Respiratory Flashcards
1
Q
Why is it important to do an FBC in suspected COPD?
A
Need to investigate for secondary polycythaemia
2
Q
What is the gold standard test for diagnosing COPD?
A
Spirometry
3
Q
What are the indications for prescribing azithromycin to copd patients regularly?
A
- Non-smoker
- Optomised medical management
- Referred for pulmonary rehabilitation
- 4 or more infective exacerbations per year with at least 1 hospitilisation
4
Q
Recall some conservative measures for managing COPD
A
Smoking cessation
Mucolytics
Vaccines
5
Q
What is the 1st line for medically managing COPD?
A
SAMA or SABA prn
6
Q
Give an example of a SAMA
A
Ipratropium
7
Q
What is the 2nd line for medically managing COPD?
A
It depends if there are asthmatic features:
Asthmatic features: LABA + ICS
No asthmatic features: LABA + LAMA
8
Q
Give an example of a LAMA
A
Tiotropium
9
Q
What is Symbicort?
A
LABA + ICS
10
Q
What would count as ‘asthmatic features’ in a patient with COPD?
A
- History of asthma/ atopy
- FEV1 variation over time
- Eosinophilia
- Diurnal variation in PEFR (>20%)
11
Q
Recall some surgical options for managing emphysema
A
- Bullectomy
- Lung resection surgery (if emphysema is heterogenous)
- Endobrachial valve placement
- Lung transplant
12
Q
Recall the requirements for long term oxygen therapy in COPD
A
Non smoker plus either:
- pO2 <7.3
- pO2 = 7.3-8 and one of secondary polycythaemia/ peripheral oedema/ pulmonary hypertension
13
Q
Recall some possible local and systemic complications of COPD
A
Local: pneumothorax, lung Ca, bullae formation, lobar collapse
Systemic: pulmonary htn, cor pulmonale, polycythaemia
14
Q
What are the best investigations for assessing the possibility of asthma in 5-16 year olds?
A
Spirometry with BDR (bronchodilator reversibility) test +/- FeNO test
15
Q
What are the best investigations for assessing the possibility of asthma in adults?
A
FeNO test followed by spirometry with BDR (bronchodilator reversibility) test +/-:
- PEFV (peak expiratory flow variation)
- Bronchial challenge
16
Q
What is a bronchial challenge?
A
Patient breathes in slowly whilst dose of metacholine/ histamine is increased (airway irritants) to see how high a dose they can tolerate
17
Q
What is a ‘PC20’ in asthma diagnosis?
A
Measurement taken in bronchial challenge
Provocative concentration causing a 20% fall in FEV1
18
Q
What is the positive test threshold for diagnosing asthma in a FeNO test?
A
> 40 parts per billion
19
Q
What is the positive test threshold for diagnosing asthma using FEV1/FVC ratio?
A
<70% (indicative of obstructive picture)
20
Q
What is the positive test threshold for diagnosing asthma in a BDR test?
A
> 12% variability and >200mL increase in volume after SABA administration
21
Q
What is the positive test threshold for diagnosing asthma using peak flow variability?
A
> 20% PEFR variability
22
Q
What is the positive test threshold for diagnosing asthma using a bronchial challenge?
A
PC20 <8mg/mL (with both histamine and metacholine challenge)
23
Q
Systematically recall some differentials for wheeze
A
Respiratory: obstructive pathologies eg asthma, COPD, inhald foreign body
Rheumatological: granulomatosis with polyangiitis (obliterative bronchiolitis), rheumatoid arthritis
Cardiac: heart failure
24
Q
At what PEFR should someone definitely be admitted to hospital for an acute asthma attack?
A
<33%
25
At what SaO2 is an acute asthma attack considered 'life-threatening?
<92%
26
At what PEFR is an acute asthma attack considered 'life-threatening?
<33%
27
When would an acute asthma attack be considered 'near fatal'?
When the pCO2 is raised
28
When can you discharge someone following an acute asthma attack safely?
When they have been stable for 48 hours - then review 48 hours post-discharge
29
What is the acronym for things to counsel the patient on before discharge following an acute asthma attack?
```
TAME
Technique (for inhalers)
Avoidance (of triggers)
Monitor (PEFR)
Educate
```
30
What should be the TTA drugs following an acute asthma attack?
