Respiratory Flashcards
1
Q
Give the histological types of lung cancer
A
Non-small cell:
1. Adenocarcinoma
2. Squamous cell carcinoma
3. Large cell carcinoma
Small cell
2
Q
Give the presentation of lung cancer
A
- SOB
- Cough (+/- haemoptysis)
- Weight loss
- Lymphadenopathy
- Finger clubbing
3
Q
Give the investigations for lung cancer
A
- CXR (hilar lymphadenopathy, visible tumour, unilateral pleural effusion)
- Staging CT scan
- PET-CT
- Bronchoscopy
4
Q
Give the management of lung cancer
A
Non-small cell:
1. Surgery
2. Radiotherapy
3. Chemotherapy
Small cell:
1. Chemotherapy
2. Radiotherapy
5
Q
Give the extra-pulmonary manifestations of lung cancer
A
- Recurrent laryngeal nerve palsy (hoarse voice)
- Phrenic nerve palsy (SOB)
- SVC obstruction (facial swelling, difficulty breathing, distended neck veins)
- Horner’s syndrome (ptosis, anhidrosis, miosis)
6
Q
Give the pathophysiology of Lambert-Eaton myasthenic syndrome
A
Caused by antibodies produced in response to small-cell lung cancer cells, which attack motor neurones
7
Q
Give the presentation of Lambert-Eaton myasthenic syndrome
A
Proximal muscle weakness
Ocular muscle weakness
8
Q
Give the investigations for mesothelioma
A
Diagnosis of a mesothelioma is made on histology, following a thoracoscopy
9
Q
Give the aetiology of mesothelioma
A
Asbestos inhalation
10
Q
Give the pathophysiology of pneumonia
A
Infection (commonly by Strep. pneumoniae) of the lung tissue causing inflammation, and resulting in sputum filling the airways and alveoli
11
Q
Describe the classification of pneumonia
A
- Community-acquired: develops outside of hospital
- Hospital-acquired: develops >48 hours after hospital admission
- Aspiration pneumonia
12
Q
Give the causative organisms of pneumonia
A
- Streptococcus pneumoniae
- Haemophilus influenzae
- Staphylococcus aureus
13
Q
Give the presentation of pneumonia
A
- SOB
- Productive cough (sputum or blood)
- Fever
- Pleuritis chest pain (sharp, worse on inspiration)
- Delirium
- Sepsis
- Tachypnoea/tachycardia/hypoxia/hypotension
14
Q
Give the chest signs seen in pneumonia
A
- Focal coarse crackles
- Bronchial breath sounds
- Dullness to percussion
15
Q
Which scoring system is used to assess the severity of community acquired pneumonia?
A
CURB-65
16
Q
Describe the CURB-65 score
A
C- confusion
U- urea > 7
R- resp. rate =/> 30
B- BP =/< 90 systolic or =/< 60 diastolic
65- age =/> 65
Score:
0/1: treat at home
2: hospital management
3: ICU management
17
Q
Describe the management of atypical pneumonia
A
CLARITHROMYCIN
Pneumonia where the organism can not be cultured.
18
Q
Give the investigations for pneumonia
A
- CXR - consolidation
- FBC (raised WCC)
- U+Es (for urea)
- CRP
- Sputum/blood cultures
19
Q
Give the management of pneumonia
A
- PO amoxicillin (mild)
- PO/IV Amoxicillin PLUS clarithromycin (severe)
20
Q
Give the complications of pneumonia
A
- Sepsis
- Pleural effusion
- Empyema
- Lung abscess
- Death
21
Q
Define asthma
A
A chronic inflammatory condition of the airways, causing episodic exacerbations of bronchoconstriction. This causes airway obstruction.
22
Q
Is asthma reversible?
