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PACES > Respiratory > Flashcards

Respiratory Flashcards

1
Q

What are the indications of thoracotomy scar (anterior or posterior)

A
  • lobectomy
  • pneumonectomy
  • open lung biopsy
  • lung volume reduction/bullectomy
  • single lung transplants
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2
Q

What are the indications of clamshell incision scar

A
  • bilateral lung transplant
  • widespread traumatic chest injury requiring bilateral access
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3
Q

What are the indications of VATS

A
  • biopsy/removal of masses/LNs
  • pleurodesis for recurrent effusion
  • recurrent PTX
  • lobectomy/segmentectomy
  • bullectomy
  • decortication
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4
Q

What are the benefits of VATS over open thoracotomy

A
  • reduced pain
  • reduced wound complications
  • reduced healing time
  • reduced length of stay
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5
Q

What are the main indications of a lobectomy

A
  • lung cancer
  • infection (aspergilloma/TB), lung abscess
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6
Q

What FEV1 is preferred for lobectomy

A

> 1.5

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7
Q

What FEV1 is required for a pneumonectomy

A

> 2

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8
Q

What VO2 max confers good prognosis after thoracotomy

A

VO2 max > 15ml/kg/min

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9
Q

Can examination of chest after lobectomy be normal?

A

Yes if operation was some time ago, adjacent lope can hyperinflate

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10
Q

Which NSCLC is most strongly associated with smoking

A

SCC

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11
Q

What is the benefit of thoracotomy over VATS for pneumothorax

A

Thoracotomy has reduced risk of recurrence of PTX

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12
Q

What are the causes of bilateral pleural effusion

A

CCF, hypoalbuminaemia, renal failure, liver failure, SLE/other AI causes, widespread malignancy, bilateral PE

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13
Q

What are the causes of obstructive airway disease

A

Asthma, COPD, bronchiectasis, Bronchiolitis obliterans

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14
Q

Which lung condition causes fixed airway obstruction after lung transplant

A

Bronchiolitis obliterans

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15
Q

What classes as reversibility on spirometry

A

200ml improvement in FEV1 or 15% change compared to baseline

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16
Q

What are the differentials for bibasal inspiratory crepitations

A

Pulmonary fibrosis
Bronchiectasis
Infection
Heart failure

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17
Q

What are the causes of a low TLCO (transfer factor)

A

Pulmonary fibrosis
Pneumonia
PE
Pulmonary oedema
COPD
Anaemia
Low cardiac output
Sarcoidosis

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18
Q

What are the causes of a raised TLCO (transfer factor)

A

Pulmonary haemorrhage
Asthma
Polycythaemia
Left-to-right cardiac shunt
Exercise

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19
Q

What causes increased KCO (transfer coefficient) with normal/low TLCO (transfer factor)

A

Pneumonectomy/lobectomy
Scoliosis

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20
Q

Which antifibrotic agents are used to treat IPF

A

Pirfenidone, nintedanib

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21
Q

What will pulmonary fibrosis show on lung function tests

A
  • Restrictive pattern (reduced FEV1 and FVC but normal ratios)
  • reduced total lung capacity
  • reduced transfer factor
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22
Q

What finding on HRCT suggests pulmonary fibrosis that will respond well to steroids

A

Ground glass changes (inflammation)

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23
Q

What are the 2 most common morphologies of ILD

A
  1. Usual interstitial pneumonia
  2. Non-specific interstitial pneumonia
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24
Q

What are the differences between UIP and NSIP

A

UIP: honeycombing, less responsive to steroids
NSIP: ground glass opacification, more responsive to steroids

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25
Q

What is pneumoconiosis

A

Any lung disease causes by inhalation of dust and fibres - includes asbestosis, silicosis and coal workers pneumoconiosis

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26
Q

What is seen on HRCT in bronchiectasis

A

Signet ring sign

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27
Q

What is the surgical management of pulmonary fibrosis

A

Single lung transplant can be considered

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28
Q

What FEV1 is antifibrotic treatment indicated for IPF

A

50 - 80%

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29
Q

Is biopsy needed to diagnose IPF?

A

Not if the MDT is happy with the diagnosis from history, exam, PFTs and HRCT

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30
Q

When is biopsy useful in ILD

A

When there is diagnostic uncertainty after initial tests

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31
Q

How is ILD monitored after diagnosis

A

PFTs at 6 months to determine speed of progression and need for treatment

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32
Q

Which organism confers worse prognosis in cystic fibrosis

A

Burkholderia

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33
Q

Which organism is a direct contraindication for lung transplant in cystic fibrosis

A

Burkholderia

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34
Q

Where in the lungs does bronchiectasis tend to occur most in CF patients

A

Upper lobes

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35
Q

What is the non-pharmacological management of CF

A
  1. MDT (CF specialist, PT, dietician, SN)
  2. Daily chest physio (postural drainage)
  3. Vaccinations
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36
Q

