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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
Q

What shifts oxygen dissociation curve to the right?

A

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
Q

Asthma patients on SABA + ICS but not well controlled.
Next step?

A

Add LTRA
~~~~
(not LABA, e.g., salmeterol)

26
Q

What are signs of life-threatening asthma attack?

A
  • 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
Q

Most common infective cause of COPD exacerbations? (1)

A

Haemophilus influenzae (most common cause)

28
Q

Common causes (3) of infective exacerbation of COPD?

A
  • Haemophilus influenzae (most common cause)
  • Streptococcus pneumoniae
  • Moraxella catarrhalis
29
Q

COPD patients are prone to developing type (x) respiratory failure?

A

2
~~~
(hypercapnia)

30
Q

COPD exacerbation complicated with type 2 respiratory failure despite medical therapy?

Next step?

A

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
Q

In patients who are diagnosed with lung cancer, what percentage of recent chest x-rays were reported as normal?

A

10%

31
Q

Function of alpha-1 antitrypsin?

A

Protease inhibitor of neutrophil elastase
~~~~~
* Deficiency can cause emphysema and cirrhosis.

32
Q

What is not an indication of NIV?

A

Bronchiectasis
~~~~~
* limited by excessive secretions

33
Q

Upper/mid zone fibrosis
Cause?

A

Extrinsic allergic alveolitis (EAA)
~~~~~
* no eosinophilia
* treatment: avoid precipitating factors or oral steroids

34
Q

Bronchoconstriction (wheeze, cough, dyspnea) + recurrent infections + eosinophilia
Most likely diagnosis

A

ABPA (Allergic Bronchopulmonary Aspergillosis)

35
Q

Management of ABPA?

A

Oral glucocorticoids
~~~~~
* itraconazole is sometimes introduced as a second-line agent

36
Q

SVC obstruction + non-small cell lung cancer

Can surgery be proceeded?

A

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
Q

Pleural plaques on CXR

Next step in management?

A

None
~~~~~~~
* Pleural plaques are benign and do not undergo malignant change.
* They are the most common form of asbestos-related lung disease and generally occur after a latent period of 20-40 years.
* They, therefore don’t require any follow-up.

38
Q

The most common organism causing infective exacerbations of COPD is …?

A

Haemophilus influenzae

39
Q

ABG findings in heroin overdose

A

Respiratory acidosis
~~~~~
* Respiratory depression leading to hypoventilation

40
Q

HRCT findings of **extrinsic allergic alveolitis **?

A

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
Q

Most important intervention for long-term symptom control in bilateral bronchiectasis?

A

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
Q

(What?) has been associated with an increased risk of developing tuberculosis (TB).

A

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
Q

Indications for placing a chest tube in pleural infection:

  1. (color) of pleural fluid
  2. (positive/negative) gram stain
  3. pH ?
A

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
Q

Causes of upper zone pulmonary fibrosis:
CHARTS

Causes of lower zone pulmonary fibrosis:
MAID

A

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
Q

Methotrexate-induced lung fibrosis affects the (upper/mid/lower) lung zone.

A

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
Q

Asbestosis-induced lung fibrosis affects the (upper/mid/lower) lung zone.

A

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
Q

Parotid enlargement, fever, and anterior uveitis in an Afro Caribbean females
Most likely diagnosis?

A

**Heerfordt syndrome **
* a subset of sarcoidosis

47
Q
A
48
Q

Chronic infection with (??) is an important CF-specific contraindication to lung transplantation

A

Burkholderia cepacia

49
Q
A

MRCP PART 1 (2 decks)

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