Respiratory Flashcards
CD4 count in HIV for septin prophylaxis
<200
most common cause of pneumonia
Strep pneumo
Common cause of pneumonia with cold agglutins present?
Mycoplasma pneumoniae
CAP in pregnancy (if treated in community)? if allergy to 1st line?
Amox
Erythromycin
[would be doxy if not pregnant]
Class of antibiotic is clari?
Levofloxacin
C - Macrolide
Levo - fluoroquinolone
How long Rx for CAP, HAP, Leigionella
Cap - 5 days
HAP - 7-10
Leigon - 21 days
Severe Rhem A. Develops stridor. What is this? Ix? Rx?
Criocoarytenoid arthritis
Spirometry with flow volume loop
CT larynx
Laryngoscopy
IV steroids
Possible emergency trache
Cirrhosis -> SOB with normal CXR especially when standing
Hepatopulmonary syndrome
Due to vasodilation of vessles (mostly in lower lobes) which inhibits the ability of oxygen transfer.
When stand up -> more poorly oxygenated blood through lower lobes -> hypoxia
Chlamydia pssitaci penumonia would have what clue in question? What is it called when you have it?
Exposure to birds
Ornithosis
Primary pulmonary HTN linked to which drug use?
Amphetamines
[-fenfluramines (used as anorexic drugs in severe obesity) ]
What is cor pulmonale
Pulm HTN -> Right heart failure
Most Pulm HTN is secondary to COPD
What is the gene implicated in familial disease?
BMPR2 - Bone morphogenic protein receptor 2
[Big massive pulm respiratory 2] - Also on chromosome 2
Heart sound in pulm HTN?
Key thing on echo bar RV dilation/ hypertrophy
Loud P2
Peak tricuspid regurgitation velocity
PPH standard Rx
All get digoxin
Anticoag to prevent clot
PDE-5 inhibitors - Eg sildenafil
[May use bosentan which is a endothelin receptor blockade]
Drug to bridge severe pulm HTN to transplant ?
Prostacyclin (PGI2)
Given as IV continuous infusion though central line
CI to CTPA eg Severe CKD. What Ix?
VQ scan
Mab for severe allergic asthma
omalizumab - binds to IgE
Work prev making cutting tools / jet engines. -> slow progressive lung disease. Called? Seen on histology?
Hard metal lung disease - caused by cobalt particles
Multinucleated giant cells (Giant cell interstitial pneumonia)
What happens in CF ? Gene/chrom?
Abnormal Cloride transport
-> Thick secretions in Respiratory / gut / reproductive most commonly
CFTR - chromosome 7
Usual bugs in CF chest kids vs teens?
Kids - Staph aureus -> H influenzae
Teens - pseudomonas
What happens in GI system CF
Pancreatic duct blocked
-> exocrine deficiency -> ADEK deficiency + malabsorbsion of food
->Endocrine deficiency -> diabetes
Bowel obstruction due to undigested food
Obstruction of biliary tract -> cirrhosis and portal hypertension
Why are men with CF infertile
Often have congenital lack of vas deferens
(or blocked with thick secretions)
Acute chest pain in CF
Pneumothorax likely
Diagnosis of CF
Any of:
Guthrie heel prick test (blood spot immunoreactive tripsin test) -> sweat test for confirmation
Sweat cloride > 60mmol/l
First choice mucoactive agent in CF ?
Chronic Pseudomonas ?
Who gets fluclox prophylaxis
First choice mucoactive agent in CF ? Dornase alfa
Chronic Pseudomonas - Tobramycin inhaler
Children under 3 - fluclox prophylaxis against S aureus
Which bug colonisation is a contra indication to lung Tx in CF
Burkholderia cepacia
Histological of sarcoid. 2 bits?
Multinucleated giant cells with macrophage, lymphocytes and epithelioid histocytes
Non caseating granulomas
Lymphadenopathy, splenomegaly, erythema nodosum, uveitis
Sarcoid
Sarcoid with fever, uveitis, parotid enlargement, CN palsies =
Heerfordt-waldenstrom syndrome
Which is most common electrolyte abnormality in sarcoid
HyperCa
- Either from renal / bone involvement
Bi hilar lymph enlargement, erythema nodosum, fever, arthralgia = which syndrome
Lofgren syndrome (sarcoid)
Common blood test in Sarcoid?
