Respiratory Flashcards

Question

Explain the scoring system for CURB 65

Answer 1

Score 0/1: Consider treatment at home Score ≥ 2: Consider hospital admission Score ≥ 3: Consider intensive care assessment

Answer 2

**Streptococcus pneumoniae (50%)** **Haemophilus influenzae** (20%) _Other Causes and Associations_ **Moraxella catarrhalis** in immunocompromised patients or those with chronic pulmonary disease **Pseudomonas aeruginosa** in patients with cystic fibrosis or bronchiectasis (also hospital acquired) **Staphylococcus aureus** in patients with cystic fibrosis

Answer 3

The definition of atypical pneumonia is pneumonia caused by an organism that cannot be cultured in the normal way or detected using a gram stain. They don’t respond to penicillins

Answer 4

macrolides (e.g. clarithomycin), fluoroquinolones (e.g. levofloxacin) or tetracyclines (e.g. doxycycline).

Answer 5

Legionella pneumophila Mycoplasma pneumoniae. Chlamydophila pneumoniae Coxiella burnetii AKA “Q fever”. Chlamydia psittaci

Answer 6

Legionella pneumophila The typical exam patient has recently had a cheap hotel holiday and presents with hyponatraemia.

Answer 7

Mycoplasma pneumoniae

Answer 8

The presentation might be a school aged child with a mild to moderate chronic pneumonia and wheeze. Be cautious though as this presentation is very common without chlamydophilia pneumoniae infection

Answer 9

exposure to animals and their bodily fluids. he MCQ patient is a farmer with a flu like illness.

Answer 10

This is typically contracted from contact with infected birds. The MCQ patient is a from parrot owner.

Answer 11

Pneumocystis jiroveci (PCP)

Answer 12

patients that are **immunocompromised**. It is particularly important in patients with poorly controlled or new **HIV** with a **low CD4 count**. It usually presents subtly with a **dry cough without sputum**, **shortness of breath on exertion** and **night sweats**. Treatment is with **co-trimoxazole** (trimethoprim/sulfamethoxazole) known by the brand name “**Septrin**”. Patients with low CD4 counts are prescribed prophylactic oral co-trimoxazole to protect against PCP.

Answer 13

Chest xray FBC (raised white cells) U&Es (for urea) CRP (raised in inflammation and infection) Sputum cultures Blood cultures **Legionella and pneumococcal urinary antigens** (send a urine sample for antigen testing)

Answer 14

Mild CAP: 5 day course of oral antibiotics (amoxicillin or macrolide) Moderate to severe CAP: 7-10 day course of dual antibiotics (amoxicillin and macrolide)

Answer 15

Sepsis Pleural effusion Empyema Lung abscess Death

Answer 16

Asthma is a **chronic inflammatory condition** of the airways that causes episodic exacerbations of **bronchoconstriction.** In asthma there is **reversible airway obstruction** that typically responds to **bronchodilators** such as **salbutamol**. This bronchoconstriction is caused by **hypersensitivity** of the airways and can be triggered by environmental factors.

Answer 17

Infection Night time or early morning Exercise Animals Cold/damp Dust Strong emotions

Answer 18

* Episodic symptoms * Diurnal variability. Typically worse at night. * Dry cough with wheeze and shortness of breath * A history of other atopic conditions such as eczema, hayfever and food allergies * Family history * Bilateral widespread “polyphonic” wheeze heard by a healthcare professional

Answer 19

Wheeze related to coughs and colds more suggestive of viral induced wheeze Isolated or productive cough Normal investigations No response to treatment Unilateral wheeze. This suggests a focal lesion or infection.

Answer 20

First line investigations: * **Fractional exhaled nitric oxide** * **Spirometry with bronchodilator reversibility** If there is diagnostic uncertainty after first line investigations these can be followed up with further testing: * **Peak flow variability** measured by keeping a diary of peak flow measurements several times per day for 2 to 4 weeks * **Direct bronchial challenge test** with histamine or methacholine

Answer 21

This is a combination inhaler containing a low dose inhaled corticosteroid and a fast acting LABA. This replaces all other inhalers and the patient uses this single inhaler both regularly as a “preventer” and also as a “reliever” when they have symptoms.

