MRCP Resp Flashcards
What Epworth score and above is OSA and the management including DVLA advice
10 or more
DVLA- lorry driver cannot drive until treated
Mx:
All: weight loss
First line: CPAP at night
Second: Mandibular advancement if CPAP not tolerated or mild OSA
Modafanil for day time sleepiness
Outline lung function test for obstructive and restrictive with examples
Obstructive:
FEV1/FVC <75%
- asthma (normal transfer factor)
- COPD (reduced transfer factor)
- bronchiectasis
- early CF
Restrictive:
FEV1/FVC >75%
- pulmonary fibrosis
- severe obesity
- scoliosis
- sarcoidosis
- asbestosis
- neuromuscular disease
What is the investigation and management of goodpastures?
Renal biopsy
Medical:
- steroid
- cyclophosphamide
- dialysis
- plasma exchange
What is paradoxical hemidiaphragm movement?
With unilateral paralysis of diaphragm, during sniff test in fluoroscopy- normal side descends forcefully -> increasing intraabdo pressure-> pushing the paralysed side up
What is hypogammaglobuninaemia ataxia telangiectasia?
Auto recessive
Deficiency in humoural immunity -> recurrent infection and tumour risk
Progressive ataxia and multiple telangiectasia (bleed)
Risk of bronchiectasis
What should you monitor in GBS for respiratory muscle involvement?
FVC
What is the management of radiation pnuemonitis?
Steroids
for 3-4 weeks
then taper and stop
What is another name for Lyme disease
Borreliosis due to Borellia Burgdoferi
Tick bite
Headache/malaise/fever/facial paralysis/arthritis/erythema migrans
What is hepatopulmonary syndrome
liver failure-> NO release-> cause vasodilation of lung vasculature esp in bases (most oxygen exchange occur here) -> increased perfusion due to AV shunt -> less gaseous exchange as too quick -> hypoxaemia -> desaturation (on standing)
Presentation of GPA
Haemoptysis
Sinusitis
Nasal bridge collapse
Glomerulonephritis
What is the gold standard imaging choice for bronchiectasis?
HRCT
What test should be done pre op in patients with severe RA?
Spirometry - due to cricoarytenoid arthritis can cause stridor post op
Why do you repeat CXR with consolidative pneumonia after 4-6 weeks?
To ensure resolution- if not need to rule out bronchial carcinoma
What is the minimum number of hrs LTOT should be used per day?
15 hours, ideally 18 to maintain pO2 >8
What is the criteria for LTOT?
pO2 <7.3, normal/high pCO2
pO2 7.3-8, with cor pulmonale/peripheral oedema/nocturnal hypoxaemia
What is CREST syndrome and how does it manifest?
Calcinosis
Raynaud
Esophageal dysmotility
Sclerdactyly
Telangiectasis
Scleroderma => interstitial lung disease
What causes FVC to drop from 88% to 55% on lying down?
Diaphragmatic palsy
Note: obesity should not cause a huge drop
What is the BTS guideline for imaging pleural effusion after tap?
- CT thorax for architecture of effusion and cause and possible drain placement
- Bronchoscopy if CT and pleural biopsy non diagnostic
What causes neutrophil infiltrates in transbronchial biopsy and no granuloma?
polyarteritis nodosa.
medium artery vasculitis
What is Histiocytosis X, also known as Langerhans cell histiocytosis?
XS histiocytes - langerhan cells in bronchiolar (immune cell)
forms eosinophilic granuloma- seen as widepread nodules in lungs
CXR- bilateral symmetrical reticulonodular upper/middle zone
When is immunotherapy indicated for anaphylaxis
Latex exposure unavoidable
12 month treatment
slowly injecting allergen with increasing dose
protect for 3-5 years
How do you give mag sulf for acute asthma
single dose 1.2-2g IV over 20min
What is aspergillus precipitins?
IgG ab to aspergillus
(CHRONIC ABPA +/- aspergilloma)
What is Brucellosis?
Zoonotic bacterial infection
FLAW symptoms + arthralgia + GI + neuropsych symptoms
What is Wunchereria bancrofti?
South asian tropical pulmonary eosinophilia
associated with microfilaria
cough/wheeze/fever/weight loss/LL swelling due to lymphatic obstruction
What medical management can you give for SIADH if fluid restriction fails?
demeclocycline
What treatment in COPD has mortality benefit ?
LTOT
What respiratory complications is RA associated with?
Bronchiolitis obliterans- inflamm and scarring of bronchioles-> irreversible obstructive lung
Methotrexate induced fibrosis (lower)
What is caplan syndrome?
