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MRCP PART 1 > Respiratory > Flashcards

Respiratory Flashcards

1
Q

Most common cause of occupational asthma?

A

Isocyanates

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2
Q

Most appropriate management?

Symptomatic pneumothorax + high-risk features (e.g., underlying lung disease)

A

Chest drain

High-risk characteristic

Asymptomatic regardless of size - conservative

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3
Q

High-risk features of pneumothorax

A
  • haemodynamic compromise (suggesting a tension pneumothorax)
  • significant hypoxia
  • bilateral pneumothorax
  • underlying lung disease
  • ≥ 50 years of age with significant smoking history
  • haemothorax
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4
Q

Causative organism of malt workers’ lungs?

A

Aspergillus clavatus

A type of extrinsic allergic alveolitis (EAA, also known as hypersensiti

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5
Q

Causes of raised TLCO?

A
  • Pulmonary hemorrhage (the carbon monoxide is taken up by free blood in the airways)
  • Asthma
  • Left-to-right cardiac shunts
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6
Q

Late stage treatment of alpha 1-antitrypsin deficiency

A

Lung volume reduction surgery

!! Why are you trying to expand a hyperinflated lung ??

  • Lung volume reduction surgery removes the worst affected part of the lungs in order to improve airflow and alveolar gas exchange in the remaining portion of the lung.
  • Similar to late stage COPD
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7
Q

Mechanism of hypercalcemia in sarcoidosis

A

increased activity of 1α hydroxylase produced by the sarcoid macrophages → increased calcitriol

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8
Q

Next step in COPD pt who remains breathless despite using SABA/SAMA + no asthma/steroid responsive features

A

add a LABA + LAMA

  • ICS is next step for asthma
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9
Q

What are steroid responsive features?

A
  • previous dx of asthma or of atopy
  • a higher blood eosinophil count
  • substantial variation in FEV1 over time (at least 400 ml)
  • substantial diurnal variation in peak expiratory flow (at least 20%)
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10
Q

Lung cancer in smokers?
CXR findings?

A

Squamous cell

CXR: Cavitating lesions

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11
Q

Asbestosis vs Mesothelioma
Which one is related to duration of exposure?

A

Asbestosis

  • The severity of asbestosis (lower lobe fibrosis) is related to the length of exposure.
  • This is in contrast to mesothelioma (malignancy) where even very limited exposure can cause disease
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12
Q

Histologic feature of lungs mets secondary to chondrosarcoma or osteosarcoma

A

Calcification

*

  • Calcification in lung metastases is uncommon except in the case of chondrosarcoma or osteosarcoma
  • cavitation = sqamous cell carcinoma
  • Haemorrhagic pulmonary metastases = choriocarcinoma and angiosarcoma.
  • Miliary pattern of metastases = renal cell carcinoma and malignant melanoma
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13
Q

Fibrosis predominately affecting the lower zones of lung?

A
  • idiopathic pulmonary fibrosis
  • most connective tissue disorders (except ankylosing spondylitis) e.g. SLE
  • drug-induced: amiodarone, bleomycin, methotrexate
  • asbestosis
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14
Q

Predominant location of methotrexate-induced lung fibrosis?

A

Lower zone

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15
Q

Causes of upper zone fibrosis?

A

Acronym for causes of upper zone fibrosis:

CHARTS
C - Coal worker’s pneumoconiosis
H - Histiocytosis/ hypersensitivity pneumonitis
A - Ankylosing spondylitis
R - Radiation
T - Tuberculosis
S - Silicosis/sarcoidosis

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16
Q

Asthma not controlled with a SABA + ICS

Next step in management?

A

Add a leukotriene-receptor antagonist (eg, montelukast)

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17
Q

Epistaxis, sinusitis, coryzal symptoms and nose deformity
Most likely diagnosis?

A

Granulomatosis with polyangiitis (Wegener’s granulomatosis)

  • Involvement of the upper respiratory tract (nose and sinuses etc)
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18
Q

Poorly controlled asthma and constitutional sxs (fever, malaise, cough) in an asthma patient started on LTRA (montelukast) + raised white cell count and lung infiltrates
Most likely diagnosis?

A

Churg-Strauss syndrome (eosinophilic granulomatosis with polyangiitis)
*

  • Montelukast is used in patients with poorly controlled asthma, who are already established on inhaled corticosteroids and long-acting β2-agonists.
  • The drug has been associated with the unmasking of eosinophilic granulomatosis with polyangiitis
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19
Q

Retired roofer with multiple calcified plaques in lower zone of lungs and no consolidations on CXR

Next step in management?

