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Y6 PASSMED > RESP > Flashcards

RESP Flashcards

1
Q

What is tension pneumothorax?

A

Accumulation of air in the pleural space under positive pressure - this pressure causes the lung to collapse and a shift of the medistinum towards the contralateral side

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2
Q

Why can tension pneumothorax lead to a reduction in cardiac output?

A

There is impaired venous return to the heart - this causes a reduction in cardaic output and can cause cardiovascular collapse/arrest
-Left and right ventricular filling is impaired

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3
Q

How is the pressure created in the pleural space in a tension pneumothorax?

A

There is a one way valve that lets aiur in but not out, air is drawn in during inspirsation but can not escape

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4
Q

What are the signs of a tension pneumothorax?

A

-Tracheal deviation away from the side of pneumothorax
-Reduced air entry on the affected side (absent chest sounds)
-Increased resonance to percussion on affected side
-Tachycardia and hypotension

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5
Q

What can cause tension pneumothorax?

A

TRAUMA - penetrating or blunt chest trauma

IATROGENIC - thoracentesis, central venous catheter palacement, postive pressure ventilation

SPONTANEOUS - underlying disease such as COPD or cystic fibrosis
Lung blebs (blisters on lung surfaces) which can rupture and cause air to leak into pleural space

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6
Q

Management of tension pneumothorax?

A

-Insert large bore cannula into second ICS un midclavicular line on affected side - decompression of pleural space
-This is followed by placement of chest drain in safe triangle to allow continuous drainage of air
NOTE: DO NOT WAIT FOR INVESTIGATION

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7
Q

Even though clinically a large bore cannula is inserted into 2ICS midclavicular line what do the Advanced traumatic life support guidelines state?

A

-4th or 5th ICS anterior to midaxillary line

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8
Q

Pregnant women smoking cessation?

A

varenicline and bupropion are contraindicated
-Smoking clinic referall is first line but NRT can also be offered

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9
Q

Acute respiratory distress syndrome?

A

-Caused by increased permeability of alveolar capillaries (due to inflammatory process) which leads to accumulation of fluid in the alveoli
(noncardiogenic pulmoary oedema)

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10
Q

What are causes of acute respiratory distress syndrome?

A

-Infection: sepsis, pneumonia, COVID19
-Trauma
-Smoke inhalation
-Acute pancreatitis
-Massive blood tranfusion
-Cardio-pulmonary bypass

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11
Q

What are clinical features of ARDS?

A

-Dyspnoea
-Elevated RR
-Bilateral lung crackles
-Low oxygen saturation - despite oxygen therpay

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12
Q

Criteria for ARDS?

A

-Acute onset (within one week of known risk factor)
-Pulmonary odema - bnilateral infilrates on CXR
-non-cardiogenic
-pO2/FiO2 <40kPa

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13
Q

What is the management of ARDS?

A

-ITU
-Oxygenation/ventilation
-Organ support e.g. vasopressors
-Treat underlying cause
-Ventilation and proning

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14
Q

In ARDS lun g protectivce venitaltion is used what does this invole?

A

-Low tidal volume and pressure ventilation to reduce over inflating and trauma to remaining lung
-Positive end-expiratory pressure - this is to prevent lungs from collapsing further

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15
Q

CURB 65 score?

A

C-Confused?
U- Urea >7mmol/L
R- Respiratory rate >30?
B- Blood pressure <90 systolic <60 diastolic
65- over 65

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16
Q

CURB score intrepretation?

A

1 - Home treatment
2 - consider hospital admission
3 - Consider ITU

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17
Q

What are pleural plaques?

A

-Fibrosis/thickening - they are benign and do not undergo malignant change
-No follow-up is required
-Most common form of asbestosis related lung disease and occur after a latent period of 20-40 years

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18
Q

What else can asbestosis cause in the lung?

A

Pleural thickening

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19
Q

What is abestosis?

A

A type of pulmonary fibrosis (scarring of lung tissue) that occurs as a result of long-term asbestos exposure

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20
Q

Calcified plaques/ plueral plaques?

A

Abestosos exposure - no follow up - do not require CT scan

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21
Q

What is silicosis?

A

Fibrosing lung disease caused by inhalation of fine particles silica

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22
Q

What disease is silicosis a risk factor for?

A

TB silica is toxic to macrophages

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23
Q

What occupations are at risk of silicosis?

A

-Mining
-SLate works
-Foudnries
-Potteries

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24
Q

Features of silicosis on CXR?

A

-Upper fibrosing lung disease (increased lung markings)
-Egg shell calcifation of hilar lymphnodes

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25
Q

What does CT scan show silicosis?

A

-Upper zone prominent mass like scaring with calcification and volume loss
-Hilar calcifation

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26
Q

COPD management first line?

