resp

Question 1

causes of bronchiectasis and common infections

Answer 1

1. Cystic fibroisis - pseudomonas, H influenzae
2. chronic granulomatous diseases 0 disorder of phagocyte cells, inability of neutrophils to kill bacteria = severe bacterial and fnungal infections e.g. aspergillus
   3.T cell deificency in HIV/AODS associated with viral/fungal infection
3. hypogammaglobulinmia - recurrent LRTI and UTRI (otitis media, sinusitis, bronchitis, bronchiectasis, pneumonia). Encapsulated bacteria e.g. streptococcus p, strep pyogenes, haemophilus influenzae, staph a
   5/Primary ciliary dyskinesia - recurrent URTI and lRTI inability to clear secretions. infertility.

Question 2

carbon monoxide poisoning

Answer 2

normal pO2
measure carboxyhaemoglobin
CO poisoning causes tissue hypoxia, anaerobic metabolism and lactic acidosis.

Question 3

Indications for LTOT

Answer 3

pO2 < 7.3 with or without hypercapnia
pO2< 8 if evidence of pulmonary HTN/cot pulmonale/polycythemia
LTOT and smoking cessation are currently the only interventions in COPD that have been shown to prolong life.

Question 4

silicosis

Answer 4

Silicosis is a fibrotic lung disease associated with the inhalation of silicon dioxide (silica). It is usually found in quarry workers or miners and also sandblasters, pottery workers and stonemasons (if the dust contains quartz).

Diagnosis is made on industrial history and typical chest x ray changes.

The pathognomonic radiological changes are hilar eggshell calcification.

Question 5

pneumothorax management

Answer 5

spontaneous
- no SOB <2cm: discharge
- SOB <2cm aspirate
>2cm chest drain

secondary needs intervention
aspirate if not working chest drain

Question 6

occupational asthma

Answer 6

symptoms of asthma that improve when she is on holiday from her job.

confirming the diagnosis and are best performed using serial peak expiratory flow rate (PEFR) measured two hourly from waking to sleeping at least over a four week period which should include at least three periods away from work for at least two consecutive days, although patients with more severe disease may require more than 10 days away from the work environment before improvements are noted.

Question 7

high KCO

Answer 7

Extra-pulmonary restriction produces a characteristic pattern where Kco is greater than normal with a normal or slight reduction in Tlco because of the patient’s inability to achieve a full inspiration.

Causes of extrapulmonary restriction include:

Pleural disease
Skeletal deformities, or
Respiratory muscle weakness.

Question 8

pseudomonas on growth plate

Answer 8

Pseudomonas aeruginosa, characterised by the green colouration of the colonies - due to production of the pigment pyocyanin.

Question 9

pancoasts tumor

Answer 9

a Pancoast or superior sulcus tumour.

The tumour arises in the apex of the lung and infiltrates locally into the brachial plexus, ribs and mediastinum. Patients often have signs of local extension on presentation such as:

Neurological signs in the arm and hand (C8,T1 distribution)
Ipsilateral Horner’s syndrome, or
Radiological evidence of rib destruction.
CT scan is the investigation of choice.

Question 10

yension pneumo management

Answer 10

Where there is a tension pneumothorax neither oxygen alone nor needle aspiration are the definitive treatment and a chest tube must be inserted. The definitive treatment is the one that will lead to resolution of the pathology and a needle aspiration (or thoracocentesis) will not be big enough to allow the tension pneumothorax to resolve.

Question 11

squamous cell ca lung

Answer 11

Hypercalcaemia in absence of bony metastases occurs in about 15% of squamous cell lung carcinoma from parathyroid hormone related protein (PTHrP) production. This is a feature of non-metastatic manifestation of malignancy.

Clubbing is predominantly associated with squamous cell cancers and occasionally adenocarcinoma.

Question 12

small cell ca lung

Answer 12

Inappropriate antidiuretic hormone (ADH) secretion (hyponatraemia) and ectopic adrenocorticotropic hormone (ACTH) production (Cushing’s syndrome) occur with small cell lung cancer.

