Resp Flashcards
1
Q
What results after exposure to antigen in sensitised individual during anaphylactic shock
A
Histamine release ~> capillary leak, oedema, wheeze, cyanosis
2
Q
List the steps in treating a patient with anaphylaxis
A
- remove trigger
- maintain airway and intimate if necessary
- 100% O2
- IM adrenaline 0.5mg
- IV hydrocortisone 200mg
- IV chlorpheniramine 10mg
- fluid resusc if hypotension
- NEB salbutamol
- NEB adrenaline
3
Q
List the drugs given IM or IV in anaphylactic shock, and their doses
A
- IM adrenaline
- IV hydrocortisone
- IV chlorpheniramine
4
Q
What NEBs would you give in anaphylaxis
A
Salbutamol
Adrenaline
5
Q
Define mild asthma
A
Pefr > 75%
6
Q
Define moderate asthma
A
Pefr 50-75%
7
Q
Define severe asthma
A
- Pefr 33-50% of best or predicted
- cannot complete sentences
- resp rate > 25/min
- hr > 110/min
8
Q
Define life threatening asthma
A
- Pefr less than 33%
- sats less than 92% or po2 less than 8kpa
- silent chest
- exhaustion, confusion
- normal pco2
9
Q
Define near fatal asthma
A
Raised paco2 (co2 retention)
10
Q
What are the steps for managing acute asthma exacerbation
A
- ABCDE
- O2 as needed
- nebulised salbutamol 5mg
- oral prednisolone 40mg / IV hydrocortisone if po not possible
11
Q
How do you manage sever asthma
A
Nebulised ipratropium bromide 500mcg
Salbutamol back to back may be needed
12
Q
How do you manage life threatening or near fatal asthma
A
- urgent itu/anaesthetist assessment
- urgent portable CXR
- IV aminophylline
- IV salbutamol if nebulised is ineffective
13
Q
What is the mechanism of action of ipratropium bromide
A
Anticholinergic - blocks M3 receptors
14
Q
What so2 would you aim for in a patient with COPD
A
88-92%
15
Q
How do you manage COPD exacerbations
A
Oxygen via Venturi mask NEBs - salbutamol, ipratropium Prednisolone 30mg od 7/7 Abx if infection indicated CXR Consider niv/itu
16
Q
When would you consider niv in a patient with exacerbation of COPD
A
Type 2 resp failure and ph 7.25-7.35
17
Q
When would you consider itu referral in a patient with COPD exacerbation
A
Ph less than 7.25
18
Q
What are the features on investigation and CXR that would indicate pneumonia
A
- consolidation on CXR
- fever
- purulent sputum
- raised wcc
- raised CRP
19
Q
Define anaphylaxis
A
A type 1 ige-mediated hypersensitivity reaction
20
Q
What are the parts that make up the CURB65 score
A
C - confusion, mmt 2 or more points worse
U - urea >7.0
R - Resp rate > and including 30/min
B - BP less than 90 systolic or 60 diastolic
65 yo or older
21
Q
What does the CURB65 score predict
A
Mortality in community acquired pneumonia
22
Q
How should a patient with a curb65 of 0-1 be treated
A
As outpatient
23
Q
How should patient with curb65 of 2 be treated
A
Consider short hospital stay
24
Q
How should a patient with curb65 of 3-5 be treated
A
Hospitalisation + consider if they need itu
25
What are the two ways to define a massive haemoptysis
- >240mls in 24 hours
| - >100mls/day over consecutive days
26
How is massive haemoptysis managed
ABCDE
- lie patient on side of suspected lesion
- oral tranexamic acid
- stop NSAIDs/aspirin/anticoagulants
- abx if suspected RTI
- consider vit k
27
How would you investigate someone with massive haemoptysis
Ct aortogram
28
How does tranexamic acid work?
Inhibits breakdown of fibrin by inhibiting plasminogen being converted to plasmin (plasmin acts to cause fibrin degradation)
29
What features would you see on an X-ray of a patient with tension pneumothorax
- lung is blacker on side of tension pneumothorax
- mediastinum shifted into contralateral hemithorax
- trachea deviated away from side of pneumothorax
- kinking and compressing of great veins
30
What may be found on examination of patient with tension pneumothorax
- increased percussion note (hyper resonance)
- reduced air entry
- reduced breath sounds
...on affected side
31
What is the management of tension pneumothorax
- large bore iv cannula into 2nd intercostal space in mid clavicular line
- chest drain into affected side
32
List some of the symptoms and signs of PE
- sudden onset pleuritic chest pain
- pleural rub
- sob
- haemoptysis
- syncope
- hypotension
- tachypnoea
- cyanosis
33
At what O2 sats would you perform abg
Less than92%
34
What are the major risk factors for PE
- surgery
- obstetric causes
- lower limb #
- varicose veins
- malignancy
- reduced mobility
- previous proven vte
35
Give a couple of surgical procedures that are major risk factors of PE
Abdo/ pelvic
| Knee or hip replacement
36
Give the steps for managing PE
ABCDE
- O2
- fluids
- thrombolysis if massive PE confirmed
- full anticoagulation
37
What would you thrombolyse with in massive PE
Iv alteplase
38
What defines massive PE
Hypotension/imminent cardiac arrest
39
List some of the relative factors which act to contraindicate thrombolysis
Warfarin
Pregnancy
Advanced liver disease
Infective endocarditis
40
What may an ecg show with PE
Sinus tachycardia
Right axis deviation
Rbbb
Af
41
What may be seen on CXR with a PE
- Small pleural effusion
| - Wedge shaped area of infarction
42
What may ABGs show in a patient with PE
Pao2 reduced
Paco2 reduced
Often acidosis
(Hypervenitaltion and decreased gas exchange)
43
What is a d diner blood test helpful in diagnosing
PE
44
What towns investigations apart from ecg and CXR may you perform in a patient with suspected PE
CT pulmonary angiogram
| V/Q scan
45
Give some of the preventative measures for PE
- TED stockings
- LMWH
- avoid contraceptive pill
- anticoagulation
46
