Respiratory Flashcards
Which size vessels does Churg-Strauss syndrome affect?
small- to medium-sized
What are the main symptoms of Churg-Strauss syndrome?
Pulmonary - asthma, rhinitis, sinusitis, nasal polyposis
Cardiac - myocarditis, HF, MI
Also skin, GI, renal
Systemic features - fever, myalgia, fatigue, WL
Which Ab is sometimes present in Churg-Strauss syndrome?
p-ANCA (30-40%)
How to treat Churg-Strauss?
High-dose steroids
Immunosuppressants e.g. cyclophosphamide
What are the main organs affected in Granulomatosis with Polyangiitis?
ELK classification
E - ear/nose/throat: epistaxis, haemoptysis, sinusitis
L - lung
K - kidney: rapidly progressive glomerulonephritis
Also - saddle-shape nose deformity
Which Abs are positive in Granulomatosis with Polyangiitis?
c-ANCA (>90%) and p-ANCA (25%)
Management of Granulomatosis with Polyangiitis?
steroids
cyclophosphamide (90% response)
plasma exchange
median survival = 8-9 years
What age group does idiopathic pulmonary fibrosis usually affect?
Men 50-70s
What are the symptoms of idiopathic pulmonary fibrosis?
Dry cough
Exertional dyspnoea
WL
+ Malaise, arthralgia
What sign might you hear on auscultation in Idiopathic Pulmonary Fibrosis?
Fine end-inspiratory crackles
What screening investigation might you perform in Idiopathic Pulmonary Fibrosis?
Reduced transfer factor coefficient (TLCO)
What might you see on CXR in Idiopathic Pulmonary Fibrosis?
Decreased lung volume
Bilateral lower zone reticulonodular shadows
Ground glass -> Honeycomb lung (adv disease)
What is the investigation of choice in Idiopathic Pulmonary Fibrosis?
CT
Management of Idiopathic Pulmonary Fibrosis?
Best supportive care – O2, pulmonary rehabilitation, opiates, palliative care input
High-dose steroids – ONLY use if diagnosis of IPF is in doubt
Lung transplantation
Prognosis of Idiopathic Pulmonary Fibrosis?
50% survival at 5 years
Management of acute asthma?
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
Which asthma medications are safe during pregnancy and breast-feeding?
All of them
Which abx is used to treat pneumonia caused by Chlamydia psittaci?
Tetracyclines
What are the RFs for Klebsiella pneumonia?
Elderly, DM, alcoholics
What are the RFs for Pseudomonas pneumonia?
Bronchiectasis/CF
What are the RFs for Legionella pneumonia?
Colonised water tanks (hotel zircon/hot water systems)
Which abx to treat Legionella pneumonia?
Clarithromycin/erythromycin - macrolides
Complications of pneumonia?
T1 resp failure, hypotension, AF, pleural effusion, empyema, lung abscess, septicaemia, pericarditis/myocarditis
Most common organism for CAP?
Strep pneumoniae -> often assoc with reactivation of cold sores
H. influenzae
Mycoplasma pneumoniae -> haemolytic anaemia, erythema nodosum/multiforme
Most common organism for HAP?
Gram neg enterobacteria
Staph aureus
Pseudomonas, Klebsiella
What are the causes of lower zone lung fibrosis?
‘RAID’ causes of lower zone fibrosis - rheumatological conditions, asbestos exposure, idiopathic and drug-induced - amiodarone, Mtx
What are the causes of extrinsic allergic alveolitis?
Bird-fanciers/pigeon-fancier’s lung
Farmer’s/mushroom worker’s lung
Malt worker’s lung
What might you see on CXR in extrinsic allergic alveolitis?
upper/mid zone fibrosis
Management of extrinsic allergic alveolitis?
avoid precipitating factors
oral glucocorticoids
Symptoms of extrinsic allergic alveolitis?
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
How would you define sarcoidosis?
a multisystem granulomatous disorder of unknown cause
In who is sarcoidosis more common?
Black women
What might you see on CXR in sarcoidosis?
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
What is the presentation of pulmonary sarcoidosis?