What are the indications of single lung transplant

A

COPD, pulmonary fibrosis

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37
Q

What are the indications of double lung transplant

A

CF, bronchiectasis, pulmonary hypertension

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38
Q

What is the leading cause of death after the first year of lung transplant

A

Bronchiolitis obliterans

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39
Q

What is the most common malignancy in the first year after lung transplant

A

Lymphoproliferative disorder

40
Q

Which patients with UIP and fibrotic NSIP should be referred for consideration of lung transplant

A

All patients with UIP/fibrotic NSIP that have no absolute contraindications

41
Q

When should CF patients be referred for lung transplant

A

FEV1 <30%
Significant pulm HTN
High exacerbation frequency
Recurrent PTX
Requirement for NIV

42
Q

What is the most common indication for lung transplant worldwide

A

COPD (40%)

43
Q

Which blood tests are important in bronchiectasis along with basics

A

HIV
Immuloglobulins
Aspergillus serology
CF genetic testing if <40 yrs old

44
Q

Which conditions might benefit from a positive expiratory pressure device

A

COPD, CF, bronchiectasis (helps bring up mucous)

45
Q

What causes traction bronchiectasis

A

Bronchiectatic dilation from adjacent lung fibrosis

46
Q

What are the causes of bronchiectasis

A
  • CF, PCD
  • Immunodeficiency
  • Post-infectious
  • Rheumatological
  • ABPA
  • Yellow nail syndrome
  • Traction (PF)
  • Idiopathic
47
Q

What is the most common lung condition associated with inflammatory myositis (eg polymyositis)

A

ILD

48
Q

What are the differential diagnoses of reduced breath sounds with tracheal deviation

A
  • Pneumonectomy
  • Collapse of a lobe
  • Pleural effusion (trachea deviated away)
  • Tension pneumothorax
49
Q

What are the causes of lung collapse

A
  • Intra-luminal: mucous plugging, FB
  • Luminal: dynamic obstruction (COPD), bronchial wall carcinoma
  • Extra-luminal: lymphadenopathy, mediastinal mass, primary/metastatic lung cancer
  • Atelectasis: compressive (effusion), adhesive (ARDS)
50
Q

Why is spirometry important in the work up for suspected lung cancer

A

Will guide on suitability for surgery

51
Q

Where are lung squamous cell carcinomas usually found

A

More centrally (adeno = peripheral)

52
Q

What may be heard on auscultation of a patient with COPD

A

Expiratory polyphonic wheeze (crackles if consolidation too), reduced breath sounds at apices

53
Q

What signs are suggestive of cor pulmonale

A

Raised JVP, ankle oedema, RV heave, loud P2 with PSM of TR

54
Q

What distinguishes COPD from chronic asthma on investigations

A

Less reversibility - <15% change in FEV1 post-bronchodilator

55
Q

Why are LFTs important in COPD

A

Low albumin indicates severity

56
Q

What is the non pharmacological management of COPD

A
  • smoking cessation
  • cessation clinics and NRT
  • pulmonary rehab
  • exercise
  • nutrition
  • vaccinations - pneumococcal and influenza
57
Q

What is the surgical management of COPD

A

careful patient selection is important:
- bullectomy (if bullae >1L and compressing surrounding lung)
- lung reduction surgery (only suitable for a few pts with heterogenous emphysema)
- single lung transplant

58
Q

What are the indications for LTOT in COPD

A
  • non-smoker
  • PaO2 <7.3 on RA
  • PaO2 <8 if cor pulmonale
  • PaCO2 does not rise on O2

Improves survival by 9 months

59
Q

What are the differentials of a wheezy chest

A

Bronchiolitis obliterans
- GPA (saddle nose)
- Rheumatoid arthritis

60
Q

What are the causes of a dull lung base on percussion

A
  • pleural effusion (dull)
  • consolidation (crackles)
  • collapse (trachea towards)
  • previous lobectomy (scar)
  • pleural thickening (normal resonance)
  • raised hemidiaphragm
61
Q

What organism causes rusty sputum

A

Pneumococcus

62
Q

What will auscultation of pneumonia reveal

A

Focal course crackles, increases vocal resonance, bronchial breathing

63
Q

What is the atypical screen for pneumonia

A

Serology: mycoplasma, chlamydia
Urine antigen: legionella, pneumococcal

64
Q

What are the most common organisms seen in pneumonia

A
  1. Streptococcus pneumoniae
  2. Mycoplasma pneumoniae
  3. Haemophilus influenzae (COPD)
  4. Chlamydia pneumoniae
65
Q

Which organisms should be considered in pneumonia in the immunocompromised patient

