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Resp for RACP Flashcards

1
Q

What are the fleischner guidelines? Who do they not apply to?

A

these are the guidelines that are used for the monitoring of asymptomatic pul nodules

Doesnt apply to young pts (<35yrs), pt with cancer, and pts who are immunosupressed

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2
Q

Which type of lung nodule needs to be followed up for the longest period of time? how long do these need to be followed up for? what is the usual length of time for follow up?

A

Ground glass nodules
- these are a very slow growing type of nodule, hence need to be followed up for longer than most

usually follow up nodule for 2 years
If ground glass, follow for 5yrs

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3
Q

What are some pul nodule specific RF. What is the most important of these and what are the associated cut offs?

A

SIze
Margins - spiculated
Location - Upper lobe more common
Number - lower risk with > 5 nodules (more likely to be malignancy than 5x primaries)

SIze is main RF
- <6mm in low risk clinical situation is not concerning
- 6mm-20mm is monitored
- >20mm is bad

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4
Q

What are some patient factors in the fleischner guidelines?

A

Age
Smoking - 30 pk year Hx, quiting within 3 years
Presence of emphysaemia or fibrosis

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5
Q

According to the fleischner guidelines, what combination of patient and nodule risk factors constitute the highest risk of primary lung cancer?

A

Older
Smoking Hx > 30pyh (active or ceased within 15 years)
Large nodule size
Spiculated margin
upper lobe

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6
Q

Where is aspergilosis found in the environ? any particular buzz words?

A

Aspergilus is ubiquitous in the environment
Found in soul, vegetation, farming

Buz word: moist hay (hay shed)

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7
Q

WHat are the 4 key groups that get aspergilus infection? WHat sort of infection do they classically get?

A

Reastive lung disease (ie asthma)
- ABPA (Allergic bronchopulmonary aspergillosis)
- Asthma with fungal sensitisation

Structural lung disease - eg advanced COPD, bronchiectasis
- Aspergiloma
- Chronic pulmonary aspergillosis infection

Immunocopremised pts:
- Invasive aspergiullus infection

Serious viral infection pts
- covid in ICU

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8
Q

What is the basic psychophysiology of ABPA? what is the treatment?

A

Aspergillus in the airway causes airway inflammation and reactivity

Treatment:
- Pred + itraconazole - 6 months treatment

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9
Q

What is the treatment of aspergiloma?

A

Usually surgery (unless pt cant have surgery)
- Degree of haemoptysis is main indication for surg (ie lots of haemoptysis then need surg)

Usually give voraconazole pre surg to eliminate as many organism as possible then surgery.
Source control without surg is virtually impossible

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10
Q

Treatment of invasive aspergilosis?

A

Voriconazole
- stronger and better tissue penetration than itraconazole

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11
Q

Is galactomanin associated with aspergiloma, ABPA, invasive aspergilosis or a combination?

A

Only invasive aspergilossis

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12
Q

Explain the classification and types of ILD?

A

Overarching term is ILD (includes anything with interstitial involvment)
- there is 7 groups within ILD

Idiopathic interstitial pneumonia
Iatrogenic/drug induced
Occupational/environmental
Granulamoatous disease (sarcoidosis)
Collagen-vascular disease (diffuse scleroderma mainly)
Inherited group (alpha 1 antitripsan def)
Unique identities (eg LAM - dont worry about it)

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13
Q

Is all idiopathic ILD IPF?

A

No
IPF is one of several types of idiopathic ILDs (grouped into the catagory of idiopathic interstitial pneumonias)

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14
Q

What are the 4 most common drugs that cause ILD? WHat is teh other iatrogenic cause of ILD that is not a drug?

A

Drugs cause ILD. This is grouped into iatrogenic/drug induced ILD

4 most common are
- Bleomycin (most risk. Usually testicular cancer or NHL. Have to do DLCO monthly to monitor because so high risk)
- Methotrexate
- amiodarone
- Nitrofurantoin

Radiotherapy

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15
Q

Radiotherapy is a cause of itatrogenic ILD. what is the characteristic finding on imaging that is diagnostic of radiotherapy induced ILD (in someone with a hx of radio ofc)?

A

ILD that follow non anatomical lines
- only radio will cause this

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16
Q

What are the common causes of occupational/environmental ILD?

A

Farming and non farming related

Non farming:
- silicosis
- Asbestosis
- Coal workers pneumaconiosis

Farming:
- hypersensitivity pneumonitis (acute and chronic)

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17
Q

Who gets silicosis?

A
  • Stone masons
  • Stone kitchen bench workers
  • Road work workers involved in breasking up road (jack hammers etc)
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18
Q

What are the characteristic features of silicosis on CT?

