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Resp Flashcards

1
Q

Name four features of moderate acute asthma

A

PEFR 50-75% best or predicted
Speech normal
RR < 25 / min
Pulse < 110 bpm

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2
Q

Name four features of severe acute asthma

A

PEFR 33 - 50% best or predicted
Can’t complete sentences
RR > 25/min
Pulse > 110 bpm

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3
Q

Name five features of life threatening acute asthma

A 
PEFR < 33% best or predicted
Oxygen sats < 92%
Silent chest, cyanosis or feeble respiratory effort
Bradycardia, dysrhythmia or hypotension
Exhaustion, confusion or coma
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4
Q

Normal CO2 in acute asthma attack indicates what?

A

Exhaustion

Classify as life threatening

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5
Q

What are the three most common causes of acute exacerbation of COPD?

A

Haemophilus influenzae (most common cause)

Streptococcus pneumoniae

Moraxella catarrhalis

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6
Q

What is management of acute exacerbation of COPD?

A
  1. Increase frequency of bronchodilator
  2. 7-14 days of 30mg Prednisolone
  3. Antibiotics if signs of pneumonia (Amoxicillin or Tetracycline or Clarithromycin)
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7
Q

What are the pathogenesis and features of acute respiratory distress syndrome (ARDS)?

A

Increased permeability of alveolar capillaries leading to fluid accumulation in the alveoli.

Criteria:

  1. Acute onset (<1 weeks of known risk factor)
  2. Pulmonary oedema (bilateral infiltrates on CXR)
  3. Non-cardiogenic
  4. p)2/FiO2 <40kPa

Treatment: Aim for FiO2 below 40%. Add PEEP might help. Maintain low tidal volume ventilation.

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8
Q

What are the features and investigation findings of allergic bronchopulmonary aspergillosis?

A

Due to allergy to aspergillus spores. History of bronchiectasis and eosinophilia

Features
bronchoconstriction: wheeze, cough, dyspnoea. ?asthmatic
bronchiectasis (proximal)

Investigations
eosinophilia
flitting CXR changes
positive radioallergosorbent (RAST) test to Aspergillus
positive IgG precipitins (not as positive as in aspergilloma)
raised IgE

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9
Q

Management of allergic bronchopulmonary aspergillosis?

A

Steroids

Itraconazole as second line

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10
Q

Features of alpha-1 antitrypsin deficiency?

A

Panacinar emphysema

Liver cirrhosis and HCC

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11
Q

Management of alpha-1 antitrypsin deficiency?

A

no smoking
supportive: bronchodilators, physiotherapy
intravenous alpha1-antitrypsin protein concentrates
surgery: lung volume reduction surgery, lung transplantation

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12
Q

Management of HACE and HAPE (altitude)?

A

Management of HACE
descent
dexamethasone

Management of HAPE
descent
nifedipine, dexamethasone, acetazolamide, phosphodiesterase type V inhibitors*
oxygen if available

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13
Q

Latent period of asbestos exposure for:
Pleural plaques
Asbestosis

A

Pleural plaques 20-40 years

Asbestosis 15-30 years

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14
Q

What bacteria are often implicated in aspiration?

A 
The bacteria often implicated in aspiration pneumonia are aerobic, and often include:
Streptococcus pneumoniae
Staphylococcus aureus
Haemophilus influenzae
Pseudomonas aeruginosa

Other aerobic, and anaerobic, organisms can also result in aspiration pneumonia, but are less common.

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15
Q

Management of acute asthma attack?

A
  1. Nebuliser Salbutamol and Ipratropium Bromide
  2. Magnesium Sulphate (1.2-2g IV over 20 mins)
  3. If no response, consider IV salbutamol
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16
Q

Diagnosis of asthma?

A

Age > 17 (all below)

  • Symptoms better/worse away from work. If so, refer for occupational asthma
  • Spirometry with bronchodilator reversibility test
  • FeNO test

Age 5-16

  • Spirometry with bronchodilator reversibility test
  • FeNO test if normal spirometry or obstructive spirometry with negative BDR test

NOTE:
FeNO >40 positive
Spiro FEV1/FVC ratio <70% is obstructive
Reversibility Improvement FEV1 12% or more and increase in volume of 200ml or more

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17
Q

What seven things are associated with occupational asthma? How can you investigate?

A 
isocyanates - the most common cause. Example occupations include spray painting and foam moulding using adhesives
platinum salts
soldering flux resin
glutaraldehyde
flour
epoxy resins
proteolytic enzymes

Serial measurements of peak expiratory flow are recommended at work and away from work.

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18
Q

What is Berylliosis?

Name two features and two occupational risk factors

A

Occupational lung disease caused by inhalation of fumes of molten beryllium.

