Phase 4 > Respiratory > Flashcards

Respiratory Flashcards

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1
Q

if you are aiming for sats of 88-92% what device is best used?

A

Venturi mask 28% at 5L/ min

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2
Q

What is the single best advice that can be given to help stop a pneumothorax reoccurring?

A

Stop smoking

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3
Q

If there is COPD symptoms in a young person, what should you think of?

A

Anti - Alpha 1 deficiency

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4
Q

What is the definition of a Hospital acquired Pneumonia and what are the most likely organisms?

A

> 48 hours after admission or <7 days after discharge.

Staph aureus
Pseudomonas
Klebsiella Bacteroides
Clostridia

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5
Q

Who are at risk of aspiration pneumonia?

A 
Stroke victims 
Myasthenia gravis bulbar palsies 
Low GCS 
Achalasia 
Poor dental hygiene patients
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6
Q

List some clinical signs you may expect on someone with pneumonia:

A 
Pyrexia 
Cyanosis 
Confusion 
Tachy/ pnoae/ cardia 
Signs of consolidation
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7
Q

What are some signs of consolidation?

A 
Reduced chest expansion 
Dull to percussion
Increased tactile fremitus 
Reduced breath sounds 
Bronchial breathing 
Pleural rub
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8
Q

What investigation should be carried out on suspected pneumonia?

A

Bloods

  • FBC
  • CRP
  • U&Es
  • ABG

Sputum cultures
+/- urine cultures (if history suggestive of legionella)

CXR

special tests:

  • pleural biopsy
  • Viral serology
  • Bronchoscopy
  • Bronchoalveolar lavage
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9
Q

What thing supercede the CURB 65 score when working out if a patient has severe pneumonia or not?

A

Respiratory Failure: Pa O2 <8

Spreading of the infection: Bilateral, multilobular

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10
Q

What types of pneumonia require serological antigen testing?

A

Chlamydophila Psittaci

Mycoplasma Pneumonia

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11
Q

If a young person develops pneumonia what is an important investigation to carry out and what is needed before doing it?

A

HIV test

Permission

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12
Q

Which pneumonia are alcoholics most likely to acquire?

A

Klebsiella Bacteroides

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13
Q

List some complications of pneumonia along with initial treatment:

A

Respiratory failure

  • 60% high flow
  • consider ITU if not improving of hypercapnia

AF
- treat

Hypotension
- give fluid challenge

Pleural effusion
- aspiration and Light’s criteria

Empyema
- drainage

Lung abscess
- drainage
- antibioitics for 4-6 weeks post drainage
+/- surgical intervetion

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14
Q

Which drug can trigger asthma?

A

Aspirin

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15
Q

What is the management of a P.E?

A

ABCDE

  • oxygen
  • Un-fractioned heparin - (5000 units medium, 10000 if large) - warfarin

If massive P.E/ clinical unstable:
- Alteplase 10mg IV followed by infusion

  • Warfarin and Enoxaparin together for first few days until INR >2. After which enoxaparin should be stopped
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16
Q

What test can be performed to establish if a person has had/ has TB? what kind of results are there and what may cause false negatives?

A

Mantoux test/ Tuberculin Skin testing
<6mm diameter - never been in contact
6-15mm - suggests previous exposure/ or vaccinated
>15mm - active infection

False Negatives include:

  • <6 months
  • HIV
  • miliary TB
  • Sarcoidosis
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17
Q

What vaccine can be given to patients with TB?

A

BCG vaccine
- live attenuated mycobacterium bovis

also provides some immunity against leprosy

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18
Q

What are some features of hypercapnia?

A
  • Headache
    • Peripheral dilation - facial flushing/ Malory rash
    • Tachycardia
    • Bounding pulse
    • CO2 retention flap
    • Confusion
    • Reduced GCS / Coma
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19
Q

What is considered severe hypoxia?

A

<6.7kPa

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20
Q

What investigations can be done into asthma? and what findings would suggests asthma?

A

PEEK Flow diary
- diurnal variation >20% on >3days/week over 2 weeks

Histamine provocation test
- >20% drop on FEV1 from baseline

Spirometry
- >15% reversibility on FEV1/FVC

Scratch Test

Sputum
- eosinophils

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21
Q

What are the differentials for asthma?

A

COPD

Pulmonary Oedema (cardiac asthma) - polyphonic wheeze

SVC obstruction

Bronchiectasis

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22
Q

Contrast COPD and asthma:

A

COPD:

  • smokers
  • rare <35 years
  • Chronic cough is common
  • Persistent shortness of breath
  • Night symptoms are uncommon
  • variability in symptoms is minimal

Asthma is the opposite to all these.

