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MRCP > Respiratory > Flashcards

Respiratory Flashcards

1
Q

Which size vessels does Churg-Strauss syndrome affect?

A

small- to medium-sized

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2
Q

What are the main symptoms of Churg-Strauss syndrome?

A

Pulmonary - asthma, rhinitis, sinusitis, nasal polyposis
Cardiac - myocarditis, HF, MI
Also skin, GI, renal
Systemic features - fever, myalgia, fatigue, WL

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3
Q

Which Ab is sometimes present in Churg-Strauss syndrome?

A

p-ANCA (30-40%)

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4
Q

How to treat Churg-Strauss?

A

High-dose steroids

Immunosuppressants e.g. cyclophosphamide

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5
Q

What are the main organs affected in Granulomatosis with Polyangiitis?

A

ELK classification
E - ear/nose/throat: epistaxis, haemoptysis, sinusitis
L - lung
K - kidney: rapidly progressive glomerulonephritis
Also - saddle-shape nose deformity

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6
Q

Which Abs are positive in Granulomatosis with Polyangiitis?

A

c-ANCA (>90%) and p-ANCA (25%)

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7
Q

Management of Granulomatosis with Polyangiitis?

A

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

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8
Q

What age group does idiopathic pulmonary fibrosis usually affect?

A

Men 50-70s

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9
Q

What are the symptoms of idiopathic pulmonary fibrosis?

A

Dry cough
Exertional dyspnoea
WL

+ Malaise, arthralgia

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10
Q

What sign might you hear on auscultation in Idiopathic Pulmonary Fibrosis?

A

Fine end-inspiratory crackles

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11
Q

What screening investigation might you perform in Idiopathic Pulmonary Fibrosis?

A

Reduced transfer factor coefficient (TLCO)

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12
Q

What might you see on CXR in Idiopathic Pulmonary Fibrosis?

A

Decreased lung volume
Bilateral lower zone reticulonodular shadows
Ground glass -> Honeycomb lung (adv disease)

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13
Q

What is the investigation of choice in Idiopathic Pulmonary Fibrosis?

A

CT

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14
Q

Management of Idiopathic Pulmonary Fibrosis?

A

Best supportive care – O2, pulmonary rehabilitation, opiates, palliative care input
High-dose steroids – ONLY use if diagnosis of IPF is in doubt
Lung transplantation

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15
Q

Prognosis of Idiopathic Pulmonary Fibrosis?

A

50% survival at 5 years

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16
Q

Management of acute asthma?

A

1) SABA (salbutamol)
If asthma not controlled/new Dx + symptoms ≥3 times/wk or night-time waking:
2) Low-dose ICS (beclometasone)
3) Add a LTRA (montelukast), continue if responsive
4) LABA (salmeterol)
5) Switch to low dose MART (maintenance + reliever therapy) is now an option for patients with poorly controlled asthma – contains ICS + LABA in a single inhaler
6) Switch to medium dose MART
7) Stop MART, use high dose ICS OR start theophylline/LAMA

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17
Q

Which asthma medications are safe during pregnancy and breast-feeding?

A

All of them

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18
Q

Which abx is used to treat pneumonia caused by Chlamydia psittaci?

A

Tetracyclines

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19
Q

What are the RFs for Klebsiella pneumonia?

A

Elderly, DM, alcoholics

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20
Q

What are the RFs for Pseudomonas pneumonia?

A

Bronchiectasis/CF

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21
Q

What are the RFs for Legionella pneumonia?

A

Colonised water tanks (hotel zircon/hot water systems)

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22
Q

Which abx to treat Legionella pneumonia?

A

Clarithromycin/erythromycin - macrolides

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23
Q

Complications of pneumonia?

A

T1 resp failure, hypotension, AF, pleural effusion, empyema, lung abscess, septicaemia, pericarditis/myocarditis

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24
Q

Most common organism for CAP?

