r e s p i r a t o r y

Question 1

describe the classification of pneumonia anatomically

Answer 1

Bronchopneumonia
 Patchy consolidation of different lobes
Lobar Pneumonia
 Fibrosuppurative consolidation of a single lobe
 Congestion → red → grey → resolution

Question 2

describe the aetiological classification of pneumonia and causative microbes

Answer 2

Community Acquired Pneumonia
 Pneumococcus, mycoplasma, haemophilus
 S. aureus, Moraxella, Chlamydia, Legionella
 Viruses: 15%

Hospital Acquired Pneumonia
 >48hrs after hospital admission
 Gm-ve enterobacteria, S. aureus
Pneumonia

Aspiration pneumonia

immunocompromised = usual suspects PCP, TB, fungi, CMV/HSV

Question 3

what increases risk of aspiration

Answer 3

↑ Risk: stroke, bulbar palsy, ↓GCS, GORD, achalasia

Question 4

what are the sx of pneumonia

Answer 4

Fever, rigors
 Malaise, anorexia
 Dyspnoea
 Cough, purulent sputum, haemoptysis
 Pleuritic pain

Question 5

what are signs of pneumonia

Answer 5

↑RR, ↑ HR
 Cyanosis
 Confusion
 Consolidation
 ↓ expansion
 Dull percussion
 Bronchial breathing  ↓ air entry
 Crackles
 Pleural rub
 ↑VR

Question 6

what investigations are required in pneumonia

Answer 6

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
 Pleural tap

Question 7

how do you assess severity of pneumonia

Answer 7

Confusion (AMT ≤ 8)
 Urea >7mM
 Resp. rate >30/min
 BP <90/60
 ≥65

score 0-1 - home rx
score 2 hospital rx
score 3 or more = consider ITU

Question 8

describe the general management for pneumonia

Answer 8

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 9

what are the abx used in mild, moderate, severe CAP and PCP

Answer 9

amoxicillin (or and clarithromycin) for mild/ moderate

severe = co amoxiclav and clarithromycin (add fluclox if staph suspected)

atypical = PCP - tetracycline

Question 10

what abx are used in HAP

Answer 10

mild = co amoxiclav 
severe = tazocin w vancomycin w gentamicin

Question 11

what abx are used in aspiration pneumonia

Answer 11

co amoxiclav

Question 12

what vaccination is given against pneumonia and what are the indications for this

Answer 12

pneumovax

≥65yrs
 Chronic HLKP failure or conditions
 DM
 Immunosuppression: hyposplenism, chemo, HIV

Question 13

what are the contraindications to pneumovax

Answer 13

CI: P, B, fever

Question 14

what are the complications of pneumonia

Answer 14

resp failure = type 1 and type 2 . manage with oxygen therapy, ventilation

hypotension = dehydration and septic vasodilation. management 250ml fluid challenge over 15min, ITU for inotropes if refractory, central line with iv fluids if no improvement

AF - usually resolves. give digoxin or b-blocker for rate control

pleural effusion = exudate - tap and send for MCS, cytology and chemistry

empyema = USS guided chest drain with abx

lung abscess

sepsis

Question 15

what are the complications of pneumonia

Answer 15

resp failure = type 1 and type 2 . manage with oxygen therapy, ventilation

hypotension = dehydration and septic vasodilation. management 250ml fluid challenge over 15min, ITU for inotropes if refractory, central line with iv fluids if no improvement

Question 16

describe the pathophysiology of bronchiectasis

Answer 16

Chronic infection of bronchi/bronchioles → permanent dilation

Retained inflammatory secretions and microbes → airway damage and recurrent infection

Question 17

which organisms affect pt with bronchiectasis

Answer 17

H. influenza
 Pneumococcus  S. aureus
 Pseudomonas

Question 18

what are the causes of bronchiectasis

Answer 18

causes = idiopathic
congenital = CF, kartagener’s, young’s syndrome
post infectious = measles, pertussis, pneumonia, TB, bronchiolitis

Question 19

what are the sx of bronchiectasis

Answer 19

Persistent cough ̄c purulent sputum
 Haemoptysis (may be massive)
 Fever, wt. loss

