Respiratory Flashcards

1
Q

Name the different types of lung cancer

A
Non-small cell (80%)
- Adenocarcinoma 
- Squamous cell carcinoma 
- Large cell carcinoma 
Small cell (20%)
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2
Q

Describe small cell lung cancers

A

Contain neurosecretory granules that release neuroendocrine hormones - multiple paraneoplastic syndromes

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3
Q

Give the signs and symptoms of lung cancer

A
SOB
Cough - haemoptysis
Clubbing
Recurrent pneumonia
Weight loss
Lymphadenopathy - supraclavicular
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4
Q

What are signs of lung cancer on CXR?

A

Hilar enlargement
Peripheral opacity
Pleural effusion - unilateral
Collapse

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5
Q

What is the first line treatment for non-small cell lung cancer

A

Surgery - lobectomy or segmentectomy or wedge resection

Chemo or radiotherapy

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6
Q

What is the treatment for small cell lung cancer

A

Chemo or radiotherapy

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7
Q

Describe recurrent laryngeal nerve palsy

A

Hoarse voice - caused by the cancer pressing on or affecting the recurrent laryngeal nerve as it passes through the mediastinum

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8
Q

Describe phrenic nerve palsy

A

Compression causing diaphragm weakness and presents as SOB

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9
Q

Describe superior vena cava obstruction

A

Compression of the tumour on the superior vena cava

Presents with facial swelling, difficulty breathing and distended veins in the neck and upper chest

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10
Q

Describe Pembertons sign

A

SVC obstruction

Raising arms above head causes facial congestion and cyanosis

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11
Q

Describe Horner’s syndrome

A

Partial ptosis, anhidrosis and miosis

Associated with Pancoast tumour (pulmonary apex)

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12
Q

How does SIADH present?

A

Euvolemic hyponatraemia

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13
Q

Describe limbic encephalitis

A

Autoimmune antibodies to the limbic tissues causing inflammation and short term memory impairment, hallucinations, confusion and seizures
Associated with anti-HU antibodies

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14
Q

Describe lambert eaton myasthenic syndrome

A

Result of antibodies produced by the immune system against SCLC. They target voltage gated Ca channels on the presynaptic terminals in motor neurone leading to weakness of the proximal muscles and causes diplopia, ptosis, slurred speech and dysphagia. They also experience dry mouth, blurred vision, impotence and dizziness due to autonomic dysfunction

Reduced reflexes which become normal after a period of maximal contraction (post tetanic potentiation)

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15
Q

Describe mesothelioma

A

Lung mesothelial cells of the pleura
Strongly linked to asbestos and development of mesothelioma - 45years
Prognosis is poor and chemotherapy is palliative

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16
Q

Define hospital acquired pneumonia

A

Develops >48hrs of hospital admission

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17
Q

Describe the presentation of pneumonia

A
SOB
Cough - haemoptysis 
Pleuritic chest pain 
Delirium 
Sepsis 
Tachycardia
Tachypnoea 
Hypoxia
Hypotension 
Fever
Confusion 

Bronchial breath sounds - harsh breath sounds on inspiration and expiration

Focal coarse crackles - air passing through sputum

Dullness to percussion - lung tissue collapse and or consolidation

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18
Q

What is the CURB 65 score

A

Prediction of the severity of pneumonia and helps guide treatment

Confusion
Urea >7
RR >30 
BP <90/60 
Age >65 

0 or 1 - home treatment
>2 - hospital admission
>3 - consider ICU

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19
Q

What are the common causes of pneumonia

A

Streptococcus pneumoniae

Haemophilus influenza

Moraxella catarrhalis
Pseudomonas aeruginosa
Staphylococcus aureus

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20
Q

What is an atypical pneumonia?

