Pulmonology

Question 1

Clubbing definition

Answer 1

Bogginess and increased fluctuance of nailbed

Soft tissue expansion of distal phalanx

Question 2

Respiratory causes of clubbing

Answer 2

Lung cancer

• bronchial
• mesothelioma

Chronic lung suppuration

• empyema
• bronchiectasis, CF

Fibrosis

• Idiopathic pulmonary fibrosis
• TB

Question 3

Cardiac causes of clubbing

Answer 3

Infective endocarditis
Congenital cyanotic heart disease
Atrial myxoma

Question 4

GI causes of clubbing

Answer 4

Cirrhosis 
Crohn's
ulcerative colitis
Coeliac
Cancer, GI lymphoma

Question 5

Other causes of clubbing

Answer 5

Familial
thyroid acropachy
upper limb av malformations

Question 6

Cyanosis definition

Answer 6

Blue discoloration of mucosal membranes or skin

Deoxygenated blood Hb>5g/dL

Question 7

Classifying cyanosis

Answer 7

peripheral - cold with blue nails

central - blue tongue and lips

Question 8

Respiratory causes of cyanosis

Answer 8

hypoventilation - copd msk
decreased diffusion of gases - pulmonary oedema and fibrosing alveolitis
V/Q mismatch - PE, AVM

Question 9

Cardiac causes of cyanosis

Answer 9

Congenital - Fallot, transposition great vessels

Decreased CO
- Mitral stenosis, LV failure

Vascular

• Raynauds
• DVT

Question 10

RBC causes of cyanosis

Answer 10

Low affinity Hb

may be hereditary or acquired

Question 11

Anatomical classification of pneuonia

Answer 11

Bronchopneumonia
- patchy consolidation of both lobes

Lobar pneumonia

• fibrosuppurative consolidation of a single lobe
• Congestion → red → grey → resolution

Question 12

Aetiological classification of pneumonia

Answer 12

Community acquired pneumonia

• usually strep pneum or haemophilus
• viruses 15%

Hospital acquired pneumonia

• > 48 hours after hospital admission
• gram negative enterobacteria eg Staph aureus

Question 13

Aspiration pneumonia

Answer 13

High risk patients

• stroke
• bulbar palsy
• low GCS
• GORD
• Parkinsons
• achalasia

Mostly caused by anaerobes

Question 14

Pathogens causing pneumonia in the immunocompromised

Answer 14

TB
Fungi
CMV
HSV

Question 15

Pneumonia symptoms

Answer 15

Fever
Rigors
malaise and anorexia
Dyspnoea
Cough 
Purulent sputum
Haemoptysis 
Pleuritic pain

Question 16

Signs of pneumonia

Answer 16

 ↑RR, ↑ HR
 Cyanosis
 Confusion

Consolidation
 ↓ expansion
 Dull percussion
 Bronchial breathing 
 ↓ air entry
 Crackles
 Pleural rub
 ↑VR

Question 17

Investigations pneumonia

Answer 17

 Bloods: FBC, U+E, LFT, CRP, culture, ABG (if ↓SpO2)

 Urine: Ag tests (Pneumococcal, Legionella)

 Sputum: MC&S

 Imaging: CXR
 infiltrates, cavities, effusion

 Special
 Paired sera Abs for atypicals Mycoplasma, Chlamydia, Legionella
 Immunofluorescence (PCP) 
 BAL bronchiiolar lavage 
 Pleural tap

Question 18

Assessing pneumonia severity

Answer 18

CURB-65 only used if Xray changes

Confusion < 8 AMTS
Urea > 7mM
Respiratory rate >30
Blood pressure <90/60
>65 years old 

Scores 0-1 = Home treatment
2 == Hospital treatment
3+ == Consider ITU

Question 19

Management pneumonia

Answer 19

General protocol 
 Abx
 O2: PaO2≥8, SpO2 94-98%
 Fluids
 Analgesia
 Chest physio
 Consider ITU if shock, hypercapnoea, hypoxia
 F/up @ 6wks  ̄c CXR
 Check for underlying Ca

Question 20

Antibiotics for CAP

Answer 20

Mild:
amoxicillin 500mg TDS PO for 5d
or clarithro 500mg BD PO for 7d

Mod
amoxicillin 500mg TDS
and clarithro 500mg BD PO/IV (clarithro alone if pen allergy) for 7d

Sev
Co-amoxiclav 1.2g TDS IV / cefuroxime 1.5g TDS IV
and clarithro 500mg BD IV for 7-10d
Add fluclox if staph suspected.