Question 20

what are the signs of bronchiectasis

Answer 20

clubbing
 Coarse inspiratory creps
 Wheeze
 Purulent sputum
 Cause
 Situs inversus (+ PCD = Kartagener’s syn.)  Splenomegaly: immune deficiency

Question 21

what are the complications of bronchiectasis

Answer 21

Pneumonia
 Pleural effusion
 Pneumothorax
 Pulmonary HTN
 Massive haemoptysis
 Cerebral abscess
 Amyloidosis

Question 22

what investigations are required

Answer 22

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
 CF sweat test

Question 23

how is bronchiectasis managed

Answer 23

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
 Immune deficiency: IVIg
 Surgery may be indicated in severe localised disease

Question 24

describe the pathophysiology behind CF

Answer 24

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 25

what is the inheritance pattern being CF

Answer 25

autosomal recessive

Question 26

what are the clinical features of CF

Answer 26

Neonate  FTT  Meconium ileus  Rectal prolapse Children / Young Adults  Nose: nasal polyps, sinusitis  Resp: cough, wheeze, infections, bronchiectasis, haemoptysis, pneumothorax, cor pulmonale  GI:  Pancreatic insufficiency: DM, steatorrhoea  Distal Intestinal Obstruction Syndrome  Gallstones  Cirrhosis (2O biliary)  Other: male infertility, osteoporosis, vasculitis

Question 27

what are the clinical signs associated with CF

Answer 27

Clubbing ± HPOA  Cyanosis  Bilateral coarse creps

Question 28

what are the common resp organisms in CF

Answer 28

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

Question 29

describe how CF is dx

Answer 29

sweat test: Na and Cl > 60mM  Genetic screening for common mutations  Faecal elastase (tests pancreatic exocrine function)  Immunoreactive trypsinogen (neonatal screening)

Question 30

describe the lx required in CF

Answer 30

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 31

how is CF managed

Answer 31

``` 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 Advanced Lung Disease  O2  Diuretics (Cor pulmonale)  NIV  Heart/lung transplantation ```

Question 32

describe the sx of lung Ca

Answer 32

``` Cough and haemoptysis  Dyspnoea  Chest pain  Recurrent or slow resolving pneumonia  Anorexia and ↓wt.  Hoarseness ```

Question 33

what are the signs of lung Ca

Answer 33

``` 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 34

what are the complications of lung Ca

Answer 34

``` Local  Recurrent laryngeal N. palsy  Phrenic N. palsy  SVC obstruction  Horner’s (Pancoast’s tumour)  AF Paraneoplastic  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 ``` ``` Metastatic  Pathological #  Hepatic failure  Confusion, fits, focal neuro  Addison’s ```

Question 35

what are the investigations for lung Ca

Answer 35

``` bloods = FB, U+E, Ca, LFTs cytology = sputum, pleural fluid ``` 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 Biopsy  Percutaneous FNA: peripheral lesions and LNs  Bronchoscopy: biopsy and assess operability

Question 36

what is type 1 resp failure

Answer 36

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

Question 37

what is type 2 resp failure

Answer 37

PaO2 <8KPa and PaCO2 >6KPa |  Alveolar hypoventilation ± V/Q mismatch

Question 38

what are the causes of V/Q mismatch

Answer 38

``` Vascular  PE  PHT  Pulmonary Shunt (R → L)  Asthma (early)  Pneumothorax  Atelectasis ```

Question 39

what are the obstructive causes of alveolar hypoventilation

Answer 39

``` COPD  Asthma  Bronchiectasis  Bronchiolitis  Intra- and Extra-thoracic (Ca, LN, epiglottitis...) ```

Question 40

what are the restrictive causes of alveolar hypoventilation

Answer 40

``` ↓ drive: CNS sedation, trauma, tumour  NM disease: cervical cord lesion, polio, GBS, MG  Chest: flail, kyphoscoliosis, obesity  Fluid and fibrosis ```

Question 41

what are the causes of diffusion failure

Answer 41

``` Fluid  Pulmonary oedema  Pneumonia  Infarction  Blood  Fibrosis ```

Question 42

how do you manage type 1 and type 2 resp failure

Answer 42

Type 1  Give O2 to maintain SpO2 94-98%  Assisted ventilation if PaO2<8KPa despite 60% O2 Type 2  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 43

what are the various types of oxygen masks and how much oxygen do they deliver

Answer 43

``` 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 44

what is the asthma

Answer 44

Episodic, reversible airway obstruction due to bronchial hyper-reactivity to a variety of stimuli.