A

Strep pneumoniae -> often assoc with reactivation of cold sores
H. influenzae
Mycoplasma pneumoniae -> haemolytic anaemia, erythema nodosum/multiforme

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25
Q

Most common organism for HAP?

A

Gram neg enterobacteria
Staph aureus
Pseudomonas, Klebsiella

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26
Q

What are the causes of lower zone lung fibrosis?

A

‘RAID’ causes of lower zone fibrosis - rheumatological conditions, asbestos exposure, idiopathic and drug-induced - amiodarone, Mtx

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27
Q

What are the causes of extrinsic allergic alveolitis?

A

Bird-fanciers/pigeon-fancier’s lung
Farmer’s/mushroom worker’s lung
Malt worker’s lung

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28
Q

What might you see on CXR in extrinsic allergic alveolitis?

A

upper/mid zone fibrosis

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29
Q

Management of extrinsic allergic alveolitis?

A

avoid precipitating factors

oral glucocorticoids

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30
Q

Symptoms of extrinsic allergic alveolitis?

A 
acute (occurs 4-8 hrs after exposure)
- dyspnoea
- dry cough
- fever
chronic (occurs weeks-months after exposure)
- lethargy
- dyspnoea
- productive cough
- anorexia and weight loss
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31
Q

How would you define sarcoidosis?

A

a multisystem granulomatous disorder of unknown cause

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32
Q

In who is sarcoidosis more common?

A

Black women

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33
Q

What might you see on CXR in sarcoidosis?

A

bilateral hilar lymphadenopathy +/- pulmonary infiltrates/fibrosis

stage 0 = normal
stage 1 = BHL
stage 2 = BHL + interstitial infiltrates
stage 3 = diffuse interstitial infiltrates only
stage 4 = diffuse fibrosis
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34
Q

What is the presentation of pulmonary sarcoidosis?

A 
Dry cough
Progressive dyspnoea
Decreased exercise tolerance
Chest pain
\+ systemic symptoms (fever, WL, fatigue)
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35
Q

Non-pulmonary presentation of sarcoidosis?

A

Liver (20%) – nodes, cirrhosis, cholestasis
Eyes (20%) – uveitis, conjunctivitis, optic neuritis
Skin (15%) – erythema nodosum, lupus pernio
Heart/kidney/CNS affects are more rare

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36
Q

What might you see on bloods in sarcoidosis?

A

Raised serum ACE (60%) and Calcium (10%)

Rasied Igs, ESR, LFTs

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37
Q

What would you see on tissue biopsy in sarcoidosis?

A

non-caseating granulomata with epithelioid cells

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38
Q

How to manage sarcoidosis?

A

Bilateral hilar lymphadenopathy alone – no Rx needed
Acute – bed rest, NSAIDs
Consider steroids – prednisolone 6-12 months, immunosuppressants

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39
Q

What are the indications for steroids in sarcoidosis?

A

symptoms + stage 2-3 on CXR
hypercalcaemia
eye, cardiac or neurological involvement

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40
Q

Indications for NIV?

A

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

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41
Q

Recommended initial pressures for BiPAP in COPD?

A

IPAP = 10 cm H2O; EPAP = 5 cm H20

LIES
1ie5

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42
Q

Which asthma med is associated with the unmasking of granulomatosis with polyangiitis?

A

Montelukast

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43
Q

What is the most common bacterial organism seen in an infective exacerbation of COPD?

A

H. influenzae

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44
Q

What might be seen on imaging of bronchiectasis?

A

tramlines, signet ring sign

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45
Q

Causes of raised TLCO?

A 
asthma
pulmonary haemorrhage (Wegener's, Goodpasture's)
left-to-right cardiac shunts
polycythaemia
hyperkinetic states
male gender, exercise
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46
Q

Causes of lower TLCO?

A 
pulmonary fibrosis
pneumonia
pulmonary emboli
pulmonary oedema
emphysema
anaemia
low cardiac output
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47
Q

What is the TLCO test?

A

Breathe in CO + helium, hold breath, breathe out
Tells you how well gas exchange is occuring
Poor = less than 80% predicted

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48
Q

What is A1AT deficiency?

