Respiratory Flashcards
1
Q
CD4 count in HIV for septin prophylaxis
A
<200
2
Q
most common cause of pneumonia
A
Strep pneumo
3
Q
Common cause of pneumonia with cold agglutins present?
A
Mycoplasma pneumoniae
4
Q
CAP in pregnancy (if treated in community)? if allergy to 1st line?
A
Amox
Erythromycin
[would be doxy if not pregnant]
5
Q
Class of antibiotic is clari?
Levofloxacin
A
C - Macrolide
Levo - fluoroquinolone
6
Q
How long Rx for CAP, HAP, Leigionella
A
Cap - 5 days
HAP - 7-10
Leigon - 21 days
7
Q
Severe Rhem A. Develops stridor. What is this? Ix? Rx?
A
Criocoarytenoid arthritis
Spirometry with flow volume loop
CT larynx
Laryngoscopy
IV steroids
Possible emergency trache
8
Q
Cirrhosis -> SOB with normal CXR especially when standing
A
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
9
Q
Chlamydia pssitaci penumonia would have what clue in question? What is it called when you have it?
A
Exposure to birds
Ornithosis
10
Q
Primary pulmonary HTN linked to which drug use?
A
Amphetamines
[-fenfluramines (used as anorexic drugs in severe obesity) ]
11
Q
What is cor pulmonale
A
Pulm HTN -> Right heart failure
12
Q
Most Pulm HTN is secondary to COPD
What is the gene implicated in familial disease?
A
BMPR2 - Bone morphogenic protein receptor 2
[Big massive pulm respiratory 2] - Also on chromosome 2
13
Q
Heart sound in pulm HTN?
Key thing on echo bar RV dilation/ hypertrophy
A
Loud P2
Peak tricuspid regurgitation velocity
14
Q
PPH standard Rx
A
All get digoxin
Anticoag to prevent clot
PDE-5 inhibitors - Eg sildenafil
[May use bosentan which is a endothelin receptor blockade]
15
Q
Drug to bridge severe pulm HTN to transplant ?
A
Prostacyclin (PGI2)
Given as IV continuous infusion though central line
16
Q
CI to CTPA eg Severe CKD. What Ix?
A
VQ scan
17
Q
Mab for severe allergic asthma
A
omalizumab - binds to IgE
18
Q
Work prev making cutting tools / jet engines. -> slow progressive lung disease. Called? Seen on histology?
A
Hard metal lung disease - caused by cobalt particles
Multinucleated giant cells (Giant cell interstitial pneumonia)
19
Q
What happens in CF ? Gene/chrom?
A
Abnormal Cloride transport
-> Thick secretions in Respiratory / gut / reproductive most commonly
CFTR - chromosome 7
20
Q
Usual bugs in CF chest kids vs teens?
A
Kids - Staph aureus -> H influenzae
Teens - pseudomonas
21
Q
What happens in GI system CF
A
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
22
Q
Why are men with CF infertile
A
Often have congenital lack of vas deferens
(or blocked with thick secretions)
23
Q
Acute chest pain in CF
A
Pneumothorax likely
24
Q
Diagnosis of CF
A
Any of:
Guthrie heel prick test (blood spot immunoreactive tripsin test) -> sweat test for confirmation
Sweat cloride > 60mmol/l
25
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
26
Which bug colonisation is a contra indication to lung Tx in CF
Burkholderia cepacia
27
Histological of sarcoid. 2 bits?
Multinucleated giant cells with macrophage, lymphocytes and epithelioid histocytes
Non caseating granulomas
28
Lymphadenopathy, splenomegaly, erythema nodosum, uveitis
Sarcoid
29
Sarcoid with fever, uveitis, parotid enlargement, CN palsies =
Heerfordt-waldenstrom syndrome
30
Which is most common electrolyte abnormality in sarcoid
HyperCa
- Either from renal / bone involvement
31
Bi hilar lymph enlargement, erythema nodosum, fever, arthralgia = which syndrome
Lofgren syndrome (sarcoid)
32
Common blood test in Sarcoid?