A

SABA or SAMA (bronchodilators)

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27
Q

After initial bronchodilator therapy what is used to decide next maanagement in COPD?

A

-Asthmatic features or features of steroid responsiveness?

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28
Q

Criteria for asthmatic features of features suggestive of steroid responsiveness?

A

-Previosu asthma or atopy
-Increased eosinophuil count
-Substantial variation in FEV1 over time (400ml)
-Substantial variation in PEFR (20%)

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29
Q

If no asthmatic or steriod responsiveness in COPD patients what is next step?

A

-SABA required
-LAMA and LABA regualrly

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30
Q

If patient has features of asthma/steroid responsievness what is next step in management?

A

-SABA or SAMA as required
-LABA and ICS regularly

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31
Q

What is the third step in COPD patient if still symptoms still not controlled for all patients with COPD?

A

-SABA as required
-LAMA and LABA and ICS

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32
Q

BTS guidelines for ABG in asthma?

A

Acute asthma if oxygen stats <92%

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33
Q

Upper zone fibrosis causes?

A

-Hypersensitivity pneumonitis
-Coal workers pneumoconiosis
-Silicosis
-Sarcoidsosi
-AK (rare)
-Histocytosis
-TB
-Radiation induced PF (breast or lung cancer?

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34
Q

Lower lobe fibrosis?

A

-IPF
-Connective tissue disorders (excluding AK), SLE
-Drug induced
-Fibrosis

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35
Q

Bronchiectasis most common organsim?

A

Haemophilus influenzae

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36
Q

Differentials for cavitating lung lesions

A

-Abscess (staph aureus, klebsiella and pseudomonas)
-Squamous cell lung cancer
-TB
-Wegeners granulomatosis
-PE
-Rheumatoid arthritis
-Aspergillosis, histoplasmosiss, coccoidiomycosis

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37
Q

When to consider COPD as a diagnosis?

A

->35
-Smokers or ex smokers
-Exertional breathlessness
-Chronic cough
-Regular sputum production

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38
Q

Post bronchodilator spirometry to invetsigate COPD?

A

-Post-bronchodilator spirometry - demonstrates airflow obstruction FEV1/FVC ratio <70%

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39
Q

What CXR findings for COPD

A

-Hyperinflation
-Bullae
-Flat hemidiaphragm
ALSO important to rule out lung cancer

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40
Q

What investigation for suspected COPD?

A

-Post bronchodilator spirometry
-CXR
-FBC (exclude secondary polcythaemia)
-BMI

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41
Q

Why do you need to do a blood test in patients with suspected COPD?

A

-FBC to rule out secondary polycythemia which occurs due to chronic hypoxia

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42
Q

What are blood test findings for polycytheamia?

A

RBC increased in response to hypoxia
-Increased Hb and hematocrit
-Elevated EPO (secondary) - this is ordered is hemoglobin and hematocrit levels are high

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43
Q

What does spirometry measure?

A

-FVC - Forced vital capacity - this is the amount of air you can forcefully exhale after a deep breathe
-FEV1 - Forced expiratory volume in 1 second - amount of air can forcibly exhale in one second
-FVC/FEV1 ratio

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44
Q

What does FEV1/FVC ratio tell you?

A

Differentiate between obstructive and restrictive lung disease
-Obstructive - Reduced (70%)
-Restrictive - ratio is increased or normal

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45
Q

Stages of COPD and values

A

-FEV1/FVC <0.7
-STAGE 1 MILD - FEV1>80%
-Stage 2 MODERATE - FEV1 50-79%
-STAGE 3 SEVERE - FEV1 30-49%
-STAGE 4 VERY SEVERE- FEV1 <30%

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46
Q

Causes of COPD exacerbations

A

BACTERIA
-Haemophilus influenza most common
-Streptococcus penumonia
-Moraxella catarrhalis
VIRUSES
-30% of exacerbations
-Human rhinovirus

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47
Q

Features of exacerabtion of COPD

A

-Increase in dyspnoea, cough, wheeze
-Hypoxia and acute confusion
-Increase in sputum

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48
Q

NICE for acute exacerbation of COPD

A

-Increase bronchodilator and consider giving it via a nebuliser
-Prednisolone 30mg 5 days
-Antibiotics common practise - Especially if purulent sputum or clinical signs of pneuomonia

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49
Q

What antibiotics are recommended for acute exacerbation of COPD BNF?

A

-Amoxicillin, clarithromycin or doxycycline

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50
Q

Admission to hospital COPD exacerbation?

A

-Severe breathlessness
-Acute confusion
-Cyanosis
-O2<90%
-Social reason
-Significant comorbidity

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51
Q

Oxygen therapy COPD?