Question 13

legione;;a pneumonia

Answer 13

hyponatremia
fever
loaber pneumonia
levofloxacin

Question 14

ankylosing spondylitis

Answer 14

sacroilitis
uveitis
young
HLA b27

Question 15

raised DLCO

Answer 15

grossly elevated DLco is secondary to the left-right shunt and increased pulmonary blood flow. In contrast, chronic pulmonary emboli will cause a low DLco. Although the patient has a mild ventilatory defect secondary to obesity, this does not explain the clinical findings.

Other causes of a raised DLco include asthma, obesity, exercise, polycythaemia and any cause of alveolar haemorrhage (Goodpasture’s syndrome, Granulomatosis with polyangiitis, etc).

Question 16

Hornerss syndrome and recurrent laryngeal nerve involvement

Answer 16

Pancoasts tumor
Upper lobar malignancies involving the superior pulmonary sulcus can destroy surrounding structures leading to a characteristic clinical pattern - Pancoast’s syndrome. The syndrome consists of pain in a C8-T2 distribution (caused by infiltration of these nerves) often accompanied by radiological evidence of destruction of the first and second ribs.

Horner’s syndrome frequently co-exists due to infiltration of the sympathetic trunk. Horner’s syndrome consists of enophthalmos, ptosis, miosis and ipsilateral loss of the ability to sweat

Question 17

kCO

Answer 17

represents gas exchange co-efficient

raised in extrpukmonary causes, polycythemia, pulmonary haemorrhae
in restictive disease kCO is high but TCLO is low e.g. pleural thickening

Question 18

sarcoid

Answer 18

Sarcoidosis is suggested by the presence of:

ankle arthritis
bilateral hilar adenopathy
pulmonary fibrosis, and
a high serum ACE level.
Inflammatory arthritis in sarcoidosis typically targets the ankle joint.

Question 19

SEs of TNF a

Answer 19

anti-TNF-alpha increases the risk of opportunistic infections and in particular, there is a significant increase in the risk of TB reactivation in conjunction with infliximab. Therefore patients are often screened for Hepatitis B, C, TB and HIV prior to commencing infliximab.

Question 20

Radial nerve palsy

Answer 20

The typical causes of wrist drop are damage to the radial nerve in the spiral groove of the humerus in a midshaft fracture, and also as a result of acute compression. This is commonly caused by the “Saturday night palsy”, when the affected subject falls asleep with their arm over the side of a chair.

Question 21

ulitareal pleural calcification causes

Answer 21

Unilateral pleural calcification most commonly occurs as a chronic change secondary to pleural infection (particularly tuberculous empyema), pyogenic empyema, or haemothorax. Unilateral pleural calcification rarely is related to asbestos exposure.

Bilateral calcified pleural plaques are usually considered asbestos-related.

Other rarer causes of bilateral disease include radiation exposure, hyperparathyroidism, pulmonary infarction, and pancreatitis.

Question 22

polymyositis

Answer 22

poximal muscle weakness
anti-Jo 1
ILD
mechnics hands (fissuring of distal digits)

Question 23

symtpoms of PMR/GCA

Answer 23

Polymyalgia rheumatica/temporal arteritis may be associated with:

Predominantly polymyalgia symptoms, for example, proximal muscle pain, stiffness, or
Arteritis symptoms, for example, headaches, scalp tenderness and jaw claudication.
Systemic involvement is common, for example, fever, malaise and weight loss.

Typically the ESR is very high.

The main reason to diagnose and treat the condition is to prevent blindness.

Question 24

GCS<8

Answer 24

Intubate and high flow oxygen

Question 25

asthma no peak flow

Question 26

raised kco

Answer 26

Other causes of raised KCO include:

Pulmonary haemorrhage
Polycythaemia
Left to right shunts, and
Neuromuscular weaknes

Question 27

side effect of amiodarone

Answer 27

Pneumonitis and lung fibrosis present with

A progressively-worsening dry cough
Pleuritic chest pain
Dyspnoea
Malaise.
Other side-effects of amiodarone include

Neutropenia
Hepatitis
Phototoxicity and slate-grey skin discolouration
Hypothyroidism
Hyperthyroidism
Arrhythmias
Corneal deposits
Peripheral neuropathy
Myopathy.

