Resp Flashcards
Stepwise management of inhalers in adults
- low dose ICS
- Add LABA to low dose ICS
- Consider increasing ICS to medium dose or adding LTRA (if no response to LABA - consider stopping)
- refer for specialist care
Stepwise management of inhalers in children
- very low dose ICS (or LRTA if < 5 yrs)
- very low dose ICS plus
a. LABA or LRTA if > 5 yrs old
b. LRTA if < 5 - Increase ICS to low dose or in children > 5 add LRTA or LABA (if no response to LABA, consider stopping)
- refer for speclialist care
Features of life threatning asthma
Hypoxaemia (<92%)
PEFR <33% of predicted
Exhaustion
Bradycardia or arrythmia
Hypotension
Silent chest
Altered consciousness
Poor resp effort
Cyanosis
Normal or raised PCO2
What is Bronchiolitis Obliterans
The term used to describe the fibrous scarring of the small airways, seen in the following;
- inhalation of toxic fumes
- exposure to mineral dust
- viral infections
- mycoplasma infections
- legionella
- bone marrow, heart or lung transplant
- RA or SLE
- Penicillamine treatment
Presentation of bronchiolotiis obliterans
Dry cough
Dyspnoea
Signs of bronchiolitis obliterans
Unremarkable
Expiratory wheeze may be audible
CXR findings of bronchiolitis obliterans
Can vary
Normal
Reticular pattern
Reticulonodular pattern
Diagnosis of bronchiolitis obliterans
Lung biopsy
Prognosis of bronchiolitis obliterans
Poor
Rarely respond to steriods
Investigation specific to allergic bronchopulmonary aspergillosis
Early positive skin prick test for aspergillus fumigatus (antigen-specific IgE)
What does FEF reflect
Status of the small airways
What is sent away when a pleural aspiration is carried out
Cytology
Protein
LDH
pH
Gram stain
Culture
Sensitivity
Stepwise Tx of COPD
1 SABA or SAMA
2. Combined therapy
- a) no asthmatic or steriod responsive features; LABA + LAMA
- b) asthmatic or steriod responsive featutres; LABA + ICS
3. 3x therapy; add ICS to 2a or LAMA to 2b
What epworth sleepiness score is suggestive of OSA
11 or more
(can be up to 24)
What is an azygous lobe
Normal variant
Seen as reverse comma sign behind the medial end of the right clavicle
right upper zone
What is the only treatment proven to improve long term prognosis in patients with chronic hypoxaemia in COPD
Long term domicillary oxygen therapy
Presentation of histoplasmosis
Acute URTI
Substernal pain
Xray changes in histoplasmosis
Patchy pulmonary infiltrates
Mediastinal widening
10% arthralgia
5% have pleural effusions
Diagnosis of histoplasmosis
Culture of histoplasma capsultatum from urine, blood and bone marrow and sputum
Treatment of histoplasmosis
Amphotericin B - not required unless patients show signs of respiratory insufficiency
Causes of upper lobe fibrosis on CXR
Ankylosing spondylitis (apices)
TB
Sarcoidosis
Extrinsic allergic alveolitis
Silicosis
ABPA
Post Radiotherapy
Causes of lower lobe fibrosis
RA
Scleroderma
SLE
IPF
Criteria of allergic bronchopulmonary aspergillosis
Clinical deterioration in asthma symptoms
Raised IgE levels
Positive aspergillosis serology
Pulmonary infiltrates on CXR
Treatment of ABPA
Corticosteriods
Itraconazole
WHat genotype is most commonly assosiated with early onset a1at
PIZZ
Diagnosis of sarcoid
Skin biopsy - non ceasating granulomas
Which lung cancer can progress rapidly in under 3 months
small cell lung carcinoma
Xray findings of radiation pneumonitiis
