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Finals > Resp > Flashcards

Resp Flashcards

1
Q

Pneumothorax

when does it occur

A

when air gets into the pleural space separating the lung from the chest wall

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2
Q

Pneumothorax

Causes

A
  • spontaneous
  • trauma
  • iatrogenic: lung biopsy, mechanical ventilation or central line insertion
  • lung pathology: infection, asthma or COPD
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3
Q

Pneumothorax

inx of choice for a simple pneumothorax

A

erect chest x-ray

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4
Q

Pneumothorax

chest x-ray results

A

area between lung tissue and chest wall where there are no lung markings

line demarcating the edge of the lung where the lung markings ends and the pneumothorax begins

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5
Q

Pneumothorax

how to measure the size of the pneumothorax according to BTS guidelines

A

measure horizontally from the lung edge to the inside of the chest wall at the level of the hilum

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6
Q

Pneumothorax

what can be used to detect a small pneumothorax that is too small to see on CXR or be used to accurately assess the size of the pneumothorax

A

CT thorax

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7
Q

Pneumothorax

mnx if no SOB and <2cm rim of air on CXR

A

no trx as it will spontaneously resolve

follow up in 2-4w

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8
Q

Pneumothorax

mnx if SOB and/or >2cm rim of air on CXR

A

aspiration and reassessment

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9
Q

Pneumothorax

what happens if aspiration mnx fails twice

A

it will require a chest drain

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10
Q

Pneumothorax

who will require a chest drain

A

unstable patient

bilateral or secondary pneumothoraces

if aspiration fails twice

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11
Q

Pneumothorax

what causes a tension pneumothorax

A

trauma to chest wall that creates a one-way valve that lets air in but not out of the pleural space

during inspiration, air is drawn into the pleural space and during expiration, the air is trapped in the pleural space

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12
Q

Pneumothorax

why is lot of air in the pleural space dangerous in a tension pneumothorax

A

it creates pressure inside the thorax that will push the mediastinum across, kink the big vessels in the mediastinum and cause cardiorespiratory arrest

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13
Q

Pneumothorax

signs of tension pneumothorax (5)

A
  • tracheal deviation away from the side of pneumothorax
  • reduced air entry to affected side
  • increased resonant to percussion on affected side
  • tachycardia
  • hypotension
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14
Q

Pneumothorax

mnx of a tension pneumothorax

A

insert a large bore cannula into the 2nd ICS in the midclavicular line

then chest drain for definitive mnx

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15
Q

Pneumothorax

where are chest drains inserted

A

into the ‘triangle of safety’

obtain CXR to check positioning

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16
Q

Pneumothorax

what forms the ‘triangle of safety’

A
  • 5th ICS (or inferior nipple line)
  • mix-axillary line (lateral edge of latissimus dorsi)
  • anterior axillary line (lateral edge of pec major)
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17
Q

Pneumothorax

why is the needle inserted just above the rib in a chest drain

A

to avoid the neurovascular bundle that runs below the rib

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18
Q

Lung Function Tests

what test is used to establish objective measures of lung function

A

spirometry

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19
Q

Lung Function Tests

what does spirometry involve

A

different breathing exercises into a machine that measures volumes of air and flow rates and produces a report

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20
Q

Lung Function Tests

what does reversibility testing involve

A

giving a bronchodilator (eg salbutamol) prior to repeating the spirometry to see the impact this has on the results

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21
Q

Lung Function Tests

what is FEV1

A

forced expiratory volume in 1 second

the amount of air a person can exhale as fast as they can in 1 sec

it will be reduced if there is any OBSTRUCTION to the air flow out of the lungs

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22
Q

Lung Function Tests

what is FVC

A

forced vital capacity

the total amount of air a person can exhale after a full inhalation

measure of the total volume of air the person can take into their lung s

it will be reduced if there is any RESTRICTION on the capacity of their lungs

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23
Q

Lung Function Tests

what will be reduced if there is any obstruction

A

FEV1

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24
Q

Lung Function Tests

what will be reduced if there is any restriction

A

FVC

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25
Q

Lung Function Tests

how can obstructive lung disease be diagnosed

A

when FEV1 is less than 75% of FVC

FEV1 : FVC ratio <75%

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26
Q

Lung Function Tests

in asthma, what is the obstruction due to

A

narrowed airway due to bronchoconstriction

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27
Q

Lung Function Tests

in COPD, what is the obstruction due to

A

chronic airway and lung damage

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28
Q

Lung Function Tests

the difference between asthma and COPD

A

test for reversibility of the obstruction by giving a bronchodilator.

the obstructive picture is typically reversible in asthma

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29
Q

Lung Function Tests

how can restrictive disease be diagnosed

A

FEV1 and FVC are equally reduced

and FEV1 : FVC ratio > 75%

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30
Q

Lung Function Tests

what is restrictive lung disease

A

where there is restriction to the ability of the lungs to expand and take air in

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31
Q

Lung Function Tests

causes of restrictive lung disease (4)

A
  • interstitial lung disease
  • neurological (eg MND)
  • scoliosis or chest deformity
  • obesity
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32
Q

Lung Function Tests

what is a peak flow a measure of

A

the ‘peak’ or fastest point, of a person’s expiratory flow of air

PEFR: peak expiratory flow rate

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33
Q

Lung Function Tests

what is the predicted peak flow based on

A

sex, height and age

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34
Q

COVID-19

where were the first cases reported

A

Wuhan, China

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35
Q

COVID-19

which animal did it originate

A

bats

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36
Q

COVID-19

clinical features (3)

A
  • fever
  • dry cough
  • SOB
  • nausea
  • headache
  • sore throat
  • diarrhoea
  • loss of smell/taste
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37
Q

COVID-19

how long is the incubation period

A

2-10d

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38
Q

COVID-19

severe covid disease pathogenesis

A

thought to be due to hyper-inflammatory response to the virus

raised inflammatory biomarkers (IL-2R, IL-6, IL-10 and TNFa)

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39
Q

COVID-19

what is death usually from

A
  • respiratory failure
  • multi-organ failure (heart, liver, kidney)
  • neuro complications (stroke)
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40
Q

COVID-19

RFs for severe covid disease

A
  • older age
  • male sex
  • comorbidities (chronic heart/lung disease, HTN, DM)
  • high BMI
  • lower socio-economic level
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41
Q

COVID-19

prognostic markers for severe covid disease

A
  • present with tachypnoea, tachycardia, low paO2
  • very low lymphocyte count <0.5 x 10(9)/ml
  • raised CRP and ferritin (inflammatory markers)
  • abnormal clotting: coagulopathy with increased D-dimers and fibrinogen, often leading to PE)
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42
Q

COVID-19

what predicts poor outcomes

A

hyperinflammation

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43
Q

COVID-19

distinct features of hyperinflammation

A
  • earlier onset of ARDS
  • prominent thrombo-embolic features
  • relatively low levels of cytokines + ferritin
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44
Q

COVID-19

why is being male a RF for severe disease

A
  • innate (adaptive) immune function enhanced in females
  • ACE2 receptor distribution
  • Male mice accumumlated inflammatory macrophages
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45
Q

COVID-19

what ethnicity is a RF for severe disease

A

South Asian

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46
Q

COVID-19

genetic factors contributing to critical illness

A
  • OAS genes
  • DPP9 gene variants
  • low IFNAR2 and elevated TYK2
  • Baricitinib
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47
Q

COVID-19

respiratory support for mnx of severe disease

A
  • supplementary O2
  • CPAP
  • Mechanical ventilation
  • Proning
  • monitor for PE, secondary infection
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48
Q

