Isce Resp

Front 1

DDx Pleural Effusion

Back 1

Pul oedema
Consolidation –pneumonia
Exacerbation of chronic lung disease- COPD, asthma
Lung cancer
Pneumothorax if breathless

Front 2

Investigations for Pleural Effusion

Back 2

Beside- sputum, PEFR, temperature
-FBC- signs of infection, look at Hb chronic infection
-U&E- in terms of suspected malignant cause it is important to have a baseline as contrast is used in CT which will be part of workup.
-CRP- inflammation
-Spirometry
-CXR
-Thoracocentesis- look for color, biochemistry, gram stain, cell count and differentiation, cytopathology
-CT PET if suspected malignancy

Front 3

MGMT Pleural Effusion

Back 3

-transudate: manage underlying cause
-drain gradually to prevent rapid shift of mediastinum
CXR
-if not adequately drained by needle/small bore catheter, surgical intervention
-chemical pleurodesis with talc/bleomycin for recurrent
-pleurx catheter also for refractory

Front 4

Transudate vs. exudate

Back 4

transudate <30g protein (caused by decreased oncotic pressure/increased hydrostatic pressure)
exudate >30 g protein. altered permeability of membranes/capillaries.

Front 5

Light criteria for pleural effusion

Back 5

EXUDATE
if ratio of protein pleural:serum >.5
if ratio of LDH pleural:serum >.6

Front 6

definition of pleural effusion

Back 6

abnormal collection of fluid between the pleura due to increased production/impaired reabsorption. normally 1 ml.

Front 7

atypical pneumonia

Back 7

legionella, mycoplasma, PCP, chlamydia psittici

Front 8

CURB 65 score

Back 8

predicts mortality and guides management with abx.
C: confusion amts 8 or less
U: urea >7
R: rr >30
B: BP systolic >90, diastolic<60
>65.

0-1- outpatient treatment
2 short stay in hospital
3-5 hosp/ICU

Front 9

characteristics of interstitial lung dz/ pulm fibrosis

Back 9

scar tissue in lungs
decreased compliance (restrictive pattern on PFT-
Fev1/FCV>80%)
endstage honeycomb lung, cystic spaces
. can be localised (pneumonia), bilateral (tb), widespread (ipf)

Front 10

causes of pul fibrosis

Back 10

think SARCOID
systemic sclerosis
asbtestosis
rheumatoid
connective tissue disorders
occupation (coal workers pneumoconiosis, farmers extrinsic allergic alveolitis)
idiopathic (most common)
drugs (mtx, amiodorone, cyclophosphamide, gold)

Front 11

Pulmonary fibrosis si/sx
(4 D's)

Back 11

dry cough, dyspnoea, digital clubbing, diffuse inspiratory crackles

also, reduced chest expansion, fine late crackles, central cynaosis, cor pulm, pul htn late in dz.

Front 12

MGMT idiopathic PF

Back 12

high dose prednisolone for 6 weeks followed by taper. few respond well.
can also use immunosuppression (azothioprine and cyclophosphimide)
poor prog- most die within 5 yrs

Front 13

Asbestos exposure related lung dz

Back 13

blue is worst, white is lest dangerous
lag of 20-40 years from exposure
pleural plaques and thickening
ca. bronchus
asbestosis
mesothelioma

Front 14

extrinsic allergic alveolitis features:

Back 14

type III (Immune complexes) and IV (cell mediated) HS.
acute: SOB, cough, fever within hours
chronic- fibrosis Sx
CXR: upper zone fibrosis

Front 15

mgmt
extrinsic allergic alveolitis

Back 15

remove from allergen.
acute: o2, hydrocortisone 200 mg IV, oral pred 40 mg.
chronic: long term steroids

Front 16

DDX
extrinsic allergic alveolitis

Back 16

COPD, asthma, bronchiectasis, CHF, atypical pneumonia, lung Ca

Front 17

Investigations
extrinsic allergic alveolitis

Back 17

fbc- anemia
ESR/CRP
ANA (+30%), RF (+50%)
ABG
PFT- restrictive. follow progression
reduced TLC, RC, RV, TF
CXR may be normal, or shot reticular/nodular opacities. honeycomb is late.
HRCT more sensitive- ground glass
Bx

Front 18

Bronchiectasis defn

Back 18

a COPD with inflamed airways that are easily collapsible. result in obstruction and SOB. impaired clearance of secretions.

Front 19

Bronchiectasis causes

Back 19

congenital,
mechanical obstruction (extrinsic or intrinsic),
post-infective,
granuloma,
diffuse lung dz (ipf),
immune deficiency,
mucociliary clearance defects.