Features: Lung fibtosis and bilateral hilar lymphadenopathy

Occupational risk factors:
Aerospace industry
Manufacture of fluorescent light bulbs/golf club heads

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19
Q

Name four contraindications to chest drain

A

INR >1.3
Platelet Count <75
Pulmonary Bullae
Pleural Adhesions

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20
Q

Name five complications of chest drain insertion

A 
Failure of insertion
Bleeding
Infection
Penetration of lung
Re-expansion pulmonary oedema

Should not exceed 1L fluid over 6 hours or may cause re-expansion pulmonary oedema

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21
Q

When should chest drain be removed for fluid draining or pneumothorax?

A

Fluid: When no output for > 24 hours and resolution of collection on imaging

Pneumothorax: When no longer bubbling spontaneously/when coughs and imaging shows resolution

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22
Q

Name 7 causes of bronchiectasis

A

post-infective: tuberculosis, measles, pertussis, pneumonia
cystic fibrosis
bronchial obstruction e.g. lung cancer/foreign body
immune deficiency: selective IgA, hypogammaglobulinaemia
allergic bronchopulmonary aspergillosis (ABPA)
ciliary dyskinetic syndromes: Kartagener’s syndrome, Young’s syndrome
yellow nail syndrome

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23
Q

Most common organisms isolated from bronchiectasis patients?

A

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

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24
Q

Management of bronchiectasis?

A 
Physical training
Postural drainage
Antibiotics for exacerbations
Long term rotating antibiotics
Bronchodilators for some
Immunisations
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25
Q

What is bronchiolitis? Name five features

A

Acute bronchiolar inflammation
75-80% caused by RSV

coryzal symptoms (including mild fever) precede:
dry cough
increasing breathlessness
wheezing, fine inspiratory crackles (not always present)
feeding difficulties associated with increasing dyspnoea are often the reason for hospital admission

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26
Q

Differentials for cavitating lung lesion on CXR? (name 7)

A

abscess (Staph aureus, Klebsiella and Pseudomonas)
squamous cell lung cancer
tuberculosis
Wegener’s granulomatosis
pulmonary embolism
rheumatoid arthritis
aspergillosis, histoplasmosis, coccidioidomycosis

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27
Q

Differentials for coin lesions on CXR? Name 4

A

malignant tumour: lung cancer or metastases
benign tumour: hamartoma
infection: pneumonia, abscess, TB, hydatid cyst
AV malformation

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28
Q

Causes of lobar collapse on X-Ray? Name 3

A

lung cancer (the most common cause in older adults)
asthma (due to mucous plugging)
foreign body

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29
Q

Name five cancers that commonly metastases to lung?

Which causes cannonball metastases?

A 
breast cancer
colorectal cancer
renal cell cancer
bladder cancer
prostate cancer

Cannonball metastases commonly renal

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30
Q

Causes of lung white out as by trachea deviation (pulled towards, central, pushed away)

A

Pulled Toward:
Pneumonectomy
Complete lung collapse
Pulmonary Hypoplasia

Central:
Consolidation
Pulmonary oedema
Mesothelioma

Pushed Away:
Pleural effusion
Diaphragmatic hernia
Large thoracic mass

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31
Q

Name five causes of COPD

A

Smoking!

Alpha-1 antitrypsin deficiency

Other causes
cadmium (used in smelting)
coal
cotton
cement
grain
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32
Q

How is COPD diagnosed and then categorised?

A

Post-bronchodilator FEV1/FVC <0.7

Mild >80% FEV1
Moderate 50-79%
Severe 30-49%
Very Severe <30%

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33
Q

Investigations for COPD?

A

Post bronchodilator spirometry
CXR
FBC
BMI

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34
Q

Who qualifies for LTOT in COPD? Who to assess and how?

What is the minimum time it must be used per day?

A

Assess if FEV1<30%, cyanosis, polycythaemia, perioheral oedema, raised JVP, O2 <92%

Assess with ABG 2x at least 3 weeks apart

Offer if pO2 <7.3kPa
Offer if pO2 7.3-8kPa and 
secondary polycythaemia
peripheral oedema
pulmonary HTN

Do not offer if continue to smoke

15 hours per day (including night time)

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35
Q

What are the 7 steps of asthma management?

A
  1. SABA
  2. SABA + ICS (low)
  3. SABA + ICS (low) + LRTA
  4. Continue LRTA if effective. SABA + ICS (low) + LABA
  5. SABA +/- LRTA + MART (low)
  6. SABA +/- LRTA + MART (medium)
  7. SABA +/- LRTA + high dose ICS + LABA

Steroid
Low dose <400
Moderate 400-800
High >800

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36
Q

What are the steps for COPD stable management?

A 
General:
Smoking cessation
Annual influenza vaccination
One off pneumococcal vaccination
Pulmonary rehab if functionally disabled

Medical:
1. SABA or SAMA

Not steroid responsive:
2. LABA + LAMA (+ SABA)

If steroid responsive (previous asthma/atopy, high eosinophils, substantial variation in FEV1 (>400ml), substantial diurnal variation in peak flow (at least 20%))

  1. LABA + ICS (+SABA/SAMA)
  2. LAMA + LABA + ICS + SABA

Oral theophylline - only after trials of short and long-acting bronchodilators. Reduce if macrolide co-prescribed

Prophylactic antibiotics:
Azithromycin (if optimal medical therapy and continue to have exacerbation)

Mucolytics: If chronic productive cough

Cor Pulmonale:
Loop diuretic +/- LTOT

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37
Q

Management of cystic fibrosis?