Either
Prednisolone 40mg OD, PO, 5 days (if they were admitted)
Or
Quadruple ICS dose for 14 days (if they weren't admitted)
31
Recall the steps of acute asthma attack management in hospital
1. Oxygen
2. Nebulised salbutamol (5mg)
3. Nebulised ipratropium bromide (0.5mg)
4. Steroid: either PO prednisolone 50mg (to be taken for 5 days) or 100mg IV hydrocortisone
5. Call for senior support
6. IV Magnesium sulphate
7. IV aminophylline
8. ITU + intubation
32
When should someone be admitted to hospital because of an acute asthma attack?
Always if PEFR <33%
| If PEFR is between 33 and 50% and there is no response to medication in A&E
33
How often can i) salbutamol and ii) ipratropium bromide nebulisers be given?
Salbutamol: back to back prn
Ipratropium: 4 hourly
34
If a patient's sputum is described as 'rusty' in an SBA, what sort of pneumonia is it most likely referring to?
Streptococcus pneumoniae
35
Which type of typical pneumonia is associated with pre-existing lung disease?
Haemophilus influenzae
36
Which type of typical pneumonia is most strongly associated with smoking?
Moraxella catarrhalis
37
If a patient's sputum is described as 'red currant jelly' in an SBA, what sort of pneumonia is it most likely referring to?
Klebsiella
38
Which type of atypical pneumonia is associated with erythema multiforme?
Mycobacterium pneumoniae
39
Which type of atypical pneumonia is associated with steven johnson syndrome?
Mycobacterium pneumoniae
40
Which type of typical pneumonia is most associated with alcoholism?
Klebsiella
41
Which type of typical pneumonia is most associated with diabetes?
Klebsiella
42
Which type of typical pneumonia is most associated with haemoptysis?
Klebsiella
43
What risk factors are C. Psittaci associated with?
Birds
44
Recall one important complication of C. Psittaci pneumonia
Haemolytic anaemia
45
What is the main association with C. burnetti pneumonia in SBAs?
Farm animals
46
Recall the CURB65 score for assessing pneumonia
```
Confusion (AMTS<8)
Urea >7
Resp rate >30
BP <90/60mmHg
Age >65
```
47
What is the most common pathogen implicated in early-onset (<48 hours) vs late-onset (>4 days) hospital-acquired pneumonia?
Early-onset: Streptococcus pneumonia
| Late-onset: enterobacteria (E coli/ Klebsiella pneumoniae) > MRSA
48
What is the antibiotic of choice for MRSA pneumonia?
Vancomycin
49
What is the antibiotic of choice according to NICE for non-severe vs severe hospital-acquired pneumonia?
Non-severe: co-amoxiclav or doxycycline
| Severe: Piptazobactam
50
Which tests for TB will be positive if the infection has been eliminated by the acquired immune response?
Tuberculin skin testing
| IGRA (interferon gamma release assay)
51
Which tests for TB will be positive in latent TB?
Tuberculin skin testing
| IGRA (interferon gamma release assay)
52
Which tests for TB will be positive in subclinical TB?
Tuberculin skin testing
IGRA (interferon gamma release assay)
(Intermittently a sputum culture)
53
Recall a possible side effect of each of the drugs used most commonly in multi-drug therapy for TB
```
Rifampicin: orange secretions
Isoniazid: neuropathy
Pyrizinamide: Liver toxicity
Ethambutol: eye toxicity
Mnemonic = ONLY
```
54
How can histology be obtained when investigating TB (and other lung diseases)?
EBUS (endobronchial ultrasound-guided transbronchial needle)
55
At what CD4 count should someone with HIV be given PCP prophylaxis?
<200
56
What counts as 'extremely drug-resistant TB'?
Resistant to rifampicin, isoniazid, fluoroquinolones and at least 1 injectable
57
Which lung infection typically gives a history of desaturating on exercise?
PCP pneumonia
58
Recall 3 possible extrapulmonary signs of PCP pneumonia
Hepatosplenomegaly
Lymphadenopathy
Choroid lesions (pneumocystis choroiditis)
59
What stain is the most useful for investigating for PCP pneumonia and what will it show?
Silver stain
| Cysts
60
What is the management for i) mild-moderate and ii) severe PCP pneumonia?
Mild-moderate: co-trimoxazole
| Severe: IV pentamidine
61
What is the quickest vs the gold standard method for diagnosing active TB from sputum?
Quickest: NAAT (takes 24-48 hours, 50-80% sensitive)
| Gold-standard: culture (takes 1-3 weeks)
62
Which stain for sputum is used for TB screening vs diagnosis?
Screening: auramine
Diagnosis: Ziehl-Neelson
63
Recall some immediate, early and late complications of a chest drain
Immediate: pain, failure, haemorrhage, pneumothorax
Early: infection, haematoma, blockage, long thoracic nerve damage (--> winged scapula)
Late: scar formation
64
When is bubbling normal in a chest drain?