A
Yes
23
Q
Describe the presentation of asthma
A
- Episodic symptoms
- Diurnal variability (worse at night)
- Dry cough, wheeze, SOB
- Hx of atopy
- FHx
- Bilateral wheeze
24
Q
Describe the investigations for asthma
A
- Can treat based upon clinical suspicion
- Spirometry - shows reversible obstruction
- Peak flow
25
Describe the management of asthma
1. SABA (salbutamol)
2. ICS (beclometasone)
3. Leukotriene receptor agonist (montelukast)
4. LABA (salmeterol)
5. LAMA (tiotropium)
6. Theophylline
26
Describe the presentation of an asthma exacerbation
1. SOB
2. Tachypnoea
3. Use of accessory muscles
27
Describe the grading system used for asthma exacerbation
Moderate: PEFR 50-75%
Severe: PEFR 33-50% (RR>25, HR>110, unable to complete sentences)
Life threatening: PEFR <33% (sats <92%, silent chest, haemodynamic instability)
28
Describe the management of acute exacerbations of asthma
1. Nebulised salbutamol (IV if severe)
2. Nebulised ipratropium
3. Oral prednisolone/IV hydrocortisone
4. Oxygen (to maintain sats 94-98%)
5. IV magnesium sulfate
6. IV aminophylline
29
Describe the ABG changes seen in acute exacerbation of asthma
Respiratory alkalosis
(Respiratory acidosis if life-threatening)
30
Give 1 side effect of salbutamol
Hypokalaemia - must monitor U&Es
31
Describe reversibility testing
Give salbutamol and repeat spirometry to see if the results improve
32
Describe FEV1
Forced expiratory volume in 1 second - reduced in obstruction
33
Describe FVC
Forced vital capacity - reduced in restriction
34
Describe the pattern seen on spirometry in obstruction
FEV1 <75% of FVC (FEV1:FVC <75%)
Good volume but air is struggling to flow
35
Describe the pattern seen on spirometry in restriction
FEV1 and FVC reduced equally (FEV1:FVC >75%)
Inability of lungs to expand and take in air
36
Define COPD
Non-reversible, long-term deterioration of air flow through the lungs (obstruction) - making it more difficult to ventilate, and individuals more prone to infection.
37
Describe the presentation of COPD
1. Smoker
2. Chronic SOB
3. Productive cough
4. Wheeze
5. Recurrent respiratory tract infection
38
Describe the investigations for COPD
1. Spirometry PLUS clinical presentation (shows obstructive pattern)
2. No dramatic response to reversibility testing
3. CXR - exclude other causes
4. Sputum culture
39
Give the management of COPD
1. Stop smoking
2. Pulmonary rehabilitation
3. Oxygen therapy where appropriate
Step 1: SABA or SAMA (salbutamol or ipratropium)
Step 2: Add LABA and LAMA (salmeterol and tiotropium) - if asthma/steroid unresponsive
OR
LABA and ICS (salmeterol and beclomethasone) - if asthma/steroid responsive (e.g. Hx atopy, FEV1 variation with time)
Step 3: Add ICS (beclomethasone)
40
Describe a COPD exacerbation
Worsening of symptoms due to viral or bacterial infection
41
Describe the ABG findings in acute COPD exacerbation
Respiratory acidosis
Reduced O2 indicates respiratory failure
Normal pCO2 indicates type 1 resp. failure
Raised pCO2 indicates type 2 resp. failure
42
Give the management of acute COPD exacerbation
Aim for 88-92% sats
1. Salbutamol
2. Steroids
3. Abx (amoxicillin, doxycycline, co-amoxiclav)
43
Describe interstitial lung disease
Conditions which affect the lung parenchyma - causing inflammation and fibrosis.
Replacement of normal elastic tissue with scar tissue.
