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Respiratory Flashcards

1
Q

What conditions have a high FENO?

A

Asthma (Eosinophilic asthma specifically)

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2
Q

What conditions have a high DLCO?

A
  • Asthma
  • Polycythaemia
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3
Q

What conditions have a reduced DLCO?

A
  • COPD
  • ILD
  • PE
  • Neuromuscular Disease
  • Anaemia
  • Heart Failure
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4
Q

What conditions have a normal DLCO?

A

Obesity

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5
Q

Causes of Raised A-a Gradient

A

V/Q Mismatch
R/L Shunt
Diffusion defect

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6
Q

A-a Gradient formula

A

(150 - PaCO2/0.8) - PaO2
Normal = 5-10mmHg for young adult, add 1mmHg for each decade of life

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7
Q

Risk Factors for EGFR mutant Lung Cancer

A

Asian
Female
Non smoker

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8
Q

Most common mutation in non small cell lung cancer

A

KRAS

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9
Q

Most common histopathological subtype of lung cancer

A

Adenocarcinoma

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10
Q

Which type of lung cancer are EGFR and ALK mutations present in?

A

Adenocarcinoma

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11
Q

Which type of lung cancer are CTLA-4 and PD-1/PD-L1 mutations present in?

A

Squamous Cell Carcinoma

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12
Q

When considering Fleischner Guidelines, what patient factors would make a patient high risk?

A

Heavy smoking
Older age
Upper lobe
Irregular/spiculated margin

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13
Q

Follow up for single solid nodule <6mm

A

Low risk: no routine follow up
High risk: Consider CT at 12 months particularly if suspicious

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14
Q

In what conditions does Pulus Paradoxus occur?

A

Tamponade, Asthma, COPD

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15
Q

What is Allergic Bronchopulmonary Aspergillosis?

A

Type 4 hypersensitivity due to colonisation of airway with Aspergillus (i.e. not infection). Can result in eosinophilic pneumonia, and upper lobe predominant bronchiectasis.

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16
Q

What’s a key cause of a lack of improvement in Oxygen Saturations with supplemental oxygen?

A

Methaemoglobinaemia

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17
Q

What is the most common cause of death in COPD? (Mild, and severe?)

A

Mild: CVD
Severe: Respiratory Failure

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18
Q

In asbestosis, are straight blue or curly white fibres more carcinogenic and why?

A

Straight blue, as they can get further into the lungs

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19
Q

Of the causes of hypoxaemia, which has a normal A-a gradient?

A

Hypoventilation

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20
Q

As CO2 rises, what should happen to HCO3?

A

For every increase of 10 in CO2 above 40, bicarb should rise by:
Acute: 1
Chronic: 4

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21
Q

Which causes of ILD are predominantly in upper zones?

A

Farmer’s
Ankylosing Spondylitis
Sarcoid
Silicosis
Tuberculosis
Eosinophilic Granuloma
Neurofibromatosis

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22
Q

Which causes of ILD predominantly involve the lower zones?

A

Rheumatoid Arthritis
Scleroderma
Asbestosis

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23
Q

What is the mechanism of Omalizumab? What condition is it indicated in?

A

Blocks IgE interactions. Indicated in severe Allergic Asthma and chronic rhinosinusitis with nasal polyps

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24
Q

What is the mechanism of Benralizumab? What are the indications?

A

Anti- IL-5. Indicated in Eosinophilic Asthma (also EGPA)

