Resp Flashcards

1
Q

Serious complications of sinusitis

A

Infection of meninges

Orbital cellulitis

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2
Q

Kartagener’s sx triad and pathophysiology

A

Bronchiectasis
Sinusitis
Situs inversus

Abnormal ciliary function: failure to clear mucus + bacteria

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3
Q

Most common association with nasopharyngeal carcinoma

A

EBV
Rare outside E/SE Asia - usually undetected until metastasises to lymph nodes
Decent prognosis with radiation therapy

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4
Q

Causes of acute laryngitis

A

Pathogens
Irritants (esp cigarette smoke)
Mechanical factors, eg endotracheal intubation
Overuse of voice

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5
Q

Sequelae of acute laryngitis

A
  1. Resolution
  2. Spread of infection: bronchitis, bronchopneumonia, lung abscess
    3 Airway obstruction: laryngeal oedema (esp epiglottitis in children)
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6
Q

Causes of atelectasis

A

Obstruction: foreign object, mucus plugging

Compression: pneumothorax, oedema

Scarring:

Surfactant loss

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7
Q

Causes of bronchiectasis

A

Irreversible dilatation of bronchi

Congenital: CF, Kartagener’s etc.
Acquired: infection (esp measles + pertussis), obstruction (foreign object or tumour)

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8
Q

Signs of idiopathic pulmonary fibrosis

A

Dyspnoea
Cough
Finger clubbing

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9
Q

3 most common pneumoconioses

A

Coal worker’s
Silicosis (slate minining, quarrying, stone masonry)
Asbestosis

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10
Q

What are farmer’s lung/ pigeon-fanciers’ lung examples of?

A

Extrinsic allergic alveolitis

type III and type IV

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11
Q

Predisposing factors for pneumonia

A
INSPIRATION
Immunosuppression
Neurological impairment of the cough reflex
Secretion retention
Pulm oedema
Impaired mucociliary clearance
Resp tract infection
Abx and cytotoxics
Tracheal intubation
Impaired alveolar macraphages
Other
Neoplasia
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12
Q

Pathogens causing CAP

A

Generally Gram +ve
Strep pneumoniae
Haemophilus influenzae

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13
Q

Pathogens causing HAP

A
Generally Gram -ve
Klebsiella
Pseudomonas
MRSA
E.coli
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14
Q

Who gets viral pneumonia?

A

Children, eg measles, varicella

Immunocompromised, eg CMV - esp common after bone marrow transplant

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15
Q

Pathogens causing fungal pneumonia

A

Candida and aspergillus
Can cause widespread areas of necrosis - mortality is high

PCP (Pneumocystis carinii pneumonia) - small fungal yeasts

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16
Q

How can TB spread from the Ghon complex?

A

If no resolution, e.g. in immunocompomise:
Bronchus: from lymph nodes erodes into bronchus > other bronchus > neighbouring lung
Blood vessel: causing miliary TB
Direct lymphatic spread: pleura, pericardium

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17
Q

What is secondary TB?

A

Reactivation of latent infection - occurs in ~5-10%
Apical Assmann focus

Primary TB has small granulomatous focus but large lymph node response
Secondary TB has large granulomatous disease but minimal lymph node involvement

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18
Q

Types of lung ca

A

Squamous (slow-growing, metastasises late)
AC (slow-growing, including from peripheries, metastasises early)
Large-cell anaplastic
Small-cell (neuroendocrine) - mets normally present at diagnosis

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19
Q

Common primary sites for lung mets

A
Breast
Kidney
Uterus
Ovaries
Testes
Thyroid

usually via blood, ie bilateral deposits

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20
Q

Meds that can cause chronic pulmonary fibrosis

A

Some anticancer agents
CCBs
amiodarone

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21
Q

Causes of haemothorax

A

Trauma, esp rib #
Surgery
Pulmonary infarcts
Spontaneous rupture of diseased arteries, eg atheroma, dissecting aortic aneurysm

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22
Q

Causes of chylothorax

A

Leakage from thoracic duct, typically malignant infiltration, surgery, trauma

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23
Q

Where is the anatomical dead space?

A

Conducting part of tract ~150 mL

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24
Q

Where does aspirated material tend to go?

A

R bronchus

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25
Q

How many lung lobes?

