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Finals > Respiratory > Flashcards

Respiratory Flashcards

1
Q

Asthma - type of hypersentivity?

A

type 1

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2
Q

Investigations for asthma?

A
  1. spirometry (obstructive pattern - FEV1% reduced - <70%)
  2. bronchodilator reversibility test (>12% increase in FEV1%)
    3.FeNO test (>/= 40ppd)
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3
Q

Treatment for asthma?

A
  1. SABA
  2. add ICS
  3. add leukotriene receptor agonist
  4. add LABA

*Start on ladder based on symptoms I.e. if newly diagnosed but asthma symptoms >3 times a week or woken up at night by asthma then start at step 2.

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4
Q

ICS examples?

A

beclometasone,
budesonide,
ciclesonide,
fluticasone,
mometasone.

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5
Q

Leukotriene receptor agonist (LTRA) examples?

A

Monteleukast,
zafirlukast

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6
Q

LABA examples?

A

salmetarol
formeterol
olodetarol

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7
Q

small cell lung cancer % of cases?

A

15%

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8
Q

lung cancer investigations?

A
  1. CXR (Hilar enlargement, peripheral opacity, pleural effusion, collapse)
  2. CT chest, abdo and pelvis - with contrast
  3. bronchoscopy
  4. transthoratic needle aspiration biopsy
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9
Q

small cell lung cancer treatment?

A

Chemotherapy + radiotherapy

if very early then surgery

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10
Q

SCLC or NSCLC - worse prognosis?

A

SCLC

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11
Q

SCLC metastasis to where?

A

brain
bone
liver
adrenal gland

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12
Q

paraneoplastic syndrome in SCLC - which hormones?

A

ADH
ACTH

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13
Q

types of NSCLC?

A
  • adenocarcinoma (most common - 40%)
  • squamous - 20%
  • large cell - 10%
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14
Q

management of NSCLC?

A

Surgery if disease isolated to single area - Lobectomy - 1st line.

radiotherapy - can be curative when early enough.

Chemotherapy - certain patients to improve outcomes or palliative.

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15
Q

pneumothorax, simple (no SOB), <2cm management?

A

conservative - follow up in 2-4 weeks.

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16
Q

When would you consider going straight to chest drain instead of aspiration for pneumothorax?

A

Presence of high-risk characteristics:
- haemodynamic compromise (tension pneumothorax)
- significant hypoxia
- bilateral
- underlying lung disease
- >50 years with significant smoking history

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17
Q

pneumothorax, simple, >2cm, haemodynamically stable, management?

A

oxygen + aspiration (16G-18G cannula)

if this fails - chest drain

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18
Q

Tension pneumothorax manegement?

A

oxygen + needle decompression (2nd intercostal space - mid clavicular line) - once pressure relived then chest drain

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19
Q

Complication of pneumothorax and why?

A

cardiac arrest - due to increased intrathoracic pressure causing reduced venous return.

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20
Q

Additional long-term management options for asthmatics?

A
  • yearly flu jab
  • annual asthma review
  • asthma care plan
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21
Q

PEFR Cut offs in acute asthma?

A

moderate - 50 - 75%
severe - 33-50%
life - threatening - <33%

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22
Q

moderate acute asthma treatment?

A
  1. salbutamol nebs 5mg PRN
  2. Ipratropium bromide nebs
  3. steroids, oral prednisolone, IV hydrocortisone (5DAYS)
  4. antibiotics if sign of infection
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23
Q

severe acute asthma treatment?

A

same as moderate + IV aminophyline + consider iv salbutamol

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24
Q

life threatening asthma treatment?

A

same as severe + IV magnesium sulphate + admit to HDU.

intubation is worse cases

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25
Q

investigations for COPD?

A

Spirometry - obstructive but no reversibility
FBC
CXR

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26
Q

What are the FEV1 cut offs for staging of severity of COPD?