A

an inherited disease (Chr 14) affecting the lung (emphysema) and liver (cirrhosis and hepatocellular cancer)

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49
Q

What is the function of A1AT?

A

Protein that protects against neutrophil elastase

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50
Q

What investigations for A1AT deficiency?

A

Low serum A1AT levels
Spirometry
Liver biopsy
Phenotyping

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51
Q

Management of A1AT deficiency?

A 
Supportive Tx may be adequate
Quit smoking (lack of A1AT acts like cigarette smoke)
Bronchodilators
May need liver transplantation
IV A1AT
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52
Q

What is the most common cause of death in A1AT deficiency?

A

Emphysema

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53
Q

What should the target saturation be for COPD patients before knowing whether or not they are retainers?

A

88-92%

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54
Q

Which type of lung cancer is most common among non-smokers or found peripherally?

A

adenocarcinomas

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55
Q

What is the most common type go lung Ca?

A 
Non-small cell carcinomas (85%)
Small cell (15%)
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56
Q

Which type of lung Ca is more aggressive?

A

Small cell tumours

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57
Q

What investigations for lung Ca?

A

Sputum/pleural fluid cytology
CXR
Fine needle biopsy
Bronchoscopy for histology and assess operability
CT+/-PET for staging
Radionucleotide bone scan if mets suspected
Lung function tests - help to assess suitability for lobectomy

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58
Q

Prognosis of lung Cas?

A

NSCLC – 50% 2 year survival without spread

SCLC – 50% 1-1.5 year survival with treatment

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59
Q

Complications of lung Ca?

A

Local - recurrent laryngeal/phrenic nerve palsy, SVC obstruction, Horner’s syndrome (Pancoast tumour), pericarditis, AF
Mets - bone, brain, liver, adrenals
Endocrine - SIADH, Cushings d/t ectopic hormone secretion from SCLC
Neurological (non-metastatic) - confusion, fits, cerebellar syndrome, Lambert Eaton syndrome

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60
Q

Which bacteria is responsible for farmer’s lung?

A

Saccharopolyspora rectivirgula

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61
Q

Which bacteria is responsible for malt worker’s lung?

A

aspergillus clavatus

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62
Q

What lifelong advice would you give to a patient with a pneumothorax?

A

Avoid deep sea diving for life

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63
Q

What are examples of obstructive lung disease?

A

Asthma, COPD, Bronchiectasis

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64
Q

What are examples of restrictive lung disease?

A

Pulmonary fibrosis, Asbestosis, Sarcoidosis, ARDS, Kyphoscoliosis, NM disorders, severe obesity

  • FEV1/FVC >0.7
  • Harder to get air in
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65
Q

What would you do to investigate for occupational asthma?

A

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

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66
Q

What are the stages of CXR in sarcoidosis?

A 
1 = BHL
2 = BHL + infiltrates
3 = infiltrates
4 = fibrosis
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67
Q

Common causes of resp alkalosis?

A 
anxiety leading to hyperventilation
pulmonary embolism
salicylate poisoning
CNS disorders: stroke, subarachnoid haemorrhage, encephalitis
altitude
pregnancy
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68
Q

What findings might you see on CXR in silicosis?

A

Fibrotic lung disease

‘egg-shell’ calcifications of the hilar LNs

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69
Q

Who is at risk of silicosis?

A

miners, slate workers, pottery workers

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70
Q

What does having silicosis put you more at risk of?

A

TB

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71
Q

How can a diagnosis of mesothelioma be made?

A

CXR/CT – pleural thickening/effusion
Bloody pleural fluid
Official diagnosis: Made on histology, following thoracoscopy – often post-mortem

72
Q

What are the CIs to NSCLC surgery?

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

73
Q

What are the landmarks for inserting a chest drain?

A

Base of axilla, lateral pectoralis major, 5th intercostal space, anterior latissimus dorsi

74
Q

Colonisation of which bug is a CI for transplant in CF?

