Respiratory Flashcards
Treatment for large pneumothorax
Intercostal catheterisation to remove air
X-ray of lady with 25 pack year history showed left lung base consolidation. Shortness of breath, dry cough, also had 4 weeks leg pain and b/l proximal leg weakness?? further investigations
- Bronchoscopy
- Lung biopsy
- Chest CT
- Sputum cytology
Chest CT
Interpret:
Man with dyspnoea. pH 7.1, CO2 60, HCO3 24
Acidosis
CO2 + H2O <-> H+ + HCO3-
= resp acidosis without metabolic compensation
Girl with airways disease. % change in FEV1 was 20%. 11% reversibility
a) Interstitial lung disease
b) Reversible airway disease
c) Anxiety
d) COPD
Reversible airway disease e.g. asthma
Bronchodilator response = >=10% improvement in FEV1 or FVC relative to predicted value
Lady with history of asthma stopped her salbutamol and fluticasone a month ago because asthma was sweet as. Moved into a new house recently and now asthma not so sweet as. Able to speak in full sentences, RR ?20-30. As well as restarting her inhalers what other medicine is useful for managing this exacerbation?
a. LAMA
b. LABA
c. Oral montelukast
d. Dust mite desensitization
e. Oral prednisone
Oral prednisone
The mainstay of treatment during the acute attack is supplementary oxygen, repeated inhaled bronchodilator and systemic corticosteroids
oung male with asthma comes in with breathlessness. Recently been using salbutamol inhaler more often - several times a week. He has good inhaler use technique. What treatment should be given to control his symptoms?
Low dose inhaled steroid (ICS)
Inhaled steroid + LABA
LABA
High dose steroid
Leukotriene receptor antagonist
Oral steroid
Low dose ICS
Old lady with COPD. increasing SOB, taking Salbutamol prn only - increasing use over last ?6 months. Investigations show the current presentation is not due to infective exacerbation but progression of her COPD. ? next step in management.
Inhaled Fluticasone
Inhaled tiotropium bromide (LAMA)
Theophylline
Prednisone
Montelukast
Inhaled tiotropium bromide (LAMA)
COPD step up for moderate – if SABA not working add LAMA
Management
Intercostal catheterisation
Women came into hospital with symptoms of CAP. Started on antibiotics (IV amoxicillin + PO roxithromycin), improved over 3 days becoming afebrile then on 5th day got worse, became febrile again with mild general headaches, nausea and rigors plus lower L lobe creps, was tachycardic and hypotensive (shock). What is the most likely cause?
Hospital acquired pneumonia
IV line bacteremia
Empyema
Reaction to penicillin
Empyema
20 year old male, heavy smoker came in with pleuritic chest pain and dyspnoea. On exam, dull on percussion R lower lobe. Bronchial breath sounds R middle zone. Absent breath sounds R lower zone. What’s the most likely cause?
R lower lobe collapse
R lower lobe consolidation
Pleural effusion.
Tension pneumothorax
R lower lobe consolidation
note tht bronchial sounds aren’t normal - sounds overly well transmitted to the chest wall as a consequence of increased sound transmission through the consolidated lung parenchyma
IVDU has cough for a while then has a chest x-ray with one abscess and bilateral patchy consolidation. What is the most likely causative organism?
- Aspergillus
- Pneumocystis jirovecii
- Strep pneumoniae
- S. aureus
- Pseudomonas aeruginosa
S. pneumoniae i think
S. aureus is infective endocarditis
Right sided pleural effusion. Albumin 16 in effusion, 36 (N) in blood. What caused the effusion?
- Cardiac failure
- nephrotic syndrome
- bronchial carcinoma
- renal failure
- other cancers
- pneumonia
- pulmonary infarct
this is a transudate not exudate so a systemic balance, something to do with pressure imbalances.
Must be heart failure, as nephrotic syndrome would have LOW albumin.
Man with SOB and COPD as well as a small pleural effusion. On maximal bronchodilators and oral steroids haven’t helped in the past. Not infective. What can you give him to help?