Atyp
Chlamydia: tetracycline
PCP: Co-trimoxazole
Legionella: Clarithro + rifampicin

Question 21

Antibiotics for HAP

Answer 21

 Mild / <5d: Co-amoxiclav 625mg PO TDS for 7d

 Severe / >5d: Tazocin ± vanc ± gent for 7d

Question 22

Aspiration pneumonia antibiotics

Answer 22

 Co-amoxiclav 625mg PO TDS for 7d

As tend to be the anaerobes as causatives

Question 23

Pneumonia vaccine

Answer 23

Pneumovax 23 valent

• > 65
• Chronic heart, liver, kindey, pancreas failure
• Diabetes
• Immunosuppression

revaccinate every 6 years

Question 24

Complications of pneumonia

Answer 24

Respiratory failure 
Hypotension 
AF
Pleural effusion 
Empyema 
Lung abscess
Sepsis 
Pericarditis 
Jaundice

Question 25

Hypotension in pneumonia

Answer 25

 Cause: dehydration + septic vasodilatation Mx  If SBP<90 → 250ml fluid challenge over 15min  If no improvement: central line + IV fluids  If refractory: ITU for inotropes

Question 26

Pleural effusion in pneumonia

Answer 26

Exudate - inflammatory Mx: - pleural tap - send for MCS, cytology and chemistry

Question 27

Empyema of pneumonia

Answer 27

Pus in the pleural cavity Anaerobes, staph, gram -ve associated with anaerobes and aspiration a patient with resolving pneumonia develops recurring fever Pleural tap == turbid pH <7.2, low glucose, High LDH Mx; US guided drain and ABx

Question 28

Lung abscess causes

Answer 28

often a complication of pneumonia - aspiration - bronchial obstruction - tumour, foreign body - Septic emboli - sepsis, IVDU, RH endocarditis - Pulmonary infarction - Subphrenic, hepatic abscess

Question 29

Features of lung abscess

Answer 29

``` Swinging fever cough foul purulent sputum haemoptysis malaise, weight loss Pleuritic pain Clubbing Empyema ```

Question 30

Investigations for lung abscess

Answer 30

 Blood: FBC, ESR, CRP, cultures  Sputum: micro, culture, cytology  CXR: cavity ̄c fluid level  Consider CT and bronchoscopy

Question 31

Bronchiectasis pathophysiology

Answer 31

chronic infection of bronchi/bronchioles leads to permanent dilation Less efficient clearance leads to retained inflammatory secretions and microbes == airway damage and recurrent infection causative agents: - H.influenza - Pneumococcus - S aureus - Pseudomonas

Question 32

Bronchiectasis causes

Answer 32

idiopathic = 50% Congenital - CF - Young's syndrome (azoospermia and bronchiectasis) Post infectious - Measles - pertussis - pneumonia - TB - bronchiolitis Immunodeficiency - hypogammaglobulinaemia

Question 33

Symptoms bronchiectasis

Answer 33

Persistent cough and purulent sputum Haemoptysis Fever and weight loss

Question 34

Bronchiectasis signs

Answer 34

clubbing coarse inspiratory crackles wheeze purulent sputum

Question 35

complications of bronchiectasis

Answer 35

``` Pneumonia pleural effusion pneumothorax pulmonary HTN amyloidosis cerebral abscess ```

Question 36

bronchiectasis investigations

Answer 36

Sputum: MCS Blood: Se Ig, Aspergillus precipitins, RF, α1-AT level Test Ig response to pneumococcal vaccine CXR: thickened bronchial walls (tramlines and rings) Spirometry: obstructive pattern HRCT chest  Dilated and thickened airways  Saccular dilatations in clusters ̄c pools of mucus Bronchoscopy + mucosal biopsy  Focal obstruction  PCD primary ciliary dyskinesia CF sweat test (pilocarpine iontopheresis)

Question 37

Treatment bronchiectasis

Answer 37

 Chest physio: expectoration, drainage, pulm. rehab  Abx for exacerbations: e.g. cipro for 7-10d  Bronchodilators: nebulised β agonists  Treat underlying cause  CF: DNAase  ABPA: Steroids allergic bronchopulmonary aspergillosis  Immune deficiency: IVIg  Surgery may be indicated in severe localised disease

Question 38

Cystic fibrosis pathogenesis

Answer 38

 Auto recessive, 1:2000 live Caucasian births  Mutation in CFTR gene on Chr 7 (commonly ∆F508)  → ↓ luminal Cl secretion and ↑ Na reabsorption → viscous secretions.  In sweat glands, ↓ Cl and Na reabsorption → salty sweat

Question 39

Clinical features of CF

Answer 39

neonate - FTT - meconium ileus (even stickier than normal and causes obstruction) - rectal prolapse Children - nasal polyps and sinusitis resp: cough wheeze, infections, bronchiectasis, haemoptysis, pneumothorax, cor pulmonale GI: pancreatic insufficiency, diabetes, steatorrhoea, distal intestinal obstruction syndrome, gallstones, secondary biliary cirrhosis Male infertility, osteoporosis, vasculitis

Question 40

Signs of CF

Answer 40

clubbing cyanosis bilateral coarse crepitations

Question 41

Common respiratory infections in CF

Answer 41

Early  S. aureus  H. influenza Late  P. aeruginosa: 85%  B. cepacia: 4%

Question 42

Diagnosis CF

Answer 42

sweat test -- Na and Cl > 60mM genetic screening for common mutations Faecal elastase- tests pancreatic exocrine function immunoreactive trypsinogen test on heel prick