A

2 on L: superior + inferior

3 on R: superior + middle + inferior

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26
Q

What is the normal V/Q

A

0.8

1 is ideal

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27
Q

Which conditions are obstructive? How would this be reflected by FEV1/FVC?

A

Asthma, COPD, bronchiectasis

<0.7

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28
Q

Asthma steps

A
  1. Inhaled SABA
  2. Add inhaled CS (400 mcg/day usual starting dose - up to 800)
  3. Add LABA (discontinue if poor response)
  4. Increase inhaled CS up to 2000 mcg/day, or add leukotriene receptor antagonist
  5. Oral steroids in addition to inhaled steroids
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29
Q

Possible cause of emphysema in younger patients

A

alpha-1-antitrypsin deficiency

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30
Q

Most common pathogen implicated in acute exacerbations of COPD

A

Haemophilus influenzae

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31
Q

MRC dyspnoea scale

A

Grade 1: only on exertion
Grade 2: SOB on walking up hill
Grade 3: slower than contemporaries
Grade 4: has to stop after few mins/ 100 m
Grade 5: too breathless to leave house/ on dressing

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32
Q

What is the BODE index

A
For prognosis in COPD
BMI
Obstruction
Dysnoea (MRC scale)
Exercise tolerance
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33
Q

COPD steps

A
  1. SABA or SAMA
  2. LABA or LAMA (+ICS if FEV <50%)
  3. Theophylline, mucolytics - oral CS not recommended
  4. LTOT
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34
Q

What may be seen on bronchiectasis CXR?

A

Tram-tracks/ fluid lines

HRCT is gold-standard

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35
Q

What are the GI/ endo features of CF?

A

DM, pancreatic insufficiency, liver disease, gallstones, osteoporosis, infertility in males (absent ductus deferens bilaterally), subfertility in females

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36
Q

First-line investigation in CF

A

Sweat test

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37
Q

What is the acute presentation of sarcoid?

A

Lofgren syndrome
Good prognosis: bedrest and NSAIDs
fever, erythema nodosum, bilat hilar lymphadenopathy, polyarthralgia

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38
Q

What is Caplan syndrome?

A

Coal workers’ pneumoconiosis associated with RA

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39
Q

What pathogen commonly causes pnemonia after influenza?

A

Staph aureus

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40
Q

Pathogen most likely to cause pneumonia in alcoholics?

A

Klebsiella

also most common in diabetics

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41
Q

What are the features seen on blood tests in Legionella pneumonia?

A

Deranged LFTs

Hyponatraemia

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42
Q

Erythema multiforme is associated with which pneumonia

A

Mycoplasma infections

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43
Q

CURB-65

A
Confusion (AMTS <8)
Urea >7
RR >30
BP <90 or diastolic <60
65 years

0/1: treat at home

2: inpatient treatment
3: consider ITU

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44
Q

Causes of lung abscess

A

Primary: existing pneumonia or lung disease

Secondary: aspiration, septic emboli from R sided infective endocarditis

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45
Q

Clinical features of lung abscess

A

Swinging fevers, night sweats, productive cough (purulent sputum)

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46
Q

Extra-pulmonary manifestations of TB

A

arthritis, meningitis, Pott spine, erythema nodosum, clubbing

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47
Q

Why request LFTs in TB?

A

Meds tend to be hepatotoxic

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48
Q

Medications for TB

A

2 months RIPE

4 months RI

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49
Q

TB drug side-effects

A

Rifampicin (RED-fampicin): reddish/orange secretions, hepatitis

Isoniazid (Iso-NEURO-zid): peripheral neuropathy (supplement with vit B6 prophylaxis), agranulocytosis, hepatitis

Pyrazinamide (Pyr-OUCH-zinamide): hyperuricaemia causing gout, myalgia, hepatitis

Ethambutol (EYE-thambuto): optic neuritis, renal impairment

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50
Q

What is Meig syndrome?

A

Triad of ovarian cancer, ascites and R-sided pleural effusion

Causes transudate

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51
Q

Causes of pleural effusion transudates

A

Heart failure
Renal failure
PE
Meig syndrome

52
Q

Causes of pleural effusion exudates

A

Pneumonia, TB

Lung ca

53
Q

Symptoms of pleural effusion

A

Dyspnoea
Pleuritic chest pain
May be asymptomatic

54
Q

Signs of pleural effusion

A

Dull to percuss
Reduced breath sounds
Trachea deviated to opp side (if large)

55
Q

How may refractory pleural effusions be managed?

