Respiratory

Question 1

How long should an unprovoked PE be treated for?

Answer 1

6 months

Question 2

What can happen as a result of prolonged intubation?

Answer 2

physical communication between the trachea and oesophagus due to proximity of structures and inflammation around the tube in the trachea. Knows as a tracheooesophageal fistula

Question 3

What is Barrett’s oesophagus?

Answer 3

Metaplasia of the lower oesophageal mucosa, with the usual squamous epithelium being replaced by columnar epithelium

Question 4

Where is an inhaled foreign body most likely to be found?

Answer 4

Right main bronchus

Question 5

what are contraindications to insertion of a chest drain?

Answer 5

INR >1,3
platelet count < 75
Pulmonary bullae
Pleural adhesions

Question 6

what are indications for inserting a chest drain?

Answer 6

pleural effusion
pneumothorax
empyema
haemothorax
hemopneumothorax
chylothorax
in some cases of penetrating chest wall injury in ventilated patients

Question 7

How should patients with suspected PE be treated?

Answer 7

DOAC i.e. apixaban or rivaroxaban

Question 8

What are characteristic features of streptococcal pneumonia?

Answer 8

rapid onseet
high fever
pleuritic chest pain
herpes labialis (cold sores)

Question 9

what antibiotic is given in non-severe community acquired pneumonia that can be managed as an outpatient?

Answer 9

oral amoxicillin

Question 10

what investigation should be done to confirm SIADH?

Answer 10

paired urine and plasma osmolalities

Question 11

what is allergic bronchopulmonary aspergillosis?

Answer 11

complex hypersensitivity reaction often in patients with asthma or cystic fibrosis that occurs when bronchi become colonized by Aspergillus species
Repeated episodes of bronchial obstruction, inflammation and mucoid impaction can lead to bronchiectasis, fibrosis and respiratory compromise

Question 12

what is allergic bronchopulmonary aspergillosis?

Answer 12

complex hypersensitivity reaction often in patients with asthma or cystic fibrosis that occurs when bronchi become colonized by Aspergillus species
Repeated episodes of bronchial obstruction, inflammation and mucoid impaction can lead to bronchiectasis, fibrosis and respiratory compromise

Question 13

what are the features of allergic bronchopulmonary aspergillosis?

Answer 13

bronchoconstriction: wheeze, cough, dyspnoea
bronchiectasis - proximal

Question 14

What is seen on investigation in allergic bronchopulmonary aspergillosis?

Answer 14

• eosinophilia
• flitting CXR changes
• positive RAST test to aspergillosis
• positive IgG precipitins
• raised IgE

Question 15

What is the management of allergic bronchopulmonary aspergillosis?

Answer 15

oral glucocorticoids
itraconazole sometimes introduced second-line

Question 16

What are the signs of life-threatening asthma?

Answer 16

PEFR < 33% Best or predicted
oxygen sats < 92%
normal PCO2
silent chest, cyanosis or feeble respiratory effort
bradycardia, dysrhythmia, hypotension
exhaustion, confusion, coma

Question 17

How is pneumocystic jirovecci treated?

Answer 17

co-trimoxazole

Question 18

what are the CURB65 criteria?

Answer 18

C = confusion
U = urea > 7mmol/L
R = respiration rate >/= 30
BP = systolic </=90 and/or diastolic </=60
65

Question 19

what is a transudative effusion and what could cause it?

Answer 19

<30g/L protein:
- heart failure - most common transudate cause
- hypalbuminaemia - liver disease, nephrotic syndrome, malabsorption
- hypothyroidism

Question 20

what is an exudative effusion and what could cause it?

Answer 20

> 30g/L protein:
- infection: pneumonia - most common exudate cause, TB
- connective tissue disease - RA, SLE
- neoplasia - lung cancer, mesothelioma, metastases
- pancreatitis
- pulmonary embolism
- Dressler’s syndrome

Question 21

What are the features of carcinoma on needle biopsy?

Answer 21

nuclear enlargement, hyperchromasia, pleomorphism

Question 22

what should you do if you have a strong suspicion of PE but there is a delay in performing a scan?

Answer 22

start patient on treatment dose apixaban whilst awaiting scan

Question 23

what are pleural plaques?

Answer 23

change that can be seen on CXR in people with asbestos exposure
pleural plaques are benign and do not undergo malignant change - therefore don’t require any follow-up

Question 24

what are the indications for BIPAP/NIV in patients with COPD?

Answer 24

• COPD with resp. acidosis pH 7.25-7.35
• type II respiratory failure 2ndary to chest wall deformity, neuromuscular disease or OSA
• cardiogenic pulmonary oedema unresponsive to CPAP
• weaning from tracheal intubation

Question 24

what are the indications for BIPAP/NIV in patients with COPD?

Answer 24

• COPD with resp. acidosis pH 7.25-7.35
• type II respiratory failure 2ndary to chest wall deformity, neuromuscular disease or OSA
• cardiogenic pulmonary oedema unresponsive to CPAP
• weaning from tracheal intubation

Question 25

diagnostic testing of asthma?

Answer 25

patients >/= 17 - patients should be asked if symptoms are better on days away from work/during holidays, if so, patients should be referred to a specialist as possible occupational asthma, all patients should have spirometry with a bronchodilator reversibility test, all patients should have an FeNO test
children 5-16 years: all children should have spirometry with bronchodilator reversibility testing, FeNO should be requested if normal spirometry
patients < 5 years: diagnosis should be made on clinical judgement

Question 26

How is an acute exacerbation of COPD treated?

Answer 26

• increase frequency of bronchodilator use and consider giving nebs
• give prednisolone 30mg daily for 5 days
• oral abx are recommended if sputum is purulent or there are clinical signs of pneumonia
• BNF recommends one of following oral antibiotics first line: amoxicillin/clarithromycin/doxycycline

Question 27

in what cancer are ‘cavitating lesions’ most commonly seen?

Answer 27

squamous cell lung cancer

Question 28

what is flail chest?

Answer 28

chest wall disconnects from thoracic cage
multiple rib fractures - at least 2 fractures per rib in at least 2 ribs
associated with pulmonary contusion
abnormal chest motion
avoid over hydration and fluid overload

Question 29

what is flail chest?

Answer 29

chest wall disconnects from thoracic cage
multiple rib fractures - at least 2 fractures per rib in at least 2 ribs
associated with pulmonary contusion
abnormal chest motion
avoid over hydration and fluid overload

Question 30

what is the long-term management of COPD?

Answer 30

1: short-acting bronchodilators - salbutmaol/terbutaline or short acting antimuscarinics (ipratropium)
2a: if they do not have asthmatic or steroid responsive features they should have a combined LABA and LAMA
2B: if they have asthmatic or steroid responsive features they should have a combined LABA and ICS - e.g. fostair/symbicort - if this does not work they can be stepped up to a LABA,LAMA and ICS - “trimbo”
3. In more severe cases additional options are:
- nebulisers (salbutamol and/or ipratropium)
- oral theophylline
- oral mucolytic therapy to break down sputum
- long term prophylactic antibiotics
- long term oxygen therapy at home - used for severe COPD that is causing problems such as chronic hypoxia, polcythaemia, cyanosis or heart failure secondary to pulmonary hypertension (cor pulmonale)