Rasied serum ACE
(May have anaemia / leuopenia due to bone marrow/ spleen involvement
May Have derranged LFTs/Ur/Cr)
What is found on bronc lavage of sarcoid
Raised CD4:CD8 ratio
Corticosteroids in sarcoid are first line. When do they get used?
Any neuro / opthal symptoms
Raised serum Ca
[Most people 60% have spontaneous resolution over 2-5 years)
What FEV1:FVC is obstruction
<0.7
What is doxapram
Respiratory stimulant
Usually used in post op hypoventilation
[sometimes used in COPD with persistent hypercapnia + acidosis in hospital]
2 scoring tools for COPD
Which for general prognosis ?
Which for inpatient exacerbation ?
BODE
DECAF
Old TB cavity often gets infected with what?
Aspergilioma
What does radiation pneumonitis look like on XR? What else might make you think this rather than an infective cause
Patchy shaddowing.
Normal WCC
Only mild fever
Non productive cough
Most common cause of occupational asthma
Isocyanates
[followed by flour/grain]
When could you just discharge a PTX home
<50years, spontaneous and <2cm
How to test eosinophilic airway inflamation
FeNO testing
Anti-GBM target?
Main Presentation?
Rx?
Good pastures (antibodies target alpha-3 chain of collagen IV)
HLA-DR2 / DR15 / DRB1
Rapidly progressive glomerulonephritis and pulm haemorrhage
Pred, cyclophosphamide, Palsma exchange
Granulomatosis with polyangitis blood test
C-ANCA directed at PR3
Most common Ca in lung
Mets
Then Squamous cell
Length of Rx for PE
Provoked?
Unprovoked?
Ca?
Recurrent?
3 months
6 months
3-6 months
Lifelong
[These are all reviewed in clinic and based individually]
Which therapy in COPD has been shown to impact long term survival
Stopping smoking
LTOT - in those who meet crieria
What is Kco and how do you calculate it
Kco is the transfer coefficient. It represents the uptake of carbon monoxide (Tlco) per liter of effective alveolar volume (Va)
Kco = Tlco/Va
[It allows for correction of any lung size reduction Eg resection as both Tlco and Va will be reduced to a similar amount]
What causes a high Kco? Low?
High - conditions where there is an increase in red cells in lungs Eg Polycythaemia, haemorrhage, increased flow.
-Rarely also be increased in restrictive pathologies where you get an increased density of pulmonary capillaries in relation to lung tissue.
Low - Pneumonia / PE / Asthma / intersitial lung disease etc..
Which pneumonia bug causes haemolytic anaemia most commonly
Mycoplasma pneumonia
What type of fungi are aspigillous
filamentous
Imaging of choice and blood test for aspergillous
CT
Serum galactomanam (aspergilous antigen)
Most common form of aspergillos? Which is type carries a worse prognosis and why?
A. Fumigatus - 70% of cases
A. Terreus - Resistant to amphortericin B
[the Terrur mwah hahaha]
What is allergic bronchopulmonary aspergilliosis? Which type of Aspergilous usually? Who gets it ? Pathophysiology?
Hypersensitivity reaction to antigens from A Fumigatus
Usually people with CF / asthma due to increased mucous secretion / impaired mucocillliary clearance -> reduced clearance of spores
-> Type I and III hypersensitivity reactions
-> Proximal bronchi get dilated and filled with mucous -> bronchiectasis and airway obstruction
Which condition decribes an apsergilous cavity (or multiple) / aspergilioma
chronic pulmonary aspergiliosis
What is invasive aspergiliosis
Into lungs -> disseminate round body via blood
[may get direct invasion via paranasal sinus to orbit / brain]
BD glucan or glactomanan which is better? why? What other test for Invasive aspergillis
Galactomanan - (component of the cell wall)
BD glucan - positive in other fungal infections so less specific
PCR of ribosomal DNA
What blood findings in Allergic Bronchopulmonary aspergiliousis? Skin? On Chronic pulmonary Aspergilious?
Raised IgE (and aspergilis specific IgE/IgG)
Riased eosiniphils
Positive weal and flare reaction on skin test
CPA - Raised serum IgG antibodies
Sometimes aspergilius requires VATS - what is this? What stain is used?
