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Respiratory MLA revision Eilidh Simpson Final Year ScotGEM StudentABG revision • Respiratory failure: • Type 1: low PO2 = hypoxia • Type 2: Low PO2 AND high CO2: can be compensated (normal Ph ie COPD) or decompensated (high Ph • Respiratory acidosis : • High Co2 = acidosis • With raised bicarbonate = there is some compensation • Respiratory alkalosis: • Low CO2 • Eg: hyperventilation, PE (low Pao2) • Metabolic acidosis: • Low pH; Low bicarbonate • Check anion gap: (Na + K) – (Cl – HCO3) • Normal anion gap:; renal tubular acidosis; Addison’s; Diarrhoea (RAD) • Raised anion gap: lactate (shock, sepsis); ketones (DKA); urate (renal failure); acids (salicylates) • Metabolic alkalosis: • Low pH; high bicarb • Causes: vomiting; diuretics; hypokalaemia; primary hyperaldosteronism; Cushing’s A 65-year-old gentleman with a history of chronic obstructive pulmonary disease (COPD) presents with progressively worsening shortness of breath and a productive cough. He describes an increase in sputum production with the sputum colour changing from clear to yellow. His arterial blood gas (ABG) results are as follows; Normal range pH: 7.22 (7.35 - 7.45) pO2: 7.4 (10 - 14)kPa pCO2: 8.6 (4.5 - 6.0)kPa HCO3: 30 (22 - 26)mmol/l BE: +5 (-2 to +2)mmol/l Based on this information provided, what does his arterial blood gas show? A: Type 2 respiratory failure, acute on chronic respiratory acidosis B: Type 1 respiratory failure, acute on chronic respiratory acidosis C: Metabolic acidosis with partial respiratory compensation D: Metabolic alkalosis with partial respiratory compensation E: Acute respiratory acidosis with complete metabolic compensation A 65-year-old gentleman with a history of chronic obstructive pulmonary disease (COPD) presents with progressively worsening shortness of breath and a productive cough. He describes an increase in sputum production with the sputum colour changing from clear to yellow. His arterial blood gas (ABG) results are as follows; Normal range pH: 7.22 (7.35 - 7.45) pO2: 7.4 (10 - 14)kPa pCO2: 8.6 (4.5 - 6.0)kPa HCO3: 30 (22 - 26)mmol/l BE: +5 (-2 to +2)mmol/l Based on this information provided, what does his arterial blood gas show? A: Type 2 respiratory failure, acute on chronic respiratory acidosis B: Type 1 respiratory failure, acute on chronic respiratory acidosis C: Metabolic acidosis with partial respiratory compensation D: Metabolic alkalosis with partial respiratory compensation E: Acute respiratory acidosis with complete metabolic compensationRemember for MLA • Check pH; check CO2; check bicarb • Remember to look at O2 if they ask for respiratory failure type • Learn main causes of acidosis and alkalosis so it’s easy to spot without having to rely only on ABG • Obstructive disease: • Will have low EV1:FVC ratio <70% • Asthma, COPD Lung • Restrictive disease: Function T est • Both FEV1 and FVC are reduced • FEV1:FVC ratio >70% Revision • Mixed disease: • AND low FVC0% • Step 1: • ICS/LABA for symptom relief • Step 2: Chronic • Low dose MART (ICS + LABA) • Step 3: Asthma • Moderate-dose MART • Step 4: Management • Ch• Raised : refer to specialist • Normal: trial LTRA or LAMA in addition to MART • Step 5: • Refer • Moderate: • PEFR 50-75% • RR <25 • Pulse <110 • Severe: • PEFR 33-50% • Can't complete sentences • RR >25 Acute • Pulse >110 Asthma • Life threatening: • PEFR <33% • Normal CO2 • Silent chest • Exhausion/confusion/hypotension • Near fatal: • Raised CO2 • Oxygen: • 15l non-rebreathe mask • Aim 94-98% • SABA • Nebuliser if life-threatening/near fatal • Steroids: • 40-50mgprednisolone daily for at least 5 days Acute • Continue normal meds alongside • Ipratropium bromide: Asthma • Severe or life-threatening or not responding Management • IV Mg sulphate: • Severe or life-threatening • ITU/MHDU • For discharge: • Been stable for 12-24h • Inhaler technique checked • PEF >75% • General: • Smoking cessation; annual flu