Respiratory

Question 1

Describe the clinical features of pulmonary hypertension

Answer 1

Exertional dyspnoea
Lethargy
Fatigue
RVF – peripheral oedema & abdominal pain from hepatic congestion

Question 2

Describe the management of pulmonary hypertension

Answer 2

Oxygen
Anticoagulation
Diuretics for oedema
Oral CCBs

Question 3

Describe the management of type 1 respiratory failure

Answer 3

Treat underlying cause
Give oxygen
Assisted ventilation

Question 4

Describe the management of type 2 respiratory failure

Answer 4

Treat underlying cause
Controlled oxygen therapy – should be given with care
Recheck ABG after 20 minutes, if PaCO2 steady or lower, increase O2 concentration to 28%
If this fails – consider intubation and ventilation if appropriate

Question 5

Describe the different severities of asthma

Answer 5

Mild: no features of severe asthma, PEFR > 75%
Moderate: no feature of severe asthma, PEFR 50-75%
Severe (if any one of the following): PEFR 33-50% of best or predicted, cannot complete sentences in one breath, respiratory rate > 25, heart rate > 110/min
Life-threatening (if any one of the following): PEFR < 33% of best or predicted, sats < 92%/ABG pO2 < 8kPa, cyanosis, poor respiratory effort, near/fully silent chest, exhaustion, confusion, hypotension/arrhythmias, normal pCO2
Near fatal: raised pCO2

Question 6

Describe acute asthma management

Answer 6

Acute asthma management: ABCDE, aim for spO2 94-98% with oxygen, ABG if sats <92%
5mg nebulised salbutamol
40mg oral prednisolone STAT
Severe: nebulised ipratropium bromide 500 micrograms, consider back to back salbutamol
Life threatening or near fatal: urgent ITU/anaesthetist assessment, urgent portable CXR, IV aminophylline & consider IV salbutamol if nebulised route ineffective

Question 7

Describe differentials in eosinophilia

Answer 7

Asthma – some patients have eosinophilic inflammation which typically responds to steroids
Differentials: hayfever/allergies, lymphoma, SLE, eosinophilic pneumonia

Question 8

Describe outpatient COPD management

Answer 8

COPD care bundle
Smoking cessation
Pulmonary rehabilitation
Bronchodilators
Antimuscarinics
Steroids
Mucolytics
Diet

Question 9

Describe long term oxygen therapy in COPD

Answer 9

Extended periods of hypoxia cause renal & cardiac damage – can be prevented by LTOT (to be used at least 16 hours/day)
Offered if pO2 consistently below 7.3kPa or below 8kPa with cor pulmonale
Must be non-smokers and not retain high levels of CO2

Question 10

Describe pulmonary rehabilitation in COPD

Answer 10

Many COPD patients with COPD avoid exercise & physical activity because breathlessness
-may lead to a vicious cycle of increasing social isolation and inactivity leading to worsening of symptoms
Pulmonary rehab – aims to break this cycle -> an MDT 6-12 week programme of supervised exercise, unsupervised home exercise, nutritional advice & disease education

Question 11

Describe COPD exacerbation management

Answer 11

ABCDE
Oxygen – target SaO2 94-98% but if any evidence of acute/previous type 2 respiratory failure, then target SaO2 88-92%
Salbutamol and ipratropium
Steroids – prednisolone 30mg STAT and OD for 7 days
Abx if raised CRP/WCC or purulent sputum
CXR
Consider IV aminophylline
Consider NIV if type 2 resp failure & pH 7.25-7.35, pH < 7.25 consider ITU referral

Question 12

Describe pneumonia management (emergency)

Answer 12

ABCDE
If any features of sepsis – immediately treat using sepsis pathway (NO DELAY in initiating IV abx and fluids)
If not, treat with abx as per CURB-65 score

Question 13

List the CURB-65 score

Answer 13

C = confusion, MMT 2 or more points worse
U = urea > 7
R = > 30/min
B = < 90mmHg systolic or < 60mmHg diastolic
65 = age above 65 years

Question 14

Describe the different organisms which cause pneumonia

Answer 14

Community acquired:
1) Common organisms – streptococcus pneumonia, haemophilus influenza, Moraxella catarrhalis
2) Atypical – legionella pneumophilia, chlamydia pneumoniae, mycoplasma pneumoniae
Hospital acquired – E.coli, MRSA, peudomonas

Question 15

List the causes of a non-resolving pneumonia

Answer 15

CHAOS
Complication – empyema, lung abscess
Host – immunocompromised
Antibiotic – inadequate dose, poor oral absorption
Organism – resistant or unexpected organisms not covered by empirical abx
Second diagnosis – PE, cancer

Question 16

Describe the hospital management of covid-19

Answer 16

Oxygen supplementation – CPAP or invasive ventilation
Dexamethasone (& consider tocilizumab +/- remdesivir)
Abx may be needed if suspected superadded bacterial infection

Question 17

List investigations for a suspected pulmonary embolus

Answer 17

U&Es, FBC, baseline clotting
ECG
CXR
ABG
Serum d-dimer
CT pulmonary angiography

Question 18

Describe the management of a pulmonary embolus

Answer 18

Acute: oxygen, morphine & anti-emetic
LMWH/fondaparinux
Long-term anticoagulation: either DOAC or warfarin
Treat underlying cause