A

Burkholderia cepacia

75
Q

What is a catamenial pneumothorax?

A

Pneumothorax that occurs when women are menstruating. Can occur monthly and pain may radiate to the shoulder

76
Q

How to investigate COPD?

A

Post-bronchodilator spirometry
CXR - hyperinflation, flat hemidiaphragm, bullae
ECG - right atrial/ventricular hypertrophy (cor pulmonale)
ABG – decreased PaO2 +/- increased PaCO2
Bloods

77
Q

What is the NICE classification for the severity of COPD?

A
  • Stage 1; Mild: FEV1 > 80%
  • Stage 2; Moderate: FEV1 = 50-79%
  • Stage 3; Severe: FEV1 = 30-49%
  • Stage 4: Very severe: FEV1 < 30% (or FEV1 < 50% but with respiratory failure)
78
Q

What values give you a positive bronchodilator reversibility test?

A

improvement of FEV1 >12% and increase in volume of >200ml

79
Q

If spirometry is normal, can asthma be excluded?

A

No, need to do a fractional exhaled nitric oxide test (FeNO) - level of NO tends to rise in inflammatory cells so will be higher if asthma is present

80
Q

Which conditions results in upper zone fibrosis?

A 
CHARTS
C - Coal worker's pneumoconiosis
H - Histiocytosis/ hypersensitivity pneumonitis
A - Ankylosing spondylitis
R - Radiation
T - Tuberculosis
S - Silicosis/sarcoidosis
81
Q

What is the difference between TLCO and KCO?

A 
TLCO = total capacity of the lung to gas exchange
TLCO = Va (volume of lung) x KCO (each alveolars capacity to gas exchange)
82
Q

What are causes of pneumothorax?

A

asthma, COPD, TB, pneumonia, lung abscess, Ca, CF

83
Q

In what circumstance would you insert a chest drain in the first instance for a pneumothorax?

A

SOB and age >50 and rim of air >2cm on CXR

84
Q

When to seek surgical advice for pneumothoraces?

A

• Bilateral pneumothoraxes
• Failure of IC drain insertion
• 2+ previous pneumothoraxes on same side
• History of pneumothorax on the opposite side
 

85
Q

Causes of COPD?

A

Smoking!
Alpha-1 antitrypsin deficiency
cadmium (used in smelting), coal, cotton, cement, grain

86
Q

What is a transudate?

A

Transudates (<25g/L protein)
- A transudate is fluid that is pushed out of the vessels due to hydrostatic pressure – either too much fluid (e.g. back up of blood into pulmonary vessels due to CCF, fluid overload) or due to hypoproteinaemia (e.g. in cirrhosis, malabsorption)

87
Q

What is an exudate?

A

Exudates (>35g/L protein)
- Exudate fluid leaks out of vessels in an inflammatory response – gap between the endothelial cells widen and fluids and proteins leak out, therefore there is a high protein content found in exudates e.g. caused by infection, Ca, PE, RA, SLE, pancreatitis etc

88
Q

Uni + bilateral pleural effusions are more likely to be exudates or transudates?

A

Unilateral pleural effusion more likely to be exudates, bilateral more likely to be transudates

89
Q

Management of pleural effusion?

A

May require drainage if symptomatic,
chemical (using tetracycline, bleomycin) or surgical artificial obliteration of the pleural space,
Surgery

90
Q

What are the indications for chest tube insertion in patients with pleural effusions?

A
  • purulent/cloudy fluid on aspiration
  • fluid that grows a bug on culture
  • fluid with pH <7.2
91
Q

What is Lofgren’s syndrome in Sarcoidosis?

A

bilateral hilar lymphadenopathy, erythema nodosum, polyarthritis and fever

92
Q

What factors are associated with poor prognosis in sarcoidosis?

A 
insidious onset, symptoms > 6 months,
absence of erythema nodosum,
extrapulmonary manifestations: e.g. lupus pernio, splenomegaly,
CXR: stage III-IV features,
black people
93
Q

When can you travel after pneumothorax resolutions?