vaccine; pneumococcal vaccine; pulmonary rehab • Step 1: • SABA or SAMA Chronic • Step 2: No asthmatic features: COPD • Switch SABA to SAMA Managemen • Step 2: Asthmatic features: • Add LABA + ICS t • Step 3: Asthmatic features: • Change to LABA + LAMA + ICS • Step 4: • Oral theophyliline with abx after trialling LABA • Only if person can't use inhalers • Common causes: • H influenzae; strep pneumoniae; moraxella catarrhalis • 30% of the time is viral • Management: • Increase SABA usage • Give prednisolone 30mg for 5d Acute COPD • Purulent sputum/signs of pneumonia: give amoxicillin/ clarithromycin/ doxycycline Managemen t • Severe exacerbation: • O2 therapy (aim 88-92, via venturi mask) • Nebulised SAMA (salbutamol) or SAMA (ipatropium) • Steroids: consider IV • IV theophylline • May require BiPaPA 52-year-old man presents to the emergency department acutely short of breath. He is unable to complete full sentences and is sitting in the tripod position. He suffers from asthma and this is his second attack this year. On examination, he appears pale and distressed.Auscultation reveals a bilateral wheeze. Observations: • Heart rate: 137 bpm • Respiratory rate: 33/min • Oxygen saturation: 93% on air • Blood pressure: 120/85 mmHg • Temperature: 37.4 deg C An arterial blood gas is taken. pH 7.34 (7.35-7.45) paO2 10 (10.5-13.5) PaCO2 6.2 (5.1-5.6) HCO3 25 (22-26) What is the most worrying finding? A: Heart rate 137bpm B: PaCO2 of 6.2 C: Sats of 93% D: Unable to complete full sentences E: use of accessory musclesA 52-year-old man presents to the emergency department acutely short of breath. He is unable to complete full sentences and is sitting in the tripod position. He suffers from asthma and this is his second attack this year. On examination, he appears pale and distressed.Auscultation reveals a bilateral wheeze. Observations: • Heart rate: 137 bpm • Respiratory rate: 33/min • Oxygen saturation: 93% on air • Blood pressure: 120/85 mmHg • Temperature: 37.4 deg C An arterial blood gas is taken. pH 7.34 (7.35-7.45) paO2 10 (10.5-13.5) PaCO2 6.2 (5.1-5.6) HCO3 25 (22-26) What is the most worrying finding? A: Heart rate 137bpm Remember that CO2 increasing suggests B: PaCO2 of 6.2 exhaustion C: Sats of 93% D: Unable to complete full sentences E: use of accessory musclesA 28 year old woman has pain on swallowing. She has asthma that is well controlled using metered dose salbutamol and beclometasone dipropionate (800 micrograms/day) inhalers. She has white plaques in her mouth. An anti-fungal oral suspension is prescribed. What is the most appropriate management with regard to her beclometasone? A. Change beclometasone dipropionate to a dry powder formulation B. Change beclometasone dipropionate to fluticasone C. Change beclometasone dipriopionate to salmeterol D. Take beclometasone dipropionate using a large volume spacer E. Take salbutamol and beclometasone dipropionate at least 1h apartA 28 year old woman has pain on swallowing. She has asthma that is well controlled using metered dose salbutamol and beclometasone dipropionate (800 micrograms/day) inhalers. She has white plaques in her mouth. An anti-fungal oral suspension is prescribed. What is the most appropriate management with regard to her beclometasone? A. Change beclometasone dipropionate to a dry powder formulation B. Change beclometasone dipropionate to fluticasone C. Change beclometasone dipriopionate to salmeterol D. Take beclometasone dipropionate using a large volume spacer This patient has developed oral candidiasis E. Take salbutamol and beclometasone dipropionate at least 1h apart and this is most likely due to local deposition of the inhaled steroid (beclometasone dipropionate). The risk of this happening again can be reduced by using a large volume spacer as there will be less local deposition of the drug in her mouth. Changing to a dry powder or a different steroid inhaler is unlikely to help and may make things worse.Remember for MLA • Learn the