Question 43

CF investigations

Answer 43

 Bloods: FBC, LFTs, clotting, ADEK levels, glucose TT  Sputum MCS  CXR: bronchiectasis  Abdo US: fatty liver, cirrhosis, pancreatitis  Spirometry: obstructive defect  Aspergillus serology / skin test (20% develop ABPA)

Question 44

CF management

Answer 44

General  MDT: physician, GP, physio, dietician, specialist nurse ``` Chest  Physio: postural drainage, forced expiratory techniques  Abx: acute infections and prophylaxis  Mucloytics: DNAse  Bronchodilators  Vaccinate ``` GI  Pancreatic enzyme replacement: pancreatin (Creon)  ADEK supplements  Insulin  Ursodeoxycholic acid for impaired hepatic function  Stimulates bile secretion ``` Advanced Lung Disease  O2  Diuretics (Cor pulmonale)  NIV  Heart/lung transplantation ``` Other  Rx of complications: e.g. DM  Fertility and genetic counselling  DEXA osteoporosis screen

Question 45

Pulmonary aspergillus infections diseases

Answer 45

``` Asthma - type 1 HS reaction to spores Allergic bronchopulmonary aspergillosis aspergilloma invasive aspergillosis extrinsic allergic alveolitis ```

Question 46

ABPA cause

Answer 46

T1 and T3 reaction to aspergillus fumigatus | Bronchoconstriction leads to bronchiectasis

Question 47

Symptoms of ABPA

Answer 47

wheeze productive cough dyspnoea

Question 48

Investigations for ABPA

Answer 48

``` CXR: bronchiectasis Aspergillus in sputum (black on silver stain) Aspergillus skin test or IgE RAST +ve se precipitins ↑ IgE and ↑ eosinophils ```

Question 49

Treatment of ABPA

Answer 49

pred 40mg/day + itraconazole for acute attacks pred maintenance 5-10mg/day bronchodilators for asthma

Question 50

Lung cancer classification

Answer 50

Small cell lung cancer Non SCLC - adeno - large cell - squamous cell

Question 51

Features of squamous cell carcinoma lung

Answer 51

35% lung cancer M>F smoking centrally located evidence of squamous differentiation - keratinisation locally invasive late mets via lymph nodes PTH releasing ==> increase calcium

Question 52

Features of adenocarcinoma lung

Answer 52

``` 25% lung cancer females non smokers peripherally located glandular differentiation extrathoracic mets common and early 80% present with mets ```

Question 53

Features of large cell carcinoma lung

Answer 53

10% lung cancer peripheral or central large poorly differentiated cells poor prognosis

Question 54

small cell lung cancer features

Answer 54

20% lung cancer to do with smoking central location near bronchi histology == small poorly differentiated cells 80% present with advanced disease v chemosensitive BUT v poor prognosis Ectopic hormone secretion

Question 55

Lung cancer symptoms

Answer 55

``` cough and haemoptysis dyspnoea chest pain recurrent pneumonia anorexia and weight loss hoarseness ```

Question 56

Lung cancer signs

Answer 56

Chest  Consolidation  Collapse  Pleural effusion ``` General  Cachexia  Anaemia  Clubbing and HPOA (painful wrist swelling)  Supraclavicular and/or axillary LNs ``` ``` Metastasis  Bone tenderness  Hepatomegaly  Confusion, fits, focal neuro  Addison’s ```

Question 57

complications of lung cancer

Answer 57

``` recurrent laryngeal nerve palsy phrenic nerve palsy SVC obstruction Horner's syndrome - pancoast tumour AF ```

Question 58

Paraneoplsatic complications of lung cancer

Answer 58

Endo  ADH → SIADH ( euvolaemic ↓Na+)  ACTH → Cushing’s syndrome  Serotonin → carcinoid (flushing, diarrhoea)  PTHrP → 1O HPT (↑Ca2+, bone pain) – SCC Rheum  Dermatomyositis / polymyositis Neuro  Purkinje Cells (CDR2) → cerebellar degeneration  Peripheral neuropathy Derm  Acanthosis nigricans (hyperpigmented body folds)  Trousseau syndrome: thrombophlebitis migrans

Question 59

Lung cancer investigations

Answer 59

Bloods Cytology Imaging ``` CXR  Coin lesion  Hilar enlargement  Consolidation, collapse  Effusion  Bony secondaries ``` Contrast-enhanced Volumetric CT  Staging: lower neck, chest, upper abdomen  Consider CT brain PET-CT: exclude distant mets Radionucleotide bone scan

Question 60

Performance status analysis lung cancer

Answer 60

``` 0= Normal 1= symptomatic without significant decrease in activities 2= In bed or chair less than 50% day 3= In bed or chair more than 50% day 4= Bedridden ```