Rasied serum ACE
(May have anaemia / leuopenia due to bone marrow/ spleen involvement
May Have derranged LFTs/Ur/Cr)
33
What is found on bronc lavage of sarcoid
Raised CD4:CD8 ratio
34
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)
35
What FEV1:FVC is obstruction
<0.7
36
What is doxapram
Respiratory stimulant
Usually used in post op hypoventilation
[sometimes used in COPD with persistent hypercapnia + acidosis in hospital]
37
2 scoring tools for COPD
Which for general prognosis ?
Which for inpatient exacerbation ?
BODE
DECAF
38
Old TB cavity often gets infected with what?
Aspergilioma
39
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
40
Most common cause of occupational asthma
Isocyanates
[followed by flour/grain]
41
When could you just discharge a PTX home
<50years, spontaneous and <2cm
42
How to test eosinophilic airway inflamation
FeNO testing
43
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
44
Granulomatosis with polyangitis blood test
C-ANCA directed at PR3
45
Most common Ca in lung
Mets
Then Squamous cell
46
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]
47
Which therapy in COPD has been shown to impact long term survival
Stopping smoking
LTOT - in those who meet crieria
48
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]
49
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..
50
Which pneumonia bug causes haemolytic anaemia most commonly
Mycoplasma pneumonia
51
What type of fungi are aspigillous
filamentous
52
Imaging of choice and blood test for aspergillous
CT
Serum galactomanam (aspergilous antigen)
53
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]
54
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
55
Which condition decribes an apsergilous cavity (or multiple) / aspergilioma
chronic pulmonary aspergiliosis
56
What is invasive aspergiliosis
Into lungs -> disseminate round body via blood
[may get direct invasion via paranasal sinus to orbit / brain]
57
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
58
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
59
Sometimes aspergilius requires VATS - what is this? What stain is used?
Video Assisted Thoracic Sugery
Gomori's Methanamine Silver (GMS) stain
60
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
61
Usual Rx for Allergic Aspergilious
Steroids for exacerbations and management of underlying condition (eg asthma / CF)
Antifungals may be used as adjunct
62
aspergiloma doesn't really respond well to antifungals. What is Rx ? Common acute complication and RX?
Often just monitored
Lobectomy
Embolisation to control haemoptysis
63
Gradual wheeze, haemoptysis well demarkated nodule on CXR in a non smoker
Broncial carcinoid
64
Definitive diagnosis of mesothelioma
Biopsy
[May get diagnosis from cytology of pleural fluid]
65
NIV has best evidence for ....
Decompensated Type 2 respiratory failure with acidosis
66
Rx of pulm oedema and hypertension
Diruetics + GTN
-> NIV
67
Most common cause of pulm fibrosis? Seen on XR? Rx?
Idioppathic pulmonary fibrosis
Bilateral lower zone reticulonodular shaddows
Pirfenidone
68
Extrinsinsic Allergic alveolitis usually affects which area of lungs
Upper zones
[though if bad can affect everywhere]
69
What difference would you expect in Peak flow in occupational asthma?
>20% in area which triggers symptoms
70
How much bronchodilator reversibility for asthma?
>15%
or >200mls in FVC
71
Herpes Labialis (cold sores) + pneumonia =
Viral infection -> pneumonia =
COPD -> Pneumonia =
Herpes Labialis (cold sores) = Strep penumonia
Viral infection -> = S aureus
COPD -> = H influenzae
72
in hosital Rx of pneumonia Non severe? severe?
oral amox + clari
IV Co-amox + IV clari (not oral clari)
73
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
74
Most common cause of bronchiectasis
Previous severe lung infection
75
Most common cause of bronchiectasis
Previous severe lung infection
76
Who gets idopathic bronchiectasis
Marfans
77
CF bronchiectasis mucolytic ? If not cf?
rhDNase
N-Acetylcistine
78
Chronic Rx of bronchiectais
Vaccine - Pneumococcal and influenza
Abx prophylaxis - considered if >3 exacerbations / year
79
Bronchiectasis has thickened and dilated airways. How might this appear on cxr
Small, cyst like spaces + crowded lung markings
80
Pen allergic + breast feeding with pneumonia 1st choice?
