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Med School Finals > Respiratory > Flashcards

Respiratory Flashcards

1
Q

Control of airway smooth muscle?

A

NA on β2 receptors = bronchodilation
ACh on M3 receptors = bronchoconstriction

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2
Q

Muscles of passive inspiration vs forced inspiration vs expiration?

A

Passive inspiration = diaphragm, external intercostals
Forced inspiration = SCM, scalenes, pectoralis major
Expiration = internal intercostals, subcostals, transversus thoracis, anterior abdominal wall muscles

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3
Q

Location of central vs peripheral chemoreceptors?

A

Central = medulla oblongata
Peripheral = carotid and aortic bodies

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4
Q

Brain centres for inspiration, expiration, breath inhibition and prolongation?

A

Inspiration = dorsal (medullary) group
Expiration = ventral (medullary) group
Inhibition = pneumotaxic (pontine) centre
Prolongation = apneustic (pontine) centre

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5
Q

What does the oxygen dissociation curve demonstrate?

A

Relationship between pO2 and SpO2%

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6
Q

List causes of left shift on the oxygen dissociation curve (↑ O2 affinity,↓ O2 delivery).

A

HbF
Low pCO2
Low H
Raised pH
Low 2,3-DPG
Low temperature

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7
Q

List causes of right shift on the oxygen dissociation curve (↓ O2 affinity,↑ O2 delivery).

A

Raised pCO2
Raised H
Low pH
Raised 2,3-DPG
Raised temperature

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8
Q

List some gram +ve vs gram -ve cocci?

A

Gram +ve = staphylococcus, streptococcus
Gram -ve = neisseria meningitidis, neisseria gonnorhoeae, moraxella catarrhalis

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9
Q

Classification of streptococci?

A

α = viridans and pneumoniae
β = pyogenes (group A) and agalactiae (group b)
γ = enterococci

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10
Q

List some gram +ve vs gram -ve bacilli?

A

Gram +ve = bacillus, clostridium, corynebacterium, listeria, mycobacterium
Gram -ve = shigella, salmonella, legionella, klebsiella, E.coli, campylobacter, pseudomonas, haemophilus

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11
Q

Cause of obstructive vs restrictive lung disease and examples?

A

Obstructive = reduced airflow
→ asthma, COPD, bronchiectasis
Restrictive = reduced expansion
→ IPF, sarcoidosis, pneumoconiosis

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12
Q

FEV1, FVC and FEV1/FVC in obstructive lung disease?

A

FEV1 = significantly reduced
FVC = reduced or normal
FEV1/FVC = reduced (< 0.7)

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13
Q

FEV1, FVC and FEV1/FVC in restrictive lung disease?

A

FEV1 = reduced
FVC = significantly reduced
FEV1/FVC = normal or increased (> 0.7)

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14
Q

What is TV, IRV, ERV and RV?

A

TV = air breathed in/out during normal respiration
IRV/ERV = extra air breathed in/out after TV
RV = air left in lungs after maximum expiration

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15
Q

IC, VC, FRC and TLC calculations?

A

IC = TV + IRV
VC = IC + ERV
FRC = ERV + RV
TLC = VC + RV

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16
Q

ABG interpretation steps?

A

1st = PaO2 (hypoxic or not)
2nd = pH (acidosis, alkalosis)
3rd = PaCO2 (check if respiratory system causing acidosis/alkalosis or compensating)
4th = HCO3 (check if metabolic system causing acidosis/alkalosis or compensating)
5th = BE (> +2 = excess HCO3, < -2 = lack of HCO3)

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17
Q

Examples of added breath sounds and associated conditions?

A

Wheeze (e.g. asthma)
Stridor (e.g. epiglottitis)
Coarse crepitations (e.g. bronchiectasis)
Fine end-inspiratory crackles (e.g. pulmonary fibrosis)

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18
Q

Atopic triad and Ig mediator?

A

Asthma, allergic rhinitis, atopic eczema
→ IgE (type I hypersensitivity)

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19
Q

Features of asthma?

A

Wheeze
Breathlessness
Chest tightness
Cough (often worse at night)
Diurnal variation of symptoms
PMH or FH of atopy e.g. eczema

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20
Q

Investigations for asthma?