A

Pleurodesis

56
Q

Site for chest drains

A

4-6th ICS MAL

57
Q

Pneumothorax definition

A

Abnormal accumulatio of air in pleural space

58
Q

Symptoms of pneumothorax

A

Sudden-onset dyspnoea or unilateral pleuritic chest pain
Sudden deterioration existing lung problem
Or asynptomatic - esp if small or they’re healthy

59
Q

Signs of pneumothorax

A

Decreased chest expansion, reduced breath sounds, hyper-resonance on percussion

60
Q

Treatment tension pneumothorax

A

Large bore cannula into 2nd ICS mid-clavicular line

61
Q

Lambert-Eaton myaesthenic sx associated with which lung ca

A

Small cell

62
Q

Which lung ca association with ectopic PTH

A

Squamous cell carcinoma

63
Q

How to get cells for histopathology in lung ca

A

Fibre-optic bronchoscopy for central lesions, needl-guided bx (under CT or US) in peripheral lesion

64
Q

Causes T1RF

A

Obstruction problem: alveoli are perfused but not ventilated
PaO2 < 8kPa

severe acute asthma
pneumonia
PE
pulmonary oedema

65
Q

Causes T2RF

A

Ventilation problem
CO2 > 6.5 kPa

COPD
asthma
pneumonia
pulmonary fibrosis
obstructive sleep apnoea
reduced resp drive: trauma, sedatives
neuromuscular: cervical cord lesion, MG, GBS, diaphragm paralysis
66
Q

Signs and symptoms of hypercapnia

A

headache, drowsiness, reduced GCS, bounding pulse, tremor in hands, peripheral vasodilatation, papilloedema

67
Q

Options for non-invasive respiratory support

A

Humidified supplemental O2: for T1RF

CPAP: for T1RF

BiPAP: for T2RF

68
Q

Why is invasive mechanical ventilation useful? When may it be used?

A

Set a desired pressure, desired tidal volume, desired RR

Severe resp failure/ increased work of breathing/ NIV not tolerated
Airway protection (eg GCS <8 or airway compromised by burns)
Control pO2 and pCO2 in acute neuro diease/ increased ICP

69
Q

What are the options for invasive mechanical ventilation?

A

ETT (requires anaesthesia, sedation) initially

Long-term: tracheostomy (little/ no sedation, improved comfort, improved nursing/ oral care)

70
Q

Risks of ETT

A

Volutrauma
Barotrauma
Tension pneumothorax

71
Q

Types of pulmonary embolus

A

Thrombosis
Fat (fractures)
Amniotic fluid
Air (neck vein: cannulation or bronchial trauma)

72
Q

Symptoms PE

A

Dyspnoea, chest pain (pleuritic or retrosternal), cough, haemoptysis

Severe: RHF –> dizziness, syncope, arrest

73
Q

Sign of PE

A

Tachypnoea, tachycardia, hypotension
hypoxia, pyrexia
pleuritic rub
increased JVP, gallop rhythm

74
Q

Investigations for PE

A

FBC, U&Es, baseline clotting, troponin, consider BNP

Well Score: D-dimer if less likely

ABG

ECG: S1, Q3, T3 - tachy, RBB, RAD
CXR
Echo: may show thrombus and if location haemodynamically important

CTPA + leg USS (if Wells Score high)

If under 40, consider looking for cancer: hx, CXR, mammogram, CT AP, antiphospholipid antibodies, thrombophilia screen)

75
Q

When would V/Q scan be offered?

A

Cannot have contrast/ renal impairment

76
Q

Thrombolysis regimen in arrest/ pre-arrest

A

Suggested regime is Alteplase 10 mg iv bolus and 90 mg iv over two hours (total
dose 100 mg).

The total dose should not exceed 1.5 mg/kg in patients with a body weight below 65 kg.

If cardiac arrest is imminent and there is a high suspicion of massive PE thrombolysis
accelerated dosing is recommended even if the diagnosis has not been confirmed with
imaging. Alteplase 50 mg iv bolus, followed by IV UFH

Continue anticoagulation with heparin after thrombolysis.