Answer 22

1. Add short-acting beta 2 agonist inhaler (e.g**. salbutamol**) as required for infrequent wheezy episodes. 2. Add a regular low dose corticosteroid inhaler. 3. Add **LABA** inhaler (e.g. salmeterol). Continue the LABA only if the patient has a good response. 4. Consider a trial of an oral **leukotriene receptor antagonist** (i.e. montelukast), **oral beta 2 agonist** (i.e. oral salbutamol), oral **theophylline or an inhaled LAMA (i.e. tiotropium).** 5. Titrate inhaled corticosteroid up to “high dose”. Combine additional treatments from step 4. Refer to specialist. 6. Add oral steroids at the lowest dose possible to achieve good control.

Answer 23

Each patient should have an individual asthma self-management programme Yearly flu jab Yearly asthma review Advise exercise and avoid smoking

Answer 24

An acute exacerbation of asthma is characterised by a rapid deterioration in symptoms. This could be triggered by any of the typical asthma triggers such as infection, exercise or cold weather.

Answer 25

* Progressively worsening shortness of breath * Use of accessory muscles * Fast respiratory rate (tachypnoea) * Symmetrical expiratory wheeze on auscultation * The chest can sound “tight” on auscultation with reduced air entry

Answer 26

PEFR 50 – 75% predicted

Answer 27

* PEFR 33-50% predicted * Resp rate \>25 * Heart rate \>110 * Unable to complete sentences

Answer 28

* PEFR \<33% * Sats \<92% * Becoming tired * No wheeze. This occurs when the airways are so tight that there is no air entry at all. This is ominously described as a “silent chest”. * Haemodynamic instability (i.e. shock)

Answer 29

* Nebulised **beta-2 agonists** (i.e. salbutamol 5mg repeated as often as required) * Nebulised **ipratropium bromide** * **Steroids.** Oral prednisolone or IV hydrocortisone. These are continued for 5 days * Antibiotics if there is convincing evidence of bacterial infection

Answer 30

* Oxygen if required to maintain sats 94-98% * **Aminophylline** infusion * Consider IV salbutamol

Answer 31

* IV **magnesium sulphate** infusion * Admission to HDU / ICU * **Intubation** in worst cases – however this decision should be made early because it is very difficult to intubate with severe bronchoconstriction

Answer 32

Initially patients will have a **respiratory alkalosis** as **tachypnoea** causes a drop in CO2 A normal pCO2 or hypoxia is a concerning sign as it means they are tiring and indicates life threatening asthma. A respiratory acidosis due to high CO2 is a very bad sign in asthma.

Answer 33

use: Respiratory rate Respiratory effort Peak flow Oxygen saturations Chest auscultation

Answer 34

Monitor serum potassium when on salbutamol as it causes potassium to be absorbed from the blood into the cells. Salbutamol also causes tachycardia (fast heart rate).

Answer 35

Chronic obstructive pulmonary disease (COPD) is a non-reversible, long term deterioration in air flow through the lungs caused by damage to lung tissue. This lung damage is almost always the result of smoking. The damage to the lung tissues causes an obstruction to the flow of air through the airways making it more difficult to ventilate the lungs and making them prone to developing infections.

Answer 36

Suspect COPD in a long term smoker presenting with chronic shortness of breath, cough, sputum production, wheeze and recurrent respiratory infections, particularly in winter. Always consider differential diagnoses such as lung cancer, fibrosis or heart failure. COPD does NOT cause clubbing. It is unusual for it to cause **haemoptysis** (coughing up blood) or chest pain. These symptoms should be investigated for a different cause.