A

Peak expiratory flow rate (PEFR)
Spirometry (FEV1/FVC)
Bronchodilator reversibility test (BDR)
Fraction of expired nitric oxide (FeNO)

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21
Q

BDR, PEFR and FeNO results indicative of asthma?

A

BDR = ≥12% FEV1 improvement
PEFR = ≥20% variability
FeNO = > 40 ppb (adults) or > 35 ppb (kids)

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22
Q

Investigation if asthma diagnosis unclear?

A

Fraction of expired nitric oxide (FeNO)

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23
Q

Drugs which can worsen asthma?

A

Aspirin
Other NSAIDs (e.g. ibuprofen)
Beta blockers (e.g. bisoprolol)

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24
Q

Drug options for asthma (adult)?

A

1st line = SABA + ICS
2nd line = SABA + ICS + LABA
3rd line = ↑ ICS or SABA + ICS + LTRA

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25
Q

Drug options for asthma (kids)?

A

1st line = SABA
2nd line = SABA + very low dose ICS (≥ 5) or SABA + LTRA (< 5)
3rd line = SABA + very low dose ICS + LABA/LTRA (≥ 5) or SABA + very low dose ICS + LTRA (< 5)
4th line = ↑ ICS or specialist referral

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26
Q

Outline good inhaler technique?

A
  • Remove cap and shake well
  • Sit/stand straight with chin tilted up
  • Exhale slowly until lungs empty
  • Make a tight seal around mouthpiece
  • Press inhaler whilst inhaling slowly until lungs full
  • Remove inhaler and hold breath for 10 seconds
  • Exhale and wait 30 seconds if 2nd dose needed
  • Wash mouth out if inhaler contains steroid
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27
Q

Indication for step-up asthma treatment?

A

SABA used 3 or more times a week

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28
Q

ICS dosage in step-down asthma treatment?

A

Reduce by 25-50%

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29
Q

Key signs of a severe vs life-threatening asthma attack?

A

Severe = PEFR 33-50%, SaO2 < 92%, can’t talk
Life-threatening = PEFR < 33%, SaO2 < 92%, pCO2 normal, silent chest, confusion, poor resp effort

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30
Q

Hospital management of asthma attack?

A

15L/min O2 via non-rebreather then:
1st line = nebulised salbutamol/ipratropium
2nd line = oral prednisolone or IV hydrocortisone
3rd line = IV magnesium sulphate
4th line = IV aminophylline
N.B. give antibiotics if infective exacerbation

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31
Q

Main cells involved in asthma vs COPD?

A

Asthma = mast cells, eosinophils, T helper cells (CD4+)
COPD = neutrophils, cytotoxic T cells (CD8+)

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32
Q

Example of a SABA, LABA, SAMA, LAMA, ICS and LTRA.

A

SABA = salbutamol
LABA = salmeterol
SAMA = ipratropium
LAMA = tiotropium
ICS = beclamethasone
LTRA = montelukast

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33
Q

Pathology of chronic bronchitis and emphysema?

A

Chronic bronchitis = goblet cell proliferation and mucus hypersecretion
Emphysema = permanent alveoli hyperinflation and membrane loss

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34
Q

Types of emphysema, location and their associated cause?

A

Centriacinar (upper lobes) = tobacco smoking
Panacinar (lower lobes) = A1AT deficiency

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35
Q

Features of COPD?

A

Cough (often productive)
Breathlessness
Chest hyperinflation
Accessory muscle use
Smoking history

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36
Q

Complications of COPD?

A

Pneumothorax (ruptured bulla)
Cor pulmonale (PHTN)
Polycythaemia (chronic hypoxia)
Infection (reduced ciliary clearance)

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37
Q

CXR features of COPD?

A

Hyperinflation (> 6 ribs visible)
Pulmonary bullae
Loss of lung markings
Flattened hemidiaphragms

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38
Q

Type 1 vs type 2 respiratory failure and cause?

A

Type 1 = hypoxia without hypercapnia
→ V/Q mismatch (low oxygen but well perfused)
Type 2 = hypoxia with hypercapnia
→ alveolar hypoventilation

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39
Q

Pathogenesis of CO2 retention?

A
  • Loss of elastic recoil means lungs can’t fully empty CO2
  • Chronic hypercapnia makes respiratory centre less sensitive to PaCO2 so relies on PaO2
  • Giving O2 will ↓ respiratory drive and ↑ PaCO2
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40
Q

Drug options for COPD?