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25
What is the most common cause of spontaneous secondary pneumothorax?
1st: COPD (50-70%) 2nd: Lung Cancer
26
What medical therapy is indicated for CTEPH in patients who have inoperable disease or recurrence post surgery? And what is its mechanism?
Riociguat Soluble Guanylate Cyclase stimulator, targets NO - cGMP pathway to cause vasodilation
27
What is the key complication of Cystic Fibrosis in males, and what is the mechanism?
Infertility due to obstructive azoospermia secondary to congenital lack of vas deferens
28
What does the Delta F508del mutation do to CFTR function?
CFTR works, but isn't transported to the cell membrane and thus is dysfunctional. (Class II)
29
What is the mechanism of Ivacaftor?
CFTR potentiator → improves function/opening of the channel
30
What is the mechanism of Bosentan and Macitentan?
Endothelin antagonism -> pulmonary vasodilation
31
What is the mechanism of Elexacaftor and Tezacaftor?
Both bring the CFTR protein to the surface
32
What happens if DNAse is given in the same nebuliser as hypertonic saline?
Becomes inactivated
33
Ivacaftor monotherapy can work for which mutation?
G551d, as the protein is at the surface but doesn't work properly. Increases weight, increased exercise tolerance, marked drop in pancreatitis.
34
What is the key predictor of efficacy for Benralizumab and Mepolizumab?
Raised Eosinophils
35
What are the key side effects/risks of Omalizumab?
Thrombocytopaenia Can unmask/cause EGPA
36
What is the mechanism of Mepolizumab, and what are the indications?
Binds to IL-5, reducing production and survival of eosinophils. Indicated in Eosinophilic asthma and EGPA
37
What is the mechanism and indication/s for Dupilumab?
Inhibits IL-4 and IL-13, reducing atopy and immune response Indicated in Eosinophilic asthma, atopic dermatitis, severe chronic rhinosinusitis with nasal poylps
38
What is a key cause of irreversible loss of lung function post lung transplant?
Bronchiolitis Obliterans Syndrome. 50% of patients at 5 years post transplant. Risk increases with age
39
What is a key risk factor for Post transplant lymphoproliferative disorder?
EBV positivity
40
What is the key indication for a combined heart/lung transplant?
Almost exclusively congenital heart disease, e.g. Eisenmenger Syndrome
41
What are the indications for Lung Transplant?
IPF ILD other than IPF CF COPD Alpha-1 antitrypsin Deficiency Pulmonary Hypertension
42
What are the features of low risk Pulmonary Hypertension?
No features of right heart failure No progression of symptoms No syncope WHO Functional Capacity I or II 6MWD >440m NT-proBNP <300 RA area <18cm^2 RAP <8mmHg
43
What are the features of High Risk Pulmonary Hypertension?
Features of RHF present Rapid progression of symptoms Repeated syncope WHO Functional Classification IV 6MWD <165m NT-proBNP >1100 Ra area >26cm^2 RAP >14mmHg
44
What is the key indication for the Endothelin Receptor Antagonists?
Indicated for low risk group 1 PAH either as monotherapy or with PDE5i. Examples: Ambrisartan, Bosentan, Macitentan
45
mPAP cut off for PAH diagnosis
Now >20, but PBS still uses 25
46
What does a raised PAWP indicate in PAH diagnosis?
Suggestive of left ventricular dysfunction and thus suggestive of group II Pulmonary Hypertension
47
Contraindications to Bronchoscopy
Respiratory insufficiency Thrombocytopaenia (Plt <50 is cutoff) Coagulopathy (INR >1.5) Uncorrected bleeding diathesis is key issue, as can't seen anything if there is bleeding, and very difficult to control it.
48
How long does home oxygen therapy need to be used to see a mortality benefit in COPD?
At least 15 hours a day
49
When is home oxygen indicated in COPD?
PaO2 <60mmHg Doesn't need to be as low if there are other complications such as PAH or polycythaemia
50
Which immune cells are implicated in the pathogenesis of Asthma?
Mast Cells Eosinophils Th2
51
Spirometry in Asthma
FEV1/FVC ratio >0.7 10% improvement post bronchodilator (or 8% if lung volumes normal) This increase is compared to mean predicted value: ((post bronchodilator value - prebronchodilator value) x 100)/Predicted value
52
What is the benefit of ICS in Asthma?
Reduces risk of exacerbation
53
What is first line therapy for Asthma?
ICS-LABA used as a reliever
54
When could a SABA be considered as first line therapy for asthma?
Daytime asthma symptoms <2 times a month No waking due to asthma when using SABA alone No history of severe flares in last 12 months No risk factors for severe flares