A

stage 1 - >80% (mild)
stage 2 - 50 -79% (moderate)
stage 3 - 30-49% (severe)
stage 4 - <30% (very severe)

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27
Q

chronic treatment for COPD (non asthmatic )?

A
  1. SABA or SAMA
  2. LABA + LAMA
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28
Q

chronic treatment for COPD (asthmatic )?

A
  1. SABA or SAMA
  2. LABA + ICS
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29
Q

Prophylactic antibiotic of choice for COPD?

A

azithromycin

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30
Q

Acute management of COPD?

A
  1. steroids (oral prednisolone, IV hydrocortisone)
  2. inhalers / nebs
  3. antibiotics if infection signs
  4. chest physio
    if severe - IV aminophylline.
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31
Q

What is cor pulmonale?

A

right heart failure secondary to lung disease - caused by pulmonary hypertension as result of hypoxia.

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32
Q

Non-pharmocological management of COPD?

A
  1. stop smoking
  2. pneumococcal + flu vaccines
  3. pulmonary rehab
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33
Q

what might you add if someone with COPD is still breathless after maximum treatment?

A

oral theophylline
or
mucolytic therapy (carbocisteine)

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34
Q

what is bronchiectasis?

A

chronic dilation of the airways

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35
Q

management of bronchiectasis?

A
  • Physical training (inspiratory muscle training)
  • Postural drainage
  • Antibiotics for exacerbations
  • Bronchodilators (not commonly)
  • Immunisations
  • Surgery in selected cases
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36
Q

Antibiotic of choice for acute bronchitis?

A

oral doxycyline

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37
Q

When do you consider antibiotic therapy for acute bronchitis?

A
  • systemically very unwell
  • pre-existing co-morbidities
    -CRP 20-100 (delayed prescription)
    -CRP >100
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38
Q

sleep apnoea diagnostic test?

A

polysomnography (sleep study)

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39
Q

sleep apnoea management?

A
  1. weight loss / cut down on alcohol / stop smoking
  2. CPAP
  3. surgery (uvulopalatopharyngoplasty (UPPP).)
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40
Q

indications for steroids in sarcoidosis?

A
  • chest x-ray stage 2 or 3 disease who are symptomatic
  • hypercalcaemia
    -eye, heart or neuro involvement
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41
Q

classical examination findings in COPD?

A

hyper-reasonant percussion
hyperinflated lungs
use of accessory muscles
pursed breathing

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42
Q

Lung cancer associated with non-smokers?

A

adenocarcinoma

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43
Q

acute management of PE?

A

ABCDE

DOAC e.g. apixiban/ rivaroxaban
OR
LMWH (if DOAC unsuitable or in Antiphosphlipid syndrome) e.g. enoxoparin/delteparin

thrombolysis (Alteplase/streptokinase/tenecteplase) if patient haemodynamically unstable or massive PE

anticoagulation

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44
Q

Transudate pleural effusion protein level?

A

<30g/L

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45
Q

Exudate pleural effusion protein level?

A

> 30g/L

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46
Q

Investigations for pleural effusion?

A

PA CXR
Ultrasound
contrast CT - to investigate underlying cause
pleural aspiration

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47
Q

Low glucose in pleural fluid findings suggestive of?

A

RA or TB

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48
Q

Raised amylase in pleural fluid findings suggestive of?

A

pancreatitis or oesophageal perforation

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49
Q

heavy blood staining in pleural fluid finding suggestive of?

A

mesothelioma, pulmonary embolism, tuberculosis

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50
Q

Exudative causes of pleural effusion?

A
  • Infection - pneumonia / TB
  • malignancy - bronchial carcinoma, mesothelioma or metastases
  • inflammatory conditions - rheumatoid arthritis, lupus, or acute pancreatitis.
  • Pulmonary infarct (for example secondary to a pulmonary embolism) and trauma.
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51
Q

Transudative causes of pleural effusion?

A
  • Congestive heart failure
  • hypoalbuminaemia
  • hypothyroidism
  • Meig’s syndrome (right sides pleural effusion with ovarian malignancy)
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52
Q

Transudative plueral effusion is more likely to be bilateral/unilateral?