Video Assisted Thoracic Sugery
Gomori’s Methanamine Silver (GMS) stain
Which drug used for Invasive aspergillosis and how long? prophylaxis in immunocompromised?
Voriconazole and isavuconazole - 3 months if improve
-> If deterirorate switch vori to Amphotericin B
Posaconazole
Usual Rx for Allergic Aspergilious
Steroids for exacerbations and management of underlying condition (eg asthma / CF)
Antifungals may be used as adjunct
aspergiloma doesn’t really respond well to antifungals. What is Rx ? Common acute complication and RX?
Often just monitored
Lobectomy
Embolisation to control haemoptysis
Gradual wheeze, haemoptysis well demarkated nodule on CXR in a non smoker
Broncial carcinoid
Definitive diagnosis of mesothelioma
Biopsy
[May get diagnosis from cytology of pleural fluid]
NIV has best evidence for ….
Decompensated Type 2 respiratory failure with acidosis
Rx of pulm oedema and hypertension
Diruetics + GTN
-> NIV
Most common cause of pulm fibrosis? Seen on XR? Rx?
Idioppathic pulmonary fibrosis
Bilateral lower zone reticulonodular shaddows
Pirfenidone
Extrinsinsic Allergic alveolitis usually affects which area of lungs
Upper zones
[though if bad can affect everywhere]
What difference would you expect in Peak flow in occupational asthma?
> 20% in area which triggers symptoms
How much bronchodilator reversibility for asthma?
> 15%
or >200mls in FVC
Herpes Labialis (cold sores) + pneumonia =
Viral infection -> pneumonia =
COPD -> Pneumonia =
Herpes Labialis (cold sores) = Strep penumonia
Viral infection -> = S aureus
COPD -> = H influenzae
in hosital Rx of pneumonia Non severe? severe?
oral amox + clari
IV Co-amox + IV clari (not oral clari)
Cushing syndrome in Small cell lung Ca presents how?
Not with classical features such as bufallo hump / central obesity as short history of this cancer….
-> Hypertension, hyperglycaemia, hypokalemia / muscle weakness
Most common cause of bronchiectasis
Previous severe lung infection
Most common cause of bronchiectasis
Previous severe lung infection
Who gets idopathic bronchiectasis
Marfans
CF bronchiectasis mucolytic ? If not cf?
rhDNase
N-Acetylcistine
Chronic Rx of bronchiectais
Vaccine - Pneumococcal and influenza
Abx prophylaxis - considered if >3 exacerbations / year
Bronchiectasis has thickened and dilated airways. How might this appear on cxr
Small, cyst like spaces + crowded lung markings
Pen allergic + breast feeding with pneumonia 1st choice?
Clary
Most common cause of community empyema? Hospital?
Strep (pneumo / milleri)
Staph Aureus
Lymphocyte predominant pleural effusion is?
TB
Or Malignancy
Needed after thorascopy for biopsy of mesothelioma
Radiotherapy of tract site
[prevents tumour seeding and growth]
Cotton worker with respiratory Sx worst in 1st hour of work?
Byssinosis
Key sensitive test in allergic aspergillosis
Early positive skin prick test
Respiratory failure in MSK conditions eg ankylosing spond
Type 2
[hypoventillation]
Viral illness -> cavitating pneumonia =
Staph (most likely)
What are the values in curb 65. How many for IV co-amox +clari
urea >7 mmol/L;
respiratory rate ≥30/minute,
systolic <90 mmHg and/or diastolic ≤60 mmHg
age ≥65 years
Score of 2 or more = severe
Progressive DRY cough and SOB
Often seen in SLE, Post chest infection, post-transplant or penicillamine?
Bronchiolitis obliterans
[Bronchiectasis would have a productive cough]
Coal workers lung associated with? Ca risk?
Progressive massive fibrosis
->cor pulminale
It is NOT associated with cancer
Coal worker pneumociosis RhF and nodules in lungs =
Caplan syndrome
1st line Ix in occupational asthma
Serial peak flow
Kco in Idiopathic pulm fibrosis
about 60%
Prev failed Tb treatment. What Ix before starting treatment again?
Rifampicin sensitivity testing
CIs to surgical rx of lung Ca?
FEV1 levels?
Contralateral lymph nodes or worse
Pleural effusion / pleural involvement
FEV1 <1.5L
What is Mendelson syndrome?