At what blood pressure would you start to consider massive PE
Less than 90mmhg systolic
47
What conditions is asthma often associated with in patients
- eczema
- hay fever
- allergies
- (significant portion also have acid reflux)
48
Give some of the signs of asthma on inspection
- tachypnoea
- audible wheeze
- hyper inflated chest
49
What may you find when examining the chest of a patient with asthma
- hyper resonant percussion
- diminished air entry
- widespread
- polyphonic wheeze
50
What is asthma
A chronic inflammatory disease of the airways, where obstruction is reversible
51
Describe the diurnal variation of asthma
Marked morning dipping of peak flow can predispose to attack
52
Give the two main differentials for wheeze
Acute asthma exacerbation
| Bronchitis (inc COPD)
53
What is churg Strauss syndrome
autoimmune condition causing vasculitis, occurs in patients with a history of airway hypersensitivity
54
What is wegeners granulomatosis
Form of vasculitis that can cause damage to the lung and kidneys
55
What is the pathophysiology of asthma
- airway epithelial damage
- inflammatory reaction - mast cells, eosinophils, T cells
- increased numbers of goblet cells
- cytokines amplify inflamm
- mucus plugging if severe
56
What are the features of airway epithelial damage in asthma
- BM thickening
| - Sub epithelial fibrosis
57
What are some of the inflammatory mediators involved in asthma pathophysiology
- histamine
- leukotrienes
- prostaglandins
58
What is the criteria that make a patient suitable for discharge following exacerbation of asthma
- pefr >75%
| - not needed nebulised inhalers for at least 24hours
59
What steps would be take to manage a patient after discharge following presentation with acute asthma exacerbation
- 5 days oral prednisolone
- provide pefr meter
- written asthma action plan
- gp follow up 2 working days
- Resp clinic follow up within 4 weeks
60
What is eosinophilia
Increased eosinophil count in response to allergens, drugs etc
61
List the trigger factors for asthma
- smoking
- urti
- allergens
- exercise/cold air
- occupational irritants
- drugs
- foods/drinks
- stress
62
How may aminophylline/theophylline be useful in treating asthma
Given as prophylaxis at night to prevent morning dip
63
What are some of the side effects of b2 agonists
- tachy
- reduced K+
- tremor
- anxiety
64
Why may LABAs be useful in treating asthma
Can help nocturnal symptoms and reduce morning dips
65
Why should a patient rinse their mouth after using inhaled steroids
Prevent oral candidiasis
66
How may you distinguish whether there is an occupational explore which brings on asthma attacks
Ask patient if they get less/no symptoms over the weekend or during holidays; ask them to measure their peak flow during work and home
67
What is step 1 of the BTS guidelines for asthma management
Inhaled short acting B2 agonist
68
What is step 2 of the BTS guidelines for asthma management
Add inhaled steroid (appropriate to severity of disease)
69
What is step 3 of the BTS guidelines for asthma management
Add LABA +/- theophylline +/- B2 agonist tablet
- if only some response, increase steroid dose
- if no response, stop LABA and increase steroids
70
What is step 4 of the BTS guidelines for asthma management
Add leukotriene receptor antagonist eg montelukast
71
What is step 5 of the BTS asthma management plan
Daily steroid tablet
| Refer for specialist care
72
On a ct scan, if one were to see dark round areas, what do they indicate
Air retention causing bullae
73
When is anti IgE monoclonal antibody treatment indicated in a patient with asthma e.g. Omalizumab
Selected patients with persistent allergic asthma
74
What is the definition of COPD
A condition characterised by irreversible airway obstruction which is usually progressive and predominantly caused by smoking
75
What two conditions is COPD an umbrella term for
Emphysema and bronchitis
76
Define emphysema
Enlarged air spaces distal to terminal bronchioles, with destruction of alveolar walls
77
Define bronchitis
Inflammation of airways with cough, sputum production for most days for 3 months of 2 successive years
78
What is the difference between diagnosis of emphysema and bronchitis
Emphysema is defined histologically, bronchitis is defined clinically
79
What are the pathophysiological features of COPD
- mucous gland hyperplasia
- loss of filial function
- emphysema
- chronic inflammation (macrophages and neutrophils)
- fibrosis of small airways
80
List the causes of COPD
Smoking
a1-antitrypsin deficiency
Industrial exposure
81
What fev1 ranges indicate mild, moderate and severe COPD
```
Mild = 50-80%
Mod = 30-49%
Severe = less than 30%
```
82
How are patient sight COPD managed
- SMOKING CESSATION
- pulmonary rehab
- bronchodilators
- antimuscaricins
- steroids
- mucolytics
- Ltot if appropriate
- lung volume reduction if appropriate
83
What are the indications for lung vol surgery in patient with COPD
Recurrent pneumothorax
| Bullous disease
84
How would you treat mild COPD
Antimuscarinic
| Or B2 agonist PRN
85
How is moderate COPD managed pharmacologically
Regular antimuscarinic
Or LABA
+ inhaled corticosteroid e.g. Beclamethasone
86
How is severe COPD treated
LABA
+ inhaled steroid
+ anticholinergic
87
What may ecg and CXR show in a patient with COPD
Ecg : ra and rv hypertrophy
| CXR: hyperinflation, flat hemidiaphragm, large central pulmonary arteries, bullae
88
How do you know that a lung is hyper inflated on CXR
More than 6 ribs in the MCL above the diaphragm
89
What are the medical features of pink puffers in COPD