Front 20

Bronchiectasis classic si/sx

Back 20

sx: chronic cough, excessive sputum, foetor, hemoptysis at some stage, chronic sinusitis.

si: anemia CD, cyanosis, crackles, wheeze, corpulm.

Front 21

Bronchiectasis Investigations

Back 21

cxr- normal in 10%. ring shadows/tramlines/cysts
HRCT- confirms. signet rings. 97% sensitive
sputum: C & S for abx
Serum Ig for cause
sinux xray
saccharin test- mucociliary clearance
PFT- obstructive
ABG if RF

Front 22

Bronchiectasis MGMT

Back 22

postural drainage- physio
bronchodilators- beta ags, antichol, and inh. steroid
ABX- high dose and longer (10-14 days) ie cefaclor, cipro, fluclox if SA
O2, LTOT if chronic
Lobe resection if massive hemoptysis.
Transplant if young and fev1<30

Front 23

CF presenting complaints

Back 23

Perinatal- screening, meconium ileus
Child/adult: malabsorption, RTI's +purulent sputum, atypiccal asthma, electrolyte disturbance
adult: bronchiectasis, infertility in males

Front 24

CF complications

Back 24

liver dz,
wt. loss,
hemoptysis,
pneumothorax,
resp. failure,
osteoporosis,
nasal polyps,
DM,
infertility (males)

Front 25

CF signs

Back 25

clubbing
cough + purulent sputum
crackles
wheezes
obstructive pattern
maybe cor pulm

Front 26

CF investigations

Back 26

sweat test (98% sens)
cftr gene
sinus xr/ct shows opacification
cxr/ct lung
pft. only reliable after age 6
sputum micro
fbc, u/e, glucose, lft only abnormal of >4x normal. vitamin adek

Front 27

CF MGMT- prevention

Back 27

prevention: physio for clearance
Inhaled mannitol, pulmozyme for increased clearance
reduce exacerbations with inhaled tobramycin, bronchodilators, high dose ibuprofen

complications:
pnemonia

Front 28

CF MGMT- complications

Back 28

complications:
pnemonia- abx, hemoptysis, pneumothorax, RF. Tx may be necessary
nasal polyps: topical steroids, or -ectomy
pancreatic insuff: enzymes (creon) before meals
nutriton: adek vitamins and high protein meals
liver dz- ursodoexycholic acid improves bile flow/transplant
DM- insulin
reproductive- IVF and gene counceling
osteoporosis- ca, vit d, dexa scans, bisphosphonates

Front 29

asthma defn

Back 29

chronic obstructive inflammatory disease leading to narrowing of airways and causing reversible airway obstruction
hypersensitivity of airways- triggers cause bronchospasm and excessive secretion

Front 30

asthma features

Back 30

polyphonic wheeze, sob, cough, chest tightness. worse at night, with dust, air and exercise.

Front 31

asthma exam points

Back 31

breathing: fast? laboured? anxious? speaking in full sentences? acessory muscles? pursed lips? cyanosis? hypervenilation?
ratio of insp: exp normal is 2:1
chronic asthma may have harrison's sulci - childhood

Front 32

asthma Dx

Back 32

mainly clinical, spirometry is preferred.
divide into high, int, low probability based on sx.
High: FEV1/FVC <.7 trial of Rx.
Int: FEV1/FVC>.7 investigate
low: investigate/treat other condition

a 400 ml improvement in FEV1 after salbutamol is considered significant.

peak flow less sensitive. look for diurnal variation % greater than 20% over 2 weeks.

Front 33

ASTHMA stepwise MGMT

Back 33

control extrinsic factors
1. mild intermittent: inhaled SABA as req.

2. regular preventer: +inhaled steroid (200-800 mcg/d). 400 starting

3. initial add on: a. LABA b. assess control- if good, continue. if inadequate, LABA + more steroid (800). if no response to LABA, stop LABA and increase steroid to 800. try LR antag/theophylline

4. persistent poor control: consider increasing steroid to 2000 mcg/d, add LRA, THeo, B2 ag tablet

5. use of steroids: daily steroid in lowest dose to maintain control. refer.

Front 34

ASTHMA acute MGMT

Back 34

1. O2- via facemask/cannulae. 94-98%

2. B2 ag in nebulizer or IV for those who cant inhale. repeat 15-30 min or continuous 5-10 mcg.hr
3. steroid- pred 40-50 mg po or IV hydrocortisone 400 mg/day. continue pred for atleast 5 days
4. Ipra. add to b2 ag treatment if life threatening or poor response. .5 mg/4-6 hourly
5. MgSo4. single dose 1.2-2 IV over 20 min when poor response or life threatenting.

Front 35

when to refer asthma to ITU

Back 35

requires ventilation
acute severe not respondin:
falling PEF, worsening or persistent hypoxia, hypercapnia, ABG- acidosis, exaustion/confusion, respiratory arrest.

