Respiratory Flashcards
1
Q
What findings on spirometry are associated with a restrictive deficit?
A
FEV1 - reduced
FVC - significantly reduced
FEV1/FVC - normal or increased
2
Q
What findings on spirometry are associated with an obstructive deficit?
A
FEV1 - significantly reduced
FVC - reduced or normal
FEV1/FVC - reduced
3
Q
Normal/raised total gas transfer with raised transfer coefficient indicates what diganosis?
A
Asthma
4
Q
What advice should be given regarding inhaler technique?
A
- Remove cap and shake
- Breathe out gently
- Put mouthpiece in mouth and as you begin to breathe in, which should be slow and deep, press canister down and continue to inhale steadily and deeply
- Hold breath for 10 seconds, or as long as is comfortable
- For a second dose wait for approximately 30 seconds before repeating steps 1-4
5
Q
What is the first line management of COPD?
A
Start SABA or SAMA, if uncontrolled add:
If no asthamatic features: LABA + LAMA
If asthmatic features: consider LABA + ICS
6
Q
Patient with COPD on LABA + LAMA, has symptoms impacting QOL. What do you prescribe next?
A
Consider 3 month trail of LABA + LAMA + ICS
If no improvement, revert to LABA + LAMA
7
Q
Patient with COPD on LABA + LAMA, has 1 severe or 2 moderate exacerbations within a year. What do you prescribe next?
A
Consider LABA + LAMA + ICS
8
Q
Patient with COPD on LABA + ICS has symptoms impacting QOL or one severe/two moderate exacerbations in a year. What do you prescribe next?
A
LABA + LAMA + ICS
9
Q
Give an example of a LAMA
A
Tiotropium
10
Q
What are the indications for corticosteroid treatment for sarcoidosis?
A
Parenchymal lung disease, uveitis, hypercalcaemia, neurological or cardiac involvement, deterioration (PFTs or CXR changes)
11
Q
What are the asthmatic features/features suggesting steroid responsiveness in COPD?
A
- Previous diagnosis of asthma or 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%)
12
Q
Give an example of a LABA
A
Salmeterol
13
Q
Give an example of an inhaled corticosteroid
A
Beclomethasone
14
Q
Name a drug used in smoking cessation that is contraindicated in epilepsy
A
Bupropion
15
Q
What are the common causes of upper lobe pulmonary fibrosis?
A
- C- Coal worker’s pneumoconiosis
- H - Histiocytosis/ hypersensitivity pneumonitis
- A - Ankylosing spondylitis
- R - Radiation
- T - Tuberculosis
- S - Silicosis/sarcoidosis
16
Q
What ABG result is seen in DKA?
A
Metabolic acidosis with increased anion gap
17
Q
What are the features of moderate asthma?
A
- PEFR 50-75% best or predicted
- Speech normal
- RR < 25 / min
- Pulse < 110 bpm
18
Q
What are the features of severe asthma?
A
- PEFR 33 - 50% best or predicted
- Can’t complete sentences
- RR > 25/min
- Pulse > 110 bpm
19
Q
What are the features of life-threatening asthma?
A
- PEFR < 33% best or predicted
- Oxygen sats < 92%
- ‘Normal’ pC02 (4.6-6.0 kPa)
- Silent chest, cyanosis or feeble respiratory effort
- Bradycardia, dysrhythmia or hypotension
- Exhaustion, confusion or coma
20
Q
What are the features of near-fatal asthma?
A
Raised pC02 and/or requiring mechanical ventilation with raised inflation pressures
21
Q
How would you confirm a chest dain is located in the pleural cavity?
A
The water seal rises on inspiration and falls on expiration
22
Q
Fine end-inspiratory crepitations are seen what condition?
A
Idiopathic pulmonary fibrosis
23
Q
How would you manage a patient with acute asthma who does not respond to full medical treatment and is becoming acidotic?