COVID-19

medications for mnx of severe disease

A
  • Dexamethasone
  • Remdesivir (anti-viral therapy)
  • Tociluzamab (monoclonal antibody to IL-6)
  • Anakinra (monoclonal antibody to IL-1 for hyper-inflammation)
  • Antibody therapy (Regeneron/Ronapreve)
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49
Q

COVID-19

what can be given for pts developing lung fibrosis

A

additional high dose steroids

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50
Q

COVID-19

how long do covid symptoms last

A

Zoe data shows 1/10 are sick for 3w or more

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51
Q

COVID-19

what is the most common cause of ‘breathlessness’ after covid

A

dysfunctional breathing: umbrella term for hyperventilation, disordered breathing, mechanical changes

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52
Q

Pleural Effusion

what is it

A

a collection of fluid in the pleural cavity

it can be exudative or transudative

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53
Q

Pleural Effusion

exudative meaning

A

high protein count

>3g/dL

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54
Q

Pleural Effusion

transudative meaning

A

there is a relatively lower protein count

<3g/dL

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55
Q

Pleural Effusion

what causes it to be exudative

A

inflammation results in protein leaking out of the tissues into the pleural space (ex- meaning moving out of)

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56
Q

Pleural Effusion

exudative causes

A

inflammation causes:

  • lung cancer
  • pneumonia
  • RA
  • TB
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57
Q

Pleural Effusion

what causes it to be transudative

A

relate to fluid moving across into the pleural space (trans- meaning moving across)

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58
Q

Pleural Effusion

transudative causes

A

fluid shifting causes:

  • congestive cardiac failure
  • hypoalbuminaemia
  • hypothyroidism
  • Meig’s syndrome
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59
Q

Pleural Effusion

what is Meig’s syndrome

A

right sided pleural effusion with ovarian malignancy

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60
Q

Pleural Effusion

presentation (4)

A
  • SOB
  • dullness to percussion over the effusion
  • reduced breath sounds
  • tracheal deviation away from the effusion
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61
Q

Pleural Effusion

inx

A
  • CXR

- pleural fluid sample by aspiration or chest drain: protein count, cell count, pH, glucose, LDH, microbiology testing

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62
Q

Pleural Effusion

what will the CXR show

A
  • blunting of the costophrenic angle
  • fluids in the lung fissures
  • larger effusions have a meniscus: curving upwards where it meets the chest wall and mediastinum
  • tracheal and mediastinal deviation if massive effusion
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63
Q

Pleural Effusion

trx if small effusion

A

conservative mnx

will resolve with trx of underlying cause

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64
Q

Pleural Effusion

trx for larger effusions

A

pleural aspiration:

chest drain

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65
Q

Pleural Effusion

what does pleural aspiration involve

A

sticking a needle in and aspirating fluid

temporarily relieves pressure but the effusion may recur

repeated aspiration may be required

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66
Q

Pleural Effusion

what is an empyema

A

where there is an infected pleural effusion

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67
Q

Pleural Effusion

when should you suspect an empyema

A

in a pt who has improving pneumonia but new ongoing fever

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68
Q

Pleural Effusion

what would pleural aspiration show in empyema

A

pus

acidic pH <7.2

low glucose

high LDH

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69
Q

Pleural Effusion

how are empyemas treated

A

by chest drain to remove pus

abx

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70
Q

Interstitial lung disease

what is it

A

an umbrella term to describe conditions that affect the lung parenchyma causing inflammation and fibrosis

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71
Q

Interstitial lung disease

what is fibrosis

A

the replacement of the normal elastic and functional lung tissue with scar tissue that is stiff and does not function effectively

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72
Q

Interstitial lung disease

how to make a diagnosis

A

clinical features + high resolution CT scan of the thorax

when unclear, lung biopsy can be used for histology

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73
Q

Interstitial lung disease

what does high resolution CT scan show

A

ground glass appearance

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74
Q

Interstitial lung disease

what makes the prognosis poor

A

damage is irreversible

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75
Q

Interstitial lung disease

mnx

A

generally supportive:

  • treat underlying cause
  • home O2 if hypoxic at rest
  • stop smoking
  • physio + pulmonary rehab
  • pneumococcal + flu vaccine
  • advanced care planning and palliative care if appropriate
  • lung transplant perhaps
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76
Q

Interstitial lung disease

sx of idiopathic pulmonary fibrosis

A
  • insidious onset of SOB

- dry cough >3m

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77
Q

Interstitial lung disease

whom does idiopathic pulmonary fibrosis usually affect

A

adults >50 years old

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78
Q

Interstitial lung disease

signs in idiopathic pulmonary fibrosis

A
  • bibasal fine inspiratory crackles

- finger clubbing

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79
Q

Interstitial lung disease

prognosis of idiopathic pulmonary fibrosis

A

poor with a life expectancy of 2-5yrs from diagnosis

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80
Q

Interstitial lung disease

which 2 medications are licensed that can slow the progression of the idiopathic pulmonary fibrosis

A
  • Pirfenidone

- Nintedanib

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81
Q

Interstitial lung disease

Idiopathic Pulmonary Fibrosis: what is Pirfenidone

A

an antifibrotic and anti-inflammatory

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82
Q

Interstitial lung disease

Idiopathic Pulmonary Fibrosis: what is Nintedanib

A

a monoclonal antibody targeting tyrosine kinase

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83
Q

Interstitial lung disease

what drugs can cause pulmonary fibrosis

A

MANC

  • amiodarone
  • cyclophosphamide
  • methotrexate
  • nitrofurantoin
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84
Q

Interstitial lung disease

what conditions can pulmonary fibrosis occur secondary to?

A
  • alpha-1 antitripsin deficiency
  • RA
  • SLE
  • systemic sclerosis
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85
Q

Interstitial lung disease

What is hypersensitivity pneumonitis?

A

aka extrinsic allergic alveolitis

a type III hypersensitivity reaction

to an environmental allergen

that causes parenchymal inflammation

and destruction in people that are sensitive to that allergen

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86
Q

Interstitial lung disease

Hypersensitivity Pneumonitis: what does bronchoalveolar lavage involve?

A

collecting cells from the airways during bronchoscopy

by washing the airways with fluid

then collecting that fluid for testing

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87
Q

Interstitial lung disease

Hypersensitivity Pneumonitis: what will the bronchoalveolar lavage show

A

raised lymphocytes and mast cells

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88
Q

Interstitial lung disease

Hypersensitivity Pneumonitis mnx

A
  • removing the allergen
  • giving oxygen where necessary
  • steroids
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89
Q

Interstitial lung disease

Hypersensitivity Pneumonitis: reaction to bird droppings

A

Bird-fanciers lung

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90
Q

Interstitial lung disease

Hypersensitivity Pneumonitis: reaction to mouldy spores in hay

A

farmers lung

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91
Q

Interstitial lung disease

Hypersensitivity Pneumonitis: reaction to specific mushroom antigens

A

mushroom workers’ lung

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92
Q

Interstitial lung disease

Hypersensitivity Pneumonitis: reaction to mould on barley

A

malt workers lung

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93
Q

Interstitial lung disease

what is Cryptogenic organising pneumonia

A

previously known as bronchiolitis obliterans organising pneumonia

focal area of inflammation of the lung tissue

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94
Q

Interstitial lung disease

Cryptogenic Organising Pneumonia: cause

A 
idiopathic or 
triggered by:
- infection 
- inflammatory disorders 
- medications
- radiation 
- environmental toxins 
- allergens
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95
Q

Interstitial lung disease

Cryptogenic Organising Pneumonia: presentation

A

very similar to infectious pneumonia:

  • SOB
  • cough
  • fever
  • lethargy

focal consolidation on CXR

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96
Q

Interstitial lung disease

Cryptogenic Organising Pneumonia: definitive inx

A

lung biopsy

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97
Q

Interstitial lung disease

Cryptogenic Organising Pneumonia: trx

A

systemic corticosteroids

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98
Q

Interstitial lung disease

what is asbestosis

A

lung fibrosis related to the inhalation of asbestos

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99
Q

Interstitial lung disease

Asbestosis: what makes it fibrogenic

A

it causes lung fibrosis.