44
Give the presentation of interstitial lung disease on CT
"Ground glass" appearance
45
Give the management of interstitial lung disease
1. Remove or treat underlying cause
2. Home oxygen
3. Physiotherapy and pulmonary rehab
4. Advanced care planning and palliative care where appropriate
46
Give the presentation of idiopathic pulmonary fibrosis
1. Insidious onset SOB and dry cough
2. Bibasal fine crackles
3. Finger clubbing
47
Give the management of idiopathic pulmonary fibrosis
1. Pirfenidone - antifibrotic
2. Nintedanib - monoclonal antibody
Both act to slow progression
48
Give causes of drug-induced fibrosis
1. Amiodarone
2. Cyclophosphamide
3. Methotrexate
4. Nitrofurantoin
49
Give causes of secondary causes interstitial fibrosis
1. Alpha-1-antitrypsin deficiency
2. Rheumatoid arthritis
3. SLE
50
Describe hypersensitivity pneumonitis
Type III hypersensitivity reaction to an environmental allergen
51
Give the management of hypersensitivity pneumonitis
Bronchoalveolar lavage
Remove allergen
52
Give 2 examples of hypersensitivity pneumonitis
1. Bird fancier's lung
2. Farmer's lung
53
Describe pleural effusion
Collection of fluid in the pleural cavity
54
Give the classification of pleural effusion
1. Exudative: high protein count
2. Transudative: low protein count
55
Give the causes of pleural effusion
Exudative (inflammation): lung cancer, pneumonia, TB
Transudative (fluid shift): congestive heart failure, hypoalbuminaemia, Meig's syndrome
56
Describe Meig's syndrome
Right sided pleural effusion secondary to ovarian malignancy
57
Give the presentation of pleural effusion
1. SOB
2. Dullness to percussion
3. Reduced breath sounds
4. Tracheal deviation (away from effusion)
58
Give the investigations for pleural effusion
CXR:
1. Blunting of the costophrenic angle
2. Fluid in lung fissures
3. Meniscus (curving upward where lung meets chest wall)
4. Tracheal/mediastinal deviation
Effusion fluid sampling
59
Give the management of pleural effusion
1. Conservative if small
2. Pleural aspiration (relieves pressure but may recur)
3. Chest drain (definitive)
60
Define empyema
Infected pleural effusion
61
Give the presentation of empyema
1. New or ongoing fever despite management on a patient with pneumonia
2. Pleural aspiration shows pus, pH<7.2, low glucose
62
Give the management of empyema
Chest drain and antibiotics
63
Define pneumothorax
Where air has entered the pleural space, separating the lung from the chest wall.
64
When are antibiotics given in the management of acute exacerbations of COPD?
In the presence of purulent sputum or clinical signs of pneumonia
65
Give the causes of pneumothorax
1. Spontaneous (young, tall, thin man playing sports)
2. Trauma
3. Iatrogenic (e.g. lung biopsy, mechanical ventilation)
4. Asthma/COPD
66
Give the investigations for pneumothorax
1. Erect CXR (allows for full expansion of the chest) - area between lung and chest wall with no lung markings
2. CT thorax - to identify smaller pneumothorax
67
Give the management of pneumothorax
1. If small may spontaneously resolve
2. If SOB or large pneumothorax: aspiration or chest drain
68
Define tension pneumothorax
One way valve created by chest trauma that allows air into, but not out of, the pleural space.
69
Give the pathophysiology of tension pneumothorax
1. Air allowed to enter, but not leave, the pleural space
2. Pneumothorax enlarges with each breath
3. Pressure is created which causes mediastinal shift, pressure on the vasculature around the heart, and cardio-respiratory arrest
70
Describe the presentation of tension pneumothorax
1. Tracheal deviation away from pneumothorax
2. Reduced air entry on affected side
3. Increased resonance to percussion on affected side
4. Tachycardia
5. Hypotension
71
Give the management of tension pneumothorax
1. "Insert a large bore cannula into the second intercostal space at the midclavicular line" to aspirate the pneumothorax - needle decompression
2. Chest drain - definitive
72
Describe a positive reversibility testing
An increase in the FEV1 of 12% or more after inhalation of a short-acting bronchodilator is indicative of asthma
Prescribe SABA +/- ICS
73
Which lung cancer is associated with gynaecomastia?
Associated with adenocarcinoma of the lung
74
Which histological variety of lung cancer most commonly causes hypokalaemia
SIADH is a paraneoplastic feature of small-cell lung cancer
75
Can breastfeeding women take prednisolone?
Yes
76
Define pulmonary embolism
Where a thrombus forms in the pulmonary arteries - commonly as a result of DVT. This blocks blood supply to the lung tissue, reducing perfusion and putting strain on the right side of the heart.
77
Give the risk factors for pulmonary embolism
1. Immobilisation
2. Surgery
3. Long-haul flights
4.Oestrogen-based medications
5. Pregnancy
6. Malignancy
78
Give the management of DVT risk in hospital
LMWH - e.g. enoxaparin
79
Give the presentation of pulmonary embolism
1. SOB
2. Cough +/- haemoptysis
3. Pleuritic chest pain
4. Hypoxia
5. Tachycardia
6. Tachypnoea
7. Hypotension (sign of haemodynamic instability)
80
What does the Wells score assess?
The likelihood of venous thromboembolism in those presenting with appropriate symptoms
81
Describe the diagnosis of pulmonary embolism
Wells score outcome:
1. PE Likely: CT pulmonary angiogram
2. PE Unlikely: D-Dimer
a) If D-Dimer positive: CTPA
The vast majority of chest x rays in patients with PEs are normal.
