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MRCP PACES > Respiratory > Flashcards

Respiratory Flashcards

1
Q

What are the clinical signs of pulmonary fibrosis?

A 
Clubbing
Central cyanosis
Fine end inspiratory crackles
Signs of associated autoimmune disease
Signs of steroid treatment
Discoloured skin secondary to amiodarone
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2
Q

How would you investigate a patient with suspected pulmonary fibrosis?

A

Bloods - ESR, rheumatoid factor, eosinophils
CXR - reticulonodular changes, loss of definition of heart border, small lungs
ABG - type 1 respiratory failure
Lung function tests - FEV1/FVC > 0.8 (restrictive), low total lung capacity, reduced transfer factors
Bronchoalveolar lavage to exclude infection prior to starting treatment
High resolution CT scan
Lung biopsy

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3
Q

What is the treatment of pulmonary fibrosis?

A

Immunosuppression if inflammatory
Pirfenidone for usual interstitial pneumonia when FEV1 50-80% predicted
N-acetylcysteine
Single lung transplantation

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4
Q

What is the prognosis of pulmonary fibrosis?

A

Variable as depends on aetiology
Increased risk of bronchogenic carcinoma

Highly cellular with ground glass infiltrates and responds to immunosuppression has 80% 5 year survival

Honeycombing with no response to immunosuppression has 80% 5 year mortality

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5
Q

What are the causes of basal fibrosis?

A

Usual interstitial pneumonia
Asbestosis
Rheumatoid arthritis
Aspiration

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6
Q

What are the causes of an apical fibrosis?

A

Substances: Berylliosis, pneumoconiosis, sillicosis, radiation

Infective/immune: Extrinsic allergic alveolitis, Allergic bronchopulmonary aspergillosis, TB

Sarcoidosis
Ankylosing spondylitis
Psoriasis

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7
Q

What are the respiratory causes of clubbing?

A 
Interstitial lung disease
Cancer
Mesothelioma 
Bronchiectasis
Cystic fibrosis
Lung abscess
Empyema
Tuberculosis
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8
Q

What are the clinical signs of bronchiectasis?

A 
Cachexia
Clubbing
Crackles that alter with coughing
High sputum load
Cor pulmonale
Yellow nail syndrome
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9
Q

How would you investigate a patient with suspected bronchiectasis?

A

Sputum culture and cytology
CXR - tramlines and ring shadows
High resolution CT - signet ring sign

Immunoglobulins
Aspergillus RAST
Rheumatoid serology
Saccharine ciliary motility 
Genetic screening
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10
Q

What are the causes of bronchiectasis?

A

Congenital - Kartagener’s and cystic fibrosis
Childhood infection - measles and TB
Immune over activity - ABPA, inflammatory bowel disease
Immune under activity - hypogammaglobulinaemia, common variable immunodeficiency
Aspiration

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11
Q

How would you manage a patient with bronchiectasis?

A

Physiotherapy
Prompt antibiotics for infections
Low dose azithromycin prophylaxis
Bronchodilators and inhaled corticosteroids
Surgery may be used for localised disease
Ensure up to date vaccinations
Long term oxygen therapy in advanced cases
Lung transplantation in cystic fibrosis

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12
Q

What are the possible complications of bronchiectasis?

A

Sepsis
Cor pulmonale
Secondary amyloidosis
Massive haemoptysis due to mycotic aneurysm

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13
Q

What are the most common pathogens in patients with bronchiectasis?

A 
Staphylococcus aureus
Haemophillus influenzae
Pseudomonas
Streptococcus pneumoniae
Klebsiella
Aspergillus
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14
Q

Explain the pathophysiology of cystic fibrosis

A

Autosomal recessive condition that occurs in 1 in 2500
Defect in chromosome 7 that encodes the CFTR gene
Respiratory manifestations - nasal polyps, bronchiectasis
GI - malabsorption, meconium ileus, gallstones
Non-erosive arthropathy and infertility

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15
Q

What are the side effects of tuberculosis medications?