A
Intubation and ventilation
24
Q
What is the protein level in an exudative pleural effusion?
A
Over 30 g/L
25
What is the protein level in an transudative pleural effusion?
Less than 30 g/L
26
What is Light's criteria?
If the protein level is between 25-35 g/L, Light's criteria should be applied.
An exudate is likely if at least one of the following criteria are met:
* Pleural fluid protein divided by serum protein >0.5
* Pleural fluid LDH divided by serum LDH >0.6
* Pleural fluid LDH more than two-thirds the upper limits of normal serum LDH
27
What is the first line management for acute bronchitis in an adult?
Doxycycline
28
What is the first line management for acute bronchitis in pregnant women and young people aged 12-17?
Amoxicillin
29
A 32-year-old woman attends her general practice for a routine asthma review. She has had no acute exacerbations in the past 3 years and has reported not using her blue reliever inhaler for the past 6 months.
She has currently prescribed salbutamol as required and a once-daily Seretide 500/50 (fluticasone propionate/salmeterol).
The asthma nurse is considering beginning to step down her treatment.
What is the most appropriate prescription today?
As required salbutamol and Seretide 250/50
## Footnote
In the step-down treatment of asthma, aim for a reduction of 25-50% in the dose of inhaled corticosteroids
30
What are the causes of lower lobe fibrosis?
* Idiopathic pulmonary fibrosis
* Most connective tissue disorders (except ankylosing spondylitis) e.g. SLE
* Drug-induced: amiodarone, bleomycin, methotrexate
* Asbestosis
31
How should patients with ARDS who are being ventilated be positioned?
Prone positioning
32
What is the main finding on the film?
Right upper lobe consolidation
## Footnote
Abnormal opacity within the right upper lobe abutting the horizontal fissure
33
What is the main finding on the x-ray?
Left lingula consolidation
34
What is the main finding on the x-ray?
Pleural plaques
35
What is the most appropriate initial management?
Pleural aspiration
## Footnote
To guide further management and determine the aetiology of the effusion
36
What is the treatment of choice for allergic bronchopulmonary aspergillosis?
Oral glucocorticoids
37
What is Meig's syndrome?
Benign ovarian tumour, ascites, and pleural effusion
38
Where should the tip of the NG tube be?
Below the diagphragm in the stomach
39
What PEF is required for safe discharge following an acute asthma attack?
>75 of best or predicted
40
When should you consider antibiotic therapy for patients with acute bronchitis?
* Are systemically very unwell
* Have pre-existing co-morbidities
* Have a CRP of 20-100mg/L (offer delayed prescription) or a CRP >100mg/L (offer antibiotics immediately)
41
What results on spirometry are indicative of stage 1 COPD?
< 0.7 post-bronchodilator FEV1/FVC
FEV1 > 80% of predicted
Symptoms should also be present
42
What patients with COPD should be offered LTOT?
pO2 of < 7.3 kPa or to those with a pO2 of 7.3 - 8 kPa and one of the following:
* Secondary polycythaemia
* Peripheral oedema
* Pulmonary hypertension
43
What are the 'gold standard' investigations required to confirm asthma in adults?
FeNO test and spirometry with reversibility
44
What are the high-risk characteristics that determine the need for a chest drain in a pneumothorax?
* Haemodynamic compromise
(suggesting a tension pneumothorax)
* Significant hypoxia
* Bilateral pneumothorax
* Underlying lung disease
* ≥ 50 years of age with significant smoking history
* Haemothorax
45
When should NIV be considered in patients with an acute exacerbation of COPD?
Respiratory acidosis (PaCO2>6kPa, pH <7.35 ≥7.26) persists despite immediate maximum standard medical treatment
46
Which patient group with pneumonia can be managed in the community with oral antibiotics?
Patients whos CRB-65 is 0
47
Describe the presentation of ARDS
* Acute onset within the past day, on the background of a known risk factor (pneumonia)
* Bilateral pulmonary oedema (crackles, x-ray changes)
* Hypoxia despite oxygen therapy
48
What are the causes of a transudate pleural effusion?