Hazy consolidation demarcated by a sharp margin that corresponds to the limits of the irridation field
Treatment of idiopathic pulmonary fibrosis
Nintedanib (tyrosine protein kinase inhibitor)
Common features of sarcoidosis
Erythema nodosum
Bilateral hilar lymphadenopathy on CXR
Uveitis
Hypercalcaemia
What lung condition develops in people with a1at defieicny
Empysema
transfer factor in stable astham
unafffected
Which lung cancer is related to hyponatraemia and how
small cell lung cancer
syndrome of innapropriately secreated anti diuretic hormone (SIADH)
Which is the most aggressive lung cancer
Small cell lung cancer
Which lung cancer is most assosiated with smoking
squamous cell carcinma
Which lung cancer is often peripheral
adenocarcinoma
What is the most important thing to consider in the mangement of pneumothoraxes
Degree of clinical compromise, not the pneumothorax
Management of a patient < 50 with a primary spontaneous pneumothorax with no clinical distress which is < 2cm
No specific therapy
Supplemental o2 as required
F/u CXR to ensure lung expansion
Management of patient with primary spontaenus pneumothorax < 50 yrs old who is breathless or a large pneumothorax (>2cm)
Supplemental oxygen
Percutaneous needle aspiration (midclavicular line 2nd/3rd IC space)
If aspiration fails - insert a chest tube or a small bore catheter
Management of a secondary pneumothorax or patient > 50 yrs old if it is a small (<1cm) penumothorax and no SOB
Supplemental O2
Observe in hospital
Management of a secondary pneumothorax or a patient > 50 if it is moderate (1-2cm) pneumothorax and no SOB
Supplemental 02
Observe in hospital
Percutaneus needle aspiration
Chest drain
Suction
Hyponatraemia in small cell lung cancers
SiADH secretion
Dilutional
Low serum osmolality
High urine osmolality
Tx of hyponatraemia in small cell lung cancers
Fluid restriction
anti-GBM antibody is assosiated with what
Goodpastures syndrome
What antibody is assosiated with eosinophilic granulomatsosi with polyangitis
anti-myeloperoxidase antibody
Investigation of choice for eosinophilic granulomatosis with polyangitis
Skin biopsy
- small vessel ateriopathy
- granuloma formation
Treatment of eosinophilic granulomatosis with polyangitis
High dose methylpred
+/- cyclophosphamide
Example of a condition where the antibody anticardiolipin is found
antiphopsholipid syndrome
SLE
Examples of anaerobic pleuropulmonary infections
Aspiration pneumonia
Necrotising pneumonitis
Lung abscess
Empyema
Infection secondary to bronchiectasis and bronchial carcinoma
Example of pneumonia secondary to gram positive areobes
Strep
Staph
Example of presentation of allergic bronchopulmonary aspergillosis
Deteriorating asthma sx
Haemoptysis
General malaise
Headache
Investigations for ABPA
Peropheral blood eosinophilia
Increased serum IgE
Bilateral infiltrates on CXR
Increased aspergillus specific IgE or IgG
What is the main driver for LTOT prescription
02
Criteria for LTOT prescription
PO2 < 7.3
P02 > 7.3 but < 8 when stable, who also have
- Secondary polycythaemia
- peripheral oedema
- noctural hypoxaemia
- pulmonary HTN
What is indicated in the treatment of asthma when symptoms are still not controlled despite inhaled corticosteriods, LABA and LTRAs
Theophylline
Assosiations of OSA
Stroke
HTN
T2DM
Over 98% of men with cystic fibrosis have what
Bilateral Abscence of vas deferens
What sweat chloride value is diagnostic for CF?