A

-Initial target 88-92% - prior to blood gas if patient is at risk of hypercapnia
-28% venturi mask at 4/L
-Adjust target rnage 94-98% if pCO2 is normally

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52
Q

Reasons for hypercapnia in patient with COPD

A

-Blunted hypoxic drive - in COPD body adpats to high levels of CO2, when oxygen is given brain sense improved oxygenation reducing drive leading to hypoventilation and more co2 retention
-Ventilation perfusion mismatch
-Haldane effect - With supplemental oxygen, hemoglobin releases CO₂ into the bloodstream, raising arterial CO₂ level

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53
Q

What bronchodilators are given?

A

-beta adrenergic agonist - SABA, salmutamol
-Muscuranic antagonists - Ipratropium (SAMA)

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54
Q

Steroid therpay

A

-Oral prednisolone
-IV hydrocortisone

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55
Q

What is used if patient is not responding to nebulised bronchodilators

A

IV theophylline

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56
Q

COPD patient prone to develop T2RF ?

A

Non-invasive ventilation - if respiratory acidosis

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57
Q

Patients who are more acidotic <7.2 with COPD NIV?

A

-Can still be used
-Greater degree of monitoring and a lower threshold for intubation and ventilation

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58
Q

What NIV is used in COPD?

A

-BiPAP
-Expiratory and inspiratory
-EPAP: 4-5 cm H2O
-IPAP: 10 cm (RCP) or 12-15 cm (BTS)H20

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59
Q

Step down treatment for asthma ?

A

Can reduce dose of ICS by 25-30% at a time

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60
Q

Bronchitis requiring ABx?

A

if CRP>100

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61
Q

What is pneumothorax?

A

AIr in the pleural space which separates lung from chest wall

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62
Q

What are the causes of penumothorax?

A

-Spontaneous
-Trauma
-Iatrogenic (lung biposy, mechanical ventilation,)
-Lung pathology

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63
Q

Investigation for pneumothorax

A

-CXR (measure size of pneumothorax)
-CT - accurately mesaures size

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64
Q

Management of pneumothorax

A

Based on size and symptoms

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65
Q

If pneumothorax is <2cm and asymptomatic?

A

-Likely resolve spontaneously
-Follow up in 2-4 weeks

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66
Q

If pneumothorax 2>cm or symptomatic?

A

-Aspiration is required followed by re-assessment
-If aspiration fails twice - chest drain
NOTE: now more based on clinical picture no symptoms and oxygenating fine can follow up patient

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67
Q

When do you consider a chest drain as initial management in a patient with a pneumothorax?

A

-Unstable
-Bilateral
-Secondary pneumothroax

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68
Q

Hwo to measure size of pneumothorax CXR?

A

-Interpleural distance at hilum
-Measure lung edge to hilum

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69
Q

What is empyema?

A

Collection of infective fluid/pus in pleural cavity

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70
Q

Pleural fluid analysis in empyema?

A

-Low ph
-High LDH
-Low glucose

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71
Q

First line treatment for empyema?

A

Chest drain with Abx

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72
Q

Severe acute asthma classifications

A

MODERATE - 70-75%
SEVERE - 33-50%
LIFE THREATENING -<33%

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73
Q

Asthma diagnosis >17

A

-All patients Spirometry and bronchodilator reversibility test
-All patients FeNO test
-Ask if symptoms are better away from work - occupational asthma

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74
Q

Asthma diagnosis 5-16 years

A

-Spirometry and bronchodilator reversibility
-FeNO if normal spirometry or obstructive spirometry with a negative BDR test

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75
Q

Results of FeNO considered positive in asthma diagnosis?

A

Adults: =>40 ppb
Children:=>35ppb

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76
Q

When is spirometry considered obstrictive?

A

FEV1/FVC <70%

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77
Q

Reversibility testing values in asthma diagnosis

A

-Adults FEV1 improvement of 12% or more and increase volume in 200ml
-Children FEV1 improvement 12% or more

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78
Q

How can pleural effusions be classified?

A

TRANSUDATE: <30g/L protein
EXUDATE: >30g/L protein

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79
Q

Causes of transudate pleural effusion

A

-Heart failure (most common)
-Hypoalbuminamiea (liver disease, nephrotic syndrome, malabsorption)
-Meig’s syndrome

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80
Q

Causes of exudate pleural effusion

A

-Infection (penumonia most common)
-Connective tissue (RA, SLE)
-Neoplasia (lung cancer, metastases, mesothelimo)
-Pancreatitis
-PE
-Pulmonary embolism
-Dresslers

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81
Q

What characterises sarcoidosis?

A

-Non-caseating granulomas

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82
Q

pH to benfit from NIV?

A

ph 7.25-7.35

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83
Q

risk factor for aspiration pneumonia?

