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Resp Flashcards

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1
Q

Which abx is prophylacticly given in COPD and who qualifies

A

Azithro
The patient no longer smokes.
Has optimised non-pharmacological management & inhaled therapies.
Referred to pulmonary rehab (if appropriate).
4 acute exacerbations in the last year (producing sputum), requiring hospital admission at least once.

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2
Q

Asthma classification of severity

A

Mod- PEFR 50-75% best or predicted
Speech normal

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

Life threatening- PEFR < 33% best or predicted
Oxygen sats < 92%
‘Normal’ pCO2 (4.6-6.0 kPa)
Silent chest, cyanosis or feeble respiratory effort
Bradycardia, dysrhythmia or hypotension
Exhaustion, confusion or coma

Near fatal- raised CO2

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3
Q

Lights Criteria

A

Effusion lactate dehydrogenase (LDH) level greater than 2/3 the upper limit of normal serum LDH
Pleural fluid LDH divided by serum LDH >0.6
Pleural fluid protein divided by serum protein >0.5

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4
Q

Indications of placing chest tube with pleural infections

A

Patients with frankly purulent or turbid/cloudy pleural fluid on sampling should receive prompt pleural space chest tube drainage.

The presence of organisms identified by Gram stain and/or culture from a non-purulent pleural fluid sample indicates that pleural infection is established and should lead to prompt chest tube drainage.

Pleural fluid pH < 7.2 in patients with suspected pleural infection indicates a need for chest tube drainage.

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5
Q

Tests before TB treatment

A

FBC
LFT
U+E
Vision

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6
Q

Asthma treatment adults

A

1st- AIR therapy (ICS/LABA) - e.g. Budesonide / Formoterol 100/6, used as-required

2nd- low dose MART
E.g. Budesonide / Formoterol 100/6, regularly

3rd- moderate dose MART
E.g. Budesonide / Formoterol 200/6.

4th
check the fractional exhaled nitric oxide (FeNO) level if available, and the blood eosinophil count

if either of these is raised, refer to a specialist in asthma care
if neither FeNO nor eosinophil count is raised-(LTRA) or a long-acting muscarinic receptor antagonist (LAMA) used in addition to moderate-dose MART
if control has not improved, stop the LTRA or LAMA and start a trial of the alternative medicine (LTRA or LAMA)

Step 5
refer people to a specialist in asthma

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7
Q

COPD mx long term

A

SABA Or SAMA PRN

Any asthmatic features?
any previous, secure diagnosis of asthma or of atopy
a higher blood eosinophil count - note that NICE recommend a full blood count for all patients as part of the work-up
substantial variation in FEV1 over time (at least 400 ml)
substantial diurnal variation in peak expiratory flow (at least 20%)

Asthmatic features/features suggesting steroid responsiveness
LABA + inhaled corticosteroid (ICS)
if patients remain breathless or have exacerbations offer triple therapy i.e. LAMA + LABA + ICS
if already taking a SAMA, discontinue and switch to a SABA

No asthmatic features
add a long-acting beta2-agonist (LABA) + long-acting muscarinic antagonist (LAMA)
if already taking a SAMA, discontinue and switch to a SABA

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8
Q

COPD vaccines

A

Annual influenza
One off pneumococcal

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9
Q

Transfer factor and coefficient

A

TLCO (Transfer factor for carbon monoxide) — measures how well gases transfer from the alveoli into the pulmonary capillary blood.
TLCO reflects:
Alveolar surface area available for gas exchange
Thickness of alveolar-capillary membrane
Pulmonary capillary blood volume

KCO = TLCO / VA
Efficiency of gas transfer per unit of lung volume

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10
Q

Reduced TLCO

A

Pulmonary fibrosis Thickened alveolar-capillary membrane

Emphysema Loss of alveolar surface area

Pulmonary embolism Reduced perfusion (less capillary blood volume)