steps for asthma and COPD management • Remember to check for asthmatic features in COPD • Asthma patients need to be stable for at least 12h before they leave • Look at CO2 to see if life-threatening or near fatal asthma • Inflammation and fibrosis of lung tissue • Idiopathic pulmonary fibrosis: • Bibasal fine end expiratory crackles • Clubbing • Can use: pirfenidone, nintedanib to slow progression Interstitial • High res CT thorax: ground glass • Secondary pulmonary fibrosis: lung disease • Caused by drugs: amiodarone, cyclophosphamide, methotrexate, nitrofurantoin • Hypersensitivity pneumonitis: • Type II and IV reactions • Eg bird fancier’s lung, farmer’s lung • Cryptogenic organising pneumonia: • Similar to pneumonia, with focal consolidation • Asbestosis: • Lung fibrosis • Link to mesothelioma • Permanent bronchi dilation • Key features: • Productive cough • Recurrent chest infections • Weight loss • Finger clubbing Bronchiectasis • Scattered wheeze, squeaks and crackles • Investigate: • Sputum culture • Haemophilus influenzae ; pseudomonas aeruginosa • Manage: • Vaccines, resp PT, abx, LABA, O2, surgery, transplant • Chronic granulomatous disorder • Typical patient: • 20-40y old • Black female • Dry cough, SOB • Erythema nodosum • Lofgren’s syndrome: • Erythema nodosum • Bilateral hilar lymphadenopathy Sarcoidosis • Polyarthralgia • Diagnosis: • Bloods:ACE; hypercalcaemia • Imaging: CXR, high res CT • Management: • Conservative if mild • Oral steroids • Methotrexate • Lung transplant A 60 year old man has 6 months of dry cough and increasing shortness of breath on effort. He was previously fit and well, and is a non-smoker. His temperature is 36.8°C, pulse rate 60 bpm and oxygen saturation 89% breathing air. He has finger clubbing. Cardiac examination is normal, and chest examination reveals bibasal crepitations. Which is the most likely diagnosis? A. Bronchiectasis B. Extrinsic allergic alveolitis C. Idiopathic pulmonary fibrosis D. Lung carcinoma E. Pulmonary tuberculosis A 60 year old man has 6 months of dry cough and increasing shortness of breath on effort. He was previously fit and well, and is a non-smoker. His temperature is 36.8°C, pulse rate 60 bpm and oxygen saturation 89% breathing air. He has finger clubbing. Cardiac examination is normal, and chest examination reveals bibasal crepitations. The dry cough, increasing shortness of breath on exertion, hypoxia, finger clubbing and bibasal crepitations are all in keeping with IPF. Which is the most likely diagnosis? A. Bronchiectasis Lung cancer is less likely as the patient is a non- B. Extrinsic allergic alveolitis smoker and the signs are bilateral in the chest. C. Idiopathic pulmonary fibrosis Extrinsic allergic alveolitis is a possible correct D. Lung carcinoma answer but it is less common than IPF and it is usually E. Pulmonary tuberculosis associated with a history of exposure to a specific antigen. Pulmonary TB is less likely as there is no fever, the cough is dry and the signs are bibasal.A 22 year old woman has worsening shortness of breath and cough productive of four to five tablespoons of sputum per day. She had childhood pneumonia and recurrent chest infections. She coughed up blood on two occasions many years ago. She has bilateral scattered wheezes and coarse inspiratory crackles. Which is the most likely diagnosis? A. Bronchiectasis B. COPD C. Lung cancer D. Pulmonary fibrosis E. SarcoidosisA 22 year old woman has worsening shortness of breath and cough productive of four to five tablespoons of sputum per day. She had childhood pneumonia and recurrent chest infections. She coughed up blood on two occasions many years ago. She has bilateral scattered wheezes and coarse inspiratory crackles. Bronchiectasis is most likely due to the copious sputum production, and the history of childhood pneumonia and recurrent chest infections. Cystic fibrosis should be considered also as a cause of the bronchiectasis. Often there are