A
  1. BD Chest Physio and postural drainage
  2. High calorie diet
  3. Avoid contact with other CF
  4. Vitamin supplementation
  5. Pancreatic enzyme supplements
  6. Lumacaftor/Ivacaftor (Orkambi) - if homozygous for dF508 mutation
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38
Q

Features of eGPA

A

Churg Strauss
Small-medium vessel vasculitis

asthma
blood eosinophilia (e.g. > 10%)
paranasal sinusitis
mononeuritis multiplex
pANCA positive in 60%

eGPA associated with Leukotriene Receptor antagonists

Three Phases:
1. Atopy (asthma, rhinitis, sinusitis), 2. Eosinophilia >10% (pulmonary infiltrates), 3. Necrotizing multi-system small vessel vasculitis (rash, peripheral neuropathy, renal involvement - RPGN)

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39
Q

Features of extrinsic allergic alveolitis (aka Hypersensitivity Pneumonitis)

A

immune-complex mediated tissue damage (type III hypersensitivity) although delayed hypersensitivity (type IV) is also thought to play a role in EAA, especially in the chronic phase.

Bird fanciers lung (avian protein)
Farmers lung (spores of Saccharopolyspora rectivirgula)
Malt workers lung (aspergillus clavatus)
Mushroom workers lung (terhmophilic actinomycetes)

Presentation
acute: occur 4-8 hrs after exposure, SOB, dry cough, fever
chronic

Patients well between episodes

Investigation
chest x-ray: upper/mid-zone fibrosis
bronchoalveolar lavage: lymphocytosis - eosinophilia
blood: NO eosinophilia

Acute neutrophilic inflammation followed by lymphocytic infiltration and colllagen deposition

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40
Q

Features of GPA?

A

Wegner’s Granulomatosis

Features
upper respiratory tract: epistaxis, sinusitis, nasal crusting
lower respiratory tract: dyspnoea, haemoptysis, cavitating lung lesions
rapidly progressive glomerulonephritis (‘pauci-immune’, 80% of patients)
saddle-shape nose deformity
also: vasculitic rash, eye involvement (e.g. proptosis), cranial nerve lesions

Investigations
cANCA positive in > 90%, pANCA positive in 25%
chest x-ray: wide variety of presentations, including cavitating lesions
renal biopsy: epithelial crescents in Bowman’s capsule

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41
Q

Management of GPA

A

steroids (methylprednisolone)
cyclophosphamide (90% response)
plasma exchange
median survival = 8-9 years

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42
Q

Features, investigation and management of idiopathic pulmonary fibrosis? What is life expectancy?

A 
Features
progressive exertional dyspnoea
bibasal fine end-inspiratory crepitations on auscultation
dry cough
clubbing
Diagnosis:
Spirometry - restrictive
TCLO reduced
Bilateral interstitial shadowing (ground glass --> honeycombing)
ANA positive 30%
RF positive 10%
CXR - reticulonodular shadowing

Management:
Pulmonary rehabilitation
Pirfenidone
Supplemental O2

Life expectancy 4 years

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43
Q

Features of klebsiella pneumonia? Four things

A

more common in alcoholic and diabetics
may occur following aspiration
‘red-currant jelly’ sputum
often affects upper lobe

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44
Q

What is Lofgren’s Syndrome? What four features should I be aware of?

A 
acute form sarcoidosis 
bilateral hilar lymphadenopathy (BHL)
erythema nodosum, 
fever 
polyarthralgia.

More common in scandanavians
Good prognisis

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45
Q

Paraneoplastic syndromes from small cell lung cancer (3)

A

ADH

ACTH

Lambert-Eaton Syndrome

N.B. Usually centally located

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46
Q

Paraneoplastic syndromes from squamous cell lung cancer (3)

A

PTH-rp

Hypertrophic pulmonary osteoarthropathy

Ectopic TSH

NOTE: Also clubbing present

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47
Q

Paraneoplastic syndromes from adenocarcinoma lung cancer (1)

A

Hypertrophic pulmonary osteoarhropathy

NOTE: Gynaecomastia also present

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48
Q

For which lung cancer is PET scanning considered?

A

Non-small cell lung cancer

To establish eligibility for curative treatment

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49
Q

What is the management of Non-small cell lung cancer?