A

One that cannot be cultured in the normal way or detected using gram stain

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21
Q

Describe legionella pneumonophila

A

Caused by infected water supplies or air conditioning units

Causes a hyponatraemia - causing SIADH

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22
Q

Describe mycoplasma pneumoniae

A

Milder pneumonia
Erythema multiformed rash - target lesions formed by pink rings with pale centres - can also cause neurological symptoms in young patients

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23
Q

Describe coxiella burnetii

A

Q fever

Farmers - caused by contact with animals and body fluids

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24
Q

Describe chlamydia psittaci

A

Contracted from contact with infected birds

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25
Describe fungal pneumonia
Pneumocystis jiroveci | Occurs in HIV patients
26
What is given to patients with fungal pneumonia
co-trimoxazole
27
What antibiotics are given to those with a mild CAP
5 day PO course - amoxicillin or macrolide
28
What antibiotics are given to those with moderate to severe CAP
7-10 day course of dual antibiotics - amoxicillin and macrolide
29
List some complications of pneumonia
``` Sepsis Pleural effusions Empyema Lung abscess Death ```
30
Describe FEV1
Forced expiratory volume in 1 second The amount of air a person can exhale as fast as they can in 1 second Will be reduced if there is any obstruction
31
Describe FVC
Forced vital capacity The total amount a person can exhale after a full inhalation - measure of the total volume of air a person can take into their lungs Reduced if any restriction to the capacity of the lungs
32
Describe obstructive disease
FEV1:FVC ratio <75%
33
What type of lung picture is asthma and COPD
Obstructive
34
Described restrictive disease
FEV1:FVC>75%
35
List some causes of restrictive lung disease
``` Interstitial lung disease Neurological - MND Scoliosis Chest deformity Obesity ```
36
Explain how to complete a peak flow
Stand up tall, take a deep breath in, make a good seal around the device with the lips and blow as hard and as fast as possible into the device - take 3 attempts and record the best one
37
What does peak flow vary with?
Age, Sex and height of the patient
38
What does peak flow measure
How much obstruction is in a patients lungs
39
List some triggers of asthma
``` Infection Night time or early morning Exercise Animals Cold/damp Dust Strong emotions ```
40
Describe features of a presentation suggesting asthma
``` Episodic symptoms Diurnal variability - worse at night Dry cough with wheeze and SOB History of other atopic conditions such as eczema, hay fever and food allergies Family history Bilateral widespread polyphonic wheeze ```
41
How is asthma diagnosed?
High probability- trial of treatment Moderate probability - spirometry for reversibility testing Low probability - referral and investigating for other causes
42
What are the first line investigations for asthma
Fractional exhaled nitric oxide | Spirometry with bronchodilator reversibility (>12% improvement)
43
Describe the long term management for Asthma
SABA SABA + ICS LABA or LTRA Annual flu jab Annual asthma review Advise exercise Stop smoking
44
Describe the mechanism of action of SABAs
Relax the bronchial smooth muscle causing bronchodilation
45
Describe the management of ICS
Reduce the inflammation and reactivity of the airways
46
Describe the mechanism of action of LAMAs
Block the acetylcholine receptors which are normally stimulated by the parasympathetic nervous system and cause inflammation, bronchoconstriction and mucus secretion
47
Describe the mechanism of action of theophylline
Relax bronchial smooth muscle and reduce inflammation
48
When is theophylline monitored
5 days after starting treatment | 3 days after a dose change
49
List some features of severe acute asthma
PEF 33-50% best or predicted RR >25 HR >110 Inability to complete sentences in one breath
50
List the features of life threatening asthma