A

1st line = SABA or SAMA
2nd line = SABA + LABA + LAMA (no asthmatic features) or SABA/SAMA + LABA + ICS (asthmatic features)
3rd line = SABA + LABA + LAMA + ICS

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41
Q

Most important management for survival in COPD?

A

Smoking cessation

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42
Q

Smoking cessation management options?

A

Normal = NRT or bupropion or varenicline
Pregnant = NRT

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43
Q

When to commence NRT, bupropion and varenicline?

A

NRT = on quit day
Bupropion/varenicline = 7-14 days before quit day

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44
Q

Indications for LTOT in COPD?

A

2 readings of PaO2 < 7.3 or PaO2 7.3-8 with COPD complications e.g. PHTN

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45
Q

Indication for NIV (BiPAP) in COPD?

A

Respiratory acidosis pH 7.25-7.35

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46
Q

COPD severity categories and associated FEV1?

A

Mild (FEV1≥ 80%)
Moderate (FEV1 50-79%)
Severe (FEV1 30-49%)
Very severe (FEV1 < 30%)

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47
Q

Management of a COPD exacerbation?

A

4L/min O2 via Venturi 24-28% then:
1st line = nebulised salbutamol/ipratropium
2nd line = oral prednisolone or IV hydrocortisone
3rd line = IV theophylline
N.B. give antibiotics if infective exacerbation

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48
Q

Target SpO2 for COPD exacerbation before vs after ABG results?

A

Before = 88-92%
After = 94-98% (if pCO2 normal)
N.B. if very hypoxic high-flow O2 given regardless

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49
Q

Vaccination advice for COPD patients?

A

One-off pneumococcal + annual influenza

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50
Q

Most common bacterial cause of COPD and bronchiectasis exacerbations and antibiotic options?

A

Haemophilus influenzae
1st line = amoxicillin
2nd line = doxycycline

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51
Q

Antibiotic prophylaxis for recurrent COPD and bronchiectasis exacerbations and screening test?

A

Azithromycin
ECG (can cause QT prolongation)

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52
Q

Features of bronchiectasis?

A

Productive cough (LOTS of sputum)
Recurrent infections
Breathlessness
Finger clubbing

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53
Q

Investigation for bronchiectasis and key feature?

A

High-resolution CT (HRCT)
Signet ring appearance

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54
Q

Outline α1-antitrypsin (A1AT) deficiency effect on the lungs?

A
  • A1AT is an antiprotease which inhibits neutrophil elastase
  • Deficiency allows neutrophil elastase to destroy alveolar walls (emphysema)
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55
Q

Malignancy associated with α1-antitrypsin deficiency?

A

Hepatocellular carcinoma

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56
Q

Features of PHTN?

A

Breathlessness
Tachycardia
Raised JVP
Peripheral oedema
Hepatomegaly

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57
Q

Investigation for PHTN and diagnostic value?

A

Right heart catheterisation
Pulmonary arterial pressure = ≥25mmHg

58
Q

Management options for PHTN?

A

CCBs e.g. nifedipine
PDE-5 inhibitors e.g. sildenafil
Prostacyclin analogues e.g. iloprost
Endothelin receptor antagonists e.g. bosentan

59
Q

Causes of chronic pulmonary infection?

A

Hypogammaglobuminaemia
Ciliary dysfunction
Cystic fibrosis
Immunosuppression
Allergic bronchopulmonary aspergillosis (ABPA)

60
Q

Management of allergic bronchopulmonary aspergillosis?

A

1st line = oral steroids
2nd line = oral itraconazole

61
Q

Medical name for a typical cough?

A

Acute bronchitis

62
Q

CRP level needing antibiotic for chest infection and options?

A

CRP > 100
1st line = amoxicillin
2nd line = doxycycline

63
Q

Most common cause of noisy breathing in children?

A

Laryngomalacia

64
Q

Most common cause of coryza (common cold)?

A

Rhinovirus

65
Q

Influenza known to cause pandemics?

A

Influenza A

66
Q

Advice for influenza management?

A

Only treat those at risk of complications
Must be initiated within 48 hours of onset
→ oseltamavir
→ zanamivir

67
Q

Age at first dose, type and live/inactivated influenza for young vs elderly?