Question 28

risk factors for PCP

Answer 28

steroids
cyclophosphamide

start on co-trimoxazole

Question 29

management of sever GPA requiring intubation

Answer 29

cyclophosphamide. prednisolone and plasmapharesis to remove immune complexes

Question 30

mortality CURB score

Answer 30

Low severity: CURB-65 0-1, mortality <3%
Moderate severity: CURB-65 2, mortality 9%
High severity: CURB-65 3-5, mortality 15-40%

Question 31

optimal treament of GPA

Answer 31

IV methylpred and IV cycloposphamide after renal biopsy

Question 32

hypersensitivity pneumonitis

Question 33

ARDS management

Answer 33

A high-PEEP strategy is recommended to reduce atelectotrauma.

ARDSNet VENTILATION STRATEGY
Ventilator Setup and Adjustment

calculate predicted body weight (PBW)
select any ventilator mode
achieve a TV of 6mL/kg
set respiratory rate (RR) to maintain optimal minute ventilation (MV) (not RR > 35/min)
aim for SpO2 88-95% or PaO2 55-80mmHg
increase PEEP with increasing FiO2 (5-24 cmH2O) according to a sliding scale (see table below)
aim for plateau pressure (Pplat) <30cmH2O
if necessary decrease TV stepwise by 1 mL/kg PBW to a minimum of 4 mL/kg PBW
If Pplat < 25 cmH20, increase TV stepwise by 1 mL/kg PBW until Pplat >25 cmH20 or TV of 6 mL/kg PBW
Pplat >30 cmH20 allowed if TV 4 mL/kg IBW and pH <7.15
TV could be increased up to 8 mL/kg PBW for patients with severe dyspnoea if Pplat maintained <30 cmH20
pH goal = 7.30-7.45
if pH < 7.15 increase TV, give NaHCO3

Question 34

psittacosis

Answer 34

obligate, intracellular, gram-negative bacterium (formerly known as ), which causes community-acquired, atypical pneumonia or conjunctivitis
pet shop worker with features of an atypical pneumonia.
atypical pneumonia contracted from birds and is treated with tetracyclines
pharngitis, splenomegaly
treat with tetracyclines

Question 35

predictors of increased severity and risk of death from community acquired pneumonia

Answer 35

predictors of increased severity and risk of death from community acquired pneumonia including

White cell count less than 4 ×109/L or greater than 20 ×109/L
Co-morbidity such as renal disease
Multi-lobar involvement on CXR and
Temperature less than 35°C or more than 40°C.
Thrombocytosis is associated with increased mortality compared to thrombocytopaenia or normal platelet levels.

Question 36

rifampicin and steroids

Answer 36

The metabolism of corticosteroids is increased by rifampicin.

Patients on long term steroids should have their dose of steroids increased when starting antituberculous therapy.

Question 37

TB tests

Answer 37

Interferon/T-spot

The Heaf test involves the multipuncture of skin using 100,000 tuberculin units/ml. It is read after one week and graded according to the coalescence of the puncture dots.

The Mantoux test involves the intradermal injection of 0.1 ml of 1 in 1000 tuberculin units and is read after 48 hours. An induration of less than 5 mm is considered negative. Mantoux test will be unreliable since the patient is on maintenance steroids.

Question 38

OSA

Answer 38

Obstructive sleep apnoea (or sleep apnoea/hypopnoea) syndrome occurs when episodes of partial or complete obstruction of the pharyngeal airway occur during sleep.

This causes

A. Repetitive apnoeas (cessation of airflow for more than 10 seconds) and hypopnoeas (50% reduction in airflow for greater than 10 seconds)

B. Loud snoring and

C. Excessive daytime somnolence as a result of repeated arousals.

The gold standard diagnostic test is overnight polysomnography.

Increasingly though simpler sleep monitoring systems or simple overnight oximetry are being used often with the studies undertaken in the patient’s home.

The treatment of choice is weight loss, avoid sedatives drugs/excess alcohol and nasal continuous positive airway pressure (CPAP).