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23
Q

Outwith medicines, name some important factors in managing asthma:

A

Quit smoking

Avoid triggers

Weight loss

Good inhaler technique

Twice daily PEF recordings

Training and understanding regarding what to do in emergencies

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24
Q

What is the difference between obstructive sleep apnoea and obstructive sleep apnoea syndrome?

A

Obstructive sleep apnoea syndrome is the associated daytime symptoms as well

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25
What is the criteria for obstructive sleep apnea?
A decrease in 4% sats over >10seconds (apneaic episode) + >15 episodes an hour or >5 episodes an hour with significant day time solmenace
26
When stepping down asthma treatment, when should medications etc be reviewed and what targets are recommended?
Review 3 monthly. Step down aim for 25-50% reduction in ICS
27
What assessments and investigations should be done into sleep apnea?
Referral to ENT: History from partner Mallampati score Clinical examination - neck size, BMI, Craniofacial appearance Investigations: - polysomnography - Transcutaneous Oxygen saturations and Carbon Dioxide Assessment (TOSCA)
28
What does polysomnography all entail?
``` Oxygen saturation airflow through nose and mouth ECG EMG of chest muscles Abdominal wall movement Audio Video ```
29
What are the differentials for sleep Apnea?
Hypopnea - reduced flow but does not meet criteria Respiratory effort related arousals -
30
What is the major complication of sleep apnoea?
Hypertension
31
What is the management of sleep Apnoea?
Weight reduction Avoidance of alcohol before bed Mandibular adjustment device CPAP Surgery - to relieve pharyngeal obstruction
32
What mutations are commonly attributed to lung cancer?
p53 EML4 - ALK (non- small cell) KRAS PDL-1
33
What are some complications of lung cancer?
Recurrent Laryngeal nerve palsy Superior vena cava obstruction Horner's syndrome Pericarditis Pleural effusion Paraneoplastic syndromes
34
What are the paraneoplastic syndromes of lung cancer?
SIADH - small cell Cushing's syndrome ectopic ACTH - small cell Hypercalcemia - PTHrP - Squamous cell Eaton Lambort Syndrome
35
What might you see on a CXR of lung cancer?
Consolidation Hilar mass Pleural effusion Atelectasis - lung collapse
36
What investigations should be done into suspected lung cancer?
CXR - lateral - PA Bronchoscopy with endobronchial ultrasound - to assess the lesion - to take biopsy Cytology - sputum - bronchial wash PET -CT - for metastasis spread CT - thorax - abdomen - pelvis * assess for metastasis Radionucleotide Bone scan
37
What are the different types of lung cancer in order of their prevalence and name the cell they derive from?
Squamous cell - metaplastic squamous cells Adenocarcinoma - Goblet cells Small cell - neuroendocrine Large cell Anaplastic - neuroendocrine
38
What things must be taken into consideration first before carrying out treatment for lung cancer?
Before carrying out treatment the functioning of: - heart - lungs (remaining lung) need to be considered as there is a likely chance there is going to be a lobectomy
39
What is the treatment for Small cell lung cancer?
Chemotherapy + radiotherapy Palliative radiotherapy for complications such as bone pain, obstruction + stenting of bronchi Analgesics Bronchodilators cough linctus antidepressants
40
What is the treatment for Non- small cell lung cancer?
Lobectomy - often performed using Video Assisted thoracoscopic Surgery (VATS) *leaves 3 small scars Radiotherapy + chemotherapy for more advanced cancer (usually platinum based)
41
List some causes of exudative pleural effusions:
Infection Malignancy Autoimmune Pancreatitis
42
What investigations should be done into a pleural effusion?
Diagnostic tap: - microscopy and culture Cytology pH (<7.2 indication for chest drain) LDH
43
What is a serious cause of pleural effusion that can follow after excessive vomiting or endoscopy that can be fatal?
Boerhaave's syndrome
44
What is the investigation of choice into idiopathic pulmonary fibrosis?
High resolution CT scan
45
What has been shown to improve survival in patients with COPD and when should it be offered?
Long term Oxygen therapy (LTOT) When stopped smoking and oxygen <7.3 kPa
46
What does COPD have to include?
• Chronic Bronchitis - Production of sputum on most days, for least 3 months in at least 2 years. + • Emphysema Permanent enlargement of airspaces distal to bronchioles
47
What is needed for the diagnosis of COPD?
FEV1 <80% FEV1/ FVC ratio <0.7 with little no reversibility (<400ml or 15%)
48
Why are blue bloaters called blue bloaters?