A

1-2 weeks, depending on guidelines

94
Q

What shifts the O2 dissociation curve to the right?

A

Everything goes up
Imagine running uphill:
High temp, high CO2, acidosis (think lactate), high 2-3 DPG

95
Q

What causes A1AT deficiency?

A

Lack of protease inhibitor normally produced in the liver

96
Q

Causes of occupational asthma?

A 
GF works at PEPSI factory and comes home every day with asthma symptoms
GF— Glutaraldehyede. Flour 
PEPSi : 
Platinum salt 
Epoxy resins 
Proteiolytic enzymes 
Soldering flux resins 
Isocynayes
97
Q

Typical VC in male and females?

A

Males - 4.5L

Females - 3.5L

98
Q

What can be used to prevent altitude related sickness?

A

Acetazolamide, a carbonic anhydrase inhibitor
- it causes a primary metabolic acidosis and compensatory respiratory alkalosis which increases respiratory rate and improves oxygenation

99
Q

Which type of lung Ca is most associated with cavitating lesions?

A

Squamous cell

100
Q

Which type of lung Ca mets are most associated with calcified lesions?

A

osteosarcomas and chondrosarcomas

101
Q

Which type of lung Ca is most associated with consolidation?

A

Adenocarcinoma

102
Q

Which type of lung Ca is most associated with haemorrhage?

A

choriocarcinoma and angiosarcoma

103
Q

Which type of lung Ca is most associated with miliary pattern?

A

renal cell carcinoma and malignant melanoma

104
Q

What is the best way to investigate for upper airway obstruction?

A

Flow volume loop

105
Q

Management of high altitude cerebral edema (HACE) and high altitude pulmonary oedema?

A

HACE: Descent and dexamethasone
HAPE: Descent + dex/acetazolamide/nifedipine (all work by decreasing systolic artery pressure)

106
Q

Causes of bronchiectasis?

A

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

107
Q

What are the predisposing factors for OSA?

A

obesity
macroglossia: acromegaly, hypothyroidism, amyloidosis
large tonsils
Marfan’s syndrome

108
Q

Which HLA is associated with bronchiectasis?

A

HLA-DR1

109
Q

What is ARDS?

A

rapid onset widespread inflammation in the lungs
fluid accumulation in the alveoli caused by increased permeability of alveolar capillaries -> non-cardiogenic pulmonary oedema and impaired gas exchange

110
Q

Causes of ARDS?

A

Direct: Infections, trauma, smoke inhalation, aspiration

Indirect: sepsis, pancreatitis, massive blood transfusion

111
Q

Presentation of ARDS? Symptom + clinical examination

A

Characterised by bilateral pulmonary infiltrates + severe hyoxaemia
SOB (hrs-days after an event), raised RR, bilateral lung crackles, low O2

112
Q

Management of ARDS?

A 
Generally managed in ITU
Oxygenation/ventilation
General organ support e.g. vasopressors
Treatment of underlying cause e.g. abx for sepsis
Prone positioning/muscle relaxation
113
Q

What is the mortality of ARDS?

A

40%

114
Q

Management of COPD?

A

SABA/SAMA
Then consider asthmatic features
If no asthmatic -> LABA + LAMA
If asthmatic -> LABA + ICS

115
Q

Example of LABA?

A

Salmeterol/Formeterol

116
Q

Example of SAMA?

A

Ipratropium

117
Q

Example of LAMA?

A

Tiotropium

118
Q

Criteria for LTOT?

A

Very severe airflow obstruction (FEV1<30%)
Cyanosis
Polycythaemia (increased conc of Hb)
Peripheral oedema
Raised JVP
O2 sats less than or = to 92% on room air

119
Q

How to determine if COPD patients required LTOT?

A

Need 2x ABGs on 2 occasions at least 3wks apart in patients with stable COPD

Offer LTOT to patients with a pO2 of < 7.3 kPa or to those with a pO2 of 7.3 - 8 kPa and one of the following:
secondary polycythaemia
peripheral oedema
pulmonary hypertension

120
Q

Examples of T1 resp failure?