Question 61

Lung cancer biopsy options

Answer 61

Percutaneous FNA bronchoscopy endoscopic bronchial US biopsy Mediastinoscopy

Question 62

TNM staging lung cancer

Answer 62

Tx - malignant cells in bronchial secretions Tis - Carcinoma in situ T0 - None evident T1- <3cm in lobar or more distal airway T2- >3cm and >2cm from carina or pleural involvement T3- <2cm from carina or involves chest wall or diaphragm T4 - Involves mediastinum or malignant effusion present N0- None involved N1- Peribronchial or ipsilateral hilum N2- Ipsilateral mediastinum N3- Contralateral mediastinum or supraclavicular

Question 63

Lung cancer Mx overview

Answer 63

MDT involvement Use PSA score for chemo advise smoking cessation

Question 64

NSCLC Mx

Answer 64

Surgical Resection  Rx of choice for peripheral lesions ̄c no metastatic spread = stage I/II (~25%)  Need good cardiorespiratory function  Wedge resection, lobectomy or pneumonectomy  ± adjuvant chemo Curative radiotherapy  If cardiorespiratory reserve is poor Chemo ± radio for more advanced disease  Platinum-based regimens  MAbs targeting EGFR (e.g. cetuximab) or TKI (e.g. erlotinib)

Question 65

SCLC Mx

Answer 65

 Typically disseminated @ presentation |  May respond to chemo but invariably relapse

Question 66

Lung cancer palliation

Answer 66

 Radio: bronchial obstruction, haemoptysis, bone or CNS mets  SVC obstruction: stenting + radio + dexamethasone  Endobronchial therapy: stenting, brachytherapy  Pleural drainage / pleurodesis  Analgesia

Question 67

ARDS pahtogenesis

Answer 67

Lungs suddenly stop being able to supply rest of body with enough O2 May result from direct insult or secondary to a systemic illness Pulmonary oedema can arise from inflammatory mediators leading to increased capillary permeability and non cardiogenic pulmonary oedema

Question 68

Clinical features of ARDS

Answer 68

Tachypnoea Cyanosis Bilateral fine crepitations SIRS - systemic inflammatory response syndrome

Question 69

Diagnosing ARDS

Answer 69

Acute onset CXR shows bilateral infiltrates No evidence of congestive cardiac failure PaO2:FiO2 <200

Question 70

Mx ARDS

Answer 70

admit to ICU for organ support and treatment of the underlying cause Ventilation Indications  PaO2<8KPa despite 60% FiO2  PaCO2>6KPa Method  6ml/kg + PEEP (e.g. 10cm H2O) SEs  VILI ventilation induced lung injury  VAP ventilation associated pneumonia  Weaning difficulty ``` Circulation  Invasive BP monitoring  Maintain CO and DO2 ̄c inotropes  E.g. norad or dobutamine  RF may require haemofiltration ``` Sepsis  Abx Other  Nutritional support: enteral (best), TPN

Question 71

Causes ARDS

Answer 71

``` Pulmonary  Pneumonia  Aspiration  Inhalation injury  Contusion ``` ``` Systemic  Shock  Sepsis  Trauma  Haemorrhage and multiple transfusions  Pancreatitis  Acute liver failure  DIC  Obs: eclampsia, amniotic embolism  Drugs: aspirin, heroin ```

Question 72

DDX ARDS

Answer 72

ARDS is caused by exudates any cause of transudates - DDx - nephrosis - cirrhosis - gastrosis - decreased lymphatic drainage due to cancer

Question 73

Respiratory failure type 1

Answer 73

 PaO2 <8KPa and PaCO2 <6KPa  V/Q mismatch and diffusion failure

Question 74

Respiratory failure type 2

Answer 74

 PaO2 <8KPa and PaCO2 >6KPa - alveolar hypoventilation +- V/Q mismatch

Question 75

Alveolar hypoventilation

Answer 75

``` Obstructive  COPD  Asthma  Bronchiectasis  Bronchiolitis  Intra- and Extra-thoracic (Ca, LN, epiglottitis...) ``` ``` Restrictive  ↓ drive: CNS sedation, trauma, tumour  NM disease: cervical cord lesion, polio, GBS, MG  Chest: flail, kyphoscoliosis, obesity  Fluid and fibrosis ```

Question 76

Clinical features respiratory failure Hypoxia

Answer 76

``` Acute  Dyspnoea  Agitation  Confusion  Cyanosis ``` Chronic  Polycythaemia  PHT  cor pulmonale

Question 77

Clinical features respiratory failure hypercapnoea

Answer 77

``` headache flushing and peripheral vasodilation bounding pulse flap Confusion ==> coma ```

Question 78

Mx type 1 respiratory failure

Answer 78

 Give O2 to maintain SpO2 94-98% |  Assisted ventilation if PaO2<8KPa despite 60% O2

Question 79

Mx type 2 respiratory failure

Answer 79

 Controlled O2 therapy @ 24% O2 aiming for SpO2 88-92% and a PaO2 >8kPa  Check ABG after 20min  If PaCO2 steady or lower can ↑ FiO2 if necessary  If PaCO2 ↑>1.5KPa and pt. still hypoxic, consider NIV or respiratory stimulant (e.g. doxapram)