A
  1. Lobectomy if Stage 1, 2. Curative intent
    NOTE: Perform mediastinoscopy prior to surgery for ?mediastinal lymph nodes
  2. Radiotherapy if Stage 1, 2, 3. Curative intent
  3. Chemotherapy if Stage 3, 4. Improve survival and QoL

N.B.
Adjuvant chemotherapy if complete resection

Adjuvant radiotherapy if incomplete resection

Consider chemoradiotherapy for all stage 1-3 if not suitable for surgery

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50
Q

What is the management of small cell lung cancer?

A
  1. Surgery ONLY if very early Stage 1 or 2

Limited Stage T1-4, N0-3, M0
Cisplatin combination chemotherapy
Adjuvant radiotherapy only if good response to chemo

Extensive Stage M1
Platinum based chemotherapy
Adjuvant radiotherapy only if good response to chemo at both primary and metastasis

Relapse after initial treatment
Further Chemo
Palliative radiotherapy

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51
Q

Contraindications for surgery in non-small cell lung cancer?

A

assess general health
stage IIIb or IV (i.e. metastases present)
FEV1 < 1.5 litres is considered a general cut-off point*
malignant pleural effusion
tumour near hilum
vocal cord paralysis
SVC obstruction

  • if FEV1 < 1.5 for lobectomy or < 2.0 for pneumonectomy then some authorities advocate further lung function tests as operations may still go ahead based on the results
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52
Q

Causes of upper zone lung fibrosis (7)

A

hypersensitivity pneumonitis (also known as extrinsic allergic alveolitis)
coal worker’s pneumoconiosis/progressive massive fibrosis
silicosis
sarcoidosis
ankylosing spondylitis (rare)
histiocytosis
tuberculosis

CHARTS
C - Coal worker's pneumoconiosis
H - Histiocytosis/ hypersensitivity pneumonitis
A - Ankylosing spondylitis
R - Radiation
T - Tuberculosis
S - Silicosis/sarcoidosis
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53
Q

Causes of lower zone lung fibrosis (4)

A

idiopathic pulmonary fibrosis
most connective tissue disorders (except ankylosing spondylitis) e.g. SLE
drug-induced: amiodarone, bleomycin, methotrexate
asbestosis

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54
Q

How to investigate suspected mesothelioma?

A

CXR
Pleural CT
If effusion, MC&S, biochemistry, cytology
Local anaesthetic thorascopy if negative effusion sample
Pleural nodularity on CT –> Image guidd pleural biopsy

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55
Q

Features of microscopic polyangitis?

A 
Renal impairment
Fever
Palpable Purpura
Cough/ SOB/Haemoptysis
Diffuse alveolar haemorrhage
Mononeuritis Multiplex
Lethargy/Myalgia/Weight Loss

NOTE: Spares the URT

pANCA (against MPO) - positive in 50-75%
cANCA (against PR3) - positive in 40%

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56
Q

Where is MERS from and what is it caused by?

A

Middle East respiratory syndrome (MERS) is caused by the betacoronavirus MERS-CoV.

Arabian Peninsula

2-14 day incubation period

Lymphocytopenia
Thrombocytopenia
Derranged LFTs

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57
Q

Indications for non-invasive ventilation? (4)

A

COPD respiratory acidosis pH 7.25-35

Type 2 resp failure due to chest wall deformity, neuromuscular disease or OSAS

Cardiogenic pulmonary oedema unresponsive to CPAP

Weaning from tracheal intubation

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58
Q

Three main disease types for non-tuberculous mycobacteria?

A

Hypersensitivity like disease
Cavitating disease
Bronchiectasis with or without nodules

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59
Q

Features and management of obesity hypoventilation syndrome?

A 
Morning headaches
Daytime sleepiness
Reduced exercise tolerance
Poor concentration
Day time hypercapnia

Management:
Weight loss
Assisted ventilation
Supplemental oxygen

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60
Q

Assessment and diagnostic tests for OSAS

A

Epworth Sleepiness Scale
Multiple Sleep Latency Test (how long to fall asleep in dark room)

Diagnostic Test:
Sleep studies (polysomnography)

NOTE: Over long periods of time: CO2 compensated by renal retention of bicarbonate. Become CO2 retainers.

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61
Q

Management of OSAS?

A

Weight loss
CPAP
Intra-oral device if CPAP not tolerated OR mild OSAS with no daytime sleepiness

Should inform DVLA if excessive day time sleepiness

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62
Q

Causes of pleural transudate? What is the protein level?

A

(< 30g/L protein)
heart failure (most common transudate cause)
hypoalbuminaemia (liver disease, nephrotic syndrome, malabsorption)
hypothyroidism
Meigs’ syndrome

63
Q

Causes of pleural exudate? What is the protein level?

A 
(> 30g/L protein)
infection: pneumonia (most common exudate cause), TB, subphrenic abscess
connective tissue disease: RA, SLE
neoplasia: lung cancer, mesothelioma, metastases
pancreatitis
pulmonary embolism
Dressler's syndrome
yellow nail syndrome
64
Q

What is lights criteria and when is it used?