Question 19

List investigations for suspected TB

Answer 19

Culture
If productive cough – x3 sputum samples for acid-alcohol fast bacilli
Routine bloods (especially LFTs) & HIV test and vit D levels

Question 20

Describe the management of TB

Answer 20

4 antibiotics for first two months – rifampicin, isoniazid, pyrazinamide, ethambutol
2 antibiotics for 4 months – rifampicin & isoniazid
Dose of anti-TB abx is weight dependent

Question 21

List the major side effects of TB treatment

Answer 21

Rifampicin – hepatitis, rashes, orange/red secretions
Isoniazid – hepatitis, rashes, psychosis
Pyrazinamide – hepatitis, rashes, vomiting, arthralgia
Ethambutol – retrobulbar neuritis

Question 22

List investigations for suspected bronchiectasis

Answer 22

High resolution CT
Blood tests – immunoglobulin, cystic fibrosis genotype, HIV test, RF
Sputum culture

Question 23

Describe management of bronchiectasis

Answer 23

Treat underlying cause
Physiotherapy
10-14 abx according to sputum cultures
1) Haemophilus influenza: amoxicillin
2) Pseudomonas aeruginosa: ciprofloxacin
IV abx for severe infections
Long-term prophylactic abx for patients with recurrent infective exacerbations

Question 24

List investigations for suspected cystic fibrosis

Answer 24

One or more of:
1) History of CF in sibling
2) Positive newborn screening result
AND:
1) Increased chloride concentration in sweat test
2) Identification of two CF mutations
3) Demonstration of abnormal nasal epithelial ion transport

Question 25

Describe the management of cystic fibrosis

Answer 25

Physiotherapy, exercise
Mucolytics
Pancreatic enzyme replacement therapy for patients with pancreatic insufficiency
Fat soluble vitamins ADEK
Nutritional supplementation for underweight

Question 26

List investigations for suspected interstitial lung disease

Answer 26

Pulmonary function tests – restrictive pattern
Bloods – ANA, ENA, Rh F, ANCA, anti-GBM, ACE, IgG

Question 27

Describe the management for interstitial lung disease

Answer 27

Depends on underlying pathology
Remove occupational exposure/environmental exposure
Avoid drugs associated
Stop smoking
MDT approach
Treatment of infective exacerbations

Question 28

List the investigations for suspected lung cancer

Answer 28

Bloods – FBC, U&E, calcium, LFTs, INR
CXR
Staging CT
Histology – bronchoscopy
PET scan – MDT decision if patient is a surgical candidate & initial CT suggestive of low stage

Question 29

Describe the management of lung cancer

Answer 29

Curative surgery for stages I & II
Chemotherapy
Radiotherapy
Palliative care

Question 30

List investigations for suspected pleural effusion

Answer 30

Ultrasound guided pleural aspiration – biochemistry, cytology, microbiology
Consider thoracoscopy or CT pleural biopsy
CXR

Question 31

Describe the management of pleural effusion

Answer 31

Conservative management – small effusions will resolve treatment of the underlying cause
Pleural aspiration – sticking a needle in & aspirating the fluid -> temporarily relieve the pressure
Chest drain – drain the effusion & prevent it recurring

Question 32

List exudative and transudative causes of pleural effusion

Answer 32

Exudative – lung cancer, pneumonia, rheumatoid arthritis, TB
Transudative – CCF, hypoalbuminaemia, hypothyroidism, Meig’s syndrome (right sided effusion with ovarian malignancy)

Question 33

Describe the management of pneumothorax

Answer 33

Primary – if symptomatic and rim of air >2cm on CXR, give O2 and aspirate; if unsuccessful consider re-aspiration/intercoastal drain
Secondary – as above but lower threshold for ICD
Persistent air leak > 5 days – refer to thoracic surgeons

Question 34

List investigations done for obstructive sleep apnoea

Answer 34

Sleep study
1) Overnight oximetry
2) Limited sleep study (inc. oximetry, snoring, body movement, heart rate = study of choice
3) Full polysomnography

Question 35

Describe the management for obstructive sleep apnoea

Answer 35

Weight loss, sleep upright, avoid/reduce evening alcohol intake
Snorers & mild OSA – mandibular advancement devices, consider pharyngeal surgery as last resort
Significant OSA – nasal CPAP, consider gastroplasty/bypass & rarely tracheostomy
Severe OSA & CO2 retention – period of NIV prior to CPAP if acidotic, but compensated CO” may reverse with CPAP alone

Question 36

Describe cor pulmonale

Answer 36

Right sided heart failure caused by respiratory disease
Right ventricle being unable to effectively pump blood out of the ventricle & into the pulmonary arteries -> back pressure of blood in the right atrium, vena cava & systemic venous system

Question 37

Describe the management of cor pulmonale

Answer 37

Treating the symptoms and underlying cause
Long term oxygen therapy
(NB: prognosis is poor unless reversible underlying cause)