Pneumothorax
nb: abnormal in pleural effusion
If NO bubbling in pneumothorax then there is likely to be a blockage
65
In what patients would a pneumothorax be counted as secondary?
Age >50
Smoking history
Evidence of underlying lung disease on exam or CXR
66
How should secondary pneumothoraces be managed?
If >2cm or breathless proceed straight to chest drain
If 1-2cm, try aspiration, and only try chest drain if still >1cm
If <1cm, or successful aspiration --> admit, high flow oxygen and observe for 24 hours
67
How should primary pneumothoraces be managed?
If >2cm or breathless --> attempt aspiration
If aspiration unsuccessful (still >1cm) --> chest drain
If aspiration successful --> consider discharge and review in OPC
If <2cm, consider discharge straight away and review in OPC
68
What is a flail chest?
3 or more consecutive ribs fracture in 2 or more locations resulting in part of the chest wall moving paradoxically and independently of the rest
This is a life-threatening condition
69
In which direction does the flail segment move during inspiration vs expiration in a flail chest?
Inspiration --> inwards
| Expiration --> outwards
70
Why is flail chest so dangerous?
Increases work of breathing and pulmonary contusions
| Free rib can puncture the lung and cause a tension pneumothorax
71
What might be seen on CXR in flail chest?
Rib fractures
Subcutaneous emphysema
Pneumothorax
Mediastinal shift if tension
72
What are the principles of management of flail chest?
Analgesia and chest physiotherapy for all
| Some may also need CPAP and/or surgical fixation
73
Differentiate some causes of exudate vs transudate pleural effusion
Exudate ('eggsudate') involves protein - causes include: infection, PE, malignancy, trauma and pancreatitis
Transudate is caused by a disturbance of osmotic or colloid pressure - so organ dysfunction is the main cause as organs stop regulating these pressures: liver (cirrhosis), kidney (nephrotic syndrome), heart (CCF). Can also be caused by myxoedema and Meig's syndrome (nb ascites is a component of this so osmotic pressure must be unbalanced)
74
Recall some important bedside investigations for the cause of a pleural effusion
Examination
Basic obs
Urine dip for protein (nephrotic syndrome --> transudate pleural effusion)
75
Recall some useful forms of imaging in investigating a pleural effusion
1. CXR
2. If confirmed on CXR --> contrast CT (especially if cause is exudative)
3. If cause is CCF (transudate) do an echo
76
What equipment should be used for a pleural tap?
21G needle and 50mL syringe
77
What would a pleural tap show in empyema?
pH<7.2
LDH high
Glucose low
78
How are exudate and transudate defined?
```
Exudate = >30g/L protein
Transudate = <30g/L protein
```
79
What are Light's criteria used for and what are the 3 criteria?
Light's Criteria = used in pleural effusion to establish whether fluid is exudate or transudate when protein is 25-35g/L
An exudate is likely if pleural fluid/ serum:
1. Protein >0.5
2. LDH >0.6
Or if pleural fluid LDH >2/3rds upper limit of normal of serum LDH
80
When should a pleural effusion have a chest drain inserted into it?
If aspirate is:
- Turbid/ cloudy
- tests positive on MC&S
- Has a pH<7.2
81
What are the general principles of managing pleural effusion?
1. Insert chest drain if indicated
| 2. Treat cause
82
Recall some options for managing recurrent pleural effusions
1. Could insert an indwelling pleural catheter
2. Could perform pleurodesis
3. Could recurrently aspirate
83
What is pleurodesis?
"Pleurodesis is a procedure which involves putting a mildly irritant drug into the space between your lung and chest wall (the pleural space), on one side of your chest. This is done to try to 'stick' your lung to the wall of your chest and prevent a further collection of fluid or air in this space."
84
Recall some differentials for the cause of upper lobe vs lower lobe pulmonary fibrosis
Upper lobe = TAPE (TB, ABPA, Pneumoconiasis, EAA (hypersensitivity pneumonitis))
Lower lobe = STAIR (sarcoidosis, toxins*, asbestosis, idiopathic pulmonary fibrosis, rheumatological (RhA, SLE, Sjogren's, scleroderma, CREST)
*toxins = bleomycin, amiodarone, nitrofurantoin, sulfasalazine, methotrexate
85
Recall some signs and symptoms of pulmonary fibrosis on examination
Progressive exertional dyspnoea
Dry cough
Clubbing
Bibasal fine inspiratory crepitations
86
What is the gold-standard form of imaging for visualing pulmonary fibrosis?