Answer 37

This is a 5 point scale that NICE recommend for assessing the impact of their breathlessness: Grades: * Grade 1 – Breathless on strenuous exercise * Grade 2 – Breathless on walking up hill * Grade 3 – Breathless that slows walking on the flat * Grade 4 – Stop to catch their breath after walking 100 meters on the flat * Grade 5 – Unable to leave the house due to breathlessness

Answer 38

Diagnosis is based on clinical presentation plus spirometry. Spirometry will show an “obstructive picture”. FEV1/FVC ratio \<0.7 The obstructive picture does not show a dramatic response to reversibility testing with beta-2 agonists such as salbutamol during spirometry testing. If there is a large response to reversibility testing them consider asthma as an alternative diagnosis.

Answer 39

* Stage 1: FEV1 \>80% of predicted * Stage 2: FEV1 50-79% of predicted * Stage 3: FEV1 30-49% of predicted * Stage 4: FEV1 \<30% of predicted *

Answer 40

**Chest xray** to exclude other pathology such as lung cancer. **Full blood count** for polycythaemia or anaemia. Polycythaemia (raised haemoglobin) is a response to chronic hypoxia. **Body mass index** (BMI) as a baseline to later assess weight loss (e.g. cancer or severe COPD) or weight gain (e.g. steroids). **Sputum culture** to assess for chronic infections such as pseudomonas. **ECG** and **echocardiogram** to assess heart function. **CT thorax** for alternative diagnoses such as fibrosis, cancer or bronchiectasis. **Serum alpha-1 antitrypsin** to look for alpha-1 antitrypsin deficiency. Deficiency leads to early onset and more severe disease. **Transfer factor for carbon monoxide (TLCO)** is decreased in COPD. It can give an indication about the severity of the disease and may be increased in other conditions such as asthma.

Answer 41

Remember that CO2 makes blood acidotic by breaking down into **carbonic acid (H2CO3).** Low pH (acidosis) with a raised pCO2 suggests they are acutely retaining (not able to get rid of) more CO2 and their blood has become acidotic. This is a **respiratory acidosis**. **Raised bicarbonate** indicates they **chronically retain** CO2 and their kidneys have responded by producing more **bicarbonate** to balance the acidic CO2 and maintain a normal pH. In an acute exacerbation, the kidneys can’t keep up with the rising level of CO2 so they become acidotic despite having a higher bicarbonate than someone without COPD.

Answer 42

Low pO2 indicates hypoxia and respiratory failure Normal pCO2 with low pO2 indicates type 1 respiratory failure (only one is affected) Raised pCO2 with low pO2 indicates type 2 respiratory failure (two are affected)

Answer 43

**Chest xray** to look for pneumonia or other pathology **ECG** to look for arrhythmia or evidence of heart strain (heart failure) **FBC** to look for infection (raised white cells) **U&E** to check electrolytes which can be affected by infection and medications **Sputum culture** if significant infection is present **Blood cultures** if septic

Answer 44

* If retaining CO2 aim for oxygen saturations of **88-92%** titrated by venturi mask * If not retaining CO2 and their bicarbonate is normal (meaning they do not normally retain CO2) then give oxygen to aim for oxygen saturations **\> 94%**

Answer 45

* **Prednisolone** 30mg once daily for 7-14 days * Regular inhalers or home **nebulisers** * **Antibiotics** if there is evidence of infection

Answer 46

* **Nebulised bronchodilators** (e.g. salbutamol 5mg/4h and ipratropium 500mcg/6h) * **Steroids** (e.g. 200mg hydrocortisone or 30-40mg oral prednisolone) * **Antibiotics** if evidence of infection * **Physiotherapy** can help clear sputum

Answer 47

* IV **aminophylline** * **Non-invasive ventilation** (NIV) * **Intubation** and **ventilation** with admission to intensive care * **Doxapram** can be used as a respiratory stimulant where NIV or intubation is not appropriate

Answer 48

Interstitial lung disease is an umbrella term to describe conditions that affect the lung parenchyma (the lung tissue) causing inflammation and fibrosis. Fibrosis involves the replacement of the normal elastic and functional lung tissue with scar tissue that is stiff and does not function effectively.