A

-Intubation
-Poor dental hygiene
-Swallowing difficulties
-Prolonged hospitalisation
-Impaired consciousness
-Impaired mucocilary clearance

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84
Q

Most common sites to be affected by aspiration pneumonia?

A

Right middle and lower lung lobes

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85
Q

Why is the right middle and lower lung lobes most commonly affected by aspiration pneumonia?

A

-Right bronchus is larger and more vertical

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86
Q

Sudden deterioration after patient ventilated?

A

Tensionpneumothorax

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87
Q

Upper lobe fibrosis

A

CHARTS
-Coal worker pneumoconisis
-Histiocytosis/hypersensitvity
-Ankylosing spondylitis
-Tuberculosis
-Siliosis/sarcoidosis

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88
Q

Churg-Strauss syndrome/Eosinophilic granulomatosis with polyangiitis

A

pANCA associated small-medium vessel vascultits

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89
Q

What are the features of eosinophilic granulomatosis with polyangiitis ?

A

-Asthma
-Blood eosinophila
-Paranasal sinusitis
-Mononeuritis multiplex (causes pain weakness and sensory loss)
-pANCA postiev 60%

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90
Q

three stages of eosinophilic polyaginiitis?

A
  1. allergy and asthma - inflammation of small vessels
  2. Eosinophilia
  3. Vascultis - kidney failure (petechial rash)
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91
Q

Pleural effusion investigationn?

A

-PA chest CXR
-Ultrasound is recommended - sussesful aspiration and sensitive for detecting pleural fluid septations
-CT with contrast - underlying cause and exudative effusions

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92
Q

Pleural aspiration management?

A

-Ultrasound - reduce complication
-21G needle and 50ml syringe

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93
Q

What is Light’s criteria?

A

Used to distinguish between transudates and exudates
-Transudates <30g/L
-Exudates >30g/L
If >30g/L then apply Lights criteria

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94
Q

Lights criteria - exudate is likely if one of following criteria is met

A

-Pleural fluid protein/serum >0.5
-Pleural LDH /serum LDH >0.6
-Pleural LDH is 2/3 upper limit of normal serum LDG

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95
Q

Pleural fluid findings?

A

-Protein
-pH
-LDH
-GLucose (low RA and TB)
-Amylase (pancreatitis and esophageal perforation)
-Heavy blood stainng (mesothelioma, PE, TB)
-Send for cytology and microbiology

96
Q

Pleural infection?

A
  • if associated with sepsis
    -iffluid is purulent or turbid/cloudy a chest tube should be inserted
    -FLuid clear <7.2 with suspected infection a chest tube should be inserted
97
Q

Mesothelioma most diagostic test?

A

-Thoracosopy and histology

98
Q

In an acute presentation of COPD oxygen?

A

-Always start 15L NRB
-Set down if patient gets worse

99
Q

TB CXR findings?

A

Upper zone pulmonary fibrosis

100
Q

Pulmonary fibrosis spirometry?

A

-FEV1/FVC ratio >70%
-TLCO reduced

101
Q

Disease where there is an increase in ACE?

A

Sarcoidosis

102
Q

How are ACE levels used in sarcoidosis?

A

Can be used to indicated sarcoidosis, but also with CXR findings and clinical picture

103
Q

CXR findings and staging of sarcoidosis

A

Stage 0- Normal
Stage 1 - bilateral hilar lymphadenopathy (BHL)
Stage 2 - BHL and interistial infiltrates
Satge 3 - Diffuse interistial infilrates only
Stage 4 - Diffuse fibrosis

104
Q

Other investigations for sarcoidosis?

A

Spirometry - may be restrictive
Tissue biposy - non-caseating granulomas

105
Q

Criteria for treating sarcoidosis with steroids?

A

-Stage 2 or 3 on CXR with symptoms
-Hypercalcemia
-Eye, heart or neuro involvment

106
Q

What characterises non-caseating granuloms?

A

-no necrosis
-immune dirven/sterile unlike caseating

107
Q

What is sarcoidosis?

A

Multisystem disorder that is characterized by no-caseating granuloma

108
Q

What is cor pulmonale?

A

-Right sided heart failure caused by respiratory disease

109
Q

How does cor pulmonale occur?

A

-Increased pressure in pulmonary arteries (pulmonary hypertension)
-This limits right ventricle from pumping blood into the pulmonary arteries
-This in turn causes back pressure into right atrium, vena cava and systemic venous system

110
Q

What are the causes of cor pulmonale?

A

-COPD (most common)
-PE
-Interstitial lung disease
-CF
-Primary pulmonary hypertension

111
Q

Symptoms of cor pulmonale?

A

-In early stages asymptomatic
-SOB
-Breathless on exertion
-Syncope
-Chest pain

112
Q

What are signs of cor pulmonale on exmaination?

