T- yr CPL Flashcards
(122 cards)
1
Q
Definition of asthma
A
Chronic inflamm. disorder of the airways 2ndary to type 1 hypersensitivity
2
Q
How do the Sx of asthma manifest?
A
Reversible bronchospasm –> progresses to airway obstruction
3
Q
Criteria for moderate acute asthma
A
- PEFR 50-75%
- Norm. speech
- RR< 25
- HR< 110
4
Q
Criteria for severe acute asthma
A
- PEFR 33-50%
- incomplete sentences
- RR> 25
- HR> 110
5
Q
Criteria for life-threatening acute asthma
A
Dx if ONE feature is present
- PEFR < 33%
- O2 sats < 92%
- Norm. pCO2
- Silent chest, cyanosis, decrea. resp. efoort
- Bradycardia, dysrrhythmia, hypotension
- coma, confusion
6
Q
What makes acute asthma life-threatening?
A
An increa. pCO2
7
Q
What are the Sx of asthma?
A
- Dyspnoea
- Nocturnal cough
- Wheeze
- Chest tightness
- increa. sputum
- Diurnal variation- PF decrea. in AM
- Acid reflux- 40% pt.
8
Q
What are the signs of asthma on Px
A
- expiratory polyphonic wheeze
- tachypnoea
- decrea. air entry
- Hyperinflat.
- decrea. peak expiratory flow rate (PEFR)
9
Q
What are some conditions assoc. w/ asthma?
A
- atopic dermatitis (eczema)
- allergic rhinitis
- aspirin sensitivity
10
Q
What are the causes/ RF for asthma?
A
- Hx/ FHx of atopy
- antenatal factors: mat. smoking, RSV infect., decrea. birth weight
- formula-fed
- allergen exposure
- air pollution
- NSAIDs
- Beta- blockers
- Hygiene hypothesis- predom. Th2 immune response
- occupational asthma: isocyanates, flour
11
Q
Bed-side Ix for asthma + expected result in asthmatic pt.
A
- Peak expiratory flow (PEF)
- Result= variable
- +ve test= > 20% variability (PEF x2/ day 2-4wks)
12
Q
When would you consider a CXR when Dx asthma?
A
- older pt.
- pt. w/ smoking Hx
13
Q
What special tests are used to Dx asthma?
A
- Spiromety: FEV1, FVC, FEV1%
- Fractional exhaled nitric oxide (FeNO)
- Bronchodilator reversibility test (BDR)
14
Q
What are the expected spirometry results in an asthma pt.?
A
- FEV1= signif. decrea.
- FVC= norm.
- FEV1% <70%
- Shows obstructive lung disease
15
Q
What are the expected FeNO results in an asthma pt.?
A
- increa. iNOS- increa. eosinophil airway inflamm.
- adult +ve test= > 40ppb
- child +ve test= > 35 ppb
16
Q
What are the expected BDR results in an asthma pt.?
A
- Asthma= +ve result
- adult +ve test= 12% increa. FEV1+ increa. vol. 200ml
- child +ve test= 12% increa. FEV1
17
Q
What is the criteria to dx asthma in a child <5yo?
A
- Clinical judgment
18
Q
What is the criteria to dx asthma in a child 5-16yo?
A
- obstructive spirometry result
- +ve BDR
- (+ FeNO if BDR= -ve)
19
Q
What is the criteria to dx asthma in an adult >17yo
A
- ? occupational asthma
- Obstrucive spirometry result
- +ve BDR
- +ve FeNO
20
Q
What is the 1st line treat. for asthma w/ e.g.?
A
- SABA
- salbutamol, terbutaline
21
Q
What is the 2nd line treat. for asthma w/ e.g.?
A
- SABA + low- dose ICS
- SABA: salbutamol, terbutaline
- ICS: beclometasone
- admin. if sx uncontrolled- increa. sx 3x/ wk OR night waking
22
Q
What is the 3rd line treat. for asthma w/ e.g.?
A
- SABA + low-dose ICS + LTRA
- SABA: salbutamol, terbutaline
- ICS: beclometasone
- LTRA= leukotriene receptor antag.: montelukast
23
Q
What is the 4th line treat. for asthma w/ e.g.?
A
- SABA + low-dose ICS + LABA
- Continue LTRA depending on pt. response
- SABA: salbutamol, terbutaline
- ICS: beclometasone
- LABA: formeterol
- LTRA= leukotriene receptor antag.: montelukast
24
Q
What is the 5th line treat. for asthma w/ e.g.?
