Respiratory Flashcards
1
Q
What is bronchiectasis ?
A
Chronic respiratory disease where chronic inflammation causes permanent bronchial dilation. The dilated bronchi are usually breeding grounds for microbial colonisation and hence results in a cycle of inflammation, then dilation.
2
Q
What are some of the causes of bronchiectasis ?
A
- Idiopathic
- CT disorders like RA, SLE and sarcoidosis.
-Pulmonary disease like COPD and asthma - Cystic fibrosis
- Post infectious like repeated LRTI
3
Q
What are the MAIN clinical features of bronciectasis ?
A
- Daily chronic cough
- Production of large amounts of sputum
- Haemoptysis
- Fatigue
- Rhinosinusitus symptoms like nasal discharge, nasal pressure ect
4
Q
What is likely to be in the history of a patient with bronchiectasis ?
A
- Hx of childhood RTI.
- FHX or congenital conditions like CF
- Smoking history.
5
Q
What is present on clinical examination of a patient with bronchiectasis ?
A
- Finger clubbing ( due to increased secretion of GF)
- Course creps - On inspiration caused by sudden opening and closing of the airways
- Dyspnoea
- Wheeze
6
Q
What investigations are needed in a patient with suspected bronchiectasis ?
A
- O2 sats
- Sputum culture - Pseudomonas aeruginosa (common as it forms protective films to antibiotics). Haemophilus influenza is also common
- Lung function tests - Typically show an obstructive pattern ( FEV1/FVC ratio < 70), but may be normal. Spirometry
- Echo - Can cause pulmonary hypertension.
- Patients ECC may be raised and CRP may be raised in acute exacerbation’s.
7
Q
What is the gold standard of imaging in bronchiectasis ?
A
Gold standard - High resolution CT chest. Will show bronchial dilation with or without airway thickening. Gold standard for diagnosis.
8
Q
What imaging modalities (apart from high contract CT) can be used in diagnosing bronchiectasis ?
A
normal in mild bronchiectasis. In severe disease, there may be tram lines and ring shadows ( thickened bronchial walls and cystic appearance)
Endoscopy, in patients with localised bronchiectasis, that may be caused by foreign body aspiration or bronchial lesion.
9
Q
How is bronchiectasis managed Conservative ?
A
- Pulmonary rehab - ways to offload mucus and clear the airway techniques. Is initiated in patients when first presenting with the symptoms
- Smoking cessation
- Influenza and one off pneumococcal vaccination to protect against any
- Patient education and support groups
10
Q
How is bronchiectasis managed medically ?
A
- Mucolytics - Carcocystine which reduces the viscosity of sputum.
- Corticosteroid - Prednisolone in ABPA
- Long term antibiotics ( azithromycin 3x per week ) in patients that have three or more exacerbation’s per year.
- Bronchodilators - Long term bronchodilator like formoterol/salbutamol in patients with activity limiting SOB.
- Specific condition treatment like in CF.
- Long term oxygen therapy if o2 saturation’s on room air are less than 88 percent.
11
Q
What are the side effects of macrolydes like azithromycin ?
A
side effects such as long QT syndrome, tinnitus and hearing loss.
12
Q
How is bronchiectasis managed surgically ?
A
- Lung resection - Local that is not controlled by optimum medical management.
- Lung transplant - Patients younger than 65, with rapid deterioration despite optimum medical management.
13
Q
What are some of the possible complications of bronchiectasis ?
A
- Respiratory failure
- Massive heamoptysis if there is a rupture of one of the bronchial arteries
- Anxiety and depression.
14
Q
What is the gold standard of investigation diagnosis for ILD ?
A
High resolution CT scan of the thorax.
15
Q
In ILD, what will be present on high resolution CT ?
A
Ground glass appearance
16
Q
If you suspect a patient has ILD, but it is unclear on CT, what is indicated as the next standard of investigation ?
A
- Lung biopsy
17
Q
How is ILD managed ?
A
- Usually, the damage is irreversible.
- Remove/treat the underlying cause
- Home oxygen if hypoxic at rest
- Smoking cessation.
- Pul rehabilitation
- Pneumococcal and flu vaccine
- Advanced life care plan/palliative care if possible
- Lung transplant - in severe cases.
18
Q
What is idiopathic pulmonary fibrosis ?
A
Progressive pulmonary fibrosis with no clear cause. Usually presents at an older age and is more common in men and smokers.
19
Q
What will be spirometry results in a patient with IPF ?
A
FEV1/FVC will be more than 70. TLCO (carrying capacity of CO) will also be reduced
20
Q
What drugs can cause idiopathic pulmonary fibrosis ?
A
Amiodarone (used to treat ventricular arrhythmias) - Can cause IPF as well as thyroid eye disease and corneal deposits.
Nitrofurantoin is also used commonly to treat UTIs and can cause ILD
21
Q
What are the common symptoms of idiopathic pulmonary fibrosis ?
A
- dry cough
- SOB
- Fatigue
- Arthralgia
22
Q
What signs are commonly seen in patients with idiopathic pulmonary fibrosis ?
A
Cyanosis, clubbing, Fine end inspiratory crackles. Reduced chest expansion.
23
Q
What are some of the common complications of IPF ?
A
- T2RF
- Increased risk of lung cancer
- Cor pulmonale
24
Q
What is present on a CXR in patients with idiopathic pulmonary fibrosis ?
A
- Honeycomb appearance on CXR
- Reticulonodular shadowing.