A

Multiple calcified LN
- only three things that can result in calcified mediastinal LN: silicosis, sarcoidosis and old inactive TB

Predominately upper lobe ILD

Progressive massive fibrosis
- marked upper lobe distorsis that come from the central upperlobes or hilar
- Only silicosis and sarcopidopsis can cause this

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19
Q

systemic sclerosis and limited cutaneous sclerosis can both cause ILD by different mechanisms. How does CREST vs systemic sclerosis cause ILD?

A

CREST / limited cutaneous sclerosis
- Causes Pul HTN. Does not result in ILD

Systemic sclerosis
- Causes ILD directly. Then pul HTN as a result of ILD

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20
Q

What class of pul HTN does crest cause? What sort of ILD does systemic sclerosis cause? (class of Pul HTN)

A

Type 1 (pulmoary arterial HTN)
Type 5 ILD (disease associated)

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21
Q

What are the three different types of resp disease that can be caused by alpha 1 anti trypsan def?

A

Emphysaema
Bronchiectasis
ILD

Can have combined of in isolation

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22
Q

IPF is always resistant to which medication?

A

Steroids
- NEVER use steroids in IPF, it will HARM the pt

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23
Q

IPF is the main form of idiopathic interstitial pneumonia. What are the other types of idiopathic interstitial pneumonia?

A

NSIP (idiopathic nonspecific interstitial pneumonia)
COP (cryptogenic ortganising pneumonia)
RB-ILD (respiratory bronchiolitis ILD)
DIP (desquamative intersitial pneumonia)
AIP (acute interstitial pneumonia)

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24
Q

Which of the idiopathic interstitial pneumonias is smoking related?

A

RB-ILD (respiratory bronchiolitis ILD)
DIP (dresquamative interstitial pneumonia)

they are not all smoking related, but some are
None of the other idiopathic ones are smoking related

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25
Q

What are the two types of ILD that can be reversed with nil medications required (ie LIFESTYLE changes)?

A

RB-ILD and DIP (both idiopathic interstitial pneumonias) are smoking related
- stop smoking and condition will reverse

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26
Q

Most pts with IDL are breathless, this is a universal features. What is the most important factor re the breathlessness in the Hx taking?

What are some other important factors in Hx?

A

The onset of the breathlessness
- for example pt with acute hypersensitivity pneumonitis (occupational/environmental ILD) the onset will be hrs to 1 day. Pt with IPF will have breathlessness that onset over months

  • Full drug Hx
  • Occupational Hx (what the dad does, what the husband does)
  • Exposure to pets, bird, farming (often long lag time)
  • Family Hx
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27
Q

What is the hall mark / pathopneumonic finding in ILD examination?

A

Fine inspiratory crackles

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28
Q

Characteristic lung function test in ILD?

A

Restrictive spirometry
- reduced FEV, preserved or increased FEV1/FVC ratio

Lung volumes in a equal ILD pattern
- TLV = RV + VC
- If TLC, RV, VC are reduced equally, then this is ILD (this is how it is distinguished form neuromusclular pattern)

DLCO reduced (usually <40%
- this will be the first thing to decline (lung thickens before the clinical restriction occurs)

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29
Q

What degree of desaturation on a 6 min walk test is associated with a poor prognosis in ILD?

A

<88% at all during the 6 min walk test

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30
Q

CXR findings in ILD (IPF as an example)?

A

Early disease:
- normal

Late disease:
- Small lung volumes
- Diffuse changes throughout both lung fields
- Predominant basal changes (gradient)

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31
Q

SOme ILD changes on CXR are often written off in ED as what?

A

Poor insp effort
- small volumes with increased markings is exactly what you see in ILD therefore often described as poor insp effort by radiology

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32
Q

What is teh most useful test in Dx ILD? Explain what this is?

A

HRCT
- 1mm slices from neck to adrenals, looking at parenchyma by definition (usually other structures are whited out

THis meas HRCT and CT chest are different tests
- ie HRCT wont tell you anything about mediastinal LN

33
Q

ILD can be put into one of three catagories base on CT findings. What are these three catagories?

A

Fibrotic
Inflammatory
Mixed

34
Q

What is the hall mark feature of fibrosis on HRCT?
What is the hall mark feature of inflammation on HRCT

A

Fibrosis = architectural distortion
- therefore if a pt has ANY architectural distortion then they have fibrosis radiologically

Inflammatory = ground glass

35
Q

What are the radiological indications of fibrosis on HRCT?

A

Intra and interlobular thickening

Traction bronchiectasis

Honeycombing = end product of fibrosis (all pts with honeycombing have definitive fibrosis)

36
Q

What are the HRCT findings in IPF?