A
- SABA +/- LTRA + MART (inclu. low-dose ICS)
- SABA: salbutamol, terbutaline
- LTRA= leukotriene receptor antag.: montelukast
- MART= Maintenance reliever therapy= combo ICS + fast-acting LABA: Fostair
25
What is the 6th line treat. for asthma?
- SABA +/- LTRA + med.-dose ICS MART
OR
- SABA +/- LTRA + mod. ICS + LABA
26
What is the 7th line treat. for asthma?
- SABA +/- LTRA +:
- High- dose ICS
OR
- trial LAMA- ipratropium
OR
- trial theophylline
OR
- refer for specialist input
27
How often should you step down asthma treat.?
Every 3 mths
28
What are the Sx of acute asthma?
- increa. dyspnoea
- wheeze + cough
- Sx NOT responding to salbutamol
29
What Ix should you carry out in acute asthma?
- ABG- O2< 92%
| - CXR- life-threatning, ? pneumothorax, no response to treat.
30
When should you admit for acute asthma?
- life-threat.
- severe if no treat. response
- prev. near- fatal episode
31
What is the management for acute asthma?
- O2 if hypoxaemic- 15L non-rebreathe titrated down until maintain sats 94-98%
- Bronchodilate w/ SABA- nebulised if life-threat.
- Corticosteroid: 40-50mg prednis. PO daily for min 5 days (continue norm. ICS)
- Ipratropium bromide- if no response to prev. treat.
- IV MgSO4- severe + life-threat.
- Last resort= intubat. + ECMO
32
When should you discharge a pt. after acute asthma?
- Stable on discharge meds. 12- 24hrs
- Inhaler technique checked
- PEFR> 75%
33
What is the definition of COPD?
- Progressive airway obstruct. disorder inclu. chronic bronchitis + emphysema
- Sx NOT reversible
34
What is the definition of chronic bronchitis?
- clin. definition
| - cough + sputum on most days 3/12 of 2 success. yrs.
35
What is the definition of emphysema?
- Histolog. definition
| - permanent dilation of airways dist. to terminal bronchioles
36
What are the sx of COPD?
- Chronic product. cough
- dyspnoea
- Wheeze
- progressive dyspnoea
- R- sided HF --> periph. oedeme
37
What is the definition of acute COPD exacerbation?
Sudden sustained worsening in pt. sx beyond norm. variation
38
What are the RF for COPD?
- Smoking
- Alpha- 1- antitrypsin def.
- dust. inclu. coal dust
39
What are causes of COPD exacerbat.?
- infect. of airways
- pneumothorax
- PE
- LVF
- lung carcinoma
40
What organisms cause infect. exacerbat. of COPD?
- H. influenzae
- S. pneumoniae
- M. Catarrhalis
41
What bloods to Ix COPD?
FBC- exclu. 2ndary polycythaemia
42
What imaging to Dx COPD?
CXR
- hyperinflation
- bullae
- flat hemidiaphragm
- (exclude lung Ca)
43
What special test can Dx COPD + expected result for COPD pt.?
post- bronchodilator spirometry
- Result: FEV1% <70%
- shows airflow obstruct.
44
What is stage 1 COPD?
- Sx must be present
- FEV1%< 70%
- FEV1> 80% (of predict.)
45
What is stage 2 COPD?
- Moderate
- FEV1%< 70%
- FEV1= 50-79% (of predict.)
46
What is stage 3 COPD?
- Severe
- FEV1%< 70%
- FEV1= 30-49% (of predict.)
47
What is stage 4 COPD?
- v. severe
- FEV1%< 70%
- FEV1<30% (of predict.)
48
What is the general management of COPD?
- Smoking cessat. + nicotine replacement
- Annual flu vacc.
- pneumococcal vacc.
- pulm. rehab.
49
What is 1st line treat. for COPD?
- SABA/ SAMA as requ.
50
What is the prep. for 2nd line treat. of COPD?
? asthmatic fx/ steroid responsiveness fx
- prev. dx asthma/ atopy
- increa. serum eosinophil count
- substant. FEV1 variation over time (>400ml)
- Diruranl variation in peak flow (>20%)
51
What is 2nd line treat. for COPD?
?Asthma fx YES:
- SABA/ SAMA as requ.