If renal impairment (and therefore unsuitable for CTPA - due to contrast) - ventilation perfusion scan. Compares the ratio of ventilation:perfusion - in PE the lungs will be ventilated but not perfused.
82
Give the management of mild pulmonary embolism with no haemodynamic instability
1. Oxygen
2. Analgesia
Initial management: apixaban/rivaroxaban (LMWH if not suitable - e.g. in antiphospholipid syndrome)
Long term anticoagulation: warfarin, NOAC or LMWH
Continue for:
- 3 months if reversible cause
- >3 months if unsure of cause or irreversible cause
- 6 months in active cancer
83
When switching from LMWH to warfarin, how long should LMWH be continued for
5 days
Or until INR 2-3 for 24 hours
84
Describe the management of massive pulmonary embolism with haemodynamic instability
Thrombolysis - acts as fibrinolytic
e.g. IV alteplase/streptokinase
85
Define pulmonary hypertension
Increased resistance and pressure of blood in the pulmonary arteries - putting strain on the right heart and causing a back log of blood through the systemic venous system
86
Describe the aetiology of pulmonary hypertension
1. Primary pulmonary hypertension
2. SLE
3. Left sided heart failure (e.g. due to MI)
4. COPD
5. PE
87
Describe the presentation of pulmonary hypertension
1. SOB
2. Syncope
3. Tachycardia
4. Raised JVP
5. Peripheral oedema
6. Hepatomegaly
88
Describe the investigations for pulmonary hypertension
ECG:
1. Right ventricular hypertrophy
2. Right axis deviation
3. RBBB
CXR:
1. Dilated pulmonary arteries
2. Right ventricular hypertrophy
89
Describe the presentation of right ventricular hypertrophy on ECG
Large R waves on V1-V3 (R side leads)
Large S waves on V4-V6 (L side leads)
90
Describe the presentation of right axis deviation on ECG
Positive QRS in II, III, aVF
Negative QRS in I, aVL
91
Give the management of pulmonary hypertension
1. Treat underlying cause
2. IV prostanoids (e.g. epoprosterol)
3. Endothelin receptor antagonist (e.g. macitentan)
4. Supportive management - very poor prognosis
92
Define sarcoidosis
Granulomatous inflammatory condition with unknown aetiology - usually presenting with respiratory symptoms, but with many extra-pulmonary manifestations
93
Give the presentation of sarcoidosis
1. Erythema nodosum
2. Lymphadenopathy (mediastinal)
3. Pulmonary fibrosis
4. Lupus pernio - raised purple lesions on cheek and nose
94
Define Lofgren's syndrome
Classical presentation of sarcoidosis. Triad of:
1. Erythema nodosum
2. Bilateral hilar lymphadenopathy
3. Polyarthralgia
95
Describe the investigations for sarcoidosis
1. Raised serum ACE
2. Hypercalcaemia
3. CXR - hilar lymphadenopathy
4. Biopsy
96
Give the management of sarcoidosis
No treatment - often resolves spontaneously
If symptomatic:
1. Oral steroids (+bisphosphonate)
2. Methotrexate
3. Lung transplant
97
Give the indications for corticosteroid use in sarcoidosis management
1. Parenchymal lung disease
2. Uveitis
3. Hypercalcaemia
4. Neurological/cardiac involvement
98
Define obstructive sleep apnoea
Collapse of the pharyngeal airway during sleep, leading to a temporary cessation of breathing
99
Give the risk factors for obstructive sleep apnoea
1. Middle age
2. Obesity
3. Male
4. Alcohol and smoking
100
Give the presentation of obstructive sleep apnoea
Often reported by partner as occurs during sleep
1. Apnoeic episodes during sleeop
2. Snoring
3. Morning headache
4. Daytime tiredness
101
Give the management of obstructive sleep apnoea
1. Address risk factors (e.g. weight, smoking)
2. ENT/sleep specialist referral for sleep studies
3. CPAP
4. Surgery - uvulopalatopharyngoplasty
102
Which landmarks form the triangle of safety for chest drain insertion?
