Respiratory Flashcards
Prior to discharge, following an acute asthma attack, how long should patients be stable on their discharge medication (i.e. no nebulisers or oxygen)?
12-24h
Decrease in pO2/FiO2 in poorly patient with non-cardiorespiratory presentation → condition?
ARDS
Pneumothorax management: what are the high-risk characteristics that determine the need for a chest drain?
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
Mx of pleural plaques?
Benign - no follow up
What is often seen on CXR in bronchiectasis?
Parallel line shadows (often called tram-lines) are common in bronchiectasis and indicate dilated bronchi due to peribronchial inflammation and fibrosis.
1st line Abx for prophylaxis of COPD exacerbations?
Azithromycin
Who should LTOT be offered to in COPD?
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
Prognosis of sarcoidosis?
The majority of patients with sarcoidosis get better without treatment
What class of drug is ipratropium?
SAMA
Mx of minimally symptomatic pneumothorax, regardless of size?
conservative treatment / regular follow-up
1st line for mx of high altitude cerebral oedema?
Dexamethasone
1st line for prevention of high altitude cerebral oedema?
Acetazolamide
total gas transfer (TLCO) in asthma?
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.
In what 2 conditions would you see raised TLCO?
1) Asthma
2) L to R cardiac shunt
How can kyphoscoliosis (e.g. caused by ankylosing spondylitis) affect lung function tests?
Can cause a restrictive picture on spirometry (i.e. normal or increased FEV1/FVC ratio).
What is hypogammaglobulinemia?
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.
What is the main complication for a patient with hypogammaglobulinemia?
Development of bronchiectasis
PTH level in 1ary hyperparathyroidism?
May be raised or normal
Normal PTH still indicates 1ary hyperparathyroidism as level should be reduced by high calcium level.
What is the severity of COPD based on?
FEV1 spirometry reading
Describe the 4 stages of COPD severity
Stage 1 (mild) - FEV1 >80%
Stage 2 (mod) - 50-79%
Stage 3 (severe) - 30-49%
Stage 4 (very severe) - FEV1 <30%
At what age should a patient presenting with unexplained haemoptysis be referred under the 2WW for suspected lung cancer?
≥40 y/o
Does a negative result on spirometry exclude asthma?
No - do further investigations (e.g. FeNO)
What is FVC
The volume of air in the lungs that can be exhaled following a deep inhalation
What is FEV1
A measure of how much air can be exhaled in one second following a deep inhalation
What is TCLO (Transfer factor for carbon monoxide, also known as diffusing capacity for carbon monoxide or DLCO)?
A measure of how much O2 diffuses from the lung alveoli to blood in the capillaries.
Reduced TCLO indicates impaired gas exchange.
What are the 3 first line Abx for an infective exacerbation of COPD?
1) amoxicillin
2) clarithromycin
3) doxycycline
What are the adverse effects of amiodarone use?
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
Why should IV amiodarone be ideally given into central veins?
As is a common cause of thrombophlebitis
What 4 investigations are required prior to amiodarone treatment?
1) TFTs
2) LFTs
3) U&Es
4) CXR
What 2 investigations are required every 6 months whilst on amiodarone treatment?
1) LFTs
2) TFTs
In COPD patients, if they are still breathless despite using SABA/SAMA and a LABA + ICS, what is next step?
Add a LAMA
How does sarcoidosis cause hypercalcaemia?
Due to the uncontrolled synthesis of 1,25-dihydroxyvitamin D3 (i.e. vitamin D) by macrophages.
Key investigation in ILD/pulmonary fibrosis? What does it show?
High resolution CT of thorax - shows ‘ground glass’ appearance.
What are 2 congenital causes of bronchiectasis?
1) CF
2) A1AT deficiency
What are 3 connective tissue causes of bronchiectasis?
1) RA
2) SLE
3) Sarcoidosis
What are 3 drugs that can cause bronchiectasis?
1) Nitrofurantoin
2) Methotrexate
3) Amiodarone
What is the test of choice for establishing a bronchiectasis diagnosis?
High resolution CT
What is the most common cause of bronchiectasis in developed countries?
What about in developing countries?
Developed - CF
Developing - TB
What are the 2 most common organisms causing infection in bronchiectasis?
1) Pseudomonas aeruginosa
2) Haemophilus influenzae
What should be done before prescribing Abx in bronchiectasis?
Sputum culture
What 2 medications are licensed that can slow the progression of pulmonary fibrosis
1) Pirfenidone
2) Nintedanib
What long term Abx can be given in bronchiectasis for frequent exacerbations?
Azithromycin
What is the Abx of choice for bronchiectasis exacerbations caused by Pseudomonas aeruginosa?