* Heart failure (most common transudate cause)
* Hypoalbuminaemia
* Liver disease
* Nephrotic syndrome
* Malabsorption
* Hypothyroidism
* Meigs' syndrome
49
What are the causes of an exudate pleural effusion?
* Infection - pneumonia, TB, tubprenic abscess
* CTD - RA, SLE
* Neoplasia - lung cancer, mesothelioma, mets
* Pancreatitis
* PE
* Dressler's syndrome
50
COPD - still breathless despite using SABA/SAMA and asthma/steroid responsive features.
What do you add next?
LABA + ICS
51
How do you diagnose a mesothelioma?
Histology, following a thoracoscopy
52
A 24-year-old male is admitted with acute severe asthma. Treatment is initiated with 100% oxygen, nebulised salbutamol and ipratropium bromide nebulisers and IV hydrocortisone. Despite initial treatment there is no improvement. What is the next step in management?
IV magnesium sulphate
53
Cavitating lesions in the lungs on CXR is associated with what type of lung cancer?
Squamous cell carcinoma
54
What is the most likely diagnosis?
Lung cancer
55
When are patients with lung cancer offered surgery?
* Surgery is offered first-line in non-small-cell lung cancer to patients with disease isolated to a single area
* The intention is to remove the entire tumour and cure the cancer
56
57
What ectopic syndromes are associated with SCLC?
* SIADH - hyponatraemia
* Ectopic ACTH - Cushings
* Limbic encephalitis
* Lambert Eaton myasthenic syndrome
58
What neoplasic syndrome is asssociated with squamous cell lung cancer?
Ectopic PTH - hypercalcaemia
59
Where are small cell lung cancers most commonly located?
Around the hilum/central
60
Where are lung adenomas most commonly located?
More often found peripherally – therefore present late because they less likely to cause obstruction symptoms
61
Where are large cell carcinomas most commonly located?
Centrally
62
Adult with asthma not controlled by a SABA. What do you add next?
Low dose ICS e.g. budenoside
63
What causative organism of pneumonia is associated with empyema formation?
Klebsiella
64
What is the first-line pharmacological treatment of COPD?
SABA (e.g. salbutamol) or SAMA (e.g. ipratropium)
65
A 52-year-old man who was born in India presents with episodic haemoptysis. His only history is tuberculosis as an adolescent. Chest x-ray shows a rounded opacity in the right upper zone surrounded by a rim of air.
What is the most likely diagnosis?
Aspergilloma
66
Describe the presentation of granulomatosis with polyangiitis
Pulmonary haemorrhage (haemoptysis), renal impairment (rapidly progressive glomerulonephritis) and flat or saddle nose (due to a collapse of the nasal septum)
67
What is the most likely diagnosis?
Left upper lobe pneumonia
68
What are the causes of bronchiectasis?
* Post-infective: tuberculosis, measles, pertussis, pneumonia
* Cystic fibrosis
* Bronchial obstruction e.g. lung cancer/foreign body
* Immune deficiency: selective IgA,
Hypogammaglobulinaemia
* Allergic bronchopulmonary aspergillosis (ABPA)
* Ciliary dyskiinetic syndromes: Kartagener's syndrome, Young's syndrome
69
What finding on spirometry would theoretically seen in a patient with recurrent PEs?
Reduced TLCO
## Footnote
Recurrent pulmonary embolism can cause areas of the lung to be poorly perfused and ventilated, leading to a ventilation-perfusion mismatch. This results in reduced gas exchange, hence a reduced TLCO
70
Acute exacerbation of COPD. ABG gets worse on 2L oxygen. What do you do?
NIV
71
At what pH are patients with an acute exacerbation of COPD most likely to receive benefit from NIV?
7.25-7.35
72
At what pH would you consider invasive ventilation for a patient with an infective exacerbation of COPD?