25
How is IPF managed ?
- Smoking cessation
- Pulmonary rehabilitation
- Long term oxygen therapy
26
What drugs can be given in idiopathic pulmonary fibrosis ?
Antifibrotic drugs like pirdenidone (lung transplant in very severe cases)
27
What drugs can cause pulmonary fibrosis ?
- Amiodarone ( anti arrhythmic used in ventricular dysfunction)
- Cyclophosphamide (chemotherapy)
- Methotrexate (can be used in cancer, chrones)
- Nitrofurantoin ( antibiotic that can be used in UTI)
28
What are some common causes of secondary pulmonary fibrosis ?
- Rheumatoid arthritis
- SLE
- Systemic sclerosis
- Alpha 1 antitrypsin deficiency.
29
What is asbestosis ?
Diffuse **interstitial lung fibrosis** that manifests in patients with plural plaque disease usually more than 10 years following the first exposure.
30
What criteria make asbestosis more likely ?
- History of asbestos exposure
- Dyspnoea
- Cough
- Creps on auscultation, finger clubbing, cyanosis, reduced chest expansion
- Obstructive spirometry pattern
- High resolution CT
- Bronchoscopy and biopsy
31
What is present on CXR in a patient with asbestosis ?
- Linear interstitial fibrosis
- Pleural plaques
- Pleural thickening
- Atelectasis
32
How is asbestosis managed ?
- Smoking cessation
- Pulmonary rehabilitation
- Oxygen therapy if the sP02 is less than 89 percent
- Lung transplant
33
What is hypersensitivity pneumonitis ?
HP is a type 3 hypersensitivity reaction to an environmental allergen that causes parenchymal inflammation and destruction.
34
What will be present on bronchoscopy in patients with hypersensitivity pneumonitis ?
then collecting the fluid for testing which will show raised lymphocytes and mast cells.
35
How is hypersensitivity pneumonitis managed ?
Removal of the allergen, steroids and giving oxygen where necessary.
36
What is CAP in comparison to HAP ?
- CAP (outside of hospital)
- HAP ( pneumonia that develops more than 48hrs after hospital admission)
37
What are the most common causes of HAP ?
- Pseudomonas aeruginosa, common in patients with COPD/Bronchiectasis
- Staphylococcal aureus (common in patients with CF)
- Enerobacteria.
38
How does pneumonia commonly present ?
- SOB
- Cough productive of sputum
- Fever
- Haemoptysis
- Pleuritic chest pain (sharp chest pain worse on inspiration)
- Delirium
- Sepsis.
39
What are the signs of pneumonia ?
- Tachypnoea
- Tachycardia
- Hypoxia
- Hypotension
- Fever
- Confusion
40
What is present on auscultation in pneumonia ?
- **Bronchial breath sounds** - Harsh breath sounds on inspiration and expiration caused by consolidation
- **Focal coarse crackles** - air passing through sputum
- **Dullness to percussion**
- **Increased vocal resonance**
41
What system is used to grade severity in pneumonia ?
CURB - 65
42
What does CURB - 65 stand for ?
**C- confusion**
**U - Urea >7**
**R - RR>30**
**B - BP<90 systolic or <60 diastolic**
**65 - 65>age**
43
What CURB - 65 score indicates admission into hospital ?
- Score 0/1: Consider treatment at home
- Score ≥ 2: Consider hospital admission
- Score ≥ 3: Consider intensive care assessment
44
What are the common causative organisms of Pneumonia ?
Streptococcus pneumoniae
Heamophilus influenzae
Mycoplasma pneumoniae
45
What conditions is infection with moraxella catarrhalis pneumonia associated with ?
- Immunocompromised
- COPD
46
What conditions are patients with psudomonas aeurginosa pneumonias associated with ?
- COPD
- Bronchiectasis
47
In what condition does staphylococcus pneumonia commonly invade the airways ?
Cystic fibrosis
48
What should atypical pneumonias be treated with ?
- Macrolides (mycin)
- Tetracyclines (docycycline)
Dont respond to penicillin
49
What are the five atypical pneumonia's ?
- Legions (legionella, infected pool water or air conditioning)
- Psittaci (Chlamydia psittaci, associated with birds)
- M (mycoplasma pneumoniae - can cause erytheme multifome and associated with the young)
- C (chlaymidia pneumonia), school age children
- Q (Coxiella burnetii (Q fever), exposure to animal bodily fluids like a farmer)
50
What does legionella pneumonia cause (biochemically)?
Hyponatraemia
51
What is the most common cause of fungal pneumonia ?
Pneumocytis Jiroverci
52
In what group of patients does Pneumocycitis Jiroveci occur ?
Occurs in the immunocompromised. Commonly in patients with poorly controlled or new HIV or low CD4 count like in HIV
53
How is pneumocycitis jiroveci treated ?
- Treatment - Co-trimoxazole (septrin)
- Patients with low C4 counts are prescribed this anyways in order to protect.
54
How does pneumocycitis Jiroveci present ?
Subtle dry cough without sputum. SOB on exertion and night sweats.
55
Generally, how is mild CAP treated ?
Mild CAP - 5 days of oral antibiotics like amoxicillin or macrolide (clarithromycin)
56
Generally, how is moderate/severe CAP treated ?
Moderate to severe CAP - 7-10 day course of dual antibiotics (amoxicillin and macrolide)
Usually IV and changed to oral prep as symptoms improve.
