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Question 1

Question: What are the common features of an acute asthma attack?

Answer 1

Answer: Common features include:

Worsening dyspnoea, wheeze, and cough not responding to salbutamol
May be triggered by a respiratory tract infection

Question 2

Question: How are patients with acute severe asthma stratified?

Answer 2

Answer: Patients are stratified into moderate, severe, or life-threatening asthma.

Question 3

Question: What are the criteria for moderate acute asthma?

Answer 3

Answer:

PEFR: 50-75% best or predicted
Speech: Normal
Respiratory rate (RR): < 25 / min
Pulse: < 110 bpm

Question 4

Question: What are the criteria for severe acute asthma?

Answer 4

Answer:

PEFR: 33-50% best or predicted
Speech: Can’t complete sentences
Respiratory rate (RR): > 25 / min
Pulse: > 110 bpm

Question 5

Question: What are the criteria for life-threatening asthma?

Answer 5

Answer:

PEFR: < 33% best or predicted
Oxygen saturation: < 92%
Signs: Silent chest, cyanosis, or feeble respiratory effort
Vital signs: Bradycardia, dysrhythmia, or hypotension
Mental status: Exhaustion, confusion, or coma

Question 6

Question: What does a normal pCO2 in an acute asthma attack indicate, and how should it be classified?

Answer 6

Answer: A normal pCO2 in an acute asthma attack indicates exhaustion and should be classified as life-threatening.

Question 7

Question: What characterizes near-fatal asthma?

Answer 7

Answer: Near-fatal asthma is characterized by a raised pCO2 and/or requiring mechanical ventilation with raised inflation pressures.

Question 8

Question: What further assessments are recommended by the BTS guidelines for patients with oxygen sats < 92%?

Answer 8

Arterial blood gases should be checked.
Chest X-ray is recommended in cases of life-threatening asthma, suspected pneumothorax, or failure to respond to treatment.

Question 9

Question: When should all patients with life-threatening asthma be admitted to the hospital?

Answer 9

Answer: All patients with life-threatening asthma should be admitted immediately.

Question 10

Question: What are the criteria for admitting patients with severe acute asthma?

Answer 10

Failure to respond to initial treatment.
Previous near-fatal asthma attack.
Pregnancy.
Attack occurring despite already using oral corticosteroids.
Presentation at night.

Question 11

Question: What is the initial oxygen therapy for hypoxaemic patients?

Answer 11

Start on 15L of supplemental oxygen via a non-rebreathe mask, which can then be titrated down to maintain SpO2 94-98%.

Question 12

Question: What is the role of short-acting beta2-agonists (SABA) in acute asthma management?

Answer 12

Answer: High-dose inhaled SABA (e.g., salbutamol, terbutaline) is used for bronchodilation. Nebulised SABA is recommended for patients with features of life-threatening asthma.

Question 13

Question: What corticosteroid regimen is recommended for all patients with acute asthma?

Answer 13

Answer: 40-50mg of prednisolone orally (PO) daily, continued for at least five days or until the patient recovers from the attack.

Question 14

Question: What additional treatments are recommended for severe or life-threatening asthma?

Answer 14

Nebulised ipratropium bromide.
IV magnesium sulphate.
IV aminophylline (following consultation with senior medical staff).

Question 15

Question: What are the criteria for discharging a patient with acute asthma?

Answer 15

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

Question 16

Question: What is acute bronchitis and how long does it usually last?

Answer 16

Answer: Acute bronchitis is a type of chest infection resulting from inflammation of the trachea and major bronchi, often producing sputum. It is usually self-limiting and resolves before 3 weeks, although 25% of patients may have a cough beyond this time.

Question 17

Question: What is the leading cause of acute bronchitis and during which seasons does it most commonly occur?

Answer 17

Answer: Viral infection is the leading cause of acute bronchitis, with around 80% of episodes occurring in autumn or winter.

Question 18

Question: What are the typical presenting symptoms of acute bronchitis?

Answer 18

Cough: may or may not be productive
Sore throat
Rhinorrhoea
Wheeze

Question 19

Question: What are the common physical examination findings in patients with acute bronchitis?

Answer 19

The majority of patients have a normal chest examination, but some may present with:

Low-grade fever
Wheeze

Question 20

Question: How can you differentiate between acute bronchitis and pneumonia based on history?

Answer 20

Answer: In acute bronchitis, sputum, wheeze, and breathlessness may be absent, whereas in pneumonia, at least one of these symptoms tends to be present.

Question 21

Question: What are the examination findings in acute bronchitis compared to pneumonia?

Answer 21

Answer: Acute bronchitis usually lacks other focal chest signs (e.g., dullness to percussion, crepitations, bronchial breathing) and systemic features (malaise, myalgia, fever) that are commonly present in pneumonia.

Question 22

Question: What investigation is typically used to diagnose acute bronchitis?

Answer 22

Answer: Acute bronchitis is usually a clinical diagnosis, but CRP testing may be used if available to guide antibiotic therapy.

Question 23

Question: What is the general management of acute bronchitis?

Answer 23

Answer:

Analgesia
Good fluid intake
Consider antibiotic therapy if the patient:

Is systemically very unwell
Has pre-existing comorbidities
Has a CRP of 20-100 mg/L (offer delayed prescription) or CRP >100 mg/L (offer antibiotics immediately)

Question 24

Question: What is the first-line antibiotic recommended for acute bronchitis according to the BNF, and what are the alternatives?

Answer 24

Answer:

First-line: Doxycycline (not suitable for children or pregnant women)
Alternatives: Amoxicillin

Question 25

Question: What are the most common bacterial causes of acute exacerbations of COPD?

Answer 25

Haemophilus influenzae (most common) Streptococcus pneumoniae Moraxella catarrhalis

Question 26

Question: What are the most important respiratory viruses that cause COPD exacerbations, and what percentage do they account for?

Answer 26

Answer: Respiratory viruses account for around 30% of exacerbations, with human rhinovirus being the most important pathogen.

Question 27

Question: What are the typical features of an acute exacerbation of COPD?

Answer 27

Increase in dyspnoea, cough, wheeze Possible increase in sputum suggestive of an infective cause Patients may be hypoxic and, in some cases, have acute confusion

Question 28

Question: According to NICE guidelines from 2010, what is recommended for the management of an acute exacerbation of COPD?

Answer 28

Increase the frequency of bronchodilator use, consider nebuliser Prednisolone 30 mg daily for 5 days Antibiotics if sputum is purulent or there are clinical signs of pneumonia First-line antibiotics: amoxicillin, clarithromycin, or doxycycline

Question 29

Question: What are the admission criteria for acute exacerbations of COPD?

Answer 29

Severe breathlessness Acute confusion or impaired consciousness Cyanosis Oxygen saturation < 90% on pulse oximetry Social reasons (e.g., inability to cope at home) Significant comorbidity (e.g., cardiac disease, insulin-dependent diabetes)

Question 30

Question: What is the initial oxygen saturation target for COPD patients at risk of hypercapnia, and what device should be used?

Answer 30

An initial oxygen saturation target of 88-92% should be used. A 28% Venturi mask at 4 l/min should be used until blood gas results are available.

Question 31

Question: What are the nebulised bronchodilators recommended for severe exacerbations of COPD?

Answer 31

Beta adrenergic agonists: e.g., salbutamol Muscarinic antagonists: e.g., ipratropium

Question 32

Question: What steroid therapy is recommended for acute exacerbations of COPD, and when might IV hydrocortisone be considered?

Answer 32

Prednisolone 30 mg orally daily for 5 days IV hydrocortisone may be considered instead of oral prednisolone in some cases

Question 33

Question: When might IV theophylline be considered in the management of acute exacerbations of COPD?

Answer 33

Answer: IV theophylline may be considered for patients not responding to nebulised bronchodilators.

Question 34

Question: What type of respiratory failure are patients with COPD prone to develop, and what is a common treatment for it?

Answer 34

Answer: Patients with COPD are prone to develop type 2 respiratory failure. Non-invasive ventilation (NIV) may be used, typically with bilevel positive airway pressure (BiPAP).

Question 35

Question: What is the primary pathological mechanism in Acute Respiratory Distress Syndrome (ARDS)?

Answer 35

Answer: ARDS is caused by the increased permeability of alveolar capillaries, leading to fluid accumulation in the alveoli, resulting in non-cardiogenic pulmonary oedema.

Question 36

Question: What is the approximate mortality rate associated with ARDS?

Answer 36

Answer: The mortality rate of ARDS is around 40%.

Question 37

Question: What are the common causes of ARDS?

Answer 37

Infection: sepsis, pneumonia Massive blood transfusion Trauma Smoke inhalation Acute pancreatitis COVID-19 Cardio-pulmonary bypass

Question 38

Question: What are the typical clinical features of ARDS?

Answer 38

Dyspnoea Elevated respiratory rate Bilateral lung crackles Low oxygen saturations

Question 39

Question: What are the key investigations for diagnosing ARDS?

Answer 39

Chest x-ray Arterial blood gases (ABGs)

Question 40

Question: What are the American-European Consensus Conference criteria for diagnosing ARDS?

Answer 40

Acute onset (within 1 week of a known risk factor) Pulmonary oedema: bilateral infiltrates on chest x-ray (not fully explained by effusions, lobar/lung collapse, or nodules) Non-cardiogenic: pulmonary artery wedge pressure needed if doubt pO2/FiO2 < 40 kPa (300 mmHg)

Question 41

Question: What is the general management approach for ARDS?

Answer 41

Oxygenation/ventilation to treat hypoxaemia General organ support: e.g., vasopressors as needed Treatment of the underlying cause: e.g., antibiotics for sepsis

Question 42

Question: Which specific strategies have been shown to improve outcomes in ARDS?

Answer 42

Prone positioning Muscle relaxation

Question 43

Question: What causes Allergic Bronchopulmonary Aspergillosis (ABPA)?

Answer 43

Answer: ABPA results from an allergy to Aspergillus spores.

Question 44

Question: What clinical history is often associated with ABPA in exam questions?

Answer 44

Answer: A history of bronchiectasis and eosinophilia.

Question 45

Question: What are the typical features of ABPA?

Answer 45

Bronchoconstriction: wheeze, cough, dyspnoea (patients may have a previous diagnosis of asthma) Bronchiectasis (proximal)

Question 46

Question: What investigations are commonly conducted for ABPA?

Answer 46

Eosinophilia Flitting CXR changes Positive radioallergosorbent (RAST) test to Aspergillus Positive IgG precipitins (not as positive as in aspergilloma) Raised IgE

Question 47

Question: What is the first-line management for ABPA?

Answer 47

Answer: Oral glucocorticoids

Question 48

Question: What is a potential second-line agent for managing ABPA?

Answer 48

Answer: Itraconazole

Question 49

Question: What is Alpha-1 Antitrypsin (A1AT) deficiency?

Answer 49

Answer: A1AT deficiency is a common inherited condition caused by a lack of a protease inhibitor normally produced by the liver. It protects cells from enzymes such as neutrophil elastase and classically causes emphysema in young, non-smoking patients.

Question 50

Question: What are the features of A1AT deficiency?

Answer 50

Lungs: Panacinar emphysema, most marked in the lower lobes Liver: Cirrhosis and hepatocellular carcinoma in adults, cholestasis in children

Question 51

Question: What investigations are used to diagnose A1AT deficiency?