- LABA + ICS reg.
? Asthma fx NO:
- SABA as requ.
- LABA + LAMA reg.
52
Whats is the 3rd line treat. for COPD?
- SABA as requ.
| - LABA, LAMA + ICS reg.
53
What is the 4th line treat. for COPD?
oral theophylline
54
How does cor pulmonale develop in COPD?
- emphysema --> loss pulm. arterioles + capillaries
- Chronic hypoxia --> pulm. art. constrict.
- Chronic hypoxia --> increa. EPO --> increa. erythrocytosis --> increa. blood viscosity
55
What are the main causes of death in COPD pt.?
- bronchopenuomia
- Resp. failure
- Heart failure
56
What is oral prophylactic ABX in COPD pt.
Azithromycin
pt. criteria:
- not smoke
- optimised on standard treat. --> still have exacerbat.
- CT thorax to exclu. bronchiectasis
- Sputum culture to exclude atyp. infect. + TB
- LFTs
- ECG exclude QT prolongation
57
What is a SE of azithromycin?
QT prolongation
58
When would you Rx mucolytics in COPD?
pt. w/ chronic product. cough- continue if sx improve
59
Sx of cor pulmonale?
- periph. oedema
- increa. JVP
- syst. parasternal heave
- loud P2
60
What is the treat. for cor pulmonale?
- loop diruetic
| - LTOT
61
What is LTOT for COPD?
Breathe O2 15h/ day
62
Criteria for COPD pt. to be asses. for LTOT?
- v. severe airway obstruct.- FEV1< 30%
- cyanosis
- polycythaemia
- periph. oedema
- increa. JVP
- O2 sats< 92% room air
63
How to assess. pt. for LTOT?
2 ABG 3wks apart w/ stable COPD on optimal management
64
When to offer LTOT for COPD pt.?
```
pt. w/ pO2 <7.3
OR
pO2 7.3- 8 +:
- 2ndary polycythaemia
- peipheral oedema
- pulm. HTN
```
DO NOT offer if pt. still smokes
65
What is the definition of respiratory failure?
- Hypoxia
| - PaO2< 8kPa
66
Definition of type 1 resp. failure?
- Hypoxia
| - w/ norm OR decrea. PaCO2
67
Definition of type 2 resp. failure?
- Hypoxia
| - Hypercapnia- PaCO2> 6 kPa
68
Sx of resp. distress in resp. failure
- tachypnoea
- dyspnoea
- access. musc. use
- stridor
- inabil. to speak
- cyanosis
69
Sx of hypoxia
- dyspnoea
- restelssness
- anxiety + agitation
confusion
- cyanosis
- headache
70
Sx of hypercapnia
- headache
- periph. vasodilation
- tachycardia
- CO2 retention flat
- papillodema
- confusion + coma
- severe: comfort. @ rest --> progress. hypoventilate --> coma
71
Sx long standing hypoxia
- polycythaemia
- pulm. HTN
- cor pulmonale
- tachycardia + arrhythmias from hypoxaemia + acidosis
72
What are modifiable RF for resp. failure?
- cigarrettes
- opiods + sedatives
- toxic fumes + gases
73
Non- modifiable RF for resp. failure
- v. young
| - v. old
74
Pre-existing path. RF for resp. failure
- pulm. infefct.
- chronic lung disease
- airway obstruct.
- alveolar abnormal.
- Perfusion abnormal.
- cardiac failure
- periph. nerve damage + musc. abnormal./ injury
75
Causes of type 1 resp. failure
- V/Q mistmach
- hypoventilation
- abnormal diffusion
- cardiac shunts
76
Causes of V/Q mismatch
- pneumonia
- pulm. oedema
- PE
- Asthma
- Emphysema
- ARDS
77
Causes of type 2 resp. failure
Alveolar hypoventilation w/ OR w/o V/Q mismatch
- pulm. disease: asthma, COPD, pneumonia
- decrea. resp. drive
- neuromusc. disease
- thoracic wall disease/ injury
78
Bedside Ix in resp. failure
- pulse oximetry
- FVC
- ECG
79
Blood Ix in resp. failure
- FBC
- U&Es
- CRP
- D-dimer
- Toxicology
- ABG
80
ABG results in resp. failure
pH PaCO2 HCO3-
Metabolic acidosis Low Normal/ low Low
Resp. Acidosis Low High Normal/ high
Metabolic Alkalosis High Normal/ high High
Resp. Alkalosis High Low Normal/ low
Chronic hypercapnia- metabolic compensation has occurred: increa. PaCO2 + increa. HCO3- + slightly decrea./ norm. pH
81
What special tests can be used to Ix resp. failure?