Pulmonary hypertension ↓ Blood flow across membrane

Anemia ↓ Hemoglobin → less CO uptake

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11
Q

Conditions causing Increased TLCO

A

Asthma- Increased pulmonary blood flow + recruitment of capillaries
Pulmonary hemorrhage- CO uptake by intra-alveolar blood
Polycythemia- More hemoglobin available to bind CO
Left-to-right cardiac shunts Increased pulmonary blood volume

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12
Q

Interpreting TLCO and KCO Together

A

TLCO↓ KCO ↓ Emphysema (↓ surface area and poor efficiency)

TCLO↓KCO ↑ Pulmonary fibrosis (small lung volume but normal perfusion per unit)

TLCO↓ Normal KCO Pulmonary vascular disease (e.g., PE)

Normal TLCO ↑KCO Asthma or obesity (small lungs but normal or increased perfusion)
↑TLCO ↑KCO Pulmonary hemorrhage, polycythemia

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13
Q

Criteria for discharge after asthma attack

A

Criteria for discharge
been stable on their discharge medication (i.e. no nebulisers or oxygen) for 12-24 hours
inhaler technique checked and recorded
PEF >75% of best or predicted

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14
Q

Management of acute asthma attack

A

Oh - Oxygen
Shit - Salbutamol
I - Ipratropium
Hate - Hydrocortisone
My - Magnesium
Asthma - Aminophylline

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15
Q

Symptom relief in non CF bronchiectasis

A

inspiratory muscle training + postural drainage

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16
Q

Severity of COPD

A

FEV1 > 80% Stage 1 - Mild - symptoms should be present to diagnose COPD in these patients
50-79% Stage 2 - Moderate
30-49% Stage 3 - Severe
< 30% Stage 4 - Very severe

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17
Q

CURB65 score

A

C Confusion (abbreviated mental test score <= 8/10)
U urea > 7 mmol/L
R Respiration rate >= 30/min
B Blood pressure: systolic <= 90 mmHg and/or diastolic <= 60 mmHg
65 Aged >= 65 years

consider home-based care for patients with a CURB65 score of 0 or 1 - low risk (less than 3% mortality risk)
consider hospital-based care for patients with a CURB65 score of 2 or more - intermediate risk (3-15% mortality risk)
consider intensive care assessment for patients with a CURB65 score of 3 or more - high risk (more than 15% mortality risk)

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18
Q

Differentiating white outs on CXR

A

Trachea pulled toward the white-out
Pneumonectomy
Complete lung collapse

Trachea central
Consolidation
Pulmonary oedema (usually bilateral)
Mesothelioma

Trachea pushed away from the white-out
Pleural effusion
Diaphragmatic hernia
Large thoracic mass

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19
Q

Organism causing IE of COPD

A

H Influenza

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20
Q

Active TB mx

A

Initial phase - first 2 months (RIPE)
Rifampicin
Isoniazid
Pyrazinamide
Ethambutol

Continuation phase - next 4 months
Rifampicin
Isoniazid

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21
Q

Features of Silicosis

A

Mining occupation, upper zone fibrosis, egg-shell calcification of hilar nodes

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22
Q

Pneumonia in an alcoholic bacteria

A

Klebsiella

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23
Q

Pathophysiology behind high Ca in squamous cell

A

High PTHrP
Low PTH

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24
Q

Management of acute bronchitis

A

consider antibiotic therapy if patients:
are systemically very unwell
have pre-existing co-morbidities
have a CRP of 20-100mg/L (offer delayed prescription) or a CRP >100mg/L (offer antibiotics immediately)