RA + pneumoconiosis
Lambert eaton syndrome vs Myaesthenia gravis
Both autoimmune disorders affecting the neuromuscular junction
LEMS: antibodies attacking calcium channels, leading to muscle weakness that improves with use, often starting in the legs, and is associated with small cell lung cancer, mainly in older men with a smoking history.
MG, caused by antibodies attacking muscle cell receptors, results in muscle weakness worsening with use, often beginning in the eyes with drooping eyelids and double vision, and is linked to thymoma, affecting younger women and older men.
Pathophysiology of TB
macrophage migrate to LN
LN and lung lesion = > ghon complex
form granuloma with histiocyte
centre of caseous necrosis
calcified ipsilateral hilar node is Rhanke’s complex
4 Types of hypersensitivity
ACID
Anaphylaxis - IgE
Cytotoxic (activated by antibodies)
Immune complex
Delayed type T cell
Where does aspiration pneumonia commonly affect?
Right upper and middle lobe
What medication would you give for liver capsule pain?
Dexamethasone
Which occupational lung disease predisposes to TB?
Silicosis - toxin to macrophage hence immunocompromises
Which pathogen is associated with increased mortality and is contraindication to lung transplant in CF?
Burkholderia cenocepacia
Which medication should you give in pen allergic CAP?
Doxy/clarithromycin
Note:
Cefalexin cross cover with penicillin
What are the 4 subtypes of aspergillosis?
- aspergilloma - no sx, mild haemoptysis
- invasive- fever/cough/pleuritic chest pain
- ABPA- cough/wheeze/SOB
- Chronic BPA- cough/SOB
What does halo sign on HRCT indicate?
Aspergilloma
What additional test should you perform in patients that present with invasive fungal disease/PCP
HIV
What is the difference between bronchial carcinoid and carcinoid syndrome
Bronchial carcinoid are slow-growing neuroendocrine tumors that originate in the bronchi of the lungs
symptoms like coughing, wheezing, and chest pain due to airway obstruction.
Carcinoid syndrome is a group of symptoms including flushing, diarrhea, and rapid heart rate that occur when a carcinoid tumor secretes serotonin hormones into the bloodstream.
Which scan should be done to assess the nodes prior to further treatment in lung cancer?
PET
Gold standard test for CO poisoning and treatment?
ABG
High levels of oxygen to displace CO
Outline investigation for APBA bronchiectasis
MOST SPECIFIC:
positive (RAST) test to Aspergillus (skin prick)
eosinophilia
CXR- proximal bronchiec
positive IgG precipitins (not as positive as in aspergilloma)
raised IgE
What is contraindication for pneumonectomy in bronchial carcinoma?
FEV1 drop >50%
FEV1 <1.6L
Metastatic lung cancer/distant lymph nodes
SVC obstruction
Malignant pleural effusion
Recurrent laryngeal nerve palsy
Note:
mediastinal LN does not confirm malignant spread
3 hallmarks to suggest ITU review needed in acute asthma
unable to speak in full sentences
peak flow <33%
normocapnia
What is the abx choice for chlamydia pneumonia/atypical pneumonia in pregnancy?
Erythromycin
What is the screening test for TB (previously not had BCG or TB)
Mantoux
> 15mm ACTIVE
6-15- possible
What conditions are associated with T2RF with CO2 rising due to hypoventilation?
Obesity
End stage NMD
Kyophoscoliosis
Ank sponk (fibrosis)
Drug overdose
Give examples of gram negative and positive aerobes and anaerobe that cause pneumonia
Positive aerobe
- staph and strep
Negative aerobe
- klebsiella
Anaerobe
- aspiration
Radiation induced pneumonitis vs chemotherapy induced pneumonitis
Radiation= localised
Chemo= diffuse
What is the function of alpha 1 antitrypsin
prevent neutrophil elastase hence alveolar destruction
What are the respiratory manifestation of CREST syndrome (scl70)
Pulmonary HTN
Pulmonary fibrosis
Which chromosome containing tumour suppressor gene is defective in mesothelioma?
Chr 22
When would you perform CT scan in TB?
When mediastinal nodes are causing upper airway obstruction- stridor
How should you biopsy a lung lesion too small and near mediastinum
Endobronchial ultrasound biopsy
Note: CT guided may not reach
Polymyositis vs dermatomyositis
Muscle
Skin
Proximal myopathy
Small finger joint and nail pathology
Pulmonary fibrosis risk
Which occupational fibrosis show mixed restrictive/obstructive pattern on LFT?