The triangle of safety for chest drain insertion involves the base of the axilla, lateral edge pectoralis major, 5th intercostal space and the anterior border of latissimus dorsi
103
Give the presentation, prevention and management of acute mountain syndrome
Presentation:
1. headache
2. nausea
3. fatigue
Prevention:
1. Acetazolamide
Management:
1. Descent
104
Give the presentation and management of high altitude pulmonary oedema
HAPE presents with classical pulmonary oedema features
Management:
1. descent
2. dexamethasone
3. nifedipine, acetazolamide, phosphodiesterase type V inhibitors
4. oxygen if available
105
Give the presentation and management of high altitude cerebral oedema
HACE presents with headache, ataxia, papilloedema
Management:
1. Descent
2. Dexamethasone
106
What management should be offered to those who have frequent COPD exacerbations?
A home supply of prednisolone and an antibiotic
107
Which histological subtype of lung cancer is most associated with Cushing's syndrome?
Small cell lung cancer - secrete ACTH
Present with swollen abdomen, fat face, purple stretch marks
108
Define bronchiectasis
Permanent dilation of the airways in response to chronic inflammation
109
Give the management of bronchiectasis
1. Inspiratory muscle training
2. Postural drainage
3. Antibiotics for exacerbations
4. Bronchodilators
110
Give the organisms most commonly seen in bronchiectasis exacerbations
1. Haemophilus infleunzae
2. Klebsiella (presents with upper lobe lesions)
3. Pseudomonas aeruginosa
4. Streptococcus pneumoniae
111
Define acute respiratory distress syndrome
Increased permeability of the alveoli to their capillaries, resulting in fluid accumulation in the lungs.
112
Give the causes of acute respiratory distress syndrome
1. Infection (sepsis, pneumonia, COVID-19)
2. Massive blood transfusion
3. Trauma
4. Smoke inhalation
5. Acute pancreatitis
113
Give the presentation of acute respiratory distress syndrome
1. Dyspnoea
2. Raised respiratory rate
3. Bilateral crepitations
4. Low O2 sats
114
Give the investigations for acute respiratory distress syndrome
1. CXR: pulmonary oedema, bilateral infiltrates
2. ABG: (pO2/FiO2 < 40kPa)
115
Give the management of acute respiratory distress syndrome
1. ITU admission
2. Oxygenation/ventilation
3. Vasopressors - general organ support
4. Treat underlying cause (e.g. Abx in sepsis)
116
Give the most common cause of bronchiolitis
RSV
117
Describe the diagnosis of bronchiolitis
Clinical
118
Give the management of bronchiolitis
Usually self-limiting with minimal treatment required - give O2 and fluids
Indications for hospital admission: O2 sats < 92%, not feeding, increased work of breathing.
119
Give the presentation of bronchiolitis
Typically aged <18 months
1. Coryzal symptoms
2. Dry cough
3. Breathlessness
4. Wheezing
5. Fever
6. Difficulty feeding (due to dyspnoea)
120
What is the causative organism of COVID-19
Novel coronavirus SARS-CoV-2
121
Describe the presentation of COVID-19
Often asymptomatic
1. Fever
2. Cough
3. Fatigue
4. SOB
5. Muscle ache
6. Headache
7. Sore throat
8. Loss of tase/smell
122
Describe the investigations for COVID-19
1. PCR - from nasopharyngeal/oropharyngeal swabs
2. Rapid antigen testing
3. Serology (for antibodies)
4. CXR - shows bilateral opacity
123
Describe the complications of COVID-19
1. ARDS
2. Encephalitis
3. Cardiomyopathy
4. AKI
5. Multi-organ failure
124
Give the management of COVID-19
1. ICS
2. Oxygen
3. Vaccination
4. Self-isolation
125
Give the causative organism for tuberculosis
Mycobacterium tuberculosis
126
Describe the pathophysiology of tuberculosis
Mycobacterium tuberculosis bacteria enter the lung where they are engulfed by alveolar macrophages - forming granulomas in the lung.
The bacteria remains latent in these granulomas until active infection begins and the bacteria spread throughout the body - forming many more granulomas.