A

-Hypoxia
-Cyanosis
-Raised JVP (backlog of blood in jugular vein)
-Perepheral heav e
-Loud 2nd heart sound
-Murmurs (PANSYSTOLIC and TRICUSPID)
-Hepatomegaly - this is due to back pressue of hepatic vein

113
Q

What is the management of cor pulmonale?

A

-Loop diuretics for symptoms of odema
-Long term oxygen therapy to treat underlying cause - improves survival

114
Q

When should Long term oxygen therapy be offered to patients with COPD?

A

-pO2 of <7.3
-Po2 of 7.3-8kPa
-Secondary polycythaemia
-Nocturnal hypoxaemia
-Peripheral odema
-Pulmonary hypertension

115
Q

Lung cancer in non-smoker?

A

Adenocarincoma - non small cell lung cancer

116
Q

How is lung cancer first classified?

A

-Small cell lung cancer (15%)
-Non small cell lung cancer (85%)
-Mesothelioma

117
Q

Which type of lung cancer generally carries the worse prognosis?

A

Non small cell lung cancer

118
Q

Divisions of non small cell lung cancer?

A
  1. Adenocarcinoma (40% total LC)
  2. Squamous cell carcinoma (20%) - cavitating lesions are more common than in other types of lung cancer
  3. Large cell carcinoma
119
Q

Features of life-threatening asthma attack?

A

-Confusion
-Normal pCO2
-Silent chest
-Hypotension
-Exhaustion, confusions or coma

120
Q

Lupus perino?

A

Lupus pernio - raised purple lesions covering nose, cheeks and lips - seen in sarcoidosis

121
Q

Does a negative spirometry exclude asthma as a diagnosis?

A

No - FeNO testing must be carried out a postive result is >40ppm in adults and >35ppm in children

122
Q

What is the criteria for discharge after an asthma attack?

A

-Stable on discharge medication for 12-24 hours
-PEF >75% of best or predicted
-Inhaler technique must be checked and recorded

123
Q

Persistent / recurrent pneumothorax management?

A

Video-assisted thoracoscopic surgery (VATS)
-If recurrent pneumothoraces or persistent air leak/ lung re-expansion despite chest drain

124
Q

What is extrinsic allergic alveolitis also known as?

A

Hypersensitivity pneumonitis

125
Q

What is extrinsic allergic alveolitis?

A

Condition caused by hypersensitivity induced lung damage due to inhaled organic partciles?

126
Q

Give examples of what can cause extrinsic extrinsic allergic alveolitis?

A

-Birds: protiens from bird droppping
-Farmers from wet hay
-Malt workers lung
-Mushroom worker lung

127
Q

How does extrinsic allergic alveolitis present acutely?

A

(after 4-8 hours of exposure)
-Dyspnoea
-Dry cough
-Fever

128
Q

how does chronic extrinsic allergic alveolitis present?

A

-Lethargy
-Dyspnoea
-Productive cough
-Anorexia and weight loss

129
Q

What investigations for EAA?

A

-CXR: upper/mid zone fibrosis
-Bronchoalveolar lavage: lymphocytosis
-Seroloigcal assays for specific IgG AB
-Blood: no eosinophila - it is a type 3 and 4 hypersensitivity

130
Q

What is the management of extrinsic allergic alveoltis?

A

-Avoid precipitating factors
-oral glucocorticoids

131
Q

What is near fatal asthma?

A

Raised carbon dioxide - require mechanical ventilation

132
Q

Paraneoplastic features of small cell lung cancer?

A

-ADH (SIADH)
-ACTH (cushing’s)
-Lambert-eaton
-Small cell lung cancer more likely to be paraneoplastic

133
Q

What is a paraneoplastic syndrome?

A

Symptoms caused by immune responses or substances released by tumour

134
Q

What are the paraneoplastic features caused by squamous cell (NSCLC)?

A

-Parathyroid hormone related protein (PTH-rp) secretion which causes hypercalcaemia
-Clubbing
-Hypertrophic pulmonary osteoarthropathy (clubbing joint pain and swelling)
-Hyperthyroidism due to TSH

135
Q

What are the paraneoplastic features caused by adenocarcinoma (NSCLC)?

A

-Gynaecomastia
-Hypertrophic pulmonary osteoarthropathy

136
Q

What is hypertrophic pulmonary osteoarthropathy?

A

-periostitis (inflammation of periosteum) which causes pain, swelling and bone deformity
-Typically involves long bones

137
Q

Pulmonary fibrosis spirometry?

A

FEV1/FVC >70% with reduced TLCO

138
Q

Relative contraindications for chest drain?