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100
Q

Interstitial lung disease

Asbestosis: what makes it oncogenic

A

it causes cancer

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101
Q

Interstitial lung disease

Asbestosis: what problems does asbestos inhalation cause

A
  • lung fibrosis
  • pleural thickening and pleural plaques
  • adenocarcinoma
  • mesothelioma
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102
Q

PE

what is it

A

where a blood clot (thrombus) forms in the pulmonary arteries

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103
Q

PE

what are DVTs and PEs collectively known as

A

VTE

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104
Q

PE

what are the RFs for developing a DVT or PE (9)

A
  • immobility
  • recent surgery
  • long haul flights
  • pregnancy
  • hormone therapy with oestrogen
  • malignancy
  • polycythaemia
  • SLE
  • thrombophilia
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105
Q

PE

if pts are at increased risk of VTE, what should they receive

A

prophylaxis with LMWH e.g. enoxaparin

anti-embolic compression stockings

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106
Q

PE

when would LMWH (e.g. enoxaparin) be contraindicated

A
  • active bleeding

- existing anticoagulation with warfarin or NOAC

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107
Q

PE

what is the main CI for compression stockings

A

significant peripheral arterial disease

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108
Q

PE

presenting features

A
  • SOB
  • cough with or without blood
  • pleuritic chest pain
  • hypoxia
  • tachycardia
  • reduced RR
  • low grade fever
  • haemodynamic instability causing hypotension
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109
Q

what score predicts the risk of a pt actually having a DVT or PE

A

Wells Score

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110
Q

VTE

if the Wells score is ‘likely’, what next?

A

perform a CT pulmonary angiogram

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111
Q

VTE

if the Wells score is ‘unlikely’, what next?

A

perform a d-dimer and if +ve, perform a CTPA

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112
Q

PE

what are the 2 main options for establishing a definitive dx

A
  1. CTPA

or

  1. ventilation perfusion scan
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113
Q

PE

when would you use a VQ scan instead of a CTPA

A

in pts with renal impairment, contrast allergy or at risk from radiation

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114
Q

PE

what may the ABG show and why

A

respiratory alkalosis

high RR causes them to ‘blow off’ extra CO2 so the blood becomes alkalotic

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115
Q

what are the only 2 causes of respiratory alkalosis

A
  1. PE

2. hyperventilation syndrome

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116
Q

on an ABG, what is the difference between a PE and hyperventilation syndrome

A

PE will have a low pO2 whereas pts w/ hyperventilation syndrome will have a high pO2

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117
Q

PE

initial mnx

A

apixaban or rivaroxaban started immediately if suspected VTE

before confirming dx

alternative: LMWH (enoxaparin, dalteparin) if unsuitable or in antiphospholipid syndrome

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118
Q

PE

what are the options for long term anticoagulation in VTE

A

warfarin, NOAC or LMWH

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119
Q

PE

when switching to warfarin, how long should you continue LMWH for

A

5 days

or until the INR is 2-3 for 24 hours

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120
Q

PE

what are the main DOACs

A

apixaban
dabigatran
rivaroxaban

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121
Q

PE

what is the 1st line trx in pregnancy or cancer

A

LMWH

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122
Q

PE

how long should pt continue long term anticoagulation if there is an obvious reversible cause

A

3m

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123
Q

PE

how long should pt continue long term anticoagulation if the cause is unclear; there is recurrent VTE or there is an irreversible cause such as thrombophilia

A

beyond 3m (6m in practice)

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124
Q

PE

how long should pt continue long term anticoagulation if pt has active cancer

A

6m (then review)

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125
Q

PE

mnx for a massive PE with haemodynamic compromise

A

thrombolysis: streptokinase, alteplase, tenecteplase

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126
Q

PE

which 2 ways can thrombolysis be performed

A
  • IV using a peripheral cannula

- directly into pulmonary arteries using a central catheter (catheter-directed thrombolysis)

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127
Q

Pulmonary Hypertension

causes: group 1

A

Primary pulmonary hypertension or connective tissue disease

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128
Q

Pulmonary Hypertension

causes: group 2

A

L heart failure due to MI or systemic HTN

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129
Q

Pulmonary Hypertension

causes: group 3

A

chronic lung disease such as COPD

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130
Q

Pulmonary Hypertension

causes: group 4

A

pulmonary vascular disease such as PE

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131
Q

Pulmonary Hypertension

causes: group 5

A

miscellaneous causes: sarcoidosis, glycogen storage disease + haem disorders

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132
Q

Pulmonary Hypertension

main presenting sx

A

SOB

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133
Q

Pulmonary Hypertension

signs and sx

A
  • SOB
  • syncope
  • tachycardia
  • raised JVP
  • hepatomegaly
  • peripheral oedema
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134
Q

Pulmonary Hypertension

ECG changes (3)

A
  • R ventricular hypertrophy
  • R axis deviation
  • RBBB
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135
Q

Pulmonary Hypertension

how does R ventricular hypertrophy present on an ECG

A

larger R waves on the R sided chest leads (V1-3)

S waves on the L sided chest leads (V4-6)

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136
Q

Pulmonary Hypertension

CXR changes (2)

A
  • dilated pulmonary arteries

- R ventricular hypertrophy

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137
Q

Pulmonary Hypertension

what blood test result may indicate R ventricular failure

A

a raised NT-proBNP

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138
Q

Pulmonary Hypertension

what inx can be used to estimate pulmonary artery pressure

A

Echo

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139
Q

Pulmonary Hypertension

what can primary pulmonary hypertension be treated with? (3)

A
  1. IV prostanoids e.g. epoprostenol
  2. Endothelin receptor antagonists (e.g macitentan)
  3. Phosphodiesterase-5 inhibitors (e.g. sildenafil)
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140
Q

Pulmonary Hypertension

mnx of secondary pulmonary hypertension

A

treat underlying cause such as PE or SLE

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141
Q

PE

ECG changes

A
  • S1Q3T3
  • RBBB + right axis deviation
  • sinus tachycardia
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142
Q

PE

what is S1Q3T3

A
  • large S wave in lead I
  • large Q wave in lead III
  • inverted T wave in lead III
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143
Q

ipsilateral Horner’s syndrome + thoracic outlet syndrome (shoulder pain radiating down arm, motor weakness of the intrinsic hand muscles)

cause?

A

Pancoast tumour
invasive apical lung cancer invading the sympathetic plexus and brachial plexus.

can also cause a hoarse voice and bovine cough if it is affecting the laryngeal nerve.

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144
Q

smoke inhalation

mnx for all pts

A

endotracheal tube

+ analgesia + anxiety trx: morphine, propofol

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145
Q

smoke inhalation

mnx for CO poisoning

A

high-flow supplemental oxygen

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146
Q

what does a CO-Hb level >15% indicate

carboxyhaemoglobin

A

CO poisoning

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147
Q

COVID medication mnx

A
  • dexamethasone
  • IL-6 inhibitor: tocilizumab, sarilumab
  • Remdesivir
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148
Q

Acute Asthma

presentation

A
  • progressively worsening SOB
  • use of accessory muscles
  • tachycardia
  • symmetrical expiratory wheeze on auscultation
  • chest can sound ‘light’ on auscultation with reduced air entry
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149
Q

Acute Asthma

moderate PEFR

A

50-75% predicted

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150
Q

Acute Asthma

severe signs?