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25
A1AT def spirometry picture
Obstructive
26
Mx of sleep apnea
weight loss continuous positive airway pressure (CPAP) is first line for moderate or severe OSAHS intra-oral devices (e.g. mandibular advancement) may be used if CPAP is not tolerated or for patients with mild OSAHS where there is no daytime sleepiness the DVLA should be informed if OSAHS is causing excessive daytime sleepiness
27
Mx of legionella
Macrolides
28
Indication for surgery for bronchiectasis
uncontrollable haemoptysis and localised disease
29
Surgery for a1aT
lung volume reduction surgery, lung transplantation
30
Criteria for asthma discharge
been stable on their discharge medication (i.e. no nebulisers or oxygen) for 12-24 hours inhaler technique checked and recorded PEF >75% of best or predicted
31
Silicosis features
Mining occupation, upper zone fibrosis, egg-shell calcification of hilar nodes
32
Most common organism causing LRTI in cystic fibrosis
Pseudomonas
33
Characteristics of each organisms in resp infections
Klebisiella pneumonia: in alcoholics Streptococcus : CAP, A/w Cold sores Legionella : In air conditioning Staphylococcus: Cavitating lung lesion, preceded by a influenze infection Haemophilus Influenza: in COPD pts Mycoplasma pneumonia: A/w Hyponatremia and Hemolysis Pesudomonas aerogenosa: Cystic firbrosis
34
Mx of IPF
pulmonary rehabilitation pirfenidone or nintedanib if fvc 50-80%
35
Mx of IE COPD
first-line antibiotics are amoxicillin or clarithromycin or doxycycline
36
Investigation to diagnose COPD
Post-bronchodilator spirometry
37
A 68-year-old man with a history of heart failure presents with a 4-day productive cough and wheeze. He is afebrile and examination reveals a diffuse wheeze with no focal signs. Oxygen saturations are 96% on air.
Doxy- treat bronchitis with comorbidities
38
Score for assessing whether PE can be managed as OP
PESI
39
What causes high PTHrP
Squamous cell carcinoma
40
Asbestosis features
Asbestosis typically causes lower lobe fibrosis. The severity of asbestosis is related to the length of exposure. dyspnoea and reduced exercise tolerance clubbing bilateral end-inspiratory crackles lung function tests show a restrictive pattern with reduced gas transfer
41
Reducing treatment in asthma and when
When reducing the dose of inhaled steroids the BTS advise us to do this by 25-50% at a time. After at least 3 months of well-controlled asthma (no exacerbations, minimal symptoms, normal lung function).
42
Prophylactic abx in COPD, what is the criteria to receive it
azithromycin prophylaxis is recommended in select patients patients should not smoke, have optimised standard treatments and continue to have exacerbations other prerequisites include a CT thorax (to exclude bronchiectasis) and sputum culture (to exclude atypical infections and tuberculosis)
43
Next step for Asthmatic symptomatic on moderate-dose ICS/formoterol combination inhaler as maintenance and reliever therapy (MART)
FeNO and eosinophils if either of these is raised, refer to a specialist in asthma care if neither FeNO nor eosinophil count is raised, consider a trial of either a leukotriene receptor antagonist (LTRA) or a long-acting muscarinic receptor antagonist (LAMA) used in addition to moderate-dose MART
44
Ix for erythema nodosum
chest x-ray (to assess for sarcoidosis, tuberculosis, other pulmonary infections, and lymphoma) Throat swab for Group A strep FBC, CRP
45
Mx of first presentation of asthma with night waking
If an adult presents with highly symptomatic asthma (for example, regular nocturnal waking) or with a severe exacerbation then treat the acute symptoms and start MART
46
ABG CO2 retainer
ABG triad for chronic CO2 retention: Normal pH High pCO2 High HCO3