Dry cough Progressive dyspnoea Decreased exercise tolerance Chest pain \+ systemic symptoms (fever, WL, fatigue)
Non-pulmonary presentation of sarcoidosis?
Liver (20%) – nodes, cirrhosis, cholestasis
Eyes (20%) – uveitis, conjunctivitis, optic neuritis
Skin (15%) – erythema nodosum, lupus pernio
Heart/kidney/CNS affects are more rare
What might you see on bloods in sarcoidosis?
Raised serum ACE (60%) and Calcium (10%)
Rasied Igs, ESR, LFTs
What would you see on tissue biopsy in sarcoidosis?
non-caseating granulomata with epithelioid cells
How to manage sarcoidosis?
Bilateral hilar lymphadenopathy alone – no Rx needed
Acute – bed rest, NSAIDs
Consider steroids – prednisolone 6-12 months, immunosuppressants
What are the indications for steroids in sarcoidosis?
symptoms + stage 2-3 on CXR
hypercalcaemia
eye, cardiac or neurological involvement
Indications for NIV?
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
Recommended initial pressures for BiPAP in COPD?
IPAP = 10 cm H2O; EPAP = 5 cm H20
LIES
1ie5
Which asthma med is associated with the unmasking of granulomatosis with polyangiitis?
Montelukast
What is the most common bacterial organism seen in an infective exacerbation of COPD?
H. influenzae
What might be seen on imaging of bronchiectasis?
tramlines, signet ring sign
Causes of raised TLCO?
asthma pulmonary haemorrhage (Wegener's, Goodpasture's) left-to-right cardiac shunts polycythaemia hyperkinetic states male gender, exercise
Causes of lower TLCO?
pulmonary fibrosis pneumonia pulmonary emboli pulmonary oedema emphysema anaemia low cardiac output
What is the TLCO test?
Breathe in CO + helium, hold breath, breathe out
Tells you how well gas exchange is occuring
Poor = less than 80% predicted
What is A1AT deficiency?
an inherited disease (Chr 14) affecting the lung (emphysema) and liver (cirrhosis and hepatocellular cancer)
What is the function of A1AT?
Protein that protects against neutrophil elastase
What investigations for A1AT deficiency?
Low serum A1AT levels
Spirometry
Liver biopsy
Phenotyping
Management of A1AT deficiency?
Supportive Tx may be adequate Quit smoking (lack of A1AT acts like cigarette smoke) Bronchodilators May need liver transplantation IV A1AT
What is the most common cause of death in A1AT deficiency?
Emphysema
What should the target saturation be for COPD patients before knowing whether or not they are retainers?
88-92%
Which type of lung cancer is most common among non-smokers or found peripherally?
adenocarcinomas
What is the most common type go lung Ca?
Non-small cell carcinomas (85%) Small cell (15%)
Which type of lung Ca is more aggressive?
Small cell tumours
What investigations for lung Ca?
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
Prognosis of lung Cas?
NSCLC – 50% 2 year survival without spread
SCLC – 50% 1-1.5 year survival with treatment
Complications of lung Ca?
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
Which bacteria is responsible for farmer’s lung?
Saccharopolyspora rectivirgula
Which bacteria is responsible for malt worker’s lung?
aspergillus clavatus
What lifelong advice would you give to a patient with a pneumothorax?
Avoid deep sea diving for life
What are examples of obstructive lung disease?
Asthma, COPD, Bronchiectasis
What are examples of restrictive lung disease?
Pulmonary fibrosis, Asbestosis, Sarcoidosis, ARDS, Kyphoscoliosis, NM disorders, severe obesity
- FEV1/FVC >0.7
- Harder to get air in
What would you do to investigate for occupational asthma?
Serial measurements of peak expiratory flow are recommended at work and away from work
What are the stages of CXR in sarcoidosis?
1 = BHL 2 = BHL + infiltrates 3 = infiltrates 4 = fibrosis
Common causes of resp alkalosis?
anxiety leading to hyperventilation pulmonary embolism salicylate poisoning CNS disorders: stroke, subarachnoid haemorrhage, encephalitis altitude pregnancy
What findings might you see on CXR in silicosis?