PEFR <33% best or predicted Oxygen sats <92% Normal PCO2 Silent chest, cyanosis, feeble respiratory effort, bradycardia, dysrhythmia or hypotension, exhaustion, confusion or coma
51
List the features of moderate asthma
PEFR 50-75% best or predicted Speech normal RR <25/min Pulse <110
52
Describe the treatment of a moderate asthma attack
Nebulised salbutamol and ipatropium bromide Steroids - oral prednisolone for 5 days Antibioitcs if sign of infection
53
Describe the treatment of severe asthma
Oxygen to maintain sats 94-98% Aminophylline infusion IV salbutamol
54
Describe the treatment of life threatening asthma
IV magnesium sulphate Admission to HDU/ICU Intubation in worst cases
55
Describe the initial ABG picture of a person with acute asthma
Respiratory alkalosis - tachypnoea causes a drop in CO2
56
What are some concerning ABG signs in acute asthma
Normal PCO2 or hypoxia - tiring and indicates life threatening asthma Respiratory acidosis - high PCO2
57
How can you monitor the response of treatment in acute asthma
``` RR Respiratory effort Peak flow O2 sats Chest auscultation ```
58
Which electrolyte should you monitor when on salbutamol for acute asthma
Potassium - absorbed into cells with salbutamol
59
Which peripheral sign does COPD NOT cause?
Clubbing
60
Describe the MRC dyspnoea scale
Grade 1 - Breathless on strenuous exercise Grade 2 - breathless on walking up a hill Grade 3 - Breathless that slows walking on the flat Grade 4 - Stop to catch their breath after walking 100m on the flat Grade 5 - unable to leave the house due to breathlessness
61
Describe the spirometry picture of COPD
Obstructive FEV1:FVC <0.7 No reversibility with SABA
62
Describe the severity of COPD
Stage 1: FEV1 >80% predicted Stage 2: FEV1 50-79% Stage 3: 30-49% Stage 4: <30%
63
Describe type 1 respiratory failure
Low PaO2
64
Describe type 2 respiratory failure
Raised PCO2 despite low PaO2
65
Describe the ABG in someone with COPD
Acutely retaining CO2 - respiratory acidosis | The kidneys produce bicarbonate to try and normalise the pH
66
What are the target O2 sats for a COPD patient who chronically retains CO2
88-92%
67
Why is it dangerous to give too much O2 to a COPD patient?
These patients rely on their respiratory drive and therefore too much O2 will slow down their respiratory effort
68
Describe Venturi masks
Have holes in them - bigger the hole, the less O2 ``` 24% blue 28% white 31% orange 35% yellow 40% red 60% green ```
69
Describe the severity of COPD
Stage 1: FEV1 >80% Stage 2: FEV1 50-79% Stage 3: FEV1 30-49% Stage 4 : FEV1 <30%
70
Describe the long term management of COPD
SABA or Short acting antimuscarinic LABA plus LAMA or LABA plus ICS if asthmatic features More severe cases - nebulisers, oral theophylline, oral mucolytic therapy (carbocisteine), long term prophylactic antibiotics (azithromycin), long term O2 therapy at home
71
Who is long term O2 therapy reserved for in COPD?
Chronic hypoxia Polycythaemia Cyanosis heart failure secondary to pulmonary hypertension
72
Describe the medical treatment of a mild exacerbation of COPD
Prednisolone 30mg OD for 7-14 days Regular inhalers or home nebulisers Antibiotics
73
Describe the medical management of a moderate to severe COPD exacerbation
Nebulised bronchodilators - salbutamol or ipatropium Steroids Antibiotics Physiotherapy
74
Describe the treatment of severe COPD exacerbations
IV aminophylline NIV Intubation and ventilation with admission to ITU Doxapram
75
Describe BiPAP
Bilevel positive airway pressure - involves a cycle of high an low pressure to correspond to the patients inspiration and expiration. Used when type 2 resp failure and resp acidosis not responding to medical treatment
76
Describe CPAP
Continuous positive airway pressure Provides continuous air being blown into the lungs to keep the airway open so air can travel in easily Used to maintain the patients airway in conditions where it is prone to collapse - Obstructive sleep apnoea - Congestive cardiac failure - Acute pulmonary oedema
77
Describe the presentation of idiopathic pulmonary fibrosis
Pt aged >50yo Insidious onset SOB and dry cough > 3months Finger clubbing and binasal crackles
78
Which drugs may lead to pulmonary fibrosis
Amiodarone Cyclophosphamide Methotrexate Nitrofurantoin