A

Isoniazid - peripheral neuropathy, hepatitis
Rifampicin - hepatitis, enzyme inducer
Ethambutol - hepatitis, retro-bulbar neuritis
Pyrazinamide - hepatitis

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16
Q

What are the indications for a single lung transplantation?

A

COPD, pulmonary fibrosis

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17
Q

What are the indications for a double lung transplantation?

A

Cystic fibrosis
Bronchiectasis
Pulmonary hypertension

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18
Q

What are the clinical signs of COPD?

A 
CO2 retention flap, bounding pulse
Hyper- expanded chest
Resonant percussion with loss of cardiac dullness
Expiratory polyphonic wheeze
Cor pulmonale
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19
Q

What are the causes of COPD?

A

Smoking
Industrial dust exposure
Alpha 1 antitrypsin deficiency

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20
Q

How would you investigate a patient with COPD?

A 
CXR - hyperexpanded, pneumothorax 
ABG - type 2 respiratory failure 
Bloods - look for infection, alpha 1 antitrypsin 
Spirometry - low FEV1, FEV1/FVC <0.7
Reduced gas transfer factor
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21
Q

What is the treatment of COPD?

A 
Smoking cessation is single most beneficial intervention
Long term oxygen therapy
Pulmonary rehabilitation 
Beta agonists
Tiotropium
Inhaled corticosteroids 
Vaccinations
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22
Q

What are the inclusion criteria for long term oxygen therapy?

A

Non smoker
PaO2 <7.3 on air (<8 if cor pulmonale)
PaCO2 that does not rise excessively on oxygen
Improves average survival by 9 months

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23
Q

What are the differential diagnoses of a wheezy chest?

A

COPD
Granulomatous polyangitis
Obliterative bronchiolotis
Rheumatoid arthritis

24
Q

What are the clinical signs of a pleural effusion?

A 
Asymmetrically reduced expansion
Trachea deviated away from effusion
Stony dull percussion
Absent tactile vocal fremitus
Reduced breath sounds
25
Q

What are the causes of a pleural effusion?

A 
Cancer
Heart failure
Liver failure
Renal failure
Connective tissue disease
Infection
26
Q

How would you differentiate between a transudative and an exudative effusion?

A

Transudate protein count <30

Exudate protein count >30

27
Q

What would you look for in pleural aspiration?

A

Protein (compare effusion albumin and plasma albumin)
LDH
Glucose
pH

28
Q

What is an empyema?

A

Collection of pus within the pleural space
Anaerobes, staphylococci and gram negative organisms most commonly
Associated with bronchial obstruction (cancer) and recurrent aspiration

29
Q

How would you classify lung cancer?

A

Small cell and non-small cell

Squamous is the most common type, associated with smoking
Small cell more common in non-smokers

Small cell usually disseminated at presentation and therefore not amenable to radical surgical treatment

30
Q

What are the treatment options for non-small cell lung cancer?

A

Surgery (lobectomy or pneumonectomy)
Radiotherapy
Chemotherapy

31
Q

What is the definition of COPD?

A

Progressive and irreversible (or partially reversible) airflow obstruction due to chronic bronchitis and emphysema

32
Q

What is the definition of chronic bronchitis?

A

Cough productive of sputum most days for 3 months during two consecutive years

33
Q

What is the definition of emphysema?

A

Abnormal and permanent enlargement of air spaces distal to the terminal bronchioles associated with destruction of their walls without obvious fibrosis

34
Q

What is the appearance and composition of normal pleural fluid?

A 
Clear ultrafiltrate of plasma
pH 7.6-7.64
Protein <1.2g/litre
WCC <1000
LDH <50% of plasma concentration 
Glucose similar to plasma concentration
35
Q

What are Light’s criteria for an exudate?

A

Pleural fluid protein:serum protein > 0.5
Pleural fluid LDH:serum LDH > 0.6
Pleural fluid LDH >2/3 of the upper limit of the normal serum value

36
Q

What are the causes of high LDH in pleural fluid?