57
How does pneumonia present on a CXR ?
Consolidation
58
What is the most common cause of CAP ?
Streptococcus pneumonia
59
What is used in patients with CAP and penicillin allergy ?
Clarithromycin
60
What bacteria causes TB ?
Myocobacterium TB bacteria
61
What are the staining characteristics of TB ?
Require a special staining called Zeihl Neelsen stain that turns bacteria bright red against a blue background. Grows acid fast bacilli.
62
What is Miliary TB ?
When the immune system is unable to control the disease causing a disseminated, severe disease.
63
How does TB commonly present ?
- Chronic, gradually worsening symptoms.
- Lethargy
- Fever and nigh sweats
- Cough, with or without haemoptysis.
- Lympandenopathy
- Erythema nodosum
- Spinal pain in spinal TB (potts disease of the spine)
64
What is the mantoux test ?
Looks for a previous immune response to TB by injecting tuberculin into the intradermal space in the forearm.
In duration of 5mm or more = positive result.
65
What is nucleic acid amplification in TB ?
used in patients who are at higher risk of developing complications. Faster than traditional cultures and looks at TB
66
What are interferon gamma release assays (TB) ?
Mix blood sample with TB antigens. If there has previous TB contact, WC will produce IG as part of the immune response and is a positive result. Used in patients that do not have active TB but do have a positive Mantoux test for latent TB.
67
What will be present on CXR in patient with TB ?
- Patchy consolidation
- Plural effusions
- Hiliar lympandenopathy
In reactivated TB, there may be cavitated lesions.
68
What does disseminated milary TB look like on a CXR ?
Look on google. Lots of seeds.
69
How are patients with latent Tb managed ?
- They do not necessarily need treatment, but patients that are at a higher risk of re-activation should be treated with
- Isoniazid and rifampicin for 3 months
- Or Isoniazid (what is it search) for 3 months.
70
What therapy are patients with acute pulmonary TB treated with ?
RIPE
R - Rifampicin (6)
I - Isoniazid (6)
P - Pyrazinamide (2)
E - Ethambutol (2)
71
What are some of the side effects of Rifampicin ?
Red/orange discolouration of secretions and can effect the metabolism of the contraceptive pill
72
What are the side effects of isoniazid (anti TB agent) ?
Can cause peripheral neuropathy
73
What are the side effects of Pyrazinamide ?
Hyperuricaemia and hence gout
Most common cause of hepatotoxicity
74
What are the side effects of Ethambutol ?
Colour blindness and reduced visual acuity.
75
What should prescribed with isoniazid to reduce the chance of peripheral neuropathy ?
Pyrioxine (B6)
76
What is the first line of management of a patient with suspected active TB ?
Quadruple therapy - before waiting for culture
77
What should all patients with Tb be investigated for ?
HIV
78
How is a patient with an acute exacerbation of COPD managed ?
- O2 therapy (aim for 88-92)
- Nebulised bronchodilators like salbutamol and ipratropium.
- Steroids - Hydrocortisone 200mg Iv and prednisone 40mg PO for 7-10 days.
- Antibiotics if there is evidence of infection.
79
What two subtypes is COPD comprised of ?
- Chronic bronchitis and emphysema.
80
What are the clinical features of COPD ?
- Chronic productive cough for at least 3 months in at least 2 consecutive years without other identifiable cause
- Purulent sputum production
- Hypoxia
- Hypercapnia
- Exertional dyspnoea
- Cyanosis ('Blue bloaters')
- Peripheral oedema secondary to cor pulmonale
- Barrel shaped chest and pursed lip breathing
- Excertional dyspnoea
81
What is emphysema ?
Abnormal, irreversible enlargement of the airspaces distal to the terminal bronchioles, reducing the alveolar surface area and effecting gaseous exchange.
Seen in smoking and A1 trypsin deficiency.
82
What are the signs on clinical examination in a patient with COPD ?
- Pursed lip breathing
- Tripod position
- Use of accessory muscles
- Barrel shaped chest
- Hyper-resonant on percussion
- Wheeze on auscultation
- Reduced chest expansion
- Decreased or quiet breath sounds
83
Is COPD a restrictive or obstructive disease and what will be the spirometry pattern ?
- Obstructive
- FEV1/FVC < 0.7
84
What does a lower FEV1 indicate in COPD ?
More severe disease and a greater need for intervention.
85
P pulmonale is an indicator of COPD. What are the signs of P pulmonale on ECG ?
Large P waves in L2,3 and aVF.
86
What is present on CXR in patients with COPD ?
- Hyperinflated chest
-Bullae
-Decreased peripheral vascular markings
- Flattened hemidiaphrams.
87
How is chronic COPD managed ?
1 - SABA and SAMA
2 - patients with persistent exacerbation's but no asthmatic features, add a LABA and LAMA.
2 - In patients with exacerbations and history of asthma, add LABA and inhaled corticosteroid
88
What are the indications for long term oxygen therapy ?
- Pa02 < 7.3 on two readings more than 3 weeks apart and non smokers.
- Pa02 7.3-8 alongside nocturnal hypoxia, polycythaemia, peripheral oedema and pulmonary hypertension.
89
When is long term home oxygen absolutely CI ?
Smokers
90
What are the indications for surgery in patients with COPD ?
Lung volume reduction surgery.
- Upper lobe predominant emphysema
- Fev1> 20 percent of indicated value.
-PaCO2 < 7.3
91
What is the best method of oxygen administration in patients with COPD ?