Answer 51

A1AT concentrations Spirometry: Shows an obstructive pattern

Question 52

Question: What are the management strategies for A1AT deficiency?

Answer 52

No smoking Supportive care: Bronchodilators, physiotherapy Intravenous alpha1-antitrypsin protein concentrates Surgery: Lung volume reduction surgery, lung transplantation

Question 53

Question: What is the threshold for hypoxaemia in ABG interpretation?

Answer 53

Answer: A PaO2 less than 10 kPa indicates hypoxaemia.

Question 54

What are the steps in interpreting ABG

Answer 54

Answer: How is the patient? Assess the overall clinical condition of the patient. Answer: Is the patient hypoxaemic? The PaO2 on air should be >10 kPa. Answer: Is the patient acidaemic or alkalaemic? Determine if the pH is <7.35 (acidaemia) or >7.45 (alkalaemia). Answer: Respiratory component: What has happened to the PaCO2? Answer: Metabolic component: What is the bicarbonate level/base excess?

Question 55

Question: What indicates acidaemia in ABG interpretation?

Answer 55

Answer: A pH less than 7.35 indicates acidaemia.

Question 56

Question: What indicates alkalaemia in ABG interpretation?

Answer 56

Answer: A pH greater than 7.45 indicates alkalaemia.

Question 57

Question: What does a PaCO2 > 6.0 kPa suggest?

Answer 57

Answer: A PaCO2 > 6.0 kPa suggests respiratory acidosis (or respiratory compensation for a metabolic alkalosis).

Question 58

Question: What does a PaCO2 < 4.7 kPa suggest?

Answer 58

Answer: A PaCO2 < 4.7 kPa suggests respiratory alkalosis (or respiratory compensation for a metabolic acidosis).

Question 59

Question: What does a bicarbonate level < 22 mmol/L or a base excess < -2 mmol/L suggest?

Answer 59

Answer: A bicarbonate level < 22 mmol/L or a base excess < -2 mmol/L suggests metabolic acidosis (or renal compensation for a respiratory alkalosis).

Question 60

Question: What does a bicarbonate level > 26 mmol/L or a base excess > +2 mmol/L suggest?

Answer 60

Answer: A bicarbonate level > 26 mmol/L or a base excess > +2 mmol/L suggests metabolic alkalosis (or renal compensation for a respiratory acidosis).

Question 61

Question: What is the most common form of asbestos-related lung disease?

Answer 61

Answer: Pleural plaques are the most common form of asbestos-related lung disease.

Question 62

Question: Are pleural plaques malignant?

Answer 62

Answer: No, pleural plaques are benign and do not undergo malignant change. They do not require follow-up.

Question 63

Question: How long is the latent period for pleural plaques?

Answer 63

Answer: The latent period for pleural plaques is typically 20-40 years after asbestos exposure.

Question 64

Question: What is pleural thickening in asbestos exposure?

Answer 64

Answer: Pleural thickening is a condition that may occur following asbestos exposure and resembles patterns seen after empyema or haemothorax. Its pathophysiology is not fully understood.

Question 65

Question: What is the typical latent period for asbestosis?

Answer 65

Answer: The latent period for asbestosis is typically 15-30 years.

Question 66

Question: What are the common features of asbestosis?

Answer 66

Dyspnoea and reduced exercise tolerance Clubbing Bilateral end-inspiratory crackles Restrictive pattern with reduced gas transfer on lung function tests

Question 67

Question: How is asbestosis treated?

Answer 67

Answer: Asbestosis is treated conservatively, as no interventions offer significant benefit.

Question 68

Question: What is mesothelioma?

Answer 68

Answer: Mesothelioma is a malignant disease of the pleura, often caused by asbestos exposure, particularly crocidolite (blue) asbestos.

Question 69

Question: What are the common features of mesothelioma?

Answer 69

Progressive shortness of breath Chest pain Pleural effusion

Question 70

Question: What is the prognosis for mesothelioma?

Answer 70

Answer: The prognosis for mesothelioma is very poor, with a median survival from diagnosis of 8-14 months.

Question 71

Question: What is the most common form of cancer associated with asbestos exposure?

Answer 71

Answer: Lung cancer is the most common form of cancer associated with asbestos exposure.

Question 72

Question: How does smoking affect the risk of lung cancer in patients exposed to asbestos?

Answer 72

Answer: Smoking increases the risk of lung cancer in individuals with asbestos exposure. The combination of asbestos exposure and smoking has a synergistic effect, significantly raising the risk.

Question 73

Question: What is aspiration pneumonia?

Answer 73

Answer: Aspiration pneumonia is a pneumonia that develops as a result of foreign materials (usually oral or gastric contents) entering the bronchial tree, causing inflammation and infection.

Question 74

Question: What are the common causes of aspiration pneumonia?

Answer 74

Common causes include: Incompetent swallowing mechanisms (e.g., neurological diseases such as stroke, multiple sclerosis, or intoxication) Iatrogenic causes (e.g., intubation)

Question 75

Question: What are the risk factors for aspiration pneumonia?

Answer 75

Risk factors include: Poor dental hygiene Swallowing difficulties Prolonged hospitalization or surgical procedures Impaired consciousness Impaired mucociliary clearance

Question 76

Question: Which lung lobes are most commonly affected by aspiration pneumonia?

Answer 76

Answer: The right middle and lower lung lobes are most commonly affected due to the larger calibre and more vertical orientation of the right main bronchus.

Question 77

Question: What types of bacteria are implicated in aspiration pneumonia?

Answer 77

Both aerobic and anaerobic bacteria can cause aspiration pneumonia. Aerobic bacteria: Streptococcus pneumoniae Staphylococcus aureus Haemophilus influenzae Pseudomonas aeruginosa Klebsiella (often seen in aspiration lobar pneumonia in alcoholics) Anaerobic bacteria: Bacteroides Prevotella Fusobacterium Peptostreptococcus

Question 78

Question: What is asthma?

Answer 78

Answer: Asthma is a chronic inflammatory disorder of the airways caused by type 1 hypersensitivity, leading to variable and recurring symptoms such as reversible bronchospasm, airway obstruction, and difficulty breathing.

Question 79

Question: What are common risk factors for developing asthma?

Answer 79

Risk factors include: Personal or family history of atopy Maternal smoking, viral infections during pregnancy, low birth weight, not being breastfed Exposure to allergens (e.g., house dust mite) Air pollution and the "hygiene hypothesis" Occupational allergens (e.g., isocyanates, flour)

Question 80

Question: What are common symptoms of asthma?

Answer 80

Cough (often worse at night) Dyspnoea (difficulty breathing) Wheeze and chest tightness

Question 81

Question: What are the signs of asthma on examination?

Answer 81

Expiratory wheeze on auscultation Reduced peak expiratory flow rate (PEFR)

Question 82

Question: How is asthma diagnosed?

Answer 82

Diagnosis is confirmed using spirometry which shows: Reduced FEV1 (forced expiratory volume in 1 second) Normal FVC (forced vital capacity) FEV1/FVC ratio < 70% Other tests include fractional exhaled nitric oxide (FeNO) to assess inflammation and chest x-ray for older or smoking patients.

Question 83

Question: What are the main drug classes used in asthma management?

Answer 83

Drug classes include: Short-acting beta-agonists (SABA) (e.g., Salbutamol) – for acute relief Inhaled corticosteroids (ICS) (e.g., Beclometasone) – for long-term control Long-acting beta-agonists (LABA) (e.g., Salmeterol) – for maintenance Leukotriene receptor antagonists (e.g., Montelukast) – oral medication

Question 84

Question: What is Maintenance and Reliever Therapy (MART)?

Answer 84

Answer: MART is a combined therapy of ICS and LABA, where a single inhaler containing both is used for both daily maintenance and symptom relief. It requires a fast-acting LABA (e.g., formoterol).

Question 85

Question: What is the first-line investigation for suspected asthma in adults according to the 2024 NICE guidelines?

Answer 85

The first-line investigations include measuring: Eosinophil count, or Fractional exhaled nitric oxide (FeNO) If eosinophil count is above the reference range or FeNO is ≥ 50 ppb, asthma can be diagnosed without further investigations.

Question 86

Question: What is the diagnostic threshold for bronchodilator reversibility (BDR) in adults with suspected asthma?

Answer 86

Asthma is diagnosed if: The FEV1 increase is ≥ 12% and 200 mL from the pre-bronchodilator measurement, or The FEV1 increase is ≥ 10% of the predicted normal FEV1

Question 87

Question: If spirometry is not available in adults, how can asthma be diagnosed?

Answer 87

If spirometry is not available or delayed, peak expiratory flow (PEF) can be measured twice daily for 2 weeks. Asthma is diagnosed if: PEF variability (amplitude percentage mean) is ≥ 20%

Question 88

Question: What is the diagnostic threshold for FeNO in children aged 5-16?

Answer 88

Answer: Asthma is diagnosed in children aged 5-16 if FeNO is ≥ 35 ppb.

Question 89

Question: What investigations are used to diagnose asthma in children aged 5-16 if FeNO is not raised?

Answer 89

If FeNO is not raised or not available, the following tests are used: Bronchodilator reversibility (BDR) with spirometry, diagnosing asthma if FEV1 increase is ≥ 12% or ≥ 10% of the predicted normal FEV1. If spirometry is unavailable, PEF variability (≥ 20%) over 2 weeks may support diagnosis. Skin prick testing or measuring total IgE levels to assess allergen sensitivity.

Question 90

Question: How should asthma be diagnosed in children under 5 according to NICE guidelines?

Answer 90

In children under 5, diagnosis is challenging. The guidelines suggest: Treating with inhaled corticosteroids and regular review. Referral to a specialist if there are 2 or more emergency admissions with wheezing in 12 months.

Question 91

Question: What role do eosinophils play in asthma?

Answer 91

Answer: Eosinophils are involved in type 2 inflammation, releasing cytotoxic proteins that damage epithelial cells and perpetuate inflammation. They are a key marker for disease activity in asthma.

Question 92

Question: What does FeNO reflect in asthma diagnosis?

Answer 92

Answer: FeNO reflects the level of nitric oxide produced by airway epithelial cells in response to eosinophilic inflammation, a hallmark of asthma. It is measured non-invasively in parts per billion (ppb).

Question 93

Question: What is the significance of bronchodilator reversibility (BDR) in asthma diagnosis?

Answer 93

Answer: BDR testing evaluates the reversibility of airway obstruction after bronchodilator administration. In asthma, an increase in FEV1 of ≥ 12% and ≥ 200 mL confirms reversible airway obstruction, distinguishing asthma from fixed obstruction (e.g., COPD).

Question 94

Question: How does peak expiratory flow (PEF) variability help diagnose asthma?

Answer 94

Answer: PEF variability reflects diurnal changes in airway calibre due to underlying inflammation and smooth muscle tone. A ≥ 20% variation in PEF between morning and evening supports the diagnosis of asthma.

Question 95

Question: What is the role of skin prick testing in diagnosing asthma in children?

Answer 95

Answer: Skin prick testing for house dust mite is used to identify sensitisation to common allergens, such as house dust mite, which may trigger asthma. Sensitisation supports the diagnosis of allergic asthma.