The risks of bleeding should be explained to the patient and documented (BTS quoted 20%
bleeding risk with lysis).

77
Q

Mx low to medium risk PE

A
General
Oxygen 35-50% (higher if shocked)
Adequate analgesia for pleuritic pain
Allow right atrial pressure (i.e. JVP) to remain high if elevated
AVOID diuretics

Specific
Low molecular weight heparin (LMWH) for at least 5 days despite therapeutic INR.
Once diagnosis confirmed initiate Warfarin, (until INR >2 for two consecutive days), or direct
oral anticoagulant (DOAC).
Offer Class II stockings ideally full length, (patients may choose below knee) to be worn for
at least two years (unless contraindications)

Continue 6 months: cancer/ unprovoked
3 months: provoked

May need surgical embolectomy/ IVC filter

78
Q

Causes of ARDS

A

Pulmonary: trauma, infection, smoke inhalation, gastric contents aspiration, mechanical ventilation, near-drowning

Non-pulmonary: Gram-negative sepsis, pancreatitis, burns, CABG, perforated viscus, DIC, O2 toxicity, drug OD

79
Q

Mx ARDS

A

Identify cause + support
-ve fluid balance as in HF
PEEP: prevent alveolar walls from collapsing during expansion
also vasodilators, steroids in late stages….
30-45% mortality

80
Q

Causes of pneumothorax

A

Primary/ spontaneous: rupture of pleural pleb (congenital weakness), tall/ slim males - often apical

Secondary: COPD (emphysematous bullae), COPD, TB, pneumonia, bronchial ca, sarcoidosis, CF, trauma

81
Q

Ix for OSA

A

Polysomnography gold standard (electrodes on eyes/ chin)

82
Q

Mx OSA

A

Lifestyle, avoid supine sleeping
CPAP is gold standard
Modafinil for sleepiness maybe, maybe surgery

83
Q

What happens in central sleep apnoea

A

Airway patent but no respiratory effort –> hypercapnia –> arouses pt

84
Q

Causes pulmonary hypertension

A

Idiopathic is rare: associated with CREST/ autoimmune

Secondary to COPD, interstitial lung disease, congenital cardiac disease, others

85
Q

How is pulmonary HTN confirmed?

A

R heart catheterisation

PAH by exclusion

86
Q

Mx pulmonary HTN

A

Warfarin to minimise risk of thrombosis
CCBs to reduce pressure in pulmonary vasculature
HF should be treated aggressively

87
Q

Prevalence of asthma

A

5% adults, 20% children

88
Q

Extrinsic vs intrinsic asthma

A

Extrinsic: atopic childhood asthma - remits in teens
Intrinsic: usually adult, progressive, less responsive to treatment

89
Q

Precipitating factors to asthma attacks

A

viral infections, beta-blockers, NSAIDs

90
Q

Management of acute asthma

A

O2
5 mg salbutamol nebs (oxygen-driven) every 15-30 minutes (continuous if life-threatening)
100 mg IV hydrocortisone
0.5 mg ipratropium nebs (every 4-6 h)

then need senior for IV magnesium, IV aminophylline

91
Q

Mx of COPD in addition to medication

A
Yearly influenza jab, 5-yearly pneumococcus
Pulmonary rehab (6-12 weeks) to work on exercise tolerance
92
Q

Mx acute exacerbation of COPD

A

O2 venturi
Nebulised SABAs (salbutamol, ipratropium)
Oral steroids (30 mg pred) - for 7-14 days (may need reducing regimen)
Abx if infected
BiPAP if resp failure/ acidotic

93
Q

Ix IECOPD

A
ABG
ECG
Sputum microscopy/ culture if purulent
FBC/ U&amp;Es
Blood cultures if pyrexial
Theophylline levels if on theophylline
BODE Index
94
Q

Common complications of influenza

A

Secondary bacterial pneumonia (Staph aureus)
Otitis media
Sinusitis
Encephalitis

95
Q

Complications of pneumonia

A

Empyems/ lung abscess

AF

96
Q

What are the HIV-related lung diseases?