- Microbiology: sputum, blood cultures
- capnometry- used in intubat. pt. to measure expired CO2- reflect. arterial CO2
- spirometry: PEFR + FEV- obstruct. + restrict. should NOT cause resp. failure
82
General managment for resp. failure
1. treat. underlying cause
2. O2
3. correction of acidosis/ alkalosis- may be achieved through ventilatory support
4. NIPPV
5. Endotrach. intubat. + ventilation
83
Management of type 1 resp. failure
1. treat underlying cause
2. O2 24-60% non-RB facemask
3. if pt. still hypoxic w/ 60% O2 --> NIPPV
84
Management of airway obstruction
1. airway clearance + O2
| 2. treat. underlying cause
85
Management of Type 2 resp. failure
```
Resp centre= CO2 insensitive
1. Treat the cause
2. controlled O2 via non-RB facemask- start @ 24%
MAKE SURE HYPOXIA IS TREATED
3. recheck ABG after 20 mins
- PaCO2 decrea. --> increa. O2
- PaCO2 increa. --> NIPPV
4. Endotrach. intubat. + ventilat.- CPAP + BIPAP
```
86
Definition of pulmonary embolism
1+ emboli arising from venous thrombus in pelvis/ legs lodge in --> obstruct. art. pulm. circulation --> resp. dysfunct.
87
How does a small PE often present?
asx
88
Sx of PE
- acute tachypnoea
- pleuritic chest pain
- haemoptysis
- dizziness
- syncope
- dyspnoea
89
Signs of a PE
- pyrexia
- cyanosis
- tachypnoea
- tachycardia
- hypotension
- increa. JVP
- chest usually clear BUT can hear crackles
- pleural rub
- pleural effusion
- AF
- loud P2
- RV parasternal heave
90
Sx of massive PE (embolus in R outflow tract)
Haemodynamic collapse
91
Considerations in pt. presenting w/ PE
- ? RFs
- ? PMH/ FHx thromboembolism
- ? signs of cause e.g. DVT
92
RF in PE
increa. coagulability
- recent surgery- decrea. risk if prophylaxis used
- thrombophilia
- leg #
- decrea. motility
- malignancy
- preg. COCP, (HRT)
- Prev. PE
- myeloproliferative disorder
- acitve inflamm.
93
How to prevent PE
- heparin in all immobile pt.
| - stop HRT + COCP pre-op
94
ECG signs for PE
- norm.= norm./ sinus tachy
- common: RV strain, V1- V3, RAD, AF, RBBB
- classical BUT rare= S1Q3T3
95
Bedside Ix for PE
- O2 sats
- RR
- HR
- Temp.
- ECG
96
Bloods for PE
- FBC
- U&Es
- baseline clotting
- ABG- hyperventilation + decrea. gas exchange --> decrea. PaO2, decrea. PaCO2, increa. pH
- D- dimer
97
Significance of D-dimer test in Ix for PE
- -ve result excludes PE
| - low specificity t/f only test pt. w/ low probabil. of PE
98
Imaging Ix in PE
- CXR
| - USS of pelvic/ femoral vein clots
99
PE findings on CXR
- decrea. vasc. markings
- small pleural effusions
- edge shaped infarctions
- atelectasis
100
What is the Gold standard Ix for PE?
CTPA
101
What are the special Ix to dx PE?
- CTPA
| - V/Q scan- aid dx BUT often equivocal results (preferred if renal impairment; COPD would show matched defects)
102
When to Dx PE?
- always suspect. in sudden collapse 1-2wks post- surg.
- CTPA= test of choice in high- risk pt./ low risk pt. w/ +ve d-dimer
- Wells Criteria: score > 4; score < 4 + d-dimer +ve
103
Management process of PE
1. Pulm. embolism rule out criteria (PERC)
2. Calculate modified Wells Score
3a. >4= immed. CTPA/ treat. w/ DOAC
4a1. CTPA +ve= Dx PE
4a2. CTPA -ve= prox. leg vein USS for DVT
3b. <4- d-dimer
4b1. d-dimer +ve= immed. CTPA/ DOAC
4b2. d-dimer -ve= alternative dx + stop anticoag.