Front 36

signs of severe asthma

Back 36

cant complete sentences in one breath
tachy >110
rr >25
<50% PEFR

Front 37

signs of life threatening asthma attack

Back 37

<33 pefr
<92% sat
Cyanosis- 84-85%
Hypotension
Exhaustion
Silent Chest
Tachy/Brady cardia

Front 38

COPD Def

Back 38

Progressive, irreversible airway obstruction usually due to smoking- incl chronic bronchitis, emphysema or both.

Front 39

COPD Si

Back 39

although may not have any
cachexia
hyperinflation
pursed lips
accessory muscles
paradoxical mvmt of lower ribs
reduced cricosternal distance
wheeze/quiet breath sounds
reduced cardiac dullness on percussion
peripheral edema
cyanosis
raised JVP

Front 40

COPD Dx

Back 40

FEV1/FVC <.7 if FEV1 >80%, dx should only be makde in presence of sx.

pts over 35 who have a risk factor and prsent with one or more:
exertional breathlessness (MRC scalre_
chronic cough
regular sputum production
frequent winter bronchitis
wheeze
ask about wight loss, exercise intolerance, night waking, ankle swelling, fatigue

Front 41

MRC breathlessness scale

Back 41

1- only on strenuous excercise
2-sob when hurrying or walking on slight hill
3-walks slower than contemporaries on level ground, or stops for breath at own pace
4- stops for breath after 100 m or few minutes on level ground
5- cant leave house, breathless when dressing

Front 42

COPD MGMT

Back 42

stop smoking.
annual vaccination-flu
one off pneumonia vaccine
SABA/SAMA
if still breathless/exacerbations, Rx determined by Fev1
FEV1 >50%, LABA, or LAMA
FEV1<50% combo inhaler LABA + ICS or LAMA

oral theo, mucolytics, cor pulm: loop D, LTOT

Front 43

things that can improve survival in stable COPD

Back 43

smoking cessation
LTOT
lung volume reduction surgery (remove bullae, allows reinflation)

Front 44

COPD Investigations

Back 44

spirometry. however, poor predictor of QOL and disability

Dx if FEV1/FVC <.7 and FEV1 <80%

stage1: mild 80% or above with Sx
stage 2 moderate: 50-79%
3: severe 30-49%
4 very severe <30% or FEV1 <50 but with resp. failure.

if reversible with bronchodilators- reconsider Dx

FBC- anemia/polycy
CXR to exclude
BMI
alpha 1 anti trypsin if early or non-smoker
TLCO to ix symptoms out of proportion to pft
pulse ox to assess need for LTOT, if cor pulp, cyanosis, or fev1<50

peak flow no use.

Front 45

copd complications:

Back 45

cold weather
infective:
Haem. infl., S. Pneum, M. Catarr, Viruses (30%)

patients with frequent infective exacerbations should be given home course of steroid and abx and encouraged to use if purulent sputum.

Cor Pulm due to vasocontriction in lung due to hypoxia

Front 46

managing complications of copd

Back 46

broncodilators by nebuliser: SABA 2.5-5 mg & SAMA 500mcg with pred 30 mg/day 5-7 days

if hx of purulent sputum or CXR consolidation, ABX (RD & E say doxy po 200 stat hen 100 mg OD 5/7)
O2 aim for 88-92 via venturi mask at home or 24% in hospital pending ABG
if still acidotic, NIV

Front 47

LTOT

Back 47

at least 15 hrs a day
if obs very severe (<30% fev)
consider if severe (30-49)
cyanosis, poly cy, edema, JVP, o2 <92 on room air

measure abg 3 weeks apart

offer LTOT to those with pa02 7.3-8 AND 2ndary polycy, noctural hypoxemia, edema, pulm htn.

decreases risk of cor pulm.

Front 48

COPD pathophys, main points

Back 48

chronic inflammation taht affects central airways, periph. airways, parenchyma and alveoli, and vasculature of lung
narrowing and remodelling of airways. increased number of goblet cells (reid index), enlargement of mucus secreting glands of central airways, and vascular bed changes leading to hypertension.
inflammatory- macrophages, neuts, leuks
not eosinophils (unlike asthma).
emphysema- elastin breakdown and loss of alveolar integrity.
chr. bronchitis- ciliary dysfunction and increased goblet cell size and number, more mucus secretion.
both are PROGRESSIVE AND NOT REVERSIBLE
increased airway resistance. decreased recoil, fibrotic changes in parenchyma, and luminal obstruction all contribut to resistance.
expiratory flow limitiation contributes to hyperinflation. these changes lead to hypoxia. vascular smooth muscle thickening with subsequent pulm hypertension which is late and indicates poor prog.