79
Which conditions may lead to secondary pulmonary fibrosis
Alpha 1 antitrypsin deficiency RA SLE Systemic sclerosis
80
Which drugs can be given in pulmonary fibrosis
Pirfenidone - antifibrotic and anti-inflammatory | Nintedanib - antibody targeting tyrosine kinase
81
Describe hypersensitivity pneumonitis (extrinsic allergic alveolitis)
Type 3 hypersensitivity reaction to environmental allergen that causes parenchymal inflammation and destruction in people sensitive to that allergen
82
How is EAA diagnosed?
Bronchoalveolar lavage - collecting cells from airway by washing airway with fluid during bronchoscopy
83
How is EAA managed?
Remove allergen | O2 where appropriate
84
Describe cryptogenic organising pneumonia
Used to be called bronchiolitis obliterans organising pneumonia Focal areas of inflammation of lung tissue Idiopathic or triggered by infection, inflammatory disorders, medications, radiation or environmental toxins and allergens Presentation is very similar to infectious pneumonia so delayed diagnosis Treatment is with systemic corticosteroids
85
What is the long term effects of asbestosis
Lung fibrosis Pleural thickening and pleural plaques Adenocarcinoma Mesothelioma
86
How is interstitial lung disease diagnosed
Ground glass appearance on High resolution CT scan
87
What is interstitial lung disease
Umbrella term for the conditions that affect the lung parenchyma causing inflammation and fibrosis
88
What is a pleural effusion
Fluid in the pleural space
89
What is a transudative pleural effusion
Fluid moving across into the pleural space
90
List some causes of transudative pleural effusion
Congestive cardiac failure Hypoalbuminemia Hypothyroidism Meigs syndrome
91
What is Meigs syndrome
Right sided pleural effusion with an ovarian malignancy
92
What is an exudative pleural effusion
Related to inflammation | Protein leaking out of the tissue into the pleural space
93
List the causes of exudative pleural effusion
Lung cancer Rheumatoid arthritis Pneumonia Tuberculosis
94
Describe the signs and symptoms of pleural effusions
Shortness of breath Dullness to percussion over the effusion Reduced breath sounds Deviation of the trachea away from the effusion if massive
95
Describe the CXR appearance of pleural effusion
Blunting of the costophrenic angles Tracheal and mediastinal deviation away from the pleural effusion if massive Fluid in the lung fissures Larger effusions have a meniscus
96
Describe the treatment of pleural effusion
Conservative - treat underlying cause Pleural aspiration - aspirate the fluid Chest drain - drain the effusion and prevent it from occurring
97
What is an empyema and when is it suspected?
Infected pleural effusion Suspected when pneumonia is resolving but patient has a new and ongoing fever
98
What does pleural aspiration show in empyema
pH <7.2 Low glucose High LDH
99
How is empyema treated
Chest drain and antibiotics
100
What is a pneumothorax
Air in the pleural space separating the lung from the chest wall
101
What causes a pneumothorax?
Spontaneous Trauma Iatrogenic Secondary to lung pathology
102
How is pneumothorax diagnosed
Erect CXR
103
How is the size of a pneumothorax measured
Measure horizontally from the lung edge to the inside of the chest wall at the level of the hilum
104
How is pneumothorax managed
If <2cm rim of air on CXR and no SOB - spontaneous resolution and OP follow up in 2-4 weeks If SOB and/or >2cm rim on CXR then aspirate and reassessment If aspiration fails twice then chest rain Unstable patients of bilateral or secondary pneumothoraxes generally require a chest drain
105
Describe a tension pneumothorax
Trauma to chest wall that reates a one way valve that lets air in but not out of the pleural space One way valve means more air is pulled in with each inspiration and the air becomes trapped. Pressure in the thorax keeps building, pushes the mediastinum across, kinks the big vessels and can cause cardiorespiratory arrest
106
List some signs of tension pneumothorax
Tracheal deviation away from side of pathology Reduced air entry to affected side Increased reasonant to percussion on afected side Tachycardia Hypotension