Question 96

Question: What is the bronchial challenge test used for in asthma diagnosis?

Answer 96

Answer: The bronchial challenge test assesses airway hyperresponsiveness by exposing the airways to a provocative agent (e.g., methacholine or histamine). A significant decline in FEV1 indicates asthma.

Question 97

Question: What is the first-line treatment for newly diagnosed asthma in adults aged ≥12 according to the 2024 NICE guidelines?

Answer 97

Answer: The first-line treatment is a low-dose inhaled corticosteroid (ICS)/formoterol combination inhaler to be taken as needed for symptom relief. This is known as anti-inflammatory reliever (AIR) therapy.

Question 98

Question: What is the recommended treatment for a patient with newly diagnosed asthma who presents with severe exacerbation or highly symptomatic (e.g., regular nocturnal waking)?

Answer 98

Answer: For such patients, start treatment with low-dose Maintenance and Reliever Therapy (MART), which includes a combination of ICS/formoterol for daily maintenance and as needed for symptom relief. Acute symptoms may also require oral corticosteroids.

Question 99

Question: What does Maintenance and Reliever Therapy (MART) consist of?

Answer 99

Answer: MART involves using a combination inhaler containing ICS and formoterol for both daily maintenance therapy and the relief of symptoms as needed, i.e., regularly and as required.

Question 100

Question: How is asthma management escalated to Step 3 in adults according to the NICE guidelines?

Answer 100

Answer: In Step 3, the treatment involves a moderate-dose MART, which is a combination of ICS and formoterol at a higher dose.

Question 101

Question: What should be done at Step 4 if asthma control is inadequate despite moderate-dose MART?

Answer 101

Answer: At Step 4, check fractional exhaled nitric oxide (FeNO) and blood eosinophil count. If either is raised, refer to a specialist. If neither is raised, trial either a leukotriene receptor antagonist (LTRA) or a long-acting muscarinic antagonist (LAMA) alongside moderate-dose MART. If control does not improve, switch to the alternative treatment (LTRA or LAMA).

Question 102

Question: What is the recommended action if asthma control is still not achieved at Step 5 despite treatment?

Answer 102

Answer: Refer the patient to a specialist in asthma care if asthma is not controlled despite treatment with moderate-dose MART and trials of LTRA or LAMA.

Question 103

Question: What is the recommended treatment for adults with asthma who were previously managed with SABA as required only?

Answer 103

Answer: Switch the patient to a low-dose ICS/formoterol combination inhaler used as needed, which is now termed anti-inflammatory reliever (AIR) therapy.

Question 104

Question: How should patients previously managed with SABA and regular low-dose ICS or LABA be treated according to the new guidelines?

Answer 104

Answer: These patients should be transitioned to a regular low-dose ICS/formoterol combination inhaler as Maintenance and Reliever Therapy (MART).

Question 105

Question: What is the recommended treatment for patients previously managed with moderate-dose ICS and other add-ons like LTRA or LAMA?

Answer 105

Answer: These patients should be transitioned to a regular moderate-dose ICS/formoterol combination inhaler as part of MART therapy.

Question 106

Question: What should be done for patients currently on high-dose ICS for asthma management?

Answer 106

Answer: Patients on high-dose ICS should be referred to a respiratory specialist.

Question 107

Question: What symptoms may suggest that a patient's asthma is related to their occupation?

Answer 107

Answer: Symptoms may worsen at work and improve on weekends or when away from work. Patients may also report concerns that chemicals or substances at work are exacerbating their asthma.

Question 108

Question: What are some common chemicals associated with occupational asthma?

Answer 108

Chemicals commonly associated with occupational asthma include: Isocyanates (most common cause) Platinum salts Soldering flux resin Glutaraldehyde Flour Epoxy resins Proteolytic enzymes

Question 109

Question: Which occupations are at higher risk for occupational asthma due to isocyanate exposure?

Answer 109

Answer: Occupations at higher risk include spray painting and foam moulding using adhesives, where isocyanates are commonly used.

Question 110

Question: How can occupational asthma be investigated?

Answer 110

Answer: Serial measurements of peak expiratory flow (PEF) are recommended to be taken both at work and away from work to assess variability and identify patterns related to the workplace.

Question 111

Question: How often should asthma treatment be stepped down, according to the British Thoracic Society (BTS) guidelines?

Answer 111

Answer: Asthma treatment should be considered for stepping down every 3 months, or more frequently if the patient has had recent treatment escalation.

Question 112

Question: What factors should be considered when stepping down asthma treatment?

Answer 112

Duration of treatment Side effects of treatment Patient preference

Question 113

Question: When reducing the dose of inhaled steroids, what is the recommended decrease according to the BTS guidelines?

Answer 113

Answer: The recommended decrease in inhaled steroids is 25-50% at a time.

Question 114

Question: How often should stable asthma patients be formally reviewed?

Answer 114

Answer: Stable asthma patients should be formally reviewed on an annual basis, although more frequent reviews may be needed after recent treatment escalation.

Question 115

Question: What is atelectasis?

Answer 115

Answer: Atelectasis is a common postoperative complication where basal alveolar collapse leads to respiratory difficulty, often caused by airway obstruction due to bronchial secretions.

Question 116

Question: When should atelectasis be suspected in a postoperative patient?

Answer 116

Answer: Atelectasis should be suspected when a patient presents with dyspnoea and hypoxaemia around 72 hours postoperatively.

Question 117

Question: What is the management for atelectasis?

Answer 117

Positioning the patient upright Chest physiotherapy, including breathing exercises

Question 118

Question: What are the most common causes of bilateral hilar lymphadenopathy?

Answer 118

Sarcoidosis Tuberculosis

Question 119

Question: What are other causes of bilateral hilar lymphadenopathy?

Answer 119

Lymphoma or other malignancies Pneumoconiosis (e.g., berylliosis) Fungal infections (e.g., histoplasmosis, coccidioidomycosis)

Question 120

Question: What are the key features of bronchiectasis?

Answer 120

Persistent productive cough with large volumes of sputum Dyspnoea Haemoptysis

Question 121

Question: What signs might be observed in a patient with bronchiectasis?

Answer 121

Signs include: Abnormal chest auscultation Coarse crackles Wheeze Clubbing (may be present)

Question 122

Question: What are the key management strategies for bronchiectasis after assessing for treatable causes?

Answer 122

Physical training (e.g. inspiratory muscle training) Postural drainage Antibiotics for exacerbations and long-term rotating antibiotics in severe cases Bronchodilators in selected cases Immunisations Surgery in selected cases (e.g., localized disease)

Question 123

Question: What are the most common organisms isolated from patients with bronchiectasis?

Answer 123

Haemophilus influenzae (most common) Pseudomonas aeruginosa Klebsiella spp. Streptococcus pneumoniae

Question 124

Question: What are the common indications for chest drain insertion?

Answer 124

Pleural effusion Pneumothorax (not suitable for conservative management or aspiration) Empyema Haemothorax Haemopneumothorax Chylothorax Some cases of penetrating chest wall injury in ventilated patients

Question 125

Question: What are the relative contraindications for chest drain insertion?

Answer 125

INR > 1.3 Platelet count < 75 Pulmonary bullae Pleural adhesions

Question 126

Question: What is the recommended positioning for a patient undergoing chest drain insertion?

Answer 126

The patient should be positioned: In a supine position or at a 45º angle Forearm behind the head for easy axillary access Use ultrasound guidance to determine the optimal position, especially for fluid within the pleura

Question 127

Question: What are the complications that may occur during chest drain insertion?

Answer 127

Failure of insertion (e.g., drain in wrong position) Bleeding (around the site or into the pleural space) Infection Penetration of the lung Re-expansion pulmonary oedema

Question 128

Question: How is re-expansion pulmonary oedema managed after chest drain insertion?

Answer 128

If re-expansion pulmonary oedema is suspected: Clamp the chest drain Obtain an urgent chest x-ray To prevent, avoid rapid fluid output (e.g., no more than 1L in less than 6 hours)

Question 129

Question: When should a chest drain be removed in cases of fluid drainage or pneumothorax?

Answer 129

For fluid drainage: Remove the drain after >24 hours of no output and imaging showing resolution of fluid. For pneumothorax: Remove when no bubbling is seen and imaging shows resolution.

Question 130

Question: What are the key features of the 'safe triangle' for chest drain insertion?

Answer 130

The 'safe triangle' for chest drain insertion is located: In the mid-axillary line at the 5th intercostal space. Bordered by: Anterior edge of the latissimus dorsi Lateral border of the pectoralis major A line superior to the horizontal level of the nipple Apex below the axilla

Question 131

Question: What are the general guidelines for choosing the size of the chest drain based on the indication?

Answer 131

Large bore chest drains are preferred for trauma and haemothorax drainage. Smaller diameter chest drains are used for pneumothorax or pleural effusion drainage.

Question 132

Question: What are the main differential diagnoses for a cavitating lung lesion on a chest x-ray?

Answer 132

Abscess (e.g., Staphylococcus aureus, Klebsiella, Pseudomonas) Squamous cell lung cancer Tuberculosis Wegener's granulomatosis Pulmonary embolism Rheumatoid arthritis Fungal infections (e.g., Aspergillosis, Histoplasmosis, Coccidioidomycosis)

Question 133

Question: Which bacterial organisms are commonly associated with lung abscesses causing cavitating lesions?

Answer 133

Staphylococcus aureus Klebsiella Pseudomonas

Question 134

Question: Which types of cancer may present with cavitating lung lesions?

Answer 134

Answer: Squamous cell lung cancer can present with cavitating lung lesions on a chest x-ray.

Question 135

Question: What is the relevance of tuberculosis in cavitating lung lesions?

Answer 135

Answer: Tuberculosis can lead to cavitating lung lesions, which can be detected on a chest x-ray.

Question 136

Question: How does Wegener's granulomatosis present on a chest x-ray?

Answer 136

Answer: Wegener's granulomatosis can present with cavitating lung lesions on a chest x-ray due to granulomatous inflammation in the lungs.

Question 137

Question: What role does rheumatoid arthritis play in cavitating lung lesions?

Answer 137

Answer: Rheumatoid arthritis can cause cavitating lung lesions, especially in the context of rheumatoid nodules or associated interstitial lung disease.

Question 138

Question: Which fungal infections can lead to cavitating lung lesions?

Answer 138

Answer: Fungal infections such as Aspergillosis, Histoplasmosis, and Coccidioidomycosis can cause cavitating lung lesions.

Question 139

Question: What are the common causes of lobar collapse on a chest x-ray?

Answer 139

Lung cancer (most common cause in older adults) Asthma (due to mucous plugging) Foreign body

Question 140

Question: What are the general signs of lobar collapse on a chest x-ray?

Answer 140

Tracheal deviation towards the side of the collapse Mediastinal shift towards the side of the collapse Elevation of the hemidiaphragm

Question 141

Question: How does lung cancer cause lobar collapse?

Answer 141

Answer: Lung cancer can obstruct the bronchus, leading to a lobar collapse due to blockage of airflow.

Question 142

Question: How does asthma lead to lobar collapse?

Answer 142

Answer: Asthma can lead to lobar collapse due to mucous plugging in the airways, causing obstruction and collapse of the lung segment.

Question 143

Question: How does a foreign body cause lobar collapse?