Answer 49

Diagnosis of interstitial lung disease requires a combination of clinical features and **high resolution CT** scan of the thorax. HRCT shows a **“ground glass”** appearance with interstitial lung disease. When diagnosis is unclear lung biopsy can be used to take samples of the lung tissue and confirm the diagnosis on **histology.**

Answer 50

Generally there is a poor prognosis and limited management options in interstitial lung disease as the damage is irreversible. Generally the treatment is supportive and where possible to prevent further progression of the disease. Options are: * Remove or treat the underlying cause * Home oxygen where they are hypoxic at rest * Stop smoking * Physiotherapy and pulmonary rehabilitation * Pneumococcal and flu vaccine * Advanced care planning and palliative care where appropriate * Lung transplant is an option but the risks and benefits need careful consideration

Answer 51

This is a condition where there is progressive pulmonary fibrosis with no clear cause. It presents with an insidious onset of shortness of breath and dry cough over more than 3 months. It usually affects adults over 50 years old. Examination can show **bibasal fine inspiratory crackles and finger clubbing**. Prognosis is poor with a life expectancy of 2-5 years from diagnosis.

Answer 52

Two medications are licensed that can slow the progression of the disease: * Pirfenidone is an antifibrotic and anti-inflammatory * Nintedanib is a monoclonal antibody targeting tyrosine kinase

Answer 53

Amiodarone Cyclophosphamide Methotrexate Nitrofurantoin

Answer 54

Alpha-1 antitripsin deficiency Rheumatoid arthritis Systemic lupus erythematosus (SLE) Systemic sclerosis

Answer 55

Hypersensitivity pneumonitis is a **type III hypersensitivity** reaction to an environmental allergen that causes **parenchymal inflammation** and destruction in people that are sensitive to that **allergen**. **Bronchoalveolar lavage** involves collecting cells from the airways during **bronchoscopy** by washing the airways with fluid then collecting that fluid for testing. This shows **raised lymphocytes** and mast cells in hypersensitivity pneumonitis.

Answer 56

Management is by removing the allergen, giving oxygen where necessary and steroids

Answer 57

* **Bird-fanciers lung** is a reaction to bird droppings * **Farmers lung** is a reaction to mouldy spores in hay * **Mushroom workers’ lung** is a reaction to specific mushroom antigens * **Malt workers lung** is a reaction to mould on barley

Answer 58

It involves a focal area of inflammation of the lung tissue. This can be idiopathic or triggered by infection, inflammatory disorders, medications, radiation or environmental toxins or allergens. presentation is very similar to infectious pneumonia with shortness of breath, cough, fever and lethargy. It also presents on similarly to pneumonia on a chest xray with a focal consolidation. Diagnosis is often delayed due to the similarities to infective pneumonia. Lung biopsy is the definitive investigation. Treatment is with systemic corticosteroids.

Answer 59

Asbestosis is lung fibrosis related to the inhalation of asbestos. Asbestos is fibrogenic, meaning it causes lung fibrosis. It is also oncogenic, meaning it causes cancer. The effects of asbestos usually take several decades to develop.

Answer 60

Lung fibrosis Pleural thickening and pleural plaques Adenocarcinoma Mesothelioma

Answer 61

A pleural effusion is a collection of fluid in the pleural cavity. This can be **exudative** meaning there is a high protein count (\>3g/dL) or **transudative** meaning there is a relatively lower protein count (\<3g/dL). Whether it is exudative or transudative helps determine the cause.

Answer 62

Exudative causes are related to **inflammation**. The inflammation results in protein leaking out of the tissues in to the pleural space (ex- meaning moving out of). Think of the causes of inflammation: * Lung cancer * Pneumonia * Rheumatoid arthritis * Tuberculosis

Answer 63

Transudative causes relate to fluid moving across into the pleural space (trans- meaning moving across). Think of the causes of fluid shifting: * **Congestive cardiac failure** * **Hypoalbuminaemia** * **Hypothroidism** * **Meig’s syndrome** (right sided pleural effusion with ovarian malignancy)

Answer 64

* Shortness of breath * Dullness to percussion over the effusion * Reduced breath sounds * Tracheal deviation away from the effusion if it is massive