Question 80

Principles of O2 therapy

Answer 80

 Critically ill pts. should receive high conc O2 immediately.  O2 should be prescribed to achieve target SpO2  94-98% for most patients  88-92% for those at risk or hypercapnic resp failure  In pts. at risk of hypercapnic resp failure:  Start O2 therapy at 24% and do an ABG – Blue Venturi @ 2-4L/min  Clinically: ↓ RR ̄c O2 may be useful sign  If PCO2 ≤6kPa: ↑ target SpO2 to 94-98%  If PCO2 >6kPa: maintain target SpO2

Question 81

Oxygen delivery options

Answer 81

Nasal Prongs: 1-4L/min = 24-40% O2 Simple Face Mask Non-rebreathing Mask  Reservoir bag allows delivery of high concentrations of O2.  60-90% at 10-15L ``` Venturi Mask Provide precise O2 concentration at high flow rates  Yellow: 5%  White: 8%  Blue: 24%  Red: 40%  Green: 60% ```

Question 82

Chronic asthma definition

Answer 82

Episodic reversible airway obstruction due to bronchial hyperreactivity to a variety of stimuli

Question 83

Chronic asthma pathophysiology

Answer 83

Acute - Mast cell - Ag interaction and histamine release - Bronchoconstriction, mucous plugs and mucosal swelling Chronic - Th2 cells release IL 3,4,5 gives mast cell eosinophil and B cell recruitment - Airway remodelling

Question 84

Causes of asthma

Answer 84

Atopy  T1 hypersensitivity to variety of antigens  Dust mites, pollen, food, animals, fungus ``` Stress  Cold air  Viral URTI  Exercise  Emotion ``` Toxins  Smoking, pollution, factory  Drugs: NSAIDS, β-B

Question 85

Asthma symptoms

Answer 85

Cough and sputum often at night Wheeze dyspnoea diurnal variation with morning dipping (worse)

Question 86

Asthma signs

Answer 86

``` tachypnoea tachycardia widespread polyphonic wheeze hyperinflated chest decreased air entry signs of steroid use ```

Question 87

Asthma associated diseases

Answer 87

GORD Churg strauss ABPA

Question 88

Investigations asthma

Answer 88

Bloods  FBC (eosinophila)  ↑IgE  Aspergillus serology CXR: hyperinflation Spirometry  Obstructive pattern ̄c FEV1:FVC < 0.75  ≥15% improvement in FEV1 ̄c β-agonist PEFR monitoring / diary  Diurnal variation >20%  Morning dipping Atopy: skin-prick, RAST

Question 89

Mx asthma general measures

Answer 89

TAME Technique - inhaler use Avoidance - known irritants Monitor - peak flow diary (2-4x/day) Educate- specialist nurse, crisis plan, emphasise importance of treatment

Question 90

Drug ladder for asthma 2016 bts guidelines

Answer 90

SABA PRN ``` 1- low dose ICS 2-Add LABA to low dose ICS 3- Consider increased dose Consider adding theophylline, LAMA, Leukotriene agonist 4- Refer to specialist Consider increased dose Consider 4th drug 5- Refer to specialist Add daily oral steroid ```

Question 91

Acute severe asthma info

Answer 91

Acute breathlessness and wheeze ask: - precipitant - usual treatment - previous attacks and itu - best pefr

Question 92

Acute asthma investigations

Answer 92

``` PEFR ABG - PaO2 usually normal or slightly low - PaCO2 usually low - If PaCO2 high send to ITU for ventilation FBC UE CRP Blood cultures ```

Question 93

Assessing asthma attack severity

Answer 93

``` Severe: any one of  PEFR <50%  RR>25  HR >110  Can’t complete sentence in one breath ``` ``` Life Threatening: any one of  PEFR <33%  SpO2 <92%, PCO2 >4.6kPa, PaO2 <8kPa  Cyanosis  Hypotension  Exhaustion, confusion  Silent chest, poor respiratory effort  Tachy-/brady-/arrhythmias ```

Question 94

DDX acute asthma

Answer 94

Pneumothorax Acute exacerbation COPD Pulmonary oedema

Question 95

Admission and discharge of asthma attack

Answer 95

admit if life threatening admit if severe and not responding to treatment Discharge if PEFR> 75% 1hr after initial treatment Discharge if stable on meds for 24 hours Discharge if PEFR>75% with diurnal variability <20%

Question 96

Discharge plan for asthma attack

Answer 96

TAME po steroids for 5 days GP appointment within 1 week Respiratory clinic within 1 month

Question 97

Mx acute asthma attack

Answer 97

1. sit up 2. 100% O2 non rebreathe mask 94-98% 3. Nebulised salbutamol 5mg and ipratropium (anti muscarinic) 4. Hydrocortisone 100mg IV or pred 50mg po or both 5. Write no sedation on drug chart Life threatening - ITU, MGSO4 2g IV infusion over 20 min nebulised salbutamol every 15 minutes and monitor ECG

Question 98

Acute asthma not improving further treatment

Answer 98