Clary
81
Most common cause of community empyema? Hospital?
Strep (pneumo / milleri)
Staph Aureus
82
Lymphocyte predominant pleural effusion is?
TB
Or Malignancy
83
Needed after thorascopy for biopsy of mesothelioma
Radiotherapy of tract site
[prevents tumour seeding and growth]
84
Cotton worker with respiratory Sx worst in 1st hour of work?
Byssinosis
85
Key sensitive test in allergic aspergillosis
Early positive skin prick test
86
Respiratory failure in MSK conditions eg ankylosing spond
Type 2
[hypoventillation]
87
Viral illness -> cavitating pneumonia =
Staph (most likely)
88
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
89
Progressive DRY cough and SOB
Often seen in SLE, Post chest infection, post-transplant or penicillamine?
Bronchiolitis obliterans
[Bronchiectasis would have a productive cough]
90
Coal workers lung associated with? Ca risk?
Progressive massive fibrosis
->cor pulminale
It is NOT associated with cancer
91
Coal worker pneumociosis RhF and nodules in lungs =
Caplan syndrome
92
1st line Ix in occupational asthma
Serial peak flow
93
Kco in Idiopathic pulm fibrosis
about 60%
94
Prev failed Tb treatment. What Ix before starting treatment again?
Rifampicin sensitivity testing
95
CIs to surgical rx of lung Ca?
FEV1 levels?
Contralateral lymph nodes or worse
Pleural effusion / pleural involvement
FEV1 <1.5L
96
What is Mendelson syndrome?
Aspirate something chemical Eg gastric juice
-> bronchoconstriction
97
What is the most important antigen-presenting cell for sensitisation
Dendritic cell
98
first loine rx Granulomatosis with polyangitis
Steroids + cyclophosphamide
99
The characteristic hallmark of sarcoid?
What is a Schaumann body?
Non-caseating granuloma
Crystalised (calcium phosphate) central area in a sarcoid granuloma
100
Fancy drug for idiopathic pulmonary fibrosis
nintedanib - Tyrosine kinase inhibitor
[it makes Nin defference]
or pirfenidone
[neither improves, but are thought to slow progression]
101
Pulm HTN heart sound
Loud P2
102
What happens to the alveolar-arterial gradient on exercise in chronic thromboembolic pulm HTN
Widens on exercise
103
Investigation of severe inhalation burn injury
Bronch
104
When has LTOT therapy been shown to improve life expectancy
COPD
Cor pulmunale
105
Worsening asthma in adult. Raised eosinophils/ IgE and haemoptysis. Infiltrates on XR. Diagnosis?
Allergic bronchopulmonary aspergillosis
106
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
107
How does A1AT prevent COPD
Elastase inhibitor
108
Isocyanates Eg chemical factory are high risk for which type of lung Ca
Usually squamous
109
Key thing in question which would make you not go for NIV in Exacerbation
Reduced conscious level
110
Catagory 1-3 pneumoconiosis
1 - few opacities, clear lung markings
2 - some opacities, lung markings visible
3 - lots of opacities, lung markings obscured
111
Epworth score for OSA
>10
112
Tracer on PET scanning
Flurodeoxyglucose
[rapidly dividing cells need lots of glucose so take it up]
113
Best initial Ix for tracheal compression
Flow-volume loop
[usually more reduced inspiratory aspet]
114
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...