A
  • PEFR 33-50% predicted
  • RR>25
  • HR >110
  • unable to complete sentences
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151
Q

Acute Asthma

life-threatening signs

A
  • PEFR <33%
  • Sats <92%
  • becoming tired
  • no wheeze
  • haemodynamic instability
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152
Q

Acute Asthma

what is silent chest

A

in life threatening asthma

airways are so tight that there is no air entry at all

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153
Q

Acute Asthma

mnx for moderate acute asthma

A
  • neb salbutamol 5mg repeat as often as required
  • neb ipratropium bromide
  • PO prednisolone or IV hydrocortisone (continued for 5d)
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154
Q

Acute Asthma

mnx for severe acute asthma

A
  • O2 if required to maintain sats 94-98%
  • aminophylline infusion
  • consider IV salbutamol
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155
Q

Acute Asthma

mnx for life-threatening acute asthma

A
  • IV magnesium sulphate infusion
  • admission to ICU/HDU
  • intubation in worst cases
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156
Q

Acute Asthma

initially what will ABG show and why

A

respiratory alkalosis as tachypnoea causes a drop in CO2

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157
Q

Acute Asthma

which ABG results is a very bad sign

A

resp acidosis due to high CO2

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158
Q

Acute Asthma

when an ABG has normal pCO2 or hypoxia, what does it mean

A

a concerning sign as it means they are tiring and indicates life threatening asthma

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159
Q

Acute Asthma

what needs to be monitored when on salbutamol and why

A

serum K as salbutamol causes K to be absorbed from the blood into the cells

160
Q

COPD

does it cause clubbing

A

NO

161
Q

COPD

what is used to assess the impact of their breathlessness

A

MRC (Medical Research Council) Dyspnoea Scale

162
Q

COPD

MRC Dyspnoea Scale: grade 1

A

Breathless on strenuous exercise

163
Q

COPD

MRC Dyspnoea Scale: grade 2

A

Breathless on walking up hill

164
Q

COPD

MRC Dyspnoea Scale: grade 3

A

Breathless that slows walking on the flat

165
Q

COPD

MRC Dyspnoea Scale: grade 4`

A

Stop to catch their breath after walking 100 meters on the flat

166
Q

COPD

MRC Dyspnoea Scale: grade 5

A

Unable to leave the house due to breathlessness

167
Q

COPD

dx

A

clinical presentation plus spirometry.

168
Q

COPD

spirometry findings in COPD

A

FEV1/FVC ratio <0.7

obstructive

169
Q

COPD

how is severity graded

A

using FEV1

170
Q

COPD

stage 1 in severity

A

FEV1 >80% of predicted

171
Q

COPD

stage 2 in severity

A

FEV1 50-79% of predicted

172
Q

COPD

stage 3 in severity

A

FEV1 30-49% of predicted

173
Q

COPD

stage 4 in severity

A

FEV1 <30% of predicted

174
Q

COPD

mnx if they do not have asthmatic or steroid responsive features

A

stop smoking

1) salbutamol / ipratropium bromide

2) LABA + LAMA
e. g. “Anoro Ellipta”, “Ultibro Breezhaler” and “DuaKlir Genuair

175
Q

COPD

mnx if they have asthmatic or steroid responsive features

A

stop smoking

1) salbutamol / ipratropium bromide

2) LABA + ICS
e. g. “Fostair“, “Symbicort” and “Seretide”

3) LABA + ICS + LAMA
e. g. “Trimbo” and “Trelegy Ellipta

176
Q

COPD

mnx in more severe cases

A
  • Nebulisers (salbutamol and/or ipratropium)
  • Oral theophylline
  • Oral mucolytic therapy to break down sputum (e.g. carbocisteine)
  • Long term prophylactic antibiotics (e.g. azithromycin)
  • Long term oxygen therapy at home
177
Q

COPD

indications for long term O2 therapy

A

severe COPD that is causing problems such as:

  • chronic hypoxia
  • polycythaemia
  • cyanosis
  • heart failure secondary to pulmonary hypertension (cor pulmonale).
178
Q

COPD

why can’t smokers use long term O2 therapy

A

oxygen plus cigarettes is a significant fire hazard.

179
Q

COPD

ABG: what does low pH with a raised pCO2 suggest

A

they are acutely retaining more CO2 and their blood has become acidotic.

respiratory acidosis.

180
Q

COPD

ABG: what does a raised bicarbonate suggest

A

they chronically retain CO2 and their kidneys have responded by producing more bicarbonate to balance the acidic CO2 and maintain a normal pH.

181
Q

COPD

target O2 saturation If not retaining CO2 and their bicarbonate is normal (meaning they do not normally retain CO2)

A

> 94%

182
Q

COPD

target O2 saturation If retaining CO2 aim for oxygen saturations

A

88-92% titrated by venturi mask

183
Q

COPD

medical trx of an exacerbation if they are well enough to remain at home

A
  • prednisolone 30mg OD for 7-14d
  • regular inhalers or home nebs
  • abx if evidence of infections
184
Q

COPD

medical trx of an exacerbation if in hopsital

A
  • neb bronchodilators (salbutamol 5mg/4h + ipratropium 500mcg/6h
  • steroids (200mg hydrocortisone or 30-40mg PO prednisolone)
  • abx if evidence of infection
  • physio
185
Q

COPD

medical trx of an exacerbation in severe cases not responding to first line treatment

A
  • IV aminophylline
  • NIV: BiPAP
  • Intubation and ventilation with admission to intensive care
  • Doxapram can be used as a respiratory stimulant where NIV or intubation is not appropriate
186
Q

Lung cancer

what is the biggest cause

A

smoking

187
Q

Lung cancer

types

A
  • non small cell lung cancer (80%)

- small cell lung cancer (20%)

188
Q

Lung cancer

type of non-small cell lung cancer

A
  • Adenocarcinoma (~40%)
  • Squamous cell carcinoma (~20%)
  • Large-cell carcinoma (~10%)
  • Other types (~10%)
189
Q

Lung cancer

signs + sx

A
  • SOB
  • Cough
  • Haemoptysis (coughing up blood)
  • Finger clubbing
  • Recurrent pneumonia
  • Weight loss
  • Lymphadenopathy
190
Q

Lung cancer

what nodes are often found first on examination

A

supraclavicular nodes

191
Q

Lung cancer

1st line inx

A

CXR

192
Q

Lung cancer

findings on CXR

A
  • Hilar enlargement
  • “Peripheral opacity”
  • Pleural effusion – usually unilateral in cancer
  • Collapse
193
Q

Lung cancer

CXR: what is peripheral opacity

A

a visible lesion in the lung field

194
Q

Lung cancer

what inx is used to stage and check for lymph node involvement and metastasis

A

contrast enhanced CT scan of chest, abdomen and pelvis

195
Q

Lung cancer

when are PET-CT scans useful

A

in identifying areas that the cancer has spread to by showing areas of increased metabolic activity suggestive of cancer

196
Q

Lung cancer

what is involved in a PET-CT scan

A

injecting a radioactive tracer

and taking images using a a CT scanner and a gamma ray detector

to visualise how metabolically active various tissues are.