A

-INR >1.3
-Platelet count<75
-Pulmonary bullae n
-Pleural adhesions

139
Q

Bronchitis presentation

A

-Cough - may or not be productive
-Sore throat
-Rhinorrhoea
-Wheeze
-low grade wheese

140
Q

Bronchitis vs pneumonia

A

-Bronchitis may not have wheeze, breathlessness or sputum whereas present in penumonia
-Examination in bronchitis only a wheeze is present

141
Q

What is used to guide antibiotic therapy in bronchitis?

A

CRP >100

142
Q

What is first line ABx for bornchitis?

A

BNF - doxycycline
-if pregnant or children consider amoxicillin

143
Q

LABA medication?

A

Salmeterol

144
Q

LAMA medication?

A

tiotropium

145
Q

LTRA medication?

A

Monetlukast

146
Q

SABA medication?

A

Salbutamol

147
Q

SAMA medication?

A

Ipratropium

148
Q

How long should you wait when repeating inhaler dose?

A

30 seconds

149
Q

Features of Klebsiella penumonia?

A

-Upper lobes
-Ref jelly sputum
-Can occur following aspiration
-More common with heavy alcohol use and peoples with diabetes

150
Q

What is prognosis of klebsiella pneumonia?

A

-Causes lung abscess formation and empyema
-Mortality 30-50%

151
Q

chest drain vs needle aspiration smoking and >50?

A

Chest drain

152
Q

When do you keep a patient in hospital with pneumothorax even if it is small and no symtoms?

A

secondary spontaneous pneumothorax - monitor as inpatient

153
Q

Contraindications to lung cancer surgery?

A

-SVC obstruction
-Malignant pleural effusion
-FEV<1.5 for lobetomy <2 for pneumonectomy
-Metastases present
-Tumour near hilum
-Vocal cord paralysis

154
Q

silicosis ?

A

-mining
-upper zone fibrosis
-eggshell calcification hilar nodules

155
Q

Canonball metastses?

A

-Multiple, round well-defind
-Associated with renal cell cancer -CT abdomen

156
Q

Management of allergic bronchopulmonarty aspergillosis?

A

-Oral glucorticoids
-itraconazole

157
Q

Prophylactic ABx for patients with chronic COPD?

A

Azithromycin 250mg three times a week

158
Q

NICE guideliens for prophylatic ABx?

A

-Patient no longer smokes
-Optimised non-pharmacological and inhaled therpapies
-4 acute exacerbations (producing sputum), with one hospital admission
-Referred to pulmonary rehab

159
Q

Most common cause of mediastinal widening on CXR?

A

Due to technical findings such a s patient rotation

160
Q

Causes of acute mediastinal widening on CXR?

A

-Vascular: thoracic aortic aneurysm
-Lymphoma
-Retrosternal goitre
-Teratoma
-Thumour of thymus

161
Q

When should NIV be considered in COPD patients?

A

paCO2 >6kpa and pH<7.35

162
Q

In acute respiratory alkalosis what happens to bicarbonate?

A

Remains the same or is only slightly reduced this is because kindeysa have not had to do compensate

163
Q

Information for patients in the resolution of penumonia symptoms ?

A

1 week - fever resolve
4 weeks - chest pain and sputum production
6 weeks - cough and breathlessness
3 months - most symptoms gone may feel fatigued
6 months - back to normal

164
Q

When to repeat CXR after symptoms resolve?

A

6 weeks to ensure consolidation has resolved

165
Q

Discharging patients with pneumonia ?

A

If patients have had 2 or more of the follwoing findings in the past 24 hours:
1. temp higher than 37.5
(this alone consider no discharging)
2. RR>24
3. HR >100
4. Systolic <90mmHg
5. Oxygen <90 RA
6. altered mental status
7. inability to eat

166
Q

idiopathic pulmonary fibrosis sounds?

A

Bibasal fine end-inspiratory crepitations

167
Q

What causes obstructive sleep apnoea?

A

-Collapse of pharyngeal airway
-Apenoa is an episode where patient stop breathing for a few minutes

168
Q

Predisposing factors to OSA?

A

-Obesity
-Macroglossia (amyloidosis, hypothyroidism)
-Large tonsils
-Marfan’s syndrome
-Smoking
-Alcohol
-Most common in middle age

169
Q

Presentation of OSA?

A

-Apnoea during sleep
-Snoring
-Morning headache
-Not refreshed from sleep
-Daytime sleepness - resulting in concentration issues
-Reduced oxygen saturation during sleep

170
Q

WHat can severe cases of OSA cause?

A

-Hypertension
-Heart failure

171
Q

What can can OSA increase the risk of?

A

-MI
-Stroke

172
Q

OSA with daytime sleepiness?

A

Ask about occupation - patient may need amended work duties when waiting for assessment and treatment

173
Q

What are used to assess sleepiness in OSA?