Silicosis
Why does elastic recoil increase with restrictive lung disease?
Tightly stretched rubber band snaps back quick and forcefully.
Fibrotic stiff lungs recoil back more on expiration
What is the firstline medication for newly diagnosed asthma, including pregnancy?
low dose ICS and formoterol
Outline genotype of alpha 1 antitrypsin deficiency
PiMM = normal
PiMZ = associated with smoking
PiSS = 60% normal enzyme, asx
PiSZ = associated with smoking
PiZZ = 10% normal enzyme (CIRRHOSIS + early onset)
Note:
heterozygous= risk with smoking
homozygous= early presentation
What is the most common malignant tumour found in the lung?
metastatic carcinoma
(colon)
How should you manage patient with metastatic lung cancer (to brain) with oedema
dexamethasone
CT head with contrast
Which innate immune cell is antigen presenting cell?
Dendritic cell (KEY) => to t cell
also macrophage
Why is statin stopped during clarithromycin therapy?
CYP3A4 inhibitory effect of abx
What is Gilbert’s syndrome?
Elevated Bilirubin
Normal liver enzymes
Which vitamins are fat soluble?
DAKE
What are the risk factors for MDRTB?
Poor compliance
Previous TB treatment
HIV
contact with drug resistant TB
What is the best predictor of OSA?
Neck size >43cm
What vaccine is contraindicated whilst on high dose steroid?
Live attenuated vaccine
- yellow fever
- MMR
What would indicate mixed metabolic and respiratory acidosis?
Low bicarb
high co2
acidosis
What imaging should be ordered for suspected lung cancer?
CT chest => then bronchoscopy
COPD target sats:
88-92% in acute IECOPD
ABG not showing chronic CO2 retention
- then target sats >94% if patient not admitted for acute respiratory condition
What is the mainstay treatment for bronchiectasis to reduce exacerbations?
postural drainage (physio)
What are the 3 pathophysiology of asthma?
- reversible airway limitation
- hyper sensitive airways to external stimuli
- eosinophilic inflammation causing mucus plug -> smooth muscle hypertrophy -> damage
What is a consequence of inhaled ICS and how can you prevent it?
oral candidiasis
rinse mouth each time inhaled using spacer
What drug treats narcolepsy
modafinil - stimulant
Describe the 2 types of systemic sclerosis
Limited cutaneous
- anti- centromere
- a/w pulmonary hypertension and reduced gas transfer
Diffuse cutaneous systemic sclerosis
- anti-Scl 70
What blood test should be tested for bronchiectasis?
Serum immunoglobulin (IgE, IgA and IgG)
In a post mortum respiratory epithelium of CF patient, what cell type would you see?
Neutrophil infiltration
What is the definitive investigation in assessing inhalation of hot smoke?
Bronchoscopy for upper airway oedema/ulcer
What feature is acute exacerbation of bronchiectasis?
haemoptysis, purulent sputum, fever
What are the commonest form of hypersensitivity pneumonitis?
Farmer’s lung
Bird fancier’s lung
Fibrosis without clubbing
What is the complication of hyponatraemia?
cerebral oedema
What is the histology of bronchial carcinoma?
eosinophilic granular staining of cytoplasm
What is the histology of squamous cell carcinoma?
intercellular bridging
What is the histology of SMALL cell lung carcinoma?
granular salt and pepper nuclear
What is the most common cause of haemoptysis in the UK
Acute infection
PE
TB
Cancer
Rare: Good pasture, PAN, trauma
What is horner’s syndrome and why is this relevant in lung cancer?
Ptosis
Miosis
Anhydrosis
Pancost tumour
What CSF findings do you see in TB meningitis?
Lymphocytosis
Low glucose
High protein
What is the normal dead space?
150ml
What does reduced transfer capacity of CO but normal CO transfer coefficient suggest?
Extrathoracic restriction i.e obesity
What is the risk of lung cancer with smoking and asbestos exposure?
asbestos x5
smoking x10
both together: x50
How can obesity and OSA lead to secondary pulmonary hypertension?
Chronic hypoxia => pulmonary arterial vasoconstriction => pulmonary HTN => RHF
What is an option for drowsy patient requiring NIV?
Intubation
Provided patient is for resus
What is diagnostic of sarcoidosis?
HRCT
Serum ACE may be negatvie
What abx choice for atypical pneumonia and CRUB3 and pen allergic
Levofloxacin (fluoroquinolone)