Question 45

describe the pathophysiology of asthma

Answer 45

Mast cell-Ag interaction → histamine release |  Bronchoconstriction, mucus plugs, mucosal swelling

Question 46

what are the causes asthma

Answer 46

``` 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 47

wear are the sx of asthma

Answer 47

ough ± sputum (often at night)  Wheeze  Dyspnoea  Diurnal variation ̄c morning dipping

Question 48

what are the questions to ask in hx for asthma

Answer 48

``` Precipitants  Diurnal variation  Exercise tolerance  Life effects: sleep, work  Other atopy: hay fever, eczema  Home and job environment ```

Question 49

what are the signs of asthma

Answer 49

``` Tachypnoea, tachycardia  Widespread polyphonic wheeze  Hyperinflated chest  ↓ air entry  Signs of steroid use ```

Question 50

what are the ddx for asthma

Answer 50

Pulmonary oedema (cardiac asthma)  COPD

Question 51

what investigations are required

Answer 51

``` 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 52

describe general measures behind management asthma

Answer 52

General Measures: TAME  Technique for inhaler use  Avoidance: allergens, smoke (ing), dust  Monitor: Peak flow diary (2-4x/d)  Educate  Liaise ̄c specialist nurse  Need for Rx compliance  Emergency action plan

Question 53

describe the drug ladder for chronic asthma

Answer 53

1. SABA 2. SABA + ICS (budesonide) 3. SABA + ICS + LTRA 4. increasing dose of ICS

Question 54

describe the acute management of asthma

Answer 54

Sit-up 2. 100% O2 via non-rebreathe mask (aim for 94-98%) 3. Nebulised salbutamol (5mg) and ipratropium (0.5mg) 4. Hydrocortisone 100mg IV or pred 50mg PO (or both) 5. Write “no sedation” on drug chart back to back nebs, consider aminophylline if lifethreatening = inform ITU, MgSO4 IVI over 20 min, nebs salbutamol every 15 mins monitor ECG

Question 55

what defines severe acute asthma

Answer 55

``` any one of  PEFR <50%  RR>25  HR >110  Can’t complete sentence in one breath ```

Question 56

what defines life threatening asthma

Answer 56

``` 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 57

what defines fatal acute asthma

Answer 57

PCO2 increasing

Question 58

ddx for asthma

Answer 58

pneumothorax acute exacerbation of COPD pulmonary oedema

Question 59

when do you discharge pt after acute asthma attack

Answer 59

Been stable on discharge meds for 24h |  PEFR > 75% ̄c diurnal variability < 20%

Question 60

what things are required in pt with asthma as part of discharge plan

Answer 60

TAME pt.  PO steroids for 5d  GP appointment w/i 1 wk.  Resp clinic appointment w/i 1mo

Question 61

how are pleural effusions classified

Answer 61

Effusion protein < 25g/L = transudate Effusion protein >35g/L = exudate

Question 62

what are the exudative causes of pleural effusions

Answer 62

``` Exudates: ↑ capillary permeability  Infection: pneumonia, TB  Neoplasm: bronchial, lymphoma, mesothelioma  Inflammation: RA, SLE  Infarction ```

Question 63

what are the transudatice causes of pleural effusions

Answer 63

↑ capillary hydrostatic or ↓ oncotic pressure  CCF Renal failure  ↓ albumin: nephrosis, liver failure, enteropathy  Hypothyroidism

Question 64

how do pt with pleural effusion present

Answer 64

Asymptomatic  Dyspnoea  Pleuritic chest pain

Question 65

where the signs of pleural effusion

Answer 65

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 66

what investigations are required in pleural effusions

Answer 66

``` 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 Diagnostic Tap  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 67

how do you manage pleural effusion

Answer 67

Rx underlying cause  May use drainage if symptomatic (≤2L/24h)  Repeated aspiration or ICD  Chemical pleurodesis if recurrent malignant effusion  Persistent effusions may require surgery