A
TB in 40% (more likely to have atypical symptoms, CXR often atypical, higher risk multidrug-resistant)
PCP
CMV
Aspergillus
pulmonary Kaposi's sarcoma
97
Q

Mx Pneumocysis jiroveci

A

High-dose co-trimoxazole

Check with senior as toxic - are alternatives

98
Q

How does Goodpasture’s affect the resp sx?

A

Pulmonary haemorrhage

Pts present with haemoptysis, haematuria and anaemia

99
Q

How does Wegener’s affect the resp sx?

A

affects small vessels of midline structures: nose, lungs, kidneys
rhinorrhea, cough, haemoptysis, dyspnoea

rare, necrotising vasculitis

100
Q

How does Churg-Strauss affect the resp sx?

A

late-onset asthma
(also eosinophilia and vasospasm: MI, PE, DVT)

small vessel vasculitis

101
Q

How does RA affect lungs?

A
10-15% have lung involvement
diffuse pulmonary fibrosis
pleural fibrosis
pleural effusions
rheumatoid nodules on lung (rare)
other stuff...
102
Q

How does SLE affect lungs?

A

Usually pleurisy, with or without effusions

103
Q

How does systemic sclerosis affect lungs?

A

Pulmonary fibrosis > rapidly-progressive pulmonary HTN

104
Q

How does ankylosis spondylitis affect lungs?

A

apical lung fibrosis

105
Q

Complications of lung ca

A
Ulceration of bronchus
Bronchial obstruction
Central necrosis (causing abscess)
Pancoast tumours causing Horner's
Paraneoplastic syndromes
hypertrophic pulmonary osteoarthropathy
106
Q

Why may Hb be increased or decreased as a result of respiratory disease?

A

Secondary polycythaemia due to longstanding hypoxia

Decreased (normocytic) in anaemia of chronic disease

107
Q

What may cause a reduced eosinophil count in respiratory disease?

A

Steroid therapy

108
Q

Which respiratory disease may cause increased monocytes?

A

TB

109
Q

What does an ASO titre confirm?

A

Recent strep infection

110
Q

Causes of hypercalcaemia in respiratory disease?

A

malignancy
sarcoid
squamous cell carcinoma of lung

111
Q

What can cause an increase in ACE?

A

sarcoid

112
Q

When doing pleural tap how may fluid appear?

A

Transudates clear
Exudates cloudy
Empyema
Haemothorax

113
Q

Causes of respiratory acidosis?

A

Impaired ventilation

asthma, COPD, pneumonia, sleep apnoea, acute PE, severe obesity, neuro musc problems, scoliosis, sedative OD, arrest

114
Q

Causes of respiratory alkalosis?

A

Hyperventilation

heart attack, pain, asthma, anxiety, fever, COPD, infection, PE, pregnancy

115
Q

Side-effects of SAMA/ LAMA

A

muscarinic sx

116
Q

Side effects of SABA/ LABA

A

Fight or flight symptoms: anxiety, tremor, palpitations

117
Q

Differentials for haemotysis

A

acute bronchitis, PE, lung malignancy, lung abscess, pneumonia, TB, bronchiectasis

118
Q

1st web space wasting

A

T1 lesion, eg Pancoast

119
Q

Hand signs of hypercapnia

A

Dilated veins
Palmer erythema
Asterexis

120
Q

Resp causes of clubbing

A

Ca
ILD
suppurative lung disease

121
Q

When may JVP be raised?

A

RHF
PE
SVC obstruction

122
Q

Cause of crackles on resp exam

A

Early: small airway disease, eg bronchiolitis
Mid-inspiration: pulm oedema
Late inspiration: ILD, COPD, pneumonia
throughout: bronchiectasis

123
Q

Mx anaphylaxis

A

Adrenaline

ABCDE

Fluids 500 mL - 1000 mL, keep repeating
10 mg chlorphenamine, IM or slow IV

Consider corticosteroids
Consider salbutamol

Measure tryptase levels within 4 h

Observe for 6-12 h

124
Q

Blood vessels on a rib

A

VAN

so trains go above the rib

125
Q

What is a saddle embolus?

A

straddles pulmonary artery in lumens of both R and L pulmonary artery

126
Q

Mendelson’s syndrome

A

Chemical pneumonitis secondary to aspiration

127
Q

Which lobes commonly involved in aspiration pneumonia?

A

Supine: RUL
Sitting: RLL