A

bilateral

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53
Q

Exudative plueral effusion is more likely to be bilateral/unilateral?

A

Unilateral

54
Q

What is empyema?

A

pus in pleural space (infected pleural effusion)

55
Q

PaCO2 > 6.0 kPa suggests?

A

respiratory acidosis (or respiratory compensation for a metabolic alkalosis)

56
Q

PaCO2 < 4.7 kPa suggests?

A

respiratory alkalosis (or respiratory compensation for a metabolic acidosis)

57
Q

Bicarbonate < 22 mmol/l (or a base excess < - 2mmol/l) suggests?

A

a metabolic acidosis (or renal compensation for a respiratory alkalosis)

58
Q

Bicarbonate > 26 mmol/l (or a base excess > + 2mmol/l) suggests?

A

metabolic alkalosis (or renal compensation for a respiratory acidosis)

59
Q

What does the ‘ROME’ mnemonic for ABG’s refer to?

A

Respiratory = opposite
(low pH + high PaCO2 i.e. acidosis, or
high pH + low PaCO2 i.e. alkalosis)

Metabolic = equal
(low pH + low bicarbonate i.e. acidosis, or
high pH + high bicarbonate i.e. akalosis)

60
Q

Risk factors for PE?

A

Immobility
Recent surgery
Long haul flights
Pregnancy
Hormone therapy with oestrogen
Malignancy
Polycythaemia
Systemic lupus erythematosus
Thrombophilia

61
Q

Scoring system for predicting likelihood of PE/DVT?

A

WELLS

62
Q

If PE is likely on the WELLS score then what investigation?

A

CT pulmonary angiography

63
Q

If PE is ‘less likely’ on the Wells score then what investigation?

A

D-dimer and if +ve then CT angiography

64
Q

PE ABG result?

A

Respiratory alkalosis

65
Q

Acute bronchitis, CRP >100 management?

A

doxycycline unless pregnant then amoxicillin

66
Q

Cystic fibrosis inheritance type + which gene affected?

A

autosomal recessive

CF transmembrane conductance regulator (CFTR) gene

67
Q

How is cystic fibrosis diagnosed?

A

Neonatal heel prick day between day 5 and day 9

Sweat test: sweat sodium and chloride >60mmol/L

Faecal elastase: this can provide evidence for abnormal pancreatic exocrine function.

Genetic screening: This can identify CF mutations

68
Q

Common organisms in bronchiectasis?

A

Haemophilus influenzae (most common)
Pseudomonas aeruginosa
Klebsiella spp.
Streptococcus pneumoniae

69
Q

Lung cancer extra-pulmonary manifestations?

A
  • recurrent laryngeal nerve palsy
  • phrenic nerve palsy
  • superior vena cava obstruction
  • Horner’s syndrome
  • syndrome of inappropriate ADH
  • cushing’s syndrome
  • Lambart eaton myasthenic syndrome
70
Q

Lung cancer associated with asbestos?

A

mesothelioma

71
Q

Definition of hospital acquired pneumonia?

A

Pneumonia which develops >48hrs after hospital admission

72
Q

What is the pneumonia scoring system and what does it consist of?

A

C - confusion
U - Urea >7
R - RR>/= 30
B - BP <90 systolic or </= 60 diastolic
65 - age =/>65y

if >1 then consider admission

73
Q

Common causes of pneumonia?

A

Streptococcus pneumoniae (50%)
Haemophilus influenzae (20%)

74
Q

Pneumonia in immunocompromised patient / chronic pulmonary disease likely cause?

A

Moraxella catarrhalis

75
Q

Pneumonia in patient with CF or bronchiectasis likely cause?

A

Haemophilus influenzae - most common cause.
Pseudomonas aeruginosa

Staphylococcus aureus - CF

76
Q

pneumonia after travel + hyponatraemia - most likely cause?