Question 68

what is usually cause for PE

Answer 68

Usually arise from DVTs in proximal leg or iliac veins Rarely:  Right ventricle post MI  Septic emboli in right sided endocarditis

Question 69

what are the rx factors associated with PE

Answer 69

``` SPASMODICAL  Sex:F  Pregnancy  Age:↑  Surgery (classically 10d post-op straining at stool)  Malignancy  Oestrogen: OCP/HRT  DVT/PE previous Hx  Immobility  Colossal size  Antiphospholipid Abs  Lupus Anti-coagulant ```

Question 70

how do pt with PE present

Answer 70

Dyspnoea  Pleuritic pain  Haemoptysis  Syncope

Question 71

what are the signs associated with PE

Answer 71

``` ever  Cyanosis  Tachycardia, tachypnoea  RHF: hypotension, ↑JVP , loud P2  Evidence of cause: DVT ```

Question 72

what investigations are required in PE

Answer 72

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

Question 73

How is PE dx

Answer 73

``` ssess probability using Wells’ Score 2. Low-probability → perform D-dimers  Negative → excludes PE  Positive → CTPA 3. High probability → CTPA ```

Question 74

what things are done to prevent or reduce risk of PE

Answer 74

Risk assessment for all pts  TEDS  Prophylactic LMWH  Avoid OCP/HRT if @ risk

Question 75

describe the acute management of PE

Answer 75

1. oxygen via non rebreather mask 2. morphine with metoclopramide 3. alteplase bolus stat if critically ill with massive PE 4. LMWH = enoxaprin 5. SBP reduced = fluids, inotropes

Question 76

what is a pneumothorax

Answer 76

Accumulation of air in the pleural space ̄c 2O lung collapse

Question 77

what is a tension pneumothorax

Answer 77

air enters pleural cavity through one-way valve | and cannot escape → mediastinal compression.

Question 78

what are the causes of pneumothorax

Answer 78

``` Spontaneous  1O: no underlying lung disease  Young, thin men (ruptured subpleural bulla)  Smokers  2O: underlying lung disease  COPD  Marfan’s, Ehler’s Danlos  Pulmonary fibrosis, sarcoidosis Trauma  Penetrating  Blunt ± rib #s ```

Question 79

what are the investigations required in pneumothorax

Answer 79

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 80

what is the acute management of a pneumothorax

Answer 80

Resuscitate pt.  NoCXR  Large bore Venflon into 2nd ICS, mid-clavicular line  Insert ICD

Question 81

what is COPD

Answer 81

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 air spaces distal to terminal bronchioles ̄c destruction of alveolar walls.

Question 82

what are the causes of COPD

Answer 82

Smoking  Pollution  α1ATD

Question 83

what are the sx of COPD

Answer 83

Cough + sputum  Dyspnoea  Wheeze  Wt. loss

Question 84

what are the clinical signs seen in COPD

Answer 84

``` Tachypnoea  Prolonged expiratory phase  Hyperinflation  Wheeze  Cyanosis  Cor pulmonale: ↑JVP , oedema, loud P2 ```

Question 85

destine pink puffers vs blue bloaters in COPD

Answer 85

pink puffers = emPhysema = blue bloaters = chronic bronchitis

Question 86

describe pink puffers COPD

Answer 86

↑ alveolar ventilation → breathless but not cyanosed  Normal or near normal PaO2  Normal or low PaCO2  Progress → T1 respiratory failure

Question 87

describe blue bloaters COPD

Answer 87

alveolar ventilation → cyanosed but not breathless  ↓PaO2 and ↑ PaCO2: rely on hypoxic drive  Progress → T2 respiratory failure and cor pulmonale

Question 88

What score is used in COPD for SOB and what are the stages

Answer 88

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

Question 89

what are the complications of COPD

Answer 89

``` Acute exacerbations ± infection  Polycythaemia  Pneumothorax (ruptured bullae)  Cor Pulmonale  Lung carcinoma ```