47
2 week history of flu-like illness, accompanied by a worsening dry cough and sore throat. Bloods show raised inflammatory markers and anaemia with elevated reticulocytes and decreased haptoglobin. Mx
Doxycycline or Clarithromycin for mycoplasma Causes haemolytic anaemia
48
Abx on CURB score
Low severity (CURB 0–1 or CRB65 = 0) 1st line: Amoxicillin 500mg TDS 5 days Penicillin allergy: Clarithromycin or doxycycline Moderate severity (CURB 2 or CRB65 = 2) Amoxicillin + Clarithromycin Penicillin allergy: Doxycycline or clarithromycin High severity (CURB or CRB65 ≥ 3) IV Co-amoxiclav + Clarithromycin Penicillin allergy: Levofloxacin
49
What investigations for legionella
Hyponatraemia (SIADH) Deranged LFTs Diagnosis: Urinary Legionella antigen
50
Mx of legionella
Macrolides
51
Features of Chlamydia psittaci ix and mx
Contact with birds, esp. parrots, pigeons, poultry Dry cough and fever (atypical pneumonia picture) Headache and systemic malaise Hepatosplenomegaly and deranged LFTs Diagnosis: Serology 1st line: Doxycycline
52
HIV patient with dry cough and dyspnoea
Pneumocystis jiroveci Usually if CD4 <200
53
Ix of PJP
BAL with silver stain
54
Mx of COVID pneumonitis
Management: Dexamethasone, Remdesivir, IL-6 inhibitors, VTE prophylaxis
55
Aspergilloma vs ABPA
Aspergilloma Colonises an existing lung cavity (which might have been caused by Tb, previous pneumonia, PE, lung cancer etc.) Symptoms: Haemoptysis, cough Imaging: rounded opacity with crescent sign ABPA (Allergic bronchopulmonary aspergillosis) Affects patients with an allergy to aspergillus spores Features: Bronchiectasis, wheeze/cough/SOB due to bronchoconstriction Bloods: eosinophilia High levels IgE Positive RAST to aspergillus Positive IgG precipitins Management: 1st line: Steroids, 2nd line: Itraconazole
56
Occupational asthma
Suspect if adult-onset with improvement on weekends/holidays and noticeably worse at work Causes immediate wheeze and dyspnoea after exposure; lacks systemic features like fever. Common exposures: isocyanates (spray paint), baking (flour), working w/ animals, welding, lab work
57
Cause of upper lobe fibrosis
CHARTSS Coal worker's pneumoconiosis Hypersensitivity pneumonitis Ankylosing spondylitis Radiation Tuberculosis Silicosis Sarcoidosis Nb. CHARTSS are hung 'up' on the walls
58
Cause of lower zone fibrosis
ACID Asbestosis Connective tissue diseases (e.g. RA, SLE) Idiopathic pulmonary fibrosis Drugs: amiodarone, bleomycin, methotrexate, nitrofurantoin Nb. ACIDs have a 'low' pH
59
Sx of fibrosis
Progressive dyspnoea on exertion Dry cough Clubbing Bilateral, fine end-inspiratory crepitations
60
Ix of fibrosis and findings
HRCT: Gold standard for diagnosis (honeycombing, ground-glass)
61
Hypersensitivity Pneumonitis causes
Bird fancier’s Farmer’s lung Mushroom workers
62
Hypersensitivity Pneumonitis sx
Acute phase: Type 3 hypersensitivity reaction (immune complex deposition) Symptoms occur 4-8 hours post exposure - shortness of breath, cough, fever Chronic phase: Type 4 hypersensitivity reaction (T cell mediated) Progressive symptoms which develop after weeks to months of repeated exposure - shortness of breath, weight loss, productive cough
63
Mx of Hypersensitivity Pneumonitis
Management: Steroids, avoid allergen
64
Bloods of sarcoid
Bloods: ↑ ACE, ↑ calcium, ↑ ESR
65
When to give steroids in sarcoidosis
Symptomatic and infiltrates on CXR (in addition to BHL) 2. Hypercalcaemia 3. Eye, heart or neurological involvement
66
Ix of new symptoms suggestive of asthma
1st line: 5-16 years: FeNO 17+: FeNO or Blood eosinophils Diagnose asthma if eosinophils raised of FeNO >50 If non diagnostic: 2nd line: Spirometry with Bronchodilator Reversibility Spirometry with bronchodilator reversibility: FEV₁ increase ≥12% and ≥200mL 3rd line (if spirometry unavailable): PEFR variability > 20% (if spirometry not available) → confirms asthma