> 60
If a sweat chloride test is 30 - 60, what should be done next
CFTR gene analysis
WHat is an auscultation finding of consolidation
Whisphering pectoriloquy
What picture do you get with silicosis
Mixed obstructive / restrictive picture
Investigation of legionella
Urinary antigen test
Presentation of legionella
Cough
SOB
Wheeze
Pleurtic pain
Fevers
Neurological / confusion
GI Sx / diarrhea / deranged LFTs
AKI
Hyponatraemia
What is GPA assosiated with
Midline sinusitis
Pulmonary haemorrhage
Retinal vasculitis
What is the syndrome called when you aspirate stomach contents and what pathology does this cause
Mendelson syndrome
bronchospasm
WHat bacteria commonly causes LRTIs in people with herbes libialis
strep pneumonia
An obstructive spirometry with raised lung volumes may indicate what
asthma
COPD
Transfer factor in asthma
normal
Beside test to assess lung function in a patient with GBS
forced vital capacity (FVC)
Indications for draingage of pleural effusion
Infected fluid
ph < 7.2
gram stain showing the prescence of organisms
fluid is frankly purulent
clinical improvement slow despite antibiotic therapy
WHat does oeosinophilia in a pleural cavity suggest and what does it make the diagnosis LEAST likely
suggests air in the pleural cavity
malignancy and TB less likely
Causes of low gluocse levels in pleural aspirate
RA
TB
Empyema
Malignancy
What do high levels of salivary amylase indicate
Oesophageal rupture
The prescence of anti-nuclear factor in a pleural aspirate is virtually diagnostic of what?
SLE
What is cricoartenyoid arhtisi related to
RA
Presentation of cricoartenyoid arthritis and what can exacerbate symptoms
Sore throat
hoarse voice
stridor
asymptomatic
post op period can rapidly worsen symptoms
Investigations of cricoartyeniod arthriits
spirometry with flow volume loop
Direct laryngoscopy and CT of larynx
CXR findings in pneumocystitis jirovecci
diffuse pulmonary infiltrates extending from perihilar region
Treatment of narcolepsy and how does it work
Modafinil
CNS stimulant
WHat are the strongest predictors of survival in COPD
Age
Baseline FEV1
Predisopsing factors for recurrent PE
Antithrombin III deficiency
Protein C defieincy
Factor V Leiden mutation
WHat is suggestive of EAA (EXTRINSIC ALLERGIC ALVEOLITIS)
Circulating IgG precipitans
Types of pleural effusions
Exudate
Transudate
WHat are exudates high in
proteins
Causes of exudative pleural effusion
Infections
Malignancy
PE
Connective tissue disorders
Pancreatitis, subphrenic abscess
Trauma
causes od transudative pleural effusion
LVF
Liver cirrhosis
Nephrotic syndrome
Other causes of hypoproteinaemia
PE
sarcoid
peritoneal dialysis
myoexema
Protein in transudative effusions
low
Antibodies of eosinophilic granulomatosis with polyangitis
pANCA
Presentation of esoinophilic granulomatosis with polyangitis
Asthma
Mononeuritis multiplex / peripheral nerve impariemnt
Atopy
recurrent nasal polyps
Renal impariement
raised esoinophil count
How does a 1 antitrypsin limit emphysema
Elastase inhibitor
What is meigs syndrome
In the prescence of an ovarian fibroma / tumour
Ascites
Pleural effusion
Treatment of meigs sydnrome
Removal of fibroma / tumour causes resolution of ascites / effusion
Features of yellow nail syndrome
Abnormality of lymphatic drainge
Recurrent bronchiectasis
Small bilateral pleural effusions
Lymphodema
Grossly thickened, yellow nails
Assosiated lung condition of RA
Bronchiectasis
On auscultation what would you hear with bronchiectasis
Coarse creps
On auscultation what would you hear with lung fibrosis
Fine fixed end inspiratry crackles
Who is at risk of getting mycoplasma
Those in institutions
Who is langerhans cells histocytosis seen in
younger
ex or current smokers
radiological findings of langerhans cells histocytosis
bilateral symmetrical reticlulonodular pattern
affecting upper and mid zones
later diseases may lead to cyst formation
What is cryptogenic organising pneumonia
non specific inflammatory pulmonary process with buds of granulation tissue forming in the distal air spaces
Treatment of COOP
Steriods
Lymphocyte predominant pleural fluid suggests what
Lymphoma
Cancer
TB
CXR findings in PJP
diffuse ground glass opacities
nodular opacities
lobar consolidations
normal film
What is polyarteritis nodosa
affects medium sized arteries
infiltrate composed of neutrophils
absent granulomas
How often does polyarteritis nodosa affect the lungs?