High resolution CT
87
Why would an echocardiogram be useful in a patient with pulmonary fibrosis?
May show presence of pulmonary hypertension
88
What are the symptoms of Kartagener's syndrome (triad)?
Situs inversus
Bronchiectasis
Chronic sinusitis
89
What are the symptoms of Young's syndrome (triad)?
Bronchiectasis
Chronic sinusitis
Male infertility
90
Recall 4 causes of pneumonia that are most likely to cause bronchiectasis
Streptococcus pneumoniae
Haemophilus influenzae
Klebsiella spp.
Pseudomonas aeruginosa
91
What is the most common cause of bronchiectasis?
Idiopathic
92
Which allergic pathology can cause bronchiectasis?
ABPA (due to eosinophilia)
93
What is the most useful imaging modality for investigating bronchiectasis?
High-resolution CT
94
What is the mainstay of medical management for ABPA?
Oral glucocorticoids
95
What are the 2 main medications used in managing acute exacerbations of bronchiectasis?
Bronchodilators and antibiotics
96
Recall some possible local and systemic complications of bronchiectasis
Local: haemorrhage, lobar collapse, T2 resp failure
Systemic: pulmonary hypertension, cachexia
97
What is the rate of live birth with cystic fibrosis in the UK?
1 in 2,500
98
What protein is mutated in cystic fibrosis?
cAMP-dependent chloride channel on chromosome 7
99
Recall some signs and symptoms of cystic fibrosis
```
CLUBBING FINGERS
Meconium ileus
Recurrent chest infections, wheeze, coughing
ABPA, sinusitis, nasal polyps
Male sterility
Growth faltering
Bronchiectasis due to airway damage
Jaundice (cirrhosis, portal hypertension)
Diabetes mellitus
```
100
What result would be positive for cystic fibrosis in a sweat test?
Abnormally HIGH NaCL
101
What abnormalities due to cystic fibrosis might be seen on a chest x ray?
Hyperinflation
Peri-bronchial shadowing
Bronchial wall thickening
Ring shadows (bronchi seen end-on)
102
What are the 1st and 2nd line options for mucolytic therapy in cystic fibrosis?
1st line: Dornase alfa
| 2nd line: rhDNase + hypertonic saline, mannitol dry powder (INH)
103
Which prophylactic oral antibiotics are given to patients with cystic fibrosis to prevent chance of exacerbation?
Flucloxacillin and azithromycin
104
What adjustments to diet should be made for patients with cystic fibrosis?
High calorie and high fat (150% of normal)
Fat soluble vitamin supplements
CREON pancreatic enzyme replacement with every meal
105
How can liver problems in cystic fibrosis be medically managed?
Ursodeoxycholic acid
106
What sort of bowel obstruction can people with cystic fibrosis develop?
Distal intestinal obstruction syndrome (DIOS)
| Viscous muco-faeculent material obstructs the bowel
107
How can distal intestinal obstruction syndrome be managed?
Usually can be cleared with oral laxatives
108
Recall 5 subtypes of non small cell lung cancer
```
Adenocarcinoma
Squamous cell carcinoma
Large cell carcinoma
Alveolar cell carcinoma
Bronchial adenoma
```
109
What % of all lung cancers are small cell?
15%
110
What is hypertrophic osteoarthropathy (HPOA)?
Painful proliferative periostitis affecting long bones - commonly affecting the wrists and ankles - a cause of clubbing
111
Which types of lung cancer are associated with HPOA?
Adenocarcinoma
| Squamous cell carcinoma
112
Which type of lung cancer is associated with gynaecomastia?
Adenocarcinoma
113
Which type of lung cancer is associated with PTHrP?
Squamous cell carcinoma
114
Which type of lung cancer is associated with ectopic TSH?
Squamous cell carcinoma
115
Which type of lung cancer is associated with beta HCG?
Large cell carcinoma
116
For the following lung cancers, say whether they are typically central or peripheral:
- Small cell
- Adenocarcinoma
- Squamous cell
- Large cell
- Small cell: central
- Adenocarcinoma: peripheral
- Squamous cell: central
- Large cell: peripheral
117
Which type of lung cancer is associated with Lambert-Eaton Myasthaenic syndrome?
Small cell carcinoma
118
Which type of lung cancer is associated with SIADH?
Small cell carcinoma
119
Which type of lung cancer is associated with production of ectopic ACTH?
Small cell carcinoma
120
Which lung cancer is more common in non-smokers?