Increased alveolar ventilation
Near normal pao2 with normal or slightly low paco2
Breathless
90
What are the medical features of blue bloaters in COPD
Decreased alveolar ventilation
Pao2 is decreased and paco2 is increased
Cyanosed but not breathless
Rely on hypoxia drive
91
Why do blue bloaters rely on hypoxic drive
Their respiratory centres have a decreased sensitivity to co2
92
What can blue bloaters go on to have
Cor pulmonale
93
What can pink puffers go on to have
Type 1 resp failure
94
Why may Ltot be given in a patient with severe COPD
To prevent renal and cardiac damage from prolonged hypoxia
95
How is Ltot (long term O2 therapy) given
Continuous oxygen therapy for most of the day - at least 16 hours/day for a survival benefit
96
At which po2 levels is Ltot offered in COPD patients
Po2 consistently below 7.3 kpa or below 8kpa with cor pulmonale
97
What are some of the drawbacks of Ltot
Reduced mobility and independence
98
Describe the cycle which pulmonary rehabilitation tries to break in patient with COPD
You feel breathless > avoid activity > do less > muscles weaken > get more breathless > feel depressed > you feel breathless
99
What adverse social effects can the vicious cycle of COPD lead to
Increasing isolation and inactivity, which leads to worsening of symptoms
100
What are some of the complications of COPD
```
Acute exacerbation
Infections
Polycythaemia
Resp failure
For pulmonale
Cancer
Bullae rupture leading to pneumothorax
```
101
What are the symptoms of COPD
Cough
Sputum
Wheeze
Dyspnoea
102
What are the signs of COPD
```
Tachypnoea
Use of accessory muscles
Hyperinflation of chest
Reduced expansion
Increased percussion note
Cyanosis
Quiet breath sounds
Wheeze
Cor pulmonale
```
103
What types of organism tend to cause hospital acquired pneumonia
- gram negative enterobacteria
- s aureus
- pseudomonas
- klebsiella
- bacteroides
- clostridia
104
Give some conditions that may predispose to aspiration pneumonia
```
Stroke
Myasthenia gravis
Bulbar palsies
Decreased consciousness
Oesophageal disease eg GORD
Poor dental hygiene
```
105
List some organisms causing pneumonia in immune improvised patients
- pneumocystis jirovecii/P. Carinii
- fungi
- M. Catarrhalis
106
What are the common organisms causing community acquired pneumonia
- strep pneumoniae
- h influenzae
- mycoplasma pneumoniae
- viruses and flu also
107
What will be seen on CXR of patient with pneumonia
Consolidation
Lobar or multi lobar infiltrates
Cavitation
Pleural effusion
108
What are the differentials for consolidation on CXR
- pneumonia
- TB
- lung ca
- lobar collapse (blockage of bronchi)
- haemorrhage
109
What does a curb 65 score act as a guide for
Risk of mortality for patients with pneumonia
110
What other features, except for a high scoring curb 65 can increase risk of death in a patient with pneumonia
- coexisting disease
- bilateral involvement
- multi lobar involvement
- pao2
111
What investigation should you perform in a febrile patient with pneumonia
Blood cultures
112
In severe cases/high curb 65 score, what investigations would you do
Investigations for atypical causes e.g. Serology and urine legionella antigen test
113
On examination of a patient with pneumonia, what signs may you pick up?
signs of consolidation e.g.
- decreased percussion note
- diminished expansion
- bronchial breathing
- increased Fremitus
114
Give some of the steps of pneumonia follow up
- HIV test
- immunoglobulins
- pneumococcal IgG serotypes
- H influenzae B IgG
115
When would you do a follow up appointment and CXR in a patient with pneumonia
In 6 weeks
116
What factors may cause a non-resolving pneumonia (CHAOS)
```
Complications
Host immunocompromised
Antibiotic inadequate
Organism resistant
Second diagnosis - not pneumonia
```
117
List some of the complications of pneumonia
```
Empyema
Lung abscess
Resp failure
Septicaemia
Pericarditis, myocarditis
Pleural effusion
AF
```
118
What is the management of pneumonia usually
Amoxicillin + clarithromycin/doxycycline (look at hospital guidelines)
119
What is the treatment for aspiration pneumonia
Cefuroxime + metronidazole
120
What is the treatment for atypical pneumonia
Coamoxiclav or cefuroxime/other cephalosporin
+ clarithromycin
+ flucloxacillin (if S. aureus is indicated)
121
When treating a patient with pneumonia, what are your targets for pao2 and sats
Pao2 > 8kpa
| Sats >94%
122
If a patient with penumonai becomes septic, who do you refer them to
ITU
123
What can precipitate hypotension in a patient with pneumonia
Dehydration and sepsis
124
Give a skin feature of TB
Erythema nodosum
125
Give non-chest manifestations of TB
Erythema nodosum, lymphadenopathy, meningitis, frequency, dysuria, pericardial effusion
126
By which route is TB spread to become milliary
Haematogenous
127
What is the characteristic CXR feature of TB
Reticulonodular shadowing, usually in upper zone
128
What is the tuberculin test
TB antigen is injected intradermally,
If it is positive, it indicates immunity
If it is strong positive, it indicates active infection
129
What may cause positive tuberculin test in a patient
Immunity - either previous exposure or BCG vaccination
130
What are some of the infective differential causes of haemoptysis
- pneumonia
- TB
- bronchiactesis
- CF
- cavitation lung lesion (e.g. Fungal)
131
What are some of the haemorrhagic differential causes for haemoptysis
- bronchial artery erosion
- PE
- vasculitis
- coagulopathy
132
List the differential diagnoses for haemoptysis
- infections (TB, pneumonia etc.)