A

No follow-up required
~~~
* In the context of his profession as a retired roofer, these are likely to represent pleural plaques as a consequence of asbestos exposure. They are benign and** do not require specific follow-up**
* HRCT would be indicated if lung nodules were present

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20
Q

Which part of the lung does Klebsiella pneumonia affect?

A

Upper lobe
~~~
associated with aspiration pneumonia

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21
Q

Differences in PFT for kyphoscoliosis and pulmonary fibrosis?

A
  • Similarities: Restrictive pattern (reduced FEV1 and FVC values but a normal or increased FEV1/FVC ratio)
  • Differences: TLCO is decreased in pulm fibrosis
21
Q

Common examples of obstructive lung diseases?

A

Asthma, COPD, bronchiectasis & bronchiolitis oliterans

22
Q

When are steroids indicated in sarcoidosis?

A

Neurosarcoidosis and Hypercalcemia
~~~
Neurosarcoidosis is manifested as unilateral or bilateral facial nerve palsy

Steroid indications in sarcoidosis
* patients with chest x-ray stage 2 or 3 disease who are symptomatic. Patients with asymptomatic and stable stage 2 or 3 disease who have only mildly abnormal lung function do not require treatment
* hypercalcaemia
* eye, heart or neuro involvement

23
Q

What shifts oxygen dissociation curve to the left?

A
  • Low 2,3-DPG
  • Low pCO2
  • Low [H+] (alkali)
  • Low temperature
  • Carboxyhaemoglobin, HbF, methememoglobin
    ~~~
  • shifts to left (binds tightly) = for given oxygen tension there is increased saturation of Hb with oxygen i.e. decreased oxygen delivery to tissues
  • shifts to right (donatesss) = for given oxygen tension there is reduced saturation of Hb with oxygen i.e. enhanced oxygen delivery to tissues
24
What shifts oxygen dissociation curve to the **right**?
**Raised** 2,3-DPG **Raised** pCO2 **Raised** [H+] - (acidosis) **Raised** temperature ~~~ * shifts to left (binds tightly) = for given oxygen tension there is increased saturation of Hb with oxygen i.e. decreased oxygen delivery to tissues * shifts to right (donatesss) = for given oxygen tension there is reduced saturation of Hb with oxygen i.e. enhanced oxygen delivery to tissues
25
Asthma patients on **SABA + ICS** but not well controlled. ***Next step?***
Add LTRA ~~~~ (not LABA, e.g., salmeterol)
26
What are signs of **life-threatening asthma attack**?
* PEFR<33% best or predicted * O2 sat <92% * Normal pCO2 * Silent chest * Bradycardia, hypotension * Confision or coma ~~~ The PEFR is a measure of how fast someone can blow out air after maximal inhalation and it is usually reduced during an asthma exacerbation due to bronchial constriction.
27
Most common infective cause of COPD exacerbations? (1)
Haemophilus influenzae (most common cause)
28
Common causes (3) of infective exacerbation of COPD?
* Haemophilus influenzae (most common cause) * Streptococcus pneumoniae * Moraxella catarrhalis
29
COPD patients are prone to developing type (x) respiratory failure?
2 ~~~ (hypercapnia)
30
COPD exacerbation complicated with **type 2 respiratory failure** despite medical therapy? ***Next step?***
NIV - BiPAP ~~~~~~~ **Typically used initial settings:** * Expiratory Positive Airway Pressure (**EPAP**): 4-5 cm H2O * Inspiratory Positive Airway Pressure (**IPAP**): RCP advocate 10 cm H20 whilst BTS suggest 12-15 cm H2O
30
In patients who are diagnosed with lung cancer, what percentage of recent chest x-rays were reported as normal?
10%
31
Function of alpha-1 antitrypsin?
Protease inhibitor of neutrophil elastase ~~~~~ * Deficiency can cause emphysema and cirrhosis.
32
What is **not** an indication of NIV?
**Bronchiectasis** ~~~~~ * limited by excessive secretions
33
Upper/mid zone fibrosis ***Cause***?
Extrinsic allergic alveolitis (EAA) ~~~~~ * no eosinophilia * treatment: avoid precipitating factors or oral steroids
34
Bronchoconstriction (wheeze, cough, dyspnea) + recurrent infections + eosinophilia **Most likely diagnosis**
ABPA (Allergic Bronchopulmonary Aspergillosis)
35
**Management** of ABPA?
**Oral glucocorticoids** ~~~~~ * itraconazole is sometimes introduced as a second-line agent
36