A
  • fungal
  • multi-resistant mycobacteria
  • PCP
  • CMV
66
Q

How can severity of pneumonia be established

A

CURB-65 score:
- Confusion
- Urea >7
- RR >30
- BP <90 or <60
- Age >65

67
Q

What are the complications of pneumonia

A
  • sepsis
  • lung abscess
  • para-pneumonic effusion/empyema
  • haemoptysis
68
Q

What were the historical surgical treatments for tuberculosis

A
  1. Plombage
  2. Phrenic nerve crush
  3. Thoracoplasty
  4. Apical lobectomy
  5. Recurrent medical pneumothoraces
69
Q

What are the serious side effects of rifampicin

A

Hepatitis
Enzyme inducer (COCP)

70
Q

What are the serious side effects of isoniazid

A

Hepatitis
Peripheral neuropathy

71
Q

What are the serious side effects of pyramzinamide

A

Hepatitis

72
Q

What are the serious side effects of ethambutol

A

Hepatitis
Retro-bulbar neuritis

73
Q

What should be checked before starting TB treatment

A

Baseline LFTs
Visual acuity

74
Q

What should you advise patients about to start TB treatment in relation to side effects

A
  1. Check eyes for jaundice
  2. Monitor for change of colour vision
  3. Secretions likely will turn orange
  4. May develop paraesthesia
  5. Use barrier contraception
75
Q

What are the causes of an exudative pleural effusion

A
  • malignancy (primary or secondary)
  • infection (parapneumonic)
  • infarction (PE)
  • inflammation (RA, SLE)
76
Q

What are the causes of a transudate pleural effusion

A
  • heart failure
  • liver failure
  • renal failure
  • hypoalbuminaemia
77
Q

What are the two kinds of pleurodesis and what are their indications

A
  1. Chemical
  2. Mechanical

Used for recurrent effusions, recurrent PTXs or persistent PTX

78
Q

How can a tissue diagnosis of lung cancer be obtained

A
  1. Bronchoscopy
  2. CT guided biopsy
  3. Lymph node biopsy
  4. Pleural effusion cytology
79
Q

What should pleural fluid be sent off for

A
  • pH
  • protein (paired with serum)
  • LDH (paired with serum)
  • cytology
  • gram stain and culture
  • acid fast bacilli
80
Q

What is suggestive of effusion secondary to RA on pleural aspirate

A

Very low glucose <1.6 mmol/L

81
Q

Which way will the trachea be deviated in a pneumonectomy

A

Towards the side of the pneumonectomy

82
Q

List the patterns of distribution of bronchiectasis according to underlying aetiology

A

CF -> upper lobes
Others -> lower lobes
ABPA -> proximal airways

83
Q

What are the causes of normal spirometry but reduced gas transfer

A
  • anaemia
  • pulmonary vascular disease
84
Q

What are the causes of restrictive spirometry but normal gas transfer

A

Extrapulmonary restriction e.g. neuromuscular, scoliosis

85
Q

What does a raised FeNO indicate on pulmonary function tests

A

Amount of inflammation in the lungs (used to aid diagnosis of asthma)

86
Q

Which crackles are early inspiratory vs end inspiratory

A

Early inspiratory = bronchiectasis (large airways)

End inspiratory = PF (small airways)

87
Q

What might an inhaler at the bedside suggest

A

Asthma
COPD
(Bronchiectasis)

88
Q

What are the main indications for pneumonectomy

A
  1. Malignancy
  2. Trauma
  3. Chronic infection eg TB
89
Q

What are the complications of lung transplant

A

Acute: rejection, opportunistic infection

Chronic: rejection, Bronchiolitis obliterans, malignancy, side effects of immunosuppression

90
Q

What are the contraindications to lung transplant

A
  • malignancy in last 5 years
  • smoking/drug abuse
  • burkholderia/mycobacterium in CF
  • irreversible organ failure
  • acute illness
  • serious psychological illnesses
91
Q

You have found a lung mass on CT that is suspicious for cancer, what is the next step

A

Obtain a tissue sample for diagnosis

92
Q

How can a tissue diagnosis be obtained for a suspected lung cancer

A
  • bronchoscopy
  • CT-guided biopsy
  • endobronchial US
  • lymph node biopsy
  • aspiration of pleural effusions
93
Q

Which NSCLC is most commonly seen in smokers

A

Squamous cell

(Look for thoracotomy + tar staining, evidence of COPD)

94
Q

What are the differentials of a thoracotomy scar with a normal underlying lung and no tracheal deviation

A
  • lobectomy
  • bullectomy
  • lung transplant
  • wedge resection
  • open lung biopsy
  • trauma
95
Q

What indicates an educative pleural effusion on pleural fluid analysis

A

Protein >30g/L

Using lights criteria:
- pleural protein >0.5 of serum
- pleural LDH >0.6 of serum
- pleural LDH >2/3 UL of normal

PACES (6 decks)

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