- malignancy
- haemorrhagic
- PE
133
If there is a CXR suggestive of TB, what investigation would you do next
Sputum sample
134
If a patient has active non respiratory TB, which investigations would you choose to cover as much as possible
- sputum sample
- CXR
- pleural fluid
- urine sample
- pus
- csf
135
List some risk factors for TB
- past history of TB
- known history of TB contact
- born in country with high TB incidence
- travel to country with high TB incidence
- immunosuppression
136
What is the histological hallmark of TB
Caseating granuloma
137
How would you test for TB bacterium
Ziel Neelsen testing for acid fast bacilli
138
What are the CXR signs for a patient with TB
- consolidation
- cavitation
- fibrosis
- calcification
139
Should you wait for cultures results if histology and clinical picture is consistent with TB
No
140
If a patient with TB has a productive cough, what samples should you collect
Three sputum cultures for acid fast bacilli and TB culture
141
If you have a patient with suspected TB which has atypical features on examination and CXR, what investigation would you then do
Ct
142
If you are unsure between diagnosis of TB or p euro ka, how would you manage that patient
Which treatment as per pneumonia, while investigation possibility of TB
143
What is the standard therapy for TB
- 4 antibiotics for the first 2 months: Rifampicin, Isoniazid, Pyrazinamide, Ethambutol
- then followed by two antibiotics for the next 4 months: Rifampicin and isoniazid
144
Why is weight Important when treating a patient with TB
Dose of anti TB antibiotics depends on weight
145
Why do you need to check visual acuity before giving ethambutol
He drug causes ocular toxicity, so you need to test colour vision and acuity before commencing treatment
146
What is DOT
Directly observed therapy - observing patient staking anti TB meds to help with compliance
147
What drug can you give in conjunction with isoniazid to act as prophylaxis for peripheral neuropathy
Pyridoxine
148
What are the two major side effects of Rifampicin
Hepatitis
| Orange /red secretions
149
What is the major side effects of isoniazid
Peripheral neuropathy
150
What is the major side effect of Pyrazinamide
Arthralgia
151
What is the main Side effect of ethambutol
Optic neuritis/retro bulbar neuritis
152
What is the pathophysiology of bronchiactesis
Chronic/recurrent infections of the bronchi + bronchioles leading to permanent dilatation of the airways
153
What is the gold standard diagnostic test for bronchiactesis
High res ct
154
What are some of the infective causes for bronchiactesis
Whooping cough, TB, pneumonia, measles
155
What immune deficiency disorder is associated with bronchiactesis
Hypogammaglobulinaemia
156
List some mucus/clearance disorders that are associated with bronchiactesis
Cf
Primary ciliary dyskinesia
Youngs syndrome
Kartagener syndrome
157
What is the triad of youngs syndrome
Bronchiactesis, sinusitis and reduced fertitility
158
What is the triad of Kartagener syndrome
Bronchiactesis, sinusitis and situs inversus
159
What does youngs syndrome cause
Abnormally viscous mucus --> bronchiactesis
160
What does kartageners syndrome cause
Defect in action of cilia --> bronchiactesis
161
What are some of the obstructive causes of bronchiactesis
Foreign body, tumour, extrinsic lymph node
162
List some of the common organisms of bronchiactesis
```
H influenzae
Pseudomonas aeuroginosa
Mortadella catarrhalis
Strep pneumoniae
S aureus
Aspergillus
```
163
How is bronchiactesis managed
Treat underlying cause
Physiotherapy
Bronchodilators are supportive
Pulmonary rehab
164
What are the symptoms of bronchiactesis
Persistent cough
Copious purulent sputum
Intermittent haemoptysis
165
What are the signs o/e of patients with bronchiactesis
Finger clubbing
Coarse insp crepts
Wheeze
166
How would you treat latent TB
3 month prophylaxis of Rifampicin and isoniazid (shorter course can improve compliance)
167
How may you treat a patient with renal impairment differently from other patients if they have TB
Give triple rather than quadruple therapy, omitting either Pyrazinamide or ethambutol, as these are renally excreted
168
What is cystic fibrosis
An autosomal recessive disease leading to mutations in the cftr channel, leading to multisystemic disease characterised by thickened mucus
169
What chromosome is the cftr gene found on
17
170
What are some of the feature in neonates that may alert you that they child has cf
Failure to thrive, meconeum ileus, rectal prolapse
171
How is CF diagnosed
characteristic phenotypic features OR history of sibling CF OR +ve newborn screening test
AND +ve sweat test, genotype +ve, demonstration of abnormal nasal epithelial transport
172
What is a positive sweat test for CF
>60mmol/L Cl-
173
What is the screening for pancreatic exocrine dysfunction I. Patients with cf
Faecal elastase
174
What are the presentations for cf
1) meconeum ileus
2) intestinal malabsorption
3) recurrent chest infections
4) newborn screening
175
What is meconeum ileus
The bowel is blocked by sticky secretions, causing signs of intestinal obstruction
176
What are the symptoms and signs of meconeum ileus
Bilious vomiting, abdo distension, delay in passing meconeum
177
What signs may be seen in a patient's hands if they have cf
Finger clubbing
| Cyanosis
178
What features in the urt may a patient with cf have
Chronic sinusitis
| Nasal polyps
179
What lrt signs may a patient with cf have
```
Repeated lrti's
Bronchiactesis
Cough, wheeze,
Pneumothorax
Haemoptysis
Resp failure
Cor pulmonale
```
180
What GI symptoms may a patient with cf have
- liver disease
- portal hypertension
- gallstones
- pancreatic insufficiency, diabetes
- distal instensti obstruction syndrome
- steatorrhoea
181
What MSK symptoms may be associated with cf
Osteoporosis
Hpoa
Arthritis
Arthropathy
182
What reproductive problems may be found in patients with cf
Male infertility
183
What is the role of the cftr usually and what happens in cf
Usually transports chloride ions outside the cell and into the mucus, and water follows to thin the mucus. In cf this doesn't function normally so the mucus remains thick
184
List some complications of cf
- resp infections
- low body weight
- distal intestinal obstruction syndrome
185
How are resp infections in cf managed
Chest Physio and abx,
| Abx may be needed prophylactically to maintain health
186
How may pancreatic insufficiency be managed in cf
Pancreatic enzyme replacement therapy
High calorie intake
Extra supplements
May need NG or PEG feeding
187
How does Distal Intestinal Obstruction Syndrome in CF present usually
Rif mass
188