A

Empyema
Malignant effusion
Rheumatoid effusion

37
Q

What are the causes of low glucose in a pleural effusion?

A 
Malignancy
Empyema
Tuberculosis 
Oesophageal rupture
Rheumatoid arthritis
SLE
38
Q

What are the indications for pleurodesis?

A

Recurrent malignant pleural effusion

Recurrent pneumothoraces

39
Q

What agents can be used for chemical pleurodesis?

A 
Talc
Doxycycline
Bleomycin
Zinc sulphate
Quinacrine hydrochloride
40
Q

What is the most common type of non small cell lung cancer?

A

Adenocarcinoma (50%)
Squamous cell (30%)
Bronchoalveolar
Large cell (least common)

41
Q

What are the endocrine paraneoplastic manifestations of lung cancer?

A 
SIADH 
Cushing’s syndrome 
Hypercalcaemia
Hyperthyroidism
Hypoglycaemia
42
Q

What are the neurological paraneoplastic manifestations of lung cancer?

A

Lambert-Eaton myasthenic syndrome
Sensory neuropathy
Limbic encephalopathy

43
Q

What are the musculoskeletal paraneoplastic manifestations of lung cancer?

A

Polymyositis
Dermatomyositis
Clubbing
Hypertrophic pulmonary osteoarthropathy

44
Q

What are the cutaneous paraneoplastic manifestations of lung cancer?

A

Acanthosis nigricans
Gynaecomastia
Thrombophlebitis
Herpes zoster

45
Q

What are the possible indications for a lobectomy?

A 
Bronchiectasis
Malignancy 
Solitary pulmonary nodule
Cystic fibrosis
Tuberculosis 
Lung abscess
46
Q

What are the possible indications for a pneumonectomy?

A

Bronchiectasis
Malignancy
Tuberculosis

47
Q

What are the clinical features of old tuberculosis infection?

A 
Apical fibrosis
Thoracoplasty
Pneumonectomy
Lobectomy
Phrenic nerve crush (left supraclavicular scar)
Recurrent pneumothoraces
48
Q

What is the prevalence of tuberculosis?

A

2 billion individuals worldwide, with 8 million new diagnoses every year

49
Q

What are the risk factors for developing tuberculosis?

A 
Immigrant population 
Immunocompromised
Elderly patients
Alcoholics
Malnutrition 
Homeless individuals 
Occupational exposure
50
Q

What are the acute complications of tuberculosis?

A

Respiratory: Pneumothorax, Pleural effusion, Empyema, Collapse, ARDS, respiratory failure

Tubulointerstitial nephritis
Tuberculous meningitis
Miliary TB

51
Q

What are the chronic complications of tuberculosis?

A 
Pulmonary fibrosis 
Bronchiectasis 
Cor pulmonale
Aspergilloma
Reactivation
52
Q

How would you investigate a patient with suspected tuberculosis?

A

Blood tests including HIV serology
CXR: upper lobe cavitating lesion, mediastinal lymphadenopathy
Sputum: three samples, Ziehl-Neilson staining for acid-alcohol fast bacilli
CT scanning
Bronchoscopy

53
Q

How would you treat pulmonary tuberculosis?

A

Rifampicin, isoniazid, pyrizinamide and ethambutol for 2 months followed by rifampicin and isoniazid for 4 months

If multi-drug resistant, treatment with at least three different drugs should be continued until the sputum culture becomes negative, and then at least two different drugs should be continued for 12-24 months

54
Q

What are the causes of a pneumothorax?

A

Primary

Secondary (respiratory disease, connective tissue disease, lung cysts, iatrogenic, trauma, )

55
Q

What are the BTS guidelines on the management of a spontaneous primary pneumothorax?

A

Minimal symptoms and air rim of <2cm can be allowed home with repeat CXR in 7 days

56
Q

How would you manage a secondary pneumothorax?

A

Observation alone (<1cm or isolated apical pneumothorax in an asymptomatic patient)
Aspiration if <50, asymptomatic or <2cm
Chest drain if >50, symptomatic or >2cm

MRCP PACES (5 decks)

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