Answer 143

Answer: A foreign body can obstruct an airway, leading to lobar collapse as the affected lung cannot fully expand due to the blockage.

Question 144

Question: What types of cancer are commonly associated with lung metastases?

Answer 144

Breast cancer Colorectal cancer Renal cell cancer Bladder cancer Prostate cancer

Question 145

Question: What are 'cannonball metastases'?

Answer 145

Answer: Cannonball metastases are multiple, round, well-defined lung secondaries, often seen in renal cell cancer. They can also occur due to choriocarcinoma and prostate cancer.

Question 146

Question: In which cancers is lung metastases calcification uncommon?

Answer 146

Answer: Calcification in lung metastases is rare except in cases of chondrosarcoma or osteosarcoma.

Question 147

Question: What are the typical radiographic features of cannonball metastases on a chest x-ray?

Answer 147

Answer: On chest x-ray, cannonball metastases appear as multiple, well-defined, round nodules distributed in both lung fields. They are most commonly associated with renal cell cancer.

Question 148

Question: What is the most common cause of mediastinal widening on a chest x-ray?

Answer 148

Answer: The most common cause of mediastinal widening on a chest x-ray is technical factors, such as patient rotation.

Question 149

Question: What are the potential causes of actual mediastinal widening on a chest x-ray?

Answer 149

Vascular problems: Thoracic aortic aneurysm Lymphoma Retrosternal goitre Teratoma Tumours of the thymus

Question 150

Question: How can a lateral chest x-ray view assist in evaluating mediastinal widening?

Answer 150

Answer: A lateral view can help determine whether the mass causing the mediastinal widening is anterior or posterior.

Question 151

Question: What is the preferred method for further investigation if there is doubt about the cause of mediastinal widening?

Answer 151

Answer: CT imaging is typically performed if there is any doubt about the cause of mediastinal widening, as it provides more detailed information.

Question 152

Question: What are some features of pulmonary oedema seen on a chest x-ray?

Answer 152

Interstitial oedema Bat's wing appearance Upper lobe diversion (increased blood flow to the superior parts of the lung) Kerley B lines Pleural effusion Cardiomegaly (may be seen if the cause is cardiogenic)

Question 153

Question: What are the cardiac causes of clubbing?

Answer 153

Cyanotic congenital heart disease (e.g., Fallot's, TGA) Bacterial endocarditis Atrial myxoma

Question 154

Question: What are the respiratory causes of clubbing?

Answer 154

Lung cancer Pyogenic conditions (e.g., cystic fibrosis, bronchiectasis, abscess, empyema) Tuberculosis Asbestosis, mesothelioma Fibrosing alveolitis

Question 155

Question: What are the other causes of clubbing?

Answer 155

Crohn's disease (to a lesser extent UC) Cirrhosis, primary biliary cirrhosis Graves' disease (thyroid acropachy) Rarely: Whipple's disease

Question 156

Question: What is the most common cause of COPD?

Answer 156

Answer: Smoking is the most common cause of COPD.

Question 157

Question: What is another genetic cause of COPD?

Answer 157

Answer: Alpha-1 antitrypsin deficiency is another cause of COPD.

Question 158

Question: What are some occupational and environmental causes of COPD?

Answer 158

Cadmium (used in smelting) Coal Cotton Cement Grain

Question 159

Question: What are the main features of Chronic Obstructive Pulmonary Disease (COPD)?

Answer 159

Cough (often productive) Dyspnoea Wheeze In severe cases, right-sided heart failure may develop, leading to peripheral oedema.

Question 160

Question: What investigations are recommended in patients with suspected COPD?

Answer 160

Post-bronchodilator spirometry (to show airflow obstruction with FEV1/FVC ratio < 70%) Chest x-ray (for hyperinflation, bullae, flat hemidiaphragm, and to exclude lung cancer) Full blood count (to exclude secondary polycythaemia) BMI calculation

Question 161

Question: How is the severity of COPD classified?

Answer 161

Stage 1 - Mild: FEV1/FVC < 0.7, FEV1 > 80% Stage 2 - Moderate: FEV1/FVC < 0.7, FEV1 50-79% Stage 3 - Severe: FEV1/FVC < 0.7, FEV1 30-49% Stage 4 - Very Severe: FEV1/FVC < 0.7, FEV1 < 30%

Question 162

Question: What is the limitation of using peak expiratory flow (PEF) in COPD diagnosis?

Answer 162

Answer: PEF is of limited value in diagnosing COPD, as it may underestimate the degree of airflow obstruction.

Question 163

Question: Who should be assessed for long-term oxygen therapy (LTOT) in COPD patients according to NICE guidelines?

Answer 163

Very severe airflow obstruction (FEV1 < 30% predicted) or severe obstruction (FEV1 30-49% predicted) Cyanosis Polycythaemia Peripheral oedema Raised jugular venous pressure Oxygen saturations ≤ 92% on room air

Question 164

Question: How is the assessment for LTOT performed in COPD patients?

Answer 164

Answer: The assessment for LTOT is done by measuring arterial blood gases on 2 occasions, at least 3 weeks apart, in patients with stable COPD on optimal management.

Question 165

Question: What are the criteria for offering LTOT to COPD patients?

Answer 165

pO2 < 7.3 kPa (in any patient) pO2 7.3 - 8 kPa with one of the following: Secondary polycythaemia Peripheral oedema Pulmonary hypertension

Question 166

Question: What does NICE recommend regarding LTOT for patients who continue to smoke?

Answer 166

Answer: NICE recommends not offering LTOT to patients who continue to smoke despite being offered smoking cessation advice and treatment, and referral to specialist stop smoking services.

Question 167

Question: What structured risk assessments should be carried out before offering LTOT?

Answer 167

Risks of falls from tripping over the equipment Risks of burns and fires, particularly for people who live in homes with smokers (including e-cigarettes)

Question 168

Question: What general management strategies are recommended for stable COPD according to NICE guidelines?

Answer 168

Smoking cessation advice, including offering nicotine replacement therapy, varenicline, or bupropion Annual influenza vaccination One-off pneumococcal vaccination Pulmonary rehabilitation for people who are functionally disabled by COPD (usually MRC grade 3 and above)

Question 169

Question: What is the first-line bronchodilator therapy for stable COPD?

Answer 169

Answer: The first-line treatment is a short-acting beta2-agonist (SABA) or short-acting muscarinic antagonist (SAMA).

Question 170

Question: What should be done if a COPD patient remains breathless or experiences exacerbations despite using short-acting bronchodilators?

Answer 170

The next step depends on whether the patient has asthmatic features or features suggesting steroid responsiveness. No asthmatic features/steroid responsiveness: Add a long-acting beta2-agonist (LABA) + long-acting muscarinic antagonist (LAMA). Asthmatic features/steroid responsiveness: Add LABA + inhaled corticosteroid (ICS). If further exacerbations occur, offer triple therapy (LAMA + LABA + ICS).

Question 171

Question: When is oral theophylline recommended in COPD management?

Answer 171

Answer: Theophylline is recommended only after trials of short and long-acting bronchodilators or in patients who cannot use inhaled therapy.

Question 172

Question: When is oral prophylactic antibiotic therapy recommended in COPD?

Answer 172

Azithromycin prophylaxis is recommended for select patients who: Do not smoke Have optimised standard treatments Continue to have exacerbations Have had a CT thorax to exclude bronchiectasis and sputum culture to exclude atypical infections and tuberculosis Have normal LFTs and an ECG to exclude QT prolongation.

Question 173

Question: What are the indications for using mucolytics in stable COPD?

Answer 173

Answer: Mucolytics should be considered in patients with a chronic productive cough and continued if symptoms improve.

Question 174

Question: When are phosphodiesterase-4 (PDE-4) inhibitors recommended for COPD?

Answer 174

Answer: PDE-4 inhibitors (e.g., roflumilast) are recommended for patients with severe COPD (FEV1 < 50% predicted) and a history of frequent exacerbations despite triple inhaled therapy (LAMA, LABA, ICS).

Question 175

Question: What is the management for cor pulmonale in stable COPD?

Answer 175

For cor pulmonale, features include peripheral oedema, raised jugular venous pressure, systolic parasternal heave, and loud P2. Management includes: Use of loop diuretics for oedema Consideration of long-term oxygen therapy ACE inhibitors, calcium channel blockers, and alpha blockers are not recommended.

Question 176

Question: What are the key features of Eosinophilic Granulomatosis with Polyangiitis (EGPA)?

Answer 176

Asthma Blood eosinophilia (e.g., > 10%) Paranasal sinusitis Mononeuritis multiplex pANCA positivity (in 60% of cases)

Question 177

Question: What medication is associated with precipitating the disease in Eosinophilic Granulomatosis with Polyangiitis (EGPA)?

Answer 177

Answer: Leukotriene receptor antagonists may precipitate EGPA.

Question 178

Question: What is the cause of Extrinsic Allergic Alveolitis (EAA), also known as hypersensitivity pneumonitis?

Answer 178

Answer: EAA is caused by hypersensitivity-induced lung damage due to inhalation of various organic particles, leading to immune-complex mediated tissue damage (type III hypersensitivity) and delayed hypersensitivity (type IV) in the chronic phase.

Question 179

Question: What are some examples of conditions that lead to Extrinsic Allergic Alveolitis (EAA)?

Answer 179

Bird fanciers' lung: Avian proteins from bird droppings Farmers' lung: Spores of Saccharopolyspora rectivirgula (from wet hay) Malt workers' lung: Aspergillus clavatus Mushroom workers' lung: Thermophilic actinomycetes

Question 180

Question: What are the clinical presentations of Extrinsic Allergic Alveolitis (EAA)?

Answer 180

Acute (4-8 hours after exposure): Dyspnoea, dry cough, fever Chronic (weeks to months after exposure): Lethargy, dyspnoea, productive cough, anorexia, weight loss

Question 181

Question: What is the management for Extrinsic Allergic Alveolitis (EAA)?

Answer 181

Avoidance of precipitating factors Oral glucocorticoids for inflammation control

Question 182

Question: What is Granulomatosis with Polyangiitis (formerly Wegener's Granulomatosis)?

Answer 182

Answer: Granulomatosis with Polyangiitis is an autoimmune condition characterized by necrotizing granulomatous vasculitis that affects both the upper and lower respiratory tracts as well as the kidneys.

Question 183

Question: What are the clinical features of Granulomatosis with Polyangiitis?

Answer 183

Upper respiratory tract: Epistaxis, sinusitis, nasal crusting Lower respiratory tract: Dyspnoea, haemoptysis Kidneys: Rapidly progressive glomerulonephritis ("pauci-immune" in 80% of patients) Other features: Saddle-shaped nose deformity, vasculitic rash, eye involvement (e.g. proptosis), cranial nerve lesions

Question 184

Question: What investigations are used for Granulomatosis with Polyangiitis?

Answer 184

cANCA positive in >90% of cases pANCA positive in 25% Chest x-ray: Can show a wide variety of presentations, including cavitating lesions Renal biopsy: Epithelial crescents in Bowman's capsule

Question 185

Question: What is the management for Granulomatosis with Polyangiitis?

Answer 185

Steroids (to control inflammation) Cyclophosphamide (90% response) Plasma exchange Median survival: 8-9 years

Question 186

Question: What are the main causes of haemoptysis?