A 
caused by a ventilation/perfusion mismatch (V/Q mismatch) e.g. in:
	Pneumonia
	Pulmonary Oedema
	PE
	Asthma
	Emphysema
	Pulmonary fibrosis
121
Q

Examples of T2 resp failure?

A

Caused by alveolar hypoventilation with or without V/Q mismatch e.g. in:
 Pulmonary disease – asthma, COPD, pneumonia, end-stage pulmonary fibrosis etc
 Reduced respiratory drive – sedative drugs, CNS tumour or trauma
 Neuromuscular disease – cervical cord lesion, myasthenia gravis, GBS
 Thoracic wall disease – flail chest, kyphoscoliosis

122
Q

Management of PE?

A

LMWH - stop when INR >2
Warfarin - for a minimum of 3 months (aim for INR 2-3)
Thrombolysis for massive PE + hypotension (alteplase)
Consider vena cava filter in patients with emboli despite adequate anticoagulation

123
Q

ECG changes in PE?

A

 Tachycardia
 RBBB
 T wave inversion/depression in V1 + V2
 S1Q3T3 – deep S waves in lead 1, path Q’s in lead 3, inverted T waves in lead 3

124
Q

Paraneoplastic features of squamous cell Ca?

A
  • parathyroid hormone-related protein (PTH-rp) secretion causing hypercalcaemia
  • clubbing
  • hypertrophic pulmonary osteoarthropathy (HPOA)
  • hyperthyroidism due to ectopic TSH
125
Q

Paraneoplastic features of adenocarcinoma?

A
  • gynaecomastia

* hypertrophic pulmonary osteoarthropathy (HPOA)

126
Q

Paraneoplastic features of SCLC?

A
  • ADH
  • ACTH - not typical, hypertension, hyperglycaemia, hypokalaemia, alkalosis and muscle weakness are more common than buffalo hump etc
  • Lambert-Eaton syndrome
127
Q

Which type of lung Ca more commonly causes Horner’s syndrome?

A

Squamous cell carcinoma

128
Q

In addition to Horners, what other complications can be caused by a pancoast tumour?

A

Causes voice hoarseness from compression on recurrent laryngeal N
Can also infiltrate part of the brachial plexus and ribs, causing severe pain and neurological symptoms down the arm

129
Q

What occurs in allergic bronchopulmonary aspergillosis?

A

allergic reaction to aspergillosis

Early on inflammation causes bronchoconstriction, turns into permanent damage and bronchiectasis

130
Q

How to treat allergic bronchopulmonary aspergillosis?

A

Steroids PO

131
Q

What is cor pulmonale?

A

right heart failure caused by chronic pulmonary arterial hypertension

132
Q

Causes of cor pulmonale?

A

Chronic lung disease (COPD, bronchiectasis, pulmonary fibrosis, asthma)
Pulmonary vascular disorders (PE, pulmonary vasculitis)
Thoracic cage abnormality (Kyphosis, scoliosis)
NM diseases (Myasthenia gravis, polio, motor neuron disease)

133
Q

What is the cause of CF?

A

D/t defect in the CF transmembrane conductance regulator gene (CFTR) which codes a cAMP-regulated chloride channel
In UK, 80% are due to delta F508 on the long arm of Chr 7

134
Q

Which organisms may colonise CF patients?

A
  • Staphylococcus aureus
  • Pseudomonas aeruginosa
  • Burkholderia cepacia
  • Aspergillus
135
Q

What the symptoms and blood results like in pneumonia caused by legionella?

A

Flu-like symptoms + dry cough, blood tests may show hyponatraemia, deranged LFTs

136
Q

How would you diagnose legionella causing pneumonia?

A

Urinary antigen

137
Q

What are the different grades of sleep apnoea?