``` Nebulised salbutamol every 15 mins Continue ipratropium 0.5mg every 4-6 hrs MGSO4 IVI 2mg over 20 mins Salbutamol IVI3-20ug/min Consider aminophylline ITU for invasive ventilation ```

Question 99

Monitoring following asthma attack

Answer 99

PEFR every 15-30 mins - pre and post B agonist SpO2 keep >92% ABG if initial PaCO2 normal or increased

Question 100

COPD definition

Answer 100

Airway obstruction FEV1<80% FEV1:FVC < 0.70 Chronic bronchitis == cough and sputum production on most days for 3mo of 2 successive years Emphysema == histological diagnosis of enlarged airway spaces distal to terminal bronchioles with destruction of alveolar walls

Question 101

COPD causes

Answer 101

Smoking | a1Anti trypsin deficiency

Question 102

COPD symptoms

Answer 102

Cough and sputum Dyspnoea Wheeze Weight loss

Question 103

COPD signs

Answer 103

``` Tachypnoea prolonged expiratory phase Hyperinflated lungs - decreased cricosternal distance normally 3cm - loss of cardiac dullness - displaced liver edge wheeze early inspiratory crackles cyanosis cor pulmonale - raised jvp - oedema - loud P2 signs of steroid use ```

Question 104

Pink puffers emphysema

Answer 104

Increased alveolar ventilation ==> breathless but not cyanosed Normal PaO2 Normal or low PaCO2 Progresses to ==> Type 1 respiratory failure

Question 105

Blue bloaters chronic bronchitis

Answer 105

decreased alveolar ventilation ==> cyanosed but not breathless Decreased PaO2 Increased PaCO2 - now reliant on hypoxic respiratory drive Progresses to ==> type 2 respiratory failure and cor pulmonale

Question 106

mMRC dyspnoea score

Answer 106

1. dyspnoea only on vigorous exertion 2. SOB on hurrying or walking up steps 3. Walks slowly or has to stop for breath 4. Stops for breath after <100m/ few mins 5. Too breathless to leave house or SOB on dressing

Question 107

COPD complications

Answer 107

``` Acute exacerbation +- infection Polycythaemia pneumothorax == ruptured bullae cor pulmonale lung carcinoma ```

Question 108

Investigations for COPD

Answer 108

 BMI Bloods: FBC (polycythaemia), α1-AT level, ABG ``` CXR  Hyperinflation (> 6 ribs anteriorly)  Prominent pulmonary arteries  Peripheral oligaemia  Bullae ``` ECG:  R atrial hypertrophy: P pulmonale  RVH, RAD Spirometry: FEV1 <80%, FEV1:FVC <0.70, ↑TLC, ↑RV Echo: PHT

Question 109

General management chronic COPD

Answer 109

Assess severity based on FEV1 % General measures - Stop smoking MDT and nicotine - pulmonary rehabilitation - Treat nutrition - flu and pneumococcal vaccine - review 1-2 yrs - air travel risky if FEV1 <50%

Question 110

Pharmacological management COPD

Answer 110

Mucolytics - chronic productive cough SABA and SAMA PRN Exacerbations = LABA or LAMA if FEV>50% LABA + ICS <50% FEV1 Persistent exacerbations or breathlessness - LABA+LAMA+ICS - theophylline may be considered - consider home nebs LTOT - aim to keep PaO2>8 for >15 hours /day increases survival 50% - know criteria for home oxygen (7.3-8 with PHT, polycythaemia, cor pulmonale, nocturnal hypoxaemia)

Question 111

What surgery used for COPD

Answer 111

used for recurrent pneumothoraces used for isolated bullous disease used for lung volume reduction

Question 112

Acute exacerbation of COPD causes and history

Answer 112

Viral URTI and can be bacterial ask about smoking status exercise capacity current treatment previous exacerbations present with - dyspnoea - cough and sputum - wheeze

Question 113

Investigations for acute COPD

Answer 113

``` PEFR Bloods Sputum culture CXR- infection, pneumothorax ECG ```

Question 114

DDX COPD exacerbation

Answer 114

pneumothorax asthma PE Pulmonary oedema

Question 115

When to discharge COPD exacerbation

Answer 115

``` done spirometry establish optimal maintenance GP and specialist therapy Prevention using home steroids and oral ABx Pneumococcal and flu vaccine Home assessment ```

Question 116

Management COPD exacerbation

Answer 116

1. sit up 2. 24% O2 via venturi mask 88-92% 3. Vary fiO2 and sats target according to ABG - aim for paO2 >8 and an increase in PCO2 of <1.5kPa Nebulised bronchodilators - air driven - salbutamol 5mg/4hr - ipratropium 0.5mg/6hr Steroids - hydrocortisone 200mg IV - Prednisolone 40mg PO for 7-14 days ABx - if evidence of infection - doxycyline 200mg PO stat then 100mg OD PO for 5 days IF no response - repeat nebs and consider aminophylline IV - consider NIV if pH< 7.35 and or RR>30 - consider invasive ventilation if pH<7.26