Answer 186

Lung cancer - History of smoking, weight loss, anorexia Pulmonary oedema - Dyspnoea, bibasal crackles, S3 Tuberculosis - Fever, night sweats, anorexia, weight loss Pulmonary embolism - Pleuritic chest pain, tachycardia, tachypnoea Lower respiratory tract infection - Acute history of purulent cough Bronchiectasis - Long history of cough, daily purulent sputum production Mitral stenosis - Dyspnoea, atrial fibrillation, malar flush, mid-diastolic murmur Aspergilloma - Past tuberculosis history, severe haemoptysis, chest x-ray shows rounded opacity Granulomatosis with polyangiitis - Epistaxis, sinusitis, nasal crusting, haemoptysis, glomerulonephritis, saddle-nose deformity Goodpasture’s syndrome - Haemoptysis, fever, nausea, glomerulonephritis

Question 187

Question: What are the characteristic symptoms of lung cancer causing haemoptysis?

Answer 187

History of smoking Symptoms of malignancy: weight loss, anorexia

Question 188

Question: What are the key signs of pulmonary oedema with haemoptysis?

Answer 188

Dyspnoea Bibasal crackles S3 heart sound (most reliable signs)

Question 189

Question: What are the characteristic features of tuberculosis causing haemoptysis?

Answer 189

Fever, night sweats Anorexia, weight loss

Question 190

Question: What are the features of pulmonary embolism associated with haemoptysis?

Answer 190

Pleuritic chest pain Tachycardia, tachypnoea

Question 191

Question: What is the clinical presentation of bronchiectasis causing haemoptysis?

Answer 191

Long history of cough Daily purulent sputum production

Question 192

Question: What are the signs and symptoms of mitral stenosis associated with haemoptysis?

Answer 192

Dyspnoea, atrial fibrillation Malar flush on cheeks Mid-diastolic murmur

Question 193

Question: What are the key features of aspergilloma causing haemoptysis?

Answer 193

Often a past history of tuberculosis Severe haemoptysis Chest x-ray: Rounded opacity

Question 194

Question: What are the symptoms of Granulomatosis with Polyangiitis causing haemoptysis?

Answer 194

Upper respiratory tract: Epistaxis, sinusitis, nasal crusting Lower respiratory tract: Dyspnoea, haemoptysis Glomerulonephritis, saddle-nose deformity

Question 195

Question: What are the features of Goodpasture’s syndrome causing haemoptysis?

Answer 195

Haemoptysis Systemically unwell: fever, nausea Glomerulonephritis

Question 196

Question: What is Idiopathic Pulmonary Fibrosis (IPF)?

Answer 196

Answer: IPF is a chronic lung condition characterized by progressive fibrosis of the lung interstitium. It occurs without an identifiable underlying cause, unlike other forms of lung fibrosis which may be secondary to medications, connective tissue disease, or asbestos exposure.

Question 197

Question: What are the common features of Idiopathic Pulmonary Fibrosis (IPF)?

Answer 197

Progressive exertional dyspnoea (shortness of breath) Bibasal fine end-inspiratory crepitations (crackles) on auscultation Dry cough Clubbing (nail deformity)

Question 198

Question: What are the diagnostic tests for Idiopathic Pulmonary Fibrosis (IPF)?

Answer 198

Spirometry: Restrictive pattern: FEV1 normal or decreased, FVC decreased, FEV1/FVC increased Gas exchange: Reduced transfer factor (TLCO) Imaging: Chest x-ray: Bilateral interstitial shadowing with ground-glass opacities, progressing to honeycombing High-resolution CT scan: Preferred for diagnosis Serology: ANA positive in 30%, rheumatoid factor positive in 10% (low titres, not necessarily indicative of connective tissue disease)

Question 199

Question: What is the management for Idiopathic Pulmonary Fibrosis (IPF)?

Answer 199

Pulmonary rehabilitation Medications: Pirfenidone (antifibrotic agent) may be useful for selected patients (evidence-based) Supplementary oxygen may be required in advanced cases Lung transplant: Considered for suitable candidates

Question 200

Question: What is the prognosis for Idiopathic Pulmonary Fibrosis (IPF)?

Answer 200

Answer: The prognosis is generally poor, with an average life expectancy of around 3-4 years after diagnosis.

Question 201

Question: What is the correct technique for using a metered-dose inhaler (MDI)?

Answer 201

Remove the cap and shake the inhaler. Breathe out gently to empty the lungs. Place the mouthpiece in your mouth. As you begin to breathe in slowly and deeply, press the canister down to release the medication, and continue inhaling steadily. Hold your breath for 10 seconds (or as long as comfortable). Wait for 30 seconds before repeating the process for a second dose (if needed). Use the inhaler for the number of doses on the label and then start a new inhaler.

Question 202

Question: What are the key features of Klebsiella pneumoniae infections, and who is at higher risk?

Answer 202

Gram-negative rod that is part of the normal gut flora. Commonly causes pneumonia, especially following aspiration. More common in people with alcoholism and diabetes. 'Red-currant jelly' sputum is a characteristic sign. Affects the upper lobes of the lungs. Prognosis: Frequently leads to lung abscess formation and empyema. Mortality rate: 30-50%.

Question 203

Question: What are the common causes of lung abscess?

Answer 203

Aspiration pneumonia (most common) Haematogenous spread (e.g. from infective endocarditis) Direct extension (e.g. from an empyema) Bronchial obstruction (e.g. secondary to a lung tumour)

Question 204

Question: What are the risk factors for developing a lung abscess?

Answer 204

Poor dental hygiene Previous stroke Reduced consciousness

Question 205

Question: What are the monomicrobial causes of lung abscess?

Answer 205

Staphylococcus aureus Klebsiella pneumoniae Pseudomonas aeruginosa

Question 206

Question: What are the features of a lung abscess?

Answer 206

Subacute pneumonia presentation (symptoms develop over weeks) Systemic features: Night sweats, weight loss Other symptoms: Fever, productive cough, foul-smelling sputum Haemoptysis in some cases Chest pain and dyspnoea Signs: Dull percussion, bronchial breathing, clubbing

Question 207

Question: What are the key investigations for diagnosing a lung abscess?

Answer 207

Chest x-ray: Fluid-filled space within consolidation, air-fluid level Sputum and blood cultures to identify causative organism

Question 208

Question: What is the management for a lung abscess?

Answer 208

Intravenous antibiotics (first-line treatment) Percutaneous drainage if not resolving Surgical resection in very rare cases

Question 209

Question: What is the role of a chest x-ray in investigating lung cancer?

Answer 209

Chest x-ray is often the first investigation in suspected lung cancer. Around 10% of patients diagnosed with lung cancer have a normal chest x-ray

Question 210

Question: What is the investigation of choice for suspected lung cancer?

Answer 210

CT scan is the investigation of choice for further investigation of suspected lung cancer.

Question 211

Question: How does bronchoscopy aid in the diagnosis of lung cancer?

Answer 211

Bronchoscopy allows a biopsy to be taken for histological diagnosis. It is sometimes aided by endobronchial ultrasound.

Question 212

Question: What is the role of PET scanning in lung cancer management?

Answer 212

PET scanning is typically done in non-small cell lung cancer to establish eligibility for curative treatment. 18-fluorodeoxygenase is preferentially taken up by neoplastic tissue, improving diagnostic sensitivity for local and distant metastasis.

Question 213

Question: What abnormality may be observed in the bloods of a patient with lung cancer?

Answer 213

Raised platelets may be seen in the blood tests of patients with lung cancer.

Question 214

Question: What percentage of non-small cell lung cancer patients are suitable for surgery?

Answer 214

Only 20% of non-small cell lung cancer patients are suitable for surgery.

Question 215

Question: Why is a mediastinoscopy performed before surgery in non-small cell lung cancer management?

Answer 215

Mediastinoscopy is performed to assess mediastinal lymph node involvement, as CT does not always show it accurately.

Question 216

Question: What are the treatment options for non-small cell lung cancer?

Answer 216

Treatment options include curative or palliative radiotherapy. Chemotherapy often has a poor response.

Question 217

Question: What are the contraindications for surgery in non-small cell lung cancer?

Answer 217

Stage IIIb or IV (i.e. metastases present) FEV1 < 1.5 liters (general cut-off for surgery) Malignant pleural effusion Tumor near hilum Vocal cord paralysis Superior vena cava (SVC) obstruction

Question 218

Question: How is lung function assessed before surgery for non-small cell lung cancer?

Answer 218

FEV1 < 1.5 liters is the general cut-off for surgery, but if FEV1 < 1.5 for lobectomy or < 2.0 for pneumonectomy, further lung function tests may be conducted, and surgery could still be considered based on the results.

Question 219

Question: What paraneoplastic features are associated with small cell lung cancer?

Answer 219

ADH secretion - hyponatraemia ACTH secretion (more common features: hypertension, hyperglycaemia, hypokalaemia, alkalosis, and muscle weakness) - cushings, bilateral adrenal hyperplasia and lead to hypokalaemic alkalosis. Lambert-Eaton syndrome

Question 220

Question: What paraneoplastic features are associated with squamous cell lung cancer?

Answer 220

Parathyroid hormone-related protein (PTH-rp) secretion, causing hypercalcaemia Clubbing Hypertrophic pulmonary osteoarthropathy (HPOA) Hyperthyroidism due to ectopic TSH

Question 221

Question: What paraneoplastic features are associated with adenocarcinoma?

Answer 221

Gynaecomastia Hypertrophic pulmonary osteoarthropathy (HPOA)

Question 222

Question: According to the 2015 NICE cancer referral guidelines, when should people be referred using a suspected cancer pathway for lung cancer?

Answer 222

If they have chest x-ray findings suggestive of lung cancer. If they are aged 40 or over with unexplained haemoptysis.

Question 223

Question: When should an urgent chest x-ray be offered to assess for lung cancer in people aged 40 and over, according to NICE guidelines?

Answer 223

If they have 2 or more of the following unexplained symptoms: Cough Fatigue Shortness of breath Chest pain Weight loss Appetite loss Or, if they have ever smoked and have 1 or more of these symptoms.

Question 224

Question: What additional scenarios should lead to consideration of an urgent chest x-ray for lung cancer in people aged 40 and over?

Answer 224

Persistent or recurrent chest infection Finger clubbing Supraclavicular or persistent cervical lymphadenopathy Chest signs consistent with lung cancer Thrombocytosis

Question 225

Question: What are the two main classifications of lung cancer, and how are they differentiated?

Answer 225

Small Cell Lung Cancer (SCLC): Accounts for ~15% of cases, has a worse prognosis. Non-Small Cell Lung Cancer (NSCLC): Includes several subtypes with different management and prognosis.

Question 226

Question: What is the most common type of lung cancer, and what factors contribute to its increase?

Answer 226

Adenocarcinoma is the most common type of lung cancer. It has increased due to the rise in the use of low-tar cigarettes. Adenocarcinoma is often seen in non-smokers, making up 62% of cases in never smokers (compared to 18% for squamous cell carcinoma).

Question 227

Question: What are some characteristics of squamous cell carcinoma of the lung?

Answer 227

Squamous cell carcinoma often presents with cavitating lesions, which are more common than in other types of lung cancer.

Question 228

Question: What other types are included in non-small cell lung cancer (NSCLC)?