197
Q

Lung cancer

which inx is used for detailed assessment of the tumour and US guided biopsy

A

Bronchoscopy with endobronchial ultrasound (EBUS)

endoscopy of the bronchi with US on the end of the scope

198
Q

Lung cancer

what trx is offered 1st line in non-small cell lung cancer to patients that have disease isolated to a single area with intention to cure the cancer

A

Surgery - lobectomy

radiotherapy can also be curative if early on enough

199
Q

Lung cancer

when is chemo offered

A
  • in addition to surgery or radiotherapy in certain patients to improve outcome (adjuvant chemo)
  • palliative treatment to improve survival and QoL in later stages of non-small cell lung cancer.
200
Q

Lung cancer

trx for small cell lung cancer

A

chemo + radio

201
Q

Lung cancer

which has a worse prognosis: small cell or non small cell

A

small cell

202
Q

Lung cancer

palliative trx to relieve bronchial obstruction

A

endobronchial trx w/ stents or debulking

203
Q

Lung cancer

extrapulmonary manifestations (9)

A
  1. recurrent laryngeal nerve palsy
  2. phrenic nerve palsy
  3. superior vena cava obstruction
  4. horner’s syndrome
  5. SIADH
  6. Cushing’s syndrome
  7. Hypercalcaemia
  8. Limbic encephalitis
  9. Lambert-Eaton myasthenic syndrome
204
Q

Lung cancer

extrapulmonary manifestations: how does recurrent laryngeal nerve palsy present

A

hoarse voice

205
Q

Lung cancer

extrapulmonary manifestations: cause of recurrent laryngeal nerve palsy

A

the cancer pressing on or affecting the recurrent laryngeal nerve as it passes through the mediastinum

206
Q

Lung cancer

extrapulmonary manifestations: how does phrenic nerve palsy present

A

SOB

diaphragm weakness

207
Q

Lung cancer

extrapulmonary manifestations: how does superior vena cava obstruction present

A

medical emergency!

  • facial swelling
  • difficulty breathing
  • distended veins in the neck and upper chest
  • “Pemberton’s sign”
208
Q

Lung cancer

what is Pemberton’s sign

A

a sign of superior vena cava obstruction

raising the hands over the head causes facial congestion and cyanosis

209
Q

Lung cancer

what is Horner’s syndrome caused by

A

a Pancoast’s tumour (tumour in the pulmonary apex) pressing on the sympathetic ganglion

210
Q

Lung cancer

what is SIADH caused by

A

ectopic ADH secretion by a small cell lung cancer

211
Q

Lung cancer

what is cushing’s syndrome caused by

A

ectopic ACTH secretion by a small cell lung cancer.

212
Q

Lung cancer

what is hypercalcaemia caused by

A

ectopic parathyroid hormone from a squamous cell carcinoma.

213
Q

Lung cancer

what is limbic encephalitis

A

a paraneoplastic syndrome

the small cell lung cancer causes the immune system to make antibodies to tissues in the brain

specifically the limbic system, causing inflammation in these areas.

214
Q

Lung cancer

sx of limbic encephalitis

A
  • short term memory impairment
  • hallucinations
  • confusion
  • seizures
215
Q

Lung cancer

what antibodies is limbic encephalitis associated with

A

anti-Hu antibodies

216
Q

Lung cancer

what is Lambert-Eaton myasthenic syndrome

A

antibodies produced by the immune system against small cell lung cancer cells also target and damage voltage-gated calcium channels sited on the presynaptic terminals in motor neurones.

217
Q

Lung cancer

presentation of Lambert-Eaton myasthenic syndrome

A
  • weakness in proximal muscles
  • diplopia
  • ptosis
  • slurred speech
  • dysphagia
  • autonomic: dry mouth, blurred vision, impotence, dizziness
218
Q

Lung cancer

what is a notable finding on examination of someone with Lambert-Eaton myasthenic syndrome

A

post-tetanic potentiation

reflexes become temporarily normal for a short period following a period of strong muscle contraction

219
Q

Lung cancer

old patient who smokes and sx of Lambert-Eaton syndrome

what do you consider

A

small cell lung cancer

220
Q

Lung cancer

what is mesothelioma

A

a lung malignancy affecting the mesothelial cells of the pleura

221
Q

Lung cancer

what is mesothelioma strongly linked to

A

asbestos inhalation

222
Q

Lung cancer

is there a huge latent period between exposure to asbestos and the development of mesothelioma

A

yes - up to 45 years!

223
Q

Lung cancer

prognosis of mesothelioma

A

poor

chemo may help but it is essentially palliative

224
Q

Pneumonia

definition of hospital acquired pneumonia

A

If it develops more than 48h after hospital admission

225
Q

Pneumonia

definition of aspiration pneumonia

A

If it develops as a result of aspiration

meaning after inhaling foreign material such as food

226
Q

Pneumonia

presentation

A
  • SOB
  • Cough productive of sputum
  • Fever
  • Haemoptysis
  • Pleuritic chest pain
  • Delirium
  • Sepsis
227
Q

Pneumonia

characteristic chest signs

A
  • bronchial breath sounds
  • focal coarse crackles
  • dullness to percussion
228
Q

Pneumonia

what are bronchial breath sounds

A

harsh breath sounds equally loud on inspiration and expiration

caused by consolidation of the lung tissue around the airway

229
Q

Pneumonia

what causes focal coarse crackles

A

air passing through sputum in the airways

230
Q

Pneumonia

why is there dullness to percussion

A

lung tissue collapse and/or consolidation.

231
Q

Pneumonia

signs (which could indicate sepsis secondary to pneumonia)

A 
Tachypnoea
Tachycardia 
Hypoxia 
Hypotension 
Fever
Confusion
232
Q

Pneumonia

what is the severity assessment called

A

CURB-65

233
Q

Pneumonia

what does CURB-65 stand for

A

C – Confusion (new disorientation in person, place or time)

U – Urea > 7
R – Respiratory rate ≥ 30
B – Blood pressure < 90 systolic or ≤ 60 diastolic.

65 – Age ≥ 65

234
Q

Pneumonia

CURB-65 score of 0 or 1

A

Consider treatment at home

235
Q

Pneumonia

CURB-65 score of 2

A

Consider hospital admission

236
Q

Pneumonia

CURB-65 score of 3 or more

A

Consider intensive care assessment

237
Q

Pneumonia

common organisms

A
  • Streptococcus pneumoniae (50%)

- Haemophilus influenzae (20%)

238
Q

Pneumonia

cause in immunocompromised patients or those with chronic pulmonary disease

A

Moraxella catarrhalis

239
Q

Pneumonia

cause in patients with cystic fibrosis or bronchiectasis

A

Pseudomonas aeruginosa

240
Q

Pneumonia

cause in patients with cystic fibrosis

A

Pseudomonas aeruginosa

Staphylococcus aureus

241
Q

Pneumonia

definition of atypical pneumonia

A

pneumonia caused by an organism that cannot be cultured in the normal way or detected using a gram stain.

They don’t respond to penicillins

242
Q

Pneumonia

what can atypical pneumonias be treated with

A
  • macrolides (e.g. clarithromycin)
  • fluoroquinolones (e.g. levofloxacin)
  • tetracyclines (e.g. doxycycline)
243
Q

Pneumonia

Legionella pneumophila (Legionnaires’ disease) key points

A
  • infected water supplies or air conditioning units

- can cause SIADH –> hyponatraemia

244
Q

Pneumonia

Mycoplasma pneumoniae key points

A
  • milder pneumonia
  • erythema multiforme: target lesions
  • neuro sx
245
Q

Pneumonia

Chlamydophila pneumoniae key points

A

school aged child with a mild to moderate chronic pneumonia and wheeze

246
Q

Pneumonia

Coxiella burnetii AKA “Q fever” key points

A
  • linked to exposure to animals and their bodily fluid

- farmer with a flu like illness

247
Q

Pneumonia

Chlamydia psittaci key points

A
  • typically contracted from contact with infected birds
248
Q

Pneumonia

what are the 5 causes of atypical pneumonia

A

“Legions of psittaci MCQs’’

  • Legionella pneumophila
  • Chlamydia psittaci
  • Mycoplasma pneumoniae
  • Chlamydophila pneumoniae
  • Q fever (coxiella burnetii)
249
Q

Pneumonia

name a fungal pneumonia

A

Pneumocystis jiroveci (PCP)

250
Q

Pneumonia

whom is Pneumocystis jiroveci (PCP) common in

A

the immunocompromised

poorly controlled or new HIV with a low CD4 count

251
Q

Pneumonia

presentation of fungal pneumonia

A

subtle

dry cough without sputum, SOB on exertion and night sweats

252
Q

Pneumonia

treatment of Pneumocystis jiroveci (PCP)

A

Septrin: co-trimoxazole (trimethoprim/sulfamethoxazole)

253
Q

Pneumonia

what are patients with low CD4 counts prescribed

A

prophylactic oral co-trimoxazole to protect against PCP.