Why does Distal Intestinal Obstruction Syndrome occur in cf
Intestinal contents in distal ileum and proximal colon are thick and dehydrated, causing obstruction. This is due to insuffiencient pancreatic enzymes
189
Where does faecal obstruction occur in cf patients with Distal Intestinal Obstruction Syndrome
Ileoceacum (unlike constipation, which is whole bowel)
190
What does AXR show in cf patients with DIOS show
Faecal loading at junction of small and large bowel
191
What is some of the lifestyle advice that should be given to patient with cf
- no smoking
- avoid others with infections
- avoid jacuzzis
- clean and dry nebulisers thoroughly
- avoid stables etc
- annual influenza immunisation
- nacl tablets in hot weather
192
List some of the non-lifestyle management techniques for cf
- treat DM if present
- abx
- chest physio
- mucolytics
- bronchodilators
- pancreatic enzyme replacement
- fat soluble vitamin supplements
- urodeoxycholic acid
193
What are the fat soluble supplements
A/d/e/k
194
What bloods would you do on a patient with cf
```
FBC
U+E
LFT
clotting
Vit a/d/e/k
Annual glucose tolerance test
```
195
What bacteriological investigations should be carried out in a patient with cf
Cough swab
| Sputum culture
196
What may CXR show in a patient with cf when not infected
Hyperinflation
| Bronchiactesis
197
What may be the findings on abdo ultrasound in a patient with cf
Fatty liver
Cirrhosis
Chronic pancreatitis
198
What pattern would spirometry show in cf
Obstructive pattern
199
How do you manage advanced cf
- O2
- niv
- lung+/- heart transplant
- diuretics for cor pulmonale
200
What is the pleural cavity
Potential space between the pleural surfaces of the visceral and partietal pleural layers, containing fluid
201
What is the parietal pleura attached to
Chest wall
202
What are pleural plaques
Discrete fibrous areas in the pleura
203
List the types of pneumothorax
- spontaneous - either primary or secondary
- traumatic
- TENSION
- iatrogenic e.g. Post central line insertion
204
What are the risk factors for pneumothorax
- pre existing lung disease
- height
- smoking/cannabis
- diving
- trauma/chest procedure
- Marfans and other connective tissue disorders
205
How is primary pneumothorax over 2cm treated
If symptomatic, give o2 and aspirate
206
What advice would you give to a patient with pneumothorax
No flying or diving until resolved within certain period
207
List the causes of translate effusions
1) hf
2) cirrhosis
3) hypoalbuminaemia
4) PE
208
What is meigs syndrome
Triad of ascites, pleural effusion and benign ovarian tumour
209
How do you treat persistent transudate pleural effusion despite treatment
Aspiration/drainage
210
What defines a pleural effusion as being exudate or transudate
If >30g/l pleural protein, then it's an exudate
211
List the causes of exudate effusion
1) malignancy
2) infections
3) ra and other inflammatory conditions
212
What is lights criteria for pleural effusion used
If the pleural fluid protein is between 25 and 35 g/l, use lights criteria to determine if transudate or exudate
213
What 3 extra factors are used in lights criteria to indicate an exudate rather than transudate
- pleural fluid/serum protein >0.5
- pleural fluid/serum LDH >0.6
- pleural fluid LDH>2/3 of upper limit of normal
214
What is malignant mesothelioma
Tumour of mesothelioma cells, usually in Pleura and associated with asbestos exposure
215
What are the signs and symptoms of mesothelioma
```
Chest pain
Dyspnoea
Weight loss
Finger clubbing
Recurrent pleural effusion
```
216
What are the symptoms of spread of mesothelioma
Lymphadenopathy
Hepatomegaly
Bone pain/tenderness
Abdo pain
217
What tests do you perform in a patient with mesothelioma
CXR
Ct
Showing pleural thickening/effusion
Bloody pleural fluid
218
How is mesothelioma treated
Chemo
219
What are the symptoms of pleural effusion
Asymptomatic or dyspnoea, pleuritic chest pain
220
What are the signs on examination of a patient with pleural effusion
- decreased expansion
- stony dull percussion note
- diminished breath sounds
- tactile vocal Fremitus and resonance are decreased
- bronchial breath sounds above effusion
221
What is pluerodesis
Where the pleural space is artificially obliterated with drugs etc
222
What is the definition for ILD
Umbrella term for conditions that affect the lung parenchyma in a diffuse manner
223
What are the pathological features of ild
Fibrosis and remodelling of the interstitium
| Hyperplasia of type 2 pneumocytes
224
Which blood investigations should you obtain with ild patients
- ANA
- ENA
- ANCA
- RhF
- anti gbm
- IgG to serum precipitins
- ACE
225
What do positive serum precipitins indicate in ild
Exposure only
226
What is the commonest type of ild
UIP - usual interstitial pneumonia
227
What are the classical findings on examination with a patient with ild
Clubbing, reduced chest expansion, fine inspiratory crepts (Velcro) best heard basally
228
What are some of the signs and symptoms that are shared in conditions that fall under the category of ild
Dyspnoea on exertion
Progressive sob
Non productive dry paroxysmal cough
Abnormal breath sounds
229
What does tlco show in patients with ild
Reduced
230
What imaging investigations would you use for ild
CXR
| High res ct
231
In idiopathic pulmonary fibrosis, what is the pathophysiology
Idiopathic interstitial pneumonia, with inflammatory cell infiltrate and pulmonary fibrosis of unknown cause
232
What investigation may be needed for IPF diagnosis
Lung biopsy
233
What are the symptoms of Idiopathic Pulmonary Fibrosis
- dry cough
- exertional dyspnoea
- malaise
- weight loss
- Arthralgia
234
What signs may a patient with IPF have
Cyanosis
Finger clubbing
Fine end inspiratory crepts
235
What are two complications of IPF
Resp failure
| Increased chance of lung ca
236
What is the management of IPF (poor prognosis)
Pulmonary rehab
O2
Opiates
Lung transplant
237
Do you give steroids to IPF patients
No
238
Give three respiratory causes of clubbing
- ILD
- lung ca
- bronchiactesis
239
Give some examples of occupations associated with extrinsic allergic alveolitis
1) those in contact with birds
2) farmers
3) mushroom workers
4) sugar workers
5) malt workers
6) coal workers
7) industrial - asbestosis, silicosis
240
What causes extrinsic allergic alveolitis
Inhalation of organic antigen e.g. Fungal spore, to which the individual has been sensitised
241
What are the pahtophysiological changes that occur in patients with extrinsic allergic alveolitis
- alveoli are infiltrated by inflammatory cells
242
What are the pathophysiological changes that occur in chronic phase of extrinsic allergic alveolitis
