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RACP 2023 > RESPIRATORY > Flashcards

RESPIRATORY Flashcards

1
Q

Causes of upper and lower lobe fibrosis?

A

SCART
- Silicosis, sarcoid
- Coal pneumonicosis, CF, chronic allergic alveolitis/ eosinophilic pneumonitis
- AnkSpond, ABPA, alveolar haemorrhage syndromes
- Radiation
- TB

RASIO
- RA
- Asbestosis, acute allergic alveoli’s, acute eosinophilic pneumonitis
- Scleroderma
- IPF
- Other

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2
Q

UIP causes and pattern

A

Causes
- IPF
- Smoking

Pattern
- subpleural involvement
- lower lobe predominance
- honeycombing
- NO: ground glass, opacities, nodules, cysts

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3
Q

NSIP causes and pattern

A

Causes
- CTD
- drugs
- nonsmoking females in 50s

Pattern
- sub pleural sparing
- ground glass
- reticular opacities

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4
Q

COP causes and pattern

A

Causes
- Drugs
- CTD

Pattern
- opacities patchy subpleural
- bronchovascular

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5
Q

HSP causes and pattern

A

Causes
- hot tub
- birds droppings

Pattern
- fine nodules
- upper predmoinance
- airway involvement

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6
Q

Tuberous sclerosis ILD pattern?

A

LAM

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7
Q

ILD treatment?

A

Steroids unless scleroderma
Antigen eviction for HSP

Then steroid sparing agents
Then antifibrotic agents

ILD –> straight to antifibrotics

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8
Q

pTH diagnostic values?

A

PAHTN
- mPAP > 20
- PVR > 3
- PAWP < 15

Cardiac
- mPAP > 20
- PAWP > 15
- PVR <3

MIXED
- mPAP > 20
- PVR > 3
- PAWP > 15

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9
Q

pHTN therapies, MoA and names?

A

Endothelin antagonists
- santan

Prostacyclin analogues
- nol/ iloprost

PDE5 inhibitors
- fil

Ricociguat
- stimulates guanylate cyclase –> incr NO sensitivity

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10
Q

Causes of metabolic acidosis: high and normal anion gap

A

HARDUP

MUDPILES

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11
Q

Causes of respiratory alkalosis and acidosis?

A

Acidosis: hypoventilation
CNS depression
Pneumonia
APO
Myopathy
PTX

Alkalosis: hyperventilation
Anxiety
Hypoxia
Pain
Sepsis
Salicilates
Mechanical ventilators

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12
Q

What is a poor prognostic factor in bronchiectasis?

A

Elevated platelets:

Incr mortality, incr hospitalisations for exacerbations, incr severity, incr hospitalisations

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13
Q

Treatment for bronchiectasis exacerbation caused by pseudomonas?

A

Cipro
Taz
Ceftazidime

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14
Q

Options for prophylaxis in bronchiectasis?

A

Macrolides
Doxy
Inhaled tobramycin

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15
Q

Interventions that improve QOL or reduce exacerbations in bronchiectasis?

A

Hypertonic saline
Prophylactic Abs

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16
Q

Most common form of lung cancer?

A

Adenocarcinoma

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17
Q

Classification of asthma?

A

IgE mediated via adaptive system
- Th2 high –> IgE –> eosinophilia

Non-IgE mediated via innate system (Th2 low)
- allergen directly triggers IL2 –> eosinophils

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18
Q

Cells involved in T2 high and low asthma?

A

T2 high
- IL4,5,13
- IL9, IL33

T2 low
- TH1: IFN gamma, TNF alpha
- Neuter: proteases, ROS
- Th17: IL17/22/23/CXCR2

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19
Q

Pathophys of asthma?

A

Bronchoconstriction
Angiogenesis (VEGF)
Mucous hyper secretion
Hypertrophy and hyperplasia of smooth muscle: PDGF, endothelin
Bronchial hyperresponsiveness

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20
Q

Direct vs indirect tests of asthma?

A

Direct –>
- good for ruling out (higher sensitivity)
- tests inflammatory component
- if (+) use bronchodilators > ICS
- methylcholine, histamine
- methylcholine higher sensitivity

Indirect –>
- good for ruling in (specific)
- tests remodelling components
- exercise, mannitol, hypertonic saline, eucapnic hyperventilation, adenosine
- predicts response to ICS

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21
Q

Other tests than can be used for asthma?

A

Total IgE
Eosinophilia
Exh NO: marker for inflammation/steroid responsiveness

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22
Q

Montelukast use in asthma indication? What can it be assoc with?