SVC obstruction + **non-small cell lung cancer** **Can surgery be proceeded?**
**NO** ~~~~~ **Surgery contraindications:** * assess general health * stage IIIb or IV (i.e. metastases present) * FEV1 < 1.5 litres is considered a general cut-off point* * malignant pleural effusion * tumour near hilum * vocal cord paralysis * SVC obstruction
37
**Pleural plaques on CXR** Next step in management?
**None** ~~~~~~~ * Pleural plaques are **benign** and do not undergo malignant change. * They are the **most common form of asbestos-related lung disease a**nd generally occur after a latent period of 20-40 years. * They, therefore don't require any follow-up.
38
The most common organism causing infective exacerbations of COPD is ...?
Haemophilus influenzae
39
ABG findings in **heroin overdose**
**Respiratory acidosis** ~~~~~ * Respiratory depression leading to hypoventilation
40
HRCT findings of **extrinsic allergic alveolitis **?
Extensive bilateral ground-glass opacities predominantly affecting the **mid** zones ~~~~~~ Ddx: **Silicosis**: diffuse multiple small nodules accompanied by calcifications predominantly through the **upper** lobes
40
Most important intervention for long-term symptom control in **bilateral bronchiectasis**?
Postural drainage ~~~~~ * help clear mucus from the lungs by positioning the patient so that the affected lung segments are above the trachea * i.e., tilt head down
41
(What?) has been associated with an increased risk of developing **tuberculosis** (TB).
Silica exposure ~~~~~~ * This is because silica particles can cause damage to the lungs, impairing their ability to clear bacteria, and leading to a higher susceptibility to infections, including TB.
42
Indications for placing a chest tube in pleural infection: 1. (color) of pleural fluid 2. (positive/negative) gram stain 3. pH ?
*Do not close an infective space!!* ~~~~~ * Frankly purulent or turbid/cloudy pleural fluid. * The **presence of organisms** identified by** Gram stain** and/or **culture** from a non-purulent pleural fluid sample indicates that pleural infection is established and should lead to prompt chest tube drainage. * Pleural fluid pH < 7.2
43
**Causes of upper zone pulmonary fibrosis:** **CHARTS** **Causes of lower zone pulmonary fibrosis:** **MAID**
**Causes of upper zone pulmonary fibrosis:** * Coal workers pneumoconiosis * Hypersensitivity pneumonitis, histiocytosis * Ankylosing spondylitis * Radiation * Tuberculosis * Silicosis, sarcoidosis _____________________________________ **Causes of lower zone pulmonary fibrosis:** * Most connective tissue diseases (e.g. rheumatoid arthritis) * Asbestosis * Idiopathic pulmonary fibrosis * Drugs (e.g. methotrexate)
44
Methotrexate-induced lung fibrosis affects the (upper/mid/lower) lung zone.
Lower ____________________________________ **Causes of upper zone pulmonary fibrosis:** * Coal workers pneumoconiosis * Hypersensitivity pneumonitis, histiocytosis * Ankylosing spondylitis * Radiation * Tuberculosis * Silicosis, sarcoidosis **Causes of lower zone pulmonary fibrosis:** * Most connective tissue diseases (e.g. rheumatoid arthritis) * Asbestosis * Idiopathic pulmonary fibrosis * Drugs (e.g. methotrexate)
45
Asbestosis-induced lung fibrosis affects the (upper/mid/lower) lung zone.
Lower ____________________________________ **Causes of upper zone pulmonary fibrosis:** * Coal workers pneumoconiosis * Hypersensitivity pneumonitis, histiocytosis * Ankylosing spondylitis * Radiation * Tuberculosis * Silicosis, sarcoidosis **Causes of lower zone pulmonary fibrosis:** * Most connective tissue diseases (e.g. rheumatoid arthritis) * Asbestosis * Idiopathic pulmonary fibrosis * Drugs (e.g. methotrexate)
46
Parotid enlargement, fever, and anterior uveitis in an Afro Caribbean females *Most likely diagnosis?*
**Heerfordt syndrome ** * a subset of sarcoidosis
47
48
Chronic infection with (??) is an important **CF-specific contraindication** to **lung** **transplantation**
**Burkholderia cepacia**
49

MRCP PART 1 (2 decks)

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