Due to the risk of CO2 retention, it is best to give patients oxygen in a controlled method like via a venturi mask.
92
What is ARDS ?
Non cardiogenic pulmonary odema and diffuse lung inflammation usually secondary to an underlying illness. There is diffuse alveolar damage with hyaline membrane formation.
Usually 7 or more days after the onset of a lung injury. Patients usually have bilateral alveolar injury as a result of inflammation.
93
What is the most common cause of ARDS ?
Pneumonia.
94
What are some of the side effects of methotrexate (key to remember in respiratory) ?
Patients taking methotrexate for rheumatoid arthritis can develop pulmonary fibrosis and can cause restrictive pattern, exertion dyspnoea and SOB
95
What is acute respiratory distress syndrome ?
Non cardiogenic pulmonary odema and diffuse lung inflammation and is typically due to an underlying illness. Can develop up to 7 days post onset of lung injury.
96
What is the most common cause of ARDS ?
Pneumonia
97
Apart from pneumonia, what are the other common causes of ARDS ?
- Sepsis
- Aspiration
- Pancreatitis
- Transfusion reactions
- Trauma and fractures
- Fat embolism
98
How does ARDS present (including lung sounds)
?
- Acute onset resp failure that fails to resolve with supplemental oxygen.
- Severe dyspnoea
- Tachypnoea
- Confusion
- Pre-syncope
- **Fine bibasal crackles,**
99
What will be present on auscultation in a patient with ARDS ?
Fine bibasal crackles
100
What will be present on CXR in a patient with ARDS ?
Bilateral alveolar infiltrates, without other features of HF (cardiomegaly/kerley B lines)
101
How is ARDS managed ?
Transfer to intensive care.
- Ventilatory support (mechanical support rather than bipap on a low pressure (associated with better outcomes))
- Haemodynamic support
- DVT prophylasis
- Nutritional support
- Repositioning for ulcer prophylaxis
- Antibiotics if there is an infectious cause like in pneumonia or sepsis.
102
What are some of the key features of a life threatening asthma exacerbation ?
- PEF < 33
- SO2 < 92 or PO2 < 8
- Cyanosis
- Hypotension
- Exhaustion
- Altered consciousness
- Silent chest
- Tachyarrhythmias.
103
On auscultation, what is a sign of a severe asthma exacerbation ?
Silent chest
104
What are some of the signs of a severe asthma exacerbation ?
- PEF 33-50 percent
- RR > 25
- HR > 100
- **Inability to complete sentence in one breath**
105
If a patient suffering from an acute exacerbation of COPD has a raised PCO2 on ABG, what is this a sign of ?
Near fatal asthma
106
What criteria required ICU referral in a patient with life threatening asthma ?
- Requires ventilatory support
- Deteriorating PF
- Persisting or worsening hypoxia
- Hypercapnia
- Exhaustion, feeble respiration
- Respiratory arrest
107
What is the immediate management of a patient having an acute asthma exacerbation (non pharmacological)?
- Sit the patient up
- 100 percent O2 via a non rebreathe.
108
What is the immediate management of a patient having an acute asthma exacerbation (pharmacological)?
Nebulised salbutamol (5mg) and ipratropium (0.5 mg). If the patient responds to nebulised salbutamol, they do not need addition of ipratropium.
- **Hydrocortisone** 100mg IV or **prednisolone** 50mg PO
109
What should patients be discharged with post asthma exacerbation ?
Prednisolone 40mg PO for over 5 days post acute asthma exacerbation.
110
How are patients managed pharmacologically if they have a bout of life threatening asthma ?
- Inform the intensive care team
- **Mg sulphate** 2g IV over 20 mins
- **Nebulised salbutamol** every 15 mins.
- IV aminophylline can be given if the patient does not improve with nebulisers.
111
What can be given to a patient who is experiencing an acute asthma exacerbation who is not responding to nebulisers ?
IV aminophylline
112
What type of lung pattern does asthma have ?
obstructive
113
What is the atopic triad ?
- Eczema
- Asthma
- Hay fever
114
What are the symptoms of asthma ?
- Wheeze
- Dyspnoea
- Cough (can be nocturnal)
- Chest tightness
- Dinural variation (worse in the morning)
- Personal/family history of atopy may be present, and symptoms may worsen following excersise or NSAIDS/BB
115
What are the signs on clinical examination in asthma ?
- Tachypnoea
- Hyperinflation of the chest
- Hyper resonance on percussion
- Decreased air entry - SIGN OF SEVERE illness
- Wheeze on auscultation
116
How is asthma managed first line ?
Step 1 - Short acting B2 agonists like salbutamol
117
If salbutamol inhalers fail, what is the next step in the management of asthma ?
Adding a Low dose inhaled corticosteroid like beclomethasone.
118
If asthma is uncontrolled with reliever and preventer, what is the next line of treatment ?
Add long acting B2 agonist like salmeterol. If to no benefit, increase ICS dose (beclamethasone)
119
What is the final line of asthma management ?
Trial oral leukotriene receptor antagonist, high dose steroid and oral B2 agonist.
120
What is inheritance of cystic fibrosis ?
Autosomal recessive
121
If both parents are healthy, one sibling has cystic fibrosis and a second child does not have the disease, what is the likelihood of the second child being a carrier?
2/3, as we know one child has the condition and this child does not have the condition
122
What are the key consequences of cystic fibrosis ?