Aspirate something chemical Eg gastric juice
-> bronchoconstriction
What is the most important antigen-presenting cell for sensitisation
Dendritic cell
first loine rx Granulomatosis with polyangitis
Steroids + cyclophosphamide
The characteristic hallmark of sarcoid?
What is a Schaumann body?
Non-caseating granuloma
Crystalised (calcium phosphate) central area in a sarcoid granuloma
Fancy drug for idiopathic pulmonary fibrosis
nintedanib - Tyrosine kinase inhibitor
[it makes Nin defference]
or pirfenidone
[neither improves, but are thought to slow progression]
Pulm HTN heart sound
Loud P2
What happens to the alveolar-arterial gradient on exercise in chronic thromboembolic pulm HTN
Widens on exercise
Investigation of severe inhalation burn injury
Bronch
When has LTOT therapy been shown to improve life expectancy
COPD
Cor pulmunale
Worsening asthma in adult. Raised eosinophils/ IgE and haemoptysis. Infiltrates on XR. Diagnosis?
Allergic bronchopulmonary aspergillosis
Pneumothorax rx
Primary <2cm not breathless
Primary >2cm not breathless
Primary >2cm breathless
Secondary <2cm
Secondary >2cm breathless
Primary <2cm not breathless - conservative
Primary >2cm not breathless - Needle aspiration
Primary >2cm breathless - Chest drain
Secondary <2cm - needle
Secondary >2cm - chest drain
How does A1AT prevent COPD
Elastase inhibitor
Isocyanates Eg chemical factory are high risk for which type of lung Ca
Usually squamous
Key thing in question which would make you not go for NIV in Exacerbation
Reduced conscious level
Catagory 1-3 pneumoconiosis
1 - few opacities, clear lung markings
2 - some opacities, lung markings visible
3 - lots of opacities, lung markings obscured
Epworth score for OSA
> 10
Tracer on PET scanning
Flurodeoxyglucose
[rapidly dividing cells need lots of glucose so take it up]
Best initial Ix for tracheal compression
Flow-volume loop
[usually more reduced inspiratory aspet]
Hypersensitivity pneumonia Eg EAA are mediated by?
IgG
[Extrinsic allergic alveolitis is not an allergic reaction despite its name so there is no rise in IgE, skin prick tests…
CABG - now ++SOB when lying flat with reduced VC when flat
Diapragmatic palsy
Epworth score >10 and struggling to keep awake at wheel. Rx
CPAP
[weight loss too but this is more chronic Rx]
LTOT indications
PO2 <7.3 when stable
PO2 <8 with risk factors … Oedema, polycythemia, Pulm HTN
Gillian barre which breathing test
FVC
Widespread eosinophilic granulomas in young persons with early and progressive fibrosis
Histiocytosis X
[Produce too many Langerhans cells]
What is berylliosis
Occupational lung disease from manufacturing industry
[Presents similar to sarcoid with non caseating granulomas]
What is histoplasmosis
Most common fungal lung disease in north America -> granulomas
Vitamin suplements in CF
ADEK
malabsorption of fat soluble
Usual interstitial pneumonia Vs Hypersensitivity pneumonitis on radiology
UIP - Subpleural reticulation
Honeycombing
Hypersensitivity - Ground glass shadowing with reticular and nodular findings
Differentiate chronic and allergic aspergilliosis
Both have raised Aspergillus IgG Precepitins
Chronic
Cough and haemoptysis common
Allergic
More Sx of wheeze / raised IgE. May still have haemoptysis
Pulm rehab what positive benefits
Increased exercise tolerance
Reduced hospital admissions
[Does NOT improve lung function]
What is better at staging lymph node involvement in Lung Ca - CT or MRI?
CT
-Too much movement with respiration for MRI
Exposure to TB and now positive tuberculin skin prick test but ASx. NICE guidelines for Rx
Rifampicin and Isoniazid for 3 months
or just Isoniazid for 6
Does not need time off work
Pulm fibrosis - what is:
Elastic recoil?
Alveolar-arterial gradient on exercise?
Increased elastic recoil
-Low compliance = high recoil (as they stiff)
Widening of gradient on exercise
-Think becomes hypoxic on minimal exersion
Consolidation and Foul smelling sputum
Anaerobic pneumonia
Low transfer capacity eg 50% with mostly preserved Kco Eg 90% =?Eg?
