV1
  • Normal FVC
  • FEV1/FVC ratio: <0.7

Reversibility testing involves giving a bronchodilator and observing changes in spirometry findings:
* Adults: improvement in FEV1 of ≥12% and a volume of ≥200 ml is positive
* Children: improvement in FEV1 of ≥12% is positive

34
Q

Nitric oxide (NO) and asthma

A

is released by eosinophils during inflammatory reactions. In asthma, FeNO levels are raised:
* Adults: ≥40 ppb is raised
* Children: ≥35 ppb is raised

35
Q

investigations for asthma : : 5-16 years

A
  • Spirometry with BDR testing
  • Offer FeNO if spirometry is normal or spirometry shows an obstructive picture with a negative BDR test
36
Q

investigating asthma :<5

A

Diagnosis is made clinically

37
Q

management of asthma: >17 years old

A

First line:
- SABA e.g. salbutamol

Second line:
- SABA + low dose inhaled ICS e.g. beclometasone

Third line:
- SABA + low dose ICS + LTRA

Fourth line
- SABA + low-dose ICS + long-acting beta-agonist (LABA e.g. salmeterol) +/- LTRA (depending on response)

Fifth line
- ABA + maintenance and reliever therapy (MART) that includes a low-dose ICS +/- LTRA
- MART is a single inhaler containing ICS and LABA which can be used for relief of symptoms and maintenance therapy

Sixth line
- SABA + medium-dose MART +/- LTRA or SABA + moderate-dose ICS + LABA

Seventh line
SABA +/- LTRA and one of:
- Fixed high-dose ICS (i.e. not as a MART)
- Trial adding long-acting muscarinic receptor antagonist (LAMA) or theophylline
- Refer to specialist

38
Q

asthma patients 5-16 years

A

Management is very similar to adults:

  • 1st-line: SABA
  • 2nd-line: SABA + paediatric low-dose ICS
  • 3rd-line: SABA + paediatric low-dose ICS + LTRA
  • 4th-line: SABA + paediatric low-dose ICS + LABA (stop LTRA if it has not helped)
  • 5th-line: SABA + MART that includes paediatric low-dose ICS
  • 6th-line: SABA + paediatric moderate-dose ICS MART or SABA + moderate-dose ICS + LABA
  • 7th-line: SABA and one of:
  • High-dose paediatric ICS as fixed-dose or part of a MART
  • Trial adding theophylline
  • Refer to specialist
39
Q

all asthma patients should have an annual

A

influenza jab

40
Q

stepping down treatment of asthma

A

Consider stepping down asthma treatment every 3 months if the patient is stable and treatment is sufficient. This involves reducing the dose of ICS by 25-50% at a time.

41
Q

acute asthma exacerbation risk factors

A
  • Previous near-fatal asthma
  • Previous admission for asthma, particularly if in the last year
  • Frequent emergency attendance for asthma, particularly in the last year
  • Asthma requiring 3 or more medications to manage
  • Increasing use of beta2-agonists
  • Having brittle asthma – this is asthma that is difficult to control and may unpredictably lead to life-threatening attacks
  • NSAID sensitivity
  • Smoking or passive smoking
  • Exposure to triggers/allergens such as animal fur
  • Pregnancy
  • Inadequately treated disease
42
Q

classification of asthma exacerbation

A

Moderate asthma

  • Peak expiratory flow rate (PEFR): 50-75% best (or predicted if best unknown)
  • Respiratory rate <25 /min
  • Pulse <100 bpm

Severe asthma

  • PEFR 33-50% best (or predicted if unknown)
  • Respiratory rate >25 /min
  • Pulse >110 bpm

Life-threatening asthma

  • PEFR <33% best (or predicted if unknown)
  • Oxygen saturations <92%
  • Signs of exhaustion:
  • PaO2 <8kPa
  • Normal PaCO2
  • Cyanosis
  • Silent chest
  • Poor respiratory effort
  • Arrhythmia
  • Hypotension
  • Exhaustion
  • Altered consciousness