127
Describe the risk factors for tuberculosis
1. HIV
2. Overcrowding/urban areas
3. Minority ethnic groups
4. IVDU
5. Immunosuppression
128
Give the presentation of tuberculosis
1. Cough +/- haemoptysis
2. Night sweats
3. Fever
4. SOB
5. Weight loss
6. Lymphadenopathy
129
Give the diagnosis of tuberculosis
1. CXR - shadows in upper zones
2. Sputum sample
3. Biopsy - use Ziehl-Neelsen stain
4. Mantoux skin test (for latent TB)
5. Quantiferon test (for latent TB)
130
Give the management of tuberculosis
RIPE:
1. Rifampicin
2. Isoniazid
3. Pyrazinamide
4. Ethambutol
Vaccination (BCG)
131
Give the side effects of rifampicin
1. Orange discolouration of excreted bodily fluids
2. Anorexia
132
Give a side effect of isoniazid
1. Peripheral neuropathy
133
Give the side effects of pyrazinamide
1. Sideroblastic anaemia
2. Hepatotoxicity
134
Give a side effect of ethambutol
1. Optic neuritis
135
Define emphysema
The formation of enlarged airspaces distal to the terminal bronchioles with destruction of the elastin alveolar walls - causing decreased elastic recoil
136
Describe the pathophysiology of emphysema
1. Loss of alveolar elasticity
2. Inflammation and scarring of lung tissue - decreasing elasticity and the size of the airway lumen
3. Mucus hypersecretion
137
What are emphysematous bullae?
Large closed off air spaces with air trapped inside them.
May mimic a pneumothorax
138
Give the management of emphysema
1. Bullectomy
2. Lung transplant
Bullae do not respond to aspiration.
139
Give the inheritance pattern seen in cystic fibrosis
Autosomal recessive
140
Describe the pathophysiology of cystic fibrosis
1. Cystic fibrosis transmembrane regulator protein - a chloride channel which normally allows Cl- out of cells and into the lumen - is affected
2. Therefore there is a reduced Cl- level in the lumen, causing increased reabsorption of sodium (and therefore water) from the lumen into the walls
3. This results in excessively viscous secretions
141
Describe the presentation of cystic fibrosis
Commonly diagnosed in children:
1. Meconium ileus (no passage of meconium within 24 hours)
2. Recurrent LRTI
3. Pancreatitis
4. Failure to thrive
Additional symptoms:
1. Chronic cough
2. Steatorrhoea (pancreatic insufficiency)
3. Thick sputum
4. Abdo pain and bloating
5. "Child tastes salty" due to excess salt in sweat
142
Give the investigations for cystic fibrosis
1. Heel prick test on newborn
2. Sweat test (gold standard) - raised Cl- in sweat
143
Describe the management of cystic fibrosis
1. Chest physiotherapy
2. Propjhylactic flucloxacillin
3. Salbutamol
4. Mucolytic (e.g. dornase alfa)
5. Oral pancreatic enzymes
144
Describe Wegener's granulomatosis
Autoimmune condition associated with necrotising granulomatous vasculitis - affecting the upper/lower respiratory tract and the kidneys
145
Give the presentation of Wegener's granulomatosis
1. URTI (epistaxis, sinusitis)
2. LRTI (dyspnoea, haemoptysis)
3. Glomerulonephritis
4. Saddle-shaped nose deformity
5. Proptosis, cranial nerve lesion
146
Which autoantibody is most associated with Wegener's granulomatosis?
cANCA
147
Give the investigations for Wegener's granulomatosis
1. cANCA positive
2. CXR
3. Renal biopsy
148
Give the management of Wegener's granulomatosis
1. Steroids
2. Cyclophosphamide
149
Which autoantibody is most commonly associated with Churg-Strauss syndrome?
pANCA
150
Define allergic bronchopulmonary aspergillosis
Allergy to aspergillus spores - often with a history of bronchiectasis and eosinophilia
151
Give the management of allergic bronchopulmonary aspergillosis
1. Oral glucocorticoids (e.g. prednisolone)
2. Itraconazole - second line
152
Give the criteria for long term oxygen therapy in COPD
LTOT if 2 measurements of pO2 < 7.3 kPa on ABG
OR if pO2 of 7.3 - 8 kPa AND one of the following:
1. secondary polycythaemia
2. peripheral oedema
3. pulmonary hypertension
153
Give the criteria for hospital admission in moderate severity acute asthma attack
'Admit people with a moderate asthma exacerbation with worsening symptoms despite initial bronchodilator treatment and/or who have had a previous near-fatal asthma attack.'
154
What advice should be given following spontaneous primary pneumothorax?
life long ban on deep sea diving