107
Describe the management of a tension pneumothorax
Insert a large bore cannula into the 2nd ICS mid clavicular line Chest drain is definitive treatment
108
Where is the chest drain inserted
Triangle of safety
109
Describe the borders of the triangle of safety
5th ICS - inferior nipple line Mid axillary line - latissimus dorsi Anterior axillar line - lateral edge of pectoris major
110
Where is the needle inserted when putting in a chest drain
Just above the rib to avoid the neurovascular bundle
111
Describe the gas picture in someone with a PE
Respiratory alkalosis - blowing off the CO2 (low CO2 and low O2)
112
Who is a V/Q scan performed in?
People with contrast allergy Renal impairment Pregnancy (however higher risk of leukaemia in the child)
113
If the Wells score for PE is likely what is the next step?
CTPA
114
If the Wells score for PE is unlikely, what is the next step
D-dimer and if positive then CTPA
115
Describe the Wells score
Predicts the likelihood of someone presenting with symptoms of a PE actually having a PE - Haemoptysis - Tachycardia - RF
116
What are the RF for PE
``` Immobility Recent surgery HRT with oestrogen Polycythaemia SLE Pregnancy COCP Malignancy ```
117
Describe VTE prophylaxis
LMWH - enoxaparin | Compression stockings
118
Who are compression stockings CI in?
Peripheral arterial disease
119
Describe the initial treatment of PE
Oxygen PRN Analgesia PRN Apixaban or rivaroxaban LMWH (enoxaparin or Dalteparin) -if waiting for a scan or if apixaban or rivaroxaban not suitable/antiphospholipid syndrome
120
Describe the long term anticoagulation in PE
Warfarin, DOAC or LMWH Target INR for warfarin is 2-3 Warfarin plus LMWH for 5 days until INR in range for 24hrs as warfarin as prothrombotic properties to begin with LMWH long term in pregnancy or cancer Continue for 3 months if obvious reversible cause, beyond 3 months if the cause is unclear, irreversible underlying cause or active cancer (6 months)
121
Describe the use of thrombolysis in PE
Massive PE - haemodynamic compromise Fibrinolytic agent - streptokinase, Alteplase or Tenecteplase 2 ways of giving it - IV or directly into the pulmonary arteries using a central catheter (catheter directed thrombolysis) Catheter directed thrombolysis - delivered into the venous system through the right side of the heart into the pulmonary artery - inject the agent directly into the clot
122
What is pulmonary hypertension
Increased resistance and pressure of blood in the pulmonary arteries Causes strain on the right side of the heart trying to pump blood through the lungs - causes back pressure of blood on the systemic venous system
123
List the causes of pulmonary hypertension
Group 1 - primary pulmonary hypertension or connective tissue disease (SLE) Group 2 - left heart failure due to MI or systemic hypertension Group 3 - chronic lung diseases such as COPD Group 4 - pulmonary vascular disease - PE Group 5 - sarcoidosis, glycogen protein disorder, haematological disorders
124
List the symptoms of pulmonary hypertension
Syncope Tachycardia Raised JVP Hepatomegaly Peripheral oedema
125
Describe the ECG changes in pulmonary hypertension
Right ventricular hypertrophy - Larger R waves on the Right sided chest leads (V1-3) and S waves on the left sided chest leads (V4-6) Right axis deviation Right bundle branch block
126
Describe the CXR signs of pulmonary hypertension
Dilated pulmonary arteries | Right ventricular hypertrophy
127
Describe the management of pulmonary hypertension
Primary - IV prostenoids (epoprostenol), Endothelin receptor antagonists (macitentan), phosphodiesterase 5 inhibitors (sildenafil) Secondary pulmonary hypertension - treat underlying cause Supportive therapy for complications
128
Describe the typical sarcoidosis patient
Young black female presenting with dry cough, SOB and may have nodules on their shins
129
What is sarcoidosis
Granulomatous inflammatory condition - nodules of inflammation full of macrophages develop
130
Describe how sarcoidosis affects the lungs
Mediastinal lymphadenopathy Pulmonary fibrosis Pulmonary nodueles
131
List the systemic symptoms of sarcoidosis
Fever Fatigue Weight loss