A

Fibrotic changes (ie hoineycombing) that is predominately subpleural (circumfrential) and shows a basal predmoninently

37
Q

Why is a prone HRCT included in early IPF workup?

A

Changes on HRCT in IPF are subpleural and lower lobe

Pt who are overweight and supine can get dependant changes that are subpleural and basal predminant, therefore to distinguish them we do a prone film
- If image does not change on prone then IPF

38
Q

What is teh main approach used for a lung Bx? What is teh only ILD that can be Dx on transbronchial Bx?

A

Usually VATS Bx
Sarcoidosis is only one that can be Dx on transbronchial

39
Q

Treatment for sarcoidosis?

A

Pred
MTX as main steroid sparing agent

40
Q

What are the main treatment principles of ILD?

A

Can you treat the disease itself? (only sarcoidosis)
Can I treat or remove the cause?
- remove the drug
- remove the trigger
- treat the connective tissue disease
Can you treat the complications?
- pulmonary rehab
- Consider O2 therapy

41
Q

When are anti fibrotics indicated?

A

For any progressive fibrotic lung disease not just IFP
- initially studied in IPF. Slow rate of lung disease progression by 50%

42
Q

Main side effects of perfinedone? Nintedanib?

A

Photo sensitivity
Vomiting and dia

43
Q

What is the main steroid sparing agent used in ILD and what is the exception?

A

Mycophenylate
- sarcoid is the exception where MTX is used

44
Q

Pt has bad systemic sclerosis ILD. What would be first line medical management?

A

NOT steroids, this will precipitate a renal crisis

45
Q

What is the definition of bronchiectasis?

A

It is a radiological definition
- the airway is bigger then the vessel that runs with it. (signet ring sign)

46
Q

How is bronchiectasis categorized?

A

Focal or diffuse
- diffuse is the most common

47
Q

What is the cause of focal bronchiectasis?

A

focal bronchiectasis means focal cause and therefore focal solution
- focal cause in a endobronchial lesion (not usually a lung cancer because will usually die from lung cancer before bronchiectasis has the time to develop). Most commonly an adenoma, carcinoid or FB

48
Q

What immunological state is associated with bronchiectasis? what comditions would result in this immunological state?

A

Low IgG states
- Primary hypogammaglobulinaemia
- Seconary - CLL, myeloma, chemo, etc

49
Q

WHat are the only 2 conditions that cause upper lobe bronchiectasis?

A

CF
ABPA

50
Q

What the 4 features in adults that make you think about testing for potential CF? What is teh nedxt test that is done in an adult suspected o having CF?

A

Upper lobe bronchiectasis
Age <40
FHx (Hx of CF OR recurrent chest infection)
Recurrent porecence of MSSA in sputum

CF genetic panel
- sweat test wont be positive in a adult presentation of CF (ie milder form)

51
Q

What is the most common congenital cause of bronchiectasis (aside from CF)? How is The spot Dx made?

A

Primry cilliary dyskinesia

Hallmarks is that upper resp tract often much worse than lower resp tract. Hence often Dx by ENT instead of resp. It is a disease of the sinuses

Main feature is the lack of frontal sinuses, severe sinus disease, recurrent otitis media in younger adult

52
Q

WHat is the Dx test for primary cilliary dyskinesia?

A

cilliary studies
Need EM to look at cillia

53
Q

WHa tis teh best test to Dx severity of bronchiectasis?

A

Sputum culture
- the presence of pseudomonas is main factor with bronchiectasis. this si teh most imp prog factor with someone with bronchiectasis

54
Q

How is the severity of asthma determined?

A

severity is determined by the control of asthma, not the lung function tests

Asa opposed to COPD where the severity is determined by the lung funciton test

55
Q

Whst is difficult to control asthma? What is severe asthma?

A

Difficult to control asthma is asthma that is not controlled with high dose inhaled corticosteroids or that requires high dose inhaled corticosteroids to remain controlled

Severe asthma is a subset of difficult to control asthma. Severe asthma is asthma that remain uncontrolled / or requires this regime to remain controlled. Treatment with high dose inhaled steroids + LABA or leukotrines modifier or theophylin or ORAL steroids for at least half of teh previous year

56
Q

What are the three most common bronchospastic viruses?

A

RSV (worse by a long way. will need to give steroids for longer because of how bronchospastic it is)

Influenza
Covid

57
Q

SHoudl try to avoid NSAIDs in asthma pts if posssible. Which is the group of asthma pts that cannot have NSAIDs at all?

A

ASthma with nasal polyps
- these pts usually eosinophilic

58
Q

What is one of the potential triggers for predominatly noctural asthma?

A

Reflux disease

59
Q

What are the 4x phenotypes of asthma?