Answer 228

Large cell carcinoma Alveolar cell carcinoma: Not related to smoking Bronchial adenoma: Mostly carcinoid tumors

Question 229

Question: What are some conditions causing upper zone fibrosis in the lungs?

Answer 229

Hypersensitivity pneumonitis (extrinsic allergic alveolitis) Coal worker's pneumoconiosis (progressive massive fibrosis) Silicosis Sarcoidosis Ankylosing spondylitis (rare) Histiocytosis Tuberculosis Radiation-induced pulmonary fibrosis (following breast or lung cancer radiotherapy)

Question 230

Question: What are some conditions causing lower zone fibrosis in the lungs?

Answer 230

Conditions causing lower zone fibrosis include: Idiopathic pulmonary fibrosis (IPF) Most connective tissue disorders (except ankylosing spondylitis), e.g., SLE Drug-induced: amiodarone, bleomycin, methotrexate Asbestosis

Question 231

Question: What is the acronym for remembering causes of upper zone fibrosis?

Answer 231

C: Coal worker's pneumoconiosis H: Histiocytosis / Hypersensitivity pneumonitis A: Ankylosing spondylitis R: Radiation T: Tuberculosis S: Silicosis / Sarcoidosis

Question 232

Question: What are the common features of mesothelioma?

Answer 232

Dyspnoea, weight loss, chest wall pain Clubbing 30% present as painless pleural effusion Only 20% have pre-existing asbestosis History of asbestos exposure in 85-90% Latent period of 30-40 years

Question 233

Question: What are the basic facts about mesothelioma?

Answer 233

Malignancy of mesothelial cells of the pleura Metastases to contralateral lung and peritoneum Right lung affected more often than the left

Question 234

Question: How is mesothelioma diagnosed?

Answer 234

Chest x-ray (showing pleural effusion or pleural thickening) Pleural CT to assess further Pleural fluid sent for MC&S, biochemistry, and cytology (cytology is only helpful in 20-30%) Local anaesthetic thoracoscopy for cytology-negative exudative effusions (diagnostic yield ~95%) Image-guided pleural biopsy if nodularity is seen on CT

Question 235

Question: What is the management and prognosis for mesothelioma?

Answer 235

Symptomatic management Industrial compensation Chemotherapy, surgery if operable Prognosis is poor with a median survival of 12 months

Question 236

Question: What are the key features of microscopic polyangiitis?

Answer 236

Renal impairment: raised creatinine, haematuria, proteinuria Fever Other systemic symptoms: lethargy, myalgia, weight loss Rash: palpable purpura Respiratory symptoms: cough, dyspnoea, haemoptysis Mononeuritis multiplex

Question 237

Question: What are the key indications for non-invasive ventilation (NIV)?

Answer 237

COPD with respiratory acidosis (pH 7.25-7.35) Type II respiratory failure secondary to chest wall deformity, neuromuscular disease, or obstructive sleep apnoea Cardiogenic pulmonary oedema unresponsive to CPAP Weaning from tracheal intubation

Question 238

Question: What are the predisposing factors for Obstructive Sleep Apnoea/Hypopnoea Syndrome (OSAHS)?

Answer 238

Obesity Macroglossia (e.g., acromegaly, hypothyroidism, amyloidosis) Large tonsils Marfan's syndrome

Question 239

Question: What are the common consequences of Obstructive Sleep Apnoea/Hypopnoea Syndrome (OSAHS)?

Answer 239

Daytime somnolence (sleepiness) Compensated respiratory acidosis Hypertension

Question 240

Question: How is sleepiness assessed in patients with OSAHS?

Answer 240

Epworth Sleepiness Scale - Questionnaire completed by the patient and/or partner Multiple Sleep Latency Test (MSLT) - Measures time to fall asleep in a dark room using EEG criteria

Question 241

Question: What diagnostic tests are used for Obstructive Sleep Apnoea/Hypopnoea Syndrome (OSAHS)?

Answer 241

Sleep studies (polysomnography): From pulse oximetry monitoring at night to full polysomnography measuring EEG, respiratory airflow, thoraco-abdominal movement, snoring, and pulse oximetry.

Question 242

Question: What is the first-line treatment for moderate or severe OSAHS?

Answer 242

Continuous Positive Airway Pressure (CPAP)

Question 243

Question: What management options are available if CPAP is not tolerated or for mild OSAHS?

Answer 243

Intra-oral devices (e.g., mandibular advancement) may be used for mild OSAHS without daytime sleepiness.

Question 244

Question: What is the initial oxygen administration for critically ill patients (e.g., anaphylaxis, shock) according to the British Thoracic Society (BTS) guidelines?

Answer 244

Reservoir mask at 15 l/min for critically ill patients (e.g., anaphylaxis, shock).

Question 245

Question: What are the oxygen saturation targets for acutely ill patients?

Answer 245

94-98% for acutely ill patients.

Question 246

Question: What are the oxygen saturation targets for patients at risk of hypercapnia (e.g., COPD patients)?

Answer 246

88-92% for patients at risk of hypercapnia.

Question 247

Question: What should be the oxygen target for stable COPD patients with no prior history of respiratory acidosis?

Answer 247

28% Venturi mask at 4 l/min to achieve an oxygen saturation of 88-92%.

Question 248

Question: What should be the oxygen target for COPD patients if the pCO2 is normal?

Answer 248

Adjust target oxygen saturation to 94-98%.

Question 249

Question: In which conditions should oxygen therapy not be used routinely if there is no evidence of hypoxia?

Answer 249

Myocardial infarction and acute coronary syndromes Stroke Obstetric emergencies Anxiety-related hyperventilation

Question 250

Question: How are pleural effusions classified based on protein concentration?

Answer 250

Transudate: < 30g/L protein Exudate: > 30g/L protein

Question 251

Question: What are the common causes of transudative pleural effusion?

Answer 251

Heart failure (most common transudate cause) Hypoalbuminaemia Liver disease Nephrotic syndrome Malabsorption Hypothyroidism Meigs' syndrome

Question 252

Question: What are the common causes of exudative pleural effusion?

Answer 252

Pneumonia (most common exudate cause) Tuberculosis Subphrenic abscess Connective tissue diseases: Rheumatoid arthritis Systemic lupus erythematosus Neoplasia: Lung cancer Mesothelioma Metastases Pancreatitis Pulmonary embolism Dressler's syndrome Yellow nail syndrome

Question 253

Question: What are the common features of pleural effusion?

Answer 253

Answer: Symptoms: Dyspnoea Non-productive cough Chest pain Examination findings: Dullness to percussion Reduced breath sounds Reduced chest expansion

Question 254

Question: What imaging should be performed for pleural effusion?

Answer 254

Chest x-ray (posterior-anterior (PA) view) should be performed in all patients. Ultrasound is recommended to increase the likelihood of successful pleural aspiration and detect pleural fluid septations. Contrast CT is increasingly used to investigate the underlying cause, especially for exudative effusions.

Question 255

Question: What are the steps for pleural aspiration and fluid analysis?

Answer 255

Ultrasound is recommended to guide the procedure and reduce complications. A 21G needle and 50ml syringe should be used. Fluid should be sent for: pH Protein Lactate dehydrogenase (LDH) Cytology Microbiology

Question 256

Question: What are Light's criteria for distinguishing between transudate and exudate in pleural fluid?

Answer 256

If the protein level is between 25-35 g/L, Light's criteria should be applied. An exudate is likely if at least one of the following criteria is met: Pleural fluid protein / serum protein > 0.5 Pleural fluid LDH / serum LDH > 0.6 Pleural fluid LDH is more than two-thirds the upper limit of normal serum LDH.

Question 257

Question: What are some characteristic pleural fluid findings and their causes?

Answer 257

Low glucose: rheumatoid arthritis, tuberculosis Raised amylase: pancreatitis, oesophageal perforation Heavy blood staining: mesothelioma, pulmonary embolism, tuberculosis

Question 258

Question: When is a chest tube indicated for pleural infection?

Answer 258

Purulent or turbid/cloudy fluid: chest tube for drainage. If the fluid is clear but the pH is less than 7.2 in patients with suspected pleural infection, a chest tube should be placed.

Question 259

Question: What are the management options for recurrent pleural effusion?

Answer 259

Recurrent aspiration Pleurodesis Indwelling pleural catheter Drug management: opioids to relieve dyspnoea and alleviate symptoms

Question 260

Question: What is the most common cause of pneumonia in clinical practice?

Answer 260

Bacterial infection is the most common cause of pneumonia, with Streptococcus pneumoniae accounting for 80% of cases.

Question 261

Question: What are some common causes of pneumonia?

Answer 261

Bacterial: Streptococcus pneumoniae Haemophilus influenzae (common in COPD patients) Staphylococcus aureus (post-influenza) Mycoplasma pneumoniae (atypical, dry cough) Legionella pneumophila (associated with air conditioning units) Klebsiella pneumoniae (common in alcoholics) Pneumocystis jiroveci (seen in HIV patients) Viral Fungal: e.g., Pneumocystis jiroveci

Question 262

Question: What is the distinction between community-acquired pneumonia (CAP) and hospital-acquired pneumonia (HAP)?

Answer 262

CAP: Pneumonia acquired outside of a hospital. HAP: Pneumonia that occurs 48 hours or more after admission to the hospital. The causative organisms and first-line antibiotics differ for each.

Question 263

Question: What are common symptoms and signs of pneumonia?

Answer 263

Answer: Symptoms: Cough Sputum Dyspnoea Chest pain (pleuritic) Fever Signs: Fever Tachycardia Reduced oxygen saturation Reduced breath sounds Bronchial breathing

Question 264

Question: What are the key investigations in pneumonia?

Answer 264

Chest x-ray: The classical finding is consolidation. Blood tests: Full blood count (neutrophilia in bacterial infections) Urea and electrolytes (check for dehydration) CRP (raised in infection) Arterial blood gases: If oxygen saturation is low or if the patient has respiratory disease (e.g., COPD).

Question 265

Question: What is the management for pneumonia?

Answer 265

Antibiotics: To treat the underlying infection. Supportive care: Oxygen therapy (if hypoxaemic) Intravenous fluids (if hypotensive or dehydrated)

Question 266

Question: What is the CRB-65 score used for in pneumonia management?

Answer 266

The CRB-65 score is used to assess the severity and risk of mortality in community-acquired pneumonia. Criteria: C: Confusion (mental test score ≤ 8/10) R: Respiration rate ≥ 30/min B: Blood pressure (systolic ≤ 90 mmHg or diastolic ≤ 60 mmHg) 65: Age ≥ 65 years Management: Score 0: Home care with oral antibiotics (e.g., amoxicillin). Score 2 or more: Hospital assessment required.

Question 267

Question: What is the role of the CRP test in pneumonia management according to NICE?

Answer 267

CRP < 20 mg/L: Do not routinely offer antibiotics. CRP 20-100 mg/L: Consider a delayed antibiotic prescription. CRP > 100 mg/L: Offer antibiotic therapy.

Question 268

Question: What investigations should be done for pneumonia in intermediate or high-risk patients?

Answer 268

Chest x-ray Blood and sputum cultures Pneumococcal and Legionella urinary antigen tests CRP monitoring to assess treatment response

Question 269

Question: What is the recommended first-line treatment for low-severity community-acquired pneumonia?