104
What DOACs are used in management of PE?
Apixaban + rivaroxaban
| - if unsuitable: LMWH + dabigatran/edoxaban OR LMWH + warfarin
105
What is the Pulm. embolism rule-out criteria (PERC)
```
used to exclude PE in pt. known to have low-pretest probabil. (<15%) of PE- if probail. >15% then skip --> Wells criteria
- age >50
- HR> 100
- O2 sats <94%
- prev. DVT/ PE
- recent surge./ trauma in last 4 wks
- haemoptysis
- unilat. leg. swelling
- oestrogen use
If all above absent then probability of PE< 2%
```
106
What is the Wells Criteria
- Clinical signs + Sx DVT 3
- HR> 100 1.5
- Recently bed-ridden (>3/7)/ maj. surgery (<4/52) 1.5
- prev. DVT/ PE 1.5
- Haemoptysis 1
- Ca receiving active treat., treat. last 6/12, palliat. 1
- Alternative Dx < likely than PE 3
<4= PE unlikely
> 4= PE unlikely
107
Lenght of treat. for PE
- Provoked= 3/12 --> reasses whether RF persists + risk/ benefit
- Unprovoked= > 3/12
- Malig.= continue w/ DOAC 6/12 until Ca cured
- Preg.= LMWH heparin continued until delivery/ end of preg.
108
Options for long term anticoagulation
- DOACs= rapid onset + no need for LMWH overlap
- Warfarin (Vit. K agonist)- stop heparin when INR= 2-3 d/t initial prothrombotic effect warfarin
- Vena caval filter if anticoag.= CI
109
Immediate treat. of PE
1. O2 if hypoxic- 10-15L/ min
2. IV morphine 5-10mg + anti-emetic
3. IV access --> DOAC/ LMWH/ vit. K agonist
4. if hypotensive 500ml IV fluid bolus- ICU input
5. ?haemodynamically unstable
6a. NO: persist. low BP --> vasopressors- aim for syst. BP> 90
- Dobutamine IV
- NA IV
6b. YES: thrombolysis- alteplase 10mg IV bolus --> IVI 90mg/ 2h
7. long- term anti-coag.
110
Definition of primary pneumothorax
no underlying lung disease
111
Definition of secondary pneumothorax
underlying lung disease
112
Definition of large pneumothorax
visible rim > 2cm
113
Definition of small pneumothorax
visible rim < 2cm
114
Sx of pneumothorax
Sudden onset
- dyspnoea
- pleuritic chest pain
- sweating
- increa. HR
- increa. HR
- decrea. ipsilat. breath sounds + chest expansion
115
Sx of tension pneumothorax
- tracheal shift
- hyper-resonant on affected side
- cardiopulm. deterioration
116
RF for a pneumothorax
- pre- existing lung disease: COPD, asthma, CF, lung Ca, pneumocystis pneumoniae
- connect tissue disease: Marfans; RA
- Ventilation inclu. non- invasive
- Catamenial pneumothorax- endometriosis in thorax
- thoracic trauma where lung parenchymal flap formed
117
Bloods to Ix pneumothorax
- FBC
- clotting screen- correct abnromal before chest drain
- ABG- O2< 92% on room air
118
What imaging is done to dx pneumothorax?
- CXR (PA)
| - Chest CT if Dx uncertainty/ trauma pt.
119
What is the treatment of a tension pneumothorax?
1. needle aspiration w/ wide bore cannula (grey), 2nd ICS midclav.
2. O2 + admit
120
What is the treat. of a primary pneumothorax?
Air< 2cm + no SOB
1. O2 + obs --> discharge
Air> 2cm
1. aspiration <2.5L w/ wide bore cannula (if successful discharge)
2. chest drain 5th ICS mid- axillary --> admit
121
What is the treat. of a secondary pneumothorax?
pt. > 50yo + air> 2cm +/or SOB
1. Chest drain
air 1-2cm- admit all pt. 24h
1. aspiration w/ wide bore cannula 2nd ICS midclav.
2. chest drain 5th ICS midaxill.
air < 1cm
1. O2 + obs --> admit 24h
122
Treatment for iatrogenic pneumothorax
most resolve on their own
1. aspiration w/ wide bore cannula 2nd ICS midclav.
2. Chest drain 5th ICS midaxill.- more likely in COPD + ventilat. pt.