A

Young = 2-3 years, intranasal, live
Elderly = 65 and over, vaccine, inactive

68
Q

Medication contraindicating a child’s influenza vaccine and why?

A

Aspirin
Risk of Reye’s syndrome

69
Q

Main cause of epiglottitis, croup, bronchiolitis and whooping cough?

A

Epiglottitis = haemophilus influenzae
Croup = parainfluenza virus
Bronchiolitis = RSV
Whooping cough = bordatella pertussis

70
Q

CXR finding in acute epiglottitis vs croup (laryngotracheobronchitis)?

A

Acute epiglottitis = thumbprint sign
Croup = steeple sign

71
Q

Features and management of acute epiglotittis?

A

Generally unwell (e.g. fever)
Inspiratory stridor
Drooling
Tripod position
Management = secure airway + IV antibotic e.g. ceftriaxone

72
Q

Features and management of croup?

A

Generally unwell (e.g. fever)
Barking cough
Inspiratory stridor
Management = don’t upset child, oral dexamethasone (1st line), nebulised budesonide, nebulised adrenaline (2nd line)

73
Q

Features and management of bronchiolitis?

A

Generally unwell (e.g. fever)
Dry cough
Breathlessness
Wheeze, fine inspiratory crackles
Poor feeding
Management = supportive

74
Q

Features and management of pertussis?

A

Generall unwell (e.g. fever)
Paroxymal cough worse at night
Post-tussive vomiting
Apnoeic spells
Management = oral macrolide if onset < 21 days

75
Q

School exclusion for children with pertussis?

A

48 hours after starting antibiotics
21 days after onset if no antibiotics

76
Q

When is a pertussis vaccine offered to pregnant women?

A

16-32 weeks

77
Q

List causes of bilateral hilar lymphadenopathy?

A

Sarcoidosis
Tuberculosis
Lymphoma
Fungal infections
Pneumoconiosis

78
Q

Features of Kartagener’s syndrome?

A

Bronchiectasis (ciliary dysfunction)
Dextrocardia
Situs inversus
Sinusitis
Infertility

79
Q

Features of cystic fibrosis?

A

Recurrent chest infections
Chronic sinusitis
Meconium ileus
Failure to thrive
Infertility
Pancreatic insufficiency
Liver disease
Malabsorption

80
Q

Ions affected in cystic fibrosis and diagnostic test result?

A

Chloride (Cl) and sodium (Na)
→ Cl sweat levels > 60

81
Q

Management of CF?

A

Chest physiotherapy (at least twice a day)
High calorie/high fat diet
Pancreatic enzyme supplements
Vitamin supplements
Lung transplantation

82
Q

Specific CF drug and indication?

A

Lumacaftor/ivacaftor (Orkambi)
→ those homozygous for delta F508 mutation

83
Q

CAP vs HAP?

A

CAP = outside hospital or within 48 hours admission
HAP = 48 hours after admission

84
Q

CURB65 and management plan per score?

A

Confusion
Urea > 7
Respiratory rate > 30
Blood pressure < 90 systolic OR < 60 diastolic
65 or over
0-1 = home management, 2 = consider hospital, 3-5 = hospital/ITU admission

85
Q

Follow-up CXR post-pneumonia?

A

6 weeks

86
Q

Pneumonia organisms most linked to CAP, COPD, CF, post-flu, air-con, alcoholics/diabetics, HIV, bird contact, red jelly sputum, dry cough, SIADH, erythema multiforme, cold AIHI, exertional SOB?

A

CAP = strep pneumoniae
COPD = haemophilus influenzae, moraxella
CF = psuedomonas
Post-flu = staph aureus
Air-con/dry cough/SIADH= legionella
Alcoholics/diabetics/red jelly sputum = klebsiella
HIV/exertional SOB = pneumocystic jiroveci
Bird contact = chlamydia psitacci
Dry cough/erythema multiforme/cold AIHI = mycoplasma

87
Q

Specific test for Legionella infection?

A

Urinary antigen enzyme immunoassay

88
Q

Most common area affected in aspiration pneumonia?

A

Right lower (or middle) lobe

89
Q

Clinical features, pleural aspirate features and management of empyema?

A

Clinical = failure to respond to antibiotics, swinging fever
Pleural aspirate = low pH (<7.2), low glucose, high LDH
Management = drainage + IV antibiotics

90
Q

Types of pleural effusion, value and most common cause?