A

-Epworth sleepiness scale (questionnaire to be completed by patient assess symptoms )
-Multiple sleep latency test (MSLT)- measures time to fall asleep in a dark room

174
Q

What are the diagnostic tests for OSA?

A
  • Sleep studies (polysomnography)
175
Q

What are the types of sleep studies?

A
  1. A simple sleep study - wearing oxygen monitor at home
  2. Respiratory polygraphy - measures RR, flow rate, o2 and HR - can be done at home
  3. Complex sleep studies - overnight stay with polysomnography - measure brain (EEG), muscle(EMG) and heart activity (ECG)
176
Q

Management of OSA?

A

-Address reversible risk factors (weight loss, smoking, reduce alcohol)
-CPAP first line for moderate or severe
-If CPAP not tolerated intra-oral devices
-Surgery but this involves reconstruction of soft palate and jaw

177
Q

What is alpha-1 antitrypsin deficiency?

A

-inherited conditions caused by lack of protease inhibitor and therefore a deficiency in alpha-1 antitrypsin
-located on chromosome 14
-autosommal recessive

178
Q

What is the role of alpha-1 antitrypsin (A1AT)?

A

Protects cells from enzymes, if there is a deficiency it can cause emphysema (COPD) i patients who are young and non smokers

179
Q

What are investigation for A1AT defieincy?

A

-A1AT concentrations
-Spirometry (obstructive picture)

180
Q

What level of A1AT normal cause features of A1AT deficiency to manifest ?

A

-10% of nromal A1AT levels

181
Q

Why does A1AT cause abnormal LFTs?

A

-Accumulation of abnormal A1At in liver cells can cause damage leading to deranged LFTs

182
Q

What are the features of A1AT deficinecy?

A

Lungs: emphysema (COPD), lower lobes (decreased breath sounds/expiratory wheeze)
Liver: Cirrhosis and hepatocellular carcinoma

183
Q

Management of A1AT?

A

-No smoking
-Supportive: bronchodilators, physio
-IV A1AT protein concentrates
-Surgery

184
Q

Restrictive picture with spirometry but no impaired gas transfer?

A

Obesity

185
Q

What does TLCO stand for and how is it carried out?

A

-Transfer of carbon monoxide
-Patient inhales CO holds breath for 10 seconds and exhales
-concentration of CO inhaled vs exhaled is compared - gas exchange over alveolar capillary membrane

186
Q

Near fatal asthma ?

A

pCO2 >6.0 kPa

187
Q

Difference between high-resolution CT and CTPA?

A

-High resolution CT - imaging of parenchyma, insterstital lung disease and structure
-CTPA - pulmonary vasculature (PE)

188
Q

Gold standard for OSA?

A

Nocturnal polysomnography

189
Q

Hospital acquired pneumoina, hospital for 3-5 days abx?

A

co-amoxiclav

190
Q

Kartagener’s syndrome causes and most reason occurs in examination finding?

A

-Also known are primary ciliary dyskinesia - cause by defect in structure and function of cilia
-Most frequently occurs in examinations due to associated with dextrocardia (quiet heart sounds)

191
Q

What are the features of kartagener’s syndrome?

A

-Dextrocardia or complete situs inversus
-Bronchiectasis
-Recurrent sinusitis
-Subfertility (secondary to impaired sperm motility and defective ciliary action in fallopian tubes)

192
Q

Klebsiella associated infection?

A

Pneumonia and UTI

193
Q

What does klebsiella cause in lung?

A

Caviating lesions in upper lobes

194
Q

Most common reason for lung abcess?

A

Secondary to aspiration pneumonia

195
Q

What is atelectasis?

A

-Postoperative complication where there is basal alveolar collapse
-Airways become obstructed with bronchial secretions

196
Q

Atelectasis features and when does it usually occur?

A

-Dyspnoea and hypoxaemia
-Occurs 72 hours postoperatively

197
Q

What is the management of atelectasis?

A

-Position patient upright
-Chest physiotherapy: breathing exercises

198
Q

Most common organism causing infective exacerbation of COPD?

A

Haemophilus influenzae

199
Q

CXR findings COPD?

A

-Hyperinflation
-Flattended hemidiaphragms
-Hyperlucent lung fields

200
Q

Prognosis of sarcoidosis?

A

Most patients will get better even without treatment (2/3)

201
Q

What is bronchictasis?

A

-Permanent dilation and damage of bronchus
-Secondary to chronic inflammation or infection

202
Q

What are presenting symptoms of bronchiectasis?

A

-SOB
-Chronic productive cough
-Recurrent chest infections
-Weight loss
-Haemopysis

203
Q

Why does bronchiectasis occur?

A

Due to damage of the bronchi

204
Q

What are the causes of bronchiectasis?