A

Aspirin intolerance; aspirin tolerance

Can be assoc with unmasking Churg Strauss

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23
Q

Monoclonal Ab options for asthma

A

Mepolizumab, Benralizumab: IL5
Dupilumab: Ig4/13
Omalizumab: IgE

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24
Q

Pathophys of TB?

A

M TB/ M bovis (pyrazinamide resistance)

–> macrophages phagocytose and make a granuloma
–> T cell mediated response

25
Q

Risk factors for TB: highest to lowest

A

Highest: HIV coinfection
Transplant
CKD
H+N cancer
Fibronodular CXR
TNF-alpha antagonist
Fred > 15 mg daily

26
Q

How to screen for TB?

A

IGRA
- detects TB exposure
- checks T cell response to TB
- does not (+) with vaccination
- False (-) in immunosupressed

27
Q

Gold standard for TB diagnosis?

A

TB mycobacterial culture

28
Q

Purpose of TST?

A

Checks for latent TB
- also (strong +) in active

29
Q

TB treatment options:

A

Standard
4 months RIPE then 2 months RI

Resistance
Aim 4 effective drugs, >3 after BDQ stopped

Levoflox
Amikacin
Meropenem
P-ASA
Ethionamide
Cycloserine
Clofazimine
Bedaquiline
Linezolid

30
Q

When to use steroids in TB? when to be cautious

A

○ Severely ill: resp failure, ICU, hypotension in first 6-8 weeks
○ Meingeal: REDUCES MORTALITY
○ Pericardial
○ Pleural
○ Dissemianted

NB: Rifampicin increases metabolism of steroids = need lower doses

31
Q

How to treat TB in pregnancy

A

Same

32
Q

When to treat latent TB?

A

HIV
Immunocomp
Preg
HCWs
< 35
Recent converter neg –> positive
Recent exposure
Close contacts of smear positive pulm

33
Q

How to treat latent TB?

A

Rifamp
Isoniazid
Rifapentine

SINGLE AGENT

34
Q

SE’s TB therapy?

A

Rifampcin: drug interactions, hepatitis, HS

Izonaizid: hepatitis, rash, peripheral neuro
- INH competes with vitamin B6 (pyridoxine) in its action as a cofactor in the synthesis of synaptic neurotransmitters
- Results in ataxia, peripheral neuropathy, paraesthesia

Ethambutol: optic neuropathy

Pyrazinamide: hepatitis, skin, polyarthralgia, gout

35
Q

Definition of elastic recall vs compliance

A

Elastic recoil
Tendency for lung to collapse and chest wall to spring outward

Compliance
Change in lung volume for change in pressure
Inversely proportional
Low compliance = harder to fill
○ High compliance = easier to fill

36
Q

What moves dissociation curve to (R)

A

Incr H+
Incr CO2
Exercise
Incr 2.3 BPG
High altitude
High temperature

37
Q

Aerobic respiration formula

A

Carbs/fats/proteins –> glucose + O2 –> H2O + CO2 + Energy

38
Q

Anaerobic respiration formula

A

Pyruvate –> lactate

39
Q

DLCO: what causes incr and decr?

A

INCR
* asthma
* pulmonary haemorrhage (Wegener’s, Goodpasture’s)
* left-to-right cardiac shunts
* polycythaemia
* hyperkinetic states
* male gender, exercise

DECR
* pulmonary fibrosis
* pneumonia
* pulmonary emboli
* pulmonary oedema
* pHTN
* emphysema
* anaemia
low cardiac output

40
Q

What does O2 administration NOT have an effect in? Poor ventilation or poor perfusion?

A

Shunt: venous blood passes through lung unaltered
Mixed venous + arterial bloods lowers arterial PaO2
Refractory to supplemental inspired O2
Has no effect no nonventilated alveoli
Hb is already nearly fully saturated

41
Q

Effect of lung volume reduction surgery on COPD?

A

Can improve lung function, QOL, exercise tolerance

	○ REDUCES SIZE MISMATCHING BETWEEN HYPERINFLATED LUNGS + CHESTY CAVITY --> OUTWARD CIRCUMFERENTAL PULL ON BRONCHIOLES + elastic pull improved 
	○ Improvement in function of diaphragm + intercostal muscles --> decreases FRC
	○ Improved LV filling + ED dimension
	○ Reduction in lung volumes during exercise (dynamic hyperinflation) --> reduced exertional dyspnea, improved VR + CO (improved exercise tolerance 100%)
	○ Improved endothelial function + blood pressure
	○ Decreased circulating inflamamtory markers
42
Q

Factors which may improve survival in patients with stable COPD?