- Thick pancreatic and bilary secretions causing duct blockages, therefore lack of enzymes in the digestive tract
- Low volume thick airway secretions that reduce airway clearance (leading to increased bacterial colonisations and infection)
- Congenital bilateral absence of the vas deferens ( infertility in males)
123
How is CF screened for at birth ?
Newborn bloodspot test
124
What is the first sign of CF ?
Meconium ileus - The first stool a baby passess is meconium. In 20 percent, the stool is thick and stick, causing it get stuck and obstruct the bowel.
Not passing stool in 24 hours, abdominal distention and vomiting.
125
What are the symptoms of CF is not picked up at birth ?
- Chronic cough
- thick sputum production
- Recurrent RTI
- Steatorrhoea
- Abdominal pain and bloating
- Salty when kissing
- Poor weight and height gain
126
What are some of the physical signs of CF on examination ?
- Low weight/height on growth charts
- Nasal polyps
- Finger clubbing
- Abdominal distention
- Crackles and wheeze on auscultation
- Osteoporosis
127
What are the three key methods for establishing a CF diagnosis ?
- Newborn blood spot testing - heelprick test
- Sweat test
- Genetic testing for the CTFR gene
128
What is the gold standard investigation in CF testing ?
The sweat test - Chloride concentration > 60 mmol/l
129
What are the key common colonisers in CF ?
- Staph aureus and pseudomonas (harder to treat and worsens prognosis)
130
What antibiotic do patients with CF take prophylactically to prevent staph aureus infection ?
Flucoxacilllin
131
What is the general rule for children meeting other children with CF ?
- They should avoid contact due to the risk of spreading Pseudomonas, which is particularly troublesome to get rid of due to resistance and has poor prognosis
132
What can Pseudomonas colonisation be treated with ?
Long term nebulised antibiotics like tobramycin.
133
How is CF managed non pharmacologically ?
- Chest physiotherapy - several times a day to clear mucus and reduce risk of infection
- Excersise
- High calorie diet
- Treat infections as they occur
- Vaccinations against pneumococcus, influenza and varicella.
134
How is CF managed pharmacologically ?
- CREON tablets - In pancreatic insufficiency
- Prophylactic flucoxacillin tablets
- Salbutamol
- Nebulised DNase to break down resp secretions
- Nebulised hypertonic saline.
135
How often are patients with CF monitored ?
- Typically, every 6 months and sputum monitoring for pseudomonas
136
What will be present on CXR in CF ?
- Hyperinflation
- Bronchiectasis
137
A patient presents with chronic sputum production, cough, nasal polyps, clubbing and wheeze on auscultation, what is the most likley diagnosis and what test is most likley to confirm the diagnosis ?
CF
Sweat chloride test 70mmol/L
138
What is the most appropriate treatment of a patient with CF and history of diabeties presenting with steatorrhoea ?
Creon (pancrelipase)
139
A patient presents with copious sputum production and infertility, what is the most likley diagnosis ?
CF
140
What are the risk factors for developing DVT/PE ?
- Immobility
- recent surgery
- Long haul flights
- Pregnancy
- Hormones (oestrogen)
- Malignancy
- SLE
- Thrombophillia
141
What are patients at a high risk of developing a VTE given, in and out of hospital ?
LMWH prophylactic like enoxaparin unless CI like in active bleeding or existing anticoagulation with warfarin or NOAC
- Compression stockings unless CI (PAD)
142
How does a PE present ?
Shortness of breath
Cough with or without blood (haemoptysis)
Pleuritic chest pain
Hypoxia
Tachycardia
Raised respiratory rate
Low grade fever
Haemodynamic instability causing hypotension
- May also be signs of DVT like leg swelling and tenderness
143
What scoring system is used in predicting likleyhood of PE ?
Wells score
144
How is a PE imaged if the wells score indicates PE likley ?
CT pulmonary angio
145
How is a PE imaged if the wells score indicates PE unlikley ?
- Perform D dimer
- If positive = CTPA
146
When is a VQ scan used over a CTPA in patients with suspected PE ?
- Renal impairment
- Contrast allergy
- Risk from radiation
147
What will a VQ scan show in patients with a PE ?
There will be a defect in perfusion as the thrombus blocks blood supply to the lungs.
148
What will be present on ABG in patients with a PE ?
Respiratory alkalosis (tachypnoeic and blow off CO2)
low pO2
149
What is the first line initial management of a PE ?
The initial recommended treatment is apixaban or ribaroxaban
150
What is given to patients in a PE who cannot have a DOAC (like in antiphospholipid syndrome) ?
LMWH like enoxaparin.
151
When should anticoagulation be given in a PE ?
Before confirming diagnosis in patients where DVT/PE is suspected and there is a delay in getting the scan.
152
How long should you continue anti-coagulation in patients with a PE that have an obvious reversible cause ?
3 months then review
153
How long should you continue anti-coagulation in patients with a PE that have an unclear cause, recurrent VTE or there is an irreversible underlying cause like thrombophilia ?
Beyond 3 months, often 6 months in practice.
154
How long should you continue anti-coagulation in patients with a PE that a malignancy ?
6 months then review
155
When is thrombolyisis indicated in a PE ?
In massive PE with haemodynamic compromise.
156
What is the first line of long term treatment of a PE in pregnancy ?
LMWH like enoxaparin.
157
What are some of the options for long term anti-coagulation in a PE ?