A 
Mild OSA: AHI 5-14/h
Mod OSA: AHI 15-30/h
Treat above two if symptomatic
Severe OSA: AHI >30/h
Treat even if not symptomatic
138
Q

What is OHS (obesity hypoventilation syndrome)?

A

Sleep disordered breathing, hypercapnoea, high BMI, without other cause

139
Q

What are the ITU options for acute life-threatening asthma?

A

intubation and ventilation

extracorporeal membrane oxygenation (ECMO)

140
Q

What counts as a positive results in FeNO testing?

A

Positive result: Adults >40, children >35

141
Q

How would you diagnose allergic bronchopulmonary aspergillosis?

A 
eosinophilia
flitting CXR changes
positive RAST test to Aspergillus
positive IgG Abs (not as positive as in aspergilloma)
raised IgE
142
Q

What are the symptoms of mesothelioma and which is the most dangerous type of asbestos?

A 
Chest pain
Dyspnoea
WL
Clubbing
Recurrent pleural effusions

Crocidolite asbestos

143
Q

What are pleural plaques?

A

NEVER undergo malignant change

Related to asbestos

144
Q

When should you start an ICS in asthma?

A

If not controlled with SABA
OR
Newly-diagnosed asthma with symptoms >= 3 / week or night-time waking (probably maj of patients - so start as first medication with SABA)

145
Q

What doses constitute low -> high ICS?

A

LOW <= 400 mcgs budesonide
MODERATE = 400 - 800 mcgs budesonide
HIGH > 800 mcgs budesonide

146
Q

What is the pathological process in atelectasis and what causes it? How to treat?

A

when airways become obstructed by bronchial secretions
Common post-op complications
Sitting upright, chest physio

147
Q

Causes of bilateral hilar lymphadenopathy?

A 
BFs tell lies
Berylliosis
Fungi
Sarcoidosis
TB
Lymphoma/other malignancy
148
Q

Most common organisms isolated from patients with bronchiectasis?

A

Haemophilus influenzae (c)
Pseudomonas aeruginosa (think CF)
Klebsiella spp.
Streptococcus pneumoniae

149
Q

Relative contraindications for chest drain?

A

INR > 1.3
Platelet count < 75
Pulmonary bullae
Pleural adhesions

150
Q

What is re-expansion pulmonary oedema? How to avoid this complication?

A

Re-expansion pulmonary oedema is an uncommon complication occurring in less than 1% of cases where a lung has been rapidly re-expanded after being passively collapsed by a large pleural effusion or a pneumothorax
To avoid this, should limit drainage amounts to encourage slow re-inflation

151
Q

What is the differential diagnosis for a cavitating lesion?

A

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

152
Q

Ca that met to lung?

A 
breast cancer
colorectal cancer
renal cell cancer
bladder cancer
prostate cancer
153
Q

What are the criteria to determine if a patient has asthmatic/steroid responsive features in COPD?

A

any previous, secure diagnosis of asthma or atopy
a higher blood eosinophil count
substantial variation in FEV1 over time (at least 400 ml)
substantial diurnal variation in peak expiratory flow (at least 20%)

154
Q

What is cryptogenic organizing pneumonia, what are the blood test and what is the management?

A

diffuse interstitial lung disease that affects the distal bronchioles, respiratory bronchioles, alveolar ducts and alveolar walls
Unknown cause
Elevated inflam markers
CXR - bilateral patchy/diffuse consolidation
Tx: watch + wait
severe = steroids

155
Q

Symptoms of CF?

A
  • Neonatal -> meconium ileus, prolonged jaundice
  • Recurrent chest infections (40%)
  • Malabsorption – steatorrhoea, failure to thrive
  • Other – liver disease
Other features of cystic fibrosis:
• short stature
• diabetes mellitus
• delayed puberty
• rectal prolapse (due to bulky stools)
• nasal polyps
• male infertility, female subfertility
156
Q

Management of CF?

A
  • Twice daily chest physio + postural drainage
  • High calorie diet incl high fat intake
  • Minimise contact with other CF patients to prevent spread of infections
  • Vitamin supplements + pancreatic enzyme supplements with meals
  • Lung transplantation (CI: chronic infection)
157
Q

Medication options in CF?