115
CABG - now ++SOB when lying flat with reduced VC when flat
Diapragmatic palsy
116
Epworth score >10 and struggling to keep awake at wheel. Rx
CPAP
[weight loss too but this is more chronic Rx]
117
LTOT indications
PO2 <7.3 when stable
PO2 <8 with risk factors ... Oedema, polycythemia, Pulm HTN
118
Gillian barre which breathing test
FVC
119
Widespread eosinophilic granulomas in young persons with early and progressive fibrosis
Histiocytosis X
[Produce too many Langerhans cells]
120
What is berylliosis
Occupational lung disease from manufacturing industry
[Presents similar to sarcoid with non caseating granulomas]
121
What is histoplasmosis
Most common fungal lung disease in north America -> granulomas
122
Vitamin suplements in CF
ADEK
malabsorption of fat soluble
123
Usual interstitial pneumonia Vs Hypersensitivity pneumonitis on radiology
UIP - Subpleural reticulation
Honeycombing
Hypersensitivity - Ground glass shadowing with reticular and nodular findings
124
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
125
Pulm rehab what positive benefits
Increased exercise tolerance
Reduced hospital admissions
[Does NOT improve lung function]
126
What is better at staging lymph node involvement in Lung Ca - CT or MRI?
CT
-Too much movement with respiration for MRI
127
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
128
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
129
Consolidation and Foul smelling sputum
Anaerobic pneumonia
130
Low transfer capacity eg 50% with mostly preserved Kco Eg 90% =?Eg?
Extra thoracic issues
Eg Obese, thorax abnormalities, neuromuscular dysfunction of chest wall
131
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]
132
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
133
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
134
Where is fibrosis in EAA
Upper lobe
135
What is the fibrotic lung pattern in scleroderma?
Non-specific interstitial pneumonia
136
Emphysema Lung Function tests
Obstructive
Normal FVC with reduced FEV1:FVC
137
Differentiate interstitial lung disease and obesity on pulm function tests
Both restrictive
Kco would be lower eg 60% in ILD and normal in obesity
138
A1AT deficiency causes what in the lungs
Fibrosis, specifically Emphysema
139
Volume of anatomical dead space
150mls
140
Can you operate on a lung Ca with vocal cord palsy
NO as indicates soft tissue invasion
141
COPD on salbutamol PRN. 2 Options for next line Rx
Inhaled steroid + Long acting bronchodilator
Long acting Anticholinergic
142
Keeps birds which pneumonia is it
Chlamydia psittaci
143
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]
144
Asthma in ICS + SABA. What next
LRA eg montelukast
Or LABA
145
Unilateral pleural effusion on CXR. Ix in order
Aspirate with US
-> CT
146
How does a venturi deliver specific % FIO2
Air entrainment
147
Why TB in silicosis
Silica acts as toxin to macrophages
148
How to confirm dx of pleural Tb
Pleural biopsy + M&C
149
What does FEF 25-75% reflect
status of small airways
150
When do you hear Whispered pectoriloquy
lung consolidation
-cancer (solid mass)
-pneumonia (fluid mass)
151
What chromosomal change seen in mesothelioma
Loss of material from chromosome 22
152
OSA is predisposes to
Stroke, Arrythmias, CAD, T2DM
153
Asthma Rx
SABA
+ICS
+Montelukast
+LABA
154
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]
155
Spontaneous PTX
Flying?
Scuba dive?
5 days for flying if treated
Never scuba dive
156
What is the cause of primary PTX
Rupture of apical subpleural blebs
157
Sarcoid with hyper Ca and mild rise in Cr management
Rehydration
Pred only if persistent hypercalcaemia / neuro / opthal involvement
158
Sarcoid. Diagnostic Ix? next best?
Biopsy
CT scan
Serum ace non specific and only raised in 60%
159
What blood Ix might you do in new Dx of bronchiectasis ?
Serum Igs
[IgE might be allergic aspergillus
IgA might be deficienct]
160
Bronchiectasis mainstay of Rx is?
Postural drainage
161
2 most predictive measures of survival in COPD
Age
FEV1