Answer 65

Chest xray shows: * **Blunting** of the **costophrenic angle** * Fluid in the lung **fissures** * Larger effusions will have a **meniscus.** This is a curving upwards where it meets the chest wall and mediastinum. * Tracheal and mediastinal **deviation** if it is a massive effusion Taking a sample of the pleural fluid by aspiration or chest drain is required to analyse it for protein count, cell count, pH, glucose, LDH and microbiology testing

Answer 66

**Conservative management** may be appropriate as small effusions will resolve with treatment of the underlying cause. Larger effusions often need aspiration or drainage. **Pleural aspiration** involves sticking a needle in and aspirating the fluid. This can temporarily relieve the pressure but the effusion may recur and repeated aspiration may be required. **Chest drain** can be used to drain the effusion and prevent it recurring

Answer 67

Empyema is where there is an infected pleural effusion. Suspect an empyema in a patient who has an improving pneumonia but new or ongoing fever. Pleural aspiration shows pus, **acidic pH (pH \< 7.2)**, low glucose and high LDH. Empyema is treated by chest drain to remove the pus and antibiotics.

Answer 68

Pneumothorax occurs when air gets into the pleural space separating the lung from the chest wall. It can occur spontaneously or secondary to trauma, medical interventions (“iatrogenic”) or lung pathology. The typical patient in your exams is a young, tall, thin young man presenting with sudden breathlessness and pleuritic chest pain, possibly whilst playing sports. ## Footnote **air in the pleural space**

Answer 69

* Spontaneous * Trauma * Iatrogenic such as due to lung biopsy, mechanical ventilation or central line insertion * Lung pathology such as infection, asthma or COPD

Answer 70

Erect chest xray is the investigation of choice for a simple pneumothorax. A chest xray will show an area between the lung tissue and the chest wall where there are no lung markings. There will be a line demarcating the edge of the lung where the lung markings ends and the pneumothorax begins. no lung markings and edge of lung

Answer 71

This is based on the 2010 guidelines from the British Thoracic Society: If no SOB and there is a \< 2cm rim of air on the chest xray then no treatment required as it will spontaneously resolve. Follow up in 2-4 weeks is recommended. If SOB and/or there is a \> 2cm rim of air on the chest xray then it will require aspiration and reassessment. If aspiration fails twice it will require a chest drain. Unstable patients or bilateral or secondary pneumothoraces generally require a chest drain.

Answer 72

Tension pneumothorax is caused by trauma to chest wall that creates a one-way valve that lets air in but not out of the pleural space. The one-way valve means that during inspiration air is drawn into the pleural space and during expiration, the air is trapped in the pleural space. Therefore more air keeps getting drawn into the pleural space with each breath and cannot escape. This is dangerous as it creates pressure inside the thorax that will push the mediastinum across, kink the big vessels in the mediastinum and cause cardiorespiratory arrest.

Answer 73

* Tracheal deviation away from side of pneumothorax * Reduced air entry to affected side * Increased resonant to percussion on affected side * Tachycardia * Hypotension

Answer 74

The management sentence you need to learn and recite in your exams is: **“Insert a large bore cannula into the second intercostal space in the midclavicular line"** If a tension pneumothorax is suspected do not wait for any investigations. Once the pressure is relieved with a cannula then a chest drain is required for definitive management. .

Answer 75

“triangle of safety” ## Footnote The 5th intercostal space (or the inferior nipple line) The mid axillary line (or the lateral edge of the latissimus dorsi) The anterior axillary line (or the lateral edge of the pectoris major)

Answer 76

Pulmonary embolism (PE) is a condition where a blood clot (thrombus) forms in the **pulmonary arteries.** This is usually the result of a **deep vein thrombosis (DVT)** that developed in the legs and travelled (**embolised)** through the venous system and the right side of the heart to the pulmonary arteries in the lungs. Once they are in the pulmonary arteries they block the blood flow to the lung tissue and create strain on the right side of the heart. DVTs and PEs are collectively known as **venous thromboembolism (VTE).**

Answer 77

There are a number of factors for developing a DVT or PE. In many of these situations we give patients prophylactic treatment with **low molecular weight heparin to reduce the risk.** * Immobility * Recent surgery * Long haul flights * Pregnancy * Hormone therapy with oestrogen * Malignancy * Polycythaemia * Systemic lupus erythematosus Thrombophilia

Answer 78

periods of immobility, surgery and long haul flights to score extra points from your examiners.