Adenocarcinoma
121
Which type of lung cancer can present with hoarseness?
Pancoast tumours (apical)
122
What is the most common initial symptom of SVC obstruction?
Feeling full in the face when leaning forwards
123
Recall some signs and symptoms of lung cancer
Classically: Cough, haemoptysis, weight loss
Also: SOB, chest pain, anorexia, SVCO
124
In what order should imaging be requested for suspected lung cancer?
CXR
Volumentric CT
FDG-PET-CT
125
What is the use of spirometry in lung cancer patients?
Determining fitness for surgery
126
How can a biopsy be obtained in lung cancer?
Bronchoscopy and EBUS
127
What are the 2 week wait guidelines for lung cancer for under 40s?
```
At least 2 symptoms in non-smokers, or at least 1 symptom in ex/current-smokers:
Cough
Chest pain
Fatigue
Unintedned weight loss
SOB
Appetite loss
```
128
What are the 2 week wait guidelines for lung cancer for over 40s?
At least one of the following symptoms:
mnemonic = INTEL
Infection (chest, recurrent)
Nail clubbing
Thrombocytosis
Examination signs consistent with lung Ca
Lymphadenopathy (supraclavicular/ persistent cervical)
129
What minimum result on spirometry is necessary for a lung cancer patient to be considered fit for surgery?
FEV1>1.5L on spirometry
130
What 2 tests are used to detemine whether a lung cancer patient is fit for surgery?
Spirometry and mediastinoscopy
131
Which stages of small cell lung cancer might be suitable for surgery?
T1-2a, N0 M0
132
How would late stage small cell lung cancer be managed?
If limited disease: combination chemoradiotherapy
| If extensive disease: palliative chemotherapy
133
How is non-small cell lung cancer that is not suitable for surgery managed?
Palliative/ curative radiotherapy (poor response to chemo)
134
What sort of nerve palsy can be a local complication of lung cancer?
Phrenic nerve palsy or recurrent laryngeal nerve palsy
135
Recall some possible systemic complications of lung cancer
Depending on type of tumour, may get:
- Gynaecomastia
- Ectopic hormone production (LEMS, SIADH, ACTH, PTHrP)
- Dermatomyositis
136
How would FEV1 and FVC be affected by obstructive vs restrictive lung pathologies?
Obstructive: FEV1 very reduced; FVC reduced or normal
Restrictive: FEV1 reduced; FVC very reduced
137
Why would the TLCO be reduced in obstructive and restrictive lung disease?
TLCO = overall measure of gas transfer
Obstructive disease: O2 can't get in --> reduced TLCO
Restrictive disease: fewer capillaries to access --> reduced TLCO
138
What do TLCO and DLCO stand for?
TLCO = transfer factor of CO
DLCO = diffusion capacity of CO
Who knows where the Ls come from??
139
How should the TLCO be managed?
Inhale and hold breath for 10 seconds then exhale. There shouldn't be any CO in the exhalation
140
How does the TLCO relate to the amount of CO being exhaled
Raised TLCO = less CO being exhaled than normal
| Caused of increased perfusion: diastolic CHF, exercise, alveolar haemorrhage, polycythaemia, asthma
141
What sign on chest x ray is produced by left lower lobe collapse?
Sail sign
142
What sign on chest x ray is produced by left upper lobe collapse?
Veil sign
143
When prescribing macrolides for CAP, recall one common drug that has a significant drug interaction with it
Statins
144
What are the indications for corticosteroid treatment in sarcoidosis?
Parenchymal lung disease
Uveitis
Hypercalcaemia
Neurological or cardiac involvement
145
If a patient has well-controlled asthma, how much is it reasonable to reduce their steroid dose by?
25-50%
146
What are the borders of the area in which a chest drain can be inserted?
Base of the axilla
Lateral edge pectoralis major
5th intercostal space
Anterior border of latissimus dorsi
147
How do emphysematous bullae appear on CXR?
Lucency without a visible wall
148
Recall one rheumatoid arthritis drug that can cause pulmonary fibrosis
Methotrexate
149
How should pulmonary fibrosis affect FEV1:FVC ratio and TLCO?
FEV1:FVC ratio should be normal (>70%)
| TLCO should be decreased
150
In what lung pathology might you get raised platelets on an FBC?
Lung malignancy
151
What is re-expansion pulmonary oedema?
If a pleural effusion is drained too quickly, re-expansion pulmonary oedema is a rare but important complication that can develop
152
Recall 4 drugs that can cause pulmonary fibrosis
Amiodarone
Nitrofurantoin
Sulfasalazine
Methotrexate