Ciprofloxacin
TLCO in pulmonary fibrosis?
reduced
Which lung has 3 lobes?
R (L doesn’t have middle lobe due to presence of heart)
How does CT appearance progress in idiopathic pulmonary fibrosis?
‘Ground glass’ appearance in early stages.
Progresses to ‘honeycombing’.
What picture does asbestosis give on lung function tests?
Restrictive
What is a parapneumonic effusion?
Pleural effusion 2ary to a pneumonia
What is Young’s syndrome?
A rare condition characterised by:
1) azoospermia (absence of motile sperm)
2) sinusitis
3) bronchiectasis
What are 4 key causes of LOWER zone fibrosis?
1) Drugs e.g. amiodarone, methotrexate
2) Connective tissue e.g. RA, SLE
3) Asbestosis
4) Idiopathic pulmonary fibrosis
Does idiopathic pulmonary fibrosis cause upper or lower zone fibrosis?
Lower
Does asbestosis cause upper or lower zone fibrosis?
Lower
What 4 features can be seen in Kartagener’s syndrome (AKA primary ciliary dyskinesia)?
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)
What is the most common cause of occupational asthma?
Isocyanates e.g. factories producing spray painting, foam moulding using adhesives
Pleural fluid findings of raised amylase may indicate what?
(2)
1) pancreatitis
2) oesophageal perforation
Give some common causes of respiratory alkalosis
(6)
1) Anxiety (leading to hyperventilation)
2) PE
3) Altitude
4) Salicylate OD
5) Pregnancy
6) CNS disorders e.g. stroke, SAH, encephalitis
What pCO2 indicates near-fatal asthma?
Raised >6.0 kPa
How can a stroke lead to respiratory alkalosis?
Results from hyperventilation due to the effect of the stroke on the respiratory centre.
In which type of pneumonia can you see ‘red currant jelly’ sputum?
Klebsiella
Which organism causing pneumonia is classically seen in alcoholics?
Klebsiella
What does lung abscess most commonly form 2ary to?
Aspiration pneumonia
How can C. diff present on a FBC?
Marked neutrophilia
When is Abx prophylaxis required in COPD patients?
> 3 exacerbations requiring steroid therapy in 1 year, with at least 1 exacerbation requiring hospital admission.
Features of Cushing’s syndrome?
- Weight gain, moon face, buffalo hump
- HTN
- Hyperglycaemia
- Hypokalaemia
- Striae
- Proximal muscle weakness & muscle fatigue
What Abx prophylactic is recommended in COPD patients who meet certain criteria and who continue to have exacerbations?
Macrolide e.g. azithromycin
Most common causes of bullae? (2)
1) smoking
2) emphysema
Where in the lungs does asbestosis cause fibrosis?
Lower zone fibrosis
1st line Abx in infective exacerbation of COPD?
(3)
Amoxicillin
Doxycycline
Clarithromycin (caution as can cause long QT)
Where in the lungs does idiopathic pulmonary fibrosis cause fibrosis?
Lower zones
Where is emphysema in A1AT most prominent?
What about in COPD?
A1AT - lower lobes
COPD - upper lobes
What should you aim for in the step down treatment of asthma?
Reduction in ICS 25-50% (consider every 3 months or so)
What is there often a history of in aspergilloma?
TB
What is silicosis a risk factor for?
Developing TB
In terms of smoking, what is the NICE advice for LTOT in COPD?
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
Gold standard investigation to diagnose mesothelioma?
Thoracoscopic biopsy –> histology performed
Which type of pneumonia can cause cavitating lesions in the upper lobes on a CXR?
Klebsiella
What are high-risk characteristics in a pneumothorax?
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
Following a splenectomy, what infections are patients particularly at risk from? (3)
1) pneumococcus
2) haemophilus
3) meningococcus
What Abx prophylaxis can be given in a splenectomy?
penicillin V - protects against Strep. pneumoniae
What are the main 2 indications for surgery in bronchiectasis?
1) uncontrollable haemoptysis
2) localised disease
What cancer can cause ‘cannonball’ mets in the lungs?
Renal cell carcinoma
What type of lung cancer is gynaecomastia most commonly associated with?
Adenocarcinoma
What is the treatment of choice for allergic bronchopulmonary aspergillosis?
Prednisolone
what is the most common organism causing infective exacerbation in bronchiectasis?
H. influenzae
How can obstructive sleep apnoea affect BP?
HTN
What is the gold standard investigation to confirm the diagnosis of mesothelioma?
Thoracoscopy & biopsy
Mx of a secondary pneumothorax <1cm?
Admit & O2 for 24 hours