Warfarin, NOAC and LMWH
158
What are some examples of anti-thrombolytic agents ?
streptokinase, alteplase and tenecteplase.
159
What are the two methods of thrombolysis ?
Intravenously using a peripheral cannula.
Directly into the pulmonary arteries using a central catheter. This is called catheter-directed thrombolysis
160
What is the most common ECG finding in a PE
Sinus tachycardia and right ventricular strain
161
What does exudative mean ?
High protein count>3g/dL
162
What does transudative mean ?
Lower protein count (<3g/dL)
163
What are some exudative (high protein) causes of a pleural effusion ?
Usually linked to inflammation
- Lung cancer
- Pneumonia
- Rheumatoid arthritis
- TB
164
What are some transudative (low protein) causes of a pleural effusion >
Usually due to fluid shifting into the lungs
- Congestive cardiac failure
- HYpoalbuminaemia
- Hypothyroidism
- Meigs syndrome (RS pleural effusion with ovarian malignancy)
165
What is meigs syndrome ?
RS pleural effusion with ovarian malignancy
166
How does a pleural effusion present ?
- SOB
- Dullness to percussion over the effusion
- Reduced breast sounds
- IN massive effusions, there may be tracheal deviation away from the efffusion
167
What is present on examination in patients with a pleural effusion ?
- Dullness to percussion
- Reduced breath sounds
168
What is present on CXR in a pleural effusion ?
- Blunting of the costophrenic angle.
- fluid in the lung fissures
- large effusions may have a meniscus
Tracheal and mediastinal deviation in massive effusions
169
Can pleural effusions be treated conservative
Yes. Usually in small effusions with treatment of the underlying cause.
170
How are larger effusions treated ?
- Plural aspiration (can recur)
- Chest drain ( can prevent effusion and stop it from coming back)
170
How are larger effusions treated ?
- Plural aspiration (can recur)
- Chest drain ( can prevent effusion and stop it from coming back)
171
What is empyema ?
Infected pleural effusion
172
When should you suspect emphyma ?
Patient with improving pneumonia but new or ongoing fever.
173
What will aspiration show in emphyma ?
- Pus
- Acidic pH (pH<7.2)
- Low glucose
- High LDH
174
How is empyema treated ?
Treated by chest drain to remove the pus and antibiotics.
175
What is broncholitis ?
Inflammation and infection of the bronchioles (smaller airways)
176
When is FEV1 usually reduced ?
If there is an obstruction to the air flow out of the lungs.
177
When is FVC usually reduced ?
Reduced in restrictive disease
178
What FEV1/FVC ratio indicated obstructive disease ?
less than 75 percent
179
What FEV1/FVC ratio indicated restrictive disease ?
Over 75 percent and both are equally reduced
180
What are some examples of restrictive disease shown by spirometry ?
ILD, Neurological like MND, Scoliosis or chest wall deformity and obesity.
181
What are some examples of obstructive disease in spirometry ?
Examples - Asthma and COPD but in asthma there will be reversibility.
182
What is the biggest risk factor for the development of lung cancer ?
Smoking
183
Non small cell lung cancer makes up the majority of the cases of lung cancer. What are the sub-types ?
- Adenocarcinoma (40)
- Squamous cell (20)
- Large cell (10)
- Other types ..
184
What is small cell lung cancer responsible for in comparison to not being responsible in non small cell ?
Contain neurosecretory granules that can release neuroendocrine hormones. This makes SCLC responsible for multiple para-neoplastic syndromes.
185
What is small cell lung cancer responsible for in comparison to not being responsible in non small cell ?
Contain neurosecretory granules that can release neuroendocrine hormones. This makes SCLC responsible for multiple para-neoplastic syndromes.
185
Which type of lung cancer is responsible for paraneoplastic syndromes ?
Small cell lung cancer
186
What is small cell lung cancer responsible for in comparison to not being responsible in non small cell ?
Contain neurosecretory granules that can release neuroendocrine hormones. This makes SCLC responsible for multiple para-neoplastic syndromes.
187
What are the signs and symptoms of lung cancer ?
- SOB
- Cough
- Haemoptysis
- **Finger clubbing**
- Recurrent pneumonia.
- Weight loss
- Lymphandenopathy of the supraclavicular lymph nodes.
188
What is seen on examination of the hands in lung cancer ?
Finger clubbing
189
What is present on CXR in lung cancer ?
- Hilar enlargement
- Peripheral opacity
- Unilateral pleural effusion
- Lung collapse.
190
What is the first line investigation in lung cancer ?
CXR
191
Apart from CXR, what other investigations are used when investigating lung cancer ?
- Contrast enhanced CT scan of the chest to stage the cancer.
- PET-CT - See how metabolically active some of the tissues are (more metabolic activity = increased likelihood of cancer.
- Bronchoscopy with endobronchial USS - USS guided biopsy and identification of tumour.
- Histological diagnosis.
192
What is the first line of treatment in non small cell lung cancer patients where the cancer is isolated to a single lobe ?
Lobectomy with the intention to cure.
(segmetectomy and wedge resection) can also be used.
193
In what type of lung cancer is radiotherapy indicated ?
Early stages of non small cell.
194
When is chemotherapy indicated in small cell lung cancer ?
Can be offered adjuvant to surgery and radiotherapy or as palliative treatment in non small cell lung cancer that is advanced.
195
When is chemotherapy indicated in lung cancer ?
Can be offered adjuvant to surgery and radiotherapy or as palliative treatment in non small cell lung cancer that is advanced.