Question 90

what Lx are required in COPD and would each show

Answer 90

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 91

describe the management of chronic COPD

Answer 91

General Measures  Stop smoking  Specialist nurse  Nicotine replacement therapy  Bupropion, varenicline (partial nicotinic agonist)  Support programme  Pulmonary rehabilitation / exercise  Rx poor nutrition and obesity  Screen and Mx comorbidities  e.g. cardiovasc, lung Ca, osteoporosis  Influenza and pneumococcal vaccine  Review 1-2x/yr  Air travel risky if FEV1<50% Mucolytics  Consider if chronic productive cough  E.g. Carbocisteine (CI in PUD) Breathlessness and/or exercise limitation  SABA and/or SAMA (ipratropium) PRN  SABA PRN may continue at all stages Exacerbations or persistent breathlessness  FEV1 ≥50%: LABA or LAMA (tiotropium) (stop SAMA)  FEV1 <50%: LABA+ICS combo or LAMA Persistent exacerbations or breathlessness  LABA+LAMA+ICS  Roflumilast / theophylline (PDIs) may be considered  Consider home nebs

Question 92

when is LTOT in COPD pt indicated

Answer 92

Aim: PaO2 ≥8 for ≥15h / day (↑ survival by 50%)  Clinically stable non-smokers ̄c PaO2 <7.3 (stable on two occasions >3wks apart)  PaO2 7.3 – 8 + PHT / cor pulmonale / polycythaemia / COPD nocturnal hypoxaemia  Terminally ill pts.

Question 93

name a surgical option in COPD pts

Answer 93

lung volume reduction

Question 94

describe acute management of COPD exacerbation

Answer 94

4% O2 via Venturi mask: SpO2 88-92%,  Vary FiO2 and SpO2 target according to ABG  Aim for PaO2 >8 and ↑ in PCO2 of <1.5kPa Nebulised Bronchodilators  Air driven ̄c nasal specs  Salbutamol 5mg/4h  Ipratropium 0.5mg/6h Steroids (IV and PO)  Hydrocortisone 200mg IV  Prednisolone 40mg PO for 7-14d Abx  If evidence of infection  Doxy 200mg PO STAT then 100mg OD PO for 5d NIV if no response = consider back to back nebs very 15 mins

Question 95

how does ILD present, clinical characteristics

Answer 95

Dyspnoea  Dry cough  Abnormal CXR / CT  Restrictive Spirometry

Question 96

what are the causes of ILD

Answer 96

``` Environmental: asbestosis, silicosis  Drugs: BANS ME  Bleomycin, Busulfan  Amiodarone  Nitrofurantoin  Sulfasalazine  MEthotrexate, MEthysergide  Hypersensitivity: EAA  Infection: TB, viral, fungi can be idiopathic = IPF ```

Question 97

what are systemic disease associated with ILD

Answer 97

sarcoidosis RA SLE, Sjogren's UC, AS

Question 98

what are the causes of ILD by location ? upper zone?

Answer 98

``` A PENT  Aspergillosis : ABPA  Pneumoconiosis: Coal, Silica  Extrinsic allergic alveolitis  Negative, sero-arthropathy  TB ```

Question 99

what are the causes of ILD by location ? lower zone?

Answer 99

``` STAIR  Sarcoidosis (mid zone)  Toxins: BANS ME  Asbestosis  Idiopathic pulmonary fibrosis  Rheum: RA, SLE, Scleroderma, Sjogren’s, PM/DM ```

Question 100

what are the sx of IPF

Answer 100

``` Dry cough  Dyspnoea  Malaise, wt. loss  Arthralgia  OSA Signs ```

Question 101

What are the signs of IPF

Answer 101

Cyanosis  Clubbing  Crackles: fine, end-inspiratory

Question 102

what are the complications associated with IPF

Answer 102

↑ risk Ca lung |  Type 2 respiratory failure and cor pulmonale

Question 103

Lx required and results expected in IPF

Answer 103

``` Bloods  ↑CRP  ↑Ig  ANA+ (30%)  RF+ (10%)  ABG: ↓PaO2, ↑PaCO2 ``` ``` CXR  ↓ lung volume  Bilat lower zone retic-nod shadowing  Honeycomb lung HRCT  Shows similar changes to CXR  More sensitive ``` Spiro  Restrictive defect  ↓ transfer factor

Question 104

how is IPF managed

Answer 104

``` Supportive care  Stop smoking  Pulmonary rehabilitation  O2 therapy  Palliation  Rx symptoms of heart failure  Lung Tx offers only cure ```

Question 105

name 3 industrial lung diseases and their rx factors

Answer 105

coal workers pneumoconiosis silicosis asbestosis

Question 105

name 3 industrial lung diseases and their rx factors

Answer 105

coal workers pneumoconiosis silicosis asbestosis

Question 106

asbestosis has increased risk of ...