A

To distinguish between transudate and exudate if protein level 5-35g

Exudate if:
pleural fluid protein divided by serum protein >0.5

pleural fluid LDH divided by serum LDH >0.6

pleural fluid LDH more than two-thirds the upper limits of normal serum LDH

65
Q

What does low glucose in pleural fluid suggest?

A

rheumatoid arthritis, tuberculosis

66
Q

What does raised amylase in pleural fluid suggest?

A

pancreatitis, oesophageal perforation

67
Q

What does heavy blood staining in pleural fluid suggest?

A

mesothelioma, pulmonary embolism, tuberculosis

68
Q

When would you suspect a pleural infection with a pleural effusion that requires chest drain insertion?

A

Fluid purulent or turbid

Clear fluid but pH <7.2 with suspected pleural infection

69
Q

Features of mycoplasma pneumoniae?

A

Dry cough
Atypical CXR
AIHA
Erythema Multifrome

70
Q

Features of legionella pneumophilia?

A

Hyponatraemia
Lymphopenia
Classically secondary to infected air conditioning

71
Q

Components of CURB 65 score?

A 
Confusion (AMTS 8 or less)
Urea > 7
RR > 30
BP < 90 sys, <60 dys
Age 65+
72
Q

What to do with CURB 65 score of:
0
1
2

A

0 - manage community
1 - if sats >92%, manage in community and CXR. If bilateral/multilobar shadow, admit
2+ - admit

73
Q

What are the risks associated with CURB 65 score?

A

0 -1 - Low risk <3% mortality
2+ - intermediate risk 3-15% mortality
3+ - high risk 15% mortality

74
Q

When should you not discharge following a pneumonia?

A

If two or more in the past 24 hours

Temp 37.5 +
RR 24 +
HR 100+
BP <90
O2<90
Abnormal mental state
Can't eat
75
Q

Management of pneumothorax in Primary cases

A

<2cm and no SOB - consider discharge

Otherwise aspirate

If fails (remains >2cm or SOB), chest drain

76
Q

Management of secondary pneumothorax?

A

If 50+ and >2cm and/or patient SOB - chest drain

Otherwise, if 1-2cm - aspirate. If fails (remains >1cm) - chest drain

If <1cm, give O2 and admit for 24 hours

(NOTE: 2cm = 50% pneumothorax)

77
Q

Causes of pulmonary eosinophilia? (8)

A 
Churg-Strauss syndrome
allergic bronchopulmonary aspergillosis (ABPA)
Loffler's syndrome
eosinophilic pneumonia
hypereosinophilic syndrome
tropical pulmonary eosinophilia
drugs: nitrofurantoin, sulphonamides, ampicillin, NSAIDs, minocycline
less common: Wegener's granulomatosis
78
Q

Cause of tropical pulmonary eosinophilia?

A

Wuchereria bancrofti/Brugia malayi infection

History of paroxysmal nocturnal cough
Wheeze
SOB

Diagnosis aided by clinical response to Diethylcarbamazine

Spread by mosquito
Mature in the lymphatics
Can cause elephantiasis

79
Q

What is Loffler’s syndrome? Can you name some features?

A

Transient CXR shadow
Blood eosinophilia

Ascaris lumbricoides/strongyloides/ancylostoma causing an alveolar reaction

Fever, cough, night sweats

Self limiting (2 week)

Can treat with Mebendazole for 3 days

80
Q

Can you classify the five types of pulmonary hypertension?

A

Pulmonary arterial hypertension - idiopathic
(familial, collagen disorder, cogenital heart disease with systemic shunts, drugs and toxins, persistent pulmonary HTN of newborn)

Pulmonary hypertension with left heart disease
(LV systolic and diastolic dysfunction, mitral stenosis, mitral regurgitation)

Pulmonary HTN secondary to lung disease/hypoxia
(COPD, ILD, OSAS, altitude)

Pulmonary HTN due to thromboembolic disease

Miscellaneous conditions
(lymphangiomatosis)

81
Q

What are the Centor criteria?

A

presence of tonsillar exudate
tender anterior cervical lymphadenopathy or lymphadenitis
history of fever
absence of cough

82
Q

What are the respiratory manifestations of rheumatoid arthritis?

A

pulmonary fibrosis

pleural effusion

pulmonary nodules

bronchiolitis obliterans

complications of drug therapy e.g. methotrexate pneumonitis

pleurisy

Caplan’s syndrome - massive fibrotic nodules with occupational coal dust exposure

infection (possibly atypical) secondary to immunosuppression

83
Q

Name three syndromes associated with Sarcoidosis

A

Lofgren’s syndrome - BHL, erythema nodosum, fever, polyarthralgia (good prognosis)

Mikulicz Syndrome - elnargement of parotid and lacrimal glands (sarcoid, TB or lymphoma)

Heerfordt’s Syndrome (uveoparotid fever) - parotid enlargement, fever, uveitis

84
Q

Features associated with sarcoidosis?