196
When is chemotherapy indicated in small cell lung cancer ?
Can be offered adjuvant to surgery and radiotherapy or as palliative treatment in non small cell lung cancer that is advanced.
197
What is the treatment for small cell lung cancer ?
Chemotherapy and radiotherapy
198
When is endobronchial treatment indicated in lung cancer ?
Endobronchial treatment with stents of debulking can be used as part of palliative treatment to relieve bronchial obstruction caused by lung cancer.
199
What is mesothelioma ?
Cancer of the mesothelioma cells of the pleura. It is strongly linked to asbestos inhalation. Very large latent period between exposure and development of the cancer and prognosis is poor. Palliative but chemotherapy can improve outcomes.
200
What is mesothelioma ?
Cancer of the mesothelioma cells of the pleura. It is strongly linked to asbestos inhalation. Very large latent period between exposure and development of the cancer and prognosis is poor. Palliative but chemotherapy can improve outcomes.
201
What group and condition is lambert eaton syndrome indicative in ?
In older patients that smoke and have lambert eaton syndrome consider small cell lung cancer.
202
What causes eaton lambert myashenic syndrome ?
- (paraneoplastic syndrome)
**Result of antibodies produced by the immune system against small cell lung cancer cells.**
203
What are the symptoms of eaton myasthenic syndrome ?
- Causes weakness in the proximal muscles
- Can affect the intraoccular muscles causing diploplia.
- Ptosis
- Dry mouth, blurred vision, impotence and dizziness.
- Slurred speech and dysphagia
- Patients with Lambert-Eaton have reduced tendon reflexes. A notable finding is that these reflexes become temporarily normal for a short period following a period of strong muscle contraction. For example, the patient can maximally contract the quadriceps muscle for a period, then have their reflexes tested immediately afterwards, and display an improvement in the response. This is called ***post-tetanic potentiation***
204
What is post tetanic potentiation and what condition is it seen in ?
Patients with Lambert-Eaton have reduced tendon reflexes. A notable finding is that these reflexes become temporarily normal for a short period following a period of strong muscle contraction. For example, the patient can maximally contract the quadriceps muscle for a period, then have their reflexes tested immediately afterwards, and display an improvement in the response.
Small cell lung cancer
205
What type of cancer is lambert eaton myasthenic syndrome associated with ?
Small cell lung cancer
206
A 40 year old patient with a history of IV drug use presents with SOB, a productive cough, and bilateral consolodation on CXR. What is the most likley causative organsim ?
Pneumocystitis jiveorieci (fungal pneumonia)
207
What staining can be used to identify pneumocystitis jiveorieci bacteria ?
Silver stain
208
What is the most common cause or ARDS ?
Sepsis
209
How is secondary pneumothorax treated ?
Chest drain
210
How is secondary pneumothorax treated ?
Chest drain
211
How is a primary pneumothorax treated ?
Aspiration
212
What do very high levels of bicarbonate on an ABG indicate ?
Indicate metabolic compensation. Very high levels take a while to develop
213
What are the symptoms of a lung abscess ?
Foul smelling sputum, fever and history of stroke
214
What is sarcoidosis ?
Multi-system disease characterised by granuloma formation (inflammation of macrophages), resulting in widespread inflammatory changes and complications.
215
What is the typical MCQ question in sarcoidosis ?
The typical MCQ exam patient is a 20-40 year old black woman presenting with a dry cough and shortness of breath. They may have nodules on their shins suggesting erythema nodosum.
216
What is the triad associated with Lofgren syndrome (acute sarcoidosis ?)
Erythema nodusum, bilateral hiliar lymphandenopathy and polyarthralgia.
217
How is lofgren syndrome treated ?
Bed rest and NSAIDS
218
How does sarcoidosis present (resp symtpoms) ?
- Dry cough
- Dyspnoea
- Reduced exercise tolerance
- Mediastinal lymphadenopathy, pulmonary fibrosis and pulmonary nodules.
- Bilateral parotid gland swelling
219
What are the constitutional symptoms of sarcoidosis ?
- Fatigue
- Weight loss
- Low grade fever
220
How can sarcoisosis manifest neurologically ?
- CNS - Nodules, pituitary involvement (DI) and encephalopathy
- PNS - Facial nerve palsy, mononeuritis multiplex.
221
How does sarcoidosis manifest occular ?
- Uveitis
- Conjunctivitis
- Optic neuritis
222
How can sarcoidosis manifest cardiac ?
- Arrhythmias
- Restrictive cardiomyopathy.
- BBB
- Heart block
223
How can sarcoidosis manifest abdominally ?
- Hepatomegaly, splenomegaly and renal stones.
- Liver nodules, cirrosis and cholestasis.
224
How can sarcoidosis manifest dermatological ?
Erythema nodosum and lupus pernio (indurated purple rash on the face)
225
How can sarcoidosis manifest in the bones ?
- Arthralgia
- Arthritis
- Myopathy
226
How can sarcoidosis manifest in the kidneys ?
- Kidney stones due to hypercalcaemia
- Nephrocalcinosis
- Intestinal nephritis
227
What blood tests will be abnormal in patients with sarcoidosis ?
- Raised serum ACE
- Hypercalcaemia
- Raised CRP and immunoglobulins
- Raised serum soluable IL-2
228
What electrolyte will be abnormal in sarcoidosis ?
Hypercalcaemia
229
What will be present on CXR in sarcoidosis ?