A

Lumacaftor – increased number of CFTR proteins that are transported to cell surface
Ivacaftor – increases probability that the CFTR channel will be open and allow Cl ions through

158
Q

MOA of theophylline?

A

Non-specific inhibitor of phosphodiesterase resulting in an increase in cAMP

159
Q

Which blood test on FBC is NOT raised in extrinsic allergic alveolitis?

A

NO eosinophils

160
Q

What is Kartanger’s syndrome?

A 
A type of primary ciliary dyskinesia 
dextrocardia or complete situs inversus
bronchiectasis
recurrent sinusitis
subfertility (secondary to diminished sperm motility and defective ciliary action in the fallopian tubes)
161
Q

Which type of asthma are LTRA most useful?

A

aspirin-induced asthma

162
Q

Why typically gets Lofgren’s syndrome and what is the prognosis?

A

Young females

Excellent prognosis

163
Q

Who typically gets lung carcinoid tumours and what do you see on bronchoscopy?

A

40-50yr non-smokers
Slow-growing tumour
‘Cherry red balls’ on bronch

164
Q

Factors that increase (and one that dose not) the risk of lung Ca?

A 
smoking
asbestos
arsenic
radon
nickel
chromate
aromatic hydrocarbon
cryptogenic fibrosing alveolitis

Not increase: coal dust

165
Q

What cells do SCLC arise form?

A

APUD
Amine - high amine content
Precursor Uptake - high uptake of amine precursors
Decarboxylase - high content of the enzyme decarboxylase

166
Q

Contact with which animal is a RF for MERS?

A

Camels

167
Q

When should the DVLA be informed in OSA?

A

if OSAHS is causing excessive daytime sleepiness

168
Q

What is Omalizumab, in who is it indicated and what is a potential SE?

A

A Mab which binds to free human IgE - given as s/c 2-4wkly in ASTHMA
Risk - Churg-strauss syndrome

169
Q

What is Light’s criteria?

A

if the protein level is between 25-35 g/L, Light’s criteria should be applied. An exudate is likely if at least one of the following criteria are met:
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

170
Q

What is Psittacosis? How is it spread and how to Ix and Tx?

A

Infection caused by Chlamydia psittaci
Most common presentation = atypical pneumonia
Often history of bird contact (reported in 84%) or failure to respond to penicillin-based antibiotics
Confirmation with serology (usually as part of atypical pneumonia screening)

Tx: Tetracyclines, 2nd line = macrolides

171
Q

What is Loffler’s syndrome?

A

Presents with fever, cough and night sweats which often last <2 wks
transient CXR shadowing and blood EOSINOPHILIA
due to parasites such as Ascaris lumbricoides causing an alveolar reaction

172
Q

How to define pulmonary hypertension?

A

mean pulmonary arterial pressure of greater than 25 mmHg at rest

173
Q

What are the 5 groups of pulmonary HTN?

A

1) Pulmonary artery hypertension
2) Pulmonary hypertension with left heart disease
3) Pulmonary hypertension secondary to lung disease/hypoxia
4) Pulmonary hypertension due to thromboembolic disease
5) Miscellaneous conditions

174
Q

What is the functional residual capacity?

A

the volume in the lungs at the end-expiratory position

Including the expiratory reserve volume and the residual volume (dead space)

175
Q

What is Caplan’s syndrome?

A

A combination of rheumatoid arthritis and pneumoconiosis related to mining dust (coal, asbestos, silica) that manifests as intrapulmonary nodules

176
Q

What is Heerfordt’s syndrome?

A

(uveoparotid fever) there is parotid enlargement, fever and uveitis secondary to sarcoidosis

177
Q

Other than hot water tanks, what other signs might you get for a legionella cause of pneumonia?

A

hyponatraemia, relative bradycardia, confusion, deranged LFTs

MRCP (14 decks)

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