A 
Acute:
Erythema nodosum
BHL
Swinging fever
Polyarthralgia
Insidious:
SOB
Non-productive cough
Malaise
Weight Loss

Skin:
Lupus pernio

Hypercalcaemia

85
Q

Features of sarcoidosis and staging on chest x-ray?

A

stage 0 = normal
stage 1 = bilateral hilar lymphadenopathy (BHL)
stage 2 = BHL + interstitial infiltrates
stage 3 = diffuse interstitial infiltrates only
stage 4 = diffuse fibrosis

86
Q

Sarcoidosis spirometry and tissue biopsy results?

Use of ACE levels?

A

spirometry: may show a restrictive defect
tissue biopsy: non-caseating granulomas

ACE levels have a sensitivity of 60% and specificity of 70% and are therefore not reliable in the diagnosis of sarcoidosis although they may have a role in monitoring disease activity.

87
Q

Management of sarcoidosis?

A

Steroids if:
CXR - stage 2 or 3 with symptoms
Hypercalcaemia
Eye, heart or neuro involvement

88
Q

Occupations at risk of silicosis? Features?

A

Mining
Slate works
Foundries
Potteries

Features:
Fibrosing lung disease
Egg shell calcification of hilar lymph nodes

89
Q

Whos the coolest F2 I know? / Whos Milkshake Brings all the boys to the yard? / Who will bring balance to the force?

A

Dr Olli Sharp BMBS BSc

90
Q

What is the air speed velocity of an unladen swallow

A

African or European?

91
Q

What three options for smoking cessation are there?

A

Nicotine replacement therapy
Varenicline
Bupropion

Do not favour one over another. Do not combine

Prescribe for only 2 weeks after stop date for NRT, 3-4 weeks for the other two

If fail, do not represcribe within 6 months

92
Q

Adverse effects of nicotine replacement therapy?

A

N&V
Headache
Flu like symptoms

93
Q

Adverse effects of Varenicline?

Contraindication?

A

Start one week before stop date. 12 week course

Nausea
Headache
Insomnia
Abnormal dreans

Contraindication
Depression/self harm (relative)
Pregnancy
Breast feeding

94
Q

Adverse effects of Varenicline?

Contraindication?

A

1-2 weeks before stop date

Contraindication
Epilepsy
Pregnancy
Breast feeding
Eating disorder (relative)

NOTE: Small risk of seizure

95
Q

Smoking cessation in pregnant women?

A

All should be tested

  1. CBT, Motivational interview, structured self help
  2. Nicotine replacement therapy if fails

the other varenicline and bupropion are contraindicated

96
Q

What are the guidelines for monitoring lung nodules?

A

< 5mm and benign - discharge

5-6mm or => 8mm and low risk - CT surveillance

=> 8mm and high risk - CT PET. If abnormal, biopsy

CT 5-6mm - at one year
CT =>6 - three months

97
Q

Features and management of theophylline poisoning?

A 
Features:
Acidosis, Hypokalaemia
Vomiting
Tachycardia, arrhythmia
Seizure

Management:
Gastric lavage
Activated charcoal
Seizures controlled by benzodiazepines or intubation

98
Q

Causes of raised TLCO? (6)

A 
asthma
pulmonary haemorrhage (Wegener's, Goodpasture's)
left-to-right cardiac shunts
polycythaemia
hyperkinetic states
male gender, exercise
99
Q

Causes of low TLCO? (7)

A 
Restrictive lung disease
•	Idiopathic pulmonary fibrosis
•	Occupational lung disease
•	Hypersensitivity pneumonitis
•	Miliary tuberculosis
•	Pneumonectomy

Obstructive lung disease
• Cystic fibrosis
• Emphysema

Other causes
• Chronic pulmonary embolism
• Congestive heart failure (pulmonary oedema, low cardiac output)
• Primary pulmonary hypertension

Anaemia

100
Q

Sites of secondary TB?

A 
central nervous system (tuberculous meningitis - the most serious complication)
vertebral bodies (Pott's disease)
cervical lymph nodes (scrofuloderma)
renal
gastrointestinal tract
101
Q

Management of latent TB? Two options…

A

NICE now give two choices for treating latent tuberculosis:

3 months of isoniazid (with pyridoxine) and rifampicin

6 months of isoniazid (with pyridoxine)

102
Q

What is thunderstorm asthma?

A

Sudden spore and pollen release due to pressure change resulting in asthma attack

103
Q

What levels of pressure should BiPAP be started on?

A

IPAP 15
EPAP 3

If pH <7.25 IPAP 20
Neuromuscular disease start with IPAP 10

104
Q

Complications of NIV?

A

Breathing against machine (dyssynchrony)

Aspiration (vomiting/secretions) –> Mucous Plug

Pneumothorax

Ventilator associated pneumonia

105
Q

In a patient with acute exacerbation of COPD with Type respiratory failure and acidosis, when should NIV be considered?

A

Failure of optimal medical therapy meaning hypercapnia and acidosis do not improve

The NIV

If fails to improve, for consideration of invasive ventilation

106
Q

What can be used in COPD exacerbations when NIV is unavailable or inappropriate?