Fibrotic lung disease
‘egg-shell’ calcifications of the hilar LNs
Who is at risk of silicosis?
miners, slate workers, pottery workers
What does having silicosis put you more at risk of?
TB
How can a diagnosis of mesothelioma be made?
CXR/CT – pleural thickening/effusion
Bloody pleural fluid
Official diagnosis: Made on histology, following thoracoscopy – often post-mortem
What are the CIs to NSCLC surgery?
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
What are the landmarks for inserting a chest drain?
Base of axilla, lateral pectoralis major, 5th intercostal space, anterior latissimus dorsi
Colonisation of which bug is a CI for transplant in CF?
Burkholderia cepacia
What is a catamenial pneumothorax?
Pneumothorax that occurs when women are menstruating. Can occur monthly and pain may radiate to the shoulder
How to investigate COPD?
Post-bronchodilator spirometry
CXR - hyperinflation, flat hemidiaphragm, bullae
ECG - right atrial/ventricular hypertrophy (cor pulmonale)
ABG – decreased PaO2 +/- increased PaCO2
Bloods
What is the NICE classification for the severity of COPD?
- 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)
What values give you a positive bronchodilator reversibility test?
improvement of FEV1 >12% and increase in volume of >200ml
If spirometry is normal, can asthma be excluded?
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
Which conditions results in upper zone fibrosis?
CHARTS C - Coal worker's pneumoconiosis H - Histiocytosis/ hypersensitivity pneumonitis A - Ankylosing spondylitis R - Radiation T - Tuberculosis S - Silicosis/sarcoidosis
What is the difference between TLCO and KCO?
TLCO = total capacity of the lung to gas exchange TLCO = Va (volume of lung) x KCO (each alveolars capacity to gas exchange)
What are causes of pneumothorax?
asthma, COPD, TB, pneumonia, lung abscess, Ca, CF
In what circumstance would you insert a chest drain in the first instance for a pneumothorax?
SOB and age >50 and rim of air >2cm on CXR
When to seek surgical advice for pneumothoraces?
• Bilateral pneumothoraxes
• Failure of IC drain insertion
• 2+ previous pneumothoraxes on same side
• History of pneumothorax on the opposite side
Causes of COPD?
Smoking!
Alpha-1 antitrypsin deficiency
cadmium (used in smelting), coal, cotton, cement, grain
What is a transudate?
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)
What is an exudate?
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
Uni + bilateral pleural effusions are more likely to be exudates or transudates?
Unilateral pleural effusion more likely to be exudates, bilateral more likely to be transudates
Management of pleural effusion?
May require drainage if symptomatic,
chemical (using tetracycline, bleomycin) or surgical artificial obliteration of the pleural space,
Surgery
What are the indications for chest tube insertion in patients with pleural effusions?
- purulent/cloudy fluid on aspiration
- fluid that grows a bug on culture
- fluid with pH <7.2
What is Lofgren’s syndrome in Sarcoidosis?
bilateral hilar lymphadenopathy, erythema nodosum, polyarthritis and fever
What factors are associated with poor prognosis in sarcoidosis?
insidious onset, symptoms > 6 months, absence of erythema nodosum, extrapulmonary manifestations: e.g. lupus pernio, splenomegaly, CXR: stage III-IV features, black people
When can you travel after pneumothorax resolutions?
1-2 weeks, depending on guidelines
What shifts the O2 dissociation curve to the right?
Everything goes up
Imagine running uphill:
High temp, high CO2, acidosis (think lactate), high 2-3 DPG
What causes A1AT deficiency?
Lack of protease inhibitor normally produced in the liver
Causes of occupational asthma?
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
Typical VC in male and females?
Males - 4.5L
Females - 3.5L
What can be used to prevent altitude related sickness?
Acetazolamide, a carbonic anhydrase inhibitor
- it causes a primary metabolic acidosis and compensatory respiratory alkalosis which increases respiratory rate and improves oxygenation
Which type of lung Ca is most associated with cavitating lesions?
Squamous cell
Which type of lung Ca mets are most associated with calcified lesions?
osteosarcomas and chondrosarcomas
Which type of lung Ca is most associated with consolidation?