< 7.25
73
COPD - still breathless despite using SABA/SAMA and no asthma/steroid responsive features.
What do you prescribe next?
Add a LABA + LAMA
74
Patient with pneumothorax started with chest drain. A few hours later experiences signs of unilateral pulmonary oedema.
What is the most likely cause?
Over rapid aspiration/drainage of pneumothorax - can result in re-expansion pulmonary oedema
75
True or false: any critically ill patient (including CO2 retainers) should initially be treated with high flow oxygen which is then titrated to achieve target sats
True
76
Patient on with COPD ipratropium inhalers. You are starting a LAMA + LABA as symptoms are uncontrolled.
What else should you do?
Switch SAMA to SABA
77
A 32-year-old man presents to the acute surgical unit with acute pancreatitis. Over the next few days he becomes dyspnoeic and his saturations are 89% on air. A CXR shows bilateral pulmonary infiltrates. His pulmonary capillary wedge pressure is normal. What is the most likely diagnosis?
ARDS
78
At what pH aspirate is an NG tube safe to use?
< 5.5
79
What is the most likely diagnosis?
TB/sarcoidosis - bilateral hilar lymphadenopathy
80
What imaging is indicated for a pleural effusion?
* PA CXR
* Pleural aspiration with US guidance
* Contrast CT - underlying cause
81
What is the most likely diagnosis?
Acute heart failure
## Footnote
Shows alveolar oedema (bat wings), Kerley B lines, and cardiomegaly
82
What is the mechanism of action of bupropion?
Norepinephrine and dopamine reuptake inhibitor, and nicotinic antagonist
83
Pneumothorax: persistent air leak or recurrent episodes. What is the most appropriate definitive management option for this man to prevent recurrence?
Consider referral for VATS to allow for mechanical/chemical pleurodesis +/- bullectomy
84
What is the prognosis of pleural plaques?
* Pleural plaques are benign and do not undergo malignant change
* Don't require any follow-up
85
What pleural effusion fluid protein/serum protein ratio indicates an exudate?
> 0.5
86
When do NICE recommend giving oral antibiotics in an acute exacerbation of COPD?
In the presence of purulent sputum or clinical signs of pneumonia
87
What changes may be seen on the FBC of a patient with COPD?
Polycythaemia (increased concentration of haematocrit)
## Footnote
Long-term hypoxia results in increased erythropoietin production by the kidneys causing haemoglobin levels to rise
88
A 53-year-old man is admitted to the Emergency Department complaining of a 'chest infection'. His symptoms have not improved despite a course of antibiotics from his GP.
What is the most likely diagnosis and appropriate next investigation?
Renal cell carcinoma (cannonball mets)
High resolution CT thorax
89
90
What lung function findings are most characteristic of a patient with idiopathic pulmonary fibrosis?
Increased FEV1/FVC ratio and reduced transfer factor
91
What is the most common organism causing infective exacerbations of COPD?
Haemophilus influenzae
92
What is the most likely diagnosis?
COPD - shows hyperinflation, flattened hemidiaphragms, and hyperlucent lung fields
93
What is the treatment of choice for allergic bronchopulmonary aspergillosis?
Oral glucocorticoids
94
How do you calculate pack years?
1 pack year is defined as 20 cigarettes per day for 1 year
95
An increase to the FEV1 of what percentage following a short-acting bronchodilator is indicative of asthma?
14%
96
Describe the presentation of allergic bronchopulmonary aspergillosis
* Bronchoconstriction: wheeze, cough, dyspnoea - patients may have a previous label of asthma
* Bronchiectasis (proximal)
97
What are the common investigation findings in allergic bronchopulmonary aspergillosis?