A

Respiratory Stimulants (doxapram)

107
Q

Contraindications to NIV? (7)

A

Recent facial/upper airway surgery or injury

Recent UGI surgery

Confusion/agitation

Bowel obstruction

Upper airway obstruction

Excessive upper airway secreitions

Acute vomiting

108
Q

Should nebulisers with NIV be given together or should the mask be taken off to administer nebuliser?

A

Take off mask to administer nebuliser

increased efficacy

109
Q

Features and management of eosinophilic pneumonia?

A

Sub-acute respiratory symptoms
Alveolar/blood eosinophilia
Peripheral pulmonary infiltrates on imaging

Treat with oral corticosteroids

Good prognosis

110
Q

When is Roflumilast used?

A

Already on maximal medical therapy

Recommended in COPD where =>2 exeracerbations per year and FEV1 <50%

Phosphodiesterase-4 inhibitor

111
Q

Fun fact!

A

Silicosis increases susceptibility to TB

112
Q

Most common cause of cannon ball metastases?

A

Renal cell cancer

113
Q

Name two common scenarios in which CPAP is used?

A

OSAS

Pulmonary Oedema

114
Q

What is Mepolizumab? When is it used?

A

IL-5 antagonist (monoclonal antibody)

Treatment of severe eosinophilia
resistant asthma

115
Q

What is omalizumab? When is it used?

A

Treatment of allergic asthma with significant elevation in IgE

Add on therapy for step four.

116
Q

What might you give for symptomatic relief of SOB in end stage COPD?

A

Opioids
+/- Benzodiazepines

Renal Failure: Alfentanil

117
Q

What is the significance of nasal polyps in asthma?

A

More likely to have an adverse reaction to NSAIDs

118
Q

What is the time lag for complications following asbestos exposure?

Is compensation possible?

A

10 Years - pleural plaque

20 Years - asbestosis

30 Years - Mesothelioma

NOTE: Clubbing is associated with progression to mesothelioma

Compensation for asbestosis or mesothelioma from Department of Social Security or Civil Law Claim

119
Q

What is hypertrophic pulmonary osteoarthropathy and how does it present?

A

Intermittent aching and swelling in wrists and ankles (squamous cell lung cancer)

120
Q

What are the investigation findings for invasive aspergillosis?

How is it treated?

A

Classical halo sign on CT
Hyphae on silver staining
Mortality 40-90%

  1. Voriconazole (IV)
  2. Lipsomal Amphotericin
121
Q

What is re-expansion pulmonary oedema?

When does it occur?

A

Life threatening condition. Following chest drain insertion. Large volume or air is rapidly drained

Sudden onset SOB
Cough
Hypoxaemia

122
Q

Where is histoplasma endemic?

What is the treatment?

What are the features?

A

Mississippi River Valley

Mild: Itraconazole

Severe: Admit, IV Amphotericin B

Signs: Fevers, mildly elevated WBC, nodular shadow on CXR, urine and serum antigen positive

May present many years down the line

123
Q

What does raised Beta-D-glucan suggest?

A

Suggests fungal infection

124
Q

Investigations in Pulmonary hypertension. What can you use?

A

RIght Heart Catheterisation - assess pulmonary pressures

Left Heart Catheterisation - assess coronary arteries

6 minute walk test - assess prognosis

125
Q

SOB following TIPS. What possible complication has occurred?

A

Pulmonary Hypertension

  • due to increased cardiac preload -
126
Q

If during the LTOT assessment in COPD patient, the PaCO2 has risen >1kPa, what should you do?

A

May have clinically unstable disease

Further medical optimisation

Re-assess at 4 weeks

127
Q

Differential for Bilateral hilar lymphadenopathy?

A 
Sarcpodpsos
TB
Malignancy
Cystic Fibrosis
eGPA
HIV
EEA
Phenytoin
Pneumoconioses (berylliosis)
128
Q

How should you investigate for TB in HIV patients with CD4 <200?

A

IFN-gamma
Mantoux

Both should be done. If positive, clinical assessment to exclude active TB.

129
Q

What is non-tuberculous mycobacteria (NTM)? What are common managements?

A

Presentation:
Hypersensitivity disease
Cavitating disease
Bronchiectasis

Radiology: Cavities, bronchiectasis, nodules

Microbiology: 2 or more positive sputum samples on separate days

Mycobacterium Avium Complex (MAC) - Rifampicin, Clarithromycin, ethambutol (until sputum culture negative for 12 months)

M. Kansaii: Rifampicin, isoniazid, ethambutol (until sputum culture negative for 12 months)

130
Q

What is the treatment of narcolepsy?

A

Methylphenidate

131
Q

Nintedanib?Pirfenidone?

What are they used for?