67
Indicators of uncontrolled asthma
Exacerbation requiring oral steroids Frequent reliever use (≥3 days/week) Nocturnal symptoms ≥1/week
68
Diagnosis of occupational asthma
Diagnosis: serial PEFR + specialist referral
69
Mx of IE of bronchiectasis
Send sputum culture before starting ABx Initial/empirical antibiotics - amox/clari or co-amox/levoflox if high risk 7-14 days NICE - Admit for IV ABx: temp > 38/ cyanosis/confusion/dyspnoea
70
Causes of bronchiectasis
🦠 Post-infective TB, pneumonia, pertussis 🧬 Genetic Cystic fibrosis, Kartagener’s (PCD + situs inversus + sinusitis) 🧫 Immunodeficiency IgA deficiency, hypogammaglobulinaemia 🦴 Autoimmune Rheumatoid arthritis 🫁 Chronic lung disease Severe/poorly controlled asthma/COPD 🧱 Obstruction Bronchial tumour 🦶 Yellow nail syndrome Thick yellow nails + pleural effusions + bronchiectasis
71
Features of bronchiectasis
copious, mucopurulent sputum Haemoptysis Dyspnoea, fatigue, weight loss
72
Imaging of bronchiectasis
Chest X-ray: ‘Tramlines’ (parallel thickened bronchial walls) Diagnostic investigation of choice: HRCT chest (gold standard): Signet ring sign – dilated bronchus adjacent to artery
73
Mx of bronchiectasis
Chest physiotherapy: Postural drainage, sputum clearance Medical Vaccinations: Annual flu + pneumococcal Bronchodilators: LABA (e.g. formoterol) if SOB LTOT: Consider if PaO2 < 7.3 or SpO2 < 88% Antibiotics: Prophylaxis if ≥3 exacerbations/year: Azithromycin or erythromycin Pseudomonas colonisation: Inhaled colistin
74
Pathogen causing IE Bronchiectasis
H influenza
75
Kartageners features
Young adult w/ chronic cough + chronic sinusitis + situs inversus
76
Persistent colonisation with pseudomonas bronchiectasis
Consider colistin
77
Lung tumour causing plethoric face, engorged neck veins, and symptoms that worsen with arm elevation
superior vena cava (SVC) obstruction. symptoms that worsen with arm elevation (Pemberton’s sign) Dexamethasone is the immediate management of choice
78
2WW Referral lung cancer
Any age with: Chest X-ray suggestive of lung cancer Age ≥ 40 with: Unexplained haemoptysis
79
Urgent Chest X-Ray (within 2 weeks)
Age ≥ 40 with 2 or more unexplained symptoms (1 if ever smoked): Cough Breathlessness Fatigue Chest pain Weight loss Loss of appetite
80
Adenocarcinoma features
Most common type of lung cancer in non-smokers Peripheral location Paraneoplastic features: HPOA Gynaecomastia
81
Carcinoid tumour features on bronchoscopy
Bronchoscopy shows cherry red ball
82
Transudate vs exudate on aspiration
Transudate < 30 g/L, Exudate > 30 g/L
83
When to use Light's criteria
Use when pleural fluid protein is 25–35 g/L. Effusion is exudative if ANY of the following are true: Pleural fluid LDH > 2/3 upper limit of serum LDH Pleural fluid/serum LDH ratio > 0.6 Pleural fluid/serum protein ratio > 0.5
84
When to suspect empyema and mx
Turbid/cloudy fluid pH < 7.2 Low glucose Positive culture/gram stain Place chest drain
85
Diagnosis of COPD
Fev1/FVC < 0.7 post-bronchodilator with no significant reversibility.
86
LTOT criteria for COPD
PaO2 < 7.3 kPa PaO2 7.3–8.0 kPa with one or more of: Cor pulmonale Polycythaemia Pulmonary hypertension CI if smoking
87
Mx of COPD
A - Mild symptoms, ≤1 exacerbation, CAT 0-10 - Any bronchodilator- short or long- long preferred B - Severe symptoms, CAT >10, ≤1 exacerbation - mmRC > 2- LAMA+LABA combo E - LAMA+LABA - ADD ICS if eosinophils > 300 (e.g. trimbow) Anyone favouring ICS or 2 or more exacerbations per year AVOID ICS if recurrent pneumonia, or Eos < 100
88
Mx of pneumothorax