rarely
Treatment of TB that is fully sensitive
4 drugs (rifampicin, isonizaid, ethambutol, pyrazinamide) for 2 months
then 2 drugs (rifampicin and isonizaid) for 4 months
How is unilateral paralysis of the diaphragm diagnosed
flurosccopy
Investigation for OSA
Polysomnography
What should be checked before TB treatment is started
LFTs
Drug assosiations of PHTN
Anorectics (flenfuramine, dexfenfluramine)
Amphetamines
Cocaine
What is horner syndrome caused by
Pancoast (apical) tumour
Leads to damage to spinal nerve roots at levels C8 and T1
Presentation of horner syndrome
Pupil constriction
Ptosis
Facial anhidrosis
When does a staph pneumonia occur
after a proceeding viral illness
What are common in staph pneumonias
pneumothorax
pleural effusion
empyema
What is commonly seen 1-2 weeks after infection with mycoplasma pnuemonia in young adults
acute cold autoimmune haemolytic anaemia
treatment of mycoplasma pneumonia
erythromycin
Which lung cancer is assosiate dwith increased skin pigmentation
Small cell carcinoma
What is a positive tuberculin test in a patient with chronic sarcoid suggestive of
active TB
What is the mainstay of treatment of bronchiectasis
Postural drainage by physios
What is the best way to ascertain the effects of an extrathoracic tracheal compression
flow volume loop
What is the thing that prolongs a COPD patients life
LTOT
What is the PEFR a sensitive measure of
airflow obstruction
Which vaccine is contraindicated in patients taking high dose steriods
Yellow fever vaccination
Examples of live vaccines
Influenza
Yellow fever
MMR
Which type of TB needs 12 month therapy
TB meningitis
Is asbestos related pleural plaque disease assosiated with abnormal lung function
no
What is loeffer syndrome
transisent respiratory illness with blood eosinophilia and pulmonary infiltrates
Self limiting and lasts under a month
Where is the gene defect in cystic fibrosis
chromosome 7
What is the significant pathogen in CF that is a contraindication to lung transplant
Burkholderia cenocepacia
Features of scleroderma
Raynauds
Peripheral calcinosis
Oesopheageal symptoms
Sclerodactyly
Telangiectasia
Evidence of pulmonary fibrosis
Haemopytsis after exposure to aspergillus environments would indicate what
Chronic aspergillosis rather thanABPA
How does a venturi mask deliver a certain percentage of oxygen
Air entrainment
Is a pancoast tumour a contranindication to surgery
yes
Presentation of idiopathic pulmonary haemsiderosis
Occurs in young people
Pallor
Weakness
Lethargy
Dry cough
Occassional haemoptysis
No abnormal immunological features
Gas transfer elevated
What can develop in an old lung cavity where a patient has had previous TB?