254
Q

Pneumonia

inx in hospital

A
  • CXR
  • FBC: raised WCC
  • U+Es: urea
  • CRP: raised
255
Q

Pneumonia

inx in hospital for moderate or severe cases

A
  • Sputum cultures
  • Blood cultures
  • Legionella and pneumococcal urinary antigens (send a urine sample for antigen testing)
256
Q

Pneumonia

what can be helpful in monitoring the progress of the patient towards recovery.

A

Inflammatory markers such as white blood cells and CRP

257
Q

Pneumonia

mnx

A

depends on local area guidelines

mild CAP: 5d PO amoxicillin or macrolide

mod-severe CAP: 7-10d dual abx (amox + macrolide)

258
Q

Pneumonia

complications

A
  • Sepsis
  • Pleural effusion
  • Empyema
  • Lung abscess
  • Death
259
Q

what is the most common form of lung cancer in non smokers

A

Lung adenocarcinoma

260
Q

centrally located cavitating mass in the left upper lobe

and smoker

what type of lung cancer is this

A

squamous cell carcinoma

261
Q

what is acute respiratory distress syndrome

A

inflammation of the lung due to infective or other causes

fluid accumulation in the alveoli

262
Q

what is the 4 diagnostic criteria for ARDS

A
  1. bilateral diffuse infiltrates seen on a CXR or chest CT
  2. acute onset (within 1 week of a known risk factor)
  3. non-cardiogenic (pulmonary artery wedge pressure needed if doubt)
  4. pO2/FiO2 < 40kPa (200 mmHg)
263
Q

causes of ARDS

A
  • infection: sepsis, pneumonia
  • massive blood transfusion
  • trauma
  • smoke inhalation
  • acute pancreatitis
  • cardio-pulmonary bypass
264
Q

features of ARDS

A
  • dyspnoea
  • elevated respiratory rate
  • bilateral lung crackles
  • low oxygen saturations
265
Q

key inx for ARDS

A

CXR + ABG

266
Q

mnx fo ARDS

A
  • ITU
  • oxygenation/ventilation
  • treatment of the underlying cause e.g. antibiotics for sepsis
  • prone
267
Q

mnx of acute exacerbation of COPD and PaCO2 is rising

A

NIV

268
Q

pleural effusion: what is light’s criteria

A

an effusion is an exudate if:

  • pleural fluid to serum protein ratio is >0.5,
  • pleural fluid to serum LDH ratio is >0.6,
  • or the pleural fluid LDH is >2/3 the upper reference limit for serum LDH.
269
Q

Non Invasive Ventilation

when is it used

A

as an alternative to full intubation and ventilation to support the lungs in respiratory failure due to obstructive lung disease

270
Q

what does intubation and ventilation involve

A

giving the patient a general anaesthetic, putting a plastic tube into the trachea and ventilating the lungs artificially.

271
Q

Non Invasive Ventilation

what does it involve

A

using a full face mask or a tight fitting nasal mask to blow air forcefully into the lungs and ventilate them without having to intubate them

272
Q

Non Invasive Ventilation

what types can it be

A

BiPAP or CPAP.

273
Q

Non Invasive Ventilation

what is BiPAP

A

bilevel positive airway pressure

a cycle of high and low pressure to correspond to the patients inspiration and expiration

274
Q

Non Invasive Ventilation

when is BiPAP used

A

where there is type 2 respiratory failure typically due to COPD

275
Q

Non Invasive Ventilation

what is the criteria for initiating BiPAP

A

Respiratory acidosis (pH < 7.35, PaCO2 >6)

despite adequate medical treatment.

276
Q

Non Invasive Ventilation

what are the CIs

A

an untreated pneumothorax or any structural abnormality or pathology affecting the face, airway or GI tract

277
Q

Non Invasive Ventilation

what is needed prior to NIV

A

CXR to exclude pneumothorax where this does not cause a delay

278
Q

Non Invasive Ventilation

what plan should be in place in case it fails

A

whether the patient should proceed to intubuation and ventilation and ICU or whether palliative care is more appropriate.

279
Q

Non Invasive Ventilation

BiPAP: what is IPAP

A

inspiratory positive airway pressure

the pressure during inspiration. This is where air is forced into the lungs.

280
Q

Non Invasive Ventilation

BiPAP: what is EPAP

A

expiratory positive airway pressure

the pressure during expiration.

This provides some pressure during expiration so that the airways don’t collapse and it helps air to escape the lungs in patients with obstructive lung disease.

281
Q

Non Invasive Ventilation

BiPAP: what must be done after initiation

A

ABG 1 hour after every change and 4 hours after that until stable

IPAP is increased by 2-5 cm increments until the acidosis resolves.

282
Q

Non Invasive Ventilation

what is CPAP

A

continuous positive airway pressure

continuous air being blown into the lungs that keeps the airways expanded so that air can more easily travel in and out.

used to maintain the patient’s airway in conditions where it is prone to collapse.

283
Q

Non Invasive Ventilation

indications for CPAP

A
  • Obstructive sleep apnoea
  • Congestive cardiac failure
  • Acute pulmonary oedema
284
Q

Sarcoidosis

what is it

A

a granulomatous inflammatory condition

285
Q

Sarcoidosis

what are granulomas

A

nodules of inflammation full of macrophages

286
Q

Sarcoidosis

when are the 2 spikes in incidence

A

young adulthood

again around age 60

287
Q

20-40 year old black woman presenting with a dry cough + SOB.

may have nodules on their shins (erythema nodosum)

what is it

A

sarcoidosis

288
Q

Sarcoidosis

what is the most commonly affected organ

A

lungs

289
Q

Sarcoidosis

what are the lung problems

A
  • Mediastinal lymphadenopathy
  • Pulmonary fibrosis
  • Pulmonary nodules
290
Q

Sarcoidosis

systemic sx

A
  • fever
  • fatigue
  • weight loss
291
Q

Sarcoidosis

what are the liver problems

A

Liver nodules
Cirrhosis
Cholestasis

292
Q

Sarcoidosis

what are the eye problems

A

Uveitis
Conjunctivitis
Optic neuritis

293
Q

Sarcoidosis

what are the skin problems

A
  • Erythema nodosum
  • Lupus pernio
  • Granulomas develop in scar tissue
294
Q

Sarcoidosis

what is erythema nodosum

A

tender, red nodules on the shins caused by inflammation of the subcutaneous fat

295
Q

Sarcoidosis

what is lupus pernio

A

raised, purple skin lesions commonly on cheeks and nose

296
Q

Sarcoidosis

what are the heart problems

A
  • Bundle branch block
  • Heart block
  • Myocardial muscle involvement
297
Q