A

Small molecule tyrosine kinase inhibitor inhibitor

Treatment of idiopathic pulmonary fibrosis

Use when:
FVC 50-80% predicted
Treatment is stopped if disease progression in any 12 month period

132
Q

Name some drugs which can cause chronic cough?

A 
ACEi
Smoking
Statins
Amiodarone
ARBs
IFN-alpha
IFN-beta
133
Q

What is combined pulmonary fibrosis and emphysema (CPFE)?

A

Higher rates of lung cancer and risk of pulmonary arterial hypertension

Features:
Exertional SOB
Uppler Lobe Emphysema
Lower lobe fibrosis
Preserved lung volume
Reduced capacity gas exchange
134
Q

What is subglottic stenosis and how can it occur (3)?

A

Congenital
Idiopathic
Post-intubation

Consider if obstructive picture

135
Q

What is chylothorax? What is it high in?

A

Accumulation of lymph in pleural space

High in triglycerides
and chylomicrons

136
Q

What is a pseudochylothorax high in? When does it occur

A

Cholesterol

Occurs with longstanding fibrotic pleura

137
Q

What drugs can cause pleural effusion?

A

Nitrofurantoin
MTX
Amiodarone

138
Q

How should you investigate for TB? What is the best type?

A

Multiple samples (3 deep cough sputum samples) for microscopy and culture

If not possible, induction of sputum or bronchoscopy and lavage

Bronchoscopy - best specimen

Mantoux and IFN-gamma for latent TB

139
Q

What does a high KCO but low DLCO imply for a patient with restrictive lung disease?

A

It is an extra-pulmonary cause

140
Q

What is lymphangioleiomyomatosis?

A

Affects premenopausal women
Proliferation of smooth muscle cells in lungs, lymphatics and uterus

Likely caused by oestrogens

Association with Tuberous Sclerosis and renal angiomyolpomas

Symptoms:
SOB
Pneumothorax
Chylous pleural effusion

Management:
Medroxyprogesterone (anti-oestrogen)

141
Q

What is atypical langerhans cell histiocytosis?

A 
Affects smokers (age 20-40)
SOB
Cough
Spontaneous Pneuomthorax
Clubbing
Granuloma infiltration in bones and hypothalamus
142
Q

Symptoms and signs of Primary ciliary dyskinesia?

A 
Autosomal recessive
Sinusitis
Otitis media
Male infertility
Recurrent respiratory infections
40-50% situs inversus
143
Q

What is chronic eosinophilic pneumonia

A

SOB
Fever
Weight Loss

Skin, liver and spleen involvement

Atopic history - sinusitis, rhinitis, angioedema

Extensive dense peripheral infiltrates on CXR

144
Q

What are the modified acute eosinophilic penumonia Philit Criteria?

A
  • acute respiratory illness of less than or equal to 1-month duration
  • pulmonary infiltrates on chest radiography or computed tomography (CT)
  • pulmonary eosinophilia as demonstrated by more than 25% eosinophils in BAL fluid (can be accompanied by variably increased percentages of lymphocytes and neutrophils) or eosinophilic pneumonia on lung biopsy (bronchoscopic or surgical), and
  • the absence of other specific pulmonary eosinophilic diseases e.g. eosinophilic granulomatosis with polyangiitis (previously known as Churg-Strauss syndrome)
145
Q

What is the Kveim Test? What is it used for?

A

Part of spleen from patient with known sarcoidosis is injected under the skin

No longer used due to converns of cross infection

146
Q

What is the bulging fissure sign and what is it seen in?

A

Classical feature of klebsiella pneumonia

Due to large volumes of consolidation (typically RUL) causing displacement of adjacent fissure

147
Q

Rusty coloured sputum and proceeding herpes labialis?

A

Streptococcal pneumoniae

148
Q

Proceeding flu like illness with subsequent rapid deterioration into a bacterial pneumonia?

A

Staphylococcus aureus

149
Q

What is treatment for infected bronchiectasis?

A

Oral Ciprofloxacin 14 days

Failure of this: IV Tazocin, Ceftazidime, aztreonam, meropenem

150
Q

Name two common pathogens in cystic fibrosis. Which has worse prognosis?

A 
Pseudomonas
Burkholderia (worse prognosis)
151
Q

If draining a pneumothorax, at 3-5 days there is still an air leak/failure to re-expand, what should you do?

A

Thoracic surgical opinion

152
Q

Which emphysema patients benefit from lung volume reduction surgery?

A
  1. UL emphysema and low exercise capacity (improved function and survival)
  2. UL and high exercise capacity (improved function, no difference survival)
  3. Non-UL and low exercise capacity

The following will not do well and have high risk of death:

  • Non-UL and high exercise capacity
  • Poor pulmonary function and homogenous emphysema distribution or poor CO diffusing capacity
153
Q

Possible options for treatment to eradicate pseudomonas aeruginosa in CF patients?

A

IV anti-pseudomonal abx + inhaled aminoglycoside 14 days

Oral ciprofloxacin (6 weeks)

MRCP2 (6 decks)

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