Answer 79

Every patient admitted to hospital should be assessed for their risk of **venous thromboembolism (VTE)**. If they at increased risk of VTE they should receive prophylaxis with a **low molecular weight heparin** such as **enoxaparin** unless contraindicated. Contraindications include active bleeding or existing anticoagulation with **warfarin** or a **NOAC. Anti-embolic compression stockings** are also used unless contraindicated. The main contraindication for compression stockings is significant **peripheral arterial disease.**

Answer 80

Pulmonary embolism can present with subtle signs and symptoms. In patients with potential features of a PE, risk factors for PE and no other explanation for their symptoms have a low threshold for suspecting a PE. Presenting features include: * Shortness of breath * Cough with or without blood **(haemoptysis)** * Pleuritic chest pain * Hypoxia * Tachycardia * Raised respiratory rate * Low grade fever * Haemodynamic instability causing hypotension

Answer 81

The Wells score predicts the risk of a patient presenting with symptoms actually having a DVT or pulmonary embolism. It takes in to account risk factors such as recent surgery and clinical findings such as **tachycardia** (heart rate \>100) and **haemoptysis**.

Answer 82

NICE recommend assessing for alternative causes with a: * History * Examination * Chest xray Perform a **Wells score** and proceed based on the outcome: * **Likely:** perform a CT pulmonary angiogram * **Unlikely**: perform a d-dimer and if positive perform a CTPA There are two main options for establishing a definitive diagnosis: **CT pulmonary angiogram** or **ventilation–perfusion (VQ) scan.**

Answer 83

CT pulmonary angiogram (CTPA) involves a chest CT scan with an intravenous contrast that highlights the pulmonary arteries to demonstrate any blood clots. This is usually the first choice for investigating a pulmonary embolism as it tends to be more readily available, provides a more definitive assessment and gives information about alternative diagnoses such as pneumonia or malignancy.

Answer 84

Ventilation-perfusion (VQ) scan involves using radioactive isotopes and a gamma camera to compare the **ventilation** with the **perfusion** of the lungs. They are used in patients with renal impairment, contrast allergy or at risk from radiation where a CTPA is unsuitable. First, the isotopes are inhaled to fill the lungs and a picture is taken to demonstrate **ventilation**. Next a contrast containing isotopes is injected and a picture is taken to demonstrate **perfusion**. The two pictures are then compared. With a pulmonary embolism there will be a deficit in perfusion as the thrombus blocks blood flow to the lung tissue. This area of lung tissue will be ventilated but not perfused.

Answer 85

Patients with a pulmonary embolism often have a **respiratory alkalosis** when an ABG is performed.

Answer 86

* Admission to hospital * Oxygen as required * Analgesia if required * Adequate monitoring for any deterioration

Answer 87

The initial management guidelines from NICE were updated in March 2020. The initial recommended treatment is **apixaban or rivaroxaban**. **Low molecular weight heparin (LMWH)** is an alternative where these are not suitable, or in **antiphospholipid syndrome**. It should be started immediately before confirming the diagnosis in patients where DVT or PE is suspected and there is a delay in getting the scan. Examples are **enoxaparin and dalteparin.**

Answer 88

warfarin, a NOAC or LMWH.

Answer 89

NOACs or DOACs

Answer 90

apixaban, dabigatran and rivaroxaban.

Answer 91

LMWH long term is first line treatment in pregnancy or cancer.