Extra thoracic issues
Eg Obese, thorax abnormalities, neuromuscular dysfunction of chest wall
Left raised hemidiaphragm - what is the ‘sniff test’
Forced inspiratory manouver
-> affected side paradoxically rises
[due to reduced intrathoracic pressure causing affected paralysed side to rise]
TB Rx. When would the recommendation be to stop all therapy in relation to LFTs
ALT > 5x upper limit of normal
-Can then slowly re introduce meds, usually starting with ethambutol
Cough for 6 months, worse in the morning when wakes and when walking outside. Pulm function tests / CXR unremarkable. What do you next?
High-dose inhaled steroids / oral steroid course.
-likely cough-variant of asthma. So Peakflow will be negative
-Unlikely reflux given symptoms when walking outside
Where is fibrosis in EAA
Upper lobe
What is the fibrotic lung pattern in scleroderma?
Non-specific interstitial pneumonia
Emphysema Lung Function tests
Obstructive
Normal FVC with reduced FEV1:FVC
Differentiate interstitial lung disease and obesity on pulm function tests
Both restrictive
Kco would be lower eg 60% in ILD and normal in obesity
A1AT deficiency causes what in the lungs
Fibrosis, specifically Emphysema
Volume of anatomical dead space
150mls
Can you operate on a lung Ca with vocal cord palsy
NO as indicates soft tissue invasion
COPD on salbutamol PRN. 2 Options for next line Rx
Inhaled steroid + Long acting bronchodilator
Long acting Anticholinergic
Keeps birds which pneumonia is it
Chlamydia psittaci
Upper lobe fibrosis causes
BREASTS
Berylliosis
Radiation
Extrinsic alergic alveolitis / eosinophilic pneumonia
Ankylosing spond / allergic bronchopulmonary aspergillosis
Sarcoid
TB
Silicossis
Important - Allergic Ankylosing spond, Sarcoid, Silicosis
[Lower
CABRIOS
Collagen vascular disease / cryptogenic fibrosis alveolitis
Asbestosis
Bronchiectasis
Rheum arthritis
Idiopathic
Other… (Blah never mind BNM) Bleomycin Nitrofurantoin MTX
Scleroderma]
Asthma in ICS + SABA. What next
LRA eg montelukast
Or LABA
Unilateral pleural effusion on CXR. Ix in order
Aspirate with US
-> CT
How does a venturi deliver specific % FIO2
Air entrainment
Why TB in silicosis
Silica acts as toxin to macrophages
How to confirm dx of pleural Tb
Pleural biopsy + M&C
What does FEF 25-75% reflect
status of small airways
When do you hear Whispered pectoriloquy
lung consolidation
-cancer (solid mass)
-pneumonia (fluid mass)
What chromosomal change seen in mesothelioma
Loss of material from chromosome 22
OSA is predisposes to
Stroke, Arrythmias, CAD, T2DM
Asthma Rx
SABA
+ICS
+Montelukast
+LABA
Lower Lung fibrosis
CABRIOS
Collagen vascular disease / cryptogenic fibrosis alveolitis
Asbestosis
Bronchiectasis
Rheum arthritis
Idiopathic
Other… (Blah never mind BNM) Bleomycin Nitrofurantoin MTX
Scleroderma
Important - Bronciectasis, Asbestosis, Rheum A, Scleroderma
[Upper BREASTS
Berylliosis
Radiation
Extrinsic alergic alveolitis / eosinophilic pneumonia
Ankylosing spond / allergic bronchopulmonary aspergillosis
Sarcoid
TB
Silicossis]
Spontaneous PTX
Flying?
Scuba dive?
5 days for flying if treated
Never scuba dive
What is the cause of primary PTX
Rupture of apical subpleural blebs
Sarcoid with hyper Ca and mild rise in Cr management
Rehydration
Pred only if persistent hypercalcaemia / neuro / opthal involvement
Sarcoid. Diagnostic Ix? next best?
Biopsy
CT scan
Serum ace non specific and only raised in 60%
What blood Ix might you do in new Dx of bronchiectasis ?
Serum Igs
[IgE might be allergic aspergillus
IgA might be deficienct]
Bronchiectasis mainstay of Rx is?
Postural drainage
2 most predictive measures of survival in COPD
Age
FEV1