* Eosinophilia
* Flitting CXR changes
* Positive radioallergosorbent (RAST) test to Aspergillus
* Positive IgG precipitins (not as positive as in aspergilloma)
* Raised IgE
98
IPF causes fibrosis of the (lower/upper) zones
Lower
99
Describe the presentation of a pancoast tumour
Pancoast tumours can suppress the recurrent laryngeal nerve causing hoarseness of voice
100
How would you investigate a pancoast tumour?
CT scan chest
101
What is the first line management of an acute COPD exacerbation?
* Increase the frequency of bronchodilator use and consider giving via a nebuliser
* Give prednisolone 30 mg daily for 5 days
102
Previous radiotherapy causes (upper/lower) lung fibrosis
Upper
103
What advice should be given to patients following a pneumothorax?
* Avoid smoking
* Current pneumothorax is a complete contraindication to flying, BTS recommend waiting until 1 week post check x-ray
* Lifetime ban on scuba diving (unless the patient has undergone bilateral surgical pleurectomy and has normal lung function and chest CT scan postoperatively)
104
Coal workers' pneumoconiosis typically causes (upper/lower) zone fibrosis
Upper
105
What findings on spirometry are associated with pulmonary fibrosis?
Restrictive spirometry picture (FEV1:FVC >70%, decreased FVC) and impaired gas exchange (reduced TLCO)
106
What is the first line management of sarcoidisis?
Monitoring
Prednisolone if certain critera fulfilled
107
Which stage of COPD has normal FEV1 readings but is symptomatic?
Stage 1
108
When would you treat a patient with a pneumothorax with a chest drain rather than aspiration as first line?
If a secondary pneumothorax > 2cm and/or the patient is short of breath
109
What drugs can trigger asthma?
* NSAIDS
* Beta blockers
110
What is the most likely diagnosis?
Right middle lobe pneumonia
111
Suspected pneumothorax treated with chest tube. No improvement is seen.
What is the most likely diagnosis?
Large emphysematous bullae
112
What findings on spirometry are associated with emphysema?
Reduced FEV1/FVC
Reduced TLCO
113
What is the mechanism of action of montelukast?
Leukotriene receptor antagonist
114
What vaccines should be offered to patients with COPD?
Annual influenza + one-off pneumococcal
115
What are the consequences of obstructive sleep apoea?
* Daytime somnolence
* Compensated respiratory acidosis
* Hypertension
116
117
118
119
120
Amiodarone causes (lower/upper) lung fibrosis
Lower
121
COPD: FEV1/FVC< 0.7, 50-79%.
What severity?
Stage 2 - moderate
122
COPD: FEV1/FVC< 0.7, 30-49%.
What severity?
Stage 3 - severe
123
COPD: FEV1/FVC< 0.7, < 30%
What severity?
Stage 4 - very severe
124
What are the features of transfusion-related lung injury?
Acute onset
Dyspnoea
Elevated respiratory rate
Bilateral lung crackles
Low oxygen saturations
125
What are the criteria for acute respiratory distress syndrome?
* Acute onset (within 1 week of a known risk factor)
* Pulmonary oedema: bilateral infiltrates on chest x-ray ('not fully explained by effusions, lobar/lung collapse or nodules)
* Non-cardiogenic (pulmonary artery wedge pressure needed if doubt - should be normal)
* pO2/FiO2 < 40kPa (300 mmHg)
126
What are the contraindications to surgery in lung cancer?
* SVC obstruction
* FEV < 1.5
* Malignant pleural effusion
* Vocal cord paralysis
127
Can alpha-1 antitrypsin deficiency be tested prenatally?
Yes
128
129
All cases of pneumonia should have a repeat chest X-ray at how many weeks following clinical resolution?
6 weeks
130
Suspected asthma in a child. Normal spirometry.
What next?
Organise fractional exhaled nitric oxide testing
131
What investigations are indicated in diagnosing adult asthma?
Adults with suspected asthma should have both a FeNO test and spirometry with reversibility
132
What does the x-ray show?
Lung abscess
133
Name one cause of high pressure NIV
Pneumothorax
134