Answer 269

Amoxicillin is first-line. If penicillin allergic, use a macrolide or tetracycline. 5-day course of antibiotics is recommended.

Question 270

Question: What is the recommended management for moderate and high-severity community-acquired pneumonia?

Answer 270

Dual therapy with amoxicillin and a macrolide. 7-10 day course of antibiotics. For high-severity, consider beta-lactamase stable penicillin (e.g., co-amoxiclav, ceftriaxone, or piperacillin-tazobactam) with a macrolide.

Question 271

Question: What are the discharge criteria for pneumonia according to NICE?

Answer 271

Do not discharge if any of the following occur in the past 24 hours: Temp > 37.5°C Respiratory rate ≥ 24/min Heart rate > 100 beats/min Systolic BP ≤ 90 mmHg Oxygen saturation < 90% Abnormal mental status Inability to eat without assistance.

Question 272

Question: When should a repeat chest x-ray be done after pneumonia treatment?

Answer 272

A repeat chest x-ray should be done 6 weeks after clinical resolution to ensure consolidation has resolved and rule out underlying abnormalities (e.g., lung cancer).

Question 273

Question: What happens in the pathophysiology of pneumonia?

Answer 273

In pneumonia, pathogens enter the lower respiratory tract, triggering an inflammatory cascade. Neutrophils migrate to the infected alveoli, releasing cytokines that activate the immune response and induce fever. This leads to fluid and pus accumulation in the alveoli, impairing gas exchange and causing hypoxia.

Question 274

Question: What is pneumothorax?

Answer 274

Pneumothorax is a condition characterized by the accumulation of air in the pleural space, causing partial or complete collapse of the affected lung.

Question 275

Question: What are the types of spontaneous pneumothorax?

Answer 275

Primary spontaneous pneumothorax (PSP): Occurs without underlying lung disease, often in tall, thin, young individuals, and is associated with the rupture of subpleural blebs or bullae. Secondary spontaneous pneumothorax (SSP): Occurs in patients with pre-existing lung disease, such as COPD, asthma, cystic fibrosis, lung cancer, and Pneumocystis pneumonia. It is also associated with connective tissue diseases like Marfan's syndrome.

Question 276

Question: What is traumatic pneumothorax?

Answer 276

Traumatic pneumothorax occurs due to penetrating or blunt chest trauma, leading to lung injury and air accumulation in the pleural space.

Question 277

Question: What is iatrogenic pneumothorax?

Answer 277

Iatrogenic pneumothorax occurs as a complication of medical procedures such as thoracentesis, central venous catheter placement, non-invasive ventilation, or lung biopsy.

Question 278

Question: What is a tension pneumothorax?

Answer 278

A tension pneumothorax is a severe form of pneumothorax where air accumulates and cannot escape, causing displacement of mediastinal structures and resulting in severe respiratory distress and haemodynamic collapse.

Question 279

Question: What is catamenial pneumothorax?

Answer 279

Catamenial pneumothorax occurs in 3-6% of spontaneous pneumothoraces in menstruating women and is thought to be caused by endometriosis within the thorax.

Question 280

Question: What are the clinical features of pneumothorax?

Answer 280

Symptoms: Sudden onset of dyspnoea and pleuritic chest pain. Signs: Hyper-resonant lung percussion Reduced breath sounds Reduced lung expansion Tachypnoea Tachycardia

Question 281

Question: What are the signs of tension pneumothorax?

Answer 281

Respiratory distress Tracheal deviation away from the side of the pneumothorax Hypotension

Question 282

Question: What is the first step in managing pneumothorax according to the BTS guidelines?

Answer 282

The first step is assessing whether the patient is symptomatic. If there are no significant symptoms or physiological compromise, conservative care is recommended.

Question 283

Question: What are the high-risk characteristics for pneumothorax that require more aggressive intervention?

Answer 283

Haemodynamic compromise (suggesting a tension pneumothorax) Significant hypoxia Bilateral pneumothorax Underlying lung disease ≥ 50 years with a significant smoking history Haemothorax

Question 284

Question: What are the management options for a symptomatic pneumothorax with no high-risk characteristics?

Answer 284

Conservative care Ambulatory device (e.g., Rocket® Pleural Vent®) Needle aspiration

Question 285

Question: When should a chest drain be inserted for a pneumothorax?

Answer 285

A chest drain should be inserted if needle aspiration is unsuccessful or if the patient has high-risk characteristics.

Question 286

Question: How is safety for intervention in pneumothorax determined?

Answer 286

Safety is typically assessed by the size of the pneumothorax on chest X-ray (≥ 2cm laterally or apically) or any size on CT scan that can be safely accessed with radiological support.

Question 287

Question: What is the management approach for persistent or recurrent pneumothorax?

Answer 287

For persistent air leak or insufficient lung reexpansion despite chest drain insertion, or recurrent pneumothorax, video-assisted thoracoscopic surgery (VATS) is considered for mechanical/chemical pleurodesis and bullectomy.

Question 288

Question: What discharge advice is given to pneumothorax patients regarding smoking?

Answer 288

Patients should avoid smoking to reduce the risk of further episodes, as the lifetime risk of pneumothorax is much higher in smokers (10%) compared to non-smokers (0.1%).

Question 289

Question: What is the fitness to fly recommendation after pneumothorax treatment?

Answer 289

Patients can travel by air 2 weeks after successful drainage if no residual air is present. The previous recommendation of 6 weeks has been updated to 1 week post check X-ray.

Question 290

Question: What is the characteristic finding in obstructive lung disease on pulmonary function tests?

Answer 290

FEV1: Significantly reduced FVC: Reduced or normal FEV1/FVC ratio: Reduced

Question 291

Question: What is the characteristic finding in restrictive lung disease on pulmonary function tests?

Answer 291

FEV1: Reduced FVC: Significantly reduced FEV1/FVC ratio: Normal or increased

Question 292

Question: What are some examples of obstructive lung diseases?

Answer 292

Asthma COPD Bronchiectasis Bronchiolitis obliterans

Question 293

Question: What are some examples of restrictive lung diseases?

Answer 293

Pulmonary fibrosis Asbestosis Sarcoidosis Acute respiratory distress syndrome (ARDS) Infant respiratory distress syndrome Kyphoscoliosis (e.g., ankylosing spondylitis) Neuromuscular disorders Severe obesity

Question 294

Question: What are the common causes of respiratory acidosis?

Answer 294

COPD Decompensation in other respiratory conditions (e.g., life-threatening asthma, pulmonary oedema) Neuromuscular disease Obesity hypoventilation syndrome Sedative drugs (e.g., benzodiazepines, opiate overdose)

Question 295

Question: What are common causes of respiratory alkalosis?

Answer 295

Anxiety leading to hyperventilation Pulmonary embolism Salicylate poisoning (mixed respiratory alkalosis and metabolic acidosis) CNS disorders (e.g., stroke, subarachnoid haemorrhage, encephalitis) Altitude Pregnancy

Question 296

Question: What is tidal volume (TV) and its average volume?

Answer 296

The volume inspired or expired with each breath at rest. 500 ml in males, 350 ml in females.

Question 297

Question: What is inspiratory reserve volume (IRV) and its average volume?

Answer 297

The maximum volume of air that can be inspired at the end of a normal tidal inspiration. 2-3 L.

Question 298

Question: What is expiratory reserve volume (ERV) and its average volume?

Answer 298

The maximum volume of air that can be expired at the end of a normal tidal expiration. 750 ml. Significantly reduced in obesity due to abdominal fat mass pushing against the diaphragm.

Question 299

Question: What is residual volume (RV) and its average volume?

Answer 299

The volume of air remaining after maximal expiration. 1.2 L. Increases with age.

Question 300

Question: What is functional residual capacity (FRC) and how is it calculated?

Answer 300

The volume in the lungs at the end-expiratory position. FRC = ERV + RV.

Question 301

Question: What is vital capacity (VC) and its average volume?

Answer 301

The maximum volume of air that can be expired after maximal inspiration. 5 L (4,500 ml in males, 3,500 ml in females). Decreases with age. VC = inspiratory capacity + ERV.

Question 302

Question: What is total lung capacity (TLC)?

Answer 302

The sum of vital capacity + residual volume.

Question 303

Question: How is physiological dead space (VD) calculated?

Answer 303

VD = tidal volume * (PaCO2 - PeCO2) / PaCO2 Where: PaCO2 = partial pressure of CO2 in arterial blood PeCO2 = partial pressure of CO2 in expired air

Question 304

Question: In which conditions is an immediate antibiotic prescribing approach considered for respiratory tract infections?

Answer 304

Children < 2 years with bilateral acute otitis media. Children with otorrhoea (discharge from the ear) and acute otitis media. Patients with acute sore throat/pharyngitis/tonsillitis who meet 3 or more Centor criteria.

Question 305

Question: What are the Centor criteria for determining whether to prescribe antibiotics for acute sore throat/pharyngitis/tonsillitis?

Answer 305

Tonsillar exudate Tender anterior cervical lymphadenopathy or lymphadenitis History of fever Absence of cough

Question 306

Question: When is an immediate antibiotic prescribing policy recommended for patients with respiratory tract infections according to NICE?

Answer 306

The patient is systemically very unwell. There are signs suggestive of serious illness or complications (e.g. pneumonia, mastoiditis, abscesses). The patient is at high risk of complications due to comorbidities (e.g. heart, lung, renal, liver diseases, immunosuppression, cystic fibrosis, premature birth). Patients are older than 65 years with acute cough and two or more risk factors, or older than 80 years with acute cough and one or more risk factors.

Question 307

Question: What are the risk factors for prescribing antibiotics to older patients with acute cough?

Answer 307

For patients older than 65 years with acute cough and two or more of the following, or older than 80 years with acute cough and one or more of the following: Hospitalisation in the previous year Type 1 or type 2 diabetes History of congestive heart failure Current use of oral glucocorticoids

Question 308

Question: What duration do respiratory tract infections typically last, according to NICE guidelines?

Answer 308

Acute otitis media: 4 days Acute sore throat/pharyngitis/tonsillitis: 1 week Common cold: 1 1/2 weeks Acute rhinosinusitis: 2 1/2 weeks Acute cough/acute bronchitis: 3 weeks

Question 309

Question: What is sarcoidosis, and what is its hallmark feature?

Answer 309

Sarcoidosis is a multisystem disorder of unknown aetiology characterized by the formation of non-caseating granulomas. It is more common in young adults and individuals of African descent.

Question 310

Question: What are the acute features of sarcoidosis?

Answer 310

Erythema nodosum Bilateral hilar lymphadenopathy (BHL) Swinging fever Polyarthralgia

Question 311

Question: What are the insidious features of sarcoidosis?

Answer 311

Dyspnoea Non-productive cough Malaise Weight loss

Question 312

Question: What ocular and skin features are associated with sarcoidosis?

Answer 312

Ocular: Uveitis Skin: Lupus pernio

Question 313

Question: Why does hypercalcaemia occur in sarcoidosis?

Answer 313

Hypercalcaemia occurs because macrophages within the granulomas cause an increased conversion of vitamin D to its active form, 1,25-dihydroxycholecalciferol.

Question 314

Question: Is there a single diagnostic test for sarcoidosis?