Aspergilloma
What is a well known determinant of progression in cystic fibrosis
Neutrophils
Drug interactions of theophylline
Clarithyrmycin
Cipro
Cimetidine
Oral contraceptives
Allopurinol
What is the most common organism found in childrens sputum with CF
Staph A
What is most common organism found in adults in sputum with CF
Psueodmonas aueringosa
What is an aspergilloma assosiated with (blood test)
Aspegillus precipitans
WHat is the key antigen presenting cell during sensitisation
Dendritic cells
Example of a LRTA
Montelukast
What is macleod syndrome
Unliateral emphysema following childhood bronchiolitis
Treatment of an extrinsic cause of SVC obstruction
Stenting
Inheritance of CF
AR
Risk factors for multi drug resistant TB
Poor compliance
Previous anti-TB treatment
HIV infection
Contact with drug resistant TB
What kind of lung tumour would be most common in a patient who is a lifelong no smoker and a peripheral nature
adenocarcinoma
Guideliens for a health care worker with a positive tuberculin test after exposure to TB
Combination of isonizaid and rifampicin for 3 months or isonizaid alone for 6 months
Means latent TB - no need to stay off work
What lung test correlates most with mortality in COPD
FEV1
Which lung cancer is most assosiated with hypercalcaemia
Squamous cell carcinoma
What can non resolving pneumonia be a sign of
Carcinoma
What is the usual tracer in PET imaging used for lung cancer
Flurodeoxyglucose
Genetics of mesothelioma
Loss of material on chromosome 22
Who tends to get klebsiella pneumonia
Alcoholics
Typical picture of klebsiella pneumonia
Cavitating lesions
Predominantely affecting upper lobes (can affect lower)
Blood tests of a legionella pneumonia
Hyponatraemia
Deranged LFTs
Normal anatomical dead space
150ml
Pulmonary function test of a large compression lung cancer
flow volume loop
Causes of an increased transfer coefficient
Increase in RBCs in the lungs due to greater blood flow
Pulmonary haemorrhage
Polycythaemia
What is the most common malignant tumour of the lung
Metastatic carcinoma
Limited cutaenous sclerosis antibodies
anti-centromere AbS
Antibodies of diffuse cutaneous sclerosis
Anti-Scl-70
WHats occupational asthma most triggered by
Isocycanates
Pleural fluid analysis of empyema
Presence of macroscopic pus
ph < 7.2
Glucose < 3.3
LDH >1000
Which anti-TB agent is responsible for increasing hydrocortisone requirements
Rifampicin
Which test is the most reliable measure of asthma control
FEV1
What does nicoteine primarily bind to
Acetylcholine receptor
Which cell type is increased most in inflammation related to cystic fibrosis
Neutrophils
Murmur assosiated with pulmonary HTN
Tricuspid regurgitation (pansystolic murmur at lower left sternal edge)
What deficiency is seen in 95% of congenital adrenal hyperplasia
21-hyroxylase deficiency
Most patients with OSA have what lung function
NORMAL
Diabetes management in CF patients
Insulin
Mode of action of ambrisentan (treatment of type 1 PAHTN)
Endothelian A receptor antagonist
Causes of haemoptysis in bronchiectasis
Capillary engorgement
When analysing pleural fluid samples - what indicates exudative effusion
(highish pleural protein and LDH)
More specifically
- Pleural protein to serum protein ratio > 0.5
- pleural LDH to serum LDH ratio > 0.5
During oxygen therapy, what impacts the most on the oxygen delivered to the patient
oxygen flow rate
Mode of action of nintedanib (treatment for IPF)
Tyrosine kinase inhibitor
Best way to monitor disease progression in IPF
FVC
What is a useful lung function test as a measure of obstructive lung disease
FEV1
Contraindication to pneumonectomy
Predicted Post pneumonectomy FEV1 <0.8
Treatment of a patient with eosinophilic asthma with significant number of exacerbations despite optimised asthma therapy (and how does it work)
Mepolizumab (lowers eosinophil count)
Where are beta 3 receptors located
Adipose tissue
Bladder smooth muscle
Treatment of COPD in cases where the patient has 2 or more exacerbations in 12 months and FEV1 is < 50% predicted while on treatment with triple inhaled therapy
Roflumilast
Feautres of pleural fluid in a transudative effusion
Normal protein
normal Ph
Normal glucose
Treatment of klebsiella pneumonia
2 weeks of ceftriaxone
Antibodies of Granulomatosis with polyangitis
cANCA
anti-serine protease 3
