Respiratory

Question 1

Prior to discharge, following an acute asthma attack, how long should patients be stable on their discharge medication (i.e. no nebulisers or oxygen)?

Answer 1

12-24h

Question 2

Decrease in pO2/FiO2 in poorly patient with non-cardiorespiratory presentation → condition?

Answer 2

ARDS

Question 3

Pneumothorax management: what are the high-risk characteristics that determine the need for a chest drain?

Answer 3

1) Haemodynamic compromise (suggesting a tension pneumothorax)

2) Significant hypoxia

3) Bilateral pneumothorax

4) Underlying lung disease

5) ≥ 50 years of age with significant smoking history

6) Haemothorax

Question 4

Mx of pleural plaques?

Answer 4

Benign - no follow up

Question 5

What is often seen on CXR in bronchiectasis?

Answer 5

Parallel line shadows (often called tram-lines) are common in bronchiectasis and indicate dilated bronchi due to peribronchial inflammation and fibrosis.

Question 6

1st line Abx for prophylaxis of COPD exacerbations?

Answer 6

Azithromycin

Question 7

Who should LTOT be offered to in COPD?

Answer 7

Patients with a pO2 of < 7.3 kPa or to those with a pO2 of 7.3 - 8 kPa and one of the following:

1) secondary polycythaemia

2) peripheral oedema

3) pulmonary hypertension

Question 8

Prognosis of sarcoidosis?

Answer 8

The majority of patients with sarcoidosis get better without treatment

Question 9

What class of drug is ipratropium?

Answer 9

SAMA

Question 10

Mx of minimally symptomatic pneumothorax, regardless of size?

Answer 10

conservative treatment / regular follow-up

Question 11

1st line for mx of high altitude cerebral oedema?

Answer 11

Dexamethasone

Question 12

1st line for prevention of high altitude cerebral oedema?

Answer 12

Acetazolamide

Question 13

total gas transfer (TLCO) in asthma?

Answer 13

Normal or raised

This is because the problem is not affecting the alveoli directly or gas exchange and so the lungs try to compensate for the problem by improving gas exchange.

Question 14

In what 2 conditions would you see raised TLCO?

Answer 14

1) Asthma

2) L to R cardiac shunt

Question 15

How can kyphoscoliosis (e.g. caused by ankylosing spondylitis) affect lung function tests?

Answer 15

Can cause a restrictive picture on spirometry (i.e. normal or increased FEV1/FVC ratio).

Question 16

What is hypogammaglobulinemia?

Answer 16

A disorder caused by low serum immunoglobulin or antibody levels i.e. an immune deficiency.

This is known to cause a range of conditions such as bronchiectasis and IBD.

Question 17

What is the main complication for a patient with hypogammaglobulinemia?

Answer 17

Development of bronchiectasis

Question 18

PTH level in 1ary hyperparathyroidism?

Answer 18

May be raised or normal

Normal PTH still indicates 1ary hyperparathyroidism as level should be reduced by high calcium level.

Question 19

What is the severity of COPD based on?

Answer 19

FEV1 spirometry reading

Question 20

Describe the 4 stages of COPD severity

Answer 20

Stage 1 (mild) - FEV1 >80%

Stage 2 (mod) - 50-79%

Stage 3 (severe) - 30-49%

Stage 4 (very severe) - FEV1 <30%

Question 21

At what age should a patient presenting with unexplained haemoptysis be referred under the 2WW for suspected lung cancer?

Answer 21

≥40 y/o

Question 22

Does a negative result on spirometry exclude asthma?

Answer 22

No - do further investigations (e.g. FeNO)

Question 23

What is FVC

Answer 23

The volume of air in the lungs that can be exhaled following a deep inhalation

Question 24

What is FEV1

Answer 24

A measure of how much air can be exhaled in one second following a deep inhalation

Question 25

What is TCLO (Transfer factor for carbon monoxide, also known as diffusing capacity for carbon monoxide or DLCO)?

Answer 25

A measure of how much O2 diffuses from the lung alveoli to blood in the capillaries. Reduced TCLO indicates impaired gas exchange.

Question 26

What are the 3 first line Abx for an infective exacerbation of COPD?

Answer 26

1) amoxicillin 2) clarithromycin 3) doxycycline

Question 27

What are the adverse effects of amiodarone use?