Granuloma formation and obliterative bronc holistic
243
What is the histological hallmark for sarcoidosis
Non Caseating granulomas
244
What does chest X Ray in a patient with sarcoidosis show
Lots of small nodules
245
What can coal workers pneumoconiosis progress to
Massive fibrosis and eventually cor pulmonale
246
What is ca plans syndrome
Ra
Pneumoconiosis
Pulmonary rheumatic nodules
247
How is ild managed
- remove exposure
- stop smoking
- review drugs that are associated with ild
- transplant
- O2
- palliative
248
What are the three classes of ild
- known cause e.g occupational
- idiopathic
- associated with systemic disorders
249
What are some of the known causes of ild
1) occupational/environmental exposure
2) drugs
3) hypersensitivity reactions
250
What are some of the systemic disorders associated with ild
1) sarcoidosis
2) ra
3) sle, systemic sclerosis, mixed connective tissue disease, sjogrens
4) UC, renal tubular disease, autoimmune thyroid disease
251
List some drugs associated with ild
nitrofuratoin
Bleomycin
Amiodarone
Sulfasalazine
252
List the three idiopathic conditions of ild
1) IPF
2) cryptogenic organising pneumonia
3) lymphocytic interstitial pneumonia
253
What is the definition of obstructive sleep apnoea
Intermittent closure/collapse of the pharyngeal airway, causing aponeic episodes during sleep. Terminated by partial arousal
254
Describe a typical patient with obstructive sleep apnoea
Male, upper body obesity, undersized mandible
255
What is the process that causes obstructive sleep apnoea
EITHER already small pharyngeal size undergoes normal muscle relaxation during sleep and closes airway
OR there is excessive narrowing occurring with relaxation during sleep
256
Give some causes of small pharyngeal size
- fatty infiltration or pharyngeal tissues
- large tonsils
- craniofacial abnormalities
- extra submucosal tissue e.g. Myxeodema
257
Give some physiological causes of excessive narrowing of the airway during sleep (sleep apnoea)
- obesity
- neuromuscular disease
- muscles relaxants e.g. Alcohol, sedatives
- age
258
Why do patients wake up during airway collapse in obstructive sleep apnoea
Arousal deactivates the pahryngeal dilators
259
What are the signs and symptoms of obstructive sleep apnoea
```
Recurrent arousals during sleep
Poor sleep quality
Daytime somnolence
Sob
Daytime rise in BP
Morning headache
```
260
What is the name of the scale used to assess daytime sleepiness in patients with obstructve sleep apnoea
Epworth sleepiness scale
261
Give some examples of activities that are assessed when using the epworth sleepiness scale
Reading, watching TV, sitting and talking, resting etc.
262
How are the scores for sleepiness during activities rated in patients with obstructive sleep apnoea
0- would never doze
1- slight chance of dozing
2- moderate chance
3- high chance
263
What are the sleep study options for investigating patients with obstructive sleep apnoea
- overnight oximetry to pick up fluctuations
- limited sleep study
- full polysomnography
264
What does a limited sleep study investigate for patients with sleep apnoea
- overnight oximetry
- snoring
- body movement
- heart rate
- oronasal flow
265
What is full polysomnography
Limited sleep study + eeg and emg
266
Give some of the lifestyle changes a patient with obstructive sleep apnoea can make
- weight loss
- sleep in decubitus position
- avoid evening alcohol
267
How do you treat significant obstructive sleep apnoea
CPAP +/- niv prior to CPAP if acidotic
268
How does CPAP help with obstructive sleep apnoea
Opens collapsed alveoli, prevents airway collapse and improves v/q matching
269
What is fio2
Fraction of inspired oxygen
270
What is the difference between CPAP and BIPAP
CPAP provides constant positive pressure during inspiration and expiration
BIPAP applies two pressures - IPAP during inspiration and EPAP during expiration
271
List the different histological types of lung cancer
- squamous cell
- Adenocarcinoma
- small (oat) cell
- large cell
272
What sign may you see in the eyes of a patient with lung cancer
Horner syndrome
273
Patients with lung cancer may have svc obstruction, what are the characteristic signs in a patient with svc obstruction
Oedema of the face and arms, swollen chest veins
274
List some areas of the body where lung cancer may spread
```
Pleura
Liver
Adrenals
Brain
Bone
```
275
List risk factors for lung cancer
- large number of years smoking
- airflow obstruction
- increasing age
- family history of lung cancer
- exposure to carcinogens e.g. Asbestos
276
What is 0 on the WHO scale for performance status
Normal - fully active without restriction
277
What is 1 on the WHO scale of performance status
Restricted in physically strenuous activity but ambulatory and able to carry out light work e.g. Housework
278
What is stage 2 on the WHO performance scale
Ambulatory and capable of all self care but unable to carry out work activities
279
What is grade 3 on the WHO scale for performance status
Capable of limited self care, confined to bed or chair more than half of waking hours
280
What is grade 4 on the WHO performance scale
Completely disabled, cannot self care and totally co fed to bed/chair
281
What is stage 5 on the WHO performance status
Dead
282
How do you investigate possible lung cancer spread to the lymph nodes
Aspiration
283
What bloods would you do to investigate lung cancer
FBC, u+e, calcium, LFTs, INR
284
What signs do you look for on CXR
- mass
- lung collapse
- pleural effusion
- consolidation
- hilar enlargement
285
Where on a CXR would you look for bone secondaries
Ribs
286
What would you use a ct scan for in patients with lung cancer
Staging, Tnm
287
What cytology would you perform on a patient with lung cancer
Sputum and pleural fluid
288
What are some of the local nerve complications of lung cancer
- recurrent laryngeal nerve palsy
- phrenic nerve palsy
- Horner's syndrome
289
What type of tumour can cause Horner's syndrome
Pancoasts tumour
290
What are some of the heart-related complications of lung cancer
Pericarditis
| AF
291
If lung cancer has spread to the bone, what findings may there be
Raised calcium
| Anaemia
292
How do you treat stage I/II non small cell lung cancer
Curative surgery,
| or curative radiotherapy if Resp reserve is poor
293
How do you treat stage III non small cell lung cancer
Surgery and adjuvant chemo if patient is fit
294
How do you treat patients with stage III/IV non small cell lung cancer
Chemotherapy
295
How is small cell lung cancer treated
As it has a rapid growth rate, it is almost always too extensive for surgery at the time of diagnosis. Mainstay treatment is chemo, palliative therapy.