55
What is the stepwise approach to Asthma management?
1. PRN ICS-LABA 2. Regular ICS 3. Low dose regular ICS-LABA 4. Medium dose ICS-LABA 5. High dose ICS-LABA, plus additional therapies
56
What are the benefits of ICS/LABA vs ICS monotherapy in Asthma?
Improved FEV1 Reduced exacerbations Improved quality of life
57
When are biologics indicated in Asthma, and what is their benefit?
Indications: Frequent exacerbations despite maximal therapy, generally with high IgE titre or eosinophil count. Benefits: reduce exacerbations, reduce oral steroid use, modest improvement in lung function
58
When are Leukotrien Modifiers (Montelukast) indicated in Asthma, and what benefits do they provide?
Indicated as an add on therapy for difficult to control eosinophilic and aspirin sensitivity asthma. Reduce symptoms, improve quality of life, decrease need for SABA, prevent exercise induced asthma
59
Treatment of Severe Asthma
Salbutamol and Ipratropium via nebuliser Adrenaline if: poor respiratory effort, unresponsive, peri-arrest IV Mg Sulphate Oral steroid within first hour Consider whether anaphylaxis is contributing/present
60
Pregnancy and Asthma
Pregnancy can induce or worsen asthma Consequences of poorly controlled asthma during pregnancy: - Low birth weight - Pre-eclampsia - Premature labour - Increased infant mortality
61
Diagnostic Features of Allergic Bronchopulmonary Aspergillosis
Asthma or CF Elevated total IgE >1000, or Aspergillus IgE RAST or positive Aspergillus skin prick tests Consistent CT findings or total eosinophil count >0.5 or positive aspergillus precipitant CT findings: - Tree in bud pattern - proximal upper lobe bronchiectasis - mucus plugging - mosaicism
62
Management of Allergic Bronchopulmonary Aspergillosis
High dose steroids with slow wean (exacerbations common during weaning) Antifungals for frequent relapses (Intraconazole has best evidence) - Reduces circulating IgE - Improves radiological appearance - Reduces exacerbation frequency Omalizumab emerging as another option for resistant disease with high IgE titres
63
GOLD Classification of airflow impairment
1. Mild (FEV1 >80%) 2. Moderate (FEV1 50-80%) 3. Severe (FEV1 30-50%) 4. Very Severe (FEV1 <30%)
64
Usual Interstitial Pneumonia
Findings: Honeycombing, traction bronchiectasis, subpleural reticular opacities Lower lobe predominant Seen in: IPF, Rheumatoid Arthritis, CTD-ILD, Asbestosis
65
Non Specific Interstitial Pneumonia
Findings: Ground glass changes, subpleural sparing Lower lobe predominant Seen in: Systemic sclerosis, CTD-ILD
66
BAL Cell Patterns
High Neutrophils: IPF, Asbestosis High Lymphocytes: Hypersensitivity pneumonitis, sarcoid, berrylium High Eosinophils: Eosinophilic pneumonia
67
Hypersensitivity Pneumonitis Radiology
Acute findings: ground glass nodularity Chronic findings: fibrotic changes akin to UIP with ground glass and mosaicism (gas trapping) Centrilobar predominance Seen in Hypersensitivity pneumonitis shockingly!
68
Testing for Cushing Syndrome
Midnight Salivary Cortisol High dose Dexamethasone test to confirm Short Synacthen to determine if ACTH dependent or independent Image adrenals if independent Petrodollar sinus ACTH levels if dependent, may also be paraneoplastic
69
Indication for Bilateral lung transplant
CF, Bronchiectasis, PAH Survival advantage in younger patients Can be done for COPD
70
When may single lung transplant be done?
COPD ILD without PAH
71
Risks of Sleep Disorders
Obesity hypoventilation syndrome Nacrolepsy REM behavioural disorder
72
Impact of CPAP on cardiovascular risk in OSA
Does not reduce risk of cardiovascular events in moderate to severe OSA
73
Benefits of CPAP in OSA
- Reduced respiratory events - Decreased daytime sleepiness - Small BP improvements - Decreased erectile dysfunction - Reduced risk of MVA - Improved QOL
74
What medications appear to have benefit for OSA?
Tirzepatide - reduced AHI in obese patients with OSA Sulthiame (Carbonic anhydrase inhibitor): ~50% reduction in AHI
75
Distinguish OSA from CSA
Respiratory effort key - OSA: ongoing respiratory effort, trying to overcome obstruction - CSA: intermittent drop in respiratory effort
76
Diagnosis of Obesity Hypoventilation Syndrome
Elevated pCO2 during or immediately after sleep, BMI >35, no other reason for hypercarbia (e.g. COPD, neuromuscular) Patients usually hypersomnolent
77
What lung volume is reduced in Obesity Hypoventilation Syndrome?
Expiratory reserve volume

BPT (20 decks)

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