Answer 27

1) thyroid dysfunction: both hypo- and hyper- 2) corneal deposits 3) pulmonary fibrosis/pneumonitis 4) liver fibrosis/hepatitis 5) peripheral neuropathy 6) photosensitivity 7) 'slate-grey' appearance 8) thrombophlebitis and injection site reactions 9) bradycardia 10) lengths QT interval

Question 28

Why should IV amiodarone be ideally given into central veins?

Answer 28

As is a common cause of thrombophlebitis

Question 29

What 4 investigations are required prior to amiodarone treatment?

Answer 29

1) TFTs 2) LFTs 3) U&Es 4) CXR

Question 30

What 2 investigations are required every 6 months whilst on amiodarone treatment?

Answer 30

1) LFTs 2) TFTs

Question 31

In COPD patients, if they are still breathless despite using SABA/SAMA and a LABA + ICS, what is next step?

Answer 31

Add a LAMA

Question 32

How does sarcoidosis cause hypercalcaemia?

Answer 32

Due to the uncontrolled synthesis of 1,25-dihydroxyvitamin D3 (i.e. vitamin D) by macrophages.

Question 33

Key investigation in ILD/pulmonary fibrosis? What does it show?

Answer 33

High resolution CT of thorax - shows 'ground glass' appearance.

Question 34

What are 2 congenital causes of bronchiectasis?

Answer 34

1) CF 2) A1AT deficiency

Question 35

What are 3 connective tissue causes of bronchiectasis?

Answer 35

1) RA 2) SLE 3) Sarcoidosis

Question 36

What are 3 drugs that can cause bronchiectasis?

Answer 36

1) Nitrofurantoin 2) Methotrexate 3) Amiodarone

Question 37

What is the test of choice for establishing a bronchiectasis diagnosis?

Answer 37

High resolution CT

Question 38

What is the most common cause of bronchiectasis in developed countries? What about in developing countries?

Answer 38

Developed - CF Developing - TB

Question 39

What are the 2 most common organisms causing infection in bronchiectasis?

Answer 39

1) Pseudomonas aeruginosa 2) Haemophilus influenzae

Question 40

What should be done before prescribing Abx in bronchiectasis?

Answer 40

Sputum culture

Question 41

What 2 medications are licensed that can slow the progression of pulmonary fibrosis

Answer 41

1) Pirfenidone 2) Nintedanib

Question 42

What long term Abx can be given in bronchiectasis for frequent exacerbations?

Answer 42

Azithromycin

Question 43

What is the Abx of choice for bronchiectasis exacerbations caused by Pseudomonas aeruginosa?

Answer 43

Ciprofloxacin

Question 44

TLCO in pulmonary fibrosis?

Answer 44

reduced

Question 45

Which lung has 3 lobes?

Answer 45

R (L doesn't have middle lobe due to presence of heart)

Question 46

How does CT appearance progress in idiopathic pulmonary fibrosis?

Answer 46

'Ground glass' appearance in early stages. Progresses to 'honeycombing'.

Question 47

What picture does asbestosis give on lung function tests?

Answer 47

Restrictive

Question 48

What is a parapneumonic effusion?

Answer 48

Pleural effusion 2ary to a pneumonia

Question 49

What is Young's syndrome?

Answer 49

A rare condition characterised by: 1) azoospermia (absence of motile sperm) 2) sinusitis 3) bronchiectasis

Question 50

What are 4 key causes of LOWER zone fibrosis?

Answer 50

1) Drugs e.g. amiodarone, methotrexate 2) Connective tissue e.g. RA, SLE 3) Asbestosis 4) Idiopathic pulmonary fibrosis

Question 51

Does idiopathic pulmonary fibrosis cause upper or lower zone fibrosis?

Answer 51

Lower

Question 52

Does asbestosis cause upper or lower zone fibrosis?

Answer 52

Lower

Question 53

What 4 features can be seen in Kartagener's syndrome (AKA primary ciliary dyskinesia)?

Answer 53

1) dextrocardia or complete situs inversus bronchiectasis 2) recurrent sinusitis 3) subfertility (secondary to diminished 4) sperm motility and defective ciliary action in the fallopian tubes)

Question 54

What is the most common cause of occupational asthma?

Answer 54

Isocyanates e.g. factories producing spray painting, foam moulding using adhesives

Question 55

Pleural fluid findings of raised amylase may indicate what? (2)

Answer 55

1) pancreatitis 2) oesophageal perforation

Question 56

Give some common causes of respiratory alkalosis (6)

Answer 56

1) Anxiety (leading to hyperventilation) 2) PE 3) Altitude 4) Salicylate OD 5) Pregnancy 6) CNS disorders e.g. stroke, SAH, encephalitis

Question 57

What pCO2 indicates near-fatal asthma?