296
List some of the supportive treatments given to lung cancer patients
```
Analgesia
Steroids
Antiemetics
Antitussive
Bronchodilator
```
297
What is the definition of type 1 respiratory failure
Hypoxia (pao2 less than 8kpa), with normal or low paco2. Caused primarily by ventilation perfusion mismatch
298
List some conditions that can lead to type 1 respiratory failure
1) pneumonia
2) pulmonary oedema
3) ARDS
4) PE
5) fibrosing alveolitis
6) emphysema
7) asthma
299
Define type 2 respiratory failure
Hypoxia (pao2 less than 8kpa) with hypercapnia (paco2 >6kpa), caused by alveolar hypoventilation +/- vq mismatch
300
What are some pulmonary diseases that can lead to type 2 Resp failure
```
Asthma
COPD
Obstructive sleep aponea
Pneumonia
Pulmonary fibrosis
```
301
List some of the causes of decreased respiratory drive that can cause type 2 respiratory failure
Sedative drugs
CNS tumour
Trauma
302
List some of the neuromuscular diseases that can cause type 2 respiratory failure
```
Cervical cord lesion
Diaphragmatic paralysis
Poliomyelitis
Myasthenia gravis
Guillain barre syndrome
```
303
Give some thoracic wall diseases that can cause type 2 respiratory failure
Kyphosis
Scoliosis
Flail chest
304
What is guillain barre syndrome
Rapid onset muscle weakness due to damage to peripheral nervous system
305
In respiratory failure, list some of the signs and symptoms associated with the hypoxic effects of the condition
- dyspnoea
- restlessness
- agitation
- confusion
- central cyanosis
306
In respiratory failure, what are some of the sequelae to long term hypoxia
- polycythaemia
- pulmonary hypotension
- cor pulmonale
307
In respiratory failure, list some of the features of hypercapnia
- headache
- peripheral vasodilatation
- tachycardia
- bounding pulse
- tremor/flap
- papilloedema
- confusion, drowsiness
- coma
308
Which investigations would you perform on a patient with respiratory failure
```
FBC, u+e, CRP
ABG
CXR
Sputum and blood cultures if febrile
Spirometry
```
309
How do you treat type 1 respiratory failure
Venturi mask delivering 35-60% oxygen via face mask
| Assisted ventilation if pao2
310
How do you manage type 2 respiratory failure
Treat underlying cause
Controlled O2 therapy starting at 24% via Venturi mask
Recheck abg after 20mins
If paco2 is steady or lower, then increase O2 to 28%
311
What measures are taken to control type 2 respiratory failure if giving lower flows of oxygen via a Venturi mask isnt reaching the desired effects
Consider respiratory stimulant or assisted ventilation if still hypoxic and paco2 has risen over 1.5 kpa
If all else fails, intubation and ventilation
312
When would you consider doing an ABG
1) unexpected deterioration in the ill patient
2) acute exacerbation of chronic chest infection
3) impaired consciousness
4) impaired respiratory effort
5) signs of co2 retention
6) cyanosis, confusion, visual hallucinations
7) validation of pulse oximetry
313
What is the management of COPD patients with breathlessness and exercise limitation
Short acting beta agonists
| Short acting muscarinic antagonists
314
What is the treatment for COPD patients with occasional exacerbations or persistent breathlessness
If fev >50 then LABA + LAMA instead of SAMA
| If fev
315
How do you treat COPD patients with persistent exacerbations of COPD and breathlessness
LABA + ICS if fev1 >50
| LAMA + LABA + ICS if fev1
316
What is Ltot
Long term oxygen therapy - where continuous home oxygen therapy is given to patients with chronic hypoxaemia of
317
List some of the indications for Ltot
```
COPD
ILD
CF
Bronchiactesis
Chronic HF
```
318
If you're not sure as to whether a patient has pneumonia or TB, how do you go on to treat them
Treat as if pneumonia as per curb65 while investigation for pneumonia
319
TB cultures can take weeks to come back, so how do you treat a patient with highly suspected TB in the meanwhile
Start anti TB therapy and send off sputum cultures at the same time (looking for acid fast bacilli etc)
320
List absolute contraindications for thrombolysis
- haemorrhagic/ischaemic stroke
321
How does aminophylline work
Inhibits phosphodiesterase, increasing camp levels and causing bronchodilation. Inhibits TNF alpha and leukotriene synthesis
322
Levels of which intracellular molecule do b2 agonists increase
Camp
323
List tow drug classes that can worsen asthma
Beta blockers, NSAIDs
324
What is tryptase a marker of, hence should be measured in which emergency lung condition
Mast cell activation - measure serum tryptase in anaphylaxis
325
What is LTOT used for
Preventing organ damage caused by prolonged hypoxia, for survival benefit
326
How many hours a day is LTOT used for
Most of the day - at least 16 hours or more
327
What are the criteria for LTOT treatment
Po2 consistently below 7.3 kpa or below 8kpa with cor pulmonale
Must be non smokers and not retain high levels of co2
328
Describe the cycle that COPD patients go through, that Pulmonary Rehabilitation tires to break
Feel breathless -> avoid activities that make you breathless -> do less -> muscles weaken -> get more breathless -> feel depressed -> avoid activities that make you feel breathless
329
How many weeks does the MDT pulmonary rehabilitation programme last
6-12 weeks
330
What does the pulmonary rehabilitation programme involve
Supervised exercise, unsupervised home exercise, nutritional advice, disease education
331
What are the gold criteria for COPD severity classification
Mild - fev higher or equal to 80%
Mod - fev 50-80%
Sev - fev
332