Answer 314

No, there is no single diagnostic test for sarcoidosis. The diagnosis is still largely clinical.

Question 315

Question: What is the role of ACE levels in diagnosing sarcoidosis?

Answer 315

ACE levels have a sensitivity of 60% and specificity of 70%. They are not reliable for diagnosing sarcoidosis but may help in monitoring disease activity.

Question 316

Question: What may routine blood tests show in patients with sarcoidosis?

Answer 316

Routine blood tests may show hypercalcaemia (seen in 10% of patients) and a raised ESR (erythrocyte sedimentation rate).

Question 317

Question: How is sarcoidosis staged on a chest x-ray?

Answer 317

Stage 0: Normal Stage 1: Bilateral hilar lymphadenopathy (BHL) Stage 2: BHL + interstitial infiltrates Stage 3: Diffuse interstitial infiltrates only Stage 4: Diffuse fibrosis

Question 318

Question: What spirometry finding may be seen in sarcoidosis?

Answer 318

Spirometry may show a restrictive defect in sarcoidosis.

Question 319

Question: What does a tissue biopsy show in sarcoidosis?

Answer 319

A tissue biopsy typically shows non-caseating granulomas.

Question 320

Question: What is the primary treatment for sarcoidosis?

Answer 320

The primary treatment for sarcoidosis is steroids (e.g., prednisone).

Question 321

Question: When are steroids indicated in the management of sarcoidosis?

Answer 321

Stage 2 or 3 disease with symptoms (e.g., dyspnoea, cough) Asymptomatic stable Stage 2 or 3 disease with mildly abnormal lung function (no treatment required) Hypercalcaemia Involvement of eye, heart, or nervous system

Question 322

Question: What is the management approach for asymptomatic stable Stage 2 or 3 sarcoidosis?

Answer 322

For asymptomatic stable Stage 2 or 3 sarcoidosis with only mildly abnormal lung function, no treatment is required.

Question 323

Question: What percentage of patients with sarcoidosis experience remission without treatment?

Answer 323

Approximately two-thirds of people with sarcoidosis experience remission without treatment.

Question 324

Question: What factors are associated with a poor prognosis in sarcoidosis?

Answer 324

Factors associated with a poor prognosis in sarcoidosis include: Insidious onset and symptoms lasting > 6 months Absence of erythema nodosum Extrapulmonary manifestations (e.g., lupus pernio, splenomegaly) CXR Stage III-IV features (advanced disease) Black African or African-Caribbean ethnicity

Question 325

Question: What is a characteristic feature of Chronic Obstructive Pulmonary Disease (COPD)?

Answer 325

Chronic obstructive pulmonary disease is invariably seen in smokers. It often presents with a chronic productive cough and features of right heart failure may be seen.

Question 326

Question: Which features are characteristic of Heart Failure causing chronic shortness of breath?

Answer 326

Characteristic features of heart failure include: History of ischaemic heart disease or hypertension Orthopnoea and paroxysmal nocturnal dyspnoea Bibasal crackles and a third heart sound (S3) for left-sided failure Peripheral oedema and a raised JVP for right-sided failure

Question 327

Question: What symptoms are typical of Asthma?

Answer 327

Asthma typically presents with cough, wheeze, and shortness of breath. Symptoms often worsen at night and may be precipitated by cold weather or exercise. It is associated with hay fever and eczema.

Question 328

Question: What are the characteristic features of Aortic Stenosis?

Answer 328

Characteristic features of aortic stenosis include: Chest pain, shortness of breath, and syncope in symptomatic patients An ejection systolic murmur radiating to the neck Narrow pulse pressure

Question 329

Question: What are the features of Recurrent Pulmonary Emboli?

Answer 329

Features of recurrent pulmonary emboli include: History of predisposing factors (e.g., malignancy) Pleuritic chest pain and haemoptysis (symptoms can be vague) Tachycardia and tachypnoea in acute situations Symptoms of right heart failure in severe cases

Question 330

Question: What are common presentations of Lung Cancer?

Answer 330

Common presentations of lung cancer include: Seen in smokers Haemoptysis, chronic cough, or unresolving infection Systemic symptoms such as weight loss and anorexia

Question 331

Question: What are the typical findings in Pulmonary Fibrosis?

Answer 331

Pulmonary fibrosis typically presents with: Progressive shortness of breath as the only symptom Fine bibasal crackles Restrictive pattern on spirometry

Question 332

Question: What symptoms and history are associated with Bronchiectasis?

Answer 332

Bronchiectasis is associated with: Large amounts of purulent sputum History of previous infections (e.g., tuberculosis, measles), bronchial obstruction, or ciliary dyskinetic syndromes (e.g., Kartagener's syndrome)

Question 333

Question: How does Anaemia present in terms of chronic shortness of breath?

Answer 333

Anaemia may present with: History of gastrointestinal symptoms Pallor on examination

Question 334

Question: How does Obesity contribute to chronic shortness of breath?

Answer 334

Obese patients tend to be more short of breath due to the increased work of activity.

Question 335

Question: What is Silicosis?

Answer 335

Silicosis is a fibrosing lung disease caused by the inhalation of fine particles of crystalline silicon dioxide (silica). It is a risk factor for developing tuberculosis because silica is toxic to macrophages.

Question 336

Question: Which occupations are at risk of developing Silicosis?

Answer 336

Occupations at risk include: Mining Slate works Foundries Potteries

Question 337

Question: What are the characteristic features of Silicosis?

Answer 337

Upper zone fibrosing lung disease 'Egg-shell' calcification of the hilar lymph nodes

Question 338

Question: What is Tension Pneumothorax?

Answer 338

Tension pneumothorax is a life-threatening condition characterized by the accumulation of air in the pleural space under positive pressure, leading to the collapse of the lung on the affected side and a shift of the mediastinum towards the contralateral side, resulting in impaired venous return to the heart and reduced cardiac output.

Question 339

Question: What are the causes of Tension Pneumothorax?

Answer 339

Traumatic: Penetrating or blunt chest trauma Iatrogenic: Thoracentesis, central venous catheter placement, positive pressure mechanical ventilation Spontaneous: Particularly in those with underlying lung diseases (e.g., COPD or cystic fibrosis) or ruptured lung blebs.

Question 340

Question: What is the pathophysiology of Tension Pneumothorax?

Answer 340

Tension pneumothorax develops when air enters the pleural space and is unable to escape, creating a one-way valve effect. This leads to: Increased intrapleural pressure exceeding atmospheric pressure throughout the respiratory cycle. Lung collapse: Decreased functional residual capacity and impaired gas exchange. Mediastinal shift: Pressure pushes the mediastinum towards the contralateral side, compressing the opposite lung. Impaired venous return: Compression of the great veins reduces venous return to the heart, diminishing cardiac output. Reduced cardiac filling: Pressure on the heart and reduced venous return impairs right and left ventricular filling, lowering cardiac output and systemic blood pressure.

Question 341

Question: What are the clinical features of Tension Pneumothorax?

Answer 341

Features include: Acute onset of dyspnoea Pleuritic chest pain Tachypnoea Signs: Hyperresonance on percussion, diminished breath sounds on the affected side. Tracheal deviation away from the affected side Shock signs: Hypotension and tachycardia in severe cases.

Question 342

Question: How should Tension Pneumothorax be managed?

Answer 342

Management involves decompression of the pleural space: Needle thoracostomy: Insert a cannula into the second intercostal space in the midclavicular line on the affected side. Chest drain (tube thoracostomy): Place in the safe triangle of the chest for continuous drainage of air.

Question 343

Question: What does the transfer factor (TLCO) describe?

Answer 343

The transfer factor describes the rate at which a gas, typically carbon monoxide, diffuses from the alveoli into the blood. It is used to assess the efficiency of gas exchange in the lungs.

Question 344

Question: What are the causes of a raised TLCO?

Answer 344

Asthma Pulmonary haemorrhage (e.g., granulomatosis with polyangiitis, Goodpasture's syndrome) Left-to-right cardiac shunts Polycythaemia Hyperkinetic states Male gender, exercise

Question 345

Question: What are the causes of a lower TLCO?

Answer 345

Pulmonary fibrosis Pneumonia Pulmonary emboli Pulmonary oedema Emphysema Anaemia Low cardiac output

Question 346

Question: How does KCO relate to age and other factors?

Answer 346

KCO (transfer coefficient) tends to increase with age. Some conditions may cause an increased KCO despite a normal or reduced TLCO, including: Pneumonectomy/lobectomy Scoliosis/kyphosis Neuromuscular weakness Ankylosis of costovertebral joints (e.g., ankylosing spondylitis)

Question 347

when should you give standby meds for copd

Answer 347

short course of oral corticosteroids and oral antibiotics to keep at home if: NICE have had an exacerbation within the last year understand how to take the medication, and are aware of associated risks and benefits know to when to seek help and when to ask for replacements once medication has been used

Question 348

When would you give ipratropium bromide in acute management of asthma

Answer 348

in severe/life threatening cases

Question 349

What is tiotropium

Answer 349

lama

Question 350

When is A1T1 deficiency diagnosed

Answer 350

can be done prenatally

Question 351

What chest condition can result from NIV

Answer 351

pneumothorax

Question 352

What blood condition is a complication of COPD

Answer 352

polycythaemia (increased haematocrit)

Question 353

Painful red lesions on shin with high calcium

Answer 353

sarcoidosis - erythema nodosum

Question 354

Recurrent chest infections + subfertility

Answer 354

Kartageners syndrome

Question 355

What is meant by 1 pack year

Answer 355

20 cigarettes per day for 1 year

Question 356

Type 1 vs type 2 respiratory failure

Answer 356

Type 1 is lack of oxygen, Type 2 is lack of oxygen + excess CO2

Question 357

At what pH is NIV used in resp failure for COPD

Answer 357

7.25-7.35

Question 358

How do you screen for latent TB

Answer 358

Mantoux

Question 359

Differentiation between causes of pneumonia

Answer 359

1. Staphylococcus aureus --> cavitating lesions, recent flu 2. Klebsiella pneumoniae --> alcoholics and diabetics 3. Haemophilius influenzae --> pneumonia in COPD 4. Legionella --> deranged LFTs, hyponatraemia, headache, AC exposure 5. Pseudomonas aeruginosa --> associated with CF, green sputum 6. Streptococcus pneumoniae --> cold sores, most common type of pneumonia if no specific indications for other types of pneumonia. 7. mycoplasma > erythema multiforme, dry cough, rash

Question 360

What is Meigs syndrome triad

Answer 360

fibroma, ascites, pleural effusion

Question 361

What must you do if youre considering giving TB vaccine to someone older than 6

Answer 361

tuberculin skin test

Question 362

Cause of bronchiectasis

Answer 362

haemophillus influenza if new bronchiectasis, pseudomonas if long lasting bronchiectasis

Question 363

What lung pathology is a contraindication to lung transplant

Answer 363

TB

Question 364

What dose of adrenaline do you give in anaphylaxis

Answer 364

0.5mg (0.5 ml of 1 in 1000) IM

Question 365

What special feature does COVID present with

Answer 365

leucopoenia

Question 366

how can you reduce risk of oral candidiasis through inhaler use

Answer 366

use a spacer

Question 367

What blood marker is raised in lung cancer

Answer 367

platelets