Sarcoidosis

what are the kidney problems

A
  • Kidney stones (due to hypercalcaemia)
  • Nephrocalcinosis
  • Interstitial nephritis
298
Q

Sarcoidosis

what are the CNS problems

A
  • Nodules
  • Pituitary involvement (diabetes insipidus)
  • Encephalopathy
299
Q

Sarcoidosis

what are the peripheral nervous system problems

A
  • Facial nerve palsy

- Mononeuritis multiplex

300
Q

Sarcoidosis

what are the bone problems

A
  • Arthralgia
  • Arthritis
  • Myopathy
301
Q

Sarcoidosis

What is Lofgren’s Syndrome

A

specific presentation of sarcoidosis:

  1. Erythema nodosum
  2. Bilateral hilar lymphadenopathy
  3. Polyarthralgia
302
Q

Sarcoidosis

Ddx

A
  • TB
  • Lymphoma
  • Hypersensitivity pneumonitis
  • HIV
  • Toxoplasmosis
  • Histoplasmosis
303
Q

Sarcoidosis

screening inx

A

raised serum ACE

304
Q

Sarcoidosis

will calcium be raised

A

yes

305
Q

Sarcoidosis

what other blood tests (apart from Ca + ACE)

A
  • Raised serum soluble interleukin-2 receptor
  • Raised CRP
  • Raised immunoglobulins
306
Q

Sarcoidosis

what will CXR show

A

hilar lymphadenopathy

307
Q

Sarcoidosis

what will high resolution CT thorax show

A

hilar lymphadenopathy and pulmonary nodules

308
Q

Sarcoidosis

what can MRI show

A

CNS involvement

309
Q

Sarcoidosis

what can PET scan show

A

active inflammation in affected areas

310
Q

Sarcoidosis

what is the gold standard for confirming dx

A

histology from biopsy

by doing bronchoscopy with US guided biopsy of mediastinal lymph nodes

311
Q

Sarcoidosis

what will histology show

A

non-caseating granulomas with epithelioid cells.

312
Q

Sarcoidosis

1st line trx in patients with no or mild symptoms

A

none as the condition often resolves spontaneously

313
Q

Sarcoidosis

1st line trx in patients with sx

A

1st line: PO steroids (+ bisphosphonates)

2nd: methotrexate or azathioprine

314
Q

Sarcoidosis

prognosis

A

spontaneously resolves within 6 months in around 60% of patients

315
Q

Sarcoidosis

what does it progress to in a small number of pts

A

pulmonary fibrosis and pulmonary hypertension

potentially requiring a lung transplant

316
Q

Sarcoidosis

what is death due to usually

A

when it affects the heart (causing arrhythmias) or the CNS

317
Q

Obstructive Sleep Apnoea

what is it caused by

A

collapse of the pharyngeal airway during sleep

318
Q

Obstructive Sleep Apnoea

characteristic feature

A

apnoea episodes during sleep where the person will stop breathing periodically for up to a few minutes

319
Q

Obstructive Sleep Apnoea

RFs (5)

A
  • Middle age
  • Male
  • Obesity
  • Alcohol
  • Smoking
320
Q

Obstructive Sleep Apnoea

features

A
  • Apnoea episodes during sleep (reported by partner)
  • Snoring
  • Morning headache
  • Waking up unrefreshed from sleep
  • Daytime sleepiness
  • Concentration problems
  • Reduced oxygen saturation during sleep
321
Q

Obstructive Sleep Apnoea

what can severe cases cause

A
  • hypertension
  • heart failure
  • can increase the risk of MI and stroke
322
Q

Obstructive Sleep Apnoea

what is uses to assess sx of sleepiness associated with OSA

A

Epworth Sleepiness Scale

323
Q

Obstructive Sleep Apnoea

what do patients that need to be fully alert for work, for example heavy goods vehicle operators, require

A

urgent referral and may need amended work duties whilst awaiting assessment and treatment.

324
Q

Obstructive Sleep Apnoea

who do you refer to

A

ENT specialist or a specialist sleep clinic

325
Q

Obstructive Sleep Apnoea

inx

A

sleep studies : monitor O2 sats, HR, RR + breathing

326
Q

Obstructive Sleep Apnoea

1st step in mnx

A

correct reversible risk factors

  • stop drinking alcohol
  • stop smoking
  • lose weight
327
Q

Obstructive Sleep Apnoea

2nd step in mnx

A

CPAP machine

provides continuous pressure to maintain the patency of the airway.

328
Q

Obstructive Sleep Apnoea

last line mnx

A

surgery: uvulopalatopharyngoplasty (UPPP)

restructuring of the soft palate + jaw

329
Q

Asthma

BTS/Sign Guidelines on Diagnosis

A
  • High probability of asthma clinically: Try treatment
  • Intermediate probability of asthma: Perform spirometry with reversibility testing
  • Low probability of asthma: Consider referral and investigating for other causes
330
Q

Asthma

NICE Guidelines on Diagnosis

A

specifically advise not to make a diagnosis clinically and require testing (1st line inx):

  • Fractional exhaled nitric oxide
  • Spirometry with bronchodilator reversibility
331
Q

Asthma

NICE Guidelines on Diagnosis: if uncertainty after 1st line inx, what further testing can be done?

A
  • peak flow diary

- Direct bronchial challenge test with histamine or methacholine

332
Q

Asthma

how do SABAs work (Short acting beta 2 adrenergic receptor agonists)

A

Adrenalin acts on the smooth muscles of the airways to cause relaxation

333
Q

Asthma

name an example of an ICS

A

beclomethasone

334
Q

Asthma

name an example of a LABA

A

salmeterol

335
Q

Asthma

how does LABA work

A

same way as short acting beta 2 agonists but have a much longer action.

(Adrenalin acts on the smooth muscles of the airways to cause relaxation)

336
Q

Asthma

name an example of a LAMA

A

tiotropium

337
Q

Asthma

how do LAMAs work

A

they block the ACh receptors which leads to bronchodilation

338
Q

Asthma

name an example of a LTRA (Leukotriene receptor antagonists)

A

montelukast

339
Q

Asthma

how do LTRAs work

A

Leukotrienes are produced by the immune system and cause inflammation, bronchoconstriction and mucus secretion in the airways.

LTRAs block the effects of leukotrienes

340
Q

Asthma

how does theophylline work

A

relaxing bronchial smooth muscle and reducing inflammation

341
Q

Asthma

why is monitoring of plasma theophylline needed

A

it has a narrow therapeutic window and can be toxic in excess

342
Q

Asthma

when is plasma theophylline monitored

A

5 days after starting treatment and 3 days after each dose change

343
Q

Asthma

what is a MART (Maintenance and Reliever Therapy)

A

a combination inhaler containing a low dose ICS + fast acting LABA

This replaces all other inhalers and the patient uses this single inhaler both regularly as a “preventer” and also as a “reliever” when they have symptoms.

344
Q

Asthma

BTS/SIGN Stepwise Ladder of mnx

A
  1. SABA
  2. SABA + ICS
  3. SABA + ICS + LABA
  4. trial of PO LTRA/SABA/theophylline or inh LAMA
  5. step 4 + high dose ICS + refer
    • low dose PO steroid
345
Q

Asthma

NICE Guidelines mnx

A
  1. SABA
  2. SABA + ICS
  3. SABA + ICS + LTRA
    • LABA (continue only if good response)
  5. consider changing to MART
  6. change to moderate dose ICS
  7. change to high dose ICS or PO theophylline or inh LAMA
  8. refer
346
Q

Asthma

additional mnx

A
  • individual asthma self-management programme
  • Yearly flu jab
  • Yearly asthma review
  • Advise exercise and avoid smoking
347
Q

what is Samter’s triad

A

three conditions which commonly cluster together:

  • asthma
  • nasal polyps
  • aspirin sensitivity
348
Q

what is a Positive hepato-jugular reflux

A

(distension of neck veins when pressure is applied over the liver) is a major Framingham criteria for the diagnosis of heart failure.