A
  • IgE mediated (allergic)
  • Eosinophilic asthma (eosins >0.3)
  • Neutrophilic asthma
  • paauci immune (very rare)
  • Fixed obstruction (usually older pts with some degree of fixed obstruction due to lack of initial treatment in the old days)
60
Q

Which group of asthma pts should always be offered a biologic? What are some examples of biologics for asthma?

A

Pts with IgE or eosinophilic asthma that is poorly controlled or severe.

Omalizumab - anti IgE
Mepolizumab - anti IL5
Benzalizumab - Anti IL5
Dupilimab - Anti IL4

61
Q

Which form of asbestos related lung disease requires the most prolongued exposure to get?

A

Asbestosis
- mesothelioma can get on single exposure

62
Q

What are the three types of asbestos and which one is most related to mesothelioma?

A

Blue - most associated with meso
- Aus has highest rates of meso due to used to mine blue asbestos
White
Brown or grey

63
Q

What are the five types of asbestos related lung disease ?

A

Pleural plaques
Abestos related pleural disease
Asbestosis
mesothilioma
Lung cancer (NSCLC, particular SCC)

64
Q

What is the significant of prognosis of a pleural plaque?

A

Plural plaques appear as thin hyperdense lines around the lungs on CXR

they are a marker of asbestos exposure (ie more plaques then more exposure), but are not premalignant and will not turn into cancer

65
Q

Why do we monitor pleural plaques?

A

Pleural plaques are not pre malignant
We monitor these pts because the have had asbestos exposure and can develop some other form of malignant asbestos related disease

66
Q

What is asbestos related pleural disease?

A

This is different from plaques because it is more diffuse pleural thickening rather than patch like discrete areas

Definition is pleural thickening more than 25% of the CT
ASbestos related pleural disease is also benign, like pleural plaques

67
Q

What are some other radiological features that can be associated with asbestos pleural disease?

A

may be initiall associated with pleural effusiuon, but often not

May be associated with rounded atalectasis
- this is a hyperdense lung lesion that is immediately adjacent to the pleura. Crows feet sign positive (pleura wrapping around the atelectasis)

68
Q

What is the rarest form of asebestos related lung disease?

A

ASbestosis

69
Q

What is asbestosis? WHo gets it? Treatment and prog?

A

This is fibrotic type of ILD
- need long exposure (ie builder who has worked with asbestos for 40 yrs)

Antifibrotics, but dont work that well
Progressive and uncurable

70
Q

What is the distinguishing feature about mesothelioma compared to asbestosis in relation to exposure?

A

Can get meso with single exposure (may not even know you have been exposed)
- dont let lack of occupation hx deter from potential Dx

71
Q

What is the very specific exam finding of mesothelioma? What is the classic presentaiton of meso?

A

Chest wall ache in pt with pleural effusion

Old man
Pleural effusion
Dull chest wall ache at night

72
Q

Reflection of pleural thickening on the pericardium is concerning for what type of asbestos related lung disease?

A

Mesothelioma

73
Q

Pt with pleural effusion and chest drain. Chest drain was takne out and subsequent over many weeks pt developed mass along the chest tube tract. Dx?

A

Mesotherlioma
It will relentlessly seed and invade anything

74
Q

Chemo regime of meso?

A

Pemitrexed +/- immuno

75
Q

How can you tell the difference between MTX related lung disease and RA related lung disease for pt with RA on MTX?

A

The key is to look at the disease activity. RA lung disease will mimic the disease activity

  • If have pt with elevated inflam markers, flare of RA (ie joint pains etc) and CT showing more inflamatory type ILD (ground glass) -> then this is CT ILD and shoudl not stop MTX

If have pt with good disease control, normal inflam markers and more fibrotic picture on chest imaging then this is MTX related lung disease. Should stop MTX for 8 weeks and do lung fucntion and CT tests. Then repeat lung function and CT 8 weeks later to see if there has been an improvment

76
Q

Pts with which type of ILD are at increased risk of reactivation of TB?

A

SArcoidosis
- unclear why

77
Q

How is thunderstorm asthma dif from asthma that triggers in thunderstorms?

A

Thunderstorm asthma is asthma that only triggers in thunderstorms

Asthma that triggers in thunderstorm can have other triggers

78
Q

What are pts with thunderstorm asthma alergic to? What is required for thunderstorm asthma to occur?

A

Rye grass

  • Have the live in an area that grows rye grass
  • Thunderstorm has to occur
  • Thunderstorm has to occur in the time the the rye grass is polinating (6 weeks of the year)

WInd takes polinating rye grass antigens into the clouds
- lightning in clouds breaks up the pollen into small enough particles that can enter small airways

majority of people with thunderstorm asthma have hay fever

Respiritory (2 decks)

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