A

Legionella pneumophila (Legionnaires’ disease)

77
Q

Pneumonia + erythema multiforme (‘target lesions’) + neurological symptoms - likely cause?

A

Mycoplasma pneumoniae

78
Q

Pneumonia after animal contact - likely cause?

A

Coxiella burnetii

79
Q

Pneumonia after contact with infected birds - likely cause?

A

Chlamydia psittaci

80
Q

Treatment for atypical pneumonia?

A

macrolides (e.g. clarithomycin), fluoroquinolones (e.g. levofloxacin) or tetracyclines (e.g. doxycycline).

81
Q

Treatment for fungal (Pneumocystis jiroveci) pnuemonia?

A

Co-trimoxazole

82
Q

How does Pneumocystis jiroveci pneumonia usually present?

A
  • immunocompromised patient
    dry cough without sputum
    SOB on exertion
    night sweats
83
Q

Investigations for pneumonia?

A

CXR
FBC
U&E’S
CRP

If moderate/severe then:
sputum culture
blood culture
Legionella and pneumococcal urinary antigens

84
Q

Investigations for interstitial lung disease?

A

High resolution CT - shows ‘ground glass’ appearance.

85
Q

Treatment of idiopathic pulmonary fibrosis?

A

Pirfenidone - antifibrotic and anti-inflammatory
Nintedanib - monoclonal antibody targeting tyrosine kinase

86
Q

Prognosis of Idiopathic pulmonary disease?

A

poor - life expectancy 2-5years

87
Q

Medications which cause drug-induced pulmonary fibrosis?

A
  • Amiodarone
  • Cyclophosphamide
  • Methotrexate
  • Nitrofurantoin
88
Q

Secondary pulmonary fibrosis can occur secondary to which conditions?

A
  • Alpha-1 antitripsin deficiency
  • Rheumatoid arthritis
  • Systemic lupus erythematosus (SLE)
  • Systemic sclerosis
89
Q

What is hypersensitivity pneumonitis?

A

AKA extrinsic allergic alveolitis

Type III hypersensitivity reaction to an environmental allergen that causes parenchymal inflammation and destruction in people that are sensitive to that allergen.

90
Q

Investigations for hypersensitivity pneumonitis?

A

Bronchoalveolar lavage - collecting cells from the airways during bronchoscopy by washing the airways with fluid then collecting that fluid for testing.

This shows raised lymphocytes and mast cells in hypersensitivity pneumonitis.

91
Q

Management of hypersensitivity pneumonitis?

A
  • remove the allergen
  • give oxygen
  • steroids
92
Q

Examples of specific causes of hypersensitivity pneumonitis (4)?

A

Bird-fanciers lung - bird droppings
Farmers lung - mouldy spores in hay
Mushroom workers’ lung - mushroom antigens
Malt workers lung - mould on barley

93
Q

Examples of conditions which can be caused by asbestos?

A
  • Lung fibrosis
  • Pleural thickening and pleural plaques
  • Adenocarcinoma
  • Mesothelioma
94
Q

Management of mesothelioma?

A

Palliative chemotherapy

very poor prognosis - median survival is 8-14 months

95
Q

Treatment of empyema?

A

Chest drain + antibiotics

96
Q

Treatment of pleural effusion?

A
  • Conservative - if small
  • pleural aspiration - may temporarily relieve symptoms but may come back
  • chest drain
97
Q

Which criteria to distinguish exudative and transudative causes of pleural effusion?

A

Light’s criteria

98
Q

Investigation for PE if patient has renal impairment, contrast allergy or at risk of radiation?

A

Ventilation-perfusion (VQ) scan

99
Q

How long do you continue anti-coagulation for after a PE?

A

3 months - if obvious cause
6 months - cause unclear or irreversible cause (e.g. thrombophilia, cancer)

100
Q

Causes of pulmonary hypertension (5 groups)?