Answer 92

* **3 months** if there is an obvious reversible cause (then review) * **Beyond 3 months** if the cause is unclear, there is recurrent VTE or there is an irreversible underlying cause such as thrombophilia. This is often 6 months in practice. * **6 months** in active cancer (then review)

Answer 93

thrombolysis

Answer 94

**Thrombolysi**s involves injecting a fibrinolytic medication (they break down **fibrin)** that rapidly dissolves clots. There is a significant risk of bleeding which can make it dangerous. It is only used in patients with a massive PE where the benefits outweigh the risks

Answer 95

streptokinase, alteplase and tenecteplase.

Answer 96

* **Intravenously** using a peripheral cannula. * Directly into the **pulmonary arteries** using a central catheter. This is called **catheter-directed thrombolysis.**

Answer 97

In catheter-directed thrombolysis a catheter is inserted into the venous system, through the right side of the heart and in to the pulmonary arteries. The operator can then administer the **thrombolytic agent** directly into the location of the thrombus. Special equipment can also be used to physically break down the thrombus and aspirate it. There is a risk of damaging the pulmonary arteries doing this.

Answer 98

Pulmonary hypertension is increased resistance and pressure of blood in the pulmonary arteries. Increasing the pressure and resistance in the pulmonary arteries causes strain on the right side of the heart trying to pump blood through the lungs. This also causes a back pressure of blood into the systemic venous system.

Answer 99

Group 1 – **Primary pulmonary hypertension** or connective tissue disease such as **systemic lupus erythematous (SLE)** Group 2 – Left heart failure usually due to myocardial infarction or systemic hypertension Group 3 – Chronic lung disease such as COPD Group 4 – Pulmonary vascular disease such as pulmonary embolism Group 5 – Miscellaneous causes such as sarcoidosis, glycogen storage disease and haematological disorders

Answer 100

Shortness of breath is the main presenting symptom. Other signs and symptoms are: * Syncope * Tachycardia * Raised JVP * Hepatomegaly * Peripheral oedema.

Answer 101

**ECG Changes** The right sided heart strain causes ECG changes such as: Right ventricular hypertrophy seen as 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 **Chest Xray Changes** Dilated pulmonary arteries Right ventricular hypertrophy **Other investigations** A raised NT-proBNP blood test result indicates right ventricular failure Echo can be used to estimate pulmonary artery pressure

Answer 102

**Primary pulmonary hypertension** can be treated with: * IV prostanoids (e.g. epoprostenol) * Endothelin receptor antagonists (e.g. macitentan) * Phosphodiesterase-5 inhibitors (e.g. sildenafil) **Secondary pulmonary hypertension** is managed by treating the underlying cause such as pulmonary embolism or SLE. **Supportive treatment** for complications such as respiratory failure, arrhythmias and heart failure.

Answer 103

Sarcoidosis is a granulomatous inflammatory condition. Granulomas are nodules of inflammation full of macrophages. The cause of these granulomas developing is unknown.

Answer 104

It is usually associated with chest symptoms but also has multiple **extra-pulmonary manifestations** such as **erythema nodosum** and **lymphadenopathy**. Symptoms can vary dramatically from asymptomatic (in up to 50%) to severe and life-threatening

Answer 105

The typical MCQ exam patient is a 20-40 year old black woman presenting with a dry cough and shortness of breath. They may have nodules on their shins suggesting erythema nodosum. Young black woman with a cough

Answer 106

Sarcoidosis can affect almost any organ in the body. The most commonly affected are the lungs so sarcoidosis is usually managed by respiratory physicians **Lungs (affecting over 90%)** * Mediastinal lymphadenopathy * Pulmonary fibrosis * Pulmonary nodules **Systemic Symptoms** * Fever * Fatigue * Weight loss **Liver (affecting around 20%)** * Liver nodules * Cirrhosis * Cholestasis **Eyes (affecting around 20%)** * Uveitis * Conjunctivitis * Optic neuritis **Skin (affecting around 15%)** * Erythema nodosum (tender, red nodules on the shins caused by inflammation of the subcutaneous fat) * Lupus pernio (raised, purple skin lesions commonly on cheeks and nose) * Granulomas develop in scar tissue **Heart (affecting around 5%)** * Bundle branch block * Heart block * Myocardial muscle involvement **Kidneys (affecting around 5%)** * Kidney stones (due to hypercalcaemia) * Nephrocalcinosis * Interstitial nephritis **Central nervous system (affecting around 5%)** * Nodules * Pituitary involvement (diabetes insipidus) **Encephalopathy** * Peripheral Nervous System (affecting around 5%) * Facial nerve palsy * Mononeuritis multiplex **Bones (affecting around 2%)** * Arthralgia * Arthritis * Myopath