349
Q

what hypersensitivity reaction is asthma

A

type 1: IgE antibodies

350
Q

what can be seen on histology if a pt has asthma

A

Curschmann spirals: when shed epithelium becomes whorled mucous plugs

351
Q

CXR: right lower lobe consolidation with central cavitation with an air-fluid level

what is it

A

lung abscess

352
Q

stony dull to percussion

what is it

A

pleural effusion

353
Q

A 76y: recurrent fever, productive cough with foul smelling sputum and dyspnoea. PMH of middle cerebral artery stroke. Finger clubbing. what could it be

A

lung abscess

354
Q

why may a PMH of stroke indicate lung abscess

A

risk of aspiration due to impaired swallow

355
Q

constipation and bone pain
finger clubbing and an inspiratory monophonic wheeze

what is it

A

Squamous cell lung cancer

hypercalcaemia from PTH or bony mets!

356
Q

sx of carcinoid syndrome

A

facial flushing, diarrhoea and asthma

357
Q

what could a well demarcated opacification is found in the right upper lobe be

A

a carcinoid tumour

358
Q

diagnostic inx for a carcinoid tumour

A

identifying the serotonin metabolite 5-HIAA in a 24 hour urinary collection

359
Q

1st line trx for pneumonia if CURB 0 or 1

A

amoxicillin

if allergic:
doxycycline

360
Q

1st line trx for pneumonia if CURB 2

A

amoxicillin + clarithromycin

if allergic:
doxycycline + clarithromycin

361
Q

1st line trx for pneumonia if CURB 3-5

A

co-amoxiclav + clarithromycin

if allergic:
levofloxacin

362
Q

Bronchiectasis

what is it

A

permanent dilation of the bronchi and bronchioles due to chronic infection

363
Q

Bronchiectasis

main organisms patients are infected by

A

Haemophilius Influenzae, Pseudomonas aeruginosa, Streptococcus Pneumoniae, Staphylococcus aureus.

364
Q

Bronchiectasis

causes

A
  • Post-Infection: TB; HIV; Measles; Pertussis; Pneumonia
  • Obstruction by foreign body or tumour
  • Allergic Bronchopulmonary aspergillosis (ABPA)

Congenital: CF; Kartagener’s syndrome; Primary ciliary dyskinesia; Young syndrome

  • Hypogammaglobulinaemia
  • Idiopathic
365
Q

Bronchiectasis

sx

A
  • Productive Cough
  • Large amounts of purulent sputum
  • Haemoptysis
366
Q

Bronchiectasis

signs

A
  • Finger clubbing
  • Coarse inspiratory crepitations
  • Dyspneoa
  • Wheeze
367
Q

Bronchiectasis

diagnostic investigation

A

High-resolution CT

368
Q

Bronchiectasis

what may CXR show

A

thickened bronchial walls, and cystic appearance aka tramline and ring shadows

369
Q

Bronchiectasis

what will spirometry show

A

obstructive pattern

370
Q

Bronchiectasis

what inx identify pathogens and guide management with antibiotics

A

sputum culture

371
Q

Bronchiectasis

what inx can locate areas of obstruction, haemoptysis or sample tissue for culture

A

Bronchoscopy

372
Q

Bronchiectasis

conservative mnx

A
  • Patient Education
  • Support Group
  • Chest Physio – Postural drainage at least BD to aid mucous drainage
  • Smoking Cessation
373
Q

Bronchiectasis

medical mnx

A
  • abx
  • bronchodilators
  • Carbocysteine - Mucolytic which reduces the viscosity of sputum
374
Q

Bronchiectasis

surgical mnx

A
  • Surgical excision of localized area of disease or cessation of haemoptysis.
  • Lung transplant may be indicated in certain patients
375
Q

what will histology show in small cell lung cancer

A

dense neurosecretory granules.

376
Q

chest pain, SOB, weight loss
CXR: pleural effusion and pleural thickening
what is it

A

mesothelioma

377
Q

what is the PERC

A

PE rule out criteria. All features must be absent for the likelihood of it being a PE <2% . If not, move to Well’s

378
Q

what are the features of PERC

A
  • ≥50y
  • HR ≥ 100
  • O2 sats ≤ 94%
  • previous DVT or PE
  • recent surgery or trauma in the past 4w
  • haemoptysis
  • unilateral leg swelling
  • oestrogen use (HRT, contraceptives)
379
Q

what is the Wells score criteria

A

CHIMPAH
Clinical signs + sx of DVT (minimum of leg swelling + pain with palpation of deep veins)
Haemoptysis
Immobilisation >3d or surgery in the previous 4w
Malignancy (on treatment, treated in last 6m, or palliative)
Previous DVT/PE
An alternative diagnosis is less likely than PE
HR > 100 bpm

380
Q

What is the score to estimate the prognosis of PE in 30 days?

A

Pulmonary embolism severity index (PESI)

381
Q

what 4 things to do before discharging pt on anticoagulants

A
  1. arrange appropriate anticoag monitoring/follow up
  2. provide written and verbal info on new anticoagulant drug
  3. provide written and verbal info on PE
  4. give pt an anticoagulant alert card
382
Q

how do you define an acute exacerbation of COPD

A

Anthonisen criteria

  • 2 major symptoms
  • or 1 major + 1 minor symptom
383
Q

Anothonisen criteria major symptoms

A
  • dyspnoea
  • increased sputum volume
  • increased sputum purulence
384
Q

Anothonisen criteria minor symptoms

A
  • cough
  • wheeze
  • nasal discharge
  • sore throat
  • pyrexia
385
Q

what is the most common bacterial organisms that cause infective exacerbations of COPD

A

H. Influenzae

386
Q

what is the 11 clinical criteria of the PESI score

A
  • Age
  • Sex
  • History of cancer
  • History of heart failure
  • History of chronic lung disease
  • Heart rate ≥110
  • Systolic BP <100 mmHg
  • RR ≥30
  • Temperature <36°C
  • Altered mental status (disorientation, lethargy, stupor, or coma)
  • O2 saturation <90%
387
Q

mnx of high-severity community acquired pneumonia

A

co-amoxiclav + clarithromycin

388
Q

mnx of moderate severity community acquired pneumoni

A

amoxicillin + clarithromycin

389
Q

what would make you admit a pneumonia patient for outreach or ICU

A
  • resp failure requiring mechanical ventilation
  • septic shocl requiring vasopressors
  • score 3-5 on CURB-65
  • class V on pneumonia severity score
390
Q

two pathological features of the airways in asthma

A
  1. airway hyperresponsiveness

2. inflammation and remodelling (causing bronchoconstriction)

391
Q

What receptor does salbutamol attach to

A

Beta 2 Adrenergic Receptors

392
Q

mnx if pt has a sub-massive pulmonary

embolus but is also at risk of haemorrhage.

A

IV heparin as it can be stopped and reversed in event of recurrent bleeding

393
Q

Which is the most appropriate method for providing analgesia during the early
postoperative period after major abdo surgery if they have resp disease?

A

Epidural is best because it can be topped up and titrated

opioid, by whatever route, should be avoided

394
Q

what inx to confirm pulmonary fibrosis

A

High resolution CT scan of chest

395
Q

If a patient presents with signs or symptoms of PE carry out an assessment of their general medical history, a physical examination
and a ___to exclude other causes.

A

CXR

then CTPA/D-dimer

Finals (47 decks)

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