Asymptomatic (any size) Conservative + follow-up Symptomatic + high-risk (e.g. secondary pneumothorax, >50, hypoxia) Chest drain Symptomatic + no high-risk characteristics Needle aspiration or procedure avoidance Avoid scuba diving permanently unless pleurectomy + clearance Follow-up to confirm full resolution
89
Cough/SOB after chest drain
re-expansion oedema → clamp and re-image.
90
IPF antibodies
30% ANA positive
91
Transudative effusions causes
Cardiac failure Liver cirrhosis Nephrotic syndrome
92
Features of strep pneumonia
Rust coloured sputum Rapid onset, may co-occur with HSV (cold sores). Hyponatraemia can occur secondary to SIADH in pneumococcal pneumonia
93
Ix of PE in pregnancy
Baseline: ECG + CXR for all If signs of DVT: USS legs → treat if positive, no further imaging needed Avoids need for CTPA/V/Q adverse effects If no DVT signs: CXR normal: V/Q scan preferable CXR abnormal: CTPA preferable
94
Dry cough, otoscopy of the right ear there are multiple bullous vesicles.
Mycoplasma pneumonia causing bullous myringitis
95
Hx of Kartangers, with haemoptysis and cough what ix is most important
Sputum MCS
96
Criteria for chest drain in pneumothorax
If the patient is asymptomatic - manage conservatively with regular follow up If the patient symptomatic, determine whether they have high-risk characteristics. If high-risk pneumothorax - chest drain insertion is 1st line If low-risk - consider the patient's preferences: Rapid symptom relief - Needle aspiration or chest drain Procedure avoidance - consider conservative management with follow up
97
Ix for OSA
Polysomnography
98
What scoring for OSA and what score suggests sleepiness
Epworth Sleepiness Scale > 10 suggests significant sleepiness
99
Ix if unilateral effusion on CXR
US pleural tap
100
Mx of PE if recently admitted, has end stage renal disease
Warfarin - 3m LMWH until in range
101
What hormone can large cell lung cancer secrete
Can secrete β-hCG, leading to gynaecomastia Large cell, large boobs!
102
Chronic cough, haemoptysis and weight loss. He complains of painful swelling affecting his ankles and wrists.
Hypertrophic pulmonary osteoarthropathy (HPOA). Squamous cell
103
What score should you get a CTPA
5 or more
104
CXR finding of PE
Can see elevated hemidiaphragm
105
What pleural fluid pH suggests empyema
<7.2
106
Protein level in effusion to be exudative
>30g/L
107
What is FEV1%
FEV1/FVC
108
ESRF and well score 9
V/Q scan
109
When to get urgent CXR vs 2ww lung cancer
Urgent Chest X-Ray (within 2 weeks) Age ≥ 40 with 2 or more unexplained symptoms (1 if ever smoked): Cough Breathlessness Fatigue Chest pain Weight loss Loss of appetite 2WW Referral Any age with: Chest X-ray suggestive of lung cancer Age ≥ 40 with: Unexplained haemoptysis
110
Abx prophylaxis for bronchiectasis and who qualifies
Prophylaxis if ≥3 exacerbations/year: Azithromycin or erythromycin
111
Young man, breathlessness, FEV1% 0.88, first degree heart block
Ankylosing spondylitis
112
ARDS criteria
Acute onset (within 1 week of insult) Bilateral opacities on chest imaging (CXR/CT) Hypoxaemia (e.g. PaO₂/FiO₂ < 300 mmHg) despite oxygen therapy Not explained by cardiac failure or fluid overload Normal pulmonary capillary wedge pressure (<18 mmHg)
113
Normal FEV1/FVC ratio
>0.7
114
Reversibility on spirometry suggesting asthma
>12%
115
Rheumatoid arthritis has a chronic productive cough with green sputum, coarse bilateral crepitations, inspiratory squeaks
Bronchiectasis
116
Mycoplasma pneumonia features
Dry (non-productive) cough rather than purulent sputum. Systemic symptoms (fever, myalgia, sore throat). Patchy or bilateral consolidation on imaging. May be associated with haemolytic anaemia (cold agglutinins) or erythema multiforme.
117
Mx of PJP
Co-trimoxazole + steroids if PaO2 < 9.3
118
PE tx with CKD 5
Warfarin with LMWH bridging
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