A

Transudate (< 30g/L protein)
→ heart failure
Exudate (> 30g/L protein):
→ pneumonia

91
Q

Light’s criteria?

A

Used if protein content is borderline (25-35 g/L)
Effusion is an exudate if serum:protein > 0.5 or pleural LDH is > 2/3rd upper limit for serum LDH

92
Q

Meigs syndrome triad?

A

Pleural effusion
Ascites
Benign ovarian tumour

93
Q

Acute surgical management of a tension pneumothorax?

A

Needle decompression

94
Q

Management of a primary pneumothorax?

A

< 2cm and not breathless = discharge and 2-4 week OP review
> 2cm or breathless = aspiration (1st line), chest drain (2nd line)

95
Q

Management of a secondary pneumothorax?

A

< 1cm and not breathless = 24 hour observation
1-2 cm and not breathless = aspiration (1st line), chest drain (2nd line)
> 2cm, > 50 or breathless = chest drain

96
Q

Management for persistent air leaks or recurrence of pneumothorax?

A

Thoracic surgery referral for VATS pleurodesis

97
Q

Insertion site for needle decompression vs aspiration/drain?

A

Needle decompression = 2nd intercostal space, mid-clavicular line
Aspiration/drain = 5th intercostal space, mid-axillary line

98
Q

What is atelectasis and management?

A

Collapse of basal alveoli caused by obstruction
Management = sit patient upright + breathing exercises

99
Q

What is a Pancoast tumour, give a complication and explain?

A

Mainly NSCLC tumour at the lung apex
Horner’s syndrome (ptosis, miosis, anhydrosis)
Loss of sympathetic innervation to one side of face due to sympathetic trunk damage

100
Q

Investigation for pulmonary fibrosis and key feature?

A

High-resolution CT (HRCT)
Honeycomb appearance

101
Q

Conditions which cause upper zone fibrosis?

A

CHARTS:
Coal worker’s pnuemoconiosis
Histiocytosis/Hypersensitivity pneumonitis
Ankylosing Spondylitis
Radiation-induced fibrosis
Tuberculosis
Sarcoidosis/Silicosis

102
Q

Conditions which cause lower zone fibrosis?

A

Idiopathic pulmonary fibrosis
Drugs (e.g. amiodarone)
Asbestosis
CTDs (except ankylosing spondylitis)

103
Q

List medications which cause pulmonary fibrosis?

A

Amiodarone
Bleomycin
Methotrexate
Nitrofurantoin

104
Q

What is hypersensitivity pneumonitis and give some examples?

A

Reaction to inhaled allergen:
Bird-fancier’s lung
Farmer’s lung
Hot-tub lung

105
Q

What is pneumoconiosis and give some examples?

A

Reaction to inhaled metal or dust:
Silicosis
Asbestosis
Coal miner’s lung

106
Q

Egg shell calcification of hilar lymph nodes and increased TB risk?

A

Silicosis

107
Q

Caplan’s syndrome?

A

Rheumatoid arthritis + pneumoniosis

108
Q

Features of acute sarcoidosis (Löfgren syndrome)?

A

Fever
Polyarthralgia
Erythema nodosum
Bilateral hilar lymphadenopathy

109
Q

Blood test and pathological findings in sarcoidosis?

A

Bloods = raised ACE, ESR and Ca, low lymphocytes
Pathology = non-caseating granulomas

110
Q

Management of sarcoidosis?

A

Mostly self-limiting
Steroids
Immunosuppressants

111
Q

Outline latent vs active TB?

A

Latent = mycobacterium engulfed by macrophages, move to hilar lymph nodes and are surrounded by granulomas (primary TB)
Active = inability to fight initial exposure (miliary TB) or reactivation of pathogen (secondary TB)

112
Q

Ghon complex?

A

Ghon focus (primary TB lesion) + nearby lymphadenopathy

113
Q

Commonest extrapulmonary manifestation of TB?

A

Pott’s disease of the spine

114
Q

Main test for latent vs active TB?

A

Latent = Mantoux test
Active = sputum culture

115
Q

Treatment for latent vs active TB?

A

Latent = 3 months of RIP or 6 months of IP
Active = 2 months of RIPE + 4 months of RI

116
Q

Side effects of RIPE drugs?