Adenocarcinoma
Which type of lung Ca is most associated with haemorrhage?
choriocarcinoma and angiosarcoma
Which type of lung Ca is most associated with miliary pattern?
renal cell carcinoma and malignant melanoma
What is the best way to investigate for upper airway obstruction?
Flow volume loop
Management of high altitude cerebral edema (HACE) and high altitude pulmonary oedema?
HACE: Descent and dexamethasone
HAPE: Descent + dex/acetazolamide/nifedipine (all work by decreasing systolic artery pressure)
Causes of bronchiectasis?
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
What are the predisposing factors for OSA?
obesity
macroglossia: acromegaly, hypothyroidism, amyloidosis
large tonsils
Marfan’s syndrome
Which HLA is associated with bronchiectasis?
HLA-DR1
What is ARDS?
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
Causes of ARDS?
Direct: Infections, trauma, smoke inhalation, aspiration
Indirect: sepsis, pancreatitis, massive blood transfusion
Presentation of ARDS? Symptom + clinical examination
Characterised by bilateral pulmonary infiltrates + severe hyoxaemia
SOB (hrs-days after an event), raised RR, bilateral lung crackles, low O2
Management of ARDS?
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
What is the mortality of ARDS?
40%
Management of COPD?
SABA/SAMA
Then consider asthmatic features
If no asthmatic -> LABA + LAMA
If asthmatic -> LABA + ICS
Example of LABA?
Salmeterol/Formeterol
Example of SAMA?
Ipratropium
Example of LAMA?
Tiotropium
Criteria for LTOT?
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
How to determine if COPD patients required LTOT?
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
Examples of T1 resp failure?
caused by a ventilation/perfusion mismatch (V/Q mismatch) e.g. in: Pneumonia Pulmonary Oedema PE Asthma Emphysema Pulmonary fibrosis
Examples of T2 resp failure?
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
Management of PE?
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
ECG changes in PE?
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
Paraneoplastic features of squamous cell Ca?
- parathyroid hormone-related protein (PTH-rp) secretion causing hypercalcaemia
- clubbing
- hypertrophic pulmonary osteoarthropathy (HPOA)
- hyperthyroidism due to ectopic TSH
Paraneoplastic features of adenocarcinoma?
- gynaecomastia
* hypertrophic pulmonary osteoarthropathy (HPOA)
Paraneoplastic features of SCLC?
- ADH
- ACTH - not typical, hypertension, hyperglycaemia, hypokalaemia, alkalosis and muscle weakness are more common than buffalo hump etc
- Lambert-Eaton syndrome
Which type of lung Ca more commonly causes Horner’s syndrome?
Squamous cell carcinoma
In addition to Horners, what other complications can be caused by a pancoast tumour?
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
What occurs in allergic bronchopulmonary aspergillosis?
allergic reaction to aspergillosis
Early on inflammation causes bronchoconstriction, turns into permanent damage and bronchiectasis
How to treat allergic bronchopulmonary aspergillosis?
Steroids PO
What is cor pulmonale?
right heart failure caused by chronic pulmonary arterial hypertension
Causes of cor pulmonale?
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)
What is the cause of CF?
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
Which organisms may colonise CF patients?
- Staphylococcus aureus
- Pseudomonas aeruginosa
- Burkholderia cepacia
- Aspergillus
What the symptoms and blood results like in pneumonia caused by legionella?
Flu-like symptoms + dry cough, blood tests may show hyponatraemia, deranged LFTs
How would you diagnose legionella causing pneumonia?
Urinary antigen
What are the different grades of sleep apnoea?
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
What is OHS (obesity hypoventilation syndrome)?
Sleep disordered breathing, hypercapnoea, high BMI, without other cause
What are the ITU options for acute life-threatening asthma?
intubation and ventilation
extracorporeal membrane oxygenation (ECMO)
What counts as a positive results in FeNO testing?
Positive result: Adults >40, children >35
How would you diagnose allergic bronchopulmonary aspergillosis?
eosinophilia flitting CXR changes positive RAST test to Aspergillus positive IgG Abs (not as positive as in aspergilloma) raised IgE
What are the symptoms of mesothelioma and which is the most dangerous type of asbestos?