Question 117

PE causes

Answer 117

usually arise from DVTs in proximal leg rarely right ventricle post MI septic emboli in right sided endocarditis

Question 118

PE risk factors

Answer 118

SPASMODICAL ``` Sex- F Pregnancy Age Surgery Malignancy Oestrogen - COCP/HRT DVT/PE previous history Immobility Colossal size Antiphopholipid Abs Lupus anti-coagulant ```

Question 119

Symptoms of PE

Answer 119

Dyspnoea Pleuritic chest pain Haemoptysis Syncope

Question 120

Signs of PE

Answer 120

``` Fever cyanosis tachycardia tachypnoea RHF- hypotension, raised JVP, loud P2 Evidence of cause DVT ```

Question 121

Investigations PE

Answer 121

 Bloods: FBC, U+E, clotting, D-dimers  ABG: normal or ↓PaO2 and ↓PaCO2, ↑pH  CXR: normal or oligaemia, linear atelectasis  ECG: sinus tachycardia, RBBB, right ventricular strain (inverted T in V1-V4)  S1, Q3, T3 is rare  Doppler US: thigh and pelvis (+ve in 60%)  CTPA + venous phase of legs and pelvis  85-95% sensitivity  V/Q scan no longer used

Question 122

Diagnosis of PE

Answer 122

first assess patient using WELLS score if high risk go straight to CTPA if low risk to D-Dimer - negative - excludes PE - positive - CTPA

Question 123

PE prevention

Answer 123

Risk assess all patients TED stockings Prophylactic LMWH Avoid COCP/HRT if at high risk

Question 124

PE management

Answer 124

- Sit up - 100% O2 via non rebreath mask - Analgesia - Morphine +- metoclopramide if distressed Critically ill with massive PE == - Alteplase 50mg bolus stat - surgical or interventional embolectomy LMWH - enoxaparin 1.5mg/kg/24 hr subcut If SBP<90 give 500ml colloid If SBP> 90 start warfarin and confirm diagnosis IF low BP still give inotropes Ongoing use TED and continue LMWH target INR 2-3

Question 125

Pneumothorax definition

Answer 125

Accumulation of air in the pleural space with secondary lung collapse

Question 126

Pneumothorax classification

Answer 126

Closed - intact chest wall and air leaks from lung into cavity Open - Defect in the chest wall allows communication between pleural cavity and outside world Tension - air enters pleural cavity through one way valve and cannot escape ==> mediastinal compression

Question 127

Causes of pneumothorax

Answer 127

spontaneous primary -- young thin men with ruptured subpleural bullae - smokers secondary - COPD - marfans, ehlers danlos - pulmonrary fibrosis, sarcoidosis Trauma - penetrating wound - rib fractures Iatrogenic - subclavian CVP line - NIV - liver biopsy - transbronchial biopsy

Question 128

Pneumothorax symptoms

Answer 128

sudden onset dyspnoea pleuritic chest pain TENSION== respiratory distress and cardiac arrest

Question 129

pneumothorax signs

Answer 129

Chest - decreased expansion - resonant percussion - decreased breath sounds TENSION - increased jvp - medastinal shift - raised HR - decreased BP Crepitus - surgical emphysema

Question 130

Pneumothorax investigations

Answer 130

ABG US CXR (expiratory film may be helpful)  Translucency + collapse (2cm rim = 50% vol loss)  Mediastinal shift (away from PTX)  Surgical emphysema  Cause: rib #s, pulmonary disease (e.g. bullae)

Question 131

Management tension pneumothorax

Answer 131

ABCDE and resus No CXR Large bore venflon cannula into 2nd ICS mid clavicular line thoracocentesis Insert intrapleural chest drain in to safe triangle

Question 132

Management traumatic chest drain

Answer 132

ABCDE resus Analgesia - morphine 3 sided wet dressing if sucking Insert chest drain safe triangle

Question 133

Management primary pneumothorax

Answer 133

SOB and greater than 2cm from hilum -yes = aspirate first then failing that chest drain -no consider discharge

Question 134

Management of secondary pneumothorax

Answer 134

SOB and >50 years and greater than 2cm from hilum - yes = chest drain and admit - if 1-2cm = aspirate first then chest drain then admit and monitor - no admit for 24 hours with oxygen therapy

Question 135

Pleural effusion classification

Answer 135

effusion protein < 25g/L = transudate | effusion protein >35g/L = exudate

Question 136

Causes of pleural effusion | Exudate

Answer 136

``` Exudates: ↑ capillary permeability Infection: pneumonia, TB Neoplasm: bronchial, lymphoma, mesothelioma Inflammation: RA, SLE Infarction ``` ``` Transudates: ↑ capillary hydrostatic or ↓ oncotic pressure CCF Renal failure ↓ albumin: nephrosis, liver failure, enteropathy Hypothyroidism Meig’s Syndrome Right pleural effusion Ascites Ovarian fibroma ```