Near-fatal asthma

  • PaCO2 raised
43
Q

Investigations asthma exacerbation

A

In the community and hospital

  • Peak flow measurements – to help gauge severity
  • Pulse oximetry – to help gauge the severity

In hospital

  • Arterial blood gases – if patients show signs of life-threatening asthma
  • Consider a chest x-ray if there is suspicion of another condition such as pneumothorax
44
Q

management of acute asthma exacerbation

A

All patients

  1. 15L oxygen via non-rebreathe mask (aim for SpO2 94-98%) + short-acting beta2-agonists (SABA) + corticosteroids:
    * If patients have moderate/severe asthma, SABAs can be given through pressurised metered-dose inhalers (pMDI)
    * If patients have life-threatening/near-fatal asthma, nebulised SABAs are used
    * The corticosteroid should be continued for at least 5 days following the attack
  2. Nebulised ipratropium bromide:
    * If patients have not responded to SABA + corticosteroid treatment or have a severe/life-threatening attack
  3. IV magnesium sulfate
    * This is often given for severe/life-threatening asthma
  4. IV aminophylline – must be started under specialist guidance
  5. Escalate to intensive care and consider intubation and ventilation or extracorporeal membrane oxygenation (ECMO)
45
Q

Discharging asthma patients from hospital

A

Patients should only be discharged following treatment provided all of the following apply:

  • They have been stable on their medication they are to be discharged with
  • Their inhaler technique has been checked and recorded
  • They have been given a personal asthma action plan
  • Their PEFR is >75% of their best (or predicted if best unknown)
46
Q

Occupational asthma

A

should be suspected in all adults with new-onset asthma. This is a form of asthma caused by the workplace triggered by stimuli that may or may not be allergenic. It may be helpful to ask the following:

Are symptoms better on days away from work?
Are symptoms better on holiday?

47
Q

occupational asthma causes

A

Causes

  • Isocyanates (used in making foams/fibres/paints etc.)
  • Flour and grains
  • Adhesives
  • Metals
  • Resins
  • Animal exposure
48
Q

investigations for occupational asthma

A

Serial peak flow measurements at work and away from work

49
Q

lung abscess

A

An abscess is a localised collection of pus within the lung leading to the formation of a cavity.

This differs from an empyema, where the collection of pus occurs in a pre-existing normal anatomical cavity.

50
Q

Causes of lung abscess

A

Bacterial infection:
* Staphylococcus aureus
* Klebsiella pneumoniae
* Pseudomonas aeruginosa
* Tuberculosis

MOA
* Aspiration (e.g. inhalation of a foreign body)
* Haematogenous (e.g. secondary to infective endocarditis)
* Extension of a hepatic abscess
* Lung cancer
* Severe or incompletely-treated pneumonia
* Trauma

51
Q

Risk Factors lung abscess

A
  • Risk factors for gastric aspiration (e.g. strokes leading to dysphagia)
  • Pneumonia
  • Diabetes mellitus
  • Immunodeficiency
  • Severe dental disease
  • Excess alcohol consumption
  • Drug misuse
  • Underlying respiratory diseases e.g. COPD, bronchiectasis
52
Q

presentation of lung abscess

A

Often develop over weeks

  • Fever (swinging)
  • Productive cough – often copious amounts of foul-smelling sputum are produced
  • Pleuritic chest pain
  • Constitutional symptoms – weight loss, night sweats, malaise
  • Dyspnoea
  • Some patients may have haemoptysis
  • Finger clubbing may be seen in chronic cases
53
Q

investigations for lung abscess

A

Chest x-ray:
* Shows focal consolidation with central cavitation and an air-fluid level

Blood cultures:
* May show causative organism and should ideally be taken before antibiotics are given, but do not delay treatment

Sputum cultures:
May show causative organism

54
Q

management of lung abscess

A

1st-line: IV antibiotics and sepsis six if necessary
Drainage may be necessary or surgery

Medicine (Year 5) (34 decks)

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