List the bacteria most commonly responsible for atypical pneumonia
Mycoplasma pneumoniae,
Chlamydia pneumoniae
Legionella pneumophilia
333
List the viruses most common in community acquired and atypical pneumonia
Influenza virus, RSV, adenovirus
334
What are the four main antibiotics used to treat pneumonia empirically
1) doxycycline
2) clarithromycin or azithromycin
3) levofloxacin
335
What are some of the vaccines which may be given to certain individuals to prevent community acquired pneumonia
Pneumococcal vaccine, flu vaccine
336
If a pneumonia patient has a high curb 65 score, which extra tests should you do on them
Atypical pneumonia screen, serology and urine legionella test
337
What is sarcoidosis
Multisystemic granulomatous disorder of unknown cause, usually affecting afrocarribbeans and Northern Europeans
338
How does acute sarcoidosis tend to present
Erythema nodosum +/- polyarthralgia
339
How does pulmonary disease sarcoidosis present on CXR
Bilateral hilar lymphadenopathy +/- pulmonary infiltrates or fibrosis
340
What does tissue biopsy in sarcoidosis show
Non Caseating granuloma
341
How is acute sarcoidosis managed
As it'll usually recover spontaneously, NSAIDs and best rest are recommended
342
When are steroids indicated in sarcoidosis
If it is causing parenchymal lung disease or affecting other systems e,g, causing uveitis or hypercalcaemia
343
What is allergic bronchopulmonary aspergillosis
Hypersensitivity reactions to aspergillus fumigatus causing brocnhoconstriction when early and bronchiactesis if chronic
344
How is allergic boncropulmonary aspergillosis treated
Prednisolone
345
What is an aspergilloma
A fungus collection inside a cavity
346
How is aspergilloma treated
Surgical excision
347
What is cor pulmonale
Right heart failure due to chronic pulmonary arterial hypertension
348
How do you manage cor pulmonale
- treat underlying cause e.g. COPD
- treat resp failure
- assess for LTOT
- treat hf with diuretics etc
- consider venesection if haemorrhoids is >55%
349
What is he a-a gradient in the lungs
Alveolar:arterial gradient
| This is the measure of difference between alveolar O2 conc and arterial O2 conc
350
What does A-a gradient determine
Is the problem in oxygenation is intra- or extra pulmonary
351
What is the healthy A-a gradient in young people
Less than 2 kpa difference
352
What is the healthy A-a gradient in older people
Less than 4kpa gradient
353
What does an A-a gradient of >4 kpa indicate
Lung pathology is present
354
How is the aveolar partial pressure of oxygen measured, in order to then work out the A-a gradient
Alveolar partial pressure of oxygen = (room air oxygen partial pressure (usually 20kpa)) - (paco2 in blood/0.8)
Then this PA02 value - pao2 in blood gives you the A-a gradient
355
What is the typical apprance on blood film of a patient infected with CMV
Owls eye cells
356
What is chlorpheniramine
Antihistamine
357
What CXR signs may be seen in a patient with PE
Small pleural effusion,
| Wedge shaped infarct (much later)
358
What are the nice guidelines for PE and ctpa management
If wells score over 4, PE is likely so assess for ctpa.
If ctpa/(v/q) unavailable/unsuitable then immediately thrombolyse
Ctpa diagnoses PE, which can then be treated appropriately according to guidelines. If ctpa doesn't diagnose PE then assess for DVT likeliness
If avail ale
359
How long do patients who have had a PE have to wait before they can fly
At least one week following normalisation of CXR before they're allowed to fly
360
What is the most common cause of monophonic wheeze
Bronchial carcinoma
361
When a patient who has had an asthma exacerbation is discharged, what steps are taken
- asthma nurse review - inhaler technique, adherence
- asthma action plan
- pefr over 75%
- stop NEBs 1 day prior to discharge
- provide pefr
- at least 5 days of oral pred
- gp follow up in 2 working days
- Resp clinic follow up in 4 weeks
- consider psychosocial
362
Describe the pulmonary rehabilitation programme
Aims to break the cycle of breathlessness and I activity patients with COPD undergo, with a 6-12 week MDT approach, where a patient is encouraged to do supervised exercise, home exercises and nutritional and disease education is given
363
What does giving Ltot avoid in patients
Hypoxaemic damage to kidneys or heart
364
Which condition can give coarse end inspiratory crepts on auscultation
Bronchiactesis
365
What is kussmauls breathing
Deep and laboured breathe , often associated with ps every metabolic acidosis
366
List the different symptoms related to para neoplastic syndrome in lung tumours
Clubbing, hypercalcaemia, anaemia, SIADH, cushings, thromboembolic disease
367
How do you treat mild community acquired pneumonia
Amoxicillin or Doxycycline or clarithromycin
368
How do you treat moderate community acquired pneumonia
Amoxicillin and either clarithromycin or doxycycline
369
How do you treat severe community acquired pneumonia
Coamoxiclav or cefuroxime + clarithromycin.
Add flucloxacillin if staph aureus suspected
Or add vancomycin if mrsa suspected
370
What antibiotic do you consider adding in patients with pneumonia in whom you suspect legionella infection
Rifampicin
371
Which antibiotic do you add in patients with pneumonia in whom you suspect chlamydia as a cause
Tetracycline
372
Which antibiotic do you consider adding in a patient with pneumonia in whom you suspect pneumocystis jirovecii
Cotrimoxazole
373
How do you treat hospital acquired pneumonia
Aminoglycoside + antipseudomonal penicillin/cephalosporin