Hypercapnia - inducing the blue tinge Hypoxic pulmonary vasoconstriction induces cor pulmonale
49
Radiologically what types of pneumonia and can be seen and what are they most associated with?
Lobar pneumonia - strep pneumonia Bronchial Pneumonia - H. Influenzae - moraxella * usually superimposed on COPD Interstitial Pneumonia - spreads throughout the interstitium
50
What are the differentials for pneumonia?
Acute Bronchitis Heart failure Lung cancer Asthma/ COPD Bronchiectasis
51
What drugs are not recommended for COPD?
Mucolytics
52
Which disease may cause a rash over the face called lupus perinco?
Sarcoidosis
53
What signs may be seen on xray in a pleural effusion?
Blunting of costa phrenic angles Fluids in fissures Meniscus sign Tracheal deviation - away from affected side
54
What are the key diagnostic tests for asthma?
Spirometry with beta reversibility Fraction exhaled NO Histamine provocation PEAK flow diary - 20% variation, >3 days for 2 weeks
55
What can be done to increase mucus production?
Chest Physiotherapy Sodium Chloride Carbocysteine
56
What is the screening test for sarcoidosis and what is the definitive test?
Blood ACE levels is screening Biopsy is definitive - non caseating granulomatous epithelioid cells
57
What is the common skin manifestations of sarcoidosis?
Lupus Pernio Erythema nodosum
58
What is the treatment of sarcoidosis?
- majority spontaneously remissive - steroids More advance: - methotrexate - azathioprine Lung transplant
59
Following severe COPD exacerbation - the patient has been given aminophylline and is not able to be intubated, what drug can be given?
Doxapram | - respiratory stimulator
60
What are the severities of COPD?
Based on FEV1 Mild >80 moderate 50-80 Severe 30-50 Very Severe <30 or <50 + respiratory failure
61
When is long term oxygen therapy given for COPD?
<7.3kPa
62
Which conditions tend to cause pulmonary fibrosis in the upper lobes?
CHARTS - Coal miners - hypersensitivity - Ankylosing spondylitis - Radiation - TB - Sarcoidosis
63
For exacerbations of COPD what is the most appropriate NIV to put patients on?
Bi PAP
64
What is the markers for light's criteria?
Protein > 30g/L Pleural protein: serum protein >0.5 Pleural LDH: serum LDH >0.6
65
What is the single most important intervention to increase survival in COPD?
Stop smoking
66
What investigations should be done into a pleural effusion sample?
Gross appearance Cytology Clinical biochemistry - Lights criteria Immunology
67
Which drugs should be withheld during C.Diff?
Anti-motility drugs - opioids - loperamide * predispose to toxic megacolon PPIs
68
At which blood pH should invasive intubation be considered?
<7.25 between 7.25- 7.35 are the optimal zone for non-invasive ventilation
69
List some devices used for NIV?
Nasal Face mask Bilevel positive airway pressure - BiPAP
70
What is the management for a recurrent pleural effusion?
pleurodesis Indwelling pleural catheter Drug management to control dyspnoea
71
In smoking terms what is a 1 pack year defined as?
20 Cigarettes daily for 1 year
72
What are the indications of life threatening asthma attack?
PEFR <33% Sats <92% Low GCS Chest hyporesonance Normal PaCO2
73
What are the signs of severe asthma attack?
Can't complete sentences 33-55% PEFR Tachy >110bpm Tachypneic >25
74
What features would support a steroid response for COPD patients?
Atopy/ Asthmatic features - raised eosinophils - variation in Peak Flows - 20% - variation of FEV1
75
Which pneumonia causes bilateral cavitating lesions on x-ray? and who is it most commonly seen in?
Klebsiella pneumonia - alcoholics - diabetic patients
76
Who should be informed when there is a diagnosis of obstructive sleep apnea?
DVLA
77
What is the management of IPF?
Pulmonary rehabilitation Oxygen therapy Pirfenidone - antifibrotic agent Lung transplant
78
What are the type biopsy results of IPF? and what histological findings?
usual interstitial Pneumonia pattern Temporal heterogeneity Fibroblastic Foci
79
What is the management for atelectasis following surgery?
Respiratory physiotherapy
80
What are the common causes of hypersensitivity pneumonitis?
Bird Fanciers Lung - avian proteins Malt workers lung - Aspergillus clavatus Farmers lung - Saccharopolyspora Rectivirgula
81
When is NIV indicated in exacerbation of COPD?
When patient fails to respond to initial treatment pH <7.35 paCO2 >6 usually need to be admitted to HDU
82
What is an important history to take from someone with as asthma attack that my influence your management of them?
If they have been previously admitted due to an asthma attack and if it was severe. did they end up in ICU What their normal PEF is Do they have allergies - penicillin? What are their usual meds and how well controlled? Recent illness? - underlying cause? Prior chest pain - pneumothorax?