Answer 106

mesothelioma

Question 107

how does asbestosis present and what changes are seen on CXR. how is it dx

Answer 107

Chest pain, wt. loss, clubbing, recurrent effusions, dyspnoea. CXR: pleural effusions, thickening  Dx by histology of pleural biopsy  <2yr survival

Question 108

what is pulmonary HTN

Question 108

what is pulmonary HTN

Answer 108

PA pressure greater than 25mmHg

Question 109

what are the causes of pulmonary HTN

Answer 109

left heart disease = mitral stenosis, mitral regurgitation, LVF, left to right shunt lung parenchymal disease = COPD, asthma, ILD, CF, bronchiestasis pulmonary vascular disease = idiopathic pulmonary HTN, sickle cell, PE, portal HTN hypoventilation - morbid obesity, MND, polio

Question 110

describe the mechanism of pulmonary HTN via lung parenchyma disease

Answer 110

Chronic hypoxia → hypoxic vasoconstriction  Perivascular parenchymal changes

Question 111

Lx for pulmonary htn

Answer 111

ECG  P pulmonale  RVH Echo  Velocity of tricuspid regurgitation jet  Right atrial or ventricular enlargement  Ventricular dysfunction  Valve disease Right heart catheterisation: gold standard  Mean pulmonary artery pressure

Question 112

what is cor pulmonale

Answer 112

RHF due to chronic PHT

Question 113

what are the sx of cor pulmonale

Answer 113

Dyspnoea  Fatigue |  Syncope

Question 114

what are the signs seen in cor pulmonale

Answer 114

↑ JVP ̄c prominent a wave 2. Left parasternal heave 3. LoudP2±S3 4. Murmurs 5. Pulsatile hepatomegaly 6. Fluid: Ascites + Peripheral oedema

Question 115

lx for cor pulmonale

Answer 115

Bloods: FBC, U+E, LFTs, ESR, ANA, RF  ABG: hypoxia ± hypercapnoea  CXR  ECG: P pulmonale + RVH  Echo: RVH, TR, ↑ PA pressure  Spirometry  Right heart catheterisation

Question 116

how is cor pulmonale managed

Answer 116

```  Rx underlying condition  ↓ pulmonary vascular resistance LTOT CCB: e.g. nifedipine Sildenafil (PDE-5 inhibitor) Prostacycline analogues Bosentan (endothelin receptor antagonist) ```  Cardiac failure  ACEi + β-B (caution if asthma)  Diuretics  Heart-Lung Tx

Question 117

what is obstructive sleep apnoea

Answer 117

Intermittent closure/collapse of pharyngeal airway → apnoeic episodes during sleep.

Question 118

rx for obstructive sleep apnoea

Answer 118

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

Question 119

Lx for obstructive sleep apnoea

Answer 119

SpO2 |  Polysomnography is diagnostic

Question 120

how is it managed

Answer 120

Wt. loss  Avoid smoking and EtOH  CPAP during sleep

Question 121

what are the clinical features of obstructive sleep apnea nocturnal

Answer 121

 Snoring |  Choking, gasping, apnoeic episodes

Question 122

what are the clinical features of sleep apnoea day time

Answer 122

Morning headache  Somnolence  ↓ memory and attention  Irritability, depression

Question 123

complications of sleep apnoea

Answer 123

 Pulmonary hypertension  Type 2 respiratory failure  Cor pulmonale

Question 124

how is sleep apnoea managed

Answer 124

``` wt. loss  Stop smoking  CPAP @ night via a nasal mask  Surgery to relieve pharyngeal obstruction  Tonsillectomy ```

Question 125

advice and management of pt who wants to stop smoking

Answer 125

Ask: enquire as to smoking status  Advise: best way to stop is with support and medication  Act: provide details of where to get help  E.g. NHS stop smoking helpline  Refer to specialist stop smoking service  Nicotine replacement Gum or Patches  Varenicline: selective partial nicotine receptor agonist bupropion