A

Group 1 – Primary pulmonary hypertension or connective tissue disease such as systemic lupus erythematous (SLE)

Group 2 – Left heart failure usually due to myocardial infarction or systemic hypertension

Group 3 – Chronic lung disease such as COPD

Group 4 – Pulmonary vascular disease such as pulmonary embolism

Group 5 – Miscellaneous causes such as sarcoidosis, glycogen storage disease and haematological disorders

101
Q

Investigations for pulmonary hypertension?

A

ECG
CXR
raised NT-proBNT
echo

102
Q

Management of pulmonary hypertension?

A

Primary:
- IV prostanoids (e.g. epoprostenol)
- Endothelin receptor antagonists (e.g. macitentan)
- Phosphodiesterase-5 inhibitors (e.g. sildenafil)

103
Q

What is sarcoidosis?

A

Granulomatous inflammatory condition. Granulomas are nodules of inflammation full of macrophages.

104
Q

How does sarcoidosis present / which organs affected?

A

LUNGS (90%)
- mediastinal lymphadenopathy
- Pulmonary fibrosis
- pulmonary nodules

SYSTEMIC:
- fever
- fatigue
- weight loss

LIVER (20%)
- liver nodules
- cirrhosis
- cholestasis

EYES (20%)
- uveitis
- conjunctivitis
- optic neuritis

SKIN (15%)
- erythema nodosum
- lupus pernio

HEART (5%):
- BBB
- heart block
- myocardial muscle involvement

KIDNEY (5%)
- kidney stone (hypercalcaemia)
- nephrocalcinosis
- interstitial nephritis

CNS (5%)
- pituitary involvement
- encephalopathy
- facial nerve palsy

BONES (2%)
- arthralgia
- arthritis
- myopathy

105
Q

Which is Lofgren’s syndrome?

A

This is a specific presentation of sarcoidosis. It is characteristic by a triad of:

Erythema nodosum
Bilateral hilar lymphadenopathy
Polyarthralgia (joint pain in multiple joints)

106
Q

Investigations for sarcoidosis?

A
  • raised serum ACE - screening test
  • hypercalcaemia - key finding
  • raised serum soluble IL-2 receptor
  • raised CRP
  • raised immunoglobulins
  • CXR
  • CT
  • histology from biopsy (bronchoscopy) - GOLD STANDARD
107
Q

Histological appearance of sarcoidosis?

A

non-caseating granulomas with epithelioid cells.

108
Q

Management of sarcoidosis?

A
  • Conservative - first line in patients with no or mild symptoms.
  • Oral steroids - first line where treatment is required (between 6 and 24 months course) + bisphosphonates
  • methotrexate or azathioprine - 2nd line
109
Q

What is obstructive sleep apnoea?

A

Collapse of the pharyngeal airway during sleep.

110
Q

What is used to assess symptoms of sleep apnoea?

A

The Epworth Sleepiness Scale

111
Q

What is ARDS?

A

Acute respiratory distress syndrome (ARDS) is defined as non-cardiogenic pulmonary oedema and diffuse lung inflammation, typically secondary to an underlying illness. The pathophysiology includes diffuse alveolar damage with hyaline membrane formation.

acute resp failure within 7 days of the onset of lung injury

112
Q

Causes of ARDS?

A

-Pneumonia (most common cause)
-Sepsis
-Aspiration
-Pancreatitis
-Transfusion reactions
-Trauma and fractures
- Fat embolism

113
Q

Management of ARDS?

A

Transfer to ITU

Ventilatory support - a low tidal volume is associated with better outcomes.

Haemodynamic support to maintain mean arterial pressure >60 mmHg.

DVT prophylaxis.

Nutritional support with enteral/parenteral means if necessary.

Regular repositioning of patient for pressure ulcer prophylaxis.

Note that antibiotics need only be administered if an infectious cause for the ARDS is identified (such as pneumonia or sepsis).

114
Q

Investigations for bronchiectasis?