132
List the liver symptoms of sarcoidosis
Liver nodules Cirrhosis Cholestasis
133
List the eye symptoms of sarcoidosis
Uveitis Conjunctivitis Optic neuritis
134
List the skin conditions caused by sarcoidosis
Erythema nodosum - tender red nodules on shins by inflammation in the subcutaneous fat Lupus pernio - raised, purple skin lesions commonly on the cheeks and nose Granulomas form in scar tissue
135
List the heart conditions caused by sarcoidosis
Bundle branch and heart block | Myocardial muscle involvement
136
List the kidney conditions caused by sarcoidosis
Kidney stones (hypercalcaemia) Nephrocalcinosis Interstitial nephritis
137
List the CNS sarcoidosis problems
Nodules Pituitary involvement - diabetes insipidus Encephalopathy
138
List the PNS sarcoidosis problems
Facial nerve palsy | Mononeuritis multiplex
139
List the bone problems caused by sarcoidosis
Arthralgia Arthritis Myopathy
140
Describe Lofgren's syndrome
Bilateral hilar lymphadenopathy Erythema nodosum Polyarthralgia
141
What investigations would you do to diagnose sarcoidosis
``` Serum ACE Calcium (high) Serum soluble IL-2 receptor (high) CRP (high) Immunoglobulins (high) CXR - hilar lymphadenopathy HRCT - hilar lymphadenopathy and pulmonary nodules MRI - CNS involvement PET scan - active inflammation ``` Biopsy - non-caseating granulomas with epithelioid cells - bronchoscopy with USS guided biopsy of the mediastinal lymph nodes
142
Describe the treatment of sarcoidosis
No treatment if no or mild symptoms Oral steroids between 6-24months Second line is methotrexate or azathioprine Lung transplant if severe pulmonary disease
143
Describe the prognosis of sarcoidosis
Spontaneously resolves within 6 months in 60% patients. Small number develop pulmonary fibrosis and pulmonary hypertension
144
List the RF for obstructive sleep apnoea
``` Male Middle aged Obesity Alcohol Smoking ```
145
Describe features of obstructive sleep apnoea
``` Daytime sleepiness Morning headache Snoring Apnoea episodes during sleep Concentration problems Waking unrefreshed ```
146
What can severe cases of sleep apnoea cause
Heart failure Hypertension Increased risk of MI and stroke
147
What tool can be used to assess for symptoms of sleepiness associated with obstructive sleep aponeoa
Epworth sleepiness scale
148
Describe the management of obstructive sleep apneoa
Lifestyle - lose weight, stop smoking and drinking CPAP - continous positive pressure during sleep to maintain patency of airway Surgery - UPPP
149
How does lung Cancer cause chest pain
Chest wall involvement | Rib mets
150
Where does mesothelioma spread to?
Other pleural cavity Hilar lymph nodes Lung
151
How is mesothelioma diagnosed?
Thoracoscopy with biopsy and histology of pleura
152
What can be injected to prevent re-accumulation of pleural effusions in mesothelioma?
Sclerosant substances
153
What is the test for TB
Acid fast bacilli sputum
154
Where should patients with active TB be treated?
Negative pressure isolation room
155
What is a mycetoma
Fungus ball forming in a pre-existing lung cavity
156
What investigations would you do for aspergillus?
Skin test (positive in 30%) Serum precipitins Sputum culture
157
Which anti-TB drug can cause hepatitis?
Rifampicin
158
Which anti-TB drug can cause optic neuritis
Ethambutol
159
Why is pyridoxine supplementation recommended with isoniazid therapy
Isoniazid therapy can cause peripheral neuropathy due to vitamin depletion
160
What is an air bronchogram
Consolidated lung outlining an air filled bronchus
161
List the radiographical changes associated with bronchiectasis
Thickened bronchial walls Ring shadows - thickened airways seen end on Volume loss secondary to mucous plugging Air fluid levels within dilated bronchi
162
List some causes of bronchiectasis
``` Aspergillosis Cystic fibrosis Immunodeficiency Sarcoidosis TB ```
163
Which antibiotic is given to serious gram negative infections
Gentamicin
164
Which antibiotic is given to pneumocystis jirovecci
Co-trimoxazole
165
List the four drugs used to treat TB
Rifampicin Isoniazid Pyrazinamide Ethambutol
166
Which type of organism is the most common cause of aspiration pneumonia
Anaerobic