83
What is the management of a >50 year old patient with significant smoking history who present with a pneumothorax 1-2cm?
Aspiration. if not resolved pleural drain If resolved High Flow oxygen
84
What is the management of a young male with no underlying lung disease who presents with a pneumothorax <2cm?
Discharge and review 2-4 weeks so long as there is no adverse features.
85
Clinical findings of pneumothorax?
``` Increased resonance to percussion Reduced breath sounds Reduced chest expansion Reduced tactile fremitus +/- tracheal deviation +/- Diaphragmatic movement - up in non tension, down in tension ```
86
What are the signs and symptoms of a tension pneumothorax?
``` Hypotension Distended neck veins reduced chest expansion Tracheal deviation Hyperresonance to percussion ```
87
What are the landmarks for the "safe triangle" in placing a chest drain?
Posterior body of the pectoralis (anterior border) Anterior of the Lat dorsi (posterior border) line across from nipple (inferior border) Axillar (superior border)
88
How is a tension pneumothorax managed?
100% oxygen Large bore cannula into either: - 2nd intercostal space midclavicular line - safe triangle *keep the cannula in Insert chest drain
89
What investigations should be done into pneumonia?
Bloods: - FBC - U&Es - CRP * ABG * Blood cultures if moderate to severe pneumonia Orifices: - Sputum samples - Urine samples - legionella X-ray: - CXR
90
When can someone with pneumonia be discharged?
``` Off oxygen Oral antibiotics CRP falling Apyrexial RR <24 HR <100 BP>90mmHg ``` 6 week CXR Smoking advice
91
Which CURB score is admitted? and what is the antibiotic choice?
CURB 2
92
What is the general management of pneumonia?
CURB 1: PO antibiotics CURB >2: - IV antibiotics - Oxygen - Fluids - VTE prophylaxis - Analgesia is pleuritic chest pain - Chest physiotherapy - Anti- mucolytics CURB 3: - consider ICU admission especially if hypercapnia or hypoxia remains
93
Which pneumonia typically comes from birds?
Chlamydia Psittaci - Flu symptoms before hand + D&V - Dry cough
94
What is the antibiotic management for CURB 3?
Clarithromycin + Amoxicillin or if in HDU/ ICU: IV co- amoxiclav
95
If a person has a CURB score of > 3 and sepsis and is penicillin allergic what antibiotic should they receive?
Levofloxacin
96
If a person develops HAP and has no sepsis what is the best antibiotic to prescribe?
Doxycycline
97
If a person develops HAP and has sepsis what is the best antibiotic to prescribe? i.e. CURB >3
Amoxicillin + Gentamicin
98
What is the antibiotics for aspiration pneumonia?
Metronidazole + Amoxicillin
99
In the emergency situation of stridor what should the initial management be?
Contact ICU Contact anaesthetist ABCDE - High flow oxygen - Dexamethasone - Nebulised salbutamol Options needed to be considered: - tracheostomy - nebulised adrenaline
100
What is the long term management of COPD?
1st line: SABA or SAMA ``` Establish if asthma symptoms: 2nd LABA+ LAMA or LABA + ICS + LAMA ``` 3rd Oral theophylline +/- Macrolides Long term O2 therapy - <7.3kPa - Pulmonary hypertension - terminally ill * yearly flu vaccine * smoking * chest physio
101
What are some other measures to improve target SaO2?
Chest physiotherapy Adequate Hb - treat anaemia Improve cardiac output
102
What are some causes of ARDS?
Pneumonia Sepsis Pancreatitis Trauma
103
How is ARDS diagnosed and what is the management?
Acute onset within 1 week of risk factor Bilateral pulmonary oedema Bilateral pulmonary infiltrates ``` ICU Ventilation General organ support Antibiotics Prone positioning ```
104
What should the PaO2 be in comparison to SiO2?
-10 of it. | therefore SiO2 of 30% you would expect PaO2 of 20
105
What are some complications of asthma?
``` Respiratory failure Lobar collapse Pneumothorax side effects from treatment - tachy - tremor - Hypokalemia Fatigue ```
106
What are the causes of bronchiectasis?
Congenital - CF - Ciliary dysfunction Acquired: - pneumonia - TB - Aspergillosis
107
How is Bronchiectasis investigated and what are the treatments?
High resolution CT scan Spirometry Sputum sample Analysis for primary congenital disease - primary ciliary dysmotility Management: - prevent complications - antibiotics, vaccines - Bronchodilators - ICS - Chest physiotherapy - breathing exercises - autogenic drainage surgical procedures - resection
108
How is Mycoplasma investigated?
Mycoplasma serology Positive cold agglutinin test
109
When would you carry out a CXR on an exacerbation of asthma?
Suspicion of infectious causes Life threatening Unresponsive to treatment
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