A

-Pneumonia
-TB
-A1AT deficiency
-Connective tissue
-Cystic fibrosis
-Yellow nail syndrome (yellow nails, bronchiectasis, lymphedema)
-Whopping cough

205
Q

Signs that may be present with bronchiectasis?

A

-Sputum pot
-Finger clubbing
-May be signs of cor pulmonale
-Coarse crackles - chnage or clear with cough
-Scattered Wheeze

206
Q

Investigations for bronchiectasis?

A

-Sputum culture - to identify haemophilus influenzae and pseudomonas aeruginosa (klebsiella and strep also)
-CXR
-High-resolution CT scan

207
Q

CXR findings in bronchiectasis?

A

-Ring shadows
-Tram track opacities

208
Q

What is gold standard for diagnosing bronchiectasis?

A

High resolution CT (HRCT)

209
Q

General management of bronchiectasis? after treating causes

A

-Vaccines (pneumococcal and influenza)
-Respiratory physio to help clear sputum (non-CF)
-Pulmonary rehabilitation
-Postural drainage
-Bronchodilators
-Surgery if localised disease
-Long term antibiotics
-Inhaled colistin for pseudomonas
-ABx prophylaxis

210
Q

What is the management for an infective exacerbation of bronchiectasis?

A

-Sputum culture before Abx
-Extended course of antibiotics (7-14 days)
-Ciprofloxacin for pseudomonas aeruginosa

211
Q

What equipment is used for aspiration of pleural effusion?

A

21G needle and 50ml syringe

212
Q

Test before macrolide such as azithromycin?

A

-ECG can cause QT interval prolongation - lead to cardiac arrhythmias
-Liver function test also needed

213
Q

Referral for lung cancer (2WW)?

A

-CXR findings
->40 with haemoptysis

214
Q

ARDS can only be diagnosed in absence of cardiac cause, how is this assessed?

A

-If increased pulmonary capillary wedge pressure

215
Q

Asthma not responding to full medical treatment and are becoming acidotic?

A

Intubation and ventilation rather than CPAP or BiPAP

216
Q

What is ARDS charcterised by?

A

bilateral pulmonary infiltrates and hypoxemia - no cardiac cause

217
Q

Granulomatosis with polyangiitis vs Eosinophilic granulomatosis with polyangiitis ?

A

Both
-Sinusitis
-Vasculitis
-Dyspnoea

Granulomatosis with polyangiitis
-Renal failure
-Epistasis/haemoptysis
-cANCA

Eosinophilic granulomatosis with polyangiitis
-Asthma
-Eosinophila
-pANCA

218
Q

Medications for smoking cessation?

A

Varenicline - nicotinic receptor partial agonist

Bupropion - norepinephrine-dopamine reuptake inhibitor and nicotinic antagonist

219
Q

Assessment of long term oxygen therapy with COPD?

A

2 ABG 3 weeks apart

220
Q

What patients with COPD do you offer LTOT to?

A

-pO2 <7.3
-pO2 7.3-8 and one of the following:
-Secondary polycythaemia
-Pulmonary hypertension
-Peripheral oedema

221
Q

Pattern of spirometry of neuromuscular disorder?

A

Restrictive pattern
FEV1/FVC >0.7 and FVC reduced

222
Q

What is superior vena cava syndrome?

A

Increased venous pressure due to obstruction or compression of SVC

223
Q

why does superior vena cava syndrome ?

A

-Due to reduced venous outflow there is increase in pressures in head and neck
-This can be due to malignancy such as lung cancer

224
Q

Signs of superior vena cava syndrome?

A

-Engorged veins chest wall and neck
-Cyanosis/plethora of face
-Facial and limb swelling

225
Q

iatrogenic pneumothorax causes?

A

-Central venous catheter
-Ventilation
-Non-invasive ventilation
-Lung biopsy

226
Q

Prednisolone and breastfeeding?

A

-Safe in pregnancy
-only 0.1% reach the infant
-benefits outweigh the risk to infant

227
Q

Empyema aspirate results?

A

-pH <7.2, low glucose, high LDH
-turbid

228
Q

Severe asthma resp rate?

A

> 25

229
Q

What is the most common bacteria in bronchiectasis?

A

Haemophilus influenza

230
Q

what is a pneumoectomy?

A

A complete lung collapse

231
Q

Trachea with pneumonectomy?

A

Trachea pulled towards white out

232
Q

Trachea in pulmonary oedema, consolidation, mesothelioma?

A

Trachea central

233
Q

Trachea in pleural effusion or large thoracic mass?

A

Trachea pushed away from white out

234
Q

Cannon ball metastases what cancer most commonly cause?

A

renal cell carcinoma

235
Q
A

Y6 PASSMED (8 decks)

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