A
  • smoking cessation - the single most important intervention in patients who are still smoking
    • long term oxygen therapy in patients PaO2 < 60
    • Triple therapy
      Home NIV
43
Q

Narcolepsy

A

Type 1
- Cataplexy + POSITIVE mean sleep latency test OR low CSF hypocretin aka orexin
- Natural history stable
- Almost 100% are HLA DQB1*06:02 positive

Type 2
- NO cataplexy
- POSITIVE MSLT
- Normal CSF hypocretin
Spontaneous improvement - 15%

44
Q

Pathophys of narcolepsy?

A
  • Autoimmune destruction of hypothalamic neurons that produce hypocretin (orexin) –> disordered regulation of arousal + sleep/wake transition
45
Q

What do you see on PSG with Narcolepsy?

A
  • Mean sleep latency < 8 minutes
    • Episodes of REM in atleast 2 of the naps
    • REM sleep within 15 minutes of sleep onset
      Goes straight into REM
46
Q

Pathophys of RLS?

A

Low dopamine
Low Fe

Opioids improve

47
Q

RLS treatment

A

First line
○ Dopamine agonists
§ Pramiprexole
□ Ses: sleepiness, impulsive behaviours, augmentation, paradoxical worsening of RLS (spreading to trunk, during day)

Second line
○ Alpha delta ligands
§ Gabapentin/ pregabalin
Opioids

48
Q

Benefits of cPAP in OSA

A

§ Improves daytime sleepiness, depression, cognitive function, QOL, sys/diastolic BP, HTN, LVEF
§ Reduces MCA risk
§ Increased insulin sensitivity in patients with DM
NO EVIDENCE THAT DECR CV MORTALITY

49
Q

CSA breathing patterns on PSG?

A

Absence of respiratory effort AND airflow for atleast 10 seconds

Cheyne Stokes: Cyclic cresc/ decresc pattern of respiratory flow

50
Q

Treatment for CSA

A

Risk factor modification
○ Cease opioids

CCF
- Optimise heart failure therapy
- NO EVIDENCE CPAP REDUCES MORTALITY
○ Consider trialling CPAP, BiPAP, O2

51
Q

Hypoventilation Syndrome sign on PSG?

A
  • Progressive hypoxemia/ hypercapnia throughout the night
52
Q

Hypoventilation syndrome treatment?

A

CPAP improves survival
○ First choice if significant co-existing OSA
○ Reduces hypercapnia, RHF, pulm HTN, inmproves symptoms

NIV
○ significant hypoventilation/ respiratory failure (acute or chronic)

53
Q

Lights criteria:

A

Pleural fluid protein to serum protein ratio >0.5

Pleural fluid LDH to serum LDH ratio >0.6

Pleural fluid level >2/3 of upper value for serum LDH

54
Q

Most common symptoms of PE?

A

Tachypnea (73%)
Chest pain (pleuritic)- (66% - implies infarction)

55
Q

How to risk stratify PE?

A
  • Troponin
  • RV dysfunction
  • PESI: PE severity index
  • Haem instability
56
Q

Physiologic changes post lung transplant?

A

FVC + FEV1 improve
DLCO improves
Improved functional capacity; however, a persistent exercise limitation remains regardless of the type of surgery or the underlying lung disease

Disease specific changes
○ COPD
§ forced vital capacity (FVC) and forced expiratory volume in 1 second (FEV1) increase
§ Better physical activity
§ Diaphragmatic strength improves
○ CF
§ FEV1 increases
○ ILD
§ VC improves
○ PAH
§ mPAP/ pulmonary vascular resistance/ cardiac index returns to normal

57
Q

ABPA Pathophysiology?

A
  • Complex hypersensitivity reaction in response to colonisation of airways with Aspergillus fumigatus
    ○ Results in IgE and IgG mediated immune responses
    • Almost exclusively occurs in asthma/CF
      ○ ABPA without asthma or CF is a rare occurrence
58
Q

ABPA diagnostic criteria?

A

Predisposing conditions (one must be present):
- Asthma
- Cystic fibrosis (CF)

Obligatory criteria (both must be present):
- Detectable serum IgE levels against Aspergillus fumigatus (>0.35 kU/L)
○ Or Aspergillus skin test positivity
- elevated total IgE

Other criteria (at least two must be present):
- Precipitating serum antibodies to A. fumigatus or elevated Aspergillus fumigatus-specific IgG levels (>27 mg/L)
- Radiographic pulmonary opacities consistent with ABPA (see ‘Imaging’above)
- Total eosinophil count >500 cells/microL in glucocorticoid-naïve patients (may be historical)

59
Q

Most specific test for asthma?
Most sensitive test for asthma?

A

Specific: exercise/mannitol/saline
Sensitive: methylcholine/histamine

RACP 2023 (17 decks)

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