- Bilateral hiliar lymphandenopathy
230
What will be present on imaging in sarcoidosis?
- High resolution CT thorax = hilar lymphandenopathy and pulmonary nodules
- MRI = CNS involvement
- PET - Active inflammation in the affected areas.
231
What is gold standard of disgnosis in sarcoidosis ?
Gold standard - Histology from biopsy by bronchoscopy with USS guided biopsy of mediastinal lymph nodes
232
What will be present on biopsy in sarcoidosis ?
Non ceasating granulomas with epithelioid cells.
233
What other investigations are needed to look for systemic manifestations of sarcoidosis ?
- ***U&Es*** for kidney involvement
- ***Urine dipstick*** or urine ***albumin-creatinine ratio*** to look for ***proteinuria*** indicating nephritis
- ***LFTs*** for liver involvement
- ***Ophthalmology*** review for eye involvement
- ***ECG*** and ***echocardiogram*** for heart involvement
- ***Ultrasound*** abdomen for liver and kidney involvement
234
What is the treatment of sarcoidosis in asymptomatic/Mild symptoms ?
No treatment, usually spontaneously resolves
235
What is the first line of treatment of sarcoidosis in patients that are symptomatic with systemic manifestations ?
Oral steroids - First line where treatment is required for between 6 and 24 months. Patients should also be given biphosphonates so prevent osteoporois whilst on long term steroids.
236
What is the second line line of treatment of sarcoidosis in patients that are symptomatic with systemic manifestations ?
Methotrexate or azathiopurine
237
What can severe sarcoidosis progess to and what will be needed to treat it ?
- Pulmonary fibrosis/hypertension
May need a lung transplant
238
What are the presenting symptoms of a fat embolism ?
- Tachycardia, tachypnoea, hypoxia, petechial rash, confusion and retinal haemorrhage
239
What typically causes a fat embolsim ?
Fracture of the long bones like the femur
240
What is a fat embolism ?
Fat embolism occurs when fragments of fat enter the systemic circulation and lode in the small vessels of the lungs or other tissues.
241
How is a fat embolism managed ?
Management is primary supportive
242
What type of gout is associated with hypothyroidism ?
Psudogout (positivley birefringent rhomboid crystals)
243
What type of oxygen therapy is used in type 1 respiratory failure ?
CPAP
244
What type of oxygen therapy is used in type 2 respiratory failure ?
Bipap
245
When is NIV contraindicated ?
Facial burns
Vomiting
Untreated pneumothorax
Severe co-morbidities
Haemodynamically unstable
Patient refusal
246
How does bronchitis commonly present ?
Acute onset of cough, sore throat and rhinorrhoea
Some patients will have a low grade fever and wheeze but not in all cases.
247
How do you compare acute bronchitis vs pneumonia ?
In pneumonia, wheeze, SOB and sputum production tend to be present wheras in bronchitis, they do not necessarily need to be present. There will also be focal chest signs in pneumonia and systemic features tend to be more present.
248
How is acute bronchitis managed ?
- analgesia
- Good fluid intake
- Consider AbX therapy in certain patients
249
When is AbX therapy indicated in bronchitis and what is the first line therapy ?
- patients are systemically unwell, have pre-existing co-morbidities or a CRP of 20-100mg/L (delayed prescription) or immediate if over 100.
First line is **doxycyline** (cannot be used in children or pregnant women).
250
What conditions increase the likleyhood of developing a lung abscess ?
- Aspiration of oropharyngeal secretions
- Lung malignancy
- Pneumonia
251
How does a lung abscess typically present ?
Fever
Productive cough: foul-smelling purulent mucus
Dyspnoea
Lethargy
Night sweats
Weight loss/ cachexia
Finger clubbing
Dental Erosions/ periodontal disease
Localised dull percussion note
Bronchial breathing
252
How is a lung abscess managed ?
- Chest physiotherapy for postural drainage
- Smoking cessation
- Supportive
-ABx - IV therapy for 3 weeks followed by oral Abx for 1-2 months.
253
What drugs are associated with pulmonary fibrosis ?
- Nitrofuratonin
- Methotrexate
-Bleomycin
-Amiodarone.
254
What is the management of a pneumothorax less than 2cm but the patient is symptomatic ?
Discharge and outpatient review in 2 weeks
255
What is the management of a pneumothorax less than 2cm but the patient is symptomatic ?
Aspirate with a 2G needle.
256
A patient presents with fever following pneumonia and a diagnosis of emphyma is suspected. What is the diagnostic standard for empyma ?
PH less than 7.2
257
What are the first line antibiotics in an infective exacerbation of COPD ?
Amoxicillin, doxyclin or clarithromycin
258
What causes characteristic swinging fever ?
Emphyma
259
Indications for long term oxygen therapy ?
PaO2 less than 7.3 on more than 2 occasions more than 3 weeks apart and NON SMOKER
PaO2 7.3-8 and symptomatic
260
What is used in preference to a DOAC in PE in patients with severe renal infufficiency ?
Unfractionated heparin
261
How does OSA present ?
Excessive daytime sleepiness, lack of concentration, snoring, non-refreshing sleep, irritability and personality change.
262
What is the gold standard investigation of OSA ?
Polysomnography.
263
How is OSA managed ?
- Weight loss and smoking cessation
- Alcohol avoidance
- CPAP is gold standard.
264
What is the gold standard of intervention management in OSA ?
Overnight CPAP