Chest pain Dyspnoea WL Clubbing Recurrent pleural effusions
Crocidolite asbestos
What are pleural plaques?
NEVER undergo malignant change
Related to asbestos
When should you start an ICS in asthma?
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)
What doses constitute low -> high ICS?
LOW <= 400 mcgs budesonide
MODERATE = 400 - 800 mcgs budesonide
HIGH > 800 mcgs budesonide
What is the pathological process in atelectasis and what causes it? How to treat?
when airways become obstructed by bronchial secretions
Common post-op complications
Sitting upright, chest physio
Causes of bilateral hilar lymphadenopathy?
BFs tell lies Berylliosis Fungi Sarcoidosis TB Lymphoma/other malignancy
Most common organisms isolated from patients with bronchiectasis?
Haemophilus influenzae (c)
Pseudomonas aeruginosa (think CF)
Klebsiella spp.
Streptococcus pneumoniae
Relative contraindications for chest drain?
INR > 1.3
Platelet count < 75
Pulmonary bullae
Pleural adhesions
What is re-expansion pulmonary oedema? How to avoid this complication?
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
What is the differential diagnosis for a cavitating lesion?
abscess (Staph aureus, Klebsiella and Pseudomonas)
squamous cell lung cancer
tuberculosis
Wegener’s granulomatosis
pulmonary embolism
rheumatoid arthritis
aspergillosis, histoplasmosis, coccidioidomycosis
Ca that met to lung?
breast cancer colorectal cancer renal cell cancer bladder cancer prostate cancer
What are the criteria to determine if a patient has asthmatic/steroid responsive features in COPD?
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%)
What is cryptogenic organizing pneumonia, what are the blood test and what is the management?
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
Symptoms of CF?
- 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
Management of CF?
- 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)
Medication options in CF?
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
MOA of theophylline?
Non-specific inhibitor of phosphodiesterase resulting in an increase in cAMP
Which blood test on FBC is NOT raised in extrinsic allergic alveolitis?
NO eosinophils
What is Kartanger’s syndrome?
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)
Which type of asthma are LTRA most useful?
aspirin-induced asthma
Why typically gets Lofgren’s syndrome and what is the prognosis?
Young females
Excellent prognosis
Who typically gets lung carcinoid tumours and what do you see on bronchoscopy?
40-50yr non-smokers
Slow-growing tumour
‘Cherry red balls’ on bronch
Factors that increase (and one that dose not) the risk of lung Ca?
smoking asbestos arsenic radon nickel chromate aromatic hydrocarbon cryptogenic fibrosing alveolitis
Not increase: coal dust
What cells do SCLC arise form?
APUD
Amine - high amine content
Precursor Uptake - high uptake of amine precursors
Decarboxylase - high content of the enzyme decarboxylase
Contact with which animal is a RF for MERS?
Camels
When should the DVLA be informed in OSA?
if OSAHS is causing excessive daytime sleepiness
What is Omalizumab, in who is it indicated and what is a potential SE?
A Mab which binds to free human IgE - given as s/c 2-4wkly in ASTHMA
Risk - Churg-strauss syndrome
What is Light’s criteria?
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
What is Psittacosis? How is it spread and how to Ix and Tx?
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
What is Loffler’s syndrome?
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
How to define pulmonary hypertension?
mean pulmonary arterial pressure of greater than 25 mmHg at rest
What are the 5 groups of pulmonary HTN?
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
What is the functional residual capacity?
the volume in the lungs at the end-expiratory position
Including the expiratory reserve volume and the residual volume (dead space)
What is Caplan’s syndrome?
A combination of rheumatoid arthritis and pneumoconiosis related to mining dust (coal, asbestos, silica) that manifests as intrapulmonary nodules
What is Heerfordt’s syndrome?
(uveoparotid fever) there is parotid enlargement, fever and uveitis secondary to sarcoidosis
Other than hot water tanks, what other signs might you get for a legionella cause of pneumonia?
hyponatraemia, relative bradycardia, confusion, deranged LFTs