A

Rifampicin = hepatitis, p450 inducer, orange/red secretions
Isoniazid = hepatitis, p450 inhibitor, peripheral neuropathy
Pyrazinamide = hepatitis, gout
Ethambutol = visual disturbances

117
Q

Drug which reduces the risk of isoniazid-induced peripheral neuropathy?

A

Pyridoxine (vitamin B6)

118
Q

Broad summary of lung cancer types?

A

Small cell (SCLC)
Non-small cell (NSCLC) = adenocarcinoma, squamous cell, large cell

119
Q

Paraneoplastic features of small cell lung cancer?

A

Increased ACTH → Cushing’s
SIADH → hyponatraemia
Lambert-Eaton syndrome

120
Q

Paraneoplastic features of squamous cell carcinoma?

A

Increased PTHrp → hypercalcemia
Increased TSH → hyperthyroidism
Hypertrophic pulmonary osteoarthropathy (HPOA)

121
Q

Paraneoplastic features of adenocarcinoma?

A

Gynaecomastia
Hypertrophic pulmonary osteoarthropathy (HPOA)

122
Q

Investigations for lung cancer?

A

CT chest, liver and adrenals
Bronchoscopy with EBUS + biopsy

123
Q

Management of SCLC vs NSCLC?

A

SCLC = chemo + radiotherapy
NSCLC = surgery (e.g. lobectomy) + radiotherapy + chemo

124
Q

Lung cancer associated with non-smokers, poorest prognosis, cavitating?

A

Non-smokers = adenocarcinoma
Poorest prognosis = SCLC
Cavitating = squamous cell carcinoma

125
Q

Mesothelioma association and CXR findings?

A

Asbestos exposure
Pleural thickening and pleural effusion

126
Q

Most common pleural manifestation of asbestos exposure?

A

Pleural plaques (benign)

127
Q

Pathology of ARDS vs NRDS?

A

ARDS = inflammation of alveoli leads to type II alveolar destruction and surfactant loss
NRDS = prematurity means immature type II alveoli and insufficient surfactant production

128
Q

CXR finding in ARDS and NRDS?

A

Bilateral pulmonary infiltrates

129
Q

Management of RDS?

A

Supportive care
High-flow oxygen
Assisted ventilation
Surfactant (NRDS)

130
Q

Prevention of NRDS?

A

If mum at risk of premature birth, IM corticosteroids to stimulate foetal lung maturation

131
Q

Features of eosinophilic granulomatosis with polyangitis (Churg-Strauss)?

A

pANCA +ve
Small vessel vasculitis
Recurrent sinusitis
Pulmonary disease
Asthma/eosinophilia

132
Q

Features of granulomatosis with polyangitis (Wegener’s)?

A

cANCA +ve
Small vessel vasculitis
Recurrent sinusitis
Pulmonary disease
Epistaxis/haemoptysis
Rapidly progressive glomerulonephritis

133
Q

Features of Goodpasture’s syndrome?

A

Anti-GBM +ve
Pulmonary haemorrhage
Rapidly progressive glomerulonephritis

134
Q

Features of obstructive sleep apnoea?

A

Snoring
Morning headache
Daytime sleepiness
Inability to concentrate

135
Q

Investigations and management of obstructive sleep apnoea?

A

Investigations = epworth sleepiness scale, polysomnography (sleep study)
Management = lifestyle changes, CPAP

136
Q

Management of choking?

A

Able to breathe = encourage to cough
Unable to breathe = 5 back blows then 5 abdominal thrusts (repeat)
Unconscious = call 999, start CPR

137
Q

Features of anaphylaxis?

A

Urticaria
Angioedema
Breathlessness
Wheeze, stridor
Abdominal pain

138
Q

Test to confirm anaphylaxis and time-frame?

A

Serum mast cell tryptase
→ within 6 hours of the event

139
Q

Adrenaline dosage for < 6 months, 6 months-6 years, 6-12 years and > 12 years?

A

< 6 months = 100-150 mcg
6 months-6 years = 150 mcg
6-12 years = 300 mcg
> 12 years = 500 mcg (0.5 ml 1 in 1,000)

140
Q

Refractory anaphylaxis and management?

A

Respiratory and/or cardiovascular problems persisting after 2 doses of IM adrenaline
Management = IV adrenaline + IV fluid bolus

Med School Finals (18 decks)

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