A
  • spirometry - obstructive
  • sputum culture
  • CXR
  • High-resolution CT - diagnostic
  • bronchoscopy
115
Q

Management of CF?

A

Infective exacerbations - antibiotics, bronchodilators, neb mucolytics

pancreatic insufficiency - insulin replacement, exocrine enzymatic replacement (creon), vitamin A,D,E,K

abnormal LFT - ursodeoxycholic acid

116
Q

What is Horner’s syndrome?

A

Characterised by ptosis, miosis (small pupil ) with or without anhydrosis (loss of sweating on one side of face), enophthalmos (sunken eye)

Can be caused by pancoast tumour, stroke or carotid artery dissection

117
Q

Definition of Type 1 and Type 2 respiratory failure?

A

Type 1 Respiratory Failure = PaO2 <8 kPa; PaCO2 Normal

Type 2 Respiratory Failure: PaO2 < 8 kPa; PaCO2> 6 kPa

118
Q

What is Type 1 respiratory caused by?

A

Due to a ventilation- perfusion (V/Q) mismatch. The volume of air passing in and out of the lungs is comparatively smaller than the volume of blood perfusing the lungs.

Causes include asthma, congestive cardiac failure, PE, pneumonia, pneumothorax.

119
Q

What is Type 2 respiratory caused by?

A

Due to alveolar hypoventilation. This means that the lungs fail to effectively oxygenate and blow off carbon dioxide.

Causes:
- Obstructive lung disease
- restrictive lung disease
- depression of resp system
- neuromuscular disease
- thoracic wall dsiease

120
Q

What is tuberculosis caused by?

A

Mycobacterium tuberculosis.

121
Q

What is primary, secondary and miliary TB?

A

Primary - Bacteria is engulfed by macrophages and localised in hilar lymph nodes where it is eliminated or encapsulated by a barrier of granulation tissue (dormant state)

Secondary - active TB (usually in immunocompromised patients) - usually in apex of lungs but can spread.

Miliary - when patient is unable to contain primary infection and it disseminates into bloodstream

122
Q

Investigations for TB?

A
  • CXR
    -sputum smear - 3 samples, stained with ziehl-Neelsen or auramine staining
    -sputum culture - GOLD STANDARD, can take 1-3 weeks.
  • Mantoux test - screening test - checks for latent disease also.
123
Q

Management of TB?

A

Isoniazid, rifampicin, ethambutol, and pyrazinamide for 2 months, then Isoniazid and rifampicin for a further 4 months.

124
Q

Most important side effects of TB drugs?

A

Isoniazid - peripheral neuropathy, liver toxicity
Rifampicin - Liver toxicity, hepatic enzyme inducer, turns bodily fluids red/orange
Ethambutol - visual disturbance
Pyrazinamide - liver toxicity

125
Q

Management of allergic rhinitis?

A
  • allergen avoidance
  • mild/moderate - oral/intranasal antihistamines
  • moderate/severe persistant symptoms - intranasal corticosteroids
126
Q

Management of influenza?

A
  • Largely supportive (analgesia, antipyretic, fluids, oxygen)
  • Antiviral treatment with neuraminidase inhibitors e.g. Oseltamivir (‘Tamiflu’)
  • Infection control and respiratory isolation to prevent onward transmission
127
Q

Cancers which commonly metastasise to the lungs?

A

breast
colon
rectum
head and neck
kidney, testicular
uterine
lymphomas.

128
Q

When would you offer long-term oxygen therapy for COPD?

A

To patients with a pO2 of < 7.3 kPa or to those with a pO2 of 7.3 - 8 kPa and one of the following:
- secondary polycythaemia
- peripheral oedema
- pulmonary hypertension

129
Q

Which scale is used to assess severity of COPD?

A

MRC Dyspnoea Scale

130
Q

PE + renal impairment - investigation of choice?

A

V/Q perfusion scan

131
Q

Indications for thoracotomy in haemothorax?

A

> 1.5L blood initially or losses of >200ml per hour for >2 hours

Finals (18 decks)

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