Answer 57

Raised >6.0 kPa

Question 58

How can a stroke lead to respiratory alkalosis?

Answer 58

Results from hyperventilation due to the effect of the stroke on the respiratory centre.

Question 59

In which type of pneumonia can you see 'red currant jelly' sputum?

Answer 59

Klebsiella

Question 60

Which organism causing pneumonia is classically seen in alcoholics?

Answer 60

Klebsiella

Question 61

What does lung abscess most commonly form 2ary to?

Answer 61

Aspiration pneumonia

Question 62

How can C. diff present on a FBC?

Answer 62

Marked neutrophilia

Question 63

When is Abx prophylaxis required in COPD patients?

Answer 63

>3 exacerbations requiring steroid therapy in 1 year, with at least 1 exacerbation requiring hospital admission.

Question 64

Features of Cushing’s syndrome?

Answer 64

- Weight gain, moon face, buffalo hump - HTN - Hyperglycaemia - Hypokalaemia - Striae - Proximal muscle weakness & muscle fatigue

Question 65

What Abx prophylactic is recommended in COPD patients who meet certain criteria and who continue to have exacerbations?

Answer 65

Macrolide e.g. azithromycin

Question 66

Most common causes of bullae? (2)

Answer 66

1) smoking 2) emphysema

Question 67

Where in the lungs does asbestosis cause fibrosis?

Answer 67

Lower zone fibrosis

Question 68

1st line Abx in infective exacerbation of COPD? (3)

Answer 68

Amoxicillin Doxycycline Clarithromycin (caution as can cause long QT)

Question 69

Where in the lungs does idiopathic pulmonary fibrosis cause fibrosis?

Answer 69

Lower zones

Question 70

Where is emphysema in A1AT most prominent? What about in COPD?

Answer 70

A1AT - lower lobes COPD - upper lobes

Question 71

What should you aim for in the step down treatment of asthma?

Answer 71

Reduction in ICS 25-50% (consider every 3 months or so)

Question 72

What is there often a history of in aspergilloma?

Answer 72

TB

Question 73

What is silicosis a risk factor for?

Answer 73

Developing TB

Question 74

In terms of smoking, what is the NICE advice for LTOT in COPD?

Answer 74

Can offer if pO2 <7.3 kPa Or if pO2 7.3-8kPa plus one of the following: 1) 2ary polycythaemia 2) pulmonary HTN 3) peripheral oedema

Question 75

Gold standard investigation to diagnose mesothelioma?

Answer 75

Thoracoscopic biopsy --> histology performed

Question 76

Which type of pneumonia can cause cavitating lesions in the upper lobes on a CXR?

Answer 76

Klebsiella

Question 77

What are high-risk characteristics in a pneumothorax?

Answer 77

1) Haemodynamic instability (may indicate tension pneumothorax) 2) Underlying lung disease 3) Significant hypoxia 4) Bilateral pneumothorax 5) >/= 50 years of age with significant smoking history 6) Haemothorax

Question 78

Following a splenectomy, what infections are patients particularly at risk from? (3)

Answer 78

1) pneumococcus 2) haemophilus 3) meningococcus

Question 79

What Abx prophylaxis can be given in a splenectomy?

Answer 79

penicillin V - protects against Strep. pneumoniae

Question 80

What are the main 2 indications for surgery in bronchiectasis?

Answer 80

1) uncontrollable haemoptysis 2) localised disease

Question 81

What cancer can cause 'cannonball' mets in the lungs?

Answer 81

Renal cell carcinoma

Question 82

What type of lung cancer is gynaecomastia most commonly associated with?

Answer 82

Adenocarcinoma

Question 83

What is the treatment of choice for allergic bronchopulmonary aspergillosis?

Answer 83

Prednisolone

Question 84

what is the most common organism causing infective exacerbation in bronchiectasis?

Answer 84

H. influenzae

Question 85

How can obstructive sleep apnoea affect BP?

Answer 85

HTN

Question 86

What is the gold standard investigation to confirm the diagnosis of mesothelioma?

Answer 86

Thoracoscopy & biopsy

Question 87

Mx of a secondary pneumothorax <1cm?

Answer 87

Admit & O2 for 24 hours