Question 137

Symptoms pleural effusion

Answer 137

Asymptomatic dyspnoea Pleuritic chest pain

Question 138

Signs pleural effusion

Answer 138

Chest Tracheal deviation away from effusion ↓ expansion Stony dull percussion ↓ air entry Bronchial breathing just above effusion ↓VR ``` Associated disease Ca: cachexia, clubbing, HPOA, LNs, radiation burn, radiation tattoo Chronic liver disease Cardiac failure RA, SLE Hypothyroidism ```

Question 139

Pleural effusion investigations

Answer 139

Blood: FBC, U+E, LFT, TFT, Ca, ESR ``` CXR Blunt costophrenic angles Dense shadow ̄c meniscus Mediastinal shift away Cause: coin lesion, cardiomegaly ``` US: facilitates tapping Volumetric CT

Question 140

Diagnostic tap pleural effusion

Answer 140

Percuss upper boarder and go 1-2 spaces below Infiltrate down to pleura ̄c lignocaine. Aspirate ̄c 21G needle Send for: Chemistry: protein, LDH, pH, glucose, amylase Bacteriology: MCS, auramine stain, TB culture Cytology Immunology: SF, ANA, complement

Question 141

Pleural effusion management

Answer 141

Treat underlying cause Drainage if symptomatic Chemical pleurodesis (attach pleurae together) if recurrent malignant effusion Persistent effusions may require surgery

Question 142

Sarcoidosis definition

Answer 142

Multisystem granulomatous disorder of unknown cause

Question 143

Clinical features sarcoidosis

Answer 143

granulomas 20-40% cases present incidentally on CXR General - fever - anorexia and weight loss - fatigue - lymphadenopathy Respiratory - upper: otitis and sinusitis - lower: dry cough SOB chest pain and reduced lung function Arthralgia Neurological - bells palsy, meningitis Urine - renal stones due to calcium Low hormones - amenorrhoea Ophthalmological - uveitis sjogrens syndrome Myocardial - restrictive cardiomyopathy due t granulomas and fibrosis pericardial effusion Abdominal - hepatomegaly and cholestatic lfts splenomegaly Skin - lupus pernio raised dusky purple patches on nose cheek and fingers

Question 144

Investigations sarcoidosis

Answer 144

``` Bloods ↑ESR ↑Ca Lymphopenia ↑seACE ↑Ig ↑LFTs ``` CXR, CT, MRI Tuberculin skin test Negative in 2/3 Lung function tests Restrictive pattern ̄c ↓FVC ↓ transfer factor Tissue Biopsy Lung, LNs, skin nodules, liver Diagnostic: non-caseating granulomas Ophthalmology assessment

Question 145

Treatment sarcoidosis

Answer 145

Acute: - usually resolves spontaneously - bed rest and NSAIDS chronic - steroids - immunosuppression, ciclosporin and MTX

Question 146

Granulomatous disease DDX

Answer 146

Infections: TB, leprosy, syphilis, crypto, schisto AI: PBC primary biliary cirrhosis Vasculitis: GCA, PAN, Wegener’s, Takayasu’s Idiopathic: Crohns, Sarcoid Interstitial lung: EAA extrinsic allergic alveolitis , silicosis

Question 147

Pulmonary hypertension definition

Answer 147

PA pressure >25mmHg

Question 148

Pulmonary HTN causes

Answer 148

Cardiac- Left heart failure - mitral stenosis - mitral regurgitation - L-R shunt - LV failure Left lung parenchyma disease - chronic hypoxia = global vasoconstriction and vascular changes - COPD - Asthma - bronchiectasis - CF Pulmonary vascular disease - idiopathic pulmonary hypertension - sickle cell disease - SLE - PE Hypoventilation - myaesthenia gravis - nm disease - scoliosis - osa

Question 149

Investigations pulmonary htn

Answer 149

ECG P pulmonale RVH RAD Echo Velocity of tricuspid regurgitation jet Right atrial or ventricular enlargement Ventricular dysfunction Valve disease ``` Right heart catheterisation: gold standard Mean pulmonary artery pressure Pulmonary vascular resistance CO Vasoreactivity testing to guide Rx ```

Question 150

OSA definition

Answer 150

intermittent closure/ collapse of pharyngeal airway leads to apnoeic episodes throughout the day

Question 151

OSA risk factors

Answer 151

``` Obesity Male Smoker EtOH Idiopathic pulmonary fibrosis Structural airway pathology: e.g. micrognathia NM disease: e.g. MND ```

Question 152

Investigations OSA

Answer 152

O2 sats | polysomnography is diagnostic

Question 153

Treatment OSA

Answer 153

stop smoking lose weight NIV at night

Question 154

Features OSA

Answer 154

``` apnoeic episodes morning headache somnolescense loss of memory and attention Irritability and depression ``` Pulmonary HTN type 2 respiratory failure

Question 155

Smoking cessation

Answer 155

ask and advise give both pharmacological support and psychological drugs - verenicline - partial nicotine receptor agonoist makes you ill while smoking so encourages cessation can also use bupropion - normally used for SAD and depression