Morphine
Theophylline
Prednisone
Drain the effusion
Morphine can decrease the feeling of SOB
Old lady with COPD. Increasing SOB on a SABA prn only with increasing use over the last ?6 months. Investigations show the current presentation is not due an infective exacerbation, but progression of her COPD. What is the next step in management? (repeat question)
· LAMA +15
· Inhaled steroid
· Montelukast thingy
LAMA!!! For COPD
Man in 80s with history of idiopathic pulmonary fibrosis with background of COPD. Has been on salbutamol and oral steroid have not helped previously. 2 day history of SOB at rest. X-ray shows small pleural effusion at edge of chest. Has SATs of 96% on air What do you do to IMMEDIATELY RELIEVE HIS SOB?
morphine
Theophylline
Oxygen
Oral steroid
Drain effusion
Drainage i think….
20 year old woman came in with a 7 day history of a non-productive cough, fever and dyspnoea. Bilateral patchy consolidation on Xray. What is the most likely cause? (repeat)
CAP
Tb
sarcoidosis
CAP
Guy gets pericardial effusion drained then has asymmetrical chest, decreasing sats and respiratory distress, and then trachea deviated to right. What is the best initial management?
· Left 5th intercostal midaxillary space drain
· Right 5th intercostal midaxillary space drain
· Left 2nd intercostal space midclavicular needle thoracostomy +5
· Right 2nd intercostal space midclavicular needle thoracostomy
· Left 2nd intercostal midaxillary chest drain
In a tension pnemothorax the trachea goes to the NORMAL side. Site = 2nd ICS midclavicular on LEFT side
3 years of cough non-smoker, over winter, green sputum, clubbing- diagnosis?
a. Bronchiectasis
b. Chronic Bronchitis
c. Bronchiolitis
d. COPD
Bronchiectasis
What is true about the association?
It is a two-way relationship
OSA is a RF for stroke
there is no relationship
It is a two-way relationship actually
Lady with cavities on xray, SOB, has positive acid fast bacilli, from vietnam, also
vitamin D deficient. What should you do?
Vit D supplementation, commence TB treatment, quantiferon gold,
mantoux test
Commence TB treatment
30yo patient with wheezing and crackles, blood resutls show raised pCO2 and HCO3
of 30, pH and pO2 are low. diagnosis?
Acute on chronic respiratory failure
I think there is moderate change in pH relative to the increase in CO2.
Patient with CHF, ++ SOB, bilateral respiatory oedema. How should they be transported?
Sitting in ambulance
Which is the most common cancer in asbestos?
Bronchogenic carcinoma
Which organism is associated with CF?
Pseudomonas aeruginosa
Farmer with (+) sputum production in winter every year.
Chronic bronchitis
Patient with breathlessness not alleviated by B agonists or steroids, liver biopsy
positive for acid-stain
alpha-1-antitrypsin deficiency
3 years of cough over winter. Green sputum. Clubbing. What is the diagnosis?
Bronchiecstasis
X-Ray showing consolidation of RLL. Rusty brown sputum - which organism? Also
stated she was an alcoholic.
Strep pneumoniae
Rusty sputum + alcoholic both risk factors.
Man with acute pleuritic pain with SOB. No risk factor. Best investigation?
D-dimer ?PE
Pneumonia not responding to cephalosporins & involving more lobes,
Mycoplasma pneumonia
Patient with obstructive lung function test, non-reversible, with bronchodilators,
chronic cough with sputum
COPD
Only COPD factor that affects prognosis
Smoking cessation
Steroids do not change COPD
SABAS + LAMA for symptoms.
Man has VQ scan which shows mismatch. Next management?
CTPA
want to see where blood is flowing in lungs
Man on ventilator, what would happen if you switch off Bipap?
PCO2 up and pH down
26 year old with asthma. Has had 6 puffs of ventolin with no spacer over 4 hours,
but still RR 24 and struggling, sats 97%
oral prednisone to get on top of attack
Pneumonia + hyponatremia
Legionnaires–> atypical pneumonia with cough, SOB, fever, muscle pains, headaches and low Na+
Low sodium via ADH release! Very unusual.