coarse crackles on examination Which is the most likely diagnosis? and there may be wheeze if there is an exacerbation. A. Bronchiectasis Haemoptysis can be a feature of bronchiectasis especially when B. COPD there is an exacerbation. C. Lung cancer COPD and lung cancer are very uncommon in this age group. D. Pulmonary fibrosis E. Sarcoidosis Pulmonary fibrosis generally has fine crackles and copious sputum production is less common. Sarcoidosis can cause fine crackles also, but it is unusual in this age group and it does not usually present with recurrent chest infections and copious sputum production.A 52 year old man has 4 weeks of joint pain, fever and weight loss. He is a non-smoker and has no significant medical history. Examination is unremarkable. Investigations: Calcium 3.12 mmol/L (2.2–2.6) Phosphate 0.82 mmol/L (0.8– 1.5) Serum alkaline phosphatase 154 IU/L (25–115) Parathyroid hormone 7.9 pmol/L (1.6–8.5) Serum electrolytes and urea are normal. Which is the most likely diagnosis? A. Granulomatosis with polyangiitis B. Hodgkin's lymphoma C. Primary hyperparathyroidism D. Sarcoidosis E. TuberculosisA 52 year old man has 4 weeks of joint pain, fever and weight loss. He is a non-smoker and has no significant medical history. Examination is unremarkable. Investigations: Calcium 3.12 mmol/L (2.2–2.6) Phosphate 0.82 mmol/L (0.8– 1.5) Serum alkaline phosphatase 154 IU/L (25–115) Parathyroid hormone 7.9 pmol/L (1.6–8.5) Serum electrolytes and urea are normal. The most likely diagnosis is sarcoidosis due to the history, elevated calcium and perihilar lymphadenopathy. The elevated calcium and low parathyroid hormone can occur in sarcoidosis Which is the most likely diagnosis? due to increased production of 1,25-dihydroxyvitamin D by activated macrophages in the granulomas. A. Granulomatosis with polyangiitis Hodgkin’s lymphoma and tuberculosis can also cause B. Hodgkin's lymphoma lymphadenopathy, weight loss and fever but hypercalcaemia is C. Primary hyperparathyroidism less likely. D. Sarcoidosis E. Tuberculosis The normal plasma parathyroid hormone level makes primary hyperparathyroidism less likely. Granulomatosis with polyangiitis may present with joint pain and fever but does not usually cause hypercalcaemia.Remember for MLA • Imaging findings: • Bronchiectasis: • CXR: tram track opacities; ring shadows • IPF: • High res CT: ground glass appearance • Sarcoidosis: • CXR: hilar lymphadenopathy • High res CT: hilar lymphadenopathy, pulmonary nodules • Rule out answers based on what it says in the question • Presents with: • Productive cough; fever; haemoptysis; pleuritic chest pain; delirium • Signs: • Bronchial breath sounds; focal coarse crackles; dull to percuss Pneumonia • Score: CURB-65 for mortality : 0-3 • Causes: • Strep pneumoniae (most common) • Haemophilus influenzae • Remember atypical causes of pneumoniaA 65-year-old woman presents with shortness-of-breath associated with a productive cough. A chest x- ray is done on admission. What does the chest x-ray show? A. R middle lobe pneumonia B. Pulmonary oedema C. R upper lobe collapse D. Bronchiectasis E. R sided pneumonia + pneumothoraxA 65-year-old woman presents with shortness-of-breath associated with a productive cough. A chest x- ray is done on admission. What does the chest x-ray show? A. R middle lobe pneumonia B. Pulmonary oedema C. R upper lobe collapse D. Bronchiectasis E. R sided pneumonia + pneumothoraxRemember for MLA • Remember atypical causes of pneumonia • Legionella • Hyponatremia • Air con • Chlamydia psittaci • birds • Mycoplasma pneumoniae • Assoc with erythema multiform • Chlamydophila pneumoniae • School age children • Coxiella burnetti • Linked to animal body fluids • Pneumonia CXR: area of consolidation possibly with pleural effusionReferences • https://www.passmedicine.com/menu.php • https://zerotofinals.com/ • https://www.medschools.ac.uk/media/3028/akt-practice-mla-paper-1-with-answers- and-justifications.pdf