Answer 107

This is a specific presentation of sarcoidosis. It is characteristic by a triad of: * Erythema nodosum * Bilateral hilar lymphadenopathy * Polyarthralgia (joint pain in multiple joints)

Answer 108

* Tuberculosis * Lymphoma * Hypersensitivity pneumonitis * HIV * Toxoplasmosis * Histoplasmosis

Answer 109

* Raised serum ACE. This is often used as a screening test. * Hypercalcaemia (rasied calcium) is a key finding. * Raised serum soluble interleukin-2 receptor * Raised CRP * Raised immunoglobulins

Answer 110

* Chest xray shows **hilar lymphadenopathy** * High-resolution CT thorax shows **hilar lymphadenopathy** and **pulmonary nodules** * **MRI** can show CNS involvement * **PET scan** can show active inflammation in affected areas

Answer 111

The gold standard for confirming the diagnosis of sarcoidosis is by histology from a biopsy

Answer 112

The histology shows characteristic non-caseating granulomas with epithelioid cells.

Answer 113

* U&Es for kidney involvement * Urine dipstick or urine albumin-creatinine ratio to look for proteinuria indicating nephritis * LFTs for liver involvement * Ophthalmology review for eye involvement * ECG and echocardiogram for heart involvement * Ultrasound abdomen for liver and kidney involvement

Answer 114

* **No treatment** is considered as first line in patients with no or mild symptoms as the condition often resolves spontaneously. * **Oral steroids** are usually first line where treatment is required and are given for between 6 and 24 months. Patients should be given bisphosphonates to protect against osteoporosis whilst on such long term steroids. * Second line options are **methotrexate or azathioprine** * **Lung transplant** is rarely required in severe pulmonary disease

Answer 115

Obstructive sleep apnoea is caused by collapse of the pharyngeal airway during sleep. It is characterised by apnoea episodes during sleep where the person will stop breathing periodically for up to a few minutes. This is usually reported by the partner as the patient is unaware of these episodes.

Answer 116

* Middle age * Male * Obesity * Alcohol * Smoking

Answer 117

* Apnoea episodes during sleep (reported by partner) * Snoring * Morning headache * Waking up unrefreshed from sleep * Daytime sleepiness * Concentration problems * Reduced oxygen saturation during sleep

Answer 118

Severe cases can cause **hypertension, heart failure** and can increase the risk of **myocardial infarction** and **stroke.**

Answer 119

The Epworth Sleepiness Scale is used to assess symptoms of sleepiness associated with obstructive sleep apnoea. TOM TIP: If interviewing someone that you suspect has obstructive sleep apnoea ask about their daytime sleepiness and their occupation. Daytime sleepiness is a key feature that should make you suspect obstructive sleep apnoea. Patients that need to be fully alert for work, for example heavy goods vehicle operators, require urgent referral and may need amended work duties whilst awaiting assessment and treatment.

Answer 120

Referral to an **ENT specialist or a specialist sleep clinic** where they can perform sleep studies. This involves the patient sleeping in a laboratory whilst staff monitor their oxygen saturations, heart rate, respiratory rate and breathing to establish any apnoea episodes and the extent of their snoring. The first step in management is to **correct reversible risk factors** by advising them to stop drinking alcohol, stop smoking and lose weight. The next step is to use a **continuous positive airway pressure (CPAP)** machine that provides continuous pressure to maintain the patency of the airway. Surgery is another option. This involves quite significant surgical restructuring of the soft palate and jaw. The most common procedure is called **uvulopalatopharyngoplasty (UPPP).**