Male with hemoptysis, TB in 1950, lymph nodes, 50 pack years
bronchogenic carcinom
bronchogenic carcinoma
20 year old woman with asthma. Previously well controlled on salbutamol + fluticasone, but she stopped a month ago due to being symptom free for ages. Moved into a new house recently and now having an asthma flare. Able to speak in full sentences, RR 24, sats 97%. Has had 6 puffs of Ventolin with no spacer over 4 hours. For acute management on exacerbation, what would you add to control this episode?
a) LAMA
b) LABA
c) Oral montelukast
d) Dust mite desensitization
e) Oral prednisone
Oral prednisone
This is mild asthma exacerbation
Man with dyspnoea. Has T2DM and asthma. ABG: pH 7.1 (low), CO2 60 (high), HCO3 24 (N). Interpretation?
Acidosis
Caused by high CO2 = resp acidosis
N HCO3 so no metabolic compensation
Patient with chronic cough with sputum. Spirometry obstructive (FEV1/FVC ratio below LLN). Non-reversible with bronchodilators.
a) Interstitial lung disease
b) Reversible airway disease
c) Anxiety
d) COPD
Both asthma + COPD obstructive pattern, but COPD not reversible
Restrictive patterns: pulmonary fibrosis
60 year old Indian lady with worsening breathlessness due to right pleural effusion. Aspirate of effusion albumin 16 (low), serum albumin 36 (normal). Normal creatinine. What is the cause of her symptoms?
a) Lung cancer
b) Pneumonia
c) Chronic heart failure
d) Nephrotic
e) Nephritic
f) Mesothelioma
g) Metastatic
We know this is a transudate not an exudate. therefore caused by pressure imbalances across the pleura…. CHF (as albumin low in serum in nephrotic!!)
Differentials - cirrhosis
What are causes of exudate?
malignany, infection (parapneumonic), PE
Man in 80s with history of idiopathic pulmonary fibrosis with background of COPD. Has been on salbutamol and oral steroid have not helped previously. 2 day history of SOB at rest. X-ray shows small pleural effusion at edge of chest. Has sats of 96% on air What do you do to immediately relieve SOB?
a) Morphine
b) Theophylline c) Oxygen
d) Oral steroid e) Drain effusion
?morphine… palliative
IPF acute exacerbation
- O2 if <88% sats
- Glucocorticoids
- Palliative strategies reduce SOB – opioid, relaxation, fan?ma
40 year old Asian man, non-smoker, 3 year history of coughing up green phlegm with blood streaks. Worse in winter. Has clubbing and coarse crackles. Diagnosis?
a) Bronchiectasis
b) Chronic Bronchitis
c) Bronchiolitis
d) COPD
Bronchiectasis
Bronchiectasis = recurrent lung infection damaged and enlarged bronchi mucus build in space unable to be cleared by cilia prone to infection
- Sx: chronic productive cough, smelly green-yellow sputum, haemoptysis, clubbing, dyspnoea, usually feel well
- Exacerbations: fever, fatigue, night sweats
X-ray of lady with 25 pack year history showed left lung base consolidation. Shortness of breath, dry cough, also had 4 weeks leg pain and bilateral proximal leg weakness. Further investigations?
a) Bronchoscopy
b) Lung biopsy
c) CT chest
d) Sputum cytology
Sounds like cancer
CT chest, guides a biopsy
Man feels fatigued, falls asleep at work is embarrassed and falls asleep in traffic. Large BMI. Reason?
a) Anaemia
b) Obstructive sleep apnoea
c) Central sleep apnoea
d) Narcolepsy
Obstructive sleep apnoea
Guy with COPD. pH 7.1, HCO3 high, CO2 high, PO2 low.
a) Acute on chronic respiratory failure.
b) Type 1 respiratory failure
c) Type 2 respiratory failure
Hypoxia and hypercapnia
With ACUTE ON CHRONIC
COPD basically gave him chronic hypercapnia (type II) which will have been compensated to maintain normal pH, exacerbation has caused type I failure (hypoxia)
Man has VQ scan which shows mismatch. Next management? a) CTPA
b) CXR c) ECG
CTPA
VQ mismatch could signal a PE
Thoracic duct injury causing SOB. Dx? a) Chylothorax
b) Aspiration pneumonia
Chylothorax = disruption of the thoracic duct leakage of chyle (lipid rich lymph) into pleural space.
Diaphragmatic rupture stomach herniate into chest NG tube in chest
